Imaging Pearls ❯ July 2025
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3D and Workflow
- “Our Leadership and People Teams are dedicated to creating an environment in which all team members feel cared for, included, and empowered to reach their fullest potential. We strive to create a sense of belonging through our Culture Committee. This committee designs monthly programming to celebrate diversity, equity, inclusion, and belonging through events and panels that feature and celebrate HCPs from underrepresented groups. We also dedicate resources to promote employee health and wellness.”
Team Building and Employee Satisfaction-How We Do It.
Spear T, Chu LC, Fishman EK, Rowe SP.
J Am Coll Radiol. 2025 Jun;22(6):704-706. - “These lessons can be applied beyond the boundaries of our company to any environment, but especially to medicine. By adopting an employee-first mind-set, HCPs can improve the health, well-being, and development of their teams. By encouraging HCPs to take care of themselves and providing them with resources and opportunity to do so, you create an environment in which your team can perform at a higher level. Creating opportunities for learning and growth within your organization will lead to higher engagement from your employees, which will translate to a better patient experience.”
Team Building and Employee Satisfaction-How We Do It.
Spear T, Chu LC, Fishman EK, Rowe SP.
J Am Coll Radiol. 2025 Jun;22(6):704-706. - In his book The Cleveland Clinic Way, Toby Cosgrove explains the value of collaboration and creativity in medicine: “True creativity in medicine doesn’t take place within disciplines so much as it does at the boundaries between disciplines. Increasing opportunities for collaboration among specialists and instilling a culture that encourages creativity will lead to the creation of exciting new treatments that save lives” [3]. By communicating and working as a team, HCPs can dramatically reduce the burden of administrative tasks and wasted resources (ie, tests and laboratory work are run multiple times by multiple offices) while also leveraging the unique expertise of each team member in developing the best possible solutions. Taking a collaborative approach to the treatment of patients drives patient outcomes both via new discovery and greater efficiency.
Team Building and Employee Satisfaction-How We Do It.
Spear T, Chu LC, Fishman EK, Rowe SP.
J Am Coll Radiol. 2025 Jun;22(6):704-706. - Follow your dreams and aim high. If you want to be successful in radiology, you need to build on strong foundations be it in clinical, research, or the educational domain. Do not let the doomsayers make you compromise your long-term goals. Treat your customers well and understand their needs. If your customers are happy, then your company will likely be successful. In radiology, we have many customers, but our most important customers are our patients. We need to make sure they are happy so that they will be active partners in sharing our team’s vision. Treat your radiologic technologists and radiologic nurses well as they too impact how people see you and your vision.
Team Building and Employee Satisfaction-How We Do It.
Spear T, Chu LC, Fishman EK, Rowe SP.
J Am Coll Radiol. 2025 Jun;22(6):704-706. - “We seem so busy in the present that the future seems a lifetime away. However, it is only by planning for the future that we can guarantee long-term success. In planning ahead, be bold and challenge yourself and the common thinking. Invest in talented human resources, invest in state-of-the-art equipment, and keep abreast of current literature. Enjoy the ride. Whether you are in business or medicine, the job will occupy a high proportion of your time and will often help identify who you really are and what you truly value. It may be a long ride, so enjoy the ups and downs of your journey.”
Team Building and Employee Satisfaction-How We Do It.
Spear T, Chu LC, Fishman EK, Rowe SP.
J Am Coll Radiol. 2025 Jun;22(6):704-706.
Adrenal
- Intracellular lipid is characteristic of the majority of adenomas and can be identified by low attenuation on non-contrast CT or signal loss on chemical shift MR imaging. However, hepatocellular carcinoma (HCC) and clear-cell subtype renal cell carcinoma (ccRCC)—along with their metastases—are also known to contain intracellular fat. In fact, this is utilized as an ancillary feature favoring HCC in the Liver Imaging Reporting & Data System and in the calculation of the clear cell likelihood score in RCCs, respectively. Therefore, in patients with known HCC or ccRCC, adrenal nodules should be assessed with caution, as microscopic fat does not exclude the possibility of metastasis.
Pitfalls in Genitourinary Imaging
Mark D. Ehrhart, Steven C. Eberhardt
Radiol Clin N Am 2025 (in press) - However, lipid-poor adenomas may lack sufficient intracellular/microscopic fat to yield low enough density on unenhanced CT or sufficient signal drop on chemical shift MR imaging to make the diagnosis. While this generally carries minimal clinical impact due to their benign nature, pheochromocytomas—by contrast—can have overlapping appearance and be functionally significant. On MR imaging, pheochromocytomas are classically T2 hyperintense and avidly enhancing, but classic findings are only present in one-third of cases. Due to this variability, radiologists may mistakenly omit pheochromocytoma from the differential diagnosis. Identification is critical prior to surgical intervention to prevent potential hypertensive crisis and radiologists should consider including pheochromocytoma in the differential diagnosis of any adrenal nodule that lacks diagnostic features of another entity.
Pitfalls in Genitourinary Imaging
Mark D. Ehrhart, Steven C. Eberhardt
Radiol Clin N Am 2025 (in press)
Cardiac
- “Pulmonary artery (PA) aneurysms are rare vascular abnormalities with potentially life-threatening complications such as rupture, massive hemoptysis, and pulmonary infarction. These conditions are often asymptomatic and incidentally detected but can present with nonspecific symptoms like cough, dyspnea, or hemoptysis in an emergency setting. Multidetector CT pulmonary angiography (CTPA) has outshone traditional angiography, supplemented by advanced 3D post-processing techniques such as maximum intensity projection (MIP), volumetric rendering (VR), and cinematic rendering (CR) techniques, playing a pivotal role in diagnosis and management of PA aneurysms.”
CT imaging of pulmonary artery aneurysms in the emergency department - What you need to know.
Yasrab M, Crawford CK, Fishman EK, Kawamoto S.
Curr Probl Diagn Radiol. 2025 May 17:S0363-0188(25)00094-5. - “Pulmonary artery (PA) aneurysms are rare vascular abnormalities involving the PA or its branches, with an incidence of 0.007 % according to classical autopsy series. In an emergency setting, they can pose a risk of rupture and massive hemoptysis, which itself has a mortality rate of over 50 % if untreated. Ten percent of massive hemoptysis is due to PA pathology, most commonly aneurysms and pseudoaneurysms. True PA aneurysms are dilatations involving all three layers of the vessel, whereas pseudoaneurysms are outpouchings contained by the innermost layer, with a comparatively higher risk of rupture. Other complications include thrombosis and dissections, which can lead to pulmonary infarction.”
CT imaging of pulmonary artery aneurysms in the emergency department - What you need to know.
Yasrab M, Crawford CK, Fishman EK, Kawamoto S.
Curr Probl Diagn Radiol. 2025 May 17:S0363-0188(25)00094-5. - “PA aneurysms can be idiopathic or develop in association with various underlying etiologies, including congenital cardiovascular anomalies, infections, neoplastic processes, trauma, connective tissue disorders, and systemic inflammatory conditions. Iatrogenic injury during catheterization can also predispose to aneurysm and pseudoaneurysm formation, with the latter more frequently a consequence of trauma or infection. Patients are often asymptomatic with aneurysms being discovered incidentally during imaging for other reasons; however, when symptomatic, patients can present with nonspecific complaints including cough, dyspnea, and/or hemoptysis, as well as palpitations or syncope. Additional symptoms can provide further diagnostic clues depending on the underlying cause.”
CT imaging of pulmonary artery aneurysms in the emergency department - What you need to know.
Yasrab M, Crawford CK, Fishman EK, Kawamoto S.
Curr Probl Diagn Radiol. 2025 May 17:S0363-0188(25)00094-5. - Causes of PA Aneurysms and Pseudoaneurysms
- “At our institution, CTPA is currently performed on 64- or 128-detector multidetector CT (MDCT) scanners (Somatom Definition Force or Siemens Definition Flash, Siemens Healthcare, Erlangen, Germany). Scans are performed in a craniocaudal direction from the lung apices to the diaphragm. 100 ml of intravenous (IV) non-ionic contrast (Omnipaque 350 mg I/ml, GE Healthcare) is injected peripherally at a rate of 4- 5 ml/second. 200 HU or 250 HU trigger threshold is set for bolus tracking at the pulmonary trunk as the region of interest. Tube potential is set at 100-120 kV, tube current at 120-200 mA (automatically modulated with CareDose, Siemens), and collimation of 128 × 0.6 mm. Scan time is usually under 10 seconds and can be even shorter when using high pitch scanners.”
CT imaging of pulmonary artery aneurysms in the emergency department - What you need to know.
Yasrab M, Crawford CK, Fishman EK, Kawamoto S.
Curr Probl Diagn Radiol. 2025 May 17:S0363-0188(25)00094-5. - “Involvement of more peripheral branches and multiple sites of aneurysm formation should raise concern for systemic pathologies including connective tissue disease and vasculitis. This is especially true in younger patients who present with PA aneurysms and may even show involvement of the aorta and its branches, for instance in Marfan’s syndrome.8 Behcet’s disease is a systemic vasculitis predominantly common in Middle Eastern, Asian, and particularly Turkish populations, is another important cause for PA aneurysms. Obliterative endarteritis of the vasa vasorum (in Behcet’s disease) results in aneurysm formation, which can have variable sizes and locations involving the segmental and even subsegmental PA branches and associated thrombosis in up to a third of these cases."
