2013 RSNA (Filtered Schedule) Sunday, December 01, 2013 08:30

 2013 RSNA (Filtered Schedule) Sunday, December 01, 2013
08:30-10:15 AM • PS10 • Arie Crown Theater • Opening Session 10:15-11:30 AM • BA10 • Room: Booth 1152 • Hologic: 3D Breast Tomosynthesis Imaging with C-View™ for Breast Cancer Screening and
Diagnosis - limite... 10:30-11:30 AM • MSRA11 • Room: S402AB • Patient Assessment: Requirements, Reimbursement and Radiology Procedures (An Interactive
Session) 10:30-12:00 PM • VSPD11 • Room: S100AB • Pediatric Radiology Series: Pediatric Neuroimaging I 10:45-12:15 PM • SPOI11 • Room: E353C • Oncodiagnosis Panel: Pediatric Sarcoma (An Interactive Session) 10:45-12:15 PM • SSA01 • Arie Crown Theater • Breast Imaging (Diagnostic Ultrasound) 10:45-12:15 PM • SSA02 • Room: S502AB • Cardiac (Coronary CT/MR I) 10:45-12:15 PM • SSA03 • Room: S504AB • Cardiac (Radiation Dose Reduction) 10:45-12:15 PM • SSA04 • Room: S404CD • Chest (Vascular) 10:45-12:15 PM • SSA05 • Room: N228 • Emergency Radiology (Imaging Chest Emergencies) 10:45-12:15 PM • SSA06 • Room: E353A • Gastrointestinal (CT Dose Reduction I) 10:45-12:15 PM • SSA07 • Room: E450A • Gastrointestinal (Rectal Carcinoma Imaging) 10:45-12:15 PM • SSA08 • Room: E450B • Gastrointestinal (Hepatic Fibrosis Imaging) 10:45-12:15 PM • SSA09 • Room: E351 • ISP: Genitourinary (New Methods of Detection and Characterization of Urolithiasis) 10:45-12:15 PM • SSA10 • Room: E353B • Genitourinary (Adrenal Masses: New Methods for Specific Diagnosis) 10:45-12:15 PM • SSA11 • Room: S403A • ISP: Informatics (Education and Research) 10:45-12:15 PM • SSA12 • Room: S504CD • ISP: Molecular Imaging (Oncology I) 10:45-12:15 PM • SSA13 • Room: E451A • Musculoskeletal (Shoulder I) 10:45-12:15 PM • SSA14 • Room: E451B • Musculoskeletal (Tumor I) 10:45-12:15 PM • SSA15 • Room: N226 • Neuroradiology/Head and Neck (Temporal Bones) 10:45-12:15 PM • SSA16 • Room: N227 • Neuroradiology/Head and Neck (Vascular Disease of the Head and Neck) 10:45-12:15 PM • SSA17 • Room: N229 • Neuroradiology (Parkinson's Disease) 10:45-12:15 PM • SSA18 • Room: S505AB • Nuclear Medicine (PET/CT in Oncology) 10:45-12:15 PM • SSA19 • Room: S403B • Physics (CAD I) 10:45-12:15 PM • SSA20 • Room: S404AB • Physics (Low-dose CT Imaging) 10:45-12:15 PM • SSA21 • Room: S405AB • Physics (Ultrasound) 10:45-12:15 PM • SSA22 • Room: S104A • Radiation Oncology and Radiobiology (Lung I) 10:45-12:15 PM • SSA23 • Room: E350 • Vascular/Interventional (Embolotherapy/Guidance Technology) 10:45-12:15 PM • SSA24 • Room: E352 • Vascular/Interventional (Portal Interventions/TIPS) 11:00-12:30 PM • ICIA11 • Room: S401CD • Slicer: Quantitative Medical Imaging for Clinical Research and Practice: Hands-on Workshop 11:00-12:30 PM • ICII11 • Room: S501ABC • IHE Clinical Solutions for Interoperability - Imaging and Beyond 11:00-12:30 PM • ICIW11 • Room: S401AB • National Library of Medicine PubMed: Find Articles You Need: Searching PubMed/MEDLINE
Efficiently 11:45-12:45 PM • MSRA12 • Room: S402AB • Patient Radiation Dose: Reduction and Recording (An Interactive Session) 12:00-12:45 PM • BA11 • Room: Booth 1152 • Hologic: 3D Tomosynthesis Guided Breast Biopsy 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-MSE-SUA • Room: Lakeside Learning Center • Multisystem/Special Interest - 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-OBE-SUA • Room: Lakeside Learning Center • Obstetrics/Gynecology - Sunday Posters and Exhibits (12:30 - 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-OBE-SUB • Room: Lakeside Learning Center • Obstetrics/Gynecology Sunday Posters and Exhibits (1:00 - 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) 01:15-02:30 PM • BA12 • Room: Booth 1152 • Hologic: 3D Breast Tomosynthesis Imaging with C-View™ for Breast Cancer Screening and
Diagnosis - limite... 01:30-06:00 PM • VSIO11 • Room: S405AB • Interventional Oncology Series: Controversies and Emerging Questions in the Management of
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Renal Tumors 02:00-02:45 PM • BC10 • Room: Booth 8355 • lifeIMAGE: Image Sharing 101 - Securely Transfer Exams, Wherever Needed 02:00-03:00 PM • MSRA13 • Room: S402AB • Abdominal Imaging Clinical Pathways (An Interactive Session) 02:00-03:30 PM • RC101 • Room: E451B • Lung Cancer Screening: How I Do It 02:00-03:30 PM • RC102 • Room: E350 • What's New from the Radiology Residency Review Committee: Milestones, New for 2013 02:00-03:30 PM • RC103 • Room: N227 • Cardiovascular Risk Assessment: The Role for the Radiologist 02:00-03:30 PM • RC104 • Room: E353C • Sports Injuries in the Chest and Abdominal Wall: A Core Curriculum of the Body's Core 02:00-03:30 PM • RC105 • Room: S406B • Traumatic Brain Injury 02:00-03:30 PM • RC106 • Room: E451A • Eye and Orbit 02:00-03:30 PM • RC107 • Room: N226 • Quality and Safety 2013: Best Practices, Radiation and Contrast Media 02:00-03:30 PM • RC108 • Room: E353B • Imaging of the Traumatized Spine (Traditional) (An Interactive Session) 02:00-03:30 PM • RC109 • Room: E450A • Gastrointestinal: Liver (An Interactive Session) 02:00-03:30 PM • RC110 • Room: E450B • Renal Ultrasound and Doppler (An Interactive Session) 02:00-03:30 PM • RC111 • Room: S505AB • Multi-modal Imaging Workup for Alzheimer's Disease, Parkinson's Disease, and Related Disorders:
Case-based App... 02:00-03:30 PM • RC112 • Room: S105AB • Thoracic Aorta: Key Concepts (An Interactive Session) 02:00-03:30 PM • RC113 • • No Course RC113. See Series VSPD12 Pediatric Radiology Series: Pediatric Musculoskeletal 02:00-03:30 PM • RC114 • Room: S404CD • Venous Disease 02:00-03:30 PM • RC115 • Room: S406A • Current Issues in Breast Cancer Screening 02:00-03:30 PM • RC116 • Room: S102D • RSNA Educational Programs Around the World: An International Forum (Sponsored by the RSNA
Committee on Interna... 02:00-03:30 PM • RC117 • Room: S504CD • Combining In Vitro Diagnostics and Imaging for Integrated Decision Making 02:00-03:30 PM • RC118 • Room: E353A • Interactive Game: Interactive Quiz Cases in Neuro-oncologic Imaging 02:00-03:30 PM • RC120 • Room: E352 • Radiographic Evaluation of the Post-Radiotherapy Brain 02:00-03:30 PM • RC121 • Room: N228 • Medical Physics 2.0: Computed Tomography 02:00-03:30 PM • RC122 • Room: S504AB • Uncertainties in Imaging for Radiation Oncology: Sources and Mitigation Techniques-Image
Guidance in the Treat... 02:00-03:30 PM • RC123 • Room: N229 • Minicourse: Current Topics in Medical Physics-Clinically Focused Physics Education: Principles to
Practice 02:00-03:30 PM • RC124 • Room: S403B • Extranodal Lymphoma from Head to Toe (In Conjunction with the American Institute for Radiologic
Pathology) 02:00-03:30 PM • RC125 • Room: S104A • Quantitative Imaging: Current and Future Practice in Radiology and Clinical Trials 02:00-03:30 PM • RC126 • Room: S103AB • Health IT Tools to Improve Quality and Safety in Radiology (An Interactive Session) 02:00-03:30 PM • RC127 • Room: E351 • The Future of Radiology: What Are the Threats and How to Respond to Them 02:00-03:30 PM • RC129 • Room: S404AB • Interactive Game: MR Imaging Innovations for the Oncological Practice: Case-based Instruction 02:00-03:30 PM • RC130 • Room: S403A • Standardized Terminology in Radiology: Applications and New Developments 02:00-03:30 PM • RC132 • Room: S502AB • What Is Driving Health Care Reform and How It Is Changing Your Radiology Practice 02:00-03:30 PM • RC150 • Room: E260 • MR Imaging-guided Breast Biopsy (Hands-on Workshop) 02:00-03:30 PM • RC151 • Room: E261 • Introduction to Cardiac MR: Infarcts, Cardiomyopathies and Masses (How-to Workshop) 02:00-03:30 PM • RC152 • Room: E264 • Techniques for Interventional Sonography and Thermal Ablation (Hands-on Workshop) 02:00-03:30 PM • RC153 • Room: S401CD • Introduction to Social Media (Hands-on Workshop) 02:00-03:30 PM • RC154 • Room: S401AB • Introduction to Workflow Engines, Hands-on with an Open-source Platform 02:00-03:30 PM • VSPD12 • Room: S102AB • Pediatric Radiology Series: Pediatric Musculoskeletal 03:00-03:45 PM • BA13 • Room: Booth 1152 • Hologic: 3D Tomosynthesis Guided Breast Biopsy 03:00-03:45 PM • BC11 • Room: Booth 8355 • lifeIMAGE: Sharing Images Across the Community at Boston Children's 03:15-04:15 PM • MSRA14 • Room: S402AB • Imaging the Bariatric Surgery Patient (An Interactive Session) 04:00-04:45 PM • BC12 • Room: Booth 8355 • lifeIMAGE: Ensuring Return on Investment (ROI) in Your Medical Image Sharing Deployment 04:00-05:30 PM • ICIA12 • Room: S401CD • Structured Annotation and Image Markup (AIM) Template and Toolsets: Hands-on Workshop 04:00-05:30 PM • ICII12 • Room: S501ABC • Ergonomics 04:00-05:30 PM • ICIW12 • Room: S401AB • The RSNA Image Share Network - How It Operates and How to Put It into Your Office 04:00-05:45 PM • PS12 • Arie Crown Theater • Sunday Afternoon Plenary Session 04:30-05:30 PM • MSRA15 • Room: S402AB • The Practice of the Radiology Assistant - Full Integration into Rural and Medical Center Settings
(An Interact... Opening Session Sunday, 08:30 AM • Arie Crown Theater PR
LM GN PS10 • AMA PRA Category 1 Credit ™: 1.75 • ARRT Category A+ Credit: 1 To receive credit, relinquish attendance voucher at end of session.
Presiding
Sarah S Donaldson , MD , Palo Alto, CA
President, Radiological Society of North America
Greetings
John D Hazle , PhD , Houston, TX
President, American Association of Physicists in Medicine
Joy S Sclamberg , MD , Deerfield, IL
President, Chicago Radiological Society
Back to top Presentation of the Outstanding Educator Award
Bruce G Haffty , MD , New Brunswick, NJ Recipient
Presentation of the Outstanding Researcher Award
Norbert J Pelc , ScD * , Stanford, CA Recipient
Dedication of the 2013 RSNA Meeting Program to the Memory of David H. Hussey, MD (1937-2013), and Philip E.S. Palmer,
MD (1921-2013)
Sarah S Donaldson , MD , Palo Alto, CA President's Address: The Power of Partnership
Sarah S Donaldson , MD , Palo Alto, CA Introduction by
Richard T Hoppe , MD , Palo Alto, CA First Vice President, Radiological Society of North America
LEARNING OBJECTIVES In the current healthcare environment, radiologists must reexamine their traditional expectations, attitudes, and behaviors so as to
embrace a requisite change in culture that builds partnerships throughout radiology, the general medical community, and the larger
community of patients and families. This address illustrates the perils of technology that have unintentionally fragmented radiology
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community of patients and families. This address illustrates the perils of technology that have unintentionally fragmented radiology
and radiologists. Yet in this current era of precision imaging and therapy, we find natural partnerships throughout the radiologic
community. Within the general medical community, multi-disciplinary team medicine mandates visibility of the radiologist, who must
accept responsibility for patient care beyond rapid communication of imaging results. Team-based practice promotes collaborative
clinical and research programs, augments one�s expertise, and builds careers. Professional interdependence promotes innovation
and adds value to our collective endeavors. However, our most important partners are the patients we serve. When we commit
ourselves to focusing on their care and becoming their partners, they will come to understand our contribution to diagnosis and
treatment, and will become our advocates. The physician / patient bond that is well developed in oncology serves as a model for all of
radiology, and confirms the gratifications that come from being a patient-oriented radiologist. Annual Oration in Diagnostic Radiology: We Must Stand on the Shoulders of Giants
Damian E Dupuy , MD * , Providence, RI Introduction by
Matthew A Mauro , MD * , Chapel Hill, NC Chairman, Scientific Program Committee
LEARNING OBJECTIVES Over the past 50 years the field of Radiology has undergone incredible growth that has led to greater diversity and sub specialization.
A clear division between Radiation Oncology and Diagnostic Radiology was made in the early 1970s and since that time each has
become even more complex and subspecialized. Within Radiology, the subspecialty of Interventional Radiology has emerged as a
unique entity � similar to the demarcation between Radiology and Radiation Oncology over 40 years ago. The newly approved dual
Interventional Radiology (IR) and Diagnostic Radiology (DR) primary certificate for resident education emphasizes that IR is distinct in
its incorporation of diagnostic imaging, image-guided procedures and patient care. Radiology and Interventional Oncology share a
strong focus on cancer detection and diagnosis, tumor staging, locoregional therapy and treatment follow-up. Both specialties are
vitally important to patients during their cancer treatment and should strive for collaboration to optimize patient care. Despite their
mutual goals and complementary skill sets, many Radiology and Radiation Oncology Departments struggle to be autonomous and are
at times in direct competition for both hospital resources and patients. In the new health care paradigm where evidence-based
medicine (e.g. cost and quality) becomes a more important determinant of treatment decision-making, a cohesive team approach to
cancer care makes the most economic sense. According to an American College of Radiology survey of United States Radiology and
Radiation Oncology practices in 2008, most practices from both specialties preferred a large multi-specialty group practice either
within or separate from an academic medical center. This is no surprise given the growth of medical knowledge and technical
innovation that our specialties have benefited from. It is becoming more difficult for smaller groups to maintain state of the art
specialization within their respective fields. Radiology groups, on average, are almost three times the size of Radiation Oncology
practices. It behooves these departments to reach a stronger axis of collaboration given the shared common interests and marked
synergy between many of the cancer treatments each possesses in their armamentarium. Advanced imaging of treatment response
with contrast-enhanced imaging, perfusion and diffusion magnetic resonance imaging as well as PET/CT and PET/MRI is providing a
clearer picture into tumor anatomy and pathophysiology. Radiologists can place fiducial markers and brachytherapy catheters to
provide more precise localization for stereotactic body radiotherapy techniques and higher local radiotherapy boosts for recurrent local
cancers, respectively. Advanced imaging technology provides radiation oncologists with more accurate tumor targeting, thus reducing
toxicity to adjacent normal and critical tissues. Combination therapies with external beam radiotherapy or brachytherapy and thermal
ablation technology have shown synergistic effects with promise for improved local control in larger tumors. Intraarterial
radioembolics with 90 Yttrium embolic agents utilize beta particles to destroy regional cancer of the liver. Newer non-ionizing
techniques such as high intensity focused ultrasound can provide stereotactic like thermal destruction of soft tissue tumors; exciting
preliminary results have shown potential in bone cancer, breast cancer and prostate cancer. Radiation oncologists have great expertise
at treatment planning with ionizing radiation. This experience has come from decades of research as well as technical advances in
computer science and photon delivery. Concurrently, radiologists who target tumors with ablative techniques have begun to realize
the great need for 3-dimensional treatment planning. The time has come for a reunification of spirit as well as intellect. Our patients
and the medical community will reap the benefits of a stronger collaboration. As Isaac Newton said, �If I have seen further than
others, it is by standing upon the shoulders of giants.� Hologic: 3D Breast Tomosynthesis Imaging with C-View™ for Breast Cancer Screening and Diagnosis - limited to 34 attendees
Sunday, 10:15 AM - 11:30 AM • Booth 1152
BA10 Back to Top LEARNING OBJECTIVES Registration Online at Hologic.com Hologic is offering a series of 75 minute sessions that include hands-on experience reading 3D breast
tomosynthesis images in combination with conventional and generated 2D(C-View) images. A brief lecture will provide an overview of the
technologies prior to the hands-on. The sessions are inteded for radiologists interested in learning more about breast tomosyntesis for
screening and diagnosis. Please note, the program does not qualify as FDA mandated training for Tomosyntesis. The course is not a CME
activity. Patient Assessment: Requirements, Reimbursement and Radiology Procedures (An Interactive Session)
Sunday, 10:30 AM - 11:30 AM • S402AB
QA
HP MSRA11 • AMA PRA Category 1 Credit ™:1 • ARRT Category A+ Credit:1 Joy J Renner , MA, RT(R) * Back to Top LEARNING OBJECTIVES This course will review the organizations and agencies who play a role in determining patient assessment requirements. The link between
reimbursement and documented assessment will be addressed in various patient scenarios. The last segment of this session will review and
highlight the focused patient assessments most common to radiology procedures. Pediatric Radiology Series: Pediatric Neuroimaging I Sunday, 10:30 AM - 12:00 PM • S100AB
PD
MR NR VSPD11 • AMA PRA Category 1 Credit ™:3.75 • ARRT Category A+ Credit:4 Moderator
Marvin D Nelson , MD Moderator
Sanjay P Prabhu , MBBS VSPD11-01 • MR Imaging of the Neonatal Brain
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Back to Top Marvin D Nelson MD (Presenter) LEARNING OBJECTIVES 1) To review the common adversities and reactions to such in the fetal and neonatal brain. 2) To demonstrate the use of various imaging
techniques for assessing acquired fetal and neonatal brain lesions. 3) To highlight the importance of the placenta on normal brain
development. VSPD11-02 • Impaired Preoperative Global and Regional Cerebral Perfusion in Newborns with Complex Congenital Heart Disease
Usha D Nagaraj MD (Presenter) ; Iordanis Evangelou DPhil ; Mary Donofrio ; Gilbert Vezina MD ; Catherine Limperopoulos
PhD PURPOSE To compare global and regional cerebral perfusion in neonates with congenital heart disease (CHD) versus healthy controls using arterial
spin labelling (ASL) MRI. METHOD AND MATERIALS ASL is a non-invasive technique for evaluating cerebral perfusion without the use of an exogenous contrast agent. We performed brain
MRIs in 73 newborns (30 with complex CHD, 43 controls) prior to open heart surgery on a 3T scanner. 3D FSE Pseudo-continuous ASL
sequence was utilized. Post-acquisition image processing was undertaken on a Linux workstation using FSL software. All cases were
reviewed by a board certified radiologist (UN) who was blinded to clinical parameters and case/control status. Mean whole brain cerebral
blood flow (CBF) was calculated using the scanner software and recorded in mL/100g/min. CBF ASL images were linearly co-registered to
the axial T2 images for anatomic delineation and selection of regions of interest to further evaluate regional blood flow using ITK-SNAP
software. Areas studied included the frontal white matter, posterior white matter, thalami and basal ganglia. RESULTS Mean gestational age at MRI of the neonates studied was 40.9 weeks. Mean birth weight in reported neonates was 3174 grams. Affected
newborns represented a variety of CHD diagnoses including hypoplastic left heart syndrome, tetralogy of Fallot, transposition of the great
vessels, and ventricular septal defects. Average whole brain CBF in the controls (20.1 +/-4.6 mL/100g/min,) was significantly higher than
in the newborns with CHD (17.4 +/- 4.1 mL/100g/min, p=0.01). Average regional perfusion in the occipital white matter of the controls
(13.9 +/- 5.1 mL/100g/min) was also significantly higher than in the patients with CHD (11.3 +/- 3.8 mL/100g/min, p=0.02). Regional
CBF in the frontal white matter, thalamus and basal ganglia did not demonstrate a statistically significant difference between the controls
and CHD newborns. CONCLUSION ASL MRI demonstrates differences in cerebral perfusion between newborns with CHD versus normal healthy controls. Our data suggests
that newborns with CHD may have decreased whole brain perfusion and a regional vulnerability in the occipital white matter prior to open
heart surgery. CLINICAL RELEVANCE/APPLICATION ASL MRI is a promising non-invasive tool for evaluating changes in cerebral perfusion resulting from abnormal hemodynamics in neonates
with complex congenital heart disease. VSPD11-03 • Abnormal Glutamatergic Metabolism during Cooling Correlates with Poor Outcome in Neonates Undergoing
Hypothermia Therapy
Jessica L Wisnowski PhD (Presenter) ; Tai-Wei Wu ; Ida Ashoori ; Marvin D Nelson MD ; Istvan Seri MD, PhD * ; Ashok
Panigrahy MD ; Stefan Bluml PhD PURPOSE To study glutamatergic metabolism in neonates undergoing hypothermia therapy (HT) for suspected hypoxic-ischemic injury (HII) METHOD AND MATERIALS RESULTS Neonates with poor outcome had lower creatine (? 24%), N-acetyl-aspartate (? 27%) and myo-inositol (? 11%) and higher lactate (Lac; ?
285%) and glutamine (Gln; ? 184%) during HT (see Figure). Glutamate (Glu) concentration during HT did not distinguish outcome
groups; however, after HT, Glu was lower in neonates with poor outcome. Finally, as predicted from models, Glu concentration was lower
(? 20%) during HT compared to after. CONCLUSION HII affects 3-5/1000 neonates and nearly half face death or severe disability despite therapy. Glutamate excitotoxicity in the setting of
energy failure is widely hypothesized to be a key mechanism of cell death following HII. We found elevated glutamine in the neonates
with poor outcome, and it is possible that this is indicative of excitotoxic injury as well as some ongoing capacity for astrocytes to detoxify
excessive glutamate, albeit ultimately at a level insufficient to prevent poor outcome. However, it is important to consider that glutamine
is not only synthesized from glutamate in astrocytes, but also that glutamine can be used as an energy metabolite. More research is
needed to map the metabolic fate of glutamate and glutamine in neonates with HII. CLINICAL RELEVANCE/APPLICATION MR examinations during HT may not only aid clinical management but also the development of adjuvant therapies that aim to alleviate
glutamate excitotoxicity. VSPD11-04 • Longitudinal Changes in Diffusion Properties in White Matter Pathways in Patients with Tuberous Sclerosis
Complex
Jae W Song MD, MS (Presenter) ; Fiona Baumer MD ; Paul D Mitchell MS ; Rudolph Pienaar PhD ; Mustafa Sahin MD, PhD ; Ellen Grant MD ; Emi Takahashi PhD PURPOSE The purpose of this study was to identify predictors of longitudinal changes in diffusion properties of white matter tracts of projection,
association and commissural fibers in patients diagnosed with Tuberous Sclerosis Complex. METHOD AND MATERIALS Structural and diffusion magnetic resonance imaging was carried out in 17 subjects diagnosed with Tuberous Sclerosis Complex (TSC)
(mean age, 7.2 ± 4.4 years, range: 2 � 17.5 years) and with at least 2 scans (mean number of days between the 2 scans 419.4 days ±
105.4 days, range: 309 � 741 days). There were 10 males and 7 females; 5 of whom had autism spectrum disorder (ASD); and 10 of
whom had seizure disorder. A coordinate-based tractography atlas was used to guide ROI placement to delineate the internal
capsule/corona radiata, cingulum, and corpus callosum. These ROIs were then co-registered using FLIRT to each subject�s second scan.
The outcomes were mean change in apparent diffusion coefficient (ADC) and the mean change in fractional anisotropy (FA). RESULTS Multiple linear regression analyses showed gender to be a significant predictor of mean change in ADC in TSC subjects in the left internal
capsule, right and left cingulum, and corpus callosum, adjusting for initial ADC scan measures. Gender was only a significant predictor of
mean change in FA in the corpus callosum. Adjusting for initial ADC or FA scan measures, seizure disorder also emerged as a significant
predictor of mean change in ADC, but not for mean change in FA, in the left internal capsule. ASD did not emerge as a significant
predictor in either the mean change in ADC or FA in the studied white matter tract pathways. Page 4 of 183
CONCLUSION Gender and seizure disorder were independent predictors of mean change in ADC or FA in some white matter tract pathways in TSC
subjects. White matter microstructural integrity was more affected in males than in females in the left internal capsule, right and left
cingulum, and corpus callosum and more affected in TSC subjects with seizure disorder in the left internal capsule than in subjects
without seizure disorder. CLINICAL RELEVANCE/APPLICATION Effects of new therapies for TSC are being evaluated by changes seen on neuroimaging. Thus, understanding how specific patient
characteristics differentially affects neuroimaging in TSC is recommended. VSPD11-05 • Posterior Fossa Morphometry and Volumetric Analysis in Three Different Groups of Pediatric Patients: Congenital
Chiari Type 1 Malformation, Posterior Craniosynostosis and Costello Syndrome
Rosalinda Calandrelli ; Gabriella D'Apolito MD (Presenter) ; Mariavalentina Tumino ; Luigi M Pedone MD ; Simona Gaudino
MD ; Cesare Colosimo MD PURPOSE Cerebellar tonsils herniation is caused by heterogeneous group of disorders with different pathogenic origins and it may occur early or
late in childhood. In order to better evaluate the mechanism of herniation we performed a morphometric and volumetric analysis of the
posterior cranial fossa in three different groups of pediatric patients in which cerebellar tonsil herniation occurs: children with congenital
Chiari I malformation, children with posterior craniosynostosis and children with Costello Syndrome. METHOD AND MATERIALS Volumes of the posterior cranial fossa (PCFV) and cerebellum (CV) were assessed on axial T2-weighted MR images in 26 children with
congenital Chiari I malformation (average 60 + 24 months), 6 children with Costello Syndrome (average 32+ 22 months) and 10
children with posterior craniosynostosis (average 12+ 11 months). The ratio of PCFV and CV was calculated to obtain the proportion of
the PCFV occupied by the CV and to reduce the variability among the different groups. Each group was compared with an age matched
control group. Volumetric measurements were correlated with diameter of the foramen magnum, tentorial angle, supraocciput and
basiocciput lengths. RESULTS In children with congenital Chiari type I malformation, PCFV/CV ratio, antero-posterior diameter of the foramen magnum, supraocciput
and basiocciput lengths were found significantly reduced (p In children with Costello Syndrome, PCFV/CV ratio, PCFV, antero-posterior
and latero-lateral diameters of the foramen magnum and basiocciput length were found significantly reduced, while tentorial angle was
found significantly increased (p In children with posterior craniosynostosis, PCFV, CV, latero-lateral diameter of the foramen magnum,
supraocciput and basiocciput lengths were found significantly reduced (p CONCLUSION Our findings support the theory that reduction of PCFV plays an important role in developing cerebellar tonsillar herniation but other
factors like foramen magnum diameters, supraocciput and basiocciput lengths and tentorial angle, contribute to explain the mechanism
of cerebellar tonsils herniation. CLINICAL RELEVANCE/APPLICATION Morphometry and volumetric analysis of the posterior fossa are helpful to understand cerebellar tonsillar herniation mechanism guiding
clinical or surgical approach. VSPD11-06 • MRI Findings of Hypertrophic Olivary Degeneration after Surgery for Posterior Fossa Tumors in Children
Tommaso Tartaglione MD (Presenter) ; Annibale Botto ; Andrea M Alexandre MD ; Giana Izzo MD ; Mariacarmela Sciandra
MD ; Simona Gaudino MD ; Cesare Colosimo MD PURPOSE Hypertrophic olivary degeneration (HOD) is a possible consequence of injuries along dento-rubro-olivary pathway. The purpose of our
study was: 1) To evaluate the incidence of HOD after surgery for posterior fossa pediatric tumors. 2) To show the typical MRI findings of
HOD. 3) To analyze time correlation between surgery and MRI evidence of HOD. METHOD AND MATERIALS We based our study on a retrospective evaluation of 57 patients surgically trated for posterior fossa tumors in our institution between
2007 and 2012. For each patient Magnetic Resonance (MR) examination was performed before surgery. Every patient underwent clinical
and radiological follow-up by serial MR examinations with variable time interval from surgery date (from 1 week to 5 years). All
examinations included conventional MRI sequences before and after gadolinium injection and DWI images. For each exam we evaluated:
1) signal intensity of inferior olivary nucleus (ION) 2) dimensions of ION (normal, enlarged, atrophic) 3) signal intensity along the
dento-rubro-olivary pathway (red nucleus, dentate nucleus, central tegmental tract, inferior and superior cerebellar peduncles) that could
explain HOD. 4) evidence of haemorrhagic lesions. Findings were correlate with time interval between surgery and MR examination RESULTS HOD was diagnosed in 18/57 patients (31 %). In all the 18 patients, MRI showed high signal intensity on T2w images in ION and lesions
in dentate nuclei (mono- or bilaterally), with subsequent controlateral or bilateral HOD. Enlargement of ION (hypertrophy) was found in
only 3/18 cases, with variable time delay from surgery (from 1 to 5 months). In 2 cases of bilateral HOD we observed hyperintensity on
T2w images in both superior cerebellar peduncles. DWI and contrast enhanced T1w images did not show alterations of ION. CONCLUSION 1) Hyperintensity on T2w MRI images in the ION was the most common finding in HOD, and was often associated to lesions in
controlateral dentate nucleus. 2) Enlargement of ION was not always present and time interval between surgery and its MRI evidence was
variable. 3) The low incidence of ION enlargement could be related to the absence of hemorrhagic lesions in our population CLINICAL RELEVANCE/APPLICATION MRI changes in HOD were frequently assessed after posterior fossa surgery for pediatric tumors. VSPD11-07 • MRI of Pediatric White Matter Disease
Sanjay P Prabhu MBBS (Presenter) LEARNING OBJECTIVES 1) To become familiar with the spectrum of white matter disease in children including demyelination, dysmyelination and neurometabolic
disorders. 2) To provide a step-wise algorithm for approaching imaging studies with white matter abnormality and use a
pattern-recognition approach to narrow the differential diagnosis. 3) To illustrate examples of conditions with characteristic imaging
findings and elaborate use of advanced imaging techniques in refining the diagnosis. ABSTRACT Oncodiagnosis Panel: Pediatric Sarcoma (An Interactive Session) Sunday, 10:45 AM - 12:15 PM • E353C
Back to Top Page 5 of 183
PD
RO OI MK SPOI11 • AMA PRA Category 1 Credit ™:1.5 • ARRT Category A+ Credit:1.5 Moderator
Nina A Mayr , MD Moderator
John Breneman , MD Gregory S Stacy , MD * Lynn Million , MD Raffi S Avedian , MD LEARNING OBJECTIVES 1) Understand the principles of musculo-skeletal imaging as it relates to soft tissue tumors arising in the extremity and trunk. Specifically,
the learner will understand the importance of how appropriate imaging modalities are critical to correct diagnosis, staging and treatment of
soft tissue tumors in children. 2) Apply basic physics principles to the imaging and therapeutic modalities involved in diagnosis, staging and
management of soft tissue sarcomas in children. Specifically, the learner will be able to apply specific imaging modalities and techniques in
order to improve the detection, accuracy of staging and management of soft tissue sarcomas, while minimizing the risk of ionizing radiation
exposure in children. 3) Analyze the value of different imaging modalities and therapeutic techniques for children with soft tissue sarcomas.
Specifically, the learner will be able to analyze the importance of specific imaging studies required for patient enrollment in clinical trials and
ensure safe administration of cancer therapy with respect to cost. 4) Demonstrate how cultural and economic differences may influence
practices of care for radiologic imaging in children with soft tissue sarcomas today and the future. 5) Compare relative value of image
guided techniques in management of pediatric soft tissue sarcomas. Specifically, the learner will be able to compare the pros and cons of
current imaged guided techniques for the diagnosis and management of soft tissue sarcomas in children to optimize outcome and minimize
complications. Breast Imaging (Diagnostic Ultrasound) Sunday, 10:45 AM - 12:15 PM • Arie Crown Theater
US
BR SSA01 • AMA PRA Category 1 Credit ™:1.5 • ARRT Category A+ Credit:1.5 Moderator
Wendie A Berg , MD, PhD * Moderator
Jung Min Chang , MD Moderator
Regina J Hooley , MD * Back to Top SSA01-01 • Utility of Targeted Ultrasound in the Evaluation of Breast MRI-detected Non-mass Enhancement (NME)
Adrienne R Newburg MD (Presenter) ; Chloe M Chhor MD ; Jiyon Lee MD ; Samantha L Heller MD, PhD ; Hildegard B Toth MD
; Linda Moy MD PURPOSE Prior studies showed the likelihood of identifying an ultrasound (US) correlate for an MRI-detected abnormality depends on lesion type.
NME was less likely to be seen on US compared to a mass or focus. Targeted second-look US may result in prolonged work-up time,
added expense, and false reassurance in the setting of a negative US. Our study was performed to determine the utility of targeted US
and to determine how often a MRI-US discordant lesion was found. METHOD AND MATERIALS An IRB-approved retrospective review was performed for breast MRI examinations performed from 2005-2008. Data regarding patient
demographics, MRI findings and subsequent sonographic and pathologic results were recorded. Of 2,222 breast MRI exams, 70 (3.2%)
NME lesions were identified for which targeted US was recommended. An additional 85 NME lesions went directly to an MRI biopsy
because the interpreting radiologist felt it unlikely that an US correlate would be seen. The rate of subsequent malignancy was analyzed. RESULTS Targeted US was performed in 59 of 70 (84%) women. In the remaining 11 (16%) cases, targeted US was not performed because 5
women underwent mastectomy or had metastatic disease. MRI-guided biopsy was pursued directly in 2 women and 4 women did not
undergo further imaging at our institution. Mean age was 46.7 years, range was 25 to 99 years. In 14 (24%) of 59 sonograms, an US
correlate was seen. An US-guided biopsy was performed in 7 (50%) of 14 cases. None yielded cancer. One of 7 (14%) yielded papillomas
which were subsequently excised. One of 7 (14%) yielded atypia. Three benign biopsies were discordant with the MRI findings. At
subsequent MRI biopsy, one lesion was an invasive ductal carcinoma (IDC). Forty-five of 59 (76.3%) cases had no US correlate; 15
proceeded to MRI-guided biopsy. Two (13%) yielded cancer, 1 IDC and 1 DCIS. An additional 2 (13.3%) cases demonstrated atypia/ADH.
In the 11 remaining cases, pathology was benign. The cancer yield for the 85 NME lesions that went directly to MRI biopsy was 12%
(12/85); 2 were IDC and 10 were DCIS. CONCLUSION The yield for detecting an US correlate for an MRI-detected NME is low (24%) with no detection of malignancy. CLINICAL RELEVANCE/APPLICATION Confident MRI-US correlation for an MRI-detected abnormality can be challenging. It may be advisable to forego targeted US and proceed
directly to MRI-guided core biopsy. SSA01-02 • 3D Breast Ultrasound: Diagnostic Yield Compared to MR Imaging and Histopathology
Mathijn D De Jong MD (Presenter) ; Gerrit J Jager MD, PhD ; Ivo Dubelaar MD ; Thomas A Fassaert MD ; Matthieu Rutten MD PURPOSE To prospectively assess the performance characteristics of 3D ultrasound (3DUS) for the detection and classification of breast tumors
compared to breast magnetic resonance imaging (MRI) and histopathology. METHOD AND MATERIALS Two hundred twentyone patients with an indication to undergo breast MRI provided informed consent were enrolled in an institutional
review board-approved 3DUS study protocol. Patients underwent 1.5T MRI and 3DUS within 10 days. 3DUS was performed with a 5-14
MHz broadband transducer featuring Harmonic Imaging and compound scanning. The 3D US findings were reviewed by 2 observers
independently, who were blinded for histopathological diagnoses and prior imaging findings such as mammography, handheld 2D US and
MRI. Histopathological findings or MRI with 12 months clinical follow-up were used as reference standard. Diagnostic yield, sensitivity,
specificity, positive (PPV) and negative (NPV) predictive values were determined. RESULTS 3DUS scanning was technically successful in 220 patients. One patient was excluded due to erroneous data transfer. Each breast was
evaluated with 3 to 5 scans. The overall examination time was 15-20 (mean 14) minutes per patient. Mean patient age was 48 years
(range 18-78). 194 and 191 benign and 43 and 46 malignant breast tumors were detected with 3D-US and MRI, respectively. In 61
patients 67 histopathological findings were available as reference standard. The sens, spec, PPV and NPV of 3D US was compared to MRI
85, 97, 91, 96, respectively, and compared to the histopathological findings 93, 96, 91, 98, respectively. Page 6 of 183
CONCLUSION 3D US is a reliable imaging technique for the detection and classification of benign and malignant breast tumors. CLINICAL RELEVANCE/APPLICATION 3DUS can reliably be used in a clinical setting and can probably be feasible for dense breasts in a screening program. SSA01-03 • Breast Cancer Detection with CD276-targeted Ultrasound Imaging
Sunitha Bachawal PhD (Presenter) ; Ferdinand Knieling ; Amelie M Lutz MD ; Lu Tian ; Juergen K Willmann MD * PURPOSE CD276 has been shown to be differentially expressed in various cancers including human breast cancer. Our goal was to compare the
potential of ultrasound (US) molecular imaging using microbubbles (MB) targeted to CD276 with vascular endothelial growth factor
receptor type2 (VEGFR2)-targeted MB for assessment of breast tissue progression to early breast cancer in transgenic mice (FVB/N Tg
(MMTV/ PyMT634Mul). METHOD AND MATERIALS A transgenic mouse model of breast cancer (FVB/N-Tg(MMTV-PyMT634Mul)) was used in this study. The progression of breast tissue from
normal to invasive cancer was examined using US molecular imaging (Vevo2100, Visualsonics) with VEGFR2- and CD276- targeted MB in
160 mammary glands. Ex vivo expression levels of VEGFR2 and CD276 were examined using immunofluorescence staining followed by
confocal microscopy. RESULTS There was a significant (p CONCLUSION Combined VEGFR2- and CD276- targeted molecular imaging information can further improve accuracy of US for in vivo assessment of
breast tissue progression from normal to breast cancer in this transgenic mouse model CLINICAL RELEVANCE/APPLICATION US molecular imaging of tumor angiogenesis using tumor specific endothelial markers in breast cancer may help improve accuracy of US
in breast cancer detection in future clinical trials. SSA01-04 • Sonographic Findings in 691 Pure Ductal Carcinoma in Situ Lesions with Histopathologic and Biologic Correlation
Marion E Scoggins MD (Presenter) ; Gaiane M Rauch MD, PhD ; Patricia S Fox MS ; Ana Paula Benveniste MD ; Henry M
Kuerer MD ; Wei T Yang MD ; Young Mi Park MD, PhD ; Sara Lari ; Savitri Krishnamurthy MD PURPOSE Sonographic (US) findings in 691 pure ductal carcinoma in situ (DCIS) lesions were retrospectively analyzed by estrogen receptor (ER)
status, nuclear grade, and comedonecrosis to evaluate the prognostic value of US as an adjunct to mammography (M). METHOD AND MATERIALS An institutional review board approved retrospective single institution database search performed for patients with pure DCIS evaluated
from January 1996 to July 2009 who underwent pre-operative M and whole-breast US. Images were reviewed per ACR BI-RADS lexicon.
Pathologic features recorded were ER status, nuclear grade, and comedonecrosis. ER+ was defined as nuclear staining in at least 1% of
cells. Statistical comparisons were made using t-test, Chi-square, Fisher�s exact test, Kruskal-Wallis or Wilcoxon rank-sum test. RESULTS There were 1911 pure DCIS patients identified; those with incomplete data (n=5), lacking pre-operative US (n=1214) or M (n=1) were
excluded leaving 691 patients for analysis. Of 691 lesions, 304 (44%) were visible on M and US, 315 (46%) visible on M only, 58 (8%)
visible on US only, and 14 (2%) visible on neither M nor US. There were 425 (62%) ER+, 104 (15%) ER-, and 162 (23%) lesions with
unknown ER. Comedonecrosis was present in 296 (43%) lesions, absent in 395 (57%). There were 334 (48%) non-high grade (nuclear
grade I/II) lesions, 353 (51%) high-grade (III), and 4 (1%) of unknown grade. ER- lesions were more frequently visible on US than ER+
lesions (62% vs. 48%, p
CONCLUSION ER- DCIS is more likely visible on US than ER+ DCIS. A shadowing US mass is more frequently high grade or ER-. While a mass is the
most common US finding of DCIS regardless of histopathologic features, nonmass lesions are more likely to be associated with
high-grade tumors and comedonecrosis. CLINICAL RELEVANCE/APPLICATION A shadowing mass on US should raise suspicion for ER- DCIS which provides imaging-based prognostic and biologic information during
cancer diagnosis and work-up. SSA01-05 • Detectability and Diagnostic Performance of ABVS in Suspicious Calcifications in Comparison with Hand-held US
Eunjeong Kim (Presenter) ; Sung-Hun Kim MD ; Chang Suk Park PURPOSE To prospectively evaluate the detectability and performance of automated breast US scanner and compare it with hand held breast US in
suspicious calcifications on mammography. METHOD AND MATERIALS Forty-two patients with 43 breast lesions, scheduled for US guided or stereotactic biopsy for suspicious calcifications on mammography,
underwent automated breast US and hand-held US examination. Two radiologists reviewed the automated breast US data in consensus. A
radiologist who had not performed the hand-held US examination reviewed hand-held US data. Detectability and diagnostic performance
of automated breast US and hand-held US were calculated. RESULTS Among 43 lesions, 25 (58.1%) were malignant and 18 (41.9%) were benign. Detection on ABVS was more frequent for lesions;
malignant vs. benign (96.0% [24/25] vs. 44.4% [8/18], p=0.002), of maximal extent more than 10mm (86.7% [26/30] vs. 46.2%
[6/13], p=0.009), or lesions with fine pleomorphic or fine linear shape vs. round or amorphous or coarse heterogeneous shape (94.7%
[18/19] vs. 58.3% [14/24], p=0.021) at mammography.No significant difference was found in AUC between automated breast US
(0.758, 0.603-0.875) and hand-held US (0.786, 0.634-0.896) (p=0.571). CONCLUSION Automated breast US detected 96.0% (24/25) of malignant calcifications on mammography. Detection was found to be related to the
pathology, to calcification extent, and shape at mammography. CLINICAL RELEVANCE/APPLICATION This study is the first study to compare the detectability and diagnostic performance for suspicious microcalcifications between ABVS and
HHUS. ABVS showed similar diagnostic performance to HHUS. SSA01-06 • Clinical Application of Shear Wave Elastography (SWE) in the Differential Diagnosis of Small (≤2cm) Breast Lesions
Kyung Hee Ko (Presenter) ; Hae Kyoung Jung MD ; Jung Hyun Yoon MD ; Hye Rin Kim Page 7 of 183
PURPOSE To evaluate the usefulness of SWE for the differential Diagnosis of small (=2cm) breast lesions METHOD AND MATERIALS From June 2012 to December 2012, of 215 women who had been performed conventional US and SWE, 165 masses of 155 women (mean
age: 44.97±9.54 years, range 22-87 years) who had 2cm and smaller lesions were included in this study. All patients underwent US
guided core biopsy or surgical excision. US BI-RADS final assessment and quantitative SWE parameters were recorded. Final assessments
of the 165 breast lesions were categorized as follows: category 3 in 23, category 4a in 119, category 4b in 11, category 4c in 8, and
category 5 in 4. Histopathologic diagnosis was used as reference standard. Optimal cutoff value for each quantitative SWE parameter was
calculated by ROC curve. Calculated cutoff value was used to upgrade BI-RADS 3 lesions to category 4a and downgrade BI-RADS 4a
lesions to category 3. RESULTS Of the 165 small breast masses, 20 masses (12%) were malignant and 145 masses (88%) were benign. Mean Emax of malignant masses
(141.97±98.03kPA) was significantly higher than that of benign (49.14±39.89kPa). Emax with a cutoff value of 87.5kPa had the highest
Az value (0.796, sensitivity 75.0%, specificity 85.5%, PPV 41.7%, NPV 96.1%). However, for small masses equal or smaller than 1cm, Az
values of all quantitative SWE parameters were lower than 0.6. After adding SWE to conventional US, there was no improvement of
diagnostic performance (sensitivity 80%, specificity 95.2%, PPV 69.6%, NPV 97.2%). When applying Emax CONCLUSION Small malignant masses=2cm were significantly stiffer than small benign lesions. However adding SWE parameters to conventional US
showed no improvement of diagnostic performance. SWE could give US BI-RADS some help for reducing benign biopsy rate. CLINICAL RELEVANCE/APPLICATION SWE could give conventioanl US BI-RADS some help on differential diagnosis of small breast masses 2cm or smaller with
reducing benign biopsy rate. SSA01-07 • Indications for Biopsy of Imaging-detected Intramammary and Axillary Lymph Nodes in the Absence of Concurrent
Breast Cancer
Christine Westra BS ; Vandana M Dialani MD ; Shambhavi Venkataraman MD ; Valerie J Fein-Zachary MD ; Alexander
Brook PhD * ; Tejas S Mehta MD, MPH (Presenter) PURPOSE To evaluate prevalence and identify features predictive of malignancy in imaging-detected lymph nodes (LNs) in women without
concurrent cancer. METHOD AND MATERIALS Retrospective review of all image-guided LN fine needle aspirations (FNA) and core needle biopsies (CNB) from 1/1/08-12/31/10. LNs in
patients without concurrent cancer comprised our study group (SG; n=80) and with concurrent breast cancer our control group (CG;
n=66). FNAs were sent for flow cytometry in addition to cytology at discretion of breast imager. Blinded to cytology/histology, imaging
features of LNs including size, loss of fatty hilum, and/or focal/diffuse cortical thickness were recorded. BI-RADS category was assigned by
reviewer based on LN appearance. RESULTS In 80 SG cases, 63 (78%) had FNA and 17 (22%) had CNB; all in CG had FNA. Of the 80 SG cases, 69 (86%) were negative, 2 (3%)
positive, 6 (7%) atypical and 3 (4%) non-diagnostic (ND). Of 8 atypical/positive LNs, 3 had breast cancer, 2 had lymphoma, and 3
negative on excision. Of 66 CG cases, 30 (45%) were negative, 30 (45%) positive, 5 (8%) atypical and 1 (2%) ND. There were 6 false
negative FNAs in CG; all atypical/positive LNs in CG were positive for breast cancer on excision. ND LNs were negative on follow
up/excision in both groups. Prevalence of malignancy in LNs in SG was 6% (5/80) and in CG 62% (41/66; p
= 3mm and/or eccentric/focal
cortical thickening were negative and not predictive of malignancy. If BI-RADS 4C/5 were used as threshold to biopsy, the sensitivity,
specificity, PPV, and NPV for cancer in SG would have been 100%, 99%, 83% and 100% respectively, higher than CG results of 73%,
92%, 93% and 68% respectively. CONCLUSION In the absence of concurrent breast cancer, using loss of fatty hilum as criterion to biopsy image-detected LNs keeps sensitivity of 100%
but lowers false positives. FNAs should also be sent for flow cytometry to diagnose lymphoma. CLINICAL RELEVANCE/APPLICATION Without concurrent breast cancer, loss of fatty hilum as criterion to biopsy LNs has 100% sensitivity with low false positives. Flow
cytometry is also needed in these patients to exclude lymphoma. SSA01-08 • Are Shear Wave Ultrasound Findings an Independent Predictor of Lymph Node Involvement in Women with Invasive
Breast Cancer?
Andrew Evans MRCP, FRCR (Presenter) ; Patsy Whelehan MSc * ; Petra Rauchhaus ; Colin Puride ; Lee Jordan ; Kim
Thomson ; Sarah J Vinnicombe MRCP, FRCR PURPOSE Shear wave elastography shows promise as an adjunct to greyscale ultrasound in assessing breast masses. In breast cancer, higher
lesion stiffness values have been shown to be associated with poor prognostic features. The purpose of this study was to assess whether
higher lesion stiffness at shear wave elastography is an independent predictor of lymph node involvement METHOD AND MATERIALS Patients with invasive breast cancer treated by primary surgery, who had undergone shear wave elastography examination at the time of
diagnosis, were eligible. Data were retrospectively analysed from 396 consecutive patients meeting these criteria. The mean stiffness
values were obtained using the Aixplorer� ultrasound machine from SuperSonic Imagine Ltd. Measurements were taken from a region of
interest positioned over the area identified via the colour map as the stiffest part of the abnormality. The average of the mean values
obtained in each of four projections was used for analysis. Associations between lymph node involvement and mean lesion stiffness in
kilopascals, invasive cancer size, histological grade, tumour type, ER and HER-2 receptor status and vascular invasion were assessed
using univariate and multivariate logistic regression.
Results
RESULTS Median age was 62 years, median invasive tumour size was 19 mm and 28% of patients had lymph node involvement. At univariate
analysis, invasive size, histological grade, HER-2 status, vascular invasion, tumour type and mean stiffness were significantly associated
with nodal involvement. At multivariate analysis, invasive size, tumour type, vascular invasion and mean stiffness maintained
independent significance. CONCLUSION Mean stiffness at shear wave elastography is an independent predictor of lymph node metastasis in women with invasive breast cancer. CLINICAL RELEVANCE/APPLICATION High tumor stiffness at shear wave elastography increases the risk of lymph node metastasis in women with invasive breast cancer. SSA01-09 • Diagnostic Usefulness of Breast Ultrasonography in the Evaluation of the Patients with Pathologic Nipple Discharge:
Comparison with Galactography
Page 8 of 183
Jun Ho Park ; Young Mi Park MD, PhD ; Suk Jung Kim ; Hyun Kyung Jung (Presenter) ; 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. Cardiac (Coronary CT/MR I) Sunday, 10:45 AM - 12:15 PM • S502AB
MR
CT CA SSA02 • AMA PRA Category 1 Credit ™:1.5 • ARRT Category A+ Credit:1.5 Moderator
Vincent B Ho , MD, MBA * Moderator
Gisela C Mueller , MD * Moderator
Lisa Diethelm , MD Back to Top SSA02-01 • Diagnostic Accuracy of 320-detector Computed Tomography Angiography in Evaluating In-stent Restenosis of
Coronary Artery
Yung-Liang Wan MD ; Sophie Chan MD (Presenter) ; Zhonghua Sun PhD ; Yu-Hsiang Juan MD ; I-Chang Hsieh ; Ming-Shien
Wen PURPOSE To study the sensitivity (SN), specificity (SP), accuracy, positive predictive value (PPV) and negative predictive value (NPV) of
320-detector CT angiography (CTA) in diagnosing in-stent restenosis (ISR) on the bases of invasive coronary angiography (ICA) as a
golden standard. METHOD AND MATERIALS RESULTS ISR was found in 18 (9.5%) of 189 patents and in 25 (7.9%) of 318 stents. On stent level, the SN, SP, accuracy, PPV, and NPV of CTA in
detecting ISR were 92%, 96%, 96%, 66% and 99%, respectively. On patient level, the corresponding figures were 94%, 96%, 96%,
74%, and 99%, respectively. The number of implanted stents in patients with ISR was significantly higher than that in those without ISR
(2.56 ± 1.38 vs. 1.59 ± 0.92, p = 0.009). ISR was significantly more frequently found in 12.7% (14/96) of RCA stents, 10% (5/45) of
LCX stents, and in 3.8% (6/149) of LAD stents (p = 0.027). CONCLUSION On both stent and patient levels, the SN, SP and accuracy of 320-detector CTA in diagnosing ISR is high, ranging from 92% to 96%.
However, the PPV is is 66% on stent level, and 77% on patient level. CLINICAL RELEVANCE/APPLICATION The advanced technique 320-detector CTA plays a potential and promising role in assessing ISR of coronary arteries, it is especially useful
in excluding ISR with a high NPV of 99%. SSA02-02 • Value of Super-resolution Technique in Detection of Coronary Artery Stenoses on Whole-heart Coronary MRA
Mio Uno MD (Presenter) ; Ryohei Nakayama PhD ; Masaki Ishida MD, PhD ; Tatsuro Ito MD ; Yoshitaka Goto MD ; Motonori
Nagata MD, PhD ; Kakuya Kitagawa MD, PhD ; Hajime Sakuma MD * PURPOSE Coronary MRA provides noninvasive detection of coronary artery disease without exposing the patient to radiation. However, the image
resolution of coronary MRA is limited. In the conventional coronary MR images, resolution enhancement is usually performed with bicubic
interpolation. Recently, Super-Resolution (SR) technique has been proposed to increase resolution of brain MRI. The purpose of this study
was to demonstrate the value of SR technique for the detection of coronary artery stenoses on whole-heart coronary MRA as compared
with conventional bicubic interpolation. METHOD AND MATERIALS Whole-heart coronary MRA was acquired with 32-channel cardiac coils in 36 patients at 1.5 T (n=16) and 3.0T (n=19). We have newly
developed a SR technique optimized for whole-heart coronary MRA by modifying the existing SR method. Receiver operating
characteristic (ROC) analysis was performed to evaluate the diagnostic performance of SR technique and conventional bicubic
interpolation to detect coronary stenoses of >50% on coronary angiography. In the observation study, the cases were displayed in a
random order with a custom-made viewer, and three observers independently rated the likelihood of the presence of coronary artery
stenoses using a continuous scale from 0 to 1. Two reading sessions were conducted with 3-day interval. RESULTS For all observers, the areas under the ROC curves (AUCs) were improved by using SR technique. The mean AUC was 0.861 for SR
technique, being significantly higher than that for conventional bicubic interpolation (0.797, P = .024). Interobserver variability was
reduced from 0.170 to 0.164 by using SR technique instead of conventional bicubic interpolation. Interclass correlation coefficient was
Page 9 of 183
reduced from 0.170 to 0.164 by using SR technique instead of conventional bicubic interpolation. Interclass correlation coefficient was
0.855 by SR technique and 0.812 by conventional bicubic interpolation, respectively. CONCLUSION High-resolution whole-heart coronary MRA using a Super-Resolution technique permits noninvasive detection of coronary artery stenoses
with significantly improved image quality as compared to conventional bicubic interpolation method. CLINICAL RELEVANCE/APPLICATION High-resolution coronary MRA generated by Super-Resolution technique allows for more accurate detection of coronary stenoses with
higher confidence level as compared to conventional bicubic methods. SSA02-03 • Mechanical Deformity of Coronary Stent Detected by Cardiac CT: Morphological Predictors and Clinical Implication
Mi Sun Chung MD (Presenter) ; Dong Hyun Yang MD ; Joon-Won Kang MD ; Young-Hak Kim ; Tae-Hwan Lim MD, PhD PURPOSE To evaluate the features and morphologic predictors of mechanical deformities of coronary stents and the effect of mechanical deformities
on in-stent restenosis (ISR) using cardiac CT. METHOD AND MATERIALS We retrospectively reviewed coronary CT angiography to evaluate mechanical deformities of coronary stents. A total of 864 coronary
stents from 584 patients (mean age, 62.8 years; male:female=447:137) were enrolled consecutively in our hospital. The presence of
mechanical deformities of coronary stent (partial or complete fracture, longitudinal compression [LC; distortion or shortening of a stent in
the longitudinal axis], and radial compression [RC; focal decrease of stent diameter in radial axis]), ISR (>50% stenosis of stent on
cross-sectional image) and aneurysm were evaluated. Morphologic predictors of mechanical deformity included stent location, stent
length, stent overlap by two or more stents, bifurcation lesion stent, excessive tortuosity, and side branch ballooning procedure. Multiple
logistic regression analyses were performed to find predictors of mechanical deformity, ISR, and aneurysm. RESULTS Of 864 stents, proportions of any fracture, complete fracture, LC, and RC were 12.3%, 3.9%, 2.8% and 7.2%, respectively. Stent fracture
and RC of stent were significantly higher in stent with excessive tortuosity (fracture 27.1% vs. 11.2%, p CONCLUSION Mechanical deformities of coronary stent can be effectively evaluated with cardiac CT. Excessive tortuosity and ostial stent are
independent predictors of stent fracture and LC, respectively. The presence of ISR and aneurysm are significantly associated with stent
fracture. CLINICAL RELEVANCE/APPLICATION Cardiac CT may be an effective modality to evaluate mechanical deformities and their complications of coronary stent. SSA02-04 • Evaluation of Hemodynamic Significance of Coronary Stenosis by Vessel Attenuation Measurement on CT:
Comparison with Adenosine Perfusion MRI
Martijn A Den Dekker MD, MS ; Gert Jan Pelgrim MSc ; Rozemarijn Vliegenthart MD, PhD (Presenter) ; Edwin R Van Den
Heuvel MD, PhD ; Gabija Pundziute MD, PhD ; Matthys Oudkerk MD, PhD ; Kevin G Ike PURPOSE Correlation between CT-detected coronary stenosis and myocardial ischemia is poor. Corrected contrast opacification (CCO) calculation is
a new technique based on coronary CT angiography (cCTA) data, that estimates the effect of stenosis on coronary flow. The purpose of
this study is to evaluate the association between CT-derived CCO and ischemia by adenosine perfusion magnetic resonance imaging
(APMRI) as reference standard. METHOD AND MATERIALS Sixty vascular patients without cardiac complaints (mean age 64.4±7.7 years; 78% male) underwent cCTA and APMRI for cardiac risk
assessment. The study was approved by the local medical ethical committee. cCTA was performed using a first-generation dual-source CT
scanner. On cCTA, coronary luminal attenuation values (in Hounsfield units) were measured at 4 locations from proximal to distal
coronary artery; 4 extra measurements were performed in vessels with >50% lumen stenosis. CCO was calculated by dividing coronary
CT attenuation by descending aorta CT attenuation at equal level. A 1.5T MRI scanner was used for APMRI, with an inducible perfusion
defect under adenosine considered indicative of myocardial ischemia. Decreases in CCO across the coronary artery and across stenosis
were calculated, and compared with presence of ischemia on APMRI. RESULTS In total, 166 stenoses were found in 96 coronary arteries. Seven patients with 17 stenoses in 11 coronary arteries showed myocardial
ischemia on APMRI. Baseline characteristics did not differ between patients with and without myocardial ischemia. For anatomical
stenoses, there was no significant difference in the decrease in CCO across the coronary artery between vessels with or without stenosis
(0.064±0.121 vs. 0.049±0.103; P=0.50). Difference in CCO across a coronary stenosis was significantly larger in patients with
myocardial ischemia than in those without (0.101±0.097 vs. 0.048±0.110, respectively; P CONCLUSION In cardiac asymptomatic patients, there is a significant correlation between the decrease in CCO across CT-detected coronary stenosis
and ischemia on APMRI. CLINICAL RELEVANCE/APPLICATION Corrected contrast opacification, based on common cCTA data, is a promising non-invasive method to assess the functional significance of
CT-detected stenosis. SSA02-05 • Iterative Image Reconstruction Improves Accuracy of Automated Plaque Burden Assessment in Coronary CT
Angiography: A Comparison to Intravascular Ultrasound
Stefan Puchner MD (Presenter) ; Maros Ferencik MD ; Akiko Maehara ; Paul Stolzmann MD ; Shixin Ma ; Synho Do PhD * ; Hans-Ulrich Kauczor MD * ; Gary Mintz ; Udo Hoffmann MD ; Christopher L Schlett MD, MPH PURPOSE To determine whether iterative image reconstruction algorithms improve the accuracy of coronary CT angiography (CCTA) for
(semi-)automated plaque burden assessment as compared to intravascular ultrasound (IVUS). METHOD AND MATERIALS CCTA and IVUS data were acquired from seven coronary arteries in an ex-vivo setting. CT images were reconstructed by using
filtered-back projection (FBPR), adaptive-statistical (ASIR) and model-based (MBIR) iterative reconstruction algorithms. Cross-sectional
images of the arteries were co-registered between CCTA and IVUS in 1-mm increments. In CCTA, a fully-automated (without manual
corrections) and a semi-automated (allowing manual corrections of vessel-wall boundaries) plaque burden assessment were performed
for each of the reconstruction algorithms using commercially available software. In IVUS, plaque burden was measured manually.
Agreement between CCTA and IVUS was determined with Pearson correlation coefficients. RESULTS A total of 173 corresponding cross-sections were included. The average plaque burden by IVUS was 63.39±10.63%. By CCTA, it was
54.9±11.7/53.3±13.1/55.4±12.2% for FBPR/ASIR/MBIR using fully-automated and 54.9±11.8/53.4±12.9/57.1±11.1% using
semi-automated assessment, respectively. Manual corrections in the semi-automated assessment were performed in 39% of all
cross-sections and improved the plaque burden correlation with IVUS, independent of the reconstruction algorithm (p Page 10 of 183
CONCLUSION Using MBIR algorithm in CCTA with a semi-automated assessment enables more accurate measurement of plaque burden as compared to
ASIR and FBPR using IVUS as the reference standard. CLINICAL RELEVANCE/APPLICATION Model-based reconstruction algorithm could further enhance the role of coronary CT angiography as a non invasive risk stratification tool
for patients with coronary artery disease SSA02-06 • Diagnostic Accuracy of Computed Tomography Coronary Angiography for Evaluation of Coronary Artery Disease: A
Comparison between High Definition versus Standard Definition Scanner
Gianluca Pontone MD (Presenter) ; Daniele Andreini MD ; Erika Bertella ; Saima Mushtaq ; Paola Gripari ; Sarah Cortinovis
; Monica Loguercio ; Andrea Baggiano ; Edoardo Conte ; Andrea Daniele Annoni MD ; Alberto Formenti ; Mauro Pepi PURPOSE A high-definition computed tomography coronary angiography (HDCTCA) scanner, with improved in-plane spatial resolution of 230 ?m,
has recently been developed. The aim of this study is to compare the diagnostic accuracy by HDCTCA with standard definition 64-slice
scanner (SDCTCA) by using ICA as the reference method. METHOD AND MATERIALS One-hundred-forty consecutive patients (mean age 65±8 years, male 105) scheduled for ICA were randomized to SDCTCA (n= 70, group
1) or HDCTCA-scan protocol (n= 70, group 2) (Discovery CT 750 HD scanner, GE Healthcare, Milwaukee, WI) before ICA. The scanning
parameters were: slice acquisition 64x0.625 mm, gantry rotation time 330 msec and prospective ECG-triggering. We evaluated the Likert
image quality (score 1: non-diagnostic to score 4: excellent), overall feasibility (Fe), the sensitivity (Se), specificity (Sp), negative
predictive value (NPV), positive predictive value (PPV) and accuracy (Ac) versus ICA in a segment-based model and comparing the
diagnostic performance between group 1 and group 2. RESULTS The 2 groups were homogeneous in terms of baseline characteristics. Group 2 showed a higher mean image quality score (3.8 vs 3.1, p CONCLUSION The present study showed an improved overall feasibility, positive predictive value and accuracy mainly in calcified coronary artery
lesions in HDCTCA in comparison with SDCTCA due to the better spatial resolution and the consequent reduced blooming effect. CLINICAL RELEVANCE/APPLICATION HDCTCA offers a possible and alternative solution to the problem of heavily calcified coronary arteries reducing the overestimation of
calcium volume by nearly half. SSA02-07 • Efficacy of 256 Slice Dual Source CT Angiography in Evaluation of Patients with High Heart Rates and Its Comparison
with Catheter Angiography: Do We Still Require Beta Blockers?
Neeraj Jain DMRD (Presenter) ; Sunil Kumar Puri MD ; Vasanthakumar Venugopal MD PURPOSE Comparative analysis of 256-slice dual source CT angiography (DSCTA) and catheter coronary angiography (CCA) in evaluation of
coronary arteries (CA) in patients with clinical suspicion of coronary artery disease (CAD) and to study its effectiveness at higher heart
rates (HR) without using beta blockers. METHOD AND MATERIALS This prospective study was conducted on patients (n=40) with suspected CAD using ECG triggered 256 slice DSCT (Somatom Definition
Flash, Siemens). Patients were sub grouped according to HR (Group I: 85 -100) and (Group 2: 101-115 bpm). 22 patients had HR of 85
-100 bpm while 18 patients had HR 101-115 bpm. All patients were scanned with retrospective spiral scan protocol. Coronary artery
segments were analyzed for image quality (IQ) on a 4 point scale (1 is worst while 4 is best) by two independent readers who were
blinded to patients details. Accuracy to detect significant luminal stenosis was correlated with CCA (gold standard). Statistical significance
of study was determined by chi-square test. RESULTS A total of 545 coronary artery segments were analyzed. The mean IQ score and standard deviation in group 1 and 2 were 3.45 ± 0.26
and 3.03 ± 0.36 respectively. Inter-observer agreement analysis was performed using Kappa analysis to determine consistency between
DSCTA readers. The Kappa values for group 1 and 2 were 0.838 and 0.808 respectively. The sensitivity, specificity, PPV, NPV and
accuracy for detecting significant stenosis in group 1 and group 2 were 97.3%, 98.6%, 100%, 98.7%, 98.9% and 91.3%, 96.9%,
95.4%, 95.6%, 96.9% respectively. CONCLUSION 256 slice DSCTA is a reliable technique with high sensitivity, specificity, PPV and NPV for assessment of coronary arteries even at higher
HR without using beta blocker to reduce the HR. CLINICAL RELEVANCE/APPLICATION 256 slice dual source CT can be used effectively for patients with suspected coronary artery disease irrespective of their heart rate and
without any premedication to lower the heart rate. SSA02-08 • Iterative Reconstruction Algorithms in Coronary CT Angiography for the Characterization of Coronary
Atherosclerotic Plaque-A Comparison with Histology
Stefan Puchner MD (Presenter) ; Maros Ferencik MD ; Pal Maurovich-Horvat MD ; Masataka Nakano ; Fumiyuki Otsuka ; Hans-Ulrich Kauczor MD * ; Renu Virmani ; Udo Hoffmann MD ; Christopher L Schlett MD, MPH PURPOSE To evaluate whether iterative reconstruction algorithms improve the accuracy of coronary CT angiography (CCTA) for coronary plaque
characterization as compared to histology. METHOD AND MATERIALS CCTA and histological data were acquired from coronary arteries of 3 ex-vivo hearts. CT images were reconstructed using filtered-back
projection (FBPR), adaptive-statistical iterative (ASIR) and model-based iterative (MBIR) reconstruction algorithms. First, cross-sectional
CCTA images were co-registered between all three reconstruction algorithms and second CCTA triplets were co-registered with histology.
