Atherosclerotic cardiovascular disease (ASCVD) is the leading global cause of death and evolves over decades through a prolonged subclinical phase, providing a critical opportunity for early detection and prevention. Traditional risk prediction models estimate future cardiovascular risk but may under- or overestimate individual risk, particularly in borderline- and intermediate-risk patients, making them insufficient to guide preventive therapy decisions. Imaging biomarkers complement clinical risk assessment by directly detecting and quantifying subclinical atherosclerosis, enabling more personalized preventive strategies. Coronary artery calcium (CAC) scoring with noncontrast electrocardiographic (ECG)-gated CT remains the most established and guideline-endorsed imaging biomarker for risk reclassification. Coronary CT angiography provides incremental prognostic information through assessment of plaque burden, plaque composition, and high-risk plaque features, while emerging techniques, including quantitative plaque analysis and pericoronary adipose assessment, further characterize plaque biology and inflammatory activity. Beyond coronary imaging, extracoronary biomarkers, including carotid and aortic imaging, epicardial adipose tissue, and arterial stiffness assessments provide complementary information about systemic vascular and cardiometabolic health. In addition, opportunistic biomarkers identified at routine CT and MRI examinations, such as incidental coronary and extracoronary calcifications, breast arterial calcification, hepatic steatosis, visceral adiposity, sarcopenia, osteoporosis, and cerebral imaging markers, expand opportunities for cardiovascular risk assessment without additional imaging or radiation. Although many emerging biomarkers require further standardization and outcome-based validation, integration of imaging biomarkers with clinical risk factors, standardized reporting, and artificial intelligence has the potential to improve ASCVD risk stratification and enable more precise and personalized cardiovascular prevention.

Childhood cancer predisposition syndromes (CPSs) are individually rare but collectively account for approximately 15%-20% of pediatric cancers. Advances in genomic testing have identified more than 100 cancer susceptibility genes, enabling earlier recognition of at-risk children and prompting implementation of structured surveillance programs. Imaging is central to screening, which also typically includes physical examination and biochemical testing, guided by the syndrome-specific tumor spectrum, age-related penetrance, tumor growth kinetics, and defined risk thresholds. In general, screening is recommended when the risk of developing a malignancy exceeds 5% within a specified age window. Pediatric CPS surveillance presents unique challenges. Protocols must balance early tumor detection with minimization of potential harm, including cumulative radiation exposure, contrast material-related risks, sedation requirements, and psychosocial burden associated with repeated or lifelong imaging. Ionizing radiation-free modalities, particularly US and MRI, form the backbone of surveillance. Whole-body MRI, with its large field of view and ability to allow assessment of multiple organ systems in a single examination, is increasingly incorporated into surveillance protocols for select syndromes associated with a variety of tumors. Sequence optimization and nonsedative strategies are frequently used to mitigate prolonged acquisition. Familiarity with syndrome-specific tumor imaging characteristics is essential to optimize lesion detection and reduce false-positive and false-negative interpretations. Radiologists may also be the first to recognize characteristic tumors suggestive of an underlying hereditary condition. On the basis of the updated recommendations from the 2023 American Association for Cancer Research pediatric CPS workshop, the authors review outlines guiding principles for surveillance, summarizing imaging components of current protocols for several common or clinically significant childhood CPSs.

Pancreatic cancer remains one of the most lethal malignancies, with an overall 5-year survival rate of approximately 13%. The poor prognosis is primarily due to late-stage diagnosis, as early-stage disease is often asymptomatic. Screening for pancreatic cancer in high-risk individuals offers the potential for early detection, timely intervention, and improved survival outcomes. Individuals at elevated risk for pancreatic cancer-that is, those with a family history or predisposing genes for pancreatic cancer or certain inherited syndromes and patients with precursor lesions or precancerous lesions-are considered suitable candidates for screening. Imaging is recognized as an important tool for diagnosis and staging of pancreatic cancer. Evidence supports use of endoscopic US, MRI, and CT as primary imaging modalities to facilitate early detection. Screening intervals and imaging strategies vary in high-risk individuals and those with precursor or precancerous lesions. While conventional imaging plays a key role in diagnosis and staging, it often fails to allow detection of visually occult disease, an area where artificial intelligence-enhanced imaging offers potential. These advancements have the potential to improve detection of early pancreatic cancer with prediagnostic CT and MRI. In parallel, the development of novel serum biomarkers with greater sensitivity and specificity provides promising avenues for noninvasive screening. Despite these advances, there remains a critical unmet need for validated, cost-effective, and scalable tools. The authors aim to critically appraise current screening strategies, highlight emerging technologies in imaging and biomarkers, and discuss their potential to transform early detection and improve clinical outcomes in high-risk populations. © The Author(s) 2026. Published by the Radiological Society of North America under a CC BY 4.0 license See the invited commentary by Luk and Flusberg in this issue.

