Pediatric lymphoma (PL) is the third most common malignancy to affect children, seen in up to 15% of children, after leukemia and central nervous system tumors. SEER data from 1975 - 2019 has shown an increase in the incidence of childhood cancer including leukemia and lymphomas. Fortunately, there has been an increase if the 5-year overall survival of PL. 18F-Fluordeoxyglucose PET imaging plays an important role in the diagnosis, staging and response to therapy in pediatric lymphomas. This review will focus on the incorporation of PET/MR into the standard treatment of children with PL.

INTRODUCTION:Radiological imaging is a central facet of the multidisciplinary evaluation of suspected child physical abuse. Current guidelines for the imaging of suspected child physical abuse are often unclear, incomplete and highly variable regarding recommendations on critical questions, thereby risking clinical heterogeneity, unstructured decision-making and missed diagnoses. We, therefore, aim to develop and report an evidence-based and consensus-derived international guideline for the radiological investigation of index and contact children in the context of suspected physical abuse and to ascertain areas of scientific uncertainty to inform future research priorities. METHODS AND ANALYSIS:The international guidelines for the imaging investigation of suspected child physical abuse (IGISPA) consensus group includes formal representation from 127 recognised experts across 14 subspecialties, six continents and 32 national and/or international organisations. Participants will be divided into five longitudinal subgroups (indications for imaging, skeletal imaging, visceral imaging, neuroimaging and postmortem imaging) with three cross-cutting themes (radiography, genetics and adaptations for low- and lower-middle-income countries). Each subgroup will develop preliminary consensus statements via integration of current evidence-based guidelines, systematic literature review and the clinical expertise of a multinational group of experts. Statements will then undergo anonymised voting in a modified e-Delphi process and iterative revision until consensus (≥80% agreement) is achieved. Final statements will undergo both internal and external peer review prior to endorsement. ETHICS AND DISSEMINATION:As an anonymous survey of consenting healthcare professionals, this study did not require ethical approval. Experts provided written informed consent to participate prior to commencement of the modified Delphi process. The IGISPA consensus statement and any subsequent guidance will be published open access in peer-reviewed medical journals.

Fractures are common injuries in childhood and can be caused by unintentional injury, medical conditions, and child abuse. Although the consequences of failing to diagnose an abusive injury in a child can be grave, the consequences of incorrectly diagnosing child abuse in a child whose fractures have another etiology are also significant. This report aims to review recent advances in the understanding of fracture specificity, fracture mechanisms, and other medical conditions that predispose infants and children to fracture. This clinical report will aid pediatricians and pediatric care providers in developing an evidence-based differential diagnosis and performing appropriate evaluations when assessing a child with fractures.

ImportanceExtramammary Paget disease (EMPD) is a rare, highly recurrent cutaneous malignant neoplasm of unclear origin. EMPD arises most commonly on the vulvar and penoscrotal skin. It is not presently known how anatomic subtype of EMPD affects disease presentation and management.ObjectiveTo compare demographic and tumor characteristics and treatment approaches for different EMPD subtypes. Recommendations for diagnosis and treatment are presented.Data SourcesMEDLINE, Embase, Web of Science Core Collection, and Cochrane Reviews CENTRAL from December 1, 1990, to October 24, 2022.Study SelectionArticles were excluded if they were not in English, reported fewer than 3 patients, did not specify information by anatomic subtype, or contained no case-level data. Metastatic cases on presentation were also excluded.Data Extraction and SynthesisAbstracts of 1295 eligible articles were independently reviewed by 5 coauthors, and 135 articles retained. Reporting was in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines. The analysis was cunducted in August 2019 and updated in November 2022.FindingsMost vulvar EMPD cases were asymptomatic, and diagnosis was relatively delayed (mean, 25.1 months). Although most vulvar EMPD cases were intraepidermal (1247/1773 [70.3%]), radical surgeries were still performed in almost one-third of cases. Despite this aggressive surgical approach, 481 of 1423 (34%) recurred, commonly confined to the skin and mucosa (177/198 [89.4%]). By contrast, 152 of 1101 penoscrotal EMPD cases (14%) recurred, but more than one-third of these recurrences were regional or associated with distant metastases (54 of 152 [35.5%]). Perianal EMPD cases recurred in one-third of cases (74/218 [33.9%]), with one-third of these recurrences being regional or associated with distant metastasis (20 of 74 [27.0%]). Perianal EMPD also had the highest rate of invasive disease (50% of cases).Conclusions and RelevanceThe diagnosis and treatment of EMPD should differ based on anatomic subtypes. Considerations for updated practice may include less morbid treatments for vulvar EMPD, which is primarily epidermal, and close surveillance for local recurrence in vulvar EMPD and metastatic recurrence in perianal EMPD. Recurrences in penoscrotal subtype were less common, and selective surveillance in this subtype may be considered. Limitations of this study include the lack of replication cohorts and the exclusion of studies that did not stratify outcomes by anatomic subtype.