Plaque area 200?m and circumference >60�, as well a cap thickness RESULTS In total, 173 FBPR/ASIR/MBIR triplets by CCTA were co-registered with histological cross-sections, where lipid-core plaque (LCP) was
presence in 26 locations based on histology. Plaque area CONCLUSION Plaque area CLINICAL RELEVANCE/APPLICATION Model-based reconstruction algorithm further enhances the accuracy of coronary CT angiography as a non-invasive tool for the detection
and characterization of vulnerable plaque SSA02-09 • CT Coronary Artery Opacification Gradients Using Different Iodinated Contrast Injection Protocols
Dimitris Mitsouras PhD (Presenter) ; Kanako K Kumamaru MD, PhD ; Chi Wai S Cheung MBBS ; Amir Imanzadeh MD ; Michael
Page 11 of 183
L Steigner MD * ; Frank J Rybicki MD, PhD * ; Elizabeth George MBBS ; Julie Miller MD * ; Hiraku Kumamaru PURPOSE To evaluate differences in coronary contrast opacification gradients, also known as TAG or Transluminal Attenuation Gradients, between
biphasic and triphasic coronary CTA injection protocols. METHOD AND MATERIALS Contrast opacification gradients from 320 x 0.5 mm detector row CT were computed for two populations: 32 patients with normal
coronary arteries plus 12 patients with left anterior descending (LAD) coronary artery stenosis (>50%) scanned with biphasic injection
protocol, and 11 normal patients scanned at a separate institution with a triphasic injection protocol. Linear regression determined
correlation between mean Hounsfield Unit and distance from the coronary ostium, lumen cross-sectional area, and lumen short axis
diameter. For each gradient (regression slope), multivariate regression model adjusting for BMI analyzed differences found between the
two patient cohorts. RESULTS While gradients showed strong to excellent linear-fit (Pearson r values = 0.64 - 0.91) for each injection protocol, the different protocols
introduced variability in normal coronary artery gradients. However, the gradients computed from biphasic injection protocol in LAD
arteries with >50% stenosis were significantly (p-values: from CONCLUSION Coronary contrast opacification gradients vary with respect to a biphasic versus triphasic injection protocols, with both showing
differences between normal and abnormal coronary arteries. CLINICAL RELEVANCE/APPLICATION To date, gradients have been validated using only biphasic protocols; these data suggest that both biphasic and triphasic injections can be
used to differentiate normal and abnormal coronary arteries. Cardiac (Radiation Dose Reduction) Sunday, 10:45 AM - 12:15 PM • S504AB
QA
IR CT CA SSA03 • AMA PRA Category 1 Credit ™:1.5 • ARRT Category A+ Credit:1.5 Moderator
Gregory W Gladish , MD Moderator
Konstantin Nikolaou , MD * Back to Top SSA03-01 • Detection of Coronary Artery Stenosis with Sub millisievert Radiation Dose by Prospectively ECG-triggered High
Pitch Spiral CT Angiography and Iterative Reconstruction
Wei-Hua Yin (Presenter) ; Bin Lu MD ; U. Joseph Schoepf MD * ; Zhi-Hui Hou MD ; Fang-Fang Yu ; Yang Gao ; Hui-Li Cao ; Zhi-Qiang Wang PURPOSE To evaluate the diagnostic accuracy of sub-milliSievert (mSv) coronary CT angiography (cCTA) using prospectively ECG-triggered
high-pitch spiral CT acquisition combined with iterative image reconstruction. METHOD AND MATERIALS IRB approval and informed patient consent were obtained. Forty consecutive, unselected patients (52.9±8.7 years; 30 men) underwent
contrast (370mgI/mL iopromide) enhanced dual-source cCTA using prospectively ECG-triggered high-pitch spiral acquisition. Tube
current-time product was set to 50% of standard-of-care CT examinations. Images were reconstructed with sinogram-affirmed iterative
reconstruction. Image quality was scored and diagnostic performance for detection of =50% stenosis was determined with catheter
coronary angiography (CCA) as the reference standard. RESULTS CT examinations were successfully performed in all 40 patients. Of the 601 assessable coronary segments, 543 (90.3%) had diagnostic
image quality. Per-patient sensitivity for detection of =50% stenosis was 95.7% (95% confidence interval [CI], 76.0-99.8%) and
specificity was 94.1% (95% CI, 69.2-99.7%). Per-vessel sensitivity was 89.5% (95% CI, 77.8-95.6%) with 93.2% specificity (95% CI,
86.0-97.0%). The area under the receiver-operating characteristic curve on per-patient and per-vessel levels was 0.949 and 0.913,
respectively. Mean effective dose was 0.58±0.17mSv. Mean size-specific dose estimate was 3.14±1.15mGy. CONCLUSION High-pitch prospectively ECG-triggered cCTA combined with iterative image reconstruction provides high diagnostic accuracy with a
radiation dose below 1 mSv for detection of coronary artery stenosis in an unselected patient population. CLINICAL RELEVANCE/APPLICATION Continuous reduction in radiation exposure associated with cardiac CT should widen the clinical acceptance and application of this
non-invasive test. SSA03-02 • Contrast Material and Radiation Dose Reduction Strategy for Triple-rule-Out Cardiac CT Angiography: Feasibility
Study of Serial Non-ECG-Gated Low kVp Scan of the Whole Chest
Masafumi Kidoh ; Takeshi Nakaura MD (Presenter) ; Shinichi Nakamura MD ; Kazunori Harada ; Shouzaburou Uemura ; Yasuyuki Yamashita MD * ; Tomohiro Namimoto MD ; Naritsugu Sakaino PURPOSE The purpose of this study was to investigate the feasibility of a contrast material and radiation dose reduction triple-rule-out (TRO)-CT
angiography (CTA) protocol with serial non-ECG-gated low kVp scan of the whole chest, which utilizes a recirculated contrast agent. METHOD AND MATERIALS This prospective study received institutional review board approval; prior informed consent to participate was obtained from all patients.
The 60 enrolled patients were randomly assigned to 2 TRO-CTA protocols. Thirty patients were scanned with the new TRO-CTA protocol;
after the coronary scan with retrospective ECG-gating, non-ECG-gated whole-chest CTA was performed at 80 kVp to evaluate aortic arch
(AAr) and pulmonary trunk (PT). The other 30 patients were scanned by our conventional TRO-CTA protocol at 120 kVp with retrospective
ECG-gating. We compared estimated effective dose (ED), CM (contrast medium) dose and contrast-to-noise ratio (CNR) of the ascending
aorta (AAo) between the two protocols. We also compared the rate of patients who could achieve adequate AAr attenuation (160 HU) and
adequate PT attenuation (200 HU) between the two protocols. Two-tailed Student�s t-test was used to compare CM dose, ED and CNR
on new TRO-CTA and conventional TRO-CTA scans. To compare the success rate of adequate attenuations of the PT and AAr, we used the
?2 test. RESULTS The total ED of the new TRO-CTA protocol was significantly lower than that of the conventional protocol (23.5±2.6 mSv vs. 33.4±1.4
mSv, p0.05). CONCLUSION Page 12 of 183
CONCLUSION The new TRO-CTA protocol could feasibly reduce the total dose of radiation and the contrast dose and yielded adequate vascular
enhancement compared with the conventional protocol. CLINICAL RELEVANCE/APPLICATION Triple-rule-out-CTA protocol with serial non-ECG-gated low kVp scan of the whole chest could feasibly reduce the total dose of radiation
and the contrast dose compared with the conventional protocol. SSA03-03 • Assessment of Image Quality and Radiation Dose of Prospectively Triggered Adaptive Coronary CT Angiography: In
Comparison with Retrospectively Gated Mode and High Pitch Mode
Yunling Wang (Presenter) ; Hong Wang PURPOSE The purpose of this study was to evaluate the image quality and radiation dose of dual-source computed tomography (DSCT) application
in coronary computed tomography angiography (CTA), using three different modes: prospectively electrocardiogram (ECG)-triggered
sequential scan mode, retrospectively ECG gated spiral scan mode and Flash spiral scan mode. METHOD AND MATERIALS Ninety eligible patients (47 males and 43 females, mean age 54.3 years), with heart rate within 60 to 80 beat per minute (bpm) and
relatively regular heart rhythm (fluctuation =10bpm), were included in this study. They are randomly distributed into three groups: 30
patients in Group A using prospectively ECG-triggered sequential mode, 30 in Group B using retrospectively ECG-gated spiral mode and
30 in Group C using Flash spiral mode. The X-ray tube voltages were selected according to body mass index (BMI). Both the radiation
dose and image quality were evaluated and compared, which were based on statistics analysis of image score, HU value standard
deviation (SD), Signal-Noise Ratio (SNR, mean/SD), Contrast-Noise Ratio (CNR). RESULTS The mean image score in Group A is 3.36±0.39, with effective radiation dose of 5.12±0.77 mSv, SD of 17.8±0.51, SNR of 23.64±0.49,
and CNR of 20.77±0.45. The mean image score in Group B is 3.58±0.51, with effective radiation dose of 6.79±0.41 mSv, SD of
18.8±0.46, SNR of 22.12±0.55, and CNR of 27.87±0.38. The mean image score in Group C is 1.47±0.62, with effective radiation dose of
0.89±0.81 mSv, SD of 15.1±0.44, SNR of 34.9±0.67, and CNR of 47.77±0.56. There were significant differences in the radiation dose
and image quality among these three groups (p CONCLUSION The prospectively triggered mode has a better image quality and lower radiation dose, compared with retrospectively gated mode and
Flash mode, which may be the first choice in CTA imaging. CLINICAL RELEVANCE/APPLICATION The prospectively triggered mode has a better image quality and lower radiation dose, compared with retrospectively gated mode and
Flash mode, which may be the first choice in CTA imaging. SSA03-04 • Impact of Model Based Iterative Reconstruction on Noise Reduction of Ultra Low-dose Coronary CT Angiography
Tobias A Fuchs MD (Presenter) ; Julia Stehli MD ; Sacha Bull MD, PhD ; Svetlana Dougoud MD ; Martin W Huellner MD ; Andreas Brauchlin MD ; Ronny R Buechel ; Oliver Gaemperli MD ; Philipp A Kaufmann MD PURPOSE Reduction of tube voltage and current for lowering radiation exposure from coronary CT angiography (CCTA) is associated with an
increase in noise which may render images uninterpretable. We evaluated the impact of model based iterative reconstruction (MBIR) on
noise reduction in ultra-low submillisievert dose CCTA. METHOD AND MATERIALS Twenty-five patients underwent standard low-dose CCTA (100 -120 kV; 450 � 700 mA) and an additional same-day ultra-low dose (ULD)
CCTA (80 � 100 kV; 150 � 210 mA) using MBIR. After assessing attenuation in the left main (LMA) and right coronary artery (RCA) as
well as noise in the aortic root the signal-to-noise-ratio (SNR) was calculated for LMA and RCA. RESULTS The mean body mass index of the study population was 25.4 ± 4.4 kg/m2 (range 18.4 � 40.2 kg/m2), and the mean weight 75.1 ± 15.3
kg (range 46.5 � 112.0 kg). The mean effective radiation dose was 1.3 ± 0.4 mSv in standard and 0.2 ± 0.1 mSv in ULD CCTA (p <
0.001). Nevertheless mean image noise decreased significantly from 32 ± 7 HU in standard CCTA to 21 ± 4 HU in ULD MBIR CCTA (p <
0.001). Interestingly, this was paralleled by an increase in mean attenuation in LMA from 466 ± 85HU to 563 ± 119 HU, and in RCA from
446 ± 63HU to 503 ± 83 HU (p CONCLUSION MBIR efficiently compensates for increased noise in ULD CCTA. In combination with the shift towards higher beam attenuation by iodine in
low tube voltage scanning this results in a SNR substantially higher than standard CCTA. CLINICAL RELEVANCE/APPLICATION New reconstruction algorithms such as MBIR achieve efficient noise reduction allowing substantial radiation dose reduction in cardiac CT
scanning. SSA03-05 • Dual Source Cardiac Computed Tomography Angiography (CCTA) in the Follow Up of Cardiac Transplant: Comparison
of Image Quality and Radiation Dose Using Three Different Scan Protocols
Florian Wolf MD (Presenter) ; Dietrich Beitzke MD ; Vanessa Berger-Kulemann ; Richard Nolz ; Gudrun Feuchtner MD * ; Christian Loewe MD * PURPOSE Cardiac allograft vasculopathy represents a major cause of mortality in the later course of cardiac transplant. CCTA represents a valuable
non-invasive imaging tool in the diagnosis of cardiac allograft vasculopathy with the disadvantage of radiation burden. Radiation dose
reduction in CCTA of cardiac transplant is challenging as patients often present with elevated heart rates. The aim of this prospective
randomized study was to evaluate image quality, diagnostic confidence, and radiation dose using 3 different CT scan protocols for
dual-source CCTA in heart transplant recipients. METHOD AND MATERIALS Dual source CCTA was performed in 150 consecutive patients after heart transplantation using either the conventional
retrospective-triggered spiral technique (120 kV/320 mA, tube current modulation) in group 1, the prospective ECG-gated sequence
technique (120 kV/320 mA, main padding window 40-70%) in group 2, or the prospective ECG-gated sequence technique in the systolic
phase with automated tube voltage selection (Automated kV, main padding window 35-45%) in group 3. Subjective image quality was
rated using a 16 segment coronary artery model and a four-point scale (1=excellent, 2= good, 3= fair, 4 = non-diagnostic) for each
segment. Effective dose (ED) was used to compare the differences in radiation dose. RESULTS No difference was observed in subjective image quality between the study groups regarding segments with excellent or good image
quality (Group 1: 90.5%, group 2: 89.3%; group 3: 86.8%). The number of segments with non-diagnostic image quality was lowest in
group 3 (Group 1: 1.8%, group 2: 2.1%; group 3: 1.1%) and did not differ between group 1 and 2. Mean ED did not differ significantly
between group 1 and group 2 (9.9±2.7 mSv vs. 9.1±2.3 mSv; p=0.13), but was significantly lower in group 3 (4.6±1.9 mSv; p CONCLUSION Radiation dose of dual source CCTA in heart transplant recipients can be significantly reduced by using the ECG-gated sequence
Page 13 of 183
technique in the systolic phase and automated tube voltage selection, compared to the ECG-gated sequence technique using a wide
padding window and the conventional spiral technique, while diagnostic image quality is maintained. CLINICAL RELEVANCE/APPLICATION Coronary CTA in heart transplant patients can be performed using a scan technique with relevant dose reduction with maintained image
quality compared to conventional scan modes with higher doses. SSA03-06 • Sub-mSv Coronary CT Angiography for Normal Size Patient Population (BMI
Qiang Ma (Presenter) ; Xiang Ren ; Najia Liu ; Shaoning Yan ; Zhiyuan Zhang ; Jinrui Bao PURPOSE To study the clinical feasibility of achieving sub-mSv radiation dose and acceptable image quality for normal size patient population
(20.52) in prospective ECG-triggered coronary CT angiography (CCTA) with low tube voltage. METHOD AND MATERIALS One hundred and eighty patients [heart rate: 56±4bpm, 20.52, and 190mA if BMI 22.5-25.0kg/m2). Radiation dose was recorded. CT
value and image noise on aorta were measured, and signal-noise-ratio (SNR) was calculated. The image quality was evaluated blindly (5
for excellent). Independent-sample t-test was performed on dose and Mann-Whitney test on image quality scores. RESULTS The overall dose for group A with 100kV was 0.69mSv, 35% lower than the 1.06mSv for group B with 120kV. For the patient population
with BMI2: the radiation dose for group A was 0.55±0.11mSv, 32% lower than the 0.81±0.09mSv for group B (p22.5kg/m2: the radiation
dose for group A was 0.73±0.09mSv, 35% lower than the 1.13±0.16mSv for group B (p0.05). CONCLUSION Prospective ECG-triggered CCTA with low tube voltage significantly reduces radiation exposure while maintaining acceptable image
quality. For the patient population with BMI2, sub-mSv CCTA is achievable with prospective ECG-triggering and 100kV tube voltage. CLINICAL RELEVANCE/APPLICATION The use of prospective ECG-triggering and 100kV tube voltage in CCTA can reduce radiation to patients, and achieve sub-mSv dose for
patient population with BMI2. SSA03-07 • Low Tube Voltage and High Sensitive Detector Reduce the Radiation Dose of Coronary CTA
Jian Cao (Presenter) ; Yining Wang MD ; Lingyan Kong ; Lin Lu MD ; Huadan Xue MD ; Zhiwei Wang MD ; Zhengyu Jin MD PURPOSE To investigate the application of low tube voltage (80kV) for coronary artery computed tomography angiography (CCTA) in patients with
normal body mass index (BMI) with second generation dual-source CT equipment with novel high sensitive detector. METHOD AND MATERIALS RESULTS CONCLUSION Tube voltage as 80kV in second generation dual-source CT equipped with novel high sensitive detector is feasible in patients with normal
BMI. This scan mode can obviously reduce the radiation dose while with no influence on image quality. CLINICAL RELEVANCE/APPLICATION Tube voltage as 80kV in second generation dual-source CT equipped with novel high sensitive detector is feasible in patients with normal
BMI. SSA03-08 • Feasibility and Image Quality of Ultra-low Dose Submillisievert Radiation Exposure in Coronary CT Angiography
Using Model Based Iterative Reconstruction: First Clinical Experience
Julia Stehli MD (Presenter) ; Tobias A Fuchs MD ; Sacha Bull MD, PhD ; Svetlana Dougoud MD ; Martin W Huellner MD ; Andreas Brauchlin MD ; Ronny R Buechel ; Oliver Gaemperli MD ; Philipp A Kaufmann MD PURPOSE To evaluate the feasibility and image quality of coronary CT angiography (CCTA) acquisition with a submillisievert fraction of effective
radiation dose using model based iterative reconstruction (MBIR) for noise reduction. METHOD AND MATERIALS In 25 patients undergoing standard low-dose contrast enhanced CCTA (100 � 120 kV; 450 - 700 mA) an additional same-day ultra-low
dose (ULD) CCTA was acquired (80 - 100 kV; 150 - 210 mA) and reconstructed with MBIR. Two independent readers semi-quantitatively
assessed image quality on a four-point Likert scale in each coronary segment (1: non-diagnostic, 2: good, 3: adequate, 4: excellent). RESULTS Over a wide range of weight (47 - 112 kg) and body mass index (18.4 - 40.2 kg/m 2), the mean DLP from standard and ULD CCTA was
89.5 ± 29.4 mGycm (range 69.8 � 188.3 mGycm) and 15.9 ± 6.2 mGy cm (range 10.2 - 35.6 mGy cm) resulting in an estimated mean
radiation dose exposure of 1.3 ± 0.4 mSv (range 1.0 - 2.6 mSv) for standard and 0.2 ± 0.1 mSv (range 0.1 - 0.5 mSv) for ULD CCTA (p
< 0.001). Intravenous beta-blockers were administrated for heart rate control prior to CCTA in 20 patients (80%) (10.8 ± 9.5mg, range 3
� 25 mg). The mean heart rate for standard and ULD CCTA was 57.5 ± 5.6 and 57.0 ± 5.9 bpm (p = ns).
A total of 100 vessels and 330 coronary artery segments with a diameter of = 1.5 mm were evaluated and revealed an inter-observer
agreement of image quality of ? = 0.8. The mean image quality score per segment was 3.3 ± 0.5 in standard CCTA vs. 3.4 ± 0.6 in ULD
MBIR (p < 0.05). Diagnostic image quality (score 2 - 4) was found in 319 coronary segments (97%) of standard CCTA, and 317 (96%)
segments of ULD MBIR (p = ns).
CONCLUSION Our results document the feasibility of CCTA acquisition with diagnostic image quality at an ultra-low radiation dose of 0.2 ± 0.1 mSv in
combination with MBIR reconstruction. CLINICAL RELEVANCE/APPLICATION CCTA scanning with an ultra-low radiation dose may pave the way for the broad clinical implementation of CCTA as an alternative for the
invasive coronary angiography. SSA03-09 • Optimization of Radiation and Contrast Dose for Cardiovascular Computed Tomography
Yajuan Wang PhD (Presenter) * ; Kassem Soufan ; Anjali Kottha ; Corey Kemper PhD * ; John F Kalafut PhD * ; Sandra S
Halliburton PhD * PURPOSE Lowering x-ray tube potential is an effective way to reduce both radiation exposure and contrast load from computed tomography (CT).
This study evaluated a novel algorithm for optimizing both radiation and contrast dose at cardiovascular CT. METHOD AND MATERIALS Page 14 of 183
67 patients referred for evaluation of thoracic aortic disease were imaged with a prospectively ECG-triggered axial technique on a
256-slice CT scanner (Brilliance iCT, Philips). X-ray parameters (tube potential,tube current) were determined from an attenuation
measurement on the initial radiograph using a custom algorithm. Based on the tube potential, either 50 mL (100 kV) or 90 mL (120 kV)
of contrast with a concentration of 370 mgI/mL was injected at a flow rate = 3.5 mL/s. Five circular regions of interest (ROI) were drawn
at multiple locations in the lumen of the aorta along its length and the mean attenuation and standard deviation of attenuation (noise)
were recorded. Average aortic attenuation, noise, and signal-to-noise ratio (SNR) were compared between 100 and 120 kV groups using
Student�s t test. RESULTS 100 kV [n=40] and 120 kV [27] cohorts had similar age (62±15 vs 59±13 yrs) and height (1.74±0.10 vs 1.78±0.07 m). The cohort
imaged at 100kV had significantly lower body mass index (25.7±2.8 vs. 32.0±3.2 kg/m2) and percentage of males (67.5% vs. 92.6%).
Patients scanned at 120 kV had a longer scan delay (33±8 vs. 26±4 s) but similar scan time (12±1 vs. 12±1 s) compared to 100 kV
patients. Image quality metrics were equivalent between groups (aortic attenuation: 287±83 vs 281±48 HU; noise: 27±4 vs 26±3 HU;
SNR: 11±3 vs 11±2) despite lower contrast dose (50 vs 90 mL) and effective radiation dose (1.8±0.3 vs 3.6±0.4 mSv) at 100 kV. CONCLUSION Simultaneous optimization of x-ray parameters and contrast protocols yielded equivalent image noise and blood enhancement across a
range of patient sizes for cardiovascular CT. Smaller patients required 49% less radiation and 44% less contrast. CLINICAL RELEVANCE/APPLICATION Cardiovascular CT can be performed in smaller patients using lower radiation and contrast doses compared to those used for larger
patients without compromising image quality. Chest (Vascular) Sunday, 10:45 AM - 12:15 PM • S404CD
IR
CT CH SSA04 • AMA PRA Category 1 Credit ™:1.5 • ARRT Category A+ Credit:1.5 Moderator
Phillip M Boiselle , MD Moderator
Smita Patel , MBBS Back to Top SSA04-01 • Value of Echocardiography in Patients with Acute Pulmonary Embolism with a Normal CT-derived Right-to-Left
Ventricular Diameter Ratio
Kanako K Kumamaru MD, PhD (Presenter) ; Elizabeth George MBBS ; Nina Ghosh ; Carlos J Gonzalez Quesada MD ; Marie
Gerhard-Herman ; Frank J Rybicki MD, PhD * ; Nicole Wake MS ; Arash Bedayat MD PURPOSE Decision criteria for subsequent transthoracic echocardiography (TTE) after acute pulmonary embolism (PE) are needed when the
CT-derived right-to-left ventricular (RV/LV) diameter ratio does not suggest RV dysfunction. The purpose of this study is to develop a
clinical prediction rule for low probability of incremental prognostic benefit from subsequent TTE after acute PE. METHOD AND MATERIALS A single institution retrospective cohort study included 579 consecutive patients diagnosed with acute PE by CT pulmonary angiography
between August 2003 and March 2010 with a normal RV/LV diameter ratio ( RESULTS RV strain was detected in 21.6% (51/236) of the patients who underwent TTE. The final prediction model of the �TTE-Benefit� group
(n=55) included 5 variables: congestive heart failure (adjusted odds ratio (OR):4.32, 95% confidence interval (CI):1.88-9.92), RV
diameter on CT >45mm (OR:3.07, 95%CI:1.56-6.03), age >60 years (OR:2.59, 95%CI:1.41-4.77), central embolus (OR:1.96,
95%CI:1.01-3.79), and stage 4 cancer (OR:1.94, 95%CI:0.99-3.78). If these five factors were all absent (corresponding to 37.1% of the
population), the probability of �no incremental benefit from TTE� was 0.97 (95%CI=0.95-0.99). The model had a good discrimination
(c-statistic=0.758) and was internally validated (over-fitting bias=2.52%). CONCLUSION RV diameter >45mm on CT, congestive heart failure, age >60 years, central embolus, and stage 4 cancer are useful factors in guiding
decision making regarding which patients with acute PE and normal RV/LV diameter ratio may benefit from subsequent TTE. If all factors
are negative, the incremental benefit from TTE within 14 days is minimal in terms of RV function assessment and short-term PE-related
mortality prediction. CLINICAL RELEVANCE/APPLICATION Age, RV diameter, embolus size, congestive heart failure, and cancer are useful factors in making decision regarding which patients with
acute PE and normal RV/LV ratio may benefit from subsequent TTE SSA04-02 • CT Pulmonary Angiography with Ultra Low-dose of Contrast and Radiation- Evaluation of Image Quality and
Radiation Dose
Prabhakar Rajiah MD, FRCR (Presenter) ; Calen Frolkis BA ; Luis A Landeras MD ; Jennifer Paczak ; Leslie Ciancibello RT ; Robert C Gilkeson MD * PURPOSE Iodinated contrast has been associated with renal and thyroid dysfunction. Recent literature suggests that the presence or iodinated
contrast amplifies DNA radiation damage following CT. Hence, an ideal CT scan protocol should involve the least amount of radiation dose
and contrast. The purpose of this study is to evaluate if image quality is preserved in a CT pulmonary angiographic (CTPA) protocol with
an ultra-low dose contrast and radiation dose. METHOD AND MATERIALS Retrospective analysis revealed 99 patients who underwent CTPA using an ultra low-dose technique. All the scans were performed on a
128-slice Dual-source Siemens Definition FLASH scanner. Images were acquired following intravenous injection of 30 ml of iodinated
contrast (Optiray 350) at 4 ml/sec. Images were acquired in high-pitch helical mode (3.2), with kv of 80-120 (BMI dependent) and mAs of
130. The scan length, CTDIvol and DLP were recorded. Images were independently reviewed by 2 readers and graded on a 1 to 5 scale
(1- non diagnostic, 2- probably non diagnostic, 3- probably diagnostic, 4-diagnostic, 5- excellent image quality). Signal, noise and
Signal-to-noise ratio (SNR) were also recorded in main, right and left pulmonary arteries. RESULTS The study had 67 men and 32 women with age range of 19-84 years (57.97 ± 16; Mean, std dev). 76 had a history of neoplasm. BMI
ranged from 16 to 40 (25.2 ± 4.8). Embolism was present in 22 patients. Contrast enhancement was excellent in the pulmonary arteries
(MPA- 327.4 ± 24.2, LPA 329.0 ± 24.2, RPA- 335.4 ± 26.1). SNR was good in all the pulmonary arteries (MPA 14.6 ± 6.8, LPA 14.3 ±
5.8, RPA- 13.9 ± 6.6). Image quality was considered excellent by both the readers (Reader 1, 4.3 ± 1.0, Reader 2, 4.4 ± 0.9), with no
significant difference between the readers (p value, 0.7). Only 4 studies were considered non diagnostic, which is less than the non
diagnostic rate described in the current literature. The DLP is 157.8 ± 66 with effective dose of 2.2 ± 0.9 mSv CONCLUSION Page 15 of 183
CONCLUSION Using a helical acquisition technique, CTPA images with good diagnostic quality can be obtained using a very low dose of iodinated
contrast and low radiation dose. There is also potential for further reduction in the contrast and radiation doses and cost savings. CLINICAL RELEVANCE/APPLICATION Diagnostic CTPA can be performed with ultra-low contrast dose techniques while reducing potential toxicities associated with the
administration of iodinated contrast. SSA04-03 • Diagnostic Accuracy of Low-dose CT Pulmonary Angiography: Results of a Prospective Randomized Trial (REDOPED)
Zsolt Szucs-Farkas MD, PhD (Presenter) ; Andreas Christe ; Boglarka Megyeri MD ; Martin Rohacek ; Peter Vock MD ; Endre
V Nagy ; Johannes T Heverhagen MD, PhD * ; Sebastian T Schindera MD * PURPOSE To compare diagnostic accuracy of low-dose computed tomography pulmonary angiography (CTPA), with both reduced radiation and
reduced contrast material (CM) dose with a normal-dose protocol in detecting acute pulmonary embolism (PE). METHOD AND MATERIALS The Reduced Dose in Pulmonary Embolism Detection (REDOPED) trial was a single-centre, single-blinded, HIPAA-complient, prospective
randomized study. Five hundred and one patients with body weights of RESULTS The reference diagnosis was equivocal in 20 of 501 patients. CTPA diagnosis was correct in 240 patients and incorrect in 5 in the
normal-dose group. CTPA was correct in 230 cases and incorrect in 6 in the low-dose group (odds ratio 1.25, 95% confidence interval,
0.38 to 4.16; P=0.77). Sensitivity was 96.9% and 100% and specificity was 98.1% and 97.1% in the normal-dose and low-dose groups,
respectively. No PE or PE-related death occurred during 90-day follow-up. The mean estimated effective dose was 3.28 mSv in the
normal-dose group and 2.25 mSv in the low-dose group, corresponding to a reduction by 31% (P
CONCLUSION The accuracy of low-dose CTPA with reduced radiation and reduced CM dose is not significantly different from that of normal-dose CTPA
in detecting or excluding acute PE in patients weighing CLINICAL RELEVANCE/APPLICATION CTPA with 80 kVp tube voltage provides high accuracy at reduced radiation and reduced CM dose and can be recommended for routine
PE diagnosis in patients weighing SSA04-04 • Sub-mSv CT Imaging of Pulmonary Arteries Using an Iterative Model Reconstruction Algorithm
Daniela Muenzel MD (Presenter) ; Thomas Koehler PhD * ; Bernhard Brendel * ; Kevin M Brown MS * ; Stanislav Zabic PhD *
; Alexander A Fingerle MD ; Ernst J Rummeny MD ; Martin Dobritz MD ; Peter B Noel PhD PURPOSE To investigate the improvement in diagnostic quality of iterative model reconstruction (IMR) algorithm for sub-mSv computed tomography
angiography of the pulmonary arteries (CTA). METHOD AND MATERIALS Eighteen patients (single-center, IRB approved) were imaged on a Philips Brilliance iCT (Philips, Cleveland, OH) for visualization of the
pulmonary arteries, 8 with and 10 without pulmonary artery embolism. All scans were performed at 120 kVp (average effective doses
4.34±1.99mSv). Acquisitions with reduced radiation exposure were simulated from the original CT data to 15% of the tube current,
resulting in a sub-mSv average dose of 0.65±0.30mSv. Filtered backprojection (FBP) was used to reconstruct the original data (protocol
A); sub-mSv data were reconstructed using FBP (protocol B) and IMR (protocol C). The performance of IMR was assessed with respect to
the image quality metrics image noise and contrast-to-noise ratio (CNR) and with respect to effective dose of each protocol. Two blinded
readers determined subjective image quality and assessed the detectability of pulmonary artery embolism, where ground truth was
obtained from protocol A. RESULTS With IMR noise could be subjectively removed, while the image texture (look and feel) of these images differed from FBP reconstructions.
Specifically, with IMR, the noise is significantly reduced by a factor up to 20 (B vs. C). This is reflected by an improvement in the
contrast-to-noise ratio and improved image quality with a median image quality score of 3 (IMR, B) vs. 1 (FBP, C), p < 0.05. With respect
to diagnostics the angiographic datasets protocol A and C were identical, while B was worse: To detect pulmonary artery embolism in IMR
and FBP low dose images, the sensitivity was 100% for IMR and 62.5% for FBP while specificity was 100% for both protocols. CONCLUSION This simulation study indicates that by using IMR for reconstruction, pulmonary artery embolism can be detected accurately in scans with
sub-mSv dose levels. CLINICAL RELEVANCE/APPLICATION IMR has the potential to reduce patient dose and improve image quality in clinical day-to-day routine. SSA04-05 • Impact of Perfusion Imaging on the Assessment of Peripheral Chronic Pulmonary Thromboembolism: Clinical
Experience in 62 Patients
Francesco Molinari MD (Presenter) ; Julien Le Faivre ; Francois Pontana MD ; Kanna Yasunaga MD ; Jacques Remy MD * ; Martine J Remy-Jardin MD, PhD * PURPOSE To evaluate the impact of perfusion imaging on the detection of peripheral chronic pulmonary thomboembolism (CPTE). METHOD AND MATERIALS 62 patients (30 males; 32 females; mean age: 60 yr) with chronic thromboembolic disease underwent a dual-source, dual-energy chest
CT angiographic examination with (a) reconstruction of diagnostic (i.e., averaged images from both tubes) and pulmonary blood volume
(PBV) images; (b) enabling separate depiction of peripheral CPTE on diagnostic images (i.e., cross-sectional images viewed on lung and
mediastinal window settings for analysis of segmental arteries, completed by maximum intensity projections for the subsegmental level)
and perfusion defects on MPRs of PBV images. On diagnostic scans, the CT features of CPTE included stenosed arterial branches and/or
endoluminal filling defects within segmental and subsegmental arteries. On PBV images, embolic type defects consisted of triangular,
pleural-based and sharply marginated hypoattenuated areas which recorded at a segmental level (20 segments/patient; total: 1240
segments). The readings of diagnostic and perfusion images were independently performed by two readers. RESULTS On diagnostic images: (a) the analysis of segmental arteries depicted CT features of CPTE within 476 segments; (b) the analysis of both
segmental and subsegmental arteries depicted CT features of CPTE within 872 segments. PBV imaging depicted: (a) 313 segments with
perfusion defects at the level of which segmental arteries had not been diagnosed with CPTE, increasing the number of segments affected
by CPTE by 66% (313/476); (b) 66 segments with perfusion defects at the level of which subsegmental arteries had not been diagnosed
with CPTE, increasing the number of segments affected by CPTE by 7.5% (66/872). CONCLUSION The reading of PBV images enables depiction of a greater number of segments involved in peripheral CPTE. CLINICAL RELEVANCE/APPLICATION Depiction of CT features of CPTE at the level of the segmental and subsegmental pulmonary arterial bed is improved by the reading of
Page 16 of 183
PBV images. SSA04-06 • Detection of Pulmonary Hypertension in Patients with Cystic Fibrosis (CF) Using Magnetic Resonance (MR) Flow
Measurements
Nino Kiria MD (Presenter) ; Jutta Hammermann ; Bernhard Schulte-Hubbert ; Michael Laniado MD ; Nasreddin Abolmaali
MD PURPOSE Pulmonary arterial hypertension (PAH) is a severe complication of a cystic fibrosis lung disease. The aim of this study was to evaluate MR
based flow measurements in the pulmonary trunk to detect evolving signs of PAH in patients suffering from CF. METHOD AND MATERIALS 23 patients (median age: 25 years, age range: 11-39 years, 10 female, 13 male) suffering from CF of different severity were examined
using MRI based flow measurements. The examinations were performed at 1,5 Tesla scanner using body matrix coils and were the part of
an annual follow-up. In addition to the standard CF-lung protocol an ECG-triggered phase-contrast flow measurement was acquired over
the entire cardiac cycle with a temporal resolution of 12 ms. The assessed data, especially the acceleration times (AT,[ms]) and the
average diameter of the pulmonary trunk were evaluated and the blood flow graphs in the pulmonary trunk during the heart cycle were
analysed. RESULTS The comparison of means revealed significant differences for AT and average diameter of pulmonary trunk as well as the double peak
increase of pulmonary flow during the heart cycle. It was possible to identify 5 patients demonstrating definite signs of PAH, such as
shortened AT and enlarged diameter of pulmonary trunk and its restricted distensibility during systole/diastole as well as slow/double
peak increase of the blood flow in pulmonary trunk. In patients with clinically no signs of pulmonary hypertension mean AT was 149 +- 25
ms and the mean diameter of the pulmonary trunk was 4,1 +- 1 cm. The CF-patients with suspected PAH showed a mean AT of 131+25,9 ms and a mean diameter of the pulmonary trunk of 5,1+-1,2 cm. CONCLUSION Signs for the development of a PAH (i.e. reduction of AT) are detectable using MRI based flow measurements. This technique could be a
valuable screening tool for CF patients to identify the development of a PAH. Correlation to the echocardiographic results of the respective
five patients will be presented. CLINICAL RELEVANCE/APPLICATION As PAH is a crucial complication of CF, MRI based flow measurements in pulmonary trunk can be helpful for detection, follow-up and
control of therapy of PAH in CF patients. SSA04-07 • Evaluation of Pulmonary Hypertension (PH) by Pulmonary Artery (PA) Tortuosity Measurements: Correlations with
Mean Pulmonary Artery Pressure (mPAP) and Pulmonary Vascular Resistance (PVR)
Seyed Ameli-Renani MBBS,FRCR (Presenter) ; Jenny L Bacon MRCP * ; Sarah L Sheard MBBS, FRCR ; Anand Devaraj MBBS ; Brendan P Madden MBBCh, MD ; Ioannis Vlahos MRCP, FRCR * PURPOSE To evaluate whether PA automated curved multiplanar reformat (cMPR) measurements correlate with mPAP or PVR and whether these
can discriminate patients with PH. METHOD AND MATERIALS 57 patients (22 male), suspected of PH, who underwent CT pulmonary angiography (CTPA) with contemporaneous (2 or PVR>3 WU
patient subsets was evaluated (Mann-Whitney U).
RESULTS cMPRs were successful in 100/114 (88%) of vessels. Moderate correlations were demonstrated between right, left and mean cPA with
mPAP (r=0.41, 0.46, 0.47, all p CONCLUSION PA tortuosity, quantified by limited automated artery measurements, is feasible, correlates with mPAP, and may identify patients with PH. CLINICAL RELEVANCE/APPLICATION Automated pulmonary arterial tortuosity measurement may be an indicator of pulmonary artery pressure and PH, however, relationships
to PVR are more complex, requiring correction for lung expansion. SSA04-08 • Incidence of Repeat CT Pulmonary Angiography for Suspected Pulmonary Embolism and Clinical Factors Associated
with Repeat Testing
Daniel M Adams MD (Presenter) ; Scott Woller MD ; Scott Stevens MD * ; Scott Evans PhD ; Greg Snow PhD ; Joseph
Bledsoe MD ; Jim Lloyd BS ; Todd D Lovelace MD ; Valerie Aston RT ; C. Gregory Elliott MD PURPOSE CT pulmonary angiography (CTPA) for suspected pulmonary embolism (PE) is a frequently performed exam that bears inherent risks. We
measured the proportion of exams performed for patients who undergo repeat CTPA and identified differences in characteristics for those
patients. METHOD AND MATERIALS This retrospective study was performed at Intermountain Medical Center and LDS Hospital in the Salt Lake City, Utah area. Consecutive
CTPA exams for suspected PE ordered from the emergency department from May 22, 2009 to June 30, 2010 were identified. Data for
patient characteristics were extracted from the medical record electronically and by manual review. Pretest probability was calculated
with the Revised Geneva Score (RGS), d-dimer values were collected, and the final interpretation of each CTPA was recorded. Guideline
concordant use was defined as CTPA being ordered for 'PE Likely' (RGS >10) patients or following a d-dimer that was positive among �PE
Unlikely� (RGS = 10) patients. All patients who underwent multiple examinations were identified, and comparisons of patient
characteristics from CTPA encounters were made based on whether a single exam or multiple exams were performed during the study
period. RESULTS 3500 CTPA exams for suspected PE were performed during the study period for 3279 individual patients. 3090 patients had 1 exam, 164
patients had 2 exams, 19 patients had 3 exams, 5 patients had 4 exams, and 1 patient had 5 exams. Repeat examinations were
associated with younger mean age (50 vs. 53 years); a higher incidence of prior venous thromboembolism (48.0% vs. 15.7%), trauma
(6.6% vs. 2.9%), and signs and symptoms of deep vein thrombosis (unilateral leg pain 10.5% vs. 6.7%, signs of DVT 9.5% vs. 6.2%);
and a higher mean pretest probability for PE (RGS 6.3 vs. 5.0). Repeat exams also had a higher yield of positive interpretations (14.4%
vs. 9.1%); and were less frequently performed in concordance with evidence-based guidelines (39.5% vs. 46.3%). CONCLUSION Repeat CTPA exams are commonly performed. Patients receiving multiple exams have a higher clinical pretest probability and incidence of
PE than patients receiving single CTPA exams. Repeat CTPA exams are less likely to be performed in concordance with evidence-based
guidelines. CLINICAL RELEVANCE/APPLICATION Page 17 of 183
In these settings, repeat CTPA exams were common and often show acute PE although they were less likely to be performed in
concordance with evidence-based guidelines. SSA04-09 • 70 kV CT Pulmonary Angiography - Advantages of a Dual-source Protocol with Reduced Iodine Load
Ralf W Bauer MD (Presenter) * ; Claudia Frellesen ; Firas Al-Butmeh ; Boris Bodelle MD ; Julian L Wichmann MD ; Josef
Matthias Kerl MD * ; Martin Beeres MD ; Boris Schulz MD ; Thomas Lehnert MD ; Thomas J Vogl MD, PhD PURPOSE Lower kV settings go along with higher iodine attenuation, but also with increased noise, if mA are not adapted accordingly. Low kV
scanning opens the door for the application of low iodine content contrast agents with potential benefits for patients with reduced kidney
function. We investigated the potential of a novel 70 kV dual-source CTPA protocol (DS70) with low iodine load in comparison to a
single-source 70 kV (SS70) and 100 kV (SS100) protocol with standard iodine load in terms of image quality and radiation exposure. METHOD AND MATERIALS Each 20 consecutive patients with suspected pulmonary embolism underwent CTPA either with a standard single-source 100 kV (120
mAs; group 1), a single-source 70 kV (208 mAs; group 2) or a novel dual-source 70 kV protocol (416 mAs; group 3). A dual-source
protocol can overcome tube output restrictions that occur at 70 kV by using both X-ray tubes of the scanner simultaneously. Contrast
enhancement was achieved with 70 ml of a contrast agent with 400 mgI/ml in group 1 and 2, whereas in group 3 the same volume was
injected but with a lower iodine concentration of 300 mgI/ml. Injection rate was constant at 4 ml/s and bolus tracking was used for
automated scan start. CTDIvol, DLP, noise, signal intensity in the pulmonary trunk and segmental arteries and corresponding SNR values
were compared. RESULTS Chest diameter was not statistically significantly (p>0.05) different between the groups. CTDIvol (median: 5.86 vs. 2.49 vs. 5.79 mGy)
and DLP (167 vs. 68 vs. 156 mGycm) were statistically significantly lower in group 2 with no such difference between group 1 and 3.
Vascular attenuation was significantly higher (segmental arteries, 332 HU vs. 647 HU vs. 521 HU) with both 70 kV protocols. Image noise
was significantly reduced with the DS70 protocol compared to the SS70 protocol and was at the level of the SS100 protocol. This resulted
in a significantly higher SNR in group 3 compared to group 1 (56.0 vs. 60.1 vs. 64.3). CONCLUSION 70 kV DS CTPA can achieve better SNR at similar dose values than a standard single-source 100 kV protocol, but with 25% less iodine
load. The 70 kV single-source protocol showed lowest dose values, but has a demand for a high iodine contrast material in order to
achieve equivalent image quality. CLINICAL RELEVANCE/APPLICATION The introduced 70 kV DS CTPA protocol holds potential for reducing iodine load in patients at risk for developing contrast-induced
nephropathy. Emergency Radiology (Imaging Chest Emergencies) Sunday, 10:45 AM - 12:15 PM • N228
ER
CT VA CH SSA05 • AMA PRA Category 1 Credit ™:1.5 • ARRT Category A+ Credit:1.5 Moderator
Sanjeev Bhalla , MD Moderator
Michael N Patlas , MD Back to Top SSA05-01 • Detection of Intramural Hematoma: Is a Non-contrast Phase Really Necessary?
Christopher A Potter MD (Presenter) ; Daniel S Hippe MS * ; Elan D Bomsztyk MD ; Guy E Johnson MD ; Bruce E Lehnert MD
; Lorenzo Mannelli MD, PhD ; Claire K Sandstrom MD ; Martin L Gunn MBChB * PURPOSE CT angiography is sensitive and specific for diagnosis of intramural hematoma (IMH), aortic dissection (AD) and penetrating
atherosclerotic ulcer (PAU). Most acute aortic syndrome (AAS) protocols use a pre-contrast phase to detect IMH, as contrast-enhanced
phase alone is believed insufficiently sensitive for IMH, but there is little supporting data. METHOD AND MATERIALS We retrospectively reviewed images of patients who presented to our Emergency Department with suspected AAS and received pre- and
post-contrast CTA from 2/1/2005 to 2/1/2010 for isolated acute IMH, defined as IMH without visible intimal flap. 423 studies were
reviewed. 11 cases of IMH were identified. 22 normal controls and 12 abnormal controls (AD or PAU) were age and sex matched and
added. The 45 studies were randomized. Only contrast-enhanced images were evaluated by three blinded, independent fellowship-trained
radiologists. Reviewers rated their confidence for IMH using a 5-point modified Likert scale, also indicating if they recommended a
non-contrast study to exclude IMH. Inverse probability weighting was used to extrapolate ordering rates from the matched case-control
sample to the original sample. RESULTS 423 patients underwent CTA for AAS. 11 patients were diagnosed with IMH (incidence of 2.6%). On independent case review, overall
rater sensitivity for IMH on contrast-enhanced images alone was 94% (CI 74-99%) and specificity 97% (CI 88-99%). For all false
negative cases, confidence rating for exclusion was low and delayed non-contrast examination was recommended. If delayed CT were
ordered due to suspicious findings on contrast-enhanced images, 7.1% of patients (CI 3.3-14%) would undergo a delayed CT to exclude
IMH. More conservatively, if delayed CT were ordered when confidence rating of 1 or 5 (definitely not present or definitely present) cannot
be assigned, only 14% (CI 7.5-25%) of patients would undergo additional delayed CT. While the present sample was not large enough to
be definitive, no IMH cases would be missed using this approach. CONCLUSION Acute IMH is a very uncommon diagnosis in patients with suspected AAS. A pre-contrast examination is unnecessary for diagnosis of acute
IMH. Dose and time savings may be achieved by eliminating the pre-contrast phase. CLINICAL RELEVANCE/APPLICATION Exclusion of non-contrast phase on CTA for acute aortic syndrome, used in most ED protocols, may result in overall patient time and
radiation dose savings. SSA05-02 • Is the Precontrast CT Series Necessary for Ruling Out Acute Aortic Intramural Hematoma?
Elie Portnoy MD (Presenter) ; Maria C Shiau MD ; James S Babb PhD ; Rose Weiner BS ; Francis G Girvin MBChB ; Jane P Ko
MD ; Derek M Mason MD ; Maj L Wickstrom MD PURPOSE To assess the need for pre-contrast imaging when evaluating for Acute Aortic Intramural Hematoma (IMH). The current gold standard for
the detection of Aortic Dissection (AD) is CT angiography. However, along the disease spectrum of AD, lie several related pathologies with
near identical clinical presentations. IMH, one such disease, lacks an intraluminal flap or discernible communication between the luminal
Page 18 of 183
near identical clinical presentations. IMH, one such disease, lacks an intraluminal flap or discernible communication between the luminal
blood and the intramural hematoma. It has long been posited that concern for this pathology alone necessitated pre-contrast images (in
addition to post contrast images) to conclusively rule out IMH (in addition to AD.) This study seeks to demonstrate non-inferiority to
post-contrast imaging alone in comparison to pre- and post-contrast studies. METHOD AND MATERIALS Study group of 23 patients (10M;13F;age 57-93;mean:78.5y) who underwent Pre- and Post-Contrast CT series and were diagnosed with
IMH via official radiology report at a tertiary care hospital between 2007 � 2011. 23 gender and age controlled subjects were selected
with no remarkable findings on CT. Five independently operating thoracic radiologists (dedicated experience in specialty 5-14 years) were
presented with randomized, anonymized post-contrast imaging alone of the 46 above patients, aware of suspected acute aortic injury,
and asked to comment on the absence or presence of IMH, AD, and/or penetrating ulceration. They were then presented with both the
Pre- and Post-Contrast series for these patients and asked for their diagnoses yet again. RESULTS Within the post-contrast group, the readers were diagnostically accurate for IMH 72.8% of the time, as opposed to the combined pre- and
post-contrast group, where they were accurate 76.8%. (p-value .340). ( 95% CI -2.2?8.8.) Since the difference between the 2
groups was statistically insignificant and it can be asserted with 95% confidence that no greater than 8.8% of cases of
IMH would be missed with post-contrast imaging alone, post-contrast imaging alone was statistically non-inferior to
combined pre- and post-contrast imaging. . CONCLUSION IMH is radiographically evident on post contrast imaging alone and it is statistically non-inferior to combined pre- and post-contrast
sequences. CLINICAL RELEVANCE/APPLICATION In clinical practice, when evaluating for possible aortic syndromes (Dissection, IMH, etc.) we contend that post-contrast angiography alone
may suffice. Broader/confirmatory study may be warranted. SSA05-03 • Reduced Z Axis CTPA in Pregnant Women for Pulmonary Embolism - Do We Really Miss Any Important Diagnoses?
How Much Is the Resultant Dose Reduction?
Kaushik S Shahir MD (Presenter) ; Luis A Sosa MD ; Jonathan M McCrea MD ; Lawrence R Goodman MD PURPOSE To evaluate the feasibility for applying reduced z axis coverage in CTPA in pregnant women. Were important diagnoses missed? What
dose reduction resulted? METHOD AND MATERIALS In this IRB-approved retrospective study, 84 pregnant patients underwent CTPA for pulmonary embolism during 2004-2012. New axial,
sagittal and coronal series were created with a reduced anatomic coverage extending from aortic arch to the base of the heart. These
were read individually by 2 experienced blinded readers on the PACS workstation. The scans were evaluated for PE, incidental and
pertinent findings. The readers had access to most recent chest radiograph. These results were compared with original report by the 3rd
reader. In case of missed abnormality, 3rd reader checked whether the finding was a known abnormality or whether it influenced the
clinical outcome. Additionally, we estimated dose length product (along z axis) for 40 patients as a quality control project. RESULTS Two out of 84 patients had PE and were successfully identified by both readers. 32 patients had normal exams. Rest of the patients had
57 pertinent and 20 incidental findings. 4 incidental findings including 3 benign thyroid nodules and one benign splenic calcification were
missed. One pertinent but a benign lung nodule was missed, but this was a known abnormality based on prior CT. None of these missed
findings affected further clinical outcome or management. Radiation dose was reduced by a mean of 69%. CONCLUSION No PE or any important diagnosis are missed using the reduced anatomic coverage CTPA for PE in pregnant women. The radiation dose is
reduced by approximately 69%. Hence we highly recommend this technique in pregnant women. CLINICAL RELEVANCE/APPLICATION The study helps solve any doubts as regards to using a reduced z-axis CTPA technique for PE in pregnant women. SSA05-04 • Feasibility Study of Low Dose Chest CT for Initial Evaluation of Blunt Chest Trauma Patients
Jae Yong Cho MD (Presenter) ; Joo Sung Sun MD ; Sung Jung Kim ; Kyu-Sung Kwack MD, PhD ; Sung Hoon Park MD ; Kyung
Joo Park MD ; Young Gi Min MD PURPOSE To evaluate the feasibility of low dose chest CT (LDCT) for initial evaluation of blunt chest trauma. METHOD AND MATERIALS A total of 71 patients who met criteria indicative of major trauma (76% male; age range, 16-85) were included. All patients underwent
LDCT without IV contrast and standard CT with IV contrast using parameters as followings: LDCT, 40mAs with ATCM and 100kVp or
120kVp (based on BMI); standard post-contrast CT, 180mAs with ATCM and 120kVp. Transverse, coronal, saggital images were
reconstructed with 3-mm slice thickness without gap. Reference standard images were reconstructed using standard CT data (1-mm slice
thickness without gap). Reference standard was established by 2 radiologist by consensus. Four readers independently evaluated chest
injury (fractures of bony thoracic cage, aortic injury, tracheobonchial injury, esophageal injury, hemothorax, pneumothorax, pulmonary
contusion). Four investigators recorded results with 4 confidence scale (0-3 point). Comparison of radiation dose was done. RESULTS Radiation doses (CTDIvol) of LDCT (average 2.67mGy) was significantly lower than those of standard CT (average 13.4mGy)(78% dose
reduction). ROC analysis and intraclass correlation coefficient ICC measurement demonstrated that LDCT was comparable to standard
dose CT for evaluation of chest injury. ROC comparison analysis revealed no significant difference of diagnostic performance between
LDCT and standard dose CT for the diagnosis of bony thoracic cage fracture, pulmonary contusion, hemothorax ,pneumothorax, chest wall
injury (p>0.05). ICC was measured for inter-observer consistency and revealed that there was good inter-observer consistency in each
examination of LDCT and standard dose CT for evaluation of chest injury (0.83~0.94). Aortic injury could not be appropriately compared
due to LDCT underwent without using contrast materials and this was limitation of this study. CONCLUSION Our conclusion is that there is a great potential benefit to use LDCT for initial evaluation of blunt chest trauma because LDCT could
maintain diagnostic image quality as standard dose MDCT and provide significant radiation dose reduction. Further study of LDCT with IV
contrast for evaluation of aortic injury is needed. CLINICAL RELEVANCE/APPLICATION This preliminary study suggest LDCT could be adequate initial imaging modality for blunt chest trauma patients with maintaining
diagnostic image quality and reducing radiation dose. SSA05-05 • Usefulness of Ultra Low-dose (sub mSv) Chest CT Using iDose4 Iterative Reconstruction for Initial Evaluation of
Sharp Fish-bone Esophageal Foreign Body
Page 19 of 183
Boram Yi MD (Presenter) ; Joo Sung Sun MD ; Young Gi Min MD ; Kyung Joo Park MD PURPOSE To evaluate the usefulness of ultra low dose chest CT (uLDCT) as initial imaging study for sharp fish-bone esophageal foreign body (EFB). METHOD AND MATERIALS A total of 38 subjects who visited emergency room with an obvious history and symptoms of sharp fish-bone EFB were included in this
study.uLDCT were acquired at 20mAs with ATCM and 100kVp or 120kVp on a 64 MDCT scanner (Based on BMI). All uLDCT data were
reconstructed twice, once with FBP and once with iDose4 IR, then 2 sets of CT data were randomly arranged and reviewed by 3 readers
who were blinded to the result. Readers independently reviewed 3-mm thickness transverse and coronal images. Readers also scored
subjective image quality (4 point scale). One reader measured objective image noise (SD of circular ROI, 10 pixels in diameter at the
following level: right common carotid artery of the thoracic inlet; pulmonary trunk; D-aorta of lug base). Positive findings were defined as
identification of high-density foreign body, secondary findings (soft tissue swelling, pneumomediastinum). ROC analysis was used to
evaluate diagnostic performance of uLDCT. Intraclass correlation coefficient (ICC) was measured for analysis of inter-observer
consistency. RESULTS Thirty-three fish bone EFBs were identified and removed by 31 esophagogastroscopy, and 2 operations. Among 5 cases of true negative,
false positive lesions were frequently recorded as the cervical EFB when reviewing CT data using FBP than CT data using iDose4 IR.
uLDCT provided radiation dose reduction by average 0.82 mGy of CTDIvol and 32.7 mGy*cm of DLP (0.46mSv). Significant noise
reduction (objective and subjective) of mediastinum was achieved using iDose4 IR technique (p CONCLUSION Very low dose CT using iDose4 provided satisfactory diagnostic image quality for identifying fish-bone EFB with reduced radiation dose,
therefore uLDCT would be adequate as first imaging modality for sharp fish-bone EFB. iDose4 IR would be useful to reduce image noise of
mediastinum mimicking EFB. CLINICAL RELEVANCE/APPLICATION Very low dose chest CT using iDose4 IR would be first imaging modality for initial evaluation of sharp fish bone esophageal foreign body
before flexible endoscopic removal. SSA05-06 • Increased Referral-rate for Investigation, and Increased Incidence of Symptomatic Radiologically-diagnosed
Pulmonary Embolus in a Large Teaching Hospital, over a 10 Year Period
Kenneth Muir (Presenter) ; Nicholas C Morley MA, FRCR ; Edwin J Van Beek MD, PhD * ; John Murchison MBCHB PURPOSE To measure the rate of referral for radiological investigation of suspected acute Pulmonary Embolism (PE) and the incidence of PE
detected in these scans, in a large teaching hospital. To observe changes in these measurements over the recent decade. METHOD AND MATERIALS Retrospective review of radiology records for Computed Tomography Pulmonary Angiograms (CTPA) and Perfusion Scans (Q-scans) for
suspected acute PE, between 1st April 2002 and 1st April 2012. Graphical and statistical analyses were performed with Microsoft Excel
and Graphpad Prism. Some of the data for the earlier years in this study was published previously (O'Neill et al., 2004). Our local
research ethics service approved this project. RESULTS 111% increase in total VTE investigations over 10 years, from 996 to 2111. Substantial increase in referral for CTPA, incrementaly from
706 to 2020 scans per year. We also saw a decline in Q-scans from 290 to 91 per year. Increase in total number of PEs diagnosed, with
annual incidence rising from 147 (15% positive-scan rate) to 426 (20% positive-scan rate), an increase of 190%. We observed an older
population of PE patients, with mean age at diagnosis of PE going up from 62.2 to 65.4 (p= 0.03) and a 6-fold increase in PEs diagnosed
in the 85-94 age group, from 9 to 57 per year. CONCLUSION There has been a major increase in the total number of investigations for suspected acute PE, accounted for by an increased use of CTPA
with a corresponding decrease in the use of Q scans. In spite of what is generally assumed, the positive diagnosis rate increased, which
may be a reflection of changed patient demographics combined with greater sensitivity of CTPA with newer CT scanners. CLINICAL RELEVANCE/APPLICATION The current rate of investigation for suspected acute PE is justified by a high rate of relevant diagnoses. Analysis of PE severity in these
cohorts is warranted and is ongoing. SSA05-07 • Cost and Risk Analysis of CT Pulmonary Angiography to Rule Out Pulmonary Embolism in Low and Very Low Risk
Emergency Department Patients
Scott A Atkins MD (Presenter) ; Steven Munson MD ; J. Paul Jacobson MD * ; Thomas J Kelly MD PURPOSE A recent study has shown that approximately one third of CT pulmonary angiograms (CTPAs) performed to rule out pulmonary embolism
(PE) in the emergency department (ED) are in low risk or very low risk patients based on Wells criteria and D-dimer, resulting in
potentially avoidable cost to our healthcare system and risk to patients. The purpose of this study is to evaluate the cost effectiveness of
CTPA in diagnosing PE in low risk patients and to quantify potentially avoidable cost and patient risk with the current medical practice
pattern. Other studies have been done showing that CTPA is a cost effective method to diagnose PE when used in conjunction with Wells
criteria and D-dimer. However, no studies have quantified the additional cost and patient risk when this standard of care is not followed
and potentially avoidable imaging is performed. METHOD AND MATERIALS A literature search was performed and data on the current use of CTPA in the diagnosis of PE was reviewed. A decision model was
constructed for evaluating low and very low risk patients for PE with and without the use of CTPA. The costs and patient utilities for each
outcome were plotted to determine the dominant strategy. Strategies are dominant if they have lower costs and better outcomes
compared to other strategies based on quality adjusted life years (QALYs). Sensitivity analyses were performed to test the stability of the
results over a wide range of clinically relevant values. RESULTS The strategy of ED observation, not performing CTPA, dominated the strategy of performing CTPA to rule out PE in low and very low risk
ED patients. ED observation dominated over a wide range of clinically relevant values, showing cost savings to the medical system and
better patient outcomes when compared to performing CTPA in this population. CONCLUSION Ruling out pulmonary embolism in ED patients should begin with an assessment of risk based on clinical factors (Wells criteria) and a
D-dimer to ensure that CTPA is not performed on patients who are low or very low risk. The potentially avoidable CTPAs performed on low
risk patients add significant cost to the medical system without improving patient care. In fact, potentially avoidable imaging poses
significant risk to these patients. CLINICAL RELEVANCE/APPLICATION Performing CTPA to rule out PE in low and very low risk ED patients increases medical costs and increases patient risk, worsening patient
outcomes. Page 20 of 183
SSA05-08 • Variation in Utilization and Positivity Rates of CTPA among Emergency Physicians at an Academic Tertiary
Emergency Department
Yingming Amy Chen MD (Presenter) ; Bruce G Gray MD ; Glen Bandiera MD ; David Mackinnon ; Djeven P Deva MBBCh PURPOSE This project examines the utilization and diagnostic yield patterns for CT pulmonary angiography (CTPA) ordered by individual Emergency
Physicians (EPs) at an academic tertiary care center. The study is part of the institution�s quality improvement initiative aimed at
establishing quantitative parameters for assessing individual EP�s image utilization. METHOD AND MATERIALS A cross-sectional retrospective study was conducted on 850 consecutive ED patients with suspected pulmonary embolism (PE) who
underwent CTPA. Radiology report data was extracted from our institution�s RIS PACS software (syngo Imaging, Siemens) based on a
targeted search of all CTPA reports from January 2010 to December 2012. Positivity rate for PE as well as nonthrombotic clinically
significant findings were calculated. Utilization rates and positivity rates for individual physicians were calculated and correlated with both
years of experience and certification. RESULTS Acute PE was diagnosed in 142 of the 850 patients evaluated by CTPA (16.7%). A further 25.2% of scans were negative for PE but had
other clinically significant findings: 11.2% infection, 2.7% pulmonary edema, 2.9% effusion, 3.1% tumour, and 4.9% other. EPs ordered
an average of 0.5 CTPA scans per 100 patients seen, with a significant variation across EPs in utilization (0.2 to 1 scans per 100
patients). Considerable variation also existed in the positivity rate for PE, ranging between 6.5% and 38.9%. There was no significant
correlation between EP years of experience and utilization rate (linear regression r = - 0.27; ANOVA p = 0.36 for 20 years) or positivity
rate (r = -0.32; ANOVA p = 0.39). Furthermore, utilization and positivity rates were not significantly different between EPs with
emergency medicine certification by the Royal College (FRCP) vs by the College of Family Physicians of Canada (CCFP-EM) (student t-test
p = 0.34 for utilization rate, p = 0.56 for positivity rate). CONCLUSION While average utilization and positivity rates of CTPA for ED patients with suspected PE at our institution are comparable to those in the
literature, considerable interphysician variability exists for both metrics. Utilization and positivity rates for CTPA did not correlate with
either the physicians� years of experience or specialty certification. CLINICAL RELEVANCE/APPLICATION Results of the study suggest an opportunity for a more standardized approach to the of use of CTPA among EPs. SSA05-09 • Comparison between CT Angiography of the Bronchial and Non-bronchial Systemic Arteries vs. Conventional
Angiography in Patients Undergoing Endovascular Treatment of Hemoptysis
Hosny M Hamza MD, FRCR (Presenter) ; Yasser Ragab MBBCh, MSc ; Magdy Abdelsalam MD PURPOSE To compare bronchial and nonbronchial systemic CT angiography at 320 multi-detector row computed tomography with conventional
angiography in patients undergoing endovascular treatment of hemoptysis. METHOD AND MATERIALS A retrospective study including 50 ptients (37men, 13women ) with hemoptysis of bronchial and nonbronchial systemic artery origins
underwent 320 multi-detector CT angiography of the thorax prior to embolization. Findings on CT angiograms, including CT scans,
maximum intensity projections, and three-dimensional volume-rendered images, were used to evaluate the depiction of bronchial and
nonbronchial systemic arteries. Retrospective analysis of the ostium and the course of bronchial and/or nonbronchial systemic arteries on
CT angiograms enabled evaluation of the accuracy of this technique in identification of the relevant vasculature. RESULTS Among the 50 patients initially treated with bronchial artery embolization, 56 bronchial arteries were identified at CT angiography. In
94% of cases, concordant findings were observed with both modalities. In five 6% cases, CT could not be used to identify the ostia of
bronchial arteries. In 5% cases, CT depicted bronchial arteries that could not be selectively catheterized. Three-dimensional images were
found to be superior to2 D CT angiogrphic in depicting the ectopic origin of the bronchial arteries, which enabled the interventional
radiologists to perform successful embolization after direct catherization of the ectopic vessel in every case. In 10 % of patients, the
nonbronchial systemic origin of bronchial bleeding was identified on CT angiograms. CONCLUSION CT angiography using 320 Multi-detector systems provides more accurate depiction of bronchial and nonbronchial systemic arteries than
does conventional angiography. CLINICAL RELEVANCE/APPLICATION The routine use of 320 CT scan in patients with hemoptysis can help identifying the origin of the bleeding vessels and can improve the
efficeincy of the the treatment by identifying unexpected vessels Gastrointestinal (CT Dose Reduction I) Sunday, 10:45 AM - 12:15 PM • E353A
QA
CT GI SSA06 • AMA PRA Category 1 Credit ™:1.5 • ARRT Category A+ Credit:1.5 Moderator
Joel G Fletcher , MD * Moderator
Anno Graser , MD * Back to Top SSA06-01 • Relevance of Abdominal CT Radiation Dose Reduction beyond Childhood: What Does New Data Show?
Sarabjeet Singh MD (Presenter) ; Monica Ghita PhD ; Atul Padole MD ; Ranish D Khawaja MBBS, MD ; Sarvenaz Pourjabbar
MD ; Mannudeep K Kalra MD * ; James A Brink MD PURPOSE Recent data from lifespan study from Japanese Atomic Explosion estimate increased Excess Lifetime Risks (ELR) of certain
radiation-induced solid cancers, when exposure occurs at middle age rather than in childhood. The purpose of our study was to assess
population based estimated ELR for solid cancers following abdominal CT in different age groups using size adjusted CT protocols in a
large tertiary health care center. METHOD AND MATERIALS Our IRB approved study included 2902 consecutive �routine� abdominal CT. Dose monitoring software (Exposure, Radimetrics) was used
to obtain patient demographics, scanning parameters as well as radiation dose information (Size Specific Dose Estimate (SSDE)
estimated effective doses (EED) and organ doses). Patients were stratified by age groups of 11-20, 21-30, so on, >70 years. Estimated
ELR from the time of exposure from chest CT was estimated based on recently reported literature on risk estimation from radiation
induced solid cancer risks published from 2007-2012. Page 21 of 183
induced solid cancer risks published from 2007-2012. RESULTS SSDE for routine abdominal CT examinations were highest for age group 61-70 years (11 mGy) and lowest for 10-20 years (9.4 mGy).
