Less-experienced Readers Research Articles

Society of Radiologists in Ultrasound Consensus Conference Recommendations for Incidental Gallbladder Polyp Management: Interreader Agreement Among 10 Radiologists.

BACKGROUND. The 2022 Society of Radiologists in Ultrasound (SRU) consensus conference recommendations for small gallbladder polyps support management that is less aggressive than earlier approaches and may help standardize evaluation of polyps by radiologists. OBJECTIVE. The purpose of the present study was to assess the interreader agreement of radiologists in applying SRU recommendations for management of incidental gallbladder polyps on ultrasound. METHODS. This retrospective study included 105 patients (75 women and 30 men; median age, 51 years) with a gallbladder polyp on ultrasound (without features highly suspicious for invasive or malignant tumor) who underwent cholecystectomy between January 1, 2003, and January 1, 2021. Ten abdominal radiologists independently reviewed ultrasound examinations and, using the SRU recommendations, assessed one polyp per patient to assign risk category (extremely low risk, low risk, or indeterminate risk) and make a possible recommendation for surgical consultation. Five radiologists were considered less experienced (< 5 years of experience), and five were considered more experienced (≥ 5 years of experience). Interreader agreement was evaluated. Polyps were classified pathologically as nonneoplastic or neoplastic. RESULTS. For risk category assignments, interreader agreement was substantial among all readers (k = 0.710), less-experienced readers (k = 0.705), and more-experienced readers (k = 0.692). For surgical consultation recommendations, inter-reader agreement was substantial among all readers (k = 0.795) and more-experienced readers (k = 0.740) and was almost perfect among less-experienced readers (k = 0.811). Of 10 readers, a median of 5.0 (IQR, 2.0-8.0), 4.0 (IQR, 2.0-7.0), and 0.0 (IQR, 0.0-0.0) readers classified polyps as extremely low risk, low risk, and indeterminate risk, respectively. Across readers, the percentage of polyps classified as extremely low risk ranged from 32% to 72%; as low risk, from 24% to 65%; and as indeterminate risk, from 0% to 8%. Of 10 readers, a median of zero change to 0 (IQR, 0.0-1.0) readers recommended surgical consultation; the percentage of polyps receiving a recommendation for surgical consultation ranged from 4% to 22%. Of a total of 105 polyps, 102 were nonneo-plastic and three were neoplastic (all benign). Based on readers' most common assessments for nonneoplastic polyps, the risk category was extremely low risk for 53 polyps, low risk for 48 polyps, and indeterminate risk for one polyp; surgical consultation was recommended for 16 polyps. CONCLUSION. Ten abdominal radiologists showed substantial agreement for polyp risk categorizations and surgical consultation recommendations, although areas of reader variability were identified. CLINICAL IMPACT. The findings support the overall reproducibility of the SRU recommendations, while indicating opportunity for improvement.

Reproducibility and accuracy of vessel wall MRI in diagnosing giant cell arteritis: a study with readers of varying expertise.

To evaluate the reproducibility of vessel wall magnetic resonance imaging (VW-MRI) in diagnosing giant cell arteritis (GCA) among groups of radiologists with varying levels of expertise. This institutional review board-approved retrospective single-center study recruited patients with suspected GCA between December 2014 and September 2021. Patients underwent 3-T VW-MRI before temporal artery biopsy. Ten radiologists with varying levels of expertise, blinded to all data, evaluated several intracranial and extracranial arteries to assess GCA diagnosis. Interobserver reproducibility and diagnostic performance were evaluated. Fifty patients (27 women and 23 men) with a mean age of 75.9 ± 9years were included. Thirty-one of 50 (62%) had a final diagnosis of GCA.VW-MRI had an almost perfect reproducibility among expert readers (kappa = 0.93; 95% CI 0.77-1) and substantial reproducibility among all readers, junior and non-expert senior readers (kappa = 0.7; 95% CI 0.66-0.73; kappa = 0.67 95% CI 0.59-0.74; kappa = 0.65; 95% CI 0.43-0.88 respectively) when diagnosing GCA. Substantial interobserver agreement was observed for the frontal branch of superficial temporal artery. Moderate interobserver agreement was observed for the superficial temporal artery and its parietal branch, as well as ophthalmic arteries in all groups of readers. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy varied depending on the group of readers. VW-MRI is a reproducible and accurate imaging modality for detecting GCA, even among less-experienced readers. This study advocates for the use of VW-MRI when diagnosing GCA even in less-experienced centers. VW-MRI is a reproducible and accurate imaging modality for detecting GCA, even among less-experienced readers, and it could be used as a first-line diagnostic tool for GCA in centers with limited expertise in GCA diagnosis. • Vessel wall magnetic resonance imaging (VW-MRI) is a reproducible and accurate imaging modality for detecting giant cell arteritis (GCA) in both extracranial and intracranial arteries. • The reproducibility of vessel wall magnetic resonance imaging for giant cell arteritis diagnosis was high among expert readers and moderate among less-experienced readers. • The use of vessel wall magnetic resonance imaging for giant cell arteritis diagnosis can be recommended even in centers with less-experienced readers.

