- Email: [email protected]
The Need for Standardization of Musculoskeletal Practice Reporting: Learning From ACR BI-RADS, Liver Imaging–Reporting and Data System, and Prostate Imaging–Reporting and Data System
OPINION
The Need for Standardization of Musculoskeletal Practice Reporting: Learning From ACR BI-RADS, Liver Imaging–Reporting and Data System, and Prostate Imaging–Reporting and Data System Ali Gholamrezanezhad, MD, Michael Kessler, MD, Seyed Mohammadreza Hayeri, MD INTRODUCTION Beyond technological advances, standardization has been a key method for the advancement of the field of radiology. The radiology community has attempted to standardize the communication of findings and interpretations of radiographs and CT and MRI scans by developing guidelines [1,2]. Although these guidelines have been very useful, they still suffer from complexity and heterogeneity in the diversity of the language and structure used, as well as suboptimal correlation of the final diagnostic conclusions among the different guidelines [3]. Newer structured reporting systems, such as the “*RADS,” have made huge strides in improving communication between radiologists and referring providers. However, the continued common use of free-text reports for most radiology dictations contradicts the results of multiple studies that demonstrated how capturing and analyzing medical information in a structured approach improves clinical decision making [4,5]. As a result, the ongoing revolution in the standardization of radiology reporting should focus its attention on a specialty such as musculoskeletal imaging, in which attempts at standardization began more than half a
century ago. In time, musculoskeletal imaging reports can achieve a higher standard of communication with increased comprehensibility in a concise, problem-oriented, and datadriven manner [2,5,6]. The importance of the “final report” in radiology is emphasized by the fact that it remains the mainstay of communication between radiologists and referring providers. The dangers of noninteractive and nonverbal reporting arise from the varied interpretations referring providers may arrive at through personal bias and the inconsistencies in the communication used within reports. It is a common understanding that radiology reports should provide relevant clinical information and recommendations to ordering clinicians in an understandable format, but only 86% of radiology reports have been shown to meet this standard [7,8]. Additionally, Bosmans et al [9] reported a statistically significant difference between practicing radiologists and radiology residents in multiple European countries not only in the length and structure of radiology reports but, more important, in their overall content. Similarly, discordance has been demonstrated between radiologists
ª 2017 American College of Radiology 1546-1440/17/$36.00 n http://dx.doi.org/10.1016/j.jacr.2017.06.019
and nonradiologists in the degree of diagnostic certainty associated with commonly used phrasing in radiology reports [10]. Many publications over the past several decades have proposed various practical and stylistic guidelines. General agreement as to what constitutes a radiology report includes a mention of the image acquisition protocol, a conscientious interpretation, and a deliberate clinical recommendation. Further elaborating a more comprehensive proposal for the composition of an ideal radiology reporting method, Cramer et al [5] and Weiss and Langlotz [11] explained the concept of a three-tiered system of structured reporting. The first tier consists of the use of common headings, such as “Indication,” “Findings,” and “Impression.” This approach, by far the simplest, is used by radiologists throughout the world. The second tier expands on the first by adding subheadings within sections, resulting in what is known as “itemized reporting.” An example would be adding subheadings for organs or organ systems under the “Findings” heading [5]. Although less common than the first tier, many radiologists use this system in daily practice,
1
with many young radiologists adopting this method to assist in developing a thorough search pattern. The final tier proposed by this theory of structured reporting involves the standardization of language [5]. As the top tier, the standardization of language emphasizes how the enforcement of consistent and clear communication at the phrase or word level may accomplish the ultimate goal of improving clinical decision making.
