Judy H. Squires

Deep learning–based hepatoblastoma segmentation models trained on pediatric CT and MRI scans demonstrated good agreement with human annotators and their consensus. Pediatric contrast-enhanced CT model outperformed the adult CT-trained model.

Benign and malignant primary pediatric liver tumors are reviewed, correlating imaging features with the underlying pathology and incorporating updates in imaging technology and tumor classification.

Background: Management of neonatal portal vein thrombosis (PVT), a relatively common type of pediatric deep vein thrombosis, is not completely standardized. Questions remain about the benefit of anticoagulation (ATC) therapy and about the optimal frequency and duration of doppler ultrasound (US) surveillance for liver complications such as portal hypertension and gastrointestinal bleeding. Current guidelines suggest reserving ATC only for occlusive PVT, highlighting a need for explicit grading of PVT in radiologic reports and a consensus approach to imaging and management. Methods: To address these issues, we implemented an institutional Neonatal PVT Management Algorithm using plan–do–study–act (PDSA) methodology. We aimed to standardize screening tests, reduce unnecessary ATC, and optimize imaging checkpoints. A five‐year retrospective review established baseline data, which we compared to outcomes five years post‐implementation of the algorithm. Results: The algorithm recommended ATC only for occlusive PVT and advised US imaging at Week 1, Month 1, Month 3, and Month 6 from diagnosis, with annual surveillance for unresolved or abnormal cases. Post‐implementation analysis revealed improvements in radiologic documentation of PVT grading, a reduction in the use of ATC for subocclusive PVT, and a decrease in the median duration of ATC for all patients. Follow‐up imaging adherence did not improve between the pre‐ and post‐implementation periods. Conclusions: The algorithm successfully enhanced documentation of PVT grading and reduced unnecessary ATC but highlighted persistent challenges in follow‐up adherence, suggesting a need for further refinement in future PDSA cycles.

Children with underlying systemic and predisposition disorders are subject to the development of benign and malignant masses, sometimes in the setting of chronic parenchymal liver disease, and knowledge of the pathophysiology of these disorders and the appearances of potential liver masses is important for the pediatric radiologist.

Most pediatric specialists, including hematologists/oncologists, surgeons, radiologists, and pathologists, are familiar with the diagnosis and management of Wilms tumor (WT). However, it may be challenging to identify the underlying conditions causing cancer predisposition, which can change the management for the patient and potentially their entire family. In this paper, we present 3 cases of clinically suspected WT associated with Beckwith-Wiedemann syndrome (BWS). We review the radiologic and histologic findings to diagnose BWS. We also discuss the implications of a BWS diagnosis on the clinical management of WT and follow-up guidelines for BWS patients.

Imaging plays an important role in the diagnosis and follow-up of children with acute recurrent pancreatitis (ARP) and chronic pancreatitis (CP). Consensus is lacking for a minimum MRI protocol for the child with known or suspected ARP or CP. Lack of standardization contributes to variable diagnostic performance and hampers application of uniform interpretive criteria for clinical diagnosis and multicenter research studies. We convened a working group to achieve consensus for a minimum MRI protocol for children with suspected ARP or CP. The group included eight pediatric radiologists experienced in interpreting MRI for pediatric pancreatitis and one medical pancreatologist and functioned from November 2022 to March 2023. Existing clinical protocols were summarized across sites represented by group members, and commonly used sequences guided the group's discussion. The final consensus minimum MRI protocol includes five noncontrast sequences and two postcontrast sequences (which are required only in select clinical scenarios). The working group also provides recommended acquisition parameters, sequence-specific technical suggestions, and general recommendations for optimal imaging technique. We recommend that all sites imaging children with ARP and CP for clinical care, and particularly those engaged in cooperative group trials for pancreatitis, ensure that their local protocol includes these minimum sequences.

The liver is the primary organ for the metabolism of many chemotherapeutic agents. Treatment-induced liver injury is common in children undergoing cancer therapy. Hepatic injury occurs due to various mechanisms, including biochemical cytotoxicity, hepatic vascular injury, radiation-induced cytotoxicity, and direct hepatic injury through minimally invasive and invasive surgical treatments. Treatment-induced liver injury can be seen contemporaneous with therapy and months to years after therapy is complete. Patients can develop a combination of hepatic injuries manifesting during and after treatment. Acute toxic effects of cancer therapy in children include hepatitis, steatosis, steatohepatitis, cholestasis, hemosiderosis, and vascular injury. Longer-term effects of cancer therapy include hepatic fibrosis, chronic liver failure, and development of focal liver lesions. Quantitative imaging techniques can provide useful metrics for disease diagnosis and monitoring, especially in treatment-related diffuse liver injury such as hepatic steatosis and steatohepatitis, hepatic iron deposition, and hepatic fibrosis. Focal liver lesions, including those developing as a result of treatment-related vascular injury such as focal nodular hyperplasia-like lesions and hepatic perfusion anomalies, as well as hepatic infections occurring as a consequence of immune suppression, can be anxiety provoking and confused with recurrent malignancy or hepatic metastases, although there often are imaging features that help elucidate the correct diagnosis. Radiologic evaluation, in conjunction with clinical and biochemical screening, is integral to diagnosing and monitoring hepatic complications of cancer therapy in pediatric patients during therapy and after therapy completion for long-term surveillance. ^©RSNA, 2023 Quiz questions for this article are available in the supplemental material See the invited commentary by Ferraciolli and Gee in this issue.

The World Federation for Ultrasound in Medicine and Biology (WFUMB) is addressing the issue of incidental findings (IFs) with a series of publications entitled “Incidental imaging findings—the role of ultrasound”. IFs in the liver of newborns and children are rare and much less commonly encountered than in adults; as a result, they are relatively much more frequently malignant and life-threatening, even when they are of benign histology. Conventional B-mode ultrasound is the well-established first line imaging modality for the assessment of liver pathology in pediatric patients. US technological advances, resulting in image quality improvement, contrast-enhanced ultrasound (CEUS), liver elastography and quantification tools for steatosis have expanded the use of ultrasound technology in daily practice. The following overview is intended to illustrate incidentally detected liver pathology covering all pediatric ages. It aims to aid the examiner in establishing the final diagnosis. Management of incidentally detected focal liver lesions (FLL) needs to take into account the diagnostic accuracy of each imaging modality, the patient’s safety issues (including ionizing radiation and nephrotoxic contrast agents), the delay in diagnosis, the psychological burden on the patient and the cost for the healthcare system. Moreover, this paper should help the pediatric clinician and ultrasound practitioner to decide which pathologies need no further investigation, which ones require interval imaging and which cases require further and immediate diagnostic procedures.

Imaging plays an important role in the diagnosis and management of focal liver lesions, and patient-related factors such as age, size, cardiac function, and ability to cooperate for imaging examina... A differential diagnosis based on a patient’s age, clinical presentation, and serum α-fetoprotein level will help guide the initial imaging workup in children with a liver lesion. Children vary sig...