Service and clinical impacts of reader bias in breast cancer screening: a retrospective study.

To determine factors influencing reader agreement in breast screening and investigate the relationship between agreement level and patient outcomes. Reader pair agreement for 83 265 sets of mammograms from the Scottish Breast Screening service (2015-2020) was evaluated using Cohen's kappa statistic. Each mammography examination was read by two readers, per routine screening practice, with the second initially blinded but able to choose to view the first reader's opinion. If the two readers disagreed, a third reader arbitrated. Variation in reader agreement was examined by: whether the reader acted as the first or second reader, reader experience, and recall, cancer detection and arbitration recall rate. Readers' opinions varied by whether they acted as the first or second reader. Furthermore, reader 2 was more likely to agree with reader 1 if reader 1 was more experienced than they were, and less likely to agree if they themselves were more experienced than reader 1 (P < .001). Agreement was not significantly associated with cancer detection rate, overall recall rate or arbitration recall rates (P > .05). Lower agreement between readers led to a higher arbiter workload (P < .001). In mammography screening, the second reader's opinion is influenced by the first reader's opinion, with the degree of influence dependent on the readers' relative experience levels. While less-experienced readers relied on their more experienced reading partner, no adverse impact on service outcomes was observed. Allowing access to the first reader's opinion may benefit newly qualified readers, but reduces independent evaluation, which may lower cancer detection rates.

Magnetic resonance radiographic features which might lead to misdiagnosis of muscle-invasive bladder cancer based on vesical imaging reporting and data system: the application experience of a single center.

The Vesical Imaging Reporting and Data System (VI-RADS) has been widely used for diagnosing muscle-invasive bladder cancer (MIBC), yet instances of misdiagnosis persist. However, limited research discusses the factors affecting its accuracy. This study aimed to evaluate the diagnostic efficacy of the VI-RADS in our center and to preliminarily identify possible magnetic resonance imaging (MRI) characteristics of misdiagnosis. From January 2018 to February 2023, a consecutive series of 211 participants pathologically diagnosed with bladder cancer (BC) who underwent an MRI exam were retrospectively enrolled. MRI was interpreted by 2 radiologists with different levels of experience, the diagnostic performance was validated using the receiver operating characteristic (ROC) curve, and VI-RADS ≥4 was considered to indicate MIBC-positive status. The clinical and radiographic characteristics of the true-positive (TP), true-negative (TN), false-positive (FP), and false-negative (FN) groups were analyzed using Kruskal-Wallis test or Fisher exact test. With VI-RADS ≥4 as the cutoff value, the area under the ROC curves (AUCs) were 0.951 (0.912-0.976) and 0.847 (0.791-0.893) for the more-experienced reader and less-experienced reader, respectively, with good interobserver agreement (κ=0.74105). The median tumor size in the TP (more experienced: 57 cases; less experienced: 44 cases) and FP (more experienced: 8 cases; less experienced: 9 cases) groups was larger than that in the TN (more experienced: 141 cases; less experienced: 139 cases) group for the more-experienced reader (TP: 28 mm; FP: 31 mm; TN: 19 mm; P<0.001 and P=0.031, respectively) and the less-experienced reader (TP: 31 mm; FP: 28 mm; TN: 19 mm; P<0.001 and P=0.042, respectively). The tumor base in the TP and FP groups was larger than that in the TN group for the more-experienced reader (TP: 37 mm; FP: 48 mm; TN: 15 mm; both P<0.001) and for the less-experienced reader (FP: 42 mm; FP: 36 mm; TN: 15 mm; P<0.001 and P=0.022, respectively). The median tumor base in the TP group was larger than that in the FN group for the less-experienced reader (TP: 42 mm; FN: 17 mm; P=0.004). We observed good to excellent AUCs with good interobserver agreement among radiologists with different levels of expertise using VI-RADS. Large tumor size and wide tumor base affected the accuracy of VI-RADS in MIBC diagnosis.

