close

Вход

Log in using OpenID

Monday - RSNA 2014

embedDownload
SPSC20
Controversy Session: Shoulder Imaging: US vs MR
Special Courses
US
MR MK
AMA PRA Category 1 Credits ™: 1.00
ARRT Category A+ Credit: 1.00
Mon, Dec 1 7:15 AM - 8:15 AM
Location: E351
Participants
Moderator
Laura W. Bancroft MD : Royalties, Wolters Kluwer nv
Jon A. Jacobson MD (Presenter): Consultant, BioClinica, Inc Royalties, Reed Elsevier Equipment support, Terumo Corporation
Equipment support, Arthrex, Inc
Theodore T. Miller MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Describe the indications for shoulder US. 2) Desribe the advantages and disadvantages of US for evaluating the shoulder. 3)
Describe the indications for shoulder MRI. 4) Describe the advantages and disadvantages of MRI for evaluating the shoulder.
SPSH20
Hot Topic Session: Meeting the Demand for 24/7 Coverage in Academic Medical Centers
Special Courses
ER
AMA PRA Category 1 Credits ™: 1.00
ARRT Category A+ Credit: 1.00
Mon, Dec 1 7:15 AM - 8:15 AM
Location: E352
Participants
Moderator
Stephen Ledbetter MD : Nothing to Disclose
LEARNING OBJECTIVES
Many radiology departments are actively considering different methods to best expand to 24/7 attending coverage. In this
session, three very different solutions will be explored, with particular attention to the issues relevant to academic medical
centers, including: staffing, scheduling, and sustainability; expertise and scope of practice; the academic mission including
academic productivity and implications to trainee education and autonomy; and financial considerations. Each model will be
discussed, followed by a panel session for open discussion.
Sub-Events
SPSH20A
Dedicated 24/7 ER Radiology Section Coverage Operating a Supporting Teleradiology Business
Aaron D. Sodickson MD, PhD (Presenter): Research Grant, Siemens AG
LEARNING OBJECTIVES
View learning objectives under main course title.
SPSH20B
Overnight Only ER Section in a Multi-hospital Health Care System
Lovleen
Cavanagh DO (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
View learning objectives under main course title.
SPSH20C
Moving Toward around the Clock Subspecialty Coverage of ED Imaging - A Hybrid Model
Syed Ahmad Jamal Bokhari MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
View learning objectives under main course title.
Centennial Showcase
Miscellaneous
Sat, Nov 29 12:00 PM - 5:00 PM
Location: Centennial Pavilion, Learning Center
ABSTRACT
Explore an onsite experience to see, hear, and discover the advancements that shaped radiology. The Showcase will feature a
historical timeline and a special welcome from a virtual Wilhelm Roentgen. Visitors can explore the Centennial Gallery featuring
the stories behind RSNA, and the Cases of the Century, which gives attendees a chance to try their hand at diagnosis using only
"vintage" images. Attendees will also have an opportunity to view striking images in the Art and Science gallery and contribute
their favorite RSNA memories or celebratory messages in the Memory Book. The Centennial Showcase will be open: November
29, 12:00pm-5:00pm November 30 - December 4, 7:30am-6:00pm December 5, 7:30am-12:30pm
MSAS21
Regulations and Legislation That Effect Health Care Access and Practice (Sponsored by the
Associated Sciences Consortium) (An Interactive Session)
Multisession Courses
HP
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credits: 1.50
Mon, Dec 1 8:30 AM - 10:00 AM
Location: S105AB
Participants
Moderator
Lynne Roy MBA, MS : Nothing to Disclose
Sub-Events
MSAS21A
ICD-10 for Imaging: Now What
Denise A. Merlino MBA (Presenter): Consultant, IBA Molecular Imaging Consultant, United Pharmacy Partners,
Inc Consultant, Bracco Group Spouse, Employee, Pharmalucence, Inc
LEARNING OBJECTIVES
1) At the end of the session the participant will understand the important aspects of successful ICD 10
implementation and training tips important for Imaging. 2) The participant will know where to locate important
references and resources regarding ICD-10 as it relates to Imaging.
URL's
www.merlinohccc.com
Active Handout
http://media.rsna.org/media/abstract/2014/14000893/MSAS21A sec.pdf
MSAS21B
Health Care Reform: Implications for Health Care Providers
Erika
Johnson (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Describe a new perspective on population health and efforts to contain health care spending. 2) Describe a
new population health taxonomy. 3) Describe different management approaches for each population cohort to
improve efficiencies.
MSCM21
Case-based Review of Magnetic Resonance (An Interactive Session)
Multisession Courses
MR MK GI MR MK GI
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credits: 1.50
Mon, Dec 1 8:30 AM - 10:00 AM
Location: S100AB
LEARNING OBJECTIVES
1) Understand the role of MRI for the evaluation of disorders of the upper and lower extremities, brain and neck, and abdomen
and pelvis. 2) Apply helpful tips and tricks in MRI interpretation to avoid pitfalls and make accurate diagnoses. 3) Recognize
frequently missed or misinterpreted findings on MRI of the head, neck, and body. 4) Understand the latest, clinically relevant
MRI techniques and how they can be used in practice. 5) Develop a succinct MRI-based differential diagnosis for select disorders
of the head, neck, body, and extremities.
ABSTRACT
MRI is a workhorse of imaging in most radiology practices, with applications in the brain, head and neck, abdomen and pelvis,
and extremities. As the clinical utility of MRI has grown, so has its complexity. This series of talks aims to guide participants
through the various anatomic regions of the body while highlighting the appropriate use of MRI through a series of interactive
case presentations. Speakers will emphasize frequently missed diagnoses while providing tips for avoiding interpretive pitfalls
and providing accurate diagnoses.
Sub-Events
MSCM21A
Lower Extremity
Donald Joel Flemming MD (Presenter): Royalties, Reed Elsevier
LEARNING OBJECTIVES
View learning objectives under main course title.
MSCM21B
Upper Extremity
Timothy Gene Sanders MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
View learning objectives under main course title.
MSCM21C
Upper Abdomen
Jorge A. Soto MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Use illustrative cases to highlight common sources of error in the interpretation of MR imaging examinations
of the upper abdomen (liver, pancreas, biliary tract, kidneys, adrenal glands). Issues related to poor imaging
technique/protocol planning, errors in contrast administration, anatomic variants and pseudo-lesions will be
demonstrated. 2) Review methods that can be used to decrease the likelihood or misinterpreting upper
abdominal MR images related to these potential pitfalls.
MSMC21
Cardiac CT Mentored Case Review: Part I (In Conjunction with the North American Society for
Cardiac Imaging) (An Interactive Session)
Multisession Courses
CT
CA
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credits: 1.50
Mon, Dec 1 8:30 AM - 10:00 AM
Location: S406A
Participants
Moderator
Pamela K. Woodard MD : Research support, Siemens AG Research support, Astellas Group Consultant, BIOTRONIK GmbH &
Co KG
Moderator
Jill E. Jacobs MD : Nothing to Disclose
Sub-Events
MSMC21A
Normal Coronary Anatomy
Shawn D. Teague MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Recognize normal anatomy and common variants of the coronary arteries. 2) Understand the unique
advantages and disadvantages of CT for coronary artery evaluation. 3) Describe the current State-of-the-Art
capabilities for CT in coronary artery evaluation.
MSMC21B
Coronary Artery Anomalies
Cylen
Javidan-Nejad MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Using Coronary Artery CT cases to review anomalous origins of the coronary arteries
MSMI21
Molecular Imaging Symposium: Oncology
Multisession Courses
RO OI
MI
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credits: 1.50
Mon, Dec 1 8:30 AM - 10:00 AM
Location: S405AB
Participants
Moderator
Ronald L. Korn MD, PhD : Nothing to Disclose
Sub-Events
MSMI21A
Use of Novel PET Agents to Probe Tumor Biology: From Benchtop to the Clinic
Jonathan Edward McConathy MD, PhD (Presenter): Speakers Bureau, Eli Lilly and Company Research
Consultant, Eli Lilly and Company Research Consultant, General Electric Company Research Consultant, Blue
Earth Diagnostics Ltd Research Consultant, Siemens AG
LEARNING OBJECTIVES
1) Understand key molecular and metabolic targets for PET imaging in oncology. 2) Be familiar with novel PET
tracers that are promising for translation into human oncologic imaging studies.
ABSTRACT
Positron emission tomography (PET) with the glucose analogue 2-deoxy-2-[F-18]fluoro-D-glucose (FDG) has
established molecular imaging as an important aspect of clinical oncology but only probes one facet of cancer
metabolism. A wide range of small molecule, peptide, antibody, and nanoparticle-based PET tracers are in
development for oncologic imaging and can provide important insights into tumor biology. This talk will focus
on novel PET tracers that have high translational potential to diagnose, stage, and direct therapy in oncology.
MSMI21B
Massively Multiplexed Functional and Immunophenotypic Analysis of Solid and Liquid Tumors
R. Michael
Angelo MD, PhD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Understand the basic working principles of multiplexed ion beam imaging (MIBI). 2) Understand current
research applications of MIBI. 3) Understand practical uses of MIBI in future clinical diagnostics development.
MSMI21C
Clinical Metabolic MRI with Hyperpolarized Carbon-13 Agents
Peder E. Larson PhD (Presenter): Research support, General Electric Company
LEARNING OBJECTIVES
1) Basic principles of generating hyperpolarized carbon-13 agents for metabolic MRI. 2) Imaging methods for
hyperpolarized carbon-13 agents. 3) Clinical applications.
Active Handout
http://media.rsna.org/media/abstract/2014/14004190/MSMI21C sec.pdf
MSMI21D
Spying on Cancer Metastasis Using Intravital Microscopy: Seeing Is Believing
Laila
Ritsma PhD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Understand the advantages of IVM and how it can be used to study dynamic processes in tumor biology and
beyond. 2) Get insights into metastatic colonization. 3) Get insights into intestinal stem cell homeostasis.
ABSTRACT
Purpose: Intravital microscopy can be used to visualize dynamic biological processes in their native
environment. By visualizing tissues through an optical window with a two-photon microscope, cell behavior can
be studied over weeks. Here, we report the development of an abdominal imaging window (AIW) for mice. We
use the AIW to longitudinally follow liver metastases to link cellular behavior to successful colonization.
Moreover, we use the AIW to glimpse at the short-term dynamics of intestinal stem cells (SC). Methods: A
titanium AIW was implanted into the abdomen of mice. In our metastasis study we intrasplenically injected
fluorescent C26 colorectal cancer cells to generate liver metastases. A splenectomy was performed to prevent
outgrowth in the spleen. A daily imaging regimen was used to study liver metastases. In our SC study we used
Lgr5eGFP-Ires-CreERT2/R26R-Confetti mice to visualize Lgr5+ intestinal SCs and their progeny daily. Results:
We show that single extravasated tumor cells proliferate to form so called pre-micrometastases in which cells
are highly migratory. Once the clones condense into micrometastases, cell migration is diminished. Surprisingly,
during the pre-micrometastasis stage migration is positively correlated with proliferation. Blocking of migration
during this stage greatly reduced metastatic load, suggesting that cell migration during the pre-micrometastasis
stage is a contributing step to colorectal liver metastasis. During intestinal homeostasis, we show that SCs in
the upper part of the niche can be passively displaced out of the niche after division of a near-by SC. Moreover,
we found that SCs in the central part of the niche experience a survival advantage over cells in the border. SCs
were able to transfer between border and center region in both directions, endowing each SC with long-term
self-renewal potential. Conclusion: We conclude that IVM is an important imaging platform to study complex
dynamic processes in vivo.
MSRO21
BOOST: Lung—Oncology and Anatomy (An Interactive Session)
Multisession Courses
RO OI
CH RO OI
CH
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credits: 1.50
Mon, Dec 1 8:30 AM - 10:00 AM
Location: S103AB
Participants
Moderator
Simon Shek-Man Lo MD : Research support, Elekta AB Speaker, Varian Medical Systems, Inc Travel support, Varian Medical
Systems, Inc
Michelle Segall Ginsberg MD (Presenter): Nothing to Disclose
Gregory Videtic MD, FRCPC (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) 'Patterns of spread of lung cancer. 2) Contouring of organs-at-risk e.g. esophagus, brachial plexus, heart, airway; etc. 3)
Contouring of gross tumor volume (GTV), clinical target volume (CTV), and planning target volume (PTV) for stereotactic body
radiotherapy for medically inoperable non-small cell lung cancer. 4) Contouring of gross tumor volume (GTV), clinical target
volume (CTV), and planning target volume (PTV) for conventional external beam radiotherapy for non-metastatic non-small cell
lung cancer and small cell lung cancer. Review thoracic anatomy that impacts treatment decision making: 1) Proximity to great
vessels/heart. 2) Involvement of airway/esophagus. 3) Involvement of diaphragm, phrenic nerve. 4) Involvement of vertebral
column. 5) Medistinal and hilar nodes'
MSRO24
BOOST: Gastrointestinal—Oncology Anatomy (An Interactive Session)
Multisession Courses
RO OI
GI RO OI
GI
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credits: 1.50
Mon, Dec 1 8:30 AM - 10:00 AM
Location: S103CD
Participants
Theodore Sunki Hong MD (Presenter): Nothing to Disclose
Suvranu Ganguli MD (Presenter): Research Grant, Merit Medical Systems, Inc Consultant, Boston Scientific Corporation
Mukesh Gobind Harisinghani MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Achieve a basic understanding of the hepatobiliary anatomy and imaging appearance of heopatic tumors 2) Understand
strengths and limitations of imaging techniques, including MRI, PET-CT and CT, as they are used in delineating primary tumor
and loco-regional staging 3) Identify common sites of recurrence for hepatic tumors and recognize the imaging appearances of
these recurrences 4) Improve radiation therapy delivery through understanding the contouring recommendations for the gross
tumor volume (GTV) and clinical target volumes (CTV) for hepatic tumors, both in the locally advanced and postoperative
setting
ABSTRACT
In this course MRI will be used to contour normal hepatic anatomy as well as tumors involving this anatomical region. Also
patterns of spread to adjacent lymph nodes will be shown, and cross sectional imaging will be used to contour the regional nodal
lesions. Cases will be presented and the participants will be stimulated to do the contouring themselves, and will have feed-back
on their results
RC201
Lung Cancer Screening: Structured Reporting, Management and Practice Metrics (LUNGRADS)
Refresher/Informatics
CT
CH CT
CH
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credits: 1.50
Mon, Dec 1 8:30 AM - 10:00 AM
Location: E451A
Participants
Moderator
Ella A. Kazerooni MD : Nothing to Disclose
LEARNING OBJECTIVES
1) To learn why structured reporting is important in the practice of lung cancer screening with CT. 2) To learn what the
LUNGRADS structured reporting categories are and what management is associated with each category. 3) To understand how
to evaluate lung nodules for reporting in the LUNGRADS coding scheme. 4) To learn basic practice audit variables to collect and
follow to evaluate a a lung cancer screening CT program.
ABSTRACT
Lung cancer is the leading cause of cancer death in the US for both men and women, exceeding the number of deaths from
cancers of the breast, colon, and prostate combined. For each of these cancers, there are well established screening tests.
Screening for current and former smokers with LDCT is the only method ever proven to reduce lung cancer mortality in this high
risk population and it has also been shown to be cost effective. In December 2013 the USPSTF gave lung cancer screening with
CT a grade ;B; recommendation for high risk older current and former smokers. To prepare radiologists to practice lung cancer
screening with CT, the ACR Committee on Lung Cancer Screening formed a working group to develop LUNGRADS, which made
it#39;s version 1.0;debut in 2014. Similar to BIRADS which is in ;, LUNGRADS provides practicing radiologists with a tool to
use for categorizing abnormalities found on lung cancer screening CT exams, with management recommendations for each
category. In this course we will review why structured reporting and management is important in lung cancer screening CT. As
a public health screening tool, performing the exams with high quality, using standardized reporting and following standard
management algorithms is important to minimize overdiagnosis, overutilization of diagnostic testing and interventional
procedures ranging from percutaneous biopsy to bronchoscopy and surgery. The LUNGRADS categories try to follow BIRADS
approach to coding when possible, recognizing that there are differences in screening for lung cancer and breast cancer. Exams
are coded as incomplete (category 0), negative; for clinically active cancer (category 1), benign (category 2), probably benign
(category 3) and suspicious (category 4). Additional modifers such as ;S; can be used for clinicially significant or potentially
clinically signifiant findings (non lung cancer). Details of using this coding system and metrics to evaluate a screening practice
will be discussed.
Sub-Events
RC201A
Development
Ella A. Kazerooni MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
View learning objectives under main course title.
ABSTRACT
See course abstract
RC201B
Benign and Prob Benign
Ann N. C. Leung MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) To review the CT findings and types of abnormalities that are classified under the 'Benign' and 'Probably
Benign' categories.
RC201C
Suspicious/Malignant
Reginald F. Munden MD, DMD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) To recognize the CT findings and types of abnormalities that are classified under the 'suspicious' and
'malignant' categories.
Significant Other Findings
Significant Other Findings
RC201D
Caroline
Chiles MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Recognize and report significant incidental findings on LDCT lung cancer screening examinations.
Practice Metrics and Audit
RC201E
William C. Black MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
View learning objectives under main course title.
RC202
Milestone Implementation: Practical Lessons Learned at 3 Academic Institutions
Refresher/Informatics
ED
HP ED
HP
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credit: 0
Mon, Dec 1 8:30 AM - 10:00 AM
Location: S504AB
Participants
Moderator
Angelisa Marie Paladin MD : Nothing to Disclose
LEARNING OBJECTIVES
1) Identify resources that will help Program Directors implement the Milestones. 2) Identify potential obstacles and solutions for
efficient implementation of the Milestones. 3) Identify ineffective and effective tactics in implementing the Milestones.
Sub-Events
RC202A
University of Maryland Experience
Charles S. Resnik MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
View learning objectives under main course title.
RC202B
The University of Washington Experience
Angelisa Marie Paladin MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
View learning objectives under main course title.
RC202C
The Stanford Experience
Terry S. Desser MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
View learning objectives under main course title.
RC206
Skull Base and Nerves
Refresher/Informatics
HN
NR
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credits: 1.50
Mon, Dec 1 8:30 AM - 10:00 AM
Location: E450A
Sub-Events
RC206A
The Central Skull Base
Nancy Jane Fischbein MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) To review the anatomy of the Central Skull Base. 2) To present common and uncommon pathologies that
affect the Central Skull Base. 3) To remind the audience of imaging pitfalls of the Central Skull Base. 4) To
discuss the complementary roles of CT and MR in imaging the Central Skull Base.
ABSTRACT
Imaging of the skull base presents many challenges due to its anatomical complexity, numerous normal
variants, and lack of familiarity to many radiologists. As the skull base is a region which is not amenable to
physical exam, and as lesions of the skull base are generally difficult to biopsy and even more difficult to
operate on, the radiologist plays a major role in directing patient management via accurate image
interpretation. Knowledge of the skull base should not be limited to neuroradiologists and head and neck
radiologists, however, as the central skull base in particular is routinely included in the field of view when
cross-sectionally imaging the brain, cervical spine, or head and neck with CT or MRI, and hence its nuances
should be familiar to general radiologists as well. We review the basic anatomy of the central skull base,
including bony anatomy as well as the anatomy of adjacent soft tissue structures. We will also present imaging
findings of common and uncommon pathologies of the central skull base, including primary tumors such as
chordoma and chondrosarcoma, metastases and plasmacytoma, and non-neoplastic lesions of the central skull
base. We will review some imaging pitfalls and "don't touch" lesions of the central skull base, and will emphasize
the complementary roles of CT and MR in solving difficult cases.
RC206B
Cranial Nerves I-VI
Wendy R. K. Smoker MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Review the anatomy of the upper six cranial nerves. 2) Learn the functions of these cranial nerves. 3) Be
able to identify common pathologies affecting these nerves.
ABSTRACT
Cranial nerve dysfunction is a common presenting symptom in many patients. In order to evaluate for a
causative lesion, one must have a thorough knowlegde of the anatomy of each nerve. The anatomy of cranial
nerves I-VI is presented along with a review of the function(s) of each nerve. For cranial nerves III-VI, the
entire course of each nerve from brainstem exit to innervated muscles (for III, IV, V1, and VI) is reviewed.
Pathology affecting these nerves is divided into brainstem, cisternal, base of skull (Meckle cave/cavernous
sinus), and distal lesions. Common pathogies that affect each nerve along the various segments are presented.
RC206C
Cranial Nerves VII-XII
Deborah L. Reede MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Review the anatomy of cranial nerves VII - XII. 2) Learn clinical findings associated with nerve involvement
that can help in the localization of a lesions. 3) Demonstrate lesions at various points along the nerve pathway.
RC210
First Trimester Ultrasound (An Interactive Session)
Refresher/Informatics
US
OB GU
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credits: 1.50
Mon, Dec 1 8:30 AM - 10:00 AM
Location: E450B
Sub-Events
RC210A
Diagnosis of Early Nonviable Pregnancy
Peter Michael Doubilet MD, PhD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Know the sonographic criteria for definite miscarriage and probable miscarriage in the early first trimester.
2) Understand that any saclike intrauterine structure (rounded edges, no yolk sac or embryo) in a woman with
a positive pregnancy test is highly likely to be a gestational sac. 3) Understand that nonvisualization of an
intrauterine gestational sac in a woman with hCG above the "discriminatory" level (2000 mIU/ml) does not
exclude the possibility of a viable pregnancy.
ABSTRACT
I. Sonographic Criteria for Diagnosing Pregnancy Failure (Miscarriage) in an Intrauterine Pregnancy of Uncertain
Viability [Note: an intrauterine fluid collection with rounded edges in a woman with positive hCG is almost
certainly a gestational sac; it is definitely a gestational sac if it contains a yolk sac or embryo.] 1. Criteria for
definite miscarriage (i) CRL =2 weeks after a scan that showed a gestational sac without yolk sac; (iv) Absence
of embryo with heartbeat >=11 days after a scan that showed a gestational sac with yolk sac 2. Criteria
suspicious for miscarriage (i) CRL =6 weeks after LMP; (vi) Empty amnion (amnion seen adjacent to yolk sac,
with no visible embryo); (vii) Enlarged yolk sac (>7 mm); (viii) Small gestational sac size in relation to the
embryo : II. Guidelines Related to the Possibility of a Viable Intrauterine Pregnancy in a Pregnancy of Unknown
Location (positive pregnancy test and no intrauterine or ectopic pregnancy seen on ultrasound) 1. A single hCG,
regardless of its level, does not reliably distinguish between ectopic and intrauterine pregnancy (viable or
nonviable) 2. If a single hCG is =3000 mIU/ml, a viable intrauterine pregnancy is possible but unlikely.
However, the most likely diagnosis is nonviable IUP, so it is generally appropriate to get at least one followup
hCG before treating for ectopic pregnancy.
Active Handout
http://media.rsna.org/media/abstract/2014/13010306/RC210A sec.pdf
RC210B
Diagnosis and Treatment of Ectopic Pregnancy
Hope Elizabeth Peters MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Recognize the spectrum of findings at transvaginal ultrasound in ectopic pregnancy. 2) Report TVUS findings
in suspected ectopic pregnancy when a non-specific intrauterine fluid collection is present. 3) Differentiate usual
vs. "unusual" ectopic pregnancies and understand their different treatment algorithms. 4) Understand the
limitations of ultrasound related to maternal and technical factors. 5) Assist clinicians with appropriate follow
up/management recommendations in excluding and diagnosing ectopic pregnancy.
ABSTRACT
Transvaginal ultrasound is the primary imaging modality to evaluate suspected ectopic pregnancy, performed in
patients with a positive pregnancy test and pain or bleeding. The diagnosis is most commonly made when
ultrasound demonstrates no intrauterine gestational sac and an extraovarian adnexal mass is found. Ectopic
pregnancies occur in the ampulla of the fallopian tube >90% of the time and therapy is well established
including systemic methotrexate and/or salpingectomy. When attempting to exclude or diagnose ectopic
pregnancy, TVUS may demonstrate a non-specific intrauterine fluid collection. The term "pseudogestational
sac" should not be used to describe an intrauterine fluid collection as this term can be confusing and improperly
imply ectopic pregnancy prompting premature treatment. Rather, any intrauterine fluid collection should be
regarded as a potential intrauterine pregnancy and reported as such. Ectopic pregnancies may also occur in
"unusual" locations such as: the cervix, a cesarean section scar, the interstitial portion of the fallopian tube,
within the ovary or concomitant with an intrauterine pregnancy. These "unusual" ectopic pregnancies are a
unique subset of ectopic pregnancies requiring prompt diagnosis and alternative treatment options. Ultrasound
does carry with it some limitations in the diagnosis of ectopic pregnancy related to both maternal and technical
factors. Prompt diagnosis of all types of ectopic pregnancy and recognizing potential early intrauterine
pregnancies will allow for appropriate follow up, optimal treatment and improve outcomes for these patients.
RC210C
Fetal Anatomy in the First Trimester
Phyllis
Glanc MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Improve knowledge of first trimester anatomic development. 2) Compare indications for transabdominal
versus transvaginal imaging in first trimester. 3) Recognize anomalies which typically present in first trimester.
4) Demonstrate understanding of the implications and management of common first trimester anomalies.
ABSTRACT
As sonographic technology has improved, diagnosticians have gained the ability to visualize more fetal
structures during the first trimester than used to be possible with older equipment. Because of this, it is
important that practitioners who perform and interpret first trimester ultrasound understand how the fetus
develops and recognize the sonographic appearance of fetal structures as they become apparent at different
gestational ages during the first trimester. Some fetal structures are only visible in the first trimester fetus, but
are no longer apparent after that. These include the nuchal translucency and physiologic bowel herniation. The
nuchal translucency is a hypoechoic band behind the fetal neck, that, when thickened, is associated with
increased risk of aneuploidy and cardiac anomalies. Physiologic bowel herniation is a normal protrusion of bowel
into the base of the umbilical cord that can usually be distinguished from abnormal herniations through the
ventral wall, such as omphalocele and gastroschisis. The fetal cranium and brain can be evaluated during the
latter half of the first trimester, and anomalies such as anencephaly and holoprosencephaly can often be
diagnosed. Likewise, other anomalies of the fetus can sometimes be diagnosed during the first trimester,
including amniotic band syndrome, posterior urethral valves, and cardiac anomalies. Recognition of these
anomalies in the first trimester will assist in early detection of fetal abnormalities, allowing for earlier and
improved counseling for patients.
Active Handout
http://media.rsna.org/media/abstract/2014/13010308/RC210C sec.pdf
RC212
Peripheral Artery Disease (PAD)
Refresher/Informatics
MR CT
VA MR CT
VA
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credits: 1.50
Mon, Dec 1 8:30 AM - 10:00 AM
Location: E353A
Participants
Moderator
Stephen Thomas Kee MD : Nothing to Disclose
LEARNING OBJECTIVES
1) Discuss the basic pathology of peripheral artery disease. 2) Describe the risk factors associated with the development of
peripheral artery disease. 3) Outline the benefits of providing a comprehensive clinical service in the management of PVD. 4)
Discuss how to build a PVD practice. 5) Describe the basic techniques employed in the treatment of PVD.
Sub-Events
RC212A
Clinical Overview of PAD
Stephen Thomas Kee MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
View learning objectives under main course title.
RC212B
Lower Extremity CTA
Richard Lee Hallett MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Describe techniques for patient selection, acquisition, reconstruction, and interpretation of lower extremity
CTA. 2) Describe evidence-based results for lower extremity CTA, and expected impact on patient care. 3)
Describe a coherent plan that integrates lower extremity CTA into cost-effective clinical care.
ABSTRACT
Peripheral arterial disease (PAD) is a common cause of morbidity and mortality in developed countries.
Traditionally, imaging for risk stratification and therapeutic planning involved catheter angiography. In recent
years, cross-sectional imaging by CTA and MRA has proven a robust technique for non-invasive PAD
assessment. Given ubiquity of CT scanning technology, CTA is widely available. High resolution datasets can be
acquired rapidly, which facilitates assessment of clinically labile or trauma patients. To be optimally effective,
CTA techniques require particular attention to contrast medium and scan protocol. With appropriate protocol
design, data acquisition requires limited operator dependence. The acquired 3D dataset is rich with information,
but requires careful scrutiny by the interpreting physician. Volumetric review of these datasets produces the
most accurate results. Extensive small vessel calcification remains a potential barrier to full assessment of
pedal vessels by CTA. Recent published data validates the clinical effectiveness of CTA for diagnosis of PAD and
for the direction of treatment planning. Ongoing research aims to exploit the newest generation of CT scanners
to acquire additional information, including dual energy data, time-resolved information, and radiation dose
savings.
URL's
www://stanford.edu/~hallett
Active Handout
http://media.rsna.org/media/abstract/2014/13012018/RC212B sec.pdf
RC212C
Lower Extremity MRA
Harald
Kramer MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Identify the appropriate technique for peripheral MRA depending on the available hardware and the clinical
question and condition of the patient. 2) Differentiate between different contrast agents and their specific
characteristics. 3) Chose between different contrast agent application schemes depending on the technique
used and the clinical question. 4) Compare the pros and cons of contrast-enhanced and non contrast-enhanced
techniques for peripheral MRA.
ABSTRACT
The prevalence of symptomatic peripheral artery disease (PAD) ranges around 3% in patients aged 40 and 6%
at an age of 60 years. Additionally, the prevalence of asymptomatic PAD lies between 3% and 10% in the
general population increasing to 15% to 20% in persons older than 70 years of age. However, these data still
might underestimate the total prevalence of PAD since screening studies showed that between 10% and 50% of
all patients with intermittent claudication (IC) never consult a doctor about their symptoms. These data prove
the need for an accurate and reliable method for assessment of the peripheral vasculature. Digital subtraction
angiography (DSA) still serves as the reference standard for all vascular imaging techniques. However, because
of the absence of ionizing radiation, the use of non-nephrotoxic contrast agents or even non contrast-enhanced
sequences and the large toolbox of available techniques for high-resolution static and dynamic imaging
Magnetic Resonance Angiography (MRA) constitute an excellent non-invasive alternative. Different acquisition
schemes and contrast agent application protocols as well as different types of data sampling for static,
dynamic, contrast- and non contrast-enhanced imaging enable to tailor each exam to a specific question and
patient respectively.
RC212D
Endovascular Treatment of PAD
Stephen Thomas Kee MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
View learning objectives under main course title.
RC216
Communicating Effectively with Your Referring Physicians (Sponsored by the RSNA Public
Information Committee)
Refresher/Informatics
PR
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credits: 1.50
Mon, Dec 1 8:30 AM - 10:00 AM
Location: S403A
Participants
Moderator
Judy Yee MD : Research Grant, EchoPixel, Inc
Sally Reynolds MD (Presenter): Nothing to Disclose
Stephan G. Wyers MD (Presenter): Nothing to Disclose
Mary F. Mulcahy MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Discern what referring physicians need from radiologists at various stages of patient care. 2) Recognize referring physicians'
preferences in communication methods. 3) Identify referring physicians' needs regarding structured reporting and
appropriateness criteria. 4) Understand how to improve your communications and work more effectively with referring
physicians to enhance patient care. 5) Recognize opportunities to improve/expand your interactions with referring physicians.
RC217
Elastography—Imaging Tissue Stiffness: Approaches and Applications
Refresher/Informatics
PH
US
MR
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credits: 1.50
Mon, Dec 1 8:30 AM - 10:00 AM
Location: S504CD
Participants
Moderator
Juergen Karl Willmann MD : Research Consultant, Bracco Group Research Grant, Siemens AG Research Grant, Bracco Group
LEARNING OBJECTIVES
1) To understand the principle technical aspects of ultrasound and MR elastography. 2) To learn clinical applications of
elastography. 3)To learn the advantages and disadvantages of ultrasound and MR elastography for assessing tissue stiffness in
various organs.
Sub-Events
RC217A
US Elastography of the Liver
Richard Gary Barr MD, PhD (Presenter): Consultant, Siemens AG Consultant, Koninklijke Philips NV Research
Grant, Siemens AG Research Grant, SuperSonic Imagine Speakers Bureau, Koninklijke Philips NV Research
Grant, Bracco Group Speakers Bureau, Siemens AG Consultant, Toshiba Corporation Research Grant, Esaote
SpA
LEARNING OBJECTIVES
1) To describe the clinical need for liver stiffness evaluation. 2) To describe the principles of ultrasound shear
wave liver elastography To review the technique of shear wave liver elastography. 3) To discuss pitfalls in
performing and interpreting ultrasound liver elastography To describe the basic approach to interpret
ultrasound liver elastography.
ABSTRACT
Diffuse liver disease is one of the major health problems in the world. Hepatitis C (HCV) and Hepatitis B (HBV)
viruses are the leading causes of chronic liver disease. It is estimated that 180 million and 350 million people
worldwide are chronically infected with HCV and HBV respectively. In western countries, liver disease caused
by HCV is the main indication for liver transplantation. Liver biopsy has been considered the reference standard
for fibrosis assessment and stage classification. However, biopsy is invasive, with potential complications that
can be severe in up to 1% of cases. In addition, a liver biopsy represents roughly 1/50,000 of the liver volume
and there is interobserver variability at microscopic evaluation. Elastography is a non-invasive method for liver
fibrosis assessment and has been an area of intense research. With ultrasound elastography systems now
widely available worldwide this technique is beginning to replace liver biopsy as method for diagnosis and
follow-up of liver fibrosis. This technique is easy to perform but requires attention to detail. This course will
review the principles of shear wave elastography (SWE) for liver fibrosis assessment. A review of the technique
and pitfalls will be presented. The literature will be reviewed as well as published guidelines on the use of SWE
for liver fibrosis assessment. A discussion of the clinical applications of this technique and future potential
applications will be discussed.
Active Handout
http://media.rsna.org/media/abstract/2014/14001183/RC217A sec.pdf
RC217B
Non-liver Applications of US Elastography
Anthony Edward Samir MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Identify non-liver applications for shear wave elastography. 2) Understand typical disease appearances of
non-liver pathologies on elastography. 3) Understand valid indications for sonoelastography.
RC217C
MR Elastography
Richard L. Ehman MD (Presenter): CEO, Resoundant, Inc
LEARNING OBJECTIVES
1) To describe the rationale for tissue elasticity imaging. 2) To describe the basic physical approach for
MRI-based elasticity imaging. 3) To describe the most common indications for MR elastography of the liver. 4)
To describe the basic approach to interpretation of hepatic MR elastography exams. 5) To describe pitfalls in
interpretation of hepatic MRE. 6) To describe other potential applications of MRE.
ABSTRACT
Many disease processes cause profound changes in the mechanical properties of tissues. This accounts for the
efficacy of palpation for detecting abnormalities and provides motivation for developing practical methods to
assess tissue elasticity. Magnetic Resonance Elastography (MRE) is a new commercially-available MRI-based
technique that can quantitatively image the mechanical properties of tissue.
The most advanced current application of MRE is for diagnosing hepatic fibrosis. Chronic liver disease is serious
worldwide problem, and hepatic fibrosis is the most important consequence, which if not detected and treated,
eventually leads to cirrhosis which is irreversible and associated with high mortality.
MRE can be readily implemented on a standard MRI system. A device is used to generate vibrrations in tissue.
The waves are imaged with a special MRI pulse sequence. Acquistion time for liver MRE is approximately 15
seconds. Because the incremental imaging time is so small, MRE can readily added to standard abdominal MR
imaging protocols. The data are automatically processed generate quantitative images showing the elasticity of
the liver and other tissues in the upper abdomen.
Clinical studies by multiple investigators have now established that MRE is an accurate method for diagnosing
hepatic fibrosis. MRE-measured hepatic stiffness increases systematically with fibrosis stage. Growing clinical
experience indicates that MRE is at least as accurate as liver biopsy for this diagnosis, while also being safer,
more comfortable, and less expensive.
Human studies have demonstrated that it is feasible to apply MRE to quantitatively assess other tissues and
organs such as brain, breast, heart, and kidney. MRE may be helpful in differentiating between benign and
malignant neoplasms. New research has shown that MRE is helpful in the preoperative assessment of patients
malignant neoplasms. New research has shown that MRE is helpful in the preoperative assessment of patients
with brain tumors such as menigiomas.
RC218
Imaging Tumor Response: Old and New Challenges
Refresher/Informatics
OI
MR BQ
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credits: 1.50
Mon, Dec 1 8:30 AM - 10:00 AM
Location: N226
Sub-Events
RC218A
Reporting Cancer Response—Practical Perspective
Elena Karp Korngold MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Define important terms and concepts in tumor response assessment. Describe the current use of imaging for
evaluating response of GI cancers. 2) Understand the rationale for the creation of standardized and structured
criteria for imaging evaluation of tumor response to therapy in research trials. 3) Understand the basic concept
and organization of the RECIST (Response Evaluation Criteria in Solid Tumors) criteria. Understand the
limitations of RECIST and other standardized reporting methods. 4) Recognize the reason for use of alternate
criteria in specific diseases (i.e., Cheson for lymphoma, EASL/mRECIST for HCC), biomarkers, and the evolving
role of imaging in evaluation of tumor response with novel therapeutic interventions.
RC218B
Prostate Cancer Treatment Assessment
Hedvig
Hricak MD, PhD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Understand the clinical challenges of prostate cancer post-treatment follow-up and the role of imaging in
detecting local recurrence. 2) Know how MRI protocols for detecting local recurrence should be adjusted
depending on the prior treatment and the questions being asked. 3) Understand standard and emerging uses of
bone scanning, PET/CT and MRI/PET for detecting metastasis.
ABSTRACT
MRI has emerged as the key modality for assessing local recurrence of prostate cancer after radical
prostatectomy (RP) or radiation therapy (RT). Early detection of local recurrence is important to allow potentially
curative salvage therapy. The efficacy of MRI in detecting local recurrence is treatment dependent, and MRI
protocols need to be adjusted to the questions being asked. After RT, T2-weighted MRI is limited due to
post-radiation effects on the prostate such as glandular shrinkage, loss of normal zonal anatomy, and reduced
contrast between cancer and normal tissue caused by glandular atrophy and fibrosis. MRI should include both
T2-weighted and diffusion-weighted sequences; a recent study suggested that in most patients, dynamic
contrast-enhanced (DCE)-MRI could be omitted after RT without lowering diagnostic performance, thereby
eliminating the risks and costs associated with the use of contrast. If salvage treatment is an option after RT,
MRI offers loco-regional staging. Post-RT MRI can evaluate the length of the urethra and may show urethral
shortening (which has been associated with incontinence after primary RP), decreased urethral margin
definition and other tissue changes that could conceivably affect treatment selection and planning. After
surgery, in addition to DWI, the use of DCE-MRI is essential, as it can show small lesions and differentiate
tumor from scarring. MRI may help to determine whether post-RP local recurrence is amenable to salvage RT
and may aid RT planning. Assessment of recurrence after emerging focal therapies remains problematic, since
methods for reliably differentiating necrosis or scarring from tumor are lacking. In the future, PET/CT with
targeted tracers may be able to address this need. PET/CT and bone scanning are valuable in the search for
nodal and osseous metastases, respectively. The implementation of clinical MRI/PET and the use of new tracers
will likely open new horizons in the assessment of recurrence.
RC218C
Evaluating Response in Targeted Therapy of Abdominal Malignancy
Yves M. Menu MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Understand the main challenges in abdominal tumors treated with targeted chemotherapies in clinical
situations like neoadjuvant therapy, tumor down staging or palliative treatment. 2) Know the specific situations
of most common abdominal malignancies like liver primary and secondary tumors, pancreatic adenocarcinoma
and colorectal cancer. 3) Understand how the Radiologist should manage the imaging techniques (CT, MRI, PET)
in order to meet the clinical objectives and if targeted therapies require changes over cytotoxic chemotherapies.
ABSTRACT
Abdominal malignancies are very common. Imaging is pivotal for detection, staging and evaluation of tumor
response to treatment. As targeted therapies are increasingly administered, the necessity for an update of
tumor response criteria has become obvious. Tumor size and anatomy is still required important information,
but evaluation of tissue viability is increasingly needed. Another specificity of abdominal malignancies is the
increasing number of patients who are candidates for an integrated approach including systemic therapies, local
therapies, radiation therapy and surgery. This underlines the necessity of a team approach and the major role of
the radiologist within this group. In Hepatocellular Carcinoma (HCC), targeted therapies are widely used and
mainly aimed at palliation, although potential downstaging may lead to reconsider this position. mRECIST
criteria have been developed specifically for HCC and are considered as the international standard nowadays. In
secondary liver tumors, targeted therapies are usually administered in association with cytotoxic drugs. As up to
30% of patients with liver metastases from colon cancer might become resectable, the evaluation is not limited
to volumetric response. The report should mention in addition relevant information on tumor viability and
aggressiveness and also comment on useful elements for guidance of potential surgery or intervention. In other
abdominal advanced malignancies, targeted therapies are not yet standard. However, due to the poor prognosis
of these diseases, very active research develops in this field and interestingly favors a better selection of
patients. Imaging may play a role with this issue, like classifying locally advanced vs metastatic patients as well
as highly vs less agressive tumors. In summary, the Radiologist should have knowledge of the main clinical
challenges, of ongoing and potential treatments in order to provide relevant information to the Multi Disciplinary
Team.
RC218D
Evaluation of Lung Cancer Response
Jeremy J. Erasmus MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) To understand the applicability of anatomic imaging using World Health Organization (WHO) criteria and
Response Evaluation Criteria in Solid Tumors (RECIST 1.1) in the assessment of tumor response in patients with
non-small cell lung cancer (NSCLC). 2) To be aware of the limitations of World Health Organization (WHO)
criteria and Response Evaluation Criteria in Solid Tumors (RECIST 1.1) in the assessment of tumor response. 3)
To understand the potential role of metabolic tumor response assessment with 18F-FDG PET (PET Response
Criteria in Solid Tumors (PERCIST)) in patients with NSCLC.
ABSTRACT
NSCLC commonly presents with advanced disease and chemotherapy is often an integral component
in;treatment. However, following initiation of chemotherapy, tumor progression can occur in up to 33% of
patients. Early determination of this therapeutic failure can be important in management and can assist clinical
decisions concerning discontinuation of ineffective treatment and institution of alternative therapy. Additionally,
an essential component of evaluating the results of cancer treatment in patients on clinical trials is the
reporting of the response rate. Because small differences in the response rate can affect the outcome clinical
trials, it is important that the criteria used to make this determination are meaningful and consistent. While the
antitumor effect of a treatment in patients with solid tumors can be determined clinically or by surgical
pathologic re-staging, image-based serial measurements based on WHO criteria or Response Evaluation Criteria
in Solid Tumors (RECIST) provide uniform criteria for reporting response. However, morphological alterations
detected by CT may not correlate with pathological response and tumor viability. Furthermore, the assessment
of objective response has also been complicated by the development of treatment protocols that target tumor
biology including tumor cell proliferation and invasion, angiogenesis and metastasis. Anti-tumor effect in many
of these regimens is cytostatic and, unlike anticancer cytotoxic agents, may not cause regression in tumor size.
FDG-PET may allow an early and sensitive assessment of the effectiveness of anticancer chemotherapy as FDG
uptake is not only a function of proliferative activity but is also related to viable tumor cell number. This talk will
review the status and limitations of anatomic and metabolic tumor response metrics in NSCLC including WHO
criteria, RECIST 1.1 and PET Response Criteria in Solid Tumors (PERCIST).
RC220
Imaging Evaluation of Post-Radiation Therapy Normal Tissue Effects
Refresher/Informatics
RO
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credits: 1.50
Mon, Dec 1 8:30 AM - 10:00 AM
Location: E260
Participants
Moderator
Jason Rockhill MD : Nothing to Disclose
Sub-Events
RC220A
Post-radiation Therapy CNS Imaging
Jason
Rockhill MD (Presenter): Nothing to Disclose , Thierry
Huisman MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Choose the relevant MR imaging sequences for the diagnostic work up of children who have received
radiation therapy for CNS malignancies. 2) Recognize frequent and infrequent radiation therapy induced CNS
findings. 3) Differentiate between treatment related brain injury and residual or recurrent malignancy.
ABSTRACT
Radiation therapy is frequently part of a multimodality treatment plan for pediatric CNS malignancies. Radiation
therapy aims to reduce or eliminate residual or recurrent tumor tissue. Occassionally, radiation therapy is the
only treatment option. The MR signal intensities, contrast enhancement as well as functional imaging
characteristics of tumor tissue as well as adjacent 'healthy' brain tissue are influenced/altered by the radiation
treatment. The encountered findings may be confusing. Differentiation between residual/recurrent tumor,
treatment induced injury to healthy tissue or tumor pseudo progression is essential. Familiarity with frequent
and infrequent imaging findings and complications is mandatory to monitor and guide treatment. In the current
session the various imaging findings secondary to radiation therapy will be presented. In addition, the value
and significance of the various anatomical and functional MR sequences will be reviewed for the accurate
diagnostic work up of these possibly confusing therapy induced imaging findings.
RC220B
Post-radiation Therapy Pediatric Body Imaging
Ralph Philip Ermoian MD (Presenter): Shareholder, Abbott Laboratories Shareholder, Abbvie Inc Shareholder,
Agilent Technologies, Inc Shareholder, Allergan, Inc Shareholder, Becton, Dickinson and Company Shareholder,
Boston Scientific Corporation Shareholder, Biogen Idec Inc Shareholder, Bristol-Myers Squibb Company
Shareholder, Bruker Corporation Shareholder, C. R. Bard, Inc Shareholder, Dyax Corp Shareholder, Gilead
Sciences, Inc Shareholder, Haemonetics Corporation Shareholder, Hospira Inc Shareholder, Illumina Inc
Shareholder, McKesson Corporation Shareholder, Mylan Inc Shareholder, Myrexis, Inc Shareholder, General
Electric Company Shareholder, Novartis AG Shareholder, Novo Nordisk AS Shareholder, Pfizer Inc Shareholder,
Quest Diagnostics Incorporated Shareholder, Quintiles Transnational Holdings Inc Shareholder, Regeneron
Pharmaceuticals, Inc Shareholder, F. Hoffmann-La Roche Ltd Shareholder, St. Jude Medical, Inc Shareholder,
sanofi-aventis Group Shareholder, UnitedHealth Group Shareholder, Vertex Pharmaceuticals Incorporated
Shareholder, Zimmer Holdings, Inc Shareholder, Zoetis Inc , R. Paul Guillerman MD (Presenter): Nothing to
Disclose
LEARNING OBJECTIVES
1) Recognize the imaging findings of proton radiation therapy on different organ systems in childhood. 2)
Understand how proton radiation therapy effects are influenced by the processes of growth, development, and
tissue injury repair in children.
RC220C
Post-radiation Therapy Chest Imaging
David Palma MD, FRCPC (Presenter): Nothing to Disclose , Seth Jay Kligerman MD (Presenter): Author,
Reed Elsevier
LEARNING OBJECTIVES
1) To review the differences between modern radiotherapy techniques vs. older radiation delivery methods, and
the potential impact of these differences on post-treatment imaging. 2) To discuss the expected benign
radiographic changes after stereotactic ablative radiotherapy for lung cancer. 3) To review recent data
regarding the sensitivity and specificity of various imaging characteristics for distinguishing recurrence vs.
fibrosis after stereotactic radiation.
ABSTRACT
Radiation therapy for lung cancer has undergone major changes over the past decade, with the use of
four-dimensional CT scans for treatment planning, the introduction of intensity modulated radiation therapy,
and the rapid adoption of stereotactic ablative radiatiotherapy. The changes in treatment designs and the use of
have very large daily doses can result in patterns of radiation-induced lung injury (RILI) that may be difficult to
distinguish from tumor recurrence. In some cases, patients have undergone 'salvage' surgical resection only to
find fibrotic tissue, and conversely the opportunity for early detection of recurrence and possible salvage can be
missed if recurrent tumor is not identified early in the post-treatment period. Classification systems exist for
describing acute- and late-developing patterns of RILI on CT imaging after stereotactic radiotherapy. The
identification of 'high risk features' (HRF) on CT for may allow for better discrimination of recurrence vs. fibrosis;
these features will be reviewed. The use of PET/CT has demonstrated mixed results in identifying recurrence,
but may plan a role when CT findings remain equiovcal.
RC221
Medical Physics 2.0: Ultrasonography
Refresher/Informatics
US
PH
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credits: 1.50
Mon, Dec 1 8:30 AM - 10:00 AM
Location: S403B
Sub-Events
RC221A
Ultrasonography Perspective
RC221A
Paul L. Carson PhD (Presenter): Research collaboration, General Electric Company Research collaboration,
Light Age, Inc
LEARNING OBJECTIVES
1) Understand the roles of medical physicists and other providers of ultrasound system QC, performance
evaluation and user education. 2) Gain an understanding of the longer term potential of medical ultrasound to
aid in medical physics planning and training.
ABSTRACT
A very brief overview is given of the innovations that have led to current medical ultrasound systems and QC
thereof. A clear connection to clinical performance/cost effectiveness has not been established, but the ratio is
improving. To aid in medical physics planning and training, more distant (beyond 10 years) and less robust
predictions are ventured than in Dr. Hangiandreous' talk. The reduction in artifacts and improvement in
resolution will be surprisingly large. It is posed that ultrasound will be headed toward almost ubiquitous use in
personal hands as well as those of medical personnel, for monitoring and control of chronic conditions, for direct
treatment and for precisely localized drug delivery and enhancement of radiation therapy. Medical physicists
who can help keep the computer controls integrated, the systems properly calibrated and the users properly
trained will find a substantial role in society.
Active Handout
http://media.rsna.org/media/abstract/2014/13010884/RC221A sec.pdf
RC221B
Ultrasonography 1.0
Zheng Feng
Lu PhD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Describe the current role of ultrasound medical physics in clinical practice. 2) Explain the ultrasound image
quality metrics utilized in current ultrasound QA/QC testing. 3) Outline the methods and tools available for
ultrasound system QA/QC in current clinical practices. 4) Survey the available standards and voluntary
accreditation guidelines for medical ultrasound imaging systems. 5) Understand the need for QC at different
levels of time and financial investment.
ABSTRACT
This talk will focus on the present role of ultrasound medical physics in clinical practices. It will review the
ultrasound image quality metrics currently utilized in ultrasound QA/QC testing. It will describe testing
procedures required and/or recommended by accreditation programs and advisory organizations. General
guidelines and available standards will be discussed regarding tolerances for acceptance testing and
commissioning of these devices, as well as periodic quality control tests, as applicable to diagnostic B-mode
imagers. A brief review of ultrasound phantoms used in these testing procedures will be presented.
Active Handout
http://media.rsna.org/media/abstract/2014/13010885/RC221B sec.pdf
RC221C
Ultrasonography 2.0
Nicholas James Hangiandreou PhD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Identify the roles expected for medical physics to play in future clinical ultrasound practices. 2) Demonstrate
understanding of emerging ultrasound imaging performance metrics that are expected to be in routine practice
in the future. 3) Demonstrate understanding of emerging ultrasound imaging technologies that are expected to
be in routine practice in the future. 4) Identify approaches for implementing comprehensive medical physics
services in future clinical ultrasound practices.
ABSTRACT
Ultrasound imaging is evolving at a rapid pace, adding new imaging functions and modes that continue to
enhance its clinical utility and benefits to patients. This talk will look ahead 10-15 years and consider how
medical physicists can bring maximal value to the clinical ultrasound practices of the future. The roles of physics
in accreditation and regulatory compliance, image quality and exam optimization, clinical innovation, and
education of staff and trainees will all be considered. A detailed examination of expected technology evolution
and impact on image quality metrics will be presented. Clinical implementation of comprehensive physics
services will also be discussed.
Active Handout
http://media.rsna.org/media/abstract/2014/13010886/RC221C sec.pdf
RC222
Uncertainties in Imaging for Radiation Oncology: Sources and Mitigation Techniques—Image
Registration
Refresher/Informatics
RO PH
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credits: 1.50
Mon, Dec 1 8:30 AM - 10:00 AM
Location: E261
Participants
Moderator
Kristy K. Brock PhD : License agreement, RaySearch Laboratories AB
LEARNING OBJECTIVES
1) Describe methods to perform QA/QC of deformable registration. 2) Propose methods to account for uncertainties. 3) Highlight
clinical integration.
Sub-Events
RC222A
Uncertainties in Deformable Registration
Kristy K. Brock PhD (Presenter): License agreement, RaySearch Laboratories AB
LEARNING OBJECTIVES
View learning objectives under main course title.
RC222B
Clinical Practice
Patrick
Kupelian MD : Nothing to Disclose , Allen M. Chen MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
View learning objectives under main course title.
RC223
Minicourse: Recording and Reporting Radiation Dose: National and International Perspectives
and Activities (An Interactive Session)
Refresher/Informatics
SQ
PH
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credits: 1.50
Mon, Dec 1 8:30 AM - 10:00 AM
Location: E353C
URL's
www.imp.uni-erlangen.de/RSNA2012
Sub-Events
RC223A
The American College of Radiology Dose Index Registry
Kalpana M. Kanal PhD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Understand how registries perform. 2) How facilities are using registry to monitor dose. 3) Understand the
way in which registries have altered physician behavior and improve patient care. 4) Identify the parameters
involved in optimizing radiation dose in clinical practice. 5) Apply this knowledge by participating in a dose
index registry and utilizing these techniques in Maintenance of Certification.
RC223B
The European Perspective
Willi A. Kalender PhD (Presenter): Consultant, Siemens AG Consultant, Bayer AG Founder, CT Imaging GmbH
Scientific Advisor, CT Imaging GmbH CEO, CT Imaging GmbH
LEARNING OBJECTIVES
1) Understand that CTDI is merely a technical concept for scanner acceptance and constancy testing, but not a
measure for patient dose. 2) Learn about concepts for patient- and scanner-specific patient dose estimates. 3)
Learn about the concept of diagnostic reference levels and its strengths and weaknesses.
ABSTRACT
There is no major debate regarding the validity of the computed tomography dose index (CTDI) in Europe
because it is considered as a tool for scanner acceptance and constancy testing. Its use for that purpose is
undisputed. Measures for patient dose have been a major topic for decades. There are no common regulations
valid for all of Europe, but there are a number of initiatives and concepts in place already which originated here.
Among these are primarily the generation of conversion coefficients k for estimating values of the effective
dose E from the dose length product (DLP) by E = k×DLP and the concept of dose reference levels (DRL). DRLs
for radiological examinations in the European Union were demanded by law already in 2000. Patient dose
assessment relies predominantly on pre-tabulated values generated for anthropomorphic and voxel phantoms.
Efforts are underway to provide more patient-specific dose estimates (PSDE) independent of CTDI phantom
measurements. The lecture will review the above concepts and will point to both strengths and weaknesses.
RC223C
Informatics Tools for Recording/Tracking Dose
Kevin
O'Donnell (Presenter): Employee, Toshiba Corporation
LEARNING OBJECTIVES
1) Understand how DICOM Radiation Dose SR (RDSR) captures procedure dose information, the modalities and
details covered. 2) Understand how the IHE Radiation Exposure Monitoring Profile (REM) coordinates the capture
and management of RDSR objects and how it can be applied in a radiology practice. 3) Understand how 'CT
dose screens' from legacy scanners can be ported into RDSR. 4) Understand how to apply the pre-scan dose
pop-ups on the CT console specified in the MITA CT Dose Check (XR-25) standard. 5) Understand how to
specify the above standards and features when purchasing and integrating radiology systems.
RC224
Whole Body MR
Refresher/Informatics
MR
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credits: 1.50
Mon, Dec 1 8:30 AM - 10:00 AM
Location: E351
Sub-Events
RC224A
Whole Body MRI—Non-oncologic Applications
Stefan Oswald Schoenberg MD, PhD (Presenter): Institutional research agreement, Siemens AG
LEARNING OBJECTIVES
1) To understand the indications for whole-body MRI in non-oncologic applications. 2) To optimize the protocols
with regard to the type of disease, acquisition speed and standardized reporting. 3) To show the additional
diagnostic value of whole-body MRI in comparison to routine diagnostic tests.
ABSTRACT
For many disease entities, magnetic resonance imaging (MRI) is the technique of choice for assessment of focal
organ involvement including vascular occlusive disease as well as rheumatic and pediatric diseases. Many of
these, however, affect multiple sites within the entire body with different types of disease manifestations,
favoring a systemic whole-body (wb) imaging approach. A wb-MRI protocol has to be tailored to the individial
type of disease by including high-resolution imaging of bony structures, time-resolved display of inflammatory
changes, assessment of the vascular status by angiography and information on cellular density for detection of
infiltrative diseases. Therefore, techniques such as contrast-enhanced MR angiography, sequences for cardiac
function and delayed contrast enhancement, diffusion weighted imaging and fat-suppressed T1 and T2
weighted studies before and after contrast media injection have to be integrated into the wb-MRI protocol. For
robust and time-efficient implementation, innovative approaches such as parallel acquisition techniques,
continuous table movement and multi-contrast imaging sequences are required. Clinically established
indications include screening for macro-vascular complications in vasculitis, detection and therapy monitoring of
joint and ligamentous affection in rheumatic diseases and screening for malignant features in hereditary
multifocal exostoses. Arising applications are e.g. cardiovascular risk assessment including whole-body fat
quantification, detection of micro- and macro-vascular complications in diabetes and screening for inflammatory
foci in immunocompromised patients with fever of unknown origin. For a reliable clinical application,
standardized reporting schemes and severity scores are being developed and the results have to be compared
to currently applied diagnostic reference standards.
URL's
http://www.ikrn.de/RSNA2014/Whole-Body-MRI/
RC224B
Whole Body MRI—Oncologic Applications
Tobias
Heye MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) To learn about the possibilities and challenges of whole body MRI in oncologic imaging. 2) To identify clinical
scenarios and oncologic disease entities in which whole body MRI is applicable and offers added value. 3) To be
able to create a disease specific whole body MRI protocol which balances acquisition time and the amount of
acquired information. 4) To understand how whole body MRI performs in diagnostic accuracy, acquisition time,
and cost compared to competing staging modalities.
ABSTRACT
Detection and characterization of local disease in conjunction with identification of distant metastases is the
main goal in oncologic imaging. Certain oncologic disease entities are per se affecting the body in a diffuse
pattern for example multiple myeloma or lymphoma. In both scenarios, local disease with possible distant
metastases or diffuse, multifocal disease, imaging protocols using different modalities are incorporated to
screen the entire body. The continuous development of MRI technology led to improvements in acquisition time
and volume coverage allowing for whole body imaging in a practical time period. However, MRI remains a more
challenging imaging method in terms of protocol preparation, actual scanning, providing diagnostic images,
patient comfort and acquisition time compared to other imaging modalities which offer whole body coverage
such as CT or PET-CT. On the other hand there are abundant MRI specific imaging characteristics available
including different contrasts, diffusion and perfusion imaging, which may provide additional information for a
given oncologic disease compared with other modalities. The challenge in whole body MRI is to balance the
multitude of available MRI sequences with the amount of information needed to answer the clinical question
thus providing a robust imaging protocol tailored to the clinical indication.
RC224C
Whole Body MR in Children: Applications
Prakash Mohan Masand MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) To learn the technique and principles that revolve around the performance of whole body MRI in children. 2)
To understand present day whole body MR applications in pediatrics. 3) Future developments and research
avenues linked to whole body MR imaging in children.
ABSTRACT
The applications of whole body Magnetic resonance imaging (MRI) in children continue to evolve and expand
and include both oncologic and non oncologic multisystem disorders. Whole body MRI promises to be a "one
stop shop" for disease surveillance without the use of ionizing radiation. The present day protocols vary across
institutions and in general include fluid sensitive sequences (STIR) at the least. The images are displayed in a
coronal plane, after the acquisition over multiple stations as the table moves through the scanner. This
technique will be integrated with positron emission tomography in the future which opens an exciting avenue
for research endeavors. The current course delves into the technique and clinical applications of whole body MR
imaging in pediatrics
RC225
Quantitative Imaging: Quantitative Imaging in FDG-PET
Refresher/Informatics
BQ PH
NM
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credits: 1.50
Mon, Dec 1 8:30 AM - 10:00 AM
Location: S102C
Sub-Events
RC225A
Lessons Learned from Drug Development Trials Using Molecular Imaging
Jeffrey L. Evelhoch PhD (Presenter): Employee, Merck & Co, Inc Stockholder, Merck & Co, Inc
LEARNING OBJECTIVES
1) Understand how pharma uses the information provided by FDG-PET. 2) Become familiar with site
qualification and quality control methods used in clinical trial of an investigational therapeutic agent. 3)
Understand why specific clinical trial imaging protocols may differ from clinical practice and importance of
adhering to the clinical trial imaging protocol. 4) Realize which issues confound attempts to achieve more
quantitative FDG-PET in the context of a clinical trial of an investigational therapeutic agent.
RC225B
Examples of Multi-Center Molecular Imaging Trials: Trial Design and Quantitative Approaches
David A. Mankoff MD, PhD (Presenter): Speaker, Koninklijke Philips NV Speaker, Siemens AG Speaker,
General Electric Company
LEARNING OBJECTIVES
1) Describe applications of molecular imaging as a biomarker for cancer drug therapy. 2) Discuss elements of
clinical study design for molecular imaging. 3) Contrast molecular imaging versus conventional imaging and
therapy trials.
RC225C
Understanding and Controlling Sources of Variability in Multi-Center PET Imaging
Paul Eugene Kinahan PhD (Presenter): Research Grant, General Electric Company Co-founder, PET/X LLC
LEARNING OBJECTIVES
1) Identify the importance of quantitative imaging principles in the setting of clinical trials. 2) Identify the role
of standards, including DICOM and others, in the successful application of quantitative imaging principles. 3)
Analyze quantitative imaging techniques and apply this knowledge to protocol development in the setting of
clinical trials.
RC227
The Future of Radiology Payments: Can Analytics Help Radiologists Regain Control?
Refresher/Informatics
HP HP
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credits: 1.50
Mon, Dec 1 8:30 AM - 10:00 AM
Location: S102D
Participants
Moderator
David Andrew Rosman MD : Nothing to Disclose
Richard Duszak MD (Presenter): Nothing to Disclose
Woojin Kim MD (Presenter): Co-founder, Montage Healthcare Solutions, Inc Shareholder, Montage Healthcare Solutions, Inc
Board of Directors, Montage Healthcare Solutions, Inc Advisory Board, Zebra Diagnostics Ltd
LEARNING OBJECTIVES
1) Understand how analytics can help radiologists provide value over volume and get compensated for it. 2) Understand how big
data and analytics can be made accessible to the practicing radiologist. 3) Better understand radiology's place in the economic
puzzle of bundles. 4) Understand how analytics can make the radiologists report more accurate and easier to produce. 5)
Understand how a department powered by analytics can enhance quality and payment.
ABSTRACT
As healthcare delivery models evolve into ones that reward value over volume, the mechanisms by which physicians and
facilities will be compensated will change. To date, there is little consensus on how radiologists and radiology departments will
be addressed under new payment models. This program is intended for radiologists at all stages of their careers and in various
leadership and management roles, and is intended to demonstrate the power of historical analytic data in forming the baseline
for innovative local and national payment models that will align stakeholder interests. It is also aimed at the more day to day
practical side of analytics explaining how they can help create more consistent and accurate reports while simultaneously
enhancing payment. Increasingly, practice leaders will be required to establish contracts based on risk and value. Given the
seeming lack of information regarding new payment models and how they are actually implemented, it is easy for radiologists to
feel hopeless or powerless against the oncoming tide of change. This program will show that, using data and analytics, radiology
and radiologists can regain control of their financial stake in the patient encounter. Although "Big Data" and "Analytics" may
sound like something that cannot affect your day to day practice as a radiologists, it turns out that having powerful tools work
in the background can allow for better, more consistent reports, better communication of critical results and followup and can
allow for a more proactive rather than reactive radiology practice.
RC229
Increasing Your Gynecological MRI Referral Base: Reaching Out to the Gynecologists (An
Interactive Session)
Refresher/Informatics
OB MR GU
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credits: 1.50
Mon, Dec 1 8:30 AM - 10:00 AM
Location: S402AB
Sub-Events
RC229A
Mullerian Anomalies—Guiding Management
Julia R. Fielding MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
LEARNING OBJECTIVES
1) Review the MR appearance of the septate and bicornuate uterine anomalies. 2) Define a routine MR protocol
to accurately characterize anomalies. 3) Outline the necessary components in the radiology report that are of
the most value to the referring physician.
Pelvic Floor Dysfunction and Other Postpartum Sequelae
RC229B
Amy Suzanne Thurmond MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Review the complex anatomy of the female pelvic floor. 2) Understand the effect of childbirth on the
muscles, ligaments, and organs of the pelvis. 3) Learn the appropriate use of fluoroscopic procedures,
ultrasound, CT and MRI for diagnosis of long-term sequelae of obstetric trauma. 4) Appreciate the pre-operative
considerations for treatment of pelvic prolapse and vaginal fistulas.
ABSTRACT
Anatomy of the female pelvic floor is complex, and divided into three compartments. The anterior compartment
contains the urinary bladder and the urethra; the middle compartment contains the uterus, cervix, and vagina;
and the posterior compartment contains the rectum. Pregnancy and childbirth, by nature of the process, result
in trauma to the tissues and over time lead to weakness of the tissues and pelvic floor dysfunction including
stress urinary incontinence, as well as fistula formation between the organs in the three compartments.
MR Imaging of Endometriosis: Pearls and Pitfalls
RC229C
Evan Spencer Siegelman MD (Presenter): Consultant, BioClinica, Inc Consultant, ICON plc Consultant, ACR
Image Metrix
LEARNING OBJECTIVES
1) Identify the clinical indications that should lead to imaging for the detection of endometriosis. 2) Assess the
MR techniques for the detection and characterization of endometriosis. 3) Describe the classic and unusual
locations of endometriosis.
ABSTRACT
Endometriosis, which is defined as the presence of ectopic endometrial glands and stroma outside the uterus, is
a common cause of pelvic pain and infertility, affecting as many as 10% of premenopausal women. Because its
effects may be devastating, radiologists should be familiar with the various imaging manifestations of the
disease, especially those that allow its differentiation from other pelvic lesions. The MR 'pearls' offered here
apply to the detection and characterization of pelvic endometriosis. First, the inclusion of T1-weighted
fat-suppressed sequences is recommended for all MR examinations of the female pelvis because such
sequences facilitate the detection of small endometriomas and aid in their differentiation from mature cystic
teratomas. Second, it must be remembered that benign endometriomas, like many pelvic malignancies, may
exhibit restricted diffusion. Although women with endometriosis are at risk for developing clear cell and
endometrioid epithelial ovarian cancers (ie, endometriosis-associated ovarian cancers), imaging findings such as
enhancing mural nodules should be confirmed before a diagnosis of ovarian malignancy is suggested. The
presence of a dilated fallopian tube, especially one containing hemorrhagic content, is often associated with
pelvic endometriosis. Deep (solid infiltrating) endometriosis can involve the pelvic ligaments, anterior
rectosigmoid colon, bladder, uterus, and cul-de-sac, as well as surgical scars; the lesions often have poorly
defined margins and T2 signal hypointensity as a result of fibrosis. The presence of subcentimeter foci with T2
hyperintensity representing ectopic endometrial glands within these infiltrating fibrotic masses may help
establish the diagnosis.
URL's
http://pubs.rsna.org/doi/pdf/10.1148/rg.326125518
RC231
Master Class in Musculoskeletal Ultrasound (How-to Workshop)
Refresher/Informatics
US
MK US
MK
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credits: 1.50
Mon, Dec 1 8:30 AM - 10:00 AM
Location: E258
Participants
Marnix T. van Holsbeeck MD (Presenter): Consultant, General Electric Company Consultant, Koninklijke Philips NV
Stockholder, Koninklijke Philips NV Stockholder, General Electric Company Grant, Siemens AG Grant, General Electric Company
Kenneth S. Lee MD (Presenter): Research Consultant, SuperSonic Imagine Speakers Bureau, Medical Technology Management
Institute
Catherine J. Brandon MD (Presenter): Stock options, VuCOMP, Inc
Catherine J. Brandon MD (Presenter): Stock options, VuCOMP, Inc
Michael A. Dipietro MD (Presenter): Nothing to Disclose
Alberto Stefano Tagliafico MD (Presenter): Nothing to Disclose
Joseph Hudson Introcaso MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Recognize and identify pitfalls of scanning that lead to false positive or false negative musculoskeletal ultrasound results. 2)
Perform skills for scanning difficult patients. 3) Follow rigorous protocols for the examination of different anatomic regions. 4)
Position patients for more complicated musculoskeletal ultrasound examinations. 5) Recognize and integrate the importance of
tissue movement in judging the functionality of the extremities.
ABSTRACT
In this Musculoskeletal Ultrasound Master class, an opportunity will be given to participants to start a written dialogue in
advance to RSNA 2012. The electronically submitted questions will be sorted by instructors and organized per topic. A select
number of recurrent themes in these questions will be prepared for dialogue on stage. When the questions focus on a particular
scanning skill, the authors of the questions will be invited on the examination platform to show problems they encounter in
their practice. By using a step-by step approach in solving the scanning issues, all who are present should benefit from the
technical interactions on stage. Cameras will project scanning details on large screens. The seating in the master class will
guarantee close proximity for an enriching interaction between audience and stage. At the end of the master class, the audience
will be broken up in smaller groups for a more personal interaction with the instructors with the intent of improving scanning
skills on an individual level.
RC232
Change Management in Radiology
Refresher/Informatics
LM LM
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credits: 1.50
Mon, Dec 1 8:30 AM - 10:00 AM
Location: S404AB
Participants
N. Reed Dunnick MD (Presenter): Nothing to Disclose
Michael N. Brant-Zawadzki MD (Presenter): Nothing to Disclose
William T. Thorwarth MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Participants will appreciate the importance of understanding the culture of an organization. 2) Participants will understand
that strategic planning will not result in a successful outcome if it is not consistent with the culture of the organization. 3)
Participants will learn techniques that can help modify organizational culture and make it more effective in addressing new
issues. (This course is part of the Leadership Track)
ABSTRACT
Culture may be defined as the behaviors and beliefs of a social, ethnic or age group. It is the set of shared attitudes, values,
goals and practices that characterize the group. Understanding the culture of our professional organizations is essential to
effectively creating and implementing a strategic plan. Each of us is involved in many organizations including private practice
groups, multispecialty clinics, university departments and a variety of professional societies which are linked by common
interests. These include a interests related to a specific geographic region, an anatomic organ system, or an imaging or
therapeutic modality. They may also be connected to a common goal such as education, research, reimbursement, regulation,
government affairs, or radiology administration. The pace of change in our society is quickening. This is true not only for
communication and imaging technology, but also for the entire health care industry and the regulations that govern our
behavior. American medicine has been criticized for being too expensive and having only average quality. Furthermore, a large
number of unnecessary deaths have been attributed to medical error. If our field is going to respond effectively to these many
challenges, we must understand the cultures of our various professional organizations in order to enable them to better
implement needed responses.
RC250
Interventional Stroke Treatment: Practical Techniques and Protocols (How-to Workshop) (An
Interactive Session)
Refresher/Informatics
NR ER IR NR ER IR
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credits: 1.50
Mon, Dec 1 8:30 AM - 10:00 AM
Location: E353B
Participants
Gary Ross Duckwiler MD (Presenter): Scientific Advisor, Sequent Medical, Inc Scientific Advisor, Asahi Kasei Medical Co, Ltd
Stockholder, Sequent Medical, Inc Proctor, Covidien AG
Joshua A. Hirsch MD (Presenter): Shareholder, Intratech Medical Ltd
David John Fiorella MD, PhD (Presenter): Institutional research support, Siemens AG Institutional research support, Terumo
Corporation Consultant, Covidien AG Consultant, Johnson & Johnson Consultant, NFocus Consulting Inc Owner, Vascular
Simulations LLC Owner, TDC Technologies Owner, CVSL
LEARNING OBJECTIVES
1) Describe the diagnostic evaluation and decision making algorithms leading to urgent endovascular treatment of acute stroke.
2) Review endovascular techniques for the treatment of acute stroke from microcatheter set up to intraarterial thrombolysis to
mechanical thrombectomy. 3) Discuss case examples of endovascular treatment including patient selection, technique, and
pitfalls.
pitfalls.
ABSTRACT
Rapid advances in the evaluation, selection, treatment and management of the acute stroke patient necessitates an ongoing
educational event highlighing the newest information, techniques and strategies for obtaining the best outcomes for our patients.
In this session, all of these topics will be covered in a practical 'how to' and case based approach which is designed to help the
practitioner implement best practices. The course is useful for those performing imaging, treatment or both. Analysis of the
latest ongoing trials, devices and techniques will be presented. Endovascular tips and tricks will be discussed, as well as pitfalls
in the treatment of these patients.
Active Handout
http://media.rsna.org/media/abstract/2014/4404423/RC250 sec.pdf
RC251
Abdominal Dual Energy CT in Practice (How-to Workshop)
Refresher/Informatics
CT
GI CT
GI
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credits: 1.50
Mon, Dec 1 8:30 AM - 10:00 AM
Location: S502AB
Participants
Desiree E. Morgan MD (Presenter): Nothing to Disclose
Alec Jeffrey Megibow MD, MPH (Presenter): Consultant, Bracco Group
Eric P. Tamm MD (Presenter): Nothing to Disclose
Daniel Tobias Boll MD (Presenter): Research Grant, Siemens AG Research Grant, Koninklijke Philips NV Research Grant,
Bracco Group
LEARNING OBJECTIVES
1) Understand the principles of image acquisition and post processing of dual energy CT technologies currently commercially
available in the US. 2) Learn about the most promising abdominal dual energy CT applications. 3) Discuss workflow issues and
limitations of dual energy approaches for abdominal imaging.
ABSTRACT
For this section of the presentation, a variety of topics regarding single source dual energy CT will be covered. This will include
aplications of single source dual energy CT for abdominal imaging, and, particularly unique issues for single source CT in the
development of imaging protocols, expediting workflow (such as for the generation of monochromatic energy images, and
iodine/water material density images) at the scanner and approaches to image interpretation using these provided images.
Strengths and limitations of singel source dual energy CT will also be discussed.
RC252
US-guided Interventional Breast Procedures (Hands-on Workshop)
Refresher/Informatics
US
BR US
BR
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credits: 1.50
Mon, Dec 1 8:30 AM - 10:00 AM
Location: E264
Participants
Gary J. Whitman MD (Presenter): Nothing to Disclose
Annamaria Wilhelm MD (Presenter): Research Grant, Merck & Co, Inc
Richard Merrell Chesbrough MD (Presenter): Consultant, C. R. Bard, Inc Consultant, Radnet, Inc
Michael N. Linver MD (Presenter): Nothing to Disclose
Paula Beth Gordon MD (Presenter): Stockholder, OncoGenex Pharmaceuticals, Inc Scientific Advisory Board, Hologic, Inc
Consultant, Seno Medical Instruments, Inc
Stamatia V. Destounis MD (Presenter): Investigator, FUJIFILM Holdings Corporation Investigator, Seno Medical Instruments,
Inc
Anna Irene Holbrook MD (Presenter): Nothing to Disclose
Alice S. Rim MD (Presenter): Nothing to Disclose
Alda Felicita Cossi MD (Presenter): Nothing to Disclose
Eren D. Yeh MD (Presenter): Nothing to Disclose
Gary W. Swenson MD (Presenter): Nothing to Disclose
Catherine Welch Piccoli MD (Presenter): Stockholder, VuCOMP, Inc Consultant, Real Time Tomography, LLC Stockholder, Real
Time Tomography, LLC
Michael Patrick McNamara MD (Presenter): Stockholder, Apple Inc Stockholder, General Electric Company
Selin Carkaci MD (Presenter): Consultant, Hologic, Inc
Jean M. Seely MD (Presenter): Nothing to Disclose
Phan Tuong Huynh MD (Presenter): Research Grant, Siemens AG Consultant, Siemens AG
H. Carisa Le-Petross MD (Presenter): Nothing to Disclose
Basak Erguvan Dogan MD (Presenter): Nothing to Disclose
Jay Alan Baker MD (Presenter): Research Consultant, Siemens AG
Tanya W. Stephens MD (Presenter): Nothing to Disclose
Jiyon Lee MD (Presenter): Nothing to Disclose
Alexis Virginia Nees MD (Presenter): Nothing to Disclose
William R. Poller MD (Presenter): Consultant, Devicor Medical Products, Inc
LEARNING OBJECTIVES
1) Describe the equipment needed for ultrasound guided interventional breast procedures. 2) Review the basic principles of
1) Describe the equipment needed for ultrasound guided interventional breast procedures. 2) Review the basic principles of
ultrasound guidance and performance of minimally invasive breast procedures. 3) Practice hands-on technique for ultrasound
guided breast interventional procedures.
ABSTRACT
This course is intended to familiarize the participant with equipment and techniques in the application of US guided breast
biopsy and needle localization. Participants will have both basic didactic instruction and hands-on opportunity to practice biopsy
techniques on tissue models with sonographic guidance. The course will focus on the understanding and identification of: 1)
optimal positioning for biopsy 2) imaging of adequate sampling confirmation 3) various biopsy technologies and techniques 4)
potential problems and pitfalls
RC253
Clinical Applications of 3D Printing
Refresher/Informatics
IN
ED
NR CA
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credits: 1.50
Mon, Dec 1 8:30 AM - 10:00 AM
Location: N229
Participants
Moderator
Shi-Joon Yoo MD : Owner, 3D HOPE Medical
Sub-Events
RC253A
Overview of 3D Imaging Acquisitions
Karin Evelyn Dill MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Understand the concept of three-dimensional image acquisition. 2) Comprehend the importance of high
quality three-dimensional image acquisition as it applies to three-dimensional printing.
RC253B
From 3D Visualization to 3D Printing
Michael Lally Steigner MD (Presenter): Speaker, Toshiba Corporation
LEARNING OBJECTIVES
1) Review the evolution of 3D image post-processing. 2) Demonstrate the current state-of the-art of 3D
post-processing. 3) Demonstrate the relationship between current 3D image post-processing and 3D printing.
RC253C
3D Printing as a Radiology Educational Tool
Amir
Imanzadeh MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Demonstrate the utility of 3D printing in pediatric cardiac imaging and surgery. 2) Demonstrate the surgical
anatomy of complex forms of double outlet right ventricle, congenitally corrected transposition and criss-cross
or twisted heart shown in 3D print models. 3) Observe the models of the example cases in your hands.
ABSTRACT
Precise understanding of the complex morphology of the heart with congenital heart disease is crucial in
surgical decision and undertaking the procedure. Most surgeons rely on the anatomy shown in
echocardiograms, CT or MRI. Recent advances in computer graphic technology allows virtual demonstration of
3D anatomy in the computer screen. However, the virtual anatomy still requires surgeon's mental
reconstruction and ability to discriminate between the real and the false. 3D printing ultimately provides the
surgeons with the physical replicas of the heart that allows easier and accurate understanding of the anatomy,
opportunity to practice the procedure and to prepare the tailor-made implants or patches in advance, and,
therefore, improves the accuracy of the surgery, shortens the procedure time, and improved the surgical
outcome. This presentation will show how 3D print models facilitate understanding of complex congenital heart
diseases such as aytpical forms of double outlet right ventricle, congenitally corrected transposition and
criss-croos or twisted heart.
URL's
http://www.brighamandwomens.org/Departments_and_Services/radiology/Research/aisl.aspx
RC253D
Role of 3D Printing in Congenital Heart Disease Surgery
Shi-Joon
Yoo MD (Presenter): Owner, 3D HOPE Medical
LEARNING OBJECTIVES
1) Understand 3D printing process for heart models. 2) Know how 3D printing helps pediatric cardiac surgery.
with case examples. 3) Know the future directions of 3D printing for cardiac surgery
ABSTRACT
Using rapid prototyping or 3D printing, physical replicas of the hearts can be provided to surgeons before their
surgical decision and procedure. The replicas fill the gap between the imagination from the medical images and
the reality. By having the replicas in hands, the surgeons can make optimum surgical decision and simulate the
intended procedures on the replica prior to the procedure. This allows precise surgical procedures with reduced
procedure and anasthesia time. In canses in the grey zone for biventricular versus univentricular repair, the
replicas are of tremendous help in a binary decision. The presentation will include a few clincal cases where 3D
printing played a crucial role in surgical decision making.
RC253E
3D Surgical Planning Using Printed Models: The Surgeon's Perspective (Spine and Skull)
Donald J. Annino MD, DMD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) To describe the value of 3D visualization from the surgeon's perspective. 2) To show the role of 3D printing
in current and future surgical planning. 3) To review important components of 3D models for face
transplantation.
RC253F
The Impact 3D-Printing in the Imaging Environment
Frederik Lars Giesel MD, MBA (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) History of 3D-Printing. 2) Imaging modalities and post-processing procedures to provide data surrogates for
3D-printing. 3) Concept of 3D-printing for improved clinical services. 4) Limitations and perspectives of
3D-printing in the imaging environment.
ABSTRACT
This presentation outlines the impact of 3D-printing in the imaging environment. Applications in the medical
field are reviewed and growing clinical applications are discussed. Starting with an overview of current
3D-printing technologies including fused deposition modelling (FDM), selective laser sintering (SLS), and
stereolithography (SLA) common techniques for generating 3D object models based on medical imaging are
illustrated. Typically, imaging source data from different modalities are post-processed using dedicated
algorithms and software in order to generate triangle mesh surface data. These surface data are usually
exported to STL-files that are commonly understood by current 3D printing machines. 3D-printed objects are
most often made from plastic, such as ABS, PA, or PLA, but metal or other material is even possible. Finally the
presentation will demonstrate how 3D-printed objects are valuable for treatment planning, treatment
procedures in several clinical subspecialties, intra-operative surgical navigation, or for prosthesis production.
However, medical applications of 3D-printing are still in a very early phase but the growing awareness in the
medical and non-medical field nowadays support the promising utilization and development in the very near
future.
RCA21
Data Management and Analysis with Excel for Research and for Practicing Quality
Improvement – A Hands-On Tutorial
Refresher/Informatics
RS IN RS IN RS IN
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credits: 1.50
Mon, Dec 1 8:30 AM - 10:00 AM
Location: S401AB
Participants
Jaydev Kardam Dave PhD, MS (Presenter): Nothing to Disclose
Raja Gali MS (Presenter): Nothing to Disclose
http://www.cornellphysicians.com/kjuluru/publications.html
LEARNING OBJECTIVES
1) Describe techniques for creating a spreadsheet to allow trouble-free data analysis. 2) Demonstrate key data management
skills. 3) Describe tools for performing basic descriptive statistics. 4) Identify how to perform simple statistical tests and perform
these tests with a sample dataset. 5) Understand how bad data (or bad data acquisition techniques) may corrupt subsequent
data analyses. 6) Practice data plotting/representation techniques. 7) Identify differences between a spreadsheet and a
database. 8) Identify statistical tasks that require more sophisticated software. Pre-requisites: Familiarity with Microsoft
Windows and Microsoft Excel environment will be assumed
ABSTRACT
A spreadsheet program is commonly employed to collect and organize data for practicing quality improvement, for research, and
for other purposes. In this refresher course, we will demonstrate to a user, familiar with Microsoft Excel environment, how this
spreadsheet program may be used for such purposes. The course will begin with describing efficient approach for data
acquisition and highlight key data management skills; and with reviewing commons errors that may be avoided during data
logging. Then we will provide a brief introduction on basic descriptive tests before proceeding with a hands-on tutorial using a
sample dataset to calculate basic descriptive statistics, and to perform basic statistical tests like t-test, chi-square test,
correlation analysis, etc. Effect of corrupted data on such analysis will also be demonstrated. The final hands-on component for
this course will include data plotting and representation including the use of pivot tables. The course will conclude with a
discussion on identifying differences between a spreadsheet and a database, limitations of a spreadsheet program and avenues
where a dedicated statistical software program would be more beneficial. A list of some of these dedicated statistical software
programs for analyses will also be provided. Pre-requisites: Familiarity with Microsoft Windows and Microsoft Excel environment
will be assumed
RCB21
Creating, Storing, and Sharing Teaching Files Using RSNA's MIRC® (Hands-on)
Refresher/Informatics
IN
ED
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credits: 1.50
Mon, Dec 1 8:30 AM - 10:00 AM
Location: S401CD
Participants
Daniel Peter Link MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Learn how easy it is to install the new and improved RSNA teaching file software with the one-click installer. 2) Learn how to
create, organize, and share teaching files, create conference documents and save interesting cases for yourself, your group or
your department.
RCC21
Leveraging Your Data: Informatics Approaches and Solutions to Improve Imaging Care
Delivery
Refresher/Informatics
SQ
IN SQ
IN
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credits: 1.50
Mon, Dec 1 8:30 AM - 10:00 AM
Location: S501ABC
Participants
Moderator
Arun Krishnaraj MD, MPH : Nothing to Disclose
LEARNING OBJECTIVES
1) Identify unmet needs of current and future practices with regards to emerging and existing informatics tools. 2) Apply
existing and emerging informatics applications to improve report generation. 3) Demonstrate an understanding of how best to
achieve consistency of radiologists' recommendations.
ABSTRACT
Existing and emerging informatics applications have the potential to markedly improve the quality of imaging care delivery. Much
of the inefficiency and inconsistency of report generation could be potentially solved with the appropriate informatics application.
In this session, the learner will gain an apprecation of the unmet needs of current and future pracitces and discover how novel
applications developed at various institutions across the country are seeking to plug these voids and improve imaging care
delivery.
Sub-Events
RCC21A
The Unmet Needs of Current and Future Practices
Michael Ethan Zalis MD (Presenter): Co-founder, QPID Health Inc Chief Medical Officer, QPID Health Inc
Stockholder, QPID Health Inc
LEARNING OBJECTIVES
View learning objectives under main course title.
RCC21B
Augmenting Image Interpretation through the Use of Advanced Health Record Technology
Arun
Krishnaraj MD, MPH (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Appreciate the current state of Electronic Health Record (EHR) technology and adoption in the United States.
2) Identify areas where EHR integration into the daily workflow of Radiologists is lacking. 3) Demonstrate an
2) Identify areas where EHR integration into the daily workflow of Radiologists is lacking. 3) Demonstrate an
understanding of the importance of incorporating data contained in the EHR to generate high quality reports. 4)
Understand the consequences of under utilizing data contained in the EHR.
ABSTRACT
Advanced heath information technologies, specifically EHR systems, are undergoing rapid dissemination and
widespread adoption spurred by initiatives in the American Recovery and Reinvestment Act of 2009. When
properly integrated into clinical workflow, an EHR can improve both the quality and efficiency of care delivery.
Radiology has long been at the forefront with respect to information technology (IT), however the integration of
EHR data into radiolgists' workflow is lacking which affects the efficiency, safety, and costs of Imaging.
Emerging advanced heatlh record technologies which incorporate natural language processing and semantic
search allow the radiologists to retrieve and incorporate relevant clinical data when generating reports thereby
improving both efficiency and quality. In this session, the learner will explore how one such health intelligence
platform, known as QPID (Queriable Patient Inference Dossier), allows for the creation of search queries tailored
to the workflow of an abdominal radiologist.
RCC21C
Bone Age and Skeletal Atlas Decision Support Tools with Patient Context Integrated into Clinical
Workflow
Cree Michael Gaskin MD (Presenter): Author with royalties, Oxford University Press Author with royalties,
Thieme Medical Publishers, Inc
LEARNING OBJECTIVES
1) Review concepts for contemporary decision support tools for diagnostic radiologists. 2) Discuss bone age and
skeletal atlas decision support tools integrated into clinical diagnostic workflow via context sharing.
ABSTRACT
There are numerous references available to radiologists to aid image interpretation or provide guidance on
management of imaging findings. Given the vast amounts of information we are expected to know and the
speed with which we are expected to perform our clinical work, it is helpful to quick and easy access to relevant
resources at our point-of-care (e.g., during image interpretation and reporting). Such resources should be
available in electronic format on our diagnostic workstations and, when relevant, be integrated with our clinical
applications. Our Radiology Information System (RIS), PACS, and/or Electronic Health Record (EHR) can share
study and patient context information with decision support tools to facilitate our diagnostic workflow. Examples
to be shared include modern remakes of classic printed atlases in pediatric skeletal imaging, updated to
contemporary electronic tools integrated with PACS and EHR applications to expedite workflow and reduce
error.
RCC21D
Advanced Decision Support Tools for the Radiologists
Giles W. Boland MD (Presenter): Principal, Radiology Consulting Group Royalties, Reed Elsevier
LEARNING OBJECTIVES
View learning objectives under main course title.
VSBR21
Breast Series: MR Imaging
Series Courses
MR BR
AMA PRA Category 1 Credits ™: 3.25
ARRT Category A+ Credits: 4.00
Mon, Dec 1 8:30 AM - 12:00 PM
Location: Arie Crown Theater
Participants
Moderator
Constance D. Lehman MD, PhD : Consultant, Bayer AG Consultant, General Electric Company Research Grant, General
Electric Company
Moderator
Christopher E. Comstock MD : Nothing to Disclose
Sub-Events
VSBR21-01
MR Image Acquisition
Mitchell Dennis Schnall MD, PhD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) To describe the technical elements needed to perform high-quality breast MRI. 2) To describe and illustrate
the pulse sequences needed for high-quality breast MRI. 3) To describe and illustrate the importance of
simultaneously achieving high in-plane spatial resolution, thin slices, adequate temporal resolution, adequate
signal-to-noise ratios, and full coverage of both breasts in breast MRI. 4) To show examples of high-quality and
sub-standard breast MRI exams.
VSBR21-02
Diffusion Kurtosis Imaging for Breast Lesions: Preliminary Results
Hiromi Ono MD (Presenter): Nothing to Disclose , Satoshi Goshima MD, PhD : Nothing to Disclose ,
Yukino Goto MD : Nothing to Disclose , Nobuyuki Kawai MD : Nothing to Disclose , Yukichi Tanahashi
MD : Nothing to Disclose , Yoshifumi Noda MD : Nothing to Disclose , Hiroshi Kondo MD : Nothing to
Disclose , Masayuki Kanematsu MD : Nothing to Disclose
PURPOSE
To determine the diagnostic performance of diffusion kurtosis imaging (DKI) of the breast lesions for the
detection of malignant breast tumors.
METHOD AND MATERIALS
IRB approval and written informed consent was obtained. During a 10-months period, we prospectively
evaluated 51 patients (mean age, 52.0 years; range, 13-86 years) with 58 breast lesions including 21 benign
lesions and 37 malignant tumors. DKI was performed with a single-shot echo-plannar sequence with multiple b
values (0, 100, 500, 1000, 1500, and 2000 sec/mm2). We computed the mean kurtosis (MK) and apparent
diffusion coefficient (ADC) (10-3 mm2/s) over regions of interest encompassing the entire tumor using diffusion
kurtosis model programed by MATLAB software (Mathworks, Natick, Mass). The diagnostic performance of MK
and ADC value for the detection of malignant breast tumors were compared.
RESULTS
MR image acquisition and analysis were successful in all our study patients. MK was significantly higher in
malignant tumors (1.13 ± 0.28) than in benign lesions (0.74 ± 0.22) (P < 0.001). Mean ADC value was
significantly lower in malignant tumors (1.17 ± 0.35) than in benign lesions (1.72 ± 0.41) ( P < 0.001). For the
detection of malignant tumors, there was no significant difference in AUC between MK and ADC value, whereas
ADC value (71.4%) had a greater sensitivity than MK (62.2%) (P = 0.007) and MK (100%) had a greater
specificity than ADC value (86.5%) (P = 0.04).
CONCLUSION
DKI was feasible in breast MRI. Our study findings suggest that a combination of MK and ADC may provide the
additional value for the detection of malignant breast tumors.
CLINICAL RELEVANCE/APPLICATION
When MRI is performed to evaluate the breast lesions, diffusion kurtosis imaging may improve the diagnostic
confidence of lesion characterization in addition to conventional diffusion imaging analysis in breast MR imaging.
VSBR21-03
Intravoxel Incoherent Motion MR Imaging at 3.0T in Breast: Quantitative Analysis for Characterizing
Breast Lesions
Naier
LIN MS (Presenter): Nothing to Disclose , Jia
Hua : Nothing to Disclose
PURPOSE
To compare mono-exponential model DWI and intravoxel incoherent motion(IVIM) DWI in characterizing
different subtype and different grade of breast lesions.
METHOD AND MATERIALS
51 malignant and 47 benign breast lesions in 93 patients were performed with mono-exponential DWI(b
=0,600s/mm2) and bi-exponential analysisDWI (b =0,50,100,150,200,500,800 s/mm2) at 3.0T MRI. Apparent
diffusion coefficient (ADC), as well as IVIM-based parameters:true diffusion coefficient (D), perfusion fraction
(f), and pseudo-diffusion coefficient (D*) were compared among different subtype and different grade lesions .
Receiver operating characteristic (ROC) was used for lesion discrimination.
RESULTS
All the data were fitted well (R2>0.90). In the lesions except cyst, D value was significant lower than ADC
(p<0.05).ADC, D and D* in malignant tumors were significantly smaller than those of benign ones (P = 0.000
for ADC and D ,0.002 for D*, respectively), f value was higher than that of benign lesions (P=0.000). D value
showed increasing order as the following: Invasive ductal carcinoma (IDC)< ductal carcinoma in situ (DCIS)
�Intraductal papilloma (IDP) <Fibroadenoma (FA)< breast cyst. ROC demonstrated D had the best
performance in identification of malignancy from benign lesion (AUC= 0.945) and discriminating DCIS from IDC
(AUC= 0.791) than that of ADC,f and D*. Furthermore,a direct inverse correlation had been observed between
D value and histological IDC grade,while no other parematrers showed difference among varied grade of IDC
(P>0.05).
CONCLUSION
IVIM-DWI provides quantitative measurement of cellularity and vascularity properties within breast lesions and
D showed better diagnostic ability in discrimination malignancy and tumor grading than ADC. therefore IVIM are
expected to enhance the role of MRI in diagnosis, monitoring, and treatment screening of breast cancer.
CLINICAL RELEVANCE/APPLICATION
IVIM provides noninvasive sensitivity to lesions microenvironment properties and has the potential to improve
the specificity of breast MRI without contrast agent ,thus it is recommended as part of the MR exam for
screening high-risk women.
VSBR21-04
Enhancement Parameters on Dynamic Contrast-enhanced Breast MRI: Do They Correlate with
Prognostic Factors and Subtypes of Breast Cancers?
Ji Youn Kim MD : Nothing to Disclose , Sung-Hun
(Presenter): Nothing to Disclose
Kim MD : Nothing to Disclose , Soung Moon
Yang
PURPOSE
To correlate the enhancement parameters of dynamic contrast-enhanced magnetic resonance imaging (MRI)
with prognostic factors and immunohistochemical subtypes of breast cancer.
METHOD AND MATERIALS
A total of 81 breast carcinomas were included in our study. We obtained the following enhancement
parameters: 1) background parenchymal enhancement (BPE) and BPE coefficients (BEC) from bilateral breasts,
2) the number of vessels per breast as a representation of whole-breast vascularity. In 50 patients, 3)
semiquantitative parameters of tumors (the initial enhancement percentage, the peak enhancement
percentage, the time to peak enhancement, the signal enhancement ratio) and 4) perfusion parameters
(Ktrans, kep, ve and iAUC) from tumors and ipsilateral breasts. Correlations among parameters and prognostic
factors, including tumor size, axillary node status, nuclear grade, histologic grade, estrogen receptor (ER)
expression, progesterone receptor (PR) expression, Ki-67, human epidermal growth factor receptor 2 (HER-2)
expression, epidermal growth factor receptor (EGFR) expression, bcl-2, CK5/6 and subtypes categorized as
luminal, triple negative and HER-2 were analyzed.
RESULTS
BPE was significantly correlated with EGFR expression (p=0.040). BEC was significantly higher in tumors larger
than 2 cm than in tumors smaller than 2 cm (p=0.001). The vessel numbers in ipsilateral breasts were higher
in tumors larger than 2 cm than in tumors smaller than 2 cm (p=0.034), with higher nuclear grades (grade 3)
than with lower nuclear grades (grade 1,2) (p=0.001) and with PR-negative rather than with PR-positive
(p=0.010) results. The mean Ktrans was higher in Ki-67-positive tumors than Ki-67 negative tumors (p=0.002).
The mean kep was higher in Ki-67-positive tumors than in Ki-67-negative tumors (p=0.005) and in
CK5/6-positive tumors than in CK5/6-negative tumors (p=0.015). The mean Ktrans was lower in the ipsilateral
breast parenchyma with HER-2-positive tumors compared to HER-2-negative tumors (p=0.012).
CONCLUSION
The BPE, BEC and ipsilateral whole-breast vascularity, higher Ktrans and kep of breast cancer and lower Ktrans
and iAUC of ipsilateral breast parenchyma may serve as additional predictors of poor prognosis of breast cancer.
CLINICAL RELEVANCE/APPLICATION
Enhancement parameters on breast MRI can predict the prognosis and subtypes of breast cancer and is
recommended for the preoperative evaluation of breast cancer patients.
VSBR21-05
7T Breast MR Imaging for Preoperative Characterization of Breast Cancer Using One-stop-Shop
Dynamic Contrast Enhancement, Diffusion-weighted Imaging, and Phosphorus MR Spectroscopy
Alexander Martijn Theodorus Schmitz MD (Presenter): Nothing to Disclose , Wouter B. Veldhuis MD, PhD :
Nothing to Disclose , Marian Menke-Pluijmers : Nothing to Disclose , Wybe van der Kemp : Nothing to
Disclose , Tijl A. van der Velden : Nothing to Disclose , Marc C.J.M. Kock MD : Nothing to Disclose , Pieter
Westenend : Nothing to Disclose , Dennis W. J. Klomp : Nothing to Disclose , Kenneth G.A. Gilhuijs PhD :
Nothing to Disclose
PURPOSE
Detection of breast cancer at earlier stages has raised concern of overtreatment in subgroups of patients, while
treatment failure still occurs in other. Continuing need exists for prognostic models tailored to individual
patients at time of diagnosis. Preoperative core biopsy results in discordant assessment of tumor grade in up to
40% compared to postoperative assessment. Imaging features may potentially close this gap, as they provide
full overview of the tumor. Aim of this study is to assess the potential of biomarkers at 7T functional Breast MRI
to characterize the proliferative nature of breast tumors in-vivo.
METHOD AND MATERIALS
A one-stop-shop protocol was developed at 7T MRI (Philips) including high temporal (HT; 5 s; 2,8mm³
isotropic) and high spatial (HS; 90 s; 0,7mm³-1,0mm³ isotropic) dynamic contrast-enhanced (DCE) magnetic
resonance (MR) imaging, diffusion-weighted imaging (DWI), and phosphorus spectroscopy (31P-MRS) to
analyze tumor metabolism. Sixteen women (age 53-70 years) with histologically proven invasive breast
carcinoma on biopsy were scanned prior to surgery. DCE characteristics were assessed according to BI-RADS.
ADC-values were calculated and hypointense tumor areas scored. Localized 31P-MR spectra were assessed and
scored (1-5) based on degree of tumor proliferation using a newly developed lexicon. Tumor characteristics on
pathology were assessed from the resection specimen and correlated to the MRI features. Explorative analyses
were performed using box plots, Pearson Chi-Square and Krusal Wallis tests.
RESULTS
In 16 patients, 18 malignant lesions were detected on HS DCE-MRI. The mean largest tumor diameter was
22mm (range 8-58). Time to enhancement on HT DCE-MRI ranged from 12s to 29s. Shortest interval was
observed in a rim-enhancing triple-negative tumor. First observations showed correlations between the
31P-MRS score and mitotic cell index (N=11; p=0,02) as well as a trend between ADC and modified
Bloom-Richardson tumor grade (N=11; p=0,097).
CONCLUSION
A one-stop-shop imaging protocol for breast MRI at 7T was developed to explore prognostic and predictive
tumor biomarkers in-vivo. First explorations indicate feasibility to visualize tumor grade in-vivo.
CLINICAL RELEVANCE/APPLICATION
Imaging of breast cancer biomarkers in-vivo using a one-stop-shop 7T Breast MR imaging protocol allows
stratification of tumor proliferation, an important predictive marker used in therapy selection.
VSBR21-06
DWI
Savannah Corrina Partridge PhD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Understand the physical basis of diffusion imaging and methods used to acquire diffusion-weighted data. 2)
Understand the clinical applications of diffusion-weighted imaging for cancer diagnosis and assessment of
response to therapy. 3) Be familiar with the challenges of breast diffusion imaging and technical considerations
for protocol optimization. 4) Future directions.
VSBR21-07
Diagnostic Performance of Diffusion-Weighted Imaging (DWI) versus Targeted Ultrasound (tUS) in
the Characterization of Suspicious Enhancing Lesions at Breast Magnetic Resonance Imaging
(BMRI)
Rubina Noemi Cavallin : Nothing to Disclose , Marta Maria Panzeri : Nothing to Disclose , Giulia Cristel MD
(Presenter): Nothing to Disclose , Claudio Losio MD : Nothing to Disclose , Mariagrazia Rodighiero MD :
Nothing to Disclose , Alessandro Del Maschio MD : Nothing to Disclose
PURPOSE
Percutaneous biopsy is mandatory for all suspicious BMRI-detected lesions (BI-RADS 4 of the Breast Imaging
Reporting and Data System), but the malignancy rate is variable (from 2 to 95%) and BMRI-guided biopsy is
an expensive procedure, frequently resulting in benign histopathology. Our purpose was to investigate whether
DWI and tUS could help in this setting by reducing the number of cases assigned as BI-RADS 4.
METHOD AND MATERIALS
From January 2008 to December 2012, 1757 patients underwent BMRI (1.5T) including T2-weighted sequences,
DWI (b-values: 0-900s/mm2) and dynamic study. A BI-RADS score was assigned according to conventional
morpho-dynamic criteria. For each suspicious enhancement (BI-RADS 4), the Apparent Diffusion Coefficient
(ADC) value was quantified and an ultrasonographic correlate was searched. When both DWI and tUS
downgraded the suspicious enhancement to BI-RADS 3 (probably benign), a short term follow-up was
recommended. If at least one of the two methods (DWI and/or tUS) confirmed the suspicion, the lesion
remained BI-RADS 4 and a biopsy was done using MRI or US-guidance. Histopathological results and
radiological follow up data (minimum 6 months) were recorded and considered the gold standard. Diagnostic
performance indicators of MRI+DWI and tUS were compared using Chi-square test.
RESULTS
BMRI detected 152 BI-RADS 4 lesions in 120 patients: 52% (90/152) of them were proven to be breast
cancers. Eighty percent (121/152) of the lesions were also DWI visible. The sensitivity, specificity, positive and
negative predictive value of DWI in the characterization of these lesions were 98%, 87%, 93 and 96%,
respectively. An ultrasonographic correlate was found in 66% of MRI lesions: the sensitivity, specificity, positive
and negative predictive value of tUS were inferior to those of DWI (p<0,05) (77%, 82%, 86% and 74%,
respectively). Twenty-eight percent (43/152) of the suspicious lesions were downstaged to BI-RADS 3 by means
of both DWI and tUS: 7% of these revealed to be malignant during subsequent follow-up (2 DCIS and 1 tubular
breast cancer).
CONCLUSION
The combination of Quantitative DWI and tUS showed a high accuracy in the characterization of BMRI-detected
suspicious lesions, resulting in a reduction of false positives.
CLINICAL RELEVANCE/APPLICATION
The use of DWI and tUS could theoretically reduce the need of unnecessary preoperative breast biopsies in case
of BI-RADS 4 enhancing lesions.
VSBR21-08
3.0 Tesla Breast MRI: Analysis of Apparent Diffusion Coefficient with a Small Intratumoral ROI
Improves Diagnostic Performance and Tumor Characterization
Otso Arponen (Presenter): Nothing to Disclose , Amro Masarwah MD : Nothing to Disclose , Mikko Tapani
Taina : Nothing to Disclose , Suvi Hanne Katriina Rautiainen MD : Nothing to Disclose , Mervi Kononen
MSc : Nothing to Disclose , Reijo Sironen : Nothing to Disclose , Masah Sudah : Nothing to Disclose ,
Anna Sutela : Nothing to Disclose , Juhana Hakumaki : Nothing to Disclose , Ritva Liisa Vanninen MD :
Nothing to Disclose
PURPOSE
We compared measurements of apparent diffusion coefficient (ADC) within the whole breast tumor vs. a small
intratumoral region of interest (ROI) to differentiate malignant from benign tumors and assessed whether the
ADC parameters represent surrogate markers for tumor prognostic characteristics.
METHOD AND MATERIALS
Approval of the institutional ethics board and institutional approval were obtained. The study protocol included
3.0T structural breast MRI and diffusion weighted imaging (DWI). Patients were selected according to the
recommendations of EUSOMA and the local guidelines. Forty-nine patients (mean age, 59±12 years; range,
36-82 years) and 49 lesions (17 benign, 32 malignant) were included to this prospective study. Two observers
measured the ADC values (mean, standard deviation, kurtosis and skewness) from a) the whole lesion
(WL-ROI), avoiding cystic, hemorrhagic and necrotic regions b) six small intratumoral ROIs (SI-ROIs) with
lowest-appearing values on ADC map. WL-ROI and SI-ROI with second-lowermost mean value were used for
statistical analysis. Data on estrogen and progesterone receptors, HER2-overexpression, tumor grade, Ki-67,
vascular and lymph duct invasion and metastasis to axillary lymph nodes were collected.
RESULTS
Using SI-ROI ADC mean values, reproducibility of the measurements proved to be excellent (κ=0.75;
Intra-Class Correlation Coefficient, 0.904). In receiver operating characteristic curve analysis, area under the
curve was 0.891 for observer 1 and 0.881 for observer 2. Using cut-off value of 0.602×10-3 mm2/s, sensitivity
of 82.4%, specificity of 87.5% and overall accuracy (OA) of 85.7% were reached for diagnosing malignant
lesions. ADC measurements from SI-ROIs proved to be more accurate than WL-ROIs (OA=67.3%, P<0.05).
SI-ROI ADC values inversely correlated to the presence of axillary metastases (P=0.008), and to vascular
invasion (P=0.003). There was no independent correlation between ADC values and tumor grade, estrogen,
progesterone, HER2 or Ki-67 expression.
CONCLUSION
Measuring ADC values from a small intratumoral ROI is clinically more accurate than using the whole tumor ROI
in assessment of breast tumors in 3.0T MRI and may help in tumor characterization.
CLINICAL RELEVANCE/APPLICATION
When evaluating breast tumor MRIs, ADC measurements should be targeted to most suspicious subregion
instead of the whole tumor.
VSBR21-09
Measurement of ADC Values in Malignant Breast Lesions and their Relation to Classical and
Molecular Prognostic Factors and Oncotype Dx
Manuela Durando (Presenter): Nothing to Disclose , Dilip Giri : Nothing to Disclose , Merlin Gnanasigamani
: Nothing to Disclose , Joseph Owen Deasy PhD : Nothing to Disclose , Elizabeth A. Morris MD : Nothing to
Disclose , Sunitha Thakur PhD, MS : Nothing to Disclose
PURPOSE
To measure apparent diffusion coefficient (ADC) values in malignant lesions and evaluate their relationship with
classical and molecular prognostic factors and Oncotype Dx scores.
METHOD AND MATERIALS
This HIPAA compliant retrospective study consisted 212 consecutive patients with known cancers who
underwent 3.0T MRI with DWI (b=0 and 600 s/mm2) between Jan' 2011and Jan' 2013. Lesions < 0.8 cm,
lesions undergoing neoadjuvant chemotherapy or suboptimal DW images were excluded. ADC was analyzed on
148 malignant lesions in 135 patients. A region of interest was drawn within each lesion on DW images,
avoiding any cystic/necrotic portion. Patient characteristics, classical histological prognostic factors (histologic
type, grade, size, and lymph node (LN) status), molecular factors (ER, PR, and HER2) and genetic factors
(BRCA, Oncotype DX scores) were reviewed and recorded. The relationships between ADC values and patient
characteristics and prognostic factors were analyzed. Statistical analysis was performed using Student's t-test
and ANOVA (statistical significance was established at p= 0.05). ADC values are measured in units of 10-3
mm2/s.
RESULTS
The mean ADC value of the 148 malignant lesions was 1.00±0.170. The ADC values in lesions were not
influenced by the BPE or breast density (respectively p=0.550 and p=0.967). The mean ADC values were
significantly lower for the invasive ductal carcinoma (p=0.015), mass enhancement (p<0.001), BRCA positive
lesions (p=0.032) compared to DCIS, invasive lobular carcinoma, non mass enhancement and BRCA negative
lesions. The mean ADC values tended to be lower in premenopause women, high grade, LN positive, triple
negative lesions (though not statistically significant). No statistical significant difference was observed in the
negative lesions (though not statistically significant). No statistical significant difference was observed in the
ADC values among the different subgroups in size (<2cm, 2-5cm, >5cm), and molecular prognostic factors (ER
positive, HER positive, TN). According to Oncotype Dx score (available for 27/41 ER positive tumors with
negative LN) ADC values were higher in low risk (0.106±0.207) than in intermediate risk tumors
(0.957±0.105), even if not statically significant different (p=0.100).
CONCLUSION
Our study shows that ADC may be a potential clinical adjunct in the evaluation of prognostic factors mostly in
relation to the malignant lesion aggressiveness.
CLINICAL RELEVANCE/APPLICATION
ADC may be a potential clinical adjunct in the evaluation of breast cancer prognostic factors.
VSBR21-10
Preoperative MRI Features and Patterns of Recurrence according to Breast Cancer Subtype in
Women Treated with Breast Conserving Therapy
Min Sun Bae MD, PhD (Presenter): Nothing to Disclose , Woo Kyung Moon : Nothing to Disclose , Nariya
Cho MD : Nothing to Disclose , Su Hyun Lee MD : Nothing to Disclose , Won Hwa Kim MD, PhD : Nothing
to Disclose , Sung Eun Song MD : Nothing to Disclose , A Jung Chu MD : Nothing to Disclose , Sung Ui
Shin MD : Nothing to Disclose
PURPOSE
To determine whether preoperative MRI findings differ according to breast cancer subtype and to examine the
relationship between the pattern of recurrence and breast cancer subtype in women treated with breast
conserving therapy (BCT).
METHOD AND MATERIALS
A total of 102 primary breast cancer patients (mean age, 45 years; range, 22-78 years) treated with BCT who
had preoperative breast MRI and locoregional recurrence after BCT between September 2003 and December
2012 were included in the study. Patients who underwent neoadjuvant chemotherapy or surgical excision prior
to MRI were excluded. Two breast imaging radiologists blinded to the clinicopathologic data assessed
fibroglandular tissue (FGT) and background parenchymal enhancement (BPE) on MRI using BI-RADS criteria.
Presence of multifocal/multicentric disease and lymph node involvement were evaluated. The pattern of
recurrence and detection method were examined. Breast cancer subtypes were defined as luminal (ER+ and
PR+), HER2+ (ER-, PR-, and HER2+), and triple-negative (TN; ER-, PR-, and HER2-). MRI and clinical features
were compared between the breast cancer subtypes.
RESULTS
The 102 cases were classified as 56 (55%) luminal, 17 (17%) HER2+, and 29 (28%) TN subtype. Women with
dense breasts were more likely to have luminal subtype compared to HER2+ or TN subtypes (95% vs (71%,
79%), p = 0.013). Multifocal/multicentric disease was more frequently detected by MRI in HER2+ subtype,
compared to luminal or TN subtypes (59% vs (20%, 21%), p = 0.002). Ipsilateral breast cancer recurrence was
more frequently observed in HER2+ subtype, compared to luminal or TN subtypes (88% vs (50%, 62%), p =
0.018). Compared to luminal subtype, HER2+ and TN subtypes were more likely to be associated with clinically
detected recurrence (11% vs (41%, 41%), p = 0.002). There were no significant differences in BPE and lymph
node involvement between subtypes.
CONCLUSION
Preoperative breast MRI is more likely to detect multifocal/multicentric disease in HER2+ breast cancer and FGT
on MRI is more likely to be associated with luminal breast cancer. Patients with HER2+ and TN breast cancers
more frequently have clinically detected recurrence.
CLINICAL RELEVANCE/APPLICATION
The use of preoperative breast MRI and the postoperative imaging follow-up strategy could be tailored
according to breast cancer subtype in women treated with BCT.
VSBR21-11
Diffusion-weighted Imaging Study of the Influence of Size and Position of the Region of Interest on
the Apparent Diffusion Coefficient Values of Breast Lesions and on Discriminating Benign from
Malignant
Mirjam Wielema : Nothing to Disclose , Monique D. Dorrius MD, PhD (Presenter): Nothing to Disclose ,
Hildebrand Dijkstra MSC : Nothing to Disclose , Paul E. Sijens : Nothing to Disclose , Matthijs Oudkerk
MD, PhD : Nothing to Disclose
PURPOSE
To determine the influence of the size and position of the ROI in Diffusion Weighted Images (DWI) of breast
lesions on the Apparent Diffusion Coefficient (ADC) values and on discriminating benign from malignant lesions.
METHOD AND MATERIALS
Sixty-four patients with 72 breast lesions (52 malignant and 20 benign) underwent breast DWI. ADCs were
calculated for b-value pairs: 0-1000, 0-800, 0-500, 0-200 and 0-50 s/mm2. In each lesion 4 oval regions of
interest (ROI) were drawn, ROI1- ROI4. ROI1 encompassed as much of the lesion as possible, while avoiding
surrounding tissue, ROI2 (0.5 cm2) was located in the middle of the lesion and ROI3 (0.5 cm2) and ROI4 (1.0
cm2) were selections within the lesion yielding the lowest ADC value. ROI3 and ROI4 were compared to
determine the influence of the size of the ROI. ROC analysis was used to quantify the diagnostic accuracy of the
ROI methods with the different b-value pairs Statistical significance was determined with an independent
sample t-test for malignant lesions and Mann-Whitney U test for all and benign lesions.
RESULTS
Lower b-value pairs generally showed higher ADC values in the lesions. Benign and malignant lesions
significantly differ for almost every b-value pair (p<0.001). There was a significant difference between ROI3
and ROI4 for malignant lesions (p=0.005) with a higher accuracy for ROI3 (0.943 versus 0.932), probably due
to reduced partial volume effect. The ADC outcomes of b-values 0-1000 and 0-800 s/mm2 met a higher
specificity than the lower b-value pairs, that is, up to 70-75% for ROI1 and ROI3 when choosing a sensitivity
and negative predictive value of 100%. The AUC was highest for ROI3 using b values 0-1000 and 0-800s/mm2
(0.965 and 0.964, respectively).
CONCLUSION
The size and the position of the ROI influenced the ADC values of benign and malignant breast lesions in DWI.
ROI3, a small volume selected for the lowest ADC within the lesion, had the highest accuracy in differentiating
benign from malignant lesions, with b-value pairs 0-1000 and 0-800 s/mm2.
CLINICAL RELEVANCE/APPLICATION
Different ROI methods influence the ADC in breast DWI, therefore a ROI (0.5 cm2) positioning at the lowest
ADC value within the lesion with b-value 0-1000 or 0-800s/mm2 is recommended.
VSBR21-12
Prediction of Breast Cancer Phenotypes Using Multiparametric MRI of the Breast with Dynamic
Contrast Enhancement and Diffusion Weighted Imaging at 3T
Riham H. El Khouli MD, PhD (Presenter): Nothing to Disclose , Katarzyna J. Macura MD, PhD : Nothing to
Disclose , Ihab R. Kamel MD, PhD : Nothing to Disclose , David A. Bluemke MD, PhD : Research support,
Siemens AG , Michael Anthony Jacobs PhD : Nothing to Disclose
PURPOSE
To assess the value of multiparametric breast MRI (including morphology, DCE MRI and DWI with Apparent
Diffusion Coefficient (ADC) mapping) at 3T in distinguishing among DCIS, Luminal A and B, HER2 positive, and
Triple Negative breast cancer phenotypes
METHOD AND MATERIALS
Our institutional review board approved the study. We included 219 patients with 234 lesions patients who
underwent bilateral breast MRI at 3T (mean age 53+11.5 year). Both high temporal (15 sec) DCE and high
spatial resolution (0.5 mm2 voxel size) MRI were acquired along with DWI with ADC mapping. Regions of
interest were drawn on the ADC maps of breast lesions and normal appearing glandular tissue (GT).
Morphologic features, DCE-MRI results (kinetic curve type), GT and lesion absolute and normalized ADC values
were included in multivariate models for prediction of breast cancer histological subtypes. Area under ROC curve
analysis was performed
RESULTS
Of 234 breast cancer lesions, 12% of were DCIS, 47% Luminal A, 22.2% Luminal B, 4.3% HER2 positive, and
14.5% triple negative. Lesion morphology (combining type of lesion with margin/distribution), Kinetic curve
type, time to peak enhancement, and both absolute and normalized ADC values were univariate predictors of
breast cancer phenotypes with an AUC 0.61-0.79. Combining lesion volume, morphology, kinetic curve type,
internal enhancement, and normalized ADC value showed the best accuracy in predicting estrogen receptor
expression, while combining lesion diameter, morphology and ADC value showed the best diagnostic accuracy
in predicting progesterone receptors expression, and combining lesion diameter, morphology, and normalized
ADC value showed the best accuracy in predicting the HER2 receptor expression. For the phenotypes
characterization, the multivariate diagnostic model combining lesion morphology, kinetic curve type, and
normalized ADC value showed the best diagnostic accuracy (AUC 0.83)
CONCLUSION
Multiparametric MRI including morphology, DCE and DWI can characterize breast cancer phenotypes with a very
good diagnostic accuracy (AUC =0.83) at 3T
CLINICAL RELEVANCE/APPLICATION
Breast cancer tumors with the same histological characteristic may carry different prognosis and response to
treatment due to the difference at the molecular level. In vivo identification of different breast cancer
phenotypes can improve our ability to detect more aggressive regions within the tumor and evaluate treatment
response
VSBR21-13
Improved Screening Methods
Christiane Katharina Kuhl MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) To list shortcomings of mammographic breast cancer screening. 2) To describe methods of
non-mammographic breast cancer screening. 3) To list possible advantages and disadvantages of
non-mammographic breast cancer screening.
VSBR21-14
Sensitivity of an Abridged Breast MRI Protocol to Detect Biologically Significant Breast Cancers
Laura Heacock MS, MD (Presenter): Nothing to Disclose , Amy Noel Melsaether MD : Nothing to Disclose ,
Kristine M. Pysarenko MD : Nothing to Disclose , Hildegard B. Toth MD : Nothing to Disclose , Linda Moy
MD : Nothing to Disclose
PURPOSE
Critics of breast MRI point to the high cost of the exam, the false-positive rates and the detection of indolent
breast cancers. A shorter MRI may be cheaper and still allow the detection of breast cancer. The purpose of our
study was to evaluate the ability of an MRI protocol with one post-contrast (and subtracted) sequence at 90
seconds to detect biologically significant cancers.
METHOD AND MATERIALS
An IRB approved retrospective review of 103 women with 180 findings who underwent a breast MRI at 3T was
performed by 2 readers. 90 women were newly diagnosed with breast cancer and 13 were asymptomatic
high-risk women. Prior to this study, each reader interpreted 228 abridged MRI exams. The scan time for the 3
T1-scans was 4 minutes; the scan time for the T2-sequence was 4 minutes. Final BIRADS assessment and
confidence score was assessed for each lesion. Comparison was made to the original diagnostic interpretation.
RESULTS
Of 125 cancers, 4 were foci, 86 were masses, 25 were NME and 10 were categorized in the original report as
both masses and NME. Seventy-nine were IDC, 10 were ILC, 23 were DCIS, and 13 were IDC and DCIS. The
mean size was 1.7 cm (range 0.4 - 8.6 cm). All 11 mammographically occult contralateral malignancies were
detected. Cancers with rim enhancement, spiculated margins or washout kinetics were identified with high
confidence by both readers. The sensitivity for reader 1 was 99.2% (CI 95.0-99.9%) and reader 2 was 96% (CI
90.4-98.5%). Of 6 missed cancers, one was IDC, one was ILC and 4 were DCIS. Both invasive cancers were
moderately differentiated and all DCIS were intermediate grade. Their mean size was 1.1 cm, range 0.4 - 2cm.
All 6 malignancies were seen on the 2nd post-contrast scan and they had Type 1 kinetics. Three were NME and
3 were masses. Eight of 55 (14.5%) MR biopsy proven benign lesions were not identified by each reader,
although 4 additional findings were identified by both readers.
CONCLUSION
An abridged breast MRI protocol yielded 98% sensitivity for invasive cancers, 83% sensitivity for DCIS and
increased specificity as compared with a routine breast MR exam. Total acquisition time is 7 minutes compared
to 35 minutes for the conventional exam.
CLINICAL RELEVANCE/APPLICATION
Almost all biological significant cancers are detected with an abridged MRI protocol.
VSBR21-15
Importance of MRI Monitoring of Patients with a History of Pre-menopausal Breast Cancer
Stamatia V. Destounis MD (Presenter): Investigator, FUJIFILM Holdings Corporation Investigator, Seno
Medical Instruments, Inc , Andrea Lynn Arieno BS : Nothing to Disclose , Renee Morgan RT : Nothing to
Disclose , Jennifer Gruttadauria : Nothing to Disclose
PURPOSE
To review patients undergoing high risk breast MRI due to personal history of pre-menopausal breast cancer and
to determine the incidence of additional cancers found.
