Scientific Congress Report ECR 2014 Food for Thought

Scientific Congress Report ECR 2014
Food for Thought
Edition 1 - Extracellular Contrast Media
2
Text: KONTEXTGesundheit GbR (www.kontextgesundheit.de)
Photodesign: Britta Radike (www.radike.com)
Table of Contents
4
Contrast Media Are an Integral Part of CNS MRI
6
Contrast-Enhanced MRA Catches Up With CTA
8
MRI Parameters Correlate With Tumor Response After
Neoadjuvant Chemotherapy
10
New Imaging Possibilities Create New Demands
12
Endorectal MRI of Prostate Cancer­– Do’s and Dont’s Review
14
Primary CNS Lymphoma or Glioblastoma? – Perfusion MRI Helps to Find Out
16
MRI of The Breast – Technique and Diagnosis
18
MRI and Acute Myocardial Infarction
20
Differentiation of Chronic Prostatitis From Coexistent Prostate Cancer
22
Economic Aspects and The Future of Breast MR
24
Authors
3
CNS Imaging
Contrast Media Are an
Integral Part of CNS MRI
Contrast agents are essential to obtain high quality
Contrast choice is also potentially able to improve
images of the central nervous system. Salvador
lesion detection and characterization, said Pedraza,
Pedraza, Girona, Spain, explained why contrast
providing some examples.
improves diagnostic outcome for CNS lesions.
“Perfusion is very important in the study of tumors”,
Pedraza gave an overview on contrast use in brain
emphasized Pedraza, quoting a study (Giesel FL
tumors, infectious diseases of the brain, stroke,
et al. Acta Radiol 2009, 50:521–530) that shows
vascular disease and multiple sclerosis (MS).
advantages of double-dose contrast over the single
dose, particularly for the delineation between gray
Brain tumors
and white matter and the demarcation of ­highly
Contrast media are needed for precise surgical plan-
vascularized tumor tissue on brain perfusion
ning. Contrast agents should be carefully chosen
weighted imaging performed at 3T.
to detect all lesions that can possibly be found
(Anzalone N et al. Acta Radiol 2009; 50: 933–940
“Use contrast for tumor imaging, because it
and Kim AJNR 2010; 31(6), 1055–1058). This is
­delineates tumors much better and you get high
also true for achieving good delineation of cerebral
quality perfusion”, underlined Pedraza.
neoplastic lesions (Anzalone N et al. Eur J Radiol
2013;82(1):139–145).
Infectious diseases
Contrast is also useful for the detection of possible
For brain perfusion imaging, the use double-dose
complications, such as ventriculitis. “This is some-
contrast proved to be superior to single-dose
thing you cannot see on DWI, it can only be de­mon­
(­Tombach B. Radiology 2003 Mar;226(3):880–888).
strated with contrast”, said Pedraza. This is also
true for other infectious processes like meningitis.
4
Acute stroke
Multiple Sclerosis
Multimodal MRI including contrast-enhanced per-
Contrast-enhanced MRI is the diagnostic gold stan-
fusion and magnetic resonance angiography (MRA)
dard for MS diagnosis and monitoring of disease
is useful to assess acute stroke. Pedraza comment-
progression. It is an integral part of the McDonald
ed that Time-of-Flight “kills low flow”, while post-
criteria that rely on both, the assessment of non-en-
perfusion contrast-enhanced MRA can demonstrate
hanced and contrast-enhanced lesions in the brain
arterial segments with low flow, thus avoiding the
and the spine.
overestimation of vascular obstruction (Pedraza S et
al. Stroke 2004;35(9):2105–2110). It is also able to
“Contrast media are essential to obtain high quality
detect small ischemic lesions.
MR imaging – do not forget perfusion, as it is a necessary part of CNS MRI”, concluded Pedraza.
Vascular disease
In patients with cerebral venous thrombosis,
Discussion
MRI combined with MR venography is the best
Chairman Maximilian Reiser, Munich, Germany,
diagnostic approach (Puig J et al. Radiologia.
asked about the importance of contrast media for
2009;51(4):351–361). Contrast agents are essential
the detection of MS manifestations in the spinal cord.
to find the presence of the thrombus.
Pedraza answered that spinal lesions ­definitely need
to be taken into account and that contrast plays an
ICA (internal carotid artery) dissection is also an
important role in this, adding that he and his col-
indication for contrast-enhanced MRI.
leagues look mainly at the cervical spinal cord.