Deep learning for assessing image quality in bi-parametric prostate MRI: A feasibility study

BackgroundAlthough systems such as Prostate Imaging Quality (PI-QUAL) have been proposed for quality assessment, visual evaluations by human readers remain somewhat inconsistent, particularly among less-experienced readers. ObjectivesTo assess the feasibility of deep learning (DL) for the automated assessment of image quality in bi-parametric MRI scans and compare its performance to that of less-experienced readers. MethodsWe used bi-parametric prostate MRI scans from the PI-CAI dataset in this study. A 3-point Likert scale, consisting of poor, moderate, and excellent, was utilized for assessing image quality. Three expert readers established the ground-truth labels for the development (500) and testing sets (100). We trained a 3D DL model on the development set using probabilistic prostate masks and an ordinal loss function. Four less-experienced readers scored the testing set for performance comparison. ResultsThe kappa scores between the DL model and the expert consensus for T2W images and ADC maps were 0.42 and 0.61, representing moderate and good levels of agreement. The kappa scores between the less-experienced readers and the expert consensus for T2W images and ADC maps ranged from 0.39 to 0.56 (fair to moderate) and from 0.39 to 0.62 (fair to good). ConclusionsDeep learning (DL) can offer performance comparable to that of less-experienced readers when assessing image quality in bi-parametric prostate MRI, making it a viable option for an automated quality assessment tool. We suggest that DL models trained on more representative datasets, annotated by a larger group of experts, could yield reliable image quality assessment and potentially substitute or assist visual evaluations by human readers.

Effects of deep learning on radiologists' and radiology residents' performance in identifying esophageal cancer on CT.

To investigate the effectiveness of a deep learning model in helping radiologists or radiology residents detect esophageal cancer on contrast-enhanced CT images. This retrospective study included 250 and 25 patients with and without esophageal cancer, respectively, who underwent contrast-enhanced CT between December 2014 and May 2021 (mean age, 67.9 ± 10.3 years; 233 men). A deep learning model was developed using data from 200 and 25 patients with esophageal cancer as training and validation data sets, respectively. The model was then applied to the test data set, consisting of additional 25 and 25 patients with and without esophageal cancer, respectively. Four readers (one radiologist and three radiology residents) independently registered the likelihood of malignant lesions using a 3-point scale in the test data set. After the scorings were completed, the readers were allowed to reference to the deep learning model results and modify their scores, when necessary. The area under the curve (AUC) of the deep learning model was 0.95 and 0.98 in the image- and patient-based analyses, respectively. By referencing to the deep learning model results, the AUCs for the readers were improved from 0.96/0.93/0.96/0.93 to 0.97/0.95/0.99/0.96 (p = 0.100/0.006/<0.001/<0.001, DeLong's test) in the image-based analysis, with statistically significant differences noted for the three less-experienced readers. Furthermore, the AUCs for the readers tended to improve from 0.98/0.96/0.98/0.94 to 1.00/1.00/1.00/1.00 (p = 0.317/0.149/0.317/0.073, DeLong's test) in the patient-based analysis. The deep learning model mainly helped less-experienced readers improve their performance in detecting esophageal cancer on contrast-enhanced CT. A deep learning model could mainly help less-experienced readers to detect esophageal cancer by improving their diagnostic confidence and diagnostic performance.

Diagnostic performance for detecting bone marrow edema of the hip on dual-energy CT: Deep learning model vs. musculoskeletal physicians and radiologists

PurposeTo compare the diagnostic performance of a deep learning (DL) model with that of musculoskeletal physicians and radiologists for detecting bone marrow edema on dual-energy CT (DECT). MethodThis retrospective study included adult patients underwent hip DECT and MRI within 1 month between April 2018 and December 2020. A total of 8709 DECT images were divided into training/validation (85%, 7412 augmented images) and test (15%, 1297 images) sets. The images were labeled as present/absent bone marrow edema, with MRI as reference standard. We developed and trained a DL model to detect bone marrow edema from DECT images. Thereafter, DL model, two orthopedic surgeons, and three radiologists evaluated the presence of bone marrow edema on every test image. The diagnostic performance of the DL model and readers was compared. Inter-reader agreement was calculated using Fleiss-kappa statistics. ResultsA total of 73 patients (mean age, 59 ± 12 years; 38 female) were included. The DL model had a significantly higher area under the curve (AUC, 0.84 vs. 0.61–0.70, p < 0.001) and sensitivity (79% vs. 29–66%) without loss of specificity (90% vs. 74–93%) than the non– or less-experienced readers and similar to the trained reader (AUC, 0.83, p = 0.402; sensitivity, 71%; specificity, 94%). Additionally, AUCs were strongly dependent on the reader's DECT experience. Inter-reader agreement was fair (κ = 0.303). ConclusionThe DL model showed better diagnostic performance than less-experienced physicians in detecting bone marrow edema on DECT and comparable performance to a trained radiologist.

Inter-reader agreement of the Society of Abdominal Radiology-American Gastroenterological Association (SAR-AGA) consensus reporting for key phenotypes at MR enterography in adults with Crohn disease: impact of radiologist experience.