LEARNING FROM THE *RADS Specific attempts have been made to follow the three-tiered system to standardize the structure and language of radiology reports. Initial attempts were made in the late 1980s through the development of the first version of BI-RADS, established by the ACR [12]. Similarly, the ACR convened a committee in 2008 to develop a standardized reporting system for hepatocellular carcinoma, known as the Liver Imaging Reporting and Data System. Subsequently in 2012, an expert panel from the European Society of Urogenital Radiology developed the first version of the Prostate Imaging Reporting and Data System to standardize the interpretation of multiparametric MRI of the prostate [13]. These efforts have been encouraged by third-party payers and the Institute of Medicine, as a part of strategies to reduce medical errors that may affect patient outcomes [14]. Although most radiologists are aware of the *RADS, many may be surprised by the international efforts involved in their creation. The ACR began working with national and international experts in radiology and related specialties [1]. After the 2
first draft proposal, several stages of feedback and iterative revision were undertaken before the initial consensus versions were published. The panels discussed the comprehensive lexicon of controlled terminology as well as suggestions involving uniform reporting, evidence-based management, and appropriate imaging techniques and diagnostic approaches. Since their inception, subsequent updates to these systems have been added, with the inclusion of illustrative atlases and reporting guidelines in efforts to improve and facilitate their use [1]. A crucial element of the *RADS that has helped achieve the goal of delivering clear and concise reports to referring providers is their lexicon, also called “common data elements.” A lexicon, in this sense, is defined as a dictionary of predetermined descriptors of specific imaging findings. The use of a standardized and consistent language style has been shown to improve diagnostic interpretation, interobserver consistency, and data retrieval and billing while decreasing turnaround time and reducing typographic and dictation errors [2,5]. Additionally, studies have shown that consistent terminology can emphasize the interpreting radiologist’s confidence, significantly influencing a clinician’s decision to follow a radiologist’s recommendations [15]. Structured reporting has been shown to enable improved auditing and analysis of data through the use of recognizable and consistent terminology, which has opened up new and more simplified avenues for research and quality improvement [5]. As D’Orsi and Kopans [16] stated more than 20 years ago, Without standardized terms to describe the important
features.there is no means of training or obtaining objective data to improve our specificity. There must be a concise and orderly description of the finding(s) in language understandable to both clinician and radiologist leading to a logical recommendation. Indeed, this format is important for all reports we generate. Finally, standardized reporting has helped in the understanding of the potential medicolegal consequences of the language used in radiology reports and may suggest potential protections for practicing radiologists [15].
A CASE FOR MUSCULOSKELETAL RADIOLOGY The idea of a structured classification of neoplastic bone lesions on radiographic studies was initially proposed more than 50 years ago as the “Lodwick classification.” This system used a systematic approach to categorizing osteolytic bone lesions by differentiating lesions on the basis of their margins [17,18]: n
n n
Type 1: Geographic B Type 1A: Thin, well-marginated, sclerotic border B Type 1B: Distinct, wellmarginated, nonsclerotic border B Type 1C: Indistinct border Type 2: Moth-eaten Type 3: Permeative
This classification scheme was further modified in 1981 by Madewell et al [19] with the goal of decreasing complexity [20] by reordering the categories on the basis of aggressiveness. However, because aggressiveness does not necessarily indicate malignancy (ie, osteomyelitis), Caracciolo et al [20] more recently modified the Lodwick classification
Journal of the American College of Radiology Volume - n Number - n - 2017
system and proposed the modified Lodwick-Madewell grading system, which recategorizes osteolytic lesions into those with low, moderate, or high risk for malignancy. In developing a standardized reporting system for musculoskeletal radiology, it is important to use the valuable research of the previous classification systems while continuing to follow a logical and evidence-based pathway throughout the system’s inception. Like the prior *RADS, the new system would rely on a data-driven lexicon of descriptors previously shown in literature to be predictive of benign and malignant disease, helping reduce the significant interreader variability in the description and interpretation of bone lesions [9]. The structured format for musculoskeletal studies would likely be organized into several sections, such as indication for examination, pertinent findings, comparison with previous examinations, and impression, with a key emphasis on management recommendations [7]. Through the creation of this system and with the participation of organizations such as the ACR and the Society of Skeletal Radiology, it is reasonable to expect that similar clinical, educational, research, and medicolegal advantages as seen with the use of the previous *RADS would come into fruition with the proposed Skeletal Imaging Reporting and Data System, or SI-RADS. Although complete adoption would take time and face many hurdles, the acceptance of BI-RADS has clearly
shown that such a goal is possible. By educating both radiologists and referring providers on a new SI-RADS structured reporting system and understanding critiques and subsequently integrating continual improvements, the ultimate goal of improving patient outcomes, with respect to neoplastic bone lesions, would likely manifest itself through the use of clear and concise communication and promoting the use of radiology practice guidelines.
