American Board Of Radiology Research Articles

Generative pretrained transformer-4, an artificial intelligence text predictive model, has a high capability for passing novel written radiology exam questions.

AI-image interpretation, through convolutional neural networks, shows increasing capability within radiology. These models have achieved impressive performance in specific tasks within controlled settings, but possess inherent limitations, such as the inability to consider clinical context. We assess the ability of large language models (LLMs) within the context of radiology specialty exams to determine whether they can evaluate relevant clinical information. A database of questions was created with official sample, author written, and textbook questions based on the Royal College of Radiology (United Kingdom) FRCR 2A and American Board of Radiology (ABR) Certifying examinations. The questions were input into the Generative Pretrained Transformer (GPT) versions 3 and 4, with prompting to answer the questions. One thousand seventy-two questions were evaluated by GPT-3 and GPT-4. 495 (46.2%) were for the FRCR 2A and 577 (53.8%) were for the ABR exam. There were 890 single best answers (SBA), and 182 true/false questions. GPT-4 was correct in 629/890 (70.7%) SBA and 151/182 (83.0%) true/false questions. There was no degradation on author written questions. GPT-4 performed significantly better than GPT-3 which selected the correct answer in 282/890 (31.7%) SBA and 111/182 (61.0%) true/false questions. Performance of GPT-4 was similar across both examinations for all categories of question. The newest generation of LLMs, GPT-4, demonstrates high capability in answering radiology exam questions. It shows marked improvement from GPT-3, suggesting further improvements in accuracy are possible. Further research is needed to explore the clinical applicability of these AI models in real-world settings.

Radiation Oncology Workforce: Supply and Demand

Since 2017, the specialty of radiation oncology has experienced its fifth consecutive year of decline in residency applicants, resulting in a high number of unmatched positions. The cause of this precipitous decline is multifactorial. Factors cited include concerns about future job opportunities, the decreased pass rate in the ABR radiation biology and physics boards examinations in 2018, and the continued lack of formal exposure to radiation oncology during medical school training. We summarize the issues facing the field of radiation oncology and discuss how we could learn from similar experiences in diagnostic radiology and other specialties to address these concerns. We propose potential solutions to ensure an adequate and diverse number of residency applicants to serve the future workforce needs in radiation oncology.

A Practical Guide for Paid Family and Medical Leave in Radiology, From the AJR Special Series on DEI.

Paid family and medical leave (FML) has significant benefits to organizations, including improvements in employee recruitment and retention, workplace culture, and employee morale and productivity, and is supported by evidence for overall cost savings. Furthermore, paid FML related to childbirth has significant benefits to individuals and families including but not limited to improved maternal and infant health outcomes and improved breastfeeding initiation and duration. In the case of paid non-childbearing parental leave, paid FML is associated with more equitable long-term division of household labor and childcare. Paid FML is increasingly being recognized as an important issue in medicine, as evidenced by the recent passage of policies by national societies and governing bodies including the American Board of Medical Specialties, American Board of Radiology, Accreditation Council for Graduate Medical Education, American College of Radiology, and American Medical Association. Implementation of paid FML requires adherence to federal, state, and local laws as well as institutional requirements. Specific requirements pertain to trainees from national governing bodies such as the ACGME and medical specialty boards. Flexibility, work coverage, culture, and finances are additional considerations for ensuring an optimal paid FML policy that accounts for concerns of all impacted individuals.

Redesign of the American Board of Radiology Diagnostic Radiology Certifying Examination.

On April 13, 2023, the American Board of Radiology (ABR) announced plans to replace the current computer-based diagnostic radiology (DR) certifying examination with a new oral examination, to be administered remotely, beginning in 2028. This article describes the planned changes and the process that led to those changes. In keeping with its commitment to continuous improvement, the ABR gathered stakeholder input regarding the DR initial certification process. Respondents generally agreed that the qualifying (core) examination was satisfactory but expressed concerns regarding the current computer-based certifying examination's effectiveness and impact on training. Examination redesign was conducted using input from key stakeholders with a goal of effectively evaluating competence and incentivizing study behaviors that best prepare candidates for radiology practice. Major design elements included: examination structure, breadth and depth of content, and timing. The new oral examination will focus on critical findings as well as common and important diagnoses routinely encountered in all diagnostic specialties, including radiology procedures. Candidates will first be eligible for the examination in the calendar year after residency graduation. Additional details will be finalized and announced in coming years. The ABR will continue to engage with stakeholders throughout the implementation process.