To assess inter-reader agreement of key features from the SAR-AGA recommendations for the interpretation and reporting of MRE in adult patients with CD, focusing on the impact of radiologist experience on inter-reader agreement of CD phenotypes. Two experienced and two less-experienced radiologists retrospectively evaluated 99 MRE in CD patients (50 initial MRE, 49 follow-up MRE) performed from 1/1/2019 to 3/20/2020 for the presence of active bowel inflammation (stomach, proximal small bowel, ileum, colon), stricture, probable stricture, penetrating disease, and perianal disease. The MRE protocol did not include dedicated perianal sequences. Inter-rater agreement was determined for each imaging feature using prevalence-adjusted bias-adjusted kappa and compared by experience level. All readers had almost-perfect inter-reader agreement (κ > 0.90) for penetrating disease, abscess, and perianal abscess in all 99 CD patients. All readers had strong inter-reader agreement (κ: 0.80-0.90) in 99 CD patients for active ileum inflammation, proximal small bowel inflammation, and stricture. Less-experienced readers had significantly lower inter-reader agreement for active ileum inflammation on initial than follow-up MRE (κ 0.68 versus 0.96, p = 0.018) and for strictures on follow-up than initial MRE (κ 0.76 versus 1.0, p = 0.027). Experienced readers had significantly lower agreement for perianal fistula on follow-up than initial MRE (κ: 0.55 versus 0.92, p = 0.008). There was strong to almost-perfect inter-reader agreement for key CD phenotypes described in the SAR-AGA consensus recommendations including active ileum and proximal small bowel inflammation, stricture, penetrating disease, abscess, and perianal abscess. Areas of lower inter-reader agreement could be targeted for future education efforts to further standardize CD MRE reporting. Dedicated perianal sequences should be included on follow-up MRE.

LI-RADS treatment response algorithm after first-line DEB-TACE: reproducibility and prognostic value at initial post-treatment CT/MRI.

To evaluate the inter-reader reproducibility and prognostic accuracy of the Liver Imaging Reporting and Data System (LI-RADS) treatment response algorithm (LR-TR) at the time of initial post-treatment evaluation following drug-eluting beads transarterial chemoembolization (DEB-TACE) for hepatocellular carcinoma (HCC). This retrospective study included patients with HCC who underwent first-line DEB-TACE between January 2011 and December 2015. Six readers (three fellowship-trained radiologists and three radiology trainees) independently assessed lesion-level response in up to two treated lesions per LR-TR and modified Response Evaluation Criteria in Solid Tumors (mRECIST)-target criteria, as well as patient-level response per mRECIST-overall criteria, on the initial post-treatment CT/MRI. Inter-reader agreement was calculated by Fleiss' multi-reader κ. We tested whether LR-TR, mRECIST-target, and mRECIST-overall response were associated with overall survival using Kaplan-Meier and Cox proportional hazard model analyses. A total of 82 patients with 113 treated target lesions were included. Inter-reader agreement was moderate for LR-TR and mRECIST-overall (κrange 0.42-0.57), and substantial for mRECIST-target (κrange 0.62-0.66), among all three reader-groups: all readers, experienced readers, and less-experienced readers. LR-TR and mRECIST-target response were not significantly associated with overall survival regardless of reader experience (P > 0.05). In contrast, mRECIST-overall response was significantly associated with overall survival when assessed by all readers (P = 0.02) and experienced readers (P = 0.03), but not by the less-experienced readers (P = 0.35). Although LR-TR algorithm has moderate inter-reader reproducibility, it alone may not predict overall survival on the initial post-treatment CT/MRI after first-line DEB-TACE for HCC.

Interreader variability in prostate MRI reporting using Prostate Imaging Reporting and Data System version 2.1.

To evaluate the agreement among readers with different expertise in detecting suspicious lesions at prostate multiparametric MRI using Prostate Imaging Reporting and Data System (PI-RADS) version 2.1. We evaluated 200 consecutive biopsy-naïve or previously negative biopsy men who underwent MRI for clinically suspected prostate cancer (PCa) between May and September 2017. Of them, 132 patients underwent prostate biopsy. Seven radiologists (four dedicated uro-radiologists and three non-dedicated abdominal radiologists) reviewed and scored all MRI examinations according to PI-RADS v2.1. Agreement on index lesion detection was evaluated with Conger's k coefficient, agreement coefficient 1 (AC1), percentage of agreement (PA), and indexes of specific positive and negative agreement. Clinical and radiological features that may influence variability were evaluated. Agreement in index lesion detection among all readers was substantial (AC1 0.738; 95% CI 0.695-0.782); dedicated radiologists showed higher agreement compared with non-dedicated readers. Clinical and radiological parameters that positively influenced agreement were PSA density ≥ 0.15ng/mL/cc, pre-MRI high risk for PCa, positivity threshold of PI-RADS score 4 + 5, PZ lesions, homogeneous signal intensity of the PZ, and subjectively easy interpretation of MRI. Positive specific agreement was significantly higher among dedicated readers, up to 93.4% (95% CI 90.7-95.4) in patients harboring csPCa. Agreement on absence of lesions was excellent for both dedicated and non-dedicated readers (respectively 85.1% [95% CI 78.4-92.3] and 82.0% [95% CI 77.2-90.1]). Agreement on index lesion detection among radiologists of various experiences is substantial to excellent using PI-RADS v2.1. Concordance on absence of lesions is excellent across readers' experience. • Agreement on index lesion detection among radiologists of various experiences is substantial to excellent using PI-RADS v2.1. • Concordance between experienced readers is higher than between less-experienced readers. • Concordance on absence of lesions is excellent across readers' experience.