Session Topic: Advances in contrast enhanced MRI
Session Date: Friday, March 7th 2014
Presentation Code: SY 8
Name of Speaker: Salvador Pedraza, Girona, Spain
Original Presentation Title: Highlights of contrast applications in CNS imaging
5
MR Angiography
Contrast-Enhanced MRA
Catches Up With CTA
Elena Mershina, Federal Center of Treatment and
makes use of the flow phenomenon that occurs,
Rehabilitation, Moscow, Russia, gave a comprehen-
when transverse magnetization moves in the di-
sive overview of indications for MR Angiography
rection of a magnetic field gradient. Pre-saturation
(MRA), basing her recommendations for MRA use on
permits the selective visualization of the arterial
a wide variety of clinical examples.
or venous system. Phase contrast (PC) is performed
to quantify the blood flow. It uses the fact that the
Mershina started with an outline of the various
phase shift of proton magnetization is proportional
body regions, where MRA has clinical impact:
to its velocity.
Q Intracranial arteries
Q Carotid and vertebral arteries
Contrast-enhanced MRA
Q Pulmonary arteries, especially MR-angiopulmo-
As non-contrast MRA of the aorta and its branches
nography and pulmonary perfusion
has various disadvantages, such as artifacts, turbu-
Q Thoracic and abdominal aorta
lences, the problem to depict small vessels and the
Q Renal and lower extremities arteries
rather long acquisition time, contrast media prove
Q Coronary arteries – however, MRA proves to be
to be useful. Contrast media are necessary, when
sub-optimal for clinical routine in that case.
multiphase and perfusion studies are required.
“We prefer Gadovist with its double concentration
Regarding equipment, Mershina called Gd-contrast
at our institution”, said Mershina.
media an integral part of MRA, besides a 1,5 or 3T
scanner, special software and hardware including
She cited various studies comparing ce-MRA
coils and an automatic injector. Contraindications
to other modalities:
are the same as in any other MR imaging method:
In patients with chronic thromboembolic pulmo-
they include electronic devices like cardiac pace-
nary hypertension (CTEPH), ECG-gated MD-CT angi-
makers and defibrillators.
ography outperformed ce-MRA and DSA (Ley S et al.
Eur Radiol 2012;22(3):607–16). If CTA and MRA are
She also briefly explained the technical basis of
combined, depiction of main and segmental arteries
some common techniques: Time-of-flight (TOF)
is 100% sensitive and specific, said Mershina.
6
In patients with critical limb ischemia, CTA and
New trends
­ce-MRA both demonstrate arterial disease. Both
MRA’s temporal and spatial resolution will increase,
confidently distinguish between high-grade
said Mershina. Real-time MRA will also eventually
stenoses and occlusions (Jens S. Eur Radiol.
be possible. Blood-flow quantification and plaque
2013;23(11):3104–3114).
visualization are further trends for MRA imaging.
For the carotids, a meta-analysis shows that
Conclusion
contrast-enhanced MR angiography is more
Mershina made it very clear that ce-MRA does not
sensitive and specific for 70–99% stenoses
yield to CTA in any location, except the coronaries.
than Doppler ultrasound, MR angiography,
It proves to be a useful alternative for patients that
and CT angiography. (­Wardlaw JM et al. Lancet.
should not get a CTA, like children or young w
­ omen,
2006;367(9521):1503–1512).
patients with repetitive studies and patients with
allergy-like reactions to iodine contrast. CTA
­remains the method of choice for emergencies.
“However, this might change in the future”,
­concluded Mershina.
Session Topic: Whole body MRI
Session Date: Sunday, March 9th 2014
Presentation Code: SY 30
Name of Speaker: Elena Mershina, Moskow, Russia
Original Presentation Title: Magnetic Resonance Angiography of the body –
different techniques and areas of implementation
7
Breast Imaging
MRI Parameters Correlate
With Tumor Response After
Neoadjuvant Chemotherapy
The term locally advanced breast cancer (LABC) is
Therapy response is normally measured using the
used for very heterogeneous breast malignancies,
RECIST criteria, which rely on tumor size. Nadrljans-
which are highly variable in tumor size and lymph
ki now assessed the usefulness of MRI parameters
node involvement.
for the evaluation of tumor response after NACT.
He compared the standardized assessment (RECIST)
While showing a number of rather different defini-
to a vascular score (number of vessels ≥ 30 mm in
tions currently in use, Mirjan Nadrljanski, Belgrade,
length and ≥2 mm in diameter) and the positive
Serbia, also revealed LABC’s common denominator:
enhancement integral (PEI) on MRI.
“All of them show no signs of spread beyond the
breast region”.