CT imaging of pulmonary artery aneurysms in the emergency department - What you need to know.
Yasrab M, Crawford CK, Fishman EK, Kawamoto S.
Curr Probl Diagn Radiol. 2025 May 17:S0363-0188(25)00094-5. - Pseudoaneurysms secondary to trauma or iatrogenic injury (including right heart or Swan-Ganz catheterization) are often associated with pulmonary hemorrhage with active extravasation, and consolidation or ground-glass opacities appreciated on lung windows. Multiple pseudoaneurysms can also develop in association with endocarditis, septic emboli, or lung metastases, in which cases there is a higher predilection for involvement of subsegmental branches. Infection remains the most common etiology for pseudoaneurysms (i.e. mycotic aneurysms) as granulation tissue erodes the vessel wall, although we see lower rates of the classically described Rasmusen aneurysm (secondary to tuberculosis) due to decreasing infection rates in developed countries. Nonetheless, signs and symptoms of infection with possible cavitary lesions with enhancing walls and consolidation in association with the aneurysm should prompt further workup.
CT imaging of pulmonary artery aneurysms in the emergency department - What you need to know.
Yasrab M, Crawford CK, Fishman EK, Kawamoto S.
Curr Probl Diagn Radiol. 2025 May 17:S0363-0188(25)00094-5. - Diagnosing PA aneurysms in the emergency department can be challenging due to their nonspecific symptoms like cough, dyspnea, and hemoptysis, which overlap with various pulmonary and cardiovascular diseases. Achieving optimal image quality is essential; issues such as patient movement, improper contrast timing, and technical limitations can significantly affect the resolution of standard axial images, and therefore the effectiveness of advanced postprocessing techniques like MIP, VR, and 3D CR, all of which rely on high quality standard 2D acquisitions. Additionally, precise timing of contrast administration and image acquisition is critical for adequate enhancement of the pulmonary vessels without obscuring aneurysmal features, which is particularly challenging in unstable patients where it may not be clear where the bleeding is originating from. Even in the case of hemorrhage, a CTPA is recommended to determine whether the source of the bleeding is from the pulmonary vessels or the bronchial arteries.
CT imaging of pulmonary artery aneurysms in the emergency department - What you need to know.
Yasrab M, Crawford CK, Fishman EK, Kawamoto S.
Curr Probl Diagn Radiol. 2025 May 17:S0363-0188(25)00094-5. - “Management of PA aneurysms often hinges on multiple factors, including the aneurysm’s size and location, and the patient’s stability, with a notable absence of consensus guidelines for intervention thresholds. The wide array of potential etiologies, from congenital defects to acquired diseases like connective tissue disorders or infections, demands a broad differential diagnosis that influences treatment choices based on the individual pathology and the patient’s condition after initial stabilization.”
CT imaging of pulmonary artery aneurysms in the emergency department - What you need to know.
Yasrab M, Crawford CK, Fishman EK, Kawamoto S.
Curr Probl Diagn Radiol. 2025 May 17:S0363-0188(25)00094-5. - “In summary, PA aneurysms and pseudoaneurysms are rare but critical findings in the emergency setting. CTPA, supported by advanced techniques, serves as an efficient imaging modality of choice for accurate diagnosis and effective procedural planning. The wide spectrum of underlying causes and potential complications highlights the importance of a personalized approach to management, balancing patient stability and risk of rupture. Through these illustrative cases, we aim to emphasize the indispensable role of radiological imaging in identifying and addressing these high-risk vascular abnormalities in an emergency setting.”
CT imaging of pulmonary artery aneurysms in the emergency department - What you need to know.
Yasrab M, Crawford CK, Fishman EK, Kawamoto S.
Curr Probl Diagn Radiol. 2025 May 17:S0363-0188(25)00094-5.
Chest
- “Pulmonary artery (PA) aneurysms are rare vascular abnormalities with potentially life-threatening complications such as rupture, massive hemoptysis, and pulmonary infarction. These conditions are often asymptomatic and incidentally detected but can present with nonspecific symptoms like cough, dyspnea, or hemoptysis in an emergency setting. Multidetector CT pulmonary angiography (CTPA) has outshone traditional angiography, supplemented by advanced 3D post-processing techniques such as maximum intensity projection (MIP), volumetric rendering (VR), and cinematic rendering (CR) techniques, playing a pivotal role in diagnosis and management of PA aneurysms.”
CT imaging of pulmonary artery aneurysms in the emergency department - What you need to know.
Yasrab M, Crawford CK, Fishman EK, Kawamoto S.
Curr Probl Diagn Radiol. 2025 May 17:S0363-0188(25)00094-5. - “Pulmonary artery (PA) aneurysms are rare vascular abnormalities involving the PA or its branches, with an incidence of 0.007 % according to classical autopsy series. In an emergency setting, they can pose a risk of rupture and massive hemoptysis, which itself has a mortality rate of over 50 % if untreated. Ten percent of massive hemoptysis is due to PA pathology, most commonly aneurysms and pseudoaneurysms. True PA aneurysms are dilatations involving all three layers of the vessel, whereas pseudoaneurysms are outpouchings contained by the innermost layer, with a comparatively higher risk of rupture. Other complications include thrombosis and dissections, which can lead to pulmonary infarction.”
CT imaging of pulmonary artery aneurysms in the emergency department - What you need to know.
Yasrab M, Crawford CK, Fishman EK, Kawamoto S.
Curr Probl Diagn Radiol. 2025 May 17:S0363-0188(25)00094-5. - “PA aneurysms can be idiopathic or develop in association with various underlying etiologies, including congenital cardiovascular anomalies, infections, neoplastic processes, trauma, connective tissue disorders, and systemic inflammatory conditions. Iatrogenic injury during catheterization can also predispose to aneurysm and pseudoaneurysm formation, with the latter more frequently a consequence of trauma or infection. Patients are often asymptomatic with aneurysms being discovered incidentally during imaging for other reasons; however, when symptomatic, patients can present with nonspecific complaints including cough, dyspnea, and/or hemoptysis, as well as palpitations or syncope. Additional symptoms can provide further diagnostic clues depending on the underlying cause.”
CT imaging of pulmonary artery aneurysms in the emergency department - What you need to know.
Yasrab M, Crawford CK, Fishman EK, Kawamoto S.
Curr Probl Diagn Radiol. 2025 May 17:S0363-0188(25)00094-5. - Causes of PA Aneurysms and Pseudoaneurysms
- “At our institution, CTPA is currently performed on 64- or 128-detector multidetector CT (MDCT) scanners (Somatom Definition Force or Siemens Definition Flash, Siemens Healthcare, Erlangen, Germany). Scans are performed in a craniocaudal direction from the lung apices to the diaphragm. 100 ml of intravenous (IV) non-ionic contrast (Omnipaque 350 mg I/ml, GE Healthcare) is injected peripherally at a rate of 4- 5 ml/second. 200 HU or 250 HU trigger threshold is set for bolus tracking at the pulmonary trunk as the region of interest. Tube potential is set at 100-120 kV, tube current at 120-200 mA (automatically modulated with CareDose, Siemens), and collimation of 128 × 0.6 mm. Scan time is usually under 10 seconds and can be even shorter when using high pitch scanners.”
CT imaging of pulmonary artery aneurysms in the emergency department - What you need to know.
Yasrab M, Crawford CK, Fishman EK, Kawamoto S.
Curr Probl Diagn Radiol. 2025 May 17:S0363-0188(25)00094-5. - “Involvement of more peripheral branches and multiple sites of aneurysm formation should raise concern for systemic pathologies including connective tissue disease and vasculitis. This is especially true in younger patients who present with PA aneurysms and may even show involvement of the aorta and its branches, for instance in Marfan’s syndrome.8 Behcet’s disease is a systemic vasculitis predominantly common in Middle Eastern, Asian, and particularly Turkish populations, is another important cause for PA aneurysms. Obliterative endarteritis of the vasa vasorum (in Behcet’s disease) results in aneurysm formation, which can have variable sizes and locations involving the segmental and even subsegmental PA branches and associated thrombosis in up to a third of these cases."
CT imaging of pulmonary artery aneurysms in the emergency department - What you need to know.
Yasrab M, Crawford CK, Fishman EK, Kawamoto S.
Curr Probl Diagn Radiol. 2025 May 17:S0363-0188(25)00094-5. - Pseudoaneurysms secondary to trauma or iatrogenic injury (including right heart or Swan-Ganz catheterization) are often associated with pulmonary hemorrhage with active extravasation, and consolidation or ground-glass opacities appreciated on lung windows. Multiple pseudoaneurysms can also develop in association with endocarditis, septic emboli, or lung metastases, in which cases there is a higher predilection for involvement of subsegmental branches. Infection remains the most common etiology for pseudoaneurysms (i.e. mycotic aneurysms) as granulation tissue erodes the vessel wall, although we see lower rates of the classically described Rasmusen aneurysm (secondary to tuberculosis) due to decreasing infection rates in developed countries. Nonetheless, signs and symptoms of infection with possible cavitary lesions with enhancing walls and consolidation in association with the aneurysm should prompt further workup.
CT imaging of pulmonary artery aneurysms in the emergency department - What you need to know.
Yasrab M, Crawford CK, Fishman EK, Kawamoto S.