Invited Commentary: From Unacceptable to Intolerable

Invited Commentary: From Unacceptable to Intolerable

A Novel Hands-on Approach Towards Teaching Diagnostic Radiology Residents MRI Scanning and Physics

Traditional approaches towards teaching magnetic resonance imaging (MRI) scanning and physics have limitations that a hands-on course may help overcome. A dedicated week of MRI instruction may help improve radiology resident confidence and competence. Additional benefits may include improved physician-technologist communication and accelerated mastery of MRI safety. Surveys and tests were approved by our Program Evaluation Committee and administered at the beginning and at the end of this one-week course. The course consisted of protected reading time as well as practice scanning with a research magnet and assisting with clinical scanning under the close supervision of a licensed MRI technologist. Eighteen senior residents (nine third-year and nine fourth-year) participated in this course during its first year. Few residents had previous experience with MRI physics, scanning, or research prior to residency. After this course, mean resident confidence increased by 0.47 points (3.33 vs 2.86; p=0.01) on a five-point Likert scale. Understanding of MRI physics, as measured by pre- and post-tests, increased by 22% (0.72 vs 0.50; p<0.01), corresponding to a large effect size of 1.29 (p<0.001). Resident feedback reported that this course was efficacious (5/5), engaging (4.9/5), and had optimal faculty oversight. The most highly rated component of the course was the opportunity to experiment with the research MR scanner (5/5). A dedicated week of MRI education was highly rated by residents and associated with improvements in confidence and understanding, suggesting a positive correlation between confidence and competence. Additional metrics, such as trends in scores on the American Board of Radiology's Core Examination over the next several years, may further support the apparent benefits of this hands-on MR course.

Operationalizing the New ABR Residency Leave Policy for Trainees: A Practical Guide for Program Directors

In 2021, the American Board of Radiology (ABR) announced a new residency leave policy which provided much needed guidelines for leave during residency for both trainees and program directors (PDs) (1). The policy went into effect for the 2021-2022 academic year and allows for a maximum leave “that does not exceed an average of eight weeks (40 working days) per academic year over the duration of the residency.” While PDs were eager to have guidance and a new trainee-friendly policy, many did not know where to start with implementing the policy and how it would affect scheduling.

Attending Reviews of Residents Correlate with ABR Qualifying (Core) Examination Failure

Since the American Board of Radiology (ABR) instituted the new system of board certification, there has been much discussion as to the test's validity. We decided to evaluate if subjective evaluation of resident performance correlated with ABR Qualifying (Core) Examination performance at this single institution. Data regarding resident evaluation scores by attending physicians and passage of board examinations was gathered regarding residents who had taken the ABR Qualifying (Core) Examination from 2013 through 2019 for a total of 42 residents, eight of whom failed the ABR Qualifying (Core) Examination on their first attempt. A univariate analysis comparing scores with resident passage or failure of the ABR Qualifying (Core) Examination on the first attempt and analyses correcting for class year only and class year and number of evaluations was performed. The non-weighted average evaluation score of years 1, 2, and 3 was 80.24% for those who failed the ABR Qualifying (Core) Examination and 83.71 % for those who passed. On univariate analysis along with analyses correcting for class year only and class year along with number of evaluations, there was a statistically significant correlation with decreased evaluation scores averaged over the three years of residency and failure of the ABR Qualifying (Core) Examination (p=0.0102, p=0.003, and p=0.0043). The statistical significance held for the average numerical score in each individual year of training in all analyses except for year 1 of the univariate analysis (p=0.1264). At the studied institution, there was a statistically significant correlation between lower subjective faculty evaluation scores and failure of the ABR Qualifying (Core) Examination.

Implications of Medical Board Certification Practices on Family Planning and Professional Trajectory for Early Career Female Radiation Oncologists

PurposeOur purpose was to evaluate the effect of the current structure and schedule of the American Board of Radiology (ABR) radiation oncology initial certification (RO-IC) examinations, with a primary focus on implications for family planning and early professional barriers among female radiation oncologists. Methods and MaterialsA survey was conducted of crowdsourced ABR candidates and diplomates for radiation oncology between June and July of 2020. The primary study cohort was early career female radiation oncologists of the 2016 through 2021 graduating classes. ResultsThe survey response rate of early career female radiation oncologists was 37% (126 of an estimated 337). Among this cohort, 58% (73 of 126) reported they delayed or are currently delaying/timing pregnancy or adoption to accommodate the annual schedule of the 4 qualifying and certifying examinations required to achieve board certification in radiation oncology. One in every 3 respondents who had attempted to become pregnant reported experiencing infertility (25 of 79, 32%). Women who reported intentionally delaying pregnancy to accommodate the ABR RO-IC examination schedule were significantly more likely to experience infertility (46% vs 18%, P = .008). Seven women (6%) reported at least a 1-year delay in sitting for a RO-IC examination due to an unavoidable scheduling conflict related to childbirth and/or the peripartum period. A majority reported that full board certification had a significant effect on achieving academic promotion or professional partnership (52%), annual compensation (54%), and nonclinical professional commitments (58%) — these rates mirror those of surveyed early career male counterparts (n = 101). ConclusionsThe current structure and scheduling of the ABR RO-IC examinations imposes noteworthy hurdles for many female radiation oncologists when entering the workforce. The recent transition to virtual examination platforms creates an important opportunity to increase flexibility in the structure and scheduling of the board examination process to improve equitable board certification practices.

