Scientific Informal (Posters)

 2013 RSNA (Filtered Schedule) Sunday, December 01, 2013
12:30-01:00 PM • CL-MIS-SUA • Room: S503AB • Molecular Imaging - Sunday Posters and Exhibits (12:30pm - 1:00pm) 12:30-01:00 PM • CL-NMS-SUA • Room: S503AB • Nuclear Medicine - Sunday Posters and Exhibits (12:30pm - 1:00pm) 12:30-01:00 PM • CL-PDS-SUA • Room: S101AB • Pediatric Radiology - Sunday Posters and Exhibits (12:30pm - 1:00pm) 12:30-01:00 PM • LL-BRS-SUA • Room: Lakeside Learning Center • Breast - Sunday Posters and Exhibits (12:30pm -1:00pm) 12:30-01:00 PM • LL-CAS-SUA • Room: Lakeside Learning Center • Cardiac - Sunday Posters and Exhibits (12:30pm - 1:00pm) 12:30-01:00 PM • LL-CHS-SUA • Room: Lakeside Learning Center • Chest - Sunday Posters and Exhibits (12:30pm - 1:00pm) 12:30-01:00 PM • LL-ERS-SUA • Room: Lakeside Learning Center • Emergency Radiology - Sunday Posters and Exhibits (12:30pm - 1:00pm) 12:30-01:00 PM • LL-GIS-SUA • Room: Lakeside Learning Center • Gastrointestinal - Sunday Posters and Exhibits (12:30pm - 1:00pm) 12:30-01:00 PM • LL-GUS-SUA • Room: Lakeside Learning Center • Genitourinary/Uroradiology - Sunday Posters and Exhibits (12:30pm 1:00pm) 12:30-01:00 PM • LL-HPS-SUA • Room: Lakeside Learning Center • Health Services - Sunday Posters and Exhibits (12:30pm - 1:00pm) 12:30-01:00 PM • LL-INS-SUA • Room: Lakeside Learning Center • Informatics - Sunday Posters and Exhibits (12:30PM - 1:00PM) 12:30-01:00 PM • LL-MKS-SUA • Room: Lakeside Learning Center • Musculoskeletal -Sunday Posters and Exhibits (12:30pm - 1:00pm) 12:30-01:00 PM • LL-NRS-SUA • Room: Lakeside Learning Center • Neuroradiology/Head and Neck - Sunday Posters and Exhibits (12:30pm 1:00pm) 12:30-01:00 PM • LL-PHS-SUA • Room: Lakeside Learning Center • Physics - Sunday Posters and Exhibits (12:30pm - 1:00pm) 12:30-01:00 PM • LL-ROS-SUA • Room: Lakeside Learning Center • Radiation Oncology and Radiobiology - Sunday Posters and Exhibits (12:30pm - 1:00pm) 12:30-01:00 PM • LL-VIS-SUA • Room: Lakeside Learning Center • Vascular/Interventional - Sunday Posters and Exhibits (12:30pm - 1:00pm) 01:00-01:30 PM • CL-MIS-SUB • Room: S503AB • Molecular Imaging - Sunday Posters and Exhibits (1:00pm - 1:30pm) 01:00-01:30 PM • CL-NMS-SUB • Room: S503AB • Nuclear Medicine - Sunday Posters and Exhibits (1:00pm - 1:30pm) 01:00-01:30 PM • CL-PDS-SUB • Room: S101AB • Pediatric Radiology - Sunday Posters and Exhibits (1:00pm - 1:30pm) 01:00-01:30 PM • LL-BRS-SUB • Room: Lakeside Learning Center • Breast - Sunday Posters and Exhibits (1:00pm - 1:30pm) 01:00-01:30 PM • LL-CAS-SUB • Room: Lakeside Learning Center • Cardiac - Sunday Posters and Exhibits (1:00pm - 1:30pm) 01:00-01:30 PM • LL-CHS-SUB • Room: Lakeside Learning Center • Chest - Sunday Posters and Exhibits (1:00pm - 1:30pm) 01:00-01:30 PM • LL-ERS-SUB • Room: Lakeside Learning Center • Emergency Radiology - Sunday Posters and Exhibits (1:00pm - 1:30pm) 01:00-01:30 PM • LL-GIS-SUB • Room: Lakeside Learning Center • Gastrointestinal - Sunday Posters and Exhibits (1:00pm - 1:30pm) 01:00-01:30 PM • LL-GUS-SUB • Room: Lakeside Learning Center • Genitourinary/Uroradiology - Sunday Posters and Exhibits (1:00pm 1:30pm) 01:00-01:30 PM • LL-HPS-SUB • Room: Lakeside Learning Center • Health Services - Sunday Posters and Exhibits (1:00pm - 1:30pm) 01:00-01:30 PM • LL-INS-SUB • Room: Lakeside Learning Center • Informatics - Sunday Posters and Exhibits (1:00pm - 1:30pm) 01:00-01:30 PM • LL-MKS-SUB • Room: Lakeside Learning Center • Musculoskeletal - Sunday Posters and Exhibits (1:00pm - 1:30pm) 01:00-01:30 PM • LL-MSE-SUB • Room: Lakeside Learning Center • Multisystem/Special Interest - Sunday Posters and Exhibits (12:30 - 1:00
PM) 01:00-01:30 PM • LL-NRS-SUB • Room: Lakeside Learning Center • Neuroradiology/Head and Neck - Sunday Posters and Exhibits (1:00pm 1:30pm) 01:00-01:30 PM • LL-ROS-SUB • Room: Lakeside Learning Center • Radiation Oncology and Radiobiology - Sunday Posters and Exhibits
(1:00pm - 1:30pm) 01:00-01:30 PM • LL-VIS-SUB • Room: Lakeside Learning Center • Vascular/Interventional - Sunday Posters and Exhibits (1:00pm - 1:30pm) Monday, December 02, 2013
12:15-12:45 PM • CL-MIS-MOA • Room: S503AB • Molecular Imaging - Monday Posters and Exhibits (12:15pm - 12:45pm) 12:15-12:45 PM • CL-NMS-MOA • Room: S503AB • Nuclear Medicine - Monday Posters and Exhibits (12:15pm - 12:45pm) 12:15-12:45 PM • CL-PDS-MOA • Room: S101AB • Pediatric Radiology - Monday Posters and Exhibits (12:15pm - 12:45pm) 12:15-12:45 PM • LL-BRS-MOA • Room: Lakeside Learning Center • Breast - Monday Posters and Exhibits (12:15pm - 12:45pm) 12:15-12:45 PM • LL-CAS-MOA • Room: Lakeside Learning Center • Cardiac - Monday Posters and Exhibits (12:15pm - 12:45pm) 12:15-12:45 PM • LL-CHS-MOA • Room: Lakeside Learning Center • Chest - Monday Posters and Exhibits (12:15pm - 12:45pm) 12:15-12:45 PM • LL-ERS-MOA • Room: Lakeside Learning Center • Emergency Radiology - Monday Posters and Exhibits (12:15pm - 12:45pm) 12:15-12:45 PM • LL-GIS-MOA • Room: Lakeside Learning Center • Gastrointestinal - Monday Posters and Exhibits (12:15pm - 12:45pm) 12:15-12:45 PM • LL-GUS-MOA • Room: Lakeside Learning Center • Genitourinary/Uroradiology - Monday Posters and Exhibits (12:15pm12:45pm) 12:15-12:45 PM • LL-HPS-MOA • Room: Lakeside Learning Center • Health Services - Monday Posters and Exhibits (12:15pm - 12:45pm) 12:15-12:45 PM • LL-INS-MOA • Room: Lakeside Learning Center • Informatics - Monday Posters and Exhibits (12:15pm - 12:45pm) 12:15-12:45 PM • LL-MKS-MOA • Room: Lakeside Learning Center • Musculoskeletal - Monday Posters and Exhibits (12:15pm - 12:45pm) 12:15-12:45 PM • LL-NRS-MOA • Room: Lakeside Learning Center • Neuroradiology/Head and Neck - Monday Posters and Exhibits (12:15pm 12:45pm) 12:15-12:45 PM • LL-PHS-MOA • Room: Lakeside Learning Center • Physics - Monday Posters and Exhibits (12:15pm - 12:45pm) 12:15-12:45 PM • LL-ROS-MOA • Room: Lakeside Learning Center • Radiation Oncology and Radiobiology - Monday Posters and Exhibits
(12:15pm -12:45pm) 12:15-12:45 PM • LL-VIS-MOA • Room: Lakeside Learning Center • Vascular/Interventional - Monday Posters and Exhibits (12:15pm 12:45pm) 12:45-01:15 PM • CL-MIS-MOB • Room: S503AB • Molecular Imaging - Monday Posters and Exhibits (12:45pm - 1:15pm) 12:45-01:15 PM • CL-NMS-MOB • Room: S503AB • Nuclear Medicine - Monday Posters and Exhibits (12:45pm - 1:15pm) 12:45-01:15 PM • CL-PDS-MOB • Room: S101AB • Pediatric Radiology - Monday Posters and Exhibits (12:45pm - 1:15pm) 12:45-01:15 PM • LL-BRS-MOB • Room: Lakeside Learning Center • Breast - Monday Posters and Exhibits (12:45pm -1:15pm) 12:45-01:15 PM • LL-CAS-MOB • Room: Lakeside Learning Center • Cardiac - Monday Posters and Exhibits (12:45pm - 1:15pm) 12:45-01:15 PM • LL-CHS-MOB • Room: Lakeside Learning Center • Chest - Monday Posters and Exhibits (12:45pm - 1:15pm) 12:45-01:15 PM • LL-ERS-MOB • Room: Lakeside Learning Center • Emergency Radiology - Monday Posters and Exhibits (12:45pm - 1:15pm) 12:45-01:15 PM • LL-GIS-MOB • Room: Lakeside Learning Center • Gastrointestinal - Monday Posters and Exhibits (12:45pm - 1:15pm) 12:45-01:15 PM • LL-GUS-MOB • Room: Lakeside Learning Center • Genitourinary/Uroradiology - Monday Posters and Exhibits (12:45pm 1:15pm) 12:45-01:15 PM • LL-HPS-MOB • Room: Lakeside Learning Center • Health Services - Monday Posters and Exhibits (12:45pm - 1:15pm) 12:45-01:15 PM • LL-INS-MOB • Room: Lakeside Learning Center • Informatics - Monday Posters and Exhibits (12:45pm - 1:15pm) 12:45-01:15 PM • LL-MKS-MOB • Room: Lakeside Learning Center • Musculoskeletal - Monday Posters and Exhibits (12:45pm - 1:15pm) 12:45-01:15 PM • LL-NRS-MOB • Room: Lakeside Learning Center • Neuroradiology/Head and Neck - Monday Posters and Exhibits (12:45pm 1:15pm) 12:45-01:15 PM • LL-PHS-MOB • Room: Lakeside Learning Center • Physics - Monday Posters and Exhibits (12:45pm - 1:15pm) 12:45-01:15 PM • LL-PHS-SUB • Room: Lakeside Learning Center • Physics - Sunday Posters and Exhibits (1:00pm - 1:30pm) 12:45-01:15 PM • LL-ROS-MOB • Room: Lakeside Learning Center • Radiation Oncology and Radiobiology - Monday Posters and Exhibits
(12:45pm - 1:15pm) 12:45-01:15 PM • LL-VIS-MOB • Room: Lakeside Learning Center • Vascular/Interventional - Monday Posters and Exhibits (12:45pm Page 1 of 397
1:15pm) Tuesday, December 03, 2013
12:15-12:45 PM • CL-MIS-TUA • Room: S503AB • Molecular Imaging - Tuesday Posters and Exhibits (12:15pm - 12:45pm) 12:15-12:45 PM • CL-NMS-TUA • Room: S503AB • Nuclear Medicine - Tuesday Posters and Exhibits (12:15pm - 12:45pm) 12:15-12:45 PM • CL-PDS-TUA • Room: S101AB • Pediatric Radiology - Tuesday Scientific Posters and Exhibits (12:15pm - 12:45pm) 12:15-12:45 PM • LL-BRS-TUA • Room: Lakeside Learning Center • Breast - Tuesday Posters and Exhibits (12:15pm - 12:45pm) 12:15-12:45 PM • LL-CAS-TUA • Room: Lakeside Learning Center • Cardiac - Tuesday Posters and Exhibits (12:15pm - 12:45pm) 12:15-12:45 PM • LL-CHS-TUA • Room: Lakeside Learning Center • Chest - Tuesday Posters and Exhibits (12:15pm - 12:45pm) 12:15-12:45 PM • LL-ERS-TUA • Room: Lakeside Learning Center • Emergency Radiology - Tuesday Posters and Exhibits (12:15pm - 12:45pm) 12:15-12:45 PM • LL-GIS-TUA • Room: Lakeside Learning Center • Gastrointestinal - Tuesday Posters and Exhibits (12:15pm - 12:45pm) 12:15-12:45 PM • LL-GUS-TUA • Room: Lakeside Learning Center • Genitourinary/Uroradiology - Tuesday Posters and Exhibits (12:15pm 1:15pm) 12:15-12:45 PM • LL-HPS-TUA • Room: Lakeside Learning Center • Health Services - Tuesday Posters and Exhibits (12:15pm - 12:45pm) 12:15-12:45 PM • LL-INS-TUA • Room: Lakeside Learning Center • Informatics - Tuesday Posters and Exhibits (12:15pm - 12:45pm) 12:15-12:45 PM • LL-MKS-TUA • Room: Lakeside Learning Center • Musculoskeletal - Tuesday Posters and Exhibits (12:15pm - 12:45pm) 12:15-12:45 PM • LL-NRS-TUA • Room: Lakeside Learning Center • Neuroradiology/Head and Neck - Tuesday Posters and Exhibits (12:15pm 12:45pm) 12:15-12:45 PM • LL-PHS-TUA • Room: Lakeside Learning Center • Physics - Tuesday Posters and Exhibits (12:15pm - 12:45pm) 12:15-12:45 PM • LL-ROS-TUA • Room: Lakeside Learning Center • Radiation Oncology and Radiobiology - Tuesday Posters and Exhibits
(12:15pm - 12:45pm) 12:15-12:45 PM • LL-VIS-TUA • Room: Lakeside Learning Center • Vascular/Interventional - Tuesday Posters and Exhibits (12:15pm 12:45pm) 12:45-01:15 PM • CL-MIS-TUB • Room: S503AB • Molecular Imaging - Tuesday Posters and Exhibits (12:45pm - 1:15pm) 12:45-01:15 PM • CL-NMS-TUB • Room: S503AB • Nuclear Medicine - Tuesday Posters and Exhibits (12:45pm - 1:15pm) 12:45-01:15 PM • CL-PDS-TUB • Room: S101AB • Pediatric Radiology - Tuesday Posters and Exhibits (12:45 - 1:15PM) 12:45-01:15 PM • LL-BRS-TUB • Room: Lakeside Learning Center • Breast - Tuesday Posters and Exhibits (12:45pm - 1:15pm) 12:45-01:15 PM • LL-CAS-TUB • Room: Lakeside Learning Center • Cardiac - Tuesday Posters and Exhibits (12:45pm - 1:15pm) 12:45-01:15 PM • LL-CHS-TUB • Room: Lakeside Learning Center • Chest - Tuesday Posters and Exhibits (12:45pm - 1:15pm) 12:45-01:15 PM • LL-ERS-TUB • Room: Lakeside Learning Center • Emergency Radiology - Tuesday Posters and Exhibits (12:45pm - 1:15pm) 12:45-01:15 PM • LL-GIS-TUB • Room: Lakeside Learning Center • Gastrointestinal - Tuesday Posters and Exhibits (12:45pm - 1:15pm) 12:45-01:15 PM • LL-GUS-TUB • Room: Lakeside Learning Center • Genitourinary/Uroradiology - Tuesday Posters and Exhibits (12:45pm 1:15pm) 12:45-01:15 PM • LL-HPS-TUB • Room: Lakeside Learning Center • Health Services - Tuesday Posters and Exhibits (12:45pm - 1:15pm) 12:45-01:15 PM • LL-INS-TUB • Room: Lakeside Learning Center • Informatics - Tuesday Posters and Exhibits (12:45pm - 1:15pm) 12:45-01:15 PM • LL-MIS-TUB • Room: Lakeside Learning Center • Molecular Imaging - Tuesday Posters and Exhibits (12:45pm - 1:15pm) 12:45-01:15 PM • LL-MKS-TUB • Room: Lakeside Learning Center • Musculoskeletal - Tuesday Posters and Exhibits (12:45pm - 1:15pm) 12:45-01:15 PM • LL-NRS-TUB • Room: Lakeside Learning Center • Neuroradiology/Head and Neck - Tuesday Posters and Exhibits (1:00pm 1:30pm) 12:45-01:15 PM • LL-PHS-TUB • Room: Lakeside Learning Center • Physics - Tuesday Posters and Exhibits (12:45pm - 1:15pm) 12:45-01:15 PM • LL-ROS-TUB • Room: Lakeside Learning Center • Radiation Oncology and Radiobiology - Tuesday Posters and Exhibits
(12:45pm - 1:15pm) 12:45-01:15 PM • LL-VIS-TUB • Room: Lakeside Learning Center • Vascular/Interventional - Tuesday Posters and Exhibits (12:45pm 1:15pm) Wednesday, December 04, 2013
12:15-12:45 PM • CL-MIS-WEA • Room: S503AB • Molecular Imaging - Wednesday Posters and Exhibits (12:15pm - 12:45pm) 12:15-12:45 PM • CL-NMS-WEA • Room: S503AB • Nuclear Medicine - Wednesday Posters and Exhibits (12:15pm - 12:45pm) 12:15-12:45 PM • CL-PDS-WEA • Room: S101AB • Pediatric Radiology - Wednesday Posters and Exhibits (12:15pm - 12:45pm) 12:15-12:45 PM • LL-BRS-WEA • Room: Lakeside Learning Center • Breast - Wednesday Posters and Exhibits (12:15pm - 12:45pm) 12:15-12:45 PM • LL-CAS-WEA • Room: Lakeside Learning Center • Cardiac - Wednesday Posters and Exhibits (12:15pm - 12:45pm) 12:15-12:45 PM • LL-CHS-WEA • Room: Lakeside Learning Center • Chest - Wednesday Posters and Exhibits (12:15pm - 12:45pm) 12:15-12:45 PM • LL-ERS-WEA • Room: Lakeside Learning Center • Emergency Radiology - Wednesday Posters and Exhibits (12:15pm 12:45pm) 12:15-12:45 PM • LL-GIS-WEA • Room: Lakeside Learning Center • Gastrointestinal - Wednesday Posters and Exhibits (12:15pm - 12:45pm) 12:15-12:45 PM • LL-GUS-WEA • Room: Lakeside Learning Center • Genitourinary/Uroradiology - Wednesday Posters and Exhibits (12:15pm 12:45pm) 12:15-12:45 PM • LL-HPS-WEA • Room: Lakeside Learning Center • Health Services - Wednesday Posters and Exhibits (12:15pm - 12:45pm) 12:15-12:45 PM • LL-INS-WEA • Room: Lakeside Learning Center • Informatics -Wednesday Posters and Exhibits (12:15pm - 12:45pm) 12:15-12:45 PM • LL-MKS-WEA • Room: Lakeside Learning Center • Musculoskeletal - Wednesday Posters and Exhibits (12:15pm - 12:45pm) 12:15-12:45 PM • LL-NRS-WEA • Room: Lakeside Learning Center • Neuroradiology/Head and Neck - Wednesday Posters and Exhibits
(12:15pm -12:45pm) 12:15-12:45 PM • LL-PHS-WEA • Room: Lakeside Learning Center • Physics - Wednesday Posters and Exhibits (12:15pm - 12:45pm) 12:15-12:45 PM • LL-ROS-WEA • Room: Lakeside Learning Center • Radiation Oncology and Radiobiology - Wednesday Posters and Exhibits
(12:15pm - 12:45pm) 12:15-12:45 PM • LL-VIS-WEA • Room: Lakeside Learning Center • Vascular/Interventional - Wednesday Posters and Exhibits (12:15pm 12:45pm) 12:45-01:15 PM • CL-MIS-WEB • Room: S503AB • Molecular Imaging - Wednesday Posters and Exhibits (12:45pm - 1:15pm) 12:45-01:15 PM • CL-NMS-WEB • Room: S503AB • Nuclear Medicine - Wednesday Posters and Exhibits (12:45pm - 1:15pm) 12:45-01:15 PM • CL-PDS-WEB • Room: S101AB • Pediatric Radiology - Wednesday Posters and Exhibits (12:45pm - 1:15pm) 12:45-01:15 PM • LL-BRS-WEB • Room: Lakeside Learning Center • Breast - Wednesday Posters and Exhibits (12:45PM - 1:15PM) 12:45-01:15 PM • LL-CAS-WEB • Room: Lakeside Learning Center • Cardiac - Wednesday Posters and Exhibits (12:45pm - 1:15pm) 12:45-01:15 PM • LL-CHS-WEB • Room: Lakeside Learning Center • Chest - Wednesday Posters and Exhibits (12:45pm - 1:15pm) 12:45-01:15 PM • LL-ERS-WEB • Room: Lakeside Learning Center • Emergency Radiology - Wednesday Posters and Exhibits (12:45pm 1:15pm) 12:45-01:15 PM • LL-GIS-WEB • Room: Lakeside Learning Center • Gastrointestinal - Wednesday Posters and Exhibits (12:45pm - 1:15pm) 12:45-01:15 PM • LL-GUS-WEB • Room: Lakeside Learning Center • Genitourinary/Uroradiology - Wednesday Posters and Exhibits (12:45pm 1:15pm) 12:45-01:15 PM • LL-HPS-WEB • Room: Lakeside Learning Center • Health Services - Wednesday Posters and Exhibits (12:45pm - 1:15pm) 12:45-01:15 PM • LL-INS-WEB • Room: Lakeside Learning Center • Informatics - Wednesday Posters and Exhibits (12:45pm - 1:15pm) 12:45-01:15 PM • LL-MKS-WEB • Room: Lakeside Learning Center • Musculoskeletal - Wednesday Posters and Exhibits (12:45pm - 1:15pm) 12:45-01:15 PM • LL-NRS-WEB • Room: Lakeside Learning Center • Neuroradiology/Head and Neck -Wednesday Posters and Exhibits
(12:45pm - 1:15pm) 12:45-01:15 PM • LL-PHS-WEB • Room: Lakeside Learning Center • Physicis - Wednesday Posters and Exhibits (12:45pm - 1:15PM) 12:45-01:15 PM • LL-ROS-WEB • Room: Lakeside Learning Center • Radiation Oncology and Radiobiology - Wednesday Posters and Exhibits
(12:45pm - 1:15pm) 12:45-01:15 PM • LL-VIS-WEB • Room: Lakeside Learning Center • Vascular/Interventional - Wednesday Posters and Exhibits (12:45pm 1:15pm) Thursday, December 05, 2013
12:15-12:45 PM • CL-MIS-THA • Room: S503AB • Molecular Imaging - Thursday Posters and Exhibits (12:15pm - 12:45pm) 12:15-12:45 PM • CL-NMS-THA • Room: S503AB • Nuclear Medicine - Thursday Posters and Exhibits (12:15pm -12:45pm) 12:15-12:45 PM • CL-PDS-THA • Room: S101AB • Pediatric Radiology -Thursday Posters and Exhibits (12:15pm - 12:45pm) 12:15-12:45 PM • LL-BRS-THA • Room: Lakeside Learning Center • Breast - Thursday Posters and Exhibits (12:15pm - 12:45pm) 12:15-12:45 PM • LL-CAS-THA • Room: Lakeside Learning Center • Cardiac - Thursday Posters and Exhibits (12:15pm - 12:45pm) Page 2 of 397
12:15-12:45 PM • LL-CHS-THA • Room: Lakeside Learning Center • Chest - Thursday Posters and Exhibits (12:15pm - 12:45pm) 12:15-12:45 PM • LL-ERS-THA • Room: Lakeside Learning Center • Emergency Radiology - Thursday Posters and Exhibits (12:15pm 12:45pm) 12:15-12:45 PM • LL-GIS-THA • Room: Lakeside Learning Center • Gastrointestinal - Thursday Posters and Exhibit (12:15pm - 12:45pm) 12:15-12:45 PM • LL-GUS-THA • Room: Lakeside Learning Center • Genitourinary/Uroradiology - Thursday Posters and Exhibits (12:15pm 12:45pm) 12:15-12:45 PM • LL-HPS-THA • Room: Lakeside Learning Center • Health Services - Thursday Posters and Exhibits (12:15pm - 12:45pm) 12:15-12:45 PM • LL-INS-THA • Room: Lakeside Learning Center • Informatics - Thursday Posters and Exhibits (12:15pm - 12:45pm) 12:15-12:45 PM • LL-MKS-THA • Room: Lakeside Learning Center • Musculoskeletal - Thursday Posters and Exhibits (12:15pm - 12:45pm) 12:15-12:45 PM • LL-NRS-THA • Room: Lakeside Learning Center • Neuroradiology/Head and Neck - Thursday Posters and Exhibits (12:15pm 12:45pm) 12:15-12:45 PM • LL-PHS-THA • Room: Lakeside Learning Center • Physics - Thursday Posters and Exhibits (12:15pm - 12:45pm) 12:15-12:45 PM • LL-ROS-THA • Room: Lakeside Learning Center • Radiation Oncology and Radiobiology - Thursday Posters and Exhibits
(12:15pm - 12:45pm) 12:15-12:45 PM • LL-VIS-THA • Room: Lakeside Learning Center • Vascular/Interventional - Thursday Posters and Exhibits (12:15pm 12:45pm) 12:45-01:15 PM • CL-MIS-THB • Room: S503AB • Molecular Imaging - Thursday Posters and Exhibits (12:45pm - 1:15pm) 12:45-01:15 PM • CL-NMS-THB • Room: S503AB • Nuclear Medicine - Thursday Posters and Exhibits (12:45pm - 1:15pm) 12:45-01:15 PM • CL-PDS-THB • Room: S101AB • Pediatric Radiology - Thursday Posters and Exhibits (12:45pm - 1:15pm) 12:45-01:15 PM • LL-BRS-THB • Room: Lakeside Learning Center • Breast - Thursday Posters and Exhibits (12:45pm - 1:15pm) 12:45-01:15 PM • LL-CAS-THB • Room: Lakeside Learning Center • Cardiac - Thursday Posters and Exhibits (12:45pm - 1:15pm) 12:45-01:15 PM • LL-CHS-THB • Room: Lakeside Learning Center • Chest - Thursday Posters and Exhibits (12:45pm - 1:15pm) 12:45-01:15 PM • LL-ERS-THB • Room: Lakeside Learning Center • Emergency Radiology -Thursday Posters and Exhibits (12:45pm - 1:15pm) 12:45-01:15 PM • LL-GIS-THB • Room: Lakeside Learning Center • Gastrointestinal - Thursday Posters and Exhibits (12:45pm - 1:15pm) 12:45-01:15 PM • LL-GUS-THB • Room: Lakeside Learning Center • Genitourinary/Uroradiology - Thursday Posters and Exhibits (12:45pm 1:15pm) 12:45-01:15 PM • LL-HPS-THB • Room: Lakeside Learning Center • Health Services - Thursday Posters and Exhibits (12:45pm - 1:15pm) 12:45-01:15 PM • LL-INS-THB • Room: Lakeside Learning Center • Informatics - Thursday Posters and Exhibits (12:45pm - 1:15pm) 12:45-01:15 PM • LL-MKS-THB • Room: Lakeside Learning Center • Musculoskeletal - Thursday Posters and Exhibits (12:45pm - 1:15pm) 12:45-01:15 PM • LL-NRS-THB • Room: Lakeside Learning Center • Neuroradiology/Head and Neck - Thursday Posters and Exhibits (12:45pm 1:15pm) 12:45-01:15 PM • LL-PHS-THB • Room: Lakeside Learning Center • Physics - Thursday Posters and Exhibits (12:45pm - 1:15pm) 12:45-01:15 PM • LL-ROS-THB • Room: Lakeside Learning Center • Radiation Oncology and Radiobiology - Thursday Posters and Exhibits
(12:45pm - 1:15pm) 12:45-01:15 PM • LL-VIS-THB • Room: Lakeside Learning Center • Vascular/Interventional - Thursday Posters and Exhibits (12:45pm 1:15pm) Molecular Imaging - Sunday Posters and Exhibits (12:30pm - 1:00pm) Sunday, 12:30 PM - 01:00 PM • S503AB
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CL-MIS-SUA • AMA PRA Category 1 Credit ™:0.5 Host
Heike E Daldrup-Link , MD CL-MIS-SU1A • Measuring Renal Oxygenation in a Mouse Model of Volume-dependent Hypertension Using BOLD MRI
Darah N Wright MS (Presenter) ; Stephen Lin ; Ping-Chang Lin ; Dan Zhang ; Chung-Shieh Wu ; Paul Wang ; Andre J
Duerinckx MD, PhD ; Dexter Lee PURPOSE Purpose: Hypertension is closely associated with the progression of kidney damage and dysfunction. Tissue hypoxia in the hypertensive
kidney contributes to the progression of kidney damage. Peroxisome proliferator activated receptor�? (PPAR-?) is a nuclear receptor that
plays an important role in reducing volume-dependent hypertension. The goal of this study was to determine the role of PPAR-? on renal
oxygenation using blood oxygen level-dependent (BOLD) MRI in a model of volume-dependent hypertension. METHOD AND MATERIALS Materials and Methods: Wild-type (WT) and PPAR-? knockout (KO) mice were imaged using a multiple gradient echo BOLD sequence (12
echoes from 3.2-54ms, TR=900ms) on a 9.4T MRI to measure functional changes in renal oxygenation. Imaging was performed during
baseline, day 12 of Ang II (400 ng/kg/min), and 9 days after Ang II-treatment (recovery). T2* relaxation time was measured in the
cortex and medulla of the kidney. RESULTS Results: Cortex T2* values were lower in KO vs WT during baseline (11.0 ± 1.1 ms vs 13.1 ± 1.5 ms), day 12 of Ang II (11.6 ±1.2 ms
vs 16.2 ±1.5 ms) and 9 days after Ang II (12.5 ± 0.7 ms vs 15.2 ± 0.3 ms). Medulla T2* values were lower on day 12 of Ang II in KO
(16.5 ± 2.5 ms) vs WT (20 ± 1.6 ms) mice. Medulla T2* values were similar between KO and WT mice during baseline and the recovery
period. In KO and WT mice, cortex T2* values were lower than that of the medulla, indicative of different metabolic functions between
the two tissues. CONCLUSION Conclusion: PPAR-? plays an important role in blood pressure regulation and renal oxygenation in the cortex and medulla of the kidney
during Ang II-induced hypertension. CLINICAL RELEVANCE/APPLICATION Hypertension is a risk factor for chronic kidney disease when untreated. BOLD MRI can aid in monitoring renal oxygenation changes
during hypertension and determine therapeutic interventions in humans. CL-MIS-SU2A • Frontal Watershed Sign: A Novel SPECT Imaging Finding in CNS LUPUS
Avetis Azizyan MD (Presenter) ; Paul Linesch ; Alessandro D'Agnolo ; Alan D Waxman MD * PURPOSE Single-photon emission computed tomography (SPECT) is routinely utilized for the evaluation of systemic lupus erythematosus (SLE)
patients with acute neurological symptoms, however, a clear anatomic distribution of disease has not been found. In this study, 3D
rendering of SPECT imaging was performed to determine whether a specific cortical distribution of disease is present. METHOD AND MATERIALS 37 consecutive SLE patients who presented with acute neurological symptoms underwent surface rendered brain SPECT. All studies were
performed on a three detector SPECT camera (Prism 3000) following 20mCi Tc-99m ethyl cysteinate dimer. 3D stereotactic surface
projection (3D SSP) analysis was conducted on Neurostat software comparing the 37 lupus patients averaged as a group to 19 patients
from a normal database. Differences in cortical perfusion were presented as a color map of standard deviations from the mean.
Standardized 3D rendered SPECT images from the lupus group along with 11 normal studies were then reviewed by a radiologist blinded
to any history or laboratory findings. The images were scored on a numerical scale with 10 being the most abnormal pattern and 0 being
a normal pattern. Scores of 5 and above were considered as positive while 4 and below were negative.
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a normal pattern. Scores of 5 and above were considered as positive while 4 and below were negative.
RESULTS 3D SSP analysis demonstrates decreased perfusion in the medial frontal lobes and along the watersheds between the anterior and middle
cerebral arteries which is 6 standard deviations below the mean. There is sparing of the partietal and occipital lobes as well as the inferior
temporal lobes. When the radiologist reviewed and scored the SPECT images individually, an abnormality in the frontal lobes was
detected with a specificity of 100%, but sensitivity of 64%. CONCLUSION 3D surface rendered brain SPECT detects markedly decreased perfusion in the anterior watershed territories of the frontal lobes in lupus
patients, which has not been previously described. Furthermore, blinded reading of the surface rendered imaging demonstrates that this
finding is specific for lupus when present. CLINICAL RELEVANCE/APPLICATION The finding of diminished perfusion in the frontal watersheds on 3D surface rendered SPECT imaging is novel and helps elucidate the
pathophysiology of acute CNS lupus. CL-MIS-SU3A • Conventional vs. Dedicated Head SPECT System: Image Quality Comparison
William F Sensakovic PhD (Presenter) ; Matthew C Hough MSc ; Elizabeth Kimbley PURPOSE To compare a new SPECT system with a scanning geometry specialized for the head with a conventional SPECT system under similar
clinical scanning conditions. METHOD AND MATERIALS A dediacated head SPECT scanner (Neurologica inSPira HD) consisting of 72 detectors with focused cone collimators in a rotating ring
geometry was compared to a conventional GE millennium VG SPECT scanner. A small ACR phantom was scanned in the inSPira HD and
GE millennium VG. Images were acquired with both high and low activities of Tc-99m with acquisition parameters selected to simulate a
clinical ictal scan. Resolution, contrast, noise, and uniformity were compared. RESULTS The inSPira was able to resolve rods 7.9mm and greater vs. 11.1mm and greater for the VG. Noise was increased from a
coefficient-of-variation of 2.1 in the VG to 3.0 in the inSPira. Contrast was 24% better on the inSPira on average over all spheres.
Spheres 12.7mm and larger were visible on the VG vs. 6.4mm and larger on the neurologica. Spheres appeared larger in VG images due
to lower resolution and increased partial volume artifact. Integral uniformity of the inSPira was 6.9 compared to 4.6 in the VG. CONCLUSION The dedicated head SPECT system demonstrated substantially better resolution, contrast, and less partial volume artifact. Subjectively,
the improvement of these characteristics in the inSPira produced qualitatively better images than the conventional SPECT scanner despite
increased noise and lower uniformity. CLINICAL RELEVANCE/APPLICATION The improved resolution and contrast of the dedicated head SPECT system may lead to more accurate mapping of the brain and
improved localization and size estimation of lesions. CL-MIS-SU4A • Quantitative Evaluation of FDG-PET Lesions with Low Dose Protocol
Wenli Wang PhD (Presenter) * ; Ting Xia PhD * ; Hongwei Ye PhD * ; Xiaofeng Niu PhD * ; Changguo Ji PhD * ; Mark L
Winkler MD ; Manabu Teshigawara PhD * ; Yasuhiro Noshi ; Edward Haines PhD * ; Daniel Gagnon PhD * PURPOSE Advancements of PET scanner design and reconstruction algorithm offer the opportunity to reduce patient�s radiotracer dose and/or
imaging time. The purpose of this paper is to evaluate how low the dose reduction can be without sacrificing the FDG-PET lesion�s
detectability and quantitative accuracy. METHOD AND MATERIALS Several lung and/or breast cancer patients' FDG-PET data are used, with IRB approval and patient�s consent. The data were acquired
from a PET/CT prototype scanner, where the PET data is reconstructed with 3D list-mode time-of-flight ordered-subset
expectation-maximization algorithm with full physical corrections, and low-dose CT data for PET attenuation correction. The original PET
data was acquired with whole-body imaging protocol with regular injection dose and imaging time (i.e., default-dose protocol). The PET
data with different levels of lower injection dose and shorter imaging time (i.e., low-dose protocol) is then mimicked from the original
data by taking a uniform sub-sampling. Different levels of smoothing post-filters will be applied to the PET image to achieve similar
signal-to-noise-ratio in soft tissue among different dose protocols. The lesion�s standard-uptake-values (SUV) are then measured and
compared for different dose protocols to represent the lesion�s detectability. RESULTS Moderate size and spherical-shape lesions will be used for the SUV analysis. The percentage change of lesion�s SUV (referenced to the
default-dose) will be plotted for different levels of dose protocols and also as a function of the post-filter kernel for the default dose.
Different metrics of SUVs, such as SUV
max, SUV mean and SUVpeak, or total lesion glycolysis, will be compared. CONCLUSION The most stable SUV metric will be proposed and the lowest dose protocol with acceptable SUV degradation will be recommended. More
patients needed to be recruited in the study in the future to indicate any statistical significance. CLINICAL RELEVANCE/APPLICATION Provide objective guidelines on imaging protocol and image quality metric for dose reduction of FDG-PET oncology application. Nuclear Medicine - Sunday Posters and Exhibits (12:30pm - 1:00pm) Sunday, 12:30 PM - 01:00 PM • S503AB
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CL-NMS-SUA • AMA PRA Category 1 Credit ™:0.5 Host
Ukihide Tateishi , MD, PhD CL-NMS-SU1A • Evaluating the Metastatic Cure Probability (MCP) of Targeted Radionuclide Therapy (TRT) for Head and Neck
Cancer (HNC) Using a Pretargeting System
Tod W Speer MD (Presenter) ; Jenna Borkenhagen MD PURPOSE Purpose/Objectives: TRT is a systemic radiotherapy that uses radionuclides to target malignant tissue. Clinical data has been generated
using 90Y (anti-CEA, B72.3 antibody) for the treatment of HNC with TRT using pretargeting. A maximum of 70 mCi 90Y was instilled. This
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using 90Y (anti-CEA, B72.3 antibody) for the treatment of HNC with TRT using pretargeting. A maximum of 70 mCi 90Y was instilled. This
study simulated the mean equivalent dose (Deq) required to cure metastatic carcinoma using 90Y and assesses the theoretical feasibility
of delivering this dose in terms of the current reported administered activity. METHOD AND MATERIALS A model for tumor growth (Gompertzian) and metastatic formation was developed using human data. Monte Carlo simulations were
performed to determine the 90% metastatic cure probability (MCP) for the metastatic formation rate constants (c=%[day/g]) of 0.01,
0.1, 1.0, 10 and corresponding total metastatic mass (g) groups of 1.4, 16, 160, 1600. Calculations were performed to estimate the
required administered activity (mCi) that would result in the simulated Deq that accomplishes the MCP for each metastatic mass group.
The following were assumed: uniform dose distribution, radionuclides completely decay, all decay energy was absorbed by the mass
group. RESULTS Simulated metastatic mass distributions for �c� of 0.01, 0.1, 1.0, 10 resulted in detectable metastasis (lesions > 1.0 g) of 0.17, 1.7, 17,
180 and a total number of metastases of 0.92, 9.7, 170, 9000, respectively. The Deq (Gy) required for MCP for 90Y against the total
metastatic mass (g) of 1.4,16, 160, 1600 was: 5,200 Gy, 11,000 Gy, 17,000 Gy, 28,000 Gy. The required administered activities (mCi)
to exercise the MCP are: 3.97 mCi, 96 mCi, 1483 mCi, 24,429 mCi. CONCLUSION If a large amount of administered activity of TRT is focused in malignant tissue, current data indicates a potential to cure systemic
disease with a mass range of 1.4 to 16 grams. Stratagies should be employed to use TRT earlier in the therapeutic process and to
increase dose to malignant tissue (pretargeting, fractionation, bone marrow support). CLINICAL RELEVANCE/APPLICATION Because current administered TRT activities have the potential to cure a limited range of metastatic disease, the future direction of TRT
should be to employ early and increase overall dose. CL-NMS-SU2A • Estimation of Pulmonary Nodule Malignancy: Effect of a Computer-aided Diagnosis System Integrating PET and
HRCT Findings on the Performance of Radiologists
Daisuke Komoto MD (Presenter) ; Masahito Aoyama PhD ; Yuichirou Takaki ; Toru Higaki PhD ; Wataru Fukumoto ; Kazuo
Awai MD * PURPOSE High-resolution CT (HRCT) and 18F-FDG PET are major techniques to differentiate malignant- from benign pulmonary nodules; however,
the interpretation of these images relies on the knowledge and experience of the radiologist who is performing the interpretation. We
developed a computer-aided diagnosis (CAD) system that integrates HRCT and PET findings for the differentiation between malignant and
benign pulmonary nodules and investigated the effect of our system on the diagnostic performance of radiologists. METHOD AND MATERIALS We evaluated 39 non-calcified solitary pulmonary nodules less than 3.0 cm in maximal diameter in 39 patients who underwent HRCT and
PET imaging. Our CAD system analyzes 6 morphological features on HRCT images and one PET feature (standardized uptake value).
Receiver operating characteristic (ROC) analysis on a continuous rating scale was used to compare observer performance for estimating
the likelihood of malignancy. The readers were 5 attending radiologists with board certification for PET diagnosis and 5 radiology
residents. HRCT and PET images were first presented without the CAD output. After each reader marked the initial level of confidence,
the CAD output for likelihood of malignancy (0: absolutely benign, 100: absolutely malignant) was displayed on the monitor and each
reader could change his/her confidence level. Before the observer performance study all readers were shown that the true positive rate,
false positive rate, and the area under the ROC curve (AUC) were 0.84, 0.25, and 0.84. RESULTS For the attending radiologists the mean AUC values without and with CAD were 0.90 ± 0.02 (standard deviation) and 0.89 ± 0.03,
respectively (p = 0.62). For the residents they were 0.74 ± 0.07 and 0.79 ± 0.07, respectively (p = 0.02). CONCLUSION Use of the CAD system significantly (p = 0.02) improved the diagnostic performance of radiology residents assessing the malignancy of
pulmonary nodules but not of attending radiologists. CLINICAL RELEVANCE/APPLICATION Use of the CAD system that integrates PET and HRCT findings can improve the diagnostic performance of less experienced readers
assessing pulmonary nodules for malignancy. CL-NMS-SU3A • A New Radiation Dose Minimization Protocol in Early Chemotherapy Response in Lymphoma Using 18F-FDG
PET-CT
Luke I Sonoda PhD, FRCR (Presenter) ; Bal Sanghera PhD ; Subhadip Ghosh-Ray ; Thomas Wagner ; Kyoko Sonoda ; Wai
Lup Wong PURPOSE There is ever-increasing evidence of 18F-FDG-PET-CT being useful in monitoring early response to chemotherapy in lymphoma. With a
concern of radiation burden this study aimed to assess if PET-CT acquisition area could be minimised in order to reduce radiation dose
and acquisition time. METHOD AND MATERIALS Retrospective analysis of 1000 consecutive lymphoma patients (553 male, mean 42.4years-old, 421 Hodgkin�s Lymphoma (HL), 579
Non-HL) was performed to record sites of disease on pre-chemotherapy PET-CT and the first post-chemotherapy PET-CT. The body is
divided into four conventional parts (head-and-neck, thorax, abdomen and pelvis) for recording sites of disease. The potential reduction
in radiation dose and time-saving achieved by limiting to the sites of known disease identified on pre-chemotherapy PET-CT was
calculated. RESULTS No FDG-uptake was seen in 744/1000 first post-chemotherapy PET-CT. FDG-uptake at known disease sites was seen in 256/1000 cases.
902/1000 of the patients had disease confined to only one or two body parts out of four.
Incidental synchronous non-lymphomatous malignancy (such as colonic or lung carcinoma) was identified in 48/1000 cases in
pre-chemotherapy PET-CT. Post-chemotherapy PET-CT did not reveal any unexpected sites of lymphoma or incidental interval malignancy.
Limiting PET-CT to the sites of known disease would have reduced a mean radiation dose by 3.6 mSv (24.3 %), with a mean time-saving
of 16 minutes (66.6%).
CONCLUSION In order to assess early response to chemotherapy it may be sufficient to scan the sites of known disease. This leads to reduce the
incidence of secondary cancers, particularly in the young patients experiencing multiple radiation exposure. CLINICAL RELEVANCE/APPLICATION Early interval response to chemotherapy in lymphoma may be monitored with FDG-PET-CT scan limited to the original site of the disease
in order to minimize the total radiation dose to the patients. CL-NMS-SU4A • The Significance of 18F-FDG Uptake in Neck Lymph Nodes in Pediatric Patients without Head and Neck
Malignancy
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Reza Vali MD (Presenter) ; Amer Shammas MD ; Mohamad El Zein ; Martin Charron MD PURPOSE 18F-FDG PET/CT has been widely used in oncology. Reactive neck lymph nodes (N LNs) have been reported as a cause of false positive
findings on PET studies. The purpose of this study was to evaluate the frequency and the significance of N LNs uptake in patients without
malignancy originating from head and neck (H and N). METHOD AND MATERIALS 367 patients (882 studies) who were referred for a PET/CT study from 2008 till 2011 were evaluated retrospectively. 120 patients (316
studies) were excluded from the study due to the history of a malignancy involving H and N. FDG uptake in N LNs was recorded in 247
patients (567 studies) without any malignancy originating from H and N region (130 lymphoma, 30 post transplant lymphoproliferative
disease (PTLD) and 87 others) . The diagnosis of malignancy versus reactive/inflammatory process was confirmed with follow up studies
or biopsy. Maximum Standardized uptake values (SUV-max) were recorded for semi-quantitative analysis. RESULTS FDG uptake in N LNs was indentified in 74/247 (29.9%) of the patients (83/567; 14.6% of studies). In 41 patients the N LNs with FDG
uptake were proved as benign (39 on F/U evaluations and 2 with biopsy). In 8 patients the LNs were proved to be malignant (one on F/U
evaluations and 7 with biopsy). In 25 patients, we were not able to confirm the final diagnosis. 7 out of the 8 malignant LNs were in
patients with history of PTLD. The size of the positive LNs was less than 1 cm in 3 out of 8 positive LNs. The mean SUV-max was
significantly higher in malignant lesions (5.2) compared to the benign group (2.1). 7 out of 8 malignant LNs had an SUV-max of more
than 3 while only 3 out of 41 patients with non-malignant LNs had an SUV-max of more than 3. CONCLUSION Mild to moderate FDG uptake in N LNs is relatively common in pediatric patients and is frequently due to reactive LNs in patients without
history of H and N cancer when the SUV-max is less than 3. The frequency of malignant NLNs is higher in PTLD patients compared to
other groups. CLINICAL RELEVANCE/APPLICATION It is important to differentiate malignancy versus inflammation in neck lymph node with FDG uptake CL-NME-SU5A • Quality Improvement Initiative to Reduce Patient Pain during Preoperative Sentinel Node Localization Injections
and Maintain Diagnostic Accuracy of Axillary Sentinel Node Identification for Breast Cancer
Cindy S Lee MD ; Vered Stearns MD * ; Jill Kessler ; Eman Sbaity ; Karineh Tarpinian ; David J Eisner MD (Presenter) ; Lisa
Jacobs MD ; Mehran Habibi ; Kimberly Aguirre ; Amanda Blackford MSc ; Stacie Jeter ; Nagi F Khouri MD ; Evelyn A May
MD ; Paul G Nagy PhD PURPOSE Preoperative sentinel node localization (SNL) is now a standard of care for patients undergoing surgical treatment for breast cancer. It
requires a subareolar injection of radiotracer Tc99-sulfur colloid which often causes severe pain for a few minutes (if lidocaine is not
used), but has been characterized by numerous patients as the "worst pain of my life." Subareolar administration of lidocaine in
conjunction with the radiotracer injection has been demonstrated to be effective in alleviating pain during SNL. However, the use of
lidocaine during SNL is not a widely adopted practice. One concern is that lidocaine use can obscure the subsequent identification of
sentinel node during surgery and thereby reduce the diagnostic accuracy of SNL. This project aims to compare the diagnostic accuracy of
SNL with and without lidocaine injection prior to the injection of Tc99-sulfur colloid utilizing ultrasound guidance. We hypothesize that
lidocaine administration will not impact accurate identification of the axillary sentinel lymph node. METHODS This study is IRB approved and HIPAA compliant. For the pre-intervention phase, we performed a retrospective analysis of surgical rates
of sentinel lymph node identification from 205 women from 2005-2009 who did not receive lidocaine during preoperative SNL. For the
post-intervention phase, women were enrolled from January 2011 to July 2012 and surgical identification rates were analyzed. Both
groups were identified from the Johns Hopkins Breast Center and the same eligibility criteria were used. Exclusion criteria include painful
cancer, lidocaine allergy, age younger than 18, lesion or microcalcifications >4cm in the upper outer breast, prior surgical interventions in
upper outer breast, and history of chemotherapy and tamoxifen treatment. All of the exclusions were for the possibility of impeding
lymphatic drainage to the axilla for reasons other than the additional injection of lidocaine. Patients who consented to the prospective
portion were interviewed and given the McGill pain questionnaire to complete prior to and after the SNL. The diagnostic accuracy of SNL
was determined by successful identification of the sentinel node during surgery based on medical record review, for both pre- and
post-intervention groups. We evaluated the proportion of women with successful SNL by technetium alone and those requiring additional
periareolar intraoperative injection of methylene blue dye or saline to assist in the sentinel node identification. To assess the similarity
between the pre- and post intervention groups, demographic and tumor characteristics of both groups were collected and compared,
including age, ethnicity, tumor type, size, grade, estrogen receptor/progesterone receptor/HER2 positivity, and status of nodal
metastasis. P values for differences between cohorts are from Wilcoxon rank sum tests comparing continuous measures and Fisher's
exact test for categorical measures. RESULTS The pre- and post-intervention groups have similar demographic and tumor characteristics. In the pre- intervention group, 204 patients
were included; the diagnostic accuracy of SNL is 94% and 100% with the use of intraoperative methylene blue dye/saline (table). In the
post-intervention group, 107 patients (80% participation rate) consented to and received the lidocaine administration prior to the
radiotracer injection. The post-lidocaine diagnostic accuracy of SNL is 95% and 100% with the use of intraoperative methylene blue
dye/saline (table). There is no significant difference in diagnostic accuracy of SNL pre- and post- lidocaine intervention. The reported level
of pain following lidocaine injection is very low (mean = 0.481) on the McGill pain scale of 0 to 10. CONCLUSION The administration of lidocaine during preoperative SNL not only reduces patient pain but also maintains diagnostic accuracy of the
procedure itself. Our project validates a patient-centered approach for performing a standard-of-care procedure in breast cancer
treatment. At our institution, because of the encouraging result of this project, we have changed our practice behavior to incorporate the
use of lidocaine during all preoperative sentinel lymph node injections (unless there is a lidocaine allergy). CL-NME-SU6A • High Radiation Badge Readings among Technologists in an Outpatient PET/CT Practice: Analysis and Solution
Josephine N Rini MD (Presenter) ; Jason J Naidich MD ; Eran Ben-Levi MD ; Cythia Kubala ; Christopher J Palestro MD ; Kenneth Nichols PhD * PURPOSE Technologists in our high volume outpatient PET/CT practice (approximately 3,500 studies/year) consistently received high radiation
badge readings (>0.5 mSv/month). We undertook this investigation as part of a quality improvement project aimed at understanding and
reducing technologist radiation exposure. To address these issues we (1) analyzed technologist radiation badge readings as a function of
work hours; (2) determined relative radiation exposure during various segments of PET/CT workflow; (3) implemented and assessed the
effectiveness of a radiopharmaceutical auto-injector for reducing technologist radiation exposure. METHODS Monthly body and ring radiation badge readings and work hours were analyzed for 6 technologists performing 2-3 manual injections of
444-555 MBq 18F-FDG/shift. For 4 technologists 12 months of data were available for analysis. For the fifth and sixth technologists, nine
months and five months, respectively, of data were available for analysis. Annual mean radiation dose equivalent values per hour
(mSv/hr) were computed for each technologist for the manual injection technique. PET/CT workflow was divided into 3 segments: (1)
preparation/injection of 18F-FDG; (2) positioning patient on scanner; and (3) removing patient from scanner. For both manual and
Page 6 of 397
auto-injector techniques the technologists used pocket dosimeters to determine their radiation exposure from 10 patients during each of
the 3 segments of PET/CT workflow. Total radiation exposure and per cent of total radiation exposure from each workflow segment, for
both injection techniques, were compared.
RESULTS Using the manual injection technique, mean body dose was 0.0037±0.0012 mSv/hr (institutional ALARA limit 0.0025 mSv/hr) and mean
hand dose was 0.0129±0.0074 mSv/hr (institutional ALARA limit 0.025 mSv/hr). By two-way ANOVA, radiation doses per MBq of injected
activity were similar among technologists for segment 1 (p=0.86) and for the entire procedure (p=0.24), but were significantly higher for
the manual injection technique than for the auto injector (p=0.003). For the manual injection technique, radiation doses per MBq of
injected activity were significantly higher for segment 1 than for segments 2 (0.0084±0.0005 versus 0.0048± 0.0022, p=0.002), and
segment 3 (0.0084±0.0005 versus 0.0028±0.0012, p Based on analysis of technologist radiation badge readings and work hours,
assuming current staffing and patient volumes, technologists working full time (150 hr/month), could be expected to receive an average
of 0.56 mSv/month to the body and 1.94 mSv/month to the hand, using the manual injection technique. Although well below
occupational dose limits, this mean body dose exceeds institutional ALARA limits. Analysis of relative radiation exposure during each of
the 3 PET/CT workflow segments showed that process improvement in the injection phase would be most beneficial for reducing
technologist exposure. Re-analysis of relative radiation exposure during the 3 PET/CT workflow segments using the auto-injector
technique demonstrated a 55% decrease in technologist radiation exposure during the injection phase and a 40% overall decrease in
radiation exposure.
CONCLUSION The introduction of a radiopharmaceutical auto-injector, as our data indicate, has the potential to significantly reduce radiation exposure
to technologists administering 18F-FDG. Pediatric Radiology - Sunday Posters and Exhibits (12:30pm - 1:00pm) Sunday, 12:30 PM - 01:00 PM • S101AB
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CL-PDS-SUA • AMA PRA Category 1 Credit ™:0.5 Host
Sanjay P Prabhu , MBBS CL-PDS-SU1A • Core vs. Complete MRI Protocols for Diagnostic Assessment of Temporomandibular Joints (TMJ) in Juvenile
Idiopathic Arthritis (JIA). Is There a Diagnostic Interpretation Difference at 1.5 and 3T?
Emilio Inarejos Clemente MD (Presenter) ; Jennifer Stimec MD ; Nikolay Tzaribachev ; Bernd Koos ; Lynn Spiegel MD ; Andrea S Doria MD * PURPOSE To evaluate the inter-reader reliability for interpretation of TMJ exams utilizing a core vs complete MRI protocol, and to assess readers�
capability for visualization of anatomic structures using core vs complete protocols at 1.5 and 3T.
METHOD AND MATERIALS MRI exams of 25 JIA patients (20 F/5 M; age range,8-17 years; mean,13.7 years) were acquired on a 1.5T Philips Systems scanner and of
23 JIA patients (18 F/5 M; age range,7.7-17 years; mean,13.2 years) on a 3T Philips Systems scanner. All MRI exams were independently
scored by 3 blinded readers (scores 0-3, normal-severe) with regard to specific items (synovitis [0-3, none-severe]/synovial thickness
[mm], extension[0-3]/ bone erosions depth [mm]) using a core (3 planes T1 fat saturated [FS] post-gadolinium [Gd]) and an expanded
(coronal T1, sagittal T2FS, sagittal PD, 3 planes T1FSGd) protocol. Readers scored individual MRI sequences according to the capability of
visualization of anatomic structures (scores 0-5, 0=not visible, 5=excellent visibility). RESULTS Total scan time for core/expanded MRI protocols at 1.5 and 3T were 13.86 / 27.36 min and 12.39 / 20.41 min, respectively. Inter-reader
agreement for semi-quantitative scores was poor to moderate for synovitis both at 1.5T (intraclass correlation coefficient [ICC],
0.37-0.46) and 3T (0.48-0.62), which improved for quantitative measurements: variable/substantial ICCs for synovial thickness (variable
ICcs at 1.5T and 0.80-0.82 at 3T) and variable/substantial for bone erosion depth (ICC, 0.37-0.76 at 1.5T and 0.79-0.84 at 3T). The
reader's capability for visualization of anatomic structures was not different between core and complete protocols for synovitis at 1.5T
(mean, SD, 3.96 [0.87] and 3.87 [0.54], P>0.05); or at 3T (4.39 [0.71] and 4.13 [0.81], P>0.05), or for bone erosions extent at 1.5T
(3.16 [1.01] and 2.96 [1.05], P>0.05) or at 3T (4.17 [0.93] and 4.13 [0.86], P>0.05). CONCLUSION Regardless of the MRI strength field further improvement of semi-quantitative assessment of JIA TMJs is required. Optimization of MRI
protocols towards decreasing scanning times does not significantly affect the capability of readers for interpretation of basic findings in
TMJs of JIA patients which do not require pre- and post-contrast assessment, either at 1.5 or 3T. CLINICAL RELEVANCE/APPLICATION A faster MRI protocol for TMJ in JIA can obtain diagnostic information for specific clinical questions regardless the strengh of the magnet. CL-PDS-SU2A • Changes in the Amplitude of Low-frequency Fluctuations and Its Correlation with Children Suffered from Irritable
Bowel Syndrome: A Resting-state fMRI Study
Na Chang (Presenter) ; Na Liu MD ; Bing Yu MD ; Qiyong Guo MD PURPOSE To measure the changes of amplitude of low-frequency fluctuations (ALFF) using resting-state functional magnetic resonance imaging
(R-fMRI) in children with irritable bowel syndrome(IBS). METHOD AND MATERIALS Thirty IBS children(15 female;age8±2.1y) and thirty controls(15 female;age8±1.2y) were recruited. The functional MRI was performed at
resting state on a 3.0T MR scanner. The resting-state fMRI data of patients diagnosed with IBS and healthy children were obtained and
performed ALFF analysis. The ALFF data of IBS and controls were analyzed by student�s t test. A P value of less than 0.05 was
considered to indicate statistical significance.
RESULTS Compared with normal controls, ALFF values was increased significantly in bilateral medial prefrontal cortex (MPFC) , bilatreal thalamus
and right insula in IBS children(p CONCLUSION The functional changes in bilatreal MPFC, bilatreal thalamus and right insula might be associated with children with IBS. CLINICAL RELEVANCE/APPLICATION The functional changes in MPFC, thalamus and insula might be associated with children with IBS. CL-PDS-SU3A • Apparent Diffusion Coefficient (ADC) In Characterization of Posterior Fossa Tumors in Children-Egyptian
Experience
Page 7 of 397
Experience
Mohamed A Aggag MD (Presenter) ; Amal M Refaat MD ; Ayda A Youssef MSc, PhD PURPOSE This study aims to assess the correlation between the apparent diffusion coefficient (ADC) and the type of posterior fossa tumors in
children. METHOD AND MATERIALS Retrospective review of patient charts with histologically proved neoplasm in the CCHE database from Jan 2008 till Dec 2011 was
performed. The preoperative Diffusion Weighted Imaging (DWI) and ADC characteristics of posterior fossa tumors in 104 children (38
Female, 66 Male; Age range 6 months - 15 years, median: 6.4 years) were compared with post-operative histopathology diagnosis.
Kruskal-Wallis test was performed to measure the difference in the ADC between different histological sub-diagnoses. Post Hoc method
was used to test the significant difference between each two sub-diagnoses. Statistical analyses were performed using SPSS. RESULTS There was a significant difference between ADC in different histological subgroups (p 0.05). CONCLUSION In our sample, ADC is useful for differentiation between different posterior fossa tumors at paediatric age, when used to compare
different common histology. These results are expected to be of great impact on preoperative evaluation of brain tumors. CLINICAL RELEVANCE/APPLICATION Correlation between the apparent diffusion coefficients (ADC) calculated from DW images and tumor cellularity shows growing confidence
;in tumor tissue characterization.Correlation between the apparen CL-PDS-SU4A • On the Etiology of the Cam Deformity in Femoroacetabular Impingement: A Cross-sectional Paediatric MRI Study
Sasha Carsen MD (Presenter) ; Kawan S Rakhra MD ; Paul Moroz MD ; Hal J Dunlap MD ; Leanne M Ward ; John A Hay PhD ; R. Baxter Willis ; Paul E Beaule MD * PURPOSE Little is known on the etiology of the cam morphology associated with femoroacetabular impingement (FAI). The purpose of our study
was to determine when the cam morphology associated with femoroacetabular impingement developed in a cross-sectional cohort study
of pediatric patients pre- and post-physeal-closure using magnetic resonance imaging (MRI). METHOD AND MATERIALS Alpha angles were measured at the 3:00 o�clock (anterior head-neck junction) and 1:30 (antero-superior head-neck junction) positions
in both hips with a cam deformity defined as an alpha angle >50.5� at the 3:00 o�clock position. RESULTS Forty-four volunteers (88 hips) were studied: 23 with open physes (12 females, mean age 9.7 years; 11 males, age 11.7), 21 with closed
physes (5 females, age 15.2; 16 males, age 16.2). None of the 23 (0%) patients pre-physeal-closure had cam morphology, whereas 3 of
21 (14.3%, p=0.02; all males) post-closure had at least one hip with cam morphology. Mean alpha angles at 3:00 head-neck position
were 38.1� (95% CI = 37.2� � 39.1�) in the open physes group, and 42.0� (95% CI = 40.16� � 43.90�) in the closed physes group;
at the 1:30 head-neck position were 45.2� (95% CI = 44.0� � 46.4�) in the open physes group, and 50.1� (47.9� � 52.3�) in the
closed physes group. CONCLUSION The presence of cam morphology in only the closed physeal group strongly supports its development during the period of physeal
closure. Alpha angles showed significant differences between the 3:00 and 1:30 positions, with consistently greater alpha angles at the
1:30 (antero-superior head-neck junction) position. This has important implications for the diagnosis of cam morphology. CLINICAL RELEVANCE/APPLICATION Cam FAI morphology develops during the period of physeal closure. In the pediatric population, as in adults, interpretation of alpha
angles is dependent on radial MRI position. CL-PDS-SU5A • Maturation of White Matter and Grey Matter Is 'Out-of-Sync' in Premature Born Infants
Stefan Bluml PhD (Presenter) ; Jessica L Wisnowski PhD ; Lisa Paquette ; Marvin D Nelson MD ; Ashok Panigrahy MD PURPOSE To compare metabolism of white matter and grey matter at equivalent post-conceptional (PC) age in term and preterm infants. METHOD AND MATERIALS MR examinations and medical records of 656 patients aged between 270 (term) � 370 post-conceptional (PC) days were reviewed. All
subjects had clinically indicated MR examinations. However, 81 subjects had normal MRI (including normal diffusion MRI) and
unremarkable clinical follow-up for a minimum of six months. Among these infants, 51 were full-term (gestational age (GA) at birth:
40+/- 1 weeks) and 30 were premature-born (GA: 30+/- 5 weeks). MR spectra acquired with single voxel PRESS (echo time 35ms,
repetition time = 1.5s, 128 averages) of parietal white matter (WM) and parieto/occipital grey matter (GM) were analyzed with
automated LCModel software and absolute metabolite concentrations were obtained. Metabolite versus age curves for term and preterm
cohorts were generated and compared for statistical significant differences. RESULTS CONCLUSION The biochemical maturation of white matter of term and preterm infants is significantly different whereas no significant differences were
observed for grey matter. This indicates that mainly processes of WM maturation, such as axonal growth and possibly myelination are
affected by premature birth. Consequently, the timing and synchronization of white and grey matter maturation is disturbed. There
appears to be a "false start" of some maturational processes in WM triggered by physiological and/or stimulatory events after birth. This
may contribute not only to the greater risk of long-term neurological problems of premature babies, but also to their higher risk for brain
injury. CLINICAL RELEVANCE/APPLICATION Therapeutic interventions that aim to alleviate the possible adverse impact of prematurity on brain function may need to emphasize
strategies that prevent a "false start" of white matter maturation. CL-PDE-SU6A • The Pediatric Aorta: CTA and MRA Imaging of Inherited Connective Tissue Disorders
Kevin Ching MD ; Ariel Hsu MD (Presenter) ; Shobhit Madan MD,MPH ; Sameh Tadros MD, MSc PURPOSE/AIM Connective tissue disorders affecting the cardiovascular system may have unusual clinical presentations which lead to their eventual
genetic diagnosis. Advanced vascular imaging with CTA and MRA plays a vital role in screening and follow up of arterial pathology. This
exhibit will review the imaging findings of Marfan, Ehlers-Danlos, and Loeys-Dietz syndrome on CTA, MRA, and Cardiac-MR. CONTENT ORGANIZATION Page 8 of 397
1. Overview of Marfan, Ehlers-Danlos, and Loeys Dietz Syndromes. a. Review of genetic mutations and disease classifications.
b. Unique clinical features with a focus on vascular pathology.
c. Signs, symptoms, and clinical presentation.
2. Arterial tortuosity, dissection, and aneurysmal dilatation on CTA, MRA, and Cardiac MR. 3. Impact on the peripheral arteries and imaging findings on CTA and MRA.
4. Treatment and recommendations for initial and follow up imaging.
SUMMARY 1. Inherited connective tissue disorders may have a profound effect on the central and peripheral arteries in children leading to arterial
tortuosity, aneurysms, and dissection.
2. Advanced imaging techniques (Cardiac-MR, MRA, and CTA) are important for initial diagnosis and long-term screening.
3. Due to the importance of follow up imaging in pediatric patients with genetic vascular syndromes, non-ionizing radiation modalities
should be highly considered. CL-PDE-SU7A • MR Arthrography of the Pediatric Shoulder, Not just for Adults
Mittun C Patel MD (Presenter) ; Deepa R Biyyam MD ; Seth Vatsky DO ; Scott A Jorgensen MD ; Richard B Towbin MD PURPOSE/AIM MR Arthrography of the shoulder is being performed on adolescents more frequently and is immensely helpful in identifying surgical
candidates. The purpose of this exhibit is to review shoulder MR Arthrography and injury patterns in children. CONTENT ORGANIZATION 1. Review the normal anatomy of the shoulder
2. Review normal anatomical variants
3. Review the imaging findings of common and uncommon shoulder pathology
4. Review interesting postoperative changes
SUMMARY MR Arthrography of the pediatric shoulder is now a common imaging tool utilized by orthopedic surgeons to evaluate children with
shoulder injuries. As more adolescents become involved in competitive athletics, shoulder pathology encountered in the adult population is
now being seen in children. We have seen an increase in imaging of both pediatric shoulder injuries and of the postoperative shoulder. MR
arthrography is the modality of choice to evaluate the labrum, joint cartilage, ligaments of the shoulder, joint capsule and the rotator
cuff. MR Arthrography efficiently triages patients who need surgical care. In order to accurately interpret shoulder MR arthrography, it is
important for the Radiologist to be familiar with both shoulder pathology and postoperative changes. Breast - Sunday Posters and Exhibits (12:30pm -1:00pm) Sunday, 12:30 PM - 01:00 PM • Lakeside Learning Center
Back to Top BR
LL-BRS-SUA • AMA PRA Category 1 Credit ™:0.5 Host
Donna M Plecha , MD * LL-BRS-SU1A • Measurement of Invasive Breast Cancer Using Digital Breast Tomosynthesis, Full Field Digital Mammography and
Ultrasonography
Asif Iqbal MBBS (Presenter) ; Michael J Michell MBBCh ; Rema Wasan MBBCh ; Abdel Douiri PhD ; David Evans MBBS ; Clare
Peacock MBBS ; Juliet C Morel MBChB, MRCP PURPOSE In preoperative assessment of local extent of breast cancers, full field digital mammography (FFDM) and
ultrasonography (US) imaging are routinely used. Digital breast tomosynthesis (DBT), an application of FFDM which displays the breast
structures as a series of thin slices, overcomes the problem of overlying tissues and displays more clearly the tumour outline. We compare
DBT with FFDM and US in the size measurement of invasive cancers.
METHOD AND MATERIALS A retrospective analysis was carried out on 139 invasive breast cancers examined by DBT, FFDM and US. Only soft tissue lesions were
included. Separate tumour size measurements on three imaging modalities and histological tumour size confirmed following surgical
resection, were recorded. Statistical analysis was done by following Bland-Altman method and concordance correlation coefficient (CCC);
the size differences in millimetres between imaging modality measurements and histology measurements were plotted. RESULTS Histologically, 108 lesions (77.7%) were diagnosed as invasive ductal carcinoma, 22 (15.8%) as invasive lobular carcinoma and 9 (6.5%)
as other invasive types. For the whole dataset, on Bland-Altman analysis, the DBT showed the lowest bias 1.216±7.99; 95% CI [-14.44
to 16.87], whereas the FFDM was 1.88±9.387; [-16.51 to 20.28] and US was 5.647±9.424;[-12.82 to 24.11]. In the subanalysis by
mammographic features, the CCC values demonstrated significantly high (p rho=0.925, FFDM rho=0.704, US rho=0.422]; asymmetric
density [DBT rho=0.892, FFDM rho=0.685, US rho=0.534]; spiculate masses [DBT rho = 0.652, FFDM rho=0.556, US rho=0.523] and
circumscribed masses [DBT rho =0.519, FFDM rho=0.519, US rho=0.452]. CONCLUSION This study has shown that DBT has a higher accuracy for determining invasive cancer size than FFDM and US. The most significant effect
is seen with parenchymal distortion and asymmetric density, where measurement using FFDM and US is difficult and unreliable. CLINICAL RELEVANCE/APPLICATION Use of digital breast tomosynthesis in the diagnostic workup of breast cancers for accurate pre-surgical assessment of tumour size could
help in choosing appropriate treatment. LL-BRS-SU2A • The Added Value of Dual Energy Contrast Enhanced Digital Mammography in Breast Cancer Diagnosis
Athanasios N Chalazonitis MD, MPH ; Zoi Antoniou BMedSc (Presenter) ; Eleni Feida ; Spiros Liopiris ; Dionisis Goutzamanis
; Olga Giouvri ; Efi Christopolou PURPOSE The purpose of our study is to evaluate the diagnostic accuracy of dual energy contrast enhanced digital mammography (CEDM), as an
adjunctive technique to digital mammography, using the histological results of all lesions and to study the added value of this method in
the evaluation of early breast cancer. METHOD AND MATERIALS Fifty (50) consenting women, with suspicious findings on digital mammography and/or on U/S, enrolled in this study.
A pair of low and high energy images was acquired using a modified full field digital mammography system with a CsI absorber. MLO and
CC projections of the breast with the suspicious findings were performed 2 minutes after 1,5 ml/kg iodinated contrast agent intravenous
injection and then both projections of the �normal� breast were also performed. Two subtracted images with contrast agent uptake
Page 9 of 397
injection and then both projections of the �normal� breast were also performed. Two subtracted images with contrast agent uptake
were reviewed by two experienced breast radiologists and compared with the histological results.
RESULTS A) One or more enhancing breast lesions were depicted in 34 women. 26 of the enhancing mammograms were histologically proven to be
malignancies. In this group 5 women had multicentric enhancing malignant lesions.
From the 8 rest of the 34 patients with enhancing lesions, 4 proved to be sclerosing adenosis, 2 fibroadenomas and 2 fibrosis-adenosis of
the breast.
B) In the remaining 16 women, without enhancing lesions, histological results were benign in 15 of them. The one missed lesion was a
7mm invasive ductal carcinoma with associated DCIS.
CONCLUSION Dual energy CEDM as an adjunctive tool to mammography can improve the diagnostic accuracy and the sensitivity to malignant breast
lesions. CLINICAL RELEVANCE/APPLICATION Dual energy CEDM is a new and advanced clinical application, easily implemented, fast and reproducible, with radiation comparable to
that of standard digital mammography. LL-BRS-SU3A • Breast Density Bill: Is This a Good Idea?
Hannah Nien MD (Presenter) ; Yasmeen K Shariff MD ; Cynthia A Barone DO PURPOSE Breast density is an emerging topic that has received significant media attention recently. Currently, there is a push to pass a bill
requiring that a letter be sent to patients post mammography, detailing the patient�s breast density. The purpose of our study was to
survey the Breast Imagers across the country to find out whether or not they support the breast density bill and their reasoning behind
their stance. METHOD AND MATERIALS Permission was obtained from the Society of Breast Imagers to use the SBI email list. An anonymous survey was emailed to the members
of SBI across the United States regarding the recent State and Federal effort to pass the breast density bill. Questions included whether
or not they support the breast density bill, and what would be their argument for or against the bill. There were questions specifically
asking those who practice in the state that have already passed the bill whether or not they thought it has had a positive impact on
patient care and their practice. RESULTS A total of 351 responses were obtained. 68.6% did not support the bill and 31.4% supported the bill. Patient confusion was the most
frequently stated argument against the bill, followed by unnecessary patient anxiety and fear. Patient education was the most frequently
stated argument for the bill, followed by improved/early cancer detection. Of those who practice in states that have already passed the
bill, 36% reported positive effect on patient care while 28% reported negative effect and 20% were unsure. CONCLUSION Breast density influences the sensitivity of mammography and the breast density bill addresses the issue of alerting patients of this
limitation of annual mammograms. The result of our study suggests that a majority of Breast Imagers across the nation does not support
the bill because the sending density information to the patients would cause patient confusion, unnecessary anxiety and fear.
Furthermore, there are complex issues involving the adjunct screening modalities including the limited availability of equipment and
adequately trained personnel as well as the high false positive rates and higher radiation doses. CLINICAL RELEVANCE/APPLICATION Our study addresses the recent State and Federal push to pass the bill that makes density reporting to patients mandatory which would
have a large clinical impact on how Breast Imagers practice daily. LL-BRS-SU4A • Diagnostic Usefulness of Breast Ultrasonography in the Evaluation of the Patients with Pathologic Nipple
Discharge: Comparison with Galactography
Jun Ho Park (Presenter) ; Young Mi Park MD, PhD ; Suk Jung Kim ; Hyun Kyung Jung ; Ji-Hwa Ryu ; Sun Joo Lee MD ; Hye
Jung Choo MD ; Young Jun Cho PURPOSE The purpose of this study was to evaluate the usefulness of breast ultrasonography (US) for the evaluation of pathologic nipple discharge,
as compared with galactography. METHOD AND MATERIALS 117 cases in 105 patients (all women; mean, 43.2 years; range, 20 - 76years) with pathologic nipple discharge were enrolled in this
study, who had underwent US and galactography between 2004 and 2012. Eighty three cases were pathologically proved by surgical
excision (n=66), or US-guided core needle biopsy (n=17), and the remaining cases were followed up for mean 24 months by US and
mammography. Two radiologists retrospectively reviewed and compared US and galactography images with regard to detectability of
lesion and evaluation of disease extent. RESULTS The lesions were depicted at galactography in 98 cases (83.8%), at US in 96 cases (82.1%) and both examinations in 85 cases (72.6%).
Eight cases (6.8%) showed poor visualization of lesions at both examinations. The lesions were depicted at galatography only in 13 cases
(11.1%) and US only in 11 cases (9.4%), of which galactograms were negative (n=1), only ductal dilatations (n=3), or failure of
procedure (n=7). In 85 cases which abnormalities were visualized at both examinations, the evaluation of lesion extent was superior at
US in 19 cases and superior at galactogram in 12 cases. Of 117 cases, US was superior or equal to galactography in 88 cases (75.2%)
with respect to detection of lesion and extent evaluation. Galactography was superior or equal to US in 57 cases (48.7%). CONCLUSION Breast US is useful to detect the causes of pathologic nipple discharge and to evaluate the lesion extent exactly. Therefore, in the
evaluation of patients with pathologic nipple discharge, we suggest that galactography may be skipped if the lesion is well detected at US. CLINICAL RELEVANCE/APPLICATION Galactography may be skipped in the evaluation of patients with pathologic nipple discharge if the lesion is well detected at
ultrasonography. LL-BRE-SU5A • 'Physics and Tips' Behind the Scenes for Successful Stereotactic Breast Biopsy Results in Technically Limited
Cases
Luis F Serrano MD (Presenter) ; John Sfondouris MD PURPOSE/AIM To teach Radiologists, fellows and residents technical aspects and applications involving Physics and tips , for stereotactic breast biopsy in
difficult patients with considerable reduction rate of stereotactic breast biopsy cancellations after the patient has been involved in the
procedure. CONTENT ORGANIZATION Page 10 of 397
A. Most typical technical issues B. How to avoid failures C. Understanding the physics and how it helps D. How to improve lesion
visualization E. Negative stroke margin principle and technical aspects to avoid it. SUMMARY Applying the 'unused parameters', improve technical aspects, and helps the radiologist to perform those difficult stereotactic breast
procedures, with better confidence and satisfactory results. The implementation of these variations will also reduce significantly the rate
of cancellations during the biopsy, after the patient has been involved, causing unnecessary anxiety for the patient, and waste of time for
both Health personnel and patient. Likewise, improving the utilization of our stereotactic resources in such challenging cases, will benefit
the patients by keeping them as ambulatory minimally invasive procedures, instead of go through unnecessary open surgeries in the
operating room under general anesthesia. LL-BRE-SU6A • Sources of Error in MR Directed Breast Biopsies
Phillip B Shaffer MD (Presenter) PURPOSE/AIM MR directed breast biopsy is an essential component of any breast program which includes breast MR. However, it can be very diifficult at
times to position patients for biopsy. Further, unlike ultrasound or stereo biopsy, verifying that the targeted lesion has been biopsied is
complicated by the fact that 1) the lesion has faded by the time that a post biopsy image is obtained and 2) anesthetic and bleeding
obscure the lesions. The wide variety of breast pathology (and even normal tissue) that can demonstrate enhancement complicates the
determination of concordant vs discordant pathology even further. This exhibit will review proven "misses" and analyze how the miss
occurred and how it may have been recognized. CONTENT ORGANIZATION 1)Review of method of MR directed biopsy. 2) Review of cases in which there was a definitive miss of the targeted tissue. 3) Review the
common causes of misses and their avoidance 4) Suggest methods to recognize when misses may have occurred. SUMMARY MR directed biopsy is a necessary component of a comprehensive breast imaging program. Yet, they are much more difficult to perform
than stereotactic or ultrasound directed breast biopsies. Given this difficulty, misses are inevitable. This work should aid radiolgists in
avoiding misses and then recognizing them when they occur LL-BRE-SU7A • Images a Radiologist Should Never See: Common Mammography Artifacts and Their Root Causes
Thomas Oshiro PhD (Presenter) ; Karen Neiberg BS, RT ; Tami Samuel BS, RT ; Lawrence W Bassett MD PURPOSE/AIM Artifacts from positioning and technical errors are frequent causes of substandard image quality during mammography examinations.
While many of these images are repeated by the technologist prior to interpretation, some can slip through the review process. It is
important for the radiologist to understand the root causes of these artifacts and possible methods of correction. CONTENT ORGANIZATION The presentation will be given as a slideshow in quiz format. A problem image will be shown with no annotations for the reviewer to
develop an unbiased impression. Subsequent slides will highlight problem areas, root causes and post correction images. Five
classifications of artifacts will be presented:
-Obstruction due to patient anatomy
-Underexposure (noise)
-Overexposure (detector saturation)
-Equipment failure
-Patient motion
The content will also convey the importance of the repeat analysis and will review other feedback mechanisms radiologists can implement
in the clinic.
SUMMARY When artifacts in mammography are not caught during the review process, it is important to understand how to identify and correct for
these problems. Monitoring of quality control procedures can help reduce the amount of these images being sent to the radiologist.
LL-BRE-SU8A • It's Not All in the CAD or BI-RADS: Optimizing Your Interpretation of Breast MRI by Avoiding the Perils of CAD
and Including Diagnostic Imaging Data Not Yet Included in BI-RADS
Frederick Kelcz MD, PhD (Presenter) PURPOSE/AIM Computer aided evaluation (CAE/CAD) has helped most radiologists to interpret the hundreds of images associated with breast MRI. Our
purpose is to advance your MRI reading skills by discussing and illustrating: (1) The pitfalls of using CAE/CAD - don't just 'hit the button'
and believe all those colors (2) Imaging techniques, anatomic and contrast enhancement patterns that contribute to diagnosis, but are
not currently included in the BI-RADS lexicon. CONTENT ORGANIZATION A. Proper use of CAD/CAE - illustrating: 1. Incorrect setup can result in missing peak enhancement 2. Check for patient motion first,
before trusting the color assignment! 3. Motion compensation can lead you astray - use cine mode to visually check for software induced
artifacts 3. Threshold properly to achieve balance of sensitivity and specificity B. Review of MRI findings not yet in BI-RADS 1. T2 signal
intensity 2. Blooming sign (not just a sign of Spring) 3. Hook sign 4. Edema sign 5. Diffusion properties SUMMARY After viewing this exhibit the viewer will: 1. Approach CAE/CAD software with healthy skepticism, knowing how to set it up, use it
properly and what to do when things seem wrong. 2. Go beyond the BI-RADS descriptors and be able to incorporate additional subtle
information to improve accuracy of diagnosis. Cardiac - Sunday Posters and Exhibits (12:30pm - 1:00pm) Sunday, 12:30 PM - 01:00 PM • Lakeside Learning Center
CA
Back to Top LL-CAS-SUA • AMA PRA Category 1 Credit ™:0.5 Host
W. Brian Hyslop , MD, PhD LL-CAS-SU1A • Radiation Reduction at Single-Heartbeat Coronary CT Angiography Combined with Automatic Exposure Control
and Iterative Reconstruction at 320-MDCT Volume Scanning
Yoshinori Funama PhD (Presenter) ; Daisuke Utsunomiya MD ; Katsuyuki Taguchi PhD * ; Seitaro Oda MD ; Toshiaki
Shimonobo ; Yasuyuki Yamashita MD * Page 11 of 397
PURPOSE The purpose of this study was to evaluate the radiation dose and image quality at single-heartbeat coronary CT angiography (CTA)
combined with automatic exposure control (AEC) and iterative reconstruction (IR) using a 320-MDCT volume scanner. Assessments were
at multiple heart rates and phase window widths, and with different reconstruction techniques. METHOD AND MATERIALS Using an anthropomorphic chest CT phantom we performed prospectively ECG-gated single-heartbeat coronary CTA on a
second-generation 320-MDCT volume scanner (Aquilion ONE ViSION, Toshiba). The tube voltage and rotation time were 120 kV and 275
msec. The tube current was automatically changed in response to the noise setting for AEC (20 and 25 HU) with and without IR (AIDR3D
standard). Acquisitions were at multiple heart rates (60 - 80 bpm) and different phase window widths of the R-R interval. To measure the
radiation dose, a pencil ionization chamber was inserted into the center of the phantom. We computed the effective dose and radiation
reduction at different phase window widths and heart rates, and with and without IR. To compare the set AEC value and the actual image
noise we measured the image noise and its variations along the z axis on all acquired images. RESULTS At half-reconstruction at a heart rate of 60 bpm and AEC of 20 and 25 HU without IR, the radiation dose to the center of the phantom
was 18.63 and 12.40 mGy, respectively, at a phase window width of 70-80%; at AEC with IR it was 4.61 mGy at 20 HU and 3.10 mGy at
25 HU. This corresponds to a dose reduction of 75.3 and 74.97%. At two-segment reconstruction at a heart rate of 80 bpm, the radiation
dose reduction was 76.13 and 75.78%, respectively, at AEC of 20 and 25 HU. However, the levels and variations of the image noise
along the z-axis were almost the same with and without IR. With AEC and IR the effective dose at 60 bpm was 0.77 and 0.514 mSv at
20 and 25 HU, respectively. At a heart rate of 60 bpm and AEC of 20 HU, the radiation dose was 18.82-, 18.63-, 38.8-, and 89.44 mGy
at a phase window width of 75%, 70-80%, 40-80%, and 0-100%, respectively. It was the same as at window widths of 75% and 70-80%
(100 msec) because one rotation required less than 275 msec. CONCLUSION AEC and IR reduce the radiation dose substantially at single-heartbeat coronary CTA. CLINICAL RELEVANCE/APPLICATION In combination, AEC and IR allow for a reduction in the radiation dose without loss of image quality. LL-CAS-SU2A • A New Method for Noise Reduction at Coronary CT Angiography with Multi-phase Data-averaging and Non-rigid
Image Registration
Fuminari Tatsugami (Presenter) ; Toru Higaki PhD ; Masao Kiguchi RT ; Wataru Fukumoto ; Shuji Date ; Kazuo Awai MD * PURPOSE We developed a new method for radiation dose reduction at cardiac CT that uses multi-phase data-averaging and non-rigid image
registration. The purpose of our study was to investigate the clinical feasibility of our method. METHOD AND MATERIALS Twenty patients (8 women, mean age 65.9 ± 8.8 years) who underwent coronary CT angiography (CTA) using a 64-slice CT scanner
(VCT, GE) at 120 kV and 400 - 750 mA with prospective ECG-triggering were enrolled. The range of the phase window was set at 70-80%
of the R-R interval. First, we prepared three sets of consecutive volume data at 70-, 75-, and 80% of the R-R interval, reconstructed with
adaptive statistical iterative reconstruction (40% ASIR). Second, we applied non-rigid registration to align the 70- and 80% images to the
75% image. Finally, we performed weighted averaging of the three images and generated a de-noised image. We measured the image
noise and CT attenuation in the ascending aorta to calculate contrast-to-noise ratio (CNR). Two radiologists visually evaluated the image
quality based on motion artifacts and noise-related blurring using a 5-point scale ranging from 1 = nondiagnostic to 5 = excellent. Image
noise and contrast-to-noise ratio (CNR) between the conventional 75% images reconstructed with filtered back projection (FBP), 40%
ASIR and de-noised images were compared using the paired t-test, image quality scores with the Wilcoxon signed-rank test. RESULTS Mean image noise on de-noised images was lower than on conventional 75% images reconstructed with FBP or 40% ASIR (14.6 ± 2.6
HU vs. 22.4 ± 4.1 HU; p < 0.01, 14.6 ± 2.6 HU vs.18.6 ± 3.5 HU; p < 0.01, respectively), and the CNR on de-noised images was also
improved (p < 0.01). The mean image quality score for conventional 75% images reconstructed with FBP, 40% ASIR and de-noised
images were 3.5, 4.1 and 4.5, respectively; the differences were also significant (p < 0.05). CONCLUSION As our method reduces image noise and improves image quality at coronary CTA, it may allow for a reduction in radiation exposure. CLINICAL RELEVANCE/APPLICATION Our new method combined with 40% ASIR achieved a 35% image noise reduction at coronary CTA and may allow for a reduction by 58%
of the radiation exposure compared to the conventional method. LL-CAS-SU3A • Combined Novel Post-processing Technique with Non-rigid Registration in Cardiac Phases and Iterative
Reconstruction to Reduce Image Noise in Coronary CTA Using 256-slice CT Scanner with 0.27sec/Rotation Speed
Yasuyuki Kobayashi MD, PhD (Presenter) ; Kouichi Watanabe ; Iwao Uejima MD ; Kazuhito Nozu MD ; Sou Oode MD ; Yukihisa Ogawa ; Yasuo Nakajima MD ; Hiroshi Niimi PURPOSE Radiation dose reduction remains crucial in cardiac CT. Recently iterative reconstruction (IR) algorithms has been reported to reduce
image noise and improve image quality, compared to Filter Back Projection(FBP). And the post-processing technique with non-rigid
registration (NRR) can also reduce image noise while preserving anatomical details. The purpose of this study is to evaluate the
combination of this post-processed technique with NRR and IR in coronary CTA using 256-slice cardiac CT with 0.27sec/rotation speed. METHOD AND MATERIALS Coronary CTA was performed in 24 patients by using 256-slice CT scanner with 0.27sec/rotation speed (iCT, Phillips, Netherlands); 13
patients with Step and Shoot scan, and 11 patients with retrospective helical CT scan. The images were reconstructed by each 5%
cardiac phases adjacent to optimal cardiac phase for CTA. These images were post-processed by workstation (PhyZiodynamics, QI
imaging, CA, USA), using the deformable registration to align the voxels in each cardiac phase and the interphase filtering algorithms. SD
and CT values of ascending aorta were statistically compared between the four different groups; 1) FBP, 2) IR, 3) FBP with NRR, 4) IR
with NRR. And image quality of coronary artery and plaque was compared by using five-scale score method. RESULTS Mean heart rate of 24 patients was 64 +/- 9.7 bpm. IR showed significantly 29.7 +/- 7.9 % noise reduction in aorta, as comparison to the
original FBP images (p CONCLUSION Both IR and NRR techniques could reduce noise while improving image quality in coronary CTA using 256-slice CT Scanner with
0.27sec/rotation speed. NRR technique can be combined with IR, and the combined IR and NRR technique enable less noise and less
radiation dose. CLINICAL RELEVANCE/APPLICATION The post-processing technique with non-rigid registration can reduce noise and is recommended to be combined with iterative
reconstruction algorithms to reduce radiation dose. LL-CAS-SU4A • Impact of Different Levels of Iterative Reconstruction on Quantitative and Qualitative Image Quality in CCTA
Page 12 of 397
Bettina M Gramer MD (Presenter) ; Daniela Muenzel MD ; Vivian Leber MD ; Michael Rasper ; Ernst J Rummeny MD ; Armin
M Huber MD PURPOSE To evaluate the ability of a new iterative reconstruction algorithm (IR) to improve quantitative and qualitative image quality (IQ) in
coronary computed tomograpy angiography (CCTA) in patients with suspected coronary artery disease (CAD) and to investigate feasibility
of radiation dose reduction. METHOD AND MATERIALS ECG-gated 256-slice MDCT CCTA scans were performed in 30 patients at 120 kVp and 200 mAs, with data reconstructed using the
conventional standard filtered back projection (FBP) and seven different levels of IR (L1 - L7). Image noise, contrast-to-noise ratio (CNR)
and signal-to-noise ratio (SNR) were evaluated for all data. Further qualitative IQ was analyzed by dint of a 5-point grading scale (5:
excellent to 1: nondiagnostic) concerning detail resolution and oversmoothing, not CNR. RESULTS CONCLUSION IR (iDose) improves SNR and CNR compared to FBP without loss of detail resolutions. Thus a reduction of 30% radiation dose seems
feasible. CLINICAL RELEVANCE/APPLICATION The iterative reconstruction algorithm is promising for future reduction of radiation dose in CCTA. LL-CAS-SU5A • Impact of Increasing Levels of Advanced Iterative Reconstruction on Image Quality in Low-dose Cardiac CT
Angiography
Patric Kroepil MD (Presenter) ; Amir H Bigdeli MD ; Hans Dieter Nagel * ; Gerald Antoch MD * ; Mathias Cohnen MD PURPOSE To investigate the effects of an advanced iterative reconstruction (IR) technique on subjective and objective image quality (IQ) in
low-dose cardiac CT angiography (CCTA). METHOD AND MATERIALS 30 datasets of prospectively triggered �step-and-shoot� CCTA acquired on a 256-slice CT-scanner were processed on a prototype
IR-system using filtered back projection (FBP) and 4 levels of an advanced IR technique (iDose4, Philips) providing incremental rates of
IR (level 2,4,6,7) involving both raw and image data space. In addition, effects of different reconstruction kernels (semi-smooth [CB],
standard [XCB]) and �multi-resolution� technique [MR] to preserve the noise power spectrum at higher levels of IR were evaluated
resulting in a total of n=480 image stacks. Contrast-to-noise ratios (CNR) were evaluated using ROI measurements at 9 coronary
locations throughout all image stacks. Subjective IQ was rated on a 4-point-scale with �classical� image appearance and noise-related
artifacts as main criteria. RESULTS Mean effective dose of CCTA was 1.7±0.7mSv. Mean CNR significantly improved with IR when compared to FBP and with every increasing
level of IR (range 14.2-34.6; p CONCLUSION Objective IQ of CCTA progressively improves with increasing level of IR. Best subjective IQ, however, is reached at medium level of IR,
XCB-kernel and �multi resolution� feature providing a more �classical� image appearance at minimal artifacts. CLINICAL RELEVANCE/APPLICATION Medium level of iterative reconstruction combined with an edge-enhancing algorithm leads to significant improvement of image quality in
low dose CCTA suggesting application in clinical routine. LL-CAE-SU6A • Multimodality Imaging of the Tricuspid Valve: Normal Appearance and Pathological Entities
John P Nazarian MD ; Trevor Jenkins ; Robert C Gilkeson MD * ; Prabhakar Rajiah MD, FRCR (Presenter) PURPOSE/AIM Though paid relatively little attention in the literature, the tricuspid valve can be affected by a wide range of pathological entities. It is
increasingly recognized that tricuspid valve disease has a significant impact on morbidity and mortality. The aim of this exhibit is to
demonstrate the value of multimodality imaging, including CT, MRI and echocardiography in the evaluation of tricuspid valve
abnormalities. CONTENT ORGANIZATION The exhibit will discuss and illustrate the following topics related to tricuspid valve. 1. Normal tricuspid valve anatomy and physiology
2. Tricuspid stenosis
3. Tricuspid regurgitation- Qualitative and quantitative grading using different imaging modalities
4. Tricuspid atresia/dysplasia
5. Ebstein�s anomaly
6. AV canal defect
7. Double-orifice valve
8. Cleft
9. Prolapse
10. Infective endocarditis
11. Thrombus
12. Tumors- fibroelastoma, myxoma, carcinoid, angiosarcoma, metastases
13. Amyloid
14. Pre and post surgical imaging of tricuspid valve replacement
SUMMARY In this era of improved treatment options for tricuspid valve disorders, it is important for radiologists to understand the utility of imaging
in the evaluation of such disorders. Knowledge of normal anatomy, pathophysiology and imaging appearances of several disorders is
essential to make accurate diagnosis and guide treatment. LL-CAE-SU7A • MR-imaging of Cardiac Masses: A Pictorial Guide for Diagnosis
Gabriele Ironi (Presenter) ; Antonio Esposito MD ; Paolo Marra ; Francesco A De Cobelli MD ; Alessandro Del Maschio MD PURPOSE/AIM To show specific magnetic resonance features of the most frequent heart neoplasms providing a smart guide for differential diagnosis. CONTENT ORGANIZATION We introduce the rare problem of cardiac tumors presenting aspects that the radiologist needs to know in order to perform a correct
diagnosis, such as epidemiology, clinical presentation and imaging features. In particular, the role of magnetic resonance (MR) imaging in
the assessment of cardiac masses is discussed and the MR features, helping to differentiate benign tumors from malignancies, are
presented. Subsequently, cases regarding the MR assessment of the commonest heart masses, collected from the archives of our
Institution, are reported underlining MR imaging features that characterize each tumor, which are also summarized in schematic
Page 13 of 397
portraits. SUMMARY MR imaging is the modality of choice in the evaluation of cardiac tumors, helping to orient the diagnosis toward the benign or malignant
nature and to guide the patient management toward biopsy, surgical resection, medical therapy or watchful waiting. However, to take
advantages of these capabilities, radiologists should be familiar with the specific features characterizing each single mass, that are
presented in this educational exhibit. LL-CAE-SU8A • Chagas Disease in the U.S. and the Importance of Cardiac MRI in Patients with Normal Electrocardiograms and
Normal Echocardiograms
Stephanie A Lee-Felker MD ; Ely R Felker MD ; Mariam Thomas MD (Presenter) ; Tony Koppula MD ; Salvador Hernandez ; Mahmoud Traina MD ; Margaret H Lee MD ; Sheba Meymandi MD PURPOSE Chagas Disease was previously considered a rare disease in the U.S, but the Center of Disease Control considers Chagas Disease as one
of the five neglected parasitic diseases in the U.S. The purpose of this study was to determine the importance of cardiac MRI in patient's
with Chagas Disease in the U.S with negative electrocardiograms and normal echocardiographic findings. METHOD AND MATERIALS From June 1, 2008- April 4, 2013, 55 patients who were residing in Los Angeles County, with serology proven Chagas Disease, were
evaluated with MRI to evaluate for delayed enhancement and scarring . MRI images were obtained using a 1.5 Tesla Avanto MRI system,.
The sequences acquired included axial HASTE, cine- TruFISP in four chamber, three chamber, two chamber and short axis, contrast
enhanced MRA and delayed enhancement inversion recovery gradient echo images. Retrospective analysis was performed of the
electrocardiogram and echocardiographic findings of all the 55 patients that underwent MRI imaging. Correlation was made between the
electrocardiograms and echocardiographic findings with the MRI findings. Of the 55 patients that underwent MRI, 35 patients (63.6%)
had a normal electrocardiogram, 41 (74.5%) had normal contractility on echocardiogram and 29 patients (52.7%) had both normal
electrocardiogram and normal contractility on echocardiogram. This was correlated with the cardiac MRI findings for delayed
enhancement. RESULTS Myocardial fibrosis was present in 25..5%( 14) of all patients. Of the patients with Myocardial fibrosis, 35.7 % had normal
electrocardiogram findings and 42.9% had normal echocardiogram findings and 14.3 % had normal electrocardiogram and
echocardiogram findings. CONCLUSION Chagas Disease is a chronic disease commonly seen in Latin America but Chagas Disease has been increasingly diagnosed in the U.S and
Europe and it is crucial that the radiologist be aware of the radiographic manifestations of Chagas Disease. The cardiac manifestations is
the main factor in the prognosis in Chagas Disease. Although Chagas Disease may manifest with electrocardiographic and
echocardiographic abnormalities, negative electrocardiogram and echocardiograms do not preclude cardiac disease.. CLINICAL RELEVANCE/APPLICATION Delayed enhancement cardiac MR is useful to evaluate damaged cardiac tissue and should be utilized in all patients with a diagnosis of
Chagas regardless of the EKG and echocardiographic findings. LL-CAE-SU9A • Dual Origin, Course and Supply in Coronary Artery System: Role of CT Angiography
Zaihleen S Keller MD ; Ashley E Prosper MD ; David Shavelle MD ; Farhood Saremi MD (Presenter) PURPOSE/AIM 1.Dual coronary artery variants are common and in some instances can be a confusing diagnosis or a misleading finding. 2. Misdiagnosis
may increase the risk of incorrect placement of a coronary graft or stent and in certain interventional procedures may increase
complications. CONTENT ORGANIZATION *Classifications: 1. Dual origin (real duplication): LAD (Type IV and V), RCA, left main 2. Dual course or termination (Duplication or early
bifurcation?); Dual RCA, Dual LAD (Type I, II, III), Dual LCx, Dual PDA, Dual SANa, Dual AVNa 3. Dual Supply: SANa, PDA variants in
codominant coronary circulation *Case examples and DDx *Associated congenital heart disease *Implications for surgery and
percutaneous coronary revascularization *Implications for percutaneous ablations: PTSMA, atrial ablation, SUMMARY 1. CT interpreters should be aware of these variants, their types, and the important implications for interventional and surgical planning.
2.Familiarity with the variants of dual LAD or PDA is important for avoiding incorrect placement of an arteriotomy and for
revascularization of the correct vessel. 3. A short LAD can be the source of all septal perforators and its diagnosis is essential before
alcohol ablations. 4. Variants of the sinuatrial or atrioventricular node arteries may be damaged during atrial RF ablations Chest - Sunday Posters and Exhibits (12:30pm - 1:00pm) Sunday, 12:30 PM - 01:00 PM • Lakeside Learning Center
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Brett W Carter , MD * LL-CHS-SU1A • Classification of T1 Lung Adenocarcinoma by the Size of Solid Components on Thin-section CT: Correlation with
Pathological Findings
Yukihiro Ogihara (Presenter) ; Kazuto Ashizawa MD ; Hideyuki Hayashi ; Akihumi Nishida ; Naoya Yamasaki ; Tomoshi
Tsuchiya ; Keitaro Matsumoto ; Takeshi Nagayasu ; Tomayoshi Hayashi ; Sumihisa Honda ; Masataka Uetani MD PURPOSE A statement from the Fleischer Society suggests that the size of the solid component in lung adenocarcinoma is best measured in its
largest dimension visible on axial thin-sections with a mediastinal window setting (WS). Tsutani Y et al. stated that the pathologic lymph
node (LN) negative status criteria of a size of the solid component were less than 8mm in its maximum dimension with a lung WS.. The
purpose of our study was to correlate the size of solid components on thin-section CT (TS-CT) with pathological findings (LN metastasis
and local invasion such as lymphatic or vascular invasion) in T1 lung adenocarcinoma, and to evaluate the predictive value of the size of
solid components for pathological status. METHOD AND MATERIALS From January 2008 to August 2012, 192 patients with surgical resected T1 lung adenocarcinoma were retrospectively analyzed. Two chest
radiologists, who were blinded to the results of pathological findings, measured long and short dimensions of the solid components with a
lung (WW 1600, WL -600) and/or a mediastinal (WW 320, WL 30) WS. The average sizes of the solid components measured by the two
radiologists were correlated with the pathological findings. Page 14 of 397
RESULTS 7 out of 192 patients (3.6%) had pathological LN metastasis. Patients with a long axis of solid component of less than 5 mm with a
mediastinal WS or 8 mm with a lung WS, were observed to have no LN metastasis, resulting in positive predictive value (PPV) for
predicting pathologic LN-negative status of 100% with each WS. 62 out of 192 patients (32%) had pathological local invasion. In patients
with a long axis of solid component of less than 5 mm with a mediastinal WS or 8 mm with a lung WS, PPV for predicting pathological
local invasion-negative status was 91% (40/44) and 90% (55/61), respectively. CONCLUSION The long axis of the solid component with a mediastinal WS bounded by 5mm (Fleischer Society), or that with a lung WS bounded by
8mm was valid for prediction of pathologic LN-negative metastasis. CLINICAL RELEVANCE/APPLICATION The patients who meet these predictive criteria may be optimal candidates for limited resection without the systemic LN dissection. LL-CHS-SU2A • Volumetric FDG PET-CT in the Preoperative Assessment of Patients with Thymic Epithelial Malignancies
Marcelo K Benveniste MD (Presenter) ; Cesar Moran MD ; Osama R Mawlawi PhD ; Patricia S Fox MS ; Stephen G Swisher
MD * ; Edith M Marom MD PURPOSE Metabolic tumor volume assessment using positron-emission tomography (PET)�CT has a role for monitoring response to therapy in
oncologic patients. Assessment of tumor volume above a specific SUV threshold has a potential promise to distinguish between early
(Stage I and II) and advanced thymoma (stage III and IV) as well as high risk thymoma (Type B3) from low risk according to WHO
Classification. It is important to differentiate these neoplasms before surgery, as patients with a worst histological type or locally
advanced tumors require neoadjuvant chemotherapy that enables effective resection. Thus, tumor volumetric assessment could be used
to direct those patients. This study assessed whether the volumetric standardized uptake value (SUV) measurements can predict
advanced thymoma and whether it can separate type B3 thymoma from low risk thymoma. METHOD AND MATERIALS We retrospectively reviewed FDG positron emission tomography (PET)-CT scans of 51 consecutive newly diagnosed patients with thymic
epithelial malignancy. PET-CT findings documented were focal FDG activity: SUVbwmax, SUVbwmean, SUVbwpeak and total body
volumetric standardized uptake value (SUV) measurements. These were correlated with Masaoka-Koga staging and WHO classification.
Wilcoxon rank-sum tests were used to assess association between SUV and pathological stage, cancer type, and classification. RESULTS Among the study patients, 37 had thymoma, 12 thymic carcinoma, and 2 thymic carcinoid. Higher total tumor volume above SUV 3.5
was seen in patients with type B3 thymoma than in those with type A, AB, B1, or B2 thymoma (p=0.04). Total tumor volume above SUV
3.5 was higher in patients with advanced stage than in early stage disease (p=0.0008). Additionally, patients with thymic carcinoma or
carcinoid demonstrated a higher total tumor volume above SUV 3.5 than in those with thymoma (p=0.02). CONCLUSION Metabolic tumor volume assessment is helpful in distinguishing early from advanced stage thymoma, low-risk thymoma from more
aggressive thymoma (type B3) and thymic carcinoma/carcinoid tumors from thymoma. CLINICAL RELEVANCE/APPLICATION Metabolic tumor volume assessment has a potential to differentiate between early and invasive thymomas and help in clinical decisions. LL-CHS-SU3A • The Utility of Routine Pelvic Imaging during CT Staging of Primary Lung Cancer
Nasser F Alamri MBBS (Presenter) ; Hadas Moshonov PhD ; Greg Korpanty MD ; Natasha Leighl MD ; Narinder S Paul MD * PURPOSE The purpose of this study is to investigate whether routine pelvic CT has a role in the baseline staging of lung cancer patients. METHOD AND MATERIALS A retrospective review of an institutional lung cancer database containing 970 patients registered from 1/2002-1/2012. Inclusion criteria
for the study required the following; a diagnosis of primary lung cancer established at our Institution, pelvic CT performed on initial
staging CT and the availability of all images including subsequent MRI, CT-PET, Tc-99m bone scans and surveillance CT if performed.
Histological confirmation of disease stage was also required. 225 patients satisfied the inclusion criteria. The primary study aims were to
determine whether: a) the initial staging CT demonstrated evidence of pelvic metastases, b) if the presence of pelvic metastases changed
the disease stage and / or c) if the presence of pelvic metastases changed patient management compared to review of the chest and
abdominal images alone. Secondary study aims included the detection of occult pelvic metastases on MRI, bone scan or CT: PET and the
detection of incidental abnormalities on the initial pelvic CT. RESULTS Of 225 lung cancer patients; 138 (61.6%) had disease limited to the thorax, 35 (15.6%) patients had abdominal and pelvis metastasis,
and 5 (2.2%) patients had isolated pelvic metastasis. Of the 40 (17.8%) patients that had pelvic disease, 33 (82.5%) had metastases to
the bony pelvis, and 5 (12.5%) had lymph node metastasis demonstrated on staging CT. Overall, the findings on pelvic CT did not
change the disease stage in any patient. However, the findings on pelvic CT influenced patient management in 14/225 (6.2%) patients,
compared to review of the chest and abdominal images alone, as these patients were referred for radiotherapy to treat the metastatic
pelvic disease. Pelvic MRI or CT: PET images demonstrated occult pelvic metastases in an additional 2/225 (0.9%) of patients. Staging
pelvic CT demonstrated incidental abnormalities in 15/225 (6.7%) patients.
CONCLUSION Pelvic CT performed routinely during baseline staging for lung carcinoma does not result in a change in disease stage but does influence
patient management in 6% of patients. CLINICAL RELEVANCE/APPLICATION Accurate baseline staging of lung cancer determines prognosis and patient management. Addition of routine pelvic CT to the staging
protocol does not appear to provide additional prognostic information LL-CHS-SU4A • Effectiveness of Pulmonary MRA for the Primary Diagnosis of Pulmonary Embolism: Outcomes Analysis of 578
Consecutive Symptomatic Patients
Mark L Schiebler MD (Presenter) * ; Christopher J Francois MD ; Michael D Repplinger MD ; Karl Vigen PhD ; Scott B Reeder
MD, PhD ; Harald Kramer MD ; Thomas M Grist MD * ; Alejandro Munoz Del Rio PhD ; Azita Hamedani MD ; Scott K Nagle
MD, PhD * PURPOSE Determine the effectiveness of using pulmonary magnetic resonance imaging as the primary test for the determination of pulmonary
embolism (MRA-PE) in a symptomatic population. METHOD AND MATERIALS We performed a retrospective review of our experience with 578 consecutive symptomatic patients studied over a five year period with
MRA-PE for the primary diagnosis of pulmonary embolism (PE). Contrast enhanced MRA images were performed in a single breath hold at
1.5 Tesla. The negative predictive value at three months and Kaplan-Meier analysis were calculated from the available time to venous
Page 15 of 397
thromboembolism (VTE) follow up data obtained from the electronic medical record. RESULTS There were 578 consecutive symptomatic patients who underwent pulmonary MRA as their primary examination for the determination of
PE. There were 467 females (average age ± 1S.D: 36.6 years, ± 16), and 111 males (average age ± 1S.D: 44.9 years± 19.5). Out of
578 MRA exams, 25 were non-diagnostic due to motion. Of the remaining 553 patients, 53 were positive and treated on the basis of MRA
findings alone. Of the 500 negative MRA�s, 76 were lost to 3-month follow up, leaving 424 patients with an initial negative MRA and 3
months of complete EMR follow up. Of these, 8 were found to have VTE during F/U. The negative predictive value for MRA-PE at three
months was 98% (97-99, 95% CI). Kaplan-Meier estimate values, for time to VTE at one year, was found to be 0.98 (97-0.99, 95% C.I). CONCLUSION In this single site retrospective study, MRA-PE was found to be effective as a primary imaging modality for the diagnosis of PE in
symptomatic patients with a high rate of technical success. At those sites with sufficient technical expertise in performing pulmonary MRA,
and knowledgeable of the artifacts associated with this technique, should consider use of this modality where appropriate clinical settings
warrant. CLINICAL RELEVANCE/APPLICATION MRA-PE can be safely used for the primary diagnosis of pulmonary embolism in symptomatic patients. This test should be considered as
an acceptable alternative to CTA-PE for vulnerable patients. LL-CHE-SU5A • Non Resolving Lung Consolidation: Pandora's Box
Archana T Laroia MD (Presenter) ; Sandeep T Laroia MD PURPOSE/AIM To review the radiological diagnosis of subacute or chronic lung consolidation. CONTENT ORGANIZATION A pictorial assay of non resolving lung consolidation will be presented. A wide variety etiologies include benign entities like atypical
infections (fungal),sarcoisdosis, cryptogenic organising pneumonia (COP), eosinophilic pneumonia, Wegeners, pulmonary infarcts,
alveolar protienosis, lipoid and radiation pneumonia and drug reaction. Lung cancer with lepidic growth and lymphoma are dangerous
mimics of the benign causes. SUMMARY Non resolving lung consolidation has a broad differential diagnosis ranging from infection, inflammatory and vascular etiology to rare
benign causes like COP, wegners, lipoid pneumoia etc. Slow growing cancer is a dangeous mimic that can be missed if not suspected. Emergency Radiology - Sunday Posters and Exhibits (12:30pm - 1:00pm) Sunday, 12:30 PM - 01:00 PM • Lakeside Learning Center
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Savvas Nicolaou , MD LL-ERS-SU1A • Hands up! The Effect of Arm Position on Dose and Image Quality in Whole Body CT for Multitrauma
Charlie Sayer MBBS,FRCR ; Sananda Haldar MBBS ; Tharsi Sarvananthan MBBS, MRCS ; Ahmed Daghir MRCP, FRCR (Presenter) PURPOSE To investigate the effect of patient arm position on dose, subjective and objective image quality in split bolus whole body CT in
polytrauma. METHOD AND MATERIALS As part of a large retrospective cohort study at a UK major trauma centre we performed a comparison study of the effect of position the
patient with the arms down and the arms up. From a data set of 177 patients scanned over a 9 month period 31 patients were scanned
with the arms elevated above the shoulder girdle. Patients were matched for body size and presence of a scoop with 31 patients scanned
with both arms down to the sides. Measurement of: Dose (DLP mGy/cm); Subjective image quality in five regions (liver, spleen, aorta,
lung bases and T6-L3 vertebrae) using a 3 point scale (1 = no artefact, 2 = minor artefact and 3 = major artefact non-diagnostic); and
objective noise (standard deviation (SD) of the average CT number (HU) for a 4cm ROI in liver segment 6/7) was performed for both
groups. RESULTS There was a significant improvement in the subjective assessment of image quality in all the regions of interest (p -30). In the arms down
group in 96.8% (n=30) of artefact scored 2 or 3 was judged to be predominantly caused by the arms (rather than scoop or external
lines). In the arms up group where there was measurable artefact this was most often due to the presence of the scoop (32.3%, n = 10)
followed by external lines (12.9%, n = 4). Preliminary data show a reduction in mean dose in the arms up group (1110 mGy/cm vs 1216
mGy/cm), although this difference was not statistically significant (p = 0.11). No significant effect on objective image noise in either the
arms up or arms down groups was observed (p = 0.06). CONCLUSION When practical and safe to do so positioning the patient with the arms raised results in a significant improvement in subjective image
quality and the rate of non-diagnostic scans. Although the effect on dose and objective noise were not statistically significant, trends
towards lower dose and improved objective image quality were found. CLINICAL RELEVANCE/APPLICATION In whole body trauma CT positioning the patient with the arms raised results in a significant improvement in subjective image quality and
the rate of non-diagnostic scans LL-ERS-SU2A • Sensitivity and Specificity of Chest Radiography and Rib Series for Detection of Rib Fractures
Ryan L Lo MD (Presenter) ; Shelby J Bennett MD ; Heber Macmahon MD * PURPOSE It is the current standard of practice to perform chest radiography in patients with suspected rib fractures, however the sensitivity of chest
radiographs and rib series for this purpose has not been defined. Therefore, we performed a study to establish the sensitivity and
specificity of chest radiography as compared to dedicated rib radiographs using CT scans as the criterion standard for the detection of
traumatic rib fractures. METHOD AND MATERIALS We searched the University of Chicago imaging database from January 2009 to June 2012 for chest radiographs (CXR), rib series, and CT
reports mentioning rib fracture. Cases were included in the study if the patient has had at least two of three studies (chest radiograph, rib
series, or CT) within two months of each other. All CT studies were reviewed, and were considered positive if an acute rib fracture was
seen. Page 16 of 397
seen. RESULTS Of the 2,670 reports mentioning rib fractures between January 2009 and June 2012, 178 cases from 174 patients were found that met
our criteria.
With CT used as the criterion standard, detection of rib fractures on CXR had a sensitivity of 54.7% and a sensitivity of 96.8% and rib
series had a sensitivity of 100% and a specificity of 100%. CXR missed 68.8% of rib fractures below the diaphragm whereas rib series did
not miss any. Using rib series as the criterion standard, CXR sensitivity was only 42% though specificity 97%. CONCLUSION Rib series have a much better sensitivity for detecting rib fractures when compared with CXR, especially for rib fractures below the
diaphragm. CLINICAL RELEVANCE/APPLICATION Rib fracture detection on rib series is superior to CXR, and almost equal to CT and is recommended if there is clinical concern for a rib
fracture. LL-ERS-SU3A • Computerized Tomography Correlates with Ventilator Days in Inhalation Injury: Preliminary Data from the
Inhalation Severity Injury Scoring System (ISIS) Trial
David L August MD (Presenter) * ; Kevin Foster MD,MBA ; Karen Richey RN ; Dan G Gridley MD ; Michael Peck MD ; Melissa
Pressman PhD PURPOSE Burn subjects with inhalation injury (II) demonstrate increased morbidity and mortality compared to burn subjects without II. The goal of
this multicenter study is to develop a standardized scoring system for II that quantifies and predicts II severity in adults. This study looks
at patients enrolled to date. METHOD AND MATERIALS Data from burn patients with II enrolled in the ISIS study at one center were evaluated. II was diagnosed based on history, physical
exam, lab data, and bronchoscopy findings. II severity was scored on a scale of 1-5 for carbon staining, edema, secretion, and erythema.
Data included demographics, burn and II data, and outcome. Outcome data included mortality, ventilator days, ICU days, bronchoscopy
score, and CT findings. Descriptive data was calculated and correlated to assess for presence and strength of associations among
variables. RESULTS 7 subjects were enrolled with II during the first 9 months of the study. Average age was 58 years, 86% male. Mechanism of injury for all
subjects was flame/fire. Mean total body surface area burned was 20.3% (range 0-80%). Average ventilator time was 17 days, length of
stay 21 days, with one subject still inpatient, and 1 death (14%). Average total bronchoscopy score was 7.9 (range 3-11). Average score
for II severity was 3.3 (range 1-4) for carbon staining, 2 (range 0-3) for edema, 1.6 (range 1-2) for secretions, and 1 (range 0-2) for
erythema. 43% of patients had pleural effusion, none with pneumothorax or tracheal/bronchial abnormalities present on CT. Average CT
score/slice was 3.0 (range 0.8-5.1) and fraction of abnormal lung tissue (FALT) was 6.8% (range 0.1-18.6%). No bronchoscopies or CT
were stopped early secondary to subject condition. There were statistically significant associations (p CONCLUSION Preliminary data from ISIS demonstrated CT findings correlate positively with ventilator days in burn patients with II. This suggests that
CT scanning may be helpful in predicting the severity of injury and likely clinical course in these patients. CLINICAL RELEVANCE/APPLICATION CT scanning may help predict severity and hospital length of stay in the setting of inhalation injury. LL-ERS-SU4A • Helical Thoracic Computed Tomography Angiography with Individualized Contrast Protocol: Effects on Radiation
Dose and Image Quality
Charbel Saade MS (Presenter) ; Ali A Haydar MD, FRCR ; Fadi M El-Merhi MD ; Mukbil H Hourani MD PURPOSE To investigate the dose length product (DLP) during helical thoracic CT angiography (CTA) using a patient-specific contrast formula. METHOD AND MATERIALS Thoracic CTA was performed in 200 patients with suspected acute aortic syndrome using a 64 channel computed tomography scanner and
a dual barrel contrast injector. Patients were subjected in equal numbers to one of two acquisition/contrast regimens. Patient age and
gender were equally distributed. Regimen A, the department�s standard protocol, consisted of a caudocranial scan direction with 100mL
of contrast (Ultravist 370 mgI/mL), intravenously injected at a flow rate of 4.5 mL/s; Regimen B, involved a caudocranial scan direction
and a novel contrast formula based on patient cardiovascular dynamics, using 80 mLs of saline at 4.5 mL/s. Each scan acquisition
comprised of 120 kVp, 300 mA with modulation, temporal resolution 0.4 sec and pitch 0.981:1. The DLP was measured between each
regimen and data generated were compared using Mann-Whitney U non-parametric statistics. Receiver operating characteristic (ROC)
analysis and visual grading characteristic (VGC) was performed. RESULTS Mean vessel enhancement in the segments of the ascending aorta, transverse and descending aorta all measured were up to 12% (p CONCLUSION Significant reduction in radiation dose during helical thoracic CTA can be achieved using low contrast volume based on patient specific
contrast formula. CLINICAL RELEVANCE/APPLICATION The gold standard in the assessment of acute aortic syndrome is thoracic CT Angiography. Improved arterial opacification and contrast
dose reduction provides diagnostic accuracy. LL-ERE-SU5A • The Acutely Presenting Oncologic Patient: Abdominal Complications
Dinushi S Perera MD (Presenter) ; Hima Prabhakar MD PURPOSE/AIM Cancer patients are at increased risk for complications of the abdomen, and given the aging population, more patients with known or
unknown malignancy are presenting with acute symptoms. Imaging these patients is often a challenge to the radiologist due to complex
pathology. The purpose of this exhibit is to review etiologies for acute abdominal conditions in cancer patients. CONTENT ORGANIZATION Pathophysiology: Most abdominal conditions arise from direct effects of the primary tumor and metastases, including invasion of nearby
structures, occlusion of vessels, infiltration of abdominal viscera, and tumor hemorrhage. Cases of acute abdominal conditions in the
oncologic population at our institution will be presented using a symptoms based approach: 1. Severe abdominal pain - thrombosis of
abdominal vessels, infarction of abdominal viscera, bowel perforation 2. Abdominal distention - large volume malignant ascites,
hemoperitoneum, bowel obstruction 3. Back pain - hydronephrosis secondary to extrinsic compression of the ureter, pathologic fracture 3.
Neurologic symptoms - spinal mass, pelvic mass compressing the sciatic nerve SUMMARY When a cancer patient presents with acute abdominal symptoms, knowledge of potential complications related to malignancy will allow
Page 17 of 397
the radiologist to make a timely diagnosis and facilitate prompt intervention. Gastrointestinal - Sunday Posters and Exhibits (12:30pm - 1:00pm) Sunday, 12:30 PM - 01:00 PM • Lakeside Learning Center
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Nirvikar Dahiya , MD LL-GIE-SU10A • Imaging after Transcatheter Arterial Chemoembolization (TACE) of the Liver: Normal Findings, Complications,
Follow-up and Recurrence
Tony T Lee MD (Presenter) ; Beatriu Reig MD, MPH ; Yosef Golowa MD ; Louis C Tsai MD, MS ; Debra Green MD ; Rona J
Orentlicher MD ; Anna Bader MD PURPOSE/AIM 1) Review the spectrum of early and delayed normal cross sectional imaging findings after TACE of hepatic tumors 2) Discuss imaging in
the immediate postprocedural time period, including pertinent findings of successful embolization, evaluation of tumoral necrosis, and
predictors of recurrence. 3) Illustrate complications after TACE and follow up imaging preceding recurrences. 4) Demonstrate evolution of
treated lesions and postprocedural liver changes over time. CONTENT ORGANIZATION 1) Role of TACE in the treatment of primary and secondary liver tumors 2) Pre-TACE evaluation 3) Expected CT and MRI findings following
TACE -Evaluation of tumoral necrosis and grading lipiodol staining -Normal post-treatment changes such as perfusion abnormality
-Indicators for long term success 4) Complications -Immediate postprocedure complications -Delayed complications, including recurrence SUMMARY Major teaching points: 1) Postprocedure CT and MR should report absence of intratumor enhancement and findings supporting the
presence of tumoral necrosis. 2) Nonenhancing lesions after TACE without findings supporting tumoral necrosis warrant close attention on
follow-up imaging. 3) Hepatic complications of TACE include nontarget embolization, hepatic abscess, biloma, liver infarct and hepatic
failure. LL-GIE-SU11A • Complicated and Uncomplicated Meckel's Diverticulum: Spectrum of CT Appearance
Satomi Kawamoto MD (Presenter) * ; Siva P Raman MD ; Ralph H Hruban * ; Elliot K Fishman MD * PURPOSE/AIM 1. Meckel's diverticulum is estimated to occur in approximately 2% of the population. Complications of Meckel's diverticulum are well
known, but difficult to diagnose preoperatively. 2. To review embryology and clinical presentation of Meckel's diverticulum 3. To review
and illustrate uncomplicated and complicated Meckel's diverticulum on CT, and discuss the radiologic evaluation of suspected Meckel's
diverticulum CONTENT ORGANIZATION 1. Review embryology of Meckel's diverticulum 2. Clinical presentation and work-up of complication of Meckel's diverticulum 3. CT
appearance of Meckel's diverticulum in pediatric and adult population Incidentally seen normal Meckel's diverticulum
Ectopic gastric mucosa and bleeding
Small bowel obstruction
Inverted Meckel's diverticulum
Neoplasm associated with Meckel's diverticulum
4. CT technique which may influence visualization of Meckel's diverticulum 5. Role of CT and other radiological studies for diagnosis of
complicated Meckel's diverticulum
SUMMARY Meckel's diverticulum may be visualized on CT as a bilnd-ending outpouching of variable size. CT is helpful for diagnosis of ssociated
complications, most commonly hemorrhage from peptic ulceration, small bowel obstruction and diverticulitis. LL-GIE-SU12A • MR Imaging of Perianal Fistulas: Beyond the St. James Classification
Ryan O'Malley MD (Presenter) ; Neil Hansen MD ; Zachary W Washburn MD ; Mahmoud M Al-Hawary MD ; Peter S Liu MD ; Hero K Hussain MD * PURPOSE/AIM Discuss unique etiologies of complex perianal fistulas that are frequently encountered in practice, but do not fit within the St. James
classification. Demonstrate the MRI findings and discuss its unique advantages for depicting these complex fistulas. Discuss how accurate
characterization affects management. CONTENT ORGANIZATION Brief review of anorectal anatomy, St. James classification, and MR findings in perianal fistulas. Discuss specific entities that are prone to
complex fistulizing disease and how they do not follow St. James classification scheme: Long-standing inflammatory bowel disease with tracts that can involve any (and often multiple) adjacent structures
Fistulas arising from anorectal neoplasms (including lesions presenting solely as fistulizing disease)
Fistulas arising at the site of prior anorectal surgical or radiation therapy
Sample cases with specific attention to how accurate diagnosis and characterization impacts patient management and quality of life. SUMMARY MRI is uniquely valuable for assessing complex perianal fistulas that do not fit into traditional classification schemes and can be clinically
underestimated. As such, radiologists must be aware of and accurately characterize these entities, which often have a profound impact on
patient management and quality of life. LL-GIS-SU1A • Correlation between MRI- and MRS-estimated Proton Density Fat Fraction (PDFF) in 506 Adult Subjects with
Non-alcoholic Fatty Liver Disease (NAFLD)
Elhamy R Heba BMBCh (Presenter) ; Ajinkya S Desai MBBS ; Tanya Wolfson MS ; Tanya Chavez ; Kevin A Zand MD ; Jessica
Lam BS ; Jonathan C Hooker BS ; Lisa Clark MPH, PhD ; Rohit Loomba MD, MSc ; Anthony Gamst PhD ; Claude B Sirlin MD *
; Michael S Middleton MD, PhD * PURPOSE To evaluate MRI proton density fat fraction (PDFF) accuracy in quantifying hepatic steatosis using MRS PDFF as reference in a cohort of
506 adult subjects with known or suspected non-alcoholic fatty liver disease (NAFLD). Page 18 of 397
506 adult subjects with known or suspected non-alcoholic fatty liver disease (NAFLD). METHOD AND MATERIALS RESULTS 506 adult subjects were enrolled in this study. Regression analysis showed close agreement between MRI PDFF and MRS PDFF with
intercept = 0.599%, slope = 1.006, and R2 = 0.979 (p < 0.001; see Figure). There was agreement between MRI and MRS PDFF for
subjects with either MRI or MRS PDFF less than 10%, with intercept = 0.401, slope = 1.038, and R2 = 0.838 (p < 0.001).