EED (ICRP 103) were 6.9-8.7 mSv and 11.4-9.1 mSv for these age groups (p CONCLUSION SSDE and estimated effective doses are suboptimal for cancer risk estimation and organ doses should be used for solid cancer radiation
induced risk estimation, regardless of patient�s age CLINICAL RELEVANCE/APPLICATION Contrary to the prior belief, dose concerns are not only important for the younger age groups (0-20) but also for older patients (30-60
years), especially for risk estimations of lung, breast cancers SSA06-02 • Multi-reader Detectability of Simulated Low-contrast, Low-attenuation (LCLA) Liver Lesions on MDCT: Effect of Dose
and Reconstruction Method
Ajit H Goenka MD (Presenter) ; Brian R Herts MD * ; Nancy A Obuchowski PhD ; Andrew Primak PhD * ; Frank Dong PhD * ; Wadih Karim RT ; Mark E Baker MD * PURPOSE To assess the effect of reduced radiation exposure and reconstruction method on detection of lesions that are low-contrast,
low-attenuation (LCLA) relative to the background liver METHOD AND MATERIALS Semi-anthropomorphic phantom containing custom inserts with 36 spherical liver lesions of 3 sizes and attenuations (10 and 15-mm at 6,
12 and 18HU, and 5-mm at 12, 18 and 24HU below 90HU simulated liver) was scanned at 120kVp, 0.6-mm collimation, 200 (CTDIvol
13.49), 150, 100 and 50mAs on a 128-slice MDCT scanner (Definition Flash, Siemens). Lesions were distributed non-uniformly to reduce
memory bias. Images were reconstructed at 3-mm thickness using filtered back projection (FBP) and sinogram-affirmed iterative
reconstruction (SAFIRE, S3). A randomized dataset containing 256-images was generated for each reader (12 images with one lesion, 12
with two lesions and 8 without lesions, for each dose and reconstruction method). Eighteen Radiologists blinded to phantom and study
design independently reported region-level lesion presence or absence on a 5-point diagnostic confidence scale. Statistical evaluation
included multi-reader, multi-case (MRMC) ROC analysis using nonparametric methods with the area under the ROC curve (AUC)
considered accuracy. RESULTS Pooled AUC decreased with each 25% reduction from 100% dose: 0.848, 0.842, 0.792 and 0.743 for FBP; and 0.862, 0.855, 0.785 and
0.735 for SAFIRE. At a given dose, improvement in AUC with SAFIRE was, however, not statistically significant. For both FBP and SAFIRE,
accuracy at 75% dose was statistically equivalent to 100% dose FBP (p =0.002 and CONCLUSION In this LCLA liver lesion model, a 25% dose reduction did not reduce detection of the lesions studied. However, detection was inferior with
each subsequent dose reduction regardless of reconstruction method. For lesions with attenuation differences larger than or equal to
12HU, lesion detection was not reduced even at 50% dose with FBP. CLINICAL RELEVANCE/APPLICATION Estimates of loss of accuracy at reduced doses and limits of iterative reconstruction should be known especially for low contrast, low
attenuation liver lesions to enable dose optimization in practice SSA06-03 • Effect of the Learning Curve on Radiologist’s Diagnostic Performance for Hypervascular Liver Lesion Detection and
Image Quality Perception Using an Adaptive Statistical Iterative Reconstruction Algorithm
Daniele Marin MD (Presenter) ; Achille Mileto MD ; Lisa M Ho MD ; Brian C Allen MD ; Rajan T Gupta MD * ; Ehsan Samei PhD
* ; Rendon C Nelson MD * PURPOSE To prospectively evaluate the effect of experience with an adaptive statistical iterative reconstruction (ASiR) algorithm on diagnostic
accuracy and confidence for the diagnosis of hypervascular liver tumors, as well as reader�s perception of image quality, using dual
energy CT (DECT). METHOD AND MATERIALS Patient consent was obtained for this IRB-approved, HIPAA-compliant, prospective study. The final study cohort comprised 40 patients
(29 M; mean age, 60±8.4 years; mean BMI, 28±5.6 kg/m2) with 65 hypervascular liver tumors who underwent DECT during the hepatic
arterial phase. The low energy (80 kVp) image set was reconstructed with standard filtered backprojection (FBP) and ASiR at 20%, 40%,
60%, and 80% levels of blending. Two readers (one attending and one fellow in abdominal imaging) inexperienced with the imaging
appearance of ASiR reconstructions randomly assessed all image sets for confidence in detecting and characterizing liver lesions, as well
as evaluation of image quality (1st session). The same cases were re-examined by the same readers after three years of readers�
experience with ASiR in their daily practice (2nd session). RESULTS For both reading session, there was no significant difference in diagnostic accuracy and sensitivity for lesion detection using different
reconstruction algorithms, among different readers. Diagnostic accuracy did not change significantly between the 1st and 2nd session for
both FBP (0.91 vs 0.90) and any levels of ASiR reconstruction (0.90 vs 0.92). However, while ASiR yielded a significant decrease in
specificity for lesion detection compared to FBP during the 1st session (0.81 vs. 0.62, P=.001), no significant difference in specificity was
observed between ASiR and FBP in the 2nd session. Readers� perception of image quality improved significantly for any levels of ASiR
reconstruction between the 1st and 2nd session (P
CONCLUSION Reader�s experience with ASiR does not significantly change diagnostic accuracy for hypervascular liver lesion detection, but may
decrease the number of false positive findings as well as improve reader�s perception of image quality. CLINICAL RELEVANCE/APPLICATION Reader's experience with ASiR improves subjective perception of image quality and may significantly decrease false-positive findings. SSA06-04 • Potential of Radiation Dose Savings in Abdominal and Chest CT Using Automated Tube Voltage Selection in
Combination with Automated Tube Current Modulation
Mathias Meyer (Presenter) ; Caroline Mayer ; Christian Fink MD ; Bernhard Schmidt PhD * ; Martin U Sedlmair MS * ; Paul
Apfaltrer MD ; Thomas G Flohr PhD * ; Stefan O Schoenberg MD, PhD * ; Thomas Henzler MD PURPOSE To evaluate the simultaneous use of automatic tube current modulation (ATCM) and automatic tube voltage selection (ATVS) for
abdominal and thorax contrast-enhanced CT examinations regarding radiation dose reduction and image quality. METHOD AND MATERIALS In total 617 consecutive patients were enrolled in this retrospective single center study who all either underwent a portal-venous
abdomen CT examination or a contrast-enhanced arterial phase chest CT examination and were divided into two groups. In group A, 317
patients were enrolled using ATCM with a fixed body-mass-index adjusted tube voltage of either 120 kV or 100 kV. In group B, consisting
of 300 patients, ATCM as well as ATVS was used. Image attenuation and noise was measured in different abdominal and thoracic regions
for each patient. To compare the CT density and image noise, signal-to-noise ratio, contrast-to-noise ratio and radiation parameters
Page 22 of 183
between both groups a 1-way analysis-of-variance was preformed. RESULTS The mean contrast-to-noise ratio and the signal-to-noise ratio of abdomen and chest CT scans was higher in group B if compared to group
A (p CONCLUSION The simultaneous use of ATVS and ATCM allows for significant radiation dose reduction in abdominal and thoracic contrast enhanced CT
examinations when compared to the use of ATCM alone while maintaining adequate image quality and diagnostic confidence without user
interaction. The ATVS tool reduced tube voltage effective in the majority of patients (49%) resulting in a dose reduction of 18%,
demonstrating the potential of this new dose modulation tool. CLINICAL RELEVANCE/APPLICATION Simultaneous use of ATCM and automatic tube voltage selection allows for significant radiation dose reduction in abdominal/thoracic CT
examinations of up to 18% when compared to ATCM alone. SSA06-05 • Model Based Iterative Reconstruction Algorithm for Abdominal CT at Variable Radiation Doses: Assessment of
Image Quality, Lesion Conspicuity and Radiation Dose in Anthromorphic Liver Phantoms
Jeong Hee Yoon MD (Presenter) ; Jeong-Min Lee MD * ; Mi Hye Yu MD ; Joon Koo Han MD ; Byung Ihn Choi MD, PhD * PURPOSE To assess the image quality, lesion conspicuity and radiation dose of model-based iterative reconstruction algorithm (IMR) compared with
filtered back projection (FBP) and hybrid iterative reconstruction algorithm (iDose) for the liver computed tomography (CT) at radiation
dose. METHOD AND MATERIALS Small and large anthromorphic phantoms with 4 simulated hypervascular tumors and 4 hypovascular tumors were scanned using a
256-channel CT scanner using 120 and 100kVp with 20, 40, 60, 80, 100, 130, 150, 180 and 200mAs. CT images of both phantoms at the
two kVp were classified by radiation dose: standard dose (200mAs); mild dose reduction (DR) (130-180mAs), moderate DR (60-100mAs),
severe DR groups (20-40mAs). All scans were reconstructed using FBP, iDose level 4 and IMR. Signal-to-noise ratio (SNR) and
contrast-to-noise ratio (CNR) were calculated in the organs and compared among the different reconstruction modes. In addition, two
radiologists assessed the image quality and lesion conspicuity of 8 focal liver lesions (FLLs). RESULTS SNR and CNR of IMR images were significantly higher than those of others, at the same radiation dose in both phantoms by reducing
noise effectively (p CONCLUSION IMR significantly reduces noises and improved SNR and CNR compared with FBP and iDose, and provide the similar image quality with
mild to moderate dose reduction in variable body habitus. However, IMR can improve FLL conspicuity only with mild to moderate dose
reduction. CLINICAL RELEVANCE/APPLICATION IMR can reduce noise and improve image quality and allows use of lower radiation dose for abdominal CT. Lesion conspicuity can be
improved with IMR at mild to moderate dose reduction, severe dose redu SSA06-06 • Assessment of Hybrid and Pure Iterative Reconstruction with Filtered Back Projection Technique for Low Dose
Abdominal CT
Atul Padole MD (Presenter) ; Sarabjeet Singh MD ; Michael A Blake MBBCh * ; Garry Choy MD, MS ; Sanjay Saini MD ; Mannudeep K Kalra MD * ; Synho Do PhD * ; Ranish D Khawaja MBBS, MD ; Sarvenaz Pourjabbar MD ; Diego A Lira MD PURPOSE To evaluate standard and low dose abdominal CT images reconstructed with filtered back projection (FBP), hybrid (hIRT) and pure (pIRT)
iterative reconstruction techniques. METHOD AND MATERIALS In an IRB approved, prospective clinical study, 20 patients (mean age 59 ± 14 years, mean weight 181±41 lbs, M:F 13:7, undergoing
routine abdomen CT on a 64 channel MDCT (Discovery CT750 HD) gave written informed consent for acquisition of an additional
sub-milli-Sievert (submSv) abdomen CT series. The latter series were acquired with reduced tube current but identical scan length
compared to the routine abdomen CT. Sinogram data of submSv series were reconstructed with FBP, hIRT (SS50, SS70, SS90 GE
Healthcare) and pIRT (GE Healthcare) and compared with FBP images of standard dose chest CT (n= 6*35=210 series). Three board
certified abdomen radiologists performed independent and blinded comparison for lesion detection, lesion margin, visibility of small
structures and diagnostic acceptability. Objective measurements, noise spectral density was obtained. RESULTS Mean CTDIvol were 9.3±3.5 and 1.3±0.2 mGy for standard and submSv CT, respectively. Lesion conspicuity was improved from poorly
visualized margins in FBP and hIRT images to well defined margins on submSv pIRT. All 3 radiologists found suboptimal noise in submSv
FBP and hIRT images, whereas noise was acceptable with pIRT. Except for minor pixilated appearance of pIRT images, no significant
artifacts were seen. Noise power spectrum analyses showed hIRT retains the noise spectral signature as FBP, in spite of lowering the
noise, whereas pIRT had lower noise as well as more regularized noise spectral pattern. CONCLUSION SubmSv abdominal CT examinations when reconstructed with pIRT improves the visualization of lesion margins and normal abdominal
structures and are associated with lower image noise as compared to hIRT and FBP, without any significant image artifacts affecting
diagnostic interpretation. CLINICAL RELEVANCE/APPLICATION Pure iterative reconstruction technique can allow use of submsv radiation dose for routine abdominal CT with retained diagnostic
confidence. SSA06-07 • Comparison of Dose from Single Energy and Dual Energy Multi-detector Computed Tomography Examinations in the
Same Patient Screened for Hepatocellular Carcinoma
Andrei S Purysko MD (Presenter) ; Mark E Baker MD * ; Andrew Primak PhD * ; Erick M Remer MD ; Nancy A Obuchowski
PhD ; Binu John MD, MPH ; Federico Aucejo ; Brian R Herts MD * PURPOSE To compare the dose and noise level between single energy (SE) and dual energy (DE) multi-detector computed tomography (MDCT)
examinations in patients undergoing screening for Hepatocellular Carcinoma (HCC). METHOD AND MATERIALS IRB-approved, HIPPA-compliant prospective study of 59 adult subjects (mean age 59.5yrs) undergoing HCC screening with 3-phase CT
(unenhanced, arterial and portal-venous phases), who were each examined on both SE (Sensation 64, Siemens Healthcare) and DE CT
scanners (Flash, Siemens Healthcare) on different dates. SE scans were performed using 120kVp and weight-based mAs (mAs=patient's
weight), and DE scans at 100kVP and 140kVp, with mAs adjusted to match the estimated CTDIvol of a weight-based mAs SE scan. The
CTDIvol and DLP of each phase were recorded. Maximum anteroposterior and transverse dimensions measured from CT radiographs were
Page 23 of 183
used to calculate the effective diameter (ED) and size-specific dose estimate (SSDE). Regions of interest (ROI) were drawn in liver,
retroperitoneal (RP) fat, IVC, and aorta and Hounsfield unit values with Standard Deviation (SD) recorded. Paired t-tests were used to
compare BMI, weight, and ED at the time of the two imaging studies. Distributions of outcome variables (dose and noise) were examined
using Q-Q plots and Shapiro tests. RESULTS BMI and weight of the subjects were highly correlated with the ED (r=0.75 and 0.87) and did not differ significantly between the two
scans. CTDIvol and SSDE were significantly lower for all the phases on DE scans compared to SE scans (p-values CONCLUSION Dose with the MDCT DE scanning protocol was significantly lower when compared to SE examinations, with either similar or lower noise
levels. CLINICAL RELEVANCE/APPLICATION DE scanning protocols can be an alternative to decrease dose in patients undergoing HCC screening who require repetitive imaging. SSA06-08 • Ultra Low-Dose CT for Patients with Clinically Suspected Acute Appendicitis: Optimal Strength of Sinogram Affirmed
Iterative Reconstruction for Image Quality and Diagnostic Performance
Seung Ho Kim MD (Presenter) ; Janghee Lee MD ; Kyeong Hwa Ryu MD ; Een Young Cho MD ; Jung Hee Yoon MD ; Yun-Jung
Lim ; Choong K Eun MD PURPOSE To evaluate the optimal strength of Sinogram Affirmed Iterative Reconstruction (SAFIRE) to obtain the best image quality on
ultralow-dose CT (ULDCT) and to compare its diagnostic performance with that of the half-dose CT (HDCT) for the diagnosis of acute
appendicitis. METHOD AND MATERIALS This prospective study was IRB approved, and informed consent was obtained from all patients. A total of 102 consecutive patients (47
men, 55 women; mean age, 41.2 years; range, 15-82 years) with right lower quadrant pain underwent low dose CT, which consisted of
enteric phase HDCT (120 kVp, 100 mAs, effective dose=3.6 mSv) and portal phase ULDCT (120 kVp, 30 mAs, 1.5 mSv). ULDCT images
were reconstructed separately with five levels strength levels (S1-S5). Two blinded radiologists recorded scores for the subjective image
quality of the ULDCT data set (S1-S5 and S0 [filtered back projection]) according to the European guidelines on quality criteria for CT, as
well as confidence scores for the diagnosis of acute appendicitis on each set and HDCT. Histopathological findings served as a reference
standard for diagnostic performance. For the quantitative analysis, CT image noise was measured for each set. Subjective image quality
data were analyzed by Wilcoxon rank test, measured noise data by repeated measures ANOVA, and diagnostic performance by pair-wise
comparison of ROC curves. RESULTS The study population consisted of 58 positives and 44 negatives. There was no significant difference in diagnostic performance between
HDCT and ULDCT with any strength for both readers (AUC for reader 1, S0-S5=0.965, HDCT=0.933, p>0.05; for reader 2, S0=0.963,
S1-S5=0.964, HDCT=0.966, p>0.05). The measured noise decreased as the strength increased from S0 to S5 (mean,
19.1>17.3>15.1>13.0>10.9>8.8, pS4>S5, p CONCLUSION Although measured noise declined as SAFIRE strength increased, S3 seems optimal for the best subjective image quality on ULDCT. The
diagnostic performance of ULDCT with any strength is comparable to that of HDCT for the diagnosis of acute appendicitis. CLINICAL RELEVANCE/APPLICATION For reducing radiation dose and maintaining diagnostic performance in patients with clinically suspected acute appendicitis, ULDCT with
S3 reconstruction can be recommended. SSA06-09 • Imaging of Acute Appendicitis: Role of Low-Dose CT
Gopesh Mehrotra MBBS, MD (Presenter) ; Anupama Tandon MD, MBBS ; Sanjay Gupta MD ; Agarwal A Durgadas MD ; Ajai K
Srivastava PURPOSE The clinical diagnosis of acute appendicitis is not always accurate and twin objectives of imaging are to avoid negative appendicectomies
and to diagnose alternate pathologies. There is controversy about optimal imaging techniques and accuracy of imaging modalities. This
study compared the diagnostic accuracy of ultrasonography (USG), low dose CT and standard dose CT in diagnosis of acute appendicitis. . METHOD AND MATERIALS Subjects were hundred patients of all age group and either sex with clinical suspicion of acute appendicitis. Informed consent and
clearance from institutional ethical committee was taken. USG was conducted by two reviewers and Low dose CT images obtained at
predefined protocols were presented to the two reviewers, who were blinded to clinical findings. Standard dose CT was done thereafter
only if required (in 36 cases). Patients who refused consent, had contrast allergy, fulminant peritonitis or pregnancy were excluded from
the study. A control group was 75 patients who had USG / CT done for non-GI complaints. The sensitivity, specificity, PPV, NPV of each
modality and finding was calculated in comparison to operative findings. RESULTS The overall sensitivity , specificity, PPV, NPV and accuracy of USG was 98.6%, 96.2%, 98.6%, 96.2% and 97.4 and low dose CT was
95.9%- 97.2%, 95.7%, 98.6% and 88%-91.7%respectively. Standard dose CT had highest sensitivity and specificity of 100%.
Overall detection rate of appendix was 88% on USG, 100% on standard dose CT and 85.6% to 87.6% on low dose CT. On USG
statistically significant association was found between acute appendicitis and thickened wall of appendix (>2mm), fluid in lumen and
peri-appendicial fluid and on low dose CT between acute appendicitis and hyperdense wall, periappendicial fluid and stranding.
Mean radiation dose was 0.664mSv on low dose CT (eff mAs 20) and 4.286mSv on standard dose (eff mAs 120).
CONCLUSION Overall diagnostic performance of USG and low dose CT was good and was almost similar. There were no false positives or negatives on
imaging, using USG and low dose CT together and a diagnosis was possible in most cases. Alternative diagnoses were seen in 17% cases
and could be detected in all cases. CLINICAL RELEVANCE/APPLICATION Low dose CT in association with sonography has the potential to be used as a less radiating alternative for standard dose CT for
diagnosing acute appendicitis or alternative diagnosis. Gastrointestinal (Rectal Carcinoma Imaging) Sunday, 10:45 AM - 12:15 PM • E450A
OI
MR GI SSA07 • AMA PRA Category 1 Credit ™:1.5 • ARRT Category A+ Credit:1.5 Moderator
Michael E Zalis , MD * Moderator
Marc J Gollub , MD Page 24 of 183
Back to Top Marc J Gollub , MD Moderator
Byung Ihn Choi , MD, PhD * SSA07-01 • Texture Analysis of MR Dixon Images in Primary Colorectal Cancer: Initial Experience Using PET-MRI
Balaji Ganeshan PhD (Presenter) * ; Asim Afaq FRCR ; Shonit Punwani MBBS ; Alec Engledow ; Daren Francis ; Nicholas
Rhys-Jones ; Tan Arulampalam ; Sanjay Dindyal ; Omer Jalil ; Anna Barnes ; Celia O'Meara ; Manuel Rodriguez-Justo ; Peter J Ell MD * ; Kenneth Miles * ; Ashley M Groves MBBS * PURPOSE To describe the technique and initial results obtained from texture analysis of MR Dixon images derived from PET-MRI in primary
colorectal cancer. METHOD AND MATERIALS 10 consecutive prospectively recruited primary colorectal cancer patients (6 male and 4 female; Mean age 61.3±10.02) underwent
PET-MRI including acquisition of Dixon images for attenuation correction, measurement of tumor fluorodeoxyglucose uptake (SUVmean)
and MRI apparent diffusion coefficient (ADCmean). A parametric image of fractional water content was produced from the Dixon images
from the ratio of the water-weighted image and the summed water- and fat-weighted images. Fractional water images underwent texture
analysis using a filtration-histogram method. Filtration highlighted image features ranging between approximately 2mm and 7mm
diameter. Histograms of filtered images quantified as standard-deviation (SD) and proportion of positive pixels (PPP) were correlated
against SUVmean and ADCmean using Spearman Rank Correlation. RESULTS The mean tumor fractional water content was 0.88 (range: 0.74 � 0.95). Fractional water content did not correlate significantly with
ADCmean (rs = 0.358, p=0.310) and SUVmean (rs = -0.030, p=0.934). Fractional water texture expressed as SD correlated negatively
with ADCmean (rs = -0.75, p=0.013) with PPP values correlated positively with SUVmean ( rs = 0.75, p=0.013). CONCLUSION Texture analysis of Dixon images can potentially assess tumor water distribution. Tumor ADCmean and SUVmean measurements may be
related to tumor water distribution in colorectal cancer. CLINICAL RELEVANCE/APPLICATION Texture analysis of Dixon images in colorectal cancer can potentially provide information about tumor biology with possible applications in
personalized medicine. SSA07-02 • CT Manifestations of the Mesorectal Fascia Invasion of Rectal Carcinoma
Chen Nan MD (Presenter) ; Kuncheng Li MD PURPOSE The total mesorectal excision (TME), which the surgical removal of rectal tumor and the surrounding mesorectum along the mesorectal
fascia (that is circumferential resection margin, CRM), has become the standard surgical method of rectal cancer which originated from
the section below the pelvic peritoneum reflection. Therefore, to preoperatively comprehensive evaluate the state of mesorectal fascia is
very important an impact on the decision of potential for TME surgical removal as well as whether neoadjuvant therapy should be
administered. So, our Purpose is to evaluate the CT manifestations of the mesorectal fascia invasion of rectal carcinoma. METHOD AND MATERIALS Seventy-eight patients with rectal carcinoma which originated from the section below the pelvic peritoneum reflection underwent
preoperative CT examinations and the operations were performed with TME method in 72 resectable tumor. Compared the CT
characteristics of mesorectal fascia invasion of rectal carcinoma with the pathologic findings. RESULTS In 78 cases, 51 cases rectal carcinoma had penetrated through the rectal wall present patching-like, lining or mass shadows distributed
within the perirectal fat tissue on CT. Among them, none of rectal fascia was thicken on CT in 27 cases. In these cases, no tumor cells
infiltrating was found in the CRM proved by pathology. The thickenings of the rectal fascia present even or irregularly thickened was
found in 24 cases on CT. In these cases, the invasion outside of rectal fascia into the pararectal space on CT and the CRM involvement
proved by pathology was 11 cases and 13 cases, respectively. The e values was 0.818 and the p CONCLUSION CT is valuable in identifying tumor invasion mesorectal fascia. The state of mesorectal fascia on CT is excellent agreement with the
pathologic findings of CRM. CLINICAL RELEVANCE/APPLICATION it�s very import for preoperative determination of resectability, surgical approach and prognosis of rectal carcinoma. SSA07-03 • The Correlation of Radiologic Serosal Involvement in Rectal Cancer to Pathologic Assessment, and Comparison of
Impact on Survival, Local Recurrence and Metachronous Peritoneal Carcinomatosis
Michael R Torkzad MD, PhD (Presenter) * ; Faoz Dranichnikov ; Hakan Ahlstrom ; Peter Nygren ; Lars Pahlman ; Haile
Mahteme MD, PhD PURPOSE To investigate the correlation between radiologic and pathologic assessment of serosa involvement in patient with rectal cancer, and also
compare the impact of serosa involvement on survival, local recurrence and metachronous peritoneal carcinomatosis (MPC). METHOD AND MATERIALS 100 consecutive patients diagnosed with T3 and T4 primarily rectal cancer between 2007 and 2008 made the basis of this study. Detailed
radiologic analysis of magnetic resonance imaging (MRI) of rectum at the time of diagnosis of rectal cancer was performed by an
experienced radiologist blinded to the clinical data. T4s was defined as tumor growing locally into the serosal layer; rT4s was when the
radiologist made such an assessment and pT4s when the pathologist made such assessment. The clinical data at the time of diagnosis
and surgery, and 4-5 years postoperative follow-up regarding survival and adverse outcomes (cancer-related mortality and recurrence)
and development of MPC were recorded. RESULTS 94 patients had complete clinical data of which 63 had MRI prior to treatment. 11 patients showed radiologic signs of local peritoneal
involvement (rT4s), while 6 patients showed this at pathology (pT4s). Only two of these were assessed as T4s by both the radiologist and
the pathologist. Cancer-related mortality and local recurrence rate were higher among rT4s patients than pT4s (55% vs. 33% and 58%
vs. 17%, respectively with odds ratio of 1.67 and 3.49). The only two cases of MPC were seen among rT4s patients. Step-wise
multivariate regression showed higher impact by rT4s than pT4s classification on survival, recurrence rate and MPC with adjusted
correlation coefficients (R2) of 0.04, 0.15 and 0.14. rT4s staging was the only factor with adjusted R2 > 0.03 for development of MPC. CONCLUSION There seems to be a large discrepancy between rT4s and pT4s though the latter was usually after neoadjuvant therapy. rT4s showed
higher impact on development of MPC, local recurrence and even cancer-related survival. CLINICAL RELEVANCE/APPLICATION Involvement of serosal layer in rectal cancer denotes a higher risk for metachronus development of peritoneal carcinomatosis, local
Page 25 of 183
recurrence and cancer-related mortality than pathologic assessment. SSA07-04 • Diffusion Weighted Imaging for Evaluating Lymph Node Eradication after Neoadjuvant Chemoradiation Therapy in
Locally Advanced Rectal Cancer
Kyeong Hwa Ryu MD (Presenter) ; Seung Ho Kim MD ; Jung Hee Yoon MD ; Yedaun Lee MD ; Yun-Jung Lim ; Choong K Eun
MD PURPOSE To evaluate the added value of the diffusion-weighted imaging (DWI) for evaluating lymph node (LN) eradication after neoadjuvant
chemoradiation therapy (CRT) in patients with locally advanced rectal cancer (LARC). METHOD AND MATERIALS Institutional review board approved this retrospective study and waived informed consent. Ninety-five consecutive patients (64 men, 31
women; mean age: 59 years, range: 32-82 years) with LARC (=T3 or LN metastasis) who underwent CRT and subsequent surgery, were
enrolled in this study. All patients underwent pre-and post-CRT 1.5-T rectal MRI with DWI (b=0, 1000). To evaluate the added value of
the DWI for evaluating LN eradication after CRT, two blinded radiologists independently read the pre-and post-CRT T2-weighted images
(T2WI) first and then the combined image set of the T2WIs and pre-and post-CRT DWI with a four-week interval and recorded their
confidence score for LN eradication with a 5-point scale on a per-patient basis. The diagnostic performances were compared between the
two reading sessions for each reader by using pair-wise comparison of receiver operating characteristic curves. Histopathology reports
served as the reference standard for LN eradication. RESULTS Study population consisted of LN-eradicated group (n=65) and non-eradicated group (n=30). The diagnostic performances did not
significantly differ between the two reading sessions for both readers (AUC, for reader 1, 0.770, 0.774, p=0.8155; for reader 2, 0.794,
0.798, p=0.8588). The sensitivity, specificity and accuracy for LN eradication were stationary after adding DWI for both readers (for
reader 1, from 88%, 63% and 80% to 88%, 73% and 83%, respectively; for reader 2, from 77%, 77% and 77% to 77%, 80% and
78%, respectively). CONCLUSION Adding DWI to T2WI provides no additional diagnostic benefit for evaluating LN eradication after CRT in patients with LARC. CLINICAL RELEVANCE/APPLICATION Adding DWI to T2WI provides no additional diagnostic benefit for evaluating LN eradication after CRT in patients with LARC. SSA07-05 • Magnetic Resonance Imaging of Tumor Initiation and Progression, and Response to Vitamin D in a Mouse Model of
Colitis and Colitis-associated Colon Cancer
Devkumar Mustafi PhD (Presenter) ; Urszula Dougherty MS ; Erica Markiewicz BA ; Xiaobing Fan PhD ; Marc Bissonnette MD
; Gregory S Karczmar PhD * PURPOSE Colon cancer is a leading cause of cancer-deaths in the US. Ulcerative colitis is causally linked to colitis-associated neoplastic progression
but is difficult to detect and monitor non-invasively. Goals of this study were to determine MRI characteristics of early colitis-associated
colon cancer and to assess vitamin D chemopreventive efficacy. METHOD AND MATERIALS This study included CF1 female control mice (n=12), and mice treated with azoxymethane i.p. and dextran sulfate sodium in the drinking
water (n=25) to induce colitis and colon cancer. Mice were fed a Western diet or Western diet supplemented with vitamin D (500 �g/kg
chow). Western diets are relatively deficient in vitamin D and calcium. Mice were studied serially using anatomic and dynamic contrast
enhanced MRI (DCEMRI) with a Gd-based contrast agent.In vivo MR and ex vivo histological images were co-registered using an agar
based color-coded phantom in a flexible tube (2 mm o. d.) that was inserted via the rectum to the cecum. The phantom provided visual
and MRI-detectable reference markers to co-registerin vivo and ex vivo images. RESULTS We demonstrated that: 1) a visible reference marker could be used to successfully co-register MRI abnormalities with histological
features identified in HandE stained sections; 2) T2 values distinguished normal colon from colitis, and from focal neoplastic lesions
(ptrans values assessed by DCEMRI (a measure of perfusion/capillary permeability) reliably distinguished normal colon from tumor
(0.12±0.01 min-1 vs. 0.61±0.05 min-1 , respectively, p3-fold larger adjacent to early colonic tumors compared to vessels in control mice,
suggesting that MRI might be used to detect dilated blood vessels as biomarkers of early colorectal cancer; 5) Vitamin D reduced the
number of colonic tumors and degree of inflammation detected by MRI (p CONCLUSION A novel technique was successfully developed to co-register MR and histological images. Several reliable image-based markers for colitis
and colon cancer were identified. These MRI methods could monitor the chemopreventive efficacy of vitamin D in this model in real time
and without sacrifice. CLINICAL RELEVANCE/APPLICATION Non-invasive MRI/DCEMRI studies of colitis and colon cancer in mice will improve understanding of these diseases, produce new MRI
markers to improve diagnosis, and guide development of new therapies. SSA07-06 • Neoadjuvant Radiochemotherapy Response Evaluation with Magnetic Resonance and FDG-PET/CT in Rectal Cancer
Patients: Predictive Value of Combined Quantitative Parameters of ADC and SUV Compared with TRG at Histology
Davide Ippolito MD (Presenter) ; Pietro A Bonaffini MD ; Davide Fior MD ; Cristina Capraro MD ; Chiara Trattenero MD ; Sandro Sironi MD PURPOSE To determine the clinical value of functional imaging by analyzing quantitative parameters of ADC and SUV max values before and after
chemo-radiation therapy in prediction of tumor response of patients with rectal cancer, correlated with the histologic examination
expressed as tumor regression grade. METHOD AND MATERIALS A total of 45 patients with biopsy proven diagnosis of rectal carcinoma were enrolled in our study.All patients underwent a whole body 18
FDG PET/CT scan and a pelvic MR examination before(PET 1,MR 1) and after the neoadjuvant chemoradiation therapy(PET 2,MR
2).Subsequently all patients underwent total mesorectal excision and the histological results were compared with imaging findings.MR
scanning,performed on 1,5 T magnet(Philips,Achieva),comprised T2-weighted multiplanar imaging and in addition DW images with
b-value of 0 and 1000 mm²/sec. On PET/CT the SUVmax of the rectal lesion were calculated in PET1 and PET2. The percentage decrease
of SUVmax(?SUV) and ADC(?ADC) values from baseline to presurgical scan were assessed and correlated with pathologic response
classified as tumor regression grade (Mandard�s criteria;TRG 1= complete regression,TRG5= no regression). RESULTS At histological examination,according to Mandard�s criteria, 29 tumors(68%) showed complete or subtotal regression(TRG1-2) and were
classified as responders;16 tumors(32%) were classified as non-responders(TRG3-5).Considering all patients the mean values of SUVmax
in PET 1 was higher than mean value of SUVmax in PET 2 (p -3mm 2/s) with high sensitivity and specificity.Combining in a single analysis
median quantitative value, the PPV in predicting the different group category response, related to TRG system,presented an AUC of 96%,
higher than DWI (88.2%) or SUVmax (93.3%). Page 26 of 183
CONCLUSION Combination of PET-CT and MR imaging, evaluating changes in glucose metabolism and ADC, allows the identification of spatially distinct
regional responses to therapy within tumor tissues, with higher sensitivity than either method alone. CLINICAL RELEVANCE/APPLICATION In era of PET/MRI scanner, the combination of DWI and PET/CT represents the most feasible method to evaluate LARC patients,with
accuracy values higher than those reported for other imaging technique. SSA07-07 • Most Accurate Selection of Complete Responders After Chemoradiation for Rectal Cancer with a Combination of
T2-weighted MRI, Diffusion-weighted MRI and Endoscopy
Monique Maas MD (Presenter) ; Doenja M Lambregts MD, PhD ; Luc Heijnen ; Milou Martens ; Jeroen Leijtens ; Meindert
Sosef ; Karel Hulsewe ; Geerard L Beets MD, PhD ; Regina G Beets-Tan MD, PhD PURPOSE Chemoradiation (CRT) for rectal cancer leads to complete tumour response (CR) in 15-25% of the cases. Accurate identification of a CR is
necessary to allow for less invasive treatments (e.g. local excision or waitandsee). Standard imaging cannot accurately identify a CR due
to incorrect overestimation of fibrosis as residual tumour. Aim was to evaluate what is the best strategy to identify patients with a CR by
use of T2W MRI, DWI and endoscopy. METHOD AND MATERIALS 49 patients underwent CRT and restaging consisting of T2W-MRI, DWI and endoscopy 8 weeks after completion of CRT. One reader
scored the T2W images followed by immediate evaluation of the DWI images with the T2W images at his disposal. A second reader
scored the endoscopy images. Readers were blinded for histology and each others� results. Scoring was performed with a confidence
level score (0=definitely residual tumour, 4=definitely CR). RESULTS Of the 49 patients, 18 had residual tumour and 31 had a CR. The AUCs for T2W-MRI, T2+DWI and endoscopy were 0.71, 0.78 and 0.88,
respectively. Corresponding sensitivities and specificities were 39%and87% for T2W, 39%and93% for T2+DWI and 67%and97% for
endoscopy. When a combination of MRI (T2W and DWI) with endoscopy was used the highest accuracy was reached: 0.91. CONCLUSION The combination of endoscopy, T2W-MRI and DWI leads to a very high accuracy for the identification of patients with a CR after CRT for
rectal cancer. Endoscopy corrects for overestimation of fibrosis as residual tumour with MRI. MRI provides a low risk for missing residual
tumour and thus guarantees a safe selection process. It is therefore highly recommendable to use this combination of endoscopy and
T2W-MRI with DWI to select patients with a CR after CRT, particularly now less invasive treatment is increasingly being considered as an
alternative for standard TME. CLINICAL RELEVANCE/APPLICATION Use of endoscopy with T2WMRI+DWI for the selection of a CR after CRT for rectal cancer leads to a high accuracy and is recommended
for restaging when considering less invasive treatment instead of TME. SSA07-08 • Diffusion-weighted MR Imaging for the Follow-up of Patients after Primary Surgical and Non-surgical Treatment for
Rectal Cancer
Doenja M Lambregts MD, PhD (Presenter) ; Max Lahaye MD, PhD ; Luc Heijnen ; Monique Maas MD ; Milou Martens ; Regina
G Beets-Tan MD, PhD ; Geerard L Beets MD, PhD PURPOSE Detection of local recurrences after primary treatment of rectal cancer is crucial in order to allow for timely surgical intervention. Standard
imaging is known to experience difficulties in differentiating between post-treatment effects (inflammation/fibrosis) and recurrent tumor.
Diffusion-weighted MRI (DWI) has in various studies shown to be a powerful technique for the detection of tumors. Hence, DWI may also
be a promising tool for follow-up (FU) after treatment. Aim of this study was to evaluate the diagnostic value of DWI for the FU of patients
after primary surgical or non-surgical treatment for rectal cancer. METHOD AND MATERIALS The study group consisted of 117 patients who had previously undergone rectal cancer treatment, consisting of either standard surgical
resection +/- neoadjuvant (chemo-)radiotherapy (n=36), a local transanal excision (n=40, of which 15 after chemoradiotherapy), or a
non-operative �wait-and-see�-policy (n=41). During clinical FU all patients underwent one or more FU-MRIs (1.5T) including DWI
(highest b-value b1000), as part of routine FU or because of a suspected local recurrence (e.g. clinical complaints or rising CEA levels)
after surgery. Two readers in consensus evaluated each MRI and scored the b1000 DWI-images as �no high signal�, �high signal
suspected of recurrence� or �not adequately assessable due to artefacts�. RESULTS Patients underwent a mean number of 3 FU-scans (range 1-11) with a mean FU-time of 44 months (4-144). 27/117 patients developed a
local recurrence, of which 23 (85%) were accurately detected on DWI. The other 90 patients (without recurrence) together underwent a
total of 261 FU scans, of which 194 (74%) consistently remained true negative on DWI. 57 DWI-scans (19%) could not adequately be
assessed due to artefacts. 14 DWI scans were false positive (mainly at the first FU-scan after surgery), of which 50%, however, again
normalised during further FU. CONCLUSION 1. DWI can be a useful tool for the FU of patients after primary rectal cancer treatment. 2. False positive DWI findings may occur shortly after surgery, but the DWI signal generally normalises during further follow-up. This
should be taken into acount when using DWI for the clinical FU of rectal cancer patients.
CLINICAL RELEVANCE/APPLICATION Diffusion-weighted MRI can be a useful tool for the follow-up of rectal cancer patients after primary surgical or non-surgical treatment and
can help detect locally recurrent disease. SSA07-09 • MRI with DWI Compared with FDG-PET/CT in the Evaluation of Suspected Local Recurrence in Rectal Cancer
Matteo Cappucci MD (Presenter) ; Marco Di Girolamo MD ; Vincenzo David MD ; Daniela Prosperi ; Stefania Durante ; Elsa
Iannicelli MD PURPOSE In case of suspicion of locally recurrent rectal cancer, the use of MRI with diffusion-weighted MRI or [18F]-fluorodeoxyglucose (FDG)
PET/CT still remains debated. Our purpose was to compare the two imaging modalities in the discrimination between local recurrence and
post-treatment scar tissue. METHOD AND MATERIALS Since september 2010, all patients treated with neo-adiuvant chemio-radiation therapy and surgical resection for rectal cancer were
referred, in case of high suspicion of local recurrence during follow-up, for MRI and PET/CT.25 patients were enrolled (17M, 8F; mean
age: 64) and the mean time of the diagnostic evaluation after surgical resection was 14 months. MRI was performed with 1,5T
superconductice magnet with TSE T2-w. scan on sagittal, axial and coronal planes, DWI axial scans (b values:50,400,800) and
post-contrast fat saturated Flash 2D T1-w. axial scans. All exams were reported by two radiologists in consensus. Total-body PET/CT
Page 27 of 183
images were aquired 60 minutes after i.v. injection of 185 MBq FDG and reported by two physicians who were unaware of MRI findings. In
case of concordantly negative findings, the patients followed a routinary follow-up. Patients with concordantly positive findings or
discordance were subjected to a CT-guided biopsy or surgical excision for histological evaluation. RESULTS MRI+DWI and PET/CT were concordantly negative in 15pts and concordantly suggestive of recurrence in 7pts. The patients with
concordantly findings of fibrosis remained disease-free after 10 months follow-up. In 6pts the concordantly imaging suggestion of
recurrence was confirmed by biopsy while in one patient hystology disconfirmed the suspected diagnosis. A discordance with negative
MRI+DWI and positive PET-CT was found in 3 cases: in 2pts the histological speciment was negative (2 PET/CT false positive) while in 1
patient a recurrence was found at biopsy (MRI+DWI false negative). The sensitivity, specificity and diagnostic accuracy of MRI+DWI was
respectively 86%, 94% and 92% while for PET/CT was 100%, 83% and 88% CONCLUSION MRI+DWI shows higher specificity than PET/CT, especially in case of active inflamatory tissue while PET/CT has a higher sensitivity than
MRI+DWI and can detect distant metastasis. MRI is also essential in the local recurrence surgical planning. CLINICAL RELEVANCE/APPLICATION MRI with DWI shows higher specificity than PET/TC in the evaluation of suspected local recurrence rectal cancer and it is recommended. Gastrointestinal (Hepatic Fibrosis Imaging) Sunday, 10:45 AM - 12:15 PM • E450B
OI
MR GI SSA08 • AMA PRA Category 1 Credit ™:1.5 • ARRT Category A+ Credit:1.5 Moderator
Nirvikar Dahiya , MD Moderator
Hero K Hussain , MD * Moderator
Wui K Chong , MD * Back to Top SSA08-01 • The Effect of Echo Times on the Accuracy of Susceptibility Weighted Magnetic Resonance Imaging in Staging Liver
Fibrosis
Csilla Balassy MD (Presenter) ; Diana S Feier MD ; Friedrich Wrba ; Stephan Witoszynskyj ; Gert Reiter * ; Ahmed
Ba-Ssalamah MD PURPOSE To assess the effect of echo-sampling on the accuracy of magnetic resonance (MR) susceptibility-weighted imaging (SWI) to detect and
stage liver fibrosis in patients with chronic liver diseases (CLD), using histology as reference standard. METHOD AND MATERIALS This prospective study was approved by the local ethics committee. All subjects gave written informed consent. Sixty-eight consecutive
patients (mean age 55.86 years; 60% males) with CLD and histologically proven liver fibrosis were included. Liver fibrosis was evaluated
according to the Metavir scoring system. SWI MRI sequences were performed on a 3 Tesla unit and data were collected at two different
echo times (TE), 2.5 ms and 10ms. Signal intensity (SI) of the liver and spinal muscle was defined using region-of-interest
measurements and liver-to-muscle signal intensity ratios (2.5TE LMR and 10TE LMR) were calculated. The diagnostic performance of both
LMR in staging liver fibrosis was assessed using sensitivity (Se%), specificity (Sp%) and area under receiver operating characteristics
(AUROC) analysis. RESULTS Histology resulted F0 (n=13, 19.4%), F1 (n=6, 9%), F2 (n=8, 11.9%), F3 (n=12, 17.9%), F4 (n=28, 41.8%). Both 2.5TE LMR and 10TE
LMR correlated strongly with liver fibrosis (r=-0.74, p CONCLUSION SWI is a promising non-invasive tool to detect and stage liver fibrosis in CLD patients, having increased accuracy with higher TE values. CLINICAL RELEVANCE/APPLICATION Implementation of imaging parameters as assessed in our study will enable improved and accurate assessment of liver fibrosis in patients
with CLD using SWI. SSA08-02 • Intravoxel Incoherent Motion Magnetic Resonance Imaging of the Liver: Diagnostic Accuracy in Classifying the
Severity of Liver Fibrosis
Sae Rom Chung MD (Presenter) ; Seung Soo Lee MD ; Namkug Kim PhD ; Eunki Kim ; Seong Ho Park MD * ; So Yeon Kim
MD ; Jae Ho Byun MD ; Moon-Gyu Lee MD PURPOSE To investigate the relationship of liver ADC and intravoxel incoherent motion (IVIM) parameters with liver fibrosis and to evaluate the
diagnostic performance of these parameters in classifying the severity of liver fibrosis. METHOD AND MATERIALS RESULTS CONCLUSION CLINICAL RELEVANCE/APPLICATION IVIM magnetic resonance imaging of the liver can be used as a diagnostic test to assess the severity of liver fibrosis. SSA08-03 • Correlation of Magnetic Resonance Elastography (MRE) with Hepatic Fractional Extracellular Space (fECS) Preliminary Findings
Sudhakar K Venkatesh MD, FRCR (Presenter) ; Bogdan Dzyubak BS ; Benjamin M Yeh MD * ; Joel G Fletcher MD * ; Jeff L
Fidler MD * ; Naoki Takahashi MD * ; David M Hough MD ; Jayant A Talwalkar MD * ; Richard L Ehman MD * ; Adam J
Weisbrod MD PURPOSE The purpose of the study was to evaluate the correlation of two promising MRI techniques of measuring diffuse liver disease: magnetic
resonance elastography (MRE) and hepatic fractional extracellular space (fECS) measured with gadolinium (Gd-DTPA) enhanced MRI. METHOD AND MATERIALS Thirty-two consecutive clinical patients underwent routine liver MRI examinations. The MRI protocol included MRE as well as Gd-DTPA
enhanced equilibrium phase (10-15 minute delay) sequences. MRE was performed with a standard GRE-based sequence to calculate liver
stiffness. Hepatic fECS (%) was calculated from equilibrium phase liver and aortic enhancement normalized to the pre-enhancement
Page 28 of 183
stiffness. Hepatic fECS (%) was calculated from equilibrium phase liver and aortic enhancement normalized to the pre-enhancement
signal and hematocrit. Pearson�s correlation coefficient between MRE and fECS was calculated. Comparison of mean fECS values of
normal and elevated liver stiffness group was also performed using the current clinical cut-off value of 2.93kPa for detection of liver
fibrosis. RESULTS The liver stiffness and fECS of the study population ranged from 1.68kPa to 8.6kPa and 17.5% to 40.1% respectively. There was good
correlation between MRE measures of liver stiffness and equilibrium phase measures of fECS (Pearson�s correlation coefficient r=0.86,
95% CI, 0.73-0.93, p CONCLUSION Liver stiffness with MRE correlates strongly with fECS. Future study of these methods is warranted improve the multiparametric
evaluation of diffuse liver disease. CLINICAL RELEVANCE/APPLICATION MRE correlates strongly with hepatic fECS suggesting a complementary role in the evaluation of diffuse liver disease. SSA08-04 • Liver Fibrosis Staging: Magnetic Resonance Elastography Is Better than Liver Biopsy
Hiroyuki Morisaka MD (Presenter) ; Utaroh Motosugi MD ; Shintaro Ichikawa MD ; Katsuhiro Sano MD ; Satoshi Ikenaga ; Tadao Nakazawa MD, PhD ; Tetsuo Kondo MD, PhD ; Tomoaki Ichikawa MD, PhD * ; Ryouhei Katoh MD, PhD PURPOSE Liver biopsy for the staging of liver fibrosis has some clinical concerns; sampling errors, variability and reproducibility. In this study, we
aimed to compare magnetic resonance elastography (MRE) of the liver with liver biopsy specimens for liver fibrosis staging by using
surgically resected samples as a reference. METHOD AND MATERIALS In this retrospective study, we included 55 patients with chronic liver disease who underwent preoperative MRE on a 1.5 or 3-Tesla
clinical MRI scanner and subsequent surgical liver resection. Liver biopsy specimens were obtained from 55 surgically resected liver
tissues by using an 18-gauge biopsy needle; the sample size was more than 15 mm, and the specimens were stained with Masson
trichrome. Whole sections were used as a reference for liver fibrosis. Liver stiffness (kPa) was measured using MRE, and the results were
divided into 5 stages corresponding to the METAVIR scoring system�F 0�4. Liver fibrosis was graded on biopsy specimens and whole
sections by using the METAVIR system. The concordance rate (kappa value) with reference fibrosis grades in the two methods was
calculated. The proportion of correct diagnosis was compared between the two methods. RESULTS The kappa coefficient value between MRE staging and the reference fibrosis staging was 0.49 (moderate agreement) and that between
the biopsy staging and the reference fibrosis staging was 0.18 (slight agreement). The proportion of correct diagnosis of MRE was
significantly higher than that of biopsy specimens (33/55 vs. 18/55, respectively; p = 0.004). CONCLUSION A substantial sampling error of biopsy specimens was observed. MRE is an accurate and promising method of noninvasive liver fibrosis
staging as compared with biopsy specimens. CLINICAL RELEVANCE/APPLICATION Liver MR elastography is more accuarate than liver biopsy specimens in liver fibrosis staging and can be serve as biopsy in clinical
practice. SSA08-05 • Automated Technique for Hepatic MR Elastography Analysis: Comparison to Skilled Human Interpretation
Bogdan Dzyubak BS (Presenter) ; Armando Manduca PhD * ; Joel P Felmlee PhD ; Kevin J Glaser * ; Sudhakar K Venkatesh
MD, FRCR ; Richard L Ehman MD * PURPOSE To test the performance of an automated technique for the analysis of clinical MR Elastography (MRE) images. METHOD AND MATERIALS In a retrospective analysis of 64 MRE cases performed for fibrosis screening, the performance of an automated algorithm (A) was
compared to that of clinical readers (R), with gold standard (G) measurements provided by a radiologist highly experienced with MRE.
The algorithm presented here has been developed to fully automate MRE ROI selection and yield a standardized stiffness measurement.
First, a crude outline of the liver was found by using the known relative positions and intensities of the dominant tissue types in the
abdominal images (abdominal fat, lung, liver, and �other�). A Random Walker segmentation was subsequently run on the MRI
magnitude images to capture liver tissue and exclude vessels, and then again on the reconstructed stiffness images to remove
partial-volume effects. The average stiffness from the ROIs was then calculated.
To test the ability of the algorithm to reproduce manual measurements, a conventional diagnostic threshold of 2.93 kPa was used to
separate patients into normal (below) and fibrotic (above) based on the results of the three analysis methods, and the diagnostic
accuracy of A with respect to G was compared to that of R. Additionally, the absolute percent differences in the measured stiffness
between R and G were compared to the differences between A and G using a Wilcoxon Signed-Rank test. RESULTS Of the 64 cases, 28 were classified by G as having fibrosis. The accuracy of A for diagnosing fibrosis was 92% and was superior to R�s
84%. It was shown to be statistically non-inferior within 10% accuracy with a p CONCLUSION The fully automated algorithm presented here has been shown to yield results as accurate as the manual methods currently used in the
clinic. If implemented as a standard, it can remove biases due to inter-reader variability as well as facilitate future MRE developments by
creating a consistent framework for ROI selection and artifact exclusion. CLINICAL RELEVANCE/APPLICATION The automated algorithm presented here can provide a standard for the practice of clinical hepatic MRE that reduces the measurement
variability and improves diagnostic accuracy. SSA08-06 • Ultrasound Elastography with Concomitant Liver Biopsy: Comparison of Acoustic Radiation Force Impulse (ARFI)
Measurement with Histolopathological Grading
Minal C Jagtiani MBBS, MD (Presenter) ; Philip J Shorvon FRCR, FRCPC ; Paul Bassett ; Kesavan Kandiah ; Paul Tadrous ; David I Sherman PURPOSE To correlate ultrasound elastography stiffness measurements in chronic liver disease patients with concomitant liver biopsy
histopathological scores of fibrosis. METHOD AND MATERIALS Patients from January 2010 through January 2013 (n= 161; 84 males) who underwent ultrasound guided liver biopsy for chronic liver
disease, performed by an Attending Radiologist with a specialist interest in liver imaging, were assessed prospectively. All patients also
underwent ultrasound elastography for liver stiffness immediately prior to the biopsy by the same Attending Radiologist. Elastography
measurements (ARFI method shear velocity m/ sec; mean of 10 measurements) were obtained in the same anatomical region of the liver
as the biopsy. All histopathology reports were scored by a specialist Attending Pathologist. ISHAK and Metavir fibrosis scores were then
Page 29 of 183
correlated with the ARFI measurements using Spearman�s rank correlation. A sub-group analysis was also performed to compare these
variables in patients with viral hepatitis. RESULTS Data for 159 patients (mean age 49 ± 14 years) were available. The mean elastography measurement was 1.7 ± 0.7 m/sec.
The results demonstrated statistically significant associations between higher histological grading and increasing ARFI measurements in
all analyses. Significant correlation was obtained between the ARFI measurement and both the ISHAK (r value= 0.58; p value < 0.001)
and Metavir scores (r value= 0.58; p value < 0.001) in all comers. For the subgroup of patients with viral hepatitis (n= 85), the
correlation coefficient for ISHAK and METAVIR scores were 0.51 and 0.53 respectively with p values < 0.001 in both groups. CONCLUSION To the best of our knowledge, this is the first study with a large cohort to assess ARFI elastography measurements and liver biopsy taken
concomitantly and validating its accuracy in 'all- comers'. It has demonstrated a highly significant statistical correlation between
elastography measurements by the ARFI method and the histological grading of fibrosis. CLINICAL RELEVANCE/APPLICATION This study demonstrates that ARFI elastography can be performed as part of a routine ultrasound study of the liver to aid in the
assessment of liver fibrosis thus optimising patient pathway. SSA08-07 • Accuracy of Shear-wave Elastography to Determine the Degree of Liver Fibrosis in Patients with Hepatitis C Virus
Infection
Anand Rattansingh (Presenter) ; Hosein Amooshahi MSc ; Sandra Fischer MD ; Morris Sherman * ; Richard Kirsch MD, PhD ; Mostafa Atri MD PURPOSE The purpose of this study was to determine the accuracy of shear-wave elastography in grading fibrosis in patients with Hepatitis C virus
(HCV) infection. METHOD AND MATERIALS 105 patients (85 Men and 20 women), mean age 56 (range23-74) with HCV infection underwent US guided random core biopsy and
shear-wave elastography on the same day. Elastography was performed on a Supersonics machine using a 3.5 MHz probe. Five samples
were obtained from the right lobe of liver of each patient and averaged to determine stiffness measured as kilo-Pascal (kPa). The same
pathologist reported all pathology specimens using METAVIR fibrosis scoring 0 to 4. Student�s t-test was used for comparison of
continuous variable, and ROC curve to calculate Area Under Curve (AUC). RESULTS There were 82 patients with no to moderate fibrosis (METAVIR 0 to 2) and 23 with severe fibrosis or cirrhosis (METAVIR 3and4) with the
prevalence of severe fibrosis or cirrhosis being 22% (23/105). Stiffness ranged from 3.2 to 26.4 (mean 9.6) kPa. Stiffness of livers with
no or moderate fibrosis on pathology ranged from 3.2 to 26.4 (mean 9.1) kPa and for severe fibrosis and cirrhosis 6.2 to 24.3 (mean
12.2) kPa (p=0.01). ROC curve showed an AUC of 0.78 (CI: 0.68-0.89) (p < 0.0001). CONCLUSION Shear-wave elastography has the potential to discriminate between = moderate liver fibrosis and severe liver fibrosis or cirrhosis in
patients with HCV infection. CLINICAL RELEVANCE/APPLICATION Ultrasound shear-wave elastography has the potential to assess parenchymal stiffness of the liver with good correlation to degree of
fibrosis SSA08-08 • Comparison of Liver Stiffness Measurement by Acoustic Radiation Force Imaging (ARFI) and Fibroscan for the
Non-invasive Diagnosis of Liver Fibrosis
Victoire Cartier MD (Presenter) ; Derek Bardou ; Jerome Boursier ; Jerome Lebigot MD ; Sophie Michalak ; Isabelle
Fouchard-Hubert ; Christophe Aube MD, PhD * PURPOSE To compare ARFI and Fibroscan in an intention-to-diagnose (ITD) basis for the non-invasive diagnosis of liver fibrosis in chronic liver
disease. METHOD AND MATERIALS 219 patients with chronic liver disease and liver biopsy were prospectively included. Liver stiffness measurements (m/s) were performed
by ARFI (right lobe: ARFI-D, left lobe: ARFI-G) and Fibroscan (right lobe). ARFI-DG corresponded to the median value of all valid
measurements obtained in both lobes. Reference for fibrosis was Metavir F staging. Diagnostic accuracy was evaluated using AUROC and
Obuchowski index (�adjusted AUROC). For ITD analysis, failures of elastographic measurement were replaced by the median value
measured in the opposite group of the biopsy diagnosis. RESULTS Fibrosis stage prevalence was F=2: 50%, F=3: 26% and F4: 9%. Rate of measurement failure was ARFI-D or ARFI-G: 0.5% versus
Fibroscan: 5.9% (p=0.002). In per-protocol analysis, AUROCs of Fibroscan were significantly higher than those of ARFI-D for each
diagnostic target (p CONCLUSION ARFI and Fibroscan have close and high accuracy for liver fibrosis diagnosis. Due to a higher failure rate, accuracy of Fibroscan decreases
in the ITD analysis but remains not significantly different from ARFI accuracy. CLINICAL RELEVANCE/APPLICATION The high feasibility and reliability of ARFI could be useful to detect undiagnosed significant fibrosis during any abdominal ultrasound
examination, with a high diagnostic accuracy. SSA08-09 • Simply Combine the Results of Multiple Elastographies and Serum Fibrosis Markers Using Bayesian Prediction for
Noninvasive Liver Fibrosis Staging
Utaroh Motosugi MD (Presenter) ; Katsuhiro Sano MD ; Hiroyuki Morisaka MD ; Shintaro Ichikawa MD ; Tomoaki Ichikawa
MD, PhD * PURPOSE Elastography, using ultrasound or MRI, has been applied to liver fibrosis staging, while serum fibrosis marker has commonly been used to
predict the fibrosis stage. The combined use of elastographies and fibrosis marker may be a superior method to their individual use. This
study was aimed to evaluate the usefulness of Bayesian prediction method to combine the results of elastographies and serum fibrosis
marker for noninvasive liver fibrosis staging.
METHOD AND MATERIALS This study included 20 cases of chronic liver disease. The pathological fibrosis staging were performed with the specimen of partial
hepatectomy by using METAVIR staging system in all cases. The use of Bayesian prediction to stage liver fibrosis can provide the
possibility of the fibrosis stages on the basis of the results of elastographies or serum fibrosis markers. We used aspartate
transferase-to-platelet ratio index (APRI) as a serum fibrosis marker and ultrasound transient elastography (UTE) and MR elastography
(MRE) as imaging-based elastographies for liver fibrosis stage estimation. We compared the accuracy of fibrosis staging and the
Page 30 of 183
confidence of the Bayesian prediction among the 3 groups; i) APRI only, ii) APRI + UTE, iii) APRI + UTE + MRE. RESULTS The most probable stage by Bayesian prediction were accurate in 6 (30%), 8 (40%), and 15 (75%) of 20 cases for APRI only, APRI+UTE,
and APRI+UTE+MRE, respectively. The confidence of Bayesian prediction significantly increased by adding UTE and MRE to APRI (mean
[SD] confidence of prediction [SD]; APRI only, 42.6 [6.7]%; APRI+UTE, 67.1 [23.0]%; APRI+UTE+MRE, 77.7 [18.0]%). CONCLUSION Bayesian prediction is simple and useful method to combine variable methods for noninvasive liver fibrosis staging. CLINICAL RELEVANCE/APPLICATION Probability of each liver fibrosis stage for the patient can be estimated with Bayesian prediction which can simply combine the results of
multiple elastographies and serum fibrosis markers. ISP: Genitourinary (New Methods of Detection and Characterization of Urolithiasis) Sunday, 10:45 AM - 12:15 PM • E351
CT
GU SSA09 • AMA PRA Category 1 Credit ™:1.5 • ARRT Category A+ Credit:1.5 Moderator
Douglas S Katz , MD Moderator
Naoki Takahashi , MD * Back to Top SSA09-01 • Genitourinary Keynote Speaker
Parvati Ramchandani MD (Presenter) * SSA09-02 • Detectability of Urinary Stones on Virtual Nonenhanced Images Generated at Nephrographic and Excretory Phase
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 To evaluate the detectability of urinary stones on virtual nonenhanced (VNE) images generated at nephrographic and pyelographic phase
dual-source dual-energy computed tomography (DsDeCT). METHOD AND MATERIALS This prospective study was approved by our institutional review board, and written informed consent was obtained from each patient. A
total of 100 patients were examined with single-energy nonenhanced CT and DsDeCT in the nephrographic and excretory phase
(100kVp/230mAs and Sn140kVp/178mAs). Commercial software was used to create VNE images by suppressing the contrast medium in
the urinary system from the nephrographic and excretory phase DsDeCT, respectively. Two radiologists evaluated the VNE images for
the presence of stones in consensus. The true nonenhanced (TNE) scan was considered the reference standard. The sensitivity regarding
the detection of calculi on two sets of VNE images compared with TNE images was determined. By using logistic regression, the
influences of stone size and attenuation of the contrast medium on the stone detection rate were assessed. RESULTS 185 stones were detected on TNE images. All (sensitivity, 100%) and 158 (sensitivity, 85.4%) calculi were identified on VNE images
generated on nephrographic and excretory phase images, respectively. Size (long-axis diameter [P = .017], short-axis diameter [P =
.027]) and attenuation of the contrast medium (P = .0012) were significantly associated with the detection rate on VNE images
generated on excretory phase images. As threshold values, size larger than 3mm, maximum attenuation of the contrast medium than 640
HU were found. CONCLUSION VNE images generated at nephrograhic and excretory phase DsDeCT enabled the detection of urinary stones with good and moderate
accuracy, respectively. Small size of stones (640HU) might affect the diagnostic capability of VNE images generated at excretory phase
DsDeCT . CLINICAL RELEVANCE/APPLICATION The VNE images generated at nephrographic phase DsDeCT is superior to that generated at excretory phase in detection of urinary
stones. SSA09-03 • Incidental Findings on CT for Suspected Renal Colic: Prevalence and Clinical Importance in 5383 Consecutive
Examinations
Mohammad M Samim MD, MRCS (Presenter) ; Sarah Goss MD ; Seth Luty MS ; Jeffrey C Weinreb MD * ; Christopher Moore
MD PURPOSE To determine the prevalence and clinical consequences of incidental findings (IFs) found on non-contrast enhanced �flank pain protocol�
CT scans (FPP CT) obtained for suspected renal colic in adults presenting to two emergency departments (EDs) over more than 5 year
period based on the American College of Radiology�s (ACR) Incidental Findings Committee White paper and other published guidelines. METHOD AND MATERIALS Reports of all FPP CTs performed in two EDs between April 2005 and November 2010 were reviewed retrospectively for IFs. Using
established guidelines, IFs were classified into two groups: �not important� (follow-up not required) and �important� (further radiologic
characterization or additional surgical or medical evaluation recommended). The prevalence for each group was determined and
correlated with various demographic features. Inter-rater reliability was determined by blinded re-review of randomly selected subsets of
the CT reports. RESULTS 5383 FPP CT reports for 4845 unique patients, revealed 875 important IFs in 681 scans for an overall prevalence of 12.65% (95% CI:
11.79%-13.56%). Prevalence of important IFs was significantly associated with age (p 80 years having important IFs compared to 6.9%
(95% CI: 5.5%-8.6%) of patients aged 18-30 years. Females had higher prevalence of important IFs compared to males: 13.4% (95%
CI: 12.2%-14.7%) vs. 11.9% (95% CI: 10.7%-13.2%). Inter-rater reliability for the presence of IFs was excellent (kappa 0.93), with
substantial agreement (kappa 0.69) regarding presence of important IFs.
CONCLUSION This is the largest study of its type and the first to use the ACR guideline to strictly define important IFs. The prevalence of important IFs
in FPP CT is high and increases with age. CLINICAL RELEVANCE/APPLICATION In addition to concerns about ionizing radiation, the potential burden of IFs should be considered when FPP CT is contemplated in ED
setting. Page 31 of 183
SSA09-04 • Comparison of Three Commercially Available Iterative Reconstruction Algorithms (ASiR, Idose Safire) on Image
Quality and Radiation Dose in Kidney Stone CT Exams
Yasir Andrabi MD, MPH (Presenter) ; Oleg S Pianykh ; Aditya Yadavalli BS ; Mukta D Agrawal MBBS, MD * ; Jorge M Fuentes
MD ; Dushyant V Sahani MD PURPOSE To evaluate the impact of threecommercially available iterative reconstruction (IR) algorithms ASIR, iDOSE and SAFIRE on the image
quality and radiation dose inkidney stone abdominal CT exams in a busy academic practice. METHOD AND MATERIALS We reviewed 380consecutive adults kidney stone CT exams performed on16 scanners (GE=12, Siemens=2, Philps=2) between Dec12 to
Mar 13. A total of 138/380 exams were reconstructed using FBP while 242/380exams wereprocessed using IR (ASIR=163, iDOSE=41 and
SAFIRE=36). The standard dose (SD) scanning parameters for various FBP scanners including weight based kV (100,120), mA(150-450),
slice thickness 5mm in the IR scanner the dose was modified (DM). Two radiologistsblinded to image reconstruction and scanning
technique independently reviewed the CTexams for image quality(IQ) and diagnostic acceptability.Size specific dose estimate(SSDE)
within patient cohorts was compared using ANOVA. RESULTS All 350 CT exams were rated of diagnostic quality with higher IQ for the DM-IR group compared with SD-FBP group (p CONCLUSION CT exams for kidney stones performed with IR preserves the diagnostic acceptability of images with significant reduction (25%) in
radiation dose irrespective to the type of commercial IR algorithm. CLINICAL RELEVANCE/APPLICATION Introduction of commercially available IR techniques are beneficial to CT practice for lowering substantial radiation dose in a busy practice
while yielding diagnostic quality imagesirrespective of th SSA09-05 • Differentiation of Uric Acid and Non-uric-Acid Urinary Stones Using a Single-source CT Scanner: Initial Clinical
Experience
Song-Tao Ai ; Shuai Leng PhD (Presenter) ; Mingliang Qu MD ; Maria Shiung ; Cynthia H McCollough PhD * PURPOSE To prospectively assess the accuracy of a single-source CT technique that uses two consecutive scans for differentiating uric acid (UA) and
non-uric-acid (NUA) urinary stones. METHOD AND MATERIALS 33 patients (15 males and 18 females) undergoing clinically-indicated dual-source (DS), dual-energy CT to differentiate UA and NUA
urinary stones were enrolled in this IRB-approved study. Immediately following the DS scan, each patient was scanned on a single-source
(SS) CT scanner with two consecutive scans (80 and 140 kV) over a scan range limited to where stones had been identified using DSCT.
