Objectives: There has been slow adoption of thyroid ultrasound guidelines with adherence rates as low as 30% and no population-based studies investigating adherence to guideline-based malignancy risk assessment. We therefore evaluated the impact of adherence to the 2015 ATA guidelines or 2017 ACR-TIRADS guidelines on the quality of thyroid ultrasound reports in our healthcare region. Methods: We reviewed 899 thyroid ultrasound reports of patients who received fine-needle aspiration biopsy and were diagnosed with Bethesda III or IV nodules or thyroid cancer. Ultrasounds were reported by radiology group 1, group 2, or other groups, and were divided into pre-2018 (before guideline adherence) or 2018 onwards. Reports were given a utility score (0–6) based on how many relevant nodule characteristics were included. Results: Group 1 had a pre-2018 utility score of 3.62 and 39.4% classification reporting rate, improving to 5.77 and 97.0% among 2018-onwards reports. Group 2 had a pre-2018 score of 2.8 and reporting rate of 11.5%, improving to 5.58 and 93.3%. Other radiology groups had a pre-2018 score of 2.49 and reporting rate of 32.2%, improving to 3.28 and 61.8%. Groups 1 and 2 had significantly higher utility scores and reporting rates in their 2018-onward reports when compared to other groups’ 2018-onward reports, pre-2018 group 1 reports, and pre-2018 group 2 reports. Conclusions: Dedicated adherence to published thyroid ultrasound reporting guidelines can lead to improvements in report quality. This will reduce diagnostic ambiguity and improve clinician’s decision-making, leading to overall reductions in unnecessary FNA biopsy and diagnostic surgery.

Real-world evidence surrounding EGFR positive NSCLC patients in Canada is limited. Administrative databases in Alberta, Canada were used to evaluate EGFR testing and mutation prevalence in de novo metastatic NSCLC, as well as the characteristics, treatment patterns, and outcomes of individuals with Exon 19, L858R and Exon20ins mutations. Between 2013–2019, 2974 individuals underwent EGFR testing, of which 451 (15.2%) were EGFR positive. Among EGFR positive individuals, 221 (49.0%) had an Exon 19 mutation, 159 (35.3%) had an L858R mutation, and 18 (4%) had an Exon20ins mutation. The proportion of individuals who initiated 1L systemic therapy was 89.1% for Exon19, 85.5% for L858R, and 72.2% for Exon20ins carriers. The primary front-line systemic therapy was gefitinib or afatinib monotherapy for individuals with Exon 19 (93.4%) and L858R (94.1%) mutations versus platinum combination therapy for individuals with Exon20ins mutations (61.5%). The Exon20ins cohort had worse median overall survival from initiation of 1L systemic therapy (10.5 months [95% CI: 8.0-not estimable]) than the Exon19 (20.6 months [95% CI: 18.4–24.9]), and L858R cohorts (19.1 months [95% CI: 14.5–23.1]). These findings highlight that Exon20ins mutations represent a rare subset of NSCLC in which treatment options are limited and survival outcomes are worse relative to individuals with more common types of EGFR mutations.

The most recent guidelines for magnetic resonance imaging (MRI) in multiple sclerosis (MS) recommend three-dimensional (3D) MRI sequences over their two-dimensional (2D) counterparts. This development has been made possible by advances in MRI scanner hardware and software. In this article, we review the 3D versions of conventional sequences, including T1-weighted, T2-weighted and fluid-attenuated inversion recovery (FLAIR), as well as more advanced scans, including double inversion recovery (DIR), FLAIR², FLAIR*, phase-sensitive inversion recovery, and susceptibility weighted imaging (SWI).