METHOD AND MATERIALS
With Institutional Review Board approval and waiver of informed consent, a retrospective review was conducted
to determine patients diagnosed with pre-menopausal breast cancer undergoing screening high risk MRI. 296
High risk MRI exams were performed in 127 patients from 2003 to 2014. Data recorded included patient age
and breast density, lesion size on MRI (if applicable), type of biopsy procedure (if applicable), and pathology
results (if applicable).
results (if applicable).
RESULTS
Total number of MRI exams performed per patient ranged from 1 to 8. Average patient age at the time of first
cancer diagnosis was 40.6 years (range 19-48). 76% of patients had heterogeneously dense or extremely dense
breast tissue. Of 296 exams, there were 68 (23%) suspicious MRI findings. 47 needle biopsy procedures were
performed (69%); 3 did not have a biopsy and proceeded to surgery. MRI biopsy was performed in 30 and
ultrasound biopsy in 13. One stereotactic biopsy was performed and FNAC was performed in 3. The remaining
18 findings were determined to be benign by targeted ultrasound, were no longer visualized when MRI biopsy
was attempted or were followed and remained stable. Pathology revealed 15 malignancies (10 invasive and 5
non-invasive), 30 benign findings, and 5 atypical findings. Of those diagnosed with cancer, average time
between diagnoses was 6.6 years (range 3-16). Seven cancers were in the ipsilateral breast; 5 were of the
same pathology as the original malignancy and 2 were different. Eight new cancers were diagnosed in the
contralateral breast.
CONCLUSION
Screening MRI in patients with a personal history of pre-menopausal breast cancer detected a new suspicious
finding in 23% of exams. Of 127 patients screened, malignancy was detected in 15 (12%). The cancer
diagnoses were detected up to 16 years after initial diagnosis, which demonstrates the importance of
monitoring these patients.
CLINICAL RELEVANCE/APPLICATION
Monitoring women with a history of pre-menopausal breast cancer is important as these patients are at
increased risk of a second breast cancer diagnosis.
VSBR21-16
Investigate the Value of Multiple B-Value Diffusion-Weighted Imaging based on Intravoxel
Incoherent Motion (IVIM) in Differentiating Benign and Malignant Breast Lesions
Baoying Chen (Presenter): Nothing to Disclose , GUANGBIN CUI : Nothing to Disclose , Zhuo
Nothing to Disclose , linfeng yan : Nothing to Disclose , yuchuan hu : Nothing to Disclose
Xie :
PURPOSE
To show the diagnostic value of bi-exponential ADC based on IVIM with multiple b-value DWI in benign and
malignant breast lesions, in comparison to the conventional mono-exponential apparent diffusion coefficient
(ADC) with single b-factor DWI.
METHOD AND MATERIALS
32 patients diagnosed with 20 malignant and 15 benign breast lesions were enrolled in the study. Consent form
has been obtained prior to the study. Patients underwent DWI at 3.0T with single b-factor range (b=0, 1000
s/mm2) and multiple b-factor range (b=0, 25, 50, 75, 100, 300, 500, 800, 1000, 1200, 2000, 3000 s/mm2). 32
contralateral normal healthy glandular tissues from the same cohort were considered as control. ADC (b=0 and
1000 s/mm 2) and IVIM parameters (tissue diffusivity D, pseudo-diffusion coefficient D*, perfusion fraction f)
were calculated respectively based on mono-exponential and bi-exponential analysis. The data were compared
in between malignant, benign lesions and normal healthy glandular tissues. The diagnostic efficiency of these
parameters was evaluated by ROC curve and area under the ROC curve (AUC).
RESULTS
It was found out that ADC and D values of malignant group were significant lower than those of benign group
and control group (P<0.05). There were significant differences between benign and malignant group, benign
and control group, malignant and control group in value of f (P<0.01, P<0.05, P<0.01 respectively).
Importantly, the f value of malignant tumors was significantly higher than that of benign lesions especially in
the b-factor range of 0-800 s/mm2 (P = 0.000).D* value was not significantly different between benign and
malignant group in the b-factor range of 800-3000 s/mm2. The diagnostic sensitivity of D, ADC, f, D*
decreased progressively. D and ADC values showed higher specificity than f, D*. The combination of D and f
represented higher sensitivity and specificity.
CONCLUSION
Quantitative IVIM parameters provide separate information of fast and slow diffusion component by
bi-exponential decay model. They can be used in differential diagnosis of benign and malignant lesions.
CLINICAL RELEVANCE/APPLICATION
Multi-b-value DWI has been most simply performed, and IVIM can separately estimate tissue perfusion and
diffusivity. Although some questions are remained to be clarified, multi-b-value DWI and IVIM will certainly be
of great help for the diagnosis of breast lesions.
VSBR21-17
Three-dimensional Fused Images of Gadolinium Enhancement and Diffusion Restriction: Value in
Preoperative Determination of Multifocality, Multicentricity, and Bilaterality of Breast Carcinoma
Hanan Sherif MD (Presenter): Nothing to Disclose , Ahmed-Emad Mahfouz MD : Nothing to Disclose ,
Ahmed El Sayed Sayedin MBBCh : Nothing to Disclose , Aalaa Salaheldin Kambal MBBS : Nothing to
Disclose , Imaad Bin Mujeeb MD : Nothing to Disclose
PURPOSE
To evaluate 3-D fused gadolinium-enhanced and diffusion-weighted images in preoperative assessment of
multicentricity, multifocality, and bilaterality in patients with breast carcinoma
METHOD AND MATERIALS
72 patients with biopsy-proven breast carcinoma have been sent to MR imaging for preoperative assessment of
multicentricity, multifocality, and bilaterality. Based on mastectomy/ lumpectomy specimens, 47 patients had
single lesions. 12 multicentric , 10 multifocal, and 3 bilateral carcinoma with a total number of 116 proven
malignant foci. The preoperative MR images were post-processed on an advanced workstation to obtain 3D
fused images of the unenhanced breast parenchyma, early gadolinium enhancement (coded red), and
diffusion-weighted images with b=1500 s/mm2(coded green). To eliminate the T2-shine-through effect, lesions
with ADC ≥ 1× 10-3 mm 2 /s were eliminated. The post-processed images were reviewed by an experienced
radiologist, blinded to the histopathology, who noted all the lesions with a diameter ≥ 5 mm classifying them
into three groups: matched enhancement and diffusion restriction, unmatched diffusion restriction, and
unmatched enhancement.
RESULTS
313 Lesions with a diameter ≥ 5 mm have been identified. 101 lesions showed matched enhancement and
difusion restriction. Taking matched lesions as indicative of malignancy, the sensitivity, specificity, positive
predictive value, negative predictive value, and accuracy for diagnosis of malignant foci have been 84.5, 98.5,
97, 91, and 93.3 % respectively. Three false positive foci of matched E-DR were due to fibroadenomas. 18 false
negative foci have been due to foci of DCIS less than 1 cm in diameter. The method correctly identified all cases
of bilaterality and multifocality, Three patients with multicenteric malignancy were diagnosed as individual
lesion. Three patients with multicentricity were diagnosed as multifocal because of fibroadenomas. Three
patients were correctly classified as multicentric with underestimated number of foci.
CONCLUSION
Fused gadolinium-enhanced and diffusion-weighted MR images of the breast offer a reasonably accurate
assessment of bilaterality, multifocality, and multicentricity in patients with breast carcinoma.
CLINICAL RELEVANCE/APPLICATION
The technique may be useful in patients with breast carcinoma suspected to have multiple lesions. The 3D and
color coded images are easy to read and optimal to use by the surgeon for surgical planning.
VSCA21
Cardiac Series: Transcatheter Aortic Valve Replacement (TAVR)
Series Courses
IR CA IR CA
AMA PRA Category 1 Credits ™: 3.25
ARRT Category A+ Credits: 4.00
Mon, Dec 1 8:30 AM - 12:00 PM
Location: S404CD
Participants
Moderator
Suhny Abbara MD : Research Consultant, Radiology Consulting Group
Moderator
Robert M. Steiner MD : Consultant, Educational Symposia Consultant, Johnson & Johnson
Sub-Events
VSCA21-01
TAVR—The Interventionalist's Perspective
Stephan Achenbach MD (Presenter): Research Grant, Siemens AG Research Grant, Bayer AG Research Grant,
Abbott Laboratories Speaker, Guerbet SA Speaker, Siemens AG Speaker, Bayer AG Speaker, AstraZeneca PLC
Speaker, Berlin-Chemie AG Speaker, Abbott Laboratories Speaker, Edwards Lifesciences Corporation
LEARNING OBJECTIVES
1) To understand the typical Implantation techniques used in TAVI. 2) To learn the infomation that the
interventionalist requires from pre-procedural Imaging in order to optimize the Implantation procedure. 3) To
appreciate the relevance of pre-procedural imaging for prosthesis selection and outcome.
VSCA21-02
How to Optimize the Scan Acquisition for TAVR
Brian Burns Ghoshhajra MD (Presenter): Nothing to Disclose
VSCA21-03
Precision of CTA-based Aortic Annulus Area Measurements for Transcatheter Aortic Valve
Replacement (TAVR): Effects of Reader Experience and Implications for Appropriate Device Sizing
Scott K. Nagle MD, PhD (Presenter): Stockholder, General Electric Company Research Consultant, Vertex
Pharmaceuticals Incorporated , Sarah Sweetman : Nothing to Disclose , Carrie Bartels : Nothing to Disclose
, Giorgio Gimelli MD : Nothing to Disclose , Amish N. Raval MD, FRCPC : Nothing to Disclose ,
Christopher Jean-Pierre Francois MD : Research support, General Electric Company , Alejandro Munoz Del
Rio PhD : Research Consultant, Cellectar Biosciences, Inc Reviewer, Wolters Kluwer nv
PURPOSE
To determine the precision of CTA aortic annulus area measurements and the impact on TAVR device selection.
METHOD AND MATERIALS
This retrospective study included 86 consecutive clinical TAVR screening CTAs performed on a 64-slice scanner
(LightSpeed VCT, GE Healthcare) using retrospective ECG gating. A 1st year medical student (R1, after training
on 10 separate CTAs), a 3D lab technologist (R2, 3 yrs experience), and a cardiothoracic radiologist (R3, 6 yrs
experience) independently measured the aortic annulus in systole in a random, blinded fashion. The annular
plane, containing the hinge points of all 3 valve cusps, was located using multiplanar reformats (Vitrea, Vital
Images). The annular area was measured using a freely drawn contour. All measurements were repeated >2
weeks later to avoid recall bias. Bland-Altman analysis was used to assess each reader's repeatability. The
difference between the 95% limits of agreement and the bias was used to estimate the measurement precision.
To assess differences between readers, variance ratios (VR) were calculated along with their 95% confidence
intervals and compared with an F test. The impact on device sizing was evaluated using the Edwards SAPIEN
valve as an example. Annular size was grouped into 5 categories, based on the recommended device: too
small, 23mm, either, 26 mm, or too large. Percent agreement between the measurements was calculated for
each reader.
RESULTS
Bias between measurements was 6 [-1,13] (R1), -3 [-11,5] (R2), and 1 [-5,7] (R3) mm2. Precision was ±64
[52,76] (R1), ±70 [57,83] (R2), and ±55 [44,66] (R3) mm2. The difference in precision between R2 and R3
was statistically significant (VR: 1.60 [1.04,2.46], p=0.03). Device size recommendations from the 2
measurements differed in 23% (R1), 29% (R2), and 22% (R3) of the cases and differed by more than 1
category in 2% (R1), 4% (R2), and 1% (R3) of the cases.
CONCLUSION
Within reader annular area measurement imprecision results in different TAVR device size recommendations
~25% of the time, even for an experienced cardiovascular CTA reader. Reports should include estimated
measurement precision to aid in the interpretation of the results.
CLINICAL RELEVANCE/APPLICATION
Knowing the precision of CTA-based aortic annulus area measurements is very important for multidisciplinary
TAVR treatment planning. A single point estimate of the annular area may not be sufficient.
VSCA21-04
A Non-Contrast, Free-Breathing, Self-Navigated MR Technique for Aortic Root and Vascular Access
Route Assessment in the Context of Transcatheter Aortic Valve Replacement
Matthias Renker MD : Nothing to Disclose , Akos Varga-Szemes MD, PhD (Presenter): Nothing to Disclose
, Carlo Nicola de Cecco MD : Nothing to Disclose , Stefan Baumann MD : Nothing to Disclose , Edgar
Muller : Employee, Siemens AG , U. Joseph Schoepf MD : Research Grant, Bracco Group Research Grant,
Bayer AG Research Grant, General Electric Company Research Grant, Siemens AG , Davide Piccini : Employee,
Siemens AG , Wolfgang Rehwald : Employee, Siemens AG , Daniel H. Steinberg MD : Nothing to Disclose
PURPOSE
Because of the high comorbidity of TAVR candidates, a rapid, robust, non-contrast MR technique for assessing
the aortic root complex along with the entire vascular access route would be desirable for TAVR procedural
planning. We tested a newly developed non-contrast, free-breathing, self-navigated 3D (SN3D) MR sequence
for assessing the entire aorta, from the root to the ilio-femoral run-off. A non-contrast steady-state
free-precession (SSFP) sequence which has previously been shown to enable accurate aortic valve assessment
was used for comparison.
METHOD AND MATERIALS
We performed non-contrast MR angiography on a 1.5T system (Avanto, Siemens) using the novel SN3D and
the SSFP sequence in 6 healthy subjects. The SN3D sequence was applied to assess the aorta from its root to
the ilio-femoral arteries. The parameters for the SN3D acquisitions were: FOV 220/370mm, ST 1.15mm, IM
1922, slices 192, TR 265.2ms, TE 1.5ms, and FA 90°. Both the thoracic and abdominal acquisitions were ECG
gated. The parameters for the SSFP sequence were: FOV 340mm, ST 6mm, IM 1922, NS 15, reconstructed
phases 25, TR 39.7ms, TE 1.1ms, FA 77°, averages 3, acceleration factor 2. With SSFP only the thoracic
acquisitions were ECG gated. Systolic aortic root measurements and subjective image quality (5-point scale)
were compared. Vessel diameter and area measurements down to the level of the ilio-femoral arteries were
obtained from the SN3D dataset. Acquisition times were recorded.
RESULTS
The mean area-derived effective diameter in the aortic annular plane was comparable between SSFP and SN3D
(26.7±0.7mm vs. 26.1±0.9mm, P=0.23). Median image quality of the aortic valve was rated slightly (p=0.03)
higher with SSFP (4 - interquartile ranges, IQR; 4-4) than with SN3D (3 - IQR, 2-4). No significant differences
were observed between the diameter and area of the thoracic and abdominal aorta, and the ileo-femoral run-off
(p>0.05). The acquisition time of the SN3D sequence for the whole aorta was 12.1±2.7min.
CONCLUSION
These preliminary results in healthy volunteers suggest that the proposed SN3D acquisition technique enables
rapid, free-breathing assessment of the aortic root, the aorta and the ilio-femoral arteries without the
administration of contrast medium.
CLINICAL RELEVANCE/APPLICATION
The features of the proposed SN3D sequence appear well suited to address the requirements for TAVR
procedural planning in a population which frequently suffers from renal insufficiency and dyspnea.
procedural planning in a population which frequently suffers from renal insufficiency and dyspnea.
VSCA21-05
Size of Aortic Valve Calcium with Regard to Post-Procedural Aortic Regurgitation after Transcatheter
Aortic Valve Implantation with First- and Second-generation Transcatheter Heart Valves
Maxim Avanesov MD (Presenter): Nothing to Disclose , Moritz
Lunau : Nothing to Disclose
Seiffert : Nothing to Disclose , Clemens
PURPOSE
Aortic valve calcium is a predictor for aortic regurgitation (AR) after transcatheter aortic valve implantation
(TAVI) and is associated with adverse outcome. 2nd generation devices promise to reduce residual AR, so we
evaluated aortic valve calcium and post-procedual AR in 1st and 2nd generation transcatheter aortic valves as
well as among different 2nd generation devices.
METHOD AND MATERIALS
TAVI was performed using 1st and 2nd generation devices in 156 patients with severe aortic stenosis and high
surgical risk. Devices implanted were Edwards SapienXT(n=52), Medtronic CoreValve (n=33), Symetis
Acurate(n=25), JenaValve(n=20) and Medtronic Engager(n=26) valves. All patients received preoperative
contrast-enhanced CT scans with prospective ECG gating. 3D-reconstructions were performed by 3Mensio
software (3MensioMedical Imaging, Bilthoven).Calcium load was quantified within the device-landing area,
sub-divided into zone 1 (left coronary artery ostium to aortic annulus and zone 2 (aortic annulus to 10mm
below). A cutoff of 500HU was used to distinguish aortic calcium from intraluminal contrast agent. In another
group of 138 patients receiving 2nd generation devices only, aortic calcium was measured separately for each
leaflet and compared among all implanted devices with regard to residual AR.
RESULTS
The highest aortic valve calcium(zone1+2) among 1st generation devices was seen in patients with
CoreValve(3141±2232mm3) whereas the Engager valve reveiled the highest calcium loads among 2nd
generation valves(2396±1027mm3). Mean post-procedural AR was none/trace in 66% and greater trace in
34%, CoreValve showed the highest rate of AR greater trace with 59%. Only Engager valve had the highest
calcium score (896±445mm³), while AR rates weren't significantly different among other valve types.
Re-Dilatation rates increased with higher calcium load (p=0.01) while the number of pacemaker implantation
didn't alter significantly
CONCLUSION
TAVI using 1st and 2nd generation devices revealed good hemodynamic results, irrespective of annular
calcification. CoreValve was associated with highest rate of AR greater trace, while Engager valve, mostly used
in patients with higher calcium load, showed no difference in post-procedural AR.
CLINICAL RELEVANCE/APPLICATION
1st and 2nd generation TAVI devices are safe irrespective of aortic valve calcium. Only Engager valve reveiled
low residual AR despite significantly higher aortic valve calcium.
VSCA21-06
The Role of Imaging Prior to TAVR
Jonathon Avrom Leipsic MD (Presenter): Speakers Bureau, General Electric Company Speakers Bureau,
Edwards Lifesciences Corporation Consultant, Heartflow, Inc Consultant, Circle Cardiovascular Imaging Inc
LEARNING OBJECTIVES
1) Review the role of MDCT and TEE for annular sizing and device selection. 2) Discuss the role of
pre-procedural CT in identifying patients at risk of TAVR related complications such as coronary occlusion and
annular rupture. 3) Discuss the evolving role of MDCT to help guide transcatheter valve in valve procedures.
VSCA21-07
MDCT for Cardiac Intervention Planning—Beyond TAVR
Pal
Maurovich-Horvat MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
Cardiac CT is able to evaluate coronary artery disease with high diagnostic accuracy and provide comprehensive
information regarding structural heart disease. Due to its ability to reconstruct 3-dimensional images with
submilimeter isotropic resolution, cardiac CT is a uniquely suited tool for planning and appropriate selection of
coronary and non-coronary interventional procedures. The detailed characterisation of coronary geometry and
plaque morphology might improve the evaluation of bifurcation lesions and provide important information
regarding selection of CTO PCI technique. The application of computational fluid dynamic simulation in CT
datasets provides novel avenues in PCI planning through virtual stenting and post-stenting CT-derived
computed fractional flow reserve (FFRCT) assessment. Other structural heart interventions might benefit from
CT planning, like the evaluation of left atrial appendage, paravalvular leak and atrial or ventricular septal
defects in patients candidate for closure devices.
VSCA21-08
320-row CT Transcatheter Aortic Valve Implantation Planning Using a Single Reduced Contrast
Media Bolus Injection: A Prospective Study on 50 Patients
Mickael Ohana MD, MSc (Presenter): Nothing to Disclose , Aissam Labani MD : Nothing to Disclose ,
Soraya El Ghannudi-Abdo MD : Nothing to Disclose , Mi-Young Jeung MD : Nothing to Disclose , Karim
Haioun : Employe, Toshiba Corporation , Patrick Ohlmann MD, PhD : Nothing to Disclose , Catherine Roy
MD : Nothing to Disclose
PURPOSE
Reduce the iodine load required for CT TAVI planning by acquiring the ECG-gated aortic root volume and the
non-gated aortoiliac scan within the same single contrast media bolus injection.
METHOD AND MATERIALS
50 patients (60% women, 83yo ±7) were prospectively included and underwent TAVI planning with a
second-generation 320-row CT scanner. The aortic root was acquired in volume mode using retrospective
ECG-gating (100kV, 0.275s rotation time, 2 beats maximum) and immediately followed by a non-gated CAP
aortic ultra-fast helical acquisition (100kV, 0.275s rotation time, pitch=0.813), all within a single bolus of 40 to
70mL of Iohexol 350mgI/mL. Image quality of both cardiac and aortic acquisitions was independently assessed
by two radiologists on a qualitative five-point scale, and HU enhancement measured in the aorta and the iliac
arteries to calculate the signal to noise (SNR) and contrast to noise ratios (CNR). These qualitative and
quantitative results were compared to 24 procedures (62% women, 84yo ±5) previously performed on a
64-row scanner with a conventional two-step protocol using two contrast media boluses. Qualitative results
were analyzed by a Kruskal-Wallis nonparametric test and quantitative data were compared using a
Mann-Whitney test. A p<0.05 was considered significant.
RESULTS
Mean iodine load was commonsensically significantly lower in the 320-row group (23.1g±3.6 vs 43.2g ±8,
p<0.01). Image quality of the ECG-gated aortic root and the CAP aorta were equivalent (respectively 4.9 and
4.7 vs 4.4 and 4.9, p>0.05). Mean HU enhancement was similar (388 vs 400, p=0.4) while mean noise was
significantly lower (24.5 vs 28.5, p<0.01), leading to a slightly improved SNR and CNR (16.3 and 13.9 vs 14.7
and 12.5, p=0.34 and 0.57). Radiation dose was significantly lower for both the ECG-gated acquisition
(547mGy.cm vs 800, p<0.01) and the whole-body aortic scan (487mGy.cm vs 785, p<0.01).
CONCLUSION
Second-generation 320-row CT scanner enables a 47% reduction of the iodine load in TAVI planning, by
subsequently acquiring the ECG-gated aortic root and the CAP aorta within a single contrast media bolus
injection, while maintaining excellent aortoiliac arterial enhancement and lowering radiation dose.
CLINICAL RELEVANCE/APPLICATION
TAVI planning with subsequent acquisition of the ECG-gated aortic root and the non-gated whole-body aorta is
possible within a single contrast media injection when using a 320-row CT.
VSCA21-09
In Vivo Assessment of Aortic Root Geometry in Normal Controls Using 3-Dimensional Analysis of
Computed Tomography
Dong Hyun Yang MD (Presenter): Nothing to Disclose , Joon-Won Kang MD : Nothing to Disclose ,
Namkug Kim PhD : Stockholder, Coreline Soft, Inc , Jae-Kwan Song MD, PhD : Nothing to Disclose ,
Tae-Hwan Lim MD, PhD : Nothing to Disclose
PURPOSE
In vivo geometric analysis of the normal human aortic root is lacking. The aim of this study was to obtain the
comprehensive geometric data of the normal aortic root using computed tomography (CT).
METHOD AND MATERIALS
One hundred thirty subjects who underwent cardiac CT for atypical chest pain or health check-up were enrolled.
Subjects without hypertension, diabetes, significant coronary artery disease, and cardiac valvular dysfunction
were included (mean age, 51.4 years; 55 men; number of subjects in each decade - third 15, forth 20, fifth 30,
sixth 21, seventh 23, and eighth 21). Mid-diastolic phase of CT images were analyzed using customized
software (Omni4D). Individual volume of the aortic sinus and leaflet surface areas (LSA) of the right, left and
non-coronary cusps were measured. Intercommissural (IC) distance in each aortic sinus was also investigated.
All measured parameters were indexed to body surface area.
RESULTS
The left coronary sinus showed significantly smaller geometric parameters including sinus volume, LSA, and IC
distance than the other two sinuses (left/non-coronary/right: sinus volume [ml/m2] 1.54/1.95/2.08; LSA
[cm2/m2] 2.56/3.03/3.03; IC distance [cm/m2] 1.84/1.94/2.23; p <0.001). Between the right- and
non-coronary sinuses, there were no significant differences other than IC distance. In the older decade of age,
the volume and IC distance of all coronary sinuses showed an increasing tendency on the test for trend (p <
0.05). However, no significant difference was found in the LSA and annular area with age.
CONCLUSION
Detailed analysis of aortic root geometry reveals normal asymmetry in the aortic sinus and leaflet surface area.
The size of left coronary sinus was smaller than the other two sinuses. The size of aortic sinus showed increasing
tendency in older age group, however LSA did not changed with age.
CLINICAL RELEVANCE/APPLICATION
Knowledge of the normal aortic root anatomy is relevant to understand the pathophysiology of the aortic
regurgitation and to improve the method of surgical aortic root reconstruction.
VSCA21-10
Morphology of Left Ventricular Outflow from the Left Ventricular Outflow Tract to the Sinotubular
Junction: Comparison of Patients with Normal Aortic Valves to Those with Severe Aortic Stenosis
Gilda Boroumand MD (Presenter): Nothing to Disclose , Hugh White MD : Nothing to Disclose , Praneil
Patel MD : Nothing to Disclose , Ethan J. Halpern MD : Nothing to Disclose
PURPOSE
The shape of the left ventricular outflow tract (LVOT), aortic annulus and aortic root may impact the proper
sizing of a percutaneous aortic valve replacement (TAVR). We evaluated the sphericity of left ventricular outflow
with ECG-gated coronary CTA from the LVOT through the sinotubular junction in both diastole and systole.
METHOD AND MATERIALS
ECG-gated CTA studies were reviewed from 52 consecutive patients with normal aortic valves and 13 TAVR
candidates with severe aortic stenosis and dense valvular calcification. Using a dedicated 3D workstation,
orthogonal measurements of the outflow tract were obtained to define the antero-posterior (AP) and transverse
diameters (short and long axis) at 4 levels: LVOT, aortic annulus, aortic root and sinotubular junction.
Sphericity was defined as the ratio of the AP to transverse diameter at each level.
RESULTS
Analysis of variance demonstrated that both the level of the measurement and the phase of the cardiac cycle
were significantly associated with sphericity (p<0.0001), while the presence of aortic stenosis was
non-significant (p=0.96). Mean sphericity during diastole measured 0.61 at the LVOT, 0.77 at the aortic
annulus, 0.94 at the aortic root and 1.00 at the sinutubular junction (p<0.0001 for comparison of any two
adjacent levels). During systole, mean sphericity measured 0.69 at the LVOT, 0.81 at the aortic annulus, 0.93
at the aortic root and 1.00 at the sinutubular junction (p<0.0001 for comparison of any two adjacent levels).
Differences in sphericity between diastole and systole were significant at the LVOT (p<0.0001) and at the aortic
annulus (p=0.0061).
CONCLUSION
The shape of the left ventricular outflow changes from an oval at the level of the LVOT to a more circular shape
at the level of the sinotubular junction. Although the entire outflow tract changes in size and sphericity during
the cardiac cycle, this change is most pronounced at the LVOT, and is statistically significant only at the LVOT
and aortic annulus levels. The sphericity of left ventricular outflow structures and the change in sphericity
during the cardiac cycle is similar among patients with a normal aortic valve and those with severe aortic stenosis.
CLINICAL RELEVANCE/APPLICATION
The oval shape of the proximal left ventricular outflow is not altered by the presence of aortic stenosis and
calcification. This shape may have important implications for the design and positioning of aortic valve implants.
VSCA21-11
CT for Planning Transcatheter Aortic Valve Replacement: Accuracy for Diagnosing Obstructive
Coronary Artery Disease
Richard Bayer (Presenter): Nothing to Disclose , Brett S. Harris PhD : Nothing to Disclose , Felix G. Meinel
MD : Nothing to Disclose , Daniel H. Steinberg MD : Nothing to Disclose , Carlo Nicola de Cecco MD :
Nothing to Disclose , U. Joseph Schoepf MD : Research Grant, Bracco Group Research Grant, Bayer AG
Research Grant, General Electric Company Research Grant, Siemens AG , Aleksander Krazinski : Nothing to
Disclose , Kevin Dyer : Nothing to Disclose , Monique Sandhu : Nothing to Disclose , Michael R. Zile MD :
Nothing to Disclose
PURPOSE
Patients referred for transcatheter aortic valve replacement (TAVR) typically undergo a CT study of the heart,
aortic root and vascular access route for pre-interventional planning. In this study we evaluated the accuracy of
cardiac CT, performed for TAVR planning purposes for diagnosing obstructive coronary artery disease (CAD)
using coronary catheter angiography (CCA) as the reference standard.
METHOD AND MATERIALS
With institutional review board approval, waiver of informed consent and in HIPAA compliance we
retrospectively analyzed the data of 100 consecutive TAVR candidates (61 male, mean age 79.6±9.9 years) who
underwent both TAVR planning CT and CCA. The presence and degree of coronary artery stenosis was assessed
at both modalities. Additionally, in patients with coronary bypass grafts these were rated as either patent or
occluded. Using CCA as the reference standard, we calculated the accuracy of CT for lesion detection on a
per-vessel and per-patient basis. We further analyzed the accuracy of CT for the assessment of graft patency.
RESULTS
Our data show that in a per-vessel/per patient analysis, CT had 94.4/98.6% sensitivity and 68.4/55.6%
specificity for the detection of >50% stenosis in the native coronary arteries. Negative and positive predictive
values were 94.7/93.8% and 67.0/85.7%, respectively. On CT, the per-patient sensitivity for >70% stenosis
was found to be 100.0%. Furthermore, all 12 vessels on which percutaneous coronary intervention was
performed were correctly identified on CT as demonstrating >50% stenosis. Finally, there was good agreement
between CT and CCA regarding graft patency in 114/115 grafts identified on CCA.
CONCLUSION
Our study indicates that TAVR planning CT does indeed have high sensitivity and negative predictive value in
excluding obstructive CAD. For prospective TAVR candidates this would suggest that an additional
pre-procedural CCA study may not be required in those patients with a CT negative for obstructive CAD.
CLINICAL RELEVANCE/APPLICATION
Our analysis suggests a new management algorithm that would benefit the rising numbers of TAVR candidates
with increases in cost effectiveness and improvements in patient safety.
VSER21
Emergency Radiology Series: Evidence-based Imaging in Emergency Radiology—What Is the
Evidence?
Series Courses
ER
AMA PRA Category 1 Credits ™: 3.50
ARRT Category A+ Credits: 4.00
Mon, Dec 1 8:30 AM - 12:00 PM
Location: N230AB
Participants
Moderator
Michael Nathan Patlas MD, FRCPC : Nothing to Disclose
Moderator
Jamlik-Omari Johnson MD : Nothing to Disclose
Moderator
Aaron D. Sodickson MD, PhD : Research Grant, Siemens AG
Sub-Events
VSER21-01
Imaging of Pediatric Head Injury
L. Santiago
Medina MD, MPH (Presenter): Editor, Springer Science+Business Media Deutschland GmbH
LEARNING OBJECTIVES
1) Have a clear understanding of the newer clinical criteria for imaging in pediatric head trauma based on the
more recent large multicenter studies. 2) Optimization of the imaging protocols to enhancing the diagnostic
performance. 3) The importance of integrating the pretest probability (clinical criteria) and the diagnostic test in
order to have the highest posttest probability (probability after the imaging study).
VSER21-02
Fast Spin-Echo Inversion-Recovery (FSE-IR) Detects Cervical Ligamentous Injury in Non Accidental
Trauma
Karyn Alayne Ledbetter MD (Presenter): Nothing to Disclose , Michael Eric Stone MD : Nothing to Disclose ,
Sheena Saleem MD, MBBS : Nothing to Disclose , Deniz Altinok MD : Nothing to Disclose
PURPOSE
Although magnetic resonance imaging is routinely utilized in cases of suspected non accidental head trauma,
little data exists regarding the use of imaging to evaluate for associated cervical spinal ligamentous injury.
Furthermore, the association between ligamentous cervical injury and intracranial abnormalities on MRI has not
been documented. Through retrospective review of MRI brain examinations, we aim to establish the value of fast
spin-echo inversion-recovery (FSE-IR) in assessing for cervical spinal ligamentous injury in cases of suspected
abusive head trauma.
METHOD AND MATERIALS
MRI brain examinations performed in all cases of suspected non accidental head trauma between 2010 and
2013 were retrospectively reviewed. First, the fast spin-echo inversion-recovery (FSE-IR) sequence was
examinated on each study to evaluate for hyperintense signal in the apical, anterior longitudinal, posterior
longitudinal and interspinous ligaments. Subsequently, each positive study was evaluated for abnormal signal
intensity on diffusion-weighted imaging, susceptibility-weighted imaging and on T2*.
RESULTS
A total of 60 patients with non accidental head trauma received MRI brain examinations in our institution
between January 2010 and December 2013. Of these patients, 17 (29%) were found to have ligamentous
injury on FSE-IR. Additional findings of severe trauma were also present on other MR sequences in all patients.
Hypoxic ischemic injury, detected on diffusion-weighted imaging, was present in 10 patients (59%). Retinal
hemorrhages, seen on the T2* sequence, were identified in 8 patients (47%) with concomitant ligamentous
injury. Cortical venous thrombosis, detected on either susceptibility-weighted imaging or T2*, was present in 16
patients (94%).
CONCLUSION
The fast spin-echo inversion-recovery (FSE- IR) sequence detects cervical ligamentous injury in patients with
non accidental head trauma and is associated with significant intracranial injuries including hypoxic-ischemic
injury, thrombosed cortical veins and retinal hemorrhages. FSE-IR should be performed routinely in all cases of
suspected abusive head trauma.
CLINICAL RELEVANCE/APPLICATION
Fast spin-echo inversion-recovery detects ligamentous cervical spinal injury and should be routinely used
whenever non accidental trauma is suspected.
VSER21-03
Facial Fracture in the Setting of Whole Body Computed Tomography for Trauma: Incidence and
Clinical Predictors
Ryan Whitesell MD (Presenter): Nothing to Disclose , Scott David Steenburg MD : Nothing to Disclose ,
Changyu Shen PhD : Nothing to Disclose , Hongbo Lin MS : Nothing to Disclose
PURPOSE
To identify the incidence and clinical predictors of facial fracture in the setting of whole-body multi-detector
computed tomography (MDCT) for trauma.
METHOD AND MATERIALS
500 consecutive patients who received dedicated maxillofacial CT as part of whole-body MDCT for trauma were
studied. Patients younger than 18 and those who received initial evaluation at an outside facility were excluded.
Fracture incidence and clinical parameters were obtained from the electronic medical record. Clinical and
demographic variables were compared between patients who had an acute fracture and those who did not. Two
sample t-tests were used to compare continuous variables, and the Fisher's exact tests were used to compare
categorical variables.
RESULTS
A total of 221 (44.2%) patients had acute fracture demonstrated on the maxillofacial CT. In all, 470 (94.0%)
patients had documented positive facial physical exam findings at presentation. Of the 30 patients without
exam findings, 29 (negative predictive value = 96.7%) did not have a facial fracture. Orbital fractures were
most common overall, seen in 52.5% of positive cases. Nasal fractures were the most common isolated fracture
(18.6% of all fractures; 42.3% of isolated fractures). Statistically significant difference was found between
positive and negative cases of facial fracture in GCS score ≤ 8 (p <0.0001), intubated at presentation
(p<0.0001), Injury Severity Score (ISS) of ≥ 16 (p<0.0001), positive facial physical exam (p<0.0001), and loss
of consciousness (p = 0.0299). By history, the highest fracture rates were seen in falls from elevation or
standing height and open-vehicle accidents (80.0%, 58.9%, and 55.2%, respectively).
CONCLUSION
The absence of physical exam findings reliably excludes facial fractures. Clinical variables that positively
associate with facial fracture include: GCS ≤ 8, ISS ≥ 16, intubated status, positive loss of consciousness, and
presence of facial physical exam findings.
CLINICAL RELEVANCE/APPLICATION
These data can support clinical decision-making by identifying those at greatest risk for facial fracture and
those who are less likely to have a fracture based on the initial clinical survey.
VSER21-04
Imaging of Cervical Spine Injury
C. Craig
Blackmore MD,MPH (Presenter): Royalties, Springer Science+Business Media Deutschland GmbH
LEARNING OBJECTIVES
1) Understand the evidence for best practices in cervical spine imaging of trauma. 2) Develop an evidence
based approach to selection of appropriate imaging in cervical spine trauma.
ABSTRACT
There is abundant evidence on when it is appropriate to image the cervical spine in trauma victims, and with
which imaging modality. However, controversies persist. This session will focus on the evidence supporting the
roles of CT, MRI, and radiography in cervical spine imaging. We will discuss special populations, including
children, the elderly, obtunded patients, patients with neurological deficits, and patients with spinal fusion.
Included will be a discussion of accuracy of imaging, cost effectiveness analysis, and use of clinical prediction
rules to risk-stratify subjects.
VSER21-05
Utility of CTA in Patients with Isolated Dens Fractures
Vicky Thi Nguyen MD (Presenter): Nothing to Disclose , Gabriel C. Fine MD : Nothing to Disclose ,
Kathleen R. Tozer Fink MD : Nothing to Disclose , Michael L. Richardson MD : Nothing to Disclose ,
Annemarie Relyea-Chew : Nothing to Disclose , Martin Lee David Gunn MBChB : Medical Advisor,
TransformativeMed, Inc Spouse, Consultant, Wolters Kluwer nv Grant, Koninklijke Philips NV
PURPOSE
Blunt carotid and vertebral artery injuries (BCVI) can cause devastating ischemic neurologic events. The Denver
criteria are often used to guide BCVI screening and include all patients with C2 fractures (fxs). We hypothesize
that patients with ground level falls (GLF) and isolated dens fxs (IDF) have a very low risk of BCVI and do not
require vascular imaging.
METHOD AND MATERIALS
All patients with C2 fxs in the hospital trauma registry from 2006-2012 were retrospectively reviewed. Age, sex,
injury mechanism (GLF or non-GLF, a higher risk mechanism), C2 fracture type (IDF or other C2 fracture
(OthC2F)), vascular imaging type, and Biffl injury grade were evaluated.
RESULTS
Of 789 subjects with C2 fxs, 176 (22%) had IDF and 613 (78%) had OthC2F. 538 of 789 (68%) subjects
underwent vascular imaging, and 141 (26%) had BCVI. 76 of 176 (43%) patients with IDF underwent vascular
imaging and 6 (8%) had BCVI. Of the 31 subjects with type 1 or 2 IDF and vascular imaging, 1 (3%) had BCVI
compared to 5/45 (11%) with type 3 IDF. Of the 462 patients with OthC2F and vascular imaging, 135 (29%)
had BCVI. There was a significantly decreased prevalence of BCVI in IDF compared to OthC2F (p<0.001). In 31
patients with IDF after GLF who had vascular imaging, only 1 (3%) patient with a type 3 IDF had a BCVI,
compared to 35/144 (24%) with OthC2F. Compared to patients with OthC2F and non-GLF, there was an odds
ratio of 0.11 for vascular injury in patients with IDF and GLF. There was a significantly decreased risk of BCVI in
patients with IDF (p=0.0002) and GLF (p=0.02) compared to patients with OthC2F and non-GLF.
CONCLUSION
In patients with vascular imaging, only 8% with IDF had BCVI compared to 29% of those with OthC2F. The
rate of BCVI in IDF sustained after GLF is low (1/31), and no patients with type 2 IDF after GLF had BCVI. Thus,
these patients may not require routine screening, suggesting the need for further evaluation of the Denver
criteria to decrease unnecessary imaging utilization. The rate of BCVI in OthC2F is higher (24-29%) and these
patients should be screened regardless of injury mechanism.
CLINICAL RELEVANCE/APPLICATION
Patients with type 2 isolated dens fractures resulting from ground level falls may not require screening for BCVI.
Patients with other C2 fractures regardless of mechanism should be screened.
VSER21-06
Patients with Acute Pancreatitis and Suspected Pancreatic Necrosis: When to Perform Computed
Tomography?
Murat Karul MD (Presenter): Nothing to Disclose , Maxim Avanesov MD : Nothing to Disclose , Thomas
Kraus : Nothing to Disclose , Thorsten Derlin : Nothing to Disclose , Gerhard B. Adam MD : Nothing to
Disclose , Jin Yamamura MD : Nothing to Disclose
PURPOSE
To assess the value of multidetector computed tomography (MDCT) in patients with acute pancreatitis and
suspected pancreatic necrosis with regard to both lab tests (C-reactive protein, lipase, creatinine) and
histopathology.
METHOD AND MATERIALS
102 consecutive patients with acute pancreatitis and suspected pancreatic necrosis underwent
contrast-enhanced MDCT. Two blinded readers assigned patients into one of three groups (GR). Patients in GR1
showed edematous organ swelling, peripancreatic fluid collection, and pseudocysts; patients in GR2 showed
necrotic collection and a lack of pancreatic parenchymal contrast-enhancement; and patients in GR3 had no
evidence of pancreatitis. Findings were correlated with results from pancreatic surgery and guided fine-needle
aspiration (FNA). Mann-Whitney's U test was used to evaluate significant differences in lab findings between the
groups. Cut-off values were calculated using ROC curve analysis.
RESULTS
Using MDCT, 54/102 patients (52.9%) were classified as GR1, 17/102 patients (16.7%) as GR2, and 31/102
patients (30.4%) as GR3. 13/17 patients (76.5%) in GR2 underwent either surgery (n=6, 46.2%) or FNA (n=7,
53.8%) and pancreatic necrosis was confirmed histopathologically in all of them. Statistical analysis showed
significant CRP differences between GR2 vs. GR3 (p=0.001; cut-off point: 82mg/L; AUC 0.76) as well as
between GR1 vs. GR3 (p<0.001; cut-off point: 98mg/L; AUC 0.84). The comparison between GR2 vs. GR3 and
GR1 vs. GR3 revealed no significantly different lipase (p=0.35; AUC 0.58/p=0.85; AUC 0.52) or creatinine
levels (p=0.96; AUC 0.5/p=0.24; AUC 0.6).
CONCLUSION
In patients with acute pancreatitis, MDCT may help when CRP values are highly elevated to rule out
complications such as pancreatic necrosis. In contrast, lipase and creatinine are poor predictors.
CLINICAL RELEVANCE/APPLICATION
Patients with clinically suspected pancreatic necrosis and mild to moderate elevated lab parameters could be
saved from unnecessary MDCT examinations.
VSER21-08
Imaging of Pulmonary Embolus
Sanjeev
Bhalla MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Review the evidence behind the use of CTA for acute pulmonary embolism (PE) 2) Discuss the concept of
overdiagnosis 3) Review ACR appropriateness criteria for the disgnosis of PE
VSER21-09
Does Better MDCT Technology Lead to an Increase of Clinically Irrelevant Diagnoses of Solitary
Subsegmental Pulmonary Embolism in the Emergency Department?
Stefan Puig MD, MSc (Presenter): Nothing to Disclose , Rebekka Voegeli : Nothing to Disclose ,
Carmen Andrea Pfortmueller : Nothing to Disclose , Jennifer L.C. Cullmann : Nothing to Disclose ,
Johannes T. Heverhagen MD, PhD : Speaker, Bracco Group , Gregor Lindner MD : Nothing to Disclose
PURPOSE
Pulmonary embolism (PE) is a relative common, potentially fatal disease which remains a challenge in the daily
clinical practice. Computed tomography pulmonary angiography (CTAP) has become the gold-standard
non-invasive test in patients with suspected PE. Several studies have shown that due to the introduction of
Multi-detectors-Computed-Tomography (MDCT) the sensitivity of CTAP increased significantly compared to
single-detector-CT without changing the PE mortality rate. In July 2012, the MDCT-scanner in our ED was
changed from a 16-row to a 128-row single source MDCT scanner. The aim of this retrospective study was to
evaluate if the number of diagnoses of possibly clinically irrelevant solitary subsegmental PE (SPE) has
increased after changing from a 16-row to a 128-row-MDCT-scanner.
METHOD AND MATERIALS
We included all CT-scans requested by the ED between January 1st, 2005 and December 31st, 2013. All scans
before July 16th, 2012 were performed with 16-row-MDCT-scanner (Siemens Somatom Sensation 16), and
thereafter, with a 128-row-MDCT- scanner (Siemens Somatom Edge). All examinations were performed with
standard protocols for pulmonary embolism, triple-rule-out or poly-trauma.
RESULTS
3,533 examinations were included in this retrospective analysis, 2,661 with the 16-row (mean age: 49.2 years;
male: 56.4%) and 872 with the 128-row scanner (mean age: 60.7 years; male: 60.2%). There were no
significant differences in the number of PE or SPE diagnoses before and after change of the scanner. PE was
diagnosed in 388/2,661 cases (14,6%) with the 16-row-scanner and in 118/872 cases (13,5%) with the
128-row-scanner (p=.44), SPE was diagnosed in 69/2,261 (2,6%) and in 24/872 cases (2.8%), respectively
(p=.80).
CONCLUSION
Changing from a 16-row- to a 128-rowMDCT-scanner will not increase the number of possibly clinically
irrelevant SPE and, therefore no further increase in unnecessary thrombolytic therapies based on radiological
diagnoses has to be expected.
CLINICAL RELEVANCE/APPLICATION
Although the detection rate of possibly clinically irrelevant SPE increased significantly after the introduction of
MDCT compared to single-detector-CT, it seems that there is no further increase in the detection rate changing
from an 16-row- to a 128-row scanner.
VSER21-10
Implications of Increasing the D-Dimer Threshold in Patients with a Lower Pretest Probability to
Exclude Pulmonary Embolism prior to CT Pulmonary Angiography
Daniel Matheson Adams MD (Presenter): Nothing to Disclose , Scott Stevens MD : Researcher, Iverson
Genetic Diagnostics, Inc , Scott Woller MD : Nothing to Disclose , Joseph Bledsoe MD : Nothing to Disclose
, Todd Delton Lovelace MD : Nothing to Disclose , Scott Evans PhD : Nothing to Disclose , Jim Lloyd BS :
Nothing to Disclose , Valerie Aston RT : Nothing to Disclose , C. Gregory Elliott MD : Nothing to Disclose
PURPOSE
Compared to original trials which derived pre-test probability systems for suspected pulmonary embolism (PE),
the prevalence of PE at each given level of pre-test probability has decreased. Consequently, higher values of
d-dimer may safely exclude PE in suspected cases. We therefore examined the implications of increasing the
d-dimer threshold for patients with decreasing clinical pretest probability.
METHOD AND MATERIALS
Consecutive CT pulmonary angiography (CTPA) exams performed for suspected PE over a 14 month period
were retrospectively identified and final interpretations were recorded. Data to calculate the Revised Geneva
Score (RGS) for each encounter were extracted from the electronic medical record by electronic means and
manual review, and d-dimer values were collected. All patient encounters for which pretest probability was
calculated as low (RGS 0-3) or intermediate (RGS 4-10) and for which d-dimer testing was performed were
included in the study. The prevalence of PE for low and intermediate probability patients with d-dimer values
below adjusted thresholds was then determined.
RESULTS
Of 3500 CTPA exams performed, 1745 involved encounters for patients with low or intermediate probability and
d-dimer testing performed. The remainder included 167 with high probability, and 1588 with low to
intermediate probability and no d-dimer testing performed. Intermediate probability patients had a slightly
higher mean age (53.2 vs. 50.1 years, p=0.001), but there was no significant difference in the prevalence of PE
for low and intermediate probability patients at d-dimer levels below 1000 (3.7% vs. 2.5%, p=0.29). For both
groups combined, prevalence of PE remained below 2% with a threshold of 700 (1.8%, 95% CI 1.1-3.1%),
which accounted for 41% of the CTPA exams.
CONCLUSION
Prevalence of PE is not significantly different between patients with low and intermediate pretest probability at
d-dimer levels below 1000. Prevalence of PE remains below 2% for all low and intermediate probability patients
below 700, and 41% of the CTPA exams could be avoided if this level was used to exclude PE. Prospective
management studies to select the optimal adjustment of d-dimer are necessary before clinical implementation
may occur.
CLINICAL RELEVANCE/APPLICATION
CTPA utilization could be substantially reduced if d-dimer thresholds were increased for exclusion of PE for
patients with both low and intermediate pretest probability.
VSER21-11
Is Oral Contrast Necessary for MDCT of Emergency Room Patients with Acute Abdominal Pain?
Abdullah Alabousi MD (Presenter): Nothing to Disclose , Douglas S. Katz MD : Nothing to Disclose , Niv
Sne MD : Nothing to Disclose , Michael Nathan Patlas MD, FRCPC : Nothing to Disclose
PURPOSE
The purpose of the study was to validate the hypothesis that discontinuing the use of oral contrast (OC) for
MDCT will not affect the detection of acute abdominal abnormalities in emergency room (ER) patients.
METHOD AND MATERIALS
We conducted a retrospective study to assess the effect of eliminating OC use for 64MDCT scans of the
abdomen and pelvis (AP) for patients presenting with acute abdominal pain to ER and BMI greater than 25.
Patients with BMI less than 25 continued to receive OC. Only patients who underwent AP 64MDCT imaging in
the portal venous phase without OC were included. The study was approved by the REB. Informed consent was
waived. The electronic medical records were reviewed to determine the rate of repeat imaging within seven
days from initial CT scan, as well as delayed or missed diagnoses related to the lack of OC.
RESULTS
1378 patients had an AP 64MDCT between November 1, 2012 and October 31, 2013. 375 patients met the
inclusion criteria (174 males and 201 females, mean age 57, range 18-97). 7/375(1.9%) patients had repeat
CT examination with OC within 7 days. Of these 7 patients, none had a change in the course of their
management due to the utilization of OC. No delayed or missed diagnoses related to the lack of OC were
identified.
CONCLUSION
Omitting OC for imaging patients with BMI greater than 25 presenting with acute abdominal pain in an ER
setting resulted in no delayed or missed diagnoses. The benefits of prompt imaging diagnosis outweighs the
minimal potential need for repeat imaging.
CLINICAL RELEVANCE/APPLICATION
64MDCT evaluation of ER patients with acute abdominal pain can be safely performed without oral contrast.
VSER21-12
Imaging of Hip Fracture
Joseph Sekiguchi Yu MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Review pertinent osseous landmarks of the hip joint. 2) Translate evidence based knowledge to the observed
imaging findings. 3) Discuss important features that the surgeons needs to know. 4) Employ ACR
appropriateness criteria for CT and MRI utilization.
VSER21-13
Comparison of Outcomes for Patients Evaluated with Magnetic Resonance Imaging vs CT for
Suspected Occult Femoral Neck Fractures
Paul McAllister BS (Presenter): Nothing to Disclose , Timothy J. Mosher MD : Research Consultant, Medical
Metrics, Inc Research Consultant, eImage, Inc Research Consultant, Johnson & Johnson Stockholder, Johnson &
Johnson
PURPOSE
To determine if there is a difference in outcomes for patients with suspected fragility fractures at the femoral
neck evaluated using CT in comparison to those evaluated with MRI.
METHOD AND MATERIALS
This study was an observational retrospective cohort design. Imaging studies ordered through the emergency
department at Milton S. Hershey Medical Center were searched to identify participants. Due to higher
prevalence of radiographic occult osteoporotic fractures of the hip, the study was limited to females over the
age of 65 who had experienced a fall and were suspected of having a fracture. Patients were included if initial
radiographic evaluation of the pelvis or hip was negative for fracture and followed by either a non-contrast CT or
MRI of the hip or pelvis. Records were grouped based on whether evaluation for occult fracture was made with
CT or MRI. Their electronic medical records were searched for hospitalizations in the year following their index
evaluation in the emergency department. Our primary analysis was to compare outcomes thought to be directly
related to delayed diagnosis or treatment of suspected fragility fractures. These outcomes include death,
secondary displacement, avascular necrosis, rapid progression of osteoarthritis, delayed diagnosis, and
malunion. These were determined based on a literature search conducted prior to the collection of data.
RESULTS
A database search from the dates of 1/1/05 to 12/31/12 yielded 926 records. After review, 119 of these records
met the inclusion criteria; 21 were evaluated with MRI and 98 with CT. Statistical analysis showed no significant
difference in clinical outcomes during the year following initial evaluation. 8.3% of patients evaluated with MRI
experienced adverse outcomes directly related to hip fracture within one year in comparison to 10.6% of
patients evaluated with CT (p=1.0). The most common of these adverse events in both groups was death within
the following year.
CONCLUSION
In contrast to current guidelines that recommend MRI, our results indicate there is no significant difference in
clinical outcomes between elderly female patients evaluated with CT or MRI for suspected fragility fractures of
the hip following fall.
CLINICAL RELEVANCE/APPLICATION
Appropriateness criteria recommending MRI for suspected occult fragility fractures are based on studies of
diagnostic accuracy; however, our results suggest no difference in patient centered outcome.
VSER21-14
Lumbar MRI Imaging in the Emergency Room Setting in Patients with a prior Examination: A Pain in
the Back?
Edwin Gulko MD : Nothing to Disclose , William
MD : Nothing to Disclose
Walter MD (Presenter): Nothing to Disclose , Judah
Burns
PURPOSE
To determine factors that increase the likelihood of new or progressive lumbar MRI findings in patients with a
prior MRI.
METHOD AND MATERIALS
Retrospective review was performed on ED patients with a lumbar MRI who had a prior MRI within 6 years.
Demographics and 'red flag" symptoms (malignancy, infection, fracture) were recorded. Lumbar MRIs were
reviewed for acute findings (infection, new tumor, fracture, disc herniation, cord compression). Degenerative
change was considered predominately facet joint arthropathy (FJA), degenerative disc disease (DDD), or both
(BFD), and categorized as single or multi-level change. Images were compared with the prior MRI to assess
change in canal stenosis. Odds Ratio analyses evaluated likelihood of worsening canal stenosis for single vs
multi-level change, FJA vs DDD, and either FJA or DDD vs BFD.
RESULTS
285 lumbar MRIs were performed on patients with prior MRIs within 6 years. 7 cases were excluded. 136
patients (49%) had a 'red flag'. There were 66 cases with acute findings, 34 of which were patients with
malignancy. Among 212 cases without an acute finding, 44 had more than 1 repeat exam and 16 had no
degenerative change. As a result, 152 cases were evaluated for change in spinal canal stenosis. 42 (28%) had
single level degenerative change and 110 (72%) had multilevel change. More patients with multilevel changes
exhibited worsening spinal canal stenosis over time than patients with single level degeneration (OR 8.95, CI
2.0-39.2). There was no significant difference in the change in canal stenosis between patients with
predominately FJA or DDD. More patients with BFD had worsening canal stenosis over time than patients with
FJA or DDD (OR 2.9, CI 1.33-6.29).
CONCLUSION
ED lumbar spine MRIs are commonly performed when prior MRIs exist. Clinical "red flags" increase the
likelihood of acute findings, consistent with previously published data. Patients with single level degeneration
and no acute finding are less likely to have progressive spinal canal stenosis. Progression is more likely in
patients with both FJA and DDD, than in those with one or the other.
CLINICAL RELEVANCE/APPLICATION
This research will help clarify the role of repeat lumbar MRIs in the ED for patients with various low back pain
presentations and will allow for more prudent use of a limited imaging resource. Additionally we aim to explore
which lumbar degenerative risk factors predispose to worsening spinal canal stenosis over time.
VSGI21
Gastrointestinal Series: Imaging of the Cirrhotic Patient
Series Courses
US
OI
MR IR GI
AMA PRA Category 1 Credits ™: 3.25
ARRT Category A+ Credits: 4.00
Mon, Dec 1 8:30 AM - 12:00 PM
Location: E350
Participants
Moderator
Mark Elwood Lockhart MD : Nothing to Disclose
Moderator
Kathryn Jane Fowler MD : Research support, Bracco Group
Sub-Events
VSGI21-01
MRI and MR Elastography
Frank H. Miller MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Discuss the role of conventional MRI in the diagnosis of HCC and benign hepatic nodules. 2) Use of
gadoxetate and diffusion weighted imaging in characterizing focal liver lesions in cirrhotic patients. 3) MR
elastography in the assessment of fibrosis.
ABSTRACT
MR imaging plays in important role in the diagnosis of cirrhosis. The classic and atypical MR imaging features of
hepatocellular carcinoma and the distinction from benign hepatic nodules will be discussed. The use of ancillary
features of HCC will be discussed including the utility of gadoxetate and diffusion weighted imaging in
characterizing focal hepatic lesions in cirrhotic patients. MR elastography, a relatively new technique will be
emphasized for the staging of fibrosis and diagnosis of cirrhosis.
Active Handout
http://media.rsna.org/media/abstract/2014/14000543/VSGI21-01 sec.pdf
VSGI21-02
The Outcome of Hypovascular and Hypointense Nodules on Hepatocyte-phase Gadoxetic
Acid-enhanced Magnetic Resonance Imaging; When Does It become a Conventional HCC?: 5 Years'
Experience
Katsuhiro Sano MD,PhD (Presenter): Nothing to Disclose , Utaroh Motosugi MD : Nothing to Disclose ,
Tomoaki Ichikawa MD, PhD : Consultant, DAIICHI SANKYO Group , Shintaro Ichikawa MD : Nothing to
Disclose , Hiroyuki Morisaka MD : Nothing to Disclose , Kojiro Onohara MD : Nothing to Disclose ,
Tomohiro Takamura : Nothing to Disclose , Hiroshi Onishi : Nothing to Disclose
PURPOSE
Nodules that appear hypointense on hepatocyte phase of gadoxetic acid-enhanced magnetic resonance imaging
(EOB-MRI) and hypovascular on arterial-phase are often encountered in clinical practice. Such nodules cannot
be diagnosed using routine imaging criteria. The pupose of this study was to elucidate the natural history over a
long period of hypovascular nodules that appear hypointense on hepatocyte-phase EOB-MRI by focusing on
hypervascularization.
METHOD AND MATERIALS
In this study, 235 such nodules in 84 patients were examined. Hypovascularity of the nodules was confirmed
using dynamic CT. All nodules were retrospectively examined using serial follow-up CT and MRI. examinations
until hypervascularity was observed on arterial-phase dynamic CT or EOB-MRI, or CT during hepatic
arteriography.
RESULTS
The mean follow-up duration was 702 days (range: 69 to 2085 days). Of the 235 nodules, 148 (63%)
developed hypervascularization. The optimal cut off value of the size of hypervascularization was 10mm. Of the
102 nodules (=10mm or >10mm), 81 (79%) developed hypervascularizaion. The size of the nodules (=10mm
or >10mm) and increase in size of the nodules were independent risk factors of hypervascularization by
multivariate analysis. The 1-year cumulative risks of hypervascularization were 20% (=10mm or >10mm).
These values were significantly differences.
CONCLUSION
About 80% of hypovascular and hypointense nodules on EOB-MRi (=10mm or >10mm) progressed to
conventional hepatocellular carcinoma. Large nodular size (=10mm or >10mm) and increase in size of the
nodules is the MR imaging findings that higher risk of hypervascularization.
CLINICAL RELEVANCE/APPLICATION
About 80% of hypovascular and hypointense nodules on EOB-MRI with the size equal to 10mm or larger 10mm.
Large nodular size (=10mm or >10mm) and increase in size of the nodules are the MR imaging findings that
indicate higher risk of hypervascularization.
VSGI21-03
Texture Analysis of Non-enhanced and Gadoxetate Disodium-enhanced MR Images of the Liver: A
Comparison with Histological Grade of Liver Fibrosis
Akira Yamada MD (Presenter): Nothing to Disclose , Kazuhiko Ueda MD : Nothing to Disclose , Yasunari
Fujinaga MD : Nothing to Disclose , Masahiro Kurozumi MD : Nothing to Disclose , Shinichi Miyagawa :
Nothing to Disclose , Masumi Kadoya MD : Nothing to Disclose
PURPOSE
To evaluate value of gadoxetate disodium on noninvasive diagnosis of liver fibrosis by texture analysis of MR
images.
METHOD AND MATERIALS
Consecutive 46 patients who underwent preoperative gadoxetate disodium-enhanced MR imaging using 3 Tesla
MR system were included in this retrospective study. The grade of liver fibrosis (the fibrosis score: F) was
histologically diagnosed by surgical specimen in all patients. Pre-contrast respiratory-gated 2D fast spin echo
T2-weighted images (voxel size = 0.7 x 0.7 x 5 mm), pre- and post-contrast (20 minutes after venous
administration) breath-hold 3D gradient recalled echo T1-weighted images (voxel size = 0.7 x 0.7 x 3 mm)
were used for evaluation. Fat-suppression was applied to all images. Region of interests sized 60 x 60 pixels
were located in the liver avoiding major vessels and hepatic lesions in each MR image. Four feature values
('contrast', 'correlation', 'energy', and 'heterogeneity') of the liver were determined by texture analysis of region
of interests. A stepwise liner regression analysis of the fibrosis score on the feature values obtained from
texture analysis was performed using 3 different image sets (pre-contrast MR images, post-contrast MR images,
and the both). ROC analysis of obtained 3 regression models in differentiation of liver fibrosis (F1-4) from
normal liver (F0) was performed.
RESULTS
The area under ROC of obtained 3 regression models in differentiation of liver fibrosis from normal liver was
0.64 for pre-contrast MR images, 0.83 for post-contrast MR images, and 0.85 for the both. Two feature values
(x1: 'correlation' in post-contrast T1-weighted images, P < 0.0001; x2: 'energy' in pre-contrast T2-weighted
images, P = 0.017) were significant predictors for the fibrosis score in eventual regression model (y =
-31.232x1 - 10.39x2 + 32.137, R = 0.63, P < 0.0001).
CONCLUSION
Gadoxetate disodium can add value on noninvasive diagnosis of liver fibrosis by texture analysis of MR images.
CLINICAL RELEVANCE/APPLICATION
The degree of liver fibrosis especially at its early stage can be predicted non-invasively by texture analysis of
non-enhanced and gadoxetate disodium-enhanced MR images.
VSGI21-04
State-of-Art Sonography
Stephanie R. Wilson MD (Presenter): Research Grant, AbbVie Inc Grant, Johnson & Johnson Consultant,
Lantheus Medical Imaging, Inc Equipment support, Siemens AG Equipment support, Koninklijke Philips NV
LEARNING OBJECTIVES
1) The attendee will appreciate the unique contribution of contrast enhanced ultrasound (CEUS) to imaging of
HCC in terms of its real time dynamic performance, superior spatial and temporal resolution, and incomparable
vascular sensitivity. 2) The attendee will analyze the imaging performance of microbubble contrast agents for
liver mass characterization with CEUS, which are purely intravascular, as compared to the interstitial agents
commonly used for CT and MR scan.
VSGI21-05
Assessment of Hepatic Vascular Network Connectivity by Automated Graph Analysis of Dynamic
Contrast Enhanced Ultrasound to Evaluate Portal Hypertension in Patients with Cirrhosis: A Pilot
Study
Ivan Amat-Roldan PhD (Presenter): Nothing to Disclose , Annalisa Berzigotti MD, PhD : Nothing to Disclose
, Rosa Gilabert MD : Nothing to Disclose , Jaime Bosch MD : Nothing to Disclose
PURPOSE
The liver vascular network is characterized by a highly organized structure. This is progressively deranged due
to fibrosis and hepatocyte drop-out in patients with chronic liver diseases, leading to portal hypertension. We
hypothesised that graph analysis of vascular images obtained by dynamic contrast-enhanced ultrasound
(DCE-US), would allow calculating the hepatic vascular network connectivity, which would predict the degree of
organization of the liver circulation, and that this would mirror the severity of portal hypertension.
METHOD AND MATERIALS
This pilot study includes 4 healthy subjects and 15 well characterized patients with liver cirrhosis who
underwent DCE-US and hepatic venous pressure gradient measurement (HVPG; gold standard method to
assess portal hypertension in cirrhosis). Individual graph models ('vascular connectomes') were computed
based on time series analysis of video sequences of DCE-US examination (disruption-reperfusion technique).
Graph analysis was carried out by calculation of clustering coefficient; according to graph theory a higher
clustering coefficient indicates a more organized network. Based on clustering coefficient we calculated
statistical models to predict HVPG from DCE-US video sequences.
RESULTS
Healthy subjects had a high clustering coefficient of vascular connectome suggesting a highly organized liver
vascular network. Patients with cirrhosis showed a lower clustering coefficient indicating disruption of normal
anatomy. Clustering coefficient decreased as HVPG increased. The correlation between the best model derived
from distribution of clustering coefficient (10 bins) of vascular 4 connectome and HVPG had a Pearson's
correlation of 0.977 and a root mean square error of 1.57 evaluated by leave one out cross-validation.
CONCLUSION
Computer based graph-analysis of video sequences generated by DCE-US permits to calculate a vascular
connectome that reflects the degree of organization of hepatic microvascular network
CLINICAL RELEVANCE/APPLICATION
This non-invasive method is able to quantify automatically the degree of liver vascular derangement and
accurately mirrors the severity of portal hypertension in patients with cirrhosis.
VSGI21-07
LIRADS and UNOS Classifications of Liver Lesions
Cynthia Sawhney Santillan MD (Presenter): Consultant, Robarts Clinical Trials Research Group
LEARNING OBJECTIVES
1) To demonstrate the use of the LI-RADS and UNOS imaging categorization systems for observations seen in
patients at risk for hepatocellular carcinoma with sample cases. 2) To highlight the different purposes of each
categorization system. 3) To illustrate the differences and similarities in how observations are categorized with
each system.
VSGI21-08
A Review of LI-RADS Categorization in 201 Pathology Proven Hepatocellular Carcinomas
Eric Christopher Ehman MD (Presenter): Nothing to Disclose , Spencer Caton Behr MD : Research Grant,
General Electric Company , Rizwan Aslam MBBCh : Research support, Bayer AG , Benjamin M. Yeh MD :
Research Grant, General Electric Company Consultant, General Electric Company , Linda Ferrell MD :
Nothing to Disclose , Thomas A. Hope MD : Speaker, Guerbet SA Research Grant, General Electric Company
PURPOSE
To explore the trends in imaging appearance and differences in findings by modality for the new LI-RADS
v2014 definitions in a large group of pathology proven cases of hepatocellular carcinoma.
METHOD AND MATERIALS
Pathology reports from liver specimens (explants and partial hepatectomies) of 605 sequential patients with
cirrhosis were reviewed to identify specimens with at least one focus of viable hepatocellular carcinoma, then
cross-correlated with pre-operative CT and MR imaging. Patients with completely necrotic treated tumor, those
without available prior pre-treatment multiphase imaging and tumors smaller than 1 cm were excluded. Each
lesion was examined, the imaging features recorded, and the lesion retrospectively graded using the LI-RADS
2014 criteria.
RESULTS
147 patients with a total of 201 hepatocellular carcinomas diagnosed between 12/2008 and 10/2013 were
analyzed. Average time between the most recent pre-treatment prior imaging study and surgery was 13
analyzed. Average time between the most recent pre-treatment prior imaging study and surgery was 13
months. 150 (75%) lesions were imaged by multiphase CT, and 51 (25%) lesions by MRI. Overall, 64 (32%)
lesions measured ≥1cm and <2cm, while 137 (68%) were ≥2cm. There were 21 (13%) LIRADS-3 lesions, 75
(37%) LIRADS-4 lesions and 102 (50%) LIRADS-5 lesions. 171 (85%) of lesions exhibited arterial
hyperenhancement, 136 (68%) demonstrated washout and 29 (14%) showed evidence of capsule. At CT, the
rate of LIRADS-3, -4 and -5 lesions was 13%, 37% and 50% respectively. At MR, these rates were 4%, 39%
and 55%. At CT, 13% of 1-2 cm lesions were graded LIRADS-5, and at MR, 38% were graded LIRADS-5.
Arterial phase hyperintensity and washout appearance rates were equivalent between MR and CT, but capsule
appearance was more common on MR (29%) imaging than at CT (10%), with χ2 = 10.7 (p<0.05).
CONCLUSION
The rate of arterial enhancement and portal venous or delayed washout are similar between lesions diagnosed
via CT and those diagnosed with MR. Capsule appearance was seen significantly more frequently at MR,
resulting in a higher rate of LIRADS-5 lesions measuring 1-2 cm at MR compared to CT.
CLINICAL RELEVANCE/APPLICATION
Differences in sensitivity for LI-RADS 5 lesions exist for MR and CT, which may support the use of MR imaging
for the evaluation of HCC over that of CT in the pre-transplant population
VSGI21-09
Performance of LI-RADS Criteria for Diagnosis of Pathologically Proven Hepatocellular Carcinoma
Using Gd-EOB-DTPA, and Comparisons with the Japan Society of Hepatology 2010 Criteria
Stephanie Channual MD (Presenter): Nothing to Disclose , Anokh Pahwa MD : Nothing to Disclose ,
Katrina Richards Beckett MD : Nothing to Disclose , James Sayre PhD : Nothing to Disclose ,
David Shin-Kuo Lu MD : Consultant, Covidien AG Speaker, Covidien AG Consultant, Johnson & Johnson
Research Grant, Johnson & Johnson Consultant, Bayer AG Research Grant, Bayer AG Speaker, Bayer AG ,
Steven Satish Raman MD : Consultant, Bayer AG Consultant, Covidien AG
PURPOSE
Only recently has LI-RADS (LR) expanded to apply to hepatobiliary (HB) contrast agents, with lesion
appearance on the HB phase considered to be an ancillary feature that favors the diagnosis of hepatocellular
carcinoma (HCC). In contrast, the Japan Society of Hepatology (JSH) includes lesion appearance on the HB
phase as a major criteria that favors the diagnosis of HCC. The purpose of our study was to determine the
performance of LI-RADS v2014 and Japan Society of Hepatology (JSH) 2010 criteria for the non- invasive
diagnosis of HCC.
METHOD AND MATERIALS
This was an IRB approved, HIPAA compliant retrospective study with 131 consecutive suspected HCC nodules in
114 patients confirmed by percutaneous biopsy, resection, or explant within 90 days of Gd-EOB-DTPA MRI.
Nodule size, presence of a capsule, and enhancement patterns were recorded. The nodules were then
categorized as LR3, LR4, or LR5 based on the LI-RADS major criteria, and categorized as either meeting or not
meeting the JSH criteria (defined as arterial enhancement and venous wash out, or arterial enhancement and
lack of Gd-EOB-DTPA uptake on HB phase imaging).
RESULTS
Of the 131 nodules, 116 were pathologically confirmed HCC (88.5%). Of 131 nodules, 23 (18%), 41 (31%),
and 67 (51%) were categorized as LR3, LR4, and LR5 respectively. Of these, 15/23, 37/41, and 64/67 LR3,
LR4 and LR5 nodules were pathologically proven as HCC, respectively (sensitivities, 13%, 32%, and 55%,
respectively; specificities, 47%, 73%, and 80%, respectively). The PPV of LR3, LR4, and LR5 were 65%, 90%,
and 96%, respectively. The sensitivity, specificity, and PPV for the JSH criteria were 72.4%, 53.3%, and
92.3%, respectively. The accuracy of LR4 and LR5 combined was 83% (109/131), while the accuracy for the
JSH criteria was 70.2% (92/131).
CONCLUSION
Although use of LI-RADS with Gd-EOB-DTPA yields a high PPV and accuracy for diagnosing HCC, moderate
sensitivity and specificity suggest that further refinement of the criteria may be necessary and percutaneous
nodule biopsy may be complementary for diagnosis. However, LR4 and LR5 combined was more sensitive and
accurate for diagnosing HCC compared to the JSH criteria.
CLINICAL RELEVANCE/APPLICATION
The use of hepatobiliary specific MR contrast agents, such as Gd-EOB-DTPA, is becoming more prevalent, and
understanding its applicability with LI-RADS is essential for the noninvasive evaluation of nodules in cirrhotic
livers.
VSGI21-10
Ablation of Liver Lesions
Fred T. Lee MD (Presenter): Stockholder, NeuWave Medical, Inc Patent holder, NeuWave Medical, Inc Board
of Directors, NeuWave Medical, Inc Patent holder, Covidien AG Inventor, Covidien AG Royalties, Covidien AG
LEARNING OBJECTIVES
LEARNING OBJECTIVES
1) Understand the basic rationale for ablation of liver lesions. 2) Understand the differences between ablation of
liver tumors in cirrhotic and non-cirrhotic livers. 3) Understand the differences between the different ablation
technologies.
VSGI21-11
Imaging Evaluation of Ablative Margin and Index Tumor Immediately after Radiofrequency Ablation
for Hepatocellular Carcinoma: Comparison between Multi-detector CT and MR Imaging
Jin Woong Kim MD : Nothing to Disclose , Sang Soo Shin MD (Presenter): Nothing to Disclose , Suk Hee
Heo MD : Nothing to Disclose , Hyo Soon Lim MD : Nothing to Disclose , Sung Mo Kim : Nothing to
Disclose , Yong-Yeon Jeong MD : Nothing to Disclose , Heoung-Keun Kang MD : Nothing to Disclose
PURPOSE
To prospectively compare multi-detector CT and MR imaging in assessment of ablative margin (AM) and index
tumor within ablation zones immediately after radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC).
METHOD AND MATERIALS
Based on our preliminary data, necessary number of patients was estimated to be at least 30 when an α error
of 0.05 and a β error of 0.2 were applied. A total of 33 consecutive patients with 42 HCCs, who had successfully
undergone contrast-enhanced CT and MR imaging after RFA, was enrolled in this study. CT and MR imaging
were performed within 3 and 7 hours after completion of RFA, respectively. Both CT and MR images were
reviewed in consensus by two radiologists in two separate sessions regarding visual discrimination between AM
and index tumor and status of AM within ablation zones. The status of AM was classified as AM plus (AM
completely surrounded tumor), AM zero (AM was partly discontinuous, without protrusion of tumor beyond
postulated border of ablated area) and AM minus (AM was partly discontinuous, with protrusion of tumor). Any
ablation zone with AM plus or AM zero was considered as imaging evidence to predict technical effectiveness,
which was based on one-month follow-up CT, as well as to represent technical success.
RESULTS
With CT and MR imaging, visual discrimination between AM and index tumor was possible in 4 (9.5%) and 34
(81%) of 42 ablation zones, respectively (P< .001). Among 4 and 34 ablation zones in which status of AM could
be evaluated on CT and MR imaging, respectively, all of 4 ablation zones were classified as AM plus on CT
images, whereas 34 ablation zones were categorized into AM plus (n=28), AM zero (n=5) and AM minus (n=1)
on MR images. Based on CT and MR imaging, technical success was determined to be achieved in 4 (9.5%) and
33 (78.6%), respectively (P< .001). The technical effectiveness was noted in all of ablation zones on
one-month follow-up CT. CT and MR imaging predicted technical effectiveness in 4 (9.5%) and 33 (78.6%),
respectively, (P< .001).
CONCLUSION
MR imaging was superior to multi-detector CT for assessment of ablative margin and index tumor within
ablation zones immediately after RFA.
CLINICAL RELEVANCE/APPLICATION
MR imaging performed immediately after RF ablation can provide sufficient information regarding necessity of
additional ablation after RF ablation with more confidence than contrast-enhanced CT.
VSGI21-12
Thermal Ablation in the Treatment of Hepatocellular Carcinoma (HCC): Radiofrequency Ablation
(RFA) vs. Microwave Ablation (MWA)
Thomas Josef Vogl MD, PhD (Presenter): Nothing to Disclose , Stefan Zangos MD : Nothing to Disclose ,
Jorg Trojan MD : Nothing to Disclose , Nagy Naguib Naeem Naguib MD, MSc : Nothing to Disclose ,
Nour-Eldin Abdelrehim Nour-Eldin MD, MSc : Nothing to Disclose
PURPOSE
To prospectively evaluate and compare the therapeutic response of radiofrequency ablation (RFA) and
microwave ablation (MWA) therapy of hepatocellular carcinoma (HCC).
METHOD AND MATERIALS
Institutional review board approval was obtained prior to this prospective study and written informed consent
was obtained from all patients included in the study for both the ablation procedure and anonymous use of their
data for research purposes. From September 2008 to December 2011, 53 consecutive patients (42 males/11
females; mean, 59 years; range 40-68; SD, 4.2) underwent CT-guided percutaneous RFA and MWA of 68 HCC
lesions. The inclusion and exclusion criteria were in accordance with the Barcelona Clinic Liver Cancer (BCLC)
criteria for indications and contraindications for ablation therapy of HCC. The morphologic tumor response
(number, location and size) was evaluated by MRI. Follow-up protocol was 24 hours post ablation, then in
3-month intervals post ablation in the first year and in 6-month intervals thereafter.
RESULTS
Complete therapeutic response was documented in 84.4% (27/32) of lesions treated with RFA and in 88.9%
(32/36) of lesions treated with MWA (p=0.6). Complete response was achieved in all lesions ≤2.0 cm in
diameter in both groups. There was no significant difference in rates of residual foci of HCC lesions between RFA
and MWA groups (p=0.15, Log-rank test). Recurrence rate for 3, 6, and 9 months in patients with HCC who
underwent RFA vs. MWA were 6.3%, 3.1%, 3.1% vs. 0%, 5.6%, 2.8%. Time-to-progression in patients treated
with RFA compared with MWA was 6.6 vs. 8.3 months. Progression-free-survival rate for patients treated with
RFA was 96.9%, 93.8% and 90.6% at 1, 2, and 3 years, for patients treated with MWA it was 97.2%, 94.5%,
and 91.7%, respectively (p=0.98).
CONCLUSION
In conclusion, RFA and MWA therapy showed no significant difference in the treatment of HCC regarding
complete response, rates of residual foci of untreated disease and recurrence rate.
CLINICAL RELEVANCE/APPLICATION
RFA or MWA can be used with similar results concerning local tumor control of HCC
VSGU21
Genitourinary Series: Prostate MR 2014: Current Role in Staging and Surveillance and
Intervention
Series Courses
OI
MR GU
AMA PRA Category 1 Credits ™: 3.25
ARRT Category A+ Credits: 4.00
Mon, Dec 1 8:30 AM - 12:00 PM
Location: N228
Participants
Moderator
Peter L. Choyke MD : Researcher, Koninklijke Philips NV Researcher, General Electric Company Researcher, Siemens AG
Researcher, iCAD, Inc Researcher, Aspyrian Therapeutics, Inc Researcher, ImaginAb, Inc Researcher, Aura
Sub-Events
VSGU21-01
Intro to Prostate Cancer
Coordinator Peter L. Choyke MD Researcher, Koninklijke Philips NV Researcher, General Electric Company
Researcher, Siemens AG Researcher, iCAD, Inc Researcher, Aspyrian Therapeutics, Inc Researcher, ImaginAb,
Inc Researcher, Aura
LEARNING OBJECTIVES
1) To understand the limitations of PSA screening and random prostate biopsy. 2) To introduce the concepts of
novel screening tests and genomic analysis of prostate biopsies. 3) To review the importance of MRI in
improving tumor localization, guiding biopsy, monitoring active surveillance and focally ablating prostate cancer.
ABSTRACT
The diagnosis of prostate cancer is evolving quickly. There is increasing recognition that the combination of
routine PSA screening and random prostate biopsy overdiagnoses low grade disease and underdiagnoses high
grade disease. Autopsy studies show that the normal prostate harbors many low grade and microscopic cancers
that never becomes clinically apparent. On the other hand, random biopsies undersample the anterior prostate
gland. More accurate screening tests (e.g. PCA-3) are under development for determining which men warrant
biopsy. Genomic testing of prostate biopsy samples is also becoming more common and it is thought to
improve the prediction of tumor aggressiveness. The increased use of genomics to guide therapy clearly
requires that the biopsy sample be representative of the tumor. MR guided biopsies, whether performed in
gantry or using MR-US fusion, will improve the quality of the prostate biopsy specimen enabling more accurate
genomic testing. Armed with more accurate and reliable tissue diagnosis, more rational decisions regarding
active surveillance and/or focal therapy can be made. This course will review advances in MR guided diagnosis,
biopsy and therapy of prostate cancer.
VSGU21-02
Multiparametric MRI Predicts 2 Year Outcomes for Low Risk Prostate Cancer Patients on Active
Surveillance
Anwar Roshanali Padhani MD (Presenter): Advisory Board, Acuitas Medical Ltd Advisory Board, Siemens AG
Speakers Bureau, Siemens AG Researcher, Siemens AG Speakers Bureau, Johnson & Johnson , Giuseppe
Petralia MD : Nothing to Disclose , Heminder Kaur Sokhi MRCS, FRCR : Nothing to Disclose , Francesco
Sanguedolce PhD, MD : Nothing to Disclose , Nicola Anyamene : Nothing to Disclose , Giles Hellawell MD,
MRCS : Nothing to Disclose
PURPOSE
To investigate the ability of multiparametric MRI (mpMRI) to predict early treatment outcomes of Active
Surveillance (AS) patients.
METHOD AND MATERIALS
METHOD AND MATERIALS
100 AS patients (cT1a-c; PSA≤10ng/ml; PSA density ≤0.2ng/ml/cc; Gs≤6; highest tumor volume in cores
≤50%) underwent 3 monthly PSA testing and repeat TRUS biopsy at 1 and 4 years. mpMRI (T2W, DWI, DCE
andMRSI) was undertaken annually. The first mpMRI was evaluated by two independent radiologists (1and4
years experience), blinded to the 2yr outcome (continued/discontinued AS). mpMRI features including index
lesion (IL) presence, location, size, type (diffuse/nodular), sequence PI-RADS score, ADC value, MRSI metabolic
ratio, and DCE curve type were recorded. Overall Likert score for clinically significant disease and reader's
evaluation of suitability for AS were noted. Interobserver agreement, univariate and multivariate analysis and
treatment free survival curves were calculated.
RESULTS
Mean time on AS was 24.7 months; 44 withdrew from AS for PSA DT ≤2 years (11.4%), upgrading at repeat
biopsy (11.4%), worsening mpMRI appearances (17.4%) and due to patient preference (2.3%). No differences
were found between the continued/ discontinued AS groups for age, PSA, gland volume, PSA density.
Interobserver agreement was moderate for DCE PI-RADS score (0.57) and substantial to almost perfect
(0.63-97) for the remaining continuous/ordinal variables). A number of mpMRI features were significantly
correlated to outcome on univariate analysis (both radiologists). Using logistic regression, significant variables
were T2W PI-RADS score and ADC value for the more experienced radiologist, while stage, IL type, DCE
PI-RADS score, overall Likert score and suitability assessment for the less experienced radiologist. mpMRI
significantly improved outcomes prediction for the more experienced radiologist only (odds ratio 2.4). Survival
curves showed clear separation for IL PI-RADS score, overall Likert score and suitability for AS for both
observers (p<0.001).
CONCLUSION
Baseline mpMRI can identify additional features that predict short term outcomes of AS.
CLINICAL RELEVANCE/APPLICATION
mpMRI has the potential to increase the precision of patient selection at initial triage for AS by helping to
confirm suitability of patients by minimizing the inclusion of higher risk patients.
VSGU21-03
Automatic Classification of Prostate Cancer and Gleason Scores through Machine Learning and
Salient Feature Selection from Multiparametric MRI
Duc Fehr PhD (Presenter): Nothing to Disclose , Harini Veeraraghavan : Nothing to Disclose ,
Andreas Georg Wibmer MD : Nothing to Disclose , Hebert Alberto Vargas MD : Nothing to Disclose , Evis
Sala MD, PhD : Nothing to Disclose , Hedvig Hricak MD, PhD : Nothing to Disclose
PURPOSE
To develop a machine learning-based automatic feature selection for classification of PCa and the associated
Gleason Score (GS) from multiparametric prostate MRI (mpMRI).
METHOD AND MATERIALS
158 prostate cancer patients who underwent mpMRI within 6 months prior to prostatectomy were
retrospectively analyzed. Volumes of interest were placed in cancerous and normal peripheral zone on
T2-weighted MRI (T2WI) and apparent diffusion coefficient (ADC) maps, using step-section pathology maps of
the surgical specimens as reference. Statistical image features (mean, standard deviation, skewness, kurtosis)
and Haralick texture features (energy, entropy, correlation, homogeneity, contrast) were computed from these
maps. Adaptive Boosting using support vector machine (AdaBoost-SVM) machine learning was applied to
extract salient features and learn the best classification model. Robust classifier performance was obtained
through 10-fold crossvalidation. In each fold a small percentage of the samples was kept for testing, while the
rest was used for training. Thus, the testing was done with novel data whose true classification labels were
unknown to the classifier.
RESULTS
The algorithm achieved an accuracy of 93% for classifying cancerous vs normal structures and 83% for
classifying GS (6/7+). The algorithm extracted ADCentropy, T2kurtosis, T2mean, and ADCenergy as features
for cancer vs normal tissue and ADCkurtosis, T2entropy, T2correlation, and ADCcontrast for GS classification. A
statistical t-test analysis confirms the salient features found by our approach for normal vs cancerous tissue:
ADCentropy (p<0.001), T2kurtosis (p<0.001), T2mean (p=0.45), ADCenergy (p<0.001). For GS classification,
T2entropy (p=0.03) was significant.
CONCLUSION
We developed an algorithm that extracts salient features from MRI and classifies PCa and GS. The relevance of
machine learning extracted features was confirmed by t-test. The extracted features can be used to generate
new images that can potentially assist radiologist interpretation.
CLINICAL RELEVANCE/APPLICATION
Image-based automatic prostate cancer and GS classification can assist radiologists in interpreting MRI and
contribute to patient risk-stratification and treatment selection.
VSGU21-04
Multi-parametric MRI (including PIRADS)
Clare M. C. Tempany-Afdhal MD (Presenter): Research Grant, InSightec Ltd Research Consultant, Profound
Medical Inc
LEARNING OBJECTIVES
1) The state of the art mpMR protocols/sequences for prostate cancer imaging. 2) How to acquire and interpret
high quality images. 3) What ACR-Pi-Rads is and how it can be implemented in clinical practice. 4) Current and
future role of Prostate MR and ACR- PiRads.
ABSTRACT
The current state of the art approaches to prostate cancer Multi-parametric MR(mpMR) Prostate imaging will be
presented. MRI techniques at 1.5T and 3.0T and pulse seqeunce optimization for a state of the art mpMRI exam
will be reviewed. The roles of each seqeunce will be illustrated with clinical case examples to outline technical
aspects and interpretative approaches. As the examinations have become complex and the clinical demands are
increasing there isa need for standarization of our techniques and interpretative reporting. Thus in keeping with
Bi-Rads and Li-Rads, we are developing Pi-Rads. The current ACR-PiRads will be reviewed - goals, methods and
clinical applications will be presented and future vision for the role of prostate MR and ACR-PiRADS will be
presented
VSGU21-05
Evaluation of PI-RADS for Multi-parametric Prostate MRI: How to Improve the Overall Score?
E. H. J. Hamoen MD (Presenter): Nothing to Disclose , Les Thompson : Nothing to Disclose , Fred Witjes
MD, PhD : Nothing to Disclose , Maroeska M. Rovers PhD : Nothing to Disclose , Jelle O. Barentsz MD, PhD
: Nothing to Disclose
PURPOSE
To evaluate the accuracy and interobserver variability of the final PI-RADS classification based on a dominant
MR-sequence compared to the often used single-modality sum score.
METHOD AND MATERIALS
223 biopsy-na�ve men suspected of having prostate cancer were included in a prospective clinical trial. All men
underwent a 3T mp-MRI, including T2-weighted imaging (T2WI), diffusion-weighted imaging (DWI), and
dynamic contrast-enhanced (DCE) MRI. Histology of all lesions was obtained by in-bore MR-guided biopsy
followed by standard TRUSGB in MR-positive men, or only standard TRUSGB in MR-negative men. All MRI
sequences were co-read independently by 2 investigators. Any discrepancies were resolved by consensus. Both
investigators assigned single-modality scores and an overall "dominant" PI-RADS to all lesions, of which the
latter was based on DWI in peripheral zone lesions, and on T2WI in transitional zone lesions. Single-modality
sum-scores were calculated and compared to overall "dominant" PI-RADS. 2x2 contingency tables were created
to calculate sensitivity, specificity, PPV and NPV. Proportions of agreement were calculated.
RESULTS
Best accuracy rates were reached using the overall "dominant" PI-RADS with a threshold of ≥ 4. Reader 1 and
respectively 2 achieved a sensitivity of 89.8% (97/108) and 81.5% (88/108), specificity of 86.1% (99/115) and
86.1% (99/115), PPV of 85.8% (97/113) and 84.6% (88/104), and NPV of 90.0% (99/110) and 83.2%
(99/119) for detecting significant prostate cancer. Using the sum score with a threshold of ≥ 10, reader 1 and
respectively 2 achieved a sensitivity of 89.8% (97/108) and 81.5% (88/108), specificity of 73.9% (85/115) and
80.9% (93/115), PPV of 76.4% (97/127) and 80.0% (88/110), and NPV of 88.5% (85/96) and 82.3% (93/113)
for detecting significant prostate cancer. Proportions exact agreement were 73.1% for overall "dominant"
PI-RADS, 44.4% for DCE-MRI, 51.1% for T2WI, and 56.5% for DWI.
CONCLUSION
The overall "dominant" PI-RADS is a robust interpretation score for mp-MRI to detect significant cancer with
good inter-reader agreement, which outperforms the commonly used single-modality sum-score.
CLINICAL RELEVANCE/APPLICATION
Overall 'dominant' PI-RADS accurately detects significant prostate cancer with good interreader agreement and
is recommended in the evaluation of mp-MRI in men suspicious for prostate cancer instead of the
single-modality sum score.
VSGU21-06
The Use of the Prostate Imaging Reporting and Data System (PI-RADS) for Prostate Cancer
Diagnosis on Multiparametric Magnetic Resonance Imaging: A Systematic Review and Meta-analysis
E. H. J. Hamoen MD (Presenter): Nothing to Disclose , Maarten De Rooij MD : Nothing to Disclose , Fred
Witjes MD, PhD : Nothing to Disclose , Maroeska M. Rovers PhD : Nothing to Disclose , Jelle O. Barentsz
MD, PhD : Nothing to Disclose
PURPOSE
To determine the diagnostic accuracy of the Prostate Imaging Reporting and Data System (PI-RADS) in
prostate cancer detection using multiparametric magnetic resonance imaging (mp-MRI).
METHOD AND MATERIALS
We searched electronic databases, including MEDLINE, Embase, and Cochrane Central Register of Controlled
Trials, up to March 20, 2014. We included diagnostic accuracy studies referring to the use of PI-RADS scales to
detect prostate cancer on mp-MRI. Histopathologic data from prostatectomy or biopsy could be used as the
reference standard. Data necessary to complete 2x2 contingency tables were obtained from the included
studies, and test characteristics including sensitivity, specificity, and predictive values were calculated.
Sensitivity and specificity values of all included studies were pooled and the results were plotted in a summary
receiver operating characteristics plot.
RESULTS
Fourteen studies that met the inclusion criteria (1785 patients) could be analyzed. The pooled data showed a
specificity of 0.79 (95% CI, 0.69-0.86) and sensitivity of 0.78 (95% CI, 0.70-0.84) for prostate cancer
detection, with negative predictive values (NPVs) ranging from 0.58 to 0.95. Subgroup analysis showed a
pooled specificity of 0.84 (95% CI, 0.71-0.92) and sensitivity of 0.81 (95% CI, 0.71-0.88) in studies that
correctly used the PI-RADS criteria per modality, versus a specificity of 0.71 (95% CI, 0.58-0.80) and sensitivity
of 0.73 (95% CI, 0.60-0.83) in studies with a probably less strict or adjusted use of PI-RADS criteria.
CONCLUSION
Accurate use of PI-RADS leads to good sensitivity and specificity rates for prostate cancer detection. Included
studies showed fairly large heterogeneity regarding the calculation of an overall PI-RADS score and used cut-off
values. Therefore, a standardized method for deriving an overall score is needed for a correct comparison of
different studies.
CLINICAL RELEVANCE/APPLICATION
PI-RADS is a promising tool for prostate cancer detection and is recommended in the evaluation of mp-MRI in
men suspicious for prostate cancer.
VSGU21-07
MR and MR-US Guided Biopsy
Daniel Jason Aaron Margolis MD (Presenter): Research Grant, Siemens AG
LEARNING OBJECTIVES
1) Optimize multiparametric MRI protocol for surgical staging versus detection/biopsy planning. 2) Compare the
advantages of in-bore and image fusion biopsy approaches. 3) Understand the differences between the various
image fusion MRI-ultrasound targeting approaches. 4) Describe the advantages that image-guided prostate
biopsy offers to men with known or suspected prostate cancer.
ABSTRACT
Multiparametric MRI has transformed from a tool primarily used for staging of known cancer into one for
detection, localization, and sampling of suspected cancer. This has allowed for streamlining and simplifying the
protocol use for imaging the prostate, which presents its own challenges, including managing decreased
signal-to-noise ratios and interfacing with image-guided targeted biopsy software and hardware. The various
platforms available for image-fusion targeted biopsy include in-bore MRI-directed, "cognitive-" or
"mental-fusion" MRI-ultrasound targeted biopsy, software image fusion, articulated arm, and electromagnetic
tracking. Attendees will learn how to incorporate image-guided targeted biopsy into their practice, how to
interface with clinical collaborators and referrers, and how image-guided targeted biopsy improves confidence
in managing men with suspected or known prostate cancer.
Active Handout
http://media.rsna.org/media/abstract/2014/14000839/VSGU21-07 sec.pdf
VSGU21-08
Prostate Cancer Detection in Biopsy-naïve Men: Targeted MR-guided in-bore Biopsy versus
Systematic Transrectal Ultrasound Guided Biopsy
Michael Quentin MD (Presenter): Nothing to Disclose , Lars Schimmoeller MD : Nothing to Disclose ,
Christian Arsov MD : Nothing to Disclose , Frederic Dietzel : Nothing to Disclose , Gerald Antoch MD :
Speaker, Siemens Medical AG Speaker, Bayer AG Speaker, BTG International Ltd , Dirk Blondin MD :
Nothing to Disclose , Andreas Hiester : Nothing to Disclose , Erhard Godehardt : Nothing to Disclose ,
Robert Rabenalt : Nothing to Disclose , Peter Albers MD, PhD : Nothing to Disclose
PURPOSE
This study prospectively compares MR-guided in-bore biopsy with the standard systematic TRUS-guided biopsy
in biopsy-na�ve men with elevated PSA.
METHOD AND MATERIALS
132 biopsy-na�ve men with elevated PSA (>4 ng/ml) were included in this study. After functional
multiparametric MRI at 3T, patients were referred to targeted MR-guided in-bore biopsy of prostate lesions
(max 3) followed by a standard systematic TRUS-guided biopsy (12 cores). Analysis of detection rates for PCa
and significant PCa (>5 mm total cancer length and/or any Gleason pattern >3).
RESULTS
128 patients (age 66.1±8.1 years; median PSA 6.7 ng/ml, lower quartile 4.1 ng/ml, upper quartile 92.9 ng/ml)
met all study requirements. The detection rate of both biopsy methods was 53.1% (significant PCa: TRUS
79.4%; MRI 85.3%). 7.8% of clinically significant PCa were missed by the MR-guided in-bore biopsy and 9.4%
by the TRUS biopsy. MR-guided in-bore biopsy needed significantly fewer cores (p<0.01) and showed higher
percentage of cancer involvement per biopsy core (p<0.01). The combination of both methods showed a
detection rate of 60.9% (significant PCa: 82.1%).
CONCLUSION
In our population, MR-guided in-bore biopsy and systematic TRUS-guided biopsy achieved equally high
detection rates in biopsy-na�ve patients with elevated PSA levels. MR-guided in-bore biopsy needed
significantly fewer cores and showed a significantly higher percentage of cancer involvement per biopsy core.
CLINICAL RELEVANCE/APPLICATION
In biopsy-na�ve patients with elevated PSA levels the MR-guided in-bore biopsy is a promising approach for
prostate cancer diagnosis. This biopsy method enables equal cancer detection rates with fewer biopsy cores
compared to the standard systematic transrectal ultrasound-guided biopsy.
VSGU21-09
Does Intravenously Administered Gadolinium Enter into the Glandular Lumen of the Prostate: X-ray
Fluorescence Microscopy Imaging of a Mouse Model
Devkumar Mustafi PhD (Presenter): Nothing to Disclose , Marta A. Zamora BS : Nothing to Disclose ,
Sophie-Charlotte Gleber : Nothing to Disclose , Stefan Vogt PhD : Nothing to Disclose , Gregory Stanislaus
Karczmar PhD : Nothing to Disclose , Aytekin Oto MD : Research Grant, Koninklijke Philips NV Consultant,
Guerbet SA
PURPOSE
Dynamic contrast enhanced MRI (DCEMRI) has become a standard component of multi-parametric prostate MRI
protocols and its use is incorporated into current guidelines for prostate MRI. Analysis of DCEMRI data from
prostate is usually based on distribution of gadolinium (Gd) into two well-mixed compartments (the Toft model)
and assumes that Gd does not enter into the glandular lumen. However, this assumption has not been directly
tested. The purpose of our study was to measure the concentration of Gd in the glandular lumen of the normal
mouse prostate following I.V. injection, using X-ray fluorescence microscopy (XFM) imaging in situ.
METHOD AND MATERIALS
Six C57Bl6 male mice (28-weeks old) were sacrificed 10 minutes after Gd injection I.V. (a dose of 0.13
mmol/kg) and two mice were sacrificed after saline injection. Prostate tissue samples (ventral and anterior)
from each mouse were harvested and frozen; 7-μm thick slices were sectioned for XFM; and adjacent 5-μm
thick slices were sectioned for HandE staining. XFM images with in-plane resolution of 0.5-1 µm were acquired
using an X-ray microprobe at the Argonne National Laboratory. Concentrations of metal ions and other elements
were determined.
RESULTS
Baseline concentration of Gd of 0.002±0.0007 mM was determined from measurements of prostatic tissue
samples when no Gd was added and was used to determine the measurement error. This 'background' value
was subtracted from the measured Gd concentrations in areas of normal prostatic epithelium and lumen when
Gd was added. In 32 prostatic glands in 6 mice, average Gd concentrations in regions of normal epithelium and
lumen were 0.27±0.07 mM and 0.18±0.09 mM, respectively.
CONCLUSION
Our data suggest that intravenously administered Gd enters into the glandular lumen in the normal mouse
prostate. Moreover, we were able to quantitatively determine Gd distributions in mouse prostatic epithelium and
lumen in situ. The results suggest that the conventional two compartment model should be modified to take the
glandular lumen into account. Future work will investigate the kinetics of uptake and washout from the prostatic
lumen and compare the kinetics in normal lumens and cancer-containing lumens.
CLINICAL RELEVANCE/APPLICATION
The validation of these findings in human prostate is very critical since this may have a significant impact on
quantitative analysis and interpretation of DCEMRI for diagnosis of prostate cancer.
VSGU21-10
Active Surveillance with MRI
Sadhna
Verma MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) What is active surveillance and how it is done. 2) Who is a candidate for active surveillance. 3) The role of
mpMRI in risk stratification for active surveillance. 4) The relevance of mpMRI in addition to clinical parameters
in disease management.
ABSTRACT
Active Surveillance with MRI Active surveillance is increasingly acknowledged as a preferred strategy for most
men with low-risk disease. This lecture will discuss low risk prostate cancer and how it is managed clinically.
Role of mpMRI will be reviewed with clinical case examples to show selection, follow- up or possible removal of
patients from active surveillance protocols.
VSGU21-11
Pain during MR-guided in-bore and MRI/US-fusion Prostate Biopsy: Comparison of Different
Analgesic Techniques
Michael Quentin MD (Presenter): Nothing to Disclose , Lars Schimmoeller MD : Nothing to Disclose ,
Christian Arsov MD : Nothing to Disclose , Frederic Dietzel : Nothing to Disclose , Gerald Antoch MD :
Speaker, Siemens Medical AG Speaker, Bayer AG Speaker, BTG International Ltd , Dirk Blondin MD :
Nothing to Disclose , Andreas Hiester : Nothing to Disclose , Robert Rabenalt : Nothing to Disclose , Peter
Albers MD, PhD : Nothing to Disclose
PURPOSE
Retrospective investigation of patient comfort during MR-guided in-bore and MRI/ultrasound (MRI/US)
fusion-guided prostate biopsies.
METHOD AND MATERIALS
260 patients with MR-guided in-bore biopsies and prior intrarectal instillation of 2% lidocaine gel (group A,
n=67) or periprostatic nerve block (PPNB) with 2% mepivacaine (group B, n=128), and patients with MRI/US
fusion-guided biopsies plus additional systematic transrectal, ultrasound-guided biopsy and prior application of
PPNB with 2% mepivacaine (group C, n=65) were included. The maximal procedural pain (MPP) was based on a
0-10 visual analog scale and the operating room time (ORT) was recorded for each biopsy session.
RESULTS
Patients in group A had significantly higher biopsy-related MPP scores (3.1±2.1) compared to subjects in group
B (2.0±1.9; p<0.01) or group C (1.8±1.7; p<0.01). Pain did not significantly differ between group B and group
C (p=0.84). Biopsies in group C required significantly less time (29.4±11.3 minutes) compared to biopsies in
group A (41.4±10.8; p<0.01) and group B (39.3±10; p<0.01). There was a weak correlation between MPP
scores and ORT (rS=0.25, rS=0.22 and rS=0.27 for groups A, B and C, respectively), but no correlation
between MPP scores and number of targeted cores or prostate volume. Increased experience led to a reduction
of the mean ORT in each biopsy technique.
CONCLUSION
MR-guided in-bore and MRI/US fusion-guided biopsies are equal in terms of MPP using the same analgesic
technique. With PPNB during MR-guided in-bore biopsy patients report significantly less pain compared to
intrarectal instillation of lidocaine gel. The MRI/US fusion-guided biopsy is superior in terms of ORT.
CLINICAL RELEVANCE/APPLICATION
Pain levels are low for both targeted MR-guided biopsy techniques. Using the same analgesic technique both
biopsy techniques are equal to each other. For the MR-guided biopsy patients report significantly less pain with
prior PPNB compared to intrarectal instillation of a local anesthetic. The MRI/US fusion-guided biopsy can easily
incorporate a targeted and systematic biopsy into one session requiring less time compared to MR-guided
in-bore biopsy.
VSGU21-12
Evaluation of a Novel Combined T2-weighted and Diffusion-weighted MR Imaging Sequence for
Diagnosis of Prostate Cancer and Determination of Its Aggressiveness: Correlation with
Histopathology Following Prostatectomy
Meredith Sadinski BA (Presenter): Nothing to Disclose , Gregory Stanislaus Karczmar PhD : Nothing to
Disclose , Yahui Peng PhD : Nothing to Disclose , Milica Medved PhD : Nothing to Disclose , Shiyang
Wang PhD : Grant, Koninklijke Philips NV , Aytekin Oto MD : Research Grant, Koninklijke Philips NV
Consultant, Guerbet SA
PURPOSE
To investigate the role of a novel, hybrid T2-diffusion-weighted (DW) MR imaging sequence for diagnosis of
prostate cancer and differentiation between aggressive and non-aggressive prostate cancers. This sequence
exploits the dependence of ADC values on TE, and dependence of T2 relaxation time on b values and has the
potential to improve registration between T2 and DW-MR images.
METHOD AND MATERIALS
22 patients with prostate cancer underwent pre-operative prostate MR including a hybrid imaging sequence;
DW-MR images were acquired with up to 4 b-values between 0 and 750 s/mm² and TE's between 47 and 200
ms, resulting in a 2x3 to 4x5 data array associated with each voxel. The voxel-based ADC and T2 decay
constants were calculated using a least squares fit at each TE and b-value, respectively. ROIs of cancer and
normal tissue were delineated by a radiologist and pathologist based on correlation with histopathology of the
prostatectomy specimen. The behavior of ADC and T2 with changing TE and b-value for normal and cancer
voxels was evaluated by comparing the number of voxels within a single ROI which display increased T2 with
increasing b value and decreased ADC with increasing TE. The Spearman rank-order test was used to evaluate
correlation of this MRI parameter with Gleason score (GS) and Student's t test for the difference between
cancer and normal ROIs.
RESULTS
A significantly higher percentage of voxels in cancer ROIs (n=41) demonstrated increased T 2 and decreased
ADC values with increasing b and TE compared to normal ROIs (n=21) (mean 18.9% vs. 3.0%, p=0.00035).
This percentage increased as GS increased (mean 9.5% for GS 6, 22.6% for GS 7, and 30.0% for GS 8 and 9
ROIs); this was a statistically significant trend with Spearman coefficient ρ=0.508 (p=2.5x10-5).
CONCLUSION
Hybrid T2-DW- MR imaging shows promise for detection of prostate cancer and determination of its
aggressiveness. Likely due to smaller glandular lumen volume, restricted diffusion, and high intracellular T 2 in
cancer cells, an increased number of voxels in prostate cancer ROIs demonstrate increased T2 and decreased
ADC values with increased b and TE values.
CLINICAL RELEVANCE/APPLICATION
In addition to combining the already proven useful information from T 2 and DW-MR images, Hybrid T2-DW-MR
imaging can provide added quantitative parameters helpful for diagnosis of prostate cancer.
VSGU21-13
Focal Therapies
Aytekin
Oto MD (Presenter): Research Grant, Koninklijke Philips NV Consultant, Guerbet SA
LEARNING OBJECTIVES
1) Emerging paradigm of focal therapy for early stage low risk prostate cancer. 2) Current status of different
focal therapy methods including laser ablation, high intensity focused US, electroporation and cryotherapy. 3)
Challenges in patient monitoring following focal therapy. 4) Future developments in focal therapy of prostate
cancer and the importance of radiologist's involvement.
ABSTRACT
TITLE: Image guided focal therapy of prostate cancer Focal therapy of low risk early stage prostate cancer is
increasingly important as a minimally invasive option for many patients. The rationale, patient selection criteria
and challenges for image-guided focal prostate cancer therapy will be discussed. The essential technical details,
advantages and disadvantages of clinically available focal therapy methods will be reviewed. Post-therapy
patient monitoring options will be presented. Future developments in the area of focal therapy of prostate
cancer and opportunities for involvement of radiologists in focal therapy will be explored.
VSIN21
Radiology Informatics Series: Mobile Computing Devices
Series Courses
IN
AMA PRA Category 1 Credits ™: 3.25
ARRT Category A+ Credits: 3.50
Mon, Dec 1 8:30 AM - 12:00 PM
Location: E352
Participants
Moderator
David S. Hirschorn MD : Nothing to Disclose
Moderator
Asim F. Choudhri MD : Nothing to Disclose
Moderator
George Lee Shih MD, MS : Consultant, Image Safely, Inc Stockholder, Image Safely, Inc Consultant, Angular Health, Inc
Stockholder, Angular Health, Inc
Sub-Events
VSIN21-01
Introduction
David S. Hirschorn MD (Presenter): Nothing to Disclose
VSIN21-02
Multi-Touch Control Device for PACS Workstation Implemented on a Consumer Tablet
Gabriel
Howles-Banerji MD, PhD (Presenter): Nothing to Disclose , Daniel
Holstein : Nothing to Disclose
CONCLUSION
A radiology-specific multi-touch controller for PACS workstations has been implemented on a consumer tablet.
Background
The traditional computer mouse is the primary tool for operating a PACS workstation, but its use can be
cumbersome and is associated with ergonomic hazards. Meanwhile, dramatic advances in trackpad and
touchscreen technology have revolutionized the way humans interact with computers, particularly smartphones
and tablets. We sought to explore whether contemporary "touch" technologies could be used to operate a PACS
workstation. More specifically, we sought to develop a peripheral device with radiology-specific touch controls
which might make navigating imaging studies more efficient and less fatiguing.
Evaluation
An application was written for the Apple iPad tablet that displays a collection of touch controls used for
operating the PACS workstation. The tablet communicates wirelessly with the PACS workstation and is used as
a peripheral device, like a mouse or keyboard. A client application on the workstation executes the commands
from the tablet. The device can be used with any vendor's workstation. The displayed controls allow the
radiologist to directly execute common PACS functions. For example, the Window/Level control works by
touching the control and then dragging the finger horizontally and vertically to control the displayed window
and level, respectively. Harnessing the "multi-touch" capability of the tablet, some controls respond to multiple
fingers. For example, the rate at which the Scroll control moves between slices in a CT scan is dependent on
the number of fingers used -- one finger for precise scrolling, four fingers for fast scrolling. The collection of the
controls can be customized for each type of study. For example, a Cine Loop control is provided for ultrasound
studies but not plain films.
Discussion
This work demonstrates that a touch control interface can be used for navigating imaging studies on an existing
commercial PACS workstation. Having developed a prototype with a suite of radiology-specific controls, the
next step is to test the device in routine use to determine what advantages it may offer in the daily work of
radiologists.
VSIN21-03
Diagnostic Imaging in Live Streaming using High Tech Mobile Devices: Is Real Time Diagnosis, While
Being on the Move, Possible?
Vasileios Moustakas MD (Presenter): Nothing to Disclose , Demosthenes D. Cokkinos MD : Nothing to
Disclose , Eleni Antypa : Nothing to Disclose , Panagiotis Tserotas MD : Nothing to Disclose , Alkmini
Skoura MD : Nothing to Disclose , Ploutarhos A Piperopoulos MD, PhD : Nothing to Disclose
CONCLUSION
Real time remote diagnosis of complete US examinations performed elsewhere using a wireless setting and a
tablet is feasible and useful.
Background
Mobile devices are already part of daily routine radiological practice. We built a remote real time wireless review
system using ultrasound (US). In this modality visualisation of a complete examination in real time, instead of
static images, is important to establish the best possible diagnosis.
Evaluation
The live streaming wireless system is composed of 3 components: a hardware video compression system that
also sends video clips in 1080p Full HD; a WiFi router capable of connecting to HDSPA+ / LTE(4G) mobile
networks and a tablet with an Octa Core CPU featuring a 10.1", super-clear LCD 2560 x 1600 WQXGA display.
37 patients were scanned by a Consultant Radiologist for various indications. 42 complete US examinations of
the abdomen (18 examinations), carotids (10), leg arteries (5), leg veins (6) and thyroid (3) were reviewed
remotely in real time by another Consultant Radiologist in another area, with no contact to the examining
doctor. The two doctors' independent double blinded reports were compared using standardised reporting
systems to assess imaging quality of the tablet in comparison to the US machine image. In 538/545 (98.72%)
results (organ measurements, echogenicity of normal findings and lesions, degree of blood perfusion, suggested
diagnosis) complete interobserver agreement was observed. The few (7/545=1.28%) contradicting results were
limited to different evaluations of liver/kidney echogenicity and thyroid nodule perfusion, data which also often
present discrepancies between different examiners on the same monitor.
Discussion
In most of the evaluated parameters, good interobserver agreement showed that the real time wireless
streaming did not affect image quality and therefore did not alter diagnosis. Therefore, this technique can be
used in cases where a second (usually more experienced) look on whole US examinations is needed, instead of
specific static images as is the usual practice.
VSIN21-04
The Perks and Pitfalls of Implementing an iPad Program at a Large Radiology Residency Program
Evan Johnson MD (Presenter): Nothing to Disclose , Jason Sherwin : Nothing to Disclose , Theodora A.
Bakker MS : Nothing to Disclose , Cecilia Luz Mercado MD : Nothing to Disclose
PURPOSE
Tablet computing is now ubiquitous in society and is seeing widespread implementation in education. Radiology,
as a technology and knowledge based specialty, is suited to the introduction of tablet computing and residency
is an ideal place for implementation as this is when the maximal amount of knowledge is required to be
absorbed. Tablets increase the portability and interactivity of residency education.
METHOD AND MATERIALS
Apple iPad Airs are to be introduced to 40 diagnostic radiology residents at a major academic medical center in
mid-April 2014. Early surveys have been performed recording resident's interest and study habits prior to
widespread implementation. Issues addressed include whether there is interest in increasing the interactivity of
conferences and whether or not there would be interest in implementing the iPads clinically. Similar surveys
and metrics will be obtained following implementation of the iPad. Issues that arose during implementation
including management, funding, software, and utilization will be discussed.
RESULTS
Early results have been promising with 81% of residents finding a positive impact with increased interactivity in
noon conference (utilizing a previous audience response system). Though 59% of respondents did have a
previously purchased tablet computer, 100% felt that a program provided unit would provide a benefit to their
education.
CONCLUSION
Tablet computing is rapidly becoming a commonplace item in residency education. The task of implementing a
Tablet computing is rapidly becoming a commonplace item in residency education. The task of implementing a
tablet computer on a large scale and with the appropriate software is not an easy one. The authors hope to
provide insight into their experiences and give a roadmap for residency programs hoping to implement a similar
program.
CLINICAL RELEVANCE/APPLICATION
Implementation of an Apple iPad in a radiology residency can be a daunting task but one that can reap great
educational rewards.
VSIN21-05
Platforms and Security
George Lee Shih MD, MS (Presenter): Consultant, Image Safely, Inc Stockholder, Image Safely, Inc
Consultant, Angular Health, Inc Stockholder, Angular Health, Inc
LEARNING OBJECTIVES
1) Mobile platforms: (a) Provide understanding of key features and advantages of mobile platforms including
platform owner, app developers, and end-users (b) Discuss mobile healthcare trends and evolution involving
Apple iOS and Google Android, with focus on healthcare-specific concerns. 2) Mobile Security: Provide basic
understanding of different security concerns i.
ABSTRACT
Mobile healthcare devices of all shapes and sizes are now ubiquitous in clinical setting. Radiologists and other
providers are leveraging mobile solutions in their clinical workflow. The major mobile platforms provide distinct
advantages for both app developers and end users (ie, clinicians and patients) in the healthcare setting. The
two main platforms for tablet mobile devices are Apple iOS and the Google Android. Mobile devices will need to
have the same or enhanced security compared with traditional computers because of increased portability and
the Bring Your Own Device (BYOD) phenomenon where clinicians are increasingly using their personal devices
for work. Managing enterprise mobile security on a wide range of work and personal mobile devices will remain
challenging although can be alleviated by using Mobile Device Manager software which can deploy updates and
enforce security policies. Shared mobile devices for patients in the clinical setting may also present similar
challenges.
VSIN21-06
Apps, Bandwidth, and Integration
Asim F. Choudhri MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) To have an understanding of available applications available for mobile medical imaging, including native
clients, web clients, and virtual desktop/terminal server approaches. 2) To have an understanding of bandwidth
concerns in mobile medical imaging, including device data handling, network speeds, and possible bandwidth
cost issues. 3) To have an understanding of possible clinical implementations of mobile medical imaging within
radiology departments and in health care networks overall.
ABSTRACT
Applications: There are several vastly different approaches to mobile viewing of medical images. Native clients
are programs written using a software development kit for a given platform. These clients can retrieve data
from remote servers and view locally stored image data. Web clients are web-based programs which are often
(but not always) platform independent. They will typically access remotely stored data which may be stored in
a local cache but is usually not permanently stored on the mobile device. Virtual desktop/terminal server
software allows a mobile device to access a remote computer or server. The remote server handles all higher
level processing and data storage, minimizing the processing requirements of the mobile device but possibly
straining bandwidth limitations. Examples of several applications using each of these approaches will be
presented, with a discussion of pros and cons for each method as it pertains to an individual user and as it
pertains to widespread implementation within a healthcare network. Bandwidth: Viewing medical images may
require transfer of datasets that are tens or hundreds of megabytes in size. This provides a special challenge for
mobile devices which typically receive data via wireless communication. If using a cellular network, network
bandwidth can be a limiting factor (as can data transfer costs). File compression can reduce the size of files,
however requires data processing power and may involve compromises in image quality. Once data is on a
device, image processing may overwhelm its processing capabilities compared with dedicated PACS
workstations. We will discuss both network and device bandwidth concerns as it relates to mobile medical
imaging, and possible solutions for overcoming obstacles. Integration into a healthcare system: Mobile review
of medical imaging is a tool which has potential to significantly change health care delivery, but the specifics for
implementation are unclear. After a device platform has been selected, security protocols established, and
bandwidth concerns solved, each institution will need to determine what role this technology will play.
Possibilities include radiology residents (or even faculty) consulting with subspecialty faculty, surgeons and
interventionalists triaging patients for procedures and for procedure planning, however these approaches are
simply extensions of existing practices. New frontiers in consultation will be discussed, including an example
involving mobile imaging review in a multidisciplinary stroke team. Guidance will also be provided regarding
training and establishing institutional "standard operating procedures" documents. The current state of
medical-legal concerns and risk management strategies will also be discussed.
VSIN21-07
A Collaborative Approach to Implementing a Tablet-Computing Program at an Academic Radiology
Residency
Evan Johnson MD (Presenter): Nothing to Disclose , Jason Sherwin : Nothing to Disclose , Theodora A.
Bakker MS : Nothing to Disclose , Cecilia Luz Mercado MD : Nothing to Disclose
CONCLUSION
An interdisciplinary team was a key component in implementation of a tablet-computing program within our
residency. Utilization of such a team will ease the transition to a tablet-computing program and ensure that all
of the appropriate hardware and software factors are considered and to more fully integrate the program into
the infrastructure of an academic medical center.
Background
Tablet-computing is seeing widespread implementation in medical education. Radiology residency, as a
technology and knowledge based specialty, is well suited to the introduction of tablet-computing. Several
programs have sought the introduction of tablet-computing but none have described the interdisciplinary
approach that is needed to incorporate the entire spectrum of clinical information needs of the resident within
the tablet program.
Evaluation
Introducing a tablet-computing program on a large scale that incorporates the specific needs of a radiology
residency can be a complex undertaking. This includes access to imaging tools (PACS and teaching file),
education tools (electronic books and journals as well as online study tools, etc.), clinical applications (EHR),
response ware, and productivity tools (centralized calendaring, note taking, etc). It also requires
conceptualizing hardware needs such as the tablet device and wireless access. The program must adapt to the
evolving needs of residents as they progress through the program. Assessment of the program will involve
ongoing evaluations of the participants as well as a cost-benefit analysis of ongoing support.
Discussion
An interdisciplinary approach was formed to implement a tablet-computing program at an academic radiology
residency program consisting of 40 residents. Radiology information technology, library informatics, radiology
administration, and resident input were part of the program's implementation. Utilizing this approach allowed us
to expedite the introduction of and find the best tools for our tablet-computing program. This partnership also
expanded to include a longitudinal assessment plan for the impact and efficacy of the program in the aims of
improving resident knowledge and ease of access to critical tools and information.
VSIN21-08
First-person Simulation of Interventional Procedures Using Google Glass™ as Both a Recording and
Display Device
Adnaan Moin MD (Presenter): Nothing to Disclose , Alaa Beydoun MD : Nothing to Disclose , Eliot L.
Siegel MD : Research Grant, General Electric Company Speakers Bureau, Siemens AG Board of Directors,
Carestream Health, Inc Research Grant, XYBIX Systems, Inc Research Grant, Steelcase, Inc Research Grant,
Anthro Corp Research Grant, RedRick Technologies Inc Research Grant, Evolved Technologies Corporation
Research Grant, Barco nv Research Grant, Intel Corporation Research Grant, Dell Inc Research Grant, Herman
Miller, Inc Research Grant, Virtual Radiology Research Grant, Anatomical Travelogue, Inc Medical Advisory
Board, Fovia, Inc Medical Advisory Board, Toshiba Corporation Medical Advisory Board, McKesson Corporation
Medical Advisory Board, Carestream Health, Inc Medical Advisory Board, Bayer AG Research, TeraRecon, Inc
Medical Advisory Board, Bracco Group Researcher, Bracco Group Medical Advisory Board, Merge Healthcare
Incorporated Medical Advisory Board, Microsoft Corporation Researcher, Microsoft Corporation
CONCLUSION
Application of wearable technology should continue to expand in healthcare in both the educational and clinical
realms. Radiology must be at the forefront of such technology given our strengths in both innovation and
imaging. While a teaching video series may represent the most basic application of such technology, dynamic
use such as procedural assistance and PACS integration as well as further optimization with appropriate
shielding of wearable devices should continue to be explored.
Background
With the increasing popularity and functionality of wearable technology such as Google Glass™, focused
investigation has only begun into the utility of such devices in the field of healthcare. While currently there
exists a dearth of literature on clinical applications of wearable technology, at the most basic level, interactive
educational models can be developed utilizing this unique first-person perspective as a supplement to other
traditional teaching methods. Within radiology in particular, education of interventional procedures and
periprocedural patient management can be enhanced through the perspective of experienced radiologists.
Evaluation
Multiple interventional radiology procedures were recorded from a first-person perspective through Google
Glass™ on simulation models. The wearable device was primarily used to document what an operator may
observe both at the level of their hands as well as their eyes during the course of a procedure. These recordings
were then compiled to create a library of simulation videos of a diverse range of procedures. Additionally, the
device was used as a display for procedural guidance.
Discussion
The functionality of wearable technology provides a unique opportunity within the academic model, as residents
and fellows are able to experience a procedure from a first-person perspective without combatting with physical
and visual limitations in an interventional suite or procedure room. While this video series may be introductory
in the potential use of wearable devices in radiology, it provides further insight on the vast educational and
clinical applications of the technology throughout healthcare, such as using wearable media as a primary display.
Adoption of a Mobile Clinical Decision Support Tool for Radiologists
VSIN21-09
Adoption of a Mobile Clinical Decision Support Tool for Radiologists
Roy
Kwak MD (Presenter): Founder, Medocratic LLC CEO, Medocratic LLC , Steve
Do : Nothing to Disclose
CONCLUSION
The creation and rapid adoption of RadsBest, proves the need for Radiology decision support. Aggregate user
data can provide insights into the utilization of management guidelines by practicing Radiologists.