UA and NUA stones were differentiated using commercial dual-energy software that included 3D deformable registration (Syngo DE,
Siemens). The ranges of the smoothing filter were set to 3 for both DS and SS exams. The accuracy of stone classification for stones >
2mm in diameter was calculated using the results from the DS scanner as the reference standard. RESULTS A total of 469 stones were identified in DS exams (26 UA and 443 NUA). Average stone diameter was 4.4 ± 2.5 mm (range 2 to 18.9
mm). Among these stones, SS exams detected 63 UA and 406 NUA stones. Overall sensitivity and specificity for identifying UA stones
were 74% and 90%. For stones =3 mm (28 UA and 323 NUA on SS exams, 20 UA and 341 NUA on DS exams), sensitivity and specificity
were 95% and 97%. Image quality of the SS exam was similar to or slightly better than that of the DS exam. CONCLUSION Differentiation of UA and NUA urinary stones is feasible by using two consecutive scans. UA stones could be identified using a SS CT
scanner with an accuracy of 97% for stone sizes >3mm. CLINICAL RELEVANCE/APPLICATION Accurate identification of UA stones using SS scanners may increase availability for this technique, which is clinically useful in identifying
patients with medically treatable stones. SSA09-06 • Material Decomposition Generated from Excretory-phase Spectral CT: Determinants of Detection of Urinary Calculi in
the Renal Collecting System
Yan Chen (Presenter) ; Peijie Lv MMed ; Jianbo Gao MD PURPOSE To determine which features of urinary calculi are associated with their detection on material decomposition images generated from
spectral computed tomograpic(CT) urography. METHOD AND MATERIALS This retrospective study was approved by the insititutional ethics committee with waiver of informer consent. 34 patients were examined
with true nonenhanced (TNE) CT and spectral CT urography in the excretory phase. The contrast medium was virtually removed from
excretory-phase images by using water-based (WB) and calcium-based (CaB) material decomposition (MD) analysis . The sensitivity
regarding the detection of calculi on MD images using true nonenhanced (TNE) images as the reference standard was determined. By
using logistic regression, the influences of image noise, attenuation, and stone size, as well as attenuation of the contrast medium, on
the stone detection rate were assessed on CaB and WB images. The signal-noise-ratio (SNR) and contrast-noise-ratio (CNR) were
calculated to evaluate the detectability of MD images . RESULTS 129 stones were detected on the TNE images;110 stones were identified on CaB images (sensitivity 85.9%) and 106 stones on WB
images(sensitivity,82.5%). Size (long-axis diameter and short-axis diameter), attenuation of the calculi and image noise were
significantly associated with the detection rate on CaB and WB images (both P CONCLUSION After virtual elimination of contrast medium with material decomposition, large and high-attenuation calculi can be detected with high
reliability. CLINICAL RELEVANCE/APPLICATION Material decomposition images generated at excretory-phase spectral CT can depict calculi larger than 2.9 mm in the presence of contrast
medium. SSA09-07 • Low-dose CT for Renal Colic with Automatic Tube Current Modulation, Adaptive Statistical Iterative Reconstruction
and Low kV: Impact of Body Mass Index
Alban Gervaise MD, MSc ; Pierre Naulet ; Florence Beuret (Presenter) ; Christelle Henry ; Matthieu Pernin ; Yann Portron ; Marie Lapierre-Combes PURPOSE Page 32 of 183
The purpose of our study was to evaluate the impact of body mass index on the dose, diagnostic performance and image quality of
low-dose CT for renal colic, performed with automatic tube current modulation, adaptive statistical iterative reconstruction (ASIR) and low
kV. METHOD AND MATERIALS This retrospective study included all patients who underwent low-dose CT for renal colic in our imaging department during 2012.Only CTs
performed with automatic tube current modulation, ASIR and low kV were evaluated. The study was approved by the institutional ethics
committee. Three radiologists independently reviewed all the images and evaluated diagnostic confidence (scale 1-3), image quality
(scale 1-5), and the presence of renal colic. These results, along with the radiation doses, were compared between patients with different
categories of BMI and between patients with a BMI < 25 kg/m2 and = 25 kg/m2. RESULTS A total of 86 patients were included in the study, with 39 (45%) having a BMI < 25 kg/m2, and 47 (55%) a BMI = 25 kg/m2. No
statistically significant difference was found between the accuracy rates for the diagnosis of renal colic, when the rates reviewed by the
three readers were averaged across both patient groups (respectively 95.7% vs. 96.4%, p = 0.83). Image quality and diagnostic
confidence were significantly better for patients with a BMI = 25 kg/m2, compared to patients with a BMI < 25 kg/m2 (respectively 3.7
vs. 3.4, p CONCLUSION The diagnostic performance of our low-dose CT for renal colic was excellent for all patients, with a significantly better image quality and
diagnostic confidence for patients with a BMI = 25 kg/m2. However, it also required exposure to a greater dose of radiation for
overweight and obese patients. CLINICAL RELEVANCE/APPLICATION Our low dose CT for renal colic shows better image quality and diagnostic confidence for patients with a BMI=25 kg/m2. However, it
requires exposure to a greater dose for overweight and obese patients SSA09-08 • Detection of Urolithiasis: Comparison of FBP and ½ Dose FBP with Iterative Reconstruction in 99 Patients
Erick M Remer MD (Presenter) ; Mark E Baker MD * ; Andrew Primak PhD * ; Andrei S Purysko MD ; Myra K Feldman MD ; Daniel M Roesel DO ; Alison C Greiwe MD ; Shubha De MD ; Shetal N Shah MD ; Wadih Karim RT ; Nancy A Obuchowski
PhD ; Manoj Monga MD * ; Brian R Herts MD * PURPOSE To assess the effect of CT dose reduction on the detection of urolithiasis. METHOD AND MATERIALS 99 patients with 192 kidneys (6 solitary) were imaged to follow urolithiasis on a dual energy scanner [Definition Flash (Siemens
Healthcare)] in dual-source mode using 120 kVp, 128x0.6 collimation and pitch 0.9. Dose modulation used with weight-based reference
mAs. Data from both tubes was reconstructed with standard filtered back projection (100% FBP). Data from primary tube (50% total
dose) was reconstructed using sonogram-affirmed iterative reconstruction i31 (50% IR). 7 readers (2 senior and 2 junior staff, 2 imaging fellows, 1 urology fellow) evaluated 100% FBP and 50% IR images in a randomized
fashion for presence or absence of calculi in 9 regions (pyelocalyceal, proximal, mid, distal ureter, and bladder). Largest axial stone size
on magnified bone windows per region was measured and categorized as =1,2-3, 4-5, 6-7, =8mm. Confidence scored on 5 point scale.
Presence or absence of ancillary findings (hydronephrosis, stranding) or alternative diagnosis to explain flank pain was noted. Findings
unrelated to history were scored using the CT colonography extracolonic reporting system. Truth was determined by 2 senior
uroradiologists in consensus with access to medical record and other imaging. Nonparametric methods for clustered data were used to estimate the ROC curves and their areas for each reader. A 95% CI was
constructed for the difference in the mean ROC areas.
RESULTS 113 locations had stones and 752 did not (86 pyelocalyceal, 7 proximal, 4 mid, 15 distal ureter). Mean ROC area for FBP was 0.879
(range 0.607-0.967) and 50% IR was 0.883 (0.646-0.971). For one reader, ROC area with 50% IR was significantly better. The p-value
for the hypothesis of non-inferiority was 0.001, indicating that 50% dose IR was not inferior. The 95% CI for the difference in ROC areas
between 100% FBP vs. 50% IR is [-0.025, +0.031]. There was hydronephrosis or stranding in 23, an alternate diagnosis to explain pain
in 1, clinically unimportant incidental findings in 37, likely unimportant findings in 5, and potentially significant findings in 9 patients.
CONCLUSION 50% CT dose reconstructed with IR was equivalent to standard dose reconstructed with conventional FBP to detect urolithiasis. CLINICAL RELEVANCE/APPLICATION 50% dose reduction does not alter urolithiasis identification efficacy. SSA09-09 • A Novel Technique to Assess Delineation of the Whole Ureter Using the Non-contrast Curved Sagittal Oblique
Reformatted CT Images
Haisam A Atta MD (Presenter) ; Enas A Abd El Gawad MBBCh, MD ; Ahmad S. El-Azab MD ; Medhat A Saleh MD ; Hisham M
Imam MBBCH, MD PURPOSE Our aim was to develop a standardized technique to assess delineation of the whole ureter for the evaluation of symptomatizing urologic
patients. METHOD AND MATERIALS Two thousand and five hundred patients were subjected to this technique during the period between 2007 to 2012 using 64-row
multidetector scanner. Examinations were performed with oral hydration alone (each patient ingested 500-750 ml. of water over a 15�30
min. period before scanning began) Group I (n=834), Group II received 20 mg of IV furosemide alone (n=847 ), or Group III with nothing
at all (n=819 ). Curved planar reformatted (CPR) images were obtained manually by drawing a line over the entire course of the ureter.
The ureter was traced in the sagittal oblique image to obtain the entire ureter in a single coronal oblique image. The ureter was divided
into 3 anatomic segments (proximal, middle, and distal) for estimating the degree of its delineation, at least two radiologists assessed the
degree of delineation where if the segment is assessed along it whole length is graded as satisfactory delineation, and if the ureters
cannot be assessed along its whole length is graded as non-proper delineation . The delineation degree for each ureteral segment with
patient group were compared. RESULTS Degree of satisfactory delineation obtained with group II (86.18%) were statistically much higher than those obtained with group I
(62.47%) or group III (59.70%) with p value =0.000 , regarding the degree of ureteric delineation, there was a statistical significant
result (p=0.000) where the upper ureteric segment showed satisfactory delineation with all 3 techniques with percentage 100%, the
middle ureteric segment showed satisfactory delineation in 86% of cases with group II , 62.5% in group I and 60% in group III while the
lower third segment showed satisfactory degree of delineation in 86.2% in group II, 61% with group I and 54.6% with group III. The sex
of patients also showed a significant statistical result (p=0.000) where there was non proper delineation is higher in females with
percentage 44.4% among groups II and III. CONCLUSION Unenhanced curved sagittal oblique reformatted image with IV furosemide allows better delineation and tracing of the whole course of the
ureter CLINICAL RELEVANCE/APPLICATION Page 33 of 183
Non-contrast MSCT with intravenous diuretics Curved Reformatted Images allows assessment of the Whole Length of the Ureter Genitourinary (Adrenal Masses: New Methods for Specific Diagnosis) Sunday, 10:45 AM - 12:15 PM • E353B
CT
GU SSA10 • AMA PRA Category 1 Credit ™:1.5 • ARRT Category A+ Credit:1.5 Moderator
Seung Hyup Kim , MD Moderator
Zhen J Wang , MD Back to Top SSA10-01 • MDCT of the Indeterminate Adrenal Mass: Identification of a Venous Enhancement Level to Distinguish
Pheochromocytoma from Adenoma
Benjamin G Northcutt MD ; Erin N Zingarelli BS ; Michael A Trakhtenbroit MD ; Siva P Raman MD ; Elliot K Fishman MD * ; Pamela T Johnson MD (Presenter) * PURPOSE Adrenal protocol CT identifies adenomas due to rapid washout. Hypervascular lesions, including pheochromocytoma and metastatic renal
cell carcinoma, can also exhibit rapid washout due to high levels of enhancement. The purpose of this study was to compare the absolute
venous phase enhancement level of adenoma and pheochromoctyoma, the two most commonly identified incidental adrenal masses.
Delineation of a venous phase enhancement level predictive of pheochromocytoma could prevent misdiagnosis of vascular
pheochromocytomas as adenoma with washout CT. METHOD AND MATERIALS Retrospective review of medical records was performed between 2002-2012 to identify adrenal masses measuring < 4 cm. Inclusion
criteria for adrenal adenomas was venous phase IV contrast enhanced CT (single phase, dual phase, or adrenal protocol CT),
confirmatory adrenal CT (precontrast +/- washout) and absence of clinical indicators of pheochromocytoma. All pathologically proven
pheochromocytomas with venous phase CT imaging were evaluated. CT examinations were reviewed by a body CT attending, who
recorded size and venous attenuation (± precontrast and delayed attenuation when available). T-test analysis was used to compare
venous enhancement levels. RESULTS 79 subjects with 88 adenomas were compared to 22 subjects with 26 pheochromocytomas. Mean±SD venous enhancement level for all
adenomas (61±24 HU) and lipid poor adenomas (90±18) was lower than that of pheochromocytomas (111±38 HU) (p 110 HU,
compared to 50% (13/26) of the pheochromocytomas. A threshold of 110 HU to identify pheochromocytoma was 50% sensitive and 98%
specific for pheochromocytoma, whereas a threshold of 130 HU was 38% sensitive and 100% specific. Of the 21 pheochromocytomas
with washout imaging, rapid washout was identified in 12/12 (100%) that enhanced >110 HU on the venous phase, compared to 11%
(1/9) that enhanced CONCLUSION For indeterminate adrenal masses in patients without a history of malignancy, venous phase enhancement >110 HU should prompt
consideration of pheochromocytoma; a mass with venous enhancement >130 HU should be considered pheochromocytoma until proven
otherwise. CLINICAL RELEVANCE/APPLICATION High levels of venous phase enhancement (>110-130 HU) are specific for pheochromocytoma and should be used in conjunction with
wash-out characteristics to distinguish this lesion from adrenal adenoma. SSA10-02 • Intra-individual Comparison of Chemical Shift MRI and Washout CT for Characterizing a Hyperattenuating Adenoma
(>10 HU) on Unenhanced CT
Moon Young Kim MD (Presenter) ; Byung Kwan Park MD ; Sung Yoon Park ; Chan Kyo Kim MD, PhD PURPOSE To retrospectively compare the accuracy of MRI and CT in characterizing hyperattenuating adrenal adenomas with respect to lesion
attenuation values measured on unenhanced CT. METHOD AND MATERIALS Fifty-two hyperattenuating adrenal masses measuring >10HU on unenhanced CT were identified in 52 patients who underwent both
chemical shift MRI and washout CT. Accuracies using adrenal-to-spleen ratio (16.5%) for MRI and using absolute (=60%) or relative
(=40%) percentage washout for CT were calculated to determine which modality was more accurate for hyperattenuating adenoma
characterization. Sensitivities of MRI and CT were also compared according to the lesion attenuation values measured on unenhanced CT.
Either follow-up imaging or histologic diagnosis was used as the standard reference. McNemar�s test was used to compare the
accuracies of CT and MRI. RESULTS Hyperattenuating adrenal masses consisted of 37 adenomas and 15 non-adenomas. The sensitivities and specificities for adenoma on
MRI versus CT were 75.7% (28/37) versus 100% (37/37), and 60.0% (9/15) versus 80.0% (12/15), respectively. CT achieved a higher
accuracy than did MRI (p=0.008). The sensitivities for adenomas measuring =20HU on unenhanced CT were 100% (12/12) in both MRI
and CT, while those measuring >20HU were 64.0% (16/25) and 100% (25/25) in MRI and CT, respectively. CONCLUSION MRI is equivalent to CT for characterizing adenomas measuring =20HU on unenhanced CT. However, MRI is inferior to CT for adenomas
measuring >20HU due to decreased MR sensitivity. CLINICAL RELEVANCE/APPLICATION MRI may be used the first-line examination for patients with an incidental adrenal mass measuring = 20 HU on unenhanced CT if
contrast-enhanced CT scans are contraindicated. SSA10-03 • Differentiate Adrenal Metastases from Adrenocortical Adenoma with Single-source Dual-energy Computed
Tomography, a Preliminary Study
Lifeng Wang (Presenter) ; Xuejun Chen ; Liang H Li ; Jinrong Qu ; Jianbo Gao MD ; Weili Xia ; Cuicui Liu PURPOSE To evaluate the ability of spectral CT imaging in distinguishing adrenal metastases from adenoma on enhanced CT. METHOD AND MATERIALS 35 patients with 40 lesions(24 adenomas and 16 metastases) underwent conventional plain CT and spectral CT to generate conventional
plain CT images and monochromatic images of the arterial phase (AP) and the portal venous phase (PVP). Adenoma was divided into into
lipid-rich group(14 lesions) and lipid-poor group(10 lesions) by 10HU on unenhanced CT. Iodine(water, fat)-contribution value on
enchanced CT were obtained to analyse. ROC analyses were performed to evaluate the diagnostic value of spectral CT, and to calculate
the threshold value for diagnosis of metastases. Page 34 of 183
the threshold value for diagnosis of metastases. RESULTS Iodine-contribution value of adrenal adenoma, lipid-rich adenoma, the lipid-poor adenoma was statistically significant higher than that of
metastases during the AP(13.65, 12.67,15.83 vs. 2.28 100ug/cm 3, P =0.00,0.00,0.00) and PVP(20.96, 19.99, 22.92 vs. 2.16
100ug/cm3, P3, P 3, P 3, P CONCLUSION Spectral CT can differentiate adrenal metastases from adenoma on enhanced CT, especially in differentiating metastases from lipid-poor
adenoma. CLINICAL RELEVANCE/APPLICATION Spectral CT can differentiate adrenal metastases from lipid-poor adenoma. SSA10-04 • The Value of 15-minute Delayed Contrast-enhanced CT to Differentiate Hyperattenuating Adrenal Masses: Subgroup
Analysis Based on Underlying Malignancy
Hyun Jung Koo MD (Presenter) ; Hyuck Jae Choi MD ; Hwa Jung Kim ; Mi-Hyun Kim MD ; Kyoung-Sik Cho MD PURPOSE To retrospectively investigate the diagnostic values of 15-minute delayed enhanced computed tomography (15-DECT) compared with
those of chemical shift magnetic resonance (CSMR) imaging for differentiating hyperattenuating adrenal masses in a large group of
patients and to perform subgroup analysis in the underlying malignancy and non-malignancy groups. METHOD AND MATERIALS We included 670 consecutive patients with hyperattenuating adrenal masses who underwent 15-DECT or CSMR from January, 2000 to
March, 2012. Four parameters including relative percentage washout (RPW), absolute percentage washout (APW) seen on 15-DECT, and
signal intensity index (SII) and adrenal-to-spleen ratio (ASR) on CSMR were calculated. In order to minimize selection bias, we performed
subgroup analysis regarding the presence of malignancy and after excluding adenoma-mimicking malignancies. The attenuation on
unenhanced CT images and the size of the adrenal masses were also analyzed in order to correlate with the risk of nonadenoma. RESULTS Four hundred and seventy-eight adrenal masses in 453 patients with 15-DECT and 235 masses in 217 patients with CSMR were included
in this study. Among the four calculated parameters, RPW on 15-DECT showed the highest diagnostic performance for characterizing
hyperattenuating adrenal masses. After excluding the adrenal adenoma-mimicking lesions, the sensitivity, specificity, and accuracy of
RPW on 15-DECT were 91.9%, 96.9%, and 92.2% in all patients, 91.55%, 100%, and 93.6% in the underlying malignancy group,
92.0%, 85.7%, and 91.8% in the non-malignancy group, respectively. There were statistical differences in sensitivity and accuracy, but
no statistical difference in specificity between RPW on 15-DECT and SII on CSMR in the patients with underlying malignancy and
non-malignancy groups after excluding adenoma-mimicking malignancies. The risk of non-adenoma was increased by approximately three
times as the size of an adrenal mass increased by 1 cm or the attenuation value of the mass increased by10 Hounsfield units (HU) on
unenhanced CT. CONCLUSION 15-DECT showed a higher diagnostic accuracy compared to CSMR for characterizing hyperattenuating adrenal masses in both the
underlying malignancy and the non-malignancy groups. CLINICAL RELEVANCE/APPLICATION In patients with hyperattenuating adrenal masses, the recommended post-test modality is 15-DECT regardless of whether or not there is
an underlying malignancy. SSA10-06 • Differentiation of Large Adrenal Adenomas (≥ 3cm) and Cortical Carcinomas Using Washout CT
Moon Young Kim MD (Presenter) ; Byung Kwan Park MD ; Sung Yoon Park ; Chan Kyo Kim MD, PhD PURPOSE To retrospectively differentiate large adrenal adenomas (= 3cm) and cortical carcinomas in patients with no history of extra-adrenal
malignancy using washout CT. METHOD AND MATERIALS Between January 2004 and November 2012, 141 adenomas (mean size, 2.5 ± 1.2 cm, range 1.0 � 7.3 cm) and 16 cortical carcinomas
(mean size, 7.9 ± 4.5 cm, range 2.4 � 17.8 cm) were histologically diagnosed in 141 and 16 patients, respectively. Of these adenomas,
34 adenomas and 13 cortical carcinomas were 3 cm or larger in size. All of these patients underwent unenhanced CT, 1 minute
post-contrast CT, and 15 minute post-contrast CT. The attenuation values were measured at three different areas within a mass using a
region-of-interest (ROI); (a) the highest attenuated area at 1 minute post-contrast image (highest ROI), (b) lowest attenuated area at 1
minute-postcontrast image (lowest ROI), and (c) ROI covering more than half of a mass (largest ROI). On unenhanced and 15
minute-postcontrast images, attenuation values were also measured at the corresponding areas, and percentage washouts were
calculated. The CT diagnoses of adenoma were made if a mass had = 60% absolute percentage washout or = 40% relative percentage
washout. The CT diagnosis of carcinoma was made if a mass had < 60% absolute washout and RESULTS The sensitivities for small (< 3 cm) adenoma were 99.1% (106/107), 95.3% (102/107), and 99.1% (106/107) while those for large
adenomas (= 3 cm) were 100% (34/34), 52.9% (18/34), and 64.7% (22/34) at highest, lowest, and largest ROIs, respectively. As an
adenoma increased in size, heterogeneous enhancement of the lesion increased (p< 0.001) and subsequently the sensitivity for adenoma
decreased significantly (p< 0.001). The sensitivities for carcinoma (= 3 cm) were 46.2% (6/13), 100% (13/13), and 100% (13/13) at
highest, lowest, and largest ROIs, respectively. CONCLUSION The diagnosis of small adenomas can be confidently made using washout CT wherever an ROI is placed. However, the differentiation of
large adenomas and carcinomas is not easy because CT sensitivity widely varies according to an ROI placement in the heterogeneous
lesion. CLINICAL RELEVANCE/APPLICATION The preoopeative diagnosis of an large adenoma is not easy becasue it is much similar to cortical carcinoma in terms of CT densitometry
or percentage washout. SSA10-07 • 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 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
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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 SSA10-08 • The Value of Spectral CT Imaging in Differentiating Metastases from Adenoma in Adrenal Glands
Ye Ju (Presenter) ; Ailian Liu MD ; Meiyu Sun ; Yijun Liu ; Renwang Pu MBBCh, FRCPC ; Shifeng Tian PURPOSE METHOD AND MATERIALS RESULTS CONCLUSION The spectral CT provides a multi-parameter approach for identifying adrenal metastases from adenomas, and the fat concentration of
spectral CT provides a sensitive approach for differential diagnosis. CLINICAL RELEVANCE/APPLICATION SSA10-09 • Variation of Radiologist Recommendations for Adrenal Lesions Detected at CT: Comparison of Departmental
Standards with and without a Point-of-Care Clinical Decision Support (CDS) tool
David A Rosman MD (Presenter) * ; Tarik K Alkasab MD, PhD ; Anand M Prabhakar MD ; Daniel I Rosenthal MD ; Keith J
Dreyer DO, PhD * ; Debra A Gervais MD * ; Giles W Boland MD PURPOSE To determine if implementation of a CDS software tool which auto-generates best practice recommendations for a given set of imaging
and clinical findings would be successful in improving report consistency by abdominal and emergency radiologists in adrenal lesion
characterization detected at CT. METHOD AND MATERIALS A point-of-care CDS tool was created into which radiologists input key imaging and clinical patient data real-time. CDS output language
was automatically inserted into the report body, impression and recommendation fields within a standardized template (radiologists could
make free-text modifications). We evaluated performance from 10/24/12-12/31/12 in 7499 consecutive abdominal CT examinations.
Those RESULTS A total of 177 total nodules ranging from 8mm-10.5cm in 172 patients were evaluated with a final diagnosis of 77 adenomas, 14
myelolipomas/cysts/hemorrhage, 10 metastases and 76 indeterminate lesions. The CDS tool was used in 44/177 lesions and not used
in133/177 lesions. Recommendation concordance rates of the subgroups were as follows (by chi-square, p All Non-CDS Lesions: 64%
level I, 19% level II, 35% clinical.
All CDS lesions: 100% level I, 88% level II, 86% clinical.
CDS Adenoma: 100% level I, 95% level II, 74% clinical
Non-CDS Adenoma: 53% level I, 52% level II, 7% clinical.
CDS Indeterminate: 100% level I, 84% level II, 96% clinical.
Non-CDS Indeterminate: 62% level I imaging, 15% level II imaging, 38% clinical.
Correlation with the CDS was not perfect as free-text additions were permissible and used 12% of cases.
CONCLUSION After implementation of CDS, there was significantly improved correlation between the departmental guidelines and the
recommendations made in the radiologists� report. CLINICAL RELEVANCE/APPLICATION An automated CDS tool increases consistency in recommendations for adrenal lesion characterization with implications for adherence to
best practice guidelines and referring physician expectations. ISP: Informatics (Education and Research) Sunday, 10:45 AM - 12:15 PM • S403A
IN
ED SSA11 • AMA PRA Category 1 Credit ™:1.5 • ARRT Category A+ Credit:1.5 Moderator
Gary H Danton , MD, PhD Moderator
Ayis T Pyrros , MD * Back to Top SSA11-01 • Informatics Keynote Speaker: Informatics and Education
Gary H Danton MD, PhD (Presenter) SSA11-02 • An Anonymized Radiological Database with Open-source Search Engine and Image Request System for Biomedical
Researchers
Michael D Torno DSc (Presenter) ; Nicholas P Gruszauskas PhD ; Roger Engelmann MS * ; Adam Starkey ; Paul J Chang MD *
; Samuel G Armato PhD CONCLUSION Software which de-identifies and indexes clinical data for a queryable research database was created. Users have the ability to save
radiology reports and request de-identified medical images via the system�s web interface. Additionally, the opt-out paradigm provided
a substantial number of consented patients and maximized the amount of data available to researchers. Autonomous operation of our
dedicated research system resulted in minimal PACS performance degradation. Background A system to mine, organize, anonymize, and request de-identified images from a radiological database was required to fulfill the needs of
biomedical researchers. The system must function autonomously from a clinical PACS to minimize its impact on performance during
clinical use. Independent operation allows keyword queries of anonymized radiology reports through a web interface; this interface also
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clinical use. Independent operation allows keyword queries of anonymized radiology reports through a web interface; this interface also
functions as a database creation and de-identified image request system. A custom database interface was designed to fill this need. Evaluation The software includes (1) Perl and VB apps to extract data from a clinical PACS and anonymize PHI in accordance with IRB and HIPAA
standards; (2) an indexing search engine that allows keyword queries via a web browser; (3) PHP-based exporting of queried radiology
reports with an option to request associated de-identified images through the Human Imaging Research Office at our institution. An
�opt-out� IRB paradigm was created: outpatients in radiology reception areas are presented with an opt-out form to establish consent
for use of clinical images and associated data for research. Discussion The �opt-out� paradigm began in October 2008; to date 128,000 patients are enrolled and de-identified image data is available for
query via our database interface. 1,324 patients have declined the study resulting in a 1% withdrawal rate. Previous �opt-in�
paradigms resulted in an enrollment of less than 3,000 patients over a 5 year period. Over 1.2 million radiology reports encompassing
over a decade of data were anonymized and indexed from our PACS and are available for use in medical research. SSA11-03 • Workflow, Standards and Database of Quality Control in Multi-institutional Clinical Trials of Cancer Imaging at the
Alliance Imaging Corelab
Jun Zhang PhD (Presenter) ; David Poon BS ; Preethi Subramanian ; Richard Jacko BS ; Nathan C Hall MD, PhD * ; Michael V
Knopp MD, PhD ; Kristin Sullivant ; Ajay Siva ; Stephanie Telek ; Andrea Markowitz ; Talha Saif ; Michael Finneran ; Katherine Binzel BS ; Joe Milacek PURPOSE To introduce and evaluate the workflow, standard and database established at the Alliance Imaging Corelab for cancer imaging quality
control in multi-institutional clinical trials METHOD AND MATERIALS The imaging Corelab (ICL) established an overall clinical trial implementation pipeline from trial initiative to trial closure. Along the
roadmap, workflows of data quality control were defined with more than 15 individual sub-components integrated (site credentialing,
virtual site visit, automatic quality check, real-time image remote review and so on). Quality control standard in 15 items under 4-level
categories (timing, imaging, data and patient) was established with SOP driven. (Semi)-automatic softwares were developed enabling
mega-data processing and database management in 10 important steps and audit process. RESULTS A total of 2992 patients with 8246 studies (PET/CT, CT, MR, NM) from 27 clinical cancer trials over 300 participating sites within USA were
included in this assessment. The established thin-client real-time image review approach enables off-site reviewers performing remote
image review with no data transfer required; a success rate of better than 91% in adaptive trials has been achieved in evaluating over
1500 real-time central reviews of which 75% enabled CONCLUSION Quality control is critical component of cancer imaging clinical trials to assure appropriate executions and the success of clinical trial. The
study proposed and evaluated our established workflow, standards and database of quality control in 10-yr multi-institutional clinical
trials implementations experiences at the imaging corelab with efforts in helping people better understand the components, challenges
and strategies of doing quality control for clinical trials. CLINICAL RELEVANCE/APPLICATION Conducting multi-institutional clinical trials requires a set of standards and workflows in quality control defined for professional trial
implementations making sure trials to be valid and successfu SSA11-04 • Implementation and Clinical Evaluation of Content-based Searching Engine in RIS-integrated PACS
Jianguo Zhang PhD (Presenter) ; Tonghui Ling MS ; Jianyong Sun ; Suo Li ; Yuanyuan Yang MS ; Kai Zhang BS PURPOSE We had designed a searching engine combining semantic space searching and CBIR techniques to search lung CT images with solitary
pulmonary nodules (SPN) in PACS environment, and presented this prototype system in scientific presentation in 2009 RSNA Conference.
In this presentation, we present new approach to extend this searching engine to cover more organs and lesions, gave an implementation
of this searching engine in RIS-integrated PACS, and discussed its clinical evaluation. METHOD AND MATERIALS The studies of cardiology CT images with coronary heart disease, brain CT and MR images with stroke, and abdomen CT with colorectal
cancer as well as lung CT images with SPN, were included in our research. The diagnostic reports of the studies with findings of lesions
are first analyzed by a NLP engine and then indexed in an inverted index. The contents of images of related to the reports are identified
by their low level features extracted from the ROIs of images containing the lesions and indexed in a specified high-dimensional database.
The first step in using this search engine uses the inverted index to search for relevant radiology report matching the symptoms or
diagnoses specified by users as query criteria. The second step searches and retrieves the features of images from the high dimensional
database associated with each report returned in the first step and computes the feature similarities between user query image and the
retrieved images. The final search results are then sorted by similarities computed on the second step. RESULTS The developed searching engine was integrated a clinical RIS-integrated PACS, and operated for two years in Huadong hospital in
Shanghai. There were about more than 30 cases averagely being searched and retrieved by using this searching engine daily. But the
usages of this search engine for the purposes of decision support, research, and education were quite different. CONCLUSION The developed content-based searching engine can be easily integrated with a clinical RIS-integrated PACS and has been operating for
two years in a hospital. The evaluation results showed that searching engine can be used for the purposes of decision support, research,
and education. CLINICAL RELEVANCE/APPLICATION The presented search engine is extremely useful to assist radiologists, medical researchers and students to mine meaningful information
from PACS and RIS for their decision support, research and case- SSA11-05 • Development of a Dedicated Workstation to Facilitate Rapid Performance of Observer Studies in Low-dose CT
David R Holmes PhD (Presenter) ; Rickey Carter PhD ; Kurt E Augustine MS ; Yu Liu MD ; Maria Shiung ; Lifeng Yu PhD ; Phillip Edwards ; Cynthia H McCollough PhD * ; Joel G Fletcher MD * PURPOSE While numerous CT noise reduction methods have been developed, it is difficult to directly measure the clinical impact of each approach.
We have developed an open source computer workstation to efficiently conduct observer studies of low dose CT protocols to determine
the superiority or non-inferiority of new reconstruction methods. METHOD AND MATERIALS The workstation allows a user to conduct lesion detection and characterization, and image quality assessment in a time-efficient manner.
The user is required to identify the location and size of all lesions in a dataset by delineating the long axis of the lesion. Both manual and
automatic software tools have been developed to match corresponding lesions between an observer and routine dose FBP reference
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standard. The automatic matching algorithm computes correspondence by determining if the reference ROI overlaps with an observer
ROI. Matching rules are employed to insure lesions are appropriately characterized (e.g., benign/malignant) if they are detected. The
algorithm reports true positives (TP), false positives (FP), and false negatives (FN) to a back-end database for export and JAFROC
analysis. RESULTS The automated matching algorithm was validated using ten radiologist observers � each reviewing 10 datasets. The study PI created the
reference standard based on correlative imaging, follow-up and pathology reports. Observers required an average of 5.6 minutes (range
0.5 � 25.4) min to review each case. The PI completed semi-automated visual matching of observer and reference marks and diagnoses.
The observers delineated a combined 644 lesions (including TP, FP, and FN) across all 10 observers. Automated matching required < 1
second and correctly matched 94.7% of the lesions (compared to the manual matching). Incorrect responses by the algorithm included
11 overmatched (e.g. multiple overlapping ROIs) detections and 23 mis-matches between reference and observer ROIs. CONCLUSION A system for interactively evaluating CT denoising methods must minimize radiologist effort, accurately match reference detections and
classifications with observer markings using automated and manual visual tools, and create a streamlined workflow and statistical
analysis. CLINICAL RELEVANCE/APPLICATION Dedicated workstations for observer performance in low dose CT minimize radiologist effort with streamlined workflow and provide
automated and visual tools for reference standard matching. SSA11-06 • Compression of Radiology Reports Using a Semi-static Dictionary and Directed Pseudoforest
Naveen Garg MD (Presenter) * ; Peter Kamel ; Sarfaraz Sadruddin MD ; Jorge Herskovic MD, PhD ; David J Vining MD * ; Kevin W McEnery MD * PURPOSE A radiologist will generally dictate a normal chest the same way every day, and usually describe the same pathology in a consistent style.
Speech recognition systems rely on these recurring patterns of reporting style to develop statistical language models for improving.
Because of this, we hypothesized that radiology reports would be highly compressible using static dictionaries. The more commonly used
compression algorithms such as gzip obtain approximately 4x compression, but lose random access of the compressed data. In this work,
we report on the compression ratios achieved on a large corpus of radiology reports using static dictionaries. We also present a novel
method of compressing the static dictionary itself using a directed pseudoforest. METHOD AND MATERIALS We constructed dictionaries from a variable number of radiology reports. Dictionaries were constructed using a variation of a generalized
suffix tree pruned by a threshold frequency of the suffixes. The dictionary was then itself compressed using a directed pseudoforest,
taking advantage of the shared structure between phrases in the dictionary. Source documents were then compressed using the integer
indices into the dictionary, coded with a prefix-free entropy code. The algorithm was coded in c++11 with no platform specific
dependencies. RESULTS Compression ratios improved with increasing number of reports. A million reports compressed to 18.7% of original size including the
compressed reports, and dictionary.
These randomly accessible compressed reports were further compressible by gzip, bringing compressed size to 13.7 %. Pruning the
dictionary of less frequently used n-grams substantially decreased the size of the dictionary with only a minor increase in the size of the
compressed reports. On a million reports, limiting the dictionary to n-grams that occur at least 30 times in the corpus results in overall
better compression than allowing n-grams that occur 10 or more times.
CONCLUSION Static dictionaries with directed pseudoforests can compress radiology reports with a very high efficiency while retaining random access
capability. CLINICAL RELEVANCE/APPLICATION Better compression of radiology reports and other medical records can be used to enable data mining applications to retain more data in
memory allowing faster analytics. SSA11-07 • Detailed Comparison of Average Journal Impact Factors of Oral and Poster Abstracts Presented at Scientific Session
that Achieved Publication at 2009 Radiological Society of North America Scientific Assembly and Annual Meeting
Hiroyuki Takaoka MD, PhD (Presenter) ; Nobusada Funabashi MD, PhD ; Naoko Mizuno ; Koya Ozawa MD ; Yoshio Kobayashi PURPOSE To determine the average journal impact factors of oral and poster abstracts presented at the scientific sessions of the 2009 Radiological
Society of North America (RSNA) 95th scientific assembly and annual meeting that achieved publication for each category using Pubmed. METHOD AND MATERIALS From the 2009 RSNA meeting program (total of 1509 oral abstracts, and 684 poster abstracts), authors� names and abstract titles were
entered into PubMed. Publication consistent with abstract content was confirmed by PubMed in March 2013.
RESULTS Percentages of all oral and poster abstracts in the scientific sessions achieving publication were 18.4 and 11.4% and that of oral abstracts
was significantly higher than that of poster abstracts. The percentage of oral abstracts achieving publication was significantly higher than
the poster abstracts in Breast (26.3 vs 10.0%, P < 0.05), Nuclear Medicine (20.6 vs 3.2%, P < 0.05), Musculoskeletal (29.0 vs 14.0%, P
< 0.05), and Radiation Oncology categories (12.7 vs 0.1%, P < 0.05). Even though impact factors were significantly higher for the oral
abstracts that achieved publication (3.3 ± 1.8) than for the poster abstracts that achieved publication (2.6 ± 1.3) in all categories (P <
0.04), but there were no significant differences in average Impact factors achieving publication between oral and poster abstracts in each
category.
CONCLUSION Although the percentages of oral abstracts to achieve publication were significantly higher than poster abstracts in all, Breast, Nuclear
Medicine, Musculoskeletal, and Radiation Oncology categories, both oral and poster abstracts at the 2009 RSNA 95th scientific assembly
and annual meeting were similar in achieving publication in terms of average journal impact factor in each category. CLINICAL RELEVANCE/APPLICATION Both oral and poster abstracts presented at the scientific sessions of the 2009 RSNA annual meeting were similar in achieving publication
in terms of average journal impact factor in each category. SSA11-08 • Developing a Computer Game for Problem Based-learning (PBL) of Radiology for Undergraduate Medical Education
(MEDGAME)
Salvador Pedraza MD, PhD (Presenter) * ; Joan C. Vilanova MD, PhD ; Elda Balliu MD ; Carles Munoz ; Enric Marti ; Jordi
Arnal ; Pere Nolla ; Joan Domenech ; Albert Ramon ; Luis Branda CONCLUSION In response to the need to improve the learning of radiology in medical schools using PBL, we have created MEDGAME. We discuss the
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task to build a computer educational game and thorough radiological aspects involved Background Problem-based learning (PBL) is a recognized and implemented educational strategy in the learning of radiology. In this project we
developed and validated a learning tool radiological computer game (MEDGAME) of image interpretation in order to improve the
effectiveness of PBL applied to radiology and its associated disciplines. Evaluation The study population was composed of 150 second-year medical students at the Medical School of the University of Girona during the
2012-2013 academic year. MEDGAME has been developed under Mac Platform with the Unity3D Engine which allows deployment for Mac
and Windows standalone application. 3D Studio MAX program was used to the create 3D characters and environments models. Images of
five scenarios of typical radiology departments were obtained: a reporting room, a plain-film X-ray room, a sonography room, a
computed tomography room, and a magnetic resonance imaging room. It was decided to include only three roles: a) The player requests
a radiological examination and then must answer the questions asked by the senior radiologist; b) senior radiologist, who asks the player;
c) patient, whose avatar is different in each challenge. Summarizing picture is shown in Figure 1. On the other hand, four challenges
have been developed into the game: Cervical trauma, appendicitis, pulmonary embolism, and acute stroke. Each challenge contains
several questions about the patient�s radiological diagnoses.
Discussion This project will make it possible to examine the degree of relevance of a specific computer game dedicated to PBL radiology education.
Each student trained with MEDGAME is completing a written surview about the knowledge and skills acquired in the Educational program.
Currently, we are analyzing the preliminary results for demonstrating whether this new tool is improving students� motivation and their
learning of radiology.
SSA11-09 • A Diagnostic Problem? Think www.diagnologic.com!
Raphael E Khayat MD (Presenter) PURPOSE Diagnologic.com is a free innovating medical database allowing an unique computer assisted diagnosis in radiology. The website has
several goals:
- To provide a quick and reliable computer assisted diagnosis in radiology using more than 500 gamuts.
- To educate radiologists by showing more than 150 000 images, Diagnologic.com publishes cases of radiology everyday on fabecook
with the account Diagnologic Radiology METHOD AND MATERIALS After 4 years of collaboration between radiologists, and experts in database, a Diagnostic Decision Support System has been developed.
The website has more than
- 100 000 images,
- 2500 diagnostics,
- 200 anatomical locations,
- 500 gamuts RESULTS Three search modes are available:
- A search mode by gamuts, which allows the user to make a diagnosis in just a few clicks, through the use of more than 500 gamuts
- A search mode by anatomy, which lists all diagnoses present in database according to a simple but comprehensive anatomic
classification
- A keyword search, which works like a conventional search engine, for which the user enters the name of diagnosis, allowing access to
many images of the same diagnosis Diagnologic is present on social networks, and presents the 'case of the day' commented by
radiologists woldwilde. CONCLUSION www.diagnologic.com is a simple, rapid, and complete website, to solve diagnoses problems, even the most complex one CLINICAL RELEVANCE/APPLICATION Diagnologic.com is a free radiologic website to help and educate radiologists. ISP: Molecular Imaging (Oncology I) Sunday, 10:45 AM - 12:15 PM • S504CD
RO
OI MI SSA12 • AMA PRA Category 1 Credit ™:1.5 • ARRT Category A+ Credit:1.5 Moderator
Daniel C Sullivan , MD Moderator
Heike E Daldrup-Link , MD Back to Top SSA12-01 • Molecular Imaging Keynote Speaker: Multi-modal Molecular Imaging of Cancer
Heike E Daldrup-Link MD (Presenter) SSA12-02 • Utilization of Ultrasound Molecular Imaging Targeted to Thy1(CD90) for the Detection of Pancreatic Ductal
Adenocarcinoma in an Orthotopic Murine Xenograft Model
Steven B Machtaler PhD (Presenter) ; Kira Foygel PhD ; Huaijun Wang MD, PhD ; Ru Chen ; Teresa A Brentnall MD ; Juergen
K Willmann MD * PURPOSE To describe the identification of Thy1/CD90 as vascular tumor marker for human pancreatic ductal adenocarcinoma (PDAC) and assess
the feasibility of using ultrasound (US) molecular imaging directed against human Thy1 (hThy1) to detect pancreatic tumors in an
orthotopic murine xenograft model. METHOD AND MATERIALS Proteomic analysis of whole tissues from patients with PDAC (n=5), chronic pancreatitis (n=5), and normal pancreas (n=10) using a
LTQ-Orbitrap hybrid mass spectrometer identified Thy1 as a pancreatic tumor marker. Expression of Thy1 in human PDAC vasculature
was verified by IHC of pancreatic tissue obtained from normal, primary chronic pancreatitis, and PDAC patient samples. An orthotopic
murine xenograft tumor model was created to assess human (h) CD90-specific in vivo microbubble (MB) binding. Murine vascular
endothelial (MS1) cells stably expressing hCD90 and human AsPC1 PDAC cells were co-injected into the tail of the pancreas of nude mice.
In all PDAC xenografts, intra-animal comparisons of ultrasound imaging signals were performed following injection of both MB Thy1 and
MBControl in a randomized order during the same imaging session using a VEVO2100 US system. RESULTS Page 39 of 183
RESULTS IHC analysis validated the proteomic data showing that hThy1 was expressed on the vasculature and significantly increased in PDAC
tumors (score: 2.1±0.1, 81% of tumors were Thy1-positive) in contrast to normal pancreata (score: 0.5±0.1; PIn vivo binding of MBThy1
to PDAC xenografts was assessed using US molecular imaging. A targeted signal using MBThy1 of 7.7±2.3 au was observed in hThy1
expressing PDAC xenografts compared to 1.9±1.8 in control tumors and 1.4±2.2 using non-targeted MBs. CONCLUSION These results illustrate the development of a translational US-MB directed against a vascular tumor marker and the development of a
novel, orthotopic human PDAC model expressing hThy1 within the tumor vasculature, which may eventually aid in earlier detection of
PDAC. CLINICAL RELEVANCE/APPLICATION This work provides the first steps towards the development of an US molecular imaging contrast agent targeted to a vascular tumor
marker for the detection of pancreatic tumors in humans. SSA12-03 • Characterization of Perfusion and Therapeutic Resistance in a Renal Cell Carcinoma Mouse Model with
Hyperpolarized 13-C-tert-butanol
Leo L Tsai MD, PhD (Presenter) * ; Xiaoen Wang MD ; Gopal Varma PhD ; David C Alsop PhD * ; Rupal Bhatt ; Aaron K Grant
PhD PURPOSE METHOD AND MATERIALS 12 mice were implanted with A498 RCC tumors. 5 were treated with sunitinib, 5 controls were administered phosphate-buffered saline
(PBS), and 2 were untreated. Sunitinib-treated mice were imaged pretreatment, 5-7 days after treatment initiation, and at resistance.
Control mice were imaged pre-PBS, 5-7 days with PBS treatment, and at a tumor limit of 20 mm. Tumors were harvested after final
images for immunohistological analysis. MRI was performed at 4.7 T using: (1) 1H-T2-weighed rapid acquisition with refocused echoes
for anatomical localization, TR/TE=3000/80ms, 128x128 matrix, 2mm slice, 3.5cm FOV, (2) h13C-tert-butanol imaging with 2D balanced
steady state free precession (bSSFP), 128x128 matrix, 8.5cm FOV, 3.3 mm slice, 512ms/frame for 100 frames, (3) arterial-spin-label
(ASL) perfusion mapping with flow-sensitive inversion-recovery. RESULTS Fig (a) and (b) show interval growth of a control tumor (outlined in red, over an axial T2-weighted 1H image) and increased perfusion
(green overlay). Sunitinib-treated tumors are vascular at pretreatment (c) but demonstrate unperceivable perfusion and growth at
postreatment day 7 (d). Reperfusion is seen at resistance (e). The peak intratumoral h13C-tert-butanol SNR of 7.9 exceeds ASL by
~2-fold. Moreover, multiple h13C-tert-butanol frames can be averaged to obtain perfusion-weighted images with greater SNR. Peripheral
tumor enhancement was consistent with central necrosis as seen on 1H imaging and histopathology. Increased perfusion during
resistance was detected in all mice using h13C-tert-butanol. CONCLUSION h13C-tert-butanol MRI provides high-SNR in vivo perfusion mapping of RCC and detects reperfusion with sunitinib resistance in a
xenograft mouse model. CLINICAL RELEVANCE/APPLICATION h13C-tert-butanol provides quantitative perfusion mapping with improved detection of vascular tumor progression and therapeutic
resistance, with high potential for translation into clinical use. SSA12-04 • Next-generation Nanoparticle Allows Accurate Prediction of Nodal Status in Pre-operative Patients with Pancreatic
Adenocarcinoma
Shaunagh McDermott FFRRCSI (Presenter) ; Sarah Thayer ; Carlos Fernandez-Del Castillo MD ; Mari Mino Kenudson MD ; Ralph Weissleder MD, PhD ; Mukesh G Harisinghani MD PURPOSE The purpose of this study was to assess the ability of a lymphotrophic nanoparticle-enhanced MRI to preoperatively detect lymph node
metastases in patients with pancreatic cancer. METHOD AND MATERIALS This exploratory study was performed as a prospective, pilot study and was approved by the Institutional Review Board. All patients with
known or high index of suspicion of pancreatic cancer and who were scheduled for surgical resection were eligible for enrollment in this
study. The study group consisted of thirteen patients (6 males, 7 females) with a mean age of 64 years; range 40 -91 years. Eleven
patients underwent surgery with an average of 23 lymph nodes resected; range 7 - 42. In total 264, lymph nodes were resected and
available for analysis. In two patients liver metastases were identified on the pre-operative MRI and therefore they did not undergo
resection. Patients underwent MRI before, and immediately and 48 hours after the intravenous administration of ferumoxytol.
Signal-to-noise ratios and subjective nodal characterization were determined based on the T2*-weighted sequences. Following resection,
the pathologic and imaging findings were compared on a regional basis. RESULTS CONCLUSION Lymphotropic nanoparticle-enhanced MRI is an accurate and safe method for detecting nodal metastases in patients with pancreatic
cancer. CLINICAL RELEVANCE/APPLICATION The ability to preoperatively identify metastatic lymph nodes in patients with pancreatic cancer could alter management, possibly making
an extended lymphadenectomy or systemic therapy a better option SSA12-05 • Targeted Biodegradable Nanoparticles MRI Contrast Agent for Enhanced Tumor Imaging and Non-viral Gene Delivery
Xiaolong Gao PhD (Presenter) ; Peijun Wang MD, PhD ; Chao Lin ; Guoliang Wang PURPOSE To prepare targeted biodegradable nanoparticles to connect folic acid MRI contrast agent with appropriate size. To explore the feasibility
of the macromolecular contrast agent for tumor targeting and the characteristics of imaging in vivo and in vitro with folic
receptor-positive tumor cells in nude mice models. METHOD AND MATERIALS RESULTS CONCLUSION In summary, SSPUA-DTPA-FA-PEG-Gd was successfully developed as a target specific, biodegradable and non-toxic delivery system of
siRNA therapeutics. Treatment with SSPUA-DTPA-FA-PEG-Gd/siVEGF complex reduced VEGF mRNA and protein expression in vitro and in
vivo, and it also retarded tumor growth in vivo. The SSPUA-DTPA-FA-PEG-Gd helps to intensify the effect in MR enhancement in nude
mice models. Therefore, SSPUA-DTPA-FA-PEG-Gd might be effective non-viral gene vector for gene therapy. Page 40 of 183
CLINICAL RELEVANCE/APPLICATION no SSA12-06 • In Vivo Reporter Imaging in a Large Animal Pre-clinical Model Demonstrates that Angiotensin II Improves Gene
Expression Upon Intra-arterial Adenovirus Delivery
Vikas Kundra MD, PhD (Presenter) * ; Murali Ravoori ; Lin Han ; Sheela Singh ; Katherine Dixon RT ; Rajesh Uthamanthil
DVM, PhD ; Sanjay Gupta MD ; Kenneth C Wright PhD * PURPOSE Gene therapy has been hampered by low levels of gene expression upon in vivo delivery. Using a somatostatin receptor type 2
(SSTR2)-based reporter, we assessed whether angiotensin II can improve gene expression by adenovirus upon intra-arterial delivery. METHOD AND MATERIALS A SSTR2-based reporter that can be imaged with the FDA approved radiopharmaceutical111-In-octreotide was used to assess gene
expression in vivo. 8 rabbits bearing VX2 tumors in each thigh were randomly injected intra-arterially with adenovirus containing a
human somatostatin receptor type 2A (Ad-CMV-HA-SSTR2A) gene chimera + angiotensin II or control adenovirus containing green
fluorescent protein (Ad-CMV-GFP). 3 days later, 111-In-octreotide was given IV after CT imaging using a clinical CT scanner and
intravenous contrast. Tumor uptake of 111-In-octreotide was evaluated the next day using a clinical gamma camera. Gene expression
was normalized to tumor weight and morphology from CT to obtain in vivo biodistribution. RESULTS SSTR2-based expression was readily visualized. VX2 tumors infected with Ad-CMV-HA-SSTR2 upon intra-arterial delivery with angiotensin
II had greater in vivo biodistribution, thus greater gene expression, than without angiotensin II (P CONCLUSION Angiotensin II can improve in vivo gene expression by adenovirus upon intra-arterial delivery. In vivo SSTR2-based reporter imaging can
be used to compare methodologies for improving gene expression. CLINICAL RELEVANCE/APPLICATION SSTR2-based reporter imaging may be useful in comparing methods for improving gene expression. Intra-arterial co-delivery of
angiotensin II with adenovirus may improve gene therapy efficacy. SSA12-07 • PSMA Imaging with 18F-DCFBC PET for Detection of Primary Prostate Cancer: Initial Evaluation Using MRI and
Pathologic Analysis
Kenneth L Gage MD, PhD (Presenter) ; Sheila Friedrich Faraj MD ; George Netto MD ; Katarzyna J Macura MD, PhD * ; Martin
G Pomper MD, PhD * ; Steve Cho MD * ; Ronnie Mease PhD ; Enrico Munari MD ; Akimosa Jeffrey-Kwanisai MBA PURPOSE 18F-DCFBC (DCFBC) is a novel low-molecular weight PET agent targeted to prostate specific membrane antigen (PSMA) that has
previously demonstrated uptake at sites of metastatic prostate cancer (PC). We present our preliminary findings evaluating quantitation of
DCFBC for the detection of primary PC. METHOD AND MATERIALS Eight patients with biopsy-proven PC with Gleason score (GS) >= 6 were imaged with both DCFBC PET and pelvic MRI (T2 and DWI) prior
to prostatectomy. PET imaging with 35 min pelvic imaging (30 min 2D and 5 minute 3D) and whole body imaging was started 2 hrs after
injection of 370 MBq (10 mCi) of DCFBC. Post-surgical prostatectomy specimens were sectioned in 4mm planar increments from apex to
base, divided into quadrants and analyzed by both HandE and PSMA immunohistochemistry (IHC). PET and MRI were visually correlated
and co-registered for analysis, and compared with the anatomically reassembled pathology results. The area of highest GS (postsurgical)
determined the location for analysis. The PET ROI (SUVmax) was correlated using Spearman's rank correlation with Gleason score, MRI
ADC values, H-score for PSMA IHC staining, degree of staining (strong, moderate, weak), and lesion size. RESULTS Three pts showed strongly positive (pos) intraprostatic DCFBC PET signal which correlated with signal on MRI and prostatectomy
pathology with dominant GS of 4+5=9 tumor. Three pts were negative (neg) by DCFBC PET with low-grade disease (GS 6, 4+3=7,
3+4=7). Two additional patients had discernible but subtle uptake which also correlated with signal on MRI and pathology with dominant
GS 4+3=7 and GS 3+4=7 PC. DCFBC PET SUVmax on WB and 2D pelvic imaging was positively correlated with GS (? coeff=0.85,
p=0.0079; ? coeff=0.72, p=0.045, respectively), and trended toward significance when compared to PSMA IHC H-score results in this
small dataset. MRI DWI imaging was able to localize sites of prostate cancer but ADC values did not correlate significantly with PC GS or
PSMA IHC. CONCLUSION DCFBC PET imaging of primary PC demonstrates tumor PET SUVmax is positively correlated with GS and trended toward significance with
tumor PSMA expression by IHC. These findings will need further confirmation in our ongoing clinical trial. CLINICAL RELEVANCE/APPLICATION PSMA imaging with DCFBC PET may provide a novel biomarker for noninvasive detection of high-grade primary prostate cancer and tumor
PSMA expression. SSA12-08 • MR Colonography with Intestine-absorbable Nanoparticle Contrast Agents in Evaluation of Colorectal Tumors
Yin Jin (Presenter) ; Jihong Sun MD, PhD ; Xia Wu ; Xiaozhe Shi ; Peng Hu ; Xiaoming Yang MD, PhD PURPOSE To develop a novel nanoparticle-based magnetic resonance (MR) colonography technique, which enabled us to evaluate colorectal tumors
via transrectal administration of intestine-absorbable nanoparticle contrast agents. METHOD AND MATERIALS Solid lipid nanoparticles (SLNs) were synthesized with loading of gadolinium (Gd) diethylenetriaminepenta acetic acid (Gd-DTPA ) and
otcadecylamine fluorescein isothiocyanate (FITC) to construct Gd-FITC-SLNs for histologic confirmation of MR findings. Twelve APCMin/+
female mice were treated with 1-2 administration cycles of 2% dextran sulfate sodium in the drinking water for 5-7 days to create the
colorectal tumors. The neoplastic mice were administered by a transrectal enema with Gd-FITC-SLNs (40mg/ml). T1-weighted MR
colonographies using spin echo sequence (TR/TE, 840/15 msec) were then performed to detect various Gd-carrying SLNs within the
colonic walls. MRI findings were correlated with subsequent histological confirmation. RESULTS MR colonographies displayed mild enhancement of the tumor masses and significant enhancement of normal colorectal walls. Confocal
fluorescence microscopy demonstrated the delivered Gd-FITC-SLNs as highly-concentrated green fluorescent spots into the surface of the
tumor mass with less spots within the tumor of APCMin/+ mice (Figure). CONCLUSION This study establishes the �proofs-of-principle� of a new MR colonography technique, which enables the differentiation of colorectal
tumors from the normal colorectal walls based on various absorption capability of nanoparticle contrast agents. Solid lipid
nanoparticle-based MR colonography may open new avenues for efficient management of colorectal tumors. CLINICAL RELEVANCE/APPLICATION Solid lipid nanoparticle-based MR colonography may open new avenues for efficient management of colorectal tumors. Page 41 of 183
SSA12-09 • Interventional Optical Molecular Imaging: Intra-procedural Imaging Guidance via a Translatable Handheld Device
for Percutaneous Sampling of Focal Hepatic Lesions
Rahul A Sheth MD (Presenter) ; Shadi A Esfahani MD, MPH ; Pedram Heidari MD ; Umar Mahmood MD, PhD PURPOSE As a real-time, high resolution imaging modality, optical molecular imaging has the potential to significantly advance image guidance
during interventional radiology (IR) procedures. The clinically approved optical molecular imaging agent indocyanine green (ICG) has
recently been shown to localize to both primary and metastatic malignant hepatic lesions. We assessed the ability of ICG to serve as a
molecular beacon for hepatic malignancy by highlighting lesions with high target-to-background ratios (TBRs). We also evaluated the
ability of custom-designed, translatable, catheter-based handheld imaging system to perform intra-procedural measurements of ICG
fluorescence intensity during the percutaneous sampling of focal hepatic lesions. METHOD AND MATERIALS A handheld optical molecular imaging device was constructed to pass through the introducer needle of a standard 18 gauge percutaneous
biopsy kit. Intrahepatic colorectal cancer metastases (human colorectal cancer cell line HT-29) were generated in nude mice (n = 25).
Epifluorescence imaging of the tumors was performed 4 weeks post-implantation at multiple time points following the intravenous
administration of 0.5mg/kg ICG. The mice were then imaged using the custom designed handheld imaging device, and measurements of
fluorescence intensity within normal liver versus tumor were acquired. RESULTS There was avid localization of ICG to the focal hepatic lesions at all time points by epifluorescence imaging. Similarly, fluorescence
intensity within the tumors was significantly greater than within normal liver as detected by the handheld imaging system, with a TBR of
3.9 ± 0.2 at 24 hours. A core biopsy of tumor and normal adjacent liver using a standard 18 gauge biopsy needle demonstrates a sharp
margin of fluorescence intensity at the tumor-liver interface, with a 10%-90% rise distance of 4mm. CONCLUSION The custom-designed molecular imaging device, in combination with ICG, was able to readily differentiate between normal versus
malignant tissue, an ability that is of tremendous potential utility in IR. Both the device and imaging agent are ready for immediate
clinical translation. CLINICAL RELEVANCE/APPLICATION Optical molecular imaging may improve the accuracy and obviate the need for cytologic �wet reads� or frozen section analysis during
percutaneous biopsy procedures. Musculoskeletal (Shoulder I) Sunday, 10:45 AM - 12:15 PM • E451A
MR
MK SSA13 • AMA PRA Category 1 Credit ™:1.5 • ARRT Category A+ Credit:1.5 Moderator
Michael J Tuite , MD Moderator
Kirkland W Davis , MD Back to Top SSA13-01 • The Detour Sign on MR Image for Subluxation of the Long Head of Biceps Tendon with Arthroscopic Correlation
Eun Kyung Khil MD (Presenter) ; Jang Gyu Cha MD ; Hyun Joo Kim MD ; Kyung Dae Min ; Hyun-Sook Hong MD, PhD ; Beom
Ha Yi ; Jae Myeong Lee PURPOSE To determine whether detour sign at magnetic resonance (MR) imaging is an indicator of subluxation of the long head of the biceps
tendon in the shoulder joint. METHOD AND MATERIALS This retrospective study evaluated 65 patients (M: F=29: 36; age range: 49-79 years, mean: 58 years) who had shoulder pain and
underwent arthroscopic surgery, between January 2012 and February 2013. All patients underwent 3T MR imaging for diagnosis of
shoulder diseases, and the MR scans were independently reviewed by two musculoskeletal radiologists. When MR imaging showed a
subscapularis tear with biceps pulley lesion (Habermeyer group 4)(criterion 1) or additional �detour sign� of the biceps (criterion 2) on
the axial images, the lesion was considered to be a subluxation of the long head of the biceps tendon (SLBT). After MR imaging, shoulder
arthroscopy was performed in all patients for a definitive diagnosis of SLBT. Descriptive statistics were calculated and the sensitivity
values were compared by using the McNemar test. A kappa statistic was recorded for interobserver agreement regarding the presence of
the detour sign, subscapularis tear, and pulley lesion on MR imaging. RESULTS Arthroscopy showed SLBT in 18 patients. When MR imaging diagnosis was based on criteria 1 only, SLBT was diagnosed with a sensitivity
of 44.4%, and an accuracy of 80.4%. When MR imaging diagnosis was based on both the criterion 1 and the criterion 2 using �detour
sign�, SLBT was diagnosed with a sensitivity of 83.3% and an accuracy of 81.5%. By adding criterion 2 for diagnosis, 10 patients with
SLBT were additionally diagnosed, of which 7 patients had been confirmed SLBT on arthroscopy. There is a significant difference (p CONCLUSION The detour sign based on axial MR images may be regarded as an additional anatomical feature that helps improve diagnostic
performance for detecting SLBT. CLINICAL RELEVANCE/APPLICATION The detour sign will make it easy to detect the lesion with only several images on the axial plane, and may improve the detection rate of
SLBT and provide the reasonability for surgery. SSA13-02 • ABER Position MR Arthrography of the Shoulder: Diagnostic Signs for Capsular Laxity in Patients with Atraumatic
Multidirectional Instability
Christoph Schaeffeler MD (Presenter) ; Simone Waldt MD ; Jan S Bauer MD ; Chlodwig Kirchhoff MD ; Bernhard Haller ; Michael Schroeder ; Ernst J Rummeny MD ; Andreas Imhoff ; Klaus Woertler MD PURPOSE To retrospectively evaluate diagnostic signs for capsular laxity on ABER position MR arthrography (MR-A) of the shoulder in patients with
atraumatic multidirectional instability. METHOD AND MATERIALS Clinical data of patients with 275 consecutive MR-Arthrographies including T1w ABER position were reviewed. Patients with MDI were
identified through typical clinical history and instability in two or more directions. Patients with traumatic instability, previous surgery,
overhead athletes (including posterosuperior impingement), and age >45 years were excluded. The control group comprised patients with
clinical stable shoulders. ABER position MR-A were independently assessed by three blinded radiologists for two defined signs (Figure): (1)
Crescent sign: Presence of contrast agent between the anterior inferior glenohumeral ligament (AIGHL) and the humeral head (HH); (2)
Page 42 of 183
Crescent sign: Presence of contrast agent between the anterior inferior glenohumeral ligament (AIGHL) and the humeral head (HH); (2)
Triangle sign: Contrast filled triangular shaped space between AIGHL, HH, and glenoid. Centering of the HH in the glenoid fossa was
determined. All images were reevaluated by observer 1 two months after the initial assessment. RESULTS 21 MR-A were added to the study group, 17 to the control group. Sensitivity for the crescent sign in the diagnosis of MDI was 57/62/48%
(observer 1/2/3), specificity was 100/100/94/% with excellent multirater-agreement (? =0.813); area under the ROC-Curve (AUC) was
0.786/0.810/0.709. Sensitivity for the triangle sign was 48/57/48%, specificity was 94/94/94% with excellent multirater-agreement (?