Curr Probl Diagn Radiol. 2025 May 17:S0363-0188(25)00094-5. - Diagnosing PA aneurysms in the emergency department can be challenging due to their nonspecific symptoms like cough, dyspnea, and hemoptysis, which overlap with various pulmonary and cardiovascular diseases. Achieving optimal image quality is essential; issues such as patient movement, improper contrast timing, and technical limitations can significantly affect the resolution of standard axial images, and therefore the effectiveness of advanced postprocessing techniques like MIP, VR, and 3D CR, all of which rely on high quality standard 2D acquisitions. Additionally, precise timing of contrast administration and image acquisition is critical for adequate enhancement of the pulmonary vessels without obscuring aneurysmal features, which is particularly challenging in unstable patients where it may not be clear where the bleeding is originating from. Even in the case of hemorrhage, a CTPA is recommended to determine whether the source of the bleeding is from the pulmonary vessels or the bronchial arteries.
CT imaging of pulmonary artery aneurysms in the emergency department - What you need to know.
Yasrab M, Crawford CK, Fishman EK, Kawamoto S.
Curr Probl Diagn Radiol. 2025 May 17:S0363-0188(25)00094-5. - “Management of PA aneurysms often hinges on multiple factors, including the aneurysm’s size and location, and the patient’s stability, with a notable absence of consensus guidelines for intervention thresholds. The wide array of potential etiologies, from congenital defects to acquired diseases like connective tissue disorders or infections, demands a broad differential diagnosis that influences treatment choices based on the individual pathology and the patient’s condition after initial stabilization.”
CT imaging of pulmonary artery aneurysms in the emergency department - What you need to know.
Yasrab M, Crawford CK, Fishman EK, Kawamoto S.
Curr Probl Diagn Radiol. 2025 May 17:S0363-0188(25)00094-5. - “In summary, PA aneurysms and pseudoaneurysms are rare but critical findings in the emergency setting. CTPA, supported by advanced techniques, serves as an efficient imaging modality of choice for accurate diagnosis and effective procedural planning. The wide spectrum of underlying causes and potential complications highlights the importance of a personalized approach to management, balancing patient stability and risk of rupture. Through these illustrative cases, we aim to emphasize the indispensable role of radiological imaging in identifying and addressing these high-risk vascular abnormalities in an emergency setting.”
CT imaging of pulmonary artery aneurysms in the emergency department - What you need to know.
Yasrab M, Crawford CK, Fishman EK, Kawamoto S.
Curr Probl Diagn Radiol. 2025 May 17:S0363-0188(25)00094-5.
Deep Learning
- Liver cancer remains a significant global health concern, ranking as the sixth most common malignancy and the third leading cause of cancer-related deaths worldwide. Medical imaging plays a vital role in managing liver tumors, particularly hepatocellular carcinoma (HCC) and metastatic lesions. However, the large volume and complexity of imaging data can make accurate and efficient interpretation challenging. Artificial intelligence (AI) is recognized as a promising tool to address these challenges. Therefore, this review aims to explore the recent advances in AI applications in liver tumor imaging, focusing on key areas such as image reconstruction, image quality enhancement, lesion detection, tumor characterization, segmentation, and radiomics. Among these, AI-based image reconstruction has already been widely integrated into clinical workflows, helping to enhance image quality while reducing radiation exposure.
Artificial intelligence in imaging diagnosis of liver tumors: current status and future prospects
Masatoshi Hori· Yuki Suzuki· Keitaro Sofue
Abdominal Radiology 2025 (in press) - ”In liver imaging, progress remains slower compared to that of chest imaging. Several factors contribute to this challenge: (a) the contrast between lesions and surrounding tissues in liver CT is significantly lower than that in chest CT; (b) dynamic multiphasic imaging plays a critical role in liver CT, making the processing more complex; and (c) liver MRI requires the interpretation of several image types. These are key challenges that must be addressed for AI-based liver tumor detection systems to become well-established in clinical practice.”
Artificial intelligence in imaging diagnosis of liver tumors: current status and future prospects
Masatoshi Hori· Yuki Suzuki· Keitaro Sofue
Abdominal Radiology 2025 (in press) - Commonly extracted radiomic features include shape features (e.g., diameter, volume), first-order features (e.g., mean, standard deviation), and texture features derived from the spatial distribution of pixel values. The total number of extracted features can exceed hundreds. To select the most relevant features and avoid overfitting, dimensionality reduction techniques are applied. A commonly used method is the least absolute shrinkage and selection operator (LASSO), which performs both variable selection and regularization to enhance prediction accuracy. Random forests, another widely used algorithm, are ensemble learning methods that construct multiple decision trees and output the class that is the mode of the classes from individual trees. These algorithms are frequently employed in radiomic analyses for classification, regression, and feature importance ranking.
Artificial intelligence in imaging diagnosis of liver tumors: current status and future prospects
Masatoshi Hori· Yuki Suzuki· Keitaro Sofue
Abdominal Radiology 2025 (in press) - The role of AI in liver tumor imaging has been discussed and its significance continues to grow. AI-based image reconstruction is widely used in clinical practice, providing benefits such as improved image quality and reduced radiation exposure. AI-assisted diagnostic software is less common in liver imaging compared to other areas, such as the lungs; however, its application is gradually increasing and is expected to become an integral part of routine clinical practice. Advancement in emerging technologies (such as radiomics, currently at the research stage) is expected to have broader applications in image assessment, treatment planning, treatment evaluation, and prognosis prediction. Moreover, recent developments in generative AI, including large language models such as ChatGPT, show significant promise for potential applications in medical imaging.
Artificial intelligence in imaging diagnosis of liver tumors: current status and future prospects
Masatoshi Hori· Yuki Suzuki· Keitaro Sofue
Abdominal Radiology 2025 (in press)
- Multimodal artificial intelligence (AI) is a powerful new technological advance, capable of simultaneously learning from diverse data types, such as text, images, video, and audio. Because clinical decisions are usually based on information from multiple sources, multimodal AI has the potential to significantly improve clinical practice. However, unlike most developed multimodal AI workflows, clinical medicine is both a dynamic and interventional process in which the clinician continually learns about the patient’s health and acts accordingly as data is collected. In this article, we argue that multimodal clinical AI must be fully attuned to the particular challenges and constraints of the clinic, and clinician involvement is needed throughout development, not just at clinical deployment. We propose ways that clinician involvement can add value at each stage of the multimodal AI development pipeline, and argue for the establishment of actively managed multidisciplinary communities to work collaboratively towards the shared goal of improving the health of all.
Clinicians must participate in the development of multimodal AI
Christopher R. S. Banerji et al.
eClinicalMedicine 2025;84: 103252 - Clinician involvement throughout the multimodal clinical AI development pipeline is therefore essential— to guide model design, construction, development, deployment, and iterative refinement. However, clinician involvement in the AI development loop is not standard practice. Indeed, a recent systematic review of AI tools that directly sought clinician input found that just 22% of studies involved clinicians throughout development, while the majority (82%) involved clinicians specifically in the deployment phase.
Clinicians must participate in the development of multimodal AI
Christopher R. S. Banerji et al.
eClinicalMedicine 2025;84: 103252 - Furthermore, the survey findings by Busch et al3 revealed that patients prefer less accurate AI systems that are explainable over highly accurate but opaque “closed box” models. This preference underscores the importance of transparency and the ability to audit AI-assisted processes, reinforcing the notion that patients value augmented health care processes in which physicians maintain oversight. Interestingly, the emphasis of patients on explainable AI aligns with the perspective of physicians, as many express a strong intention to integrate AI into their practice but stress the need for transparency, trust, and explainability in these tools.
A Patient-in-the-Loop Approach to Artificial Intelligence in Medicine
Maxime F. Griot, MSc, MD; Graham A.Walker,
JAMA Network Open. 2025;8(6):e2514460. doi:10.1001 - Involving patients in the design and development of AI systems can play a pivotal role in making these technologies more acceptable and aligned with patient values. This approach reduces the risk of a mismatch between the capabilities of deployed solutions and the expectations of patients, ensuring that the systems are tailored to clinical practice needs. Moreover, active patient involvement fosters trust, a critical factor for the adoption of AI in health care. Combining this with a The physician-in-the-loop strategy could provide a robust framework for AI integration, with both patients and clinicians shaping the development and use of these tools. Rather than aiming to outperform clinicians on narrowly defined tasks, this collaborative approach emphasizes augmenting care processes in ways that resonate with all stakeholders involved.
A Patient-in-the-Loop Approach to Artificial Intelligence in Medicine
Maxime F. Griot, MSc, MD; Graham A.Walker,
JAMA Network Open. 2025;8(6):e2514460. doi:10.1001
'- The radiomics features with the highest AUC values included ART_first order_Root Mean Squared (AUC = 0.896, p < 0.01) in the arterial phase and VEN_firstorder_Median (AUC = 0.737, p < 0.05) in the venous phase for all lesions, and ART_first order_Root Mean Squared (AUC = 0.859, p < 0.01) and VEN_first order_Median (AUC = 0.713, p < 0.05) for lesions smaller than 5 cm. Texture analysis of pancreatic pathology has shown good predictability in defining the PNET histotype. This analysis potentially offering a non-invasive, imaging-based method to accurately differentiate between pancreatic tumor types. Such advancements could lead to more precise and personalized treatment planning, ultimately optimizing the use of medical resources.