Background
As part of the focus on quality within Radiology, Radiologists have been encouraged to create more actionable
reports with consistent management recommendations based on published guidelines and consensus
statements. There are hurdles to incorporating these guidelines. A mobile decision support tool was recently
developed for Radiologists called RadsBest. It allows Radiologists to navigate many of these guidelines and
recommendations very easily. We evaluate the early adoption of this technology and how users are utilizing the
application in clinical practice.
Evaluation
Within the app, users choose a specific tool applicable to the clinical scenario. Then they tap through a few
questions. The recommendations are output on the next screen and can be used verbatim, or modified, based
on the users expertise. All content is based on major publications relevant to the management of radiologic
findings. The app collects generic aggregated information about how users are utilizing the application. On
average, there has been approximately 104 new user accounts created per month since the app was initially
released. The app is opened 2.71 (+/-0.52) per month by each active user. The distribution of activity is
skewed toward a smaller subset of users. The five most frequently utilized tools were (decreasing order)
guidelines for thyroid nodules, asymptomatic ovarian cysts, solitary pulmonary nodules, incidental adrenal
mass, and asymptomatic liver mass.
Discussion
Early adoption rates supports the existence of demand for tools such as this. Although there is a high level of
early engagement, the majority of users are not considered 'active users'. Amongst 'active users' there appears
to be a subset of 'power users' who use the application frequently. The relative popularity of the individual tools
may provide insight into the the prevalence of the imaging finding, characteristics of the guideline, and/or the
effectiveness of the app for that guideline.
VSIN21-10
Displays and Quality Assurance
David S. Hirschorn MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Discuss ranges of spatial and contrast resolution for medical imaging. 2) Explore options for calibration and
quality assurance. 3) Understand the impact of ambient light and viewing distance and angle on medical image
display.
ABSTRACT
Mobile devices have significantly smaller displays than desktop or even laptop computers to make them lighter
and more easily transported. They are also designed for shorter viewing distances which require smaller pixels.
The smaller total display size tends to reduce the number of pixels, while the smaller pixel size tends to
increase the number of pixels. On balance, these displays typically have considerably fewer pixels than their
stationary counterparts. Nonetheless, even desktop displays typically have less resolution than the original
image size of a radiograph which is typically about 5 megapixel (MP) for a chest radiograph. And both types of
displays have more resolution than a single CT image, which is 0.25 MP. Since these devices do allow zooming
and panning, they may be suitable for image interpretation under controlled circumstances.
The main purpose of the DICOM Part 14 Grayscale Display Function is to ensure that contrast is preserved
across the range of shades of gray from black to white, particularly at the edges where uncalibrated displays
tend to fall off. With desktop displays this can be measured with a photometer, either external or built-in, and
graphics adapter adjustments can be made to make the display conformant. Mobile devices typically do not
offer this degree of adjustability. This requires a different approach to DICOM curve conformance, and a
reasonable alternative is to present the user with a visual challenge to identify low contrast targets placed
randomly on the display. If the user can find them and tap on them, then the display may be considered
compliant, and if not, then the display should not be relied upon.
VSIR21
Interventional Series: Embolotherapy
Series Courses
IR VA
AMA PRA Category 1 Credits ™: 3.25
ARRT Category A+ Credits: 3.75
Mon, Dec 1 8:30 AM - 12:00 PM
Participants
Location: S406B
Moderator
Jafar Golzarian MD : Nothing to Disclose
LEARNING OBJECTIVES
1) Describe indications and technical aspects of embolization for symptomatic prostatic hypertrophy. 2) Explain the rationale
and treatment of low flow malformations. 3) Describe the preparation of cyanoacrylates for embolization. 4) Describe two
complications related to embolization. 5) List two important studies on embolotherapy.
Sub-Events
VSIR21-01
Using Glue—How I Do It
Yasuaki
Arai (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Learn features of glue as embolic material, 2) Learn clinical situations that glue is preferable to be chosen,
3) Understand how to use glue, and 4) Be aware of pitfalls using glue in embolization.
VSIR21-02
A Mixture of N-Butyl Cyanoacrylate, Lipiodol and Ethanol under Flow Control Using an Arteriovenous
Malformation (AVM) Model, Is It Useful for Embolization
Masaki Ishikawa MD (Presenter): Nothing to Disclose , Masahiro Horikawa MD : Nothing to Disclose ,
Barry T Uchida : Nothing to Disclose , Hans A Timmermans : Nothing to Disclose , John Andrew Kaufman
MD : Consultant, Bio2 Technologies, Inc Consultant, Cook Group Incorporated Consultant, Covidien AG
Consultant, W. L. Gore & Associates, Inc Consultant, Guerbet SA Stockholder, Hatch Medical LLC Stockholder,
VuMedi, Inc Stockholder, Veniti, Inc Royalties, Reed Elsevier Advisory Board, Delcath Systems, Inc Researcher,
W. L. Gore & Associates, Inc Researcher, Guerbet SA , Kazuo Awai MD : Research Grant, Toshiba
Corporation Research Grant, Hitachi Ltd Research Grant, Bayer AG Research Consultant, DAIICHI SANKYO
Group Research Grant, Eisai Co, Ltd , Takuji Yamagami MD : Nothing to Disclose
PURPOSE
Recently, a mixture of n-butyl cyanoacrylate, Lipiodol and ethanol at ration of 1:1:3 (NLE 113) as new
embolization material was introduced. The character of this embolization material is changed because n-butyl
cyanoacrylate (NBCA) polymerization can be accelerated by addition of ethanol to NBCA and Lipiodol.
Controllability of embolization for AVMs remains controversial. We evaluated usability of NLE in vitro model for
AVMs.
METHOD AND MATERIALS
An original simulation circuit component including an artificial nidus was constructed to generate pulsatile flow
(Figure 1). This system was filled with heparinized swine blood. NBCA and Lipiodol mixtures at ratios of 1:1,
1:3, 1:5 and 1:10, and NLE 113 with flow control or without flow control was injected to achieve complete
embolization. Results of embolization were classified as complete filled, proximal embolization, pass through or
sift to distal after balloon deflation, and each session was compared (Figure 2).
RESULTS
NLE 113 with flow control was complete filled in 6/6 cases (Figure 3). NBCA and Lipiodol mixture at ration of 1:1
with flow control was complete filled in 3/6 cases. NBCA and Lipiodol mixture at ration of 1:5 without flow
control was complete filled in 3/6 cases. Other sessions did not achieve complete filled embolization.
CONCLUSION
Optimal embolization control of the AVM model was best using NLE 113 with flow control.
CLINICAL RELEVANCE/APPLICATION
In liquid embolic materials have difficult controllability, NLE 113 have excellent controllability under flow control.
NLE 113 can be acceptable as embolic material for arteriovenous malformation.
VSIR21-03
Embolization Treatment for Intractable Bladder Bleeeding-Clinical Efficacy and Safety
Maria Tsitskari MD (Presenter): Nothing to Disclose , Lazaros Reppas BS : Nothing to Disclose , Dimitrios
Filippiadis MD, PhD : Nothing to Disclose , Kostantinos Palialexis : Nothing to Disclose , Chrisostomos
Kostantos : Nothing to Disclose , Elias Brountzos MD : Nothing to Disclose
PURPOSE
We evaluated the outcomes of embolization treatment for intractable bladder bleeding after failed conservative
treatment.
METHOD AND MATERIALS
We retrospectively studied the records of 1 woman and 10 men with a mean age of 76 years referred between
February 2008 and March 2014 for bladder embolization after failed conventional therapy. The underlying
pathologies included bladder cancer in 9 patients, prostate cancer in 1 and metastatic osteosarcoma of the
urinary bladder in 1 case. Embolization was feasible in 10 out 11 patients. It consisted of superselective
urinary bladder in 1 case. Embolization was feasible in 10 out 11 patients. It consisted of superselective
embolizaion of the superior or inferior vesical arteries with particles or glue in 10 patients, and selective
proximal gelfoam sponge particle occlusion of the anterior division of the internal iliac artery in 1 patient. Clinical
bleeding control and post-embolization angiography findings were used to assess outcomes.
RESULTS
The technical success rate was 90% (10 of 11 cases). In the one patient embolization was not possible, due to
severe tortuosity of the iliac arteries. Bleeding was controlled after the first procedure in 8 patients, and after a
repeat procedure in 2. Non target embolization of the buttocks ant the anterior abdominal wall was encountered
in 1 patient. Late bleeding recurrence was reported in 2 of the 10 survivors. Mean post-embolization follow up
was 30 months. During follow up 4 patients died, due to underlying conditions.
CONCLUSION
Selective vesical artery embolization is effective for the control of refractory, life threatening bladder bleeding
CLINICAL RELEVANCE/APPLICATION
Selective angiographic embolization is safe and effective to control refractory, life threatening bladder bleeding.
This procedure should be considered the treatment of choice since it usually obviates the need for emergency
surgery in these severely ill patients
VSIR21-04
Endovascular Treatment for Aldosterone Producing Adrenal Adenoma: A Long Term Follow-up Study
Yasutaka Baba MD (Presenter): Nothing to Disclose , Sadao Hayashi MD : Nothing to Disclose , Kohei
Nagasato : Nothing to Disclose , Takashi Yoshiura MD, PhD : Nothing to Disclose
PURPOSE
To investigate the efficacy of endovascular treatment for aldosterone producing adrenal adenoma (APAA)
including the long term results.
METHOD AND MATERIALS
We retrospectively analyzed treatment results of 42 APAAs in 42 consecutive patients (12 male and 30 females;
mean age, 47 years) that were treated by endovascular treatment (arterial or venous embolization) with
absolute ethanol (AE) between August 1992 and June 2013. 25 adenomas were located in the right adrenal
gland while 17 were in the left. The mean size of the adenomas was 14mm (range, 8-30 mm) in diameter.
Before embolization, we mapped all feeding arteries of the adenoma. Then we determine the volume of AE to
use for embolization by adrenal arteriograms or CT images. Prophylactic microcoil embolization of distal feeding
arteries was performed in order to avoid unintentional AE injection. In venous embolization, a balloon catheter
was used to avoid the reflux of AE. In order to prevent pain and vascular spasm during arterial embolization,
we injected lidocaine into the feeding arteries. In addition, we used anti-alpha blocker and calcium blocker to
prevent hypertension and hypercatecholaminemia. We evaluated the technical success rate which was defined
as normal range of both serum aldosterone concentration and renin activity within 1 month after treatment and
acute complications. Moreover, we evaluated rates of improvement in hypertension and normalization of serum
aldosterone concentration and renin activity in the follow-up period. The mean follow-up period was 1309 days.
RESULTS
The number of treatment session was 56 and average dosage of AE was 1.8 mL. (range, 0.2-7 mL). Technical
success rate was 88% (37/42) and five patients were subsequently treated by operation. Acute complication
comprised of pain (64%), unstable blood pressure (23%) and pleural effusion (11%) without major
complications. Rates of improvement in hypertension, normalization of serum aldosterone concentration and
renin activity in the follow-up period were 72% (27/37), 97% (36/37), and 97% (36/37), respectively.
CONCLUSION
Endovascular treatment is less invasive and efficient therapeutic option for APAAs.
CLINICAL RELEVANCE/APPLICATION
Endovascular embolization of APAA is a promising treatment option.
VSIR21-05
Embolotherapy—My Best Tips and Tricks
Robert Anthony Morgan MD (Presenter): Consultant, Cook Group Incorporated Consultant, AngioDynamics,
Inc Proctor, Covidien AG
LEARNING OBJECTIVES
View learning objectives under main course title.
VSIR21-06
Embolization Disasters—The 5 Worst Cases I've Ever Seen
VSIR21-06
Michael David Darcy MD (Presenter): Advisory Board Member, AngioDynamics, Inc Speakers Bureau, W. L.
Gore & Associates, Inc Speakers Bureau, Argon Medical Devices, Inc Consultant, Boston Scientific Corporation
LEARNING OBJECTIVES
1) Learn of some potential complications that can occur with interventional procedures. 2) Be aware of how to
recognize these complications. 3) Understand strategies for managing complications.
ABSTRACT
5 major complications for various vascular and non-vascular cases will be presented to highlight the range of
major disasters that an interventional radiologist might encounter. Discussion will cover potential causes,
recognition, management of, and future prevention of similar complications,
VSIR21-07
Low Flow Malformations—How I Treat Them
William S. Rilling MD (Presenter): Research support, BTG International Ltd Research support, Sirtex Medical
Ltd Research Support, B. Braun Melsungen AG Advisory Board, Angiodynamics, Inc Consultant, Cook Group
Incorporated Consultant, B. Braun Melsungen AG Consultat, Guerbet SA Consultat, Vascular Solutions, Inc
LEARNING OBJECTIVES
View learning objectives under main course title.
VSIR21-08
Embolization of Intraosseous AVM
Wayne Francis Yakes MD (Presenter): Nothing to Disclose
PURPOSE
AVM of bone is a difficult management problem. Because standard embolic agents are rarely curative and only
palliative, ethanol and ethanol with coils are evaluated to curatively treat bone AVMs as an alternative
management strategy.
METHOD AND MATERIALS
Twenty-nine patients (17 f, 12 m); age range 6 - 48 years, mean: 19 years) presented with bone AVMs
involving the upper extremity, lower extremity, pelvis, spine, and head and neck areas. All patients underwent
MR, arteriography, and endovascular repair of their bone AVMs. Ethanol alone, ethanol with coils, and coils were
the sole embolic agents utilized.
RESULTS
Twenty-eight of twenty-nine patients are cured of their intraosseous AVM at follow-up (range 8 months - 168
months; mean: 54 months). One patient's therapy is on-going (mandible/maxilla/face AVMs). Complications
include one coil migration to the lung (retrieved without sequelae), three patients with skin injury in the lower
extremity (healed uneventfully), and one patient with chronic weakness left quadriceps femoris muscle group,
which was present prior to treatment and not improved with treatment of her pelvic/iliac wing AVM. One patient
had a right maxilla infection/sinusitis treated by antibiotics.
CONCLUSION
Bone AVMs in the literature are rarely cured, save by amputation. Ethanol or ethanol with coils has proven to
be consistent in ablating bone AVMs and are durable at long-term follow-up, in essence curing the AVM. When
bone AVM is present in an extremity, multiple AVMs in that extremity can occur, an unexpected finding.
Acceptable low complication rates are noted in this series.
CLINICAL RELEVANCE/APPLICATION
AVM of bone is a difficult management problem. Because standard embolic agents (glue, PVA, Onyx,
Embospheres, etc.) are rarely curative and only palliative, ethanol and ethanol with coils are evaluated to
curatively treat bone AVMs as an alternative management strategy.
VSIR21-09
Acquired Non–Traumatic Peripheral Arteriovenous Fistula
Wayne Francis Yakes MD (Presenter): Nothing to Disclose
PURPOSE
To determine the etiology of acquired non-traumatic arteriovenous vascular fistula (AVF), evaluate their venous
physiology and determine management strategies. Non-traumatic acquired AVF of the peripheral vascular
system and its management has not been described or published in the world's literature.
METHOD AND MATERIALS
Ten patients (2 males, 8 female; age range 47 - 84 yrs; mean age: 66 years) presented with acquired
peripheral arteriovenous fistualization of veins causing swelling and venous hypertensive changes in the lower
extremities and left upper extremity. All presented with enlargement and swelling of their left lower extremity.
Additionally, one patient had enlargement of her left buttock; one patient had bilateral lower extremity severe
swelling with venous stasis changes in the legs, one patient had gross edema of the left upper extremity, two
patients had non-healing venous stasis ulcers complicated with cellulitis; and one patient had a left femoral
fracture that was surgically treated previously and due to a spine injury, was paraplegic. All patients had great
difficulty with ambulating. No patient had a history of blunt or penetrating trauma. All patients underwent
ultrasound, arteriography and lower extremity venography in their work-up.
RESULTS
All patients were discovered to have acquired (non-congenital) extensive AVF in the pelvic, groin, leg, thigh and
left shoulder; four patients had major venous chronic occlusions. After treating their AVF endovascularly, all
patients had resolution of their swelling despite the venous occlusions. The non-healing ulcers totally healed.
CONCLUSION
This lesion is not described in the world's literature. The only similar lesion reported in the world's literature is
dural AVF of the saggital/ transvers/sigmoid/cavernous sinuses. This is the first report of this entity occurring in
the periphery and successful management strategies.
CLINICAL RELEVANCE/APPLICATION
Cure of these difficult lesions is possible with endovascular approaches utilizing coils and by eliminating the
fistulas and the venous hypertension; stenting of the disease vein segments also proved successful in
eliminating the numerous AVF in the vein wall.
VSIR21-10
Treatment of Peripheral Vascular Malformation (PVM): A New Concept of Low Pressure
Sclerotherapy (LPS)
Khawla
Boughanmi (Presenter): Nothing to Disclose , Khalil Riadh Hamza MD : Nothing to Disclose
PURPOSE
Intra lesion injection of sclerosant agent and peripheral compression of venous out flow are responsible of
elevation of intra lesion's pressure that can induce peripheral diffusion of the sclerosis agent. We developed the
concept of (LPS) by placing multiple needles in the (PVM).These needles work as multiple valves that allow the
free circulation of the sclerosant agent and the outflow of the extra injected fluid.This technique is used for the
treatment of low flow vascular malformations and peripheral AVM (nidus and venous side)
METHOD AND MATERIALS
In a period of76months (September 2006-december 2013),170 patients were treated with this concept:122
patients with venous malformations (VM), 28 patients with lymphatic malformation(LM) including 26 patients
with macro cystic LM and two patients with micro cystic LM and 20 patients with superficial (AVM).3%
tetradecyl sulphate foam, and since three years, lauromacrogol 400 have been used in all cases of VM(20-60
ml)and in two case of micro cystic LM. Absolute ethanol (AE) was used in 88 patients:in 44VM complementary to
foam, in 24 LM and in 20 cases of peripheral AVM. Glue (isobutyl 2 cyanoacrylate) was used in4 cases of AVM
complementary to AE or before using AE.Up to7 sessions were performed per patient
RESULTS
Technical success was reached in all cases. Loss of volume at MRI ranged from 25% to 80% except for two
patients who presented with large size VM.All patients were cosmetically improved and relieved of pain.
Swelling of the lesion occurred in all treated cases and it was well tolerated and controlled with NSAIDs with
resolution in few days(4-7days). Significant complications occurred in 3 patients and consisted of phlyctena,
fistula and necrosis.They were managed conservatively
CONCLUSION
LPS concept using 3% STS foam,lauromacrogol and AE in our experience over more than six years has proven
the technique to be effective with dramatic decreasing of complications.AE is used to treat macro cystic LM,
superficial AVM and complementary to STS foam in some VM with extreme care concerning the volume injected
CLINICAL RELEVANCE/APPLICATION
Placing multiple needles in peripheral Vascular malformation allow free circulation of the sclerosing agent these
needles work as multiple valves that allow an exit of the sclerosing agent .The technique is effective with
dramatic decreasing of complication.Actually we used this approach to treat VM, cystic LM and superficial AVM
VSIR21-11
Predictive Quantification of Infarction Volume before Partial Splenic Embolization for Hypersplenism
Toshihiro Tanaka MD (Presenter): Nothing to Disclose , Tetsuya Masada : Nothing to Disclose , Hideyuki
Nishiofuku : Nothing to Disclose , Takeshi Sato : Nothing to Disclose , Shinsaku Maeda : Nothing to
Disclose , Kimihiko Kichikawa MD : Nothing to Disclose , Hiroshi Anai MD, PhD : Nothing to Disclose ,
Masayoshi Inoue MD : Nothing to Disclose
PURPOSE
To obtain the optimal splenic infarction volume is the key to achieve high efficacy and to reduce the risk of
complications after partial splenic embolization (PSE). We have developed a new system to predict the infarction
splenic volume before PSE using computed volumetric analysis software. The aim of this study is to evaluate the
accuracy of this prediction system.
METHOD AND MATERIALS
The data, from 12 patients with hypersplenism who had received PSE, was retrospectively analyzed.
3-dimensional (3-D) arteriography image was reconstructed from the contrast enhanced CT obtained before
PSE. Using a 3-D image analysis system (SYNAPSE VINCENT TM ), the volume of the area supplied from each
splenic branch was calculated based on the Voronoi Diagram. The estimated infarction volume was defined by
the total sum of the volume supplied from each embolized branch. The actual infarction volume was calculated
on the contrast enhanced CT obtained 1 week after PSE. Pearson Correlation Coefficients was used to assess
the correlation between the estimated infarction volume and the actual infarction volume.
RESULTS
The mean estimated and actual infarction volumes were 65.4±14.6% and 60.9±10.2%, respectively. The mean
difference between them was 7.29±6.93%. The actual infarction volume was strongly correlated with the
estimated infarction volume (ρ= 0.791, P=0.002). There were no complications in any of the patients. The
mean platelet count significantly increased from 7.96×104/µL before PSE to 15.6×104/µL two weeks after PSE
(the increased ratio: 259±93.9%).
CONCLUSION
Our results demonstrated that infarction splenic volume can be precisely predicted before PSE using computed
volumetric analysis software. This new system could be helpful for tailoring planning of PSE to achieve optimal
splenic infarction volume in patients with hypersplenism.
CLINICAL RELEVANCE/APPLICATION
Predictive quantification of splenic infarction volume using the Voronoi Diagram method is accurate, which could
be useful for planning before PSE.
VSIR21-12
Technical Aspects of Prostate Embolization—Why this is not UFE
Jafar
Golzarian MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
View learning objectives under main course title.
VSIR21-13
5 Papers in 15 Minutes: Studies in Embolotherapy that Everyone Should Know
Sue Ellen Hanks MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Describe indications and technical aspects of embolization for symptomatic prostatic hypertrophy. 2) Explain
the rationale and treatment of low flow malformations. 3) Describe the preparation of cyanoacrylates for
embolization. 4) Describe two complications related to embolization. 5) List two important studies on
embolotherapy.
VSMK21
Musculoskeletal Series: Elbow, Hand and Wrist Imaging
Series Courses
ER MR MK ER MR MK
AMA PRA Category 1 Credits ™: 3.25
ARRT Category A+ Credits: 3.50
Mon, Dec 1 8:30 AM - 12:00 PM
Location: E451B
Participants
Moderator
Bruce B. Forster MD : Investor, Doyen Medical Incorporated
Moderator
Miriam Antoinette Bredella MD : Nothing to Disclose
LEARNING OBJECTIVES
The 'Elbow, Hand and Wrist' Series Course will review multimodality upper extremity imaging through 5 expert refresher course
presentations interspersed among scientific presentations.
Sub-Events
VSMK21-01
Sports Related Injuries of the Elbow
Bruce B. Forster MD (Presenter): Investor, Doyen Medical Incorporated
LEARNING OBJECTIVES
1) Demonstrate an understanding of the technical and procedure-related considerations in MR imaging of the
elbow. 2) Identify the normal anatomic structures and variants within the four compartments of the elbow. 3)
Diagnose common sports injuries of the elbow, using this compartmental approach.
VSMK21-02
Correlation of Elbow MRI findings with Innings Pitched in Symptomatic and Asymptomatic Major
League Baseball Pitchers
Nicholas Mark Gutierrez MD (Presenter): Nothing to Disclose , Jean Jose MS, DO : Nothing to Disclose ,
Michael Baraga : Nothing to Disclose , Bryson Lesniak MD : Nothing to Disclose , Kevin O'Donnell MD :
Nothing to Disclose , James Banks MD : Nothing to Disclose , Lee Kaplan MD : Nothing to Disclose
PURPOSE
To analyze the relationship between the total innings pitched and MRI findings of the elbow in asymptomatic
and symptomatic professional pitchers, and to identify whether any asymptomatic MRI findings predicted a
subsequent throwing related elbow injury that required a stay on the disabled list.
METHOD AND MATERIALS
Between 2001 to 2010, 25 asymptomatic Major League Baseball pitchers underwent MRI of their pitching arm at
the time of a contract signing or a trade. Thirteen additional MRIs were performed on players as a result of new
onset elbow symptoms during the course of the season. 2 MR arthrograms and 38 MRIs without intra-articular
contrast were performed with a closed 1.5-T magnet at 1 of 4 different centers. The images were reviewed by a
musculoskeletal radiologist who was blinded to the original MRI interpretations, the subjects' injury status, and
innings pitched. The total innings that the player pitched prior to the MRI was recorded in addition to elbow
injuries requiring a stay on the disabled list following the MRI. Statistical analysis was performed to examine
association between total career innings pitched and the presence of a particular MRI finding as well as between
MRI findings and a subsequent disabled list stay.
RESULTS
When grouped as a whole and analyzed for MRI findings in relation to innings pitched several trends were
observed that reached statistical significance. There was a greater number of innings pitched in players with
degenerative findings of the UCL, cartilage lesions, olecranon osteophytes, flexor pronator mass tendinosis, and
increased signal in the extensor wad.
CONCLUSION
The major league baseball pitcher's elbow is subject to repetitive valgus torque over the course of their career,
leading to adaptive and degenerative changes with the medial elbow and intra-articular structures. Though
detected on MRI, these findings do not necessarily correlate with elbow pain or dysfunction. Analysis of a small
but significant number of asymptomatic pitchers, who later sustained elbow injuries requiring a stay on the
disabled list, revealed that all had degeneration of the UCL with olecranon osteophytes, and most had flexor
pronator mass tendinosis.
CLINICAL RELEVANCE/APPLICATION
Degenerative findings along the medial elbow are commonly observed on MRI in professional pitchers. However,
these findings are often clinically insignificant and do not correlate with time on the disabled list.
VSMK21-03
Quantitative MRI Analysis of the Relationship between the Anconeus Epitrochlearis Muscle and Ulnar
Compression Neuropathy
Hing Yee Eng MD (Presenter): Nothing to Disclose , Carlos Luis Benitez MD : Nothing to Disclose
PURPOSE
The anconeus epitrochlearis muscle (AEM) is an anomalous accessory muscle in the elbow, coursing from the
medial olecranon to the medial epicondyle. Several cases in the literature have suggested the association of this
muscle with ulnar compression neuropathy. The purpose of this study is to review the MRI findings of the AEM,
assess the relationship between muscle size and ulnar nerve morphology, and investigate the muscle's
correlation with ulnar compression neuropathy.
METHOD AND MATERIALS
Thirty two cases of elbow MRI studies of patients with an AEM from July 2007 to March 2014 were reviewed
retrospectively. All of these patients presented with elbow pain and/or numbness with mean age of 40 years
(range 18 to 60 years). The following parameters were evaluated: ulnar nerve diameter proximal, within, and
distal to the cubital tunnel (CT); AEM cross sectional area (MA) and volume (MV); and encroachment ratio of
the muscle at the superior and inferior aspects of the CT. Changes in ulnar nerve caliber and signal were also
assessed.
RESULTS
The mean ulnar nerve diameters proximal, within, and distal to the CT were 3.63, 3.97, and 3.39 mm
respectively. The mean MA was 68.47 mm2 and mean MV was 6300 mm3. The mean encroachment ratio of the
AEM in the CT was 0.58 superiorly and 0.56 inferiorly. There was no statistically significant correlation between
the ulnar nerve diameter within the CT and MA (r = 0.05) or MV (r = 0.06). There were positive correlations
between the MA and both the superior (r = 0.66) and inferior (r = 0.64) encroachment ratios as well as
between the MV and the superior (r = 0.65) and inferior (r = 0.57) encroachment ratios. The most common
abnormalities involved the common extensor (n = 17) and biceps (n = 6) tendons. Four of the thirty two cases
demonstrated focal T2 hyperintensity and/or thickening of the ulnar nerve consistent with ulnar neuritis, three
within the CT and one just proximal to the CT.
CONCLUSION
Most findings of anconeus epitrochlearis muscle are incidental and asymptomatic without ulnar compression
neuropathy. There is no significant correlation between anconeus epitrochlearis muscle size and ulnar nerve
caliber in the cubital tunnel.
CLINICAL RELEVANCE/APPLICATION
Anconeus epitrochlearis muscle is usually incidentally found and not associated with symptoms or ulnar
compression neuropathy. This knowledge can help the clinician in the management of elbow pain.
VSMK21-04
Entrapment Neuropathies of the Upper Extremity
Ali M. Naraghi MD, FRCR (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Describe the normal peripheral nerve anatomy and muscle innervation in the upper extremity with an
emphasis on sites of compression. 2) Identify the common sites of nerve entrapment in the upper extremity. 3)
Recognize the imaging features of peripheral nerve entrapment in the upper extremity. 4) Recognize the
limitations in imaging of upper limb entrapment neuropathies.
VSMK21-05
The Triangular Fibrocartilage Complex: High- Resolution Morphologic and Quantitative MR
Evaluation
Monica Tafur MD (Presenter): Nothing to Disclose , Mohammed Jamal Aakef : Nothing to Disclose , Tania
Kumar : Nothing to Disclose , Jiang Du PhD : Nothing to Disclose , Sheronda Statum : Nothing to Disclose
, Christine B. Chung MD : Nothing to Disclose
PURPOSE
The objectives of this study are to implement high-resolution magnetic resonance imaging (MRI) using
ultrashort time-to-echo (UTE) techniques to evaluate the triangular fibrocartilage complex (TFCC) and to
quantify the MR properties of the TFCC.
METHOD AND MATERIALS
Institutional review board approval with exemption of informed consent was obtained. Wrists of subjects and
human cadavers were imaged in a 3T Signa TwinSpeed scanner (GE Healthcare) with optimized coils
(microscopy and dedicated wrist coils). Morphologic evaluation sequences included high-resolution proton
density (PD), 3D spoiled gradient echo (SPGR) and 2D/3D UTE. Quantitative evaluation included conventional
(T2 SE), T1rho sequences tailored for long T2 values (2D/3D T1rho) and UTE (UTE T2* and UTE T1rho)
sequences and an in-house MatLab analysis algorithm fitting regions of interest (ROIs) to determine average
values.
RESULTS
High-resolution MR images demonstrated the different structures of the TFCC as well as pathological findings
including perforations, degeneration and calcifications of the fibrocartilage among others. UTE sequences
allowed the visualization of structures with short T2 components and subtraction techniques facilitated the
identification of these components, such as TFC calcifications, which were better demonstrated in UTE
sequences as compared with conventional PD sequences. Quantitative MR analysis of the TFC showed a
bi-component decay behavior in normal subjects (short T2* = 0.31 ms, long T2* = 9.68 ms). T2, UTE T2* and
T1rho values were increased with degeneration of the TFC. In the presence of calcifications, UTE T2* values
were decreased probably due to magnetic susceptibility effects. In some cases, certain areas of the TFC showed
increased UTE T2* values despite a normal appearance on standard PD sequences, which may indicate early
stages of degeneration.
CONCLUSION
UTE MRI allows the visualization of short T2 components of the TFCC and improved the demonstration of certain
pathologies as compared with the standard clinical sequences. Quantitative MR analysis reflected changes in
TFC composition in some pathological cases.
CLINICAL RELEVANCE/APPLICATION
Morphological and quantitative UTE sequences allow visualization of the short T2 components of the TFCC and
demonstration of some pathological cases not provided by the standard clinical sequences.
VSMK21-06
Comparison of Wrist MR Arthrography Alone and Wrist MR Arthrography Plus Dynamic
Cine-arthrography: The Usefulness in the Diagnosis of Triangular Fibrocartilage Complex and
Intrinsic Ligament Tear
Seun Ah Lee MD (Presenter): Nothing to Disclose , Baek Hyun Kim MD : Nothing to Disclose , Seon Jeong
Oh : Nothing to Disclose , Jong Woong Park : Nothing to Disclose , Kyung-Sik Ahn MD : Nothing to
Disclose , Ji Yung Choo MD : Nothing to Disclose , Suk-Joo
Kang MD : Nothing to Disclose
Hong MD : Nothing to Disclose , Chang Ho
PURPOSE
The purposes of this study were to introduce dynamic cine-arthrography (DCA) and compare the diagnostic
performance between MR arthrography (MRA) alone and MRA with DCA for evaluating triangular fibrocartilage
complex (TFCC) and intrinsic ligament tears.
METHOD AND MATERIALS
93 wrists of 88 patients underwent both DCA and MRA from May 2010 to February 2014. Among them, 44
wrists of 42 patients who had undergone arthroscopy were included in this study. DCA was performed during
contrast injection for MRA. After puncture of the radio-carpal joint, DCA was taken while slowly injecting
contrast under fluoroscopic guidance during passive wrist exercise. We obtained 3.0T MRA with fat-suppressed
coronal, sagittal, and axial images. Two radiologist evaluated TFCC, scapho-lunate (S-L) ligament, and
luno-triquetral (L-T) ligament tears on MRA and MRA with DCA, respectively. Based on the arthroscophic
findings, we compared the diagnostic values between MRA and MRA with DCA by the McNemar test.
RESULTS
The overall sensitivity and specificity of the diagnosis of TFCC tear were the same between MRA and MRA with
DCA (reader 1, sensitivity 96.4%/96.4% (MRA/MRA with DCA), specificity 68.8%/68.8%, accuracy
86.4%/86.4%, reader 2, sensitivity 96.4%/96.4%, specificity 93.8%/93.8%, accuracy 95.5%/95.5%). For
intrinsic ligaments, all diagnostic values were increased on MRA with DCA as compared with MRA for both
readers (S-L ligament: reader 1, sensitivity 77.8%/77.8% (MRA/MRA with DCA), specificity 92.3%/96.2%,
accuracy 86.4%/88.6%, reader 2, sensitivity 61.1%/61.1%, specificity 76.9%/88.5%, accuracy 70.5%/77.3%,
L-T ligament: reader 1, sensitivity 66.7%/100%, specificity 89.7%/89.7%, accuracy 81.8%/93.2%, reader 2,
sensitivity 60.0%/86.7%, specificity 82.8%/86.2%, accuracy 75%/86.4%), without statistical significance
(p>0.05). The inter-observer agreement was more increased on MRA with DCA than MRA alone.
CONCLUSION
Wrist MR arthrography with dynamic cine-arthrography resulted in a higher diagnostic value of intrinsic ligament
tear and increased the inter-observer agreement of TFCC and intrinsic ligament tear as compared with wrist MR
arthrography alone.
CLINICAL RELEVANCE/APPLICATION
The use of wrist MR arthrography plus dynamic cine-arthrography which was performed during contrast
injection for MRA, may help increase diagnostic performance for TFCC and intrinsic ligament tear.
VSMK21-07
Wrist MRI vs MR Arthrography
Mark Douglas Murphey MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
View learning objectives under main course title.
VSMK21-08
Sports Related Injuries of the Wrist
Wilfred C. G. Peh MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Review relevant anatomical structures in the wrist that may be injured during sports. 2) Discuss the
biomechanics of various types of wrist injuries. 3) Illustrate the imaging features of common sports injuries
demonstrated on different imaging modalities.
ABSTRACT
Many anatomical structures in the wrist may be injured in a variety of ways during participation in sports. Many
of these sporting activities, whether competitive or recreational, are associated with specific injury patterns
related to actions and stresses associated with a particular sport. Imaging has an important role in the
evaluation of the range of bone and soft tissue injuries sustained. Knowledge of the biomechanics behind a
particular sporting activity is useful for understanding the pathophysiology of wrist injury and helps explain the
findings seen at imaging. Recognizing the imaging features aids in the early diagnosis, identification and
prevention of potential complications, management and follow-up of these injuries. It is particularly important to
be aware of wrist injuries affecting the immature skeleton of pre-aldolescent and aldoescent athletes, as
continued sporting activity may result in growth arrest and other long-term problems.
Active Handout
http://media.rsna.org/media/abstract/2014/13010800/VSMK21-08 sec.pdf
VSMK21-09
Cost-effectiveness Analysis of Utilizing 3T MRI to Select Which Patients with Chronic Wrist Pain
Should Undergo Arthroscopy
Sahar Jalali Farahani MBBS (Presenter): Nothing to Disclose , John Eng MD : Nothing to Disclose , John A.
Carrino MD, MPH : Consultant, BioClinica, Inc Consultant, Pfizer Inc Advisory Board, General Electric Company
, Shadpour Demehri MD : Nothing to Disclose
PURPOSE
To evaluate the cost effectiveness of performing 3T MRI in patients with chronic wrist pain
METHOD AND MATERIALS
A decision analysis model was designed to compare the following diagnostic algorithms in the patients with
chronic wrist pain (> 3 months): (1) 3T MRI followed by diagnostic arthroscopy for positive findings; and (2)
Diagnostic arthroscopy. The assumption was the detected injuries were treatable by surgical repair or
therapeutic arthroscopy. Short-term and long-term outcome were considered as unnecessary arthroscopy
avoided and Quality-Adjusted-Life (QALY), respectively. Costs from societal perspective and incremental cost to
effectiveness ratio were calculated. Accuracy of MRI in detection of wrist injuries, utility loss due to wrist pain
and costs associated with each strategy were estimated from literature and Medicare reimbursement data for
2013. The willingness-to-pay threshold was considered to be $50000. Sensitivity analysis was conducted to
examine the model's stability to variations in the clinically plausible range of the model's variables.
RESULTS
Sensitivity and specificity of MRI was considered as 74% and 84%, respectively. The prevalence of ligamentous
injuries in the study population was considered as 25%. The analysis showed that using MRI as the primary
indicator of necessity of performing arthroscopy cost average of $1425 per patient, while performing
arthroscopy in all patients cost $2500 per patient. The incremental cost of using MRI to avoid one unnecessary
arthroscopy was estimated as $793. The incremental costs of performing non-selective arthroscopy in all the
patients in comparison to using MRI was $82692 per one QALY gained. Considering a subgroup of patients
whose ligamentous injury is not amenable by arthroscopy, this amount decreased to $8035. The sensitivity
analysis showed the model was stable to variation in clinically plausible ranges of 3T MRI sensitivity and
specificity, providing prevalence of repairable wrist injury between the patients with chronic wrist pain did not
exceed 34%.
CONCLUSION
Performing 3T MRI to determine the necessity of diagnostic arthroscopy in patients with chronic wrist pain may
be cost-effective.
CLINICAL RELEVANCE/APPLICATION
In practices where most patients with wrist pain require no arthrosopic repair; MRI may be cost-effective both
in avoiding unnecessary diagnostic arthroscopy and long-term societal perspective.
VSMK21-10
Imaging Techniques for Evaluating Elbow and Wrist Instability
Miriam Antoinette Bredella MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Demonstrate understanding of the complex anatomy, kinematics and injury patterns of the wrist and elbow.
2) Become familiar with routine and novel static and dynamic imaging techniques to assess wrist and elbow
instability.
VSMK21-11
Diagnosis of Scapholunate Dissociation: Cine-MR Imaging as a New Approach
Soenke Langner MD, PhD : Nothing to Disclose , Inga Langner MD : Nothing to Disclose , Paul-Christian
Krueger MD : Nothing to Disclose , Rebecca Kessler MD : Nothing to Disclose , Andreas Eisenschenk MD,
PhD : Nothing to Disclose , Per-Olaf Behrndt MD (Presenter): Nothing to Disclose
PURPOSE
Posttraumatic injuries of the scapholunate ligament (SLL) may cause scapholunate dissociation (SLD) which
bears a high risk of osteoarthritis. Plain radiographs are used for initial diagnostic work up and MR imaging
(MRI) is the preferred imaging modality for the assessment of ligamentous injuries. However, dynamic
instability can only be assessed by cineradiography. The aim of the study was to evaluate diagnostic accuracy
of cine-MRI for the assessment of SLD in comparison to arthroscopy.
METHOD AND MATERIALS
23 Patients with clinically suspected SLD were included. All patients underwent static MRI and cine-MRI of wrist
at 3T. We acquired T2-weighted (T2w) images in axial and coronal planes and sagittal T1w images. Cine-MRI
was performed from extreme radial to ulnar abduction and during clenching and unclenching of the fist with a
temporal resolution of 5 images/s. Cineradiography was performed in all patients with a temporal resolution of
12.5 images/s. Afterwards all patients underwent arthroscopy. Images were evaluated by one hand surgeon
and one experienced MSK radiologist blinded for intraoperative finding. Cineradiography and cine-MRI were
evaluated for scapholunate (sl) distance, sl alignement, synchronous motion of carpal bones and continuitiy of
Gilula lines. Sensitivity, specificity, positive (pLR) and negative (nLR) likelihood ratio for cine-MRI with respect
to intraoperative findings were calculated. Differences between cineradiography and cine-MRI were evaluated
using t-test. A p-value
RESULTS
Cine-MRI was of diagnostic quality in all patients. There was no statistical significant difference between
Cine-MRI was of diagnostic quality in all patients. There was no statistical significant difference between
cineradiography and cine-MRI (p=0.081). SLD was correctly diagnosed in 5 patients and excluded in 16
patients. SLD was diagnosed false positive and negative in one case each. Sensitivity and specifity of cine-MRI
for SLD was 83% and 94%, respectively. PLR and nLR was 13,83 and 0,18 respectively.
CONCLUSION
Cine-MRI has a high sensitivity and specificity for the diagnosis of SLD. It can be easily integrated in
conventional MR imaging and may eliminate the need for cineradiography.
CLINICAL RELEVANCE/APPLICATION
CINE-MRI is a safe and feasible method to identify scapholunate dissociation and may prevent exposure of the
patients to radiation.
VSMK21-12
Evaluating MRI-detected Tenosynovitis of the Hand and Wrist in Early Arthritis
Wouter Nieuwenhuis MD (Presenter): Nothing to Disclose , Annemarie Krabben : Employee, Johnson &
Johnson , Wouter Stomp MD : Speaker, General Electric Company , Johan L. Bloem MD, PhD : Nothing to
Disclose , Tom WJ Huizinga : Nothing to Disclose , Annette Van Der Helm-Van Mil : Nothing to Disclose ,
Monique Reijnierse MD : Nothing to Disclose
PURPOSE
This study aimed to identify the frequency of MRI-detected tenosynovitis at the metacarpophalangeal (MCP)
and wrist joints in early arthritis, the diagnostic value for RA and the association with severity features within
RA.
METHOD AND MATERIALS
178 early arthritis patients underwent unilateral 1.5T extremity-MRI at baseline. MRI-scans were made and
scored using the RAMRIS-protocol. Tenosynovitis was scored at the wrist and MCP joints by two readers using
the method as described by Haavardsholm et al. During the first year 69 patients fulfilled the
2010-classification criteria for RA; patients with and without RA were compared. Within RA-patients
comparisons were made for anti-citrullinated-peptide-antibody (ACPA)-positivity and for radiographic
progression (increase in Sharp van der Heijde score) during the first year.
RESULTS
65% of the 178 early arthritis patients had MRI-detected tenosynovitis at any of the studied locations. The
flexor tendon at MCP-3 and the tendon of the extensor carpi ulnaris were most frequently affected (22% and
34%). Furthermore, tenosynovitis was more often present in RA than non-RA patients (75% versus 59% p
0.023). More commonly affected locations in RA than in non-RA were the tendons of the flexors at MCP-5 (odds
ratio (OR) 2.8 95% CI 1.2-7.0), the extensors at MCP-2 (OR 9.1 95% CI 1.9-42.8) and MCP-4 (OR 14.2 95%
CI 1.7-115.9) and extensor compartment I at the wrist 4.0 (95% CI 1.4-11.1). The specificity for these
locations ranged 92-99% and the positive predictive value between 61-89%. The associations between
tenosynovitis at these locations and RA were independent of the presence of local synovitis. Within RA-patients,
the tenosynovitis scores were not associated with the presence of ACPA or radiographic progression during the
first year.
CONCLUSION
MRI-detected tenosynovitis is common in early arthritis and is more common in RA patients than in early
arthritis patients with other diagnoses. Locations with a high specificity for RA are the tendons of the flexor at
MCP-5, the extensor at MCP-2 and MCP-4 and the first extensor compartment of the wrist.
CLINICAL RELEVANCE/APPLICATION
MRI is a sensitive method to detect tenosynovitis. However, the prevalence of MRI-detected tenosynovitis and
its diagnostic and prognostic value in early arthritis patients are unclear.
VSMK21-13
Opposed-phase Gradient Echo MR Imaging Improves Image Quality and Visualization of Erosions in
Arthritis
Wouter Stomp MD (Presenter): Speaker, General Electric Company , Johan L. Bloem MD, PhD : Nothing to
Disclose , Tom WJ Huizinga : Nothing to Disclose , Annette Van Der Helm-Van Mil : Nothing to Disclose ,
Monique Reijnierse MD : Nothing to Disclose
PURPOSE
In rheumatoid arthritis, identifying the exact demarcation of erosions on MR images can be difficult because the
cortical defect might be obliterated by either synovium or bone marrow edema.. Opposed-phase MR imaging
might enhance the visibility of this transition by visualizing it as a clear black line due to the presence of both
water and fat protons within the same voxel. The purpose of this study was to determine whether opposed
phase gradient-echo imaging improves visualization of erosions when compared to regular T1w TSE sequences.
METHOD AND MATERIALS
Unilateral wrist and MCP joints of 14 early arthritis patients were imaged on a 1.5T extremity MRI. T1w TSE and
opposed phase T1w gradient-echo sequences were obtained in the coronal plane, both before and after
gadolinium contrast administration. T2w TSE images were also obtained and were available to support scoring
for both image sets. Images were assessed for image quality on a 0-5 scale and scored according to the
OMERACT RAMRIS score for erosions in consensus by two observers blinded to clinical data. A reference score
was established using all available images together.
RESULTS
Scanning time was 0:43 for the opposed phase sequence and 3:30 for the TSE sequence. Overall image quality,
absence of movement artifacts and sharpness were significantly better using opposed phase images than T1w
TSE images. Homogeneity, Signal-to-noise ratio, RAMRIS erosion scores and rater confidence did not differ
between sequences. There was a trend towards higher sensitivity of opposed phase images for detection of
erosions (85.6%, 95%CI 76.6-91.6% vs 68.0%, 95%CI 57.7-76.9%). Specificity, positive predictive value and
negative predictive value were similar between the sequences and all >85%.
CONCLUSION
Our results demonstrate the feasibility of using a fast out-of-phase T1w spoiled-gradient echo sequence to
assess erosions according to OMERACT RAMRIS score. It decreases imaging time while providing better image
quality and might increase sensitivity for small erosions.
CLINICAL RELEVANCE/APPLICATION
Shorter scanning time of the opposed phase sequence reduces movement artifacts and patient discomfort, and
better delineation of the bone-tissue interface may improve reliability of erosion detection.
VSMK21-14
Arthritides—What's Hot in the Rheumatology Literature
Eric Y. Chang MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Discuss the roles of the radiologist in diagnosis and management of arthropathies. 2) Describe the imaging
findings of rheumatoid arthritis and spondyloarthritis based on current literature. 3) Identify the various
categories of disease modifying therapies (DMOADs and DMARDs).
ABSTRACT
1) Discuss the roles of the radiologist in diagnosis and management of arthropathies.
2) Describe the imaging findings of rheumatoid arthritis and spondyloarthritis based on current literature.
3) Identify the various categories of disease modifying therapies (DMOADs and DMARDs).
VSNM21
Nuclear Medicine Series: Assessment of Cancer Treatment Response: Updates
Series Courses
OI
NM
BQ
AMA PRA Category 1 Credits ™: 3.25
ARRT Category A+ Credits: 4.00
Mon, Dec 1 8:30 AM - 12:00 PM
Location: S505A
Participants
Moderator
Terence Zekon Wong MD, PhD : Advisory Board, Eli Lilly and Company Consultant, Koninklijke Philips NV Advisory Board,
Bayer AG
Sub-Events
VSNM21-01
PET Quantification—The Devil Is in the Details
Terence Zekon Wong MD, PhD (Presenter): Advisory Board, Eli Lilly and Company Consultant, Koninklijke
Philips NV Advisory Board, Bayer AG
LEARNING OBJECTIVES
1) Understand the factors that affect meaurement of Standardized Uptake Values (SUVs)
2) Recommend technical steps that can be taken to maximize quality of SUV measurements
ABSTRACT
A growing application of PET imaging is evaluation of response early during the course of therapy. This can
confirm that the current therapy is effective or allow ineffective therapies to be changed early in the course of
confirm that the current therapy is effective or allow ineffective therapies to be changed early in the course of
treatment. While response can be dramatic and assessed visually for some malignancies (e.g. Hodgkins
lymphoma), early response in many other tumors can be subtle, requiring some form of quantification.
Standardized uptake values (SUVs) are the most commonly used measurements in PET to quantify tracer
accumulation. These measurements are convenient to perform and widely available, but highly dependent on
technical and biological factors. Understanding the limitations and technical considerations for obtaining valid
SUV measurements is essential, since these measurements are now being used for therapeutic decisions. The
technical factors contributing to the SUV calculation will be reviewed, and recommendations made on how to
minimize the potential sources of measurement error that are controllable.
VSNM21-02
Diffusion-weighted Magnetic Resonance Imaging for Follow-up and Treatment Response
Assessment of Lymphoma: Results of an 18F-FDG-PET/CT-controlled Prospective Study in 64
Patients
Marius Erik Mayerhoefer MD, PhD (Presenter): Nothing to Disclose , Georgios Karanikas MD : Nothing to
Disclose , Helmut Prosch MD : Nothing to Disclose , Barbara Kiesewetter MD : Nothing to Disclose ,
Michael Weber : Nothing to Disclose , Thomas Knogler MD : Nothing to Disclose , Markus Raderer MD :
Nothing to Disclose
PURPOSE
To determine the value of diffusion-weighted magnetic resonance imaging (DWI-MRI) for treatment response
assessment in fluorodesoxy-glucose (FDG)-avid lymphoma.
METHOD AND MATERIALS
Patients with FDG-avid Hodgkin (HL) or Non-Hodgkin lymphoma (NHL) at pre-therapeutic 18F-FDG-PET/CT,
who had also undergone pre-therapeutic whole-body DWI-MRI, were included in this prospective study.
Depending on the histological lymphoma subtype, patients received different treatment regimens, and
follow-up DWI-MRI and 18F-FDG-PET/CT were performed at one or more time points, depending on the clinical
course. For each follow-up DWI-MRI, region-based sensitivity/specificity and agreement in terms of treatment
response (complete remission, partial remission, stable disease, or progressive disease), relative to the
corresponding 18F-FDG-PET/CT, were calculated.
RESULTS
64 patients were included: 10 with HL, 22 with aggressive NHL, and 32 with indolent NHL. Overall region-based
DWI-MRI sensitivity and specificity were 97.6% (95% confidence interval (CI), 91.7-99.3%), and specificity was
99.5% (95% CI, 99.0-99.9%). For the 51 interim DWI/MRI examinations (performed after 1-3 therapy cycles)
region-based sensitivity and specificity were 95.1% (95% CI, 83.9-98.7%) and 99.4% (95% CI, 98.9-99.9%),
and for 48 end-of-treatment DWI/MRI examinations examinations, sensitivity and specificity were 100% (95%
CI, 89.6-100%) and 99.8% (95% CI, 99.4-100%). With regard to treatment response assessment, DWI-MRI
agreed with 18F-FDG-PET/CT in in 99/102 follow-up examinations (97.1%), with a kappa value of 0.94
(P<.0001).
CONCLUSION
In patients with FDG-avid lymphoma, DWI-MRI is a feasible alternative to 18F-FDG-PET/CT for follow-up and
treatment response assessment, regardless of the histological subtype (i.e., Hodgkin lymphoma, agressive NHL,
indolent NHL).
CLINICAL RELEVANCE/APPLICATION
DWI-MRI may be used as an alternative to 18F-FDG-PET/CT for follow-up and monitoring of lymphoma, due to
its lower cost, general availability, and lack of ionizing radiation exposure. The latter is of particular relevance
for younger lymphoma patients that may require life-long follow-up, to lower the risk of radiation-induced
secondary cancers.
VSNM21-03
Predictive Value of FDG PET/CT prior to Allogeneic and Autologous Stem Cell Transplant for
Lymphoma
Gary Allan Ulaner MD, PhD (Presenter): Research support, General Electric Company Research support,
Seragon Pharmaceuticals, Inc , Debra A. Goldman MS : Nothing to Disclose , Joshua Lilienstein MD :
Nothing to Disclose , Mithat Gonen PhD : Nothing to Disclose , Jocelyn Maragulia BA : Nothing to Disclose
PURPOSE
Determine the value of FDG PET/CT prior to allogeneic and autologous stem cell transplant (SCT) of lymphoma
patients in predicting outcome following transplant.
METHOD AND MATERIALS
A retrospective review was performed under IRB waiver. Patients who underwent allogeneic or autologous SCT
for lymphoma at our institution from 2005-2010, and had FDG PET/CT within 3 months before transplant, were
included. PET/CT examinations were evaluated for suspicious lesions with FDG-avidity greater than liver
background (Deauville 4/5). Clinical records were used to document overall survival (OS), disease specific
survival (DSS), and progression free survival (PFS). The relationship between pre-transplant PET/CT and
outcome was assessed using Kaplan-Meier methods and log-rank test separately for each group. The
relationship between SUVmax and PFS was assessed using a piecewise linear univariate Cox regression in time.
RESULTS
273 patients were identified, 114 with FDG PET/CT prior to allogeneic SCT and 159 with FDG PET/CT prior to
autologous SCT. Prior to SCT, 33 of 114 (29%) allogeneic patients and 21 of 159 (13%) autologous patients
had suspicious FDG-avid lesions. For both allogeneic and autologous SCT patients, there was a significant
relationship between suspicious FDG avid lesions and PFS (p=0.01 and p<0.0001). In allogeneic cases, the 2
year PFS estimates were 70±5% for FDG negative cases, but only 42±9% for FDG positive cases. In
autologous cases, the 2 year PFS estimates were 70±4% for FDG negative cases, but only 24±9% for FDG-avid
cases. Similar differences were seen in OS and DSS for both groups of patients. The higher the SUVmax of
lesions before allogeneic or autologous transplant, the greater the risk of progression is for the first 12 months
post transplant (p=0.0002 and p<0.0001). This relationship was not sustained after 12 months.
CONCLUSION
The presence of suspicious FDG-avid lesions on PET/CT prior to both allogeneic and autologous SCT identifies
lymphoma patients where transplant has a low likelihood of sustained success. The higher the SUVmax of
lesions, the greater the risk of recurrence is for the first 12 months following transplant.
CLINICAL RELEVANCE/APPLICATION
FDG PET/CT prior to both allogeneic and autologous SCT predicts the likelihood of transplant success in
aggressive lymphomas. PET/CT can help guide selection of patients for both of these procedures.
VSNM21-04
FDG-PET/CT Response Assessment Criteria for Hodgkin’s and Aggressive Non-Hodgkin’s Lymphoma
at Completion of Therapy
Ur Metser MD (Presenter): Nothing to Disclose , Grainne Mairead Murphy MBBCh, MMedSc : Nothing to
Disclose , Ravi Michael Mohan MD, DPhil : Nothing to Disclose , Vaughan Beckley : Nothing to Disclose ,
David Christopher Hodgson MD, MPH : Nothing to Disclose
PURPOSE
Based on the International Harmonization Project (IHP) criteria, PET response assessment of residual nodal
masses in patients with lymphoma after completion of therapy is performed visually using mediastinal blood
pool (MBP) as the reference. The purpose of this study was to define the optimal reference for PET response
assessment and to determine whether visual inspection or semiquantiative measures are the preferred method
of assessment.
METHOD AND MATERIALS
The study included 137 patients (age range: 18-94 years; median: 50), with Hodgkin's (n=43) or
non-Hodgkin's lymphoma (n=94) assessed for residual masses after completion of therapy. Two experienced
readers independently assessed response by IHP criteria, and on a separate read used Deauville-adapted
scoring system with liver as reference for residual disease. Pathology and clinical and imaging surveillance data
(mean: 19 months) was used as standard of reference. Inter-reader agreement and performance of visual
versus semiquantitative analysis was performed. Comparison between methods was performed using McNemar
test, with a p-value <0.05 considered significant. Kappa coefficients assessed level of agreement between
readers.
RESULTS
Based on the standard of reference, 36 patients (26.3%) had residual lymphoma, while 101 patients (73.7%)
had complete response. For IHP and Deauville-adapted criteria, sensitivity was 97.2% (p=1), specificity was
79.2% and 92.1% (p<0.001), and overall accuracy was 83.9% and 93.4% (p=0.001), respectively; with
strong interobserver agreement for both methods (Kappa = 0.858 and 0.854, respectively). For both, visual
assessment performed better than uptaked-based analysis with overall accuracy of visual and SUV-based
analysis was 85.4% and 68.2% for MBP (p<0.001) and 93.8% and 89.8% (p=0.039) for liver.
CONCLUSION
Using liver rather than mediastinal blood pool as standard of reference for response assessment of patients with
aggressive lymphoma and residual masses at end of therapy maintains high sensitivity for detection of residual
disease and improves specificity and overall accuracy. Visual assessment outperforms semiquantitative
analysis.
CLINICAL RELEVANCE/APPLICATION
IHP criteria for response assessment of patients with lymphoma and residual masses at end of therapy has yet
to be validated. Results from current study suggest that using liver rather than MBP impvoes specificity and
overall accuracy.
VSNM21-05
Response Assessment Recommendations in Solid Tumors: RECIST vs PERCIST
Heather
Jacene MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) To compare anatomic and metabolic imaging for response assessment. 2) To discuss limitations of current
widely used criteria for assessing response. 3) To discuss the benefits and limitations of metabolic imaging for
response assessment.
VSNM21-06
Utility of 18F-FDG PET/MR in Differentiation of Recurrent High-grade Intra-axial Neoplasm from
Radiation Changes: A Comparison of PET/CT to PET/MR
Jesse Montagnese DO (Presenter): Nothing to Disclose , Andrew Sher MD : Research Grant, Koninklijke
Philips NV , Salim E. Abboud MD : Nothing to Disclose , Lisa Rogers MD : Nothing to Disclose , Norbert
Avril MD : Nothing to Disclose , Leo John Wolansky MD : Nothing to Disclose
PURPOSE
Advanced imaging is often utilized in the post-treatment period of high-grade intra-axial neoplasm to better
characterize enhancing lesions. Our study compares the diagnostic accuracy of 18F-FDG PET/CT and 18F-FDG
PET/MR in differentiating progressive disease (PD) from radiation change (RC).
METHOD AND MATERIALS
We evaluated 12 patients with high-grade intra-axial neoplasm whom had undergone radiation therapy and
developed MR evidence of PD per RANO criteria. 13 lesions were evaluated:10 glioma; 2 metastatic patients (3
lesions). All patients underwent 18F-FDG PET/CT, 18F-FDG PET/MR (with MR attenuation correction,
PET/MRAC), conventional diagnostic MR (PET/MRD), and perfusion MR in a single exam. Four separate
interpretations were performed of the PET/CT, PET/MRAC, PET/MRD, and perfusion PET/MR with consensus
readings by two fellowship-trained radiologists (1 neuroradiology; 1 nuclear). A qualitative subjective rating
was given to each lesion (1 = definite RC; 2 = probable RC; 3 = equivocal; 4 = probable PD; 5 = definite PD).
The fourth interpretation session was considered the reference standard (11 PD, 2 RC). Sensitivity, specificity,
AC, PET/MRD) via ROC
and accuracy were determined for the three interpretation sessions (PET/CT, PET/MR
analysis after binary reclassification, with a rating of 1-3 defined as RC and 4-5 as PD. Wilcoxon-rank test was
used for rating comparison between the three interpretations.
RESULTS
PET/CT yielded a sensitivity, specificity, and accuracy of 0.64, 1.00, and 0.82 (p=0.17), respectively. PET/MRAC
demonstrated a sensitivity, specificity, and accuracy of 0.91, 1.00, and 0.96 (p<0.05), respectively. PET/MRD
had the highest sensitivity, specificity, and accuracy of 1.00, 1.00, and 1.00 (p<0.05), respectively. There was
a statistically significant difference in interpretation between PET/MRD and PET/CT (p<0.05), but not
PET/MRAC and PET/CT (p=.08).
CONCLUSION
In this small series, 18F-FDG PET/MR utilizing either diagnostic or attenuation-only MR sequences was more
accurate in differentiating radiation change from progressive disease compared to 18F-FDG PET/CT, with a
statistically significant difference in interpretation between 18F-FDG PET/MR with diagnostic MR and 18F-FDG
PET/CT.
CLINICAL RELEVANCE/APPLICATION
Differentiation of radiation change from progressive disease has significant clinical ramifications requiring
divergent treatment. PET/MR is a promising technique in differentiating PD from RC.
VSNM21-07
18F-FDG PET/CT as an Indicator of Survival in Bone Primary Ewing Sarcoma
Usama Ibrahim Salem MBBCh, MSC (Presenter): Nothing to Disclose , Behrang Amini MD, PhD : Nothing to
Disclose , Hubert H. Chuang MD, PhD : Nothing to Disclose , Najat C. Daw MD : Nothing to Disclose , Wei
Wei : Nothing to Disclose , Colleen Mary Costelloe MD : Nothing to Disclose , Tamara Miner Haygood MD,
PhD : Nothing to Disclose , John E. Madewell MD : Nothing to Disclose
PURPOSE
The existing literature of 18 F-FDG PET/CT in Ewing sarcoma investigates heterogeneous populations of patients
with both soft tissue and bone primary tumors. The aim of our study was to evaluate whether the maximum
standardized uptake value (SUV (max)) using 18 F-FDG PET/CT before and after initiation of chemotherapy, can
be used as an indicator of survival in patients with primary Ewing sarcoma of bone.
METHOD AND MATERIALS
A retrospective database search was conducted from 2004 - 2011 and 178 patients with pathologically proven
bone primary Ewing sarcoma were identified. Patients who received treatment before the initial PET/CT or
underwent PET/CT at other institutions were excluded. Twenty-nine patients underwent 18 F-FDG PET/CT
before and after starting chemotherapy at our institution. The study included 10 females and 19 males, with a
median age of 18 years. One female patient was excluded from the analysis because she underwent partial
tumor resection before the initial PET/CT as a symptomatic treatment to relieve nerve compression. Median
follow up time for patients alive was 6.2 years (range: 2.6-9.8 years). Univariate Cox proportional hazard
model was used to assess effects of baseline SUV (max), post-chemo SUV (max), and the change of SUV (max)
on overall survival (OS) and progression-free survival (PFS). OS started from chemo start date, and PFS started
from post-chemo PET/CT date.
RESULTS
SUV max ranged from 37-2.2 with a median of 8.7 for baseline and from 16.6-1.4 with a median of 3.2 post
chemotherapy. High SUV (max) before (HR = 1.1, 95% CI: 1.0-1.2, P = 0.008) and after (HR =1.2, 95% CI:
1.0-1.4, P = 0.04) chemotherapy was associated with worse overall survival. No significant cut points for SUV
(max) were identified.
CONCLUSION
Baseline and post chemotherapy SUV (max) can be used as a prognostic indicator for overall survival in bone
primary Ewing sarcoma.
CLINICAL RELEVANCE/APPLICATION
18F-FDG PET/CT can be used as a prognostic indicator of overall survival in bone primary Ewing sarcoma.
VSNM21-08
A Phase II Prospective Trial of Triphasic PET/CT: Delta Slope of SUVmax Differentiates True
Positive from False Positive Scans at the Primary Site after Radiation in Head and Neck Squamous
Cell Carcinoma
Tangel Chang DO (Presenter): Nothing to Disclose , Carryn Anderson MD : Nothing to Disclose ,
Michael M. Graham MD, PhD : Nothing to Disclose , Gerry Funk MD : Nothing to Disclose , Anna Button
MPH : Nothing to Disclose , Yusuf Menda MD : Research Grant, Advanced Accelerator Applications ,
Wenqing Sun MD, PhD : Nothing to Disclose , Michael Marquardt BS : Nothing to Disclose , John M. Buatti
MD : Nothing to Disclose
PURPOSE
FDG-PET/CT is used for response assessment post-radiotherapy (RT) in head and neck squamous cell
carcinoma (HNSCC), but the false positive (FP) rate is approximately 50%. The positive predictive value (PPV)
remains low due to inability to differentiate between inflammation and malignancy. We hypothesize that the
SUVmax slope when imaged at 60-, 90-, and 120- min after FDG injection (Triphasic PET/CT) would better
predict recurrence because tumors should increase uptake between 60- and 120- min whereas nonmalignant,
inflammatory uptake will plateau or decrease. The goal is to improve the diagnostic accuracy of FDG-PET/CT as
a post-RT response assessment tool.
METHOD AND MATERIALS
Patients with HNSCC were prospectively enrolled to undergo Triphasic 3-month post-RT PET/CT. In addition to
our standard whole-body PET scan at 90-min, enrolled patients had a PET of the head and neck with low-dose
CT at 60- and 120-min. SUVmax was measured for the three time points and the delta change in SUVmax
slope, [(SUVmax 120-SUVmax 90)-(SUVmax 90-SUVmax 60)], was calculated. Standard outcomes are defined
by the 90 min PET/CT as equivocal (EQ), false negative (FN), true negative (TN), true positive (TP), and FP,
and the delta change in SUVmax slope between 60-, 90-, and 120-min was evaluated to differentiate between
TP and FP.
RESULTS
57 HNSCC patients were eligible for analysis. Median follow-up post-RT was 15.4 months. 16% recurred at the
primary site. There were 8 EQ, 3 FN, 38 TN, 4 FP, and 4 TP scans. In those with positive scans, (TP + FP)
defined by the 90 min time point, the delta change in SUV max slope could differentiate TP from FP in all cases
and was statistically significant using the Wilcoxon Rank Sum Exact test as a predictor of outcome (p=0.02).
CONCLUSION
Analysis of the prospective Triphasic FDG-PET/CT trial demonstrated that the delta change in SUVmax slope at
the 60-, 90-, and 120- min post FDG injection allows improved differentiation between inflammation and
malignancy in HNSCC patients. Utilizing the SUVmax slope along with the standard SUVmax at a single time
point, the FPs induced by inflammation may be better identified. This method improves the PPV, and enhances
the accuracy of FDG-PET/CT.
CLINICAL RELEVANCE/APPLICATION
PET/CT post-RT for HNSCC has PPV of 50%, resulting in significant anxiety and morbidity from
biopsy/dissection. Delta change in SUVmax slope of triphasic PET/CT may accurately differentiate TP vs FP.
VSNM21-09
Challenges of Solid Tumor Measurements and Techniques to Address This
Haesun
VSNM21-10
Choi MD (Presenter): Nothing to Disclose
Value of Simultaneous PET MR Mammography in Patients with Breast Cancer Undergoing
Neoadjuvant Chemotherapy – Preliminary Results
Sonja Kinner MD (Presenter): Nothing to Disclose , Johannes Grueneisen : Nothing to Disclose , Oliver
Hoffmann : Nothing to Disclose , Ann-Kathrin Bittner : Nothing to Disclose , James Nagarajah : Nothing to
Disclose , Thorsten D. Poeppel : Nothing to Disclose , Agnes Bankfalvi : Nothing to Disclose , Kai
Nassenstein : Nothing to Disclose
Nassenstein : Nothing to Disclose
PURPOSE
To assess if simultaneous 18F-Fluorodeoxyglucose (FDG) positron emission tomography (PET) magnetic
resonance mammography (MRM; PET/MRM) performed before and after neoadjuvant chemotherapy (NAC) can
discriminate between responders and non-responders and predict response to therapy in patients with invasive
breast cancer compared to PET and MRM alone.
METHOD AND MATERIALS
15 Patients with initial diagnosis of invasive breast cancer underwent simultaneous PET/MR mammography
(Biograph mMR, Siemens, Erlangen, Germany) before and under NAC. Two readers evaluated in consensus i)
MR mammography concerning size difference, ii) PET concerning changes of standard uptake value and iii)
simultaneous PET/ MRM concerning both features to determine response. Image ratings were correlated with
histopathology (complete response: CR; non-complete response: non-CR) and regression score after Sinn (0:
no effect; 4: no residual tumor detectable) after breast conserving surgery or mastectomy.
RESULTS
Overall, MR mammography alone diagnosed CR in 8 patients and non-CR in 7 patients while PET alone
diagnosed CR in 9 patients and non-CR in 6 patients. With PET/MRM readers were able to diagnose CR in 8
patients and non-CR in 7 patients. One patient with no definable tracer uptake on PET (rated as CR) showed a
residual contrast enhancing lesion on MRM (non-CR) and was diagnosed correctly as non-CR on PET/MR with a
Sinn score of 2 on histopathological examination. On the other hand, in another patient with a reduction of SUV
(PET: non-CR but responder) and no change in size (MRM: non-CR, non-responder) histopathology showed
partial reaction with a Sinn score of 2. PET/MRM correctly diagnosed this patient as non-CR, responder.
CONCLUSION
In this preliminary study we could show that simultaneous PET/MR mammography in breast cancer patients
under NAC is feasible. Both imaging modalities complement one another and can help to distinguish responders
from non-responders as well as predict complete response or non-CR.
CLINICAL RELEVANCE/APPLICATION
The combination of PET and MRM helps to discriminate responder and non-responder as well as those with CR
and non-CR. PET/ MRM can therefore be a valuable diagnostic tool for breast cancer patients undergoing NAC.
VSNM21-11
The Bone Scan Index (BSI) Is a Prognostic Factor in Breast Cancer Patients with Bone Metastasis
Treated with Zoledronic Acid
Yukinori Okada MD (Presenter): Nothing to Disclose , Yasuo Nakajima MD : Nothing to Disclose , Itsuko
Okuda MD : Nothing to Disclose , Yasuyuki Kojima : Nothing to Disclose
PURPOSE
Artificial neural network-based bone scan index (BSI) has been used to quantify the spread of bone metastasis.
Currently, BSI has been used as a prognostic indicator in prostate cancer. However, the utility of BSI in breast
cancer patients who has bone metastasis is not clear. To elucidate the role of BSI in breast cancer patients with
bone metastasis used zoledronic acid, we examined the relationship between BSI, their tumor maker and
survival.
METHOD AND MATERIALS
Fifty-four female patients, ranging from 32 to 78 years of age with average of 54.4 years old, were treated for
bone metastasis of breast cancer between 1 January 2006 and 27 October 2012. Bone scintigraphies were
analyzed using BONE NAVI version 1 (FUJIFILMRI pharma, Co. Ltd. Tokyo Japan; EXINI BoneExini Diagnostics,
Sweden) and BSI were calculated at the time whose bone metastasis were found, and the time after 6 months
(range 3 months to 9 months) and 12 months (range10 months to 17 months). At the same time, the serum
marker of CA15-3 (51 patients) or CEA (49 patients) were examined. Survival rates were compared with BSI
and tumor makers using the Kaplan-Meier method.
RESULTS
Survival was significantly better in patients with a BSI change rate ≤1 after 6 months and 12 months than in
patients with a BSI change rate >1 after 6 months and 12 monthes (6 months, p=0.028; 12 months,
p=0.005). Survival was significantly better in patients with a tumor marker change rate ≤1 after 12 months
than in patients with a tumor marker change rate >1 after 12 months (CA15-3; p=0.041, CEA; p=0.048), but
there were no significant intergroup differences of there survival between patients with a tumor marker change
rate ≤1 and a tumor marker change rate >1 after 6 months (CA15-3; p=0.507, CEA; p=0.585). There were no
significant intergroup differences between patients with a BSI ≤ median and BSI > median (median; 0.67,
p=0.67), with a BSI ≤ mean and BSI > mean (mean; 1.414, p=0.421).
CONCLUSION
The BSI change rate after 6 months and after 12 months, and the tumor marker change rate after12 months
after onset of bone metastasis are a prognostic factor in breast cancer patients with bone metastasis. The BSI
can predict patient`s prognosis earlier than tumor makers.
CLINICAL RELEVANCE/APPLICATION
The BSI change is a useful prognositc factor in breast cancer patients with bone metastasis.
VSNR21
Neuroradiology Series: Spine
Series Courses
NR
AMA PRA Category 1 Credits ™: 3.25
ARRT Category A+ Credits: 3.75
Mon, Dec 1 8:30 AM - 12:00 PM
Location: N227AB
Participants
Moderator
Jeffrey Gil Jarvik MD, MPH : Stockholder, PhysioSonics, Inc Consultant, HealthHelp, LLC Co-editor, Springer Science+Business
Media Deutschland GmbH Royalties, Springer Science+Business Media Deutschland GmbH Travel support, General Electric
Company
Moderator
Allison Michele Grayev MD : Research Grant, Bayer AG
Sub-Events
VSNR21-01
Back Pain, Healthcare Reform, and Economic Realities
Michael Terrence Modic MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) The participant should gain an appreciation for the objective prognostic value of imaging in spinal disorders.
2) The participant should have an elevated awareness for the current deficiencies in the literature relative to
therapeutic trials for spinal intervention. 3) Should be able to characterize peer reviewed publications as they
relate to outcomes.
VSNR21-02
Early Imaging in Senior Primary Care Patients with Back Pain: Impact on Resource Utilization and
Patient Outcomes
Jeffrey Gil Jarvik MD, MPH (Presenter): Stockholder, PhysioSonics, Inc Consultant, HealthHelp, LLC Co-editor,
Springer Science+Business Media Deutschland GmbH Royalties, Springer Science+Business Media Deutschland
GmbH Travel support, General Electric Company , Laura S. Gold PhD : Nothing to Disclose , Bryan A.
Comstock : Nothing to Disclose , Patrick Heagerty : Nothing to Disclose , Andrew Avins : Nothing to
Disclose , Zoya Bauer : Nothing to Disclose , Brian W. Bresnahan PhD : Stockholder, Johnson & Johnson
Investigator, General Electric Company Consultant, General Electric Company Consultant, Johnson and Johnson
Consultant, Novartis AG , Janna Friedly : Nothing to Disclose , Katherine T. James : Nothing to Disclose ,
Larry G. Kessler : Consultant, General Electric Company , Srdjan Nedeljkovic : Nothing to Disclose , Jason
Schwalb : Nothing to Disclose , Xu Shi : Nothing to Disclose , Sean D. Sullivan PhD : Nothing to Disclose ,
Judith Turner : Nothing to Disclose , Richard A. Deyo MD, MPH : Nothing to Disclose
PURPOSE
To compare the effects of early imaging (within six weeks of presentation) to no early imaging with respect to
function, pain and subsequent resource utilization in senior patients with new primary care visits for back pain
without radiculopathy.
METHOD AND MATERIALS
We analyzed data from 5,239 patients enrolled in the Back pain Outcomes using Longitudinal Data (BOLD)
Study, a prospective cohort of patients ≥65 years old with a new primary care visit for back pain. This analysis
includes patients completing 1 year of follow-up by 11/2013 (n=3881) but will present data from the entire
cohort. Our primary outcome was back-related disability measured by the Roland-Morris Disability
Questionnaire (RMDQ) at 12 months. Secondary outcomes included 0-10 numerical rating scale of average back
pain in the past week, EQ5D and cumulative 12-month back-related relative value units (RVUs). We performed
propensity score matching to construct comparable early imaging and no-early imaging groups creating two
propensity-matched comparisons: 1) early x-ray vs. no-early imaging (n=652/group); 2) early CT or MR vs.
no-early imaging (n=312/group).We used separate generalized estimating equation models on the matched
samples to compare outcome measures between the early vs. no early imaging groups. We adjusted each
model for site and important precision variables.
RESULTS
There were statistically significant but clinically unimportant differences between patients who received early
x-ray compared to patients who did not (adjusted 12mo RMDQ: early x-ray: 8.4±6.5 vs. 9.1±6.9 no-early
imaging;p=0.04; adjusted 12mo EQ5D-Index (high=better) early x-ray: 0.79±0.16 vs. no-early imaging:
0.77±0.18;p=0.02). There was no difference in adjusted 12-month RMDQ or EQ5D in the early CT/MR group
vs. no-early imaging. Total RVUs were ~2.2 times greater in the early CT/MR group (170±400) as in the
no-early imaging group (77±230,p=0.001). The difference for spine-related RVUs was ~10 times higher in the
early CT/MR group compared with the no-early imaging group (120±350 vs. 12±72,p=0.0001).
CONCLUSION
Senior patients undergoing early imaging had similar 12-month RMDQ, pain and EQ5D scores to patients not
undergoing early imaging but had substantially higher back-related and total RVUs.
CLINICAL RELEVANCE/APPLICATION
Guidelines for imaging seniors with back pain should have similar limitations to those in younger patients and
not exempt seniors simply because of their age.
VSNR21-03
Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic
Populations
Waleed Brinjikji : Nothing to Disclose , Patrick H. Luetmer MD (Presenter): Nothing to Disclose , Bryan A.
Comstock : Nothing to Disclose , Brian W. Bresnahan PhD : Stockholder, Johnson & Johnson Investigator,
General Electric Company Consultant, General Electric Company Consultant, Johnson and Johnson Consultant,
Novartis AG , Linda Chang Chen MD : Nothing to Disclose , Richard A. Deyo MD, MPH : Nothing to Disclose ,
Safwan Halabi MD : Nothing to Disclose , Judith Turner : Nothing to Disclose , Andrew Avins : Nothing to
Disclose , Kathryn M. James : Nothing to Disclose , John Thomas Wald MD : Nothing to Disclose , David F.
Kallmes MD : Research support, Terumo Corporation Research support, Covidien AG Research support,
Sequent Medical, Inc Research support, Benvenue Medical, Inc Consultant, General Electric Company
Consultant, Covidien AG Consultant, Johnson & Johnson , Jeffrey Gil Jarvik MD, MPH : Stockholder,
PhysioSonics, Inc Consultant, HealthHelp, LLC Co-editor, Springer Science+Business Media Deutschland GmbH
Royalties, Springer Science+Business Media Deutschland GmbH Travel support, General Electric Company
PURPOSE
Imaging evidence of spine degeneration influences medical decision making in back pain patients. Prior studies
demonstrate that degenerative changes are highly prevalent in asymptomatic individuals. We performed a
systematic review to study the prevalence of imaging evidence of spine degeneration in asymptomatic
individuals. Findings from this systematic review are being used to help physicians with clinical decision making
for low back pain patients in A Pragmatic Trial of Lumbar Image Reporting with Epidemiology (LIRE); a
multicenter randomized controlled trial aimed at reducing testing and unnecessary treatments for low back
pain.
METHOD AND MATERIALS
We performed a comprehensive literature review for articles describing the prevalence of the following relevant
imaging findings in asymptomatic individuals: disc degeneration, disc signal loss, disc height loss, disc bulge,
disc protrusion, annular fissures, facet degeneration, and spondylolisthesis. We selected age groupings of
18-39, 40-59 and 60+ years old for age-specific prevalence estimates. For each imaging finding, we fit a
generalized non-linear mixed effects model for the age-specific prevalence estimate clustering on study and
adjusting for the midpoint of the reported age interval.
RESULTS
Twenty-seven articles were included in our study. Among asymptomatic individuals, disc degeneration was
present in 53% of individuals under 40, 75% of individuals 40-59 and 91% of individuals ≥60 years old. Disc
signal loss was present in 39% of individuals 18-39, 60% of individuals 40-59 and 89% of individuals ≥60 years
old. Disc bulge was present in 44% of individuals under 40, 60% of individuals 40-59 and 75% of individuals
≥60 years old. Disc protrusion was present in 32% of individuals 18-39, 35% of individuals 40-59 and 36% of
individuals ≥60 years old. Facet degeneration was present in 20% of individuals 18-39, 20% of individuals
40-59 and 55% of individuals ≥60 years old.. Annular fissures were present in 12% of individuals 18-39, 20%
of individuals 40-59 and 35% of individuals ≥60 years old.
CONCLUSION
Imaging evidence of spine degeneration is present in up to 90% of asymptomatic individuals. Many
imaging-based degenerative features may be a part of normal aging and unassociated with pain.
CLINICAL RELEVANCE/APPLICATION
The results from this systematic review strongly suggest that normal age-related changes must be considered
when interpreting lumbar spine imaging studies.
VSNR21-04
Differentiating Benign from Malignant Vertebral Fractures with Dynamic Contrast-enhanced MRI
Julio Arevalo Perez MD (Presenter): Nothing to Disclose , John Lyo MD : Nothing to Disclose , Kyung K.
Peck PhD : Nothing to Disclose , Eric Lis MD : Nothing to Disclose , Sasan Karimi MD : Nothing to
Disclose
PURPOSE
Differentiating pathologic from benign vertebral fractures can be challenging especially among cancer patients
who are prone to developing both types. We hypothesize that DCE-MRI can aid in non-invasive distinction
between pathologic and benign fractures, improving patient care and management.
METHOD AND MATERIALS
Consecutive patients with vertebral fractures who underwent DCE MRI, biopsy and kyphoplasty were reviewed.
A total of 47 fractures were analyzed for this study. Fractures were divided into 2 groups according to biopsy
results; 19 pathologic fractures from 12 patients and 28 benign fractures from 9 patients (subgroups 13 chronic
and 15 acute). ROIs were placed over fractured and normal appearing vertebral bodies on sagittal imaging.
Perfusion parameters: blood plasma volume (Vp), time-dependent leakage (Ktrans), wash-in slope, peak
enhancement and area under the curve(AUC) were calculated. Indices were compared between the 3 different
groups of fractures: pathologic and benign, chronic and acute, and pathologic and acute. A Mann-Whitney U
test at a significance level of corrected p<0.01 was conducted to assess the difference between the groups.
RESULTS
Pathologic fractures had significantly higher perfusion parameters (Vp, Ktrans, wash-in slope, peak enhancent
and AUC) (p<0.01) when compared with benign fractures. Among benign vertebral fractures we also found
significant differences (p<0.001) in all parameters comparing chronic and acute fractures. Vp and Ktrans were
also able to discriminate between pathologic and acute fractures (p<0.01). Wash in was only marginally
significant (p<0.02). No significant differences were found with peak enhancement (p<0.21) and AUC (p<0.4)
in this last group.
CONCLUSION
Our data demonstrates that DCE - MRI helps to distinguish between pathologic and benign, acute and chronic
and even benign acute and pathologic vertebral fractures. Adding DCE perfusion maps to standard MRI can aid
to improve diagnostic accuracy.
CLINICAL RELEVANCE/APPLICATION
DCE MRI is a useful non invasive method that could help to distinguish between pathologic and benign vertebral
fractures, avoiding unnecessary biopsy or preventing diagnostic and treatment delay
VSNR21-05
Diffusion Weighted Imaging, Diffusion Tensor Imaging, and Enhanced MRI in Patients with Spinal
Cord Infarct: Differentiation with Other Acute Myeolpathy
Dong-Ho
Ha (Presenter): Nothing to Disclose , Sunseob
Choi MD, PhD : Nothing to Disclose
PURPOSE
To evaluate the diagnostic value of diffusion weighted imaging (DWI), diffusion-tensor imaging (DTI), and
enhanced MRI in patients with spinal cord infarct, focused on the differentiation from acute inflammatory and
demyelinating lesions
METHOD AND MATERIALS
Institutional review board approval was obtained, but informed consent was waived. We retrospectively
reviewed the MRI data and medical record of patients who admitted with acute myelopathy between August
2011 and December 2013. Twenty two patients (seven with spinal cord infarct, 15 with other acute
myelopathy) were included in the study. The group of other acute myelopathy consists of 6 patients with
neuromyelitis optica or spectrum disorder, 5 patients with transverse myelitis, 4 patients with multiple sclerosis.
Exclusion criteria were traumatic or compressive acute myelopathy. The following imaging findings were
analyzed: (a) length of lesion on T2 weighted image, (b) presence of high SI on DWI, (c) DTI indices (FA value
and mADC), (d) degree of enhancement
RESULTS
The patients with spinal cord infarct had a significantly greater frequency of the presence of high SI on DWI (6
of 7, p<0.05) and showed more decreased FA values (0.31± 0.15, P<0.05). The length of lesion on T2
weighted image showed similar appearance between two groups. On enhanced MRI image, all of cases of spinal
cord infarct revealed non-enhancement or minimal enhancement, other acute myelopathy showed more
frequent prominent enhancement (4 of 15), however statistically no significant (p=0.34).
CONCLUSION
DWI, DTI and enhanced MRI were useful to differentiate spinal cord infarct from the other acute myelopathy.
CLINICAL RELEVANCE/APPLICATION
DWI MRI is the essential imaging tool to diagnosis the spinal cord infarct, even it has various technical
challenging.
VSNR21-06
Providing Value in Spine Imaging
Michael D. Phillips MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Discuss the concepts of price, cost and value of imaging in spinal disorders. 2) Gain an appreciation for the
available literature regarding the economics of spinal imaging. 3) Gain an appreciation for changing role of
spinal imaging in the transition from fee for service to ACO models.
VSNR21-07
Imaging of the Craniovertebral Junction
Jeffrey S. Ross MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Recognize the difference between basilar impression and basilar invagination. 2) Identify the pathologies
associated with basilar invagination. 3) Identify the pathologies associated with basilar impression. 4)
Understand the common measurements useful in disease of the craniovertebral junction.
ABSTRACT
The craniovertebral junction is a complex anatomic area, with a confusing array of pathologies and
nomenclature. This presentation will define the commonly used terms and their associated pathologies.
Commonly used eponymous measurements will be discussed. Basilar impression, basilar invagination, cranial
settling and basilar kyphosis will be defined via imaging and measurements, and correlating pathologies
demonstrated.
VSNR21-08
Quantitative Magnetic Resonance Imaging for Spinal Cord Degeneration in Whiplash Associated
Disorders
Mark A Hoggarth MS (Presenter): Nothing to Disclose , James Matthew Elliott PhD : Owner, Pain Id, LLC ,
Todd B. Parrish PhD : Co-owner, Pain Id, LLC
PURPOSE
Whiplash Associated Disorder (WAD) has been commonly treated as a homogenous condition but there remains
little evidence that doing so will improve functional recovery in the long-term. No structural mechanism of WAD
has been found leading to the assertion that chronic WAD is primarily and uniquely found in the psychologically
weak-willed. However, recent evidence has identified degenerative changes in neck muscles specific to those
with chronic WAD, suggesting a biological contribution. Precise mechanisms, however, remain elusive.
Magnetization Transfer (MT) imaging is a method of investigating white matter integrity in multiple pathologies,
including demyelination in the spinal cord. MT ratio (MTR) analysis in the spinal cord could refine diagnosis in
WAD. The goal of this work is threefold: 1) introduce quantitative MTR methods by which patients with WAD can
be characterized; 2) promote quantitative metrics in the study of WAD; 3) present degeneration in regional
spinal cord pathways which may be present in a subpopulation of persons with chronic WAD.
METHOD AND MATERIALS
15 subjects, 5 chronic WAD, 5 recovered and 5 controls were recruited into this study. Images were gathered
perpendicular to the cervical spinal cord at the superior aspect of the fifth vertebra using MEDIC MRI. The MT
pulse was 1.5kHz off-resonance with Flip angle/duration of 5400/10ms. Scan time was 8 minutes for MT and
non-MT imaging. Ventral, dorsal, and lateral (left and right) aspects of the cord were segmented, and MTRs
were calculated. The range in MTR values (dMTR) was then recorded.
RESULTS
dMTR differences were significant between WAD versus control and recovered groups (P < 0.01) . Average
dMTR values were dMTR: 18.87, recovered: 7.45 and control: 6.59. Control and recovered were not
distinguishable (P = 0.37).
CONCLUSION
A quantitative imaging technique was introduced and preliminary findings suggest that the group of concern
demonstrates reductions of magnetization transfer ratios in spinal cord white matter pathways. Recovered and
healthy controls do not have such findings. These findings provide foundation for larger-scaled work.
CLINICAL RELEVANCE/APPLICATION
50% of people with a whiplash injury from a motor vehicle collision will never fully recover and 25% have
complex clinical presentations. This work contributes to the understanding of potential neurological pathologies
in the spinal cord underlying chronic WAD.
VSNR21-09
Diagnostic Accuracy of MRI Following Whiplash Injury Is Improved by Routine Imaging of the
Cranio-cervical Junction
Francis William Smith MD (Presenter): Nothing to Disclose
PURPOSE
To improve diagnosis in patients following whip-lash injury
METHOD AND MATERIALS
20 patients (14 female, 6 male) age range 15 - 69 yrs (Mean 47yrs), previously investigated following a
hyperextension injury of the neck with reportedly normal MRI examination of the cervical spine were entered in
to the study. Previous MRI examinations had comprised sagittal T1 and T2 weighted images together with axial
T2 weighted images at all levels from C2/3 to C7/T1 . For the study, patients were studied in the seated upright
position, where in addition to the sequences above, had a series of Coronal T2 weighted images and coronal
and axial proton density images made from the skull base down to the C2/3 level.Spinal alignment, integrity of
the intervertebral discs, alignment of the atlanto axial joints and atlanto-occiptal joints, the integrity of the alar
and cruciate ligaments, as well as the integrity of the neck muscles were assessed in all cases. If dislocation of
either the atlanto-axial or atlanto-occipital joints were observed, further axial imaging at these levels was made
with the head turned to the right and the left to assess for instability.
RESULTS
In 50% of the patients, the comprenhensive imaging protocol found no cause that could be attributed to
hyperextension injury of the neck. In the other 10 patients, eight had dislocation at the atlanto-axial joint two of
which showed instability when the rotation images were assessed. Two showed stable dislocation at the
antlanto-occipital joint, one of which also had low lying cerebellar tonsils.
CONCLUSION
We believe that the accepted practice of imaging the cervical spine, limiting the axial images to below the axis
is inadequte and under estimates the incidence of significant post traumatic dislocation above this level. For
thorough MRI examination of the neck in patients following hyper-extension injury, the use of good resolution
imaging of the cranio-cervical junction in both the coronal and axial planes is mandatory, both to find evidence
of dislocation and also to exclude it when it is not present.
CLINICAL RELEVANCE/APPLICATION
The cost implications of under diagnosis of mechanical damage at the cranio-cervical junction, both in terms of
patient suffering and cost in insurance claims, is very large. We believe it is of paramount importance to not
only to show dislocation and ligamentous damage when present, but also to categorecally exclude such damage
when it is not present.
VSNR21-10
4D-phase-Contrast Evaluation of Cerebrospinal Fluid Dynamics in a Rigid-wall 3D Printed in-vitro
Model of Chiari I Malformation with Idealized Spinal Cord Nerve Roots
Jan Robert Kroger MD (Presenter): Nothing to Disclose , SURAJ THYAGARAJ : Nothing to Disclose , Daniel
Giese : Nothing to Disclose , Dennis Hedderich MD : Nothing to Disclose , Richard Lukas Clemens Uwe
Morsdorf-Schulte : Nothing to Disclose , David Christian Maintz MD : Nothing to Disclose , Theresia
Yiallourou : Nothing to Disclose , Soroush Heidari Pahlavian : Nothing to Disclose , Alexander Christian
Bunck : Nothing to Disclose , Bryn A Martin PhD : Nothing to Disclose
PURPOSE
The mechanisms of cerebrospinal fluid (CSF) hydrodynamics in the pathophysiology of Chiari malformation Type
1 (CMI) are still poorly understood. The aim of this study was to reverse-engineer 3D printed models of the
subarachnoid space (SAS) at the craniocervical junction, based on subject-specific MR measurements, to help
understand the accuracy of 4D-phase-contrast-(PC)-MRI and the hydrodynamics in CMI.
METHOD AND MATERIALS
4D-PC-MRI and high-resolution T2-weighted MR-images were obtained for a CMI patient and healthy control.
Four subject-specific 3D-printed models of the subarachnoid space near the craniocervical junction were
constructed based on the in-vivo images, two with idealized nerve roots. A pulsatile computer-controlled pump
was constructed to produce subject-specific flow waveforms. The four in-vitro models were scanned by
4D-PC-MRI and peak velocities were compared along the cervical spine for the in-vivo and in-vitro
measurements.
RESULTS
For the healthy volunteer, in-vitro and in-vivo flow characteristics were similar. Peak CSF flow velocities
correlated with the area of the SAS in all models (r=0.6; p<0.001) and in the healthy volunteer (r= 0.7;
p<0.05) but not in the CMI patient (p>0.05). For the CMI patient, in-vivo and in-vitro velocities had poor
agreement, particular near the foramen magnum. At this region, in-vivo flow patterns in the CMI patient showed
unilateral dominated flow jets and elevated flow velocities that were not present in the corresponding in-vitro
models. The in-vitro models with nerve roots showed elevated flow velocities compared to the models without
nerve roots. Flow distribution along the cervical spine was similar for the models with and without nerve roots
with localized flow disturbances surrounding the nerve roots.
CONCLUSION
Quantification of the CSF flow field by 4D-PC-MRI showed good agreement with in-vivo flow characteristics in
the healthy case and poor agreement for the CMI patient. These differences demonstrate that a replication of
static morphology is insufficient to explain the alterations in CSF dynamics seen in CMI patients and that neural
tissue motion and/or a systematic error in the 3D model geometry reconstruction could be an important factor.
CLINICAL RELEVANCE/APPLICATION
The simulation of CSF hydrodynamics in our controlled set-up promotes a better understanding of the crucial
variables causing the characteristic alterations in CSF dynamics seen in patients with CMI.
VSNR21-11
Psoas Sign in Lumbar Vertebral Infections: “Look at Me Lesion!”
Luke N. Ledbetter MD (Presenter): Nothing to Disclose , Karen Lisa Salzman MD : Consultant, Amirsys, Inc
Stockholder, Amirsys, Inc , Lubdha Mahavir Shah MD : Nothing to Disclose
PURPOSE
Spine infections, including vertebral body osteomyelitis and discitis, are relatively common causes of morbidity
and mortality. The most common clinical symptom is nonspecific back pain, making a clinical diagnosis difficult.
Magnetic resonance imaging (MRI) is the optimal modality for evaluation of suspected vertebral infections.
Characteristic MRI characteristics of spine infections include low T1 signal and high T2 signal within the vertebral
bodies, high T2 signal within the intervertebral disc, and variable post contrast osseous and disc enhancement.
These findings often overlap with noninfectious etiologies, such as degenerative disc disease, inflammatory
spondyloarthopathy, neuropathic arthopathy, and hemodialysis associated spondyloarthropathy. Our purpose in
this study is to demonstrate that abnormalities with in the psoas musculature, the psoas sign, is strongly
associated with lumbar discitis-osteomyelitis and not commonly observed in noninfectious etiologies of lumbar
pathology such as degenerative disc disease, inflammatory spondyloarthopathy, neuropathic arthopathy, and
hemodialysis associated spondyloarthropathy.
METHOD AND MATERIALS
A retrospective imaging and chart review was preformed of all patients who received a MRI of the lumbar spine
in the calendar year of 2013 with the clinical indication or findings that included the key words "infection,"
"discitis," or "osteomyelitis." Patients were divided into an infectious (23 patients) and noninfectious group (25
patients) based on either biopsy and/or clinical treatment for infection after imaging. Studies were reviewed for
presence or absence of abnormal T2 signal and, if available, enhancement within the psoas musculature.
Statistical analysis was performed with a two-tailed Fisher's exact test.
RESULTS
The infection group showed a positive psoas sign in 21 of 23 patients. The noninfection group had a positive
psoas sign in 2 of 25 patients. The association of psoas sign with discitis-osteomyelitis was found to be
statistically significant (p <0.05).
CONCLUSION
The psoas sign is strongly associated with lumbar discitis-osteomyelitis.
CLINICAL RELEVANCE/APPLICATION
Discitis-osteomyelitis can be a difficult clinical and imaging diagnosis secondary to nonspecific symptoms and
imaging findings. A positive psoas sign on MRI can be used as a reliable finding to suggest lumbar
discitis-osteomyelitis as opposed to noninfectious etiologies.
VSNR21-12
Pearls and Pitfalls in Spinal Imaging
Roland Robert Lee MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Correlate the patient's symptoms with imaging findings, to optimize interpretation. 2) Categorize the various
etiologies of spondylolisthesis, and recognize/describe the clinical significance of each. 3) Diagnose various
common but under-recognized spinal pathologies. 4) Recognize and avoid common pitfalls in reporting spinal
MRIs.
VSPD21
Pediatric Series: MSK
Series Courses
PD
MK
AMA PRA Category 1 Credits ™: 3.25
ARRT Category A+ Credits: 3.50
Mon, Dec 1 8:30 AM - 12:00 PM
Location: S102AB
Participants
Moderator
Peter Jackson Strouse MD : Nothing to Disclose
Moderator
J. Herman Kan MD : Nothing to Disclose
Sub-Events
VSPD21-01
Evaluation of Pediatric Foot Radiographs
Tal
Laor MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) To recognize the radiographic appearance of the normal pediatric foot. 2) To identify and evaluate
radiographic alignment abnormalities of the foot in children.
T2 and T1 Rho Cartilage Value Variations Based on the Presence or Absence of a Joint Effusion when
VSPD21-02
T2 and T1 Rho Cartilage Value Variations Based on the Presence or Absence of a Joint Effusion when
Morphologically Normal Cartilage is Present on Anatomic Cartilage MR Sequences
Johanna Monsalve MD (Presenter): Nothing to Disclose , J. Herman Kan MD : Nothing to Disclose , David
Chu PhD : Nothing to Disclose
PURPOSE
T1 Rho and T2 mapping of articular cartilage has been shown to be more sensitive for chondral injuries
compared with conventional anatomic MR sequences. The purpose of this study is to validate if the presence of
a large joint effusion affects T2 or T1 Rho cartilage mapping values in children when proton density weighted
fat saturated MR sequences are otherwise normal.
METHOD AND MATERIALS
We performed a prospective study of children between 0-18 years who underwent MRI of the knee from
12/13-3/14 at our institution. MRI exams were performed on a 3T Philips unit with a dedicated knee coil and
axial T1rho and T2 mapping axial sequences were added at the end of a standard sports knee protocol which
includes multiplanar T2 and PDW sequences. Patients were included in the study provided that the anatomic
sequences showed no evidence of chondral injury or subchondral marrow edema and a joint effusion was
subjectively identified on MR. A control population was similarly generated but without evidence of a joint
effusion. Region of interest T2 and T1rho maps were obtained in identical locations in the medial and lateral
patellar facet and values for a total of 4 individual cartilage sampling points for each study and control patient.
Values were generated and statistically compared between study and control population.
RESULTS
Seventeen children with joint effusion (12 female, 5 male, average age 15.1) and 10 without joint effusion (6
female, 4 male, average age 14.9) were included in the study. In the study population, T2 and T1rho values of
the 68 cartilage sampling points were 33.12 +/- 4.98 msec and 47.16 msec +/-8.97, respectively. In the
control population, T2 and T1rho values of the 40 cartilage sampling points were 33.83 +/-4.91 msec and
51.28 +/-9.67 msec, respectively. Both study and control population T1rho and T2 values were within the
normal expected range. There was no difference in T1rho (P=0.130) and T2 mapping values (P=0.614)
between the study and control populations.
CONCLUSION
Although T2 mapping values of cartilage are affected by relative water content compared with T1rho values,
neither of these parameters appear to be adulterated when assessing cartilage when there is subjective
presence of a joint effusion.
CLINICAL RELEVANCE/APPLICATION
Subjective presence of a joint effusion does not affect T1rho and T2 mapping values of when anatomic T2 and
PDW MRI sequences are normal.
VSPD21-03
Analysis of Risk Factors for Ultrasonographic Graf Type 2a Hips in Developmental Dysplasia: A
Hospital-based Case-control Study with a Screening Program
Burcu Sahin MD (Presenter): Nothing to Disclose , Elif Aktas MD : Nothing to Disclose , Hidir Kaygusuz :
Nothing to Disclose , Cengiz Tuncay : Nothing to Disclose , Bilgin Kadri Aribas MD : Nothing to Disclose
PURPOSE
Ultrasonographic Graf type 2a hips are considered as "physiologically immature". There is very scarce
information in the literature about the risk factors for specifically these Graf type 2a immature hips. Hence, the
purpose of this case-control study was to examine the association between ultrasonographic Graf type 2a hips
and maternal and infant risk factors of the newborns who were screened for the developmental hip dysplasia.
METHOD AND MATERIALS
In a one-year period, 679 infants were screened for developmental dysplasia by ultrasonography using Graf's
method. As an inclusion criterion, only Graf type 1 and type 2a's were accepted. Overall, 619 infants (321 boys,
298 girls, mean age: 6.3 weeks) were eligible. A total of 60 cases (17 boys, 43 girls) with ultrasonographic Graf
type 2a(+) and (-) hips and 559 controls (304 boys, 255 girls) with ultrasonographic Graf type 1 mature hips
were recruited. Sociodemographic status of the infants, including gestational age, birth weights and associated
congenital anomalies, maternal characteristics and, if any, the degree of consanguinity, were recorded. A
backward stepwise logistic regression model was used to evaluate the relationship between idiopathic Graf type
2a hips and maternal and infant risk factors. Unadjusted and adjusted odds ratios (OR) with 95% confidence
interval [CI] were calculated.
RESULTS
Among maternal and infant characteristics, significant risk factors for Graf type 2a hips in the regression
analysis were gestational age (>42 weeks, adjusted OR: 2.321), birth weight (>3500 gr, adjusted OR: 3,274)
and gender (girls adjusted OR: 2,741). Congenital anomalies, multiple pregnancy and family history - although
accepted as risk factors for developmental dysplasia - had no relation with Graf type 2a immature hips.
CONCLUSION
In conclusion, girls born after 42 weeks of gestation with an over 3500 grams of weight had a more than twice
the risk for a physiologically immature Graf type 2a hips. To obtain more accurate results, a population-based
screening study with an increased number of cases and controls should be performed in future studies.
CLINICAL RELEVANCE/APPLICATION
For ultrasonographic screening of developmental hip dysplasia,we recommend that gender,birth weight and
gestational age should be questioned in order to be alert for Graf type 2a hips.
VSPD21-04
DCE-MRI Curve Shape Patterns in Active and Inactive Juvenile Idiopathic Arthritis Patients Using a
Pixel-by-Pixel Time-intensity Curve Shape Analysis Method
Robert Hemke MD,PhD (Presenter): Nothing to Disclose , Cristina Lavini DPhil : Nothing to Disclose ,
Charlotte M. Nusman MSc : Nothing to Disclose , J. Merlijn van den Berg : Nothing to Disclose , Koert M.
Dolman : Nothing to Disclose , Marion Van Rossum MD, PhD : Nothing to Disclose , Taco Kuijpers MD,
PhD : Nothing to Disclose , Mario Maas MD, PhD : Nothing to Disclose
PURPOSE
To compare dynamic contrast-enhanced (DCE)-MRI parameters and the relative number of time intensity curve
(TIC) shapes as derived from pixel-by-pixel DCE-MRI TIC-shape analysis between knees of clinically active and
inactive juvenile idiopathic arthritis (JIA) patients.
METHOD AND MATERIALS
This prospective observational study was approved by the institutional review board and written informed
consent was obtained. DCE-MRI datasets of JIA patients were prospectively obtained. Patients were classified
into two clinical groups: active disease (n=49) and inactive disease (n=36). Parametric maps, showing 7
different TIC shape types, were created per slice. Statistical measures of the relative number of different TIC
shapes, maximal enhancement (ME), maximal initial slope (MIS), initial area under the curve (iAUC),
time-to-peak (TTP), and enhancing volume (EV) of each voxel were calculated in a three-dimensional volume of
interest of the synovial membrane.
RESULTS
Imaging findings from 85 JIA patients were analyzed. Significantly higher numbers of TIC shape 4 (P=0.001),
median ME (P=0.004), MIS(P=0.001), iAUC (P=0.002), and EV (P=0.013) were observed in clinically active
compared with inactive patients. TIC shape 5 was more present in the clinically inactive patients (P=0.018).
The intra-observer reliability was very good regarding all DCE-MRI parameters (ICC=0.93-1.00)
CONCLUSION
The pixel-by-pixel DCE-MRI TIC-shape analysis method proved capable of differentiating clinically active from
inactive JIA patients by the difference in the number of TIC shapes 4 and 5, as well as by the descriptive
parameters ME, MIS, iAUC and EV. Therefore, it may serve as an objective, more quantitative outcome
measure of imaging in clinical trials and future research.
CLINICAL RELEVANCE/APPLICATION
The pixel-by-pixel DCE-MRI TIC-shape analysis is able to differentiate clinically active from inactive JIA patients
using the relative number of TIC shapes 4 and 5 and descriptive parameters ME, MIS, and iAUC.
VSPD21-05
Imaging the Pediatric Hip—Non-FAI
Diego
Jaramillo MD, MPH (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) To recognize the normal appearance of developmental changes of the hip on MR images. 2) To be familiar
with the main indications for MRI in pediatric hip disorders. 3) To be familiar with the MR appearance of the
main pediatric hip pathologies. 4) To be aware of technical factors that are unique to children.
Handout:Diego Jaramillo
http://media.rsna.org/media/abstract/2014/14001041/Pediatric Hip Jaramillo 2014 Handout.pdf
VSPD21-06
Diffusion-weighted MRI in Paediatric Patients with Gonarthritis: A Novel Approach to Imaging of
Synovitis
Henning Neubauer MD, MBA (Presenter): Nothing to Disclose , Annette Holl-Wieden : Nothing to Disclose ,
Nicole Hassold MD : Nothing to Disclose , Thomas Alois Pabst PhD : Nothing to Disclose ,
Thorsten Alexander Bley MD : Nothing to Disclose
PURPOSE
Contrast-enhanced (ce-)T1w MRI is the current diagnostic standard for imaging synovitis in arthritis joints
aiming at early diagnosis and sensitive therapy surveillance. Native MR imaging techniques for synovitis have
been a focus of research for concerns of patient safety and cost. We evaluated diffusion-weighted MRI (DWI) as
a novel technique for imaging of synovitis in young patients with gonarthritis.
METHOD AND MATERIALS
Twenty-five children and adolescents (age 11±5 years, 13 females) with clinically suspected gonarthritis and
nine age-matched controls underwent routine MRI, including transversal ce-T1w and single-shot echoplanar
diffusion-weighted imaging (SS-EPI DWI, two b-values 0-50 and 800-1000 s2/mm, slice thickness 4-6 mm, 1.8
x 1.8 mm in-plane resolution, 2-6 averages, acquisition time 41 s to 190 s). DWI and ce-T1w images were
evaluated for the presence of synovitis. Signal intensity ratios were calculated for synovia vs. bone marrow and
synovia vs. effusion.
RESULTS
All examinations yielded diagnostic image quality. All patients showed synovial thickening and contrast
enhancement on ce-T1w and corresponding synovial signal increase on DWI at high b-values. Mean total ADC
was 2.2±0.5 (*10-3 mm2/s) for synovitis and 2.8±0.4 for joint effusion. Mean signal intensity (SI) ratios were
5.4 (ce-T1w) vs. 9.1 (DWI) for SI (synovitis/bone marrow) and 4.8 (ce-T1w) vs. 1.5 (DWI) for SI
(synovitis/effusion). There were no false-positive cases among controls.
CONCLUSION
Diffusion-weighted MRI reliably visualises synovitis of the knee joint based on altered tissue diffusivity and
presents a novel approach to imaging of synovitis without application of i.v. contrast agent. A combination of
DWI with dark-fluid techniques should be evaluated to further improve the delineation of synovitis in the
presence of joint effusion.
CLINICAL RELEVANCE/APPLICATION
Imaging synovitis with diffusion-weighted MRI holds potential to increase patient safety, to streamline scan
protocols and to reduce costs and thus deserves further evaluation.
VSPD21-07
The Use of DWI to Quantify Sacroiliitis in Adolescents with Enthesitis-related Arthritis (ERA) and
Correlation with Conventional STIR Score
Kanimozhi Vendhan MBBS, FRCR : Nothing to Disclose , Timothy James Bray MBBCHIR, MA (Presenter):
Nothing to Disclose , David Atkinson : Nothing to Disclose , Corinne Fisher : Nothing to Disclose , Debajit
Sen : Nothing to Disclose , Yiannakis Ioannou : Nothing to Disclose , Margaret Anne Hall-Craggs MD :
Nothing to Disclose
PURPOSE
To use diffusion weighted images to quantify inflammation of the sacroiliac joints in adolescents with enthesitis
related arthritis (ERA) and to correlate this with the conventional STIR inflammation score.
METHOD AND MATERIALS
We performed a retrospective case control study on 20 patients (10 ERA cases; 10 controls with mechanical
back pain). All patients had conventional MRI of the sacroiliac joints along with diffusion weighted MRI. The
anonymised images were exported to Matlab for analysis. The STIR scoring was performed by two readers and
was based on a modification of an established scoring system used in adults with ankylosing spondylitis.
Inflammation was also scored on the ADC maps using a methodology previously developed and piloted by our
research group. In this technique the synovial portion of the SIJs are evaluated using multiple linear regions of
interest (ROI). A profile of ADC values are obtained across each of those ROIs. Disease severity and extent were
quantified using 'integrated normalised ADC value' - a summation of normalised ADC values along the
standarised 14mm line profile expressed as 10-6 mm2s-1 x mm.
RESULTS
There was a highly significant difference in mean integrated ADC values between cases (8000 x 10-6 mm2s-1 x
mm) and controls (2000 x 10-6 mm2s-1 x mm). There was good agreement in STIR scores between the two
observers as shown by an intra-class correlation value of 0.96 for controls and 0.94 for cases. Pearson
correlation was used to examine the association between the STIR scores and the average integrated ADC
values. For cases, the Pearson correlation coefficient was 0.89 and for controls it was 0.82. This suggests a
highly significant association between the two scores.
CONCLUSION
This data shows clear separation between normal subcortical bone and areas of inflammation using 'integrated
normalised ADC' scores obtained from ADC maps. It has the potential to serve as a quantitative tool to assess
sacroiliitis.
CLINICAL RELEVANCE/APPLICATION
This technique can be used to assess change in ADC scores with treatment and to determine if there is a
significant difference in scores between ERA patients treated with disease modifying anti-rheumatic drugs and
those treated with anti- TNF agents.
Active Handout
http://media.rsna.org/media/abstract/2014/14014844/VSPD21-07 sec.pdf
VSPD21-08
Feasibility of Ultrasound-guided Sacroiliac Joint Injections in Children Presenting with Sacroiliitis
Mohamed Mahmoud Hamdy Abd Ellah MD (Presenter): Nothing to Disclose , Michaela Sailer Hoeck MD :
Nothing to Disclose , Juergen Brunner MD, PhD : Nothing to Disclose , Christian Siedentopf MD : Nothing
to Disclose , Gudrun Feuchtner MD : Nothing to Disclose , Mihra S. Taljanovic MD : Nothing to Disclose ,
Fabian Plank MD : Nothing to Disclose , Werner R. Jaschke MD, PhD : Nothing to Disclose , Andrea
Klauser MD : Nothing to Disclose
PURPOSE
To evaluate feasibility and effectiveness of ultrasound guided sacroiliac joint injection in the treatment of
sacroiliitis in pediatric patients
METHOD AND MATERIALS
In thirteen patients (7 females and 6 males), 9-16 years (mean +/- std 11.39 +/- 1.98), eighteen SI joint
injections were performed under US guidance. All patients suffered from severe sacroiliitis. US scanning was
performed using a linear-array transducer operating at 5-18 MHz. Rating of the patients pain using a 0-10
dolorimetry scale on a visual analog score (VAS) was recorded before, immediately after, and 3months after
injection to monitor severity and therapeutic response
RESULTS
Injection could be performed in all patients without complication showing good response immediately and 3
months after injection with a decrease of the VAS from (mean +/- std 9.44 +/- 1.097, to 3.89 +/- 3.82, p
<0.001, and to 0.56 +/- 1.097, p <0.05) respectively was noted
CONCLUSION
US guided SI joint injection was feasible in all children, relatively quick and easy to perform and appeared
effective in the treatment of pediatric patients with sacroiliitis
CLINICAL RELEVANCE/APPLICATION
Dealing with sacroiliitis, US guided sacroiliac joint injection in the pediatric patients showed easy, safe, relatively
fast, and effective treatment option.
VSPD21-09
Kocher Criteria Revisited in the Era of MRI: How Often Does the Kocher Criteria Identify Underlying
Osteomyelitis?
Alexander Nguyen BS (Presenter): Nothing to Disclose , J. Herman Kan MD : Nothing to Disclose , Scott B.
Rosenfeld MD : Nothing to Disclose , George S. Bisset MD : Nothing to Disclose
PURPOSE
The Kocher criteria are established clinical parameters that predict hip septic arthritis (SA) with a 93% or
greater positive predictive value when 3 or 4 variables are present but the incidence of underlying osteomyelitis
has not been reported. The purpose of this study is to evaluate the incidence of underlying osteomyelitis (OM) in
patients who have 3 or 4 positive Kocher criteria.
METHOD AND MATERIALS
77 consecutive patients (mean age 5.2 years) treated between 1/07 and 6/13 for suspected hip SA who had 3
or 4 positive Kocher criteria were retrospectively reviewed. The Kocher criteria variables include:
nonweightbearing status, fever>38.5 C, WBC 12K, and ESR > 40 mm/hr. All patients underwent US and MRI as
part of their work-up.
RESULTS
There were a total of 77 patients with 3 or 4 positive Kocher criteria. Of these, 37.7% (n=29) had a diagnosis
of SA and 44.2% (n=44.2%) had a diagnosis of OM. Of the 77 patients, 56% (43/77) had a hip effusion by US.
When an effusion was identified, 39.5% (17/43) had SA only and 37% (16/43) had OM. When no effusion was
identified, 18/34 (51%) had underlying OM.
CONCLUSION
Patients with 3 or 4 Kocher criteria have a high incidence (44%) of underlying osteomyelitis. Our results
suggest that the combination of Kocher criteria and US results is not sufficient to make a diagnosis in patients
presenting with hip irritability.
CLINICAL RELEVANCE/APPLICATION
Patients with hip pain and 3 or 4 Kocher criteria should all routinely undergo MRI during work-up for suspected
septic arthritis.
VSPD21-10
Cam-type FAI in the Pediatric Patient
Sarah Dantzler Bixby MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) To recognize findings on plain radiographs and magnetic resonance imaging (MRI) examinations in children
and adolescents that indicate cam-type femoroacetabular impingement (FAI). 2) To identify the pediatric hip
conditions that most commonly lead to cam-type FAI in children and adolescents. 3) To understand the
mechanism by which cam-type FAI leads to joint damage and disability, and illustrate how surgical
intervention, in the appropriate setting, may minimize this damage
Appearance of the Synovium on Contrast-enhanced MRI of the Knee in Asymptomatic Controls
VSPD21-11
Appearance of the Synovium on Contrast-enhanced MRI of the Knee in Asymptomatic Controls
Compared to Juvenile Idiopathic Arthritis Patients
Charlotte M. Nusman MSc (Presenter): Nothing to Disclose , Robert Hemke MD,PhD : Nothing to Disclose ,
Marc Benninga MD, PhD : Nothing to Disclose , Angelika Kindermann MD, PhD : Nothing to Disclose ,
Marion Van Rossum MD, PhD : Nothing to Disclose , Taco Kuijpers MD, PhD : Nothing to Disclose , Mario
Maas MD, PhD : Nothing to Disclose
PURPOSE
The primary target of disease in juvenile idiopathic arthritis (JIA) is inflamed synovium, which can be objectified
with magnetic resonance imaging (MRI) with administration of intravenous (IV) contrast. Adequate
differentiation between pathologic from physiologic extent of synovial enhancement has important implications
for (dis)continuation of therapy. The purpose of this study was to assess the enhancing synovium on MRI of the
knee in asymptomatic children compared to JIA patients.
METHOD AND MATERIALS
An axial fat-saturated T1-weighted MRI sequence of the knee of 25 asymptomatic controls and 25 JIA patients
was collected, blinded and randomized. The asymptomatic controls were children who underwent MR
enterography with IV contrast, had no (history of) joint complaints or signs of joint inflammation and gave
permission for an additional sequence of the knee. JIA patients were age/sex-matched and divided in three
clinical subgroups: new-active, relapse and inactive. Two readers independently measured enhancing synovium
and scored synovial thickening (ST) on a scale from 0-2 (none, mild, moderate/severe) at six locations.
Afterwards agreement on incongruent cases was obtained. Differences in ST score and thickness of enhancing
synovium between the controls and (subgroups) of JIA patients were assessed.
RESULTS
Mean age of all subjects (42% female) was 13.5 years (SD 2.5). Enhanced thickened synovium was present on
knee MRI in 36% of the controls (ST score range 1-3) and 80% of the patients. A significant difference
(p=0.000) in the ST score was found between controls and JIA children. ST score could differentiate controls
from all JIA subgroups (p=0.003-0.028) (Figure 1). Synovial thickness differed between controls (mean
1.4-1.9mm) and patients with clinically active arthritis (mean 1.8-2.6mm) on 4 out of 6 locations
(p=0.020-0.049).
CONCLUSION
This study is the first to objectively quantify enhanced synovial thickening in an asymptomatic population
compared to JIA patients. ST score on MRI can adequately differentiate asymptomatic controls from (subgroups
of) JIA patients. These findings further establish MRI as diagnostic and disease activity monitoring tool in JIA
patients.
CLINICAL RELEVANCE/APPLICATION
Synovial thickening on contrast-enhanced MRI can distinguish between asymptomatic controls and JIA patients
in all disease activity stages.
VSPD21-12
Implementation of Novel Ultra-Short TE (UTE) and Conventional Imaging Techniques for
Assessment of Blood Degradation Products in Hemophiliac Joints - Work in Progress
Arvind Kaur Shergill MBBS (Presenter): Nothing to Disclose , Marshall Stephen Sussman PhD : Nothing to
Disclose , Denise A. Castro MD : Nothing to Disclose , Carina Man : Nothing to Disclose , Arun Mohanta :
Nothing to Disclose , Andrea Schwarz Doria MD : Research Grant, Baxter International Inc Research Grant,
Physicians Services Incorporated
PURPOSE
Quantification of early soft tissue joint changes with MRI and ultrasound (US) techniques that enhance
visualization of blood products are crucial for diagnosis and follow-up of arthropathy in hemophilic children. The
purposes of this study are: 1. To compare UTE and conventional MRI sequences for assessing blood degradation
products in hemophilic children with subacute and chronic bleeds. 2. To assess the echogenicity/color pixel
amount of soft tissues in hemophiliac joints at different time points after bleeds using gray-scale and color
doppler (CD) US in relation to corresponding MR images.
METHOD AND MATERIALS
30 hemophilic boys (5-17 years) with history of a subacute (<1 week) joint bleed [group 1], no history of a
recent (<4 weeks) joint bleed [group 2], and 13 healthy controls (9-18 years) underwent US and MRI scans
using conventional and UTE sequences. For UTE scans, the images from two echo times were subtracted to
produce a short-T2 image. Two blinded radiologists reviewed US and MRI examinations according to
International Prophylaxis Study Group scores.
RESULTS
In group 1 (n=14) intra-articular blood on US appeared hypo, iso and hyperecho in (6/14) 42.9%, (1/14) 7.1%,
and (3/14) 21% of cases, respectively. On MRI (T1/T2) it showed intermediate/high signal in (12/14) 86% and
low signal in (2/14) 14% of cases. In group 2, intra-articular blood appeared hypo, iso and hyperechoic in
(8/16) 50%, (1/16) 6%, and (2/16) 13% cases. On MRI (T1/T2) it appeared as low signal in (12/16) 75% and
intermediate/high signal in (2/16) 12.5% of scans (which presented with superimposed recent bleeds). On
CDUS, increased synovial vascularity was seen in 38% of ankles and 50% of knees in group 1, and in 13% of
ankles and 60% of knees in group 2. In all available UTE images chronic blood products demonstrated
intermediate signal as opposed to dark signal on MPGR MR images.
CONCLUSION
Conversely to conventional MRI, neither gray-scale nor CDUS could distinguish subacute from chronic bleeds in
hemophilic joints. The use of UTE MRI holds promise for detecting minimal joint bleeds since the lack of
susceptibility artifacts (in contrast to gradient-echo MRI) may improve its accuracy.
CLINICAL RELEVANCE/APPLICATION
Gray-scale and CD US cannot stage timing of blood degradation products in hemophilic joints. UTE holds
potential as an accurate MRI techinique for detection of subclinical joint bleeds, thus encouraging further
investigation.
VSPD21-13
Reference Values of Fat Infiltration and Muscle Volume Loss for Morpho-functional Predictive
Behaviour in Duchenne Muscular Dystrophy: A Longitudinal MRI Study
Claudia Godi MD (Presenter): Nothing to Disclose , Alessandro Ambrosi : Nothing to Disclose , Corrado
Santarosa : Nothing to Disclose , Sara Napolitano : Nothing to Disclose , Antonella Iadanza : Nothing to
Disclose , Letterio Salvatore Politi MD : Nothing to Disclose , Francesca Nicastro : Nothing to Disclose ,
Marina Scarlato : Nothing to Disclose , Stefano Previtali : Nothing to Disclose , Fabio Ciceri : Nothing to
Disclose , Giulio Cossu : Nothing to Disclose , Yvan Torrente : Nothing to Disclose
PURPOSE
i) Quantitative and semiquantitative assessment of fat infiltration (FI) and muscle volume loss in lower limbs of
children with Duchenne Muscular Dystrophy (DMD) by Magnetic Resonance Imaging (MRI); ii) computation of
time-related quantitative curves of FI increase and MVI decay (Muscle Volume Index, a residual-to-total muscle
volume ratio) in a cohort of DMD patients aged 6 to 14; iii) establishment of a morpho-functional relationship
between MRI values and functional outcomes.