=0.934); AUC was 0.709/0.756/0.738/0. The presence of at least one of these laxity signs had a sensitivity of 86/91/81%, a specificity of
94/88/94% with an AUC of 0.899/0.894/0.875 (? =0.842); Intraobserver-agreement was excellent (? =1.000). Patients with a positive
triangle sign showed significantly increased posterosuperior decentration of the HH (? CONCLUSION Considered separately, the crescent and triangle sign showed inappropriate diagnostic performance. However, the presence of either the
crescent or the triangle sign or both on ABER position MR arthrography of the shoulder allows for accurate diagnosis of capsular laxity in
patients with atraumatic MDI. CLINICAL RELEVANCE/APPLICATION Functional MR-Arthrography of the shoulder including images in ABER position enables the radiologist to accurately assess laxity of the
anteroinferior joint capsule by using simple and objective signs. SSA13-03 • Correlation of MRI with Arthroscopy for the Diagnosis of Subscapularis Tendon Tears: A Musculoskeletal Division’s
Experience
Soterios Gyftopoulos MD (Presenter) ; John S O'Donnell MD ; Neil P Shah MD ; James S Babb PhD ; Michael P Recht MD PURPOSE To determine the accuracy of MRI for the diagnosis of subscapularis tendon tears utilizing arthroscopy as the gold standard. METHOD AND MATERIALS The MR and arthroscopy reports from 286 consecutive patients were reviewed with 3 inclusion criteria: 1) Non-contrast MRI performed at
our institution, 2) Arthroscopy (OR) within 6 months of the MRI, and 3) No prior subscapularis surgery. 42 patients were excluded (6
non-specific OR reports, 4 tears of the inferior tendon, 32 MR arthrographic studies). The MR and OR reports were reviewed for the
presence and degree of tearing (partial (PT)/full-thickness (FT)). Only PT-articular tears were included, as tears that involved only the
intrasubstance and/or bursal surface are not typically seen on arthroscopy as per our orthopaedists. Estimates of the accuracy,
sensitivity, specificity, and positive and negative predictive values were derived for MRI using arthroscopy as the gold standard. RESULTS There were a total of 244 patients (161 men/83 women; mean 48 yrs/range 15-83) and 111-1.5T/133-3T MRIs. There were 25 (16 PT/9
FT) tears and 219 intact tendons on arthroscopy. Nineteen of the 25 arthroscopic tears (10/16 PT; 9/9 FT) and 200 of the 219
arthroscopic normal studies were correctly diagnosed on MRI. One tear was called FT on MRI, but was PT in the OR. There were 18 PT
and 1 FT tears identified on MRI that were not seen in the OR as well as 5 PT tears found in the OR, but not on MRI. Without
differentiating between PT and FT tears, our analysis demonstrated 80% sensitivity, 91% specificity, 90% accuracy, and 51% positive
and 98% negative predictive values. There was 91% accuracy for the diagnosis of PT tears and 99% accuracy for the diagnosis of FT
tears. Retrospective review of the false positive cases demonstrated 3 common causes of reader error: volume averaging, misdiagnosis of
an intrasubstance tear as an articular tear, and associated underlying advanced tendinosis. CONCLUSION MRI can be used to accurately diagnose subscapularis tendon tears utilizing arthroscopy as the gold standard. CLINICAL RELEVANCE/APPLICATION MRI is an effective tool in the evaluation of the subscapularis tendon. Familiarity with common causes of reader error (i.e. volume
averaging) will decrease the likelihood of overcalling pathology. SSA13-04 • Subscapularis (SSC) Tendon Tears: Diagnostic Performance and Inter-observer Reliability of Direct Magnetic
Resonance Arthrography (MRA) among Observers with Varying Levels of Experience with Arthroscopic Correlation
Eugene Lee (Presenter) ; Jung-Ah Choi MD ; Ju Han Oh MD ; Eugene Joe ; Sujin Kim ; Sung Hwan Hong MD ; Heung S
Kang MD PURPOSE To retrospectively review the diagnostic performance and inter-observer reliability of direct MRA in the diagnosis of articular/bursal-sided
partial thickness and full-thickness SSC tendon tears among observers with varying levels of experience. METHOD AND MATERIALS Preoperative direct MRAs of 297 consecutive patients with arthroscopic confirmation (164 with normal or tendinopathy SSC tendons, 100
with articular/bursal-sided partial thickness tears, and 33 with full thickness tears) were evaluated independently by three radiologists
with differing levels of experience in interpretation of musculoskeletal images. Diagnosis was made on T1 axial and/or sagittal images
with fat suppression regarding the following findings, i.e. defect, thinning, thickening, increased signal intensity, leakage of gadolinium
MR contrast, and was divided into three groups: 1= normal/tendinopathy, 2= articular/bursal-sided partial thickness tear, 3= high grade
partial (more than 50% thickness)/full thickness tear. Sensitivity, specificity, and diagnostic accuracy were calculated. Inter-observer
reliability was also evaluated using ICC between each pair of observers. RESULTS For full thickness tears, sensitivity was 87.9%/69.7%/66.7% (reader 1/reader 2/reader3); specificity was 97%/98.5%/89.0%, and
accuracy was 78.4%/85.1%/43.1%. For partial thickness tears, sensitivity was 75%/71%/56%; specificity was 81.7%/80.2%/69.0%, and
accuracy was 67.6%/64.5 %/47.9%. For normal SSC tendons, sensitivity was 79.3%/82.3%/61.6% ; specificity was
85.7%/81.2%/78.9%, and accuracy was 87.2%/84.4%/78.3%. The interclass correlation coefficient (ICC) was excellent for reader
1/reader 2 (ICC : 0.7918), good for reader 1/reader 3 (ICC : 0.6959), and fair for reader 2/reader 3 (ICC: 0.5927). CONCLUSION For diagnosis of SSC lesions on direct MRA, specificity was higher than sensitivity and accuracy for all three observers, especially for
partial thickness tears. Accuracy was especially low in less experienced observer. Interobserver reliability varied according to level of
experience, lower in observers with less experience. CLINICAL RELEVANCE/APPLICATION Depending on the level of experience of the radiologist, diagnostic performance of direct MRA in the diagnosis of subscapularis tendon
tears varies, especially in diagnosis of partial thickness tears. SSA13-05 • PASTA Lesion of Rotator Cuff Foot Print: Direct MR Arthrographic Findings in Surgically Confirmed Patients
Eun Hae Park (Presenter) ; Ja Young Kim ; Young Han Lee MD ; Sungjun Kim MD ; Ho-Taek Song MD ; Jin-Suck Suh MD PURPOSE To evaluate MR arthrographic (MRA) findings and to compare the MR findings with arthroscopic findings of characteristics, anatomical
distribution and extent of PASTA (partial articular-sided supraspinatus tendon avulsion) in arthroscopically confirmed patients. METHOD AND MATERIALS Page 43 of 183
Sep 2009 to Feb 2013, 62 patients arthroscopically confirmed as PASTA. We excluded one lesion mixed with arthroscopically full-thickness
tear. Total 61 patients were enrolled, and all patients underwent MRA with using 3-T MR. Mean interval time between MRA and
arthroscopy was 77.3 days. Two musculoskeletal radiologists retrospectively reviewed the MRA by consensus blind to arthroscopic
findings. PASTA was defined as undersurface tendon discontinuity at the footprint with articular side contrast. Anatomical locations were
divided by four: anterior, posterior, transition zone, inferior half of the middle facet of the greater tuberosity. Vertical extension divided
into 3 grade: grade 1; involving 1-2mm of tendon insertion, grade 2; involving =50%, grade 3; involving >50%. Arthroscopies were
done by one experienced orthopedic surgeon. Pearson correlation test was used to correlate the vertical grade and surgical percentage of
the PASTA. RESULTS Of the 61 patients, 51 patients were diagnosed as PASTA (83.6%): anterior in 36 (70.6%), posterior in 10 (19.6%), and transitional zone
in 5 (9.8%). There was no involvement inferior half of the middle facet. Grade 1 vertical extension were 12 (23.5%), grade 2 in 18
(35.3%), and grade 3 in 21 (41.2%). The Pearson correlation test between MR vertical extension grade and surgical percentage was
0.69 (p
CONCLUSION PASTA lesion is well visualized on MRA as showing contrast filling at the partial articular-sided footprint avulsion at the greater tuberosity.
The vertical extension grade was good correlation with surgical grade. In patients with extra-articular contrast leakage, the PASTA lesion
could be misdiagnosed on MRA. CLINICAL RELEVANCE/APPLICATION PASTA lesion is well diagnosed on MRA and its extent was good correlation with surgical grade. SSA13-06 • Postoperative MR Six Months after Rotator Cuff Surgery: Which MR Finding Is Correlated to Clinical Outcome?
Wooil Kim (Presenter) ; Young Cheol Yoon MD ; Sanghee Lee MD PURPOSE The purpose of this study is to evaluate the correlation between various post-operative MR findings and clinical score. METHOD AND MATERIALS This retrospective study protocol was approved by our institutional review board and informed consent was waived. MRI examinations
were performed on 180 shoulders of 178 patients who underwent rotator cuff repair surgery (64 males, 114 females; mean age, 60.2
years; age range, 22�80 years). The mean interval between MR and surgery was 160.6 (120�180) days. Two radiologists who were
blinded to clinical score evaluated continuous variables (bone marrow edema-maximum, bone marrow edema-summation, thickness of
repaired tendon) independently, and categorical variables (adhesive capsulitis, foot print coverage, subcortical cyst, fatty atrophy of
rotator cuff muscles, subacromial enthesophyte, subacromial fluid, and signal intensity grade of repaired tendon) with a consensus. Each
finding was correlated to American Shoulder and Elbow Surgeons (ASES) score and the Constant-Murley (Constant K) score of clinical
outcome. Pearson correlation coefficient was calculated and p value less than 0.05 was regarded as statistically significant. Intraclass
coefficients were obtained for continuous values. RESULTS Thickness of repaired tendon (p=0.014 for reviewer 1, p=0.001 for reviewer 2 with ASES score; p=0.002 for reviewer 1, p CONCLUSION Thickness of repaired tendon and fatty atrophy of rotator cuff muscle were significant findings correlated to clinical outcome at six-months
after rotator cuff surgery. CLINICAL RELEVANCE/APPLICATION Attention should be paid to thickness of repaired tendon and fatty atrophy of rotator cuff muscle when evaluating post-operative MR after
rotator cuff surgery. SSA13-07 • Decentering Syndrome: An Important Cause of Isolated Teres Minor Atrophy
Scott Lenobel MD (Presenter) ; Michael Olson DO, MBA ; Jason E Payne MD ; Alan Rogers MD ; Erin Shropshire ; Barbaros S
Erdal DDS, PhD ; Joseph S Yu MD PURPOSE To evaluate imaging findings related to humeral head decentering as a potential cause of isolated teres minor atrophy. METHOD AND MATERIALS We retrospectively reviewed 500 shoulder MRI examinations performed from 2004-2013 to identify patients with isolated teres minor
atrophy. We excluded patients with quadrilateral space or Parsonage-Turner syndromes and those with a history of posterior shoulder
dislocation. 37 patients fit our selection criteria with 2 patients exhibiting bilateral disease. Decentering was defined as posterior humeral
head subluxation at rest. The images were reviewed by a musculoskeletal radiologist and fellow for posterior labral tears, posterior
capsular pathology, and humeral head decentering. Additional findings recorded were the presence of a rotator cuff, biceps tendon, and
superior or anterior labral tear, and glenohumeral arthritis. An age and sex matched control group of 39 patients was identified in which
each patient had a posterior labral tear but no teres minor atrophy. RESULTS The incidence of isolated teres minor atrophy is 1.6%. In our group of 39 patients (30 males/9 females; average age 54 years, range 33
to 79 years), 38 (97.4%) had a posterior labral tear, posterior capsular pathology, or humeral head decentering. Posterior labral tears
were seen in 32 (82.1 %), 14 (35.9%) had posterior capsular pathology, and 19 (48.7%) demonstrated posterior humeral head
subluxation. 33 had a rotator cuff tear, none of which involved the teres minor, 11 had a biceps tear, 32 had an anterior labral tear, 29
had a superior labral tear, and 26 had glenohumeral joint arthritis. In the control group, 7 (17.9%) had posterior humeral head
subluxation compared to 19 (48.7%) in the teres minor atrophy group (p value < 0.01). CONCLUSION Humeral head decentering is a frequent finding in patients with isolated teres minor atrophy in addition to secondary signs of posterior
glenohumeral instability suggesting that traction on the teres minor nerve may be integral to this condition. A statistically significant
difference in the presence of humeral head decentering was shown between patients with isolated teres minor atrophy compared to
patients without isolated teres minor atrophy. CLINICAL RELEVANCE/APPLICATION Ours is the first project to identify a statistically significant association between posterior humeral head decentering and isolated teres
minor atrophy. SSA13-08 • Subcoracoid Impingement; Is the Consequence of Narrow(ed) Coracohumeral Interval or Narrow Coracohumeral
Angle?
Eser Sanverdi MD (Presenter) ; Ali Oznur MD ; Mehmet Ali Gurses MD ; Safak Salvarli MD PURPOSE Subhoracoid impingement (SCI) is the one of the most frequent reason of the anterior shoulder pain. Degeneration of subcoracoid muscle
tendon secondary to repetetive microtrauma is the main problem.In this magnetic resonance imaging study we aimed to investigate if
the angle between the free edge of the coracoid process and the humeral head (CHA),or the distance of the coracohumeral interval (CHD)
was causative in the development of SCI. METHOD AND MATERIALS Page 44 of 183
RESULTS CONCLUSION To our best knowledge,CHA was not assessed as an indicator of SCI until now. In the development of isolated subcoracoid
tendinopathy,our findings suggested that CHA is more important than CHD.However further clinical and radiological studies are needed. CLINICAL RELEVANCE/APPLICATION Coracoplasty indications and techniques might be influenced by the course of the coracoid. SSA13-09 • Does Reducing the Concentration of Bupivacaine when Performing Therapeutic Shoulder Joint Injections Impact the
Clinical Outcome? Our Experience after 1500 Injections
Michael G Fox MD (Presenter) * ; James Patrie MS PURPOSE Since the chondrotoxicity of local anesthetics is dose dependent, we reduced the Bupivacaine concentration when performing therapeutic
joint injections from 0.50% to 0.25% in 2011. This study determines if this lower Bupivacaine concentration impacted the 10 minute and
1 week post-injection pain scores in patients receiving steroid-anesthetic joint injections. METHOD AND MATERIALS This IRB approved HIPPA compliant study included all out-patient fluoroscopic guided glenohumeral injections performed by
musculoskeletal (MSK) radiologists and/or MSK fellows between 9/09 and 3/13. Intra-articular placement was confirmed with iodinated
contrast or rarely air. Patients received either 2.5 mL of Bupivacaine 0.5% (Group A) or 2.5 mL of Bupivacaine 0.25% (Group B). All
injections included 0.5 cc of Kenalog 40mg/mL. Group A included 493 injections (210M:283F) (mean age 57) and Group B included 1049
injections (448M:601F) (mean age 57). The patients� pain level was recorded by someone blinded to the Bupivacaine concentration on a
numeric scale of 0-10 (0=no pain and 10=extreme pain) immediately prior to and 10 minutes post-injection (all injections) and 1 week
post-injection (877 injections). Orthopedics referred 92.9% of Group A and 95% of group B injections. Statistical analysis was performed
using linear mixed models. RESULTS The pre- and 10 minute post-injection mean pain scores (all injections) was 5.5/10 and 1.9/10 for Group A and 5.2/10 and 2.1/10 for
Group B. The pre- and 1 week post-injection (877 injections) mean pain scores was 5.7/10 and 3.0/10 for Group A and 5.4/10 and
3.3/10 for Group B. Adjusting for sex, age and pre-pain level, the estimated mean difference in pain reduction between Groups A and B
was 0.27 (95% CI:[0.03,0.51]p=0.030) 10 minutes post-injection and 0.46 (95% CI:[0.14,0.78]p=0.005) 1 week post-injection with
pain greater reduction in Group A. Mean fluoro time was 20.5 sec in group A and 13.7 sec in Group B (p
CONCLUSION Patients reported statistically greater pain reduction both 10 minutes and 1 week after therapeutic glenohumeral injections when a higher
concentration of Bupivacaine was utilized. CLINICAL RELEVANCE/APPLICATION Glenohumeral injections using a higher Bupivacaine concentration provided greater pain relief. However, the actual numeric estimated
reduction in pain is small and may not be clinically significant. Musculoskeletal (Tumor I) Sunday, 10:45 AM - 12:15 PM • E451B
OI
MR MK SSA14 • AMA PRA Category 1 Credit ™:1.5 • ARRT Category A+ Credit:1.5 Moderator
Mark D Murphey , MD Moderator
Jim S Wu , MD * Back to Top SSA14-01 • Diagnostic Performance of Ultrasound Elastography in the Evaluation of Benign and Malignant Soft Tissue Tumors
Se Kyoung Park (Presenter) ; In Sook Lee ; You Seon Song ; Jeung Il Kim MD, PhD ; Hoon Soo Kim PURPOSE To evaluate the diagnostic performance of ultrasound elastography for differentiating malignant from benign soft tissue tumors. METHOD AND MATERIALS From December 2012 to March 2013, 52 consecutive patients with soft tissue mass lesions underwent ultrasound including elastography
by two musculoskeletal radiologists. One radiologist measured quantitatively the size, elasticity ratio between lesion and normal
subcutaneous fat layer, region-of-interest (ROI) values and semiquantitatively elasticity score (1-10) by color pattern on obtained cine
elastographic images by using Q-Lab software consulting other radiologist. Also two radiologists analyzed the location (5 types according
to depth), echogenecity (6 types), margin, the presence or absence of posterior enhancement and vascularity by consensus.
RESULTS 36 patients had benign lesions and 16 had malignant soft tissue tumors. In the cases of benign tumors, mean ROI value, elasticity ratio,
and elasticity score were 73.4, 1.53, and 5.25, respectively. In the malignant tumors, those are 52.3, 1.88, and 2.93, respectively. By
two sample t-test, the ROI values, the size, the elasticity score and the location were significant factors (p < 0.05). The elasticity ratio,
echogenecity, the presence or absence of posterior enhancement and vascularity and margin not affected to differentiate between benign
and malignant lesions (p > 0.05). In the measurement of elasticity ratio, intra-class correlation coefficient was 0.896 (p < 0.05) and the
difference of measured values was insignificant. Also, the locations of tumors did not affect to the elasticity ratio. By ROC analysis, only
the size (AUC, 0.825; SE, 0.0611; 95% confidence interval, 0.694-0.916; p < 0.0001, criterion > 28 mm) was statistically significant.
CONCLUSION Although the elasticity ratio of the soft tissue mass was not significant, the elasticity score by color pattern was helpful for differentiating
between benign and malignant lesions on ultrasound elastography.
CLINICAL RELEVANCE/APPLICATION The quantitative measurement such as elasticity ratio was not yet useful for differentiating between benign and malignant soft tissue
tumors. However the elasticity score by color pattern was helpful. SSA14-02 • Cost-effectiveness of Advanced Cross-sectional Imaging in the Work-up of Newly Discovered Soft Tissue Masses
Sahar J Farahani MBBS (Presenter) ; John Eng MD ; Christian Meyer ; John A Carrino MD, MPH * ; Laura M Fayad MD PURPOSE To determine the required accuracy of an advanced imaging modality to be cost-effective over biopsy in the work-up of new soft tissue
masses (STMs) that have already undergone a conventional work-up. METHOD AND MATERIALS Page 45 of 183
METHOD AND MATERIALS A decision analytic model was developed to estimate quality-adjusted-life (QALY) and costs associated with biopsy and advanced imaging
(such as MR spectroscopy) in differentiating between malignant and benign STMs for the first five years after diagnosis. The model
incorporated prevalence of malignant and benign STMs at the community level, the performance characteristics of the imaging modality
of choice, 1-5 year overall survival rate for the different stages at the time of diagnosis, and costs and effectiveness associated with each
strategy. A discount rate of 3% was considered. An incremental cost per QALY gained was compared between two strategies. One-way
sensitivity analysis was performed to evaluate the stability of the model to change in the clinically-plausible range for all the variables.
Threshold analysis was used to determine the performance characteristic of the imaging tool, which could justify its utilization regarding
costs and effectiveness instead of biopsy. RESULTS Considering a malignancy prevalence of 0.01 and sensitivity and specificity of 95% and 82% for the imaging modality, we ran a Monte
Carlo micro-stimulation model 10000 times. The results demonstrated that the incremental cost for one QALY gained by advanced
imaging was $776, whereas by biopsy, was $1472. Threshold analysis revealed a required sensitivity of 83% and specificity of 75% for
justifying advanced imaging over biopsy. One-way sensitivity analysis showed the model is stable to change in a clinically plausible range
for the other variables.
Conclusion: For the work-up of new STMs, advanced imaging is a cost-effective non-invasive alternative to biopsy.
CONCLUSION For the work-up of new STMs, advanced imaging is a cost-effective non-invasive alternative to biopsy. CLINICAL RELEVANCE/APPLICATION Benign STMs present to Orthopaedic clinics 100 times more commonly than malignant STMs and are often unnecessarily referred for
biopsy. Decision analysis proves the value of advanced imaging as the in SSA14-03 • Detection of Soft Tissue Sarcoma Recurrence: Added Value of Functional MR Imaging Techniques at 3T
Filippo Del Grande MD, MBA (Presenter) ; Ty K Subhawong MD ; Kristin L Weber MD ; Michael R Aro MBBS * ; Charles M
Mugera MBBCh, MRCP ; Laura M Fayad MD PURPOSE To define the added value of dynamic contrast-enhanced (DCE-MR) and quantitative diffusion weighted imaging (DWI) with apparent
diffusion coefficient (ADC) mapping to detect recurrence of soft tissue sarcomas (STS) after surgical resection. METHOD AND MATERIALS The study is HIPPA compliant and approved by our institutional review board. 58 MR patients referred for post-operative surveillance
following STS resection were studied with 3 T MR. The MR protocol included: T1-weighted, fluid-sensitive, contrast-enhanced
T1-weighted, DCE-MR, and DWI with ADC map. Two readers independently reviewed for signal and morphologic characteristics on
conventional sequence, the presence or absence of arterial enhancement by DCE-MR and ADC measurements of the surgical bed.
Mass-like signal abnormality on conventional sequences, arterial enhancement by DCE-MR or a low signal mass on ADC maps were
defined as recurrence. The readers reviewed first the conventional sequences, second the addition of DCE-MR, and third the DWI/ADC
maps. The diagnostic performance of conventional MR for detecting recurrence was compared to that with the addition of functional
sequences. RESULTS There were eight histologically-proven recurrences out of 58 studies. The sensitivity and specificity of MR for detecting tumor recurrence
were 100% and 48.0%, 60.0% and 93.2%, and 100% and 90.7% for conventional sequences, for addition of DCE-MR, and for addition
of DWI/ADC mapping, respectively. CONCLUSION The addition of functional MR sequences to a routine MR protocol increase specificity over 90%. In particular DCE-MR alone has a
discrimination ability of 95% for distinguishing recurrent sarcoma from post-surgical scarring CLINICAL RELEVANCE/APPLICATION For detecting recurrence, the improved specificity offered by functional sequences has the potential to reduce unnecessary biopsies and
patient anxiety SSA14-04 • Mural Nodule in a Postoperative Fluid Collection after Soft Tissue Sarcoma Resection at MRI: Not a Sign of Recurrent
Tumor
Joshua Lantos MD (Presenter) ; Sinchun Hwang MD ; David M Panicek MD PURPOSE To determine the prevalence and clinical significance of nodules within fluid collections at MRI after surgical resection of primary soft
tissue tumors. METHOD AND MATERIALS This retrospective study includes 175 consecutive patients who underwent resection of primary soft tissue sarcoma at a tertiary cancer
center and showed fluid collections at least 1 cm in largest diameter in the surgical bed at postoperative MRI. Images were reviewed to
determine the presence of nodules within the collections, defined as a well-defined focus measuring at least 0.7 cm on T1-weighted and
fluid-sensitive images. Collections were classified based on signal intensity (homogeneous, heterogeneous), and the presence of septa,
blood products (hyperintense T1 signal), and rim (thin, thick, enhancing). The size, signal intensity, and contrast enhancement of
nodules were reviewed. Nodules were classified as benign or malignant based on histologic results, or clinical or MRI follow-up. RESULTS Collections were present in 75 patients (43%). 43 collections showed homogeneous fluid intensity (57.3%) and 32 were heterogeneous
(42.6%). Internal septa were present in 49 (65.3%) and blood products in 16 (21.3%). The majority of collections showed a thin rim
(66.6%) and rim enhancement (90.6%). Nodules were present inside six (8%) collections. All collections that contained nodules were
heterogeneous, and half showed an enhancing rim. Three (50%) nodules enhanced and two (33%) were T1-hyperintense. At follow-up
MRI, three nodules resolved, two were stable in size, and one decreased in size. Nodules in two patients were biopsied, and surgically
resected in another; all three nodules were benign. Two other patients had no recurrence at clinical or imaging follow-up, and another
died within three months from metastases. CONCLUSION Nodules infrequently develop within a fluid collection at MRI after surgical resection of a primary soft tissue sarcoma, and are unlikely to
represent local tumor recurrence. CLINICAL RELEVANCE/APPLICATION A nodule within a postoperative fluid collection at MRI after soft tissue sarcoma resection generally does not represent tumor recurrence;
follow-up MRI is recommended rather than immediate biopsy. SSA14-05 • Magnetic Resonance Imaging of Incompletely Excised Soft Tissue Sarcomas
Anna McNaught MBBS (Presenter) ; Ali M Naraghi ; Ravi Menezes PhD ; Bader Alhariqi ; Peter C Ferguson MD ; Jay Wunder
MD ; Lawrence M White MD * PURPOSE Page 46 of 183
The aim of this study was to assess the utility of MRI in identifying the presence of residual disease in incompletely excised soft tissue
sarcomas. METHOD AND MATERIALS Following IRB approval, 315 consecutive cases of incomplete excision of soft tissue sarcoma were identified from a surgical database. 237
patients with a positive margin at initial surgery who underwent MRI prior to re-excision were included. Two MSK radiologists, blinded to
the final pathological finding at re-operation reviewed all MRIs in consensus. Pulse sequences varied but included axial and longitudinal
T1 and fat suppressed fluid sensitive images in all cases. Post-gadolinium T1 fat-suppressed images were available in some. Imaging
features evaluated included lesion morphology, location, fascial penetration, signal characteristics and enhancement. An overall consensus
prediction was made regarding the presence of residual disease. The individual findings and the overall prediction were compared to the
final pathology. RESULTS There were 98 females and 139 males with an average age of 55 years (range 17-89). The pathological diagnosis was malignant fibrous
histocytoma (n=67), leiomyosarcoma (n=47) and liposarcoma (28). The remaining 96 patients had undifferentiated sarcomas or rare
subtypes.
120 patients had residual disease, 48 with microscopic foci and 72 with macroscopic foci greater than 10 mm in diameter. 117 patients
had no residual disease on pathology. MRI had a sensitivity of 60%, specificity of 91%, PPV of 87% and NPV of 69%. When a mass was
present on pathology, MRI had a high sensitivity (88%) and specificity (88%) and a high NPV (94%). There was a poor sensitivity (19%)
in detection of microscopic residual disease.
82 lesions had nodular, 40 plaque and 115 reticular morphology. The presence of a nodule had a high specificity (89%) and PPV (84%)
but a low sensitivity (58%). Plaque and reticular morphology had low sensitivities and predictive values.
CONCLUSION MRI performs poorly in identifying those with microscopic disease but has a better performance in the presence of macroscopic disease.
The presence of a nodule is the most specific morphologic predictor of residual disease. CLINICAL RELEVANCE/APPLICATION Many soft tissue sarcomas have positive margins at initial surgery. MRI is the modality of choice for re-evaluation. Further investigation of
its utility in predicting disease is of value. SSA14-06 • Comparison of 3T Diffusion-weighted MR Imaging and PET/CT in Bone and Soft Tissue Tumors: Quantitative Analysis
of ADC and SUV
So-Yeon Lee MD (Presenter) ; Won-Hee Jee MD ; Ie Ryung Yoo ; Joon-Yong Jung MD ; Yang-Guk Chung MD PURPOSE To retrospective determine whether the apparent diffusion coefficients (ADC) on 3T diffusion-weighted magnetic resonance imaging
(DWI) correlate with the standardized uptake values (SUV) on positron emission tomography (PET)/computed tomography (CT) in bone
and soft tissue tumors. METHOD AND MATERIALS The institutional review board approved this HIPAA-compliant study, and informed consent was waived. This study included 45 patients
(30 men, 15 women, mean age 57 years, range 17-90) with pathologically confirmed soft tissue (n = 34) and bone (n = 15) tumors who
underwent 3T MR imaging including DWI and whole-body fluorine 18 fluorodeoxyglucose PET/CT before treatment. Maximum (SUVmax)
and average (SUVav) SUVs of the tumors were obtained by one nuclear medicine physician. Two musculoskeletal radiologists
independently measured minimum (ADCmin) and average (ADCav) ADCs of tumors on the corresponding regions of the tumors where
SUVs were obtained. ADC (ADCmus) of normal skeletal muscle was measured on the same axial plane. The ratios ADCmin/ADCmus and
ADCav/ADCmus were calculated by ADCmin and ADCav of tumors divided by ADCmus, respectively. The Spearman rank correlation was
obtained for statistical analysis. The differences in areas under the receiver operating characteristic curves (AUCs) were assessed. RESULTS There was significant, inverse correlation between SUVmax and the ratio ADCmin/ADCmus (r = -0.435 for reviewer 1 and r = -0.449 for
reviewer 2, respectively, P < .005). SUVav and ADCav/ADCmus showed significant, inverse correlations (r = -0.444 for reader 1 and r =
-0.440 for reviewer 2, respectively, P < .005). The AUCs of ADCmin/ADCmus and ADCav/ADCmus (0.955 for reviewer 1, 0.959 for
reviewer 2, respectively) were significantly higher than those of SUVmax and SUVav (0.820 and 0.777, respectively) (P < .05). CONCLUSION There was significant correlation between ADC at 3T DWI and SUV at PET/CT in bone and soft tissue tumors and DWI showed better
diagnostic performance than PET/CT for diagnosing malignancy. CLINICAL RELEVANCE/APPLICATION Quantitative DWI at 3T is comparable to PET/CT for evaluating bone and soft tissue tumors. SSA14-07 • Dynamic Contrast Enhanced (DCE) Targeted MR-guided Biopsy of Soft Tissue Tumors at 3Tesla: Feasibility,
Preliminary Results on Accuracy, and Correlation with Diffusion Weighted Imaging (DWI), and Multivoxel 1H-MR Spectroscopy
(1H-MRS)
Iris-Melanie Noebauer-Huhmann MD (Presenter) ; Gabriele Amann MD ; Martin Krssak PhD ; Joannis Panotopoulos MD ; Christian Czerny MD ; Siegfried Trattnig MD PURPOSE To test the dynamic contrast enhanced (DCE) sequence of soft tissue tumor staging MR for intralesional targeting with subsequent
minimally MR-guided biopsy at 3T, and to compare DCE �hotspots� with diffusion-weighted imaging (DWI) and multivoxel 1H-MR
spectroscopy (1H-MRS). METHOD AND MATERIALS Fifty-six patients with suspected soft tissue tumors prospectively underwent preoperative staging MR with subsequent MR-guided core
needle biopsy at 3T after written informed consent, according to Institutional review board approval. Surgical histology available in 54
patients revealed 53 soft tissue tumors (29m, 24f, mean age 54 years, range 19-90). DCE was conducted in 50/53 patients (contrast
agents: Gd-BOPTA, Gd-DOTA, and Gd-DO3A-butrol), DWI-MSh FH in 51/53 patients, and 1H-MRS in 37/53 patients. Matching of the most
suspicious regions in DWI and 1H-MRS with DCE results was assessed. RESULTS DCE was heterogeneous in 42 cases, including all malignant tumors. In 2 cases, DWI was additionally used for targeting. In 6 cases
appearing homogeneous on all sequences, biopsy was taken arbitrarily. 3 small lesions required no region selection. Diagnostic yield was
98.1% (52/53). The accuracy rates of biopsy were 100% (52/52) in predicting the dignity, 96.2% for definitive tissue diagnosis, and
92.3% for tumor grade. DCE matched with preselected DWI regions in 87.5%, and with 1H-MRS in all assessable regions. The diffusion
weighted sequence was of limited value for the selection of the biopsy area. Spectroscopy could be compared with the DCE target region
in 23/37 patients only. Area match of 1H-MRS with the hotspots revealed by DCE was observed in all assessable cases, but, due to
technical restraints, tumor coverage was not possible by 1H-MRS in feasible examination time. CONCLUSION Our preliminary study indicates, that biopsy of soft tissue tumors can be performed accurately and safely by DCE targeted MR-guidance
at 3T, using the DCE staging sequence in combined staging/biopsy MRI in outpatients. DWI was of limited value. 1H-MRS results were
promising, but the method cannot be recommended for biopsy targeting in its present form. Page 47 of 183
CLINICAL RELEVANCE/APPLICATION In soft tissue tumors, the DCE-sequence of staging MR can be used accurately and safely for targeting of minimally-invasive MR-guided
biopsy, which might be useful especially in heterogeneous tumors. SSA14-08 • Preoperative Tractography Assessment of the Anatomic Relationship between Peripheral Nerve Sheath Tumors and
Fibers within the Nerve of Origin Correlate with Intraoperative Findings
Stephanie W Hou MD (Presenter) ; Esther L Yuh MD, PhD ; Jared A Narvid MD ; Gregory E Punch MD ; Jason F Talbott MD,
PhD ; Suchandrima Banerjee * ; Michel Kliot ; Cynthia T Chin MD PURPOSE Magnetic resonance neurography (MRN) is an emerging tool for anatomic depiction of nerves and their pathology. To investigate the
preoperative utility of MRN, including diffusion tensor tractography, we compared MRN findings to intraoperative findings and
histopathology in 7 patients. METHOD AND MATERIALS Seven patients (ages 24-69 years) with a clinical/imaging diagnosis of peripheral nerve sheath tumor were referred by neurosurgeons for
MRN at our institution in 2011-2013 and subsequently underwent surgical resection. Preoperative DTI was performed with 28 directions,
and tractography was performed by placing seed points along the peripheral nerve proximal and distal to the mass, using FA minimum
threshold of 0.18 and maximum turning angle threshold of 45o. The neuroradiologist and surgeon used the following categorical rating
system to describe the spatial relationship of the dominant location of most of the peripheral nerve fibers relative to the mass: fibers
predominantly anterior-1, medial-2, posterior-3, lateral-4, anterior and medial-5, posterior and medial-6, posterior and lateral-7, anterior
and lateral-8. We calculated Cohen�s kappa for agreement between neuroradiologist assessment of MRN tractograms and operative
findings. RESULTS Seven resected masses consisted of 6 schwannomas (including 2 cellular schwannomas) and one neurofibroma. ADC within the solid
portion of the masses was 1.9+/-0.8 x 10-3 mm2/sec (mean+/-SD), consistent with prior reports of relatively higher ADC within benign
tumors. Six of seven cases were concordant for nerve fibers predominantly along the posterior and medial margins (n =4), posterior
margin (n = 1), or anterior and medial (n =1) margins of the tumor. The �discrepant� case was interpreted as predominantly dorsal
fibers on the MRN, with operative findings indicating both dorsal and medial fibers. Cohen�s kappa for agreement between
neuroradiologist and intraoperative findings was 0.73 (p = 0.006). CONCLUSION In the setting of nerve sheath tumors planned for resection, DTI tractography may be useful preoperatively to assess the spatial
relationships of tumor to fibers within the nerve of origin and thereby reduce the risk of causing a functional deficit during surgery. CLINICAL RELEVANCE/APPLICATION This study is the first to demonstrate the application of DTI tractography in preoperative characterization of the relationship of peripheral
nerve sheath tumors to fibers within the nerves of origin. SSA14-09 • Differential MRI Diagnosis between Benign and Malignant Bone or Soft Tissue Tumors Using Dynamic
Contrast-enhanced and Diffusion-weighted Images
In Sook Lee (Presenter) ; You Seon Song ; Se Kyoung Park ; Jeung Il Kim MD, PhD ; Hak Jin Kim MD ; Jong Woon Song PURPOSE to evaluate the diagnostic performance of dynamic contrast-enhanced (DCE) and diffusion-weighted (DW) MR images for differentiation
between benign and malignant bone or soft tissue tumors METHOD AND MATERIALS Forty-two patients with bone or soft tissue masses prospectively performed DCE and DW MR examinations addition to routine protocols.
On DCE images using tissue 4D perfusion software, K(trans) (transfer constant), Kep (rate constant), Ve (volume fraction), and iAUC
(initial area under curve) were calculated from quantitative analysis. Also, the graphs of VOI (volume of interest) about whole mass and
region-of-interest (ROI) within the mass were automatically obtained. The types of graphs were classified into five. On DW and apparent
diffusion coefficient (ADC) images, ROIs of masses were measured. RESULTS Twenty-three patients had benign tumors and nineteen had malignant tumors. The mean values of Ktrans, Kep, Ve, iAUC, and ROI in
benign tumors were 0.0596, 0.308, 0.251, 3.761, and 1.801 respectively. Those in malignant tumors were 0.157, 0.476, 0.298, 10.471,
and 0.72 respectively. Ktrans, iAUC and ROI values were statistically significant (p < 0.05) for differentiating benign and malignant
tumors. By ROC curve analyses, Ktrans (AUC, 0.8; standard error (SE), 0.0696; 95% confidence interval (CI), 0.648-0.907; p < 0.0001,
criterion > 0.117), ROI value on ADC (AUC, 1; SE, 0; 95% CI, 0.694-0.916; p = 0, criterion = 0.97), Kep (AUC, 0.745; SE, 0.0779; 95%
CI, 0.588-0.867; p=0.0016; criterion > 0.287) and iAUC (AUC, 0.832; SE, 0.0632; 95% CI, 0.685-0.929; p < 0.0001; criterion > 4.908)
were significant. CONCLUSION Ktrans, representing permeability into the extracellular space from blood plasma and contrast delivery (perfusion) on DCE images and
ADC values were helpful for differentiating between benign and malignant bone or soft tissue tumors. CLINICAL RELEVANCE/APPLICATION The perfusion study from DCE and ADC values from DW MR examination may helpful for differentiating between benign and malignant
bone or soft tissue tumors, quantitatively and semi-quantitatively. Neuroradiology/Head and Neck (Temporal Bones) Sunday, 10:45 AM - 12:15 PM • N226
NR
HN SSA15 • AMA PRA Category 1 Credit ™:1.5 • ARRT Category A+ Credit:1.5 Moderator
Richard H Wiggins , MD Moderator
Ashley H Aiken , MD * Back to Top SSA15-01 • Image Quality and Radiation Dose Assessment in Temporal Bone CT Using an Ultra High Resolution Mode and an
Iterative Reconstruction Algorithm Temporal Bone CT: Improved Image Quality and Potential for Decreased Radiation Dose
Using an Ultra High Resol
Shuai Leng PhD (Presenter) ; John I Lane MD ; Kelly K Koeller MD ; Felix E Diehn MD ; Robert J Witte MD ; Michael R
Bruesewitz ; Thomas J Vrieze RT ; Cynthia H McCollough PhD * PURPOSE To assess spatial resolution and image noise for a temporal bone CT imaging method that uses an ultra-high resolution (UHR) scan mode
combined with iterative reconstruction (IR), and to compare to a protocol with reduced dose efficiency due to use of z-axis collimation
Page 48 of 183
combined with iterative reconstruction (IR), and to compare to a protocol with reduced dose efficiency due to use of z-axis collimation
(zUHR). METHOD AND MATERIALS Patients with prior temporal bone CT scans acquired using a zUHR protocol who received a follow-up scan using the UHR+IR technique
were identified. Left and right side of temporal bone images were reconstructed in axial, coronal and Poschl planes. Spatial resolution was
evaluated independently by 3 neuroradiologists with focus on the following structures: round and oval windows, incudomallear joint,
incudostapedial joint, spiral lamina in the basal turn, and scutum. The zUHR and UHR+IR images were displayed side by side, with the
order randomized and blinded to the readers. The following grading scale was applied to the UHR+IR images (relative to the zUHR
images): 1=inferior resolution, degrades visualization, 2=slightly inferior resolution, not affect visualization, 3=equivalent, 4=slightly
superior resolution, not affect visualization, 5=superior resolution, improves visualization. Image noise was measured in regions of
interest over the posterior fossa and compared. RESULTS 8 patients with 16 sets (left and right side) of temporal bones were identified, of which 3 sets were excluded due to surgery between the
two exams (13 left). The average scores across readers for spatial resolution on the UHR+IR images compared to zUHR were 3.4, 3.5
and 2.9 in axial, coronal and Poschl planes, respectively, indicating comparable or slightly better spatial resolution using the UHR+IR
technique. Wilcoxon signed-rank test showed significant differences (p CONCLUSION The UHR+IR scan mode has similar or slightly better resolution relative to the zUHR mode, but significantly lower (32%) image noise. An
estimated 50% dose reduction may be achievable using the UHR+IR mode. CLINICAL RELEVANCE/APPLICATION Substantial dose reduction can likely be achieved for temporal bone CT imaging using the investigated combined UHR+IR technique. SSA15-02 • The Dehiscent Bony Wall of Dural Sinus in Patients Presenting with Pulsatile Tinnitus: The Evaluation with CT
Angiography and Venography
Pengfei Zhao MD (Presenter) ; Zhenchang Wang MD, PhD ; Junfang Xian MD ; Fei Yan ; Zhaohui Liu MD ; Hong Jiang MD ; Cheng Dong ; Han Lv ; Xiaoyi Han PURPOSE To assess the imaging characteristics about dehiscent wall of dura sinus in patients presenting with pulsatile tinnitus (PT) on CT
angiography and venography (CTA+V) METHOD AND MATERIALS Following approval of the institutional review board, we reviewed all hospitalized patients with PT from 2008 to 2013 who underwent
thorough clinical and laboratory tests, including otomicroscopic and audiometric evaluations, CTA+V and DSA. Finally, 13 patients
diagnosed with the dehiscent bony wall of dural sinus as the causative finding and cured by surgical reconstruction were enrolled. CTA+V
images were blindly evaluated by 2 experienced neuroradiologists for the location, extent and amount of the bony dehiscence as well as
the presence of arachnoid granulation, dominant venous system and high jugular bulb. RESULTS CONCLUSION The dehiscence of dural sinus inducing PT mostly manifests as single defect of bony wall, involves the dominant side of venous system
and the lateral wall of the dural sinus, coexists with a large arachnoid granulation beneath the transverse sinus and the high jugular bulb. CLINICAL RELEVANCE/APPLICATION This paper is about a new curable cause of PT. Our results benefit the intra-operative localization of the bony dehiscence of dural sinus so
as to eliminate the symptom with less damage. SSA15-03 • Sigmoid Plate Dehiscence: The Prevalence as an Incidental Finding in Patients without Pulsatile Tinnitus
Christopher Trimble MD, MBA (Presenter) ; David Eisenman MD ; Dheeraj Gandhi MBBS, MD ; Robert E Morales MD PURPOSE Dehiscence of the sigmoid plate overlying the sigmoid sinus has been reported as a surgically treatable cause of pulsatile tinnitus. We
investigated the incidence of this as an incidental finding in patients without a documented history of pulsatile tinnitus. METHOD AND MATERIALS Using a retrospective review, we evaluated thin section (1 mm slice thickness) temporal bone CT scans of 125 consecutive trauma
patients (102 male and 23 female, with an average age of 39 years) imaged according to a standard institutional trauma protocol during
a 9 month period. Sigmoid plate dehiscence was defined as an imperceptible well defined osseous barrier between the sigmoid sinus and
adjacent pneumatized mastoid air cells on at least three consecutive images reconstructed in the axial plane, parallel to the hard palate.
This finding was confirmed on a second plane. Patients with temporal bone fractures were excluded. RESULTS Twenty-five patients in the series were excluded due to temporal bone fractures. Of the 100 remaining patients, 5 (3 male and 2 female)
met criteria for sigmoid plate dehiscence. The areas of sigmoid plate dehiscence exclusively involved the junction of the transverse and
sigmoid sinuses on the right side. The average dehiscent diameter was 5.8mm (min 3.8mm, max 7.6mm). CONCLUSION Though the prevalence of pulsatile tinnitus attributable to sigmoid plate dehiscence has been estimated at 20%, the prevalence of this
finding in the asymptomatic population has not been previously reported. Using our diagnostic criteria, surveying 100 trauma patients, we
found the prevalence to be 5%. Patients in our series demonstrated dehiscence exclusively on the right side and located at the junction
of the transverse and sigmoid sinuses. CLINICAL RELEVANCE/APPLICATION The prevalence of sigmoid plate dehiscence in the asymptomatic population appears quite low; its CT diagnosis in evaluating pulsatile
tinnitus is key because surgical treatment has high success rates. SSA15-04 • Patterns of Ossification in Patients with Labyrinthitis Ossificans
Karen Buch MD (Presenter) ; Alex Gutierrez ; Akifumi Fujita MD ; Anand Devaiah MD ; Osamu Sakai MD, PhD * PURPOSE Labyrinthitis ossificans (LO) is a pathologic process involving ossification of the membranous labyrinth leading to hearing loss. Prior
studies describe multiple causes of LO including infection, inflammation, trauma, surgery, and hematologic etiologies. However, no prior
study describes the pattern of labyrinth involvement. The purpose of this study was to identify potential etiology-specific ossification
patterns using CT scans of patients with LO. METHOD AND MATERIALS Following IRB approval, temporal bone CT scans of 34 LO patients were identified from scans done between November 2005-January
2012. Membranous labyrinth structures were evaluated for the degree of ossification and were assigned a grading score from 0-4 based
on degree of ossification (0: no ossification, 1: 75%). Medical records were reviewed for etiology of LO. Page 49 of 183
RESULTS Of the 34 patients with LO: 19 patients had local infection/inflammation or surgery, 6 had history of meningitis, 4 had sickle cell disease,
and 5 had other etiologies. Overall, the lateral semicircular canal had the highest degree of ossification and the vestibule had the least. In
cases of local infection/inflammation all of the semicircular canals were most severely affected followed by the basal cochlea, middle
cochlea, apical cochlea, and lastly, the vestibule. In cases of meningitis, the posterior and superior semicircular canals were most affected
followed by the middle cochlea, apical cochlea, basal cochlea, lateral semicircular canal, and lastly, the vestibule. In cases of SCD, the
lateral semicircular canal was most severely affected, then followed by the other structures in the membranous labyrinth with an equal
distribution. CONCLUSION LO results in specific patterns of membranous labyrinth involvement. Overall, the lateral semicircular canals were most severely affected
and the vestibules were the least affected. Different causes of LO may result in different ossification patterns. CLINICAL RELEVANCE/APPLICATION Etiology specific patterns of ossification appear to occur in LO. These findings may identify an underlying cause or predict progression of
ossification in patients with labyrinthitis ossificans. SSA15-05 • MR Imaging of Inner Ear Endo-perilynphatic Spaces at 3 Tesla after Intratympanic Contrast Agent Administration in
Definite Meniere’s Disease
Marco Colasurdo MD ; Simone Salice MD (Presenter) ; Antonella Centonze ; Giampiero Neri ; Armando Tartaro MD PURPOSE MRI findings in Meniere�s disease are not yet defined. The purpose of this study was to determine the main findings of
endo-perilymphatic spaces in patients affected by Definite Meniere�s disease using Magnetic Resonance Imaging (MRI) with
intratympanic administration of contrast agent. METHOD AND MATERIALS Twelve patients with Definite Meniere�s disease underwent 3 Tesla MRI. 3D FLAIR and 3D T2 SE sequences were acquired 24 hours after
intratympanic administration of 0.4-0.5 ml of gadobutrol diluted eightfold with saline. Contrast agent was injected through the tympanic
membrane with a 25 G needle. Multi Planar Reconstructed (MPR) images were analyzed. According to literature, vestibular endolymphatic
hydrops was graded considering the ratio of the area of the endolymphatic space to the vestibular fluid space (sum of the endolymphatic
space and perilymphatic space). Patients with no hydrops had a ratio of one third or less, those with mild hydrops had between one-third
and a half and those with severe hydrops had a ratio of more than 50%. Cochlear and semicircular canals endolymphatic hydrops was
defined as positive when a MRI signal void was detected. RESULTS No adverse events due to contrast agent administration were observed. Three patients didn�t show perilymphatic enhancement thereby
they were not considered for data analysis. Vestibular endolymphatic hydrops was observed in 100% of patients and it was severe in 7
out of 9 patients and mild in 2 out of 9. Whereas posterior semicircular canal endolymphatic hydrops was observed only in 5 out of 9
patients; lateral and superior semicircular canals endolymphatic hydrops was observed only in 4 out of 9 patients; cochlear
endolymphatic hydrops was observed only in 5 out of 9 patients. CONCLUSION Our study confirms that endolymphatic hydrops can be detected at 3T MR images after intratympanic contrast agent administration and
is the main finding in patients with Definite Meniere�s disease. Moreover, our preliminary results seem to suggest that endolymphatic
hydrops may affect more often the vestibule than cochlea or semicircular canals. CLINICAL RELEVANCE/APPLICATION 3T MRI with intratympanic administration of contrast agent might open the door to objective evaluation of endolymphatic space and
reveal Meniere�s disease pathophysiology improving diagnostic efficacy. SSA15-06 • Correlation of Ear Symptoms with Increased Cochlear Fluid-attenuated Inversion Recovery Signal in Patients with
Acoustic Neuroma
Dae Yoon Kim (Presenter) ; Jeong Hyun Lee MD, PhD ; Won-Jung Chung ; Young Jun Choi MD ; Sohyun Jo ; Jung Hwan
Baek ; Ka-Gyoung Yoon MD PURPOSE It is well-known that cochlear fluid-attenuated inversion recovery (FLAIR) signal is increased in patients with acoustic neuroma (AN). The
purpose of this study was to investigate if cochlear FLAIR signal in patients with AN correlates with ear symptoms or audiometric findings,
and if there is any difference in the cochlear signal according to the extent of AN in a large series. METHOD AND MATERIALS This retrospective study enrolled 102 patients with surgically confirmed or radiologically diagnosed AN from 2008 to 2012. There were 22
patients (M : F = 10 : 12; mean age: 50 ± 13.2 years) with AN confined to the internal auditory canal (ANIAC) and 80 (M : F = 48 : 32;
mean age: 49.9 ± 12.3 years) with AN located in the cerebellopontine angle cistern as well as in the IAC (AN CPA). We quantitatively
measured the signal intensity (SI) of the entire volume of the cochlea on the affected side by placing ROIs semi-automatically drawn on
3D T2-VISTA images of the same slices. We compared the SI ratios (rSI) of the cochlea to the brainstem with ear symptoms including
tinnitus, hearing disturbance or vertigo and with the audiometric findings in AN IAC and ANCPA.patients, respectively. RESULTS The rSI of the cochlea was positively correlated with the audiometric findings in AN IAC (r = 0.471; p=0.027), but showed no correlation
in ANCPA (p = 0.427). The rSI of the cochlea was significantly higher with the presence of hearing disturbance or tinnitus only in patients
with ANIAC (p = 0.001 and p = 0.004, respectively). There was no correlation between the rSI of the cochlea and the presence of hearing
disturbance or tinnitus in patients with ANCPA (p = 0.600 and p = 0.506, respectively). Both ANIAC and ANCPA did not show any
difference of the rSI of the cochlea whether they had vertigo or not (p = 0.082, p = 0.782, respectively). CONCLUSION Cochlear FLAIR signal is significantly higher with the presence of hearing disturbance or tinnitus and shows positive correlation with the
audiometric findings only in patients with AN limited to the IAC. CLINICAL RELEVANCE/APPLICATION The results of this study suggest that functional evaluation of the cochlea could be possible with FLAIR images in patients with acoustic
neuroma limited to the IAC. SSA15-07 • Imaging of the Inner Ear in Menière’s Disease: Round and Oval Window Pathology as Possible Influential Factors for
Restricted Contrast Medium Permeability
Wilhelm H Flatz MD (Presenter) ; Robert Guerkov ; Maximilian F Reiser MD ; Birgit B Ertl-Wagner MD * PURPOSE To prospectively evaluate MRI- and CT-findings of the temporal bone, including the middle and inner ear as well as adjacent soft tissue,
as potantial causes for restricted diffusion of Gd-DTPA into the inner ear. METHOD AND MATERIALS We retrospectively evaluated 32 patients with suspected Menière�s disease who underwent both multislice-CT- and locally enhanced MR
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imaging of the temporal bone. 24 hours prior to the MRI-scan intratympanal Gd-DTPA was administered. In addition to structural
MR-imaging of the brain, CISS-, FLAIR- and IR-sequences of the temporal bone were acquired on a 3 T MR scanner using a 32 channel
head coil. Slice thickness of FLAIR- and IR-images was 0.5 mm and 0.6 mm respectively. Signal intensities of the endolymphatic spaces
of the basal turn of the cochlea were evaluated using ROI-based analysis. CT images were reviewed by two blinded radiologists with
regard to temporal bone pathology including sclerosis of the round and oval window membrane, middle ear findings and soft tissue
assessment. Thickening/sclerosis of the round and oval windows membrane were evaluated using a 6-point scale with 1 being no
sclerosis and 6 high grade sclerosis. RESULTS In 9 respectively 13 patients CT-analysis of the round window respectively oval window was not possible due to acquired slice thickness.
11 of 19 patients demonstrated sclerotic changes of the oval window (grades 2 to 6). 8 of 23 patients showed sclerotic changes of the
round window (grade 2 to 6). Significant differences were observed between measured signal intensities of perilymphatic spaces of the
basal turn of the cochlea and degree of oval window sclerosis (P=0.0143), but not between sclerotic changes of the round window and
signal intensities of the endolymphatic spaces of the basal turn of the cochlea. CONCLUSION Sclerotic changes of the oval window may be responsible for a restricted diffusion of contrast medium from the middle ear into the inner
ear. CLINICAL RELEVANCE/APPLICATION Sclerotic changes of the oval window may be responsible for a restricted diffusion of a whole variety of substances from the middle ear
into the inner ear, including therapeutic agents. SSA15-08 • Volumetric Assessment of the Membranous Vestibular System in Patients Presenting with Vertigo
Nagy N Naguib MSc (Presenter) ; Ahmed F Emam MBBCh ; Nour-Eldin A Nour-Eldin MD, MSc ; Tatjana Gruber-Rouh ; Boris
Bodelle MD ; Thomas Lehnert MD ; Renate M Hammerstingl MD ; Stefan Zangos MD ; Katrin Eichler MD ; Thomas J Vogl
MD, PhD PURPOSE To assess the volume of membranous vestibular system in patients presenting with vertigo and to compare the volume with the
vestibular system volume in patients with normal vestibular function using three dimensional (3D) reconstruction of the high resolution
MR-Imaging sequences. METHOD AND MATERIALS The study was retrospectively performed on 153 patients (74 females and 79 males) with a mean age of 48.9 year (standard deviation:
25.4, range: 5 month - 88 year). Of the 153 patients 61 patients presented with vertigo and 92 patients presented with other diseases of
the ear and normal vestibular function. High resolution MR-Imaging was performed using a T2-weighted SPACE sequence with 0.6 mm
slice thickness. 3D reconstructions were performed using Advantage Workstation for diagnostic imaging. Assessed were the volumes of
the semicircular canals and the volume of vestibule. The difference between the volumes in patients with and without vertigo (normal
vestibular function) was tested using the Two-Sample t-Test. RESULTS Three dimensional reconstructions were successfully performed in all patients. In patients with vertigo the mean volume of the
semicircular canals was 0.258 mm 3 (SD: 0.061, Range: 0.130 � 0.430 mm3) and the mean volume of the vestibule was 0.069 mm3
(SD: 0.013, Range: 0.040 � 0.110 mm3). In patients with no vertigo (normal vestibular function) the mean volume of the semicircular
canals was 0.306 mm3 (SD: 0.074, Range: 0.180 � 0.550 mm3) and the mean volume of the vestibule was 0.075 mm3 (SD: 0.016,
Range: 0.040 � 0.13 mm3). There was a statistically significant difference between the semicircular canal volume and the vestibular
volume in patients with and without vertigo (normal vestibular function) (p < 0.0001 and p = 0.0019 respectively). CONCLUSION Patients presenting with vertigo show a statistically significant smaller volume of the semicircular canals and vestibule compared to
patients not presenting with vestibular dysfunction or vertigo. CLINICAL RELEVANCE/APPLICATION A reduced volume of the membranous vestibular system might be the reason for vertigo symptomatic in patients presenting with vertigo. SSA15-09 • New Grading System for Patients with Congenital Aural Atresia Scheduled for Active Middle Ear Implants
Henning Frenzel MD, PhD (Presenter) ; Gerlig Widmann ; Dirk Petersen MD ; Barbara Wollenberg ; Christian Mohr MD PURPOSE Active middle ear implants (aMEI) are being increasingly used for hearing restoration in congenital aural atresia. The existing gradings
used for CT findings do not meet the requirements for these implants. Some items are expendable, whereas other important imaging
factors are missing. We aimed to create a new grading system that could describe the extent of the malformation and predict the viability
and challenges of implanting an aMEI as well as the hearing outcome. METHOD AND MATERIALS 103 malformed ears were evaluated using HRCT of the temporal bone. The qualitative items middle ear and mastoid pneumatization, oval
window, stapes, round window, tegmen mastoideum displacement and facial nerve displacement were included. An anterior- and
posterior round window corridor, oval window and stapes corridor were quantified and novelly included. They describe the size of the
surgical field and the sight towards the windows. 35 ears were implanted and evaluated for hearing outcome. RESULTS The ears were graded on a 16-point scale (16-13 easy, 12-9 moderate, 8-5 difficult, 4-0 high risk). The strength of agreement between
the calculated score and the performed implantations with regard to the level of difficulty of the implantation was good. The comparison of
the new 16-point scale with the Jahrsdoerfer score showed that both were able to conclusively detect the high-risk group; however the
new 16-point scale was able to further determine which malformed ears were favorable for aMEI, which the Jahrsdoerfer score could not
do. There was no correlation between the new 16-point scale and the hearing outcome using stapes attachment. The round window
attachment in difficult cases may lead to inferior results. CONCLUSION The Active Middle Ear Implant Score for Aural Atresia (aMEI-score) allows more precise risk stratification and decision making regarding
the implantation. The use of operative corridors seems to have significantly better prognostic accuracy than the Jahrsdoerfer score. The
hearing outcome does not rely on the severity of deformation, once a successful coupling of the implant is achieved. The aMEI-score
represents the likelihood of achieving a successful implantation. CLINICAL RELEVANCE/APPLICATION The Active Middle Ear Implant Score for Aural Atresia (aMEI-score) satisfies the new requirements for diagnostic imaging of congenital
aural atresia with regard to active middle ear implants. Neuroradiology/Head and Neck (Vascular Disease of the Head and Neck) Sunday, 10:45 AM - 12:15 PM • N227
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NR
HN SSA16 • AMA PRA Category 1 Credit ™:1.5 • ARRT Category A+ Credit:1.5 Moderator
Majda M Thurnher , MD SSA16-01 • Dose Savings and Image Quality in CT of the Neck Using Automated Selection of Tube Potential
Boris Bodelle MD (Presenter) ; Martin Beeres MD ; Sebastian Scheithauer ; Claudia Frellesen ; Boris Schulz MD ; Firas
Al-Butmeh ; Nagy N Naguib MSc ; Ralf W Bauer MD * ; Thomas Lehnert MD ; Thomas J Vogl MD, PhD PURPOSE To investigate the impact of automated attenuation-based tube potential selection on image quality and radiation dose in patients
undergoing CT of the neck. METHOD AND MATERIALS 360 patients [median age 52 years (range 4 � 89)] underwent 128-slice CT of the neck. First group (n=40) was examined with fixed 120
kV with 180 ref.mAs and automated exposure control (AEC) modulating only mA output. The second group (n=320) underwent CT with
AEC and topogram-based automated tube potential selection (Care-kV) by the scanner software with either 80 kV/406 ref.mAs, 100
kV/223 ref.mAs, 120 kV/180 ref.mAs or 140 kV/125 ref.mAs. CTDIvol, DLP, BMI, organ enhancement, image noise, SNR and subjective
diagnostic image quality (5-point scale, 2 readers in consensus) were compared between the groups and sub-groups using
Mann-Whitney-U test and Cohen's weighted kappa analysis for inter-observer agreement. RESULTS 100 kV was automatically selected in 279 patients, 120 kV in 40 patients and 80 kV in 1 patient of the Care-kV group. Patients mean BMI
(20 kg/m² at 80 kV, 24.2 kg/m² at 100 kV and 28.1 kg/m² at 120 kV) increased with higher kV settings. The average CTDIvol (9.7 vs.
12.2 mGy) and DLP (255 vs. 342 mGycm; p < 0.05) in the entire Care-kV group were 20%/25% lower than in group 1 with fixed 120 kV.
This effect was even more pronounced in the patients in whom 100 kV was selected (CTDIvol 8.9 mGy, -27%; DLP 244 mGycm, -29%).
Organ enhancement increased with lower kV, while image noise and SNR were at a stable level. Subjective diagnostic image quality (4.61
vs. 4.56, p>0.05) were not rated significantly different with a good interobserver agreement for all tube potential levels (?=0.5-0.8). CONCLUSION Software-based automated selection of the tube potential allows for significant dose savings in CT of the neck while image quality is
maintained or even improved. CLINICAL RELEVANCE/APPLICATION Automated selection of tube potential in CT of the neck allows significant dose reduction and preserves image quality, which is relevant
for staging patients with lymphoma or head and neck cancer. SSA16-02 • Metal Artefact Reduction from Dental Hardware in Carotid CT Angiography Using Iterative Reconstructions
Fabian Morsbach (Presenter) ; Moritz Wurnig ; Andreas Krauss PhD * ; Bernhard Schmidt PhD * ; Spyros S Kollias MD ; Hatem Alkadhi MD PURPOSE To determine the value of a metal artefact reduction (MAR) algorithm with iterative reconstructions for dental hardware in carotid CT
angiography. METHOD AND MATERIALS Twenty-four patients (6 female, mean age 70±12 years) with dental hardware undergoing carotid CT angiography were included.
Datasets were reconstructed with filtered back projection (FBP) and using a MAR algorithm employing normalization and an iterative
frequency-split (IFS) approach. Three blinded, independent readers measured CT attenuation values and evaluated image quality and
degrees of artefacts using axial images, multi-planar reformations (MPR), and maximal intensity projections (MIP) of the carotid arteries. RESULTS CT attenuation values of the internal carotid artery on images with metal artefacts were significantly higher in FBP (324±104HU) datasets
as compared to those reconstructed with IFS (278±114HU;P CONCLUSION The MAR algorithm with the IFS approach allowed for a significant reduction of artefacts from dental hardware in carotid CT angiography,
hereby increasing image quality and improving the accuracy of CT attenuation measurements. CLINICAL RELEVANCE/APPLICATION Metal artifact reduction with an iterative frequency split approach can be used to increase diagnostic confidence in carotid CT angiography SSA16-03 • Variations in Carotid Bifurcation Geometry by MRI Are Associated with Carotid Atherosclerosis in Asymptomatic
Individuals
Christopher Maroules MD (Presenter) ; Kevin S King MD ; Colby Ayers MS ; Ronald M Peshock MD ; Jarett Berry MD PURPOSE To investigate the relationship between objective measures of carotid bifurcation geometry and carotid atherosclerosis within
asymptomatic individuals using MRI. METHOD AND MATERIALS We included 80 participants from the Dallas Heart Study (mean age 53 ± 9 years, 46% females) free of cardiovascular disease who
underwent multi-sequence MRI of the distal common carotid artery (CCA), carotid bulb, and proximal internal and external carotid arteries
(ICA and ECA, respectively) at 3 Tesla. Semiautomated techniques were used to define vessel wall contours, lipid-rich necrotic core
(LRNC) volume, and the 3D geometry of the carotid bifurcation. We examined associations between carotid artery geometric parameters
and both wall thickness and the presence of LRNC using Spearman correlation and multivariable logistic regression. RESULTS LRNC was identified in 11 participants (13.8%). After controlling for age, sex, hypertension, cigarette smoking, hypercholesterolemia, low
high-density lipoprotein, diabetes, and body mass index, LRNC was associated with a lower ICA planarity [OR 95% CI: 13.3 (1.8-100.0)
per SD, p=0.01] and a lower ICA/CCA ratio [6.7 (1.1-33.3) per SD, p=0.03]. LRNC was not associated with a lower bifurcation angle
after multivariable adjustment [OR 95% CI: 2.2 (0.5-9.1) per SD, p=0.3]. Total LRNC volume within the carotid artery correlated with
ICA/CCA diameter ratio (r= -0.32, p=0.03). Carotid bulb wall thickness correlated with ECA/CCA diameter ratio (r= -0.49, p CONCLUSION Objective geometric measurements of the carotid bifurcation by MRI are associated with carotid atherosclerosis and the presence of lipid
rich necrotic core within carotid plaque. These findings support a geometric risk for carotid atherosclerosis. CLINICAL RELEVANCE/APPLICATION Variations in carotid bifurcation geometry by MRI are independently associated with carotid atherosclerosis, supporting a 'geometric risk'
for atherosclerosis. SSA16-04 • Atherosclerotic Plaque in the Left Carotid Artery Is More Vulnerable than at the Contralateral Side
Mariana Selwaness MD (Presenter) ; Quirijn v Bouwhuijsen ; Albert Hofman MD, PhD ; Oscar H Franco ; Jolanda J Wentzel
Page 52 of 183
PhD ; Aad Van Der Lugt MD, PhD PURPOSE Ischemic cerebrovascular events are most frequently reported in the left hemisphere compared to the right side. Whether this is related
to an asymmetry in atherosclerotic plaque frequency and morphology in the carotid arteries is unknown. We investigated plaque
distribution and composition in the left and right carotid artery in healthy individuals. METHOD AND MATERIALS 1501 participants (=45 years) from The Rotterdam Study, a population-based cohort, with atherosclerotic plaque present on carotid
ultrasound were selected. We used 1.5T Magnetic Resonance Imaging (MRI) with standard multisequence scanning protocol to assess
plaque prevalence, thickness and predominant component: lipid core, intraplaque haemorrhage (IPH), calcification or fibrous tissue.
Differences between left and right side were tested using Pearson chi-square test and Generalized Estimating Equations analyses adjusted
for age, gender and carotid wall thickness. RESULTS Carotid MRI revealed 2775 atherosclerotic plaques, (bilateral 1274; right 76; left 151) corresponding with 5% higher prevalence of
unilateral plaques left than right (P CONCLUSION We found an unequal distribution of atherosclerotic plaque size and composition in the carotid arteries. IPH and fibrous tissue were more
frequently observed in the left carotid artery, whereas calcification was more often present in the right. Our findings suggest that the
predilection of cerebrovascular disease to the left side may be explained by the vulnerable phenotype of plaques in the left carotid artery. CLINICAL RELEVANCE/APPLICATION We show for the first time that left and right plaque composition differ in carotid arteries. Understanding distribution patterns of
atherosclerosis is important for stroke recognition and management. SSA16-05 • Automated Interpretation of Carotid Plaque Composition Identifies High-risk Lesions: A Prospective MRI Study
Daniel S Hippe MS (Presenter) * ; Xin Pu ; Hunter R Underhill MD, PhD ; Jie Sun ; William S Kerwin PhD * ; Wei Yu MD ; Yan Song MD, PhD ; Jianming Cai MD ; Xihai Zhao ; J. Kevin Demarco MD * ; Chun Yuan PhD * ; Thomas S Hatsukami MD * PURPOSE Carotid MRI is an effective modality for quantifying atherosclerotic plaque composition and identifying lesions associated with stroke/TIA.