Nadrljanski included 30 women with a median age
of 55.4 (± 11 years). LABC was confirmed clinically
With 10 to 20 percent of all newly diagnosed breast
and radiologically for all patients. Each patient
cancers in industrial nations and up to 75% in the
underwent an initial MR-mammography at 1.5T,
developing countries, LABC are globally important.
then the first MRI control after initial chemotherapy
with anthrcyclines. A 2nd follow-up MRI scan was
Their treatment aims at controlling locoregional
performed after another 4-week NACT cycle with
disease and eradicating occult metastases. Neo-
paclitaxel. All MRM examinations were contrast-en-
adjuvant chemotherapy (NACT) with paclitaxel is
hanced.
commonly used. If pathologic complete response
(pCR) is achieved, overall survival (OS) and disease
free survival (DFS) are likely to increase and operability of an otherwise inoperable tumor might be
achieved. “EUSOBI has recognized this indication in
2008”, said Nadrljanski.
8
Nadrljanski found that tumor size shrunk signifi-
Chairman Pascal Baltzer, Vienna, Austrian, asked
cantly upon therapy. The change in vascularity
about the definition of the post-enhancement inter-
and PEI was also highly significant. The correlation
val. “We take the whole time curve of the interval”,
between RECIST and vascularity and PEI after the
answered Nadrljanski.
first therapy cycle was weak (0.36 and 0.22 respectively). It was moderate after the second cycle (0.61
Further literature
and 0.50 respectively).
The EUSOBI guideline on Breast MRI Nadrljanski referred to can be downloaded via www.ncbi.nlm.nih.
“Tumor size, vascularity and PEI significantly
gov/pmc/articles/PMC2441490/pdf/330_2008_Arti-
change during and after NACT” said Nadrljanski.
cle_863.pdf
Change in tumor size after the first therapy cycle
and after the 2nd cycle strongly correlates. There is
a moderate positive correlation between RECIST and
vascularity and PEI after completion of NACT.
Session Topic: Different ways to evaluate treatment response
Session Date: Thursday, March 6th 2014
Presentation Code: SS202, B-0216
Name of Speaker: Mirjan Nadrljanski, Belgrade, Serbia
Original Presentation Title: Locally advanced breast cancer response to neoadjuvant chemotherapy –
correlation between RECIST, positive enhancement integral values and tumor vascularity
9
Breast Imaging
New Imaging Possibilities
Create New Demands
Breast imaging continuously develops, causing
For the reading protocol, she named a couple of
radiologists to constantly cope with change. Sylvia
special demands: Sometimes there are ­additional
Heywang-Koebrunner, Munich, Germany, took her
views, which need to be displayed separately.
audience through a mammography lecture that
Repeat scans really need to replace the picture that
laid a base for choosing the right method at the
was repeated. Contrast needs to be adaptable for
right time.
a series of images, including the priors, in order to
make images comparable.
Heywang-Koebrunner started by naming the
different requirements ¬¬for screening and disease
Because contrast differs between different vendors,
assessment. Screening methods have to work with
readers should be trained for differences between
high patient loads and still need to be comprehen-
vendors.
sive, while disease assessment calls for easy access
to all the necessary imaging information.
In the future, it will be more and more important
to assess overall breast density. Different equip-
Screening
ment and different software programs still cause
In 2D FFD Mammography, all images need to be
problems. “There is still research to be done”, said
available at once. “We still experience that the
Heywang-Koebrunner.
priors do not pop-up all the time”, she commented. Images are evaluated for symmetry, cc and
CAD for mammography screening is not yet
mlo view per side are assessed and compared
­recommended – but as sensitivities of computer
to ­previous films. Enlargement options are also
aided reading programs approach the quality of
needed. “Always compare priors to the recent view”,
conventional readings, CAD programs are becoming
underlined Heywang-Koebrunner.
more and more interesting.
10
“Tomosynthesis for screening must be considered”,
detection and assessment of small lesions and
said Heywang-Koebrunner regarding the future of
slight architectural distortions.
breast screening. However, she also mentioned the
challenges that need yet to be overcome: radiation
The workflow in assessment is as follows:
dose (which differs from vendor to vendor) is one
1 If a cyst is expected or a lesion biopsy is
major concern. Fatigue of the readers has also not
planned, ultrasound (US) and additional TS
been looked at adequately yet.
views are sufficient.