Histology-determined fibrosis grade did not show a significant effect on MRI PDFF estimation in the subset of 72/506 subjects who had
liver biopsy. CONCLUSION MRI accurately quantifies hepatic PDFF in adults with known or suspected NAFLD. To our knowledge, this is the largest study to date
evaluating MRI PDFF accuracy to assess hepatic steatosis. CLINICAL RELEVANCE/APPLICATION This study helps support validation of MRI PDFF as a non-invasive biomarker for hepatic steatosis by showing high accuracy in a large
cohort of adults with known or suspected NAFLD. LL-GIS-SU2A • Diagnostic Efficacy of Gadoxetic Acid-enhanced MR Imaging in the Detection of Hepatic Metastasis from
Colorectal Carcinoma: Prospective Comparison with Contrast-enhanced CT in the Same Patients
Masakatsu Tsurusaki MD, PhD (Presenter) ; Yoko Hieda MD, PhD ; Keitaro Sofue ; Tomoko Hyodo MD ; Mitsuru Matsuki MD ; Takamichi Murakami MD, PhD * ; Masahiro Okada MD ; Yasuaki Arai MD * PURPOSE The purpose of this study was to retrospectively evaluate diagnostic efficacy of gadoxetic acid-enhanced magnetic resonance (MR) imaging
compared with contrast-enhanced CT in the detection of hepatic metastasis in patients with colorectal carcinoma. METHOD AND MATERIALS Consecutive 158 patients with histopathologically confirmed colorectal carcinoma underwent gadoxetic acid-enhanced MR imaging and
contrast-enhanced CT. Sixty-eight with 105 histopathological confirmed hepatic metastases by surgery. All MR studies were performed at
a 3 T scanner (Magnetom Trio, Siemens Medical Systems, Germany or Achieva 3.0T TX, Philips Medical Solutions, Netherlands ) and CT
were performed at 64-detector rows helical CT scanner (Aquilion Multi, Toshiba Medical, Japan). MR examination consisted of T1-weighted
3D-GRE dynamic sequences after bolus-injection of 0.025 mmol gadoxetic acid (Primovist; Bayer Schering Pharma, Japan). Diagnostic
analysis was performed by sensitivity and positive predictive value (PPV) for the detection of hepatic metastases in combined arterialand hepatocyte- phase images compared with contrast-enhanced CT by 2 blinded readers. Sensitivity and PPV for the detection of
hepatic metastases were compared using McNemar test. Diagnostic accuracy and sensitivity were evaluated using the alternative-free
response receiver operator characteristic (AFROC) method. RESULTS The overall sensitivity of gadoxetic acid-enhanced MR imagings (91.1%) were significantly higher than that of contrast-enhanced CT
(78.5%, p 2cm). The gadoxetic acid-MR imagings showed significantly higher increased area under the ROC curve (Az value = 0.970)
compared with contrast-enhanced CT (Az value = 0.899, p CONCLUSION The results of this study demonstrated gadoxetic acid-enhanced MR imagings provided higher detectability for hepatic metastases,
especially in smaller size of lesion, compared with contrast-enhanced CT in patients with colorectal carcinoma. CLINICAL RELEVANCE/APPLICATION Gadoxetic acid-enhanced MR imaging can detect smaller size of hepatic metastases compared with CT and would provide more feasible
therapeutic direction for patients with colorectal carcinoma. LL-GIS-SU3A • Radiation Dose Reduction from a Newly Proposed Surveillance CT Scan Protocol for Hepatocecullar Carcinoma
Patients after Resection
Dan Liu BMedSc, MSc (Presenter) ; Albert Chan ; Daniel Fong ; Bingsheng Huang ; Ronnie T Poon ; Pek Lan Khong PURPOSE The purpose of our study was to develop a recurrence risk classification rule for postoperative Hepatocellular Carcinoma (HCC) patients
and to propose an appropriate protocol for surveillance CT scans. METHOD AND MATERIALS Institutional board approval was obtained for this retrospective study. We identified all consecutive HCC patients who had initial resection
surgery at our institution from 8/2003 to 12/2009 and evaluated the postoperative surveillance CT scans for positive or negative findings
of recurrent disease. Volume CT dose index (CTDIvol), dose length product (DLP), and effective diameter (ED) and size-specific dose
estimate (SSDE) were computed. Patient age at surgery and known tumor risk factors including cirrhosis, tumor size (=5cm), presence of
portal or hepatic vein involvement, solitary vs multiple, presence of vascular invasion, cell differentiation and pathologic T stage were
recorded. Multivariable Cox regression analysis was performed to identify risk factors, and then those factors were analyzed by
Classification and Regression Tree analysis. P RESULTS There were 2776 postoperative surveillance CT studies performed on 258 patients (206 male/ 52 female, 29- 82 years old (56.5±21.8 )
over a follow up period of 52.8 (±57.2) months. The mean number of surveillance CT studies per patient, DLP, CTDIvol, ED and SSDE of
an individual CT were 11 (±9.9), 1627.8 (±892.3) mGy.cm , 89.6 (±42.6) mGy , 26.0 (±5.2) cm, and 128.9 (±52.1) mGy, respectively.
The new classification rule identified three risk groups of HCC recurrence. Based on these findings, extending the interval of surveillance
CT scans from the current 6 monthly to 9 monthly from 2 years post-surgery will not reduce or delay the detection rate of HCC
recurrence for low-risk group. This translates to a dose savings of 14.29% for a five year follow protocol. CONCLUSION Computed Tomography used in HCC surveillance protocol imparts significant radiation doses. Low recurrence risk patients for whom
extending the CT scan interval for surveillance will reduce radiation detriment without compromising surveillance benefits. CLINICAL RELEVANCE/APPLICATION The newly proposed surveillance CT scan protocol for postoperative Hepatocecullar carcinoma patients will reduce radiation detriment
without compromising surveillance benefits. LL-GIS-SU4A • Noninvasive Assessment of Hepatic Fibrosis by Liver Stiffness Measurement: Comparison of MR Elastography and
Ultrasound Transient Elastography
Shintaro Ichikawa MD (Presenter) ; Utaroh Motosugi MD ; Katsuhiro Sano MD ; Hiroyuki Morisaka MD ; Tomoaki Ichikawa
MD, PhD * PURPOSE MR elastography (MRE) and ultrasound transient elastography (UTE) are noninvasive techniques for assessing hepatic fibrosis. We directly
compared the efficacy of them for the diagnosis of hepatic fibrosis. METHOD AND MATERIALS This study included 113 patients who underwent liver biopsy or surgery, UTE, and MRE. The histological fibrosis score was F0 in 15
Page 19 of 397
patients, F1 in 12, F2 in 19, F3 in 24, and F4 in 43. MR imaging was performed using a 1.5T or 3T (Signa EXCITE HD and Discovery 750;
GE Healthcare). UTE was performed using Fibroscan � (EchoSens) by a gastroenterologist. Receiver operating characteristic curve
analysis was performed to determine the optimal cutoff value and accuracy of MRE and UTE for staging of hepatic fibrosis. RESULTS The mean stiffness values of the liver increased with an increase in the fibrosis stage (MRE: F0, 2.03 ± 0.22 kPa; F1, 2.37 ± 0.33 kPa;
F2, 2.92 ± 0.39 kPa; F3, 4.11 ± 0.76 kPa; and F4, 6.34 ± 1.68 kPa and UTE: F0, 5.95 ± 2.34 kPa; F1, 6.93 ± 2.02 kPa; F2, 7.47 ± 3.44
kPa; F3, 14.3 ± 5.99 kPa; F4, 27.1 ± 15.8 kPa). There was a significant correlation between histological fibrosis score and the liver
stiffness determined using MRE (r = 0.9166, p < 0.0001) and UTE (r = 0.8100, p < 0.0001). The Az values for diagnosing each fibrosis
score were as follows (MRE vs. UTE): =F1, 0.97 [0.92�0.99] (mean [95% confidence interval]) vs. 0.87 [0.76�0.93] (p = 0.0126); =F2,
0.98 [0.94�0.99] vs. 0.87 [0.79�0.92] (p = 0.0003); =F3, 0.99 [0.96�0.99] vs. 0.96 [0.91�0.98] (p = 0.0526); =F4, 0.97
[0.93�0.99] vs. 0.93 [0.87�0.96] (p = 0.0308). The optimal cutoff values were as follows: =F1, 2.5 kPa; =F2, 2.7 kPa; =F3, 3.5 kPa;
=F4, 4.3 kPa with MRE and =F1, 6.9 kPa; =F2, 9.9 kPa; =F3, 10.1 kPa; F4, 13.9 kPa with UTE. The predicted sensitivity and specificity of
differentiating fibrosis score with these cutoff values were as follows: =F1, 88/98 (89.8%) and 15/15 (100%); =F2, 81/86 (94.2%) and
26/27 (96.3%); =F3, 56/62 (90.3%) and 50/51 (98.0%); =F4, 40/43 (93.0%) and 61/70 (87.1%) with MRE and =F1, 78/98 (80.0%)
and 13/15 (86.7%); =F2, 59/86 (68.6%) and 25/27 (92.6%); =F3, 56/62 (90.3%) and 47/51 (92.2%); =F4, 39/43 (90.7%) and 60/70
(85.7%) with UTE. CONCLUSION The efficacy of MRE is better than of UTE for diagnosing hepatic fibrosis. CLINICAL RELEVANCE/APPLICATION There is only 1 previous report of a direct comparison of MRE and UTE. MRE in our study was performed using a different protocol, but our
results were similar to those of the previous report. LL-GIS-SU5A • Reducing Radiation Dose at CT Colonography: The Size-dependent Effect of Iterative Reconstruction on Reduced
kV Imaging
Kevin J Chang MD (Presenter) ; Michael A Heisler MD ; Walter Huda PhD * ; Grayson L Baird MS ; William W Mayo-Smith MD
* PURPOSE Reducing kVp in CT colonography (CTC) without iterative reconstruction has been shown to decrease radiation dose at all patient sizes at
a cost of increased image noise. The purpose of this study was to show the effect of patient size on radiation dose in exams using iterative
reconstruction. METHOD AND MATERIALS This retrospective study included 113 patients undergoing CTC. Each patient underwent a supine scan at 120 kVp and a prone scan at
100 kVp. All other scan parameters including automatic dose modulation (noise index) were unchanged. 63 patients had the exam
performed without adaptive statistical iteration (ASiR) and 50 patients had 30% ASiR in the protocol. CT Dose Index (CTDIvol), Dose
Length Product (DLP), and patient size (AP diameter at the level of the right renal hilum) were recorded at both 120 and 100 kVp. A
general linear model with a logarithmic transform was used to compare CTDIvol and DLP versus patient size and kVp prior to and
following incorporation of ASiR. RESULTS Scans with ASiR had significantly lower CTDIvol and DLP relative to scans without ASiR. As size increased, CTDIvol and DLP also
increased non-linearly, regardless of ASiR and kVp (all p CONCLUSION The relationship between dose reduction and patient size in CTC exams using ASiR is complicated. Larger patients (over 26 cm) appear to
have decreased dose reduction benefits from lower kVp exams when ASiR is employed. CLINICAL RELEVANCE/APPLICATION While kVp reduction is a viable option to decrease radiation dose, dose savings may not be realized when combined with iterative
reconstruction in larger patients. LL-GIS-SU6A • Added Value of Morphologic Characteristics in Diffusion Weighted Imaging for Evaluating Lymph Nodes in
Primary Rectal Cancer
Een Young Cho MD (Presenter) ; Seung Ho Kim MD ; Jung Hee Yoon MD ; Yun-Jung Lim ; Yedaun Lee MD ; Choong K Eun
MD PURPOSE To identify the morphologic features of metastatic and non-metastatic lymph nodes (LNs) on diffusion-weighted imaging (DWI) and to
evaluate the added value of the morphologic features for evaluating LNs in patients with primary rectal cancer. METHOD AND MATERIALS Institutional review board approved this retrospective study and waived informed consent. Forty-four consecutive patients (17 men, 27
women; mean age: 63 years, range: 37�82 years) with primary rectal cancer who underwent surgery, were enrolled in this study. All
patients underwent 1.5-T rectal MRI with DWI (b=0, 1000). To identify morphologic features on DWI, two blinded radiologists in
consensus categorized each LN into the several groups according to the imaging characteristics (border, shape and signal intensity). By
Fisher�s exact test, the morphologic features were determined. To evaluate the added value of the morphologic features for evaluating
LNs, other two blinded radiologists independently interpreted the T2WI first and the combined image set of T2WI with DWI on a per-LN
basis for the same study population with a four-week interval. The diagnostic predictive values were compared between the two reading
sessions for each reader by using McNemar test. Pathology reports served as the reference standard. RESULTS 226 LNs (54 metastatic and 172 non-metastatic LNs) were radiologic-pathologically matched and analyzed. Metastatic LNs showed
amorphous subtle high or lobulating heterogeneous signal intensity (SI), whereas non-metastatic LNs showed dense bright dot on DWI
(p=0.000001). The specificity and accuracy for metastatic LNs increased after adding DWI for both readers (specificity, from 59% to 73%
for reader 1, from 41% to 68% for reader 2; accuracy, from 58% to 68% for reader 1, from 45% to 64% for reader 2, p CONCLUSION Metastatic LNs showed amorphous subtle high or lobulating heterogeneous SI on DWI. These additional morphologic characteristics
provided better diagnostic specificity and accuracy than T2WI alone did for evaluating LNs in primary rectal cancer. CLINICAL RELEVANCE/APPLICATION Metastatic LNs show different morphologic features from non-metastatic LNs on DWI. These additional morphologic characteristics can be
useful for evaluating LNs in primary rectal cancer. LL-GIS-SU7A • Reproducibility of mRECIST and Volumetric Quantification of Viable Tissue in HCC Lesions
Fernanda D Gonzalez Guindalini MD * ; Marcos P Botelho MD * ; Keyur Parekh MD (Presenter) * ; Adeel R Seyal MD * ; Hamid Chalian MD ; Vahid Yaghmai MD PURPOSE To compare the reproducibility of mRECIST and volumetric quantification of viable tissue within HCC lesions after locoregional therapy. METHOD AND MATERIALS Page 20 of 397
This HIPAA compliant retrospective study was IRB approved. Fifty-eight patients with known diagnosis of HCC treated with 90Y
radioembolization and follow-up MDCT study after the treatment were included. Two independent radiologists measured the viable tissue
within the lesion, defined as arterially enhancing component, using both mRECIST and volumetric quantification, assessed manually and
with semi-automated segmentation software, respectively. Paired t-test, Lin�s concordance correlation coefficient (rc), and precision
were used to assess intra- and interobserver reproducibility. RESULTS Fifty-eight HCC lesions in 58 patients, 43 males (74.1%) and 15 females (25.9%), were evaluated. The mean age was 67.1+11.8 years.
Intraobserver comparison showed comparable volumetric measurements of the viable tissue (P=0.744) while mRECIST measurements
were significantly different (P=0.025). Concordance correlation coefficient was excellent for volumetry (rc=0.999) and moderate for
mRECIST (rc=0.953) with higher precision of 22.8% for volumetry in comparison with 32.0% for mRECIST. Interobserver comparison
showed comparable measurements for mRECIST (P=0.306) and volumetry (P=0.463) but concordance correlation coefficient for
volumetric measurement of the viable tissue was excellent (rc=0.999) while it was moderate for mRECIST (rc=0.918). Volumetric
measurement also had better precision (12.0%) compared to mRECIST (35.5%). CONCLUSION Volumetric quantification of the viable tissue in HCC lesions demonstrated better inter- and intraobserver correlation as well as precision
in comparison with mRECIST. CLINICAL RELEVANCE/APPLICATION Necrosis in treated HCC can have heterogeneous distribution. Volumetric quantification of viable tissue demonstrated better agreement
between readers than mRECIST. LL-GIE-SU8A • Hard to Swallow: Dysphagia, Odynophagia, and the Esophagram in the Emergency Department
Karl C Schlobohm MD (Presenter) ; Daniel D Tarver MD ; Dmitriy G Akselrod MD ; Brendan M Banyon MD ; Robert
D'Agostino MD PURPOSE/AIM 1. Recognize the imaging characteristics and differential diagnosis of common and uncommon causes of dysphagia and odynophagia in
the ER population. 2. Understand the importance of clinical history and review indications and tecniques for esophagrams in these
patients.
CONTENT ORGANIZATION Special consideration should be given to patients with acute swallowing difficulties. The varying causes of dysphagia and odynophagia
make the clinical history and choice of imaging technique important in making accurate diagnoses and aiding in patient management.
Cases will be drawn from the Emergency Room at the University of Vermont/Fletcher Allen Health Care. All patients presented with a
chief complaint of difficult or painful swallowing. Using a quiz format, clinical history, techiques for esophagram, imaging findings,
diffential diagnosis and final diagnosis will be presented. Diagnoses will be supported by radiographic, endoscopic, and pathologic images.
Cases presented will include candiadisis, pill esophagitis, food impaction, foreign body, radiation stricture, giant peptic ulcer, eosinophilic
esophagitis, complication of gastric banding, along with others. Important information to relay to the emergency department will conclude
each case.
SUMMARY Cases will be presented where an esophagram used for accurate rapid diagnosis, assisting in effective management. LL-GIE-SU9A • Radiological Imaging Workup of the Patient Prior to Small Bowel and Multi-visceral Transplantation
Nikhil B Amesur MD (Presenter) * ; Anil K Dasyam MD ; Amir Borhani MD ; Albert B Zajko MD ; Kareem Abu-Elmagd MD, PhD
; Guilherme Costa MD PURPOSE/AIM To review the types of visceral transplantation and the radiological workup of the potential recipient prior to the transplantation. CONTENT ORGANIZATION Introduction: Types of intestinal transplantation: Isolated intestinal transplantation
Combined liver and intestinal transplantation
Modified multi-visceral transplantation (stomach, duodenum, pancreas and intestine)
Full multi-visceral transplantation (stomach, duodenum, pancreas, intestine and liver)
Review the role of non-invasive radiological imaging required in these patients particularly to assess the gastrointestinal anatomy,
abdominal vasculature and the status of liver using Abdominal/Pelvic CT scan or MRI
UGI/SBFT and contrast enema
Review the more invasive imaging required in these patients including:
A Visceral arteriograms: Splenic and superior mesenteric arterial and portal venous studies
B Central venograms: utilized for intraoperative supra and infra-diaphragmatic venous access planning
use of CO2 to decrease iodinated contrast load
C Transjugular liver biopsy - to ensure if a liver transplant is also needed SUMMARY To enlighten the target audience on the exhaustive radiological imaging requirements in the potential small bowel or multi-visceral
transplant recipient. Genitourinary/Uroradiology - Sunday Posters and Exhibits (12:30pm - 1:00pm) Sunday, 12:30 PM - 01:00 PM • Lakeside Learning Center
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LL-GUS-SUA • AMA PRA Category 1 Credit ™:0.5 Host
Katherine E Maturen , MD LL-GUS-SU1A • Outpatient Uterine Artery Embolization for Fibroids-An Initial Experience
Tyler M Coupal BMedSc (Presenter) ; Sriharsha Athreya FRCR, MBBS Page 21 of 397
Tyler M Coupal BMedSc (Presenter) ; Sriharsha Athreya FRCR, MBBS PURPOSE To evaluate the initial experience of patients undergoing outpatient uterine artery embolization for fibroids. METHOD AND MATERIALS This retrospective study was approved by the Research Ethics Board. The list of all patients who underwent UAE for symptomatic fibroids
from January 2012 to February 2013 was obtained from the radiology information system. A total of 12 patients were provided with
questionnaires. Patients evaluated pain using a visual analogue scale (VAS) from 0-10 during UAE, throughout recovery, and during the
night of discharge. During the two week follow-up appointment, patient�s recommendations and preferences regarding outpatient UAE
procedures were qualitatively assessed. RESULTS UAE was performed on 12 patients (age range, 28-53 years; mean age, 43.3 years) with 100% technical success and no immediate
complications. All 12 patients completed the study questionnaires. The mean pain score was 3.5 during embolization, 6.9 during
recovery, and 6.7 throughout the night of discharge. No patients required overnight admission. At the 2 week follow-up appointment,
100% of patients preferred UAE to surgical intervention and 91.7% of patients preferred outpatient over inpatient UAE. 50% of patients
cited no areas needing improvement. Recommendations for improvement included pain control (33.3%), GI symptom control (16.7%),
greater post-discharge counseling (8.3%), and use of other medical aids (8.3%). CONCLUSION With increased vigilance surrounding pain control, GI symptom control, and patient education, outpatient UAE can be safely performed.
Given the positive patient response and dramatic reduction in healthcare costs, widespread implementation could be studied with larger
study cohorts. CLINICAL RELEVANCE/APPLICATION Initial findings demonstrate outpatient UAE as a viable alternative to inpatient protocols. Given dramatic reductions in healthcare costs, it
is recommended in the treatment of symptomatic fibroids. LL-GUS-SU2A • Image Texture Analysis on Primary Tumor Can Stratify Differences in Overall Survival, Distant Metastases,
Tumor Stage, and Fuhrman Grade in Patients with Clear Cell Renal Carcinoma: Results of a Feasibility Study
Raghunandan Vikram MBBS, FRCR (Presenter) ; Payel Ghosh ; Pheroze Tamboli MD ; Arvind Rao PURPOSE To identify textural features on contrast-enhanced CT derived on primary tumors associated with overall survival, distant metastases,
tumor stage and Fuhrman grade in patients with Clear cell Renal carcinoma (CRCC). METHOD AND MATERIALS The study was performed on CT scans of 39 CRCC patients from The Cancer Genome Atlas (TCGA) clear cell carcinoma database. The
primary tumor was segmented using the Medical Image Interaction Tool Kit (mitk.org). 73684 imaging features were extracted on each
phase (non-contrast, nephrographic, cortico-medullary and excretory phases) on MATLAB. 3-D textural algorithms (Laws', Wavelet,
Haralick), volumetric features and ratios at different image resolutions. These were correlated with overall survival, metastases, tumor
stage and Fuhrman grade using the Wilcoxon-Ranksum test. Cox proportional hazards model was used for obtaining survival-associated
univariate p-values. Multiple testing corrections for p-values were done using Benjamini-Hochberg FDR correction. RESULTS The number of features that could stratify survival were: 2099 in non-contrast, 1424 in cortico-medullary, 551 in nephrographic and 345
in excretory phase. The number of features that could stratify presence of metastases (M1vsM0) were 1935 in non-contrast, 312 in
cortico-medullary, 1468 in nephrographic and 3822 in excretory phase. Only nephrographic and excretory phases had 273 significant
features each after FDR correction (q-value < 0.05). The number of features that could stratify T stage (T1&T2 versus T3&4) were:
10453 in non-contrast phase, 2919 in cortico-medullary, 5103 in nephrographic and 2936 in excretory phase. 290 nephrographic and 180
excretory phase features could be ratified after FDR correction (q-value < 0.05). The number of image features that could stratify
Fuhrman grade were: 18467 in non-contrast, 12081 in cortico-medullary, 3086 in the nephrographic and 2936 in the excretory phase. CONCLUSION Image texture features are associated with overall survival, distant metastases, tumor stage and Fuhrman grade in patients with clear
cell renal carcinoma. Non-contrast phase had strongest correlation with survival and Fuhrman grade. Features from nephrographic and
excretory phases correlated strongly with metastasis and TNM stage in this initial analysis. CLINICAL RELEVANCE/APPLICATION Image texture analysis on routine staging CT is a promising risk assessment tool in patients with clear cell renal carcinoma. LL-GUS-SU3A • Novel Approach on the Characterization of Adrenal Nodules Using Standard Abdominal MRI Protocol
Antonio Matos MD (Presenter) ; Miguel Ramalho MD ; Vasco Heredia ; Joao M Palas DO ; Filipe Veloso Gomes MBBCh ; Richard C Semelka MD PURPOSE To describe a novel approach for the evaluation of adrenal nodules using a standard abdominal MRI protocol. METHOD AND MATERIALS A consecutive search was performed between January 2008 and December 2012. The final sample comprised 149 subjects with 132
adenomas and 40 non-adenomas. Adrenal signal intensity indices (AI) were calculated. Lesions were clustered in 3 groups according to
the wash-in time to peak (arterial-Type1EP, portal-venous-Type2EP or interstitial-Type3EP). The relative and absolute washouts were
calculated. Independent-samples Student-t test was used to test for mean differences between adenomas and non-adenomas concerning
quantitative parameters and ratios. ROC curve analysis was performed. An optimal threshold value was calculated. The probability for
lipid-poor adenomas occurring with Type1EP, Type2EP and Type3EP was calculated by means of multiple event probability. RESULTS The mean AI of adrenal adenomas was significantly higher than that of nonadenomas (p CONCLUSION The presence of intracytoplasmatic lipid calculated by means of CSI continues to be the strongest indicator of benignity. In the absence of
intracytoplasmatic lipid, a lesion presenting with Type1EP is very likely to be an adenoma and, conversely, a non-adenoma when
presenting with Type3EP. There is considerable overlap for lesions presenting with Type2EP and in our approach we suggest the choice of
the relative washout calculation, as an additional tool to separate lipid-poor adenomas from non-adenomas. CLINICAL RELEVANCE/APPLICATION Late washout periods are not usually performed on MRI for the diagnose of adrenal nodules. A combination of CSI with categorization of
dynamic enhancing patterns yields high diagnostic accuracy. LL-GUS-SU4A • Improved Differentiation of Calcium Oxalate and Uric Acid Composition in Urinary Calculi with Dual-source
Dual-energy CT
Hao Sun MD (Presenter) ; Huadan Xue MD ; Xuan Wang MD ; Yu Chen MD ; Yonglan He MD ; Zhengyu Jin MD PURPOSE Page 22 of 397
To prospectively evaluate the ability to in vivo differentiate calcium oxalate and uric acid composition in urinary calculi by using
dual-source dual-energy CT. METHOD AND MATERIALS Patients referred for clinically-indicated dual-source dual-energy CT (DsDeCT) for urinary stone composition analysis whose stones were
subsequently surgically removed were enrolled. DsDeCT images were processed using a custom-developed software tool that could in
vivo discriminate four compositions: uric acid, cystine, hydroxylapatite and oxalat. Stone compositions were determined using DsDeCT
data were compared to the reference standard (fourier transform infrared spectrometry). RESULTS Fourty urinary stones from 40 patients (30 male, 10 female, mean age: 46 years) were included in this study. There are 14 stones with
single composition (uric acid n=4, cystine n=1, hydroxylapatite n=4, calcium oxalate monohydrate n=5) and 26 stones with mixed
composition. The overall accuracy by using DsDeCT data alone provided 92.5% accuracy. The accuracy for identifying uric acid (n=4),
cystine (n=1), hydroxylapatite (n=28) and oxalat (n=30) were 100%, 100%, 92.9% and 100%. CONCLUSION Unenhanced DsDeCT can help differentiate between four urinary calculi compositions with high accuracy, especially for calcium oxalate
and uric acid compositions. CLINICAL RELEVANCE/APPLICATION Unenhanced DsDeCT can in vivo differentiate four urinari stone compositions accurately, that can help physicians optimize therapeutic
decisions. LL-URE-SU5A • Update and Review of DECT Clinical Applications of the Kidney.
Bryan S Yi MD,MPH (Presenter) ; Wendy L Stiles MD ; Alvin C Silva MD ; Amy K Hara MD * ; Robert G Paden ; Thomas F
Boltz MS ; William Pavlicek PhD PURPOSE/AIM � Review DECT technique and discuss clinically specific renal protocols
� Apply various DECT imaging displays and advance post-processing techniques to evaluate renal pathology
CONTENT ORGANIZATION Imaging review of DECT protocols used to characterize different renal lesions: simple and complex cysts, angiomyolipoma, renal cell
carcinomas (cystic and solid), metastases, and focal mass-like inflammation. On iodine images, iodine density can be directly quantified.
A threshold value of 20 iodine density (100 ug/cc) has been applied to characterize renal lesions. Effective Z relates to elemental atomic
number; thus, identifying materials such as iodine in an enhancing lesion, but also can be use to determine renal lesion complexity.
Spectral HU curves for a renal lesion can be compared to internal controls (enhancing renal cortex, fluid filled structures), which
exemplifies how matching a renal lesion�s curve configuration to either the curve for enhancing cortex or nonenhancing fluid increases
confidence in diagnosis. Furthermore, iodine color overlay images improve performance, providing a quick qualitative assessment of a
renal lesion; differences in hue between solid and cystic lesions allow differentiation. SUMMARY DECT provides diverse, easily utilized series that aid in more accurate characterization of renal lesions, increasing confidence and
performance. LL-URE-SU6A • Role of Multiparametric Prostate MRI in Recurrent Prostate Cancer
Varaha Tammisetti MD (Presenter) ; Venkateswar Rao Surabhi MD ; Eduardo J Matta MD ; Larry A Kramer MD ; Robert J
Amato PURPOSE/AIM PURPOSE OF THE EXHIBIT: 1. Discuss the various patterns of recurrences in clinical settings such as after post prostatectomy or after
radiotherapy or androgen deprivation therapy and multiparametric MR (mp-MR) imaging appearances. 2. Discuss the implications of the
recurrences in each setting on management. 3. Discuss and distinguish the mp-MR imaging appearances of post treatment or post
surgical change from local recurrence. 3. Discuss the role of mp-MRI and it�s inclusion in the imaging strategies in each of the setting CONTENT ORGANIZATION 1. Introduction - Rising PSA levels after first line treatment of prostate cancer 2. Recurrence after Radical Prostatectomy- mp-MRI
imaging appearance of recurrence and expected post surgical changes 3. Recurrence after External Beam Radiotherapy - mp-MRI imaging
appearance including DCE-MR and DWI, expected post treatment changes are also discussed 4. Recurrence after androgen deprivation
therapy- mp-MRI imaging appearance including DCE-MR and DWI, expected post treatment changes are also discussed 5. Discuss the
role of mp-MRI and imaging strategies in each of the setting SUMMARY Prostate mp-MRI is useful in identifying local recurrence, post prostatectomy and after radiation failure and can help guide biopsies,
assess the extent of local tumor, this information may be helpful in treatment planning. Health Services - Sunday Posters and Exhibits (12:30pm - 1:00pm) Sunday, 12:30 PM - 01:00 PM • Lakeside Learning Center
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LL-HPS-SUA • AMA PRA Category 1 Credit ™:0.5 Host
Aine M Kelly , MD Host
Paul P Cronin , MD,MS LL-HPS-SU1A • The Practicality of Radiology Fellowships: A Mayo Clinic Perspective
Nathan C Hull MD (Presenter) ; Kristen B Thomas MD ; Chad J Fleming MD ; Tara L Henrichsen MD ; Timothy Welch MD PURPOSE To evaluate the influencing factors in the decision to pursue a radiology fellowship, and if this additional training translates to practical
benefits like securing employment, job satisfaction, and use of subspecialty knowledge. METHOD AND MATERIALS A short questionnaire was sent via an online survey service to fellowship trained radiologists who completed some training (residency
and/or fellowship) at Mayo Clinic in the last 15 years to evaluate their perspectives on job satisfaction, use of subspecialty knowledge,
and factors in selecting a fellowship. Percentages were calculated from the collected responses. RESULTS Survey response rate was 65% (142/218). 92.2% felt prepared to make a decision about fellowship with 52.5% reporting that sometime
during the 4th year of radiology residency training was the best time to decide on fellowship training. The most important selection
Page 23 of 397
during the 4th year of radiology residency training was the best time to decide on fellowship training. The most important selection
factors were personal interest in a particular field (99.3%), and to help secure employment (77.7%), with influence of mentors (68.6%),
lifestyle (63.3%), and geography (55.0%) also ranked highly. 78.9% felt they could have not secured the same employment without
fellowship training. 95.6% felt more confident in their practice after fellowship. 93.5% report use of their fellowship training on a regular
basis in their respective practices. 97.0% are pleased they chose to complete fellowship training. The average overall job satisfaction was
89.3%. CONCLUSION Most residents feel prepared to choose a fellowship by sometime between the third and fourth year of residency. The most important
selection factors are personal interest in a particular field and to help secure employment. Fellowship has many practical applications
including: to secure employment, daily use of advanced training, high job satisfaction, and increased knowledge and confidence at initial
employment. With initiation of the new ABR exams, it remains to be seen if practice groups will hire residents straight out of residency
who are only board eligible and not board certified. This could increase the number of residents seeking fellowship training in the future. CLINICAL RELEVANCE/APPLICATION Radiology fellowship training is a practical means of increasing a radiologist's marketability, job satisfaction, initial confidence, and use of
subspecialty knowledge. LL-HPS-SU2A • Study Habits of High-Score Achievers in the American College of Radiology In-Training Exam (DXIT)
Fadi Toonsi MBBS (Presenter) ; Jeffrey Chankowsky MD PURPOSE Residency training programs must ensure that candidates have attained certain benchmarks before they take a board certification
examination, The American College of Radiology Diagnostic Radiology In-Training examination (DXIT) is widely used by many programs
across Canada for this purpose.
Radiology residents, on the other hand, use different study habits to acquire radiology material. We aim to identify these habits and
investigate which ones, if any, correlate with higher DXIT scores. METHOD AND MATERIALS A questionnaire-based cross sectional survey focusing on seven aspects of study related habits. The study population was second to
fourth year radiology residents at McGill University. Responses were correlated with participants� 2012 DXIT scores. Fisher's Exact test,
Spearman's Rho and Pearson Chi-Square tests were used. RESULTS 23 residents completed the questionnaire (79% response rate). Almost half of the responders (52%) study 5 or less hours per week.
Reference textbooks were the top ranked source for radiology reading, followed by case-based format books. All residents consider the
journal �Radiographics� an important source for their reading. A significant correlation exists between higher DXIT scores and 1) higher
residency levels (p=0.048) 2) reading from textbooks (p=0.006), 3) less reading from the radiological journal 'Radiology' (p=0.004) and
4) less frequent use of highlighter pens (p=0.040). A nearly significant correlation was found between higher scores and 1) spending
more money on textbooks (p=0.051) and 2) less preference for the differential diagnosis based lecturing format (p=0.074). CONCLUSION Radiology residents use different study habits, some of which correlate with higher in-training exam scores. The results could inform both
low performing residents and residency programs with the aim of improving exam scores and performance. CLINICAL RELEVANCE/APPLICATION Higher residency levels, reading form textbooks and journals focusing on educational material more than scientific research and less
frequent use of highlighter pens relate to higher DXIT scores. LL-HPS-SU3A • Redesigning the Medical Student Radiology Elective: A More Clinically-oriented and Active Learning Approach
R. J Weinfurtner MD (Presenter) ; Indravadan J Patel MD ; Raj M Paspulati MD ; Mark R Robbin MD PURPOSE The current radiology elective at our institution and at many institutions involves medical students shadowing residents and attendings
and listening to readout sessions in a largely passive role. Our goal was to redesign the medical student curriculum to make it more
interactive between the students, residents, and staff in an effort to improve teaching and learning. METHOD AND MATERIALS An anonymous, voluntary, needs-assessment , subjective survey was emailed to medical students who took the elective in the current
form over the past 6 months. Results indicated areas of strength and weakness of the current elective. The new curriculum was then
introduced based around a 'case of the day' model in which each student was assigned a case to present each day. The medical student
would gather clinical information on the patient and, in some instances, see the patient on the medical ward. The medical student would
then go over the radiology study with the resident and, finally, present the entire case to the attending. Discussion of the case would
then follow. Survey data collection following implementation of the new curriculum was then performed. RESULTS Only a small minority of medical students surveyed after the 'traditional' radiology elective felt like an active part of the radiology team
(22%). After implementation of the new curriculum to address this need, 91% felt like an active part of the team. This result was
statistically significant (p CONCLUSION The results of our study demonstrate that the implementation of a medical student radiology elective based around a �case of the day�
model leads to improvement in medical student perception as active members of the radiology team. It is hoped that this improvement in
medical student active learning will translate into improvement in radiologic competency. Positive evaluation of the �new� elective was
demonstrated with a trend toward statistical significance in improved perception of radiology as a career choice as well as increased
likelihood of recommending the elective to a fellow classmate. CLINICAL RELEVANCE/APPLICATION Implementation of a medical student radiology elective based around a �case of the day� model leads to improvement in medical
student perception as active team members. LL-HPE-SU4A • Medical Imaging in Pregnant Patients: Current Recommendations
Alexandre M Silva MD (Presenter) ; Gustavo S Meirelles MD, PhD PURPOSE/AIM The purpose of this exhibit is: To demonstrate the facts about the risks to the fetus of the imaging methods most commonly performed,
of contrast media used in these tests, as well as update about the recommendations relating to these diagnostic procedures. CONTENT ORGANIZATION 1. Introduction 2. Fetal risks related to ionizing radiation a. Stochastic effects b. Deterministic effects 3. Fetal risks related to magnetic
resonance imaging (MRI) 4. Risks of using iodinated contrast media 5. Risks of using gadolinium (MRI) 6. Breast-feeding
recommendations SUMMARY Fetal risks are minimal when radiological examinations are performed with proper technique, with proper indications and following the
Page 24 of 397
recommendations presented. LL-HPE-SU5A • A Multicenter Analysis of the Quality of Transfer Image Reporting
Richard B Ruchman MD ; Robert Schiff MD (Presenter) ; Andrew C Schiff BS ; Kirsten Windos PURPOSE The Emergency Medical Treatment and Active Labor Act outlines the necessity of medical records accompanying individuals transferring
to another hospital. No studies to date have methodically analyzed the quality of radiologic reports received by tertiary facilities at the
time of patient transfers. The objective of our study is to review the quality of transferred patients� radiology reports received from three
outside institutions. METHODS All patients transferred from three outside facilities to Monmouth Medical Center from 1/1/2012 to 9/31/2012 were considered. Patients
excluded were those with long term acute care or psychiatric admitting diagnoses, inpatient transfers and those without radiologic
studies. Three independent observers reviewed the patients� medical records. Radiologic reports were analyzed according to a modified
Likert scale with scores ranging from 1 to 5, representing studies wherein no information was provided versus studies with a complete
report, respectively. The data was analyzed with respect to average reader scores, scores according to imaging modality and variance
among observers. RESULTS Of the initial 447 transfer patients, 111 without imaging were excluded and 53 inpatient transfers were excluded. Of the 283 patients
included, the overall modified Likert scale score resulted at 3.43. Per institution, the average scores were 2.92, 3.08 and 4.31. The
overall distribution of scores for all institutions across three readers was as follows: 1 - 17.4% (n = 131), 2 - 22.3% (n = 168), 3 - 13.0%
(n = 98), 4 - 13.4% (n = 101), 5 - 33.8% (n = 254). Computed tomography (CT) accounted for the majority of studies at 49.6% (n =
140); plain film radiography (XR) was second at 44.7% (n = 126), followed by ultrasonography (US) at 5.7% (n = 16). Within the CT
modality, 52.1% (n = 201) of reports were rated as a 5, with 27.1% (n = 108) being rated as a 2 or less; within the XR modality, only
12.4% (n = 40) were rated as a 5, with 54.7% (n = 176) being rated as a 2 or less. By modality, the following variance among
observers was seen: US - 0.39, CT - 0.19 and XR - 0.33. CONCLUSION The modified Likert scale score average of 3.43 reveals that most patients arrive with reports entailing only a primary diagnosis and
minimal supporting information. Overall, nearly one in three patients in our study arrived with a complete report; more than one third of
the patients arrived with an unsupported diagnosis or with no radiology report at all. A more formalized approach to the process of
transferring radiologic reports is warranted. LL-HPE1075-SUA • Biostatistical Considerations in Diagnostic Imaging
Vivian Bishay MD (Presenter) ; Chenchan Huang MD ; Grace C Lo MD ; Thomas J Ward MD ; Serge Sicular MD ; Michael A
Kadoch MD PURPOSE/AIM The purpose of this exhibit is to:
1. Review the major biostatistical considerations in diagnostic imaging.
2. To apply these concepts to the everyday clinical practice of the radiologist: diagnostic testing, screening, and radiation risk.
3. To apply fundamental biostatistical concepts to aspects of radiology research.
4. To provide the busy radiologist with a free and easy to access online reference for use whenever these concepts may be encountered. CONTENT ORGANIZATION Biostatical considerations in diagnostic testing
- Specificity and sensitivity
- Positive and negative predictive values
- Receiver operating characteristic (ROC) curve
Biostatistical considerations in screening
- Relative risk reduction, absolute risk reduction, number needed to screen, and survival (disease-specific and all-cause mortality)
- False positives and false negatives
- Pseudodisease and overdiagnosis
Biostatistical considerations in radiation biology
Biostatistical considerations in radiology research
Illustrative cases and examples
Summary SUMMARY The major teaching points of this exhibit are:
1. To review the major biostatistical considerations in diagnostic imaging.
2. To provide the busy radiologist with a free and easy to access online reference for use whenever these concepts may be encountered. Informatics - Sunday Posters and Exhibits (12:30PM - 1:00PM) Sunday, 12:30 PM - 01:00 PM • Lakeside Learning Center
IN
Back to Top LL-INS-SUA • AMA PRA Category 1 Credit ™:0.5 Host
Ayis T Pyrros , MD * LL-INS-SU1A • DAISY: Open Source Mobile App Helping Patients Prepare for Radiology Exams and Procedures after Order Entry
Qinglin Chen (Presenter) ; Daisy Q Huang MD ; Ramin Zabih PhD * ; Deborah Estrin PhD ; Keith D Hentel MD, MS ; George L
Shih MD, MS * CONCLUSION DAISY provides a simple interface to enhance the preparation for imaging exams and procedures, providing both how the exam is
performed and also walks the patients through any preparations required, thereby reducing the potential for rescheduling as well as
improving patient satisfaction and overall efficiency of healthcare delivery. Background Certain imaging exams (eg, CT) or procedures (eg, barium enema) will often have a short list of instructions (eg, NPO after midnight).
After ordering an exam, some patients either never get these instructions or forget to follow them, which may result in rescheduling of
these exams. Rescheduling of exams may delay patient care and disrupt clinical workflow, as well as having financial implications for
unused healthcare resources (physician time, imaging equipment). As more patients rely on smartphones to organize their lives and their
health, a mobile app may help address these exam preparation issues, instead of relying on paper instructions.
Evaluation We created an open source mobile app called DAISY which provides both information about the exam and procedure, and also uses both
Page 25 of 397
We created an open source mobile app called DAISY which provides both information about the exam and procedure, and also uses both
mobile notifications to remind patients to complete each task and also has mobile calendar integration to add each exam preparation step
as events. When a exam get ordered, an email will be sent to patients' email address, and then patients can launch the app via a special
URL which can then populate all the relevant exam information, including exam appointment time. Patients can then acknowledge each
part of the exam preparation, and can also provide additional information (eg, allergies) and comments (eg, couldn�t tolerate bowel
prep) to the radiologist. The open source ohmage framework is used in order to keep track of the app usage and obtain feedback for app
improvement. Discussion DAISY may be used to provide useful information about what to expect for imaging procedures as well as to give them step-by-step tasks
for any preparation required, all customized for their particular imaging procedure, which may reduce potential confusion as to when to
perform each task, since the reminders via the mobile device are customized for the exact time of appointment. LL-INS-SU2A • Under Scrutiny: The Role of Radiology in Imaging Approval
Sarah Russell (Presenter) ; Alison Wilcox MD * ; Cameron Hassani MD ; Christopher Lee MD ; Ana Maliglig MD, MPH ; Suzanne L Palmer MD * CONCLUSION Though a CT request may be initiated by a physician, nurse practitioner, or physician's assistant with a sound knowledge of the question
asked, there is variable understanding of the complexities of CT scanning protocols. Institutions may have several protocols for evaluation
of the same body part, each answering a different clinical question. These complexities lead to both confusion and inaccurate ordering of
CT scans. The review of CT requests is both time consuming and under-appreciated by the requesting physician. However, there is clearly
a benefit for both the patient and the institution when this review occurs. If the provided information is sufficient, studies are approved
without further review. Background CT scans are frequently ordered inaccurately or with inadequate justification. In this era of managed health, limited financial resources,
and increasing concerns regarding ionizing radiation exposure, a review process may become a necessity. The purpose of this review was
to assess the clinical impact of a radiologist overseen imaging approval process at a large academic medical center. Evaluation All CT imaging orders are placed into a radiology information system system by nonradiologists. A radiologist reviews all CT requests
(excluding trauma) and either approves without changes, approves with changes, or deems the study inappropriate. Records for all CT
studies ordered between March 1, 2012 and September 1, 2012 were collected and analyzed. CT studies that were approved with changes
were categorized as a clarification to the order, intravenous (IV) contrast change, or protocol change. Discussion During this 6 month period, a total of 23,337 CT studies were ordered. 9049 exams were ordered from the ER. Of the non-ER studies,
2571 (14.2%) were approved with changes by a radiologist. 719 (27.9%)of these studies required a change in the IV contrast protocol,
860 (33.4%) required a clarification of the order, and 436 (16.9%)required a change in the protocol. In the ER, 5073 (56.1%) studies
were not reviewed by a radiologist, as they were related to trauma. Additionally, 1795 (9.9%) of all studies and 228 (2.5%) of all ER
studies were deemed not appropriate by a radiologist reviewer. LL-INS-SU3A • Computer-aided Volumetry of Ground-glass Opacity and Solid Component through the Nodule Segmentation and
Vascular Structure Elimination in Chest CT Images
Ju Lip Jung BEng (Presenter) ; Helen Hong PhD ; Jin Mo Goo MD, PhD * ; Kyunghee Lee MD ; Sang Joon Park ; Jae Yeon Wi
MD CONCLUSION The proposed method can be used to differentiate malignant and benign nodules by analyzing the volumetry changes of GGO and solid
component in follow-up chest CT scans. Background To differentiate malignant and benign nodules through computer-aided volumetry of ground-glass opacity (GGO) and solid component,
we propose a GGO nodule segmentation method using asymmetric multi-phase deformable model with intensity constraint and vascular
structure elimination. Evaluation The chest CT images were obtained on the Lightspeed Ultra CT scanner (GE) and the Sensation 16 Scanner (Siemens) with various
reconstruction kernels (B30f, B50f and B60f). The dataset is consisted of 10 pure GGO nodules and 24 mixed-GGO nodules (diameter
7.4-25.7mm, mean diameter 17.1±5.1mm). To extract initial GGO and solid component, optimal volume circumscribing a nodule was
decided by clicking inside nodule and solid component was extracted by applying thresholding with -200HU. Then GGO was extracted by
estimating the adaptive threshold value based on intensity histogram modeling. To segment final GGO and solid component, GGO and
solid component were simultaneously separated from lung parenchyma using asymmetric multi-phase deformable model with intensity
constraint. To eliminate vessels inside GGO nodule, vessel-like structures are enhanced by Hessian-based vessel enhancement filtering
with oval blob-like structures suppression. To evaluate the performance of computer-aided volumetry, solid component proportion
difference (SCPD) between computer-aided volumetry and manual volumetry was measured. The solid component proportion was
calculated as (solid component volume / GGO nodule volume) and the SCPD was calculated as ((computer-aided volumetry � manual
volumetry) / manual volumetry × 100). The average SCPD was 2.7±6.6% and the limits of agreement were 15.7% and -10.4%. Discussion Our asymmetric multi-phase deformable model with intensity constraint accurately seperates GGO and solid cpmponent from lung
parenchyma. Our vessel enhancement filtering with oval blob-like structures suppression helps to eliminate vessels without the loss of
solid component and accurately measure the GGO and solid component volumes. LL-INS-SU4A • Visualizing Biomedical Literature: Integration and Application of Clinical, Imaging, and Genomic Evidence
Reported in Research Studies
William Hsu PhD (Presenter) ; Maurine Tong ; Rick K Taira PhD ; Alex A Bui MS, PhD CONCLUSION We present a framework for structuring, integrating, and visualizing scientific claims and associated context from biomedical papers. We
demonstrate the utility of this information in translational research by facilitating hypothesis generation and knowledge discovery. Background The rate of scientific discovery is greatly outpacing our ability to comprehend and apply this knowledge. Medline indexed over 2,900
papers about non-small cell lung cancer in 2012 alone. The number of papers reflects the fast pace at which insights are being generated.
However, this growing body of literature also exposes our inability to effectively integrate and understand the vast body of evidence.
Current literature retrieval tools do not provide functionality to easily identify and summarize studies based on participant demographics,
study design, and measured variables. This information is useful in identifying areas of active research, studies reporting conflicting
evidence, and gaps in our understanding of a disease. We have created an interactive visualization that permits clinical scientists with
exploring information provided by biomedical papers, summarizing scientific claims, and understanding relationships among studies. Evaluation The visualization tool is presented in the context of characterizing the role of EGFR expression in treatment response of NSCLC patients
Page 26 of 397
through the lens of clinical, imaging, and genomic factors. Scientific claims from a set of 31 full-text papers were extracted, standardized,
and mapped to entities and attributes in the standardized data model. Use cases were developed to guide development and usability
assessment of the user interface. Discussion This work addresses the need for a standardized data model for biomedical literature, text extraction tools to map information from
full-text papers to the data model, and a web-based visualization to explore and query a large, multidimensional dataset. Informatics
challenges related to the semantic characterization of scientific claims and integration of heterogeneous evidence encompassing multiple
biological scales are discussed. LL-INE-SU5A • Pathological Lung Segmentation in Computed Tomography (CT) Images: Current Approaches, Challenges, and
Future Trends
Awais Mansoor PhD (Presenter) ; Ulas Bagci PhD, MSc ; Brent Foster ; Ziyue Xu PhD ; Jayaram K Udupa PhD ; Daniel J
Mollura MD PURPOSE/AIM 1.
2.
3.
4.
To identify the clinical importance of lung segmentation and explain why CT images are used to quantify lung pathology.
To review the current state-of-the-art image segmentation approaches for pathological lungs from CT scans.
To identify the challenges in pathological lung segmentation.
To discuss the future of lung segmentation methods and explain how engineering advancements in CT plays a valuable role.
CONTENT ORGANIZATION 1. Introduction a. Lung disease b. Clinical importance of segmentation 2. Segmenting Lung Pathology from CT images a. Why use CT
images? b. Lung disease or normal lungs�no difference 3. State-of-the-Art Segmentation Methods for CT Images a. CT-based
attenuation correction methods b. Registration-assisted methods c. Registration-assisted image smoothing methods d. Graph-based
methods e. Model-based methods 4. The Challenges of Segmenting Lung Pathology a. Image quality b. Time needed for analysis 5.
Concluding Remarks and future trends in lung segmentation pathology SUMMARY Review the clinical importance of lung segmentation.
Review state-of-the-art lung segmentation methods for CT images.
Review the challenges of lung segmentation.
Review the challenges of lung segmentation.
LL-INE-SU6A • Structured MRI Report Templates for Initial Staging of Cervical and Endometrial Cancers
Rekha N Mody MD (Presenter) ; Namita S Gandhi MD ; Myra K Feldman MD ; Noushin Vahdat MD ; Shetal N Shah MD ; Dipika Patel MD PURPOSE/AIM � Illustrate a structured reporting template for Cervical and Endometrial Cancer MRI at initial staging.
� Describe the FIGO staging system and the role of MRI in staging cervical and endometrial cancer
� Discuss key interpretive points essential in the pre-operative staging of cervical cancer with respect to TNM classification
CONTENT ORGANIZATION � Female Pelvis MRI Protocol
� Anatomy of the uterus, cervix and parametrium
� TNM/FIGO staging classification of cervical and endometrial cancers.
� Structured report for cervical cancer MRI with imaging examples to highlight the specific content pertinent to staging of cervical cancer
for example parametrial invasion and lymph node status
� Structured report for endometrial cancer with imaging examples to highlight the pertinent staging features like depth of myometrial
invasion and nodal status.
SUMMARY Structured reports for cervical (table 1) and endometrial cancers can provide an accurate, reproducible and concise framework for
communication of pertinent positive and negative findings to aide oncologists and surgeons in developing appropriate treatment strategy
and can be helpful for clinical outcome measurements. LL-INE3243-SUA • Cloud Computation of Anatomical Features from Imaging Studies to Discover Radiation Toxicity Trends Using
a DICOM-based Decision Support System
Ruchi Deshpande MS (Presenter) ; Anh H Le PhD ; John J Demarco PhD ; Daniel A Low PhD * ; Patrick Kupelian MD * ; Brent
J Liu PhD Background Radiation therapy treatment plans are determined by patient anatomy, which often limits the dose to the tumor and the degree of
protection to surrounding organs-at-risk. Targeting the tumor sometimes holds priority over limiting damage to normal tissue, leading to
radiation toxicity. Since the dose distribution and treatment plan are determined by the patient's anatomy, it is possible that different
patterns and combinations of anatomical features, plan parameters and dose characteristics lead to specific radiation toxicity outcomes.
Our decision support module uses cloud computing for discovering and utilizing these patterns, thereby obviating the need to download
and install software, by providing Software as a Service (SaaS). This follows current trends in Radiation Oncology departments, which are
trying to move away from traditional in-house stand-alone workstations, towards a client-server architecture. Evaluation We have collected 80 treatment-planning data sets of patients who have undergone radiation therapy for prostate cancer. This data
includes CT slices, DICOM RT Dose, Structure Set, Plan as well as quantified radiation toxicity outcomes. We are using this data to test
our algorithms and evaluate the workflow of the system's ability to predict toxicity outcomes in a cloud-computing environment. Discussion We have created a knowledge base by quantifying anatomy and radiation toxicity outcomes of retrospective patients. This can be used to
predict the radiation toxicity of future patients, or to search for treatment plans of previous patients with similar anatomy in order to
optimize treatment for new patients. Our decision support tools are embedded in a cloud-based web application that features several
presentation and visualization tools for analyzing treatment data. CONCLUSION We have developed a web application that utilizes cloud computing and quantifies patient anatomy using imaging studies, in order to
categorize radiation toxicity risks associated with external beam radiation therapy. The methods and results of this work can also be
applied to other computationally intensive post processing workflows in radiology. Page 27 of 397
LL-INE3237-SUA • Automatic Creation of Structured Cardiothoracic Computed Tomography Reports Using Natural Language
Processing
Paras Lakhani MD (Presenter) ; Christopher G Roth MD * ; Richard E Sharpe MD, MBA ; Kristen E McClure MD ; Paul J Read
MD ; George P Hobbs MD ; Vijay M Rao MD ; Adam E Flanders MD Background Structured reporting (SR) is felt to have many advantages over free-text reporting, including that it is preferred by clinicians, facilitates
data-mining, business analytics, retrospective research, and quantitative imaging. However, traditional SR reporting applications were
found to be time-consuming by some radiologists, resulting in decreased productivity. Thus, the purpose of this study was to determine
the feasibility a natural language processing (NLP) solution to automatically create standardized reports from free-text radiology
dictations. Such a solution could provide the benefits of structured reporting with minimal loss in productivity. In this exhibit, we
demonstrate the ability of an NLP solution to transform free-text cardiothoracic CT interpretations into structured reports. Evaluation A web-based computer programming application using NLP techniques was developed at our institution to transform free-text
cardiothoracic CT interpretations into structured reports. Examples of the software in converting free-text to structured reports will be
provided. In addition, users will be able to enter in their own free-text cardiothoracic CT dictations, and test the software's ability to
structure their reports in real-time. Discussion This NLP solution re-organizes the report by placing text into anatomy-driven subheadings. The goal of this is to improve the readability
and consistency of the reports. The application can transform reports in real-time during sign-off or retrospectively on a database of
reports. The software uses common web-based programming languages (PHP, Javascript, HTML) and can integrate with different
reporting and radiology information systems. Future efforts are underway to adapt the lexicon of the free-text report into those
supported by RADLEX. CONCLUSION Natural language processing can automatically generate structured cardiothoracic CT radiology reports from free-text. The organization
and content of such reports can be customized for institutional or individual preferences. LL-INE3162-SUA • Improving Persuasiveness of Computer-aided Differential Diagnosis (CADx) System by Disclosing Reasons
for Diagnosis
Masahiro Yakami MD, PhD (Presenter) ; Masami Kawagishi ; Gakuto Aoyama ; Koji Fujimoto MD, PhD ; Takeshi Kubo MD ; Kaori Togashi MD, PhD * ; Ryo Sakamoto ; Koji Sakai ; Hiroyuki Sekiguchi ; Yutaka Emoto MD, PhD ; Yoshio Iizuka ; Hiroyuki Yamamoto Background Many CADx systems have been reported to improve differential diagnosis on lung nodules by radiologists. However, radiologists still have
reluctance to accept CADx suggestion. To improve diagnostic accuracy with a CADx system, it is also important to improve
persuasiveness of CADx suggestion, as well as the diagnostic accuracy. Thus we developed a CADx system which suggests the diagnosis
on a specified lesion and reasons for the diagnosis, and evaluated the persuasiveness of the suggestion. Evaluation With the approval of the institutional review board, we built a database on 491 lung nodules on which diagnoses were clinically confirmed
as primary lung cancer, metastatic nodules or other benign nodules. This database consisted of CT images, image findings on the nodules,
the confirmed diagnosis, clinical information such as laboratory data and patient history. The image findings were described by consensus
of two board-certified radiologists.
The CADx was trained and evaluated by using 179 and 312 nodules in the database, respectively. The CADx derived and suggested a list
of possibilities for differential diagnoses on each nodule using a Bayesian network (ICAD). It also derived image findings and/or clinical
information having high influence on the diagnosis with the highest possibility and suggested them as the reasons for the inference in
addition to the list (RCAD).
Eleven radiologists, with five years� experience in diagnostic imaging, interpreted the 312 nodules under three different conditions
(without CAD, with ICAD, with RCAD) with more than one month intervals.
The numbers of cases on which each radiologist disagreed with the CADx initially, and changed his/her diagnosis to follow the CADx
suggestion, were counted as disagreed and �persuaded� cases for evaluation, respectively. Discussion The average number of disagreed cases among the 11 radiologists were 99.5 (SD=13.5).
That of �persuaded� cases by RCAD among them was 47.5 (SD=15.2), and significantly larger than that by ICAD, 43.9 (SD=13.9)
(Wilcoxon signed-rank test, p CONCLUSION RCAD was more persuasive for the radiologists than ICAD. LL-INE3166-SUA • A Computer Aided Diagnosis (CADx) which Discloses the Reason of Diagnosis May Improve a Low Accuracy
Group of Radiologist More than a CADx without Reason Disclosure
Yutaka Emoto MD, PhD (Presenter) ; Masahiro Yakami MD, PhD ; Koji Fujimoto MD, PhD ; Takeshi Kubo MD ; Ryo Sakamoto
; Kaori Togashi MD, PhD * ; Gakuto Aoyama ; Masami Kawagishi ; Koji Sakai ; Hiroyuki Sekiguchi ; Yoshio Iizuka ; Hiroyuki Yamamoto Background Computer Aided Diagnosis (CADx) has been expected to help radiologists. Because a CADx does not always suggest the right diagnosis, a
radiologist may not agree the suggestions. If a CADx shows why it suggests the diagnosis, a radiologist can make better decision. We
developed a CADx system which discloses the reasons of diagnosis of lung nodules in CT images, and evaluated the accuracy of
radiologists influenced by the CADx. Evaluation We built a database of 491 lung nodules whose diagnoses were clinically confirmed as primary lung cancer, metastatic nodules or benign
nodules. The database consisted of CT images, image findings, clinically confirmed diagnosis, clinical information such as laboratory data
and patient history. The image findings were described by consensus of two board-certified radiologists. 179 and 312 nodules in the
database were used for training the CADx and for evaluation, respectively. The inference model of the CADx was a Bayesian network,
which was constructed using the Markov chain Monte Carlo method with the training data set. The CADx derives a set of inference
probabilities of each diagnosis (ICAD). In addition to the result, image findings and/or clinical information are indicated as reason of the
inference for each case (RCAD). The reason is derived based on influence degree for the diagnosis with the highest inference probability.
11 radiologists, with 5 years� experience for diagnostic imaging, interpreted the 312 nodules with three different conditions (with no
CAD, ICAD, RCAD) with more than 1 month interval.
Mean accuracy rates are 0.714, 0.763, 0.766, 0.74 with no CAD, ICAD, RCAD, CAD alone, respectively.
Discussion Radiologists are grouped into 2 groups by the average accuracy rate with no CAD. In the high accuracy group, 2 radiologists are better
with ICAD than with RCAD, 2 show no change. In the low accuracy group (LA), 2 are better with ICAD than with RCAD, 5 are better with
RCAD than with ICAD. RCAD improves LA better than ICAD. CONCLUSION A CADx which discloses the reason of diagnosis may be effective for radiologist with low accuracy rate of lung nodule diagnosis. Page 28 of 397
LL-INE3200-SUA • Imaging Informatics System Utilizing DICOM Objects for Treating Pain in Spinal Cord Injury Patients Utilizing
Proton Beam Radiotherapy
Sneha K Verma MS (Presenter) ; Brent J Liu PhD ; Ruchi Deshpande MS ; Sophia Chun ; Daila S Gridley PhD Background Many US combat personnel have sustained nervous tissue trauma during service, which causes Neuropathic pain that is difficult to
manage. In select patients, synapse lesioning can provide significant pain control. Our goal is to determine the effectiveness of using
Proton Beam radiotherapy for treating spinal cord injury (SCI) related neuropathic pain as an alternative to invasive surgical lesioning.
The research is a joint collaboration of USC, Spinal Cord Institute VA Healthcare System, Long Beach, and Loma Linda University. Evaluation This is the first system of its kind that integrates preclinical data, from animal studies and research related human studies, on one
web-based platform with standardized DICOM data objects. It supports integration and standardization of imaging informatics data in
DICOM format; clinical evaluation forms outcomes data and treatment planning data from the Treatment planning station (TPS) utilized
to administer the radiation dose in DICOM-RT format. In addition, it supports evaluation of SCI subjects for recruitment into the clinical
study, which includes the development, and integration of digital forms and tools for automatic subject evaluation and classification of SCI
pain as well as a rules-based decision tree. For evaluation and development purposes of the overall system, data sets from 10 human
and 5 animal studies will be used and integrated into the system. Discussion This imaging informatics system is capable of integrating different datasets like patient recruitment, preclinical studies and patient related
studies - all accessible via web-based platform. In this computer exhibit we will show design of DICOM standard database that incorporate
preclinical data with patient related studies on a web-based platform and a fully developed graphical interface for a pain classification
tool, as well as viewing patient recruitment and preclinical studies. CONCLUSION We present a medical informatics system capable of integrating various data objects, such as patient recruitment information; preclinical
studies, treatment related information utilizing the DICOM standard and implemented on single web-based platform. LL-INE3239-SUA • A Comprehensive Ontology of Radiology Differential Diagnosis
Charles E Kahn MD, MS (Presenter) * ; Dhiraj Baruah MD ; Joseph J Budovec MD ; Gerald Cameron MS ; Stephen W Goth BS,
MD ; Cesar A Lam MD ; Kaushik S Shahir MD ; Matthew W Shore MD ; Kenneth C Wang MD, PhD * Background Radiology 'gamuts' -- lists of differential diagnoses of imaging observations -- are an important source of knowledge in diagnostic
radiology. Although gamuts appear in radiology textbooks and online information resources, there has been little effort to develop a
formal treatment of this form of knowledge. We sought to develop the Radiology Gamuts Ontology (RGO) as a comprehensive knowledge
model of radiology differential diagnosis, to provide the ontology's knowledge to radiologists and others through an interactive Web site,
and to integrate its knowledge with heterogeneous biomedical knowledge resources for research, education, and clinical decision support. Evaluation The RGO contains more than 1,300 differential-diagnosis lists with 20,699 terms for disorders and imaging observations with 1,766
synonyms and abbreviations; it specifies 1,175 subsumption relations and 49,819 causal relations. The RGO spans imaging findings in all
organ systems and a variety of imaging modalities. The ontology is made available primarily through an open, interactive web site
(www.gamuts.net) where users can browse the terms, view their relationships to other entities, and follow hyperlinks to view the related
concepts. The model's knowledge also can be accessed through a RESTful web service and a Web Ontology Language (OWL) document. Discussion The Radiology Gamuts Ontology provides a form of �computable knowledge� for differential diagnosis in radiology, and has been applied
to create an illustrated gamuts reference and a differential-diagnosis quiz generator. The interactive Web interface allows information to
be incorporated from other sources, such as Wikipedia, ARRS GoldMiner, and the biomedical literature. CONCLUSION Radiological knowledge, such as the relationships of medical conditions and their imaging manifestations, can be represented and shared
through Semantic Web technologies. The Radiology Gamuts Ontology promotes integration of radiology differential diagnoisis with
decision support systems, clinical image repositories, and the biomedical literature. Musculoskeletal -Sunday Posters and Exhibits (12:30pm - 1:00pm) Sunday, 12:30 PM - 01:00 PM • Lakeside Learning Center
MK
Back to Top LL-MKS-SUA • AMA PRA Category 1 Credit ™:0.5 Host
Jeffrey J Peterson , MD LL-MKS-SU1A • Can Dynamic Rotation during Arthro-MRI Be Useful in the Diagnosis of Long Head of Biceps Tendon (LHBT)
Instability in Patients with Biceps Pulley Lesions of the Shoulder?
Silvia Mariani MD (Presenter) ; Alice La Marra MD ; Francesco Arrigoni ; Vittorio Calvisi MD ; Antonio Barile ; Carlo
Masciocchi PURPOSE Arthro-MRI is proven to be the diagnostic gold standard in the evaluation of biceps pulley anatomy and lesions. The purpose of our study
was to evaluate the added value of the internal and external rotation during arthro-MRI scans in identifying the LHBT instability and the
possible development of an antero-superior impingment (ASI). METHOD AND MATERIALS We retrospectively analyzed MRI exam of 70 patients (55 males and 15 females) who underwent arthro-MRI exam with a 1.5 T U and
arthroscopy within the following 7-45 days. All patients had clinical suspicion of biceps pulley lesions and all were positive to Palm-up,
O'Brien and Hawkins tests. During the MRI, the shoulder was studied with a dedicated coil with the arm in neutral position, in internal and
external rotation to evaluate the LHBT. ABER position was used in 12 patients. We did an intrarticular injection of 13-18 cc of contrast
agent under fluoroscopic guide. RESULTS Patients were divided in 4 groups based on the Habermayer classification and then evaluated for the presence of an unstable LHBT.
According to the Habermeyer classification: 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 no subluxation in patients with type I lesion, 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. The dynamic tests during arthroscopy, confirmed LHBT instability and ASI features in all patients with Type
Page 29 of 397
Type III and Type IV lesions. The dynamic tests during arthroscopy, confirmed LHBT instability and ASI features in all patients with Type
III and Type IV lesions. CONCLUSION Only high grade lesions of the biceps pulley can be associated with LHBT instability. MRI external and internal rotation scans 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 Dynamic arthro-MRI scans allow a correct evaluation of the LHBT instability , and it is a very important diagnostic tool in the planning of
arthroscopic treatment. LL-MKS-SU2A • Posteromedial Olecranon Impingement: CT and MR Imaging Findings of Pitching Elbow
Ching-Chung Ko MD (Presenter) ; Kuen-Huang Chen MD ; Jeon-Hor Chen MD ; Wen-Sheng Tzeng MD ; Ginger Shu ; Chung-Da Wu PURPOSE Posteromedial olecranon impingement (PMOI) is the most common diagnosis in the baseball players with throwing-induced elbow injuries.
Imaging manifestations of PMOI have seldom been reported before. We aimed to investigate imaging features of PMOI with emphasis on
CT and MRI, and compare the imaging findings in these two modalities. METHOD AND MATERIALS From July 2010 to February 2013, imaging studies of the elbow joints from 24 baseball players are reviewed by an experienced
musculoskeletal radiologist. All of these players had elbow pain when throwing and decreased range of motion in the elbow joint. All
subjects are male with a mean age of 17.6 years (range, 12 to 31 years). The mean duration of playing baseball was 8 years (range, 3 to
19 years). The dominant arm was affected in all patients. The imaging modalities for evaluating PMOI include plain film (n=24), CT
(n=12), MRI (n=24). RESULTS The imaging findings by CT or MRI include PMOI (n=20, 83%), injury of ulnar collateral ligament(UCL) (n=15, 63%), avulsion fracture of
medial epicondyle(ME) (n=10, 42%), osteochondritis dissecans(OCD) (n=7, 29%), stress fracture of olecranon process (n=5, 21%), and
ulnar neuritis (n=1, 4%). The findings in the plain film include osteophytes, loose bodies, and stress fracture of olecranon process. In
the 20 players with PMOI findings, 10 players received CT and MRI studies simultaneously. The imaging manifestations in
CT studies of these 10 players include cartilage space loss (n=10, 100%), subchondral sclerosis (n=10, 100%),
osteophytes (n=10, 100%), OCD (n=4, 40%), and stress fracture of olecranon process (n=4, 40%). As compared with CT,
the MRI showed lower sensitivity in detecting PMOI findings such as cartilage space loss, osteophytes, and OCD. The MRI
is good in detecting associated findings of PMOI like UCL injury (n=7, 70%) and bone marrow edema (n=6, 60%) in these
10 players, which cannot be evaluated by CT because of poor image resolution. The most common associated findings of
PMOI in this study are UCL injury (n=15, 75%) and avulsion fracture of ME (n=9, 45%). CONCLUSION Although CT is more sensitive for detecting PMOI, MRI is necessary for evaluating associated injuries. In patients diagnosed with PMOI
and need surgical intervention, CT offers fast and helpful information. CLINICAL RELEVANCE/APPLICATION CT is a good choice in evaluating PMOI and could be used before surgical intervention in patients diagnosed with PMOI previously. LL-MKS-SU3A • MRI of the Knee-Do 2 Millimeter Slices Improve Diagnostic Performance?
Jacob J Visser MS ; Annick C Weustink MD, PhD ; Edwin H Oei MD, PhD (Presenter) ; Galied S Muradin MD PURPOSE To determine whether 2 millimeter slice thickness on knee MRI has additional value for evaluating menisci and cruciate ligaments in
symptomatic patients. METHOD AND MATERIALS 74 consecutive patients undergoing knee arthroscopy following MRI of the knee from January 1, 2011 until November 1, 2012 were
included retrospectively. A routine clinical MRI protocol was acquired with 3 millimeter (mm) slice thickness followed by additional sagittal
and axial 2 mm proton density (PD) weighted sequences. 2 sets of MR sequences per patient were created: routine protocol with 3 mm
only and the extended protocol with additional 2 mm sequences. All MR imaging studies were reviewed independently by two
musculoskeletal radiologists for presence of ligament and meniscal tears. Sensitivity and specificity of the routine and extended MRI
protocol in the detection of meniscal tears and cruciate ligament tears were calculated with arthroscopy used as the reference standard.
Logistic regression analysis was used to assess the additional value of the 2 mm PD-slices. RESULTS The extended MR imaging protocol with 2 mm slices had higher sensitivity than the routine MR imaging protocol for the detection of
meniscal tears (94% versus 90%) and similar specificity (94% and 95% respectively). Sensitivity for detection of medial meniscal tears
was 98% with the extended protocol versus 93% with the routine protocol with no difference in specificity (88%). For detection of lateral
meniscal tears, both sensitivity and specificity were higher for the extended MR imaging protocol (89 versus 85% and 100 versus 98%
respectively). Sensitivity for anterior cruciate ligament tears was 90% for the extended MR imaging protocol versus 92% for the routine
imaging protocol, whereas the specificity was 83% for the extended imaging protocol versus 75%. Logistic regression analysis showed
statistically significant additional value for the extended versus the routine MR imaging protocol in the detection of meniscal and anterior
cruciate ligament tears (P CONCLUSION An extended knee MRI protocol with 2 mm slice thickness has additional value in the detection of meniscal and anterior cruciate ligament
tears. CLINICAL RELEVANCE/APPLICATION Routine knee MRI protocols are often based on sequences with 3-4 millimeter slices. Two millimeter sequences improve diagnostic
performance and may be an alternative to 3D isotropic scanning. LL-MKS-SU4A • Estimation of Glenoid Bone Loss Using 3DMR Reconstructions of the Shoulder
Soterios Gyftopoulos MD (Presenter) ; Avner Y Yemin MD ; Luis S Beltran MD ; James S Babb PhD ; Marissa L Albert MD,MSc
; Laith M Jazrawi MD * ; Robert Meislin MD ; Eric J Strauss MD PURPOSE To assess the accuracy of 3DMR shoulder reconstructions for estimating glenoid bone loss (GBL). METHOD AND MATERIALS A retrospective review of patients who underwent MR shoulder examinations at our institution over the past 6 months was conducted with
the following inclusion criteria: 1) history of shoulder dislocation, 2) Dixon 3D-T1W-FLASH sequence included in the protocol and
post-processed into 3D reconstructions, 3) arthroscopy (OR) within 6 months of MRI and 4) GBL estimation performed in the OR using
the bare-spot method and included in the OR report. Two readers blindly, independently estimated the percentage of bone loss along the
width of the glenoid on the 3DMR reconstructions using the best-fit circle-method. Statistical analysis included a Wilcoxon test, and 95%
confidence intervals to calculate the mean bias and absolute error for MRI compared to the OR estimates. Inter-reader agreement was
Page 30 of 397
assessed using intraclass (IC) and concordance correlation (CC) coefficient analysis. RESULTS There were a total of 14 patients (12-men, 2-women; mean age 29, range 19-51) that could be included in the study. There was no
significant difference, on average, between the MRI and OR measures (p=0.767). A 95% confidence interval for the mean bias extended
from -1.40% to 1.12%, implying that, when averaged over all patients, the true mean difference between the MRI and corresponding OR
measures is expected to be less than 1.5%. A 95% confidence interval for the mean absolute error extended from 0.50% to 2.35%,
implying that, when averaged over all patients, the true mean absolute error of the MRI measures relative to the OR measures is
expected to be less than 2.35%. For inter-reader agreement, the measurements between the 2 readers had an IC of 0.92 and CC of
0.90, suggesting strong agreement. CONCLUSION 3DMR reconstructions can be used to accurately quantify glenoid bone loss. CLINICAL RELEVANCE/APPLICATION The efficacy of 3DMR shoulder reconstructions in the estimation of glenoid bone loss decreases the need for 3DCT and its associated
radiation dose and cost. LL-MKS-SU5A • Could 3D-CT of the Shoulder Be Omitted from Pre-operative Evaluation for Anterior Instability? -Comparison of
3D-MRI with 3D-CTYoshinao Sato MD (Presenter) ; Taiki Nozaki MD ; Atsushi Tasaki MD ; Masaki Matsusako MD, PhD ; Hiroshi Yoshioka MD ; Yukihisa Saida MD ; Yuka Morita MD ; Saya Horiuchi MD ; Gensuke Akaike MD ; Goto Makoto ; Takaharu Suzuki PURPOSE The purpose of this study is to assess the accuracy of quantification of glenoid bone loss and evaluation of bony fragment on 3D-MRI as a
substitute for 3D-CT. METHOD AND MATERIALS Both MRI and CT were performed in 25 anterior instability patients. We used fat-suppressed 3D volumetric interpolated breath-hold
examination on 3T-MRI, and 320-slice CT scanner that renders 3D-image. Based on the result of 3D-CT as the golden standard, the
sensitivity and specificity of 3D-MRI for detection and quantification of glenoid bone loss and bony fragment were determined by two
radiologists. RESULTS Glenoid bone loss were noted in 13 (52%), and bony fragment were found in 10 (40%) on 3D-CT. Compared with 3DCT, the sensitivity
and specificity of 3D-MRI in detecting glenoid bone loss were 84.3%-92.3% and 91.7%-100%, respectively (kappa value = 0.92) and
those of in detecting bony fragment were 90.0%-100% and 100%, respectively (kappa value = 0.96 ). Angular degree of glenoid bone
loss was 87.5±34.8 on measurement used 3D-MRI, 80.0±29.4 on 3D-CT. There was no significant difference (p=0.109). CONCLUSION 3D-MRI is a promising substitute for 3D-CT as a reliable method for evaluating glenoid bone loss and bony fragment in anterior shoulder
instability. CLINICAL RELEVANCE/APPLICATION 3D-CT of the shoulder could be skipped from preoperative evaluation for anterior instability, and substituted 3D-MRI. LL-MKE-SU6A • 'When Blood Corrodes' Musculoskeletal System Manifestations of Hemophilia A Multimodal Approach in a Cohort
Gabriel F Daza Cajas MD (Presenter) ; Jhon J Echeverri MD PURPOSE Classification and review of the acute and chronic abnormalities of the musculoskeletal system in hemophilic patients.
Pathophysiology of the complications in this group of patients
To identify findings in plain radiography, CT and MRI as part of the management protocol of musculoskeletal injuries. METHOD AND MATERIALS Retrospective case series based on the cohort of patients with hemophilia in a referral center.
We describe factor VIII deficiency, its etiology, global pathophysiology, and overall the most common and expected manifestations on the
musculoskeletal system in patients with hemophilia.
Description of the most prevalent radiological findings in patients who are part of an cohort of 500 individuals.
Multimodal approach with surgical-pathologic correlation. RESULTS Approximately 150 events of documented pathology in the musculoskeletal system of the cohort are described.
Approximation flowcharts are established for the diagnosis of pathology prevalent in patients with this disease:
- Traumatic Injuries
- Injuries with arthritic consequences
- Pseudo tumor-like lesions
- Intra Abdominal Injury CONCLUSION Hemophilia is an entity which, under controlled circumstances, allows an adequate quality of life and an acceptable survival rate.
However, unless there is an accurate and early diagnosis, as well as intervention by a multidisciplinary team of specialists in
hematological disease which could prevent or reduce complications and sequelae attributable to bleeding in the musculoskeletal system,
everyday circumstances can generate unexpected complications affecting the musculoskeletal system significantly. CLINICAL RELEVANCE/APPLICATION This paper is clinically useful for providers specialized in the management of patients with coagulation factor deficiency. These include
orthopedists, hematologists and radiologists. LL-MKE-SU7A • MSCT in the Evaluation of Painful Hip Replacement: A Pictorial Guide
Hector Vidal Trueba (Presenter) ; Elena Gallardo MD, PhD ; Rosa Maria A Landeras MD ; Rosario Garcia-Barredo ; Rosa De
La Puente ; Gerardo Lopez Rasines MD PURPOSE/AIM Describe a systematic MSCT protocol to measure acetabular and femoral components positioning. Illustrate the MSCT findings of the most frequent complications of hip replacement. Propose a systematic reading method of the different components and possible pathologies that could be the origin of the symptoms.
CONTENT ORGANIZATION This exhibit will be divided into four main parts:
A) Early complications: dislocations, fractures and infections
B) Late complications: septic and mechanical loosening , components migration, particle disease, fractures and heterotopic ossification
C) Specific complications of resurfacing arthroplasty
D) Check list
Page 31 of 397
SUMMARY Hip replacement is one of the most frequent orthopedic treatment with a high rate of success and few complications. Follow-up, in
symptomatic patients, is usually performed with simple radiographies and bone scintigraphy, due to the important metallic artifact on MR
and MCTC. However a proper MSCT study protocol and a systematic reading can be extremely useful in these patients. In this exhibit we
illustrate the most important complications of hip replacement and propose a systematic reading method. LL-MKE-SU8A • Interventional Procedures in Musculoskeletal Oncology and Development of a Multidisciplinary Musculoskeletal
Oncology Clinical Service
Debkumar Sarkar DO (Presenter) ; Joshua S Chern DO ; Anton Mahne MD ; Richard D Lackman MD * ; Walson Metzger MD,
PhD ; Siva P Jasti PURPOSE/AIM Educational review for development of a musculoskeletal oncology clinical service involving a multidisciplinary approach to management
of adult and pediatric bone and soft-tissue tumors. In this exhibit we review a spectrum of Interventional procedures in the diagnosis,
management and treatment in musculoskeletal oncology. CONTENT ORGANIZATION A. Review of imaging anatomy and pathology of bone and soft tissue tumors. B. Interventional Procedures 1. Biopsies. 2. Ablations
-Radiofrequency -Cryoablation - Microwave 3. Embolization D. Musculoskeletal oncology clinical service and multidisciplinary conference
and clinic. SUMMARY There are a vast number of procedures in musculoskeletal oncology including CT, US and MR guided percutaneous procedures from
radiofrequency ablations to biopsies. Additionally endovascular procedures can utilize cone beam CT techniques along with digital
subtraction angiography to analyze vascularity and perform embolizations for pre-surgical devascularization or targeted
chemoembolization. Furthermore endovascular and percutaneous procedures can be performed for palliative or pain management
consideration. In this exhibit we review several interventional procedures in musculoskeletal oncology while providing framework for
developing a clinical service with mutidisciplinary conference and clinic. Neuroradiology/Head and Neck - Sunday Posters and Exhibits (12:30pm - 1:00pm) Sunday, 12:30 PM - 01:00 PM • Lakeside Learning Center
Back to Top NR
LL-NRS-SUA • AMA PRA Category 1 Credit ™:0.5 Host
Pratik Mukherjee , MD, PhD * LL-NRE-SU10A • Neuroimaging of Immunosuppression-related Complications in Solid Organ Transplant Recipients: A Pictorial
Review
Ulysses S Torres MD ; Eduardo P De Oliveira (Presenter) ; Fernanda D Braojos Braga MD ; Horacio J Ramalho ; Antonio S
Souza MD ; Jose Roberto L Ferraz-Filho PURPOSE/AIM This education exhibit aims to: 1) Discuss the spectrum of neurological complications related to immunosuppression in the setting of solid
organ transplantation (SOT). 2) Categorize these complications in major groups according their clinical and radiological manifestations,
facilitating the diagnostic approach by radiologists. 3) Illustrate the main neuroimaging findings of confirmed cases of
immunosuppression-related complications occurring in SOT recipients. CONTENT ORGANIZATION This exhibit will address the spectrum of immunosuppression-related neurological complications after SOT (mainly kidney and liver
transplants) in a case-based format. Representative cases will include calcineurin-inhibitors' neurotoxicity, neurotoxoplasmosis,
neurocryptococcosis, cerebral aspergillosis, cerebral pyogenic abscesses, encephalitis due to Chagas' disease reactivation, cerebral
lymphomas, among others. SUMMARY Immunosuppression has improved graft survival in SOT recipients, but it leaves the patient susceptible to a gamut of CNS complications
occurring within a few days to several years after the procedure. Neuroimaging has a pivotal role in characterizing these complications.
After reviewing this exhibit, radiologists should be able to recognize the main correspondent imaging findings in this setting and to
formulate appropriate differential diagnoses. LL-NRE-SU11A • Dual Energy CT Imaging of the Brain and Neck
Jeffrey Hu (Presenter) ; Niv Khorrami ; Behrang Homayoon MD ; Dave Russell MD ; Paul I Mallinson MBChB ; George
Papachristopoulos MD ; Savvas Nicolaou MD PURPOSE/AIM 1. Review the characteristic findings and indications for computed tomography (CT) of the brain and neck
2. Discuss advantages of dual energy (DE)/spectral CT in adding to the clinical utility of CT in head and neck imaging
CONTENT ORGANIZATION 1. Indications for CT of the brain and neck
Intra/extracranial vessel stenosis and aneurysms
Intracranial haemorrhage
Intracranial and neck masses
2. Principles, technical aspects, and physics of DE/spectral imaging
3. Clinical applications of DECT
Radiation dose reduction
Improved bone/plaque removal reconstructions
Plaque analysis
Differentiating iodine from haemorrhage post thrombolysis
Greater grey/white differentiation and reduction of beam hardening artifacts in the posterior fossa
Material quantification of abnormal enhancement neoplasms
4. Clinical utility evaluating/staging neck masses
5. Current limitations of DE/spectral CT in head and neck imaging
6. Cases of DE/spectral CT imaging of the brain, intra/extracranial vessels, and neck from our institution with a discussion of
Page 32 of 397
characteristic findings and clinical applicability
SUMMARY 1. CT is valuable in many indications in head and neck imaging
2. DECT has significant clinical advantages over single energy CT in the evaluation of the brain, neck, and intra/extracranial vessels
LL-NRS-SU1A • MR Evaluation of Brain and Laryngeal Edema during Anaphylactic Hypotension: An Experimental Study
Ichiro Toyota MD, PhD (Presenter) ; Hisao Tonami MD ; Toshishige Shibamoto MD PURPOSE Anaphylactic shock is sometimes accompanied by local interstitial edema due to increased permeability. We performed examination of
magnetic resonance (MR) imaging to detect edema in the larynx and brain during anaphylactic hypotension in anesthetized rats, with
comparison of that during vasodilator-induced hypotension. METHOD AND MATERIALS Male Sprague Dawley rats were subjected to hypotension induced by the ovalbumin antigen (n=8) and a vasodilator sodium nitroprusside
(n=8). Apparent diffusion coefficient and T2-relaxation time were quantified on MR imaging performed repeatedly for up to 68 min after
an injection of either agent. The presence of laryngeal edema was also examined by histological examination. Separately, the occurrence
of brain edema was assessed by measuring brain water content using the wet/dry method in the rats with anaphylaxis (n=5) or sodium
nitroprusside (n=5), and the non-hypotensive control rats (n=5). Mast cells in the hypothalamus were morphologically examined. RESULTS Mean arterial blood pressure similarly decreased to 35 mmHg after an injection of the antigen or sodium nitroprusside. Hyperintensity on
T2-weighted images, as reflected by elevated T2-relaxation time, was found in the larynx as early as 13 min after an injection of the
antigen but not sodium nitroprusside. Postmortem histological examination revealed epiglottic edema in the rats with anaphylaxis, but not
sodium nitroprusside. In contrast, no significant changes in T2-relaxation time or apparent diffusion coefficient were detectable in the
brain of any rats studied. In separate experiments, brain water content quantified was not increased in either anaphylaxis or sodium
nitroprusside rats, as compared with the non-hypotensive control rats. The number of mast cells was similar in the hypothalamus of rats
with anaphylaxis and sodium nitroprusside, suggesting absence of anaphylactic reaction in the brain. CONCLUSION MR imaging elucidates presence of edema in larynx, but not brain, during anaphylactic hypotension in experimental study. CLINICAL RELEVANCE/APPLICATION MR evaluation by T2-relaxation time as well as apparent diffusion coefficient elucidates presence of edema in larynx, but not brain, during
anaphylactic hypotension. LL-NRS-SU2A • The Utility of Follow-up Imaging in Nontraumatic Lobar Intraparenchymal Hemorrhage with Negative Initial
Imaging Work-up
Sean W Wilson MD (Presenter) ; Matthew R Plunk MD ; James R Fink MD * ; Annemarie Relyea-Chew PURPOSE Hemorrhage into the brain parenchyma can have devastating clinical consequences. While hemorrhage into the basal ganglia is
overwhelmingly due to hypertension, hemorrhage in a lobar distribution is more likely to have an underlying vascular or malignant
etiology. While it has been recognized that hemorrhage can potentially obscure an underlying lesion in the acute setting, the frequency
with which this occurs is not well established. Our goal was to quantify how often repeat imaging in patients with spontaneous, idiopathic
lobar hemorrhage reveals an underlying etiology. METHOD AND MATERIALS Institutional Review Board approval was obtained. A retrospective review was conducted over 54 months to identify patients with lobar
distribution intracranial hemorrhage. Imaging and chart review was conducted for individuals with lobar hemorrhage who were evaluated
with a combination of CT, MRI, and/or catheter angiography and had subsequent imaging and clinical follow-up within the University of
Washington system. Exclusion criteria included patients less than 18 years old, preceding trauma, hemorrhagic transformation of known
infarct, and subarachnoid hemorrhage as the predominant feature. RESULTS A cohort of 327 patients with spontaneous lobar hemorrhage was identified. A causative etiology was identified on initial imaging in 67
patients (23%). 170 patients (52%) either expired or were lost to follow up before adequate imaging work up was completed. Of the
remaining 90 patients who had negative initial imaging and adequate clinical/imaging follow up (mean/median 475 and 354 days) an
underlying lesion was discovered in 10 patients (11%). CONCLUSION Repeat imaging was able to reveal an underlying etiology in approximately 11% of patients whose initial exams were negative. This is
about half the rate with which the initial imaging for patients with new lobar hemorrhage is able to identify an etiology; routine follow up
imaging should be considered when there is a concern for an underlying etiology in patients with spontaneous lobar hemorrhage. CLINICAL RELEVANCE/APPLICATION This information on the yield of follow up imaging in idiopathic lobar intracranial hemorrhage would be valuable for clinicians and
radiologists in managing these patients. LL-NRS-SU3A • Computed Tomography Angiography of Carotid and Coronary Artery via a Single-bolus Injection Protocol, a
Feasibility Study Using 320-row Multi-detector CT
Weiguo Zhang MD (Presenter) ; Guang Zhi Wang ; Mengsu Zeng MD, PhD PURPOSE To investigate the feasibility of using a single-dose injection protocol in CT angiography (CTA) of the extra-cranial carotid artery and
coronary artery (CA) with 320-row multi-detector CT. METHOD AND MATERIALS A total of 82 consecutive patients with suspected carotid artery disease underwent an original comprehensive CTA protocol aiming at
capturing the extra-cranial carotid arteries and coronary arteries simultaneously using 320-row MDCT. The image quality, attenuation,
and CNRs of the carotid, and coronary arteries were assessed. The delayed time of two acquisitions (extra-cranial carotid artery and CA)
was also compared between patients with and without cardiac venous opacification. The contrast medium volume and radiation dose were
recorded. RESULTS All of the scanning was performed successfully. The image quality was diagnostic in the carotid(100 %) and CA (93.2 %). The mean
attenuation of carotid and coronary artery was 416.3±72.5 Hu, 435.3±69.3 Hu and 477.8±83.4Hu,489.7±73.4Hu. The mean CNR of
carotid and coronary artery was 14.3±4.1 and 17.1±3.5. The delayed time in patients with coronary venous opacification was
significantly longer than that of patients without coronary venous opacification(5.3±1.7s vs. 3.1±1.5s), The mean radiation dose was
7.7±5.2 mSv (range 3.1 -16.8 mSv), The mean volume of contrast media was 78.6±10.3ml. Page 33 of 397
CONCLUSION carotid and coronary artery can be imaged successfully with our original tailored single-dose injection CTA protocol using 320-row CT with
acceptable image quality and relatively lower radiation exposure. CLINICAL RELEVANCE/APPLICATION The coexistent nature of atherosclerosis in carotid and coronary artery can be evaluated via our original CTA protocol LL-NRS-SU4A • Utility of Susceptibility-weighted MRI in Differentiating Parkinson’s Disease and Multiple System Atrophy:
Correlation with 18F-FDG PET
Ragyoung Yoon (Presenter) ; Sang Joon Kim MD ; Deok Hee Lee ; Ho Sung Kim ; Jae Seung Kim ; Choong Gon Choi MD ; Jungsu Oh ; Dae Yoon Kim PURPOSE To investigate different iron-deposition patterns of Parkinson�s disease (PD) and multiple system atrophy (MSA) in the putamen by using
susceptibility-weighted images (SWI), and to correlate them with 18F-FDG PET findings. METHOD AND MATERIALS Thirty patients with PD twenty-six with MSA (11 with MSA-P, 15 with MSA-C), and thirty-two age-matched healthy controls underwent
3-T magnetic resonance imaging with SWI of the brain. 18F-FDG PET studies were obtained in patients with PD and MSA.. Signal intensity
(SI) was measured on SWI in the posterior half of the putamen using region of interest (ROI) in both sides and normalized by SI of the
CSF. 18F-FDG PET images were coregistered to SWI using SPM-5 and standardized uptake value (SUV) was measured in the putamen
using ROI mask obtained in SWI. Normalization of SUV was done using mean global cortical metabolism measured in each patient.
Dominant hypointense side of the putamen on SWI was chosen for statistical analysis. Analysis included group-level comparison of SWI
SI values of ROI , and these results were correlated with 18F-FDG PET data in PD and MSA patients. RESULTS Hypointensity of the posterior putamen was different between MSA and PD group (p=0.010). Especially, patients with MSA-P had
significantly lower SI in the posterior putamen compared with those with PD, MSA-C and healthy control group (p CONCLUSION Signal intensity in the posterior putamen may differentiate MSA-P from PD, MSA-C and healthy controls. There was moderate correlation
between SI on SWI correlate with metabolism on 18F-FDG PET in MSA. Out study suggests that SWI SI in the posterior putamen
well-correlated with metabolism of 18F-FDG PET in patients with MSA and we speculate that iron deposition may have relationhsip with
decreased metabolism. CLINICAL RELEVANCE/APPLICATION SWI showed different patterns of brain iron deposition in clinically diagnosed groups of PD and MSA, and may be useful in discrimitating
these conditions as is 18F-FDG PET. LL-NRS-SU5A • Echostructure Characterisation of Carotid Plaques with Strain-Ultrasound Elastography as Compared with CT or
MRI
Vito Cantisani MD ; Pietro Lodise ; Mattia Di Segni MD ; Cristina Fioravanti ; Sarah Montechiarello MD ; Paolo Ricci MD ; Ferdinando D'Ambrosio ; Carlo Catalano MD ; Hektor Grazhdani (Presenter) PURPOSE To assess the feasibility of Color-Doppler US and ultrasound strain elastography (USE) to better characterize carotid plaque composition
and vulnerability as compared with high-resolution magnetic resonance imaging (MRI) or CTA. METHOD AND MATERIALS 55 patients (38 males, 17 females) with 50 % or greater carotid stenosis underwent color-doppler US and USE and at least one of second
imaging modality such as high-resolution MRI (N: 30) or CTA (40) of internal carotid arteries. US-color-map elastographic US evaluations
of segmented plaques were achieved. On MRI or CTA, corresponding plaques and components were segmented and quantified.
Associations between strain parameters, plaque composition and clinical presentation were estimated with curve-fitting regressions and
Mann-Whitney tests. RESULTS 2 patients were excluded from the study since strain-US elastography did not provide sufficient informations. In the remaining patients,
no significant difference was found in determining the mean stenosis between color-doppler US and second imaging modalities. Among
53 plaques, 12 were symptomatic, 17 contained lipid and 8 were vulnerable on MRI or CTA. Strains were significantly lower in plaques
containing a lipid core compared with those without lipid, with 90 % sensitivity and 85 % specificity. A statistically significant correlation
was found between strain and lipid content (P? CONCLUSION Color-doppler US and ultrasound strain elastography (USE) is feasible in patients with significant carotid stenosis and can detect the
presence of soft plaque with high sensitivity and moderate specificity. CLINICAL RELEVANCE/APPLICATION US-strain elastography provides additional information to vascular ultrasound since may help to better characterize carotid plaque LL-NRE-SU6A • As the World Turns: The Imaging Spectrum of Vertigo and Dizziness
Young Park MD (Presenter) ; Vinh T Nguyen MD PURPOSE/AIM -Review the definition of vertigo and dizziness
-Review the differential diagnosis for patients presenting with these symptoms
-Discuss the role of imaging in diagnosis and management of such diseases
CONTENT ORGANIZATION Review anatomy, clinical presentation, pathophysiology, and imaging findings
-Inner ear: M�nière�s disease, labyrinthitis, semicircular canal dehiscence
-Cranial nerve: vestibular schwannoma, leptomeningeal carcinomatosis, microvascular compression
-Vertebrobasilar insufficiency, cerebrovascular disease
-Demyelination
-Cerebellar tumors
-Skull base and craniovertebral junction: clival chordoma, meningioma
Sample cases
Multidisciplinary approach
-Symptomatology frequently overlaps within this broad spectrum of diseases, patients cross over between different specialties
-Radiologist is in central overarching role to differentiate between various etiologies and facilitate multidisciplinary approach to evaluate
vertigo and dizziness SUMMARY -Vertigo and dizziness are symptoms of a broad scope of diseases affecting the vestibular system
-Neuroimaging is particularly valuable in cases demonstrating neurologic signs/symptoms, cerebrovascular risk factors, or progressive
unilateral hearing loss
Page 34 of 397
-Frequent overlap in symptomatology necessitates multidisciplinary approach towards diagnosis and management of these patients
LL-NRE-SU7A • Dehiscent Sigmoid Plate (DSP) Presenting as Pulsatile Tinnitus (PT): CT Analysis of 23 Cases
Zhaohui Liu MD (Presenter) ; Zhenchang Wang MD, PhD ; Shusheng Gong MD, PhD ; Junfang Xian MD PURPOSE/AIM To evaluate the detailed CT features of DSP accompanied with PT CONTENT ORGANIZATION DSP was located on the same side of PT in all cases. Only 1 defect was showed in 17 cases, 2 defects in 5 cases, and 4 defects in 1 case.
Ten defects located on the superior curve, 15 on the descending segment, 12 on inferior curve, and the other 4 defects involved the
superior curve and descending segment of sigmoid sinus simultaneously. 14 defects were shown on the anterior border, 12 on the
anterolateral border, and 5 on the lateral border of the sigmoid plate. Among 18 cases with unilateral dominant brain venous systems, all
SDP were seen on the dominant side. In contrast, the other 5 cases showed co-dominant brain venous systems, with 2 presenting SDP on
the right side and 3 on the left. In addition, temporal bone hyper-pneumatization was found in 14 cases, and good pneumatization in 9
cases. More notably, among 17 cases whose PT disappeared after surgery, 15 cases only had one defect in sigmoid plate. However, 4 of
6 cases had more than one defect in sigmoid plate, whose PT did not disappear completely. SUMMARY DSP frequently located on the outer wall of the sigmoid sinus and the side of the dominant brain venous systems, usually coexists with
extensive pneumatized temporal bone. Dual phase contrast enhanced CT is the modality of choice for diagnosis of the disease. LL-NRE-SU8A • Congenital Ocular and Orbital Anomalies: Embryology, Pathophysiology and Imaging
Bhaven M Shah (Presenter) ; Kavita B Shah MBBS, MS PURPOSE/AIM - To review embryogenesis of orbit and correlate abnormal embryological pathways with anatomy of congenital ocular anomalies. - To
review imaging findings of congenital ocular & orbital anomalies. - To discuss the imlication on management. CONTENT ORGANIZATION Normal embryogenesis of orbit. Embryological basis of congenital ocular anomalies including microphthalmos, anopthalmos,
meningoencephalocele, congenital ocular tumours, clefting syndromes etc. Imaging findings of congenital occular anomalies. Systemic
syndormes associated with congenital ocular anomalies like crouzon's syndrome, apert's syndrome. SUMMARY Congenital ocular & orbital abnormalities present with varied imaging and clinical manifestations. Understanding the anomalous
embryogenesis enable radiologist to detect primary occular abnormalities and systemic syndormes associated with them. Imaging plays a
crucial role in the diagnosis and management of these abnormalities. LL-NRE-SU9A • Seeing the HAND: The Link between HIV Status and Dementia
Sean Maldonado BS (Presenter) ; Gabriella B Tantillo BA ; Cedric W Pluguez-Turull MD ; Richard Zack-Guasp ; Cristina
Quintero BA ; Melisa Rivera ; Guido E Santacana-Laffitte MD ; Eduardo J Labat MD PURPOSE/AIM Prior to the advent of Highly Active Antiretroviral Therapy (HAART), opportunistic infections were the main causes of CNS pathology in
HIV/AIDS patients. In patients currently on HAART, HIV-associated neurodegenerative disorders (HAND) are replacing infections as the
primary CNS pathologies. This exhibit will review the pathophysiology, clinical presentation, and characteristic imaging findings for HAND
spectrum diseases. CONTENT ORGANIZATION HIV illness can result in a spectrum of neurocognitive deficits ranging from asymptomatic neurodegeneration to full blown AIDS Dementia
complex. These clinical findings can manifest as changes in neuroimaging. This exhibit will review the characteristic imaging findings
present in the HAND spectrum. Clinical history and physical exam will be correlated with imaging findings drawn from a PACS database at
our institution. Particular attention will be paid to the pattern of neurodegeneration, the localization of brain lesions, and the severity of
neurocognitive impairment. SUMMARY AIDS Dementia Complex is an AIDS-defining illness that is part of the HAND spectrum. However, history and physical exam findings may
be nonspecific or insufficient to make the diagnosis given the wide gamut of CNS lesions affecting immunosuppressed patients.
Neuroimaging can help point to the diagnosis of HAND and exclude other neuropathologies. Physics - Sunday Posters and Exhibits (12:30pm - 1:00pm) Sunday, 12:30 PM - 01:00 PM • Lakeside Learning Center
Back to Top PH
LL-PHS-SUA • AMA PRA Category 1 Credit ™:0.5 Host
Xiao Han , MSc LL-PHS-SU1A • A New Concept of CT with Fixed Anodes (Fixed Anodes CT, FA-CT)
Markus Kellermeier (Presenter) ; Reinhold Muller PURPOSE We started with studies to thermal loads of X-ray anodes. Based on the best results an optimal CT concept was newly developed and
compared with a common clinical system. METHOD AND MATERIALS The energy deposition in a X-ray anode was obtained by Monte Carlo simulation (GAMOS/GEANT4). Using acquired initial values the
temperature distribution was calculated in space and time by applying of Finite Element Method (COMSOL Multiphysics).
Out of common dimensions for anodes we developed a simulation model for fixed and rotary anodes. Geometric dimensions and material
uncertainties were considered parametrically.
2500 K were adjusted as maximum temperature for tungsten as target layer. For cooling, a heat bath of 300 K was defined on a copper
body base.
Simulations were carried out presuming short-term exposure (1 ?s�1 s).
Long-term loads are examined in terms of the continuous operation of FA-CT.
A virtual model was created using characteristics of sources and detectors. RESULTS Simulations to thermal loads of anodes are in good agreement with literature data regarding absolute values and trends. Optima from
parametric studies lead to the concept of fixed anodes, FA-CT.
Page 35 of 397
parametric studies lead to the concept of fixed anodes, FA-CT.
Results from virtual model evidence profits up to 6 times in scan time or performance. Short integration times per projection of about 10
?s lead to a higher amount of data (>25x). A dense physical information system handled by pre- or post-processing allows a familiar
image quality and enhanced resolution in the axial direction. CONCLUSION Several promising improvements can be recognised for FA-CT in comparison to a conventional clinical CT. The elimination of mechanical
moving components results in an arrangement of a row of 1160 small fixed anodes covering 360�. The distribution around the patient
leads to a source ring in parallel to a detector ring. It is not necessarily restricted to a circular arrangement.
The components enable a compact design, making it easier to be combined with other imaging devices (MRI/PET/SPECT) and also to
have a close combination of X-ray therapy devices (e.g. LINACs, particle accelerators, and also brachy therapy) with real-time imaging. CLINICAL RELEVANCE/APPLICATION The FA-CT technology without mechanical moving components provides by several factors shorter scanning, promises a great leap
forward in image-based medicine. LL-PHS-SU2A • A Simple and Accurate Measurement Method of Temporal Resolution for Cardiac Computed Tomography
Kazuya Ohashi (Presenter) ; Katsuhiro Ichikawa PhD ; Makoto Kawano ; Yuta Shibamoto MD, PhD PURPOSE The temporal resolution (TR) has been used for image evaluation of cardiac computed tomography (CT). However, since the practical
method for measuring TR for cardiac CT has not been established, most of papers about the cardiac CT have used nominal TR values for
TR descriptions, which are generally indicated in technical manuals. The purpose of this study was to propose a simple and accurate TR
measurement method for the cardiac CT. METHOD AND MATERIALS We employed a dual source CT (DSCT) system (Somatom Definition, Siemens Medical Solutions) equipped with two X-ray tubes with an
angular offset of 90�. The DSCT system has three reconstruction modes with nominal TRs of 83, 125, and 165 ms.
We measured TR for each mode using an impulse signal method. In this method, the temporal impulse signal was generated by using a
metal ball with an 11-mm diameter, which pass through scan planes at a very high speed (>5 m/sec) during cardiac CT scanning. By
using this method, we were able to obtain phase sensitivity profiles (PSPs) as correct indices of TR of the cardiac CT. PSP was measured
from region of interest (ROI) values in reconstructed impulse response CT images at every phase percentages of the cardiac cycle. We
also calculated temporal MTFs by Fourier transform of PSPs for respective TR modes, and compared them.
RESULTS The shapes of the 83- and 165-ms TR modes were simple trapezoids with full width at half maximum (FWHMs) of exact 83 ms and 165
ms, respectively. However, since the 125-ms mode presented a complicated PSP shape like a convex, its FWHM could not be evaluated.
In contrast, the temporal MTF curves provided effective results for the TR comparison. From the temporal MTF results, we found that the
three TR modes of DSCT have valid TRs equivalent to their nominal values. CONCLUSION PSP of the cardiac CT was able to be measured accurately by using the impulse method we proposed in this study. The temporal MTF
calculated from the PSP was also effective to compare the TR in case of PSP with a complicated shape. Although this method can not be
applied to the multi segment reconstruction modes, the half reconstruction modes which are becoming the standard can be evaluated by
this method. CLINICAL RELEVANCE/APPLICATION The correct TRs measured using our proposed method would be effective for clarifying the relationship between TR and cardiac CT image
quality. LL-PHS-SU3A • Metal Artifact Reduction for Orthopedic Implants in Lower Extremity Angiography: Evaluation of Image Quality
and Vessel Visualization
Kwang Nam Jin MD (Presenter) ; Jee Won Chai MD ; Hyo Bin Seo ; Young Ho Choi MD ; Young Ho So ; Su Jin Kim MD ; Youkyung Lee MD ; Jae Yeon Wi MD ; Hyun Kyong Lim MD PURPOSE The purpose of this study was to evaluate whether O-MAR (metal artifact reduction algorithm for orthopedic implants) improve the image
quality and vessel visualization in lower extremity CT angiography. METHOD AND MATERIALS In 15 patients who had orthopedic implants in the hip (n = 6) or knee (n = 19) and underwent lower extremity CT angiography, we
reconstructed O-MAR corrected 5 mm-thick axial CT images (OM) and non-corrected images (NC) in each patient. We recorded the type
of implants in total 25 limbs. For each limb, 2 reviewers evaluated the subjective image quality, using 3-point scale, in terms of overall
beam hardening artifact reduction (0, no; 1, minimal; 2, marked; 3, no residual artifact) and peri-implant artifact in OM (0, no; 1, artifact
not invading vessels; 2, artifact invading vessels and diagnosis of thrombus or stenosis is possible; 3, artifact invading vessels and
making diagnosis impossible), respectively. For subjective evaluation of vessel visualization, we counted the number of axial images, in
which vessel was evaluable, and total number of images covering whole implants. We compared percentage of image with evaluable
vessel in OM and NC, respectively. RESULTS There were 18 limbs with total knee replacement implants (TKR), 6 with total hip replacement implants (THR), 1 limb with cruciate
ligament reconstruction (CLR). Marked reduction of overall beam hardening artifact was achieved in all patients for both reviewers. There
was peri-implant artifact invading adjacent vessels on OM in 17 patients (68.0 %) for R1 and 18 (72.0 %) for R2 (100 % in 17 limbs with
TKR and 0 % in 6 with THR). Number of images with evaluable vessels was higher in OM than NC (19.0 ± 10.8 vs 17.6 ± 11.0, p <
0.001). Percentage of images with evaluable vessel was 76.5 ± 17.4 in OM and 69.8 ± 19.8 in NC (p < 0.001). Although the difference
was significant in 17 limbs with TKR (69.0 ± 12.7 in OM and 60.7 ± 12.5 in NC, p < 0.001), there was no significant difference in 6 with
THR (100.0 ± 0.0 in OM and 98.5 ± 2.8 in NC, p = 0.25). CONCLUSION With the use of O-MAR algorithm, image quality and vessel visualization of lower extremity angiography can be improved in patient with
orthopedic implants. CLINICAL RELEVANCE/APPLICATION Postoperative CT imaging in patients with orthopedic implants in hip or knee is challenging. O-MAR will help the diagnosis of deep vein
thrombosis or atherosclerosis by reducing artifacts. LL-PHS-SU4A • Changing from Excision Biopsy to Core Biopsy in the Diagnosis of Neck Lymphoma - An Audit of 4 Years
Experience
Kit H Chow MBBCh, FRCR (Presenter) ; Unnikrishnan Anoop MBBS, FRCR ; Rathinavelu Balamurugan MBBS ; Chris Stonard ; Yuliya Khober CONCLUSION Core biopsy should be the initial biopsy technique for diagnosis of lymphoma. Page 36 of 397
Background The process of change from excision biopsy(EB) to core biopsy(CB) for neck lymphoma is often a creeping development of an imaging
service. This purpose of this study is to discover changes that had taken place over a period of four years in an UK, NHS district general
hospital, when the initial technique for initial tissue evaluation of lymphoma has changed from EB in 2008 to CB in 2011, with incremental
implementation from 2009-2010. Discussion All clinicians preferred CB as the method of tissue biopsy for the initial pathological diagnosis of lymphoma despite its lower diagnostic
rate compare to EB. The advantage of Ultrasound Guided CB technique is the ease of this cheap relatively non-invasive technique. The
number of cases diagnosed from neck biopsy increased in 2011 by 67%. This finding would requires further research and may reflect: 1) Lead-time. 2) Neck preferred body biopsy site. 3) Improved histo-chemistry. LL-PHS-SU5A • Application of Low-dose Dual-energy Electronic Cleansing to Sub-mSv Fecal-tagging CT Colonography
Wenli Cai PhD (Presenter) ; Simone Mazzetti ; Daniele Regge MD ; Hiroyuki Yoshida PhD * PURPOSE Application of dual-energy fecal-tagging CTC (DE-CTC) to electronic cleansing (EC), denoted as DE-EC, provides a promising EC solution
for identifying and cleansing iodine-tagged fecal materials in CTC images. With the technical advances in image reconstruction and
post-processing, low-dose DE-EC offers the technical feasibility for visualization of the entire colonic surface. The purpose of the study was
to develop a low-dose DE-EC scheme that works efficiently for sub-mSv DE-CTC. METHOD AND MATERIALS 17 patients underwent a 24-hour bowel preparation with a low-fiber, low-residue diet, and oral administration of 150 ml of iodinated
contrast agent. Dual-energy CT scanning (SOMATOM Definition Flash) was performed with the following low-dose imaging protocol: Tube
A at 80 kVp / 40 mAs and tube B at 140 kVp / 15 mAs with Sn Filter, automatic dose exposure control module (CARE Dose 4D), and
SAFIRE iterative reconstruction (I30f). CT dose index (CTDIvol) and effective dose length products (DLP) were recorded in each scan for
dose measurement. Resulting DE-CTC images were subjected to the low-dose DE-EC scheme consisting of the following steps: (1) initial
segmentation of the colon, (2) noise reduction using our previously developed dual-energy structural diffusion filter, (3) virtual colon
tagging (VCT) using material maps calculated with our localized 3-material decomposition model, (4) computation of Hessian response
field in VCT images, and (5) segmentation and removal of the fecal materials in the colonic lumen.
RESULTS The average radiation dose per position was 1.08 mGy / 0.89 mSv, which was less than 70% than that of the recommended radiation
dose for conventional single-energy CTC screening (2.5 ~ 2.8 mSv). Visual assessment of the virtual colon fly-through indicated that our
low-dose DE-EC achieved the similar quality as that of DE-CTC cases scanned with normal radiation dose. Preliminary evaluation showed
that all submerged polyps were clearly visualized with 0-1 minor EC artifacts per case compared to 5-6 significant EC artifacts per case in
single-energy EC. CONCLUSION Our low-dose DE-EC scheme may provide an effective solution in electronically cleansing sub-mSv DE-CTC images in colon cancer
screening. CLINICAL RELEVANCE/APPLICATION New low-dose dual-energy EC can substantially reduce the radiation dose and it may lead to sub-mSv CT colongraphy for colon cancer
screening. LL-PHS-SU6A • Minimizing Radiation Dose in Children Paranasal Sinuses CT with a Model-based Iterative Reconstruction
Algorithm
Ji Hang Sun (Presenter) ; Yun Peng MD PURPOSE To evaluate the clinical value of a model-based iterative reconstruction (MBIR, trade name 'VEO') to minimize radiation dose in children
paranasal sinuses CT. METHOD AND MATERIALS 15 leukemia children (10 months to 11y of age, median age 4 years) for the follow-up CT examination within 2 months of the initial scan
(control group) were included in the study group. The children in the study group underwent an extremely low dose helical scan using
80kV and 10mA, and images were reconstructed using VEO technique with 0.625mm slice thickness. The scans in the control group used
a standard protocol with 120kV, automatic tube current modulation for noise index (NI) of 14. Images in this group were reconstructed
with filtered back projection (FBP) with 0.625mm slice thickness. Two radiologists independently evaluated the multi planar reformat
(MPR) images including the subjective image noise, the bones of paranasal sinuses, and the soft tissue on a 5-point scale with 3 being
clinically acceptable (5 is the best); Quantitative image noises on the left vitreous body and the thickness of Maxillary sinus wall were
measured and statistically compared between the two groups. The CT dose index (CTDIvol) and dose-length product (DLP) were
recorded. RESULTS CONCLUSION Compared with routine-dose CT with FBP, the lower-dose CT with VEO provided 95.0% dose reduction in pediatric paranasal sinuses CT
examinations, while maintaining diagnostically acceptable images. CLINICAL RELEVANCE/APPLICATION The use of a full model-based iterative reconstruction algorithm (VEO) provides significant radiation dose reduction to eyes in pediatric
paranasal sinuses CT. LL-PHS-SU7A • IMRT, Hybrid IMRT, and 3D Conformal Plan for Carcinoma Esophagus-A Dosimetric Comparison from a
Prospective Randomized Controlled Study
Pritee Chaudhari (Presenter) ; Seema Sharma MS ; Supriya Mallick MBBS ; Subhash Chander MD, MBBS ; Sushmita Pathy MD,
MBBS ; Durai Manigandan PhD ; Pk Julka ; Ashish A Patil MBBS LL-PHE-SU8A • CT Radiation Dose: A Review of the Current Controversies and Dose Reduction Strategies through Clinical
Scenarios and Patient/Clinician Questions
Justin E Costello DO (Presenter) ; Nathan D Cecava MD ; Jonathan Tucker ; Jennifer L Bau MD PURPOSE/AIM 1. Awareness and compilation of radiation doses of typical exams performed on patients entering through the ER and in the hospital
setting 2. To discuss BEIR VII strengths and weaknesses in calculating potential cancer risks associated CT 3. To demonstrate increased
risk (if any) of future cancers, through theoretical patient scenarios, based on CT dose and application of BEIR VII biologic models 4. To
review strategies for CT dose reduction CONTENT ORGANIZATION Attention to patient radiation dose, as well as dose reduction strategies are of paramount concern. In this educational exhibit, we will
track theoretical patients entering through the ER using an interactive format with the learner to answer questions about radiation doses,
specific organ doses, and potential cancer risk. We will report the risk (if any) of future cancer development using BEIR VII biological
Page 37 of 397
models. Opportunities and ideas for radiation dose reduction will be presented, as they relate to our clinical scenarios. SUMMARY 1. Knowledge of effective doses for typical emergency room CT exams 2. Understanding the application of and controversies associated
with BEIR VII in the calculation of cancer risk associated with CT scans 3. Implication of current modulation, low-voltage protocols, breast
shields, and iterative reconstruction as CT dose reduction strategies LL-PHE-SU9A • Artifacts a Novice Sonologist May Encounter: How to Recognize, Correct or Utilize Them!
Prashant J Thoriya MBBS (Presenter) ; Nandini Bahri MD ; Hiral Parekh MD ; Pankaj Watal MBBS ; Swetang G Brahmbhatt
MBBS PURPOSE/AIM During ultrasonography artifacts are commonly encountered by sonologist which may confuse them. In this article, we will review common
artifacts in grey scale, spectral and color doppler imaging. For each artifact, emphasis is placed on the physics behind it, imaging
appearance, diagnostic importance, and when applicable, scanning technique modifications to improve image quality CONTENT ORGANIZATION This work was carried out at our institution in department of Radio-Diagnosis on diseased patients and on healthy volunteers using My
LAB 60 ESAOTE ultrasound machine. Causes of artifacts :- those resulting from (i) improper scanning technique and equipment setting (ii)
anatomic factors (iii) technical limitations of modality. Based on our study common artefacts encountered during routine grey scale
imaging are beam width, side lobe, reverberation, comet tail, ring-down, mirror image, speed displacement, attenuation, shadowing, and
increased through transmission. Common artefacts during spectral and Doppler ultrasound are gain setting error, aliasing and velocity
scale errors, mirror image artefacts; color in non vascular structures, direction ambiguity and spectral broadening artefact. SUMMARY Misdiagnosis can be avoided when the sonologist is aware to these artifacts and thus improve quality of his scans and provide optimal
patient care. Radiation Oncology and Radiobiology - Sunday Posters and Exhibits - (12:30pm - 1:00pm) Sunday, 12:30 PM - 01:00 PM • Lakeside Learning Center
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LL-ROS-SUA • AMA PRA Category 1 Credit ™:0.5 Host
Nina A Mayr , MD LL-ROS-SU1A • Dosimetric Impact of Interfractional Variation during the Treatment of Pancreatic Cancer Using Tomotherapy
Daniel Glick MD (Presenter) ; Eric Vorauer ; Lee Chin ; Hans Chung MD ; Frances Tonolete ABSTRACT Purpose/Objective(s): Intrafractional and interfractional variation exists during the treatment of pancreatic cancer due to respiratory
motion, bowel gas, patient weight loss, tumor response and peritumoral edema. This study sought to investigate interfraction organ
motion and its dosimetric consequences.
Materials/Methods: Initial planning KVCT images were compared to day 1 and day 30 MVCT images for 7 unresectable, locally
advanced pancreatic cancer patients treated with radical radiotherapy (dose>45 Gy) using Tomotherapy. Organ motion was calculated by
measuring centroid translation. Dice Similarity Coefficient (DSC) was performed to evaluate overlapping volumes on planning and daily
scans. Dose distribution was calculated on electron density calibrated daily MVCT images and projected onto daily MVCT with daily
physician drawn GTV, liver, kidney and spinal cord contours. This dose distribution was also deformed onto a reference planning KVCT
image using SlicerRT to create a cumulative dose volume histogram that could be compared to the original treatment plan.
Results: Mean GTV and organ at risk translation were less than 1 cm with considerable variation between patients and fractions (Table
1). There was no significant difference in translation or DSC for day 1 and day 30, and for all subsequent analysis n=14. Mean DSC for
GTV, liver, right kidney, left kidney and spinal cord were 0.61, 0.78, 0.74, 0.78 and 0.53, respectively. Compared to original plan, mean
GTV dose was 99.5%, mean right kidney dose was 99.9%, mean left kidney dose was 103.7% and maximum spinal cord dose was
93.7%. Deformed doses were similar with mean GTV dose 100.3%, mean right kidney dose 91.2%, mean left kidney dose 93.8% and
max cord dose 92.8% compared to planned. Thirteen of the fourteen daily plans evaluated had recalculated GTV V95 greater than 99%.
Conclusions: This study demonstrates that there is sub-centimeter variation in anatomy between planning CT scan and daily treatment
scans which vary between patients and fractions. These variations have minimal impact on GTV dose. By better understanding organ
motion and its impact on dose deposition, one can potentially customize or shrink PTV margins to improve OAR sparing and allow for dose
escalation to tumor.
Mean organ displacement
Page 38 of 397
Superior-Inferior
Anterior-Posterior
Left-Right Mean
(mm)
Standard
Deviation
Mean
(mm)
Standard
Deviation
Mean
(mm)
Standard
Deviation
GTV
7.12
5.88
3.26
2.17
3.41
2.67
Right
Kidney
4.89
3.79
3.63
3.40
2.71
2.31
Left
Kidney
6.72
4.31
3.31
3.11
3.06
2.70
Liver
4.19
3.47
9.56
9.33
4.89
3.62
Spinal
Cord
6.26
3.01
3.47
2.72
2.56
1.97
LL-ROS-SU2A • Clinical and Dosimetric Factors Associated with Prolonged Percutaneous Endoscopic Gastrostomy (PEG) Tube
Usage in Intensity Modulated Radiation Therapy (IMRT) Treated Head and Neck Cancer Patients
Wuyang Yang (Presenter) ABSTRACT Purpose/Objective: Post radiotherapy dependency on Percutaneous Endoscopic Gastrostomy (PEG) tube feeding following radiotherapy
(RT) in head and neck squamous cell carcinoma (HNSCC) patients has been associated with poor patient swallowing function and weight
loss. As such, it is important to identify potential risk factors associated with prolonged PEG use. In this retrospective analysis, we
incorporated clinical and dosimetric factors in expectation to find factors that are associated with prolonged PEG usage.
Methods: PEG tube use data was collected from our institutional clinical database and SQL relational dosimetric database from 2010 to
2012. HNSCC patients treated with intensity modulated radiotherapy (IMRT) with recorded PEG usage were retrospectively evaluated.
PEG tube prolonged use was defined as greater than 30 days and binarized as the primary outcome variable. Clinical and dosimetric
factors associated with prolonged use was pulled from both databases and included in a stepwise multivariate logistic regression model.