METHOD AND MATERIALS
26 male children with DMD (baseline age: 6-12 years) were longitudinally assessed by lower limb 3T MRI and
functional tests (Gowers, 10-meter time, North Star, 6-minute walking test). 5 age-matched controls were also
examined. A total of 85 MRI studies were performed. FI, atrophy and hypertrophy were visually scored on hips,
thighs and calves. T1 Signal Intensity Ratio (SIR) of muscle and nearby fat was used to quantify FI. Muscle
volume was measured by applying thresholds on T1-weighted images, and results were normalized for the
whole muscle volume to obtain a MVI. Permutation and regression analyses according to both age and
functional tests were calculated. P-values
RESULTS
FI was present on glutei and adductor magnus in all patients since the age of 6, with a proximal-to-distal
progression in the lower limb and selective sparing of sartorius and gracilis. Atrophy was almost parallel to the
FI pattern, whereas hypertrophy was observed in sartorius, gracilis and calf muscles. SIRs and MVIs were
significantly different from the control values, except for SIRs of sartorius and gracilis. Age-related curves with
percentile values were calculated for SIRs and MVIs, to provide a reference background for future experimental
therapy trials. SIRs and MVIs significantly correlated with all clinical measures, and could reliably predict
functional outcomes in a linear or exponential fashion.
CONCLUSION
SIRs and MVIs are objective predictors of functional outcomes, which can improve the staging of DMD patients.
MRI-based curves display the multistep muscle involvement over time and can provide reference values of FI
and muscle volume loss for both clinical and research settings.
CLINICAL RELEVANCE/APPLICATION
MR-based indexes of fat infiltration and muscle volume can track the progression of DMD in lower limbs,
providing background reference data for patients potentially involved in future therapy trials
VSPD21-14
T2 Mapping Evaluation of Occult Lateral Patellofemoral Compartment Chondral Injury in Children
with Patellar Dislocation
Lorell Ruiz-Flores MD (Presenter): Nothing to Disclose , J. Herman Kan MD : Nothing to Disclose , Johanna
Monsalve MD : Nothing to Disclose , Megan May MD : Nothing to Disclose , Zili David Chu PhD : Nothing
to Disclose
PURPOSE
T2 mapping has been shown to improve detection of occult cartilage injury that may normally not be seen on
conventional anatomic MRI sequences. Cartilage injuries are common in the medial patellar facet in the setting
of lateral patellar dislocation (LPD), but are less common in the lateral patellar facet and trochlea. The purpose
of this study is to determine the utility of T2 mapping in identifying occult lateral compartment chondral injuries
in the setting of LPD in children.
METHOD AND MATERIALS
This retrospective case-control study with waiver of informed consent. The study group consisted of 27 patients
(11 male, 16 female, average age of 14.6 years,) who underwent MRI in the setting of LPD. All patients
underwent multiplanar T2 and proton density fat saturated sequences and T2 mapping in the axial plane (Fig
1). T2 mapping sequence is a SENSE Multi-slice multi-echo sequence providing 6 echoes with TR of 2000 ms;
TEs of 13*n ms, where n=1, 2, 3,4,5,6; FOV of 160 mm; voxel size of 0.29x0.29x2.5 mm3, slice gap of 0.25
mm, 10 slices, acquisition time of 5:54 minutes. To be included in the study group, patients had to have a
clinical history and classic MRI findings of LPD with no cartilage injury identified in the lateral patellofemoral
compartment on multiplanar proton density and T2W sequences. T2 mapping measurements of the lateral
patellar and lateral trochlear facets were obtained. A control group of 27 patients with normal knee MRI's was
used for reference (14 male, 13 female, average age of 14.4 years).
RESULTS
Review of the T2 color maps for both LPD and normal patients show no focal areas of increased T2 values in
lateral patellar or trochlear cartilage.The T2 values of the lateral patellar facet in LPD and normal patients were
35.89 +/-5.62 msec and 36.93 +/-6.77 msec, respectively (P=0.388). The T2 values of the lateral trochlear
facet in LPD and normal patients were 40.97 +/-5.39 msec and 42.45 +/- 6.61 msec, respectively (P=0.205).
CONCLUSION
In the absence of anatomic cartilage injury seen on conventional MRI sequences, T2 mapping does not appear
to identify additional lateral patellofemoral compartment chondral injuries in the setting of LPD in children.
CLINICAL RELEVANCE/APPLICATION
Lateral patellofemoral compartment cartilage injuries are rare in LPD, and T2 mapping sequences does not
identify additional cartilage injuries that are not already present on conventional cartilage MRI sequences in
children.
VSPD21-15
Skeletal Hallmarks of Child Abuse
Paul K. Kleinman MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) To learn patterns of skeletal injury characteristic of child abuse. 2) To learn radiologic-histopathologic
correlates of of these hallmark injuries. 3) To learn the appropriate imaging protocols for skeletal surveys in
suspected child abuse.
Hologic: Low-dose 3D Mammography for Breast Cancer Screening.
Vendor Workshops
Mon, Dec 1 10:15 AM - 11:45 AM
Location: Booth 1465
LEARNING OBJECTIVES
Hologic is offering a series of 90 minute sessions that include a brief lecture by a leading breast radiologist providing their
clinical perspective on the use of Hologic Low-dose 3D Mammography using C-ViewTM software. The lecture will be followed by
hands-on experience reading 3D mammograms in combination with conventional and generated 2D images. The sessions are
intended for radiologists interested in learning more about 3D mammography for screening and diagnosis. Please note the
program will provide a certificate of completion that may be used towards the FDA mandated training for tomosynthesis. The
course is not accredited for CME. <br> <br> Please visit <a href="http://www.hologic.com/RSNAtomo-courses"
target='_blank'>www.hologic.com/RSNAtomo-courses</a> to register for this Vendor Workshop.
Hologic: Essentials of 3D Mammography Self-Guided Training
Vendor Workshops
Mon, Dec 1 10:30 AM - 12:30 PM
Location: Booth 1465
LEARNING OBJECTIVES
Hologic is offering a series of ongoing sessions to allow radiologists to participate in an online Hologic 3D Mammography
interactive virtual training. Each session takes approximately 2 hours to complete, therefore the last session will commence no
later than 3:00 p.m. each day. Participants will be provided a workstation with headphones to enhance their learning
experience. The sessions will include a lecture by a leading breast radiologist and an interactive case review module. The
sessions are intended for radiologists interested in learning more about 3D mammography for screening and diagnosis. Please
note the program will provide a certificate of completion that may be used towards the FDA mandated training for
tomosynthesis. The course is not accredited for CME. <br> <br> Please visit <a
href="http://www.hologic.com/RSNAtomo-courses" target='_blank'>www.hologic.com/RSNAtomo-courses</a> to register for
this Vendor Workshop.
GE Healthcare: GE Healthcare Breast Health Advantage: 3D Automated Breast Ultrasound
(ABUS): An Interactive Hands on Workshop
Vendor Workshops
Mon, Dec 1 10:30 AM - 11:30 AM
Location: Booth 4782
LEARNING OBJECTIVES
To secure your seat, please register at the link below.
View beyond mammography, with breast screening technology that looks differently at dense breast tissue.
Join ABUS radiologist Automated Breast Ultrasound experts as they lead a comprehensive one-hour workshop that will
Join ABUS radiologist Automated Breast Ultrasound experts as they lead a comprehensive one-hour workshop that will
introduce you to 3D ABUS interpretation, including how to navigate the coronal plane to efficiently to highlight potential
abnormalities and streamline the screening workflow.
Attendees will:
Learn how 3D ABUS screening helps increase cancer detection in women with Dense Breast Tissue and no prior clinical
breast interventions
See how quickly whole breast image volumes are acquired on the InveniaTM ABUS system
Review clinical cases on the Invenia ABUS Workstation during physician guided hands-on exam interpretation
Please visit http://www.register.inputinput.com/ to register for this Vendor Workshop.
MSAS22
Think Inside the Box: Combining Strategy and Design to Re-invent Radiology Master
Planning (Sponsored by the Associated Sciences Consortium) (An Interactive Session)
Multisession Courses
HP HP
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credits: 1.50
Mon, Dec 1 10:30 AM - 12:00 PM
Location: S105AB
Participants
Moderator
Morris A. Stein BArch : Nothing to Disclose
Carlos L. Amato (Presenter): Nothing to Disclose
Katherine Margaret Richman MD (Presenter): Spouse, Employee, Agfa-Gevaert Group
John T. McGarry (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Identify strategic master planning initiatives to address ACA impacts as well as innovative future delivery of care models. 2)
Describe how technology trends such as mobile health, cloud computing, big data, inteligent patient models, intelligent
infrastructure and patient empowerment will affect future physical radiology department designs. 3) Demonstrate the benefits of
parametric master planning and why it will radically change the traditional design process commonly used today. 4) Understand
parametric planning and simulation modeling to objectively evaluate and compare department functional organizations, staffing
models, efficiency and patient throughput.
ABSTRACT
Every hospital and outpatient center faces several common and overlapping challenges: limited space, growing demands for
efficiency, finite resources and increased patient volume. Master planning for Radiology is more than simply technology change
or squeezing more inside existing space. This refresher course will describe how using strategtic planning, physical design and
functional organization all best contribute for a modern reinvention of master planning. The same clues that large institutions
are using globally are valuable for radiology specific planning.
MSCM22
Case-based Review of Magnetic Resonance (An Interactive Session)
Multisession Courses
MR NR HN
GU
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credits: 1.50
Mon, Dec 1 10:30 AM - 12:00 PM
Location: S100AB
Sub-Events
MSCM22A
Female Pelvis
Antonio
Luna MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Review the use of MRI in gynecological disorders in a case-based format. 2) Highlight common pearls and
pitfalls in MRI of the female pelvis. 3) Enhance findings that should not be overlooked in MRI of gynecological
disorders.
MSCM22B
Head and Neck
Christine M. Glastonbury MBBS (Presenter): Investor, Amirsys, Inc
LEARNING OBJECTIVES
1) To learn the key points that create a succinct imaging differential diagnosis while appreciating the 'big
picture' in HandN imaging. 2) To recognize the imaging findings of critical disease and what to do or
recommend next with your patient.
Active Handout
Active Handout
http://media.rsna.org/media/abstract/2014/14001471/MSCM22B sec.pdf
MSCM22C
Brain
Jonathan H. Burdette MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Understand the latest brain imaging techniques and how they can be used in routine clinical practice. 2)
Recognize commonly missed or misinterpreted findings/abnormalities. 3) Recognize imaging features of various
brain pathologic entities, such as neoplastic, infectious, inflammatory, and vascular diseases.
ABSTRACT
Magnetic Resonance Imaging continues to be the workhorse technique in brain imaging. The brain imaging
capabilities of MRI continue to make MRI a more sensitive and specific diagnostic tool compared with CT for
most clinical entities. The past 15 years has ushered in the era of Physiologic MRI techniques, such as
diffusion-weighted imaging, diffuson tensor imaging, gadolinium-based and arterial spin labeled perfusion
imaging, spectroscopy, functional MRI (fMRI), and, most recently, connectivity/network-based imaging. This
presentation will cover the MR imaging features of several brain pathologic entities, and some of the latest brain
MR imaging techniques will be introduced.
MSMC22
Cardiac CT Mentored Case Review: Part II (In Conjunction with the North American Society
for Cardiac Imaging) (An Interactive Session)
Multisession Courses
CT
VA
CA
AMA PRA Category 1 Credits ™: 1.75
ARRT Category A+ Credits: 2.00
Mon, Dec 1 10:30 AM - 12:15 PM
Location: S406A
Participants
Moderator
Geoffrey D. Rubin MD : Consultant, Fovia, Inc Consultant, Heartflow, Inc Consultant, Informatics in Context, Inc Research
Consultant, General Electric Company
Moderator
Vincent B. Ho MD, MBA : In-kind support, General Electric Company
LEARNING OBJECTIVES
1) Understand how to interact with 4D cardiac CTA data for proper interpretation. 2) Compare methods for characterizing
coronary stenoses and learn what is most appropriate in various situations.
Sub-Events
MSMC22A
Coronary Artery Disease I: Native Vessel Disease
Geoffrey D. Rubin MD (Presenter): Consultant, Fovia, Inc Consultant, Heartflow, Inc Consultant, Informatics
in Context, Inc Research Consultant, General Electric Company
LEARNING OBJECTIVES
View learning objectives under main course title.
MSMC22B
Coronary Artery Disease II: Native Vessel Disease
Smita
Patel MBBS (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
View learning objectives under main course title.
MSMC22C
Valves and Cardiac Function
Andrew John Bierhals MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
View learning objectives under main course title.
ABSTRACT
Cardiac CT can provide information on valves and function when retrospective ECG gating is used in the
acquisition. These studies require extensive image post-processing to accurately depict the moving structures.
This presentation will highlight basic image acquisition as well as the evaluation of normal and abnormal
patients.
MSMI22
Molecular Imaging Symposium: Radiogenomics: Linking Imaging to the Future - How to
Prepare for the Radiogenomic Revolution
Multisession Courses
RS MI BQ
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credits: 1.50
Mon, Dec 1 10:30 AM - 12:00 PM
Location: S405AB
Participants
Moderator
Ronald L. Korn MD, PhD : Nothing to Disclose
LEARNING OBJECTIVES
1) To understand how radiogenomics enables translation of everyday CT, MRI and PET findings into clinical molecular markers.
2) To understand emerging clinical applications of radiogenomics. 3) To discuss and highlight new directions and challenges for
the field of radiogenomics.
Sub-Events
MSMI22A
Integrating Histology and Genomics: Spatial and Molecular Heterogeneity of Immune Infiltration in
Triple-negative Breast Tumours
Yinyin
Yuan PhD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
View learning objectives under main course title.
MSMI22B
An Introduction to the Technical Framework for Quantitative Biomarker Imaging Analysis for
Radiogenomic Analysis
Jong Hyo Kim PhD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
View learning objectives under main course title.
MSMI22C
Radiogenomics-multiscale Molecular Imagaing: Applications in Clinical Practice
Michael D. Kuo MD (Presenter): Consultant, Boehringer Ingelheim GmbH Consultant, Confluence Life
Sciences, Inc
LEARNING OBJECTIVES
View learning objectives under main course title.
MSRO22
BOOST: Lung Cancer—Integrated Science and Practice (ISP) Session
Multisession Courses
RO OI
CH
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credits: 1.50
Mon, Dec 1 10:30 AM - 12:00 PM
Participants
Location: S103AB
Moderator
Simon Shek-Man Lo MD : Research support, Elekta AB Speaker, Varian Medical Systems, Inc Travel support, Varian Medical
Systems, Inc
Moderator
Feng-Ming Kong MD, PhD : Nothing to Disclose
Sub-Events
MSRO22-01
Invited Speaker:
David
MSRO22-02
Palma MD, FRCPC (Presenter): Nothing to Disclose
Long Time Prognosis on 474 Patients of Locally Advanced Non-small Cell Lung Cancer after
Three-dimensional Conformal Radiotherapy (3d-crt)--Single Centre Data
Yu-Xiang
Wang MD (Presenter): Nothing to Disclose
ABSTRACT
Purpose/Objective(s)To retrospective evaluate long time prognosis and its related prognostic
factors for locally advanced non-small cell lung cancer (NSCLC) after involved field
three-dimensional conformal radiotherapy(3D-CRT).: Materials/Methods:From August 2000 to
December 2010, 474 patients who suffered with locally advanced NSCLC was diagnosied and
treated with involved field 3D-CRT. Among them, 211 cases with stage IIIA, 263 cases with stage
IIIB; males in 382 and female in 92 cases; median ages was 63 years old. 55 cases received
conventional radiotherapy(CRT) add late-course 3D-CRT, 340 cases with 3D-CRT, and 79 cases with
intensity modulated radiation therapy(IMRT).The median equivalent dose was 60Gy(range
44-77Gy). There were 165 cases treated with radiotherapy alone, 175 cases with concurrent
chemoradiotherapy, and 134 cases with sequential chemoradiotherapy. 270 of 474 cases had intact
radiation treatment planning and ralated parameter was analysis with Dose Volume
Histogram(DVH). Statistics analysis was used with SPSS13.0 software.
Results:The deadline of
follow-up was 30 August 2013, and the follow-up rate was 96.6%. After radiotherapy, CR in 41
cases, PR in 392 cases, SD in 31 cases, PD in 10 cases, and the total efficiency(CR+PR) is 91.4%.
Rates of CR+PR was higher in T1-2 than in T3-4(p<0.05). Rate of acute radiation-related
pneumonitis was 53.8% (255/474), grade 1 in 62 cases,grade 2 in 74 cases, 114 cases in grade 3,
grade 4 in 5 cases, respectively; rate of acute radiation esophagitis rate was 41.1% (195/474 ), 95
cases in grade 1, 93 cases in grade 2 , 7 cases in grade 3. 1-, 3- and 5-years overall survival and
median was 63.0%, 24.9%, 17.8% and 18 months. With univariate analysis, the prognostic facter
was gender, age, style of radiotherapy, chemotherapy, primary tumor volmle, short-time response,
radiation-related pneumonitis, and GTV, GTVD100, GTVD95, GTVV60, CTV, CTVD100, CTVD90,
CTVV60, CTVV55, PTV in DVH(p0.05). Conclusions:In patients with local advanced NSCLC, the
independent prognostic factor were gender, age, short-time response, and GTV after 3D-CRT.
3D-CRT comparied with chemotherapy could increased survival comparied with radiotherapy alone
and boost dose did not increase survival.
MSRO22-03
FLT-PET/CT Differentiates Post-radiation Therapy Changes from Local Recurrence in Thoracic
Malignancies
Susan Mary Hiniker MD (Presenter): Nothing to Disclose , Andrew Quon MD : Nothing to Disclose ,
Maximilian Diehn MD, PhD : Research Consultant, Varian Medical Systems, Inc Research Grant, Varian
Medical Systems, Inc , Billy Wiseman Loo MD, PhD : Research support, Varian Medical Systems, Inc Research
support, RaySearch Laboratories AB
PURPOSE
Radiation therapy (RT) is increasingly used in the treatment of thoracic malignancies. Post-RT changes are
often difficult to distinguish from local recurrence by FDG-PET or CT. This is a pilot study of
3-deoxy-3-[18F]fluorothymidine (FLT)-PET/CT in patients with equivocal post-RT FDG-PET/CT, to assess the
utility of FLT-PET/CT in identifying tumor recurrence.
METHOD AND MATERIALS
We prospectively enrolled 10 patients who had a FDG-PET/CT scan that was indeterminate for local disease
recurrence after thoracic RT and performed FLT-PET/CT for further characterization. Interpretation criteria for
FLT-PET included a semi-quantitative assessment of SUVmax of the lesion and background activity in lung and
mediastinum and a qualitative assessment of the focality of the suspicious lesion. The FDG-PET/CT occurring
immediately prior to FLT-PET was also evaluated for maximum SUV of the suspicious lesion. Biopsy or clinical
follow-up including serial diagnostic contrast CT and FDG-PET/CT imaging served as the reference and
outcomes measurement.
RESULTS
10 patients with a median age of 70 years (51-81) underwent FLT-PET/CT. 9 patients received stereotactic
ablative RT (SABR), and 1 patient received conventionally fractionated RT. To date, 5 patients have undergone
biopsy and 2 patients had serial imaging that resulted in either unequivocal disease progression or resolution of
the suspicious lesion. 5/7 were found to have disease recurrence. In 4/5 patients with disease recurrence, the
ratio of FLT SUV in the suspicious lesion to FLT SUV in the mediastinal blood pool was > 2.0, while this was true
in 0/2 patients without disease recurrence. Focality of the lesion on FLT was a specific marker for disease
recurrence, as 3/3 patients with focal lesions were found to have recurrent disease on biopsy or unequivocal
progression on subsequent FDG-PET scans.
CONCLUSION
Adjunctive FLT-PET/CT can complement FDG-PET/CT in distinguishing post-RT changes from disease recurrence
in thoracic malignancies. A ratio >2.0 between the SUVmax of the lesion of interest and the mediastinal blood
pool may be a useful criteria for diagnosing recurrence in patients treated with thoracic RT.
CLINICAL RELEVANCE/APPLICATION
FLT-PET/CT imaging may differentiate local recurrence from post-treatment changes in patients treated with
thoracic RT and with equivocal findings on follow-up FDG-PET/CT imaging.
MSRO22-04
Comparison of Internal Gross Target Volumes Delineated on 4DCT Maximum Intensity Projection
(MIP) and FDG-PET/CT Images of Non-Small Cell Lung Cancer
Yili
Duan (Presenter): Nothing to Disclose
ABSTRACT
Objective To compare the positional and volumetric differences of internal gross target volumes(IGTV) based
on the maximum intensity projection(MIP) of four-dimensional CT(4D-CT) images and different standardized
uptake values of 18F-fluorodeoxyglucose positron emission tomography CT(PET-CT) for the primary tumor of
non-small cell lung cancer(NSCLC). Methods Ten NSCLC patients underwent enhanced three-dimensional CT
scan followed by enhanced 4D-CT scan of the thorax under normal free breathing and then 18F-FDG PET-CT
scan was performed in the same position based on the same positioning parameters. IGTV of the primary tumor
were contoured by the same radiotherapist on the MIP images of 4D-CT to generate IGTVMIP. IGTV PET were
determined with nine different threshold methods using the auto-contouring function and manual contouring.
The differences in the position, volume, matching index (MI) and degree of inclusion(DI)of the targets between
IGTVPET and IGTVMIP were compared. Results There were statistically significant differences between the
centric coordinate positions of IGTVPET and IGTV MIP only in z axes (P=0.014~0.044). In volume terms,
IGTV PET2.0 and IGTV PET20% approximated closely to IGTVMIP with mean volume ratios of 1.02±0.35 and
1.06±0.43, respectively, but there was no significant difference between them(P=0.806). The highest MI were
between IGTVMIP and IGTVPET2.0 or between IGTVMIP and IGTV PET20% (0.46±0.24 and 0.45±0.23), and
there was no significant difference between them (P=0.603). The best DI were IGTVPET20% in IGTVMIP or
IGTVPET2.0 in IGTVMIP (0.61±0.26 and 0.61±0.25), and there was no significant difference between
them(P=0.963). Conclusion The IGTV PET contoured by SUV2.0 or 20% of SUVmax approximate closely to the
IGTVMIP in target size and the extent of spatial missing is relatively lower between them, but neither of them
could replace each other in spatial position.[Key words] Non-small cell lung cancer; Fluorodeoxyglucose
positron emission tomography; Four-dimensional computed tomography; Maximum intensity projection;
Standardized uptake value
MSRO22-05
Real-time Profile Based 3D Tumor Volume Generation in Image Guided Cancer Radiation Treatment
Songan Mao (Presenter): Nothing to Disclose , Huanmei Wu PhD : PerkinElmer Inc Varain Inc , George
Sandison : Nothing to Disclose , Shiaofen Fang : Nothing to Disclose
PURPOSE
Generating 3D volume of the tumor and critical organs in real-time during image guided radiation treatment will
be of great importance for precise dose delivery and accurate dose calculation. This project will develop an
algorithm to generate 3D volume of the tumor and critical organs in real-time for image guided cancer radiation
treatment.
METHOD AND MATERIALS
The markers had been implanted before the 4DCT images were acquired. For any interested time instance, only
the 3D positions of the markers were acquired (target phase). The 3D volume were reconstructed based on the
following procedure. First, based on the motion sequence similarity using the combined amplitude and phase
information, the most appropriate phase of the 4DCT is chosen as the source phase. The corresponding
displacements of markers between the source and target phases are calculated. For each marker, the distance
based weight coefficient displacement vectors are computed based on the marker displacement. The smaller
Euclidean distance, the larger weight coefficient will be. For each voxel, the weighted marker displacement
vector is applied to predict its new positions in the target phase. Iteratively predicting all the voxels will
generate the 3DCT at the target phase.
RESULTS
The simulation framework prototype have been implemented. For the validation, a 4DCT phase is randomly
chosen as the source image. A non-linear artificial deformation function, which has considered the effect of
target movement, rotation, and volume deformation, has been applied to the source 3DCT to generate the
ground truth at the target phase. The marker positions at the target phase can also be computed from the
deformation function. With the target and source marker positions and the source 3DCT, the iterative morphing
approach will predict the 3DCT at the target phase. The voxel level difference between the ground truth and
predicted 3DCT is used to assess the simulation accuracy. In one simulation, the average voxel coordinate
differences averaged over 5443 voxels on the directions of the x, y, z-axis are 0.31, 1.10 and 0.19 pixels,
respectively. The average Euclidean distance between the corresponding voxels is 1.3 pixels.
CONCLUSION
The proposed algorithm can simulate and accurately predict 3D volume information in real-time situation, which
is potentially useful for image guided cancer radiation treatment.
CLINICAL RELEVANCE/APPLICATION
NA
MSRO22-06
Stage I Lung Cancers Treated with Stereotactic Body Radiation Therapy (SBRT): Comparable Results
in a South-east Asian Population
Seng Hup Chia MBChB (Presenter): Nothing to Disclose , Su Woon Kim : Nothing to Disclose , Kam Weng
Fong : Nothing to Disclose , Whee Sze Ong : Nothing to Disclose , Swee Peng Yap : Nothing to Disclose ,
Tian Rui Siow : Nothing to Disclose , Anuradha Thiagarajan : Nothing to Disclose , Yoke Lim Soong :
Nothing to Disclose
ABSTRACT
Objectives
Stereotactic body radiation therapy (SBRT) is a well established treatment option for medically inoperable stage
I lung cancer patients. Several studies have shown its benefits in local control and survival. We report the first
outcomes of lung cancer patients treated with SBRT at our institution and the factors that influence the outcome.
Materials and methods
All stage 1 lung cancer patients treated with SBRT since the technique was introduced in our hospital was
retrospectively reviewed. Patients were identified using radiotherapy department electronic records and the
details of patient characteristics, diagnosis and treatments were collected. Survival distributions were estimated
using Kaplan-Meier method and univariate Cox regression analyses were performed. Toxicities were graded
using common terminology criteria for adverse events (CTCAE) version 4.
Results
A total of thirty five stage I lung cancer patients were treated with SBRT between May 2009 and November
2012. Median follow-up was 20.3 months. Thirty four patients (97%) had biopsy proven primary lung cancer.
Twenty one patients (60%) were treated with 48 Gy in 4 fractions and the remaining patients were treated with
60 Gy in 5 fractions. At the time of analysis three patients developed local relapse and seventeen developed
regional and/or distant relapse. Thirteen deaths were observed of which ten were due to lung cancer. Local
relapse free survival, overall survival (OS) and cancer specific survival (CSS) at 2 years was 85 %, 65.4 % and
70 % respectively. Univariate analysis showed significantly higher rates of OS in patients who underwent
pre-treatment PET-CT scan (HR 0.23, 95% CI: 0.07 - 0.72; p=0.006). Higher numbers of regional and distant
relapses were seen in stage IA patients where only 68% of the patients underwent PET scan compared to 100
% in stage IB (HR 0.21, 95% CI: 0.05-0.98; p=0.033) The presence of an active synchronous cancer was
associated with lower rates of OS (HR 10.78, 95% CI: 1.95 - 59.69; p=0.001). Clinically significant grade 2 and
above toxicities were seen in rib fracture (11%), dyspnoea (12%), cough (9%), pleural effusion (9%), chest
wall pain (6%) and fatigue (3%).
Conclusions
SBRT remains an important treatment option for medically inoperable stage I lung cancer patients.
Pre-treatment PET-CT scan has a significant association with survival. This could be accounted for by the
improved staging accuracy and is thus recommended for all patients planned for SBRT.
MSRO22-07
Stereotactic Ablative Body Radiation Therapy (SABR) Using Volumetric Modulated Arc Therapy to
Early Stage Non-small Cell Lung Cancer (NSCLC) And Lung Oligometastases. Brazilian Single
Institution Early Experience and Clinical Outcomes
Lisa
Morikawa : Nothing to Disclose , Ernani
Anderson MD (Presenter): Nothing to Disclose
ABSTRACT
Purpose/Objectives: Although radiotherapy technology is advancing rapidly, the availability of some new
techniques such as Volumetric Modulated Arc Therapy (VMAT) remains low in Brazil due to their high
implementation costs. Others such as SABR are still not covered by any health insurers in the country. The aim
of this study is to report the preliminary clinical outcomes and toxicity of SABR delivered to early stage NSCLC
and lung oligometastases using VMAT without a rigid imobilization system.Materials/Methods: Between March
2012 and November 2013, a total of 20 lung lesions were treated with SABR in 18 patients (16 by VMAT and 2
by 3D conformal technique). Among these lesions, 13 (65%) were peripheral and 7 (35%) were centrally
located. Histology was proven in 17 patients (12 adenocarcinoma, 4 squamous cell carcinoma, 4 others).
Median age was 75 years old (53 - 88). Serial PET scans and/or CT scans confirmed local control (LC). No 4DCT
was used, instead ins-expiration technique or slow imaging acquisition using a conventional CT scan were
employed. The dose/fractionation regimes most used were: 50-60 Gy in 5 fractions (BED 100-132 Gy10) and
60Gy in 8 fractions (BED 105 Gy10). Median ITV-PTV margin was 5 mm. Dose was prescribed to the median
97% isodose. Cone-beam CT was used for lesion localization and no fiducials were utilized. All patients were
treated using a low-cost and simple setup: thin mattress, wing board and knee support.Results: The median
follow-up was 12 months (1 - 19). Two patients died, giving a crude overall survival rate of 89%. The cause of
death was progression of disease in 1 patient. There was evidence of in-field disease progression in only 1
lesion giving a crude local control rate of 95%. This local progression occurred in the lesion located close to the
diaphragm on a patient with 2 primary lung lesions. Treatment was well tolerated and there were no
interruptions because of acute toxicity. Pulmonary late complication of NCI-CTC grade >=3 was noted in 1
patient who had a single lung.Conclusions: SABR using VMAT is a feasible and well-tolerated treatment in early
stage NSCLC and for selected patients with lung oligometastatic disease. Due to the inexpensive setup and fast
delivery provided by VMAT, which maximized the number of patients treated per machine, individual costs were
significantly reduced thus making it feasible for patients to privately afford SABR in our reality. Although no
4DCT was used, LC rates were excellent in this series. Nonetheless, a longer follow up is needed to confirm our
findings.
MSRO22-08
The Effects of Abdominal Compression on the Motion and Volume of the GTV, Lungs and Heart in
Lung Cancer Patients Using 4DCT
Abdullah
Rasheed (Presenter): Nothing to Disclose
ABSTRACT
Purpose/Objective(s): Lung cancer tumors exhibit motion during respiration, complicating the delivery of
radiation therapy (RT). The abdominal compression plate (ACP) is thought to mitigate this clinical problem by
controlling respiratory motion. This study intends to quantify the effect of ACP on respiratory-induced motion
by evaluating volume and displacement changes of the heart, lungs, and tumor with and without ACP as
demonstrated by 4DCT.
Materials/Methods: Lung cancer patients (n=17) received 4DCT simulation scans (10
CTs from 0%-90% breathing phases) with and without ACP. Maximally tolerated diaphragmatic pressure was
applied and tumor motion was visualized by fluoroscopy. The gross tumor volume (GTV), heart and lungs were
contoured in treatment planning software for each of the 10 phases. Structures were exported for external
algorithmic analysis. For each phase of the 4DCT with and without ACP, tumor and organ absolute centroid
range of motion, 3D centroid displacement from the average, and volume were calculated. Parametric Student's
t-test comparing the motion and volume with and without ACP were conducted with significance set at
p<0.05.
Results: 9 patients (53%) had upper lobe tumors, 4 (24%) had middle lobe tumors and 4 (24%) had
lower lobe tumors. Averaged across all patients, centroid range of motion for GTV, heart, and lungs without
compression was 4.77 ± 4.75 mm, 5.92 ± 2.13 mm and 6.99 ± 2.79 mm, respectively and 4.80 ± 3.85 mm,
5.65 ± 1.99 mm and 5.99 ± 3.19 mm, with compression, respectively. With ACP use, GTV centroid
displacement was reduced in 3 patients (17.6%; 3 upper lobe tumors) by a mean of 1.13 mm (p<0.01),
increased in 5 patients (29.4%; 3 upper lobe tumors, 1 middle lobe, 1 lower lobe) by a mean of 0.87 mm
(p<0.01), and not significantly changed in 9. Of the 8 patients with a significant change in GTV centroid
displacement, on average, all exhibited increased mean GTV volume and decreased centroid
displacement/mean volume of the heart and lungs.
Conclusions: ACP efficacy is patient specific, with variation
possibly attributable to preexisting factors such as COPD severity, chest wall elasticity, lung tumor location, or
patient comfort. Tumor lobe location does not pre-determine compression efficacy. Patients should be simulated
with and without ACP, regardless of tumor location, to grossly assess feasibility of ACP use. It appears that GTV
motion is most important in determining whether a patient is suitable for compression. Of the 8 patients with a
significant change in GTV motion (increased or decreased), on average, all experienced improved motion and
volume control of the heart and lungs. Alternative motion control should be considered in patients who do not
benefit from compression. In patients who clearly benefited, ACP may enhance tumor coverage while
minimizing toxicity to surrounding organs. Larger scale studies are necessary to make definitive treatment
recommendations.
MSRO22-09
Documentation of Clinical Radiotherapy Lung Target Motion Beyond the Treatment Planning Internal
Target Volume
Joseph Charles Barbiere MS (Presenter): Nothing to Disclose
ABSTRACT
Purpose: Recent studies have questioned whether the traditional internal target volume (ITV)
defined by a four-dimensional computed tomography (4DCT) accurately represents all the motion
actually present during radiotherapy. Unpredictable variations in breathing pattern combined with
poor sampling during a single 4DCT are often cited as the leading causes for underestimating the
ITV. Numerous phantom studies have correlated variation of motion parameters with computed ITV.
However, clinical studies based on a limited data set may not represent a complete motion history.
The purpose of our work is to present a methodology using routine daily imaging that can be used
retrospectively to document if the target motion ever exceeded the treatment planning ITV. By
performing a large series of such studies an institution can realistically asses the selection of
appropriate margins. Our hypothesis is that a large series of free breathing CTs are a better
representation of all possible target motion than a limited series of 4DCTs.
Method: A T1 NSCLC patient had a Philips Bellows 4DCT (0.071 pitch, 0.5 sec per rotation), a free
breathing CT, and contoured using Philips Pinnacle. Target contours on the left side were drawn on a
single representative phase using automated density thresholding to avoid user bias. The target
contours were converted to a mesh and propagated automatically to all other phases. The center of
mass for each phase target was computed. The ITV4D was constructed as the sum of all ten phase
targets and associated with the free breathing CT.
The patient was treated using TomoTherapy with daily imaging. Thirty-two daily MVCTs (10 sec per
rotation, 0.6 mm/sec couch speed) were transferred to Pinnacle. Each MVCT was registered to the
free breathing planning CT concentrating mainly on the spine and lungs. It was not possible to
automatically propagate the ITV4D to each of the MVCT due to differences in quality but an
experienced user manually placed the reference mesh in each study so that all visible target was
included. The treatment internal target (ITVRT ) was constructed as the sum of all MVCT targets and
also associated with the free breathing CT.
Results: The center of mass motion in the 4DCT target was as expected, approximately 10.0 mm
Sup-Inf, 4mm Ant-Post, and 1.5 mm Rt-Lt.
The ITV4D volume was 5.93cm3 and ITVRT was 10.24 cm3 , an increase of 72.7%. This dramatic
difference may be accentuated by motion due to the targets proximity to the heart.
The ITVRT expansion from the ITV4D was approximately 2.8 mm Sup-Inf, 5.8mm Ant-Post, and 8.9
mm Rt-Lt.
Conclusions: The methodology presented in this work can be used with any daily CT imaging
technique. Careful analysis of an entire course may reveal that some proposed ITV 4D tight margins
under 10 mm may be inappropriate.
MSRO25
BOOST: Gastrointestinal—Integrated Science and Practice (ISP) Session
Multisession Courses
RO OI
GI
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credits: 1.50
Mon, Dec 1 10:30 AM - 12:00 PM
Location: S103CD
Participants
Moderator
Richard Tuli MD, PhD : Nothing to Disclose
Moderator
Tarita O. Thomas MD, PhD : Nothing to Disclose
Sub-Events
MSRO25-01
Invited Speaker:
Edward Y. Kim MD (Presenter): Nothing to Disclose
MSRO25-02
Active Surveillance Following Neoadjuvant Chemoradiotherapy for Distal Rectal Tumors
Paul
Menzel : Nothing to Disclose , Justin
Linam MA, MD (Presenter): Nothing to Disclose
ABSTRACT
Purpose/Objective(s):
Neoadjuvant chemoradiotherapy (nCRT) and surgery is the standard of care for locally advanced rectal cancer
(LARC), with pathologic complete response rates around 15%. Some patients with distal tumors and clinical
complete response (cCR) after nCRT, however, refuse surgery, citing favorable disease attributes and fear of a
permanent stoma. We hypothesize that such patients will have an elevated locoregional recurrence (LRR) rate
but that most can be successfully salvaged if followed closely. We present here our experience offering active
surveillance (AS) for distal LARC.
Materials/Methods:
This is multi-institutional review of two women and nine men at a median age of 61 years (range, 54-90) with
T2-3N0-1M0 distal rectal adenocarcinoma who have been prospectively followed. All patients had cCR, including
negative rectal biopsies, after 5-fluorouracil-based chemotherapy (5-FU CT) with 48.6-55.8 Gy (median, 50.4)
concurrent radiotherapy (RT) and refused surgery. T3 and N1 patients also received adjuvant 5-FU CT.
Following extensive counseling that nCRT alone is non-standard treatment, AS was offered in lieu of surgery. AS
consisted of imaging, CEA levels, endoscopies, and clinical exams every 1-12 months, at decreasing intervals
over time. Follow-up was calculated from the start of nCRT. Our primary interests were the LRR rate and
success of salvage therapy among these patients.
Results:
At a median follow-up of 42 months (range, 23-134), 2 of 11 (18%) patients developed LRR. There were no
distant recurrences or deaths. One recurrent patient presented with T3N0 disease, had a local recurrence (LR)
at 11 months, and underwent salvage abdominoperineal resection. He remains disease-free 60 months later.
The second recurrent patient presented with T2N0 disease, had a LR with presacral extension at 23 months,
and received salvage brachytherapy. She has slowly progressive disease seven months later and continues to
refuse surgery.
Conclusions:
Patients with distal LARC who exhibit cCR after nCRT and forgo surgery have a LRR rate near 20%, or at least
twice that of those proceeding with surgery. Close follow-up is therefore critical in these patients. Despite
producing only two failures, our review adds to the limited existing literature that suggests at least half of
carefully selected LARC patients undergoing AS can be salvaged successfully. Additional studies are needed to
define an optimal subset of LARC patients for AS; to establish an appropriate surveillance protocol for such
patients, particularly in the first two years; and to evaluate the role of dose-escalation in nCRT for LARC, as
recent radiobiological data suggest a significant dose-response up to 70 Gy in LARC. In the interim, distal LARC
patients with cCR after nCRT who undergo AS appear to have an encouraging prognosis, and AS is reasonable
for those declining surgery.
MSRO25-04
Is the Outcome Following Chemo-Radiation Equivalent to R1/R2 Resection Adjuvant Chemotherapy
in Stage I-III Pancreatic Cancer?
Myroslav Yuri Lutsyk MD (Presenter): Nothing to Disclose , Fadi Mezied MD : Nothing to Disclose , Ron
Epelbaum MD : Nothing to Disclose , Rahamim Ben-Yosef : Nothing to Disclose
ABSTRACT
Puropse/Objective: The current treatment approach for exocrine pancreatic cancer is primary surgery followed
by either gemcitabine based chemotherapy or chemo-radiotherapy. Patients who had questionable complete
resection undergo a resection assuming that bulky removal of the tumor will probably prolong their survival.
The purpose of this study was to evaluate retrospectively whether primary chemo-radiotherapy is equivalent to
R1/R2 resection (followed by adjuvant chemotherapy) in pancreatic cancer.Materials and Methods: 110 patients
(74 male, 36 females, mean age of 62.8 yrs, range 38-84) with localized adenocarcinoma of pancreas, who
were treated at Rambam Health Care Center in the last decade were enrolled to this study. Tumor location was
in head of pancreas in 74 pts and in body/tail in the remaining 36 pts. Sixty nine pts were treated by surgery
followed by gemcitabine based chemotherapy while 41 pts who their tumor found to be clinically non-resected,
were treated with chemo-radiotherapy. The chemotherapy was based on combination of cisplatin and
gemcitabine and only gemcitabine, in a reduced dose, during the radiation. The total dose of the radiation was
50.4 Gy, given in 1.8Gy per fraction, 5 times a week. Overall survival were explored in dependence to
treatment approach and surgical margins' status.Results: Thirty seven pts underwent complete resection of the
tumor (R0), 32 pts had R1/R2 and undetermined surgical margins and 43 pts had primary chemo-radiotherapy.
No differences in overall survival were noted in terms of gender, tumor localization or involvement of nodes.
Overall survival was higher for pts who underwent surgery, 2.132±0.25 years (CI 95%, 1.64-2.62) vs 1.2±3
0.09 years with primary chemo-radiotherapy (p<0.0001). The difference was noted after stratification of pts in
accordance to margins status. Significant difference was note between R0 surgery vs primary
chemo-radiotherapy and no difference between R1+R2 vs chemo-radiotherapy ( p=0.15).Conclusions: The
absence of significant difference in OS between R1/R2 resection vs primary chemo-radiotherapy suggests that
performance a surgery without strong evidence of R0 margin is unnecessary.
MSRO25-05
The Effect of MRI or PET Fusion in Radiotherapy Treatment Planning on the Pathological Complete
Response Rate in Rectal Adenocarcinoma
Zaker
Rana BS (Presenter): Nothing to Disclose
ABSTRACT
Purpose/Objective(s): A pathological complete response rate of 10 to 30% has been noted to occur following
preoperative chemoradiation with CT-based treatment planning in patients with rectal cancer. Fusion of the
treatment planning CT with other imaging modalities like MRI or PET may help identify tumor location and
improve tumor coverage. The impact of MRI or PET fusion on pathological complete response rate has yet to be
determined. This retrospective study sought to evaluate the effect of adding MRI or PET imaging to CT-based
treatment planning and its impact on pathological complete response rates in patients with rectal cancer.
Materials/Methods: A retrospective analysis was performed on 39 patients, who received neoadjuvant
chemoradiation for biopsy proven rectal adenocarcinoma from February, 2009 to September, 2013. Patients
were divided into two groups. The first group was treated using CT-only based treatment planning (n=9) and
the second was treated using either PET or MRI fusion with the simulation CT scan (n=30). There were a total of
19 cases of lower rectal cancer (0-7 cm from the anal verge), 12 cases of middle rectal cancer (7-11 cm from
the anal verge), and 8 cases of upper rectal cancer (11-15 cm from the anal verge). Patients were treated to a
total of 5,040 cGy in 28 fractions. Pathological complete response rates (ypT0N0M0) were assessed using
postoperative pathologic reports following lower anterior resection or abdominoperineal resection.
Results: 39 patients with a median age of 62 received preoperative chemoradiation with an interval to surgery
ranging from 34-162 days and a median of 70 days. Patients treated with PET or MRI fusion treatment planning
showed a complete pathological response rate at the primary site of 60% and a complete lymph node
pathological response rate of 70.83% (in patients who were clinically node positive) compared to 22.22% at the
primary site and 66.66% at lymph node sites in patients with CT-only treatment planning. In patients treated
using MRI or PET fusion, middle rectal cancer showed the best complete pathological response rate at 80%,
followed by lower rectal cancer at 41.66%, and upper rectal cancer at 37.5%.
Conclusions: Utilization of MRI or PET fusion resulted in a higher pathological complete response rate when
compared to CT-only based treatment planning, especially in middle rectal cancers. Further studies are needed
to accurately identify those patients with a complete pathologic response after chemoradiation with the goal of
potentially omitting the need for surgical resection.
MSRO25-06
Retrospective Analysis of Patients Suffering from GIST Liver Metastases Resistant to Tyrosine
Kinase Inhibitors being Treated with SIRT
Nils Rathmann MD (Presenter): Nothing to Disclose , Joachim Schuette MD : Nothing to Disclose , Daniel
Pink MD : Nothing to Disclose , Stefan Oswald Schoenberg MD, PhD : Institutional research agreement,
Siemens AG , Steffen J. Diehl MD : Nothing to Disclose , Peter Hohenberger : Nothing to Disclose
PURPOSE
To our knowledge no data exists in concern of gastrointestinal stromal tumor (GIST) liver metastases being
treated with selective internal radiation therapy (SIRT). Purpose of this study is to evaluate the therapy
response and progression free interval (PFI) of GIST liver metastases after SIRT.
METHOD AND MATERIALS
From 2008 to 2013 nine patients with GIST liver metastases being progressive under tyrosine kinase inhibitors
(TKI) treatment were referred. Five patients had liver metastases only, in another four patients extrahepatic
disease was controlled by TKI. Depending on intrahepatic tumor distribution, either one or both liver lobes were
treated intraarterially. Contrast enhanced (CE) MRI, CE CT and 18F-FDG PET-CT were used for follow-up. All
patients resumed the TKI therapy after SIRT.
RESULTS
16 liver lobes of 9 patients were treated with a mean activity of 1.06GBq per lobe. No radiation induced liver
disease (RILD) occurred, however one patient required surgery for persistent stomach ulcer. Three patients had
a complete remission (CR), five patients partial response (PR) and one patient stable disease (SD). No patient
showed progression after SIRT. Median PFI was 15.89 months (range 4-29). Median survival was 29.78 months
(range 10-72).
CONCLUSION
SIRT offers a safe and effective treatment option in patients with liver metastases from GIST not or no longer
responding to TKI treatment. In patients with mutational status known to be insensitive to available tyrosine
kinase inhibitors SIRT could be an option for earlier phases of therapy. The results might also contribute to
challenging the radiation resistance assumed for GIST.
CLINICAL RELEVANCE/APPLICATION
Our study presents distinct advantages of SIRT in terms of PFI and survival in patients with GIST suffering from
progression of liver metastases.
MSRO25-07
The Impact of Radiation Therapy after Resection on Survival in Rectal Melanoma
May Abdel-Wahab MD, PhD : Nothing to Disclose , Chandana A. Reddy MS : Nothing to Disclose , Luca
Stocchi MD : Nothing to Disclose , I. Emre Gorgun MD : Nothing to Disclose , Matthew Kalady MD :
Consultant, Precision Therapeutics, Inc Speaker, Precision Therapeutics, Inc , Ravi Kashyap MD (Presenter):
Nothing to Disclose , David W. Dietz MD : Nothing to Disclose
ABSTRACT
Purpose/Objective(s):The poor prognosis for rectal melanoma has prompted the use of adjuvant radiation as a
treatment approach. The purpose of this study is to determine if a survival benefit is seen when radiation
therapy is administered after surgical resection in rectal melanoma patients in a large population-based
database.Materials/Methods:Analysis of rectal melanoma cases in the SEER Registry between 1973 and 2008
who either underwent surgery alone (S) or surgery and radiation (S+RT) was done. Chi-square and unpaired
tests were used to compare cases that did and did not receive radiation. Overall survival (OVS) and cause
specific mortality (CSM) were analyzed. For CSM, a competing risk regression was done, where death from
causes other than rectal melanoma were treated as competing events. Multivariate analysis (MVA) included
treatment arm, extent of disease (regional vs Localized vs distant), age at diagnosis, race, and
gender.Results:One hundred and fifty-five patients with melanoma of the rectum were studied (S 130; S+RT
25). The median follow up was 14 months for all patients, with median survival of 15 months in both groups.
There were more localized tumors in the S group (43.8%) than the S+RT group ( 36%) (p=0.0108). No
differences in age, race, gender, grade and geographic location were seen between S vs S+RT. Median survival
was 15 months in both groups. One and 3-year OVS were 73.6% and 35.1% for the S arm versus 70.8% and
was 15 months in both groups. One and 3-year OVS were 73.6% and 35.1% for the S arm versus 70.8% and
24.8% in the S+RT arm. The addition of radiationdid not significantly influence OVS on MVA-only stage was
significant (p
MSRO25-09
Temporal Radiographic Density Change in Multiphase Liver CT after Radiotherapy for Hepatobiliary
Malignancy: Is It Predictable?
Jiho
Nam MD (Presenter): Nothing to Disclose
ABSTRACT
Purpose/Objective(s): Irradiation of liver can cause time-dependent CT imaging changes. However, it is
challenging to predict which patients will show the changes after radiotherapy or not. We compared patient
characteristics to find predictable factors associated with radiotherapy induced multiphase liver CT density
changes in the liver.Materials/Methods: We have retrospectively reviewed the medical records of total 154
patients who were treated with radiotherapy for the malignancy of hepatobiliary area or pancreas. Total
radiotherapy dose to the liver was the range of 30-54 Gy using 1.8-3.0 Gy fraction with or without combined
chemotherapy. Follow-up multiphase CT scans were serially performed after median 3 months after RT.
Radiographic findings were thoroughly evaluated and then compared with radiotherapy plan data. Statistical
analyses were performed to find any significant correlations between radiographic change and the patient
characteristics.Results: Overall 67/154 patients showed significant radiographic changes (i.e., newly visible
hypodense areas in the liver) in the multiphase liver CT scan during the follow-up periods. Liver cirrhosis, portal
vein thrombosis, primary tumor site, and the use of chemotherapy appeared to be correlated with the
radiographic changes (pConclusions: Density changes in multiphase liver CT images after liver radiotherapy can
be occurred more frequently when the patient has liver cirrhosis. However, their clinical nature and the relevant
pathophysiology have yet to be determined from further clinical research.
RCA22
Correlating Imaging with Human Genomics (Hands-on)
Refresher/Informatics
IN IN
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credits: 1.50
Mon, Dec 1 10:30 AM - 12:00 PM
Location: S401AB
Participants
Daniel L. Rubin MD, MS (Presenter): Nothing to Disclose
Sandy Napel PhD (Presenter): Medical Advisory Board, Fovia, Inc Consultant, Carestream Health, Inc Scientific Advisor,
EchoPixel, Inc
Olivier Gevaert PhD (Presenter): Nothing to Disclose
Debra Willrett (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Understand the methods for and the potential value of correlating radiological images with genomic data for research and
clinical care. 2) Learn how to access genomic and imaging data from The Cancer Genome Atlas (TCGA) and The Cancer Imaging
Archive (TCIA) databases, respectively. 3) Learn about methods and tools for annotating regions within images with semantic
and computational features. 4) Learn about methods and tools for analyzing molecular data, generating molecular features and
associating them with imaging features.
ABSTRACT
Radiogenomics is an emerging field that integrates medical images and genomic data for the purposes of improved clinical
decision making and advancing discovery of critical disease processes. In cancer, both imaging and genomic data are becoming
publicly available through The Cancer Imaging Archive (TCIA) and The Cancer Genome Atlas (TCGA) databases, respectively.
The TCIA/TCGA provide examples of matched molecular and image data for five cancer types, namely breast, lung, brain,
prostate and kidney. The data in TCGA includes various omics data such as gene expression, microRNA expression, DNA
methylation and mutation data. The community is beginning to extract image features from the MRI, CT and/or PET images in
TCIA, including tumor volume, shape, margin sharpness, voxel-value histogram statistics, image textures, and specialized
features developed for particular acquisition modes. They are also annotating the images with semantic descriptors using
controlled terminologies to record the visual characteristics of the diseases. The availability of these linked imaging-genomic
data provides exciting new opportunities to recognize imaging phenotypes that emerge from molecular characteristics of disease
and that can potentially serve as biomarkers of disease and its response to treatment. They also provide an opportunity to
discover key molecular processes associated with distinct image features, within one cancer type and across different cancer
types. This workshop will describe datasets and tools that enable research at the intersection of imaging and genomics, and that
point to opportunities to develop future applications that leverage this knowledge for diagnostic decision support and treatment
planning.
Active Handout
http://media.rsna.org/media/abstract/2014/14001877/RCA22 sec.pdf
RCB22
Creating and Delivering Online and Mobile Education Content: From Online Courses to
Interactive iBooks (Hands-on)
Refresher/Informatics
IN
ED IN
ED
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credits: 1.50
Mon, Dec 1 10:30 AM - 12:00 PM
Location: S401CD
Participants
Moderator
George Lee Shih MD, MS : Consultant, Image Safely, Inc Stockholder, Image Safely, Inc Consultant, Angular Health, Inc
Stockholder, Angular Health, Inc
LEARNING OBJECTIVES
1) Assess the potential of online and mobile e-learning innovations to augment your residents', medical students', and staff's
educational curricula. 2) Acquire the domain knowledge to use already available content (eg, PowerPoint presentations) to both
create video content and deploy e-learning courses on modern web-based and mobile platforms. 3) Acquire the domain
knowledge to create an interactive Apple iBook (electronic books) with text, images, video, and interactive questions.
ABSTRACT
1. From OpenCourseWare to the Khan Academy, and now to Coursera, e-learning has been dramatically improved over the last
decade, changing education from the normal classroom into learning done at convenience, and also allows for more creative and
engaging content during the typical lecture. Stanford Med published positive initial findings in utilizing video-based lectures in
an interactive class setting. Leveraging this new way of learning, requires knowledge about the types of technology and
platforms for these courses. 2. The workflow required to host an e-learning course can be summarized in 3 steps: (a) creating
the educational content, (b) hosting the materials, and (c) making the materials available to the intended audience. E-content
today typically consists of lecture slides along with video recordings captured by technology like TechSmith Camtasia (non-free)
and Apple Quicktime (free). Once the materials are created and edited, one must choose a suitable hosting platform realistic to
the skills and goals of the instructor with options that include coursesites.com, iTunes U, and YouTube / Google Hangouts.
Students can then be invited to view the material or the content can be made available to the public. 3. Creating and publishing
e-books is a great way to share your teaching material as an engaging interactive tool. Publishing in e-book format solves many
logistical problems of conventional publishing and the e-book format has interactive features that paper books can't match. We
will review the process of creating your own e-book from assembling material to layout design to submitting for e-publication.
Specifically Apple iBooks Author software will be used to demonstrate converting an existing Powerpoint presentation or journal
publication into an e-book. In addition, the course will go over how to publish with or without DRM (copy-protection) and ways
to obtain an ISBN for publishing for sale. Online resources will also be reviewed.
Sub-Events
RCB22A
Screencasting Basics on the Desktop and on the iPad
Ian Ross Drexler MD, MBA (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
View learning objectives under main course title.
RCB22B
Massive Open Online Course (MOOC) Creation and Hosting
Kurt T. Teichman BSC, MENG (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
View learning objectives under main course title.
Active Handout
http://media.rsna.org/media/abstract/2014/14002173/RCB22B sec.pdf
RCB22C
Interactive iBooks to Supplement your Online Course
Richard S. Ha MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
View learning objectives under main course title.
RCC22
Monitoring Radiation Exposure: Standards, Tools and IHE REM
Refresher/Informatics
SQ
IN
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credits: 1.50
Mon, Dec 1 10:30 AM - 12:00 PM
Location: S501ABC
Participants
Moderator
Kevin O'Donnell : Employee, Toshiba Corporation
Kevin O'Donnell (Presenter): Employee, Toshiba Corporation
Michael F. McNitt-Gray PhD (Presenter): Institutional research agreement, Siemens AG Research support, Siemens AG
Tessa S. Cook MD, PhD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Learn about key radiation exposure metrics, such as CTDI, and how to interpret them. 2) Learn about radiation exposure
monitoring methods and tools including 2a) Capturing dose information with the DICOM Radiation Dose SR (RDSR) standard.
2b) Managing RDSR objects with the IHE Radiation Exposure Monitoring (REM) Profile. 2c) Integrating 'CT dose screens' from
legacy systems into RDSR. 2d) Pre-scan dose pop-ups on the CT console defined by the MITA Dose Check standard and AAPM
guidance on their use. 3) Learn how to specify the above features when purchasing and integrating Radiology Systems. 9) Learn
about components of a dose management program such as protocol optimization. 4) Participation in the ACR Dose Registry, and
reporting requirements such as California SB-1237.
SPCP21
Korea Presents: Exploring Evidence in Cardiovascular Imaging
Special Courses
IR CT
VA
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credits: 1.50
Mon, Dec 1 10:30 AM - 12:00 PM
Location: E353C
Participants
Moderator
Tae-Hwan Lim MD, PhD : Nothing to Disclose
Moderator
Arthur E. Stillman MD, PhD : Nothing to Disclose
LEARNING OBJECTIVES
This session is part of Korea Presents at RSNA 2014.
Sub-Events
SPCP21A
Opening Remarks
RSNA President N. Reed Dunnick MD Nothing to Disclose , Tae-Hwan
Jongmin John Lee MD, PhD Nothing to Disclose
Lim MD, PhD Nothing to Disclose ,
LEARNING OBJECTIVES
Korea and Korean Society of Radiology (KSR)
This session is part of Korea Presents at RSNA 2014.
ABSTRACT
Korea and Korean Society of Radiology (KSR) Following dinosaurs, Homo erectus, and Homo sapiens, ;our
ancestors have inhabited in and around Korean peninsula. In a history of many dynasties for 5000 years,
Republic of Korea was established in 1947 AD. In 2013, the population was counted as 51,098,531 (26th / 225
countries) within 100,210 km2(111th / 208 countries). The number of medical doctor per 100,000 population
has been increasing continuously up to 214 in 2012. Among 113.000 medical doctors, 3,465 board-certified
radiologists are registered in 2014. KSR was founded in 1945. Korean congress of radiology (KCR) has continued
every year till now. From 2010, KCR was organized as an international congress with the official language of
English. This year, over 75% of sessions were conducted in English. Topics for only Korean doctors and some
basic educational sessions were in Korean. Additional on the regular members (76.0%), 604 resident members
(13.3%) and 478 international members (10.5%) are registered in KSR (4,547 in total). During the KCR, about
10% of registrants are usually from abroad. As a diligent radiology society in Asia-Oceania region, KSR conducts
diverse international activities including visiting symposium, KSR fellowship, invited speaker exchange, awarded
poster exchange, joint symposium, national delegate exchange, journal collaboration, booth exchange, and
visiting professorship. So far, international collaboration has been established between KSR and 20 countries or
societies world-wide. The globalization of KSR is on the purpose of giving more opportunities for KSR members
to improve themselves through international communication. Also KSR aims for ;a synergic evolution together
with our partner societies. As a world leading radiology society, RSNA has been a source of motivation and is a
chance of globalization for KSR and its members.
URL
http://www.radiology.kr
SPCP21B
What are Risk Factors for Stroke? Imaging Assessment of Cardiovascular Risk in Stroke
Jin
Hur MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Understand the stroke subtype and the risk factors of cardio-embolic stroke. 2) Describe the imaging
modalities in the assessment of cardiovascular risk in stroke patients. 3) Describe the advantages and
disadvantages of cardiac CT and MRI in the use of assessing cardio-embolic sources in stroke patient. 4) Discuss
the prognostic value of cardiac CT for risk stratification in stroke patients.
This session is part of Korea Presents at RSNA 2014.
ABSTRACT
Cardiogenic emboli have been estimated to be the causative factor in 20% to 40% of all stroke cases.
Therefore, identification of a cardiac source of embolism in stroke patients is important for proper therapeutic
management. Currently, transesophageal echocardiography (TEE) is considered the reference standard method
for the detection of potential sources of cerebral embolism. TEE offers high resolution images of the left atrium
(LA) and its appendage as well as the thoracic aorta for the evaluation of left atrial blood stasis and aortic
atherosclerosis. Although TEE is widely available, it is a semi-invasive test, usually performed under conscious
sedation. In current clinical practice, there is a need for a less invasive modality that is capable of assessing the
cardiovascular system for embolic stroke patients. Cardiac magnetic resonance imaging (MRI) is an appealing
modality to evaluate a suspected embolic stroke patient. Cardiac MRI can adequately image potential embolic
sources such as LV thrombi, cardiac masses, aortic plaques or LAA thrombi. Recently introduced multidetector
computed tomography (MDCT) with subsecond rotation times and a dedicated cardiac reconstruction algorithm
can acquire 3-dimensional data of the heart, enabling detailed visualization of not only the coronary arteries but
also other cardiac structures such as the left atrial appendage (LAA), myocardium, valves, and septa.;
Therefore, MDCT can play a significant role as a noninvasive procedure in the detection of the cardioembolic
origin of stroke. Radiologists should be familiar with their imaging features as identification has significant
management and prognostic implications.
SPCP21C
Is Screening of Coronary Heart Disease with Coronary CT Angiography Necessary? Coronary CT
Angiography in Asymptomatic Patients
Sang Il
Choi MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) To review the use of various multimodality imaging techniques for assessing subclinical coronary artery
disease. 2) To demonstrate the current multimodality appropriate use criteria for detection and risk
stratification of coronary artery disease in asymptomatic subjects. 3) To recognize the potential role and
limitations of coronary CT angiography as screening tool in asymptomatic subjects.
This session is part of Korea Presents at RSNA 2014.
SPCP21D
Is CT Stress Perfusion Comparable to FFR in Assessing Ischemic Heart Disease? Multicenter Trial
PERFUSE
Byoung Wook
Choi MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Understand the clinical role and indication of myocardial perfusion with computed tomography. 2) Acess the
study design and rationale to compare myocardial perfusion with computed tomography with FFR regarding to
clinical utility. 3) Able to set up a proper protocol of computed tomography for myocardial perfusion in clinical
practice. 4) Assess the technical advances and consideration of computed tomography in myocardial perfusion.
This session is part of Korea Presents at RSNA 2014.
ABSTRACT
The FAME trial demonstrated the superiority of FFR (fractional flow reserve)-guided revascularization strategy
over angiography-guided treatment. The functional significance of coronary artery stenosis is now considered as
the standard reference for revascularization. Non-invasive imaging for myocardial ischemia can be used for
identifying functionally significant stenosis as well. Evaluation of myocardial ischemia by using CT has been
reported as a new alternative non-invasive method. According to a recent study, as compared to FFR and
invasive angiography, the combination of CT angiography (CTA) and CT perfusion (CTP) was highly accurate in
detection and exclusion of myocardial ischemia. The PERFUSE (Stress Coronary PErfusion Versus FRactional
Flow Reserve GUided PercutaneouS Coronary IntErvention) trial is a multicenter, randomized, controlled,
noninferiority trial in the comparison of CTP- and FFR-guided percutaneous coronary intervention (PCI). The
objective of this trial is to compare outcomes of composite of any of all cause mortality, myocardial infarction,
and unplanned hospitalization with revascularization at 1 year after CTP-guided PCI to FFR-guided PCI in
angina patients with coronary artery disease. The inclusion criteria is patients who referred for CTA because of
angina or angina equivalent symptom and having more than 70% diameter stenosis at least one major
epicardial coronary artery on CTA. A total 1000 patient will be enrolled (500 per each arm) and randomized to
either FFR guided or CTP-guided groups. Twenty centers in Korea are participating in the study.
SPCP21E
Closing Remarks
Byung Ihn Choi MD, PhD (Presenter): Research Consultant, Samsung Electronics Co Ltd , James P.
Borgstede MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
This session is part of Korea Presents at RSNA 2014.
ABSTRACT
First of all, I'd like to thank members of Board of Directors of RSNA including Dr. Dunnick (President), and Dr.
Baron (Chairman) and Dr. Borgstede (Liaison for international affairs) for inviting Korea to RSNA which is the
most prestigious organization in the field of Radiology in the year of meaningful centennial anniversary of RSNA.
During the last 30 years, I have attended RSNA more than 20 times since 1985 when I was a visiting fellow of
UC San Francisco. Since then, advance of RSNA has been amazing in every aspect of the meeting not only in
quality but also in quantity, about 60,000 attendants for the meeting and more than 50,000 members from all
over the world. RSNA really became a global congress of Radiology. Therefore, KSR is now trying to follow this
unbelievable progress of RSNA as a role model of KCR. Personally, I love RSNA because RSNA is an ideal place
for me to learn recent updated knowledge and cutting edge information of radiology, and to meet old and new
friends. Also, I can enjoy rich cultural environment in Chicago including music, fine art and natural resources.
As an honorary member of RSNA and a past president of KSR, I'll try to do my best to enhance a mutual
friendship and collaboration between RSNA and KSR. Finally, I'd like to congratulate the celebration of 100th
scientific assembly and annual meeting of RSNA and wish RSNA a glorious future.
SSC01
Cardiac (Valve Disease)
Scientific Papers
MR CT
CA
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credits: 1.50
Mon, Dec 1 10:30 AM - 12:00 PM
Location: S502AB
Participants
Moderator
Scott Robert Akers MD, PhD : Nothing to Disclose
Sub-Events
SSC01-01
Is the Access Path Angle in Transapical Aortic Valve Implantation a Risk Factor for the Occurrence of
Postprocedural Paravalvular Leakage?
Borek Foldyna (Presenter): Nothing to Disclose , Martin Haensig : Nothing to Disclose , Christian Luecke
MD : Nothing to Disclose , David Holzhey : Nothing to Disclose , Claudia Andres : Nothing to Disclose ,
Matthias Grothoff MD : Nothing to Disclose , Friedrich-Wilhelm Mohr : Nothing to Disclose , Matthias
Gutberlet MD, PhD : Nothing to Disclose , Lukas H. J. Lehmkuhl MD : Nothing to Disclose
PURPOSE
To analyze the angle between left ventricular long axis and the outflow tract (ΑLV-LVOT) on cardiac computed
tomography (CT) and to describe its impact on occurrence of paravalvular leakage (PL), fluoroscopy time and
postoperative CK-MB levels in transapical aortic valve implantation (TA-AVI).
METHOD AND MATERIALS
High-risk patients with severe aortic stenosis, scheduled for TA-AVI using an Edwards-SAPIENTM prosthesis
were retrospectively included. The ΑLV-LVOT was measured on CT during systole and diastole as far as
retrospectively gated data sets were available. The ΑLV-LVOT was correlated with the occurrence of PL, total
fluoroscopy time and postoperative CK-MB levels. Inter-observer variability was assessed in all cases.
RESULTS
Eighty-two patients with an average age of 81.9±5.7 years were included in the study (females/males 57/25
[69.5%/30,5%]). The mean ΑLV-LVOTs were 61.4°±9.7° and 61.0°±10.2° during systole and diastole,
respectively. There was a minimal, non-significant change in the ΑLV-LVOT between systole and diastole of
0.1°±4.2°(p=0.85). PL was found in 39 patients (0°=43[52.4%];I°=30[36.6%];II°=9[11.0%]). Patients with a
clinically significant PL (>=II°) showed a significantly steeper mean ΑLV-LVOT than patients with I° or without
PL (mean difference: 13.8±3.3°;p
CONCLUSION
During TA-AVI, steeper ΑLV-LVOTs were associated with significantly higher grades of PL. Thus, the ΑLV-LVOT
might influence the selection of the transapical implantation path and could have a significant impact on
designs for future stents or novel delivery devices.
CLINICAL RELEVANCE/APPLICATION
The greater ΑLV-LVOTs were associated with significantly higher grades of PL and might influence the selection
of the transapical implantation path.
SSC01-02
Diagnostic Evaluation of Prosthetic Valve Dysfunction by Multi-Detector Cardiac Computed
Tomography Using Intraoperative Findings as Gold Standard
Kongkiat Chaikriangkrai MD (Presenter): Nothing to Disclose , Dimitrios Maragiannis : Nothing to Disclose ,
Stephen Little : Nothing to Disclose , Mahwash Kassi : Nothing to Disclose , Sama Alchalabi : Nothing to
Disclose , Sayf Khaleel bala : Nothing to Disclose , Su Min Chang : Nothing to Disclose
PURPOSE
To assess role of multi-detector cardiac computed tomography (MDCT) in evaluation of prosthetic heart valve
(PHV) dysfunction using intraoperative findings as gold standard.
METHOD AND MATERIALS
We reviewed 21 cases with PHV dysfunction that underwent 22 redo valve procedures in our hospital from
December 2008 to July 2013. Intraoperative findings were used as gold standard to be compared with
preoperative MDCT findings as shown in the figure. The MDCT reader was blinded from intraoperative findings.
RESULTS
Our series comprised of 21 cases (16 men and 5 women) with a mean age of 58 years (range 40-70).
Preoperatively, there were 15 aortic PHV (11 mechanical and 4 bioprosthetic), 6 mitral PHV (4 mechanical and 2
bioprosthetic) and 1 bioprosthetic tricuspid PHV. Operative findings showed 15 PHV regurgitation and 7 PHV
stenosis which were 100% correctly detected by MDCT. Etiologies included 15 PHV dehiscence, 3 pannus, 1
mixed thrombus and pannus, 1 vegetation, 1 PHV defect and 1 calcific degeneration of the PV. Ninety six
percent of the etiologies of PHV dysfunction was precisely identified by MDCT except for one case with small
pannus. MDCT also showed non-obstructive coronary arteries or bypass grafts in 20 studies and obstructive left
anterior descending and left circumflex arteries in one patient.
CONCLUSION
MDCT is accurate for diagnosis and evaluation of etiologies of PHV dysfunction using intraoperative findings as
gold standard. It also provides noninvasive assessment of coronary artery anatomy prior to the surgery.
CLINICAL RELEVANCE/APPLICATION
MDCT is a reasonably accurate modality for evaluation of patients suspected for prosthetic heart valve
dysfunction.
SSC01-03
Mitral Annular Evaluation with Computed Tomography in the Context of Transcatheter Mitral Valve
Implantation: A New Paradigm
Philipp Blanke MD (Presenter): Nothing to Disclose , Bruce Precious MD : Nothing to Disclose , Shalan
Alaamri : Nothing to Disclose , Cameron John Hague MD : Nothing to Disclose , Darra Thomas Murphy MD,
FRCPC : Nothing to Disclose , Jonathon Avrom Leipsic MD : Speakers Bureau, General Electric Company
Speakers Bureau, Edwards Lifesciences Corporation Consultant, Heartflow, Inc Consultant, Circle Cardiovascular
Imaging Inc , Adam Berger : Nothing to Disclose , John Webb MD, FRCPC : Consultant, Edwards
Lifesciences Corporation
PURPOSE
To define the methodology for computed tomography (CT)-based functional "D -shaped" mitral annular
assessment for transcatheter mitral valve implantation (TMVI) and compare these novel measurements to
traditional "saddle-shaped" mitral annular assessment.
METHOD AND MATERIALS
ECG-gated, end-diastolic CT data sets of 28 patients (mean age 72.7±10.2 years) with severe functional mitral
valve regurgitation undergoing diagnostic work-up for potential minimal-invasive mitral intervention were
analyzed. The annular contour was manually segmented and fibrous trigones were identified yielding annular
perimeter, projected area, trigone-to-trigone (TT) distance, septal-lateral (SL) distance and annular height. The
traditional saddle shaped annulus was defined including the aortomitral continuity. The functional D-shaped
annulus was defined as being limited anteriorly by the TT line, excluding the aortomitral continuity. Hypothetical
left ventricular outflow tract (LVOT) clearance and orthogonal projection angles were calculated.
RESULTS
Projected area, perimeter and SL distance were found to be significantly smaller for the functional, D-shaped
annulus than for the saddle-shaped annulus (11.2±2.7mm2 vs. 13.0±3.0cm2, 122.5±13.0mm vs.
136.0±15.5mm, 32.1±4.0mm vs. 40.1±4.9mm respectively, p<0.001). TT distances were identical
(32.7±4.1mm). The D-shaped annulus was more planar demonstrating a reduced annular height (2.4±1.0mm
vs. 10.6±1.8mm, p<0.001). Hypothetical LVOT clearance was significantly reduced for the saddle-shaped
annulus, but preserved for the D-shaped annulus (10.7±2.2mm vs. 17.5±3.0mm, p<0.001). A line of
perpendicularity for orthogonal views was identified. SL views were on average found at 25.5±7.7° RAO,
22.5±10.2° cranial, whereas TT views were found at 74.7±20.5° RAO, 57.0±8.4° caudal.
CONCLUSION
The historically established methodology for sizing a saddle-shaped mitral annulus appears inappropriate for
TMVI, yielding significantly larger dimensions and reduced LVOT clearance compared to the functional,
D-shaped annulus approach. CT-based annular assessment may aid pre-procedural sizing, ensuring appropriate
patient and device selection and the derivation of appropriate co-axial angles of deployment.
CLINICAL RELEVANCE/APPLICATION
CT-based mitral annular assessment may aid pre-procedural sizing, ensuring appropriate patient and device
selection and the derivation of appropriate co-axial angles of deployment in th context of TMVI.
SSC01-04
Medium-term Biventricular Heart Remodeling after Percutaneous and Surgical Pulmonary Valve
Implantation: A Cardiac MR Study
Francesco Secchi MD (Presenter): Nothing to Disclose , Francesca Romana Pluchinotta MD : Nothing to
Disclose , Paola Maria Cannao MD : Nothing to Disclose , Gianfranco Butera : Nothing to Disclose ,
Massimo Lombardi MD : Nothing to Disclose , Francesco Sardanelli MD : Speakers Bureau, Bracco Group
Research Grant, Bracco Group Speakers Bureau, Bayer AG Research Grant, Bayer AG Research Grant, IMS
International Medical Scientific , Mario Carminati MD : Nothing to Disclose
PURPOSE
Percutaneous pulmonary valve implantation (PPVI) is an alternative to surgical pulmonary valve replacement
(SPVR) in select patients with congenital right ventricular outflow tract (RVOT) obstruction. Objective of this
study is to evaluate the medium-term impact of PVVI and SPVR on biventricular function as assessed by cardiac
magnetic resonance (CMR).
METHOD AND MATERIALS
From 2008 to 2013, 33 patients (median 20 years) underwent PPVI while 16 patients (median 30 years)
underwent SPVR. CMR (1.5 T) acquired before and after an average of 10 months (range 3-15) were analyzed,
and post- versus pre- pulmonary valve replacement findings were compared. Cine true-FISP sequence was
performed (TR/TE=45/1.5 ms, thickness 8 mm) to study the right (RV) and left ventricles (LV) function. MR
angiography after administration of contrast material (0.01 mmol/kg Gd-BOPTA) was performed to define
pulmonary arteries anatomy before PPVI. Wilcoxon and Pearson test was used.
RESULTS
The right ventricular end-diastolic volume index (RVEDVI, ml/m2) decreases significantly for PPVI and SPVR:
from 81±37 to 68±16 (P=.030) and from 142 ± 34 to 88 ± 21 (P=.001) respectively. RV ejection fraction
(RVEF, %) increased significantly in the SPVR group compared to the PPVI patients: from 46±11 to 53±9
(P=.038) and from 49 ±14 to 53 ±12 (P=.109) respectively. The left ventricular end-diastolic volume index
(LVEDVI, ml/m2) increased more significantly after the procedure in the PPVI group, while changes were less
evident and delayed in the SPVR patients: from 66±16 to 74±17 (P<.001) and from 61±7 to 66±12 (P=.055)
respectively. Left ventricular stroke volume index (LVSVI, ml/m2) increased in both groups after PPVI and
SPVR: from 38±12 to 41±11 (P=.004) and from 35±10 to 40±8 (P=.058) respectively. Finally there is an
inverse correlation between the RV and LVEDVI (r=-0.014): as the RVEDVI decreased in the follow-up, the
LVEDVI increased.
CONCLUSION
Alleviation of RVOT dysfunction is associated with reduction of RV volume and an improvement in global RV
function, as well as positive effects on ventricular-ventricular interaction demonstrated by the increased LVSVI
after the procedure.
CLINICAL RELEVANCE/APPLICATION
Medium-term follow-up showed permanent beneficial effect of pulmonary valve replacement in both groups.
SSC01-05
Right Ventricular Functions Measured by Cardiac Magnetic Resonance Imaging in Patients who
underwent Tricuspid Valvular Surgery: Implication for Patients Outcome
Won Jin Choi MD (Presenter): Nothing to Disclose , Dong Hyun Yang MD : Nothing to Disclose , Joon-Won
Kang MD : Nothing to Disclose , Tae-Hwan Lim MD, PhD : Nothing to Disclose
PURPOSE
To evaluate right ventricular (RV) function using cardiac magnetic resonance imaging (CMRI) in pateints who
underwent tricuspid valvular surgery and to identify predictors of poor prognosis.
METHOD AND MATERIALS
During seven years, 842 patients underwent tricuspid valvular surgery due to moderate or severe tricuspid
regurgitation. Among them, 124 patients underwent preoperative CMRI to evaluate right ventricular function.
Short-axis cine MRI images were analyzed using dedicated software. Ejection fraction, end-diastolic volume,
end-systolic volume, myocardial mass of both ventricles were evaluated. By reviewing electronic medical record,
baseline characteristics and patient outcome data. The primary composite outcome was any cause of death,
rehospitalization due to aggravated heart failure, and redo open heart surgery. (In this preliminary analysis,
results from 62 patients were only available and included in this abstract. Complete results including
quantitative analysis of delayed myocardial enhancement and Cox-regression analysis will be presented in the
RSNA meeting.)
RESULTS
Among 62 pateints, the primary outcome rate was 31% (n=19) (median follow-up of 278 days; range 17 - 2120
days). In patient with positive outcome, LV mass index and RV mass index were significantly greater than
patient without outcome (LV mass index, AUC 0.747, cut-off 61 g/m2; RV mass index, AUC 0.763, cut-off 27
g/m2). RV ejection fraction was significantly decreased and RV end-systolic volume index was enlarged as
compared with those of control group (RV ejection fraction, AUC 0.684, cut-off 36%; RV end-systolic volume,
AUC 0.700, cut-off 52ml/m2). Unadjusted Kaplan-Meier survival curves showed significantly lower survival rate
in patients with large RV systolic volume and large ventricular mass index of both RV and LV.
CONCLUSION
RV function measured by CMRI may provide prognostic information in patients who underwent tricuspid
valvular surgery. Measurement of both ventricular mass index and right ventricular end-systolic volume may
help to identify pateints with poor prognosis.
CLINICAL RELEVANCE/APPLICATION
Cardiac MRI may be used for prediction of poor prognosis in pateints who underwent tricuspid valvular surgery.
SSC01-06
Multidetector-row CT Findings Six Weeks Post Prosthetic Heart Valve Implantation: Results of the
IMPACT Study
Dominika Sucha MD (Presenter): Nothing to Disclose , Steven Chamuleau MD, PhD : Nothing to Disclose ,
Petr Symersky MD : Nothing to Disclose , Renee B.A. Van Den Brink MD, PhD : Nothing to Disclose , Bas
De Mol MD, PhD : Nothing to Disclose , Willem P. Mali MD, PhD : Nothing to Disclose , Jesse Habets MD :
Nothing to Disclose , Lex Van Herwerden : Research Consultant, St. Jude Medical, Inc , Ricardo P.J. Budde
MD, PhD : Nothing to Disclose
PURPOSE
To present the first prospective trial in prosthetic heart valve (PHV) patients that has been performed short
after PHV implantation to assess normal postoperative multidetector-row computed tomography (MDCT)
reference images, image quality and detect unexpected pathology.
METHOD AND MATERIALS
All patients were prospectively included and underwent contrast-enhanced 256-slice retrospectively ECG-gated
MDCT approximately six weeks after uncomplicated PHV implantation. Overall image quality was scored by two
observers in best systolic and diastolic phases (1=non-diagnostic, 2=moderate, 3=good, 4=excellent).
Moreover, leaflet motion, surrounding anatomy and PHV-related abnormalities were evaluated.
Echocardiography was performed at the same moment as MDCT imaging.
RESULTS
Forty-six patients (mean age 64±12 yrs) with 33 mechanical (12 Carbomedics, 12 St-Jude, 5 ON-X, 4 Sorin)
and 16 biological (12 Perimount, 4 Mitroflow) PHVs were imaged (mean 47±10 days postimplant). Median
(range) image quality for PHVs was 3.0 (2.0-4.0) Carbomedics; 3.0 (2.0-4.0) St-Jude; 3.0 (3.0-3.5) ON-X; 2.5
(2.5-3.0) Sorin; 3.0 (2.5-4.0) Perimount; 2.5 (2.0-2.5) Mitroflow. All mechanical PHVs showed symmetrical
leaflet motion. Minor postoperative findings were present in 40 patients and included moderate pericardial
effusion (3/46 patients), periaortic/pericardial hematoma (3/46 patients), slight PHV angulation (3/40 aortic
PHVs) and fuzziness of the periaortic fat (33/40 aortic PHVs). Unexpected pathology was found with MDCT in
three cases. One showed pseudoaneurysms with severe PHV dehiscence requiring reoperation. The other
concerned aspecific subprosthetic tissue and a supraprosthetic pseudoaneurysm, both requiring follow-up. The
latter also revealed an unexpected relevant coronary anomaly.
CONCLUSION
Post-implantation MDCT showed overall good image quality for biological and mechanical PHVs and symmetrical
leaflet motion in all mechanical PHVs. Minor postoperative findings were present in most patients and MDCT
detected three cases of unexpected clinically relevant pathology requiring reoperation or follow-up. These first
postoperative MDCT reference characteristics allow discrimination of normal and pathological conditions.
CLINICAL RELEVANCE/APPLICATION
Normal postoperative MDCT imaging characteristics and findings in patients with commonly implanted PHVs
allow discrimination of normal and pathological conditions short after implantation and at follow-up
SSC01-07
Evaluation of Aortic Valve Morphology at Cardiac MRI Compared to Operative Findings: Influence of
Partial Leaflet Fusion on Accuracy of Pre-surgical Classification
Vistasp Jimmy Daruwalla MD (Presenter): Nothing to Disclose , Preeti P. Kansal MD : Nothing to Disclose ,
Benjamin Freed : Nothing to Disclose , Daniel Lee : Research funded, CardiacAssist, Inc Spouse, Employee,
Takeda Pharmaceutical Company Limited , James Christopher Carr MD : Research Grant, Astellas Group
Research support, Siemens AG Speaker, Siemens AG Advisory Board, Guerbet SA , Chris Malaisrie :
Consultant, Edwards Lifesciences Corporation Proctor, Edwards Lifesciences Corporation Speaker, Edwards
Lifesciences Corporation Consultant, Baxter International Inc Speaker, ABIOMED, Inc Speaker, Werfen Life
Group SAU , Jeremy Douglas Collins MD : Consultant, B. Braun Melsungen AG
PURPOSE
Cardiac MRI (CMR) is highly accurate for pre-surgical classification of aortic valve morphology. Partial leaflet
fusion, the forme frust lesion of a bicuspid aortic valve may be difficult to detect as this maintains a triangular
valve orifice. The purpose of this study is to evaluate the impact of partial leaflet fusion of aortic valve
morphologic classification at CMR compared to operative findings
METHOD AND MATERIALS
Retrospective analysis of consecutive 218 subjects referred for aortic surgery. All the subjects underwent
pre-surgical imaging at 1.5T CMR. Subjects with history of aortic valve replacement or without dedicated aortic
valve imaging were excluded. At surgery aortic valves were classified as bicuspid (BAV) or tricuspid (TAV). The
studies were randomized and evaluated by an experienced cardiovascular radiologist. Balanced steady state
free precession (bSSFP) and phase-contrast images were obtained at the level of the aortic valve. Images were
reviewed for fusion of the commissures of the aortic valve. BAVs were categorized according to Siever's
classification. Partial or complete fusion and involved commissures were noted. The reader was blinded to the
CMR study indication, other imaging findings, and operative results. The sensitivity, specificity, and accuracy for
AoV classification at CMRI compared to operative findings. Misclassification rates for BAV and TAV were
calculated, with subgroup analysis for complete and partial fusion BAVs
RESULTS
Five patients met at least one exclusion criteria, resulting in a cohort of 213 subjects. 82 and 131 subjects were
classified as TAV and BAV at surgery respectively. All BAVs were correctly classified, including 58 subjects with
partial fusion of at least one commissure (Table 1) . 6 (7.3%) TAVs were incorrectly classified as BAV at CMR;
all 6 were thought to have a partial commissural fusion but were classified as TAV at surgery. The sensitivity,
specificity, and accuracy for CMR classification was 100%, 92.7%, and 97.2% respectively
specificity, and accuracy for CMR classification was 100%, 92.7%, and 97.2% respectively
CONCLUSION
CMR is able to accurately characterize BAV morphology, including patients with varied degrees of partial leaflet
fusion. Using standard bSSFP and phase-contrast sequences, TAVs are rarely misclassified as BAVs
pre-operatively
CLINICAL RELEVANCE/APPLICATION
Partial leaflet fusion, the forme frust of bicuspid aortic valve morphology, is easily identified at cardiac MRI using
standard cine and phase contrast imaging sequences
SSC01-08
Epicardial Adipose Tissue is Associated with Cardiovascular Performance during Exercise in
Asymptomatic Women with the Metabolic Syndrome
Christopher Maroules MD (Presenter): Nothing to Disclose , Nicolle Fernandez BS : Nothing to Disclose ,
Susan Lakoski MD : Nothing to Disclose , Susan Matulevicius MD : Nothing to Disclose , Suhny Abbara
MD : Research Consultant, Radiology Consulting Group , Alice Y. Chang MD, MSc : Nothing to Disclose
PURPOSE
Prior studies have demonstrated that epicardial adipose tissue (EAT) is significantly reduced in patients with
heart failure and that lower EAT correlates with lower left ventricular ejection fraction. Other studies have
demonstrated a positive correlation between EAT and insulin resistance. We sought to determine the
association between EAT and cardiovascular performance during exercise among asymptomatic women with the
metabolic syndrome.
METHOD AND MATERIALS
We recruited 27 asymptomatic premenopausal women with the metabolic syndrome who underwent cardiac
magnetic resonance imaging (CMR) at 3 Tesla. EAT thickness was measured along the left ventricular anterior
wall from a two chamber, ECG-gated cine image at end-diastole. Insulin sensitivity was calculated from a
frequently sampled intravenous glucose tolerance test. Measurements of cardiovascular performance were
obtained during an exercise treadmill test, including oxygen uptake (VO2). Body fat composition was
determined by hydrostatic underwater weighting. Univariate analyses were performed using Spearman
correlation. Adjustment for insulin sensitivity was performed using linear regression.
RESULTS
The median age of study participants was 39 (interquartile range, IQR: 34-45) years and the median body mass
index (BMI) was 35 (IQR: 29-38) kg/m2. EAT positively correlated with BMI (p=0.04), waist circumference
(p=0.03), and hip circumference (p=0.02), but did not correlate with percent body fat (p=0.13). EAT positively
correlated with VO2 indexed to weight during steady state exercise (r=0.59, p=0.03), but not at rest or
maximum effort. In linear regression models after adjusting for insulin sensitivity, EAT remained significantly
associated with steady state exercise VO2 indexed to weight (p=0.01).
CONCLUSION
Among asymptomatic women with the metabolic syndrome, epicardial adipose tissue by CMR is associated with
VO2 during exercise independent of insulin sensitivity.
CLINICAL RELEVANCE/APPLICATION
Depletion of epicardial adipose tissue may be a useful marker of subclinical cardiovascular disease. Future
studies should explore the role of epicardial adipose tissue as a predictor of cardiovascular risk and response to
therapeutic interventions.
SSC01-09
Coronary Artery and Aortic Valve Calcifications Seen at Lung Cancer Screening Low-Dose CT: Clinical
Meaning and Correlation with Echocardiographic Findings
Yoon Ki Cha MD (Presenter): Nothing to Disclose , Hee Young Lee MD : Nothing to Disclose , Kyung Soo
Lee MD, PhD : Nothing to Disclose , So Hyeon Bak MD : Nothing to Disclose , Hyoun Cho MD : Nothing
to Disclose , Sung Mok Kim MD : Nothing to Disclose
PURPOSE
To correlate the presence and extent of coronary artery calcium(CAC) with those of aortic valve calcium(AVC),
and to compare the presence and extent of CAC and AVC at low-dose ungated MDCT for lung cancer screening
(LDCT) with measures at ECG-synchronized MDCT for coronary calcium score (CCS).
METHOD AND MATERIALS
From 2008 to 2009, 454 patients (68.1 ± 7.9 years, 420 male) underwent screening same-day LDCT
(5.0-mm-section thickness) followed by CCS CT in asymptomatic patients for chest disease. In 278 patients
with a CCS CT positive for AVC, CAC and AVC were quantified using Agatston scores. The severity of AS was
evaluated with Doppler echocardiography using a peak velocity and a pressure gradient. The severity of AS was
compared with AVC measured at LDCT.
RESULTS
The median CAC score was higher in individuals with combined AVC+CAC than in those with CAC only. 14.7 %
of individuals with AVC had CAC score >400 (extensive plaque burden). There was weak correlation or some
linear tendency between CAC and AVC score (r = 0.20, p = 0.001) at LDCT. In patients with AS, Doppler
echocardiography demonstrated a mean peak velocity of 2.74 ± 1.27 m/s and a mean pressure gradient of
17.45 ± 17.37 mmHg. The median AVC score at LDCT was 947.9 (interquartile range, 163.0-2924.3). The AVC
score at LDCT positively correlated with the peak velocity and pressure gradient (r =0.71 for both, p = 0.009
and p = 0.005, respectively) of the AV. All patients with severe AS had a calcium score of >3300. CAC and AVC
scores from LDCT showed strong positive correlation with those from the CCS (r = 0.87, limits of agreement
-533.1 to 260.58 for CAC and r = 0.88, limits of agreement -397.07 to 457.17 for AVC).
CONCLUSION
Weak correlation or some linear tendency is seen in CAC and AVC scores at LDCT and a close linear relation
between echocardiographic parameters of severity of AS and AVC scores at LDCT is identified. Moreover, using
non-gated MDCT for lung cancer screening, we can detect CAC and AVC and obtain results comparable to those
obtained with dedicated ECG-gated calcium-scoring CT.
CLINICAL RELEVANCE/APPLICATION
LDCT for lung cancer screening, performed in high-risk smokers for lung cancer having also a potential for
coronary artery disease with such smoking, should be evaluated for the presence and extent of coronary artery
and aortic valve calcifications, because the LDCT technique appears to be feasible in detecting and quantifying
the calcifications.
SSC02
Cardiac (Coronary Artery Disease/Low Dose Techniques)
Scientific Papers
CT
CA
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credits: 1.50
Mon, Dec 1 10:30 AM - 12:00 PM
Location: S504AB
Participants
Moderator
U. Joseph Schoepf MD : Research Grant, Bracco Group Research Grant, Bayer AG Research Grant, General Electric Company
Research Grant, Siemens AG
Moderator
Martin J. Lipton MD : Research Consultant, DataPhysics Research, Inc Stockholder, DataPhysics Research, Inc
Moderator
Harold Ira Litt MD, PhD : Research Grant, Siemens AG Research Grant, Heartflow, Inc
Sub-Events
SSC02-01
Influence of Motion on Calcium Scores in Iterative Reconstructed CT: A Multivendor Dynamic
Phantom Study
Niels R. van der Werf : Nothing to Disclose , Martin J. Willemink MD : Nothing to Disclose , Bronislaw
Abramiuc : Nothing to Disclose , Tineke Petra Willems MD, PhD : Nothing to Disclose , Tim Leiner MD, PhD
: Speakers Bureau, Koninklijke Philips NV Research Grant, Bayer AG Research Grant, Bracco Group , Marcel
Greuter PhD (Presenter): Nothing to Disclose
PURPOSE
The amount of coronary calcium per patient can be expressed as coronary calcium score (CCS) in computed
tomography (CT). Coronary arteries can reach velocities up to 60 mm/s during the scan phase, which can
influence the CCS. Also, new iterative reconstruction (IR) techniques, which allow the dose in CT to be reduced,
influence the CCS. The purpose of the current study was to evaluate the influence of motion on CCS in IR CT for
the high-end CT systems of four major vendors.
METHOD AND MATERIALS
A calcium hydroxyapatite-containing cylinder (198.4 mm3, 157.1 and 38.5 mg calcifications) attached to a
computer controlled lever was moved in the center of an anthropomorphic thorax phantom at velocities ranging
from 0-60 mm/s. An extension ring around the thorax simulated an averaged sized patient. Clinical acquisition
protocols were used on Brilliance iCT (Philips), Aquilion One (Toshiba), Discovery CT 750 HD (GE) and Somatom
Definition Flash (Siemens). Image reconstruction was performed with filtered back projection (FBP) and
increasing levels of IR. CCS was quantified as Agatston scores with the vendor's software.
RESULTS
For the 157.1 mg calcification the FBP CCS was 414±12, 414±13, 427±30 and 460±11 at 0 mm/s for Philips,
Siemens, GE and Toshiba respectively. At 60 mm/s scores increased 64-182% to 838±88, 682±73, 1205±128
and 940±47. The highest IR level resulted in 2-5% reduced CCS relative to FBP to 820±89, 645±72, 1176±125
and 918±44. For 38.5 mg calcification FBP CCS decreased 22-65% with increasing velocity for all vendors from
100±12, 96±12, 109±10 and 120±6 at 0 mm/s to 34±23, 75±20, 83±16 and 48±20 at 60 mm/s. The highest
IR level resulted in 14-42% reduced CCS relative to FBP to 29±22, 43±20, 62±17 and 35±20.
CONCLUSION
The influence of motion on coronary calcium scores (CCS) is much larger than the influence of iterative
reconstruction (IR). For fast moving arteries, CCS are overestimated up to 300% for high density calcifications
and underestimated up to 65% for a low density calcifications compared to the static score. The influence of IR
is relatively small at 5% for high density and 42% for low density calcifications.
CLINICAL RELEVANCE/APPLICATION
Coronary calcium scores are highly depended on motion, density and CT system. The influence of iterative
reconstruction is relative small.
SSC02-02
Does Iterative Reconstruction Allow for Radiation Dose Reduction in CT Coronary Calcium Scoring?
A Multivendor in vitro Study on High-end CT Scanners
Bronislaw Abramiuc : Nothing to Disclose , Niels R. van der Werf : Nothing to Disclose , Martin J. Willemink
MD : Nothing to Disclose , Tineke Petra Willems MD, PhD : Nothing to Disclose , Tim Leiner MD, PhD :
Speakers Bureau, Koninklijke Philips NV Research Grant, Bayer AG Research Grant, Bracco Group , Marcel
Greuter PhD (Presenter): Nothing to Disclose
PURPOSE
To investigate the effect of iterative reconstruction (IR) and low radiation dose for quantification of small
coronary calcifications in clinical calcium scoring protocols on high-end computed tomography scanners from
four major vendors.
METHOD AND MATERIALS
An anthropomorphic thorax phantom with a cardiac cylinder containing 100 small calcifications (size 0.5-2 mm
and density 92-548 mg HA/cm3) was scanned 5 times with clinical calcium scoring protocols at the vendor
recommended clinical dose and at 25, 50 and 75% radiation dose reduction on Philips Brilliance iCT, Siemens
Definition Flash, GE Discovery CT750 HD, and Toshiba Aquilion ONE. Each scan series included 3 increasing IR
steps. The Agatston score (AS) and mass score (MS) were derived using vendor-specific software. Coronary
calcium scores (CCS) at full dose were taken as reference, and statistical comparison with CCS at lower dose
was performed using the Wilcoxon matched pairs test.
RESULTS
At full dose the CCS resulted in median (25th-75th percentiles) AS of 10 (8-37), 34 (29-37), 113 (43-141), 87
(84-97) for Philips, Siemens, GE and Toshiba, respectively, and MS of 4 (2-10), 8 (8-9), 18 (9-22), 20 (19-21)
mg, respectively. At reduced radiation dose the median AS and MS generally increased. Increasing the IR level
decreased the median CCS for GE (68 - 105 AS, 13 - 18 mg) and Toshiba (47 - 70 AS, 12 - 18 mg), but no
significant difference was registered for Philips (10 - 11 AS, 4 - 6 MS). However, for Siemens the CCS increased
(38 - 52 AS, 10 - 13 mg) with the first IR level, followed by a decrease (32- 45 AS, 9 - 11 mg) with higher IR
levels. Compared to full dose CCS, the modified protocols (low dose + IR) resulted in similar CCS only for Philips
(0.89 > P > 0.14), Siemens (0.68 > P > 0.08) and GE (0.89 > P > 0.07). For Toshiba, similarity was only
achieved for filtered back projection reconstructed scans at 75% and 50% dose reduction (0.68 > P > 0.22).
CONCLUSION
Calcium scores increase at lower dose and decrease with IR. Calcium score in low-dose-IR protocols results in
comparable scores with vendor recommended dose protocols for Philips, Siemens and GE.
CLINICAL RELEVANCE/APPLICATION
The number of asymptomatic individuals at intermediate cardiovascular risk that will undergo coronary calcium
scoring examination is growing. A reduced radiation dose at constant calcium score can be achieved with
iterative reconstruction in combination with lower dose.
SSC02-03
The Relationship between Instantaneous Wave-free Ratio Computed from Coronary CT Angiography
(iFR-CT) and Invasively Measured Fractional Flow Reserve (FFR) in Patients with Coronary Artery
Stenosis
Yue Ma (Presenter): Nothing to Disclose , Hou Yang MD : Nothing to Disclose , Yuke Wang : Nothing to
Disclose , Qiyong Guo MD : Nothing to Disclose , Mei Yu : Nothing to Disclose , Yingying Hou MS :
Nothing to Disclose
PURPOSE
To determine whether iFR-CT using end-diastole resting coronary CT angiography (CTA) can be used to predict
the functional stenosis defined by invasive FFR measurement.
METHOD AND MATERIALS
We retrospectively examined the performance of iFR-CT versus FFR at the time of invasive angiography in 19
vessels of 15 patients who were identified as having an intermediate stenosis(diameter reduction from 50% to
70%)defined by coronary CT angiography. Patient-specific models were built by input original resting
end-diastolic high-quality DICOM format coronary CTA images (usually R-R interval 75-80%) into Mimics
software. The models were surface-meshed and body-meshed, then coupled model of vessel wall and blood was
established by using the finite element method.These data results were imported into ANSYS software for
visualized pictures of parameter distributions. Computed iFR-CT was obtained by dividing end-diastole resting
mean pressure distal to the coronary stenosis by the mean aortic pressure based on the visualized pictures.
The correlation between iFR-CT and invasive FFR was determined with Spearman's rank correlation. And the
diagnostic efficiency of iFR-CT for functional ischemia was evaluated with FFR as "gold standard".
RESULTS
The difference between noninvasive iFR-CT and invasive FFR was not significant (0.813±0.086 Vs 0.828±0.091,
p=0.163). Correlation coefficient between iFR-CT with FFR was 0.811 (P<0.001). iFR-CT had equally good
diagnostic agreement with FFR (receiver-operating characteristic area under the curve 0.92, p=0.002).
Diagnostic accuracy of iFR-CT to predict lesion-specific ischemia (FFR≤0.8) was 84.2% (sensitivity: 87.5%,
specificity: 81.8%, positive predictive value:77.8%, and negative predictive value: 90.0%).
CONCLUSION
iFR-CT as a noninvasive, adenosine-independent technology has a significant correlation with invasively
measured FFR. iFR-CT appears to be a promising index to assess the functional ischemia of coronary stenosis.
CLINICAL RELEVANCE/APPLICATION
Computed tomography-derived instantaneous wave-free ratio (iFR-CT) is a novel noninvasive,
adenosine-independent technology that can be used for patients with coronary artery disease (CAD) to assess
functional stenosis.
SSC02-04
Ultra Low Tube Voltage (70kV) FLASH Scan with Low Contrast Volume Injection Protocol for
Dual-source CT Coronary Angiography: Image Quality and Radiation Exposure
Jian Cao MD : Nothing to Disclose , Yining Wang MD (Presenter): Nothing to Disclose , Lu Lin MD :
Nothing to Disclose , Lingyan Kong MD : Nothing to Disclose , Yan Yi : Nothing to Disclose , Jiuhong
Chen MD, PhD : Employee, Siemens AG , Zhengyu Jin : Nothing to Disclose
PURPOSE
To investigate the application of ultra low tube voltage (70kV) for coronary artery CT angiography (CCTA) with
low contrast volume and injection flow rate on dual-source CT (DSCT) equipment with integrated circuit (IC)
detector.
METHOD AND MATERIALS
Thirty patients with body mass index (BMI) no more than 25 kg/m2 were scanned using high pitch (3.4) and
prospectively ECG-triggering CCTA protocol on DSCT. All patients were givenβ-blocker before examination in
order to make the mean heart rate lower than 70 bpm. All patients were randomly divided into two groups:the
injection flow rate and volume of contrast for Group A was 4.0 mL/s and 32 mL(350 mgI/mL); those for Group
B were 4.0 mL/s and 50 mL (350 mgI/mL), respectively. Tube voltage of both groups was 70 kV. The raw data
were reconstructed with both FBP and sinogram affirmed iterative reconstruction (SAFIRE). The differences of
SNR, CNR, noise, CTDIvol, effective dose (ED) and segment-based image quality (1-4, excellent to
non-assessable) between the two groups were compared.
RESULTS
There were no significant differences in age, BMI or heart rate between the two groups (all P>0.05). Radiation
exposure (CTDIvol and ED) between the two groups showed no significant difference (all P>0.05), and the
mean ED was about 0.90 mSv. Besides, there were no significant differences between the two groups in SNR
and CNR. By means of SAFIRE, the image noise decreased and CNR and SNR increased significantly (all P <
0.001). And the contrast CT value, SNR and CNR of each coronary artery segment reconstructed with SAFIRE
were significantly higher than FBP in both groups (all P < 0.01), except in the distal segment of LAD, where
there were no significant difference. Mean segment-based image quality scores showed no significant difference
between the two groups reconstructed with SAFIRE (Group A, 1.16 ± 0.18, Group B, 1.18 ± 0.18; p = 0.75).
The percentage of assessable segments in each group was more than 98%.
CONCLUSION
For patients with normal BMI, the use of tube voltage as 70kV with SAFIRE technique in DSCT equipped IC
detector is feasible. And both the contrast injection flow rate and volume can be much lower.
CLINICAL RELEVANCE/APPLICATION
For patients with BMI no more than 25 kg/m2 and mean heart rate of less than 70 bpm, the CCTA of ultra low
tube voltage (70kV) and low contrast volume (4.0 mL/s, 32 mL) with high pitch scanning protocol is feasible.
SSC02-05
Total Coronary Plaque Volume by Coronary CT Angiography: Relationship between Plaque Burden
and Risk Factors
Karen Rodriguez (Presenter): Nothing to Disclose , Veit Sandfort MD : Nothing to Disclose , Puskar
Pattanayak MBBS, FRCR : Nothing to Disclose , Shenghan Lai : Nothing to Disclose , Davis M. Vigneault
BS : Nothing to Disclose , Marissa Mallek : Nothing to Disclose , Andrew Sams : Nothing to Disclose ,
Christopher Sibley : Nothing to Disclose , David A. Bluemke MD, PhD : Research support, Siemens AG
PURPOSE
The relationship of calcium score (CAC) and risk factors has been determined. The purpose of this study is to
assess the relationship between total coronary plaque burden (including noncalcified plaque) and cardiovascular
risk factors as assessed by coronary CTA.
METHOD AND MATERIALS
149 subjects were recruited in this ongoing, prospective study designed to evaluate the effect of HMG-CoA
reductase inhibitors on atherosclerosis progress. Eligible subjects were >55 years of age, eligible for statin
therapy, and had no known history of cardiovascular disease. Coronary artery imaging was performed using
contrast enhanced CT angiography with a 320-detector row scanner. Images were analyzed using QAngioCT
software v2.0.5 (Medis Medical Imaging Systems, Netherlands) using a lumen attenuation adaptive algorithm.
Coronary wall thickness was evaluated in the total coronary artery tree for vessels > 2 mm diameter. Plaque
index was defined as plaque volume divided by coronary length. Noncalcified plaque burden was defined as the
sum of fibrous and fibrous fatty plaque.
RESULTS
The average age was 66±6.5 years (38% women). Median coronary artery calcium was 65 (IQR 1-253). In
univariate analysis, total plaque index was greater in men than women (42.7±10.6 vs 34.1±8.6 mm2,
p=<0.001), and in patients with higher BMI (r=0.21, p=0.004). In multivariate analysis controlling for all risk
factors but CAC, total plaque index was higher in men than women (standardized β=10.6 ; p=<0.001) and in
patients with higher BMI (β=0.5 ; p=<0.001). In multivariate analysis, noncalcified plaque index was
significantly correlated with LDL (β=0.05, p=0.01) and diabetes (β=4.0, p=0.04) but not with BMI (p=0.28).
CONCLUSION
Body mass index is a major determinate of total plaque burden as assessed by coronary CT angiography,
independent of calcium score. LDL and diabetes, but not BMI, were also associated with greater noncalcified
plaque burden.
CLINICAL RELEVANCE/APPLICATION
Total coronary plaque burden by CTA may provide additional and independent prognostic information beyond
traditional risk factors. BMI is an important modifiable risk factor.
SSC02-06
Influence of Dose Reduction on Calcium Scores in Iterative Reconstructed CT: A Multivendor
Dynamic Phantom Study
Niels R. van der Werf : Nothing to Disclose , Martin J. Willemink MD : Nothing to Disclose , Bronislaw
Abramiuc : Nothing to Disclose , Tineke Petra Willems MD, PhD : Nothing to Disclose , Tim Leiner MD, PhD
: Speakers Bureau, Koninklijke Philips NV Research Grant, Bayer AG Research Grant, Bracco Group , Marcel
Greuter PhD (Presenter): Nothing to Disclose
PURPOSE
The dose in coronary calcium scoring (CCS) can be reduced with respect to filtered back projection (FBP) using
iterative reconstruction (IR) in computed tomography (CT). However, the influence of dose on depiction of
coronary calcium in moving coronary arteries in IR CT is still unknown. Therefore, the purpose of the current
study was to evaluate the influence of dose on CCS in IR CT for high-end CT scanners of the four major vendors
with moving calcifications.
METHOD AND MATERIALS
Two calcifications of equal volume (198.4 mm3) but different mass (157.1, and 38.5 mg) were used in an
anthropomorphic thorax phantom at a velocity of 20 mm/s. An extension ring was placed around the thorax
phantom to resemble a medium sized patient. Vendor recommended clinical protocols were used. Subsequently
dose was reduced by 80%. The phantom was scanned five times with a small translation on Brilliance iCT
(Philips), Aquilion One (Toshiba), Discovery CT 750 HD (GE) and Somatom Definition Flash (Siemens). CCS was
quantified as Agatston scores with vendor software.
RESULTS
For the 157.1 mg calcification full dose FBP resulted in CCS of 500±45, 442±14, 529±55 and 717±31 for
Philips, Siemens, GE and Toshiba respectively. At 80% reduced dose CCS was 625±96, 552±21 and 665±36
and 710±30. Using IR CCS decreased with 7-15% to 527±54, 476±19, 614±29 and 639±27. For the 38.5 mg
calcification full dose FBP resulted in CCS of 102±12, 99±15, 100±7 and 112±10. At 80% reduced dose CCS
was 265±41, 157±11, 148±9 and 187±15. Using IR CCS decreased with 34-58% to 110±48, 90±5, 97±8 and
85±7.
CONCLUSION
Dynamic coronary calcium scores are overestimated up to 157% at 80% reduced dose, which can be
compensated for up to 58% using iterative reconstruction, depending on calcification density and CT system.
CLINICAL RELEVANCE/APPLICATION
Dose reduction in CT results in overestimated calcium scores and thereof overestimated patient's risk estimates
which can be compensated for by using iterative reconstruction.
SSC02-07
Total Coronary Plaque Volume: Reproducibility Using CCTA
Puskar Pattanayak MBBS, FRCR (Presenter): Nothing to Disclose , Karen Rodriguez : Nothing to Disclose ,
Davis M. Vigneault BS : Nothing to Disclose , David A. Bluemke MD, PhD : Research support, Siemens AG
PURPOSE
Both hard (calcium) and soft plaque can be readily assessed to determine the overall volume of coronary
plaque using MDCT. However to date, the scan-rescan reproducibility of plaque volume has not been previously
plaque using MDCT. However to date, the scan-rescan reproducibility of plaque volume has not been previously
reported.
METHOD AND MATERIALS
A total of 30 coronary arteries and 82 segments were analyzed for ten volunteer subjects (mean age, 63.7).
Within a short period (mean, 20 days), study subjects (mean age 63.7) underwent baseline and repeat
coronary CT angiography (CCTA) on a 320 detector scanner. CTA images were analyzed for calcium and
noncalcified plaque using Medis QAngio semi-automated software. A second reader interpreted the follow-up
CT. Total and plaque subtype amounts indexed by segment length were measured. Plaque quantification was
optimized using both standard and "narrow vessel wall thickness" setting settings using an adaptive algorithm
that adjusted for coronary lumen density.
RESULTS
Mean radiation dose per scan was 4.5msv. Total plaque burden had good intra-observer reproducibility
(Intra-class Correlation Coefficient, ICC: 0.84). Total plaque indexed by length showed excellent inter-observer
reproducibility (ICC 0.94). Calcified plaque showed excellent intra-observer and inter-observer reproducibility
(ICCs 0.98 to 0.99). Fibrous fatty and necrotic core plaque had good intra-observer (ICCs 0.74 and 0.78) and
inter-observer reproducibility (ICCs 0.96 and 0.83). Fibrous plaque was poorly reproducible (ICCs 0.03 and
0.65 for intra- and inter-observer measurements).
CONCLUSION
Calcified plaque has excellent reproducibility and correlates highly with Agatston calcium scores. Scan-rescan
reproducibility was very good for plaque indexed by length, fibrous fatty and necrotic core plaque. Only fibrous
plaque is poorly reproducible.
CLINICAL RELEVANCE/APPLICATION
Total coronary plaque volume by coronary CT angiography shows very good scan-rescan reproducibility. This
measure should be useful as a patient centered index of atherosclerosis for clinical trials and therapy.
SSC02-08
Coronary Artery Calcification on Low-dose Computed Tomography: Comparison of Agatston and
Ordinal Scores
Yu Htwe MD (Presenter): Nothing to Disclose , Matthew D. Cham MD : Nothing to Disclose , Rowena Yip
MPH : Nothing to Disclose , Artit C. Jirapatnakul PhD : Nothing to Disclose , David F. Yankelevitz MD :
Research Grant, AstraZeneca PLC Royalties, General Electric Company , Claudia I. Henschke MD, PhD :
Nothing to Disclose
PURPOSE
To compare the Ordinal Scores with the Agatston Scores obtained on non-gated low-dose CT scans
METHOD AND MATERIALS
636 asymptomatic participants (women 416, men 220, mean age 55 years) had low-dose CT screening scans .
Each participant was graded as to the extent of coronary artery calcification (CAC) in the 4 arteries (left main,
left anterior decending, circumflex and right) and received a Ordinal Score between 0 and 12. Standard
software was used to obtain the Agatston Score, but it could not be obtained on 5 participants, reducing the
total number for evaluation of 631. Each participant was classified into 1 of 3 Ordinal Score Categories (0, 1-3,
4-12) and 1 of 3 standard Agatston Score Categories (0, 1-400, 400+).
RESULTS
The Ordinal Score of 0 was in agreement with the Agatston Score of 0 in 440 (70%) of the 631 participants, the
Ordinal Score of 1-3 was in agreement with the Agatston Score of 11-400 in 78 (12%) participants, and the
Ordinal Score of 4-12 was in agreement with the Agatston Score of 400+ in 21 (3%) participants. Thus there
was agreement in 539 (85%) of the 631 participants. In 36 of the remaining 92 participants, the Agatston Score
was 0 because the calcifications that were actually present were too small to meet the criteria of acceptance by
the Agatston software. The remaining 56 (9%) of the 631 participants differed only by 1 category. Overall, the
Ordinal Score Categories showed excellent agreement (weighted kappa of 0.83- 95% CI: 0.79-0.88) with the
Agatston Score Categories.
CONCLUSION
The use of the Ordinal Score is readily obtained on low-dose CT scans. It shows excellent agreement with the
Agatston Score and is thus useful for risk stratification of coronary artery disease.
CLINICAL RELEVANCE/APPLICATION
It is important to provide information obtained from low-dose CT scan about coronary artery disease by
providing either the Ordinal or Agatston Scores.
SSC02-09
Influence of a Novel Motion Correction Algorithm on Quality and Interpretability of Images of
64-detector Coronary CT Angiography among Patients Grouped by Heart Rate
Haruhiko Machida MD (Presenter): Nothing to Disclose , Xiao Zhu Lin MD : Nothing to Disclose , Rika
Fukui : Nothing to Disclose , Yun Shen PhD : Employee, General Electric Company Researcher, General
Electric Company , Isao Tanaka : Nothing to Disclose , Eiko Ueno MD : Nothing to Disclose , Takuya
Ishikawa : Nothing to Disclose , Etsuko Tate : Nothing to Disclose , He Qing Wang MSc : Nothing to
Disclose
PURPOSE
To retrospectively investigate the influence of use of a novel motion correction algorithm (MCA) on quality and
interpretability of coronary CT angiography (CCTA) images among patients grouped by heart rate (HR).
METHOD AND MATERIALS
We divided 105 patients who underwent 64-detector CCTA into 6 groups based on their average HRs (25 with
average HR ≤ 59 bpm; 23, 60-64 bpm; 23, 65-69 bpm; 13, 70-74 bpm; 14, 75-79 bpm; and 7, ≥ 80 bpm),
and 2 readers independently evaluated quality of axial images of the left main trunk, anterior descending
artery, circumflex artery, and right coronary artery (RCA) reconstructed with and without the MCA at 75% of
the R-R interval in patients with average HR ≤ 64 bpm and at 40% (systole) and at 75% (diastole) in patients
with HR ≥ 65 bpm. For each different HR group and cardiac phase, per-vessel and per-segment image quality
regarding motion artifacts was visually graded using a 5-point scale and compared using Wilcoxon signed rank
test, and percentages of interpretable image quality (scores, 3-5) were compared between images
reconstructed between with the MCA at the diastole with average HR of 65-69 bpm or ≤ 69 bpm and at the
systole with HR of 70-79 bpm (the higher or more extensive HR group, respectively) and without the MCA at
the diastole with average HR ≤ 64 bpm (the reference group) using chi-square test. We assessed inter-reader
agreement of image quality scores by segment using κ-statistics. P < 0.05 was considered statistically
significant.
RESULTS
Use of the MCA significantly improved image quality and interpretability in all groups, providing similar or better
per-vessel (92-100% or 96-100% versus 88-100%) and per-segment interpretable quality (98% or 99% versus
97%) in the higher or more extensive HR group, respectively, compared to the reference group without
significant difference except for the more extensive HR group (P = 0.008 for the RCA, 0.0002 for all segments).
The inter-reader agreement was excellent (κ = 0.965).
CONCLUSION
Quality and interpretability of images of CCTA reconstructed with the MCA were similar or better in patients with
average HR ≤ 79 bpm than those of the reference group.
CLINICAL RELEVANCE/APPLICATION
Use of a novel MCA may increase the upper limitation of HR to 79 bpm for use with step-and-shoot scan and
reasonably reduce radiation dose compared to retrospectively-gated helical scan.
SSC03
Chest (Lung Nodule)
Scientific Papers
NM
CT
CH
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credits: 1.50
Mon, Dec 1 10:30 AM - 12:00 PM
Location: S404AB
Participants
Moderator
Cornelia Maria Schaefer-Prokop MD : Advisory Board, Riverain Technologies, LLC
Moderator
David F. Yankelevitz MD : Research Grant, AstraZeneca PLC Royalties, General Electric Company
Sub-Events
SSC03-01
Dual Time-point and Respiratory-gated 18FDG PET/CT in the Characterization of Indeterminate
Pulmonary Nodules
Jonathan Hero Chung MD (Presenter): Research Grant, Siemens AG Royalties, Amirsys, Inc , Demitry
Kazlouski : Nothing to Disclose , Hope McGee : Nothing to Disclose , Ramya Rajaram : Employee, Siemens
AG , David Augustine Lynch MBBCh : Research support, Siemens AG Scientific Advisor, PAREXEL International
Corporation Consultant, Boehringer Ingelheim GmbH Consultant, InterMune, Inc Consultant, Gilead Sciences,
Inc Consultant, F. Hoffmann-La Roche Ltd Consultant, Veracyte, Inc Research support, Johnson & Johnson
Research support, AstraZeneca PLC
PURPOSE
Previous studies have shown mixed results in the setting of dual time-point 18FDG PET in characterizing
indeterminate pulmonary nodules as benign or malignant. The purpose of this study was to determine if
respiratory gating would increase the accuracy of the dual time-point PET technique in characterizing
indeterminate pulmonary nodules.
METHOD AND MATERIALS
Subjects with pulmonary nodules ranging in size from 6-20 mm, being evaluated with 18FDG PET/CT were
prospectively recruited for our study. Subjects were imaged with 18FDG PET/CT one and two hours after
injection of approximately 15 mCi 18FDG using static and phase-based respiratory-gated techniques. The
maximum SUVs of pulmonary nodules were measured on static PET images as well as for every gate of
respiratory-gated PET images. Malignancy or benignity was determined by tissue biopsy or follow-up imaging.
RESULTS
There were 29 malignant and 78 benign nodules. The maximum SUV of malignant nodules was statistically
higher than that of benign nodules at the first (8.35+/- 7.29 vs. 2.34 +/-2.13) and second (10.39 +/- 8.91 vs.
2.55 +/-2.42) hour time points (p-values <0.0001). The percentage change in the maximum SUV values for
respiratory-gated data (19.3% +/- 30.2% vs 7.5% +/- 20.1%, p-value 0.0210) and static data (23.3% +/60.0% vs 3.8% +/- 23.0%, p-value 0.0161) from 1st to 2nd time points was significantly higher in malignant
than benign nodules. This relationship persisted even when considering nodules with a maximum SUV of
greater than 3.0 (with gating: 29.0% +/-23.7% vs 9.9% +/- 29.0%, p-value 0.0107; without gating: 32.3%
+/-53.3% vs 2.0% +/- 26.9%, p-value 0.0217).
CONCLUSION
There is a statistical difference in percentage change of maximum SUV values from 1st to 2nd time points
between malignant and benign pulmonary nodules for both respiratory-gated and static PET images. This
relationship persists even when considering pulmonary nodules with substantial 18FDG uptake (maximum SUV
greater than 3.0). There was less dispersion of percentage change of maximum SUV across time points with
than without respiratory gating (standard deviation of 30% compared to 60%).
CLINICAL RELEVANCE/APPLICATION
A dual-time point technique may be helpful in characterizing indeterminate pulmonary nodules as malignant or
benign even in nodules with substantial 18FDG uptake.
SSC03-02
Accuracy and Potential of Maximum Standard Uptake Value in the Diagnosis of Solitary Lung Nodules
Alberto Bazzocchi MD : Nothing to Disclose , Stefano Brocchi MD (Presenter): Nothing to Disclose ,
Valentina Ambrosini : Nothing to Disclose , Giancarlo Facchini : Nothing to Disclose , Salvatore Ascanio :
Nothing to Disclose , Giuseppe Battista : Nothing to Disclose , Stefano Fanti MD : Research Consultant,
Siemens AG Advisory Board, Bayer AG
PURPOSE
Criticisms and limitations of standard uptake value (SUV) in positron emission tomography (PET) imaging are
well known. Our aim was to investigate the role of SUVmax in the detection of malignancy of solitary lung
nodules and to study its potential prognostic value.
METHOD AND MATERIALS
We retrospectively analyzed the clinical history of 1010 patients (657 males, 353 females, 72.6±11.8 year-old)
who were submitted to PET/CT for solitary lung nodules, between January 2002 and May 2012 in a single
centre. The analysis included the evaluation of images and physicians' reports of PET/CT exams, anamnesis of
patients and subsequent diagnostic examinations in their follow-up (imaging, biopsy specimen and/or
pathological analysis after surgical resection). Follow-up of all patients ended with survival control at the time of
the present study. Receiver operating characteristic (ROC) curves and Kaplan-Meier method were used for
statistical analysis.
RESULTS
In 457/1010 (45.2%) subjects a non-small cell lung cancer (NSCLC) was diagnosed; in all other patients
553/1010 (54.8%) lesions were classified as non-oncologic diseases or benign. Area under the ROC curve was
0.956, with SUVmax cut-off value of 2.3, resulting in 93.6% and 90.4%, sensitivity and specificity respectively.
The survival analysis was possible in 459 patients (217/459 NSCLC), with a mean follow-up of 70.2±30.34
months. Nodules with higher SUVmax value (>2.3) were associated with lower survival rate (p<0.0001): for
SUVmax >2.3 and <2.3 the survival rates 1 year after PET imaging were respectively 75% and 94%, at 2
years after PET 59% and 90%, while survival expectancies at 3 years were 51% and 85%. The outcome was
independent from the dimension of the lesion or from surgical/non-surgical treatment approach.
CONCLUSION
In conclusion, our single-centre experience showed that a cut-off value of 2.3 SUVmax is a very accurate
marker for prognosis stratification in patients with solitary lung nodules.
CLINICAL RELEVANCE/APPLICATION
The detection of a solitary lung nodule is common and its management critical. A PET/CT scan is often required
to guide the clinicians in the management of such patients. The use of SUVmax from PET/CT imaging in a local
large population showed to be very accurate in differentiating malignant from benign lesions and it deserves
consideration in predicting patients prognosis.
SSC03-03
Pulmonary Nodule Detection in Patients with a Primary Malignancy Using Hybrid PET/MRI: Is there
Value in Adding Gadolinium-enhanced MR Imaging?
