In 1978, Sinner reported computed tomographic (CT) findings of pulmonary thromboembolism and infarction for the first time, and CT imaging has been considered a useful modality for diagnosing proximal pulmonary thromboembolism since then. In 1992, Remy-Jardin et al reported the first evaluation of spiral volumetric CT imaging in the diagnosis of pulmonary thromboembolism, with angiographic correlation. With the advancement of CT technology, spiral CT imaging has quickly become the method for evaluating patients with suspected pulmonary thromboembolism with high sensitivity and specificity . For multidetector CT scanning of the chest, sensitivity and specificity range from 83% to 100% and from 89% to 97%, respectively . Technical advances have improved image quality even in patients with dyspnea and/or underlying respiratory diseases . In a recent meta-analysis of 15 studies in 3500 patients, the clinical validity of CT imaging to rule out acute pulmonary embolism (PE) was 1.0% to 2.8% . Now, CT pulmonary angiography (CTPA) has become the clinical tool of choice in daily practice, used for the diagnosis for PE .
In this issue, Abujudeh et al address the very interesting and important issue of “radiology reports” of CTPA. They analyzed 2151 radiology reports of CTPA, which were conclusive in 66%, including conclusively positive for PE in 10%, conclusively negative for PE in 29%, and negative for PE to the segmental arteries in 27%. Of the remaining 34%, 21% were negative for PE to the central pulmonary arteries, 8% were negative but considered suboptimal examinations, and 5% were nondiagnostic. Moreover, limitations in image quality were mentioned in 91% (1954 of 2151). In particular, respiratory motion artifacts and contrast enhancement were mentioned in 62% and 28% of all reports, respectively. Radiologists tended to report limitations in image quality if they were thoracic radiology subspecialists, had >10 years of experience, or worked independently without residents ( P < .001).
Considering the complexity of demographics of the patients in a major academic center, it is reasonable to report that 66% of patients who underwent CTPA had conclusive diagnoses in the radiology reports. The extremely high rate of descriptions of limitations in image quality in 91% of radiology reports raises some concerns. Describing image quality is one thing; stating it as a limitation is another. If the confident diagnostic rate is 66%, then obviously, the 91% rate of limitations of image quality is likely an overstatement. We as radiologists may see a somewhat grainy image, but that does not limit our ability to confidently interpret our findings. As the authors state in their introduction, “the radiology report is the final document that describes the findings of a radiologic consultation by a radiologist and is forwarded to the referring physician” as a medical and legal document. There will be consequences, including potential ambiguity and delays in diagnostic and therapeutic decisions, repeated CT studies or additional tests with other modalities, extended hospital stays, patient anxiety, and credibility by referring physicians who receive radiology reports.
Of course, there are many issues, including need to improve CT technology, potential electrocardiographic gating, the need to improve scan techniques, and contrast bolus timing. However, we as radiologists may also have to consider how we report and communicate our findings to our colleagues and patients. It may be a problem if we say that 91% of our products, namely, our radiology reports, are “incomplete” or “not satisfactory.” There are subsequent potential costs and consequence when our radiology reports contain “uncertainty” and/or limitations. In the good old days, our senior mentors used to say to us, “Say normal when the study is normal. For such commitment, we are paid as radiologists.”
References
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