PI-RADS version 2: optimal time range for determining positivity of dynamic contrast-enhanced MRI in peripheral zone prostate cancer

To analyse the optimal time cut-off for determining positivity of dynamic contrast-enhanced (DCE) magnetic resonance imaging (MRI) in peripheral zone (PZ) prostate cancer (PCa). A consecutive series of 89 patients with PZ PCa who had undergone diffusion-weighted imaging (DWI) and subtraction DCE MRI were included. An experienced reader visually analysed the earliest time after contrast medium injection to visualise the best contrast between an index tumour and normal PZ on DCE MRI (i.e., best contrast time). The best contrast time cut-off for clinically significant cancer (csPCa) according to Epstein criteria or International Society of Urological Pathology (ISUP) grade ≥2 was analysed by an experienced reader, and applied to a less-experienced reader. For the index lesion of DWI category 3, the added value of DCE MRI (increased true positive and negative rates of PI-RADSv2 for csPCa) was evaluated using the cut-off time. The best contrast time cut-off for csPCa was ≤72 seconds for Epstein criteria and ≤56 seconds for ISUP grade ≥2 by an experienced reader. The weighted kappa to determine positivity of DCE MRI was 0.622 for ≤72 seconds and 0.527 for ≤56 seconds between the two readers. The added value of DCE MRI was 55-75% by an experienced reader and 39.1-69.6% by a less-experienced reader. For interpreting PI-RADSv2, imaging findings within 60-72 seconds following contrast media injection seem to reliably determine positivity of DCE MRI in PZ, and have added value for detecting csPCa.

Can eye-tracking metrics be used to better pair radiologists in a mammogram reading task?

To propose a framework for optimal pairing of radiologists when reading mammograms based on their search patterns. Four experienced and four less-experienced radiologists were asked to assess 120 cases (59 with cancers) while their eye positions were tracked. Fourteen eye-tracking metrics were extracted to quantify the differences among radiologists' visual search pattern. For each radiologist and metric, less-experienced radiologists and expert readers were ranked based on the level of similarities in gaze patterns (from the most different to the most similar). Less-experienced readers and experts were also ranked based on the values of area under the receiver operating characteristic curve (AUC) after pairing (the best possible way of ranking). Using the Kendall's tau distance, rankings based on different metrics were compared with the best possible ranking. Using paired Wilcoxon signed-rank test, the AUC values when pairing in the best way were compared with pairing based on different metrics. Finally, we investigated the robustness of pairing strategies against the small sample size. For ranking the experienced radiologists, results from eight metrics were as good as the best possible ranking. For the less-experienced ones, only one metric resulted in a ranking comparable to the best possible way of ranking. The AUC values of pairings based on these metrics did not differ significantly from the best pairing scenario. Compared to the pairings based on the cognitive metrics, the ranking based on AUC values varied more greatly with the sample size, suggesting that it is less robust against the small sample size compared to the cognitive metrics. Different pairings may have different effects on performance; some are detrimental while some improve the performance of the pair. Using the suggested cognitive metrics, we can optimize the pairings even with a small dataset.

Recurrence quantification analysis of radiologists' scanpaths when interpreting mammograms.

The purpose of this study was to Propose a classifier based on recurrence quantification analysis (RQA) metrics for distinguishing experts' scanpaths from those of less-experienced readers and to explore the association of spatiotemporal dynamics of the mammographic scanpaths with the characteristics of cases and radiologists using RQA metrics. Eye movements were recorded from eight radiologists (two cohorts: four experienced and four less-experienced) while reading 120 mammograms (59 cancer, 61 normal). Ten RQA measures were extracted for each recorded scanpath. The measures described the temporal distribution of recurrent fixations as well as laminar and deterministic eye movements. Recurrent fixations are fixations that are located close to a previously fixated point in a scanpath. Deterministic eye movements represent looking back and forth between two locations, while laminar eye movements indicate detailed scanning of an area with consecutive fixations. The RQA metrics along with six conventional eye-tracking parameters were used to construct a classifier for distinguishing experts' scanpaths from those of less-experienced readers. Leave-one-out cross validation was used for evaluating the classifier. For each reader cohort, the ANOVA analysis was done to study the relationship of RQA measures with breast density, case pathology, readers' expertise, and readers' decisions on the case. The proportions of laminar and deterministic movements involved fixations in the location of lesions were also compared for two reader cohorts using two proportion z-tests. All RQA measures differed significantly between scanpaths of experienced readers and those of less-experienced readers. The classifier achieved an area under the receiver operating characteristic curve of 0.89 (0.87-0.91) for detecting experts' scanpaths. Proportionately more refixations and laminar and deterministic sequences were in the location of the lesion for the experienced cohort compared to the less-experienced cohort (all P-values<0.001). Eight and four RQA measures differed between normal and cancer cases for the experienced and less experienced readers, respectively. None of metrics differed between fatty and dense breasts for the less experienced readers, while two measures resulted into a significant difference for the experienced readers. For experts, six measures differed significantly between true negatives and false positives and nine were significantly different between true positives and false negatives. For the less-experienced cohort, the corresponding figures were seven and one measures, respectively. The RQA measures can quantify the differences among experienced and less experienced radiologists. They also capture differences among experts' scanpaths related to case pathology and radiologists' decisions on the case.