Radiomics in differential diagnosis of pancreatic tumors
Robertis, Ricacardo et al.
European Journal of Radiology Open
'- Background and Objectives: We explored the ability of large language models (LLMs) ChatGPT‐4 and Gemini 1.0 Ultra in guiding clinical decision‐making for six gastrointestinal cancers using the National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines. Methods: We reviewed the NCCN Guidelines for anal squamous cell carcinoma, small bowel, ampullary, and pancreatic adenocarcinoma, and biliary tract and gastric cancers. Clinical questions were designed and categorized by type, queried up to three times, and rated on a Likert scale: (5) Correct; (4) Correct following clarification; (3) Correct but incomplete; (2) Partially incorrect; (1) Absolutely incorrect. Subgroup analysis was conducted on Correctness (scores 3–5) and Accuracy (scores 4–5).
AI at the Forefront: Navigating Oncologic Care for Six Gastrointestinal Cancers According to the NCCN Guidelines Utilizing Gemini‐1.0 Ultra and ChatGPT‐4
Tamir E. Bresler, Tyler Wilson, Tadevos Makaryan
Journal of Surgical Oncology, 2025; 1–6 - Results: A total of 270 questions were generated (range‐per‐cancer 32–68). ChatGPT‐4 versus Gemini 1.0 Ultra score differences were not statistically‐significant (Mean Rank 278.30 vs. 262.70, p = 0.222). Correctness was seen in 77.78% versus 75.93% of responses, and Accuracy in 64.81% versus 57.41%. There were no statistically‐significant differences in Correctness or Accuracy between LLMs in terms of question or cancer type. Conclusions: Both LLMs demonstrated a limited capacity to assist with complex clinical decision‐making. Their current Accuracy level falls below the acceptable threshold for clinical use. Future studies exploring LLMs in the healthcare domain are warranted.
AI at the Forefront: Navigating Oncologic Care for Six Gastrointestinal Cancers According to the NCCN Guidelines Utilizing Gemini‐1.0 Ultra and ChatGPT‐4
Tamir E. Bresler, Tyler Wilson, Tadevos Makaryan
Journal of Surgical Oncology, 2025; 1–6 - The pace of development for AI is only quickening. Since conducting our research, OpenAI has released ChatGPT‐4o, which can interact with and search the Internet. On September 12, 2024, an even newer version called ChatGPT‐o1 was released, which fundamentally retrains the way ChatGPT processes and analyzes information. ChatGPT‐o1 is so powerful that it has outscored human subjects in PhD‐level accuracy on benchmark testing related to physics, biology, and chemistry problems. As this technology progresses, it will become more important than ever to understand not just the abilities, but also the limitations of these platforms.
AI at the Forefront: Navigating Oncologic Care for Six Gastrointestinal Cancers According to the NCCN Guidelines Utilizing Gemini‐1.0 Ultra and ChatGPT‐4
Tamir E. Bresler, Tyler Wilson, Tadevos Makaryan
Journal of Surgical Oncology, 2025; 1–6 - ”In the age of informatics, where clinicians grapple with a faster‐than‐exponential expanding body of medical knowledge, AI emerges as a potential ally, and may fundamentally reshape the practice of medicine. Our study falls into this framework as an effort to continue probing the potential possibilities and pitfalls of this new technology in the field of clinical oncology. We showed that the achievements of the LLMs are significant. However, ChatGPT‐4 and Gemini‐1.0 Ultra are not yet capable of providing clinical recommendations with enough Correctness or Accuracy to assist with clinical reasoning. We are encouraged by the future direction of this study and believe future studies may elucidate a higher level of LLM engagement and understanding as the technology platform grows.
AI at the Forefront: Navigating Oncologic Care for Six Gastrointestinal Cancers According to the NCCN Guidelines Utilizing Gemini‐1.0 Ultra and ChatGPT‐4
Tamir E. Bresler, Tyler Wilson, Tadevos Makaryan
Journal of Surgical Oncology, 2025; 1–6
Kidney
- AMLs are typically easy to diagnose by identifying intralesional bulk fat. However, lipid-poor AMLs lack enough fat to be detected radiologically, making diagnosis more difficult. Their imaging appearance may closely mimic renal malignancies— particularly papillary RCC. On MR imaging, both can appear as enhancing renal lesions that are hypointense on T2-weighted sequences. Biopsy may be necessary to distinguish between the 2 in equivocal cases.
Pitfalls in Genitourinary Imaging
Mark D. Ehrhart, Steven C. Eberhardt
Radiol Clin N Am 2025 (in press) - While most radiologists are familiar with common renal cysts, autosomal dominant polycystic disease, and the Bosniak-classified neoplasms, lithium nephropathy is a less recognized cause of cystic renal change. Chronic lithium use for psychiatric treatment can result in renal dysfunction, with severity related to dose and duration. Microcysts ranging from 1 to 3 mm may develop in the renal cortex and medulla, best seen on T2- weighted MR imaging. Unlike other cystic disorders, lithium nephropathy features numerous uniformly small cysts. MR imaging appearance—without the need for contrast—may serve as a useful marker of lithium-induced nephrotoxicity.
Pitfalls in Genitourinary Imaging
Mark D. Ehrhart, Steven C. Eberhardt
Radiol Clin N Am 2025 (in press) - - AML is a benign tumor comprised of a mixture of vessels (“angio”), smooth muscle (“myo”), and adipose tissue (“lipo”). It belongs to a group of unusual mesenchymal tumors with myogenic and melanocytic differentiation known as PEC tumors.
- The most important clinical complication is tumoral hemorrhage, which may lead to tumor rupture and retroperitoneal hemorrhage, also known as Wunderlich syndrome.
- The detection of macroscopic fat within a renal mass is essential for making the radiologic diagnosis of classic AML. While AML can also contain microscopic fat, a renal mass with only microscopic fat and not macroscopic fat is concerning for a possible RCC, most frequently the clear cell subtype.
Spectrum of Renal Angiomyolipoma with Radiologic-Pathologic Correlation
Meghan G. Lubner, et al.
RadioGraphics 2025; 45(7):e240159 - - MRI findings closely match the histologic findings of fat-poor AML. The dominant smooth muscle components demonstrate low T2 signal intensity and avid enhancement
- AMLEC appears as a mixed solid and cystic mass. The solid components demonstrate features of a fat-poor AML, including isoechogenicity in the renal parenchyma at US, high attenuation at non–contrast-enhanced CT, low T2 signal intensity at MRI, and homogeneous enhancement.
Spectrum of Renal Angiomyolipoma with Radiologic-Pathologic Correlation
Meghan G. Lubner, et al.
RadioGraphics 2025; 45(7):e240159 - Angiomyolipoma (AML) is a benign tumor comprised of a mixture of vessels (“angio”), smooth muscle (“myo”), and adipose tissue (“lipo”). It belongs to a group of unusual mesenchymal tumors with myogenic and melanocytic differentiation known as perivascular epithelioid cell (PEC) tumors. AMLs are commonly sporadic tumors but may be associated with tuberous sclerosis complex (TSC) and/or lymphangioleiomyomatosis (LAM).
Spectrum of Renal Angiomyolipoma with Radiologic-Pathologic Correlation
Meghan G. Lubner, et al.
RadioGraphics 2025; 45(7):e240159 - Classic AML is a cortically based solid renal mass that contains regions of macroscopic fat. AML demonstrates an expansile pattern of growth with well-defined margins. Large or peripherally located lesions will distort the renal contour and may appear exophytic or involve the renal sinus . When compared with RCC, AML often demonstrates a nonround, unusual, or lobulated shape. AML may exhibit an angular interface and/or have the “drooping” sign. It may also have an “ice cream cone” shape with angular and tapering margins that result in a definable apex within the parenchyma and a bulging peripheral margin. Classic AML contains variable proportions of nonfatty elements, including smooth muscle components and ectatic blood vessels. It is the disorganized vasculature that can lead to the complication of hemorrhage. Calcification is exceedingly rare.
Spectrum of Renal Angiomyolipoma with Radiologic-Pathologic Correlation
Meghan G. Lubner, et al.
RadioGraphics 2025; 45(7):e240159 - CT has an excellent sensitivity, specificity, positive predictive value, and negative predictive value for the imaging diagnosis of AML. Macroscopic fat can be detected within a renal mass by identifying areas with an attenuation less than –10 to –20 HU. Thin-section contrast-enhanced CT images with a section thickness of 1.5–3 mm increase the sensitivity of fat detection compared with images that have thicker 5-mm sections . MRI is sensitive and specific for the diagnosis of classic AML. The macroscopic fat within classic AML can be identified at MRI as areas of T1-hyperintense signal intensity that demonstrate signal intensity loss with chemical selective fat suppression.
Spectrum of Renal Angiomyolipoma with Radiologic-Pathologic Correlation
Meghan G. Lubner, et al.
RadioGraphics 2025; 45(7):e240159 - Epithelioid AML
Limited data exist regarding the imaging appearance of EAML. Cui et al described the CT imaging features of 10 pathologically proven EAMLs and reported common features including a large size, renal contour deformity, marked heterogeneous enhancement, and areas of necrosis . No lesions had macroscopic fat. The masses were hyperattenuating compared with the adjacent renal parenchyma, likely reflecting the epithelioid and smooth muscle components.”
