Download Scientific and Educational Exhibits

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Scientific and
Educational Exhibits
Abdominal Viscera (Solid Organs).............. 338
Breast ......................................................... 353
Cardiac ....................................................... 364
Chest .......................................................... 378
Computer Applications ............................... 393
Contrast Media ........................................... 398
Genitourinary .............................................. 401
GI Tract ....................................................... 418
Head and Neck ........................................... 434
Interventional R adiology ............................. 443
Molecular Imagi ng ...................................... 454
Musculoskeletal .......................................... 457
Neuro .......................................................... 475
Pediatric ...................................................... 490
Physics in Radiology .................................. 497
Radiographers ............................................ 502
Vascular ...................................................... 504
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Scientific and Educational Exhibits
Abdominal Viscera (Solid Organs)
Abdominal Viscera (Solid Organs)
Biliary Tract
Liver
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Purpose: To determine radiologic features useful in the differential diagnosis
between gallbladder carcinoma and inflammatory conditions.
Methods and Materials: We reviewed radiologic images (sonography and CT)
from 200 patients, 74 with gallbladder carcinomas, 100 with chronic cholecystitis and 26 with complicated acute cholecystitis. Multiple imaging findings were
evaluated including focal or diffuse wall thickening, intraluminal or pericholecystic
mass, enhancement patterns, biliary dilatation, hepatic infiltration and focal hepatic
lesions. These features were compared between inflammatory conditions and
gallbladder carcinoma.
Results: The wall of the gallbladder is thicker and more irregular in carcinoma than
in cholecystitis (p 0.001). The wall enhancement is useful in differentiating gallbladder carcinoma from chronic cholecystitis (p 0.001). The following morphological
criteria were found more frequently encountered in gallbladder carcinoma: biliary
dilatation (56.7%), hepatic infiltration (54%) and metastases (24.3%).
Conclusion: Usually gallbladder carcinoma is an unsuspected condition and so an
understanding of radiologic features is essential for a correct diagnosis. Overlapping
features between gallbladder carcinoma and inflammatory conditions is important.
Analysis of the wall thickening and enhancement patterns may be useful in differentiating gallbladder carcinoma from inflammatory conditions.
Purpose: To investigate the optimal imaging delays between portal dominant and
hepatobiliary phases for the detection of HCC on Gd-EOB-DTPA enhanced MRI.
Methods and Materials: Of 100 patients who underwent EOB enhanced MR using
a 1.5-T MR with high-performance gradient system, we identified 13 patients with
16 hypervascular HCCs. After EOB injection (0.1 mL/kg), all images of THRIVE
(T1 High Resolution Isotropic Volume Examination) with SENSE were obtained at
70 sec, 5 min, 10 min, 15 min, 20 min and 30 min post EOB injection by a single
breath hold. Time-intensity analysis was performed for each HCC and surrounding
liver parenchyma by placing regions of interest on a workstation. Wilcoxon-signed
rank test was used for further analysis.
Results: Of all 16 HCCs, the peak tumor-to-liver contrast was obtained at 30 min
in 13 HCCs, 20 min in 1, 10 min in 1 and 70 sec in 1. Tumor-to-liver contrast of
30 min was significantly (p 0.05) higher than that of 20 min. From time-intensity
analysis, the peak enhancement of liver parenchyma was obtained at 30 min in
10 pts, 10 min in 1 pt and 70 sec in 2 pts. And signal intensity of liver parechyma
substantially increased over time from 70 sec to 30 min post EOB injection.
Conclusion: Peak tumor-to-liver contrast is substantially obtained at 30 min post
Gd-EOB-DTPA injection, and liver parenchymal enhancement tends to increase
over time, if patients do not have bad liver function.
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Differential diagnosis between gallbladder carcinoma and inflammatory
conditions
C.L. Fernandez Rey, S.M. Costilla Garcia, E. Montes Perez, P. Sanchez Lopez;
Oviedo/ES ([email protected])
Normal variants of the biliary tree: What the surgeon needs to know
J.F.G.M. Costa, A. Canelas, B. Gonçalves, O. Vaz, A. Costa, C. Marques,
F. Caseiro-Alves; Coimbra/PT
Learning Objectives: To review the most frequent normal variants of the biliary
ducts, as seen at MR cholangiopancreatography, emphasizing their clinical relevance for surgical interventions.
