Role of Radiologists in Contract Research Organizations (CROs)

Clinical trials play a vital role in advancing technology and novel therapies in the healthcare world. However, the increasing scale of trials and the complexity of the regulatory approval process is often a barrier for those interested in conducting research. Contract research organizations (CROs) aim to address this problem by offering their infrastructure and expertise to bring a therapy from conception to approval without the need for in-house staff. Clinical trial imaging often plays an essential role in this process, creating a need for radiologists and a unique opportunity to provide irreplaceable value in their ability to interpret and analyze the imaging outcomes of therapies in question. This paper explores the concept of CROs, the crucial role played by radiologists in their operation, and the nature of the CRO - radiologist relationship.

Chest CT Findings in Patients with HIV Presenting to the Emergency Department: A Single Institute Experience

PURPOSE

The aim of this study was to analyze chest CT imaging findings and relevant clinical factors in patients with HIV presenting to the emergency department (ED).

MATERIALS AND METHODS

A retrospective review was performed to identify patients with HIV who received chest CT imaging evaluation in the acute ED setting. Analyzed patients included adults with a known diagnosis of HIV who presented to the ED at a single tertiary care center between 2004 and 2020 and received chest CT imaging. Chest CT findings were assessed by 2 radiologist readers, and relevant clinical data were gathered. Statistical analysis was performed to determine if imaging and clinical factors demonstrate significant associations with CD4 count, viral load, and antiretroviral therapy status.

RESULTS

A total of 113 patients with HIV were identified who presented to the ED and underwent chest CT imaging evaluation (mean age 47 ± 11 years). Frequently detected chest CT findings included infectious pneumonia (24%), malignancy (11%), pleural effusion (17%), pericardial effusion (13%), and pulmonary embolism (4%). CD4 count, viral load, and active retroviral therapy demonstrated statistically significant associations with a number of key imaging and clinical factors, including presence of pneumonia, malignancy, average length of hospital admission, and survival.

CONCLUSION

Patients with HIV present with a wide range of imaging findings when presenting in the acute ED setting. CD4 count, viral load, and active retroviral therapy status demonstrate statistically significant associations with multiple key imaging findings and clinical factors. Chest CT plays an integral role in the clinical management of this unique patient population.

A Decade of Success in Melanoma Immunotherapy and Targeted Therapy: What Every Radiologist Should Know

ABSTRACT

Treatment strategies for malignant melanoma have rapidly evolved over the past decade. Because of its propensity to develop advanced stage and metastatic disease, melanoma has contributed to the majority of mortalities among patients with skin cancer. The development of novel therapeutics such as immunotherapy and targeted molecular therapies has revolutionized the treatment of patients with advanced stage and metastatic malignant melanoma. Immune checkpoint inhibitors, BRAF/MEK inhibitors, and other revolutionary therapies have demonstrated remarkable success in the treatment of this common malignancy. Along with these advancements in systemic therapies, imaging has continued to play a critical role in the diagnosis and follow-up of patients with malignant melanoma. As the use of these novel therapies continues to expand, knowledge of the evolving therapeutic landscape of melanoma is becoming critical for radiologists. In this review, we provide a primer for radiologists outlining the evolution of immunotherapy and targeted therapy in the treatment of melanoma. We discuss the critical role of imaging in evaluation of treatment response, including a summary of current imaging response guidelines. Last, we summarize the essential role of imaging in the evaluation of potential adverse events seen in patients with malignant melanoma undergoing treatment with immune checkpoint inhibitors.

Efficacy of Immune Checkpoint Inhibitors against Advanced or Metastatic Neuroendocrine Neoplasms: A Systematic Review and Meta-Analysis

We performed a systematic review and meta-analysis of the treatment efficacy of immune checkpoint inhibitors (ICIs) in advanced/metastatic neuroendocrine neoplasms (NENs). MEDLINE and EMBASE were searched to identify studies that provide data on treatment response and/or survival outcomes of advanced/metastatic NEN patients treated with ICIs. The overall response rate (ORR) was pooled using a random-effects model. Meta-regression was performed to explore factors influencing the ORR. Individual patient data (IPD) meta-analysis of survival was performed using stratified Cox regression. Ten studies (464 patients) were included. The overall pooled ORR was 15.5% (95% confidence interval (CI), 9.5-24.3%), and it varied according to the primary site (thoracic, 24.7%; gastro-entero-pancreatic, 9.5%), tumor differentiation (poorly differentiated, 22.7%; well-differentiated, 10.4%), and drug regimen (combination, 25.3%; monotherapy, 10.1%). All these variables significantly influenced the ORR. Tumor differentiation was associated with both overall survival and progression-free survival (hazard ratio of poorly differentiated tumors, 4.2 (95% CI, 2.0-8.7) and 2.6 (95% CI, 1.6-4.4), respectively). Thus, the treatment efficacy of ICIs for advanced/metastatic NENs varied according to primary site, tumor differentiation, and drug regimen. Poorly differentiated NENs showed a better ORR than well-differentiated NENs but had a negative impact on survival.

The modern therapeutic & imaging landscape of metastatic prostate cancer: a primer for radiologists

Prostate cancer represents one of the leading causes of cancer-related mortality in the United States and the most common cancer among men. Treatment paradigms for the management of advanced stages of prostate cancer have continued to evolve in recent years. These advancements in the therapeutic landscape of metastatic prostate cancer and diagnostic imaging modalities have fundamentally changed the treatment of patients with prostate cancer. In this review article we provide a primer for radiologists highlighting the most recent developments in treatment options and imaging techniques utilized in the modern oncologic management of metastatic prostate cancer. We will examine current therapy options and associated toxicities with an emphasis on relevant imaging findings commonly encountered by radiologists. We also summarize the role of modalities including CT, MRI, PET, bone scintigraphy, and PET in the diagnosis and follow-up of patients with metastatic prostate cancer.

Primary peritoneal serous carcinoma: a primer for radiologists

Primary peritoneal serous carcinoma (PPSC) is a rare primary peritoneal tumor characterized by a unique range of clinical features and imaging findings. Though it shares many clinical, histologic, and imaging features with serous ovarian carcinoma, it remains a distinct clinical entity. Although less common than its primary ovarian counterpart, PPSC is characterized by a prognosis that is often equally poor with presentations common in late stages of disease. Key imaging modalities used in the evaluation of PPSC include ultrasound, CT, MRI, and PET/CT. For radiologists, an understanding of the pertinent imaging findings, pathologic correlations, and clinical features of PPSC is essential for arriving at the correct diagnosis and guiding the subsequent appropriate management of this complex malignancy.

Overview of serum and tissue markers in colorectal cancer: a primer for radiologists

Serum and tissue tumor markers provide crucial information in the diagnosis, treatment, and follow-up of colorectal cancers. Tissue tumor markers are increasingly used for determination of targeted chemotherapy planning based on genotyping of tumor cells. Recently, plasma-based technique of liquid biopsy is being evaluated for providing tumor biomarkers in the management of colorectal cancer. Tumor markers are commonly used in conjunction with imaging during initial staging, treatment determination, response assessment, and determination of recurrence or metastatic disease. Knowledge of tumor markers and their association with radiological findings is thus crucial for radiologists. Additionally, various novel imaging techniques are being evaluated as potential noninvasive imaging biomarkers to predict tumor genotypes, features, and tumor response. We review and discuss the potential role of these newer imaging techniques.