We read with great interest the article by Farmakis and colleagues entitled "Mandatory radiology education for medical students (1)." In this article the authors very well illustrate the importance of radiology education during medical school and propose a well-organized and flexible model of radiology curriculum development with suggestions on strategies for implementation (1). Two of the several important considerations and reforms proposed by the authors include: 1) Adoption of more active learning methods during core clerkship, and 2) Strong emphasis on optimal imaging utilization as a part of the curriculum.

This paper provides imaging recommendations for pediatric abdominal tumors that arise outside of the solid viscera. These tumors are rare in children and have been categorized in two groups: abdominal wall and peritoneal tumors (desmoid tumor and desmoplastic small round cell tumor) and tumors that arise from the gastrointestinal tract (gastrointestinal stromal tumor and gastrointestinal neuroendocrine tumor). Authors offer consensus recommendations for imaging assessment of these tumors at diagnosis, during follow‐up, and when off‐therapy.

We appreciate the interest of Valencia et al ( 1 Valencia VF, Valderrama BAP, Llinás JRO, Ortegón JDC. Promoting research in medical practice. What a challenge! Academic Radiology. 2022. Online ahead of Print. Google Scholar ) in our proposed model titled “Resident Managed Peer-Mentoring Program”: A Novel Way to Engage Medical Students and Radiology Residents in Collaborative Research ( 2 Lakhani DA Swaney KJ Hogg JP. Resident managed peer-mentoring program”: a novel way to engage medical students and radiology residents in collaborative research. Acad Radiol. 2022; 29 (Epub 2021 Dec 2. PMID: 34863631; PMCID: PMC9156656): 1425-1431https://doi.org/10.1016/j.acra.2021.11.004 Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar ). We agree that participation in research projects and scholarly activity is an extracurricular activity for residents and medical students. We also agree that exploration of a research question and hypothesis can be labor and time intensive, as is the process of submission to different journals. Involvement in research activity for trainees has several advantages such as gaining specialized knowledge, exposure to academic practices, learning the art of “critical thinking,” enhancing mentorship skills, and developing the mentor-mentee relationships ( 2 Lakhani DA Swaney KJ Hogg JP. Resident managed peer-mentoring program”: a novel way to engage medical students and radiology residents in collaborative research. Acad Radiol. 2022; 29 (Epub 2021 Dec 2. PMID: 34863631; PMCID: PMC9156656): 1425-1431https://doi.org/10.1016/j.acra.2021.11.004 Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar , 3 Lakhani DA Doo FX Chung C. Developing a comprehensive resident-driven research training pathway: A chief resident's perspective. Curr Prob Diagnos Radiol. 2022; (Online ahead of print)https://doi.org/10.1067/j.cpradiol.2022.07.004 Crossref Scopus (4) Google Scholar ) that are so important in cultivating academic community and participation. Efforts by faculty and resident research preceptors to raise awareness among medical students and residents about how research today shapes practice tomorrow can help instill interest and enthusiasm for research among novice investigators. In addition, learners who engage in research and publication can make their applications stand out compared to the general applicant pool when medical students apply for residency or residents apply for competitive fellowship positions. To answer the question specifically, we did not keep record of the time spent by medical students, residents, resident preceptors and faculty advisors in the academic year studied. All the time commitments were outside work hours, clinical commitments and strictly on a volunteer basis. We did not have a standard evaluation form for the participants enrolled with us. However, we did provide individualized feedback on a task-by-task basis to the participants and asked for their feedback and implemented changes as needed to make their experience better.