2 If a subtle mass or architectural disturbance is
“We do not know the acceptable number of tomo-
suspected, spot, rolled or lateral TS and US
synthesis (TS) cases for stack reading”, she said. The
are used.
optimal selection of cases for tomosynthesis is also
not clear (all density ranges or ACR 2–3).
The optimal method for comparison with priors
is also yet to be defined. Once these problems are
3 If the lesion is visible on one view, TS followed
by targeted US should be done.
4 In case of microcalcifications, TS should be used,
if skin calcifications are suspected.
solved, it might turn out that there are not enough
readers for TS screening.
“The possibilities have increased and new possibilities create new demands”, said Heywang-Koebrun-
Disease Assessement
ner, adding that ongoing research will be needed to
“This it, what we do already”, said Heywang-­
guarantee optimal breast imaging.
Koebrunner. She called TS “really helpful” for the
Session Topic: What does a breast imaging system have to perform?
Session Date: Thursday, March 6th 2014
Presentation Code: SY2
Name of Speaker: Sylvia H. Heywang-Koebrunner
Original Presentation Title: Optimized Workflow, possibilities and challenges with 2D FFDM vs 3D DBT
11
Prostate MRI
Endorectal MRI of Prostate
Cancer – Do’s and Dont’s Review
It is difficult to establish a routine for prostate MR
What urologists expect from radiology
imaging. During a Bayer HealthCare lunch symposium
Prostate MRI is used:
on ECR 2014, Sergey Morozov from Sechenov Moscow
Q To increase detection rate of prostate cancer
Medical University gave some insights and shared his
experiences.
and to reduce ‘over-diagnosis
Q To localize the disease
Q To improve risk stratification
Background on prostate cancer
Q To improve treatment decision-making
In the decade from 2002 to 2012, prostate can-
Q To guide therapy
cer prevalence showed an increase by 155% and
Q To facilitate differential diagnosis
a mortality increase of 59% in Russia, said Sergey
Morozov from Sechenov Moscow Medical University.
Typical cases that urologists refer to
The clinical course varies from insignificant tumors
the radiologist are:
to aggressive cancers. “Many of those cancers are not
Q Borderline PSA-values with non-palpable nodule
clinically significant”, he said. The mainly used grading tool for prostate tumor is the Gleason score.
and doubt about the indication for biopsy
Q Staging of prostate cancer
Q PSA recurrence after radical prostatectomy
Primary Gleason score ranges from 1 to 5; score 1
indicates normal prostate tissue in the tumor, score 5
One out of three prostate MRI findings in patients
indicates none or only few recognizable glands in the
with increased PSA are normal, “but it is harder to
tissue. “We are not good in MRI differentiation of Glea-
make a negative interpretation compared to a pos-
son score 3”, said Morozov. Higher primary Gleason
itive one”, said Morozov and added: “Avoid over-di-
scores (4 and 5) indicate high-grade prostate cancer.
agnosis of cancer and extra-capsular extension.”
Major treatment options are – next to active sur-
Communication is everything
veillance – surgery, radiation therapy, cryosurgery,
Diagnosing and treating prostate cancer requires an
hormone therapy, and chemotherapy.
interdisciplinary team approach of urologists, radiologists, and pathologists, said Morozov, in which
“the major thing is communication”.
12
The European Society of Urogenital ­Radiology
painful having the coil inside” and “more uncom­
(ESUR) has released guidelines on prostate
fortable than biopsy” to “you will know it is there,
MRI in 2012. They were published in European
but it does not hurt” and “may be slightly uncom-
­Radiology (2012;22:746–757). The guidelines are
fortable”.
available online: http://link.springer.com/­article/­
10.1007%2Fs00330-011-2377-y
Image-guided biopsy: TRUS, MRI or both combined
Finally, Morozov addressed the image-guided biopsy
Key elements of prostate MRI
using either transrectal ultrasound (TRUS) or MRI.
Even for the best radiologist it is hard to establish a
“Sometimes TRUS misses or underestimates prostate
routine for prostate MR imaging, said Morozov, as
cancer” he said. MRI-guidance has the advantage
expectations by urologists are high and there is of-
that biopsies may be performed directly; however, it
ten a lack of knowledge about the clinical context.
is more time consuming and uncomfortable.
Regarding the type of MR scanner, Morozov gave
“In men with clinical suspicion of prostate cancer
some recommendations: Field strength should be
and an enlarged prostate due to benign prostate
at least 1.5 T, the number of channels is important,
hyperplasia, MR_TRUS fusion biopsy should be
and an endorectal coil plus artifact correction for
considered a first-line diagnostic approach”, he
this coil is mandatory.
quoted Diaz et al. (J Urol 2013). Combined MR/TRUS
diagnostics increases Gleason Score in one third of
Patient preparation and correct placing of the en-
the cases. “This means that without combined MR/
dorectal coil are essential. “CAD is useful now”, said
TRUS we underestimate prostate cancer”, explained
Morozov, as it supports both visual reporting and
Morozov.
quantitative assessment.