Imaging-based Toxicity and Response Pattern Assessment Following CAR T-Cell Therapy

Background Chimeric antigen receptor (CAR) T-cell immunotherapy is increasingly used for refractory lymphoma but may lead to cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS). Imaging may assist in clinical management. Associations between CRS or ICANS grade and imaging findings remain not fully established. Purpose To determine associations between imaging findings and clinical grade of CRS or ICANS, evaluate response patterns, and assess imaging use following CAR T-cell treatment. Materials and Methods Patients with refractory B-cell lymphoma who received CAR T-cell infusion between 2018 and 2020 at a single center were analyzed retrospectively. Clinical CRS or ICANS toxicity grade was assessed using American Society for Transplantation and Cellular Therapy, or ASTCT, consensus grading. Thoracic and head images (radiographs, CT scans, MRI scans) were evaluated. Associations between imaging findings and clinical CRS or ICANS grade were analyzed. Wilcoxon signed-rank and χ² tests were used to assess associations between thoracic imaging findings, clinical CRS toxicity grade, and imaging-based response. Response to therapy was evaluated according to Deauville five-point scale criteria. Results A total of 38 patients (mean age ± standard deviation, 59 years ± 10; 23 men) who received CAR T-cell infusion were included. Of these, 24 (63% [95% CI: 48, 79]) and 11 (29% [95% CI: 14, 44]) experienced clinical grade 1 or higher CRS and ICANS, respectively. Patients with grade 2 or higher CRS were more likely to have thoracic images with abnormal findings (10 of 14 patients [71%; 95% CI: 47, 96] vs five of 24 patients [21%; 95% CI: 4, 37]; P = .002) and more likely to have imaging evidence of pleural effusions (five of 14 [36%; 95% CI: 10, 62] vs two of 24 [8.3%; 95% CI: 0, 20]; P = .04) and atelectasis (eight of 14 [57%; 95% CI: 30, 84] vs six of 24 [25%; 95% CI: 7, 43]; P = .048). Positive imaging findings were identified in three of seven patients (43%) with grade 2 or higher ICANS who underwent neuroimaging. The best treatment response included 20 of 36 patients (56% [95% CI: 39, 72]) with complete response, seven of 36 (19% [95% CI: 6, 33]) with partial response, one of 36 (2.8% [95% CI: 0, 8]) with stable disease, and eight of 36 (22% [95% CI: 8, 36]) with progressive disease. Conclusion Thoracic imaging findings, including pleural effusions and atelectasis, correlated with cytokine release syndrome grade following chimeric antigen receptor (CAR) T-cell infusion. CAR T-cell therapy yielded high response rates. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Langer in this issue.

Past, Present, and Future of Serum Tumor Markers in Management of Ovarian Cancer: A Guide for the Radiologist

The ability to accurately detect early ovarian cancer and subsequently monitor treatment response is essential to improving survival for patients with ovarian malignancies. Several serum tumor markers (STMs)-including cancer antigen 125 (CA-125), human epididymis protein 4 (HE4), cancer antigen 19-9 (CA 19-9), and carcinoembryonic antigen (CEA)-have been used as a noninvasive method of identifying ovarian cancer in conjunction with imaging. Although current guidelines do not recommend use of STMs as screening tools for ovarian cancer, these markers have clinical utility in both diagnosis and surveillance for women with ovarian cancer. CA-125 is the most commonly used STM; its level may be elevated in several types of ovarian cancer, including epithelial cell tumors, carcinosarcoma, teratomas, and secondary ovarian malignancies. An elevated level of CA 19-9 is associated with clear cell tumors, teratomas, and secondary malignancies. CEA is most commonly associated with mucinous ovarian cancers. Finally, HE4 is being increasingly used to identify certain subtypes of epithelial ovarian cancers, particularly serous and endometrioid tumors. Diagnosis of ovarian cancers relies on a combination of CA-125 levels and US findings, which include a large adnexal mass or high-risk features, including septa and increased vascularity. CT is preferred for staging and is used along with PET and STM monitoring for surveillance. Increasingly, MRI is being used to characterize ovarian lesions that are indeterminate at US or CT. The future of STM testing involves development of "liquid biopsies," in which plasma samples are analyzed for evidence of tumors, including circulating tumor DNA or tumor cells and tumor micro-RNA. When combined with traditional imaging techniques, liquid biopsies may lead to earlier diagnosis and improved survival. An invited commentary by Shinagare is available online. ^©RSNA, 2021.

COVID-19 infection in the cancer population: a study of emergency department imaging utilization and findings

Purpose

To analyze emergency department (ED) computerized tomography (CT) utilization in cancer patients with coronavirus disease 2019 (COVID-19).

Methods

A retrospective chart review was performed to identify cancer patients who received COVID-19 diagnosis within the single healthcare system and presented to the ED within 30 days of COVID-19 positive date between May 1 and December 31, 2020.

Results

In our 61 patients, the mean age was 72.5 years old, with 34% of patients (n = 21) on active cancer therapy and 66% (n = 40) on surveillance only. Most patients (n = 53) received their COVID-19 diagnosis within the ED, with 8 patients diagnosed prior to initial ED visit. The most common CT studies ordered within the ED were CT chest (n = 25), CT abdomen/pelvis (A/P) (n = 20), CT head (n = 8), and CT chest/abdomen/pelvis (C/A/P) (n = 7). COVID-19 findings were present on 33 scans, findings of worsening malignancy on 12 scans, and non-COVID non-cancer findings on 9 scans. Significant differences in CT severity score (p = 0.0001), indication for hospitalization (p = 0.026), length of hospitalization (p = 0.004), interventions (remdesivir, mechanical ventilation, and vasopressor support) while hospitalized (p < 0.05), and mortality (p = 0.042) were found between the prior diagnosis and ED diagnosis groups. No such differences were found between the active treatment and surveillance groups.

Conclusion

ED CT imaging findings in patients with cancer and COVID-19 are predominantly related to COVID-19 infection, rather than cancer history or anti-cancer therapy status.

High-dose interleukin-2 therapy related adverse events and implications on imaging

High-dose interleukin-2 (HDIL-2) therapy was initially approved by the U.S. Food and Drug Administration for metastatic renal cell carcinoma (mRCC) and metastatic melanoma. IL-2 is able to promote CD8+ T cell and natural killer (NK) cell cytotoxicity to increase tumoricidal activity of the innate immune system. HDIL-2 therapy is associated with a wide spectrum of immune-related adverse events (irAEs) that can be radiologically identified. HDIL-2 toxicity can manifest in multiple organ systems, most significantly leading to cardiovascular, abdominal, endocrine, and neurological adverse events. The collective impact of the irAEs and the rise of immune checkpoint inhibitors (ICIs) and tyrosine kinase inhibitors led to the demise of HDIL-2 as a primary therapy for mRCC and metastatic melanoma. However, with innovation in ICIs and the creation of mutant IL-2 conjugates, there has been a drive for combination therapy. Knowledge of the HDIL-2 therapy and HDIL-2 related adverse events with radiology relevance is critical in diagnostic image interpretation.

Trends in Medicare Part B Payments and Utilization for Imaging Services Between 2009 and 2019

BACKGROUND

In 2019, the total National Healthcare Expenditure (NHE) reached $3.8 trillion, or nearly 20% of the total Gross Domestic Product. This represents a 4-fold increase in its Gross Domestic Product share since 1960. Given the magnitude and growth of such expenditures, healthcare cost containment is central to the country's financial sustainability. Moreover, as Medicare represents nearly 20% of the total NHE, it is a primary target for piloting, implementing and scaling initiatives that reduce expenditures.

OBJECTIVE

To assess trends in Medicare Physician Fee Schedule for Service (Part B) payments and utilization for Imaging relative to other services from 2009 through 2019.

MATERIALS AND METHODS

We conducted a retrospective observational study of annual expenditures and utilization of imaging services using data from Centers for Medicare and Medicaid Services Medicare Part B. Data was grouped according to the Berenson-Eggers Type of Service Classification. The values were adjusted for inflation and we calculated the annual changes and the compound annual growth rates and the price elasticity of supply.

RESULTS

For the 10-year period, Imaging represented on average 8% of the total Medicare Part B expenditures, an equivalent of 1.4% of total Medicare expenditures or 0.05% of the NHE. While NHE, overall Medicare and overall Part B had positive growth rates of total expenditures, Imaging did not. Moreover, Imaging had the most negative CAGR compared to all other categories, including Drugs, Procedures, Evaluation and Management and Durable Medical Equipment.

CONCLUSION

Imaging did not contribute to the increase in Medicare Part B expenditures, and it might have been disproportionately affected by cost containment policies.

Imaging features of hypercalcemia: A primer for emergency radiologists

Hypercalcemia is a marker for a wide variety of underlying etiologies, and its presentation in the emergency setting may be asymptomatic, incidental, or a primary complaint with associated symptoms and physical exam findings. While the workup is initially driven through serum laboratory testing, imaging plays an important role in diagnosis and post-treatment follow up. This review covers multiple common and uncommon etiologies of hypercalcemia, details their underlying mechanisms, and identifies the most important associated imaging findings. It is important for radiologists to be familiar with these etiologies and imaging findings, particularly in the emergency setting since hypercalcemia may represent the only significant laboratory abnormality associated with the presenting condition. Furthermore, the radiologist's interpretation of a study may be directly influenced by knowing about a patient's hypercalcemia.