Long-Term Survival Following Definitive Radiation Therapy for Oligometastases in Gynecological Malignancies: A Landmark Analysis

Radiation therapy (RT) has been shown to prolong survival for patients with select oligometastatic cancers. Limited long-term follow-up data exist to determine if the prolonged survival correlates with cure versus a delayed relapse. To investigate this, we evaluated the clinical and disease characteristics of long-term survivors treated with definitive RT for oligometastatic gynecological cancer at our institution.We performed a landmark analysis in patients with oligometastatic gynecological cancer (OMGC) who survived for at least 5 years following treatment of their metastasis. OMGC was defined as metastasis (maximum of 5 total and 3 per site) present at a distant site at time of diagnosis or at a regional or distant site at time of recurrence. All patients received definitive RT between 2000 and 2015. Demographic and clinical variables were extracted from the medical record. Disease-free survival (DFS) after treatment of the first ROMGC was modeled using Kaplan Meier curves.48 patients with OMGC were analyzed; 20 (41.7%) had ovarian cancer, 16 (33.3%) had uterine cancer, 11 (22.9%) had cervical cancer, 1 (2.1%) had vaginal cancer. Median age was 52 years. A majority (45.8%) were stage III at primary diagnosis. The most common histology was adenocarcinoma (35.4%). The most common site of OMGC was in the pelvic lymph nodes (LN) (40.7%), with the following other sites: para-aortic LN (38.9%), supraclavicular LN (7.4%), lung (5.6%), mediastinal LN (3.7%), and axillary LN (3.7%). The median size was 2 cm. The median [interquartile range (IQR)] total RT dose and fractionation was 62.1 [52.5-64.5] Gy and 2.1 [2-2.2] Gy/fraction. The majority (70.8%) were treated with intensity-modulated RT. 25 (52.1%) patients received concurrent chemoRT (CRT) for their OMGC. After a median follow-up of 9.9 years after OMGC treatment, median [range] DFS for all patients was 73 [4-212] months (mo). 5-year DFS for cervical, uterine, and ovarian cancers was 82% (95% confidence interval [CI], 45-95%), 69% (CI, 41-86%), and 35% (CI, 16-55%), respectively. Patients who received CRT had better median DFS than those treated with RT alone (103 vs. 65 mo, P = 0.18). Patients with nodal OMGC had similar median DFS as those with non-nodal OMGC (73 vs. 66 mo, P = 0.86). During the first OMGC course, patients treated for 1 site had worse median DFS than those treated for 2+ sites (65 vs. 103 mo, P = 0.61). Of all 48 patients, 8 (16.7%) died of gynecologic cancer, 11 (22.9%) died of other causes, 3 (6.3%) had progression of disease. The remaining 26 (54.2%) patients were disease free at long-term follow up.Cure is possible for patients treated definitively for OMGC. Patients with cervical cancer, a greater number of treated OMGC sites, and treated with CRT had the longest DFS among this selected cohort. A randomized trial in oligometastatic gynecologic cancer is needed to determine if RT increases overall survival.K.L. Corrigan: None. A.K. Yoder: None. L.L. Lin: Employee; VA Hospital. Research Grant; Astra Zeneca. Travel Expenses; Astra Zeneca. A. Jhingran; American Board of Radiology. M.M. Joyner: Consultation with executive management and participation in board meetings; Frontline Bioenergy. P.J. Eifel: Travel Expenses; National Cancer Center Network. Stock; Apple Computer. L. Colbert: None. K.H. Lu: None. A.H. Klopp: Research Grant; MD Anderson Cancer Center SPORE Grant.

Circulating and Tumor-Associated Neutrophils Function as a Powerful Biomarker for Response to Chemoradiation in Locally Advanced Cervical Cancer