Conclusion
PI-RADS classification
“The dialogue with clinicians is extremely impor­
He also recommended using PI-RADS classification
tant”, concluded Morozov and recommended using
for standardized interpretation of prostate MRI
MRI for high-grade prostate cancer. However, it has
findings. An Android App for mobile devices is avail-
limited value in patients with tumors smaller than
able in Google’s playstore. It allows PI-RADS scoring
1 cm or Gleason score of 3+3=6 or smaller.
according to the ESUR guidelines.
His final advice was to prevent overestimation of
Patients’ expectations
the disease and to not be afraid of underestimating
In terms of the patients’ expectations, Morozov
focal and minor capsule involvement.
­quoted various testimonies from patients who had
undergone prostate MRI. They ranged from “very
Session Topic: Prostate MRI
Session Date: Sunday, March 9th 2014
Presentation Code: Lunch Symposium BHC (Russia): “Whole Body MRI”
Name of Speaker: Sergey Morozov, Sechenov Moscow Medical University/Russia
13
CNS MRI
Primary CNS Lymphoma or
Glioblastoma? – Perfusion
MRI Helps to Find Out
In T1-weighted MRI, primary CNS lymphoma and
Method
glioblastoma present very similar and cannot
At total of 60 patients with glioblastoma and eleven
be ­differentiated with certainty. MRI perfusion
with PCNSL were included in this retrospective anal-
para­meters may have the strength to unveil their
ysis. All patients underwent contrast-enhanced 3D
­difference.
T1w-spoiled GE-MRI on a 3T scanner prior to surgery.
After scanning, three parameters were measured
Distinguishing between primary CNS lymphoma
with help of Tofts Kernmode model:
(PCNSL) and glioblastoma plays a crucial role for
Q Volume transfer constant (Ktrans)
clinicians as the two malign diseases demand
Q Volume of extravascular extracellular space (Ve)
very d
­ ifferent treatment strategies. ­Alexander
Q Flux-rate constant (Kep)
Radbruch and colleagues from Heidelberg,
Germany, tested, whether vascular permeability
Histological findings acted as the standard of
parameters gained during dynamic contrast-­
reference.
enhanced (DCE) MRI may give additional infor­
mation for this differential diagnosis.
14
Results
15
Conclusion
Median K
trans
and Kep values presented significantly
Significantly higher K
trans
and Kep values in PCNSL
higher in PCNSL compared with the values in glio-
indicate a higher vascular permeability of the PCNSL
blastoma (0.145/0.396 vs. 0.064/0.230, p<0.01). No
tumor tissue. Considering these MRI-parameters,
significant differences were seen for Ve levels.
perfusion measurements may in future help to better
differentiate between glioblastoma and PCNSL.
ROC-analysis highlighted that K
trans
is the best dis-
criminative parameter for differentiating between
the two malign CNS diseases. The best Ktrans threshold
was at 0.093 (sens 90.9%, spec 95.0%, AUC 95.1%).
Optimal Kep threshold was at 0.272 (sens 90.0%, spec
78.3%, AUC 90.3%).
Session Topic: Evaluation of microvascular permeability with dynamic contrast-enhanced MRI for the
differentiation of primary CNS lymphoma and glioblastoma: radiologic pathologic correlation
Session Date: Friday, March 7th 2014
Presentation Code: SS 611, B-0487
Name of Speaker: Alexander Radbruch, Universitätsklinikum Heidelberg, Heidelberg/Germany
Breast Imaging
MRI of The Breast –
Technique and Diagnosis
Breast MRI has become a very sensitive method to
To avoid motion artifacts, the patient should lie in
detect breast lesions and monitor treatment re-
a comfortable prone position. Kinkel therefore uses
sponse. Karen Kinkel from Chêne-Bougeries in Swit-
certain devices that are especially designed for breast
zerland, shared her experiences in daily practice.
MRI. But not only the patient’s position , also the way
radiologists and radiographers approach the patient,
Breast MRI usually consists of T2-weighted
impact image quality. To prevent motion artifacts,
sequences and contrast-enhanced dynamic
Kinkel tries not to disturb the patient during scan-
T1-weighted scans with fat suppression. Kinkel
ning: “Don’t talk to the patient during examination.”