Impact of BRAF mutations on outcomes in metastatic melanoma with central nervous system metastases treated with immune checkpoint inhibitors

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Background: Half of patients (pts) with melanoma (mel) develop central nervous system (CNS) metastases (mets), leading to death in over 90% in the pre-immune checkpoint inhibitor (ICI) era. Overall survival (OS) has improved in the ICI era for those with CNS mets, yet the association of survival with ICI treatment for those with tumors harboring genomic variants (var) remains unclear. Methods: We retrospectively reviewed our electronic medical records to identify pts with mel and CNS mets who received ICI from 2010 to 2018. Treatment history, systemic and CNS responses, and genomic data were recorded. Genomic var were categorized as BRAFV600E (BRAF), NRAS, cKIT, other var, and no var. Concurrent RT (CRT) was defined as RT to CNS mets within 30 days of ICI. OS was calculated from date of first ICI or RT to date of death or last follow up, and comparison analyses made using Kaplan-Meier estimate. Fisher's exact or Chi-squared tests were used to compare categorical variables and Wilcoxon or Kruskal-Wallis tests to compare continuous variables. A two-sided p-value of < 0.05 was considered statistically significant. Results: A total of 49 pts were identified; 37 had var results available. BRAFV600E was the most common var identified (32%), followed by NRAS (19%), cKIT (5%), and other (5%); 38% had no var. BRAFV600K was not identified. Pts with BRAF had lower rates of CNS progression on ICI at 3 and 6 months than all other pts (17% vs 50%, p< 0.01 and 12.5% vs 40%, p< 0.01, respectively). Of 38 pts (10 BRAF) who had CNS mets at the start of ICI, 6-month OS was 50% in pts with BRAF, compared to 0% in pts with non-BRAF var ( p= 0.01) and 36% in pts with no var ( p= 0.7). 4 of the 10 pts with BRAF who had CNS mets at start of ICI received BRAF-targeted therapy after ICI. On ICI, only 30% of pts with BRAF developed new CNS mets, compared to 57% of all other pts ( p= 0.08). Pts who developed new CNS mets on ICI had worse OS than pts who did not (median OS (mOS) 314 days vs 662 days, p= 0.04). A majority of pts (55%) received anti-CTLA4 monotherapy as first ICI, and 39% received anti-CTLA4 plus anti-PD1. Pts with BRAF were just as likely to receive dual anti-CTLA4/PD-1 as pts without BRAF (33% vs 40%, p= 0.74). 40 pts underwent RT for CNS mets, of whom 22 received CRT. There was no difference in mOS between pts who received CRT and non-concurrent RT/no RT (468 days vs 314 days, p= 0.8). Rates of CRT between pts with BRAF and pts without BRAF were similar ( p> 0.9), and there was no difference in mOS between these groups (400 days vs 536 days, p= 0.9). Conclusions: Pts with BRAF-mutated mel with CNS mets receiving ICI had lower rates of progression in CNS and improved OS compared to other var. CRT was not associated with improved survival over non-concurrent RT. There has been significant improvement in OS of pts with mel CNS mets in the era of ICI and additional studies are warranted to understand the biology of BRAF var and the host immune system response in the CNS.

Correlation of liver-to-spleen ratio, lung CT scores, clinical, and laboratory findings of COVID-19 patients with two consecutive CT scans

PURPOSE

Given the lack of information about abdominal imaging findings and correlation with clinical features of COVID-19, we aimed to evaluate the changes in hepatic attenuation during the course of disease. Our aim was to correlate the liver-to-spleen ratio (L/S), clinical, laboratory findings, and lung CT scores of patients with COVID-19 who had two consecutive chest CTs.

METHODS

A retrospective search was performed between March 1, 2020 and April 26, 2020 to identify patients who had positive RT-PCR tests and two unenhanced chest CTs. Scans that were obtained at hospital admission and follow-up were reviewed to assess L/S and lung CT scores. Patients were divided into two groups based on lung CT scores (non-progressive vs progressive). Patient demographics, laboratory findings, length of hospital stay, and survival were noted from electronic medical records.

RESULTS

Twenty patients in the progressive group and 7 patients in the non-progressive group were identified. The mean L/S of the progressive group (1.13 ± 0.3) was lower than that of the non-progressive group (1.21 ± 0.29) at hospital admission but there was no significant difference between the two groups (p = 0.547). L/S at follow-up was significantly different between the groups as the mean L/S values of the progressive and non-progressive groups were 1.02 ± 0.23 and 1.25 ± 0.29, respectively (p = 0.009). L/S was negatively correlated with AST and ALT (r =  - 0.46, p = 0.016 and r =  - 0.534, p = 0.004, respectively). There were significant differences between the two groups in terms of WBC, neutrophil, lymphocyte, monocyte, and platelet counts that were obtained at hospital admission. Length of hospital stay was significantly longer in patients in the progressive group (p = 0.035).

CONCLUSIONS

Decrease in L/S may be observed in patients with elevated lung CT scores at follow-up. WBC, neutrophil, lymphocyte, monocyte, and platelet counts at hospital admission may predict the progression of COVID-19.

Definition, Incidence, and Challenges for Assessment of Hyperprogressive Disease During Cancer Treatment With Immune Checkpoint Inhibitors: A Systematic Review and Meta-analysis

IMPORTANCE

Hyperprogressive disease (HPD) is a recognized pattern of rapid tumor progression during immune checkpoint inhibitor (ICI) treatment. Definitions of HPD have not been standardized, posing the risk of capturing different tumoral behaviors.

OBJECTIVES

To provide a systematic summary of definitions and the incidence of HPD in patients undergoing ICI treatment and discuss the challenges of current assessment of HPD.

DATA SOURCES

Articles that evaluated HPD published before March 3, 2020, were identified from MEDLINE and EMBASE.

STUDY SELECTION

Clinical trials and observational studies providing the incidence and definition of HPD from patients with cancer treated with ICIs.

DATA EXTRACTION AND SYNTHESIS

Factors included in the analysis comprised authors, year of publication, cancer type, ICI type, number of previous treatment lines, definition of HPD, time frame used to assess HPD, number of patients with HPD, onset of HPD, and prognosis of patients with HPD. Quantitative and qualitative syntheses for the incidence of HPD were performed.

MAIN OUTCOMES AND MEASURES

Definitions of HPD were categorized and the range of incidence of HPD was evaluated. Subgroup analysis on the incidence of HPD according to the category was performed and the challenges associated with current HPD assessment were evaluated.

RESULTS

Twenty-four studies with 3109 patients were analyzed. The incidence of HPD varied from 5.9% to 43.1%. The definitions were divided into 4 categories based on the calculation of tumor growth acceleration: tumor growth rate ratio (pooled incidence of HPD, 9.4%; 95% CI, 6.9%-12.0%), tumor growth kinetics ratio (pooled incidence, 15.8%; 95% CI, 8.0%-23.7%), early tumor burden increase (pooled incidence, 20.6%; 95% CI, 9.3%-31.8%), and combinations of the above (pooled incidence, 12.4%; 95% CI, 7.3%-17.5%). Hyperprogressive disease could be overestimated or underestimated if the assessment was limited to tumor growth rate or tumor growth kinetics ratio, target lesions, or response evaluation criteria in solid tumors (RECIST)-defined progressors, or if the assessment time frame conformed to RECIST. Study results on clinical outcome were heterogeneous on discriminating patients with HPD from those with natural progressive disease.

CONCLUSIONS AND RELEVANCE

Definitions of HPD appear to be diverse, with the incidence of HPD varying from 5.9% to 43.1% across studies examined in this meta-analysis. Varying incidence and definitions of HPD indicate the need for establishing its uniform and clinically relevant criteria based on currently available evidence.

Trends in imaging utilization for small cell lung cancer: a decision tree analysis of the NCCN guidelines

PURPOSE

To investigate the differences in small cell lung cancer (SCLC) diagnostic imaging utilization relative to National Comprehensive Cancer Network (NCCN) guidelines.

METHODS

We retrospectively reviewed SCLC records at our institution between January 1, 2003 and August 1, 2019 (n = 529). Patients were grouped by extensive-stage versus limited-stage and diagnosis date. Clinical, CT, MRI, and nuclear imaging data was collected. Imaging utilization was compared using Student's t-test or Kruskal-Wallis-test/Wilcoxon-Rank-Sums test. Survival was compared using Log-rank-test and Kaplan-Meier-curves.