The role of the immune system in mediating the cytotoxic effects of chemoradiotherapy, remains incompletely understood. The integration of immunotherapies into treatment will require insight into features and timing of immune microenvironment associated with treatment response. Here, we investigate the role of circulating and tumor-associated neutrophils (TANs) as potential agents and biomarkers for disease-related outcomes in LACC.Hematologic parameters for two patient cohorts, a retrospective clinical and a prospective translational cohort, were obtained at baseline, weekly during chemoradiation, and at first follow up visit. Baseline, mean and lowest on-treatment values for platelets, hemoglobin, absolute neutrophil count (ANC), and absolute lymphocyte count (ALC) were correlated with disease-related outcomes using univariate (UVA) and multivariable analyses (MVA). Circulating neutrophils were isolated from peripheral blood mononuclear cells (PBMCs) and TANs were isolated from tumor tissue via a novel serial cytobrush sampling assay. The samples were analyzed by flow cytometry and correlated via linear regression analysis.A total of 151 patients were included in the retrospective cohort with a median follow up of 33 months. Of the tested hematologic parameters elevated on-treatment mean ANC (mANC) was associated with lower rate of local control on UVA (HR 1.314; 95% CI, 1.102-1.567, P = 0.002) and MVA (HR 1.369; 95% CI, 1.104-1.697, P = 0.004). mANC was the only hematologic factor associated with lower survival on MVA (HR 1.255; 95% CI, 1.048-1.502, P = 0.013). mANC was not associated with a difference in distant metastases (HR 1.002; 95% CI, 0.810-1.241, P = 0.984). In an independent, prospectively-accrued cohort, mANC was similarly associated with lower OS (HR 1.636, 95% CI, 1.172-2.285, P = 0.004) on UVA. Analysis of the tumor-associated neutrophils (TAN) demonstrated that neutrophils constituted 22.4% (standard error [SE] 3.96%) of all live leukocytes in the tumor at baseline, which steadily increased and peaked at 41.3% (SE 7.8%) at week 5 of treatment (P = 0.027). Neutrophils constituted of 78.2% (SE 4.6%) of live leukocytes in PBMCs at baseline, and steadily decreased with a nadir of 65.7% (SE 8.5%) at week 5 of treatment (P = 0.137). Regression analysis showed an inverse relationship between circulating neutrophils and TANs, with the strongest correlation observed at week 5 of chemoradiation (R2 = 0.29).These findings implicate neutrophils in chemoradiation treatment resistance, identify on-treatment mean neutrophil count as a robust and optimal predictor of disease-related outcomes, and establish an inverse relationship between circulating and tumor-associated neutrophils.O. Gjyshi: None. A. Grippin: Student; University of Florida. D. Boyce-Fappiano: None. A. Jhingran: American Board of Radiology. L.L. Lin: Employee; VA Hospital. Research Grant; AstraZeneca. Travel Expenses; AstraZeneca. P.J. Eifel: Travel Expenses; National Cancer Center Network. Stock; Apple Computer. M.M. Joyner: Consultation with executive management and participation in board meetings; Frontline Bioenergy. J. Sastry: None. K. Court: None. T. Solley: None. V. Hegde: None. L. Colbert: None. A.H. Klopp: Research Grant; MD Anderson Cancer Center SPORE Grant.

Bone Mineral Density Changes Within and Outside of RT Fields Used to Treat Cervical Cancer

Pelvic insufficiency fractures and decreased bone mineral density (BMD) can occur in women treated with radiotherapy (RT) for gynecologic cancers. The purpose of this study was to compare the magnitude of BMD changes inside and outside of the radiation field in patients treated with radiation +/- chemotherapy for cervical cancer.In an IRB-approved prospective study, women (N = 78) with cervical cancer were assessed with serial tomographic scans and dual-energy x-ray absorptiometry (DXA) scans to evaluate the incidence of pelvic fractures (previously reported) and post-treatment BMD changes. Patients were treated with definitive RT or chemoradiation (CRT) at a single institution between 09/2008 and 07/2015. DXA scans were obtained at baseline (before CRT), 3 months, 1 year, and 2 years after completion of therapy. Serial BMD values at L1, L2, L3 and L4 were extracted from DXA reports. Patients with a pre-treatment history of pelvic fractures, bone metastases, or pelvic RT were excluded. The current analysis focused on a subset of 78 patients whose RT fields had upper borders below L1 and above L4, permitting a comparison of BMD changes in the field (L4) with those in a vertebral body outside the field (L1). Linear mixed models (LMM) were performed to examine the impact of radiotherapy on BMD change over time, and were adjusted for covariates (age, menopausal status, BMI, number of chemotherapy cycles).The median age of 78 patients was 45.5 years (range 23-88); all received RT and 76/78 (97.5%) received concurrent CRT. Treatment was associated with a significant decline in BMD in all 4 lumbar vertebral bodies over time, P < 0.05 with nadir at 3 months (L4) and 1 year (L1). By pairwise comparisons at 3 months and 2 years after treatment, BMD in L4 (inside RT field, P = 0.037) significantly improved while BMD in L1 (outside RT field) did not significantly change. After controlling for covariates noted above, there was no significant difference in BMD between 3 months and 2 years. Levels of C-terminal telopeptide of type I collagen (P = 0.018), bone alkaline phosphatase (P < 0.001), and number of chemotherapy cycles (P = 0.031) were significant predictors of L1 BMD loss. A trend of higher BMD at all time points was found for patients who were premenopausal versus postmenopausal at study entry. At 1- and 2-years of follow-up, trends towards BMD at levels higher than baseline were seen for patients who received hormone replacement therapy (HRT) after RT.Significant BMD loss following radiation treatment in all lumbar vertebrae (both in and out of field) was observed. On multivariate analysis, in-field vertebral bodies experienced no additional significant BMD decline earlier than those out-of-field, suggesting multifactorial contributors to bone density loss. HRT may improve BMD recovery and emphasizes the need for HRT after radiotherapy in appropriate premenopausal women.J. Wu: None. D.S. Lakomy: None. B. Fellman: None. M.P. Salcedo: IGCS-International Gynecologic Cancer Society, Brazilian Federation of Gynecology and Obstetricians (FEBRASGO)/BRAZIL (Federação Brasileira de Ginecologia e Obstetricia, FEBRASGO). A. Sood: Consultant; Kiyatec, Astra Zeneca. Stock; BioPath. sponsored research; M-Trap. A. Jhingran: American Board of Radiology. A.H. Klopp: Research Grant; MD Anderson Cancer Center SPORE Grant. R.B. Iyer: None. C. Jimenez: None. L. Colbert: None. K. Schmeler: None. P.J. Eifel: Travel Expenses; National Cancer Center Network. Stock; Apple Computer. L.L. Lin: Employee; VA Hospital. Research Grant; AstraZeneca. Travel Expenses; AstraZeneca.