Spectrum of Renal Angiomyolipoma with Radiologic-Pathologic Correlation
Meghan G. Lubner, et al.
RadioGraphics 2025; 45(7):e240159 - Liposarcoma also tends to have a less prominent feeding vasculature and lacks the renal parenchymal defect that is often seen with AMLs. Similarly, although adrenal myelolipomas contain bone marrow and fatty elements, they (a) are less likely to contain prominent or disorganized vascular structures; (b) are often more circumscribed, with a capsule or pseudocapsule up to 75% of the time; and (c) may contain calcification in 25% of cases. Extra-adrenal myelolipomas can also occur and can mimic AML when they are present in the perinephric space. It is rare for RCC to contain macroscopic fat. If present, it is often sparse, associated with calcification, and readily differentiated from AML.
Spectrum of Renal Angiomyolipoma with Radiologic-Pathologic Correlation
Meghan G. Lubner, et al.
RadioGraphics 2025; 45(7):e240159 - ”Active surveillance may be appropriate for AMLs that are asymptomatic, sporadic, and less than 4 cm. Patients who are poor candidates for active surveillance include female patients of childbearing age, female patients who require ongoing hormonal therapy, patients unlikely to be compliant with periodic follow-up imaging, and patients with limited access to emergency care. Some authors have advocated for active surveillance in low-risk patients with AMLs that measure up to 6 cm.”
Spectrum of Renal Angiomyolipoma with Radiologic-Pathologic Correlation
Meghan G. Lubner, et al.
RadioGraphics 2025; 45(7):e240159 - ”Fat-poor AMLs and other AML variants such as EAML and AMLEC are more difficult to diagnose with certainty at imaging, although some imaging clues may suggest their diagnosis. Ultimately, histologic confirmation may be required to distinguish these AML variants from RCC. In the future, radiomics may assist radiologists in differentiating them more confidently. Because AMLs are not uncommon, radiologists who interpret abdominal imaging examinations need to be familiar with their imaging features and variants to ensure that patients are managed optimally.”
Spectrum of Renal Angiomyolipoma with Radiologic-Pathologic Correlation
Meghan G. Lubner, et al.
RadioGraphics 2025; 45(7):e240159
- Pyelonephritis is a well-known radiologic finding, commonly seen as a striated nephrogram. However, edematous and hypoenhancing infected renal parenchyma may have a pseudotumor appearance, potentially leading to misidentification as a suspicious renal mass. Conversely, infiltrative renal tumors may mimic a striated nephrogram, leading to misdiagnosis and delayed treatment of malignancy.
Pitfalls in Genitourinary Imaging
Mark D. Ehrhart, Steven C. Eberhardt
Radiol Clin N Am 2025 (in press) - Most radiologists primarily review axial images but incorporating coronal and sagittal planes is critical—particularly when evaluating the kidneys. Exophytic renal lesions located at the extreme upper or lower poles may be overlooked if their protrusion is not clearly appreciated, especially when the phase of renal enhancement resembles that of the surrounding parenchyma or there is motion. Coronal reconstruction can improve visualization by highlighting exophytic extension and offering a broader parenchymal contrast backdrop.
Pitfalls in Genitourinary Imaging
Mark D. Ehrhart, Steven C. Eberhardt
Radiol Clin N Am 2025 (in press)
Liver
- Liver cancer remains a significant global health concern, ranking as the sixth most common malignancy and the third leading cause of cancer-related deaths worldwide. Medical imaging plays a vital role in managing liver tumors, particularly hepatocellular carcinoma (HCC) and metastatic lesions. However, the large volume and complexity of imaging data can make accurate and efficient interpretation challenging. Artificial intelligence (AI) is recognized as a promising tool to address these challenges. Therefore, this review aims to explore the recent advances in AI applications in liver tumor imaging, focusing on key areas such as image reconstruction, image quality enhancement, lesion detection, tumor characterization, segmentation, and radiomics. Among these, AI-based image reconstruction has already been widely integrated into clinical workflows, helping to enhance image quality while reducing radiation exposure.
Artificial intelligence in imaging diagnosis of liver tumors: current status and future prospects
Masatoshi Hori· Yuki Suzuki· Keitaro Sofue
Abdominal Radiology 2025 (in press) - ”In liver imaging, progress remains slower compared to that of chest imaging. Several factors contribute to this challenge: (a) the contrast between lesions and surrounding tissues in liver CT is significantly lower than that in chest CT; (b) dynamic multiphasic imaging plays a critical role in liver CT, making the processing more complex; and (c) liver MRI requires the interpretation of several image types. These are key challenges that must be addressed for AI-based liver tumor detection systems to become well-established in clinical practice.”
Artificial intelligence in imaging diagnosis of liver tumors: current status and future prospects
Masatoshi Hori· Yuki Suzuki· Keitaro Sofue
Abdominal Radiology 2025 (in press) - Commonly extracted radiomic features include shape features (e.g., diameter, volume), first-order features (e.g., mean, standard deviation), and texture features derived from the spatial distribution of pixel values. The total number of extracted features can exceed hundreds. To select the most relevant features and avoid overfitting, dimensionality reduction techniques are applied. A commonly used method is the least absolute shrinkage and selection operator (LASSO), which performs both variable selection and regularization to enhance prediction accuracy. Random forests, another widely used algorithm, are ensemble learning methods that construct multiple decision trees and output the class that is the mode of the classes from individual trees. These algorithms are frequently employed in radiomic analyses for classification, regression, and feature importance ranking.
Artificial intelligence in imaging diagnosis of liver tumors: current status and future prospects
Masatoshi Hori· Yuki Suzuki· Keitaro Sofue
Abdominal Radiology 2025 (in press) - The role of AI in liver tumor imaging has been discussed and its significance continues to grow. AI-based image reconstruction is widely used in clinical practice, providing benefits such as improved image quality and reduced radiation exposure. AI-assisted diagnostic software is less common in liver imaging compared to other areas, such as the lungs; however, its application is gradually increasing and is expected to become an integral part of routine clinical practice. Advancement in emerging technologies (such as radiomics, currently at the research stage) is expected to have broader applications in image assessment, treatment planning, treatment evaluation, and prognosis prediction. Moreover, recent developments in generative AI, including large language models such as ChatGPT, show significant promise for potential applications in medical imaging.
Artificial intelligence in imaging diagnosis of liver tumors: current status and future prospects
Masatoshi Hori· Yuki Suzuki· Keitaro Sofue
Abdominal Radiology 2025 (in press)
Pancreas
- '
- The radiomics features with the highest AUC values included ART_first order_Root Mean Squared (AUC = 0.896, p < 0.01) in the arterial phase and VEN_firstorder_Median (AUC = 0.737, p < 0.05) in the venous phase for all lesions, and ART_first order_Root Mean Squared (AUC = 0.859, p < 0.01) and VEN_first order_Median (AUC = 0.713, p < 0.05) for lesions smaller than 5 cm. Texture analysis of pancreatic pathology has shown good predictability in defining the PNET histotype. This analysis potentially offering a non-invasive, imaging-based method to accurately differentiate between pancreatic tumor types. Such advancements could lead to more precise and personalized treatment planning, ultimately optimizing the use of medical resources.
Radiomics in differential diagnosis of pancreatic tumors
Robertis, Ricacardo et al.
European Journal of Radiology Open
Small Bowel
- Acute abdominal complaints constitute up to 40% of all emergency department (ED) presentations in oncology patients due to a multitude of causes. Small bowel pathologies present a diagnostic challenge due to their diverse range and frequently overlapping clinical presentation. In oncology patients, structural changes resulting from tumor growth, surgery and treatment effects can further complicate the diagnostic process. Due to a weakened immune system, oncology patients are also highly susceptible to infections of the gastrointestinal tract (GIT). Traditional computed tomography (CT) scans are used as the gold standard diagnostic modality. However, three-dimensional (3D) postprocessing techniques including maximal intensity projection (MIP), volume rendering (VR) and cinematic rendering (CR) have been employed to aid image evaluation.
Imaging of acute small bowel pathologies in oncology patients in the ER part I: the role of Computed Tomography (CT) for the evaluation of Tumor and infections
Hajra Arshad · Satomi Kawamoto · Linda C. Chu · Elliot K. Fishman
Emergency Radiology 2025 https://doi.org/10.1007/s10140-025-02341-6 
Imaging of acute small bowel pathologies in oncology patients in the ER part I: the role of Computed Tomography (CT) for the evaluation of Tumor and infections
Hajra Arshad · Satomi Kawamoto · Linda C. Chu · Elliot K. Fishman
Emergency Radiology 2025 https://doi.org/10.1007/s10140-025-02341-6- “Acute abdominal pain is the most common primary complaint in the emergency department (ED), accounting for 5–10% of all ED presentations. However, in oncology patients, it constitutes 40% of all ED presentations [4]. Acute abdomen manifests as severe abdominal pain, accompanied by a multitude of gastrointestinal and systemic symptoms, such as nausea, vomiting, fever, and weight loss, and requires urgent attention and treatment. In certain instances, it may present with signs of peritoneal irritation, including rigidity and guarding. In severe cases, it can lead to sepsis, shock, and organ failure.”