Dynamic contrast-enhanced imaging in localizing local recurrence of prostate cancer after radiotherapy: Limited added value for readers of varying level of experience.

The incremental value of dynamic contrast-enhanced (DCE) imaging in localizing radiorecurrent prostate cancer is uncertain. To assess the added-value of DCE imaging to the combination T2 -weighted imaging (T2 W)+diffusion-weighted imaging (DWI) in detecting locally radiorecurrent prostate cancer (PCa), by radiologists with different levels of experience. Analytic retrospective study. In all, 52 men with biological suspected PCa recurrence after radiotherapy were retrospectively included. All men underwent prostatic MRI (1.5T or 3T), including T2 W, DWI, and DCE imagings, before biopsies. Two junior (6 months' experience) and two senior readers (more than 3 years' experience) independently assigned a Likert score for each prostatic sextant on T2 W+DW+DCE imagings, then on T2 W+DW imagings, 4 weeks later. The reference standard was prostatic biopsies. For two levels of positivity of Likert score, 3/5 and 4/5, sensitivity, specificity, area under the receiver operating curve (AUC), and interreader agreement were compared. T2 W+DWI+DCE and T2 W+DWI imaging had similar AUC at lobe and sextant level (0.853-0.946 vs. 0.819-0.955, P from 0.071-0.534). Using a Likert score ≥4/5, T2 W+DWI+DCE significantly improved the sensitivity for junior readers at the patient, lobe, and sextant level (40-80% vs. 22-66%, P < 0.0001-0.041). Sensitivity was not significantly modified with DCE imaging for senior readers (54-95% vs. 50-91%, P from 0.074-1). Specificity was not modified for all readers (50-100% vs. 50%-100%, P from 0.134-1). DCE imaging improved interreader agreement for a Likert score ≥4/5 (kappa from 0.6-0.73 vs. 0.38-0.73). The addition of DCE imaging did not significantly improve accuracy in recurrent PCa detection after radiotherapy, whatever the level of experience of the readers. However, the addition of DCE imaging slightly improved the sensitivity for less-experienced readers and increased their diagnostic confidence. 3 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2018;48:1012-1023.

The value of adding diffusion-weighted images for tumor detection and preoperative staging in renal pelvic carcinoma for the reader's experience.

This retrospective study aimed to assess the value of adding diffusion-weighted magnetic resonance imaging (DWI) or gadolinium-enhanced fat-suppressed T1WI (CEI) to T2-weighted imaging (T2WI) for preoperative T categorization in renal pelvic carcinoma by the reader's experience using surgical specimens as the reference standard. Two radiologists (Reader 1; 3years, 2; 13years) reviewed 49 cases with urothelial carcinoma who underwent magnetic resonance imaging examination before surgery, independently, using three image sets: T2WI alone, T2WI plus DWI, and T2WI plus CEI for tumor detection and T categorization. The differences in the apparent diffusion coefficient values between tumors and renal parenchyma, histopathologic grade were analyzed. T2WI plus CEI or DWI had high detection rates (93.4%) compared to T2WI alone. When discriminating T3a/T3b, for Reader 1, the use of T2WI plus DWI (88.0%) and T2WI plus CEI (92.0%) was significantly more accurate than T2WI alone (73%), with AUCs of 0.86, 0.86 and 0.77, respectively. For Reader 2, the accuracies were high on all image sets, with AUCs of 0.87-0.95, and the mean ADC of the tumors was significantly lower than that of the normal renal parenchyma. In addition, the mean ADC values of high-grade tumors were significantly lower than that of low-grade tumors. DWI and CEI could be more helpful than T2WI alone for preoperative T categorization by less-experienced reader and DWI could be used for preoperative T categorization and for predicting the histopathologic grade of renal pelvic carcinoma.