Risk of Secondary Malignancies in Ovarian Cancer Survivors: 54,305 Patients Analyzed With 40 Years of Follow-up

Survivors of ovarian cancer are at risk of developing a secondary malignancy (SM). We sought to evaluate the risk of developing SM, stratified by treatment modality and site of SM.Standardized incidence ratios (SIR, observed-to-expected [O/E] ratio) and absolute excess risk of SM, were assessed in 54,305 patients diagnosed with ovarian cancer as a first malignancy between 1975 and 2016 in the National Cancer Institute's Surveillance, Epidemiology, and End Results Program. Follow-up was available through 2016. Importantly, the SIRs take into account age at diagnosis, race, year of diagnosis and patient-years at risk. Non-melanoma skin cancers were not counted as SM. SIRs were also evaluated for patients according to latency from their initial diagnosis.Of 54,305 patients diagnosed with ovarian cancer, 1,010 received radiation therapy (RT) alone, 35,842 received chemotherapy (CT) alone, and 1,035 were treated with chemotherapy and radiation (CRT). 16,418 patients received neither CT or RT. Overall, 3,981 patients (7.3%) developed SM, which was more than the endemic rate [O/E 1.13 (95% CI 1.09- 1.16); P < 0.05]. Patients who received any RT (RT+CRT) had an increased risk of SM compared to those who didn't [O/E 1.42 (95% CI 1.24- 1.61) vs O/E 1.11 (95% CI 1.08- 1.15), respectively; P < 0.05] which included an excess risk of 4.82 bladder cancers per 10,000 patient-years at risk. Patients who received any CT (CT+CRT) had a similar risk of developing SM compared to those not treated with CT [O/E 1.11 (95% CI 1.07- 1.16) vs O/E 1.14 (95% CI 1.09- 1.12), respectively; P < 0.05]. Those who received any CT had an excess risk of 4.1 cases of leukemia per 10,000 patient-years at risk compared to those who did not receive CT. When stratified into treatment groups (No CT/RT, RT alone, CT alone, CRT), the CRT group had higher rates of SM than the no CT/RT and CT groups [O/E 1.56 (95% CI 1.25- 1.93)]. There was no statistically significant difference in the SM rate between the RT group and no CT/RT group [O/E 1.35 (95% CI 1.14- 1.57) vs O/E 1.13 (95% CI 1.07- 1.18), respectively]. The CT and CRT groups had an increased risk of leukemia compared to the no CT/RT group (P < 0.05). The CT only group had a lower risk of developing lung cancer than the no CT/RT group (P < 0.05). The excess risk of developing a solid tumor was greatest at latencies of 10-20 years. The excess risk of developing leukemia was greatest at latencies up to 10 years.This is the largest study to examine the risk of SM in patients with ovarian cancer and has the longest follow-up. The risk of SM was increased after having ovarian cancer and varied with treatment modality. Patients treated with any RT had higher rates of SM than those not treated with RT. Importantly, CT did not result in an increased excess risk of solid tumor SM, only in an increased excess risk of leukemia. These results may help inform SM screening protocols for women with ovarian cancer.A.C. Casper: None. M.W. Parsons: None. J. Chipman: None. L.M. Burt: ARRO executive committee. G. Suneja: Research Grant; National Institutes of Health. Honoraria; National Comprehensive Cancer Network. Travel Expenses; National Comprehensive Cancer Network, Radiation Oncology Institute, American Board of Radiology; Radiation Oncology Institute, National Comprehensive Cancer Network, ASTRO.K.A. Maurer: None. D.K. Gaffney: Research Grant; NCI. Consultant; NCI. run meetings; NCI.