Imaging of acute small bowel pathologies in oncology patients in the ER part I: the role of Computed Tomography (CT) for the evaluation of Tumor and infections
Hajra Arshad · Satomi Kawamoto · Linda C. Chu · Elliot K. Fishman
Emergency Radiology 2025 (in press) - However, acute abdomen in oncology patients encompasses a diverse range of causes, including tumor- and treatment related complications, as well as infectious, ischemic, and other miscellaneous factors. Oncology patients are also highly vulnerable to infections affecting the GIT. Therefore, it is imperative to promptly identify the potential causes, ranging from benign to life-threatening conditions, to initiate prompt intervention and minimize morbidity and mortality, particularly in this vulnerable population.
Imaging of acute small bowel pathologies in oncology patients in the ER part I: the role of Computed Tomography (CT) for the evaluation of Tumor and infections
Hajra Arshad · Satomi Kawamoto · Linda C. Chu · Elliot K. Fishman
Emergency Radiology 2025 (in press) - Small bowel obstruction (SBO) can result from intrinsic, extrinsic, or functional causes. Intrinsic malignant obstruction, characterized by an intraluminal or intramural mass, is more frequently caused by metastatic tumors compared to primary small bowel tumors, which consist of less than 2% of all gastrointestinal (GI) cancers [10]. The most common primary small bowel tumors are adenocarcinoma, carcinoid, and gastrointestinal stromal tumors, while common primary tumors that metastasize to the small bowel include melanoma, breast, colorectal, and ovarian cancers [11]. SBO due to malignancy accounts for 2–10% of all cases, being the third leading cause of SBO after adhesions and hernia.
Imaging of acute small bowel pathologies in oncology patients in the ER part I: the role of Computed Tomography (CT) for the evaluation of Tumor and infections
Hajra Arshad · Satomi Kawamoto · Linda C. Chu · Elliot K. Fishman
Emergency Radiology 2025 (in press) - Bowel perforation is a life-threatening medical emergency that typically necessitates prompt surgical intervention, particularly in patients undergoing oncologic treatment. The underlying etiology may stem from tumor growth and necrosis, resulting in invasion and rupture through the bowel wall. Alternatively, it could occur secondary to malignant SBO or, less commonly, typhlitis characterized by transmural bowel inflammation and necrosis. Bowel perforation is more common in patients with lymphoma, especially those receiving chemotherapy, and in malignant stromal tumors of the small bowel. A review of lymphoma patients reported a 9% gastrointestinal perforation rate, with 59% of cases occurring in the small bowel.”
Imaging of acute small bowel pathologies in oncology patients in the ER part I: the role of Computed Tomography (CT) for the evaluation of Tumor and infections
Hajra Arshad · Satomi Kawamoto · Linda C. Chu · Elliot K. Fishman
Emergency Radiology 2025 (in press) - Intussusception involves one bowel segment (intussusceptum) telescoping into an adjacent segment (intussuscipiens), often with its mesentery. Asymptomatic transient intussusception occurs without an attributable cause and does not require surgical intervention, however, symptomatic intussusception frequently causes bowel obstruction. Symptomatic intussusception is a rare phenomenon in adults and mostly occurs in the small bowel with benign or malignant tumors acting as the lead point in 90% of the cases and may present with clinical symptoms similar to SBO.
Imaging of acute small bowel pathologies in oncology patients in the ER part I: the role of Computed Tomography (CT) for the evaluation of Tumor and infections
Hajra Arshad · Satomi Kawamoto · Linda C. Chu · Elliot K. Fishman
Emergency Radiology 2025 (in press) - Small bowel volvulus (SBV) is an extremely rare phenomenon in adults which is characterized by the twisting of a segment of small intestine around its mesenteric axis, leading to obstruction and potential ischemia. It can be either primary, without any underlying cause or secondary, associated with acquired conditions like postsurgical adhesions, anatomical bands, pregnancy, congenital malrotation or tumors. Cancer patients may be at increased risk for secondary SBV due to factors such as adhesions from prior surgeries, tumor masses, or treatment- induced changes in bowel motility. Due to high risk of bowel necrosis, early diagnosis and prompt surgical management are important.
Imaging of acute small bowel pathologies in oncology patients in the ER part I: the role of Computed Tomography (CT) for the evaluation of Tumor and infections
Hajra Arshad · Satomi Kawamoto · Linda C. Chu · Elliot K. Fishman
Emergency Radiology 2025 (in press) - “Oncology patients, especially those undergoing chemotherapy, are highly susceptible to thromboembolic events (TEE), obstructing the superior mesenteric vessels, with venous thrombosis more common than arterial . Occasionally, large tumor growth can directly obstruct the vessels due to mass effect. In rare instances, mesenteric ischemia can be the presenting symptom that leads to the diagnosis of an underlying malignancy, as reported in a case of spindle cell carcinoma of the lung . The diagnosis of mesenteric ischemia in cancer patients can be challenging, as symptoms may be non-specific and overlap with other treatment-related complications. CT scan depicts bowel wall thickening and distention with mesenteric edema and ascites, however, these findings are common in other inflammatory or infectious causes..”
Imaging of acute small bowel pathologies in oncology patients in the ER part I: the role of Computed Tomography (CT) for the evaluation of Tumor and infections
Hajra Arshad · Satomi Kawamoto · Linda C. Chu · Elliot K. Fishman
Emergency Radiology 2025 (in press) - “Due to decreased immunity and the toxic effects of various treatment modalities, oncology patients are highly susceptible to new infections or the reactivation of latent ones. Different types of infections with their effects on small bowel and imaging findings are summarized in Table 1. The most frequent infections are caused by bacterial and viral agents and commonly involve the distal small bowel and colon. Figure 9 describes a case of infectious enterocolitis with 3D CR images illustrating the internal structures in depth, aiding clinicians and radiologists in achieving an accurate diagnosis. Enteritis caused by infections, ischemia or inflammation, present with similar radiologic findings making it challenging to make a confirmatory diagnosis.”
Imaging of acute small bowel pathologies in oncology patients in the ER part I: the role of Computed Tomography (CT) for the evaluation of Tumor and infections
Hajra Arshad · Satomi Kawamoto · Linda C. Chu · Elliot K. Fishman
Emergency Radiology 2025 (in press) 
Imaging of acute small bowel pathologies in oncology patients in the ER part II: the role of computed tomography (CT) in detection of treatment‑related small bowel complications
Hajra Arshad1 · Satomi Kawamoto1 · Linda C. Chu1 · Elliot K. Fishman1
Emergency Radiology 2025 (in press)- Oncology patients frequently undergo abdominal surgeries for the resection of tumors, metastases, or the management of tumor-related complications. Intraperitoneal adhesions can develop as part of the body’s healing mechanism following surgical intervention. Peritoneal adhesions are the underlying cause of 65–75% of small bowel obstructions with significant variation in the time between the initial abdominal surgery and the first occurrence of acute small bowel obstruction (SBO), ranging from 8 days to 60 years, with an average interval of 3.7 to 8.9 years.
Imaging of acute small bowel pathologies in oncology patients in the ER part II: the role of computed tomography (CT) in detection of treatment‑related small bowel complications
Hajra Arshad · Satomi Kawamoto · Linda C. Chu · Elliot K. Fishman
Emergency Radiology 2025 (in press) - Another prevalent surgical complication is an anastomotic leak (AL), which can manifest as a small, contained leak without symptoms or as a more severe complications such as an abdominal abscess or peritonitis, potentially leading to sepsis and organ failure. Given the high frequency of abdominal surgeries in cancer patients, there is a corresponding elevated risk of complications resulting in emergency department (ED) presentations for acute abdomen. It is paramount to recognize these complications on radiological imaging for appropriate treatment planning. CT scans are commonly used as the diagnostic modality that may show signs of SBO, with dilated bowel loops and feces sign, and cause for obstruction such as intraabdominal adhesions.
Imaging of acute small bowel pathologies in oncology patients in the ER part II: the role of computed tomography (CT) in detection of treatment‑related small bowel complications
Hajra Arshad · Satomi Kawamoto · Linda C. Chu · Elliot K. Fishman
Emergency Radiology 2025 (in press) - Patients with hematologic cancers often undergo hematopoietic stem cell transplantations (HSCT). However, a major cause of morbidity and mortality in such patients is graft-versus-host disease (GVHD), occurring in about half of the patients undergoing HSCT. It is characterized by donor immunocompetent T cells attacking the host tissues, commonly gastrointestinal tract, skin, mucosa, liver and lungs. Acute GVHD, arising within 100 days post-transplantation, is triggered by tissue damage caused by pre-transplant conditioning treatments leading to a T-cell-driven inflammatory response that targets the skin, gastrointestinal tract, and liver. In contrast, chronic GVHD generally appears after the initial 100 days involving dysregulated B and T cell immunity, impacting various organs, often leading to fibrosis. In the gastrointestinal tract, GVHD mostly affect the small intestine, commonly the ileum.