ACKNOWLEDGMENT We acknowledge editorial assistance from Professor Donald Resnick, University of California, San Diego. REFERENCES 1. American College of Radiology. Liver Imaging Reporting and Data System version 2014. Available at:. http://www.acr.org/Quality-Safe ty/Resources/LIRADS. Accessed December 2016. 2. Liu D, Zucherman M, Tulloss WB Jr. Six characteristics of effective structured reporting and the inevitable integration with speech recognition. J Digit Imaging 2006;19:98-104. 3. Davenport MS, Khalatbari S, Liu PS, et al. Repeatability of diagnostic features and scoring systems for hepatocellular carcinoma by using MR imaging. Radiology 2014;272:132-42. 4. Buntin MB, Jain SH, Blumenthal D. Health information technology: laying the infrastructure for national health reform. Health Aff (Millwood) 2010;29:1214-9. 5. Cramer JA, Eisenmenger LB, Pierson NS, Dhatt HS, Heilbrun ME. Structured and templated reporting: an overview. Appl Radiol 2014;43(8). Available at:. http:// appliedradiology.com/articles/structured-andtemplated-reporting-an-overview. Accessed June 30, 2017. 6. Bosmans JM, Van Goethem JW, De Schepper AM. Structure and content of the radiological report: an audit of 94 reports
7. 8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
from a university education center [article in Dutch]. JBR-BTR 2004;87:260-4. Cohen M. Content of a radiology report. Pediatr Radiol 2009;39:1254. Lee R, Cohen MD, Jennings GS. A new method of evaluating the quality of radiology reports. Acad Radiol 2006;13:241-8. Bosmans JM, Weyler JJ, Parizel PM. Structure and content of radiology reports, a quantitative and qualitative study in eight medical centers. Eur J Radiol 2009;72:354-8. Khorasani R, Bates DW, Teeger S, Rothschild JM, Adams DF, Seltzer SE. Is terminology used effectively to convey diagnostic certainty in radiology reports? Acad Radiol 2003;10:685-8. Weiss DL, Langlotz CP. Structured reporting: patient care enhancement or productivity nightmare? Radiology 2008;249:739-47. Burnside ES, Sickles EA, Bassett LW, Rubin DL, Lee CH, Ikeda DM, et al. The ACR BI-RADS experience: learning from history. J Am Coll Radiol 2009;6:851-60. Barentsz JO, Richenberg J, Clements R, et al, European Society of Urogenital Radiology. ESUR prostate MR guidelines 2012. Eur Radiol 2012;22:746-57. Dunnick NR, Applegate KE, Arenson RL. Quality—a radiology imperative: report of the 2006 Intersociety Conference. J Am Coll Radiol 2007;4:156-61. Srinivasa Babu A, Brooks ML. The malpractice liability of radiology reports: minimizing the risk. Radiographics 2015;35: 547-54. D’Orsi CJ, Kopans DB. The American College of Radiology’s mammography lexicon: barking up the only tree. AJR Am J Roentgenol 1994;162:595. Priolo F, Cerase A. The current role of radiography in the assessment of skeletal tumors and tumor-like lesions. Eur J Radiol 1998;27(suppl 1):S77-85. Lodwick GS. Radiographic diagnosis and grading of bone tumors, with comments on computer evaluation. Proc Natl Cancer Conf 1964;5:369-80. Madewell JE, Ragsdale BD, Sweet DE. Radiologic and pathologic analysis of solitary bone lesions. Part I. Internal margins. Radiol Clin North Am 1981;19:715-48. Caracciolo JT, Temple HT, Letson GD, Kransdorf MJ. A modified LodwickMadewell grading system for the evaluation of lytic bone lesions. AJR Am J Roentgenol 2016;207:150-6.