Opportunistic CT screening refers to the extraction of clinically relevant imaging biomarkers from CT examinations routinely performed for unrelated primary indications. This screening does not require additional radiation exposure, imaging time, or patient burden. Advances in automated image analysis and artificial intelligence (AI) have substantially expanded the feasibility of opportunistic CT screening across a range of conditions, including low bone mineral density, hepatic steatosis, sarcopenia, adiposity, and vascular calcifications. These biomarkers are increasingly being recognized as important contributors to fracture risk, cardiometabolic disease, and frailty; yet they often remain undiagnosed in routine clinical practice. While numerous studies have demonstrated technical feasibility and diagnostic performance, widespread clinical adoption of opportunistic CT screening remains limited. Key challenges include those related to workflow integration, standardization of measurement techniques, quality assurance, interpretability of results, and uncertainty regarding downstream clinical management and value. In particular, not all opportunistic imaging biomarkers are equally actionable, and inappropriate or indiscriminate reporting may contribute to overdiagnosis or unnecessary follow-up. The authors summarize common applications of opportunistic CT screening, highlighting typical imaging findings and biomarkers. The authors discuss the evolution of automated and AI-based approaches, with emphasis on practical considerations for deployment, including pre- and postdeployment quality assurance, algorithm monitoring, and practical considerations for clinical integration. Emerging applications also are reviewed, with attention to current limitations. With a focus on clinical integration, this review is intended to inform radiologists, informaticians, and others working in health care systems who seek to translate opportunistic CT screening from proof-of-concept studies into scalable, clinically meaningful practice.

Screening and diagnostic evaluation for breast cancer is increasingly common during pregnancy and lactation due to delayed childbearing and identification of elevated hereditary and familial risk during reproductive years, with patients often undergoing risk assessment beginning at 25 years of age. Although mammography is safe for pregnant and lactating patients, its sensitivity may be reduced because hormonal changes increase parenchymal density and can obscure malignant lesions. US is widely used because it does not involve exposure to ionizing radiation and serves as the primary modality for evaluating symptomatic patients. However, its role in routine screening remains uncertain because evidence regarding screening performance and outcomes in pregnant and lactating populations is limited. MRI is contraindicated during pregnancy but may be performed during lactation for screening of patients at high risk for or with newly diagnosed breast cancer, despite its pronounced background parenchymal enhancement. Timely evaluation of breast symptoms and imaging abnormalities is critical given the rising incidence of pregnancy-associated breast cancer and the potential for delayed diagnosis. Therefore, radiologists must balance diagnostic performance with maternal and fetal safety when selecting imaging modalities. The authors review the current American College of Radiology Appropriateness Criteria and the guidelines of other professional organizations; summarize the epidemiology of pregnancy-associated breast cancer and the physiologic breast changes that affect imaging interpretation; and highlight modality-specific limitations, safety considerations, and contraindications. Strategies for identifying patients at high risk for breast cancer who require continued screening and for effectively communicating imaging risks, benefits, and expectations to patients and referring clinicians are also discussed.

Newborns and infants with certain perinatal exposures, congenital conditions, and genetic syndromes are at increased risk for clinically significant diseases and may benefit from early detection. In these children, imaging serves as a targeted screening tool to identify actionable abnormalities during a window in which intervention may reduce morbidity and long-term sequelae. The authors summarize evidence-based US screening strategies for high-risk newborns and infants encountered in clinical practice, including preterm infants, newborns with a breech presentation, children with congenital and syndromic conditions, and children with tumor predisposition syndromes. For each group, the authors discuss the rationale for screening, optimal timing, key technical considerations, and imaging findings that directly influence management. Across indications, effective screening follows common principles: risk-based selection rather than universal imaging, adherence to standardized protocols, and interpretation by radiologists familiar with population-specific disease patterns. When embedded within structured clinical pathways, targeted screening supports early diagnosis, guides multidisciplinary management, and helps prevent avoidable complications in vulnerable pediatric populations.