However, complexity of manual image interpretation and limited prospective data has hindered translation of carotid MRI into clinical
practice. In this study we developed an automated technique for stratifying lesion severity and subsequently conducted a prospective
study to determine if the algorithm predicts lesion growth or development of vulnerable features. METHOD AND MATERIALS Participants (N=536) from 17 institutions and centers in the US and China were imaged with an established multi-contrast carotid MRI
protocol. A histologically-validated segmentation algorithm was applied to the MR images to automatically measure lipid-rich necrotic
core (LRNC) and calcification (CA). Associations between manually identified high-risk features (i.e. intraplaque hemorrhage, IPH; and
fibrous cap rupture, FCR) and clinical risk factors, plaque morphology, and composition were investigated to develop an optimized,
automated carotid atherosclerosis score (ACAS) for stratifying lesion severity. Subsequently, ACAS was evaluated prospectively using an
independent cohort of 73 asymptomatic subjects that underwent serial carotid MRI over a 3 year period. RESULTS During systematic analysis of potential risk factors, the most effective metric to detect lesions with IPH or FCR was percent size of LRNC
(AUC=0.89). This metric was used to define ACAS from low to high risk: 1) LRNC absent; 2) LRNC < 30%; 3) LRNC 30-50%; and 4)
LRNC > 50%. Applied prospectively, ACAS was associated with new FCR (AUC=0.84, p 0.1). CONCLUSION Automated plaque interpretation is an effective technique for stratifying lesion severity that predicts lesion growth and development of
FCR � a key risk factor associated with stroke/TIA. Automated plaque analysis is expected to simplify carotid MRI interpretation, enabling
the translation to clinical practice for improved management of patients with carotid atherosclerotic disease regardless of stenotic
severity. CLINICAL RELEVANCE/APPLICATION The automated plaque interpretation technique developed is predictive of carotid plaque growth and fibrous cap rupture so utilization may
improve management of patients over carotid stenosis alone. SSA16-06 • Analysis of Association between Carotid Artery Plaque Volume and Cerebral Microbleeds
Luca Saba MD (Presenter) ; Michele Anzidei MD ; Lorenzo Mannelli MD, PhD ; Jasjit S Suri ; Michele Di Martino ; Mario Piga PURPOSE Cerebral microbleeds (CMBs), have become increasingly recognised with the widespread use of MRI techniques that are sensitive to iron
deposits. The purpose of this work was to explore the association between carotid plaque volume (total and the sub-components) and
CMBs. METHOD AND MATERIALS 72 consecutive (males 53; median age 64) patients were prospectively analyzed. Carotid arteries were studied by using a 16-detector row
CT scanner whereas brain was explored with a 1.5 Tesla system. CMBs were studied using a T2*-weighted gradient-recalled echo (GRE)
sequence. Microbleeds were classified as absent (grade 1), mild (grade 2; total number of microbleeds, 1�2), moderate (grade 3; total
number of micro-bleeds, 3�10), and severe (grade 4; total number of microbleeds, >10). Component types of the carotid plaque were
defined according the following HU ranges: lipid < 60 HU; fibrous tissue from 60-130 HU; calcification > 130 HU and plaque volumes of
each component was calculated. Each carotid artery was analyzed by 2 observers. Chi square, multiple logistic regression analysis as well
as ROC was calculated. RESULTS The prevalence of CMBs was 35.3%. A statistically significant difference was observed between symptomatic (40%) and asymptomatic
(11%) patients (p value = 0.001; OR = 6.07). Linear regression analysis demonstrated an association between the number of CMB and
the symptoms (p = 0.0018). A statistically significant correlation was observed between the increase of the volume of the fatty
component and CMBs (rho = 0.89; p = 0.001). CONCLUSION Results of this study confirm the association between CMBs and symptoms and that there is an increased number of CMBs in symptomatic
patients. Moreover we found that an increased volume of the fatty component is associated the presence and number of CMBs. CLINICAL RELEVANCE/APPLICATION The presence of fatty components in the carotid artery plaque are associated with an increased prevalence of cerebral micro-bleeds SSA16-07 • Dual Energy Computed Tomography Quantification of Carotid Plaques Calcification: Comparison between
Monochromatic and Polychromatic Energies with Pathology Correlation
Lorenzo Mannelli MD, PhD (Presenter) ; Lawrence MacDonald PhD ; Marina Ferguson MS ; Dongxiang Xu PhD ; William P
Shuman MD * ; Chun Yuan PhD * ; Lee M Mitsumori MD, MS * Page 53 of 183
PURPOSE To compare the size and number of carotid plaque calcifications identified on monochromatic spectral CT and polychromatic CT images
with a pathological reference standard. METHOD AND MATERIALS Ex-vivo carotid endarterectomy specimens were imaged with spectral and conventional CT. Monochromatic CT images were reconstructed
at 40, 60, 80, 100, 120, and 140 keV. Conventional polychromatic images were acquired using 80, 100, 120, and 140 kVp.
Cross-sectional area of the plaque calcifications was measured. The histological calcium areas were measured on digitized images of
Toluidine-Blue/Basic-Fuchsin stained plastic sections. The CT images and corresponding histology sections were matched. Pearson�s
correlation coefficient for a linear relationship was calculated between the results from pathology and CT, and between different CT
techniques. We also calculated the mean percent error (bias) and root-mean-square error (RMSE) in CT calcification size, taking
pathology measurements as the gold standard. The mean percent error was calculated as (CTsize � Pathology size)/(Pathologysize)
averaged over the calcifications found by the CT technique of interest. RESULTS 116 pathologic sections were evaluated, the calcification area per section ranged between 0.20 mm2 and 26.4 mm2. Fig. 1 is a scatter
plot of calcification sizes measured by pathology and CT for three CT image types (40 keV, 140 keV, and 120 kVp). Fig. 2 shows that
when compared to pathology, the amount of plaque calcifications identified with spectral CT decreased with higher reconstructed energy
level: at 80 keV 90% were found, at 100 keV only 77%; on polychromatic 120 kVp CT images 95% of the calcifications were found. Fig.
2 also shows the Pearson correlation coefficient. The RMSE and average percent error are shown in figure 3: there is an overestimation
in calcification size by CT for lower monochromatic CT images, decreasing to an underestimation for higher keV monochromatic CT
images and polychromatic CT images. Monochromatic 80 keV and 100 keV images show the lowest RMSE and %error. CONCLUSION The size and number of plaque calcifications detected by CT depends upon the energy level used for the image acquisition and
reconstruction. Monochromatic 80keV images were the most comparable to histology. CLINICAL RELEVANCE/APPLICATION 80 keV monochromatic images allow for a better evaluation of atherosclerotic calcifications; this may help characterizating the whole
atherosclerotic plaque. SSA16-08 • Radiological Assessment of Thoracic Outlet Syndrome: Four Years of Institutional Experience
Dean Donahue ; Omid Khalilzadeh MD, MPH ; Julien Dinkel MD ; Gaetano T Pastena MD ; Martin Torriani MD ; Rajiv Gupta
PhD, MD (Presenter) PURPOSE Imaging studies play a significant role in assessment of thoracic outlet syndrome (TOS). In this study, we reviewed the spectrum of CT
and MR imaging findings in patients with TOS in our institution, over a period of four years. METHOD AND MATERIALS Our study included a total of 349 consecutive TOS patients, referred to our hospital between December 2008 and December 2012.
Patients with non-specific symptoms were excluded. All patients underwent a biphasic contrast-enhanced CT angiography of the thoracic
outlet using a TOS-optimized protocol and an MR scan with a postural maneuver. A single radiologist (RG) assessed all the scans. The
findings associated with TOS were classified under the categories of vascular (venous or arterial), neurologic (due to soft tissue, bone or
anatomical space abnormalities causing mass effect on the brachial plexus) and a combination of the two, i.e, neurovascular (typically
secondary to post-operative or traumatic insult). RESULTS Positive CT or MR findings were seen in 78.5% of patients. Overall, 6% of patients had vascular TOS (2% venous and 4% arterial), 7.4%
had neurovascular, and 86% had neurogenic TOS. Bone abnormalities were the most common cause of neurogenic TOS. Narrowing of
anatomic compartments (inter-scalene triangle and costoclavicular space) was seen in 43.7% of patients with neural TOS. C7 transverse
process variations were the most common bone abnormality (67.9%). Fibrous bands were the most common soft tissue abnormalities
associated with neurogenic TOS. CONCLUSION This study describes the range of CT and MR findings associated with TOS. Based on our experience, a combination of CT angiography and
MR imaging (with a postural maneuver) effectively demonstrate TOS abnormalities. CLINICAL RELEVANCE/APPLICATION A combination of biphasic contrast-enhanced CT angiography and MR imaging (with a postural maneuver) effectively demonstrate TOS
abnormalities. SSA16-09 • Bilateral Inferior Petrosal Sinus Sampling Using Desmopressin: A Single Center Experience
Amy R Deipolyi MD, PhD (Presenter) ; Bailin Alexander BA ; Junsung Rho BSc ; Zubin Irani MD ; Stephan Wicky MD ; Rahmi
Oklu MD, PhD PURPOSE Bilateral inferior petrosal sinus sampling (BIPSS) following corticotropic-releasing hormone (CRH) stimulation is the current gold standard
technique in the diagnosis of Cushing disease. However, as a result of CRH shortage, desmopressin (DDAVP) has become the
replacement of choice for BIPSS. We present a single tertiary care center experience using the modified BIPSS protocol. METHOD AND MATERIALS This IRB approved, HIPAA compliant study involved using the radiology department's electronic database to identify BIPSS procedures
performed at our institution using DDAVP. Electronic medical records and imaging studies were reviewed. Clinical history, demographics,
endocrine test results, complications of BIPSS and patient outcome was recorded. BIPSS data was analyzed for centralization (3:1, central
to peripheral ACTH gradient) and lateralization (1.4:1 ACTH gradient). RESULTS We identified 17 BIPSS cases (14 female, mean age 37.9 years (range 13-64)) performed using DDAVP between 2012 and 2013. The 17
cases demonstrated conventional, bilateral IPS anatomy and were successfully cannulated bilaterally. 16 patients met the criteria for both
centralization and lateralization. 14 of the 17 patients had undergone a transphenoidal tumor resection, 1 patient was lost to follow up
and 2 had not yet been surgically treated. All 14 patients demonstrated ACTH secreting adenoma on pathology review and all 14 were
concordant with lateralization predicted by BIPSS. There were no complications resulting from the use of DDAVP, specifically
thromboembolic events. CONCLUSION DDAVP is a safe alternative to CRH producing satisfactory diagnostic results. CLINICAL RELEVANCE/APPLICATION BIPSS is the current gold standard technique in the diagnosis of Cushing disease. Given the shortage of CRH, desmopressin has been safe
and demonstrates similar diagnostic results. Neuroradiology (Parkinson's Disease) Page 54 of 183
Sunday, 10:45 AM - 12:15 PM • N229
MR
NR SSA17 • AMA PRA Category 1 Credit ™:1.5 • ARRT Category A+ Credit:1.5 Moderator
Christopher P Hess , MD, PhD * Back to Top SSA17-01 • Dopaminergic Neurodegeneration in Nigrostriatal System of the MPTP-treated Parkinsonian Marmoset Monkey
Detected by Voxel-based Analysis of Longitudinal MRI
Keigo Hikishima PhD, MS (Presenter) ; Kiyoshi Ando ; Yuji Komaki ; Kenji Kawai ; Takashi Inoue ; Masayuki Yamada ; Toshio Itoh ; Suketaka Momoshima MD ; Hirotaka J Okano ; Hideyuki Okano MD, PhD PURPOSE The evaluation of substantia nigra (SN) and nigrostriatal fiber is essential to assess the severity of degeneration and efficacy of treatment
protocols in Parkinson's disease (PD). The purpose of the present preclinical study was to investigate dopaminergic neurodegeneration by
longitudinal voxel-based morphometry (VBM) and diffusion tensor imaging (DTI) at 7T MRI in the preclinical primate model of PD. METHOD AND MATERIALS The common marmosets (n=6) received 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) at the daily dose of 2, 2 and 1 mg/kg,
s.c., respectively, for 3 consecutive days were used for the present imaging study. These marmosets showed long lasting and stable
Parkinsonism such as moving tremor, immobility measured objectively as decreased locomotion counts, etc. Before and after several
weeks after the MPTP administration, 3D T1WI (isotropic resolution of 200?m) and 2D DTI (in-plane resolution of 200?m and slice
thickness of 1mm) were performed. After the acquisitions of longitudinal MRI, ex vivo microscopic DTI (isotropic resolution of 60?m) and
histological examination with Kluver-Barrera and tyrosine hydroxylase (TH) staining were also performed to the fixed brains (n=4). VBM
and diffusion tensor tractography (DTT) were obtained with SPM8 and TrackVis software, respectively. RESULTS Volume decreases in SN were observed by longitudinal VBM with positive correlation with decreased locomotion counts, a central PD sign
(P CONCLUSION The present longitudinal MR neuroimaging using DTI and VBM on the nigrostriatal system has an invaluable ability in the preclinical
studies for developing new treatments and understanding the mechanism of PD, and possibly in the clinical evaluation of PD patients. CLINICAL RELEVANCE/APPLICATION By using voxel-based analysis of longitudinal MRI at 7T, we may have a new noninvasive tool to diagnose the nigrostriatal system for
Parkinson's disease. SSA17-02 • Longitudinal Monitoring of Intrastriatal Transplanted Retinal Pigment Epithelial Cells Survival In Vivo by 18F-P3BZA
PET/CT
Lihong Bu MD, PhD (Presenter) ; Renfei Li MD, PhD ; Hongguang Liu PhD ; Bao-Zhong Shen ; Zhen Cheng PhD PURPOSE To understand the anti-Parkinson�s disease (PD) efficacy of human retinal pigment epithelial (hRPE) cells implantation, we hypothesized
that the melanin targeted probe, N-(2-(diethylamino)ethyl)-18F-5-fluoropicolinamide (18F-P3BZA),could be used for monitoring and
trafficking the implanted cells because of its high melanin contents. METHOD AND MATERIALS 18F-P3BZA was prepared by direct radiofluorination of the bromopicolinamide precursor using no-carrier-added 18F-fluoride. In vitro cell
uptake assay were performed by incubation 18F-P3BZA with melanotic porcine RPE (pRPE) cells or control ARPE-19 cells for different
incubation time. To assess the in vivo brain uptake and clearance of 18F-P3BZA in normal rat, dynamic small animal PET/CT scans were
initiated immediately after administration of the probe and terminated 60 min later. To validate the capability of 18F-P3BZA for
monitoring the long-term survival of implanted RPE cells in vivo, normal rats were intrastriatally injected with pRPE-GM, control
ARPE-19-GM or GM, and longitudinal 10 min-static PET/CT scans were acquired at day 2, 7 and 14 days after implantation. Postmortem
analysis was performed subsequently. RESULTS Cell uptake studies demonstrated that 18F-P3BZA accumulated effectively in pRPE cells, but not in control ARPE-19 cells. Further melanin
assay confirmed that the amount of melanin in pRPE was 6-folder higher than that in ARPE-19 cells. Time-brain activity curve from
dynamic PET/CT demonstrated that 18F-P3BZA could passed through blood brain barrier and accumulated in the brain rapidly, and then
gradually decreased to background level 17min post injection.18F-P3BZA-PET could clearly visualize the implanted pRPE cells, and the
accumulation of the probe in the pRPE-GM was much higher than that of ARPE-19-GM or GM. Furthermore, longitudinal PET/CT scans
revealed that little pRPE-GM cells survived long-term after transplantation, as evident by the significant reduced uptake of 18F-P3BZA
uptake in the pRPE-GM transplantation sites. Lastly, autoradiography, HandE and Fontana-Masson staining further confirmed the in vivo
imaging results. CONCLUSION 18F-P3BZA-PET/CT could visualize, characterize and detect the long-term survival of implanted RPE cells via melanin targeting
mechanism. CLINICAL RELEVANCE/APPLICATION This study provides neurologists with high sensitive, high signal to background ratio probe targeting to melanin for tracking the implanted
RPE cells. SSA17-03 • A Preliminary Study of Global Resting-state Activations in PD Patients from Postural Instability and Gait Difficulty
Group
Quanquan Gu MD, PhD (Presenter) ; Peiyu Huang ; Min Xuan ; Xiaojun Xu ; Wei Luo ; Minming Zhang MD, PhD PURPOSE In Parkinson disease (PD), postural instability and gait difficulty (PIGD) is regarded as a refractory issue because of its bad prognosis.
According to these motor signs, PD patients are grouped into PIGD-group and non-PIGD-group. In our study, we used the resting-state
fMRI to explore different brain activation patterns of PIGD-group as distictive to non-PIGD-group patients. METHOD AND MATERIALS 24 PD patients and 22 healthy controls(HC) were recruited in this study. All the patients were drug-na�ve or off medications =12 hours,
devided into PIGD group (12 patients, F/M=4/8) and non-PIGD group (12 patients, F/M= 5/7). Resting-state fMR imaging and
T1-weighted data were performed using a 3T MRI scanner (GE Signa EXCITE HD). All data was processed with SPM8, spatially normalized
into the MNI template. Significant signal changes were considered for P RESULTS As compared to HC, patients from both PD subgroups had a wide-spread increase of activations in bilateral superior frontal and middle
gyri , parietal gyri and mid-cingulate cortex, specially dominant in PIGD group( Fig.1A, 1B). Compared to non-PIGD group, PIGD group
showed a remarkable activation medial to the left superior frontal gyrus (SFG) ( Fig.1C). Page 55 of 183
CONCLUSION PIGD-group showed greater activation than non-PIGD group as referred to HC, mainly covering areas participating in premotor planning,
vestibular,attention for action and regulations for skeletomotor. As to intrasubgroup comparison, left SFG has been found associate to
visual hallucination, imaginary motor, self-awareness and sensory organization. Thus,our study indicated that although PIGD-group
patients behave abnormal posture and gait, the non-motor mental functions rather than motor functions should be respossible for those
clinical performance. CLINICAL RELEVANCE/APPLICATION It is indicated that although PIGD-group patients behave abnormal posture and gait, the non-motor mental functions (i.e., vision,
cognition, sensory, etc.) rather than motor functions should be noted. SSA17-04 • Resting-state Causal Connectivity in Parkinson's Disease with Depression: Aberrant within-network and
between-network Pathways
Peipeng Liang (Presenter) ; Kuncheng Li MD PURPOSE Depression is a common problem in patients with Parkinson's disease, but its neural mechanism is poorly understood. The goal of this
study was to examine effective connectivity (EC) in Parkinson's Disease with Depression (DPD) based on Granger causality. METHOD AND MATERIALS Sixteen patients with DPD, twenty patients of PD with no depression (NDPD), twenty-two patients with major depression (MD), and
twenty-one healthy controls underwent 8-min fMRI scans while resting quietly. Correlation-purged Granger causality analysis was
performed, based on four basic functional networks � default mode network (DMN), dorsal attention network (DAN), motor network
(MN), and emotion network (EN), to compare the group difference. RESULTS It was found that the causal connectivity in patients with DPD are significantly altered, as compared to NDPD, MD and healthy controls,
with some causal pathways decreased (e.g., Hy?OFC/vACC) and some others increased (e.g., R DLPFC?R ITC). Some alterations are
significantly correlated with neuropsychological measures. CONCLUSION The present study demonstrates the coexistence of causal disconnection and compensation in DPD patients, and suggest that DPD has
different neural substrates from NDPD, MD and HC. CLINICAL RELEVANCE/APPLICATION These findings might provide insights into biological mechanism of the disease. SSA17-05 • Fractional Amplitude of Low-frequency Fluctuation Study of Resting-state fMRI in Parkinson’s Disease Patients with
and without Resting Tremor
Min Xuan (Presenter) ; Peiyu Huang ; Quanquan Gu MD, PhD ; Xiaojun Xu ; Wei Luo ; Minming Zhang MD, PhD PURPOSE Resting tremor (RT) is present in 75-100% of Parkinson�s disease (PD) patients, but the explanation of this symptom still remains poorly
known. Here we investigate how the functional changes happen in brains of PD patients with and without resting tremor, and whether
these changes relate to the severity of resting tremor. METHOD AND MATERIALS 15 PD patients with resting tremor (RT group), and 18 gender-, age-, duration-matched patients without resting tremor (non-RT group)
participated in the resting-state functional magnetic resonance imaging (fMRI) analysis. We measured the fractional amplitude of
low-frequency fluctuation (fALFF) between the two groups and investigated the correlation between RT scores and fALFF in the regions
displaying significant group differences. RESULTS The RT group demonstrated an decreased fALFF in the right supplementary motor area (SMA), and bilateral prefrontal cortex compared
to non-RT group. There was no significant correlation between RT rating and fALFF in right SMA. CONCLUSION Our results suggest that the generation of resting tremor may be related to the decreased brain activity of right SMA, but the severity of
resting tremor may not. CLINICAL RELEVANCE/APPLICATION Used to help understand the causes of resting tremor of PD, may eventually contribute to the treatment of this symptom. SSA17-06 • Alternation of Functional Connectivity and Global Disturbance of FNC of Parkinson’s Disease by Resting-state fMRI
Haibo Xu (Presenter) ; Yuhui Wang ; Dongling Jiang ; Cheng Luo ; Dan Zhang PURPOSE The aim was to estimate the alteration of brain functional connectivity in Parkinson�s disease (PD) during resting state of brain by
resting-state fMRI. METHOD AND MATERIALS A total of 16 right-handed patients with PD diagnosed according to the UK Parkinson�s Disease Society Brain Bank diagnostic criteria,
and 14 gender- and age-matched right-handed healthy controls were carried out on resting-state fMRI for two levels of analyses, that is
functional connectivity within resting state networks (RSNs) and functional network connectivity (FNC) analysis. Using group independent
component analysis, sixteen RSNs were identified, and selected for assessment of the difference of functional connectivity within RSNs
and FNC between groups. RESULTS Compared with HC, the patients with PD showed decreased significant functional connectivity within the regions in the putamen network,
thalamus network, cerebellum network, attention network and self-referential network in bilateral putamen, bilateral thalamus, left
cerebellum, right superior frontal gyrus, left medial frontal gyrus (orbitofrontal area), left anterior cingulated. The execution network was
the only one revealing increased functional connectivity in bilateral paracentral lobule ( P < 0.01). Furthermore, the results showed
significant functional connectivity disturbance inter- RSNs in patients with PD. The PD had a trend to show increased functional
connectivity within most of RSNs and decreased functional connectivity within a small part of RSNs.The caudate network showed
increased functional connectivity with anterior DMN network and execution network and decreased functional connectivity with cerebellum
network. Functional connectivity with execution network was significantly increased in DMN network, motion network, self-referential
network and primary auditory network. The posterior DMN network showed decreased functional connectivity with thalamus network. CONCLUSION Our findings might suggest that decreased resting state functional connectivity and global disturbance of FNC are two remarkable
characteristics of Parkinson�s disease. CLINICAL RELEVANCE/APPLICATION The multi-perspective analysis based on RSNs may be a valuable means to understand the underlying neuro-pathophysiological
Page 56 of 183
mechanism of PD. SSA17-07 • Dysfunction of Central Olfactory Network in the Parkinson's Disease
Kaiyuan Zhang MD (Presenter) ; Xuemin Wu ; Kuncheng Li MD ; Qing X Yang PhD ; Jianli Wang PURPOSE Olfactory dysfunction is prevalent in majority of idiopathic Parkinson's disease (PD) patients. Even though typical PD pathology, Lewy
pathology, has been found in the olfactory structures, the cause of olfactory deficits in PD is still not clear. We hypothesized that in PD
patients, the central olfactory network (CON) is deteriorated. In this study, we applied task related and resting state fMRI (rsfMRI)
methods to study the functional deficit of the CON in the PD brain. METHOD AND MATERIALS Nineteen PD patients (HandY stage 1-4) and ten age-/gender-matched healthy controls (HC) received respiration-triggered olfactory fMRI
with lavender odor as the stimulant and rsfMRI on a 3T scanner. The olfactory function was evaluated with University of Pennsylvania
Smell Identification Test (UPSIT). The PD patient's clinical status was evaluated with Unified Parkinson�s Disease Rating Scale (UPDRS).
During the imaging protocol, there were no cues provided to the subjects and no tasks for the subjects to do. The olfactory fMRI data
were preprocessed with qMRI V2.1 and then analyzed using general linear model approach with SPM8. The rsfMRI data were processed
with DPARSF V2.2 for resting state functional connectivity (FC) analysis using the major activation cluster in the primary olfactory cortex
(POC) from the HC group as the seed. The FC at the group level was processed with REST V1.8 for the correlation analysis with clinical
status. RESULTS In response to the odorant stimulation, significant activation was shown in the POC and secondary olfactory structures of the HC brains
(e.g., orbitofrontal and insular cortex ), but not in the PD brains. Significant decrease of FC with POC was observed in the anterior
cingulate and right inferior temporal cortex (two-sample t-test with age effect corrected, p CONCLUSION The FC decrease within the CON contributes to the olfactory deficit in PD, and the connectivity change worsens when PD progresses. CLINICAL RELEVANCE/APPLICATION The findings in this study improve our understanding of olfactory deficits in Parkinson's disease and provide a foundation for further
clinical research in its diagnosis and treatment. SSA17-08 • Quantitative Assessment of Iron Deposition in Parkinson's Disease Using Quantitative Susceptibility Mapping at 3T:
An In Vivo MR Study
Minako Azuma (Presenter) ; Toshinori Hirai MD ; Kazumichi Yamada ; Tian Liu PhD ; Yasuyuki Yamashita MD * ; Yi Wang
PhD PURPOSE To evaluate the usefulness of assessing brain iron deposition in patients with Parkinson's disease (PD) by quantitative susceptibility
mapping (QSM). METHOD AND MATERIALS All MRI studies were performed with a multi-echo gradient-echo sequence on a 3.0 T Siemens scanner. We studied 8 PD patients (5
females, 3 males; age range 54-75 years, mean age 67 years) and 8 age-matched healthy controls. For QSM we used both the
magnitude and phase components from all TEs in the morphology-enabled dipole inversion method. The mean susceptibility values
(MSVs) of the bilateral substantia nigra (SN), red nucleus (RN), caudate nucleus (CN), globus pallidus (GP), and putamen (PT) was
measured on QSM images. To place the region of interest (ROI) in the SN while avoiding contamination of the subthalamic nuclei we used
coronal multiplanar reconstruction images with reference to the Schaltenbrand and Wahren atlas. Measurements were in the
anteromedial and posterolateral (aSN, pSN) areas of the SN. Axial images were used for measurements in the other structures. In each
patient, the most and least affected side was identified using the Unified Parkinson�s Disease Rating Scale motor score (UPDRS-III).
Measurement differences were assessed with the paired and independent t test; P < 0.05 was considered to indicate a statistically
significant difference. RESULTS In healthy subjects the MSVs of both hemispheres for the GP, aSN, pSN, RN, PT, and CN were 157 ± 34, 152 ± 49, 94 ± 31, 122 ± 38,
82 ± 24, and 74 ± 14 ppb, respectively. In PD patients the MSVs of the aSN and pSN on the most affected side were 148 ± 54 and 130 ±
60 ppb, and on the least affected side were 126 ± 58 and 185 ± 65 ppb, respectively. On both sides of healthy subjects and on the least
affected side of PD patients, the MSV was significantly higher in the aSN than pSN (P < 0.01). There was no significant difference
between the aSN and pSN on the most affected side of PD patients. The MSV in the pSN on the least affected side of PD patients was
significantly higher than the controls (P < 0.01); the difference was not statistically significant in the other structures between the two
groups. CONCLUSION Our QSM study suggests that the iron deposition in the SN in PD patients is different from that in healthy subjects. CLINICAL RELEVANCE/APPLICATION QSM may provide useful quantitative information for evaluating brain-iron deposition in PD patients. SSA17-09 • Difference in Phase Value of Putamen on SWI between Parkinsonian Syndrome and Age Matched Control
Jin Hee Jang MD (Presenter) ; Hyun Seok Choi MD ; Bum-Soo Kim MD, PhD ; Kookjin Ahn MD, PhD ; So L Jung ; Bom-Yi Kim
MD PURPOSE Susceptibility weighted image (SWI) is sensitive to paramagnetic material such as iron. Iron deposition is considered not only as
phenotype of neurodegenerative disease but also as normal aging. Decreased uptake of putamen on FP-CIT PET has been known as one
of imaging biomarkers of Parkinson disease. The purpose of this study is to evaluate difference in phase value of putamen between
patient with Parkinsonian syndrome and age matched control. METHOD AND MATERIALS We retrospectively enrolled patients of three groups with idiopathic Parkinson disease (IPD) (n=20), atypical Parkinsonian syndrome or
2ndary Parkinsonism (n=14), and age matched control (n=16). SWI were taken from all the enrolled subjects (n=50). Region of interest
(ROI) was drawn to measure phase values of bilateral caudate head and putamen on the axial images at the level of foramen of Monro.
Patient with IPD (n=20) and atypical Parkinsonian syndrome or 2ndary Parkinsonism (n=14) underwent F-18 FP-CIT PET/CT. Tracer
activity of ROI was measured in caudate, putamen and a reference region of occipital cortex. Statistical analyses were performed to
compare phase values and tracer activity between groups. RESULTS Mean age was 64.7±8.3 year-old in idiopathic Parkinson disease; 66.1±1.5 year-old, in atypical Parkinsonian syndrome or 2ndary
Parkinsonism; and 65.7±6.0 year-old, in control. The mean ages were not different among 3 groups. The phase values of right and left
putamen in IPD (0.068±0.038, 0.062±0.031 radian) were higher than those of age matched control (0.030±0.030, 0.037±0.032 radian).
The phase values of atypical Parkinsonian syndrome or 2ndary Parkinsonism (0.079±0.039, 0.084±0.039 radian) were higher than those
of age matched control. There was no difference of phase value between IPD and atypical Parkinsonian syndrome or 2ndary
Parkinsonism. However, normalized FP-CIT tracer activity of right and left putamen in IPD (3.1±0.6, 2.9±0.5) were lower than those of
atypical Parkinsonian syndrome or 2ndary Parkinsonism (3.9±1.2, 3.9±1.2). Page 57 of 183
CONCLUSION Phase value of Parkinsonian syndrome was higher than that of age matched control. Further investigation of phase value is needed with
larger population. CLINICAL RELEVANCE/APPLICATION Iron deposition and metabolism of normal aging brain and neurodegenerative disease has been poorly understood. Phase value of SWI is
a quantifiable variable which can be obtained from SWI. Nuclear Medicine (PET/CT in Oncology) Sunday, 10:45 AM - 12:15 PM • S505AB
OI
NM CT SSA18 • AMA PRA Category 1 Credit ™:1.5 • ARRT Category A+ Credit:1.5 Moderator
Andrew Quon , MD * Back to Top SSA18-01 • Anti-3-[18F] FACBC PET Is Useful to Improve Salvage Radiotherapy Failure Rates in Recurrent Prostate Cancer
Oluwaseun Odewole MBBS, MPH (Presenter) ; Ashesh B Jani MD ; Pooneh Taleghani MD ; Bital Savir-Baruch MD ; Leah M
Bellamy ; Weiping Yu PhD ; Peter Nieh MD ; Viraj Master MD ; Mark M Goodman PhD * ; David M Schuster MD ; Raghuveer
K Halkar MD * PURPOSE Salvage radiotherapy after prostate cancer recurrence is associated with failure rates of up to 50% (Radiation Medicine Rounds 2:1
(2011) 59�80), probably from failure to detect extra-regional disease. Therefore, detection of such disease on imaging has substantial
value. anti-3-[18F] FACBC is a synthetic amino acid PET radiotracer with utility in detection of prostate cancer (Radiology 2011;
259:852). Our aim was to determine if FACBC PET could be used to improve salvage radiotherapy failure rates METHOD AND MATERIALS Retrospective analysis of 11 patients who had salvage radiotherapy for prostate cancer recurrence (9 post-prostatectomy; 2
non-prostatectomy) selected by findings from FACBC PET-CT. PSA failure was defined as nadir PSA + 0.2 ng/mL for prostatectomy and
nadir PSA + 2.0 ng/mL for non-prostatectomy. RESULTS 11 patients without FACBC PET extra-pelvic disease were qualified for salvage radiotherapy. Mean original Gleason score (±SD, range)
was 7 (±0.74, 6 - 8). 9/11 patients had radiotherapy to the prostate bed and 2/11 also to the pelvis. Average time (±SD, range) from
FACBC to radiotherapy was 7.9 (±5.9, 4-22) months; average pre-radiotherapy PSA (±SD, range) was 4.4 (± 5.2, 0.2-15.3) ng/ml.
Average PSA follow-up from time of scan (±SD, range) was 29.9 (±9.5, 15-54) months and 20.9 (±7.2, 8-35) months from time of
radiotherapy. 18.2% (2/11) of our patients had PSA failure at time of analysis. Of these, one did not receive radiotherapy until 16 months
after FACBC scan. Salvage radiotherapy was successful in 3/5 patients with PSA > 2.0 ng/ml at time of radiotherapy. CONCLUSION Guidance with advanced molecular imaging using anti-3-[18F] FACBC PET-CT may be valuable in selecting recurrent prostate carcinoma
patients for salvage radiotherapy. Impact on salvage radiotherapy outcomes is currently being studied at our institution in a prospective
randomized controlled trial. CLINICAL RELEVANCE/APPLICATION Patient selection for salvage radiotherapy guided by molecular imaging with anti-3-[18F] FACBC PET-CT may enable better response rate
at higher PSA's as compared with conventional imaging guidance. SSA18-02 • Pre-treatment Whole-body Total Lesion Glycolysis and Metabolic Tumor Volume at FDG PET-CT as Prognostic
Indicators in Advanced Cervical Cancer
Mohammad A Husainy MD (Presenter) ; Farhina Sayyed MRCS ; Helene Thygesen PhD ; Chirag Patel FRCR ; Mark Barnfield ; Andrew F Scarsbrook FRCR PURPOSE To study the prognostic value of whole body total lesion glycolysis (TLG) and total metabolic tumor volume (MTV) derived from
pre-treatment fluorine 18 fluorodeoxyglucose (FDG) positron emission tomography - computed tomography (PET-CT) in locally advanced
cervical cancer. METHOD AND MATERIALS Patients with locally advanced cervical cancer who underwent pre-treatment FDG PET-CT from the year 2010-12 were identified from an
institutional cancer database. Mean and maximum standardized uptake value and MTV of each primary tumor and any nodal or distant
disease were determined. Whole body MTV was calculated by summation of the primary tumor and any other disease site volumes. TLG
was calculated by summation of individual tumor volume multiplied by mean SUV. Univariate analysis was performed to assess the
prognostic significance of clinical stage, SUVmax, whole-body MTV and TLG on subsequent patient outcome. RESULTS 34 patients were included in data analysis. Median follow up time was 2.2 years. The estimated median overall survival (OS) for the
cohort was 2.1 years. The 1-year OS was 64.7% for patients with high whole-body TLG (> 385.29) and 88.2% for those with low
whole-body TLG (67) and 88.2% for those with low whole-body MTV (14.7). Univariate Cox analysis showed that whole-body TLG,
whole-body MTV and clinical stage were significant prognostic factors for OS. For statistical test, we used the confidence level 95%. Cox
proportional hazard modeling showed a significant prognostic value of whole body-TLG (hazard ratio= 3.63; 95% confidence interval:
1.15, 11.43; p
CONCLUSION Whole-body TLG and MTV may be better prognostic indicators than primary tumor SUVmax for predicting outcome in advanced cervical
cancer. CLINICAL RELEVANCE/APPLICATION Whole-body TLG and MTV may be better prognostic indicators in the advanced cervical cancer and could have a role for treatment
stratification in the future. SSA18-03 • Is MDP Bone Scan Necessary for Initial Staging of Ewing Sarcoma If FDG PET/CT Is Performed?
Gary A Ulaner MD, PhD (Presenter) ; Heather Magnan MD ; John Healey MD ; Wolfgang A Weber MD * ; Paul Meyers MD PURPOSE To determine whether MDP bone scans are necessary during initial staging of Ewing sarcoma (ES) patients, if FDG PET/CT is performed. METHOD AND MATERIALS An IRB approved retrospective review was performed of patients who underwent FDG PET/CT and MDP bone scan prior to treatment of
newly diagnosed ES from 1/04 to 11/12. Studies were reviewed to document suspected primary and metastatic malignancy. Pathology
Page 58 of 183
newly diagnosed ES from 1/04 to 11/12. Studies were reviewed to document suspected primary and metastatic malignancy. Pathology
and imaging follow-up were used to determine the presence or absence of disease at suspected sites. RESULTS 60 patients were identified with FDG PET/CT and MDP bone scans performed prior to treatment of newly diagnosed ES. 44 primary
malignancies demonstrated a lytic CT appearance, 3 were sclerotic, and 13 involved only soft tissue. 11/12 patients with osseous
metastases were detected on PET/CT, with the 1 false negative occurring in a sclerotic primary tumor. 9/12 patients with osseous
metastases were detected on MDP bone scan, with the 3 false negatives occurring in patients with lytic primary tumors. Only 1 of 13
patients with a soft tissue primary malignancy demonstrated bone metastases, evident on both bone scan and PET/CT. PET/CT also
demonstrated 8 patients with lung metastases and 3 patients with lymph node metastases, which were not evident on MDP bone scan. CONCLUSION When ES is lytic, MDP bone scan does not add to staging performed by FDG PET/CT, thus MDP bone scanning may be omitted. However,
when ES is sclerotic, MDP bone scan may detect patients with osseous metastases which are not detected by FDG PET/CT. CLINICAL RELEVANCE/APPLICATION Bone scan may be omitted from the staging of newly diagnosed ES when the primary tumor is lytic. When the primary tumor is sclerotic,
MDP bone scan may detect osseous metastases missed on FDG PET/CT. SSA18-04 • Prognostic Value of Concurrent Staging 18F-FDG PET/CT and Staging Endoscopic Ultrasound in Esophageal Cancer
Vinod Malik MBBCh, MA (Presenter) ; Ciaran J Johnston MD ; Julie A Lucey PhD ; Zieta Claxton BSc ; Dermot O'Toole MD ; John V Reynolds MD PURPOSE Staging of esophageal cancer is improved by the concurrent use of 18F-fluorodeoxyglucose positron emission tomography/computed
tomography (18F-FDG PET/CT) and endoscopic ultrasound (EUS). This study ascertained if these complementary adjuncts can enhance
staging by proposing correlating independent prognostic factors in esophageal cancer. METHOD AND MATERIALS From December 2008 to May 2011, 150 patients with biopsy-proven cancer of the esophagus or esophagogastric junction underwent
concurrent staging 18F-FDG PET/CT and staging EUS. 18F-FDG PET/CT obtained maximum standardized uptake value (SUVmax) and
metabolic tumor volume (MTV) of the primary tumor was recorded. EUS evaluated the tumor for T stage (T1-T4), regional lymph node
metastases (N0 or N+) and the presence or absence of celiac axis nodes and hepatic metastasis. Relationships between parameters were
investigated using the spearman rho correlation coefficient, survival analysis performed using Kaplan-Meier and independent prognostic
factors determined using Cox regression multivariate analysis. RESULTS A strong positive correlation between 18F-FDG PET/CT MTV and EUS �T� stage was demonstrated (r=0.566, p18F-FDG PET/CT MTV was
noted between early EUS tumors (T1/T2) and late EUS tumors (T3/T4) (p18F-FDG PET/CT MTV < 7.5cm3 (p=0.0013), 18F-FDG PET/CT
SUVmax < 4.1 (p=0.0014), EUS �T� stage (p18F-FDG PET/CT MTV < 7.5 cm3 (p=0.0006), EUS �T� stage (p=0.01) and EUS �N�
stage (p=0.01). CONCLUSION MTV, a volumetric parameter of 18F-FDG PET/CT is a valuable independent prognostic factor in esophageal cancer, more so than SUVmax
and enhances staging when used in conjunction with EUS �T� stage and EUS �N� stage by predicting survival. CLINICAL RELEVANCE/APPLICATION Independent prognostic factors identified by staging 18F-FDG PET/CT and EUS in esophageal cancer may facilitate selection of patients to
treatment regimens with the benefit of enhanced outcomes. SSA18-05 • Intratumoral Heterogenity of Tracer Uptake on 18F-FDG PET/CT for Characterization of Peripheral Nerve Sheath
Tumors in Patients Suffering from Neurofibromatosis Type 1
Johannes M Salamon MD (Presenter) ; Peter Bannas MD ; Jasmin D Busch MD ; Jochen Herrmann MD ; Gerhard B Adam MD
; Victor F Mautner MD ; Thorsten Derlin PURPOSE Peripheral nerve sheath tumors (PNSTs) in patients with neurofibromatosis type 1 (NF1) may undergo focal malignant transformation,
and heterogeneity of tumor composition is therefore a histopathological hallmark of malignant PNSTs (MPNSTs). MPNSTs usually
demonstrate strongly increased and inhomogenous tracer uptake. The aim of this study was to evaluate the potential usefulness of
intratumoral tracer uptake heterogeneity on 18F-fluorodeoxyglucose (FDG) PET/CT as compared to a cut-off SUVmax for characterization
of PNSTs in NF1. METHOD AND MATERIALS 50 patients suffering from NF1 underwent 18F-FDG PET/CT. Intralesional18F-FDG uptake was analyzed qualitatively and
semiquantitatively by measuring the mean and maximum standardized uptake value (SUV). Heterogeneity of tracer uptake was evaluated
by computing a SUV-based heterogeneity index (HISUV) and qualitatively graded using a three-point scale. Inter- and intrarater
agreement was determined using Cohen`s ?. Histopathologic evaluation as well as clinical and radiological follow-up served as reference
standard. RESULTS Using either intralesional heterogeneity or SUVmax malignant tumors could be identified with a sensitivity of 100%. Qualitative
intratumoral uptake heterogeneity and malignant transformation in peripheral nerve sheath tumors showed a significant association (p CONCLUSION 18F-FDG PET/CT reveals strong intratumoral heterogeneity of tracer uptake in MPNSTs in patients with NF1. Either a SUVmax cut-off
value or a heterogeneity index can be used to identify malignant PNSTs with a sensitivety of 100%, however the approach using a cut-off
value leads to a higher specificity. There is no significant improvement in diagnostic performance using both methods in combination. CLINICAL RELEVANCE/APPLICATION New imaging parameters for the characterization of peripheral nerve sheath tumors in NF1 patients may help reducing unnecessary
morbidity due to biopsies or surgery. SSA18-06 • Can I-124 PET/CT Predict the Uptake of Therapeutic Dosages of Radioiodine (I-131) in Differentiated Thyroid
Carcinoma?
Gauke K Lammers MD (Presenter) ; P.C.M. Pasker ; M. E. Sanson-Van Praag ; John M De Klerk MD, PhD PURPOSE Follow up of differentiated thyroid carcinoma (DTC) is currently mainly based on monitoring of serum thyroglobulin (Tg) levels. In the
case of an elevated serum Tg level and suspected recurrent DTC, but negative diagnostic imaging, a so called �blind� I-131 therapy is
recommended, followed by whole body scintigraphy to assess the extent of disease. Regrettably, in a significant number of patients this
�blind� I-131 therapy results in no visible abnormal I-131 uptake and hence in probably no beneficial therapeutic effect. Iodine-124
PET/CT is a promising tool for identifying patients who will benefit from I-131 therapy, by predicting iodine uptake. I-124 PET/CT could
therefore be important in personalizing treatment for patients with DTC. METHOD AND MATERIALS Page 59 of 183
The results of 34 I-124 PET/CT scans performed in our hospital between 2007 and 2012 were retrospectively evaluated. All scans were
made in patients under follow up, replacing the diagnostic I-131 scintigraphy. In all cases Tg was stimulated (by recombinant TSH or
thyroid hormone withdrawal). A dosage of 40MBq I-124 was used, with scans at 24 hours and 96 hours after administration. Results were
compared to subsequent I-131 post-treatment scans (6 cases) and a combination of follow up, stimulated Tg and other imaging tools
results available to assess presence of recurrence. RESULTS Recurrence of DTC was found in 14/34 cases. I-124 PET/CT correctly detected recurrence in 2 cases, with false negative results in 12
cases. In 1 case a false positive I-124 PET/CT result was recorded. 19 true negative results were found. For I-124 PET/CT this meant a
sensitivity of 14% and a specificity of 95%. PPV was 67%, NPV 61%. Post-treatment I-131 uptake (6 cases) was correctly predicted in 1
case, with false negative results in 4 cases and 1 true negative result. CONCLUSION In this study I-124 PET/CT did not reliably detect recurrent differentiated thyroid carcinoma. More importantly it failed to predict I-131
uptake on post-treatment scintigraphy in a significant number of cases, which would lead to under-treatment. CLINICAL RELEVANCE/APPLICATION I-124 PET/CT in follow up of differentiated thyroid cancer cannot reliably identify the patients who would benefit from I-131 treatment. SSA18-07 • Whole-body MRI vs. Co-registered Whole-body FDG-PET/MRI vs. Integrated Whole-body FDG-PET/CT: Capability for
TNM and Stage Assessment in Non-small Cell Lung Cancer Patients
Yoshiharu Ohno MD, PhD (Presenter) * ; Shinichiro Seki ; Mizuho Nishio MD * ; Hisanobu Koyama MD ; Maho Tsubakimoto
MD ; Hitoshi Yamagata PhD * ; Kota Aoyagi * ; Yumiko Onishi MD ; Takeshi Yoshikawa MD * ; Sumiaki Matsumoto MD, PhD
* ; Nobukazu Aoyama RT ; Katsusuke Kyotani RT ; Akiko Kusaka RT ; Kazuro Sugimura MD, PhD * PURPOSE To directly and prospectively compare the capability for TNM and clinical stage assessments among whole-body MR imaging (MRI),
co-registered FDG-PET/MRI and integrated FDG-PET/CT in non-small cell lung cancer (NSCLC) patients. METHOD AND MATERIALS 70 consecutive pathologically diagnosed NSCLC patients (37 men, 33 women; mean age 73 years) prospectively underwent whole-body
MRIs at 3T system, integrated FDG-PET/CTs, conventional radiological examinations, surgical biopsies and/ or treatments, pathological
examinations and follow-up examinations. Final diagnosis of TNM factors and clinical stage in each patient was determined according to all
examination results. All co-registered FDG-PET/MRIs were generated by means of our proprietary software. Then, TNM factor and clinical
stage on all methods were visually assessed by radiologists and nuclear medicine physicians. Then, final diagnosis in each patient was
made by consensus of two readers on each method. To determine the agreements of TNM factor and clinical stage between each method
and final diagnosis, kappa statistics were performed. To compare the diagnostic capability for operability assessment (T factor: T1 or T2
vs. T3 or T4, N factor: N0 or N1 vs. N2 or N3, M factor: M0 vs. M1, clinical stage: stage I or II vs. stage III or IV) among all methods,
sensitivities, specificities and accuracies were statistically compared each other by using McNemar�s test. RESULTS Each agreement with final diagnosis was as follows: T factor, 0.90=?=0.93; N factor, 0.60=?=0.88; M factor, 0.78=?=0.93; clinical
stage, 0.55=?=0.87, respectively. When compared each operability assessment capability according to TNM factor, accuracies (97.1
[68/70] %) of N factor on MRI and FDG-PET/MRI were significantly higher than that on FDG-PET/CT (88.6 [62/70] %, p CONCLUSION Whole-body MRI and co-registered FDG-PET/MRI are more useful than integrated FDG-PET/CT for TNM and clinical stage assessments in
non-small cell lung cancer patients. CLINICAL RELEVANCE/APPLICATION Whole-body MRI and co-registered FDG-PET/MRI are more accurate than integrated FDG-PET/CT for TNM and clinical stage assessments
in non-small cell lung cancer patients. SSA18-08 • Correlations between FDG Uptake Indices and the Expression of Various Type Oncogenes (KRAS, BRAF, HIF-1, EGFR,
CDH13, p53, Ki67, Glut 1 and Glut 3) in Biliary Cancer: A Comparison Study to MRI Diffusion Weighted Image Parameters
Shigeki Nagamachi MD, PhD (Presenter) ; Ryuichi Nishii MD, PhD ; Youichi Mizutani ; Syogo Kiyohara ; Nobuhiro Shibata ; Kazuhiro Kondo ; Masahiro Kai ; Shozo Tamura MD, PhD ; Kazuo Chijiiwa ; Keiichi Kawai ; Seigo Fujita MD ; Hideyuki
Wakamatsu MD ; Shigemi Futami PURPOSE We investigated the correlations between FDG uptake and the expression of various type oncogenes in biliary cancer. In addition, we also
analyzed the correlation between parameters of diffusion weighted MRI image (DWI) and oncogenes expression. Then, we compared both
correlation coefficients to find which imaging parameters were more associated with the expression of which oncogenes in biliary cancer. METHOD AND MATERIALS We investigated forty-three patients of biliary cancer who underwent both MRI and FDG-PET/CT before operation. Using Reverse
Transcription-Polymerase Chain Reaction (RT-PCR) analysis, we measured the various DNA content (EGFR, CDH13, p53, Ki67, KRAS,
BRAF, HIF-1, Ki-67, p53, Glut 1 and Glut 3) in surgically resected cancer tissues. We investigated the correlation coefficients between the
expression of oncogenes DNA and FDG uptake parameters (SUV max early and SUV max delayed), or between the expression of
oncogenes DNA and apparent diffusion coefficient (ADC mean and ADC min). RESULTS FDG uptake parameters (SUV max early and SUV max delay) were positively correlated with B-RAF (0.34 and 0.43), HIF-1(0.41 and
0.48), Glut1 (0.45 and 0.52) or Glut 3(0.35 and 0.48). In contrast, DWI parameters (ADC mean or ADC min) showed positive correlation
only with HIF-1 (0.48 and 0.16). However, there was not any significant correlation in other parameters. CONCLUSION In biliary cancer, both SUV max and DWI parameters showed the close association with the expression of oncogenes related with
hypoxia. In addition, SUV max was more associated with the expression of oncogenes associated with RAF/MEK/ERK signaling pathway. CLINICAL RELEVANCE/APPLICATION By the correlation analysis, we may estimate the expression of oncogenes such as B-RAF or HIF-1 by the values of SUVmax. We may
estimate the expression of HIF-1 by ADC also. SSA18-09 • Incremental Value Of FDG PET CT in Differentiating Benign and Malignant Cardiac Masses
Kavitha Yaddanapudi DMRD, MBBS (Presenter) ; Michael A Bolen MD ; Ahmed El-Sherief MD ; Carmela Tan MD ; Richard
Brunken MD * PURPOSE To evaluate the incremental value of FDG-PET CT over contrast enhanced magnetic resonance imaging (CE MRI) and computed
tomography (CT) in differentiating benign cardiac masses from malignant lesions.
METHOD AND MATERIALS Retrospective evaluation of eleven patients with cardiac masses who underwent CE MRI (n=9), CT (n=2) and FDG-PET (n=11) was
performed. The gold standard was histopathology after surgical excision (n=8) and long term follow up of more than 2 years (n=3).
Page 60 of 183
Patients were divided into two groups benign (n=7) and malignant (n=4) cardiac masses. On FDG PET CT the maximum standardized
uptake values (SUV max) of the lesions was determined. A SUV max cutoff of 3.5 was used to differentiate benign from malignant
lesions. MRI and CT characteristics as size, invasiveness and tissue characterization were evaluated. The ability of SUV max on FDG PET
to differentiate benign and malignant lesions was then compared to morphological imaging diagnosis and correlated with pathology and
follow up.
RESULTS The mean SUV max for malignant lesions was 5± 2.5. The mean SUV for benign lesions was 0.85. No FDG uptake was seen in 5 of the 7
benign lesions (71%). The sensitivity and specificity for determining malignancy by FDG PET CT was 75% and 100% respectively. FDG
PET CT has a 100% positive predictive value for diagnosing malignancy with a SUV max cut off of 3.5. Morphological imaging could not
differentiate between benign and malignant lesions in 36% (n=4) cases. In 3 of these 4 cases FDG PET CT was able to differentiate
between benign and malignant lesions. In one case of osteosarcoma of left atrium that was densely calcified both FDG PET CT and
morphological imaging could not point towards the malignant nature preoperatively. CONCLUSION FDG PET CT is a useful adjunct to morphological imaging in differentiating benign from malignant cardiac masses. FDG uptake by the
mass with a high SUV (>3.5) has a good positive predictive value for malignancy. CLINICAL RELEVANCE/APPLICATION FDG PET CT with a high positive predictive value can noninvasively differentiate benign from malignant lesions in most situations and is a
powerful tool in the evaluation of cardiac masses.
Physics (CAD I) Sunday, 10:45 AM - 12:15 PM • S403B
PH
IN CT SSA19 • AMA PRA Category 1 Credit ™:1.5 • ARRT Category A+ Credit:1.5 Moderator
Heang-Ping Chan , PhD Moderator
Kyongtae T Bae , MD, PhD * Back to Top SSA19-01 • Virtual Colon Tagging Based Dual-energy Electronic Cleansing for Fecal-tagging CT Colonography
Wenli Cai PhD (Presenter) ; Se Hyung Kim ; Da Zhang PhD ; June-Goo Lee PhD ; Yasuji Ryu MD ; Hiroyuki Yoshida PhD * PURPOSE Material decomposition ability in dual-energy CT (DE-CT) provides a promising solution to identify tagged fecal materials in electronic
cleansing (EC) for fecal-tagging CT colonography (CTC). The purpose of this study was to develop and evaluate a novel dual-energy
electronic cleansing (DE-EC) scheme based on 'virtual colon tagging' (VCT) for minimizing EC artifacts in the cleansed CTC images. METHOD AND MATERIALS Based on our localized three-material decomposition model for DE-CT, we developed a DE-EC scheme denoted as VCT-EC, with the
following steps: 1) DE-CTC images were decomposed into three material mixture fields of luminal air, soft tissue, and iodine-tagged fecal
material; 2) a Poisson-based derivative smoothing algorithm smoothed the gradients and implicitly smoothes each material mixture field;
3) VCT images were calculated by virtually elevating the CT value of luminal air to be as high as that of tagged fecal materials and thus
virtually tagging the entire colonic lumen, and 4) the entire colonic lumen was segmented and thus cleansed by its high values in VCT
images. Twenty-one patients underwent a bowel preparation with a low-fiber, low-residue diet, and oral administration of iodine contrast
agents. Dual-energy CT scanning (SOMATOM Definition Flash) was performed at two photon voltages of 140 kVp and 80 kVp with the
automatic dose exposure control module (CARE Dose 4D) in both supine and prone positions. Resulting DE-CTC data were subjected to
VCT-EC scheme. For comparison purpose, we applied a conventional single-energy EC (SA-EC) to the standard fused DE-CTC images. RESULTS A visual assessment was performed by two radiologists for evaluating the cleansing quality by counting of the regions with distractive
cleansing artifacts observed in the fly-through of the colon. Compared to SA-EC, the total number of EC artifacts in VCT-EC was reduced
significantly by 72%. In specific, the numbers of three types of EC artifacts were reduced by 63% (type1 - caused by
pseudo-enhancement), 75% (type 2 - caused by partial volume effect), and 70% (type 3 - caused by inhomogeneous tagging),
respectively. CONCLUSION Our VCT-based DE-EC scheme provides an effective solution for significantly reducing EC artifacts by use of the material decomposition
ability in dual-energy CT. CLINICAL RELEVANCE/APPLICATION New dual-energy EC method can substantially reduce EC artifacts and it may lead to artifact-free visualization of the colon. SSA19-02 • Computer Aided Detection of Ureter Abnormalities on Multi-detector Row CT Urography
Lubomir M Hadjiiski PhD (Presenter) ; Heang-Ping Chan PhD ; Elaine M Caoili MD, MS ; Richard H Cohan MD * ; Chuan Zhou
PhD PURPOSE To develop a CAD system for automated detection of ureter abnormalities in multi-detector row CT urography, which potentially can assist
radiologists in detecting ureter cancer. METHOD AND MATERIALS Our CAD system consists of two stages. In the first stage, an automatic tracking of the ureter is performed by previously proposed
COmbined Model-guided Path-finding Analysis and Segmentation System (COMPASS). Given an initial starting point, the ureter is tracked
by COMPASS based on the CT values of the contrast filled lumen. In the second stage, lesion candidates are identified using histogram
analysis within the ureter to differentiate the abnormality from the background, which is the ureter filled with contrast material. A
uniformity measure is designed to detect non-uniformity of the CT values within the ureter volume. If an abnormality is present in the
ureter, the uniformity of the CT values will be distorted and reduce the uniformity measure. The size and shape of the detected region
further differentiate lesions from noise. In this pilot study, a limited data set of 15 patients (13 malignant and 2 benign) with
biopsy-proven ureter lesions was used. Experienced radiologists identified 30 biopsy-proven ureter lesions (25 cancers and 5 benign) on
the multi-detector row CT images. The average lesions size was 3.4 mm (range: 2.1 mm � 7.6 mm). The average conspicuity was 3.5
(range: 2 to 5) on a scale of 1 to 5 (5 very subtle). RESULTS The COMPASS successfully tracked the ureters in all patients. 90% (27/30) of the ureter lesions including 88% (22/25) of the ureter
cancers were detected with 2.5 (37/15) false positives per patient. The three missed cancers were small lesions with average size of 2.2
mm. CONCLUSION The preliminary results show that our COMPASS and CAD system can track the ureter and detect ureter cancer of medium conspicuity
Page 61 of 183
The preliminary results show that our COMPASS and CAD system can track the ureter and detect ureter cancer of medium conspicuity
and relatively small size. Further study is underway to improve the detection performance with a larger data set. This pilot study is a first
step towards the development of a CAD system for detection of ureter cancer in multi-detector row CT urography.
CLINICAL RELEVANCE/APPLICATION An accurate CAD system has the potential to assist radiologists in detection of ureter cancers at an early stage which usually are small in
size with subtle appearance. SSA19-03 • Detecting Vertebral Degenerative Disease on 18F-NaF PET/CT Using a Novel Cortical Shell Map
Jianhua Yao PhD * ; Hector Munoz ; Joseph E Burns MD, PhD ; Karen A Kurdziel MD * ; Peter L Choyke MD * ; Le Lu PhD ; Ronald M Summers MD, PhD (Presenter) * PURPOSE Vertebral degenerative disease can mimic metastatic disease on 18F-NaF PET/CT. The purpose of this study is to develop a computer
system to automatically detect vertebral degenerative disease on 18F-NaF PET/CT. METHOD AND MATERIALS The dataset consisted of 46 18F-NaF PET/CT scans (36 men, 10 women, mean age 65±9 yrs). All patients were scanned on a Philips
GEMINI TF scanner. The PET resolution was 4*4*4mm. The CT portion of the studies was performed with 5mm slice thickness and
without intravenous contrast.
The PET data was first resampled to have the same resolution as the CT data. The spine was segmented on the CT images. The cortical
shell of each vertebral body was then extracted and unwrapped to a 2D map using a cylindrical coordinate system. The maps were
stacked to form a panoramic map of the spinal column (figure). The novel panoramic cortical shell map converted the complex 3D
detection problem to a 2D problem. Morphological and physiological features derived from both CT and PET were projected onto the map.
A three-tier classification scheme was then applied to detect spinal degenerative osteophytes. The annotated location markers for the
osteophytes were used as the reference standard to train the classifiers at each stage. The system was trained on 20 cases and tested on
26 cases. The performance was evaluated using FROC analysis.
RESULTS The numbers of osteophytes larger than 5mm were 163 and 179 in the training and testing sets, respectively. The sensitivities and false
positives per case were 82.2% and 4.7, and 77.1% and 4.6 for the training and test sets respectively. The performance with CT and PET
data alone were 69% (4.7) and 59% (4.4) respectively. Missed osteophytes were most commonly due to image artifact. Common false
positives include the costovertebral junction and partial volume averaging. CONCLUSION This is the first CAD system to detect spinal osteophytes on 18F-NaF PET/CT. The novel unwrapped cortical shell map facilitates the
detection and visualization of degenerative disease. The combination of PET and CT features improved the performance of CAD. CLINICAL RELEVANCE/APPLICATION By enabling the detection of degenerative change on PET/CT, it may in future be possible to exclude such areas from the images to
improve the ability of physicians to perceive metastatic lesions. SSA19-04 • Automated Axial Right Ventricle to Left Ventricle Diameter Ratio Computation in Computed Tomography Pulmonary
Angiography (CTPA)
German Gonzalez PhD (Presenter) ; Kanako K Kumamaru MD, PhD ; Daniel Jimenez-Carretero MSc ; Elizabeth George MBBS ; Maria J. Ledesma-Carbayo PhD ; Frank J Rybicki MD, PhD * ; Sara Rodriguez-Lopez ; Raul San Jose Estepar PhD ; Dimitris
Mitsouras PhD ; Arash Bedayat MD PURPOSE The RV/LV diameter ratio is a proven metric of prognosis in patients with CT pulmonary angiography (CTPA) findings of acute pulmonary
embolism (PE). The purpose of this report is to introduce and test, using radiologist and clinical outcomes reference standards, a
completely automated algorithm to output the right ventricular to left ventricular (RV/LV) diameter ratio from CTPA images. METHOD AND MATERIALS A completely automated algorithm with the following six steps was designed to compute the RV/LV diameter ratio. Step 1: image
pre-processing. Step 2: right and left heart detection based on machine-learning techniques. Step 3: detection on clustering and seed
positioning. Step 4: septum detection. Step 5: right and left heart segmentation based on level-sets with curvature constraints and edge
priors. Step 6: caliper positioning and ratio computation. Implemented in Matlab, the algorithm analyzes 600 CTPA reconstructed slices in
10 minutes (Intel i7 computer). Automated reports with snapshots of the slices where the RV and LV diameters are found are sent to the
physician for reporting. The algorithm was tested in 198 consecutive patients with acute PE diagnosed with CTPA using (a) reference
standard RV/LV radiologist measurements and (b) 30-day PE-specific mortality plus the need for intensive therapies. RESULTS Using radiologist reference standard, the algorithm correctly detected and segmented 96% (190/198) of CTPA studies. Even including
failure cases, the correlation between the RV/LV diameter ratio obtained by the algorithm and that obtained by the radiologist was high
(r=0.72). Compared to the radiologist, the algorithm equally achieved high accuracy in predicting 30-day PE-specific mortality plus the
need for intensive therapies, with area under the curve of 0.74 for the automated method and 0.77 for the radiologist measurements.
Failure cases were readily identified by the output snapshots available to the radiologist. CONCLUSION An automated algorithm for determining the CT derived RV/LV diameter ratio in patients with acute PE has high accuracy when compared
to measurements made by a radiologist and prognostic significance when tested against reference standard outcomes. CLINICAL RELEVANCE/APPLICATION An automated RV/LV diameter ratio algorithm has promise to generate data for prognosis in patients with acute PE that can be readily
implemented into clinical reporting. SSA19-05 • Computer-aided Diagnosis (CADx) as a Surrogate Measure of Image Quality: Dependence of CADx Performance on
Reconstruction Parameters in Dedicated Breast CT
Ingrid Reiser PhD (Presenter) ; Robert M Nishikawa PhD * ; John M Boone PhD * ; Karen K Lindfors MD * ; Kai Yang PhD PURPOSE The purpose of this work was to investigate whether the performance of computer-aided diagnosis (CADx) of breast masses in CT images
with different reconstructions parameters can serve as surrogate measure for image quality. The first step towards this goal is an
investigation into the relationship between reconstruction parameters and CADx performance, which is presented here. METHOD AND MATERIALS The data set consisted of cone-beam breast CT data from 69 patients containing 78 masses (24 benign, 54 malignant). 3cm^3
regions-of-interest centered on each mass were reconstructed with the FDK reconstruction algorithm. Volumes were generated for two
apodization filter cut-off values (L=1.0 and L=0.5) and three reconstructed image voxel sizes (150 mum, 300 mum and 450 mum
isotropic). All parameters produced images that were visually judged to be of diagnostic quality. From each set of ROIs, lesions were
segmented and feature analysis was performed using algorithms that were developed previously. Three features were manually selected
to ensure that variation in CADx performance was due to different image parameters rather than different feature sets. ROC analysis was
used to estimate CADx performance in the task of distinguishing benign from malignant lesions using a leave-one-out resampling
Page 62 of 183
scheme. RESULTS Visually, reconstruction parameters affected the sharpness and apparent noise of the images. As expected, L=0.5 produced smoother
images than L=1.0, and images with smaller voxel size had a noisier appearance. CADx performance, measured as area under the ROC
curve (AUC), ranged between 0.78 and 0.86, with larger reconstructed voxels, and smoother images (L=0.5) producing higher AUC
values. This trend was also observed for individual features. CONCLUSION Our study indicates that CADx performance depends on reconstruction parameters and therefore it has the potential to measure the
quality of the reconstructed images. The next step of this research is to measure the correlation between CADx and radiologists'
performance as reconstruction parameters are changed. CLINICAL RELEVANCE/APPLICATION This CADx methodology has potential for assessing clinical performance of reconstruction algorithms, and ultimately to improve diagnostic
accuracy by optimizing CT reconstruction. SSA19-06 • Computerized Risk Assessment Imaging System for Predicting the Likelihood of Breast Cancer
David Izhaky PhD (Presenter) * ; Tamar Sella MD ; Maya Cohen MD ; Arnaldo Mayer PhD * ; Tanir Allweis MD ; Miriam
Sklair-Levy MD * PURPOSE Early detection and prevention strategies for breast cancer depend on the ability to accurately identify individuals with significantly
increased breast cancer risk. Currently, such risk assessment models are statistical in nature and rely mainly on clinical features such as
genetic susceptibility, family history or mammography breast density. The purpose of this study is to develop a computerized imaging
system and method for assessing the likelihood of a malignant tumor based on breast vascular maps. METHOD AND MATERIALS 3D breast vascular maps of 334 women were included in the study. IRB approval was obtained. Vascular maps were acquired using a
prototype 3D functional infrared imaging device (Real Imaging). Of these 334 women, 209 were healthy (mammography BIRADS 1), 36
had benign lesions (mammography BIRADS 2) and 94 had biopsy proven breast cancer. A linear discriminant classifier with feature
selection which was previously trained to compute the cancer likelihood on image dataset was applied. Analysis was blinded to clinical
and pathological diagnosis. The diagnostic accuracy of the breast cancer likelihood was evaluated using receiver-operating characteristic
(ROC) analysis and bootstrapping. RESULTS An area under the ROC curve of 0.84 (95% CI 0.77-0.89) was obtained for determining the cancer likelihood. CONCLUSION A risk assessment model for predicting the likelihood of malignant tumor based on vascular maps was developed. The results warrants
further evaluation in a larger population-based clinical trial. CLINICAL RELEVANCE/APPLICATION A novel imaging system and method for assessing the likelihood of breast cancer was developed with accurate performance. This
technology could be implemented as an adjunct to mammography. SSA19-07 • Effect of Adaptive Iterative Dose Reduction (AIDR 3D) on a Computer-aided Detection System for Lung Nodules:
Performance Evaluation Using CT Scans in Standard to Ultra-low-Dose Range
Sumiaki Matsumoto MD, PhD (Presenter) * ; Yoshiharu Ohno MD, PhD * ; Takatoshi Aoki MD, PhD ; Tae Iwasawa MD, PhD ; Fumito Okada MD ; Kota Aoyagi * ; Hiroyasu Inokawa * ; Hitoshi Yamagata PhD * ; Kazuro Sugimura MD, PhD * PURPOSE To assess the effect of adaptive iterative dose reduction (AIDR 3D) on the stand-alone performance of a prototype computer-aided
detection (CAD) system for lung nodules using CT data acquired at standard-, low-, and ultra-low-dose levels. METHOD AND MATERIALS This study used CT data of 60 patients who prospectively underwent a chest CT examination using a multidetector-row scanner with a
protocol including standard-dose (125 mAs), low-dose (25 mAs), and ultra-low-dose (5 mAs) unenhanced scans. Each scanned data
were reconstructed into 1-mm-thick images without and with AIDR 3D. The following groups of CT images, each consisting of 60
datasets, were thus obtained: (S-wo) at 125 mAs, without AIDR 3D; (S-w) at 125 mAs, with AIDR 3D; (L-wo) at 25 mAs, without AIDR
3D; (L-w) at 25 mAs, with AIDR 3D; (U-wo) at 5 mAs, without AIDR 3D; (U-w) at 5 mAs, with AIDR 3D. Two experienced chest
radiologists carefully reviewed the group S-wo and determined a gold standard of nodules ranging 5-30 mm in diameter by consensus.