Background In the Children’s Oncology Group ANBL1221 phase 2 trial for patients with first relapse/first declaration of refractory high-risk neuroblastoma, irinotecan and temozolomide (I/T) combined with either temsirolimus (TEMS) or immunotherapy (the anti-GD2 antibody dinutuximab (DIN) and granulocyte macrophage colony stimulating factory (GM-CSF)) was administered. The response rate among patients treated with I/T/DIN/GM-CSF in the initial cohort (n=17) was 53%; additional patients were enrolled to permit further evaluation of this chemoimmunotherapy regimen. Potential associations between immune-related biomarkers and clinical outcomes including response and survival were evaluated. Methods Patients were evaluated for specific immunogenotypes that influence natural killer (NK) cell activity, including killer immunoglobulin-like receptors (KIRs) and their ligands, Fc gamma receptors, and NCR3. Total white cells and leucocyte subsets were assessed via complete blood counts, and flow cytometry of peripheral blood mononuclear cells was performed to assess the potential association between immune cell subpopulations and surface marker expression and clinical outcomes. Appropriate statistical tests of association were performed. The Bonferroni correction for multiple comparisons was performed where indicated. Results Of the immunogenotypes assessed, the presence or absence of certain KIR and their ligands was associated with clinical outcomes in patients treated with chemoimmunotherapy rather than I/T/TEMS. While median values of CD161, CD56, and KIR differed in responders and non-responders, statistical significance was not maintained in logistic regression models. White cell and neutrophil counts were associated with differences in survival outcomes, however, increases in risk of event in patients assigned to chemoimmunotherapy were not clinically significant. Conclusions These findings are consistent with those of prior studies showing that KIR/KIR-ligand genotypes are associated with clinical outcomes following anti-GD2 immunotherapy in children with neuroblastoma. The current study confirms the importance of KIR/KIR-ligand genotype in the context of I/T/DIN/GM-CSF chemoimmunotherapy administered to patients with relapsed or refractory disease in a clinical trial. These results are important because this regimen is now widely used for treatment of patients at time of first relapse/first declaration of refractory disease. Efforts to assess the role of NK cells and genes that influence their function in response to immunotherapy are ongoing. Trial registration number NCT01767194 .

ObjectivesChild abuse should be considered in cases of sudden unexpected infant death (SUID). Postmortem skeletal surveys (PM-SS) are recommended to evaluate for abusive fractures in SUID. Little is known about the yield of PM-SS among infants presenting to emergency care with SUID. Our objectives were to (1) describe the presentation and care of infants with SUID at a tertiary children's hospital emergency department and (2) report PM-SS use and findings.MethodsWe performed a retrospective study of infants younger than 12 months with SUID presenting to an urban emergency department from 2007 to 2019. We describe their presentation and care, including PM-SS performance and findings, referrals to the medical examiner, and reports to child protective services (CPS). We assessed for associations between race, payer, and presentation with reports to CPS.ResultsOf 73 infants with SUID, concern for unsafe sleep was documented in 45 (61.6%) and 71 (97.3%) underwent cardiopulmonary resuscitation by a medical professional. All 73 (100%) underwent PM-SS and were referred to the medical examiner. Twelve definite fractures (11 rib, 1 classic metaphyseal lesion) and 8 possible fractures (7 rib, 1 classic metaphyseal lesion) were identified among 6 (8.2%) infants. Forty-three (58.9%) were reported to CPS. There were no associations between race, payer, age, or history of unsafe sleep and CPS reports.ConclusionsOne in 12 cases of SUID had a possible and/or definite fracture identified on plain radiography. Multicenter studies are needed to compare yield across different postmortem imaging modalities and populations.