Ali Gholamrezanezhad, MD, is from Division of Musculoskeletal Imaging, Department of Radiology, Keck School of Medicine, University of Southern California (USC), Los Angeles, California. Michael Kessler, MD, and Seyed Mohammadreza Hayeri, MD, are from the Department of Radiology, University Hospitals of Cleveland, Case Western Reserve University, Cleveland, Ohio. The authors have no conflicts of interest related to the material discussed in this article. Ali Gholamrezanezhad, MD: Department of Radiology, Division of Musculoskeletal Imaging, Department of Radiology, Keck School of Medicine, University of Southern California (USC), 2051 Marengo St, Los Angeles, CA 90033; e-mail: [email protected]. Journal of the American College of Radiology Gholamrezanezhad, Kessler, Hayeri n Opinion
3
The Need for Standardization of Musculoskeletal Practice Reporting: Learning From ACR BI-RADS, Liver Imaging–Reporting and Data System, and Prostate Imaging–Reporting and Data System Ali Gholamrezanezhad, MD, Michael Kessler, MD, Seyed Mohammadreza Hayeri, MD INTRODUCTION Beyond technological advances, standardization has been a key method for the advancement of the field of radiology. The radiology community has attempted to standardize the communication of findings and interpretations of radiographs and CT and MRI scans by developing guidelines [1,2]. Although these guidelines have been very useful, they still suffer from complexity and heterogeneity in the diversity of the language and structure used, as well as suboptimal correlation of the final diagnostic conclusions among the different guidelines [3]. Newer structured reporting systems, such as the “*RADS,” have made huge strides in improving communication between radiologists and referring providers. However, the continued common use of free-text reports for most radiology dictations contradicts the results of multiple studies that demonstrated how capturing and analyzing medical information in a structured approach improves clinical decision making [4,5]. As a result, the ongoing revolution in the standardization of radiology reporting should focus its attention on a specialty such as musculoskeletal imaging, in which attempts at standardization began more than half a
century ago. In time, musculoskeletal imaging reports can achieve a higher standard of communication with increased comprehensibility in a concise, problem-oriented, and datadriven manner [2,5,6]. The importance of the “final report” in radiology is emphasized by the fact that it remains the mainstay of communication between radiologists and referring providers. The dangers of noninteractive and nonverbal reporting arise from the varied interpretations referring providers may arrive at through personal bias and the inconsistencies in the communication used within reports. It is a common understanding that radiology reports should provide relevant clinical information and recommendations to ordering clinicians in an understandable format, but only 86% of radiology reports have been shown to meet this standard [7,8]. Additionally, Bosmans et al [9] reported a statistically significant difference between practicing radiologists and radiology residents in multiple European countries not only in the length and structure of radiology reports but, more important, in their overall content. Similarly, discordance has been demonstrated between radiologists
ª 2017 American College of Radiology 1546-1440/17/$36.00 n http://dx.doi.org/10.1016/j.jacr.2017.06.019
and nonradiologists in the degree of diagnostic certainty associated with commonly used phrasing in radiology reports [10]. Many publications over the past several decades have proposed various practical and stylistic guidelines. General agreement as to what constitutes a radiology report includes a mention of the image acquisition protocol, a conscientious interpretation, and a deliberate clinical recommendation. Further elaborating a more comprehensive proposal for the composition of an ideal radiology reporting method, Cramer et al [5] and Weiss and Langlotz [11] explained the concept of a three-tiered system of structured reporting. The first tier consists of the use of common headings, such as “Indication,” “Findings,” and “Impression.” This approach, by far the simplest, is used by radiologists throughout the world. The second tier expands on the first by adding subheadings within sections, resulting in what is known as “itemized reporting.” An example would be adding subheadings for organs or organ systems under the “Findings” heading [5]. Although less common than the first tier, many radiologists use this system in daily practice,
1
with many young radiologists adopting this method to assist in developing a thorough search pattern. The final tier proposed by this theory of structured reporting involves the standardization of language [5]. As the top tier, the standardization of language emphasizes how the enforcement of consistent and clear communication at the phrase or word level may accomplish the ultimate goal of improving clinical decision making.