Results: A total of 56 evaluable patients were identified. Univariate analysis identified multiple predictors associated with prolonged use
of PEG tube. After a stepwise exclusion of variables for the logistic multivariate regression model, race (African American) , minimum
dose of inferior constrictor muscles and patient smoking pack years were selected into the multivariate model. Minimum dose of inferior
constrictor muscle (CI = [0.00, 0.00], p = .33) and pack years (CI = [0.02, 0.10], p = .01) are positively associated with prolonged PEG
use, race (African American) was not associated with the outcome variable.
Conclusions: Our results demonstrate that dose to the inferior constrictor muscles and smoking status are two important predictors of
prolonged PEG use. LL-ROS-SU3A • Imaging and Oxygen Radiation Sensitization under Normal Breathing Conditions by Using Targeted Folated
Receptor (FR)-mediated Endocytosis via Radiotherapy
Satoshi G Harada MD (Presenter) ; Shigeru Ehara MD ; Keizo Ishii PhD ; Takahiro Satoh DSc ; Koichiro Sera ; Goto Shyoko
RT PURPOSE We aimed to treat SKOV3 (FR+) cell micrometastasis in SCID-bg mice by using microcapsule-encapsulated nanoparticles in 2
radiotherapy sessions. In the 1 st session, CT-detectable microcapsules containing P-selectin and folated nanoparticles were intravenously
injected into the mice to detect micrometastasis via VEGFR-1 and -2 antibody-antigen accumulation. In the 2nd session, the
micrometastatic cells were sensitized using folated and O2-rich nanoparticles released from microcapsules by radiation and endocytosed
by lesions through the folate receptor (FR). METHOD AND MATERIALS In the 1st session, nanoparticles (1.0 × 1014) prepared from folated poly-G-glutamic acid (FA-PGA) and 0.5 nm chitosan (CH) along with
0.5 nmol dexamethasone and 5% iopamiron were mixed with 1.0 ml of a solution of 4.0% alginate, 3.0% hyaluronate and 1 �g/mL
P-selectin, which was then sprayed into 0.5 mmol/L FeCl2 solution supplemented with 1 �g/mL VEGFR-1 and -2 antibodies. In the 2nd
session, nanoparticles prepared from FA-PGA and CH with 120 ppm O2-rich water were mixed with the above mentioned mixture and
sprayed into 0.5 mol/L FeCl 2 solution containing 0.1 �mol/L FcSv antibody against P-selectin. In the 1 st session, the microcapsules were
intravenously injected into the mice. Nine hours after injection, the mice were exposed to 10 or 20 Gy 60Co G-radiation. In the 2nd session, 1 × 10 10 microcapsules were intravenously injected and allowed to interact with P-selectin for 9 h to treat the micrometastatic
lesions. Both sessions were conducted in a similar manner. RESULTS Anti-VEGFR-1/-2 microcapsules accumulated around micrometastatic sites and were detected using CT. These microcapsules released the
P-selectin antigen and nanoparticles with iopamiron and dexamethasone in response to the 1st irradiation treatment. The nanoparticles
were endocytosed via FRs, prolonging micrometastasis detection by iopamiron and increasing FR expression by dexamethasone. In the
2nd session, the microcapsules released O2- rich nanoparticles, which were endocytosed by the metastatic cells via enhanced FR
expression and reduced metastasis by 90.4 ± 2.1%. CONCLUSION Targeting metastatic cells using nanoparticles allowed better diagnosis and treatment of micrometastasis. CLINICAL RELEVANCE/APPLICATION Imaging and Oxygen radiation sensitization using nanoparticles targeted by folate receptor-mediated endocytosis via radiotherapy will
enable better diagnosis and treatment of micrometastasis. LL-ROS-SU4A • Is There a Role for Intensity Modulated Radiation Therapy (IMRT) in the Treatment of Locally Advanced Lung
Cancer?
Sudha Amarnath (Presenter) ABSTRACT Purpose/Objective(s): Lung cancer continues to be the leading cause of cancer mortality in the United States. The introduction of
concurrent chemoradiation therapy has significantly improved the survival rates for locally advanced lung cancer to 20-30% in phase III
randomized trials from historical rates of 1% with chemotherapy alone and 5% with radiation (XRT) alone. The standard XRT dose for
locally advanced lung cancer is 60-74 Gy. However, due to normal tissue constraints, it is not always feasible to deliver adequate doses
to tumor with 3D-conformal radiation (3DCRT). In cases where 3DCRT cannot achieve adequate dose due to normal tissue constraints,
intensity modulated radiation therapy (IMRT) is sometimes used. We sought to evaluate the dosimetric benefits of IMRT compared to
3DCRT in a select subset of patients where 3D-CRT plans were not feasible.
Materials/Methods: Ninety-seven patients with LA-LC (AJCC version 7 stage IIIA/IIIB) treated definitively with radiation therapy
between 2010-2011 were identified in our database. Sixteen patients (16.5%) were treated using IMRT plans. Fourteen out of 16 patients
received concurrent chemotherapy. None received prior thoracic surgery or XRT. All patients underwent simulation using four-dimensional
computed tomography (4D-CT). No elective nodal coverage was performed. Each patient initially underwent 3DCRT planning, and only if
normal tissue constraints (per NCCN guidelines) could not be met was IMRT planning initiated. Doses ranged from 45 Gy (BID
fractionation for small cell) to 73.8 Gy (1.8 Gy daily).
Results: Thirteen patients had NSCLC and 3 patients had SCLC. One patient could only be planned to 54 Gy with 3DCRT; all others were
re-planned using 3DCRT techniques to equivalent doses as the IMRT plan. Mean PTV volume was 645 cc (range: 229-2052 cc). Dosimetric
comparisons between the IMRT and 3DCRT revealed significant differences in tumor coverage: mean 95% PTV coverage 92% vs. 77%,
respectively, and mean 98% GTV coverage 94% vs. 76% when normal tissue constraints were respected (mean lung V20 28.7% vs.
28.4%, max cord dose 44.7 Gy vs. 47.8 Gy, and mean heart dose 15.5 Gy vs. 13.9 Gy). The benefit in IMRT tumor coverage was seen in
13/16 patients.
Conclusion: From a dosimetric standpoint, IMRT does show a significant benefit over 3DCRT for a subset of patients that would
otherwise not have been able to receive an adequate dose of radiation, compromising their chance at long-term survival. Further analysis
is needed to determine if there are specific predictive patient/anatomic factors that could select which patients would benefit from IMRT
planning versus 3DCRT. LL-ROS-SU5A • Feasibility of Simultaneous Integrated Boost for Dose Escalation in Spine Radiosurgery
Stephen L Lewis MD (Presenter) ; Zheng Chang PhD ; Pretesh R Patel MD ; John P Kirkpatrick MD, PhD ; Alvin Cabrera MD LL-ROE-SU6A • Comparison of Soft-Tissue Matching on Cone-Beam Computed Tomography and Fluoroscopy-based
Bony-Structure Matching in the Target Localization for the IMRT of Prostate Cancer
Hiraku Sato MD (Presenter) ; Eisuke Abe ; Hidefumi Aoyama MD, PhD Page 39 of 397
Hiraku Sato MD (Presenter) ; Eisuke Abe ; Hidefumi Aoyama MD, PhD PURPOSE To evaluate the set-up accuracy of cone-beam computed tomography (CBCT) compared with fluoroscopy-based bony-structure matching
in prostate intensity-modulated radiotherapy (IMRT). METHODS Twenty patients with localized prostate cancer examined between November 2010 and March 2012 at our institution. Each patient
underwent simulation in the supine position with a customized vacuum immobilization device using a sixteen-slice CT scanner with
2.5-mm slice thickness.IMRT plans were generated using an Eclipse treatment planning system with seven coplanar beams and 6-MV
photons. All patients were treated on a Novalis-Tx stereotactic radiosurgery system. After an initial set-up based on skin markers,
bony-structure matching was carried out using a fluoroscopy-based set-up system. After that, CBCT was taken and soft-tissue matching
using the prostate-rectal interface as a landmark was carried out. A shift of the coordinates of the isocenter between the CBCT-based
set-up and the fluoroscopy-based set-up was recorded in the anterior-posterior (AP), superior-inferior (SI), and left-right (LR) axes and
was considered a potential inter-fractional shift when the bony structure-based set-up was employed. Post-treatment CBCT was also
taken once a week in order to measure the intra-fractional shift. Inter-fractional and intra-fractional shifts were analyzed using 577
pre-treatment CBCTs and 131 post-treatment CBCTs, respectively. RESULTS The mean and standard deviation (SD) of the inter-fractional shifts when only the bony structure-based set-up was used was 0.9?±?2.8
mm in AP, -0.9?±?2.2 mm in SI, and 0.1?±?0.7 mm in LR axes. The mean and SD of the intra-fractional shifts was -0.3?±?1.4 mm in AP,
-0.1?±?1.2 mm in SI, and -0.1?±?0.7 mm in LR axes. The SDs of the inter-fractional and the intra-fractional shifts were 2.8 and 1.4 mm
in AP, 2.2 and 1.2 mm in SI, and 0.7 and 0.7 mm in LR. CONCLUSION The application of CBCT-based prostate-rectal interface matching may reduce the inter-fractional shift compared to fluoroscopy-based
bony-structure matching in all coordinates with a standard deviation ranging from 0.7 mm to 2.8 mm. Vascular/Interventional - Sunday Posters and Exhibits (12:30pm - 1:00pm) Sunday, 12:30 PM - 01:00 PM • Lakeside Learning Center
IR
VA LL-VIS-SUA • AMA PRA Category 1 Credit ™:0.5 Host
Thomas-Evangelos G Vrachliotis , MD, PhD Back to Top LL-VIS-SU2A • Pancreatic Drainage 101 - Radiation Exposure: How Much and What Can We Do about It?
Justin M Owens MD (Presenter) ; Jessica Caraway MD ; Michael C Gates MD ; David R Wallace MD ; Daniel V Do MD ; Horacio R D'Agostino MD ; Katherine S Crow MS PURPOSE Patients undergoing percutaneous drainage (PD) of pancreatic fluid collections (PFCs) experience multiple imaging studies using ionizing
radiation. The purpose of this study is to evaluate radiation exposure during initial diagnosis, image-guided percutaneous drainage
(IGPD), post-drainage monitoring/revision and follow up. METHOD AND MATERIALS An IRB-approved, retrospective study was performed of 101 patients (73 male, 28 female; mean age 46.5 years) who underwent IGPD of
PFCs from December 12, 2002 to July 17, 2012. Pancreatitis causes were alcoholism ( n=41,40.2%), trauma (n=25,24.5%), gallstones
(n=21,20.6%), hypertriglyceridemia (n=8,7.8%), drugs (n=1,1%) and unknown (n=6,5.9%). Imaging studies where categorized as
diagnostic (pre-drainage), procedural (image-guidance), post-drainage (with drainage catheters) and follow up (catheters removed). All
imaging studies were recorded per patient on a spreadsheet for radiation exposure analysis. RESULTS The series included a total of 810 imaging studies: CT, 577 (71.2%); fluoroscopy, 229 (28.3%); US, 4 (0.5%). There were 156
diagnostic: CT, 154 (98.7%); US, 2 (1.3%); 176 procedural: CT, 26 (14.8%); fluoroscopy/US, 150 (85.2%); 393 post-drainage: CT, 314
(79.9%); fluoro, 79 (20.1%); 85 follow up: CT, 83 (97.6%); fluoro, 0; US, 2 (2.4%). Post-drainage imaging accounted for the highest
radiation exposure; exposure was negligible in the follow up period. CONCLUSION Our findings suggest pancreatitis patients undergoing IGPD of PFCs receive substantial radiation exposure. While the potential for
long-term harm is ever present with any study that utilizes ionizing-radiation, this exposure risk is greatly outweighed by the benefit
provided through minimally invasive management and the excellent resolution rate it achieves. Assertive post-drainage indication of CT
and fluoroscopy may further decrease radiation exposure to these patients, thus improving the overal risk-to-benefit ratio. CLINICAL RELEVANCE/APPLICATION The findings of this study serve to increase radiation exposure awareness of both clinicians and radiologists. By doing so, more strategic
monitoring can be accomplished using optimized modalities. LL-VIS-SU3A • Contrast Enhanced Ultrasound for Early Assessment of Transarterial Chemoembolization of Hepatocellular
Carcinoma using Drug Eluting Beads: Preliminary Safety and Efficacy
John R Eisenbrey PhD (Presenter) ; Colette Shaw MBBCh ; Andrej Lyshchik MD ; Daniel A Merton ; Priscilla Machado MD ; Laura Pino ; Daniel B Brown MD * ; Flemming Forsberg PhD * PURPOSE To evaluate the safety and utility of contrast-enhanced ultrasound (CEUS) imaging for early efficacy assessment of transarterial
chemoembolization (TACE) of hepatocellular carcinoma (HCC) using drug-eluting beads. METHOD AND MATERIALS Following IRB approval, 9 patients with a total of 12 previously untreated tumors scheduled for TACE with 100-300 ?m
doxorubicin-eluting beads underwent CEUS exams the morning prior to TACE, 1-2 weeks post TACE, and the morning prior to routine
imaging follow-up (multiphase contrast enhanced MRI or CT 1 month post TACE) and CT/MR results were evaluated using mRECIST
criteria. Ultrasound imaging was performed using a Sequoia 512 scanner with 4C probe (Siemens Medical Solutions, Mountain View, CA).
Following baseline imaging, patients received a bolus injection of 0.6-0.7 ml of Definity (Lantheus Medical Imaging, N. Billerica, MA)
followed by 10 ml saline flush and were imaged using Cadence Pulse Sequencing (Siemens). In patients with multiple tumors, injection
was repeated. All imaging parameters were kept constant at follow-up. Microbubble enhancement pattern and size of the embolized area
were compared to the reference imaging standard. RESULTS One case of lower back pain and no other adverse events were reported over the 17 CEUS exams performed to date. All 12 tumors
showed microbubble enhancement prior to treatment. One patient was excluded after being reassigned for alternative treatment. A total
of 4 patients with 4 lesions have completed the study to date. CEUS findings at 1-2 weeks persisted on CEUS at one month post
treatment (3 consistent non-enhancing / 1 consistent partially enhancing lesions; average change after treatment of non-enhancing area
Page 40 of 397
treatment (3 consistent non-enhancing / 1 consistent partially enhancing lesions; average change after treatment of non-enhancing area
along longest diameter = 2 ± 1.8 mm). In all 4 cases microbubble enhancement within the tumor (3 complete embolization, 1 partial
response) correlated with the reference imaging standard. CONCLUSION Preliminary results suggest that results of CEUS at 1-2 weeks post TACE correlate well with routine MRI or CT imaging performed 1
months post treatment. Therefore, treatment outcomes may potentially be evaluated earlier with CEUS. CLINICAL RELEVANCE/APPLICATION CEUS may provide an earlier and safer means of drug eluting beads TACE treatment response evaluation. LL-VIS-SU4A • Portal Vein Thrombosis after Tips with the Viatorr Stent Graft: Imaging Frequency and Correlation with Site of
Puncture
Jorge E Lopera MD (Presenter) * ; Venkata S Katabathina MD ; Martin Goros ; Brian T Bosworth MD ; Deepak Garg MBBS,
MD ; Ghazwan M Kroma MD ; Andres Garza ; Rajeev Suri MD PURPOSE To study the incidence of portal vein thrombosis (PVT) after elective Tips using the Viatorr stent graft and determine if there is any
potential relationship between the puncture site and development of PVT. METHOD AND MATERIALS A retrospective review of medical records of patients that underwent elective Tips with the Viatorr stent graft was performed. Contrast
enhanced cross sectional imaging studies, performed within 1 year after Tips were evaluated for PVT. The puncture site for Tips was
determined in direct portograms and classified as central or peripheral. Any potential relationship between the puncture site and the
presence of PVT was determined. RESULTS Elective Tips with the Viatorr was performed in 48 patients (ages 28-70 mean 54 ). Follow-up imaging demonstrated that the presence of
branch PVT was very frequent (38/48, 79%), and affected the right anterior (n=6), right posterior (n=25) or left (n=7) portal veins.
There were no main portal vein thromboses. Central punctures in 12 patients were associated with PVT in 9 occasions. More peripheral
punctures at the confluence of the right portal branches in 22 patients, or in a more peripheral right branch in 14 patients, were
associated with segmental PVT in 17 and 12 patients, respectively. In only in 1 patient there was a technical problem with stent
placement. Overall there was no correlation between the puncture site and the presence of PVT ( Fisher Exact test p=0.1) . CONCLUSION Thrombosis of major portal vein branches is a very frequent imaging finding after elective Tips with the Viatorr stent graft. There was no
correlation between the puncture site, central or peripheral , and the presence of PVT. CLINICAL RELEVANCE/APPLICATION Thrombosis of major portal vein branches is a frequent imaging finding after elective Tips with the Viatorr stent. However, there is not
correlation between PVT and the site of puncture . LL-VIE-SU5A • Endovascular Abdominal Aortic Aneurysm Repair Made Simple: Patient and Device Selection, Technique, and
Procedure Specific Complications
Yolanda Bryce MD (Presenter) ; Philip A Rogoff MD ; Donald F Romanelli MD ; Ralph L Reichle MD PURPOSE/AIM The purpose of this exhibit is: 1. To review the benefits of endovascular repair of abdominal aortic aneurysms. 2. To review available
clinical assessment scoring systems for appropriate patient selection. 3. To review vascular anatomy and its severity scoring. 4. To
review available prostheses and their appropriate usages including suprarenal and infrarenal fixation. 5. To review the appropriate
technique including preprocedural imaging, the procedure, and post procedural imaging. 6. To review procedure specific complications. CONTENT ORGANIZATION Benefits of endovascular repair of abdominal aortic aneurysms. Patient selection -Clinical assessment scoring -Vascular anatomy scoring
Device selection Procedure technique -Preprocedural imaging -Ancillary procedures -Procedure technique -Postprocedural follow-up
Procedure specific complications -Prosthesis thrombosis -Prosthesis migration -Type 1, 2, 3, 4, and 5 endoleaks -Aneurysm sac rupture. SUMMARY The major points of the exhibit are: 1. The importance of preprocedural planning including appropriate patient and device selection. 2.
The improtance of appropriate technique. 3. The importance of the knowledge of and follow-up for procedure-specific complications. LL-VIE-SU6A • The Radiographic Natural History of Aortic Dissection
Timothy Huber MD (Presenter) ; John F Angle MD * PURPOSE While there has been much written about the identification and management of aortic dissection, less work has been done examining the
transition from normal aorta to dissection. This study investigates the natural history of aortic dissection, as it appears in medical
imaging, to better understand the types of aortas that dissect, and the manner in which they do so. METHOD AND MATERIALS The UVA clinical data repository and PACS were searched to identify adult patients with a history of aortic dissection who had imaging
between 2003 and 2012. The clinical history and imaging were reviewed to identify patients who had undergone CTA of the aorta before
and after dissection. These images were reviewed to identify the location of the dissection flap, and to compare the morphology and
atheroma burden before and after dissection. RESULTS The patients identified showed four patterns of progression. One group of patients, with underlying connective tissue disease, showed
proximal dissection with a rapid time course. A second group consisted of patients with an underlying history of vascular disease. These
patients demonstrated multiple large atheromas, one of which eventually dissected. In a third group, patients showed a progression from
intramural hematoma to penetrating aortic ulcer to aortic dissection. The fourth group included younger patients with low atheroma
burden. In these patients, a small plaque progressed rapidly to dissection. CONCLUSION Aortic dissection remains difficult to predict, both in terms of which patients will dissect, and where they will dissect. After comparison of
the imaging of aortas both before and after dissection, several patterns of progression to dissection were identified. One of these groups
consisted of younger patients with little vascular calcification, who dissected rapidly. This may suggest a population of patients who are at
risk for dissection, but present few clinically apparent risk factors. This study also demonstrates that there is not a single pattern of
progression to dissection. Instead, there appear to be subtypes of dissection, each of which are predisposed to dissect in different
locations, along different time courses. CLINICAL RELEVANCE/APPLICATION There are several distinct patterns of progression to aortic dissection that each affect a unique patient population, one of which includes
younger, healthier patients. Page 41 of 397
LL-VIE-SU7A • Simple and Easy to Implement Tips for Dramatic Dose Reduction in CT Guided Interventional Procedures:
Breaking the One mSV Barrier!
Ramit Lamba MD ; Kunal Sidhar MD (Presenter) ; Puneet Bhargava MD ; Michael T Corwin MD ; Chandana G Lall MD PURPOSE/AIM 1. Discuss and illustrate several simple and easy to implement strategies that will result in dramatic dose reduction for CT guided
interventional procedures. 2. Illustrate how careful attention and meticulous planning can routinely result in a dose of less than1mSv
during CT guided interventional procedures. CONTENT ORGANIZATION 1. Overview of image guided procedures. 2. Appropriate choice of guidance modality. 3. Typical doses during CT guided interventional
procedures. 4. Risks of cumulative and high radiation exposure over a limited territory. 5. Structure and challenges of a CT guided
interventional procedure. 6. Strategies for decreasing dose at different steps of the procedure. 7. How to achieve consistent breath holds
during the procedure. 8. Tips on accurate needle placement. 9. Illustrate use of a mobile app to measure the angle of the needle during
placement. 10. Choosing the simplest factors for dose economy. 11. Utility and indications of post procedure scans. 12. Illustrate
examples of procedures routinely performed at a dose of less than 1msV. SUMMARY After review of this exhibit, radiologists performing CT guided interventional procedures will be able to routinely implement 1) new
techniques for accurate needle placement and 2) simple and easy to use dose reduction strategies into their practice. Molecular Imaging - Sunday Posters and Exhibits (1:00pm - 1:30pm) Sunday, 01:00 PM - 01:30 PM • S503AB
Back to Top MI
CL-MIS-SUB • AMA PRA Category 1 Credit ™:0.5 CL-MIS-SU2B • The Diagnostic Value of DTI and Fiber Tractography Parameters in Differentiating Solitary Intracranial Masses
Paloma Puyaito MD (Presenter) ; Juan Jose Sanchez MD, PhD ; Montserrat Virumbrales ; Carles Aguilera ; Angel Olazabal
Zudaire ; German Camilo ; Magally Padilla PURPOSE To establish the parameters that differentiate metastases and primary high grade glial tumors by diffusion-tensor sequences. METHOD AND MATERIALS 51 patients with solitary intracranial mass were analyzed: 24 metastasis and 27 GBM.Fractional anisotropy(FA),medium
diffusion(MD),pure anisotropic diffusion (q*) and total magnitude of the diffusion (L) were studied, both in the contrast enhanced tumor
area and the affected adjacent white matter region. These measures were reproduced in the contrataleral unaffected side of the brain by
obtaining mirror images. RESULTS DTI sequences and mainly q* (P CONCLUSION Differentiating the etiology of brain tumors and achieving an accurate measurement of their real extension (discriminating peritumoral
edema from tumor infiltration beyond the enhanced area) will have a great repercussion in the decrease of the number of the cerebral
biopsies, reduction of the extension of the surgical resections, as well as an indirect reduction of the hospitable stay and better
therapeutic decisions. CLINICAL RELEVANCE/APPLICATION DTI and fiber tractography add valuable information for the differential diagnosis between glioblastoma multiforme (GBM) and
metastases in patients with a solitary cerebral expansive lesion. CL-MIS-SU3B • Temporal Subtraction of Torso FDG-PET Images by Using Anatomical Standardization Approach
Takeshi Hara PhD (Presenter) ; Daisuke Fukuoka PhD ; Tetsuro Katafuchi ; Xiangrong Zhou PhD ; Chisako Muramatsu PhD ; Hiroshi Fujita PhD ; Shinichiro Kumita MD ; Kenta Hakozaki ; Satoshi Itoh MD, PhD PURPOSE To develop a new computer-aided diagnosis system with temporal subtraction technique for FDG-PET scans and to show the fundamental
usefulness based on an observer performance study. METHOD AND MATERIALS The computerized system consists of the following steps: (1) Anatomical standardization of normal FDG-PET scans, (2) Normal model
construction from the normal FDG-PET scans, (3) Z-score mapping based on statistical image analysis, (4) Automated detection of
abnormal region, (5) Comparison of detected regions between previous and current scans, and (6) Image subtraction of previous and
current scans. An automated detection technique has been applied to each scan of previous and current examinations independently at
the fourth step. The detection technique is based on SUV and Z-score threstholding. The detected regions were compared between two
scans to show the changes of activities. Observer performance study based on ROC (receiver operating characteristics) was also
performed without and with the system results to shows the usefulness of the computerized scheme. RESULTS The recognition performance of the computer outputs for the 43 pairs was 96% sensitivity with 31.1 false-positive marks per scan. The
average of area under-the-ROC-curve (AUC) from 4 readers in the observer performance study was increased from 0.85 without
computer outputs to 0.90 with computer outputs (p=0.0389, DBM-MRMC). The average of interpretation time was slightly decreased
from 42.11 to 40.04 seconds per case (p=0.625, Wilcoxon test). CONCLUSION We concluded that the computerized scheme for torso FDG-PET scans with temporal subtraction technique might improved the diagnostic
accuracy of radiologist in cancer therapy evaluation. CLINICAL RELEVANCE/APPLICATION New application of anatomical standardization method to torso region. Temporal subtraction of 3D torso FDG-PET scans to enhance
temporal changes of SUV. CL-MIS-SU4B • F-18 Fluoroacetate PET Imaging -Biodistribution in Healthy Subjects and Preliminary Study for Diagnosis of Liver
Tumors
Ryuichi Nishii MD, PhD (Presenter) ; Tatsuya Higashi MD ; Shinya Kagawa ; Masaaki Takahashi MD ; Yoshihiko Kishibe ; Hiroshi Yamauchi MD, PhD ; Shigeki Nagamachi MD, PhD ; Shozo Tamura MD, PhD PURPOSE F-18 Fluoroacetate (FACE) is a potential tracer for the quantitative evaluation of TCA cycle/membrane metabolism of cancers. Based on
Page 42 of 397
F-18 Fluoroacetate (FACE) is a potential tracer for the quantitative evaluation of TCA cycle/membrane metabolism of cancers. Based on
our previous reports of this PET tracer, we have started to investigate FACE PET imaging in normal volunteers and in patients with liver
tumors as preliminary studies. METHOD AND MATERIALS The clinical trial studies were conducted with a total of twenty-four healthy volunteers and eight patients with liver tumor. All subjects
were injected FACE and dynamic PET were acquired, followed by whole body static scans. In the study of patients with liver tumor, FDG
PET was also performed on each day respectively. Qualitative analysis and quantitative analysis of tumors (4 hepatocellular carcinoma/
HCC, 1 cholangiocellular carcinoma/ CCC, 3 metastatic tumors from colon cancer and P-NET) was performed using SUVmax and TNR
(Tumor-to-normal Liver Ratio). RESULTS Dynamic PET imaging demonstrated that the renal and hepatobiliary systems were the principal pathways of clearance of FACE. The
average SUVmean values in the brain, lung, myocardium, liver, muscle and fat tissue at 1hr imaging were 1.34, 0.46, 2.20, 1.76 1.28
and 0.44, respectively. There was no deposition of radioactivity in the skeletal structures, indicating metabolic stability over 1 to 2hr
post-injection of the radiotracer. FDG uptake of liver tumors (SUVmax: 6.1+/-3.9, TNR: 2.4+/-1.5) was significantly higher than that of
FACE (2.7+/-0.6, 1.5+/-0.4), while normal physiological uptake of FACE (SUVmean: 1.8+/-0.2) was lower than that of FDG (SUVmean:
2.5+/-0.2). In qualitative analysis, FDG was positive in 3 tumors (2 HCC, 1 CCC) and negative in the other 5 tumors, while FACE was also
positive in 3 tumors which were the same tumors with positive FDG uptake. Pathological results showed that a case of moderately
differentiated HCC showed high FACE uptake (SUVmax=3.0), while FDG also showed high uptake (SUVmax=5.7). CONCLUSION FACE PET would be suitable and promising imaging as a tumor seeking molecular imaging. Tumor FACE uptake was positive in three
patients with HCC and CCC, but the uptake pattern was similar to FDG. Further evaluation was needed. CLINICAL RELEVANCE/APPLICATION FACE PET would be suitable and promising imaging for the quantitative evaluation of TCA cycle/membrane metabolism of cancers. Tumor
FACE uptake was positive in patients with HCC and CCC. Nuclear Medicine - Sunday Posters and Exhibits (1:00pm - 1:30pm) Sunday, 01:00 PM - 01:30 PM • S503AB
Back to Top NM
CL-NMS-SUB • AMA PRA Category 1 Credit ™:0.5 CL-NMS-SU1B • The Value of Intratumoral Heterogeneity of FDG Uptake to Differentiate between Primary Benign and Malignant
Musculoskeletal Tumors on PET/CT
Masatoyo Nakajo MD, PhD (Presenter) ; Masayuki Nakajo PhD ; Yoshihiko Fukukura MD, PhD ; Megumi Jinguji ; Yoshiaki
Nakabeppu PURPOSE To examine whether the intratumoral heterogeneity of FDG uptake on PET/CT can be helpful to discriminate between primary benign and
malignant musculoskeletal (MS) tumors. METHOD AND MATERIALS The study population consisted of 63 patients who underwent PET/CT examinations before therapy for primary MS tumors. The
intratumoral heterogeneity was evaluated by the calculated cumulative standardized uptake value (SUV)-volume histograms which were
describing % of total tumor volume above % threshold of maximum SUV (SUVmax). Percent tumor areas above a threshold from 0 to
100% of the SUVmax were plotted and the area under curve of the cumulative SUV histograms (AUC-CSH) was used as a heterogeneity
index, with lower values corresponded with increased heterogeneity. The differences in the SUVmax and AUC-CSH between benign and
malignant tumors were examined using the Mann-Whitney�s U test. To examine the applicability of SUVmax and AUC-CSH for
discrimination between benign and malignant tumors, receiver operating characteristic (ROC) analyses were conducted. RESULTS There were 35 benign (8 schwannomas, 5 giant cell tumors and 22 others) and 28 malignant (11 MFHs, 4 liposarcomas, 4
myxofirosarcomas and 9 others) tumors. There was no significant difference in the SUVmax between benign and malignant tumors (6.9
± 4.4 vs. 9.2 ± 6.0, P=0.17). However, the AUC-CSH was significantly lower for malignant tumors than for benign tumors (0.43 ± 0.14
vs. 0.52 ±0.10, P=0.004), and malignant tumors exhibited more heterogeneous uptake than benign tumors.
The optimal threshold values were >6.9 for SUVmax and =0.42 for AUC-CSH to diagnose malignant tumors. The sensitivity, specificity,
accuracy and area under the ROC curve (AUC-ROC) were 61% (17/28), 66% (23/35), 63% (40/63) and 0.60 for SUVmax, and 61%
(17/28), 89% (31/35), 76% (48/63) and 0.71 for AUC-CSH, which was superior to SUVmax in the AUC-ROC (P=0.018).
CONCLUSION Primary malignant MS tumors exhibited more heterogeneous intrarumoral uptake than primary benign ones. Evaluation of the
intratumoral heterogeneity of FDG uptake may be more helpful than SUVmax in discrimination between primary benign and malignant MS
tumors. CLINICAL RELEVANCE/APPLICATION Evaluation of the intratumoral heterogeneity of FDG uptake may help in discrimination between primary benign and malignant
musculoskeletal tumors. CL-NMS-SU2B • The Impact of 18F-Choline PET/CT in the Staging and Restaging of Prostate Cancer. First Single Center
Experience in Lebanon
Mohamad B Haidar MD ; Mario G Jreige MD ; Marwan Haddad MD ; Jean Abi Ghosn MD ; Feras Chehade MD, PhD ; Tatiana
Khoury MD (Presenter) PURPOSE METHOD AND MATERIALS RESULTS 18F-Choline showed positive findings in 64/86 pts (74%).
In the staging of patients, PET/CT detected a primary lesion within the prostate in 22/23 pts (96%), locale metastatic lymph node in
3/23pts (13%) and bone metastasis in 6/23 pts (26%).
In the restaging of patients PET/CT was negative in 21/23 pts (33%); however, there was local recurrence within the prostate bed in
22/63 pts (35%), nodal metastasis in 25/63 pts (39%) and extra nodal metastatic disease in 19/63 pts (30%).
In the staging group, patients with metastatic bone deposit were treated by pelvic radiotherapy and hormonal therapy rather than
surgery.
In the restaging group, patients with localized recurrent disease (prostate bed and pelvic lymph node metastasis) were treated by
radiotherapy 16/63 pts (25%). As for patients with multiple metastatic sites, they were treated by hormonal therapy and/or
chemotherapy.
Therefore, 18F-CHOLINE PET/CT played a major role in altering the therapeutic management. Page 43 of 397
Therefore, 18F-CHOLINE PET/CT played a major role in altering the therapeutic management. CONCLUSION F18-PET/CT was able to detect distant metastasis in the staging of newly diagnosed prostate cancer.
It was also able to identify relapse and distant metastasis in the restaging of prostate cancer. This was even noteworthy in cases where
PSA level elevation was inferior to 7ng/ml.
18F-choline PET/CT altered the therapeutic management of patients by guiding physicians towards a more suitable treatment modality
especially in patients with only pelvic disease.
CLINICAL RELEVANCE/APPLICATION F18-PET/CT was able to detect distant metastasis in the staging and restaging of prostate cancer and altered the therapeutic
management by guiding physicians towards a more suitable treatment. CL-NMS-SU3B • FDG PET-CT: Patterns and Imaging Features Following Percutaneous Cryoablation Treatment for Primary
Non-Small Cell Lung Cancer
Robert Matthews MD ; Brendan Logiurato (Presenter) ; Elham Safaie MD ; William H Moore MD * ; Thomas Bilfinger MD ; Nand Relan ; Dinko Franceschi MD PURPOSE The aim of this study is to understand the patterns and imaging features of fluorodeoxyglucose (FDG) positron emission tomography with
computed tomography (PET-CT) in post cryoablation lung cancer patients in order differentiate benign from malignant findings. METHOD AND MATERIALS We identified 24 patients with 26 lesions treated by percutaneous cryoablation for primary non-small cell lung cancer. Two patients had
metachronous lesions with different ablation dates. Two experienced nuclear radiologists blindly reviewed baseline images and follow up
FDG PET-CT scans for up to 36 months with discrepancy determined by consensus. Seventeen lesions had baseline PET-CT while 9 had
CT only. Follow up PET-CT studies were obtained at 6, 12, 18, 24, and 36 months with variability due to adherence to protocol. RESULTS CONCLUSION Patterns and imaging features of FDG PET-CT following percutaneous cryoablation are complex. New ablation site nodules or enlargement
with focal FDG uptake predicts recurrence. CLINICAL RELEVANCE/APPLICATION Understanding the changes of FDG PET-CT imaging is critical for evaluating treatment responses after percutaneous cryoablation of
primary lung cancer. CL-NMS-SU4B • Posttreatment FDG PET/CT in Predicting Survival of Patients with Ovarian Carcinoma
Linda C Chu MD (Presenter) ; Hua-Ling Tsai ; Mehrbod Javadi MD ; Teresa Diaz-Montes ; John Crandall ; Hao Wang ; Richard L Wahl MD * PURPOSE The purposes of this study are to evaluate the prognostic value of posttreatment PET/CT in predicting survival of patients with ovarian
carcinoma and to determine the incremental value of combining posttreatment PET/CT with CA-125 in predicting patient survival. METHOD AND MATERIALS This was an IRB approved retrospective study. From July 2001 to July 2011, 48 patients (mean age 58.1 years) who completed initial
therapy for ovarian carcinoma with concurrent 3 to 9 month initial posttreatment PET/CT and serum CA-125 were identified from the
radiology database. PET/CT reports were systematically reviewed to determine the presence or absence of suspected disease recurrence
on PET/CT. Medical records were reviewed to determine patient demographics, initial tumor stage, CA-125 values near the time of
PET/CT, and mortality. The prognostic value of posttreatment PET/CT and CA-125 were determined from time-dependent receiver
operator curve (ROC) analysis to evaluate accuracy of PET/CT and CA-125 in predicting survival at 12, 24, 30, and 36 month follow-up. RESULTS Time-dependent ROC showed area under the curve for PET/CT was 0.7 at 12 month, 0.73 at 24 month, 0.76 at 30 month, and 0.75 at
36 month follow-up. The addition of PET/CT to CA-125 increased the area under the curve compared to PET/CT alone or CA-125 alone
across all time points. For example, at the 24 month follow-up, area under the receiver operator curve was 0.93 for combination of
PET/CT and CA-125, compared with 0.73 for PET/CT alone and 0.89 for CA-125 alone. ROC at 12, 30 month, and 36 month follow-up
showed similar results. CONCLUSION Posttreatment PET/CT predicts survival of patients with ovarian carcinoma. The addition of posttreatment PET/CT to the CA-125 serum
biomarker further improves prognostic accuracy. Combining imaging with serum biomarker provides superior diagnostic accuracy
compared to imaging alone. CLINICAL RELEVANCE/APPLICATION Posttreatment FDG PET/CT is useful in predicting survival of patients with ovarian carcinoma and further improves risk stratification when
combined with serum CA-125. CL-NME-SU5B • Iatrogenic and Treatment-related 18F FDG Uptake in the Breast: What the Radiologist Needs to Know
Kelli Y Ha (Presenter) ; Umesh D Oza MD PURPOSE/AIM � Illustrate iatrogenic and post-treatment etiologies for abnormal breast FDG uptake
� Emphasize the importance of obtaining relevant clinical and surgical history prior to PET-CT interpretation
� Distinguish patterns of benign vs. malignant FDG uptake using relevant clinical/surgical history
� Provide histopathologic and radiologic correlation for several case examples
CONTENT ORGANIZATION Multiple benign etiologies for abnormal breast FDG uptake exist. Many conditions arise from iatrogenic sources and post-treatment
related change. These include lymphedema from lymph node dissection, radiation therapy, fat necrosis, abscess formation,
chemotherapy port leak, silicone implant rupture, and changes from recent/remote mastectomy and breast reconstruction. Examples will
be provided with histopathologic/radiologic correlation, and emphasis on the importance of obtaining relevant history discussed. Patterns
of benign FDG uptake will be distinguished from neoplastic entities, providing the radiologist with a thorough understanding of the
spectrum of breast FDG-avid lesions. SUMMARY Radiologists will become familiar with multiple etiologies of benign, post-treatment and iatrogenic causes for breast hypermetabolism.
These examples will aid them in accurately describing and diagnosing non-neoplastic etiologies for breast FDG avidity on PET-CT given
relevant clinical/surgical history. CL-NME-SU6B • Current Role of Lymphoscintigraphy in Oral Squamous Cell Carcinoma with a Focus on SPECT/CT
Page 44 of 397
Brandon P Olivieri MD (Presenter) ; Anjeza Chukus MD ; Nikki Tirada MD ; Alexander Daoud BS ; Chetan D Rajadhyaksha MD
; Jose A Pizarro MD PURPOSE/AIM Lymphatic metastases are an important prognostic indicator in patients with oral squamous cell carcinoma (SCC). While modified radical
neck dissection has been the diagnostic procedure of choice in early oral SCC, it frequently yields negative results while putting the
patient at risk for procedure-related morbidity. Although knowledge of its utility has yet to become widespread, lymphoscintigraphy in oral
SCC is an excellent staging and treatment planning tool given its high specificity. Through a review of the literature and 8 years
experience at our institution, our objective is to review current evidence concerning lymphoscintigraphy in oral SCC, diagnosis pearls and
pitfalls, and up-to-date recommendations for its utilization. CONTENT ORGANIZATION Review the utility of lymphoscintigraphy for detection of lymphatic metastases in oral SCC.
The different techniques and methods of performing and optimizing intraoral lymphoscintigraphy will be described.
Pearls and pitfalls in diagnosis of lymphoscintigraphy with sample cases and corresponding surgical and pathological findings.
Practicality and up-to-date recommendations on lymphoscintography.
SUMMARY The participant will gain familiarity with the acquisition, interpretation, current evidence, and clinical values of lymphoscintigraphic
images in oral SCC. Pediatric Radiology - Sunday Posters and Exhibits (1:00pm - 1:30pm) Sunday, 01:00 PM - 01:30 PM • S101AB
Back to Top PD
CL-PDS-SUB • AMA PRA Category 1 Credit ™:0.5 CL-PDS-SU1B • Shoulder MRI with and without Arthrogram: Is the Needle Necessary to Diagnose Labral Tears in Children?
Isabelle Drolet MD (Presenter) ; Gavin Clague MBBS ; Jacob L Jaremko MD PURPOSE Shoulder labral tears can lead to long-term morbidity in youth. The definitive imaging test for labral tear, magnetic resonance
(MR)-arthrogram, requires joint injection, which is logistically cumbersome, painful, and not entirely without risk. With improved MR
sequences, non-contrast MRI might adequately detect labral tears. Our objective was to quantify the sensitivity of non-enhanced MR
sequences vs. MR arthrograms for detection and classification of labral tears in children, in comparison to surgery, which is considered
the gold standard. METHOD AND MATERIALS Ethics-approved retrospective review of pediatric ( RESULTS Sixty-three of 65 surgical cases had labral tears confirmed operatively. These were detected at pre-arthrogram MR with SN 87%, SP
100%, PPV 100%, NPV 33%. At post-arthrogram MR, we had SN 82%, PPV 100%, but could not compute SP or NPV because all 33
post-arthrogram cases were positive at surgery. Sensitivity was highest for detection of antero-inferior and superior labral tears on both
pre- and post-arthrogram MR and lowest for posterior labral tears. CONCLUSION If a labral tear is detected at pediatric non-arthrogram shoulder MR, this strongly predicts a finding of labral tear at surgery (PPV 100%).
Depending on surgical preference, this may be sufficient information to avoid invasive arthrogram in these children. However, if a labral
tear is not detected on pre-arthrogram MR and clinical suspicion is high, post-arthrogram MR is suggested, since the pre-arthrogram NPV
is 33%. CLINICAL RELEVANCE/APPLICATION This study shows that invasive arthrogram MR could be avoided in children with a labral tear on non-arthrogram MR, but is still advisable
when a labral tear is not detected on non-arthrogram MR. CL-PDS-SU2B • Aberrant Insular Functional Connectivity in Children with Irritable Bowel Syndrome: A Resting-state fMRI Study
Bing Yu MD (Presenter) ; Na Chang ; Na Liu MD ; Qiyong Guo MD PURPOSE To explore the differential of connectivity between the insular lobe and other brain regions in children with irritable bowel syndrome(IBS)
and healthy children by performing functional magnetic resonance imaging at resting state. METHOD AND MATERIALS Thirty IBS children(15 female;age8±2.1y) and thirty controls(15 female;age8±1.2y) were recruited. The functional MRI was performed at
resting state on a 3.0T MR scanner. Insular connectivity was investigated by examination of the correlation between low frequency fMRI
signal fluctuations in the insular lobe and those in all other brain regions. Insular connectivities of IBS children and controls were
compared between groups.
RESULTS Functional connectivities between the insular lobe and a set of regions were different in IBS children compared with controls. The
functional connectivities of bilateral medial prefrontal cortex (MPFC) and left anterior cingulate cortex (ACC) between insluar lobe were
increased, however the connectivity between right amygdala and insluar lobe was decreased. CONCLUSION The abnormal insular functional connectivities to bilateral MPFC, left ACC and right amygdala might be associated with the IBS. CLINICAL RELEVANCE/APPLICATION The abnormal insular functional connectivities to bilateral MPFC, left ACC and right amygdala might be associated with the IBS. CL-PDS-SU3B • Quantitative Ventriculometry for Children Using MRI
Katsumi Hayakawa MD (Presenter) ; Hiroyuki Tatekawa MD ; Sozo Okano ; Hiroko Matsushita ; Kozue Shiomi ; Naoe
Satogami MD ; Masato Tanikake MD ; Ryota Fujimoto MD ; Hiroshi Kuroda PURPOSE MRI is the promising tool for the evaluation of white matter injury at the term equivalent age for assessment of clinical outcome for
premature infants. For the evaluation of white matter abnormality, one of the five area assessments on MRI is ventricular dilatation,
which is graded into three degrees including normal, moderate and more global enlargement qualitatively. But this grading system was
subjective. We assume that the relative atrial width which reflects white matter injury at the occipital and temporal lobe in addition to the
Evans and Cella media ratios could improve the measurement of the lateral ventricular size. The aim of this study is to evaluate the
Page 45 of 397
clinical values of the new ventriculometry. METHOD AND MATERIALS The subjects consisted of 38 healthy neonates up to 32 weeks of age and 64 healthy children from 1 to 15 years of age as well as 67
children with white matter injury of PVL (N=48) and non-PVL (N=19). The measurement of lateral ventricle was done at the three points
of frontal horn, atrium and cella media using T2-weighted image. The Evans ratio was the maximal frontal horn width divided by the
maximal inner diameter between the inner tables at the same slice. The atrial ratio was the maximal atrium width divided by the maximal
inner diameter between the inner tables at the same slice. The cella media ratio was the minimal width of the center of the lateral
ventricle body divided by the maximal inner diameter between the inner tables at the same slice. The sum of the three ratios which could
cover the entire cerebral white matter volumes was defined as the ventricular size. RESULTS The average ventricular sizes were 1.02±0.056(SD) for the neonates and 0.99±0.044 for the children. As there was no significant
difference between two age groups, we combined the two data and the average size was 1.00±0.05. On the other hand, the average
ventricular sizes of the children with white matter injury were 1.16±0.101 in PVL group and 1.20±0.095 in non-PVL group and the
combined average size of white matter injury groups was 1.17±0.101 (vs normal children, p CONCLUSION The new developed ventriculometry using MRI is the useful and feasible for neonatal ventriculometry in busy clinical practices. CLINICAL RELEVANCE/APPLICATION White matter injury of premature neonates may cause ventriculomegaly, which reflects shrinkage of white matter volume. Quantitative
ventriculometry is useful to assesscerebral white matter injury. CL-PDS-SU4B • Value of Lower-limb MRI Examination for the Prediction of Joint Collapse in Hematological Pediatric Patients
with Osteonecrosis of Femoral Heads and Condyles: Role of Lesion Volume Assessment
Alessandro Masetto MD (Presenter) ; Davide Ippolito MD ; Pietro A Bonaffini MD ; Alessandra S Casiraghi ; Cammillo R Talei
Franzesi ; Sandro Sironi MD PURPOSE To assess the reliability of the measurement of the osteonecrotic lesion volume as a predictive factor of joint collapse in femoral heads
and femoral condyles of pediatric patients treated for hematologic malignancies. METHOD AND MATERIALS A total of 120 patients with lymphoproliferative diseases, treated with chemotherapy and corticosteroids and/or bone marrow transplant
and with clinical suspicion of osteonecrosis (ON), underwent a lower-limb MRI examination between June 2005 and January 2013. MRI
studies were performed, both at baseline and during follow-up, on a 1.5T magnet (Achieva, Philips), with step-table technique and
acquiring coronal short tau inversion recovery (STIR) and T1-weighted sequences from the hips to the ankles. On baseline MRI, the
volumes of femoral heads (FHs), medial condyles (MCs), lateral condyles (LCs) and the osteonecrosis volume (ONV) were measured. The
relative volumetric involvement (relative volume, RV) of the bone by necrosis was calculated (ON volume/epiphyseal bone volume) and
the statistical analysis was performed with ROC curve test. RESULTS Twenty-six patients (9 males, mean age 15 years) presented ON affecting the femoral heads and/or condyles, for a total of 23 FHs, 23
MCs and 28 LCs. During the follow-up (11±2 months), joint deformity was observed in 12 FHs, 2 MCs and 5 LCs. Considering a threshold
of 24% of volume involvement, RV predicted joint deformity in 12/12 of FHs, with sensitivity=100%, specificity=90%, accuracy=95%,
PPV=93% and NPV=100%. Using a threshold of 27% and 11% of volume involvement, RV predicted joint deformity in 2/23 (8%) of MCs
(SN=100%, SP=57%, ACC=61%, PPV=9%, NPV=100%) and in 5/28 (18%) of LCs (SN=100%, SP=35%, ACC=46%, PPV=25%,
NPV=100%), respectively. CONCLUSION In hematological pediatric patients with post-treatment osteonecrosis, RV proved to be a reliable parameter with a high prognostic value
for the prediction of deformity in femoral heads, but not in distal femoral epiphyses. CLINICAL RELEVANCE/APPLICATION The measurement of RV of femoral heads affected by ON may offer complementary information, useful in the follow-up and management
of hematologic pediatric patients. CL-PDS-SU5B • Cerebral Perfusion Influences Signal Intensity in Sulci on FLAIR Imaging
Julie Harreld MD (Presenter) ; Reem Awwad MD ; Noah D Sabin MD, JD ; Ying Yuan PhD ; Michael Rossi ; Wilburn E Reddick
PhD ; John O Glass MS ; Qing Ji PhD ; Amar Gajjar MD ; Kathleen J Helton MD ; Zoltan Patay PURPOSE Artifactual sulcal signal intensity (SSI) on FLAIR MR imaging, common with anesthesia and supplemental oxygen (FiO2), can mimic or
obscure detection of leptomeningeal disease. Prior work (Harreld et al, ASNR 2012) suggests anesthetic effects on cerebral vasculature,
blood flow (CBF) and volume (CBV) may be contributory. The purpose of this study was to investigate the relationship of SSI on pre and
post-contrast FLAIR imaging to CBF, CBV and FiO2 in patients receiving propofol , sevoflurane, or no anesthesia at MRI. METHOD AND MATERIALS Pre- and post-contrast FLAIR brain imaging in 39 children without leptomeningeal disease aged 1 to 18 years (8.97 +/- 4.80 years)
receiving no anesthesia (NA, n=13), propofol (n=21) or sevoflurane (n=5) were retrospectively reviewed and SSI graded by two
independent neuroradiologists on a 5-point scale (0=no SSI, 4=significant SSI). CBF and CBV by DSC perfusion MRI were calculated for
segmented gray matter (GM) and white matter (WM). Spearman�s rank correlation, linear regression models and dominance analysis
were used to investigate the effects of anesthesia group, FiO2, WM and GM CBF and CBV on mean SSI. RESULTS Mean pre- and post-contrast SSI were positively correlated with anesthesia type (sevoflurane > propofol > NA, r=0.83, 0.78 for pre-and
post-contrast SSI respectively), FiO 2 (r=0.79, 0.74), GM CBV (r=0.57, 0.54), WM CBV (pre-SSI only, r=0.35) and GM CBF (post-SSI
only, r=0.32) (significance level: p CONCLUSION Cerebral perfusion, particularly GM CBV, appears to contribute to increased signal intensity in sulci on FLAIR imaging. The dominant role
of anesthesia type may be due to a relationship with FiO2 due to oxygen delivery device and effects on cerebral vasculature and perfusion
in addition to intrinsic T1 properties of anesthetic agents in CSF. CLINICAL RELEVANCE/APPLICATION Anesthesia may affect SSI in part through effects on cerebral vasculature and perfusion. CL-PDE-SU7B • Climbing the Metabolic Peaks: MR Spectroscopy of Pediatric Brain Tumors
Nishard Abdeen MD (Presenter) ; Mohamed A Aggag MD PURPOSE/AIM The purpose of this exhibit is to demonstrate the practical application of MR spectroscopy to diagnosis of pediatric brain tumors and their
mimics using a case based approach. CONTENT ORGANIZATION Page 46 of 397
1. MR spectroscopy phyics 2. MR spectroscopy: the major metabolic peaks and what they mean 3. MR spectroscopy: practical trechnique
and pitfalls 4.Illustrative Cases focussing on the contribution of MR spectroscopy to differential diagnosis: Posterior fossa:a.
Medulloblastoma b. Ependymoma c. Atypical teratoid rhabdoid tumor Supratentorial: d. Choroid plexus carcinoma e. Glioblastoma
multiforme f.Juvenile Pilocytic Astrocytoma g.Germinoma h. PNET i. DNET Other: j. Pineoblastoma k. Craniopharyngioma l. Meningioma
m. Lymphoma n. Cerebral metastases 5.Important mimics of brain tumors: demyelination, brain abscess, cerebellitis and radiation
necrosis SUMMARY MR spectroscopy is a useful complement to conventional MR in the differential diagnosis of pediatric brain tumors. Some neoplasms are
associated with characteristic and unusual peaks while in others the differential diagnosis is considerably narrowed. Familiarity with MR
spectrosocopy technique, pitfalls, and characteristic findings in various tumors will aid the radiologist to make an accurate diagnosis as
well as distinguish important mimics which should not be treated as tumor. CL-PDE3023-SUB • Pediatric Magnetic Resonance Urography: A Primer, including Systematic Approach to Review Interpretation
Elliot Dickerson MD (Presenter) ; Jonathan R Dillman MD * ; Ethan A Smith MD ; Robert L Lebowitz MD ; Michael A Dipietro
MD ; Kassa Darge MD, PhD PURPOSE/AIM To provide a basic introduction to pediatric MR urography (MRU) technique, clinical indications, and a systematic approach to
review/interpretation.To provide a basic introduction to the technical basis of pediatric MRU as well as a systematic approach to
interpreting MRU. CONTENT ORGANIZATION We will present:
-Pediatric MRU technique and clinical indications.
-Data provided by MRU in children, including: Anatomy of renal parenchyma, collecting systems, ureters, and the bladder.
Functional assessment, based on renal contrast material uptake and excretion.
-Advantages and disadvantages of MRU compared to other kidney/urinary tract imaging methods.
-Systematic approach for MRU review/interpretation.
-Numerous case-based examples of normal and abnormal anatomy/function, including complex/difficult cases where MRU affected clinical
management.
SUMMARY MRU is a useful tool for depicting both anatomy and function of the pediatric kidneys and urinary system. The technique can demonstrate
abnormalities that are difficult to understand using conventional imaging modalities, and it can provide comprehensive evaluation
minimizing the need for multiple imaging studies. This educational exhibit will demonstrate the clinical value of pediatric MRU and provide
the audience with a basic approach to reviewing/ interpreting these exams.. Breast - Sunday Posters and Exhibits (1:00pm - 1:30pm) Sunday, 01:00 PM - 01:30 PM • Lakeside Learning Center
Back to Top BR
LL-BRS-SUB • AMA PRA Category 1 Credit ™:0.5 LL-BRS-SU1B • The Radiation Dose of Breast Tomosynthesis Comparison with Conventional Digital Mammography
So Young Jung RT (Presenter) ; Meoung Mi Jang ; Kyung Sun Lee ; Sung Suk Bae ; Dong Sung Kim ; Jung Min Chang MD ; Ka Hee Jung PURPOSE Early clinical results with DBT are very promising. However, it has been reported that the radiation dose of DBT is higher than MG. To
investigate how breast density characteristics and the presence of cancer can affect the dose of digital breast tomosynthesis (DBT)
compared with conventional digital mammography(MG).
METHOD AND MATERIALS Between January 2012 and April 2012, DBT and MG were performed in 211 women (mean age 50.3;range 25~77 years), including 148
patients with breast cancer. For Phantom experiments, the radiation dose of both DBT and MG were compared using ACR phantom (CIRS
model15). For clinical data evaluation, the radiation dose of DBT and MG were compared between breast density (BI-RADS grade 1,2
[N=50], Grade3 [N=94] and Grade4 [N=67]). In addition, the radiation dose of DBT and MG were compared in breasts with cancers and
contralateral normal breasts in patient with breast cancer [N=148]. RESULTS The radiation dose of DBT was 1.32 mGy, which was 20% higher than MG(1.1mGy)in phantom study. According to the composition of the
breast density in 211 women, DBT dose increased 44% in breast density grade1,2 (p=0.00), 11% in grade 3 (p=0.01), and 1% in grade
4 (p=0.585) when compared to MG. The dose differences between DBT and MG were significant in all breast density except for grade 4.
The dose increase in DBT compared to MG was 9% in the breast with cancer, and 15% in normal contralateral breasts. CONCLUSION The radiation dose of DBT was generally higher compared to MG. However, the difference of radiation dose between DBT and MG grew
smaller with higher breast density, and breast with cancers. CLINICAL RELEVANCE/APPLICATION In evaluation of dense breast, and breast with malignancy, concerns on increased dose could be minimized. Because in that case, the
minimal dose differences were noted between DBT and MG is. LL-BRS-SU2B • Microcalcifications in 1,658 Patients with Pure Ductal Carcinoma in Situ of the Breast: Imaging Findings with
Clinical, Histopathologic and Biologic Correlation
Gaiane M Rauch MD, PhD (Presenter) ; Brian Hobbs PhD ; Henry M Kuerer MD ; Marion E Scoggins MD ; Sara Lari ; Wei T
Yang MD ; Ana Paula Benveniste MD ; Young Mi Park MD, PhD ; Beatriz E Adrada MD ; Patricia S Fox MS ; Savitri
Krishnamurthy MD PURPOSE Analyze microcalcifications (MC) on mammography (M) in patients with pure ductal carcinoma in situ (DCIS) by nuclear grade (G),
comedonecrosis (CN), estrogen receptor (ER) status, patient age and surgical outcome. METHOD AND MATERIALS An institutional review board approved retrospective single institution database search was performed from January 1, 1996 to July 31,
2009 of patients with pure DCIS who underwent preoperative M. All M and, when available, ultrasound (US) images were reviewed
according to the ACR BIRADS� lexicon. Imaging findings were analyzed in respect to clinical, histopathologic, and biologic characteristics.
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Statistical analyses used multiple logistic regression with model selection via AIC or Pearson�s chi-squared test for marginal homogeneity
or linear dependence. RESULTS There were 1911 patients with pure DCIS. Patients with negative M (n=98) and noncalcified lesions (n=155) were excluded, 1658
patients were included in final analysis. M was performed in all patients; US in 506 (31%) patients. Mean age at diagnosis was 55 years
(SD, 11.0). G3 lesions were associated with fine linear morphology and segmental distribution of MC (p CONCLUSION G3 DCIS and CN are associated with fine linear MC, segmental distribution, large size, ER (-) lesions, and visibility on US. Dense breasts
are associated with multicentricity and close surgical margins. CLINICAL RELEVANCE/APPLICATION Patients with dense breasts should be carefully evaluated for multicentricity and the possibility of close surgical margins, and might
benefit from supplemental imaging. LL-BRS-SU3B • Correlation between Cancer Detection and Image Quality in an Organized Provincial Screening Mammography
Program
Rasika Rajapakshe PhD (Presenter) ; Brent A Parker BSc ; Cynthia Araujo PhD ; Teresa Wight ; Nancy Aldoff ; Janette Sam
RT ; Christine M Wilson MD PURPOSE Studies from the Screening Mammography Program of British Columbia (SMPBC) and the U.S. FDA National Mammography Quality
Standard�s Act have shown that improvements in mammographic technologies improved image quality over the 1990s and early 2000s.
These studies also show that increases in image quality came at the expense of roughly doubling the mean glandular dose per
mammogram. There is little understanding whether these changes improved mammography screening outcomes at a populational level.
This study investigates the extent that improvements in film based mammographic image quality influenced the detection of breast cancer
within the SMPBC between the years 1994-2005. METHOD AND MATERIALS The SMPBC performs annual image quality tests on all of their units at each of their centers and these are reported by the BC Cancer
Agency. From this data an annual average Image Quality (IQ) Score using the ACR accreditation phantom was calculated. An IQ clinic
average was calculated by averaging the score of each mammographic unit within a clinic, and a provincial average was calculated from
each of the clinic�s average scores. The SMPBC also publishes annual reports that describe participation and screening outcomes. This
data was used to calculate the annual cancer detection rates for women between the ages of 40-79 who had cancer detected from the
SMPBC between the years 1994-2005. The calculation of this data enabled longitudinal comparison of cancer detection rates against the
provincial average IQ score. RESULTS The screening program grew from 123,881 screens with 19 sites in 1994 to 256,961 screens with 37 fixed and 3 mobile sites in 2005.
Both IQ and detection (CDR) of invasive tumours =5 mm increased over this time period. (IQ increased 20%, CDR =5 mm increased
107%). In contrast, the detection of tumours >5mm was reduced by 30%. The R 2 values, based on linear fitting, for these trends is 0.65
(CDR =5 mm) and 0.64 (CDR >5mm). The detection rate of DCIS varied from 4-8 detections per 10,000 screens. The program�s
sensitivity and specificity remained constant (± 2%) over this period of time. CONCLUSION Between 1994-2005 mammographic image quality, mean glandular dose and the detection of invasive tumours = 5mm increased while
detection of tumours >5mm decreased. CLINICAL RELEVANCE/APPLICATION Improvements in image quality over the years are associated with increased detection of small invasive breast tumours. This came at the
cost of increased radiation dose. LL-BRS-SU4B • Evaluation of Spiculation and Retraction Patterns in Coronal Reconstructions in 3D Automated Breast Ultrasound
(ABUS) Improve Differentiation between Benign and Malignant Breast Lesions
Jan Van Zelst (Presenter) ; Tao Tan * ; Bram Platel PhD ; Nico Karssemeijer PhD * ; Ritse M Mann MD, PhD * PURPOSE To investigate the value of coronal reconstructions of transversal 3D ABUS data in differentiation of benign from malignant breast lesions. METHOD AND MATERIALS This study received a waiver by the local ethics committee. For this reader study we obtained 96 3D ABUS casus with 37 malignant and
59 benign ultrasound guided core biopsied breast lesions. The localization of the lesions was done by a physician with 1 year 3D ABUS
experience based on the primary radiology reports and biopsy results. The 3D ABUS view in which the lesion was best visible, was
presented to 3 experienced breast radiologists with 2 years experience with 3D ABUS.
They were first asked to detect and classify the most suspicious lesion in the view using the BIRADS lexicon and scoring system. A
likelihood-of-malignancy (LOM) score between 0 and 100 was also requested. Thereafter the coronal reconstruction was shown and
readers were asked to re-assess the lesion. Spiculation and retraction in the coronal plane were scored on a five point scale (Spiculation
and Retraction Severity Index (SRSI)). Subsequently LOM and BI-RADS scores could be adjusted.
Az-values for differentiation of benign from malignant lesions based on LOM scores were computed with DBM-MRMC method. Pearson�s
correlation coefficient between the re-assessed LOM on the coronal reconstructions and SRSI was calculated for all readers.
RESULTS Three readers respectively pointed out 92%, 97% and 92% of 37 cancers as the most suspicious lesion in the 3D ABUS acquisition. After
evaluation of the coronal reconstructions, detected malignant lesions were not downgraded to BI-RADS 2, however, 7 benign lesions were
downgraded from BI-RADS 3 to BI-RADS 2. After re-evaluation the discrimination between benign and malignant lesions significantly
improved from 0.84 (95% CI 0.76-0.92) to 0.87(95% CI 0.80-0.94) (p=0.02). SRSI scores correlated significantly with the re-assessed
LOM scores for all readers, r = 0.85, 0.75 and 0.75, respectively (p CONCLUSION Coronal reconstructions in 3D ABUS significantly improve the differentiation between benign and malignant breast lesions, by providing
new visual information on breast cancer spiculation and retraction. CLINICAL RELEVANCE/APPLICATION Better differentiation between malignant and benign breast lesions may reduce false positive biopsies in evaluation of automated breast
ultrasound. LL-BRE-SU5B • Do We Describe the Response of Breast Cancer to Neoadjuvant Chemotherapy Accurately? A Systematic
Approach to Reporting
Rosa M Lorente-Ramos MD, PhD (Presenter) ; Javier Azpeitia Arman MD ; Eva Cueva Perez ; Isabel Casado Farinas ; Teresa
Rivera Garcia ; Miguel Angel Lara Alvarez PURPOSE/AIM To review imaging findings in advanced breast cancer after neoadjuvant chemotherapy with correlation with pathological changes
occurring during treatment. To analyse and illustrate the appropriate description and reporting of the differente types of radiological
response to neoadjuvant therapy, including residual tumor features and complete remission. Page 48 of 397
CONTENT ORGANIZATION The imaging findings in 62 patients with advanced breast cancer undergoing neoadjuvant chemotherapy (NAC) were reviewed and
compared with responses after treatment and pathological findings at surgery. Mammograms, US and MR, dynamic contrast-enhanced
and diffusion weighted imaging (DWI), were performed in all the patients before and after NAC. We describe and illustrate a schematic
reporting system including a description of the residual lesion with comparison with the pretreatment tumor: - morphologic type of
response: absence of lesion (complete response), mass shrinkage, fragmentation (scattered foci) - tumour size (longest diameter and
volume) - tumour signal intensity on MR T2-weighted images - peak signal enhancement ratio on dynamic contrast-enhanced MR - ADC
ratio - response in lymph nodes SUMMARY Imaging features correlate with pathologic findings after surgery. Accurate description and reporting of the differente types of radiological
response helps in tumor evaluation. LL-BRE-SU6B • Histopathologic Components of Breast Cancer: Radiologic Findings and Pathologic Correlation
Ken Yamaguchi MD (Presenter) ; Takahiko Nakazono MD, PhD ; Ryoko Egashira MD ; Shuji Toda ; Hiroyuki Irie MD, PhD PURPOSE/AIM To identify the histopathologic components of breast cancer including calcification, hemorrhage, necrosis, edema, mucin, fibrosis
To review the radiologic findings of each histopathologic components of breast cancer
To correlate the radiologic findings with histopathology
CONTENT ORGANIZATION 1. Pathophysiology of histopathologic components
2. Radiologic findings, including mammography, US, and MRI of each histopathologic components of breast cancer with pathologic
correlation
3. Discussion about radiological differential diagnosis using histopathologic components
SUMMARY Breast cancer is heterogeneous disease. Besides the cancer nest, breast cancer contains many histopathologic components including
calcification, hemorrhage, necrosis, edema, mucin and fibrosis. In this exhibit, we have shown the radiologic findings of these
histopathologic components of breast cancer with pathologic correlation. Identifying the radiologic findings of histopathologic components
with understanding its pathophysiology is useful for differential diagnosis for breast cancer, including DCIS and some special types. LL-BRE-SU7B • Breast Biopsies under MRI Guidance: What Have We Learned in the Past Decade? Challenges of an Essential but
Imperfect Technique
Isabelle Trop MD, MPH ; Marie-Claude Chevrier MD (Presenter) ; Isabelle Thomassin-Naggara MD ; Mona M El Khoury MD ; Lucie Lalonde MD ; Maude Labelle MD ; Julie David MD PURPOSE/AIM The goals of this exhibit are 1. to present and discuss the technical challenges related to MRI-guided breast biopsy, and propose
management tips for challenging situations, 2. to discuss radio-pathologic correlation and management recommendations for benign and
high-risk breast lesions diagnosed after biopsy, and 3. to present algorithms to minimize the risk of false negatives. CONTENT ORGANIZATION 1. Technical challenges of MRI-guided breast biopsy: due to lesion position, to lesion size, to enhancement characteristics; 2.
Management tips for challenging situations: vanishing lesion, missed lesions; 3. Radio-pathologic correlation examples, with management
recommendations for benign and high-risk breast lesions diagnosed after biopsy; 4. False negatives: how to identify them, how to
prevent them. SUMMARY MRI-guided breast biopsy is an essential tool of the breast imager, yet, a decade after its introduction, this technique remains challenging
and imperfect. Challenges include technical considerations related to adequate lesion sampling, and difficulties in confirming
radiologic-pathologic correlation for enhancing lesions. Through various clinical examples, this exhibit will offer practical tips for the
radiologist, as well as propose evidence-based algorithms for the management of benign and high-risk lesions diagnosed after
MRI-guided biopsy. LL-BRE-SU8B • Breast Anatomy and Characteristics of Breast Lesions in Digital Breast Tomosynthesis
Paola Clauser MD (Presenter) ; Arianna De Nicolo' MD ; Viviana Londero MD ; Rossano Girometti MD ; Chiara Zuiani MD ; Massimo Bazzocchi MD PURPOSE/AIM To define breast anatomy and characteristics of the more frequently encountered breast lesions in Digital Breast Tomosynthesis (DBT). CONTENT ORGANIZATION 1. Normal breast anatomy in DBT: a. glandular tissue; b. ligaments and vessels; c. lymph nodes. 2. Benign breast lesions: a.
fibroadenomas; b. cysts; c. fibrocystic changes. 3. Malignant breast lesions: a. invasive ductal carcinoma; b. invasive lobular carcinoma;
c. ductal carcinoma in situ. 4. Pitfalls in DBT: macrocalcifications and metallic markers. SUMMARY DBT is able to show more details on breast anatomy and lesions, compared to Digital Mammography; several specific tips and tricks
should be taken into account in assessing normal or pathologic findings. Cardiac - Sunday Posters and Exhibits (1:00pm - 1:30pm) Sunday, 01:00 PM - 01:30 PM • Lakeside Learning Center
CA
Back to Top LL-CAS-SUB • AMA PRA Category 1 Credit ™:0.5 LL-CAS-SU1B • Effect of a Vendor-specific Motion-correction Algorithm on Image Quality and Interpretability of Daily Routine
Coronary CTA with Heart Rate Control
Heon Lee (Presenter) ; In Wan Cho ; Sang Hyun Paik MD ; Eun Kyung Khil MD ; Soyeoun Lim MD ; Jai Soung Park PURPOSE To assess a novel vendor-specific motion-correction (MC) algorithm for its effect on improvement of image quality and interpretability in
patients undergoing daily routine coronary CT angiography (CTA) with heart rate control. METHOD AND MATERIALS Fifty consecutive patients undergoing coronary CTA with rate control were included. Using the best R-R interval for reconstruction,
coronary CTAs were interpreted with standard (STD) and MC algorithm by 2 experienced readers who assigned quality scores (graded
Page 49 of 397
coronary CTAs were interpreted with standard (STD) and MC algorithm by 2 experienced readers who assigned quality scores (graded
1-4) on per segment level of 3 major coronary arteries. Interpretability was defined as grade > 1. The segments (177/450) both rated as
4 on STD and MC algorithm were excluded from the comparison. Then, we compared image quality and interpretability between standard
and MC reconstruction. RESULTS Mean age was 56.7± 11 years; 31 were men. Mean heart rate was 64.3±8.71 (42-83 bpm) and mean heart rate variability was
6.26±13.1. MC reconstruction showed higher image quality on a per-segment level of right coronary artery (RCA, 2.94±0.57 vs 2.28±
0.54; P CONCLUSION The use of a novel MC algorithm improves image quality of RCA and LCx, and overall interpretability in patients undergoing daily routine
coronary CTA with rate control. CLINICAL RELEVANCE/APPLICATION The use of this new motion correction algorithm may be used to improve image quality and interpretability in patient undergoing coronary
CTA using single source CTwith insufficient temporal resolution LL-CAS-SU2B • Reverse Attenuation Gradient Sign at Coronary Artery Computed Tomographic Angiography (CCTA) for
Differentiating Coronary In-stent Total Occlusion from Subtotal Occlusion
Li Yang MD, PhD (Presenter) ; Shuping Tian MD, PhD PURPOSE To evaluate the clinical value of the reverse attenuation gradient (RAG) sign(defined as the reverse intraluminal opacification gradient of
vessels distal to the occlusive lesions, which has lower attenuation in the proximal segment and gradually increased attenuation along the
vessel.) for Differentiating inplanted stent total occlusion from subtotal occlusion observed with coronary computed tomographic (CT)
angiography. METHOD AND MATERIALS All patients gave written informed consent, and the study protocol was approved by the hospital ethics committee. Contrast
material-enhanced coronary CT angiography was performed in 956 patients (651 men, 305 women; mean age, 63years±9[standard
deviation] range, 34�88years) suspected of having stent restenosis. Scanning was retrospectively electrocardiographically gated, and an
automatic bolus-tracking method was used. For image reconstruction, an edge-enhancing kernel(B46f) was used. The RAG sign were
recorded. Coronary Conventional coronary angiographic findings were �Gold standard�. Two physicians analyzed coronary CT
angiographic data, and conventional coronary angiographic results were interpreted by one of several observers in consensus for stent
restenosis; they were blinded to coronary CT angiographic data. Mann-Whitney Wilcoxon and Fisher exact tests were used for comparison.
RESULTS At CCTA, 196 stents had in-stent restenosis. Conventional coronary angiography confirmed 91 total occlusions (TOs) and 105 subtotal
occlusions (SOs).The RAG sign appeared significantly more frequently in the TOs group than in the SOs group (71% [65 of 91] vs 8.5%
[9 of 105]; P CONCLUSION The RAG sign which represents the retrograde collateral flow distal to an occlusive lesion is highly specific for TOs and helps to
differentiate TOs from SOs CLINICAL RELEVANCE/APPLICATION The RAG sign is highly specific for TOs and helps to differentiate TOs from SOs. LL-CAS-SU3B • The Difference of Coronary Vasodilation Based on the Plaque Characteristics by the Use of Sublingual
Nitroglycerin on a 64-slice Coronary CT Angiography
Munemasa Okada MD, PhD (Presenter) ; Yoshiteru Nakashima MD ; Toshiro Miura ; Tomoko Nao ; Masayuki Yoshimura ; Yuichi Sano ; Naofumi Matsunaga MD, PhD PURPOSE The purpose of our study was to evaluate the coronary vasodilatation in each coronary segment by the use of sublingual nitroglycerin and
compare coronary vasodilation ratio (VR) with baseline coronary diameter base on the plaque characteristics using a 64-slice coronary
dual-source CT angiography (CTA). METHOD AND MATERIALS Sixty-nine patients ( mean: 66.3 years, 24 male and 45 female) having an atypical chest pain were prospectively included in this study
and underwent coronary CTA before and after the administration of sublingual nitroglycerin without heart rate control. The institutional
review board approved this protocol and written informed consent was obtained from all patients. Coronary diameters were measured in
each coronary segment from #1 to #15, including high lateral branch, and VRs were compared with baseline coronary diameter and
analyzed by the plaque characteristics classified into four groups; no plaques, non-calcified plaque, partial-calcified palque (soft plaque
with spotty calcification), calcified plaque (spotty calcified plaque within 1/4 of coronary circumference and circular calcified plaque over
1/4 of coronary circumference). RESULTS A total of 989 coronary segments were evaluated, and coronary plaques were mainly noted in large vessels near the coronary ostium. VR
without coronary plaque (14.9%) was significantly larger than those with various coronary plaques ranging from 1.7 to 8.0%. However,
there no significant difference in VR among the coronary arteries with various plaque characteristics on this study. In the coronary
arteries with its diameter more than 2.5mm, VR in the coronary arteries with circular calcification was significantly smaller than those
with other plaques. CONCLUSION The coronary plaque might decrease coronary vasodilatation regardless of plaque characteristics and coronary plaque itself might cause
the coronary vasodilatation dysfunction, even after the administration of nitroglycerine. Especially circular calcified plaques might
deteriorate the coronary vasodilatation. CLINICAL RELEVANCE/APPLICATION Coronary CTA could show the decreased coronary vasodiatation based on the coronary plaques, suggesting the endothelial dysfunction of
coronary artery after the administration of nitroglycerin. LL-CAS-SU4B • Second Generation Iterative Model Reconstruction Provides Diagnostic Quality Images with Substantial
Reduction in Radiation Exposure
Ethan J Halpern MD (Presenter) ; Eric L Gingold PhD ; Hugh White MD ; Katrina M Read MS * PURPOSE Iterative Model Reconstruction (IMR), as implemented in the second generation Philips software for multislice CT, is a knowledge-based
reconstruction with marked reduction in image noise. The purpose of this study was to evaluate the application of IMR to reduce radiation
dose in coronary CT angiography (cCTA). METHOD AND MATERIALS We evaluated 25 consecutive cCTA studies acquired on a 256-slice iCT scanner with tube current modulation (TCM). TCM lowers systolic
Page 50 of 397
phase tube current to 20% of that in diastole, resulting in photon-limited systolic images. Systolic phase images from each study were
reconstructed at 40% of the R-R interval with filtered back projection (FBP), first generation iterative reconstruction (iDose) and second
generation IMR (Philips Medical Systems; Cleveland, OH). Each case was evaluated by two independent reviewers. The mean and
standard deviation (sd) of pixel values were computed in a standardized region of interest in the left ventricle and left main coronary
artery. Subjective rating scores were obtained from each reviewer (1-5 scale for poor-excellent) for definition of: 1) contours of small
coronary arteries (
RESULTS There was no significant difference in mean pixel intensity among FBP, iDose and IMR (p>0.8). However, image noise within a
contrast-enhanced region of interest in the left ventricle was reduced by a factor of 2.4 from FBP to iDose (sd=348 vs 144,p 2.7 > 1.6 (p
2.8 > 1.6 (p 2.6 > 1.6 (p 3.0 > 1.7 (p CONCLUSION Second generation IMR reduces intravascular noise on cCTA by 88% compared with FBP, providing significantly improved image quality
at radiation exposure levels 80% lower than those currently used with FBP and iDose. CLINICAL RELEVANCE/APPLICATION Second generation IMR reconstruction may allow diagnostic quality cCTA imaging with a substantial reduction in patient radiation
exposure. LL-CAS-SU5B • Coronary Fistula-Experience of Cardiac CT and MR in a Western Population
Elham Najafpour MD (Presenter) ; Cylen Javidan-Nejad MD ; Annalori Panunzio ; Eric T Kimura-Hayama MD ; Saman
Panahipour MD ; Sanjeev Bhalla MD PURPOSE We aim to characterize coronary artery fistulas (CAFs) by CT and MR angiography using the past 5-year experience of our tertiary referral
center by assessing both imaging findings and patient factors. METHOD AND MATERIALS Medical charts of 5947 consecutive patients who underwent ECG-gated coronary CT angiography(CTA) or coronary MR angiography(MRA)
from 2007 to 2012 were retrospectively reviewed. The studies were reviewed by 2 cardiac radiologists. The CAF were assessed for the
following: origin, site of termination, single or multiple nature of fistulae, tortuosity, calcification, maximal cross-sectional diameter,
dilation of the remaining coronary arteries and systemic arterial feeders. The following information were collected from the charts: age
and symptom at presentation, coexisting congenital heart disease (CHD), results of stress echocardiography, scintigraphy, and catheter
angiography(CA) were documented. RESULTS A total of 12 patients(9 female:3 male) were identified with an overall incidence 0.2%. The average age of presentation was 44 years old.
10 had CTA and 2 had coronary MRA. 9/12 (75%) presented with chest pain and dyspnea and 2/12 (17%) with cardiac murmur. 9 had a
single CAF and 3 had multiple, totaling 16 CAFs. The frequencies of origins are: 10/16(63%) left anterior descending artery(LAD),
3/16(19%) left circumflex(LCX), 2/16(13%) right coronary artery(RCA) and 1/16(6%) left main coronary artery. None had an anomalous
origin. The frequencies of insertion sites are: 6/16 (38%) to main pulmonary artery(PA), 5/16 (31%) to right ventricle(RV), 4/16 (25%)
to right atrium or superior vena cava, and 1/16 (6%) to coronary sinus. 16/16 (100%) showed tortuosity and 4/1 6(25%) calcification,
present in all CAFs measuring > 6mm in maximal diameter but absent in those < or = 6mm. Mean diameter was 8 mm (range 3-21). 2
patients had CHD, both single CAF originating from LAD and terminating in RV. 10 patients had CA confirming the CAF. 3/7 of the patients
with a documented stress test had positive findings for ischemia, 2 of which had multiple CAF and 1 had a large LAD to RV fistula. CONCLUSION The most common origin of a CAF was LAD and the most common insertion site the PA. Aneurysmal dilation and tortuosity were present
in all CAF, with calcification seen only in CAFs having a diameter above 6 mm. CLINICAL RELEVANCE/APPLICATION This is the first reported study from the US or other Western populations characterizing the CT and MR of a small series of CAF patients.
The results differ from that in Asia. LL-CAE-SU6B • Skipping a Beat: Common Appearances of Malpositioned Conducting Device Leads and Associated Complications
Aditi Dhakar MD (Presenter) PURPOSE/AIM The purpose of this exhibit is to: 1) Introduce the basic components of pacemakers and AICD devices. 2) Demonstrate the optimal
positioning of cardiac leads and discuss the limitations of current imaging. 2) Elaborate on the early and late complications from
malpositioned leads. CONTENT ORGANIZATION Pictures and radiographs with explanatory text will be presented in the following order. - The key components of various pacemakers and
AICD devices. - The normal course and ideal imaging appearance of different cardiac leads. - The optimal imaging methods and
limitations for evaluation. - Acute complications seen within minutes to days after lead placement. These include pneumothorax,
hemothorax, dislodgement, perforation, and phrenic nerve stimulation. - Late complications seen with cardiac pacing devices including
Twiddler's Syndrome and fractured leads. SUMMARY This presentation will have conveyed: 1) The optimal placement and accepted positional variations of cardiac conducting device leads. 2)
The role of immediate post-operative and subsequent imaging. 3) The complications associated with cardiac leads in order of severity,
chronicity, and the degree of follow-up required. LL-CAE-SU7B • Imaging the Tricuspid Valve: Spectrum of Congenital and Acquired Conditions
Daniel Ocazionez MD (Presenter) ; Demetrius L Dicks MD ; Gregory Kicska MD, PhD * ; Randolph K Otto MD ; Mark R
Ferguson MD ; Rachael M Edwards MD ; Gautham P Reddy MD PURPOSE/AIM 1. To illustrate anatomy and embryology.
2. To describe the spectrum of congenital and acquired conditions.
3. To exemplify the role of different imaging modalities including echocardiography, CT and MR in the evaluation of the tricuspid valve.
CONTENT ORGANIZATION 1. Introduction 2. Anatomy and embryology 3. Use of imaging techniques (echocardiography, CT and MRI). 4. Congenital anomalies:
a) Stenosis/atresia
b) Ebstein anomaly
c) Valve dysplasia
d) Double-orifice tricuspid valve (DOTV) 5. Acquired conditions:
a) Functional regurgitation from RV failure and pulmonary hypertension
b) Myxomatous degeneration
c) Infectious endocarditis
d) Rheumatic heart disease
e) Carcinoid syndrome
f) Iatrogenic and traumatic injuries
Page 51 of 397
g) Marfan syndrome
h) Systemic lupus erythematosus
6. Indications for valvular replacement.
SUMMARY Upon reviewing this exhibit, the radiologist will become familiar with the spectrum of congenital and acquired conditions involving the
tricuspid valve. Ecocardiography, CT and MRI are useful tools in the evaluation and characterization of these disease entities and provide
significantly important anatomical and functional information not only in the initial workup, but also in future management decisions. LL-CAE-SU8B • Multidetector Computed Tomography (MDCT) Imaging of Coronary Artery Fistulas: Pictorial Review
Sachin S Saboo FRCR, MD (Presenter) ; Yu-Hsiang Juan MD ; Mike Landzberg ; Ashish R Khandelwal MD ; Anne Marie
Valente ; Frank J Rybicki MD, PhD * ; Michael L Steigner MD * ; Kulbir Ahlawat MD ; Saurabh Gupta MD ; Rani D
Bhivasankar MBBS ; Elizabeth George MBBS PURPOSE/AIM Review clinical presentations and coronary artery anatomy on MDCT applicable to patients with coronary artery fistulas (CAF)
Review the MDCT appearance of various CAF
Discuss clinical implications of MDCT based information in the management of patients with CAF
CONTENT ORGANIZATION a) Etiology, pathophysiology, and clinical presentation of CAF
b) MDCT technique and 3D post-processing of CAF with examples:
1) Coronary artery to cardiac chambers
2) Coronary artery to pulmonary artery
3) Coronary artery to cardiac and pulmonary veins
4) Coronary artery to bronchial artery fistula
c) Characteristic MDCT findings of CAF with regards to origin, course, diameter, aneurysm,
termination and multiplicity along with associated congenital and acquired coronary
artery disease
d) Post treatment MDCT findings
e) Clinical implications and the treatment options
f) Conclusion
SUMMARY Coronary artery fistulas are one type of coronary artery anomalies with abnormal termination. Complex findings are occasionally
encountered on MDCT images. These images are highly efficient to characterize CAF to plan intervention and in follow-up. This
educational exhibit will familiarize radiologists and clinicians with MDCT features of various CAF along with its clinical implications to
facilitate accurate diagnosis and management. Chest - Sunday Posters and Exhibits (1:00pm - 1:30pm) Sunday, 01:00 PM - 01:30 PM • Lakeside Learning Center
Back to Top CH
LL-CHS-SUB • AMA PRA Category 1 Credit ™:0.5 LL-CHS-SU1B • Accuracy of Diffusion-weighted (DW) Magnetic Resonance (MR) Imaging with Background Signal Suppression
(MR-DWIBS) in Diagnosis of Mediastinal Lymph Node Metastasis of Non-small Cell Lung Cancer (NSCLC)
Liang Xu (Presenter) ; Yuhui Liu ; Yong Huang PURPOSE To prospectively evaluate the accuracy of diffusion-weighted (DW) magnetic resonance (MR) imaging with background signal suppression
(MR-DWIBS) for detecting mediastinal lymph node metastasis of non-small cell lung cancer (NSCLC). METHOD AND MATERIALS MR-DWIBS was performed in 42 consecutive patients (27 men, 15 women; age range, 42� 78 years; median age, 55 years) with
pathologically proven NSCLC. The visualization rate of metastatic lymph node (MLN) and benign lymph node (BLN) of all size and normal
size (less than 1cm in diameter) was compared by using Fisher's exact test on a per-nodal basis. By manually drawing regions-of-interest
(ROIs), signal intensity (SI) and apparent diffusion coefficient (ADC) of MLN and BLN was measured and compared by using two-tailed
unpaired student t-test. Receiver operating characteristic (ROC) analysis was used to assess the overall diagnostic accuracy of SI and
ADC. The optimal cut-off value was determined and the sensitivity, specificity, positive predictive value (PPV), negative predictive value
(NPV) and accuracy was calculated. RESULTS CONCLUSION MR-DWIBS with SI and ADC measurement appears to be clinically helpful to determine mediastinal lymph node metastasis of NSCLC
without reference to nodal size. CLINICAL RELEVANCE/APPLICATION MR-DWIBS might be a practical technique of clinical significance in determination of mediastinal lymphnode metastasis of NSCLC. LL-CHS-SU2B • Thymic Epithelial Tumors: Prognostic Determinants among Clinical, Histopathologic, and Imaging Findings
Jung Won Moon (Presenter) ; Kyung S Lee MD, PhD ; Yo Won Choi MD ; Dong-Wook Sung MD ; Myung-Hee Shin ; Joungho
Han ; Geewon Lee MD PURPOSE To evaluate the value of imaging modality in predicting patient prognosis in thymic epithelial tumors stratified with WHO classification and
Masaoka-Koga staging schemes. METHOD AND MATERIALS From 1994 to 2011, 544 patients (M:F = 301:243; mean age, 51.4 years) were diagnosed to have a thymic epithelial tumor (A, AB, B1,
B2, B3 and C series) with core biopsy or surgical resection. All patients underwent contrast-enhanced CT at the presentation. Two
observers reviewed CT findings retrospectively in terms of tumor shape, margin, the presence of necrosis or calcification, internal
characteristics (homogeneous vs. heterogeneous, degree of enhancement [Hounsfield Unit on pre-, and post-contrast enhancement
images for net enhancement], invasion of surrounding structures, and the presence of pleural or pericardial seeding and nodal or
extra-thoracic metastasis. Final decisions on the findings were reached by consensus. Pathologic results were subcategorized by using
WHO classification and disease extents by the use of Masaoka-Koga staging system. The presence of myasthenia gravis (MG) was
evaluated, and overall survivals were assessed. And then, CT findings, histologic classification and prognosis were correlated from each
other. RESULTS Page 52 of 397
RESULTS Analysis using Cox-proportional hazards model was performed. Of CT findings, tumor size, shape (hazard ratio [HR] = 1.352), margin (HR
= 1.364), the presence of calcification (HR = 1.585), net enhancement, findings of seeding and metastasis (HR = 1.374) were
significantly correlated with overall survival (P < .05), while heterogeneity of tumor, the presence of necrosis or invasion of surrounding
structures were not. Masaoka-Koga staging system appeared as an independent prognostic factor (HR = 1.018 - 1.392, P < 0.001) for
survival. Higher B series tumors of WHO classification (HR = 1.090 - 1.322, P < 0.05) were also survival determinant. The presence of MG
was also a bad prognostic factor for survival (P = .021, HR = 2.467). CONCLUSION This study provided a rough information for the possibility of CT findings as predictor of overall survival, and also revealed stratification of
clinico-pathologic correlation. CLINICAL RELEVANCE/APPLICATION Because CT findings, WHO classification and Masaoka-Koga staging schemes are prognostic determinants, the integration of all
information is mandatory for patient prognosis prediction. LL-CHS-SU3B • Accuracy of CT-guided Percutaneous Transthoracic Needle Biopsy for Diagnosis of Anterior Mediastinal Lesions
Milena Petranovic MD (Presenter) ; Carol C Wu MD * ; Subba R Digumarthy MD ; Victorine V Muse MD ; Amita Sharma MBBS
; Jo-Anne O Shepard MD * ; Ashok Muniappan MD ; Robert P Hasserjian MD ; Matthew D Gilman MD PURPOSE To determine the clinical role and accuracy of CT-guided percutaneous needle biopsy in diagnosis of anterior mediastinal lesions. METHOD AND MATERIALS A review of CT-guided needle biopsies of anterior mediastinal lesions performed at our institution between January 2003 and December
2012 was conducted. All biopsies were performed by dedicated thoracic interventionalists. Data were collected on characteristics of the
lesions, patient demographics, tumor markers, complications, and subsequent surgical intervention and/or other treatment. Both cytology
and core biopsy results were reviewed. Surgical pathology results were recorded if available. RESULTS The study cohort consisted of 52 patients (M:F 32:20, mean age 49y) with mean diameter of mediastinal mass = 9.1 ± 3.7cm. 34/52
(65%) patients also had subsequent surgical biopsy or resection. CT-guided biopsy was accurate in 40/52 (77%) patients: 11/11 (100%)
thymic neoplasms, 13/22 (59%) lymphomas, 2/3 (67%) germ cell tumors, 4/5 (80%) metastatic lesions, 6/7 (86%) primary lung
neoplasms, 2/2 (100%) sarcomas, 1/1 (100%) mesothelioma and 1/1 (100%) thyroid goiter. Non diagnostic results were seen in 12/52
(23%) patients, consisting of lymphoma (9), germ cell tumor (1), primary lung neoplasm (1) and metastasis (1). FNA alone made the
correct diagnosis in 31/52 (60%) patients, and provided a discordant diagnosis with final pathology in 4/52 (7.7%). Core biopsy had a
36/47 (77%) diagnostic rate and none of the core biopsies were discordant with final pathology. Of the 5 patients who did not have core
biopsy performed, 3/5 (60%) had a non-diagnostic FNA. Flow cytometry was performed in 33/52 (63%) patients. There was no
statistically significant difference between the diagnostic and the non-diagnostic groups in patients� age, lesion size, and presence of
necrosis or cystic region in the lesion. Complication rate was 2/52 (3.8%), compromised of small self resolving pneumothoraces. CONCLUSION CT-guided needle biopsy of anterior mediastinal lesions is a safe and well-tolerated diagnostic procedure. The sensitivity of needle biopsy
is better for thymic neoplasms than for lymphoma and germ cell tumors. Core biopsy improves the diagnostic accuracy compared to FNA
alone. CLINICAL RELEVANCE/APPLICATION Our study highlights differences in diagnostic accuracy of CT-guided percutaneous needle biopsy depending on the pathology. It also
raises the importance of providing core biopsy samples for analysis. LL-CHS-SU4B • Dual-energy CT for Differentiating Acute and Chronic Pulmonary Thromboembolism: An Initial Experience
Seung-Seob Kim MD (Presenter) ; Jin Hur MD ; Young Jin Kim MD ; Hye-Jeong Lee MD ; Yoo Jin Hong MD ; Byoung Wook
Choi MD PURPOSE The purpose of this study was to evaluate the diagnostic capability of dual-energy CT in differentiating acute and chronic pulmonary
thromboembolism (APTE and CPTE). METHOD AND MATERIALS We prospectively enrolled 22 patients (8 males, 14 females; mean age: 67.3 years old) with a filling defect larger than 5mm in diameter
in the pulmonary artery (PA). All patients underwent dual-energy CT using gemstone spectral imaging (GSI) mode (GE HD750). For
quantitative analysis, two investigators measured the following parameters for emboli: CT attenuation density (HU values), iodine
concentration (mg/ml), and iodine-related HU values (IHU). Statistical analysis included calculation of means and standard deviations, the
t-test and ROC analysis. RESULTS Among 22 patients, 14 were categorized with APTE and 8 with CPTE. The mean HU values of emboli were significantly different between
the APTE and CPTE groups (24.5 ± 16.4 vs 60.3 ± 19.8 HU; p = 0.008). The mean iodine concentration and IHU values were significantly
different between the two groups (0.61 ± 0.26 vs 1.79 ± 0.42; p = 0.0001 and 6.4 ± 3.1 vs 29.0 ± 8.7 HU; p = 0.0001). The area under
the ROC curve (AUC) for differentiating APTE and CPTE using HU, iodine concentration, and IHU values were 0.911 (95% CI: 0.710,
0.976), 0.997 (95% CI: 0.844, 1.000), and 0.997 (95% CI: 0.844, 1.000), respectively. CONCLUSION Dual-energy CT using a quantitative analytic methodology can be used to differentiate between APTE and CPTE. CLINICAL RELEVANCE/APPLICATION Radiologists can help patients to avoid unnecessary treatment by differentiating APTE and CPTE on initial CT scan, since the therapeutic
management between APTE and CPTE is completely distinct. LL-CHE3110-SUB • Recent Advances in Computed Tomography of the Aorta and Their Application in Aortic Pathologies in Every
Day Clinical Practice
Fabian Rengier MD (Presenter) ; Matthias Muller-Eschner MD ; Paul Schoenhagen MD ; Hendrik Von Tengg-Kobligk MD * ; Rolf Vosshenrich MD ; Hans-Ulrich Kauczor MD * ; Sasan Partovi BS * PURPOSE/AIM 1. Illustrate current state-of-the-art computed tomography (CT) of the aorta including recent advances and technological developments.
2. Discuss their application in aortic pathologies in every day clinical practice. CONTENT ORGANIZATION 1. State-of-the-art CT of the aorta: A. Non-ECG-gated CT angiography. B. ECG-gated CT angiography. C. Dual-energy CT of the aorta
including virtual non-contrast. D. Three-dimensional image processing for advanced preoperative planning of endovascular repair. 2.
Application to aortic pathologies: A. Aortic dissections Stanford Type A and B. B. Intramural hematoma. C. Penetrating atherosclerotic
ulcers. D. Thoracic aortic aneurysms. E. Abdominal aortic aneurysms. 3. Conclusions. Page 53 of 397
SUMMARY This exhibit gives recommendations for CT imaging protocols in every day clinical practice. It is also shown how recent technological
developments such as dual-energy CT and three-dimensional image processing can be effectively integrated into the clinical workflow.
The reviewer of this exhibit will learn the value and application of different imaging protocols, contrast media phases and image
processing techniques with regards to the most common aortic pathologies. Emergency Radiology - Sunday Posters and Exhibits (1:00pm - 1:30pm) Sunday, 01:00 PM - 01:30 PM • Lakeside Learning Center
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LL-ERS-SUB • AMA PRA Category 1 Credit ™:0.5 LL-ERS-SU1B • Lower Extremity Arterial Imaging Using a Reduced Tube Voltage and Automatic Tube Current Modulation
Technique with 64-slice Computed Tomography
Ying Guo MD (Presenter) ; Dapeng Shi MD ; Ying Hui Ge MD, PhD PURPOSE The purpose of this study was to determine whether comparable results to the standard 120kVp protocol could be obtained with reduced
radiation dose for lower extremity arterial imaging by 64-slice CT at a tube voltage of 80 kVp. METHOD AND MATERIALS Eighty-two consecutive outpatients with lower extremity occlusive disease were randomly divided into three groups. They were scanned
with a 64-slices CT scanner by using different scanning techniques. The first group (group1, n=26) used standard 120kVp and fixed tube
current of 180mAs (group1), and the second (group2, n=26) and third groups (group3, n=30) used 120kVp and 80kVp with automatic
tube current modulation, respectively. We selected the observing levels at pelvic, knee, calf and foot levels for noise measurement and
image quality assessment with a 3-point scale. Paired analyses were performed on radiation dose, image quality, and image noise using
t-test. RESULTS CONCLUSION Using automatic tube current modulation for lower extremity arterial scanning can reduce radiation dose. Radiation dose can further be
reduced with equivalent image quality by using 80 kVp. CLINICAL RELEVANCE/APPLICATION Radiation dose can be minimized for lower extremity arterial scanning with optimized scan protocol which includes the use of 80kVp and
automatic exposure control. LL-ERS-SU2B • Whole-body CT in Polytrauma Patients Using Automatic Tube Current Modulation: Impact of a Vacuum Mattress
and Spine Board on the Image Quality and the Radiation Dose
Andre Euler MD (Presenter) ; Marc Luthy ; Sebastian T Schindera MD * PURPOSE To assess the impact of a vacuum mattress and spine board on image quality and radiation dose in whole-body polytrauma CT using
automatic tube current modulation. METHOD AND MATERIALS An anthropomorphic whole-body phantom (head, neck, thorax and abdomen) was scanned with a 128-slice MDCT scanner (Somatom
Definition Flash, Siemens) with our standard whole-body polytrauma protocol using automatic tube current modulation (120 kVp, 200
reference mAs). Four different setups for the CT scans were applied: the phantom without immobilisation device (setup A), the phantom
placed on vacuum mattress 1 (setup B), the phantom placed on vacuum mattress 2 (setup C), and the phantom placed on a spine board
(setup D). The major difference between vacuum mattress 1 and 2 was the location of the inflation valve. The image noise was measured
and the contrast-to-noise ratio (CNR) was calculated. The location and the degree of artifacts (no, minor, average, severe) was assessed
by two radiologists in consensus. The radiation dose was assessed with the volume CT dose index (CTDIvol). Statistical analysis included
t-test. RESULTS The image noise measured 18.9, 20.9, 20.4 and 20.5 HU in setup A, B, C, and D, respectively (P < 0.05). The CNR was 2.8, 2.5, 2.5 and
2.7 in setup A, B, C, and D, respectively (P < 0.05). The measured CTDIvol was 7.9, 8.1, 8.3 and 8.5 mGy in setup A, B, C, and D,
respectively. Artifacts, which were provoked by the inflation valve, were only detected in the scans with the vacuum mattress. Vacuum
mattress of setup B produced severe artifacts at the head, while the vacuum mattress of setup C only had minor artifacts at the shoulder
girdle. CONCLUSION Applying immobilisation devices for whole-body CT with automatic tube current modulation results only in a minimal increase of the
radiation dose. Image quality is only degraded in the proximity of the inflation valve of the vacuum mattress. CLINICAL RELEVANCE/APPLICATION From a radiation-dose point of view, immobilisation devices are safe for whole-body CT scans. If possible, the inflation valve of a vacuum
mattress has to be placed away from the head and neck region. LL-ERS-SU3B • Enhanced Pneumothorax Visualization in ICU Patients
Hassan Shoushtari MD (Presenter) ; Julia Ley-Zaporozhan MD ; Yasser Karimzad BSc ; Ravi Menezes PhD ; Devang Odedra
BS ; Laura Jimenez-Juan MD ; Leon Zelovitsky ; Narinder S Paul MD * PURPOSE To determine whether edge enhancement post processing software improves pneumothorax (PTx) detection in portable chest radiographs
(CXR) performed on ICU patients METHOD AND MATERIALS 206 ICU portable CXR were selected by 2 radiologists such that 103 had a PTx. Each CXR had a complexity score based on image quality,
patient size, body rotation and presence of tubes and lines. Each metric was scored 0-3, so each CXR scored 0-12. Each CXR was
available as a conventional (C-CXR) and an enhanced (E-CXR) image created using commercially available edge enhancement software. 5
readers (R1-5) with variable experience in CXR interpretation were selected (R1> 40yrs, R5 RESULTS There was no significant intra-observer difference in PTx detection for C-CXR at the patient or lung level. Reader preference:3/5
readers strongly preferred E-CXR (95%, 87%, 100%), the 2 other readers either slightly preferred the E-CXR or liked both. Reader
preference was not correlated with reader experience. Diagnostic performance (patient level): Overall, all readers performed well for
PTx detection with accuracy of 78-90% for C-CXR and 82-90% for E-CXR. The only significant difference was for R5 (least experience)
with 84% accuracy in PTx detection with E-CXR compared to 78% with C-CXR (pDiagnostic performance (lung level): Overall, all readers
performed well, the AUC ranged from 0.819 (C-CXR, least experienced reader) to 0.973 (E-CXR, middle experienced reader). The largest
Page 54 of 397
performed well, the AUC ranged from 0.819 (C-CXR, least experienced reader) to 0.973 (E-CXR, middle experienced reader). The largest
improvement was for R5 with AUC 0.819 (95% CI 0.766, 0.873) in C-CRX to 0.880 (95% CI 0.835, 0.924) with E-CXR. R5 had the
largest increase in reader confidence in identifying small PTX with E-CXR (p CONCLUSION Edge enhancement software improves reader performance and confidence in identifying PTx in ICU patients. The largest benefit is for
inexperienced readers. CLINICAL RELEVANCE/APPLICATION PTx detection in ICU patients is important. Often the most inexperienced person is first to read the CXR and edge enhancement software
improves their confidence and accuracy in detecting PTx. LL-ERS-SU4B • Clinical Utility of Fully Integrated Chip CT Detector in Suspected Pulmonary Embolism Imaging
Teresa Liang MD, BSc (Presenter) ; Patrick McLaughlin FFRRCSI ; Graeme J McNeill MRCP, FFRRCSI ; Darra T Murphy FFRRCSI
; Luck J Louis MD ; Tim O'Connell MD, MEng * ; Hugue A Ouellette MD ; John R Mayo MD * ; Savvas Nicolaou MD PURPOSE Recently 3rd generation CT detectors that employ integrated (IC) rather than discrete (DC) electronic circuits have been introduced into
clinical practice. Initial phantom studies demonstrated reduced electronic noise and increased spatial resolution, however, the benefits of
the IC detectors for diagnosis of pulmonary embolism have yet to be evaluated. We compare both quantitative and qualitative image
quality, between the traditional DC detector and a novel IC detector in diagnosis of pulmonary embolism in the acute setting. METHOD AND MATERIALS 45 consecutive patients underwent CT Pulmonary Angiograms (CTPA) with the DC detector at 100 kV with iterative reconstruction using a
128 slice Dual Source CT scanner. 45 different patients who had been previously scanned using the same CT system with DC detectors
were included in this retrospective study. A single blinded reader used graded spatial resolution (sharpness of delineation of edge of
vessel/organ from the background) at the main pulmonary trunk, segmental and subsegmental pulmonary vessels and the spleen.
Streak artifact from contrast in the superior vena cava was also graded as was overall diagnostic quality. Mean HU and standard deviation
of 1cm2 regions of interest of the pulmonary arteries, muscle and air were used to calculate signal to noise (SNR) and contrast to noise
ratios (CNR). RESULTS There was no difference in age, sex, number of pulmonary emboli, and lateral and AP body diameter size between the IC and DC groups.
The mean size specific dose estimates were 3.82 mGy and 3.40 mGy for the DC and IC groups respectively (p=0.26). There was no
significant difference in SNR (45.0 vs 39.59, p=0.27) or CNR (20.68 vs 20.18, p=0.78) in the DC and IC groups respectively. Subjective
analysis showed that spatial resolution at all levels was significantly higher (5 vs 4, 5 vs 3, 5 vs 3, p CONCLUSION In this study utilization of a fully integrated chip CT detector resulted in improved spatial resolution and reduced streak artifact which
improved diagnostic confidence in detecting pulmonary emboli on CT Pulmonary Angiography. CLINICAL RELEVANCE/APPLICATION The 3rd generation IC CT detector allows significant streak artifact reduction and improved spatial resolution, allowing better diagnostic
confidence in assessment of acute pulmonary embolism. LL-ERE-SU5B • Acute Abdominal Pain Following Colonoscopy: What Could It Be?
Katherine M Troy MD ; Robin B Levenson MD (Presenter) PURPOSE/AIM To discuss colonoscopy complications that may be seen on CT in patients presenting to the emergency department (ED) with acute
abdominopelvic (AP) pain status post recent colonoscopy. To review various imaging findings that can be seen on ED AP CT in patient's
status post recent colonoscopy and demonstrate case examples. To provide radiologist awareness and understanding of these potential
findings to help optimize diagnosis. CONTENT ORGANIZATION 1. Introduction/Background 2. Colonoscopy. 3. Describe potential findings seen on Emergency Department abdominopelvic CT in patients
presenting with acute abdominopelvic pain status post recent colonoscopy. Review imaging features and demonstrate imaging examples,
including a. Appendicitis b. Diverticulitis c. Splenic injury and hemoperitoneum d. Bowel perforation d. Bowel wall hematoma. 5.
Management and Conclusions SUMMARY Patients may present to the emergency department with acute abdominal pain following recent colonoscopy. It is imperative that the
emergency radiologist is aware of the various potential post-colonoscopy imaging findings and related complications that can be seen on
CT to optimize diagnosis. Gastrointestinal - Sunday Posters and Exhibits (1:00pm - 1:30pm) Sunday, 01:00 PM - 01:30 PM • Lakeside Learning Center
Back to Top GI
LL-GIS-SUB • AMA PRA Category 1 Credit ™:0.5 LL-GIE-SU10B • The Pharyngoesophagram: A Traditional GI Imaging Examination Which Has Survived into the 21st Century!
Neeraj Lalwani MD (Presenter) ; Puneet Bhargava MD ; Alampady K Shanbhogue MD ; Mariam Moshiri MD ; Carlos Cuevas
MD * PURPOSE/AIM Despite the ever increasing popularity of new age cross sectional imaging in GI radiology, the pharyngoesophagram has survived and has
been refined as one of the most common and useful imaging tools to evaluate pharyngoesophageal anatomy and function. The aims of
our exhibit are to describe the role of the pharyngoesophagram in the 21st century and to review the concepts of performing a tailored
and informative examination. CONTENT ORGANIZATION � Introduction
� Indications in the modern clinical scenario
� Practical approach to perform a complete pharyngoesophagram
� Ideal vs. tailored examinations
� VFSS: Evaluation of aspiration and role of speech pathologist
� Dysphagia: Diagnostic pitfalls and review of anatomy
� GERD
� Dysmotility (Syndromes)
� Achalasia: Modification of Technique, Differentiating from secondary achalasia
� Post-operative evaluation
� Future of fluoroscopic procedures
Page 55 of 397
� Future of fluoroscopic procedures
� Conclusion
SUMMARY The radiologist can make crucial contributions in the evaluation of dysphagia, esophageal motility, and a wide variety of pathologies
including functional or structural abnormalities of the oral cavity, pharynx, esophagus, and gastric cardia exist which may cause
dysphagia. The conventional pharyngoesophagram remains the gold standard investigation for precise assessment of these pathologies.
LL-GIE-SU11B • Appendiceal Cancer: An Update on Pathology, Imaging, and Therapy
Tara L Sagebiel MD (Presenter) ; Priya R Bhosale MD ; Keith F Fournier MD ; Melissa W Taggart MD ; Aurelio Matamoros MD PURPOSE/AIM � Review the epidemiology and clinical presentations of appendiceal cancers � Explain how appendiceal cancer pathologic subtypes are
related to differences in tumor spread, prognosis and treatment � Review the indications for cytoreductive surgery (CRS) and heated
intraperitoneal chemotherapy (HIPEC) and the associated radiologic evaluation � Discuss common complications after CRS and HIPEC CONTENT ORGANIZATION � Epidemiology � Clinical presentation 1. Appendicitis
2. Adnexal mass
3. Incidentaloma
� Pathology 1. Carcinoid
2. Adenocarcinoid
3. Adenocarcinoma
Mucinous
Non-mucinous
� Tumor Staging and Prognosis � Selection Criteria for CRS and HIPEC � Common Complications following CRS and HIPEC SUMMARY Appendiceal cancer is rare with a variable clinical course that is secondary to differences in the pathologic subtypes. This exhibit reviews
the differences in tumor spread, clinical presentation, treatment and prognosis based on appendiceal tumor pathology. Imaging�s role in
preoperative staging and its limitations will be discussed, along with the imaging findings of common complications seen after therapy. LL-GIE-SU12B • Oh Baby! MR Imaging of Suspected Acute Appendicitis in Pregnancy
Kelly A MacLean MD (Presenter) ; Roshni Patel MBBS, MRCS ; Silvia D Chang MD ; Alison C Harris MBChB PURPOSE/AIM This educational exhibit will review the technique, imaging findings, and common mimickers encountered when performing MRI in the
workup of suspected acute appendicitis in pregnancy. CONTENT ORGANIZATION With respect to the use of MRI in the workup of suspected acute appendicitis in pregnancy, we will: 1) Provide a brief overview of safety
considerations and clinical indications. 2) Review the MR imaging protocols performed at our institution. 3) Review the normal MR
imaging appearance of the appendix. 4) Review the MR imaging findings of acute appendicitis, including increased appendiceal diameter,
thickened appendiceal wall, periappendiceal inflammatory changes, and periappendiceal phlegmon/abscess formation. 5) Present the MR
findings of common mimickers of acute appendicitis, including ovarian torsion, fibroid degeneration, and dermoid cysts. SUMMARY The evaluation of acute abdominal and pelvic pain in pregnant patients often poses a diagnostic challenge. Although ultrasound is
considered first-line in the evaluation of such patients, MR is a valuable second-line tool in the investigation of pregnant patients with
sonographically indeterminate findings. LL-GIS-SU1B • Indeterminate Cystic-like Lesions at Liver Ultrasound: Additional Value of Microbubbles Injection
Orlando Catalano ; Antonio Nunziata MD (Presenter) ; Sergio Venanzio Setola MD ; Fabio Sandomenico MD ; Antonella
Petrillo MD PURPOSE �Dirty� cystic focal liver lesions (FLLs) at US scanning represent a challenge, since true cysts may mimic a solid FLL as well as a solid
FLL may be confused as a cyst. Our single-cancer center prospective study analyzes the additional value of microbubble contrast medium
injection in cancer patients with �dirty� cysts at baseline US. METHOD AND MATERIALS January 2006 to December 2012 we identified 48 patients with 50 �dirty� liver cysts (slightly hypoechoic content in 24 lesions, lack of
posterior enhancement in 10 lesions, both findings in 16 lesions) at US scanning. These 48 subjects were imaged for cancer staging or
follow-up and had no previous liver study for comparison. They underwent real-time contrast-enhanced ultrasound (CEUS) after the
injection of a sulphur hexafluoride-based contrast medium. Diagnosis was confirmed by further imaging in 30 lesions, follow-up in 18, and
biopsy in 2. RESULTS US was indeterminate by definition in all 50 FLLs (9-39 mm, mean 20). The liver echotexture was fatty in 37 patients and normal in the
remaining 11 patients. The inhomogeneous content at US was more predictive of a solid nature than did the lack of a dorsal
enhancement. CEUS correctly diagnosed all 24 true cysts (100%) in 24 patients and 25/26 solid lesions (96%) in the remaining 24
patients. Among these 25 solid FLLs there were 18 metastases and 7 hemangiomas, all receiving a definitive, confirmed diagnosis by
CEUS. One deeply located metastasis was incorrectly diagnosed as cyst by CEUS. CONCLUSION CEUS allows achieving a definitive diagnosis in patients with a nonspecific US finding of �dirty� liver cyst, allowing at the same time to
rule out a solid FLL and to characterize the truly solid lesions. CLINICAL RELEVANCE/APPLICATION CEUS allows obtaining a correct diagnosis in patients with nonspecific findings of �dirty� cysts at US.This is of value in countries where
US is regarded as the first choice modality for liver survey. LL-GIS-SU2B • Cholangiographic Patterns of Ischemic Cholangiopathy Correlated with Clinical Outcomes in Donation after
Cardiac Death Liver Transplants
Kirk Giesbrandt MD (Presenter) ; Ilynn Bulatao ; Ricardo Paz-Fumagalli MD ; Burcin Taner MD PURPOSE Page 56 of 397
Our purpose was to define the cholangiographic patterns of ischemic cholangiopathy (IC) and clinically silent non-anastomotic biliary
strictures in donation after cardiac death (DCD) liver grafts in a large single institution series. We also examined the correlation of the
radiologic findings with laboratory data and clinical outcomes. METHOD AND MATERIALS Data were collected for all DCD liver transplants at our institution from December 1998 to October 2010. Post-transplant cholangiograms
were performed on days 3 and 21, and also when clinically indicated. Intrahepatic biliary strictures were classified by anatomic
distribution and chronologic development. Radiologic findings were correlated with laboratory data and with 1, 3, and 5 year grafts and
with patient survival. RESULTS There were a total of 216 patients with DCD grafts. Of these, 171 patients had cholangiograms. Post-operative cholangiographic findings
were correlated with clinical data and divided into three groups: (A) normal cholangiograms with normal laboratory values, (B) abnormal
cholangiographic appearance and laboratory values (cholangiopathy), and (C) radiologic abnormalities without laboratory abnormalities.
Group B had four distinct abnormal cholangiographic patterns: hilar confluence nonanastomotic stenoses, multifocal progressive stenoses,
centrifugal progressive stenoses, and rapid progression to peripheral duct necrosis. The varying patterns were predictive of graft survival.
Group C had mild non-progressive multifocal stenoses and demonstrated decreased 1, 3, and 5 year graft and patient survivals when
compared with group A; although, cholangiopathy was not detected by laboratory data in these patients. CONCLUSION Patterns of nonanastomotic biliary abnormalities in DCD liver transplants can be defined radiologically. The pattern and severity of the
radiographic findings correlate with clinical outcomes. Postoperative cholangiography can identify mild biliary abnormalities,which occur in
a subclinical manner yet significantly decrease graft and patient survival in DCD liver transplants. CLINICAL RELEVANCE/APPLICATION The prognostic information from post-operative cholangiography may identify those DCD patients who require earlier, more aggressive
intervention and earlier consideration for retransplantation. LL-GIS-SU3B • The Effect of Slice Thickness on Image Noise and Image Quality in Abdominal CT with Advanced Reconstruction
Algorithms: Initial Clinical Experience
Yingming Zhao (Presenter) ; Kexue Deng MD ; Wei Wei ; Shicheng Xu ; Yingzi Luo PURPOSE To compare image noise and image quality of abdominal CT with images reconstructed to different thickness with filtered back projection
(FBP), adaptive statistical iterative reconstruction (ASIR), and model based iterative reconstruction (MBIR) techniques. METHOD AND MATERIALS This prospective study was institutional review board approved, and written informed consent was obtained from all patients. A total of 20
patients underwent plain abdominal CT with a 64-detector CT scanner (Discovery CT750 HD; GE Healthcare).The projection data sets
were reconstructed to images of 0.625mm, 1.25mm, 2.5 mm and 5mm thickness with FBP, ASIR and MBIR. Image quality, including the
boundary of the lesion, detail of the lesion and artifacts was blindly evaluated (excellent: 5; bad: 1) by two experienced radiologists. The
mean CT values, image noise and contrast-to-noise ratio (CNR) relative to muscle for the liver with each algorithm were assessed. Paired
t test was used for statistical analysis. RESULTS For images of 0.625mm, 1.25mm, 2.5mm and 5mm slice thickness, the average image noise with MBIR, ASIR and FBP were
(10.9±1.4HU, 22.4±3.6HU and 32.1±5.5HU ), (9.4±1.1HU, 18.6±2.3HU and 27.4±3.9HU ), (8.5±0.9HU, 14.0±2.3HU and 17.9±3.0HU )
and (6.6±1.1HU, 9.7±1.5HU and 10.5±2.1HU ), respectively. MBIR reconstructions revealed statistically lower image noises (p 0.05).
Using MBIR, the scores of image quality for 4 different slice thickness were (4.3±0.7, 4.4±0.5, 5.0±0.0 and 5.0±0.0) which was
significantly better as compared to ASIR (2.4±0.9, 2.7±0.5, 3.8±0.4 and 4.8±0.5; p CONCLUSION Advanced MBIR reconstruction algorithms greatly reduces image noise and improves image CNR at 0.625mm slice thickness, and can
replace conventional FBP images with 5mm slice thickness. This may further improve the visualization of small lesion and allow radiation
reduction. CLINICAL RELEVANCE/APPLICATION MBIR techniques have the ability to reduce radiation dose through their improvement in image quality compared with available FBP, and
can provide promising potentials for quantitatively image analysis LL-GIS-SU4B • Analysis of Liver Stiffness Using High Frequency Magnetic Resonance Elastography (MRE) at 7T on an Ex-vivo
thin Liver Slices Rat Model
Maxime Ronot MD (Presenter) ; Simon Lambert ; Mathilde Wagner ; Sabrina Doblas PhD ; Valerie Paradis ; Ralph Sinkus
PhD ; Valerie Vilgrain MD ; Bernard E Van Beers MD, PhD PURPOSE To develop a high-resolution MRE-assessed fibrous liver analysis in an ex-vivo rat model using METHOD AND MATERIALS Fibrosis was induced in rats using CCl4 intoxication. Rats were anesthetized and sacrificed, livers were resected and RESULTS Rats had different stages of fibrosis: F0 (n=8), F1 (n=8), F2 (n=3), F3 (n=8), and F4 (n=15). Three (6%) rats were excluded due to
technical problems during MR. Liver elasticity significantly increased with the progression of fibrosis, with mean Gd values of 2.7
(+/-0.45), 2.9 (+/-0.3), 3.0 (+/-0.16), 3.2 (+/- 0.42), and 3.8 (+/-0.44) kPa for F0, F1, F2, F3 and F4 livers respectively (p CONCLUSION Our ex vivo thin-liver slice rat model allowed accurate analysis of liver stiffness on MR at 7T. CLINICAL RELEVANCE/APPLICATION MRE could be a non-invasive biomarker for evaluation of liver fibrosis but requires further clinical and experimental explorations. Our
results show a preclinical validation in a model of pure liver f LL-GIS-SU5B • A Clinical Approach to Adjusting Noise Index with Respect to Patient Size to Obtain Consistent Image Quality in
CT
Dianna D Cody PhD (Presenter) * ; Eric P Tamm MD ; Nicolaus A Wagner-Bartak MD ; Minesh P Patel ARRT ; Xinming Liu PhD
; Corey T Jensen MD ; Xiujiang J Rong PhD PURPOSE Automated tube current modulation (TCM) as implemented by General Electric for CT is quite sensitive to patient size when a constant
level of image noise is expected. This poses a severe clinical challenge to maintaining uniform image quality when patients of widely
varying size present for abdomen-pelvis CT exams. METHOD AND MATERIALS Detailed patient size versus Noise Index (NI) tables were developed, and evaluated, in an incremental manner on a weekly basis. The
image quality of each exam was scored by a radiologist. An analysis of these scores guided the adjustment of NI value in the table for the
subsequent week. The tables were based on measured patient circumference (abdomen) and AP localizer radiograph lateral width
(pelvis). Separate scan acquisitions for the abdomen and the pelvis allowed for independent NI values for each region on each patient.
Page 57 of 397
Image noise was measured in the spleen region of each patient. All patients (over 600 to date) were lymphoma patients undergoing
follow-up CT scans. CTDIvol was compared to the prior (routine) exam for each patient. RESULTS Patients quite often present with unique shapes; this approach provided images of excellent quality irrespective of unusual patient
proportions. Radiologists could tolerate more noise in the pelvis region than in the abdomen. The NI range for the abdomen is currently
16-42, and 20-46 for the pelvis, when generating 3.75mm thick primary images. Measured noise values prompted the adjustment of NI
more aggressively for both the very small and very large patients, who seem to benefit from very different levels of image noise relative
to those patients in between these extremes. Average CTDIvol was reduced by about half relative to the prior exam CONCLUSION For several reasons, abdomen and pelvis CT images of smaller patients require less noise for clinical evaluation than images of larger
patients. Attenuation data from very large patients are processed differently by this TCM scheme than data from other patients, which
also decreases measured image noise. A scheme for optimizing image quality is critical in order to generate acceptable abdomen-pelvis
CT images for patients with widely varying size and shape using this TCM tool. CLINICAL RELEVANCE/APPLICATION Quite different levels of image noise were tolerated for very small and very large patients, and the NI levels for very large patients can be
especially aggressive. LL-GIS-SU6B • Magnetic Resonance Imaging-Extramural Vascular Invasion in Rectal Cancer and Synchronous Liver Metastases,
Our Experience
Alberto C Seehaus MD (Presenter) ; Analia S Varela MD ; Mariana Calvo ; Marcos Quadrelli MD ; Jesica L Savluk MD ; Ricardo D Garcia-Monaco MD, PhD ; Sergio Terrasa ; Valeria Vietto PURPOSE To show the experience in our center regarding the association between magnetic resonance imaging (MRI) - extramural vascular
invasion (EMVI) and synchronous liver metastases in patients with rectal cancer. METHOD AND MATERIALS We performed a retrospective cohort study which included 71 patients, of whom 26 were male (36.62%) and 45 females (63.38%), all
diagnosed with cancer of middle and lower rectum, which were evaluated with MRI at our institution for initial staging in the period from
January 2011 to January 2012 inclusive.
All patients were evaluated with MRI for EMVI and were followed for a year to detect synchronous liver metastases by imaging methods
(MRI, CT, ultrasound, positron emission tomography) or pathology after surgery.
Multivariate analysis was performed by logistic regression to demonstrate the association of various predictors (MRI EMVI, gender, age)
with synchronous liver metastases. RESULTS Of all patients, 68 completed the clinical follow-up in our center (95.77%). Of these, 20 had liver metastases during the observation
period (29.41%), of whom 15 had signs of MRI EMVI (75%).
The incidence of synchronous liver metastases has a marginally significant association with the presence of MRI EMVI (OR, 3.35; 95% CI:
1.0001 - 11.2187) and female sex (OR, 4.86; 95% CI: 1.2117 - 19.5323). No association was found for the age variable. CONCLUSION The presence of MRI EVMI and female gender were predictors of development of synchronous liver metastases in patients with rectal
cancer. CLINICAL RELEVANCE/APPLICATION Our experience suggests that MRI is a useful tool as a prognostic marker due to the association between MRI EMVI and the incidence of
synchronous liver metastases. LL-GIE-SU8B • A Systematic Review of Enhancement Patterns at Gadoxetate-Enhanced MRI for Diagnosis of Hypervascular HCC
in Patients with Cirrhosis or Other Risk Factors for HCC
Kevin A Zand MD (Presenter) ; Eduardo A Costa MD ; Ajinkya S Desai MBBS ; Marilia P Ferreira MD ; Masahiro Tanabe MD ; Cynthia S Santillan MD ; Claude B Sirlin MD * PURPOSE/AIM The purpose of this exhibit is to systematically review in patients with cirrhosis or other risk factors for HCC: 1. Enhancement patterns at Gadoxetate-enhanced MRI for diagnosis of hypervascular HCC.
2. The probability of HCC for each enhancement pattern.
3. The differential diagnosis for each enhancement pattern.
CONTENT ORGANIZATION Introduction: Four enhancement patterns at Gadoxetate-enhanced MRI have been described in the Radiology literature for
diagnosis of hypervascular HCC in at risk patients. These patterns are based on relative enhancement in Arterial (A), Portal
Venous/Transitional (PV/T), and HepatoBilliary (HB) phases. For each pattern we show schematic illustrations, selective images,
the reported probability of HCC, and the differential diagnosis.