RESULTS

SCLC patients had a median survival of 290 days. Extensive-stage patients with SCLC demonstrated an increase in emergency imaging utilization when diagnosed in 2011-2019 compared to 2003-2010 (CT abdomen/pelvis p < 0.001, CTA chest for pulmonary embolism p < 0.01, CT head p < 0.003). Limited-stage patients with SCLC demonstrated an increase in inpatient imaging utilization (CT abdomen/pelvis p < 0.04) and decreased total/outpatient imaging utilization (CT chest-abdomen-pelvis p < 0.05, CT head p < 0.003) when diagnosed in 2011-2019 compared to 2003-2010. All patients with SCLC had decreased average number of bone-scan studies when diagnosed in 2011-2019 compared to 2003-2010 (Extensive-stage p < 0.006, Limited-stage p < 0.0006).

CONCLUSION

Imaging utilization trends in the management of patients with SCLC at our institution differed between 2003 and 2010 and 2011-2019 reflecting the changes in the NCCN guidelines.

A Foundational Guide to Understanding Radiology Department Business Operations for Trainees

The financial success of a radiology department is crucial to the well-being of both the hospital and the community it serves. Radiology trainees should therefore be conscious of how the department maintains its value within the health system. The purpose of this review is to provide a concise foundational resource for contemporary radiology residents and fellows to understand the basic financial operations of a hospital-based radiology department and to demonstrate its importance in supporting clinical activities. The radiology report is at the heart of reimbursement. Coders use this tool to assign International Classification of Diseases and Current Procedural Terminology codes to file reimbursement claims. Medicare, commanding the highest market share for third-party payers, sets algorithmic standards for compensation practices. Private insurers contract with hospitals, and providers use these systems or create their own contractual framework. Radiology leaders strategically balance these revenue streams with various departmental costs utilizing tools such as budgets and forecasts to ensure long-term organizational viability. Notably, payment practices in the United States are transforming from fee-for-service to value-based care. The roles of the radiologist and the radiology report are evolving with it. Examples of value-based payment models are accountable care organizations and bundled payments. Radiologists participating in these models are increasingly expected to be stewards of imaging utilization and effectively manage health care resources. Within this context of a globally changing incentive structure, trainees must reconceptualize their educational experience to equip themselves for both current and future types of clinical practice.

Extraprostatic extension in prostate cancer: primer for radiologists

The presence of extraprostatic extension (EPE) on multiparametric MRI (mpMRI) is an important factor in determining the management of prostate cancer. EPE is an established risk factor for biochemical recurrence of prostate cancer after radical prostatectomy (RP) and patients with EPE may be considered for wider resection margins, non-nerve-sparing surgery, adjuvant radiation therapy (RT), or androgen deprivation therapy (ADT). Several statistical nomograms and scoring systems have been developed to predict pathological stage at time of RP but with varying accuracies. Using the current PI-RADS v2 mpMRI staging guidelines results in high specificity but lacks in sensitivity. These findings reveal the need for more standardization and further refinement of existing MRI protocols and prostate cancer prediction tools. Current studies have looked into indirect additional imaging criteria such as index tumor volume, length of capsular contact, and apparent diffusion coefficient. Measuring for these features can improve the robustness of mpMRI in staging prostate cancer, as they have been shown to be independent predictors of EPE. MRI/ultrasound fusion-guided targeted biopsy can detect EPE not found on standard biopsy. Collectively, these measurements and imaging techniques can augment the detection of EPE and subsequent risk stratification.

Imaging and clinical manifestations of immune checkpoint inhibitor-related colitis in cancer patients treated with monotherapy or combination therapy

PURPOSE

To determine the frequency, imaging, and clinical manifestations of immune checkpoint inhibitor (ICI)-related colitis in cancer patients on monotherapy or combination therapy.

METHODS

The electronic medical records of 1044 cancer patients who received ICIs were retrospectively reviewed to identify 48 patients who had a clinical diagnosis of immune-related colitis. Imaging studies were reviewed to identify patients with imaging manifestations of colitis. Demographic data, type of ICIs, symptoms, presence of other immune-related adverse events (irAEs), and management were recorded.

RESULTS

There was imaging evidence of immune-related colitis in 34 patients (24 men; median age: 63.5 years). The median time to onset of colitis was 75 days (IQR 25-75, 49.5-216 days) in patients receiving monotherapy (group 1) and 78 days (IQR 25-75, 44.3-99.5 days) in patients undergoing combination therapy (group 2) following start of ICI. Symptoms included diarrhea (91.1% [31 of 34]), nausea/vomiting (52.9% [18 of 34]), and abdominal pain (52.9% [18 of 34]). The most common imaging findings were bowel wall thickening (97% [33 of 34]) and fluid-filled colon (82.3% [28 of 34]). Colitis was diffuse in 21 of 34 (61.8%) patients. Imaging manifestations did not differ between the two groups (p > 0.05). Steroids and antibiotics were used to treat colitis in 29 of 34 (85.2%) and 13 of 34 (38.2%) patients, respectively. No patients in group 1 experienced concurrent irAEs, but 5 of 18 (27.8%) of patients in group 2 had other irAEs (p = 0.046).

CONCLUSION

Immune-related colitis occurred in 3.3% of patients receiving ICIs with bowel wall thickening, fluid-filled colon and pancolitis being the most common imaging manifestations. Imaging manifestations did not differ between patients receiving monotherapy or combination therapy. However, concurrent irAEs were significantly observed in patients undergoing combination therapy.

Imaging features of gastrointestinal toxicity in non-small cell lung cancer patients treated with erlotinib: A single institute 13-year experience

OBJECTIVES

To investigate the imaging features of erlotinib-associated gastrointestinal toxicity (GT) in patients with non-small cell lung cancer (NSCLC).

MATERIALS AND METHODS

The electronic medical records of 157 patients with NSCLC who received erlotinib between 2005 and 2018 were retrospectively reviewed to identify patients with GT. Clinical and radiologic evidence of erlotinib-associated GT was evaluated. Imaging findings were cross-referenced with clinical presentation, management, and outcomes.

RESULTS

24 (15%) patients (16 women; median age, 68 years) with radiologic evidence of GT were identified. The median time to detection of GT on imaging was 4.5 months (range: 0-58 months). 3/24 (12.5%) patients had no clinical symptoms, but GT was radiologically identified. Erlotinib-associated GT manifested in the large bowel in either a diffuse (42%) or segmental (58%) pattern. The most common imaging finding was fluid-filled bowel (23/24, 96%).

CONCLUSION

Erlotinib-associated GT was identified in 15% patients with NSCLC. Fluid-filled colon and segmental involvement were the most common imaging manifestations.

Quantifying the decrease in emergency department imaging utilization during the COVID-19 pandemic at a multicenter healthcare system in Ohio

Purpose

To illustrate the change in emergency department (ED) imaging utilization at a multicenter health system in the state of Ohio during the COVID-19 pandemic.

Methods

A retrospective observational study was conducted assessing ED imaging volumes between March 1, 2020, and May 11, 2020, during the COVID-19 crisis. A rolling 7-day total value was used for volume tracking and comparison. Total imaging utilization in the ED was compared with new COVID-19 cases in our region. Utilization was first categorized by modality and then by plain films and computed tomography (CT) scans grouped by body part. CT imaging of the chest was specifically investigated by assessing both CT chest only exams and CT chest, abdomen, and pelvis (C/A/P) exams. Ultimately, matching pair-wise statistical analysis of exam volumes was performed to assess significance of volume change.

Results

Our multicenter health system experienced a 46% drop in imaging utilization (p < 0.0001) during the pandemic. Matching pair-wise analysis showed a statistically significant volume decrease by each modality and body part. The exceptions were non-contrast chest CT, which increased (p = 0.0053), and non-trauma C/A/P CT, which did not show a statistically significant volume change (p = 0.0633).

Conclusion

ED imaging utilization trends revealed through actual health system data will help inform evidence-based decisions for more accurate volume predictions and therefore institutional preparedness for current and future pandemics.

COVID-19 Pandemic Impact on Decreased Imaging Utilization: A Single Institutional Experience

RATIONALE AND OBJECTIVES

Predictive models and anecdotal articles suggest radiology practices were losing 50%-70% of their normal imaging volume during the COVID-19 pandemic. Using actual institutional data, we investigated the change in imaging utilization and revenue during this public health crisis.