­recommended to follow only well established
­imaging protocols, and to abide by the BI-RADS
Radiologists have to be aware of the fact that
criteria for a standardized image interpretation.
background enhancement varies with breast cycle.
Strong background enhancement usually occurs in
How to do it?
the second phase of the cycle, and during estrogen
T1-weighted imaging includes a native scan and
treatment. So, best time for scanning is during the
contrast-enhanced scans. First post-­contrast scan
second week of the menstrual cycle between day
is acquainted 90sec after injection, a ­delayed scan
seven and twelve.
7:30min post-contrast. For contrast-enhance­
ment, Kinkel recommended the standard dose of
0.1 mmol/kg BW of one of the three contrast agents:
gadoteric acid, gadobenate dimeglumine or
gadobutrol.
16
Reading MR images of the breast
MRI mammography helps clinicians to assess therapy
First of all Kinkel assesses both breasts for back-
response and drive treatment towards a patient-­
ground enhancement and breast density and then
tailored strategy: If the original tumor shrinks concen-
reports each breast separately using the BI-RADS
trically, lumpectomy might be sufficient. If the tumor
lexicon. For each lesion, the following parameters
fragments, mastectomy might be the better strategy.
are considered: location, size, lesion type, morpho­
logy, kinetic, BI-RADS category.
Radiologists have to be aware of the fact that the
­different types of treatment also influence MR-
There are two main MRI-descriptors that point to
enhance­ment. Chemotherapy for example, leads to
malignant lesions: irregular or speculated margins
reduced wash-out, while radiation therapy reduces
and rim-enhancement. Benign lesions often present
background enhancement. So it is always n
­ ecessary
with a smooth margin and non-enhanced septae.
to take into account the clinical context of the
examination.
Session Topic: MRI of the breast – Technique and diagnosis
Session Date: Friday, March 7th 2014
Presentation Code: E3 620, A-133
Name of Speaker: Karen Kinkel, Clinique de Grangettes, Chêne-Bougeries/Switzerland
17
Heart Imaging
MRI and Acute
Myocardial Infarction
Cardiac MRI nowadays has become a convenient tool
are ruptured and it accumulates even more in
for assessing the heart muscle’s status after an isch-
the extracellular space of scar tissue. Thus, in LGE
emic event. It offers tests for viability, function and
images necrotic tissue appears white, whereas black
even helps to predict recovery. And there may be even
areas point to intact cells. “That’s very simple,”
more options in the future. So be prepared.
commented Lombardi.
For assessing myocardial viability after acute
CE-MRI is also helpful for detecting small
myocardial infarction (MI), MRI nowadays has
non-transmural myocardial infarcts that can easily
become the gold standard. But it offers some more
be overseen in SPECT images as spatial resolution is
modalities to collect useful details about the hearts
to low with this CT-technique. Lombardi presented
current condition. Massimo Lombardi form Milan,
a study that demonstrated a significant benefit
Italy, gave an overview.
for LGE compared to SPECT for infarct detection
(Wagner A, Lancet 2003): LGE-MRI appeared nearly
LGE - simple and convenient
equal with the gold standard tetrazolium staining
Late gadolinium enhancement (LGE) MRI is the
(TTC; a method frequently used in experimental
right method for detecting necrotic tissue after
animal-models) in detecting infarcts with a small
acute myocardial infarction. Contrast media immi-
extent, whereas SPECT fell away sharply (TTC 73%
grates into necrotic cells as their cell membranes
vs. LGE 64% vs. SPECT 15%).
18
MRI has more than one bullet to shoot
Where the future lies?
“Is this useful for clinic? Yes!”, emphasized
The fourth bullet of MRI might be the evaluation
­Lombardi. With help of LGE-MRI findings, a cardio­
of MI-metabolites through hyperpolarized 13C-­
logist might already be able to decide, whether
pyruvate MRI. This is at least a research topic,
revascularization is useful or not. Beside viability
Lombardi and colleagues are currently working on.
tests, MRI can provide information about wall thick-
After injection of 13C-pyruvate lactate, alanine,
ness and even helps to predict the heart’s recovery.
bicarbonate and pyruvate appear highlighted in the
MR-images. Their patterns point to the status of
The latter is “the third bullet in the gun: low dose
blood supply in cardiac tissue. Lombardi concluded
dobutamine stress test,” highlighted Lombardi.
that 13C-pyruvate MRI is not only a pie in the sky:
A review article demonstrated that cardiac MRI
“It is already possible in humans.”
including contrast-enhanced imaging with and
without stress has a high sensitivity and specificity
in assessing coronary artery diseases (sens 94%,
spec 87%; Camici et al. Circulation 2008).