Pattern 1: A=Hyper, PV/T=Hypo, HB=Any
Pattern 2: A=Hyper, PV/T=Iso, HB=Hypo
Pattern 3: A=Hyper, PV/T=Iso, HB=Iso
Pattern 4: A=Hyper, PV/T=Iso, HB=Hyper
Summary
SUMMARY The major teaching points of this exhibit are: 1. Pattern 1 is diagnostic for HCC. The positive predictive value for HCC diagnosis is nearly 100%.
2. Pattern 2 is highly suggestive but not diagnostic of HCC.
3. Patterns 3 and 4 usually indicate benign entities. However, they may be interpreted as intermediate or high suspicion for HCC
depending on size and other imaging features.
LL-GIE1258-SUB • Colorectal Cancer in the Era of Molecular Medicine: What the Radiologist Needs to Know
Rahul A Sheth MD (Presenter) ; Arun Krishnaraj MD, MPH PURPOSE/AIM Molecularly targeted therapies are revolutionizing cancer care. For colorectal cancer (CRC), the oncology community has recently gained
insights into specific gene expression profiles that predict responsiveness to antibody therapy. We will summarize the relevant new branch
points in the management of CRC, with a specific focus on the use of molecular therapies. We will also highlight the imaging features as
well as the unique and potentially life-threatening complications of each of these agents. Page 58 of 397
CONTENT ORGANIZATION - Mutation analysis and molecularly targeted therapies Microsatellite instability and chemotherapy
Bevacizumab
EGFR, KRAS, and BRAF and cetuximab/panitumumab
- Imaging in staging and management of CRC Resectability and conversion to resectability
Liver volume and function
Molecular imaging for response to targeted therapies
- Imaging for specific complications of chemotherapy Steatohepatitis with irinotecan
Hepatic toxicity of oxaliplatin
Venous thromboembolism of cetuximab/panitumumab
Bowel perforation with bevacizumab
SUMMARY The expanding repertory of molecularly targeted therapies offers new opportunities and challenges for the radiologist. Imaging will serve
as a pivotal tool for identifying the appropriate use, efficacy, and complications of these drugs. Genitourinary/Uroradiology - Sunday Posters and Exhibits (1:00pm - 1:30pm) Sunday, 01:00 PM - 01:30 PM • Lakeside Learning Center
Back to Top GU
LL-GUS-SUB • AMA PRA Category 1 Credit ™:0.5 LL-GUS-SU1B • Sonographic Patterns of Residual or Recurrent Endometrial Polyps
Cristian A Jurau MD (Presenter) ; Samuel C Johnson MD ; Kirti Agarwal MD PURPOSE Endometrial polyps are common intrauterine growths, mostly benign, present in about 8% of the general asymptomatic population and
10 to 30% of women with abnormal vaginal bleeding. In symptomatic women or those with increased risks for endometrial malignancy,
surgical polypectomy is the definitive treatment. Recurrent, residual, or development of new polyps can complicate treatment. Our study
aims at delineating sonographic patterns that may predict such polyps. METHOD AND MATERIALS We performed a retrospective review of 59 consecutive patients with endometrial polyps. 12 patients were identified who had undergone
surgical polypectomy and demonstrated endometrial masses postoperatively. The patient age at the time of surgery was 47±11 years
(mean ± standard deviation). Polyp location, appearance, vascularity, and size were assessed pre- and post-operatively. Particular
attention was paid to location as an indicator of whether the polyps were recurrent or residual rather than new. RESULTS The patients underwent dilatation and curettage with or without polypectomy (92% under hysteroscopic guidance). No polyp was
visualized at surgery in 2 cases with pathologically proven polyps. The uterine cavity was distorted in one case by a submucosal fibroid.
There was no change in polyp position in any of the postoperative sonograms (performed at 19±13 months after surgery), indicating a
recurrent or residual preexisting polyp rather than occurrence of a new polyp in a different location. 67% of the polyps were fundal in
origin, whereas 33% originated in the uterine body. A few polyps exhibited changes in appearance (17%) and vascularity (17%), with an
equal, but different 58% of cases exhibiting cystic changes as well as an equal, but different 92% of cases exhibiting internal color
Doppler signal pre- and post-operatively. Subjective changes in size were evident in 50% of cases. Pre- vs. post-operative mean polyp
size (average of three orthogonal dimensions) and volume were 1.4±0.9cm vs. 1.7±2.2cm and 3.2±7.3cm3 vs. 2.9±5.3cm3,
respectively. CONCLUSION Sonographically detectable residual endometrial polypoid tissue or recurrent polyps may be found following surgical polypectomy, even
when performed under direct visualization. CLINICAL RELEVANCE/APPLICATION Sonographic endometrial patterns after polypectomy may demonstrate features compatible with recurrence or incomplete excision. This
may have clinical ramifications regarding surgical techniques. LL-GUS-SU2B • CT Findings in Adrenal Adenoma: A New Sign, the Vessel Sign
Carlos L Vergara Diaz (Presenter) ; Juan Carlos Pernas ; Diana Hernandez ; Magdalena Menso ; Carmen Perez Martinez MD
; Antonio Moral PURPOSE To describe a new helpful CT sign for diagnosis of adrenal adenoma with certainty. METHOD AND MATERIALS We designed a descriptive study based on the review of the clinical history and follow-up of 50 patients who undergone diagnosis of
adrenal adenoma by means of contrast enhanced computed tomography and who presented with The Vessel Sign. Patients were followed
up either by computed tomography, positron emission tomography, magnetic resonance imaging or surgery. RESULTS We found a high degree of correlation between The Vessel Sign and the diagnosis of adrenal adenoma, close to a 100%. The Vessel Sign
was best depicted on venous phase (all cases). None of the control adrenal lesions such as adrenal cortical carcinoma (4 cases),
metastases (16 cases), lymphoma (4 cases), pheocromocytoma (4 cases), haemnagioma (2 case) and myelolipoma (2 case) presented
The Vessel Sign. Secondarily, we also found that all adrenal adenomas presented themselves according to imaging state of the art
characteristics, with an average size of 25.7 mm (long axis for right adrenal adenomas), 26.25 mm (long axis for left adrenal adenomas)
and an average time stability of 1055 days (35.1 months). CONCLUSION When present, The Vessel Sign is a helpful and reliable sign for the diagnosis of adrenal adenoma. CLINICAL RELEVANCE/APPLICATION The Vessel Sign is a helpful and reliable sign for the diagnosis of adrenal adenoma, mostly when other diagnostic imaging modalities are
not possible or available Page 59 of 397
LL-GUS-SU3B • Single-source Dual-energy CT for Urinary Stone Characterization: Feasibility and Value of Iterative
Reconstructions
Fabian Morsbach (Presenter) ; Moritz Wurnig ; Bernhard Krauss PhD * ; Johannes G Korporaal PhD * ; Hatem Alkadhi MD PURPOSE To evaluate the feasibility and accuracy of single-source dual-energy CT (SS-DECT) with sequential data acquisition and co-registration
motion correction for urinary stone characterization and to evaluate the value of iterative reconstructions (IR) in DECT. METHOD AND MATERIALS Thirty-five urinary stones placed in cylindrical phantoms (diameters 30cm and 40cm) were scanned with 64-section CT using a SS-DE
protocol consisting of two sequential acquisitions at 80 and 140kVp, with phantom movement between acquisitions. Images were
reconstructed with filtered back projection (FBP) and IR, and data were coregistered. Two readers evaluated image quality. Image noise
and HU values of stones were measured; the dual energy index (DEI) was calculated. Datasets were analyzed using standard
post-processing software for differentiating stones. RESULTS The motion correction algorithm achieved a good coregistration of acquisitions at different energy levels. Image quality was significantly
higher on IR in the 40cm phantom as compared to FBP (P CONCLUSION SS-DECT with sequential acquisitions and using co-registration motion correction is feasible and accurate for characterizing urinary stone
composition. Use of IR in DECT reduces noise, improves image quality and visibility of stones and helps avoiding false stone
classifications. CLINICAL RELEVANCE/APPLICATION Single Source Dual-Energy CT with sequential acquisitions can be used to accurately differentiate between uric acid stones and iterative
reconstruction can improve image quality LL-URE-SU4B • Diagnostic Approach to Hereditary Renal Cell Carcinoma (RCC)
Shiva Gupta MD (Presenter) ; Hyunseon C Kang MD, PhD ; Dhakshina M Ganeshan MBBS, FRCR ; Tharakeswara Kumar
Bathala MD ; Vikas Kundra MD, PhD * PURPOSE/AIM Review histopathology and genetics of hereditary RCC syndromes.
Discuss imaging findings and tumor subtypes of hereditary RCC syndromes.
Provide a pattern-based approach for diagnosing hereditary RCC syndromes.
CONTENT ORGANIZATION 1. Introduction
2. Histopathology, Genetics, and Clinical Presentation of Hereditary RCC Syndromes
3. Imaging of Hereditary RCC Syndromes by Predominant Tumor Subtype
Clear Cell RCC: Von Hippel-Lindau Disease, Tuberous Sclerosis Complex, Succinate Dehydrogenase Complex Subunit B-Associated
RCC, Constitutional Chromosome 3 Translocations, Familial Clear Cell RCC
Papillary RCC: Hereditary Papillary RCC, Hereditary Leiomyomatosis and RCC, Hereditary Hyperparathyoidism-Jaw Tumor
Syndrome, Papillary Thyroid Carcinoma with Associated Papillary Renal Neoplasia, PTEN Hamartoma Tumor Syndrome
Chromophobe and Hybrid Chromophobe/Oncocytic RCC: Birt-Hogg-Dube Syndrome
Medullary RCC: Sickle Cell Trait-Associated Renal Medullary Carcinoma
SUMMARY Radiologists may be the first to suggest the diagnosis of a hereditary RCC syndrome, which should be suspected in the setting of multiple,
bilateral, or early onset RCC. A pattern-based approach incorporating imaging features of the tumor subtype with certain associated
findings may help radiologists distinguish between various hereditary RCC syndromes. LL-URE-SU5B • Imaging of Renal Infections: Acute, Chronic and Fungal Forms
Emilio Quaia MD (Presenter) * ; Paola Martingano MD ; Roberta Angileri ; Ferruccio Degrassi MD ; Luca De Paoli MD ; Biagio Cabibbo ; Fulvio Stacul MD ; Maria A Cova MD PURPOSE/AIM The purposes of this exhibit are:
To review the pathophysiology of acute and chronic renal infections
To discuss both the general and the most typical imaging findings in acute, chronic, and mycotic renal infections
To explain the utility of imaging modalities in the diagnosis and in the therapy monitoring of renal infections
CONTENT ORGANIZATION Clinical features and pathophysiology of acute and chronic renal infections Acute renal infections - Imaging findings Renal and perinephric
abscess - Imaging findings Gas-forming renal infections Chronic pyelonephritis - Imaging findings Renal tuberculosis - Imaging findings
Xanthogranulomatous pyelonephritis - Imaging findings Renal malacoplakia Cholesteatoma Fungal renal infections - Imaging findings
SUMMARY The major teaching points of this exhibit are:
1. To describe the different imaging findings of acute and chronic renal infections on ultrasound, CT and MR imaging.
2. To understand the utility of imaging technique in the planning and monitoring of medical therapy of renal infections.
3. To describe the major complications of the acute and chronic renal infections.
Health Services - Sunday Posters and Exhibits (1:00pm - 1:30pm) Sunday, 01:00 PM - 01:30 PM • Lakeside Learning Center
Back to Top HP
LL-HPS-SUB • AMA PRA Category 1 Credit ™:0.5 LL-HPS-SU1B • The Value of a Medical Student Radiology Triage Program in Enhancing Clinical Education and Skills
Jim Y Chen MD (Presenter) ; Petra J Lewis MD * PURPOSE The Medical Student Radiology Triage Program (MSRTP) at the authors' institution recruits third and fourth year medical students to
streamline imaging workflow for on call radiology residents. We sought to evaluate the benefit of this program for improving medical
Page 60 of 397
student education. METHOD AND MATERIALS Members of the program were surveyed anonymously from 2010 to 2012 using a web-based survey. The survey asked the students to
rate the program in several categories from 1 (very poor) to 5 (very good). Students also marked if they are learning any of the selected
skills. RESULTS Thirty of 54 (56%) former and current members responded to the survey. Support from on call residents (mean rating 4.7) and
interactions with residents (mean rating 4.7) were rated the highest of the categories. Students ranked training provided (4.2),
interactions with technologists (4.2), and interactions with clinicians (4.1) the lowest. The medical training experience and overall
experience were graded with means of 4.4 and 4.5, respectively. Ninety-six percent of students felt they acquired triaging skills while
92% of students responded to learning communication skills. Sixty-nine percent and 62% of students stated that they gained radiological
knowledge and general medical knowledge, respectively. Sixty-five percent of students and 50% of students responded to learning
imaging appropriateness criteria and image interpretation skills, respectively. The most popular reason for joining the program was for
financial compensation, followed by exposure to radiology, radiology education, and clinical exposure. Major strengths of the program
included interactions with residents, learning experience, and triaging of workflow. Students listed the top two problems with the program
as CT technologists and clinicians not wanting to speak to students. MSRTP is continuing strong with 33 current members as of April
2013. Students have covered 296 out of 312 (95%) possible shifts for the year of 2012. CONCLUSION The Medical Student Radiology Triage Program serves as a valuable clinical learning experience. Participants of MSRTP gain clinical skills
that they will use during residency. CLINICAL RELEVANCE/APPLICATION The Medical Student Radiology Triage Program provides medical students with valuable clnical and radiological experience. LL-HPS-SU2B • Personalized Technologist Education to Reduce Excess Z-Axis Scanning: Quality Assurance and Radiation Dose
Reduction
Stuart L Cohen MD (Presenter) ; Thomas J Ward MD ; Adam Jacobi MD ; Mary M Salvatore MD ; Matthew D Cham MD PURPOSE To implement a personalized method for monitoring and decreasing technologist specific excess Z-axis scanning, and to assess its effect
on radiation dose reduction. METHOD AND MATERIALS Noncontrast chest CTs were evaluated for excess Z-axis scan length (ES). ES was defined as the scanned distance superior or inferior to
the lung parenchyma and was calculated to determine each technologist's average ES above and below the lungs. This data was used to
implement personalized technologist education to reduce ES. From February 2012 to July 2012, three months of consecutive noncontrast
chest CTs before and after technologist education was analyzed to determine the impact of the education protocol on ES and radiation
dose reduction. Two tailed t-tests were performed to evaluate the differences in ES. RESULTS 1120 total consecutive noncontrast CTs were evaluated. Each technologist's ES for 677 patients before the education were compared to
their ES for the 626 patients after the education. The average excess Z-axis scan length superior to the lung (ESS) decreased by 19% (p CONCLUSION Excess Z-axis scan length on chest CT contributes to clinically unnecessary patient radiation. Personalized technologist education
significantly reduces (p CLINICAL RELEVANCE/APPLICATION Personalized feedback based on each technologist's excess Z-axis scan length should be an essential part of quality assurance and can
result in up to 59% reduction in excess radiation dose. LL-HPS-SU3B • Ordering Imaging: Enhancing Medical Student Education and Communication with Non-radiologist Physician
Providers
Cherng Chao MD, JD (Presenter) ; Mazen Zawaideh BS PURPOSE Communication between radiologists and referring providers is critical for interpretation of medical imaging and patient care. A shared
background and understanding of radiology is an important component for communication. However, medical education of
non-radiologists on radiology topics such as ordering imaging including indications for imaging and contrast guidelines may be lacking.
We proposed, developed and implemented a lecture on ordering imaging and evaluated the utility of the lecture and satisfaction with
current radiology education. METHOD AND MATERIALS A powerpoint lecture on ordering imaging was provided to the entire fourth year medical student class. The lecture discussed indications
for imaging modalities and studies, the radiologist protocol process, ideal descriptive indications and intravenous and oral contrast
guidelines including renal function and allergies. An anonymous electronic survey was sent to the entire class after the lecture. We
surveyed the students for their impression of the amount and adequacy of their radiology education to date. We also tested their
knowledge on basic ordering imaging topics such as best study for an indication and about intravenous contrast guidelines. We also
queried their impressions of the ordering imaging lecture.
RESULTS We received 34 completed surveys. The vast majority, 85%, had taken a radiology elective/course. Only 15% of those surveyed reported
that they knew all the information in the lecture. Although the percentage of correct responses to questions regarding the correct study
for a reported indication ranged from 79% to 94%, the percentage of correct responses regarding intravenous contrast guidelines range
from 47% to 76%. Over 76% of the participants thought that current radiology education could be improved. Over 97% thought that the
lecture on ordering imaging was useful and recommended the lecture to other individuals. CONCLUSION Although the majority of nearly graduating medical students received some type of radiology education, the vast majority thought
radiology education could be improved and that the lecture on ordering imaging was useful and recommended it. CLINICAL RELEVANCE/APPLICATION Education on ordering imaging may enhance medical student education and, hopefully, communication with non-radiologist physicans. LL-HPE-SU4B • Top Ten Commonly Misordered Diagnostic Imaging Studies by Primary Care Physicians
Zachary Nuffer BS (Presenter) ; Nikhil B Amesur MD * PURPOSE/AIM The purpose of this exhibit is: 1. To emphasize that choosing the wrong imaging study leads to unnecessary costs, side effects, and a
delay in diagnosis. 2. To emphasize that despite the availability of the American College of Radiology Appropriateness Criteria, many
well-trained and experienced primary care providers remain unsure of the appropriate imaging work up of certain clinical presentations 3.
To list and discuss ten clinical presentations that can result in result in the wrong imaging studies being ordered.
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CONTENT ORGANIZATION Present a list based on published expert opinion and a survey of the University of Pittsburgh Medical Center radiology department of ten
commonly misordered diagnostic imaging studies Discuss each presentation (for example, non-thyroid neck mass of unknown origin) for
which these studies were ordered and what the proper imaging workup would have been, if any.
SUMMARY From this exhibit, the viewer should learn: 1. Ten clinical presentations that often result in misordered tests 2. The proper imaging
workup of these ten clinical presentations. 3. Radiologists are available to help health care providers choose the appropriate study. LL-HPE-SU5B • How to Explain Effects of Radiation Dose to Children, Those with Special Needs, and Those with Limited Mental
Capacity (....Even Orthopedists...)
Brian M Rodgers MD (Presenter) ; Eduard V Kotlyarov MD, PhD PURPOSE/AIM Explaining radiation dose effects can be difficult even in the best of circumstances. Several case scenarios provide a framework to
approach this subject with children, the mildly mentally handicapped, and even difficult to teach adults. For those who do not have the
ability or interest to understand the true details of radiation dose effects or the concept of risk vs benefit analysis, these will provide a
usable approximation. This can be part of making medical imaging 'people friendly'. CONTENT ORGANIZATION Case scenarios are provided to help explain dose effects from medical imaging studies to:
- children
- mildly mentally handicapped adults
- adults who only want the briefest and most simplistic explanations SUMMARY Explaining radiation dose effects from medical imaging exams can be very difficult. Using a fairy tale or comic book type approach can be
very useful for children. Emphasizing how the test can help them feel better soon is also important. Parents will likely desire a more
complete explanation. Engage the mentally handicapped in conversation. For other adults who only want the fastest answers, providing
equivalents in harm done by smoking some cigarettes or comparable time from background radiation dose should suffice. This also
provides Imaging Physicians a unique and valuable means for patient education and even to market the practice. LL-HPE1078-SUB • Essentials of Statistical Methods for Assessing Reliability and Agreement in Quantitative Imaging
Arash Anvari MD (Presenter) ; Anthony E Samir MD ; Elkan F Halpern PhD * PURPOSE/AIM This exhibit will provide a review of the statistical methods for assessing measurement reproducibility in quantitative imaging. CONTENT ORGANIZATION 1. Definition of reliability(reproducibility) and measurement error.
2. The difference between reliability and validity.
3. Describing sources of measurement variability, with a special focus on intra- and inter-observer variability
4. Considerations when designing reliability and agreement studies
5. Statistical methods for analyzing reliability of quantitative measurement, including Standard Error of measurement and coefficient of
variation (CV), Intraclass Correlation Coefficient (ICC), and Bland-Altman Analysis.
6. Guidelines for reporting reliability and agreement studies (GRRAS).
7. Why Pearson�s Correlation Coefficient should not be used to assess reliability.
8. Role of reliability in generalizability and clinical decision studies.
9. Strategies for reducing variability.
SUMMARY Quantitative imaging has a promising role in diagnosis and the prediction of clinical outcomes. We emphasize core statistical concepts by
providing practical examples of reliability assessment in imaging studies. Informatics - Sunday Posters and Exhibits (1:00pm - 1:30pm) Sunday, 01:00 PM - 01:30 PM • Lakeside Learning Center
Back to Top IN
LL-INS-SUB • AMA PRA Category 1 Credit ™:0.5 LL-INS-SU1B • A Mobile Web Application for Learning and Documenting Competency in Radiology Procedures
Joel M Stein MD, PhD (Presenter) ; Suyash Mohan MD CONCLUSION A cross-platform application for mobile device can be created to facilitate learning and documenting competency in neuroradiology
procedures. Background Learning to perform routine procedures is an important component of radiology training at the residency and fellowship levels.
Documenting procedural experience can be important for licensing. In addition, with the new ACGME Milestones initiative, attendings will
need to verify and evaluate procedures performed by trainees. The smartphones and other mobile devices that many trainees already
carry could be used to facilitate learning and rapid documentation of procedural experiences. Evaluation We developed a mobile web application that incorporates step-by-step procedure guides, a procedure log, attending assessment and
review into a single platform. The application uses the Sencha Touch JavaScript framework to mimic a native application on iPhone,
Android and Blackberry smartphones as well as the Apple iPad and other tablets. It also runs on Mac and Windows desktop computers.
The procedure log includes fields to enter procedure type, date, accession number, and attending radiologist as well as an evaluation
form that can be completed and electronically signed by the attending radiologist. These data may be stored locally or remotely. A
summary page presents a graphical representation of procedures performed and trends and averages with respect to fluoroscopy time.
Data can be made available to the program director for comparison across trainees. Discussion Our application should enable rapid documentation and attending verification of trainee radiology procedural experiences at the time and
location they are performed. The cross-platform nature of the application facilitates data entry where the procedure is perfomed. Remote
storage of the procedure and evaluation data should prevent data loss. We have initially focused on neuroradiology procedures, lumbar
punctures and myelograms, but the application could be easily expanded to include other procedures. In the future, we also intend to
allow additional user customization of procedure guides, procedure types and evaluation forms. LL-INS-SU2B • Communicating Radiology Results to Patients: Results from Universal Online Release by an Academic Radiology
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LL-INS-SU2B • Communicating Radiology Results to Patients: Results from Universal Online Release by an Academic Radiology
Department
Seetharam C Chadalavada MD (Presenter) ; Tessa S Cook MD, PhD ; Curtis P Langlotz MD, PhD * CONCLUSION Our experience with the online release of radiology reports shows that release of reports is feasible, with no significant adverse effects. As
measured by patient viewing rates, patients have a strong interest in their radiology results. Background As patients become more involved in their care, organizations are providing access to radiology reports via online patient portals. Portals
provide an opportunity for radiologists to engage patients and to meet meaningful use requirements. Since May 2012, we released all
radiology reports to patients with activated portal accounts. Evaluation We conducted a retrospective review of the utilization of our patient portal (MyChart, Epic Systems, Verona, WI) from May 2012 to March
2013. Patient demographics and online metrics were obtained from audit logs. Our health system is responsible for 2.1 million outpatient
visits annually. Since the portal�s inception, 315,450 accounts have been issued, and 105,095 (33.3%) have been activated. 63% of
accounts were activated for female patients. Women aged 50-59 and men aged 60-69 had the largest number of activated accounts.
Unless embargoed by the referring physician during a 3-day delay, all imaging test results were released to patients with activated
accounts. 118,901 imaging test results were released, of which 49.3% (58,580) were viewed--similar to laboratory results released
during the same period (51.8%; 588,567/1,134,389).
The most frequently viewed imaging results were screening mammograms (50.1% view rate), chest X-rays (52.7%), and dual-energy
X-ray absorptiometry (DEXA) scans (55.1%). No adverse events were reported. Patient phone calls to clinics and radiologists were
unchanged. Discussion Many patients seek direct access to their imaging results, making them a voluntary partner in their care and promoting environmentally
friendly communication. The potential savings relative to printing and mailing results to patients may be substantial. The number of calls
from patients to clinics seeking radiology results may be reduced. LL-INS-SU3B • Automation Process for Pulsed Wave Doppler Measurement Using Bloodstream Information
Yunsub Jung MS (Presenter) ; Hwan Shim PhD * ; Beunggeun Cheon MS * ; Hyungjoon Lim MS * ; Youngtae Kim PhD * PURPOSE Measuring the blood velocity with Pulsed wave (PW) Doppler is affected by parameters such as Doppler angle, positioning of the sample
volume (SV), and Doppler gain and these parameters are generally decided by human. To overcome error by human, operation
complexity and time consumption in measurement, we present an automation process for PW Doppler. METHOD AND MATERIALS Proposed automation method was designed based on vessel and bloodstream information and include the following steps; 1) vessel
detection and aliasing area removal 2) region of interest (ROI) searching and SV positioning 3) B, C-mode image fusion 4) vessel angle
estimation using virtual ray 5) computing of Doppler and steering angle 6) measurement of blood velocity. As a result of mentioned
process, SV position and vessel angle are automatically computed without user intervention. Then, the vessel angle obtained from
automation method were compared with manual results by two experts, also repetition test was performed to evaluate a reproducibility
of each way. We collected 300 pair images (B-mode : 300, C-mode : 300) including the carotid artery from three subjects without
vascular disease for clinical assessment. RESULTS Vessel angle in collected images is distributed approximately from -40 to 40 degree. To evaluate the vessel angle accuracy of automation
method, we calculated the mean absolute difference (D) between computed angle and manual measurement angle, at this time, each
angle was estimated under same conditions such as ROI and SV position. Automation method compared to manual results by two experts
shows D1 = 1.2 ± 0.7 and D2 = 1.7 ± 0.9 respectively. In the case of repetition test, automation method always present D = 0 ± 0,
however, manual measurement (D1 = 1.7 ± 0.4, D2 = 2.3 ± 0.7) shows a variation definitely. CONCLUSION Automation method for PW Doppler allows the robustness measurement of blood velocity without variance caused by subjective human
factors, moreover, enhance the accuracy and reproducibility of the results. CLINICAL RELEVANCE/APPLICATION The described technique might be useful for current clinical environment in aspect of time reduction and reproducibility. LL-INS-SU4B • A Comprehensive and Innovative Program in Radiology for Medical Students
Andres Vasquez MD (Presenter) ; Bibiana Pinzon MD ; Diego A Aguirre MD ; Anibal J Morillo MD ; Yenny A Moreno Vanegas
BSc ; Sergio A Puentes MS ; Alfonso Esguerra MD CONCLUSION Combined theoretical/on-site programs combined with the latest WEB 2.0 and 3.0 technologies can be key in the training of medical
students in diagnostic imaging. Background The use of diagnostic imaging has increased significantly on a global scale in the past two decades.Because of this it is essential that
medical students acquire more knowledge related to the adequate use of these diagnostic tools, their indications, interpretation of basic
findings and patient safety. In Colombia less than 5% of medical schools have a radiology course or clinical rotation. When they do exist,
they often end up becoming a rotation where the students sit behind a radiologist listening to him/her dictate studies. Evaluation We created a live and virtual 6 weeklong course last year medical students at Los Andes University in Bogot� Colombia. This program
was created based on the aims and competencies described by AMSER. The students would have a Problem Based Learning (PBL) session
and would have to revise academic reviews on a daily basis in addition to clinical rotations divided by sections. At the same time, students
had access to platforms based on WEB 2.0 and WEB 3.0 where they would have the possibility of reviewing podcasts of the classes and
answer questions in forums based on practical cases of basic pathologies, which would place the student in the midst of learning and
generate discussion among peers creating the concept of collective learning. There were a total of 90 participating students between the
years 2009-2012. We applied exams at the beginning and end of the course. The mean of the pre-course exam was 24/100 compared to
85/100 for the post-program exam. A complete statistical analysis was done. Discussion It is necessary to create innovative programs for teaching the basics of Diagnostic Imaging to medical students in order for them to
acquire an adequate training in the use and interpretation of these tools due to their ample use in the present world. This is very
important in order to ensure the adequate use of medical resources by all practitioners and at the same time will result in benefits and
greater safety for patients. LL-INE-SU5B • The Liver Imaging Atlas: A Structured Learning Resource of Liver Imaging
Orpheus Kolokythas MD * ; David L Coy MD, PhD ; Puneet Bhargava MD (Presenter) ; Sadaf F Zaidi MD ; Sherif Osman MD ; Page 63 of 397
Neeraj Lalwani MD ; Claudia T Sadro MD ; Lee M Mitsumori MD, MS * ; Grace S Phillips MD ; Alex P Tornow MD ; Larissa A
Alemany MD ; Luana Stanescu MD ; Adeel R Seyal MD * ; Sarah Bastawrous DO PURPOSE/AIM 1. To present a structured web-based interactive reference of liver imaging that includes a comprehensive spectrum of liver pathology in
CT, MR, and ultrasound imaging. 2. To provide an educational resource for liver imaging targeted to radiologists in training and in
practice. CONTENT ORGANIZATION The interactive educational website www.liveratlas.org has been designed with a detailed tagging system that allows authors to
upload, structure, and categorize cases of liver imaging in CT, MR, and ultasound. The tagging system permits users of the atlas to filter,
search, and retrieve cases by their general or modality-specific imaging features, disease category, diagnosis, or through a free text
search. A quiz mode feature has been designed to allow the Liver Imaging Atlas to be used as a training tool by educators and residents.
Cases in the atlas can be shared with colleagues via email and can be also saved for educational presentations and quizzes. SUMMARY The website www.liveratlas.org is an interactive comprehensive reference tool to rapidly and effectively access imaging examples of
liver pathology on CT, MR and ultrasound. It allows radiologists to narrow down their differential diagnoses in specific clinical scenarios,
test their diagnostic skills, and compile selections of interesting liver imaging cases to save and share. LL-INE-SU6B • Improving Critical Test Result Notifications Performance
Ingy Hanna MD ; Jacquelyn Copeland MD (Presenter) ; Mark A Flyer MD ; Brian D Gale MD * Background Failure to communicate is an increasing source of litigation against physicians, and specifically radiologists. From 1991-2009, radiology
malpractice awards increased by an average of $4.7 million annually with communication failures accounting for 7-8% of the total cost.
Unread test results may also be a source of significant CMS compliance penalties. Consequently, many institutions expedite reportable
result notification by using critical test result management (CTRM). These systems enable the radiologist to asynchronously communicate
findings to referring clinicians. After the radiologist sends the finding into the CTRM system, the referring physician receives a notification
that a critical or significant radiologic finding has been made allowing them to both retrieve the finding and trigger a receipt time stamp.
This facilitates and documents communication of significant radiologic findings to the referring physician. Evaluation We implemented a performance report that allows us to quickly and effectively analyze the data from the CTRM system over a given
period of time. Administrators can determine, amongst other things, the significance of the message sent, the referring physicians and
departments with the longest message retrieval intervals, and how referring physicians rank amongst others in compliance with message
retrieval times. This information can be used to manage providers' performance and optimize communications of diagnostic test results. Discussion Compiling this information into a unified summary would allow institutions to assess the strong and weak points in communication of
radiologic information, thereby allowing them to focus corrective efforts on those that are not in compliance. Importantly, it allows
departments to track improvement in compliance after corrective efforts are made. CONCLUSION Using CTRM performance metrics could enable institutions to target weak points in communication, improving test result communication
reliability and accelerating appropriate treatment decisions. This can improve length of stay, reduce the incidence of medical errors and
enhance patient safety, subsequently reducing liability from malpractice litigation and compliance penalties. LL-INE3196-SUB • Fast and Automated MRA/ MRV Reconstruction Technique to Fly-through the Artery/ Vein
Mallikarjunarao Kasam PhD (Presenter) ; Yunhong Shu PhD ; Kirk M Welker MD ; Vaibhav Juneja PhD, MS Background Accurate quantification of artery/vein occlusion in acute ischemic stroke is necessary as this information can aid in reaching precise
diagnosis. Recently several angiographic reconstruction methods were used to quantify occlusion in acute stroke. But these methods
need long computational time. In the conventional clinical practice, artery/vein occlusion in an ischemic stroke patient is usually detected
by MRA/MRV or CTA/CTV followed by Doppler ultrasound to confirm the stenosis profile. But the ultrasound exam is limited by its
qualitative nature and high degree of subjectivity. More quantitative methods are needed to visualize the site of occlusion and measure
the extent of occlusion. Evaluation Patient exams were performed under an IRB-approved protocol. Two 3D SWIRLS single phase contrast-enhanced angiographies with
1mm 3 spatial resolution were used for this work. Clinical exams were acquired on 3.0T MRI(GE, WI). Data analysis: The raw data was
post-processed using tree analysis and virtual endoscopy modules of Analyze 11.0 software (Analyze 11.0; Biomedical Imaging Resource,
Mayo Clinic, Rochester, MN) to fly through the vessel. A statistical parameter called Brightness Area Product (BAP) was defined as the
sum of the intensities above the sample minimum intensity/threshold set by the user. Discussion We proposed a simple and fast automated post-processing method to fly through the artery/vein using Analyze11 software. This
technique can be extended to any arteries or veins for neuro, cardiac and body applications to monitor internal vasculature and to
estimate the stenosis using the statistical parameter BAP, which generates a master profile/database of arteries/vein. CONCLUSION This isthe first step towards the above problem by establishing a simple, automated post-processing method to fly through the vessels
using tree analysis module and visualization of these vessels.This technique provides a simple, fast and automated method to fly through
and have virtual endoscopic view of entire artery/vein trees especially at the regions of bifurcations where the occlusion possibility is
prominent.The computation time for this method is < 5 min compared to the other reconstruction techniques (>~ 30 min). LL-INE3199-SUB • A Stand-alone Decision Support Tool for Managing Liver Lesions on CT and MRI Based on the LI-RADS
v2013.1 Criteria
Ramin Javan MD (Presenter) ; Mustafa R Bashir MD * Background Decision support tools will likely become an integral part of many aspects of radiology in the near future, especially as part of the Imaging
3.0 movement by the ACR. In the field of breast imaging, standardized management and recommendations have been guided by the
BI-RADS. Recently, an effort to standardize classification of liver lesions in the setting of cirrhosis has lead to the development of
LI-RADS. This method aims to add consistency to radiologists' interpretations and provides a lexicon of terms, decision algorithms, and
an atlas of imaging findings. Evaluation A decision support tool must be ideally simple, user friendly, intuitive, and preferably work in a step-wise fashion, minimizing the
possibility of confusing the user with an excessive number of choices, features, and definitions. Microsoft Visual Basic 2010 was
implemented for creating an application that allows the user to arrive at the appropriate LI-RADS category and therefore a standardized
recommendation, which can then be copied to the clipboard for insertion into the radiology report. A step-wise algorithm as well as a
tabulated algorithm with the exact appearance as the LI-RADS v2013.1 is developed. This user interface functions based on the
Page 64 of 397
active/inactive state of each command point and includes features such as 'educational mode', 'image atlas' and allows for 'backtracking'
through the algorithm, lending more control to the user, which especially proves useful for training purposes and in practical situations. Discussion With the current boom in health IT and government's emphasis on meaningful use, emerging decision support tools can utilize a vast
array of patient data to allow for better decision making and enabling evidence-based radiology. The fundamentals behind the design of
such tools can also be applied elsewhere, such as a PACS plug-in or a web-based application. CONCLUSION A PC-based stand-alone decision support tool was designed and implemented, for simplifying the use of the newest version of LI-RADS.
We hope that this tool encourages the widespread use of this recently developed scheme by radiologists and aids in bringing consistency
to the recommendations made to clinicians. LL-INE3238-SUB • Generating Structured Reports through Calculator Applications
Alex Towbin MD (Presenter) * ; Jonathan Borders ; Jay A Moskovitz MS ; Timothy OConnor MBA ; Neil D Johnson MD * Background Calculators have been created for multiple medical specialties in an attempt to help physicians perform complex calculations more
efficiently and accurately. When typical medical calculators are used, the output is the answer to a specific equation. This is not the
output needed for most radiologists�the end product of a radiologist�s work is not the answer to a formula but a dictated report. The
purpose of this exhibit is to show a series of radiology-based calculators and demonstrate how they can be used to generate structured
reports. Evaluation A novel, web-based application was created to help radiologists calculate leg length discrepancies, femoral/tibial torsion, and bone age.
Each calculator was designed with two components. The graphical user interface (GUI) component directs the user to enter data for
specified variables based on the examination being interpreted. Images are presented as part of the GUI to instruct the radiologist how to
obtain each data point. After entering data for each variable, the calculator displays the answer to the equation along with a
standardized, structured report via the second component�a structured report generator. Discussion While computerized, equation-based calculators have been used in medicine for over 15 years, they are infrequently used in radiology.
Coupling a calculator with a structured report generator is a novel concept that allows radiologists to work efficiently while at the same
time creating accurate, standardized, structured reports. Currently the three calculators in use in our department help radiologists
interpret nearly 2,500 examinations each year, accounting for approximately 1% of all studies. CONCLUSION Structured reports can be generated through calculator applications. These applications can help to improve radiologist efficiency along
with reporting accuracy and standardization. LL-INE3161-SUB • Relationship between Characteristics of Pulmonary Nodules and Performance Improvement of Radiologists:
Comparison between CADx with and without Reasoning
Takeshi Kubo MD ; Gakuto Aoyama (Presenter) ; Koji Fujimoto MD, PhD ; Masahiro Yakami MD, PhD ; Masami Kawagishi ; Kaori Togashi MD, PhD * ; Yutaka Emoto MD, PhD ; Ryo Sakamoto ; Yoshio Iizuka ; Hiroyuki Sekiguchi ; Koji Sakai ; Hiroyuki Yamamoto Background A number of studies have demonstrated the improved accuracy of nodule diagnosis using CADx systems. The gain in the accuracy,
however, may vary with nodule characteristics. Thus, to take full advantage of CADx, we evaluated the relationship between the
performance of radiologists with a CADx system and the nodule characteristics. Evaluation In accordance with the IRB approval, we built a database of 491 lung nodules with clinical or pathological confirmation as a primary lung
cancer, metastasis or benign nodule. The image findings were scored by consensus of two board-certified radiologists.
We developed a CADx system (Bayesian network / Markov chain Monte Carlo method, 179 training data) that can provide the reasoning
behind the suggested diagnosis. CADx which indicates the probability of diagnosis (ICAD) and probability of diagnosis with additional
reasoning such as image findings and/or clinical information (RCAD) were used for this experiment. The reasoning was determined by the
degree of influence on the highest possible diagnosis.
11 diagnostic radiologists with 5 years� experience made the diagnoses for the 312 nodules with three different conditions (without CAD,
with ICAD, with RCAD) with a more than 1 month interval.
We focused on 61 clinically relevant nodule characteristics. For each characteristic, a group of nodules was defined so that the nodules in
the group share that particular characteristic. With regard to 61 resultant groups, the mean accuracy of 11 radiologists was compared
among three conditions (Wilcoxon signed rank test with Bonferroni correction). Discussion For all groups, ICAD and RCAD significantly improved the diagnostic accuracy of radiologists (p For groups of nodules with 1) coarse
speculation, 2) polygonal shape and 3) satellite nodules, accuracy was significantly better with RCAD than with ICAD (p CONCLUSION Effectiveness of CADx depended on nodule characteristics. Recognition of nodule characteristics that benefit from CADx support may lead
to optimizing the CAD-assisted diagnostic process by the radiologists. LL-INE3165-SUB • Does Computer-aided Diagnosis System which Presents the Reasoning for the Diagnosis Improve
Radiologists’ Diagnostic Performance for Pulmonary Nodules on CT?
Koji Fujimoto MD, PhD (Presenter) ; Masahiro Yakami MD, PhD ; Takeshi Kubo MD ; Ryo Sakamoto ; Gakuto Aoyama ; Kaori
Togashi MD, PhD * ; Yoshio Iizuka ; Masami Kawagishi ; Hiroyuki Sekiguchi ; Yutaka Emoto MD, PhD ; Koji Sakai ; Hiroyuki Yamamoto Background Without reasoning, radiologists might not be able to determine whether the output of computer-aided diagnosis (CADx) is reliable or not.
This may lead to difficulty in judgments of the CADx output by radiologists. The purpose of this study was to evaluate the effect of CADx
software which presents reasoning for the diagnosis on radiologists� performance. Evaluation With the approval of the IRB, we built a database of 491 lung nodules with clinical or pathological confirmation as primary lung cancer,
metastatic, or benign. This database included thin-slice CT images, 49 nodule features interpreted by board-certified radiologists,
laboratory data and patients� past history. We developed a CADx that provide nodule features as reasoning for the suggesting diagnosis.
An inference model with a Bayesian network was constructed using the Markov Chain Monte Carlo method with the 179 training data set.
CADx with the inference of the Bayesian network (ICAD), with additional reasoning (RCAD) were evaluated. RCAD presented image
findings and/or clinical information as reasoning according to the relevance with the presenting diagnosis. For evaluation, 11 radiologists
interpreted 312 nodules under three different conditions; without CAD (NCAD), with ICAD, and with RCAD. Each radiologist inputted
likelihoods of diagnosis (primary, metastatic or benign), which in total should be 100% on each nodule. The likelihood agreed with the
confirmed diagnosis was regarded as the confidence in each interpretation. For each radiologist�s input, Shannon entropy was calculated
using the likelihoods and was regarded as the uncertainty of the interpretation. Accuracy, AUC for each diagnosis, confidence, and
uncertainty for 11 radiologists are compared for each condition (Wilcoxon signed rank test with Bonferroni correction). Page 65 of 397
Discussion Accuracy, AUC for primary lung cancer, and confidence were higher, and uncertainty was lower in the order of NCAD(0.71, 0.86, 59.2,
0.92, respectively), ICAD(0.76, 0.90 ,65.1, 0.80) and RCAD(0.77, 0.91, 66.3, 0.74). Significant difference was seen for NCAD vs ICAD,
and NCAD vs RCAD. CONCLUSION RCAD improved accuracy and reduced uncertainty for their diagnosis, but significance was seen only with NCAD. LL-INE3163-SUB • Can Computer-aided Diagnosis (CADx) System that Presents Reasoning Reduce Radiologists’ Inter-observer
Variability?: Evaluation in Interpreting Lung Nodules on Computed Tomography
Ryo Sakamoto (Presenter) ; Koji Fujimoto MD, PhD ; Masami Kawagishi ; Gakuto Aoyama ; Takeshi Kubo MD ; Kaori
Togashi MD, PhD * ; Masahiro Yakami MD, PhD ; Yoshio Iizuka ; Yutaka Emoto MD, PhD ; Hiroyuki Sekiguchi ; Koji Sakai ; Hiroyuki Yamamoto Background Inter-observer variability among radiologists may lead to inappropriate clinical recommendations. With appropriate reasoning, CADx may
help reducing variability among radiologists� diagnosis. The aim of this study was to compare variability of radiologists� interpretations
of lung nodules on CT between with and without using a CADx, which is capable of presenting reasoning for the diagnosis. Evaluation With the approval of the institutional review board, we built a database of 491 lung nodules consisted of primary lung cancers, metastases
and benign nodules. It includes image features scored by two board-certified radiologists and clinical data sets. We employed a Bayesian
network for the inference engine of the CADx system and trained it by 179 nodule data sets. Our CADx system infers the diagnosis of
nodule with providing the reasoning. Eleven radiologists with 5 years' experience interpreted 312 nodules under three different
conditions: without CADx (NCAD); with inference only (ICAD); with presenting reasoning (RCAD). The level of likelihood for each
diagnostic category was recorded in percentages up to 100 %. Inter-observer variability was assessed and compared among three
different conditions (NCAD, ICAD and RCAD) by using following evaluation criterion: 1) Multi-rater ? (the level of agreement for
diagnosis); 2) Standard deviation of AUC for the diagnosis in ROC analyses (variation in diagnostic accuracy); 3) The variance in
radiologists� output (degree of diagnostic consensus for each nodule). Discussion Multi-rater ? was moderate (?=0.561, 95%C.I.; 0.558, 0.564) by NCAD and was improved to good agreement by ICAD (?=0.679,
95%C.I.; 0.676, 0.682) and RCAD (?=0.692, 95%C.I.; 0.689, 0.694). The variation of accuracy was reduced with RCAD compared to
ICAD as well as NCAD. The degree of radiologists� consensus was also improved significantly by using both ICAD and RCAD, but there
was no significant difference between ICAD and RCAD. CONCLUSION CADx reduced the radiologists' variability in interpreting lung nodules. With presenting reasoning, CADx was more effective in the aspect
of improving the level of agreement for the diagnosis and variation in diagnostic accuracy. LL-INE3164-SUB • Computer Simulation of Clinical Conference: Evaluation of the Effect of Increasing Number of Participant and
Joining Computer-aided Differential Diagnosis (CADx) as a Participant
Masahiro Yakami MD, PhD (Presenter) ; Masami Kawagishi ; Gakuto Aoyama ; Hiroyuki Yamamoto ; Takeshi Kubo MD ; Kaori Togashi MD, PhD * ; Yoshio Iizuka ; Ryo Sakamoto ; Koji Sakai ; Koji Fujimoto MD, PhD ; Hiroyuki Sekiguchi ; Yutaka Emoto MD, PhD Background In the process of determining diagnosis at a clinical conference, each physician explains one�s differential diagnoses including their
possibilities. This study proposes a computer simulation of clinical conference to evaluate the effect of increasing the number of the
participant and joining a CADx as a participant. Evaluation With the approval of the institutional review board, we built a database on 491 lung nodules on which diagnoses were clinically confirmed
as primary lung cancer, metastatic nodules or other benign nodules. This database consisted of CT images, image findings on the nodules,
the confirmed diagnosis, clinical information such as laboratory data and patient history. The image findings were described by consensus
of two board-certified radiologists.
The CADx was trained and evaluated by using 179 and 312 nodules in the database, respectively. The CADx derived a list of possibilities
for differential diagnoses on each nodule using a Bayesian network.
Eleven radiologists, with five years� experience in diagnostic imaging, interpreted the 312 nodules. Each radiologist inputted the
possibilities for differential diagnoses, which in total should be 100%, on each nodule.
Among all possible diagnoses, the one with the highest total possibility in all participants was defined as the diagnosis at a conference.
The average accuracy in the simulated conference among each combination of 2 to 11 (N) radiologists (R-Only), and that among all the
combinations generated by replacing any radiologist in the combination with the CADx (R+C) were calculated for evaluation.
The radiologists interpreted the same nodules referring CADx later with more than one month interval. Discussion The average accuracies by each radiologist without/with CADx were 71.4% and 76.3%, respectively.
Those by RadOnly (N=2 to 11) were 73.5%, 75.6%, 76.4%, 76.9%, 77.2%, 77.4%, 77.5%, 77.5%, 77.8% and 77.9%, respectively.
Those by R+C (N=2 to 11) were 77.2%, 78.3%, 79.1%, 79.3%, 79.4%, 79.4%, 79.4%, 79.4%, 79.3% and 79.3%, respectively. CONCLUSION Increasing the number of participant improved the diagnostic accuracy, and joining CADx as a participant showed relatively higher
improvement. LL-INE3242-SUB • Smarter Communications: Integrating VoIP Solutions for Streamlining Radiology Workflow
Sarfaraz Sadruddin MD (Presenter) ; Rohit Ramanathan MD ; Leonardo I Valentin MD ; Sean D Raj MD ; Naveen Garg MD * Background Efficient radiology workflow with reduced distractions is essential in practice today to maintain productivity, provide quicker turnaround
times to our referring clinicians, and most importantly, to provide better patient care. Current workflow is burdened by high volumes of
phone call attendance and communications with the ordering providers and technologists. These interruptions not only decrease
efficiency, but the current telephone based system is less accommodating to an ideal workflow where majority of time is spent on PACS
and reporting. An integrated Voice Over Internet Protocol (VoIP) within a webapplication provides a great solution and promises to
revamp diagnostic radiology workflow in the near future as we demonstrate a working enterprise level solution. Evaluation Initial pilot data provided important feedback for evolution of our technology. Currently, we are collecting real-time user metrics while
testing the webapplication, in addition to user satisfaction surveys. Future implementations will study head to head evaluation of
traditional telephony service vs. VoIP integration with appropriate metrics. Discussion Using webtechnologies and server side coding, an IP based VOIP server was utilized and the newest Webrtc techonology was
implemented for DTLS-SRTP encryption, which is HIPPA compliant. A webapplication was then developed with departmental phone
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numbers and all the outpatient phone numbers in an easy to use format with a rapid AJAX based search. A click to call feature was
implemented enabling utilization of the Dictaphone directly without disturbing workflow during dictation. Additionally, a first to pick up,
first to talk rule allowed for calling multiple phone lines concurrently (for different pods at the outpatient clinic), and further reduced time
wasted by the radiologist. CONCLUSION An excellent solution to reduce the phone call burden on the radiologist is a direct browser based VoIP implementation that features
smart rules for calling and receiving via the Dictaphone to increase workflow efficiency. LL-INE3197-SUB • The Use of a Digital Camera to Measure the Luminance of a Medical Monitor
Peter A Hardy PhD (Presenter) Background Medical Image monitors used for image interpretation on MR and CT systems applying for ACR accreditation must be assessed for
adequate luminance range and uniformity. Typically this is done with a calibrated spot luminance meter. These devices are expensive and
are not readily available to most radiology departments. We sought to calibrate a digital camera so it could be used to estimate the
luminance of medical displays. Evaluation We used three digital cameras (Canon Power Shot SX100, Canon PowerShot SX10 and a Nikon D60) to take photographs of a flat panel
LCD monitor displaying a SMPTE pattern. The luminance of the varying contrast squares of the SMPTE pattern were measured using a
calibrated photometer. The photographs were exported from the cameras as JPEG files and analyzed in a program developed in IDL to
measure the average grey value within ROI encompassing 75% of the area of each contrast block. We fitted the grey values to a
polynomial equation to derive an equation L=f(G) linking the photographic grey values (G) to the monitor luminance (L). We then tested
this equation by taking similar photographs of a second monitor and comparing the luminance estimated from the photograph against
that measured using the photometer. Discussion The relationship between monitor luminance and photographic grey value was best parametrized with a quadratic function where the grey
value was transformed to x= log(1-G/Gmax) where Gmax was 255 as the photographs were three byte (RGB) JPEG files. Each camera
had a unique, but similar, opto-electronic conversion function (OECF). Using the OECF we confirmed the luminance could be corrected for
different exposure settings (EV) on the camera, (ISO, F-stop, shutter speed).This allowed us to estimate luminance even if the EV were
different between calibration and use. The ratio of the estimated to the measured luminance was 1 to within a small value (10%, 5%,
3% for the three cameras) over the luminance range 0 - 90 Cd/m2 . CONCLUSION With careful calibration a digital camera can measure monitor luminance rapidly and repeatedly. Photographs can be stored for
subsequent review. It obviates the need to acquire an expensive and seldome used piece of equipment. LL-INE3240-SUB • Quantitative Cardiac MR and Thoracic MRA Reporting with National Cancer Informatics Program (NCIP)
Annotation and Imaging Markup (AIM) with Integrated Logic Case Report Form
Jeremy D Collins MD (Presenter) * ; Vladimir Kleper ; Skip Talbot BS ; Michael Teistler PhD ; James C Carr MD * ; Pattanasak Mongkolwat PhD Background Cardiac MR (CMR) is the gold standard for assessment of biventricular function and when combined with 3D MR angiography (MRA),
enables a comprehensive assessment of the heart and thoracic aorta. Although CMR exams are well suited for structured reporting,
standard voice recognition dictation systems are not optimized to efficiently extract and store quantifiable data. There is a need to
standardize qualitative descriptions and reporting of quantifiable CMR results. The NCIP AIM 4.0 has been integrated into a ClearCanvas
open source imaging workstation, providing a foundation to integrate structured reporting into clinical practice. The case report form
created by AIM Template Builder (ATB) 2.0 is capable of branching logic and providing default answer(s). Custom case report forms and
the workstation enable a reporting tool for cardiac MR and thoracic MRA evaluation that incorporate logic to generate qualitative
descriptions of quantifiable CMR results. Evaluation Cardiac MR and Thoracic MRA templates were created using the AIM template builder for myocardial evaluation using the 17-segment
AHA model, morphological assessment of the aortic valve, and quantification of thoracic aortic size. Advanced templates incorporate left
ventricular T1 and T2* values for tissue characterization and evaluation of the left ventricular extracellular volume fraction. Discussion Anonymized CMR and thoracic MRA studies were used to collect data for purposes of trialing the AIM templates. The imaging studies were
visualized and analyzed on an NCIP AIM 4.0 enabled ClearCanvas workstation. Users were able to annotate images and store data as XML
files. This format enables ready extraction of data for clinical and research purposes. CONCLUSION The NCIA AIM 4.0 deployed on a ClearCanvas imaging workstation with the ATB is well suited for clinical reporting. Integrating this
system into clinical practice could enable efficient query of clinical data for education and research purposes, while providing efficiencies
at structured reporting. Information initially entered and stored in this manner is suitable to establish an imaging registry without
dedicated clerical staff. Musculoskeletal - Sunday Posters and Exhibits (1:00pm - 1:30pm) Sunday, 01:00 PM - 01:30 PM • Lakeside Learning Center
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LL-MKS-SUB • AMA PRA Category 1 Credit ™:0.5 LL-MKE-SU7B • MR Imaging of Solitary Osseous Lesions Involving the Spine
Mohammed M Khadir MD (Presenter) ; Burke Morin DO ; Steven P Meyers MD, PhD PURPOSE/AIM Characterization of the various MRI findings of solitary osseous lesions involving the spine can offer help in formulating an appropriate
differential diagnosis. The purpose of this presentation is to demonstrate the MRI findings of non-aggressive and aggressive solitary
vertebral tumors and tumor-like lesions. CONTENT ORGANIZATION -Normal MR imaging findings of the spine. -MR findings of benign neoplasms: Enchondroma, Chondroblastoma, Osteoid osteoma,
Osteoblastoma, Giant cell tumor, Aneurysmal bone cyst, Osteochrondroma, Hemangioma. -MR findings of malignant neoplasms:
Metastatic lesions, Myeloma/plasmacytoma, Lymphoma/leukemia, Chordoma, Chondrosarcoma, Osteogenic sarcoma, Ewing sarcoma,
Malignant fibrous histiocytoma, Hemangioendothelioma, Hemangiopericytoma. -MR findings of tumor like lesions: Paget disease, Fibrous
dysplasia, Arachnoid cyst, Perineural cyst, Dermoid, Epidermoid, Neurenteric cyst, Synovial cyst, Bone island. -MR findings of
inflammatory/infectious lesions: Rheumatoid arthritis, Eosinophilic granuloma. -MR findings of hematopoietic lesions: Amyloidoma, Bone
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inflammatory/infectious lesions: Rheumatoid arthritis, Eosinophilic granuloma. -MR findings of hematopoietic lesions: Amyloidoma, Bone
infarcts -MR findings of congenital lesions: Myelomeningocele/myelocele, Meningocele, Lipomyelomeningocele
SUMMARY Review the MR findings of solitary osseous spinal lesions. Discuss common limitations and pitfalls of MR in imaging these lesions. LL-MKE-SU6B • The Alphabet Soup of Carpal Instabilities
Carol L Andrews MD (Presenter) * ; Aaron J Wyse MD ; Saraswathi K Golla MD PURPOSE/AIM The exhibit purpose is 1. To review the normal ligamentous/osseous wrist anatomy
2. To describe assessment of lesser/greater arc injuries
4. To assess perilunate and midcarpal instabilities
5. To describe etiologies and patterns of intercalated segment instability
CONTENT ORGANIZATION Imaging anatomy Carpal instability classification
Dissociative carpal (CID)
Non-dissociative carpal (CIND)
Complex carpal (CIC)
Adaptive carpal (CIA) Lesser/greater arc injuries
Perilunate instability (PLI)
Classification of lesser and greater arc injuries(SLL, LTL tears)
Scapholunate dissociation(SLL, RSC tears)
Midcarpal instability (MCI)
Capitolunate instability (CLIP)
Palmar midcarpal instability (PMCI) Intercalated segment instability
DISI
VISI Scapholunate advance collapse (SLAC) Scaphoid nonunion advanced collapse (SNAC) Treatment options
Non-operative
Operative SUMMARY Exhibit teaching points include: 1. Understanding of normal wrist anatomy/alignment is essential for appropriate evaluation.
2.Typically lesser arc injuries result in ligament injury while greater arc injuries result in combined ligament/osseous injury.
3. Midcarpal instability is typically dynamic in nature.
4. Intercalated segment instability involves both intrinsic and extrinsic wrist ligament pathology.
LL-MKS-SU1B • MRI Findings in Arthroscopically Proven HAGL Lesions
Takouhie C Maldjian MD ; Vineet K Khanna MD (Presenter) ; James P Bradley MD ; Richard J Adam MD PURPOSE The purpose of this study is to evaluate potential signs of HAGL(Humeral avulsion of the inferior glenohumeral ligament) lesions.
METHOD AND MATERIALS We searched our database over approximately a 7 year period for cases of arthroscopically proven HAGL lesion with pre-operative MRI.
We found 12 cases of arthroscopically proven tears. 11 of the 12 cases were performed as MR arthrograms. The images were evaluated
retrospectively by 2 fellowship trained musculoskeletal radiologists for the following signs: torn ligament, �J� sign, and extravasation of
contrast into extra-articular spaces (including quadrilateral space, into posterior musculature, between the subscapularis and teres minor,
extending down humerus diaphysis). RESULTS Of the 12 cases, the diagnosis of HAGL was originally missed on MRI in 4 cases. At least one of the above signs was present on
retrospective review. All 4 demonstrated a �J� sign. Extravasation of contrast between the subscapularis and teres minor was also
present in 2 of the 4 cases. Overall, 8 of the 11 arthrograms demonstrated extravasation of contrast into an extra-articular space. The
non-arthrogram case demonstrated communication of joint fluid with the quadrilateral space, which was deemed the equivalent of
extravasation. CONCLUSION This is the largest series of arthroscopically proven HAGL lesions documenting MRI findings. While ligament disruption and abnormal
contrast extending down the humeral diaphysis are valid signs of HAGL lesions, these signs may not always be present. Communication of
contrast/joint fluid with extra-articular spaces was seen in over 70% of our cases of arthroscopically proven tears. Therefore,
extra-articular extravasation of contrast may serve as a valid sign of HAGL. In addition, 2 of the 4 cases of IGL tears that were missed on
initial MRI reports on retrospective review demonstrated a �J� sign. While the �J� sign may not be specific for these injuries, it may be
the only manifestation of such injuries in subtle cases. CLINICAL RELEVANCE/APPLICATION Extra-articular contrast extravasation may serve as a valid sign of HAGL lesions. The J sign, though nonspecific, may be the only evidence
of subtle HAGL lesions. LL-MKS-SU2B • MR Assessment of the Rotator Cables in Normal and Abnormal Rotator Cuffs
Hye Jung Choo MD (Presenter) ; Sun Joo Lee MD ; Dong Wook Kim MD, PhD ; Young Mi Park MD, PhD ; Seok Jin Choi ; Ok
Hwa Kim ; Seon-Jeong Kim MD PURPOSE To evaluate and compare the morphology and position of the rotator cables in normal shoulders and tendinosis, partial-thickness tears
and full-thickness tears of supraspinatus-infraspinatus tendons (SST-IST) on direct or indirect MR arthrography of the shoulders METHOD AND MATERIALS On the review of direct or indirect MR arthrography by two musculoskeletal radiologists, 30 MR images of normal shoulders and 74 of
tendinosis in SST-ISTs were included. Thirty-seven MR images of partial thickness tears in SST-ISTs and 65 of full-thickness tears in
SST-ISTs, which were confirmed by arthroscopic surgery, were obtained. On these types of shoulder MR imaging, the visibility, depth,
and width of rotator cables, and the distance between the lateral edge of rotator cables and medial aspect of the footprints were
measured and these were compared between the types by using Mann-Whitney test and Kruskal-Wallis test. RESULTS In every type, all rotator cables were visible on the sagittal planes of MR imaging. However, on the coronal planes, rotator cables in 11
(37%) of normal shoulders, 42 (57%) of tendinosis, 26 (70%) of partial thickness tears, and 57 (88%) of full thickness tears were
detectable. Rotator cables were significantly thinner in normal shoulders (1.1 mm, 0.6�1.7 mm) and significantly thicker in the
full-thickness tears of SST-ISTs (2.1 mm, 0.8�4.1 mm) than the others (tendinosis, 1.5 mm, 0.7�3.6 mm; partial-thickness tears, 1.6
mm, 0.9�2.5 mm). In full-thickness tears of SST-ISTs, rotator cables were significantly narrower (7.7 mm, 4.5�13.9 mm) than the
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others (normal shoulders,11.3 mm, 8.75�16.6 mm; tendinosis, 10.3 mm, 6.5�17.2 mm; partial-thickness tears, 9.5 mm, 5.9�13.0 mm)
and the distance between the lateral edge of rotator cables and medial aspect of the footprints (21.1 mm, 5.7�45.6 mm) was
significantly longer than that the others (normal shoulders; 9.0 mm, 6.7�12.3 mm; tendinosis, 8.5 mm, 3.5�12.2 m; partial-thickness
tears, 10.5 mm, 7.2�15.7 mm). CONCLUSION On the sagittal planes of direct or indirect MR arthrography, all rotator cables were visible. Rotator cables were significantly thinner in
normal shoulders and significantly thicker and narrower in full-thickness tears than other types of shoulders. CLINICAL RELEVANCE/APPLICATION 1. Every rotator cable is visible on MR imaging. 2. MR imaging is useful to evaluate the rotator cable. LL-MKS-SU3B • Functional Evaluation of Degenerative Tears of the Medial Meniscus of the Knee Using Weight-bearing MRI
Alice La Marra MD (Presenter) ; Silvia Mariani MD ; Lorenzo Maria Gregori ; Vittorio Calvisi MD ; Antonio Barile ; Carlo
Masciocchi PURPOSE To determine prospectively the role of 1.5 T, dedicated low-field standard and upright-MRI in the evaluation of stable or unstable
degenerative tears of medial meniscus in comparison with arthroscopy. METHOD AND MATERIALS Our series included 2700 knee MRI scans performed with a high field MRI scanner from January 2010 to March 2013. On the basis of the
concordance between clinical and high-field MRI diagnosis, we selected two groups of patients . In the first group (group A) we included
70 MRI exams of normal knee and in the second group (group B) we included 175 MRI exams of knee with clinical evidence of medial
meniscus degenerative lesions (Grade 1-4 lesions). In the same session, after conventional 1.5T and "dedicated" 0.25T supine MRI
exams, the patients underwent upright weight-bearing examination with the same dedicated MRI unit. We used sagittal and coronal scans
(SE T1-W) in all cases. RESULTS In group A, there were no statistically significant anatomical changes of the signal intensity, position and morphology of the medial
meniscus between standard 1.5T, dedicated supine and upright MRI. In group B, the images acquired in the supine position (dedicated
and 1.5T MRI) documented, in 55 cases (group B1) a grade 1-2 degenerative lesions, and in 120 cases a grade 3-4 degenerative tears
(group B2). In group B1, weight-bearing MRI showed presence of unstable tears only in 12 out of 55 cases. In group B2, weight-bearing
MRI showed a degenerative unstable meniscal tear in 82 out of 120 cases. Arthroscopy confirmed weight-bearing MRI diagnosis in all
cases. CONCLUSION The upright MRI allows to record load-induced physiological variation in degenerative meniscal lesions, thus showing both the meniscal
stability and a latent instability, making it possible to correctly guide the orthopedic surgeon towards an appropriate surgical treatment. CLINICAL RELEVANCE/APPLICATION This study allows to classify as stable or unstable the degenerative lesions of the medial meniscus. It is very important to select the most
appropriate surgical treatment LL-MKS-SU4B • A Comparative Study between Dynamic Contrast Enhanced-MRI and Histopathological Grading of Soft Tissue
Sarcomas
Shao Wu Wang (Presenter) ; Minting Zheng ; Xiaobo Niu ; Dianxiu Ning PURPOSE To investigate the relationship between the time intensity curve (TIC) and the dynamic parameters of dynamic contrast enhanced
magnetic resonance imaging (DCE-MRI) with histopathological grading in soft tissue sarcomas (STSs). METHOD AND MATERIALS 26 patients with histopathologically proved STSs underwent conventional MR imaging and DCE-MRI within 2 weeks prior to surgery. The
TIC of 26 STSs were divided into four types: type I: no or slightly enhancement; type II: gradual enhancement; type III: rapidly rising
and then plateau; type IV: rapidly rising and then declined. Dynamic parameters including maximum slope of increase (MSI), signal
intensity of peak (SIpeak), signal enhanced extent (SEE), etc. According to the tissue section, we classified the 26 cases of STSs into
three grades (French Federation of Cancer Centre grading system). TIC types and dynamic parameters were correlated with the
histopathological grades. RESULTS CONCLUSION TIC types can reflect the histopathological grading of STSs. Type I is an indication of grade I, type II and III are indications of grade II or
III. DCE-MRI parameters of MSI, SEE and SIpeak have good correlation with the histopathological grading, they can reflect the
histopathological grading of STSs. Grade I and III,grade II and III can be identified according to MSI, SEE and SIpeak. CLINICAL RELEVANCE/APPLICATION LL-MKS-SU5B • CEUS of Subcutaneous Masses: Can Vascular Pattern Analysis Be a New Tool in the Characterization?
Armanda De Marchi MD (Presenter) ; Simona Pozza MD ; Paola De Petro MD ; Paolo Balocco MD ; Andrea Ferro ; Paolo
Lombardo ; Ginevra Biino MSc, PhD ; Alessandra Linari MD ; Michele Boffano MD ; Raimondo Piana ; Carlo Faletti PURPOSE Purpose of this study is to evaluate the usefulness of high-resolution grey-scale and contrast enhanced ultrasonography (CEUS) in the
study of the subcutaneous soft tissue masses in order to differentiate benign from malignant lesions. METHOD AND MATERIALS From January 2009 to December 2012 a cohort of 202 consecutive patients with a palpable mass were enrolled in this study from a
multidisciplinary group of oncology.
All patients were examined with ultrasound before and after injection of ultrasound contrast agent, except a young patient (17 ys old)
who underwent only the grey-scale ultrasound.
After a qualitative perfusion analysis each mass was assigned to one of seven previously identified perfusion pattern .
Features examined included also lesion size, echogenicity, margins, location and relationship with the fascia.
Imaging results were then compared to the histological report or the clinical outcome, if surgery not indicated.
RESULTS Of 202 examined patients 32 dropped out of the study because they were referred elsewhere by their general practitioner.
Of remaining 170, 110 had a benign lesion: 59 of them underwent a biopsy while 51 are in follow-up; 49 of the 60 patients suspected for
malignant lesions underwent a biopsy while the remaining 11 went directly to surgery.
Statistical analysis showed a significant association of pattern called '6' with malignant lesions, and of patterns called 1, 2, 4 and 5 with a
benign lesion type (Chi square test, P In addition, malignant lesions had a larger mean size in respect with benign ones (T-test,
P=0.0024).
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CONCLUSION The study of vascular pattern showed a good ability to differentiate between benign and malignant lesions thus representing a possible
help in those cases in which it's not easy to distinguish between the two types of lesions. CLINICAL RELEVANCE/APPLICATION In the diagnosis of a lesion is fundamental can recognize it's potential of benignity or malignancy: CEUS in some cases may provide an
additional aid. Multisystem/Special Interest - Sunday Posters and Exhibits (12:30 - 1:00 PM) Sunday, 01:00 PM - 01:30 PM • Lakeside Learning Center
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LL-MSE-SUB • AMA PRA Category 1 Credit ™:0.5 LL-MSE-SU6B • Retrospective Evaluation of the Clinical Role of Whole-Body Diffusion-weighted MRI in 1000 Cancer Patients
Tran Seaton FRCR (Presenter) ; Kathryn L Tran MBBS ; Andrew Gogbashian MD, FRCR ; Anwar R Padhani MD * PURPOSE/AIM Whole-body diffusion-weighted imaging (WB-DWI) is an emerging technique whose role in clinical practice is not well defined. We
analyzed the 1st 1000 of 1700 WB-DWI studies done at a tertiary cancer center to assess its utility in the management of cancer patients. CONTENT ORGANIZATION -Whole-body diffusion weighted imaging (WB-DWI) technique -Potential advantages over current imaging modalities including PET
-Experience of WB-DWI in our cohort -- General clinical indications (1000 studies total) - Experience in breast cancer (587 studies)
-Experience in multiple myeloma (140 studies) -Experience in prostate cancer (109 studies) -other tumor types (including renal cancer,
melanoma and lymphoma) *Presentation of representative WB-DWI images from our cohort *Discussion of clinical utility as tool for
staging, response assessment, re-staging and surveillance -Reflection of future development roles of WB-DWI
SUMMARY The major teaching points of this exhibit are: - To educate delegates on how to introduce and incorporate WB-DWI into clinical practice To present our practical experience of how WB-DWI studies are used in the clinical management of cancer patients -To show that its key
role is in the detection and management of bony disease � an area of unmet clinical need
Neuroradiology/Head and Neck - Sunday Posters and Exhibits (1:00pm - 1:30pm) Sunday, 01:00 PM - 01:30 PM • Lakeside Learning Center
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LL-NRS-SUB • AMA PRA Category 1 Credit ™:0.5 LL-NRE-SU6B • Pipeline Embolization: Tips, Tricks and Pitfalls
Nucharin Supakul MD (Presenter) ; Ammar Taha MD ; Juan G Tejada MD PURPOSE/AIM To demonstrate the hemodynamic mechanisms involved with effective intracranial aneurysm treatment and common pitfalls, tips and
tricks for effective deployment of the Pipeline Embolization Device (PED) in the treatment of intracranial aneurysms. CONTENT ORGANIZATION 1. Demonstrate key concepts of the flow diversion mechanism
2. Review of Indications and contraindications as well as patient selection
3. Parent vessel access
4. Accurate PED diameter-length selection
5. Deployment technique
6. Common pitfalls, tips and tricks during PED deployment
7. Outcomes after treatment
SUMMARY 1. Understanding the hemodynamic mechanisms and common pitfalls of PED will increase the rate of successful treatments.
2. Learning tips and tricks techniques for proper deployment will maximize success rates and will improve patient care.
LL-NRE-SU7B • Neoplastic and Non-Neoplastic Lesions of the Pineal Region: What the Surgeon Wants to Know
Forrester Lensing MD (Presenter) ; Travis A Abele MD ; Lubdha M Shah MD ; Walavan Sivakumar MD ; Phil Taussky ; Karen
L Salzman MD * PURPOSE/AIM The purpose of this exhibit is: 1. To illustrate the relevant surgical anatomy of the pineal region. 2. To discuss different surgical
approaches to the pineal region. 3. To review the spectrum of tumors and masses that occur in the pineal region. 4. To define specific
imaging features of pineal region masses and tumors that dictate or alter neurosurgical management. CONTENT ORGANIZATION Surgical Anatomy of the Pineal Region Neurosurgical Approaches to the Pineal Region Imaging Review of Pineal Region Masses and
Tumors 1. Pineal Cysts
2. Pineal Region Tumors
3. Pineal Region Tumor-Like Masses
Surgical Planning and Pre-Operative Considerations SUMMARY Teaching Points: 1. Specific imaging features can guide the radiologist in generating a differential diagnosis for lesions of the pineal region.
2. In consultation with the neurosurgeon, the radiologist plays a critical role in determining the operative plan and neurosurgical
approach to the pineal region.
LL-NRE-SU8B • Imaging of Sinus Disease(s)
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Vivek B Kalra MD (Presenter) ; Kyle E Pfeifer MD ; Haatal B Dave MD, MS ; Ajay Malhotra MD PURPOSE/AIM Opacifications of the paranasal sinuses are frequently dismissed as just �sinus disease� without careful evaluation of features that may
suggest pathology more nefarious than simple rhinosinusitus. We present an imaging-based approach based on osseous changes,
presence of hyperdense material, and enhancement patterns. CONTENT ORGANIZATION Briefly review relevant imaging anatomy of the paranasal air sinuses and appropriate imaging criteria Highlight assessment of
distinguishing imaging findings - cortical remodeling, osseous destruction, hyperdense material, and enhancement patterns Present
nosologic classification of sinus diseases based on pathophysiology including post-surgical, infection, inflammatory, cocaine, neoplastic,
and silent sinus syndrome. SUMMARY 1. Cortical thickening suggests chronic sinusitis, as defined as greater than 12 weeks, most commonly presents with benign nodules from
mucus retention pseudocysts and nasal polyps.
2. Osseous erosion can be seen in Wegener, invasive fungal sinusitis, malignancy, cocaine, sarcoidosis, or EG.
3. High density material may suggest fungal sinusitis, with invasiveness suggested by perimaxillary fat infiltration or vascular occlusion.
4. Peripheral enhancement is benign (polyps), cerebriform enhancement is potentially malignant (inverted papilloma), and central
enhancement is malignant. LL-NRE-SU9B • The Role of Multidetector CT Imaging of the Parathyroid: What the Radiologist Needs to Know to Perform and
Interpret the Exam
Douglas S Drumsta MD (Presenter) ; Susan K Hobbs MD, PhD ; Jacob Moalem MD PURPOSE/AIM Four dimensional computed tomography (4D-CT) is a relatively new technique for the localization of parathyroid adenomas. This
technique has become more popular for preoperative localization of parathyroid adenomas in patients with inconclusive standard imaging
studies, failed surgical neck exploration and those undergoing minimally invasive parathyroidectomy. The purpose of this exhibit is to
review the technique of 4D-CT for parathyroid detection including postprocessing techniques, normal and abnormal parathyroid imaging
characteristics on CT, diagnostic pearls and pitfalls and the anatomy of the parathyroid for preoperative localization of parathyroid
adenomas. CONTENT ORGANIZATION First, this exhibit will describe the technique and indications for 4D-CT. Parathyroid anatomy and imaging characteristics will then be
described with illustrations and CT case based examples demonstrating normal and abnormal appearances as well as the pearls and
pitfalls of the imaging technique. SUMMARY Four dimensional computed tomography (4D-CT) is becoming increasingly popular for the localization of parathyroid adenomas. This
exhibit will review the technique of 4D-CT for parathyroid detection, parathyroid anatomy, and parathyroid CT characteristics, including
cases that illustrate the pearls and pitfalls of 4D-CT for preoperative parathyroid localization. LL-NRE-SU10B • Development Malformations of the Striatum: A Series of Six Cases and a Review of Embryologic and Anatomic
Aspects
Luiz A Ferreira Filho MD (Presenter) ; Bruno E Cabral ; James H Yared MD ; Fabio L Castro MD ; Ademar Lucas MD ; Nelson
F Ferreira MD ; Henrique B Zuppani MD ; Andre E Torres ; Carlos A Martinelli Pereira MD ; Clarissa B Pinto MD PURPOSE/AIM Striatum developmental abnormalities are rare with few published data. Our proposal is to present detailed description of MRI findings
and clinical data of children with striatum malformations and to review embryological and anatomical aspects of these structures. CONTENT ORGANIZATION Six cases were collected in our institution between 2012 and 2013. By qualitative analysis, we observed malalignment and asymmetries
of the caudate nucleus, putamen and thalamus with areas of reduced and enlarged volume. Fusion of the caudate`s head with the
putamen was also noticed. Associated malformations were found in some cases and will be described as well.
SUMMARY Caudate and putamen have common embryological and phylogenetic origin, and also various conective circuits related to cortex and
other basal ganglia. These nuclei are widely involved in the movement control and limbic system modulation.
The changes described are most probably due to developmental malformations of the forebrain. The absence of signal intensity alteration
of the structures evaluated in the reported cases, the similarity of some findings among patients and lack of compatible clinical history
argue against the hypothesis of acquired disorders. Moreover, several cases showed others associated malformations.
LL-NRE-SU11B • Beyond Sinusitis: An Approach to MR and CT Evaluation of Common and Unusual Maxillary Sinus Lesions
Jiamin J Zheng MD (Presenter) ; Prasad B Hanagandi MBBS, MD ; Jaron Chong MD ; Jeffrey Chankowsky MD ; Carlos I Torres
MD ; Raquel Del Carpio-O'donovan MD ; Eric S Bartlett MD, MPH * PURPOSE/AIM 1) To review usual and rare maxillary sinus pathologies presenting with common sinonasal clinical symptoms.
2) To present a systematic approach to differential diagnosis based on distinguishing MR features complemented with CT findings.
3) To advise on appropriate imaging algorithm based on the clinical query.
CONTENT ORGANIZATION - Anatomy of the sinuses.
- Common sites/tissues of origin and routes of invasion/extension for lesions.
- Imaging protocols for MR and CT.
- Pictorial review of cases (lymphoma, chloroma, melanoma, plasmacytoma, neurofibroma, squamous cell and adenocarcinoma, adenoid
cystic carcinoma, esthesioneuroblastoma, hemangioma, fungal infections, Wegener�s granulomatosis, dentigerous cyst, inverted
papilloma, schwannoma, acute and chronic inflammatory sinusitis, polyposis and fibro-osseous lesions).
- Algorithm towards differential based on morphology, the presence of calcifications, effect on adjacent bone, T1 and T2 hypointensity, T2
hyperintensity, along with CT correlation.
SUMMARY A variety of inflammatory, infectious, neoplastic, fibro-osseous and congenital pathologies can mimic sinusitis and vice-versa. The
radiologist should be familiar with these conditions to avoid diagnostic delay and complications. LL-NRE3124-SUB • PET/MR: Applications in Neuroradiology
Brice A Kessler BS (Presenter) ; Benjamin Y Huang MD, MPH ; Bhishamjit Chera MD ; Arif Sheikh MD ; Weili Lin PhD ; Mauricio Castillo MD ; Yueh Z Lee MD, PhD * PURPOSE/AIM Simultaneous PET/MR enables the acqusition of both functional and anatomic imaging during the same session. This tool is especially
Page 71 of 397
powerful in neuroradiology, where MR soft tissue discrimination is especially important for radiological diagnosis. The aim of this
presentation is to review the available literature on PET/MR applications in neuroradiology and present educational cases. Corresponding
PET/CT studies will also be shown for comparison. CONTENT ORGANIZATION Review published neuroradiology applications of the PET/MR. Educational Cases of the PET/MR with corresponding PET/CT. Brain neoplasms
Head and neck neoplasms
Spine Imaging
Brachial plexus imaging
Advanced imaging applications
Discuss workflow issues related to Neuro PET/MR. SUMMARY The major teaching points of this exhibit are: Combined PET/MR imaging can be a powerful tool for neuroradiology applications.
Careful planning and workflow development is required to optimize imaging.
Advanced imaging technique may be combined with conventional anatomic MR to further enhance the synergy of PET/MR.
LL-NRS-SU1B • CT Perfusion Imaging in Predicting Delayed Cerebral Ischemia in Patients with Aneurysmal Subarachnoid
Hemorrhage: A Systematic Review
Danial I Mir (Presenter) ; Ajay Gupta MD ; Luis A Puchi BS ; Christopher Robinson ; Allison Dunning ; Pina C Sanelli MD PURPOSE To identify and critically analyze prospective and retrospective English language published manuscripts evaluating the utility of CT
perfusion (CTP) in predicting measures related to delayed cerebral ischemia (DCI) in patients with aneurysmal subarachnoid hemorrhage
(ASAH). METHOD AND MATERIALS An experienced medical librarian conducted a comprehensive literature search to identify studies that evaluated the use of CTP in
identifying patients with any of the following outcomes of DCI: 1. clinical deterioration sufficiently judged to be due to DCI, 2. secondary
cerebral infarction identified on follow-up CT or MR imaging or 3. functional disability related to DCI. Search results were preliminary
screened via title and abstract information by a single reader with shortlisted manuscripts reviewed in full by two independent readers for
inclusion. Disagreements were resolved by consensus. Using a standardized data collection template, study characteristics including
baseline patient demographics, CTP test characteristics, and detailed DCI outcome data was collected by two independent readers with
disagreements resolved by a third reader. RESULTS Search results yielded 218 studies of which 8 cohort studies met our inclusion criteria. Together these studies encompass 381 patients.
After CTP, 196 subjected (51%) were included in the DCI group and 185 (49%) in the non-DCI group. Admission disease severity was
comparable across all groups. In only 4 studies were test characteristics reported or data presented from which they could be tabulated.
Despite differences in CTP methodology, these studies demonstrated similar diagnostic accuracy in predicting DCI outcomes. The
weighted averages and range of the extracted/tabulated sensitivities and specificities of CTP in predicting DCI outcomes from these
studies are 0.80 (0.7 - 0.93) and 0.76 (0.66 - 0.83), respectively. CONCLUSION Despite significant differences in patient populations studied and imaging techniques utilized, our systematic review demonstrates that
CTP is a useful imaging modality in identifying those patients most at risk for developing DCI in patients with ASAH. CLINICAL RELEVANCE/APPLICATION Because DCI is often diagnosed after significant and irreversible morbidity has occurred, treatment is often of limited efficacy. CTP may
predict impending DCI and allow for pre-emptive intervention. LL-NRS-SU2B • 4D Flow MR Imaging after IC Ligation for Giant Aneurysm and High Flow EC-IC Bypass Surgery: Comparison with
TOF MRA, CT Angiography and CT Perfusion
Ryo Takagi MD (Presenter) ; Tetsuro Sekine ; Yasuo Amano MD ; Yasuo Murai MD ; Elika Orita ; Akio Morita MD, PhD ; Shinichiro Kumita MD PURPOSE Time resolved 3D phase-contrast (4D-flow) MRI is a promising tool for blood flow evaluation in cerebrovascular disease. The purpose of
this study is to demonstrate the clinical feasibility of 4D-flow MRI in the evaluation of hemodynamics in patients after both ICA ligation for
Aneurysm and extracranial/intracranial (EC/IC) bypass surgery using a radial artery graft. METHOD AND MATERIALS Seven patients (6 females and one male, mean age; 68 years) with 6 giant aneurysms (size; 15-30mm, mean 21mm) and one carotid
cavernous fistula were treated with ICA ligation and EC/IC bypass surgery using a radial artery graft. We performed CT Angiography
(CTA) and CT perfusion (CTP) using 64-slice multi-detector (MD)-CT, TOF-MRA and 4D-flow MRI at 3T after surgery. The date of 4D flow
MRI was transported to another personal computer with 4D flow visualization software (GT-Flow; GyroTools). Time-resolved 3D-flow
mapping images of EC/IC bypass graft and cerebral artery were generated. The patency, stenosis and bending of radial artery graft were
evaluated independently on CTA, TOF-MRA and 4D-flow MRA. 4D-flow MRI and CTP were evaluated for the perfusion of MCA territory. RESULTS Bypass surgery was successful in all patients. The acquisition time of 4D-flow MRI data was about less than 10 minutes. 4D-flow MRI
visualized the arterial flow from radial artery graft to MCA successfully. TOF-MRA demonstrated narrowing of graft-side MCA in all patients
and stenosis of 5 locations (severe; 1, moderate; 2, mild; 2) of graft in 4 patients. 4D-flow MRI showed stenosis of 5 locations (severe; 0,
moderate; 1, mild; 4). CTA showed stenosis of 4 locations (severe; 0, moderate; 0, mild; 4). CTP demonstrated symmetrical perfusion of
MCA territory in all patients. On the other side, 4D-flow MRI demonstrated of flow delay of MCA M1 portion in 6 patients and could not
depict flow of M1 by the artifact of aneurismal clip in one patient. CONCLUSION 4D-flow MRI is a promising tool that visualizes graft flow and intracranial arterial hemodynamic in patients after IC ligation for aneurysm
and EC/IC bypass surgery. CLINICAL RELEVANCE/APPLICATION Time resolved 3D phase-contrast (4D-flow) MRI is a promising tool that visualizes cerebral blood flow and graft patency after both ICA
ligation for giant aneurysm and high flow EC/IC bypass surgery. LL-NRS-SU3B • MSCT-Criteria for Assessment of the Temporal Bone Structures before Stapes Surgery
Irina Bodrova MD, PhD (Presenter) ; Larisa Kulakova ; Nina V Gagarina MD ; Sergey K Ternovoy MD, PhD ; Ekaterina
Fominykh ; Andrey Lopatin Page 72 of 397
PURPOSE to determine MSCT capabilities in detection of anatomical and topographical characteristics of the vestibular window region before stapes
surgery. METHOD AND MATERIALS 32 persons (53 ears) with otosclerosis participated in the study. Average age was 35,6±1,7 years. All patients have been examined by
microotoscopy,audiologic tests,MSCT. 9 patients had unilateral disease and 22-bilateral. The CT study was conducted using a program of
bone reconstruction with slice thickness of 0.5mm. The niche of vestibular window was assessed in all ears on the following criteria: the
width and form of the niche,the presence and absence of overhanging of facial nerve canal over the vestibular window (similar for
promontorium),the width of the stapes footplate,stapes cruses width,distance to the internal wall of vestibule. All 53 ears underwent
stapes surgery. RESULTS CONCLUSION The proposed MSCT-criteria allows to estimate the complexity of the surgery,thoroughly plan for the surgery,to predict the outcome. CLINICAL RELEVANCE/APPLICATION Using of MSCT allowed to choose plan of operations,the special instruments and implants,to avoid frequent complications. LL-NRS-SU4B • Regional Specificity of fMRI, DTI, and MRS Data in Substantia Nigra (SN) for Characteristics of the Level of
Cognitive Impairment (CI) in Patients with Parkinson’s Disease (PD)
Zina Z Rozhkova PhD, DSc (Presenter) ; Oleksii Omelchenko MSc PURPOSE We try to find biomarkers for characteristic of the regional specificity of the fMRI, DTI, and MRS data in patients with PD and different
level of CI. METHOD AND MATERIALS Three groups of patients are studied by fMRI, DTI, and MRS with 1.5T SIGNA (GE). The 1st group (DPDG) consists of 13 PD-patients with
dementia (MMSEMMSE=25).The 3rd group (NPDG) includes 18 patients with normal cognitive function (MMSE>30). Resting state fMRI
data and simple unilateral finger tapping task are used for the acquisition of blocked design fMRI data. fMRI images are obtained
using:TR/TE=3000/60ms. The analyses was carried out with GLM and ICA (FSL5.0 software package):FEAT, and MELODIC. DTI (25
directions) are obtained in ROI=2x2x2mm in the anterior, medial, and posterior SN (ASN, MSN, PSN). Spectra are recorded with the
SVSSTEAM:TR/TE=1500/144ms. RESULTS In the NPDG connections between the APCG and PPCG, and inferior parietal gyrus bilaterally were found. In the NPDG activation of the
anterior (APCG), and of the posterior portion of cingulate gyrus (PPCG) decreased, but connectivity patterns persisted. In CIPDG activated
clusters were found precuneally. In DPDG no activation in PPCG were found. Mean diffusivity (MD)
are:(0.82+-0.05)x10-3mm2/s,(0.74+-0.05)x10-3mm2/s,(0.71+-0.05)x10-3mm2/s in DPDG, CIPDG, NPDG. The MD changes are most
pronounced in APSN. Fractional anisotropy (FA) are:(0.41+-0.05), (0.43+-0.05),(0.47+-0.05) in DPDG, CIPDG, NPDG. FA have
non-significant tendency to decrease in patients with various level of CI. In anterior part of SN (APSN) the mean values of NAA/Cr in
DPDG, CIPDG, and NPDG:(1.68+-0.02),(2.04+-0.03),(2.32+-0.05), and Cho/Cr:(0.84+-0.02),(0.81+-0.05),(0.53+-0.03). In posterior
part of SN (PPSN) the mean values NAA/Cr in DPDG, CIPDG, and NPDG are:(1.14+-0.12),(1.81+-0.02), (1.98+-0.04), and
Cho/Cr:(0.96+-0.02),(0.77+-0.03),(0.68+-0.03). Progressive decreasing NAA/Cr in the PPSN and increasing of Cho/Cr for the patient of
NPDG, CIPDG, DPDG are found, that is associated with poorer cognitive function. CONCLUSION fMRI, DTI, and MRS-data give us new approach for understanding pathophysiological changes in PD-patients associated with CI. CLINICAL RELEVANCE/APPLICATION Bringing together resting state and simple unilateral finger taping fMRI, regional DTI-, and MRS-data in SN we obtain biomarkers of
neuronal dysfunction in patients with PD and different level of CI. Radiation Oncology and Radiobiology - Sunday Posters and Exhibits (1:00pm - 1:30pm) Sunday, 01:00 PM - 01:30 PM • Lakeside Learning Center
Back to Top RO
LL-ROS-SUB • AMA PRA Category 1 Credit ™:0.5 LL-ROS-SU1B • The Impact of Pre-treatment Prostate Volume on Gastrointestinal or Genitourinary Complications in Prostate
Cancer Patients Treated with Intensity Modulated Radiation Therapy IMRT (Two Different Methods of Measurement)
Samar Azawi (Presenter) ; Juying Zhang PhD ; Mina Behdad BA ABSTRACT . retrospective review of 300 patients (2003-2012).
We identified 52 prostate cancer patients who were treated with IMRT (2008-2012) . we were able to obtain prostate volumes and DVH.
Prostate size was measured based on transrectal ultrasound at time of biopsy and CT scan during treatment planning.
Patients received a median dose of 7560 Gys delivered using IMRT (range 70007740).
Radiation dose classification are as follows:
7740 Gy/180, n=19 ; 7560 Gy/180, n=28 ; 7380Gy/180, n=3 ; 7000 Gy/250 , n=2
Prostate volume measurements by transrectal ultrasound were performed prior to treatment.
Target size was defined as less than or greater than 50 cc.
The prostate volume classification and the corresponding number of patients are as follows :
V=25-50 cc, n=16; V=51-60 cc, n=18
V= 61-80cc, n=15 ;
V > 100cc ,n=3(160cc,137.2cc, 119cc).
Evaluation of the acute and late GU complications included acute urinary retention ,hematuria and high grade frequency.
Evaluation of the acute and late GI complications included rectal bleeding .
mean follow-up time of 19 months. (Max: 48months, Min 4 months)
Results:
, 5/48 patients developed rectal bleeding (10.41%). Four of them had prostate size greater than 50 cc, with the mean of 63.92 cc per CT
measurement.
All of them received 40 Gy on 78.8 %, 69.8%, 71.73%, 65.3% of the rectum volume respectively.
They received 65 Gy on 27.5 %, 31.2%, 29.6%, 31.7% of the rectum volume respectively.
One patient developed gross hematuria 8 months after completion of the radiation therapy. In this patient prostate volume is 34.48 per
CT measurement .
Rectal bleeding resolved with APC
There was no evidence of acute urinary retention (AUR) requiring intervention due to treatment in long term follow up.
The average volume of the prostate was 55.27 (range 25.72-160.65) according to CT
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The average volume of the prostate was 55.27 (range 25.72-160.65) according to CT
and 47.09 cc (range 12- 119) according to TRUS.
Mean of CT sizes was 11.28 cc higher than TRUS sizes (59.96 vs.48.68) which is 35%.
There is a significant difference between patients who received 65 Gy to the rectum with
GI complications.
Study patients with radiation of 65 Gy to 27.5%, 31.2% and 29.6% of their rectum respectively, had higher GI complications
(p-value:0.04).
There is a significant difference between patients who received 65 Gy to the 26.4%,
45.2% and 24.9% of the bladder volume respectively. These patients who received 65
Gy to the bladder had higher GU complications (p-value:0.05).
There is a significant difference in patients who received 40 GY to the 65% of the bladder. These patients had higher GU complications
(p-value:0.05).
There is no correlation between pre-treatment CT measured volume of the prostate with GI and GU complications (p-value:0.97).
Conclusion:
There was no acute urinary retention requiring intervention.
LL-ROS-SU3B • Definitive Chemoradiation Boosted by Low-dose-Rate Brachytherapy in Cervical Cancer: Long Term Clinical
Outcomes
Tamer Refaat Abdelrhman MD,PhD (Presenter) ; Eric D Donnelly MD ; Caroline Novak ; Ye Yuan ; Jonathan B Strauss MD ; William Small MD ; Irene Helenowksi ; Alfred W Rademaker PhD ; Julian C Schink MD ; John R Lurain ABSTRACT Purpose: To review and report the long-term treatment induced adverse events and clinical outcomes of concomitant chemoradiotherapy
boosted by low-dose-rate (LDR) conventional brachytherapy (BT) in patients with locally advanced cervical cancer.
Patients and Methods: After obtaining institutional review board approval, we reviewed the records of patients with stage IB1 through
IVA, intact cervical cancer who were treated at our institution between 1983 and 2009. Eligible patients underwent definitive radiotherapy
with external beam radiation concomitant with cisplatin-based chemotherapy and boosted by LDR brachytherapy. Patients and tumor
characteristics, treatment induced adverse events including gastrointestinal (GI), genitourinary (GU) and skin toxicities, as well as clinical
outcomes including local control (LC), distant metastases free survival (DMFS), disease free survival (DFS) and overall survival (OS) were
reviewed and reported.
Results: A total of 135 patients were eligible and included; the median age was 46 (range 26 to 81), stages IB, II, III, IVA were 28.9%,
48.2%, 17.8% and 5.2% respectively, 92, 41 and 2 patients were treated with concurrent cisplatin, cisplatin and 5 Fu and cisplatin and
bevacizumab respectively. For all patients OS at 5 and 10 years was 68.3% and 62.7%, DFS was 69.8% and 59.3%, LC was 84.7% and
84.7%, and DMFS was 74.0% and 68.1% respectively. At 5 years, stages IB, II, and III specific OS was 73.0%, 69.4%, and 59.4%, DFS
was 74.6%, 72.3%, and 54.6%, LC was 86.7%, 85.8%, and 77.4%, and DMFS was 77.6%, 77.9%, and 54.6%, respectively. At 10
years, stages IB, II, and III specific OS was 58.4%, 64.4%, 59.4%, DFS was 49.0%, 67.2%, and 54.6%, LC was 86.7%, 85.8%, and
77.4% and DMFS was 67.9%, 72.3%, and 54.6%, for stages IB, II, and III respectively. GI, GU, and skin Grade 3 and 4 acute toxicities
were reported in 3.7%, 0.0% and 3.7% of patients while chronic Grade 3 and 4 toxicities were reported in 17.8%, 11.1% and 3.7% of
patients respectively.
Conclusion: Definitive chemoradiation followed by conventional LDR BT boost is effective, feasible and tolerable treatment modality for
locally advanced cervical cancer. The treatment induced adverse events and clinical outcomes are comparable with other recent reports
using image-guidance BT planning. The favorable outcomes we report are reflective of the inherent radiobiological advantage of LDR BT.
This highlights the importance of further evolution in image-guided BT to obtain superior toxicity profile or treatment outcomes compared
to the conventional BT planning. LL-ROS-SU4B • Comparison of Stereotactic Body Radiotherapy and Conventionally Fractioned Radiotherapy in Inoperable
Non-small Cell Lung Cancer
Mohammad Jaffar (Presenter) Vascular/Interventional - Sunday Posters and Exhibits (1:00pm - 1:30pm)
Sunday, 01:00 PM - 01:30 PM • Lakeside Learning Center
IR
VA LL-VIS-SUB • AMA PRA Category 1 Credit ™:0.5 Back to Top LL-VIS-SU1B • Optimizing Image Quality of Abdomen CT Venography by Model-based Iterative Reconstruction
Yuefeng Liu MD (Presenter) ; Hongzhi Cao MD PURPOSE To explore the value of model-based iterative reconstruction (MBIR) in optimizing image quality of abdomen CT venography (CTV). METHOD AND MATERIALS Totally 27 consecutive patients were chosen and underwent plain and contrast-enhanced abdomen CT with automated tube current
modulation (ACTM). The images were reconstructed with filtered back projection (FBP group), adaptive statistical iterative reconstruction
(ASiR group) 50% and MBIR (MBIR group), respectively. Image noises and CT values of muscle, fat tissue, liver, kidney and spleen, as
well as CNR for portal veins, inferior vena cava, pancreatic veins and splenic veins were measured. The image quality was evaluated using
5-point scale. Those results among the 3 different reconstructions were compared by one-way ANOVA and Wilcoxon signed-rank tests. RESULTS CONCLUSION MBIR can improve the overall image quality and has potential in decreasing radiation dose of abdomen CTV. CLINICAL RELEVANCE/APPLICATION MBIR can improve the overall image quality and has potential in decreasing radiation dose of abdomen CTV. LL-VIS-SU2B • Use of Ultrasound Doppler to Optimize the Table Speed of Lower Extremity CT Angiography Protocols
Lei Zhang MD (Presenter) ; Yanhui Yang MD ; Dong Xu ; Kuncheng Li MD PURPOSE We evaluated the relative efficacy of different table speeds predetermined by using the flow velocity measured by ultrasound Doppler in
patients with suspected peripheral arterial occlusive disease (PAOD) who underwent computed tomography angiography of the lower
extremity arteries. METHOD AND MATERIALS This prospective study enrolled 40 patients with suspected PAOD. The average aorta-popliteal artery flow velocity was measured by
ultrasound of average flow velocity of the suprarenal aorta, aortic bifurcation, common and external iliac arteries, common and superficial
(proximal/middle/distal) femoral arteries, and the popliteal artery ((Vaorta+ Vaorta2+ VCCA+ VSFA1+ VSFA2+ VSFA3+ VPOPA)/ 7). The
table speed was adjusted to be equivalent to the measured arterial flow velocity between the supraceliac aorta and popliteal artery.
Adequate vascular opacification was measured for attenuation in the suprarenal and infrarenal abdominal aorta, and in the arteries of the
lower extremities. Venous contamination was also measured. Twenty patients also underwent two monitoring scans at the level of the
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lower extremities. Venous contamination was also measured. Twenty patients also underwent two monitoring scans at the level of the
suprarenal aorta and popliteal artery seperately to measure the aorta-popliteal bolus transit time and speed. RESULTS The flow velocity from ultrasound Doppler and two monitoring scans was similar. CT angiographic images were of good quality in 39
cases, whereas prominent enhancement of abdominal veins was observed in one case. CONCLUSION Aligning flow velocity measured by US Doppler and table speed allows adequate arterial opacification and minimal venous contamination.
CLINICAL RELEVANCE/APPLICATION Aligning flow velocity measured by US Doppler and table speed allows adequate arterial opacification and minimal venous contamination. LL-VIS-SU3B • Valproic Acid as an Imageable, Multifunctional Chemoablative Agent
John Valesano BS (Presenter) ; Erik N Cressman MD PURPOSE To study the effects of valproic acid (VPA), a known inhibitor of histone deacetylase, in ex-vivo porcine hepatic tissue, to characterize it by
imaging, and to compare it to acetic acid, a known ablative agent. METHOD AND MATERIALS VPA neat or diluted in diglyme and aqueous sodium valproate (NaVPA) solutions were prepared and injected into fresh ex vivo porcine
hepatic tissue. Diglyme and acetic acid (50% and matching dilutions) served as controls. The imaging characteristics of the differing
solutions were assessed by CT and MRI both in-vitro and ex-vivo. The amount of coagulation necrosis was noted using histology and
gross pathology. RESULTS VPA was fully miscible in diglyme and both it and NaVPA caused clearly visible zones of coagulation. Lesions from pure VPA and dilutions
of VPA in diglyme were visible on CT imaging as areas of low attenuation while those created by the other conditions were at best faintly
detectable or functionally invisible on CT. No useful differences were noted in tissue at MRI. Grossly, the lesions created by pure valproic
acid were larger than any of the lesions created by the varying dilutions of VPA in diglyme and similar in size to the equivalent amount of
acetic acid. Histologically, VPA caused more hepatocellular shrinkage, increased nuclear damage, and larger areas of cell lysis than acetic
acid. In-vitro studies revealed that pure VPA had a CT attenuation value of -139 Hounsfield Units (HU) while NaVPA was measured at 54
HU. CONCLUSION VPA and NaVPA are both capable of causing coagulation necrosis in hepatic tissue, and zones of coagulation from VPA are readily
detectable in tissue using CT imaging without any added contrast agent. Given these findings and the intrinsic pharmacologic activity of
VPA, further investigation seems warranted. CLINICAL RELEVANCE/APPLICATION Valproic acid is a chemoablative agent imageable by CT that may prove superior to current agents for the ablation of hepatocellular
carcinoma due to its additional pharmacological benefits. LL-VIS-SU4B • Coil Embolization of the Splenic Artery: Impact on Splenic Volume and Factors Contributing to Volume
Preservation
Stephen R Preece MD (Presenter) ; Paul V Suhocki MD ; John Yoo ; Kingshuk Choudhury PhD ; Tony P Smith MD ; Charles Y
Kim MD * PURPOSE Splenic artery embolization can be performed as an alternative to splenectomy in the setting of splenic injury or splenic artery pathology.
However, the impact on splenic function is not well understood. The purpose of this study is to determine the impact of coil embolization
of the splenic artery on splenic volume based pre- and post-embolization CT imaging as well as hemofiltration function. METHOD AND MATERIALS Splenic artery embolization was performed on 148 consecutive patients over an 8 year period for various indications in this IRB approved
retrospective study. Sixty patients (36 males, mean age 49 years) had contrast-enhanced CT before and after coil embolization of the
splenic artery. The mean time between embolization and last follow up CT was 355 days. Pre and post-embolization splenic volumes were
calculated with volume rendering software. The presence of Howell-Jolly bodies was ascertained on lab tests. RESULTS Splenic artery embolization resulted in a mean decrease in splenic volume by 15% (range -88% to +158%). Splenic volumes on CT scans
performed within 30 days of embolization did not change significantly after embolization but after 30 days the mean percentage
reduction was 21% (p=0.004). Embolization of the distal splenic artery resulted in a 30% splenic volume reduction (p=0.003) whereas
splenic volumes did not change significantly after proximal embolization. Both traumatic and nontraumatic indications resulted in similar
degree of volume loss, although pre-embolization splenic volumes were significantly smaller in trauma patients (p=0.029), and more
trauma patients underwent distal embolization (p=0.005). Multivariate analysis revealed that only coil location significantly impacted
splenic volume reduction. Three patients transiently had Howell-Jolly bodies after embolization. No patients required repeat embolization
or splenectomy. CONCLUSION Coil embolization of the main splenic artery results in only a modest degree of splenic volume loss with retention of hemofiltration
function. These findings support the growing body of literature that some degree of splenic function is maintained after splenic artery
embolization. CLINICAL RELEVANCE/APPLICATION Splenic artery embolization for trauma and splenic artery pathology is likely preferable to splenectomy when feasible considering that at
least some degree of splenic function is retained. LL-VIE-SU5B • Classification of Peripheral Arterial Disease Lesions and Their Mimics: The Role of the Interventional Radiologist
Yolanda Bryce MD (Presenter) ; Philip A Rogoff MD ; Ralph L Reichle MD ; Donald F Romanelli MD PURPOSE/AIM The purpose of this exhibit is: 1. To review the risk factors of peripheral arterial disease. 2. To review the Trans-Atlantic Inter-Society
Consensus classification of peripheral arterial disease lesions in pictorial form and their potential treatments. 3. To review the mimics of
peripheral arterial disease in pictorial form including arteritis, Buerger's disease, popliteal entrapment syndrome, popliteal adventitial
disease, popliteal aneurysm, fibromuscular dysplasia, peripheral emboli, keys to distinguish them from peripheral arterial disease, and
their potential treatments CONTENT ORGANIZATION 1. Risk factors for peripheral peripheral disease. 2. Transatlantic Inter-Society Consensus (TASC) classification of aortoiliac lesions and
their potential treatments. 3. TASC classification of femoral popliteal lesions and their potential treatments. 4. TASC classification of
infrapopliteal lesions and their potential treatments. 5. Mimics of peripheral arterial disease and their potential treatments. Page 75 of 397
SUMMARY The major teaching points of this exhibit are: 1. TASC classification of peripheral arterial disease lesions and their potential treatments. 2.
Mimics of peripheral arterial disease and their potential treatments including LL-VIE-SU6B • A Review of Surgical Principles and Techniques for Interventional Radiologists
Kevin Ching MD (Presenter) ; Christopher J Friend MD ; Kevin M McCluskey MD PURPOSE/AIM For the majority of radiologists, formal surgical training exists only from clerkships during medical school. As interventional radiology has
evolved into the clinically focused specialty it has become today, a review of fundamental surgical principles and proper techniques is
beneficial for all IR physicians and their patients. CONTENT ORGANIZATION 1. Preoperative care: indications for pre-procedure antibiotics, skin preparation, and proper draping. 2. Physician safety: handling of
needles and sharps. 3. Pain management: local, intravenous, and oral analgesics with a review of dosing, side effects, and
contraindications for each. 4. Wound closure: absorbable vs. non-absorbable suture, cutting vs. tapered suture needles, and proper
suturing techniques to minimize formation of scars. 5. Identifying and managing infected wounds: debridement, packing, and antibiotics.
6. When things go wrong: resuscitation, surgical airways, large bore chest tubes, and emergency interventions.
SUMMARY Use of proper surgical technique and principles is critical for interventional radiologists in practice. Understanding these techniques allows
the IR physician to play a more sophisticated role in patient care, improve patient safety, and potentially develop new minimally invasive
therapies. LL-VIE-SU7B • Interventional Options for Patients with Chronically Embedded IVC Filters and Occluded or Severely Stenotic
Inferior Vena Cavas and/or Iliac Veins
Akhilesh K Sista MD (Presenter) ; David W Trost MD ; Bradley B Pua MD * ; Ronald S Winokur MD ; David C Madoff MD PURPOSE/AIM IVC filters are commonly placed for various indications. In spite of the recent movement to retrieve filters at early time points
post-placement, many remain in place for extended periods of times. In select patients, the filter causes marked caval fibrosis, narrowing,
and sometimes occlusion that frequently extends into the iliac system. Here, we present several interventional techniques to remove
chronically embedded filters and recanalize the IVC and iliac veins. CONTENT ORGANIZATION I. Indications for caval filtration II. Long-term complications of caval filtration III. Incidence/prevalence of caval stenosis or occlusion
following placement IV. Clinical presentation of caval stenosis -- recurrent thrombosis, post-thrombotic syndrome V. Filter removal
techniques VI. Iliocaval recanalization techniques VII. Complications and patient follow-up SUMMARY After viewing this exhibit, the viewer will have a better understanding of this grave late complication of IVC filter placement, as well as the
interventional options to remove the filter and recanalize the stenosis or occlusion. LL-VIE1271-SUB • Anatomy, Hemodyamic Classification, and Management of Duodenal Varices: A Hemodynamic Classification
Based Approach
Wael E Saad MBBCh (Presenter) * ; Stephen Caldwell MD PURPOSE/AIM To describe the clinical presentation and pathogenesis of duodenal varices (DV)
To detail the varying anatomy, pathology and hemodynamics of DVs
To introduce the newly published classification system
To discuss the hemodynamic classifcation based approach to managment
To detail the technical procedures in the management of DVs
CONTENT ORGANIZATION Clinical presentation Pathology and natural history Anatomy and Hemodynamics Hemodynamic and anatomical classification system
based on splanchnic (meso-portal) venous occlusion and the type of collateralization (porto-portal vs. porto-systemic vs. a combination).
Management approach based on the hemodynamic classifcation above. Detailed technical procedres (with exemplary high quality images
and photographs) of novel procedures. This includes: Surgery
Decompression by recannulation of splanchnic occlusion
Decompression with porto-systemic shunts (including TIPS)
Sclerosis of varices
Combinations of the above
SUMMARY Duodenal varices are difficult to manage and various treatment options have been used with varying results. A large part of the disparity
in the literature is poor standardization of descriptive anatomy and hemodynamics. This is a systematic approach to describe a
anatomy/hemodynamic based management algorithm. LL-VIE1287-SUB • Techniques and Approaches of Pediatric Vascular Interventional Procedures
Terrence Metz MD (Presenter) ; Stephen A Vartanian MD ; Nghia Vo MD PURPOSE/AIM An overview of pediatric vascular interventional procedures presenting the differences in the pediatric versus adult populations and what
techniques could be useful when performing a procedure on the pediatric patient. CONTENT ORGANIZATION A. How to the address the pediatric patient and parent regarding the procedure itself (what to expect, anesthesia concerns, recovery). B.
Describe categories of pediatric vascular interventions: Venous (PICC, dialysis, etc.), Arterial (Angiogram, embolization, etc.) and
Lymphatic (Sclerotherapy, chylogram, etc.) C. Choosing the best anatomic access point in relation to the procedural goal for pediatric
needs. D. Anatomic figures for each category showing access point and related structures. E. Technique of access for each procedure
including equipment choices and positioning. F. Post-procedural care including possible complications. SUMMARY This presentation will provide an overview on techniques in pediatric vascular interventions with the following goals: 1. Present
components of the pre-procedural discussion with the parents and pediatric patient undergoing vascular intervention. 2. Provide helpful
vascular techniques, positioning and device options specific to the pediatric patient. 3. Raise awareness of the various pediatric vascular
interventions performed by the interventionalist. Page 76 of 397
Molecular Imaging - Monday Posters and Exhibits (12:15pm - 12:45pm) Monday, 12:15 PM - 12:45 PM • S503AB
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CL-MIS-MOA • AMA PRA Category 1 Credit ™:0.5 Host
Vikas Kundra , MD, PhD * CL-MIS-MO1A • CT Imaging Biomarker for Evaluation of Emodin as a Potential Drugs on LPS-induced Osteoporosis Mice
Han Ah Lee (Presenter) ; Kwon-Ha Yoon MD, PhD ; Dong Min Kang MD ; Ju-Young N Kim ; Jae Min Oh ; Myung Soo Lee ; Seong Tae Jung ; Seon Kwan Juhng ; Young Hwan Lee MD PURPOSE This study was designed to identify CT imaging biomarker for evaluation of the effect of emodin as a potential drugs to treat osteoporosis
on lipopolysaccharide (LPS)-mediated bone resorption mice model METHOD AND MATERIALS We examined TRAP staining, or alkaline phosphatase (ALP) and Alizarin Red-mineralizaion staining to analyze the role of emodin on
osteoblasts or osteoclasts differentiation in vitro. Twenty male DBA/1J mice were induced bone osteoporosis by intraperitoneal injection of
LPS (5 mg/kg) on days 1 and 4. Of the twenty mice, ten were administered emodin (50 mg/kg) 1 day prior to LPS injection and every
other day for 8 days. Five were administered emodin only, and other five mice were injected saline as a control group. After 8 days, the
mice were sacrificed, and micro-CT images were obtained in the proximal femur. The images were analyzed using a software to calculate
the bone parameters such as BV/TV(%), Tb.Sp(�m), Tb.Th(�m), and trabecular number as CT imaging biomarkers. Histomorphometric
analysis was performed using hematoxylin and eosin and TRAP immunohistochemistry methods. RESULTS In vitro results, emodin inhibited RANKL-induced osteoclast differentiation in bone marrow macrophages and bone resorbing activity of
mature osteoclasts. Emodin also increased osteoblastic differentiation marker, ALP and Alizarin Red-mineralizaion activity on osteoblasts.
Mice treated with emodin demonstrated marked suppression effect of lipopolysaccharide-induced bone resorption (BV/TV: 29.7% vs
39.5%, Tb.Sp: 0.283 �m vs 0.227 �m, Tb.Th 0.098 �m vs 0.099 �m, Tb. N: 2.673 vs 3.314). On TRAP immunohistologic analysis of
femurs, the number of osteoclasts per field of tissue were revealed as 43 vs 25. The imaging biomarker of BV/TV(%) and trabecular
number were well correlated to histomorphometric analysis CONCLUSION This findings reveal a novel effect of emodin in bone remodeling in LPS-induced mice model. CT imaging biomarkers can offer as a
promising tool for assessment of therapeutic effect of a potential drugs in osteoporosis CLINICAL RELEVANCE/APPLICATION Micro-CT imaging biomakers can offer as a promising tool for assessment of therapeutic effect of a potential drug in osteoporosis. CL-MIS-MO2A • Assessment of 11C-Acetate PET for Response Monitoring of Indirect Modulators of Fatty Acid Synthase in
Prostate Cancer
Pedram Heidari MD (Presenter) ; Umar Mahmood MD, PhD ; Giorgia Zadra PhD ; Massimo Loda MD PURPOSE It has been previously shown that the uptake of 11C-acetate in PET strongly correlates with the expression of fatty acid synthase (FASN)
in the native prostate cancer (PCa) tumor models and following treatment with direct FASN inhibitors such as C75. We performed a study
to evaluate the utility of 11C-acetate PET for monitoring of the response to therapy in indirect FASN modulators specifically AMPK
activators. METHOD AND MATERIALS In this study we imaged nu/nu mice bearing subcutaneous LNCaP tumors using 11C-acetate PET at baseline and following treatment with
vehicle, MT 63-78 (30 mg/kg), AICAR (400 mg/kg) and C75 (30 mg/kg), at 24h and 1h before follow-up imaging. MT 63-78 and AICAR
are AMPK activator and C75 is FASN inhibitor. We also performed western blotting for measuring FASN expression on cells following
treatment with vehicle, MT 63-78, and AICAR. Moreover we measured 14C incorporation in lipids and 14C-CO2 release from cells
following incubation with 14C-acetate and treatment with vehicle, MT 63-78 and AICAR. RESULTS We observed that the mean SUVmean of tumors in 11C-acetate PET minimally changed following treatment with vehicle and MT 63-78,
increased 16% with AICAR and decreased 20% with C75 treatment. Western blots showed a pronounced decrease in FASN expression in
MT 63-78 and to a smaller extent in AICAR. There was a significant decrease in 14C incorporation in cell lipids following treatment with
MT 63-78 while there was a significant increase in 14C-CO2 release from cells with MT 63-78 and to a higher extent with AICAR
treatment. CONCLUSION Acetate is used as a substrate precursor during FA and cholesterol synthesis in cancer cells with increased lipogenesis (e.g. PCa) but can
also be metabolized through the tricarboxylic acid (TCA) cycle. These results suggest that AMPK activation (with MT 63-78 and AICAR)
not only causes the inhibition of FASN, but also increases of catabolic activity of enzymes of TCA cycle and mitochondrial biogenesis,
which compensates/overcompensates for the reduction in 11C-acetate uptake observed with the FASN inhibitors such as C75. Thus,
11C-acetate may not be an adequate marker for monitoring the response to therapy with indirect inhibitors of FASN such as AMPK
activators in PCa. CLINICAL RELEVANCE/APPLICATION This study helps clarify when 11C-acetate PET imaging is useful for monitoring response of prostate cancer to new targeted therapeutics
that modulate FASN directly or indirectly. CL-MIS-MO3A • Decision Modelling in the Identification of Potential Clinical Applications for Prognostic Imaging Biomarkers in
Oncology: Methods and Preliminary Results
Kenneth Miles (Presenter) * ; Thida Win ; Balaji Ganeshan PhD * ; Ashley M Groves MBBS * PURPOSE To describe a decision modeling approach for the identification of potential clinical applications for prognostic imaging biomarkers in
oncology. METHOD AND MATERIALS An approach that uses decision modeling to identify potential applications for prognostic imaging biomarkers was defined. The approach
requires cross-validated data indicating the hazard ratio and proportion of high risk patients identified by the imaging biomarker along
with the 95% confidence intervals (CI). The biomarker also needs to be prognostic independent of tumor stage and other potential
imaging biomarkers. Decision modeling is then used to assess potential health outcomes and costs from proposed biomarker
deployments with Monte Carlo analysis quantifying the likelihood of realizing beneficial outcomes. The approach was used to assess
potential applications of CT texture analysis (CTTA) for the personalization of chemotherapy for patients with advanced non-small cell lung
Page 77 of 397
potential applications of CT texture analysis (CTTA) for the personalization of chemotherapy for patients with advanced non-small cell lung
cancer. RESULTS The cross-validated mortality hazard ratio (95% confidence interval) for CTTA was 1.99 (1.14 � 3.44) with 52.5% (95% CI: 43.2 �
61.7%) categorized as high risk. Decision modeling identified CTTA-based strategies with high, intermediate and low likelihoods of clinical
benefit and/or cost-effectiveness. Two strategies that used CTTA to identify sub-sets of patients with EGFR-negative tumors for 2-agent
platinum based chemotherapy increased the survival benefit of this treatment to 5.3 months (95% CI:3.3 -7.3 months ) and were most
likely to be cost-effective (Net monetary benefit $540; 95% CI: $369-702 and $762; 95% CI: $351-1154 respectively). CONCLUSION Decision modeling can be useful in the identification of potential clinical applications for prognostic imaging biomarkers in oncology. CLINICAL RELEVANCE/APPLICATION Methods that aid the identification of clinical applications for prognostic imaging biomarkers will promote their translation to personalized
medicine. Nuclear Medicine - Monday Posters and Exhibits (12:15pm - 12:45pm) Monday, 12:15 PM - 12:45 PM • S503AB
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CL-NMS-MOA • AMA PRA Category 1 Credit ™:0.5 Host
Amir H Khandani , MD CL-NME-MO1A • Three-dimensional Reformatted PET/CT for Assessing Therapy Response in Lung Cancer
Seoung-Oh Yang MD, PhD (Presenter) ; Hong Je Lee MD ; Sang Ho Lee PURPOSE/AIM Three-dimensional (3-D) displays for medical imaging are now emerging field and very promising tools for diagnosis, therapeutic response
monitoring and detection of tumor recurrence. Morphological criteria for defining therapy response (CR, PR, SD, PD) have been
established with RECIST (Response evaluation criteria in solid tumors). Furthermore, 3-D imaging taken from PET/CT can be an excellent
approach to assess the tumor response after appropriate therapy. In this educational presentation, we will discuss the TrueD application
of F-18-FDG PET/CT for both initial staging and post-therapeutic follow-up in patients with lung cancers. CONTENT ORGANIZATION Over five hundred lung cancer patients with more than two PET/CT images enrolled in this study. A. Methods of producing 3-D PET/CT
images using TrueD software with apporpriate palettes. B. Among many galleries, the most optimal palette will be recommended
according to various metastatic lesions. C. Monitoring of tumor response to therapy was assessed using these 3-D PET/CT images. SUMMARY The development of three- and four-dimensional image processing will lead medical imaging to full definition volumetric display for
clinician as well as patients themselves. VOIs (volume of interests) of 2 or 3 time points display can be saved and exported as a
comprehensive images through the PACS systems. CL-NMS-MO2A • Scintigraphic Assessments of Reparative Process in Osteonecrosis of the Femoral Head Using Bone SPECT/CT
Fused Imaging
Goro Motomura (Presenter) ; Takuaki Yamamoto MD, PhD ; Koichiro Abe MD ; Yasuharu Nakashima ; Masanobu Ohishi ; Satoshi Hamai ; Hiroshi Honda MD ; Yukihide Iwamoto PURPOSE The purpose of this study was to assess the fused imaging of SPECT/CT with 99mTc-HMDP in early-stage osteonecrosis of the femoral
head for the better understanding of the reparative process of the disease. METHOD AND MATERIALS We retrospectively evaluated the SPECT/CT imaging, which were performed after femoral osteotomy to confirm the viability of the
proximal bone fragment. Consecutive 23 hips with untreated osteonecrosis of the femoral head contralateral to the osteotomied hips were
the subjects of this study. Patients included 16 males and seven females with a mean age of 40.4 years. According to the classification
system, 12 hips were classified as stage1 (defined as no radiographic abnormality), six hips were stage2 (demarcating sclerosis is seen
without femoral head collapse), and five hips were stage3A (less than 3mm femoral head collapse). All SPECT/CT images were processed
on a workstation and analyzed by a single experienced nuclear medicine physicians, who was blind to all patients� information including
staging. The lesion which shows the highest uptake count within the femoral head on SPECT/CT imaging was recorded. The degree of
uptake in each case was assessed by the count ratio, which was defined as the highest count within the femoral head divided by the
average uptake count of ipsilateral femur at the level of the distal end of lesser trochanter. RESULTS In stage-1 hips, the highest uptake count tended to be seen at the anterior region of the femoral head (11 of 12 hips). Meanwhile, in both
stage-2 and 3A hips, the highest uptake count was more likely to be observed at the lateral region of the femoral head ( five of six hips
and all five hips, respectively). The count ratios of stage-2 and 3A were significantly higher than those of stage-1. Based on the analysis of
Spearman rank correlation coefficient, a count ratio was positively correlated with progression of the ONFH stages. CONCLUSION The current study indicated that, during the time before collapse, there may be a gradual increase in osteoblastic activity around the
necrotic lesion, shifting the main region from anteriorly to laterally. SPECT/CT imaging will be helpful for the better understanding of the
repair mechanisms as well as the pathophysiology of ONFH. CLINICAL RELEVANCE/APPLICATION SPECT/CT clearly demonstrated the osteoblastic activity in the early stages of osteonecrosis of the femoral head. CL-NMS-MO3A • The Role of 99mTc-MDP Bone Scintigraphy in the Workup of Patients with Hepatocellular Carcinoma
Khun Visith Keu MD,FRCPC (Presenter) ; Glen Lutchman ; Andrew Quon MD ; Erik S Mittra MD, PhD ; Andrei Iagaru MD * PURPOSE Bone scintigraphy (BS) is part of the standard of care staging workup of patients with hepatocellular carcinoma (HCC) considered for liver
transplantation. The UCSF criteria for liver transplantation are less stringent than the Milan criteria and the value of BS has not been
tested in this setting. Therefore, we retrospectively analyzed the value of BS in patients evaluated under UCSF criteria, a group with
potentially higher risk for bone metastases. METHOD AND MATERIALS We retrospectively reviewed all HCC patients evaluated for liver transplantation who had BS at our institution from January 2008 to April
2012. Patients without BS performed within 3 months of routine clinical workup were excluded. BS results were catalogued as malignant,
Page 78 of 397
2012. Patients without BS performed within 3 months of routine clinical workup were excluded. BS results were catalogued as malignant,
indeterminate or benign based on the original image interpretation. Findings were correlated with other imaging procedures (including
subsequent BS), biopsies and/or clinical follow-up. The cohort was then divided into 3 groups: Milan +, Milan -/UCSF + and UCSF -. RESULTS A total of 785 patients were evaluated for liver transplantation: 592 patients did not have a BS and 31 did not have a scan performed
within 3 months from the initial visit. Therefore, only 162 patients (114 male; 38 female) with an average age (±SD) of 58.9 year-old (±
7.2) were eligible. The majority of patients (92%, N=149) had negative BS, but 8 (4.9%) had indeterminate and 5 (3.1%) had positive
BS for metastases. In the Milan + group (N = 103), there were 98 negative BS, 4 indeterminate BS and 1 positive BS. The Milan - /UCSF
+ group (N = 22) had 18 negative BS, 2 indeterminate BS and 2 positive BS. Lastly, the UCSF � group (N = 37) had 33 negative BS, 2
indeterminate BS and 2 positive BS. On follow-up, only 2 patients were diagnosed with bone metastasis. CONCLUSION Abnormal BS findings (indeterminate and positive cases) were more frequent in the Milan - /UCSF + group than the Milan + or UCSF �
groups. However, true positive bone metastases were rare. The impact of BS in the workup of HCC patients considered for liver
transplantation should be re-evaluated from a healthcare cost analysis perspective. CLINICAL RELEVANCE/APPLICATION Bone metastasis are rare in HCC patients considered for liver transplatation: a bone scintigraphy should not be perfomed routinely. CL-NMS-MO4A • Tc99m Labeled WBC SPECT/CT is Not Inferior to MRI for Diagnosis of Biopsy Proven Diabetic Foot Osteomyelitis
Francisco J Lazaga MD (Presenter) ; Kavita Bhavan MD ; Kenrick Lam BS ; Lawrence Lavery DPM ; Javier La Fontaine DPM ; Orhan K Oz MD, PhD ; William A Erdman MD PURPOSE MRI is the recommended diagnostic imaging test for diabetic foot osteomyelitis (DFO) with a reported 79% accuracy (Dinh et. al, 2008).