MATERIALS AND METHODS

Imaging performed within the 8-week span between March 8 and April 30, 2020 was categorized into the COVID-19 healthcare crisis timeframe. The first week of this date range and the 10 weeks prior were used to derive the normal practice expected volume. A rolling 7-day total value was used for volume tracking and comparison. Total imaging utilization was derived and organized by patient setting (outpatient, inpatient, emergency) and imaging modality (X-ray, CT, Mammography, MRI, Nuclear Medicine/PET, US). The three highest volume hospitals were analyzed. Revenue information was collected from the hospital billing system.

RESULTS

System-wide imaging volume decreased by 55% between April 7 and 13, 2020. Outpatient exams decreased by 68% relative to normal practice. Emergency exams decreased by 48% and inpatient exams declined by 31%. Mammograms and nuclear medicine scans were the most affected modalities, decreasing by 93% and 61%, respectively. The main campus hospital experienced less relative imaging volume loss compared to the other smaller and outpatient-driven hospitals. At its lowest point, the technical component revenue from main campus imaging services demonstrated a 49% negative variance from normal practice.

CONCLUSION

The trends and magnitude of the actual imaging utilization data presented will help inform evidence-based decisions for more accurate volume predictions, policy changes, and institutional preparedness for current and future pandemics.

Utilization of imaging in pancreatic adenocarcinoma patients status post Whipple procedure

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Background: Pancreatic adenocarcinoma (PAC) remains the third leading cause of cancer death in the Western world. The 5-year survival of patients with PAC remains at 4%. Proper utilization of imaging to detect recurrence is necessary in patients who have undergone a Whipple procedure. Currently, Carbohydrate (CA) 19-9 is used for screening and is the only biomarker approved by the Food and Drug Administration (FDA). Sensitivity and specificity range from 79-81% and 82-90%. We intend to evaluate our single institute experience of imaging utilization, CA 19-9, and surgical specimen histopathologic features in the surveillance of PAC patients status post Whipple. Methods: Retrospective analysis of patients with a diagnosis of PAC who underwent imaging status post Whipple from 2008 - 2018 was completed. Cross-sectional imaging and clinical data was obtained from the electronic health record. Results: A total of 197 PAC patients status post Whipple were identified with mean age at diagnosis at 64.4 years and male to female ratio of 1.3. 85 patients were found to have died during treatment. The median survival for these patients was 68 years. Of the patients who died status post Whipple, postoperative CA 19-9 levels within 6 months of the procedure were elevated (p = 0.01). Patients who were found to have stage II to IV PAC at diagnosis were found to have a high CA 19-9 level within 6 months post-Whipple when compared to stage I patients (p < 0.05). Patients who were found to have less than 5 surveillance CTs status post Whipple were found to have higher CA 19-9 levels within 6 months status post Whipple (p < 0.01). There was no difference in number of CT scans between stages. Of those patients who died with stage I or II PAC at diagnosis, a large number were found to have less than 5 surveillance CT studies completed status post Whipple (p < 0.05). Furthermore, a higher cancer stage at diagnosis correlated with worse pathologic differentiation of the cancer (p < 0.001). Conclusions: Post Whipple CA 19-9 correlated with stage, recurrence, number of scans, and survival.

Tyrosine Kinase Inhibitor Therapy for Brain Metastases in Non-Small-Cell Lung Cancer: A Primer for Radiologists

Treatment options for patients who develop brain metastases secondary to non-small-cell lung cancer have rapidly expanded in recent years. As a key adjunct to surgical and radiation therapy options, systemic therapies are now a critical component of the oncologic management of metastatic CNS disease in many patients with non-small-cell lung cancer. The aim of this review article was to provide a guide for radiologists, outlining the role of systemic therapies in metastatic non-small-cell lung cancer, with a focus on tyrosine kinase inhibitors. The critical role of the blood-brain barrier in the development of systemic therapies will be described. The final sections of this review will provide an overview of current imaging-based guidelines for therapy response. The utility of the Response Assessment in Neuro-Oncology criteria will be discussed, with a focus on how to use the response criteria in the assessment of patients treated with systemic and traditional therapies.

Update on Hodgkin lymphoma from a radiologist's perspective

Recent advances in the management of Hodgkin lymphoma, due to new staging and response assessment systems as well as new therapies, have redefined the role of imaging for this disease. The purpose of this article is to provide radiologists with an update on the current role of imaging in Hodgkin lymphoma from diagnosis to assessment of treatment response, in view of the new staging and response assessment system and current treatment strategies.

Overview of imaging findings associated with systemic therapies in advanced epithelial ovarian cancer

PURPOSE

To provide an overview for radiologists of the systemic agents used in the treatment of advanced epithelial ovarian cancer (EOC) and their associated toxicities.

RESULTS

EOC is a common gynecological malignancy, with the majority of patients presenting with advanced stage disease at the time of diagnosis. Although primary cytoreductive surgery and chemotherapy are the principal treatments for EOC, recurrence rates of disease remain high. As several molecular targeted therapies have been developed in the last decade, various novel agents have shown efficacy in the treatment of advanced EOC. Advanced EOC will be discussed by outlining the relevant radiological features of toxicities.

CONCLUSION

Knowledge of the systemic therapies utilized in the treatment of advanced EOC and their associated radiological features is critical in diagnostic image interpretation.

E-cigarette use related lung disease, review of clinical and imaging findings in 3 cases

Electronic-cigarette use (vaping), has gained popularity among the young adult population, causing an alarming rise in electronic-cigarette, or vaping, product use-associated lung injury (EVALI). The specific chemical agent(s) responsible for lung injuries remains to be further investigated, but tetrahydrocannabinol, the active ingredient in marijuana, and vitamin E acetate are involved in most cases. A variety of pulmonary diseases causing different imaging findings have been described with EVALI. The clinical and imaging findings of three cases recently seen in our emergency department are reviewed.

Cancer genome landscape: a radiologist's guide to cancer genome medicine with imaging correlates

The introduction of high throughput sequence analysis in the past decade and the decrease in sequencing costs has made available an enormous amount of genomic data. These data have shaped the landscape of cancer genome, which encompasses mutations determining tumorigenesis, the signaling pathways involved in cancer growth, the tumor heterogeneity, and its role in development of metastases. Tumors develop acquiring a series of driver mutations over time. Of the many mutated genes present in cancer, only few specific mutations are responsible for invasiveness and metastatic potential, which, in many cases, have characteristic imaging appearance. Ten signaling pathways, each with targetable components, have been identified as responsible for cancer growth. Blockage of any of these pathways form the basis for molecular targeted therapies, which are associated with specific pattern of response and toxicities. Tumor heterogeneity, responsible for the different mutation pattern of metastases and primary tumor, has been classified in intratumoral, intermetastatic, intrametastatic, and interpatient heterogeneity, each with specific imaging correlates. The purpose of this article is to introduce the key components of the landscapes of cancer genome and their imaging counterparts, describing the types of mutations associated with tumorigenesis, the pathways of cancer growth, the genetic heterogeneity involved in metastatic disease, as well as the current challenges and opportunities for cancer genomics research.

Immune Checkpoint Inhibitor Therapy-related Pneumonitis: Patterns and Management

In recent years, the use of immune checkpoint inhibitor (ICI) therapy has rapidly grown, with increasing U.S. Food and Drug Administration approvals of a variety of agents used as first- and second-line treatments of various malignancies. ICIs act through a unique mechanism of action when compared with those of conventional chemotherapeutic agents. ICIs target the cell surface receptors cytotoxic T-lymphocyte antigen-4, programmed cell death protein 1, or programmed cell death ligand 1, which result in immune system-mediated destruction of tumor cells. Immune-related adverse events are an increasingly recognized set of complications of ICI therapy that may affect any organ system. ICI therapy-related pneumonitis is an uncommon but important complication of ICI therapy, with potential for significant morbidity and mortality. As the clinical manifestation is often nonspecific, CT plays an important role in diagnosis and triage. Several distinct radiographic patterns of pneumonitis have been observed: (a) organizing pneumonia, (b) nonspecific interstitial pneumonia, (c) hypersensitivity pneumonitis, (d) acute interstitial pneumonia-acute respiratory distress syndrome, (e) bronchiolitis, and (f) radiation recall pneumonitis. Published guidelines outline the treatment of ICI therapy-related pneumonitis based on the severity of symptoms. Treatment is often effective, although recurrence is possible. This article reviews the mechanism of ICIs and ICI therapy complications, with subsequent management techniques and illustrations of the various radiologic patterns of ICI-therapy related pneumonitis.^©RSNA, 2019.