Session Topic: Assessing myocardial viability by CMR
Session Date: Saturday, March 8th 2014
Presentation Code: EM3, A-279
Name of Speaker: Massimo Lombardi, Policlinico San Donato, Milan/Italy
19
Prostate MRI
Differentiation of Chronic
Prostatitis From Coexistent
Prostate Cancer
For local MRI-staging of prostate cancer, it is clinically
Methods
important to distinguish cancer from adjacent regions
54 patients (mean age 61.8 years) with biopsy proven
of chronic inflammation. Hypointense, radial, centrifu-
prostate CA underwent pre-operative MRI performed
gal striations are typical MRI features of inflammation.
at 1.5 Tesla before total prostatectomy. MRI findings
suggestive of chronic inflammation were compared to
Background
prostatectomy specimens. MRI was performed with a
Despite the addition of diffusion-weighted imaging
pelvic phased-array ­surface coil in combination with
(DWI) and dynamic contrast enhanced sequences
a disposable ­endorectal prostate coil. High resolution
(DCE) to the standard T2-weighted protocol, there
T2-­weighted and DCE sequences were obtained in
remains a significant overlap in MRI features of
transverse plane.
prostate cancer, benign prostate hyperplasia (BPH)
and chronic inflammation. As 98% of patients
40 patients (74%) had a Gleason Score of 7, 10
with prostate cancer show chronic prostate inflam­
patients (19%) had a score of 6, and 4 patients (7%)
mation, there is potential for over- or underesti-
had a score of 8. PSA ranged from 2.6 to 51 ng/mL.
mation of the cancer extent, said Karen Buch from
­Boston University, USA. Therefore, the differen­
Histopathology was considered the reference
tiation of these entities is essential to accurately
standard. Imaging findings were classified as true
assess the extent of prostate cancer.
positive, true negative, false positive, and false
negative. Accuracy, sensitivity, specificity, positive
Buch and colleagues described the imaging char-
predictive value (PPV) and negative predictive value
acteristics of chronic prostatitis using high-spatial
(NPV) were calculated, and the agreement ­between
resolution DCE MRI in patients who underwent
high-resolution contrast-enhanced MRI and
prostate MRI before prostatectomy.
­histopathology was evaluated.
20
Features of chronic inflammation
Conclusion
"In T2-weighted images, we were looking for hypo­
“Our preliminary findings on high resolution
intense fine, linear centrifugal striations", ­explained
­contrast-enhanced MRI helps us to more accurately
Buch. In DCE MRI, late-enhancing ­striations with
distinguish prostate cancer from coexistent chronic
fine, linear striations in a ­centrifugal pattern were
inflammation”, concluded Buch. Typical MRI features
­considered as features of chronic inflam­mation. These
were hypointense, radial, centrifugal striations in
were seen irrespective of rapid wash-in.
T2-weighted images, and persistent enhancement of
striations in dynamic contrast-enhanced imaging. In
The histopathologic correlates were infiltration of
contrast, prostate cancer shows nodular-­geographic
chronic inflammation cells and centrifugal bands of
and confluent enhancement without striations.
collagen correlating to striations seen on MRI.
These key imaging features have a sensitivity of
100% as well as high accuracy of 94%.
Results
There was substantial agreement between MRI
For local staging by MRI, it is clinically important to
and histopathologic results. 49 out of 54 patients
distinguish prostate cancer from adjacent regions
(91%) had MRI features of chronic inflammation.
of chronic inflammation. “High resolution contrast-­
The ­sensitivity of MRI was 100% and specificity was
enhanced MRI helps us to more accurately evaluate
62.5%. PPV was 94%, NPV was 100%, and accuracy
the stage of prostate cancer”, concluded Buch.
was 94.4%.
Session Topic: Prostate MRI
Session Date: Thursday, March 6th 2014
Presentation Code: SS107, B-0083
Name of Speaker: Karen Buch, Boston University, USA
Original Presentation Title: MRI Features of Chronic Prostatitis and Differentiation
from Coexistent Prostate Cancer
21
Siemens & Bayer Breast Care Day: Beyond Breast MR Imaging
Economic Aspects and The
Future of Breast MR
MR mammography can be a very reliable tool to d
­ etect
MRM. Of these, 142 patients were sent to biopsy,
and assess breast cancer lesions. And, by the way, it
124 cases with MRM positive findings and 18 cases
has the power to save overall costs, if ­performed rou-
with MRM negative findings. Of the 1,346 patients
tinely, as a German study in cooperation with a major
without biopsy, 761 underwent further MRM for
health care insurance company demonstrated.