The accepted standard for diagnosing osteomyelitis in the clinical infectious diseases literature is the presence of abnormal bone culture
or histopathology findings from bone biopsy studies (Lipsky et al, 2012). Our purpose is to assess the accuracy of hybrid image Tc99m
labeled WBC SPECT/CT for diagnosis of diabetic foot osteomyelitis as determined by bone biopsy results in comparison to MRI. METHOD AND MATERIALS We performed a retrospective chart review of 71 patients who underwent Tc99m labeled WBC SPECT/CT and bone biopsy between 2011
to 2013 to confirm the diagnosis of diabetic foot osteomyelitis. Twenty five of the 71 patients had MRI in addition to SPECT/CT. Patients
whose scan(s) was not within a clinically relevant timeframe of biopsy, determined to be eight weeks, were excluded. RESULTS Forty three of 71 SPECT/CT patients met our inclusion criteria. The sensitivity, specificity, PPV, NPV and accuracy of SPECT/CT were 0.91,
0.25, 0.84, 0.4 and 0.79 respectively. Fifteen of 25 MRI patients met our inclusion criteria and the corresponding values for MRI were
0.67, 0.67, 0.89, 0.33 and 0.67 respectively. Nine patients had both MRI and SPECT/CT within 8 weeks of bone biopsy. Three of the 9
patients had discordant results between the MRI and SPECT/CT. SPECT/CT gave the correct diagnosis for 2/3 patients while MRI was
correct for 1/3 patients. CONCLUSION Our data suggests that SPECT/CT is not inferior to MRI in the diagnosis of diabetic foot osteomyelitis. Furthermore SPECT/CT results
correlate well with the bone biopsy results. CLINICAL RELEVANCE/APPLICATION Currently MRI is the gold standard in the radiologic diagnosis of diabetic foot osteomyelitis. This study suggests that Tc99m labeled WBC
SPECT/CT is a suitable substitute. CL-NMS-MO5A • Impact and Correction of Erroneous Lung Segmentation in PET/MR Using a Three-segment Model Attenuation
Correction Based on a 3D Multi-station T1-weighted Spoiled Gradient Echo Sequence
Christian Rubbert MD (Presenter) * ; Andres Kohan MD * ; Jose L Vercher-Conejero MD * ; Sasan Partovi BS * ; Peter F
Faulhaber MD * ; Raymond Muzic PhD * ; Karin A Herrmann MD PURPOSE To assess the impact of erroneous lung segmentation in PET/MR on the quantification of FDG-avid lesions in the chest, and to propose
methods to correct for these errors. Quantification depends on accurate MR attenuation correction (MRAC) maps, which, in turn, depend
on correct segmentation of the MR image volume. Mis-segmentation may occur in the presence of metallic implants or artifactually
increased signal in the lungs. METHOD AND MATERIALS 3D T1w spoiled gradient echo images are segmented to identify air, lung, and soft tissue. In the lung, region growing is seeded by
histogram analysis and borders are extended to lung/soft tissue interfaces. Images from 100 patients enrolled in a PET/CT and sequential
PET/MR double-scanning protocol were reviewed to identify cases in which large portions of the lungs were misidentified.
Mis-segmentation was corrected by filling in metal voids in the T1w image volume, which caused 3D growing to fail, or by depressing
spurious pixel values in the lungs. The modified T1w image volumes were segmented for MRAC. SUVmax and SUVmean of VOIs of
corresponding chest lesions were recorded in PET/CT and PET/MR in both failed and corrected datasets. Bland-Altman analysis was
performed to assess agreement between modalities. RESULTS PET/CT was acquired 70.9±12.1 min after FDG injection and PET/MR 31.5±22.1 min after PET/CT. Lung segmentation failed in 14 cases.
Each correction method was applied in 6 cases, respectively. 2 could not be corrected. 40 lesions were identified within the chest in 7
subjects. Mean SUVmax differences, PET/MR minus PET/CT, and (limits of agreements) for all lesions were 2.10 (-2.10 to 6.32) with failed
segmentation and 0.88 (-0.50 to 2.27) with corrected segmentation. The corresponding values for the SUVmean were 0.72 (-0.62 to
2.05) and 0.19 (-0.46 to 0.84). The mean differences decreased and the limits of agreement were narrower with the corrected
segmentation in all anatomical sub-regions. CONCLUSION The critical impact of mis-segmentation of the lungs is demonstrated by wide limits of agreement and mean SUV overestimation.
Correction is feasible and resulted in improved mean differences and narrower limits of agreement in all cases. CLINICAL RELEVANCE/APPLICATION Failed lung segmentation in PET/MR affects and overestimates the SUV, which, in turn, may have critical impact on a patient�s therapy.
Screening and correction of mis-segmentation is recommended. CL-NMS-MO6A • Evaluation of Staging and Response to Chemotherapy with Whole-body Diffusion-weighted Magnetic Resonance
Imaging in Malignant Lymphoma Patients: A Comparison with FDG-PET
Kazunobu Tsuji ; Tatsuro Tsuchida MD, PhD ; Shinji Kishi ; Hidehiko Okazawa MD, PhD ; Hirohiko Kimura MD, PhD
(Presenter) PURPOSE The purpose of this study was to examine the utility of diffusion-weighted magnetic resonance imaging (DW-MRI) for staging and
evaluation of response to chemotherapy in patients with malignant lymphoma in comparison to fluorodeoxyglucose positron emission
Page 79 of 397
tomography (FDG-PET). METHOD AND MATERIALS Participants comprised 28 patients with histologically confirmed malignant lymphoma (diffuse large B-cell lymphoma, n = 17; follicular
lymphoma, n = 11). All patients underwent both magnetic resonance imaging and FDG-PET before (pre-treatment) and after 2 courses of
chemotherapy (mid-treatment). Staging with MRI (DW-MRI only and with T2-weighted imaging) and FDG-PET were compared visually
and the concordance rate (kappa value; ?) was calculated. To evaluate response to chemotherapy, patients were divided into 2 groups
based on response evaluation criteria: complete remission (CR) or non-CR. Progression-free survival (PFS) and overall survival (OS) were
compared between groups using the Kaplan-Meier method. RESULTS Stage diagnosed by DWI alone and by FDG-PET was concordant in 19 patients (? = 0.67, p < 0.05), and addition of T2-WI increased the
number of concordant patients to 23 (? = 0.89, p < 0.05). On mid-treatment imaging, 19 patients were diagnosed as CR from both
images. PFS differed significantly between CR and non-CR on both DW-MRI (p = 0.0013) and FDG-PET (p = 0.037). However, OS did not
differ significantly between DW-MRI (p = 0.452) and FDG-PET (p = 0.452). CONCLUSION DW-MRI appears to be a promising tool for staging and evaluation of response to chemotherapy in patients with malignant lymphoma. CLINICAL RELEVANCE/APPLICATION DW-MRI and FDG-PET could be used depending on the availability of equipment within an institution, or could be chosen depending on
the advantages, drawbacks and contraindications of each modality. Pediatric Radiology - Monday Posters and Exhibits (12:15pm - 12:45pm) Monday, 12:15 PM - 12:45 PM • S101AB
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CL-PDS-MOA • AMA PRA Category 1 Credit ™:0.5 Host
Avrum N Pollock , MD CL-PDS-MO1A • Diffusion Tensor Imaging of the Cerebellum-prefrontal Area in ADHD Children
Pilar Dies-Suarez MD (Presenter) ; Eduardo Barrragan ; Benito De Celis ; Silvia Hidalgo ; Manuel Obregon ; Porfirio Ibanez PURPOSE The attention deficit hyperactivity disorder (ADHD) is one of the most frequent problems that affect children�s and produce scholar
failure and behavioral problems. The principal hypothesis is a dopaminergic dysfunction in the brain. Diffusion tensor imaging (DTI) is an
MRI modality that provides information about the direction and integrity of neural fibre tracks in the brain in vivo. METHOD AND MATERIALS 23 children (ages 7-12 yrs, 11 ADHD patients, 12 controls) were examined. Images were acquired on a 1.5T imager (Philips
Intera-Achieva). Diffusion Tensor Imaging (DTI) data were acquired using a SE-EPI sequence with: TR/TE = 9491/75 ms,
FOV=230x230x140 mm3, voxel size=1.60x1.60x2mm3, slices number= 70, fat supressed. Diffusion weighted gradients were applied
along 15 non-collinear directions with a b-value=800 s/mm2. High-resolution images were acquired using 3DT1 Gradient Sequence with
the following parameters: TR/TE=25/3.88ms, slice thickness 2mm, and NEX=1. Tractography: The diffusion tensor (DT) was fitted with
linear least-square after a preprocessing step correcting for head movements and eddy currents was applied by registering all volumes.
Finally, using MedINRI, diffusion tensors were calculated to obtain Fractional Anisotropy (FA) with FA threshold of 0.2 and smoothness
factor of 20 out of 100, and Mean Diffusivity values. Segmentation of the cerebellum CB was manually drawn on midline sagittal 3D-T1
images. RESULTS We present results of white matter connectivity of tracts connected cerebellum-prefrontal area. There were no discernible ADHD-Control
changes in ADC values along the connected white matter (figure 1) while generalized fractional anisotrophy is increased(p=0.08). Length
of tracts vs ADC is shown in figure 2. CONCLUSION DTI studies have revealed developmental changes in cortical WM pathways in prefrontal regions and in pathways surrounding the basal
ganglia and cerebellum in patients with ADHD, which presumably reflect decreasing myelination of axons. CLINICAL RELEVANCE/APPLICATION Affects between 3 to 7% in America Latina, and it�s consider a public health problem. We are considering MR imaging to improve the
diagnostic on ADHD patients. CL-PDS-MO2A • Aberrant Whole-brain Functional Connectivity in Children with Chronic Fatigue Syndrome
Fanxing Meng MMed (Presenter) ; Na Liu MD ; Bing Yu MD ; Qiyong Guo MD PURPOSE To assess the abnormalities of whole-brain functional connectivity in children with chronic fatigue syndrome (CFS) using resting-state
functional magnetic resonance imaging (fMRI). METHOD AND MATERIALS Resting state fMRI data were obtained from 65 right-handed children, including 31 CFS children (M/F, 17:14; age, 10.0±1.5 y) and 34
age-matched healthy controls (M/F, 19:15; age, 10.2 ±1.3 y). FMRI scans were performed on a 3.0-T MR scanner and post-processed
using REST software. Comparisons of z-score correlation coefficients between distinct cerebral regions were used to identify altered
functional connectivity in CFS children. Individual z-scores were compared with two-tailed t-tests to determine the significance of
functional connectivities between the two groups. The false discovery rate (FDR) approach was applied to identify the restriction threshold
capable of reducing the proportion of type I errors to < 0.05. RESULTS A total of 15 significantly different functional connectivities were identified in the medial prefrontal cortex(MPFC), insula, putamen,
primary somatosensory cortices (S1), secondary somatosensory cortices(S2),anterior cingulated cortex (ACC) and thalamus between the
CFS and control groups at an FDR corrected threshold of P CONCLUSION Our findings suggest that abnormalities of functional connectivities between MPFC, insula, somatosensory cortices and ACC are likely to
be involved in the onset and progression CFS in children. CLINICAL RELEVANCE/APPLICATION Abnormalities of functional connectivities between MPFC, insula, somatosensory cortices and ACC are likely to be involved in the onset
and progression CFS in children. CL-PDS-MO3A • Altered Tryptophan Metabolism and White Matter Development in Cerebellum of Children with Autistic Spectrum
Page 80 of 397
CL-PDS-MO3A • Altered Tryptophan Metabolism and White Matter Development in Cerebellum of Children with Autistic Spectrum
Disorders
Jeong-Won Jeong PhD (Presenter) ; Ajay Kumar MD, PhD ; Harry T Chugani MD ; Diane C Chugani PhD * PURPOSE METHOD AND MATERIALS RESULTS A significant inverse correlation (R2=0.46, p=0.04) was found between the LI values of SUV of the dentate nucleus and FA of the DRP
(Fig. 1 a). Increased tryptophan metabolism in the dentate nucleus was correlated with reduced axonal microstructural integrity of the
ipsilateral efferent pathway (Fig. 1 b). Furthermore, the LI values for both SUV and FA were significantly correlated with the scores of
daily living skills; higher SUV and lower FA were related to lower scores (Table 1). CONCLUSION The present study shows that unilateral disturbance in tryptophan metabolism is associated with unilateral change in white matter
integrity in the dentate nucleus efferent pathway (i.e., DRP) and deficits in daily living skills in children with ASD. Increased tryptophan
metabolism may represent increased serotonin synthesis or increased metabolism by the immune factor activated kynurenine pathway. CLINICAL RELEVANCE/APPLICATION The findings of the present study provide a better understanding of the possible pathogenesis in the dentate nuclei and its efferent
pathway, DRP, and its role in children with ASD. CL-PDS-MO4A • Apparent Diffusion Coefficient Histograms in Medulloblastoma Subtypes
Korgun Koral MD (Presenter) ; Youngseob Seo PhD ; Lynn Gargan PhD ; Derek Mathis MD ; Linda Margraf MD ; Zhiyue J
Wang PhD PURPOSE To test whether apparent diffusion coefficient (ADC) histograms allow for preoperative diagnosis of medulloblatoma subtypes. METHOD AND MATERIALS Retrospective review of Neuro-Oncology database yielded 29 patients (23 male) with medulloblastoma. The pathology specimens were
re-evaluated and subcategorized according to the latest WHO classification of the central nervous system tumors. There were 19 classic,
8 desmoplastic/ nodular and 2 large cell medulloblastomas. All patients had preoperative MR imaging performed at a single institution.
Diffusion weighted imaging was performed using a spin echo sequence with b=0 and b=1000 s/mm2. ADC maps were generated with a
monoexponential fit on a voxel-to-voxel basis for all imaging planes. Internally developed software written in IDL was used for data
analysis. T2 weighted and contrast enhanced T1 weighted images were displayed together with ADC map to help visualize the tumor
volume. A pediatric neuroradiologist, blinded to the subcategorization, traced the tumor boundaries at as many levels as possible. The
-3 mm2/s and normalized by the total number of
ADC histograms for voxels within the ROI were obtained with a bin size of 0.02 x 10
voxels. The average histogram for each subtype was calculated. Peak height, mean ADC, 10th percentile, 25th percentile, 50th percentile,
75th percentile and 90th percentile points, and skewness were computed. RESULTS The average histogram for each subtype showed significant overlap with other subtypes which did not allow for discrimination. The 10th
percentile, 25th percentile, 50th percentile, 75th percentile and 90th percentile points, and skewness were not significantly different
among subtypes. CONCLUSION Although utility of ADC histogram analysis was previously shown in preoperative diagnosis of pediatric cerebellar tumors, this method did
not prove useful in preoperative discrimination of medulloblastoma subtypes. CLINICAL RELEVANCE/APPLICATION ADC histogram analysis is not useful in preoperative discrimination of medulloblastoma subtypes. CL-PDS-MO5A • Repetitive MR Measurements of Lung Volume in Fetuses with Congenital Diaphragmatic Hernia: Individual
Development of Pulmonary Hypoplasia during Pregnancy with Calculation of Weekly Lung Growth Rates
Claudia Hagelstein MD (Presenter) ; Meike Weidner ; Angelika Debus MD ; Anna Walleyo ; Stefan O Schoenberg MD, PhD *
; Thomas Schaible ; Karen Busing ; Wolfgang Neff MD, PhD PURPOSE To investigate individual changes in fetal lung volume (FLV) in fetuses with congenital diaphragmatic hernia (CDH) and to calculate
weekly growth rates of the FLV using serial MR examinations during pregnancy. METHOD AND MATERIALS The study received approval from the institutional review board. MR-FLV was measured in 89 fetuses with CDH between 19 and 39
weeks gestation using T2-weighted HASTE imaging. All fetuses received two MR examinations with at least four weeks in between. In
addition to the absolute MR-FLV (aMR-FLV) and the observed-to-expected MR-FLV (o/e MR-FLV) a weekly growth rate of the aMR-FLV
was determined for each fetus. RESULTS In 98% of all fetuses (87/89) the aMR-FLV increased between the two examinations (mean increase 11.1 ml, range 1.5-37.7 ml). Mean
o/e MR-FLV at the first MRI (mean 26.0±3.1 weeks gestation) was 33.3±12.2% (range 10.5-79.1%) and 29.5±10.9% (range
10.8-63.7%) at the second MRI (mean 33.9±2.4 weeks gestation). 61% of the fetuses (54/89) showed a decrease of the o/e MR-FLV
during pregnancy (mean decrease 9.4%, range 2.2-31.7%). In 26% of all fetuses (23/89) the o/e MR-FLV increased (mean increase
7.7%, range 2.2-26.2%) and 13% (12/89) revealed stable values. Both, first and second o/e MR-FLV, were significantly associated with
neonatal outcome. Measuring o/e MR-FLV near delivery was of superior prognostic value than earlier measurements (mortality:
AUC=0.844 vs. AUC=0.778; extracorporeal membrane oxygenation (ECMO) requirement: AUC=0.852 vs. AUC=0.768). The mean lung
growth rate in CDH-fetuses between the two MR examinations was 1.3±0.8 ml per week, compared to a mean weekly growth rate of
5.3±0.8 ml in healthy fetuses for the identical periods of time. On average, the weekly growth rate of FLV in fetuses with CDH was only
26% of the growth rate in healthy fetuses. CONCLUSION Fetuses with CDH do not only have lower FLVs but also have lower weekly lung growth rates compared to healthy fetuses. Individual
development of FLV in CDH-patients during pregnancy is extremely variable with decreasing, stable and increasing o/e MR-FLVs. In
selected cases, the o/e MR-FLV relatively changed by more than 80% during pregnancy. CLINICAL RELEVANCE/APPLICATION Due to the variable individual development of FLV in CDH-patients during pregnancy, follow-up MR-FLV measurements are advisable prior
to decision-making about pre- and postnatal therapeutic options. CL-PDE-MO6A • Perianal Disease in Paediatric Crohn's Patients: Pelvic MRI versus MRE
Mary-Louise C Greer MBBS, FRANZCR (Presenter) ; Ryan T Lo ; Zehour E Alsabban MBBS ; Peter Church ; Rahim Moineddin ; Thomas Walters ; Jacob C Langer ; Anne Griffiths Page 81 of 397
PURPOSE/AIM The aims of this exhibit are: 1. To demonstrate the spectrum of perianal disease in paediatric Crohn's patients on pelvic MRI. 2. To
describe imaging techniques optimizing pelvic MRI in children with perianal disease, and standard magnetic resonance enterography
(MRE) technique perianal region coverage. 3. To compare perianal disease seen on both pelvic MRI and MRE, highlighting benefits and
pitfalls of both techniques. CONTENT ORGANIZATION Epidemiology: paediatric Crohn's disease and subset of perianal disease. Anatomy and pathophysiology: review of anorectal anatomy and
perianal fistula classification Imaging techniques: pelvic MRI including schematic of imaging planes; standard MRE and specific attention
to perianal region coverage. Case examples: spectrum of disease on pelvic MRI, comparison of pelvic MRI and MRE perianal disease in the
same patient. Benefits and limits: role and implications of both techniques in screening and management. SUMMARY The major teaching points are: 1. Pelvic MRI is the gold standard for detecting and classifying perianal disease in children with Crohn's
disease, as well as in adults. 2. MRE has a complementary role to pelvic MRI in detecting perianal disease. 3. The perianal region should
be a review area in MRE evaluation, in addition to small bowel, in paediatric Crohn's patients. CL-PDE-MO7A • Magnetic Resonance Imaging of the Temporomandibular Joint in Juvenile Idiopathic Arthritis and Other
Pediatric Rheumatologic Diseases
Floyd D Dunnavant MD (Presenter) ; Saurabh Guleria MD ; Yoginder N Vaid MD ; Daniel W Young MD ; Stuart A Royal MS, MD
; Randy Q Cron * ; Matthew L Stoll PURPOSE/AIM Juvenile idiopathic arthritis (JIA) is the most common cause of chronic arthritis in children. The temporomandibular joint (TMJ) is
frequently involved in JIA, with multiple associated complications, yet TMJ involvement remains one of the most underdiagnosed
conditions in JIA. TMJ involvement can also be seen less frequently in other rheumatologic diseases. MRI with contrast is considered the
gold standard for TMJ evaluation. The purpose of this exhibit is to show the spectrum of patholological changes by MRI of TMJ involvement
in JIA and other rheumatologic diseases. CONTENT ORGANIZATION This exhibit will demonstrate typical examples of the pathologic findings of TMJ involvement in JIA obtained at 3T MRI of children at our
institution. Findings include synovial enhancement, joint effusion, pannus formation, deformed or displaced disc, bone marrow edema,
condylar head flattening, erosions, and osseous destruction. Normal comparisons and CT correlations will be demonstrated. TMJ
involvement in other rheumatologic diseases will also be shown. SUMMARY Relatively little has been published about TMJ involvement in JIA, and imaging remains underutilized at many large pediatric centers.
Routine MRI screening of the TMJ has been recommended. This presentation will demonstrate the findings typical of TMJ involvement in
JIA and other rheumatologic diseases. Breast - Monday Posters and Exhibits (12:15pm - 12:45pm) Monday, 12:15 PM - 12:45 PM • Lakeside Learning Center
Back to Top BR
LL-BRS-MOA • AMA PRA Category 1 Credit ™:0.5 Host
Susan P Weinstein , MD LL-BRS-MO1A • Round and Oval Circumscribed Masses Found on Digital Mammography and Ultrasound: Is Biopsy Necessary in
Patients without Previous Cancer History or Bloody Nipple Discharge?
Wei-Shin Wang MD (Presenter) ; Shadie S Majidi MD PURPOSE To assess the positive cancer rate of round and oval circumscribed masses found on digital mammography and ultrasound in patients
without a current or previous history of cancer or breast atypia and presenting without bloody nipple discharge. METHOD AND MATERIALS This retrospective study was approved by the institutional review board. Diagnostic mammograms and ultrasounds performed at Indiana
University Health hospitals were reviewed from 2004 to 2013. All round and oval circumscribed masses described on diagnostic
mammogram and ultrasound were identified. Patient age, breast mass size and palpability, and clinical history data were collected.
Pathology results from those that underwent biopsy were reviewed. Patients with a current or previous history of cancer or breast atypia
and those presenting with bloody nipple discharge were excluded from analysis. RESULTS A total of 402 circumscribed masses were biopsied in 393 patients. Seven patients presented with bloody nipple discharge, while eight
presented with a current or prior history of cancer or breast atypia. These patients were excluded from analysis. Pathology results from
the remaining 387 circumscribed masses demonstrated carcinoma in five patients (3 ductal carcinoma in situ, 1 invasive ductal, 1 adenoid
cystic). A single case of phyllodes tumor was also identified. This corresponds to a positive biopsy rate of 1.6%. CONCLUSION In patients without a current or prior history of cancer and presenting without bloody nipple discharge, short term imaging followup can
be considered for patients demonstrating a round or oval circumscribed mass on digital mammography and ultrasound. CLINICAL RELEVANCE/APPLICATION Potentially expands the criteria for what is considered a BIRADS 3 lesion. May decrease the number of inappropriate breast biopsies. LL-BRS-MO2A • Preoperative I-125 Radioactive Seed Localization (I-125 RSL) of Breast Lesions: Impact of Lesion Selection on
Surgical Margins
Mark J Dryden MD (Presenter) ; Jamie Wagner DO ; Wei T Yang MD ; Kelly K Hunt MD ; Eric M Rohren MD, PhD * ; Basak E
Dogan MD PURPOSE To evaluate the impact of lesion selection for RSL procedure on final surgical margins. METHOD AND MATERIALS Our institutional review board approved this HIPAA compliant study. A retrospective review of mammographic (M), ultrasound (US) and
ductogram (D)-guided I-125 RSLs performed between 05/16/2012 and 03/06/2013 was performed in a single institution. 73 consecutive
RSLs were performed in 70 women prior to segmental mastectomy or excisional biopsy. Procedure time and clinicopathologic data were
recorded from the electronic medical records. Seed-to-target distance was measured on pre-operative mammograms, and specimen
radiographs reviewed for the presence of the seed and targeted lesion. Page 82 of 397
radiographs reviewed for the presence of the seed and targeted lesion. RESULTS Mean patient age was 59 years (range 40-83). Of the 73 RSLs, 39% were done using M, 60% US, and 1% D guidance. RSL was
performed with a single seed in 60 (82%), and 2 or more seeds in 13 (18%) lesions. Median lesion size was 1.7 cm (range 0-5); mean
seed-to-target distance 6 mm (range 0-13); and median procedure time was 10 minutes (range:5-60). All seeds and targeted lesions
were retrieved. Final pathology revealed negative margins (NM) in 60 (82.1%) and close or positive margins (PM, < 2mm) requiring
re-excision in 13 (17.8%). NM were observed in 32/36 (89%) masses, 2/5 (40%) calcifications, 8/11 (73%) masses with calcifications,
3/4 (75%) architectural distortions, and 11/13 (85%) single clips. All 3 focal asymmetries and 1 filling defect were excised with NM. Mean
lesion size excised with PM was 2.3 cm, compared to 1.8 cm in NM group. NM was achieved in 48/60 (80%) of lesions localized with a
single seed and 12/13 (92%) with multiple seeds. Final surgery type was segmental mastectomy in 69 (98.6%) patients and mastectomy
in 1 (1.5%). Complications included seed migration ( CONCLUSION RSL is an efficient, effective procedure for localization of non-palpable breast lesions that allows uncoupling of radiology-surgery
schedules, with a low incidence of complications and surgical outcomes similar to wire localization. Using multiple seeds for lesions >2cm
and calcifications may decrease the risk of PM. CLINICAL RELEVANCE/APPLICATION Radiologists should triage lesions to assess lesion type, lesion size, and number of seeds needed prior to RSL for optimal surgical
outcomes. LL-BRS-MO3A • Imaging Lymphatic System in Breast Cancer Patients with Magnetic Resonance Lymphangiography
Qing Lu MD (Presenter) ; Jia Hua ; Jiani Hu PURPOSE To investigate the feasibility of magnetic resonance lymphangiography (MRL) protocol using a gadolinium (Gd)-based contrast agent
(Gd-MRL) for breast patients in a typical clinical setting, and to establish a Gd-MRL protocol and identify potential MRL biomarkers for
differentiating metastatic from non-metastatic lymph nodes. METHOD AND MATERIALS Thirty two patients with unilateral breast cancer were enrolled and divided into 4 groups of 8 patients. Groups I, II, and III received 1.0,
0.5, and 0.3 ml of intradermal contrast; group IV received two 0.5 ml doses of intradermal contrast. For Gd-MRL, 3D fast spoiled
gradient-recalled echo T1-weighted coronal images with a fat saturation were acquired before and after the administration of Gd-DTPA at
different time points. All MRL images were evaluated independently by two radiologists for the number and size of enhanced lymph
nodes, lymph node contrast uptake kinetics, lymph vessel size, and contrast enhancement patterns within lymph nodes. RESULTS Group III patients had a statistically significant decrease in the total number of enhanced axillary lymph nodes and lymphatic vessels
compared to all other groups. While group IV patients had a statistically significant faster time to reach the maximum peak enhancement
than group I and II (about 3 minutes), there was no other statistically significant difference between imaging results between groups I,
II, and IV. Using the pattern of enhancement defect as the sole criterion for metastatic lymph nodes in terms of Gd-MRL interpretation
and histopathologic results as the gold standard, sensitivity and specificity were estimated to be 86% and 95%, respectively. CONCLUSION Gd-MRL can adequately depict the lymphatic system, and has the potential to differentiate metastatic from non-metastatic lymph nodes
in breast cancer patients. CLINICAL RELEVANCE/APPLICATION this study may help establish an effective MRL protocol to differentiate metastatic from non-metastatic lymph nodes in breast cancer
patients. LL-BRS-MO4A • The Role of MR-Mammography in 'BIRADS-4 Cases'-Can Biopsies Be Avoided?
Clemens G Kaiser MD, BA (Presenter) ; Julia Krammer MD ; Klaus Wasser MD ; Stefan O Schoenberg MD, PhD * ; Werner A
Kaiser MD, PhD PURPOSE To evaluate the role of MR-Mammography (MRM) in patients with 'BIRADS 4 cases', i.e. in patients in which conventional assessment
(X-Ray or Ultrasound) would otherwise require biopsy. METHOD AND MATERIALS Breast specialists from all over the country were invited to send patients with 'BIRADS- 4' findings in either X-Ray-Mammography or
Ultrasound (US) for MRM in our institution. Between 04/2006 and 12/2011 a consecutive total of 1492 women were examined resulting in
a study population of 1488 patients after dropout. MRM exams were performed using all morphological and kinetic signs. RESULTS 124 patients were diagnosed with malignant diagnoses (cancer or DCIS) by MRM, resulting in 76 true positive and 48 false positive
findings after histology. 971 true negative cases and 0 false negative cases were recorded in follow-ups of between 2-5 years. True
negative cases were either confirmed by histology upon recommendation of external physicians (18 patients), follow-up by MRM or
patient questionnaires over the next 5 years by mail (1737 cases). 393 patients were lost to follow-up. This resulted in a sensitivity of
100%, specificity of 95,2%, positive predictive value of 61,3%, a negative predictive value of 100% and an accuracy of 95,5%. For the
calculation of invasive cancers only (without DCIS cases), the results were 63 true positives, 27 false positives for malignant findings, 971
true positives and 0 false positives for benign findings (Sensitivity 100%, Specificity 97,2%, PPV 70 %, NPV 100%, Accuracy 97,5%).
CONCLUSION 'BIRADS-4' cases in conventional assessment seem to be an adequat indication for high-quality MRM, using all morphological and kinetic
signs. At least 88,7% (971/1095) of biopsies could be prevented. However, these results are strongly dependent on reader experience
and adequate technical standards as prerequisites for optimal diagnoses. CLINICAL RELEVANCE/APPLICATION 'BIRADS-4 cases' in conventional assessment as a new standard indication for MR-Mammography under high quality circumstances
reduced the number of biopsies by 88%. LL-BRS-MO5A • Accuracy of Tumor Sizing on Breast Tomosynthesis
Kathryn L Humphrey MD (Presenter) ; Pragya A Dang MD ; Phoebe E Freer MD ; Mansi A Saksena MD ; Elkan F Halpern PhD
* ; Elizabeth A Rafferty MD * PURPOSE Using tomosynthesis discrete spiculations extending from a tumor mass often appear far more prominent than on conventional
mammography. Whether these spiculations should be included in the preoperative tumor size remains unclear. This investigation
compares the size of newly diagnosed invasive breast cancers on tomosynthesis (with and without inclusion of the tumor spicules) to the
size on surgical pathology. METHOD AND MATERIALS This IRB approved study retrospectively reviewed tomosynthesis imaging for 172 invasive breast cancers diagnosed between 3/2011 and
Page 83 of 397
10/2012. The largest tumor dimension was documented with and without inclusion of any associated spicules. These imaging sizes were
compared to the true tumor size on surgical pathology. Statistical analysis evaluated whether inclusion or exclusion of the spicules seen
on tomosynthesis better predicted the actual tumor size. RESULTS A total of 172 invasive cancers were evaluated (142 invasive ductal carcinomas; 25 invasive lobular carcinomas; and 5 invasive mammary
carcinomas). 135 of the tumors presented as a mass on tomosynthesis with 115 having spiculated margins. Average size on
tomosynthesis for the 115 spiculated masses was 14.8 mm +/- 10.4 mm when excluding the spicules and 44.4 mm +/- 18.8 mm when
including the spicules. The average surgical pathology size for these 115 tumors was 16.9 mm +/- 12.4 mm. There was no significant
difference in the imaging and pathologic size when excluding associated spicules (p-value = 0.18); however, when the spicules were
included in the imaging measurement, the tumor sizes were significantly different from those found at surgical pathology (p-value =
1.41243 x 10 -29). The absolute average difference in the measured to true size without inclusion of the spicules was 5.0 +/- 6.4 mm
with 65 cases over-measured and 38 cases under-measured. When the spicules were included, the absolute average difference was 27.7
+/- 16 mm with 113 cases over-measured and 2 under-measured. CONCLUSION Measuring the central tumor mass and excluding any associated spicules on tomosynthesis imaging provides a more accurate
preoperative estimate of the true tumor size. CLINICAL RELEVANCE/APPLICATION The size of a newly diagnosed breast cancer, as measured on preoperative imaging, plays a significant role in prognosis and treatment
planning, driving the need for accuracy. LL-BRS-MO6A • Diffusion Weighted Imaging in Mantle Radiated Women: Comparison of Apparent Diffusion Coefficient Values
with a Control Group
Punam Bajaj MD, MBBS (Presenter) ; Chiara Iacconi MD ; D. David Dershaw MD ; Elizabeth A Morris MD PURPOSE To compare the value of the Apparent Diffusion Coefficient (ADC) of normal breast tissue in high risk women who underwent mantle
radiation before ages 30 years and a screening control group, matched for breast tissue density. METHOD AND MATERIALS This was a retrospective analysis of breast MRI examinations performed between 2008 and 2013 of 21 women who were treated with
mantle radiation. Based on breast tissue density evaluated on pre contrast T1W fat suppressed sequence, cases were divided into two
groups: fatty breasts (n=10) and dense breasts(n=11). A total of 41 breasts were evaluated. One breast with a benign mass lesion in the
retroareolar region was excluded. Breast MRI exams in 21 controls, matched for breast tissue density, were compared. Diffusion Weighted
Imaging(DWI) with b=0, 1000 was performed for all cases and controls and the ADC maps were evaluated on advantage workstation
(GE). ADC value of normal breast tissue were calculated by placement of the region of interest (ROI) in bilateral retroareolar regions.
Normal breast tissue was defined as absence of any finding on dynamic MRI (BIRADS-1). Statistical analysis was performed using MannWhitney unpaired t test. RESULTS Quantitative DWI study showed that median ADC value of irradiated breasts was lower ( 1.32 x 10 -3 mm 2/sec) compared to the
non-irradiated control group ( 1.63 x 10-3 mm 2/sec) ( p value= 0.0004). When matched for breast tissue density, irradiated fatty breasts
had lower median ADC value (1.23 x 10-3 mm 2/sec) compared to control group (1.54 x 10 -3 mm 2/sec) (p=0.0018). The irradiated dense
breasts also showed a similar, statistically significant, lower median ADC value (1.59 x 10-3mm2/sec) compared to the controls with
dense breasts (1.77 x 10-3 mm 2/sec) (p value=0.0435). CONCLUSION Mantle radiated breasts have lower ADC values compared to non-irradiated breasts. This difference in ADC value is independent of the
breast tissue density. CLINICAL RELEVANCE/APPLICATION Women who have received mantle radiation have lower ADC values, probably due to post-radiation fibrosis which affects the tissue
diffusion. LL-BRE-MO7A • Fat Necrosis: The Great Mimicker in Breast Imaging
Anubha Wadhwa MD (Presenter) ; Mary Beth Gonyo MD ; Carla J Shah MD ; Zainab Basir MD ; Kelly M England MD PURPOSE/AIM Fat necrosis of the breast is a benign inflammatory process which can often mimic breast cancer clinically and radiologically. The aim of
this presentation is to discuss and understand the pathogenesis of fat necrosis and its variable presentations on mammography,
ultrasound and MRI. CONTENT ORGANIZATION 1. Understanding the etiology and pathogenesis of fat necrosis and its correlation with imaging.
2. Clinical presentations of fat necrosis.
3. The varied mammographic presentations of fat necrosis and their evolution.
4. Discuss its sonographic and MR imaging appearances.
5. The postoperative breast: fat necrosis or recurrrent tumor? Discuss the evolution of fat necrosis post lumpectomy, accelerated partial
breast radiation therapy and flap reconstruction.
6. Management of fat necrosis .
SUMMARY Fat necrosis can occur due to any kind of trauma, biopsy, radiation, surgery, breast infection etc. It often poses a dilemma to both
radiologists and clinicians. Understanding the pathogenesis and imaging appearances of this condition will help solve some of this
dilemma and avoid unnecessary biopsies. Mammography is more specific than ultrasound in its diagnosis. In some cases, MR may be
useful in distinguishing fat necrosis from malignancy. An evolution of imaging findings is seen which correlates well with the histology. LL-BRE-MO8A • Revisiting Probably Benign Lesions on Mammography, Sonography, and MRI
Barbara H Bresciani MD (Presenter) ; Luciana P Silveira MD ; Luciano F Chala MD ; Bruna M Thompson MD ; Nestor De
Barros MD PURPOSE/AIM - Define the concept and the rationale of probably benign assessment - Review probably benign lesions on mammography - Address
potential probably benign lesions on sonography and MRI - Discuss the conditions necessary for its correct and safe use CONTENT ORGANIZATION - Concept of probably benign assessment - Rationale for its use: past, present and new modalities - Probably benign lesions on
mammography: case-based review - Potential probably benign lesions on sonography and MRI: case-based review - Address complete
lesions workup and correct follow-up: key factors for correct and safe use - Examples of inappropriate use of probably benign assessment.
Page 84 of 397
SUMMARY - Probably benign assessment remains important to reduce the number of biopsies with benign results, especially on sonography and MRI
breast cancer screening. - Probably benign assessment applies to a limited number of lesions and its correct use requires a complete
workup and appropriate follow-up to prevent that malignant or typically benign lesions are allocated in this assessment. - Use of this
assessment on MRI implies additional challenges. On the one hand, it can reduce biopsies with benign results. On the other hand,
indiscriminate use can lead to excessive MRI examinations. Therefore, correct selection of the lesions is critical to balance these two
opposing demands LL-BRE-MO9A • How to Correlate Breast Symptoms with Imaging Findings to Increase Yield of Breast Cancer Detection
Shilpa V Lad MD ; Lily Cao MD, PhD (Presenter) ; Jean M Seely MD PURPOSE/AIM Review the most common presenting breast symptoms and the appropriate sonographic management for 1. Breast pain or tenderness 2.
Palpable lump 3. Nipple discharge 4. Others: enlarging/shrinking breast; nipple/skin changes. CONTENT ORGANIZATION � Mastalgia is categorized as cyclic and non cyclic. Less than 1% of women with mastalgia have malignancy. For mastalgia with no other
symptoms, role of US is more for patient reassurance than for cancer detection.
� In patients presenting with a palpable lump, risk of breast cancer varies with age. Fibroadenoma is the most common cause of breast
masses in women < 35 year old. Breast mass in > 70 year old woman has >85% incidence of malignancy.
� Most nipple discharge is physiologic. Spontaneous, unilateral, bloody or clear nipple discharge has a higher association with malignancy.
� Enlarging breast is most commonly due to mastitis and breast cancer. Shrinking breast is most commonly due to invasive lobular
cancer.
SUMMARY Breast pain, palpable mass and nipple discharge are the most common presenting symptoms to breast clinics. We discussed effective
ways to triage patients based on symptoms, age group and imaging features to help differentiate benign from malignant lesions, as well
as, ways to problem solve in cases of negative findings of ultrasound and persistent breast symptoms. LL-BRE1160-MOA • Can Functional Imaging Methods Improve Assessment of Breast Lesions?
Almir Bitencourt MD (Presenter) ; Eduardo N Lima ; Elvira F Marques ; Rubens Chojniak MD, PhD ; Juliana A Souza ; Marcos
D Guimaraes MD ; Luciana Graziano MD PURPOSE/AIM To illustrate and discuss the use of functional imaging methods to improve the assessment of breast lesions. CONTENT ORGANIZATION Functional Imaging Methods - Definition - Comparison with Conventional Imaging Methods Magnetic Resonance Imaging (MRI) - Dynamic
Contrast-Enhancement (DCE) - Diffusion-Weighted Imaging (DWI) - MR spectroscopy - Indications - Limitations 18F-fluorodeoxyglucose
(FDG) PET/CT - Dedicated protocol for breast evaluation - Indications - Limitations - PET/MRI fusion Positron Emission Mammography
(PEM) - Technique - Advantages - Indications - Limitations - Guided Biopsy - New radiopharmaceuticals SUMMARY The major teaching points of this exhibit are: - Functional imaging methods show metabolic / biologic alterations in normal breast tissue
that may precede anatomic / morphologic alterations that is shown on conventional imaging methods. - MRI can provide functional
information through DCE, DWI and MR spectroscopy. - 18F-FDG PET/CT dedicated to breast evaluation can supply important information
and allows PET/MRI fusion. - PEM is a promising tool to evaluate small breast lesions and guide biopsy. Cardiac - Monday Posters and Exhibits (12:15pm - 12:45pm) Monday, 12:15 PM - 12:45 PM • Lakeside Learning Center
Back to Top CA
LL-CAS-MOA • AMA PRA Category 1 Credit ™:0.5 Host
Vincent B Ho , MD, MBA * LL-CAS-MO1A • Prevalence and Findings of Coronary to Bronchial Artery Fistula on Cardiac CT in Patients with Coexistent
Bronchiectasis
Yon Mi Sung MD ; Hye Y Oh MD (Presenter) ; Eun Young Kim ; Yoon Kyung Kim MD ; Hye-Young Choi MD, PhD PURPOSE The aim of this study was to evaluate prevalence and related findings of coronary to bronchial artery fistula (CBF) on
electrocardiogram-gated cardiac CT in patients who had coexistent bronchiectasis. METHOD AND MATERIALS In 3,856 patients who underwent electrocardiogram-gated cardiac CT from April 2009 to November 2012, 207 patients (95 males and
112 females, mean age, 62.1±11.6 years) with bronchiectasis were retrospectively included to assess the prevalence of CBF. Presence or
absence of CBF was reviewed and relation to extent of bronchiectasis and bronchial artery engorgement was assessed. For statistical
analysis, four grades were given to the extent of bronchietasis (minimal, mild, moderate, and severe) and the degree of bronchial artery
engorgement (none, mild, moderate, and severe). In the presence of CBF, origin of the coronary artery, size of the communicating artery
and dominant lung with bronchiectasis were evaluated. Missed rate of CBF on the initial radiological reports was also assessed. RESULTS Fourteen cases of CBF (6.8%) were found in patients with coexistent bronchiectasis; 10 originated from the left circumflex artery and 4
from the right coronary artery. In one patient, a single right coronary artery gave rise to a left circumflex artery as an origin. Mean size of
the communicating artery of CBFs was 1.9 mm (range, 1.0 � 2.9 mm). There was no association between origin of the coronary artery
and dominant lung with bronchiectasis (p=0.176). CBFs were more frequently seen in patients with moderate and severe bronchiectasis
(p CONCLUSION Electrocardiogram-gated cardiac CT was found to be useful for detecting CBF and providing anatomic details of the fistula in patients with
bronchiectasis. Presence of CBF was significantly related to the extent of bronchiectasis and degree of bronchial artery engorgement. CLINICAL RELEVANCE/APPLICATION Careful evaluation of CBF as a potential cause of chest pain or hemoptysis is needed on cardiac CT particularly in patients with severe
bronchiectasis and severe engorgement of the bronchial arteries. LL-CAS-MO2A • Quantitative Adverse Plaque Features from Coronary CT Angiography Predict Impaired Myocardial Flow Reserve
by 13N-Ammonia-PET
Damini Dey PhD (Presenter) * ; Erick Alexanderson-Rosas MD ; Annika Schuhback ; Yuka Otaki ; Xiaowei Ding ; Luis E
Page 85 of 397
Damini Dey PhD (Presenter) * ; Erick Alexanderson-Rosas MD ; Annika Schuhback ; Yuka Otaki ; Xiaowei Ding ; Luis E
Orozco ; Aloha Meave-Gonzalez MD ; Daniel S Berman MD * ; Stephan Achenbach MD * ; Debiao Li PhD ; Piotr Slomka PhD PURPOSE We aimed to evaluate whether integrated quantitative measurement of adverse plaque features from coronary CT Angiography (CTA)
predicts impaired Myocardial Flow Reserve (MFR) and ischemia, measured by 13N-ammonia PET myocardial perfusion imaging. METHOD AND MATERIALS Forty patients underwent combined rest-stress 13N-ammonia PET and coronary CTA scans by hybrid PET/CT. Regional MFR and ischemia
(% stress-rest perfusion deficit) were automatically derived from PET. From CT, 120 arteries were evaluated by automated software,
computing arterial non-calcified (NCP), low-density NCP, and total plaque, as well as maximum diameter stenosis, maximum remodeling
index and maximum contrast density drop over the lesions. Visually, maximum stenosis was assessed by standard grading (0-6).
Quantitative CT measures and measured myocardial mass were combined by boosted ensemble machine learning algorithm into a
composite score to predict impaired MFR (MFR = 2.0) and ischemia (=2% stress-rest perfusion deficit) by PET, in each artery. RESULTS Patients with impaired regional MFR had significantly higher NCP, low density NCP and total plaque in the corresponding arteries (NCP:
156.9 ± 152.9 vs 82.6 ± 124.7 mm3[p=0.02]; low density NCP: 36.8 ± 44.9 vs 19.4 ± 31.9 mm3[p=0.04]; total plaque: 168.6 ± 163.0
vs 93.3 ± 142.7 mm3 [p=0.03]). CP was not significantly different (10.7 ± 26.7 vs 11.7 ± 29.3 p=0.88). For prediction of impaired MFR,
Receiver Operator Characteristic area-under-curve (AUC) for the composite score was 0.80 (95% CI: 0.69-0.92), higher than for visual
stenosis grade (0.60, 95% CI: 0.49-0.72, p CONCLUSION Quantitative analysis of adverse plaque features from CTA allows significantly improved prediction of impaired MFR and ischemia
compared to visual stenosis grade, the current clinical standard. CLINICAL RELEVANCE/APPLICATION Quantitative measurement of adverse plaque features from coronary CT Angiography predicts impaired Myocardial Flow Reserve by
13N-Ammonia-PET LL-CAS-MO3A • Age-gender Normal Values of Native Myocardial T1 Relaxation Times and Lambda on 1.5T and 3T Using MOLLI: A
Single Centre, Single Vendor Card
Darius Dabir MD (Presenter) ; Toby Rogers ; Eduardo Arroyo Ucar ; Rocio Hinojar ; Valentina Puntmann ; Eike Nagel MD,
PhD * PURPOSE T1 mapping is an increasingly promising non-invasive method for quantitative assessment of conditions affected by diffuse myocardial
fibrosis. Using a validated MOLLI-type sequence, we have shown that conservative septal sampling (ConSept) is more reproducible
compared to the whole short-axis slice approach and has superior discriminatory ability between normal and abnormal myocardium. On
the premise that the septum is representative of the diffuse pathology affecting all of the myocardium, we propose that native T1 using
ConSept may allow for a simple, robust, and standardized approach to interrogate diffuse myocardial involvement. Our aim was to
examine age and gender related normal values at clinically used field strengths, 1.5 Tesla (T) and 3T, in a single centre and single
vendor study. METHOD AND MATERIALS 167 subjects with no history of cardiovascular or systemic disease and taking no regular medication underwent native and post-contrast
T1 imaging with modified look-locker inversion recovery (MOLLI; 3,3,5) either at 1.5T or 3T (Achieva, Philips Healthcare, Best, The
Netherlands) with advanced cardiac package. Parameters for native and post-contrast MOLLI were identical (FOV 320x320;
TR/TE/flip-angle: 3.3ms/1.57ms/50�, interpolated voxel size 0.9x0.9x8mm, phase encoding steps n=166, HR adapted trigger delay, with
11 (3-3-5) phase sampling arrangements. An adiabatic pre-pulse was used to achieve complete inversion. ROIs were automatically
propagated across all eleven images in the MOLLI sequence with a prior image- co-registration step for motion-correction (figure).
RESULTS Subject characteristics, mean T1 values, and calculated Lambda for the overall cohort per field strength as well as per age group and
gender are presented in the table. Results revealed no significant age related differences, neither for native T1 relaxation times, nor for
Lambda at both field strengths. Gender related native T1 values on the other hand showed significant differences between males and
females at 1.5T being greater for the female population, whereas neither native T1 values at 3T, nor Lambda at both field strengths
revealed significant differences. CONCLUSION For the first time we report age and gender normal values for native and post-contrast myocardial imaging using the Consept approach.
We furthermore demonstrate gender related differences for native T1 at 1.5T. CLINICAL RELEVANCE/APPLICATION Differentiation between normal/diseased. LL-CAS-MO4A • Cardiac MRI Predictors of Clinical Outcomes in Patients with Apical Hypertrophic Cardiomyopathy
Kate Hanneman MD (Presenter) ; Andrew M Crean MD ; Lynne Willimas ; Hadas Moshonov PhD ; Susan H James MD ; Laura
Jimenez-Juan MD ; Chritiane Gruner ; Patrick Sparrow ; Harry Rakowski ; Elsie Nguyen MD PURPOSE Apical hypertrophic cardiomyopathy (ApHCM) is a morphological subtype of HCM which was previously considered to have a relatively
good prognosis. The aim of the study was to describe cardiac MRI imaging findings and to determine their prognostic impact in patients
with ApHCM. METHOD AND MATERIALS Institutional review board approval was obtained for this retrospective study. Cardiac MRI studies of 101 consecutive patients with pure
ApHCM performed on a 1.5T scanner over a 10 year period were included. The extent of late gadolinium enhancement (LGE) was
determined using a gray-scale threshold of 5SD above the mean signal intensity of normal remote myocardium, and was expressed as a
percent of total left ventricular myocardial mass (%LGE). Statistical analysis included two-sample t-test, Fisher�s exact test and logistic
regression. Interclass correlation (ICC) was used to evaluate inter-observer agreement. RESULTS Mean age of patients was 48.3±14.0 years, 73.5% (n=75) male, with mean clinical follow-up 5.1±6.2 years. Mean %LGE was
12.4±9.7%, and was highest in apical segments (22.9±23.1%); however, LGE was also noted in non-hypertrophied mid and basal
segments. Right ventricular involvement, apical aneurysm, and intracardiac thrombus were identified in 24.8%, 17.8% and 4.0%,
respectively. Thirty-eight (37.6%) subjects experienced an adverse clinical outcome; heart failure (6.9%), appropriate AICD discharge
(2.0%), sustained ventricular tachycardia (VT) (2.0%), non-sustained VT (21.8%), atrial fibrillation (18.8%) and/or stroke (6.9%). There
were no deaths. Subjects who experienced a clinical outcome had a statistically significant greater %LGE compared to those who did not
(15.96±11.88% vs. 10.16±7.3%, p=0.011). Percent LGE was an independent predictor of adverse outcomes (odds ratio (OR) 1.1
(95%CI (1.02, 1.13), p=0.010). Females and patients who experienced shortness of breath were more likely to experience an outcome
(p=0.007 and p=0.037, respectively). High levels of inter-observer agreement were achieved for %LGE (ICC 0.93, 95%CI (0.87, 0.96)). CONCLUSION Late gadolinium enhancement by cardiac MRI is a frequent finding and has prognostic value in predicting adverse outcomes in patients
with ApHCM. Page 86 of 397
CLINICAL RELEVANCE/APPLICATION The clinical course of ApHCM may not be as benign as previously thought. Cardiac MRI detection of LGE may improve risk stratification in
this population. LL-CAS-MO6A • CMR Assessment of Isovolumetric Relaxation Time for the Transplanted Heart with Comparison to
Echocardiography
Parag M Amin MD (Presenter) ; James C Carr MD * ; Rob Gordon ; Benjamin Freed ; Jeremy D Collins MD * PURPOSE Echocardiography is currently the standard non-invasive method of obtaining diastolic indices; however, post-operative variability in left
atrial size in cardiac transplant patients complicates assessment of diastolic abnormalities. Cardiac magnetic resonance (CMR) with high
temporal resolution cine imaging offers an alternative for evaluating ventricular diastolic function. The purpose of this study is to evaluate
the assessment of a diastolic index, isovolumetric relaxation time (IVRT), in a cohort of heart transplant patients, comparing results to
echocardiography. METHOD AND MATERIALS Upon approval by our institution�s review board, a retrospective search was performed for cardiac transplant patients with
echocardiograms and CMR examinations obtained within 1 week of each other. High temporal resolution (avg TR: 11.85 msec) cine
images were acquired from 1.5T scanners (Magnetom Avanto or Espree, Siemens Healthcare, Germany) in the 3-chamber orientation
using segmented steady state free precession (SSFP) sequence (FOV: 276x340mm; voxel size: 1.7x1.7x6cm; TE: 1.16ms; TA: 15sec;
acceleration factor of 2). The SSFP cine images from 20 exams in a cohort of 18 patients (13 males, average age 45.6 yrs) enabled
calculation of time elapsed between aortic valve closure and mitral valve opening (isovolumetric relaxation time, IVRT). Bland-Altman and
linear regression analyses were performed to assess agreement and correlation respectively between CMR and echocardiography. RESULTS Bland-Altman agreement plot of IVRT reveals a clinically insignificant bias of -1.4 msec between the two methods (Figure 1a). Figure 1b
shows high positive correlation between IVRT values obtained from echocardiography and CMR (correlation R = 0.8061; P < 0.01) on
linear regression analysis. CONCLUSION High temporal resolution segmented SSFP cine imaging provided acceptable estimates of IVRT in our small cohort of heart transplant
patients with good correlation to the current standard, echocardiography. As such, CMR-obtained IVRT value may be used as a surrogate
marker in the evaluation of diastolic function and allograft rejection in post-transplant patients. Work is ongoing to validate this approach
in a larger subject cohort. CLINICAL RELEVANCE/APPLICATION High temporal resolution cine CMR can evaluate diastolic function via IVRT values with good correlation to the current standard,
echocardiography, and is recommended in cardiac transplant patients. LL-CAS-MO7A • Investigation of Arterial Pulse Wave Velocity Based on 4D Phase Contrast MR Flow Imaging (4D PC MRI)
Hanieh Mirzaee (Presenter) ; Johann Drexl ; Anja Hennemuth MS ; Andreas Harloff * PURPOSE It is common practice to measure PWV as a distance traveled by specific characteristic points identified on spatially-varying flow profiles,
per unit of time. The purpose of this study is to investigate the impact of different choices of these transient points on the value of PWV
measured in the aorta. METHOD AND MATERIALS 4D PC MRI of 7 healthy young volunteers (average age 24) were previously performed on a 3-T MR system (TRIO; Siemens, Erlangen,
Germany). For flow analysis a phase contrast gradient echo sequence with prospective ECG-gating covering the entire thoracic aorta was
used (voxel size 1.7×2.0×2.2 mm3, temporal resolution = 40.8 ms, venc= 150cm/s).
Data was processed using home-developed research software tool. PWV was then computed by automatically placing cross-sectional
planes, 10 mm apart, starting a few millimeters above the root of the aorta. For each plane, a through flow curve was computed. A
characteristic time point was then identified on each of the flow curves and a line was fitted to the resulting time points over all the flow
profiles. The slope of the line was then used to determine the value of PWV. We investigated three different choices of the characteristic
point:
1. The time point where the flow is 50% of the peak flow,
2. The intersection of a line fitted to the upslope portion of the flow curve with the time axis. We refer to this as time-to-foot (TTF),
3. The time point where the steepest increase in the through flow is observed.
We note that all the major steps are automatized and the PWV processing time on average was less than 30sec. A comparison with a
realistic digital phantom was performed to ensure the correctness of the computations.
RESULTS PWV analysis based on the 50% rule and TTF resulted in less scattered data along the path of the aorta. The average PWV for the 7
volunteers were 4.73±0.31 (range, 4.51 to 5.41 m/s), 4.48±0.36 (range, 4.16 to 5.18 m/s) and 4.49±0.74 (range, 3.14 to 5.14 m/s) for
the 50% rule, TTF and steepest increase respectively. CONCLUSION Based on our experiments, the 50% rule was slightly superior to TTF in terms of more stable estimation of waveform changes; however,
an analysis using a larger population data is needed. CLINICAL RELEVANCE/APPLICATION This technique might evolve to a noninvasive alternative to catherization for assessment of pulse wave velocity in the aorta. LL-CAS-MO8A • Functional Evaluation of the Left Ventricle in Hypertrophic Cardiomyopathy Patients after Alcohol Septal Ablation
Using Magnetic Resonance Imaging: Focus on Correlations between the dv/dt Curves and the Remodeling Parameters in
Long-term Follow-up
Yan Zhang (Presenter) PURPOSE To estimate quantitatively the significance of the unique left-ventricular (LV) diastolic parameter (dv/dt curve) acquired by stead-state
free-precession (SSFP) cardiac magnetic resonance imaging (CMRI) in hypertrophic cardiomyopathy (HCM) patients for the evaluation of
curative effects in long-term follow-up after alcohol septal ablation(ASA). METHOD AND MATERIALS CMRI examinations were performed in 23 (11 women) clinically-diagnosed HCM patients within 2 weeks before and a long interval
(23-65months, mean 34moths) after ASA. Left-ventricular dv/dt curves were generated by delineating manually the endocardial borders
of stack of short-axis cine images, from which the peak ejection rate (PER) and the peak filling rate (PFR) were reckoned out and indexed
automatically. Meanwhile other important LV morphological and functional parameters were also acquired. RESULTS CONCLUSION Page 87 of 397
Our preliminary results provided new insights into the unusual MRI dynamic parameters that reflected both systolic and diastolic functions
of the left ventricle in HCM patients after ASA and showed the clinically valuable relations with the golden standard. CLINICAL RELEVANCE/APPLICATION We demonstrated the clinical potential of evaluating non-invasively the left-ventricular functions of HCM patients with valuable MRI
indicators in the follow-up after ASA treatment. LL-CAE-MO9A • Multimodality Evaluation of Congenital Heart Disease (CHD) and Correlation with Intraoperative Findings
Anurag Yadav MBBS (Presenter) ; Tarvinder B Buxi MD ; Kishen S Rawat MBBS, MD ; Samarjit S Ghuman MBBS, MD ; Raja
Joshi ; Neeraj Agarwal ; Abhishek Agarwal ; Hiren Panwala PURPOSE/AIM To evaluate CT angiography as an ideal imaging modality for diagnosis of CHD and correlate it with 2D and 3D echocardiography,
catheter angiography and intra operative findings. CONTENT ORGANIZATION At a single institute, 30 patients underwent CT angiography over a period of 2 years. It was performed on 128 slice CT using a collimation
of 64 X 0.625mm, slice thickness 0.9mm, pitch 0.8, rotation time 0.5sec with a 512 matrix and iDose. The dose and rate of intravenous
contrast varied according to patient weight. The diagnosis included Tricuspid Atresia, Right Atrial Diverticuli, Double Aortic Arch,
Hypoplastic Ascending Aorta, Coarctation of Aorta, William Syndrome, Total and Partial Anomalous Pulmonary Venous Drainage,
Pulmonary Veno-occlusive disease and Abernethy Malformation to mention a few. Imaging findings were interpreted in conjunction with
echocardiography, catheter angiography and intra operative findings SUMMARY Multimodality evaluation is necessary for diagnosis and effective management of CHD. Ideal diagnostic modality should be able to
delineate all aspects of the anatomy, including abnormalities of cardiac structure as well as extra cardiac vessels. Low Dose CT
angiography with advanced reconstruction techniques is fast, highly accurate, non invasive, reproducible and correlates well with
intraoperative findings.
Chest - Monday Posters and Exhibits (12:15pm - 12:45pm) Monday, 12:15 PM - 12:45 PM • Lakeside Learning Center
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LL-CHS-MOA • AMA PRA Category 1 Credit ™:0.5 Host
Jane P Ko , MD LL-CHS-MO1A • Acute COPD Exacerbation: 3 Tesla MRI Evaluation of Pulmonary Regional Perfusion
Amedeo Taglieri (Presenter) ; Gian Luigi N Sergiacomi MD ; Antonio Chiaravalloti MD ; Eros Calabria MD ; Daniele Citraro
MD ; Giovanni Simonetti MD PURPOSE To compare pulmonary perfusion MR parameters in patients affected by COPD during acute clinical phase with hypercapnic syndrome
and during clinical stabilization phase. METHOD AND MATERIALS 29 patients with acute exacerbation of chronic obstructive pulmonary disease were evaluated by perfusional MRI during acute and clinical
stabilization phase. Inclusion criteria: PaCO2 >45 mmHg and respiratory acidosis (pH RESULTS CONCLUSION MRI allows quantitative evaluation of pulmonary regional perfusion in patients with COPD. Our results suggests vasospastic component as
the main responsible of pulmonary hypoperfusion due to acute hypercapnia. CLINICAL RELEVANCE/APPLICATION MRI allow identification of patients needing vasodilators therapy alone from those requiring also anticoagulants therapy for prevention of
pulmonary hypertension AND heart failure. LL-CHS-MO2A • Commercial Implementation of the Parametric Response Map for Clinical COPD Phenotyping
Craig J Galban PhD (Presenter) * ; Ryan Chamberlain PhD * ; Jennifer Boes ; Ella A Kazerooni MD ; Alnawaz Rehemtulla PhD
* ; Brian D Ross PhD * PURPOSE COPD is a complex disease where patients comprise of varying severity of emphysema and small airways disease. An unmet clinical need
is a biomarker capable of accurately quantifying small airways disease, which is considered the reversible component and thus treatable.
University of Michigan investigators have developed a voxel-based CT imaging biomarker, referred to as the Parametric Response Map
(PRM), that is capable of diagnosing the two major phenotypes in COPD: functional small airways disease (fSAD) and emphysema. For
this technology to be fully realized, a commercial grade and regulatory-approved diagnostic analysis and reporting software must be
developed. We describe the initial development of a commercial version of the PRM diagnostic software application, and our evaluation of
this platform against published results performed on CT data acquired as part of the COPDGene study. METHOD AND MATERIALS CT scans of 194 COPD patients were acquired from the COPDGene Study. PRM consisted of spatially aligning parenchymal tissue from
inspiratory and expiratory CT scans. Relative volumes of the three components were quantified by summing like-classified voxels and
normalizing to the total lung volume. All PRM analyses were performed using the commercial platform and results were compared to
previously generated PRM result. RESULTS We have implemented a fully integrated and automated diagnostic platform that completes PRM on inspiration and expiration CT scans
(Figure 1). We compared the resulting PRM values from the commercial version of the algorithm to those used in the recently published
Nature Medicine article1 and found excellent correlation (R2 = 0.93). CONCLUSION The unique property of our PRM implementation is that it is implemented in a cloud computing platform that will allow users to upload the
original CT image data, execute the PRM algorithm, then download the results without needing to install software locally. Thus, users can
run PRM without purchasing expensive hardware required for this computationally intensive algorithm. It is anticipated that cloud-based
access to PRM can be integrated seamlessly into clinical workflow. CLINICAL RELEVANCE/APPLICATION PRM provides an objective quantitative assessment of lung disease extent and progression. A commercial grade and regulatory-approved
diagnostic analysis will allow PRM to be fully realized. Page 88 of 397
diagnostic analysis will allow PRM to be fully realized. LL-CHS-MO3A • Impact of the Hybrid Iterative Reconstruction Technique on Image Quality in Ultra Low Dose 80 kilovoltage
Computed Tomographic Pulmonary Angiography (CTPA)
Azien Laqmani (Presenter) ; Marc Regier ; Simon Veldhoen MD ; Alexandra Backhaus ; Felicia Wassenberg ; Gerhard B
Adam MD ; Hans Dieter Nagel * ; Frank Oliver G Henes MD PURPOSE To determine whether an iterative reconstruction (IR) technique (iDose, Philips Healthcare) can reduce image noise and improve image
quality in ultra low dose CTPA. METHOD AND MATERIALS 40 patients (mean body weight, < 80 kg; mean BMI, 23.1) with suspected pulmonary embolism (PE) underwent CTPA with an ultra low
dose 80 kV protocol (Brilliance iCT; means: CTDIvol , 2.34 mGy; DLP, 76.45 mGy*cm; effective dose, 1.07mSv). The raw data were
reconstructed using filtered back projection (FBP) and three IR level (2, 4 and 6). Two radiologists in consensus assessed subjective
image quality and image noise on a scale of 1 (very poor) to 5 (excellent). Conspicuity of PE was assessed in central, segmental and
subsegmental arteries using a three-point scale (1, subtle; 2, sufficient; 3, excellent). CT-Attenuation, objective image noise (OIN) and
background signal (SIbackgr.) were measured, contrast-to-noise ratios (CNR) and signal-to-noise ratios (SNR) were calculated. Statistical
analysis was performed using an unpaired t-test and 1-way analysis of variance (ANOVA). RESULTS With each IR level a significant and progressive decrease in subjective and objective image noise was achieved. By implication, SNR and
CNR were significantly increased with IR 4 and 6 compared to FBP (p 2 (p CONCLUSION The hybrid IR technique with level 4 and 6 significantly reduces image noise and improves image quality in 80kV CTPA protocols. CLINICAL RELEVANCE/APPLICATION By the use of IR low dose CTPA with effective doses close to 1mSv are feasible in patients weighing less than 80 kg. LL-CHS-MO4A • Percutaneous Cryoablation of Lung Tumors: One Year Follow-up
Claudio Pusceddu MD (Presenter) ; Barbara Sotgia ; Luca Melis ; Rosa Maria Fele ; Francesco Meloni ; Giovanni Battista
Meloni PURPOSE To report the data of one year follow-up with CT-guided percutaneous cryoablation (PCA) in patients with primary and secondary
pulmonary tumors. METHOD AND MATERIALS CT-guided PCA was performed on 46 lung masses (18 NSCLC = 39%; 28 secondary lung malignancies = 61%) in 40 consecutive patients
(28 men and 12 women; mean age 65 ± 10 years) not suitable for surgical resection. Lung masses were treated using three types of
cryoprobes: IceRod, IceSfere and IceSeed capable of obtaining different size of iceball. The number of probes used ranged from 1 to 5
depending on the size of the tumor. After insertion of the cryoprobes into the lesion, the PCA were performed with two cycles each of 12
min of freezing followed by a 4 minutes active thawing phase and a 4 minutes passive thawing phase for each one for all treatments. RESULTS All cryoablation sessions were successfully completed. All tumors were ablated. No procedure-related deaths occurred. Morbidity consisted
of 20% (8 of 40) pneumothorax, 7% (3 of 40) pleural effusion and 3% (1 of 40) cases asymptomatic small pulmonary hemorrhage,
respectively, all of CTCAE grade 1 (Common Terminology Criteria for Adverse Events). Low density of entire lesion, central necrosis and
solid mass appearance were identify in 32 (70%), 8 (17%) and 6 (13%) of cryoablated tumors, respectively. Technical success (complete
lack of enhancement) was achieved in 80%, 95%, 91% and 85% of treated lesions at 1-, 3-, 6-, and 12-months CT follow-up scan,
respectively. Comparing the tumor longest diameter between the baseline and at 6 and 12 months CT images, technical success was
revealed in 91% and 83% cases, respectively. CONCLUSION Our preliminary experience suggests that PCA is a feasible and safe treatment option. Well-designed clinical trials with a larger patient
population are necessary to further investigate the long-term results and prognostic factors. CLINICAL RELEVANCE/APPLICATION Cryoablation of the lung tumors is a safe and effective procedure capable of obtaining complete ablation of the tumor in a high number of
patients after one year follow-up. LL-CHS-MO5A • Towards a Real-time Diaphragm Positioning System for Aiding in Needle Interventions Targeting Small Thoracic
Lesions
Maarten Kroes MSc (Presenter) * ; Frank De Lange PhD ; Yvonne Hoogeveen PhD ; Knut Brabrand MD * ; Lars Hoff ; Leo
Schultze Kool MD PURPOSE As breath-holds often cannot be reliably reproduced respiratory motion may compromise image guided needle interventions.
Commercially available breath-hold monitors use indirect measures for respiratory motion, e.g. chest wall or abdominal deformation.
Purpose of this study was to assess the applicability of a novel motion sensor in monitoring diaphragm movement directly. METHOD AND MATERIALS The motion sensor consists of a set of 4 independent 3.5 MHz ultrasound transducers each consisting of 8 piezoelectric elements and
mounted in a soft rubber housing, small enough to be fitted between ribs. The difference in acoustic impedance of air relative to tissue
provides a strong reflective interface. The reflection may be exploited to monitor the position of the moving diaphragm.
The position sensitive signal of the sensor was sampled every 100 ms and correlated to the position of the diaphragm as derived from
simultaneously recorded images from a diagnostic ultrasound system (GE Vivid 5, 30 fr/s) in healthy volunteers. Measurements were
taken from more than 30 breathing cycles. For every 500 ms the relative distance to the position of maximal expiration was determined
as derived from both monitoring techniques. RESULTS In the figure the relative difference in position of the diaphragm as derived from the ultrasound images is compared to the signal derived
from the motion sensor over time. The median difference between the two monitoring techniques was 3 mm (range 0-9 mm). CONCLUSION We found a strong correlation between the motion sensor signal and diaphragm movement as derived from ultrasound imaging. Future
work is to develop a feedback system for the patient to allow self monitoring aiding in reproducible diaphragm positioning. CLINICAL RELEVANCE/APPLICATION We developed a motion sensor providing direct feedback on the position of the moving diaphragm, complemented with a feedback system
this will allow patients to accurately reproduce breath-holds. LL-CHE3097-MOA • Multimodality Imaging Analysis and Diagnostic Algorithm of Congenital and Acquired Cystic Masses of the
Mediastinum in the Adult
Page 89 of 397
Francisco Garcia-Morales MD (Presenter) ; Pramod K Gupta MD ; Gregg D Rice MD PURPOSE/AIM 1)The purpose of this exhibit is to illustrate with multiple imaging modalities the cystic pathology of the mediastinum as well as imaging
pitfalls and the imaging approach based on anatomical localization. 2.To explain with cases the utility of MRI with contrast, the use of
diffusion-weighted imaging of the chest in the evaluation of atypical lesions. 3. To discuss the use of trans-esophageal endoscopic
ultrasonography (EUS) in selected cases not showing the typical featureas of non complicated cysts and its potential use for diagnosis and
tissue sampling. CONTENT ORGANIZATION 37 cases of mediastinal were reviewed with a combination of imaging tecniques including plain radiographies, computed tomography,
magnetic resonance, endoscopic ultrasound and a single case with PET. The lesions were classified as: 1)Mesothelial cysts: pericardial
and pleural cysts 2)Foregut cysts: Bronchogenic and esophageal duplication cysts 3)Lymphatic cyst 4)Thymic cysts 5) Mimics SUMMARY The imaging findings of the congenital and acquired cystic lesions of the mediastinum and mimics will be illustrated particularly with
Computed tomography and the use of Magnetic Resonance Imaging and Endoscopic Ultrasound (EUS) in selected atypical cases. The
diagnostic approach based on anatomical location will be discussed. Emergency Radiology - Monday Posters and Exhibits (12:15pm - 12:45pm) Monday, 12:15 PM - 12:45 PM • Lakeside Learning Center
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LL-ERS-MOA • AMA PRA Category 1 Credit ™:0.5 Host
Manickam Kumaravel , MD, FRCR LL-ERS-MO1A • Lipohaematoma and Fluid Effusion of Wrist Extensor Compartments Associated with Distal Radio Fracture: An
Important and Overlooked Finding
Olavo K Nakamura MD (Presenter) ; Juliana F Guimaraes MD ; Luciana S Timbo MD ; Luiz Guilherme Hartmann MD ; Laercio
A Rosemberg MD ; Durval D Santos MD ; Marcelo B Funari MD PURPOSE Traumatic fat and fluid effusion in a tendon sheath, known as lipohaematoma, in the wrist is rarely reported even in the literature. The
aim of this study is to correlate the presence of lipohaematoma and fluid effusion in cases of wrist trauma with the pattern, location and
severity of distal radio fracture. The frequency of these findings in patients with traumatic radio fracture was also estimated. METHOD AND MATERIALS From January to December 2012, 211 CT (137/64%) and MRI (74/36%) exams of patients were reviewed for the presence of distal radio
fractures. Each wrist tendon was analyzed individually, looking for fat or/and fluid effusion. Others evaluated findings were the location,
pattern and severity of distal radio fracture, such as involvement of Lister tubercle, involvement of wrist dorsal cortical, intra-articular
communication, deviated bone fragments and presence of lipohemartrosis. RESULTS 62/211 (29.3%) retrospectively reviewed cases had distal radio fracture. The mean age was 43.3 years old. The pathologic changes of
the sheaths were characterized only in patients who had distal radio fracture and only in the extensor tendons of the wrist. A sheath fluid
distention was detected in 25 cases (40.3%) and a lipohaematoma was present in 16 patients (25.8%). The most frequently affected
compartments were 2nd and 3rd extensor compartments. The fluid distension of extensor tendons sheaths was significantly associated
with dorsal radio fractures (p=0.008) and Lister tubercle involvement (p=0.009). Additionally, a significant correlation was found
between the presence of tendon lipohaematoma and lipohaemartrosis (p
CONCLUSION Fat and fluid effusion in a tendon sheath is not a rare finding in a post-traumatic wrist MRI and CT exams, probably it has not been
systematically evaluated. The traumatic involvement of extensor tendons sheaths is directly related to Lister tubercle involvement, dorsal
radio fractures, presence of lipohaemartrosis and deviated bone fragments. CLINICAL RELEVANCE/APPLICATION The presence of fluid effusion and lipohaematoma alerts to distal radio fracture with sheath disruption, which can cause persistent wrist
pain post trauma and may even result in a tendon rupture. LL-ERS-MO2A • The Use of Adaptive Statistical Iterative Reconstruction (ASIR) Technique in Evaluation of Patients with Cervical
Spine Trauma: Impact on Radiation Dose Reduction and Image Quality
Satya N Patro MD (Presenter) ; Santanu Chakraborty FRCR ; Adnan M Sheikh MD PURPOSE The aim of this study is to know the impact of Adaptive Statistical Iterative Reconstruction (ASIR) technique on the image quality and
radiation dose reduction in the evaluation of patients with cervical spine blunt trauma. The comparison was made with the traditional
Filtered Back Projection (FBP) technique. METHOD AND MATERIALS We retrospectively reviewed a total of 154 patients, who underwent emergency cervical spine CT imaging at our institution for blunt
cervical trauma from June 2010 to Nov� 2010. Out of 154 patients, 96 patients were imaged before the implementation of ASIR
technique i.e with traditional FBP technique. The remaining 58 patients were imaged after the implementation of ASIR technique. As per
the vendor�s recommendation we used a blend of 30% ASIR and 70% FBP in the ASIR category of patients. The patient demographics,
radiation dose, objective image signal and noise were recorded; while subjective noise, sharpness, diagnostic acceptability and artefacts
were graded by two radiologists blinded to the techniques. RESULTS We found that the ASIR technique was able to reduce the CTDIvol and DLP by 50.3% and 54.5% respectively, compared to FBP
technique. There was no significant difference of image noise and signal between the two groups. There was excellent inter observer
agreement on the subjective image quality and diagnostic acceptability for both ASIR and FBP group. CONCLUSION CT imaging of the cervical spine has become the standard technique for exclusion of injury related to blunt trauma. It is essential to
reduce the radiation dose without affecting the image quality. Use of ASIR technique allows us to reduce the radiation dose by 50%
without any clinical relevant degradation in the image quality. CLINICAL RELEVANCE/APPLICATION It is strongly recommended to use the ASIR technique in routine CT imaging of spine to reduce the radiation dose to the patients. LL-ERS-MO3A • The Role of MRI in Soft Tissue Injuries of Cervical Blunt Trauma Patients: 5 Years Experience at Level I Trauma
Center
Page 90 of 397
Center
Emilio Lozupone MD (Presenter) ; Simona Gaudino MD ; Marco Pileggi ; Eleonora Antichi MD ; Mariacarmela Sciandra MD ; Emiliano Visconti ; Annibale Botto ; Giuseppe M Di Lella MD ; Cesare Colosimo MD PURPOSE The diagnostic algorithm for clearance of cervical soft tissue lesions in the blunt trauma patients remains controversial, especially
regarding the role of MRI in emergency settings. Multidetector CT (MDCT) can depict significant soft tissue abnormalities, however
sensitivity, specificity and conspicuity are by far much lower than in cervical fractures. MRI is high-sensitive in detecting cervical soft
tissue lesions, however it is time-consuming, highly cost and difficult to perform in critical ill patients. Our purpose is to investigate the
added value of MRI to MDCT in cervical soft tissue injuries, and how MRI findings impacted on the therapeutic decision in blunt trauma
patients. METHOD AND MATERIALS RESULTS Main indications to MR scan were: neurologic compromise (56), obtunded/comatose patients (26), severe neck pain (5), unclear CT
findings or suggestive of soft tissue injuries (4), other (4). Mean time between CT and MR was 5.9 days. MRI showed soft tissue injuries in
40 patients: spinal cord injuries in 25 patients, ligament injuries in 17 patients, intraspinal extramedullary lesions in 8 patients. CT failed
to show ligamentous injuries in 9 patients, intraspinal extramedullary lesions in 5 patients. MRI findings changed the treatment in 4 Pts
(3,8 %), all with negative CT. CONCLUSION MDCT is enough to evaluate most cervical spine trauma in acute stage. MRI has proved superior to MDCT in depicting soft tissue injuries,
however, without significant treatment changes in most cervical trauma patients. Spinal cord damage remains the main indication to MRI
in acute stage. CLINICAL RELEVANCE/APPLICATION In our experience MRI accurately demonstrates cervical soft tissue injuries in blunt trauma patients, with a poor impact on the clinical
management of the trauma. LL-ERS-MO4A • Thoracic Spine Fractures in Patients with Minor Trauma: Is the Conventional X-ray Necessary?
Murat Karul MD (Presenter) ; Peter Bannas MD ; Amelie Hoffmann ; Bjorn P Schonnagel ; Gerhard B Adam MD ; Jin
Yamamura MD PURPOSE To investigate the accuracy of biplane radiography in detection of thoracic spine fractures in patients (pts) with minor trauma using
multidetector computed tomography (MDCT) as reference and to compare the mean effective dose of both techniques.
METHOD AND MATERIALS 107 consecutive pts (age 67±20y) with minor trauma of the thoracic spine and low to moderate back pain on physical examination were
included retrospectively. All had undergone biplane radiography first, followed by MDCT in a time frame of 10 days because of
aggravation of their symptoms. Contingency table was used for classification of screening test results. Both Chi-square test (?2) and mean
effective dose were used to compare diagnostic methods.
RESULTS MDCT revealed 77 fractures in 65/107 pts (60.7%). Biplane radiography was true positive in 32 pts (29.9%), false positive in 19 pts
(17.8%), true negative in 23 pts (21.5%), and false negative in 33 pts (30.8%), showing a sensitivity of 49.2%, a specificity of 54.7%, a
positive predictive value of 62.7%, a negative predictive value of 41.1%, and an accuracy of 51.4%. Most fractures were diagnosed in the
thoracolumbar junction (39/77; 50.6%). None of the fractures missed on biplane radiography was unstable. Presence of a fracture on
biplane radiography was highly statistical significant, if this was simultaneously proven by MDCT (?2=7.6; p=0.01). Mean effective dose
on biplane radiography was 0.7mSv, and on MDCT was 7.5mSv.
CONCLUSION Sensitivity and specificity of biplane radiography in diagnosis of thoracic spine fractures in pts with minor trauma are low. The mean
effective dose of MDCT was more than 10 times as high as on biplane radiography. CLINICAL RELEVANCE/APPLICATION Considering the wide availability of MDCT that is usually necessary for taking significant therapeutic steps, indication for biplane
radiography in minor trauma pts should be very restrictive. LL-ERS-MO5A • Effectiveness of Second-opinion Imaging Interpretation: A Study in Patients with Cervical Spine CT Scans
Omid Khalilzadeh MD, MPH (Presenter) ; Vinay Batchu ; Patrick C Johnson BS ; Michael T Lu MD ; Robert A Novelline MD ; Garry Choy MD, MS PURPOSE A second-opinion can be a valuable resource in confirming proper medical diagnosis and treatment. This study, evaluates the impact of
second-opinion (over-read) radiology evaluations of cervical spine CT scans on patents� diagnosis in the emergency setting. METHOD AND MATERIALS A total of 311 consecutive cases of cervical spine CT imaging from patients who were transferred to our institution�s emergency
department were analyzed. These patients received imaging of their cervical spine at an outside facility with an initial first-read. The
imaging was subsequently imported to our PACS and over-read (second opinion). A single radiologist compared the first- and
secondary-read radiology reports. Compared with the first-reads, the secondary-read reports were classified as: inconsistent findings,
consistent findings, and different interpretations of the findings. The rate of discordance between the first- and secondary- reads was
assessed. The radiology recommendations in the second scan were classified as: recommendation for re-scan; or scan with a different
modality (ultrasound; MR; bone scan; CT angiography or HRCT). The impact of new radiology findings on changing the final diagnosis or
hospital admission was assessed. RESULTS Patients had different indications for cervical spine CT: evaluation for fracture/dislocation or ligamentous injury (78%); evaluation for
spinal cord or nerve root compression (22%, disc herniation; spinal stenosis; degenerative changes); and evaluation for infectious;
malignant or inflammatory process in bone (9%). In the secondary reads, about 70% of patients had consistent radiological findings.
Inconsistent findings were found in 7% and different interpretations were found in 22% of patients. Request for rescan was made in 30
patients (10%); and request for scan with another modality was made in 5 patients (2%). The new radiology findings were in line with
change of diagnosis in 11% and admission to hospital in 9% of the patients. CONCLUSION This study provides insight on different circumstances that may lead to misdiagnosis or misinterpretation of findings in radiology
assessment of patients with cervical spine CT. Knowledge of these potentials for radiologists can help with faster diagnosis in the first
assessment. CLINICAL RELEVANCE/APPLICATION Second-opinion interpretation of cervical spine CT scans can impact on patients� diagnosis and management in around 11% of cases. Page 91 of 397
LL-ERE-MO6A • Maternal Abdominal and Pelvic Trauma: Imaging Choices, Algorithms, Controversies and CT Dose Reduction
Ramit Lamba MD (Presenter) ; Puneet Bhargava MD ; Jasjeet Bindra MBBS ; Chandana G Lall MD ; Michael T Corwin MD ; Douglas S Katz MD PURPOSE/AIM 1. Review current role of imaging in evaluation of maternal abdominal and pelvic trauma. 2. Discuss limitations of non ionizing modalities
(US & MR) for evaluation. 3. Discuss controversies in maternal abdominal trauma imaging and strategies for dose reduction. CONTENT ORGANIZATION 1. Pregnancy screening 2. Algorithm for imaging and management of maternal abdominal trauma 3. Limitation of FAST scans and
controversies in literature 4. Limitation and challenges of MR 5. Challenges of imaging placental abruption 6. Strategies for CT dose
reduction 7. Modified low dose CT protocol 8. Fetal doses, stochastic and non stochastic risks 9. Issues related to use of iodinated and
gadolinium based agents in pregnancy 10. Informed consent, documentation, fetal dosimetry, dose reporting, genetic counseling SUMMARY After reviewing this exhibit the radiologist will have a better understanding of the appropriate use of imaging for management of maternal
abdominal trauma, including strategies for CT dose reduction in this special population. Gastrointestinal - Monday Posters and Exhibits (12:15pm - 12:45pm) Monday, 12:15 PM - 12:45 PM • Lakeside Learning Center
Back to Top GI
LL-GIS-MOA • AMA PRA Category 1 Credit ™:0.5 Host
Brian C Lucey , MBBCh LL-GIE-MO10A • Immediate Follow-up Imaging Findings and Complications after Locoregional Treatment for Hepatocellular
Carcinoma
Victor Rodriguez MD (Presenter) ; Ana Z Gomez Moreno ; Yolanda Herrero MD ; Juan Ciampi Dopazo MD ; Jose Maria Pinto
; Rafael Gomez Rodriguez ; Soledad Fernandez Zapardiel ; Vivian Artiles Valle ; Mar Cespedes Mas ; Ivan Mauricio Vargas
Orozco MD ; Paula Maria Hernandez Guilabert MD PURPOSE/AIM The aim of this exhibit is: -To review the complications of locorregional treatment (LRT) for HCC. LRT include percutaneous ethanol
injection (PEI), radiofrequency ablation (RFA) and transarterial chemoembolization (TACE). -To describe the expected and unexpected
imaging features of treated lesions as well as the surrounding parenchima after LRT. This radiologic spectrum of the postprocedure
follow-up includes different imaging tecniques such as contrast enhanced US (CEUS), CT and MRI. CONTENT ORGANIZATION 1.Imaging features of treated HCC in the immediate follow-up at US, CEUS and MRI after each LRT (e.g. hyperemia, residual tumor): -PEI
-RFA -TACE 2.Radiological features of LRT complications : -vascular (e.g. hepatic infarction, subcapsular hematoma) -bilary (e.g. bile duct
stenosis, cholangitis) -extrahepatic (e.g. cholecystitis, mesenteric ischemia) SUMMARY Familiarity with imaging findings of treated HCC is helpful in assesing management after LRT as well as therapeutic response if
complications occur. LL-GIE-MO11A • A Lesion by Any Other Name is Not the Same: Application of New OPTN/UNOS Imaging Classification in the
Diagnosis and Reporting of Hepatocellular Carcinoma
James R Frost MD (Presenter) ; Mark D Little MD ; Lauren F Alexander MD ; John V Thomas MD, MRCP ; Rupan Sanyal MD * PURPOSE/AIM The purpose of the exhibit is: 1. To understand the basis by which chronic liver disease patients are currently selected for liver
transplantation, as it relates to HCC and non-HCC patients. 2. To review OPTN/UNOS new minimum technical specifications for
hepatocellular carcinoma imaging. 3. To demonstrate, with specific imaging examples, new OPTN/UNOS classification system for liver
nodules seen in cirrhosis, with implications on diagnosis and reporting. CONTENT ORGANIZATION 1. Introduction. Rational for new OPTN/UNOS criteria to address patients with HCC and well compensated liver failure with the purpose of
generating automatic MELD exception points. 2. Review of MELD scoring and Milan Criteria and its relation to liver transplant allocation. 3.
New recommended OPTN/UNOS technical and dynamic imaging specifications for CT and MRI. 4. Description of new OPTN/UNOS
classifications for hepatocellular carcinoma with the purpose of optimizing lesion specificity over sensitivity, with specific case examples.
5. Review guidelines to improve and standardize HCC radiologic reporting. SUMMARY Key learning objectives: 1. Understand the rational for liver transplant allocation. 2. Understand new OPTN/UNOS criteria for the
standardization of dynamic HCC imaging. 3. Apply new OPTN/UNOS classification criteria to improve HCC diagnosis and reporting. LL-GIE-MO12A • Searching for the Source of Infection: Role of Diffusion Weighted Image (DWI)
Nancy A Hammond MD (Presenter) ; Fernanda D Gonzalez Guindalini MD * ; Paul Nikolaidis MD ; Frank H Miller MD ; Vahid
Yaghmai MD PURPOSE/AIM This exhibit will review the role of DWI in improving sensitivity and specificity of MR imaging for diagnosing sources of infection in the
abdomen. CONTENT ORGANIZATION 1) Review DWI, its strengths and weaknesses
2) Demonstrate how DWI can improve the sensitivity of searching for the source of fever/infection
3) Illustrate examples where DWI increased specificity and diagnostic confidence when searching for an intra-abdominal source of fever
(and in several examples was the only sequence suggesting infection), including
� Abdominal abscess
� Acute pyelonephritis and pyonephrosis
� Acute and chronic inflammatory pelvic diseases
� Appendicitis
� Diverticulitis and colitides
� Cholecystitis
� Pancreatitis
4) Potential pitfalls will be illustrated
Page 92 of 397
SUMMARY Diffusion weighted images can help in detection of the source infection in the abdomen and pelvis, improving sensitivity and specificity of
MR LL-GIS-MO1A • Abdominal CT Perfusion: Breathhold or Free Breathing?
Takeshi Yoshikawa MD * ; Tomonori Kanda ; Yoshiharu Ohno MD, PhD * ; Keitaro Sofue (Presenter) ; Noriyuki Negi RT ; Yasuko Fujisawa MS * ; Tohru Murakami ; Hisanobu Koyama MD ; Mizuho Nishio MD * ; Naoki Kanata MD ; Kazuro
Sugimura MD, PhD * PURPOSE To assess effects of breath control technique on CT perfusion values in the abdomen METHOD AND MATERIALS One hundred eight patients (male: 69, female: 39, mean age: 70.6 years) underwent upper abdominal CT perfusion. Scans (0.5mm x
320, 80kV, AEC) were conducted 7 to 120 seconds after administration of contrast medium (CM) and 25-ml saline chaser. The patients
were randomly divided into two groups; breathhold and free breathing groups. Demographic features and scan parameters (FOV, CTDI,
and DLP) for CT perfusion were recorded and compared.
CT images were analyzed using prototype software for perfusion analysis, which also compensated first manually, then automatically for
respiratory misregistrations before perfusion analysis. Maximum length of manual compensation (mm) (usually z-direction) was recorded
for each patient and compared between the groups. Hepatic arterial and portal perfusion (HAP and HPP, ml/min/100ml), arterial
perfusion fraction (APF, %), mean transit time (MTT, s), and distribution volume (DV, ml/100ml) were calculated using dual-input
maximum slope (dMS), deconvolution (dDC), and compartment model (dCM) methods using the same ROIs. Arterial perfusions (AP),
MTT, and DV of pancreas, spleen, gastric wall were calculated using single-input MS, DC, and CM (sMS, sDC, sCM) methods. The values
were compared between the groups. RESULTS There was no significant difference in demographic features or scan parameters. Mean manual compensation length had a trend toward
larger in free breathing group (13.5 ± 7.7) than breathhold (11.3 ± 7.9). HAP with dCM (p CONCLUSION Even after careful compensations for respiratory misregistrations, CT perfusion values in the liver are affected by breath control
technique. Changes in portal perfusion values were possibly due to structure distortions, which made vessel tracking process in analysis
difficult. CM transit time changes might be caused by intra-thoracic or inferior vena caval pressure changes. CLINICAL RELEVANCE/APPLICATION CT perfusion values in the liver are affected by breath control technique. When measuring hepatic portal perfusion or CM transit time,
breathhold technique is recommended LL-GIS-MO2A • Chronic Liver Diseases Assessment with Optimized Intra-Voxel Incoherent Motion MRI Protocol at 3.0T
Herve Saint-Jalmes PhD (Presenter) ; Benjamin Leporq MS ; Frank Pilleul MD ; Olivier Beuf PhD PURPOSE To optimize a 3.0T acquisition protocol for liver Intra-Voxel Incoherent Motion imaging (IVIM) imaging to be included in a clinical study
focused on chronic liver diseases. METHOD AND MATERIALS First, acquisition protocol was evaluated on 25 healthy volunteers (16 men, 9 women; mean age: 27.1 years; mean weight: 71 kg).
Acquisitions were performed on a 3.0T GE Discovery MR 750 (GEHC, Milwaukee, WI, USA) system with 50 mT/m maximum gradient
amplitude. Sequence used was the SE-EPI eDWI sequence (enhanced Diffusion Weighted Imaging) including 12 b-factors (0, 10, 20, 40,
60, 80, 100, 200, 300, 400, 600, and 800 s/mm2) with variable NEX according to b-factor (2-2-2-2-3-3-4-5-6-7-8-9 NEX) with 2000 ms
TR and 55 ms TE. 21 axial slices were acquired with a 400 × 300 mm² FOV, 128 × 96 acquisition matrix, 8 mm slice thickness, and a 250
KHz bandwidth. Fat Sat was disabled. Signal was collected using the 32 channels body coil. Then scan duration was 5�12�.
Second, another optimization was lead to minimize the number of b-values required to keep the same data fit reliability from the protocol
using Cram�r�Rao inequality providing optimized b-factors.
Pure molecular diffusion coefficient (Dslow), perfusion-related coefficient (Dfast) and perfusion fraction (f) were obtained by a non-linear
least-square fit to the bi-exponential IVIM model. RESULTS Theoritical optimization based on Cram�r�Rao suggested the used of 0, 10, 80 and 800 s/mm 2 b-values. Mean IVIM parameters
obtained were: Dslow value of 1.08 (10-3 mm2/s), 21% for f and 79.3 to 87.9 (10 -3 mm2/s) for Dfast. Bland-Altman plots showed no
significant differences between 12b- and 4b-methods. CONCLUSION Minimization study showed that using a limited (4) number of chosen b-factors give the same results compared with 12 b-factors. The
use of SmartNex, 3-in-1 diffusion gradient scheme, free breathing technique and only 4 b-factors enabled whole liver Intra Voxel
Incoherent Motion Imaging within a minute and seem to be a suitable compromise to be added in a clinical protocol focusing on chronic
liver diseases assessment. CLINICAL RELEVANCE/APPLICATION Optimized MRI protocol at 3.0T dedicated to liver examination of chronic liver diseases focusing on fibrosis and cirrhosis. LL-GIS-MO3A • Sigmoid Stenosis Caused by Diverticulitis versus Carcinoma: Can They be Differentiated by Ultrasound?
Tomas Ripolles MD (Presenter) ; Maria Jesus Martinez Perez ; Claudia P Fernandez Ruiz ; Jose Vizuete ; Diana P Gomez
Valencia MD ; Gregorio Martin-Benitez PURPOSE To evaluate the usefulness of ultrasound as the initial diagnostic method for differentiating diverticulitis from colon cancer in patients with
sigmoid colon stenosis, especially in the emergency setting. METHOD AND MATERIALS Fifty-two patients with sigmoid stenosis were examined by US and CT during the period February 2006 - January 2013. Immediately after
US or CT scans each stenosis was classified as malignant or benign. Off-site, two readers, who were unaware of the proven diagnosis,
independently and retrospectively analyzed 13 different morphological ultrasound criteria retrieved from a literature review to
differentiate between benign and malignant strictures. The two readers were asked to give a diagnosis of malignant, benign or
indeterminate stenosis. Sensitivity, specificity and accuracy were calculated by considering the pathological analysis or by clinical follow
up of at least one year. The interobserver agreement was calculated by the kappa statistics. RESULTS There were 22 sigmoid carcinomas and 30 diverticulitis. The on-site US results were 93% sensitivity, 96% specificity and 95% accuracy
for the colon carcinoma diagnosis; CT sensitivity was 87%. The strongest sensitive morphological features for cancer were loss of normal
layer structure (87%), length 15 mm (93%) and absence of diverticula (88%) were the most specific findings for carcinoma. For
diverticulitis, the most sensitive and specific criteria were preserved mucosal folds and conservation of the inner layer (90 and 95,5%
respectively). Pericolic fat infiltration or abscess were not good criteria for differentiating them. The agreement on morphologic features
oscillated between 0,441 (length 0,8 in 5 out of 13 features. Off-site US diagnosis, excluding 4 indeterminate cases, oscillated between
Page 93 of 397
94-98% of accuracy or 95-100% of sensitivity. The interobserver agreement was 0,782, coinciding in the diagnosis of malignant or benign
stenosis in 46 out of 52 cases. CONCLUSION Our experience suggests that diverticulitis can often be differentiated from colon carcinoma on the basis of some US findings described in
the literature. CLINICAL RELEVANCE/APPLICATION It is not possible to perform colonoscopy or CT-colonography to exclude carcinoma in patients with diverticulitis subjected to conservative
management until inflammatory changes have subsided. LL-GIS-MO4A • Utility of Diffusion-weighted Imaging and Hepatobiliary Phase MRI in Detection of Hepatocellular Carcinoma: A
Meta Analysis
Joo Cho MD (Presenter) ; Salar Hakham DO ; John D Towle MD ; Paul Kim ; Younghun Han PhD ; Hoon Ji MD, PhD PURPOSE The purpose was to conduct meta analysis on the diagnostic performance of dynamic multidetector CT (MDCT), dynamic MRI with
gadolinium, diffusion-weighted imaging (DWI), Gadoxetic Acid-EOB-DTPA (Eovist) Hepatobiliary phase MRI, and combined DWI and
Eovist MRI in detection of hepatocellular carcinoma. METHOD AND MATERIALS PubMed was searched with key phrases of �DWI and HCC� and �DTPA-EOB and HCC�, which resulted in relevant original articles
published from 1993 to 2013. After reviewing each article, relevant articles were pooled for subgroup data analysis with commercially
available statistical software. RESULTS Thirty articles with 1948 patients, 2489 HCCs, and 972 benign lesions were analyzed. The overall DWI sensitivity was 84.2% (95% CI:
82.7%-85.7%), specificity 93.1% (95% CI: 91.7%-94.4%), and the sensitivity for HCC =1 cm was 68.8% (95% CI: 64.5%-73.1%). The
overall Gadoxetic Acid-EOB-DTPA Hepatobiliary MRI sensitivity was 92.2% (95% CI: 91.0%-93.4%), specificity 97.4% (95% CI:
96.4%-98.3%), and the sensitivity for HCC =1 cm was 80.3% (95% CI: 76.5%-84.1%). The diagnostic sensitivity of dynamic MDCT and
dynamic MRI were lower than the DWI or the hepatobiliary phase studies with overall sensitivity of 78.7% (95% CI: 76.3%-81.0%) and
79.5% (95% CI: 77.4%-81.7%) respectively for all HCC lesions and 23.0% (95% CI: 14.1%-32.0%) and 60.1% (95% CI:
54.8%-65.3%) respectively for HCC measuring =1 cm. The diagnostic specificity was high in all image modalities. Meta analysis of studies
that combined the diagnostic performance of DWI and Eovist MRI resulted in sensitivity of 92.9% (95% CI: 91.1%-94.7%) and specificity
of 97.1% (95% CI: 96.3%-98.0%). The overall diagnostic odds ratio for DWI was 71.9 (95% CI: 53.4-96.8), Eovist MRI 442.8 (95% CI:
281.5-696.49), dynamic MDCT 74.9 (95% CI: 53.9-104.2), dynamic MRI 52.3 (95% CI: 39.2-69.8), and DWI+Eovist MRI 438.1 (95% CI:
281.8-681.1). CONCLUSION DWI or Gadoxetic Acid-EOB-DTPA Hepatobiliary phase MRI offer added value to the diagnosis of HCC and demonstrates superior
diagnostic sensitivity, especially in HCC =1 cm, when compared to the conventional dynamic MDCT or MRI. Combined DWI and Eovist MRI
resulted in high sensitivity and specificity, but not statistically different from Eovist MRI. CLINICAL RELEVANCE/APPLICATION Further refinement of the AASLD and LI-RAD guidelines with incorporation of DWI and hepatobiliary phase MRI, leading to improved HCC
detection and clinical outcome. LL-GIS-MO5A • Assessment of Relapse in Patients with Peritoneal Carcinomatosis after Cytoreductive Surgery and Hyperthermic
Intraperitoneal Chemotherapy Using 18F FDG-PET/CT
Bernhard Klumpp MD (Presenter) ; Nina Schwenzer MD ; Ingmar Koenigsrainer ; Alfred Koenigsrainer MD ; Claus D
Claussen MD ; Christina Pfannenberg MD PURPOSE In patients with peritoneal carcinomatosis (PC) cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (HIPEC)
is an evolving therapeutic approach with curative intention. To differentiate between posttherapeutic findings and relapse of PC is
challenging. Due to promising results in the preoperative assessment of PC we evaluated the diagnostic value of 18F FDG-PET/CT in the
follow up period to detect relapse of PC after cytoreductive surgery and HIPEC. METHOD AND MATERIALS 37 patients with relapse or recurring relapse of PC after HIPEC were examined on a whole body PET/CT system (44 examinations). To
provide intestinal distention and reduce motion artifacts, 1000 ml mannitol solution were administered orally and 40 mg of
butylscopolaminiumbromid injected i.v.. 350 MBq 18F FDG were injected 1h prior to PET/CT. Image acquisition covered the whole body
from base of skull to upper limbs. Images were assessed by two experienced radiologist regarding presence and extent of PC using the
peritoneal carcinomatosis index proposed by Sugarbaker et al. Surgical findings were correlated with imaging results. Sensitivity,
specificity, PPV, NPV and diagnostic accuracy (DA) were calculated. RESULTS Relapse was suspected in 40 of 44 18F-FDG PET/CT examinations at 343±267 days after HIPEC. PC was suspected in 237 of 572
peritoneal segments. Relapse of PC was completely missed by 18F-FDG PET/CT in 4 patients and significantly underestimated in 8
patients. Resulting sensitivity for the accurate detection of relapse of PC after HIPEC was 70%, PPV 97% and DA 70%. CONCLUSION Compared to good preoperative results in the assessment of the extent of PC, the diagnostic yield of 18F-FDG PET/CT after cytoreductive
surgery and HIPEC is significantly reduced regarding the presence of PC at all as well as the extent of PC due to the restricted ability to
differentiate between posttherapeutic findings and manifestations of PC. CLINICAL RELEVANCE/APPLICATION The diagnostic value of 18F-FDG PET/CT to evaluate the presence and extent of recurring PC after cytoreductive surgery and HIPEC is
restricted to preoperative results. LL-GIS-MO6A • CT Prediction of Response for Colorectal Liver Metastases to Combination Hepatic Arterial Infusion Plus Systemic
Chemotherapy
Elizabeth J Sutton MD (Presenter) ; Richard Kinh Gian Do MD, PhD ; Kristen L Zakian ; Debra Goldman BS ; Nancy Kemeny
MD ; Michael D'Angelica MD PURPOSE Among different therapies for colorectal liver metastases (CLM), hepatic arterial infusion (HAI) can deliver high dose chemotherapy with
high response rates. However, there is limited ability to predict treatment response before surgery and this would be of obvious value.
The purpose of this study was to evaluate CT imaging and clinical predictors of CLM response to combination HAI plus systemic
chemotherapy. METHOD AND MATERIALS A retrospective review of patients with initially unresectable CLM enrolled in an institutional review board approved prospective trial for
HAI pump therapy was performed. 54 patients (mean age 55.6, range 33-76; 22 females and 32 males) were included, 51 of whom had
Page 94 of 397
available pre and post-treatment contrast enhanced CT scan available for review. Percentage best response (BR) was evaluated according
to Response Evaluation Criteria In Solid Tumors (RECIST) during the trial. For each target CLM identified by RECIST, size and mean
Hounsfield Unit (HU) attenuation were measured on pre-treatment portal venous phase CT. Clinical parameters including prior systemic
chemotherapy and eligibility for post-treatment surgical resection of CLM were documented. Spearman�s rho and Wilcoxon�s Rank Sum
test were used for statistical analysis. RESULTS Before treatment, HU attenuation of CLM was higher in patients who eventually underwent surgical resection (p=0.02), positively
correlated with BR (rho=0.33; p=0.02) and negatively correlated with size of CLM (rho=-0.32, p=0.02). No significant correlation was
found between pre-treatment size of CLM and BR (rho= -0.09; p>0.05). Size of CLM and HU were not significantly different between
those who had prior systemic chemotherapy alone and those who did not (p>0.05). No significant difference in pre treatment size of CLM
was found between patients who eventually underwent surgical resection and those who remained unresectable (p>0.05). CONCLUSION Increased HU attenuation of colorectal liver metastases on pre-treatment contrast enhanced CT correlates with volumetric response and
eventual surgical resectability following treatment with combination HAI plus systemic chemotherapy. CLINICAL RELEVANCE/APPLICATION Pretreatment prediction of response to combination HAI and systemic chemotherapy by CT imaging may be helpful in directing targeted
care of CLM. LL-GIS-MO7A • Prospectively Acquired Low Doses in Abdominal CT and Role of Sinogram Affirmed Iterative REconstruction
(Safire)
Sarabjeet Singh MD (Presenter) ; Sarvenaz Pourjabbar MD ; Ranish D Khawaja MBBS, MD ; Atul Padole MD ; Garry Choy MD,
MS ; Mannudeep K Kalra MD * ; Mischa Woisetschlager MD, PhD ; Nils Dahlstrom MD, PhD ; Anders Persson MD, PhD PURPOSE Assessment of the effect of Sinogram Affirmed iterative reconstruction (Safire) and Filtered Back Projection (FBP) technique on abdominal
CT examination acquired at 200 mAs, 100 mAs, and 50 mAs. METHOD AND MATERIALS 24 patients (mean age 64 ± 14 years, M:F 10 :14) gave informed consent for an IRB approved prospective study for additional research
images through the abdomen on 128 slice MDCT (Siemens Flash) at 100 mAs and 50 mAs over a scan length of 10 cm using combined
modulation technique. Images through entire abdomen were acquired at 200 mAs. The 50 and 100 mAs datasets were each
reconstructed with FBP and four settings of Safire (S1, S2, S3, S4). The FBP 200 mAs images were compared side-by-side with FBP and
Safire images from 50 and 100 mAs. The number and location of lesions, lesion size, lesion conspicuity, visibility of small structures were
assessed by two experienced abdominal radiologists. The diagnostic acceptability was recorded on a four point scale (1= fully acceptable,
4= unacceptable). Objective noise and HU values were measured in liver and the descending aorta. The noise power spectrum was
analyzed for FBP and different Safire settings. RESULTS A total of 43 lesions were detected on both FBP and Safire images. Minor blocky or pixilated appearance of 50 and 100 mAs images was
noted at S3 and S4 Safire settings. No significant artifacts were noted on S1 and S2 Safire images. Image noise was suboptimal in FBP
100 and 50 mAs images, whereas noise was acceptable with S1, S2 and S3 and better than average on S4 setting. Safire could render
100 mAs images as fully acceptable for diagnostic confidence but 50 mAs Safire images were deemed to have lower diagnostic confidence
compared to 200 mAs. As compared to 50 mAs FBP, objective noise was lower by 22.8% (22.9/29.7) on S1, 35% (19.3/29.7) on S2,
44.3% on S3 (16.7/29.3) and 54.8% (13.4/29.7) on S4 (p CONCLUSION Safire enabled reconstruction provides diagnostically acceptable abdominal CT images acquired at 100 mAs (50% reduced dose) but 50
mAs Safire images are not completely diagnostically acceptable despite reduced image noise CLINICAL RELEVANCE/APPLICATION Radiation dose reduction down to 100 mAs is achievable with Safire enabled abdominal CT examinations LL-GIS-MO8A • Performance of LI-RADS Criteria for Diagnosis of Pathologically Proven Hepatocellular Carcinoma (HCC) Using
Gd-EOB-DTPA: Can We Use Hepatobiliary Agents and Eliminate Tissue Diagnosis?
Stephanie Channual MD (Presenter) ; Anokh Pahwa MD ; James Sayre PhD ; Katrina R Beckett MD ; David S Lu MD * ; Steven S Raman MD PURPOSE To determine the performance of LI-RADS for the non- invasive diagnosis of HCC using Gd-EOB-DTPA MRI. METHOD AND MATERIALS This was an IRB approved, HIPAA compliant study with 84 consecutive suspected HCC nodules in 78 patients confirmed by percutaneous
biopsy, resection, or explant within 90 days of Gd-EOB-DTPA MRI (EOB). Nodule size, presence of a capsule, signal intensity on
T1-weighted imaging, and enhancement patterns were recorded. The nodules were then categorized as LI-RADS 3, 4, or 5 based on the
LI-RADS v2013.1 ACR major criteria. RESULTS Of the 84 nodules, 76 were confirmed HCC (90.5%). A total of 15/84 nodules were categorized as LI-RADS 3, 27/84 as LI-RADS 4, and
42/84 as LI-RADS 5. Of these, 11, 25, and 40 nodules were pathologically proven as HCC, respectively (sensitivities 14%, 33%, and
53%, respectively; specificities, 50%, 75%, and 75%, respectively). The PPV of LI-RADS 3, 4, and 5 were 73%, 93%, and 93%,
respectively. The NPV of LI-RADS 3, 4, and 5 were 5.8%, 10.5%, and 14.3%, respectively. The accuracy of LI-RADS 4 and LI-RADS 5
combined was 82% (69/84). CONCLUSION Although use of LI-RADS v2013.1 ACR criteria with EOB yields a high PPV and accuracy for diagnosing HCC, moderate sensitivity and
specificity suggest that further refinement of the criteria may be necessary and tissue biopsy may be complementary for diagnosis. CLINICAL RELEVANCE/APPLICATION LI-RADS standardizes the diagnosis of nodules in cirrhotic livers using MRI with extracellular contrast agents, while its performance using
Gd-EOB-DTPA, a hepatocyte-specific contrast, is unknown. LL-GIE-MO9A • Structured Reports for Rectal Cancer MR Staging: A Bottom Up Approach
Bandar O Safar MD (Presenter) ; Myra K Feldman MD ; Joseph C Veniero MD, PhD PURPOSE/AIM By viewing this exhibit, the participant will: Understand the MR diagnostic criteria used to stage rectal cancer using the TNM classification system.
Recognize tumor features that impact surgical planning.
Develop an organized, thorough approach to interpreting rectal cancer MR staging studies.
Employ structured reporting when interpreting rectal cancer MR studies to clearly communicate findings essential for staging and
surgical planning.
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CONTENT ORGANIZATION Our institution�s structured report for rectal cancer staging will be provided. Each entry of the structured report will be discussed
separately with emphasis on its importance for staging and surgical planning. Examples will be used to illustrate the spectrum of findings
for each section of the structured report. Rectal anatomy and our rectal cancer MR protocol will also be reviewed. SUMMARY Rectal cancer can be accurately staged using preoperative magnetic resonance imaging. When interpreting these studies, the radiologist
must clearly communicate findings essential for accurate staging and surgical planning. Structured reports (table 1) provide a clear
format to communicate information needed by surgeons and oncologists to determine treatment options. Genitourinary/Uroradiology - Monday Posters and Exhibits (12:15pm- 12:45pm) Monday, 12:15 PM - 12:45 PM • Lakeside Learning Center
Back to Top GU
LL-GUS-MOA • AMA PRA Category 1 Credit ™:0.5 Host
Naoki Takahashi , MD * LL-GUS-MO1A • Fusion of T2-weighted and Diffusion-weighted MR Imaging in Evaluation of Myometrial Invasion and Overall
Staging in Endometrial Cancer
Yu Guo (Presenter) ; Wang Penghui ; Wang Ping ; Shen Wen ; Qi Ji MD, PhD PURPOSE METHOD AND MATERIALS Fifty-eight patients with endometrial carcinoma who had underwent preoperative MR imaging, including conventional MR and DW MR
imaging ( b =0 and 1000 s/mm2 ) were enrolled. Interpreted the depth of myometrial invasion and overall stage on T2WI imaging and
T2WI-DWI fused imaging, respectively compared the agreement with postoperational pathology by using Kappa test. T2WI imaging and
T2WI-DWI fused imaging were compared by using X 2 test for accuracy assessment, and receiver operating characteristic curve for
diagnostic performance. RESULTS For evaluating the depth of myometrial invasion, T2WI-DWI fused imaging was significantly better compared with T2WI imaging alone.
The diagnostic accuracy of T2WI-DWI fused imaging was 94.8% , higher than T2WI imaging which was 77.6% (P CONCLUSION Fusion of T2-weighted and Diffusion-weighted MR Imaging provide higher sensitive and diagnostic accuracy in evaluating the depth of
myometrial invasion, and has higher staging accuracy and diagnostic performance compared with T2WI imaging. Fusion of T2-weighted
and Diffusion-weighted MR Imaging may become a no-wounds and no-contrast agent enhancement method, providing a new choice for
the diagnosis of endometrial cancer. CLINICAL RELEVANCE/APPLICATION Fusion of T2-weighted and Diffusion-weighted MR Imaging may become a no-wounds and no-contrast agent enhancement method,
providing a new choice for the diagnosis of endometrial cancer. LL-GUS-MO2A • The Value of Spectral CT Curve for Differentiating Metastases from Adenoma in Adrenal Glands
Ye Ju (Presenter) ; Ailian Liu MD ; Meiyu Sun ; Yijun Liu ; Sheng Wang ; Renwang Pu MBBCh, FRCPC PURPOSE METHOD AND MATERIALS RESULTS CONCLUSION The spectral curve type of metastases was different from adenomas, the majority curve of metastases shows ascending type, while the
curve of adenomas shows descending curve. It was more intuitive for differential diagnosis though observe the spectral CT curve. CLINICAL RELEVANCE/APPLICATION LL-GUS-MO3A • Feasibility Study of Low kVp CT Scans Association with Iso-osmolar Low Concentration Contrast Media Applied
in Renal Artery Imaging
Ying Guo MD (Presenter) ; Dapeng Shi MD ; Shaocheng Zhu MA ; Minghua Sun PURPOSE To investigate the feasibility of low kVp CT scans with iso-osmolar low concentration contrast applied in renal artery imaging. METHOD AND MATERIALS 10 patients (BMI RESULTS SNR of renal artery were R29.77±6.29 and L29.59±6.49 (group A) versus R30.48±3.77 and L30.48±3.77(group
B),tR=0.306,P=0.763,tL=0.197,P=0.846, P>0.05.CNR of renal artery were R24.75±6.25 and L24.55±6.41(group A) versus R25.16±3.67
and L24.73±3.92(group B),tR=0.18,P=0.86,tL=0.08,P=0.94, P>0.05. Subjective IQ was excellent in both groups (mean score 4.4±0.7
versus 4.4±0.6,P>0.05).Images quality differences between the two groups were not significant.DLP and ED of low kVp was significantly
lower than that of conventional 120 kVp(DLP 355.19±20.43 mGy.cm versus 567.59±163.67 mGy.cm, t=4.07,p=0.003,P CONCLUSION Renal artery Imaging performed at low kVp with iso-osmolar low concentration contrast can get equivalent image quality compared with
120 kVp, while radiation dose and contrast media dose can be greatly reduced. CLINICAL RELEVANCE/APPLICATION Low kVp CT scan with iso-osmolar low concentration contrast can be applied in patient with medium size and got excellent diagnostic
images. LL-GUS-MO4A • MRgFUS as an Alternative Method to Hysterectomy in Uterine Adenomyosis: Clinical Results and Technical
Approach
Fabiana Ferrari MD (Presenter) ; Anna Miccoli MD ; Francesco Arrigoni ; Eva Fascetti MD ; Giulio Mascaretti MD ; Antonio
Barile ; Carlo Masciocchi PURPOSE Page 96 of 397
To evaluate the efficacy of uterine adenomyosis treatment using magnetic resonance guided focused ultrasound surgery (MRgFUS) as a
mininvasive therapy, alternative to hysterectomy. METHOD AND MATERIALS From October 2011 to March 2013, 54 patients aged between 24 and 51 (mean age 37.5), with symptomatic adenomyosis and uterine
fibroids were treated with MRgFUS, in our department . This study includes 18 patients affected only by adenomyosis. Symptomatology
was assessed through the symptoms severity score questionnaire. The technical plan was characterized by the use of a
high-energy-grid-sonication. The mean energy delivered for each patient was of 3450 J (minimum value of 1300 J and maximum value of
5600 J). This allowed us to reach the therapeutic temperature also in more vascularized parts of the lesion. In order to treat the
peripherical parts of the lesion, we used a shorter spot length (from 4 to 6 mm) and a shorter cooling time between the sonication. All
patients were treated once and the longest treatment lasted about 120 minutes. RESULTS We evaluated "pre-treatment volume" measured in the T2-weighted sequences using an informatic method on single slice; "treated
volume" obtained from the Exablate measurement system 2100 ; "Non Perfused Volume"(NPV), evaluated on the c.e. T1-weighted
sequences made immediately after treatment. Results showed a "treated volume" mean value of 72.5% of the volume drawn by the
operator. The NPV was meanly 14% greater than the"treated volume". Comparing the three different parameters we can demostrate that
we treated a mean of 86.5% of the lesion. After 12 weeks, the symptomatic score showed a reduction of about 90% if compared to the
pre-treatment one. CONCLUSION MRgFUS is a mini-invasive treatment for adenomyosis. It permits to maintain the integrity of the uterus, a good extension of NPV, a
shorter hospitalization with significant reduction of the symptoms. In conclusion, it is a valid and conservative treatment in a pathology
which so far had limited therapeutic perspectives. CLINICAL RELEVANCE/APPLICATION The study demonstrates the effectiveness of the technique in the uterine adenomyosis treatment, allowing complete resolution of
symptomatology and mostly uterine saving, thus avoiding hysterectomy. LL-GUS-MO5A • Nephrons to Spare?: Pre Operative Prediction of Preserved Renal Parenchyma in Partial Nephrectomy with
Operative and Functional Correlation
Vinay A Duddalwar MD, FRCR (Presenter) ; Scott Leslie MBBS ; Inderbir S Gill MBBCh * ; Mihir Desai ; Syed Rahmanuddin
MD, MBBS ; Phillip M Cheng MD, MS PURPOSE Nephron sparing surgeries (NSS) are the standard of care for solitary renal masses ( SRM). Preserved renal mass following partial
nephrectomy (PN) correlates with postoperative renal function and outcomes. We assessed the accuracy of preoperative radiological
prediction of preserved renal mass using postprocessing techniques. METHOD AND MATERIALS We identified 100 patients undergoing a NSS for a SRM. The preoperative CT scan was assessed using image-processing software to
measure the volume of both kidneys, the tumor volume and to calculate the predicted volume of preserved renal mass by subtracting the
predicted resection volume. The predicted resection volume included the tumor as well as a surgical margin of normal renal parenchyma.
The actual resected volume was calculated by measuring the volume of the specimen on the back table following excision. Predicted
postoperative eGFR was calculated by multiplying the preoperative eGFR with the predicted functional remaining volume (FRV).
Predicted postop eGFR = Preop eGFR x % FRV
RESULTS The mean tumor volume was 21.3 ml, mean predicted resected volume (tumor volume + predicted resection margin) was 45.7 ml and
mean predicted FRV was 92.5%. Comparing the predicted resected volume with the actual resected volume demonstrated excellent
correlation, with a Spearman Correlation Coefficient of r=0.91 (p CONCLUSION We describe a novel technique of pre-operatively predicting the surgically resected volume and the predicted post-operative eGFR. Good
correlation with the actual resected specimen and the actual post-operative eGFR is seen. The volume calculations allow the prediction of
functional outcomes, which hold prognostic significance for patients with already impaired renal function. CLINICAL RELEVANCE/APPLICATION Analysis of CT data using dedicated post processing techniques allows good preoperative prediction of preserved renal mass and with
correlation to operative and functional outcomes. Health Services - Monday Posters and Exhibits (12:15pm - 12:45pm) Monday, 12:15 PM - 12:45 PM • Lakeside Learning Center
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LL-HPS-MOA • AMA PRA Category 1 Credit ™:0.5 Host
Annette J Johnson , MD, MS Host
Aine M Kelly , MD LL-HPS-MO1A • Reducing Radiation Exposure from CT through Utilization Management
Mark D Hiatt MD,MBA (Presenter) * PURPOSE To evaluate the efficacy of utilization management (UM) in reducing unnecessary medical radiation through assuring that exams that
irradiate patients are not performed inappropriately or unnecessarily. METHOD AND MATERIALS The results of a UM program administered by a radiology benefit management company for a national health insurance plan for nearly 5
million subscribers across the country were examined for two recent consecutive years. The radiation averted by avoiding inappropriate or
unnecessary CT was expressed in terms of posteroanterior chest x-ray equivalents (CXREs) using a consistent conversion factor relating
the radiation from CT to CXREs. The number of CTs avoided each year was derived from the sum of the number of CTs requested that
were withdrawn and the number of CTs requested that were changed to a more appropriate modality (such as MRI or ultrasound). RESULTS In the first year, 8,628 CTs were withdrawn and 2,412 were changed to a different modality, sparing approximately 3.3 million CXREs. In
the second year, 10,635 CTs were withdrawn and 2,643 were changed to a different modality, sparing approximately 4.0 million CXREs.
In total, approximately 7.3 million CXREs were spared. CONCLUSION Oversight to assure the judicious use of CT averted unnecessary radiation exposure equivalent to over 7 million chest x-rays over 2 years
for one health plan. Page 97 of 397
for one health plan. CLINICAL RELEVANCE/APPLICATION UM may be successful in reducing unnecessary radiation by limiting inappropriate and unnecessary CT. LL-HPS-MO2A • Timely Critical Results Reporting for Emergent Nuclear Medicine Studies
Moazzem Kazi MD (Presenter) ; Donna Handy ; Karsten Grabski MD PURPOSE Timely reporting of results from an emergent (�stat�, �critical�) radiology study can have a considerable impact on patient care. A
critical result, whether positive or negative, is considered to indicate a life-threatening situation and/or may alter the treatment plan of a
patient. The division of Nuclear Medicine is required by our hospital policy to verbally communicate results to the primary team of a
patient undergoing an emergent study within 4 hours of the study being ordered. This time is to allow for preparation of the radiotracer,
scanning the patient, and interpretation of the images by a radiologist. We wanted to investigate how frequently the 4-hour time
requirement was met. METHOD AND MATERIALS The written reports of all in-patient emergent Nuclear Medicine studies performed from January 1, 2012 through December 31, 2012
were identified in our department�s computer database. The time the study was ordered and the time the results were verbally
communicated to the primary team were recorded. Studies were categorized by whether or not the results were verbally communicated
within 4 hours of the study being ordered. Studies without clear documentation of verbal communication were considered to have not met
the time requirement. Data was sorted by month and the frequency of meeting the 4-hour time requirement was calculated as the
number of studies that met the requirement compared to the total number of emergent studies performed. RESULTS During our investigation period, 9.7±2.8 emergent studies were performed per month and 73% had documentation that results were
verbally communicated within 4 hours. The monthly frequency of meeting the 4-hour time requirement ranged from 50-100%. Of the
emergent studies that exceeded the time requirement, 55% lacked clear documentation that any results were verbally communicated. CONCLUSION Our data suggest that during certain months, only half (50%) of emergent study results were verbally communicated within the 4-hour
time requirement. In addition, lack of documentation was quite high (55%) when the time requirement was exceeded. Finally, the
monthly frequency of timely verbal communication (73%) fell far below an ideal communication frequency of 100%. CLINICAL RELEVANCE/APPLICATION Our analysis suggests that efforts need to be made to increase timely verbal communication with careful documentation for emergent
(�stat�, �critical�) Nuclear Medicine study results. LL-HPS-MO4A • Differences between In-network and Out-of-Network Motivators of Referral Patterns
David A Rosman MD (Presenter) * ; Jose Gutierrez ; William Barron ; Brian Cerroni ; Kristen L Dean ; Giles W Boland MD ; Michelle H Dean ; Natalie Egan ; Thomas Rizzo ; Garry Choy MD, MS PURPOSE Provision of imaging services remains highly competitive. Understanding what drives referrals to an imaging facility is critical to
successfully recruiting volume. We sought to characterize referring physicians� motivations for referring to a particular imaging facility.