Objective: The aim of this study was to prospectively evaluate the quality of postoperative neck ultrasound (POU) for thyroid cancer patients after implementing European Thyroid Association (ETA) guideline-based POU assessment. Methods: Our analysis involved 672 differentiated thyroid cancer patients. POU report quality was compared between the implementation radiology group (IRG), which implemented ETA guideline-based assessment in 2018, and all non-implementation radiology groups (NIRG). Differences in POU quality were evaluated before and after the implementation of guideline-based assessment. Additionally, we evaluated the ability of serum thyroglobulin (Tg) level <0.2 ng/mL or between 0.21 and 0.99 ng/mL and normal POU lesion status at 1-year follow-up to predict the absence of persistent disease or relapse at 3-year follow-up. Results: IRG had significantly higher mean utility scores for POU reports of abnormal thyroid bed nodules compared to NIRG (P < 0.001). IRG's POU reports for suspicious nodules and lymph nodes were considered sufficient in 94% and 85% of cases, respectively, compared to 45% and 68% for NIRG. For patients with normal US lesion status and Tg <0.2 ng/mL or Tg 0.21–0.99 ng/mL at 1-year follow-up, the negative predictive values were 96% for both. Conclusions: Implementation of 2013 ETA POU-reporting guidelines allowed for the provision of high-quality POU reports, which may lead to increased accuracy in assessing the response to treatment and in estimating the risk of recurrence of thyroid cancer and likely reduce unnecessary repeat POU or FNA.

Context: Biochemical screening for endocrine hypertension may be complex; the known presence of an adrenal mass markedly increases the pretest probability for adrenal hypertension and may inform diagnostic efforts. Objective: Model the potential incidence of adrenal masses that may be detected by routine adrenal imaging in patients with suspected endocrine hypertension. Design: Retrospective cohort study. Setting: Provincial administrative and clinical databases for radiology and biochemistry, Alberta, Canada. Participants: Patients with hypertension and any measurement of aldosterone-renin ratio (ARR), 2012 to 2019. Main Measures: Radiology report of any computed tomography or magnetic resonance imaging abdomen performed for any reason 0 to 12 years following ARR. Patients with any pre-ARR imaging data between 2002 and 2024 were excluded. The presence of adrenal mass, size, and density were recorded and stratified by imaging indication. Results: Of 6942 unique hypertension patients with ARR, 1462 (21%) had imaging done at some point after ARR, 912 (62.4%) for indications unrelated to hypertension/adrenal and at a median 771 days (69-1577) post ARR. The incidence rate estimate was 7.2% (5.6-9.2%) of scans showed adrenal mass, median 1.4 cm (1.1-2.3), a rate well above the modern series of adrenal incidentaloma prevalence in unselected adults. The number needed to screen in this population was 14 (11-18) to detect an adrenal mass without a priori indication for adrenal imaging. Conclusion: Among patients screened for PA but without prior or subsequent directed adrenal imaging, 1 in 14 were later found to have an adrenal mass on imaging done for other indications. Given the impact on pretest probability for endocrine hypertension and further investigation steps, routine adrenal imaging might be considered whenever PA suspicion is high.

Denosumab is a widely used medication for the treatment of osteoporosis. It has been observed in recent years that abruptly stopping denosumab leads to an increase in bone turnover markers, a decrease in bone mineral density, and a higher incidence of vertebral fractures. We present the case of a 53-year-old woman with few comorbidities and no prior fragility fractures who experienced 4 spontaneous and severely debilitating vertebral fractures 5-months post denosumab discontinuation. At the time of her fractures, she was found to have markedly elevated bone turnover markers, despite bone mineral density that was not significantly changed from measurements done while on denosumab treatment. She went on to be treated with an alternative antiresorptive agent, risedronate, and had substantial declines in her bone turnover markers, along with clinical improvement in her back pain. She experienced no further fractures while on treatment. Abrupt discontinuation of denosumab without starting an alternative antiresorptive agent can lead to spontaneous vertebral fractures. These fractures can occur in young patients with no prior history of fragility fractures and can be severely debilitating. An alternative antiresorptive agent should be started in the case of denosumab discontinuation.