Based on the gold standard, the sensitivity and false positive rate of the CAD system on all groups were determined. Regarding
sensitivities, the group S-wo and each of the other groups were compared using McNemar�s test; similar comparisons regarding false
positive rates were made using signed rank test. RESULTS The reference standard consisted of 198 (104 solid and 94 subsolid) nodules. The sensitivity and false positive rate (per patient) on the
group S-wo were 58.6% and 0.97. The sensitivities (corresponding p values of the comparisons with the group S-wo) on the other groups
(S-w, L-wo, L-w, U-wo, and U-w) were 67.7% ( CONCLUSION Regarding sensitivities, 25-mAs and 5-mAs groups with AIDR 3D were comparable to the 125-mAs group without AIDR, whereas 25-mAs
and 5-mAs groups without AIDR 3D were inferior to the latter group; furthermore, the 125-mAs group with AIDR 3D was superior to that
without AIDR 3D. Regarding false positive rate, corresponding comparisons showed no highly significant difference. CLINICAL RELEVANCE/APPLICATION In terms of the performance of a CAD system for lung nodules, standard-dose CT with AIDR 3D and low- or ultra-low-dose CT with AIDR
3D can respectively surpass and parallel usual standard-dose CT. SSA19-08 • Computer-aided Detection of Colitis in Computed Tomography Examinations
Evrim B Turkbey MD (Presenter) ; Le Lu PhD ; Jianhua Yao PhD * ; Zhuoshi Wei PhD ; Ronald M Summers MD, PhD * PURPOSE To develop a computer aided detection (CAD) tool for automated detection of regions with colitis in CT examinations. METHOD AND MATERIALS One representative axial CT image per patient passing through the cecum or ascending colon was selected from 17 colitis patients (mean
age= 38±13 yrs, 8 women, 9 men) and 25 healthy subjects (mean age=44±13yrs, 18 women, 7 men). Colitis was defined as presence
of colonic wall thickening (>3mm) accompanied by pericolonic fat stranding and was manually segmented by a radiologist. The CAD
method is three-tiered. An image intensity and gradient checker, trained from annotated colitis regions, is used to quickly discard
non-informative image areas. A discriminative scanning window detector using covariance descriptor, selective data resampling and
extended Gaussian kernel support vector machine follows for image patch classification as colitis or not. Finally, the local patch detections
with confidences are spatially aggregated to form statistical features per image that label the whole dataset as with or without colitis. A
k-nearest neighbor classifier is used. Three-fold cross validation is employed for classification performance assessment. Page 63 of 183
RESULTS The mean wall thickness at colitis segments was 9.3 mm (range: 4.2-20.2 mm) whereas it was 2.3 mm (range: 1.2-3.2 mm) at normal
colon segments (P=0.0001). The overall per patient classification accuracy is 83.3%. For colitis patients, the sensitivity is 88.2% (15 out
of 17). 19 out of 25 healthy subjects are classified correctly with the specificity of 76% . CONCLUSION The CAD tool introduced in the current study can detect colitis affecting the cecum/ascending colon region with high sensitivity and good
specificity. The challenge of colitis image pattern being visually ambiguous is solved by the high description power of covariance
descriptor, hard negative bootstrapping and the tiered classification at local and global image levels. CLINICAL RELEVANCE/APPLICATION Early diagnosis of colitis is critical to prevent bowel necrosis and perforation in immunosuppressive patients. A computer-aided detection
tool may help to increase detection rates of colitis in CT. SSA19-09 • A Computer-aided Diagnosis System for Detecting Renal Extracolonic Findings on CT Colonography
Jian Fei L Liu MD ; Shijun Wang ; Marius G Linguraru DPhil, MS ; Ronald M Summers MD, PhD (Presenter) * PURPOSE To accurately detect renal calculi and lesions on CT colonography (CTC) by computer-aided diagnosis. METHOD AND MATERIALS We studied 66 patients (age range, 43-72 years; mean 57±7 years) undergoing CT colonography. The slice thickness was 1 mm. There
were 52 renal calculi (size range, 1-7mm; mean size, 2±1 mm) and 58 renal lesions (size range, 3-51mm; mean size, 16±10 mm). 36
lesions and 25 calculi were located in the left kidney, and 22 lesions and 27 calculi in the right kidney. We first segmented both kidneys
on the supine CTC images. Total variational (TV) flow was used to remove image noise in the kidney regions for a maximally stable
extremal region (MSER) detector to extract calculi candidates. We detected lesions by performing manifold diffusion on the kidney surface
and searching for points with local maximum diffusion response. Both calculus and lesion candidates were finally classified by a support
vector machine to determine the final detected calculi and lesions. There were 30 patients in the training dataset and 36 patients in the
test set for renal calculi and lesion detection. The training set contained 20 calculi and 24 lesions, and the test set had 32 calculi and 34
lesions. We performed a free-response receiver operating characteristic analysis on the test set to validate the results. RESULTS There were 41 true detections on calculi (from 29 unique calculi) and 417 false positives. The sensitivity of renal calculi detection was
80% at 1 false positive per patient. There were 33 true detections on renal lesions (from 31 unique lesions) and 277 false postives. The
sensitivity of lesion detection was 87% at 7 false positives per patient. CONCLUSION Detection of renal calculi and lesions is challenging on CTC images because the primary purpose of CTC is to screen for colon cancer and
the studies are typically done with lower dose and without intravenous contrast. TV-flow and MSER detector are efficient means to detect
renal calculi by reducing image noise and extracting image regions with high intensity values. The manifold diffusion efficiently detects
kidney lesions based on their geometric properties. Our method can detect renal calculi larger than 1 mm with few false positives and
renal lesions with moderate false positive rates. CLINICAL RELEVANCE/APPLICATION Our CAD system accuately detects renal calculi and lesions on CTC images and, with future clinical validation, may lead to improved
diagnosis. Physics (Low-dose CT Imaging) Sunday, 10:45 AM - 12:15 PM • S404AB
QA
PH CT SSA20 • AMA PRA Category 1 Credit ™:1.5 • ARRT Category A+ Credit:1.5 Moderator
Willi A Kalender , PhD * Moderator
John M Boone , PhD * Back to Top SSA20-01 • Is Low-dose CT with Model-based Iterative Image Reconstruction an Advantageous Strategy for Reducing Radiation
Dose in Follow Up of Patients with Testicular Cancer? Preliminary Results of a Prospective Study
Kevin Murphy MBBCh, MRCS (Presenter) ; Lee Crush MBBCh, FFRRCSI ; Siobhan O' Neill MBBCh ; Micheal A Breen MD ; Adrian
P Brady FFRRCSI, FRCR ; Paul Kelly MBBCh ; Derek Power ; Jackie Bye BA * ; Michael M Maher MD, FRCR ; Kevin N O'Regan
MD CONCLUSION MBIR facilitated a 66% reduction in ED while producing images that were comparable or superior to CD with standard reconstruction in
terms of noise, signal to noise ratio and diagnostic acceptability Background National Comprehensive Cancer Network (NCCN) and other guidelines recommend CT surveillance usually up to 5 years for patients with
early stage testicular cancer. This is generally a young patient cohort and therefore considered an at-risk group for high cumulative
lifetime dose of ionizing radiation. We report the early results of a prospective trial to examine the effectiveness of model-based iterative
reconstruction (MBIR) to reduce effective dose (ED) due to CT in follow up of these patients. Evaluation Following ethical approval, 23 patients referred for follow up of testicular cancer [mean age 34 years, range 18-60] consented to undergo
an additional simultaneous low-dose (LD) CT of chest, abdomen and pelvis at the time of routine surveillance CT. The conventional dose
(CD) and LD images both at standard reconstruction (SR) with 40% adaptive-statistical iterative reconstruction (ASIR) and reconstruction
with MBIR of the initial 5 patients of the cohort were independently reviewed by two radiologists who assessed for diagnostic acceptability
and graded images using published image quality indices. The ED and size specific dose estimates (SSDE) for each study was calculated. Discussion The mean ED (and SSDE) for LD and CD CT were 3.5±1.6 mSv (6.1±2.9 mGy SSDE) and 10.3±3.7 mSv (17.7±4.5 mGy SSDE), a mean
dose reduction of 66% (p SSA20-02 • Comparison of Hybrid (iDose) and Model-based (IMR) Reconstruction Techniques in Sub Milli-Sievert Chest and
Abdominal CT: An Ongoing Prospective Blinded Study
Ranish D Khawaja MBBS, MD (Presenter) ; Michael A Blake MBBCh * ; Garry Choy MD, MS ; Matthew D Gilman MD ; Mannudeep K Kalra MD * ; Subba R Digumarthy MD ; Amita Sharma MBBS ; Avinash R Kambadakone MD, FRCR ; Sarabjeet
Singh MD ; Atul Padole MD ; Sarvenaz Pourjabbar MD ; Diego A Lira MD ; Kevin M Brown MS * ; Mukta Joshi * Page 64 of 183
PURPOSE To assess diagnostic quality of sub milli-Sievert (submSv) chest and abdominal CT reconstructed with iterative model reconstruction (IMR)
and iDose 4. METHOD AND MATERIALS In a prospective clinical study, 20 patients (BMI2, chest, n=10 age range:26-90; abdomen, n=10 age range:30-84) gave written
informed consent for the acquisitions of submSv additional images (0.9mSv) on a 256-slice CT (iCT, Philips). In addition to their clinical
standard-dose (SD) CT (chest: 2.9mSv; abdomen: 5.6mSv), submSv images were reconstructed with low-dose (LD) FBP, iDose4 (idose
levels ID2, ID4) and IMR (i1-5) techniques resulting in 9 stacks. Two thoracic and 3 abdominal radiologists independently evaluated in a
blinded manner for lesion detection, lesion margins, diagnostic acceptability and visibility of small structures. Objective noise was
measured in the descending thoracic aorta and abdominal aorta and noise spectral density (NSD) was obtained. Data were analyzed
using Wilcoxon Signed Rank test and analysis of variance (ANOVA). RESULTS Lesion detection in abdominal CT (11 lymph nodes, 9 liver/renal lesions, and 8 kidney stones) and chest CT (31 lung nodules, and 10
ground glass opacities), and lesion margin evaluation was identical for SD-FBP, LD-FBP, iDose 4 and IMR. Lesion margins were better seen
for 30% of detected chest lesions (mostly emphysematous air-pockets and nodules) with IMR compared to SD-FBP, LD-FBP and iDose 4.
Visibility of abdominal structures (adrenal glands and pancreatic contour), and overall diagnostic acceptability of submSv iDose and IMR
were similar to SD-FBP ( kappa value 0.72-0.88; p2,iD4 and 51%-85% noise reduction with IMR (i1-5; p CONCLUSION Although lesion detectability is not compromised in chest and abdominal CT examinations acquired at sub-mSv radiation doses, IMR
image reconstruction of sub-mSv CT data helps improve delineation of lesion margins when compared to low-dose and standard-dose
FBP, and iDose 4 techniques. CLINICAL RELEVANCE/APPLICATION Preliminary results from this ongoing prospective clinical trial show the potential of IMR for lesion evaluation in chest and abdomen CT
examinations acquired at sub milli-Sievert radiation doses. SSA20-03 • Sub-mSv Cerebral CT Perfusion Using PICCS
Jie Tang PhD (Presenter) ; Guang-Hong Chen PhD * ; Patrick A Turski MD * ; Vivek Prabhakaran MD, PhD ; Kari A Pulfer ; Howard A Rowley MD * PURPOSE With increasing concern regarding ionizing radiation from CT examinations, the radiation dose should be kept as low as possible while
maintaining sufficient diagnostic information. The purpose of this study is to evaluate whether the radiation dose from a cerebral CT
perfusion (CTP) scan can be kept under 1 mSv while maintaining diagnostic perfusion maps. METHOD AND MATERIALS An IRB approved protocol was used to perform a reduced-dose (RD) CTP scan immediately following standard-dose (SD) clinical CTP scan
for the same subject. The SD CTP protocol used a 16 slice axial Shuttle mode on a GE CT750HD scanner, with 80 kV, 500 mA, 0.4 s
gantry speed (200 mAs) and 17 time frames which lasts 45 s, with effective dose = 3.74 mSv. RD CTP used 100 mA (40 mAs) with other
parameters the same as SD, with effective dose = 0.75 mSv. 20 subjects were enrolled in this study. The SD scans were reconstructed
using FBP (filtered back projection) and the RD scans were reconstructed using FBP, ASiR(with 100% setting) and an iterative
reconstruction algorithm, PICCS (prior image constrained compressed sensing with iterative reconstruction). Perfusion maps (CBF, CBV
and MTT) were then generated by GE Perfusion 4 software using the Perfusion 3 algorithms. All image series were randomized and each
series was scored by 2 neuroradiologists using a 5-point scale (1: non-diagnostic; 2: poor; 3: fair; 4: good; 5: excellent). Clinical
findings were recorded for each series. RESULTS The mean scores for the SD FBP series are 3.9(±0.5), 3.9(±0.5) and 3.9(±0.5) for CBF, CBV and MTT maps respectively; corresponding
scores are 2.2(±0.4), 2.1(±0.4) and 2.3(±0.5) for the RD FBP series; 2.7(±0.5), 2.6(±0.5) and 2.7(±0.5) for RD ASiR series, and
3.4(±0.6), 3.4(±0.5) and 3.5(±0.5) for RD PICCS series. Subjective scores of the RD PICCS image series are higher than RD FBP series (p
CONCLUSION Prior image constrained compressed sensing with iterative reconstruction (PICCS) provides diagnostic quality perfusion maps with 20% of
the radiation dose compared to current clinical protocols. CLINICAL RELEVANCE/APPLICATION Diagnostic quality sub-mSv cerebral CT perfusion imaging can be achieved using PICCS reconstruction. SSA20-04 • Adaptive Statistical Iterative Reconstruction for Low Dose Quantitative Myocardial CT Perfusion: A Microspheres
Validation Study
Aaron So PhD (Presenter) ; Jiang Hsieh PhD * ; Jean-Baptiste Thibault * ; Kelley Branch MD * ; Ting-Yim Lee MSc, PhD * PURPOSE We validated the effectiveness of adaptive statistical iterative reconstruction (ASIR, GE Healthcare (GE)) for minimizing image noise in low
dose quantitative myocardial perfusion (MP) imaging against microspheres MP measurement. METHOD AND MATERIALS Iodinated contrast (Isovue 370, 0.7 mgI/kg) was injected at 3 to 4 ml/s into 68±25 kg normal pigs via an ear vein and the heart was
scanned using a GE Discovery 750HD scanner with a prospectively ECG triggered dynamic protocol (Snapshot Pulse (SSP), GE): axial
scan every 1-2 heart beats for 22 scans using 140 kV, 0.35 s gantry period and 80 mA (normal dose). MP measurement was repeated
with the x-ray tube current reduced to 20 mA (low dose). The normal- and low-dose SSP images were reconstructed using filtered
backprojection (FBP) (SSP80) and both FBP (SSP20
FBP) and ASIR (SSP20ASIR) respectively. All images were corrected for beam
hardening from which MP maps were generated using CT Perfusion (GE). After the CT perfusion studies, fluorescent microspheres were
injected into the left atrial appendage of the heart to measure MP. Mean MP measured with microspheres and the three CT image sets in
45 segments from the lateral, apical and septal wall in 15 slices from three pigs were compared using linear regression and Bland-Altman
analysis. Effective dose (ED) of each SSP protocol was estimated from the dose-length product provided by the scanner. RESULTS SP80 images exhibited the highest correlation with microspheres (R=0.69) compared to SSP20ASIR (R=0.60) and SSP20FBP (R=0.57).
SSP80 images also showed the smallest difference in mean MP from microspheres and narrowest limits of agreement with microspheres
(7.0 and -32.9 to 46.8 ml/min/100g (80)) compared to SSP20ASIR (11.3 and -35.3 to 57.8 (93)) and SSP20FBP (15.7 and -32.8 to 64.1
(97)). ED of the SSP80 and SSP20 protocols were 4.5 and 1.1 mSv respectively. CONCLUSION Noise in low dose SSP images reconstructed with FBP was excessive which led to less accurate and reproducible MP estimation with CT
Perfusion but such errors could be reduced with ASIR. CLINICAL RELEVANCE/APPLICATION With the proposed image acquisition and reconstruction approaches, MP measurement with low dose CT Perfusion is a feasible alternative
to MRI and SPECT for studying ischemic heart disease. SSA20-05 • Low-dose Pelvic CT Using Adaptive Iterative Dose Reduction 3D: A Phantom Study
Page 65 of 183
Remko Kockelkoren (Presenter) ; Hiromitsu Onishi MD ; Tonsok Kim MD ; Masatoshi Hori MD ; Atsushi Nakamoto MD ; Noriyuki Tomiyama MD, PhD ; Makoto Sakane MD ; Mitsuaki Tatsumi MD, PhD PURPOSE To evaluate the image quality and radiation dose reduction in pelvic CT reconstructed using an adaptive iterative dose reduction 3D (AIDR
3D) technique with a phantom model. METHOD AND MATERIALS An anthropomorphic phantom (CTU-41; Kyoto Kagaku, Kyoto, Japan) and a Catphan phantom containing low-contrast objects (Catphan
500; Phantom Laboratory, Salem, NY) were scanned with a 320�detector row CT scanner (Aquilion ONE; Toshiba Medical Systems,
Otawara, Japan) in eight tube current levels (ranged from 25 mA to 500 mA) at 80 kV and 120 kV, respectively. The rotation period was
0.5 second and the helical pitch was 0.828 (53/64). Standard filtered back projection (FBP) images and AIDR 3D images were
reconstructed for each setting and were compared. For the quantitative evaluation, image noise (standard deviation of CT number) and
contrast to noise ratio (CNR) between the model bladder and the surrounding area of the anthropomorphic phantom were calculated. For
the qualitative evaluation, image noise, image artifacts, delineation of the organs and overall image quality in the anthropomorphic
phantom were assessed by three radiologists. The detectability of the low-contrast objects of the Catphan phantom were also evaluated
using a receiver operator characteristic analysis. Sensitivities and specificities were compared by using McNemar�s chi-square test. RESULTS In the quantitative evaluation, AIDR 3D resulted in a substantial noise reduction compared to FBP and revealed higher CNRs than FBP. In
the subjective evaluation, the image noise, image artifact such as photon starvation, and overall image quality improved with AIDR 3D. In
the detectability evaluation, at 120 kVp, the sensitivities, the specificities, and the Az values were 16.7%, 100%, 0.78 for image at 100
mA (50 mAs) with AIDR 3D, 33.3%, 100%, 0.75 for images at 150 mA (75 mAs) with AIDR 3D, and 33.3%, 100%, 0.81 for those at
200 mA (100 mAs) with FBP. There were no statistically significant differences. CONCLUSION Our results in a phantom study shows that AIDR 3D technique may allow approximately 25-50% radiation dose reduction compared to
FBP technique in pelvic CT examinations maintaining the image quality and the diagnostic performance. CLINICAL RELEVANCE/APPLICATION Radiation at the pelvic region is of special importance particularly for the young patients because of the genetic risk and AIDR 3D
technique may allow the radiation dose reduction in pelvic CT. SSA20-06 • Synergistic Radiation Dose Reduction by Combining Automatic Tube Voltage Selection and Iterative Reconstruction
Jeremy R Wortman MD (Presenter) ; Alexander J Adduci MD, PhD ; Tim O'Connell MD, MEng * ; Aaron D Sodickson MD, PhD PURPOSE To evaluate radiation dose and image quality in CT pulmonary angiography (CTPA) exams with automated tube voltage selection
(CarekV) before and after implementation of sinogram affirmed iterative reconstruction (Safire). METHOD AND MATERIALS The cohort included: 1) 61 consecutive CTPAs performed on a Siemens AS+ scanner from 5/7/12 � 5/31/12 using CarekV (vascular
image quality selection, reference kVp 120, reference mAs 180), and 2) 59 consecutive CTPAs performed from 7/1/12 � 7/18/12 using
CarekV with reference mAs reduced to 120 and images reconstructed using Safire at strength of 3. All scans were performed with
longitudinal and in-plane tube current modulation (CareDose 4D). CarekV on a vascular setting uses the topogram x-ray attenuation to
select the scan kVp expected to produce the lowest achievable CTDIvol while maintaining the desired iodine contrast to noise ratio and
respecting the maximum x-ray tube current limits. We measured patient size (effective diameter = sqrt(AP X Lat)), signal (mean CT
density) and noise (standard deviation), and recorded local CTDIvol at the level of the main pulmonary artery. Linear regression models
were created for the dependent variables ln(CTDIvol), signal, noise, and signal to noise ratio (SNR) as a function of independent variables
size, age, gender, and reconstruction technique. RESULTS The 33% reduction in reference mAs in the Safire group allowed CarekV to select reduced kVp in larger patients than in the FBP group,
with an overall reduction in 120 kVp scans from 42.9% to 0% and an associated increase in 100 kVp scans from 53.6% to 62.0% and 80
kVp scans from 3.5% to 38.0%. When controlling for size and demographics, the combination of Safire and CarekV yielded an overall
CTDIvol reduction of 44.5% (p < .0001), a signal increase of 96 HU (p = .002), and an increase in image noise (p = .004) with no
significant change in SNR (p = .70). CONCLUSION The combination of CarekV and Safire resulted in a 44.5% dose reduction, substantially greater than the 33% reduction that would be
achieved by reducing the reference mAs alone. This is accomplished with preserved image quality as the reduced reference mAs allows
CarekV to scan larger patients at reduced kVp. CLINICAL RELEVANCE/APPLICATION Synergistic dose reduction can be achieved by combining automatic kVp selection with global mAs reduction (as used in concert with
iterative reconstruction) with no negative impact on image quality. SSA20-07 • Systematic Dose Evaluation of Iterative Reconstructed Computed Tomography in a Contrast Enhanced Cadaveric
Model
Tobias Penzkofer MD (Presenter) * ; Jonas C Apitzsch MD ; Yunus Alparslan ; Hong-Sik Na MD ; Timm Dirrichs ; Philipp
Bruners MD ; Peter Isfort MD ; Andreas H Mahnken MD * ; Saskia Westphal ; Ruth Knuchel-Clarke PhD ; Christiane K Kuhl
MD * PURPOSE To systematically test the potential for dose savings in computed tomography (CT) through iterative reconstruction in a contrast
enhanced human cadaveric model.
METHOD AND MATERIALS Fifteen human cadavers scheduled for contrast enhanced virtual autopsy were injected with hyperdense contrast agent through the iliac
arteries. A series of thoracic and abdominal tube current scaled CT scans (11 scans, 20mAseff - 200 mAseff in steps of 20mAs) were
performed and reconstructed using standard filtered back projection (FBP) and iterative reconstruction algorithms (IR) in soft and sharp
reconstruction kernels. The imaging datasets were evaluated in randomizedly and blinded to the reconstruction method by defining
minimally necessary doses for CT quality criteria as defined in EU16262 (36 items, 17 thoracical, 6 mediastinal, 13 abdominal)
independently by three radiologists (36x15x3x4=6480 data points). Minimal doses for every of the two reconstruction methods and
kernel types in their respective applications were compared statistically. RESULTS In all subjects a sufficient contrast filling for further analysis was achieved. Average minimal doses for soft tissue applications (soft
kernels) were 132.3±44.6 mAs (FBP) vs. 115.6±46.7 mAs (IR, p=0.0001), for bone and lung applications (sharp kernels) 140.9±47.1
mAs (FBP) vs. 130.9±49.1 mAs (IR, p=0.0001). The achieved amount of tube current saving were 12.6% (soft kernels) and 7.1% (sharp
kernels). CONCLUSION In a blinded, randomized study, iterative reconstruction yielded a statistically significant dose saving in soft tissue and sharp kernel
applications. While many publications claim dose savings of up to 5o% throughout the spectrum of CT vendors, the savings yield was
Page 66 of 183
considerably lower in this study. Most probably, the reason for this result is the comparison to lowest achievable doses also in standard
algorithms (and not the usual 160-180mAs). Hence the dose savings numbers of iterative reconstruction of earlier studies might be
partially explained by unused dose saving potential in standard FBP.
CLINICAL RELEVANCE/APPLICATION The results give an insight in to how high the dose saving potential of iterative reconstruction but also filtered back projection is,
potentially translating in to clinical CT parameter choices. SSA20-08 • Massive Dose Reduction and Image Quality Improvement Using a Commercial Iterative Reconstruction Algorithm in
CT
Artur Latorre-Musoll MSc (Presenter) ; Agustin Ruiz Martinez MSc ; Rosa M Pallerol Pinzano ARRT ; Pablo Carrasco De Fez
PhD ; Teresa Eudaldo Puell PhD ; Nuria Jornet Sala PhD ; Montserrat Ribas Morales PhD CONCLUSION Dose reductions up to 66% with no significant loss of image quality can be achieved using iDose compared to FBP algorithm. In the light
of these promising results, iDose is increasingly used in our hospital. As dose and image quality should be balanced according to patient
needs, we are presently studying the adequate choice of iDose level using clinical data. Background Radiation exposure from medical imaging has become a public health concern due to the increasing use of CT. Attempts to lower the
radiation dose associated with CT studies are limited by image noise on FBP-based reconstructions. We assessed the dose reduction
capabilities and in-phantom image quality metrics of a commercial iterative reconstruction algorithm. Evaluation We compared the performance of the iterative reconstruction algorithm iDose to the standard FBP algorithm supplied with the 256-slice
MDCT Brilliance iCT (Philips Healthcare). We used a Catphan 504 (The Phantom Laboratory) to assess image quality in terms of CT
number calibration, image noise, low contrast detectability and spatial resolution. We reconstructed 35 helical acquisitions (varying kV
and mAs/slice) using FBP and 6 noise reduction levels provided by iDose. We measured the dosimetric index CTDI vol of all acquisitions
using the solid state detector/multimeter CT Dose Profiler/Barracuda (RTI Electronics) and a phantom assembled with 3 standard PMMA
body phantoms of 32 cm diameter and 3x15 cm length. Discussion CT number calibration obtained using iDose levels and FBP was compatible within 1%. iDose reduced image noise from 10% (iDose1) to
41% (iDose6) compared to FBP, regardless of the CTDIvol of the study. Conversely, the dose reduction capability of iDose ranged from
19% (iDose1) to 66% (iDose6) maintaining the same image noise as FBP. These results are compatible with the manufacturer�s
specifications. Low contrast detectability improved compared to FBP, as contrast-to-noise ratio increased because of the noise reduction:
from 11% (iDose1) to 71% (iDose6). Spatial resolution improved slightly compared to FBP. However, we are now devising new
measurements to fully quantify the iDose spatial resolution capabilities. SSA20-09 • Evaluation of TV-minimization-based Reconstruction for Low-dose Dedicated Breast CT
Junguo Bian PhD (Presenter) ; Kai Yang PhD ; Xiao Han MSc ; Karen K Lindfors MD * ; Erik A Pearson BS, BEng ; Emil Y
Sidky PhD ; John M Boone PhD * ; Xiaochuan Pan PhD * PURPOSE Current dedicated breast CT is of low SNR in projection data and high noise in reconstruction images because a small imaging dose is
distributed into large number of projections. The small contrast and fine structure of breast tissues, together with low-SNR data has made
reconstruction improvement from low-dose breast-CT data very challenging. We have developed and tailored a TV-minimization based
reconstruction algorithm for breast CT and performed reconstruction for more than 10 patient cases. In the work, we evaluated the image
quality of TV-minimization-based reconstructions against images currently reconstructed by use of FBP algorithm. We demonstrate that
image quality can be improved over the currently used FBP-based algorithms for low-dose breast CT. METHOD AND MATERIALS The reconstruction is formulated into a constrained-TV-minimization problem. We developed and tailored an ASD-POCS algorithm for
solving the problem. Patient data were collected during an ongoing clinical trial performed at UC-Davis. We performed reconstruction of
the whole volume for more than 10 patient cases from the low-SNR data. Special attention was paid to minimize the blocky appearances
that are typically observed in images reconstructed by use of TV-minimization-based algorithms from low-dose data sets. We use the
difference between adjacent slices to quantify quantum noise and use the power-law exponent, Beta, fitted from log-log plot of the image
power spectra to quantify anatomical noise. A smaller Beta value for the reconstruction images indicates a better observer performance
on lesion detection. We also performed a 2AFC experiment in which the observers were asked their preference between images currently
reconstructed by use of FBP and the proposed algorithms. RESULTS Visual inspection shows images reconstructed with proposed algorithm have improved contrast and details. The noise variances and beta
values are consistently smaller for image reconstructed with the proposed algorithm. The results of 2AFC study also show observers�
preference of images reconstructed by use of the proposed algorithm over those currently reconstructed by use of FBP algorithms. CONCLUSION The results demonstrated that the proposed algorithm can improve image quality for current dedicated breast CT. CLINICAL RELEVANCE/APPLICATION The image quality improvement for the dedicated, cone-beam breast CT scanner may have impacts for breast cancer screening or
diagnosis. Physics (Ultrasound) Sunday, 10:45 AM - 12:15 PM • S405AB
PH
US SSA21 • AMA PRA Category 1 Credit ™:1.5 • ARRT Category A+ Credit:1.5 Moderator
Paul L Carson , PhD * Moderator
Emad S Ebbini , PhD * Back to Top SSA21-01 • Simulator-based Comparison of 2D, 3D and Fusion 3D Transrectal Ultrasound (TRUS) Needle Guidance Accuracies for
Biopsy (Bx) of Prostate MRI Lesions
Derek W Cool MD, PhD (Presenter) * ; Xuli Zhang BSc ; Cesare Romagnoli MD ; Walter M Romano MD ; Jonathan Izawa ; Aaron Fenster PhD * PURPOSE Prostate MRI�s high sensitivity to early stage prostate cancer (PCa) permits targeted biopsy as an alternative to the current non-targeted
systematic TRUS biopsy. Biopsy needle guidance under TRUS is the most economical option, but spatial correspondence of MRI findings
Page 67 of 183
systematic TRUS biopsy. Biopsy needle guidance under TRUS is the most economical option, but spatial correspondence of MRI findings
with TRUS is non-trivial. The accuracy of sampling MRI lesions under 2D and 3D TRUS and 3D TRUS fusion is quantified. METHOD AND MATERIALS Three experts performed simulated biopsies on 12 patients (Pros. Vol=37±11g, PSA=9.0±5.1ng/ml) with a total of 15 Bx-confirmed PCa
MRI lesions (0.8±0.8g) who were selected from 90 patients undergoing MRI-3D TRUS fusion biopsy. Two core-biopsies were targeted at
each MR lesion using 2D TRUS, 3D TRUS and MRI-3D TRUS fusion for needle guidance, using a validated Bx simulator. Additional single
core-biopsies were directed toward common regional targets defined for all patients. Regions included: left-anterior transition zone (TZ),
left mid-gland, right apex and right base. The simulated Bx core locations were compared to the original MRI to evaluate the sampling
accuracy. RESULTS The 15 PCa tumors were distributed as follows: Base=4, Mid-gland=5, Apex=6, with 7 lesions along the anterior prostate. Only 44±4%
and 51±14% of tumors were sampled with 2D and 3D TRUS, respectively, compared to 98±4% with fusion biopsy. Bx sampling rates
were not significantly different between anterior and posterior tumors for any modality. The Bx sampling errors for the regional targets
were significantly higher (po-90o. CONCLUSION Biopsy of prostate MRI lesions under 2D or 3D TRUS without MR-fusion may be inaccurate and lead to a falsely negative biopsy. CLINICAL RELEVANCE/APPLICATION Targeting biopsies at suspicious lesions seen on prostate MRI using 2D or 3D TRUS without image fusion is likely not accurate enough to
adequately detect many significant prostate cancers. SSA21-02 • Quantifying Tendon Damage with Ultrasound (US) Shear Wave Elastography Using a Porcine Flexor Tendon Tear
Model
Ryan J DeWall PhD (Presenter) ; Jingfeng Jiang ; John Wilson MD, MS ; Kenneth S Lee MD * PURPOSE Shear wave imaging (SWI) is an US elastography technique that measures tissue elasticity, a tissue property that often correlates with
pathology. The purpose of this study was to evaluate the ability of SWI to visualize partial tears and quantify damage in porcine flexor
tendons. METHOD AND MATERIALS Thirty porcine flexor tendons were pre-loaded to 1.25 N and stretched from 0%-2% strain using a Mark-10 (Mark-10 Corp; Copiague, NY)
testing system while being imaged using SWI (Aixplorer�; Supersonic Imagine; Aix-en-Provence, France). After imaging the normal
tendon, the deep portion was cut to 25% (n = 10), 50% (n = 10), and 75% (n = 10) of the tendon thickness and reassessed with SWI.
The deep-to-superficial wave speed ratio of the deep third (cut) and superficial third (uncut) of the tendon were compared in
regions-of-interest (ROIs) centered on (C), proximal to (P), and distal to (D) to the tear, excluding the area within the tear. Tukey
multiple comparisons were used to assess differences between normal and torn tendons. RESULTS Shear wave speed (i.e. elasticity) increased significantly with increasing tissue strain in normal and cut tendons, except in the deep third
of the 75% tear (0%, 6.7 ± 1.2 m/s; 2%, 7.7 ± 1.4 m/s). The deep-to-superficial wave speed ratio decreased significantly between
normal and cut tendons in the 50% tear in ROIs centered on (0%, 0.98 ± 0.06 to 0.91 ± 0.09; 1%, 0.97 ± 0.06 to 0.81 ± 0.09; 2%,
0.99 ± 0.07 to 0.84 ± 0.10) and distal to (1%, 0.95 ± 0.08 to 0.85 ± 0.08) the tear and in the 75% tear proximal to (1%, 1.00 ± 0.07
to 0.82 ± 0.12; 2%, 1.00 ± 0.07 to 0.81 ± 0.16), centered on (0%, 1.03 ± 0.09 to 0.70 ± 0.10; 1%, 0.99 ± 0.06 to 0.60 ± 0.11; 2%,
0.95 ± 0.10 to 0.61 ± 0.13), and distal to (1%, 0.96 ± 0.15 to 0.79 ± 0.14) the tear. CONCLUSION The decrease in deep-to-superficial wave speed ratio in cut tendon relative to normal tendon suggests loading changes in the damaged
fibers. SWI demonstrates the potential for assessing tendon damage in partially torn tendons. CLINICAL RELEVANCE/APPLICATION SWI has the potential to add quantitative information to validated US outcome measures, providing a powerful tool for future outcomes
analysis using US to monitor and assess tendon injuries. SSA21-03 • Optimizing Microbubble Formulation for Indirect Lymphosonography: Quantitative Comparison of Nanobubbles vs.
Standard Microbubbles
Chan Kyo Kim MD, PhD (Presenter) ; Boem Ha Yi MD, PhD ; Omid Yeganeh MD ; Wenjin Cui ; Christopher Barback ; Robert F
Mattrey MD * PURPOSE Indirect lymphosonography where microbubbles (MB) are injected subcutaneously within the sentinel lymph nodes (SLN) drainage field
was developed to non-invasively detect, mark and possibly stage the SLN pre-operatively. Early clinical data suggest accurate localization
but limited characterization. Since entry into the lymph duct (LD) is limited to particles METHOD AND MATERIALS 10^8 MBs of Definity (1-3�m) (Lantheus Medical Imaging) or a new formulation of DSPC/DSPE-PEG and perfluorohexane (0.2-1�m) in
0.2ml were injected in either footpad of 6 normal rabbits. The Siemens Sequoia 15L8 probe was fixed over the popliteal node that was
imaged with CPS. Immediately after injection, a few MBs entered the LD to place an ROI over the SLN and its afferent LD. The US field
was cleared and the footpad massaged for 20 sec. A time-intensity curve (TIC) was constructed in real-time using a prototype Siemens
software that analyzes the linearized CPS data but also uses the B-mode data to correct for motion while scanning at low MI and 15
frames/sec. At 20 minutes or when the TIC returned to baseline, the US field was cleared and the 20-sec massage repeated until peak
enhancement and the process repeated until no enhancement occurred. The TIC following the 1st massage and the number of massages
that refilled the SLN following each injection were recorded. RESULTS Both agents enhanced the SLN and LD after massage. NBs caused greater SLN (p=0.003) and LD (p=0.001) enhancement that lasted for
20min vs. 8 min. The SLN refilled >20 times following a NB dose but only 8 times following a MB dose (p= 0.001). CONCLUSION NBs not only improve the filling of the duct and SLN, but also provided more functional bubbles at the injection site. We will next
compare their ability to characterize nodes. CLINICAL RELEVANCE/APPLICATION Nanoscale bubbles increase duct filling and node enhancement and provide more functional bubbles at the injection site to refill the duct
and node to improve detection and possibly characterization. SSA21-04 • Ultrasound Shear Wave Speed Estimation in Elastic Phantoms: Sources and Magnitude of Variability in a QIBA
Multicenter Study
Andy Milkowski MS (Presenter) * ; Timothy J Hall PhD * ; Michael P Andre PhD * ; Paul L Carson PhD * ; Shigao Chen PhD ; Claude Cohen-Bacrie * ; Stephanie Franchi-Abella MD ; Brian S Garra MD ; Stephen McAleavey PhD * ; Steve Metz * ; Kathryn Nightingale PhD * ; Mark Palmeri MD, PhD ; Anthony E Samir MD ; Laurent Sandrin PhD * ; Mickael Tanter PhD * Page 68 of 183
PURPOSE To test commercial and research ultrasound SWS systems to identify the sources and magnitude of bias and variability in SWS
measurements. METHOD AND MATERIALS Eleven phantom pairs were built from stiff and soft batches of Zerdine� by CIRS. Larger phantoms were also prepared for correlative
testing using magnetic resonance elastography. All phantoms were initially tested by one lab to determine manufacturing variation and
were then shipped to 11 different labs for SWS measurements. At each site, 3-5 operators measure each phantom at three times at each
of three depths according to a randomized schedule. Each measurement consists of the average of ten valid SWS acquisitions as has been
reported in the clinical literature. The data are analyzed using crossed Gage R and R methodology with ANOVA. Bias is estimated by
comparing the results with known values of elastic modulus (converted to SWS) from the manufacturer and from mechanical testing
performed across a broad range of shear wave frequencies at two sites. Estimates of linearity can also be obtained since stiff and soft
phantoms are tested at each site. RESULTS Mechanical test results from the two sites performing those measurements were in excellent agreement. Initial analysis of US SWS
measurements shows overall variability of 5-7% in SWS mean values for several sites. ANOVA shows that site and measurement depth
are the dominant sources of variation with operator variability being a minor component. Variation in SWS for all phantoms was 3-5% on
initial testing of all phantoms. A 5-10% depth dependence (lower SWS at deeper depths) was also seen. Also, a small bias in SWS
estimates of 5-6% was seen. Similar variability and bias are seen for both stiff and soft phantoms. CONCLUSION Initial results show a relatively small amount of variability in SWS estimates and also show that operator variability contributes little to
total measurement variation. Phantom variation may be a significant source of the variability in measurements. Given these encouraging
results, we will add measurements from additional sites, explore the causes of the depth dependence of SWS, and extend our work to
lossy (viscoelastic) phantoms which more closely mimic human liver tissue. CLINICAL RELEVANCE/APPLICATION This work by QIBA is the first step in development of a protocol for US SWS measurement that gives accurate and repeatable results
across a range of instruments for drug testing, clinical and research use SSA21-05 • Visualization of Vascularity in Breast Lesions Using US Contrast Enhanced 3D Subharmonic Imaging
Anush Sridharan ; John R Eisenbrey PhD ; Flemming Forsberg PhD (Presenter) * ; Priscilla Machado MD ; Daniel A Merton ; Kirk Wallace PhD * ; Carl Chalek PhD * ; Kai E Thomenius PhD * PURPOSE To develop a method for improving visualization of vascularity in breast lesions using 3D contrast-enhanced subharmonic imaging (SHI). METHOD AND MATERIALS A modified Logiq 9 (GE Healthcare, Milwaukee, WI) scanner with a 4D10L probe was used for 3D harmonic imaging (HI) and SHI of
breast lesions in 72 patients after bolus injection of an ultrasound contrast agent (UCA; Definity, Lantheus Medical Imaging, N Billerica,
MA; dose: 0.25mL for HI and 20?L/kg for SHI). Fifteen biopsy-proven malignant cases were selected for image processing. A
region-of-interest (ROI) corresponding to UCA flow (within the lesion) and tissue in both 3D HI and SHI were selected for each case. A
volumetric map of the time-intensity curve for each slice within the volume was generated over time. Slices showing presence of UCA
were identified and isolated. To improve visualization of flow a volumetric background template was generated (from baseline) and used
to filter out tissue signals. Contrast-to-tissue ratios (CTR�s) were calculated for 3D HI and SHI before and after background subtraction
for vessel-tissue ROIs and also compared between the isolated slices and the entire volume. RESULTS Both 3D HI and SHI showed significant suppression of tissue signal after background filtering (p CONCLUSION 3D SHI showed better visualization of vasculature in all cases via increased tissue suppression and sensitivity to UCA flow. The
improvement in visualization of vasculature based on isolation of slices demonstrates the importance of 3D imaging to visualize breast
cancer flow. CLINICAL RELEVANCE/APPLICATION Visualizing the vascular structure of breast lesions may help improve characterization. SSA21-06 • Quantitative Biomarkers for the Assessment of Fibrosis Using M-Mode US and Shear Wave Elastography
Lauren Rosenblum BSc ; Priscilla Machado MD ; Patrick L O'Kane MD * ; Andrej Lyshchik MD ; Flemming Forsberg PhD
(Presenter) * PURPOSE To determine if M-mode or Shear Wave Elasticity (SWE) imaging (independently or combined) provide quantitative markers of liver
fibrosis compared to conventional grayscale ultrasound (US) imaging and pathology (the reference standard). METHOD AND MATERIALS Twelve subjects scheduled for an US-guided liver biopsy and 5 healthy volunteers were scanned with a broad bandwidth curvi-linear
array using an IU22 (Philips Medical Systems, Bothell, WA; for grayscale and M-mode imaging) and an Aixplorer scanner (SuperSonic
Imagine, Aix-en-Provence, France; for SWE imaging). The M-mode images were quantified using the scanners� existing calculation
software package and by a novel algorithm (implemented in Matlab; Mathworks, Natick, MA) extracting distances between lines of similar
intensities (L2LD) as a quantitative biomarker of liver status. Liver stiffness (in kPa) was recorded from the SWE images, while a
radiologist (blinded to the other results) scored the grayscale US for degree of fibrosis (on a 0-4 scale). ANOVA and Wilcoxon�s sign rank
tests were used to compare the classification of liver fibrosis by SWE, M-mode (i.e., L2LD) and radiologists scoring with fibrosis
determined by pathology as the reference standard. RESULTS In this pilot study, the radiologist was correct in 53% of assessments, which was not different from pathology when using a
non-parametric test (p=0.3). SWE did not differentiate between degrees of fibrosis (p > 0.71), while the new L2LD biomarker was able to
perform a correct classification (p = 0.044). The best differentiation was achieved between normal subjects (fibrosis score = 0) and the
subjects with fibrosis scores greater than or equal to 1 (0.30 ± 0.041 vs. 0.43 ± 0.085; p < 0.005). CONCLUSION A new biomarker for noninvasive US evaluation of liver status, based on extracting distances between lines of similar intensities from
M-mode images, have been developed. Initial results indicate this parameter can correctly classify degree of fibrosis; albeit based on a
limited sample size. CLINICAL RELEVANCE/APPLICATION If these results are reproducible in a larger patient population, it may be possible to replace some liver biopsies with evaluations based
on noninvasive, quantitative US biomarkers. SSA21-07 • Dynamic Contrast-enhanced Ultrasound Parametric Maps for the Evaluation of Intratumoral Vasculature: Preclinical
Study
Stephanie Pitre-Champagnat ; Ingrid Leguerney ; Jacques Bosq ; Fabian Kiessling MD ; Benedicte Coiffier (Presenter) ; Page 69 of 183
Nathalie B Lassau MD, PhD * CONCLUSION Parametric maps from raw linear data can be performed in short process time with moving average model, and reflect reliably the
heterogeneous histological measures within tumor by considering the contribution of the vessel size in the variations of intratumoral
blood volume. Background Parametric maps from Dynamic Contrast-Enhanced Ultrasonography (DCE-US) appear as a useful tool to describe the intratumoral
vasculature and its heterogeneity. This study was designed to identify the best processing of parametric maps from raw data and to
compare the results to histologic vascularity measurement. Evaluation DCE-US was performed on 17 melanoma-bearing nude mice after a 0.1mL bolus injection of SonoVue� (Bracco, Italy). Parametric maps
treated time intensity curves (TIC) from raw linear data to extract pixelwise two parameters related to blood volume that were area
under the curve (AUC) and peak intensity (PI). Three mathematical models were compared to fit the TIC in each pixel: a polynomial
model used in clinical routine, a moving average model and a combination of two linear regressions. Parametric maps performed from the
best fit approach were compared with histology for both region of interest (ROI) of whole tumor and several subROIs of 15mm2 within
each tumor to reflect intratumoral vascular heterogeneity. As ground truth correlate, microvessel densities (MVD) were determined, and
vessels size only for subROIs. Discussion The moving average approach was the best compromise between values determination and processing pixelwise time (40�m (rAUC=0.90
(p=0.012) ; rPI=0.83 (p=0.041)). SSA21-08 • Effects of Ultrasound Parameters on Cavitation-assisted Delivery of PLGA-PEG Nanoparticles into Tumors: Phantom
Study and Preliminary In Vivo Results
Tzu-Yin Wang (Presenter) ; Jung Woo Choe ; Steven B Machtaler PhD ; Rammohan Devulapally ; Butrus T Khuri-Yakub PhD
; Ramasamy Paulmurugan PhD ; Juergen K Willmann MD * PURPOSE Ultrasound(US)-microbubble(MB)-mediated drug delivery is a promising technique for image-guided, targeted cancer therapy. To
optimize this technique for clinical translations, we performed a systematic study on effects of various US and MB parameters on
cavitation and the corresponding delivery results of an FDA approved drug carrier, poly(D,L-lactide-co-glycolide)-block-poly(ethylene
glycol) (PLGA-b-PEG-COOH) nanoparticles (NPs) into tumors. METHOD AND MATERIALS Cavitation was induced by exposing lipid shelled, perfluorocarbon encapsulated MBs to 1.8-MHz US pulses. Cavitation was evaluated with
passive detection of the inertial cavitation dose (ICD) and active imaging of MB destruction. Effects of peak negative pressure, pulse
length, pulse repetition frequency (PRF), MB concentration, and focal scanning strategies, on cavitation were studied in an agar tissue
phantom. Preliminary in vivo studies were performed to study the feasibility of delivering PLGA-PEG NPs into hepatocellular tumors in
mice. RESULTS Passive cavitation detection showed that the ICD increased with pressures increasing from 0.5 to 5MPa, and with PRFs increasing from 10
to 100 Hz (N=6 each). The ICD also increased with increasing MB concentration from 4×106 to 1×108 bubbles/mL, but saturated at
higher concentration (N=6 each). No significant effect was found for pulse lengths below 15 cycles. Active cavitation imaging confirmed
more MB destruction with increasing pressures. When the pressure exceeded 3MPa, more violent cavitation was observed as flickering
bright spots at the focus of US. Compared to single focus treatment, electronic focal steering over a large target volume resulted in more
homogeneous treatment (N=4 each). Preliminary in vivo experiments showed successful delivery of PLGA-PEG NPs to a hepatocellular
tumor. CONCLUSION The pressure, PRF, MB concentration, and focal scanning strategies, have distinct effects on cavitation, while no significant influence was
found for short pulse lengths. Preliminary in vivo results demonstrated the feasibility of delivering PLGA-PEG NPs into tumors for targeted
cancer therapy. CLINICAL RELEVANCE/APPLICATION This study presents a clinically translatable systematic approach for spatially localized and optimized delivery of large drugs/carriers to
target sites based on quantitative measurement of cavitation SSA21-09 • Comparing Immunohistochemical Markers of Angiogenesis to Subharmonic Imaging of Vascularity in a Murine
Breast Cancer Model
Andrew Marshall ; Jaydev K Dave PhD, MS ; Flemming Forsberg PhD (Presenter) * ; Valgerdur Halldorsdottir MSc ; Anya I
Forsberg ; Manasi Dahibawkar BSc ; Traci B Fox MS, RT ; Ji-Bin Liu MD * PURPOSE To compare contrast-enhanced subharmonic ultrasound imaging (SHI) of breast tumor neovascularity to three immunohistochemical
markers of angiogenesis in nude rats. METHOD AND MATERIALS Seventy athymic, nude, female rats were implanted with 5 x 106 breast cancer cells (MDA-MB-231) in the mammary fat pad. The
contrast agent Definity (Lantheus Medical Imaging, N Billerica, MA) was injected in a tail vein (dose: 36 ?l) and fundamental ultrasound
imaging as well as pulse-inversion SHI was performed in triplicate with a modified Sonix RP scanner (Ultrasonix Imaging, Richmond, BC,
Canada) using a L9-4 linear array (transmitting at 8 MHz and receiving at 4 MHz in SHI mode). Studies were performed 21, 24 and 28
days post implantation (based on our prior experience). After the experiments, specimens were stained for endothelial cells (CD31),
vascular endothelial growth factor (VEGF), and cyclooxygenase-2 (COX-2). Fractional tumor vascularity (FV) was calculated from digital
images as contrast enhanced pixels over tumor area (for SHI; averaged over the 3 injections) and staining over tumor area (for
specimens). Results were compared using a linear regression analysis. RESULTS Of the 70 rats implanted 45 (64 %) exhibited tumor growth and 32 were successfully imaged. SHI depicted the tortuous morphology of
tumor neovessels and delineated areas of necrosis better than fundamental ultrasound imaging, due to the marked suppression of tissue
signals. VEGF varied significantly over time (p CONCLUSION Quantitative contrast-enhanced SHI measures of tumor neovascularity in a breast cancer xenograft models appear to provide a
noninvasive marker for angiogenesis corresponding to the expression of VEGF; albeit based on a limited sample size. CLINICAL RELEVANCE/APPLICATION In the future SHI may be used to monitor response for patients treated with anti-VEGF drug therapies. Radiation Oncology and Radiobiology (Lung I) Sunday, 10:45 AM - 12:15 PM • S104A
Page 70 of 183
Sunday, 10:45 AM - 12:15 PM • S104A
RO
CH SSA22 • AMA PRA Category 1 Credit ™:1.5 • ARRT Category A+ Credit:1.5 Moderator
Zhongxing Liao , MD Moderator
Matthew M Harkenrider , MD Back to Top SSA22-01 • Increased Risk of Chest Wall and Rib Toxicity in Lung SBRT Patients Treated with RTOG-0813 Protocol and Monte
Carlo Based Planning
Supriya Jain MS, BA (Presenter) ; Anil Sethi PhD ; Edward Melian MD ; Bahman Emami MD PURPOSE To evaluate Monte Carlo (MC) based lung stereotactic body radiotherapy (SBRT) plans for dosimetric parameters correlated with the
development of chest wall pain and rib fracture. METHOD AND MATERIALS Twenty consecutive lung SBRT patients treated from 2010-2012 with heterogeneity corrected Pencil Beam (PB) plans were selected.
Chest wall (CW) was contoured as a 3 cm expansion of the ipsilateral lung. Treatment plans were normalized to deliver 50 Gy PTV dose
in 5 fractions using 7-12 non-coplanar, conformal, 6 MV fields. Using MC dose algorithm, each plan was optimized for PTV dose coverage
as per RTOG-0813 protocol. Patients were classified based on PTV location: island tumors (8), adjacent to CW (9), or mixed (3); and PTV
size (cc): small (< 25), medium (25-60), or large (> 60). Treatment plans were evaluated for toxicity risk based on four dosimetric
thresholds - CW: Dmax < 50 Gy, V30 < 30 cc, V40 < 5 cc and Ribs: Dmax RESULTS Tumor size and location were strong predictors of risk of toxicity to CW and ribs. With MC planning, 0% (0/6) of small, 50% (4/8) of
medium, and 100% (6/6) of large tumors exceeded all four CW and ribs toxicity thresholds. 78% (7/9) of tumors located adjacent to CW
surpassed every CW / ribs threshold vs. 67% (2/3) of mixed and 25% (2/8) of island tumors. Mean Dmax for ribs was significantly higher
for tumors adjacent to CW than for island tumors (61.6±11.7 Gy vs. 45.00±11.7 Gy, p = .007). Transitioning from PB to MC planning
resulted in a higher overall risk of toxicity. Mean relative dose increases from PB to MC plans were 32.4±12.7%, 24.8±10.4%, and
20.3±6.4% for small, medium, and large tumors, respectively, and 32.5±11.6%, 26.6%±8.8%, and 19.5±7.2% for island, mixed, and
chest wall tumors respectively. CONCLUSION MC based lung SBRT plans that satisfy RTOG-0813 criteria for PTV dose coverage result in an increased risk of chest wall and rib toxicity.
Large tumor size and proximity to CW predict highest absolute dose to CW and ribs. However, relative increase in CW / rib dose from PB
to MC planning is directly proportional to tumor distance from CW and inversely proportional to tumor size. Low-risk small island tumors
experience the greatest increase in CW/rib dose when planned with MC algorithm. CLINICAL RELEVANCE/APPLICATION With Monte Carlo based planning, revision of RTOG-0813 guidelines for PTV dose coverage may be necessary to prevent chest wall pain
and rib fractures. SSA22-02 • Prospective Study Evaluating the Use of IV Contrast on IMRT Treatment Planning for Lung Cancer
Hua Li PhD (Presenter) ; Beth Bottani ; Todd DeWees ; Daniel A Low PhD * ; Jeff M Michalski MD ; Sasa Mutic MS * ; Jeffrey D
Bradley MD ; Cliff G Robinson MD SSA22-03 • Lung Injuries after Stereotactic Body Radiotherapy in Patients with Emphysema Who Had Stage I Non-small Cell
Lung Cancer
Moeko Ishijima (Presenter) ; Hidetsugu Nakayama ; Yu Tajima ; Sachika Nogi ; Ryuji Mikami ; Koichi Tokuuye MD, PhD ; Soichi
Akata MD SSA22-04 • Incidence of Radiation Pneumonitis after Stereotactic Body Radiation Therapy for Lung Cancer Patients with
Pulmonary Interstitial Changes
Tadamasa Yoshitake MD (Presenter) ; Katsumasa Nakamura MD, PhD ; Tomonari Sasaki MD, PhD ; Saiji Ohga MD ; Kotaro
Terashima ; Kaori Asai ; Yoshio Matsuo ; Takeshi Kamitani MD ; Hideki Hirata ; Hiroshi Honda MD SSA22-05 • Stereotactic Body Radiation Therapy for Stage I Non-small Cell Lung Cancer: A Community Hospital Experience
Charles C Vu BSE (Presenter) ; Janna Z Andrews MD ; Karen Episcopia MS ; Jeffrey G Schneider MD ; Scott L Schubach MD ; Jonathan A Haas MD * ABSTRACT Purpose/Objective(s): Stereotactic body radiation therapy (SBRT) has been shown to have increased local control and overall survival
relative to conventional external beam radiation therapy in patients with medically inoperable stage I non-small cell lung cancer (NSCLC).
Excellent rates of local control have been demonstrated both in clinical trials as well as in single-center studies at academic institutions.
However, there is limited data on the experiences of community hospitals with SBRT for Stage I NSCLC. The purpose of this study is to
report the local control and overall survival rates in patients treated with SBRT for Stage I NSCLC at Winthrop-University Hospital (WUH),
a community hospital.
Materials/Methods: This is a retrospective review of 78 Stage I central and peripheral NSCLC tumors treated between December 2006
and July 2012 with SBRT at WUH. Treatment was given utilizing fiducials and a respiratory tracking system. If the fiducials were not
trackable, a spine tracking system was used for tumor localization. CT-based planning was performed using the ray trace algorithm.
Treatment was delivered over consecutive days. The Kaplan-Meier method was used to calculate local control and overall survival.
Results: The median age was 77.4 years. 53% of the patient population was female. 67% of the tumors were Stage IA (T1N0M0), and
33% of the tumors were Stage IB (T2N0M0). 53% of the tumors were adenocarcinomas and 29% were squamous cell carcinomas, with
the remainder being of unknown histology or NSCLC, not otherwise specified. Median dose prescribed was 48Gy given in 4 fractions with
a median follow-up time of 11.0 months. The 2-year local control rate was 86.6%, and the two-year overall survival was 63.8%.
Conclusions: Our findings support that local control and overall survival at WUH, a community hospital, are comparable to that of
academic institutions' published experiences with stereotactic body radiation therapy for Stage I NSCLC. SSA22-06 • Intensity-modulated Radiation Therapy Following Extrapleural Pneumonectomy for Malignant Pleural Mesothelioma:
A Single Institution Experience
Sameer Jhavar MD, PhD (Presenter) ; Mehul Patel ; Divya Patel ; Nitika Thawani MD ; Dharanipathy Rangaraj ; Philip Rascoe ; Scott Reznik ; Alan Gowan ; W Roy Smythe ; Subhakar Mutyala MD SSA22-07 • Volumetric-modulated Arc Therapy for Lung Tumors: A Dosimetric Comparison with 3d Technique
Shino Kobayashi-Shibata (Presenter) ; Akihiro Haga ; Hideomi Yamashita ; Keiichi Nakagawa MD, PhD ABSTRACT Purpose/Objective(s):We compared a dose volume histgram (DVH) in stereotactic body radiotherapy (SBRT) and
volumetric-modulated arc therapy (VMAT) and 3D conformal method.
Materials/Methods:The investigation period was from July 2010 to Januart 2013. The solitary lung nodule was 20 cases. SBRT was
performed by 11 ports using non-coplanner beams. VMAT used a single arc. The prescription dose was 50Gy/4fr in 95% of PTV. The
aspiration suprression was performed by abdominal pressure. We created repiratory curves using ANZAI belt and devided 10 phases by
Page 71 of 183
respiratory phase. ITV was made by the sum of 10 GTVs in each 10 respiratory phase. PTV-ITV margin was 5 mm. Leaf-PTV margin was
5 mm in 3D conformal and SBRT.
Results:The mean of GTV, CTV, and PTV were 2.7cc, 4.2cc, and 18.5cc. The mean of homogeneity index (HI) was 1.34 +/- 0.10 in
multi-potrs, 1.20 +/- 0.09 in VMAT, and 1.41 +/- 0.12 in 3D-conformal. The mean lung dose was 356.5 cGy in multi-potrs, 373.3 cGy in
VMAT, and 380.3 cGy in 3D-conformal. The mean of lung V20 (%) was 5.1%, 5.6%, and 4.8%. V15% was 7.1%, 7.9%, and 7.0%. V10%
was 10.7%, 11.0%, and 10.3%. V5(cc) was 632.4cc, 553.2cc, and 703.5cc.
Conclusions:Lung VMAT SBRT was not inferior to multi-ports SBRT or 3D-conformal SBRT not only in the homogeneity but in lung low
dose volume. SSA22-08 • Are There Computed Tomography Features Predictive of Local Recurrence in Patients with Early Stage Non-small Cell
Lung Cancer Treated with Stereotactic Body Radiation Therapy?
Darragh Halpenny MBBCh, MRCPI (Presenter) ; Carole A Ridge MD ; Sara A Hayes MBBCh ; Junting Zheng ; Chaya Moskowitz
; Andreas Rimner MD * ; Michelle S Ginsberg MD PURPOSE Stereotactic body radiation therapy (SBRT) is a therapeutic option for patients with stage I non-small cell lung cancer who may not be
surgical candidates. SBRT delivers highly targeted, high dose radiation. The post-treatment radiological appearance is different compared
with conventional radiotherapy (CRT). The objective of this study is to identify computed tomography (CT) features predictive of local
recurrence after SBRT METHOD AND MATERIALS The institutional review board approved this study. 218 consecutive patients underwent SBRT (4000-6000 cGy, 3-5 fractions over 1-2
weeks) for local control of lung cancer from Jan 1, 2006-Mar 1, 2011. CT images were retrospectively, independently reviewed by 2
radiologists. CT studies prior to SBRT and at 6, 12 + 24 months after SBRT were evaluated. Signs of local recurrence recorded were:
opacity with a new bulging margin, opacification of air bronchograms, new or enlarging pleural effusion, new or enlarging mass and
increase in lung density at the treatment site. End points assessed were local recurrence (biopsy proven or on PET/CT) and death.
Landmark analyses at 6 months, 12 months and 24 months were performed to examine the association between CT features and local
recurrence free survival (LRFS). RESULTS 89 of the 218 treated patients were included as they had radiologic follow-up of at least 24 months. 10 (11.2%) patients had local
recurrence. 31 (34.8%) patients died within the period of follow up. None of the 5 morphological features usually associated with CRT
were significantly associated with LRFS after SBRT (p>0.05). Nodal recurrence at 12 and 24 months was significantly associated with
LRFS. Nodal recurrence at 12 months conferred a 50% (95%CI: 19%-100%) chance of being event free at 36 months compared to
those with no nodal recurrence (66%, 95%CI: 54%-79%, p = 0.023 both readers, kappa=1.00). Patients had a higher chance of local
recurrence or death at 36 months when they had nodal recurrence at 24 months (47% vs 29%, p=0.026, and 64% vs 26%, p CONCLUSION No local recurrence features identified on CT associated with CRT were associated with SBRT. Nodal recurrence was significantly
associated with local recurrence free survival. CLINICAL RELEVANCE/APPLICATION Radiological patterns of local recurrence associated with CRT may not be predictive of local recurrence in patients receiving SBRT for early
stage lung cancer SSA22-09 • Stereotactic Body Radiation Therapy for Unbiopsied Early Stage Lung Cancer - A Multi-institutional Analysis
Matthew M Harkenrider MD (Presenter) ABSTRACT Purpose/Objectives: Medically inoperable lung cancer patients often have comorbidities that preclude pathologic diagnosis from being
attained. We perform a multi-institutional analysis to determine if unbiopsied early stage lung carcinoma can be safely and effectively
treated with SBRT.
Material/Methods: 34 patients with unbiopsied lung cancer treated with SBRT at the University of Louisville or University of Virginia.
Patients had CT and PET imaging clinically consistent with lung malignancy. Median SBRT dose was 50 Gy (range 30-55 Gy) in a median
of 5 fractions (range 3-10 fractions) with static field SBRT or VMAT.
Results: Median follow up is 16.7 months. Primary tumors had a median longest dimension on the original CT of 1.6 cm (range 0.5-3.3
cm) and post-treatment CT scan of 1.25 cm (range 0.0-4.5 cm) (p=0.025). Median pretreatment SUV on initial PET scan is 4.6 (range
0.0-16.2) and at a median of 7.6 months after SBRT, decreased to 2.25 (range 0.0-10.9) on post-treatment PET (p=0.002). Crude local
control is 97.1%. The estimated 2 year regional control is 80%, distant control 85%, and overall survival 85%. There were no Grade 3
or greater acute toxicities and only three Grade 3 chronic treatment-related toxicitities.