Digital breast tomosynthesis as an adjunct to digital mammography for detecting and characterising invasive lobular cancers: a multi-reader study

To examine the interpretive performance of digital breast tomosynthesis (DBT) as an adjunct to digital mammography (DM) compared to DM alone in a series of invasive lobular carcinomas (ILCs) and to assess whether DBT can be used to characterise ILC. A retrospective, multi-reader study was conducted of 83 mammographic examinations of women with 107 newly diagnosed ILCs ascertained at histology. Consenting women underwent both DM and DBT acquisitions. Twelve radiologists, with varying mammography experience, interpreted DM images alone, reporting lesion location, mammographic features, and malignancy probability using the Breast Imaging-Reporting and Data System (BI-RADS) categories 1-5; they then reviewed DBT images in addition to DM, and reported the same parameters. Statistical analyses compared sensitivity, false-positive rates (FPR), and interpretive performance using the receiver operating characteristics (ROC) curve and the area under the curve (AUC), for reading with DM versus DM plus DBT. Multi-reader pooled ROC analysis for DM plus DBT yielded AUC=0.89 (95% confidence interval [CI]: 0.88-0.91), which was significantly higher (p<0.0001) than DM alone with AUC=0.84 (95% CI: 0.82-0.86). DBT plus DM significantly increased pooled sensitivity (85%) compared to DM alone (70%; p<0.0001). FPR did not vary significantly with the addition of DBT to DM. Interpreting with DBT (compared to DM alone) increased the correct identification of ILCs depicted as architectural distortions (84% versus 65%, respectively) or as masses (89% versus 70%), increasing interpretive performance for both experienced and less-experienced readers; larger gains in AUC were shown for less-experienced radiologists. Multifocal and/or multicentric and bilateral disease was more frequently identified on DM with DBT. Adding DBT to DM significantly improved the accuracy of mammographic interpretation for ILCs and contributed to characterising disease extent.

What a Girl! Fighting Gentleness in the Picture Book World: An Analysis of the Norwegian Picture Book What a Girl! by Gro Dahle and Svein Nyhus

The Norwegian picture book What a Girl! (original title Snill) by Gro Dahle and Svein Nyhus was published 2011 and immediately gained a large audience. The book tells the story about a girl who always behaves in the ways expected of her: she never confronts her parents, her teacher or her classmates. This behaviour makes her invisible; she disappears into a wall, causing those around her to take notice. After a while, she fights herself out of the wall, emerging a completely different girl, a strong girl with a will of her own. However, she does not come alone: she has taken with her all the silent females, who had disappeared into the wall before her. The picture book story has fascinated both young and adult readers, and many student teachers have discussed it as part of their curriculum at university. The experienced reader will find intertextual relationships to other texts, where women disappear into the wall such as Charlotte Perkins Gilman’s The Yellow Wallpaper (1899) and Patrice Kindl’s The Woman in the Wall (1997). The less-experienced reader will encounter a fascinating story of a girl fighting for her freedom and self-esteem. This article will present a multimodal analysis of the cover page and some significant spreads building on social semiotic theory and tools for analysing multimodal texts. The analysis will give a basis for discussing the development of the main character as a liberation project.

Interplay of Cultural Narratives in Martinique: French, African, and Indian Journeys toward a Pluralistic Society by Mahadevi Ramakrishnan, R. Scott Smith