We read with interest the article by Junn and colleagues “Virtual mentoring: A guide to navigating a new age in mentorship” published in Academic Radiology ( 1 Junn JC Whitman GJ Wasnik AP et al. Virtual mentoring: a guide to navigating a new age in mentorship. Acad Radiol. 2022; https://doi.org/10.1016/j.acra.2022.08.014 Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar ). We applaud the authors for a timely perspective on the virtual mentorship process, which is now established as a “new normal” following the COVID-19 pandemic, similar to the adoption of virtual recruitment now in common use for radiology residency ( 2 Domingo A Rdesinski RE Stenson A et al. Virtual Residency interviews: applicant perceptions regarding virtual interview effectiveness, advantages, and barriers. J Grad Med Educ. 2022; 14: 224-228https://doi.org/10.4300/JGME-D-21-00675.1 Crossref PubMed Scopus (9) Google Scholar ) and fellowship ( 3 Lakhani DA Deng F Chung C et al. Virtual radiology fellowship recruitment: benefits, limitations, and future directions. Acad Radiol. 2022; https://doi.org/10.1016/j.acra.2022.08.011 Abstract Full Text Full Text PDF Scopus (2) Google Scholar ) positions.

AbstractMalignant renal tumors account for approximately 6% of pediatric malignancies, with Wilms tumor (WT) representing approximately 90% of pediatric renal tumors. This paper provides consensus‐based imaging guidelines for the initial evaluation of a child with suspected WT and follow‐up during and after therapy co‐developed by the Children's Oncology Group (COG) Diagnostic Imaging and Society for Pediatric Radiology (SPR) oncology committees. The guidelines for Wilms Tumor Imaging in the Society of International Pediatric Oncology (SIOP) are briefly discussed to highlight some of the differences in imaging approach.

IMPORTANCE:Extramammary Paget disease (EMPD) is a frequently recurring malignant neoplasm with metastatic potential that presents in older adults on the genital, perianal, and axillary skin. Extramammary Paget disease can precede or occur along with internal malignant neoplasms.OBJECTIVE:To develop recommendations for the care of adults with EMPD.EVIDENCE REVIEW:A systematic review of the literature on EMPD from January 1990 to September 18, 2019, was conducted using MEDLINE, Embase, Web of Science Core Collection, and Cochrane Libraries. Analysis included 483 studies. A multidisciplinary expert panel evaluation of the findings led to the development of clinical care recommendations for EMPD.FINDINGS:The key findings were as follows: (1) Multiple skin biopsies, including those of any nodular areas, are critical for diagnosis. (2) Malignant neoplasm screening appropriate for age and anatomical site should be performed at baseline to distinguish between primary and secondary EMPD. (3) Routine use of sentinel lymph node biopsy or lymph node dissection is not recommended. (4) For intraepidermal EMPD, surgical and nonsurgical treatments may be used depending on patient and tumor characteristics, although cure rates may be superior with surgical approaches. For invasive EMPD, surgical resection with curative intent is preferred. (5) Patients with unresectable intraepidermal EMPD or patients who are medically unable to undergo surgery may receive nonsurgical treatments, including radiotherapy, imiquimod, photodynamic therapy, carbon dioxide laser therapy, or other modalities. (6) Distant metastatic disease may be treated with chemotherapy or individualized targeted approaches. (7) Close follow-up to monitor for recurrence is recommended for at least the first 5 years.CONCLUSIONS AND RELEVANCE:Clinical practice guidelines for EMPD provide guidance regarding recommended diagnostic approaches, differentiation between invasive and noninvasive disease, and use of surgical vs nonsurgical treatments. Prospective registries may further improve our understanding of the natural history of the disease in primary vs secondary EMPD, clarify features of high-risk tumors, and identify superior management approaches.