Kyunghee Lee MD (Presenter): Nothing to Disclose , Chang Min Park MD, PhD : Nothing to Disclose , Jin
Mo Goo MD, PhD : Research Grant, Guerbet SA , Sang Min Lee : Nothing to Disclose , Gi Jeong Cheon :
Nothing to Disclose , Jeong Min Lee MD : Research Grant, Guerbet SA Equipment support, Siemens AG
Research Grant, Bayer AG , Jeong Yeon Cho MD : Nothing to Disclose
Research Grant, Bayer AG , Jeong Yeon
Cho MD : Nothing to Disclose
PURPOSE
To investigate the added value of a gadolinium-enhanced VIBE (radial volumetric interpolated breath-hold
examination) sequence to hybrid PET/MR imaging for the detection of pulmonary nodules in patients with a
primary malignancy.
METHOD AND MATERIALS
This retrospective HIPAA-compliant institutional review board-approved study included 51 consecutive patients
who underwent 18F-fluorodeoxyglucose (FDG) PET/MR imaging followed by PET/CT for staging work-up. In all
patients, the thorax station was examined with pre-and post-contrast VIBE MR imaging and PET data were
simultaneously acquired. Two readers blinded to the patient data independently recorded their levels of
suspicion for the presence of a pulmonary nodule on a five-point scale based on PET, pre-contrast VIBE, and
PET/MR images (1st session), and reassessed them 4 weeks later after addition of the post-contrast VIBE
sequence (2nd session). Jackknife alternative free-response receiver-operating characteristic (JAFROC) analysis
was performed to evaluate detection accuracy. PET/CT served as the reference standard for the presence and
size of nodules.
RESULTS
On PET/CT, a total of 151 pulmonary nodules were detected including 43 FDG-avid nodules and 61 nodules
>0.5 cm in diameter. In the first session, the average nodule detection rate was 53.3% for all nodules, 100%
for FDG-avid nodules, and 87.7% for nodules >0.5 cm in diameter. In the second session with
gadolinium-enhancement, the average nodule detection rate was 53.3% for all nodules, 100% for FDG-avid
nodules, and 85.2% for nodules >0.5 cm in diameter. The average JAFROC figure of merit was 0.837 in the
first session and 0.848 in the second session. There were no significant differences in detection accuracy
between the first and second sessions (P = 0.48).
CONCLUSION
The addition of gadolinium-enhanced MR imaging to hybrid PET/MR imaging provided no additional value in the
detection of pulmonary nodules.
CLINICAL RELEVANCE/APPLICATION
For the simple purpose of lung nodules detection, T1-weighted gradient-echo MR sequence (VIBE) may not
necessitate additional contrast media injection for thoracic imaging in hybrid PET/MR.
SSC03-04
Staging Workup for Patients with Pure Ground Glass Nodular Adenocarcinomas: Are PET/CT and
Brain MRI Mandatory?
Hyoun Cho MD (Presenter): Nothing to Disclose , Ho Yun Lee MD : Nothing to Disclose , Kyung Soo Lee
MD, PhD : Nothing to Disclose , Byung-Tae Kim MD : Nothing to Disclose , O. Jung Kwon : Nothing to
Disclose , Joungho Han : Nothing to Disclose , Jhingook Kim : Nothing to Disclose
PURPOSE
As a staging workup for pure ground glass opacity (GGO) nodular adenocarcinoma, the role of 18F-FDG PET/CT
scanning or brain MRI has been questioned. The purpose of this study was to determine the value of 18F-FDG
PET/CT and brain MRI for the preoperative staging of lung adenocarcinoma manifesting as pure GGO.
METHOD AND MATERIALS
164 patients (M:F=73:91; mean age=62) with lung adenocarcinoma manifesting as pure GGO who underwent
18F-FDG PET/CT or brain MRI before surgery were included. Pathologic findings for nodal staging and pathologic
or follow-up imaging findings for M staging were reference standards.
RESULTS
Among all 175 tumors, 34 were adenocarcinoma in situ (19 %), 54 were minimally invasive adenocarcinoma
(31 %) and 87 were invasive adenocarcinoma (50 %). The most frequently observed histologic subtypes, in
decreasing order, were lepidic (69%), acinar (26%), and papillary (5%). On PET/CT scan, abnormal
FDG-uptake of lymph node was found in two of all 136 patients (1.5%), which were negative on final pathology.
Abnormal FDG-uptake of liver was detected in one patient, which was also negative confirmed by dedicated
abdomen CT. No brain metastasis was found in brain MRI of all 109 patients. The median follow-up time was
36.7 months, and only one patient (0.9%) developed brain metastasis after surgical resection.
CONCLUSION
18F-FDG PET/CT and brain MRI add little values in the staging of lung adenocarcinoma manifesting as pure GGO.
CLINICAL RELEVANCE/APPLICATION
Lung adenocarcinoma manifesting as pure GGO do not require 18F-FDG PET/CT scan nor brain MRI for staging.
SSC03-05
Textural Analysis and Imaging Features to Differentiate Benign from Malignant Pulmonary Nodules
Jean SZ Lee MRCP, MBBChir (Presenter): Nothing to Disclose , Lyndsey Clare Pickup MEng, DPhil :
Employee, Mirada Medical Ltd , Eugene Jueren Teoh MRCP, FRCR : Nothing to Disclose , James Franklin
MA, MBBS : Nothing to Disclose , Aymeric Larrue PhD : Employee, Mirada Medical Ltd , Mark John Gooding
MENG, DPhil : Employee, Mirada Medical Ltd , Timor Kadir : Employee, Mirada Medical Ltd , Fergus Vincent
Gleeson MBBS : Alliance Medical Ltd Consultant
PURPOSE
Differentiating benign from malignant pulmonary nodules is critical in the management of patients with
pulmonary nodules. The purpose of this study was to investigate the use of textural and imaging features to
differentiate pulmonary nodules using machine learning methods.
METHOD AND MATERIALS
33 patients with histology-proven pulmonary nodules were included. All patients underwent a volumetric chest
CT (VCT) scan, with first dynamic contrast-enhanced chest CT (dceCT) and PET-CT scans. 23 (71.9%) were
malignant. Nodules were manually contoured on the VCT and baseline dceCT scans, and propagated to the
remaining scans using deformable image registration (Mirada XD, Mirada Medical, Oxford, UK). Imaging
measures, such as maximum and mean intensity, and textural features, such as kurtosis or fractal dimension,
were calculated considering both the full-nodule volumes and sub-volumes inside and outside the drawn
contours. Volume doubling time (VDT) and SUV/TLG statistics for PET were also included to create large feature
vectors with several hundred entries per nodule. Gaussian distributions were fitted to subsets of 2-3 features for
the malignant and benign training populations separately. A leave-one-out paradigm was adopted (train on
all-but-one datapoints; test on the withheld one). Each test nodule was classified as belonging to whichever
population gave a higher likelihood score given its feature vector.
RESULTS
32/33 (97%) nodules were correctly classified as cancer/benign under the leave-one-out paradigm. The 3
optimal features were a "fractalness" measure on the nodule at 2 minutes post-contrast, the minimum intensity
within the nodule at 4 minutes post-contrast, and a skewness measure on the core of the nodule (defined as
areas not within a small distance of the contour boundary) also at 2 minutes post-contrast. These features
remained optimally discriminative when the nodule dataset was entirely re-contoured by an independent
researcher.
CONCLUSION
Textural analysis and imaging features using machine learning methods can help differentiate benign from
malignant pulmonary nodules and help guide management.
CLINICAL RELEVANCE/APPLICATION
Differentiation of benign and malignant pulmonary nodules is a common clinical problem that may be helped
using textural analysis and imaging features.
SSC03-06
Computer Extracted Texture Features on CT Predict Level of Invasion in Ground Glass Non-Small
Cell Lung Nodules
Mahdi Orooji PhD (Presenter): Nothing to Disclose , Mirabela Rusu DPhil, MENG : Nothing to Disclose ,
Prabhakar Rajiah MD, FRCR : Institutional Research Grant, Koninklijke Philips NV , Michael Yang : Nothing
to Disclose , Frank Jacono : Nothing to Disclose , Robert C. Gilkeson MD : Research Consultant, Riverain
Technologies, LLC Research support, Koninklijke Philips NV Research support, Siemens AG , Philip Aaron Linden
: Nothing to Disclose , Anant Madabhushi MS : Research partner, Siemens AG Research partner, General
Electric Company Research partner, F. Hoffmann-La Roche Ltd Founder and President, IbRiS, Inc
PURPOSE
Radiographic characteristics to reliably define the degree of invasion of early Non-Small Cell Lung nodules with
ground glass opacity (GGO) components on CT have yet to be reliably defined. Our goal is to identify
quantitative computer extracted image texture features to distinguish GGO nodules with no/minimal invasion
from those with frank invasion on pre-operative CT. Computer-extracted texture features quantitatively
describe the spatial arrangement of intensities in an image and have been shown to distinguish benign from
malignant nodules. In this study we evaluate the utility of computer extracted texture features in distinguishing
GGO with no/minimal and frank invasion.
METHOD AND MATERIALS
We used a retrospective cohort of 33 slices (15 no/minimal and 18 frank) of in vivo lung CT from patients who
had surgical resection. All nodules measured less than 16 mm in diameter. The size of the invasive component
was utilized to stratify the nodules in the no/minimal (<5mm) or invasive category (>5mm invasion). A total of
63 of computer extracted texture features including gray-level statistical, steerable Gabor, Haralick, and Laws
were obtained on CT from the manually delineated nodule. Following feature extraction, the total number of
features was reduced from 63 to 3 via principal component analysis.
RESULTS
Three texture features, Inertia, Correlation and Difference Entropy, were selected by the classifier, providing an
area under the receiver operating characteristic curve (AUC) of 0.92 for distinguishing on CT the no/minimal
invasion nodules from the frank invasion tumors. By comparison, Laws features provided an AUC of 0.61 and
Gabor features yielded an AUC of 0.68.
CONCLUSION
Texture analysis of CT scan showed reasonable discrimination of level of invasion in the context of GGO
cancerous lung nodules.
CLINICAL RELEVANCE/APPLICATION
Computerized image analysis of in vivo CT may allow for identification of computer extracted CT features
associated with no/minimal and frank invasion in GGO lung nodules. It has the potential to impact clinical,
economic, and societal burden of lung cancer by increasing average 5-year survival rate from early detection of
invasive nodules, significant economic benefits to the health care system by reduction in unnecessary
interventions, better image analytics can potentially reduce dependence on repeat or higher resolution CT
exams, and noninvasive means of assessing response to targeted therapies.
SSC03-07
Ground Glass Nodule Detectability on Ultra-Low dose Computed Tomography (CT) with Adaptive
Iterative Dose Reduction Using 3D Processing: Comparison with Low-dose CT by Receiver-Operating
Analysis Based on Nodular Characteristics and Location
Yukihiro Nagatani MD (Presenter): Nothing to Disclose , Masashi Takahashi MD : Nothing to Disclose ,
Mitsuru Ikeda MD : Nothing to Disclose , Tsuneo Yamashiro MD : Nothing to Disclose , Hisanobu Koyama
MD, PhD : Nothing to Disclose , Mitsuhiro Koyama MD : Nothing to Disclose , Hiroshi Moriya MD :
Nothing to Disclose , Kiyoshi Murata MD : Nothing to Disclose , Sadayuki Murayama MD, PhD : Nothing to
Disclose
PURPOSE
To compare ground glass nodule detectability (GGND) on computed tomography (CT) with adaptive iterative
dose reduction using three dimensional processing (AIDR3D) between ultra-low dose scanning (ULDS) and low
dose scanning (LDS) and analyze association of GGND with nodular characteristics and location.
METHOD AND MATERIALS
This was part of the Area-detector Computed Tomography for the Investigation of Thoracic Diseases (ACTIVe)
Study, a multicenter research project being conducted in Japan. The Institutional Review Board of each
institution approved this study and written informed consent was obtained. In a single visit each, 68 subjects
underwent multi-detector chest CT (64-row helical mode) at a gantry rotation speed of 0.35-sec with 3 different
tube currents: 240,120 and 20 mA (2.51, 1.26 and 0.21mSv, respectively). Axial CT images with 2-mm
thickness and increment were reconstructed using AIDR3D. Standard of reference (SOR) as to GGN presence
with the longest diameter (LD) of 3mm or more was determined based on CT images at 240mA by consensus
reading of 2 radiologists. Another 4 radiologists independently recorded GGN presence and their characteristics
by continuously-distributed rating on CT images at 20mA (ULDS) and 120mA (LDS). Receiver-operating
characteristic (ROC) analysis was used to evaluate GGND of both methods in total and subgroups classified by
nodular LD (>5mm), characteristics (pure and mixed) and locations (ventral/intermediate/dorsal,
central/peripheral and upper/middle/lower).
RESULTS
For SOR, 22 mixed and 86 pure GGN were identified. No significant difference in GGND with LD of 5mm or more
was shown between both methods, as area under ROC curve was 0.96±0.02 in ULDS and 0.97±0.01 in LDS.
For the entire mixed GGN, GGND was almost the same, as area under ROC curve was 0.97±0.02 in both
methods. Inter-observer variance of GGND with LD of 5mm or more was not demonstrated among 4 radiologists
in 5 locations except for lower, peripheral and intermediate locations.
CONCLUSION
It was demonstrated that ULDS with AIDR3D had comparable GGND to LDS with AIDR3D except for pure GGN
with LD of less than 5mm.
CLINICAL RELEVANCE/APPLICATION
ULDS with AIDR3D has a sufficient potential to be used for GGN screening except for smaller ones without solid
part.
SSC03-08
Automatic Classification of Perifissural Pulmonary Nodules in Thoracic CT Images
Francesco Ciompi PhD (Presenter): Nothing to Disclose , Bartjan De Hoop MD : Nothing to Disclose ,
Colin Jacobs MSc : Research Grant, MeVis Medical Solutions AG , Mathias Prokop MD, PhD : Speakers
Bureau, Bayer AG Speakers Bureau, Bracco Group Speakers Bureau, Toshiba Corporation Speakers Bureau,
Koninklijke Philips NV Research Grant, Toshiba Corporation , Pim A. De Jong MD, PhD : Nothing to Disclose ,
Bram Van Ginneken PhD : Stockholder, Thirona BV Co-founder, Thirona BV Research Grant, MeVis Medical
Solutions AG Research Grant, Canon Inc Research Grant, Toshiba Corporation Research Grant, Riverain
Technologies, LLC
PURPOSE
Up to one third of pulmonary nodules detected in heavy smokers are perifissural nodules (PFNs) that do not
require follow-up. An automatic method is presented to distinguish PFNs from solid nodules.
METHOD AND MATERIALS
We used all baseline scans with a pulmonary nodule from one of the sites of the NELSON trial. All participants
were either current or former heavy smokers (age between 50 and 75 years), and underwent low-dose CT
(Mx8000 IDT 16; Philips Medical Systems, Cleveland, Ohio). Experts annotated non-calcified solid nodules in
1,729 scans, and classified these as PFN (788) and non-PFN (3,038). We formulated PFN classification as a
machine learning problem where a classifier is trained to automatically label nodules as PFN or non-PFN. Given
the characteristic triangular-like shape of PFNs, a novel descriptor encoding information on nodule morphology
was designed. The descriptor is based on frequency analysis of intensity profiles sampled in the CT image.
Given a detected nodule, spherical surfaces up to a maximum radius R are considered, centered on the center
of mass of the nodule. For each sphere, the image intensity is sampled along C circular profiles on the surface
of each sphere at constant angular distance. The profiles are interpreted as a periodic signal, and their spectrum
is obtained using a Fast Fourier Transform. Each spectrum encodes information on nodule morphology through
characteristic frequencies. A set of K spectral signatures is computed applying K-means on the collection of
spectra. A compact nodule descriptor is obtained as the histogram of spectral signatures along the spheres. A
Random Forests classifier with 100 trees was used for supervised learning. A 10-folds cross-validation scheme
was applied to evaluate the method on the 3,826 nodules, using C=128, K=100. Since the range of PFNs
diameters is 2.8-10.6 mm, we used R = 7.5 mm.
RESULTS
We obtained a value of area under the ROC curve of 0.85, with an optimal operating point of 77% sensitivity
and 79% specificity. Misclassified PFNs were often close to the pleura or to other vascular structures.
CONCLUSION
Classification of pulmonary nodules as PFN is feasible and has the potential to be used as an automatic tool in
CAD.
CLINICAL RELEVANCE/APPLICATION
PFNs rarely turn out to be malignant, even though their growth rate is similar to that of malignant nodules.
Automatic recognition of PFNs could reduce the number of unnecessary follow-up CT exams.
SSC03-09
CT Nodule Enhancement Pattern in Patients after SABR
William Henry Moore MD (Presenter): Research Grant, EDDA Technology, Inc Medical Board, EDDA
Technology, Inc Research Grant, Galil Medical Ltd Research Grant, Endo Health Solutions Inc , Ammar Ahmed
Chaudhry MD : Nothing to Disclose , Yair Chaya MD : Nothing to Disclose , Thomas Bilfinger MD :
Nothing to Disclose , Samantha D. Glass MD : Nothing to Disclose , Sarel Gaur MD : Nothing to Disclose ,
George Mikhail MD : Nothing to Disclose , Kevin S. Baker MD : Nothing to Disclose , Bong S. Kim MD :
Nothing to Disclose
PURPOSE
To evaluate whether the pattern of nodule enhancement on delayed contrast-enhanced CT performed after
Stereotactic ablative Radiotherapy (SABR) for early-stage lung cancer can differentiate individuals with
recurrence from non-recurrence.
METHOD AND MATERIALS
A retrospective study was performed evaluating a total of 81 patients who underwent SABR for primary stage I
or II lung cancer with follow-up contrast chest CT at 1, 3, 6, 12, 18, and 24 months. The size of the ablation
zone was measure in addition CT density of the nodules were obtained pre-contrast and at 30 seconds and 1, 2,
3, and 4 minutes post contrast injection at each follow-up. Each ablation zone was measured five times using a
uniform region of interest pre-contrast and at each time point after contrast. The mean attenuation of these five
points was recorded. The CT bed position was used to ensure that the same area was interrogated with each
subsequent time point.
RESULTS
60 patients were included in this study. 49 patient without evidence of recurrence and 11 patients later proven
to have recurrent lung cancer in the ablation zone. In the recurrence group there was a peak of enhancement
seen with rapid washout. Specifically ,at 1 month the mean attenuation of the ablation zone in the recurrence
group was 10 HU pre-contrast with a peak in attenuation of 35 HU at 1 minute with an attenuation of 18 HU at
4 minutes. The non-recurrence group showed a mean attenuation of -13HU pre-contrast and a peak attenuation
of 47 HU at 4 minutes the mean peak attenuation. Similar findings were seen at each 3, 6 and 12 moth
follow-up CT scans. Using a paired-samples student t-test, there was no statically significant difference in the
change in attenuation .
CONCLUSION
The absolute change in attenuation is a poor discriminator of recurrence from non-recurrence. However, there
is a difference in the pattern of enhancement. The patients with evidence of recurrence showed an early peak in
enhancement and then a washout of contrast. While patients without recurrence showed continued increase in
attenuation over time. This is similar to the patterns seen in other malignancies comparing malignancy to
inflammatory masses.
CLINICAL RELEVANCE/APPLICATION
Enhancement pattern changes associated with treatment of lung cancer with SABR may assist in evaluating
potential early recurrence where a change in treatment can most affect prognosis.
SSC04
Gastrointestinal (Pancreas Cancer)
Scientific Papers
CT
GI
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credits: 1.50
Mon, Dec 1 10:30 AM - 12:00 PM
Location: E353A
Participants
Moderator
Desiree E. Morgan MD : Nothing to Disclose
Moderator
Koenraad J. Mortele MD : Nothing to Disclose
Sub-Events
SSC04-01
A Noise-optimized Mono-energetic Reconstruction Algorithm Enhances the Conspicuity of Pancreatic
Adenocarcinomas on Dual-Source Dual-Energy CT
Ralf W. Bauer MD (Presenter): Research Consultant, Siemens AG Speakers Bureau, Siemens AG , Freia
Fessler : Nothing to Disclose , Julian Lukas Wichmann MD : Nothing to Disclose , Thomas Henzler MD :
Nothing to Disclose , Josef Matthias Kerl MD : Research Consultant, Siemens AG Speakers Bureau, Siemens
AG , Claudia Frellesen : Nothing to Disclose , Thomas Lehnert MD : Nothing to Disclose , Moritz Kaup :
Nothing to Disclose , Jan-Erik Scholtz : Nothing to Disclose , Thomas Josef Vogl MD, PhD : Nothing to
Disclose
PURPOSE
To evaluate a novel mono-energetic reconstruction algorithm with improved noise reduction for dual-energy CT
of the pancreas.
METHOD AND MATERIALS
71 patients with suspected pancreatic carcinoma underwent second- or third-generation dual-source
dual-energy CT with arterial phase. Images were reconstructed as virtual 120 kV series (M_0.6) by linearly
blending the spectral information of the high and low kV dataset and with the available standard
mono-energetic application at a virtual mono-chromatic image impression at 40 keV and 55 keV. Additional
image series were reconstructed with the novel "mono-energetic plus" application promising improved noise
reduction (40+ and 55+). Image quality was compared between all series with respect to noise, signal of
healthy pancreatic tissue and tumor tissue, SNR and pancreas-to-lesion contrast (CNR).
RESULTS
32 carcinomas were detected. Compared to the standard M_0.6 series signal of healthy pancreas tissue was
significantly higher for all mono-energetic reconstructed images ( M_0.6: 92 HU; 40: 280 HU; 40+: 290 HU;
55: 166 HU; 55+: 167 HU). With the standard mono-energetic algorithm, noise gradually increased with lower
energies (55: 21 HU; 40: 37 HU), while the novel "mono-energetic plus" algorithm was able to keep the noise
at a constantly low level similar to and not significantly different from the M_0.6 series (8 HU for 55+ and 40+;
9 HU for M_0.6). Consequently, SNR of the pancreas was significantly superior in the 40+ and 55+ than in the
40 and 55 standard series (40.1 and 23.1 vs. 10.1 and 8.8) and outperformed the M_0.6 series (10.9).
Likewise, pancreas-to-lesion contrast was highest in the 40+ series (16.4) followed by the 55+ series (7.1) and
thus significantly higher than in any of the other series (M_0.6: 4; 40: 3.3; 50: 2.5).
CONCLUSION
A novel noise-optimized algorithm for reconstruction of mono-energetic images from second- and
third-generation dual-source dual-energy CT data can significantly improve image quality in the diagnosis of
pancreatic carcinoma.
CLINICAL RELEVANCE/APPLICATION
The challenging diagnosis of small pancreatic adenocarcinoma with faint tumor-to-lesion contrast may be
enhanced with this dedicated processing of dual-energy CT data, being vital for the patient.
SSC04-02
CT Evaluation of Extrapancreatic Perineural Invasion (EPI) in Carcinoma of Head and Uncinate
Process
Ritu Manoj Kakkar MBBS (Presenter): Nothing to Disclose , Sameer Surendra Soneji DMRD : Nothing to
Disclose , Shrinivas Balaji Desai MD : Nothing to Disclose
PURPOSE
To identify EPI in early pancreatic carcinoma locally confined to head and uncinate process and its clinical
relevance.
METHOD AND MATERIALS
32 patients (18:14=M:F) with early pancreatic carcinoma (T1 or T2) staged on CT were retrospectively reviewed
for EPI by 2 experienced radiologists. The two major pathways of pancreatic innervation are plexus pancreaticus
capitalis (PPC) 1 and 2. PPC 1 originates from the right celiac ganglion and courses posteriorly behind the portal
vein while PPC 2 originates from the superior mesenteric artery plexus and extends to the uncinate process
along the posteroinferior pancreaticoduodenal artery and the jejunal trunk. EPI was defined as confluent soft
tissue attenuation, similar to that of primary tumor, extending along these plexuses.3 phase contrast enhanced
CT was obtained on Discovery 750 GE VCT single source dual energy scanner with pancreas assessed in the
parenchymal phase (20-40 secs). 1.25 mm thin slices were used for reconstruction of volumetric slabs at 20
degree to the coronal plane to evaluate EPI.
RESULTS
13/32 (40%) lesions were in the uncinate process and 19/32 (59%) in the head of pancreas. The uncinate
process lesions were smaller (1.6-2.1cms) out of which 12/13 (92%) were T1 and 1/13 (8%) were T2. Head
lesions were comparatively larger (1.5-2.9 cms) with 6/19 (32%) T1 and 13/19 (68%) T2 lesions. 30/32 (94%)
patients had EPI. 17/19 (89%) head lesions showed EPI invasion with 8/17 (47%) involving only PPC 1 and
9/17 (53%) involving PPC 1 and 2. 2/19 (11%) head lesions did not show EPI and both were T1 lesions (1.5
and 1.7 cms). All 13 uncinate process lesions showed EPI and solely involved the PPC 2
CONCLUSION
All T2 and majority of T1 head and uncinate process tumors showed EPI. Head lesions involved either PPC 1 or
both depending upon size, while uncinate process masses solely involved PPC 2. Small FOV (12cms) 3D MDCT is
needed to visualize small peripancreatic vessels and ascertain EPI.
CLINICAL RELEVANCE/APPLICATION
EPI can be associated with higher positive surgical margins (R1 resection) hence poor prognosis and
recurrence. Effort should be made to identify EPI in CT staging of pancreatic cancer.
SSC04-03
Assessment of Treatment Response in Pancreatic Ductal Adenocarcinomas: Value of
Histogram-based Apparent Diffusion Coefficient analysis. Preliminary Results
Serena Pullini MD (Presenter): Nothing to Disclose , Shi-Li Chao DIPLPHYS, PhD : Nothing to Disclose ,
Julie Absil PhD, MS : Nothing to Disclose , Francesco Puleo : Nothing to Disclose , Celso Matos MD :
Nothing to Disclose , Maria-Antonetta Bali : Nothing to Disclose
PURPOSE
To measure the performance of Histogram-based Apparent Diffusion Coefficient (ADC) analysis in the evaluation
of treatment response in pancreatic ductal adenocarcinomas (PDC).
METHOD AND MATERIALS
12 patients with PDC underwent T2-weighted and Diffusion-weighted MR (DW-MR) imaging acquired with nine b
values (0,10,20,30,40,50,150,300,1000 s/mm^2), performed on 1.5T, before and after therapy (mean 6
weeks) with Gemcitabine alone (n=5) or combined Gemcitabine+nab-Paclitaxel (n=7). For each PDC, baseline
and after-treatment: 1) tumour longest diameter on T2-weighted images (RECIST criteria); 2) tumour volume
on DW-MR images and 3) Histograms ADC (H-ADC) parameters (mean, median, 10th, 25th, 75th, and 90th
centile) obtained from the entire tumour volume, were calculated. The therapeutic response was based on
clinical and biological evaluation. Mann-Whitney test and Wilcoxon test were applied for comparison.
RESULTS
8/12 patients (66,6%) were responders. In the responder group, tumour diameter decreased more than 30% in
only one patient (1/8), whereas DW-MR-based tumour volume reduction was greater than 30% in all responders
(p
CONCLUSION
DWI-based tumour volume provides a significant marker of PDC response to chemotherapy and H-ADC
parameters may be useful in evaluating and predicting tumour response.
CLINICAL RELEVANCE/APPLICATION
DWI-based tumour volume and Histogram-based ADC analysis may be useful in evaluating and predicting
chemotherapy response in advanced pancreatic ductal adenocarcinomas.
SSC04-04
Effects of Neoadjuvant Concurrent Chemoradiation Therapy in the Performance of MDCT in
Determining Resectability of Borderline Resectable Pancreas Cancer: Preliminary Results of a
Prospective Randomized Study
Ijin Joo MD (Presenter): Nothing to Disclose , Jeong Min Lee MD : Research Grant, Guerbet SA Equipment
support, Siemens AG Research Grant, Bayer AG , Dong Ho Lee MD : Nothing to Disclose , Eun Sun Lee MD,
PhD : Nothing to Disclose , Joon Koo Han MD : Nothing to Disclose , Byung Ihn Choi MD, PhD : Research
Consultant, Samsung Electronics Co Ltd
PURPOSE
To prospectively evaluate the effects of neoadjuvant concurrent chemoradiation therapy (CCRT) in the
preoperative assessment of resectability using MDCT in patients with borderline resectable pancreas cancer
METHOD AND MATERIALS
In this on-going prospective study, a total of 27 patients with borderline resectable pancreas cancer were
enrolled and divided into two randomized groups: 15 patients to upfront surgery (group 1) and 12 patients to
neoadjuvant CCRT followed by surgery (group 2). Contrast-enhanced MDCT images obtained immediately prior
to surgery were retrospectively reviewed by two independent radiologists to determine the resectability of
pancreas cancers. The diagnostic accuracies of MDCT in prediction of resectability between group 1 and group 2
were compared using the Fisher exact test.
RESULTS
Among 27 patients with borderline resectable pancreas cancers, 10 patients were confirmed as having
resectable disease (R0 resection) and 17 patients were confirmed as having unresectable disease (R1 or R2
resection in 15 patients; inoperable due to distant metastases were found before surgery in 2 patients). The
overall accuracies of the two reviewers in determining resectability of borderline resectable pancreas cancers
were higher in patients who underwent upfront surgery (86.7% and 86.7% in reviewer 1 and 2, respectively)
than in patients who had received neoadjuvant CCRT (66.7% and 66.7% in reviewer 1 and 2, respectively),
however, the differences were not statistically significant (P>0.05).
CONCLUSION
Our preliminary data from a prospective randomized study show that neoadjuvant CCRT may reduce the
accuracy of MDCT in prediction of resectability in patients with borderline resectable pancreas cancers.
CLINICAL RELEVANCE/APPLICATION
In borderline resectable pancreas cancers, neoadjuvant concurrent chemoradiation therapy may reduce the
diagnostic accuracy of MDCT in prediction of resectability.
SSC04-05
Interpreting Baseline and Follow-up 18Flurodeoxyglucose-PET Parameters in Patients with Locally
Advanced and Borderline Resectable Pancreatic Cancer
Shalini Moningi (Presenter): Nothing to Disclose , Avani Satish Dholakia BS : Nothing to Disclose , Jeffrey P.
Leal BA : Nothing to Disclose , Lauren Rosati : Nothing to Disclose , Elliot K. Fishman MD : Research
support, Siemens AG Advisory Board, Siemens AG Research support, General Electric Company Advisory Board,
General Electric Company Co-founder, HipGraphics, Inc , Siva P. Raman MD : Nothing to Disclose ,
Joseph Michael Herman MD, MSc : Nothing to Disclose
PURPOSE
Pancreatic cancer (PCA) is the 4th leading cause of cancer death and patients with unresectable disease have a
5-year overall survival (OS) of <5%. The role of positron emission tomography/computed tomography (PET/CT)
in PCA diagnosis, staging, and treatment response remains controversial due to limited data. We recently
reported that baseline PET parameters predicted for OS following gemcitabine and stereotactic body radiation
therapy (SBRT). Recent studies have also shown associations between maximum standardized uptake value and
OS and progression-free survival; however, the role of post-treatment PET/CT parameters in the prognosis of
PCA is unclear.
METHOD AND MATERIALS
Patients with locally advanced (LA) or borderline resectable (BR) PCA who received radiation therapy (RT) with
hypofractionated SBRT or intensity-modulated radiation therapy (IMRT) were retrospectively analyzed using
baseline and follow-up PET/CT scans. Total lesion glycolysis (TLG) and maximum and peak SUV based on lean
mass (SULmax and SULpeak) were calculated using in-house software. Changes in PET parameters were
assessed for prognostic potential using Cox regression analyses.
RESULTS
Median OS of the 47 patients (44 LA, 3 BR) was 18.8 months. Forty patients received SBRT (n=32, 6.6 Gy x 5
fractions; n=8, 5 Gy x 5) and 7 patients received IMRT (total dose range, 30-50.4 Gy; fraction size, 2.5
Gy).Thirty-eight patients (35 LA, 3 BR) were analyzed pre- and post-RT. Median time from end of RT to
follow-up scan was 3.67 months. Patients with a baseline SULmax of ≥3cm had inferior OS compared to
patients with a baseline SULmax < 3 g/ml (17.1 vs. 35.5 months; HR 5.6, 95% CI 1.3-24.4, p=0.02). Baseline
TLG of ≥20 cm3 resulted in inferior OS compared to a TLG <20 cm3 (18.8 vs. 35.5 months; HR 5.7, 95% CI
1.3-25.9, p=0.02). However, a decrease in TLG on post-RT PET/CT scans was associated with worse OS in
comparison with an increase in TLG (17.1 vs. 35.5 months; HR 0.3, 95% CI 0.1-0.8, p=0.02).
CONCLUSION
Our findings suggest that pre-RT PET/CT parameters may be predictive of OS in patients with LA and BR PCA.
Lower baseline PET metabolic activity before RT may be a prognostic indicator for improved OS, whereas higher
PET metabolic activity after RT may be due to local response from treatment as opposed to disease progression.
CLINICAL RELEVANCE/APPLICATION
Pre-RT PET/CT parameters might be useful in predicting overall survival in pancreatic cancer patients.
SSC04-06
MRI Using Magnetic Nanoparticles Measures Changes in Tumor Microvasculature Following
Modulation of the Tumor Microenvironment with Angiotensin Receptor Blockade
SSC04-06
Modulation of the Tumor Microenvironment with Angiotensin Receptor Blockade
Vidhya Kumar : Nothing to Disclose , Diego Santos Ferreira PhD : Nothing to Disclose , Yves Boucher PhD
: Nothing to Disclose , Rakesh K. Jain PhD : Board of Directors, XTuit Pharmaceuticals Stockholder, XTuit
Pharmaceuticals , Alexander Ramos Guimaraes MD, PhD (Presenter): Speakers Bureau, Siemens AG Expert
Witness, Rice, Dolan, Kershaw
PURPOSE
Pancreatic ductal adenocarcinoma (PDAC) responds poorly to chemotherapy partly due to a collagen rich
desmoplastic response that is a barrier to drug delivery. Angiotensin receptor blockade (ARB) with Losartan ®
has been shown to enhance the intratumoral penetration and efficacy of therapeutics in mice using in vitro
techniques. Because of its steady state approach, we hypothesize that MRI using clinically available magnetic
nanoparticles (MNP)(ferumoxytol - Feraheme ®, AMAG Pharmaceuticals, Inc.), will be sensitive to changes in
tumor microvasculature that result from ARB in PDAC. The purpose of this study was to test this hypothesis in
an orthotopic mouse model of PDAC
METHOD AND MATERIALS
All experiments were approved by the local ethical review panel. Orthotopic tumors were generated by
implanting 1mm3 chunks of AK4.4 spontaneously generated tumors (from a Ptfl-Cre/LSL-KrasG12D/p53Lox
mouse model) into the pancreas of 6-8 week old FVB mice. Tumors were allowed to grow for 1 week prior to
treatment. Animals were treated daily with an ip injection of 70mg/kg Losartan for 5 days. MRI was performed
using a home built bird-cage coil at 4.7T and included multiecho gradient echo (TE 3.5, 8.5, 13.5, 18.5 msec;
TR 750msec) and multiecho spin echo (TE 10, 20, 30, 40, 50, 60msec; TR 2000msec) pulse sequences and
were performed prior to and following iv administration of 3 mg/kg iron ferumoxytol. Data analysis was
performed by (ROI) analysis of 3 central slices within each tumor calculating ΔR2 and ΔR2*. fBV (~ΔR2*) was
normalized to an assumed fBV in muscle of 3%. Vessel size index (VSI) (~ΔR2*/ ΔR2) was also calculated
comparing control and Losartan treated animals. Statistical analyses compared both cohorts using a two-tailed
unpaired t-test.
RESULTS
Losartan treated animals (n=7) demonstrated a statistically significant difference in fBV (mean ± sem) (9.5 ±
1.3) as compared to the control population (n=5) (3.1± 2.2) (p
CONCLUSION
MRI using clinically available MNP provided a non-invasive assessment of tumor blood vessel changes following
ARB in a PDAC model. The approximate 2.5 fold increase in mean VSI and fBV is in concert with recently
published in vitro results.
CLINICAL RELEVANCE/APPLICATION
MRI using MNP may provide a readily translatable, quantitative assay of PDAC tumor microvasculature.
SSC04-07
Functional Imaging of Interstitial Brachytherapy in Pancreatic Carcinoma Xenografts Using Spectral
CT: How Does Iodine Concentration Correlate with Standardized Uptake Value of 18FDG-PET-CT?
Shudong
Hu MD, PhD (Presenter): Nothing to Disclose
PURPOSE
To investigate the correlation between iodine concentration (IC) for quantitative of spectral CT and maximum
standardized uptake value (SUVmax) of 18F-FDG-PET-CT to evaluate the therapeutic effect of interstitial
brachytherapy on transplantation tumor of human pancreatic carcinoma in Balb/c-nu mice.
METHOD AND MATERIALS
Xenograft models were created by subcutaneous injection of Swl990 human pancreatic cancer cell suspensions
into the immunodeficient Balb/c-nu mice. Twenty mice bearing Swl990 human pancreatic cancer cell xenografts
were randomly separated into two groups: experimental (n = 10; 1.0 mCi) and control (n = 10; 0 mCi). After 2
weeks treatment, spectral CT and 18F-FDG microPET-CT scan were performed. The iodine concentration (IC) in
the lesions were measured and normalized to the muscle tissue as nIC. The relationships between the nIC and
SUVmax of the transplantation tumors were analyzed.
RESULTS
The nIC of the lesion was significantly lower than that in two groups during the multiphase scan. Our results
showed that before treatment the SUVmax values among two groups had no significant statistical difference.
Two weeks after treatment the SUVmax and 125I seed implant group were significantly lower than before,
while for the empty seed group there were no significant difference compared with before treatment. The nIC
values of the three-phase scans have certain positive correlation with the SUVmax values (r = 0.64, p < 0.05; r
= 0.51, p < 0.05; r = 0.71, p < 0.05 in the 10,25 and 60 s phase respectively).
CONCLUSION
Spectral CT could serve as a valuable functional imaging modality as the nIC correlates with SUVmax of 18FDG
PET-CT for evaluating the therapeutic effect of 125I interstitial brachytherapy in a pancreatic carcinoma
xenograft.
CLINICAL RELEVANCE/APPLICATION
Spectral CT offers opportunities to assess the therapeutic response of pancreatic cancer.
SSC04-08
Comparison of CT Appearance of Tubular and Colloid Pancreatic Adenocarcinoma Arising from
Intraductal Papillary Mucinous Neoplasm
Joanna G. Becker MD (Presenter): Nothing to Disclose , Richard Kinh Gian Do MD, PhD : Nothing to
Disclose , Matthew Porembka : Nothing to Disclose , Scott Gerst MD : Nothing to Disclose , Peter J. Allen
MD : Nothing to Disclose
PURPOSE
To compare the CT appearance of tubular (t) and colloid (c) type pancreatic ductal adenocarcinomas (PDAC)
arising from intraductal papillary mucinous neoplasms (IPMN).
METHOD AND MATERIALS
An IRB approved retrospective study included patients who underwent resection of IPMN with either invasive
tPDAC or cPDAC. Consecutive patients from 1996 to 2013 were included if they had preoperative CT imaging
within 90 days of surgery. Two radiologists reviewed in consensus for the presence and size of solid enhancing
component (SC), main pancreatic duct (MPD) size, presence of MPD cutoff, and largest cyst diameter (D). SC
size on imaging was correlated with invasive tumor size as measured by pathology. Unpaired t-test, Fisher
exact test, and Spearman correlation were used for statistical analyses.
RESULTS
48 pts (25:23 M:F, median age 72) were included, with CT performed a median of 19 (range 1-79) days before
surgery. 27 pts had cPDAC (15:12 M:F, median age 73) and 21 pts had tPDAC (10:11 M:F, median age 71). No
statistically significant difference was found between tPDAC and cPDAC for D (median 33 vs 23 mm, p = 0.25)
or MPD size (median 10 vs 6 mm, p = 0.46). A SC was visible in 14 of 27 cPDAC and 16 of 21 tPDAC (p =
0.13). MPD cutoff was seen in 4 of 27 cPDAC and 8 of 21 tPDAC (p = 0.21). For the pathologic specimen, the
median size of the invasive tumor for cPDAC was 24 mm and for tPDAC was 19 mm (p=0.36). The correlation
between SC size measured on CT and pathologic tumor size was R2=0.50 (p<0.0001) for cPDAC, and R2=0.08
for tPDAC (p=0.20).
CONCLUSION
No significant difference was seen between the CT appearances of IPMN with either colloid or tubular PDAC.
However, in contrast to tPDAC, the size of solid enhancing component for cPDAC measured on CT was
associated with invasive tumor size on pathology. The abundant extracellular mucin present in cPDAC may
explain the correlation between SC size measured on CT and pathology.
CLINICAL RELEVANCE/APPLICATION
Given the differences in prognosis between IPMN with either colloid and tubular pancreatic ductal
adenocarcinomas, improved understanding of their CT appearance may prove useful.
SSC04-09
Pancreatic Cysts and Pancreatic Ductal Adenocarcinoma: What Are the Odds?
Viktoriya Paroder MD (Presenter): Nothing to Disclose , Milana Flusberg MD : Nothing to Disclose , Alla M.
Rozenblit MD : Nothing to Disclose , Victoria Chernyak MD : Nothing to Disclose
PURPOSE
To assess relationship between pancreatic cysts and pancreatic ductal adenocarcinoma (PDAC), and to compare
imaging features of pancreatic cysts in subjects who subsequently develop PDAC and in those who do not.
METHOD AND MATERIALS
This case-control study was IRB-approved and HIPAA-compliant. Case group included adult subjects with a
diagnosis of PDAC and control group included adult subjects with a diagnosis of lung cancer. Cancer diagnosis
date was between 1/1/05-1/1/14 as recorded in Cancer Registry, and only subjects with at least one abdominal
CT/MR >6 months before the cancer diagnosis date were included. The most recent abdominal CT/MR of each
subject done >6 months prior to cancer diagnosis date was reviewed by a radiologist blinded to case/control
status. The presence of pancreatic cyst(s), number, size of the largest cyst, and presence of main pancreatic
duct (MPD) dilatation (defined as MPD ≥4mm) were recorded. A pancreatic cyst was considered simple when it
lacked calcifications, septations and enhancement. Frequencies of pancreatic cysts, mean cyst sizes, frequencies
of solitary cysts, simple cysts and MPD dilatation were compared between the groups. Logistic regression model
with binary outcome of PDAC was constructed.
RESULTS
There were 162 subjects, 85 (52.5%) cases and 77 (47.5%) controls. Women comprised 62.4% (53 of 85) of
cases and 58.4% (45 of 77) of controls (p=0.61). Mean ages were 69.2 years (±10.7) and 69.6 years (±12.9)
in cases and controls, respectively (p=0.81). Pancreatic cysts were present in 23 (27.1%) of 85 cases and in 4
(5.2%) of 77 controls (p<0.001). The odds ratio of pancreatic cysts for development of PDAC was 7.0, adjusting
for age and sex (p=0.001). Mean cyst size was 13.6 mm (±8.4) in cases and 6.5 mm (±3.3) in controls
(p=0.01). Pancreatic cysts were solitary in 9 (40.9%) of 23 cases and 4 (100%) of 4 controls (p=0.04), and
simple in 16 (69.6%) of 23 cases and 3 (75%) of 4 controls (p>0.99). MPD dilatation was present in 7 (30.4%)
of 23 cases and 1 (25%) of 4 controls (p>0.99).
CONCLUSION
Pancreatic cysts are associated with 7.0 times higher odds of developing pancreatic ductal adenocarcinoma.
Pancreatic cysts in subjects who develop pancreatic ductal adenocarcinoma tend to be larger and more
commonly are multiple.
CLINICAL RELEVANCE/APPLICATION
Patients with pancreatic cysts are at higher risk of developing pancreatic ductal adenocarcinoma, particularly if
the cysts are larger and multiple.
SSC05
Gastrointestinal (Oncology: Surveillance and Response)
Scientific Papers
OI
BQ GI
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credits: 1.50
Mon, Dec 1 10:30 AM - 12:00 PM
Location: E451A
Participants
Moderator
Nirvikar Dahiya MD : Nothing to Disclose
Moderator
Bonnie N. Joe MD, PhD : Nothing to Disclose
Sub-Events
SSC05-01
Early Therapeutic Response Evaluation after FOLFOX and FOLFIRI Treatment in Patients with Liver
Metastasis from Colorectal Cancer Using IVIM DWI and DCE-MRI
Jung Hoon Kim MD (Presenter): Nothing to Disclose , Ijin Joo MD : Nothing to Disclose , Jeong Min Lee
MD : Research Grant, Guerbet SA Equipment support, Siemens AG Research Grant, Bayer AG , Joon Koo Han
MD : Nothing to Disclose , Byung Ihn Choi MD, PhD : Research Consultant, Samsung Electronics Co Ltd
PURPOSE
The purpose of this study is early therapeutic response evaluation after cytotoxic chemotherapy using FOLFOX
and FOLFIRI in patients with liver metastasis from colorectal cancer using IVIM DWI and DCE-MRI.
METHOD AND MATERIALS
This prospective study was approved by IRB and informed consent was obtained from the study patients.
Nineteen patients with liver metastasis from colorectal cancer underwent DEC-MRI and IVIM DWI (b value=0,
25, 50, 75, 100, 200, 500, and 800 sec/mm2) using a 3-T MR scanner baseline and after 1st cycle of cytotoxic
chemotherapy using FOLFOX and FOLFIRI. Following IVIM DWI parameters including ADC, true diffusion
coefficient (D), pseudo-diffusion coefficient (D*), and perfusion fraction (f) and DCE-MR perfusion parameters
including Ktrans, Kep, Ve, and iAUC were calculated. Response evaluation based on RECIST criteria. For
statistical analysis, Spearman's rank correlation and Wilcoxon signed-rank was applied.
RESULTS
There were eight response and eleven non-response patients. In the comparison of IVIM DWI parameters, ADC
(1.19±0.23 vs 1.26±0.26, 10-3/mm2/s, p=.012), D (1.08±0.23 vs. 1.17±0.24, 10-3/mm2/s, p=.012), f
(17.3±0.03 vs. 13.3±0.02,%, p=.017) showed significant change between baseline and after 1st cycle
chemotherapy in the response group. However, in the comparison of DCE-MR perfusion parameters including
Ktrans, Kep, Ve, and iAUC, there were no statistically significant change in each DCE-MR perfusion parameters.
The significant correlation was found between each of the perfusion-related IVIM parameters (D* and f) with
DCE-MR parameters (Ktrans and iAUC) before chemotherapy (r=0.506 to 0.614, p<0.05), however there were
no significant correlation after chemotherapy.
CONCLUSION
IVIM DWI is useful for early prediction of therapeutic response evaluation after cytotoxic chemotherapy in
patients with liver metastasis from colorectal cancer.
CLINICAL RELEVANCE/APPLICATION
IVIM DWI of the liver metastasis from colorectal cancer can be used as early prediction of therapeutic response
evaluation after cytotoxic chemotherapy
SSC05-02
Tumor Margin Intensity Slope to Quantify Morphological Changes in Colorectal Liver Metastasis after
Anti-angiogenic Therapy
Vahid Yaghmai MD (Presenter): Nothing to Disclose , Keyur Parekh MD : Grant, Siemens AG , Adeel Rahim
Seyal MD : Grant, Siemens AG , Thomas Patrick O'Donnell : Researcher, Siemens AG
PURPOSE
Bevacizumab, an antiangiogenic agent, can lead to morphological changes in colorectal liver metastasis. Tumor
margin intensity slope (TMIS) was used to objectively quantify morphological changes in liver metastasis after
treatment.
METHOD AND MATERIALS
The HIPAA compliant retrospective study was approved by IRB. Seventy-two colorectal liver metastases in 29
patients treated with bevacizumab with at least one pre- and one post-treatment MDCT scan were evaluated.
Metastasis response was classified as optimal, incomplete or no response according to changes in tumor
density, enhancement and margins (morphologic criteria). Tumor margin intensity slope, the first derivative of
the plot of median intensities of concentric layers of voxels from outside the tumor towards its core, was
calculated to compare different response categories. A greater negative value of TMIS corresponds to sharper
tumor margins. Treatment response groups were compared using one-way analysis of variance (ANOVA).
Student-Newman-Keuls test was applied for multiple comparisons.
RESULTS
Based on the morphological changes, 23/72 metastasis showed optimal response with remainder showing
either incomplete (29/72) or no response (20/72). Mean TMIS values were -11.65 ± 3.5 HU/layer, -8.74 ± 5.2
HU/layer, and -7.58 ± 4.8 HU/layer (P=0.013) for lesions with optimal, incomplete and no response,
respectively. On multiple comparisons, TMIS was significantly different for optimal response when compared
with incomplete and no response. TMIS values between the latter two groups were comparable (P>0.05).
CONCLUSION
Tumor margin intensity slope provides objective quantification of morphological changes in colorectal liver
metastasis and identifies lesions with optimal response to bevacizumab treatment.
CLINICAL RELEVANCE/APPLICATION
Tumor margin intensity slope is a promising imaging biomarker of response in colorectal liver metastases
treated with antiangiogenics.
SSC05-03
Volumetric Assessment of Metastatic Colorectal Cancer: Reproducibility by Reader, Site, and Time
Point
Meghan G. Lubner MD (Presenter): Nothing to Disclose , Nicholas Stabo : Nothing to Disclose , Sam
Lubner : Nothing to Disclose , Alejandro Munoz Del Rio PhD : Research Consultant, Cellectar Biosciences,
Inc Reviewer, Wolters Kluwer nv , Chihwa Song PhD : Nothing to Disclose , Perry J. Pickhardt MD :
Co-founder, VirtuoCTC, LLC Stockholder, Cellectar Biosciences, Inc
PURPOSE
To compare reproducibility of unidimensional and volumetric measures of metastatic colorectal cancer by
reader, site of disease and time point in disease assessment
METHOD AND MATERIALS
Analysis of CT images in 107 patients (mean age 58.7, range 25-81; 47 F, 60 M) undergoing systemic
treatment for metastatic colorectal cancer was performed. Unidimensional (1D) and volumetric (3D) measures
were retrospectively obtained on index lesions at three time points (mean interval 4.1 mos, median 3.7 mos)
by three readers (abdominal imager, imaging core-lab manager, medical student) using a semi-automated
technique. Measurements were summed and compared using best overall response and response at first
post-treatment time point. Patient response was categorized based on RECIST 1.1 (CR, complete response; PR,
partial response; SD, stable disease; PD, progressive disease). Intra and interobserver variability of 1D and 3D
measures was assessed. Reproducibility of measurement by metastatic lesion site was evaluated. Kaplan-Meier
models for each with categorical tumor response were constructed and compared. These models were created
both for "best overall response" and for response at the first post treatment time point.
RESULTS
Volumetric measures showed similar intra and interobserver variability to unidimensional measures. Metastatic
site (lung, liver, node, other) did not significantly impact measurement reproducibility. Kaplan-Meier curves for
unidimensional vs volumetric assessment were very similar in appearance. Both 1D and 3D measurements
separated PD from the SD/PR group, but neither separated SD and PR well. Similar KM curves were seen using
overall best response (across all time points) compared to response at the first post treatment time point.
CONCLUSION
Volumetric assessment of metastatic CRC is fairly reproducible, but does not show improved ability to predict
survival over 1D measures and may not represent an improvement over less complex standard linear measures
for this indication. Categorization of these variables either using best overall response or at the first post
treatment time point also show similar survival models.
CLINICAL RELEVANCE/APPLICATION
3D measures are reproducible, but do not improve correlation with survival over 1D measures. Assessment of
disease at the first time point correlates well with overall best response in metastatic CRC, which may enable
transition of therapy earlier.
SSC05-04
Early Prediction of Response of Gastrointestinal Stromal Tumor to Sunitinib Therapy Using
Non-Gaussian Diffusion MRI
Yi
Sui MS (Presenter): Nothing to Disclose , Lei
Tang MD : Nothing to Disclose , Frederick C. Damen PhD
Yi Sui MS (Presenter): Nothing to Disclose , Lei Tang MD : Nothing to Disclose , Frederick C. Damen PhD
: Nothing to Disclose , Shun-Yu Gao MD : Nothing to Disclose , Kejia Cai PhD : Nothing to Disclose ,
Ying-Shi Sun MD, PhD : Nothing to Disclose , Xiaohong Joe Zhou PhD : Nothing to Disclose
PURPOSE
To evaluate the performance of a non-Gaussian diffusion model in early prediction of treatment response in
recurrent gastrointestinal stromal tumor (GIST) under sunitinib therapy.
METHOD AND MATERIALS
With IRB approval, 10 patients (4 men, 6 women) with confirmed failure of previous imatinib therapy,
underwent sunitinib (50 mg/day, PO) single-drug targeted treatment. MRI scans were conducted on a 3T
scanner before treatment, one week, three weeks and one month after treatment to monitor the tumor
response. Diffusion MR images were acquired using 11 b-values up to 3000 sec/mm2. A set of diffusion
parameters (apparent diffusion coefficient ADC, intravoxel heterogeneity index β, and mean free diffusion
length µ) were fitted pixel by pixel using a fractional order calculus (FROC) model. The percentage change
(%Δ) of ADC, β and µ after one week treatment were averaged over the whole tumor regions. The MRI
parameters obtained after the first week of treatment were used to predict later treatment outcomes. All 36
tumors in 10 patients were divided into good response (n = 22) and poor response (n = 14) groups based on
the Choi and EORTC-ISG-AGITG criteria. The parametric values were compared for each individual parameter
using Mann-Whitney U test with a statistical significance set at p < 0.05. ROC analysis was performed to
evaluate the performance of individual FROC parameters as well as the combination of all parameters (binary
logistic regression) in predicting the therapeutic responses.
RESULTS
Significant differences between good and poor response groups were found in the %Δ ADC (28% vs 8%, p =
0.032), %Δ β (20% vs -6%, p = 0.013), and %Δ µ (8% vs 2%, p = 0.004). The AUCs of %Δ µ (0.782) and %Δ
β (0.747) were larger than %Δ ADC (0.714). When combining all parameters of the FROC model, the AUC was
further increased to 0.893, suggesting that the FROC model improved the performance of prediction. The
accuracy of prediction was increased to 83.3% using the FROC model, compared to using ADC alone (61.1%).
CONCLUSION
Our results demonstrate that the FROC diffusion model with high b-values can provide valuable information for
early response prediction of sunitinib targeted therapy of GIST.
CLINICAL RELEVANCE/APPLICATION
The FROC diffusion model may provide useful parameters for the prediction of GIST response to sunitinib
therapy at early period.
SSC05-05
Comparison of MRI Parameters in the Early Response Prediction of Gastrointestinal Stromal Tumor
to Targeted Therapy: A Patient-based Study
Lei Tang MD (Presenter): Nothing to Disclose , Ying-Shi Sun MD, PhD : Nothing to Disclose , Zi-Yu Li :
Nothing to Disclose , Xiao-Peng Zhang MD : Nothing to Disclose , Jia-Fu Ji : Nothing to Disclose , Xiaoting
Li : Nothing to Disclose , Lin Shen : Nothing to Disclose
PURPOSE
To investigate the performance of quantitative parameters provided by MRI in the early prediction of the
response of gastrointestinal stromal tumor (GIST) to targeted therapy.
METHOD AND MATERIALS
The institutional review board approved this prospective MRI study. All of the patients signed the written
informed consent. MRI examinations were performed in 62 patients with GIST on 1.5T scanner before and at 2
and 12 weeks after treatment with targeted agents (Imatinib mesylate, 44 cases; Sunitinib malate, 18 cases).
The longest diameter (LD) and contrast-to-noise ratio (CNR) of the tumors were measured on T2-weighted
images (T2WI), and the apparent diffusion coefficient (ADC) was measured on diffusion-weighted images
(DWI). A maximum of two lesions per organ/site and five lesions per patient were enrolled according to the
regulation of RECIST 1.1. The early percentage changes (%Δ) of the above three parameters were compared
for their performance in the differentiation of the good response (GoodR) and poor response (PoorR) groups
using ROC curves.
RESULTS
Total of 141 GIST lesions in 62 patients enrolled in the study. There were 42 patients in GoodR group and 20 in
PoorR group. After two weeks of therapy, the percentage changes of the ADC and LD were significantly different
between the two groups (ADC: GoodR 30% vs. PoorR 1%, Z = -4.819, P < 0.001; LD: GoodR -7% vs. PoorR
-2%, Z = -3.238, P =0.001), but not of the T2WI-CNR (GoodR -3% vs. PoorR -9%, Z = -0.663, P = 0.508).
Through ROC curves, the AUC for the percentage changes of LD, T2WI-CNR and ADC after two weeks of
therapy were 0.756, 0.552 and 0.881, respectively, in the early prediction of the responses. Taking %ΔADC >=
15% to predict GoodR, the PPV was 87.5% (28/32). Taking %ΔADC
CONCLUSION
The percentage change of the ADC after two weeks of therapy outperforms T2WI-CNR and longest diameter in
the early response prediction of GIST to targeted therapy.
CLINICAL RELEVANCE/APPLICATION
This patient-based study proved ADC has good performance in the early prediction of response of GIST to
This patient-based study proved ADC has good performance in the early prediction of response of GIST to
targeted therapy, which may provide surrogate biomarker for the personalized treatment of GIST.
SSC05-06
Whole-body Diffusion-weighted Imaging at 1.5T Compared with FDG-PET-CT for the Detection of
Recurrence and Metastases in Patients with Gastrointestinal Tumors
Zhiyang Zhou PhD : Nothing to Disclose , Jiaying Gong (Presenter): Nothing to Disclose , Wuteng CAO :
Nothing to Disclose , Zhong-Ping Zhang MMedSc : Nothing to Disclose , Yanbang Lian : Nothing to Disclose
PURPOSE
To compare the diagnostic accuracy of using whole-body diffusion-weighted imaging (WB-DWI) at 1.5T and
FDG-PET-CTin the dectection of recurrence and metastases in gastrointestinal cancer patients and to assess the
modification of ADC value between metastases and normal tissues.
METHOD AND MATERIALS
Twenty-eight consecutive patients diagnosedwith gastrointestinal cancer and suspected tumor recurrenceand
18 healthy controls were recruited and underwent both WB-DWI at 1.5T and PET-CT examinations for the
staging of lymph node and distant metastases. PET-CT and histology and/or a clinical follow-up of 3-6 months
served as a standard reference. Agreement between WB-DWI and FDG-PET-CT on detecting recurrence and
distant metastases was compared using kappa statistics.Diagnostic accuracy, sensitivity, specificity, negative
predictive value, and positive predictive value were calculated for each subject. Additionally,the difference of
ADC values between normal tissues in controls and metastases were compared.
RESULTS
Tumor recurrence was observed in 5 of 28 patients. Lymph node involvement was determined in 20/28 cases as
N-positive in PET-CT and in 18/28 in WB-DWI. M-stage was evaluated for liver metastases, lung, adrenal
glandand, peritoneal, and bone. One brain metastasiswas observedin 1 patient usingWB-DWI. No statistically
significant difference (t=1.332, P=0.194) of overall diagnostic performances between PET-CT and WB-DWI was
observed.WB-DWI demonstratedsatisfying agreement with PET-CT (κ=0.877) in the detection of recurrence and
distant metastases. Applying WB-DWI imaging with b=600s/mm2, statistically significant differences of the ADC
value were observed between metastatic lymph nodes and normal nodes, metastasis of liver and normal liver,
and metastasis of bones and normal bones, respectively(P<0.05).
CONCLUSION
WB-DWI provides non-radiating imaging for staging of gastrointestinal tumors and offers consistent diagnostic
performances withPET-CT. In addition, the ADC value can be applied in the determination of tumor metastasis.
CLINICAL RELEVANCE/APPLICATION
WB-DWI can be applied to stage gastrointestinaltumors and ADC is reliable in the identification of tumor
metastasis.
SSC05-07
Pattern of HCC Recurrence after Liver Transplantation: Time to Modify the Current Follow-up
Imaging Modalities?
Maxime Ronot MD (Presenter): Nothing to Disclose , Marco Dioguardi Burgio MD : Nothing to Disclose ,
David Fuks : Nothing to Disclose , Federica Dondero : Nothing to Disclose , Francois Cauchy : Nothing to
Disclose , Valerie Paradis MD : Nothing to Disclose , Francois Durand : Nothing to Disclose , Jacques
Belghiti MD : Nothing to Disclose , Valerie Vilgrain MD : Nothing to Disclose
PURPOSE
To analyze the imaging characteristics of hepatocellular carcinoma (HCC) recurrence following liver
transplantation (LT) in order to optimize follow-up imaging in diagnosing recurrence.
METHOD AND MATERIALS
Between 2000 and 2011, all HCC patients who underwent LT were searched and only patients who had tumor
recurrence were included. Pre-LT characteristics, and long-term outcome were retrospectively analyzed.
Characteristics of recurrent HCC were analyzed at diagnosis on post-LT examinations as follows: 1/ site of
recurrence defined as hepatic, extra-hepatic, or both, 2/ size of the largest lesions (mm on axial sections), and
3/ the time to recurrence, defined as the time between LT and diagnosis of recurrence. The imaging modality of
recurrence detection (ultrasound (US), CT or MRI) was noted.
RESULTS
Among 336 cirrhotic patients undergoing LT, 25 (7.4%) had HCC recurrence. All patients were males (median
age 54 (41-64) years). Before LT, 13 (52%) patients had lesions outside the Milan criteria. Median time to HCC
recurrence was 13.8 (1-75) months following LT and 8 (32%) patients experienced recurrence beyond 24
months after LT. Recurrences were detected using routine US follow-up in only 7 (28%) patients, and CT or MRI
imaging in 18 (72%) of the patients including 5 (20%) who had marked increase of serum alpha-fetoprotein.
The most frequently involved organs were the lungs in 13 (52%) patients, and the bones in 9 (36%) patients.
Recurrent HCC involved more than one organ in 11 (44%) patients. Recurrences were limited to the liver in one
(4%) patient, were exclusively extrahepatic in 18 (72%) patients and were both intrahepatic and extrahepatic
in six (24%) patients. 1, 3- and 5-y OS of patients with HCC recurrence after LT were 84%, 39%, and 28%,
respectively.
CONCLUSION
Routine US examination alone fails to detect most HCC recurrences. Because HCC recurrence is mainly
extra-hepatic, may be delayed, and is rarely seen using US examination, we suggest performing regular
whole-body imaging (CT or MRI) during follow-up visits 2 years or more after LT
CLINICAL RELEVANCE/APPLICATION
Imaging follow-up of patients undergoing LT for HCC should include regular whole-body imaging during
follow-up visits 2 years or more after LT.
SSC05-08
Ultrasound Shearwave Elastography (SWE) Predicts Response in the Treatment of Patients with
Liver Malignancies
Wey Chyi Teoh MBBS, FRCR (Presenter): Nothing to Disclose , Mark Joshua Abel MBBS : Nothing to
Disclose , Christina Kalli MENG : Nothing to Disclose , Behzad Mokri-Moayyed : Nothing to Disclose ,
Matthew F. Bruce PhD : Employee, SuperSonic Imagine , Harpreet Wasan MD, PhD : Nothing to Disclose ,
Edward Leen MD, FRCR : Equipment support, Koninklijke Philips NV Equipment support, General Electric
Company Equipment support, SuperSonic Imagine Research Consultant, General Electric Company Speakers
Bureau, Bracco Group Speakers Bureau, Koninklijke Philips NV Speakers Bureau, AngioDynamics, Inc Speakers
Bureau, General Electric Company
PURPOSE
To evaluate SWE in monitoring treatment response of patients with hepatic tumours.
METHOD AND MATERIALS
Forty-five patients undergoing non-surgical treatment for focal hepatic malignancies were studied using an
ultrasound scanner with a curvilinear SC6-1 transducer (Aixplorer, Supersonic Imagine, France) after 4 hours of
fasting. The scans were performed at baseline, 2 weeks and 8 weeks post therapy under respiratory
suspension. Three SWE scan planes of tumour and liver were acquired, analysed and averaged following
placement of fixed regions of interest (10mm3) over the peripheral and central portion of the index tumours and
adjacent hepatic parenchyma. Based on RECIST criteria, patients were classified as progressors (Pr) or
non-progressors (NPr) at 8 weeks post therapy. SWE readings from baseline, 2 and 8 weeks (Wilcoxon test)
and between Pr and NPr (Mann-Whitney test) were compared. Area under receiver operating characteristics
(AUROC) and Kaplan-Meier survival curves were plotted. The mean follow up was 233 days.
RESULTS
At baseline, liver SWE was significantly higher for Pr compared with NPr (13.4 ± 3.8kPa vs. 9.7 ±3.9kPa,
p=0.01); a cut off value of ≤8.35kPa predicted non-progression following treatment [AUROC:0.77 (p=0.01),
specificity:90.1%, sensitivity:58.3%, positive predictive value:93.3% and likelihood ratio of 6.4]. Compared
with baseline, 2-week tumour SWE was significantly increased for both Pr (41.8 ± 10.6kPa vs. 50.7 ± 18.3,
p=0.047) and NPr (51.2 ± 20.2kPa vs. 60.7 ± 22.0kPa, p=0.001). Compared with baseline, 8-week tumour
SWE was significantly increased for both Pr (41.8 ± 10.6kPa vs. 61.9 ± 18.3kPa, p=0.02) and NPr (51.2 ±
20.2kPa vs. 74.3 ± 26.1kPa, p=0.002). At baseline, patients with liver SWE of ≥15kPa have a significantly
shorter progression free survival (PFS) (Median 89 days vs 294 days, p=0.01). Compared with baseline,
patients with an increase at 8-week liver SWE (of ≥40%) have a significantly shorter PFS (Median 85 days vs.
294 days, p=0.049).
CONCLUSION
Liver SWE at baseline predicts non-progressors following therapy. Patients with a baseline liver SWE of ≥15kPa
or an increase of ≥40% at 8 weeks from baseline have shorter PFS. Tumour SWE is non prognostic.
CLINICAL RELEVANCE/APPLICATION
SWE is useful in predicting non-progressors and progression free survival following non-surgical therapy for
hepatic malignancy.
SSC05-09
Effect of Treatment on Different CT Densities in Retroperitoneal Dedifferentiated Liposarcoma
Treated with Chemotherapy or Radiotherapy prior to Surgical Resection
Sreeharsha Tirumani MBBS, MD (Presenter): Nothing to Disclose , Harika Tirumani MBBS : Nothing to
Disclose , Jyothi Priya Jagannathan MD : Nothing to Disclose , Atul Bhanudas Shinagare MD : Nothing to
Disclose , Nikhil H. Ramaiya MD : Nothing to Disclose
PURPOSE
Retroperitoneal Dedifferentiated liposarcoma (DDLPS) is a heterogeneous tumor on imaging with different
densities on CT, and biologically varied with different growth rates. In this study, we retrospectively correlated
effect of treatment on different densities in DDLPS.
METHOD AND MATERIALS
In this institutional review board-approved, retrospective study, out of 111 patients with primary or recurrent
retroperitoneal/intra-abdominal DDLPS seen between January 1999 and December 2013, 25 patients (18 men,
7 women; mean age at diagnosis= 58 years, range, 35-72years) who received chemotherapy, radiotherapy or
both before surgical resection were included. Imaging immediately prior to surgical resection (pre-surgery) and
at baseline was reviewed by two radiologists to note the density of the nonlipomatous elements and the rate of
growth during that period. Clinical and histopathological data was extracted from the electronic medical records.
RESULTS
There were 37 nonlipomatous lesions with three distinct densities: soft tissue density (SD) (>20HU), fluid
density (FD) (0-20HU), and mixed density (MD) (combination of fluid and soft tissue). The distribution of the
densities on the baseline scan and pre-surgery scans were SD=23; MD=9; FD=5 and SD=23; MD=11; FD=3
respectively. There was decrease in size of three lesions (>30%) while the rest 34 lesions were either
unchanged in size or increased in size (26/34 lesions showed an increase in size by >20%). The respective
median growth rate per month was 39% (SD), 63% (MD), and 35% (FD). There was a change in density in
2/23 SD lesions (to MD) and 2/5 FD lesions (to SD). Tumors were intermediate (10SD, 6MD, 4FD) or high
(13SD, 3MD, 1FD) grade.
CONCLUSION
The nonlipomatous component of retroperitoneal DDLPS has three distinct densities on imaging which tend to
grow at different rates despite treatment and can change their density in response to treatment. The densities
do not correlate with the histological grade.
CLINICAL RELEVANCE/APPLICATION
Knowledge of the occurrence of different densities in the nonlipomatous component of retroperitoneal DDLPS
can help radiologists to exert caution while interpreting images. Targeted biopsies in the future can help in
understanding the histopathologic relevance of the different densities.
SSC06
ISP: Health Service, Policy & Research (Quality)
Scientific Papers
SQ
HP
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credits: 1.50
Mon, Dec 1 10:30 AM - 12:00 PM
Location: S102D
Participants
Moderator
Christopher Paul Hess MD, PhD : Research Grant, General Electric Research Consultant, Imaging Endpoints Research
Consultant, Cerebrotech Medical Systems
Moderator
Pari Pandharipande MD, MPH : Nothing to Disclose
Sub-Events
SSC06-01
Health Service, Policy & Research Keynote Speaker: Defining Quality in Radiology
Christopher Paul Hess MD, PhD (Presenter): Research Grant, General Electric Research Consultant, Imaging
Endpoints Research Consultant, Cerebrotech Medical Systems
SSC06-02
High Fidelity Contrast Reaction Simulation Training: A Single Department's Comparison of
Performance and Comfort Level Amongst Faculty, Fellows, and Residents
Kyle Elmer Pfeifer MD (Presenter): Nothing to Disclose , Jay Kumar Pahade MD : Nothing to Disclose ,
Jonathan D. Kirsch MD : Nothing to Disclose , Melih Arici MD : Nothing to Disclose , Jennifer Arango :
Nothing to Disclose , Lawrence H. Staib PhD : Nothing to Disclose
PURPOSE
Reactions to contrast material are uncommon in diagnostic radiology, and vary in presentation from urticaria to
life threatening anaphylaxis. It is the responsibility of the radiologist to provide appropriate care. Prior work has
shown a high error rate in contrast reaction management, with smaller studies using simulation showing
variable data on effectiveness. Using the largest study population to date, (>150 radiologists) we sought to
assess the effectiveness of high fidelity simulation in managing contrast reactions.
METHOD AND MATERIALS
A 20 question multiple-choice test and Likert scale questions assessing subjective comfort levels and knowledge
of management of contrast reactions was created. Three simulation scenarios (moderate reaction, severe
reaction, and reaction mimic) were designed to provide simulation training. Each course was completed in one
hour in groups of 8-10 with 2-3 "responders" per simulation. All participants completed a pre-test, post
simulation debriefing, and post-test to assess effectiveness on test scores and subjective Likert ratings of
comfort in managing reactions.
RESULTS
151 radiologists participated (residents=53, fellows=24, faculty=74). There was a statistically significant
increase in the post-test scores after the simulation (p=0.03). Post simulation Likert scores regarding comfort in
managing contrast reactions showed a significant increase across mild, moderate, and severe reactions
(P<0.05). No statistical difference in test scores was noted when comparing residents to fellows to faculty.
CONCLUSION
High fidelity simulation is an effective learning tool, allowing practice of "high acuity" situations in a
non-threatening setting. Our study revealed a statistically significant improvement in test scores, and
subjective comfort in management of reactions. The study supports the use of high fidelity simulation as an
effective teaching tool for contrast reaction management.
CLINICAL RELEVANCE/APPLICATION
Our study illustrates the successful implementation of a high fidelity contrast reaction simulation program
across an entire radiology department and is the largest to date. It further supports the implementation of
simulation as an effective teaching tool in contrast reaction management training with the goal of improving
patient outcomes.
SSC06-03
Appropriateness of Use of Computed Tomography Pulmonary Angiography by Emergency
Department by Use of Decision Rules
Jadranka Stojanovska MD, MS (Presenter): Nothing to Disclose , Ruth C. Carlos MD, MS : Nothing to
Disclose , Aamer Rasheed Chughtai MBBS : Nothing to Disclose , Aine Marie Kelly MD : Nothing to Disclose
, Ella A. Kazerooni MD : Nothing to Disclose
PURPOSE
To apply the appropriateness of computed tomography pulmonary angiography (CTPA) utilization using existing
clinical decision rules in emergency department (ED) and to assess CTPA diagnostic yield by applying decision
rules.
METHOD AND MATERIALS
Institutional Review Board approval was obtained for this HIPPA-compliant prospective cohort study. A total of
602 consecutive adult ED patients undergoing CTPA for suspected pulmonary embolism (PE) formed the study
population. Primary outcome was positive or negative for PE. PE rule-out criteria (PERC) and modified Wells
(mWells) score were retrospectively calculated. Positive PERC (+PERC) was defined as having ≥1of the criteria
met. Positive mWells (+mWells) was defined if the score was > 4. PE prevalence, percentage of CTPA
examinations that could have been avoided, the diagnostic yield of CTPA among patients with -PERC compared
to -mWells were calculated.
RESULTS
Of 602 patients in total, 61 (10%) were diagnosed with PE. By applying PERC and mWells, 17.6% (106/602)
and 45 (261/602) of all CTPA examinations could have been avoided. The overall diagnostic yield of PERC was
higher at 10% (59/602) compared to diagnostic yield of mWells of 8% (49/602) p<0.0001. Among patients
with -PERC, the diagnostic yield for PE was 1.9% (2/106) compared to a diagnostic yield of positive PE of 4%
(12/273) among patients with -mWells (p=0.004).
CONCLUSION
PERC is safer triaging decision tool than mWells that reduces the probability of PE to below 2% and should be
applied in ED setting to avoid overutilization of CTPA.
CLINICAL RELEVANCE/APPLICATION
The diagnostic yield of PE among negative cases by PERC (1.9%) is lower than diagnostic yield of PE among
negative cases by mWells (4%). PERC is safer clinical decision rule than mWells that reduces PE posterior
probability to below to 2% and it should be applied in ED setting to avoid overutilization of CTPA.
SSC06-04
Determining Social Acceptance with the Use of Patients’ Photographs Integrated with Medical
Imaging Studies to Reduce Wrong Patient Errors
Gelareh Sadigh MD (Presenter): Nothing to Disclose , Kimberly E. Applegate MD, MS : Co-editor, Springer
Science+Business Media Deutschland GmbH Advisory Board, WellPoint, Inc , Timothy W. Ng MD : Nothing to
Disclose , Kamilah Hendrix MD : Nothing to Disclose , Srini Tridandapani PhD, MD : Nothing to Disclose
PURPOSE
Mislabeled imaging studies can lead to serious consequences for pediatric patients and their families due to
misdiagnosis and inappropriate therapy. Integrating pediatric patients' digital photographs with medical imaging
may increase the detection of mislabeled studies. However, photographic IDs also raise concerns about patient
privacy and whether this technology will be accepted by the public. The purpose of this study was to determine
how the parents and guardians of pediatric patients would receive this novel technology.
METHOD AND MATERIALS
Over a two-month period in 2014, parents and guardians of patients were asked to complete a 13-question
survey in the ambulatory waiting room of a Children's Hospital radiology department. The parents' anticipated
perception about the use of patients' photograph with medical imaging in different clinical scenarios was
investigated and its predictors were determined using logistic regression analysis.
RESULTS
498/600 parents responded to the survey (response rate 83%). 86% were female (mean age 37 years). 77%
had more than high school diploma. 51% had > $50,000 annual household income. Mean age of respondents'
child was 7 years. 96% and 97% of parents supported the use of a photo ID, if it improves the radiologist's
imaging interpretation, or decreases the rate of mislabeled errors, respectively. A minority of respondents
(38%) were worried that obtaining their child's photo would impact his/her privacy. 94% believed that they
should be asked for their consent prior to obtaining their child's photo. 90%, 91% and 92% of parents
supported the new technology if their child was slightly sick (outpatient), brought into the emergency
department after trauma, or hospitalized in an intensive care unit, respectively. After adjusting for independent
covariates, Caucasian parents were less worried about the impact of the new technology on child's privacy
compared to other ethnicities (P=0.009). Parents older than 45 years of age were less supportive of the
technology in outpatient setting (P=0.02).
CONCLUSION
The vast majority (96%) of parents support integrating their child's photograph with imaging studies in order to
improve safety and believe that consent should be obtained.
CLINICAL RELEVANCE/APPLICATION
Integrating patients' digital photographs with medical imaging studies is socially acceptable to patients.
SSC06-05
Frequency of Acute Kidney Injury Following Intravenous and Intra-arterial Iodinated Contrast
Material Administration in a Paired Cohort
Jennifer S. McDonald PhD (Presenter): Research Grant, General Electric Company , Robert J. McDonald MD,
PhD : Nothing to Disclose , Caleb Brandon Leake BS : Nothing to Disclose , Rickey Carter PhD : Nothing to
Disclose , Rajiv Gulati MD, PhD : Nothing to Disclose , Richard W. Katzberg MD : Research Grant, Siemens
AG Research Grant, Bayer AG Investigator, Siemens AG Investigator, Bayer AG , Eric E. Williamson MD :
Research Grant, General Electric Company , David F. Kallmes MD : Research support, Terumo Corporation
Research support, Covidien AG Research support, Sequent Medical, Inc Research support, Benvenue Medical,
Inc Consultant, General Electric Company Consultant, Covidien AG Consultant, Johnson & Johnson
PURPOSE
Purpose: Prior uncontrolled studies of contrast-induced nephropathy suggested that intra-arterial contrast
administration is associated with a higher risk of acute kidney injury (AKI) compared to intravenous
administration. We compared the risk of AKI following intravenous and intra-arterial contrast exposure in a
cohort of patients that received both routes of contrast administration.
METHOD AND MATERIALS
Materials and Methods: This retrospective study was HIPAA compliant and approved by our IRB. All patients
who received both a contrast-enhanced CT or CT angiography scan and a diagnostic or interventional cardiac
catheterization between 2000-2011 were identified. Patients who lacked sufficient pre- and post-procedure
serum creatinine (SCr) results, who were on pre-existing renal dialysis, who underwent additional
contrast-enhanced procedures within 14 days of either procedure, or whose baseline SCr changed more than
0.3 mg/dL between procedures were excluded. The incidence of AKI, defined as SCr >= 0.5mg/dl above
baseline, was compared following CT scan and cardiac catheterization using McNemar's test.
RESULTS
Results: A total of 1073 patients met all study inclusion criteria. The incidence of AKI following CT scan was
similar to the incidence following catheterization when examining all patients (4.9% CT vs. 6.0%
catheterization, p=.27). This similar AKI incidence was observed regardless of order of procedure (CT or
catheterization) or type of cardiac catheterization performed (diagnostic or interventional).
CONCLUSION
Conclusion: In this paired cohort, the frequency of AKI following intra-arterial administration of iodinated
contrast material is similar to the rate observed following intravenous contrast administration. These findings
suggest that prior reports of excess incidence of AKI following intra-arterial contrast administration compared
to intravenous administration may reflect differences in clinical status and baseline risk for AKI rather than
differences in the nephrotoxic potential in these two routes of contrast administration.
CLINICAL RELEVANCE/APPLICATION
Clinical Relevance: The nephrotoxic risk of intra-arterial contrast administration has been overstated in prior
studies lacking a suitable control group.
SSC06-06
Quality Measurements in Radiology: A Systematic Review of the Literature
Anand Narayan MD, PhD (Presenter): Nothing to Disclose , Christina McGraw Cinelli MD : Nothing to
Disclose , John A. Carrino MD, MPH : Consultant, BioClinica, Inc Consultant, Pfizer Inc Advisory Board, General
Electric Company , Paul G. Nagy PhD : Nothing to Disclose , Josef Coresh MD, PhD : Nothing to Disclose ,
Daniel Durand MD : Nothing to Disclose
PURPOSE
As the US healthcare delivery system transitions from volume to value, numerous public, private and non-profit
entities have developed quality metrics to evaluate health care providers. Radiology quality metrics currently in
use by CMS programs (e.g., Physician Quality Reporting System) do not focus on true diagnostic outcomes. We
present here an exhaustive inventory of all published radiology quality metrics and classify them according the
hierarchical framework of Donabedian et al., which is used widely throughout the broader healthcare quality
metric literature.
METHOD AND MATERIALS
A systematic review was performed in which eligibility criteria included published primary research articles,
commentaries, and review articles from 2000 onward. Multiple databases were searched (7/1/2013) as well as
the reference lists of identified articles. Studies were double-read with discrepancies resolved by consensus.
Outcome measures were organized based on standard Donabedian categories (structure, process, outcome).
Results were reported according to PRISMA study guidelines for reporting systematic reviews.
RESULTS
Our initial search yielded 1816 unique citations (Figure 1). Our double-blind abstract screen identified 110
papers for detailed review, of which 16 were included in the final analysis. A total of 75 unique metrics were
reported, which were further classified as follows: 28 (37%) structure metrics, 24 (32%) outcome metrics and
23 (31%) process metrics. The most commonly cited outcome metric was the ACR RADPEER score (50% of
papers). The most commonly cited structural metric was whether or not a facility was accredited by the ACR
(31% of papers). The most commonly cited process metric was whether ACR appropriateness criteria were
followed (25%).
CONCLUSION
Numerous radiology quality metrics have been described, which are evenly divided between structure, process
and outcomes metrics. Additional research is needed to determine why there has been low uptake of radiology
outcome metrics into existing value-based contracting (e.g., CMS PQRS).
CLINICAL RELEVANCE/APPLICATION
Radiologists must work to develop quality metrics that evaluate patient centered outcomes of radiologic studies.
SSC06-07
Intravenous Contrast Extravasation: Trends in Rate, Complications, and Demographics
Martin Lee David Gunn MBChB (Presenter): Medical Advisor, TransformativeMed, Inc Spouse, Consultant,
Wolters Kluwer nv Grant, Koninklijke Philips NV , Bruce E. Lehnert MD : Nothing to Disclose
PURPOSE
The primary purpose of this study was to examine the contrast extravasation (CE) rate and complications from
power-injected intravenous low-osmolality iodinated contrast media The secondary purpose was to determine
the impact of real-time pressure monitoring and saline test injections on the CE rate.
METHOD AND MATERIALS
Retrospective, single-center review of adult patients (18 years and older) maintained in a dedicated CE
database from 2006 to 2013 inclusive, encompassing approximately 80,000 contrast injections. Demographic
information, iv line location (peripheral or central), scan protocol used, flow rate, contrast type, volume of
contrast extravasation, and complications were examined. Statistical analysis included chi-squared tests for
contingency tables, and t-test for continuous variables.
RESULTS
From 2006-2013 inclusive, there were 290 CE's from 80,045 contrast injections, yielding an overall CE rate of
0.362%. All injections were non-ionic low-osmolality contrast media (iohexol 300, iohexol 350, iodixanol 320).
CE occurred in older patients than those without CE (52.04 vs 46.9 years, p<0.0001). There was a significant
gender difference, with males slightly less likely to have extravasations than females (relative risk 0.74; 95%CI
0.59-0.94; p=0.014).. Volume of extravasation ranged from 20 cc to 200 cc (mean 72.8cc, sd 41. 14 cc).
Following implementation of a power-injected saline test flush and real-time technologist pressure monitoring in
2008, there was no reduction in the extravasation rate (pre: 0.40%, post: 0.33% to (p<=0.17), or volume
(69.8 cc vs 75 cc 95CI = -6.1-16.35 cc, p=0.36) CE line type were: 238 (82%) peripheral, 22 (8%) central, and
30 unknown (10%)respectively. There were two serious complications - forearm compartment syndrome
requiring a fasciotomy, and central line extravasation requiring chest tube placement.
CONCLUSION
We report a low rate of CE following iv power injection. Age is correlated with risk. 2/259 serious complications
occurred, confirming the safety of LOCM CE power-injections. The implementation of saline test power-injections
and real-time pressure monitoring was not associated with a lower rate or volume of extravasations.
CLINICAL RELEVANCE/APPLICATION
The risk of a complication requiring intervention due to CE is extremely low, approx 2 / 80,000 in our series.
Using a saline test bolus, and real-time infusion pressure monitoring do not reduce, or volume of CE.
SSC06-08
Is Computerized Tomography Sufficient without Bone Scan for Routine, Asymptomatic Breast Cancer
Staging?
Jill Tichy MD (Presenter): Nothing to Disclose , Mark Raymond Waddle BS : Nothing to Disclose , Allison
Deal MS : Nothing to Disclose , Lisa A. Carey : Nothing to Disclose , Hyman Muss : Nothing to Disclose ,
Nisha
Mehta MD : Grant, Siemens AG
PURPOSE
Redundant use of imaging modalities for staging is not cost effective, and can result in unnecessary additional
workup. This study aims to assess the added utility of routine bone scan (BS) above staging CT
chest/abdomen/pelvis (CT) in detection of asymptomatic breast cancer bone metastasis (BM).
METHOD AND MATERIALS
Eligible patients had stage I-III asymptomatic breast cancer diagnosed between 2010-2013 and underwent
staging BS and CT
RESULTS
Among 124 patients, the median age was 53, median tumor size 3.45 cm, and 82 had >= 1 positive lymph
node. Varying receptor subsets were included. Median follow-up was 2.18 years. 102 (82.3%) were
radiologically concordant for BM evaluation with 93 (75.0%) negative and 9 (7.3%) raising suspicion for
metastatic disease. There were 22 (17.7%) radiologically discordant cases per initial reports, of which 9 were
deemed truly discordant on review. 13 of the discordant patients underwent further workup with 1 biopsy
confirmation. Of the 11 CT+/BS- patients, 9 are alive without disease, 1 died with BM, and 1 was lost to
follow-up. Of the 11 BS+/CT- patients, 8 are alive without disease, 1 died with visceral-only metastases, 1 died
with visceral+BM, and 1 was lost to follow up with confirmed BM. Skull-only metastases were suspected by BS
in 2 cases; 1 died with visceral+BM. There was no association of any patient or tumor characteristic with
measured discordance (p-values >= 0.07).
CONCLUSION
Of the cases demonstrating discordance between CT and BS, the vast majority had negative follow-up imaging
for metastasis, and there was only 1 case out of 124 of isolated clinically significant BM identified by BS without
associated abnormal CT findings. Therefore, bone scan routinely coupled with CT staging may be unnecessary in
asymptomatic breast cancer.
CLINICAL RELEVANCE/APPLICATION
Recommendations for asymptomatic breast cancer staging may merit reconsideration; BS may only be
necessary in those with findings suspicious for osseous or visceral metastatic disease on CT staging.
SSC06-09
Health Service, Policy & Research Keynote Speaker: Practicing Quality in Radiology
Annette Jean Johnson MD, MS (Presenter): Nothing to Disclose
SSC07
ISP: Informatics (Enterprise Integration)
Scientific Papers
IN
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credits: 1.50
Mon, Dec 1 10:30 AM - 12:00 PM
Location: S402AB
Participants
Moderator
Rasu B. K. Shrestha MD, MBA : Advisory Board, General Electric Company Medical Advisory Board, Nuance Communications,
Inc Editorial Medical Advisory Board, Anderson Publishing, Ltd Advisory Board, KLAS Enterprises LLC Advisory Board, Peer60
Moderator
Jesse Chusid MD : Nothing to Disclose
Moderator
Arnon Makori MD : Medical Advisory Board, Carestream Health, Inc
Sub-Events
SSC07-01
Informatics Keynote Speaker: Enterprise Integration—Enterprise Imaging Nuggets
Rasu B. K. Shrestha MD, MBA (Presenter): Advisory Board, General Electric Company Medical Advisory Board,
Nuance Communications, Inc Editorial Medical Advisory Board, Anderson Publishing, Ltd Advisory Board, KLAS
Enterprises LLC Advisory Board, Peer60
SSC07-02
Automated Email Delivery of Clinical and Laboratory Follow-up Data to the Radiologist from the
Dictated Report: Preliminary Results of a New IT Algorithm
Anna Ellermeier MD (Presenter): Nothing to Disclose , Jonathan S. Movson MBChB : Nothing to Disclose ,
Elaine Binns : Nothing to Disclose , Bradford Thomas March MD : Nothing to Disclose , Grayson L. Baird
MS : Nothing to Disclose , William W. Mayo-Smith MD : Author with royalties, Reed Elsevier Author with
royalties, Cambridge University Press
CONCLUSION
Using a macro within our voice dictation system, we were able to seamlessly and automatically e-mail
high-yield clinical and laboratory follow-up to radiologists for their diagnostic reports and image-guided
procedures.
Background
Correlating radiographic findings with subsequent clinical and laboratory data is important to maintain and
improve diagnostic skill. However, given the large volume of interpreted examinations, obtaining this data is
tedious. We used a speech recognition macro and interface engine algorithm to automate this process. Unique
characters inserted into radiology reports generated follow-up requests: "automatic request" for image-guided
procedures or "intentional request" placed by the interpreting radiologist. Automatic query of the EMR for
cytology, pathology, endoscopy and operative reports provided results delivered to dictating radiologists via
HIPAA-compliant e-mail. The purpose of this study was to determine the type and utility of the delivered
information.
Evaluation
The internally-developed algorithm has been in place for 22 months, generating 10,000 e-mails. We audited a
1-month data sample (February 2013) to assess for utility of provided data, as determined by e-mail
concordance with the original dictation. There were 268 unique reports (170 automatic; 98 intentional), of
which 92% (246/268) received concordant e-mail follow-up. Automatic requests were 96% useful (164/170)
and intentional requests were 79% useful (77/98). As some accession numbers generated multiple e-mails, 418
total messages were received. Useful data was contained in 90% (378) of these, with concordance by category
as follows: pathology 94% (160/171), cytology 91% (127/140), operative report 88% (73/83) and endoscopy
75% (18/24).
Discussion
The high-yield of our clinical follow-up algorithm demonstrates a useful new tool to easily correlate laboratory
and clinical outcomes with original radiographic findings. These HIPAA-compliant e-mails may be forwarded to
referring physicians, further promoting efficient communication for improved patient care.
SSC07-03
Patient Directed Internet-based Medical Image Exchange: Consumer Experience from an Initial
Multicenter Implementation
Giampaola Greco MPH (Presenter): Nothing to Disclose , Anand S. Patel MD : Stockholder, ChemoFilter, Inc
Officer, ChemoFilter, Inc , Sara Lewis MD : Nothing to Disclose , Wei Shi MS : Nothing to Disclose , Mary
Torosyan : Nothing to Disclose , Alan J. Moskowitz MD : Nothing to Disclose , Bradley J. Erickson MD, PhD :
Stockholder, Evidentia Health, Inc , Atheeth Hiremath BS : Nothing to Disclose , Wyatt Michael Tellis PhD :
Officer, EyePACS, LLC , Eliot L. Siegel MD : Research Grant, General Electric Company Speakers Bureau,
Siemens AG Board of Directors, Carestream Health, Inc Research Grant, XYBIX Systems, Inc Research Grant,
Steelcase, Inc Research Grant, Anthro Corp Research Grant, RedRick Technologies Inc Research Grant, Evolved
Technologies Corporation Research Grant, Barco nv Research Grant, Intel Corporation Research Grant, Dell Inc
Research Grant, Herman Miller, Inc Research Grant, Virtual Radiology Research Grant, Anatomical Travelogue,
Inc Medical Advisory Board, Fovia, Inc Medical Advisory Board, Toshiba Corporation Medical Advisory Board,
McKesson Corporation Medical Advisory Board, Carestream Health, Inc Medical Advisory Board, Bayer AG
Research, TeraRecon, Inc Medical Advisory Board, Bracco Group Researcher, Bracco Group Medical Advisory
Board, Merge Healthcare Incorporated Medical Advisory Board, Microsoft Corporation Researcher, Microsoft
Corporation , David S. Mendelson MD : Spouse, Employee, Novartis AG Advisory Board, Nuance
Communications, Inc Advisory Board, General Electric Company Advisory Board, Toshiba Corporation
CONCLUSION
We confirmed previous assumptions that patients highly value direct access to their medical exams and showed
that the implementation of this internet-based, interoperable, image-sharing solution meets patient and
provider expectations regarding ease of access, timeliness and privacy.
Background
Fragmentation of health information among physicians, institutions or practices and inefficient exchange of test
results decrease quality of care and contribute to high cost. The aim of this study is to evaluates patient's and
provider's satisfaction with the use of an internet-based, interoperable image-exchange system, that gives
patients ownership of their imaging exams and control over their access.
Evaluation
Patients undergoing any radiological exams in 4 academic centers were eligible to receive online Personal Health
Records (PHRs). Participants were provided a brief survey, to assess patient's and physician's experience with
the exchange of images. Patients were instructed to complete and to return the survey after their visit with their
referring physician. Survey responses were rated on a 5 point scale and comparisons were performed using
logistic regression.
Discussion
2,216 patients, mean age 49.8 (±19.9) were enrolled between July 2012 and July 2013. The median number of
exams uploaded per patient was 6. The most common types of exams were x-rays (34%), CT (26%) and MRI
(18%). 502 (23%) patients returned their survey. Of these, 448 identified the method used at the visit to share
images (Internet, CDs, both Internet and CDs, other) and 165 included a section filled by their physician.
Nearly all patients liked having direct access to images and 78% viewed their medical images independently.
Satisfaction with the privacy and security of the method by which radiologic exams were shared was similar
between PHR users and CDs users (91% vs. 92%, respectively). More PHR users than CD users were satisfied
with ease of access (89% vs. 79%, p<0.0001). Most physicians reported a favorable experience with the PHRs
with no differences compared to other methods.
SSC07-04
Patient Healthcare Provider Discovery System (PHPDS) for Connecting Emergency Departments
with Healthcare Provider of the Patient in Real Time
Nihar Sunilkumar Parikh BEng (Presenter): Nothing to Disclose
CONCLUSION
The discovery system will equip emergency departments to connect with patient healthcare providers and take
timely collaborative decision for improving patient outcome.
Background
Providing access to historical data in real-time is a key challenge faced across clinical facilities. There is a
pressing need for a system which can connect Emergency Departments with relevant clinical systems where
historical data is available in real time. This paper proposes a system to support Emergency Department in
addressing this challenge.
Evaluation
PHPDS is a zero footprint web application which searches for a patient on registered EHR/PHR systems and
displays hospital provider details where data is available by the steps below: • Emergency department (ED)
searches for patient using patient demographics data, biometric data, body marks, driving license number, etc.
• The PHPDS queries proposed emergency service on EHR/PHR system • The EHR/PHR system returns
healthcare provider name, address, emergency contact details, local patient ID along with patient photograph
which can be used for uniquely identifying the patient • ED then contacts relevant healthcare provider,
discusses the patient's condition and takes an informed clinical decision • Connecting parties can also make use
of existing image sharing solutions
Discussion
PHPDS is designed to give access to users from registered ED. The emergency service can be integrated with
XDS infrastructure of the hospital facility: • Emergency service queries PDQ server to get the matching records
along with patient photograph • The Imaging Document Source details are fetched from Document Registry •
Source Institution details are obtained from a table which maps Source ID and Institution details PDQ will need
to be enhanced to support search on biometric data and to send patient photograph for matching records. HPD
profile can be used to get the healthcare provider details. The messaging model of the emergency web service
can be designed using FHIR solutions. ED can also use PHPDS when the team is in transit. PHPDS can also be
used as a search tool for locating non-registered XCA community of the patient in case of emergency cases in
XCPD workflow.
SSC07-05
The Evolution of Global Health Radiology Informatics; Are We Equipped to Communicate to
Colleagues? A Review of the Completeness of the Radiology Informatics Alphabet Soup
Judy Wawira Gichoya MBChB, MSc (Presenter): Nothing to Disclose
CONCLUSION
RSNA initiatives should expand to support global radiology informatics through modeling and mapping
appropriate concepts for use in radiology systems. From our experience, use of value groups and coded concept
sets can be explored to comprehensively represent minimum reporting for radiology tests.
Background
Developing countries are rapidly adopting Electronic Medical Records (EMR) systems to improve patient care.
There is an increased emphasis to collect structured data types to improve reporting and clinical decision
support. Radiology systems in developing countries are characterized by continued use of analogue systems,
manual development of films, and paper based prose form reporting and inadequate radiologists for reporting.
Despite these challenges, basic radiology modalities are relied upon in managing trauma cases, obstetric care,
and to support diagnosis for primary and chronic care diseases like HIV and Tuberculosis. To improve quality of
radiology reports and clinical communication, RSNA provides a reference guide for structured reports
Evaluation
CIEL-MVP dictionary is a reference terminology provided for use in OpenMRS® , an open source medical
records system used in over 42 countries, and selected for national deployment in Kenya, Rwanda and Nigeria.
It has concepts in various local languages that are mapped to SNOMED CT and ICD10. We mapped the
structured template reports available at http://www.radreport.org/ to this dictionary, and analyzed mapped
concepts for completeness.
Discussion
A total of 119 (< 1%) concepts are classified as 'Radiology/Imaging Procedure'. None of the templates have
100% complete mapping of terminologies. Existing concepts are created for setting up order systems but are
insufficient for clinical reporting since all are mapped as normal and abnormal. Laterality and possible views are
separated into separate concepts e.g. Left and right extremity ultrasound, CXR AP view, Lateral view - and this
creates fragmentation and increased complexity of data collection. No reporting templates for barium and
obstetric studies are provided for reporting by RSNA.At present, use of the dictionary is inadequate to provide
complete radiology reports.
SSC07-06
Interactive Multidisciplinary Patient Lifetime Graph for Facilitating Rapid Review of Past Medical
Events
David Joseph Vining MD (Presenter): Royalties, Bracco Group CEO, VisionSR Stockholder, VisionSR , Andreea
Pitici : Employee, Eloquentix, Inc , Cristian Popovici : Employee, Eloquentix, Inc , Adrian Prisacariu :
Employee, Eloquentix, Inc , David Bier : Nothing to Disclose , Berhan Pirimoglu MD : Nothing to Disclose ,
Radu Rosu : CEO, Eloquentix, Inc
CONCLUSION
We have developed a multimedia structured reporting system that creates a patient lifetime graph which can
enhance the practice of diagnostic radiology.
Background
Radiology is often practiced independent of information available from other medical specialties; however, the
actions of other medical disciplines can have a profound impact upon the imaging studies that radiologists
interpret. Despite the availability of electronic health records and PACS, there is often a disconnect between
radiology reports, images, and clinical information. To facilitate the rapid review of a patient's entire medical
history in an interactive format, we have developed a multimedia structured reporting system that can be
applied to all medical specialties to generate a patient lifetime graph that depicts the occurences of medical
events against a background of disease response criteria
Evaluation
We have developed a multimedia structured reporting system that is applicable to not only diagnostic radiology
but other medical specialities including pathology, gastroenterology, oncology, radiation therapy, and surgery.
The system works by capturing key images from any diagnostic or therapeutic process, tagging each image
with metadata using an ontology, and assembling a multimedia structured report. The system can link image
findings from serial exams derived from any medical discipline in unique graphical disease timelines. Finally, the
sytem produces a patient lifetime graph which shows major medical events against a background of disease
response criteria (e.g., Response Evaluation Criteria in Solid Tumors, RECIST).
Discussion
Review of prior imaging exams, clinical information, and disease response criteria during a radiologist's analysis
of new imaging exams can be a tedious and time-consuming process. We have developed a multimedia
structured reporting system and patient lifetime graph concept that enables the rapid review of past medical
events against a background of disease response criteria. We believe that this technology will improve the
efficiency and accuracy of radiology reporting, and hence improve a radiologist's value in the healthcare
enterprise.
SSC07-07
PRICETag -- A Real-time Application for Radiology Examination Costs during Image Examination
Protocol and Interpretation
Mindy Licurse MD (Presenter): Nothing to Disclose , William W. Boonn MD : Founder, Montage Healthcare
Solutions, Inc Shareholder, Montage Healthcare Solutions, Inc Shareholder, Nuance Communications, Inc
Shareholder, Merge Healthcare Incorporated , Scott Raymond Steingall ARRT : Nothing to Disclose
CONCLUSION
There is poor cost awareness amongst radiologists at every level. While the effect on clinical utility and cost
savings has yet to be measured, a solid understanding of radiology costs is essential if radiologists are to play a
vital role in value based care.
Background
The long-standing lack of cost awareness amongst physicians is cited as one of the contributors to the high cost
of U.S. healthcare. Studies have shown substantial cost savings in specialties such as surgery due to
cost-awareness interventions. Despite surging attention on overutilization of radiology exams, radiologists
themselves have poor knowledge of exam costs. With the rise of Meaningful Use and shifts towards quality
driven and quantity controlled patient care, clinical coordination becomes paramount. Increasing cost awareness
amongst radiologists allows for an integrated and informed decision-making process between radiologists,
referring physicians, and patients. Implementation of a tool displaying a range of costs for each exam
interpreted by a radiologist allows for knowledge building towards this goal.
Evaluation
A pre-intervention survey evaluated cost perceptions amongst radiologists of differing experience and
modalities. After the survey, an application built into an institutional clinical web portal was activated. Upon
opening an exam, the application displays the average Medicare hospital reimbursement for the specific exam
and average professional reimbursement. After a period of two months, a post-intervention survey was
distributed to the same population evaluating the effect of the tool on cost awareness.
Discussion
While knowing the cost of an exam may not seem beneficial to a radiologist, it does in fact play a vital role for
patient care. Radiologist cost awareness may allow for improved multidisciplinary decision making with referring
clinicians and become a standard part of consultation regarding the cost-benefit ratio of tests both financially
and clinically. With the evolution of shared knowledge, both radiologists and referring physicians are more
likely to meet health care legislation along with possible cost-saving due to increased price transparency.
SSC07-08
Current Trend of Academic Radiology Image Archival System in Imaging Departments of a
Developing Country
Amit T. Kharat PhD, DMRD (Presenter): Nothing to Disclose , Dhaval Kanu Thakkar MBBS, MD : Nothing to
Disclose , Amol Takalkar MBBS : Nothing to Disclose , Amarjit Singh MD, DMRD : Nothing to Disclose ,
vilas kulkarni : Nothing to Disclose , Kuldip Parthibhai Chaudhary MBBS, MD : Nothing to Disclose , Mansi N
Jantre MBBS,MD : Nothing to Disclose
CONCLUSION
CONCLUSION
LHDA on workstation and PACS of academic images is efficient and fastest. It is a favored option amongst
radiologists as compared to CB system. CB system is systematic and safe, but limited by network speed,
requires local storage of data prior to upload to CB PACS. Radiologists therefore prefer local storage on the
hard disc drive to save time. A robust ARIA and storage system can be a boon to radiologists to archive
interesting cases directly from PACS.CB system can also alleviate space requirements, provide automatic
backup in case of damage to the original source and provide access to teaching file cases virtually to anyone
with an appropriate internet connection.
Background
Study the least time consuming method of academic radiology image archival (ARIA).Utility of cloud based (CB)
academic radiology image archival versus local hard disc archival (LHDA) and Picture Archiving and
Communication System (PACS) storage.
Evaluation
143 resident and consultant radiologists of the same country belonging to multiple institutions were questioned
regarding procedures used for ARIA. A questionnaire was prepared and answers were sought. Of those, 100
(69.93%) radiologists responded completely to the survey. Study was conducted over 4 months starting
October 2013 to January 2014.
Discussion
All images stored by radiologists followed HIPAA guidelines. Out of 100 radiologists, majority (95 %) used
LHDA while 5 % used CB image archival system. Of the 95% using LHDA, 65 % stored files and data on the
local hard drive while 35% used the PACS for image archival. 60% radiologists were aware of CB technology for
ARIA, while 40 % were unaware. The 60 % radiologists who were aware but not using CB system gave
following reasons: time consuming procedure to categorize, upload images (1 minute for LHDA versus 3
minutes for CB PACS), unreliable internet access; lack of technical expertise/support, lack of financial support
by institution, and few other declined to answer. 84% radiologist's acknowledged the fact that CB data was
more secure, systematic as compared to LHDA on workstation. PACS based academic image archival was
thought as adequate by 69% while 31 % radiologists suggested need for refinements and upgrade.
SSC08
ISP: Musculoskeletal (Advanced Cartilage Imaging)
Scientific Papers
MR MK
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credits: 1.50
Mon, Dec 1 10:30 AM - 12:00 PM
Location: E450B
Participants
Moderator
Timothy J. Mosher MD : Research Consultant, Medical Metrics, Inc Research Consultant, eImage, Inc Research Consultant,
Johnson & Johnson Stockholder, Johnson & Johnson
Moderator
Hollis G. Potter MD : Research support, General Electric Company
Sub-Events
SSC08-01
Musculoskeletal Keynote Speaker: MR Evaluation of Cartilage—Clinical Challenges Drive Imaging
Needs
Hollis G. Potter MD (Presenter): Research support, General Electric Company
SSC08-03
T2* Relaxation Time of Acetabular and Femoral Cartilage with and without Intra-articular
Gd-DTPA2- in Hip FAI Patients
Shabnam Mortazavi (Presenter): Nothing to Disclose , Mikko Nissi : Nothing to Disclose , John Hughes :
Nothing to Disclose , Patrick Morgan MD : Nothing to Disclose , Jutta Ellermann MD, PhD : Nothing to
Disclose
PURPOSE
To assess if the presence of intra-articular Gd-DTPA2- in clinical MR arthrography significantly alters the T2*
relaxation times of articular cartilage of the hip joint in patients with femoroacetabular impingement (FAI).
METHOD AND MATERIALS
The institutional review board (IRB) approved this study, and informed consents were obtained in this HIPAA
compliant study. T2* mapping of ten patient volunteers (F/M: 7/3, age range 14-49, mean±SD = 33.0 ± 12.2
years) with symptomatic FAI was performed before and after diluted injection of intra-articular Gd-DTPA2- (final
GD concentration of the injected mixture was 0.78 mmol/L). Overall 323 regions of interest (ROIs) were defined
in acetabular and femoral cartilage each, pre- and post-Gd injection. Agreement of the relaxation times
between pre- and post-Gd was assessed using Krippendorff's alpha coefficient and linear regression through the
origin.
RESULTS
Pre- and post-Gd T2* relaxation times in both acetabular and femoral cartilage were found to strongly agree.
Specifically, the estimated Krippendorff's alphas were greater than 0.8 for both acetabular and femoral
cartilage, indication strong agreement. Furthermore, linear regressions through the origin yielded estimated
slopes very close to 1 and R2 values greater than 0.98, which implies that over 98% of the variation in post-Gd
T2* is explained by the pre-Gd T2*.
CONCLUSION
The presence of described intra-articular Gd-DTPA2- during clinical MR arthrography does not significantly alter
T2* relaxation times of articular cartilage of the hip joint in patients with femoroacetabular impingment.
CLINICAL RELEVANCE/APPLICATION
It is safe to add a T2* relaxation time measurement in standard clinical arthrogram protocol utilizing dilute
intra-articular injection of Gd-DTPA2-
SSC08-04
Comparison of Pre-operative T1rho Values and T2 Values of Cartilage Imaging in Femoroacetabular
Impingement with Post-operative T1rho Values and T2 Values of Cartilage Imaging
Hajimu Goto MD, PhD (Presenter): Nothing to Disclose , Shingo Hashimoto MD, PhD : Nothing to Disclose
, Takaki Maeda MD : Nothing to Disclose , Yuki Iwama MD : Nothing to Disclose , Nobukazu Aoyama RT
: Nothing to Disclose , Yoshiharu Ohno MD, PhD : Research Grant, Toshiba Corporation Research Grant,
Koninklijke Philips NV Research Grant, Bayer AG Research Grant, DAIICHI SANKYO Group Research Grant, Eisai
Co, Ltd Research Grant, Terumo Corporation Research Grant, Fuji Yakuhin Co, Ltd Research Grant, FUJIFILM
Holdings Corporation Research Grant, Guerbet SA , Kazuro Sugimura MD, PhD : Research Grant, Toshiba
Corporation Research Grant, Koninklijke Philips NV Research Grant, Bayer AG Research Grant, Eisai Co, Ltd
Research Grant, DAIICHI SANKYO Group
PURPOSE
To assess the usefulness of T1rho values and T2 values for evaluating cartilage repair after surgery for
femoroacetabular impingment (FAI) throught the comparison of pre-operative and post-operative T1rho values
and T2 values of cartilage and their correlation with MHHS scores.
METHOD AND MATERIALS
A total of 96 cartilage segments(anterior zone, anterior-superior zone, superior-posterior zone, and posterior
zone in injured and control cartilage) in 12 FAI patients (4 male 8 female; median age, 22 years) were
examined at a 3.0T MRI. Mean pre-operative and post-operative(6 monthes after operation) T1rho values and
T2 values of the anterior-superior zone and the superior-posterior zone of the injured cartilage area and of
control cartilage area were compared. The differences between the T1rho values and T2 values were
determined using a paired t-Test. In addition, the MHHS scores of all patients were determined and compared
with the T1rho values and T2 values of the anterior-superior zone and the superior-posterior zone of the
injured cartilage area and the control cartilage area. The relationships between the MHHS score and MRI
imaging parameters were evaluated using non-parametric regression analysis. Statistical significance was
defiend as p <0.05.
RESULTS
The MHHS score was significantly correlation with T1rho values in both the anterior-superior zone (R2=0.712
and p=0.008) and superior-posterior zone (R2=0.667 and p=0.013) of the injured cartilage area.There was also
a significant correlation between the MHHS score and the T2 values of the anterior-superior zone of the injured
cartilage(R2=0.585 and p=0.016). Comparing the pre-operative and post-operative MRI imaging parameters,
except for the T2 values in the anterior-superior zone in the control cartilage, post-operative T1rho values and
T2 values were significantly lower than those of pre-operative values in other zones of the injured and control
cartilage.
CONCLUSION
T1rho values and T2 values can detect post-operative cartilage change in FAI. T1rho values and T2 values are
correrated with the clinical condition of FAI.
CLINICAL RELEVANCE/APPLICATION
Biochemical MRI techniques(T1rho values and T2 values)have potential benefits for evaluating cartilage repair
following surgery for FAI.
SSC08-05
The Immediate Effect of Athletic Endurance Running on T2 and T2*-relaxation Times of Articular
Cartilage of the Knee in Young Healthy Adults at 3T MRI
Cyrus Behzadi (Presenter): Nothing to Disclose , Azien Laqmani : Nothing to Disclose , Frank Oliver Gerhard
Henes MD : Nothing to Disclose , Michael Gerhard Kaul : Nothing to Disclose , Gerhard B. Adam MD :
Nothing to Disclose , Marc Regier : Nothing to Disclose
PURPOSE
To quantitatively assess the immediate effect of a 45 minute endurance run on articular cartilage of the knee
using T2 and T2* relaxation measurements at 3T.
METHOD AND MATERIALS
The study collective consisted of 30 young male adults (18-31 years) who routinely perform sports at an
amateur level without prior knee injury. After resting for 30 minutes in supine position, all participants
underwent an initial MRI at 3T. For quantitative analysis T2 (16 echo times ranging from 9.7-154.6ms; image
resolution, 0.5x3x3mm) and T2* (22 echo times ranging from 4.6-52.9ms; image resolution 0.5x2x2mm)
measurements were performed in sagittal orientation. All participants then performed a 45 minutes endurance
run using a treatmill at medium level (mean, 6.5 mph). After the run, all individuals were re-examined
identically with a delay of 2 to 6 minutes. All data sets were postprocessed using a dedicated software (ImageJ)
and quantitative maps were generated. 22 regions-of-interest (ROI) were manually drawn in the areas of the
femoral, tibial and patellar cartilage. For statistical evaluation a Wilcoxon-matched-pairs analysis was
performed.
RESULTS
After the run, a significant decrease in mean T2 and T2* relaxation times was observed for all segments in all
participants. The highest decrease was determined for the medial femoral segments, here the T2 values
decreased from 36.58ms to 31.13ms (14.91%; p=0.02) and the T2* values decreased from 23.75ms to
19.14ms (19.4%; p<0.001). The effect of running was higher at the anterior segments than posteriorly, here
the mean values decreased from 42.45ms to 37.08ms (12.65%; p=0.02) for T2 and from 32.36ms to 26.87ms
(16.96%; p=0.01) for T2* measurements. The lateral basis of the patella was least effected by the axial load
during running, here a mean decrease of 8.1% (T2; p=0.06) and 11.6% (T2*; p=0.03) was noted.
CONCLUSION
The presented data underline the ability of T2 and T2* mapping to quantitatively assess the acute effect of
endurance running on the articular cartilage of the knee. Based on our results, this effect seems to predominate
in the anterior and medial articular facette whereas the posterior segments of the femur are not affected in the
same level.
CLINICAL RELEVANCE/APPLICATION
T2 and T2* show a high concordance in the assessment of acute exercise related changes to the articular
cartilage of the knee and can be useful in the detection of initial cartilage degeneration.
SSC08-06
T2 Relaxation Times of Knee Articular Cartilage in Osteoarthritis Patients Are Not Influenced by
Gadolinium Contrast Agent
Joost Verschueren MD (Presenter): Nothing to Disclose , Jasper Van Tiel MD : Nothing to Disclose , Max
Reijman : Nothing to Disclose , Esther Bron BSC : Nothing to Disclose , Stefan Klein : Nothing to Disclose
, Jan Verhaar : Nothing to Disclose , Sita Bierma-Zeinstra PhD : Nothing to Disclose , Gabriel P. Krestin
MD, PhD : Consultant, General Electric Company Research Grant, General Electric Company Research Grant,
Bayer AG Research Grant, Siemens AG Speakers Bureau Siemens AG , Gyula Kotek PhD : Nothing to Disclose
, Edwin H.G. Oei MD, PhD : Nothing to Disclose
PURPOSE
Delayed gadolinium enhanced MRI of cartilage (dGEMRIC) and T2-mapping are often used as quantitative
imaging biomarkers in osteoarthritis (OA) research to measure proteoglycan content and collagen network
integrity, respectively, and together offer comprehensive assessment of biochemical composition and structure
of articular cartilage. Pre- and post-contrast T2 relaxation times have shown to be comparable in ex-vivo MRI of
human osteochondral samples, but results obtained in OA and intact cartilage in-vivo at 1.5T are contradictory.
As acquisition of dGEMRIC and T2-mapping within one post-contrast imaging session improves efficiency and
reduces scan time and costs, our purpose was to assess the influence of contrast agent on T2 relaxation times
acquired in-vivo at 3T in OA patients.
METHOD AND MATERIALS
Ten knee OA patients (Kellgren-Lawrence grade 2-3) underwent dGEMRIC and T2 mapping at 3T. A 3D fast
spin-echo sequence with 5 echo times (3, 13, 27, 40, 68 ms) for T2 mapping was performed before and 75
minutes after intravenous administration of gadolinium dimeglumine (0.2 mmol/kg) for dGEMRIC. Mean T2
relaxation times were calculated in 6 cartilage regions (located medially and laterally in the weight-bearing and
posterior cartilage of the femoral condyles and tibial plateaus), using in-house developed post-processing
software that incorporates automated rigid registration in 3D for motion correction. Pre- and post-contrast T2
relaxation times were compared with correlation analysis, intraclass correlation coefficient (ICC) and Wilcoxon
signed-rank test.
RESULTS
Pre- (mean 41.5; range 28.8-64.7 ms) and post-contrast (mean 41.1; range 28.5-73.0 ms) T2 relaxation times
were strongly correlated (r=0.87, r2=0.75, p<0.001) with a high ICC (0.92, 95CI: 0.86-0.95), and their mean
values were not statistically significantly different (p=0.08).
CONCLUSION
The results indicate that pre- and post-contrast T2 relaxation times of in-vivo OA knee cartilage acquired at 3T
are strongly correlated and that there is no evidence to suggest a difference in T2 relaxation times. Therefore,
T2-mapping can be performed reliably within a single post-contrast imaging session in combination with
dGEMRIC acquisition.
CLINICAL RELEVANCE/APPLICATION
For comprehensive assessment of articular cartilage structure and biochemical composition, dGEMRIC and
T2-mapping can be combined in one imaging session with reliable T2 relaxation time measurement.
SSC08-07
Changes in Delayed Gadolinium-enhanced MRI of Cartilage (dGEMRIC) Indices and the Association
with Cartilage Loss in the Tibiofemoral Compartments over 1 Year: a 3.0T MRI Study
Michel D. Crema MD (Presenter): Shareholder, Boston Imaging Core Lab, LLC , David J. Hunter MD, PhD :
Royalties, DJO GLobal, Inc , Deborah Burstein PhD : Spouse, Employee, Bruker Corporation , Frank W.
Roemer MD : Chief Medical Officer, Boston Imaging Core Lab LLC Research Director, Boston Imaging Core Lab
LLC Shareholder, Boston Imaging Core Lab LLC , Jose Roberto Silva MD : Nothing to Disclose , Ali Guermazi
MD, PhD : President, Boston Imaging Core Lab, LLC Research Consultant, Merck KgaA Research Consultant,
Sanofi-Aventis Group Research Consultant, TissueGene, Inc
PURPOSE
The dGEMRIC technique is capable of detecting early changes in the glycosamoniglycan content of cartilage,
which may potentially lead to changes in cartilage morphology. The aim of this study was to assess the
associations of baseline dGEMRIC as well as changes in dGEMRIC indices with cartilage loss in the same region
of the knee over one year, in a sample of middle-aged women.
METHOD AND MATERIALS
A total of 140 women (1 knee per subject) aged ≥ 40 years were prospectively included. 3.0T MRI of the knee
was performed at baseline and at one year follow-up. T2-weighted fat-suppressed sequences were used to
assess cartilage morphology using the BLOKS scoring system. A 3D inversion recovery-prepared SPGR sequence
90 minutes after i.v. gadolinium injection was acquired for dGEMRIC assessment. Cartilage morphology and
dGEMRIC were assessed at baseline and follow-up MRIs in four distinct regions of tibiofemoral compartments:
medial femur, medial tibia, lateral femur, and lateral tibia. A decrease in dGEMRIC indices over one year was
considered as the predictor of cartilage loss (considered here as any increase of grade in BLOKS - outcome).
The association of any decrease in dGEMRIC indices from baseline to follow-up with cartilage loss in the same
region was assessed using logistic regression. In addition we used the maximal statistical approach to
determine at which cut-off value baseline dGEMRIC would be most predictive for cartilage loss after one year.
RESULTS
A total of 433 regions were included in the analyses; 25 (5.8%) had cartilage loss over one year and 408
(92.2%) did not. Furthermore, 153 (35.3%) regions had a decrease in dGEMRIC indices over one year and 280
(64.7%) did not. No significant associations between change in dGEMRIC indices over time and cartilage loss
were observed. A cut-off value of dGEMRIC predicting cartilage loss could not be established.
CONCLUSION
The predictive effect of changes in dGEMRIC on cartilage loss in the tibiofemoral compartments over one year
could not be demonstrated in this sample of middle-aged women.
CLINICAL RELEVANCE/APPLICATION
The monitoring of changes in dGEMRIC indices over time still need to be validated before it can be applied as an
imaging biomarker of longitudinal cartilage loss.
SSC08-08
MRI in the Follow Up of Patients after Matrix Based Autologous Chondrocyte Transplantation of the
Hip Using 3 Tesla High Resolution Techniques and dGEMRIC
Andrea Lazik MD (Presenter): Nothing to Disclose , Oliver Kraff MSc : Nothing to Disclose , Konrad
Koersmeier : Nothing to Disclose , Stefan Landgraeber : Nothing to Disclose , Thomas C. Lauenstein MD :
Nothing to Disclose , Jens Matthias Theysohn MD : Nothing to Disclose
PURPOSE
Matrix based autologous chondrocyte transplantation (MACT) has become common in the therapy of focal
cartilage lesions in the knee and can be monitored by high resolution MR imaging and quantitative MR analysis,
such as delayed gadolinium enhanced MR imaging of cartilage (dGEMRIC). This T1 mapping technique
represents the glycosaminoglycane content of the cartilage. MACT is an upcoming therapy for focal cartilage
lesions in the hip as well, with only few publications up to now. The aim of this study was to follow up patients
after acetabular MACT with high resolution MRI and to evaluate the potential of dGEMRIC in imaging cartilage
transplants in the hip.
METHOD AND MATERIALS
24 patients were examined 6 - 31 months after acetabular MACT using 3D as well as sagittal and coronal 2D
high-resolution proton density weighted (PD) sequences (slice thickness 2.5 mm, in plane resolution 0.5 x 0.5
mm and 0.8 x 0.8 mm, respectively), and furthermore 3D T1 mapping in dGEMRIC technique at 3 Tesla. The
cartilage transplant was evaluated using an adapted MOCART score (maximum 85 points). T1 relaxation times
were measured in the cartilage transplant and adjacent healthy regions. Correlations between the registered
parameters were calculated using the Spearman rank correlation.
RESULTS
The cartilage transplant was morphologically definable in the PD-weighted sequences of 23 patients with a
mean MOCART score of 69 points (60 - 80 points, SD 6.5). In T1 maps clear differentiation between acetabular
and femoral cartilage was possible, but correlation with PD-weighted images was necessary in order to identify
the transplant. A statistically significant correlation was found between T1 relaxation times of the transplant
and the adjacent healthy cartilage (616.4 ms vs. 574.5 ms; p = 0.011), but not between MOCART score and T1
relaxation times of the transplant.
CONCLUSION
High-resolution PD-weighted imaging with adapted MOCART scoring and dGEMRIC are feasible after acetabular
MACT. Further studies with long-term clinical follow-up are necessary to verify the efficacy of these techniques
for the prognosis of acetabular MACT.
CLINICAL RELEVANCE/APPLICATION
dGEMRIC has the potential to become a complementary technique in the assessment of cartilage transplant
vitality in the hip.