outcome, which leads to the main point of his book: that a coalition of extreme-right leaders terminated French democracy in the wake of military defeat. Contrary to the widespread belief that the demise of the Third Republic was the whole political class’s doing, Nord argues that the Republic was“cornered into self-destruction”(111) by an alliance of army brass and senior civil servants who were “dead set on democracy’s demise”(152) and on regime change. To better account for this takeover, he underlines that democracy was still a novel concept in the light of recent history, like royalist electoral victories in 1871 and 1873,authoritarian threats like Boulanger and MacMahon, or fascist sympathizers in the 1930s. This book is a great read for a fresh look at the somber turn of events of the late 1930s and a comprehensive understanding of what unfolded. Southwestern University (TX) Francis Mathieu Ramakrishnan, Mahadevi, and R. Scott Smith. Interplay of Cultural Narratives in Martinique: French, African, and Indian Journeys toward a Pluralistic Society. Pompano Beach, FL: Caribbean Studies, 2015. ISBN 978-1-62632-370-4. Pp. 282. $24.50. This comprehensive study examines the evolution of Martinique’s hybrid society, beginning with Columbus’s discovery of the island in 1502 and continuing to the present day. Building on the premise that contextualizing emigration patterns can lead to an understanding of the interaction between host communities and immigrant groups, Ramakrishnan and Smith skillfully weave together multiple historical narratives and psychological factors that contribute to a broad understanding of the complex Martinican identity. The book is intended for introductory or intermediate students in a range of fields, including but not limited to French and Francophone studies, African and Caribbean studies, and cross-cultural psychology. A detailed glossary and discussion questions, found at the conclusion of each chapter, enable the authors to provide an excellent introduction on Martinican cultural history to students at the undergraduate level. Each of the ten chapters, arranged chronologically, focuses on a different community’s influence on Martinican society. Ramakrishnan and Smith frequently refer to Martinican society as a“braided society”(vi), and the appropriateness of this term is made evident by the structure of the book. The authors rely on a variety of sources, including historical documents, literary works, and especially a large number of personal communications with faculty at Université des Antilles, and consequently present a clear and coherent narrative of Martinican society. Two chapters are of particular note. Chapter 4 examines the complex plantation system in Martinique during the seventeenth and eighteenth centuries. The authors present expected information, such as the structure of plantation society, the methods of 250 FRENCH REVIEW 89.4 Reviews 251 transporting and selling slaves, and the mechanisms of control once slaves entered the plantation system. They also explain the ramifications of the plantation system on the French economy, thereby allowing students to understand the reciprocal relationship between the colony and the metropole. Chapter 7 is also notable for its chronicle of the narratives of Indian indentured servants that arrived in Martinique following the 1848 abolition of slavery. Ramakrishnan and Smith clarify Tamil terms and explain the structure of Tamil society, both of which might otherwise confuse those unfamiliar with Indian culture. Furthermore, they frequently draw comparisons between the treatment of indentured Tamil workers and former African slaves in order to demonstrate the emotional toll that servitude had on both individuals and on Tamil culture during their integration into the established Martinican societal structure. Enhancing the book is the inclusion of many photographs that are part of the authors’ personal collection that serve to illustrate their arguments. Faculty wishing to integrate this book into their curriculum should be aware of some minor editing issues that, while they do not significantly alter the quality of the scholarship, may pose problems to less-experienced readers. Several sentences on pages containing photographs are left incomplete, but these do not impede comprehension and should not discourage the incorporation of an otherwise excellent contribution to the field. Ithaca College (NY) Rachel Paparone Rudolph, Nicole C. At Home in Postwar France: Modern Mass Housing and the Right to Comfort. New York: Berghahn, 2015. ISBN 978-1-78238-587...

Diffusion-Tensor MRI at 3 T: Differentiation of Central Gland Prostate Cancer From Benign Prostatic Hyperplasia

The purpose of this article is to retrospectively evaluate the utility of diffusion-tensor imaging (DTI) at 3 T in differentiating central gland prostate cancer from benign prostatic hyperplasia (BPH). Eighty consecutive patients (57 with central gland cancer and 23 without central gland cancer) were included in this study. All patients underwent T2-weighted imaging and DTI at 3 T, followed by surgery. For predicting central gland cancer, experienced and less-experienced radiologists independently analyzed T2-weighted imaging and combined T2-weighted imaging and DTI, respectively. Apparent diffusion coefficient (ADC) and fractional anisotropy (FA) values were measured for central gland cancers and BPH foci of stromal and glandular hyperplasia. Statistical analyses were performed using McNemar test, linear mixed model, receiver operating characteristic (ROC), and kappa statistics. For predicting central gland cancers, the area under the curve (Az) of combined T2-weighted imaging and DTI for the experienced (0.915) and less-experienced reader (0.753) was superior to that of T2-weighted imaging (0.723 vs 0.664; p<0.001). The mean ADC and FA values were 0.77×10(-3) mm2/s and 0.35, respectively, for central gland cancers, 1.22×10(-3) mm2/s and 0.26, respectively, for stromal hyperplasia foci, and 1.59×10(-3) mm2/s and 0.21, respectively, for glandular hyperplasia foci, and the values differed significantly. For differentiating central gland cancer from stromal hyperplasia foci and glandular hyperplasia foci, Az values of ADC versus FA were 0.989 and 1.0 versus 0.818 and 0.916, respectively, and the difference was statistically different. DTI at 3 T is useful for distinguishing central gland cancers from BPH foci, with significantly different ADC and FA values. Furthermore, ADC showed greater diagnostic accuracy than FA in differentiating central gland cancers from stromal and glandular hyperplasia foci.

Book Review: Scenario-Based e-Learning: Evidence-Based Guidelines for Online Workforce Learning. Ruth Colvin Clark

Ruth Colvin Clark’s Scenario-Based e-Learning: Evidence-Based Guidelines for Online Workforce Learning presents a well-developed method for deploying scenario-based learning models in online environments. A level of general familiarity with both instructional design practice and e-learning development is assumed throughout; some sequencing of concepts within the text may prove challenging for less-experienced readers. Nonetheless, Scenario-Based e-Learning is a significant contribution to the field. Experienced practitioners will find this book an excellent introduction that repeatedly rewards the careful reader.