Imaging surveillance of gastrointestinal stromal tumour: current recommendation by National Comprehensive Cancer Network and European Society of Medical Oncology-European Reference Network for rare adult solid cancers

Imaging plays an active role in the surveillance of gastrointestinal stromal tumours (GISTs). Risk stratification schemes, based on size, mitotic count, and anatomical site of origin of the GIST, help in planning preoperative and postoperative imaging strategies especially in determining the frequency and duration of surveillance; however, there is no clear consensus on the optimal imaging strategies in patients with GISTs who are completely cured by surgery and patients who are at risk of recurrence. In addition, current surveillance protocols depend on the resectability of the primary tumour and presence of metastatic disease. The objective of this article is to provide a comprehensive review of the role of the different imaging methods for surveillance of GISTs, focusing on the guidelines recommended by National Comprehensive Cancer Network and European Society of Medical Oncology - European Network for Rare adult solid Cancers, and to propose practical guidelines for surveillance of GISTs for various risk categories.

An update on Burkitt lymphoma: a review of pathogenesis and multimodality imaging assessment of disease presentation, treatment response, and recurrence

Burkitt lymphoma (BL) is a highly aggressive, rapidly growing B cell non-Hodgkin lymphoma, which manifests in several subtypes including sporadic, endemic, and immunodeficiency-associated forms. Pathologically, BL is classically characterized by translocations of chromosomes 8 and 14 resulting in upregulation of the c-myc protein transcription factor with upregulation of cell proliferation. BL affects nearly every organ system, most commonly the abdomen and pelvis in the sporadic form. Imaging using a multimodality approach plays a crucial role in the management of BL from diagnosis, staging, and evaluation of treatment response to therapy-related complications with ultrasound, computed tomography, magnetic resonance imaging, and positron emission tomography playing roles. In this article, we review the pathobiology and classification of BL, illustrate a multimodality imaging approach in evaluating common and uncommon sites of involvement within the trunk and head and neck, and review common therapies and treatment-related complications.

Multidisciplinary approach to immune related adverse events as a potential biomarker: Single institution experience in non-small cell lung cancer

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Background: Immune checkpoint inhibitor (ICI) has emerged as a novel systemic treatment for advanced cancers. As ICI modulates immune signaling pathways by targeting cytotoxic T-lymphocyte antigen-4 (CTLA-4), programmed death-1 (PD-1) or its ligands (PD-L1), a number of immune related adverse events (IRAE) have been reported. Whether IRAE can be a predictor for treatment response has remained controversial and we evaluated the association between IRAE and outcome. Methods: Retrospective chart and Computed Tomography (CT) review of patients with stage IV NSCLC treated with single agent Nivolumab or Pembrolizumab was performed. Any abnormalities in lab values, imaging finding or clinical signs to suggest pneumonitis, thyroiditis, hepatitis, nephritis, pancreatitis, colitis, pleural/pericardial effusion, arthritis or myositis between the start of the therapy and six months after the end of the therapy were recorded in a binary fashion. Abnormality in the setting of baseline abnormal values or due to clear cause other than IRAE has been excluded. Overall survival as well as best response based on RECIST 1.1 was also recorded. Results: 88 patients treated between January 2012 and March 2017 were identified. 62 patients, 42 patients and 50 patients demonstrated abnormalities in lab values, CT and clinical signs, respectively. When each subcategory was correlated with OS using ANOVA, thyroid function test abnormality (n = 15) and liver function test abnormality (n = 36) were associated with increased OS (p = 0.021, p = 0.038, respectively). Interestingly, elevated C-reactive protein was associated with decreased OS (p = 0.01). Initially, each score was given depending upon the number of abnormal categories (lab, imaging or clinical signs), ranging from score 0 (n = 7), 1 (n = 19), 2 (n = 33) and 3 (n = 17). Increased score was associated with increased OS (p = 0.03). For more detailed analysis, we came up with scoring system which sums up each score given for any abnormality in each subcategory. On Multivariate analysis, there was significant positive correlation between higher score and increased OS (p = 0.001). Conclusions: We have identified several IRAE parameters that were associated with increased OS. Furthermore, scoring system used in the study which encompassed clinical, radiologic and laboratory aspect, showed positive association with increased OS, indicating IRAE’s potential role as a biomarker.

Sonographic and histopathologic characteristics of MMR-deficient endometrial cancer

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Background: Mismatch repair (MMR) deficiency has emerged as a key biomarker in endometrial cancer with roles in prognosis and guiding therapy. However, the differences of sonographic features between MMR-deficient and MMR-proficient endometrial cancers at initial presentation have not been established. Methods: Transvaginal ultrasound studies of 103 endometrial cancers (60 MMR-deficient, 43 MMR-proficient) at initial presentation were retrospectively analyzed by two experienced radiologists. Histopathologic findings and sonographic features of endometrial morphology recorded according to IETA terminology were compared using Likelihood Ratio Chi-Square and Mann–Whitney U tests. Results: The MMR-deficient group comprised of 90% and the MMR-proficient group of 100% endometrioid subtypes. The following sonographic features were statistically different between MMR-deficient (age 45-95) and MMR-proficient (age 45-83) groups: uniform endometrial echogenicity/pattern, non-uniform endometrial echogenicity/pattern, endometrial midline morphology, presence of a bright edge, and endomyometrial junction morphology. Ultrasound findings of endometrial thickness, synechiae, intracavitary fluid, color Doppler score, and vascular pattern were not significantly different. Statistically significant differences in pathology features included FIGO grade, myometrial invasion, and lymphovascular invasion, while FIGO stage showed no difference. Conclusions: MMR-deficient endometrial cancer is characterized by several statistically different ultrasound and histopathologic features on initial presentation compared to MMR-proficient endometrial cancer.[Table: see text]

Role of ultrasound contrast agent in a tertiary cancer center: Experience in 75 patients with liver biopsy

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Background: The sensitivity of B-mode ultrasound (US) in detecting hepatic lesions has been reported to be between 55-85%. A recently FDA approved US contrast agent has been shown to increase the detectability of liver lesions; yet, there is paucity of knowledge regarding its application in US guided biopsies. The aim of this study was to determine accuracy and applicability of contrast enhanced US (CEUS) guided biopsies of liver lesions in cancer patients. Methods: A prospective registry of 75 patients (M = 54%, F = 46%, Age: 63y±14), that underwent CEUS guided liver biopsy in 2017-2018, were retrospectively reviewed. The decision to apply US contrast was made based on pre-procedural and intra-procedural clinical findings. Lesions with negative biopsy results were reviewed in follow up imaging to determine any evidence of potential positive malignancy. Results: History of renal failure that precluded application of iodinated IV contrast was the main pre-procedural indication (17%). Intra-procedural indications included: poor visualization of lesions in B-mode US (78%), targeting enhancing part of lesions (necrotic, post ablation or cystic) (16%), and lesion selection (6%). Diameter of the lesions were ≤ 20mm in 46% of patients. Biopsy results were positive in 50 patients, and included 32% primary liver tumors (hepatocellular carcinoma and cholangiocarcinoma) and 68% metastasis (pancreas: 24%, breast: 12%, GI tract: 10%, lung: 8% and other: 14%). Of the 25 patients with negative biopsy results, 6 did not have follow up imaging and 3 were later found to have positive malignancy (Negative predictive value: 84%, accuracy: 96%). Genomic sequencing was established in 34% of the patients. Based on the biopsy/genomics results, patients underwent systemic treatment (56%), locoregional treatment (16%), combination (6%) or surgery (2%). 10% of patients selected hospice care and 10% lost follow up. Conclusions: CEUS increases the accuracy of US guided biopsies of focal liver lesions, by improving visualization, targeting viable parts and also in patients with renal failure, or small lesions. Findings from these biopsies could improve management of cancer patients by categorizing them into different treatment groups.

