Radiopaedia Blog

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November 8 is the International Day of Radiology, an event which aims to promote awareness of the amazing work done by Radiologists around the world. 

The 2013 theme is Lung Imaging and so at Radiopaedia.org we have decided to celebrate with a chest x-ray quiz! 

  • Can you correctly identify the abnormalities?
  • How do you compare to a radiologist?
  • View annotated answers to learn what a radiologist would see.
  • Share the quiz with your friends to help spread the word!

Here's what a Radiologist would've seen...

Woman B has a lung cancer hiding in the apical region often termed a Pancoast tumor (green arrow). These can be very difficult for the untrained eye to spot and this area is an important "check area" for radiologists when interpreting chest x-rays.

Woman A has a breast shadow on the right (white arrow) but does not have one on the left because she has had a mastectomy for breast cancer. Such asymmetric density can cause an inexperienced film reader to mistakenly diagnose a lung abnormality.  

Patient A has a small punctured lung (aka pneumothorax) which can be a difficult but very important diagnosis to make. Air is seen outside the lung with a thin line representing the lung margin, known as the pleura, evident in the upper chest (green arrow).

Patient B has fibrosis in their right lung apex (white arrow) which has lead to a reduction in lung volume with elevation of the diaphragm on that side. This was a case of radiation induced fibrosis.    

Patient A has multiple calcified pleural plaques on the surface of the lung which is a hallmark of asbestos exposure. These are classically described as being geographic, looking somewhat like continents on a world map (green shading). On the diaphragm they appear as thick white lines (green arrow).

Calcified pleural plaques are themselves benign and do not indicate asbestosis (pulmonary fibrosis due to asbestos) or mesothelioma although the patient would be at increased risk of developing these deadly conditions.

Patient B has a fungal infection within dilated bronchi in the right upper lobe of the lung (white arrow) known as allergic bronchopulmonary aspergillosis. This occurs most often in asthmatics and produces what is described as a 'finger in glove' appearance.     

 

 

5th Nov 2013 08:02 UTC

Radiology Quiz #6

Which church-related sign is seen in this 2yo boy? What is the diagnosis?

*** Updated 9th Feb 2015 ***

Radiologists find satisfaction in detecting abnormalities and making diagnoses. However, our judgment is required when we identify incidental findings, especially if the cost of workup is high and the benefit of workup may be low. The incidental thyroid nodule is a scenario in which we need to carefully consider the consequences of our report and recommendations (1).

A few facts about incidental thyroid nodules
  1. Incidental thyroid nodules are common whereas thyroid cancer is uncommon. 16-18% of patients will have an incidental nodule seen on CT and MRI (2,3). Only 1.6% of patients with one or more thyroid nodules will actually have thyroid cancer (4).
  2. Costs of workup of incidental thyroid nodules add up. The 2012 USA Medicare reimbursement totals over $1000 for the following steps in the workup of a thyroid nodule: office consultation, diagnostic ultrasound, US guided FNA and cytopathology (5). Other costs to consider are patient anxiety, time lost and potential complications of diagnostic lobectomy.

  3. Small thyroid cancers are typically indolent and most patients die with rather than of thyroid cancer 6,7. More than 96% of thyroid cancers are papillary and follicular cancers (well-differentiated) and have an excellent prognosis (8).

  4. The observed incidence of thyroid cancer is increasing exponentially and has doubled in the last decade (8). Mortality has not changed significantly despite this trend which raises concern that the apparent increase in incidence is due to overdiagnosis of subclinical thyroid cancers (9).

How should we be reporting thyroid nodules on CT and MRI?

Reporting practices are highly variable among radiologists which really highlights the need for clear practice guidelines (10). The American College of Radiology has formed an Incidental Thyroid Nodules Committee, and published a white paper (15) based on the Duke 3-tiered system reporting guidelines for incidental thyroid nodules on CT and MRI.  

The Duke 3-tiered system guidelines have now been studied in several cohorts. The following is a summary of the findings.

  • The 3-tiered system reduces FNA rate for incidental thyroid nodules by 34-46% (3,11)
  • The 3-tiered system captures the same proportion of thyroid cancers compared to a 1cm size cutoff (3)
  • Incidental thyroid cancers missed by the 3-tiered system represent 1% of all thyroid cancers having surgery and are small papillary cancers that are lower in stage (12)
  • The 3-tiered system results in a net 54% reduction in ITN reported in the impression section of the report (13). 

​The decision to workup ITN should also account for the patients’ comorbidities and life expectancy. In patients with significant comorbidities and advanced age, the diagnosis and treatment of thyroid cancer is unlikely to alter their quality of life or life expectancy. A high proportion of patients having imaging are older and/or have comorbidities.  Grady, et al. evaluated the indication for imaging in patients with ITNs reported on CT and MRI and found 52% are imaged for a known malignancy and 17% are imaged for vascular disease (14). 