Recent literature has raised concerns about the sensitivity and accuracy of radiographs at diagnosing rib fractures. Studies have shown that chest computed tomography (CT) has far greater sensitivity at detecting rib fractures than radiographs. The purpose of this study was to evaluate the sensitivity of skeletal survey (SS) radiographs at diagnosis of rib fractures compared to CT in the pediatric population. This retrospective review included 57 patients who had undergone both a SS and a CT chest or CT chest/abdomen/pelvis within 30 days of each other for the indication of either non-accidental (NAT) or accidental trauma between 2009 and 2017. Images and reports were analyzed by a pediatric radiology fellow for presence/absence of fracture, evidence of healing and location of rib fracture, including rib level, location within the rib (anterior, lateral, and posterior), and side (right versus left). 225 rib fractures were identified in 25 patients on CT. 38 of those fractures were missed on the preceding SS, yielding a miss rate of 17%. Acute fractures were more likely to be missed than chronic or healing fractures (p ≤ 0.01). Location within the rib did not impact rib detection on radiographs. Left-sided rib fractures were not more common in NAT patients, compared to accidental trauma. SS miss approximately 17% of all rib fractures and CT is more sensitive modality in the detection of rib fractures, particularly acute rib fractures, regardless of location. Low-dose Chest CT could be a helpful modality in the work-up of NAT trauma.

Imaging plays a critical role in identifying young victims of physical abuse. While some injuries in abused children will be readily evident on physical examination, others are only revealed through imaging. Here we describe the role of imaging in the evaluation of children when abuse is suspected.

BACKGROUND CONTEXT:The majority of existing literature describing pediatric lumbar vertebral morphology are limited to characterization of the vertebral bodies, pedicles, and spinal canal and no study has described the rates of growth for any lumbar vertebral structure. While it is known that growth of the lumbar vertebrae results in changes in vertebral shape, the dimension ratios used to quantify these shape changes do not represent the 3D morphology of the vertebral structures. Additionally, many of the previous evaluations of growth and shape are purely descriptive and do not investigate sexual dimorphism or variations across vertebral levels.PURPOSE:This study aims to establish a database of pediatric lumbar vertebra dimension, growth, and shape data for subjects between and ages of 1 and 19 years.STUDY DESIGN:A retrospective study of computed tomography (CT) data.METHODS:Retrospective, abdominal, CT scans of 102 skeletally normal pediatric subjects (54 males, 48 females) between the ages of 1 and 19 years were digitally reconstructed and manually segmented. Thirty surface landmark points (LMPs), 30 vertebral measurements, the centroid size, centroid location, and the local orientation were collected for each lumbar vertebra along with the centroid size of the LMPs comprising each subject's full lumbar spine and their intervertebral disc (IVD) heights. Nonparametric statistics were used to compare dimension values across vertebral levels and between sexes. Linear models with age as the independent variable were used to characterize dimension growth for each sex and vertebral level. Age-dependent quadratic equations were fit to LMP distributions resulting from a generalized Procrustes analysis (GPA) of the vertebrae and fixed effects models were used to investigate differences in model coefficients across levels and between sexes.RESULTS:Intervertebral level dimension differences were observed across all vertebral structures in both sexes while pedicle widths and IVDs heights were the only measurements found to be sexually dimorphic. Dimension growth rates generally varied across vertebral levels and the growth rates of males were typically larger than those of females. Differences between male and female vertebral shapes were also found for all lumbar vertebral structures.CONCLUSIONS:To the authors' knowledge, this is the first study to report growth rates for the majority of pediatric lumbar vertebral structures and the first to describe the 3D age-dependent shapes of the pediatric lumbar spine and vertebrae. In addition to providing a quantitative database, the dimension, growth, and shape data reported here would have applications in medical device design, surgical planning, surgical training, and biomechanical modeling.