Incidence and characteristics of emergency department presentations during immune checkpoint inhibitor therapy

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Background: Immune checkpoint inhibitors (ICIs) have emerged as a novel class of anticancer agents with unique response and toxicity profiles. Oncology patients undergoing ICI therapy can present acutely with cancer- or treatment-related complications, but knowledge of these acute clinical presentations is limited. The objective of this study was to investigate the features of emergency department (ED) presentations of patients undergoing ICI therapy. Methods: A retrospective chart review was performed of 1044 adult oncology patients at a single institution from 2010-2018 who underwent treatment with one or more ICI. The number of patient visits to the ED during and up to one month following ICI treatment was recorded, in addition to various clinical and demographic data. These data were compared based on stratification by number of ED visits (0 visits, 1 visit, or ≥2 visits) using Likelihood Ratio Chi-Square and Mann–Whitney U tests. Results: Mean age for the 1044 patients receiving ICI therapy was 64±13 years, with 57% males and 43% females. Primary cancer distribution included 42.0% lung, 24.2% melanoma, 6.9% head & neck, 5.1% kidney, 4.0% bladder, and 17.8% other malignancy. 83.4% of patients were treated with a single ICI, 14.9% with 2 ICIs, and 1.2% with 3-4 ICIs. 56.0% of patients had no ED visits during their treatment duration, 27.0% had 1 ED visit, and 17.0% had ≥2 ED visits. Patients with lung, kidney, and bladder cancer were more likely to present to the ED (p = < 0.001). Black ethnicity was the only demographic feature associated with more ED visits (p = 0.017). Patients receiving ≥2 ICIs or monotherapy with nivolumab, pembrolizumab, or atezolizumab more frequently presented to the ED compared to other ICIs (p = < 0.001). Patients with 1 or ≥2 ED visits had longer durations of ICI therapy (136±12 days and 216±15 days, respectively) compared to patients with no ED visits (127±8 days) (p = < 0.001). Patients with no ED visits also demonstrated better overall survival (p = < 0.001). Conclusions: More frequent ED visits during ICI therapy is statistically associated with several key clinical factors, including primary cancer type, ethnicity, specific ICI agent, ICI therapy duration, and overall survival.

Erlotinib monotherapy in the treatment of advanced non-small cell lung carcinoma: A single center experience with 187 patients from 2005-2018

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Background: Inhibition of epidermal growth factor receptors (EGFR) bearing somatic mutations in the tyrosine kinase domain is an important molecular target in the treatment of advanced non-small cell lung carcinoma (NSCLC). As such, first generation tyrosine kinase inhibitors such as erlotinib have been adopted as standard of care in the treatment of EGFR mutation positive advanced NSCLC. Herein we describe our experience with erlotinib monotherapy since its approval for clinical use in the United States in late 2004. Methods: A retrospective analysis of 187 patients with a diagnosis of NSCLC who underwent erlotinib monotherapy from 2005-2018 was performed. Clinical variables including patient age, disease stage, EGFR genomic status, adverse events and survival were analyzed. Likelihood Ratio Chi-Square test was applied and statistical significance was set to p < 0.05. Results: Among all patients who received erlotinib monotherapy (n = 187), treatment duration longer than 3 months was associated with EGFR mutant status (p < 0.001), increased rates of repeat lung biopsies (p < 0.002) as well as pulmonary (p = 0.008), gastrointestinal (p = 0.005) and cutaneous adverse events (p = 0.005). Subgroup analysis based on EGFR genomic status (n = 71) revealed that EGFR mutation positive patients remained on erlotinib for at least three months at a higher rate than wildtypes (p < 0.001), but also sustained higher rates of lung re-biopsy (p = 0.0121) and concomitant gastrointestinal (diarrhea) and cutaneous (acneiform, maculopapular rashes) adverse events (grades 1-3) (p = 0.003). EGFR mutant status was associated with increased rates of survival of 12 months or greater since the initiation of erlotinib (p < 0.001). Conclusions: Erlotinib monotherapy duration greater than 3 months and EGFR mutant status are associated with significantly higher rates of repeat lung biopsies and gastrointestinal and cutaneous adverse events. EGFR mutant status is further associated with survival of greater than 1 year.

Cross-sectional imaging utilization for EGFR, EML/ALK, and KRAS mutant non-small cell lung cancer

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Background: Targeted therapies for specific genotypic subsets of non-small cell lung cancer (NSCLC) patients have had drastic effects on overall survival at all stages. However, the NCCN guidelines have remained relatively static with respect to initial evaluation, staging, response, and imaging surveillance. In this study we evaluated 3 cohorts of patients, two with a specific targetable mutation (EGFR and EML/ALK) and one without a targetable mutation available (KRAS), for cross-sectional imaging utilization in the initial presentation and surveillance of disease. Methods: Retrospective analysis of imaging studies for patients with NSCLC who received treatment and follow-up between 2007 and 2018 was completed. CT, MRI, and PET imaging data were collected from the picture archiving system. Additional clinical data collected included age, race, smoking history, and dates of diagnosis and death. Results: 153 NSCLC patients were identified with positive EGFR (n = 65), EML/ALK (n = 15), or KRAS (n = 73) mutations. Patients averaged an age of 64 at diagnosis, with a distribution of 38% male, 62% female, 29% current smokers, 48% former smokers, and 23% never smokers. Mean duration between date of diagnosis and death for each group was 1099 ± 770 days (EGFR), 1139 ± 924 days (EML/ALK), and 542 ± 602 days (KRAS). Compared to the KRAS group, the EML/ALK group had higher utilization of chest CTs (p = 0.044), pulmonary embolus CTs (p = < 0.001), abdominopelvic CTs (p = 0.004), and PET CTs (p = 0.006). The EGFR group had significantly fewer pulmonary embolus CTs (p = < 0.001) and higher numbers of non-brain MRIs (p = 0.004) compared to the KRAS group, as well as fewer abdominopelvic CTs (p = 0.034) compared to the EML/ALK group. Conclusions: Different genotypes of NSCLC with available targetable mutations show statistically significant differences in cross-sectional imaging utilization compared to those without targetable mutations. [Table: see text]

Appendicular skeleton MRI in multiple myeloma: Utility and clinical implications

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Background: Skeletal MRI plays an integral role in diagnosing Multiple Myeloma and, in many cases, dictates need for treatment. While axial skeleton MRI is performed with established clinical utility, appendicular MRI is performed sparingly with utility not fully ascertained. We aim to assess the utility of appendicular MRI while establishing clinical factors which may predict outcomes. Methods: 107 appendicular skeleton MRIs were included for retrospective analysis over 15 years. No statistically significant age or gender related variability was noted. Variables including patient age, diagnosis, disease stage/activity, indication, transplant status, MRI result, treatment course, and survival were analyzed via Likelihood Ratio Chi-Square test or logistic regression. Results: Patient age, disease stage, presence of active marrow disease, history of relapse, and presence of axial or appendicular osseous disease were found to have a statistically significant correlation with MRI result. Disease stage and presence of active hematologic disease correlated with post MRI management alterations. Additionally, presence of active hematologic disease at time of MRI demonstrated a correlation with post MRI management strategy. Furthermore, MRI result was a predictor of downstream development of additional skeletal lesions. Interestingly, MRI result was not a predictor of survival. Conclusions: Several parameters may be used to determine a clinical pre-test probability of appendicular disease at the time of MRI. In addition, these clinical parameters and MRI results correlate with trends in subsequent patient treatment strategies. [Table: see text]

Major lab abnormalities as biomarkers in patients treated with immune checkpoint inhibitors: A single institution study of 1044 patients

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Background: Over the past decade, immune checkpoint inhibitors (ICI) have gained increased importance in modern cancer treatment. In this study we investigate the relationship between major lab abnormalities and ICI treatment duration. Methods: 1044 patients receiving ICIs between 2010-2018 were included in this retrospective study. The following parameters were analyzed: gender, age, race, cancer type, lab abnormalities for kidneys, pancreas, liver and thyroid, and treatment duration. Lab abnormalities were grouped and used in a scoring-system (0: no lab abnormalities, 1: one abnormal parameter, and 2: two or more abnormal parameters). For statistical analysis, Likelihood Ratio Chi-Square and Mann-Whitney U tests were applied. Results: The patient cohort included 386 female and 473 male patients with a mean age of 67.8±12.5 years. Primary cancer distribution included lung cancer (n = 439), melanoma (n = 253), head and neck cancer (n = 72), renal cancer (n = 53), lymphoma (n = 33), bladder cancer (n = 42), breast cancer (n = 28), and other malignancies (n = 124). Patients received one (n = 875) or a combination (n = 169) of ICIs for a mean of 152.2±215.8 days, with highest counts for nivolumab (n = 465), pembrolizumab (n = 275), ipilimumab (n = 95), and nivolumab & ipilimumab (n = 130) and others (n = 79). Patients with higher values in the scoring-system or more lab abnormalities had significantly longer treatment duration (Score 0: 107±170, 1: 159±199, 2: 244±282 days, p < 0.001). Furthermore, patients treated with ICI combination therapy demonstrated higher scores (1.1±0.8 vs. 0.5±0.7, p < 0.001) and longer treatment durations (236±304 vs. 127±175 days, p < 0.001). Patients with scores of ≥1 in the scoring system had improved overall survival (451±475 vs. 369±526 days, p < 0.001), and patients treated with two or more ICIs lived longer (563±524 vs. 377±496 days, p = 0.003). Therapy duration was also positively correlated with survival (Spearman’s rho correlation r = 0.64, p < 0.001). Conclusions: Our current exploratory study demonstrates associations between major lab abnormalities and both treatment duration and overall survival in patients treated with immune checkpoint inhibitors.