LEARNING FROM THE *RADS Specific attempts have been made to follow the three-tiered system to standardize the structure and language of radiology reports. Initial attempts were made in the late 1980s through the development of the first version of BI-RADS, established by the ACR [12]. Similarly, the ACR convened a committee in 2008 to develop a standardized reporting system for hepatocellular carcinoma, known as the Liver Imaging Reporting and Data System. Subsequently in 2012, an expert panel from the European Society of Urogenital Radiology developed the first version of the Prostate Imaging Reporting and Data System to standardize the interpretation of multiparametric MRI of the prostate [13]. These efforts have been encouraged by third-party payers and the Institute of Medicine, as a part of strategies to reduce medical errors that may affect patient outcomes [14]. Although most radiologists are aware of the *RADS, many may be surprised by the international efforts involved in their creation. The ACR began working with national and international experts in radiology and related specialties [1]. After the 2
first draft proposal, several stages of feedback and iterative revision were undertaken before the initial consensus versions were published. The panels discussed the comprehensive lexicon of controlled terminology as well as suggestions involving uniform reporting, evidence-based management, and appropriate imaging techniques and diagnostic approaches. Since their inception, subsequent updates to these systems have been added, with the inclusion of illustrative atlases and reporting guidelines in efforts to improve and facilitate their use [1]. A crucial element of the *RADS that has helped achieve the goal of delivering clear and concise reports to referring providers is their lexicon, also called “common data elements.” A lexicon, in this sense, is defined as a dictionary of predetermined descriptors of specific imaging findings. The use of a standardized and consistent language style has been shown to improve diagnostic interpretation, interobserver consistency, and data retrieval and billing while decreasing turnaround time and reducing typographic and dictation errors [2,5]. Additionally, studies have shown that consistent terminology can emphasize the interpreting radiologist’s confidence, significantly influencing a clinician’s decision to follow a radiologist’s recommendations [15]. Structured reporting has been shown to enable improved auditing and analysis of data through the use of recognizable and consistent terminology, which has opened up new and more simplified avenues for research and quality improvement [5]. As D’Orsi and Kopans [16] stated more than 20 years ago, Without standardized terms to describe the important
features.there is no means of training or obtaining objective data to improve our specificity. There must be a concise and orderly description of the finding(s) in language understandable to both clinician and radiologist leading to a logical recommendation. Indeed, this format is important for all reports we generate. Finally, standardized reporting has helped in the understanding of the potential medicolegal consequences of the language used in radiology reports and may suggest potential protections for practicing radiologists [15].
A CASE FOR MUSCULOSKELETAL RADIOLOGY The idea of a structured classification of neoplastic bone lesions on radiographic studies was initially proposed more than 50 years ago as the “Lodwick classification.” This system used a systematic approach to categorizing osteolytic bone lesions by differentiating lesions on the basis of their margins [17,18]: n
n n
Type 1: Geographic B Type 1A: Thin, well-marginated, sclerotic border B Type 1B: Distinct, wellmarginated, nonsclerotic border B Type 1C: Indistinct border Type 2: Moth-eaten Type 3: Permeative
This classification scheme was further modified in 1981 by Madewell et al [19] with the goal of decreasing complexity [20] by reordering the categories on the basis of aggressiveness. However, because aggressiveness does not necessarily indicate malignancy (ie, osteomyelitis), Caracciolo et al [20] more recently modified the Lodwick classification
Journal of the American College of Radiology Volume - n Number - n - 2017
system and proposed the modified Lodwick-Madewell grading system, which recategorizes osteolytic lesions into those with low, moderate, or high risk for malignancy. In developing a standardized reporting system for musculoskeletal radiology, it is important to use the valuable research of the previous classification systems while continuing to follow a logical and evidence-based pathway throughout the system’s inception. Like the prior *RADS, the new system would rely on a data-driven lexicon of descriptors previously shown in literature to be predictive of benign and malignant disease, helping reduce the significant interreader variability in the description and interpretation of bone lesions [9]. The structured format for musculoskeletal studies would likely be organized into several sections, such as indication for examination, pertinent findings, comparison with previous examinations, and impression, with a key emphasis on management recommendations [7]. Through the creation of this system and with the participation of organizations such as the ACR and the Society of Skeletal Radiology, it is reasonable to expect that similar clinical, educational, research, and medicolegal advantages as seen with the use of the previous *RADS would come into fruition with the proposed Skeletal Imaging Reporting and Data System, or SI-RADS. Although complete adoption would take time and face many hurdles, the acceptance of BI-RADS has clearly
shown that such a goal is possible. By educating both radiologists and referring providers on a new SI-RADS structured reporting system and understanding critiques and subsequently integrating continual improvements, the ultimate goal of improving patient outcomes, with respect to neoplastic bone lesions, would likely manifest itself through the use of clear and concise communication and promoting the use of radiology practice guidelines.