 

Download free quick reference PDF of the guidelines here.

ACR white paper (2015) available here.

 

 
Dr Jenny Hoang, MBBS FRANZCR

Associate Professor of Radiology and Radiation Oncology at Duke University Medical Center in Durham NC, United States of America. Dr Hoang has particular expertise in the area of thyroid nodules and has several papers currently in press.  

 

 

References

1. Hoang JK, Raduazo P, Yousem DM, Eastwood JD. What to do with incidental thyroid nodules on imaging? An approach for the radiologist. Semin Ultrasound CT MR 2012;33:150-157

2. Yousem DM, Huang T, Loevner LA, Langlotz CP. Clinical and economic impact of incidental thyroid lesions found with CT and MR. AJNR Am J Neuroradiol 1997;18:1423-1428

3. Nguyen XV, Choudhury KR, Eastwood JD, Lyman GH, Esclamado RM, Werner JD, Hoang JK. Incidental Thyroid Nodules on CT: Evaluation of 2 Risk-Categorization Methods for Work-Up of Nodules. AJNR Am J Neuroradiol 2013;34:1812-1817

4. Smith-Bindman R, Lebda P, Feldstein VA, Sellami D, Goldstein RB, Brasic N, Jin C, Kornak J.  Risk of thyroid cancer based on thyroid ultrasound imaging characteristics: results of a population-based study. JAMA Intern Med 2013;173:1788-1796

5. Centers for Medicare and Medicaid Services UDoHaHS. Physician Fee Schedule Search. http://www.cms.gov/apps/physician-fee-schedule/ (accessed December 2012). 

6. Ito Y, Miyauchi A, Inoue H, Fukushima M, Kihara M, Higashiyama T, Tomoda C, Takamura Y, Kobayashi K, Miya A. An observational trial for papillary thyroid microcarcinoma in Japanese patients. World journal of surgery 2010;34:28-35

7. Harach HR, Franssila KO, Wasenius VM. Occult papillary carcinoma of the thyroid. A "normal" finding in Finland. A systematic autopsy study. Cancer 1985;56:531-538

8. Hoang JK, Roy Choudhury K, Eastwood JD, Esclamado RM, Lyman GH, Shattuck TM, Nguyen XV. An Exponential Growth in Incidence of Thyroid Cancer: Trends and Impact of CT Imaging. AJNR Am J Neuroradiol 2013

9. Davies L, Welch HG. Increasing incidence of thyroid cancer in the United States, 1973-2002. JAMA 2006;295:2164-2167

10. Hoang JK, Riofrio A, Bashir MR, Kranz PG, Eastwood JD. High Variability in Radiologists' Reporting Practices for Incidental Thyroid Nodules Detected on CT and MRI. AJNR Am J Neuroradiol 2014;35:1190-1194

11. Hobbs H, Bahl M, Nelson RC, Kranz PG, Esclamado RM, Wnuk N, Hoang JK. JOURNAL CLUB: Incidental Thyroid Nodules Detected at Imaging: Can Diagnostic Workup Be Reduced by Use of the Society of Radiologists in Ultrasound Recommendations and the Three-Tiered System? AJR American journal of roentgenology 2014;202:18-24

12. Bahl M, Sosa JA, Eastwood JD, Hobbs HA, Nelson RC, Hoang JK. Using the 3-Tiered System for Categorizing Workup of Incidental Thyroid Nodules Detected on CT, MRI or PET/CT: How Many Cancers Would be Missed? In press. . Thyroid : official journal of the American Thyroid Association 2015

13. Tanpitukpongse PT, Sosa JA, Grady A, Eastwood JD, Roy Choudhury K, Hoang JK. Incidental Thyroid Nodules on CT and MRI: Discordance between What We Report and What Receives Workup. Submitted for review and under revision 2014; Oral abstract presentation at ASNR 2014, Montreal, CA. 2014.

14. Grady A, Sosa JA, Tanpitukpongse TP, Roy Choudhury K, Gupta R, Hoang JK. Radiology Reports for Incidental Thyroid Nodules on CT and MRI: High Variability Across Subspecialties. In: AJNR Am J Neuroradiol, in press, 2015

15. Hoang JK, Langer JE, Middleton WD et-al. Managing Incidental Thyroid Nodules Detected on Imaging: White Paper of the ACR Incidental Thyroid Findings Committee. J Am Coll Radiol. 2015;12 (2): . doi:10.1016/j.jacr.2014.09.038 - Pubmed citation

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