Association between age, risk of severe (Grade 3-4) immune-related adverse events (sirAE), and mortality in patients receiving immune checkpoint inhibitors (ICI)

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Background: ICI are used in the treatment of advanced malignancies with on-target adverse events of non-tumor inflammation. Many studies have shown conflicting safety results with regard to older vs younger adults where 65 - 70 years of age has been used as the discrete cut-off variable. We sought to investigate the incidence and the association between age and sirAE using age as a continuous variable at a large tertiary cancer center. Methods: Under IRB approval, our ICI outcomes database was queried for those who were hospitalized and received an immunosuppressant. Charts were individually reviewed to identify hospital admissions due to a sirAE (a grade 3 or 4 AE per CTCAE v4.0) and all-cause mortality at 12 months post ICI start. Non-linear analyses using Cox regression models with penalized smoothed splines were performed to explore association between age and sirAE. Results: There were 6.3% of 1043 patients who had a sirAE, and a total of 83 sirAE events. Mean age was 64± 13 years.ICI included anti-PD-1 (77.8%), anti-CTLA-4 (18.1%), and anti PD-L1 (4.1%). Pts with sirAE had a thirty day, and one year mortality of 12% and 49%, respectively. These events included: colitis (30.1%), pneumonitis (16.9%), hepatitis (10.8%), hypophysitis (6%), and thyroiditis (6%). There were 5 neurologic and 4 myocarditis/myositis sirAEs. The 1-year cumulative incidences of sirAE and all-cause mortality were 8.4%, and 48%, respectively. Spline analysis showed a U-shaped association between age and hazard of sirAE (P = 0.03). Every 10 years above age 60 was associated with increased sirAE (HR 1.65 [1.14-2.40], P = 0.008), while every 10 years below 60 was associated with increased sirAE (HR 1.50 [0.99-2.27], P = 0.054). However, age and mortality showed a linear association (P = 0.003). Conclusions: We observed a curvilinear U-shaped association between age and the risk of sirAE, with minimum risk at age of 60, compared with a linear relationship between age and mortality. Further studies are needed to understand this relationship and its impact on outcomes, clinical care, and underlying host immune context.

Radiologic imaging utilization of small cell lung cancer staging and treatment

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Background: Over the past several decades, first line therapy recommendations for small cell lung cancer (SCLC) have remained relatively unchanged. Additionally, the National Comprehensive Cancer Network (NCCN) guidelines regarding initial evaluation, staging, response assessment, and surveillance of SCLC have also remained relatively static. To evaluate radiologic imaging utilization for SCLC, we reviewed patients imaging data and assessed their association with staging, metastatic sites at presentation, overall survival, and other clinical factors. Methods: Retrospective analysis of patients with a diagnosis of SCLC that received treatment and follow up from 2003 through 2018 was completed. Cross-sectional radiology imaging data including computed tomography of the chest abdomen and pelvis (CT CAP), magnetic resonance imaging (MRI), and positron-emission tomography (PET) was obtained from the picture archiving and communication system (PACS) and clinical data including age, sex, race, smoking history, extensive/limited stage, and metastatic sites at presentation was obtained from the electronic medical record. Results: The average age at diagnosis for all SCLC patients (n = 518) from 2003 to 2018 was 66 with a male to female ratio of 0.89. The mean overall survival of all SCLC patients was 410.2 days with extensive (n = 371) stage = 312.5 days and limited (n = 147) stage = 718.8 days. We found a significantly increased number of patients less than age 66 presented with brain metastasis compared to those greater than age 66 ( P< 0.01). The absolute total number of CT CAP and PET studies was significantly increased in limited stage patients compared to extensive stage ( P< 0.001). However, when accounting for mean overall survival, extensive stage patients received a significantly increased number of CT Brain ( P< 0.05), PET ( P< 0.01), CT CAP, and MRI Brain ( P< 0.001) studies compared to limited stage per year. Conclusions: Overall radiology imaging utilization is significantly different between limited and extensive stage SCLC patients over the past 15 years.

Comparison of panendoscopy directed biopsies with percutaneous and image-guided biopsies during immune checkpoint inhibitor therapy

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Background: Immune checkpoint inhibitors (ICI) have been shown to be helpful in the treatment of a several cancers. Response to ICI therapy is varied. The goal of this study was to examine the role of pan-endoscopy guided biopsies as well as image-guided and percutaneous biopsies as a means to tailor treatment regimens for patients receiving ICI therapy. Methods: A retrospective chart review was performed on oncology patients at a single institution from 2010 from 2018 undergoing treatment with ICI (n = 1044). Patients undergoing biopsies within the treatment period and up to one month following conclusion of treatment were analyzed and separated into a pan-endoscopy guided biopsy cohort or image-guided/percutaneous biopsy cohort. Data regarding biopsy results and subsequent treatment plans was then gathered and compared. Results: 5.3% of patients underwent pan-endoscopy guided biopsy (n = 55). 6.0% of patients underwent image-guided/percutaneous biopsy (n = 63). The most common endoscopic procedures included EGD 42.6%, bronchoscopy 38.9%, and flexible sigmoidoscopy/colonoscopy 20.4%. The most common image/percutaneously sampled tissues included skin/soft tissue 24.6%, lymph nodes 19.7%, and liver 16.4%. Breakdown of treatment complications in the pan-endoscopy group included pneumonitis 3.2%, inflammatory or infectious esophagitis 6.4%, or colitis 4.3%. Treatment complications in the image guided/percutaneous group included skin reactions 2.2% and inflammatory mediastinal changes 1.1%. Conclusions: In our cohort, Pan endoscopy and image guided/percutaneous biopsies were successfully performed along multiple cancer cell lines and helped in the decision making process.[Table: see text]

Overview of systemic treatment in recurrent and advanced cervical cancer: a primer for radiologists

Imaging has a central role in surveillance of cervical cancer, guiding decision on when to initiate treatment for recurrent disease and to guide management in advanced cervical cancer. Due to the increased availability of pelvic radiation therapy, the rate of atypical presentation of recurrent disease has increased. Simultaneously, the array of systemic therapies now available for advanced cervical cancer has considerably expanded in the last few years, with therapies now available in mid and low-income countries. While pelvic recurrences are amenable of loco-regional treatment, recurrent disease may present with metastases to the thoracoabdominal organs, lymph nodes, bones, skin and brain, for which systemic treatment represent the standard of care. Besides combined chemotherapy regimens, alternative chemotherapies, biosimilars and immune checkpoint inhibitors are now available, each associated with a definite pattern of response and toxicity. In this review, after describing the typical and atypical presentations of recurrent and advanced cervical carcinoma on cross-sectional imaging, we will discuss systemic treatment for recurrent or advanced disease and their associated radiographic sequelae, in light of the newly available therapies.

Serum tumor markers and testicular germ cell tumors: a primer for radiologists

Serum tumor markers (STMs) play a critical role in the diagnosis, staging and follow-up of both seminomatous and nonseminomatous testicular germ cell neoplasms. Levels of alpha-fetoprotein (AFP), human chorionic gonadotropin (HCG), and lactate dehydrogenase (LDH), especially those measured after orchiectomy, also have implications for patient prognosis. Given that testicular germ cell tumors represent the most common solid tumor in men aged 20-34, radiologists must have familiarity with the clinical utilization and implications of these STMs. This article will review the classical patterns of STM elevation most commonly seen in pure seminomatous and nonseminomatous germ cell tumors while also providing case-based examples highlighting the importance of STM correlation with imaging. The role of STMs in clinical staging and disease surveillance will also be discussed.