Genetics of Osteogenesis Imperfecta in Suspected Child AbuseGerard Pals, PhD1 and Sung Ah Stolk, PhD2Audio Available | Share

Objective To quantify the effect of age on two-dimensional (2D) radiographic lung and diaphragm morphology and determine if 2D radiographic lung measurements can be used to estimate computer tomography (CT)-derived lung volume in normative pediatric subjects. Materials and Methods Digitally reconstructed radiographs (DRRs) were created using retrospective chest CT scans from 77 pediatric male and female subjects aged birth to 19 years. 2D lung and diaphragm measurements were made on the DRRs using custom MATLAB code, and Spearman correlations and exponential regression equations were used to relate 2D measurements with age. In addition, 3D lung volumes were segmented using CT scans, and power regression equations were fitted to predict each lung's CT-derived volume from 2D lung measurements. The coefficient of determination (R-2) and standard error of the estimate (SEE) were used to assess the precision of the predictive equations with p < .05 indicating statistical significance. Results All 2D radiographic lung and diaphragm measurements showed statistically significant positive correlations with age (p < .01), including lung major axis (Spearman rho >= 0.90). Precise estimations of CT-derived lung volumes can be made using 2D lung measurements (R-2 >= 0.95), including lung major axis (R-2 >= 0.97). Interpretations The reported pediatric age-specific reference data on 2D lung and diaphragm morphology and growth rates could be clinically used to identify lung and diaphragm pathologies during chest X-ray evaluations. The simple, precise, and clinically adaptable radiographic method for estimating CT-derived lung volumes may be used when pulmonary function tests are not readily available or difficult to perform.

To evaluate clinical applications of dual‐energy computed tomography (DECT) in pediatric‐specific lung diseases and compare ventilation and perfusion findings with those from single‐photon emission computed tomography (SPECT‐CT) V/Q.

In this study, we investigated the diagnostic performance of whole-body 18F-FDG imaging using a PET/MRI scanner with time-of-flight capability for low-dose clinical imaging of pediatric patients. In addition to clinically acquired image data using a dosing regimen of 3.7 MBq/kg, images from simulated low-dose regimens (1.9-0.41 MBq/kg) were evaluated using several metrics: SUV quantitation, qualitative image quality, and lesion detectability. Methods: Low-dose images were generated by truncating the list-mode PET data to reduce the count statistics. Changes in PET quantitation for low-dose images were assessed using volume-of-interest analysis of healthy tissue and suspected lesions. Three pediatric radiologists reviewed the image volumes without knowing the dose level. Qualitative image quality was assessed on the basis of Likert scoring. Radiologists were also asked to identify suspected lesions within the liver for PET-only and PET/MR images. Lesion detectability was measured using a receiver-operating-characteristic study and quantified using a free-response receiving-operating-characteristic (FROC) methodology to assess changes in performance for low-dose images. Results: Our analysis of volume-of-interest quantitation showed that SUVs remain stable down to ⅓ dose (1.2 MBq/kg). Likert scoring of PET/MR images showed no noticeable trend with dose level; however, scores of PET-only images were lower for low-dose scans, with a 12% reduction for ⅓-dose images compared with full-dose images. There was minimal change in total lesion count for different dose levels; however, all 3 readers had an increase in false-negatives for ⅓-dose images compared with full-dose images. Using the FROC methodology to quantify lesion-detection performance for human observers, no significant differences were observed for the 3 dosing levels when using the averaged reader data (all P values > 0.103). For all readers, the FROC performance was higher for PET/MRI than for PET alone. Conclusion: Reductions to the lowest recommended pediatric dosing regimens are possible when using PET/MRI. The data suggest that the administered dose can be decreased to 2.46 MBq/kg, a 33% reduction in PET activity, with no degradation in image quality, leading to a corresponding reduction in absorbed dose.