Imaging of acute small bowel pathologies in oncology patients in the ER part II: the role of computed tomography (CT) in detection of treatment‑related small bowel complications
Hajra Arshad · Satomi Kawamoto · Linda C. Chu · Elliot K. Fishman
Emergency Radiology 2025 (in press) - Abdominopelvic radiotherapy (RT) is employed for the treatment of various gastrointestinal, urologic, and gynecologic malignancies. The small bowel exhibits significant radiosensitivity, with tolerance doses ranging from 4500 to 6500 cGy, corresponding to a 5% to 50% risk of injury within five years of radiation exposure. Radiation-induced bowel toxicity can manifest as acute or chronic forms. Acute intestinal injury, which develops within a few days after RT, is caused by crypt epithelial cell death and inflammation, leading to mucosal barrier disruption, presenting with symptoms of enteritis. Delayed or chronic complications arise three months to several years after the initial RT and are characterized by irreversible changes including fibrosis, dysmotility, muscular atrophy, vascular sclerosis, which may present with symptoms of bowel obstruction and perforation. It has been reported that approximately half of the patients who undergo abdominopelvic RT experience chronic intestinal dysfunction to varying degrees, and radiation enteropathy stands out as one of the most prevalent side effects, among long-term cancer survivors.
Imaging of acute small bowel pathologies in oncology patients in the ER part II: the role of computed tomography (CT) in detection of treatment‑related small bowel complications
Hajra Arshad · Satomi Kawamoto · Linda C. Chu · Elliot K. Fishman
Emergency Radiology 2025 (in press) - Imaging features of gastrointestinal toxicity depend on the time of presentation including wall thickening and edema, luminal narrowing, loss of wall folds, strictures, and fistulas [13]. These changes may resemble inflammatory conditions, GVHD, ischemic injury, or post-surgical adhesions. However, a key distinguishing feature of radiation-induced injury is that the affected bowel segments correspond to the radiation field. There is little that can be done to treat it; however, early detection can guide preventive strategies to prevent long-term morbidity. Figure 5 illustrates the matted appearance of the bowel due to post-RT fibrosis, clearly exhibited in CR images that highlight the structural changes such as thickened walls and loss of normal anatomy.
Imaging of acute small bowel pathologies in oncology patients in the ER part II: the role of computed tomography (CT) in detection of treatment‑related small bowel complications
Hajra Arshad · Satomi Kawamoto · Linda C. Chu · Elliot K. Fishman
Emergency Radiology 2025 (in press) - Chemotherapeutic agents, while effective in targeting rapidly dividing cancer cells, can inadvertently cause substantial damage to the rapidly regenerating gastrointestinal lining, resulting in a range of gastrointestinal complications. It can lead to mucositis, diarrhea and constipation. Neutropenic enterocolitis is a complication of several chemotherapy agents due to both severe neutropenia and direct toxicity to the intestinal mucosa with superimposed bacterial infection. It commonly presents with typical abdominal pain, nausea, bloating and diarrhea. Focal or diffuse thickening of the bowel wall with contrast enhancement and dilatation are typical features on CT scan. This presents similar to infectious or ischemic injury; thus, clinical history is important to distinguish among them.
Imaging of acute small bowel pathologies in oncology patients in the ER part II: the role of computed tomography (CT) in detection of treatment‑related small bowel complications
Hajra Arshad · Satomi Kawamoto · Linda C. Chu · Elliot K. Fishman
Emergency Radiology 2025 (in press) - Vascular endothelial growth factors (VEGF) and angiopoietins play a fundamental role in tumor angiogenesis. A phase 3 trial of bevacizumab, an anti-VEGF, combined with platinum/ taxane based chemotherapy reported that use of bevacizumab is associated with increased risk of bowel perforation, fistula, necrosis, or bleeding. Imaging features are based on the complications that arise post-treatment, for example SBO, perforation, fistula or ischemic changes. Due to similar radiological findings as compared to other drug induced injury, clinical and histopathological correlation is often required for confirmation of diagnosis.
Imaging of acute small bowel pathologies in oncology patients in the ER part II: the role of computed tomography (CT) in detection of treatment‑related small bowel complications
Hajra Arshad · Satomi Kawamoto · Linda C. Chu · Elliot K. Fishman
Emergency Radiology 2025 (in press) - Non-chemotherapy medications commonly used in cancer patients for pain and symptom management can significantly impact gastrointestinal health. Opioid analgesics, while effective for pain management, frequently induce bowel dysfunction, characterized by constipation and reduced motility through the activation of enteric opioid receptors . Corticosteroids, essential for managing cancer-related symptoms, may contribute to mucosal atrophy and increase susceptibility to ulceration. Nonsteroidal anti-inflammatory drugs (NSAIDs) can cause small bowel injury through prostaglandin inhibition, leading to compromised mucosal defense mechanisms. Endoscopy or enterography can help visualize ulcers or mucosal atrophy/damage.
Imaging of acute small bowel pathologies in oncology patients in the ER part II: the role of computed tomography (CT) in detection of treatment‑related small bowel complications
Hajra Arshad · Satomi Kawamoto · Linda C. Chu · Elliot K. Fishman
Emergency Radiology 2025 (in press) - Acute abdomen, a common ED presentation in cancer patients, is often challenging for radiologists in oncological patients due to complex anatomical changes, especially the small bowel, which has a wide range of pathologies that can have similar CT appearances. We have presented a range of cases demonstrating the utility of CT scan and 3D postprocessing in evaluating treatment related small bowel complications presenting as acute abdomen in the ED, as summarized in the visual abstract. Radiologists play a critical role in early detection of treatment induced injury on imaging, thus, they must be familiar with the key imaging features to help with timely diagnosis and management.
Imaging of acute small bowel pathologies in oncology patients in the ER part II: the role of computed tomography (CT) in detection of treatment‑related small bowel complications
Hajra Arshad · Satomi Kawamoto · Linda C. Chu · Elliot K. Fishman
Emergency Radiology 2025 (in press)
Imaging of acute small bowel pathologies in oncology patients in the ER part II: the role of computed tomography (CT) in detection of treatment‑related small bowel complicationsSpleen
- “Fortunately, most incidental splenic lesions are benign and clinically insignificant. Although supporting literature is sparse, the white paper on incidental findings by the American College of Radiology (ACR) suggests that splenic lesions smaller than 1 cm in a patient without malignancy are likely benign and do not warrant further imaging. Primary malignant splenic lesions are extremely rare and tend to grow rapidly, whereas benign lesions grow at a rate of less than 3 mm per year. Therefore, small size and stability over 1 year are considered excellent markers for benignity in splenic lesions.”
Incidental Splenic Lesions: A Proposed Algorithm for Assessment and Management
Myles T. Taffel, MD1, Julie Y. An, MD1, Frank H. Miller et al.
Roentgen Ray Rev 2025; 1:e2401039 - “The primary objective of imaging and classification is not necessarily to pinpoint an exact diagnosis but to differentiate between indolent and potentially aggressive lesions, guiding appropriate follow-up or intervention on the basis of malignancy risk.”
Incidental Splenic Lesions: A Proposed Algorithm for Assessment and Management
Myles T. Taffel, MD1, Julie Y. An, MD1, Frank H. Miller et al.
Roentgen Ray Rev 2025; 1:e2401039 - Before a lesion is classified as incidental, clinical factors and concomitant nonsplenic imaging findings must exclude the possibility of acute hematoma, abscess, or malignancy. Acute splenic hematomas are almost always the result of recent blunt trauma and should be considered in patients with a compatible history. Abscesses typically present with fever, abdominal pain, chills, and leukocytosis. Microabscesses, often fungal in origin, are encountered in patients who are immunocompromised because of chemotherapy, chronic steroid use, organ transplant, or HIV. Imaging reveals numerous similarly sized small lesions, usually accompanied by hepatic involvement.
Incidental Splenic Lesions: A Proposed Algorithm for Assessment and Management
Myles T. Taffel, MD1, Julie Y. An, MD1, Frank H. Miller et al.
Roentgen Ray Rev 2025; 1:e2401039 - Lymphoma is the most common malignancy involving the spleen. Symptoms include left upper quadrant pain and constitutional systemic symptoms like weight loss, malaise, and fever . As the majority of patients have disseminated lymphoma at presentation, concomitant lymphadenopathy aids in the diagnosis . Nevertheless, primary splenic lymphoma can rarely occur, making up less than 1% of all lymphomas, and is usually non-Hodgkin type.
Incidental Splenic Lesions: A Proposed Algorithm for Assessment and Management
Myles T. Taffel, MD1, Julie Y. An, MD1, Frank H. Miller et al.
Roentgen Ray Rev 2025; 1:e2401039 - Isolated splenic lymphoma presents as solitary or multiple nodules. The nodules typically appear hypoattenuating on CT, hypointense on T1-weighted MRI, and are often hypointense or isointense on T2-weighted MRI. They show hypoenhancement, with restricted diffusion relative to surrounding parenchyma. Given the normally heterogeneous parenchymal enhancement in the arterial phase, hypoenhancing lesions are frequently better detected in the late venous or equilibrium phase of postcontrast imaging. In the absence of suspicious imaging features, these lesions may be indistinguishable from other solid lesions. Lymphoma will show avid FDG uptake on PET/CT, which may be useful in staging. When FDG avidity is absent, lymphoma is unlikely.
Incidental Splenic Lesions: A Proposed Algorithm for Assessment and Management
Myles T. Taffel, MD1, Julie Y. An, MD1, Frank H. Miller et al.