ACKNOWLEDGMENT We acknowledge editorial assistance from Professor Donald Resnick, University of California, San Diego. REFERENCES 1. American College of Radiology. Liver Imaging Reporting and Data System version 2014. Available at:. http://www.acr.org/Quality-Safe ty/Resources/LIRADS. Accessed December 2016. 2. Liu D, Zucherman M, Tulloss WB Jr. Six characteristics of effective structured reporting and the inevitable integration with speech recognition. J Digit Imaging 2006;19:98-104. 3. Davenport MS, Khalatbari S, Liu PS, et al. Repeatability of diagnostic features and scoring systems for hepatocellular carcinoma by using MR imaging. Radiology 2014;272:132-42. 4. Buntin MB, Jain SH, Blumenthal D. Health information technology: laying the infrastructure for national health reform. Health Aff (Millwood) 2010;29:1214-9. 5. Cramer JA, Eisenmenger LB, Pierson NS, Dhatt HS, Heilbrun ME. Structured and templated reporting: an overview. Appl Radiol 2014;43(8). Available at:. http:// appliedradiology.com/articles/structured-andtemplated-reporting-an-overview. Accessed June 30, 2017. 6. Bosmans JM, Van Goethem JW, De Schepper AM. Structure and content of the radiological report: an audit of 94 reports
7. 8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
from a university education center [article in Dutch]. JBR-BTR 2004;87:260-4. Cohen M. Content of a radiology report. Pediatr Radiol 2009;39:1254. Lee R, Cohen MD, Jennings GS. A new method of evaluating the quality of radiology reports. Acad Radiol 2006;13:241-8. Bosmans JM, Weyler JJ, Parizel PM. Structure and content of radiology reports, a quantitative and qualitative study in eight medical centers. Eur J Radiol 2009;72:354-8. Khorasani R, Bates DW, Teeger S, Rothschild JM, Adams DF, Seltzer SE. Is terminology used effectively to convey diagnostic certainty in radiology reports? Acad Radiol 2003;10:685-8. Weiss DL, Langlotz CP. Structured reporting: patient care enhancement or productivity nightmare? Radiology 2008;249:739-47. Burnside ES, Sickles EA, Bassett LW, Rubin DL, Lee CH, Ikeda DM, et al. The ACR BI-RADS experience: learning from history. J Am Coll Radiol 2009;6:851-60. Barentsz JO, Richenberg J, Clements R, et al, European Society of Urogenital Radiology. ESUR prostate MR guidelines 2012. Eur Radiol 2012;22:746-57. Dunnick NR, Applegate KE, Arenson RL. Quality—a radiology imperative: report of the 2006 Intersociety Conference. J Am Coll Radiol 2007;4:156-61. Srinivasa Babu A, Brooks ML. The malpractice liability of radiology reports: minimizing the risk. Radiographics 2015;35: 547-54. D’Orsi CJ, Kopans DB. The American College of Radiology’s mammography lexicon: barking up the only tree. AJR Am J Roentgenol 1994;162:595. Priolo F, Cerase A. The current role of radiography in the assessment of skeletal tumors and tumor-like lesions. Eur J Radiol 1998;27(suppl 1):S77-85. Lodwick GS. Radiographic diagnosis and grading of bone tumors, with comments on computer evaluation. Proc Natl Cancer Conf 1964;5:369-80. Madewell JE, Ragsdale BD, Sweet DE. Radiologic and pathologic analysis of solitary bone lesions. Part I. Internal margins. Radiol Clin North Am 1981;19:715-48. Caracciolo JT, Temple HT, Letson GD, Kransdorf MJ. A modified LodwickMadewell grading system for the evaluation of lytic bone lesions. AJR Am J Roentgenol 2016;207:150-6.
Ali Gholamrezanezhad, MD, is from Division of Musculoskeletal Imaging, Department of Radiology, Keck School of Medicine, University of Southern California (USC), Los Angeles, California. Michael Kessler, MD, and Seyed Mohammadreza Hayeri, MD, are from the Department of Radiology, University Hospitals of Cleveland, Case Western Reserve University, Cleveland, Ohio. The authors have no conflicts of interest related to the material discussed in this article. Ali Gholamrezanezhad, MD: Department of Radiology, Division of Musculoskeletal Imaging, Department of Radiology, Keck School of Medicine, University of Southern California (USC), 2051 Marengo St, Los Angeles, CA 90033; e-mail: [email protected]. Journal of the American College of Radiology Gholamrezanezhad, Kessler, Hayeri n Opinion
3