Conclusions: In medically inoperable patients with unbiopsied lung cancer, local control can be achieved in with minimal toxicity with the
use of SBRT. The use of SBRT for unbiopsied early stage lung cancer patients should be performed in a multidisciplinary setting and after
detailed discussion with the patient about risks and benefits of SBRT. Vascular/Interventional (Embolotherapy/Guidance Technology) Sunday, 10:45 AM - 12:15 PM • E350
IR
VA GI SSA23 • AMA PRA Category 1 Credit ™:1.5 • ARRT Category A+ Credit:1.5 Moderator
Constantino S Pena , MD * Moderator
Johannes Lammer , MD * Back to Top SSA23-01 • A Catheter to Curb your Appetite? A Novel Observation of Weight Loss Following Left Gastric Artery Embolization in
Humans
Andrew J Gunn MD (Presenter) ; Elizabeth J Hamilton ; Rahmi Oklu MD, PhD PURPOSE Suppressing serum levels of ghrelin, a neuropeptide with powerful appetite-stimulating effects produced in the gastric fundus, is an
intriguing potential means of controlling body weight. Since left gastric artery, which preferentially supplies the gastric fundus, is
sometimes embolized in interventional radiology procedures, we assessed post-procedural weight loss in patients after left gastric artery
embolization. METHOD AND MATERIALS Retrospective analysis of electronic medical records of patients who underwent left gastric artery embolization for upper gastrointestinal
(GI) bleeding were compared to age-matched controls of similar patients that had undergone embolization of an artery other than left
gastric artery for upper GI bleeding. Patients were included in the analysis if they had a recorded weight within two weeks prior to the
embolization and within three months after the procedure. Differences in post-procedural weight loss between the groups were evaluated
by a student's t test. RESULTS Page 72 of 183
RESULTS Fifteen patients (mean age: 66.1 years) were included in the experimental group analysis while eighteen patients (mean age: 63.5 years)
were included in the control group analysis. The mean pre- and post-procedural weights in the experimental group were 189.1 lbs and
174.5 lbs, respectively, representing a 7.9% decrease in body weight. The mean pre- and post-procedural weights in the control group
were 164.7 lbs and 162.8 lbs, respectively, representing a 1.2% decrease in body weight. The post-procedural weight loss of the
experimental group was significantly greater than that observed in the control group (P=0.001). CONCLUSION Patients lose significantly more weight after left gastric artery embolization than following embolization of other arteries for upper GI
bleeding. The current data suggests that body weight can be potentially modulated via left gastric artery embolization in humans. CLINICAL RELEVANCE/APPLICATION Left gastric artery embolization results in weight loss in humans, which is a novel observation. These findings may lead to a role for the
interventional radiologist in the treatment of obesity. SSA23-02 • Transarterial Embolization of Renal Artery Pseudoaneurysms Following Partial Nephrectomy
Nakul Gupta MD (Presenter) ; Anish A Patel ; Kamran Ahrar MD ; Judy U Ahrar MD ; Alda L Tam MD * ; Michael J Wallace
MD * ; Sanjay Gupta MD PURPOSE To describe the presentation, endovascular management, outcome, and effect on renal function of selective transarterial embolization of
renal artery pseudoaneurysms and arteriovenous (AV) fistulae in patients following open or laparoscopic partial nephrectomy. METHOD AND MATERIALS The medical and imaging records of 25 patients who were referred for embolization of renal artery pseudoaneurysms or AV fistulae after
partial nephrectomy were retrospectively reviewed for the following parameters: size and number of primary tumors, presenting
symptoms, number and type of angiographic abnormalities, embolization technical details, outcome, and estimated glomerular filtration
rates (eGFRs) prior to and at multiple time points following embolization. RESULTS 24 patients had primary renal tumors, 1 patient had a pancreatic tumor directly invading the kidney. The median time between surgery
and presentation was 11 days (range, 1 day to 502 days; mean, 38 days). Most patients (n=23; 92%) were symptomatic, presenting
with gross hematuria, flank pain, or both. In 2 patients, pseudoaneurysms were found incidentally on follow up CT scans. Angiography
revealed pseudoaneurysms with (n=5) or without (n=20) AV fistulae. 16 patients (64%) had multiple pseudoaneurysms, often involving
multiple segmental renal vessels. Selective embolization was performed with coils alone (n=20) or in combination with cyanoacrylate glue
(n=5). Multiple vessels were embolized in 14 patients (56%). Cessation of bleeding was achieved after one (n=22) or two (n=3)
embolization sessions in all patients. The median follow-up was 14 months. The mean eGFR values (in mL/min/1.73m2) prior to
embolization, 2-7 days after embolization and at last follow-up were 59.2, 63.4, and 66.6, respectively. One patient had transient
worsening of renal function 3 days after embolization. CONCLUSION Most patients with renal artery pseudoaneurysms after partial nephrectomy present in the immediate postoperative period with
hematuria and/or flank pain. The majority of these patients show multiple pseudoaneurysms, often requiring selective embolization of
multiple vessels. Transarterial embolization is a safe and effective treatment option with no long-term adverse effect on renal function. CLINICAL RELEVANCE/APPLICATION Transarterial embolization is a safe and effective treatment for renal artery pseudoaneurysms resulting from partial nephrectomy with no
long-term adverse effect on renal function. SSA23-03 • Particle only Embolization vs. Particle Embolization with Additional Plug/Coil Embolization - Comparison of Future
Liver Remnant Volume Gain
Dominik Geisel MD ; Dirk Schnapauff MD ; Martin Stockmann MD ; Maciej Malinowski ; Timm Denecke MD ; Bernhard
Gebauer MD (Presenter) * PURPOSE To analyze volume gain of the future liver remnant (FLR) after right portal vein embolization (PVE) in patients who received particle only
embolization compared to patients who received particle embolization with additional central plug and / or coil embolization. METHOD AND MATERIALS Patients who received PVE in our institution were retrospectively analyzed. Right PVE was performed either with particle only (PO)
embolization or additional central plug and/or coil embolization (CP/C). All patients enrolled had a CT or MRI scan before PVE and before
operation, which were used for volumetry of the future liver remnant (FLR). RESULTS Of 75 patients 40 had PO embolization and 35 additional CP/C embolization. Age, sex, tumor entities and time from PVE to preoperative
imaging were comparable in both groups. Tumor entities included cholangiocarcinoma (n = 52), metastasis from colorectal cancer (n =
14), hepatocellular carcinoma (n = 2) and other entities (n = 7). FLR volume before PVE was 329 ± 121 ml in the PO group and 333 ±
135 ml in the CP/C group and 419 ± 135 ml respectively 492 ± 165 ml before operation. Average volume gain was significantly higher in
the CP/C than in the PO group with 53.3 ± 34.5 % vs. 30.9 ± 28.8 % (p = 0.002). CONCLUSION Right portal vein embolization with additional central plug and/or coil embolization leads to a significantly higher gain in FLR volume than
embolization with particles alone. CLINICAL RELEVANCE/APPLICATION Right portal vein embolization with additional central plug and/or coil embolization should be preferred over particle only embolization. SSA23-04 • Experimental Study of Selective Portal Vein Embolization for Nonalcoholic Steatohepatitis in Rabbit Model
Sadao Hayashi MD (Presenter) ; Yasutaka Baba MD ; Shunichiro Ikeda BS ; Hiroaki Nagano ; Tetsuya Shinohara ; Michiyo
Higashi PhD ; Ryozo Kamimura ; Toshihiro Nakazono ; Teruo Komokata ; Masayuki Nakajo PhD PURPOSE Portal vein embolization (PVE) is now widely accepted as a useful preoperative procedure in selected patients undergoing extended
hepatectomy. However, the influence of PVE on the liver parenchyma with steatohepatitis has not been fully elucidated.To evaluate the
influence of PVE on the rabbit liver parenchyma with nonalcoholic steatohepatitis (NASH) compared with normal liver . METHOD AND MATERIALS Seventeen Male New Zealand rabbits were divided randomly into the normal control group (n=6) which was fed with a standard diet for
2week and the NASH group(n=11) which was fed with a high-fat diet (standard diet+10%lard+2%cholesterol) for 8weeks. Thereafter,
PVE was performed for the left lobe of each group with 1ml absolute ethanol and micro coils. All procedure were performed successfully.
Rabbits were sacrificed 2weeks after the PVE. All hepatic specimens were examined by HE staining and immunohistochemical staining of
heat shock protein 70 (HSP70). NASH stage, NASH grade and sinusoidal obstruction syndrome (SOS) score were evaluated used by HE
staining. When less than 20% were stained, the specimen was considered as HSP expression negative. Page 73 of 183
RESULTS Two of 11 NASH rabbits died of liver failure 2 days after PVE. The embolized lobe showed significantly higher NASH stage (p=0.43) and
grade(p=0.009) and severer SOS score(p=0.03) in the NASH group than in the normal control group. HSP70 expression was was
significantly lower in the NASH embolized lobe than in the normal control embolized lobe (p=0.04). CONCLUSION The rabbit fed with the present high fat diet can be a NASH model. PVE induced severer sinusoidal obstruction damage in the embolized
steatohepatitis lobe than in the embolized normal lobe. HSP70 induction in the embolized lobe was suppressed in the NASH model. These
findings suggest that the same severe damage may occur in the embolized lobe and the risk of unexpected fatal liver damage cannot be
excluded in the patients with NASH after PVE. CLINICAL RELEVANCE/APPLICATION PVE should be performed carefully even for the patients with NASH. SSA23-06 • Needle Interventions in a Phantom Model: Real-time 3D Fluoroscopy Guidance Using Cone-beam CT versus
Conventional CT Guidance
Noboru Maeda (Presenter) ; Keigo Osuga MD ; Masahisa Nakamura MD ; Kentaro Kishimoto ; Kaishu Tanaka ; Yusuke Ono
; Hiroki Higashihara MD ; Noriyuki Tomiyama MD, PhD PURPOSE Cone-beam CT (CBCT) guided targeting system or XperGuide (Philips Medical Systems) is a real-time 3D needle navigation system on
live fluoroscopy overlapped with CBCT image as a practical tool. The purpose of this study was to evaluate the accuracy and procedure
time of this system compared to conventional CT guidance technique using a phantom model. METHOD AND MATERIALS A phantom was made of corn flour and clay that contained multiple 1cm kneaded erasers as targets. The target can be recognized at
CBCT and CT images, but invisible under X-ray fluoroscopy. The needle path reaching the target was planned on CBCT or CT images of
the phantom on 3D-workstation. Four interventional radiologists inserted a 19G 20cm needle to aim at separately five targets in different
set angles under XperGuide or conventional CT guidance in one session. Each interventional radiologist performs needle interventions
totally in two sessions under XperGuide and in two sessions under conventional CT guidance. To verify the accuracy of the puncture, the
gap or distance between the needle tip and the center of the target was measured on CBCT or CT images obtained after each puncture.
Procedure time was also measured. RESULTS All targets were successfully targeted with the first needle pass in all sessions using both techniques by four interventional radiologists.
Mean distance from the surface puncture point to the target was 104±13 mm and 101±17 mm (p=0.54), mean gap was 1.88±0.83 and
4.06±1.22 mm (p CONCLUSION CBCT guided targeting system or XperGuide allows more accurate lesion targeting and quicker needle interventions in a phantom model
compared to conventional CT guidance. CLINICAL RELEVANCE/APPLICATION CBCT guided targeting system or XperGuide allows accurate lesion targeting and quick needle interventions. This system will improve
needle interventions. SSA23-07 • 3T MRI-guided Transperineal Targeted Prostate Biopsy Using a Robotic Needle Guidance Template
Sang-Eun Song ; Kemal Tuncali MD ; Junichi Tokuda PhD ; Andriy Fedorov PhD ; Tobias Penzkofer MD * ; Clare M
Tempany-Afdhal MD ; Fiona M Fennessy MD, PhD ; Nobuhiko Hata PhD (Presenter) * PURPOSE Conventional needle guidance templates used in MRI-guided targeted prostate biopsy have limited targeting accuracy, typically 5 mm
intervals, and are prone to human error in selecting holes. To overcome such problems, we developed and tested a motorized needle
guidance template (Smart Template) that allows automated targeting without restriction in a 3T MRI. METHOD AND MATERIALS Fifteen men with suspicion of prostate cancer underwent 3T wide-bore MRI-guided transperineal targeted prostate biopsy in the lithotomy
position using Smart Template and 3D Slicer navigation software. Target lesions were preprocedurally identified on multi-parametric MRI
(mpMR) by three radiologists. The targets were re-identified on intraprocedural MRI through registration. The navigation software
provided the Smart Template�s guidance position and needle placement depth for each target. Insertion was performed manually and if
needed, the guidance position was adjusted to achieve a satisfactory needle placement confirmed by MRI. RESULTS All procedures were performed successfully without adverse events and tissue samples were collected from targeted lesions in all cases. 2
to 6 targets were selected per patient, and an average of 2.4 ± 0.9 tissue samples were obtained from each target. The mean procedural
time was 122 ± 27 min including 55 ± 18 min of in-MRI preparation time, which is similar to that of using a conventional template. 10 of
the 47 sampled targets were positive for malignant tissue (21.3%), resulting in prostate cancer diagnosis for 53.3% (N = 8) of the
patients. CONCLUSION Smart Template has been successfully integrated into the procedural workflow of existing MRI-guided transperineal targeted prostate
biopsy. The robotic needle guidance demonstrated unrestricted access to any part of the prostate grand volume without noticeable image
degradation, complexity or significant prolongation of the procedural time. CLINICAL RELEVANCE/APPLICATION A robotic needle guidance template has been used for 3T MRI-guided transperineal targeted prostate biopsy to aid needle placement. SSA23-08 • Real Time Image Fusion with Contrast Enhanced CT, 18FDG-PET and US in Liver Percutaneous Ablations and
Biopsies
Giovanni Mauri MD (Presenter) ; Luca Cova MD ; Tania Tondolo ; Tiziana Ierace MD ; Enzo Di Mauro ; S. Nahum Goldberg
MD * ; Luigi Solbiati MD PURPOSE To report our preliminary experience with real time image fusion between contrast enhanced CT, 18FDG-PET and US in liver percutaneous
ablations and biopsies METHOD AND MATERIALS 24 patients with liver lesions detectable only at 18FDG-PET underwent percutaneous ablation (10 patients) or biopsy (14 patients) guided
by a novel image fusion system that combines real-time US with fusion to previously acquired and fused contrast enhanced CT and 18FDG-PET images based upon magnetic field tracking and computer reconstruction of the targeting path (Esaote, Genoa, Italy). 18FDGPET/CT was performed at 24 hours to assess the technical efficacy of thermal ablations (i.e. absence of uptake). Histological results (i.e.
adequacy of the sample) was used to assess the result of percutaneous biopsies. RESULTS In all cases it was possible to obtain correct fusion between contrast enhanced CT, 18FDG-PET and US and to perform the procedure as
Page 74 of 183
planned.
At 24 hours 8/10 (80%) treated lesions demonstrated absence of uptake at 18FDG-PET/CT , while two lesions demonstrated partial
peripheral uptake, being considered correctly targeted but incompletely ablated. A diagnostic sample was obtained in 12/14 (86%)
patients who underwent percutaneous biopsy guided with this technique. No major complications occurred.
CONCLUSION Real time image fusion between contrast enhanced CT, 18FDG-PET and US is feasible and allow for a precise targeting of many tumors
detectable only at 18FDG-PET. CLINICAL RELEVANCE/APPLICATION This method holds the potential for offering ablation and biopsy to additional patient populations. SSA23-09 • Development and Clinical Evaluation of a Three-dimensional Ultrasound System for Pre-operative Assessment and
Guiding Percutaneous Treatment of Focal Liver Tumors
Hamid Reza Sadeghi Neshat MSc (Presenter) ; Derek W Cool MD, PhD * ; Jeffrey Bax BENG * ; Kevin Barker ; Lori Gardi ; Nirmal Kakani MD ; Aaron Fenster PhD * CONCLUSION Our 3D US system improves capabilities of conventional US by facilitating targeting of lesions identified in other modalities. Ongoing work
includes automatic probe tracking and motion compensation. Background Image-guided percutaneous ablation is a standard treatment for focal liver tumors deemed inoperable and to maintain eligibility for
patients on transplant waitlists. Radiofrequency (RFA), microwave (MWA) and cryo-ablation technologies are all delivered via a
needle-shaped probe inserted directly into the tumor. Planning is mostly based on contrast CT/MRI. While intra-procedural CT (iCT) is
commonly used to confirm the intended probe placement, 2D ultrasound (US) remains the main imaging modality for needle guidance,
and in some centers is the only modality used. Correlation of the intraoperative 2D US with iCT or pre-operative imaging is essential for
accurate needle placement, however, correspondence can be challenging given the limited field-of-view (FOV) in 2D US. We have
developed a passive tracking arm with motorized scan-head and software tools to improve guiding capabilities of conventional US by
large FOV 3D US scans that can be overlaid and compared to planning and iCT. Evaluation The developed scanner was tested on phantoms to confirm accuracy of 3D measurements and probe localization as compared to CT. For
phase 1 clinical evaluation (IRB approved), a total of 17 tumors (1.0-4.5cm) were treated using 1-3 RFA or MWA probes without
re-intervention in 14 cases. Contrast CT prior to ablation (for tumor measurements) and iCT after each probe insertion (for localization
measurements) were acquired. Each CT was followed by a 3D US for comparison. 3D US and CT measurements corresponded well with
tumor volume, angle and distance between probes differing by 7.7±4.5%, 4.2±3.2� and 2.1±1.3mm respectively. Discussion Mechanically tracked 3D US provided comparable measurement results to CT in a single scan (3-8 seconds). The main limitation is for US
occult tumors. In such cases, fusion of the US with the planning CT can be used to provide an insertion roadmap. 3D US facilitates
co-registration by providing more structures visible in both modalities (e.g. vessels, surfaces) and tracker coordinates. Vascular/Interventional (Portal Interventions/TIPS) Sunday, 10:45 AM - 12:15 PM • E352
IR
VA GI SSA24 • AMA PRA Category 1 Credit ™:1.5 • ARRT Category A+ Credit:1.5 Moderator
Wael E Saad , MBBCh * Moderator
Thomas-Evangelos G Vrachliotis , MD, PhD Back to Top SSA24-01 • 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 . SSA24-02 • The Outcome of Shunt Reduction after TIPS by the Parallel Technique: A Prospective Study
Bart De Keyzer MD (Presenter) ; Frederik Nevens MD, PhD ; Sam Heye MD ; Johan Vaninbroukx MD ; Chris Verslype MD, PhD
; David Cassiman MD, PhD ; Wim Laleman ; Geert Maleux MD, PhD PURPOSE Transjugular intrahepatic portosystemic shunt (TIPS) placement became the standard treatment for a subcategory of patients with
refractory ascites and variceal bleeding. It has the disadvantage of provoking chronic hepatic encephalopathy (HE) and, in some patients
Page 75 of 183
refractory ascites and variceal bleeding. It has the disadvantage of provoking chronic hepatic encephalopathy (HE) and, in some patients
with limited liver function, TIPS-induced liver failure (LF). Reduction of the diameter of the TIPS stent is feasible by the parallel technique.
However, the experience is still limited. METHOD AND MATERIALS TIPS reduction was performed by the placement of a 10 mm self-expanding stent along with a 5-6-7 mm balloon-expandable stent. After
a learning group of 17 patients (Maleux G, JVIR 2007), 55 patients were included in this prospective study. Baseline characteristics
included age, gender, cause of cirrhosis, MELD score, indication for TIPS, time interval between TIPS and reduction, and pressure gradient
before and after reduction. RESULTS Patients with medical therapy resistant chronic HE: improvement of HE = 25/34 (74%), recurrence of initial indication = 9/34 (26%) and
six month survival = 29/34 (85%). Patients with TIPS-induced liver failure: improvement 11/21 (52%) and survival 11/21 (52%), three
of these patients received a liver transplantation. CONCLUSION Stent reductions with the parallel technique improved chronic hepatic encephalopathy in 74% of the patients and offered them a 6
months survival of 85%. In patients who developed TIPS-induced liver failure, 52% recovered and for this group, TIPS reduction can
serve as a bridge to liver transplantation. CLINICAL RELEVANCE/APPLICATION TIPS-induced hepatic encephalopathy refractory to medical therapy can be improved by shunt reducing techniques in a majority of cases. SSA24-03 • Hepatic Infarction Following Transjugular Intrahepatic Portosystemic Shunt: An Analysis of Pathogenesis and
Clinical Outcomes
Fredrik J Balldin MD (Presenter) ; Jorge E Lopera MD * ; Ryan R Scott MD PURPOSE To assess clinical outcomes and examine potential factors leading to hepatic infarction following TIPSS . METHOD AND MATERIALS A retrospective review of all patients with follow-up cross sectional imaging after TIPSS was performed. The outcomes of patients with
imaging findings suggestive of hepatic infarction were analyzed along with technical, demographic, and clinical data. RESULTS Out of 62 total patients with cross-sectional imaging after TIPSS performed between 6/2008 and 4/2012, seven (5 males and two
females, average age of 54.7 years old (range 44-66)) were identified with imaging (6 CT, 1MRI) suggestive of hepatic infarction. All
patients received PTFE stent-grafts. Average pre-TIPSS MELD score was 13.2 (range 6-20) and average post-TIPSS MELD score was 21.2
(range 9-38). Four patients developed worsening liver failure, of which two died early and two received liver transplants. One died of
complications related to recurrent upper GI bleeding, one survived with intermittent hepatic encephalopathy, and one patient was lost to
follow-up shortly after the procedure. Follow-up imaging reveald 5 patients had thrombosis of right portal vein branches and two had
right hepatic vein thrombosis. CONCLUSION Hepatic infarction following TIPSS is a rare complication with high a mortality rate that may be associated with right portal vein and/or
hepatic vein thrombosis. CLINICAL RELEVANCE/APPLICATION Currently there are only case studies of hepatic infarction after TIPSS. This case series aims to examine causes of this potentially fatal
complication while analyzing the outcomes in 7 patients. SSA24-04 • Portal Vein Thrombosis after Elective TIPS. Incidence in Follow-up Imaging and Clinical Significance
Jorge E Lopera MD (Presenter) * ; Venkata S Katabathina MD ; Brian T Bosworth MD ; Martin Goros ; Andres Garza ; Ghazwan M Kroma MD ; Rajeev Suri MD PURPOSE To study the incidence and clinical significance of portal vein thrombosis (PVT) in follow-up imaging after elective transjugular
intrahepatic portosystemic shunt (TIPS). METHOD AND MATERIALS A retrospective review of medical records of patients that underwent elective TIPS was conducted. Contrast enhanced cross sectional
images, obtained within 1 year after TIPS, were compared with previous axial images (n=59) or direct portograms (n=3) in order to
assess the patency of the main portal vein (PV) and its major branches. The branches analyzed were the right anterior (RAPV), right
posterior (RPPV), left (LPV) and main (MPV) portal veins. The presence of associated parenchymal changes was also recorded. Any
possible association between PVT and MELD score, and PVT and major adverse events after TIPS, was also studied. RESULTS Sixty-two patients (15 female, 47 male, ages: 28-70, mean 54) were included in the study. Follow�up cross sectional images were
obtained 1-346 days (mean 92 days) after TIPS. The incidence of PVT was 19 % for RAPV, 51% for the RPPV, 11% for the LPV and 1 %
for the MPV. Combined thrombosis of two major branches was observed in 6 and three branches in 4 patients. Associated lobar
parenchymal changes were lobar infarcts in 7 and heterogeneous contrast enhancement in 9 patients. The mean MELD score was 12.8
before and 16.8 one month after TIPS. Major adverse events within 6 months included hepatic encephalopathy requiring hospital
admission in 18 and death in 8 patients. There was no significant correlation between PVT and the post-TIPS MELD score, or PVT and
major adverse events after TIPS. CONCLUSION Thrombosis of major braches of the PV is a very common imaging finding after elective TIPS that can be associated with parenchymal
changes. In most patients, branch PVT has no clinical significance. CLINICAL RELEVANCE/APPLICATION Thrombosis of major PV branches is a common imaging finding after elective Tips. In most patients, branch PVT has no clinical
significance. SSA24-05 • Treating Portal Systemic Encephalopathy with Balloon-occluded Retrograde Transvenous Obliteration (BRTO) - A
Road Less Travelled
Amar Mukund (Presenter) ; S. Rajesh MBBS, MD ; Ankur Arora MD, FRCR ; Shiv Sarin PURPOSE To evaluate the efficacy of BRTO using foam sclerotherapy in managing symptoms arising due to spontaneous large porto-systemic
shunts. METHOD AND MATERIALS 20 sessions of BRTO was performed in 18 patients using sodium tetradecyl sulphate foam. All patients had cirrhosis along with history of
recurrent hepatic encephalopathy requiring hospital admission. Porto-systemic communication in the form of gastro/lieno-renal shunt was
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present in all cases and seen on pre procedure computed tomography scans. Clinical and lab parameters including arterial ammonia level
were evaluated before and after the procedure in all patients. RESULTS Technical success was achieved in 18 of 20 sessions (90%). Complete obliteration of varices was seen in 15 of 18 patients (83%) and
partial obliteration in remaining 3, on follow up imaging. Immediate clinical improvement of hepatic encephalopathy was observed in 16 of
18 patients (89%) with post procedure decrease in serum ammonia levels, two patients had delayed improvement. Post-procedure
complication consisting either of ascites, septicemia with acute kidney injury or deranged liver function tests was encountered in 5
patients. All the patients were clinically and symptomatically better on discharge and up to a follow up of 18 months (one month and
thereafter 3, 6, 12, 18 months). CONCLUSION Our experience suggests portal systemic hepatic encephalopathy refractory to medical management can be effectively treated by BRTO. CLINICAL RELEVANCE/APPLICATION This study shows that BRTO may be offered as an alternative treatment to patients having recurrent portal systemic encephalopathy
refractory to medical management. SSA24-06 • The Comparison of Balloon-occluded Retrograde Transvenous Obliteration for Gastric Varices Using Liquid and Foam
Sclerosants
Jun Koizumi MD, PhD (Presenter) ; Tatsuya Sekiguchi ; Tamaki Ichikawa MD ; Chihiro Itou ; Takuya Hara MD ; Bertrand
Janne d'Othee MD, MPH PURPOSE Liquid ethanolamine oleate which has been used traditionally for balloon-occluded retrograde transvenous obliteration (BRTO) of the
gastric varices (GV) may cause severe complications including hemolysis, allergy, etc. if overdosed. Thus, we introduced foam
sclerotherapy to reduce the dose and compared the safety and efficacy of BRTO using liquid and foam sclerosants. METHOD AND MATERIALS Forty three patients with gastric varices were performed BRTO since October �01. Of these, three patients were excluded because
simultaneous TACE or PSE was performed. Twenty patients using liquid ethanolamine oleate with iodine contrast (EOI, Fig.1) before March
�05 and twenty patients using polidocanol foam (POF, Fig.2) after May �05 were included in this study. The success rates, side effects
and complication rates were compared among the two groups. RESULTS Complete stasis of the gastric varices was obtained in all patients of both groups. Abdominal symptoms during BRTO were significantly
(p 38.0) was also significantly (p CONCLUSION Foam polidocanol provided less invasive BRTO than liquid ethanolamine oleate with comparative clinical success. CLINICAL RELEVANCE/APPLICATION EOI which is traditionally used in BRTO may cause hemolysis and require haptoglobin. In the U.S. EOI is now replaced by foam sclerosant
This comparative study supports safer properties of foam. SSA24-07 • Clinical Efficacy of Portal Venous Stent Placement for Symptomatic Portal Hypertension Caused by Malignant Tumor
Invasion
Takaaki Hasegawa (Presenter) ; Haruyuki Takaki MD ; Atsuhiro Nakatsuka MD ; Junji Uraki MD ; Takashi Yamanaka MD ; Masashi Fujimori MD ; Hajime Sakuma MD * ; Shuji Isaji ; Koichiro Yamakado MD, PhD PURPOSE To evaluate clinical outcomes of portal venous stent placement in patients with symptomatic portal hypertension caused by malignant
tumor invasion. METHOD AND MATERIALS From Jury 2005 to January 2013, eleven patients with portal venous stenosis or occlusion caused by bile duct cancer (n=6), pancreatic
cancer (n=4), and nodal metastasis from colon cancer (n=1) underwent stent placement because of gastrointestinal bleeding (n=4),
ascites (n=4), liver dysfunction (n=2), and hypersplenism (n=1). Stents were placed across the stenotic (n=7) or occluded (n=4) lesions
after percutaneous transhepatic portography. Technical success, changes in portal venous pressure, symptoms, complications, stent
patency, and survival were evaluated. Complications were evaluated by using Common Terminology Criteria for Adverse Events (CTCAE). RESULTS Stent placement was technically successful in all patients (technical success rate: 100%, 11/11). The mean portal venous pressure
gradient decreased from 12.6±4.8 mmHg (range, 5-20 mmHg) to 0.5±1.0 mmHg (range, 0-3 mmHg) (p CONCLUSION Portal venous stent placement is feasible, safe, and effective technique to relieve symptomatic portal hypertension caused by malignant
tumor invasion. CLINICAL RELEVANCE/APPLICATION Portal venous stent placement is an effective treatment option for patients with portal hypertension caused by malignant tumor invasion. SSA24-08 • Metallic Stent Placement for the Treatment of Hepatic Venous Outflow Block after Living-Donor-Liver
Transplantation
Masashi Fujimori MD (Presenter) ; Shugo Mizuno ; Atsuhiro Nakatsuka MD ; Haruyuki Takaki MD ; Junji Uraki MD ; Takashi
Yamanaka MD ; Takaaki Hasegawa ; Hajime Sakuma MD * ; Shuji Isaji ; Koichiro Yamakado MD, PhD PURPOSE To retrospectively evaluate the clinical efficacy of metallic stent placement for the treatment of hepatic venous outflow block after
living-donor-liver transplantation (LDLT). METHOD AND MATERIALS This study was approved by our institutional review board, which waived the requirement for informed consent to use data for research
purposes. From 2002 to 2012, 15 patients with a mean age of 51±30.8 years (range, 4-69 years) underwent stent placement for the
treatment of outflow block 1-341 days after LDLT with a mean interval of 24±54.7 days. Venous stenosis with a pressure gradient of
10mmHg or more was found in the inferior vena cava in 7 patients, hepatic vein in 7 patients, and in both in 1 patient. Stents were
percutaneously placed across stenosis. Technical success (pressure gradient< 3mHg), complication, improvement in clinical manifestation ,
stent patency, and survival were evaluated. RESULTS Technical success was achieved in all 15 patients (100%, 15/15). There was no death or major complications related to stent placement.
The mean pressure gradient significantly decreased from 13±8mmHg (range, 10-24 mmHg) to 0.8±2mmHg (range, 0-2 mmHg) (p CONCLUSION Stenting is a safe and useful treatment to resolve outflow block after LDLT and helps to improve prognosis of such patients. CLINICAL RELEVANCE/APPLICATION Page 77 of 183
Metalic stent placemet is a safe and useful treatment to resolve hepatic venous outflow block after LDLT and helps to improve prognosis
of such patients. SSA24-09 • Optimal Protocol of Scanning Mode in the Portal Vein Angiography with a Low-Concentration Contrast Medium
Yan Liang MMed ; Zhiren Chen MD (Presenter) ; Dongbin Shi ; Yan Wang ; Bin Li ; Huizhi Cao ; Ying Tong PURPOSE To explore the optimal protocol of CT scanning mode in the portal vein angiography with a low-concentration contrast medium. METHOD AND MATERIALS 63 patients underwent enhanced urinary CT scan All the patients were divided into 3 groups according to different body mass index(BMI).
21 patients of group A(BMI=22) received 80-100kVp CT scan, automatic exposure control (3D Auto mA) and pitch of 0.984. All the
images were reconstructed with adaptive statistical iterative reconstruction algorithm. 14 patients of group B (BMI=26) received
single-source dual-energy spectral CT (sDECT)scan at the pitch of 1.375. Monochromatic images was reconstructed and optimal keV with
best contrast-to-noise(CNR) was calculated. Another 28 patients of group C with routine 120 kVp CT scan. Low concentration of
iodixanol(270mg I/ml) was used in group A and B, and high concentration of iopamidol(370 mg I/ml) was adopted in group C. 70 ml of
total amount of contrast was injected at 2.7ml/s. ROIs were placed on abdominal aorta, renal artery, superior mesenteric artery and
portal vein. Signal-to-noise ratio (SNR) and CNR was calculated. RESULTS In low-kVp Group, the CNR and SNR were (8.12±3.09) and (14.72±4.05) for trunk of portal vein, (6.59±2.13) and (13.40±4.68) for its
left branch, and (7.24±2.19) and (13.56±4.99) for its right branch respectively. In sDECT Group, the CNR and SNR were (8.68±2.69)
and (13.38±3.06) for trunk of portal vein, (9.31±2.88) and (13.58±3.21) for its left branch, and (9.53±2.66) and (13.72±3.03) for its
right branch respectively. In 120kVp Group, the CNR and SNR were (6.68±3.41) and (13.13±4.36) for trunk of portal vein, (6.22±1.98)
and (12.82±4.11) for its left branch, and (7.09±2.04) and (12.55±4.36) for its right branch respectively. The image quality was slightly
higher in sDECT Group than routine 120kVp Group and low-kVp Group, but no significantly different was found in among three groups
(P>0.05). Compared with that in 120kVp Group (7.23±1.53mGy), the radiation dose index was significantly lower in low-kVp Group
(4.75±1.39 mGy) (P CONCLUSION With a low-concentration contrast medium, the low-kVp and sDECT scanning mode is rationally via BMI without sacrificing image quality. CLINICAL RELEVANCE/APPLICATION With low kVp and spectral CT imaging of low iodine concentration or 120kVp of moderate iodine concentration, higher intravascular
enhancement can be achieved with good vessel display. Quantitative Medical Imaging for Clinical Research and Practice: Hands-on Workshop Sunday, 11:00 AM - 12:30 PM • S401CD
IN
BQ ICIA11 • AMA PRA Category 1 Credit ™:1.5 • ARRT Category A+ Credit:1.5 Sonia M Pujol , PhD Katarzyna J Macura , MD, PhD * Ron Kikinis , MD Back to Top LEARNING OBJECTIVES 1) Enhance interpretation of DICOM images through the use of 3D visualization. 2) Gain experience with interactive, quantitative
assessment of complex anatomical structures. 3) Present current directions of quantitative imaging as a biomarker in clinical trials. ABSTRACT Quantitative imaging has the potential to bring valuable information for the accurate interpretation of clinical data. Technological
breakthroughs in medical imaging hardware and the emergence of increasingly sophisticated image processing algorithms permit the
display of complex anatomical structures, and the estimation of quantitative functional parameters with increasing sensitivity and
specificity. For the past 9 years, the National Alliance for Medical Image Computing (NA-MIC), one of the seven National Centers for
Biomedical Computing funded by the National Institutes of Health, has converted some of the major scientific advances made by the
biomedical imaging community into open-source software tools. As part of the NA-MIC toolkit, the 3D Slicer open-source software has been
developed as a technology delivery platform for clinical researchers. This workshop provides an introduction to quantitative medical
imaging data analysis for clinical research and practice. Cases from multiple imaging modalities and from multiple organ systems will be
highlighted to illustrate the depth and breath of this field, and series of hands-on sessions using 3D Slicer will provide participants with a
practical experience of quantitative image analysis. Course url: http://www.na-mic.org/Wiki/index.php/RSNA_2013 URL's http://www.na-mic.org/Wiki/index.php/RSNA_2013 IHE Clinical Solutions for Interoperability - Imaging and Beyond Sunday, 11:00 AM - 12:30 PM • S501ABC
Back to Top IN
ICII11 • AMA PRA Category 1 Credit ™:1.5 • ARRT Category A+ Credit:1.5 Moderator
David S Mendelson , MD * David S Mendelson , MD * Richard L Kennedy , MSc Albert Edwards Jean Chalaoui , MD LEARNING OBJECTIVES 1) Understand the organization of IHE and the IHE profiles. 2) Understand the importance of interoperability in healthcare. 3) Learn about
the various IHE profiles that address interoperability, including XDS. 4) Learn about how XDS-I and related profiles address interoperability
for imaging. 5) Learn about real world implementations regarding interoperability and how IHE profiles have been employed to solve
interoperability issues including: a. The RSNA Image Share b. Cleveland Clinic enterprise-wide multi-specialty imaging integration and
implementation c. Canada Health Infoway: emphasis on the Province of Quebec Project d. Kaiser Permanente. 6) Understand the
challenges in attaining safe, secure and transparent interoperability. ABSTRACT National Library of Medicine PubMed: Find Articles You Need: Searching PubMed/MEDLINE Efficiently Sunday, 11:00 AM - 12:30 PM • S401AB
IN
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ICIW11 • AMA PRA Category 1 Credit ™:1.5 • ARRT Category A+ Credit:1.5 Holly A Burt Chezire Aclimandos Annabelle Nunez , MA Wendy Wu , MS LEARNING OBJECTIVES 1) Understand how PubMed constructs a query and how to develop and refine effective search strategies in radiology. 2) Use PubMed tools
including Clinical Queries, Related Articles, Single Citation Matcher and Loansome Doc. 3) Build focused searches using the Medical Subject
Headings (MeSH) vocabulary for radiology and limit searches to radiology-oriented journals. 4) Understand how to save and download
citations. ABSTRACT This hands-on workshop covers key searching techniques, changes to PubMed, and how to develop effective search strategies for PubMed
and MEDLINE. Topics covered include: why keywords don�t always give the results you expect, how to limit to specific journals, quick
searches to find evidence-based citations, how to access full-text articles, and downloading citations to reference manger programs. The
National Library of Medicine (NLM) provides free web access to nearly 24 million citations for biomedical and clinical medical articles
through PubMed (available online at PubMed.gov). MEDLINE is a subset of PubMed which includes links to sites providing full text articles
and to other related databases and resources. Patient Radiation Dose: Reduction and Recording (An Interactive Session) Sunday, 11:45 AM - 12:45 PM • S402AB
QA
PR HP MSRA12 • AMA PRA Category 1 Credit ™:1 • ARRT Category A+ Credit:1 Douglas E Pfeiffer , MS * Back to Top LEARNING OBJECTIVES This session will include a discussion of current methods and trends toward reducing patient radiation dose with highlihgts of areas where
there is particular concern or new data. The remainder of the session will include the ethical, legal, and policy-driven practices related to
recording patient radiation dose. Hologic: 3D Tomosynthesis Guided Breast Biopsy Sunday, 12:00 PM - 12:45 PM • Booth 1152
BA11 Back to Top LEARNING OBJECTIVES Registration Online at Hologic.com Hologic is offering a seres of 45 minute sessions that include demonstration of the 3D breast biopsy
procedure. A brief lecture will provide an overview of the technology including comparison of 3D to sterotactic guided biopsy and VABB
prior to the demonstration. The sessions are intended for radiologists and general surgeons interested in learning more about breast
tomosyntesis for interventional procedures. Please note, the program does not qualify as FDA mandated training for Tomosynthesis. The
course is not a CME activity. Molecular Imaging - Sunday Posters and Exhibits (12:30pm - 1:00pm) Sunday, 12:30 PM - 01:00 PM • S503AB
Back to Top MI
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 * Page 79 of 183
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.
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
NM
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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
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
Page 81 of 183
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
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 Page 82 of 183
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
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
Back to Top PD
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.
Page 83 of 183
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
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
Page 84 of 183
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 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
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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
Page 85 of 183
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
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. Page 86 of 183
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 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
Page 87 of 183
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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 * 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 Page 88 of 183
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
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
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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
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
Page 90 of 183
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. 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
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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
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 * Page 92 of 183
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. 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
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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
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
Page 94 of 183
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). 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. Page 95 of 183
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
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 Page 96 of 183
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 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. Page 97 of 183
Genitourinary/Uroradiology - Sunday Posters and Exhibits (12:30pm - 1:00pm) Sunday, 12:30 PM - 01:00 PM • Lakeside Learning Center
Back to Top GU
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 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
Page 98 of 183
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 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
Back to Top HP
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 Page 99 of 183
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
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 Page 100 of 183
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
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
Page 101 of 183
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
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. Page 102 of 183
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
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. Page 103 of 183
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. 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
Page 104 of 183
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. 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,
Page 105 of 183
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
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
Page 106 of 183
; 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
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 Page 107 of 183
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
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. Multisystem/Special Interest - Sunday Posters and Exhibits (12:30pm - 1:00pm) Sunday, 12:30 PM - 01:00 PM • Lakeside Learning Center
Back to Top GN
LL-MSE-SUA • AMA PRA Category 1 Credit ™:0.5 LL-MSE-SU6A • Pitfalls in RECIST Data Extraction for Cancer Clinical Trials: Lessons Learned from a Quality Improvement
Review of a Cancer Imaging Support Laboratory
Richard G Abramson MD (Presenter) * ; Carrie R McGhee RT PURPOSE/AIM To illustrate common pitfalls encountered by radiologists extracting tumor measurement data for cancer clinical trials using RECIST 1.1. CONTENT ORGANIZATION Review of RECIST 1.1 Methodology Common errors and pitalls in RECIST data extraction: -- Errors in selecting target lesions at baseline
(example: lesion inappropriately chosen as target lesion when not unequivocally a metastasis) -- Errors in reassessing nontarget lesions
(example: comparison made to most recent prior, rather than study baseline) -- Errors in assessing for new lesions (example: new lesion
called prematurely, before unequivocal) Practical tips for performing RECIST data extraction for clinical trials SUMMARY Major teaching points: (1) RECIST tumor measurement forms stand alone as independent documentation of a patient's course while on a
clinical trial (2) Accuracy is paramount, as tumor measurement data are used for computing composite study endpoints such as response
rate and median time to progression (3) RECIST guidelines can minimize but not completely eliminate subjective interpretation (4)
Readers can achieve greater accuracy and uniformity by adhering to certain best practices 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 Page 108 of 183
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
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
Page 109 of 183
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. 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. Page 110 of 183
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
-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
Page 111 of 183
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. Obstetrics/Gynecology Posters and Exhibits (12:30 - 1:00pm) Sunday, 12:30 PM - 01:00 PM • Lakeside Learning Center
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LL-OBE-SUA • AMA PRA Category 1 Credit ™:0.5 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.
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. Page 112 of 183
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. 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. Page 113 of 183
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
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
Page 114 of 183
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
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
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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 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 Page 116 of 183
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
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
Page 117 of 183
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. 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
MI
Back to Top 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
Page 118 of 183
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
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
NM
Back to Top 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
Page 119 of 183
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. 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
Page 120 of 183
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
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. Page 121 of 183
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
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. Page 122 of 183
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 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
BR
LL-BRS-SUB • AMA PRA Category 1 Credit ™:0.5 Page 123 of 183
Back to Top 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.
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 Page 124 of 183
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. 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
Page 125 of 183
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
Back to Top CA
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
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
Page 126 of 183
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
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. Page 127 of 183
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
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
CH
Back to Top 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
Page 128 of 183
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 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. Page 129 of 183
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. 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
Back to Top ER
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. Page 130 of 183
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
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
Page 131 of 183
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
� 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,
Page 132 of 183
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 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 Page 133 of 183
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.
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
Page 134 of 183
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. 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 Page 135 of 183
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 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
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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
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 Page 137 of 183
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.
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.
Page 138 of 183
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
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
Page 139 of 183
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 ; 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
Page 140 of 183
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
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
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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). 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
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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
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
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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
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
Page 144 of 183
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
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 Page 145 of 183
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).
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 Page 146 of 183
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)
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 Page 147 of 183
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
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
Page 148 of 183
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 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. Page 149 of 183
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. Obstetrics/Gynecology Posters and Exhibits (1:00 - 1:30pm) Sunday, 01:00 PM - 01:30 PM • Lakeside Learning Center
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LL-OBE-SUB • AMA PRA Category 1 Credit ™:0.5 LL-OBE-SU6B • Fetal Masses: Key Imaging Findings Which Determine in Utero Management and Delivery Planning
Karen Y Oh MD (Presenter) * ; Brian Shaffer MD ; Jamie Lo MD ; Dianna M Bardo MD * ; Roya Sohaey MD * PURPOSE/AIM � Review cases of fetal masses which may require intervention or special delivery planning
� Demonstrate pertinent imaging findings which alter management
� Discuss intrapartum and peripartum relevance of imaging findings
CONTENT ORGANIZATION Case based presentation of various fetal masses 1.
2.
3.
4.
Presentation of fetal mass
Ultrasound and fetal MRI imaging of the mass
Discussion of potential fetal intervention and delivery plan with focus on relevant imaging
Correlation with postnatal imaging and outcome
SUMMARY Pregnancies complicated by a fetus with a mass can benefit from a multidisciplinary approach to management, potentially involving
perinatology, radiology, neonatology and pediatric surgery. Although uncommon, fetal tumors and even benign masses can result in
devastating outcomes. Presented cases include fetal head and neck masses, lymphangioma, sacrococcygeal teratoma, and congenital
pulmonary airway malformation. We discuss specific cases where in utero intervention can be considered, and review pertinent imaging
findings which would guide therapy and delivery planning. Radiation Oncology and Radiobiology - Sunday Posters and Exhibits (1:00pm - 1:30pm) Sunday, 01:00 PM - 01:30 PM • Lakeside Learning Center
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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
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
Page 150 of 183
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
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 Page 151 of 183
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. 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
Page 152 of 183
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. Hologic: 3D Breast Tomosynthesis Imaging with C-View™ for Breast Cancer Screening and Diagnosis - limited to 34 attendees
Sunday, 01:15 PM - 02:30 PM • Booth 1152
BA12 Back to Top LEARNING OBJECTIVES Registration Online at Hologic.com
Hologic is offering a series of 75 minute sessions that include hands-on experience reading 3D breast tomosynthesis images in combination
with conventional and generated 2D(C-View) images. A brief lecture will provide an overview of the technologies prior to the hands-on. The
sessions are inteded for radiologists interested in learning more about breast tomosyntesis for screening and diagnosis. Please note, the
program does not qualify as FDA mandated training for Tomosyntesis. The course is not a CME activity. Page 153 of 183
Interventional Oncology Series: Controversies and Emerging Questions in the Management of Renal Tumors Sunday, 01:30 PM - 06:00 PM • S405AB
RO
OI IR GU VSIO11 • AMA PRA Category 1 Credit ™:4.25 • ARRT Category A+ Credit:5 Moderator
Debra A Gervais , MD * Back to Top LEARNING OBJECTIVES 1) To review management options for small renal masses as well as indications for each. 2) To review the data supporting the energy
based thermal ablation modalities for ablation of renal masses. 3) To describe the role and limitations of biopsy of renal masses. 4) To
review the management of benign solid renal masses. 5) To describe the evidence for ablation of T1b renal masses. VSIO11-01 • Controversy 1-T1a Renal Tumor: Resect, Ablate, or Follow
LEARNING OBJECTIVES View learning objectives under main course title. VSIO11-02 • Small Renal Mass (T1a): The Case for Resection
Adam S Feldman MD (Presenter) LEARNING OBJECTIVES View learning objectives under main course title. VSIO11-03 • Long-term Results of Renal RFA Based on a Single-center 203 Cases Experience: Better than Surgery for Early RCC?
Irene Garetto MD ; Carlo Gazzera ; Marco Busso MD ; Gianluca Amadore ; Federica Solitro MD ; Andrea Veltri MD
(Presenter) * PURPOSE To evaluate the long-term effects of RFA of renal masses (RM), assessing safety, technique effectiveness and survival, in order to
compare the best results with surgical series. METHOD AND MATERIALS 203 RM (12-75 mm, m 30; 193 malignant; 123 exophytic, 67 parenchymal, 13 central) in 137 patients (95 males; 20-88 y, m 64; 13
with hereditary tumors, 31 with solitary kidney) underwent RFA in our center in the last decade (196 US-guided, 7 CT-guided). The
treatment sessions have been 220 (17 retreatments for partial ablation or early recurrence). More recently, complications were prevented
with additional techniques (namely, 10 hydrodissection and 3 pyeloperfusion). Adverse Events (including major complications) and
technique effectiveness (Complete Ablation) were evaluated, as well as predictors for adverse AE and CA. Overall (OS), Disease-Free
(DFS) and Cancer-Specific Survival (CSS) were calculated (follow-up 1-109 months, m 39). Predictors for survival (solitary kidney,
previous cancer disease, tumor type, site and size, etc.) were specifically investigated. RESULTS 17 (8.4%) AE were recorded, including 4 (2%) major complications (all before using preventing techniques). Exophytic extension and
smaller diameter were protective against AE at the uni/multivariate analysis. CA was obtained in 85% RM overall and in 115/124 with a
diameter CONCLUSION RFA of not central small RM is safe and effective and provide high long-term survival rates. Early stage RCC should be considered for RCT
comparing RFA with surgical resection. CLINICAL RELEVANCE/APPLICATION RFA of not central T1a RCC is safe and successful. Thus, RFA offers an optional choice as a first-line therapy. RCTs are still necessary to
assess if RFA is better than surgery for early RCC. VSIO11-04 • Small Renal Mass (T1a): The Case for Ablation
Jeremy C Durack MD (Presenter) LEARNING OBJECTIVES 1) Understand and compare treatment alternatives for small renal masses. 2) Recognize imaging features of small renal masses that
impact treatment alternatives. 3) Understand the risks and benefits of image guided renal mass ablation. VSIO11-05 • Small Renal Mass (T1a): Both Cases for Intervention are Weak. Active Surveillance Will Do Just as Well
Stuart G Silverman MD (Presenter) * LEARNING OBJECTIVES View learning objectives under main course title. VSIO11-06 • Controversy 2-Small Renal Mass (T1a) Ablation is Chosen. Heat or Cold?
LEARNING OBJECTIVES View learning objectives under main course title. VSIO11-07 • Small Renal Mass (T1a): The Case for Heat Based Ablation
Debra A Gervais MD (Presenter) * LEARNING OBJECTIVES View learning objectives under main course title. VSIO11-08 • 5-year Outcomes of Percutaneous Radiofrequency Ablation of 100 Renal Cell Carcinomas
Timothy D McClure MD (Presenter) ; Nelly Tan MD ; Daniel S Chow MD ; Allan Pantuck MD ; James Sayre PhD ; Steven S
Raman MD PURPOSE Determine intermediate term oncological outcomes and determine predictors of primary efficacy in the percutaneous radiofrequency
ablation (RFA) of pathologically proven renal cell carcinomas (RCC).
METHOD AND MATERIALS After IRB approval we performed a HIPAA compliant study of all patients who underwent RFA for pathologically proven RCC. Technical
Page 154 of 183
After IRB approval we performed a HIPAA compliant study of all patients who underwent RFA for pathologically proven RCC. Technical
success, local tumor progression, primary and secondary technique effectiveness were defined per the Working Group of Image Guided
Tumor Ablation. Univariante and multivariate logistic regression analysis was performed to determine predictors of primary technique
effectiveness and complications. Kaplan-Meier local tumor progression-free, metastasis-free, and overall survival were calculated. All
analyses were done using the statistical software STATA/SE� 11.2. Alpha of 0.05 was considered significant. RESULTS 115 RFA sessions for 100 RCC lesions in 84 patients were identified. Mean age was 70.3 years (range 35-93). 51/84 (61%) patients were
men and 33/84 patients (39%) were women. The median ASA score was 3 (range 2-3). The median(mean) lesion size was 2.3(2.6) cm
(range 0.7-6cm). The median(mean) follow up was 24(27) months (range 1-106 months). Total technique effectiveness was 95%.
Primary technique effectiveness was 86% (86/100 lesions). Secondary technique effectiveness was 9% (9/100 lesions). Treatment failure
was 5%(5/100). Technical success was 99.1%. Using logistic regression statistical analysis, predictors of primary efficacy were: location,
size, proximity to collecting system, R.E.N.A.L nephrometry sum, and number of ablation zones. Complications occurred in 15 of 115 RFA
sessions (13%) with no deaths. The median 2.1year local progression free, metastasis free, disease specific survival, and overall survival
was 86%, 98.7%, 100%, and 97.6% respectively. CONCLUSION Percutaneous RFA for RCC is safe and effective with excellent intermediate oncologic control. Location, size, lesion nearness to the
collecting system, R.E.N.A.L Nephrometry sum, and number of ablation zones predicts primary efficacy. CLINICAL RELEVANCE/APPLICATION Percutaneous RFA for RCC has excellent intermediate oncologic outcomes. Predictors of primary efficacy include: location, size, R.E.N.A.L
Nephrometry sum, and number of ablations. VSIO11-09 • Percutaneous Microwave Ablation of Renal Tumors: Multicenter Evaluation of Safety and Efficacy
Anna Moreland (Presenter) ; Timothy J Ziemlewicz MD ; Aaron M Fischman MD * ; J. Louis Hinshaw MD * ; Jason Abel ; Meghan G Lubner MD * ; Sarah Best ; Marci Center ; Christopher L Brace PhD * ; Fred T Lee MD * PURPOSE To evaluate the feasibility, safety, and efficacy of a high-powered, gas-cooled microwave ablation system for treatment of renal tumors. METHOD AND MATERIALS Between 1/2011 and 4/2013, 45 renal tumors were treated at 2 medical centers using ultrasound and CT-guided microwave ablation with
a high-powered, gas-cooled microwave ablation system (NeuWave Medical, Madison, WI). Tumors included biopsy-proven renal cell
carcinoma (n=36), angiomyolipoma (n=4), oncocytoma (n=2), and other (n=3). Mean patient age was 64 years. Post-procedure imaging
was performed by CECT or MRI to evaluate for enhancement in the ablation zone. RESULTS Mean pre-treatment tumor diameter was 2.7 cm (range: 1.0-5.4). Tumor diameter decreased by a mean of 11% on immediate
post-ablation CT. Mean duration of power application was 6.5 minutes, and mean generator power was 73.7 W. Technical effectiveness
was 100%. There was one major complication: a retroperitoneal hematoma on post ablation day 11. This coincided with restarting
anticoagulation for suspected pulmonary embolus in a patient with a thrombotic history, and required readmission and transfusion of
PRBCs. Median hospital stay was 1 day, and median length of clinical follow-up was 11 months. All patients are alive and without evidence
of metastatic disease, with the exception of 1 death occurring 6 months post ablation and unrelated to either the procedure or the
malignancy. 28 patients have had follow-up imaging at a mean of 6.3 months status post ablation, with local tumor progression noted at
the ablation zone in 1 case. Overall, the procedure demonstrated 95% primary treatment effectiveness and a 98% secondary treatment
effectiveness, with 1 tumor yet to be retreated.
CONCLUSION Use of a high-powered, gas-cooled percutaneous microwave ablation system for the treatment of small renal masses demonstrates safety
and technical success in the short term. CLINICAL RELEVANCE/APPLICATION Preliminary experience treating renal tumors with a high-powered, gas-cooled microwave system suggests that the procedure is
technically feasible, safe, and efficacious at early time points. VSIO11-10 • Small Renal Mass (T1a): The Case for Cold Ablation
Peter J Littrup MD (Presenter) * LEARNING OBJECTIVES 1) Understand the different approaches and techniques of thorough renal mass cryoablation that produces very low recurrence rates,
even for larger central tumors. 2) Understand the appropriate settings to utilize protective techniques (i.e., hydrodissection, balloon
interposition, ureteral stent, etc..) for adjacent calyces, bowel and ureter to avoid complications. 3) Identify major imaging follow-up
criteria for ablation success and any early failures. 4) Describe the overall cost-efficacy trade-offs for cryo vs. heat-based renal ablations
vs. partial nephrectomy, in relation to tumor location, complications and recurrence rates.
ABSTRACT Cryoablation of smaller renal cancers (i.e., T1a, or For safety, cases will be considered for avoidance of direct calyceal puncture, selection
of hydrodissection or balloon interposition for bowel protection, and protection of the uretero-pelvic junction by stent placement. Imaging
outcomes of complications and their avoidance will be shown. For optimal efficacy, tumor size in relation to number and size of cryoprobes
emphasize the �1-2 Rule� of at least 1 cryoprobe per cm of tumor diameter and no further than 1 cm from tumor margin, as well as
cryoprobe spacing of VSIO11-11 • Percutaneous Renal Cryoablation in Obese and Morbidly Obese Patients
Grant D Schmit MD (Presenter) ; Anil N Kurup MD ; Adam J Weisbrod MD ; Robert J McDonald MD, PhD ; Matthew R
Callstrom MD, PhD * ; Thomas D Atwell MD ; Robert Thompson MD ; Stephen Boorjian PURPOSE To compare percutaneous renal cryoablation complications and outcomes in obese and morbidly obese versus nonobese patients. METHOD AND MATERIALS 389 percutaneous cryoablation procedures were performed in 367 patients for treatment of 421 renal masses at our institution between
2003 and 2012. Patients were categorized into three groups based on body mass index (BMI): nonobese (BMI < 30.0kg/m2), obese (BMI
30.0�39.9kg/m2) and morbidly obese (BMI > 40.0kg/m2). Each group was retrospectively analyzed for major complications (Clavien >
Grade 2) and oncologic outcomes. RESULTS 189 (48.6%) renal cryoablation procedures were performed on nonobese patients, 161 (41.4%) on obese patients and 39 (10.0%) on
morbidly obese patients. Eleven (5.8%) major complications occurred in nonobese patients, 15 (9.3%) in obese patients and 3 (7.7%) in
morbidly obese patients. As such, there was no significant difference in the rate of major complications in obese (p=0.23) or morbidly
obese (p=0.67) compared to nonobese patients. There was one ablation-related death from complications of urosepsis. A total of 13 local
treatment failures were identified, including 5 technical failures and 8 local tumor recurrences during median imaging follow-up of 18
months (interquartile range: 8�36). Six (3.2%) local treatment failures occurred in nonobese patients, 5 (2.9%) in obese patients and 2
(4.8%) in morbidly obese patients. Again, no significant difference was noted in local treatment failure rate between obese (p=0.96) or
Page 155 of 183
morbidly obese (p=0.57) compared to nonobese patients. CONCLUSION Percutaneous renal cryoablation complication rates and outcomes in obese and morbidly obese patients are similar to those in nonobese
patients. CLINICAL RELEVANCE/APPLICATION To our knowledge, this is the first paper to evaluate percutaneous renal cryoablation complications and outcomes based on patient body
mass index (BMI). VSIO11-12 • Controversy 3-Biopsy or No Biopsy Before Ablation
LEARNING OBJECTIVES View learning objectives under main course title. VSIO11-13 • Renal Cell Cancer Subtype as a Predictor of Efficacy in Radiofrequency Ablation
Timothy D McClure MD (Presenter) ; Allan Pantuck MD ; James Sayre PhD ; Steven S Raman MD PURPOSE To determine if renal cell cancer (RCC) subtype predicts efficacy in the percutaneous radiofrequency ablation (RFA) of RCC. METHOD AND MATERIALS With IRB approval we performed a HIPAA compliant retrospective study of patients who underwent RFA for RCC and determined subtype
pathology that included clear cell, chromophobe, papillary, oncocytic neoplasm, and RCC not otherwise specified. Pathology was
determined by biopsy or post resection surgical pathology. Group comparisons were done using univariate and multivariate logistic
regression analysis to determine factors impacting primary efficacy, secondary efficacy, and technique effectiveness. All analyses were
done using the statistical software STATA/SE� 11.2. Alpha of 0.05 was considered significant. Technical success, local tumor progression,
primary and secondary technique effectiveness were defined per the Working Group of Image Guided Tumor Ablation. RESULTS 100 pathologically proven RCC masses were identified in 84 patients with the following subtypes: clear cell: 55/100 (55%), oncocytic
neoplasms: 19/100 (19%), papillary: 13/100 (13%), RCC not otherwise specified 10/100 (10%), and chromophobe: 3/100 (3%). Median
post ablation follow up was up to 106 months (mean 24 months). Non clear cell RCC subtypes had more favorable outcome compared to
clear cell RCC for primary, secondary and total technique 44/45(97.8%), 1/45 (2.2%), 45/45 (100%) versus 42/55 (76.4%), 8/55
(14.5%), 50/55 (90.9%) respectively(p=0.002). Overall primary, secondary and total technique effectiveness was 86%, 9%, and 95%
respectively. CONCLUSION Non-clear cell RCC subtypes have more favorable ablation outcomes compared to clear cell RCC after percutaneous RFA. CLINICAL RELEVANCE/APPLICATION Pathology predicts efficacy in the percutaneous RFA of renal masses. Pre-procedure biopsy should be done prior to percutaneous RFA of
renal masses to better predict outcomes. VSIO11-14 • Biopsy or No Biopsy Before Ablation? Don't Trouble Yourself or the Patient with the Renal Mass Biopsy - Go Ahead
and Ablate
Steven S Raman MD (Presenter) LEARNING OBJECTIVES 1) Understand how to image renal masses prior to ablation. 2) Understand how to use appropriate CT and MR protocols to enable renal
mass characterization. 3) Describe the most common CT and MRI enhancement signatures of common RCC subtypes, oncocytoma and
lipid poor AML. ABSTRACT Characterization of small renal masses has proven challenging. However, with appropriate CT and MR protocols, the majority of these
lesions can now be characterized pre procedurally, enabling a confident diagnosis. In this lecture, we will describe renal mass
characterization protocols and describe the common imaging signatures of RCC subtypes and their common mimics including lipid poor
AML and oncocytoma. This may eliminate need for preprocedural biopsy. VSIO11-15 • Biopsy or No Biopsy Before Ablation? Biopsy Every Renal Tumor before Percutaneous Ablation
William W Mayo-Smith MD (Presenter) * LEARNING OBJECTIVES 1) Explain the expanding role of renal mass biopsy. 2) Explain why biopsy is necessary before all renal tumor ablations. 3) Demonstrate
biopsy techniques. VSIO11-16 • Emerging Questions in Renal Tumor IR Management
LEARNING OBJECTIVES View learning objectives under main course title. VSIO11-17 • Benign Disease: Leave Alone, Ablate or Suggest Something Else?
S. William Stavropoulos MD (Presenter) * LEARNING OBJECTIVES 1) Understand and compare treatment alternatives for benign renal masses. 2) Recognize imaging features of benign renal masses that
impact treatment alternatives. 3) Understand the risks and benefits of image guided treatment of benign renal masses. VSIO11-18 • Large Renal Masses (T1b): Does Ablation Have a Seat at the Table?
Thomas D Atwell MD (Presenter) LEARNING OBJECTIVES 1) Appreciate the strengths and limitations of percutaneous ablation in treating renal tumors measuring larger than 4cm. ABSTRACT VSIO11-19 • Outcomes Following Percutaneous Cryoablation of Renal Masses 4.1-7.0cm
Jay J Vlaminck MD (Presenter) ; Grant D Schmit MD ; Anil N Kurup MD ; Adam J Weisbrod MD ; Matthew R Callstrom MD,
PhD * ; Thomas D Atwell MD ; Stephen Boorjian ; Robert Thompson MD Page 156 of 183
PURPOSE To describe safety and oncologic outcomes following percutaneous cryoablation of renal masses measuring 4.1-7.0cm. METHOD AND MATERIALS Retrospective review of 71 renal tumors measuring 4.1-7.0cm in 70 consecutive patients treated with percutaneous cryoablation between
2003 and 2011. Local recurrence, cancer-specific survival and overall survival rates were recorded. Complication rates (Clavien Dindo)
were also documented. RESULTS Mean tumor size was 4.8 cm. A single (1.4%) technical failure was observed at the time of ablation. Of the 58 (82%) tumors that were
followed for at least three months, there was a single (1.7%) recurrence. The mean duration of follow-up for the 57 tumors that did not
recur was 2.2 years (range 0.3 � 7.1). Estimated recurrence-free survival rates at 1, 3, and 5 years following cryoablation were 97.9%,
97.9%, and 97.9%, respectively. Among the 58 tumors that were followed for at least three months, 36 (62%) were RCC at biopsy, including the single recurrence. Mean
duration of follow-up for the 35 RCC tumors that did not recur was 2.0 years (range 0.3 � 6.1). Estimated recurrence-free survival rates
at 1, 3, and 5 years for these biopsy-confirmed RCC tumors were 96.4%, 96.4%, and 96.4%, respectively. Of the 36 (51%) patients
with sporadic RCC, estimated cancer-specific survival rates at 1, 3, and 5 years were 100%, 94%, and 94%, respectively. Of the 71
cryoablation procedures, there were 5 (7.0%) complications of grade 3 or greater.
CONCLUSION Cryoablation represents a safe treatment alternative for patients with renal masses, with intermediate-term oncologic efficacy for T1b
tumors. CLINICAL RELEVANCE/APPLICATION Outcomes in this study suggest that cryoablation of T1b renal cell carcinoma may be more efficacious than previously considered,
particularly when considering the AUA guidelines. lifeIMAGE: Image Sharing 101 - Securely Transfer Exams, Wherever Needed Sunday, 02:00 PM - 02:45 PM • Booth 8355
BC10 Back to Top LEARNING OBJECTIVES Registration Online at lifeIMAGE.com Learn about the workflow for managing exams from discs, receiving exams electronically from any
outside source, integrating outside images with local systems, and sharing exams with outside physicians and patients. Abdominal Imaging Clinical Pathways (An Interactive Session) Sunday, 02:00 PM - 03:00 PM • S402AB
QA
GI MSRA13 • AMA PRA Category 1 Credit ™:1 • ARRT Category A+ Credit:1 Julia R Fielding , MD Back to Top LEARNING OBJECTIVES With the growing concerns related to radiation safety and cost containment, the need for accurate imaging procedure selection to best fit
the patient and the clinical presentation is more and more critical. This session will provide clinical scenarios with patient presentation
information and a discussion of the choices of imaging pertinent to that clinical presentation. Where there are multiple imgaging pathways,
the decision will be discussed in light of radiation safety and cost containment guidelines. Lung Cancer Screening: How I Do It Sunday, 02:00 PM - 03:30 PM • E451B
OI
CH RC101 • AMA PRA Category 1 Credit ™:1.5 • ARRT Category A+ Credit:1.5 Back to Top RC101A • Current Data Summary and Recommendations
Ella A Kazerooni MD (Presenter) LEARNING OBJECTIVES 1) To understand the current guidelines for lung cancer screening with CT from major professional societies. 2) To learn what the current
position is of the U.S. Preventative Services Task Force on screening for lung cancer. 3) To understand options for reimbursement, from
self pay to third party payors.
ABSTRACT Since the results of the NLST were published in 2011, demostrating a 20% reduction in lung cancer specific mortality in high risk current
and former smokers, many professional organizations have developed guidelines that recommend screening CT in that same population:
55-74 year olds with a 30 or more pack year history of smoking who ar current smokers or who quit in the last 15 years. Some
professional organizations have somewhat controversially extended favorable recommendations to younger and older individuals, and
those at moderate risk of developing lung cancer basedon other risk factors. The last words from the US Preventative Task Force on this
issue were a non favorable receomnendation in 2004, 'The U.S. Preventive Services Task Force (USPSTF) concludes that the evidence is
insufficient to recommend for or against screening asymptomatic persons for lung cancer with either low dose computerized tomography
(LDCT), chest x-ray (CXR), sputum cytology, or a combination of these tests' followed by similar lack of endorsement in a 2009 USPSTF
publication of making decisions in the setting of 'insufficient evidence.' The latter addressed the question in 4 domains: potential
preventable burden, potential harm of the intervention, costs (both monetary and opportunity), and current practice. While an increasing
but small number of third party payors cover screening CT today, and nost self pay programs are seeing little uptake of individuals,
Medicare has not issued a statement. Like some other organizations, the cost effectiveness analysis may be very important in their
decision. Circustances that coudl lead Medicare to cover screening CT for lung cancer if there is a favorable USPSTF recommendation or if
federal legislation is passed, similar to what was done with MQSA and breast cancer screening with mammography. RC101B • Starting a Screening Program
Reginald F Munden MD, DMD (Presenter) * LEARNING OBJECTIVES 1) Understand important issues to be addressed in planning a lung cancer screening program. 2) Appreciate the need to have a
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multidisciplinary approach to lung cancer screening. 3) Determine the resources to undertake lung cancer screening program. ABSTRACT Launching a lung cancer screening program is not simply a matter of opening the doors and offering low-dose CT to anyone who wishes
to be screened. There are many decisions that need to be resolved prior to launching a screening program such as the criteria for
screening � NLST, NCCN or one based on previous screening trials. A system of registration, recording and follow-up of patients will need
to be established. Other considerations include whether the radiologist is responsible for follow up of patients or whether a physician of
record is required. Is self-referral allowed? What about structured reporting? It is extremely important to develop a protocol to manage
positive findings for patients that the physicians who will ultimately treat the patient agree upon. This session will discuss many of the
fundamental issues related to establishing a lung cancer screening program. RC101C • Management Strategies for Screen-Detected Nodules
Thomas E Hartman MD (Presenter) * LEARNING OBJECTIVES 1) Identify imaging findings and tools that can aid in the management of screen detected pulmonary nodules. ABSTRACT In order to optimize CT screening for lung cancer, appropriate management of screen detected pulmonary nodules is essential. Various
criteria from initial size, attenuation and margin to growth rate on subsequent exams can be used to help stratify risk and determine
appropriate management. Evolving computer aided diagnostic applications may improve our ability to manage screen detected nodules. RC101D • Biopsy of Screen-Detected Nodules
David F Yankelevitz MD (Presenter) * LEARNING OBJECTIVES 1) To understand indications for biopsy of screen-detected nodules. 2) To develop an approach to optimize small specimen evaluation. 3)
To improve communication between the radiologist and the cytologist to optimize diagnosis.
RC101E • Other Findings: What Do I Do?
Caroline Chiles MD (Presenter) LEARNING OBJECTIVES 1) Suggest management guidelines for incidental findings discovered at the time of lung cancer screening, with special emphasis on
COPD, coronary artery disease, and other cancers. ABSTRACT What's New from the Radiology Residency Review Committee: Milestones, New for 2013 Sunday, 02:00 PM - 03:30 PM • E350
PR
LM ED RC102 • AMA PRA Category 1 Credit ™:1.5 Lynne E Meyer , PhD, MPH Lawrence P Davis , MD Back to Top LEARNING OBJECTIVES 1) The attendee will learn about new program requirements. 2) The attendee will learn how the NAS will be used for program accreditation.
3) The attendee will be made aware of various issues pertaining to residen