­follow-up. The remaining 585 were followed-up by
help of a questionnaire.
MR mammography still in a niche
MRI is performed routinely nowadays for patients
Expenses were defined as the sum of costs for all
with back pain and headache. MR mammography
MRM assessments plus the costs for biopsy and
(MRM), however, is only indicated for a small range
­limited surgery in case of any positive f­ inding.
of indications, like screening of high-risk patients,
­Savings were determined as all biopsy costs of
detection of recurrence after breast-conserving
­patients with negative findings and costs for exten­
­therapy and CUP syndrome (cancer of unknown
ded surgeries in patients with positive findings that
primary). The reason: MR mammography is claimed
could be saved with help of MRM.
to be too expensive and too unspecific. “Is it really
true?” Clemens Kaiser from Mannheim, Germany
For the estimation of costs and savings, Kaiser
asked. To find an answer, he conducted a study in
­referred to data of the department of gynecology and
cooperation with Techniker Krankenkasse, one of
the major German health insurance companies.
­pathology of the Friedrich-Schiller-University in Jena:
Q MR mammography BEUR 418,50/assessment
Expenses and Accuracy
QBiopsy Bapprox. EUR 1,000/case
Q Limited surgery Bapprox. EUR 4,000/case
Between April 2006 and December 2011, a total of
Q Extended surgery Bapprox. EUR 10,000/case
1,488 patients with unclear findings in ultrasound or
x-ray mammography underwent contrast-­enhanced
22
No false negative results with MRM
Expenses for MR mammography plus biopsy
A total of 2,272 lesions were detected with help
and limited surgery for all benign findings were
of the MR mammography, among these were 124
­estimated at 1,5 Mio Euros, whereas savings ranged
malign lesions including ductal carcinoma in situ
between 2,9 and 4,4 million Euros. “You can save
(DCIS) and 2,140 benign lesions. Not a single false
50% of the costs by using MR mammography,”
negative finding among the benign diagnoses was
Kaiser summed up. According to him, these results
reported. Of the 124 malign lesions, 48 lesions
demonstrated that “MRM exceeds ultrasound and
finally turned out to be benign. According to these
radiography diagnostically and economically.”
results, MR mammography was performed with
100% sensitivity, 95.2% specificity and 95.6%
Kaiser knows, that results like these are possible only
­accuracy. When limiting the study group to cancer
with help of experienced radiologists: “MR is only as
cases only, specificity further increased to 97.2%.
good as the reading radiologist.” That is why he called
“That’s true strength,” noted Kaiser.
for special teachings and trainings and went further:
“We might even need a certificate of expertise.”
Session Topic: Satellite Symposium: Beyond imaging in breast MR: innovation and workflow
optimization in clinical practice
Session Date: Thursday, March 6th 2014
Presentation Code: SY1
Name of Speaker: Clemens Kaiser, Universitätsmedizin Mannheim, Mannheim/Germany
23
Authors
Salvador Pedraza, Spain
CNS Imaging: Contrast Media Are an Integral Part of CNS MRI
Elena Mershina, Russia
MR Angiography: Contrast-Enhanced MRA Catches Up With CTA
Mirjan Nadrljanski, Serbia
Breast Imaging: MRI Parameters Correlate With Tumor Response After Neoadjuvant Chemotherapy
Sylvia H. Heywang-Koebrunner, Germany
Breast Imaging: New Imaging Possibilities Create New Demands
Sergey Morozov, Russia
Prostate MRI: Endorectal MRI of Prostate Cancer – Do’s and Dont’s Review
Alexander Radbruch, Germany
CNS MRI: Primary CNS Lymphoma or Glioblastoma? – Perfusion MRI Helps to Find Out
Karen Kinkel, Switzerland
Breast Imaging: MRI of The Breast – Technique and Diagnosis
Massimo Lombardi, Italy
Heart Imaging: MRI and Acute Myocardial Infarction
Karen Buch, USA
Prostate MRI: Differentiation of Chronic Prostatitis From Coexistent Prostate Cancer
Clemens Kaiser, Germany
Siemens & Bayer Breast Care Day: Beyond Breast MR Imaging: Economic Aspects and The Future of Breast MR
24
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Radiology
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G.RI.04.2014.0210 April 2014
© Bayer Pharma AG 2014