Pathologic Primary Tumor Factors Associated With Risk of Lymph Node Involvement in Patients With High-Risk Endometrial Cancer

National Comprehensive Cancer Network guidelines recommend adjuvant systemic therapy with or without external beam radiation and/or intravaginal brachytherapy for high-risk endometrial cancer histologies. Being able to estimate the risk of pelvic/para-aortic lymph node (LN) involvement could assist in making clinical decisions regarding whether to treat with external beam versus brachytherapy alone. The National Cancer Data Base was queried to develop predictive nomograms based on primary uterine factors to estimate the risk of pathologic LN involvement.Patients diagnosed with pathologic T1-T2 clear cell, uterine papillary serous (UPS), carcinosarcoma, or mixed endometrial cancer between 2004-2016 undergoing primary surgery with at least 10 LNs sampled in the National Cancer Data Base were identified. Logistic regression was performed to identify primary pathologic tumor predictors of LN positivity. Pathologic variables assessed included primary tumor histology, pathologic tumor stage, tumor size, and presence/absence of lymphovascular invasion (LVI). Nomograms were created to predict overall, pelvic only, and paraaortic and/or pelvic LN involvement.Among 7,918 patients included, 1,407 (18%) were node positive. On multivariable analysis, relative to carcinosarcoma, both clear cell (odds ratio [OR] 1.77, 95% confidence interval [CI] 1.34-2.32, P < 0.001) and UPS (OR 1.76, 95% CI 1.46-2.13, P < 0.001) histology were significantly associated with a higher risk of LN positivity while mixed histology was not (OR 1.14, 95% CI 0.95-1.37, P = 0.16). Furthermore, increasing pathologic tumor stage (pT2 versus pT1a, OR 3.62, 95% CI 3.04-4.28, P < 0.001), increase in tumor size per centimeter (OR 1.09, 95% CI 1.06-1.11, P < 0.001), and presence of LVI (OR 5.23, 95% CI 4.58-6.02, P < 0.001) were predictive of overall LN positivity. Nomograms demonstrated that the impact of primary tumor pathologic variables was comparable for predicting any LN involvement, pelvic only, and paraaortic with or without pelvic LN involvement.Among endometrial cancer patients with high-risk histologies, predictors of LN positivity are similar to those with endometrial adenocarcinoma. Patients with carcinosarcoma are the least likely to be diagnosed with node positive disease relative to other high-risk histologies. Predictive nomograms can help to individualize the risk of pelvic and paraaortic LN involvement and may assist in adjuvant treatment decisions.E. Anderson: None. M. Luu: None. D.J. Lu: None. E.M. Chung: None. M. Kamrava: American Board of Radiology, Brachytherapy Journal, American Brachytherapy Society Board of Directors. Co-Editor; Journal of Contemporary Brachytherapy.

Association of Gut Microbiome Characteristics With the Late Gastrointestinal Toxicities After Pelvic Receiving Radiation Treatment for Cervical, Vaginal, and Anal Cancers