We also evaluated for any differences between in-network and out-of-network referrers. METHOD AND MATERIALS We deployed a 17-question survey to 4130 referring physicians to ascertain what factors drive referrals. The surveys were completed
either by the physician, other health-services personnel or their secretarial staff. Responses were accepted via an electronic survey, fax
or handout. Data was analyzed by in-network and out-of network referrer to determine mean values for importance and performance in
each category. RESULTS We received 677 responses from in-network and 141 from out-of network (total 20% of those solicited). The top three factors driving
patient referrals for in-network physicians were: quality of radiology reports, ease of scheduling an appointment and electronic access to
radiology reports/images. The top three factors for out-of-network physicians included the quality of reports, ease of scheduling and the
quality of images produced. In-network more than out-of-network referrers valued subspecialized fellowship-trained radiologists and
electronic access to radiology reports. The helpfulness of the desk staff ranked in the top 50% for out-of-network referrers but in the
bottom quintile for in-network referrers. CONCLUSION The quality of images and reports are equally important to in and out-of network referrers when choosing an imaging facility. However,
in-network providers are more focused on subspecialty reports whereas out-of network referrers consider accessibility factors (reception
staff /ease of scheduling an appointment) more important.
CLINICAL RELEVANCE/APPLICATION Difference in drivers of in-network versus out-of network referrals is critical for optimizing customer satisfaction and thus revenue for
imaging facilities. LL-HPS-MO5A • Evaluating Radiology Resident Education Using Emergency Department Musculoskeletal Study Interpretation:
The Correlation of Year of Training with Error Frequency and Type
Kevin B Hoover MD, PhD (Presenter) * PURPOSE Radiology residents at my institution generate preliminary reports at night that are reviewed in the morning by subspeciality trained
radiologists. These reports are an important source of data to identify their strengths and weaknesses. METHOD AND MATERIALS During the 2011-2012 academic year, 13,296 adult musculoskeletal (MSK) studies were reviewed on call by 23 postgraduate year (PGY)
3-5 residents. Nearly all were overread by radiologists with subspecialty training in MSK. Overreads not in agreement were identified as
having a significant discrepancy, when an error could significantly effect patient management, and having a minor discrepanc,y when an
error was not thought to significantly effect patient management. Discrepancy frequencies were analyzed by resident, PGY, site of injury,
error type, and imaging modality. RESULTS Of the 458 (3.4%) discrepancies documented 380 were minor (2.8%) and 78 significant (0.6%). The mean resident discrepancy
percentage was 3.3% (SD 1.4%) for minor and 0.6% (0.9%) for significant. Number of studies interpreted by the resident was negatively
correlated with minor discrepancies (Spearman�s rho coefficient -.535, p CONCLUSION This study indicates the residents are learning with error rates that compare well with the literature. Early identification and remediation
of those residents accounting for significant numbers of discrepancies could improve overall residency performance. CLINICAL RELEVANCE/APPLICATION Page 98 of 397
Systematic analysis of the preliminary reports of residents early in training can identify recurrent error types and help focus remediation
on those responsible for the majority of errors. LL-HPE1079-MOA • Nonparametric Tests in Radiology Clinical Research
Arash Anvari MD (Presenter) ; Anthony E Samir MD ; Elkan F Halpern PhD * PURPOSE/AIM This exhibit provides a practical review of nonparametric statistical tests for clinical radiology researchers. The description of each
statistical test will be accompanied by a clinical question that the statistical test would address. CONTENT ORGANIZATION 1. What are nonparametric tests?
2. Parametric tests vs. nonparametric tests, advantages and limitations
3. Why are nonparametric tests popular in radiology research?
4. One Sample with Two Paired Measurements
a. Dichotomous scale: McNemar test
b. Ordinal scale: Sign test
5. Comparing Two Related Samples: Wilcoxon Signed Rank Test
6. Comparing Two Unrelated Samples:
a. Categorical data: The Chi-Square and Fisher Exact tests
b. Continuous data with an interval/rational Scale: Wilcoxon rank sum test (Mann-Whitney U-Test)
7. Comparing More Than Two Related Samples:
a. Categorical data with dichotomous scale: Cochran Q test
b. Categorical data with ordinal scale OR Continuous data with an interval/rational Scale : Two-way ANOVA (The Friedman Test)
8. Comparing More than Two Unrelated Samples:
a. Categorical with nominal or ordinal scale: Chi-Square
b. Continuous with Interval /rational Scale: One-Way Rank ANOVA (The Kruskal-Wallis-Test)
9. Spearman Rank Correlation test
SUMMARY We review the common nonparametric tests used in radiology research with practical examples. Informatics - Monday Posters and Exhibits (12:15pm - 12:45pm) Monday, 12:15 PM - 12:45 PM • Lakeside Learning Center
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LL-INS-MOA • AMA PRA Category 1 Credit ™:0.5 Host
George L Shih , MD, MS * LL-INS-MO1A • Open Source Automated Web-based System for Tracking and Analyzing CT Radiation Dose Reports
Michael Y Park MD (Presenter) ; Seung Eun Jung MD ; Kwang Pyo Kim ; Kyung-Hyun Do MD ; Jung Eun Lee ; Hyung-Soo
Kim PURPOSE To develop an open source web based system for tracking and analyzing CT radiation dose reports with an emphasis on ease of use and
increased compatibility in diverse environments without dependencies on external electronical medical records (EMR) or Picture Archival
and Communication System (PACS). METHOD AND MATERIALS We identified potential problems preventing easy and widespread use of automated methods for analyzing CT radiation dose reports.
Based on an open source automated dose extraction project RADIANCE, the Ministry of Food and Drug Safety modified the project and
developed KDose to alleviate these problems. RESULTS Major obstacles of prior automated methods for dose extraction include dependencies on external electronical medical records (EMR) or
picture archiving system (PACS), difficulty in customizing solutions, difficult in automating the whole process, and CT scan protocols which
image multiple body parts in a single scan. To overcome these obstacles KDose removed dependencies on external systems by using an
easy to use fully customizable web based interface to determine CT exam types depending only on DICOM headers. This was
implemented by developing a custom text parsing system fully configurable by a web interface. KDose is also fully installable
automatically and does not require special knowledge to install. Guides for automatically sending images to the KDose system was
created for major CT vendors. KDose identifies and parses multiple CT body parts created from a single scan. The source code for KDose
is open source and may be used or modified freely. CONCLUSION KDose introduces new approaches that solve many problems preventing easy and widespread use of automated methods for analyzing CT
radiation dose reports. CLINICAL RELEVANCE/APPLICATION The development of KDose identifies real world problems in regard to using automated methods for analyzing CT radiation dose reports
and offers potential solutions. LL-INS-MO2A • Computerized Method for Detection of Swelling Lymph Nodes Adjacent to Colon Cancer on CTC Images:
Preliminary Results
Mitsuru Sato (Presenter) ; Toshihiro Ogura PhD ; Norio Hayashi PhD ; Yoshiaki Yasumoto ; Hyunjong Lim ; Kunio Doi CONCLUSION Our computerized method based on a template-matching technique would be useful in assisting radiologist in the detection of lymph
nodules adjacent to colon cancer in CTC. Background A major challenge in the current computer-aided detection (CAD) in CT colonography (CTC) is to detect polyps at a high sensitivity level.
However, there is almost no reports regarding the detection of swelling lymph nodes on CTC images. Our purpose was to develop a novel
CAD method for detection of swelling lymph nodes adjacent to tumor using a template-matching technique on CTC images. Evaluation For detection of swelling lymph nodes, our method was applied to reconstructed slab maximum-intensity-projection (MIP) images in
orthogonal plane of virtual endoscopic images. Since CT artifacts of MIP images can be reduced compared with that of MPR images, CAD
system can be developed for detection of round patterns on relatively low noise images. Our approach consisted of the following steps: 1)
creation of templates by use of swelling lymph nodes, 2) initial candidate detection using template matching technique and, 3) reduction
of false positives using image features. Our scheme was evaluated with use of FROC analysis. Page 99 of 397
of false positives using image features. Our scheme was evaluated with use of FROC analysis. Discussion Since MIP images provided extra-luminal images by depicting blood vessels as liner patterns, blood vessels were removed easily. Since
this method was applied to a large number of MIP images, it is possible to have a very high sensitivity in the detection of swelling lymph
nodes. The initial candidate detection before classification achieved a 100% (14/14) sensitivity in the detection of peripheral lymph nodes
with 12 FPs per case. The subsequent feature selection removed 66.7% (8/12) of FPs without removal of lymph nodes in a
leave-one-lesion-out cross-validation test; thus, a 100% sensitivity with 4 FPs per patient was achieved. LL-INS-MO3A • Selection of Reference Images Based on the Similarity Map by a Multidimensional Scaling: Precision for 324
Independent Test Cases
Chisako Muramatsu PhD (Presenter) ; Tokiko Endo MD ; Mikinao Ooiwa ; Misaki Shiraiwa MD ; Kunio Doi ; Hiroshi Fujita
PhD PURPOSE Previously diagnosed cases with known pathologies can be used as a reference for diagnosis of a new lesion. In order for reference
images to be useful, they must be similar to and belong to the same pathologic group as the unknown lesion. In this study, precision of
our new image retrieval method was evaluated. METHOD AND MATERIALS In our previous study, a similarity measure for image retrieval was determined using an artificial neural network (ANN) that estimates
radiologists� subjective ratings by image features. In this study, a similarity measure was determined on the basis of a multidimensional
scaling (MDS) analysis. In both studies, subjective similarity ratings for 351 pairs of masses, all possible pairs for 27 images, by 8 experts
were used. In the previous study, the average subjective ratings were used as teacher data for the ANN. In this study, the subjective
similarity ratings were linearly converted to dissimilarities and applied to MDS. Each dimension of the 3 dimensional MDS map was
modeled by ANN with the image features. Parameters for ANN were determined by a leave-one-out cross validation with the 27 cases.
For evaluation, 324 independent test images were employed. Using the similarity measures, one to ten most similar images were
retrieved for each test case. Results were compared in terms of an average precision, which is the fraction of the pathology-matched
cases in the retrieved cases. RESULTS Average precisions for the previous measure and MDS-based measures ranged from 0.70 to 0.69 and from 0.80 to 0.79, respectively,
when the number of retrieved images was varied from 1 to 10. The precision for MDS-based method can be considered high despite the
small number of training cases. Although the precision varies between cases, on average, 4 out of 5 retrieved cases were retrieved from
the same pathologic group as an inquiry case. CONCLUSION Although ANN was used in both methods, MDS analysis may be advantageous by breaking down the complicated similarity relationship to
several characteristic dimensions. Reference images retrieved by using the proposed similarity measure may be useful in the diagnosis of
a new lesion. CLINICAL RELEVANCE/APPLICATION Automated image retrieval may be useful for providing reference images in clinical practice and in education. LL-INS-MO4A • A Picture Is Worth a Thousand Words: Needs Assessment for Multimedia Radiology Reports in a Large Tertiary
Care Medical Center
Lina Nayak MD (Presenter) ; Christopher F Beaulieu MD, PhD ; Daniel L Rubin MD,MS * ; Jafi A Lipson MD PURPOSE Radiology reports are the major, and often only, means of communication between radiologists and their referring clinicians. Radiology
reports could include embedded images (�multimedia reports�) though the value to referring physicians has not been studied. The
purpose of this study is to identify referring physicians� preferences about radiology reports and quantify their perceived value of
multimedia reports compared with narrative text reports. METHOD AND MATERIALS 1800 attending physicians from a range of specialties at large tertiary care medical center were contacted by email and a hospital
newsletter linking to a 25-question web-based electronic survey between July and November 2012. 160 physicians responded, yielding a
response rate of 8.9%. Survey results were analyzed using Statistical Analysis Software (SAS Institute Inc, Cary, NC). RESULTS 142 out of the 160 referring physicians respondents (89%) indicated a general interest in reports with embedded images and completed
the remainder of the survey questions. 103 out of 142 respondents (73%) agreed or strongly agreed that reports with embedded images
could improve the quality of interactions with radiologists. 97 out of 142 respondents (68%) agreed or strongly agreed that having access
to the significant/key images embedded in an electronic version of the text report would significantly reduce the time required to
understand/process the information in the report. 129 out of 142 respondents (91%) agreed or strongly agreed that having access to the
significant/key images when reviewing a text-based report enhances understanding of the report content. Regarding physician
satisfaction, 110 out of 142 respondents (77%) agreed or strongly agreed that multimedia reports would significantly improve referring
physician satisfaction, and 85 out of 142 respondents (60%) felt strongly or very strongly that multimedia reports would significantly
improve patient care and outcomes. CONCLUSION Creating accessible, readable, and automatic multimedia reports should be a high priority to enhance the practice and satisfaction of
referring physicians, improve patient care, and enhance the critical role radiology plays in current medical care. CLINICAL RELEVANCE/APPLICATION Multimedia radiology reports are regarded as clinically valuable to referring physicians for improving patient outcomes. LL-INS-MO5A • Quality Assurance Scoring of Computed Radiography Images: Comparison of Gray Scale and Color Monitors
during Image Processing
Regina Shirley RT ; Eric A Brandser MD (Presenter) ; David Agard PhD ; Carly Smith RT ; Marcia Flaherty RT PURPOSE Techologists usually perform quality assurance (QA) at the acquiring workstation, using lower resolution color monitors compared to gray
scale higher resolution monitors found on diagnostic workstations. We noticed that some computed radiographic (CR) images seemed
adequate on the technologist workstation (TW) but not on a diagnostic workstation (DW). We wanted to test the effect of monitor type on
image QA scoring by techologists. METHOD AND MATERIALS 100 CR examinations performed at one institution were collected prospectively over a 5 day period. All images were taken on a single
sytem by two technologists not included in this study. Each case was reviewed by 3 radiology technologists twice. One viewing was on a
gray scale Barco 3220D monitor (1536x2048) and the other on a color HP LA2206x monitor (1920x1080). Both sytems used an HP 6700
tower, Windows XPpro, with McKesson HRS-A version 11.6 software. Order of image viewing was randomized for each reviewer at each
sitting with a two week delay between viewings to minimize case recall. The following grading system was used: 1= 'should never pass',
2 = 'passable/acceptable', and 3 = 'no need for improvement/perfect'. Factors reviewed were mottle, motion, density, and contrast.
Page 100 of 397
Positioning errors were not considered. 12 cases were then reviewed a second time on each system for intra observer agreement
assessment. The scores were analyzed with a multifactor Analysis of Variance (ANOVA) procedure taking into account the effects for
Monitor type, Evaluator, and image. The interaction between Monitor and Evaluator was also included in the model. Absolute agreement
assessed on test/retest cases.
RESULTS The average quality score on the TW is significantly higher than for the DW sytem. (F=74.33, p = .012). There was no significant
interaction between Monitor Type and Evaluator (F = 1.73, p = .178). Monitor effect was constant across the 3 reviewers. There was a
significantly higher intraclass agreement with the DW system. CONCLUSION There is a statistically significant difference for QA scores given by technologists for quality of CR images when viewed on a color monitor
when compared to the gray scale diagnostic monitors. Precision was higher with the gray scale DW system. CLINICAL RELEVANCE/APPLICATION The addition of a gray scale monitor may improve the precision and accuracy of technologist assessment on image quality prior to
submission for radiologist interpretation. LL-INS-MO6A • Protected Health Information on Posted Obstetric Ultrasound Images: An Analysis of Information Security
among Patients
Loyrirk Temiyakarn MD (Presenter) ; Harris L Cohen MD ; Asim F Choudhri MD CONCLUSION Obstetric ultrasound images posted on publicly accessible websites often result in inadvertent disclosure of protected health information.
Radiologists are well positioned to educate patients on taking charge of their own information security. Background With the increasing availability of high quality camera phones and mobile devices, patients now have greater access to their own imaging
and ability to capture screenshots at the point of care. A particularly common scenario is the new mother who uses a mobile device to
obtain an image of her obstetric (OB) ultrasound and then directly posts the images to a public website or forum. The oft-overlooked
concern is the public posting of protected health information, now publicly available for any would-be identity thief to take. Evaluation A consecutive series of OB ultrasound images were acquired from a publicly accessible website and analyzed using several criteria,
including method of image capture, visibility of patient name, date of birth, imaging institution, date of exam, time of exam, estimated
due date, and whether any attempt was made to obscure such data. A large percentage of images sampled were found to include
protected health information in some form, such that a savvy individual could harvest enough personal information to perpetrate identity
theft. Discussion Many patients may not realize or even care about the implications their simple image post may have. While patients are ultimately
responsible for their own information security, we as radiologists are uniquely positioned to educate patients on simple measures they
can take to prevent inadvertent posting of protected health information, such as proper framing, cropping, and photo editing. LL-INE3206-MOA • Radiology Informatics Service Ticketing System
Seth Hall ; Jonathan Borders ; Jay A Moskovitz MS ; Timothy OConnor MBA (Presenter) ; Alex Towbin MD * Background As a Radiology Informatics support team at a large tertiary care hospital with multiple outpatient centers, we were faced with the problem
of managing simultaneous complex Radiology support issues across the enterprise. To address the service and support workflow, we
designed and implemented an easy-to-use, web-based informatics issue tracking application. The system provides for the collection of
issue data as the tickets are worked to resolution. Evaluation A web-based application was created that allows our staff to easily enter service tickets. The user interface was designed for rapid ticket
entry with pre-configured problem categories and severities. Expected response times are displayed in order to communicate service
levels at the point of ticket entry. A ticket dashboard was created for service personnel to quickly view and assign tickets. As tickets are
worked to resolution, the system captures status and resolution information. Automated notification was incorporated to alert service staff
of newly entered tickets. Ticket and resolution data is maintained in an SQL database that provides a knowledge base of problems and
resolutions which can be mined for problem trends and adherence to service levels. Discussion The radiology informatics service ticketing application has been in regular use for approximately 39 months. During that period, 195
distinct users entered 1480 informatics tickets including 465 classified as �critical� in severity. Anecdotal evidence suggests the system
allows issues to be better tracked and disbursed among support staff. We have recently begun mining the database in an attempt to
identify common issues that may indicate additional user training is needed. Informatics management will be using ticket timestamps to
generate metrics related to timely service. CONCLUSION The use of an electronic issue tracking system can introduce industry standard best practice to the service and support of information
systems in Radiology. The need to provide timely resolution to issues is critical to quality patient care and business continuance. In
addition, service ticketing systems provide a better means to track, monitor and collect service quality metrics and aid in management
decision making. LL-INE3208-MOA • ISO 27001 - Implementing Medical Imaging Archiving Using Big Data Architecture: Open Source Approach
Suranarong Kamtasila MEng (Presenter) ; Krongrat Kangwanklai BS, MS Background An Image Archiving System can be characterized as a Big Data architecture.It is considered based on the growth of Modality data, various
data structure,a need for faster response time, a longer storage duration, and regulatory requirements to maintain personal data for a
very long period of time.This research focuses on exploring a suitable data architecture that meets the ISMS ISO 27001 needs and is
based on the principles of Big Data architecture and Cloud. Evaluation Based on the ISO 27001 requirements, the medical data, its DBMS, and log files are our most important concern.An archiving system
must have no limitation on the storage.The data must be encrypted, must not be tampered with and is accessible only through the
specified applications.The file system must be fault-tolerance. The backup facilities must be adequate and its copies must be available in
both a main site and a remote location. The system must be able to recover from major failures and support a business continuity
management. We use Hadoop framework to ensure that the above requirements are met.The main reasons that HDFS is selected are it
can support the Big Data architecture, stream data access, large data set, and simple coherency model. Discussion Page 101 of 397
There are three Clouds. Two of them are designed for storage and the third one is for applications. These Clouds will be resided in two
locations and connected through VPN. At each data center, it is comprised of two Hadoop framework, one cluster of MySQL, one cluster of
EJBCA, and one cluster of application. There is DICOMSync at each location which acts as a connecting point. It will compress and send
the data from one DICOMSync to another, decompress and forward the data to the storage cluster.
CONCLUSION For ISO 27001 requirements, it is required that ISMS data are secured.The business continuity management process is implemented. The
data is encrypted to maintain the data confidentiality. The log files are kept systematically to enable effective monitoring and traceability.
The application interfaces are readily available to support research activities. All these are designed and implemented using the open
source software. LL-INE3204-MOA • Learning Musculoskeletal Radiology on the Go: PACS-Like Testing of Both Recognition and Interpretive Skills
on the iPad
Benjamin L Yam MD (Presenter) ; Jose Morey MD ; Stuart D Kinsella BA ; Nora M Haney BS ; Tessa S Cook MD, PhD Background Teaching files, formal presentations, and collections of interesting cases are used to teach radiology residents and fellows. However, such
materials provide only a small subset of images in order to feature noteworthy findings, whereas to make a diagnosis in regular clinical
practice requires reviewing multiple stacks of images. To more effectively test the ability of trainees to recognize abnormalities on
musculoskeletal MRI and CT, we developed a mobile application that presents a mixed array of normal and abnormal exams. To replicate
the way they would be viewed on a PACS workstation, all cases are presented as scrollable image stacks. Presenting this content on a
mobile platform enables radiology trainees to practice outside the reading room while still simulating clinical practice. Evaluation Multiplanar image stacks from musculoskeletal MRI and CT scans are randomly presented in a scrollable image viewer. Cases are
classified as basic or advanced. For each case, the app allows the user to scroll through the image stack on a mobile device as if
reviewing at a workstation. Once the images have been reviewed, the possible diagnoses can be revealed as a multiple-choice quiz, but
only after the case images are hidden! This is intended to simulate daily practice, during which each patient's study does not arrive with
a multiple-choice list of possible diagnoses, which can sequentially be eliminated. A running score is tallied as the trainee reviews each
case. At the end of the quiz, the answers are revealed by way of explanation. Discussion We have created a mobile-friendly test of visual perception for musculoskeletal imaging that presents joint, extremity, and spine MRI and
CT scans as they would be viewed on a PACS workstation. CONCLUSION This mobile application provides an approach to giving radiology trainees additional opportunities to practice their diagnostic skills outside
the reading room. The app can potentially be used as a performance tracker during training, as well as be extended to other modalities
and subspecialties. LL-INE3202-MOA • Comparison-Bot: An Automated Preliminary-Final Report Comparison System
Amit D Kalaria MD (Presenter) ; Ross W Filice MD Background Regular comparison of preliminary to final reports is a critical part of radiology resident and fellow education as prior manual comparisons
have documented substantial preliminary to final discrepancies. Unfortunately, there are many barriers to this comparison: high study
volume; overnight rotations without an attending; the ability to finalize reports remotely; the subtle nature of many changes; and the
loss of the preliminary report after finalization. Evaluation We receive a real-time Health Level 7 (HL7) feed from our Radiology Information System (RIS) (Siemens). Our Mirth Connect HL7 engine
(Mirth Corporation) filters radiology report messages and parses report data into a MySQL (Oracle) database separated by preliminary
and final status. A Bash (GNU) script queries all preliminary reports over a desired time period, finds the associated final report, evaluates
for differences, compiles positive difference reports by radiologist, and emails these reports automatically. Discussion Our system automatically compiles and emails a weekly summary of report differences for all residents and fellows. Differences between
preliminary and final report are clearly highlighted with links to the associated study in PACS for efficient review and learning. This
provides an easy way to review changes to preliminary reports with immediate access to the associated images. We hypothesize that this
will improve our education and learning experience and may also decrease discrepancy rates over time. A comparison of discrepancy
rates prior to implementation of this system with prospective discrepancy rates will be presented to quantify impact. Subjective resident
and fellow survey results regarding opinions of the weekly report and how it affects their education and learning experience will also be
summarized across PGY levels. We will continue to refine our discrepancy algorithm to try and more intelligently distinguish significant
differences and prioritize the presentation order in the weekly reports. CONCLUSION We believe this system will improve our department education and learning experience and will hopefully reduce future radiology report
discrepancy rates. LL-INE3168-MOA • m-SARCC (Mobile Stroke Acute Radiology Command Center): Image Review and Neurological Care Team
Coordination Linking PACS and Mobile Smart Devices
C. C. Tchoyoson Lim MBBS ; K. N. Bhanu Prakash PhD ; Anand Ananthasubramaniam MEng ; Guo Liang Yang PhD (Presenter)
; Yanjiang Yang PhD ; Wieslaw L Nowinski PhD ; Mahendran Nadarajah ; Ramarajulu Srinivasan BS ; Kok Haur Ong MSc Background Widespread adoption of mobile smart-phones and tablets has potential to facilitate timely clinical care team image review, group
communication and decision making, but this is not well supported in hospital PACS. We tested a prototype command center using
iStrokeSuite (demonstrated at RSNA 2010) push technologies extending clinical PACS to test acute team coordination and neuro-oncology
multidisciplinary team management. Evaluation Time-critical acute patients with subarachnoid hemorrhage (SAH) and ischemic stroke had their emergency head CT angiography or MR
images (encrypted using HIPPA-compliant symmetric key encryption and fine-grained public key encryption) and sent to a prototype
Mobile Stroke Acute Radiology Command Center (m-SARCC). m-SARCC is connected to an SMS/Email/Notification alert system, which
alerts defined team members including radiologists, nurses, technologists and clinicians to securely log into the system to review the
decrypted images, respond and update all, triggering a �go� procedure (aneurysm coiling or mechanical thrombectomy) or �no-go�
conclusion. Non-critical scenarios involved radiologists, medical and radiation oncologists, neurosurgeons and nurses discussing case
management options. Multiple input (text, audio, video, and image annotations) and functionalities (multiplanar reformat, volume
calculation, anatomical atlas) were assessed by team members in structured and unstructured surveys. Discussion The system potentially unifies PACS image review with a communication center linking mobile devices. Rapid review and narrowcast of
results and decisions decreased communication time, with text preferred to voice files as a vehicle in time-critical situations. Non-critical
scenarios were more ambiguous but video and non-radiological image data were requested by clinicians. Page 102 of 397
CONCLUSION A radiology command center linking PACS to mobile smart-phones and tablets can support image review, group communications and
decision making especially in patients with SAH and ischemic stroke. Musculoskeletal - Monday Posters and Exhibits (12:15pm - 12:45pm) Monday, 12:15 PM - 12:45 PM • Lakeside Learning Center
Back to Top MK
LL-MKS-MOA • AMA PRA Category 1 Credit ™:0.5 Host
Gina Diprimio LL-MKS-MO1A • Model-based Iterative Reconstruction in Optimizing Image Quality of Pelvic CT
Xinhuai Wu (Presenter) ; Wei Han ; Junliang Lu ; Ning Guo PURPOSE Sexual gland (including ovary and prostate) is highly sensitive to radiation dose. This study aims to investigate the value of model-based
iterative reconstruction (MBIR) in optimizing image quality of pelvic CT, and access the potential of low dose pelvic CT. METHOD AND MATERIALS Totally 23 consecutive patients were chosen and underwent plain and contrast-enhanced pelvic CT with automated tube current
modulation (ACTM). The images were reconstructed with filtered back projection (FBP group), adaptive statistical iterative reconstruction
(ASiR group) 50% and MBIR (MBIR group), respectively. Image noises and CT values of bladder, ilium, gluteus maximus and
subcutaneous fat were measured. The image quality was evaluated using 5-point scale. Those results among the 3 different
reconstructions were compared by one-way ANOVA and Wilcoxon signed-rank tests. RESULTS CT value in three groups had no significant difference (P>0.05). The image noise in MBIR group was lower than that in ASiR group (P CONCLUSION MBIR can improve the overall image quality and may reduce ~77% radiation dose of pelvic CT. CLINICAL RELEVANCE/APPLICATION MBIR can improve the overall image quality and may reduce ~77% radiation dose of pelvic CT. LL-MKS-MO2A • An MRI Evaluation of Piriformis Muscle Modifications Induced by Botulinum Toxin (Botox) Injections
Mohammed A Alshaikh (Presenter) ; Fabrice Michel MD, PhD ; Bruno A Kastler MD, PhD ; Sebastien L Aubry MD, PhD PURPOSE Botox injection is a new treatment of the piriformis muscle syndrome and the purpose of our study was to evaluate by MRI the
morphological modifications of the piriformis muscle treated by Botox injection or by surgical desinsertion. METHOD AND MATERIALS Seventeen patients presenting with a piriformis muscle syndrome treated either by Botox injection or surgery, and who benefited from an
MRI were included retrospectively (mean age 43 y/o). The following parameters were assessed and compared to a normal contralateral
muscle: maximal thickness and volume of piriformis muscle, and its fatty infiltration according to Goutaillier's classification. RESULTS The affected side showed a significant reduction in thickness (p CONCLUSION To our knowledge, our study is the first that shows quantitatively the effect of infiltration therapy by Botox over the piriformis muscle:
atrophy and fatty infiltration CLINICAL RELEVANCE/APPLICATION Botox injection into the piriformis muscle in the treatment of the eponymous syndrome has morphological effects on the muscle that can
be demonstrated and followed-up by MRI LL-MKS-MO3A • Analysis of Ischial Spine Orientation in Patients with Compression-mediated Pudendal Neuropathy: A Study
Using 3D Computed Tomography
Lina Chen MD (Presenter) ; Richard P Marvel MD ; Howard M Richard MD PURPOSE The pudendal nerve is a predominately sensory nerve arising from s2-4 nerve roots. Several potential sites of entrapment lie along the
course of the nerve. One critical zone of compression is adjacent to the ischial spine and sacrotuberous ligament. We hypothesize that
variations in bony anatomy of the ischial spine may predispose patients to pudendal nerve compression. The goal of this study was to use
3D computed tomography (CT) to identify reliable measurement of ischial spine orientation and to determine if such metrics can
differentiate patients with pudendal neuralgia from control patients without neurological symptoms. METHOD AND MATERIALS In this IRB-approved study, CT of the bony pelvis in 32 women were retrospectively reviewed, including 16 patients (ages 22-78 y; mean
= 54.3+/-15 y) diagnosed with pudendal nerve compression syndrome and who underwent pudendal nerve block; 16 patients (ages
22-94 y; mean 64+/-19 y) who presented with trauma but had no documented neurologic symptoms. Exclusion criteria include diffuse
pelvic pathology, such as Paget disease and metabolic bone disease, pelvic fracture, extensive calcification or ossification of soft tissue,
and presence of hardware. Using the TeraRecon 3D CT application, an axial oblique CT image at the level of the tip of the bilateral ischial
spine and mid symphysis pubis was obtained. Six methods of measurements were performed by a musculoskeletal radiologist with 5 y
subspecialty experience. Each measurement was performed twice, separated by at least 1 month. The Student t test was used to
compare differences in measurements between the two groups. RESULTS Of the CT measurements, the difference in the angle between the ischial spine and inner pelvic wall was found to be statistically
significant between the control and neuralgia patients. Right side: neuralgia 126+/-4.8 degrees, control 135+/-4.9, P = 0.015; left side:
neuralgia 126+/-2.4, control 134+/-5.4, P = 0.044). Intra-observer correlation coefficient was 0.80. CONCLUSION Assessment of the orientation of ischial spine using 3D CT may help identify patients at risk of developing pudendal compression
neuropathy. CLINICAL RELEVANCE/APPLICATION This study demonstrates potential application of clinical 3D CT in identify patients at risk of developing pudendal compression neuropathy. LL-MKS-MO4A • Is Accurate Metal Artifact Reduction Feasible at 3T? A Comparison Study between 3T and 1.5T
Page 103 of 397
LL-MKS-MO4A • Is Accurate Metal Artifact Reduction Feasible at 3T? A Comparison Study between 3T and 1.5T
Lorenzo Nardo MD (Presenter) ; Misung Han ; Sonia Lee MD ; Ursula R Heilmeier MD ; Kevin Koch PhD * ; Thomas M Link
MD, PhD * ; Roland Krug PhD PURPOSE Given its higher signal-to-noise-ratio high field MRI at 3 Tesla is increasingly used for musculoskeletal applications, however, metal
artifacts and related image distortions are also more pronounced at 3.0T. We therefore studied the impact and the feasibility of metal
artifact reduction sequences at 3.0T as compared with 1.5T METHOD AND MATERIALS Twenty patients (aged 58-76) with total hip replacements were scanned at 1.5T and 3.0T within a period of 2 weeks. For signal
acquisition, 8-channel phased-array cardiac coils were used on both scanners. The sequence protocol included: multiacquisition
variable-resonance image combination (MAVRIC) PD (coronal), MAVRIC STIR (axial) as well as standard FSE sequences. Each study was
assessed by 2 radiologists for morphological abnormalities (joint effusion (including findings suggesting aseptic vascular autoimmune
lymphocytosis (AVAL)), bone marrow edema pattern, osteolysis, insertion tendinopaty at the greater trochanter) and distinction of
anatomic details (anterior and posterior femoral head, femoral neck, greater and lesser trochanters). A five-point scoring system was
used: 1- good visualization, 2- good visualization with minimum artifacts, 3- visualization not compromised by artifacts, 4- visualization
compromised by artifacts, 5- severe artifacts. Furthermore, the extent of artifacts was quantitatively measured. Wilcoxon signed rank test
was used to compare the data obtained by the two different scanners. Agreement between the two readers was reported with kappa
values. RESULTS While the extent of artifacts was significantly smaller at 1.5 T compared to 3.0 T (p0.05): average scores ranged between 2.5 and 3.4 at
1.5 T and between 2.6 and 3.3 at 3.0 T. Also the assessment of morphological abnormalities was not significantly different between the
two field strengths (p>0.05) with average scores ranging between 2.6 and 3.5 at 1.5 T and 2.5 and 3.6 at 3.0 T. Inter-reader agreement
for different anatomic details and clinical findings visualization ranged between k=0.65 and k=0.90. CONCLUSION Though artifacts were larger at 3 T compared to 1.5 T, the visualization of morphological abnormalities and anatomic details was not
significantly different between the two field strengths. CLINICAL RELEVANCE/APPLICATION 3.0 T metal artifact reduction showed no significant difference in detection of morphological abnormalities and anatomic details when
compared to 1.5 T. LL-MKS-MO5A • Anterior Knee Pain Syndrome: May One and Simple Measurement Using Weight-bearing MRI Unmask Patellar
Maltracking in Your Patients Negative at Standard-MRI?
Silvia Mariani MD (Presenter) ; Alice La Marra MD ; Stefano Necozione MD ; Vittorio Calvisi MD ; Antonio Barile ; Carlo
Masciocchi PURPOSE To prove that weight-bearing (WB)-MRI may unmask a patello-femoral maltracking with respect to standard-MRI and to define which
measurement of patellar alignment is the most reliable. METHOD AND MATERIALS RESULTS Group A patients showed no statistically significant variations at all measurements both on standard and WB-MRI. On the basis of
standard MRI-measurements, Group B patients were divided in Group B1 (23 pts) (negative or positive at 1 measurement) and in Group
B2 (52 pts) (positive at 2 or more measurements). After WB-MRI, patients of Group B1 were divided in Group B1a (6 pts) if they
remained positive at 0/1 measurement and in Group B1b (17 pts) if they became positive at 2 or more measurements). All patients of
Group B2 confirmed to be positive at 2 or more measurements at WB-MRI. Qualitative statistical analysis (K-Cohen) demonstrated that
LPT was the best predictive measurement (K=0.278) between standard and WB-MRI. Quantitative statistical analysis (Coefficient of
variations from duplicate measurements) showed that LPT (for Group B1b=60.3%) and LPA (for Group B2=69%) were the most
reproducible and clinically useful measurements. CONCLUSION The study demonstrates both the high diagnostic value of WB-MRI in unmasking PF-maltracking and the best predictive value of LPT
measurement. CLINICAL RELEVANCE/APPLICATION This study demonstrates that WB-MRI (using LPT measurement) may be very useful in unmasking patello-femoral maltracking in patients
with negative standard MRI. LL-MKS-MO6A • Dynamic Sonography of the Anterosuperior Hip during Flexion, Adduction/Internal Rotation: A Pilot Study
Neil P Shah MD (Presenter) ; Catherine N Petchprapa MD ; Roy Davidovitch ; Jose Maria Raya Garcia Del Olmo PhD ; Adler S
Ronald MD, PhD PURPOSE Demonstrate the ability of real-time ultrasound to track the relationships between the acetabulum and femoral head (FH)/neck junction
and evaluate labral morphology and femoral-labral relationship (FLR) during dynamic hip flexion (HF) and adduction/internal rotation
(ADIR). METHOD AND MATERIALS Ultrasound (US) and magnetic resonance (MR) evaluation of 10 hips in 5 asymptomatic subjects (4 Females, 1 Male, mean age/range
30.1/22-39 years). US (ACUSON S2000�, Siemens Healthcare, Mountainview, CA):High resolution longitudinal images of the femoral
neck recorded at the level of the iliopsoas (IPT) and rectus femoris (RFT) tendons, and of the intervening anterosuperior (AS) labrum
between them were acquired using 9 MHz linear phased array US transducer (TD).Dynamic US images, stored as cine clips, acquired in
same orientation using 8 Mhz small footprint sector US TD positioned between IPT and RFT during continuous passive HF to 45/90 deg
(10 subjects), and 45/90 degrees HF plus 60 degrees ADIR (6 subjects). All sonographic imaging performed by one radiologist with
expertise in MSK US. MR: Coronal, axial oblique fat suppressed proton density images of each hip (SKYRA; Siemens, Mountainview, CA,
phased array coil, TR/TE 2800/37).Consensus review of static US for appearance of AS labrum and chondrolabral junction (CLJ), and
dynamic US for FLR, course of FH motion, presence of bony conflict. MR images evaluated for presence/absence of labral/CLJ
pathology,cam lesion. RESULTS STATIC STUDY: MR:(1/10) cam, (5/10) labral tears, (9/10) CLJ separations. US:(8/10) labral tears, (5/10) CLJ separations. DYNAMIC
STUDY: Labrum visualized to 45 deg HF (10/10), 90 deg HF (0/10), and 45 deg HF/30 deg ADIR (5/6). Labrum remained apposed to FH
surface up to 45 deg HF (10/10) and vertically displaced between 45-90 HF (3/10), FH rotated smoothly under acetabular rim
(10/10);(0/10) bony conflict during F/ADIR. CONCLUSION Dynamic US can evaluate labrum and femoroacetabular relationships during dynamic 45 deg HF and 30 deg ADIR. FH rotates smoothly
under acetabular rim without bone/soft tissue conflict, and labrum rides along the surface of the femoral head as the hip is flexed. Page 104 of 397
CLINICAL RELEVANCE/APPLICATION Dynamic US combined with clinical hip examination for femoroacetabular impingement (FAI) can be used to evaluate subjects with FAI
and pain. LL-MKS-MO7A • Trabecular Bone Changes and Subclinical Secondary Osteoporosis Following Gastrectomy Detected by
Multidetector CT
Miyuki Takasu MD (Presenter) ; Yukiko Honda MD ; Shuji Date ; Masao Kiguchi RT ; Kenichiro Matsuzaki ; Kazuo Awai MD *
; Takahisa Suzuki ; Kazuaki Tanabe PURPOSE Bone loss is a common disorder associated with gastric surgery, and a large number of postgastrectomy patients remain at risk for
developing osteoporosis. The purpose of this study was to determine the prevalence of secondary osteoporosis (SO) and trabecular
microstructural changes following gastrectomy using multidetector computed tomography (CT). METHOD AND MATERIALS Spinal microarchitecture was examined in patients post distal gastrectomy (n=92), patients post total gastrectomy (n=111), and in 85
sex- and age-matched controls using a 64-detector CT. Using a bone mineral phantom and a 3D image analysis system, bone mineral
content per tissue volume (BMC/TV), trabecular parameters, and mechanical properties of the third lumbar vertebrae were caluculated.
Using BMC/TV with a reported cutoff value 58 mg/cm3, the prevalence of SO according to surgical procedures was analyzed using the
Cochran-Armitage trend test. A multivariate regression model of patients� characteristics including age, sex, postoperative period, and
surgical procedure was constructed to identify predictors of SO. The trabecular parameters were compared among three groups, including
control subjects, patients with SO, and patients without SO by the Scheffe�s post hoc test. RESULTS The prevalences of SO were 29.1% for post distal gastrectomy and 33.8% for post total gastrectomy in males, and 51.6% for post distal
gastrectomy and 62.2% for post total gastrectomy in females. There were significant increase in the prevalence of SO from control
cohort, distal gastrectomy cohort, to total gastrectomy cohort (P=0.04 for males, P=0.02 for females). Multivariate regression analysis
demonstrated that patients� age (P
CONCLUSION The prevalence of SO significantly increased from control group to total gastrectomy group. Patients� age and sex were significantly
related to the risk of SO after gastrectomy. Bone quality and failure load were significantly reduced in patients with SO. CLINICAL RELEVANCE/APPLICATION Vertebral microarchitecture parameters obtained by clinical multidetector CT, together with bone mineral content measurement, provided
useful information for assessing SO in post gastrectomy patients. LL-MKE-MO8A • The Many, Atypical Presentations of Musculoskeletal Hepatocellular Carcinoma (HCC) Metastases
Mostafa M Elian MD (Presenter) ; Hosny S Abdelghany MD PURPOSE To demonstrate many uncommon, non-classical clinical presentations of HCC that have been gathered from an endemic region in the Nile
Basin. METHOD AND MATERIALS We will highlight cases of high quality MDCT performed for various clinical symptoms not classically associated with advanced or
metastatic HCC and the role of image-guided biopsy in making these diagnoses. These will include: a) gradual progressive weakness of
both lower limbs; b) Retrosternal pain not responding to medications; c) severe right hip pain; and d) progressive cheek swelling. These
symptoms further corresponded to musculoskeletal abnormalities, not typically associated with HCC, including: a) lumbar spinal cord
compression by an expansile vertebral body lesion; b) direct invasion of the chest wall; c) a large expansile metastasis of the right
acetabulum; d) expansible rib lesions with underlying rib destruction, and e) painful cheek swelling. RESULTS Numerous patients with a range of non-specific musculoskeletal complaints and various clinical presentations whose final diagnosis was
HCC. The clinical presentation was dependent on uncommon skeletal deposits which were most often expansile with the local effect of
compression as the underlying cause for the odd presentation. The important role of MDCT and Histopathological assesment in making
the correct diagnosis will be stressed. CONCLUSION HCC can often grow silently and may present late with an odd non-classic clinical presentation. CLINICAL RELEVANCE/APPLICATION HCC first presentation may be by a typical musculoskeletal manifistaions like cord compression manifistation LL-MKE1106-MOA • Form-Over-Function?: A Review of the Injuries and Imaging Findings Associated with Minimalist and
Traditional (SHOD) Running
Ezra M Detroy MD (Presenter) ; Andrew W Lischuk MD PURPOSE/AIM To discuss the biomechanics, characteristic injuries, and imaging findings associated with barefoot/minimalist running in comparison to
tradition (SHOD) running.
CONTENT ORGANIZATION � Describe the origin of SHOD, and the emergence of barefoot/minimalist running styles.
� Describe the biomechanics of these running styles, and how they lead to distinct injury patterns.
� Review the specific imagining findings seen in injuries associated with barefoot/minimalist and tradition (SHOD) running.
� Conclusion and future research directions.
SUMMARY � In recent years there has been exponential growth in barefoot/minimalist style running, based on claims it can decrease running
related injuries. However, injuries distinct to barefoot/minimalist running are now being observed.
� A radiologic overview of barefoot/minimalist and traditional (SHOD) running is presented.
Neuroradiology/Head and Neck - Monday Posters and Exhibits (12:15pm - 12:45pm) Monday, 12:15 PM - 12:45 PM • Lakeside Learning Center
NR
LL-NRS-MOA • AMA PRA Category 1 Credit ™:0.5 Host
Pratik Mukherjee , MD, PhD * Page 105 of 397
Back to Top Pratik Mukherjee , MD, PhD * LL-NRE-MO10A • Trans-sphenoidal Approach in Endoscopic Endonasal Surgery for Skull Base Lesions: What Radiologists Should
Know and the Surgeon Needs
Elena Garcia Garrigos MD, PhD (Presenter) ; Juan Arenas MBBS ; Irene Monjas Canovas ; Javier De La Hoz ; Marilo Guirau
Rubio MD ; Paloma Tallon Guerola PURPOSE/AIM Review the anatomical structures and variants the radiologist should demonstrate and indicate in a CT report when planning surgery for
skull base lesions by endonasal approach. CONTENT ORGANIZATION Brief introduction of the anatomy and relationships of sphenoidal sinus and skull base structures.
Explanation of neuronavigation CT protocol technique, parameters and multiplanar reconstruction.
Discussion of indications, contraindications and anatomic aspects which increase the risk of complications during endoscopic endonasal
trans-sphenoid surgery (EETS).
SUMMARY EETS has grown rapidly in the last decades as a therapeutic modality for skull base lesions.
Preoperative CT with neuronavigation protocol and multiplanar reconstruction provides an accurate depiction of tumor extension,
associated bone changes and anatomic variants that are crucial for a safe and effective surgical treatment of skull base lesions by the
endonasal route.
LL-NRE-MO11A • 4-dimensional CT Assessment of Vocal Cord Palsy
Kenneth K Lau (Presenter) ; Theodore Lau PURPOSE/AIM Laryngoscopy has been the gold standard for diagnosing vocal cord palsy (VCP), but does not provide objective and quantitative
assessment, Conventional multi-detector CT only allows structural analysis of the larynx and neck. The 320-multidetector CT (320-CT)
enables dynamic viewing of larynx and airway. The aim of this exhibit is to demonstrate the usefulness of the 320-CT in diagnosing VCP. CONTENT ORGANIZATION 320-CT over 1 breathing cycle and a phonation was performed on 26 patients with suspected VCP symptoms. There were 1/26 (3.8%)
patients with bilateral VCP and 12/26 (46.2%) patients with unilateral VCP which were subsequently confirmed on laryngoscopy. The
320-CT demonstrated reduced abduction movement of affected vocal cords during breathing and phonation, with co-existing vocal cord
thickenings, tilting, and medialization in all VCP patients. Dilatation of the ipsilateral pyriform sinuses and laryngeal ventricles was found
in 76.9%. Other patients had laryngeal dysfunction (6/26), tracheobrochomalacia (3/21), excessive dynamic airway collapse (2/21),
subglottic stenosis (1/21) and vocal cord tumour (1/21). SUMMARY 320-CT is a non-invasive imaging tool providing accurate, prompt and objective assessment of vocal cord movement abnormality. It may
be a potential alternative to the semi-invasive laryngoscopy for VCP diagnosis in future. LL-NRS-MO1A • Arteriolar Elasticity Obtained from Spin-Echo Signal Fluctuations in the Human Brain
Minghui Tang (Presenter) ; Toru Yamamoto PhD PURPOSE To map arteriolar elasticity, we focused on arteriolar vasomotion driven by respiratory PaCO2 changes, and proposed a new method that
uses spectral analysis of MR signal fluctuation. METHOD AND MATERIALS A single slice of a healthy volunteer�s head was imaged for 45 s by using a SE-EPI pulse sequence (TR = 250 ms) under a 1.5-T MRI
system. The time course of MR signal at each pixel was Fourier-transformed to map the spectral intensities in the low-frequency (L: c,
and the L map represents the product of P and fluctuations in V at respiratory frequencies: P(?V)r. Therefore, the division map of R by C
(R/C map) represents [(?V) r /V]/[(?P)c /P]; while (?P)c /P is global in the brain, (?V)r /V reflects the local arteriolar elasticity. The division
map of L by C (L/C map) was also obtained. RESULTS The R/C map was almost homogeneous with a standard deviation (SD) of 10%, showing normal arteriolar elasticity of a healthy
volunteer. The SD of the L/C map increased to 13%, reflecting local neuronal activities at resting state. CONCLUSION Arteriolar elasticity could be mapped by using the spectral analysis of SE signal fluctuation. CLINICAL RELEVANCE/APPLICATION Arteriolar elasticity, which may predict the progression of dementia, is an important vascular property. Our results may provide a new MRI
technique for mapping arteriolar elasticity. LL-NRS-MO2A • High Intensity Zone between Globus Pallidus and Putamen on Phase Image: Marginal Division of Neostriatum in
the Human Brain?
Zhiye Chen BMedSc (Presenter) ; Mengyu Liu ; Lin Ma MD PURPOSE To investigated the functional and structural changes of marginal division (MrD) (high intensity zone between globus pallidus and
putamen on phase image) with aging in the human brain METHOD AND MATERIALS RESULTS MrD had the highest HIC (left: 2149.3±19.6; right: 2155.9±17.9) and LIC (left: 1996.6±18.2; right: 1999.6±20.7), the lowest LIC ratio
(left: 21.5%±7.9%; right: 19.4%±8.0%), and the highest AIC (left: 2116.4±21.4; right: 2124.7±21.0), and also showed negative with
aging. The width (Head: left/right 2.01±0.41 mm/1.86±0.36 mm; Body: left/right 1.84±0.38 mm/1.49±0.29 mm; Tail: left/right
1.17±0.36 mm/1.05±0.23 mm) and area (left/right 49.44±9.71 mm2/42.75±8.80 mm2) of MrD showed negative correlation with aging
presenting gradually narrower pattern based on CPIs. Average ADC value (left/right 0.69±0.04 mm2/s / 0.71±0.03 mm2/s) revealed
negative correlation, and FA (left, 0.19±0.03; right, 0.22±0.03) value revealed positive correlation with aging. CONCLUSION Functional and structure changes with aging based on CPIs and DTI could offer a simple and effective tool for the evaluation of MrD in
vivo in the human brain. CLINICAL RELEVANCE/APPLICATION CPIs demonstrate that the functional and structural changes of MrD , and is recommended as an initial evaluation for MrD in the brain of
Page 106 of 397
health adults. LL-NRS-MO3A • Long Term Evolution of MR Spectroscopy Following Severe Head Trauma
Aurelie Drier MD (Presenter) ; Omid Khalilzadeh MD, MPH ; Rajiv Gupta PhD, MD ; Julien Dinkel MD ; Didier Dormont MD ; Louis Puybasset MD, PhD ; Damien P Galanaud MD, PhD * PURPOSE Severe traumatic brain injury (TBI) can lead to severe brain damage that can be assessed by multiple imaging methods including MR
spectroscopy (MRS). However, the long-term evolution of the spectroscopic alterations measured at the acute phase is not well-known.
In this study, we used 2D spectroscopy to evaluate grey matter changes over a span of 2-years after the injury. METHOD AND MATERIALS This study was approved by the institutional review board of our institution. Fifteen patients who survived after a severe TBI and had a
favorable outcome (normal consciousness with minimal functional impairments) were included. The first MR examination (MRI 1) was
performed 2 to 4 weeks after the trauma and included a 2D spectroscopic acquisition (TR=1500 ms, TE=135 ms). A second MRI (MRI 2)
was performed 2 years after the trauma and included the same sequences. The N-acetyl aspartate/ Creatine (NAA/Cr) ratio was
measured in the thalamii, the lenticular nuclei and the insular cortex. For statistical comparisons, right and left ratios were pooled for
each region of interest. Data are presented as mean +/- SD. RESULTS The NAA/Cr ratio remained stable in the thalamii between the first and second examination (patients: MRI 2: 1.57 +/- 0.36 vs. MRI 1:
1.49 +/- 0.32, p=0.34 controls: 2.04 +/- 0.25) while this ratio increased in the lenticular nuclei (patients: MRI 2: 1.42 +/- 0.26 vs. MRI
1: 1.26 +/- 0.22, p=0.02, controls: 1.8 +/- 0.20) and the insular cortex (patients: MRI 2: 1.54 +/- 0.27 vs. MRI 1: 1.36 +/- 0.29,
p=0.01, controls: 1.82 +/- 0.20). CONCLUSION The NAA/Cr ratio in the thalamii on the first MRI was not significantly decreased in this population with favorable outcome and remained
stable. The decrease of the NAA/Cr ratio in the lenticular nuclei and the insula observed at the acute phase was partially reversed 2 years
after the trauma. CLINICAL RELEVANCE/APPLICATION These results support the use of MRS as a marker to assess clinical recovery after severe TBI. LL-NRS-MO4A • Imaging Genomic Biomarker Signature for MGMT Promotor Methylation Identification
Rivka R Colen MD (Presenter) ; Mark Vangel PhD ; Omar Ashour MD ; Pascal O Zinn MD PURPOSE To create an imaging biomarker signature in order to identify those Glioblastoma (GBM) patients with MGMT promoter methylation. METHOD AND MATERIALS Using The Cancer Genome Atlas (TCGA), we identified 78 treatment-na�ve GBM patients whom had both gene- and microRNA expression
profiles and pretreatment MR-neuroimaging from the Cancer Imaging Archive. The 3D Slicer software 3.6 (http://www.slicer.org) was
used for image analysis and image review was done in consensus by 2 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. Quantitative perfusion parameters where obtain using the region of interest (ROI) method (NordicICE). ROIs were
placed in the previously segmented regions of contrast enhancement, necrosis, and non-enhancing perilesional FLAIR hyperintensity- the
latter reflecting a mixture of edema/tumor infiltration. Imaging parameters were then correlated with the MGMT status and gene
expression profiles. Complex biomarker signatures based on profiling and survival were created. RESULTS An imaging biomarker signature was created using multiple parameters, including the MR perfusion parameter of rCBV. Multiple
parameters were associated with overall survival. An increase in rCBV in the non-enhancing FLAIR hyperintense portion was associated
with the strongest survival difference (p< 0.03). CONCLUSION An imaging biomarker signature using conventional MRI parameters and also advance parameters helps predict MGMT methylation status
and expression. CLINICAL RELEVANCE/APPLICATION The identification of a non-invasive imaging biomarker signature as a surrogate for MGMT promotor methylation can help stratify patients
in therapy and predict response versus nonresponse to therapy. LL-NRS-MO5A • Usefulness of 3D CISS Imaging at 3T for the Identification of Abnormal Vessels Associated with Spinal Dural
Arteriovenous Fistulas
Hiroyuki Uetani ; Toshinori Hirai MD ; Yasuhiko Iryo ; Yutaka Kai ; Minako Azuma (Presenter) ; Yasuyuki Yamashita MD * PURPOSE The purpose of this study was to compare the usefulness of 3D constructive interference in steady state (CISS) imaging at 3T with
conventional MRI for the identification of abnormal vessels of spinal dural arteriovenous fistulas (SDAVF). METHOD AND MATERIALS We enrolled 9 consecutive patients (8 men, 1 woman; age range 58-78 years, mean 66 years) who underwent conventional MRI including
sagittal and axial T1- and T2-weighted- and contrast-enhanced T1-weighted imaging (T1WI, T2WI, CET1WI) and sagittal 3D CISS
imaging on a 3T unit prior to surgery. SDAVF confirmation was by intra-arterial digital subtraction angiography (DSA) in all patients. The
SDAVF site was the thoracic region in 8 patients and the lumbar region in one. For 3D CISS imaging we obtained multiplanar
reconstructions in all patients. Two experienced neuroradiologists independently evaluated the scans for the presence of abnormal vessels
on 3D CISS and conventional MR images using a 3-point grading system where grade 3 = definitely positive, grade 2 = probably
positive, and grade 1 = equivocal or definitely negative. Final judgments were by consensus. Interobserver agreement was determined
by calculating the ? coefficient where ? < 0.20 = poor, 0.21-0.40 = fair, 0.41-0.60 = moderate, 0.61-0.80 = good, 0.81-0.90 = very
good, and ? > 0.90 = excellent. Grading differences were assessed with the paired t test; P < 0.05 was considered to indicate a
statistically significant difference. RESULTS For the presence of abnormal vessels, all cases were judged as grade 3 on 3D CISS images and as grade 1 at T1WI. On T2WI scans, 2
cases were grade 3, 5 were grade 2, and 2 were grade 1. On CET1WI scans one case was grade 3, 3 were grade 2, and 5 were grade 1.
The mean scores were significantly higher for 3D CISS than the other sequences (P < 0.01). Interobserver agreement was excellent for
3D CISS images and T1WI (? = 1.0) and good for T2WI (? = 0.73; 95% confidence interval [CI], 0.39 - 1.00) and contrast-enhanced
T1WI (? = 0.67; 95%CI, 0.22 - 1.00). CONCLUSION For the identification of abnormal vessels of SDAVF, 3-T 3D CISS is more useful than conventional MRI. CLINICAL RELEVANCE/APPLICATION In the evaluation of SDAVF, 3-T 3D CISS should be added to conventional MR sequences. Page 107 of 397
LL-NRS-MO6A • Preliminary Evaluation of MR Diffusion Kurtosis Imaging at 3-Tesla for Head and Neck Squamous Cell
Carcinoma: A New Monitoring Tool for Early Treatment Response
Yukie Shimizu (Presenter) ; Noriyuki Fujima MD ; Daisuke Yoshida ; Tomohiro Sakashita ; Akihiro Homma ; Kohsuke Kudo
MD ; Hiroki Shirato MD, PhD PURPOSE The purpose of this study is to investigate the usefulness of 3-T MR diffusion kurtosis imaging (DKI) for the assessment of patients with
head and neck squamous cell carcinoma (HNSCC). METHOD AND MATERIALS Eighteen patients who were histopathologically diagnosed as HNSCC were included in this study. All patients were treated with
super-selective arterial infusion of cisplatin with concomitant radiotherapy. TDKhey underwent magnetic resonance imaging (MRI) using
DKI sequence before the treatment and at the early treatment period (at time point of 15-25 Gyin total 65 Gy radiotherapy). All MR
scanning was performed by using a 3-T unit (Achieva TX; Philips Medical Systems, Best, The Netherlands) with a 16-channel
neurovascular coil. DKI was obtained by using single-shot echo planar diffusion weighted imaging with 4 different b values of 0, 800,
1000, 2000s/mm2. Three orthogonal motion probing gradient was used. The quantitativeDK value of the tumor in each of the 18 patients
was calculated usingDKI datasets. The change ratio of DK value between pre-treatment and early treatment period was also calculated.
After the treatment, thirteen patients were classified into complete remission (CR) group and the other five were into non-CR group
judging from multi-modality assessment and clinical follow-up. Mean of value in pre-treatment, early treatment period, and its change
ratio were compared between CR and non-CR groups using non-paired T-test. RESULTS The change ratio of DK value in CR group was significantly lower than non-CR group(0.78±0.13 vs 0.93±0.05, P CONCLUSION DKI can be useful as monitoring tool for early treatment response for the assessment of patients with HNSCC. CLINICAL RELEVANCE/APPLICATION DKI can be useful as monitoring tool for early treatment response for the patients with HNSCC by evaluating change ratio of DK value
between pre-treatment and early treatment period. LL-NRS-MO7A • Utility Assessment of Repeat Head CT in the Setting of Mild Traumatic Brain Injury Using a Natural Language
Processing Tool
Jason M Johnson MD (Presenter) ; Tarik K Alkasab MD, PhD ; Daniel Yeh MD ; Pamela W Schaefer MD PURPOSE To assess the rate of which repeat head CT following mild traumatic brain injury revealed worsening of imaging findings using a natural
language processing tool. METHOD AND MATERIALS Utilizing our institutional trauma registry, 824 adults with blunt TBI who arrived within 24 hours of injury, with arrival GCS of >12 with
initial head imaging positive for traumatic findings were identified. Patients with initial operative management were excluded, and the all
head CTs within 7 days of injury was identified. Each exam was evaluated using a natural language processing (NLP) tool designed for
high sensitivity to identify reports describing worsening findings. Imaging reports for 114 patients were manually assessed by an
experienced neuroradiologist and a Kappa score was calculated for agreement between the NLP tool and a human reader.
RESULTS Of the 819 patients identified, 164 were removed for additional review for having less than 2 CT scans. An additional 30 patients were
removed due to initial operative management. Of the remaining 625 patients, 287 had 2 CTs, 172 had 3 CTs and 166 had >3 CTs. Review
of the NLP revealed 86% (98/114) algorithm concordance with neuroradiologist review. The majority of the errors (81.3%; 13/16) were
NLP overcalls based on the report. Of the 626 patients with at least two CT scans, the second CT scan contained language suggesting
worsening in 263 cases (42.0%). CONCLUSION A supervised NLP tool can be used in conjunction with a patient registry to identify language associated with worsening head CT findings.
We expect to use this tool to further explore clinical factors associated with worsening imaging findings to improve imaging utilization
patterns. CLINICAL RELEVANCE/APPLICATION This tool may be important for exploring image utiliation patterns and outcomes for large populations. LL-NRE-MO8A • A Simplified Algorithm for Diagnosis of Spinal Cord Lesions
Dhiraj Baruah MD (Presenter) ; Tushar Chandra MD ; Saurabh Guleria MD ; Andrew P Klein MD ; Mohit Maheshwari MD PURPOSE/AIM Lesions of the spinal cord are common including congenital, neoplastic, inflammatory, vascular and neoplastic causes. Aim of this review is
to discuss the relevant anatomy from imaging standpoint with drawings/ images and important clinical and imaging points to formulate a
diagnosis. CONTENT ORGANIZATION In this exhibit, we will first overview normal anatomy of spinal cord including its vascular supply. We will present a step by step guide
including clinical and Magnetic Resonance Imaging (MRI) features to arrive at a diagnosis. SUMMARY An understanding of the normal anatomy and imaging characteristics of pathologies of spinal cord is important for making a diagnosis.
This educational exhibit will facilitate development of an easy systematic approach for MRI evaluation of spinal cord lesions. LL-NRE-MO9A • Methodology and Applications of CT and MR Perfusion Imaging in Patients with Head and Neck Cancer
Omar Parvez MD (Presenter) ; Naoko Saito MD, PhD ; Minh T Truong MD ; Jimmy W Wang MD ; Hernan Jara PhD * ; Akifumi
Fujita MD ; Osamu Sakai MD, PhD * PURPOSE/AIM To review the current CT and MR perfusion imaging methods in head and neck cancer. Also to describe various clinical applications of CT
and MR perfusion imaging in head and neck cancer. CONTENT ORGANIZATION 1. Review of the current CT and MR perfusion imaging techniques being used to evaluate head and neck cancers including pros and cons
for each technique: A)dynamic contrast enhanced CT perfusion, B)MR perfusion, i)With intravenous contrast: a)dynamic susceptibility
contrast enhanced (DSC), b)dynamic contrast enhanced (DCE), ii)Without intravenous contrast: a)arterial spin labeling (ASL), b)intravoxel
incoherent motion (IVIM). 2. Review of the clinical applications of CT and MR perfusion imaging in head and neck cancer. A)differentiation
of tumor histology, B)monitoring tumor perfusion, C)prediction of tumor response to the treatment, D)evaluation of post-treatment tumor
change, E)prediction and evaluation of treatment effect in the normal tissues. Page 108 of 397
SUMMARY The major teaching points are:
1. Understanding of various techniques of CT and MR perfusion for head and neck cancers.
2. Understanding microvascular blood supply to the tumor as well as normal tissue that affects treatment response and side-effects.
3. Perfusion information may predict tumor response to various treatments, locoregional control, and treatment-related normal tissue
injuries. LL-NRE3131-MOA • DWI-MRI and PET-MRI after Radiation Therapy of Malignant Head and Neck Tumors: What the Radiologist
Needs to Know
Arthur D Varoquaux MD (Presenter) ; Angeliki Ailianou ; Pavel D Dulguerov ; Olivier D Rager ; Karim Burkhardt ; Minerva
Becker MD, PhD PURPOSE/AIM 1. To provide a comprehensive approach for the evaluation of patients irradiated for malignant head and neck tumors. 2. To understand
key imaging features of radiation-induced complications. 3. To demonstrate the importance of DWI-MRI and PET-MRI for the detection of
residual/recurrent tumors. 4. To understand potential pitfalls of image interpretation and how to avoid them. CONTENT ORGANIZATION The retrospective analysis of 124 patients who underwent DWI-MRI with ± PET-MRI formed the basis for this exhibit. The patients were
imaged after radio(chemo)therapy for malignant head and neck tumors. Imaging findings were correlated with histology in 82 patients
and radiologic follow-up in 42 patients. We discuss expected tissue alterations and complications affecting soft tissues, vasculature, neural
tissue and bony structures. We illustrate typical findings of tumor recurrence with emphasis on early detection, added value of DWI-MRI
and PET-MRI and provide histologic correlation for the understanding of imaging findings. Pitfalls of post-therapeutic image interpretation
and how to avoid them are addressed. SUMMARY Interpretation of MRI findings after radiation therapy of head and neck cancers constitutes a diagnostic challenge. DWI-MRI and PET-MRI
increase the diagnostic confidence for the early detection of recurrent tumors and help to avoid unnecessary biopsy. Physics - Monday Posters and Exhibits (12:15pm - 12:45pm) Monday, 12:15 PM - 12:45 PM • Lakeside Learning Center
Back to Top PH
LL-PHS-MOA • AMA PRA Category 1 Credit ™:0.5 Host
Kenji Suzuki , PhD * Host
Jiang Hsieh , PhD * LL-PHE-MO10A • Iron Deposition in the Brain: A Review of Current Iron Quantification Techniques
Yunhong Shu PhD (Presenter) ; Paul Bao ; Mallikarjunarao Kasam PhD ; Kirk M Welker MD PURPOSE/AIM There has been great interest in detecting endogenous iron in the brain as it has been shown to be correlated with aging and neurological
disorders. Magnetic resonance imaging (MRI) is sensitive to iron deposition due to its abundance and high magnetic susceptibility. Given
the variable appearance of cerebral iron across pulse sequences and scanner field strengths, quantitative assessment of brain iron
concentration is preferable to visual inspection. This presentation aims to provide an overview of several methods that have been
proposed to quantitatively measure iron concentration in the brain. CONTENT ORGANIZATION 1: Introduction - Tissue iron deposition forms in the brain and their relationships with specific pathology.
2: Review of the principles of general iron quantification methods and descriptions with specific examples
3: Detailed discussion on advantages and limitations of the iron quantification techniques.
SUMMARY The ability of MRI to non-invasively measure brain iron deposition can potentially help to gain further understanding in the
pathophysiology of the normal aging process and neurodegenerative diseases. Accurate analysis of iron concentration using MRI requires
a good understanding of the underlying mechanism and confounding factors related to the various iron mapping techniques. LL-PHS-MO1A • Segmentation of the Left Ventricle Using a Distance Regularized Two-layer Level Set Approach
Chunming Li PhD (Presenter) ; Chaolu Feng ; Christos Davatzikos ; Harold I Litt MD, PhD * PURPOSE Non-invasive assessment of left ventricular function is important but difficult due to poor imaging quality and complex anatomical
characteristics. To overcome these challenges, we propose a distance regularized two-layer level set approach for segmentation of the
left ventricle (LV) from cardiac MR (CMR) short-axis images. The segmentation results can be directly used to calculate ejection fraction
(EF), which is an important indicator of the LV function. METHOD AND MATERIALS We propose a novel two-layer level set approach to segment the LV from CMR short-axis images. In our method, endocardium and
epicardium are represented by two specified level contours of a level set function (LSF). Segmentation of the LV is formulated as a
problem of optimizing the LSF such that these two level contours best fit the epicardium and endocardium. More importantly, a novel
distance regularization (DR) constraint on the level contours is introduced to ensure the smoothly varying distance between them. This
DR constraint leads to a desirable interaction between the level contours to maintain the anatomic geometry of the endocardium and
epicardium. The negative effects of intensity inhomogeneities on image segmentation are overcome by a data term derived from a local
intensity clustering property. Our method is quantitatively validated by experiments on the datasets for the MICCAI 2009 grand challenge
on left ventricular segmentation, which demonstrates the advantage of our method in terms of segmentation accuracy and consistency
with anatomic geometry. RESULTS We have validated our method using the datasets from the MICCAI 2009 challenge on LV segmentation. Comparisons with other methods
show that the average perpendicular distances for our method are the smallest: 1.82±0.48 mm and 1.73±0.43 mm for training datasets
and 1.93±0.37 mm and 1.64±0.42 mm for validation datasets. We have achieved much better results, giving nearly the best slope and
regression coefficient: 1.04 and 0.90 for EF and 0.93 and 0.85 for the mass; and demonstrating only a small bias on the Bland-Altman
plots: 3.45% for EF and -6.48 grams for LV mass. CONCLUSION Quantitative evaluation and comparison with other state-of-the-art methods demonstrate that our method achieves more accurate
segmentation results and more reliable measurement of EF and LV mass. CLINICAL RELEVANCE/APPLICATION Page 109 of 397
CLINICAL RELEVANCE/APPLICATION This method proposed in this paper is recommended in clinical measurement of LV function. LL-PHS-MO2A • Factors Causing Variability of Response Classification in RECIST 1.1.
Sebastian Keil MD (Presenter) ; Lieven Kennes ; Alexandra Barabasch ; Philipp Bruners MD ; Timm Dirrichs ; Marco Das MD
* ; Christiane K Kuhl MD * PURPOSE We conducted a systematic analysis of factors (manual vs. automated and uni- vs. three-dimensional size assessment, and impact of
different target lesion selection) contributing to variability of response categorization in RECIST 1.1. METHOD AND MATERIALS 41 female patients (58.1±13.2 years) with metastatic breast cancer underwent contrast-enhanced thoraco-abdominal CT for initial
staging and first follow-up after systemic chemotherapy. Data were independently and prospectively interpreted by three radiologists. In
addition, response was evaluated by a CAD system that allowed automated uni- and three-dimensional assessment of target lesions. RESULTS Overall, between-reader-agreement was moderate (kappa: 0.4-0.59), with diverging response classification observed in 19/41 patients
(46%). In 25 patients, readers chose the same, and in 16, readers chose different target lesions. Selection of the same target lesions was
associated with a 76% agreement rate (19/25); selection of different target lesions was associated with an 81% rate of disagreement
(13/16) (p < 0.001). After dichotomizing response classification according to its therapeutic implication into progressive vs.
non-progressive disease, disagreement was observed in 11/41 patients (27%). In 9 of these 11 patients, readers had chosen different
target lesions. Disagreement rates due to manual vs. automated or uni-dimensional vs. volumetric measurements were less important
(11/41 and 6/41; 27% and 15%, respectively). CONCLUSION Major source of variability is not the manual or uni-dimensional measurement, but the variable choice of target lesions between readers.
CAD-based analysis or tumor volumetry can help avoid variability due to manual or uni-dimensional measurements only, but will not
solve the problem of target lesion selection. CLINICAL RELEVANCE/APPLICATION Evaluation of radiological response plays a major role in oncological therapy. We investigated causes for variability of response
classification in RECIST and how they might be overcome by CAD. LL-PHS-MO3A • Coronary Artery Calcium Scoring: Comparison of Adaptive Statistical Iterative and Filtered Back Projection
Reconstruction Techniques Using a Calcified Plaque Phantom
Tatsuya Umezawa RT (Presenter) ; Fumiko Kimura MD, PhD * ; Masaru Morishita ; Itsuki Nagazumi RT ; Taiki Senoo RT ; Yasuyuki Yoshimura PURPOSE Adaptive statistical iterative reconstruction (ASiR, GE Healthcare) has been used for coronary CT angiography to improve image quality
and reduce radiation dose, but its influence on coronary artery calcium scoring (CACS) is unknown. In a calcified plaque phantom, we
compared image noise, CT values, CACS, and coronary artery calcium volume (CACV) between filtered back projections (FBP) and ASiR to
clarify if CACS differs significantly between the two and assessed factor/s influencing differences. METHOD AND MATERIALS We made calcified plaque models of 5 materials with different CT values, placed them into a long cylindrical phantom of 4-mm diameter
that contained materials of 40 HU to simulate blood to simulate the coronary artery with calcified plaques (50% stenosis; length 5 mm),
and submerged the phantom in a tank of water. We scanned it using 120 kVp and various tube currents and reconstructed images using
5 reconstruction techniques (RTs) - FBP and ASiR-FBP composites (ASiR 30%, 50%, 70%) and ASiR 100%. We measured the mean CT
2) and assessed the phantom containing the calcified plaque models
values of the 5 materials in large regions of interest (ROIs; 55-265mm
regarding image noise in the tank water, CT values of the small calcified plaques, and total CACS and CACV (sums of the 5 plaques). We
compared these values among the 5 RTs using repeated-measure ANOVA. P < 0.05 was considered significant. RESULTS The mean CT values (large ROIs) of the 5 materials were 918, 600, 392, 177, and 110 HU without significant difference among RTs.
There were significant differences among RTs in image noise (P < 0.001), CT values of the small calcified plaques (P < 0.001), total CACS
(P < 0.001), and total CACV (P < 0.01), decreasing as ASiR percentage increased. Compared to FBP, total CACS decreased 6.2% in ASiR
30%, 8.8% in ASiR 50%, 13.0% in ASiR 70%, and 18.0% in ASiR 100%. ASiR decreased pixel CT values of the rim of the calcified
plaques, which changed the weighted factors to calculate CACS. CONCLUSION Image noise, CACS, and CACV decreased as ASiR percentage increased. ASiR appeared to decrease image noise and CT pixel values of
the small calcified plaque and then affect CACS. CLINICAL RELEVANCE/APPLICATION Compared to FBP, a blend of no more than ASiR 50% limits CACS reduction to 10%, and the same reconstruction technique should be
used to assess temporal changes in CACS. LL-PHS-MO4A • A Novel Image-based Estimation Method for Magnetic Field Inhomogeneity in Brain Echo-planar Image
Seiji Kumazawa PhD (Presenter) ; Takashi Yoshiura MD, PhD ; Hiroshi Honda MD ; Fukai Toyofuku PhD CONCLUSION We have proposed a new estimation method for the magnetic field map based on the distorted EPI image and T1WI of brain. The results
demonstrate that the magnetic field inhomogeneity in EPI image can be estimated by our method, and the geometrical distortion can be
reduced. Background Echo-planar imaging (EPI) suffers from geometrical distortion due to magnetic field inhomogeneity. Conventional methods to correct the
distortion of EPI require an additional acquisition of a magnetic field map. Our purpose was to develop a new method for estimating the
magnetic field map based on the distorted EPI image and T1 weighted image (T1WI) which requires no additional acquisitions. Evaluation Instead of an additional acquisition, our method used the segmented brain T1WI to estimate the field map. Based on MR imaging physics,
our method synthesizes EPI image from tissue-objects extracted from segmented brain T1WI according to single shot EPI k-space
trajectory. First, the brain T1WI was mapped by using linear transformation into EPI image based on the image orientation and position of
DICOM header information. Next, the T1WI was divided into head region and air region based on the intensity histogram, and then brain
extraction and tissue segmentation were applied to head region by using FSL tool. Our field inhomogeneity estimation is incorporated into
the generating process of EPI image, and the estimation process is performed iteratively to minimize the cost function defined by the
synthesized EPI image and the measured EPI image with geometric distortion. In this experiment, our method was applied to the EPI
image with known magnetic field inhomogeneity, and was evaluated by comparing between the estimated field map and the known map. Discussion The magnetic field inhomogeneity map estimated by our method very accurately agreed with the filed map of the ground truth. The
Page 110 of 397
RMSE value between the estimated field map and ground truth was less than 0.17. In the simulated EPI image with removing the
estimated magnetic field inhomogeneity map, the geometrical distortion was reduced. In visual evaluation, the brain shape in the
resulting EPI was very similar to that in T1WI. LL-PHS-MO5A • The Potential of Texture Features for Differentiation of Colonic Polyp Types for CT Colonography
Jerome Liang PhD (Presenter) ; Bowen Song MS ; Guopeng Zhang MS ; Huafeng Wang PhD ; Perry J Pickhardt MD * ; Hongbing Lu PhD PURPOSE PURPOSE: Image texture features have been widely explored for computer-aided diagnosis (CADx) on breast masses and lung nodules
for malignance assessment. In our previous pilot study, we observed the discrimination in terms of image textures among differente colon
polyp types, such as hyperplastic (H), tubular adenoma (Ta), tubulovillous adenoma (Va), and adenocarcinoma (A). This study aims to
explore more high order spatial dependency texture features and also provide more quantitative measures on the discrimination
performance of the texture features in terms of the area under the receiver operating characteristic curve (AUC). METHOD AND MATERIALS MATERIALS AND METHODS: The high order spatial dependency texture feature calculation is based on the Haralick�s texture description
with expansion in the three-dimensional image density distribution space as well as the gradient and curvature distribution domains. The
database in this study includes 124 lesions (polyp and masses, confirmed by pathology) in four categories: 40 H, 45 Ta, 30 Va, and 9 A. A
semi-automated segmentation was performed to extract the volume of each lesion, given the lesion�s (x,y,z) coordinates, from the
computed tomography colonography (CTC) image. A total of 78 features were calculated from each lesion volume. These features were
fed into the support vector machines (SVM) classifier for binary classification among the four lesion categories. To avoid any bias in
selection of training and testing datasets, the splitting of the training and testing datasets was repeated 100 times randomly and the
outputs were averaged for AUC measure. RESULTS RESULTS: The binary classification for the two categories of (HandTa) and (VaandA) reached the differentiation capability of means ±
standard deviation of 0.9190±0.0363. CONCLUSION CONCLUSION: CADx for polyp malignance assessment is highly likely. The potential of CTC in colon cancer screening includes not only
the detection of the precursor or polyps but also the diagnosis of the detected polyps for optimal polyp management for the best outcome
in personalized medicine. CLINICAL RELEVANCE/APPLICATION Clinical Relevance/Application: Differentiation of the polyp types can render an optimal management of polyps in personalized medicine. LL-PHS-MO6A • Experimental Quantification of the Effects of Organ-based Tube Current Modulation on Radiation Dose and SNR
Diksha Gandhi (Presenter) * ; Dominic Crotty PhD * ; Grant M Stevens PhD * ; Taly G Schmidt PhD PURPOSE To compare the radiation dose to breast, lung, heart and spine in CT chest scans, and eye lens and brain in head scans with and without
organ-dose-based tube current modulation (ODM), using an anthropomorphic phantom and a clinical CT scanner. The signal-to-noise
ratio (SNR) was also quantified in images reconstructed with and without ODM. METHOD AND MATERIALS Axial CT scans at 120 kV were performed on anthropomorphic head and chest phantoms (Rando Alderson Research Laboratories,
Stanford, CA) on an ODM-equipped scanner (Optima CT660, GE Healthcare, Chalfont St Giles, England). ODM reduces the tube current
for the anterior source positions, without increasing current for posterior positions. ODM has different modulation settings for chest and
head exams. Dosimeters quantified radiation dose to locations in the breast, lung, heart, spine, eye lens and brain (mobile MOSFET
Dosimetry System, Best Medical, Ottawa, Canada). For both phantoms, five scans were performed with and without ODM, with all other
scan parameters constant. The non-ODM chest scans were performed with two settings � automA, which modulates the tube current
modulation in the slice direction, and smartmA, which modulates the tube current in both the slice and angular directions. SNR was
calculated in the brain and chest regions of all reconstructed images. The experimental results are now being validated with Monte Carlo
simulations. In addition, 50 adult female phantoms are being simulated to study ODM in patients of varying sizes and anatomy. RESULTS ODM reduced the dose at all dosimeter locations, with dose changes of -31.3% in the breast,-20.7% in the lung, -24.4% in the heart,
-5.9% in the spine, -10.0% in the eye and -18.7% in the brain, with respect to smartmA. The percent change in dose with respect to
automA was -37.7%, -29.8%, -35.3% and -25.0% in the breast, lung, heart and spine, respectively. ODM decreased the SNR by 3.5%
and 11.5% for head and chest phantoms, respectively. CONCLUSION Experimental studies indicate that ODM has the potential to reduce dose to sensitive organs by 5 - 38% with a decrease in SNR of less
than 12%. Simulations are in progress to investigate the performance of ODM over a range of patient sizes. CLINICAL RELEVANCE/APPLICATION Organ-based tube current modulation has the potential to reduce the dose to radiosensitive tissues with limited degradation in SNR. LL-PHS-MO7A • Contrast and Dose Dependencies of Resolution Property in Iterative Reconstruction CT Images
Tadanori Takata (Presenter) ; Katsuhiro Ichikawa PhD ; Syoichi Terakawa ; Hiroyuki Hayashi ; Kosuke Matsubara PhD ; Yukihiro Matsuura RT ; Keita Sakuta RT PURPOSE Since the iterative reconstructions (IR) are nonlinear image processing, their resolution properties are different from filtered back
projection (FBP). The purpose of this study was to evaluate contrast and dose dependencies of resolution property of the IR images using
a contrast adjustable cylindrical phantom. METHOD AND MATERIALS We evaluated an IR, sinogram affirmed iterative reconstruction (SAFIRE) provided by SIEMENS. A 100-mm diameter cylindrical acrylic
phantom placed in a 200-mm diameter cylindrical case with correct centering was used. The phantom�s surround was filled with diluted
contrast agent, and the contrast between the phantom and the surround was set to middle contrasts of 45, 65, 85, 105 and 125
Hounsfield units (HUs). The phantom was scanned at two dose levels (75 and 150 mAs), and images were reconstructed using FBP and
five strengths of SAFIRE (S1-S5). Since the image noise was obstacle for the correct resolution measurement, we added many images
obtained by multi scans. The radial edge of the phantom was analyzed to determine the edge-spread function, which was differentiated to
yield the line-spread function and Fourier-transformed to generate the modulation transfer function (MTF). RESULTS For the 45-HU contrast of S5, MTF of 75 mAs was significantly lower (up to 24%) than that of 150 mAs, while FBP offered the same MTF
for both the doses. At the same dose level for S5, MTFs of 45-HU contrast were clearly lower (up to 35% and 16% for 75 and 150 mAs,
respectively) than those of 125-HU contrast. The weaker strength of SAFIRE was applied, the less dose and contrast dependencies were
indicated. CONCLUSION Page 111 of 397
The degree of resolution degradation of SAFIRE significantly depended on not only the object contrast but also the scan dose. Even for
objects with middle contrasts, IR degraded the resolution properties.The method using the radial edge of cylindrical phantom was
effective for evaluating the resolution property of IR. CLINICAL RELEVANCE/APPLICATION Our results would be useful to optimal selection of IR strengths (modes) and to evaluate performances of different IR techniques. LL-PHS-MO8A • Quantification of Hepatic Fat Using MR Imaging and Spectroscopy
Peter A Hardy PhD (Presenter) ; Bryce Noblitt BS ; James T Lee MD PURPOSE To develop accurate spectroscopic and imaging techniques to quantify the proton density fat fraction in livers. Additionally, we sought to
understand the influence of such confounds as liver iron concentration on the accuracy of the measured fat fraction. METHOD AND MATERIALS Samples of a lipid nutritional supplement, IntraLipid� were diluted to create a series of lipid:water standards. From each sample proton
spectra were acquired with a single voxel STEAM acquisition run on a 7T Bruker ClinScan. Spectra were acquired at a variety of TE and TR
times. The spectral peaks were integrated using Siemens and JMRUI software. The integrated areas were fit to standard equations to
estimate the relaxation times T1 and T2 for each spectral peak. The amount of fat and water were corrected for the effects of decay
before calculating the proton density fat fraction. Samples of liver were extracted from both normal wild type and obese db/db mice.
Samples were heated to 37� C while they were imaged with the same spectroscopic techniques as used on the IntraLipid� samples. The
liver samples were then digested and assayed for iron quantification using ICP-OES spectroscopy.The measured relaxation times and
spectral widths were correlated with the tissue iron concentration. RESULTS We used the calculated T1 and T2 values to correct the spectral areas. The calculated proton density fat fraction was then regressed
against the nominal fat fraction. The correlation coefficient was 0.976 while the slope was 0.56. The true fat fraction may be much less
than the nominal due to differences in density and the fraction of the lipid with hydrogens in CH2. Measured fat fraction in the livers of
the mice showed a small but statistically not significant higher fat content of the livers of the db/db mice. Tissue iron measurements
showed the WT had significantly elevated tissue iron concentration (325 vs 200 ?g/gm wet weight). This concentration is sufficient to
increase the width of the water peak in the tissue samples. CONCLUSION To achieve the most accurate estimate of fat fraction in the liver it is necessary to compensate the measured peak areas of water and
lipid for their relaxation times. Through the assay of iron concentration on the murine liver samples we demonstrated an additional
confound. CLINICAL RELEVANCE/APPLICATION Fat quantitation in the liver using short TR, multi echo images will need to compensate for T1, T2 and T2* to be accurate. LL-PHS-MO9A • Photo Acoustic Imaging of Human Peripheral Joints
Gandikota Girish MBBS (Presenter) ; Xueding Wang PhD CONCLUSION PAI technology continues to improve as we translate to human joint imaging .After reviewing this exhibit, the viewer should be aware of
potential clinical role of photo acoustic imaging , its appearance , present limitations and the scope of future research . Background Photo acoustic imaging (PAI) is a very exciting new, non-ionizing, non-invasive, low cost, laser and ultrasound-based technology, with
critical dual ability of both structural and functional imaging.PAI is sensitive to blood volume, not limited by flow (unlike ultrasound),
holding great promise for the earliest detection of increase in blood volume and angiogenesis as seen in inflammation or neoplasm. Evaluation After having successfully imaged animal arthritis model and human cadaver finger ( images of which will also be reviewed), normal
controls were imaged as a part of funded research prior to imaging patients with rheumatoid arthritis.Viewer will have the opportunity to
appreciate the first ever photo acoustic images of human finger obtained demonstrating feasability. Comparable ultrasound images will
also be provided.Potential applications and limitations of PAI will be discussed. Discussion While ultrasound and MRI are helpful in diagnosing synovitis/synovial proliferation in a swollen joint, we hypothesize that PAI will be able
to demonstrate neovascularization much earlier than ultrasound or MRI, leading to early diagnosis, earlier initiation of treatment, thereby
limiting disease progression and achieving excellent outcome. Ultrasound is sensitive to neovascularity, dependent on blood flow. PAI is
sensitive to blood volume, not limited by flow, holding great promise for the earliest detection of increase in blood volume and
angiogenesis - a key early finding inflammation Radiation Oncology and Radiobiology - Monday Posters and Exhibits (12:15pm -12:45pm) Monday, 12:15 PM - 12:45 PM • Lakeside Learning Center
RO
Back to Top LL-ROS-MOA • AMA PRA Category 1 Credit ™:0.5 Host
Nina A Mayr , MD LL-ROS-MO1A • The Initial Experience of Dose Escalation for Refractory Leukemia and the Influence on Bone Marrow
Microenvironment
Yutaka Takahashi PhD (Presenter) ; Micheal R Verneris MD ; Kathryn E Dusenbery MD ; Daniel J Weisdorf MD ; Mohammad
S Islam PhD ; Susanta K Hui PhD PURPOSE To present interim report of dose escalation clinical trial of total body and marrow irradiation (TBMI) for patients with refractory leukemia.
We further investigated the microenvironment damage and repair of bone marrow specifically focused on mesenchymal stem (MSC) cells. METHOD AND MATERIALS Patients received 15Gy (n=2) followed by 18Gy (n=3) following cyclophosphamide and fludarabine chemotherapy. One day post TBMI,
patients were infused with two umbilical cord blood (UCB) units or related donor stem cells. To reduce lung dose, dynamic (4D) CT images
with or without shallow breathing while using a respiratory belt were acquired. Marrow aspirates are obtained before treatment, after
treatment but before transplant, and post BMT day 21, 60, and 100. MSC cells were separated; morphology and differentiation to
adipocyte and osteocytes were studied. RESULTS Thoracic rib motions were substantially reduced by 14%, 24%, and 70% at maximum in cranial-caudal, lateral, and anterior-posterior
Page 112 of 397
Thoracic rib motions were substantially reduced by 14%, 24%, and 70% at maximum in cranial-caudal, lateral, and anterior-posterior
directions, respectively. Mean doses to the lung were within 10Gy, even in the 18Gy group. Average dose to whole body (apart from
critical organ) were kept at approximately 14Gy. Two patients treated at 15Gy had prompt neutrophil engraftment at days 17 and 27
after BMT. In 18Gy group, the first patient did not engraft and developed severe regimen-related toxicities including respiratory failure,
sepsis and hyper-bilirubinemia and died at day 58. The next two patients had neutrophil engraftment at days 23, and 37 after
transplant, respectively. No severe acute adverse effects were observed. Common toxicities are nausea, oral mucositis, and diarrhea.
Contrary to the belief that radioresistant MSC maintains niche, host MSC cells were reduced significantly (only one colony was formed)
after treatment. Post-transplant marked recovery of MSC cells with time and its function to produce osteoblastogenesis, suggesting a
potential role of donor UCB derived MSC proliferation (supporting micro-environment niche). CONCLUSION Reduction of lung dose using shallow breathing may be useful for dose escalation study. So far engraftment at 18 Gy has been safely
achieved. Marrow microenvironment is seriously damaged by increased radiation but donor cells may contribute to reconstitution of
marrow environment. CLINICAL RELEVANCE/APPLICATION The dose escalation of total marrow irradiation could be safely achieved and offered engraftment. LL-ROS-MO2A • Involvement of the Central Glutamatergic System in the Development of Radiation-induced Nausea in Rats
Kouichi Yamamoto PhD (Presenter) ; Atsushi Yamatodani MD, PhD PURPOSE Most of patients undergoing total body irradiation (TBI) experience nausea and vomiting. Since the peripheral serotoninergic pathway is
involved in these symptoms, serotonin 5-HT3 receptor antagonists such as granisetron used as prevention. They can prevent vomiting,
but patients still suffer from nausea and refuse potentially curative treatment. Glutamate is known as the major excitatory
neurotransmitter and involved in the autonomic symptoms accompanied with nausea, such as gastric discomfort. However, its
neuropharmacological basis is incompletely understood. We previously reported that pica, kaolin ingestion behavior, could be used to
evaluate nausea in rats. To investigate the role of the glutamate in radiation-induced nausea, we investigated the effect of TBI on pica,
and on the in vivo hypothalamic glutamate release in rats. Furthermore, the effects of two types of glutamate receptor antagonists
(NMDA and AMPA) on the pica were examined. METHOD AND MATERIALS Rats received 4Gy of TBI with or without pretreatment of granisetron (0.1mg/kg), and then their kaolin consumption was monitored
hourly after the irradiation. A microdialysis probe was inserted into the anterior hypothalamus of rats and dialysis samples were collected
for 3h after the TBI and subjected to HPLC assay of glutamte. Finally, rats were intracerebroventricularly injected NMDA receptor
antagonist (MK-801: 3�g/rat) or AMPA receptor antagonist (CNQX: 1�g/rat) before the TBI and then kaolin ingestion was determined. RESULTS TBI induced pica within 1h after the irradiation and the increased kaolin intake was inhibited by a pretreatment of granisetron (p CONCLUSION Results suggest that a central pathway involving glutamate receptors in the hypothalamus contributes to radiation-induced nausea in rats
through the central AMPA receptors. CLINICAL RELEVANCE/APPLICATION We assumed that the inhibition of glutamatergic system in the brain served as a therapeutic target for the treatment of radiation-induced
nausea in patients. LL-ROS-MO3A • Intensity Modulated Radiation Therapy (IMRT) for Intracranial Germ Cell Tumors (GCT)
Mirna Abboud MD (Presenter) ; Jack Su MD ; Murali Chintagumpala MD ; Bin S Teh MD ; Pamela New ; E. Brian Butler MD ; Arnold D Paulino MD LL-ROS-MO4A • Radiation Dose to Brachial Plexus in Treatment of Head and Neck Malignancies Using 3D Conformal Radiation
Therapy
Vikram Manoor Maiya (Presenter) ; Sumeet Basu MD ; Sathiyanarayanan Vatyam MSc ; Sujai Hegde ; Minish Jain ; Sanjay
Deshmukh ; Nikhil Vaid ; Jaon Bos LL-ROS-MO5A • The Effect of Dose Volume Histogram Adoption on Locoregional Control and Esophagitis in Limited Stage Small
Cell Lung Cancer
Kevin R Kotamarti BS (Presenter) ; Daniel R Gomez MD ; Pamela Allen ; Ritsuko U Komaki MD ABSTRACT Purpose: Because small cell lung cancer has a high sensitivity to chemotherapy and radiotherapy, there has been some delay of more
sophisticated radiotherapy in the management of small cell lung cancer. We examined the effect of dose volume histogram (DVH) on a
large number of patients that were treated at our institution over the past 20 years. Our hypothesis was that the incorporation of DVH
would improve the rates of treatment failure and survival, as well as rates of high-grade esophagitis.
Materials/Methods: Four hundred forty one patients with limited stage SCLC were treated with concurrent chemoradiation at MD
Anderson Cancer Center between 1990 and 2009. 26.9% of patients received induction chemotherapy including 41.3% of patients prior
to DVH adoption and 34.3% after its adoption. The median RT dose was 45Gy (range 45-70Gy). The ECOG performance levels from 0-3
were 19%, 69.1%, 8.8%, and 1.8% respectively. Fifty two percent of patients received PCI. DVH was adopted at our institution in June
1999 and 171 patients were treated prior to its adoption. Esophagitis was graded utilizing the Common Terminology Criteria for Adverse
Events v3.0. A Cox proportional hazards model was utilized to determine the relationship of DVH adoption with locoregional failure free
survival (LRFFS), distant metastasis free survival (DMFS), and overall survival (OS) and controlling for the factors above.
Results: The LRFFS for cases from 1990- June 1999 was 55.55% and 48.61% at two and five years respectively, and 69.50% and
64.43%, respectively, for patients treated between July 1999-2009 (Logrank P=0.01). The OS for cases from 1990- June 1999 was
51.39% and 21.40% at two and five years respectively, and 63.30% and 36.56%, respectively, for patients treated between July
1999-2009 (Logrank P=0.03). Multivariate analysis showed improved overall survival in patients treated after the adoption of DVH (HR
0.74, P=0.01) and PCI (HR=0.68, P=0.001) and reduced OS in patients older than 65 (HR=1.02, P=0.001). In addition, there was
improved LRFFS in patients treated after the adoption of DVH (HR 0.65, P=0.01) and reduced LRFFS in patients with an ECOG of 2-3 (HR
1.52, P=0.109). There were a total of 397 patients who experienced esophagitis, 25% of whom experienced grade 3 or 4 toxicity. Of the
esophagitis patients, 61.4% were diagnosed post-DVH adoption. Of these high grade patients, 63.4% were diagnosed post-DVH adoption.
Conclusion: The adoption of DVH appeared to reduce rates of locoregional failure in SCLC. However, there was not a substantial impact
through this technologic advancement alone on the incidence of esophagitis or specifically high-grade esophagitis, which remains a
significant side-effect with chemoradiation in this context. LL-ROS-MO6A • Assessing Response to Radiochemotherapy Treatment on 18F-FDG PET in Non-small Cell Lung Cancer Using
Approaches of Histogram and Gray Level Co-occurrence Matrix
Changsheng Ma MS (Presenter) ; Yong Yin ABSTRACT Purpose: The aim of this study was to propose and investigate gray level histogram and texture features information provided by 18F-FDG PET to assess patient's imaging response to radiochemotherapy in non-small cell lung cancer (NSCLC).
Methods: Twelve patients with newly diagnosed NSCLC treated with combined radiochemotherapy were involved in this study. Patients
were categorized under three headings (non-responders, partial responders and complete responders) by experienced radiologists on the
basis of RECIST according PET scans changes between pretreatment and 1 month after treatment. We analyzed the percentage variation
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of PET density using histogram analysis approach which characterizes global change of tumor region on PET. Texture parameters
variation between pretreatment and 1 month after treatment completion which describe local voxel spatial distribution were extracted
from Gray Level Co-occurrence Matrix (GLCM). Correlation between characteristics' variation and three type response status were
analyzed.
Results: The uniformity of gray level histogram on the whole and the maximum percentage decrease in histogram was well associated
with tumor shrinkage and response status. The above indices derived from histogram were capable to differentiate three groups tumor
response to radiochemotherapy. Texture parameters' variation (ASM, ENT and IDM) were able to differentiate the 3 response groups
considering a high correlation with response status.
Conclusion: We demonstrated that histogram and texture analysis methods on baseline 18F-FDG PET scans provided robust,
discriminative stratification in assessing response to combined radiochemotherapy and may have a good application prospect in clinical
practice. Vascular/Interventional - Monday Posters and Exhibits (12:15pm - 12:45pm) Monday, 12:15 PM - 12:45 PM • Lakeside Learning Center
IR
VA LL-VIS-MOA • AMA PRA Category 1 Credit ™:0.5 Host
Sarah B White , MD Back to Top LL-VIS-MO1A • Low Dose Runoff CTA: Effect of Hybrid Iterative Reconstruction Technique on Quantitative and Qualitative Image
Parameters
Evgeny Kondratyev MD (Presenter) ; Grigory Karmazanovsky MD ; Vadim Shirokov ; Anna Kalinina PURPOSE To evaluate the effect of hybrid iterative reconstruction (HIR) on qualitative and quantitative parameters of data obtained using low dose
run-off CTA. METHOD AND MATERIALS 90 patients were divided into three groups. The scanning protocol was 120kVp 200mAs in first group, 80kVp 200mAs in second group,
and 120kV 50mAs in third group, data from second and third group was reconstructed using both FBP and three levels of HIR. For
quantitative and qualitative evaluation we used effective dose, visual scores (1-3), mean arterial attenuation, noise, contrast-to-noise
ratio (CNR) in three arterial segments. RESULTS The BMI ranged from 21 to 38 kg/m2 and was not significantly different between groups (p>0,05). The mean intraarterial attenuation
was significantly higher in second group (448±76HU, p CONCLUSION Average radiation dose reduction up to 77% was achieved using 80kV and 50mAs protocol providing sufficient image quality. Application
of the 80kV protocol in people with BMI>30 is limited, especially in evaluation of aorto-iliac segment due to higher noise and attenuation
levels. While at 50mAs protocol such limitation is not observed. Iterative reconstruction significantly improve image quality, reduce noise
and artifacts, allowing us to expand indications for low-dose studies, including overweight and obese patients. CLINICAL RELEVANCE/APPLICATION Low dose run-off CTA of peripheral vessels using 80kV or 50mAs and hybrid iterative reconstruction provides up to 77% dose reduction
and sufficient image quality. LL-VIS-MO2A • Optimal Scanning Parameters for Non-contrast-enhanced Time-spatial Labeling Inversion-pulse MR Angiography
of Renal Arteries
Xuan Wang MD (Presenter) ; Huadan Xue MD ; Zhengyu Jin MD ; Xinzhi Zhao PURPOSE To study the impact of inversion time(TI), respiratory rate(RR) and slice thickness(ST) on image quality and acquisition time for
non-contrast-enhanced (non-CE) renal MR Angiography with true steady-state free-precession (SSFP) and time spatial labeling inversion
pulse (Time-SLIP). METHOD AND MATERIALS Two sets of young healthy adults were examined. Voice recorder was applied to regulate RR. Set A contained 23 subjects. Six Time-SLIP
sequences were performed on each subject, with a fixed TI of 1200ms. For three coronal sequences, the RR was free, 10 and 15 breaths
per minute(bpm) respectively, with a ST of 2.5mm. For three axial sequences, the ST and RR settings were 2.0mm with free breath,
2.0mm with 10 bpm and 2.5mm with 10bpm respectively. Set B contained 22 subjects. Four coronal sequences with different TI were
performed, as 700, 900, 1200 and 1500 ms respectively. The ST and RR were fixed as 2.5mm and 15 bpm. RESULTS Set A (Figure) showed that a RR of 15bpm setting demonstrated superior quality to free breathing one. It also had significantly shorter
scan time without decreased image quality compared to RR of 10bpm. For ST comparison, 2.5mm had shorter time than 2.0 mm without
loss of image quality. Set B showed a TI of 900ms had better image quality than others with significant differences in most of the
comparisons. CONCLUSION Non-CE TIME-SLIP MRA showed excellent visualization of renal arteries. A protocol with RR of 15bpm and ST of 2.5mm is favorable since it
can both shortening the acquisition time and improving image quality. For young health adults, A TI of 900 ms is the optimal choice. CLINICAL RELEVANCE/APPLICATION The optimal parameters determined from this study could improve image quality and shorten scan time for non-CE renal MR
angiography. LL-VIS-MO3A • Remodeling of Focal Contrast Enhancement Communicating with Aortic Branch Arteries in Intramural Hematoma
Kumi Ozaki (Presenter) ; Hiroshi Ohtake ; Toshifumi Gabata MD ; Yoshihiro Sanda ; Tetsuya Fukuda ; Yoshiaki Morita ; Masahiro Higashi MD ; Hiroaki Naito MD, PhD PURPOSE To analyze the prevalence, location, morphology, and remodeling of focal contrast enhancement communicating with aortic branch
arteries in acute intramural hematoma (IMH) and compare findings with those of focal contrast enhancement not communicating with
aortic branch arteries. METHOD AND MATERIALS RESULTS There were 104 communicating lesions in 52 patients and 72 non-communicating lesions (corresponding approximately to ulcer-like
projection) in 63 patients. Communicating lesions were frequently seen (38.5%), and more than one communicating lesion was seen in
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projection) in 63 patients. Communicating lesions were frequently seen (38.5%), and more than one communicating lesion was seen in
the majority of patients (68.8% vs. 11.1%, p CONCLUSION In intramural hematoma, most regions of focal contrast enhancement communicating with aortic branch arteries are completely or
partially resorbed during follow-up, and are not associated with intervention. CLINICAL RELEVANCE/APPLICATION In intramural hematoma, most regions of focal contrast enhancement communicating with aortic branch arteries are completely or
partially resorbed, and are not associated with intervention. LL-VIS-MO4A • Developments of New Percutaneous Lithotripsy Techniques for Removal of Common Bile Duct Stones
Baojie Wei MD,PhD (Presenter) ; Yanfeng Meng MD ; Feng Zhang MD, PhD ; Xia Wu ; Patrick Willis ; RenYou Zhai MD ; Wayne L Monsky MD, PhD * ; Xiaoming Yang MD, PhD PURPOSE To develop new techniques for percutaneous removal of common bile duct (CBD) stones using three lithotripsy systems, including a
pneumatic, an electrohydraulic, and an electromagnetic lithotripters with various stone catchers. METHOD AND MATERIALS For in-vitro confirmation, a water phantom with a 6.0mm glass tube was built to simulate the cystic duct and CBD. A human gallstone
was placed into the tube. An 11 Fr custom balloon occlusion sheath (BOS) was positioned and inflated to occlude the proximal tube. A
stone catcher of the three lithotripsy systems was advanced through the BOS into the tube, to grasp the stone and then restrict it within
the XCOIL encapsulator (XE) or a basket. A lithotripsy probe was advanced into the XE or basket, where the stone was broken. Fragments
were then extracted through the BOS. Each of three lithotripsy procedures was repeated for 10 times. For in-vivo validation, via a
transcystic approach, human gallstones were implanted into CBDs of 21 pigs (7 pigs×3 lithotripsy systems). Under fluoroscopy, a stone
catcher and a lithotripsy probe of three lithotripsy systems were placed into the CBD, to break and remove the stone. Pre- and
post-cholangiograms were obtained to confirm the successes of the implantation, breaking and removal of these stones. After the
experiments, the pigs were euthanized and CBDs were harvested for histology. RESULTS Of the in-vitro experiment, an average pulse at 9.5 were required to break these stones. The average skin-to-skin lithotripsy time was
6.5 min. The average stone fragment length was at 2.1 mm compared to the pre-lithotripsy stone length at 5.1 mm (p CONCLUSION The three new lithotripsy techniques are feasible and safe for breaking and removal of CBD stones, which establishes groundwork for
their further clinical application. CLINICAL RELEVANCE/APPLICATION The development of these percutaneous lithotripsy techniques may open new avenues to efficiently remove common bile duct stones. LL-VIS-MO5A • Bimodal Treatment of Aerobic and Glycolytic Metabolism by Particle Embolization Combined with Anti-glycolytic
Compound Improves Treatment of N1-S1 Hepatocellular Mouse Model
John R Haaga MD (Presenter) ; Hanping Wu MD, PhD PURPOSE To determine if combination treatment of aerobic metabolism by embolization and antiglycolytic drugs compared to embolization alone
provides better treatment of N1-S1 hepatocellular carcinoma in a rat model. METHOD AND MATERIALS Two separate laparotomies were performed,one for subcapsular tumor implant and the second for retrograde placement of catheter into
the gastroduodenal artery for 5 different treatments. Treatments were: 1)Control (n=5, 1ml NS); 2) TAE (n=4, 10mg 50-150�m PVA
particle in 1ml NS), 3) TAE+AG-B (n=5, 10mg PVA in 1ml AG-B); 4) TAE+AG-F (n=5, 10mg PVA+30mg AG-F in 1 ml NS); 5) TAE+AG-C
(n=5, 10mg PVA+30mg AG-C in 1 ml normal saline). Tumor length (L), width (W), and height (H) was measured by 2D-ultrasound
before treatment and twice a week till 4 weeks after treatment. Tumor volume (V) was calculated by the formula: V= 0.5*L*W*H.
Relative tumor volume after treatment was calculated as the percentage of pre-treatment tumor volume. Kruskal-Wallis test was used to
compare the difference of relative tumor volume between 5 groups on each observation time point. RESULTS The initial tumor sizes in each group were statistically not significantly different . Three animals in the control group were euthanized
before the end of observation due to rapid tumor growth and anorexia. In TAE group, one kept growing after treatment. In other 3
animals, the tumor volume increased in the early observation time points (1 within 1 week, 2 within 2 weeks) and then shrunk. In other
3 TAE+AG groups, the tumor volumes decreased after treatment with significant differences between control group and 3 TAE+AG groups
on all observation time point except TAE+AG-F group on 3.5 and 4 weeks. At 4 weeks after treatment, the median relative tumor
volumes were 3,174.5% in control group, 58.2% in TAE group, 9.6% in TAE+AG-B group, 23.8% in TAE+AG-F group, and 13.4% in
TAE+AG-C group. CONCLUSION Bimodal embolic treatment of hepatocellular cancer is more effective than embolic Rx alone. . Further study of these propriety agents is
warranted because agents target enzymes specific to cancer. Optimization of drug form, dose and route adminstration (IV, oral) are
needed. Safety studies must be completed before human use. CLINICAL RELEVANCE/APPLICATION Clinical relevance is enormous. Agents should be effective against all cancers with little effect on normal tissues. Mode of delivery can be
arterial, intravenous and/or oral. Challenge is funding. LL-VIE-MO6A • Angio-CT System: Reasons Why It is Useful in Non-vascular Interventions
Miyuki Sone MD (Presenter) ; Yasuaki Arai MD * ; Yoshito Takeuchi MD ; Shunsuke Sugawara ; Hirotaka Tomimatsu ; Shinichi Morita ; Daisuke Okamoto MD PURPOSE/AIM Angio-CT system is equipment combining c-arm angiography system and CT scanner with a same sliding table. The aims of this exhibit
are:
1. To review the reasons why Angio-CT is useful in non-vascular interventions
2. To provide a case-based review of challenging non-vascular interventions using Angio-CT CONTENT ORGANIZATION 1. Background of image guidance in non-vascular interventions Treatment target does not always have anatomical landmark or baseline for needle puncture
Fluoroscopy is superior in guiding device manipulation with its real-time capability
CT is superior in confirming the position of the target and the device with its cross-sectional and 3-D information
2. Reasons why Angio-CT is useful Planning of access with CT, manipulation of device with fluoroscopy, and confirmation with CT can be performed alternately and
repeatedly
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repeatedly
In the absence of anatomical landmark, a fine needle is used as a baseline and accurate puncture can be performed with
�tandem technique�
3. Case-based review of challenging procedures Use of anatomical landmark
Use of �tandem technique�
Spacing vital organs from the target
SUMMARY Angio-CT is useful in non-vascular interventions because alternate use of fluoroscopy and CT is available. This exhibit reviews the features
of Angio-CT and its clinical use. LL-VIE-MO7A • Parastomal Varices: Diagnosis, Treatment, and Outcomes
Annie K Lim DO (Presenter) ; Joshua D Dowell MD, PhD ; Gregory E Guy MD ; Bill S Majdalany MD PURPOSE/AIM To review the epidemiology, diagnosis, and various treatment methods for parastomal varices. CONTENT ORGANIZATION Epidemiology and pathophysiology of parastomal varices will be reviewed. The numerous methods that have been described in the
literature for treatment include: direct compression, medical optimization, percutaneous or transhepatic embolization, TIPS, surgical
stomal revision, and superficial sclerotherapy. Each therapeutic option has associated complications and contraindications. Current
literature and outcome data will be reviewed and an algorithm for patient specific treatment approach will be proposed. SUMMARY Esophageal and gastric varices are a common manifestation of portal hypertension with an accepted treatment algorithm. Already, 30%
of patients with both portal hypertension and urinary or enteric diversion will develop parastomal varices. With the advent of life
prolonging treatments, which can give rise to portal hypertension, this population may increase. Although bleeding from these varices has
a relatively low overall mortality, significant morbidity exists in the form of repeated hospitalizations and transfusions. Patient specific
treatment approach is reviewed. LL-VIE1289-MOA • Irreversible Electroporation in the Abdomen: A Primer for Interventionalists
Avinash R Kambadakone MD, FRCR (Presenter) ; Raul N Uppot MD ; Rahmi Oklu MD, PhD ; Debra A Gervais MD * ; Ronald S
Arellano MD PURPOSE/AIM Irreversible electroporation is an exciting new technology which is finding increasing applications in the treatment of tumors of the liver,
kidney and the pancreas. The purpose of this exhibit is to discuss the principles, indications, technique and performance of irreversible
electroporation in the abdomen using a pictorial review. CONTENT ORGANIZATION 1. Brief review of the principles and technique of irreversible electroporation
2. Discuss the relevant anatomical considerations for successful performance of IRE
3. Discuss the indications for IRE in various tumors in the liver, kidney and pancreas
4. Describe the step-by-step interventional technique for CT guided IRE.
5. Illustrate the technique by citing examples from routine and challenging cases in a pictorial review with the tips and tricks for
successful placement.
5. Discuss the patient care issues before, during and after procedure including management of complications
SUMMARY Irreversible electroporation is an exciting new technology with immense potential in the treatment of hepatic, pancreatic and renal
tumors. A proper understanding of the indications, principles and technique of this procedure is essential to ensure a successful outcome. LL-VIE1288-MOA • Chest Complications of Abdominal Interventions
Florian J Fintelmann MD (Presenter) ; Selim R Butros MD ; Subba R Digumarthy MD ; Ashraf Thabet MD ; Jo-Anne O
Shepard MD * ; Debra A Gervais MD * ; Diane A Levis ; Peter R Mueller MD * PURPOSE/AIM A variety of abdominal interventions can result in complications in the chest. Our exhibit presents a pictorial illustration of such procedures
with their respective intrathoracic complications. Preventive measures and management will be discussed. CONTENT ORGANIZATION 1. Review anatomy of upper abdomen in relationship to pleural space and mediastinal structures. 2. Illustrate fundamentals of abdominal
procedures with potential chest complications: Ablation of liver, kidneys or adrenal glands
Biopsy of liver, kidneys, adrenal glands or retroperitoneum
Biliary drainage, nephrostomy, and right and left subphrenic abscess drainage
3. Examples of thoracic complications such as pneumothorax, hemothorax, empyema, pericardial tamponade, and leak of bile, lymph or
urine into the pleural space. 4. Discussion of pre- and intraprocedural preventive measures such as patient positioning, gantry angulation
and hydrodissection. 5. Discussion of management of said complications. SUMMARY This exhibit educates interventional radiologists how to prevent, recognize and manage chest complications related to a variety of
abdominal procedures. Molecular Imaging - Monday Posters and Exhibits (12:45pm - 1:15pm) Monday, 12:45 PM - 01:15 PM • S503AB
MI
Back to Top CL-MIS-MOB • AMA PRA Category 1 Credit ™:0.5 CL-MIS-MO1B • Comparing Photoacoustically Derived Hemoglobin and Oxygenation Measurements and Ultrasound Contrast
Agent Derived Vascularity Measurements to Immunohistochemical Staining in a Breast Cancer Xenograft Model
John R Eisenbrey PhD (Presenter) ; Andrew Marshall ; Daniel A Merton ; Ji-Bin Liu MD * ; Traci B Fox MS, RT ; Anush
Sridharan ; Flemming Forsberg PhD * Page 116 of 397
PURPOSE To compare tumor oxygenation levels derived by photoacoustic imaging (PA) and tumor vascularity measurements derived by
contrast-enhanced ultrasound (CEUS) with immunohistochemical markers in a murine subcutaneous breast cancer model. METHOD AND MATERIALS Subcutaneous MDA-MB-231 breast tumors implanted in the mammary pads of 11 nude rats were imaged in nonlinear contrast mode on a
Vevo 2100 ultrasound scanner (Visualsonics, Toronto, Canada). Rats received a bolus 36 ?l injection of Definity (Lantheus Medical
Imaging, N Billerica MA) during CEUS imaging (acoustic power=4%, frequency=24 MHz, gain=35 dB). Maximum intensity projections
were then generated over the tumor area using the VevoCQ software as a measure of tumor vascularity. PA was performed using a PA
probe (MS-250-PA, Visualsonics) on the Vevo2100. The laser was operated at 100% output power at wavelengths of 750 and 850 nm
with a PA gain of 40 dB. Hemoglobin signal (HbT), oxygenation levels in detected blood (SO2 Avg), and oxygenation levels over the
entire tumor area (SO2 Tot) were then calculated for 20 frames using the Oxygenation-Hemoglobin measurement package. Post imaging,
rats were sacrificed and the tumors stained for VEGF, Cox-2, and CD-31. RESULTS When comparing CEUS to PA measurements, significant correlation was observed between CEUS derived vascularity and both HbT and
SO2 Tot (R=0.61 and R=0.64 respectively, p0.32). Similarly, no significant correlation was observed between either HbT or SO2 Tot and
any immunohistochemical marker (p>0.18). SO2 Avg did show significant inverse correlation with Cox-2 (R=-0.65; p=0.03), but not with
either VEGF or CD-31 (p>0.5). CONCLUSION PA modes that rely on the total detection of hemoglobin appear to correlate with CEUS vascularity measurements, but not with the
studied immunohistochemical markers. Oxygenation levels within detected blood determined via PA appear to correlate with Cox-2
expression. CLINICAL RELEVANCE/APPLICATION Depending on the imaging mode, PA may be useful for detecting changes in tumor vascularity or expression of the angiogenic marker
Cox-2. CL-MIS-MO2B • Radiation-free Whole Body MR Imaging of Children with Cancer: A Solution to the Conundrum of Long-term
Side-effects from CT Scans
Christopher Klenk MD (Presenter) ; Rakhee S Gawande MD ; Deqiang Qiu PhD ; Andrew Quon MD ; Michael E Moseley PhD ; Heike E Daldrup-Link MD PURPOSE Standard CT and radiotracer-based staging procedures of children with cancer are associated with considerable radiation exposure and
risk of secondary cancer development later in life. The purpose of this study was to develop an alternative radiation-free staging
technique, based on whole body diffusion-weighted magnetic resonance (WB-DW MR) imaging and the iron supplement ferumoxytol,
used as an MR contrast agent. METHOD AND MATERIALS A novel concept for WB-DW MR was established based on color-encoded, iron oxide nanoparticle-enhanced diffusion weighted MR scans
for tumor detection, which were co-registered with nanoparticle-enhanced T1-weighted MR scans for anatomical orientation. Following
pulse sequence optimizations in nine healthy volunteers, 16 children and young adults with malignant lymphoproliferative disorders
underwent WB-DW MR and 18F-FDG PET/CT scans. The presence or absence of tumors in different anatomical areas was determined
separately for WB-DW MR and clinical routine 18F-FDG PET/CT staging exams. Histopathology and follow-up imaging served as the
standard of reference. The agreement between tumor staging results of the two imaging tests was evaluated using Cohen's kappa
statistics, with a score of 1.0 indicating perfect agreement. RESULTS Evaluation of healthy volunteers revealed optimal pulse sequence parameters for WB-DW MR as follows: TR 3400 ms, TE 45-55 ms,
b-values 50 and 600 s/mm2, and bandwidth of 0.25kHz. Duration of the diagnostic procedure was 1-1.5 hours for WB-DW MR scans and
1.5-2.5 hours for 18F-FDG PET/CT scans (radionuclide injection + imaging). WB-MRI/DWIBS and 18F-FDG-PET/CT showed very good
inter-observer agreement for tumor staging according to the Ann Arbor classification with a weighted k value of 0.889. CONCLUSION Ferumoxytol-enhanced WB-DW MR imaging provides a radiation-free alternative to 18F-FDG PET/CT for staging of children with
malignant lymphomas. To the best of our knowledge, this is the first study that integrates an MRI technique for tumor detection (WB-DW)
with an MR technique for anatomical orientation, in accordance with the concept of integrated 18F-FDG PET/CT scans. CLINICAL RELEVANCE/APPLICATION Since our new WB-DW MR approach is radiation free, it may solve the conundrum of mandatory radiographic imaging for cancer staging,
but associated risk of developing radiation-induced secondary cancer CL-MIS-MO3B • Three-dimensional Angiogenesis Imaging Using Molecular Ultrasound in Colon Cancer: Preliminary Feasibility
Study in a Mouse Model
Osamu F Kaneko MD (Presenter) ; Huaijun Wang MD, PhD ; Vijay Shamdasani MS, PhD * ; Dimitre Hristov PhD * ; Juergen K
Willmann MD * PURPOSE To explore the feasibility of three-dimensional (3D) targeted contrast-enhanced (molecular) ultrasound (US) imaging using a 3D clinical
transducer in a human colon cancer xenograft model in mice undergoing vascular disrupting treatment. METHOD AND MATERIALS Subcutaneous human colon cancer LS174T xenografts were induced in 14 female nude mice. Mice were randomly assigned to either 1) a
treatment group receiving the vascular disrupting agent ASA404 (n=8; single dose of 15 mg/kg i.v.) or 2) a control group (n=6; saline
only) with no treatment. All mice were scanned with US at baseline (day 0) and at day 1 after treatment. 3D US molecular imaging was
performed with a clinical US system (IU22 xMATRIX; Philips Healthcare, Bothell, WA) and a clinical transducer (X6-1; center frequency,
3.2 MHz) at 4 min after i.v. injection of 5×107 VEGFR2-targeted microbubbles (MB-VEGFR2) or non-targeted control microbubbles
(MB-Control) administered at the same dose in the same imaging session. After imaging, all mice were sacrificed and tumors were
analyzed for VEGFR2 expression levels on ex vivo immunofluorescence. RESULTS 3D US molecular imaging was feasible in all 14 tumors. In the treatment group, US molecular imaging signal with MB-VEGFR2 following a
single treatment with ASA404 was significantly lower (81% decrease, P CONCLUSION Volumetric US molecular imaging using a clinical US system and 3D transducer is technically feasible. Preliminary data show good
correlation of in vivo VEGFR2-targeted US imaging signal with ex vivo VEGFR2 expression levels in human colon cancer xenografts in mice
undergoing vascular disrupting treatment. CLINICAL RELEVANCE/APPLICATION 3D imaging capabilities of US may further expand its future clinical role in molecular imaging of cancer, particularly for more accurate
monitoring of treatment response in complete tumor volumes. Page 117 of 397
Nuclear Medicine - Monday Posters and Exhibits (12:45pm - 1:15pm) Monday, 12:45 PM - 01:15 PM • S503AB
Back to Top NM
CL-NMS-MOB • AMA PRA Category 1 Credit ™:0.5 CL-NMS-MO1B • Comparison of 99M-TC-MDP Bone Scintigraphy and 18F-FDG-PET/CT for the Detection of Skeletal Metastases
Connie Y Chang MD (Presenter) ; Corey Gill ; Frank J Simeone MD ; Atul K Taneja MD ; Martin Torriani MD ; Miriam A
Bredella MD PURPOSE To compare the accuracy of fluorine-18-fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) with
technetium-99m-bone scintigraphy (bone scan) for the detection of skeletal metastases. METHOD AND MATERIALS The study group comprised 202 adult cancer patients who underwent both PET/CT and bone scan within 31 days for staging. Bone scans
and PET/CT were evaluated by two musculoskeletal radiologists in consensus for the presence and location of skeletal metastatic disease.
