This week in Radiology

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Welcome to This Week in Radiology. This week we're covering 10 notable papers spanning cardiac imaging that guides intervention, oncologic staging and detection, and procedural safety and quality in everyday practice. Let's dive in.

Cardiac imaging is moving from diagnosis toward directly planning and guiding structural and coronary procedures. The headline paper is in the New England Journal of Medicine, where Collet and colleagues randomized just over eleven hundred patients with a high-grade epicardial stenosis and a CT-derived fractional flow reserve of 0.80 or less to either coronary CT angiography-guided or intravascular ultrasound-guided percutaneous coronary intervention [1]. Intravascular ultrasound guidance already has outcome data behind it, so it was a demanding comparator. At twelve months, target-vessel failure occurred in about four percent of patients in each arm, 23 patients with CT guidance and 25 with intravascular ultrasound, which met the prespecified noninferiority margin, though CT guidance was not superior. Procedural complications were few in both groups. This is a single open-label trial funded by CT and software vendors, with follow-up limited to one year and only about a fifth of participants women, so it establishes noninferiority for this selected population rather than settling long-term equivalence. Still, it strengthens the case that a well-performed pre-procedural CT can carry much of the planning work. Complementing that, European Radiology publishes a joint consensus from the European Society of Cardiovascular Radiology and the North American Society for Cardiovascular Imaging, led by Palmisano, on CT and MRI around transcatheter mitral valve replacement [2]. The document standardizes acquisition protocols, key measurements and structured reporting for device selection and follow-up. It is expert opinion rather than new outcome data, but it gives cardiovascular imagers a shared template at a time when mitral interventions are expanding.

In oncologic imaging, several papers test whether better pictures actually change management. In Radiology, Gardfjell and colleagues report the PROCEM randomized trial from two Swedish breast centers, assigning about four hundred women with early breast cancer to preoperative contrast-enhanced mammography or standard workup [3]. The trial did not meet its primary end point: treatment changed in about eight percent of women, short of the ten percent target, and there was no evidence of difference in mastectomy or reoperation rates. Contrast-enhanced mammography did, however, estimate tumor extent most closely against pathology, with a bias of about three and a half millimetres versus nearly five for mammography and tomosynthesis and nearly eleven for ultrasound, except in ductal carcinoma in situ. So the evidence supports its accuracy for sizing, but not yet a measurable surgical benefit. Also in Radiology, Ulaner and colleagues ran a phase 2 trial of a CD38-targeted immuno-PET tracer, zirconium 89 labelled daratumumab, against FDG PET in 60 patients with multiple myeloma [4]. Overall detection was similar, with just under half of patients positive on each scan, but the new tracer alone found biopsy-confirmed active myeloma in eight patients, about one in eight. That is promising but small and early, and suggests complementary rather than replacement value. Lung staging gets attention from Li and colleagues, again in Radiology, in a retrospective series of over fourteen hundred part-solid adenocarcinomas [5]. Nodal metastasis occurred in about five percent overall, in none of the 115 patients with a consolidation-to-tumor ratio of 0.25 or less, and in only one patient among 552 with a solid component of 6 millimetres or less. Solid portion diameter was the only independent predictor and outperformed consolidation-to-tumor ratio, with each additional millimetre raising the odds by roughly a quarter and a 7.3 millimetre cutoff catching nearly all nodal disease. Being single-cohort and retrospective, it informs rather than settles debates about limited nodal evaluation. On liver imaging, the Journal of Magnetic Resonance Imaging publishes an individual participant data meta-analysis by Lam and colleagues covering more than eight and a half thousand at-risk patients across 64 studies [6]. Dropping threshold growth and applying a single 10 millimetre size cutoff kept overall accuracy essentially unchanged while nudging LR-5 sensitivity up by about two points, with no loss of specificity or positive predictive value; higher cutoffs clearly hurt sensitivity. Only 17 of the 64 studies were at low risk of bias, so this is a strong argument for simplification that LI-RADS committees will need to weigh. Rounding out the theme, a Korean Journal of Radiology review by Park and colleagues outlines imaging features of IDH-mutant gliomas now that the IDH inhibitor vorasidenib has entered treatment [7], a useful primer as neuroradiology reports increasingly shape treatment decisions.

Our final theme covers procedural safety and the quality of what we deliver. In European Radiology, Chan and colleagues pooled ten studies and about twenty-two hundred patients on saline tract sealing after CT-guided lung biopsy [8]. Sealing was associated with roughly forty percent fewer pneumothoraces and about seventy percent fewer chest drains, holding up when studies using rapid rollover were excluded. But only one study was randomized, heterogeneity was high, and the authors rate certainty as very low, so this is a cheap technique with encouraging but unconfirmed support. In Radiology, Li and colleagues compared ultrasound-guided microwave ablation plus ethanol injection with surgery for nodular retrosternal goiter in about 450 propensity-matched patients followed for a median of four years [9]. Treatment success was comparable, at nearly one hundred percent in both arms, while complications fell from about a third of surgical patients to around two percent with ablation, alongside shorter stays and lower cost. It is retrospective and from experienced centers, so selection effects remain possible. Finally, in the Journal of the American College of Radiology, Smith-Bindman and colleagues report early results from the CMS ExRad measure across 254 facilities and nearly 800,000 CT examinations [10]. Close to a third of examinations were out of range, almost entirely for excess dose rather than noise. Facility scores ranged widely, with the worst-performing tenth of facilities having more than four times the out-of-range rate of the best tenth, and within a single facility, categories differed by a median of 74 points. The authors conclude that improvement depends on category-level, protocol-specific feedback rather than facility-wide scores.

If you only have time for one paper this week, make it the coronary CT angiography versus intravascular ultrasound trial in the New England Journal of Medicine [1]. It is the first randomized outcome evidence that CT-based planning can match an established intravascular standard, reopening the question of how much coronary procedural guidance can shift to the radiologist's workstation.

That's your roundup for This Week in Radiology. The full transcript and references are available on the episode page. See you next week.

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