Radiation therapy is curative for treating cervical, vaginal, and anal cancers, but can lead to gut toxicities that reduce quality of life in recovering patients. Previously, higher gut microbiome diversity was shown to be positively correlated with less severe acute gastrointestinal (GI) toxicities per patient-reported assessments of bowel function. The goal of this study was to explore effects of gut microbiome diversity and composition on late GI toxicities. We hypothesized that the occurrence of late GI toxicities in patients that receive abdominal radiation therapy correlates with gut microbiome diversity.We collected and analyzed rectal swabs from 66 patients with cervical, anal, and vaginal cancer receiving standard of care treatment. Samples from baseline and week 5 of treatment were sequenced using 16Sv4 ribosomal RNA (rRNA) gene sequencing. We also retrospectively evaluated the late (occurring after 3 months) radiation induced GI toxicities of patients who had completed their treatment 2 years prior using the RTOG/EORTC Late Radiation Morbidity Scoring Schema and the Common Terminology Criteria for Adverse Events (CTCAE) v.5. The gut microbial diversity of the patients was then characterized by indexes of richness, evenness and diversity. 59 patients were included in the analysis; exclusion criteria were lack of either follow-up or microbiome data and receiving additional radiation therapy or chemotherapy. Independent students t-tests were used to compare the alpha diversity metrics between patients who experienced late toxicities and those who did not. Beta diversity was evaluated using linear discriminant analysis effect size (LEfSe) to identify bacteria taxa that were differentially enriched in groups of patients with no toxicity against those with toxicity, and independent t-tests were used to compare the relative abundances of these taxa between patients with and without late toxicities.37.3% of patients per RTOG/EORTC criteria and 42.4% per CTCAE criteria experienced late GI toxicities (RTOG > = 1, CTCAE > = 1). Overall, neither the alpha diversity at baseline nor at week 5 was significantly different in patients who experienced late toxicities compared with those who didn't. Of the 22 taxa identified in the LEFse analysis, Sutterella species were higher at baseline in patients who did not experience late GI toxicities (0.21% vs. 0.72%, respectively, P = 0.01 for RTOG/EORTC criteria; 0.19% vs. 0.79%, respectively, P = 0.004 per CTCAE criteria).The presence of Sutterella was significantly associated with late toxicity, consistent with prior observations of acute toxicity. Overall, is no strong association between gut microbiome diversity and the presence of late GI toxicities in patients who have received radiation therapy for cervical, vaginal, and anal cancers. The observation has implications in the ongoing search for gut microbiome-targeted treatments for mitigating side effects of radiation.E.J. Lynn: None. M.B. El Alam: None. T. Karpinets: None. D. Lin: None. R. Kouzy: None. K. Court: None. X. Wu: None. M.P. Mezzari: None. N. Ajami: None. T. Solley: None. L.L. Lin: Employee; VA Hospital. Research Grant; AstraZeneca. Travel Expenses; AstraZeneca. L. Ramondetta: None. A. Jhingran: American Board of Radiology. P.J. Eifel: Travel Expenses; National Cancer Center Network. Stock; Apple Computer. K. Schmeler: None. B.D. Minsky: None. E.J. Koay: Research Grant; PANCAN-AACR, MD Anderson Cancer Center, Philips, National Institutes of Health, General Electric, Elekta, Stand Up 2 Cancer, Project Purple. Royalty; Taylor and Francis LLC. Patent/License Fees/Copyright; Pending Patent. I help coordinate scientific and advocacy activities for this Foundation, focused on radiation oncology. P. Das: Honoraria; MD Anderson Cancer Center Madrid, National Cancer Institute/Leidos, ASTRO. Consultant; Adlai Nortye. C.M. Taniguchi: Research Grant; NIH, Reaumond Foundation, Mark Foundation. Consultant; Phebra Pty, Ltd, Xerient Pharmaceuticals. Advise on various radiation products; Accuray. A.H. Klopp: Research Grant; MD Anderson Cancer Center SPORE Grant. L. Colbert: None.

Patterns of Practice for Adjuvant Treatment of FIGO 1B Grade 3 Endometrial Adenocarcinoma Following Publication of ASTRO 2014 Guidelines for Postoperative Treatment in Women With Early Stage High Risk Endometrial Cancer

In 2014, the American Society for Radiation Oncology (ASTRO) published evidence-based guidelines for the role of postoperative radiation therapy in endometrial cancer. These guidelines were also endorsed by the Society of Gynecologic Oncology (SGO). They strongly recommended that women with grade 3 endometrioid endometrial cancer with deep myometrial invasion) receive pelvic radiation (EBRT) and not vaginal cuff brachytherapy (VCBT) given their increased risk of pelvic recurrence based on high quality evidence. We analyzed patterns of practice before and after this consensus guideline was published.We queried the National Cancer Database to identify all women with either FIGO 1C grade 3 disease from 2004-2009 and FIGO 1B grade 3 disease from 2009-2017 with endometrioid histology who were treated surgically. Patients were then stratified to treatment between 2004-2014 (prior to ASTRO guideline updates) and 2015-2017. Patients were excluded from final analysis if they were metastatic at diagnosis, received palliative-intent radiation, treatment parameters were unknown, or age < 18. Multivariable logistic regression was performed to evaluate for factors associated with receipt of VCBT using clinical and sociodemographic covariates.We identified 6,792 patients with grade 3 endometrioid endometrial carcinoma meeting current FIGO 1B disease classification, diagnosed between 2004 and 2017. Adjuvant radiation was not delivered to 38% of patients identified in the study period, and 26% received both EBRT and VCBT. From 2004-2014, of the patients that received single modality adjuvant radiation, 1168 patients received VCBT only (56%) and 908 received EBRT only (44%). The corresponding numbers for 2015 to 2017 for VCBT and EBRT were 347 (62%) and 217 (38%), respectively. The increase in VCBT utilization in 2015-2017 was statistically significant (P = 0.025). Patients who received VCBT were more likely to receive chemotherapy, be treated at a community cancer center or academic cancer center, or live within 50 miles of the treatment center (all P < 0.01). Racial and sociodemographic factors were not associated with likelihood of receipt of VCBT.Based on ASTRO 2014 guidelines, EBRT is strongly recommended in patients with FIGO 1B/ grade 3 endometrioid endometrial carcinoma. However, the rate of EBRT paradoxically declined in the period after the publication of the guideline. This may be in part due to conflicting data from ongoing trials during that time such as GOG 249 and PORTEC 3. Further investigation is warranted to investigate reasons for these variations in practice.C. Weil: None. F. Lew: None. D.K. Gaffney: Research Grant; NCI. Consultant; NCI. run meetings; NCI.G. Suneja: Research Grant; National Institutes of Health. Honoraria; National Comprehensive Cancer Network. Travel Expenses; National Comprehensive Cancer Network, Radiation Oncology Institute, American Board of Radiology; Radiation Oncology Institute, National Comprehensive Cancer Network, ASTRO.V.M. Williams: Involved in planning the mission and activities for the subcommittee; ARRO Equity and Inclusion Subcommittee.