Roentgen Ray Rev 2025; 1:e2401039 - Although angiosarcoma is the most common primary splenic malignancy, it remains extremely rare with an annual incidence of 0.14–0.25 cases per million. Predominantly affecting middle-aged to elderly patients, angiosarcomas typically present with abdominal pain and weight loss; splenomegaly is common, with splenic rupture reported in up to 30%. Imaging typically shows aggressive features such as irregular shape and ill-defined margins, and it can present as a large dominant lesion or multiple nodules. On MRI, lesions are typically T1 hypointense and T2 hyperintense; however, the presence of any of necrosis, hemorrhage, hemosiderin, or calcifications can lead to signal heterogeneity. Areas of hemorrhage may cause T1 hyperintensity, whereas hemosiderin or calcifications may result in T2 hypointensity. After IV contrast administration, masses are usually heterogeneously enhancing. This heterogeneityis greater than seen in hemangiomas and may be so pronounced that the mass appears cystic. Tumors can infiltrate beyond the splenic capsule and present with local or distant metastases.
Incidental Splenic Lesions: A Proposed Algorithm for Assessment and Management
Myles T. Taffel, MD1, Julie Y. An, MD1, Frank H. Miller et al.
Roentgen Ray Rev 2025; 1:e2401039 - “The proposed Sp system presented here is based on expert consensus and has not yet undergone formal validation. Future studies are needed to assess its interreader reliability, diagnostic accuracy, and clinical utility. Despite these limitations, the framework provides a starting point to guide radiologists in evaluating and managing incidental splenic lesions, with the ultimate goal of improving patient care.”
Incidental Splenic Lesions: A Proposed Algorithm for Assessment and Management
Myles T. Taffel, MD1, Julie Y. An, MD1, Frank H. Miller et al.
Roentgen Ray Rev 2025; 1:e2401039
Vascular
- “Pulmonary artery (PA) aneurysms are rare vascular abnormalities with potentially life-threatening complications such as rupture, massive hemoptysis, and pulmonary infarction. These conditions are often asymptomatic and incidentally detected but can present with nonspecific symptoms like cough, dyspnea, or hemoptysis in an emergency setting. Multidetector CT pulmonary angiography (CTPA) has outshone traditional angiography, supplemented by advanced 3D post-processing techniques such as maximum intensity projection (MIP), volumetric rendering (VR), and cinematic rendering (CR) techniques, playing a pivotal role in diagnosis and management of PA aneurysms.”
CT imaging of pulmonary artery aneurysms in the emergency department - What you need to know.
Yasrab M, Crawford CK, Fishman EK, Kawamoto S.
Curr Probl Diagn Radiol. 2025 May 17:S0363-0188(25)00094-5. - “Pulmonary artery (PA) aneurysms are rare vascular abnormalities involving the PA or its branches, with an incidence of 0.007 % according to classical autopsy series. In an emergency setting, they can pose a risk of rupture and massive hemoptysis, which itself has a mortality rate of over 50 % if untreated. Ten percent of massive hemoptysis is due to PA pathology, most commonly aneurysms and pseudoaneurysms. True PA aneurysms are dilatations involving all three layers of the vessel, whereas pseudoaneurysms are outpouchings contained by the innermost layer, with a comparatively higher risk of rupture. Other complications include thrombosis and dissections, which can lead to pulmonary infarction.”
CT imaging of pulmonary artery aneurysms in the emergency department - What you need to know.
Yasrab M, Crawford CK, Fishman EK, Kawamoto S.
Curr Probl Diagn Radiol. 2025 May 17:S0363-0188(25)00094-5. - “PA aneurysms can be idiopathic or develop in association with various underlying etiologies, including congenital cardiovascular anomalies, infections, neoplastic processes, trauma, connective tissue disorders, and systemic inflammatory conditions. Iatrogenic injury during catheterization can also predispose to aneurysm and pseudoaneurysm formation, with the latter more frequently a consequence of trauma or infection. Patients are often asymptomatic with aneurysms being discovered incidentally during imaging for other reasons; however, when symptomatic, patients can present with nonspecific complaints including cough, dyspnea, and/or hemoptysis, as well as palpitations or syncope. Additional symptoms can provide further diagnostic clues depending on the underlying cause.”
CT imaging of pulmonary artery aneurysms in the emergency department - What you need to know.
Yasrab M, Crawford CK, Fishman EK, Kawamoto S.
Curr Probl Diagn Radiol. 2025 May 17:S0363-0188(25)00094-5. - Causes of PA Aneurysms and Pseudoaneurysms
- “At our institution, CTPA is currently performed on 64- or 128-detector multidetector CT (MDCT) scanners (Somatom Definition Force or Siemens Definition Flash, Siemens Healthcare, Erlangen, Germany). Scans are performed in a craniocaudal direction from the lung apices to the diaphragm. 100 ml of intravenous (IV) non-ionic contrast (Omnipaque 350 mg I/ml, GE Healthcare) is injected peripherally at a rate of 4- 5 ml/second. 200 HU or 250 HU trigger threshold is set for bolus tracking at the pulmonary trunk as the region of interest. Tube potential is set at 100-120 kV, tube current at 120-200 mA (automatically modulated with CareDose, Siemens), and collimation of 128 × 0.6 mm. Scan time is usually under 10 seconds and can be even shorter when using high pitch scanners.”
CT imaging of pulmonary artery aneurysms in the emergency department - What you need to know.
Yasrab M, Crawford CK, Fishman EK, Kawamoto S.
Curr Probl Diagn Radiol. 2025 May 17:S0363-0188(25)00094-5. - “Involvement of more peripheral branches and multiple sites of aneurysm formation should raise concern for systemic pathologies including connective tissue disease and vasculitis. This is especially true in younger patients who present with PA aneurysms and may even show involvement of the aorta and its branches, for instance in Marfan’s syndrome.8 Behcet’s disease is a systemic vasculitis predominantly common in Middle Eastern, Asian, and particularly Turkish populations, is another important cause for PA aneurysms. Obliterative endarteritis of the vasa vasorum (in Behcet’s disease) results in aneurysm formation, which can have variable sizes and locations involving the segmental and even subsegmental PA branches and associated thrombosis in up to a third of these cases."
CT imaging of pulmonary artery aneurysms in the emergency department - What you need to know.
Yasrab M, Crawford CK, Fishman EK, Kawamoto S.
Curr Probl Diagn Radiol. 2025 May 17:S0363-0188(25)00094-5. - Pseudoaneurysms secondary to trauma or iatrogenic injury (including right heart or Swan-Ganz catheterization) are often associated with pulmonary hemorrhage with active extravasation, and consolidation or ground-glass opacities appreciated on lung windows. Multiple pseudoaneurysms can also develop in association with endocarditis, septic emboli, or lung metastases, in which cases there is a higher predilection for involvement of subsegmental branches. Infection remains the most common etiology for pseudoaneurysms (i.e. mycotic aneurysms) as granulation tissue erodes the vessel wall, although we see lower rates of the classically described Rasmusen aneurysm (secondary to tuberculosis) due to decreasing infection rates in developed countries. Nonetheless, signs and symptoms of infection with possible cavitary lesions with enhancing walls and consolidation in association with the aneurysm should prompt further workup.
CT imaging of pulmonary artery aneurysms in the emergency department - What you need to know.
Yasrab M, Crawford CK, Fishman EK, Kawamoto S.
Curr Probl Diagn Radiol. 2025 May 17:S0363-0188(25)00094-5. - Diagnosing PA aneurysms in the emergency department can be challenging due to their nonspecific symptoms like cough, dyspnea, and hemoptysis, which overlap with various pulmonary and cardiovascular diseases. Achieving optimal image quality is essential; issues such as patient movement, improper contrast timing, and technical limitations can significantly affect the resolution of standard axial images, and therefore the effectiveness of advanced postprocessing techniques like MIP, VR, and 3D CR, all of which rely on high quality standard 2D acquisitions. Additionally, precise timing of contrast administration and image acquisition is critical for adequate enhancement of the pulmonary vessels without obscuring aneurysmal features, which is particularly challenging in unstable patients where it may not be clear where the bleeding is originating from. Even in the case of hemorrhage, a CTPA is recommended to determine whether the source of the bleeding is from the pulmonary vessels or the bronchial arteries.
CT imaging of pulmonary artery aneurysms in the emergency department - What you need to know.
Yasrab M, Crawford CK, Fishman EK, Kawamoto S.
Curr Probl Diagn Radiol. 2025 May 17:S0363-0188(25)00094-5. - “Management of PA aneurysms often hinges on multiple factors, including the aneurysm’s size and location, and the patient’s stability, with a notable absence of consensus guidelines for intervention thresholds. The wide array of potential etiologies, from congenital defects to acquired diseases like connective tissue disorders or infections, demands a broad differential diagnosis that influences treatment choices based on the individual pathology and the patient’s condition after initial stabilization.”
CT imaging of pulmonary artery aneurysms in the emergency department - What you need to know.
Yasrab M, Crawford CK, Fishman EK, Kawamoto S.
Curr Probl Diagn Radiol. 2025 May 17:S0363-0188(25)00094-5. - “In summary, PA aneurysms and pseudoaneurysms are rare but critical findings in the emergency setting. CTPA, supported by advanced techniques, serves as an efficient imaging modality of choice for accurate diagnosis and effective procedural planning. The wide spectrum of underlying causes and potential complications highlights the importance of a personalized approach to management, balancing patient stability and risk of rupture. Through these illustrative cases, we aim to emphasize the indispensable role of radiological imaging in identifying and addressing these high-risk vascular abnormalities in an emergency setting.”
CT imaging of pulmonary artery aneurysms in the emergency department - What you need to know.