In cases of discordance between the two modalities, confirmation of the final diagnosis was based on the CT or MR appearance, follow-up
imaging or histology. RESULTS The sensitivity, specificity, and accuracy of PET/CT were 97%, 98%, and 98% respectively, and the sensitivity, specificity, and accuracy
of bone scan were 83%, 98%, and 93%, respectively. The lesions that bone scan most commonly missed were located in the pelvis,
spine, and sacrum. PET/CT missed mostly lesions that were outside of the field of view, but in all of these cases the patient had additional
sites of skeletal metastatic disease. Bone scan falsely identified 6 metastatic lesions (spine, pelvis, and humerus) and PET/CT falsely
identified 3 metastatic lesions (spine, pelvis, and clavicle). CONCLUSION PET/CT is an accurate technique for detection of skeletal metastases, and is superior to bone scan, especially in the spine and pelvis. CLINICAL RELEVANCE/APPLICATION PET/CT and bone scan are performed concurrently for skeletal metastases, resulting in increased patient radiation dose and health care
dollars spent; we show that PET/CT alone may be sufficient. CL-NMS-MO2B • Osteochondral Talar Lesions: SPECT-CT Contribution to MRI
Ignacio Lopez-Vidaur Franco (Presenter) ; Adolfo Gomez Grande ; Beatriz Alvarez De Sierra Garcia MD ; Luis Banuelos
Andrio PURPOSE The osteochondral lesion in the dome of the talus is one of the most frequent treatable causes of chronic inexplicable pain. SPECT-CT,
whose impact in the treatment of this kind of lesion is not well known, can supply additional information to the MRI findings. The objective
of the present research is to assess the utility of SPECT-CT in detecting and localizing osteochondral lesions in the talar dome analyzing
the additional information to the MRI findings and its impact in the taking of therapeutic decisions. METHOD AND MATERIALS From October 2011 to January 2012 we conducted three-phase scintygraphy Tc99m-DPD/MPD and SPETC-CT studies to 10 patients with
osteochondral talar dome lesion in the MRI. We analysed the matching between the focal uptake and degree of osteochondral lesion, its
exact location and the correlation in the MRI image of the additional findings of SPECT-CT. We consulted to the responsible physician
about the influence of SPECT-CT in the diagnosis and management (surgical / conservative). RESULTS We analyzed 10 patients with talar osteochondral lesion. In 2 ausecncia active osteoblastic reaction was observed. In the remaining 8
studies where osteochondral lesion with osteoblastic activity was observed in 4 of them the SPECT-CT showed additional findings (1 reflex
sympathetic dystrophy, 2 similar injury contralateral ankle, 1 intense uptake in tibiofibular syndesmosis). And the remaining 4 SPECT-CT
studies showed a single focal uptake coincident with MRI. Surgical treatment was indicated in 3 of them. In studies with multifocal
deposits (4) or osteochondral lesion without osteoblastic activity (2), the SPECT-CT supported a conservative approach. CONCLUSION SPECT-CT provides additional useful information to MRI, suggesting other possible causes of pain and helping to decide a conservative
management when the osteochondral lesion of the talus shows no osteoblastic activity. CLINICAL RELEVANCE/APPLICATION Adding SPECT-CT to MRI can help to prevent unnecessary surgeries depending on the results. CL-NMS-MO3B • Role of 18F-FDG-PET/CT in the Follow Up of Bone Lesions Treated with Thermal Ablation
Desiree Deandreis MD (Presenter) ; Frederic Deschamps ; Camila Nascimento ; Sophie Leboulleux ; Jean Lumbroso MD ; Clarisse Dromain MD ; Caroline Caramella ; Martin Schlumberger ; Thierry Debaere PURPOSE to evaluate the interest of FDG-PET/CT in the assessment of bone thermal ablation -radiofrequency ablation (RFA) or cryoablation (CRY)efficacy in case of inconclusive morphological imaging. METHOD AND MATERIALS Ten patients (4M, 6F; mean age: 54 ys) treated with curative intent by thermal ablation for painful bone metastases and studied by FDG
PET/CT before and within 6 months after treatment were retrospectively evaluated. In all patients post-treatment morphological imaging
(CT scan and/or MRI) were inconclusive. A visual and semi-quantitative analysis (SUVmax) of PET images was performed. A significant
persistent uptake after treatment was considered when superior to background (normal bone uptake). A decrease of at least 90% of SUV
max value was considered as complete response. Gold standard for response was clinical follow up. RESULTS A total of 20 metastatic bone lesions treated by RFA (n=10), CRY (n=7) or thermal ablation (2 RFA and 1 CRY) combined with
cementoplasty were analysed. Bone lesions were localised in the pelvis (n=12), in the spine (n=7) and in the rib (n=1). They were
respectively lytic (n=12), blastic (n=5) or mixed (n=3) lesions. Median size was 25 mm (8-43). At final follow up (10 months, 5-24) 18
and 2 lesions were considered respectively completely and incompletely treated. At PET/CT, 15 completely treated lesions showed a ring
shape homogeneous peripheral mild FDG uptake and a pre-ablation and post-treatment median SUVmax of 3.9 (1.5-16.4) and 2.2
(0.6-5.3) respectively. The remaining 3 cases were lesions treated by ablation and cementoplasty and showed persistent FDG uptake on
PET images due to overcorrection artefact. One case of incompletely treated lesion appeared as persistent focal and intense uptake with
SUVmax increase from 6.7 to 22 within 2 months after treatment. The second case showed a significant SUVmax decrease but
heterogeneous �patchy� uptake. Disease relapse was detected after 11 months of follow up. Page 118 of 397
heterogeneous �patchy� uptake. Disease relapse was detected after 11 months of follow up. CONCLUSION These preliminary data show that FDG PET/CT can be a useful tool for the assessment of ablation efficacy in bone lesions. Persistent not
tumoral FDG uptake in case of cementplasty may occur. CLINICAL RELEVANCE/APPLICATION FDG PET/CT can be a useful tool for the evaluation of bone lesions ablation efficacy in case of inconclusive morphological imaging. CL-NMS-MO4B • PET Threshold for Target Volume Delineation in Cervical Cancer Using an Integrated PET/MR
Shaomin Zhang (Presenter) ; Jun Xin MD ; Hongzan Sun ; Yueyue Lu ; Qiyong Guo MD PURPOSE To determine the maximum standardized uptake value (SUVmax) optimal threshold for PET-defined gross tumor volume (PET-GTV) based
on PET/MR in patients with cervical cancer. And to compare the difference in target volume delineation between MRI-defined gross tumor
volume (MR-GTV) and PET-GTV defined by the optimal threshold. METHOD AND MATERIALS Twenty-four patients with biopsy-proven squamous cell carcinomas were enrolled in this study. All patients underwent Philips Ingenuity TF
18F-FDG PET/MR pelvic examination before radiotherapy. MR-GTV was manually outlined by consensus of two experienced radiologists on
sagittal T2-weighted MR images as the gold standard. PET-GTVs were auto-contoured on the PET images using 15%~90% SUVmax
thresholds. Pearson analysis was used to calculate the correlation between different PET-GTVs and MR-GTV. The difference between
MR-GTV and PET-GTV defined by the optimal threshold was used to compare the discrepancies in target volume delineation. RESULTS The mean±SD SUVmax of the tumors was 13.2±5.3, and the mean±SD MR-GTV was 41.0±28.6cc. The mean MR-GTV correlated
significantly (P < 0.0001) with 40% of SUVmax values with best correlation according to the Pearson bivariate correlation. The mean±SD
difference between MR-GTV and PET-GTV at the 40% threshold was 12.0±16.2cc. The PET-GTV at the 40% thresholds overestimated the
MR-GTV for 7 of 24 lesions, and underestimated the MR-GTV for 17 lesions. Patients were divided into three groups based upon MR-GTV
due to their prognostic significance. The optimal thresholds of PET-GTV were 80%, 55% and 35% SUVmax for MR-GTV measuring less
than 14cc, 14~16cc, and greater than 62cc. For the CONCLUSION The present study will provide new guidelines on the ability of integrated PET/MR to determine SUVmax threshold in target volume
delineation for cervical cancer. CLINICAL RELEVANCE/APPLICATION This study demonstrates an added value of PET/MR for definition of PET-GTV for RT planning of cervical cancer. CL-NMS-MO5B • Correlation of Preoperative Clinical, PET and CT Parameters with Histologic Grading of Residual Tumor after
Neoadjuvant Chemoradiotherapy in Pancreatic Adenocarcinoma
Makoto Sakane MD (Presenter) ; Mitsuaki Tatsumi MD, PhD ; Tonsok Kim MD ; Masatoshi Hori MD ; Jun Hatazawa MD, PhD ; Noriyuki Tomiyama MD, PhD ; Hiromitsu Onishi MD ; Atsushi Nakamoto MD ; Eku Shimosegawa PURPOSE The purpose of this study is to investigate the correlation of histological effect of chemoradiotherapy (CRT) to pancreatic adenocarcinoma
with preoperative clinical, PET and CT parameters, and to evaluate prognostic significance of those grading and parameters. METHOD AND MATERIALS This study included 25 patients diagnosed as pancreatic carcinoma by radical surgery after Gemcitabine and S-1 based preoperative-CRT
from 2009 to 2012. The extent of residual tumor was graded using the Evans grading systems by a pathologist. Clinical values of CA 19-9
and prognosis of the patients were derived from medical records. A radiologist evaluated radiographic features of pre- and post-CRT
contrast-enhanced dynamic CT and PET-CT, including size of tumors, peak standardized uptake value normalized for lean body mass
(SULpeak) and metabolic tumor volume with a threshold of SUVmax 2.0 (MTV2.0). These values were statistically compared by
commercial software. RESULTS Among the 25 patients, 8 patients (32%) showed pathologic poor response (Evans grade I), 12 cases (48%) had mild response (Evans
grade IIa), 5 cases (20%) had moderate response (Evans grade IIb), and no case showed complete response or minimal residual tumor
(Evans grade III or IV). Mean reduction rate was 35%, 44% and 37% in CA19-9, 10%, 11% and 22% in tumor size, and 32%, 34% and
43% in SUL peak, respectively for Evans grade I, IIa and IIb. Post-chemoradiation MTV
2.0 were 0 cm3 for all 5 cases of Evans grade IIb,
and were 2.4 and 3.5 cm3 for Evans grade I and IIa. Median disease free survival time for patients with negative post-chemoradiation
MTV2.0 were longer than patients with positive values (883 and 433 days, respectively (p = 0.28)). CONCLUSION The reduction rate of tumor size and SULpeak showed mild tendency to represent histological effect of CRT evaluated by Evans grade.
Negative MTV2.0 on PET-CT after CRT may indicate better histologic response and prognosis in pancreatic adenocarcinoma, although
further studies are obviously required. CLINICAL RELEVANCE/APPLICATION Tumor size, SUL peak, and MTV 2.0 were correlated with histological grading.
Negative post-CRT MTV2.0 may indicate better histological effect and prognosis.
CL-NMS-MO6B • Evaluation of Software Based Analysis of V/P SPECT/CT in Patients with Pulmonary Emphysema
Nils F Schreiter (Presenter) ; Felix Doellinger ; Alexander Poellinger MD ; Ralf-Harto Huebner ; Ralph Buchert ; Thomas J
Kroencke MD ; Bernd K Hamm MD * ; Winfried Brenner * ; Vera Froeling MD PURPOSE New software based analyzing system (SBAS) is available for ventilation / perfusion (V/P) SPECT/CT. Purpose of this study was to
evaluate reproducibility of SBAS for V/P SPECT/CT in patients with pulmonary emphysema (PE) and to compare it to visual interpretation
(VI) of V/P SPECT/CT METHOD AND MATERIALS Twenty-one patients (12 female, 9 male; median age: 69) with clinically confirmed PE and COPD (GOLD IV) were scanned with V/P
SPECT/CT (Tracer: T99m MAA and Tc99m Technegas). Data was analyzed by two independent observers using SBAS and VI,. SBAS was
used to assess counts per lung lobe (CpL) and volume per lung lobe (VpL). Counts density per lobe (CDpL=CpL/VpL) and a ratio
CpL/counts per lung (RCDpL) were calculated. VI was performed using a 100 point scale to assess mean counts per lung lobe.
Interobserver variability and association for SBAS and VI were analyzed using Spearman�s Rho correlation coefficient. Analysis was
performed lobe based and descriptive parameters are given as mean (range). RESULTS SBAS yielded excellent lobe based correlation between both observers (all; p < 0.05): CpL [perfusion: 0.96 (0.91 - 0.99); ventilation:
0.03 (0.73 - 0.99)], CDpL [perfusion: 0.96 (0.87 - 0.99); ventilation: 0.92 (0.72 - 0.99)]; RCDpL [perfusion: 0.97 (0.93 - 0.995);
Page 119 of 397
ventilation: 0.91 (0.74 - 0.99)].
Correlation of VI was modest to good and correlated in 5/5 lobes 0.66 (0.47 � 0.78) in perfusion and in 3/5 lobes 0.49 (0.36 � 0.58) in
ventilation significantly (p < 0.05).
For observer I correlation of SBAS and VI was 0.41 (0.11 - 0.63) which was significant (p < 0.05) for 3/5 lobes in perfusion and 2/5
lobes in ventilation.
For observer II correlation of SBAS and VI was 0.44 (0.15 - 0.71) that was significant (p < 0.05) with SBAS for 2/5 lobes in perfusion
and 3/5 lobes in ventilation. Mean time of SBAS analyses was 45 min compared to 5 min for VI per patient.
CONCLUSION Software based analysis offers more reproducible parameters in functional lung imaging by V/P SPECT/CT in patients with pulmonary
emphysema than visual interpretation. CLINICAL RELEVANCE/APPLICATION Software based analysis is an excellent tool for V/P SPECT/CT in an experimental setting, but has limitations in daily practice due to the
time needed for analysis. Pediatric Radiology - Monday Posters and Exhibits (12:45pm - 1:15pm) Monday, 12:45 PM - 01:15 PM • S101AB
Back to Top PD
CL-PDS-MOB • AMA PRA Category 1 Credit ™:0.5 CL-PDS-MO1B • MRI Resting State Studies in ADHD Infants and the Role of the Posterior Cingulate Cortex
Pilar Dies-Suarez MD (Presenter) ; Eduardo Barrragan ; Silvia Hidalgo ; Benito De Celis ; Manuel Obregon ; Porfirio Ibanez PURPOSE ADHD is a neurological disorder in children with prevalence�s circa 5%. This illness is considered to be in an 80% originated by genetic
factors. Most work on magnetic resonance resting states has been performed in Asia, Europe and North America,butlittle work
existsexclusively on theLatin genetic pool. Here we compared infantLatin ADHD patients with healthy ones.Wediscuss the differences with
previous studies that useddifferent genetic pools. METHOD AND MATERIALS 30 volunteers (8.4±2 years, both sexes) weredivided in two groups, healthy (H) and ADHA (AD). Volunteers laid in an MR scanner in
silence while 150 brain volumes covering the whole of the brain were acquired. Resting state analysis was performed using DPARSF
software. Low frequencies under 0.08 Hz were kept. Regions of homogeneous variance (ReHo) and amplitude of the low frequencies
(Alff)were calculated.Data was threshold at p RESULTS Figure 1A and 1Bpresent the results of a comparison of between H and AD patients(H>AD in green and AD>Hin red). H subjects
presented strong left lateralization (80% vs. 20% structures).AD patients presented a stronger right lateralization (55% vs. 45%). CONCLUSION AD patients had a larger predominance of right hemisphere activations over left in contrast tohealthy subjects. Previous work has
reported strong involvement of the brain stem and the anterior cingulate gyrus for AD patients compared to H which we did not find.Never
reported correlations with the frontal gyrus and the posterior cingulate cortex were found.Considering that similar analysis methods were
followedas in previous studies, we believe thatthe differencesshown arise by the different genetic origin of volunteers. CLINICAL RELEVANCE/APPLICATION provide to the clinical neurologist , the degree of injury in patients with TDH by image analysis resting state CL-PDS-MO2B • Multi Detector Computed Tomography (MDCT) Assessment of Tracheobronchomalacia (TBM) in Children: A
Comparison with Bronchoscopic Findings and the Severity of Air Trapping-A Preliminary Retrospective Study
Ambereen Ahmed MD, MSc (Presenter) ; Jim Carmicheal MBBS, FRCR PURPOSE The purpose of this project was to retrospectively compare MDCT with bronchoscopy to assess Tracheobronchomalacia by correlating the
site and degree of severity of air trapping with the extent of TBM. METHOD AND MATERIALS MATERIAL AND METHODS STUDY POPULATION
The retrospective cohort with TBM had 21 participants and control group 17 patients between the ages of (0-18 years). Rate and severity
of air trapping was assessed from end expiratory MDCT images using an established scoring system by two blinded paediatric
radiologists. MDCT airway diameter was defined, and percentage change in diameter between end-inspiration/end-expiration was
measured.The severity of air trapping between the groups was assessed by independent sample t-test. RECORDING OF DATA.
The data was recorded on Microsoft excel spread sheets.
STATISTICS ANALYSIS
Statistical analysis was performed using SPSS version 19.0 software.
� Agreement between MDCT and bronchoscopic measurements was assessed using Bland-Altman statistics.
� Correlations between MDCT airway diameter and air trapping score was obtained using Spearman Rank Correlation.
� A correlation between MDCT cross-sectional area and air trapping score was obtained using Spearman Rank.
� Correlation differences in measures between TBM patients and controls in group 2 without the TBM was assessed using Mann-Whitney
U test.
A p value of RESULTS Results: The demographics of TBM group and the control group were (13 males, 8 females) mean age 29 months and (12 males, 5
females) with the mean age of 33 months respectively. Differences in severity of total air trapping between the groups and the patterns of
air trapping between the two groups was not statistically significant (.78) and (P=.05) respectively. CONCLUSION Paediatric population with TBM does not incur a higher frequency and severity of air trapping opposed to the children without this
disease.The Retrospective nature of the study prevented us from controlling all the variables. Another drawback was there is no validated
classification for diagnosis of TBM.The symptomatic presentation of TBM is non -specific and could be easily missed on routine imaging
studies. CLINICAL RELEVANCE/APPLICATION (Dealing with MDCT ) 'Dynamic 64- MDCT is equal to Bronchoscopy in detecting TBM but superior in detecting a higher frequency and
severity of air trappings in children and is recommended. CL-PDS-MO3B • Patterns of Brain Morphological Changes in Children Patients with Type I Gaucher Disease
Huiying Kang (Presenter) ; Hua Cheng MD ; Bin Gu ; Gaolang Gong ; Yun Peng MD Page 120 of 397
Huiying Kang (Presenter) ; Hua Cheng MD ; Bin Gu ; Gaolang Gong ; Yun Peng MD PURPOSE Gaucher disease is the most prevalent inherited lysosomal storage disorder resulting from deficiency of the lysosomal enzyme
glucocerebrosidase. The overall incidence is approximately 1:40,000 individuals. Although classic type I gaucher disease (GDI) is defined
as non-neuropathologic involved, increasing clinical studies revealed that there are over 30% GDI patients suffering at least one
neurological symptom. Our current study aims to investigate if there are any significant morphological brain changes in GDI patients,
using voxel-based morphometry (VBM). METHOD AND MATERIALS 19 GDI children patients and 16 normal children were recruited in this study. All patients were evaluated by the severity scoring tool
(SST) to quantify the measurement scale about CNS involvement. All normal children had no history of neurological or psychiatric illness.
MR images were scanned using a 3T clinical scanner. Voxel-based morphometry of high-resolution T1-weighted MR images, processed
using VBM8 toolbox in SPM. To detect the group difference of GMV and WMV between GDI patients and controls, a general linear model
were applied to all voxels across the entire gray matter or white matter, after controlling for age, gender and whole brain volume.
Statistical significance was determined by a cluster extent threshold of p
RESULTS 9 of 19 patients show different degrees of the CNS involvement by the severity scoring tool (SST).When compared with healthy controls,
significant decrease of GMV in GDI patients was found in the right precentral gyrus and left parahippocampal gyri. In contrast, left
cerebellum showed a significant increase of WMV. No significant increase of GMV or significant decrease in WMV in GDI patients relative
to healthy controls.(supplementary Figure) CONCLUSION This preliminary study provides novel evidences for structural abnormalities in GDI patients, suggesting a necessity of adjusting the
opinion regarding the CNS-involvement of GDI. CLINICAL RELEVANCE/APPLICATION Our findings suggest that VBM analysis is a potential imaging marker in clinical studies of GDI. CL-PDS-MO5B • ADCratios Allow for Correct Preoperative Diagnosis of Common Pediatric Cerebellar Tumors with High Accuracy
Across Institutions
Nabila Choudhury MD (Presenter) ; Mahmud Mossa-Basha MD ; Song Zhang PhD ; Barjor Gimi PhD ; Ang Gao MS ; Lynn
Gargan PhD ; Daniel C Bowers MD ; Izlem Izbudak MD ; Korgun Koral MD PURPOSE To test the accuracy and applicability of decision rules utilizing ADCratios and age on the accurate preoperative diagnosis of common
pediatric cerebellar tumors across institutions. METHOD AND MATERIALS This study was performed at 2 institutions employing different MR scanners. There were 142 pediatric cerebellar tumors. At Site 1, a
blinded reviewer placed 3 ROIs on solid components of 98 tumors and normal brain (normal appearing cerebellum and thalamus) on ADC
maps. ADC ratios were calculated using umoral ADC mean and cerebellar ADC values. ROC analysis was performed to obtain useful
thresholds to discriminate pilocytic astrocytomas (PA), ependymomas and embryonal tumors (medulloblastomas and atypical teratoid
rhabdoid tumors [ATRT]). Utility of these thresholds were tested using ADCratios obtained from 44 pediatric cerebellar tumors at Site 2
where ADC measurements of the cerebellar tumors and normal brain were performed using the same method employed at Site 1. The
utility of age was tested to discriminate medulloblastomas from atypical teratoid/ rhabdoid tumors.
RESULTS ADC values of normal brain at Site 1 were significantly different from the ADC values obtained at Site 2. ADCmean of pilocytic
astrocytomas were different at Site 1 and Site 2; and ADC mean of embryonal tumors were different at Site and Site 2. The ADCratios were not significantly different for pilocytic astrocytomas, ependymomas and embryonal tumors at Site 1 and Site 2. ADC ratio of =1.7
was chosen to discriminate pilocytic astrocytomas. 51(91.43%) PAs were correctly diagnosed (32/35 at Site 1; 18/19 at Site 2). ADC ratio
of CONCLUSION ADCratios can be reliably used to discriminate common pediatric cerebellar tumors across institutions. Age 2 years is a highly accurate
discriminator among embryonal tumors. CLINICAL RELEVANCE/APPLICATION ADCratios can be reliably used to discriminate common pediatric cerebellar tumors across institutions and scanner. Age 2 years is a highly
accurate discriminator among embryonal tumors. CL-PDE-MO6B • State-of-the-Art MR Enterography in Pediatric Inflammatory Bowel Disease
Rakhee H Goel MD (Presenter) ; Ellen Park MD, MS ; Neil Vachhani MD ; Alex C Wu MD ; Unni K Udayasankar MD, FRCR PURPOSE/AIM Discuss role of state-of-the-art MR enterography (MRE) in pediatric inflammatory bowel disease (IBD) with emphasis on: 1. Newer
imaging techniques
2. Improving quality of MRE in the pediatric population
3. Imaging in decision making for diagnosis, management and assessing treatment effect
CONTENT ORGANIZATION Describe improved imaging techniques in pediatric IBD 3T vs 1.5T
Faster sequences
Optimal fat suppression: SPAIR
Diffusion weighted imaging
Motion correction algorithms
Routine use of glucagon
Post contrast subtraction imaging
Illustrate improved MRE findings of pediatric IBD with newer techniques with special emphasis on: Lesion detection
Differentiating active inflammatory process from chronic fibrotic disease
Guide therapy
Evaluate complications
Assess treatment effect
Provide an easy to use flow chart for evaluating children with IBD
SUMMARY MRE plays a key role in evaluation of children with IBD and has replaced CT as the primary imaging technique of choice. Technical
improvements as illustrated in this exhibit vastly enhance our ability to identify and characterize inflammatory process as well as
complications in pediatric IBD. Page 121 of 397
CL-PDE-MO7B • Algorithmic Approach to Pediatric Rheumatologic Emergencies
Erhan Akpinar MD ; Osman M Topcuoglu MD (Presenter) ; Nursun Ozcan ; Berna Sayan Oguz MD ; Mithat Haliloglu MD PURPOSE/AIM 1. To emphasize the diagnostic imaging findings of pediatric rheumatologic emergencies. 2. To identify the basic imaging clues for chronic
arthritis, connective tissue diseases and systemic vasculitis in pediatric age group. 3. To discuss the major complications of pediatric
rheumatic diseases with illustrative cases.
CONTENT ORGANIZATION 1. Epidemiology and overview of pediatric rheumatologic emergencies 2. Radiologic investigation of pediatric rheumatic diseases(X-ray,
CT, MRI) 3. Imaging algorithm and differential diagnosis in common emergencies in patient with rheumatic diseases:
a. The child with respiratory distress and renal failure
b. The child with pericardial tamponade
c. The febrile child with pancytopenia 4. Conclusion
SUMMARY The course of rheumatologic disease in pediatric age group and imaging findings have somewhat differences from adults. The three major
subgroup of disease will be discussed along with the X-ray, CT, and MR imaging findings. Emergency conditions such as acute respiratory
distress, acute thrombosis of main vascular structures and aneurysms that can be seen in the course of pediatric rheumatologic diseases
will be described with representative cases. Radiologist who read this exibit will be able to recognize basic clues of pediatric rheumatologic
disease and decide which condition is emergency. CL-PDE3026-MOB • Rediscovering Transthoracic Chest Ultrasonography in Children: Practicing Alara Principle
Marcelo A Rocha (Presenter) ; Yoshino T Sameshima MD ; Erika T Koshimura ; Eliane E Dutenhefner MD, BDS ; Martha
Hanemann Kim ; Flavia Faganello Gasparini ; Maysa d Ferreira BARCH ; Miguel J Francisco Neto MD ; Marcelo B Funari MD PURPOSE/AIM To illustrate normal/abnormal imaging patterns and several pleuropulmonary diseases in children through transthoracic chest
ultrasonography, and its correlation to other imaging methods;
To review in a simple and direct topic format important daily practice guidelines and imaging signs to perform state-of-the-art
transthoracic chest ultrasonography;
To emphasize the method's contribution to reducing ionizing radiation dose delivered to neonates and children (ALARA principle). CONTENT ORGANIZATION Presentation of the sonographic �pleuropulmonary lines�;
Sonographic patterns of pulmonary aeration;
Important signs in transthoracic chest ultrasonography;
Sonographic classification of pneumonia and pleural effusion;
Other applications of pediatric transthoracic chest ultrasonography.
SUMMARY Take home messages:
Normal and abnormal pulmonary aeration status can be evaluated by sonographic pulmonary patterns;
Fluid color sign finding gives high specificity in detecting small pleural effusions;
Sonographic classification of pneumonia based on color Doppler findings have high correlation with length of stay;
Transthoracic chest ultrasonography has a wide range of applicability, such as in complicated pneumonia follow-up instead of chest CT,
reducing the ionizing radiation exposure of pediatric patients respecting ALARA principle. Breast - Monday Posters and Exhibits (12:45pm -1:15pm) Monday, 12:45 PM - 01:15 PM • Lakeside Learning Center
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LL-BRS-MOB • AMA PRA Category 1 Credit ™:0.5 LL-BRS-MO2B • Ultrasound-guided Wire Localization of Mammary Duct Contour Change in the Workup and Treatment of
Pathologic Nipple Discharge
Benjamin Nulsen (Presenter) ; Christina Weltz MD ; Shabnam Jaffer MD ; Jolinda Mester MD PURPOSE To evaluate the role of ultrasound-guided needle localization of a mammary duct in patients who present with pathologic nipple discharge
(PND) and otherwise negative clinical and radiologic workup. METHOD AND MATERIALS A search of our radiology database of ultrasound-guided needle localizations from 2003-2013 was performed using the keywords �nipple
discharge� and �duct� in either the clinical history and/or radiology report. Any patient with a new positive mammogram or ultrasound
finding was excluded. All patients with PND underwent breast sonography with attention to the subareolar region of the symptomatic
breast. Those patients in whom a nondilated (< 3 mm) or dilated (> 3 mm) duct was identified in the region of PND subsequently
underwent ultrasound guided preoperative needle localization using a 12-5 MHz linear array transducer and a 3 or 5 cm Kopans
needle-wire system. The mammographic and sonographic images were reviewed and correlated with the histopathologic findings. RESULTS Twenty-six cases in 25 patients referred for breast sonography for evaluation of PND met the inclusion criteria. The median age of the
patients was 56 (range 31-80). All patients had mammograms with findings that were either negative (BI-RADS 1) or stable benign
findings (BI-RADS 2). A single nondilated or dilated duct was identified at the site of PND in 22/26 cases. No intraductal mass was
appreciated in any of these cases. Needle localization of the nondilated/dilated duct was successfully performed in the 22 cases in which a
single target for localization was identified. The histopathologic results included papilloma (14), cancer (5), ADH (2) and no lesion (1). CONCLUSION The results of our series suggest that ultrasound-guided needle localization of either a nondilated or dilated duct identified in the region of
PND can help guide the breast surgeon to the location of an intraductal lesion that is otherwise occult on both mammography and
sonography. This approach may serve as an alternative to galactography and conventional �blind� ductal excision. In our study,
imaging occult papilloma was found in 14/22 (63 %) and cancer in 5/22 (23%) of the patients. CLINICAL RELEVANCE/APPLICATION Ultrasound-guided localization of ductal changes provides a reliable alternative to techniques such as galactography and blind ductal
excision in the workup and treatment of imaging occult PND. LL-BRS-MO3B • 2D and 3D Contrast Ultrasonography of Breast Lesions: Quantitative and Morphological Vascular Analysis
Tomoyuki Ohta (Presenter) ; Norio Nakata MD ; Yukio Miyamoto MD ; Kunihiko Fukuda MD Page 122 of 397
PURPOSE The purpose of this study was to evaluate the diagnostic value of quantitative analysis and vascular morphology of benign and malignant
breast mass lesions using 2D and 3D contrast-enhanced ultrasonography (CEUS). METHOD AND MATERIALS CEUS using perflubutane-based contrast agent (Sonazoid) were performed in 65 pathologically proved palpable breast mass lesions of 63
patients, which were able to depict with B-mode ultrasonography (US). The ultrasound equipments were GE LOGIQ7 and LOGIQ E9 with
the linear transducer. CEUS movies in the vascular phase from 0 sec to 50 sec were recorded. The microvascular morphologic and
distribution features of breast mass lesions were evaluated with micro flow imaging (MFI). Retrospective quantitative analyses using the
time-signal intensity curve (TIC) of CEUS breast lesions were performed in all lesions. Kinetic curves acquired in the first 50 s after the
appearance of contrast, were used for statistical analysis. In addition, the wash-in and wash-out patterns of the contrast agent were
evaluated by quantitative assessment. In 18 breast lesions, sequential multiphase sweep scans (10-15 sec per sweep) of contrast 2D US
images were obtained and 3D images were reconstructed by those manual sensorless parallel CEUS images. RESULTS Surgical pathologic analysis showed 19 benign and 46malignant lesions. A significant difference was found between the benign and
malignant lesions in time-to-peak (P CONCLUSION CEUS is useful in the evaluation of breast mass lesions including benign and malignant tumors. CLINICAL RELEVANCE/APPLICATION CEUS has a great potential to play role of a bridge between conventional B-mode US and MRI in diagnostic breast imaging. LL-BRS-MO4B • Evaluation of Tumor Response to Neoadjuvant Chemotherapy by Diffusion Weighted Imaging (DWI): Do the
Biological Characteristics of Breast Cancer Influence Its Assessment?
Laura Martincich MD (Presenter) * ; Silvia Carabalona MD ; Rita Giada Spinelli MD ; Valentina Rossi ; Filippo Montemurro
MD ; Daniele Regge MD PURPOSE To evaluate if biological characterics of breast cancer influence the response to neoadjuvant chemotherapy (NCT) assessed by DWI. METHOD AND MATERIALS 64 patients with locally advanced breast cancer (stage II with T>3 cm or IIIA/B/C) were treated by taxane-based NCT. DWI was
performed before, during (after 2 cycles) and after NCT using 1.5T magnet and 8-channel coil (EPI sequence; b-value 0/900 s/mm2; slice
thickness 4mm; acquisition time 80s). Apparent Diffusion Coefficient (ADC) value was calculated by tracing a region of interest within the
lesion. Responders were defined as subjects achieving pathological complete response (absence of invasive cancer cells) after NCT. ADC
value before, during and after NCT was correlated with pathological response, also considering the tumor biological characteristics
(steroid receptor and HER2 status). RESULTS CONCLUSION DWI is a promising tool to assess the tumor response to NCT. Hovewer, tumor biological characteristics influence the ADC value in both
Responders and Non-Responders. These differences should be taken into account for a reliable clinical application of DWI (e.g. definition
of ADC threshold value) in monitoring the response to primary medical treatments. CLINICAL RELEVANCE/APPLICATION ADC of breast cancer differs on the basis of tumor biological characteristics. This aspect should be considered for a reliable clinical
application of DWI (e.g. definition of ADC threshold value) in monitoring the response to NCT. LL-BRS-MO5B • Predicting Tumor Aggressiveness with Breast MRI: Role of Quantitative Diffusion-weighted Imaging (DWI)
Giulia Cristel MD (Presenter) ; Elena Schiani MD ; Claudio Losio MD ; Mariagrazia Rodighiero MD ; Francesco A De Cobelli MD
; Alessandro Del Maschio MD PURPOSE The aim of our study was to assess whether or not apparent diffusion coefficient (ADC) can be used as a prognostic factor in the
pre-operative setting by evaluating the relationship between the ADC values provided by diffusion-weighted imaging (DWI) and the
histopathological features of MRI-detected malignant lesions. METHOD AND MATERIALS One-hundred-and-twenty-two patients with breast cancer underwent pre-operative breast MRI at 1.5 T. The protocol included T2-TSE
sequences, DWI (b-values: 0 and 900 s/mm2) and dynamic study. For each malignant lesion, the ADC value was quantified and
compared with histological type, grade and receptor expression (oestrogen receptor [ER], progestin receptor [PgR], Ki-67, HER-2). Based
on these features, the lesions were classified as Luminal-A (LumA), Luminal-B (LumB), HER2-enriched (HER2) and triple-negative (TN).
Correlations were analyzed using the Mann-Whitney U and Kruskal-Wallis H tests. RESULTS MRI detected 178 malignant lesions, confirmed by histological analysis (18 in situ, 160 invasive carcinomas). The mean ADC value was
significantly lower for invasive than in situ (IS) carcinomas (0.94x10-3mm2/s vs 1.15x10-3mm2/s, p CONCLUSION Our study demonstrated that, despite some overlap of ADC values among different
cancer subtypes, ADC could be a promising prognostic quantitative parameter inversely associated with histopathological factors.
CLINICAL RELEVANCE/APPLICATION Quantitative Diffusion Weighted Imaging is concordant with biological aggressiveness of breast cancer and could be an additional
prognostic predictor. LL-BRS-MO6B • Value of Additional Digital Breast Tomosynthesis Combined with Digital Mammography in a Diagnostic Setting
Mirinae Seo MD (Presenter) ; Jung Min Chang MD ; Sun Ah Kim MD ; Jihe Lim MD ; Won Hwa Kim MD, MS ; Su Hyun Lee MD
; Hye Ryoung Koo MD ; Min Sun Bae MD, PhD ; Nariya Cho MD ; Woo Kyung Moon PURPOSE To assess the value of adding digital breast tomosynthesis (DBT) to digital mammography (DM) in a diagnostic workup and to compare
abilities to detect breast cancer. METHOD AND MATERIALS RESULTS In the pooled receiver operating characteristic (ROC) analysis, the average AUC for combined DBT and DM was 0.812, significantly higher
than that of DBT alone (0.788), and DM alone (0.748), (P 0.05). Among 129 cancers detected, 50 cancers were detected on the combined
studies by at least one reader that was missed on DM alone (39 invasive cancers and 11 ductal carcinomas in situ [DCIS]). Multivariate
analysis revealed that microcalcifications (odds ratio 17.1) and architectural distortion (odds ratio 12.2) were significantly associated with
cancer detection rate, and detection of invasive cancer was more frequent than that of DCIS (odds ratio 6.4). Page 123 of 397
CONCLUSION Combined interpretation of DBT and DM showed the best diagnostic performance in diagnostic workup, and the addition of DBT to DM
increases cancer detection without decreasing the specificity. Cancer detection rate was correlated with image findings and histology in
combined studies. CLINICAL RELEVANCE/APPLICATION Adding DBT to DM improved diagnostic performance in a diagnostic setting. Invasive cancers, lesions with microcalcifications or
architectural distortion were more easily detected by the combined study LL-BRE-MO7B • Papillary Lesions of the Breast: Classification, Imaging Aspects and Management
Fabiola P Kestelman MD (Presenter) ; Clara F Gomes MD ; Fernanda B Fontes ; Carolina D Conti MD ; Marcia Jazbik ; Fernanda A Cavallieri MD ; Suzana A Cavallieri MD PURPOSE/AIM The purpose of this exhibit is: (1) to define histopathologic classification of papillary lesions, (2) to review de spectrum of findings on
breast imaging modalities and (3) to discuss the management after percutaneous diagnosis. CONTENT ORGANIZATION 1) Review the pathologic classification of papillary lesions of the breast according to WHO: a) Intraductal papilloma: central, peripheral,
atypical papillomas b) Intraductal papillary carcinoma: intracystic papillary carcinoma, papillary intraductal carcinoma c) Invasive
papillary carcinoma 2) Pictorial examples of imaging findings in ultrasound, mammography and MRI. 3) Review the literature and discuss
the management of nonmalignant papillary lesion diagnosis in percutaneous biopsy. SUMMARY The appearance of papillary lesions of the breast vary clinically, radiologically, and pathologically. There is a wide spectrum of
appearances on imaging, and differentiation of benign from malignant pathologies may be difficult. Tissue sampling is usually necessary.
Clinical management on nonmalignant breast papillary lesion diagnosed at percutaneous biopsy is controversial. Literature recommend
that atypical papillary lesions undergo surgical excision, although some studies recommend following patients with benign lesions with
serial imaging. LL-BRE-MO8B • MRI to the Rescue: Unusual Lesions of the Breast, MRI Features with Mammography, Ultrasonography and
Histopathology Correlation
Seema Sud MBBS (Presenter) ; Tarvinder B Buxi MD ; Samarjit S Ghuman MBBS, MD ; Ruhani Doda MBBS ; Aditi Sud PURPOSE/AIM 1) To illustrate the technique of performing and analyzing MRI of the breast 2) To depict the imaging findings of rare lesions of the breast
on MRI correlated with ultrasonography,mammography and histopathology. 3) Provide clues to arriving at the correct diagnosis on MRI CONTENT ORGANIZATION 1) Breast MRI equipment, sequences and parameters and importance of diffusion weighted imaging 2) Case based reviews of unusual
lesions of the breast with mammography, ultrasonography and histopathology correlation - Benign Virginal Hyperplasia
Sarcoidosis
Tubercular Mastitis
Focal adenosis
Paget�s disease of the nipple
Ductal ectasia with periductal mastitis and papillomatosis in male breast Intraductal Papillomas with Gynaecomastia and invasive carcinoma in male breast
Fat necrosis
Fibroadenolipoma
Benign and malignant phyllodes tumor
Inflammatory breast carcinoma
Colloid carcinoma
Medullary carcinoma
Invasive carcinoma with central necrosis
Lobular carcinoma
Fibroadenomatoid hyperplasia.
3) Pearls and pitfalls SUMMARY The major teaching points of this exhibit are: A wide variety of unusual pathological conditions may be seen in the breast
Breast MRI is a powerful tool which can resolve the diagnostic dilemma in many of these cases
Cardiac - Monday Posters and Exhibits (12:45pm - 1:15pm) Monday, 12:45 PM - 01:15 PM • Lakeside Learning Center
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LL-CAS-MOB • AMA PRA Category 1 Credit ™:0.5 LL-CAS-MO1B • The Combination of Lower Concentration Contrast Agent with 80 kVp in Coronary Computed Tomography
Angiography (CCTA)
Qian Li MSc (Presenter) ; Guan Hanxiong MD PURPOSE To study the clinical value of combining flow concentration contrast agent (iodixanol 270 mgI/ml) with 80 kVp in coronary computed
tomography angiography (CCTA). METHOD AND MATERIALS 60 patients were randomly divided into 2 groups to take CCTA examinations on a GE Discovery CT750 HD scanner with prospective
ECG-triggered axial scans. Half patients for group A (iodixanol 270 mgI/ml) underwent 80kVp scan with 50% ASiR reconstruction and the
other half for group B (iodixanol 370mgI/ml) underwent 120kVp scan and regular FBP reconstruction. The rest scan parameters were the
same and the total contrast dose was at 0.9 ml/kg and was injected at 5 ml/s rate for both groups. Image slice thickness was 0.625 mm.
CT value in the ostium of left coronary artery, and the CT value and SD value of subcutaneous fat tissue were measured.
Contrast-noise-ratio (CNR) of the aorta was calculated and compared between the two groups using statistical method. Radiation dose
(dose-length-product, DLP) was recorded. Page 124 of 397
RESULTS The mean CT value of the ostium of left coronary artery for group A (511.99±33.24 HU) was statistically higher than that of for group B
(395.71±22.93 HU), ( p 0.05). It was statistically lower for the radiation dose in group A (437 .38 ± 80.14 mGy*cm) than group B
(1151.12 ± 123.07 mGy*cm) ,(p CONCLUSION The combination of lower concentration of contrast agent with 80 kVp used in coronary CTA provided similar image quality with 27%
contrast dose reduction and and up to 62% lower radiation dose reduction compared to conventional CCTA. CLINICAL RELEVANCE/APPLICATION The combination of lower concentration of contrast agent with 80 kVp used in coronary CTA provided similar image quality with 27%
contrast dose reduction and and up to 62% lower radiation dose reduct LL-CAS-MO2B • Relationship between Impaired Cardiac Sympathetic Activity and Spatial Dyssynchrony in Patients with
Nonischemic Heart Failure: Assessment by MIBG Scintigraphy and Tagged MRI
Masato Yonezawa (Presenter) ; Michinobu Nagao MD * ; Yoshio Matsuo ; Satoshi Kawanami MD * ; Shingo Baba ; Takeshi
Kamitani MD ; Takuro Isoda ; Mikako Jinnouchi MD ; Yasuhiro Maruoka ; Yuzo Yamasaki MD ; Kohtaro Abe ; Taiki Higo ; Takashi Yoshiura MD, PhD ; Hiroshi Honda MD PURPOSE MIBG imaging has been widely used for the assessment of cardiac sympathetic function in heart failure (HF), and it was reported that
impaired cardiac adrenergic innervation as assessed by MIBG imaging was closely associated with mortality in patients with HF. Left
ventricular (LV) dyssynchrony is present in more than 25% of patients with HF and has been associated with a poor prognosis. Our
purpose was to investigate the relationship between LV dyssynchrony and cardiac sympathetic activity in non-ischemic HF. METHOD AND MATERIALS Twenty-seven patients with non-ischemic HF were enrolled. Cardiac sympathetic activity was assessed by heart-to-mediastinum ratio
(H/M ratio) on 123I-MIBG scintigraphy. LV dyssynchorony was assessed by cross-correlation analysis of time-curves of myocardial
circumferential strains delivered from cine-tagging MR images. Temporal dyssynchrony was defined as contraction delay between septal
and lateral segments > 110 msec. Spatial dyssynchrony was defined as the negative value of the maximum correlation for the two strain
time-curves. RESULTS H/M ratio was significantly lower for patients with spatial dyssynchrony compared to patients without (1.8±0.3 vs. 2.1±0.3, p CONCLUSION Impairment of cardiac sympathetic activity was found to be associated with spatial dyssynchrony in patients with non-ischemic HF. CLINICAL RELEVANCE/APPLICATION Evaluation of both LV dyssynchrony and cardiac sympathetic function provide information regarding the treatment strategy such as
beta-blocker or cardiac resynchronization therapy in HF patients. LL-CAS-MO3B • Association between Left Atrial Function from Cine MRI by Multimodality Tissue Tracking and Diffuse Left
Ventricular Myocardial Fibrosis by T1 Mapping in the Multi-Ethnic Study of Atherosclerosis (MESA)
Masamichi Imai (Presenter) ; Bharath Venkatesh ; Sanaz Samiei ; Sirisha Donekal ; Mohammadali Habibi MD ; Anderson
Armstrong ; Susan Heckbert ; Colin Wu ; David A Bluemke MD, PhD * ; Joao A Lima MD * PURPOSE The purpose of study is to explore the association between left atrial (LA) function and diffuse left ventricular (LV) myocardial fibrosis
with cardiac magnetic resonance (CMR). METHOD AND MATERIALS Of 1346 participants that had T1 mapping, 108 had of myocardial scar (detected by late gadolinium enhancement in the LV). Age,
gender, and ethnicity matched controls (n = 207) without myocardial scar were chosen from the same population. Multimodality tissue
tracking (MTT) was leveraged to analyze LA with 2- and 4-chamber long-axis cine CMR images (SSFP, Siemens 1.5 T scanner), and
assessed maximal indexed LA volume (LAVi), LA ejection fraction (LAEF), maximal LA strain (Smax), LA strain rate at maximum (SRmax)
and LA strain at early ventricular-diastolic peak (SR
E). T1 mapping was performed at mid-ventricle of LV using Modified Look Locker
Inversion Recovery (MOLLI) sequence before and (12 and 25 minutes) after contrast administration. The association between LA
parameters and pre- and post-contrast T1 times was assessed by Pearson�s correlation and multivariable linear regression adjusted for
age, gender, ethnicity, and presence of scar. RESULTS The participants were of average age 71 ± 9 years, 87% male, and 57% Caucasian, 26% African-American, 10% Hispanic, and 7%
Chinese. Lower 12� post-contrast T1 was associated with lower LAEF (r = 0.23, p < .001), Smax (r = 0.23, p < .001), and SRmax (r =
0.25, p < .001) and higher SRE (r = -0.21, p < .001) by Pearson�s correlation. Lower 25� post-contrast T1 had the same tendency, but
it was also associated with higher LAVi (r = -0.12, p = .034). SRmax remained significantly associated with post-contrast T1 times after
adjustment for all covariates. The association between T1 times and SRmax remained significant when analysis was performed only on
the control group. CONCLUSION In the MESA population, lower post-contrast T1 times were associated with higher LA volume, lower LAEF, lower strain, and lower
absolute value of strain rate. Lower LA function was associated with increased fibrosis as assessed by lower post-contrast T1 times
irrespective of the presence of myocardial scar. CLINICAL RELEVANCE/APPLICATION LA function from CMR is an important indicator of effect of fibrosis of the left ventricle. LL-CAS-MO4B • Assessing Image Quality and Radiation Dose of Cardiac Computed Tomography Angiography Using a 320-Row
Detector with Adaptive Iterative Dose Reduction 3D
David Tso MD (Presenter) ; Andrew Van Der Westhuizen MD ; Patrick McLaughlin FFRRCSI ; Darra T Murphy FFRRCSI ; John
R Mayo MD * ; Savvas Nicolaou MD PURPOSE The purpose of this study was to compare image quality and radiation dose of Cardiac CT angiography (CCTA) utilizing iterative
reconstruction technology compared to CCTA utilizing standard filtered back projections (FBP). METHOD AND MATERIALS This is a retrospective review of 59 consecutive patients scanned with the Toshiba Aquilion ONE 320-slice MDCT scanner using a low-dose
CCTA protocol with iterative reconstruction (Adaptive Iterative Dose Reduction 3D or AIDR 3D) who were compared with 60 consecutive
patients scanned using our institution standard CCTA protocol with FBP. The two cohorts were compared with respects to effective
radiation dose, as well as signal and noise measurements of cardiac vascular structures. Qualitative image quality of cardiac anatomy was
assessed using a 4-point scale (3-clear, 2-minor motion, 1-significant motion, 0-non-diagnostic). RESULTS There was no significant difference between the two cohorts with respect to age, BMI, and AP and lateral measurements. No significant
Page 125 of 397
difference in signal or noise measurements of the aorta and coronary arteries were appreciated. There was a 58% reduction in the mean
effective radiation dose between the FBP and AIDR 3D cohorts (4.66 mSv vs. 1.97 mSv; p < 0.0001). Although there was a reduction in
signal-to-noise ratio between FBP and AIDR 3D (32.03 vs. 25.94; p=0.012) and contrast-to-noise ratios (29.13 vs. 24.20; p=0.03),
there was a statistically significant improvement in qualitative image quality of cardiac anatomy in the AIDR 3D group (2.06 vs. 2.44; p
CONCLUSION AIDR 3D is a technology which uses iterative reconstruction in both raw and image data space to provide better qualitative image quality
while allowing CCTA to be conducted at significantly less radiation dose than traditional methods utilizing FBP. CLINICAL RELEVANCE/APPLICATION AIDR 3D uses iterative reconstruction to provide better qualitative image quality while allowing CCTA to be conducted at significantly less
radiation dose than traditional methods utilizing FBP. LL-CAS-MO5B • Percutaneous Pulmonary Valve Implantation: Long-term Follow-up with Cardiac Magnetic Resonance
Elda Chiara Resta ; Francesco Secchi MD (Presenter) ; Paola Maria Cannao ; Giovanni Di Leo ; Mario Carminati MD ; Francesco Sardanelli MD * PURPOSE To evaluate the diagnostic value of Cardiac Magnetic Resonance (CMR) before and after percutaneous pulmonary valve (Melody,
Medtronic) implantation (PPVI). METHOD AND MATERIALS After IRB approval and informed consent, patients with congenital heart diseases and pulmonary conduit dysfunction were prospectively
scheduled for 1.5-T CMR before and after 36 and 48 months from PPVI. We used a cine true-FISP sequence (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 test was used. RESULTS From January 2008 to January 2013, we enrolled 36 patients (21±8 years old), all of them studied within one week before valve
implantation and 10 of them studied after 36 months from PPVI and 6 after 48 months. One patient was excluded from the study after
surgical implantation of Elan conduit. End-diastolic volume index (EDVI), end-systolic volume index (ESVI), and ejection fraction (EF) of
the RV before PPVI were 83±38 mL/m², 44±34 mL/m², and 50±13%, the same data after 36 months were 72±19 mL/m² (P=.241),
33±15 mL/m² (P=.028), and 56±10% (P=.047), respectively; the same data after 48 months were 67±17 mL/m² (P=.916), 26±15
mL/m² (P=.042), and 62±12% (P=.027), respectively. EDVI, ESVI, and EF of LV before valve implantation were 67±17 mL/m², 30±13
mL/m², and 56±9 %, respectively, the same data after 36 months were 78±19 mL/m² (P=.333), 34±11 mL/m² (P=.475), and 57±7%
(P=.085); the same data after 48 months were 79±20 mL/m² (P=.345), 35±11 mL/m² (P=.599), and 58±7% (P=.116). CONCLUSION Four years after PPVI, we observed a significant improvement of RV EF and ESVI. A borderline significant change was observed for the left
ventricle systolic function. CLINICAL RELEVANCE/APPLICATION CMR can be used for a comprehensive noninvasive long-term follow-up after percutaneous pulmonary valve implantation. LL-CAS-MO6B • Preliminary Study of 80 kVp on Coronary CT Angiography with 300 mg I/ml Iodixanol with Iterative
Reconstruction
Rui Wang PhD (Presenter) ; He Wang MD ; Baocui Zhang ; Xiaoying Wang MD PURPOSE To evaluate the feasibility of 80 kVp and 300 mg I/ml iodixanol in coronary CT angiography (CTA) with 64-slice CT scanner, by using
iterative reconstruction. METHOD AND MATERIALS Totally 25 patients(16 men, 9 women, BMI 20-25) were recruited with clinical indication of coronary CTA in this perspective study, with
permission of ethical committee. All the patients underwent coronary CTA with prospective ECG-gated protocols, with following
parameters: 80 kVp, automatic mA and 30% adaptive statistical iterative reconstruction (ASiR). All the patients were injected 60ml
iodixanol 300 mg I/ml, with flow rate of 5ml/s and 30ml normal saline flush. Dose report was recorded in each patient. Two experienced
radiologists evaluated the CT images. The coronary artery was divided into 16 segments to subjectively evaluate the image quality,
including aorta, LM, LAD (proximal, middle and distal), D1, D2, LCX (proximal, middle and distal), OM, RCA (proximal, middle and distal),
PDA, PL, AM. The image quality was scaled as score 1 to 5, which was defined as poor, adequate, good, very good and excellent image
quality, respectively. Intravascular CT value was measured of each segment. The ROI, larger than half of lumen, was placed in the center
of vessel lumen. The data from segment which lumen diameter less than 2mm was excluded. RESULTS The BMI was 22.29±1.15 in average. The average radiation dose were as following: CTDIvol 7.87±0.49 mGy, SSDE 10.53±1.13 mGy,
and ED 1.66±0.27 mSv, respectively. Eleven segments were excluded. For the 389 segments, the maximum intravascular CT value was
606.20±114.10 HU in aorta, while the minimum CT value was 489.14±144.86 HU in D2. For subjective evaluation, 343 were scored 5, 34
were scored 4, 12 were scored 3. No segment was scored less than 3. CONCLUSION CLINICAL RELEVANCE/APPLICATION With image noise reduction by iterative reconstruction, low kVp image can be applied. CT value of iodine was higher in low kVp image,
which means we can try to use less idione in CT vascular imaging. LL-CAS-MO7B • Clinical Correlation of Left Atrial Systolic and Diastolic Functions Evaluated by Cine-MRI and Invasive Monitoring
of Left Atrial Pressure
Irfan M Khurram MD (Presenter) ; Farhan Maqbool MBBS ; Roy Beinart MD ; Hugh Calkins ; Saman Nazarian MD * ; Stefan L
Zimmerman MD PURPOSE Atrial fibrillation (AF) is associated with significant abnormalities of left atria (LA) systolic and diastolic functions. The LA diastolic
functions are routinely estimated with 2-D speckled tracking echocardiography with its own limitaions. This study describes a MRI based
volume measures along with invasive left atrial pressure tracing to accurately estimate extent of LA diastolic and systolic functions. METHOD AND MATERIALS A total of 55 AF patients (55% paroxysmal, 45% persistent) undergoing AF ablation were enrolled after IRB approved consent. Cine-MRI
was obtained in sinus rhythm before the ablation procedure. Left atrial pressures were acquired following trans-septal puncture prior to
applying ablation lesions. Patients, if not in sinus rhythm, were cardioverted at the start of the procedure for accurate pressure
measurements. Atrial pressure and volume loops were prepared for all patients. LA diastolic function was estimated by the slop of the
passive LA filling curve and was quantified by creating diastolic dysfunction score defined by the ratio of change of LA pressure to volume
during passive filling of LA (?P/?V). RESULTS The study population included 81% male, age 60.4±10.2 years, and mean CHADS2 score of 0.9±1. The mean diastolic dysfunction score
Page 126 of 397
for AF patients was 0.76±0.7 mmHg/ml (paroxysmal AF 0.60±0.5 and persistent AF 1.0±0.9; p-value 0.02). Linear regression analysis
showed rise in diastolic dysfunction score with age with increase of 0.02 per year (p-value 0.03). The diastolic score appeared to have
trend in patients undergoing multiple ablations for AF (first ablation patient 0.65±0.6 vs. repeat ablation patients 1.0±0.8; p-value 0.06).
Left atrial active emptying fraction was found to be 13.7±9.3% (paroxysmal 15.5±9.8% vs. Persistent 11.5±8.2%; p-value - NS).
Regression analysis showed linear relationship between LA diastolic score and active LA emptying fraction (R-squared=0.197; p-value
0.001). CONCLUSION Left atrial diastolic functions appear to get worse in persistent AF and is increasing age. It is also shown a trend towards higher
dysfunction score with repeat AF ablations. LA diastolic and systolic functions appear to follow the same trend in atrial fibrillation patients. CLINICAL RELEVANCE/APPLICATION Cine-MRI based volume data can be combined with invasive pressure data to obtain true left atrial diastolic and systolic functions. LL-CAS-MO8B • Detecting Diffuse Myocardial Fibrosis in Cardiomyopathy: Quantification of CT Extracellular Volume Fraction
Songtao Liu MD (Presenter) ; Karl H Schuleri MD ; Mark A Ahlman MD ; Samuel Won ; Cynthia Davies-Venn ; Fabio Raman
BS ; Marcus Y Chen MD ; John Schuzer ; Jing Han ; Christopher Sibley ; Yixun Liu ; Jianhua Yao PhD * ; Ronald M
Summers MD, PhD * ; Christopher Baines ; Albert C Lardo ; Craig Emter ; David A Bluemke MD, PhD * PURPOSE Diffuse myocardial fibrosis (DMF) is present in a variety of cardiomyopathies and heart failure. DMF is associated with increased
extracellular volume fraction (ECV) on gadolinium MRI studies. The aim of this study was to evaluate CT ECV quantification for the
detection of DMF in a swine model of compensated heart failure. METHOD AND MATERIALS RESULTS 70% reduction in ascending aortic area was achieved in the HF and HF-CsA groups. There was reduced ejection fraction in the HF-CsA
group (47%), but not in the control (54%) or HF groups (56%, p=NS). The HF-CsA group was characterized by increased end diastolic
volume (HF-CsA:80ml, CON:70ml, HF:56ml, p=0.04), increased end systolic volume (HF-CsA:43ml, CON:32ml, HF-CsA:24ml, p CONCLUSION CT with delayed scanning for calculation of extracellular volume fraction was able to detect altered myocardial composition in a large
animal model of heart failure and diffuse myocardial fibrosis. CLINICAL RELEVANCE/APPLICATION CT Extracellular Volume Fraction (CTECV) quantification has the potential to be a non-invasive imaging biomarker for diffuse myocardial
fibrosis. LL-CAE-MO9B • Multi-detector CT Coronary Angiographic Findings of Coronary-to-Pulmonary Artery Fistula
Jiyeon Lim (Presenter) ; Eun-Ah Park MD ; Jae Hyung Park MD ; Whal Lee MD, PhD ; Jin Wook Chung MD * PURPOSE To evaluate the multi-detector CT (MDCT) coronary angiographic findings of coronary-to-pulmonary artery fistula (CPAF). METHOD AND MATERIALS We retrospectively reviewed cases of CPAF from our coronary CT angiography (CCTA) database between January 2008 and December
2010. All CCTA examinations were performed with a 64-channel MDCT or DSCT. We analyzed the MDCT coronary angiographic findings for
the number and origin of feeding arteries, number, size and location of draining fistulous openings, association with peripulmonary
arterial aneurysms, and the presence of CPAF communication with bronchial arteries. RESULTS Among the 15,042 patients who underwent CCTA examinations during the selected period, a total of 55 patients (0.37%) were diagnosed
with CPAF on the basis of CCTA findings. The feeding artery was single in 19 patients and multiple in 36 patients. The feeding arterial
branch originated from the conal (n=40), left anterior descending (n=40), left main (n=14), and diagonal branches (n=3). The draining
fistulous opening was single in 54 cases and multiple in 1 case, located mostly in the anterior sinus of the main pulmonary artery (MPA,
n=54) except in one case (anterior-left sinus junction). The mean diameter of fistulous openings was 2.7 ± 1.4mm. Peripulmonary arterial
aneurysms were aneurysmal dilatations of 3-6 mm in 17 cases (31 %) and saccular aneurysms = 6 mm in diameter (mean 10.3 ± 7.3
mm, range 6.2~26.0 mm) in 7 cases (13%). CPAF communication with bronchial arteries was present in 9 cases (diameter 3.5 ± 2.2
mm). CONCLUSION The frequency of CPAF observed at MDCT coronary angiography examinations seems to be more common (0.37%) than previously
reported (0.002%). MDCT coronary angiography may provide more comprehensive and detailed findings of CPAF potentially replacing
diagnostic coronary angiography. CLINICAL RELEVANCE/APPLICATION Detailed MDCT coronary angiographic findings of CPAF can provide understanding of embryologic development and help determine
surgical or interventional management strategy for this condition. Chest - Monday Posters and Exhibits (12:45pm - 1:15pm) Monday, 12:45 PM - 01:15 PM • Lakeside Learning Center
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LL-CHS-MOB • AMA PRA Category 1 Credit ™:0.5 LL-CHS-MO1B • Pulmonary Abnormal Perfusion Detection Using the Iodine and Air Distributions in Spectral CT Imaging
Yu M Meng MD (Presenter) ; Wang Dan MD ; Bai X Dong ; Shen Baozhong MD, PhD PURPOSE To explore the feasibility of evaluating pulmonary perfusion disorders with different pathological changes using the distributions of iodine
and air in spectral CT. METHOD AND MATERIALS 47 patients underwent spectral CT pulmonary angiography (CTPA) imaging on GE Discovery CT750HD scanner. Lung window and Min IP
were used to evaluate the air content in pulmonary tissue. Combined iodine-based material decomposition images and monochromatic
CTPA images were used to detect the abnormal perfusion location, types and to measure iodine content.Based on the data to analyze the
morphology and aeration in abnormal lung parenchyma. RESULTS 18 patients with no pulmonary embolism (PE)on CTPA had even iodine distribution for the left and right parts of the lung parenchyma
(P>0.05), and homogeneous air distribution in Min IP. The iodine contents (IC, in mg/ml) in posterior, mediastinum, bilateral for the lung
Page 127 of 397
(P>0.05), and homogeneous air distribution in Min IP. The iodine contents (IC, in mg/ml) in posterior, mediastinum, bilateral for the lung
parenchyma were 1.03, 1.30, and 1.52, presenting gradient distribution from ventral to dorsal. In 12 patients with PE, a total of 186
emboli (56 occlusive and 130 non-occlusive) were found. 92 in 130 showed reduced perfusion(IC,0.62).The air content presented no
obvious increment. Perfusion exhibited noticeable reduction in all occlusive clots, (IC,0.13). The air content increased in Min IP(Figure 1).
7 patients with pulmonary infection with 4 ground-glass opacification cases (IC,2.56) and 3 consolidation cases (IC,3.84). Reduced
aeration was seen on the Min IP in the areas of hyper-perfusion. The iodine showed diffuse perfusion defect in 6 patients with pulmonary
hypertension but normal CTPA. A marked reduction of the pulmonary parenchyma density of 0.48mg/ml and corresponded to increased
content of air. In 2 cases of diffuse emphysema, the IC is 0.20. Markedly reduced density in the Min IP matched the areas with reduction
of perfusion in the iodine maps. In 2 cases of Interstitial fibrosis, reduced perfusion (IC,-0.07) of the pulmonary parenchyma was found in
both cases together with reduced aeration in Min IP(Figure 2). CONCLUSION Spectral CT Imaging is able to quantitative measure the content of iodine and the distribution of gas in lungs with different pathological
changes, which can be used as a new effective way to detect the pulmonary blood flow / ventilation changes. CLINICAL RELEVANCE/APPLICATION lung perfusion with Spectral CT can be evaluated under different pathological conditions, changes in lung function. LL-CHS-MO2B • Individually Optimized Uniform Enhancement in CT Angiography for the Diagnosis of Pulmonary Thromboembolic
Disease-A Simulation Study
Ming Xue (Presenter) ; Hao H Zhang ; Seth J Kligerman MD * ; Paul Klahr PhD * ; Warren D D'Souza PhD ; Wei Lu PURPOSE To improve the diagnostic quality of CT angiography (CTPA) for pulmonary thromboembolic disease by individually optimizing a bi-phasic
contrast injection function to achieve targeted uniform contrast enhancement. To compare the results against a previously reported
discrete Fourier transform (DFT) approach in a simulation study. METHOD AND MATERIALS This study uses a retrospective dataset of 27 consecutive patients. We developed an optimization approach consists of two steps: 1.
Compute the impulse enhancement function (IEF) based on the test bolus scan; 2. Optimize the contrast injection function using the IEF
in order to achieve uniform target enhancement. We chose a bi-phasic contrast injection function in which the injection rates and
durations are optimized by minimizing the difference between its contrast enhancement curve and the uniform target enhancement
curve. The optimization method we propose here searches the optimal bi-phasic injection function that conforms to the constraints on
injection rate and contrast volume. The contrast volume is limited firstly to the clinical standard of 65 mL and then to the same amount
used in the DFT approach. The optimization approach is compared against the DFT approaches in terms of the average root mean square
errors (RMSE) from the uniform target contrast enhancement curve and the average contrast volume used. RESULTS When the contrast volume is limited to 65 mL, the optimization approach produces contrast enhancement significantly (p CONCLUSION The optimization approach generates individually optimized bi-phasic injection functions yielding significantly improved contrast
enhancement than the DFT approach. Its implementation in clinic has great potential to improve the diagnostic quality of CTPA. CLINICAL RELEVANCE/APPLICATION With limited contrast volume, our proposed method can produce optimal uniform or plateau-like enhancement pattern to help the
diagnosis of pulmonary thromboembolic disease (PE). LL-CHS-MO3B • MRI Derived Cardiac Mass Is Decreased in Bronchiolitis Obliterans Syndrome (BOS) after Lung Transplantation:
A Novel Biomarker for Early Detection of Transplant Failure?
Jan Hinrichs (Presenter) ; Jens Gottlieb ; Julius Renne MD ; Christian Schoenfeld ; Sajoscha A Sorrentino MD ; Marcel
Gutberlet DiplPhys ; Daniela Wenzel ; Tobias Welte MD ; Frank K Wacker MD * ; Jens Vogel-Claussen MD PURPOSE Bronchiolitis obliterans syndrome (BOS) represents a severe complication following lung transplantation (LTx) and is associated with small
airway fibrosis. Currently lung function tests are used as a clinical marker to diagnose BOS with limited sensitivity for early graft failure.
This study was undertaken to assess if MRI derived biventricular cardiac mass and function parameters may predict BOS. METHOD AND MATERIALS Using 1.5T cardiac MRI, measurements of myocardial structure and function were performed in 51 patients (age and sex matched): 25
women with a mean age of 49 ± 13 years (13 without BOS; 12 with BOS) and 26 men with a mean age of 44 ± 13 years (12 without
BOS; 14 with BOS) were examined. Multiple step wise regression analysis was implemented to estimate the relationship of biventricular
cardiac mass and function parameters for BOS. T-test and Spearman rho correlation were used. RESULTS In a multiple regression analysis including age, sex, days after LTx, mean blood pressure, history of ischemic heart disease, CI, RV and
LV EF, EDV/BSA, ESV/BSA and mass/BSA as parameters only LV mass/BSA remained as an independent parameter to predict the
presence of BOS (p=0.04, OR=1.19, 95%-CI=[1.036;1.477] ). In an ordinal logistic regression model predicting various stages of BOS
(BOS 0, BOS1, BOS2 and BOS 3) using the same parameters LV mass/BSA (p=0.03,OR=1.167, 95%- CI=[1.037;1.398]) and days after
LTx (p=0,007, OR=0.998, 95%-CI=[0.997;0.999]) were both independent predictors for increasing BOS severity. Patients without BOS
showed a significantly higher LV, RV and global myocardial mass compared to patients with BOS (p
CONCLUSION Reduced LV cardiac mass may serve a novel biomarker for BOS and the severity of BOS in our cohort of lung transplant patients. Further
research should evaluate if cardiac mass can predict survival. CLINICAL RELEVANCE/APPLICATION LV mass may serve as MRI derived biomarker for detection of lung transplant failure due to BOS. LL-CHS-MO4B • Breast Density: Comparison of Chest CT with Mammography
Mary M Salvatore MD (Presenter) ; Laurie R Margolies MD ; Minal Kale MD ; Juan Winivesky MD ; Claudia I Henschke MD,
PhD ; David F Yankelevitz MD * ; Sean Kotkin PURPOSE Women with dense breast tissue on mammograms have an increased risk of breast cancer. CT scans of the chest allow for evaluation of
breast density and could provide important information. METHOD AND MATERIALS Institutional Review Board (HIPPA compliant) approval was obtained to perform a retrospective review of the mammogram and chest CT
scan of 206 women performed within 1 year of each other. Two board certified radiologists with expertise in mammography and CT scan
interpretation independently reviewed the mammograms and CT scans and classified each case into one of the four breast density grades
defined by the American College of Radiology Breast Imaging Reporting and Data System (BIRADS).Inter-reader agreements for the
mammographic and CT density grades were determined using Cohen�s weighted kappa statistics. The intra-reader correlation coefficient
was determined on a subset of CT images. RESULTS Page 128 of 397
The inter-reader agreement was higher for the CT than for the mammogram density grades (0.79; 95% CI 0.73 -0.85 vs. 0.62; 95% CI
0.54 � 0.71). The intra-reader reliability of breast density readings on CT was 0.88, at the high end of reliability. CONCLUSION Preliminary results suggest that breast density readings on CT are reliable, and may provide important additional risk information on all
CT scans of the chest. CLINICAL RELEVANCE/APPLICATION CT breast density readings represent an opportunity to provide additional information about the risk of breast cancer that is currently not
being used in a standardized manner. LL-CHS-MO5B • Development of a Simulation Model for Lung Cancer Screening by Low-dose Computed Tomography: A Validation
Study
Marjolein A Heuvelmans BSc (Presenter) ; Marcel Greuter PhD ; Roland Snijder ; Harry Groen ; Matthys Oudkerk MD, PhD ; Geertruida H De Bock PURPOSE The purpose of this study is to develop a lung cancer screening model which can be used for a valid prediction of the outcome of lung
cancer screening trials, in order to optimize scenarios for lung cancer screening. METHOD AND MATERIALS Included in the lung cancer screening simulation model were the risk to develop lung cancer during life, the sensitivity of low-dose CT,
preclinical tumor growth, tumor induction, lung cancer mortality, and mortality due to other reasons. The simulation model was validated
by comparing the outcome data of the model with the available data from two recently published lung cancer screening studies, the
American National Lung Cancer Screening Trial (NLST) and the Dutch-Belgian Lung Cancer Screening Trial (acronym NELSON). RESULTS No significant differences were found by comparing the number of tumors predicted by the model and the number of tumors found in
both lung cancer screening studies. Although the model overestimated the mortality rate for the NLST study, it predicted a mortality
reduction for lung cancer screening of 22.1% (95%CI: 14.8%-28.9%), which was not significantly different from the published mortality
reduction of 20.0% (95%CI: 6.8%-26.7%). CONCLUSION The new model can be used for further optimization of different scenarios in lung cancer screening. CLINICAL RELEVANCE/APPLICATION Using the developed model, the outcome of lung cancer screening trials in terms of lung cancer mortality reduction can be predicted. Emergency Radiology - Monday Posters and Exhibits (12:45pm - 1:15pm) Monday, 12:45 PM - 01:15 PM • Lakeside Learning Center
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LL-ERS-MOB • AMA PRA Category 1 Credit ™:0.5 LL-ERS-MO1B • A Common Traumatological Dilemma: Can the Clinical Outcome of Distal Radius Fractures be Predicted from
Initial Radiographs?
Sanja Trnavac MD (Presenter) ; Markus S Juchems MD * PURPOSE The purpose of this study was to investigate whether the displacement of conservatively treated distal radius fractures after complete
healing can be predicted from initial radiographs METHOD AND MATERIALS Radiographs of 311 patients with a conservatively treated distal radius fracture were analyzed at the time of injury, after closed reduction
and after bony consolidation. We measured the dorsal dislocation (DD), the radial angle (RA), and radial shortening (RS) at each time
point. The parameters were analyzed separately for metaphyseally �stable� (A2, C1) and �unstable� (A3, C2, C3) fractures, according
to the AO classification system. Spearman rank correlations and regression functions were determined for the analysis. RESULTS 151 (49%) fractures were classified as A2, 79 (25%) as A3, 48 (15%) as C1, 29 (9%) as C2, and 4 (1%) as C3. After reduction, the
median DD was adjusted by 40%; however, by the time complete healing, the median improvement was only 20%. There were only
minor fluctuations in the RA between the three time points. In only 8% of the stable and 14% of the unstable fractures affected by RS,
the reduction achieve a gain in length of more than 2 mm that was maintained until complete healing. The highest correlations were
found for the DD between the time points �reduction� and �complete healing� (r=0.75) and for the RA between the time points
�reduction� and �complete healing� (r=0.80). CONCLUSION In patients with conservatively treated distal radius fractures, final DD and RA can be predicted from the radiograph after closed
reduction. CLINICAL RELEVANCE/APPLICATION The clinical outcome of distal radius fractures can be predicted on initial radiographs. LL-ERS-MO2B • Comparison of Plain Film Radiography and MDCT in Suspected Fractures of the Scaphoid: Re-evaluation of
Imaging Algorithm in Daily Practice
Cyrus Behzadi (Presenter) ; Murat Karul MD ; Frank Oliver G Henes MD ; Philip Catala-Lehnen ; Gerhard B Adam MD ; Marc
Regier PURPOSE To intraindividually compare and evaluate biplane radiography and multidetector computed tomography (MDCT) under consideration of
accurate detection of suspected scaphoid fractures and individual radiation dose. METHOD AND MATERIALS A total of 124 consecutive patients (66 males; 58 females; mean age, 49 ±21 years; range, 16-91 years) were included in this
intraindividual comparative study. All patients were admitted to the emergency department of our university medical center with acute
trauma of the wrist. Within the emergency department biplane radiography was performed. Within a mean time interval of 0.7 days
(range, 0 � 8 days) a 256 slice MDCT was conducted in each patient (voltage, 120 kVp; eff. current-time product, 70 mAs). The clinical
examination and MDCT data consensually served as the reference standard. A fourfold table was used for the classification of screening
test results. Sensitivity, specificity, positive and negative predicitve values, Wilcoxon and Chi square test (?2) and mean effective doses
were used to compare the diagnostic value of both techniques. Page 129 of 397
RESULTS Reading the biplane radiography data overall 75 fractures were suspected, 34 of which were assigned to acute fracture of the scaphoid.
Subsequent MDCT revealed a total 108 fractures in 80 patients, 42 of these were identified as acute scaphoid fractures. Hence, the
sensitivity of biplane radiography for the detection of at least one mid-hand fracture was limited to 45.6%. Due to 12 false positive
findings the specificity of radiography was only 29.4%. If biplane radiography was used as the exclusive criterion the fracture detection
would have been accurate in only 54.8% of all patients. The statistical analysis revealed a distinct superiority of fracture detection at
MDCT (p CONCLUSION Compared to MDCT, the diagnostic accuracy of biplane radiography in the detection of acute fractures of the wrist and the scaphoid is
poor. Concerning its diagnostic superiority mean radiation doses of 0.3 mSv at MDCT have to be considered as negligible. CLINICAL RELEVANCE/APPLICATION The presented data suggest that in acute wrist trauma with suspected scaphoid fractures MDCT should serve as the imaging modality of
first choice and replace biplane radiography. LL-ERS-MO3B • Single-pass versus Dual-pass Scanning during Trauma Head and Neck Computed Tomography: Radiation Dose to
the Eyes and Thyroid Gland
Charbel Saade MS (Presenter) ; Zhong Hui Yin MSc ; John W Robinson BSc ; Elaine Ryan PhD, MSc PURPOSE To investigate the eye and thyroid gland dose during single-pass and dual-pass scans during multidetector computed tomography
(MDCT) of trauma head and neck. METHOD AND MATERIALS Materials and Methods: head and neck MDCT was performed on 19 patients with trauma to the head and neck using a 64 channel
computed tomography scanner (VCT, GE, Connecticut). Patients were allotted into one of two acquisitions. Patient demographics were
equally distributed. Group A (n=9), the department�s standard protocol, comprised of a head scan from the vertex to the base of skull,
and the neck from the clivus to the second thoracic vertebrae; Group B (n=10), involved a craniocaudal scan direction from the vertex of
the cranium to the second thoracic vertebrae. Skin entrance dose to eyes and thyroids were measured using GafChromic XR2-QA films
(International Specialty Products, Wayne, NJ). Visual grading characteristic (VGC) techniques assessed diagnostic clinical image quality.
Data generated were compared between groups using Mann-Whitney U non-parametric statistics. RESULTS Results: Mean dose to the thyroid gland demonstrated significant reduction in group B (2.09+0.56 mGy) compared to A (2.74+0.50 mGy)
(p = 0.0133). Mean dose to the eyes were non-significant in group B (2.22 + 0.76 mGy) compared to A (2.51 + 0.34 mGy) (p = 0.22).
VGC analysis demonstrated significant increase in image quality in group B compared to A within the brain (p = 0.0304) and cervical
spine region (cortical outline, p = 0.0087; trabecular pattern, p = 0.0081). Dose length product was reduced in group A (2010.06 +
853.83) compared to B (2289.84 + 714.62) (p=0.22). CONCLUSION Conclusion: Optimization of scanner protocols, single-pass scan acquisition and reduced radiation dose to the eye and thyroid, can
significantly improve image quality and may increase workflow during trauma MDCT imaging of the head and neck. CLINICAL RELEVANCE/APPLICATION Direct radiation effects concerning the eye and thyroid gland are well documented at dual-pass scanning, which results in cataract
formation and the development of thyroid malignancy. LL-ERS-MO4B • Variability in Management Recommendations for Incidental Thyroid Nodules Detected on Computed Tomography
of the Cervical Spine in the Emergency Department
Bruce E Lehnert MD (Presenter) ; Claire K Sandstrom MD ; Ken F Linnau MD,MS PURPOSE Thyroid nodules are common incidental findings at computed tomography (CT) however there are no CT based management guidelines,
potentially resulting in variability in practice. Demonstrating this variability in practice may illustrate the need for CT based management
guidelines for incidental thyroid nodules. METHOD AND MATERIALS We retrospectively reviewed radiology reports describing thyroid nodule(s) from consecutive CT cervical spine examinations performed in
our Emergency Department (ED) from 01/01/2009 to12/31/2011. 315 examinations met criteria. The number of nodules, nodule size,
and recommended management (US, clinical correlation, clinical follow-up, thyroid serology, comparison with prior studies, nuclear
scintigraphy, fine needle aspiration, or no follow-up needed) were recorded. RESULTS The mean study age was 64 yrs (+/- 20). 58% were female. 30% (95/315) of the thyroid nodules measured CONCLUSION Management recommendations for incidental thyroid nodules detected on CT of the cervical spine in the ED are made inconsistently and
the type of management recommended is variable. CLINICAL RELEVANCE/APPLICATION There is variability in practice for managing incidental thyroid nodules detected at CT which may benefit from the development of CT
based management guidelines LL-ERS-MO5B • 50% Dose CT in Acute Cervical Spine Injury: Improved Signal and Reduced Artifact at the Cervicothoracic
Junction Using Fully Integrated Circuit CT Detectors
Patrick McLaughlin FFRRCSI ; Teresa Liang MD, BSc (Presenter) ; Graeme J McNeill MRCP, FFRRCSI ; David Tso MD ; Luck J
Louis MD ; Hugue A Ouellette MD ; John R Mayo MD * ; Savvas Nicolaou MD PURPOSE In this study we compare subjective and objective image quality between 100% dose and 50% dose dual source cervical spine CT
datasets obtained using both traditional discrete (DC) and novel fully integrated (IC) detectors. METHOD AND MATERIALS 22 consecutive patients underwent dual source CT of the cervical spine with conventional DC detectors (DC-CSp) using a dual source
128-slice CT system. A different group of 30 consecutive patients were subsequently scanned after the installation of IC detectors
(IC-CSp)(Stellar; Siemens Healthcare, Forcheim, Germany) using the same acquisition protocol (140kv, ref mAs 440, 128x0.6 mm). Raw
data from detector A of both datasets were reconstructed to yield half dose images (IC-CSp50 and DC-CSp50) for all patients using a
validated technique. Image quality was subjectively graded using a 4-point scoring scheme for osseous and soft tissue definition of the
spinal column at C3, C5 and T1 levels. Diagnostic acceptability was also graded from 1-10 for each dataset. Mean HU and SD of 1cm2
regions of interest within the spinal canal at C3, C5 and T1 levels served as an objective measure of image quality. RESULTS Page 130 of 397
There was no significant difference in CTDIvol, age, sex, and size of patients in DC-CSp or IC-CSp groups. We found no difference in
objective or subjective quality between the IC and DC images at 100% dose (p>0.05) but significant differences were elucidated when
50% dose datasets were compared. Diagnostic acceptability was higher on IC-CSp50 vs DC-CSp50 images (8.2 vs 7.6, p=0.09) and
definition of the soft tissue structures within spinal canal was significantly improved at the T1 level (3 vs 2.5, p=0.05). Objective analysis
revealed a significant reduction in the incidence of streak artifact (mean CONCLUSION Use of fully integrated circuit CT detectors improved diagnostic acceptability and significantly reduced the incidence of streak artifact at
the cervico-thoracic junction in the acute setting on 50% reduced dose images of the cervical spine. CLINICAL RELEVANCE/APPLICATION The fully IC CT detector allows streak artifact reduction and improved visualization of the cervico-thoracic spinal canal, allowing better
diagnostic acceptability of lower C-spine at reduced dose. Gastrointestinal - Monday Posters and Exhibits (12:45pm - 1:15pm) Monday, 12:45 PM - 01:15 PM • Lakeside Learning Center
Back to Top GI
LL-GIS-MOB • AMA PRA Category 1 Credit ™:0.5 LL-GIE-MO8B • Putting the Polyps Together: Imaging of the Hereditary Colorectal Cancer Syndromes
Betty Tuong MD (Presenter) ; Silvia D Chang MD ; Alison C Harris MBChB PURPOSE/AIM 1. Enhance the participant's knowledge of the hereditary colorectal cancer syndromes (HCRCS) and their manifestations. 2. Discuss imaging findings of the HCRCs with case examples from various fluoroscopic, ultrasound, CT and MR examinations, including
CT enterography. 3. Highlight the important role of radiologists in recognizing these syndromes for diagnosis and screening. CONTENT ORGANIZATION 1. The Genetics of Colorectal Cancer 2. Classification of the Hereditary Colorectal Cancer syndromes a. Non-polyposis syndromes - Lynch syndrome b. Polyposis syndromes - Adenomatous � Familial adenomatous polyposis coli and variants including Gardner syndrome - Hamartomatous � Peutz-Jeghers syndrome, juvenile polyposis, and PTEN hamartoma syndromes 3. Take-Home Points and Conclusion SUMMARY 1. Our understanding of the hereditary colorectal cancer syndromes (HCRCS) continues to evolve, each with characteristic manifestations. 2. Radiologists should be familiar with the various HCRCS and their common imaging findings because early detection of these neoplasms
may help decrease patient morbidity and mortality. LL-GIE-MO9B • Pathways of the Subperitoneum: The Key to Challenging Diagnoses
Atalie C Thompson BA,MPH (Presenter) ; Lewis Shin MD ; Robert E Mindelzun MD PURPOSE/AIM The purpose of this exhibit is to review the anatomic spaces of the pelvis and the three major pathways of the subperitoneum through
which abnormal processes spread. CONTENT ORGANIZATION 1. Review of Pelvic Anatomic Spaces -Illustrate the prevesical, perivesical, and external iliac spaces -Review helpful imaging signs to
identify these spaces 2. Identify the three major, predictable pathways of the subperitoneum, using case examples to demonstrate
diagnostic significance: (1) Lateral pathway: anterior and posterior pararenal, perirenal, infraconal and external iliac spaces (2) Central
pathway: inferior mesenteric artery to the aorta at L3 (3) Posterior pathway: primarily along the superior mesenteric vessels and its
branches SUMMARY The major teaching points of this exhibit are: 1. Numerous radiological signs can aid in the characterization of pelvic extraperitoneal
spaces, including the following: triangle, umbilical, molar tooth, and inferior epigastric vessel signs. 2. Knowledge of pelvic spaces and
the ability to trace disease processes to their origin along these complex but predictable fascial pathways of the subperitoneum (i.e.
lateral, central, and posterior) can enable the radiologist to make challenging and critically important diagnoses. LL-GIE1227-MOB • It’s Not Always FNH: A Review of Entities That Can Appear Hyperintense on Hepatobiliary Phase Imaging
Manish Dhyani MBBS (Presenter) ; Sandeep S Hedgire MD ; Sheela Agarwal MD, MS PURPOSE/AIM The use of hepatocyte specific contrast agents such as gadoxetic acid (Eovist) is becoming increasingly common for the characterization
and detection of liver lesions. Early experience with gadoxetate was based on the straightforward principal that normal hepatocytes would
appear hyperintense on hepatobiliary phase (HBP), and non-hepatocyte containing lesions would be dark. With experience, we now know
that a number of various factors contribute to the appearance of a lesion on HBP and many entities previously not considered can appear
hyperintense. Currently, numerous case reports/publications describe unusual appearances of various liver lesions particularly on the HBP
of imaging, but there is no comprehensive repository for the range of appearances of these lesions. CONTENT ORGANIZATION 1. Typical appearance of benign and malignant lesions of the liver on HBP - gadoxetate imaging.
2. All lesions that may appear as hyperintense on HBP, and the pathophysiology for the hyperintensity.
3. Role of T2-weighted and nonfat saturated HBP imaging in differentiating lesions.
4. Pitfalls: Experience within our institution.
SUMMARY There is variable experience of a radiologist�s familarity with gadoxetate. The objective of this educational exhibit is to aid the radiologist
in understanding the range of appearances of various liver lesions on MRI with gadoxetate. LL-GIE-MO11B • Conventional Defecography and MR Defecography in Patients with Obstructive Defecation Syndrome: Pre and
Post-operative Findings
Werner Kenn MD, PhD (Presenter) ; Birgit Hartung ; Henning Neubauer MD, MBA ; Thorsten A Bley MD ; Herbert Koestler
PhD * ; Christoph Isbert PURPOSE/AIM Page 131 of 397
PURPOSE/AIM To demonstrate the whole procedure of normal and pathologic defecation in conventional (CD) and MR defecography (MRD) as well as
imaging findings after surgical treatment (e.g. STARR/POP STARR). CONTENT ORGANIZATION 1. To review the indications 2. To show the techniques including dynamic 3D MR defecography 3. To demonstrate important measures as
anorectal angle (ARA) and perineal descent (PD); to get familiar with pathologic findings such as intussuception, enterocele, rectocele,
sigmoidocele, cystocele, Retzius and Douglas hernia; to discriminate functional disorders (e.g. spastic pelvis floor syndrome) 4. To learn
about surgical treatment options like i.e. stapled transanal resection (STARR) for intussusception and POP STARR for pelvic organ prolaps
and their appearance in CD and MRD 5. Limitations of both modalities. SUMMARY The radiologist - especially when working in the coloproctologic field - should be familiar with the techniques, indications and limitations
of CD and MRD. As there are successful surgical procedures in patients with obstructive defecation syndrome he should have experience
in interpreting post-operative defecography. LL-GIE-MO12B • Body MR Imaging: Artifacts, K-space and Solutions
Pritesh Patel MD ; Ravi Seethmraju PhD * ; John Kirsch PhD * ; Peter F Hahn MD, PhD * ; Alexander R Guimaraes MD, PhD
(Presenter) * PURPOSE/AIM Body MR imaging is challenging secondary to the complex interrelationship of motion, secondary to respiration and peristalsis, and
susceptibility secondary to gas from the bowel. Some of these issues are exacerbated at higher field strengths (e.g. 3T). The purpose of
this exhibit is to familiarize the reader with the range of artifacts seen in body imaging at 1.5T and 3T, and to explain the etiology of
these artifacts from the standpoint of basic MR physics in order to find solutions and improve image quality. CONTENT ORGANIZATION We will discuss in depth with case examples artifacts associated with body imaging at both 1.5 and 3T. We will categorize artifacts based
on motion, spatial encoding, field strength, pulse sequence, coil type, location, B0 and B1 sensitivity profiles, chemical shift and parallel
imaging. We will explain the etiology of these artifacts from basic MR physics using K-space encoding, and signal processing, proposing
solutions, when possible. SUMMARY A better understanding of the cause of artifacts within the complex environment of body MRI is integral to improving the practice and
meeting the challenges of novel pulse sequence design, parallel transmission, and increasing field strength. LL-GIE-MO10B • Mesenteric Neoplasms: MRI Characteristics, Histopathological Correlation and Differential Diagnosis
Pardeep K Mittal MD (Presenter) ; Juan C Camacho ; Sajeev R Ezhapilli MBBS ; William C Small MD, PhD ; Krisztina Hanley
MD ; Courtney A Coursey MD * PURPOSE/AIM 1 This educational exhibit will highlight specific MR imaging features of mesenteric masses , associated clinicopathological findings and
provide guide lines to reach specific diagnosis
2.To demonstrate MRI characteristics frequently encountered in both neoplastic and non- neoplastic mesenteric conditions and diagnostic
clues CONTENT ORGANIZATION After a brief review of the anatomical extent and function of the mesentery, participants will be a) Presented with differential diagnosis of mesenteric pathology, highlighting those frequently encountered. for example, mesenteric
fibromatosis, desmoid tumors,, inflammatory pseudotumor, sclerosing mesenteritis, carcinoid, schwannoma, paraganglioma,and
lymphoma, etc. b) Participants will appreciate the benefit of MRI over CT due to its superior soft tissue characterization and multi-planar capabilities as an
excellent diagnostic tool in allowing precise and detailed tumor characterization. c) Optimal MR imaging of the mesentary comprising fat
suppression and dynamic contrast enhanced imaging including delayed imaging will be shown to be instrumental in successful
characterization of mesenteric masses SUMMARY This exhibit will present the characterization of mesenteric masses at MRI and will offer a rational approach to the differential diagnosis of
mesenteric masses depicted at MRI. LL-GIS-MO1B • Non-contrast MR Hepatic Arteriography Using T-SLIP at 3T
Keitaro Sofue (Presenter) ; Takeshi Yoshikawa MD * ; Nobukazu Aoyama RT ; Katsusuke Kyotani RT ; Yoshiharu Ohno MD,
PhD * ; Yoshimori Kassai MS * ; Saori Satou RT * ; Naoki Kanata MD ; Tomonori Kanda ; Hisanobu Koyama MD ; Mizuho
Nishio MD * ; Kazuro Sugimura MD, PhD * PURPOSE To evaluate non-contrast MR hepatic arteriography using time-spatial labeling inversion pulse (T-SLIP) at 3T METHOD AND MATERIALS 101 patients (m:59, f:42, mean: 65.0 yrs) who were suspected to have malignant tumor in the liver, bile duct (BD), or pancreas,
underwent MRI at a 3T scanner. Non-contrast hepatic MR arteriography were obtained with T-SLIP (3D-true SSFP, selective IR, black
blood inversion time: 1500, resp. trigger, scan time: 5-7min). Visualization of overall, right, left, and segment 4 (A4) hepatic arteries
(HA) were scored by two radiologists on a 4-point scale. Scores of 3 or 4 for overall HA were assessed to be clinically acceptable.
Anatomy was classified using Michels classification. Patients� backgrounds, irregular respiration, HA narrowing, aortic arteriosclerosis,
cardiac enlargement, and visualization of BD, fluid, portal vein, and IVC, and artifacts, were recorded on a 4-point scale and their effects
on HA visualization were assessed. In 41 patients, HA visualization was compared with CE-CTA. Presence of arterial encasement indicating
vascular invasion were recorded. RESULTS CONCLUSION Hepatic artery can be assessed and classified by non-contrast MRA using T-SLIP at 3T with exception of small proportion of patients. CLINICAL RELEVANCE/APPLICATION Hepatic artery can be assessed and classified by non-contrast MRA using T-SLIP at 3T with exception of small proportion of patients. LL-GIS-MO2B • Diagnostic Value of Diffusion-weighted Magnetic Resonance Imaging of Infected Pancreatic Fluid Collections
Bruno Borens MD (Presenter) ; Marianna Arvanitakis ; Julie Absil PhD, MS ; Said El Bouchaibi MD ; Celso Matos MD ; Thierry
Metens MD, PhD ; Maria-Antonetta Bali PURPOSE The aim of this study was to assess the diagnostic accuracy of diffusion-weighted resonance imaging (DW-MRI) in characterizing
pancreatic fluid collections (PFC) and determining the presence of infection. Page 132 of 397
METHOD AND MATERIALS 26 consecutive patients with post-pancreatitis PFCs requiring transmural endoscopic ultrasound-guided (EUS) drainage were prospectively
included. Exclusion criteria were previous drainage or surgery. Before the endoscopic procedure, DW-MRI was performed in all patients
with high b-value (b=1000 s/mm2) and ADC measurements in the collections were calculated. An infected collection was suspected when
high signal on DW-MRI of PFC and low ADC values were observed. After EUS drainage, bacteriological cultures of the intra-cystic fluid was
performed and considered infected if these were positive (gold standard). Continuous values were reported as median and the 25th and
75th percentile points. Comparisons were performed using non-parametric tests. The diagnostic performance of DW-MRI was assessed by
receiver operating characteristic analysis (ROC curve). RESULTS The underlying disease was acute (n=15, 58%) and chronic pancreatitis (n=11, 42%). Median ADC was statistically significantly lower in
infected vs non infected PFCs : 0.66 (0.42 and 0.82) vs 2.3 (2.0 and 2.5) x10-3mm2/sec, p=0.01. Sensitivity, specificity, accuracy,
negative predictive value (NVP) and positive predictive value (PPV) of DW-MRI for predicting PFC infection were, respectively, 55% (5/9),
94% (16/17), 80% (21/26), 80% (16/20) and 83%(5/6). When patients previously treated with antibiotics were excluded (n=9) from
the statistical analysis, sensitivity, specificity, accuracy, NPV and PPV were respectively 75%, 92%, 88%, 92% and 75%. ROC curve
calculated a cut-off of 0.9 x 10-3mm2/sec with a sensitivity of 100% and a specificity of 95%. CONCLUSION DW-MRI may provide additional information concerning PFC assessment before drainage. Results show high diagnostic accuracy and
negative predictive values, which can help in excluding PFC infection and determining time of drainage. CLINICAL RELEVANCE/APPLICATION Diffusion-weighted resonance imaging is a non invasive diagnostic tool showing high diagnostic accuracy that may provide useful
information for therapeutic management of pancreatic fluid collection. LL-GIS-MO3B • Reproducibility and Comparison Study for Acoustic Radiation Force Impulse Imaging and Supersonic Shear
Imaging
Hyunsik Woo MD (Presenter) ; Jae Young Lee MD ; Jeong Hee Yoon MD ; Won Kim MD, PhD ; Belong Cho PURPOSE The purpose of this study was to evaluate and compare intra-observer and inter-observer agreement of acoustic radiation force impulse
imaging (ARFI) and supersonic shear imaging (SSI). METHOD AND MATERIALS This study was prospectively designed and performed with our Institutional Review Board approval. From April 2012 to April 2013, 79
patients (49 men, 30 women, mean age 56.7 years) were enrolled, which included 29 healthy patients, 25 patients with chronic hepatitis
with Child class A, and 25 patients with chronic hepatitis Child class B or C. Three experienced abdominal radiologists performed ARFI and
SSI at the same time in each patient with 9 measurements per each imaging. Four weeks later, second session was performed with the
same protocol for the same patients by the same radiologists. Inter-observer and intra-observer agreement measured by intraclass
correlation coefficient, technical success rate, and time taken for measurement of ARFI and SSI were calculated and statistically analyzed. RESULTS Inter-observer agreements of ARFI and SSI were 0.932 and 0.805, respectively. Intra-observer agreement of ARFI and SSI between first
and second session were 0.935 and 0.825, respectively. Pearson correlation coefficient between ARFI and SSI was 0.790. The conversion
equation derived from linear regression was �SSI (m/s) = 0.9867 * ARFI (m/s) + 0.3274�. Technical success rates were 99.8% and
98.5% (p=0.07), and the average study time was 83.6 seconds and 302.0 seconds for ARFI and SSI, respectively (p < 0.0001). CONCLUSION ARFI showed slightly better reproducibility and technical success rate and significantly shorter study time than SSI. They also showed the
potential to be used interchangeably. CLINICAL RELEVANCE/APPLICATION As both ARFI and SSI show good inter-observer and intra-observer agreements and good correlation, they might be used interchangeably
in the evaluation of liver fibrosis. LL-GIS-MO4B • A Retrospective MRI Evaluation of Diffuse Peritoneal Metastatic Disease: Value in Pre-operative Assessment of
the Peritoneal Carcinomatosis Index (PCI)
Neelima Gorantla MD (Presenter) ; Drew F Pierce MD ; Arpit M Nagar MBBS ; Sherif Abdel-Misih MD ; Zarine K Shah MD PURPOSE Imaging has been an integral part in the management for patients with peritoneal metastases. MRI is emerging as a powerful tool with a
high degree of inherent contrast and improving spatial resolution with newer scanners and advanced MRI techniques. We sought to
determine how well MRI imaging findings correlates with surgical Peritoneal Carcinomatosis Index (PCI). METHOD AND MATERIALS This is a retrospective review of radiologic and clinical records of 13 patients with a history of peritoneal malignancy that underwent MRI
of the abdomen and pelvis. All patients underwent cytoreduction at a single institution between 1/1/2011 and 4/1/2012. Preoperative
abdominal and pelvic MRI of these patients with breath-hold Diffusion weighted imaging (DWI), T1-weighted spoiled gradient-echo,
T2-weighted fast spin-echo, pre-contrast and 5-minute delayed gadolinium-enhanced imaging was reviewed retrospectively by a
radiologist who was blinded to imaging and surgical impressions. Details of surgical findings and surgical PCI were compared with MRI
findings and imaging based scoring by an independent radiologist. For the purpose of this study, a difference between Surgical PCI and
imaging scoring greater than 5 was considered significant. Also, surgical findings and impressions were taken into consideration for
analysis. RESULTS 5/13 studies showed discrepancy between surgical PCI and imaging score and in 2 out of these 5 patients would have impacted surgical
decision making. In 8/13 patients, despite total surgical and imaging scores being relatively similar, there were discrepancies when
individual regions comprising the PCI score were compared. CONCLUSION MRI using DWI is a valuable tool for assessment of disease burden and location in patients with peritoneal surface malignancies, but there
is difficulty in correlation with the surgical PCI. In our study group, MRI has a higher sensitivity to detect metastatic lymph nodes,
whereas some small lesions were better seen at surgery. This is a small group of patients and we propose that a larger study group and a
more robust image based scoring system will likely result in more close correlation with surgical findings. CLINICAL RELEVANCE/APPLICATION MRI with DWI can demonstrate peritoneal metastasis and has the potential to be incorporated as part of a MR imaging prior to surgical
exploration. LL-GIS-MO5B • Low Radiation Dose Abdominal CT with Iterative Model Reconstruction (IMR): Clinical Impact on Thin Slice
Images
Takeshi Nakaura MD (Presenter) ; Shinichi Tokuyasu RT * ; Masafumi Kidoh ; Ryo Itatani ; Kazunori Harada ; Yasuyuki
Yamashita MD * Page 133 of 397
PURPOSE Recently, low radiation dose abdominal CT has become clinically available through techniques such as iterative reconstruction techniques
and low kVp imaging. However, increased image noise is a serious problem in the thin slice images. The purpose of this study was to
evaluate the usefulness of the recent introduced iterative model reconstruction (IMR, Philips Healthcare) in low dose abdominal CT with
the thin slice images. METHOD AND MATERIALS This prospective study received institutional review board approval; prior informed consent to participate was obtained from all patients.
This study enrolled 36 patients who were imaged with low radiation dose abdominal and pelvis CT at the 100 kVp setting. We
reconstructed clinical studies with filtered back projection (FBP), hybrid-iterative reconstruction (iDose 4 , Philips Healthcare) and IMR
with 1, 3 and 5 mm slice thickness. We compared the image noise and the rate of increase of image noise in 1 and 3 mm thickness
images from 5 mm thickness images between the reconstruction methods using the Sceheffe test. Two independent readers assessed
image contrast, image noise, image sharpness and overall image quality on a 4-point scale about 1mm thickness images with each
reconstruction technique. RESULTS The mean radiation dose of patients was 4.6 mSv ±1.5. The rate of increase in noise in 1mm thickness images (FBP: 2.21±0.23 and
iDose 4: 2.16±0.30) and 3mm thickness images (FBP: 1.30±0.13 and iDose4: 1.29±0.21) were almost inversely proportional to the
square-root of the rate of decrease in slice thickness in FBP and iDose4 reconstruction and the differences were not significant (p>0.05).
However, the rate of increase in image noise in thin slice images with IMR reconstruction (1mm: 1.47±0.17 and 3mm: 1.18±0.13) were
significantly lower than other reconstruction techniques (p4 reconstruction(10.8±2.7) (p CONCLUSION IMR reconstruction offers dramatic noise reduction in low dose abdominal CT especially at thin slice images as compared with FBP and
iDose4. CLINICAL RELEVANCE/APPLICATION We did not need to increase the radiation dose for thin slice images with IMR technique. LL-GIS-MO6B • Real- time Splenic Elastography as a Tool for Detection and Grading of Oesophagogastric Varices: Has Its Time
Really Come?-An Analytic Study of Correlation between Splenic Elasticity Score and Endoscopic Grade of Varices
Vasanthakumar Venugopal MD (Presenter) ; Sunil Kumar Puri MD ; Nishith Kumar MD ; Ishrat Afshan MBBS ; Santosh K
Arjun MBBS PURPOSE To evaluate the role of Splenic elasticity ratio measured by Real-time elastography(RTE) in predicting the presence of esophageal varices
in patients with portal hypertension
To analyse the correlation between the Splenic elasticity score and endoscopic grade of esophago-gastric varices
METHOD AND MATERIALS This prospective study included 34 patients with chronic liver disease being evaluated for portal hypertension and planned for
esophagogastroduodenoscopy (EGD). Initial B-mode and duplex sonographic evaluation was followed by examination of spleen by
elastography mode . Regions of interest were simultaneously placed on small intrasplenic veins and splenic parenchyma. Elasticity ratio is
then calculated as the proportion of strain of small veins to that of splenic parenchyma. A higher elastic ratio is indicative of more splenic
elasticity. The endoscopic findings were interpreted with reference to presence of varices, grade of the varices and presence/absence of
signs of active bleeding. The correlation between SE ratio and grade of varices was analyzed with the Pearson product-moment
correlation coefficient. Receiver operating characteristic (ROC) curves were constructed, and the area under the ROC curve (AUC) was
calculated. Optimal cutoff values for SE ratio were selected to maximize sensitivity, specificity, and diagnostic accuracy. Sensitivity,
specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated by using cutoffs obtained from the ROC
curves. Inter and intraobserver variability in RTE and EGD was calculated RESULTS Splenic elasticity and variceal grade show significant linear correlation (R = 0.78, P CONCLUSION There is a signifcant correlation between splenic elasticity and presence,severity of grade and propensity for bleeding of esophageal
varices.The higher the elasticity score higher is the chance for severe lifethreating bleeding. CLINICAL RELEVANCE/APPLICATION Splenic elasticity ratio can be used as a safe and cost effective screening modality to predict the presence and grading of esophageal
varices and hence the probability of severe bleeding episodes. LL-GIS-MO7B • Correlation of Perfusion Parameters on Dynamic Contrast-enhanced MRI with Prognostic Factors of Rectal
Cancer
Dong Myung Yeo ; Soon Nam Oh MD ; Joon Sung Choi (Presenter) ; Sung Eun Rha MD ; Seung Eun Jung MD ; Jae Young
Byun MD ; Michael Y Park MD PURPOSE To investigate whether quantitative parameters derived from dynamic contrast-enhanced (DCE) MRI correlate with prognostic pathologic
markers of rectal cancers. METHOD AND MATERIALS A total of 46 patients with rectal cancer underwent preoperative DCE MRI. Using a two-compartmental model, the quantitative
parameters (Ktrans , Kep , Ve and iAUC) from the whole transverse ROI of the entire tumor were calculated. Histological specimens were
analyzed for tumor size, T stage, N stage, histologic grade, lymphatic, vascular or perineural invasion, expression of epidermal growth
factor receptor (EGFR), and KRAS gene mutation. Correlations of the perfusion parameters with histologic markers were determined using
the Student T test and ANOVA. RESULTS Mean K ep showed a significant correlation with T stage (P = 0.021). EGFR positive cancers displayed a higher mean Ktrans (p = 0.045)
and Kep (p = 0.038) than EGFR negative cancers. No significant correlations were found between DCE MRI parameters and N stage,
histologic grade, or KRAS gene mutation. CONCLUSION Rectal cancers with higher Kep might have poor prognosis including higher T stage and expression of EGFR. CLINICAL RELEVANCE/APPLICATION The pharmacokinetic parameters of DCE MRI might have the potential to predict prognosis in patients with rectal cancer. Genitourinary/Uroradiology - Monday Posters and Exhibits (12:45pm - 1:15pm) Monday, 12:45 PM - 01:15 PM • Lakeside Learning Center
GU
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LL-GUS-MOB • AMA PRA Category 1 Credit ™:0.5 LL-GUS-MO1B • Utility of CT Urography (CTU) in Recurrent Urinary Tract Infections (RUTIs) in Adults under 50 Years of Age
Daniel Dolewski MD (Presenter) ; Christopher J Lisanti MD * ; Michael Berven MD ; Megan Skinner MD ; Michael J Reiter MD
; Ryan B Schwope MD PURPOSE The American College of Radiology (ACR) Appropriateness Criteria recommends CTU in patients with RUTIs if the patient has one or more
of 19 risk factors. The literature cited is over 30 years old and showed 6% of RUTIs patients with major structural abnormalities and all
these had risk factors. The purpose of this study is to assess the utility of CTU and risk factors in adults under 50 years of age with RUTIs. METHOD AND MATERIALS In this HIPAA compliant IRB approved study, 1521 CT Urograms were performed in adults under the age of 50 between January 5, 2007
and March 28, 2012. Inclusion criteria were a clinical history of RUTIs and/or 3 documented UTIs in 12 months in females or a single UTI
in males. Findings in the upper and lower urinary tracts were recorded and the clinical notes, if available, were reviewed for presence of
risk factors according to ACR guidelines and what clinical intervention, if any, was undertaken. RESULTS 74 patients met inclusion criteria (66 female; 8 male). Average age: 28.7 years. 69/74 (93.2%) clinical records were available. 100%
(69/69) had one risk factor (usually prior UTI), and 63.8% (44/69) had at least two risk factors. The following findings required
intervention: 1 (1.4%) renal cell carcinoma and 1 (1.4%) obstructing ureterolith felt unrelated to RUTIs requiring a stent. The following
findings not requiring further intervention were: 8 (10.8%) simple cysts; 12 (16.2%) nephrolithiasis; 3 (4.1%) cortical scarring; 3
(4.1%) complete renal atrophy; 1 (1.4%) papillary necrosis; 8 (10.8%) partial duplicated collecting systems; 1 (1.4%) complete
duplicated collecting system; 1 (1.4%) mildly dilated bilateral ureters felt to be physiologic; 3 (4.1%) bladder diverticula; 3 (4.1%)
bladder filling defects and 3 (4.1%) wall thickening with negative cystoscopy. 1 mildly dilated ureter, 1 bladder filling defect and 1
bladder wall thickening had no follow-up clinical records available. CONCLUSION 2.8% of adults under 50 years of age with RUTIs and at least one risk factor had urinary abnormalities identified on CTU requiring
intervention, however, none of these abnormalities were determined to be causal to the patient�s RUTIs. CLINICAL RELEVANCE/APPLICATION CTU has a low yield in adults under 50 years of age with RUTIs. Presence of risk factors does not appear to result in a higher yield than
prior research studies. LL-GUS-MO2B • MR-guided Focal Cryoablation of Locally Recurrent Prostate Cancer at 1.5 and 3T: An Initial Comparison of
Image Quality and Procedure Time
Sjoerd Jenniskens MD (Presenter) ; Christiaan G Overduin MSc ; Joyce G Bomers MSc ; Jurgen J Futterer MD, PhD PURPOSE To compare image quality and procedure time of MR-guided focal cryoablation of prostate cancer (PCa) recurrence at 1.5T and 3T field
strength. METHOD AND MATERIALS 39 consecutive patients with locally recurrent PCa after radiotherapy underwent transperineal MR-guided focal cryoablation at either a
1.5T (n=16) or 3T (n=23) MR system. In these patients, quality of imaging during the procedure was retrospectively assessed.
Anonymized axial T2-weighted turbo spin echo and T1-weighted gradient echo MR images were randomly read by 3 experienced prostate
interventional radiologists, who were blinded for field strength and imaging parameters. Image quality was assessed using a 5 points
scale (1= excellent quality � 5= non-diagnostic) for three procedure steps: tumor localization, needle targeting and treatment
monitoring. Additionally, total procedure time and procedure time adjusted for the number of needles placed between field strengths
were compared. For statistical analysis, the student t-test was used. RESULTS Mean total procedure times observed at 1.5T and 3T were 121 minutes (46,2 minutes per needle) and 125 minutes (40,6 minutes per
needle) respectively. Procedure time per needle was 12% faster at 3T (p-value 0,10).
In addition, 3T MR showed significantly higher overall image quality compared to 1.5T in tumor localization (2.0±0.6 vs. 2.8±0,5; p CONCLUSION Initial comparison of image quality and procedure time shows a trend towards faster needle placement at 3T. Moreover, capability to
monitor the cryoablation treatment was significantly better at 3T field strength. CLINICAL RELEVANCE/APPLICATION 3T MR imaging-guided focal cryoablation in patients with locally recurrent prostate cancer offers faster needle placement and higher
image quality, improving treatment monitoring, over 1.5T. LL-GUS-MO3B • Which One Shall We Choose for a Better Artery Imaging: Low kVp Scan or Spectral Imaging with Low keV One?
Ying Guo MD (Presenter) ; Dapeng Shi MD ; Peigang Ning ; Minghua Sun PURPOSE To evaluate image quality and radiation dose of spectral imaging of renal angiography compared with low kVp CTA scan. METHOD AND MATERIALS 10 patients(BMI>25,group A)referred to renal CT angiography underwent gemstone spectral CTA with pitch of 1.375 using
Iodixanol270(1ml/kg,5ml/s),10 patients (BMI>25,group B) performed conventional 100 kVp CTA with Noise Index of 11.5,pitch of 1.375
using Iopromide270(1ml/kg,5ml/s)were reviewed as control.Images of GSI scans were reconstructed to choose best keV by using CNR
tool.Images of low kVp scans were reconstructed with ASiR50%.Rois were placed in psoas muscle,renal artery of optimal keV series and
traditional 120kVp scans.CT value and noise(SD) was recorded and compared.Signal-to-noise ratio(SNR) and contrast-to-noise
ratio(CNR) was calculated with ROI measurements. Image quality and radiation dose was statistically compared. RESULTS SNR of renal artery were 34.10±4.40 for optimal low keV and 29.68±6.39 for 100 kVp ,CNR of renal artery were 29.26±4.00 for optimal
low keV and 24.65±6.33for 100 kVp. DLP was 477.36±69.48 mGy.cm for optimal low keV and 355.19±20.43 mGy.cm for 100 kVp. There
was significantly difference between low keV and low kVp scans(p CONCLUSION Spectral imaging with low keV can provide higher CT value,SNR and CNR but a little higher dose for renal artery imaging compared with
100kVp. CLINICAL RELEVANCE/APPLICATION Spectral imaging can give more information except for artery imaging. We shall make a balance of image quality, valuable information
and radiation dose according to clinical needs. LL-GUS-MO4B • Complex Cystic Renal Masses: Comparison of Cyst Complexity and Bosniak Classification between 1.5T and 3T
MRI
Page 135 of 397
Michael J Triolo MD (Presenter) ; Natasha Wehrli MD ; Thais Andrade MD ; Samir S Taneja MD * ; Andrew B Rosenkrantz MD PURPOSE To compare the perceived complexity and Bosniak cyst classification of cystic renal lesions between 1.5T and 3T MRI. METHOD AND MATERIALS A database search was performed to identify cystic renal lesions that underwent both 1.5T and 3T contrast-enhanced MRI within a 12
month span. Cysts exhibiting at least minimal complexity were included. Two radiologists (R1 and R2) independently assessed all lesions,
blinded to the field strength, in terms of number of septations, septal thickening, mural thickening, presence of mural nodule, and overall
Bosniak cyst category. Readers also subjectively scored clarity of internal morphology of all lesions on a 1-5 scale. Each reader's scores
were compared between 1.5T and 3T, with differences between these for a given lesion attributed to field strength rather than interval
progression of the lesion during the RESULTS 33 cystic renal lesions in 26 patients were identified. R1 observed greater number of septations, increased septal thickening, increased
mural thickening, and increased presence of a mural nodule at 3T in 8, 7, 4, and 2 lesions, and at 1.5T in 3, 3, 2, and 0 lesions,
respectively; R2 observed greater number of septations, increased septal thickening, increased mural thickening, and increased presence
of a mural nodule at 3T in 3, 4, 3, and 0 lesions, and at 1.5T in 2, 0, 0, and 0 lesions, respectively. R1 provided higher Bosniak category
at 3T in 9 cases and at 1.5T in 4 cases; R2 provided higher Bosniak category at 3T in 4 cases and at 1.5T in 0 cases. The higher scores
at 3T than 1.5T were associated with differences in advised clinical management in 7/9 cases for R1 and 4/4 cases for R2. Clarity of
lesion morphology was significantly greater at 3T than 1.5T (R1: 4.5±0.7 vs. 3.6±0.4, R2: 4.5±0.6 vs. 3.6±0.8; p CONCLUSION There was an overall tendency for both readers to upgrade renal cyst complexity and Bosniak cyst category at 3T than 1.5T, which
impacted advised management. We attribute this difference to known greater conspicuity of tissue enhancement at 3T. CLINICAL RELEVANCE/APPLICATION Given potential impact of MRI field strength on the perceived complexity of cystic renal lesions, we advise that serial MRI evaluation of
cystic renal lesions be performed at constant field strength. LL-GUS-MO5B • Novel Anatomic Kidney Segmentation to Describe Renal Tumors Eligible for Nephron Sparing Surgery: A
Comprehensive CT-scan Based Reporting
Pietro Lodise (Presenter) ; Valeria Panebianco MD ; Alessandro Cannavale ; Flavio Barchetti ; Rocco Papalia ; Carlo
Catalano MD PURPOSE To introduce a novel a segmental anatomy of the kidney integrated with a standardized radiological reporting method to describe small
renal masses ( METHOD AND MATERIALS Sixty patients underwent multiphase (pre-contrast, arterial, parenchimal and escretory phase) MDCT scan with 1 mm acquisitions. We
divided the kidney in three portions with perpendicular planes to the line of maximum longitudinal diameter of the kidney. These planes
pass through the bottom edge of the upper lip of the renal sinus and the other edge at the top of the lower lip. Hence the kidney was
divided into 3 zones (upper, middle, lower) and twelve segments identified with Roman numbers. Two radiologists blindly read all cases
according to a standardized report method : tumor size (TD, LD, APD), location in kidney's segment/s, exophityc growth pattern,
collecting system's relationship and tumor's feeding arteries (FA). Intra and inter-observer reliability was assessed with k-statistic test. RESULTS CONCLUSION Kidney segmentation and standardized radiological report are a simple and exhaustive manner to describe small renal masses location
and provide pointless information for clinical practice. CLINICAL RELEVANCE/APPLICATION A standardized report may help the radiologist to categorically describe small renal tumors giving the correct informations to the urologist
who has to plan nephron sparing surgery. LL-URE-MO6B • 3 Different Tools to Fuse MR to Ultrasound for Prostate Biopsy
Hayet Amalou MD (Presenter) ; Sheng Xu PhD ; Baris Turkbey MD ; Peter L Choyke MD * ; Peter Pinto ; Bradford J Wood
MD * PURPOSE To describe different methods enabling fusion biopsy for prostate cancer (PCa) as a rapidly emerging technique in GU imaging. METHOD AND MATERIALS A variety of tools have been developed for fusing MR and TRUS for prostate biopsy. The technologies are described with applications,
workflows, strengths and weaknesses. An early phase clinical trial based upon electromagnetic (EM) tracking enrolled > 850 patients who
underwent fusion guided prostate biopsy with EM tracking. MR localized suspicious targets for cancer based upon multi-parametric 3T MR
(T2, ADC, DCE, Spectroscopy) with an endorectal coil. The prostate capsule was segmented on T2. Targets were defined by GU
radiologists and sent to a workstation with segmentations and T2 volumes. Automated rigid registration with optional manual refinement
and motion compensation were performed with 2 EM coils attached to the TRUS transducer. RESULTS Fusion guided prostate biopsy can be used for at least two very different purposes: 1.) Prospective guidance of biopsy needle towards
targets pre-defined on MR. 2.) Mapping and archiving the location of standard blind sextant random conventional biopsies for potential
later retrospective referencing (such as for annual relook biopsies in patients with low Gleason scores or undergoing active surveillance or
watchful waiting). The UroNav system (In Vivo, Philips Healthcare, Gainsville, FL) is based upon an EM platform. The Artemis system
(Eigen, Grass Valley, CA) is based upon mechanical (or �passive robotic�) registration. The Urostation system (Koelis, La Tronche,
France) is based upon image fusion and image processing. Whether originally designed for function #1 or #2, most systems can perform
both. This tool may have added value for patients with Gleason 6 or 7 (3+4), when it can be helpful to watch with MR and sample with
fusion biopsy at some interval.
> 12,000 biopsies were performed with simultaneous EM tracking and fusion in an office-like outpatient setting, with patients receiving
both standard and fusion biopsies. MR-defined targets were biopsied without the requirement for the physical proximity of the MR gantry.
CONCLUSION Fusion prostate biopsy is a novel tool for referencing TRUS biopsy to prior MR, which may be useful for both prospective targeting or
retrospective mapping. CLINICAL RELEVANCE/APPLICATION Fusion biopsy improves cancer detection rates, and the radiologist should be aware of at least 3 technologies for this tool. Health Services - Monday Posters and Exhibits (12:45pm - 1:15pm) Monday, 12:45 PM - 01:15 PM • Lakeside Learning Center
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HP
LL-HPS-MOB • AMA PRA Category 1 Credit ™:0.5 LL-HPS-MO1B • Peer-to-Peer Escalation of Advanced Diagnostic Imaging Requests in a Utilization Management Program by
Facility Rural-Urban Commuting Area: Rural Providers May Need Guidance More Frequently
Kevin D Hiatt BS (Presenter) ; Jeffrey D Robinson MD * ; Daniel S Hippe MS * ; Timothy R Johnstad MBA * ; Brock A Oxford
MPH * ; Mark D Hiatt MD,MBA * PURPOSE Utilization management subjects provider requests for procedures to tiered evaluation with progressively greater clinical input at each
level, with peer-to-peer consultation at the highest tier. The purpose of this study was to determine the difference in escalation rates to
this ultimate tier between rural providers and urban ones in a prior authorization process for advanced diagnostic imaging (ADI). METHOD AND MATERIALS All ADI requests received by HealthHelp, a radiology benefit management (RBM) company, between January 1, 2012 and December 31,
2012 from providers for the nearly 5 million commercial, Medicare, and Medicaid subscribers to multiple health plans in all 50 states were
reviewed to ascertain the rates of escalation to peer-to-peer consultation, categorized by the rural-urban commuting area (RUCA) code of
the provider's facility as rural (codes 7-10), suburban (4-6), or urban (1-3). Rates of escalation were averaged within each group,
weighted by the total volume of ADI requests from each provider, and compared using linear regression. RESULTS 943,596 ADI requests were included in the data set. Of these, 46,642 exams (5%) were ordered by providers in rural areas; 114,010
(12%) by suburban providers; and 782,944 (83%) by urban providers. The mean rates of escalation were 3.16 ± 0.22% (95% CI), 2.80
± 0.14%, and 2.88 ± 0.05% for rural, suburban, and urban providers, respectively. The mean rate for rural providers was significantly
greater than for suburban (p=0.007) or urban providers (p=0.02), while mean rates were not significantly different between suburban
and urban providers (p=0.3). The mean rate was 10% higher for rural providers than urban providers. CONCLUSION Rural providers experience a significantly higher rate of escalation of their requests for ADI to the highest tier of peer-to-peer consultation
in the process of seeking prior authorization, which may reflect a greater need for clinical guidance. CLINICAL RELEVANCE/APPLICATION Rural providers, presumably with generally fewer resources and a lesser degree of subspecialization, may have greater need for the
guidance provided by RBM companies. LL-HPS-MO2B • Reduction of Turnaround Time of Radiologic Reports by Dedicated Communication Methods
Christoph Stern BA, MD (Presenter) ; Nadine Kawel-Boehm MD ; Klemens Wittig * ; Thomas Boehm MD PURPOSE With the introduction of diagnosis related groups (DRGs), there is an upcoming need to shorten the turnaround time of radiologic reports
in order to contribute to the economic success of a hospital. This important key-performance indicator is frequently not available. The
majority of hospitals are controlled and managed by financial indicators, while process orientated indicators are commonly not in use. The
purpose of our study was to define turnaround time of radiologic reports in our institution and to evaluate the influence of dedicated
communication methods on the turnaround time. METHOD AND MATERIALS The turnaround time of a radiologic report is defined as the time from confirmation of an exam till its approval. For our study purposes it
was extracted and calculated from the Radiology Information System (RIS) of our institution by a self-developed calculation tool within
the Software RadCentre Analyzer (Transact GmbH, Hamburg, Germany). The average turnaround time over all radiologic exams and the
average turnaround time for each modality � CT, MRI, x-ray and ultrasound � were calculated per month for the period between October
2012 and March 2013. Systematic and regular communication of turnaround times amongst staff radiologists was introduced in late
December 2012. RESULTS From October till December 2012 the average turnaround time over all radiologic exams (3 month average) was 33:40:18 (hh:mm:ss),
from January till March 2013 it was 25:56:44. The introduction of systematic and regular notification of the turnaround time for radiologic
reports resulted in a decrease of the turnaround time over all exams by an average of 7:43:33 (-22,9%) per month during this 3 months
follow up period. The largest decrease of turnaround time occured in reports of ultrasound (-29,5%) and x-ray exams (-27,5%), while
differences were smaller for reports of MRI (-3,2%) and CT exams (-2,2%). CONCLUSION Dedicated communication methods are effective to reduce the turnaround time of radiologic reports, however the impact on each
modality varies substantially. A longer follow up period is necessary to evaluate the long term effectiveness of communication methods. CLINICAL RELEVANCE/APPLICATION By reducing turnaround time of radiologic reports, important clinical information will be available earlier to clinicians, facilitating
immediate initiation of treatment. LL-HPS-MO3B • Effects of Using a Policy for Handling Secondary Interpretations of Outside Studies at an Academic Medical
Center on Reimbursement Rates
Robert Morgan BA (Presenter) ; Carlos J Sivit MD ; Bart Stovicek ; Pablo R Ros MD, PhD * PURPOSE To evaluate the reimbursement rates for secondary interpretations of outside imaging studies that were requested for medical necessity
by the treating physician. METHOD AND MATERIALS The policy we employed at our institution for rendering diagnostic readings of outside examinations requires that the treating physician
submit a requisition stating medical necessity for a secondary interpretation and that the study be less than 90 days old and in digital
format. Outside images are uploaded into a PACS, labeled as Outside Examinations, identified as a secondary interpretation in the
dictation, and coded with a '-77' modifier in addition to the original CPT code. The total percentage of gross charges reimbursed by
payers, including Commercial insurance, Medicare, Medicaid, Worker's Compensation and Self-pay patients for the professional
component of primary interpretations performed at our institution and for secondary interpretations were compared. Data were reviewed
for examinations performed between January 1, 2012 and October 31, 2012. RESULTS For primary interpretations the percent of gross charges reimbursed was 28.8%. For secondary interpretations the percent of gross
charges reimbursed was 32.3%. CONCLUSION Using a policy for handling secondary interpretations of outside imaging studies can result in reimbursement rates comparable to primary
interpretations. Page 137 of 397
CLINICAL RELEVANCE/APPLICATION Secondary interpretation of outside studies is often required for medical necessity. As reimbursements decline, it is imperative for
institutions to receive appropriate compensation for such work. LL-HPS-MO4B • One CT is Enough-Contrast Enhanced Ultrasound is Adequate for Blunt Abdominal Trauma Follow Up
Demosthenes D Cokkinos MD (Presenter) ; Eleni Antypa ; Dimitrios Tsiolias MD ; Dimitrios Tomais ; Stylianos V Benakis MD
; Ploutarhos A Piperopoulos MD, PhD PURPOSE To evaluate the ability of contrast enhanced ultrasound (CEUS) for imaging follow up of hospitalised patients who suffered blunt
abdominal trauma (BAT), after initial imaging on the day of injury with contrast enhanced computed tomography (CECT). To compare
subsequent CEUS findings to those of the initial CECT. METHOD AND MATERIALS 32 patients (18 men-14 women, aged 17-84 years) were imaged on an emergency basis with CECT due to BAT. CECT detected 35 solid
abdominal organ (liver, kidneys, spleen, adrenals) injuries (3 patients had injuries in 2 organs). All patients were admitted to the Hospital
and treated conservatively. In order to minimise radiation exposure, imaging follow up was performed 3-6 days later with CEUS post
injection of contrast agent SonoVue (2.4 ml). No additional CT was performed. CEUS findings were compared to the inital CECT to assess
improvement of solid abdominal organ injuries. RESULTS CEUS showed reduction in size of 26 injuries in 24 patients. 9 injuries in 8 patients showed complete resolution. All patients were
discharged from the Hospital in the following days with no additional imaging performed. CONCLUSION In all cases CEUS answered the question of following up BAT injuries with no additional CECT performed. Patients admitted for BAT
following an uneventful course can be subsequently imaged with CEUS. CLINICAL RELEVANCE/APPLICATION This practice can decrease the number of CECT, reducing patient radiation exposure, CT scanner workload and imaging cost. LL-HPS-MO5B • Radiological Anatomy: Evaluation of Integrative Education in Radiology
Sabine Dettmer ; Timm D Kirchhoff MD, PhD (Presenter) ; Andreas Schmiedl ; Simone Meyer ; Anja Giesemann ; Reinhard
Pabst ; Juergen Weidemann MD ; Frank K Wacker MD * PURPOSE Evaluation and analysis of the integrative course �Radiological Anatomy� established since 2007 in comparison with conventional
education. METHOD AND MATERIALS Anatomy and radiology are usually taught separately with a considerable time lag. Interdisciplinary teaching of these associated subjects
seems logical for several reasons. Therefore, the integrative course �Radiological Anatomy� was established in the second year of
medical education, combining these two closely related subjects. The participating students had already passed the dissection course in
the previous year. This interdisciplinary course was retrospectively evaluated a student questionnaire and staff observations. The
advantages and disadvantages of integrative teaching in medical education are discussed. RESULTS The course ratings were excellent (mean 1.4 on a scale of 1 to 6, n=94). This is significantly (p CONCLUSION Integrative teaching of anatomy and radiology was well received by the students. Both, anatomical and radiological comprehension and
the motivation to learn were improved. However, it should be considered, that the amount of work and time required by the teaching
staff is considerably increased compared to traditional teaching. CLINICAL RELEVANCE/APPLICATION Integrative teaching of anatomy and radiology can help to improve anatomical and radiological comprehension and the motivation to
learn. Informatics - Monday Posters and Exhibits (12:45pm - 1:15pm) Monday, 12:45 PM - 01:15 PM • Lakeside Learning Center
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LL-INS-MOB • AMA PRA Category 1 Credit ™:0.5 LL-INS-MO1B • Improving the Practical Capability of an Eye-tracking System in Clinical Settings
Hiroyuki Sekiguchi (Presenter) ; Masahiro Yakami MD, PhD ; Koji Fujimoto MD, PhD ; Takeshi Kubo MD ; Yutaka Emoto MD,
PhD ; Kaori Togashi MD, PhD * ; Koji Sakai ; Ryo Sakamoto ; Gakuto Aoyama ; Masami Kawagishi ; Yoshio Iizuka ; Hiroyuki Yamamoto CONCLUSION Performance of a current eye-tracking system in clinical settings can be improved with use of our eye-tracing unit. Background An eye-tracking system has great potential for innovative diagnostic applications such as an oversight indication system. However, current
eye-tracking systems are impractical in clinical settings because they cannot cover the entire diagnostic screen, especially in the height
direction. We solved this problem by employing a self-directed eye-tracing unit that automatically tilts the base of the eye-tracking
system according to the observer's eye position.