SSC08-09
Non Invasive in Vitro Evaluation of Tissue Engineered Cartilage through dGEMRIC
Francesco Santini PhD : Nothing to Disclose , Michele Pansini MD : Nothing to Disclose , Lukas Daniel
Iselin MD : Nothing to Disclose , Marina Barandun MD : Nothing to Disclose , Dirk Schaefer : Nothing to
Disclose , Ulrich Studler MD (Presenter): Nothing to Disclose , Ivan Martin : Nothing to Disclose , Oliver
Bieri PhD : Nothing to Disclose , Andrea Barbero PhD : Nothing to Disclose
PURPOSE
This study aims to investigate whether glycosaminoglycans (GAG) concentration in the cartilage layer of
engineered osteochondral (OC) grafts and native cartilage tissues evaluated by the dGEMRIC method correlates
with the biochemically measured GAG content in the same specimens.
METHOD AND MATERIALS
Chondrocytes isolated from 5 donors (mean age 36 years) were expanded in monolayer and then seeded onto
collagen matrices. The constructs were combined with a processed bone scaffold after 3 days of pre-culture in
chondrogenic medium. Combined constructs were further cultured in chondrogenic medium for a total time of 4
weeks. Control samples were generated gluing native articular cartilage tissues on the top of the bone scaffold.
The samples were scanned on a whole-body 3T MRI scanner with a 3D variable flip angle gradient echo
sequence for T1 quantification [2] (flip angles 4° and 15°, resolution 0.6.0.6x0.6mm3, FOV 150x37x34mm3,
NEX 32) in a phosphate-buffered saline bath, before and 4 hours after addition of Gd-DTPA to a concentration
of 1mM. Absolute GAG concentration was calculated from the measured T1 values in a middle slice of each
sample using Donnan equilibrium theory [1]. The samples were subsequently extracted and the GAG content
for each sample was biochemically calculated as mg
GAG/mgDNA .
RESULTS
The dGEMRIC-estimated GAG concentrations averaged 32.7±4.2 mg/ml for native cartilage and 4.9±1.9 mg/ml
for the engineered cartilage (p<0.001). The biochemically measured GAG contents averaged
363.3±32.2mg/mg for the native and 22.7±4.4mg/mg for the engineered cartilage. There was a moderate
correlation between the two techniques (R2=0.59).
CONCLUSION
dGEMRIC was able to successfully differentiate between the native cartilage and the tissue engineered
constructs. The correlation could likely be improved on samples of larger volume, as the in vivo implanted
tissue would suffer less from partial volume effects from neighboring structures and media. dGEMRIC methods
might be used to quantitatively monitor cartilage matrix remodeling/maturation in engineered tissues following
implantation in the patients. References [1] Bashir A, et al, Magn Reson Med 1999; 41: 857-865. [2] Deoni S,
et al, Magn Reson Med, 49: 515-526.
CLINICAL RELEVANCE/APPLICATION
Noninvasive radiological assessment of the health status of implanted tissue-engineered cartilage graft is
important for patient recovery monitoring and therapeutical decisions.
SSC09
Neuroradiology (Traumatic Brain Injury)
Scientific Papers
MR NR
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credits: 1.50
Mon, Dec 1 10:30 AM - 12:00 PM
Location: N229
Participants
Moderator
Pratik Mukherjee MD, PhD : Research Grant, General Electric Company Medical Adivisory Board, General Electric Company
Sub-Events
Increased Cerebrovascular Reactivity Correlated with Subjective Headache Scores in the Days
SSC09-01
Increased Cerebrovascular Reactivity Correlated with Subjective Headache Scores in the Days
Following Sports Related Concussion
Adam Richard Militana MD (Presenter): Nothing to Disclose , Manus Donahue PhD : Nothing to Disclose ,
Megan Kay Strother MD : Nothing to Disclose , Allen K. Sills MD : Nothing to Disclose , Gary S. Solomon
MD : Nothing to Disclose , Victoria L. Morgan PhD : Nothing to Disclose
PURPOSE
The measurement of cerebrovascular reactivity (CVR) in response to increased levels of carbon dioxide may be
important to investigate in an athlete following concussion because this most closely simulates the physiologic
challenge that she will encounter upon return to physical activity. To date, no study has been published using
functional MRI (fMRI) to assess CVR following sports-related concussion. The purpose of this study is to
measure CVR using fMRI in college athletes following a sports-related concussion and to correlate this measure
with days after injury and headache symptomatology.
METHOD AND MATERIALS
We enrolled 6 college athletes (3M/3F, 18-22 yrs) 3-6 days following a diagnosed sports related concussion
and 11 healthy controls (5M/6F, 18-23 yrs, 7 athletes) with no history of concussion. CVR was measured using
fMRI via a 5% carbon dioxide block paradigm. A total of 18 regions of interest (ROIs) were evaluated across the
brain. A subjective headache score (HAS) was reported at the time of scanning from 0-4.
RESULTS
CVR was increased approximately 37% across all ROIs in athletes following concussion compared to controls
(p=0.025). We found that HAS was negatively correlated with days after injury (p=0.01). Across all ROIs, CVR
was negatively correlated with days after injury (p=0.07). Individual regions which demonstrated this negative
correlation and also had increased CVR in the concussion subjects were: right inferior parietal lobule,
dorsomedial prefrontal cortex, right dorsolateral prefrontal cortex and right thalamus. Of these, the right
inferior parietal lobule showed increased CVR correlated with increased HAS (p=0.02).
CONCLUSION
We observed markedly increased CVR in college athletes in the days following a sports-related concussion.
Furthermore, this increase is associated with more recent injury, and in one region it is also associated with
increased headache symptoms. These preliminary results suggest that a hypereactive vasodilatory response to
hypercarbia may be an indicator of acute injury and contribute to recurrent headache symptoms. Future work
will investigate the role of CVR changes in symptoms upon an athlete's return to physical activity. [NIH UL1
TR000445]
CLINICAL RELEVANCE/APPLICATION
Our findings suggest that CVR is increased in the days following sports related concussion and this may be
related to headache symptomatology.
SSC09-02
Head Impacts and White Matter Changes in High School Football: A TBSS Analysis
Naeim Bahrami (Presenter): Nothing to Disclose , Elizabeth Davenport : Nothing to Disclose ,
Christopher Thomas Whitlow MD, PhD : Nothing to Disclose , Jillian Urban : Nothing to Disclose , Fatemeh
Mokhtari MS : Nothing to Disclose , Mark A. Espeland PHD : Nothing to Disclose , Youngkyoo Jung PhD :
Nothing to Disclose , Daryl A. Rosenbaum MD : Nothing to Disclose , Gerard A. Gioia PhD : Nothing to
Disclose , Alexander K. Powers MD : Nothing to Disclose , Joel Stitzel : Nothing to Disclose , Joseph Antoine
Maldjian MD : Nothing to Disclose
PURPOSE
The purpose of this study is to determine if head impacts acquired over a season of high school football produce
diffusion tensor imaging (DTI) white matter changes in the absence of clinically diagnosed concussion. We
hypothesize that players with greater levels of head impact exposure (heavy hitters) compared to those with
lower levels of impact exposure (light hitters), will have decreases in fractional anisotropy (FA) that have been
associated with white matter injury.
METHOD AND MATERIALS
24 high school football players (mean age=16.7; age range=16-18) were instrumented with the Head Impact
Telemetry System (HITs) during all practices and games. DTI images were acquired pre and post-season at 2
mm isotropic resolution in accordance with the NINDS Common Data Elements advanced protocol
recommendations on a 3T Siemens MRI. Risk weighted cumulative exposure (RWE) was computed from the
HITs data, representing the collected risk of concussion over the course of the season. Total impacts and RWE
were used to separate the players into 9 heavy hitters (HH) and 15 light hitters (LH). None of the players
experienced concussion during the season. A whole brain tract based statistics (TBSS) analysis was conducted
on the FA data. A 2x2 (group x time) repeated measures ANOVA was used to determine within group and
between group differences (HH vs LH) for pre and post-season. Results were corrected for multiple comparisons
using threshold free cluster enhancement at P < 0.05.
RESULTS
Both groups demonstrated a main effect of time, with global increases in FA (post vs pre season) likely
reflecting effects of brain development. Between group analyses revealed widely distributed statistically
significant areas of decreased delta FA (post-pre season) for HH compared to LH (Figure 1). These areas
included the splenium of the corpus callosum and deep white matter tracts.
CONCLUSION
High school football players experiencing greater levels of head impact exposure, in the absence of clinical
concussion, have more loss in FA compared to a lower impact exposure group, raising concern for white matter
injury or delayed development. Similar brain MRI changes have been previously associated with mild traumatic
brain injury.
CLINICAL RELEVANCE/APPLICATION
This study adds to the growing body of literature providing evidence that a season of play in a contact sport can
show brain MRI changes in the absence of concussion or clinical findings.
SSC09-03
Detection of Unique White Matter Injuries Underlying Neuropsychiatric Symptoms after Mild
Traumatic Brain Injury
Joseph Delic MD (Presenter): Nothing to Disclose , Lea M. Alhilali MD : Nothing to Disclose , Michael W.
Collins PhD : Nothing to Disclose , Saeed Fakhran MD : Nothing to Disclose
PURPOSE
To determine if unique white matter injury patterns underlie neuropsychiatric symptoms after mild traumatic
brain injury (mTBI) utilizing tract-based spatial statistics (TBSS) analysis of diffusion tensor imaging (DTI).
METHOD AND MATERIALS
DTI and serial neurocognitive testing with the Immediate Post-Concussion Assessment and Cognitive Testing
(ImPACT) were obtained in 38 mTBI patients with irritability, 32 with depression, 18 with anxiety, and 8 with
anger/aggression. Controls consisted of 37 mTBI patients without irritability, 43 without depression, 57 without
anxiety, and 67 without anger/aggression, respectively. Fractional anisotropy (FA) maps were generated and
analyzed using TBSS regression analysis utilizing a general linear model and unpaired t-test. DTI abnormalities
were correlated with symptom severity, neurocognitive test scores, and time to recovery with Pearson's
correlation coefficient.
RESULTS
As compared to controls, mTBI patients with depression had decreased FA values in the superior longitudinal
fasciculus, white matter around the nucleus accumbens, and anterior limb of the internal capsule (p
CONCLUSION
Unique white matter injury patterns were seen for three major post-traumatic neuropsychiatric symptoms.
Involvement of the nucleus accumbens in depression after mTBI may suggest an underlying dysfunctional
reward circuit. Similarly, injury to the cerebellum in post-traumatic anxiety correlates well with known
abnormalities seen in this region in anxiety patients in the population at large. Injury to the visual limbic
pathway in post-traumatic anger/aggression suggests a structure/function relationship between this region and
the resulting symptomatology.
CLINICAL RELEVANCE/APPLICATION
Specific white matter injury patterns underlying individual neuropsychiatric symptoms are highly likely to
provide new targets for therapeutic interventions, in addition to fundamentally advancing the field of brain
trauma research.
SSC09-04
Detection of a Central White Matter Injury Underlying Peripheral Symptoms after Mild Traumatic
Brain Injury
Joseph Delic MD (Presenter): Nothing to Disclose , Lea M. Alhilali MD : Nothing to Disclose , Michael W.
Collins PhD : Nothing to Disclose , Saeed Fakhran MD : Nothing to Disclose
PURPOSE
To determine if a central axonal injury underlies cervicalgia and parethesias after mild traumatic brain injury
(mTBI) utilizing tract-based spatial statistics (TBSS) analysis of diffusion tensor imaging (DTI).
METHOD AND MATERIALS
The institutional review board approved this study, with waiver of informed consent. Retrospective review of
diffusion tensor imaging in 19 mTBI patients with cervicalgia and 9 with peripheral paresthesias was performed.
Control subjects consisted of 56 mTBI patients without cervicalgia and 66 mTBI patients without paresthesias,
respectively. Fractional anisotropy (FA) maps were generated as a measure of white matter integrity and
analyzed using TBSS regression analysis utilizing a general linear model and unpaired t-tests.
RESULTS
As compared to controls, mTBI patients with cervicalgia had decreased FA values in the right superior
longitudinal fasciculus (p
CONCLUSION
Decreased FA values in the SLF in mTBI patients with cervicalgia support the hypothesis that post-traumatic
neck pain has a central axonal injury component. Injury to the SLF is associated with hemispatial neglect, which
is often treated with neck muscle vibration. This suggests that post-traumatic neck pain may result not from
direct injury to the cervical region, but from attempts at compensation for spatial orientation insufficiencies
after mTBI.
CLINICAL RELEVANCE/APPLICATION
Detecting a central diffuse axonal injury (DAI) underlying post traumatic cervicalgia indicates that DAI is
responsible for more post-concussion symptoms than simply the cognitive and executive deficits investigated
previously. Diagnosis and treatment of patients with post-traumatic neck pain should not merely be focused on
the cervical region, but also extend to possible intracranial injuries.
SSC09-05
Relationship of Post-concussive White Matter Injuries to Demographic Factors, Injury Mechanism,
and Major Symptoms Utilizing Global Fractional Anisotropy Histogram Analysis
Joseph Delic MD (Presenter): Nothing to Disclose , Lea M. Alhilali MD : Nothing to Disclose , Michael W.
Collins PhD : Nothing to Disclose , Saeed Fakhran MD : Nothing to Disclose
PURPOSE
To determine if different white matter injury severity relates to demographics, injury mechanism or results in
differing post-concussive symptoms by analyzing whole brain fractional anisotropy histograms.
METHOD AND MATERIALS
Fractional anisotropy (FA) maps and serial neurocognitive testing with Immediate Post-Concussion Assessment
and Cognitive Testing (ImPACT) were obtained in 75 mild traumatic brain injury (mTBI) patients. FA histograms
were obtained with the Image Histogram Function in the Tract-Based Spatial Statistics software package.
Kurtosis and skewness, previously shown as markers of overall injury severity, were extracted and correlated
with demographic factors (age, sex), concussion mechanism, neurocognitive test scores, prior concussions, and
time to recovery. Comparison of kurtosis and skewness was then performed between patients with and without
major post-concussive symptoms (vestibulopathy, oculomotor insufficiency, sleep disturbances, anxiety,
depression, anger, cervicalgia, parethesias, and migraines). Analysis was performed with Pearson's correlation
coefficient for continuous variables. Comparison between groups was performed with a two-tailed unpaired
t-test.
RESULTS
Right skewness and leptokurtosis increased with decreasing age (r=-0.302 and r=-0.280, p=0.01 and
p=0.008, respectively) and was greater in patients with sports-related injuries (p=0.007 and p=0.01,
respectively), indicating greater injury severity with a more uniform distribution of injuries in these patients.
Greater severity and variability in injuries was detected in patients with depression after mTBI (p=0.04 and
p=0.02, respectively). No significant difference was seen in injury severity or variability among the remaining
major post concussive symptoms. Injury severity and variability, as indicated by skewness and kurtosis, did
correlate with initial symptom severity (r=0.288 and 0.280, p=0.02), but not neurocognitive testing, time to
recovery, or prior injury.
CONCLUSION
More severe injuries are seen in younger patients, sports-related injuries, and depression after mTBI. No
significant difference in the overall injury severity was seen among the remaining post-concussive symptoms.
CLINICAL RELEVANCE/APPLICATION
The more severe overall white matter injury seen in younger patients, sports-related concussion, and patients
with depression after mTBI may indicate groups at risk on which to focus future clinical trials and interventions.
SSC09-06
Association of Baseline Neuroimaging with Short-term and Long-term Clinical Outcomes in
Combat-related Traumatic Brain Injury
Jeffrey Ware MD (Presenter): Nothing to Disclose , Rosette Biester PhD : Nothing to Disclose , Elizabeth
Whipple MS : Nothing to Disclose , Keith Robinson MD : Nothing to Disclose , Richard Ross MD, PhD :
Nothing to Disclose , Paolo Nucifora MD, PhD : Nothing to Disclose
PURPOSE
Mild traumatic brain injury (m-TBI) is an increasingly-recognized clinical problem, particularly in military
populations which have seen a dramatic rise in the incidence of m-TBI over the past two decades. TBI has
therefore become known as the 'signature injury' of recent miltary operations, and it is associated with poor
neuropsychiatric outcomes. Clinical evaluation of veterans with m-TBI remains challenging due to difficulties in
establishing the diagnosis and selecting appropriate therapy. Reliable biomarkers are sought to improve not
only the sensitivity and specificity of m-TBI diagnosis, but also accuracy in predicting clinical outcome and
ultimately evaluating therapeutic efficacy.
METHOD AND MATERIALS
We performed a retrospective cohort study of veterans of Operation Enduring Freedom and Operation Iraqi
Freedom who were evaluated within a single VA hospital system from 2008-2013, screened positive for m-TBI,
and were referred for brain MRI including diffusion tensor imaging and a high resolution T1-weighted sequence.
Conventional MRI sequences were regarded as normal at clinical interpretation. Additional sequences were used
for derivation of diffusion metrics, brain morphometry, and structural connectivity. Veterans underwent baseline
clinical and neuropsychological evaluation. Clinical data were collected over a follow-up period of up to 6 years.
Imaging metrics were analyzed in group-wise fashion, in addition to regression with baseline and follow-up
clinical data.
RESULTS
Significant correlations between baseline imaging metrics and both short-term and long-term clinical outcomes
were identified. At the time of imaging, fractional anisotropy in left frontal lobe white matter was positively
correlated with percentile performance on the Trail-Making Test, a measure of executive function (p < 0.05).
Furthermore, fractional anisotropy was significantly reduced in multiple brain regions in m-TBI veterans who
were unemployed at the end of the follow up period compared to those able to obtain employment (p < 0.05).
CONCLUSION
Metrics derived from baseline neuroimaging are correlated with neurocognitive function and associated with
long term employment status.
CLINICAL RELEVANCE/APPLICATION
Our study suggests that neuroimaging metrics can predict short-term as well as long-term clinical outcomes,
building upon existing evidence for imaging biomarkers of m-TBI
SSC09-07
Prognostication of Coma Caused by Traumatic Brain Injury Using Quantification of Damage to
Individual White-matter Bundles in Diffusion Magnetic Resonance Imaging
Emad Ahmadi MD (Presenter): Nothing to Disclose , Anastasia Yendiki : Nothing to Disclose , Louis
Puybasset MD, PhD : Nothing to Disclose , Damien Pierre Galanaud MD, PhD : Research Consultant, Olea
Medical , Omid Khalilzadeh MD, MPH : Nothing to Disclose , Lionel Velly MD, PhD : Nothing to Disclose ,
Vincent Perlbarg PHD : Nothing to Disclose , Rajiv Gupta PhD, MD : Nothing to Disclose
PURPOSE
Quantification of injuries to white-matter (WM) bundles in diffusion magnetic resonance images (dMRI) has a
great potential for prognostication of coma caused by traumatic brain injury (TBI). We studied a new method for
reconstructing 18 WM bundles automatically in dMRI with the purpose of quantifying and localizing damage
along each bundle. We tested this method for predicting neurologic and cognitive outcomes caused by bundle
injuries in TBI-associated coma.
METHOD AND MATERIALS
We studied dMRI and T1 images of 53 patients who remained comatose at least 7 days after TBI, and 17
controls. We used Freesurfer for automatic segmentation and labeling of brain substructures in T1 images. Fully
automated probabilistic tractography was performed with TRACULA (Tracts Constrained by Underlying
Anatomy). Up to two diffusion orientations, corresponding to crossing fiber bundles, were fit to the dMRI data at
each voxel in WM. This information was combined with the structural segmentation extracted from T1 images
to reconstruct 18 WM bundles for each subject. Diffusion anisotropy and diffusivity were calculated at every
point along the trajectory of each bundle in each subject. These values were compared between subjects at
each point along each bundle. Comparisons were made between patients and controls, and between patients
with good and poor outcome. Clusterwise correction was used to correct for multiple comparisons. The injured
areas of WM bundles in each patient were then extracted by comparing each patient's anisotropy values along
WM bundles with the distribution of the same values in controls.
RESULTS
Thirteen WM bundles showed significant difference at least in one region of neighboring points between
comatose patients and controls, and 11 WM bundles showed significant difference at least in one region
between patients with good and poor outcome. The figure shows the injured areas of WM bundles in a patient
with poor outcome.
CONCLUSION
Our method for dMRI analysis using TRACULA allows us to extract clinically relevant information about the
integrity of each WM bundle that can differentiate between patients with good and poor outcome, and might
facilitate decision making for patients in coma caused by TBI.
CLINICAL RELEVANCE/APPLICATION
We have studied a new method for analysis and visualization of diffusion imaging, and have shown its use in
prognostication and decision making for patients with TBI-associated coma
SSC09-08
Assessment of Brain Volume Changes, White Matter Hyperintensities and Microbleeds in Concussed
Hockey Players Purpose
Alexander Rauscher PhD, MSc (Presenter): Advisory Board, F. Hoffmann-La Roche Ltd , Michael Jarrett
MSc : Nothing to Disclose , Elham Shahinfard : Nothing to Disclose , Enedino Hernandez Torres PhD :
Nothing to Disclose , Yinshan Zhao : Nothing to Disclose , Shiroy Dadachanji : Nothing to Disclose ,
Warren Rienzie Perera MBBS : Nothing to Disclose , Roger Tam PhD : Nothing to Disclose , Nancy Mary
Theresa Martin MD : Nothing to Disclose , Jack E. Taunton : Nothing to Disclose , David Kwok Boon Li MD :
Researcher, sanofi-aventis Group Researcher, F. Hoffmann-La Roche Ltd Researcher, Merck KGaA Researcher,
Novartis AG Researcher, Nuron Biotech, Inc Researcher, PAREXEL International Corporation Consultant,
sanofi-aventis Group Consultant, F. Hoffmann-La Roche Ltd Scientific Advisory Board, Novartis AG Scientific
Advisory Board, Nuron Biotech, Inc Scientific Advisory Board, Opexa Therapeutics, Inc
PURPOSE
Mild traumatic brain injury is common. We prospectively investigated brain volume (BV) changes, white matter
hyperintensities (WMHI) and microbleeds prospectively in a group of 45 male and female university ice hockey
players along with 15 age matched controls.
METHOD AND MATERIALS
All players underwent neuropsychological testing and 3T MRI (3D T1 spoiled gradient scho susceptibility
weighting imaging (SWI) with multiple echoes and 3D fluid-attenuated inversion recovery (FLAIR)) at the
beginning and the end of the season. Concussed athletes underwent additional imaging and neuropsychological
testing at 72 hours, two weeks, and two months post injury. WMHI and microbleeds were identified by two
radiologists by consensus, blinded to the clinical status and scan timing . Volume changes over time measured
using SIENA and were modeled by a linear mixed-effects model.
RESULTS
At the end of the hockey season, BV was reduced compared to baseline by 0.32% (p<0.001) in the whole
cohort and by 0.26% (p<0.01) in the concussed athletes. Two months after concussion, BV was reduced by
0.23% (p=0.016). No significant volume changes were found at 72 hours and two weeks after concussion, nor
in the control group. Hockey players had on average 3.5 WMHI compared to 2.1 per control. WMHI were
significantly (p < 0.001) closer to the cortical gray matter in hockey players (2.6 ± 2.6 mm) than in controls
(5.2 ± 1.7 mm). Only 1 player had a microbleed at baseline that persisted throughout the study.
CONCLUSION
The lack of increase in volume during the first two weeks after injury suggests that there is no edema related
increase in brain volume. The significant brain volume reduction in both the concussed and non-concussed
athletes at the end of the season suggests an association with playing hockey. WMHI were significantly closer
to the nearest gray matter in hockey players compared to controls but greater number was not significantly
associated with concussion. Microbleeds were uncommon.
CLINICAL RELEVANCE/APPLICATION
A deeper understanding of the changes in brain volume and lesion load after concussion, as assessed by MRI,
will help inform clinical interventions and return to play decisions.
SSC09-09
Blood on the Brain: Differentiation of Traumatic Cerebral Fat Embolism from Hemorrhagic Shear
Injury on MR Imaging
Mahmud Mossa-Basha MD (Presenter): Nothing to Disclose , Brian Eichinger MD : Nothing to Disclose ,
Manal El Refaei MD : Nothing to Disclose , Nafi Aygun MD : Nothing to Disclose , Daniel S. Hippe MS :
Research Grant, Koninklijke Philips NV Research Grant, General Electric Company
PURPOSE
The aim of this study is to compare the MR imaging characteristics of CFE and hemorrhagic DAI, as well as
compare findings on SWI and GRE in both disease processes.
METHOD AND MATERIALS
Adult patients were selected based on clinical characteristics of CFE, GCS of 14-15 at initial presentation with a
latent decline to <6T, no LOC at time of injury and normal initial head CT. Hemorrhagic DAI patients were
selected who presented with GCS<6T, no latent decline in GCS and no long bone fractures, to exclude the
possibility of superimposed CFE. A single double blinded rater evaluated the T2-FLAIR and DWI pattern and
extent of disease, and evaluated SWI and GRE for size, configuration and number of hemorrhagic lesions at the
following stations:frontal, parietal, occipital and temporal subcortical, periventricular and deep white matter,
medulla, pons, midbrain, cerebellum and striatocapsular regions. Hemorrhages were counted and categorized
accordingly:0, 1-5, 6-10, 11-20, >20 lesions at each station, and total lesions were also categorized:0, 1-10,
11-20, 21-100, 101-200, >200. Hemorrhage size was assessed on the following criteria: punctate<3, small
4-10, medium 10-20 and large>20 mm. Mann-Whitney statistical analysis test was performed at each station
and whole brain for each sequence and for hemorrhagic lesion size and shape.
RESULTS
12 patients with CFE and 16 patients with DAI were selected. 6 CFE had SWI only, 3 GRE and 3 had both. 11
DAI had SWI, and 5 had GRE only. CFE usually presented with confluent, patchy or punctate white matter
abnormalities on FLAIR, while DAI had better defined lesions intermediate in size. On DWI, CFE had significantly
more lesions (p=.027), typically with confluent or punctate abnormality. There was no significant difference in
the total number of hemorrhagic lesions (p=.72), but CFE had significantly more lesions in the pv (p=.0011)
and deep (p=.0061) white matter, brainstem and cerebellum. CFE hemorrhages were typically smaller
(p=.0061) and punctate or small, while DAI showed small and linear hemorrhages. There was a difference in
the number of hemorrhages seen on SWI and GRE for both diseases, but this was more pronounced for CFE.
CONCLUSION
CFE can be differentiated from DAI on MRI, and should be evaluated using SWI in place of GRE.
CLINICAL RELEVANCE/APPLICATION
Differentiation of CFE from hemorrhagic DAI is important for prognostic purposes, and in CFE can prevent future
events with prompt treatment of the cause.
SSC10
Neuroradiology (New Techniques in Brain Tumor Imaging)
Scientific Papers
MR NR
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credits: 1.50
Mon, Dec 1 10:30 AM - 12:00 PM
Location: N226
Participants
Moderator
Eu-Meng Law MBBS : Speakers Bureau, Toshiba Corporation Medical Advisory Board, Bayer AG Medical Advisory Board,
Bracco Group Medical Advisory Board, FUJIFILM Holdings Corporation
Moderator
Rivka Rachel Colen MD : Nothing to Disclose
Sub-Events
SSC10-01
Differentiation of Low Grade and High Grade Gliomas Using A Non-Gaussian Diffusion Imaging Model
Yi Sui MS (Presenter): Nothing to Disclose , Ying Xiong : Nothing to Disclose , Karen Xie DO : Nothing to
Disclose , Frederick C. Damen PhD : Nothing to Disclose , Xiaohong Joe Zhou PhD : Nothing to Disclose ,
Wenzhen Zhu MD, PhD : Nothing to Disclose
PURPOSE
To investigate the feasibility of using a set of novel parameters from a non-Gaussian diffusion imaging model to
differentiate low-grade from high-grade gliomas.
METHOD AND MATERIALS
The study was performed on 27 patients with diagnosed gliomas, including 13 WHO low grade (I or II) and 14
WHO high grade (III or IV) tumors. MRI scans were conducted at 3Tesla using an 8-channel head coil. In
addition to T1, T2, FLAIR and T1+C images, diffusion images with 17 b-values (0-4000 sec/mm2) were
acquired in order to apply a new non-Gaussian diffusion model, known as fractional order calculus (FROC)
model in which tissue microstructural information can be directly obtained. A set of FROC parametric maps
(ADC, intra-voxel tissue heterogeneity index β, and mean free diffusion length µ) was calculated. The tumor
ROIs were drawn on the diffusion images by an experienced neuro-radiologist, guided by anatomic images.
Areas of necrosis, cyst, hemorrhage and edema were avoided. The parameter values averaged from the entire
ROI of each tumor were used to differentiate low grade from high grade gliomas. ADC, β and µ were also
combined using a binary logistic regression method for tumor differentiation. The difference in those
parameters between the two tumor groups was analyzed using a Mann-Whitney U-test. The performance of
tumor differentiation was further evaluated by an ROC analysis on each individual parameter and the
combination of all parameters.
RESULTS
Significant differences between the low and high grade glioma groups were found in ADC (1.7 ± 0.5 µm2/ms vs
1.1 ± 0.4 µm2/ms, p = 0.005) and β (0.84 ± 0.06 vs 0.77 ± 0.04, p = 0.001), but not in µ (8.7 ± 0.6 µm vs
8.1 ± 0.7 µm, p = 0.06). The AUC values for ADC, β and µ were 0.817, 0.876 and 0.722, respectively,
suggesting that individually β was the best indicator. The AUC value was further increased to 0.953 when
combining all three parameters of the FROC diffusion model.
CONCLUSION
The use of high b-value diffusion MRI together with a non-Gaussian diffusion model - the FROC model - can
effectively differentiate high-grade from low-grade gliomas.
CLINICAL RELEVANCE/APPLICATION
High b-value diffusion imaging and non-Gaussian diffusion analysis have great potential for differential
diagnosis of gliomas, and thereby providing valuable information for glioma patient management.
SSC10-02
Development and Validation of a Quantitative Image Signature that Predicts Clinical Survival in
Glioblastoma
Haruka Itakura MD (Presenter): Nothing to Disclose , Achal Achrol : Nothing to Disclose , Tiffany Ting Liu
BS : Nothing to Disclose , Sebastian Echegaray MS : Nothing to Disclose , Joshua Joseph Loya BA, MS :
Nothing to Disclose , Abdullah H. Feroze BS : Nothing to Disclose , Lex Allen Mitchell MD : Nothing to
Disclose , Scott Rodriguez : Nothing to Disclose , Erick Michael Westbroek : Nothing to Disclose , Samuel H.
Cheshier MD : Nothing to Disclose , Gary K. Steinberg MD, PhD : Nothing to Disclose , Daniel L. Rubin MD,
MS : Nothing to Disclose , Kristen W. Yeom MD : Nothing to Disclose , Sandy Napel PhD : Medical
Advisory Board, Fovia, Inc Consultant, Carestream Health, Inc Scientific Advisor, EchoPixel, Inc , Griffith Harsh
: Nothing to Disclose , Olivier Gevaert PhD : Nothing to Disclose
PURPOSE
To develop and validate a univariate and multivariate model-based quantitative image signature to
prognosticate survival in glioblastoma multiforme (GBM)
METHOD AND MATERIALS
Preoperative MR imaging and survival data from 553 patients from two distinct cohorts with de novo GBM were
analyzed. First, we analyzed single-institution data on 360 subjects with GBM at our medical center. A
board-certified neuroradiologist delineated Regions-Of-Interest (ROIs) around areas of enhancement in each T1
post-contrast MR slice to define a 3D tumor volume. We computed quantitative image features (morphological
characteristics and pixel density statistics) from these 3D ROIs and compared them to 2D features derived
from the largest slice of the tumor volume. We applied Cox proportional hazards modeling to individual image
features with correction for multiple hypothesis testing to identify markers significantly correlated with survival.
We then performed multivariate Cox proportional hazards regression with L1-norm regularization to build a
parsimonious model that best approximated the survival outcome. Finally, we validated this multivariate model
on an independent, validation cohort, consisting of 193 subjects whose MR imaging and survival data were
obtained from The Cancer Imaging Archive and The Cancer Genome Atlas, respectively, and processed in the
same manner as above.
RESULTS
From the training and validation sets, we extracted 138 quantitative image features in 2D and 125 in 3D for
each patient. In the univariate Cox proportional hazards model, 38 2D and 42 3D image features were
significantly associated with survival after correcting for multiple hypothesis testing (P-value <0.05, FDR
<0.05). In the multivariate Cox model, combinations of six 2D features (p=0.009), and two 3D features
(p=0.0132), respectively, were significantly associated with survival. These particular features capture the
variability of the boundary shape, with smooth shapes correlated to good prognosis and irregular shapes
correlated with bad prognosis.
CONCLUSION
Univariate and multivariate combinations of quantitative image features from both 2D and 3D MR robustly
predicted survival in GBM. The predictive strength of these features was further confirmed using an independent
validation cohort.
CLINICAL RELEVANCE/APPLICATION
A robust quantitative image signature may constitute the basis of a clinical tool for noninvasively
prognosticating survival in patients with GBM.
SSC10-03
Utility of Amide Proton Transfer Imaging for Prediction of Recurrent Glioblastoma: Initial
Experience
Kye Jin Park MD (Presenter): Nothing to Disclose , Ho Sung Kim : Nothing to Disclose , Choong Gon
MD : Nothing to Disclose , Sang Joon Kim MD : Nothing to Disclose
Choi
PURPOSE
To test the predictive value of the amide proton transfer (APT) imaging for differentiating recurrent tumor from
treatment-related effect in patients with newly diagnosed glioblastomas.
METHOD AND MATERIALS
Twenty-seven consecutive patients who showed new or enlarged, contrast-enhancing lesions within the
radiation field after concurrent chemoradiotherapy were assessed by use of conventional MR imaging and APT
imaging. APT imaging was performed using a gradient-echo multishot echo-planar imaging with thirty
frequency offsets from + 5.0 to -5.0 ppm in 0.357 ppm step. The imaging parameters for APT were as follows:
echo time = 6.2 msec; a flip angle = 25 degree; RF irradiation power = 1.0µT; and saturation duration = 70
msec/shot. The calculated APT asymmetry map at the offset of 3.5 ppm is called the APT image. The APT signal
was measured on solid (APTsolid) and necrotic (APTnecrosis) of the enlarged contrast-enhancing lesion using
'hot-spot' method. Reference standard was pathology or clinico-radiologic diagnosis. The diagnostic performance
of APT parameter was determined by receiver operating characteristic curve (ROC) and leave-one-out cross
validation. Interreader agreement was assessed using intraclass correlation coefficient (ICC)
RESULTS
Twenty-seven patients were subsequently classified as having recurrent tumor (n=19) or treatment-related
effect (n=8). There was statistically significant differences of APTsolid between the two groups (median, 0.055
vs 0.024; P = .007). But APTnecrosis was not significantly different between the two groups (median, 0.004 vs
0.009; P =.339). ROC curve and leave-one-out cross validation showed the APTsolid to be the predictor of
recurrent tumor, with a sensitivity of 94.7% and a specificity of 71.4%. The ICCs for APTsolid and APTnecrosis
were 0.81 and 0.89.
CONCLUSION
APT signal on solid portion of enlarged contrast-enhancing lesion can be used for differentiating recurrent tumor
from treatment-related effect in patients with newly diagnosed glioblastomas.
CLINICAL RELEVANCE/APPLICATION
APT imaging can be a potential, noninvasive imaging biomarker for monitoring treatment response in patients
with newly diagnosed glioblastomas.
SSC10-04
Detection of 2-Hydroxyglutarate in Gliomas Using Spatial and Spectral 2D MR Spectroscopy:
Translation to the Clinic
Alexander Peter Lin PhD (Presenter): Nothing to Disclose , Raymond Y. Huang MD, PhD : Nothing to
Disclose , Sai Merugumala MS : Nothing to Disclose , Huijun Vicky Liao BS : Nothing to Disclose , Xi Long
MD : Nothing to Disclose , Srinivasan Mukundan MD, PhD : Institutional research support, Siemens AG
Institutional research support, Toshiba Corporation Consultant, Toshiba Corporation , David A. Reardon MD :
Research support, F. Hoffmann-La Roche Ltd Advisory Board, F. Hoffmann-La Roche Ltd , Patrick Y. Wen MD :
Research Consultant, F. Hoffmann-La Roche Ltd , Nils David Arvold MD : Nothing to Disclose
PURPOSE
Gliomas are the most common primary malignant brain tumor, yet MRI provides limited functional information
regarding tumor viability/activity and represents a major research and clinical challenge. Recent studies have
shown that magnetic resonance spectroscopy can be used to non-invasively measure 2-hydroxyglutarate (2HG)
in gliomas that harbor the isocitrate dehydrogenase 1 (IDH1) mutation, thus providing a highly specific
measure for diagnosis.
METHOD AND MATERIALS
In this study we utilize two methods of measuring 2HG: 1) 2D chemical shift imaging (2D-CSI) with an optimal
echo time of 97 ms to measure the 2HG resonance at 2.25 ppm from which spatial metabolic maps can be
produced (7 min scan). 2) 2D spectral MRS using single-voxel localized correlated spectroscopy (2D-COSY) of
64 increments of 0.8 ms with a starting TE=30 ms and 8 averages (12 min scan). 15 subjects with
pathologically confirmed gliomas were recruited and examined on a 3T Siemens Skyra using a 32 channel head
coil. 2D-CSI was post-processed using clinically available software on the MRI platform (Syngo, Siemens) as
well as LCmodel (Provencher). 2D-COSY was processed using commercially available software (FelixNMR) and
crosspeaks at 2.25-4.0 and 1.9-4.0 ppm were measured. IDH status was compared with both MRS analyses.
RESULTS
Results using bothof the methods were compared with histology: 10 IDH1-mutant, 5 IDH1-wildtype. 2D-CSI
provided useful metabolite maps of the 2HG signal that were highly specific. However, there were several cases
in IDH1-mutant gliomas in which baseline and phasing issues resulted in difficulty detecting 2HG. Fortunately in
those cases where 2D-CSI failed, 2D-COSY was able to detect 2HG signal due to the use of multiple crosspeaks
that can be used for analysis that are disambiguated from surrounding spectral signal. However, 2D-COSY
suffers from partial volume effects due to the large voxel size required for adequate SNR, but this is
complimented by 2D-CSI which provides excellent spatial coverage.
CONCLUSION
The combination of 2D-CSI to provide spatial resolution and 2D-COSY to provide spectral resolution, provided
the greatest sensitivity and specificity for the characterization of 2HG in IDH1-mutant gliomas.
CLINICAL RELEVANCE/APPLICATION
Developing MRS methods to detect 2HG for the diagnosis of IDH1-mutant gliomas presents a tremendous
opportunity, and might serve as a molecular imaging biomarker of glioma treatment response.
SSC10-05
Generic SVM Model for Preoperative Glioma Survival Associations: A Multi-center Validation Study
Kyrre Eeg Emblem MSc, PhD (Presenter): Intellectual property; NordicNeuroLab AS , Marco Cunha Pinho MD
: Nothing to Disclose , Frank G. Zoellner : Nothing to Disclose , Paulina Due-Tonnessen MD : Nothing to
Disclose , John K. Hald MD : Nothing to Disclose , Lothar R. Schad PhD : Nothing to Disclose , Torstein
Meling : Nothing to Disclose , Otto Rapalino MD : Nothing to Disclose , Atle Bjornerud MSC : Intellectual
property; NordicNeuroLab AS Board Member; NordicNeuroLab AS
PURPOSE
To develop a generic support vector machine (SVM) model using MRI-based blood volume distribution data for
preoperative glioma survival associations and to prospectively evaluate the diagnostic efficacy of this model in
autonomous patient data.
METHOD AND MATERIALS
Our study was approved by institutional and regional medical ethics committees. We retrospectively included
235 preoperative adult patients from two institutions with a subsequent histologically confirmed diagnosis of
glioma after surgery. A SVM learning technique was applied to whole-tumor relative cerebral blood volume
(rCBV) histograms from dynamic contrast enhanced MRI (1,2). SVM models with the highest diagnostic
accuracy for 6-months, 1-, 2-, and 3-year survival associations were trained on 101 patients from the first
institution. Using linear and cox regression analysis for diagnostic accuracy and survival associations,
respectively, the diagnostic efficacy of the SVM models were tested on independent data from 134 patients
from the second institution.
RESULTS
Compared to histopathology and presence of contrast enhancement, the whole-tumor rCBV-based SVM model
was the strongest parameter associated with 6-months, 1-, 2-, and 3-year survival in the independent patient
data (Chi-square = 25.49-48.43, P < 0.001; ROCAUC = 0.794-0.851). Results were corrected for known
survival predictors, including patient age, tumor size, neurologic performance and postsurgical treatment.
CONCLUSION
Computer aided diagnosis in glioma survival analysis can reduce operator measurement errors (3). Our data
show that SVM machine learning in combination with whole-tumor rCBV histogram analysis identifies early
patient survival in gliomas regardless of traditional clinical and histopathological features. The SVM models
presented are insensitive to patient- and institutional variations. (1) Boxerman JL, AJNR 2006; 27(4):859-67
(2) Emblem KE, JMRI 2013; doi:10.1002/jmri.24390. (3) Zacharaki EI, AJNR 2012; 33(6):1065-71
CLINICAL RELEVANCE/APPLICATION
Machine learning techniques have the potential to improve standardization of current advanced MRI methods
for preoperative glioma characterization and from this aid treatment planning.
SSC10-06
To Assess the Added Value and Diagnostic Performance of Intratumoral Susceptibility Signals (ITSS)
on High Resolution Susceptibility Weighted MR Imaging (HR-SWI) in the Differential Diagnosis of
Solitary Enhancing Brain Lesions (SEL)
Ritu Manoj Kakkar MBBS (Presenter): Nothing to Disclose , Sameer Surendra Soneji DMRD : Nothing to
Disclose , Vinayak Vishwanath Kabate MBBS, DMRD : Nothing to Disclose , Shrinivas Balaji Desai MD :
Nothing to Disclose
PURPOSE
Determine the benefit of using adjunctive HR-SWI for differentiating SEL of brain by assessing ITSSs compared
with conventional imaging alone. Grade the gliomas depending upon the presence of ITSS Compare results with
histopathology as the gold standard
METHOD AND MATERIALS
32 Patients (age 15-65) with SEL who met with the inclusion criteria for this study were retrospectively
reviewed from our database. Conventional MR and HR-SWI sequences were analysed. ITSS was defined as
low-signal-intensity fine linear or dot like structures, which are not obvious on conventional MR images, with or
without conglomeration within a tumor as depicted on HR-SWIs. ITSS were graded as Grade 1, no ITSS Grade
2, 1-10 dotlike or fine linear and Grade 3, as ≥ 11 dotlike or fine linear ITSSs. Sensitivity, Specificity, PPV, NPV
and diagnostic accuracy were calculated for both conventional imaging alone and with adjunctive HR- SWI
imaging, comparing with histopathology as gold standard.
RESULTS
2 radiologists diagnosed accurate tumor pathology within 6 categories (GBM, anaplastic astrocytoma,
metastatic tumor, lymphoma, tumefactive MS, and inflammatory granuloma) in 20 (62.5%) of 32 SELs on
conventional MR images alone and in 26 (81.3%) of 32 SELs after reviewing both conventional MR images and
HR-SWIs. The McNemar test showed statistically significant (P =0.031) difference in overall diagnostic accuracy
of conventional MR imaging versus using adjunctive HR-SWI .ITSSs were seen in all 9 GBMs (100%), in 1 of 2
(50%) anaplastic astrocytomas, and in 8 (72.7%) of 11 metastatic tumors and were not identified in
lymphomas and nontumorous lesions. Higher grade of ITSS (grade 3) are seen in 8 out 9 GBMs.
CONCLUSION
The use of ITSSs provides a benefit for the differential diagnosis of SELs compared with conventional imaging.
Presence of ITSS reflects increased intratumoral neovascularity and is indicative of higher grade of malignancy
.Lack of ITSS can be a specific sign in the imaging diagnosis of lymphomas or nontumorous lesions.
CLINICAL RELEVANCE/APPLICATION
HR-SWI should be included in MR evaluation of SELs, to further validate its role in differential diagnosis.HR- SWI
should be combined with proton spectroscopy and perfusion to accurately grade tumors non-invasively and
provide accurate site of biopsy.
SSC10-07
Comparative Study of Predictive Classification Models for MGMT Promoter Methylation Using
Imaging Features in Glioblastoma
Ginu A. Thomas MBBS (Presenter): Nothing to Disclose , Jixin Wang PhD : Nothing to Disclose , Pascal O.
Zinn MD : Nothing to Disclose , Rivka Rachel Colen MD : Nothing to Disclose
PURPOSE
To compare multiple predictive classification models used to predict MGMT methylation status in Glioblastoma.
METHOD AND MATERIALS
We identified 86 treatment-na�ve patients from The Cancer Genome Atlas (TCGA) who had both gene and
microRNA expression profiles (MGMT methylation status) and pretreatment MRI from The Cancer Imaging
Archive (TCIA). Qualitative VASARI imaging features for these 86 patients were assessed by 3 independent
neuroradiologists and consensus was reached. Quantitative volumetric analysis was done in the 3D Slicer
software 3.6(http://www.slicer.org) using segmentation module. Fluid Attenuated Inversion Recovery (FLAIR)
was used for segmentation of the edema and post-contrast T1 weighted imaging (T1W1) for segmentation of
enhancement (defined as tumor) and necrosis. Each qualitative and quantitative feature was correlated to
MGMT methylation status both independently and as groups and subgroups. Multiple classification models were
created via regression modeling and partition analysis using various combinations of variables. JMP Pro 11 was
used for modeling and statistical analysis.
RESULTS
Multiple classification models to predict MGMT promoter methylation status were created and compared. The
logistic regression model with quantitative volumetric variables, clinical variables and the qualitative variable
'diffusion' could predict MGMT methylation with an AUC of 0.847 with a sensitivity of 82% and a specificity of
83.8%.
CONCLUSION
MGMT methylation status plays an important role in patient predictive and prognostic stratification of patients
with GBM. The identification of a non-invasive biomarker signature as a surrogate for MGMT methylation can
help stratify patients in specific therapy and predict response versus non response to therapy. An imaging
genomic signature can be expected to promote a more robust personalized approach to patient care and
accelerate drug development and clinical trials.
CLINICAL RELEVANCE/APPLICATION
Imaging prediction of MGMT methylation status will help to specifically identify and treat those patients who
respond to therapy with Temozolomide.
SSC10-08
Imaging Glioblastoma Multiforme at 7T versus 3T: The More Tesla, the Better?
Lale Umutlu MD (Presenter): Consultant, Bayer AG , Anja Fischer MD : Nothing to Disclose , Cornelius
Deuschl : Nothing to Disclose , Jorg Hense : Nothing to Disclose , Thomas C. Lauenstein MD : Nothing to
Disclose , Michael Forsting MD : Nothing to Disclose , Mark E. Ladd PhD : Nothing to Disclose , Oliver
Kraff MSc : Nothing to Disclose , Marc U. Schlamann : Nothing to Disclose
PURPOSE
Glioblastoma multiforme is known to be the most common and most aggressive malignant primary brain tumor
in humans. Pretreatment assessment of exact localization, tumor extent and tumor-associated vasculature is
inevitable. With successful introduction of ultra-high-field brain MRI within the last few years and potential
benefits associated to the increase of the field strength, the aim of this trial was to compare the diagnostic
ability of tumor assessment utilizing 3T and 7T magnetic field strength.
METHOD AND MATERIALS
10 subjects were examined on a 3T MR scanner (Magnetom Skyra) and a 7T whole-body MR system
(Magnetom 7T; both Siemens Healthcare) utilizing 32-channel head coils (Siemens Healthcare). Inter-field
strength comparisons were performed for the following sequences: (1) SWI imaging (3T voxel size =
0.7x0.8x2.6 mm3; 7 Tesla voxel size = 0.25x0.25x1.0 mm3), (2) T2w FLAIR sequence (3T voxel size =
0.4x0.4x5.0 mm3 ; 7T voxel size = 0.6x0.6x5.0 mm3) and (3) a post-contrast T1-w 3D MPRAGE (3T voxel size
= 0.5x1.0x1.0 mm3; 7 Tesla voxel size 0.7x 0.7x 0.7mm3). Two radiologists assessed the delineation of the
(1) tumor in T1w MRI, (2) microvasculature in SWI imaging, (3) potential necrosis and edema in FLAIR
imaging, (4) overall image quality for all squences and (5) impairment due to artifacts utilizing a 5-point scale
(5= excellent to 1= non-diagnostic).
RESULTS
Visual analysis revealed an equivalently high delineation of tumor extent and morphology as well as
tumor-associated edema at both field strengths (MPRAGE 3T 4.7 vs MPRAGE 7T 4.9; FLAIR3T 4.6 vs Flair7T
4.6). 7T SWI MRI demonstrated its superiority, yielding a significant improvement in the assessment of
tumor-associated microvasculature (SWI 3T 3.8 vs SWI 7T 4.8). Evaluation of artifacts showed slightly stronger
image impairment for 7T imaging (mean3T 4.7 vs mean7T 4.3).
CONCLUSION
Both field strengths provide high-quality assessment of tumor extent, morphology and tumor-associated edema
/ necrosis, with 7T SWI imaging demonstrating its superiority in the assessment of tumor-associated
microvasculature, in terms of tumor-associated neoangiogenesis.
CLINICAL RELEVANCE/APPLICATION
7 Tesla enables superior assessment of tumor-associated neoangionesis, potentially allowing for superior
therapy monitoring of patients undergoing anti-angiogenic therapy.
SSC10-09
Magnetic Resonance Fingerprinting of Brain Tumors: Initial Clinical Results
Chaitra Ashok Badve MD, MBBS (Presenter): Nothing to Disclose , Alice Yu BS, MS : Nothing to Disclose ,
Dan Ma MS : Nothing to Disclose , Anagha Deshmane : Nothing to Disclose , Yun Jiang : Nothing to
Disclose , Andrew Sloan : Nothing to Disclose , Jeffrey Lloyd Sunshine MD, PhD : Research support,
Siemens AG Travel support, Siemens AG Travel support, Koninklijke Philips NV Travel support, Sectra AB Travel
support, Allscripts Healthcare Solutions, Inc , Vikas Gulani MD, PhD : Research support, Siemens AG ,
Mark A. Griswold PhD : Research support, Siemens AG Royalties, Siemens AG Royalties, General Electric
Company Royalties, Bruker Corporation Contract, Siemens AG
PURPOSE
Magnetic Resonance Fingerprinting (MRF) is a novel framework for simultaneous accurate quantitation of
multiple MR tissue properties. Here we apply MRF for evaluation of different types of intra-axial brain tumors.
METHOD AND MATERIALS
14 patients including 7 glioblastoma multiforme (GBM), 4 oligodendrogliomas (OG) and 3 metastases (METS)
were scanned using a MRF protocol. Imaging was acquired through representative areas of brain and
quantitative T1 and T2 maps were generated. T1 and T2 quantification of solid tumor component, immediate
perilesional white matter (PWM) within 1 cm from enhancing margin, and contralateral white matter (CWM)
was performed using ROI analysis. Student's t-test was used for statistical analysis.
RESULTS
Mean T1, T2 of solid parenchyma in GBMs (n = 7) were 1786 ± 243 ms; 131 ± 30 ms, respectively. T1, T2 of
abnormal signal within 1cm of enhancing margin in GBMs (n =7) were 1704 ± 471 ms; 130 ± 47 ms. T1, T2 for
solid parenchyma in METS were 1243 ± 132 ms; 104 ± 31 ms. Measurements were in agreement with published
literature. Tumor T1, T2 were different than T1, T2 of CWM (n=14, p < 3.8 x 10-7, p < 2.4 x 10-7). There was
difference between T1, T2 of PWM of GBMs and METS from their CWM (n=10, p<0.0002, p<0.0001). There was
difference between the T1 of solid regions of GBMs and METS (T1: p < 0.01). Also, there was difference
between the PWM of GBMs and METS (T1: p < 0.03; T2: p < 0.07). T2 relaxometry revealed difference between
GBMs and OGs (p < 0.04).
CONCLUSION
MRF is able to simultaneously measure T1 and T2 values of brain tumors and surrounding tissues. It can
distinguish with high statistical significance between tumor types and PWM changes from CWM. Preliminary
data supports using MRF to identify regions of infiltrative edema in GBM, and differentiation of tumor types and
grades.
CLINICAL RELEVANCE/APPLICATION
The preliminary data on MRF of brain tumors suggest application of this technique to identify, diagnose, and
offer prognosis of intracranial masses, delineation of tumor margins, and characterization of therapeutic
response.
SSC11
ISP: Physics (Diagnostic X-ray Imaging I: New Techniques/Systems)
Scientific Papers
PH
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credits: 1.50
Mon, Dec 1 10:30 AM - 12:00 PM
Location: S504CD
Participants
Moderator
Andrew Karellas PhD : Research collaboration, Koning Corporation
Moderator
Wei Zhao PhD : Research Grant, Siemens AG
Sub-Events
SSC11-01
Physics Keynote Speaker: New X-Ray Imaging Technology in Established and New Clinical
Applications
Andrew
SSC11-03
Karellas PhD (Presenter): Research collaboration, Koning Corporation
In vivo X-ray Phase-contrast and Dark-field Small-animal CT Imaging
Andre Yaroshenko (Presenter): Nothing to Disclose , Astrid Velroyen : Nothing to Disclose , Katharina
Hellbach MD : Nothing to Disclose , Martin Bech : Nothing to Disclose , Felix G. Meinel MD : Nothing to
Disclose , Konstantin Nikolaou MD : Speakers Bureau, Siemens AG Speakers Bureau, Bracco Group Speakers
Bureau, Bayer AG , Maximilian F. Reiser MD : Nothing to Disclose , Oliver Eickelberg : Nothing to Disclose ,
Ali Onder Yildirim : Nothing to Disclose , Franz Pfeiffer : Nothing to Disclose
CONCLUSION
The obtained results are proof-of-principle results, demonstrating the feasibility to acquire in vivo small-animal
phase-contrast and dark-field CT scans with a grating interferometer. The obtained results reveal the high
potential and diagnostic value of x-ray dark-field lung imaging. The estimated animal dose is compatible with
longitudinal studies.
Background
X-ray phase-contrast and dark-field imaging are two imaging modalities that have the potential to significantly
increase the soft-tissue contrast and yield complementary information. Recently a method has been developed
that makes it possible to acquire these imaging modalities with a conventional polychromatic laboratory source.
The approach is based on the introduction of a three-grating Talbot-Lau interferometer into the beam.
However, it has been questioned weather this approach is applicable for in vivo CT scans, where interferometer
stability, image acquisition speed and patient dose have to be taken into account.
Discussion
The dark-field CT reveals information about structures below the resolution limit of the system. Thus, dark-field
can visualize the alveolar network of the lung. The regions affected by pulmonary emphysema could be clearly
visualized and a substantial difference in the signal was observed compared to the healthy animal. Thus,
dark-field CT offers additional diagnostic value for pulmonary imaging.
Evaluation
An in vivo CT of the thorax region of a healthy 10-week-old C57BL/6N mouse was acquired. Subsequently, a
mouse with pulmonary emphysema was imaged. To induce a phenotype of human-like emphysema, a solution
of pancreatic elastase was applied orotracheally (80 U per kilogram of body weight) to the mouse. During image
acquisition the mice were breathing freely. The measurements were performed with a compact preclinical
small-animal CT scanner. The scanner acquires conventional x-ray absorption simultaneously with
phase-contrast and dark-field images. The reconstructed tomography results were evaluated with respect to the
diagnostic value and compared to histological findings. The scan dose was estimated using a phantom.
SSC11-04
Direct Conversion X-ray Imager with 25 Micron Pixel Resolution for Medical Imaging Applications
Christopher C. Scott BSC (Presenter): Research Grant, Teledyne Technologies Incorporated , Shiva
Abbaszadeh : Research Grant, Teledyne Technologies Incorporated , Sina Ghanbarzadeh : Nothing to
Disclose , Gary Allan PhD : Employee, Teledyne Technologies Incorporated , Michael Farrier : Contract,
Teledyne Technologies Incorporated , Ian A. Cunningham PhD : Founder, DQE Instruments Inc , Karim S.
Karim PhD : Research Grant, Teledyne Technologies Incorporated
CONCLUSION
We believe this detector stands as one of the highest spatial resolution x-ray detectors reported to date for
diagnostic x-ray energies and shows promise for high DQE, low dose imaging.
Background
The high inherent spatial resolution of amorphous selenium (a-Se) makes it naturally suited for modalities such
as mammography, micro-angiography, and micro-CT where the feature sizes of significance are small.
However, the resolution of commercial a-Se detectors is limited entirely by pixel size (e.g. 70-85 micron) and
not by the fundamental material limit. The real challenge with smaller pixel sizes is lower signal-to-noise ratio
where image quality is at risk of being limited by the noisy amorphous silicon backplane used in all
commercially available a-Se detectors. We have developed a high resolution detector by integrating a-Se with a
complementary metal-oxide-semiconductor (CMOS) backplane. CMOS technology allows for detector operation
with much lower electronic noise, facilitating a reduction in pixel size to 25 micron for an increase in resolution
without degradation of signal-to-noise performance.
Evaluation
To predict detector performance both the modulation transfer function (MTF) and detective quantum efficiency
(DQE) were modeled. Images for the performance evaluation were captured using a tungsten x-ray source
operated at 40 kV. The MTF was calculated from the measured edge-spread function. DQE is a work in
progress, although estimates are made based on measured MTF and a predicted noise power spectrum.
Discussion
The detector MTF was measured to be 0.93, 0.75, 0.57 and 0.41 at 5, 10, 15, and 20 lp/mm respectively.
These values are consistent with our predictions and indicate very high resolution. Our 92 micron a-Se layer
has non-optimal absorption efficiency for a 40 kV spectrum. However, the DQE modeled at 28 mR exposure is
relatively high over a large frequency range with values of 0.50, 0.43 and 0.22 at 0, 10 and 20 lp/mm. When
the model is evaluated for a scenario representative of standard mammography (30 kV Mo, 200 micron a-Se
layer, 12 mR exposure) the DQE is 0.81, 0.65, and 0.33 at 0, 10 and 20 lp/mm. These results represent a
significant improvement over current a-Se technology.
SSC11-05
Grating Based Differential Phase Contrast Imaging in Digital Breast Tomosynthesis: Imaging
Performance with an Analyzer Grating
John W. Garrett MS (Presenter): Nothing to Disclose , Wei Zhao PhD : Nothing to Disclose , Yongshuai
: Nothing to Disclose , Ke Li PhD : Nothing to Disclose , Guang-Hong Chen PhD : Research funded,
General Electric Company Research funded, Siemens AG Research funded, Varian Medical Systems, Inc
Research funded, Hologic, Inc
Ge
PURPOSE
Grating-based X-ray differential phase contrast imaging (DPCI) has the potential to add two additional imaging
contrasts (in addition to x-ray attenuation) to digital breast tomosynthesis (DBT): differential phase contrast
and dark field. An analyzer grating used in this method is characterized by a high aspect ratio and essentially
acts as a one-dimensional anti-scatter grid. The purpose of this work is to determine the impact of this grating
on scatter rejection and overall image quality of absorption DBT images.
METHOD AND MATERIALS
Monte-Carlo modelling (GATE 6.2.0 simulation toolkit) was used to predict the scatter performance of a DBT
system (Hologic Selenia Dimensions, Hologic, Inc.) with and without an analyzer grating present. A novel
in-house design for the G2 grating was used; for simulation, a 40% duty cycle was used for the grating with a
depth of 50 µm Au. The width of the gold septa was 2.12 µm. A 5 cm-thick phantom simulating 50/50
adipose/glandular breast tissue was placed on the breast support 2.5 cm above the detector. The
scatter-to-primary ratio (SPR) and contrast-to-noise ratio (CNR) were quantified with and without the presence
of the analyzer grating in the x-ray beam. Experimental validation with the same system setup was performed
to validate the SPR and CNR values without the gratings.
RESULTS
The Monte-Carlo prediction for the SPR in the 5 cm thick breast matched the measured values within about
10% across the image field of view. The introduction of the analyzer grating stopped about 37% of
post-phantom photons while reducing the SPR from 0.45 to 0.20. This resulted in an equivalent CNR to that
without the grating for a given exposure. No grid lines were observed in the measured image due to the
ultra-fine pitch of the grating when compared with the detector pixel size. The one-dimensional grating
structure that was aligned parallel to the chest wall so as not to block additional x-rays incident from oblique
angles during the DBT data acquisition.
CONCLUSION
A carefully designed Talbot-Lau interferometer can be introduced in existing DBT systems to provide two
additional imaging contrast mechanisms without degradation the imaging performance of absorption contrast
DBT imaging.
CLINICAL RELEVANCE/APPLICATION
The introduction of a Talbot-Lau interferometer in a digital breast tomosynthesis system provides additional
diagnostic information without degrading imaging performance for a fixed exposure.
SSC11-06
Non-invasive Microcalcification Classification Using X-ray Phase-contrast Mammography
Zhentian Wang PhD : Nothing to Disclose , Nik Hauser MD : Nothing to Disclose , Gad Singer MD :
Nothing to Disclose , Rahel A. Kubik-Huch MD : Nothing to Disclose , Marco Stampanoni PhD (Presenter):
Nothing to Disclose
PURPOSE
Microcalcifications are an important indicator in breast cancer diagnosis. Two kinds (Type I and Type II) of
microcalcifications of different chemical composition are known to correlate with benign and malignant breast
lesions. We developed a method (Nature Communications, in press) to distinguish among them in a
non-invasive way. In this work we test the hypothesis that the positive predictive value of our method is about
2x larger than that of conventional mammography.
METHOD AND MATERIALS
Phase contrast mammography using grating interferometry provides absorption, phase and small-angle
scattering contrast of the breast simultaneously. Our microcalcification classification approach relies on the
observation that Type I and Type II microcalcifications show opposite absorption and small-angle scattering
signals. Compared with conventional mammography, the new approach reflects the internal crystal structure of
the microcalcifications in addition to their morphological information. We are currently testing our hypothesis on
biopsy samples (8 Gauge) of 20 patients (statistical power/significance of 0.8/0.05) referred for suspicious
microcalcifications, classified as BIRADS-3 and -4, undergoing vacuum assisted breast Mammotome biopsy.
RESULTS
The new approach has 100% specificity and sensibility when applied to phantom data as shown in our recent
work. At the RSNA, we will provide evidence of the solidity of the technique by statistically analyzing its
discrimination power when applied to fixed tissue specimens.
CONCLUSION
We report a non-invasive approach to classify microcalcifications based on phase contrast X-ray imaging. The
proposed method might be further developed to improve early breast cancer diagnosis and has the potential to
increase the diagnostic accuracy and reduce the number of breast biopsies, or, in case of widespread
microcalcifications, to select the optimal biopsy site before intervention.
CLINICAL RELEVANCE/APPLICATION
Phase contrast X-ray imaging using Talbot-Lau grating interferometry can distinguish two types of
microcalcification non-invasively, providing additional diagnostic hints for early breast cancer detection.
SSC11-07
Open Trajectory Cone-beam CT Acquisition Improves Liver Visualization during IR Procedures
Ruediger Egbert Schernthaner MD (Presenter): Nothing to Disclose , MingDe Lin PhD : Employee,
Koninklijke Philips NV , Rafael Duran MD : Nothing to Disclose , Julius Chapiro MD : Nothing to Disclose ,
Zhijun Wang MD : Nothing to Disclose , Jean-Francois H. Geschwind MD : Consultant, BTG International
Ltd Consultant, Bayer AG Consultant, Guerbet SA Consultant, Nordion, Inc Grant, BTG International Ltd Grant,
F. Hoffmann-La Roche Ltd Grant, Bayer AG Grant, Koninklijke Philips NV Grant, Nordion, Inc Grant,
ContextVision AB Grant, CeloNova BioSciences, Inc Founder, PreScience Labs, LLC CEO, PreScience Labs, LLC
CONCLUSION
The open trajectory CBCT acquisition allows more complete depiction of the whole liver.
Background
Cone-beam CT (CBCT) facilitates intra-procedural visualization and assessment of liver cancer during
intra-arterial therapies (IAT). However, high BMI patients present a challenge to the image acquisition in terms
of capturing the liver region of interest while still allowing for the C-arm to rotate around the patient. The
geometric motion of the C-arm at our institution (Allura FD20, Philips Healthcare, Best, The Netherlands) was
modified to rotate from 55 to -185 degrees (open trajectory) instead of 120 to -120 degrees (closed
trajectory). All other imaging parameters are the same. This opens up room for asymmetrical positioning of the
patient, allowing for centering of the liver, rather than the spine, in the field of view (FOV).
Evaluation
The purpose of this study was to evaluate the open trajectory in visualizing more of the liver. 10 patients who
underwent two sessions of IAT had CBCT acquisitions with both the closed (during 1st IAT session) and open
(during 2nd IAT session) trajectories. The volume of the whole liver as seen on intra-procedural CBCT for both
trajectories and the pre-IAT MRI were measured using a 3D segmentation software. The CBCT volumes were
compared to the corresponding pre-interventional MRI in terms of measured liver volume and number of missed
or partially depicted lesions. MRI was used as the standard given its larger FOV to capture the entire liver and
all lesions.
Discussion
Two patients had severe breathing artifacts during CBCT acquisition and had to be excluded, leaving 8 patients
for further analysis. The median BMI of these patients was 27.5 (range 15.8-39.3). The closed CBCT trajectory
covered a median liver volume of 89% (1630 cc) that of the MRI, whereas the open trajectory covered 96%
(1711 cc). In 3 out of 8 patients (37.5%), intrahepatic lesions were either missed or only partially depicted due
to the limited coverage of the close trajectory. All lesions (100%) were completely depicted using the open
trajectory.
SSC11-08
Renal Stone Assessment with X-ray Dark-field Radiography
Marian Willner (Presenter): Nothing to Disclose , Kai Scherer : Nothing to Disclose , Michael Chabior :
Nothing to Disclose , Eva Braig : Nothing to Disclose , Konstantin Willer : Nothing to Disclose , Julia
Herzen : Nothing to Disclose , Alexander Andre Fingerle MD : Nothing to Disclose , Matthias Johannes Eiber
MD : Speaker, Siemens AG Speaker, Astellas Group Speaker, Johnson & Johnson , Peter B. Noel PhD :
Nothing to Disclose , Ernst J. Rummeny MD : Nothing to Disclose , Franz Pfeiffer : Nothing to Disclose
PURPOSE
Knowledge of the composition of urinary calculi is a fundamental part of the preoperative patient evaluation and
this information influences treatment plans and recurrence prevention. The most common techniques for stone
analysis are in-vitro and require removal of exemplary stones. Recently, the characterization of renal stones has
been demonstrated to be feasible using dual-energy computed tomography. The objective of this study is to
evaluate the potential of the lately developed X-ray dark-field (scattering) contrast to differentiate most
common types of urinary calculi in radiographic imaging.
METHOD AND MATERIALS
A total of 113 extracted urinary calculi from 18 patients were imaged at a compact laboratory setup using a
three-grating Talbot-Lau interferometer and a conventional X-ray tube operated at 40 kV. Corresponding
attenuation and dark-field (scattering) signals were evaluated and matched to the respective stone
compositions determined by Fourier-transform infrared spectroscopy. The analysis included 63 calciumoxolate
stones from nine patients, 10 uric acid stones from four patients and further 40 stones of diverse composition
from five patients.
RESULTS
Calciumoxolate and uric acid stones could be clearly differentiated by their distinct attenuation and scattering
behaviour. While the calcified calculi present as high absorbing masses with rather low dark-field contrast, the
uric acid stones yield a strong scattering signal due to their crystalline inner structure. The discrimination of the
two types of calculi could be repeated with stones embedded in renal tissue of 4 cm thickness and an applied
dose exposure below 5 mSv. The mixed stones showed intermediate attenuation-scattering ratios.
CONCLUSION
Our work demonstrates the potential of the dark-field (scattering) signal as additional imaging contrast to
perform renal stone assessment in X-ray radiography.
CLINICAL RELEVANCE/APPLICATION
X-ray dark-field (scattering) contrast might complement conventional radiographic imaging to allow for
characterization of urinary calculi.
SSC11-09
Physiologically Gated Stationary Chest Tomosynthesis System Using CNT X-ray Source Array
Jing Shan (Presenter): Nothing to Disclose , Laurel Burk : Nothing to Disclose , Yueh Z. Lee MD, PhD :
Research Grant, Carestream Health, Inc , Michael David Heath : Nothing to Disclose , Xiaohui Wang PhD :
Employee, Carestream Health, Inc , David Foos MS : Employee, Carestream Health, Inc , Jianping Lu :
Research Grant, Carestream Health, Inc , Otto Zhou PhD : Board of Directors, XinRay Systems Inc Research
Grant, Carestream Health, Inc
PURPOSE
We investigated the feasibility of physiologically-gated stationary chest tomosynthesis (s-DCT) with carbon
nanotube (CNT) x-ray source array, and studied the image quality improvement from prospective gating.
METHOD AND MATERIALS
A bench-top s-DCT system was constructed using a CNT source array and a flat panel detector (Varian Medical
Systems Inc., CA). We demonstrated the feasibility of s-DCT using CNT source array. CNT X-ray sources can be
electronically switched on/off rapidly, allowing physiological signal gated tomosynthesis imaging. Pig lungs and
heart were ventilated inside of an anthropomorphic chest phantom to simulate lung respiration motion with
respiration cycle periods and volumes comparable to typical human breath. A pneumatic pressure based
respiration signal was acquired using BioVet (m2m Imaging Corp., OH). Small metal beads placed on the lungs
quantitatively measured image blur from respiratory motion. AP chest projection images were acquired at
various imaging acquisition speeds, breath periods, and respiratory phases, with and without gating. Multiple
gated images were acquired per respiration cycle. Tomosynthesis images were reconstructed using commercial
software (Realtime Tomography LLC, PA) and analyzed to evaluate the effect of gating on image quality.
RESULTS
Tomosynthesis images acquired of non-gated ventilated lung show blurred airways and vascular structures.
Without gating, the beads were blurred to 3.75mm compared to 2mm in motionless control images. When
X-ray beams were prospectively gated to end of inhalation phase or the end of exhalation phase of respiration
cycle, image quality was greatly improved, with sharper airway edges and more visible structural details. Bead
width was 2.25mm for both cases, an 85.7% decrease of motion blur.
CONCLUSION
When tomosynthesis scanning time equals or exceeds a respiration period, image quality is degraded by
motion. We demonstrated the feasibility of physiological gated s-DCT imaging using CNT source array. The
s-DCT system allows prospective gating to any phase of the respiration cycle, substantially reducing blur
associated with lung motion even with image acquisition over several respiration cycles.
CLINICAL RELEVANCE/APPLICATION
Imaging quality can be greatly improved with physiological gated s-DCT, which can improve the imaging
outcome for patients who cannot easily maintain their breath hold.
SSC12
Physics (Computed Tomography II: Dual-energy/Spectral CT)
Scientific Papers
PH
CT
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credits: 1.50
Mon, Dec 1 10:30 AM - 12:00 PM
Location: S403B
Participants
Moderator
Jeffrey H. Siewerdsen PhD : Research Grant, Siemens AG Consultant, Siemens AG Research Grant, Carestream Health, Inc
Royalties, Elekta AB
Moderator
Katsuyuki Taguchi PhD : Research Grant, Siemens AG
Sub-Events
SSC12-01
Comparison of Estimated Organ Doses with Two Radiation Dose Estimation Software
Atul Padole MD (Presenter): Nothing to Disclose , Sarabjeet Singh MD : Research Grant, Siemens AG
Research Grant, Toshiba Corporation Research Grant, General Electric Company Research Grant, Koninklijke
Philips NV , Yiming Gao : Nothing to Disclose , Ranish Deedar Ali Khawaja MD : Nothing to Disclose ,
Diego Alfonso Lira MD : Nothing to Disclose , Mannudeep K. S. Kalra MD : Nothing to Disclose , Madan M.
Rehani : Nothing to Disclose , Da Zhang PhD : Nothing to Disclose , Bob Liu PhD : Nothing to Disclose ,
George Xu PhD : Nothing to Disclose
PURPOSE
To compare the estimated organ doses obtained from two radiation dose estimation software for chest CT
examinations in adult patients of different sizes.
METHOD AND MATERIALS
In an IRB-approved, HIPAA compliant study, we included 60 patients (mean age: 62 ± 9 years; M: F=29:31)
undergoing chest CT for lung nodule follow up on a 16-slice MDCT (GE LightSpeed Pro 16). Based on weight,
patients were divided into 3 groups (20 patients each); < 61 kg, 61-91 kg, and > 91 kg. Automatic dose
monitoring software, eXposure (Radimetrics Inc.) and VirtualDose (Virtual Phantoms, Inc.) were used to obtain
patients' organ doses. Organ doses for following organs adrenal glands, breast, esophagus, heart, lungs,
stomach, liver, spleen, and kidney were recorded form two software was calculated. Scan parameters including
kV, fixed mAs, scan length, rotation time, pitch, and beam collimation, CTDIvol, and DLP were also recorded.
The difference between organ doses obtained from software. Paired t-tests were used to compare difference in
The difference between organ doses obtained from software. Paired t-tests were used to compare difference in
the organ doses, P-value of 0.05 with 95% confidence interval was considered significant.
RESULTS
The mean CTDIvol were 3.2 mGy (<61 kg), 4.8 mGy (61-91 kg), and 7 mGy (>91 kg). The organ doses for
adrenal glands, breast, esophagus, heart, lungs, stomach, liver, spleen, and kidney obtained from eXposure
were significantly greater compared to organ doses obtained from VirtualDose software (p<0.001). Mean (±
standard deviation) difference in organ doses between the both software were 1.24 ± 0.6 mSv (<61 kg), 2.1 ±
0.8 mSv (61-91 kg), 3.9 ± 1.2 mSv (>91 kg) (p<0.001). The minimum and maximum difference in organ
doses estimated with the two software was for adrenal (12-14%) and esophagus (53-61%), respectively.
CONCLUSION
The organ doses obtained from eXposure software were substantially greater compared to VirtualDose software
for patients with different weight group. Marked difference in the organ doses was noted for patients with
greater body weight.
CLINICAL RELEVANCE/APPLICATION
Accurate determination of patient size is important for estimating organ doses as observed with radiation dose
estimating software.
SSC12-02
Differentiation of Low-attenuation Intracranial Hemorrhage and Calcification Using Dual-energy
Computed Tomography in a Phantom System
Jessica Lee Nute MS (Presenter): Nothing to Disclose , Megan Jacobsen : Nothing to Disclose , Dawid
Schellingerhout MD : Nothing to Disclose , Jim W. Pennington : Nothing to Disclose , Adam Grant Chandler
PhD : Employee, General Electric Company , Dianna D. Cody PhD : In-kind support, General Electric
Company
PURPOSE
Intracranial hemorrhage and calcification with Single-Energy CT (SECT) attenuation levels below 100 HU cannot
be reliably differentiated using currently clinically available means. Calcification is typically benign but
hemorrhage can carry a risk of intracranial bleeding and contraindicate use of anticoagulant therapies. A
biologically relevant phantom was constructed to examine the effects of lesion size, lesion location, and scan
technique on the differentiating power of Dual-Energy CT (DECT).
METHOD AND MATERIALS
Spectrally-equivalent brain material was fit into the cranial cavity of an anthropomorphic head phantom.
Cylindrical lesion models (diameters: 0.5, 1.0 and 1.5cm) were created by adding calcium carbonate or ferric
oxide to the background brain material. Seven sets of lesion models were created at matched SECT HUs from
40 to 100HU. Lesion models of each size were placed in the cerebrum, while just the largest lesion size was
placed in the skull base. The phantom was scanned using a SECT routine brain protocol to verify the HU
matching of the lesions as well as five DECT protocols representing CTDIvol levels from 27 to 81mGy each
using four image thicknesses: 1.25, 2.5, 3.75 and 5mm. Each scan was reconstructed using a water/calcium
material density pair. A two-component, 3D Gaussian mixture model was applied using a 50/50
training/validation approach. Accuracy of differentiation was calculated by comparing predicted voxel
assignments with actual voxel identities.
RESULTS
Accuracy of differentiation improved with increasing dose, image thickness and lesion size. Accuracy was also
notably poor in the skull base region. Using our current analysis method, differentiation was feasible in the
cerebrum down to 70HU with close to 90% accuracy when 5mm images and 67mGy CTDIvol were applied to
the 1.5cm lesions.
CONCLUSION
SEHU matched hemorrhage and calcification models less than 100HU could be distinguished using DECT. Future
work will include expanded scan acquisition parameter sets and more sophisticated statistical analysis, which
may provide stronger results.
CLINICAL RELEVANCE/APPLICATION
The ability to distinguish between intracranial calcifications and hemorrhages using dual energy CT may help
guide the use of anti-coagulant medications.
SSC12-03
Dose Efficiency of Virtual Non-contrast Imaging from Optimal kV Combination in Dual-energy CT
Lifeng Yu PhD (Presenter): Nothing to Disclose , Joshua Grimes PhD : Nothing to Disclose , Shuai Leng
PhD : Nothing to Disclose , Joel Garland Fletcher MD : Grant, Siemens AG , Cynthia H. McCollough PhD :
Research Grant, Siemens AG
PURPOSE
PURPOSE
The purpose of this work was to determine the dose efficiency of virtual non-contrast (VNC) imaging from
various kV combinations in dual-energy (DE) CT if the VNC were to replace the true non-contrast (TNC) scan,
and to select the optimal kV combination for different patient attenuation levels.
METHOD AND MATERIALS
VNC image quality is fundamentally limited by the noise magnification in the material decomposition, which is
determined by both the spectrum separation and the noise in the original low- and high-kV images. For the
commercially available 5 DE kV combinations: 70/150Sn ("Sn": an added tin filter), 80/150Sn, 90/150Sn,
100/150Sn, and 80/140, we derived the lowest noise on the VNC image that is achievable when the optimal
dose fractions at low- and high-kV scans were used, given a fixed total radiation output. The lowest VNC noise
was compared with the noise in optimally mixed images to calculate the percent of dose reduction at each kV
combination if VNC were to replace the TNC scan. The effect of patient attenuation was studied by scanning a
series of semi-anthropomorphic phantoms with lateral width of 25, 30, 35, 40, 45, and 50 cm at each of the 5
kV combinations. To determine the optimal DE kV combination used for each phantom size, the noise power
spectrum (NPS) at each lower kV was measured and compared with a reference single energy 120 kV, and the
artifacts due to photon starvation, if any, were analyzed. Finally, the dose reduction by VNC at each kV
combination for the applicable phantom sizes was determined.
RESULTS
The optimal DE kV combination was determined for each phantom size (25 cm: 70/Sn150, 30 cm: 80/Sn150,
35 cm: 80/Sn150, 40 cm: 90/Sn150, 45 cm: 100/Sn150, 50 cm: none). The dose reduction achievable by VNC
increases with more separation of the spectra between low- and high-kV x-ray beams. For a 25 cm phantom
that all kV are applicable, the dose reductions were 39%, 35%, 30%, 27%, and 10% for 70/150Sn, 80/150Sn,
90/150Sn, 100/150Sn, and 80/140, respectively.
CONCLUSION
With the optimal DE kV combination, radiation dose reduction achievable by using VNC to eliminate the true
non-contrast scan increases from 10% to up to 39% for adult patients.
CLINICAL RELEVANCE/APPLICATION
Optimal DE kV combination was determined for different patient attenuation levels. The amount of dose
reduction achievable by VNC imaging increases from 10% to up to 39% for adult patients when using these
optimal DE kV combinations.
SSC12-04
Use of Dynamic Focal Spot Control to Reduce Focal Spot Blooming in CT, and Its Impact on
High-contrast Spatial Resolution
Xinhui Duan PhD : Nothing to Disclose , Joshua Grimes PhD (Presenter): Nothing to Disclose , Lifeng Yu
PhD : Nothing to Disclose , Shuai Leng PhD : Nothing to Disclose , Cynthia H. McCollough PhD : Research
Grant, Siemens AG
PURPOSE
To measure the effect of focal spot blooming on CT spatial resolution, and to evaluate the ability of quadrapole
dynamic focusing to counteract focal spot blooming as x-ray tube current and potential are changed.
METHOD AND MATERIALS
High-contrast spatial resolution was evaluated 1) in-plane by scanning a wire phantom (tantalum wire, 0.125
mm diameter, suspended in air) to measure modulation transfer function (MTF) and 2) along the z-axis by
scanning a foil phantom (50 micron thick, 1 mm diameter gold foil) to measures slice sensitivity profile (SSP).
Phantoms were scanned at 70-150 kV on a Siemens Force scanner with dynamic focal spot control, and 70-140
kV on a Siemens Definition Flash scanner, with tube current ranging from 100 mA to the maximum available on
each system. Images were reconstructed using 0.6 mm image thickness and 50 mm field-of-view with smooth
(Force: Br36 and Flash: B30) and sharp (Force: Br64 and Flash: B70) kernels.
RESULTS
The variation in spatial resolution in the axial plane was much smaller on Force scanner than the Flash scanner
as tube current and voltage changed. Comparing the spatial frequencies at the 50% values of the MTF curves,
the difference between the minimum and maximum values for all kV-mA combinations was 3.0% for the
smooth kernel and 4.7% for the sharp kernel on the Force scanner. These values were 10.5% and 21.9%,
respectively, for the Flash scanner. The full-width-at-half-maximum (FWHM) of the SSP increased on both
systems, but increased more slowly as tube current increased on the Force scanner (0.096 mm and 0.11 mm
per 1000 mA for the smooth and the sharp kernels, respectively) than the Flash scanner (0.19 mm and 0.17
mm per 1000 mA).
CONCLUSION
The x-ray tube equipped with dynamic focal spot control on a recently-introduced scanner greatly reduced
blooming effects, keeping the in-plane spatial resolution constant over a large range of tube currents and
voltages.
CLINICAL RELEVANCE/APPLICATION
Technical measures to limit focal spot blooming are important, especially at low kV and high mA, which is
relevant in children and smaller adults, and for dual-energy scanning.
SSC12-05
Value of an Advanced Image-based Technique to Calculate Virtual Monoenergetic CT Images Using
Third-generation Dual-energy Dual-source CT to Improve Contrast-to-Noise Ratio in Liver
Examinations
Carlo Nicola de Cecco MD (Presenter): Nothing to Disclose , James Spearman : Nothing to Disclose , U.
Joseph Schoepf MD : Research Grant, Bracco Group Research Grant, Bayer AG Research Grant, General
Electric Company Research Grant, Siemens AG , Christian Canstein : Employee, Siemens AG , Felix G. Meinel
MD : Nothing to Disclose , Andrew D. Hardie MD : Nothing to Disclose , Philip Costello MD : Nothing to
Disclose
PURPOSE
To evaluate whether a dedicated image-based algorithm for virtual monoenergetic imaging (Mono+) with a
third-generation dual-energy, dual-source CT scanner can improve the contrast-to-noise ratio (CNR) of liver
parenchyma in comparison with a standard virtual monoenergetic algorithm and also 100 and 120kV
polyenergetic data-sets.
METHOD AND MATERIALS
Eight patients underwent abdominal CT examinations including single-energy unenhanced (120kV, 147ref.mAs)
and dual-energy portal phase (100/Sn150kV, 180/90ref.mAs) imaging. Dual-energy data were processed, and
virtual monoenergetic images (range, 40-120/150/190keV) were generated using both standard monoenergetic
and Mono+ algorithms. The new algorithm performs a regional analysis-dependent frequency-based
recombination of the high signal at lower energies and the superior noise properties at medium energies to
optimize CNR and avoid the noise increases at lower calculated energies which are commonly observed with
standard algorithms. Liver parenchyma and intrahepatic portal vein attenuation and image noise were
measured and the CNR was subsequently calculated. Differences in liver attenuation and CNR were compared
between the different virtual monoenergetic datasets and the standard 100 and 120kV polyenergetic datasets.
RESULTS
For Mono+, the optimum CNR was obtained at the lowest energy level of 40keV (10.9± 13.5HU) while the
optimum CNR of the standard monoenergetic algorithm was at 70keV (5.7 ± 28.0HU). The CNR of Mono+
reconstructions was 47% greater than with the standard monoenergetic algorithm. Compared with the
corresponding standard 40 keV data-set, the incremental improvement in CNR was even higher (3.6 ± 15.8HU,
67% increment). The optimum Mono+ CNR at 40keV was also significantly higher than the CNR in the standard
120kV polyenergetic data-set (4.0 ± 50.3HU, 63% improvement) and in the 100kV data-set (5.7 ± 40.9HU,
39% improvement). In fact, all Mono+ data-sets from 40 to 70keV had a CNR significantly higher than the
optimum standard monoenergetic reconstructions at 70keV as well as the 100 and 120kV polyenergetic
datasets.
CONCLUSION
Mono+ virtual monoenergetic images have a significantly higher CNR for liver CT imaging compared with both
standard virtual monoenergetic algorithms and 100 and 120 kV polyenergetic images.
CLINICAL RELEVANCE/APPLICATION
Mono+ improves the quality of virtual monoenergetic images, which may enhance diagnostic performance and
reduce contrast medium volumes.
SSC12-06
Preliminary Results of a Prototype Quality Control Process for Spectral CT
Jessica Lee Nute MS (Presenter): Nothing to Disclose , Megan Jacobsen : Nothing to Disclose , Jim W.
Pennington : Nothing to Disclose , Adam Grant Chandler PhD : Employee, General Electric Company ,
Yasuhiro Imai MS : Employee, General Electric Company , Dianna D. Cody PhD : In-kind support, General
Electric Company
PURPOSE
A prototype quality control (QC) phantom and analysis process has been designed specifically to monitor
dual-energy CT and address the current lack of quantitative oversight of the spectral capabilities of these
scanners.
METHOD AND MATERIALS
A prototype solid water phantom was designed with multiple material inserts, and to support both head and
body protocols. Inserts included tissue equivalent and material rods (iodine, iron, calcium) at various
concentrations. The oval body phantom, measuring 30cmx40cmx15cm, was scanned using four dual-energy
protocols with CTDIvol ranges of 19.6-62mGy (0.516 pitch) and 10.3-32.5mGy (0.984 pitch), and rotation
times ranging from 0.5-1sec. The circular head phantom, measuring 22cm in diameter by 15cm, was scanned
using three dual-energy protocols with CTDIvol ranges of 67-132.6mGy (0.531 pitch) and 36.7-72.7mGy
(0.969 pitch), and rotation times ranging from 0.5-0.9sec. All images were reconstructed at 50, 70, 110 and
140 keV, and using a water-iodine material basis pair. The images were evaluated for iodine quantification
accuracy and stability of monoenergetic reconstructions. The phantom was scanned twice on ten GE 750HD CT
scanners to evaluate inter-scanner agreement, as well as ten times on a single scanner over a one-week period
to evaluate intra-scanner repeatability.
RESULTS
Preliminary analysis revealed consistent (inter- and intra-scanner) iodine quantification accuracy within 10%
was only achieved for protocols in the upper half of dose levels assessed when grouped by pitch. Although all
scanners undergo rigorous daily single-energy QC, iodine quantification accuracy from one scanner
unexpectedly deviated from the other nine substantially. In general, inter-scanner agreement and intra-scanner
repeatability varied with dose, rotation time and reconstructed keV.
CONCLUSION
Preliminary results indicate the need for a dual-energy QC process to ensure inter-scanner agreement and
intra-scanner repeatability. In particular, iodine quantification accuracy should be monitored, particularly for
lower dose techniques. Future plans include longer term dual-energy CT QC data collection.
CLINICAL RELEVANCE/APPLICATION
DECT is quickly becoming a critical part of routine exams. QC such as quantitative accuracy and long term
stability haven't been addressed but are essential to ensuring confidence in this application.
SSC12-07
Incremental Benefit and Clinical Significance of Retrospectively Obtained Spectral Data in a Novel
Spectral Detector CT Technology- Initial Experiences and Results
Claudia M. Martinez Rios Arellano MD : Research Grant, Koninklijke Philips NV , Rong Rong MD :
Institutional Grant support, Koninklijke Philips NV , Robert C. Gilkeson MD : Research Consultant, Riverain
Technologies, LLC Research support, Koninklijke Philips NV Research support, Siemens AG , Luis Alberto
Landeras MD : Institutional Grant support, Koninklijke Philips NV , Prabhakar Rajiah MD, FRCR (Presenter):
Institutional Research Grant, Koninklijke Philips NV
PURPOSE
To evaluate the incremental benefit and clinical significance of the availability and utility of spectral
reconstruction data with spectral detector CT technology.
METHOD AND MATERIALS
Seventy-eight adult patients (34 female, 44 male) were prospectively scanned at the Spectral Detector-based
CT (SDCT Philips Healthcare) scanner technology. Clinical indication was noted and two radiologists made
unanimous decision if a dual energy acquisition would have been requested in advance of the scan. The CT
images with spectral reconstructions were evaluated for clinical findings, artifacts and image quality. Readers
selected which cases would benefit from spectral reconstructions and the type of reconstruction was indicated.
Clinical significance of the spectral reconstructions was graded as 0- no significant; 1- low; 2- intermediate,
3-moderate; and 4-highly significant.
RESULTS
8 CT of chest, 29 abdomen, 9 chest, abdomen, pelvis, 31 angiograms and 1 spine were included. A dual energy
mode would have been prospectively clinically indicated in 15 patients (19%). However, readers requested
retrospective spectral reconstructions in 67 patients (84.6 %). A total of 183 additional reconstructions with high
monoenergy (monoE) images in 72 instances [(39.34%), 51 cases, 65.3%]; low monoE in 35 instances
[(19.13%), 35 patients, 44.8%]; iodine-only images in 44 instances [(39.34%), 42 patients, 53.8%]; virtual
non contrast in 17 instances [(9.29%), 17patients, 21.8%]; effective-z in 15 instances [(8.19%), 15
patients,19.2 %] were required. Additional spectral reconstructions were required on average 2.3 instances per
patient. High monoE images were clinically useful in 56.94% for artifact reduction; low monoE in 44.8% for
vascular contrast boost; iodine-only images in 15.9% for cystic and solid lesions evaluation 61.36%; and
effective z for stone analysis in 33.3%. Clinical significance was rated as 0 in 10.38%, 1 in 36.1%, 2 in
29.51%, 3 in 20.21% and 4 in 3.82%.
CONCLUSION
Additional retrospective CT data reconstructed from SDCT scanner improves the diagnostic capabilities mainly
for eliminating artifacts, improving contrast in vascular structures and characterizing lesions.
CLINICAL RELEVANCE/APPLICATION
Spectral detector-CT allows retrospective reconstruction and improved diagnostic capabilities even in patients
who would not have been preselected for a DECT technique.
SSC12-08
Performance of Today’s Dual Energy CT and Future Multi Energy CT in Virtual Non Contrast Imaging
and in Iodine Quantification
Sebastian Faby DIPLPHYS (Presenter): Nothing to Disclose , Stefan Kuchenbecker MENG : Nothing to
Disclose , David Simons MD : Nothing to Disclose , Heinz-Peter Schlemmer MD : Nothing to Disclose ,
Michael Marcus Lell MD : Research Grant, Siemens AG Speakers Bureau, Siemens AG Research Grant, Bayer
Michael Marcus Lell MD : Research Grant, Siemens AG Speakers Bureau, Siemens AG Research Grant, Bayer
AG Speakers Bureau, Bayer AG Research Consultant, Bracco Group , Marc Kachelriess PhD : Nothing to
Disclose
PURPOSE
To compare the performance of different state-of-the-art dual energy CT (DECT) techniques with novel photon
counting (PC) multi energy CT (MECT) with respect to dose efficiency in contrast-enhanced imaging.
METHOD AND MATERIALS
A typical spectral CT application is the decomposition of CT data into virtual non-contrast (VNC) and iodine
overlay images. We study its dose efficiency given that a number of spectral CT implementations are available
and that others may become available. Different clinical DECT implementations were simulated: dual source,
rapid kV switching and sandwich detector DECT. We further simulated promising types of realistic PC detectors
with a variable number of energy bins. We also simulated dual source systems with one or two detectors being
PC. For our simulation patient data were decomposed and a polychromatic forward projection yields the
corresponding rawdata. Statistically optimal material decomposition [Faby et al., SPIE 2014] was employed to
guarantee a fair comparison of all modalities. Dose, spatial resolution and contrast were the same among the
modalities and thus it is sufficient to compare image noise which can then be converted into dose reduction
values.
RESULTS
Results are expressed with dual source DECT at 100 kV/140 kV Sn (tin prefilter) being the reference. Using
dual source settings of 90 kV/150 kV Sn led to a dose reduction of -39% VNC/-45% iodine. This is comparable
to the performance of an ideal PC detector with two energy bins. Using eight energy bins results in -48%/-75%.
Sandwich detector DECT at 140 kV is showing a dose increase +56%/+92%. A realistic PC detector with two
energy bins performs as the sandwich detector for the VNC image but much better for the iodine image
(+58%/+11%). Rapid kV switching with 80 kV/140 kV evaluated to +73%/-15%. Due to a lack of space we will
present results for other spectral CT implementations at the meeting.
CONCLUSION
The results indicate significant patient dose saving possibilities for dual source CT settings of 90 kV/150 kV Sn
(-39%/-45%) and an ideal PC detector with two energy bins (-29%/-59%). Using more than two energy bins
improves the results further. Degrading effects in the PC detector set this technology back to the level of
today's DECT.
CLINICAL RELEVANCE/APPLICATION
Dose saving possibilities for the patient in the context of contrast agent enhanced imaging are evaluated based
on different dual and multi energy techniques.
SSC12-09
Dual-Energy Imaging of Bone Marrow Edema on a Dedicated Extremities Cone-Beam CT System
Wojciech Zbijewski PhD (Presenter): Research Grant, Carestream Health, Inc , Alejandro Sisniega PhD :
Research Grant, Carestream Health, Inc , Joseph Webster Stayman PhD : Research Grant, Varian Medical
Systems, Inc , Gaurav Kumar Thawait MD : Nothing to Disclose , Shadpour Demehri MD : Nothing to
Disclose , Jan Fritz MD : Research Grant, Siemens AG Research Consultant, Siemens AG , Jeffrey H.
Siewerdsen PhD : Research Grant, Siemens AG Consultant, Siemens AG Research Grant, Carestream Health,
Inc Royalties, Elekta AB
PURPOSE
Bone marrow edema (BME) is an important biomarker of arthritis and bone trauma. BME presents as increased
fluid content and decreased fat content in the cancellous bone and is challenging to detect in x-ray CT due to
trabecular structure. Virtual noncalcium (VNC) images obtained using Dual Energy (DE) enable visualization of
BME in conventional CT. We investigate the feasibility of DE imaging of BME on a dedicated flat-panel detector
extremities cone-beam CT (CBCT).
METHOD AND MATERIALS
DE CBCT imaging was performed at 0.278 mm pixel pitch and 480 projections over 240o using a low energy
(LE) beam of 70 kVp, 120 mAs/scan (~9.6 mGy), and a high energy (HE) beam of 120 kVp, 48 mAs/scan (~19
mGy). Due to power limitations of the x-ray tube (max. 0.875 kW), no high-Z filtration could be applied to the
HE beam to increase energy separation. Reconstructions were obtained at 0.5 mm voxels using FBP and
penalized-likelihood with Huber penalty (PLH). Reconstruction-based three-material DE decomposition yielded
volume fractions of soft tissue, fat, and bone. A computer simulation study with polyenergetic projections of a
digital BME knee phantom was performed. Experimental studies involved a 12 cm water phantom with two bone
inserts (50 mg/mL CaCO3) embedded in water and alcohol (simulating fat). Each insert contained a pattern of 1
mm - 4 mm cavities filled with the surrounding fluid to emulate the trabecular matrix.
RESULTS
DE noncalcium soft-tissue images correctly identified 76% of the area of simulated BME at realistic levels of
projection noise (corresponding to bare beam signal of 105-106 photons/pixel). The experimental studies show
discrimination of water and fat even in the presence of partial volume effects and resolution blur in the vicinity
of the cavities of bone inserts. PLH performed slightly better than FBP, reducing the error in estimation of the
total fat area from 46% for FBP to 19% for PLH at similar noise levels in the VNC image.
CONCLUSION
Detection of BME and quantification of water and fat content using DE were demonstrated on the extremities
CBCT, opening a broad range of diagnostic applications in e.g. detection and staging of arthritis.
CLINICAL RELEVANCE/APPLICATION
DE detects BME in extremities CBCT, overcoming a major limitation of single energy imaging and enabling novel
diagnostic applications in rheumatoid arthritis, osteoarthritis and bone trauma.
SSC13
ISP: Radiation Oncology & Radiobiology (Outcome and Quality of Life)
Scientific Papers
SQ
RO
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credits: 1.50
Mon, Dec 1 10:30 AM - 12:00 PM
Location: S104A
Participants
Moderator
Anna Shapiro MD : Nothing to Disclose
Moderator
Beatriz E. Amendola MD : Nothing to Disclose
Sub-Events
SSC13-01
Radiation Oncology & Radiobiology Keynote Speaker
Christine Megan Fisher MD (Presenter): Nothing to Disclose
SSC13-02
ROQS: A Comprehensive Error Reporting and Quality Assurance Program for Radiation Oncology
Evan Charles Osmundson MD, PhD (Presenter): Nothing to Disclose , Tiffany M. Symmes : Nothing to
Disclose , Karl Bush PhD : Nothing to Disclose , Todd F. Atwood PhD : Nothing to Disclose , Brian Chhor :
Nothing to Disclose , Michelle Kenyon : Nothing to Disclose , Lynn Million MD : Nothing to Disclose ,
Albert C. Koong MD, PhD : Nothing to Disclose
PURPOSE
Modern radiotherapy treatment planning and delivery is a complex process involving multiple medical personnel
and the transfer of critical data within organizational systems at risk for errors. In Dec 2012, the error reporting
and quality assurance (QA) program at a major academic radiation oncology department was comprehensively
updated to gather personnel- and systems-related data (Radiation Oncology Quality and Safety (ROQS)
system). The objective of our study was to assess the utility of the ROQS system for determining logistical risk
factors associated with reported errors.
METHOD AND MATERIALS
ROQS-reportable events are captured using a secure web-based form accessible to all departmental staff. A
ROQS committee comprised of clinical and management personnel meet semi-monthly to classify events and
guide quality improvement efforts. Problem solving initiatives are implemented as a result of events reported,
as appropriate. Events are classified into 3 major categories as actual events (A class), near misses (B class), or
workflow-related events (C class), and are then subclassified according to the severity of the event or potential
for harm if a near miss (e.g. A1-A3 events correspond to aberrations in dose delivered with dose differences
>=20%, 5% to 20%, and
RESULTS
31,309 treatments were delivered from Dec 2012 - Nov 2013. During this period, 7 class A and 23 class B
events were reported (0.2235/1000 and 0.7346 /1000 treatments respectively). No A1 or A2 events or events
leading to major patient harm were observed. Among linac-treated patients with complete data available for
assessment (n= 1452), class A events were significantly associated with a simulation to treatment time of less
than 7 days (RR 4.98, p=0.019).
CONCLUSION
The ROQS system is a comprehensive QA approach designed to capture organizational and procedural factors
contributing to errors. Data obtained from the ROQS system can be used to specifically target quality
improvement efforts within a complex radiation therapy delivery system.
CLINICAL RELEVANCE/APPLICATION
Targeted workflow changes designed to address logistical risk factors identified by the ROQS system are
predicted to decrease error rates and improve the safety of patients undergoing radiotherapy.
SSC13-03
Time-and-Motion Study in a Pediatric Radiation Oncology Department
Nimit
Dholakia (Presenter): Nothing to Disclose
ABSTRACT
Purpose/Objective(s): Anesthesia requirements add complexity in a pediatric hospital radiation
oncology department. Reducing inefficiencies can translate to higher quality patient care. We
performed a time and motion study following our facility remodel and equipment upgrade. Elapsed
times for each step of radiation treatment were measured and we identified possible targets to
improve time management throughout the process.Materials/Methods: In June 2013, of 15 patients
receiving radiation treatment, 11 required anesthesia (median age 6). Four patients had brain
tumors, 3 had rhabdomyosarcomas, 3 had neuroblastoma, and 1 had nasopharyngeal carcinoma.
These patients had 102 treatments (96 were available for analysis). For each patient, we collected
data from the electronic medical records from Radiation Oncology (Aria, Varian Medical Systems),
Anesthesiology (CompuRecord, Philips Medical Systems), and a hospital-wide system (KIDS,
Cerner). Data was collected from patient arrival until discharge from the 11 bed post-anesthesia
care unit (PACU). Variables included nursing time in pre-anesthesia preparation, sedation and
radiation treatment times in the linac vault, and nursing time in post-anesthesia recovery. Two
independent observers performed quality assurance of the medical records by tracking 10% of
treatments with timekeeping devices. Results: Of the 96 treatments, 48 were RapidArc, 35 were
IMRT, 4 were 3D-CRT, and 9 electron beam. The mean time for treatment was 103 minutes (range
56-178). Patient preparation averaged 22 ± 17 min, sedation was 29 ± 9 min (of which, radiation
treatment was 10 ± 7 min), and recovery 51 ± 20 min. The variability between timestamped events
in the medical record and direct observation was least for Aria and CompuRecord (5 min), and
greatest for KIDS (11 min). Conclusions: Radiation delivery can be accomplished quickly. The
majority of treatment time was consumed by anesthesia. Outliers were examined for areas for
improvement. Delays in preparation were the result of staffing capacity and inadequate
inter-departmental communication and care hand off. Delays during anesthesia were attributed to
unfamiliarity with new anesthesia and radiotherapy equipment, and less frequently with challenging
patient setups or cases of acute respiratory depression. Inaccurate communication between nurses
and parents resulted in prolonged stays in the PACU. These issues were exacerbated by the
numerous staff: 4 NPs in pre-anesthesia preparation, over 20 anesthesia staff (9 MDs), and 8
radiation oncology staff (3 RTTs). Our time-motion study is the first conducted in a pediatric
radiation oncology program and identified three main targets for improving efficiency: reducing time
sinks, clear role-assignment, and direct communication to improve care coordination.
SSC13-04
Incidental Findings on Radiation Treatment Planning CT Scans
Laura E. Kollar MD (Presenter): Nothing to Disclose , Edward Y. Kim MD : Nothing to Disclose
PURPOSE
Few studies have been reported evaluating the rate of incidental findings on radiation treatment planning CT
scans. We set out to review our own institutional experience with diagnostic radiology review of treatment
planning CT scans and the resulting impact patient care.
METHOD AND MATERIALS
At our institution, all radiation planning CTs are reviewed by a diagnostic radiologist. Reports from all radiation
treatment planning CT scans over one year from a single treatment center were reviewed. Pertinent findings
were considered those that were new or previously unreported and could potentially change or delay treatment
decisions. These included findings reported involving the bone, lung, liver, adrenal glands, or lymph nodes.
Other non-emergent, non-cancer related findings were not included in this study.
RESULTS
347 CT scans for 326 patients were performed between January 1, 2013 and December 31, 2013. 145 were for
primary breast malignancies, 19 of which were DCIS. The remainder of the scans included 35 prostate, 23
lymphoma, 16 multiple myeloma, 10 pancreatic, 10 endometrial, 7 cervical, 5 rectal, 50 metastases, and 27
other. 66 new findings were detected on a total of 56 scans (16.1%). These included 21 lung nodules, 14 bone
lesions, 15 liver lesions, 5 adrenal nodules, and 11 enlarged or suspicious lymph nodes. 12 of these scans
(21.4%) led to additional imaging. 4 patients experienced delay of radiotherapy due to further work up. 2
patients ultimately did not receive definitive treatment due to confirmation of metastatic disease. Of note, one
patient found to have an indeterminate sclerotic bone lesion on treatment planning scan was confirmed to have
bony metastatic disease 8 months later. Of the positive scans, 39 were for primary breast malignancies
(69.5%).
CONCLUSION
New or previously unreported findings are not uncommon in radiation treatment planning scans, with 16.1% of
scans showing unexpected, potentially cancer-related findings. 8.3% of all scans, and 21.4% of positive scans,
led to additional imaging.
CLINICAL RELEVANCE/APPLICATION
New findings as reported on diagnostic radiology review of radiation planning scans can have important clinical
implications and may potentially change treatment recommendations for patients undergoing radiotherapy. In
our study, we found the rate of potentially cancer-related findings to be not uncommon, with such findings often
leading to additional imaging to determine disease status.
SSC13-07
A Prospective Study of Toxicity Profiling in Patients with Squamous Cell Carcinoma of the Head and
Neck (scchn) Treated with Helical Tomotherapy Intensity Modulated Radiotherapy (htimrt), 5 Year
Results
Samy El-Sayed MD : Nothing to Disclose , Mohammed Yahia Almaghrabi MD (Presenter): Nothing to
Disclose
ABSTRACT
Purpose:Radical Radiotherapy remains the main stay of treatment in patients with SCCHN. IMRT have become
Purpose:Radical Radiotherapy remains the main stay of treatment in patients with SCCHN. IMRT have become
the norm in north America even before the benefits were proven. Previous studies have addressed some of the
toxicities. The purpose of this prospective study is to profile the all aspects of the toxicity of IMRT treatment in
patients with local-regionally advanced SCCHN.Methods: This study was carried out From 2006 - 2012. Patients
included had a histologically confirmed loco-regionally advanced SCCHN to be treated to the primary site and
regional lymphatics to 70 Gy in 35 Fractions, ECOG PS of =18 years of age, with no other active malignancy.
Radical radiotherapy had to include initial phase of 50 Gy in 25 Fractions to involved areas and areas at risk to
be followed by a boost of 20 Gy in 10 Fractions to the involved areas only using the same Fractionation as
conventional radiotherapy.Treatment related toxicities were evaluated by OMAS ( Oral mucositis assessment
scale), RTOG and CTCAE acute and late assessment scales.Weekly mucositis assessment were collected using
the OMAS and RTOG scales during the treatment and every 2 weeks after treatment until resolution.
Prospective information were collected on QOL Using EORTC HandN QOL module.Result: 92 patients were
enrolled: 87 of them were evaluable, 48 % had undergone concomitant chemotherapy. Median age was 60
year-old, 78 % were male. Most common primary tumour site was oropharynx 67 %. 80% of the patients were
smokers, 35% of them continue to smoke.Acute mucositis was evaluated using the OMAS score. 5, 15, 74 and
6% have developed grade 1, 2, 3, and 4 mucositis respectively. Pattern of mucositis will be presented. Grade
1, 2, 3, skin reaction were recorded in 26, 59 and 15 % respectively. 22% of our patients reported Grade 3
dysphagia. Only 9% suffered long term salivary gland dysfunction with Xerostomia. Grade 3 mucositis had a
higher incidence in the combined modality group, while Grade 3 dysphagia was more in XRT alone (56%). 19
patients (41%) in the radiotherapy group required tube feeding compared to 26(62%) combined modality
patients. 4.5% of our patients suffered radiation necrosis at the high dose area despite adequate dental
evaluation and use of fluoride trays.Conclusion:This study provides a bench mark for the rate and pattern of
toxicity caused by IMRT Radiotherapy in a population cohort of patients with SCCHN. Compared with toxicities of
conventional radiotherapy, there seems to be a significant improvement overall but with perhaps a different
pattern. Part of the improvement could be due to better supportive care. Longer than 5 years follow up is
required to rule out other long term toxicities such as secondary tumours and muscle dysfunction.
SSC13-08
Merkel Cell Carcinoma (MCC): Demographic, Clinical, and Treatment Parameters of Prognostic
Significance
Michael Fu (Presenter): Nothing to Disclose , Evan Charles Osmundson MD, PhD : Nothing to Disclose ,
Daniel S. Kapp MD, PhD : Nothing to Disclose , Susan J. Knox MD, PhD : Nothing to Disclose , Rie von
Eyben : Nothing to Disclose
ABSTRACT
Purpose:We explored patient, tumor, and treatment factors with regard to recurrence and overall survival in
patients with primary MCC treated at a single institution over a 31-year period.Methods:A retrospective review
was conducted of 47 patients diagnosed with primary MCC between 1981 and 2012. Outcomes of interest were:
first recurrence (local, regional, in-transit, or distant reappearance of tumor), first locoregional recurrence
(within the original tumor site or regional lymph nodes), and death. Univariate analysis (Pearson Χ2 test) and
multivariate logistic regressions were performed to identify factors associated with each outcome.Results:Our
cohort had a mean age at diagnosis of 73.3 years and was predominantly Caucasian (74.5%) and male
(66.0%). AJCC stage at diagnosis was I in 40.4%, II in 8.51%, III in 25.5%, IV in 4.26%, and unknown in
10.0%. Treatments included primary tumor resection without local radiation therapy (RT) (21.3%), primary
tumor resection followed by RT (63.8%), primary site treated with RT only (8.51%), no primary tumor resection
or RT (6.4%), sentinel lymph node biopsy (SLNB) (38.3%), lymph node dissection (LND) (27.7%), SLNB
followed by RT (27.7%), and LND followed by RT (23.4%). Mean values for RT parameters were: tumor dose
51.6 Gy (in 27.8 fractions) and regional node dose 46.2 Gy (in 24.7 fractions). In total, 53.2% of patients
recurred, with 48% failing locoregionally; 61.7% were deceased at last follow-up. Mean follow-up time was
26.0 months.On univariate analysis, lack of SLNB, low pre-RT red blood cell count, and low pre-RT hematocrit
were independently associated with recurrence, while head and neck primary site, AJCC stage, nodal stage,
and lack of RT treatment with locoregional recurrence. Furthermore, SLNB was independently associated with
overall survival. For patients who received RT, the dose, fraction number, and duration of RT treatment and
treatment breaks were not associated with outcomes. Multivariate analysis demonstrated a 4.75 adjusted
relative risk (95% CI 1.85-5.43, p < 0.05) for head and neck tumors for locoregional recurrence. Year of
diagnosis was not significantly associated with any of the outcomes studied.Conclusions:Our results confirm
prior reports on the positive impact of RT on locoregional control but not on overall survival in MCC. SLNB was
associated with improved survival. Additionally, tumor characteristics including head and neck location, AJCC
stage, and nodal stage appear be prognostic for locoregional recurrence. Improvement in survival will require
more effective systemic treatments.
SSC14
Vascular/Interventional (IR: Hepatic Tumor Embolization)
Scientific Papers
IR VA
GI
AMA PRA Category 1 Credits ™: 1.50
ARRT Category A+ Credits: 1.50
Mon, Dec 1 10:30 AM - 12:00 PM
Location: E351
Participants
Moderator
Nael El Said Saad MBBCh : Research Consultant, Veran Medical Technologies, Inc Proctor, Sirtex Medical Ltd
Moderator
Hyun Sik Kim MD : Nothing to Disclose
Sub-Events
SSC14-01
A Mechanism of Transcatheter Arterial Embolization-mediated Improvement of Drug Penetration in
Liver Cancer
SSC14-01
Liver Cancer
Bin Liang (Presenter): Nothing to Disclose , Gan-Sheng
Zheng : Nothing to Disclose
Feng MD : Nothing to Disclose , Chuansheng
PURPOSE
Transcatheter intraarterial techniques can improve drug penetration in liver cancer and thus enhance the
efficacy of chemotherapy, but its mechanism remains unclear. Intratumoral interstitial fluid pressure (IFP) has
been found to be an important determinant of drug penetration in solid tumors. The present study is designed
to determine whether transcatheter arterial embolization modifies IFP, and to evaluate whether the modified
IFP is related to the improvement of drug penetration in liver cancer.
METHOD AND MATERIALS
VX2 tumors were implanted in the livers of 16 rabbits. The animals were divided into 4 groups of 4 animals
each. Group 1 (doxo iv) animals received doxorubicin intravenous injection; group 2 (doxo ia) animals received
doxorubicin hepatic intraarterial infusion; group 3 (doxo ia + E) received doxorubicin hepatic intraarterial
infusion followed by embolization; group 4 (doxo + L ia + E) received hepatic intraarterial infusion of
doxorubicin mixed with lipiodol followed by the embolization. After transcatheter treatment, wick-in-needle
technique (Mikro-Tip pressure catheter) was used to measure IFP in tumor tissues, and immunofluorescence
technique to evaluate the distance of doxorubicin fluorescence from the nearest blood vessel (recognized by
CD31).
RESULTS
Tumors in the group 3 (doxo ia + E) and 4 (doxo + L ia + E) showed a significant decrease in IFP compared
with the group 1 (doxo iv) and 2 (doxo ia) tumors (P < 0.05) within 1 hour after treatment. Embolization led to
a decrease of IFP by 27.11% in group 3 and 31.81% in group 4 tumors, respectively. The change in IFP was
significantly correlated with doxorubicin penetration distance (r = 0.671, P = 0.004).
CONCLUSION
Transcatheter arterial embolization reduce tumor IFP, which probably is responsible for the improvement of
drug penetration in liver cancer.
CLINICAL RELEVANCE/APPLICATION
Our results reveal a novel mechanism of transcatheter arterial embolization-mediated improvement of drug
penetration in liver cancer. The decrease in tumor IFP, generated by embolization, contributes to drug
penetration in liver cancer. Thus, decreasing tumor IFP could represent a promising therapeutic strategy for
improving the effectiveness rates of transcatheter therapies for liver cancer.
SSC14-02
Comparison of Drug Release between Conventional Chemoembolization and Drug Eluting Beads
Chemoembolization
Jae Hwan Lee MD (Presenter): Nothing to Disclose , Kyu Ri
Kim MD : Nothing to Disclose
Son MD : Nothing to Disclose , Hyo-Cheol
PURPOSE
The purpose of this study was to compare the in vitro drug release characteristics of DC bead and various kinds
of Lipiodol emulsion, and to compare the tumor response in animal liver tumor model.
METHOD AND MATERIALS
We prepared 4 types of Lipiodol emulsion: A) 10mg of DOX in 0.5 ml of contrast media mixed with 2 ml of
Lipiodol, B) 10 mg of DOX in 1.25 ml of contrast media mixed with 1.25 ml of Lipiodol, C) 10 mg of DOX in 0.5
ml of normal saline (NS) mixed with 2 ml of Lipiodol, D) 10 mg of DOX in 1.25 ml of NS mixed with 1.25 ml of
Lipiodol. DC bead of 100-300 µm in diameter were loaded with DOX (37.5 mg/ml) according to the
manufacturer's instruction. Drug release from emulsions or DC bead was evaluated in in vitro model. Three
weeks after implantation of VX2 carcinomas in the liver, TACE was performed using A) 4:1 volume ratio of
Lipiodol and DOX solution, B) 1:1 volume ratio of Lipiodol and DOX solution, C) DC bead.
RESULTS
The released amounts (%) of DOX at 24 h are as follows: 20.64 ±0.20% for DC bead, 42.65 ±1.51% for
Lipiodol:DOX in NS = 4:1, 45.74 ±2.14% for Lipiodol:DOX in Pamiray = 4:1, 60.92 ±1.45% for Lipiodol:DOX in
NS = 1:1, and 56.91 ±2.31% for Lipiodol:DOX in Pamiray = 1:1. AUC value of group A was significantly lower
than that of group B (p < 0.05), but there is no significant difference compared to that of group C. AUC value of
group B was 3.43-fold higher than that of group C (p < 0.05). Cmax value of group A exhibited significant
difference compared to those values of group B and C (p < 0.05). Particularly, Cmax value of group B was
12.12-fold higher than that of group C (p < 0.05).
CONCLUSION
stable Lipiodol emulsion can be created by excessive Lipiodol mixed with DOX dissolved in contrast media. DOX
release from Lipiodol emulsion depends on volume ratio of Lipiodol and DOX solution. DC bead has more
sustained DOX release than Lipiodol emulsion.
CLINICAL RELEVANCE/APPLICATION
(Dealing with making effective chemoembolic mixture in TACE) DOX -contrast media mixture with excessive
lipiodol forms more stable emulsion, and DC bead has more sustained DOX releasing capacity than Lipiodol
emulsion. These knowledge may be useful in acheving effective drug delivery to HCC in TACE.
SSC14-03
Conventional Transarterial Chemoembolization versus Drug Eluting Bead-Transarterial
Chemoembolization for the Treatment of Hepatocellular Carcinoma
Roman Kloeckner MD (Presenter): Nothing to Disclose , Friederike Prinz : Nothing to Disclose , Christian
Ruckes : Nothing to Disclose , Arndt Weinmann : Nothing to Disclose , Christoph Dueber MD : Nothing to
Disclose , Michael Bernhard Pitton MD : Nothing to Disclose
PURPOSE
To compare the overall survival (OS) of patients suffering from hepatocellular carcinoma (HCC) treated with
lipiodol - based conventional transarterial chemoembolization (cTACE) and drug eluting bead-transarterial
chemoembolization (DEB-TACE).
METHOD AND MATERIALS
An electronic search of our radiology information system revealed a total of 674 patients receiving TACE
between 11/2002 and 07/2013. 520 received cTACE, and 154 received DEB-TACE. In total, 424 patients were
excluded due to a tumor entity different from HCC (n=91), liver transplantation following TACE (n=119), lack
of histological grading (n=58), incomplete laboratory values (n=15) and other reasons (e.g. previous systemic
chemotherapy, previous cisplatin-based TACE) (n=141). Therefore, 250 patients were included for comparative
analysis (174 cTACE; 76 DEB-TACE).
RESULTS
Both groups were not significantly different in terms of sex, etiology of liver cirrhosis, overall status (BCLC), liver
function (Child-Pugh), portal invasion, tumor load, and tumor grading (all p>0.05). Mean number of treatment
sessions was 4±3.1 in the cTACE group versus 2.9±1.8 in the DEB-TACE group. The median survival in the
cTACE group was 409 days (95% CI: 321-488 days) compared to 369 days (95% CI: 310-589 days) in the
DEB-TACE group (p=0.76). In the subgroup of Child A patients, the median OS was 602 days (484-792 days)
for cTACE versus 627 days (364-788 days) for DEB-TACE (p=0.39). In Child B and Child C patients the OS was
considerably lower with 223 days (165-315 days) versus 226 days (114-335 days) (p=0.53).
CONCLUSION
The present study showed no significant difference in OS between cTACE and DEB-TACE in a large and
well-selected cohort of HCC-patients.
CLINICAL RELEVANCE/APPLICATION
Currently, there is no firm evidence to prefer DEB-TACE to cTACE. Further prospective randomized trials with a
hard endpoint are needed.
SSC14-04
Chemoembolization with Dc Beads Preloaded with Irinotecan (DEBIRI) vs. Doxorubicin (DEBDOX)
as a Second Line Treatment for Liver Metastases from Cholangiocarcinoma: Technical Aspects,
Complications, and Efficacy
Giulia Agostini (Presenter): Nothing to Disclose , Massimo Venturini MD : Nothing to Disclose , Stefano
Cappio MD : Nothing to Disclose , Giulia Cammi : Nothing to Disclose , Francesco Aldo De Cobelli MD :
Nothing to Disclose , Alessandro Del Maschio MD : Nothing to Disclose
PURPOSE
TACE with drug-eluting beads is routinely performed using Doxorubicin and Irinotecan in the treatment of HCC
and hepatic metastases from colorectal cancer, respectively. Conversely, there is no specific drug indication in
the treatment of other hypervascular liver metastases. Aim of our study was to compare the efficacy of DEBIRI
vs. DEBDOX in the treatment of unresectable hepatic metastases from cholangiocarcinoma.
METHOD AND MATERIALS
In 2013, 10 patients affected by multiple cholangiocarcinoma hepatic metastases, resistant to the first line CT
regimen, were enrolled: 5 were submitted to lobar/segmental TACE with DEBIRI (100mg Irinotecan/1vial) and
5 with DEBDOX (50mg Doxorubicina/1vial), performed every 3 weeks. Patients treated with DEBIRI received
ant-pain pre-medication consisting of a 30 mg of morphine and 3-4 ml of intra-arterial lidocaine. All the
procedures were performed with a trans-femoral approach using a microcatheter. Complications and efficacy of
the two different types of treatment were assessed with contrast-enhanced MDCT (RECIST and mRECIST
criteria) performed at baseline and 72 hours after each procedure.
RESULTS
A total of 32 TACE were performed (mean: 3,2 TACE/patient). All the treatments were well tolerated, with one
only case of asymptomatic cholecystitis spontaneously recovered. Response rates assessed at the end of the
treatment cycle of patients treated with DEBDOX were 5/5 PD while the ones of the patients treated with
DEBIRI were 2/5 PR, 2/5 SD and 1/5 PD, with the appearance of a variable necrosis percentage.
CONCLUSION
Anti-pain drug administration in patients treated with DEBIRI and the use of the microcatheter lead to a good
treatment tolerability and a low complication rate. In our experience, DEBIRI was more effective than DEBDOX
as a second line treatment of hepatic metastases from cholangiocarcinoma, an extremely aggressive
malignancy.
CLINICAL RELEVANCE/APPLICATION
In our experience, DEBIRI was more effective than DEBDOX as a second line treatment of hepatic metastases
from cholangiocarcinoma.