The American Board of Radiology's Alternate Pathway for Diagnostic Radiology: What the Programs and the Applicants Need to Know

The American Board of Radiology (ABR) developed the international medical graduate alternate pathway to give foreign trained radiologists an alternate route to independent radiology practice without having to undergo radiology residency in the United States. After 4 years of fellowship/faculty experience in the same training institution, the foreign trained radiologist becomes eligible to sit for the radiology board examinations conducted by the ABR. As this pathway is not offered at every radiology training program, many training institutions are unfamiliar with the fundamentals of this pathway. At the same time, both the training institutions and the applying foreign-trained physicians face a plethora of confusing choices on the state and federal level. In this paper, we review the main factors which both the international medical graduate radiologists and training programs must consider before embarking on the diagnostic radiology ABR Alternate Pathway, namely, eligibility, visa options, state medical licensure requirements, their costs and implications for future employment opportunities.

Dr. Edith H. Quimby: A pioneering medical physicist and educator with outstanding contributions in radiation dosimetry

Dr. Edith H. Quimby: A pioneering medical physicist and educator with outstanding contributions in radiation dosimetry

Future mainstream platform for online adaptive radiotherapy will be using on-board MR rather than on-board (CB) CT images.

As several major non‐inferiority phase 3 clinical trial studies published their promising results, 1 , 2 and as the reimbursement pattern is reforming from fee‐for‐service payment to episode‐based payment, 3 the radiation oncology field is undergoing a major paradigm shift, from a majority of standard fractionation treatments to more hypo‐fractionation and stereotactic body radiotherapy (SBRT). With this change, the need to verify daily radiotherapy dose and adapt the radiotherapy plan according to daily anatomy has become essential. 4 Currently, the most common platforms for online adaptive radiotherapy (ART) include MRI‐guided ART (MRgART) and CT (or cone‐beam CT)‐guided ART (CTgART), both of which have only been adopted by a handful of large‐scale hospital‐based cancer centers around the world. As more experience is collected and technology matures, one would hope that advanced online ART platforms should become more affordable and accessible to a larger community. That brings this month's debate topic: “Future mainstream platform for online adaptive radiotherapy will be using on‐board MR rather than on‐board (CB) CT images.” Herein, we invited Dr. Daniel Hyer and Dr. Bin Cai to join us for this debate. Parallel to this opinion is Dr. Daniel Hyer. Dr. Hyer received his PhD in Medical Physics from the University of Florida in 2010 and was certified by the American Board of Radiology in 2013. Dr. Hyer is currently an Associate Professor and the Director of Clinical Physics at the University of Iowa. His research interests include MRI‐guided radiotherapy and proton beam therapy. On the latter topic, Dr. Hyer currently holds a National Cancer Institute grant for the development of a proton collimator. Clinically, he is the technical director of the Elekta Unity program at the University of Iowa and has been involved with the project since 2017. Opposed to this opinion is Dr. Bin Cai. Dr. Cai is Associate Professor and Director of Advanced Physics Service in the Department of Radiation Oncology at the University of Texas Southwestern Medical Center. Dr. Cai received his Ph.D. in Physics from Ohio University and completed his medical physics residency training at Washington University School of Medicine. Dr. Cai stayed as a faculty member for 6 years at Washington University after residency. In 2021, he joined UT Southwestern to help develop the adaptive radiotherapy program as well as to lead the implementation of biology‐guided radiotherapy. Dr. Cai is one of the key team members that led the clinical implementation of the world's first MRgART platform. Later he also led the clinical development and implementation of the first CBCT‐guided online adaptations in the United States. Therefore Dr. Cai has extensive and balanced experience on both CTgART and MRgART platforms.

Interprofessional Education - A Mandate for Today's Radiology Curriculum

Interprofessional education (IPE) brings educators and learners from two or more health professions together in a collaborative learning environment, specifically assuring that learners function as a team to provide patient-centered care, with each team member contributing a unique perspective. The Liaison Committee on Medical Education, the Accreditation Council for Graduate Medical Education, and the American Board of Radiology have endorsed interprofessional and team communication as essential core competencies. Radiology educators must understand, include, and optimize IPE in their pedagogy; as a specialty, radiology must innovate more interprofessional experiences for medical students, residents and other allied health professions.