Evaluation We calibrated the eye-tracking system (X120; Tobii Technology, Stockholm, Sweden) against a diagnostic screen that consisted of two
20-inch lengthwise monitors. Then, eye-tracking data from daily radiograms were interpreted by three radiologists. The recording time
for each data set was about 3 hours. During the data acquisition session, our head-tracking unit was switched on and off at 10-minute
intervals.
Finally, we compared the number of times the eye-tracking system lost the radiologist's viewpoint both with the support of the
eye-tracing unit and without this support. The improved ratios when using the eye-tracing unit were 26%, 17% and 3% for radiologists A,
B and C, respectively.
Discussion This unit had a large effect on the results of radiologists A and B, while it had almost no effect on that of radiologist C. We therefore
examined a viewpoint pattern for each radiologist and found that radiologist A divided the screen into three parts in the height direction
and looked at them almost evenly. Radiologists B and C divided the screen into two parts in the height direction. We also found that
radiologist C looked at images displayed mainly on upper parts of the screen. Therefore, his head was considered to have been almost
Page 138 of 397
radiologist C looked at images displayed mainly on upper parts of the screen. Therefore, his head was considered to have been almost
stable during his diagnosis, and that is the reason why our eye-tracing unit had no effect on the results of radiologist C. For radiologists
who use the entire diagnostic screen, this unit is helpful in improving the capacity of the eye-tracking system.
LL-INS-MO2B • Use of Natural Language Processing to Classify Radiology Reports Containing Description of the Abdominal Aorta
Amilcare Gentili MD (Presenter) ; Brian E Chapman PhD CONCLUSION Using pyContex is possible to correctly classify reports containing description of AAAs, simplifying the task of finding patients that may
need a follow-up. Background Current recommendations are for one-time screening for abdominal aortic aneurysm (AAA) by ultrasonography in men aged 65 to 75 who
have ever smoked, followed by yearly ultrasonographic screening if aortic diameter is between 3.0 to 4.0 cm; ultrasonography every 6
months if aortic diameter is between 4.0 to 4.5 cm; and referral to a vascular specialist if aortic diameter is greater than 4.5 cm. To
separate radiology reports describing AAAs from reports describing normal aortas, we use natural language processing. Evaluation For this study, we used pyConText, a Python implementation of the ConText. ConText is a simple text-processing algorithm that uses
simple lexical cues to relate modifying phrases, such as expressions of uncertainty, temporality, or negation, to findings described in text.
The classification performed by a radiologist reviewing the radiology reports was compared with pyConText classification. Discussion Out of 473 reports pyConText classified 82 patients as having an AAA, and 391 as not having an AAA including 4 false negative and 5
false positive for a sensitivity of 95.1% and a specificity of 98.7%. LL-INS-MO3B • Image-based Kernel Conversion Technique Normalized the Reconstruction Kernel Effects in the Measurement of
Emphysema Index in CT
Hyeongmin Jin (Presenter) ; Jong H Kim PhD ; Chang Yong Heo BS PURPOSE The emphysema index (EI) in CT is known to be strongly affected by reconstruction kernel. This study presents an image-based kernel
conversion technique which converts CT image of sharp kernel to that of standard kernel and evaluates its impact on EI normalization for
images obtained with different kernels. METHOD AND MATERIALS 48 sets of CT data taken at 120kVp, 40mAs, 1mm thickness, of 2 reconstruction kernels (B30f, B50f) were selected from low dose lung
cancer screening database. An image-based kernel conversion technique, which converts an image to take effect of different kernel by
applying the ratio of kernel MTFs to the Fourier transformed spectral components, was performed to the CT data set of B50f kernel to
produce a converted B30f data set. The EI (RA950) was measured with a software package (Pulmonalizer, Seoul, South Korea) and
compared between two data sets of B30f kernel and those converted B30f kernel. The accuracy of kernel conversion was evaluated with
the mean and standard deviation of pair-wise differences in EI. RESULTS Population mean of EI was 10.57±5.84% for the B30f data set, 28.76±6.24% for B50f data set, and 10.86±6.37% for the converted B30f
data set. The mean and standard deviation of pair-wise differences in EI between B30f and the converted B30f 0.85% and 0.76%,
respectively. The correlation between the EI of two data sets was 0.987 CONCLUSION Our study demonstrates the feasibility of image-based kernel conversion technique for normalization of kernel effect in measurement of
EI. CLINICAL RELEVANCE/APPLICATION This technique has a potential to be used in evaluating the longitudinal changes of EI even when the CT was reconstructed with different
kernel. LL-INS-MO4B • Data Analysis of Brain MRI at a Tertiary Hospital in Sudan
Radya G Osman MBBS (Presenter) ; Abdalla M Gabir MD, FRCR ; Mirghany O Babiker MBBS, FRCR ; Isam M Izzeldin MBBS,
MRCP CONCLUSION 16 cases of brain pathology where matched with radiology and histopathology diagnoses .Those 16 cases are presented in this study. Background Sudan is a country with a population of 36,787,012 and a size of 718,723 square miles. There are 17 MRI machines present in the entire
country. Fifteen of them are located in the capital Khartoum, while 2 machines are left to serve the other 16 states. Out of the 17 MRI
units, only 3 diagnostic MRI centers have a data archiving option, leading to the loss of valuable patient data. Evaluation For this study, a database of 1,540 MRI brain images, scanned during 2012, was created. The data was used to identify 662 cases with
brain pathology. Discussion Age and gender distribution of cases was also analyzed. For the purpose of comparison, 87 histopathology reports from the same hospital
were obtained in order to confirm the radiologic diagnosis. LL-INS-MO5B • Tablet Computer Assisted Target-oriented Forensic Autopsy
Alina Sassenberg MMed (Presenter) ; David Simons MD ; Ignaz Reicht ; Heinz-Peter Schlemmer MD ; Kathrin Yen MD PURPOSE Radiological data has proven to support forensic autopsy and often is required before or during the procedure. For e.g., detecting gas or
foreign bodies, computed tomography (CT) has shown to be superior to the autopsy. Image viewing usually requires a workstation which
is rarely located in the autopsy suite. Thus CT images are seldom accessible during autopsy. The aim of this study was to evaluate if the
display of radiological data on a tablet computer (PC) could support and guide forensic autopsy. METHOD AND MATERIALS We installed software for interpreting radiological data (MITK-pocket, a slighter version of the CE-certified MITK) on a tablet PC (iPad A
1430, Apple Inc.). In 20 randomly selected cases, postmortem CT scans (Somatom AR.SP, Siemens AG) of the head, thorax and
abdomen were performed at least 1 hour before autopsy. CT data was uploaded to the tablet PC and analyzed prior to autopsy by a
radiologist in consensus with a forensic pathologist. The tablet PC was prepared for observing hygienic standards. For the current study
we focused on bone fractures, air, foreign bodies, liquids, the position of organs, and if collapse of the aorta was present in the thorax
region. Radiological results were used to guide the autopsy process. A standardized questionnaire about handling and benefit was filled in
by both the radiologist and the forensic pathologist. Page 139 of 397
RESULTS Radiological data was easily accessible during the whole course of autopsy., Autopsy techniques could be preselected and used
target-oriented. The detection and localization of the addressed injuries was clearly supported by the additional imaging data. A fluent
workflow was established which directly guides the course of autopsy in the determined cases. CONCLUSION The tablet PC provides useful assistance, increased convenience and additional information during forensic autopsy. However, before
entering daily practice we recommend to further evaluate the use of tablet PCs at autopsy site in a multiple centre study. Tablet PC
assisted forensic autopsy supports forensic case assessment and has a general potential to be broadly used as being cheap and easily
available. CLINICAL RELEVANCE/APPLICATION The availability of radiological images during autopsy can support target-oriented forensic autopsy and injury assessment. The use of
tablet devices for delivering radiological images therefore seems LL-INS-MO6B • The Pursuit of Meaningful Use Part 2: When Penalties Don't Matter
Adeel Siddiqui MBBS (Presenter) ; Mehwish Shayaan MBBS ; Keith J Dreyer DO, PhD * CONCLUSION Group structure and timing of the upgrade cycle are key factors in determining whether a radiology group should pursue meaningful use.
Many groups may still take advantage of the EHR incentive program not only for the short term financial gain, but also for the increased
interoperability it brings with referring physicians. Background The purpose of this talk is update the radiology community regarding meaningful use to see if it is right for their practice. This is meant
as an update to the 2012 abstract �The Pursuit of Meaningful Use�. Meaningful use (MU) is a government run program to accelerate the
adoption of electronic health records in the United States. In 2014, Individual radiologists can earn up to $24,000 if they comply with the
program. Recent addition of the significant hardship exemption to radiologists gives groups a convenient way to avoid penalties. Lack of
specialty specific criteria, and availability of certified products have already made people wary. When should a practice look to upgrade to
MU? When should a practice avoid MU?
Evaluation Radiologists can claim significant hardship exemptions based on the radiology specialty codes to avoid penalties. Radiology must be listed
as the primary specialty of the physician in the Provider Enrollment, Chain, and Ownership System (PECOS). Discussion Recently published significant hardship exemption rules limit potential penalties by radiologists. On the other hand, Radiology groups
affiliated with an institution that already has a certified electronic health record (EHR), or groups that are single site with a single
radiology information system (RIS) are in a great position to benefit from MU with little effort or cost. Small groups that have resisted
upgrade cycles will never have a better time to upgrade. These types of practices can would also enjoy the benefits of being better
integrated with the entire hospital information systems. Groups that have completed upgrades recently or do not have a high Medicare
population are the most vulnerable to excessive costs and �upgrade fatigue�. These groups might take advantage of the significant
hardship exemption. LL-INE3205-MOB • Using the Scored Quiz Feature of MIRC TFS to Run a Departmental Case of the Week Contest
Tessa S Cook MD, PhD (Presenter) ; John Perry Background Case of the day (or week) contests are popular among residency programs and radiology depoartments to foster friendly competition
while still promoting individual or collaborative learning. Our case of the week (CoW) implementation has evolved over the past few years
to its current implementation using the RSNA MIRC Teaching File System (TFS). Evaluation The original CoW consisted of images posted within a Microsoft SharePoint site, with a link to a web form that collected submitted
diagnoses and emailed them to the CoW manager. Subsequently, it was revised to be a self-contained, database-driven website into
which images and content were loaded and updated on a weekly basis. Using TFS along with the new scored quiz feature, we can send
images directly from PACS via the patient-centric workflow to be incorporated into a new case. The scored quiz enables the addition of a
text box to a case so that TFS users can log in, view the case and submit their favored diagnosis. The case owner can score the
submitted entries and track users' scores during the contest using the administrative features of TFS. Discussion By implementing our CoW within TFS, we can preserve the content posted from week to week for users to access for independent
learning. In addition, the process of creating a new CoW each week has been streamlined yet again, as all the functionality of the TFS can
now be brought to bear on content creation and management. In addition to running case contests, the scored quiz can be used to create
assessment modules (such as to track ACGME milestones), interactive conference presentations (to prepare residents for the Exam of the
Future) and even to educate medical students and non-radiology residents. CONCLUSION MIRC TFS can be used to successfully maintain a case of the week application for a radiology program, without requiring the
administrator to be technically savvy or manually program the system. This latest iteration of the CoW-now using the MIRC TFS-is the
most robust to date, with the added advantage of persistent case content from week to week. Scored quizzes in MIRC TFS have a number
of potential applications which can be used to enhance radiology resident and fellow education. LL-INE3201-MOB • An Imaging Informatics-based System with a Novel Intelligent Workflow Engine to Support Rehabilitation
Clinical Trial Research
Brent J Liu PhD ; Ximing Wang MS (Presenter) ; Clarisa Martinez ; Carolee J Winstein PhD Background Workflow engines have been shown to improve efficiency in business by automating processes. Complex clinical research workflows--such
as those of rehabilitation clinical trials--that efficiently collect, analyze, and distribute multimedia data at various stages within the
workflow can also benefit from these workflow engines. Currently, the data management needs of clinical trials are typically addressed
with custom-built systems. However, the challenge arises when changes to the workflow require additional software development, a step
that can be time- and resource-consuming, and can negatively impact data collection. To address this issue, we present an intelligent
workflow engine for complex randomized control trials. We will first apply it to the existing system that was developed for a rehabilitation
clinical trial designed to understand the optimal dose of a principle-based rehabilitation intervention after stroke (DOSE). The results will
yield a new application of workflow engines that can be possibly extended to other clinical trials. Evaluation Page 140 of 397
The system enables a project coordinator to build a data collection and management system specifically related to study protocol
workflow through a graphical user interface. A library of modules can be chosen and added to each phase of the workflow. Prior to each
treatment session, the user can predetermine which evaluation tools will be utilized and in what order they will be performed according to
protocol. A web-based DICOM viewer is integrated for visualization of brain images. The usefulness of the system will be evaluated with
data from the 12 subjects enrolled in the DOSE trial. The target enrollment is 60 subjects over a 4-year period. Discussion Intelligent workflow engine provides flexibility to build and tailor the workflow for different stages within the clinical trial. By providing a
solution to tailor and automate the workflow, the system will save time and reduce errors for project coordinators. CONCLUSION We developed a new imaging informatics-based system with an intelligent workflow engine. Although our system is designed for a
rehabilitation trial, it has the potential to be extended to other non-rehabilitation clinical trials LL-INE3203-MOB • Demonstration of a Novel Diagnosis Support System for Lung Lesions: Computed Tomography with an
Image-retrieval Technology Based on Radiologists' Knowledge
Toyohiko Sakai MD (Presenter) ; Kenji Kondo * ; Kazutoyo Takata * ; Kazuki Kozuka * ; Masakai Kiyono * ; Hirohiko
Kimura MD, PhD ; Masato Tanaka PhD Background The use of diagnosis support systems, which show similar cases from medical archives, has been proposed in recent years. However,
such systems can mislead radiologists if similar cases are not appropriately selected.
In this presentation, we have proposed a novel image-retrieval system that employs a weighting technique based on radiologists�
knowledge to select reference images and demonstrated an actual system that employs this principle.
Evaluation To compile the data required for weighting, radiologists marked 1026 regions of interest (ROIs) on lung CT images and classified them
into 12 imaging patterns, including consolidation and wide-spread ground glass. Image similarity was primarily calculated using 413 types
of image features. In the new technique, the calculation was weighted on the basis of the regression coefficients for each lesion pattern
classified by radiologists. Similar images were retrieved with or without a weighting technique. Finally, image similarity was graded on a
5-point scale (with a score of 5 indicating 'very similar') by 2 radiologists in a blinded manner.
For each evaluation, 60 ROIs that included the 12 patterns were extracted as a query. The precision (subjective evaluation score = 4)
was 78.0% and 75.0% using the proposed method with a weighting technique, and 62.7% and 62.0% without it. The 2 sets of values
showed statistically significant differences (P < 0.01).
Discussion Lung disease generally involves diverse lesion patterns, and diverse image features are used in queries. Therefore, a simple combination
of all image features results in degradation of search performance. Subjective evaluation clearly showed that the use of a weighting
technique can solve this problem. CONCLUSION A novel image-retrieval technology is introduced in this study. This diagnosis support system, which uses weighted image retrieval with an
archive of images, might help radiologists make rapid and appropriate diagnoses and consequently encourage them to make greater use
of these systems. Musculoskeletal - Monday Posters and Exhibits (12:45pm - 1:15pm) Monday, 12:45 PM - 01:15 PM • Lakeside Learning Center
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LL-MKS-MOB • AMA PRA Category 1 Credit ™:0.5 LL-MKS-MO1B • Prevalence of Post-operative Complications in Patients with Articular Surface Replacement (ASR) with Hip
Prosthesis Evaluated Using Magnetic Resonance Imaging (MRI)
Silvana Sdao MD (Presenter) ; Alberto Aliprandi MD ; Carmelo Messina ; Luca Maria Sconfienza MD, PhD ; Francesco
Sardanelli MD * PURPOSE Patients with certain types of ASR hip replacement are reported to present with high prevalence of a pathologic condition known as
metallosis, caused by the localization of metallic debris in the soft tissue around the replaced hip joint. This condition has been related to
several complications including severe joint pain, implant failure or loosening, local tissue necrosis, pseudotumors and osteolysis. Our aim
was to evaluate post-operative complications in a series of patients who underwent ASR with DePuy hip prostheses. METHOD AND MATERIALS IRB approval was obtained and patients�consent was waived. This study included 65 patients who underwent ASR with DePuy hip
prosthesis (ASRTM XL Acetabular Hip System and DePuy ASRTM Hip Resurfacing System; DePuy Synthes, Johnsons and Johnsons, IN,
USA) and were imaged at our hospital between January 2011 and January 2013. We excluded 25 patients who underwent x-ray and
ultrasound examination only. Thus, our series included 40 patients (21 females, 19 males; mean age 58±15 years, range 26-86 years)
who underwent MRI using a 1.5 T system (Magnetom Sonata, Siemens) after a mean delay of 7±2 years from surgery. Imaging protocol
included three-plane T1- and T2-weighted sequences with and without fat saturation optimized for susceptivity artifact reduction without
any specific algorithm. For each patient, we evaluated the presence of ilio-psoas bursitis, peri-prosthetic fluid collection, joint effusion,
and abnormal bone marrow signal. RESULTS Out of 40 patients, 25 (62.5%) showed post-operative complications. Among them, 8 (20%) had ilio-psoas bursitis, 7 (17.5%) had
peri-prosthetic fluid collection, 3 (7.5%) had joint effusion, 2 (5%) abnormal bone marrow signal. Four patients (10%) had both
ilio-psoas bursitis and peri-prosthetic fluid collection, while one patient (2.5%) had both ilio-psoas bursitis and abnormal bone marrow
signal. CONCLUSION After 7 years from surgery, patients implanted with DePuy hip prosthesis have 62.5% complication rate. MRI is effective in detecting such
complications also without using specific artifact reduction algorithms. CLINICAL RELEVANCE/APPLICATION MRI is effective in detecting complications in patients who underwent ASR with DePuy implants without using specific artifact reduction
algorithms. LL-MKS-MO2B • Athletic Pubalgia and Other Findings in Patients Referred for MRI of Sports-related Groin Pain: With Surgical
Correlation
Matthew Maeder MD (Presenter) ; Devon Klein MD,MPH ; Mark Zoland MD PURPOSE Page 141 of 397
PURPOSE To first clarify the complex musculoskeletal anatomy involving the pubis and the assorted terminology used to describe athletic pubalgia
(including 'sports hernia') and other disorders of the groin. Then to report the incidence of athletic pubalgia, its common mimickers, and
concomitant injuries or pathology. METHOD AND MATERIALS A database query of adults referred for imaging of sports-related groin pain during a two year period yielded 64 examinations of 62
outpatients. The mean age of this population was 38 years old (range 16-71). Thirteen patients were female. There were 38 MRI-positive
cases of athletic pubalgia, defined as any abnormal signal, tear, or defect of the rectus abdominis tendon, adductor longus tendon, or
prepubic aponeurosis. The presence or absence of additional findings including inguinal hernias and acetabular labral tears were also
recorded. Surgical correlation and follow-up, when available, was obtained from the patients' surgeon. RESULTS There were 38 (59%) MRI-positive cases of athletic pubalgia, found bilaterally in 18 cases. In 14 of these positive studies, there was the
additional finding of inguinal hernia. Inguinal hernias were present in a total of 22 (34%) of all the reviewed studies. The addition of a
Valsalva sequence to our protocol was instrumental in detecting four of these inguinal hernias. Acetabular labral tears were more
commonly found, present or suspected in 44 (69%) of the studies. As of yet, an unknown number of these patients had surgical
correlation and follow up of their symptoms. CONCLUSION Athletic pubalgia was present in most outpatients presenting to our institution with sports-related groin pain. Additional pathology was
found in a significant number of cases, and specific protocols that include a Valsalva sequence are recommended to increase conspicuity
of and sensitivity for concomitant pathology such as inguinal hernia. CLINICAL RELEVANCE/APPLICATION In patients referred for MRI imaging of sports-related groin pain, pathology was frequently found. Measures to help detect correctable
conditions, such as inguinal hernia, are recommended. LL-MKS-MO3B • Assessment of the Multi-banded Anterior Talofibular Ligament Using 3D Isotropic Fast-spin Echo MR Sequence:
Normal Anatomy and Its Injury
Seung Min Nam (Presenter) ; Hye Jung Choo MD ; Sun Joo Lee MD ; Ok Hwa Kim ; Young Mi Park MD, PhD ; Seok Jin Choi ; Seon-Jeong Kim MD PURPOSE To evaluate the frequency and MR characteristics of multi-banded anterior talofibular ligaments (ATFLs) in normal ankles and to
characterize the tear types of multi-banded ATFLs in sprained ankles using a 3D isotropic proton density fast-spin echo (3D PD FSE) MR
sequence. METHOD AND MATERIALS In the first session, 3D PD FSE MR imaging of 33 ankles was obtained from 20 asymptomatic volunteers. The number of bands in the
ATFLs and locations of the ATFLs on orthogonal planes of the 3D PD FSE images and the signal intensity, depth, and width of each band
on their multiplanar reformatted images parallel to the orientation of each band of the ATFL were evaluated by 2 readers. In the second
session, 3D PD FSE MR imaging of 51 sprained ankles was evaluated by 2 readers for determining the number of bands in the ATFLs and
the presence of tears in each band. RESULTS In the first session, 3 ATFLs were single-banded, 27 were double-banded, and 3 were triple-banded. In double-banded ATFLs, the
superior band was about 2 times wider and thicker than the inferior band. The depth, width, and location of single-banded ATFLs and the
superior band of double-banded ATFLs were not significantly different. In the second session, the most common type of injury in
double-banded ATFLs was a 2-band tear. CONCLUSION In an evaluation using the 3D PD FSE sequence, most ATFLs consisted of 2 bands, and tears in both bands were the most common type of
injury in double-banded ATFLs. CLINICAL RELEVANCE/APPLICATION 1. Most anterior talofibular ligaments consist of 2 bands. 2. Tears in both of 2 bands are the most common type of injury in the
double-banded anterior talofibular ligaments. LL-MKS-MO4B • Effects of Different Voltages and Tube Currents on MDCT Attenuation of Vertebral Trabecular Bone Using
Different Reconstruction Algorithms
Marcos P Botelho MD (Presenter) * ; Fernanda D Gonzalez Guindalini MD * ; Adeel R Seyal MD * ; Keyur Parekh MD * ; Vahid Yaghmai MD PURPOSE To evaluate the effects of various kV and mAs combinations on MDCT based vertebrae trabecular bone density using different
reconstruction algorithms. METHOD AND MATERIALS An anthropomorphic torso phantom was scanned 15 times, with 80, 100 and 120 kVp and with 10, 20, 40, 75 and 110 mAs. The images
were reconstructed both with Filtered Back Projection (FBP) and with Sinogram Affirmed Iterative Reconstruction (SAFIRE). MDCT
attenuation of T11, T12 and L1 as well as noise was recorded by placing the largest possible ROIs within the trabecular bone of the
vertebrae. CNR was calculated in relation to the left paravertebral muscle. Student's t-test was used for statistical analysis. Statistical
significance was set at 0.05. RESULTS Mean attenuation measurements from phantom vertebrae were higher with 80kVp (313.6 and 313.9 HU), intermediate with 100 kVp
(261.3 and 261.4 HU), and lower with 120 kVp settings (232.5 and 233.1 HU) obtained with FBP and SAFIRE, respectively (p0.05). Noise
was significantly lower when iterative reconstructions was applied on all acquisition settings (p CONCLUSION Vertebral trabecular bone attenuation numbers increase with lower kVp settings, but do not change significantly with different mAs,
regardless of the reconstruction algorithm. CNR values are significantly higher when iterative reconstruction is applied. CLINICAL RELEVANCE/APPLICATION MDCT vertebral attenuation may quantify bone density. Settings for calibration and image acquisition may affect results. Reconstruction
algorithm may not play an important role in this scenario. LL-MKS-MO5B • Thermal Ablation Techniques for Curative Treatment of Bone Metastases
Frederic Deschamps (Presenter) ; Geoffroy Farouil ; Lambros C Tselikas MD ; Thierry J De Baere MD * PURPOSE To determine prognostic factor(s) for complete thermal ablation (TA) of bones metastases METHOD AND MATERIALS Page 142 of 397
The medical records of all the patients who had undergone curative-intent TA of bone metastases in our Institution between September
2001 and February 2012 were retrospectively reviewed. The goal of the TA was to achieve a local tumor control in order to cure all bone
metastases in oligometastatic patients or to prevent the occurrence of skeletal-related events in long life expectancy cancer patients.
We have analyzed the rate of complete treatment at 1 year according to the patients� details -gender, age, site of the primary tumorand the bone metastases� characteristics -synchronicity with the primary tumor, already treated by external radiotherapy, local
evolution within 3 months before the procedure (RECIST criteria), location (axial vs. appendicular), maximal diameter at baseline CT,
condensation aspect at CT (lytic vs. sclerotic), bone cortical erosion, critical neurological structures in the vicinity (less than 10mm), TA
technique used (radiofrequency ablation vs. cryoablation)-. RESULTS Eighty-nine consecutive patients underwent TA in a curative-intent of 124 bone metastases. The median follow-up was 22.8 months [12.2
to 44.4 months). We report a 67% of complete treatment at 1 year. In multivariate analysis the good prognostic factors for complete
treatment were: metachronous bone metastasis (p=0.004), no progression within 3 months before (p=0.004), no cortical erosion
(p=0.01), maximal diameter CONCLUSION Thermal ablation techniques are effective to cure small ( CLINICAL RELEVANCE/APPLICATION Thermal ablation techniques must be considered in oligometastatic patients or in long life expectancy cancer patients with bone
metastases. LL-MKS-MO6B • Grading Focal and Diffuse Articular Cartilage Lesions of the Knee Joint as Correlated with Arthroscopy:
Comparison of 3D Dual-echo Steady State and Fat-saturated Proton Density-weighted Fast Spin Echo Sequences on 3T MR
Imaging
Fang Zhao (Presenter) ; Shadpour Demehri MD ; Filippo Del Grande MD, MBA ; Andrew Kompel MD ; Sahar J Farahani MBBS
; Rashmi S Thakkar MD ; John A Carrino MD, MPH * PURPOSE Purpose: Two-dimensional fat-suppressed proton density turbo spin echo (2D FS PD-TSE) weighted imaging is commonly used clinically
but may suffer from anisotropic voxels and partial volume effects which can be solved and decreased by using three-dimensional water
excitation dual echo steady state (3D WE DESS) technique. The purpose of this study is to evaluate the correlation between the grading
of focal and diffuse cartilage lesions on 3D WE DESS and 2D FS PD-TSE imaging with arthroscopy and to test the inter-observer
reliability. METHOD AND MATERIALS Methods and Materials: In this IRB approved, HIPAA compliant, retrospective study, 45 patients (21 Males, 24 Females; mean age 42.8
±13.7 SD years, range 13-71 years) who had their knee arthroscopy performed within 3 months of 3T MR Imaging were included. Three
trained musculoskeletal radiologists masked to the arthroscopic results independently evaluated focal and diffuse articular cartilage
lesions of the knee and graded them according to International Cartilage Repair Society (ICRS) scoring system on isotropic 3D WE DESS
images and on 2D FS PD-TSE images with a 2-week wash out period between evaluations. Statistical analysis included spearman
correlation (rho) of 3D WE DESS and 2D FS PD-TSE with arthroscopy. Inter-observer reliability was determined with kappa. RESULTS Results: The rho values for 3D WE DESS versus arthroscopy were 0.48, 0.26, 0.36 and for 2D FS PD-TSE versus arthroscopy were 0.51,
0.27, 0.35 for readers 1, 2, 3, respectively. The reliability of 3D WE DESS was 0.29 overall with pairwise comparisons of 0.22, 0.46, 0.25
and the reliability of 2D FS PD-TSE was 0.26 overall with pairwise comparisons of 0.15, 0.46, 0.25 (for readers 1 and 2, 2 and 3, 3 and 1
respectively). CONCLUSION Conclusion: 3D WE DESS performs similarly to 2D FS PD-TSE sequence for grading cartilage lesions of the knee. 3D WE DESS sequence
has a little higher inter-observer reliability compared to 2D FS PD-TSE. CLINICAL RELEVANCE/APPLICATION Clinical Relevance: 3D-DESS on 3T MR imaging can be used to grade the articular cartilage lesions of the knee similar to 2D FS PD-TSE
obviating multi-planar acquisition. LL-MKS-MO7B • Primary Pain Palliation and Local Tumor Control in Bone Metastases Treated with MR Guided Focused Ultrasound
Beatrice Cavallo Marincola MD ; Alessandro Napoli MD (Presenter) ; Fabrizio Boni ; Brachetti Giulia MD ; Maurizio Del Monte
; Carlo Catalano MD PURPOSE To evaluate the clinical performance of MRgFUS in the primary treatment of painful bone metastases and to explore the potential of this
technique in achieving local control METHOD AND MATERIALS 26 consecutive patients (female: 12, male: 14; mean age: 64.7 ± 7.5) with painful bone metastases were enrolled. Patients were
examined clinically for pain severity and pain interference according to Brief Pain Inventory-Quality of Life (BPI-QoL) criteria before and at
regular time-points over the following 3 months after treatment. CT and MR imaging was performed before and at 3 months after
MRgFUS treatment. Local tumor control was defined as a significant imaging modification from baseline in terms of lesion size, density
and perfusion at CT or dynamic ce-MR imaging (Discovery 750, GE; Gd-Bopta, Bracco) and metabolic activity at PET or scintigraphy. The
imaging parameters for local tumor control were individually evaluated in responder and non-responder patients. RESULTS No treatment-related adverse events were recorded during the study. Statistically significant difference between baseline and follow-up
values for pain severity and pain interference (both p=0.001) was observed. Increased bone density was observed in 9/26 (34.6%)
patients. Non-Perfused Volume values ranged between 20 and 92%. There was no difference in NPV values between responder and
non-responder patients (46.7 ± 24.2% [25 � 90 %] vs. 45 ± 24.9% [20 � 93 %]; p=0.7). In 6 patients (5 prostate and 1 breast
primary cancer) there was nearly absence of metabolic activity after treatment with mean SUV=1.2. CONCLUSION MRgFUS can be safely and effectively used as the primary treatment for pain palliation in patients with bone metastases; our experience
demonstrated also a critical role of MRgFUS in local tumor control as confirmed by metabolic analysis. CLINICAL RELEVANCE/APPLICATION MRgFUS can be applied as primary non-invasive technique for pain palliation related to bone metastases with the advantage of a
relatively short treatment time and the possibility of be repeated if nec LL-MKE-MO8B • 3 Tesla Chemical Shift MR Imaging: Technique, Clinical Utility and Pitfalls for Imaging the Skeleton
Filippo Del Grande MD, MBA (Presenter) ; David Dreizin MD ; Laura M Fayad MD PURPOSE/AIM To review the technical considerations and important pitfalls of performing and interpreting chemical shift imaging (with in-phase and
opposed-phase gradient echo sequences) at 3T for the assessment of bone marrow abnormalities. The clinical utility of this sequence will
be discussed as it relates to the assessment of bone lesions, for characterization and for determining tumor extent. Page 143 of 397
CONTENT ORGANIZATION 1. Technical considerations for 3T imaging
2. Qualitative and quantitative analysis of in-phase and opposed-phase imaging
3. Clinical utility of chemical shift imaging
-Characterization of bone lesions:
-Differentiating pathologic from non-pathologic spine fractures
-Differentiating bone marrow infiltrative disorders and marrow replacement
-Determining extent of disease
-Specific pathologies amenable to evaluation by chemical shift imaging
3. Important pitfalls
-Impact of choice of time of Echo (TE) -Technical acquisition errors at 3T (compared with 1.5T)
SUMMARY Chemical shift imaging is a valuable technique for differentiating bone marrow replacement from non-bone marrow replacement
processes. However, at 3T, there are important technical factors which the radiologist must be aware of to use chemical shift imaging
correctly. In addition, the radiologist should be familiar with potential pitfalls to avoid misleading interpretations. Neuroradiology/Head and Neck - Monday Posters and Exhibits (12:45pm - 1:15pm) Monday, 12:45 PM - 01:15 PM • Lakeside Learning Center
Back to Top NR
LL-NRS-MOB • AMA PRA Category 1 Credit ™:0.5 LL-NRE-MO10B • Radiologic Evaluation of Pseudoprogression and Pseudoresponse in Glioblastoma: What Radiologists Need to
Know
Geunwon Kim (Presenter) ; Katherine M Gallagher MD ; Nadja Kadom MD ; Yukio Kimura MD ; Takaki Murata MD ; Naoko
Saito MD, PhD ; Akifumi Fujita MD ; Osamu Sakai MD, PhD * PURPOSE/AIM High-grade glioma is the most common brain malignancy in adults. Concurrent temozolomide and radiotherapy is the new standard of
care for patients with glioblastoma multiforme (GBM). Assessment of treatment response using conventional MRI is complicated by
pseudoprogression and pseudoresponse. The purpose of this exhibit is:
1. To review treatments for GBM.
2. To summarize concepts and illustrate pseudoprogression and pseudoresponse on conventional MR imaging.
3. To discuss and illustrate the use of advanced MRI and PET in differentiating true progression from pseudoprogression
CONTENT ORGANIZATION 1. Review of GBM treatments.
2. Definition and pathophysiology of pseudoprogression and psueodrtesponse.
3. Review of post-treatment conventional MRI: A. Recurrence B. Pseudoprogression C. Radionecrosis D. Pseudoresponse
4. Review criteria for tumor response after treatment and revised time-to-chemotherapy dependent criteria.
5. Discussion of imaging modalities to differentiate pseudoprogression from recurrence: A. Conventional MRI B. MR spectroscopy C. MR
perfusion D. FDG-PET/CT
SUMMARY Radiologists should be aware of the imaging features on post-treatment of GBM on conventional MRI. Having an understanding of the
concepts and the utilization of advanced MRI and PET imaging techniques can help differentiate pseudopregression from true progression. LL-NRE-MO11B • Thoracic Outlet Syndrome 2013 Update - Surgical Correlation to Imaging, EMG, and Clinical Findings
Anthony S Tadros MD (Presenter) ; Afshin Karimi MD ; Justin Brown ; Nasim Mohajeri ; Mark Mahan ; Geoffrey Sheean ; Natalie Voskanian PURPOSE/AIM To better understand the thoracic outlet syndrome by correlating CT, MRI, EMG, clinical history to the final diagnosis at time of surgery CONTENT ORGANIZATION Thoracic outlet syndrome is an often misdiagnosed, poorly understood disease entity, which deserves further attention in the radiology
literature. We review brachial plexus anatomy as relevant to neurological or vascular syndromes that can occur in light of the newer
imaging tehcniques now available in 2013. In particular, we focus on correlating surgical findings to imaging (CT ,MRI) and clinical and
electrophysiological data. Examples of negative MRI exams which have positive findings at time of surgery will be discussed. Anatomical
variations such has fibrous bands, anomalous vascular, osseous or muscular structures which contribute to presumed symptomology will
be presented. Role of dynamic or positional MRI or CT will be delineated. Use of low radiation CT in dynamic evaluation of visualized bone
and vascular structures will be further highlighted. SUMMARY Thoracic outlet pathology remains a challenging disease entity requiring a multi-disciplinary team approach. This niche area of imaging
will be reviewed with emphasis on surgical �clinical-imaging correlations that will hopefully improve clinical practice by highlighting
potential pitfalls and diagnostic pearls. LL-NRS-MO1B • Effect of Saline Flush Dose in Cerebral Perfusion MR Imaging
Kazuhiro Tsuchiya MD (Presenter) ; Miho Gomyo ; Arisa Ohara PURPOSE To investigate the effect of dose of saline flush in perfusion MR imaging of the brain. METHOD AND MATERIALS Our study group comprised 37 patients (20 men and 17 women; age range, 19-97 years; average, 58.8 years; body weight range, 39-75
kg; average, 55.2 kg) with preoperative brain tumor of miscellaneous final diagnoses. They were randomly divided into three groups in
which the saline flush dose was none (group A, 11 patients), 10 mL (group B, 13 patients), or 20 mL (group C, 13 patients). The contrast
dose and the injection rate were fixed at 0.1 mmol/kg and 3 mL/sec, respectively. The injection was performed from a right antecubital
vein using a power injector. We placed a circular region-of-interest in the normal appearing white matter of the corona radiata on the
contralateral side of the tumor and measured regional cerebral blood volume, regional cerebral blood flow, mean transit time, appearance
time of contrast material, area under the time-intensity curve (TIC), maximum slope of TIC, peak height of TIC, and time to peak of TIC.
One-way analysis of variance was used to investigate intergroup differences. RESULTS No significant difference was found among the three groups in mean transit time, appearance time of contrast material, and time to peak
of TIC. Significantly greater values of regional cerebral blood volume, regional cerebral blood flow, area under the TIC, maximum slope of
TIC, and peak height of TIC in groups B and C than group A. There was no difference between group B and C. Page 144 of 397
CONCLUSION In cerebral perfusion MR imaging, it is possible to administer a good contrast bolus by employing a flush dose of 10 mL or more. It should
be noted that the flush dose could affect absolute values of cerebral blood volume and regional cerebral blood flow. CLINICAL RELEVANCE/APPLICATION This study shows that, in cerebral perfusion MR imaging, it is recommended to employ a flush dose of 10 mL or more. LL-NRS-MO2B • EnygmaGym: Differential Anatomical Changes Following Two Intensive Computer-based Training Paradigms
Targeting Different Cognitive Domains
Sumit N Niogi MD, PhD (Presenter) ; Margaret Faso ; Umesh Rajashekar ; Irene Tseretopoulos ; Jun Maruta ; Aaron
Katzman ; Kyoko Fujimoto ; Jamshid Ghajar MD, PhD ; Barry Kosofsky MD, PhD PURPOSE Focused repetitive training could be beneficial in patients with post concussion syndrome and healthy individuals who have an innate
degree of neuroplasticity. We propose that variations and improvement in neurocognitive performance from these training programs arise
from alterations in white matter connectivity. METHOD AND MATERIALS In a normal healthy population, we test whether 2 months of intensive computer based training, using 2 separate training exercises
targeting memory and executive attention could yield cognitive improvement and corresponding anatomical changes in corresponding
neural networks. In this pilot study, 29 healthy individuals ages 18-25 were recruited to act as control subjects (n=5) or undergo 2
months of intensive computer based training in either a Visual Tracking Paradigm or Brain Exercise training program. One non-control
subject was excluded due to motion and n=11 and n=12 subjects were separated into the two training groups. Investigators remain
blinded to the subject groups. Diffusion tensor imaging (DTI) was performed prior to onset of training, at 28 days after onset, and at 57
days. A hypothesis driven region-of-interest (ROI) analysis recording fractional anisotropy (FA) values was performed on 17 regions over
8 white matter pathways bilaterally. A separate data driven analysis was performed using Tract Based Spatial Statistics (TBSS). RESULTS No change seen in the control group. Paired t-tests show a significant increase in FA in the right anterior corona radiata (R ACR,
p=0.004) and right uncinated fasciculus (R UF, p=0.02) in both training groups. When performing a time-based ANOVA analysis, there is
a dissociation between the two training groups, with the R ACR demonstrating increased coherence in one test group (p=0.01) and the R
UF demonstrating increased integrity in the other (p=0.01) when compared to controls. CONCLUSION Intensive computer-based attention and memory training yields anatomical changes in white matter pathways detected by DTI.
Interestingly, the two training groups which target different cognitive domains cause improved white matter coherence in specific white
matter pathways previously implicated to subserve attention (R ACR) and memory (R UF). CLINICAL RELEVANCE/APPLICATION Results suggest intensive computer-based training can cause anatomical changes in networks subserving memory and attention which
may improve cognitive outcome in patients with brain injury. LL-NRS-MO3B • Amide Proton Transfer Imaging of Brain Tumors at 3T: Initial Experience
Ali Yusuf Oner MD (Presenter) ; Murat Ucar ; Turgut E Tali MD * ; Ali Murat Koc MD ; Halil Ozer ; David Grodzki * ; Benjamin Schmitt * PURPOSE Amide proton transfer (APT) imaging is a technique in which the nuclear magnetization of water-exchangeable amide protons of
endogenous mobile proteins and peptides in tissue is saturated, resulting in a signal intensity decrease of the free water. The purpose of
this paper is to evaluate APT contrast of brain tumors and to compare it with magnetic resonance spectroscopy (MRS) at 3T. METHOD AND MATERIALS APT data were acquired from 10 patients with brain tumors on a 3T whole-body MR scanner
and compared with conventional magnetic resonance images, including T1W, T2W, FLAIR, post contrast T1W and diffusion weighted
images. An additional medium and short echo time multivoxel MRS data was also acquired at the same tumor area for comparison. APT
images were evaluated both visually and quantitatively by means of signal intensity, magnetization transfer ratio and magnetization
transfer ratio asymmetry calculation for the tumor, peritumoral edema and normal appearing white matter. RESULTS Good image contrast between tumor and edema was achieved in all cases with APT-weighted images. The average APT signal intensity,
magnetization transfer ratio and asymmetry of the tumoral core were higher than those of peritumoral edema and normal appearing
white matter. The increased APT signal intensity and magnetization transfer ratio of the tumoral core correlated well with increased
choline and choline/creatine ratio, revealed by the spectral sampling of the same area. CONCLUSION These initial data show that APT imaging is an emerging technique which produces unique contrast that can provide complementary
information to standard clinical MRI in the imaging workup of brain tumor patients. CLINICAL RELEVANCE/APPLICATION APT is a new and promising technique which provides unique contrast that can be used as an additional tool in the imaging workup of
brain tumors. LL-NRS-MO4B • Bimodal Histogram Analysis of Apparent Diffusion Coefficient Values for Detection of Occult Tonsil Cancer in
Patients Presenting with Neck Metastasis from an Unknown Primary
Young Jun Choi MD (Presenter) ; Jeong Hyun Lee MD, PhD ; Jung Hwan Baek PURPOSE To explore the role of bimodal histogram analysis of apparent diffusion coefficient (ADC) values for detecting occult palatine tonsillar
squamous cell carcinoma (PTSCC) in patients with neck metastasis from an unknown primary. METHOD AND MATERIALS This retrospective study was approved by the institutional review board, and informed consent was waived. We enrolled 19 patients with
occult PTSCC presenting with neck metastasis from an unknown primary, 20 with overt PTSCC on physical examination, and 20 with
normal palatine tonsils. DWI was performed with b values of 0 and 800 sec/mm2. ADC values of the entire volume of palatine tonsil were
measured by manual drawing of regions-of-interests. Bimodal histogram parameters of the ADC values were obtained using in-house and
statistically tested for difference (Kruskal-Wallis test, Mann-Whitney U test). Receiver operating characteristic (ROC) analysis was
employed to determine the best differentiating parameter between occult PTSCCs and normal tonsils. We also analyzed added values of
histogram analysis of ADC values to conventional MRI and 18F-FDG PET/CT. RESULTS The bimodal histogram analysis showed statistically significant differences in mean, 50 � and 90 � ADC values between overt PTSCCs
and occult PTSCCs/normal palatine tonsils. Between occult PTSCCs and normal tonsils, standard deviation ([0.54±0.20]x10-3 mm 2/sec vs
[0.41±0.09] x 10-3 mm 2/sec), skewness ([0.52±0.38] x 10 -3 mm 2/sec vs [0.30±0.25]x10-3 mm 2/sec), and 90 � value of ADC
Page 145 of 397
([1.75±0.27]x10 -3 mm 2/sec vs [1.52±0.25]x10-3 mm 2/sec) were significant higher (P CONCLUSION Adjunctive histogram analysis of ADC values detected five more occult PTSCCs (26.3%) than conventional MRI and 18F-FDG PET/CT,
therefore, adjunctive histogram analysis can be helpful when conventional MRI and 18F-FDG PET/CT failed to detect occult PTSCCs. CLINICAL RELEVANCE/APPLICATION Adjunctive bimodal histogram analysis can be helpful when conventional MRI and 18F-FDG PET/CT failed to detect occult PTSCCs. LL-NRS-MO5B • Cone Beam CT Angiography: Diagnostic and Therapeutic Potentials in Management of Spinal and Intra-cranial
Arteriovenous Fistulas
Amir R Honarmand MD (Presenter) ; Joseph J Gemmete MD ; Maryam Soltanolkotabi MD ; Michael C Hurley MBBCh ; Neeraj
Chaudhary ; Aditya Pandey ; Ali Shaibani MD ; Sameer A Ansari MD, PhD PURPOSE To assess the relative intra-arterial cone-beam CT angiography (IACBCTA) efficacy in the anatomical identification/localization of
arteriovenous fistulas (AVFs) and utility for surgical/endovasclar treatment planning. METHOD AND MATERIALS DSA and IACBCTA images were reviewed retrospectively and independently by two neurointerventionalists. Qualitative image analysis
was performed based on the level of delineation on a scale of 1-3 (3: Excellent/Good with minimal attenuation; 2: Moderate, relevant
visibility with restrictions; 1: Poor, nondiagnostic). The following parameters were scored: a) Arterial feeders, b) Venous drainers and
course, c) Fistula site, d) Adjacent anatomical landmarks for cross-sectional localization, and e) Overall diagnostic value for interpretation.
Differences between the scores were defined as the IACBCTA efficacy value. Observers described the treatment strategy at the end of
DSA and IACBCTA grading respectively: altered or more confident treatment plan versus no value. Wilcoxon signed rank test and Kendall
W coefficient of concordance were used for statistical analysis. RESULTS Thirty-two consecutive patients [22M/10F, mean age 60.9] were studied. Despite moderate interobserver agreement for IACBCTA overall
efficacy value (rho=0.4, P=0.02), no significant difference was observed between efficacy values (P = 0.6). Both observers assigned
significantly higher scores to IACBCTA for overall diagnostic value (both observers: P CONCLUSION IACBCTA adjunctively improves the anatomical delineation of AVFs, particularly in terms of fistula site and localization. CLINICAL RELEVANCE/APPLICATION IACBCTA adjunctively improves the anatomical delineation of AVFs conferring a more confident endovascular or surgical approach. LL-NRS-MO6B • Period of Pseudo-normalization of Diffusion Kurtosis after Cerebral Infarctions
Toshiaki Taoka MD (Presenter) * ; Masahiko Sakamoto MD ; Toshiaki Akashi MD ; Toshiteru Miyasaka MD ; Saeka Hori ; Kimihiko Kichikawa MD ; Tomoko Ochi ; Takeshi Wada MD PURPOSE Diffusion kurtosis is a statistical measure for quantifying the deviation of the water diffusion profile from a Gaussian distribution. The
current study acessed the time course of diffusion kurtosis and evaluated the period of pseudo-normalization after cerebral infarctions. METHOD AND MATERIALS Subjects included 25 cases / 30 lesions of cerebral infarction. The duration between onset and imaging ranged from 1 day to 122 days.
Diffusion kurtosis measurements were done with b values of 0, 1000, and 2000 sec/mm2 applied in 30 directions. Diffusion kurtosis
images are generated, including axial kurtosis (Kax) and radial kurtosis (Krad) to the eigenvector. We also acquired T2 weighted image
(T2WI), diffusion weighted image (DWI) and apparent diffusion coefficient (ADC) images. The time course of the relative values for T2WI,
DWI, ADC, Krad, and Kax were evaluated and the period for pseudo-normalization was obtained. RESULTS The trend curve of relative Krad indicates that there was a trend for relative Krad to decrease according to the duration after infarction
onset, and that lesions from 10 days to 2 weeks after infarction onset showed lower Krad values compared with the contralateral side.
The trend curve of the relative Kax showed high values in cases within 10 days to 2 weeks after infarction onset. There was also a trend
for relative Kax to decrease according to the duration after infarction onset, which represented the pseudo-normalization period. The
days for pseudo-normalization were 45days, 21days, 14 days and 25 days for DWI, ADC, Krad and Kax respectively. CONCLUSION Diffusion kurtosis values showed increases in lesions early after infarction and showed decreases earlier than DWI. Krad showed
pseudo-normalization earlier than that of ADC, and the pseudo-normalization of Kax was a little later than that of ADC. Because DKI can
show different time courses after the onset of infarction compared with DWI or ADC, additional information for white matter tissue with
infarction can be provided using this imaging technique. Specifically, information by DKI including Kax and Krad seems helpful in making
detailed evaluation for the duration after onset of infarction in combination with T2WI, DWI and ADC. CLINICAL RELEVANCE/APPLICATION Since DKI can show different time courses, information by DKI including Kax and Krad seems helpful in making detailed evaluation for the
duration after onset of infarction in addition to T2WI, DWI and LL-NRS-MO7B • Imaging Neurodegenerative Diseases Comparing ASL-MRI and FDG-PET
Christof Karmonik (Presenter) ; Steve H Fung MD * ; Mario F Dulay ; Belen Pascual PhD ; Daniel Lee MD, PhD ; Stephen B
Chiang MD ; Ronald E Fisher MD, PhD ; Robert G Grossman ; Gustavo C Roman PURPOSE To compare regional and voxel-level CBF estimated from ASL-MRI to 18F-FDG PET activity in elderly patients evaluated for
neurodegenerative disease. METHOD AND MATERIALS Forty-six patients (ages 59-90, M:F 0.73) evaluated for cognitive impairment (including MCI, AD, FTD, DLB, PPA, NPH, vascular and
mixed dementia) had brain MRI and FDG-PET within 24 hours. CBF (mL/min/100g) was estimated using pseudo-continuous ASL (pCASL)
with PLD of 2.5 s. ASL was acquired twice during the 20 min MRI session to determine test-retest reproducibility. Subset of patients were
instructed to keep eyes open and then closed during the initial and repeat ASL scan, respectively, to test perfusion variability in the visual
cortex. High-resolution SPGR images were obtained for registration of CBF maps and PET images. Image quality, regional and voxel-level
comparison in gray matter (GM) and white matter (WM), and histogram analysis were performed. RESULTS CBF maps from ASL had lower image quality and SNR than FDG-PET images. With exception of occipital lobe, regional hypoperfusion on
ASL correlated with regional hypometabolism on PET with good voxel-level CBF-SUV correlation in intrasubject comparisons. With
exception of occipital lobe, regional comparison of normalized cortical CBF to normalized cortical SUV also correlated well in intersubject
comparisons. In all subjects, FDG activity was consistently highest in the occipital lobes (visual cortex), whereas occipital CBF on ASL was
more variable. Histogram analysis demonstrated unimodal distribution of whole brain CBF in contrast to bimodal distribution of whole
brain SUV, consistent with smaller mean difference and larger variance of GM and WM CBF relative to that of SUV. CONCLUSION Page 146 of 397
Pattern of hypoperfusion on ASL correlates well with hypometabolism on FDG-PET in most cases and can be used to distinguish various
neurodegenerative diseases. Poor correlation between ASL and FDG-PET in the occipital lobe may be secondary to decreased ASL
efficiency in the posterior circulation versus physiologic causes with low correlation to eyes open/closed state. Caution should be made
with interpreting occipital hypoperfusion with ASL, especially when considering DLB. In such cases, occipital hypoperfusion on ASL should
be confirmed with corresponding hypometabolism on FDG-PET. CLINICAL RELEVANCE/APPLICATION Addition of ASL to routine brain MRI is recommended for evaluating neurodegnerative diseases. LL-NRE-MO8B • Practical Review of Bisphosphonate Related Osteonecrosis of the Mandible and Maxilla
Maria P Valencia MD (Presenter) ; Pavel Rodriguez MD ; Fang Yu MD ; Wilson Altmeyer MD ; Achint K Singh MD PURPOSE/AIM After reviewing this Education Exhibit the participant should be able to differentiate all the possible imaging abnormalities and
complications found in patients with osteonecrosis of the mandible and maxilla, related to Bisphosphonates exposure. CONTENT ORGANIZATION Bisphosphonate related Osteonecrosis (BRON) of the mandible and maxilla 1. Introduction. 2. Incidence and Epidemiology. 3. Clinical
Findings. 4. Imaging Findings: 4a. Panoramic radiograph. 4b. CT. 4c. MR. 5. Complications. 6. Treatment. SUMMARY Bisphosphonates are potent osteoclast inhibitors. They decrease bone turnover and are widely used in the management of bony
metastatic disease, osteoporosis, Paget disease, and malignancy-related hypercalcemia. Patients with biphosphonate related
osteonecrosis present with nonhealing extraction sockets and painful bone
exposure, which adds significantly to their morbidity. The condition has gained added significance with the increasing use of
bisphosphonates and longer survival of cancer patients.
With the clinical indications of bisphosphonate use increasing, it is important for radiologists to be familiar with
bisphosphonate related osteonecrosis. The imaging features are indistinguishable from osteomyelitis, and therefore, a history of
bisphosphonate therapy is important to suggest the correct diagnosis.
LL-NRE-MO9B • High b-value and Standard b-value Diffusion-weighted MR Imaging in the Head and Neck Region: Clinical
Application and Pitfalls
Koung Mi Kang (Presenter) ; Ji-Hoon Kim MD ; Chul-Ho Sohn MD ; Seung Hong Choi MD, PhD ; Tae Jin Yun MD ; Inseon
Ryoo MD ; Jisang Park MD ; Eun Kyoung Lee MD ; Soo Chin Kim MD PURPOSE/AIM 1. To demonstrate the incremental role of DWI with other imaging techniques in characterization of head and neck lesions.
2. To describe the merits and challenges of high b-value (b=2000 s/mm 2) DWI in comparison with standard b-value (b= 1000 s/mm2)
CONTENT ORGANIZATION 1. Technique of DWI and how to optimize it according to b-value.
2. Methodology of qualitative quantitative assessment by DWI and ADC
3. Utility of high and standard b-value DWI in conjunction with conventional MR and/or [18F] FDG-PET for evaluation of sinusitis and
glandular function, differentiation of neoplasm in various regions, grading of squamous cell carcinoma, distinguishing tumor recurrence
and post treatment change, predicting response in patients on chemoradiotherapy, and differentiation of pathological cervical lymph
nodes.
4. Technical and interpretation pitfalls of high b-value DWI in comparison with standard b-value DWI
SUMMARY DWI plays an important complementary role to other imaging techniques in evaluation of head and neck lesions. Knowledge of various
clinical application and pitfalls along with changes according to b-value may help to better interpret head and neck lesions. Physics - Monday Posters and Exhibits (12:45pm - 1:15pm) Monday, 12:45 PM - 01:15 PM • Lakeside Learning Center
LL-PHS-MOB • AMA PRA Category 1 Credit ™:0.5 Back to Top LL-PHE-MO10B • The Practicality of Ultrasound Physics in Everyday Radiology: A Case-based Review
Sarah Pittman MD (Presenter) ; Angus J Hartery MD PURPOSE/AIM 1. To demonstrate certain fundamentals of ultrasound (US) physics, including the creation and propagation of ultrasound waves. 2. To
explain several artifacts that result from the physical properties of the ultrasound beam and its interaction with soft tissue. 3. To apply
an understanding of US physics and select artifacts to enhance image interpretation. CONTENT ORGANIZATION Selected cases will demonstrate the clinical relevance of US physics, including choice of transducer frequency and common artifacts, such
as refraction and increased through-transmission. SUMMARY US continues to be a valuable primary diagnostic imaging modality. Due to the physical properties of the ultrasound beam and its
interaction with soft tissue, several unavoidable artifacts result. A working knowledge of US physics and artifacts will improve detection,
diagnosis, and management of patients. LL-PHS-MO1B • Comparison of MS-CT and Whole-body Plethysmography: Is There Any Functional Information Available Using a
Postprocessing with a Recent CAD-development?
Ansgar Malich MD (Presenter) ; Sylvia Mikulik ; Klaus Thomas ; Peter Hannemann ; Ulf K Teichgraeber MD CONCLUSION Recently developed CAD-software has the potential to quantify and differentiate obstructive and restrictive diseases of the lung based on
MS-CT data and reflect some important functional parameter of the lung. Background MS-CT currently does not offer functional parameter of the lung. Study aimed to analyze, whether there are parameters obtainable from
CT-data reflecting functional parameters calculated by whole-body plethysmography. Evaluation 100 patients were randomly selected who underwent MS-CT (128 row-CT) and whole body plethysmography (master-screen body,
Jaeger, Germany) within < 7days. All data were analyzed using CAD (MeVISPulmo3D, Fraunhofer MeVis, Germany). Vital capacity (VC),
FEV1, intrathoracal gas volume (ITGV), residual volume (RV), total lung capacity (TLC) were matched with CAD-based lung volume
Page 147 of 397
analysis (vol), mean low density (MLD), low and high attenuation values (LAV/HAV), lung weight (w) P15, PK (maximum of histogram)
and FWHM (full width half max). Central obstruction, peripheral obstruction, restrictive diseases and emphysematic patients were
analyzed. Discussion CAD-analysis was possible in all cases. Acquisition time was approx. 1 minute per case.
Correlation coefficients of VC were: Vol:r=.57,p ITGV correlates with Vol:r=0.71,p RV showed association to Vol.:r=0.6,p FEV1 showed a
correlation to vol:r=-0.67,p Correlation coefficients of TLC vs. vol.,weight, MLD, HAV, PK and P15 were: r=0.83; r=0.51; r=-0.60;
r=-0.56; R=-0.45; r=-0.52, all p-values Only moderate correlation were observed for maximum exspiratory flow (PEF) and exspiratory
reserve volume (ERV).
Severity of obstructive and restrictive diseases showed different CAD-based data of volume, MLD, LAV and HAV (Oneway Anova, p LL-PHS-MO2B • The Effects of Pure and Hybrid Iterative Reconstruction Techniques on Computer-aided Detection (CAD) System
of Pulmonary Nodules in Dose-reduced CT Scans
Masaki Katsura MD (Presenter) ; Izuru Matsuda MD ; Masaaki Akahane MD ; Koichiro Yasaka MD ; Shouhei Hanaoka MD ; Hiroyuki Akai MD ; Jiro Sato MD ; Akira Kunimatsu MD * ; Kuni Ohtomo MD * PURPOSE To evaluate the effects of pure and hybrid iterative reconstruction techniques on computer-aided detection (CAD) system of pulmonary
nodules using reference-, low-, and ultralow-dose chest CT. METHOD AND MATERIALS Fifty-nine patients(mean[SD] age, 64.7[13.4] years) gave informed consent to undergo reference-, low-, and ultralow-dose chest with
64-row multidetector CT. The reference- and low-dose CT involved the use of automatic tube current modulation with fixed noise
indices(31.5and70.44 at 0.625mm, respectively) and the ultralow-dose CT was acquired with a fixed tube current-time product of 5mAs.
Each 0.625-mm-thick image was reconstructed with filter-back projection(FBP), 50% adaptive statistical iterative
reconstruction(ASIR)-FBP blending, and model-based iterative reconstruction(MBIR). CAD output was compared with the results of the
reference standard which was established using a consensus panel of 2 radiologists, who identified 84 non-calcified nodules with
diameters of 4mm or greater on reference-dose ASIR. Sensitivity in nodule detection between different radiation dose and reconstruction
techniques was assessed using Cochran's Q test with post hoc McNemar test and Holm correction for multiple comparisons. The mean
number of false-positive findings per examination was assessed using Friedman test with post hoc testing using Wilcoxon signed-rank test
and Holm correction. RESULTS Compared with reference-dose CT(307.7±178.1mGy-cm), there was a 78.6% decrease in dose�length product with low-dose
CT(66.0±50.8mGy-cm), and a 95.3% decrease with ultralow-dose CT(14.5±1.1mGy-cm). CAD sensitivity for nodules at ultralow-dose
MBIR(26.2%) was equivalent(p=0.52-1.00) to those at reference-(FBP,23.8%;ASIR,26.2%,MBIR;26.2%) and low-dose
CT(FBP,26.2%;ASIR,25.0%,MBIR;25.0%). Mean number of false-positive findings per examination tended to increase with the use of
MBIR, particularly at low-(1.19) and ultralow-dose CT(1.32), although there were no significant differences among reconstruction
techniques at both dose levels(p=0.08-1.00). CONCLUSION CAD sensitivity for pulmonary nodules at ultra-dose MBIR is almost equal to that at reference-dose CT. MBIR can improve CAD
performance on dose-reduced chest CT despite increased false-positive findings. CLINICAL RELEVANCE/APPLICATION With the use of MBIR, CAD system on ultralow-dose CT may play an equivalent role to that on regular-dose CT in helping radiologists
detect pulmonary nodules. LL-PHS-MO3B • Accurate Measurement of Airway Wall Thickness with a Model-based Line Profile Matching Technique in MDCT
Zepa Yang MS (Presenter) ; Hyeongmin Jin ; Jong H Kim PhD PURPOSE Accuracy of airway wall measurement has been impaired by the combined effect of partial volume and point spread blurring in CT
systems. We present a novel technique which enables to determine the wall thickness of small airways by using a model-based lesion
quantification technique. METHOD AND MATERIALS Point spread functions of a commercial CT(Sensation 16, Siemens) was acquired by using a wire phantom scanning for two different
kernels(B30s and B50s). The COPDgene phantom was scanned with 120kVp, 100mAs, 1mm thickness setting and was reconstructed with
the two kernels.
A set of model-derived line profiles were created by taking convolution of the point spread functions with a set of numerical airway
phantoms having varying thickness ranging 0.1 - 5.0mm with 0.1mm thickness interval. These model-derived line profiles were compared
with the measured line profiles across the wall from the airway phantoms in COPDgene phantoms. The wall thickness of the phantom was
determined as the thickness of numerical model giving minimum error between two line profiles. Measurements were made for 4 types of
airway phantoms with wall thickness of 0.6, 0.9, 1.2, 1.5 mm in 40 CT slices. RESULTS The mean measurement error of wall thickness with B30s kernel was 0.10 ±0.03mm for 0.6mm thickness, 0.06±0.04 for 0.9mm
thickness, 0.07±0.01 for 1.2mm thickness, and 0.05±0.01 for 1.5mm thickness. The error with B50s was -0.04 ±0.07mm for 0.6mm
thickness, -0.08±0.05 for 0.9mm thickness, -0.11±0.05 for 1.2mm thickness, and -0.07±0.06 for 1.5mm thickness.
CONCLUSION By applying a model-based line profile matching technique, our technique could determine the airway wall thickness accurately even for
the small airways. CLINICAL RELEVANCE/APPLICATION Our technique may allow detection of early change of airway wall thickening in early diagnosis, patient sub-typing, and therapeutic
monitoring in the management of COPD disease. LL-PHS-MO4B • Analysis of Predictive Maintenance of Linear Accelerator Beam Uniformity Using Statistical Process Control
Charles M Able MS (Presenter) * ; Alan Baydush PhD * ; Michael T Munley PhD * CONCLUSION PdM monitoring of beam uniformity using a new method for determining SPC control limits is more effective than using traditional control
limits. SPC false alarms are reduced thereby eliminating unwarranted service intervention. We are working to develop code that will
provide an SPC evaluation using the new formula. Background The focus of this study is to determine the effectiveness of revisions to statistical process control (SPC) chart limits for linear accelerator
steering coil current (beam uniformity) predictive maintenance (PdM) monitoring Evaluation We have re-evaluated calculation of the limits for steering coil current (SCC) SPC charts based on our observations that the changes in
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SCC required for 1% change in measured beam uniformity will generally exceed the traditional limits calculated using the standard
deviation of the subgroup values alone. Using empirical data obtained from controlled experiments varying the SCC while measuring the
beam uniformity, we have developed a formulism that incorporates a scaling factor (Cm) in the calculation of control limits. Discussion SCC monitoring of an 18 MV photon beam using the new limits indicated a change in the transverse position coil operating current 2
weeks prior to multiple EXQ2 faults and unscheduled downtime. A change in beam uniformity of greater than 3% was found once the
beam was scanned using a computerized water phantom and ion chamber. SPC charts of this steering coil using traditional limits would
have resulted in 5 false positives prior to the first positive alarm indicated by the new limits LL-PHS-MO5B • Tumors in the Peripheral Zone and Central Gland of the Prostate Have Different Perfusion Characteristics on
Dynamic Contrast-enhanced MRI
Shoshana Ginsburg MS (Presenter) ; Boris N Bloch MD ; Neil M Rofsky MD ; Elizabeth Genega MD ; Robert E Lenkinski PhD *
; Anant Madabhushi MS * PURPOSE Pharmacokinetic (PK) perfusion parameters extracted from DCE MRI, such as the volume transfer constant and extravascular-extracellular
volume fraction, are useful in cancer detection and grading. Recent studies have shown that tumors in the peripheral zone (PZ) of the
prostate are more aggressive than tumors in the central gland (CG) and that the morphology of prostate cancer (PCa) differs based upon
its location in the prostate. The purpose of this study is to compare PK perfusion parameters of PZ and CG tumors. METHOD AND MATERIALS 15 endorectal 3 Tesla MRI studies, using DCE and T2W imaging, were obtained in men with biopsy proven PCa prior to radical
prostatectomy (RP). The DCE MRI protocol included 2 pre-contrast images, which were acquired at 95 second intervals before the bolus
injection of 0.1 mmol/kg of gadolinium-DTPA, and 5 post-contrast images that were acquired at the same temporal resolution. Following
RP, surgical specimens, examined with whole mount histopathology by a trained pathologist, were evaluated for the presence and extent
of PCa, which was subsequently mapped from histology to DCE MRI. The PZ and CG were manually segmented on T2W MRI by a
radiologist, and each study was classified as having PCa in a particular zone when more than 70% of the tumor volume was present in
that zone. Nine studies were found to have PCa in the PZ, and 6 had PCa in the CG. The iterative multiple reference tissue method was
used on the DCE MRI data to estimate the volume transfer constant and extravascular-extracellular volume fraction for each prostate
tumor.
RESULTS Values for the transfer constant and extravascular-extracellular volume fraction averaged 0.27 and 0.43, respectively, for PZ tumors and
0.36 and 0.62, respectively, for CG tumors. Both the transfer constant and the extravascular-extracellular volume fraction are
significantly higher in CG tumors than in PZ tumors (p = 0.045 for both perfusion parameters). CONCLUSION CG and PZ tumors manifest significantly different perfusion characteristics on DCE MRI, suggesting that vascular features of PCa depend
on the tumor location in the prostate gland and that PZ and CG tumors may have distinct biologic attributes. CLINICAL RELEVANCE/APPLICATION Since CG and PZ tumors have different perfusion characteristics, zone-specific analysis of DCE MRI should improve assessment of PCa. LL-PHS-MO6B • Optimal Reconstruction Filter on Observation of Periodontal Ligament Space in Dental Cone-beam CT
Yuuki Houno (Presenter) ; Toshimitsu Hishikawa ; Ken-Ichi Gotoh ; Munetaka Naitoh ; Eiichiro Ariji ; Yoshie Kodera PhD PURPOSE Diagnosis of the alveolar bone condition is important in the treatment of periodontal disease. However, visualization of the thin alveolar
bone and periodontal ligament space is difficult owing to image blurring using the current imaging technique. Therefore, identification of
the marginal alveolar bone level is unreliable. In this study, we try to determine high quality images of periodontal ligament space
separation were obtained by changing the reconstruction filter. METHOD AND MATERIALS Images from 4 different areas of 2 types of head phantoms were obtained using Alphard-3030 dental cone-beam computed tomography
(Asahi Roentgen Industry Co., Ltd.). The image was reconstructed from the raw data by using 5 different reconstruction filters. Post
reconstruction, these reconstructed images were compared with the Alphard-3030 reconstructed images by using Thurstone�s paired
comparison, and a scale value was calculated. The images were evaluated limiting the clarity of periodontal ligament space boundary by
3 periodontists and 3 radiologists with >5 years of clinical experience. To confirm the image characteristics, modulation transfer function
and Wiener spectrum were calculated. RESULTS The best image was one reconstructed with filter that increased the high-frequency component based on Shepp and Logan�s function.
The Alphard-3030 reconstructed image, which is used in clinical settings, was the worst. The image reconstructed with the best filter had
a higher modulation transfer factor and Wiener spectral value than the Alphard-3030 reconstructed image. These results suggest that
sharp images enhance the visualization of the periodontal ligament space, and the imaging noise is insignificant. These images enable
the observer to clearly view the periodontal ligament space boundary. CONCLUSION We determined the optimal reconstruction filter required to observe the periodontal ligament space. CLINICAL RELEVANCE/APPLICATION Image quality of periodontal ligament space may be improved by alternating reconstruction filter of cone-beam CT. This method can be
applied to various CT apparatus without hardware replacement. LL-PHS-MO7B • Fast and Easy Dose Estimates including Tube Current Modulation and Automatic Exposure Control
Natalia Saltybaeva ; Martin Hupfer PhD (Presenter) * ; Daniel Kolditz PhD * ; Bernhard Schmidt PhD * ; Willi A Kalender PhD
* PURPOSE Tube current modulation (TCM) and automatic exposure control (AEC) are widely used in modern CT. The aim of this work was to include
the effects of TCM and AEC in a software package for fast and easy organ and effective dose estimates. METHOD AND MATERIALS Measurements were carried out for a SOMATOM Definition Flash scanner (Siemens AG, Forchheim, Germany); the manufacturer provided
all necessary information on their CARE Dose4D TCM/AEC product. TCM and AEC curves were derived for anthropomorphic phantoms by
generating complete CT projection data sets by means of ray-tracing and predicting the flux at the detector. For all phantoms and
parameter combinations studied, Monte Carlo (MC) calculations wandw/o CARE Dose4D were performed to provide tabulated dose values.
These tables were included in the software package ImpactDose (CT Imaging GmbH, Erlangen, Germany) which estimates organ and
effective dose depending on patient size, scan region and scan protocol. It is based on pre-tabulated dose values calculated by means of
MC calculations for the ORNL family of anthropomorphic phantoms. Validation measurements were performed using thermoluminescence
dosimeters (TLDs) for each of three different anthropomorphic phantoms (Rando adult, 5-y.o. and 1-y.o. CIRS) wandw/o CARE Dose4D. RESULTS Page 149 of 397
Measured dose values were compared to MC results on a chip-by-chip basis. The mean differences for all TLD chips were 5%, 7%, and
6% for the adult, the 5-year old, and the 1-year old phantom, respectively. This deviation is in the range of the uncertainty associated
with TLD measurements and indicates that TCM/AEC were correctly implemented. The derived dose values wandw/o TCM/AEC allowed for
assessment of their effect on dose for different patients without the need for measurements or repeated MC calculations. CONCLUSION Dose estimates based on tabulated MC-derived dose distributions can provide accurate information on the effect of TCM and AEC in
clinical CT if information about their implementation is provided by the manufacturer. CLINICAL RELEVANCE/APPLICATION The software package allows to obtain fast and accurate dose estimates when TCM/AEC is used and furthermore may serve as a learning
tool. LL-PHS-MO8B • Evaluation of Alignment Discrepancy Based on Fiducial Seeds versus Bony Anatomy or Bony Anatomy Plus
Endorectal Balloon for Prostate Cancer Patients
Rui Zhang (Presenter) ; Connel Chu ; Maurice L King MD ; John P Gibbons PhD ABSTRACT Purpose/Objective(s): Fiducial seed has long been recognized as an accurate tool to correct prostate patient setup error. The
alternative techniques include aligning patient using bony anatomy information and endorectal balloon. The aim of this study was to
evaluate the discrepancy in prostate daily alignment based on fiducial seeds versus bony anatomy or bony anatomy plus balloon.
Materials/Methods: All alignment evaluations were carried out by using Elekta X-ray volume imaging (XVI) software. Seventeen
prostate patients with both fiducial seeds and water-filled endorectal balloon and four patients with fiducial seeds only were chosen for
this study. Each patient was followed for more than one month. Before each treatment fraction, a cone beam computed tomography
(CBCT) was acquired and the daily shift information based on fiducial seeds was recorded for each patient as the gold standard. Then the
alignment was performed again based on bony anatomy only (for patients without balloon) or based on bony anatomy plus balloon (for
patients with both fiducial and balloon) using the same CBCT data. For alignment based on bony anatomy only, the auto-fusion based on
bone filter was applied and the angular shifts were ignored. For alignment based on bony plus balloon, the same bone filter was applied
first, then the balloon was used for anterior-posterior (AP) alignment correction. The differences between shifts determined using fiducial
seeds and using the bony anatomy or bony anatomy + balloon were analyzed.
Results: In the right-left (RL) direction, discrepancies between shifts based on fiducial seeds and shifts based on bony only or bony +
balloon were all less than 4 mm. In the superior-inferior (SI) direction, the discrepancies were less than 15 mm for bony only, and less
than 8 mm for bony + balloon. In the AP direction, the discrepancies were all less than 11 mm for bony only or bony + balloon. Over 96%
(AP) and 98% (SI) of the discrepancies were within 7 mm for bony + balloon, while over 75% (AP) and 48% (SI) of the discrepancies
were within 7 mm for bony only.
Conclusions: The RL alignments are always good regardless of the alignment technique. 7 mm seems to be a reasonable setup margin
for prostate patients without fiducial seeds but with balloon. Using endorectal balloon for patients without fiducial is strongly
recommended since it helps alignments in both AP and SI directions. LL-PHS-MO9B • Feasibility of 4D Endoscopic Rendering of Interventional Devices
Erick Oberstar (Presenter) * ; Brian Davis * ; Martin Wagner ; Kevin Royalty MS, MBA * ; Markus Kowarschik PhD * ; Sebastian Schafer * ; Charles M Strother MD * ; Charles A Mistretta PhD * PURPOSE Endoscopic views of devices inside the vasculature could be beneficial for navigation placement in complicated vascular anatomy. By
leveraging 3D or 4D DSA, in with UW Madison�s 4D Omni-Plane Fluorosopy (4DOPF) technique for creating any desired virtual
fluoroscopic views from biplane fluoroscopy, endoscopic views of vascular structures can be generated to provide additional information
about the presence of complex anatomy or obstructions that would inhibit a device entering a vascular orifice or make device navigation
challenging. Although 4DOPF is typically used to show the motion of a device relative to a vascular roadmap, it could be helpful to view
the placement of interventional devices as they enter vascular structures from an endoscopic view. METHOD AND MATERIALS A 3D or 4D DSA volume is acquired in addition to orthogonal biplane fluorocopic views. A 3D vessel lumen volume is created by
subtracting a DSA volume from a dilated version of the volume to remove contrast signal inside the vessel. A device volume is generated
by 4DOPF (backprojection of segmented orthogonal biplane fluoro views) and is combined with the vessel lumen volume. Endoscopic
views of the vascular lumen are generated from the combined data set at each time frame. RESULTS The images shown were done retrospectively with parallel ray processing without correction for geometrical inconsistencies. Figure 1
shows an example of a cerebral aneurysm, and time series images of two different views of the neck of the aneurysm. Several camera
views were established showing optimal device and neck visibility as indicated by the red and yellow arrows on the aneurysm in Fig 1a.
Vessels obstructing the view of the aneurysm have been removed. The images surrounded by red and yellow backgrounds show four
time instances of a device moving into the aneurysm from superior and inferior views Fig 1b-c. CONCLUSION By leveraging 3D/4D-DSA and 4DOPF, endoscopic views of an interventional device and vascular lumen can be generated to provide
physicians additional information about the presence of complex anatomy or obstructions that would inhibit a device entering a vascular
orifice. CLINICAL RELEVANCE/APPLICATION The clinical goal of our work is to develop and optimize techniques which will enhance the ability to use road mapping techniques in
image guided abdominal and peripheral interventions. Physics - Sunday Posters and Exhibits (1:00pm - 1:30pm) Monday, 12:45 PM - 01:15 PM • Lakeside Learning Center
LL-PHS-SUB • AMA PRA Category 1 Credit ™:0.5 Back to Top LL-PHE-SU10B • Development of an Anisotropic Phantom for Quality Improvement of DTI and Tractography Algorithms in
Clinical Practice
Isabelle Filipiak (Presenter) * ; Christophe Destrieux MD, PhD ; Jean Philippe Cottier MD ; Laurent Barantin Background Phantom for diffusion studies mimicking the human white fibers anatomy is still not available. To evaluate Diffusion Tensor Imaging (DTI)
and tractography algorithms, we developed an anisotropic phantom representative of the human white fibers anatomy. It was composed
of objects having various diffusion properties, which can be used for quality control of these sequences. Evaluation The 3D phantom we developed contained fiber bundles that differ in shape (5 longitudinal, 2 U-shape, and 4 angular) and material
(dyneema and nylon).
It was scanned 20 times on a 3T MR scanner using the same parameters as in clinical practice: 2D single shot EPI sequence,
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TE/TR=96/12000 ms, voxel size = 1.7x1.7x1.7 mm3, acquisition time = 15 min.
First, fractional anisotropy (FA), mean diffusivity (MD), radial and axial diffusivity (RD and AD) were measured from region-of-interest
(ROI) delineated on each fiber; differences across fiber shapes and materials were evaluated using Wilcoxon�s test. In a given material
(dyneema or nylon), FA, MD, RD/AD did not significantly differ with fiber shape (p>0.05) and imaging session. FA measured in dyneema
(0.57±0.12) was higher than in nylon (0.18±0.04). Then tracts were reconstructed using deterministic algorithms (Interpolated
Streamline, FACT, tensorline) and propagation or position error and tractography shifts were evaluatedThe tractography algorithms we
used were able to reconstruct all fiber bundles. However, the number and length of fibers were twice time higher using interpolated
streamline or tensorline algorithms as compared to FACT. They were also higher using dyneema.
Discussion With this anisotropic phantom: (1) FA, MD, RD/AD values were similar across imaging sessions and the different fiber shapes
representative of the human white fibers anatomy; (2) tractography was doable on the phantom ; (3) the number and length of detected
fibers varied depending of the used material and algorithm. CONCLUSION This new anisotropic phantom significantly expands the potential of quality control in diffusion imaging to improve the accuracy of DTI
data and tractography in clinical practice. LL-PHS-SU1B • Development of Spiral Micro Holes Phantom for the Measurement of Slice Thickness in CT
Katsumi Tsujioka PhD (Presenter) ; Rina Terauchi ; Ayako Gonaka ; Yasutomo Sato ; Ryoichi Kato MD CONCLUSION When you evaluate the performance of multi-slice CT detector, the measurement of slice thickness is critical. However, with the small
bead phantom which widely receives recommendation requires complicated operational procedures such as multiple scans and a lot of CT
images. The Spiral Micro Holes Phantom we developed enables the slice thickness measurement with only one time scanning and achieves
equivalent precision with the method that uses small bead. When you measure the slice thickness using conventional method such as
small bead or thin plate, it requires complicated procedures such as many times of scanning and CT images. To this end, slice thickness
has to be always fixed and standardized. However our phantom we developed for the purpose of measurement of slice thickness only
requires one time scanning and one CT image.
Background We development of Spiral Micro Holes Phantom for the measurement of slice thickness in CT. Artifacts, which are commonly seen with the
conventional phantom with slant structure, are not seen in this new phantom. It enables helical scanning as well as slice measurement of
multi slice CT with single scanning only. This time, we compared the result using this phantom and by using small bead method which
had been recommended so far. Evaluation The Spiral Micro Holes phantom we developed has 0.5mm diameter holes on the surface of 40mm-diameter acrylic phantom. The depth
of each hole is 5mm and is placed with 5mm intervals in spiral manner. The number of holes is 90 for an outer circumference. You can
get the slice sensibility profile by measuring the CT numbers of CT images of this phantom. This time we compared the f measurement
precision of helical scanning and multi-slice CT with conventional small bead phantom. Discussion We were able to obtain SSPz with one single CT image using this new phantom designed for slice thickness measurement. No artifacts
appeared which is seen in conventional methods such as slant aluminum sheet or wire method. As for the precision, the measurement
result of slice thickness showed equal precision to that of conventional small bead phantom. LL-PHS-SU2B • Towards Virtual Clinical Trials: A Framework for Clinically Relevant CT Simulations
Justin B Solomon MSc (Presenter) ; Juan Carlos Ramirez Giraldo PhD ; Karl Stierstorfer PhD * ; Yuan Lin PhD * ; Ehsan
Samei PhD * PURPOSE To establish a framework for creating virtual anthropomorphic computed tomography (CT) images with realistic lesions, accounting for
attributes of commercial CT systems. METHOD AND MATERIALS A detailed computer model of a commercial CT system (Siemens Somatom Definition Flash, Siemens Healthcare, Germany) was created,
accounting for the system geometry, focal spot size and motion pattern, detector configuration, bowtie filter, and the contribution of
quantum noise. The model was used to simulate raw projection data of a virtual anthropomorphic phantom, including lesions of varying
morphology (contrast, shape, and edge profile). Both spherical and realistically shaped lesions were added. The realistic lesions were
generated based on actual clinical data, using a previously validated technique. The projection data were formatted to match those of
actual raw data from the scanner. This enabled CT images to be reconstructed using the manufacturer�s proprietary reconstruction
engine including both conventional filtered backprojection and iterative reconstruction (i.e., IRIS and SAFIRE). The reconstructed images
were evaluated for noise texture realism and artifacts. RESULTS For all reconstruction algorithms, the proposed framework resulted in realistic images with noise properties consistent with real CT
images. CONCLUSION It is possible to create realistic simulated CT images based on the properties of commercially available CT systems. This framework could
facilitate in assessing the complex relationship between scan settings and the appearance of subtle lesions in the reconstructed images,
without the need to collect clinical data. Such assessments are critical for system optimization and performance evaluation. CLINICAL RELEVANCE/APPLICATION Clinical trials can be difficult and costly to perform. Virtual clinical trials have the potential to reduce costs and expedite the process of
evaluating new CT technologies. LL-PHS-SU3B • Dedicated Mobile Volumetric CT for Human Brain Imaging
Jong Hyun Ryu (Presenter) ; Kwon-Ha Yoon MD, PhD ; Han Ah Lee ; Seung Jae Byun ; Chang Won Jeong ; Jinseok Lee ; Kyong Woo Kim ; Hee-Sin Lee ; Kyu-Gyeom Kim ; Jae Hee Kim ; Su Chong Joo PURPOSE The cone-beam based volumetric CT is popularly applied to micro CT and dental CT. However, it is difficult to obtain human brain image
of good quality because of various limitations such as artifacts when using volumetric CT with flat panel detector (FPD). We studied this
work to develop a dedicated mobile volumetric CT with FPD for human brain imaging. METHOD AND MATERIALS Cone beam x-ray source, flat-panel detector with CMOS sensor (290.8x229.8mm), embedded PC and GPU were used in this system (Fig
1). Under the x-ray source condition of 120kV and 6mA, 360 projections were grabbed at the rate of 70 frames per seconds during 5.14
seconds for optimized human brain imaging. FOV was designed 200mm(XY) x 160mm(Z) and voxel size was 200?m in 1024 3. Interface
for 2D image acquisition from FPD was CAMLINK(2cable,80MHz) and it can grab 70 frames per second at 2 binning. Feldkamp
back-projection algorithm was used as the base for image reconstruction, and it was used S/W filtering to sinogram for artifact reduction.
Reconstruction time was less than 90 seconds for 512 cube. The CT images were obtained using a head phantom (Angiographic CT head
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phantom ACS, Herago�, Japan). In addition modulation transfer function (MTF) and radiation dose were measured for the evaluation. RESULTS Using this dedicated brain volumetric CT, we could get a brain images using a head phantom with good quality. It was confirmed that
artifact was reduced by S/W filtering to sinogram at image reconstruction. Based on the MTF (Modulation Transfer Function, 10%) curve,
we found 20~21 lp/cm using phantom (QRM-ConeBeam, QRM GmbH, Germany) at 1024 cube. The CT images demonstrated cross
sections through a reconstruction of a human head obtained with the soft tissue protocol. Various brain structures are clearly
distinguishable, proving the improved contrast resolution of the system (Fig. 2). Images showed a little ring or scatter artifacts. The
effective dose for this head scan was estimated to be about 1mSv. CONCLUSION We developed a dedicated mobile volumetric CT for brain images using cone beam x-ray and flat panel detector. This system would be
perfectly suitable for intra-operative imaging and mobile imaging applications such as neurosurgery or imaging of immobilized intensive
care patients. CLINICAL RELEVANCE/APPLICATION N/A LL-PHS-SU4B • Automated Detection of Carotid Artery Calcifications on Dental Panoramic Radiographs: False Positive Reduction
by Support Vector Machine
Ryo Takahashi ; Chisako Muramatsu PhD ; Akitoshi Katsumata DDS, PhD ; Takeshi Hara PhD ; Hiroshi Fujita PhD (Presenter) PURPOSE Carotid artery calcifications (CACs) are one of the indices useful in predicting the risk of arteriosclerosis. It has been suggested that CACs
may be detectable on dental panoramic radiographs (DPR) obtained for dental examination. However, with the general window level for
dental examination, these calcifications can be easily missed on DPRs when their purpose does not lie on arteries. The purpose of this
study is to automatically detect CACs on DPRs for notifying a possible risk for arteriosclerosis. METHOD AND MATERIALS Our database included 100 DPRs, including 34 images with one or more CACs and 66 images without CAC. First, regions of interest
including carotid arteries on the right and left sides are automatically extracted on the basis of the result of automatic mandibular contour
detection. After applying top-hat filter, CAC candidates are detected by thresholding. Potential edges belonging to vertebra and hyoid
bones are identified and removed from the candidates. Thirteen image features, including shape features, locational features, and
intensity features, are determined. We employed a support vector machine for the reduction of false positives with an extensive search
for an optimal feature set. The method was evaluated by the cross validation method, in which a half of CAC cases and a half of control
cases were randomly sampled for training cases, and remaining cases were employed for testing. The sampling procedure was repeated
10 times for reducing the sampling effect. RESULTS The proposed method obtained the 90% sensitivity with average false positive marks of 2.5 per images. Considering some calcifications
are hardly detectable on DPRs, the sensitivity of 90% is satisfactory with a relatively small number of false positives. An optimal feature
set included 8 features. It was found that the shape-related features are not so useful, except for circularity, indicating the variations in
size and shape of CACs. Locational features may be useful for removing false positives due to normal structures. Intensity-related
features were considered most useful. CONCLUSION The proposed method can be useful for automatic detection of CACs on DPRs obtained in general dental examinations. CLINICAL RELEVANCE/APPLICATION Automated detection of carotid artery calcifications on dental panoramic radiographs may contribute for early diagnosis of arteriosclerosis. LL-PHS-SU5B • A Dose Finding Cadaver Study Using Model-based Iterative Image Reconstruction (MBIR) in CT Imaging of the
Chest
Kathrin Weber (Presenter) ; Fabian Mueck ; Lucas L Geyer MD * ; Maximilian F Reiser MD ; Stefan Wirth MD * PURPOSE To compare image quality (IQ) of 64-row CT scans of the chest, respectively acquired at varying dose levels and reconstructed with
model based iterative reconstruction (MBIR), to standard baseline examinations at full dose and using adaptive statistical iterative image
reconstruction (ASIR). METHOD AND MATERIALS 12 human cadavers were included. A full-dose baseline reference (FBR) was acquired (CT HD750; GE Healthcare, Waukesha, IL) using a
standard-of-care protocol (0.625mm helical, 0.984 pitch, 120kV, 10-400mA modulation, noise index NI=39 VS=0.625; NI = allowed
procentual level of noise in a water phantom in virtual slices of varying thickness (VS in mm); raw data were reconstructed in soft tissue
kernel using ASIR 50%). These baseline raw data were also reconstructed with MBIR (D0). Additionally, each cadaver was scanned with
varying dose levels D1-D5 by changing NI and VS (D1: NI=35, VS=2.5; D2: NI=70, VS=0.625; D3: NI=35, VS=5; D4: NI=70, VS=2.5;
D5: NI=70, VS=5; all reconstructed with MBIR). Except for NI, VS and MBIR, all other parameters were identical to the FBR, all series
reformatted in 3mm axial, coronal and sagittal slices. Two radiologists, blinded to the dose level, independently compared IQ for soft
tissue evaluation of D0-D5 to the full-dose FBR (IQ: -2:diagnostically inferior, -1:inferior, 0:equal, +1:superior, +2:diagnostically
superior; respectively). For statistical analysis ICC and Wilcoxon�s test were used. RESULTS Mean values were (CTDIvol in mGy: D0 = 8.6±4.0, D1 = 4.8±3.7, D2 = 4.2±3.1, D3 = 2.6±2.1, D4 = 1.3±1.0, D5 = 0.7±0.5); (IQ: D0 =
+2.0±0.3, D1 = +1.54±0.5, D2 = +1.0±0.5, D3 = +0.6±0.4, D4 = +0.0±0.5, D5 = -1.2±0.6). All values were significant different from
one another; p CONCLUSION Data reconstruction with MBIR instead of ASIR allows for significant dose reduction of 85% in non contrast enhanced CT imaging of the
chest without impairment of the image quality, resulting in a calculated mean effective dose of 0.71±0.63 mSv. CLINICAL RELEVANCE/APPLICATION For non contrast enhanced standard chest exams MBIR allows for diagnostic CT of the chest markedly below 1mSv without loss of image
quality and significant image improvement at higher dose levels. LL-PHS-SU6B • Numerical Modeling of the Dynamics of Ultrasound Contrast Agents in a Vascular Network: Validation Study
Laure D Boyer (Presenter) ; Pauline Le Notre MSc ; Stephen Randall Thomas PhD ; Ingrid Leguerney ; Nathalie B Lassau
MD, PhD * ; Stephanie Pitre-Champagnat CONCLUSION The NM with the Fluent software and with the modeling of realistic injection of CA by bolus was validated for studying the dynamics of
blood and CA in a simple geometry. Results obtained with a more realistic vascular network composed of 30 vessels will be presented. Background Dynamic Contrast-Enhanced Ultrasonography (DCE-US) is a particularly attractive method to assess tumor microvasculature from the
concentration quantification of ultrasound contrast agents (CA) within lesions. This method does not yet benefit from methodological tools
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imported from physics to characterize the ability of the quantification methods to evaluate the tumor microcirculation. In this context, we
developed the first numerical model (NM) based on Computational Fluid Dynamics software for studying the quantification methods to
describe tumoral perfusion in a complex vascular network and to apprehend their variations according to the tumor growth, hemodynamic
configuration and CA injections. The aim of this study is to validate this approach in comparison with DCE-US experiments on simple
geometrical configuration composed of 1 fluids bifurcation. Evaluation The NM was developed with Fluent software (ANSYS, France), which modeled blood and CA flows in a vascular network with laminar flow
described by Poiseuille's law. Geometry of the numerical and experimental phantom was a 31cm length tube with a diameter of 2mm with
1 bifurcation giving 2 parallel tubes located 23cm from the input. The volume of injected CA was 0.1mL with blood flows of 26, 34, 41
and 56mL/min. Realistic injection of CA by bolus was implemented in the NM. DCE-US experiments were performed with an Aplio scanner
(Toshiba Medical Systems, Japan) and a 12MHz probe with SonoVue� (Bracco, Italy) as CA. Areas under the curve (AUC) from the
time-CA concentration curves were extracted and compared between experimental data and the NM. Discussion The numerical curves of CA concentration versus time were similar to those obtained experimentally, with a decrease of AUC values
according to the blood flow, in agreement with the indicator-dilution theory. LL-PHE-SU8B • Metal Artifact Reduction in MRI: Update on Conventional and Emerging Techniques
Michael N Hoff PhD (Presenter) ; Paxton Smith MEng ; San Xiang PURPOSE/AIM 1. Review the mechanisms responsible for MRI artifacts caused by metallic implants.
2. Review standard and emerging techniques used to reduce metal-induced MRI artifacts.
3. Show examples of artifact reduction using emerging MRI methods. CONTENT ORGANIZATION * Describe the common types of embedded metal hardware found in post-surgical patients.
* Review the presentation of metal artifacts in MRI and describe the physical mechanisms of signal loss, signal pile-up, and distortion.
* Review the efficacy of metal artifact reduction in standard imaging practice using spin echo, STIR, high readout bandwidth, thin slice
selection, and increased matrix image size.
* Present advanced techniques for metal artifact reduction, such as MARS, 3D-PLACE, MAVRIC, SEMAC, and XS-bSSFP. SUMMARY 1. Metal artifacts in MRI impair the Radiologists' evaluation of structures adjacent to the metal implants.
2. Clinicians can minimize metal artifacts using standard scanner parameters.
3. Emerging techniques show great promise to further reduce metal artifacts in MRI. LL-PHE-SU9B • Changes in Tumor Shadows and Microcalcifications on Mammography in Elderly Patients with Stage I/II Breast
Cancer Following KORTUC II, a New Radiosensitization Treatment
Akira Tsuzuki MS (Presenter) ; Yasuhiro Ogawa MD, PhD ; Akihito Nishioka MD, PhD ; Kei Kubota MD, PhD ; Shin Yaogawa RT ; Kenji Itoh RT ; Youko Yamada RT ; Toshikazu Sasaki ; Norikazu Yokota RT ; Shiho Tokuhiro MS ; Ryo Akima MS, RT ; Naoya
Hayashi MS, RT Radiation Oncology and Radiobiology - Monday Posters and Exhibits (12:45pm - 1:15pm) Monday, 12:45 PM - 01:15 PM • Lakeside Learning Center
Back to Top RO
LL-ROS-MOB • AMA PRA Category 1 Credit ™:0.5 LL-ROS-MO1B • Utility of Combining Whole Body Diffusion with Post Contrast 3D m-Dixon Imaging to Assess the Disease Load in
Patients Presenting with Single Organ Involvement
Krishan K Jain MD (Presenter) ; Anoop K Pandey MD ; Bhaswati Roy ; Sandeep Vaishya MChir, MS ; Rana Patir MChir, MS ; Rakesh K Gupta MD, MBBS PURPOSE To assess the disease load in patients who presented with localized symptoms related to infective or neoplastic etiology with whole body
MR imaging (WB-MRI) using a combination of diffusion-weighted whole-body (DWIBS) and post contrast 3D m-Dixon imaging. METHOD AND MATERIALS 45 patients underwent MRI for various localized disorders. After completion of local examination including post contrast study, 3D
m-Dixon and DWIBS data sets were collected at five stations to cover whole body from skull to knees in these patients. The mean
additional time for WB-MRI was 25-30 minutes. Studies were read by 2 experienced radiologists. RESULTS Out of 45patients (15 females), 12 had initial diagnosis of tuberculosis (TB), 16 had neoplastic etiology and 17 did not have any
significant abnormality. Out of 12 TB patients, 7 presented with localized symptoms related to spine, 3 with brain and 2 with lung
involvement. Out of 7 patients with spinal involvement, 3 had disease localized to spine and other 4 had extra lesions in brain (n=1),
brain with breast (n=1), lung (n=1) and lung with musculoskeletal tissues (n=1). Among 3 patients with brain involvement, 2 had
disease localized to brain and 1 showed lesions in lower lobe of left lung confirmed as non-small cell lung carcinoma on biopsy. Other 2
TB patients had disease localized to lungs. In 16 patients with neoplastic etiology, 8 had disease localized to area of abnormality, 6
patients showed multiple metastatic lesions in brain, bone, lung, spleen and liver, 1 patient with pituitary tumor showed multiple bony
lesions with right chest wall abscess confirmed as tubercular on aspiration and one patient previously operated for left ureteric tumor
showed unrelated brain mass lesion confirmed as gliosarcoma on histopathology. CONCLUSION The combination of these two techniques is complimentary in providing information regarding multi-organ involvement in patients
presenting with symptoms relating to the localized disease. It provides high resolution images and has potential to use as one stop
imaging technique to assess the disease load in infective and neoplastic pathologies to detect multi-organ involvement. CLINICAL RELEVANCE/APPLICATION Disease load assessment in infective and neoplastic pathologies with DWIBS and post contrast 3D m-Dixon whole body imaging in
patients presenting with single organ involvement. LL-ROS-MO2B • CyberKnife® Stereotactic Radiosurgery for Arteriovenous Malformation
June Kim MD (Presenter) ; James K Goddard MD ; Leslie Nussbaum MD ; Eric Nussbaum MD ; Lori Copsey BS, RT ; Rachel
Dayton MPH ; Amy Fehrer MPH ; Camille Schwarzrock RN ; Michelle Smith BS,RT PURPOSE To examine the treatment parameters and clinical outcomes of patients with arteriovenous malformation (AVM) treated with CyberKnife�
(CK) stereotactic radiosurgery (SRS). Page 153 of 397
(CK) stereotactic radiosurgery (SRS). METHOD AND MATERIALS Patients with AVM who underwent CK SRS and had at least 1 year follow-up were included in this study (n=67). Medical records were
reviewed and demographic, treatment parameter and outcome data were gathered and analyzed. RESULTS Age of patients ranged from 14-75 years (mean 45). Pre-SRS AVM volume ranged from 0.027-62.72 ml (median 4.4 ml). The median
prescription dose was 24 Gy in 3 fractions. Per Spetzler-Martin grading, 6 patients had grade 1, 18 had grade 2, 18 had grade 3, 8 had
grade 4 and none had grade 5 AVMs. According to the Cognard classification, there were 14 dural AV fistulas (21%). Two patients had
AVMs located in the vein of Galen. The rate of re-bleed was 4% (n=3). One patient experienced ischemic stroke post-SRS. Procedure
related gliosis was observed in 19 patients (28%). The mean time to complete obliteration was 29 months. Thirty-four patients had
malformations of <15 ml and >3 year follow-up. Of these patients, the obliteration rate for parenchymal AVMs was 75% (18/24) and
50% (4/8) for dural AV fistulas. One-hundred percent (2/2) of vein of Galen AVMs were obliterated. Eight patients had parenchymal AVMs
larger than 15 ml and >3 year follow-up. The obliteration rate for these patients was 25%. No dural AV fistulas greater than 15 ml were
reported. The obliteration rate was higher in patients with compact (67%) versus diffuse (22%) nidus. Five patients had obliteration prior
to 3 year follow-up; two were parenchymal AVMs and three were dural AV fistulas. Although the sample size was small, there appeared
to be a trend towards favorable outcomes with a dose equivalent to 15 Gy or higher in a single fraction. Three cases were re-treated
following SRS. Of those, two underwent surgery and one had embolization followed by repeat SRS. CONCLUSION The results suggest CK SRS is an effective treatment for AVM and dural AV fistula comparable to similar treatment modalities. CLINICAL RELEVANCE/APPLICATION Our data show favorable outcomes for parenchymal AVM and dural AV fistula obliteration with low rates of re-bleed and re-treatment. LL-ROS-MO3B • Conformal Intracavitary Brachytherapy Planning for Carcinoma Cervix Using Transabdominal Ultrasound and
Assessment of Quality of Life
Pavankumar Lachi (Presenter) LL-ROS-MO4B • Hippocampal Sparing Whole Brain Irradiation with Boost to Metastases-A Retrospective Evaluation
Franziska Fels (Presenter) ABSTRACT Purpose/Objective(s):
For patients with multiple brain metastases a whole brain radiotherapy (WBRT) is indicated. Using new irradiation techniques, dose to the
hippocampus, center for learning and memory and location of neuronal stemm cells, can be reduced to < 10Gy. Thereby a neurocognitive
decline after radiotherapy could be avoided. However, theoretically there is an increased risk for the appearance of new metastastases in
the dose-reduced hippocampal avoidance zone. Furthermore, by the use of IMRT/VMAT-technique, it is possible to escalate the dose to
the brain metastases to obtain a better local tumor controll. This study evaluates the tumor control, morphological alterations in MR and
the appearance of new metastastases inside the hippocampus in patients who have been treated with hippocampal sparing WBRT
(HS-WBRT) and boost to individual brain metastastases.
Materials/Methods:
From 08/2011 to 01/2013, 16 patients were treated with HS-WBRT. The hippocampus was contoured as organ at risk and enlarged with
saftey margins of 7-10mm to ensure appropriate dose decline around the hippocampal avoidance volume. Whole brain was irradiated with
30Gy in 12 fractions with a restriction for the hippocampus < 10Gy maximum dose. Additionally a simulaneously integrated boost (SIB)
to individual (up to 7) brainmetastases of 51Gy or 42Gy for resection cavities, was performed. Follow-up-MRIs were planned 6 weeks
after radiotherapy and then 3-monthly.
Results:
5/16 patients were lost to follow-up. The median follow-up-time was 4 (1.5 -14) months. Evaluation of tumor control showed a complete
remission in 5 patients (45.45%), stable disease in 1 patient (9.1%) and mixed response in 1 patient. 3 patients had a progression of
their metastases (27.2%), 1 patient showed a doubtful progression in terms of a temporary irradiation reaction. 2 patients had an
increase in leukoaraiosis, 1 patient showed radionecrosis within 2 boosted metastases. No patients had intrahippocampal metastases. The
avoidance volume was free of metastases as well. Mean dose to hippocampus was < 10Gy (calculated from EQD2, average mean dose
7.4Gy).
Conclusions:
This study is the first to report about HS-WBRT and SIB to metastases. Good tumor control was seen and no patient had
intrahippocampal metastases. An upcoming prospective mulitcenter-study will evaluate this question further and analyze the effect on
neurocognition. LL-ROS-MO5B • Stereotactic Ablative Radiotherapy (SART) to Whole vs. Partial Vertebral Body for Spinal Metastasis
Anton E Khouri MD (Presenter) ABSTRACT Purpose/Objective(s): Controversy exists as to whether whole or partial vertebral body (VB) should be treated when SABR
is used for treatment of spinal metastases. This study aims to compare the treatment outcomes of patients with spinal
metastases treated to whole or partial VB with SABR.
Materials/Methods: A CyberKnife unit was used for the delivery of SABR for all patients. Clinical target volumes (CTVs) was
contoured by individual physicians with the help of a fused volumetric MRI (T1 with and without contrast and T2), so that
the gross tumor could be better delineated. Whole VB was defined as inclusion of the whole VB in the CTV, whereas partial
VB was defined as inclusion of only part of the vertebral body.
Results: 20 patients were included in the analysis. Vertebral levels included 5 cervical, 11 thoracic and 4 lumbar. Histologies
include adenocarcinoma, squamous cell carcinoma. 11 patients received SABR as postoperative treatment. Prescribed dose
was 12-30Gy in 1-5 fractions to 75%. 11 and 9 patients received SABR to whole and partial VB, respectively. With a median
follow-up of 13 months (1-19mo range), the gross tumor control rate was 76%. The index spinal segment
free-from-progression rate was 62% for the whole group and 56% for the partial VB group.
Conclusions: Gross tumor control appears to be similar for both whole and partial stereotactic ablative radiotherapy for spinal
metastasis. Further research is needed to determine the optimal CTV for spinal SABR. LL-ROS-MO6B • Which Pre-treatment FDG-PET Parameters Predict Outcome in Oropharyngeal Cancer?
Ankeet Shah (Presenter) ; Shlomo A Koyfman MD ; John Greskovich ; Ping Xia PURPOSE Prior analysis of pretreatment FDG PET/CT of patients with head-and-neck cancer (HNC) indicates mixed results for predicting outcome
using maximum standardized uptake value (SUVmax). Recently, metabolic tumor volume (MTV) has been identified as a predictive FDG
PET parameter in HNC. It is not clear, though, if primary MTV or nodal MTV is more predictive of outcome. The purpose of this study is to
assess the predictive value of various FDG PET parameters, as well as primary and nodal contribution, for outcome in HNC patients. METHOD AND MATERIALS The dataset included 70 patients with oropharyngeal squamous cell cancer who underwent FDG PET/CT scanning prior to radiation
therapy. Pretreatment parameters of SUVmax, SUVmean, total glycolytic activity (TGA), and MTV were collected as indicators of total
tumor burden, stratified into the primary tumor, total involved lymph nodes, and the largest involved lymph node. We also assessed the
largest diameter of primary tumors and largest diameter of involved lymph nodes as an alternative measure of tumor burden. The
findings were compared between the subsets of patients that had no evidence of disease (NED) on follow-up (n=54), and those patients
Page 154 of 397
that had persistent disease (PD) on follow-up FDG PET/CT (n=16). RESULTS Among the pretreatment FDG PET parameters, MTVs in cm3 for total tumor burden and primary tumors, as well as maximum diameter in
cm of primary tumor demonstrated statistically significant differences between patients with NED and PD. For total tumor burden, the PD
average MTV = 49.2, and NED average MTV = 28.5. At a cutoff of 50cm3, odds ratio (OR) = 10.2 (CI 95%: 2.2-47.7). For primary
volume, PD average MTV = 33.5 and NED average MTV = 9.8. At a cutoff of 30cm 3, OR = 24.1 (CI 95%: 2.6-227.0). MTV differences in
total involved nodal volume or largest involved nodal volume were not statistically significant. Average maximum diameter in cm of
primary tumor of PD patients = 5.03 and in NED patients = 3.44. At a cutoff of 5.5cm, OR = 11.8 (CI 95%: 2.0-69.0). CONCLUSION This study supports the use of MTV and maximum diameter of the primary tumor, as well as MTV of total tumor burden, to assess risk of
disease progression. Other FDG PET parameters were not predictive of outcome in oropharyngeal HNC. CLINICAL RELEVANCE/APPLICATION FDG PET scans that are commonly used to for staging and treatment planning can also help predict outcome of treatment in
oropharyngeal cancer. Vascular/Interventional - Monday Posters and Exhibits (12:45pm - 1:15pm) Monday, 12:45 PM - 01:15 PM • Lakeside Learning Center
IR
VA LL-VIS-MOB • AMA PRA Category 1 Credit ™:0.5 Back to Top LL-VIS-MO1B • Comparison of Conventional and Simulated Reduced-tube Current MDCT for Evaluation of Endovascular Aortic
Aneurysm Repair: A Pilot Study
Ryan H Sydnor MD (Presenter) ; Kingshuk Roychoudhury ; Claire A Bridges ; Jared D Christensen MD ; Carlos J Guevara MD
; Amy M Neville MD ; Tony P Smith MD ; David R Sopko MD ; Donald P Frush MD PURPOSE To assess the impact of simulated CT tube current reduction on radiologists� interpretation of CT angiograms (CTAs) following
endovascular repair (EVAR) of the abdominal aorta. METHOD AND MATERIALS The gold standard for this study consisted of 45 standard-dose CTA examinations (64-slice GE VCT, 2 x 128-slice Siemens SOMATOM
Definition Flash; non-contrast and arterial phase contrast-enhanced scans of the abdomen and pelvis) performed for evaluation of the
aorta following EVAR. Of these, 26 underwent simulated 50% mA reduction and 29 underwent simulated 75% mA reduction using a
validated mA reduction (noise insertion) software program. Three blinded, experienced faculty radiologists interpreted the 100 randomized
studies for the presence of an endoleak, endoleak type, maximum aortic measurements, and subjective level of noise. Finally, reader
confidence in detecting or excluding an endoleak was recorded for each image set. RESULTS Using the consensus vote (Y or N) regarding the presence of an endoleak for each full-dose examination as the gold standard, 81%
(21/26) of simulated 50% mA-reduction and 76% (22/29) of simulated 75% mA-reduction scans were positive for endoleak. Sensitivity
for endoleak diagnosis was not significantly different at 82% with 50% mA reduction and 89% with 75% mA reduction. Reader
agreement for the presence of endoleak for the full-mA, 50% mA-reduction and 75% mA-reduction exams was 57%, 55% and 64%,
respectively; thus, agreement did not significantly change with decreasing CT dose. Mean absolute measurement error for aortic
cross-sectional area (cm2) was 4.4 for the 75% mA-reduced exams, compared to 2.4 for the 50% mA-reduced exams (p < 0.001,
repeated measures ANOVA). Reader confidence decreased as the mA decreased, with average ratings of 4.73 for 100% mA, 4.66 for
50% mA and 4.32 for 25% mA exams (p < 0.001). CONCLUSION The results of this pilot study did not show a significant reduction in endoleak detection with simulated CT dose reduction; however, a
follow-up study with a larger sample size may be necessary in order to detect significant differences with subtle leaks. Decreasing dose
did result, however, in a significant decrease in reader confidence and increase in average measurement error. CLINICAL RELEVANCE/APPLICATION In order to minimize cumulative radiation dose, it is important to establish CT dose reduction thresholds above which diagnostic image
quality can be maintained. LL-VIS-MO2B • Effect of Sorafenib Combined with Transcatheter Arterial Embolization on the Therapeutic Outcome of Rabbit
Hepatic Tumors
Lingxiang Ruan PhD, MD (Presenter) ; Shunliang Xu ; Jingfeng Zhang PhD, MD PURPOSE Transcatheter arterial embolization (TAE) could result in more severe hypoxia and affected the microcirculation of hepatic tumor, which
lead to tumor recurrence and metastasis at some extent. Sorafenib, the first systemic drug approved for advanced hepatocellular
carcinoma (HCC) patients, is mainly used for the prevention of HCC recurrence and metastasis. Tumor micro-circulation has a close
relationship with the growth, development, invasion, metastasis and prognosis of hepatic carcinoma. This study was to verify the
hypothesis that sorafenib combined with TAE could improve the therapeutic outcome of pure TAE. METHOD AND MATERIALS A total of twenty-four New Zealand White rabbits were successfully implanted with VX2 tumor in liver and divided into three group at
random, such as pure Lipiodol-based TAE group (n = 8), sorafenib combined with TAE group (n = 8) and pure sorafenib group (n = 8).
Tumors were received TAE with Lipiodol, and / or oral administration of sorafenib after implanting for two weeks. One, two, and four
weeks after TAE, animals were humanely killed, and tumor samples were collected for immunohistochemical staining with CD34.
Expression level of HIF-1? protein was evaluated, and micro vascular density (MVD) was calculated. RESULTS CONCLUSION Sorafenib suppressed the development of tumor recurrence and metastasis through extracellular signal-regulated kinase signaling caused
by elevated levels of growth factors, which could enhance the therapeutic outcome in combination with TAE against liver tumors. CLINICAL RELEVANCE/APPLICATION Sorafenib could enhance the therapeutic outcome in combination with TAE against liver tumors. LL-VIS-MO3B • Evaluation of Portal Vein System in Patients after Liver Transplantation by Unenhanced MR Angiography Using
Spatial Labeling with Multiple Inversion Pulses Sequence and by CT Portography
Hao Tang (Presenter) ; Daoyu Hu MD, PhD ; Zi Wang Page 155 of 397
PURPOSE The objective of this study was to evaluate the diagnostic performance of unenhanced MR Angiography using spatial labeling with multiple
inversion pulses sequence (SLEEK) in comparison with CT portography in the detection of Portal Vein System in patients with liver
transplantation. METHOD AND MATERIALS 22 patients, 21 men and 1 women (mean age 44.3 years; age range, 15�51 years). Unenhanced MRA using SLEEK was performed on a
1.5-T MRI system for assessing portal vein system in 22 patients with liver transplantation. Then all patients underwent 16-slice CT
portography within 1�4 days. The ability to present the portal vein system and to reveal portal vein system disease with SLEEK was
evaluated by two experienced radiologists and was compared with CT portography results using a joint reading performed in consensus. RESULTS 22 patients with liver transplantation underwent SLEEK MRA. A total of 20 portal veins were successful assessed, including 16 normal
portal veins, 4 with stenoses. Nineteen of the 20 patients were performed end-to-end anastomosis between the donor�s and recipient�s
portal veins. One of the 20 patients was performed end-to-end anastomosis between the donor�s portal vein and recipient�s inferior
vena cave. There was excellent correlation between SLEEK and CT portography in presenting the diameter of portal vein (r = 0.92; p <
0.05). SLEEK was superior to CT portography in revealing the third- and fourth-order segmental branches in the hepatic parenchyma (p <
0.05). SLEEK has the advantage of avoiding interference from ribs, arterial and venous system enhancement. CONCLUSION The SLEEK has a comparable ability in demonstrating portal vein system in patients with liver transplantation as well as CT portography
does. It can provide helpful information for surgeons to make an accurate postoperative assessment. Unenhanced MRA using SLEEK is
relatively inexpensive and is not associated with renal complications. It can be as a good choice for screening portal vein system in
patients with liver transplantation, especially in patients with renal insufficiency. CLINICAL RELEVANCE/APPLICATION The SLEEK has a comparable ability in demonstrating portal vein system in patients with liver transplantation as well as CT portography
does. It can provide helpful information for surgeons to make an LL-VIS-MO4B • Study on a Combined Protocol of Chemoembolization and Microwave Ablation: Treatment of Hepatocellular
Carcinoma in Rats
Thomas J Vogl MD, PhD (Presenter) ; Jun Qian MD ; Ulli Imlau ; Yousef Hamidavi ; Huedayi Korkusuz MD ; Elsie Oppermann
; Wolf-Otto Bechstein PURPOSE To assess the effect of transcatheter arterial chemoembolization (TACE) combined with microwave ablation for the treatment of
hepatocellular carcinoma in an animal model. METHOD AND MATERIALS All experiments were approved by the German government and the institutional animal research review board. After subcapsular liver
implantation of Morris Hepatoma 3924A in 30 ACI rats, the animals were randomly assigned to three interventional treatment groups as
follows: (A) TACE (0.1 mg of mitomycin + 0.1 ml of lipiodol + 5.0 mg of degradable starch microspheres) + microwave ablation
(2450MHz; 35 W, 45 s) (n=10); (B) TACE alone (control group 1, n=10); (C) microwave ablation alone (control group 2, n=10). Tumor
volume before (V1) and after the treatment (V2) was assessed by MRI and the tumor growth ratio (V2/V1) was calculated.
Immunohistochemical analysis was performed for quantification of positive MMP-9 and VEGF tumor cells in each treatment. RESULTS Mean tumor growth ratio was 1.3385 + 0.1949 in group A, 3.1901 + 0.1323 in group B, and 4.1779 + 0.1862 in group C, respectively.
Compared with the ratio in groups B and C (controls), the ratio in group A showed significant reduction in tumor growth (P CONCLUSION Treatment with combined TACE/microwave ablation, compared with the treatment of TACE or microwave ablation alone, significantly
inhibits tumor growth and intrahepatic metastases in an animal model of hepatocellular carcinoma. CLINICAL RELEVANCE/APPLICATION Transarterial chemoembolization in combination with microwave ablation are relevant treatment options in hepatocellular carcinoma LL-VIS-MO5B • Quantification of Lower Leg Arterial Calcifications by High-Resolution Peripheral Quantitative Computed
Tomography (HR-pQCT)
Janina M Patsch MD, PhD (Presenter) ; Martin A Zulliger * ; Gundula Edelhauser MD ; Thomas M Link MD, PhD * ; Michael
Weber ; Christian Loewe MD * PURPOSE HR-pQCT is a low-radiation-dose, in-vivo research tool primarily designed for the assessment of bone geometry, density and
microarchitecture of the distal extremities. Vascular calcifications are frequently observed as incidental findings but quantitative analysis
of vascular calcifications captured by HR-pQCT has not been performed yet. The objectives of our study were to validate a quantitative
tool for the assessment of lower leg arterial calcifications (LLAC) by HR-pQCT and to test method reliability. METHOD AND MATERIALS RESULTS Agatston score was low in 24% (0-10HU), intermediate in 35% (11-400HU), and high in 41% of patients (>400HU). 76% had LLAC in
HR-pQCT. Comparing LLAC (HR-pQCT) and CAC (MDCT), there were positive correlations between LLAC mass and CAC as measured by
Agatston score, mass score, and volume score (Spearman's rho=0.6;p CONCLUSION CLINICAL RELEVANCE/APPLICATION Based on low radiation dose and significant associations with CAC, LLAC assessment might be a novel, patient-friendly, quantitative
measure applicable to epidemiological and cardiovascular research. LL-VIE-MO6B • Applications of Dual-Energy CT in Vascular Imaging
Sivasubramanian Srinivasan MD, FRCR (Presenter) ; Hui Seong Teh MBBS, FRCR ; Ashish Chawla MD, MBBS ; Jerome I Bosco
MD, MBBS PURPOSE/AIM To illustrate the usefulness of Dual-Energy computed tomography(CT) in imaging of vessels involving various anatomical region from
head to extremities. To discuss the pitfalls of Dual energy CT CONTENT ORGANIZATION Introduction.
Review of Dual Energy CT in imaging the vessels of head and neck, chest, abdomen and pelvis and extremities with case
examples.
Virtual Non-contrast images, automated dual-energy bone removal and plaque removal. Page 156 of 397
Advantages of advanced integrated tools(syngo.viaTM) with RIS-PACS which aid in faster and efficient post-processing techniques.
Pitfalls.
SUMMARY Dual energy CT helps in faster post-processing with lesser radiation dose compared to the conventional CT angiography.
Automated Dual-energy based bone removal tool is very effective especially in the head and neck, for elimination of the skull base.
Plaque removal tool is highly useful in Carotid arteries and arteries of the lower extremities.Virtual non-contrast images are useful
to rule out bleed, to assess extravascular structures and also to rule out hyperdense non-iodine material within the lumen. Pitfalls
include incomplete bone subtraction in few areas, inefficient hard plaque removal in the infrapopliteal arteries and increased noise
in obese patients.
LL-VIE-MO7B • Current Percutaneous Vascular Closure Techniques and Associated Complications
Amit Bhakoo MD (Presenter) ; Brandon P Olivieri MD ; Mohammed Ezuddin ; Anne Beasley ; Robert E Beasley MD PURPOSE/AIM An increase in the number of endovascular procedures performed over the past decade has led to the development of new techniques
intended to improve the efficacy and safety of vascular closure. Knowing the mechanism of action, components, risk-benefit and
complication profiles unique to each closure technique is important for the reduction of adverse events. Further, an understanding of
imaging findings and treatment options for vascular access-related complications is crucial for safe patient care. CONTENT ORGANIZATION Compare and contrast mechanisms of action of current vascular closure techniques.
Review risk-benefit profiles of closure techniques (manual compression, hemostasis pads, compression devices, passive and active
vascular closure devices).
Describe multimodality imaging findings and treatment options of vascular access complications (pseudoaneurysm, arteriovenous fistula,
access site/retroperitoneal hematoma, and arterial dissection/occlusion). SUMMARY Having a thorough understanding of various closure techniques is important for the reduction of adverse events in endovascular
procedures. The participant will gain understanding of the efficacy, complication and risk-benefit profiles for currently available
percutaneous vascular closure techniques, as well as the imaging findings and treatment options of their associated complications. Molecular Imaging - Tuesday Posters and Exhibits (12:15pm - 12:45pm) Tuesday, 12:15 PM - 12:45 PM • S503AB
MI
Back to Top CL-MIS-TUA • AMA PRA Category 1 Credit ™:0.5 Host
Michael S Gee , MD, PhD CL-MIS-TU1A • In Vivo Monitoring of NIS-induction and Tumor Phenotyping Using Extrathyroidal Tumor Xenograft Mouse Models
Eva J Koziolek DO (Presenter) ; Ivayla Apostolova ; Agnieszka Tarkowska ; Winfried Brenner * ; Udo Schumacher ; Gerhard B Adam MD ; Michael G Kaul PURPOSE Despite the method of gene transfer, all trans retinoic acid (atRA), a vitamin A derivative, in combination with glucocorticoides has been
used to stimulate sodium iodide symporter (NIS) expression in thyroid and breast cancer models. To apply I 131 therapy to extrathyroidal
tissue, functional and sufficient NIS-expression is a pre-condition.The purpose of this study was to evaluate the potential of atRA and
prednisolut (PRED) to i)induce functional NIS-expression in a NIS-negative pancreatic cancer model ii) enhance functional NIS in a
NIS-transfected breast cancer model. METHOD AND MATERIALS Mouse tumor xenograft models BxPC3 (pancreas), HT29 (colon) and NIS-transfected MCF7 (breast) were established over the right
scapula. Daily injections of atRA/PRED (1.3/0.7 mg/day) treatment were given subcutaneously for up to 7 days. SPECT was performed on
day 0, 5 and 7 using a nanoSPECT/CTplus (Bioscan/Mediso) and 100 MBq/mouse Tc99m pertechnetate. Tumor phenotyping (T2w, ADC,
DCE-MRI) was performed prior to the treatment using a 7T MRI (ClinScan, Bruker). RESULTS In vivo imaging of tumor-specific NIS-induction after 5 and 7 days of atRA/PRED treatment was performed by SPECT and resulted in an
increase in Tc99m-uptake. The NIS-negative pancreatic cancer model showed an up to 3 fold increase in tracer uptake (n=4) above the
background or when compared to HT29 tumor xenografts. As expected, the NIS-transfected breast cancer model (n=4) showed an initial
strong tracer uptake in the tumor tissue (3 and 4 % ID/ml) and further increased by 30-50%, on day 7 of treatment. T2w MR imaging
allowed a precise delineation of tumor mass, and was used to place the ROI with high accuracy for SPECT analysis. Tumor phenotyping
allowed a detailed characterisation of the tumor tissue prior to atRA/PRED treatment. CONCLUSION Functional NIS-expression in extrathyroidal tissues can be stimulated by atRA/PRED treatment and further increased in already
NIS-transfected tissues, when tissues initially respond with NIS- expression after atRA treatment. In vivo tumor-specific NIS-induction
can be visualized by SPECT/CT using a NIS-specific tracer. Multimodal imaging including SPECT and MRI generates useful complementary
data. CLINICAL RELEVANCE/APPLICATION The combination of gene transfer and atRA-induced NIS expression represents a convenient way to further increase NIS levels in
extrathyroidal tissues in order to achieve a therapeutic effect with I131 CL-MIS-TU2A • Optimization for Combination of Peptide Receptor Radionuclide Therapy (PRRT) and Temozolomide Therapy
Using SPECT/CT and MRI; A Mouse Study
Joost C Haeck MS (Presenter) ; Sander Bison ; Stuart Koelewijn ; Harald C Groen PhD ; Marleen Melis ; Monique R Bernsen
PhD ; Marion De Jong PhD PURPOSE Successful treatment of patients with somatostatin receptor overexpressing neuroendocrine tumors (NET) with Lutetium-177-labelled
octreotate, (PRRT) or temozolomide (TMZ) as single treatments has been described. Their combination might result in additive response,
so we studied tumor characteristics and therapeutic respo