SSC14-05
The Effect of Age on Survival Outcomes in Unresectable Hepatocellular Carcinoma Treated with
DEB-TACE: Surveillance, Epidemiology and End Results (SEER) Database vs. Tertiary Cancer Center
Minzhi Xing MD (Presenter): Nothing to Disclose , Nima
MD : Nothing to Disclose
Kokabi MD : Nothing to Disclose , Hyun Sik Kim
PURPOSE
To evaluate the effects of age on survival outcomes in patients with advanced unresectable hepatocellular
carcinoma (HCC) treated with Drug-Eluting Bead Chemoembolization (DEB-TACE) or best supportive care in a
large-scale population study.
METHOD AND MATERIALS
Under IRB approval, our institute's cancer registry was queried for patients with advanced unresectable HCC
diagnosed from Sept 2005 to Dec 2010, treated with DEB-TACE. Eighteen registries of the U.S. Surveillance,
Epidemiology and End Results (SEER) database were queried for patients with advanced HCC not amenable to
surgery/radiation diagnosed in the same time period. Baseline characteristics, median overall survival (OS)
from HCC diagnosis and median OS from first DEB-TACE were stratified by age at HCC diagnosis. Survival
analysis and 95% confidence intervals (CI) were calculated using Kaplan-Meier estimation.
RESULTS
A total of 20,897 SEER patients with unresectable HCC who received neither radiation nor cancer-directed
surgery and 231 patients who received DEB-TACE for advanced unresectable HCC were included. Of these,
11649 SEER patients and 155 DEB-TACE patients were <65 years of age at HCC diagnosis, compared with 9248
SEER and 76 DEB-TACE patients who were ≥65 years at diagnosis. All groups were similar for gender, race,
bilobar disease, portal vein thrombosis, and mean largest tumor size (p>0.05). Median OS in patients <65
years was similar to patients ≥65 years at HCC diagnosis (4.1 vs. 4.0 months, p>0.05). Significant differences
in median OS from HCC diagnosis between groups were observed in patients <65 years at diagnosis (SEER vs.
DEB-TACE, 4.0 vs. 23.47 months, p<0.0001) and ≥65 years at diagnosis (SEER vs. DEB-TACE, 4.0 vs. 21.1
months, p<0.0001).
CONCLUSION
In a population-based study, DEB-TACE therapy in patients with advanced, unresectable HCC demonstrated
significantly greater median OS compared to best supportive care regardless of age at diagnosis.
CLINICAL RELEVANCE/APPLICATION
Regardless of age at HCC diagnosis, DEB-TACE therapy in patients with advanced, unresectable HCC
demonstrates significant survival benefit vs. best supportive care.
SSC14-06
Degradable Starch Microspheres Transarterial Chemoembolisation (DSM-TACE) of Multifocal HCC:
Diffusion-weighted Magnetic Resonance Imaging (DWI) Evaluation of Therapeutic Efficacy
Compared with Contrast Enhanced CT
Fabrizio Chegai MD (Presenter): Nothing to Disclose , Antonio Orlacchio MD : Nothing to Disclose , Marco
Nezzo MD : Nothing to Disclose , Costantino Del Giudice MD : Nothing to Disclose , Giovanni Simonetti
MD : Nothing to Disclose , Daniele Morosetti MD : Nothing to Disclose
PURPOSE
To investigate usefulness of diffusion-weighted magnetic resonance imaging (DWI) for early detection of the
response after transcatheter arterial chemoembolization using degradable starch microsphere (DSM)-TACE for
hepatocellular carcinoma (HCC) compared with contrast enhanced computed tomography (CECT) using the
modified RECIST (mRECIST).
METHOD AND MATERIALS
Thirty patients with inoperable multifocal HCC underwent to DSM TACE. DSM TACE was performed every 4 to 6
weeks with a mixture of DSMs and Doxorubicin at a dose of 50 mg/m2 for three time. Magnetic resonance
imaging (MRI) including breathhold echoplanar DWI sequences was performed prior to therapy (baseline MRI),
15 days after every DSM TACE (early MRI) as well as after 3 months (follow-up MRI). Intratumoral apparent
diffusion coefficient (ADC) were measured independently by two radiologists. Relative change in ADC values
(%ADC), α-fetoprotein level and tumor response on follow-up with contrast CECT after 3 months were
determined. HCC lesions were divided into two groups, responder and non-responder. The correlation between
%ADC and mRecist results was determined, and %ADC was compared between the two groups. Statistical
analysis was performed using univariate comparison, and paired t test as well as Pearson's correlation.
RESULTS
Median progression-free survival (PFS) was 8 months, and overall survival was 21 months. Survival analyses
showed significant effects of pretreatment α-fetoprotein level (P = .03) and ADC ratio (P < .005) on PFS and
substantial effects of mRECIST (.05 < P < .1). After DSM TACE, the percent change in ADC (%ADC) from before
to after therapy was significantly increased in non-responder lesions (79.2+/-11.4%) compared to responder
lesions (7.0+/-49.7%, p=0.001).Positive correlations were observed for relative change between %mean ADC
and complete or partial response (r = 0 .536). Mean ADC were significantly greater in the responder group than
in the non-responder group.
CONCLUSION
The ADC ratio 1 month after DSM TACE was an independent predictor of PFS, which showed stronger
association with tumor response than mRECIST evaluated with CECT. In this study, therapeutic efficacy of
DSM-TACE in HCC using DWI MRI analysis could be demonstrated.
CLINICAL RELEVANCE/APPLICATION
Diffusion-weighted magnetic resonance imaging (DWI) could be useful for early detection of response in
patients with multifocal HCC treated with DSM TACE.
SSC14-07
CRP as a Predictor of Response to TACE in HCC
Patrick Nicholson MBBCh (Presenter): Nothing to Disclose , Kevin Murphy MBBCh, MRCS : Nothing to
Disclose , Karl James MBBCh, MRCS : Nothing to Disclose , Jennifer Murphy MBBCh, MRCPI : Nothing to
Disclose , David James Tuite MBBCh : Nothing to Disclose , Owen J. O'Connor MBBCh : Nothing to Disclose ,
Adrian Paul Brady FFR(RCSI), FRCR : Nothing to Disclose , Peter Mark MacEneaney MBBCh : Nothing to
Disclose
PURPOSE
The prognostic value of C-reactive protein (CRP) in patients with hepatocellular carcinoma (HCC) is well
established, but there exists relatively little data in its use in HCC patients undergoing transarterial
chemoembolization (TACE). We sought to look at outcomes in our institutions in patients who underwent TACE
for HCC. We further sought to evaluate the value of pre-embolization CRP levels in predicting clinical and
radiological outcomes following TACE.
METHOD AND MATERIALS
This multi-center study involved a retrospective review of 34 patients (73±7.9 years, 29 male) who underwent
a total of 100 TACE procedures over a six-year period. Pre-procedure CRP values were available in 90% of
cases. Other factors evaluated included liver function tests and tumour markers (Bilirubin, Alkaline Phosphatase,
transaminases (AST/ALT), gamma glutamyl transpeptidase (GGT), and alpha-fetoprotein). Following TACE, we
evaluated both clinical factors (overall survival) and radiological response to TACE (as measured by modified
RECIST criteria (mRECIST) on follow-up CT at 3 months). SPSS was used to analyze the results via T-Test,
Mann-Whitney test, Pearson correlation, Spearman correlation and Kaplan-Meier analysis
RESULTS
Follow-up imaging was available in 85% of patients. Median follow-up was 28 months (range 1-76). No
association was found between CRP and liver function tests, tumour markers, patient age or other biochemical
parameters (r<0.3 for all comparisons). An abnormal pre-procedure CRP was found to be independently and
significantly associated with both disease response (on a per procedure basis on follow up imaging, p<0.001)
and overall patient survival. A CRP >20mg/l before first TACE treatment carried the worst prognosis (mean
survival 9.25 Vs 17.76 months, p=0.007).
CONCLUSION
Serum CRP measurement can be used to predict response to TACE in patients with HCC.
CLINICAL RELEVANCE/APPLICATION
CRP is a cheap and widely-available test which can be used as a pre-procedural predictor of response to TACE
in patients which HCC. It can be used to help risk-stratify those patients who would benefit from TACE.
SSC14-08
Trans-Arterial EThanol Embolisation (TAETE) vs Conventional Chemoembolisation (cTACE) in the
Treatment of BCLC Intermediate Stage HCC
Francesco Somma MD (Presenter): Nothing to Disclose , Roberto D'Angelo MD : Nothing to Disclose ,
Gianluca Gatta : Nothing to Disclose , Roberto Grassi : Nothing to Disclose , Francesco Fiore MD :
Nothing to Disclose
PURPOSE
Hepatocellular carcinoma (HCC) is nowadays the third leading cause of cancer deaths worldwide. A variety of
treatment modalities have been reported including resection, chemoembolisation, external irradiation,
radiofrequency or percutaneous ethanol ablation. Our aim is to retrospectively evaluate the efficacy and safety
of transarterial embolisation of intermediate HCC, using a mixture 1:1 of Ethanol and Lipiodol, that we named
Trans-Arterial EThanol Embolisation (TAETE), compared with conventional Trans-Arterial Chemo-Embolisation
(cTACE)
METHOD AND MATERIALS
87 patients (37.93% male; 62.07% female; range of age 36-86 years) with documented hepatic lesions of 1.4
to 5.4 cm in size were elected to TAETE (Ethanol and Lipiodol, 1:1) or cTACE (Epirubicin and Lipiodol), through
a super-selective catheterization with direct injection in the tumor-feeding arteries. Both procedures were
followed by the intrarterial administration of embolizing agents (70-150µ).
RESULTS
TAETE and cTACE therapies were performed in 45 and 42 patients, respectively. Thirty days after the
procedure, a Multislice Computed Tomography (MSCT) showed in all patients at least partial response according
to RECIST1.1 and EASL criteria, while in 51/87 (58.62%) patients a complete resolution was observed, with no
statistically significant difference between the two groups. On the contrary, there was significant difference in
the overall incidence of side-effects, such as in the occurrence of post-embolisation syndrome (p<0.001).
CONCLUSION
Compared to cTACE, TAETE showed to be more effective in the size-reduction of tumoral mass with similar
anti-tumor effects at thirty-day MSCT control and better toxicity profile, which makes it extremely useful in
patients with more than one lesion or in case of relapse.
CLINICAL RELEVANCE/APPLICATION
Considering the onset of adverse events according to CTCAE version 4.0 (2009), TAETE is less invasive than
cTATE (p=0.019, chi2-test with Yates-correction), showing no significative difference in the radiological tumor
response according to mRECIST and EASL (p=0.958, chi2 test). TAETE could be used in elderly HCC patients or
in case of multiple treatments
SSC14-09
90Y Loaded Glass Microspheres versus Sorafenib for Hepatocellular Carcinoma with Portal Vein
Thrombosis: A Retrospective Study
Yan Rolland MD, PhD (Presenter): Consultant, BTG International Ltd , Julien Edeline : Nothing to Disclose ,
Eveline Boucher : Nothing to Disclose , Etienne Garin MD : Consultant, BTG International Ltd
PURPOSE
PVT is a main negative prognostic factor for HCC patients. The goal of this study is to analyse retrospectively
patients treated with ThereSphere (T) or sorafenib (S) or both TheraSphere plus sorafenib (T+S).
METHOD AND MATERIALS
61 consecutive PVT patients were retrospectively included. Patients treated with sorafenib received a standard
dose. Patients treated with TheraSphere were treated using a personalized dosimetric approach. Median
progression free survival (PFS) and overall survivals (OS) were estimated with the Kaplan-Meier methos and
compared with a log-rank test.
RESULTS
18 patients received T only (30%), 29 S only (48%) and 14 received both T+S (23%). Main PVT was present in
38% of the patients treated by T and 52% for those treated by S only (ns). For patients treated with T the
mean lobe dose was 146Gy and 13 patients (40%) received an intensification (mean lobe dose = 197Gy). PFS
was 7.7 m (IC 95% : 6.5-8.9) in the group T vs 3.5 (IC 95% : 1.8-5.2) in the group S only (p = 0.026). OS was
23.4 months (IC 95% : 20.6-26.2) in the group T vs 5.1 (IC 95% : 2.3- 7.8) in the group S alone (p<0.001). In
the group T, OS was not significantly different if the patients received T alone or both T+S, respectively
24.0months vs 21.5 months (p = 0,96). For patients with a maximum of 3 lesions 0S was still significantly
higher for patients treated by T (23.8 months) than for those teated by S only (5.1 months, p<0.001). For
patients with unilateral PVT results were still significantly better for T : OS weres 24.0 vs 6.5 months for
patients treated respectively with T or S alone (p<0.001).
CONCLUSION
In this retrospective study TheraSphere, using a personalized dosimetric approach and intensification,
significantly increases OS of PVT patients versus sorafenib.
CLINICAL RELEVANCE/APPLICATION
glass microsphere radioembolization signicficantly increases overal survival for hepatocellular carcinoma with
prortal vein thrombosis
Samsung: Advances in the Technology and Application of Ultrasound - RS80A Introduction
Vendor Workshops
Mon, Dec 1 11:00 AM - 11:25 AM
Location: Booth 8355
LEARNING OBJECTIVES
This session will provide ultrasound information on technique and application for Samsung ultrasound system. A lecture will
provide an overview of the technologies and applications prior to the launching show.
To register for this workshop course, please contact Kelly Kwak at eunjung.kwak@samsungmedison.com
Samsung: Introduction to New Premium Technology - RS80A System Review
Vendor Workshops
Mon, Dec 1 11:30 AM - 11:55 AM
Location: Booth 8355
LEARNING OBJECTIVES
In this session, participants will become familiar with the Samsung ultrasound system and learn more about new features and
technologies. A lecture will introduce the new technologies prior to the launching show.
To register for this workshop course, please contact Kelly Kwak at eunjung.kwak@samsungmedison.com
Hologic: 3D Breast Biopsy using the Selenia® Dimensions®, Affirm™ and Eviva® systems.
Vendor Workshops
Mon, Dec 1 12:00 PM - 12:45 PM
Location: Booth 1465
LEARNING OBJECTIVES
Hologic is offering a series of 45 minute sessions that include demonstration of the Hologic 3D breast biopsy procedure using
the Selenia® Dimensions®, Affirm™ and Eviva® systems. A brief lecture will provide an overview of the technology including
comparison of 3D to stereotactic guided biopsy prior to the demonstration. The sessions are intended for radiologists and
general surgeons interested in learning more about 3D for interventional breast procedures. The course is not accredited for
CME. <br> <br> Please visit <a href="http://www.hologic.com/RSNAtomo-courses"
target='_blank'>www.hologic.com/RSNAtomo-courses</a> to register for this Vendor Workshop.
BRS-MOA
Breast Monday Poster Discussions
Scientific Posters
BR
AMA PRA Category 1 Credits ™: .50
Mon, Dec 1 12:15 PM - 12:45 PM
Location: BR Community, Learning Center
Participants
Moderator
Debra Somers Copit MD : Scientific Advisory Board, Hologic, Inc
Sub-Events
BRS245
On the Statistical Relationships Between Quantitative DCE-, DW-, and APT-CEST-MRI: A Hypothesis
Generating Study (Station #1)
Elizabeth Vera Gadwood MD (Presenter): Nothing to Disclose
PURPOSE
New MRI techniques are being developed to quantitatively evaluate breast tumors in the diagnostic and
prognostic settings. One such method is amide proton transfer (APT), a type of chemical exchange saturation
transfer (CEST) imaging. APT provides information about protein content and distribution in tumors. Studies
have shown that APT can distinguish healthy tissue from tumor and may be sensitive enough to detect subtle
changes related to chemotherapy. This study aims to evaluate APT-CEST-MRI in relation to diffusion weighted
MRI (DW-MRI) and dynamic contrast enhanced MRI (DCE-MRI) in breast cancer patients.
METHOD AND MATERIALS
12 patients with invasive mammary carcinoma underwent MR imaging prior to therapy, which included DW-,
DCE-, and APT-CEST-MRI. Analysis of the DCE-MRI data returned the volume transfer constant (Ktrans),
extravascular extracellular volume fraction (ve), efflux constant (kep), and blood plasma volume fraction (vp).
The apparent diffusion coefficient (ADC) was estimated from the DW-MRI data, while the mean APT was
calculated from the CEST data. The Spearman's rank correlation coefficient was calculated to test for a
significant statistical relationship between all of these parameters at the whole tumor region of interest level.
RESULTS
APT and Ktrans demonstrated a strong and significant correlation (r2=0.82, p=0.002) while a modest but
non-significant correlation was seen between APT and vp (r2=0.6, p=0.051). There was no correlation between
APT and ADC (r2=0.08, p=0.8).
CONCLUSION
The significant correlation between APT and Ktrans, a marker of tumor vessel perfusion and/or permeability,
suggests that protein synthesis may be related to tumor associated angiogenesis. This hypothesis is
suggests that protein synthesis may be related to tumor associated angiogenesis. This hypothesis is
strengthened by the positive correlation between APT and vp. Lack of correlation between APT and ADC
suggests that APT is a stronger marker of extracellular protein, rather than intracellular protein, as it appears to
be independent from tumor cell density.
CLINICAL RELEVANCE/APPLICATION
Initial results suggest APT is independent from DW-MRI and complimentary to DCE-MRI. If this can be validated
in a larger patient set, measurements of APT could impact standard MRI breast protocols.
BRS246
Initial Testing of an In-bore MRI-guided Real-time Breast Biopsy System (Station #2)
Frederick Kelcz MD, PhD (Presenter): Nothing to Disclose , Raymond Harter MS : President, Marvel
Medtech, LLC , Ethan K. Brodsky PhD : Nothing to Disclose , Walter F. Block PhD : Research support,
General Electric Company , Roberta Marie Strigel MD, MS : Speaker, Bracco Group , Graham T. Reitz :
Research funded, Marvel Medtech, LLC , Sergey N. Kuro : Employee, Marvel Medtech, LLC
PURPOSE
The current method of MRI-assisted breast biopsy requires that the patient be moved into the bore for planning
and verification, then out of the bore for the biopsy procedure. This approach is subject to error due to patient
motion or trocar-induced lesion displacement between image sets. We are developing an in-bore system for
robotic interactive MR image guided interventions (iMR-IGI) using MRI-compatible actuators and a ceramic
trocar. This will allow the radiologist to efficiently and rapidly control, in real time, all aspects of the intervention
process.
METHOD AND MATERIALS
We have developed a multi-degree-of-freedom robotic proof-of-concept prototype system for in-bore MR image
guided biopsy (IGB) trocar placement. The MRI-compatible system configuration is not limited to lateral or
medial access to the breast and is constructed so as to permit a real-time imaging interface to the MRI
scanner. The system also has its own integrated radiofrequency (RF) breast coil to maximize signal to noise
ratio (SNR) and uses piezoelectric actuators. The in-bore tool positioner is mounted on a circular track
surrounding the breast cup and RF coil.
RESULTS
Video will be presented, taken during real-time MR imaging, demonstrating robotic controlled insertion of the
fluid filled, MR visible ceramic trocar into a gel breast phantom. We tested SNR levels using phantoms with all
electronics unpowered (SNR = 44) vs. a fully activated state (SNR=31) using an 8 channel commercial receive
breast coil (GE Healthcare, Waukesha, WI). While SNR degradation is measurable in this early prototype, it is
modest and acceptable given the clinical requirements for identifying and tracking a known lesion.
CONCLUSION
We have demonstrated proof-of-concept novel in-bore actuation capability with concurrent real-time imaging.
Our proposed system will provide a rapid, interactive method for placing diagnostic and therapeutic tools into
the breast under real-time MRI guidance.
CLINICAL RELEVANCE/APPLICATION
Some literature has used the term "real-time" to simply describe a surgery that can be completed entirely
within the MR suite. In such cases, the imaging guidance itself is not in real-time and device guidance is
performed by iterating between diagnostic imaging and discrete device manipulations. We have demonstrated
novel true in-bore actuation capability with concurrent real-time imaging, now to be applied to the breast, but
with potential for use in other body regions.
BRS247
Heterogeneity of Background Parenchymal Enhancement on MRI Strongly Predictive of Breast
Cancer Molecular Subtypes (Station #3)
Jeff Wang (Presenter): Nothing to Disclose , Fumi Kato : Nothing to Disclose , Kohsuke Kudo MD :
Nothing to Disclose , Hiroko Yamashita : Nothing to Disclose , Hiroki Shirato MD, PhD : Nothing to Disclose
PURPOSE
Despite many efforts having studied lesion texture as imaging biomarkers of breast cancer (BC) subtypes, it
appears none have yet been published assessing the same of background parenchymal enhancement (BPE).
This study aims to determine the prognostic ability of BPE texture surrogates with molecular subtypes of BC.
METHOD AND MATERIALS
Building evidence continues to show BC is a diverse disease. Molecular subtyping based on estrogen (ER),
progesterone (PgR), and human epidermal growth factor 2 (HER2) receptor expression provides valuable
information for treatment.
Dynamic contrast-enhanced (DCE)-MRI is standard in diagnostic breast imaging, known for its high sensitivity.
Increased BPE on DCE-MRI has been associated with higher rates of abnormal interpretation and obscured
breast masses. There is also evidence it may provide insight with BC risk.
This retrospective study included 64 women with 69 invasive mass carcinomas, who had DCE-MRI. ER, PgR, and
HER2 receptor expression of the lesions were determined by immunohistochemistry in specimens. The cancers
were also categorized triple-negative (TN) or Luminal A (LumA), as clinically significant.
Segmentation of parenchyma tissue was performed from DCE-MRI of the affected breast and BPE texture was
then quantified as first and second-order statistical features of pharmacokinetic parameter maps calculated
from the tissue compartment.
Logistic regression models were learned, using reduced BPE texture features to classify receptor status.
Accuracy (ACC), sensitivity (TPR), specificity (TNR), and area under the ROC curve (AUC) of performance were
calculated from leave-one-out cross-validation.
RESULTS
TN BC were classified with ACC of 95%, TPR of 89%, TNR of 97%, and AUC of 0.89. ER BC were classified with
ACC of 88%, TPR of 67%, TNR of 96%, and AUC of 0.81. PgR BC were classified with ACC of 68%, TPR of 42%,
TNR of 86%, and AUC of 0.61. HER2 BC were classified with ACC of 83%, TPR of 36%, TNR of 94%, and AUC of
0.63. LumA BC were classified with ACC of 61%, TPR of 65%, TNR of 57%, and AUC of 0.66.
CONCLUSION
BPE texture is demonstrated as able to predict TN and ER BC with great accuracy and discriminative ability;
PgR, HER2, and LumA BC to lesser degrees.
CLINICAL RELEVANCE/APPLICATION
BPE heterogeneity can extend the diagnostic ability of DCE-MRI, as it is strongly predictive of some molecular
subtypes of breast cancer, particularly the more aggressive triple-negative subtype.
BRS250
Incidental Findings on Breast MRI: The Added Value of Second-look Digital Breast Tomosynthesis
(Station #4)
Paola Clauser MD (Presenter): Nothing to Disclose , Luca Alessandro Carbonaro MD : Research Consultant,
im3D SpA , Martina Pancot : Nothing to Disclose , Massimo Bazzocchi MD : Nothing to Disclose , Chiara
Zuiani MD : Nothing to Disclose , Francesco Sardanelli MD : Speakers Bureau, Bracco Group Research
Grant, Bracco Group Speakers Bureau, Bayer AG Research Grant, Bayer AG Research Grant, IMS International
Medical Scientific
PURPOSE
To assess the clinical utility of second-look digital breast tomosynthesis (SL-DBT) to look for lesions detected
initially on MRI and to compare SL-DBT with second-look ultrasound (SL-US).
METHOD AND MATERIALS
This multicentric retrospective study included 143 patients with biopsy-proven breast cancer that underwent
both BT and MRI as staging. The study obtained IRB approval and patients signed the informed consent for the
examinations. Four readers with experience in breast imaging reviewed MRI examinations to find incidental
lesions not suspected on the basis of previous imaging. MRI lesions characteristics were evaluated: morphology
(mass like enhancement ML, non mass like enhancement NML or foci), dimensions (≤10 mm or > 10 mm) and
ACR BIRADS classification (3 or 4-5). DBT was then re-evaluated looking for MRI findings. Data on SL-US were
also collected for all incidental findings. Standard of reference was biopsy, surgical excision or follow up (≥1
year).
RESULTS
Eighty-two MRI incidental findings were detected in 51 patients. At SL-DBT a correlation was made in 40 cases
(49%) including 29 malignant lesions and 11 benign lesions. At SL-US a correlation was made in 41 (50%)
including 25 malignant and 16 benign lesions. Overall, 61 (74.4%) of the lesions were visible with at least one
technique other than MRI, including 40 malignant and 21 benign lesions. Of the 21 lesions non-visible at second
look, 17 were malignant and 4 were benign. When analysing the type of lesion found at SL-DBT, no significant
differences were found regarding morphology (ML vs NML vs foci), dimensions (≤10 mm or > 10 mm) and
BIRADS classification (3 vs 4-5). Though the difference was not significant, SL-DBT found more frequently NML
lesions compared to SL-US (44% vs 28%).
CONCLUSION
SL-DBT allowed to add almost 25% additional lesions in adjunct to SL-US, and it could be particularly helpful
for areas of NML enhancement. The absence of a DBT or US correlate does not warrant to avoid MR-guided
biopsy for suspicious findings.
CLINICAL RELEVANCE/APPLICATION
With the introduction of systems to perform biopsy under Tomosynthesis guidance, the use of SL-DBT could
help avoiding MR-guided biopsy, thus reducing costs and discomfort for the patients.
BRS248
Usefulness of Combined Diffusion-weighted Imaging to Dynamic Contrast-enhanced Breast MRI for
Diagnosis of the Multifocal and Multicentric Breast Cancer (Station #5)
Eun Kyung Park MD (Presenter): Nothing to Disclose , Kyu Ran Cho MD, PhD : Nothing to Disclose , Bo
Kyoung Seo MD, PhD : Nothing to Disclose , Ok Hee Woo MD : Nothing to Disclose , Sung Bum Cho :
Nothing to Disclose , Kyung Hwa Park : Nothing to Disclose
PURPOSE
The purpose of this study was to investigate the diagnostic value of an imaging protocol that addition of
diffusion-weighted imaging (DWI) to dynamic contrast-enhanced breast MRI (DCE-MRI) for diagnosis multifocal
and multicentric breast cancer.
METHOD AND MATERIALS
The prospective study included 82 consecutive women with 136 enhancing lesions on DCE-MRI for preoperative
staging in breast cancer. Morphologic and kinetic assessments were performed on DCE-MRI and findings were
classified according to the Breast Imaging Reporting and Data System (BI-RADS) lexicon. Apparent diffusion
coefficient (ADC) values were compared for benign and malignant lesions. For the combined MRI protocol,
lesions which were classified as BI-RADS 4a and had an ADC value more than the calculated cutoff value were
considered as benign. Sensitivity (SE), specificity (SP) and positive predictive value (PPV) were evaluated for
DCE-MRI alone and combined MRI protocol for unexpected additionally detected lesions on DCE-MRI. Results
were further compared by lesion size (>1cm or ≤1cm).
RESULTS
Of the 136 lesions, 26 were benign and 110 were malignant (15 ductal carcinoma in situ, 95 invasive
carcinoma). The malignant lesions (mean ADC, 0.93±0.22×10-3 mm2/s) exhibited lower mean ADC than
benign lesions (1.20±0.24×10-3 mm2/s, P <0.01). Of the 136 lesions, 49 lesions were additionally detected
lesions on DCE-MRI. DCE-MRI alone showed 97% SE, 18% SP, and 69% PPV. The combined MRI protocol
produced 97% SE, 71% SP, and 86% PPV, and showed statistically significant increase of SP (P <0.01) and PPV
(P=0.02). PPV of combined MRI protocol for larger lesions (100%) was higher than that of smaller lesions
(76%), however, combined DWI increased PPV similarly for larger lesions and small lesions.
CONCLUSION
The combined DWI to DCE-MRI has the potential to increase the SP and PPV to diagnose multifocal and
multicentric breast cancer.
CLINICAL RELEVANCE/APPLICATION
The addition of DWI can decrease the false positive diagnosis and this is recommended in preoperative staging
of breast cancer.
BRS249
Incidence of Internal Mammary Lymph Nodes on Breast MRI Following Oncoplastic Surgery (Station
#6)
Elizabeth Jennifer Watson MD, MPH : Nothing to Disclose , Elizabeth J. Sutton MD (Presenter): Nothing to
Disclose , Girard Gibbons BA : Nothing to Disclose , Elizabeth A. Morris MD : Nothing to Disclose
PURPOSE
Breast cancer oncoplastic surgery allows a tandem approach to treatment and reconstruction, which may
involve silicone implant placement. Postoperatively, magnetic resonance imaging (MRI) can diagnose silicone
implant rupture. Enlarged internal mammary lymph nodes (IMLN) can develop after silicone implant placement
but inaccessibility makes tissue diagnosis difficult. The purpose of this study was to assess among women with a
history of breast cancer and silicone implant placement, the incidence of benign and malignant internal
mammary lymph nodes on MRI.
METHOD AND MATERIALS
This retrospective study received institutional review board approval and need for informed consent waived.
Between 2000-2013, we identified women who had: a) breast cancer, b) oncoplastic surgery, c) postoperative
implant protocol MRI. Clinical and pathologic data were collected. Short and long axis measurements of the
largest IMLN, per side, were recorded. A benign IMLN was defined as having, at minimum, two years of either:
1) imaging stability and/or 2) no clinical evidence of recurrent disease. A malignant IMLN was defined if patient
had biopsy proven metastatic disease.
RESULTS
956 women with breast cancer were identified who underwent oncoplastic surgery and a postoperative implant
protocol MRI (n=552 bilateral and n=404 unilateral). The mean time between surgery and MRI was 84.4
months (range 0.5-512 months). 32 percent of patients (n=306) had IMLN. Mean short and long axis
measurements were 0.5 cm (SD 0.2) and 0.7 cm (SD 0.3), respectively. ILMN were significantly more likely to
be benign than malignant (p<0.05). Less than 5% of IMLN were metastatic.
CONCLUSION
IMLN identified on silicone implant protocol breast MRI following oncoplastic surgery for breast cancer are
significantly more likely to be benign than malignant. The results support imaging follow-up instead of
immediate metastatic work-up
CLINICAL RELEVANCE/APPLICATION
IMLN identified on implant protocol MRI are probably benign and imaging follow-up should be considered
instead of an immediate work-up to exclude metastatic disease.
instead of an immediate work-up to exclude metastatic disease.
BRE235
The Sonographic Appearance of Benign Masses of the Breast in Children and Adolescents (Station
#7)
Karina Pesce : Nothing to Disclose , Flavia Beatriz Sarquis MD (Presenter): Nothing to Disclose , Monica
Colombo : Nothing to Disclose , Eun Ae Park : Nothing to Disclose , Bernardo Oscar Blejman MD : Nothing
to Disclose
TEACHING POINTS
1-To recognize the normal ultrasound appearance of the breast in children and adolescents 2- To describe
benign masses of the breast in children and adolescents 3- To recognize the ultrasound characteristics of the
benign breast masses in children and adolescents.
TABLE OF CONTENTS/OUTLINE
1-Introduction 2- Normal Breast Development. Stages of Tanner 3- Sonographic normal appearance of the
breast in children and adolescents 4- Spectrum of benign masses of the breast in children and adolescents: the
sonographic appearance. 5-Clinical cases 6-Conclusion
BRE200
Nipple Discharge: Evaluation, Diagnosis, and Management (Station #8)
Lilian Wang MD (Presenter): Nothing to Disclose , Ellen Bachman Mendelson MD : Research support,
Siemens AG Speakers Bureau, Siemens AG Medical Advisory Board, Quantason, LLC Consultant, Quantason, LLC
TEACHING POINTS
The purpose of this exhibit is to review the causes, imaging findings, and management of benign and malignant
nipple discharge. In patients with negative mammography and ultrasound and unsuccessful ductography, MRI is
an important adjunct imaging modality in nipple discharge evaluation.
TABLE OF CONTENTS/OUTLINE
1. Distinguish clinically benign and suspicious nipple discharge. 2. Discuss pathologic entities responsible for
nipple discharge. 3. Review imaging modalities used in nipple discharge evaluation with sample cases: a.
Mammography b. Ultrasound c. Ductography d. MRI 4. Discuss management of nipple discharge with review of
current literature.
BRE183
From Lymphoma to Melanoma: Metastatic Disease to the Breast and Axilla from Extramammary
Malignancies (Station #9)
Kopal Shama Kulkarni MD (Presenter): Nothing to Disclose , Ashley Cimino-Mathews MD : Nothing to
Disclose , David J. Eisner MD : Nothing to Disclose , Ergeba H. Sheferaw MD, MPH : Nothing to Disclose ,
Bonmyong Lee MD : Nothing to Disclose , Susan Caroline Harvey MD : Nothing to Disclose , Dorothy Amy
Sippo MD : Nothing to Disclose
TEACHING POINTS
The purpose of this exhibit is:
1) To review the sources of metastatic disease to the breast and axilla.
2) To explain how metastatic disease can spread to the breast via either hematogenous or lymphatic routes.
3) To review the clinical and imaging presentations of metastatic disease to the breast and axilla.
TABLE OF CONTENTS/OUTLINE
Overview of metastatic disease to the breast and axilla: -Frequency of occurrence -Sources of metastatic
malignancy -Routes of spread -Hematogenous -Lymphatic Clinical presentation Review of imaging findings
Sample cases -Lung cancer -Adenocarcinoma -Squamous cell carcinoma -Lymphoma/leukemia -Melanoma
-Ovarian cancer -Plasmacytoma -Renal cell carcinoma Other breast lesions that may have imaging features
similar to metastatic disease -Complicated cyst -Invasive ductal carcinoma -Invasive lobular carcinoma
Summary
BRE008-b
When Cancer's Not the Answer: A Radiologic Review of Infectious and Inflammatory Breast
Pathologies (hardcopy backboard)
Nancy Anne Resteghini DO, MS (Presenter): Nothing to Disclose , Sue A. MacMaster MD : Nothing to
Disclose , Rebecca Hultman DO : Nothing to Disclose
TEACHING POINTS
1. To review imaging presentations of commonly encountered breast infections in both healthy and
immunocompromised women. Cases will include: subareolar abscess, infected sebaceous cyst, mastitis, fat
necrosis, post-biopsy infection, and Filariasis. 2. To review imaging presentations of inflammatory breast
conditions such as Granulomatous Mastitis, Breast Amyloidosis and Diabetic Mastopathy. 3. To present imaging
features that are important for the radiologist to be able to identify to characterize infectious and inflammatory
lesions. 4. To provide a multimodality pictorial review of pathologies of the infected or inflamed breast, while
highlighting optimal imaging modalities.
TABLE OF CONTENTS/OUTLINE
TABLE OF CONTENTS/OUTLINE
1. Overview of multimodality imaging appearance of common infectious and inflammatory breast pathologies. 2.
Present imaging examples of infectious and inflammatory breast pathologies: Subareolar abscess, infected
sebaceous cyst, cellulitis, mastitis, fat necrosis, post-biopsy infection and Filariasis Granulomatous Mastitis,
Breast Amyloidosis and Diabetic Mastopathy 3. Review relevant clinicopathologic features and radiologic
manifestations of each pathologic process. 4. Discuss the diagnostic value of each modality, and the importance
of differentiating infection and inflammation from breast malignancy
CAS-MOA
Cardiac Monday Poster Discussions
Scientific Posters
CA
AMA PRA Category 1 Credits ™: .50
Mon, Dec 1 12:15 PM - 12:45 PM
Location: CA Community, Learning Center
Participants
Moderator
Bernd J. Wintersperger MD : Speakers Bureau, Bayer AG Speakers Bureau, Siemens AG
Moderator
Gregory W. Gladish MD : Nothing to Disclose
Sub-Events
CAS182
An Attempt to Bring Forward the Start Time of Scan of Delayed Myocardial Enhancement (Station
#1)
Ryutaro Matsuura MSc (Presenter): Nothing to Disclose , Yuichi Omura : Nothing to Disclose , Sachiko
Goto PhD : Nothing to Disclose , Yoshiharu Azuma PhD : Nothing to Disclose , Nahoko Simada : Nothing
to Disclose , Shuhei Sato MD, PhD : Nothing to Disclose , Seiji Tahara : Nothing to Disclose
TEACHING POINTS
We have to shorten inspection time in order to decrease patient's physical burden. Early image is applicable to
diagnosis.
TABLE OF CONTENTS/OUTLINE
Background We attempted to bring forward the start time of scan in delayed myocardial Gd enhancement in
cardiac MRI. The term of whole examination was shortened by bringing forward the start time and therefore a
patient's physical burden must decrease. Evaluation Cardiac MRI was performed in patients with old myocardial
infarction (OMI), dilated cardiomyopathy (DCM), hypertrophic cardiomyopathy (HCM), cardiac sarcoidosis, and
others. 20 patients (female:10, male:10) ranged in age from 18 to 82 years participated in this study. We
evaluated the images by the delayed times of 5 and 10 minutes using Phillips Achieva 1.5T. As evaluation
criteria, CNR (contrast to noise ratio) and enhanced volume were employed, visual assessments were
performed by 2 radiologists using image viewers. Wilcoxon signed rank test was performed to compare CNR.
Discussion About visual assessments, 18 patients were able to be diagnosed by the images delayed time 5
minutes. As a result of CNR and enhanced volume ratio, the significant difference was not accepted. Conclusion
Our results show the images with delayed time of 5 minutes available for diagnosis. The physical burden to a
patient is also mitigated.
CAS183
Cardiac Enzyme Peaks and Pro-BNP at Admission could Predict Presence of Microvascular
Obstruction at Cardiac Magnetic Resonance in Patients with ST-Elevation Myocardial Infarction.
(Station #2)
Anna Damascelli MD (Presenter): Nothing to Disclose , Francesco Aldo De Cobelli MD : Nothing to Disclose
, Antonio Esposito MD : Nothing to Disclose , Giulia Benedetti : Nothing to Disclose , Paolo Guido Camici :
Nothing to Disclose , Alessandro Del Maschio MD : Nothing to Disclose
PURPOSE
Microvascular obstruction (MVO) may occur in patients with ST-Elevation Myocardial Infarction (STEMI) after
percutaneous revascularization and it has been associated with a negative outcome. We evaluated the
relationship between admission cardiac markers' levels and MVO assessed by Cardiac Magnetic Resonance
(CMR).
METHOD AND MATERIALS
We enrolled 58 consecutive STEMI patients admitted to our ER. Patients were treated with primary
percutaneous coronary intervention (PCI) and underwent CMR (1.5 T) within 5 days from the event. Blood
samples were taken before any drug administration and before PCI. Troponin-T (TpnT), CK, CK-MB and
pro-brain natriuretic peptide (NT-pro-BNP) were quantified. The CMR criteria of MVO were the presence of a
subendocardial lack of signal within areas of enhancement in FPP-sequences and/or in early and
late-enhancement sequences (5 and 15 minutes after gadolinium administration). The presence of a
hypointense region within the hyperintense area of edema on STIR sequences was considered as a marker of
hemorrhage. MVO and hemorrhage were quantified as a percentage of left ventricle myocardial mass.
RESULTS
We compared patients (age 60±10 yrs; 51 male) with and without MVO (38 and 20 respectively) and patients
with and without haemorrhage (20 and 38 respectively) for cardiac markers' levels. TpnT, CK and CK-MB peaks
were significantly higher in patients with MVO (p<0.001) and there was a significant correlation between
enzymatic levels and MVO extent (p<0.001). TpnT, CK, and CK-MB peaks were also significantly higher in
patients with hemorrhage (p<0.001) and we found a significant correlation between enzymatic levels and
hemorrhage extent (TpnT: p=0.021; CK: p=0.005 and CKMB: p=0.004). At the multivariate analysis only
CK-MB resulted as an independent predictor of MVO (p=0.007). ROC curve analysis showed that patients with
CK-MB ≥123 ng/ml have a higher risk of MVO after PCI (sensitivity: 94%; specificity: 84%; AUC: 0.93).
Patients with MVO and hemorrhage also showed a higher level of pro-BNP (p=0.02 and p=0.017).
CONCLUSION
These preliminary data suggest that CK-MB peaks could predict the risk of MVO in STEMI patients before PCI
procedure.
CLINICAL RELEVANCE/APPLICATION
MVO after PCI in STEMI patients has been associated with a negative outcome; cardiac enzyme at admission
could predict MVO occurrence and may help in prevent it.
CAS184
Potential Role of T1 and T2 Mapping Sequences in the Diagnosis of Acute Myocarditis (Station #3)
Celine Khayat (Presenter): Nothing to Disclose , Julie Mayer : Nothing to Disclose , Francois Legou MD :
Nothing to Disclose , Fourat Ridouani : Nothing to Disclose , Thibaud Damy : Nothing to Disclose , Alain
Luciani MD, PhD : Nothing to Disclose , Hicham Herve Kobeiter MD : Nothing to Disclose , Alain Rahmouni
MD : Nothing to Disclose , Jean-Francois Deux : Nothing to Disclose
PURPOSE
Evaluate the potential role of T1 and T2 mapping sequences in the diagnosis of acute myocarditis (AM)
METHOD AND MATERIALS
15 patients with suspicion of AM and 16 control subjects were included an explored on a 1.5T MR. Pre contrast
T1 and T2 shortened modified look-locker inversion recovery and STIR T2 sequences were acquired in a mid
ventricular short-axis (SA) section and in the four-chamber (4C) section. Cine SSFP, first pass and LGE
sequences were also acquired. Mean myocardial T1, T2 and STIR T2 signal intensity (SI) were calculated from
manual contouring of the short axis section. The same parameters were measured independently for lateral and
interventricular septum (IVS), both on the SA and the 4C sections. Number and location of positive segments
were noticed on LGE sequence. A non parametric test was used to compare data.
RESULTS
Mean number of involved segments on LGE was 5±1.5 with a systematic involvement of mild lateral left
ventricular wall in patients. Mean myocardial T1, T2 and STIR T2 SI were in the same range (P=NS) between
patients (998±52 ms, 53.0±5 ms and 173±42, respectively) and subjects (969±47 ms, 50.8±4 ms and
173±47, respectively). Myocardial T1 and T2 of patients were significantly (P<0.05) higher in the lateral wall,
on the SA section (1016 ± 58 and 54 ± 8 ms, respectively for T1 and T2) and on the 4C section (1023 ± 65
and 54 ± 6 ms, respectively for T1 and T2), in comparison to control subjects (957 ± 45 and 49 ± 3 ms
respectively for T1 and T2 on the SA section, and 937 ± 43 and 49 ± 3ms respectively for T1 and T2 on the 4C
section). STIR T2 SI in the lateral wall was in the same range (P=0.3) between patients and control subjects:
176 ± 50 vs. 148 ± 48 on the SA section and 170 ± 59 vs. 159 ±43 on the 4C section, respectively for patients
and control subjects. T1, T2 and STIR T2 SI of the IVS were in the same range between patients and subjects
(data not shown).
CONCLUSION
T1 and T2 were increased in the lateral wall in case of AM in comparison to control subject. T2 mapping seems
to be more efficient than STIR T2 sequence for detection of local edema in the lateral wall.
CLINICAL RELEVANCE/APPLICATION
Pre contrast mapping sequences can detect myocardial lesions of AM and could increase diagnostic accuracy of
this disease, especially in case of contraindication to contrast medium injection
CAS186
Normal Position of the Origins of the Coronary Arteries within the Aortic Root (Station #5)
Ethan J. Halpern MD (Presenter): Nothing to Disclose , Praneil
White MD : Nothing to Disclose
Patel MD : Nothing to Disclose , Hugh
PURPOSE
When performing transcatheter aortic valve replacement (TAVR), the cranial margin of the fabric surrounding
the prosthesis must be positioned below the orifices of the coronary arteries. Axial images obtained from CT
angiography (CTA) demonstrate an asymmetric appearance to the aortic root, and suggest a more superior
origin of the left coronary artery (LCA) as compared with the right coronary artery (RCA). The purpose of this
study was to define the position of the coronary artery origins relative to the aortic annulus and root at CTA.
METHOD AND MATERIALS
This retrospective study reviewed 52 consecutive ECG-gated cCTA examinations of the thoracic aorta and
coronary arteries. Two independent reviewers evaluated the position of the coronary artery origins visualized on
CTA using the Brilliance 3D workstation (Philips Medical Systems). Measurements were obtained along the long
axis of the aortic root to define the distance from the aortic annulus to each coronary artery origin.
RESULTS
Analysis of variance for the length of the aortic root demonstrated no significant effect based upon side (right
vs left), cardiac phase (diastole vs systole), or reader (p>0.55). Mean length of the aortic root (± standard
deviation) was 2.2cm ± 0.05. The coronary arteries originated below the sinotubular junction in all subjects.
Analysis of variance for the height of the coronary artery origins demonstrated a significant effect based upon
side (F=14.4; p=0.0002), but no effect based upon cardiac phase (F=0.3; p=0.6). The RCA origin was slightly
closer to the sinotubular junction than the LCA origin (mean of 1.6cm vs 1.5cm above the aortic annulus) in
both diastole and systole.
CONCLUSION
The aortic root is a clover-shaped symmetric structure, measuring approximately 2.2cm in length, with both
coronary arteries arising just below the sinotubular junction. Although the LCA origin is superior to the RCA
origin in the chest, the RCA origin is actually slightly further from the aortic annulus and closer to the
sinotubular junction.
CLINICAL RELEVANCE/APPLICATION
When a stent/prosthesis is implanted within the aortic root, the covered portion of the stent must terminate
below the coronary artery origins. The distance between the aortic annulus and the origins of the coronary
arteries is not accurately assessed on axial images, but can be measured in long axis on a 3D workstation. The
mean height of the coronary artery origins is 1.5cm above the aortic annulus.
CAS187
Cardiac Magnetic Resonance Imaging in Patients with Acute Chest Pain, Elevated Cardiac Troponin
Values and Normal Angiograms (Station #6)
Marcin Pawel Basiak MD (Presenter): Nothing to Disclose , Marek Nikodem Konopka MD, PhD : Nothing to
Disclose , Maria Dziubinska-Basiak MD : Nothing to Disclose , Damian Kawecki MD, PhD : Nothing to
Disclose , Ewa Nowalany-Kozielska MD, PhD : Nothing to Disclose , Boguslaw Okopien MD, PhD : Nothing
to Disclose
PURPOSE
Acute coronary syndrome with normal coronary arteries in coronary angiography is an important issue in
modern cardiology. The aim of this study is to evaluate the usefulness of cardiac magnetic resonance imaging in
patients with elevated values of markers of myocardial infarct and unobstructed coronary arteries in coronary
angiography imaging.
METHOD AND MATERIALS
Study group consisted of eleven patients with elevated troponin values and completely normal arteries in
coronary angiography. Four patients had upper respiratory tract infections during previous two weeks. CMR
study was performed for 10 days from cardiac episode using a 1.5 T scanner with a dedicated cardiac coil
before and after administration of contrast media include assessing left ventricular ejection fraction, the
presence of edema or delayed enhancement. Segments of the left ventricle was divided according to the AHA
guidelines.
RESULTS
Cardiovascular magnetic resonance imaging revealed myocarditis features in 6 (54.5%) patients, two patients the characteristics of transmural scar and three patients had normal results. Positive correlation was observed
beetween ischemic changes and values of troponin and CK-MB. In the group of patients with myocarditis
features mean LVEF was 56.7%, swelling was detected in 2 patients and delayed contrast enhancement in 5
patients. The results were compared with echocardiographic study.
CONCLUSION
CMR study is a useful diagnostic method in modern cardiovascular radiology. It provides valuable information
especially in patients with unexplained cause of cardiac events and can be done at an early period after the
stabilization of the clinical condition of the patient.
CLINICAL RELEVANCE/APPLICATION
Early CMR is valuable in the evaluation of the differential diagnoses and to exclude myocardial abnormalities in
patients with uncertain aetiology.
CAS189
Low Dose CT Angiography for Pre-procedural Assessment of Patients Undergoing TAVI (Station #8)
Sara Kruglick Floyd MD (Presenter): Nothing to Disclose , Olga Buzdygan : Nothing to Disclose ,
Marcos Paulo Ferreira Botelho MD : Nothing to Disclose , Timothy J. Carroll PhD : Nothing to Disclose ,
Ronan Conroy : Nothing to Disclose , Sukit C. Malaisrie MD : Nothing to Disclose , Jeremy Douglas Collins
MD : Consultant, B. Braun Melsungen AG , James Christopher Carr MD : Research Grant, Astellas Group
Research support, Siemens AG Speaker, Siemens AG Advisory Board, Guerbet SA
PURPOSE
CT angiography (CTA) is required prior to Transcatheter Aortic Valve Implantation (TAVI), in order to accurately
size the aortic valve and ensure that the pelvic vessels are sufficiently large to accommodate vascular access.
Due to advanced age and associated vascular disease, many TAVI patients suffer from chronic kidney disease
and are thus at increased risk of contrast induced nephropathy (CIN). We hypothesize that diagnostic
pre-procedural planning can be obtained using a low dose contrast CTA protocol, thereby reducing the risk of
CIN.
METHOD AND MATERIALS
A consecutive series of 65 CTA examinations, performed on a dual source 64 slice CT scanner (Siemens
Definition), were retrospectively identified for patients being considered for TAVI. The cases were divided into
low dose (=90ml contrast) groups. Quantitative analysis of image quality was calculated by measuring signal to
noise (SNR) and contrast to noise (CNR) at 10 pre-determined anatomic sites in the thoracic and abdominal
aorta. Qualitative image analysis was determined by two blinded physician reviewers, independently rating each
site on a 1-5 Likert scale, with respect to image quality, diagnostic confidence, SNR and CNR. Results between
the low dose and standard dose groups were compared using a weighted kappa statistic.
RESULTS
Quantitatively, SNR and CNR were lower in the low dose group compared to the standard dose group (SNR 17.7
compared to 35.8, CNR 14.8 compared to 30.7). For image quality, the low dose group scored 3.67 on average
compared to 3.88 in the standard dose group. Average diagnostic confidence scores were 3.96 for low dose
compared to 4.26 for standard dose. Average qualitative CNR was 3.65 for low dose compared to 4.22 for
standard dose. Average qualitative SNR was 3.44 for low dose compared to 3.79 for standard dose. The
weighted kappa statistic was 0.5873, indicating a moderate degree of agreement between reviewers.
CONCLUSION
Low dose CTA had lower image quality but acceptable diagnostic confidence compared to standard dose CTA.
In patients with renal compromise, low dose CTA may be a safer alternative in pre-procedural TAVI planning.
CLINICAL RELEVANCE/APPLICATION
CT angiography (CTA) is required for pre-procedural assessment of aortic stenosis patients prior to
Transcatheter Aortic Valve Implantation (TAVI). Low dose CTA may be a safer alternative.
CHS-MOA
Chest Monday Poster Discussions
Scientific Posters
CH
AMA PRA Category 1 Credits ™: .50
Mon, Dec 1 12:15 PM - 12:45 PM
Location: CH Community, Learning Center
Participants
Moderator
Prachi P. Agarwal MD : Nothing to Disclose
Sub-Events
CHS242
Lung Volume and Heterogeneity: CT Quantification of Lobar Contribution (Station #1)
Mario Silva MD : Nothing to Disclose , Stefan Franz Nemec MD : Nothing to Disclose , Benedikt H
Heidinger MD (Presenter): Nothing to Disclose , Mariaelena Occhipinti MD : Nothing to Disclose , Valerie
Dufresne : Nothing to Disclose , Francesco Molinari MD : Nothing to Disclose , Alexander A. Bankier MD,
PhD : Author with royalties, Reed Elsevier Consultant, Olympus Corporation
PURPOSE
To quantify the contributions of individual lobes to lung volume and to characterize quantitative morphological
metrics associated with these volumes.
METHOD AND MATERIALS
17 healthy volunteers underwent spirometrically monitored volumetric chest CT at total lung capacity (TLC),
functional residual capacity (FRC), and mean inspiratory capacity (MIC), measured half-way between TLC and
FRC. Dedicated software (Pulmo3D, MeVis, Germany) was used to measure lobar volume, lobar mean lung
density (MLD) and the standard deviation of lobar MLD (MLD-SD), as a surrogate parameter for parenchymal
heterogeneity. Differences between groups were tested by t-test and analyses of variance.
RESULTS
The biggest contributors to lung volume at TLC were RLL (27%) and LLL (27%), at MIC RLL (26%) and LLL
(26%), and at FRC LUL (25%) and RLL (24%). The smallest contributor in all three respiratory capacities was
the RML (TLC 8%, MIC 9%, FRC 11%). Relative volumes of lower lobes decreased from TLC to FRC (RLL 27 to
24%; LLL 27 to 23%), whereas relative volumes of middle (RML 8 to 11%) and upper lobes (RUL 17 to 18%;
LUL 21 to 25%) increased. All CT lung volume changes between TLC, MIC, and TRC were statistically significant
(p<0.001). Lobar MLD density was higher in lower lobes, at any lung volume (p<0.001). MLD-SD increased
from TLC to FRC, in all lobes (p<0.001), again with different pattern of variation between upper and lower
lobes. Lower lobes showed substantial increase in MLD-SD from TLC to MIC and to FRC. Otherwise, MLD-SD of
upper lobes and right middle lobe were near-identical at any lung volume.
CONCLUSION
Our study provides normative data on absolute and relative lobar contribution to lung volume and lung
heterogeneity in normals. The findings confirm the major contribution of the lower lobes to lung volume
changes and reveal that substantial physiological heterogeneity throughout all lobe is a normal finding in
healthy lungs.
CLINICAL RELEVANCE/APPLICATION
Our data provide normative reference values for lobar contribution to lung volume and lung heterogeneity, and
can be used as quantitative benchmark for the evaluation of these parameters.
CHS243
Impact of Endobronchial Coiling for Lung Volume Reduction on Pulmonary Volume and Attenuation:
Pre- and Post-interventional CT-quantification using Separate Lobe Measurements (Station #2)
Ulrich Grosse MD : Nothing to Disclose , Juergen Hetzel : Nothing to Disclose , Lutz Guendel : Employee,
Siemens AG , Sergios Gatidis MD : Nothing to Disclose , roland syha : Nothing to Disclose , Christoph
Schabel MD : Speaker, Siemens AG , Fabian Springer MD : Nothing to Disclose , Claus Detlef Claussen
MD : Nothing to Disclose , Konstantin Nikolaou MD : Speakers Bureau, Siemens AG Speakers Bureau,
Bracco Group Speakers Bureau, Bayer AG , Marius Horger MD (Presenter): Nothing to Disclose
PURPOSE
To objectify changes in volume and density of treated and untreated pulmonary lobes following endobronchial
coiling for lung volume reduction (LVR) by comparison with clinical (6 meter walk test [6MWT]) and pulmonary
function tests (PFT).
METHOD AND MATERIALS
22 lobes in 17 patients (8 men, 9 female; mean age 66.2 ± 5.9 years) with severe heterogeneous emphysema
were treated by endobronchial coils and underwent pre-and post-interventional CT-examinations (inspiratory
and expiratory phase). Clinical response was defined as an increase in the walking distance (6MWT) after
LVR-therapy. PFT measurements with forced expiratory volume in 1 second (FEV1), ratio of residual volume
over total lung capacity (RV/TLC) and single-breath diffusion capacity for carbon monoxide (DLCO SB) were
used for correlation.
RESULTS
Responders (N=14) presented a significant increase (70 ± 11 m) in the walking distance (6MWT) and
FEV1-values (61 ± 21 ml). In non-responders, walking distance significantly decreased (70 ± 15 m) and the
results of PFT did not improve. Inspiratory volume (VolIn) of the target lobe significantly decreased (10.0 ±
16.4 %; p-value = 0.0245) compared to pre-interventional lobe volume in responders, while no marked volume
change could be detected in non-responders. VolIn of the non-treated ipsilateral lobe significantly increased in
responders (5.5 ± 9.1 %; p-value = 0.0209) while the increase of VolIn of the contralateral lung did not reach
statistical significance.
CONCLUSION
Our results objectify volume reduction of the treated lobe coupled by a significant volume expansion of the
ipsilateral lobe as a sole correlate for clinical improvement in responders.
CLINICAL RELEVANCE/APPLICATION
The results of this preliminary study demonstrate the interplay between treated and untreated lung lobes with
respect to volume and density changes in patients treated with LVR-coils.
CHS245
Visual Assessment of Calcification of Solitary Pulmonary Nodule (SPN) on Chest Radiography (CXR)
According to the Nodule Size: Correlation with MDCT Volumetric Measurement of Calcification
(Station #4)
Joo Sung Sun MD : Nothing to Disclose , Eun Young Kim MD (Presenter): Nothing to Disclose , Seon
Young Park MD : Nothing to Disclose , Young Keun Sur MD : Nothing to Disclose , Jin Wook Choi MD :
Nothing to Disclose , Eun Ju Ha : Nothing to Disclose , Sung Hoon Park MD : Nothing to Disclose , Sung
Jung Kim : Nothing to Disclose , Tae Sun Han : Nothing to Disclose , Boram Yi MD : Nothing to Disclose ,
Jae Yong Cho MD : Nothing to Disclose , Hun Cho MD : Nothing to Disclose , Kyung Joo Park MD :
Nothing to Disclose
PURPOSE
To correlate MDCT volumetric information of calcification of SPN and visual assessment of calcification of SPN on
CXR
METHOD AND MATERIALS
METHOD AND MATERIALS
Retrospective review of consecutive 221 SPNs that were identified by both CXR and thin-section chest CT.
Eleven observers who blinded to the results of CT assessment about calcification reviewed all CXR. They scored
each nodules with 5 confidence scale in terms of nodule calcification. Reference standard for calcification of SPN
was made by 2 radiologist consensus reading and they were not involved review of CXR. Volumetric information
of calcification was acquired by using commercial software. ROC analysis was done and AUC was obtained to
analyse overall diagnostic performance. For ROC analysis, 2431 nodules (221*11) were used as target nodules.
Intraclass correlation coefficient (ICC) for inter-rater reliability was calculated. ROC analysis and ICC were
calculated according to the nodule size. Group1 ( < 10mm),Group2(10~20mm),group3(greater than 20mm).
RESULTS
Among 221 SPNs (mean diameter 13.9mm), a total of 76 SPNs were calcified (34.4%). Average percentage of
calcification (>=160 HU) in all each 76 calcified nodules was 41.5%. Average percentage of calcification of 17
focal calcified nodules and 59 definite benign calcified one was 4.16% (Figure 1) and 49.72% respectively.
There was significant correlation between confidence and nodule calcification. Correlation coefficient (r) was
0.625 (p < .001). The positive predictive value of a "confidence 5" assessment was 0.95, and the negative
predictive value of a "confidence 1" assessment was 0.952 in case of nodule < 10mm. AUC for group 1, 2, 3 ,
and all nodules was 0.835, 0.639, 0.6 ,and 0.71 respectively. AUC for group 1 ( < 10mm) was significantly
higher than those of group 2 and 3 (p < 0.0001). ICC for group 1, 2, 3, and all nodules, was 0.65, 0.48, 0.33,
and 0.51 respectively.
CONCLUSION
Overall diagnostic performance of perception of nodule calcification was best in nodules less than 10mm
diameter. SPNs depicting benign calcification would contain about 50% of calcification in their volume.
CLINICAL RELEVANCE/APPLICATION
Misdiagnosis of non calcified nodule as calcified one on CXR reading could lead bad choice for management of
SPN. Diagnostic performance for identifying calcification is low in case of nodules >= 10mm in diameter, so
that we should carefully evaluate calcification when nodule size is greater than 10 mm.
CHS246
Ultra-low-dose Chest CT: Should we Acquire it at 80 or 135 kV? A Qualitative and Quantitative
Prospective Study on 30 Patients (Station #5)
Claire Lucchetta MD (Presenter): Nothing to Disclose , Aissam Labani MD : Nothing to Disclose , Mi-Young
Jeung MD : Nothing to Disclose , Marysa Schaal MD : Nothing to Disclose , Karim Haioun : Employe,
Toshiba Corporation , Catherine Roy MD : Nothing to Disclose , Mickael Ohana MD, MSc : Nothing to
Disclose
PURPOSE
To qualitatively and quantitatively compare ultra-low-dose (ULD) chest CT acquired at 80 and 135kV.
METHOD AND MATERIALS
30 patients (68% men, 55yo ±14) referred for a clinically indicated unenhanced chest CT were prospectively
included. Participants underwent a triple acquisition on a second-generation 320-row scanner: a standard 'full
dose' acquisition (120kV, automated tube current modulation) and two ULD acquisition (80kV with 40mA and
135kV with 10mA), all reconstructed with mediastinal and lung kernels using an iterative algorithm (AIDR 3D).
ULD acquisition parameters were chosen to achieve the same level of radiation dose between 80 and 135kV.
Image quality of both ULD acquisitions was independently and blindly assessed by two chest radiologists, each
reader having to designate for every patient which kV provided the best diagnostic and image quality. Image
noise was measured within the trachea and compared between both ULD acquisitions with a paired Student t
test. A p<0.05 was considered significant.
RESULTS
Radiation dose was similar between 135kV and 80kV ULD acquisitions, with a mean DLP of 17.2mGy.cm ±1.6
and 16.2mGy.cm ±1.5 respectively. DLP of the standard 120kV acquisition was 210mGy.cm ±87. The 135kV
ULD acquisition was found to be better in 100% of patients for reader 1 and in 97% of patients for reader 2.
The agreement between the two readers was almost perfect with a Cohen's κ of 0.98. The noise was
significantly lower at 135kV than at 80kV (61.5 ±5.7 vs 81.4 ±11.8, p<0.01). Reference noise for standard
120kV acquisition was 44.7 ±6.5.
CONCLUSION
For ULD chest CT, acquisitions made at 135kV are qualitatively and quantitatively better than those made at
80kV.
CLINICAL RELEVANCE/APPLICATION
Ultra-low-dose unenhanced chest CT must be acquired with a high kV/low mA technique.
ERS-MOA
Emergency Radiology Monday Poster Discussions
Scientific Posters
ER
AMA PRA Category 1 Credits ™: .50
Mon, Dec 1 12:15 PM - 12:45 PM
Location: ER Community, Learning Center
Participants
Moderator
Michael J. Thali MD : Nothing to Disclose
Sub-Events
ERS211
Postmortem Adrenal Glands: CT Findings (Station #1)
Aley Talans MD (Presenter): Nothing to Disclose , Suely Fazio Ferraciolli : Nothing to Disclose ,
Viviane Sayuri Yamachira : Nothing to Disclose , Natally de Souza Maciel Rocha Horvat MD : Nothing to
Disclose , Hilton M. Leao Filho MD : Nothing to Disclose , Ronaldo Hueb Baroni MD : Nothing to Disclose
PURPOSE
To demonstrate the spectrum of adrenal CT findings commonly found postmortem, and to correlate imaging
features and histological findings.
METHOD AND MATERIALS
We retrospectively evaluated 61 corpses who underwent postmortem CT scans, and compare them to
pathological and histological findings in conventional autopsy. Abdominal CT scans were performed with
intra-arterial and intravenous iodinated contrast injection in 50 corpses. Radiologic-pathological correlation was
performed.
RESULTS
The average elapsed time between the CT scans and time of death was 11.3 hours. The mean attenuation was
27 HU (ranging from 4 HU to 48 HU), and 53% of the glands showed post contrast enhancement (considering
the 50 corpses who were submitted to pre and post contrast phases). Gas within the gland was found in 12.3%
of the cases. Calcification was found in 4,0% (5 / 122). Nodules were detected in 4% (5 / 122 of the CT scans.
The histological findings were: no pathological finding in 67% (41/61), hemorrhage in 11.5% (7/61), ischemia
and/or necrosis in 13% (8/61), nodules in 3.3% (4/122), microscopic metastatic lesions in 5% (3/61),
macroscopic metastatic lesions in 1.6% (1/61). Histological correlation revealed that four of the 5 nodules seen
on CT images had concordant pathological findings (2 metastasis of colonic adenocarcinoma and 2 metastasis of
gastric adenocarcinoma). All these nodules had attenuation > 10 HU on CT (range 23-30). CT was not able to
detect image alterations in glands with microscopic lesions. Despite the fact that we found 11.5% of adrenal
glands with hemorrhage on autopsy, there was no significant difference in the mean attenuation of these glands
when compared to the control group (31 HU and 27 HU, respectively). Considering the 28 corpses with post
contrast enhancement, only 9 (32%) showed ischemia or hemorrhage on autopsy. Only 1 of the 15 corpses that
presented gas on the CT had ischemia and/or necrosis on the autopsy.
CONCLUSION
Our study found some concordances and some differences between imaging and histological findings of
postmortem adrenal glands. Further studies are been held to elucidate those questions since virtual autopsy is a
potential alternative to conventional autopsy.
CLINICAL RELEVANCE/APPLICATION
To associate the adrenal gland alterations found on virtual autopsy with conventional autopsy, providing a
radiological-pathological correlation.
ERS212
Distribution and Patterns of Spinal Fractures Related to Different Traumatic Mechanisms in Post
Mortem CTs (Station #2)
Yanik Buetikofer (Presenter): Nothing to Disclose , Wolf-Dieter Zech MD : Nothing to Disclose , Christian
Jackowski MD : Nothing to Disclose , Daniel Ott MD : Nothing to Disclose , Levent Kara MD : Nothing to
Disclose
PURPOSE
To gather epidemiological data regarding the cause of injury, and to evaluate the incidence of spinal fractures,
in relation to different types of traumatic fatalities.
METHOD AND MATERIALS
This is a retrospective review of spinal fractures associated with different kinds of trauma over 9 years. 321
native postmortem CT scans of traumatic accidents between 2005 and 2013 have been evaluated regarding
spine fractures. The types of traumatic accidents were assessed and divided into groups (n=321); a - Motor
vehicle accidents (n=42), b - bicycle accidents (n=33), c - motorbike accidents (n=39), d - trauma involving
pedestrians (n=47), e - Falls from great height (n=100), and f - all others (n=60). All fractures were divided;
by fracture or dislocation of the atlanto-occipital joint (C0/C1), upper cervical spine fracture from C1 to C3
(upper CV), lower cervical spine fracture from C4 to C7 (lower CV), thoracic spine fracture (TV) and lumbar
spine fracture (LV). All spine fractures were subsequently classified according to the AO Comprehensive
Classification from June, 2013.
RESULTS
From a total of 359 fractures there were (21.75%) atlanto-occipital fractures, (12%) upper cervical fractures,
(14.5%) lower cervical fractures, (31.75%) thoracic fractures and (20%) lumbar fractures. By the AO
classification the upper cervical fractures comprise 51.75% Typ-A-, 31% Typ-B- and 17.25% Typ-C-fractures;
The lower cervical fractures comprise 29.25% Typ-A-, 36.5% Typ-B- and 34.25% Typ-C-fractures; The
thoracic fractures comprise 41.75% Typ-A-, 33% Typ-B- and 25.25% Typ-C-fractures; The lumbar fractures
comprise 32.5% Typ-A-, 30.5% Typ-B- and 37% Typ-C-fractures.
CONCLUSION
In all trauma types there is a higher incidence of upper cervical fractures compared to lower cervical fractures.
Pedestrians are more likely to suffer a cervical fracture compared to the other accident types, especially
compared to bicycle accidents, which are most likely to suffer a thoracic vertebrae fracture.
CLINICAL RELEVANCE/APPLICATION
Knowledge of the distribution and patterns of spinal fractures with respect to the type of accident helps the
radiologist to support the emergency physician in prioritizing trauma patients and their therapeutic needs.
ERS213
Postmortem Computed Tomography Findings in the Thorax (Station #3)
Hideki Hyodoh MD (Presenter): Nothing to Disclose , Satoshi Watanabe MD, PhD : Nothing to Disclose ,
Shunichiro Okazaki MD, PhD : Nothing to Disclose , Keisuke Mizuo PhD : Nothing to Disclose , Etsuko
Hayashi RT : Nothing to Disclose , Hiromasa Inoue MD, PhD : Nothing to Disclose
PURPOSE
To investigate findings of postmortem imaging using objective data and to define the time-related course of
lung changes using postmortem CT (PMCT).
METHOD AND MATERIALS
From April 2013 to October 2013, 199 bodies were examined on PMCT and 12 bodies (8 men, 4 women; age,
27-81 years [mean, 60.0 years]) were examined two times in a >4-hour interval (4-164 hours [mean, 30.8
hours; median, 17.5 hours). We compared pleural space fluid volume, decreased aerated lung volume (DLV),
and pulmonary volume between the two postmortem CT scans. To evaluate the volume change rate, we plotted
the volume rate (ml/hour) against pleural space fluid volume and DLV according to the postmortem period.
RESULTS
At the 2nd PMCT, the pleural space fluid (p = 0.0425) and DLV (p = 0.0186) increased and pulmonary volume
(p = 0.0229) decreased. The pleural space fluid increase peaked at 30 hours and continued until 42 hours. The
DLV rate consistently decreased throughout the postmortem period until the 30-hour mark.
CONCLUSION
The DLV rate consistently decreased throughout the postmortem period until the 30-hour mark. The pleural
space fluid increase peaked at 30 hours and continued until 42 hours.
CLINICAL RELEVANCE/APPLICATION
In early postmortem period (until 30 hours), the pleural space fluid is not increased. In early postmortem
period (until 30 hours), the hypostasis of the lung is increased.
ERS214
Analysis of Causes of Death and Injury Patterns in Multiple Trauma: A Comparison of Post Mortem
Computed Tomography (pmCT) to the Gold Standard Autopsy (Station #4)
Sonja Kirchhoff MD (Presenter): Nothing to Disclose , Oliver Peschel : Nothing to Disclose , Stefanie
: Nothing to Disclose , Maximilian F. Reiser MD : Nothing to Disclose
Kurz
PURPOSE
The aim was to analyze the conclusiveness of post mortem Computed Tomography (pmCT) regarding a reliable
and adequate cause of death in trauma patients who died either in the trauma room or during emergency
surgeries after the decision was made to terminate resuscitation procedures in comparison to the gold standard
autopsy, and to help in matters of quality control, research and teaching..
METHOD AND MATERIALS
Data of trauma patients mostly due to traffic accidents admitted to the trauma room of our University Level I
trauma center were enrolled and retrospectively analyzed. Subsequently pmCT followed by autopsy were
performed. The cause of death, types and body region of injuries were analyzed and compared respectively. For
the CT scans medical equipment placed in the patients such as intubation tubes, intravenous canules, etc. was
not removed. PmCT was also searched for an explanation if an unsuccessful resuscitation took place.
RESULTS
17 patients were enrolled. 8 patients sustained deadly injuries to the head (47.1%), 11 to the chest (64.7%), 0
to the abdomen (0%), 4 to the skeletal system (23.5%) and one patient drowned (5.8%). In 52.9% of the
cases (group I) good agreement of autopsy and pmCT resulted. In 41.2 % autopsy provided superior results
compared to pmCT (group II) whereas in 5.8% pmCT found more information compared to autopsy (group III).
PmCT was especially useful for the diagnosis of fractures, cerebral injuries and detecting gas formation of all
kinds. Autopsy was superior in finding and interpreting injuries to parenchymal organs and vessels.
CONCLUSION
PmCT is useful in persons who died due to trauma providing quick results and a detailed overview of especially
bony lesions, but also brain injuries and gas formations. It is advisable to conduct pmCT especially in cases
without consent to autopsy to gain information about possible causes of death and to rule out the possibility of
clinical mistakes, therefore to assure quality control.
CLINICAL RELEVANCE/APPLICATION
PmCT can gain worthy information about injury patterns, especially of the skeletal system, head and brain after
traumatic death. In cases when autopsy is declined, CT can outline a noninvasive alternative to evaluate
diagnosis and therapy.
ERS215
Effect of Resident Training Level with Performance of Ultrasound for the Work-up of Acute
Appendicitis (Station #5)
David Tso MD (Presenter): Nothing to Disclose , Jennifer Wang BS : Nothing to Disclose , Patrick
McLaughlin FFR(RCSI) : Nothing to Disclose , Silvia D. Chang MD : Nothing to Disclose , Savvas Nicolaou
MD : Nothing to Disclose
PURPOSE
This study evaluated the role of operator experience with the use of ultrasound for the work-up of acute
appendicitis in young adults. Specifically, we examine resident level of training and compare diagnostic
performance with ultrasound technicians and radiology fellows.
METHOD AND MATERIALS
A retrospective study design was undertaken examining patients seen in the emergency department of an urban
tertiary care teaching hospital between October 1 to December 31, 2013 with the chief complaint of right lower
quadrant pain. Patients who were investigated with ultrasound as first-line imaging were identified. Scan time,
findings on ultrasound, and need for further imaging was documented along with level of training of the operator
performing the exam. Findings were correlated with CT findings and surgical diagnosis when available.
RESULTS
106 patients were identified (80.2% female, mean age 29.1). 39.6% of ultrasound exams were performed
between the hours of 5PM and 8AM. Junior (R2 & R3) and senior (R4 & R5) radiology residents scanned 22.6%
and 19.8% of the caseload respectively with no statistical difference in scan time (31.6 vs. 26.5 minutes,
p=0.43), and did not differ from ultrasound technicians and fellows (28.1 minutes). Further imaging was
required in 45.8% of cases performed by junior residents vs. 38.1% by senior residents, although no
statistically significant difference was found. Residents as a whole did not differ with technicians/fellows with
respects to the need for further imaging (44.4% vs. 31.1%, p=0.17). The appendix was visualized by
ultrasound in 37.5% of cases scanned by junior residents, 40.0% of senior resident cases, and 34.0% of cases
performed by technicians/fellows with no significant difference found. Sensitivity and specificity for residents as
a whole was 50.0% and 90.0%, vs. 81.2% and 100% for technicians/fellows.
CONCLUSION
This study demonstrates no significant difference with respects to operator experience with the ability to
visualize the appendix, scanning time, and requirement of further imaging for the diagnosis of acute
appendicitis. There is an increase in sensitivity and specificity when comparing resident trainees and ultrasound
technicians/radiology fellows.
CLINICAL RELEVANCE/APPLICATION
This study provides a snapshot of the diagnostic performance of ultrasound for the work-up of acute
appendicitis in a tertiary care academic teaching hospital.
GIS-MOA
Gastrointestinal Monday Poster Discussions
Scientific Posters
GI
AMA PRA Category 1 Credits ™: .50
Mon, Dec 1 12:15 PM - 12:45 PM
Location: GI Community, Learning Center
Participants
Moderator
Rizwan Aslam MBBCh : Research support, Bayer AG
Sub-Events
GIS337
Reducing Beam Hardening Artifact by Monochromatic Images with CT Spectral Image: Comparison
GIS337
with Traditional Polychromatic X-ray Imaging—Quantitative Study in Phantom (Station #1)
chunwu zhou : Nothing to Disclose , Xinming Zhao MD : Nothing to Disclose , Liming Jiang MD : Nothing
to Disclose , Ning Guo : Nothing to Disclose , Zheng Zhu : Nothing to Disclose , Jing Zhao (Presenter):
Nothing to Disclose
PURPOSE
Use a quantitative phantom to evaluate the ability of beam hardening artifact (BHA) reduction by
monochromatic images with CT spectral image by comparison with traditional polychromatic X-ray imaging
(TPXI).
METHOD AND MATERIALS
A cyclical phantom with diameter of 25cm (Quantitative Standard Pulsating Phantom QSP-1, Fuyo Corporation)
was used. Three fresh pig humerus bones and three 10mm-diameter tubes filled with iodine contrast were
placed in the center of periphery of the phantom to mimic human's bones and arteries. The phantom with
bones and tubes was immersed in a water tank. Under the condition of helical scan with 120kVp, the CT value of
three bones were 1025Hu, 905Hu and 770Hu respectively, the CT value of three tubes were 1200Hu, 1000Hu
and 840Hu respectively. Both CT spectral imaging mode (protocol A) and routine CT mode (protocol B) with
120kV and 600mA were used. The other scan parameters were the same for two protocols, including FOV of
25.0cm, slice thickness of 5mm, rotation speed of 0.8s/r and pitch of 0.984. Both the monochromatic images
(40-140keV, interval of 10keV) and 120kV TPXI images were reconstructed. Beam hardening artifact index was
calculated for each image, according the fomular: BHA index=SQRT(ROIa^2-ROIb^2), where ROIa denotes to
the SD value of water in the region adjacent to tubes with obvious BHA, ROIb denotes the SD value of water in
the region far away from tubes and bones without obvious BHA. The area of ROIa and ROIb were both about
50mm2. Data was compared with rank sum test.
RESULTS
The BHA index of 120kV TPXI image was 20.45±6.30. The BHA index of each monochromatic image set
(ranging from 1.17±0.86 to 9.72±1.32) was lower than that of 120 TPXI image (p<0.001). Monochromatic
images at 80keV had the lowest BHA index (1.17±0.86). The variation of BHA index at 90keV to 140
keV(3.13±0.46 to 4.71±1.03) was smaller than that at 40keV to 70keV(9.72±1.32 to 3.28±0.26)(p<0.01).
CONCLUSION
Monochromatic images have less beam hardening artifact than TPXI images, high keV images(80keV-140keV)
are superior to low keV images(40keV-70keV).
CLINICAL RELEVANCE/APPLICATION
CT spectral image provides less beam hardening artifact and more accurate CT attenuation number, which may
help clinical diagnosis.
GIS338
Imaging Outcomes of Liver Imaging Reporting and Data System (LI-RADS) 2, 3 and 4 Categories on
CT and MR Examination (Station #2)
Masahiro Tanabe MD (Presenter): Nothing to Disclose , Eduardo Almeida Cunha Costa MD : Nothing to
Disclose , Marilia Fortes MD : Nothing to Disclose , Omid Yeganeh MD : Nothing to Disclose , Tanya
Wolfson MS : Nothing to Disclose , Claude B. Sirlin MD : Research Grant, General Electric Company
Speakers Bureau, Bayer AG Consultant, Bayer AG , Michael Simca Middleton MD, PhD : Consultant, Allergan,
Inc Institutional research contract, Bayer AG Institutional research contract, sanofi-aventis Group Institutional
research contract, Isis Pharmaceuticals, Inc Institutional research contract, Johnson & Johnson Institutional
research contract, Synageva BioPharma Corporation Institutional research contract, Takeda Pharmaceutical
Company Limited Stockholder, General Electric Company Stockholder, Pfizer Inc Institutional research contract,
Pfizer Inc
PURPOSE
The Liver Imaging Reporting and Data System (LI-RADS) released by the ACR is a comprehensive system for
standardized interpretation and reporting of CT and MR examinations performed in patients at risk for
hepatocellular carcinoma (HCC). The purpose of this study was to assess imaging outcomes of LR-2 (probably
benign), LR-3 (intermediate probability for HCC) and LR-4 (probable HCC) observations. Specifically, we sought
to determine the proportion of LR-2, LR-3, and LR-4 observations that, during clinical imaging follow-up and in
the absence of treatment progress regress or remain stable in category code.
METHOD AND MATERIALS
This was a retrospective, observational, longitudinal, single-center study of patients who underwent clinical CT
or MRI examinations for surveillance for or diagnosis of HCC.
RESULTS
The final study cohort had 158 patients (87 men, 71 women; mean age 59.0 years). All patients had chronic
liver disease, and most had cirrhosis. The patients had a total of 284 observations (LR-4 [n = 53], LR-3 [n =
170], and LR-2 [n = 61]). Among the 53 LR-4 observations, 18 (34%) progressed to LR-5 during follow-up (15
within six months, one within 12 months, two at more than 12 months), 25 (47%) remained stable, and 9
(17%) regressed in category. Among 170 LR-3 observations, 7 (4%) progressed to LR-5 during follow up (0
within six months, two within 12 months, and five at more than 12 months), 10 (6%) progressed to LR-4, 47
(28%) remained stable, and 106 (62%) regressed to LR-1 or LR-2. All 61 LR-2 observations remained stable or
regressed during follow-up.
CONCLUSION
LR-2, LR-3, and LR-4 observations have different imaging outcomes. One-third of LR-4 observations progressed
to LR-5 within 6 months. Most LR-3 observations remained stable or regressed. All LR-2 observations remained
stable or regressed.
CLINICAL RELEVANCE/APPLICATION
The LI-RADS categories were developed mainly by expert opinion. This study provides preliminary validation of
the LR-2, LR-3, and LR-4 categories by showing that they have different imaging outcomes.
GIS339
Locally-advanced Pancreatic Adenocarcinoma: Reassessment of Response with CT Scan after
Neoadjuvant Chemoradiotherapy (Station #3)
Christophe Cassinotto MD (Presenter): Nothing to Disclose , Jean-Pierre Lafourcade : Nothing to Disclose ,
Amaury Mouries : Nothing to Disclose , Bruno Lapuyade : Nothing to Disclose , Eric Terrebonne : Nothing
to Disclose , Herve Trillaud MD : Nothing to Disclose , genevieve belleannee : Nothing to Disclose ,
Laurence Chiche MD : Nothing to Disclose , christophe laurent : Nothing to Disclose , Michel Montaudon
MD : Nothing to Disclose
PURPOSE
To prospectively evaluate the ability of CT scan to determine tumor response and predict resectability after
neo-adjuvant chemo-radiotherapy (CRT) in patients with non-metastatic locally-advanced pancreatic cancer
(LAPC).
METHOD AND MATERIALS
This study received ethics approval, and all participants provided written informed consent. We prospectively
enrolled consecutive patients with cephalic LAPC who underwent surgical exploration and/or resection following
neoadjuvant CRT from June 2009 to May 2013. Two radiologists independently analyzed the baseline and
post-CRT CT scans recording the size, attenuation, and circumferential vascular contacts of the tumor.
Associations between the post-operative histological grade of tumor response (pTNM) and the clinical, biological
and CT scan criteria were assessed using Spearman's correlation coefficients. CT scan criteria related with the
presence of R0 resection were assessed using logistic regression.
RESULTS
Forty-seven patients were included, 33 with R0 resection, and 14 with R1 or no resection. Variables
demonstrating a significant correlation with the histological tumor classification of tumor response were:
post-CRT CA19-9 level (r=0.46), post-CRT tumor largest axis (r=0.44), post-CRT largest+small axis (r=0.46),
change in largest axis (r=0.31), change in largest+small axis (r=0.39), change in SMV/Portal vein contact
(r=-0.38), and post-CRT SMA contact (r=0.34). Partial regression of tumor contact with the SMV/Portal vein
was associated in all cases with R0 resection (10/10 patients, PPV = 100%), and partial regression of tumor
contact with any peripancreatic vascular axis was associated with R0 resection in 91% of cases (20/22 patients,
PPV = 91%). Persistence of SMV/Portal vein stenosis after CRT was not predictive for R1 resection.
CONCLUSION
Partial regression of tumor-vessel contact indicates suitability for surgical exploration, irrespective of the degree
of decrease in tumor size or the degree of residual vascular involvement.
CLINICAL RELEVANCE/APPLICATION
CT criteria based on the degree of tumor to vessel contact could provide valuable assistance in making decisions
about therapy after completion of neo-adjuvant chemo-radiotherapy.
GIS341
Evaluation of Tumor Recurrence after Whipple Surgery Using ssDECT (Station #4)
Manuel Patino MD (Presenter): Nothing to Disclose , Jorge Mario Fuentes MD : Nothing to Disclose ,
Pritesh Patel MD : Nothing to Disclose , Avinash Ranesh Kambadakone MD, FRCR : Nothing to Disclose ,
Dushyant V. Sahani MD : Research Grant, General Electric Company
PURPOSE
To evaluate performance of Single source Dual-energy CT (ssDECT) in detection of local recurrence on post
Whipple patients compared to conventional single-energy CT scans.
METHOD AND MATERIALS
Thirty-five patients (17 males; 18 females) with history of pancreatic adenocarcinoma and Whipple procedure
(0.1 to 5 years after the procedure) underwent a follow up ssDECT (GE-CT750 HD, 140/80 kV). Two blinded
radiologists independently reviewed the 140 kVp and DECT processed iodine and monochromatic images in a
separate session for the presence of local recurrence, liver metastasis, and surgical complications and provided
recommendations. Multiple follow up studies, tumor markers (CA-19.9) and histology served as standard
reference. Quantitative analysis of the iodine concentration in the surgical bed was performed, and
subsequently compared for post-operative changes and recurrence using t-test.
RESULTS
15 patients had local recurrence and 20 showed expected post-operative changes. The sensitivity and specificity
for SECT for local recurrence was 75% and 65% for R1, and 70% and 65% for R2 and for DECT it was 86%
and 75% for R1, and 83% and 70% for R2. Interobserver agreement for DECT was good with a kappa value of
0.7. Iodine concentration was different in patients with local recurrence vs. those with expected changes (p
CONCLUSION
ssDECT shows higher sensitivity and specificity for diagnosing local recurrence detection after Whipple surgery
compared to SECT. Tumor recurrence can be differentiated from normal post operatory changes based on
iodine quantification.
CLINICAL RELEVANCE/APPLICATION
Distinction between normal postoperative changes vs. tumor recurrence after Whipple procedure impacts
patient management, and can be challenging on conventional CT. DECT have potential to overcome these
limitations by mapping the iodine distribution within tumor and normal tissue.
GIS343
Spectral CT in Rabbit VX2 Liver Tumors: Image Fusion Technology Associated with Monochromatic
Image (Station #6)
Wang Mingyue (Presenter): Nothing to Disclose , Jianbo
Nothing to Disclose
Gao MD : Nothing to Disclose , Zhou
Yue :
PURPOSE
To evaluate the value of image fusion technology associated with monochromatic image of spectral CT
METHOD AND MATERIALS
Twenty-four rabbits with VX2 liver tumors underwent spectral CT, On the 8th day after implantation. The
conventional 140kVp polychromatic images (QC) and monochromatic images with energy level from 40 to 14o
keV were generated. In the arterial phase the optimal CNR keV (OP) and 70keV were choosen and the fusion
image (OP+70)keV was generated from OP plus 70keV. The tumor-to-liver contrast-to-noise ratio (CNR) and
image noise 0f the four groups were calculated. The lesion conspicuity scores(LCS) and overall image quality
scores(OQS) in the four groups were recorded.
RESULTS
The CNR of the group (OP+70) had no significant differences from that of the group OP, but the image noise of
group (OP+70) was significantly lower than that of group OP (2.63±2.59vs2.81±2.74,p=0.288;9.12±1.28
vs7.89±1.35,p=0.002),the CNR of the OP and (OP+70) were significantly higher than that of group
70(1.92±2.39,p
CONCLUSION
Image fusion technology associated with monochromatic image of spectral CT which combine the advantage of
high CNR and the advantage of low noise, improve the lesion detection and image quality.
CLINICAL RELEVANCE/APPLICATION
improve the lesion detection and image quality
GIS345
Hepatic Steatosis after Percutaneous Intraportal Pancreatic Islet Transplantation (PIPIT) in 108
Allo-and Auto-Transplanted Patients: Can Ultrasound Predict the Clinical Outcome? (Station #8)
Giulia Agostini (Presenter): Nothing to Disclose , Massimo Venturini MD : Nothing to Disclose , Giulia
Querques : Nothing to Disclose , Paola Maffi : Nothing to Disclose , Antonio Secchi : Nothing to Disclose ,
Alessandro Del Maschio MD : Nothing to Disclose
PURPOSE
PIPIT is a less invasive, repeatable therapeutic option in brittle type 1 diabetes, compared to surgical pancreas
transplantation: it can be performed after kidney-transplantation (IAK), alone (ITA) in type-1 diabetic pts
without chronic renal insufficiency, or as an autotransplantation (IAT) after pancreatectomy
(immunosuppression unnecessary). Steatosis is a consequence of the islets' engraftment: its meaning is
controversial. Our retrospective longitudinal study aimed to assess hepatic steatosis incidence at ultrasound
(US) after islet auto- and allotransplantation, and to identify any relationship with graft function.
METHOD AND MATERIALS
From 1989 to 2012, 108 pts (33 IAK, 50 ITA, 25 IAT) underwent PIPIT, which is performed under a combined
US and fluoroscopic guidance. US was performed at baseline/6/12/24 months. Steatosis first
detection/prevalence/duration/distribution were recorded. Steatosic (S) and non-steatosic patients (NS) were
compared for the following parameters at baseline/6/12/24 months: insulin-independence-rate, ß-score,
C-peptide, glycated-hemoglobin, exogenous-insulin-requirement, fasting-plasma-glucose, infused-islet-mass.
C-peptide is the traditional marker of islet function, but ß-score is a more comprehensive parameter, including
all the previously mentioned ones.
RESULTS
Steatosis was found in 21/108 pts, 24% (20/83) allotransplanted, 4% (1/25) autotransplanted (better
outcome), with first detection at 6 months, highest prevalence at 1 year (18 cases). Infused-islet-mass was
significantly higher in S than NS patients (IE/kg: S=10.822; NS=6.138). Metabolically, S pts had worse basal
conditions (ß score: S=1.7 ± 1.6; NS=2.8 ± 2.8), but better islet function at the time of steatosis first detection
(ß score: S=3.9 ± 2.0; NS=2.9 ± 2.3), after which a progressive islet exhaustion, along with steatosis
disappearance, was observed. Conversely, in NS pts these parameters remained more stable in time.
CONCLUSION
Steatosis at US seems to be related to islet mass and overworking activity. Presence of steatosis precedes
metabolic alterations, can predict graft dysfunction addressing therapeutic decisions before islet exhaustion.
Absence of steatosis doesn't allow any conclusion.
CLINICAL RELEVANCE/APPLICATION
Steatosis at US precedes metabolic alterations and can predict graft's dysfunction addressing to therapeutic
decisions before islet exhaustion. If steatosis doesn't appear, no conclusion can be drawn.
GIE197
Liver Imaging: Review of Commonly Used and Developing MRI Techniques (Station #9)
Wirana Angthong MD (Presenter): Nothing to Disclose , Vithya Varavithya : Nothing to Disclose ,
Panitpong Maroongroge : Nothing to Disclose , Wichet Piyawong MD : Nothing to Disclose , Kaan
Tangtiang MD : Nothing to Disclose , Surachate Siripongsakun MD : Nothing to Disclose
TEACHING POINTS
The purpose of this exhibit is:
- To review the clinical usefulness of commonly used MRI techniques and provide the indication/ limitation for
those sequences
- To explain the utility of developing MRI techniques and their application in clinical practice
- To review common pitfalls and problem solving in interpretration of liver imaging
TABLE OF CONTENTS/OUTLINE
1. Overview commonly used MRI techniques - In/ opposed-phase images Detection chemical shift cancellation
artifact Pronounce T2* and susceptibility artifacts on images with long TE - T2W Multishot T2W (FSE) with
respiratory trigger Single shot T2W (ssFSE) - Balanced gradient echo - Pre-and dynamic post contrast 3D-GE
T1W/FS - Hepatocyte-specific contrast agent Characterization of focal hepatic lesions Interpretation challenge in
cirrhotic nodules 2. Developing MRI techniques - Diffused weighted imaging Qualitative and quantitative
assessment Cirrhotic patient for HCC detection and evaluation of response to treatment - High flip-angle
Gadoxetic acid imaging
GIE179
The Powerful Role of of Barium Esophagorgraphy in Detection of Important Thoracic Esophageal
Pathologies (Station #10)
Babak Maghdoori BEng, MD (Presenter): Nothing to Disclose , Nasir M. Jaffer MD : Nothing to Disclose ,
Seng Thipphavong MD : Nothing to Disclose
TEACHING POINTS
1. Anatomy: review of esophagography specific anatomy 2. Barium esophagography: understanding of proper
technique & correct imaging acquisition 3. Esophageal structural disorders: systematic approach to important
structural pathologies, barium esophagography imaging of select diseases, & their corresponding radiological
interpretations 4. Esophageal motility disorders: systematic approach to important motility pathologies, barium
esophagorgraphy imaging of select pathologies, & their corresponding radiological interpretations
TABLE OF CONTENTS/OUTLINE
1. Esophageal anatomy a. Normal & barium esophagography-specific anatomy 2. Barium Esophagography a.
Appropriate Contrast agents barium b. Proper technique, image acquisition, & appropriate/timely utilization 3.
Structural esophageal disorders a. Important cases of thoracic esophagus structural pathologies i.
Pathophysiology, epidemiology, & clinical context ii. Pertinent barium esophagorgraphy interpretations &
caveats/pitfalls 4. Motility esophageal disorders a. Important cases of thoracic esophagus motility pathologies i.
Pathophysiology, epidemiology, & clinical context ii. Pertinent barium esophagorgraphy interpretations &
caveats/pitfalls 5. Summary
GIE267
Radiology for Dysphagia: When the Endoscopy Cannot Help (Station #11)
Alberto Ivo Carbo MD (Presenter): Nothing to Disclose , Sana
Chadha MD, MBBS : Nothing to Disclose
Naeem MD : Nothing to Disclose , Meghna
TEACHING POINTS
• To discuss causes and pathophysiology of dysphagia that can be diagnosed by radiology. Pharynx: motility
disorders. Upper esophageal sphincter: diminished opening, delay opening, early closing. Esophagus: webs,
motility disorders, severe strictures, perforations, extrinsic compressions • To analyze the contribution of
radiology in the diagnosis of causes of dysphagia that cannot be solved by endoscopy
TABLE OF CONTENTS/OUTLINE
• The symptom of dysphagia • Anatomy and pathophysiology of dysphagia • Imaging techniques • Pharyngeal
swallowing abnormalities • Cricopharyngeal dysmotilities • Pharyngoesophageal webs • Esophageal motility
disorders • Pharyngoesophageal tears and perforations • Severe pharyngeal and esophageal strictures •
Extrinsic compressions • Conclusions
GIE144
Three-Dimensional Ultrasonography of Biliary Tract Disorders (Station #12)
Jessica
Kurian MD (Presenter): Nothing to Disclose , Susan Judith Frank MD : Nothing to Disclose ,
Benjamin
Taragin MD : Nothing to Disclose
TEACHING POINTS
The purpose of this exhibit is to describe the use of three-dimensional ultrasonography (3DUS) in diagnosis of
congenital and acquired biliary tract disorders. Teaching points include: 1. Review the current literature
pertaining to 3DUS and the biliary tract 2. Review the basic technical aspects of 3DUS 3. Understand the normal
appearance of the biliary tract on 3DUS 4. Illustrate the 3DUS features of various biliary tract disorders 5. Using
examples, discuss the role of 3DUS in biliary tract imaging, including advantages and disadvantages,
comparison to CT, MRCP and ERCP, and potential future directions
TABLE OF CONTENTS/OUTLINE
1. 3DUS technique 2. 3DUS of the normal biliary tract 3. Case examples of biliary pathology illustrated by 3DUS.
The entities presented will include but are not limited to: Cholelithiasis and choldeocholithiasis,
cholangiocarcinoma and gallbladder carcinoma, adenomyomatosis, gallbladder polyps, choldeochal cyst 4.
Future directions and summary
GIE015-b
Use of a Staged US and CT Protocol to Diagnose Acute Appendicitis in Adults (hardcopy backboard)
Menaka
Nadar MD (Presenter): Nothing to Disclose , Arun
Krishnaraj MD, MPH : Nothing to Disclose
TEACHING POINTS
1. To review the current ACR guidelines for imaging in patients with suspected acute appendicitis. 2. To review
the US findings of acute appendicitis. 3. To explain the role of US in diagnosing acute appendicitis in
appropriately selected adults.
TABLE OF CONTENTS/OUTLINE
1. Presentation/workup of acute appendicitis 2. ACR guidelines for imaging patients with suspected acute
appendicitis 3. US findings in acute appendicitis 4. Staged US and CT protocol for imaging appropriately selected
adults with suspected appendicitis -US evaluation of the appendix can be effective at diagnosing appendicitis in
a variety of patients -US first can avoid unnecessary radiation and is lower cost than CT -In cases of a
nonvisualized appendix, but inflammatory changes in the right lower quadrant (i.e. free fluid or increased
echogenicity within the surrounding fat), CT is recommended for further evaluation. -In cases of equivocal
ultrasound, further evaluation with CT or other imaging can be performed as clinically indicated. 5. Limitations
of ultrasound in imaging adults with suspected appendicitis -BMI
GUS-MOA
Genitourinary/Uroradiology Monday Poster Discussions
Scientific Posters
GU
AMA PRA Category 1 Credits ™: .50
Mon, Dec 1 12:15 PM - 12:45 PM
Location: GU Community, Learning Center
Participants
Moderator
Mindy Meislich Horrow MD : Spouse, Director, Merck & Co, Inc
Sub-Events
GUS109
Power of the ESUR Scoring System: Prostate Cancer Detection Based on Targeted MR-guided in-bore
Biopsy (Station #1)
Frederic Dietzel : Nothing to Disclose , Lars Schimmoeller MD (Presenter): Nothing to Disclose , Michael
Quentin MD : Nothing to Disclose , Patric Kroepil MD : Nothing to Disclose , Gerald Antoch MD :
Speaker, Siemens Medical AG Speaker, Bayer AG Speaker, BTG International Ltd , Dirk Blondin MD :
Nothing to Disclose , Christian Arsov MD : Nothing to Disclose , Andreas Hiester : Nothing to Disclose ,
Robert Rabenalt : Nothing to Disclose , Peter Albers MD, PhD : Nothing to Disclose
PURPOSE
This study evaluates the correlation of the ESUR scoring system (PI-RADS) with prostate cancer detection using
MR-guided in-bore prostate biopsies as the reference standard.
METHOD AND MATERIALS
566 lesions in 295 consecutive patients (65.9±7.7 years, PSA 9.9±8.3ng/ml) with a multiparametric (mp)-MRI
(T2WI, DWI, DCE) of the prostate at 3T were scored according to PI-RADS. All lesions were histologically
verified by targeted MR-guided in-bore biopsy.
RESULTS
Lesions with a summed PI-RADS score below 9 contained no prostate cancer (PCa) with Gleason score (GS)
≥4+3=7. A summed PI-RADS score of 13-15 resulted in 87.8% (n=108) in PCa and in 42.3% (n=52) in
GS≥4+3=7. Transitional zone (TZ) lesions with a score of 13-15 resulted in 76.3% (n=36) in PCa and in 26.3%
(n=10) in GS ≥4+3=7, whereas for peripheral zone (PZ) lesions cancer detection rate at this score was 92.9%
(n=79) and 49.4% (n=42) for GS≥4+3=7. Using a threshold of ≥10, sensitivity was 86.0%, and negative
predictive value (NPV) was 86.2%. For higher grade PCa sensitivity was 98.6%, and NPV was 99.5%.
CONCLUSION
The summed PI-RADS score showed a very good correlation to tumor detection rates, especially for higher
grade PCa. PZ lesions demonstrated a better correlation to the PI-RADS score with higher detection rates for
higher grade PCa compared to TZ lesions. A cut-off limit of 10 for PI-RADS leads to good sensitivity and high
NPV. PI-RADS achieve for higher grade PCa detection nearly 100% sensitivity and NPV with a cut-off limit of 10.
CLINICAL RELEVANCE/APPLICATION
A summed PI-RADS score below 9 excluded a higher grade PCa, whereas lesions with a score ≥13 represented
in 88% PCa, and in 42% higher grade PCa. Nonetheless further improvement of PI-RADS is required to reduce
unnecessary over diagnostics.
GUS110
Integrated MR/PET in Prostate Cancer Comparison with Conventional Hybrid Imaging (Station #2)
Seunghyun Lee (Presenter): Nothing to Disclose , Jeong Yeon Cho MD : Nothing to Disclose , Sang Youn
Kim MD : Nothing to Disclose , Joongyub Lee : Nothing to Disclose , Myoung Seok Lee MD : Nothing to
Disclose , Sungmin Woo MD : Nothing to Disclose , Seung Hyup Kim MD : Nothing to Disclose
PURPOSE
To evaluate diagnostic value of integrated MR/PET through the comparison of standardized uptake value (SUV)
between integrated MR/PET and CT/PET, and the correlation between SUVs of integrated MR/PET and apparent
diffusion coefficient (ADC) values of MRI.
METHOD AND MATERIALS
We enrolled 18 patients with histopathologically confirmed primary prostate cancer, who underwent integrated
MR/PET using 18F-choline and 18F-fludeoxyglucose (FDG), respectively, and 18F-FDG CT/PET before surgery.
The SUV measurements were carried out side by side on corresponding lesions on fused image data sets, and
additional ADC measurements also on MR images in MR/PET. Regions of interest were drawn on 12 regions of
the prostate based on anatomy, a total of 216 sectors from 18 patients. The SUVs and ADC values from
CT/PET and MR/PET were calculated and compared with the receiver operating characteristic curves and the
areas under these curves (AUCs) analysis. The comparison of tumor detection rate between SUVs and ADC
values of CT/PET and MR/PET were tested with generalized estimating equation (GEE) method.
RESULTS
The average SUV of tumor tissue in 18F-FDG CT/PET (3.09 ± 1.75) was higher than 18F-choline MR/PET (2.75
± 1.24) or 18F-FDG MR/PET (2.25 ± 1.32). The ROC curve analysis showed that there was no significant better
modality for tumor detection, compared with each other (P > .05). The SUV of 18F-choline MR/PET and
18F-FDG MR/PET were associated with tumor detection rate at univariate analysis (P < .05). Multivariate
analysis showed that there was 1.63 times more tumor detection in the SUV of 18F-choline MR/PET than ADC
value of MRI (P < .0001). The correlation analysis of modalities for tumor detection showed there was
significant correlation between SUV of 18F-choline MR/PET and SUV or ADC value of other modalities, including
SUV of 18F-choline MR/PET and ADC value of MRI (P < .0001).
CONCLUSION
Our results suggest that there is no evidence of superior modality for tumor detection among MR/PET and
CT/PET. There is only statistical significance in SUV of 18F-choline MR/PET, compared with ADC value of MRI.
CLINICAL RELEVANCE/APPLICATION
The new method of 18F-choline MR/PET can be used with confidence in clinical practice combined interpretation
of 18F-FDG CT/PET and MRI.
GUS111
Retrospective Study of PI-RADS Scoring System: The Diagnostic Efficacy of Multi-parametric MRI in
Detection of Prostate Cancer (Station #3)
Ge Gao MD (Presenter): Nothing to Disclose , Xiaoying Wang MD : Nothing to Disclose , Juan Hu :
Nothing to Disclose , He Wang MD : Research Grant, General Electric Company , Xuedong Yang : Nothing
to Disclose
PURPOSE
To investigate the efficacy of multi-parametric(mp-MRI) in detection of prostate cancer(PCa) according to
PI-RADS scoring system of ESUR prostate MR guideline 2012, and to find an appropriate combined mode of
mp-MRI to improve the diagnostic efficacy of prostate cancer.
METHOD AND MATERIALS
A total of 226 patients suspected of PCa by urologist were enrolled in the retrospective study, with permission of
ethical committee. All patients received mp-MRI(T2WI, DWI, DCE, MRS) with subsequent ultrasound guided
biopsy within 3 months. Two experienced radiologists, without known of the pathological diagnosis, graded the
PI-RADS score of images of each sequence based on the 6 regions and patients. Inter-reader variability was
assessed. The best weighting value of each sequence(T2WI, DWI, DCE, MRS) was calculated using FLDA. The
assessed. The best weighting value of each sequence(T2WI, DWI, DCE, MRS) was calculated using FLDA. The
fourfold table and the alternating free-response receiver operating characteristic(AFROC) method were used to
analyze different modes of combined application of T2WI score, DWI score, DCE score, MRS score, highest
score, sum score, overall score and weighting score. Differences in the area under ROC curve(AUCs),
sensitivity, specificty and accuracy were calculated at a statistical significance of P
RESULTS
This retrospective study proved that there was good inter-reader agreement with Kappa=0.830(6
regions)/0.739(patients). The weighting values obtained using FLDA were as follows: DWI>T2WI>MRS>DCE.
The AUCs of the combined modes based on patients were as follows: weighting score(0.955/0.952)>overall
score(0.923/0.917)>sum score(0.922/0.913)>highest score(0.867/0.859). The AUCs, sensitivity, specificity,
PPV, NPV and accuracy of weighting score of both readers were 0.955/0.952, 93.94%/96.97%,
91.67%/85.71%, 91.18%/86.49%, 94.29%/96.77%, 92.75%/91.18% respectively.
CONCLUSION
PI-RADS scoring system, which is an effective assessment system for detection of PCa, could improve the PCa
diagnosis. While different combined mode of mp-MRI have different diagnostic efficacy, especially the weighting
score. The weighting values revealed that the most important sequences were DWI and T2WI, and more
diagnostic information could be supplemented by MRS and DCE.
CLINICAL RELEVANCE/APPLICATION
PI-RADS scoring system, which is a scoring system guidline for mp-MRI in detection of PCa, could improve the
PCa diagnosis.
GUS112
CT Features for Diagnosing Acute Torsion of Uterine Leiomyoma (Station #4)
Yoshimitsu Ohgiya MD (Presenter): Nothing to Disclose , Masaaki Kawahara : Nothing to Disclose ,
Noritaka Seino : Nothing to Disclose , Yui Onoda MD : Nothing to Disclose , Masanori Hirose MD :
Nothing to Disclose , Takehiko Gokan MD : Nothing to Disclose
PURPOSE
To evaluate usefulness of computed tomographic (CT) features for identifying acute torsions of uterine
leiomyomas.
METHOD AND MATERIALS
We retrospectively analyzed contrast enhanced CT examinations of 7 uterine leiomyomas with acute torsion and
44 without torsion, which has been surgicopathologically confirmed. Two experienced radiologists who were
blinded to the surgicopathologic findings evaluated these 2 groups of CT features. The analyzed CT features
consisted of poor contrast enhancement inside the leiomyoma, thin rim enhancement around the leiomyoma,
calcification within the leiomyoma, beak sign between the uterus and the leiomyoma, wedged poor contrast
enhancement area in the uterus adjacent to the leiomyoma, and ascites. We acquired statistical proportions for
the frequencies of these CT features in the uterine leiomyomas with torsion versus those without torsion, using
the Pearson [chi]2 and Fisher exact tests at 5% levels of significance.
RESULTS
The frequencies of CT features in uterine leiomyomas with torsion and those without torsion were as follows:
86% and 5% with poor contrast enhancement inside the leiomyoma (p = 0.001); 71% and 9% with thin rim
enhancement around the leiomyoma (p = 0.001); 29% and 18% with calcification within the leiomyoma (p >
0.05); 57% and 86% with beak sign between the uterus and the leiomyoma (p > 0.05); 57% and 0% with
wedged poor contrast enhancement area in the uterus adjacent to the leiomyoma (p = 0.001); 100% and 20%
with ascites (p = 0.01). The sensitivity, specificity, and accuracy for diagnosing acute torsion of uterine
leiomyoma were as follows: 86%, 96%, and 94%, respectively, with poor contrast enhancement inside the
leiomyoma; 71%, 91%, and 88%, respectively, with thin rim enhancement around the leiomyoma; 29%, 82%,
and 75%, respectively, with calcification within the leiomyoma; 57%, 14%, and 20%, respectively, with beak
sign between the uterus and the leiomyoma; 57%, 100%, and 94%, respectively, with wedged poor contrast
enhancement area in the uterus adjacent to the leiomyoma; 100%, 55%, and 61%, respectively, with ascites.
CONCLUSION
The CT features of poor contrast enhancement, thin rim enhancement, wedged poor contrast enhancement area
are valuable for identifying acute torsion of uterine leiomyoma.
CLINICAL RELEVANCE/APPLICATION
These valuable CT features in confirming acute torsion of a uterine leiomyoma would help guide therapeutic
decision.
GUS113
Noninvasive Evaluation of Renal Allograft Function Using Shear-Wave Elastography (Station #5)
Beom Jun Kim (Presenter): Nothing to Disclose , Chan Kyo Kim MD, PhD : Nothing to Disclose , Sung Yoon
Park : Nothing to Disclose , Jung Jae Park MD : Nothing to Disclose , Byung Kwan Park MD : Nothing to
Disclose
PURPOSE
Shear-wave elastography (SWE), as a noninvasive tool, assesses quantitatively the tissue elasticity. Few studies
have been reported for evaluating renal allograft function using SWE. The aim of our study was to investigate
the usefulness of SWE for functional assessment of renal allografts.
METHOD AND MATERIALS
81 patients (mean age, 46 years; range, 22-72 years) with renal allografts who received ultrasound-guided
biopsies were enrolled in this study. All ultrasound and elasticity examinations of renal allograft were performed
by a commercial scanner using a convex transducer (C5-1 ElastoPQ, Philips iU 22). SWE was performed
immediately before ultrasound-guided biopsies. Tissue elasticity (kPa) in the cortex and resistive index (RI)
values were measured for all renal allografts. The correlation between estimated glomerular filtration rate
(eGFR) and tissue elasticity or RI value was evaluated in all patients. Both tissue elasticity and RI values were
compared between patients with acute rejection (AR) and without AR, and among different grades of AR.
Diagnostic accuracy of tissue elasticity to distinguish between patients with AR and without AR was analyzed
using a receiver operating characteristics (ROC) curve analysis.
RESULTS
The ARs were pathologically confirmed in 39 patients. The tissue elasticity demonstrated a moderate negative
correlation with eGFR (correlation coefficient= -0.600, P< 0.001), while the RI values did not show a
correlation with eGFR (P= 0.273). In all renal allografts, the mean tissue elasticity was 36.2 ± 15.5 kPa: the
mean tissue elasticity of ARs (40.8 ± 14.6 kPa) was significantly greater than that of no ARs (32.0 ± 15.3 kPa)
(P= 0.01), while the RI values did not show significant difference between ARs and no ARs (P= 0.276). At ROC
curve analysis, the area under the curve of tissue elasticity was 0.646. No significant differences among
different grades of AR were found for each tissue elasticity and RI value (P> 0.05).
CONCLUSION
SWE, as a noninvasive tool, may demonstrate functional state of renal allografts. Furthermore, SWE may be
useful to differentiate between renal allograft patients with AR and without AR.
CLINICAL RELEVANCE/APPLICATION
As a feasible technique, shear-wave elastography may help to noninvasively assess functional state of renal
allograft patients.
GUS114
Amide Proton Transfer Magnetic Resonance Imaging of Prostate Cancer: A New Biomarker of
Prostate Cancer Aggressiveness (Station #6)
Yukihisa Takayama MD (Presenter): Research Grant, FUJIFILM Holdings Corporation , Akihiro Nishie MD :
Nothing to Disclose , Masaaki Sugimoto : Nothing to Disclose , Osamu Togao MD, PhD : Nothing to
Disclose , Yoshiki Asayama MD : Nothing to Disclose , Hiroshi Honda MD : Nothing to Disclose , Jochen
Keupp PhD : Employee, Koninklijke Philips NV , Yasuhiro Ushijima MD : Nothing to Disclose , Daisuke
Okamoto MD : Nothing to Disclose , Nobuhiro Fujita MD, PhD : Nothing to Disclose , Koichiro Morita :
Nothing to Disclose
PURPOSE
To evaluate a clinical utility of amide proton transfer magnetic resonance imaging (APT-MRI) in assessing
prostate cancer (Pca) aggressiveness
METHOD AND MATERIALS
A total of 105 patients (age = 68.4 ± 7.0 years) with biopsy proved Pca were enrolled. In addition to
conventional MRI, such as T2WI and DWI, APT-MRI was scanned on a 3T MR system. The areas of Pca,
noncancerous peripheral and transitional zones, and the Gleason score (GS) of each Pca were defined by
referring to the needle biopsy results. The MR parameters of APT-MRI were as follows: 2D-TSE sequence with
driven equilibrium refocusing, TR/TR = 5 s/6 ms, FOV = 2302 mm2, resolution = 1.8×1.8×5 mm3, 25
saturation frequency offsets = -6 to 6 ppm (step 0.5 ppm) and ω0 = -160 ppm. Saturation pulse length = 0.5
s, B1rms = 2.0 μT. δB0 maps were acquired separately for a δB0 correction. The APT signal intensity (APTSI)
was defined as: MTRasym = {S [-3.5ppm] - S [+3.5ppm] )/S 0}×100 (%). We assessed MRI-detectable 66
cancers about Pca aggressiveness after categorizing into 4 groups: GS of 6 (GS = 3 + 3, n = 23); GS of 7 (GS =
3 + 4 or 4 + 3, n = 18); GS of 8 (GS = 4 + 4, n = 11) and GS of 9 (GS = 4 + 5 or 5 + 4, n = 14). Mean ± SDs
of the APTSI of each group were calculated after drawing regions-of-interest on the APT-MRI. The mean APTSIs
among 4 groups were compared one-way analysis of variance with Tukey's HSD post hoc test.
RESULTS
Mean ± SDs of the APTSI (%) of each group were; GS of 6, 2.48 ± 0.59; GS of 7, 5.17 ± 0.66; GS of 8, 2.56 ±
0.85; and GS of 9, 1.96 ± 0.75, respectively. There was a significant difference in APTSIs between GS of 6 and
GS of 7, and GS of 7 and GS of 9, (p<.05), but no significant differences in APTSI between GS of 6 and GS of 8,
GS of 6 and GS of 9, and GS of 7 and GS of 8. The increase and decrease in APTSIs relating to the progression
of Pca aggressiveness might reflect the changes of cellularity, cell proliferation and protein synthesis of Pca.
CONCLUSION
The APTSI in GS of 7 was the highest. The APT-MRI has a possibility as a new biomarker of Pca aggressiveness.
CLINICAL RELEVANCE/APPLICATION
The APT-MRI can be useful to predict prostate cancer aggressiveness alone or in combination with other
modalities and MR sequences.
URE180
MR Imaging Characteristics of Retroperitoneal Tumors: Diagnostic Clues, Differential Diagnosis and
Histopathological Correlation (Station #7)
Pardeep Kumar Mittal MD (Presenter): Nothing to Disclose , Courtney Ann Coursey Moreno MD : Nothing to
Disclose , Nima Kokabi MD : Nothing to Disclose , William C. Small MD, PhD : Nothing to Disclose , Sadhna
Nandwana MD : Nothing to Disclose , Juan Camilo Camacho : Nothing to Disclose
TEACHING POINTS
1.To demonstrate diagnostic challenges including localization of the mass , extent of invasion and
characterization of specific pathology such as liposarcoma , leiomyosarcoma ,extragonadal germ cell,
paragangliomas and sarcoma etc. 2.To illustrate patterns of spread, tumor components, tumor vascularity
helping in narrowing the differential diagnosis
TABLE OF CONTENTS/OUTLINE
Presentation will includes MRI characterization of retroperitoneal tumors using a dedicated less than 30 minute
protocol of abdominopelvic MRI without and with contrast medium. Imaging findings will be correlated with
histopathology Primary retroperitoneal (RP) tumors originating in the retroperitoneum but outside the major RP
organs are uncommon. One of the challenges to radiologist is correct localization of the retroperitoneal lesions ,
characterization as well extent of the disease, involvement of adjacent structures, identifying the organ of
origin. Hence MR imaging is valuable in evaluating RP tumors particularly in staging, assessment of vascular
invasion and fat content due its excellent soft tissue contrast. Specific diagnosis might be difficult to achieve
because of overlapping features but certain clues will help in narrowing the differential diagnosis such as
liposarcoma,leiomysarcoma,solitary fibrous tumor, paraganglioma and lymphoma etc.
URE002-b
A Users Guide to the “Anterior” Prostate Gland: Multi-parametric (mp) MRI – Pathologic Correlation
(hardcopy backboard)
Bardia Moosavi MD : Nothing to Disclose , Trevor A. Flood MD, FRCPC : Nothing to Disclose , Nicola
Schieda MD (Presenter): Nothing to Disclose
TEACHING POINTS
After viewing this exhibit, the viewer will: a) understand the term 'anterior' prostate gland and its' normal
anatomy, histology and relevance to patients treated with active surveillance (AS) or those with negative
non-targeted transrectal ultrasound (TRUS) guided biopsies, and b) develop an approach using mp-MRI for the
diagnosis of prostate cancer in this location with pathologic correlation.
TABLE OF CONTENTS/OUTLINE
1. Define the nomenclature of the 'anterior and posterior' prostate gland and their relationship to non-targeted
TRUS biopsy. 2. Review the relevant anatomy and histology of the "anterior" gland, including the horns of the
peripheral zone, anterior fibromuscular stroma, central and transitional zones. 3. Review the significance of
mp-MRI evaluation of the "anterior" gland in the setting of elevated PSA with negative non-targeted TRUS
biopsies and AS; specifically discussing the recently proposed scoring systems such as PI-RADS and the
National Institutes of Health criteria for AS. 4. Illustrate proven cases of "anterior" gland tumors, discussing the
mp-MRI imaging appearance with a review of literature on the topic and using pathologic correlation. 5. Discuss
the mp-MRI and histologic appearance of other anterior gland processes (such as stromal and glandular benign
prostatic hyperplasia (BPH)) and how these can mimic "anterior" tumors.
HPS-MOA
Health Services Monday Poster Discussions
Scientific Posters
HP
AMA PRA Category 1 Credits ™: .50
Mon, Dec 1 12:15 PM - 12:45 PM
Location: HS Community, Learning Center
Participants
Moderator
Christopher Paul Hess MD, PhD : Research Grant, General Electric Research Consultant, Imaging Endpoints Research
Consultant, Cerebrotech Medical Systems
Moderator
Tessa S. Cook MD, PhD : Nothing to Disclose
Sub-Events
HPS142
Dare to Compare! Analysis of Recommendations for Additional Imaging in Abdominopelvic Studies
that can be Avoided by a Thorough Comparison with Prior Examinations (Station #1)
Ankur Doshi MD (Presenter): Nothing to Disclose , Michael
Rosenkrantz MD : Nothing to Disclose
Kiritsy : Nothing to Disclose , Andrew B.
PURPOSE
Abdomen and pelvic CT and MRI reports frequently contain recommendations for additional imaging (RAI) to
evaluate an indeterminate finding, generating increased utilization and cost. The purpose of this study was to
determine the frequency and characteristics of RAI that could be avoided by thoroughly reviewing all available
prior studies.
METHOD AND MATERIALS
This IRB-approved, retrospective evaluation of abdominopelvic CT and MRI reports included 1,015 RAI. An
abdominal imaging fellow comprehensively reviewed the reports and images from each patient's prior imaging
studies, including all relevant body parts and modalities. The RAI was considered avoidable if the prior imaging
demonstrated ≥2 years of stability of the finding, complete characterization of the finding, or if the
recommended study was already recently performed. The fraction and characteristics of such "avoidable" RAI
were computed/assessed using summary statistics.
RESULTS
Of the 1,015 RAI, 41 were avoidable (4%). The involved organs were as follows: 22% kidney, 15% adrenal,
15% uterus, 12% liver, 7% bone, 7% biliary, 5% chest, 5% adnexa, 2% spleen, 2% peritoneum, 2%
pancreas, 2% bowel, 2% abdominal wall. The RAI was considered avoidable on the basis of prior full
characterization in 61%, ≥2 year stability in 29% and recent completion of the recommended study in 10%.
The key prior study was a different modality from the study containing the RAI in 54% and was not mentioned
as a comparison study in 83%. The key prior study modality comprised CT (44%), MRI (32%), ultrasound
(17%), PET-CT (2%) and radiographs/fluoroscopy (5%). The key prior body imaging area included the
abdomen/pelvis (59%), spine (10%) and chest (32%). The key finding was noted in the impression of the prior
study in 22%, noted only in the report body in 17%, present on the prior images but not described in the
report in 54%, and present in an outside study uploaded to our system in 7%.
CONCLUSION
A small fraction of RAI (4%) can be avoided by a thorough evaluation of all prior imaging studies, including
studies of other body parts and modalities. More that half (54%) of the key prior studies did not report the
finding, highlighting the importance of directly reviewing all relevant prior images.
CLINICAL RELEVANCE/APPLICATION
Direct review of all prior relevant imaging, including different body parts and modalities, can help avoid
recommendations for additional imaging.
HPS143
CT Contrast Extravasation in a Large Academic Medical Center: Experience with 352,125 Injections
(Station #2)
Khalid Walid Shaqdan MD (Presenter): Nothing to Disclose , Shima Aran MD : Nothing to Disclose , Elmira
Hassanzadeh MD : Nothing to Disclose , Hani H. Abujudeh MD, MBA : Research Grant, Bracco Group
Consultant, RCG HealthCare Consulting Author, Oxford University Press
PURPOSE
To review the literature and present our experience in Contrast Extravasations (CE) for CT in a large academic
medical center.
METHOD AND MATERIALS
The investigation is IRB, HIPPA, and informed consent compliant. There were 352 125 injections between June
2008 and June 2013. The radiology data and medical records of patients in whom CE occurred were reviewed.
RESULTS
In CT, the EXR was 0.13% (451/352 125, 254 female and 197 male). There was a statistically significant
difference between females and males in overall EXR (p=0.0062), and the number of extravasations between
CT and MRI (p= <0.0001). The majority of extravasations occurred in outpatients (64.5% [291/451]), but the
overall incidence of CE was highest in inpatients (0.29% [160/54 664]).
CONCLUSION
In this large retrospective review we found that the elderly (>60 yr), females, and inpatients are at the highest
risk of extravasation after contrast-enhanced studies in CT.
CLINICAL RELEVANCE/APPLICATION
Knowledge of the risk factors associated with contrast extravasation for CT can be used to identify vulnerable
groups, and help create or strengthen CE risk modification programs.