Low-dose CT lung cancer screening reduces lung cancer mortality in individuals at high risk and frequently reveals clinically relevant incidental findings. In the National Lung Screening Trial, approximately one-third of screening CT examinations demonstrated abnormalities other than lung cancer, raising challenges related to interpretation, reporting, and further management. The absence of consistent guidance and the variable clinical significance of these findings may hinder the broader adoption of lung cancer screening. Opportunistic screening leverages low-dose CT examinations performed for lung cancer detection to identify additional serious conditions at no extra cost, radiation exposure, or patient burden. The authors provide a practical framework for recognizing, reporting, and managing common opportunistic findings on lung cancer screening CT images, with an emphasis on evidence-based recommendations and current professional society guidance. Key thoracic findings include emphysema, interstitial lung abnormalities, interstitial lung disease, coronary artery calcification, thoracic aortic aneurysm, and pulmonary artery enlargement. Each of these findings, if unrecognized, is associated with substantial morbidity and mortality. Extrapulmonary findings such as low bone density and lesions found incidentally in the upper abdominal organs further expand the clinical value of lung cancer screening. The authors highlight standardized visual and quantitative assessment methods, recommended follow-up pathways, and the importance of structured reporting, including appropriate use of the Lung CT Screening Reporting and Data System "S" (other non-lung cancer findings) modifier. Emerging artificial intelligence tools are discussed as critical enablers for scalable opportunistic screening, offering automated detection, quantification, and longitudinal assessment of emphysema, coronary calcium levels, vascular dimensions, bone density, body composition, and selected abdominal pathologic conditions. By integrating opportunistic screening into routine lung cancer screening workflows, radiologists can extend the benefit of lung cancer screening with CT beyond cancer detection to facilitate comprehensive risk stratification and preventive care.

Hepatocellular carcinoma (HCC) is the third leading cause of cancer-related mortality worldwide and most often arises in patients with chronic liver disease and cirrhosis. Since curative treatment options are largely limited to early-stage disease, effective surveillance strategies are essential to improve outcomes. Current guidelines recommend semiannual US combined with serum α-fetoprotein level testing as the standard surveillance approach for most patients at high risk. Liver Imaging Reporting and Data System 2024 guidance provides a structured framework for interpretation of surveillance US and highlights the importance of examination quality assessment and reporting by incorporating it into the management decision-making algorithm. US surveillance improves early tumor detection and survival but demonstrates suboptimal sensitivity in certain high-risk subgroups, particularly patients with obesity, hepatic steatosis, and advanced cirrhosis. Growing evidence supports the use of alternative strategies including biomarker panel results and abbreviated MRI protocols in selected patient subgroups because these approaches demonstrate higher sensitivity and favorable cost-effectiveness when applied to appropriately risk-stratified populations. Furthermore, cost-effectiveness analyses consistently indicate that surveillance efficiency strongly depends on individual HCC risk, imaging costs, surveillance use, and societal willingness-to-pay thresholds, supporting a departure from uniform "one-size-fits-all" strategies in favor of personalized, risk-adapted surveillance paradigms. Despite advances in diagnostic performance, surveillance use remains suboptimal in clinical practice due to patient-, provider-, and system-level barriers. The authors aim to synthesize current evidence on HCC surveillance including identifying target populations; evaluating the diagnostic performance of available modalities; and considering cost-effectiveness, emerging technologies, and real-world barriers to implementation of surveillance protocols.

Management of hepatocellular carcinoma (HCC) can vary substantially by region. The authors highlight differences between Eastern and Western health care systems in the use of MRI for surveillance, diagnosis, and treatment monitoring in patients with HCC. These regional differences reflect variations in disease prevalence, treatment practice patterns, and reimbursement policies as well as the evolving role of MRI in the care continuum, for which global consensus has not yet been achieved. Although variations are not uncommon, even within regions or countries, some general observations can be made and are represented by national or regional practice guidelines. For instance, in East Asia, where hepatitis B is the predominant cause of HCC and locoregional tumor ablation is preferred, guidelines emphasize high diagnostic sensitivity. Consequently, they employ broader screening criteria with MRI. Conversely, in Western regions where liver transplant for HCC is prioritized and the stakes for specificity are high, guidelines emphasize high pretest probabilities and stricter criteria for "definite HCC." Although HCC diagnostic criteria remain somewhat divergent, the criteria for assessment of treatment response have transcended regional differences to evolve globally in tandem, shifting away from measuring the gross reduction in tumor size toward assessment based on features of tumor viability. This shift has been instrumental for adoption of immunotherapy, in which conventional size criteria may allow underestimation of its therapeutic benefit. Recognition of these regional variations is important in interpretation of multicenter international studies and to facilitate global collaboration in MRI-based management of HCC.