HPS144
Near-Misadministration Events for Imaging Studies: A Detailed Analysis of Major Sources and Types
of Errors (Station #3)
Resmi Charalel MD (Presenter): Nothing to Disclose , Ian Ross Drexler MD, MBA : Nothing to Disclose ,
Pina Christine Sanelli MD : Nothing to Disclose , Michael Lyon Loftus MD, MBA : Nothing to Disclose ,
Keith David Hentel MD, MS : Nothing to Disclose , Robert J. Min MD : Medical Advisory Board, Sapheon, Inc
PURPOSE
To identify most common types and sources of imaging study near-misadministration in order to develop
tailored solutions for prevention and improvement in quality and patient safety.
tailored solutions for prevention and improvement in quality and patient safety.
METHOD AND MATERIALS
Detailed analysis of near-misadministration events in imaging studies was performed over a five-month period
as part of departmental quality improvement efforts. Multi-modality technologists were educated regarding the
risks associated with misadministration and instructed to record data, such as ordering provider, modality, and
source of error for all near-misses encountered each day. Statistical analyses were performed to identify the
most common errors and their sources.
RESULTS
Over this five-month period, in 150,604 total imaging exams performed, 148 near miss-errors were identified in
145 imaging exams (0.1% of total exams), with 98% (145/148) ordering errors and 2% (3/148) protocol
errors. 74% (107/145) of near-miss errors occurred in modalities utilizing ionizing radiation (CT or XR). 53%
(77/145) of errors occurred on inpatients, 39% (56/145) on emergency room patients and 8% (12/145) on
outpatients. The housestaff were responsible for 60% (87/145) of ordering errors, while 12% (18/145)
originated from attendings and 28% (40/145) originated from physician extenders (nurse practitioners and
physician assistants). Multiple services contributed to ordering errors, with the most from Internal Medicine
(33%, 48/145) and Emergency Medicine (23%, 33/145). The ordering errors consisted of most frequently
wrong body part (38%, 56/148), wrong side (17%, 25/148) and wrong contrast (14%, 21/148), but also
included wrong patient (5%, 8/148) and duplicate (11%, 16/148). All errors were discovered and corrected
before reaching the patient.
CONCLUSION
At our academic medical center, the majority of ordering errors occurred in modalities involving ionizing
radiation and originated from housestaff providers in departments ordering high volume imaging. By identifying
these major sources of error, we are better able to target information technology, educational and
workflow-related solutions towards subsets of ordering providers to reduce the number of near-miss ordering
errors and ultimately true miss-errors in the future.
CLINICAL RELEVANCE/APPLICATION
Near-misadministration event analysis for imaging studies is important for reducing the number of true
misadministration events leading to unnecessary radiation exposure and wasted resources.
HPS145
Six Years of Radiology Sentinel Events: Rates and Opportunities (Station #4)
Carrie Phillips (Presenter): Nothing to Disclose , Karl N. Krecke MD : Nothing to Disclose , Anil Nicholas
Kurup MD : Nothing to Disclose , Laura Tibor MBA, BEng : Nothing to Disclose , Sherrie L. Prescott RN :
Nothing to Disclose , Robert E. Watson MD, PhD : Nothing to Disclose
PURPOSE
We present our experience with and rates of occurrence of sentinel events in a large multispecialty group
practice. The use of denominators is important for benchmarking high-reliability radiology practice.
METHOD AND MATERIALS
We reviewed our institutional database for sentinel events assigned to the Department of Radiology by the
institution's quality management team from 2008-2013. Denominators were selected to reflect the total number
of patient exams performed and unique patient visits in each year. Annual rates were computed for events per
radiology exam performed and events per 10,000 unique patients. Each event represents a significant defect in
care and defect rates were computed for sigma level. Events were stratified into inpatient vs outpatient, harm
vs risk, and grouped by error type.
RESULTS
Seventy-nine sentinel events were ascribed to the department over the six year period. Annually, a mean of
210,512 patients were examined in Radiology and an average of 937,214 examinations performed. Annual rate
of sentinel event occurrence averaged 13.2 events (range: 8-19). Events occurred at a rate of 0.0014% for
exam volumes (range: 0.0008 - 0.0020%) and 0.625 events per 10,000 unique patients (range: 0.40 - 0.91).
These defects in care represent an average sigma level of 5.7 (range: 5.61 - 5.81). Of the 79 events, 43% were
associated with patient harm and 57% with increased risk of harm. Fifty-four percent of events occurred in the
outpatient setting, 41% inpatient, and 5% in the emergency department. We had one patient death due to
equipment failure during an interventional procedure. Our areas of opportunity are in defects related to
incorrect procedure or exam, medication misadministration, specimen mishandling, and delay in treatment.
CONCLUSION
Rates of significant care defects are low in our practice compared to manufacturing standards. Yet,
opportunities to improve patient care and safety remain.
CLINICAL RELEVANCE/APPLICATION
Patient safety is a preeminent priority in Radiology. While we work toward a goal of error-free practice, 'never'
is a stretch goal. Benchmarking current rates among enlightened, self-reflective practices will help guide
learning and support discovery of best practices. Adopting standard definitions and measures of defect rates is a
valuable step toward benchmarking and process improvement.
HPS146
Skin Tests in Patients with Hypersensitivity Reaction to Iodinated Contrast Media: A
Meta-analysis (Station #5)
Soon Ho Yoon MD (Presenter): Nothing to Disclose , Suh-Young Lee : Nothing to Disclose , Hye-Ryun
Kang : Nothing to Disclose , Seokyung Hahn PhD : Nothing to Disclose , Chang Min Park MD, PhD :
Nothing to Disclose , Jin Mo Goo MD, PhD : Research Grant, Guerbet SA , Yoon-Seok Chang : Nothing to
Disclose , Sang-Heon Cho : Nothing to Disclose
PURPOSE
To systematically review and meta-analyze the role of skin tests in patients with HSR to ICM in terms of
positive rate, cross-reactivity rate, and tolerability to skin test-negative ICM according to the type of HSR
(immediate or non-immediate).
METHOD AND MATERIALS
Two authors independently performed a literature search of the MEDLINE and EMBASE databases to identify
relevant publications. We included studies in which skin tests were performed in patients who experienced HSR
to ICM, with extractable outcomes. Two reviewers extracted data on the study characteristics, skin test, ICM,
and outcomes. Disagreements were resolved through consensus. Outcomes were pooled using a random-effects
model.
RESULTS
Twenty-one studies were included. Pooled per-patient positive rates of skin tests were 17% (95% CI, 10-26%;
I2, 46%) in patients with immediate HSR, and up to 52% (95% CI, 31-72%; I2, 42%) when confined to severe
immediate HSR. Among patients with non-immediate HSR, the positive rate was 26% (95% CI, 15-41%; I2,
45%). The pooled per-patient cross-reactivity rate was higher in non-immediate HSR (68%; 95% CI, 48-83%;
I2, 36%) than in immediate HSR (39%; 95% CI, 29-50%; I2, 9%). Median per-test cross-reactivity rates
between pairs of ICMs were 7% (IQR, 6-9%) in immediate HSR and 38% (IQR, 22-51%) in non-immediate
HSR. Pooled per-patient recurrence rates of HSR to skin test-negative ICM were 7% (95% CI, 4-14%; I2, 0%)
in immediate HSR, and 35% (95% CI, 19-55%; I2, 31%) in non-immediate HSR. There were heterogeneities
across studies in the severity of HSR, use of culprit ICM, number of tested ICMs for a skin test, and the time
interval between HSR and the skin test affecting the positive rate of skin tests.
CONCLUSION
Skin tests proved the causative agent in a portion of patients with HSR to ICM and identified cross-reactive
ICMs. More frequent and non-specific cross-reactivities were found in patients with non-immediate HSR. Skin
tests may help determine non cross-reactive, alternative ICM in patients with immediate HSR to ICM.
CLINICAL RELEVANCE/APPLICATION
Skin test may be helpful in diagnosing and managing patients with a previous history of HSR to ICM, especially
in patients with a history of severe immediate HSR demanding subsequent use of ICM.
HPE124
Sample Size Selection to Evaluate Emerging Imaging Technologies: A Reader's Guide (Station #6)
Anand
Narayan MD, PhD (Presenter): Nothing to Disclose , John
Eng MD : Nothing to Disclose
TEACHING POINTS
How many patients should be studied? This is one of the most commonly asked questions in designing a
research study. New imaging modalities are being developed to answer clinical questions with lower radiation
doses and decreased scanner time. Although there are many articles and textbooks written about sample size
selection and statistical power, few of these articles describe sample size selection to evaluate safer, faster
technologies with equivalent accuracy. The purpose of this exhibit is to review the basic principles underlying
sample size selection and use those principles to describe the process of sample size selection for common
study designs that evaluate new imaging technologies.
TABLE OF CONTENTS/OUTLINE
1. Basic Principles of Sample Size Calculation Type I Error Type II Error Statistical Power Types of Variables 2.
Case Studies Non-inferiority of Diagnostic Tests (Is my new imaging test/protocol at least as good as the old
one?) Diagnostic Accuracy Studies (Is my new imaging test better than the old one?) Imaging Biomarkers as
Disease Predictors (Does my imaging test predict disease outcomes?) 3. Resources Web based Articles
HPE006-b
Myths Busted—Debunking Common Fallacies Surrounding Exposure to Ionizing Radiation from
Medical Imaging (custom application computer demonstration)
Mindy
Licurse MD (Presenter): Nothing to Disclose , Tessa S. Cook MD, PhD : Nothing to Disclose
TEACHING POINTS
The purpose of this educational exhibit is to demonstrate the use of an online quiz module to debunk a variety
of myths regarding exposure to ionizing radiation from medical imaging. Upon completing the module, the
participant will:
Understand the different types of radiation effects
Differentiate between theoretical risk model data and lack of real epidemiologic data
Explain the relative risks of radiation for common radiologic exams
Define the appropriate application of radiation protection strategies
Understand the principles of ALARA, ImageWisely and ImageGently
TABLE OF CONTENTS/OUTLINE
Radiation Effects
Stochastic
Non-stochastic
Hereditary
Risk of cancer
Most common cancers related to radiation exposure
Theoretical risk models
Effective dose
Relative radiation risk for common radiologic exams
Non-ionizing radiation modalities
Ionizing radiation modalities
Interventional radiology & fluoroscopy
Radiation protection strategies
Shields
Lead aprons
“Low-dose” protocols
ALARA
ImageGently
ImageWisely
Common myths about radiation exposure
“Radiation is universally dangerous”
“Radiation exposure makes you radioactive”
“Radiation causes sterility”
INS-MOA
Informatics Monday Poster Discussions
Scientific Posters
IN
AMA PRA Category 1 Credits ™: .50
Mon, Dec 1 12:15 PM - 12:45 PM
Location: IN Community, Learning Center
Participants
Moderator
Alexander T. Ruutiainen MD : Nothing to Disclose
Sub-Events
INS140
Software Tool for Fully-automated Image Quality Control in Computed Tomography (Station #1)
Celia Juan-Cruz : Nothing to Disclose , Roberto Sanz-Requena PhD : Nothing to Disclose , Javier
Saiz-Rodriguez : Nothing to Disclose , Luis Marti-Bonmati MD, PhD (Presenter): Nothing to Disclose
CONCLUSION
The presented tool allows to automatically quantify quality image parameters, easily enabling the longitudinal
assessment of quality in CT devices without human interaction.
Background
Good practice in CT acquisitions need to accurately calculate the image quality. The aim of this study is to
develop an automatic method for CT image quality analysis. Images were acquired using a Philips phantom and
a cone-beam CT imaging system O-ARM (Medtronic Inc., USA), configured for the head protocol in the three 3D
modes: Standard, HD and Enhanced. The software for the evaluation of several quality parameters (noise,
uniformity, and spatial resolution) was developed using MATLAB (The Mathworks Inc., USA). All ROIs and
parameters were extracted and calculated automatically. Noise was calculated as the standard deviation of the
CT value of water and uniformity by the difference among the CT values of the centre of the image and 4
peripheral ROIs. Spatial resolution was determined by the Modulation Transfer Function (MTF) at the 10%,
obtained by the Edge Spread Function method.
Evaluation
The validation of the software was done by systematically varying the kVp and mA acquisition parameters for
the three modes. For the noise and uniformity the same slice at the water section of the phantom was selected.
Image noise decreased as both kVp and mA increased. Regarding uniformity, most images appeared to be
more uniform at the lower part of the phantom. For the MTF, the same slice including a Teflon bar was chosen,
as this material has a high CT value. A total of 15 automatic points were chosen, all along the edge of the Teflon
bar. The MTF was obtained at every point, with a mean value of approximately 1 cy/mm.
Discussion
Discussion
Noise values changed as expected across the study, decreasing when mA and kVp increased. Spatial resolution
was almost constant as it was not influenced by these parameters. The values were below the theoretical
reachable one calculated by the Nyquist frequency (1.2 cy/mm). It was impossible to determine the spatial
resolution for kVp values under 60 due to the higher noise.
INS141
Improving Radiology Resident Feedback and Efficiency with the Radiology Toolbox (Station #2)
Michael Francavilla MD (Presenter): Nothing to Disclose , Cuong
Liaw MD : Nothing to Disclose
Nguyen DO : Nothing to Disclose , Kevin
CONCLUSION
Incorporating the Radiology Toolbox into daily practice has improved overall workflow, report quality, and
resident education.
Background
At our institution, radiology residents begin taking independent overnight call as second years. They dictate full
reports on up to 100 to 200 exams during an overnight and 24-hour shift, respectively. Routine tasks
performed while dictating a case include looking up floor phone extensions, clinical data review, and accessing
educational websites such as StatDx can consume a considerable amount of time. Feedback on studies that are
not reviewed with an attending has traditionally been provided in an ad-hoc manner, generally via email, with
suboptimal results. In an attempt to improve clinical care as well as resident education, in-house software was
developed to facilitate attending-to-resident feedback and improve dictation efficiency and workflow. The
software also includes a searchable teaching file.
Evaluation
A few months after introducing the Radiology Toolbox to residents and attendings, a survey was crafted using
SurveyMonkey and distributed to all staff regarding its utility and the usage frequency of each function. Data
were also collected using a built-in usage tracking function.
Discussion
The Radiology Toolbox is a multi-function tool that interacts with our dictation software and our Picture
Archiving and Communication System. It automates a number of tasks to expedite dictation, including: dictating
the most recent comparison studies; looking up floor phone numbers; opening the patient's chart in the
Electronic Medical Record (EMR); and automatic log-in to educational reference sites. The software also has an
integrated searchable teaching file. Its most heavily utilized feature has been the attending to resident
feedback function, accomplished with a single button click. Finally, it allows residents to compare the
preliminary and final reports, utilizing highlighting and strikethroughs. This function helps residents learn from
past mistakes to improve dictation quality. An increased amount of feedback was provided to residents.
Functions that were utilized most by attendings and residents include the comparison feature and feedback
button.
INS142
Low Tube Voltage (100 kVp) Setting in Enhanced Chest CT: Improved Vessel Enhancement and
Simultaneous Decreased Radiation Dose and Iodine Dose (Station #3)
Zhipeng Gao BEng (Presenter): Nothing to Disclose , Xiaoyi Ren : Nothing to Disclose , Xiaonan Cui :
Nothing to Disclose , Donghua Meng : Nothing to Disclose , Jun Wang : Nothing to Disclose , Zhao Xiang
Ye : Nothing to Disclose
CONCLUSION
We can obviously find that the use of the 100 kVp protocol for chest CT substantially improved vascular
enhancement with 20% reduction in the radiation dose, even though IOCM (270 mgI/mL) was 10% less iodine
than LOCM (300 mgI/mL),
Background
Over the last decade, the use of CT has increased dramatically in clinical examination. There has been growing
interest in decreasing the radiation dose during chest CT examinations, since CT examination has the potential
risks of radiation-induced carcinogenesis. At the same time, CIN is closely related to hospital acquired acute
renal failure.
Evaluation
Vascular enhancement was significantly higher in 100 kVp protocol (group C: 204.9±32.4HUand group
D:188.7±26.0HU) than 120 kVp protocol (group A: 172.1±24.4HU and group B:155.4±21.7HU). In addition,
ED was lower in 100 kVp protocol (group C: 3.9±0.6 mSv and group D: 3.8±0.74 mSv) than 120 kVp protocol
(group A: 4.8±1.3 mSv and group B: 5.0±1.2 mSv). The subjective degree of image quality and CNR was not
significantly different among the four groups.
Discussion
In this study, ED was 20% lower in 100 kVp protocol than 120 kVp. The ED of Group D (100 kVp and 270
mgI/mL setting) was 3.8±0.74 mSv which was approximately the natural ambient radiation exposure.The
application of lower tube voltage in CT increases the photoelectric effect, leading to a higher mean attenuation
value of iodine. Vascular enhancement was significantly higher in 100 kVp (group C: 204.9±32.4HU and group
D:188.7±26.0HU) than 120 kVp (group A: 172.1±24.4HU and group B:155.4±21.7HU). The vascular
D:188.7±26.0HU) than 120 kVp (group A: 172.1±24.4HU and group B:155.4±21.7HU). The vascular
enhancement of group D(100 kVp with IOCM setting) was 188.7±26.0HU, just approximated the general setting
group A (120 kVp with LOCM setting). We used a weight-based adjustment of a combined modulation type of
automatic exposure control technique to increased the tube current-time product (reference mAs) in the 100
kVp protocol to compensate for the increased image noise .In the objective and subjective image analyses of
the image study, the image noise of the 100 kVp protocol was not significantly different from that of the 120
kVp protocol. In addition, The subjective degree of image quality and CNR was not significantly different among
the four groups.
INS143
Operationalizing a Hospital High Reliability Strategy to a Radiology Informatics Initiative (Station
#4)
Joseph Mack MS, BA (Presenter): Nothing to Disclose , Steven P. Braff MD : Nothing to Disclose , Kristen K.
DeStigter MD : Research Grant, Koninklijke Philips NV Consultant, Koninklijke Philips NV Medical Advisory
Board, McKesson Corporation
CONCLUSION
The hospital high reliability strategy provided Radiology and the imaging informatics team the opportunity to
bring forward a set of IT projects that were consistent with hospital strategic objectives. The clinical vision
provided by Radiology, the support of the hospital to provide the capital investment for new software and the
collaboraton between IT and Radiology clinical teams that brought the projects to fruition is an excellent
example of organizational focus.
Background
The Institute of Medicine (IOM) has stressed the urgency of transforming hospitals into places where each
patient receives the best quality care every time, setting a goal for hospitals to become Highly Reliable
Organizations. Radiology and IT operationalize this strategy into an initiative of 4 IT projects: Integration of a
Clinical Decision Support System with the EHR Installation of a Radiation Dose Management system Integrate
the Electronic Health Record Data on a PACS workstation Install a Critical Test Result Management for
documented closed loop communication
Evaluation
The integration of the EHR with the PACS systems has provided the Radiologist with patient episodic data that
match the presented study. The critical test results management system implementation did not reach the goal
we had envisioned. We identified workflows and physician on call processes that required improvement. The
clinical decision support system provide baselines data on imaging study ordering patterns by ordering
physicians. The dose monitoring system improves quality consistency and embeds CT dose metrics in reports.
Discussion
The integration of the EHR and PACS system has streamlined Radiologist access to the clinical chart. The critical
test results management system implementation resulted in the development of an imaging study follow-up
process for repeat studies. The clinical decision support system baseline established the ordering physician
scorecard and creates a feedback loop that match individual ordering practices against evidence based data.
The dose monitoring system provides statistical opportunities to measure radiation dosage per (study and
device) and document organ specific exposure.
INE113
3D Printing - A Primer for Radiologists (Station #5)
Stephen
Thomas MD (Presenter): Nothing to Disclose
TEACHING POINTS
Educate the user on the current techniques of 3D printing, the additive manufacturing process, printer
hardware and printing materials. Provide a step-by-step guide for image data acquisition, printable object
rendering, post-processing to create a polygonal mesh structure and object fabrication.
TABLE OF CONTENTS/OUTLINE
A) Introduction to types of additive fabrication process B) 3D printer technology and printing materials [Fused
Deposition Modeling, Selective Laser Sintering/Granular materials binding, Laminated Object Manufacturing,
Photo-polymerization, Stereolithography, Electron Beam Melting] C) Medical uses for 3D fabrication and future
directions D) CT, MR and US image data acquisition E) Editing and rendering the printable object F) Creating
and editing the polygonal mesh 3D printable model G) Printing the model H) Finishing the model
INE009-b
RadQA: Automated Quality Control of Radiological Interpretations in Prostate Cancer (custom
application computer demonstration)
Simon Han (Presenter): Nothing to Disclose , William Hsu PhD : Nothing to Disclose , Corey W. Arnold :
Nothing to Disclose , Daniel Jason Aaron Margolis MD : Research Grant, Siemens AG , Alex Anh-Tuan Bui
MS, PhD : Nothing to Disclose , Dieter Roland Enzmann MD : Nothing to Disclose
Background
Prostate imaging is increasingly being used to detect, stage, and manage individuals with prostate cancer given
its ability to characterize lesions in a non-invasive and objective way. However, the sensitivity and specificity of
these imaging exams are not well studied. We present a software tool that automatically assesses the
concordance between radiology and pathology report findings from clinical text documents. The system was
previously demonstrated to work in breast imaging (BIRADS), and we have adapted the tool to work for
prostate exams at our institution. While recommended radiological reporting guidelines exist for prostate
(PIRADS), this metric is relatively recent and not widely adopted. As such, we extract relevant elements from
retrospective imaging reports to determine the radiological interpretations and compare the results to
pathology findings in order to generate summarizing visualizations to assess the utility of imaging in diagnosing
pathology findings in order to generate summarizing visualizations to assess the utility of imaging in diagnosing
prostate cancer.
Evaluation
The Radiology Quality Assurance (RadQA) software was implemented for prostate imaging cases at a large
medical institution. 114 patients who have undergone targeted prostate biopsies or radical prostatectomies with
resulting pathology results have been processed by the tool.
Discussion
The system automatically generates statistics (e.g., number of biopsied patients, concordance to pathology
reports) in the dashboard. Users can specify filters such as time period, modality, and quality. Since prostate
imaging reports are semi-structured, a challenge is to extract relevant elements from these reports and
correctly match lesions from one report to another.
CONCLUSION
Our software tool can assist in departmental efforts to improve the quality and value of information from
radiology interpretations by objectively assessing its accuracy in comparison with downstream results.
Currently, we determine the radiological interpretation by mining text reports, but as structured reporting and
scoring systems (e.g., PIRADS) become used more widely, we will improve the ability to make meaningful
comparisons. In addition to prostate, we are exploring extending the framework to other domains such as lung
cancer.
INE010-b
Magnetic Resonance Imaging Protocol Application (custom application computer demonstration)
Hong Yang : Nothing to Disclose , Julie Young : Nothing to Disclose , Laurie A. Perry RN : Nothing to
Disclose , Timothy OConnor MBA (Presenter): Nothing to Disclose , Alex Towbin MD : Author, Amirsys Inc
Shareholder, Merge Healthcare Incorporated Consultant, Guerbet SA
Background
As a complex Radiology department at a large tertiary care hospital with multiple outpatient centers, we were
faced with the problem of maintaining standard MRI protocols on ten machines at four locations across three
vendors. Historically, the imaging protocols were documented using a word-processing application. They were
then distributed either via a shared network drive or through paper-based copies maintained in binders.
Changes to the protocols were difficult and time consuming. To address these issues, we designed and
implemented an easy-to-use, web-based MRI protocol database application.
Evaluation
A database-driven, web-based application was created which allows clinical managers to store MRI protocol
information in a database. Multiple protocols can be stored and organized based on the physical scanner,
radiology specialty, and the specific body part(s). For each protocol, individual sequence steps can be defined
and annotated along with pre-scan and post-scan steps to be followed by the technologist. Each step in the
protocol can be annotated with images in order to further convey relevant information. In addition, the system
also allows for associated documents (PDF, MS Word, etc.) and hyperlinks to be stored as part of the protocol
and referenced directly from the protocol web pages. Protocol information is displayed via a standard web
browser in a tabular, easy to understand and follow format.
Discussion
More than 100 MRI protocols are currently stored in the system with more being added as the system continues
to be rolled out. The use of web technology has allowed us to provide a single, easy to use portal for access to
all of the protocol information. We believe that consistent presentation of the sequence step instructions and
notes aids in consistency in the use of the protocols throughout the department.
CONCLUSION
Using a database-driven, web application to store and manage complex MRI protocols provides easier access to
critical information for imaging technologists and allows divisional leaders to quickly make changes that are
instantly accessible to all technologists.
INE011-b
Desktop Reporting Assistant Tools using QR Code and OCR on the Fly in the Reading Room:
Feasibility of all-in-one Cam Mouse and Web-based QR Code Templates (custom application
computer demonstration)
Norio Nakata MD (Presenter): Nothing to Disclose , Tomoyuki Ohta : Nothing to Disclose , Yukio
Miyamoto MD : Nothing to Disclose , Kunihiko Fukuda MD : Nothing to Disclose
Background
Nowadays, almost science journals are online and e-Books are becoming more popular. However, old journals
and textbooks still remain on paper in the department of radiology. Contents of e-Books are stored in the
tablet. And those smart devices are sometimes difficult to connect directly with HIS/RIS. If radiologists want to
cite the important descriptions from those references for radiological reporting, they have to copy those
descriptions manually by typing or dictation. So those jobs are tedious and time-consuming. Optical character
recognition (OCR) and QR codes enable connecting the offline world to the online environment. Webcam is
available to manage OCR and QR code. But conventional enterprise workstations for radiology reporting do not
include the web cam as standard equipment.
Evaluation
We have developed reporting assistant tools using open source OCR and QR code libraries using the cam
mouse. The cam mouse is a commercial available all-in-one wired mouse, which combines a 1200DPI mouse
with a 2.0M pixel camera. Those OCR and QR code tools are developed using HTML5 and JavaScript. Using OCR
and QR code scanner with the cam mouse, it is easy to attach the cited text to the reports and to read the QR
codes including the URL and document data. We have also developed unique web-based management system
of QR code templates for radiology reports including RSNA Radiology Reporting Templates. This QR code
templates are put in our original website. Radiologists do not input their original templates into their each
reporting system of multiple institutes. Radiologists can create and revise their own variable templates using
real-time QR code generator and OCR tool with their tablet terminals and use them in any hospitals.
Discussion
BYOD brings new security challenges for secured IT. OCR or QR code is one of those technologies. We will
discuss the pros and cons of each solution. We will also compare these technologies with other wireless data
transfer methods such as Bluetooth, transfer data using ultrasound, and other new technologies.
CONCLUSION
OCR and QR code tools for reporting using the cam mouse are feasible approach to paper-based data transfer
between reporting workstation and BYOD.
INE012-b
Single-Handed Gesture Control for Image Manipulation Using Leap Motion and Open Source
Software: Initial User Experience (custom application computer demonstration)
Derick Hsieh (Presenter): Nothing to Disclose , Philippe
Murphy MD, FRCPC : Nothing to Disclose
Kruchten : Nothing to Disclose , Darra Thomas
Background
With gesture-based control systems becoming an alternative interface to traditional computing systems, new
interactive methods can be implemented in a medical environment. Gesture-based interactions allow no-touch
control of a system that removes the need of the re-sterilization process. This may reduce procedure time and
allow the physician to focus on the primary task at hand. We propose a simple method where the primary user
can perform most common tasks such as scroll, zoom, pan and window width/level (ww/wl) adjustments with
just one hand using a Leap Motion sensor and an open source DICOM viewer, Weasis.
Evaluation
Special algorithms were derived to eliminate obstacles such as lighting conditions, noise, and interference from
other equipment. We asked 12 clinicians (9 radiologists and 3 orthopedic surgeons) to participate. All clinicians
stated they routinely reviewed patient imaging during a procedure. Following a brief introduction and
demonstration taking less than 5 minutes, the clinicians were asked to perform certain tasks on multiple CT and
MRI imaging datasets in a non-clinical test environment. Most clinicians had no prior experience with interactive
gesture sensors (10/12). All clinicians rated the experience as satisfactory or very satisfactory and provided
very positive feedback with regards to image zoom, scroll, pan and fine tuning ww/wl as well as ww/wl presets.
All 12 clinicians stated a preference of single-handed over two-handed gesture control.
Discussion
Gesture based technology for manipulation of medical images in a sterile environment is a promising tool. We
have developed an open source plugin to allow the user the ability to use one hand to finely manipulate medical
imaging data. We endeavored to make the system easy to use by developing a method where no calibration is
needed. This is simple to implement as it can easily be integrated into existing systems, requires no calibration
and is very low cost.
CONCLUSION
We have demonstrated a very positive user experience by harnessing this powerful technology. Further research
is required to evaluate the impact this may have on procedure times and user experience in the operating room
or interventional radiology suite.
INE013-b
Universal Decision Support Application and Semi-automated differential Diagnosis Generation
System for Liver CT and MR Imaging (custom application computer demonstration)
Toshimasa James Clark MD (Presenter): Nothing to Disclose , Suresh Maximin MD : Nothing to Disclose ,
Sooah Kim MD : Nothing to Disclose , Carolyn Lee Wang MD : Nothing to Disclose , Mariam Moshiri MD :
Consultant, Reed Elsevier Author, Reed Elsevier , Puneet Bhargava MD : Editor, Reed Elsevier , Tao Li MD,
PhD : Nothing to Disclose
Background
Algorithm-based characterization of hepatic lesions is well defined by the LI-RADS criteria for a small subset of
studies. LI-RADS is not applicable to patients without underlying liver disease or on MR performed with
hepatobiliary contrast agents. We therefore created a web-based application to categorize hepatic observations
along with semi-automated report generation of the differential diagnosis in descending order of probability. It
will apply to livers with or without underlying disease, imaged with multiphase CT or MR, with any contrast
agent.
Evaluation
We developed an algorithm encompassing all hepatic observation signal intensities and attenuations on all
phases where applicable, building upon prior extant work. We then developed a free Javascript web application
implementing both our algorithm and differential diagnosis generator. The decision tree is based on current
literature, can be updated as consensus evolves, and will include a comprehensive set of benign and malignant
hepatic entities. It will also allow input of other relevant data, e.g. prior studies or history of malignancy.
Discussion
There exists literature supporting definitive characterization of various hepatic entities based on imaging
characteristics on multiphase studies, yet we are unaware of any decision support applications that can be used
in imaging of both non-cirrhotic and cirrhotic livers. This application's evidence-based algorithm can be used for
decision support, structured report generation, and as a learning tool.
CONCLUSION
We have developed a free web application that can be used to characterize lesions and auto-generate a
differential diagnosis for CT or MR of both non-cirrhotic and cirrhotic livers, regardless of contrast agent choice.
Given the increasing complexity of hepatic imaging, our goal is to provide decision support that will be useful as
a learning tool as well as help radiologists become more consistent, efficient and accurate in the interpretation
and reporting of hepatic lesions.
INE014-b
Computer Aided Detection (CADe) of Retained Surgical Items (RSI) in X-ray Images (XR) (custom
application computer demonstration)
Gady agam PhD (Presenter): Shareholder, RaPID Medical Technologies, LLC , Vicko Vicko Gluncic :
Founder, RaPID Medical Technologies, LLC CEO, RaPID Medical Technologies, LLC , Serge Kobsa MD, PhD :
Nothing to Disclose , Shirley Richard MBA : Clinical Advisor, RaPID Medical Technologies, LLC , Mario Moric
: Officer, RaPID Medical Technologies , Sameer A. Ansari MD, PhD : Shareholder, RaPID Medical
Technologies, LLC
Background
RSI are commonly surgical sponges/needles inadvertently left in a patient's body (0.02-1% incidence). They are
a priority OR patient safety concern, classified as sentinel events by the Joint Commission. Measures to prevent
RSI include effective OR communication, mandatory counts of surgical instruments/sponges, methodical wound
examination, and XR. Miscounts occur in <12.5% of surgeries, requiring XR of the surgical field. Since 80-90%
of RSI occur with "correct surgical counts" hospitals may mandate XR at the end of all complex surgeries.
Although XR based protocols are crucial for RSI detection, they are limited by the sensitivity and experience of
the human eye, lack of formal training for RSI detection, and a time intensive process for complete analysis.
These limitations motivated us to develop CADe software for the ray-tec XR detectable sponge.
Evaluation
Developed CADe software involves three steps: enhancement, detection, and recognition. Enhancement
reduces noise and improves contrast to assist detection. Identification detects candidate regions and classifies
them using a supervised learning technique based on extracted 112 dimensional feature vectors. Detected
regions are clustered to form candidates using a spatial clustering algorithm. The object detection stage uses an
additional classifier that is trained in a supervised manner.
Discussion
The test collection included a total of 790 images where 277 have one or more ray-tec sponges. We manually
labeled the images by marking the area of each sponge and automatically marked negative candidate
locations. Overall we had 561 positive locations and 25,638 negative locations.10 fold cross validation was
performed and receiver operating characteristic curve generated. Using the optimal point on the curve we
obtained 509 true positives, 25,611 true negatives, 27 false positives, and 52 false negatives. CADe beta
prototype testing resulted in 99% specificity, 90% sensitivity, and 0.92 F-measure.
CONCLUSION
Our data demonstrate the feasibility of the CADe for the ray-tec sponge in XRs based on supervised learning
methods. Developed CADe software has a potential to improve OR time utilization, RSI detection rate, and
overall patient safety.
INE015-b
ISO27001-Implementing Secured DICOM Replication and Data Restore for Multiple Archiving
Servers (custom application computer demonstration)
Suranarong
Disclose
Kamtasila MEng (Presenter): Nothing to Disclose , Krongrat
Kangwanklai BS, MS : Nothing to
Background
Based on research; ISO27001-Implementing Medical Imaging Archiving using Big Data Architecture, having two
set of onsite archiving data on HDFS enable the onsite copying and unlimited storage space. We have
encountered a problem of having another set of data storage offsite. A result of using HDFS synchronization was
not satisfactory. Our solution is to develop a multisource file-transfer or swarming file-transfer replication
system. Its aim is to improve the overall performance, and accuracy of data backup to the offsite storage.
Evaluation
Performance of transferring data over DICOM protocol was not good. Using other protocols e.g., FTP or rsync,
might lead to inability to know if the data transfer was successful. This research focuses on an adaption of the
principle of multisource file-transfer. If there are changes at the Study level, a source server will modify the
structure of source directory by combining all into one file, compress and divide into smaller pieces and encrypt
each piece. The cryptography technique is used to ensure data integrity and confidentiality when data is sent
across to a destination server in the form of multisource-single receiver. In this structure, if there is more than
one copy of data, it is possible to divide and send multiple pieces of data simultaneously.
Discussion
ISO27001 standard required to have business continuity management process implemented to minimize the
impact on the organization and recover from loss of data. Also, it is required to ensure authenticity and
protecting message integrity. In the research, backup servers are online 24x7 to enable the resource
availability. The Map Reduce Framework allows compression to happen quickly and concurrently. These
implementations allow us to have reliable and efficient data transfer and be able to monitor data replication
activities at all times.
CONCLUSION
The onsite and multi-site copying with concurrent data validation in application, database and file system will
enable us to counteract interruptions to business activities and to protect critical business processes from the
effects of major failures of information systems and to ensure the timely resumption. This will fulfill ISO27001
requirements-BCP.
INE016-b
Moving Towards Big Data Analytics in Radiation Therapy: Dynamic Decision Support through Data
Mining (custom application computer demonstration)
Ruchi Deshpande MS (Presenter): Nothing to Disclose , John J. Demarco PhD : Nothing to Disclose ,
Brent Julius Liu PhD : Nothing to Disclose
Background
We have developed a decision support system for Radiation Therapy that utilizes a comprehensive DICOM RT
specific database of retrospective treatment planning data to perform data mining. These data mining results
may corroborate a clinician's radiation therapy treatment plan, thus increasing confidence or they may highlight
potential ways to improve the treatment plan by lowering dose to sensitive organs surrounding the tumor.
Since the success of such systems depends heavily on the size and composition of the training database, we
have also developed an infrastructure to facilitate data collection for cloud-based research collaborations.
Evaluation
The infrastructure and decision support algorithm have both been tested and evaluated with 51 sets of
retrospective treatment planning data of head and neck cancer patients. An expert has tested and validated the
integrity of our client-side JavaScript DICOM parser and anonymizer. An expert has also verified HIPAA
compliance of our data collection mechanism.
Discussion
An efficient data collection mechanism is essential to ensure a constantly growing and self-updating big data
repository for good system performance. DICOM compatibility ensures vendor neutrality, and a
HIPAA-compliant data sharing protocol encourages research participation. This provides the potential for a
large-scale cancer registry containing vital anatomical, dosimetric and treatment planning information, which is
harnessed by a data mining decision support algorithm in a cloud-based environment. The cloud-based
infrastructure promotes big data analytics in the field of Radiation Oncology, by paving the way for building
data warehouses, dealing with HIPAA regulations and providing a platform for testing data mining algorithms.
CONCLUSION
We will present an infrastructure for facilitating large-scale collection of radiation therapy treatment planning
data, and demonstrate the benefits of a data mining decision support algorithm that utilizes this infrastructure.
The various components of the system, including a client-side DICOM parser, a HIPAA-compliant data sharing
protocol, a cloud-based data mining and analytics engine, and a DICOM specific database will be presented.
MIS-MOA
Molecular Imaging Monday Poster Discussions
Scientific Posters
MI
AMA PRA Category 1 Credits ™: .50
Mon, Dec 1 12:15 PM - 12:45 PM
Participants
Location: S503AB
Moderator
Heike E. Daldrup-Link MD : Nothing to Disclose
Moderator
Matthias Johannes Eiber MD : Speaker, Siemens AG Speaker, Astellas Group Speaker, Johnson & Johnson
Sub-Events
MIS123
Sentinel Lymph Node Localisation in Melanoma Using a Novel Magnetic Tracer for Magnetic
Resonance Imaging (Station #7)
Bauke Anninga (Presenter): Nothing to Disclose , Samantha White : Nothing to Disclose , Paul Malcolm
MRCP, FRCR : Speaker, General Electric Company , Joost Klaase : Nothing to Disclose , Bennie ten Haken
PhD : Nothing to Disclose , Suzan Vreemann : Nothing to Disclose , Roland Bezooijen MD : Nothing to
Disclose , Marc Moncrieff : Nothing to Disclose , Margaret Anne Hall-Craggs MD : Nothing to Disclose ,
Michael Douek MD : Nothing to Disclose
PURPOSE
Sentinel lymph node biopsy (SLNB) in melanoma is currently performed using radioisotope and blue dye
injections. We recently developed a novel magnetic technique for SLNB using a superparamagnetic iron-oxide
(SPIO) tracer and a hand-held magnetometer for sentinel lymph node (SLN) localisation. The aim of this study
was to assess the ability of magnetic resonance imaging (MRI) to identify lymphatic tracts and the SLN
pre-operatively in patients with extremity melanoma, following administration of an SPIO tracer.
METHOD AND MATERIALS
Patients with primary cutaneous melanoma scheduled for SLNB, and clinically AJCC stages IB-IIC, were
recruited into the MRI sub-protocol of the MELAMAG Trial. SLN localisation was performed after administration
of radioisotope (99mTc) and SPIO tracer (Sienna+, Endomagnetics Ltd.) with lymphoscintigraphy and MRI,
respectively. For MRI localisation, pre-injection T1-weighted and T2-weighted (T2W) turbo-spin echo scans were
followed by an intradermal injection of magnetic tracer and local massage at the injection site. T2W scans were
repeated 15 minutes post-injection. Intra-operatively the magnetometer (SentiMag, Endomagnetics Ltd.) was
used to localise the SLN(s), followed by the gamma probe and blue dye. Pre-operative lymphoscintigraphy was
compared to pre-operative MRI by two independent radiologists.
RESULTS
Five patients with extremity melanoma (4 lower, 1 upper) were recruited. In all cases MRI+SPIO tracer
identified the same number and sites of lymphatic drainage compared to lymphoscintigraphy. In 4 cases MRI
and lymphoscintigraphy showed identical numbers of lymphatic channels. In 3 cases the total number of SLNs
identified was the same for both imaging modalities.
CONCLUSION
SLN localisation with MRI in melanoma using a novel magnetic tracer is feasible. Pre-operative localisation
correlates well with intra-operative findings. Additional evaluation is needed in larger and more challenging
(including head, neck and truncal primary melanoma) cohorts of patients.
CLINICAL RELEVANCE/APPLICATION
This novel approach of MRI with an SPIO tracer can provide high resolution, pre-operative SLN localisation
without the use of radiation.
MIS124
A Pocket Phantom and Method for Per-patient Quantitative Calibration of PET/CT Scans [ MI
Scavenger Hunt! ] (Station #8)
Paul Eugene Kinahan PhD (Presenter): Research Grant, General Electric Company Co-founder, PET/X LLC ,
Darrin W Byrd MS : Nothing to Disclose , Brian Helba : Employee, Kitware, Inc , Xiaoxiao Liu PhD :
Employee, Kitware, Inc , Joshua Levy : Stockholder, The Phantom Laboratory President, The Phantom
Laboratory Stockholder, Image Owl, Inc , Keith Allberg : Employee, RadQual, LLC , Ricardo Avila MS :
Employee, Kitware, Inc Shareholder, Kitware, Inc Consultant, F. Hoffmann-La Roche Ltd
PURPOSE
In clinical trials and clinical practice, standardized uptake values (SUVs) from PET images can be used to assess
response to therapy. However, PET images are subject to bias from scanner calibration and resolution effects.
PET calibration phantoms can be used, however, resolution loss causes bias for objects smaller than 3-4 cm,
limiting feasibility. We present a method that compensates for these quantitative errors on a per-patient and
per-scan basis.
METHOD AND MATERIALS
We constructed a small rectangular PET/CT 'pocket' phantom containing a linear array of three long-lived
68Ge/68Ga sources, each 1.5 cm in diameter with a NIST traceable activity concentration. This was coupled
with an image-based estimation process that retrospectively decoupled bias effects from scanner calibration
and resolution effects. The pocket phantom was imaged alongside a series of phantoms representing different
levels of complexity of PET imaging. Different levels of calibration bias and image smoothing were introduced.
Using the reconstructed image and known sphere geometries and locations, an ideal image was created that
had no blurring and no bias. The analysis software then estimated the bias and applied a blurring kernel G(σx,
σy, σz) to create a model image. By iteratively minimizing the differences between the PET image and the
model image, the algorithm estimated the resolution, defined as the full width at half maximum of G, and the
overall bias in the PET image for each combination of measurement partners for the three spheres.
RESULTS
In the reconstructed PET images with artificially introduced different levels of bias and image smoothing, the
combination of the pocket phantom and the estimation algorithm successfully decoupled the effects of bias and
resolution to within 6% residual bias.
CONCLUSION
It is possible to simultaneously estimate the global bias and resolution of reconstructed images with a small
long-lived phantom with sources smaller than the PET resolution limit of roughly 3 cm.
CLINICAL RELEVANCE/APPLICATION
The use of a small phantom, when coupled with appropriate estimation algorithms, can provide a per-patient
and per-scan method for absolute calibration of PET image data. Per scan phantom use and calibration has the
potential to improve the effectiveness of clinical trials and clinical practice.
MIS125
Characterization of Glycolytic Activity and Perfusion in a Renal Cell Carcinoma Mouse Model during
Sunitinib Response and Resistance with Hyperpolarized 13-C-pyruvate MRI (Station #9)
Leo Lee Tsai MD, PhD (Presenter): Co-founder, Agile Devices Inc Stockholder, Agile Devices Inc Research
Consultant, Agile Devices Inc , Xiaoen Wang MD : Nothing to Disclose , Gopal Varma PhD : Nothing to
Disclose , Rupal Bhatt : Nothing to Disclose , David C. Alsop PhD : Research support, General Electric
Company Royalties, General Electric Company , Aaron Keith Grant PhD : Nothing to Disclose
PURPOSE
Renal cell carcinomas (RCC) demonstrate high rates of glycolysis, associated with high expression of the glucose
transporter GLUT1, which is in turn regulated by hypoxia-induced factors (HIF). Here we use hyperpolarized
13-C pyruvate (h13C-pyruvate) to provide in vivo monitoring of glycolysis and perfusion in a renal cell
carcinoma (RCC) xenograft mouse model treated with sunitinib, and to correlate with GLUT1 and CD34
expression.
METHOD AND MATERIALS
Four mice were implanted with A498 VHL-deficient RCC. Two were treated with sunitinib, and two controls were
administered phosphate-buffered saline (PBS). One sunitinib-treated mice was imaged 7 days after treatment
initiation, the other 32-days post-treatment, at resistance. Control mice were imaged pre-PBS and 6-7 days
following PBS. Tumors were harvested after final images for immunohistological analysis. MRI was performed at
9.4 T using: (1) Proton-T2-weighed rapid acquisition with refocused echoes (RARE) sequence for anatomical
localization, (2) h13C-pyruvate imaging with echo-planar spectroscopic imaging (EPSI), and (3)
arterial-spin-label (ASL) perfusion mapping with flow-sensitive inversion-recovery.
RESULTS
Control tumors treated with PBS show high uptake of C13-pyruvate and conversion into lactate (Figure 1aproton image, 1b- lactate image overlay). Sunitnib-treated tumor at 7d demonstrated decreased perfusion on
ASL corresponding to decreased C13-pyruvate uptake, and altered lactate levels at both response and
resistance. High GLUT1 expression was sustained during growth, treatment, and at resistance, while CD-34
expression was reduced during sunitinib response, and restored at resistance, as demonstrated in Figures 2a-2c
(GLUT1-red, CD34-green, Hoechst nuclei staining-blue).
CONCLUSION
Glycolytic metabolism is altered during RCC response to sunitinib and subsequent resistance, though overall
activity is sustained, as demonstrated by persistent GLUT1 expression. C13-pyruvate uptake correlates with
perfusion as measured by ASL and CD34 expression.
CLINICAL RELEVANCE/APPLICATION
h13C-pyruvate MRI provides vivo assessment of glycolytic activity and perfusion within an RCC model,
correlating to treatment response and resistance. This method has translational potential for clinical tumor
monitoring in patients.
MIE107
Imaging of Drugs in the Brain Following Intranasal Delivery (Station #10)
Michael C. Veronesi MD, PhD (Presenter): Nothing to Disclose , Shih-Hsun Cheng PhD : Nothing to Disclose
, Hsiu-Ming Tsai PhD : Nothing to Disclose , Hannah J. Zhang PhD : Nothing to Disclose , Marta A. Zamora
BS : Nothing to Disclose , James Vosicky : Nothing to Disclose , Devkumar Mustafi PhD : Nothing to
Disclose , Xiaobing Fan PhD : Nothing to Disclose , Leuwei Lo PhD : Nothing to Disclose , Chin-Tu Chen
PhD : Stockholder, EVO Worldwide Stockholder, Medical Simulation Corporation Stockholder, EDDA
Technology, Inc Stockholder, EnDepth Vision Systems, LLC Research Consultant, DxRay, Inc Advisor, RefleXion
Medical Inc , Michael Walter Vannier MD : Nothing to Disclose
TEACHING POINTS
Intranasal (IN) drug administration provides a promising alternative to systemic administration since a direct
anatomic pathway exists between the olfactory neuroepithelium of the nasal cavity and the brain. Several drugs
have already been approved for IN application (e.g., oxytocin in autism), and others may be approved in the
near future. Since little is known about the spatial and temporal characteristics of IN drug delivery, a method of
localizing their presence in the brain of a living animal is needed. 1. Nanotheranostics, the combination of
diagnostic and therapeutic function in a single system through nanotechnology, has the potential to improve
drug administration in the central nervous system. 2. MRI and CT-PET are becoming key tools in
nanotheranostics since they can help determine the fate of nanoparticles containing drugs in the brain. 3. A
major advantage of in vivo imaging in experimental IN delivery is its noninvasive nature and potential
repeatability without the need for sacrificing animals. Thus, this imaging technology can be more easily
translatated to humans.
TABLE OF CONTENTS/OUTLINE
1. Nanotheranostics. 3. What's in a nanoparticle? 4. The nose to brain route. 4. CT-PET, MRI and their
application to small animal drug delivery. 5. From benchtop to the bedside. 6. The future of nanotheranostics.
MIE004-b
Clinical Relevance of Emerging Molecular Imaging Modalities in Prostate Cancer (custom application
computer demonstration)
Nii O. Koney MD, MBA : Nothing to Disclose , Yi Chen Zhang MD (Presenter): Nothing to Disclose , Elina
Zaretsky MD, MA : Nothing to Disclose , Munir Ghesani MD : Nothing to Disclose , E. Gordon Depuey MD
: Consultant, BioClinica, Inc Consultant, ICON plc Steering Committee, Adenosine Therapeutics, LLC ,
Alexander Cates Kagen MD : Speakers Bureau, Bayer AG
TEACHING POINTS
There is controversy over the utility of PSA as a screening tool because of its inability to differentiate indolent
from aggressive cancer types. Molecular imaging is well positioned to address this challenge. Although the
current workhorse for molecular imaging, 18F-FDG, is not effective in prostate cancer, several new agents have
been/are being developed. For example, 11C- or 18F-labeled choline are emerging tracers for detecting local
and metastatic prostate cancer. We will review the latest advances in the use of molecular imaging to screen
and diagnose prostate cancer. We will evaluate the perceived clinical relevance of current and emerging tracers
using preliminary results from a survey of practicing referring clinicians at our institution that show awareness
of molecular imaging and need to demonstrate superiority over conventional imaging as a guide
TABLE OF CONTENTS/OUTLINE
Introduction and Background on Molecular Imaging in Prostate Cancer Review of current and emerging prostate
cancer imaging tracers Review of imaging protocol: patient selection, patient preparation, radiopharmaceutical
preparation Evaluation of clinical relevance utilizing preliminary results from a survey of practicing referring
clinicians
MKS-MOA
Musculoskeletal Monday Poster Discussions
Scientific Posters
MK
AMA PRA Category 1 Credits ™: .50
Mon, Dec 1 12:15 PM - 12:45 PM
Location: MK Community, Learning Center
Participants
Moderator
Soterios Gyftopoulos MD : Nothing to Disclose
Sub-Events
MKS351
Long Head of Biceps Tendon (LHBT) Instability Due to Biceps Pulley Lesion of the Shoulder:
Arthro-MRI including “Functional” Images vs Arthroscopy (Station #1)
Silvia Mariani MD (Presenter): Nothing to Disclose , Alice La Marra MD : Nothing to Disclose , Emanuele
Costantini MD : Nothing to Disclose , Francesco Arrigoni : Nothing to Disclose , Antonio Barile MD :
Nothing to Disclose , Carlo Masciocchi MD : Nothing to Disclose
PURPOSE
To evaluate the added value of the internal and external rotation and abduction and external rotation (ABER)
images during arthro-MRI in identifying the LHBT instability and the possible development of an antero-superior
impingement (ASI).
METHOD AND MATERIALS
We retrospectively analyzed MRI exam of 70 patients who underwent arthro-MRI (1.5T) and arthroscopy within
the following 7-45 days. Patients had clinical suspicion of biceps pulley lesions. The shoulder was studied (with
dedicated coil) in neutral position, in internal and external rotation and ABER position in all patients.
RESULTS
Patients were divided in 4 groups (Habermayer classification) and evaluated for an unstable LHBT:10 patients
had superior gleno-humeral ligament (SGHL) tear (Type I),16 patients SGHL and supraspinatus (SSP) tendon
tears (Type II),21 patients SGHL and subscapularis (SSC) tendon tears (Type III) and 23 patients SGHL, SSP
and SSC tears (Type IV). At arthroscopy 2 patients were negative,8 patients had Type I,16 patients Type II,19
patients Type III and 25 patients Type IV lesions. MRI internal and external rotation showed an initial
anteromedial subluxation of the LHBT in 8 patients with Type II lesion and an anteromedial subluxation of the
LHBT in all patients with Type III and Type IV lesions. ABER position showed gleno-humeral antero-superior
malalignment in 14 cases. The dynamic tests during arthroscopy, confirmed LHBT instability and ASI features
in patients with Type III and Type IV lesions and antero-superior malalignment only in 9 cases.
CONCLUSION
Only high grade lesions of the biceps pulley can be associated with LHBT instability and antero-superior
gleno-humeral malalignment. MRI external and internal rotation led to a better identification of structures of the
biceps pulley and the detection of LHBT instability could suggest the presence of ASI.
CLINICAL RELEVANCE/APPLICATION
"Functional" MRI images allow a dynamic evaluation of the LHBT and of the antero-superiror aspect of the
gleno-humeral joint; these structures often result unstable in presence of an ASI type III and type IV confirmed
by arthroscopic dynamic tests.
MKS352
Delaminated Tears of the Rotator Cuff: Prevalence, Characteristics and Diagnostic Accuracy on
Indirect MR Arthrograph (Station #2)
Hye Jung Choo MD : Nothing to Disclose , Gi Won Shin MD (Presenter): Nothing to Disclose , Sun Joo
Lee MD : Nothing to Disclose , Young Mi Park MD, PhD : Nothing to Disclose , Young Jun Cho : Nothing
to Disclose , Seok Jin Choi : Nothing to Disclose
PURPOSE
The presence of delaminated tears of the rotator cuffs has been reported as a negative prognostic factor after
rotator cuff repairs. However, there are a few radiologic reports about delaminated tears of the rotator cuff. In
this study, the prevalence, characteristics, and diagnostic accuracy of delaminated tears at the
supraspinatus-infraspinatus tendons (SST-IST) were evaluated on indirect MR arthrography.
METHOD AND MATERIALS
Indirect MR arthrography of 231 shoulders with tears at the SST-IST were included. On MR images, the
delaminated tears at the SST-IST, defined as an intratendinous horizontal splitting between the articular and
bursal layers of the SST-IST and/or different degree of retraction between the two layers, were identified and
classified into six types: articular-delaminated full-thickness tear, bursal-delaminated full-thickness tear,
interstitial-delaminated full-thickness tear, articular-delaminated partial-thickness tear, bursal-delaminated
partial-thickness tear and interstitial-delaminated partial-thickness tear. Other radiologic findings such as the
presence of intramuscular cysts and footprint tears were evaluated. Based on the review of video records of 127
arthroscopic surgeries, the diagnostic accuracy of indirect MR imaging for the detection of the delaminated tears
was determined.
RESULTS
On MR imaging, 56% (129/231) of shoulders with SST-IST tears had delaminated tears. Articular-delaminated
full-thickness tears (n = 58) and articular-delaminated partial-thickness tears (n = 64) were the most common
types. About 82% (36/44) of articular-delaminated full-thickness tears occurring at the SST were combined
with articular-delaminated partial-thickness tears at the IST. SST-IST footprint tears and intramuscular cysts
were significantly more common in the shoulders with delaminated tears ( p = 0.007 and 0.01 respectively).
The sensitivity and specificity of indirect MR arthrography for detection of delaminated tears were 93% and
95%, respectively.
CONCLUSION
On MR imaging, about half of the shoulders with SST-IST tears were combined with delaminated tears. The
diagnostic accuracy of indirect MR arthrography for detection of delaminated tears was high.
CLINICAL RELEVANCE/APPLICATION
On MR imaging, about half of the shoulders with SST-IST tears were combined with delaminated tears. The
diagnostic accuracy of indirect MR arthrography for detection of delaminated tears was high.
MKS353
Serial Ultrasonography after Arthroscopic Repair of Rotator Cuff Tear: Temporal Evolution of
Sonographic Findings (Station #3)
Hye Jin Yoo MD (Presenter): Nothing to Disclose , Ja-Young Choi MD : Nothing to Disclose , Sung Hwan
Hong MD : Nothing to Disclose , Yusuhn Kang MD : Nothing to Disclose , Jina Park MD : Nothing to
Disclose , Ji Young Kim MD : Nothing to Disclose
PURPOSE
To evaluate the serial changes in the sonographic findings of repaired tendon after rotator cuff repair with serial
ultrasound examinations
METHOD AND MATERIALS
Sixty five arthroscopically repaired rotator cuff tears (44 full-thickness tears, 21 partial-thickness tears) were
retrospectively included in this study. Serial ultrasound examinations were performed at 5 weeks, 3 months,
and 6 months after surgery. Sonographic findings of the repaired tendon were assessed in terms of presence of
and 6 months after surgery. Sonographic findings of the repaired tendon were assessed in terms of presence of
retear, tendon thickness, morphologic tendon characteristics, and vascularity, bursitis at each time point.
RESULTS
Four recurrent tears were occurred within 3 months of surgery. Postoperative tendon thickness decreased from
5 weeks to 6 months following surgery (r=-0.245; p=0.001). There were significant changes in the morphologic
tendon characteristics including echotexture, fibrillar pattern, and surface irregularity of repaired tendon from 5
weeks to 6 months following surgery. The subacromial subdeltoid(SDAD) bursitis and vascularity of repaired
tendon were also decreased postoperatively over time.
CONCLUSION
Serial ultrasound examinations after arthroscopic rotator cuff repair were useful to monitor the postoperative
changes of repaired tendon. Morphologic appearances of repaired tendon and peritendinous soft tissue changes
were improved over time and nearly normalized within 6 months of surgery.
CLINICAL RELEVANCE/APPLICATION
Serial ultrasound examinations can monitor the postoperative changes of repaired tendon and is recommended
as a follow-up imaging modality in the early postoperative period after arthroscopic rotator cuff repair
MKS354
Ultra-high Field Analysis of Knee Cartilage in a Sheep Model by Means of Quantitative T2 Mapping
Using 7T MRI and Histological Validation (Station #4)
Milena L. Pachowsky MD (Presenter): Nothing to Disclose , Siegfried Trattnig MD : Nothing to Disclose ,
Kolja Gelse MD : Nothing to Disclose , Joachim Friske : Nothing to Disclose , Martin Brix : Nothing to
Disclose , Goetz Hannes Welsch MD : Nothing to Disclose
PURPOSE
T2 mapping at 7T might help to understand the development of osteoarthritis (OA) and of integration processes
after cartilage repair procedures, i.e. autologous chondrocyte transplantation (ACT). Purpose of this study is to
determine biochemical properties of cartilage in a sheep model, using biochemical MRI by means of quantitative
T2-mapping and establish a histological validation.
METHOD AND MATERIALS
Three groups of sheep (healthy cartilage, n=30, a model of osteoarthritis (post meniscectomy), n=30, and
sheep with cartilage defects at the femoral condyle treated by ACT, n=15) were examined. MR scans were
achieved at 7T MR whole body system (Magnetom, Siemens Healthcare, Erlanen, Germany) using a 28-channel
transmit/receive knee array coil. T2 relaxation maps were measured by a sagittal multi-echo spin sequence. TR
5260ms; TE 12, 24, 36, 48, 60, and 72ms; FOV 145x145mm, 716x869 matrix size; BW 180 Hz/pixel, slice
thickness 2mm; flip angle 145°. Semi-automatic region-of-interest analysis was performed. For stratification
with regards to anatomical (collagen) structure, subregional analysis was done (deep - superficial cartilage
layer). Results were compared to histological findings. Statistical analysis-of-variance was performed.
RESULTS
In healthy cartilage, T2 values averaged 41,92ms (SD 11,7) in the superficial layer and 32,69ms (SD 9,74) in
the deep layer. OA showed results of 60,90ms (SD 14,34) in the superficial layer and 47,28ms (SD 13,54) in
the deep layer. After ACT results averaged at 58,41ms (SD 15,53) in the superficial and 45,66 (SD 20,81) in
the deep layer. Increase of T2 values between deep and superficial zone was highly significant in the group with
healthy cartilage, significant in the OA model and the ACT group. OA and ACT group showed significantly higher
values compared to healthy cartilage. Comparison between histological scoring and MR findings showed a
significant correlation.
CONCLUSION
The sheep model shows differences between healthy cartilage, OA and cartilage repair sites in T2 mapping. Our
new approach at 7T gives additional information about the imaging techniques of the ultra-structure of cartilage
and provides one of the very few histological validations of T2 mapping in vitro.
CLINICAL RELEVANCE/APPLICATION
The presented study of T2 mapping in a sheep model and histological validation is an important approach
towards establishing T2 mapping of articular cartilage in clinical appplication.
MKS355
Diffusion Tensor Imaging, T2 Mapping, and Various Fat Suppression Imaging in Early State of
Denervated Skeletal Muscle: Experimental Study in Rats (Station #5)
Dong-Ho Ha (Presenter): Nothing to Disclose , Hwan Tae
PhD : Nothing to Disclose
Park : Nothing to Disclose , Sunseob
Choi MD,
PURPOSE
To simultaneously evaluate the sequential alteration of the DTI indices, T2 values and subjective visual signal
intensity change on various fat suppression techniques in the early state of denervated skeletal muscle in the
rat model.
METHOD AND MATERIALS
Institutional animal use and care committee approval was obtained. Complete neurotmesis of the sciatic nerve
of 8 white rats was performed. We examined MR studies of the normal muscle and follow-up studies at 3 days,
1 week, and 2 weeks after surgery. FA, mADC and T2 values ware measured at the calf muscles. We also
subjectively graded visual signal intensity change on CHESS, STIR and IDEAL imaging. Statistical significances
were obtained.
RESULTS
FA values at 3 days (0.35±0.06, P=0.012), 1 week (0.29±0.04, P=0.017), 2 weeks (0.34±0.05, P=0.017)
were significantly lower than that in control group (0.54±0.17). The mADC of the all follow up periods
decreased, but statistically insignificant. T2 values began to increase at three days without statistical
significance (34.08±1.42, P=0.069), significantly increased at 2 weeks (38.11±6.41, P=0.017) and marked
increased at 2 weeks (46.53±5.17, P=0.012), compared with control group (32.71±1.33). Visual signal
intensity changes were variously at 1 week and more prominent at 2 weeks. Grading the lesions was identical in
all cases.
CONCLUSION
FA and T2 values will be effective parameters to observe the early state of denervated skeletal muscle.
CLINICAL RELEVANCE/APPLICATION
The calculation of FA and T2 value wiil be effective noninvasive methods for the evaluation of acute skeletal
deneravated muscle, even though it has various limitations. Fat suppression techniques did not affect the early
detection of high signal abnormality on T2 weighted image and grading of lesion.
MKS356
Tarsal Navicular Bone Size in Diabetics: Radiographic Assessment (Station #6)
Elie Harmouche (Presenter): Nothing to Disclose , Douglas D. Robertson MD, PhD : Nothing to Disclose ,
Geza Kogler PhD, DPhil : Nothing to Disclose , Minzhi Xing MD : Nothing to Disclose , Tharwat Mahmoud
El Zahran MD : Nothing to Disclose , Michael R. Terk MD : Nothing to Disclose
PURPOSE
To test the anecdotal observation that isolated navicular collapse is associated with diabetes mellitus, we
quantified the size of the tarsal navicular in subjects with and without diabetes and tested for association of size
with age, height, weight, body mass index (BMI), gender, smoking, bone mineral density (BMD), duration and
level of control of diabetes.
METHOD AND MATERIALS
Ankle radiographs of 200 patients (122 females; 78 males; mean age 58 years [27-89]), 100 with type II
diabetes and 100 age-gender matched controls were selected and reviewed. The anteroposterior (AP)
dimension of the mid navicular bone was measured from lateral radiographs. For standardization, the
superoinferior (SI) dimension of the calcaneal was measured and the navicular-calcaneus ratio calculated.
Statistical evaluation included independent sample t- tests and linear regression analyses.
RESULTS
Diabetic subjects had a significantly smaller navicular AP dimension and navicular-calcaneus ratio compared to
controls (p=0.02 and p=0.0001, respectively). Age, gender, height and duration of diabetes had no association
with the navicular-calcaneus ratio. Navicular-calcaneus ratio was inversely correlated with weight (p=0.01) and
BMI (p<0.001) and directly correlated with smoking (p=0.04).
CONCLUSION
The navicular anteroposterior dimension is smaller in type II diabetic subjects compared to age-gender
matched controls. We hypothesize that this is due to navicular collapse whose cause is multifactorial.
CLINICAL RELEVANCE/APPLICATION
This study associates diabetes with dimensional changes in the tarsal navicular and expands our knowledge of
the effect diabetes on the bony foot.
MKS357
Evaluation of a Simplified Version of the Rheumatoid Arthritis Magnetic Resonance Imaging Score
(RAMRIS) Comprising 5 Joints (RAMRIS5) (Station #7)
Christoph Schleich (Presenter): Nothing to Disclose , Falk Roland Miese MD : Nothing to Disclose , Philipp
Sewerin : Nothing to Disclose , Benedikt Ostendorf : Nothing to Disclose , Gerald Antoch MD : Speaker,
Siemens Medical AG Speaker, Bayer AG Speaker, BTG International Ltd , Christian Buchbender : Nothing to
Disclose
PURPOSE
Semi-quantitative measurement of inflammatory pathologies of the hand in magnetic resonance images (MRI)
is a mandatory, but time-consuming task for MRI controlled studies in Rheumatoid Arthritis (RA). The objective
of this study was to evaluate a simplified version of the Rheumatoid Arthritis Magnetic Resonance Imaging Score
of this study was to evaluate a simplified version of the Rheumatoid Arthritis Magnetic Resonance Imaging Score
(RAMRIS) reduced to five joints of the hand (RAMRIS5).
METHOD AND MATERIALS
94 patients with rheumatoid arthritis (62 female, 32 male; age 59 ±12 years, range 25 - 83 years; disease
duration 5 ±7.5 years) from the REMISSION PLUS study cohort who had complete files on C-reactive protein
(CRP) levels and Disease Activity Score of 28 joints (DAS28) and completed MRI of the clinical dominant hand
at baseline and after one year under anti-rheumatic therapy (follow-up time 12.5 ± 3.5 months) in a dedicated
extremity MRI scanner at 0.2T were included in this retrospective study. MR images were scored according the
RAMRIS criteria by two readers in consensus. Spearman correlations of the RAMRIS sum-score, subscores for
RAMRIS of the metacarpophalangeal joints (RAMRISMCP), wrist (RAMRISWrist) and a reduced score comprising
the MCP 2 - 5 and the intercarpal joint were assessed. Additionally, Spearman correlations of MRI scores, CRP
levels and DAS28 were calculated.
RESULTS
There was a strong correlation between RAMRIS5 and the RAMRIS sum-score for all patients (r =0.88, p<0.05)
at baseline and follow up (r =0.83, p< 0.05). Among the subscores there was a good correlation between
RAMRIS5 and RAMRISMCP (baseline: r=0.64, p<0.05; follow-up: r=0.74, p< 0.05) as well as between
RAMRIS5 and RAMRISwrist (baseline: r=0.75, p< 0.05, follow-up: r = 0.63, p<0.05) at baseline and follow up.
The correlation between RAMRIS5 and CRP (baseline: r=0.13, p<0.05; follow-up: r=0.03, p<0.05) or DAS28
(baseline: r=0.15, p<0.05; follow-up: 0.30, p<0.05) were weak, just like it was observed for regular RAMRIS
(CRP baseline: r=0.18, p<0.05; follow-up: r=0.11, p<0.05; DAS28 baseline: r=0.21, p<0.05; follow-up:
r=0.33, p< 0.05).
CONCLUSION
RAMRIS5, a modified shorter RAMRIS score based on five joints of the hand is a viable tool for
semi-quantitative assessment and monitoring of joint damage in RA.
CLINICAL RELEVANCE/APPLICATION
RAMRIS5 can be used as a time and resource saving alternative for semi-quantitative description of
inflammatory joint changes and therapy monitoring in MRI-controlled studies in RA and for clinical therapy
response assessment in RA .
MKE230
What’s In a Name? Review of Specialized Radiographic Views and Stress Radiography for
Musculoskeletal Trauma (Station #8)
Chris R. Smith MD (Presenter): Nothing to Disclose , Robert J. Talbert MD : Nothing to Disclose , Sanjeev
Bhalla MD : Nothing to Disclose , Michael V. Friedman MD : Nothing to Disclose , Travis J. Hillen MD :
Consultant, Biomedical Systems Consultant, Vidacare Corporation , Jonathan Craig Baker MD : Research
Consultant, Biomedical Systems
TEACHING POINTS
The standard radiographic series is not always sufficient to diagnose and characterize subtle musculoskeletal
injuries. Specialized views and stress radiography help to detect and delineate subtle fractures, ligament
injuries, and joint abnormalities. Radiologists should be familiar with these important but less common
examinations, which yield valuable supplemental information that affects treatment decisions. Teaching Points:
Review the limitations of the standard musculoskeletal radiographic examination and frequently missed injuries.
Review important supplemental views, many of which are known by eponyms, and stress radiographic
examinations. Review proper positioning and technique for each view, including important landmarks
radiologists can use to assess the quality of the study. Understand key anatomy through 3D surface-rendered
CT images. Review the additional clinical information each specialized study provides over the standard
radiographic series through illustrative cases.
TABLE OF CONTENTS/OUTLINE
Review of commonly missed injuries
Specialized radiographic views and stress radiography
When to use each view
Patient positioning and technique
3D surface-rendered CT images of anatomic landmarks
Cases illustrating clinical utiility of each specialized study
Summary
MKE304
Ultrasound-guided Gadolinium Joint Injections for Magnetic Resonance Arthrography: A
Step-by-Step Approach (Station #9)
Kimberly Ruth Gardner MD (Presenter): Nothing to Disclose , Brian
Hsiu Su MD : Nothing to Disclose
TEACHING POINTS
At the conclusion of this presentation, the learner should be able to:
Manfredi MD : Nothing to Disclose ,
1. Recognize the advantages of ultrasound-guided over landmark-based or fluoroscopically-guided approaches
to joint injection with gadolinium prior to arthrography.
2. Gain knowledge of pre-procedural considerations and contraindications.
3. Become familiar with the step-by-step procedure for ultrasound-guided gadolinium shoulder, elbow, wrist,
hip and knee injections prior to magnetic resonance arthrography, including technical factors such as ultrasound
probe selection and imaging parameters.
TABLE OF CONTENTS/OUTLINE
1. Introduction: The Increasing Role of Sonography in Musculoskeletal Diagnostics and Therapeutics 2.
Advantages of Ultrasound-guided over Landmark-based or Fluoroscopically-guided Approaches 3.
Pre-Procedural Considerations a) Clinical History b) Prior Imaging c) Current Medications and Allergies d)
Contraindications 4. Technical Factors a) Probe Selection b) Imaging Parameters 5. Injection Preparation 6.
Step-by-Step Procedure for Ultrasound-guided Hip, Knee, Shoulder, Elbow and Wrist Injections a) Patient
Position b) Needle Approach c) Joint Space Injection under Direct Sonographic Visualization 7. Post-Procedure
Considerations/Complications including suboptimal gadolinium injection
MKE128
MSK Imaging: Manifestations of Granulomatous Disease (Station #10)
Mariko Fitzgibbons MD (Presenter): Nothing to Disclose , Kira
Masih MD : Nothing to Disclose
Chow MD : Nothing to Disclose , Sulabha
TEACHING POINTS
1) Review the immunologic basis of granulomas 2) Review of the pathogens and immune processes leading to
granuloma formation 3) Case-based review of musculoskeletal manifestations of granulomatous disease such as
sarcoidosis, tuberculosis, coccidioidomycosis, and epidermal inclusion cysts.
TABLE OF CONTENTS/OUTLINE
Discussion will begin with the definition of a granuloma and a discussion of the types of granulomatous disase.
This will be a case based presentation of various MSK granulomatous process. Imaging modalities: XR, US,
PET/CT, CT, MRI 1) Sarcoidosis Bone marrow, soft tissue changes 2) Atypical Mycobacterial Septic arthritis 3)
Tuberulosis Various manifestations including: Dactylitis, osteomyelitis, Pott's disease, soft tissue infections 4)
Coccidioidomycosis Septic arthritis, lytic lesions 5) Epidermal inclusion cyst
MKE313
Dermatofibrosarcoma Protuberans, A Rare Skin Lession That Radiologists Should Think about
(Station #11)
Claudia Leticia Hernandez Mejia (Presenter): Nothing to Disclose , JESUS JIMENEZ DEL RIO : Nothing to
Disclose , Maria Isabel Fernandez Martinez : Nothing to Disclose , Angeles Ramirez Escobar : Nothing to
Disclose , MARIA SANCHEZ PEREZ : Nothing to Disclose , Johanna Marisol Silva MD : Nothing to Disclose
TEACHING POINTS
To review the dermatofibrosarcoma protuberance tumor and discuss its key radiological findings. To explain the
role of radiology in the follow-up and gain awareness of skin lesions found in different imaging techniques.
TABLE OF CONTENTS/OUTLINE
When we come across a soft tissue mass identifying its origins (epidermis, dermis or hypodermis) can be of
help. Also we have to consider the location within the body and the age of the patient in order to narrow down
the differential diagnosis. Dermatofibrosarcoma protuberance (DFSP) is the most common mesenchymal
superficial malignancy. It originates from the dermis. The peak age is between 20 and 40 years old. It affects
more frequently men than woman (not in our series) and is most commonly seen on the trunk. It can recur and
rarely metastasizes. We will show its key feature image on MR, CT and ultrasonography with a series obtained
at our institution. We reviewed 40 cases from January 1998 until mars 2014. We found 20 males and 20
females (mean age 44 years, age range 22 to 71 years). Only 1 recurrence has been reported (9 years after
the original lesion). It is important to have free margins after resections otherwise a recurrence could happen
and long term follow up is needed. That is why we need to understand post treatment imaging changes and
differentiate it from local recurrence.
MKE286
Maneuvering Around Metal: Total Joint Arthroplasy Imaging and MR Metal Suppression Sequences
(Station #12)
Brett S. Talbot MD (Presenter): Nothing to Disclose , Eric P. Weinberg MD : Nothing to Disclose
TEACHING POINTS
The purpose of this educational exhibit is to:
1) Provide an overview of current metal suppression sequences, including a discussion of key concepts in the
associated MR physics.
2) Demonstrate an extensive series of cases where metal suppression plays a key role in the diagnosis of total
arthroplasty complications.
3) Place emphasis on specific findings in total knee and total hip arthroplasty on metal-suppressed MR imaging.
TABLE OF CONTENTS/OUTLINE
-Basic approaches to metal suppression such as metal artifact reduction sequence (MARS). -Discussion of more
contemporary approaches including WARP (MARS with view angle tilting - VAT), SEMAC, and MAVRIC. -MR
physics discussion including limitations (inability to perform fat saturation, possibility of increased imaging
time). -Field strength comparison including degrees of susceptibility artifact at 1.5 and 3.0 T. Specific
complications to be discussed include: Metallosis Particle Disease Infection (acute and chronic) Loosening
Tendon injury Muscle injury
Tendon injury Muscle injury
MKE246
Evaluation of the Intraarticular Portion of the Biceps Brachii Tendon at the Shoulder with
Ultrasound: Anatomy, Pathology and New Maneuver of Mick Jagger Position (Station #13)
Guillermo Andres Azulay MD : Nothing to Disclose , Patrick Omoumi MD (Presenter): Nothing to Disclose ,
Daniel Postan : Nothing to Disclose , Gabriel Hector Aguilar MD : Nothing to Disclose , Rafael Barousse
MD : Nothing to Disclose , Ignacio Rossi : Nothing to Disclose , Ariel Franz Gonzales Nogales MD, PhD :
Nothing to Disclose
TEACHING POINTS
It is essential to understand the dynamics of the intraarticular portion of the biceps tendon in relation to
shoulder movement for the ultrasound examination. A maneuver in abduction and internal rotation (Mick Jagger
position) can help to visualize the intraarticular portion of the biceps tendon and its pathology.
TABLE OF CONTENTS/OUTLINE
1. Anatomy: - Cadaveric study illustrating the anatomy of the intraarticular portion of the biceps tendon, the
relationship between the tendon and its surrounding structures, the position of the technique in relationship to
the shoulder movements. 2. Detailed ultrasound technique: - Description of the Mick Jagger position - Optimal
acoustic window 3. Normal ultrasonographic aspects 4. Pathological ultrasonographic aspects
MKE018-b
Basic Principles and Applications of Dual Energy Computed Tomography (DECT) in Gout (hardcopy
backboard)
Shima Aran MD (Presenter): Nothing to Disclose , Frank J. Simeone MD : Nothing to Disclose ,
Khalid Walid Shaqdan MD : Nothing to Disclose , Elmira Hassanzadeh MD : Nothing to Disclose ,
Efren Jesus Flores MD : Nothing to Disclose , Hani H. Abujudeh MD, MBA : Research Grant, Bracco Group
Consultant, RCG HealthCare Consulting Author, Oxford University Press
TEACHING POINTS
There are many exciting new applications for advanced imaging in gout. Dual energy CT (DECT) can
differentiate urate crystals from calcium by using specific attenuation characteristics and reveal even small
occult tophaceous deposits. DECT can also be used for serial volumetric quantification of subclinical tophi to
evaluate response to treatment. We plan to expose radiologists to a series of challenging cases to understand
how this unique and clinically relevant modality can facilitate diagnosis and management of gout.
TABLE OF CONTENTS/OUTLINE
1. Physical principles of DE or spectral CT on basis of photoelectric and Compton interactions as well as material
decomposition. 2. Available techniques of DE data acquisition, for example, dual source CT scanners, fast
kilovoltage switching and sandwich detector tech¬niques. 3. Image processing and reconstruction of DECT
data. 4. Clinical application of DECT for diagnosis and management of gout. 5. Sample cases. 6. Limitations of
DECT in the musculoskeletal imaging such as the effects on image quality, artifacts and radiation dose.
MSE-MOA
Multisystem/Special Interest Monday Poster Discussions
Education Exhibits
OT
AMA PRA Category 1 Credits ™: .50
Mon, Dec 1 12:15 PM - 12:45 PM
Location: MS Community, Learning Center
Sub-Events
MSE013-b
105 Years of Conventional Dacryocistography Nowdays Technique and Advances (hardcopy
backboard)
Felipe Aluja MD (Presenter): Nothing to Disclose , Rodolfo Alberto Mantilla Espinosa MD : Nothing to
Disclose , Jorge O. Suarez MD : Nothing to Disclose
TEACHING POINTS
Review the technique of dacryocystography that was originally described by Ewing in 1909 using bismuth
subnitrate as contrast media. It was the first method used to evaluate the lacrimal drainage system. Describe
the lacrimal drainage system anatomy in dacryocystography including essential structures as Rosenmüller
valve, Krause valve and Hasner valve. Recognize nasolacrimal drainage system pathologies, specially causes of
obstruction as infectious, inflammatory, congenital, tumoral and traumatic. Discusses and illustrate other
imaging methods including ultrasound, computed tomography, magnetic resonance imaging and nuclear
medicine.
TABLE OF CONTENTS/OUTLINE
Introduction
Anatomy of the lacrimal drainage system
Conventional dacriocystography technique
Obstruction of the lacrimal drainage system
Obstruction of the lacrimal drainage system
Other imaging methods
Conclusions
MSE102
Fungus Among Us: Spectrum of Imaging Findings in Coccidiomycosis (Station #1)
Asha
Goud MD (Presenter): Nothing to Disclose , Neil
Patel MD : Nothing to Disclose
TEACHING POINTS
Coccidioidmycosis, commonly known as Valley Fever, is caused by a fungus found in the soil of dry areas and is
endemic to the southwestern United States. At least 30-60% of people who live in an endemic area are infected
at some point in their lives. The infection is spread through inhalation of particles and travelers passing through
endemic areas may also contract the disease. Clinical manifestations range from minor respiratory illness that
clears on its own to severe multi-organ system disseminated disease. The goals of this exhibit are to become
familiar with the clinical manifestations be able to identify the spectrum of multi organ system imaging findings
TABLE OF CONTENTS/OUTLINE
1. Background 2. Clinical manifestations and laboratory/imaging findings of Valley Fever. 3. An emphasis is
placed on wide range of imaging findings and dissemination patterns to various organ systems on mutliple
modalities (CT, US, NM, and MRI) including: pulmonary musculoskeletal ocular gastrointestinal lymphatic
systems. 4. Conclusion: Each year there are over 150,000 cases of Valley Fever, however, there is little public
awareness of this disease. Knowledge of the wide spectrum of imaging findings are essential in the diagnosis
and management
NMS-MOA
Nuclear Medicine Monday Poster Discussions
Scientific Posters
NM
AMA PRA Category 1 Credits ™: .50
Mon, Dec 1 12:15 PM - 12:45 PM
Location: S503AB
Participants
Moderator
Ukihide Tateishi MD, PhD : Nothing to Disclose
Sub-Events
NMS158
Ultrafast PET Acquisition Using Solid-state Photomultiplier-based PET Camera under a Strong
Magnetic Field (Station #1)
Spencer Caton Behr MD (Presenter): Research Grant, General Electric Company , Thomas A. Hope MD :
Speaker, Guerbet SA Research Grant, General Electric Company , Lorenzo Nardo MD : Nothing to Disclose ,
Vahid Ravanfar : Research Grant, General Electric Company , Emily Verdin : Research Grant, General
Electric Company , Dragana Savic : Nothing to Disclose , Randall A. Hawkins MD, PhD : Nothing to Disclose
, Youngho Seo PhD : Research Consultant, sanofi-aventis Group
PURPOSE
Solid-state photomultiplier (SSPM), coupled with fast scintillators, can operate in the strong magnetic field and
still maintain time-of-flight (TOF) PET capability. The highly-sensitive large filed-of-view (25-cm axial)
SSPM-based TOF-PET integrated with 3T-MRI (TOF-PET/MRI) offers the possibility of rapid, diagnostic quality
PET studies potentially as fast as 1 minute per bed compared to 3 minutes for the current clinical PET systems.
This shortened PET scan time can allow for both rapid full-body PET studies as well as for dedicated,
organ-specific MR and PET protocols in less than 60 minutes.
METHOD AND MATERIALS
8 consecutive TOF-PET scans at 4 minutes per bed were acquired on the TOF-PET/MRI system in listmode, 120
to 180 minutes after intravenous administration of 370 MBq FDG. Listmode PET data were replayed and
reconstructed for 1- and 2-minute intervals in addition to the prospective 4-minute per bed reconstruction with
TOF and 4 minutes without TOF. Reconstructed MIP images were compared to the PET from the PET/CT for
qualitative assessment. Qualitative assessment by three radiologists; one with over 20 years of experience,
second with over 8 years of experience and another was a resident with 3 years of experience. Scoring was 1 to
5, 1 for non-diagnostic, 3 equal to PET from PET/CT and 5 superior quality/new lesions detected.
RESULTS
Qualitative scores were similar between radiologists: 4 minute without TOF was $ and 1,2, and 4 minute with
TOF was 3.3, 3.4 and 4.1, respectively.
CONCLUSION
Even with the significant loss of FDG signal from the 2-hour delayed acquisition, the new TOF-PET/MRI system
has high enough sensitivity and resolution to allow for full body diagnostic PET at 1 to 2 minutes per bed
station. However clinical PET scans are routinely performed at 60 minutes after injection, which will further
improve the signal to noise. Therefore, these findings support the hypothesis that this TOF-PET/MRI can
perform diagnostic PET studies as short as 1 minute per bed and allow ample time for focused MRI and PET
protocols. In addition, this ultrafast whole-body PET capability may be helpful for patients who have difficulty
laying flat such as pediatric or patients with back pain.
CLINICAL RELEVANCE/APPLICATION
The shortened scan time due to SSPM and TOF PET technology can allow for both rapid full-body PET studies as
well as for dedicated, organ-specific MR and PET protocols in less than 60 minutes.
NMS159
Outcome of Small Lung Nodules Missed on Hybrid PET-MR: Institutional Experience with 43 Patients
(Station #2)
Roy A. Raad MD (Presenter): Nothing to Disclose , Kent P. Friedman MD : Speaker, Bayer AG Spreaker,
Spectrum Pharmaceuticals, Inc , Amy Noel Melsaether MD : Nothing to Disclose , James S. Babb PhD :
Nothing to Disclose , Hersh Chandarana MD : Research support, Siemens AG
PURPOSE
To assess outcomes of lung nodules missed on simultaneous positron emission tomography and magnetic
resonance imaging (PET/MRI) in patients with known primary malignancy, with combined PET and computed
tomography (PET/CT) as a reference
METHOD AND MATERIALS
In this institutional review board-approved HIPAA-compliant retrospective study, 208 patients with known
primary tumor undergoing clinically indicated 18-fluorodeoxyglucose (FDG) PET/CT followed by PET/MRI were
initially reviewed. A single reader reviewed the thoracic station on PET/MR (radial T1 GRE (radial VIBE) with
PET) and PET/CT, which included lung kernel CT reconstructions. Total of 88 small lung nodules (mean size 0.4
cm, range 0.2-1 cm) in 43 patients (11 males, 32 females, mean age 64.2 years, range 35-80 years) were
detected only on the CT component of the PET/CT but were not identified on PET-MRI. None of these missed
nodules demonstrated FDG uptake above background lung/mediastinal activity, and thus were considered
non-avid. 84 /88 nodules were examined on follow-up (f/u) imaging with PET-CT or chest CT (mean f/u time
9.1 months, range 3-17 months). Remaining 4 nodules had no f/u imaging but had remote imaging studies
available for comparison.
RESULTS
Among the 84 nodules that had f/u imaging, only 3 nodules (4%) in 1 patient progressed, 10 (12%)
partially/completely resolved, whereas 71 (84%) remained stable in size and appearance. The 4 nodules that
had no f/u were all stable since prior imaging 21-72 months prior, consistent with benignity. Furthermore, most
(62/71, 87%) of the "stable" nodules were also stable since older studies over a total period of 11-78 months
(mean 36.6 months), further confirming their benignity. None of the missed nodules changed patient
management, including the 3 nodules (in 1 patient) that progressed on follow-up, in view of the patient's
extensive distant metastases.
CONCLUSION
PET-MRI remains a viable alternative imaging modality in oncology patients, despite its low sensitivity in
detecting non-FDG avid small lung nodules. The vast majority (96%) of non-FDG avid lung nodules missed on
PET-MRI compared to the reference PET-CT either resolved or remained stable on f/u imaging, consistent with
benignity.
CLINICAL RELEVANCE/APPLICATION
Compared to PET-CT, PET-MR has a lower diagnostic sensitivity in detecting small lung nodules. Assessment of
the outcome of such nodules will help validate the utility of PET-MRI in oncology patients.
NMS161
Comparative Analysis of Brain SPECT Using Tc-99m GHA and Tc-99m MIBI with MRI and MRS in
Cerebral Gliomas (Station #4)
Parul Mohan MBBS, MD (Presenter): Nothing to Disclose , Harsh
, Ravi Kashyap MD : Nothing to Disclose
Mahajan MD, MBBS : Nothing to Disclose
PURPOSE
This prospective study was undertaken to perform a comparative analysis of Tc-99mGHA ,Tc-99m MIBI, MRI
and MRS to correctly monitor therapy response in patients presenting with CNS tumors
METHOD AND MATERIALS
This study was undertaken in a group of 57 post-op cases of brain tumors. Brain SPECTwas acquired at 30
minutes and 2 hours, using a Dual headed SPECTafter injecting 20 mCi Tc-99m GHA and 20 mCi Tc-99m MIBI
intravenously on two separate sittings. MR examination was performed on a 1.5 tesla MR system. The analysis
of SPECT and MR data was performed by independent double-blinded observers.
RESULTS
Data Interpretation was done by reconstructing the views for quantitative evaluation and calculating functional
index ratio (tumor uptake/background uptake ratio. MIBI index was correlated with tumour recurrence as
proved by histology and/or rapid, fatal evolution of these cases. A value of 3.0 was considered significant for
active mitotic pathology. A similar ratio was calculated with GHA as GHA index, which was significant at a value
of 4.5. Image quality suffered in Tc-99m MIBI scans due to secretion of Tc-99m MIBI by the choroids plexus.
of 4.5. Image quality suffered in Tc-99m MIBI scans due to secretion of Tc-99m MIBI by the choroids plexus.
Good correlation of Brain SPECT was found with both MRI and MRS.Tc-99m GHA gave a sensitivity of 97.5%,
specificity of 81.2% and an accuracy of 92.9%. Tc-99m MIBI gave a sensitivity of 95.1%, specificity of 87.5%
and an accuracy of 92.9%. MRI gave a sensitivity of 92.6%, specificity of 75%, and an accuracy of 87.7%. MRS
gave a sensitivity of 95.1%, specificity of 75% and an accuracy of 89.4%.
CONCLUSION
This comparative analysis showed that MRS improves in image interpretation of MRI, however it requires a
dedicated team and an appropriate imaging system. Tc-99m MIBI and Tc-99m GHA are useful in differentiating
radionecrosis and recurrence of brain tumor. Tc-99m GHA is found to be as useful as Tc-99m MIBI. Therefore
depending on the availability and expertise developed, any two modalities could be used for decision making.
CLINICAL RELEVANCE/APPLICATION
Brain SPECT using GHA, which is cheaper and more cost-effective than MIBI, can be used to differentiate viable
tumor from radionecrosis in post-operated cases of cerebral gliomas.
NMS162
Can Pretreatment PET-CT Predict RECIST 1.1 Response in Subjects with Locally Advanced Pancreatic
Adenocarcinoma Undergoing Neoadjuvant GTX Chemotherapy? (Station #5)
Brian Jin MD (Presenter): Nothing to Disclose , Elizabeth M. Hecht MD : Nothing to Disclose , David K.
Leung MD, PhD : Nothing to Disclose , Kyung Chu NP : Nothing to Disclose , Ranjit Singh Sandhu MD :
Nothing to Disclose , William H. Sherman MD : Nothing to Disclose
PURPOSE
To investigate whether baseline FDG PET-CT parameters can be used to predict tumor RECIST 1.1 response
following neoadjuvant chemotherapy of locally advanced pancreatic adenocarcinoma.
METHOD AND MATERIALS
Patients with locally advanced pancreatic adenocarcinoma enrolled in a neo-adjuvant GTX chemotherapy trial.
All patients underwent pre-treatment FDG PET-CT and MRI. Baseline PET-CT parameters were measured:
Tumor SUV max, SUV mean, 3-D metabolic tumor volume (MTV, obtained using an automated
half-maximum-SUV threshold), and total lesion glycolysis (TLG; SUVmean*MTV). Tumor size (maximum axial
diameter) was measured on MRI (pre-treatment, post 3 and 6 cycles of GTX). Tumor response of the target
lesion after 3 and 6 cycles was recorded using RECIST 1.1 criteria: complete response (CR); partial response
(PR); progressive disease (PD); stable disease (SD). Pre-treatment PET-CT measurements in patients with CR
or PR after 3 and 6 cycles of GTX were compared to patients with SD or PD using independent t-test, P-value <
0.05 was considered statistically significant. Analysis was performed using a commercially available statistical
software package (SPSS version 16.0, Chicago, Illinois).
RESULTS
34 subjects (17M, 17F; mean 66.9 y) were enrolled. Mean tumor size: 3.4 cm. Quantitative results are as
follows: tumor SUVmax 7.0 ± 3.1, tumor SUV mean 4.5 ± 2.0, MTV 19 ± 12cm3, TLG 80 ± 59 SUV-cm3 . After
3 cycles of GTX, 8 subjects exhibited PR, 26-SD. There was no difference between tumor SUV max or SUV mean
in the PR and SD cohorts but there was a statistically significant difference in MTV (33 ± 17 cm3 - PR group, 15
± 6.7cm3 -SD group, P<0.001) and TLG (138 ± 88 SUV- cm3 versus 62 ± 31 SUV- cm3, P=0.001). After 6
cycles, 15 patients had PR, 2-CR, and 16-SD (1 death occurred between cycles 3-6). Given the small number of
CR patients, they were grouped together with PR patients (PR+CR group). No baseline PET-CT parameter
demonstrated statistically significant differences between the PR+CR and SD groups.
CONCLUSION
In patients with locally advanced PDA, baseline PET-CT quantitiative metrics including tumor SUVmax,
SUVmean, MTV and TLG fail to predict RESIST response after 6 cycles, suggesting that the prognostic ability of
PET-CT to predict anatomic response is limited.
CLINICAL RELEVANCE/APPLICATION
Pre-treatment PET-CT fails to predict anatomic tumor response in patients with locally advanced pancreatic
cancer undergoing neoadjuvant chemotherapy.
NME110
(18) F-FDG-PET/CT of Cranial Nerve Pathology (Station #6)
Osama A. Raslan MD, MBBCh (Presenter): Nothing to Disclose , Medhat M. Osman MD : Speaker,
Koninklijke Philips NV , Vilaas Shetty MD : Nothing to Disclose , Talha S. Allam MD : Nothing to Disclose
TEACHING POINTS
1. To understand the PET/CT cranial nerve (CN) cross sectional anatomy. 2. When to suspect and how to
diagnose CN pathology on FDG-PET/CT using the primary signs of CN involvement (e.g. widening of the exit
foramen), and secondary signs (e.g. hypometabolic denervated atrophic muscle). 3. Recognize the importance
of perineural spread along the CNs in assessing PET/CT scan in all patients with head and neck cancer.
TABLE OF CONTENTS/OUTLINE
• Introduction about the implication of detecting CN pathology on patient management. • Description of clinical
scenarios that should prompt a search for cranial nerve pathology. • Description of the PET/CT anatomy, as well
as the primary and secondary signs of involvement of each of the 12th CNs. The following CNs pathology are
presented with illustration: CN I, II, V2, V3, VI, VII, VIII, X and XI.
NRS-MOA
Neuroradiology Monday Poster Discussions
Scientific Posters
NR
AMA PRA Category 1 Credits ™: .50
Mon, Dec 1 12:15 PM - 12:45 PM
Location: NR Community, Learning Center
Participants
Moderator
Pratik Mukherjee MD, PhD : Research Grant, General Electric Company Medical Adivisory Board, General Electric Company
Sub-Events
NRS399
Establishing the Structural Connectome as a Quantitative Imaging Biomarker: Application to
Alzheimer's Disease (Station #1)
Jeffrey William Prescott MD, PhD (Presenter): Nothing to Disclose , P. Murali Doraiswamy MD : Research
Consultant, Bristol-Myers Squibb Company Research Consultant, Eli Lilly and Company Research Consultant,
Neuronetrix, Inc Research Consultant, Medivation, Inc Research Grant, Bristol-Myers Squibb Company Research
Grant, Eli Lilly and Company Research Grant, Neuronetrix, Inc Research Grant, Medivation, Inc Stockholder,
Sonexa Therapeutics, Inc Stockholder, Clarimedix, Inc Speaker, Forest Medical, LLC , Jeffrey Robert Petrella
MD : Advisory Board, Johnson & Johnson Speakers Bureau, Quintiles Inc Advisory Board, Piramal Enterprises
Limited
PURPOSE
The current study analyzes structural connectome topological metrics and their reproducibility in the setting of
Alzheimer's disease pathology.
METHOD AND MATERIALS
We studied 102 subjects enrolled in the multi-center biomarker study, the Alzheimer's Disease Neuroimaging
Initiative (ADNI) 2 who had both DTI and florbetapir PET data. Subjects' T1 scans were automatically
parcellated into cortical regions of interest. Standardized uptake value ratios (SUVr) were calculated from
florbetapir PET scans for 5 cortical lobes (frontal, cingulate, parietal, temporal, and occipital). Structural
connectome graphs were created from DTI scans, and connectome topology was analyzed in each lobe using
graph theoretic metrics: strength, local efficiency, clustering coefficient, and betweenness centrality. Linear
mixed effects models were fit to analyze the effect of florbetapir SUVr on the structural connectome metrics. In
addition, reproducibility of the topological metrics was analyzed in the cohort of normal controls between
baseline and 3 month scans.
RESULTS
There were strong, significant associations between florbetapir SUVr and structural connectome metrics in each
of the 5 lobes. Increased cortical florbetapir SUVr was associated with decreases in strength (p = 0.00001),
local efficiency (p = 0.00001), and clustering coefficient (p = 0.0006), but not betweenness centrality (p =
0.69). The best reproducibility between consecutive measurements for normal controls was 6% for strength,
16% for local efficiency, 13% for clustering coefficient, and 48% for betweenness centrality.
CONCLUSION
Increased amyloid burden is strongly associated with changes in the topology of the large-scale structural
network architecture of the brain (the 'structural connectome'), even in the preclinical stages of AD. The most
reproducible topological measurement studied was strength, while local efficiency and clustering coefficient had
acceptable but not great reproducibility. These results suggest that it may be possible to use structural network
topology as an imaging biomarker of Alzheimer's disease, and therefore as a target for therapy early in the
course of AD.
CLINICAL RELEVANCE/APPLICATION
These results suggest that it may be possible to use structural network topology as an imaging biomarker of
Alzheimer's disease, and therefore as a target for therapy early in the course of AD.
NRS400
Relationships between Quantitative Amyloid Burden and Cognition in Alzheimer's Dementia (Station
#2)
Alex Bibbey MD (Presenter): Nothing to Disclose , P. Murali Doraiswamy MD : Research Consultant,
Bristol-Myers Squibb Company Research Consultant, Eli Lilly and Company Research Consultant, Neuronetrix,
Inc Research Consultant, Medivation, Inc Research Grant, Bristol-Myers Squibb Company Research Grant, Eli
Lilly and Company Research Grant, Neuronetrix, Inc Research Grant, Medivation, Inc Stockholder, Sonexa
Therapeutics, Inc Stockholder, Clarimedix, Inc Speaker, Forest Medical, LLC , Jeffrey Robert Petrella MD :
Advisory Board, Johnson & Johnson Speakers Bureau, Quintiles Inc Advisory Board, Piramal Enterprises Limited
, Jeffrey William Prescott MD, PhD : Nothing to Disclose
PURPOSE
The hypothesis of the current study is that relationships between cortical amyloid burden as evaluated by
florbetapir PET imaging and cognitive testing batteries may provide complementary information about
pathologic changes in Alzheimer's Disease (AD).
METHOD AND MATERIALS
Subjects were those newly enrolled in the ADNI2 study. Baseline data was used. T1 anatomical images were
parcellated using FreeSurfer software. Parcellations were registered to florbetapir PET scans. Florbetapir SUVr
for each parcellated cortical region of interest was calculated, using the whole cerebellum as the reference
region. Clinical cognitive assessments included ADAS-Cog, MMSE, Rey AVLT, Boston Naming Test, Trail Making
Test A and B, and the Clock Drawing Test. Statistical analyses were performed between amyloid status in
selected cortical regions (superior, middle, and inferior temporal, entorhinal, precuneus, posterior cingulate,
and superior frontal) as assessed by PET and clinical cognitive measures.
RESULTS
There were 102 ADNI2 subjects (64 males, 38 females, mean age 73.8 years) available at the time of the
analysis. There were 37 normal control, 19 early mild cognitive impairment (MCI), 25 late MCI, and 21 AD
subjects, representing a spectrum of clinical cognitive status. Regression modeling of florbetapir SUVr as a
predictor of cognitive battery performance revealed the region with the most significant associations between
cognitive performance and amyloid SUVr was the right precuneus, with ADAS-cog, MMSE, and Trail A test (p <
0.05). The cognitive test with the most association with regional florbetapir SUVr was ADAS-cog, with left
entorhinal, left posterior cingulate, and right precuneus.
CONCLUSION
Significant associations between regional florbetapir PET SUVr and cognitive battery performance indices were
noted mostly in the right precuneus, with the ADAS-cog cognitive test the most associated with SUVr across
regions. It is thought that the rate of cognitive decline is greatest when the rate of amyloid accumulation has
plateaued, and further increase is minimal. Ongoing longitudinal investigations will further evaluate how
cognitive decline may be affected in the setting of increasing amyloid burden in asymptomatic subjects or those
with mild cognitive impairment.
CLINICAL RELEVANCE/APPLICATION
Quantitative amyloid PET may provide information about global and local structural changes in AD, aiding in
diagnosis and disease tracking.
NRS401
White Matter Lesions (WML), Cognitive Domains and Vascular Factors in a Population-based Cohort
Study (Station #3)
Thais Minett PhD (Presenter): Nothing to Disclose , Blossom Stephan : Nothing to Disclose , Shabina
Hayat : Nothing to Disclose , Stephanie Moore : Nothing to Disclose , Elliott Grigg : Nothing to Disclose ,
Robert Luben : Nothing to Disclose , Fiona Matthews : Nothing to Disclose , Carol Brayne : Nothing to
Disclose , Kay-Tee Khaw : Nothing to Disclose
PURPOSE
To assess the impact of White Matter Lesions (WML) on global and domain specific cognitive functions and
whether vascular co-morbidities modify these associations in a population-based sample.
METHOD AND MATERIALS
Participants were recruited from a population-based study. At baseline (1993-1997) 30,446 participants aged
40-79 years were selected from general practices. Participants were re-seen in later life, 13 years follow-up
(wave III). The core data resources include lifestyle/physical activity, diet, medical status, and blood samples.
The present study added a pilot neuroimaging component to this project. From participants seen at wave III,
67 were randomly selected weighted towards the more cognitively frail. Participants were scanned and WML
were rated using the Fazekas' scale on FLAIR acquisitions. Cognition was assessed using the Addenbrookes
Cognitive Examination (ACE-R) battery and cognitive domains divided into memory, attention, fluency,
language and visuospacial. The vascular factors considered were: stroke; heart disease; diabetes; cholesterol;
blood pressure; current smoker; body mass index (BMI); alcohol intake.
RESULTS
There was a significant association between WML intensity and attention (Β = -0.75; 95%CI(Β)= -1.42, -0.08).
This relationship was independent of age, sex and presence of multiple vascular risk factors. No significant
relationship was demonstrated between WML ratings and global cognition or memory, fluency, language and
visuospacial performance.
CONCLUSION
WML were found to be associated with impairment of attention. Moreover, this association was independent of
age, sex and the presence of multiple vascular risk factors. Our findings suggest that there might be other
factors, potentially non-vascular, contributing to the relationship between WML and impairment in executive
function.
CLINICAL RELEVANCE/APPLICATION
The fact that there might be other contributing factors to the relationship between WML and impairment in
executive function has implications for intervention targets aimed at promoting cognitive function in older aged
individuals.
NRS402
Association of Baseline Neuroimaging with Short-term and Long-term Clinical Outcomes in
Combat-related Traumatic Brain Injury (Station #4)
Jeffrey Ware MD (Presenter): Nothing to Disclose , Rosette Biester PhD : Nothing to Disclose , Elizabeth
Whipple MS : Nothing to Disclose , Keith Robinson MD : Nothing to Disclose , Richard Ross MD, PhD :
Nothing to Disclose , Paolo Nucifora MD, PhD : Nothing to Disclose
PURPOSE
Mild traumatic brain injury (m-TBI) is an increasingly-recognized clinical problem, particularly in military
populations which have seen a dramatic rise in the incidence of m-TBI over the past two decades. TBI has
therefore become known as the 'signature injury' of recent miltary operations, and it is associated with poor
neuropsychiatric outcomes. Clinical evaluation of veterans with m-TBI remains challenging due to difficulties in
establishing the diagnosis and selecting appropriate therapy. Reliable biomarkers are sought to improve not
only the sensitivity and specificity of m-TBI diagnosis, but also accuracy in predicting clinical outcome and
ultimately evaluating therapeutic efficacy.
METHOD AND MATERIALS
We performed a retrospective cohort study of veterans of Operation Enduring Freedom and Operation Iraqi
Freedom who were evaluated within a single VA hospital system from 2008-2013, screened positive for m-TBI,
and were referred for brain MRI including diffusion tensor imaging and a high resolution T1-weighted sequence.
Conventional MRI sequences were regarded as normal at clinical interpretation. Additional sequences were used
for derivation of diffusion metrics, brain morphometry, and structural connectivity. Veterans underwent baseline
clinical and neuropsychological evaluation. Clinical data were collected over a follow-up period of up to 6 years.
Imaging metrics were analyzed in group-wise fashion, in addition to regression with baseline and follow-up
clinical data.
RESULTS
Significant correlations between baseline imaging metrics and both short-term and long-term clinical outcomes
were identified. At the time of imaging, fractional anisotropy in left frontal lobe white matter was positively
correlated with percentile performance on the Trail-Making Test, a measure of executive function (p < 0.05).
Furthermore, fractional anisotropy was significantly reduced in multiple brain regions in m-TBI veterans who
were unemployed at the end of the follow up period compared to those able to obtain employment (p < 0.05).
CONCLUSION
Metrics derived from baseline neuroimaging are correlated with neurocognitive function and associated with
long term employment status.
CLINICAL RELEVANCE/APPLICATION
Our study suggests that neuroimaging metrics can predict short-term as well as long-term clinical outcomes,
building upon existing evidence for imaging biomarkers of m-TBI
NRS403
Diffusion and Conventional MR Imaging Genomic Biomarker Signature Predicts Specificity Protein 1
Expression Identification in Glioblastoma Patients (Station #5)
Mohamed G. Elbanan MBBCh (Presenter): Nothing to Disclose , Eslam Wassal Youssef MD : Nothing to
Disclose , Pascal O. Zinn MD : Nothing to Disclose , Rivka Rachel Colen MD : Nothing to Disclose
PURPOSE
Sp1 plays a critical role in the regulation of multiple genes implicated in tumorigenesis, also it represents
potential prognostic markers for glioma progression. Currently used methods to determine the Sp1 expression
status of GBM include immunohistochemical analysis and genotyping of the DNA extracted from the brain tumor
specimens. Thus, we seek to identify a diffusion and conventional MR imaging signature associated with Sp1
expression tumors that can be considered as a non-invasive predictor of the Sp1 expression status in
Glioblastoma patients.
METHOD AND MATERIALS
We identified 80 GBM patients from The Cancer Genome Atlas (TCGA) who had genetic expression profiles of
Sp1 and neuroimaging available at The Cancer Imaging Archive (TCIA). All morphological image analyses and
segmentation were done using slicer 3.6 (slicer.org) and reviewed in consensus by 3 neuroradiologists.
Fluid-Attenuated Inversion Recovery (FLAIR) was used for segmentation of the edema and post-contrast T1
weighted imaging (T1WI) for segmentation of enhancement (defined as tumor) and necrosis. The
non-enhancing perilesional FLAIR hyperintensity reflected a mixture of edema/tumor infiltration. Diffusion was
analyzed in Olea Sphere 2.3 and Conventional FLAIR/post- contrast T1WI was registered to DWI/ADC maps.
ADC, FLAIR and T1 Gadolinium enhancement values will be measured using the ROI based method, in the
perilesional edema/non enhancing tumor and the enhancing tumor zones, with dividing the perilesional
edema/non enhancing tumor into 3 zones each of 1 cm width, 3 ROI measurements will be taken from each
zone. Multiple quantitative imaging features were identified and combined to create the imaging biomarker
signature predictive of Sp1 expression status status.
RESULTS
We created a complex imaging biomarker signature using quantitative diffusion and conventional MR imaging
features to predict those GBM patients with Sp1 expression status and furthermore that was predictive of
patient survival.
CONCLUSION
GBM tumors with Sp1 expression status hold a specific imaging biomarker signature that can be used as a
predictive and prognostic biomarker and non-invasive surrogate for Sp1 expression status.
CLINICAL RELEVANCE/APPLICATION
GBM tumors with Sp1 expression hold a specific diffusion and conventional MR imaging biomarker signature
that can be used as a predictive and prognostic biomarker.
NRS404
Spectral Imaging Associated with Lower Contrast Injection Rate for Carotid Artery: Initial Clinical
Experience (Station #6)
Yunjing Xue MD (Presenter): Nothing to Disclose , Qing Duan MD : Nothing to Disclose , Jin
Nothing to Disclose , Lin LIN : Nothing to Disclose , yuanfen liu : Nothing to Disclose
Wei :
PURPOSE
To investigate the clinical value of using a Gemstone spectral imaging(GSI) protocol with 50% adaptive
statistical iterative reconstruction (ASiR) and lower contrast injection rate (3ml/s) in carotid CTA by comparison
with a conventional 120-kVp protocol with normal contrast injection rate (5ml/s).
METHOD AND MATERIALS
With local ethical committee approval, 41 patients were prospectively enrolled in the study: 21 were scanned
with parameters of 120 kVp, 240 mAs, contrast medium (CM) of 320 mg I/mL with 5ml/s injection rate in group
A, and the other 20 were scanned with GSI mode, 315 mAs, 50% ASiR using the same CM with 3 ml/s injection
rate in group B. Monochromatic images of 60keV were evaluated in GSI group. Image quality (IQ) of the two
groups was compared in terms of arterial enhancement, noise, signal-noise-ratio (SNR) and contrast-to-noise
ratio (CNR). The effective dose (ED) of radiation and contrast dose were calculated and compared. Data were
analyzed by using Independent samples t test.
RESULTS
Both carotid (9.78±2.88HU) and three main branches of thoracic aorta (19.05±6.40HU) showed lower image
noise in GSI (50% ASiR, 3ml/s) than that of 120-kVp group (26.69±4.68HU) (P<0.05, respectively). The artery
enhancement, CNR and SNR of carotid artery and three main branches of thoracic aorta has no significant
differences statistically between two groups (all of them P>0.05), respectively. The ED and contrast dose of
GSI group (2.86±0.07mSv, 49.42±8.91ml) was 10.9% and 26.79% lower than that of 120-kVp group
(3.21±0.30mSv, 67.5±13.72ml), respectively. There was significant difference statistically in ED and contrast
dose, respectively, between two groups (all of them P<0.05).
CONCLUSION
The use of spectral imaging with 50% ASiR and injection rate of 3ml/s could provide lower image noise of both
carotid and three main branches of thoracic aorta arteries than that of 120-kVp scan and provide higher image
quality than that of 120-kVp protocol with a smaller amount of iodine and a lower radiation dose.
CLINICAL RELEVANCE/APPLICATION
GSI low keV monochromatic imaging can improve the effect of enhancement and thus reducing the amount of
contrast agent, in addition, combined with ASiR, it can decrease the noise of images, improve image quality and
reduce the scanning of GSI dose.
NRS406
Assessment of Brain-blood Barrier (BBB) Permeability after Local Brain Cooling with Dynamic
Contrast Enhanced MRI in Transient Middle Cerebral Artery Occlusion (MCAO) Rat Model (Station
#8)
Eun Soo Kim (Presenter): Nothing to Disclose , Seung-Koo Lee MD, PhD : Nothing to Disclose , Hye Jeong
Kim MD : Nothing to Disclose , Kwanseop Lee : Nothing to Disclose
PURPOSE
To evaluate effect of local brain cooling by quantification of the permeability parameters (Ktrans, Kep, Ve, and
Vp) presenting the microvascular BBB permeability using dynamic contrast enhanced MRI at a transient middle
cerebral artery occlusion(MCAO) rat model
METHOD AND MATERIALS
31 Adult Sprague-Dawley rats (280-300 gram) were used in transient middle cerebral artery occlusion (MCAO)
and underwent DCE-MRI on a 3T MRI scanner with 8-channel SENSE wrist coil. MCAO was induced by an
intra-luminal filament. For one hour, middle cerebral artery was occluded at rat model. In the stroke control
group without treatment, a 1-h MCA occlusion was induced and followed by 3 hour of reperfusion. Immediate
MRI was performed and 24 hour of reperfusion was followed. The next day, the second MRI was done. In the
local saline infusion group, after a 1-h MCA occlusion, 6ml of cold and warm saline (20°C or 37°C) through the
hollow filament for about 10 minutes was infused before the onset of 3 hour of reperfusion. Immediate MRI was
also performed and 24 hour of reperfusion was followed. The next day, following MRI was done. In all animals,
the rotarod test was performed before MCAO and after MCAO for 1 to 9 days. The following day, all animals
were euthanized and their brains were sectioned. To detect BBB breakdown after MCAO, we performed
immunehistochemistry for myeloperoxidase (MPO) to identify infiltrating neutrophils associated with the
inflammatory response. Data post-processing of permeability parameter was performed using Pride tools
provided by Philips Medical system.
RESULTS
There was a statistically significant decrease of Ktrans and Kep at infarction area in cold saline (20°C) group
compared with no treatment control group and a borderline decrease of Kep in cold saline (20°C) group,
compared with warm saline (37°C) group. The behavior test was no statistically significance between three
groups. Compared to total mixed inflammatory cells, the number of MPO-positive cells was significantly higher in
control group than in cold and warm saline (20°C or 37°C) groups. In addition, the MPO-positive cells in cold
saline (20°C) group are statistically lower than warm saline (37°C) group.
CONCLUSION
Local brain hypothermia induced by local saline infusion at stroke make a stable environment as decrease of
BBB breakdown.
CLINICAL RELEVANCE/APPLICATION
DCE MRI can demostrate the microvascular BBB permeability in stroke research.
NRS407
Volumetric Evaluation of the Dorsal Root Ganglia and Nerves in the Cervical and Brachial Plexus
Using Nerve Specific MRI (Station #9)
Tessa Buckle PhD (Presenter): Nothing to Disclose , Berit Michaela Verbist MD : Nothing to Disclose , Thijs
Engelen BSC : Nothing to Disclose , Martijn J.A. Malessy MD, PhD : Nothing to Disclose , Fijs Willon Bernard
van Leeuwen PhD : Nothing to Disclose
PURPOSE
Nerve damage to the cervical or brachial plexus results in reduced sensory and/or motor function. Neuron cell
death is related to a decrease in volume of the dorsal root ganglion (DRG). The purpose of this study is to
evaluate the use of D-prep MR neurography (MRN) for specific visualization of (damaged) nerves. Morphological
features and variations in the DRGs and nerves of the cervical and brachial plexus were assessed in healthy
volunteers and patients with tumor or trauma of the plexus.
METHOD AND MATERIALS
Five healthy volunteers and six patients (nerve tumor (n=3) or brachial plexus lesion (located at C8; n=3))
underwent an MRI of the cervical and/or brachial plexus (3T; Philips Ingenia) using a D-prep MRN sequence. A
standard T2 STIR was acquired for anatomical reference. The DRGs from C1 through C8 and nerves of the
cervical and brachial plexus were assessed for their detectability and dimensions.
RESULTS
(Volumetric) measurements were feasible in all patients and volunteers. DRGs of (especially at the cervical
plexus) were more clearly visualized with D-prep MRN compared to T2 STIR. In the volunteers DRG volume
increased from 30 mm3 in C2-C4 to 180 mm3 in C7-C8. Spinal nerves of the cervical plexus (C1-C4; diameter
19.1 +/- 3.6 mm) and/or brachial plexus (C5-C8; diameter 39.7 +/- 4.8 mm) could be accurately visualized,
and traced downward from their ganglion (Figure 1). Nerve trauma did not affect nerve diameter but resulted in
a decrease in DRG volume (26 +/- 7%) at C8, compared to the contralateral side and C7. Tumor invasion and
localized edema prohibited DRG and nerve measurements when located in close proximity to tumor, while the
dimensions of unaffected nerves and DRGs were comparable to the measurements in healthy volunteers.
CONCLUSION
Measurement of the diameter of cervical nerves and the volume of their DRGs was feasible with D-prep MRN in
both healthy volunteers and patients with either a nerve tumor or neuropathy after trauma. Volumetric
measurements showed a decrease in DRG volume after trauma, while the diameter of the nerve was not
affected.
CLINICAL RELEVANCE/APPLICATION
Morphologic evaluation of nerves based on nerve specific MRI can potentially provide a non-invasive in vivo
measure of the degree of functional recuperation after damage to the cervical of brachial plexus.
NRE233
Imaging of Neurologic Complications of Pregnancy (Station #10)
Sangam Gurudas Shet Kanekar MD (Presenter): Nothing to Disclose , Shante
Disclose , Ritesh Patel : Nothing to Disclose
Bennett MD : Nothing to
TEACHING POINTS
1. To discuss with illustration neurological complications in pregnant and post-partum women.
TABLE OF CONTENTS/OUTLINE
Acute neurological symptoms in pregnant and postpartum women could be caused by exacerbation of a
pre-existing neurological condition, by initial presentation of a non-pregnancy-related problem or a new
acute-onset neurological problem that is either unique to or occurs with increased frequency during or just after
pregnancy. We retrospectively studied CT/MRI brain of 76 pregnant patients who presented with neurological
symptoms and complications. We present this exhibit into two main categories: Common complications:
Eclampsia, Venous thrombosis, Stroke (infarct or haemorrhage), SAH, vasoconstriction syndrome, PRES,
Subdural haematoma and; Rare complications: Amniotic fluid and air embolism, Pituitary apoplexy, Thrombotic
thrombocytopenic, purpura, Wernicke's encephalopathy, aneurysm or AVM rupture, neoplasms,
Choriocarcinoma, and Bell's palsy. Early diagnosis of neurological complications in pregnancy is very important
to avoid complications to the mother and fetus. Imaging especially MR plays a vital role. This exhibit will be
core learning module for understanding the imaging signs in various neurological complications in pregnancy
with 'diagnostic pearls' .
NRE172
Down but Not out! Reversible Causes of Cranial Neuropathies (Station #11)
Ammar Ahmed Chaudhry MD (Presenter): Nothing to Disclose , Maryam Gul : Nothing to Disclose ,
Luboslav Woroch DO : Nothing to Disclose , Robert George Peyster MD : Nothing to Disclose , Lev
Bangiyev DO : Nothing to Disclose
TEACHING POINTS
? Review cranial nerve anatomy, highlight common regions of nerves involved in pathology ? Case-based review
of reversible and irreversible cranial nerve pathology highlighting key imaging findings that would narrow the
differential diagnosis ? Diagnostic algorithm can assist in navigation and interpretation of cranial nerve
pathology
TABLE OF CONTENTS/OUTLINE
TOC/Outline: Cranial nerve pathology is frequently encountered in clinical neuroradiology. Complex cranial
nerve anatomy and numerous adjacent key structures can be affected by various pathology. Due to overlap in
imaging findings, a systematic approach is required to formulate a relevant differential diagnosis and aid
clinicians in arriving at the correct diagnosis. This educational exhibit presents a case-based review utilizing
age, gender, anatomic location, imaging characteristics, etc. to formulate an algorhythm that will aid in more
precise diagnosis of cranial pathology. In addition, treatment, prognosis and follow up guidelines will be briefly
discussed. Conclusion: A systematic approach is required to narrow the differential diagnosis of cranial lesions.
At completion of this educational exhibit, the viewer will be able to provide more accurate assessment of
regional pathology, guide clinical management and recommend appropriate imaging follow-up.
NRE259
Imaging Impact for Facial Aging “Basic Consideration”: CT and MR Imaging Description Based on
Anatomic Knowledge (Station #12)
Itsuko Okuda MD (Presenter): Nothing to Disclose , Keiichi Akita MD, PhD : Nothing to Disclose ,
Katsuhiro Abe : Nothing to Disclose , Masahiro Irimoto MD : Nothing to Disclose , Yukio Shirakabe MD :
Nothing to Disclose , Yasuo Nakajima MD : Nothing to Disclose
TEACHING POINTS
1. To review the anatomic features of facial aging, and the factors that it occurs in. 2. To realize the human
anatomy and CT/MRI imaging anatomy of the face. 3. To explain the comparison of imaging features with
anatomic features of the facial structures affecting facial aging.
TABLE OF CONTENTS/OUTLINE
1. Aging process in morphology: facial aging appearance, and its principles 2. Human anatomy: facial
structures Facial muscles Superficial musculoaponeurotic system (SMAS) Retinacula cutis (RC) Fat layers 3.
CT/MR imaging anatomy of the face: description based on human anatomy 4. Interpretation: facial structures
affecting aging changes 5. Summary: 1) It is necessary to know the physiological changes of the facial aging.
2) It is important to understand the superficial facial imaging features based on anatomy for the analyses
mechanism of facial aging. 3) CT and MR images could contribute to evaluate for the facial aging.
NRE329
Where Are You Going?: Geographic Approach for the Evaluation of Perineural Tumor Spread in the
Head and Neck (Station #13)
Vamsi Kunam MD (Presenter): Nothing to Disclose , Deborah L. Reede MD : Nothing to Disclose ,
Roy Andrew Holliday MD : Nothing to Disclose , Wendy R. K. Smoker MD : Nothing to Disclose
TEACHING POINTS
After viewing this module the user will know the: 1. Normal gross and imaging anatomy of nerves commonly
involved in perineural tumor spread (PNTS) with emphasis on their relation to various spaces/ locations in the
head and neck (HandN) 2. Imaging findings of PNTS and common pathways of spread encounter with lesions in
specific locations 3. Clinical findings and significance of PNTS
TABLE OF CONTENTS/OUTLINE
Cross sectional images and illustrations are used to demonstrate the anatomy of pertinent nerves most
commonly involved by PNTS (CN V, CNVII and Greater Auricular), and their relationship to various spaces of the
HandN. Common connections between these nerves are reviewed, followed by a discussion of pathophysiology,
clinical findings, therapeutic and prognostic implications. Direct and indirect imaging findings of PNTS are
presented. Cases are used to demonstrate common pathways of PNTS associated with tumors in specific
locations. Lesions locations and common patterns of nerve involvement (including retrograde spread) include:
Nasopharyngeal tumors (V2 and V3), masticator space (V3), parotid space (VII, auriculotemporal branch and
greater auricular nerve), supraorbital lesions (V1), maxillary sinus and buccal space lesions (V2) and hard
palate (palatine nerve to the pterygopalatine ganglion, vidian nerve and V2).
OBE-MOA
Obstetrics/Gynecology Monday Poster Discussions
Education Exhibits
OB
AMA PRA Category 1 Credits ™: .50
Mon, Dec 1 12:15 PM - 12:45 PM
Location: OB Community, Learning Center
Sub-Events
OBE001-b
Subtypes, Imaging, and Morphology in Ovarian Carcinoma: Radiologic-pathologic Correlation
(hardcopy backboard)
Katherine Elizabeth Maturen MD (Presenter): Research support, General Electric Company , Ashish P. Wasnik
MD : Nothing to Disclose , Andrew Sciallis MD : Nothing to Disclose , Aya Kamaya MD : Noth