Background: During the past decade, the increasing number of hepatobiliary surgical procedures, mainly laparoscopic cholecystectomies but also liver transplantations, has been associated with an increase in postoperative biliary complications.
Magnetic resonance cholangiopancreatography has become the imaging modality
of choice at many institutions for the work-up of patients with suspected bile duct
abnormalities but also for surgical planning. There are wide anatomic variations
in the extrahepatic biliary tree, some of which may make surgical access difficult.
It is imperative that the radiologist be familiar with normal variants, to report them
and prevent possible complications.
Imaging Findings: In this exhibit, we present MR cholangiograms to illustrate
normal and anatomic variants of the biliary tree (including drainage of the right
posterior duct into the left hepatic duct; triple confluence; low cystic duct insertion; a
medial cystic duct insertion; parallel course of the cystic duct and common hepatic
duct). Additionally, we present possible complications associated with unrecognized
anatomic variations of the biliary tree.
Conclusion: By reviewing this exhibit, users will be able to recognize the most
frequent normal variants of the biliary tree, which are responsible for a significant
number of surgical complications.
Hepatocellular carcinomas with Gd-EOB-DTPA enhanced MRI: Timeintensity analysis from portal dominant phase to hepatobiliary phase
M. Okada, T. Araki, Y. Kagawa, T. Katsube, S. Kumano, T. Murakami;
Osaka-Sayama/JP
Assessment of liver steatosis using MRI in comparison with results of
total hepatic triglyceride in a rat model
C. Jarlot, V. Roullier, C. Aubé, S. Michalak, J. Roux, P.-H. Ducluzeau,
C. Cavaro-Ménard, P. Calès; Angers/FR ([email protected])
Purpose: There is a need of non invasive tools for evaluating steatosis on animal
models in therapeutic trials. The purpose of this study was to quantify liver steatosis
by MRI with an assay of total triglyceride of the liver as reference standard.
Methods and Materials: Six groups of 4 rats received different periods of fatty
diet and were explored by MRI. The same slice was acquired across the liver using
two sets of parameters: IP/OP with dual flip angles and multi-echo IP/OP in free
breathing, without respiratory trigger. Liver steatosis was quantified for each MRI
sequence. Rats were sacrificed following the MR examination. Serum levels of
ASAT, ALAT, triglycerides, iron, glycaemia, total cholesterol, HDL cholesterol, LDL
cholesterol were measured in blood samples.The MRI results and laboratory data
were compared to a total triglyceride assay of the extracted liver.
Results: There is a good correlation between multi-echo MR imaging and gold
standard (Rs=0.85). Poor correlation between dual MR imaging and gold standard
(Rs=0.47) can be explained by low signal-to-noise ration (SNR) in IP/OP dual flip
angle images. Multi-echo IP/OP quantification method allows taking into account the
entire signal decay and noise in images, which leads to improved quantification. With
total triglyceride assay as the reference, multivariate regression analysis showed
multi-echo IP/OP, ALAT and HDL cholesterol as independent variables.
Conclusion: The multi-echo IP/OP MR quantification method allows a reliable and
easy practice non-invasive to measure liver steatosis in a rat model.
C-005
Radiofrequency ablation of liver tumors: What have we done in nine years?
M. Herráiz, M. Arraiza, C. Hernández, J. Arias, D. Cano, A. Benito; Pamplona/ES
([email protected])
Purpose: To show results (efficacy, survival, and complications) of hepatic radiofrequency ablation (RFA) at our institution.
Methods and Materials: Between April 1999 and April 2008 we treated 148 patients, 109 male (73.6%) and 39 female (26.4%), mean age of 62.1 years (range,
7-85 years). Always using ultrasound guidance, we performed 176 procedures
(94 percutaneously and 82 via laparotomy). Fifty-one patients had hepatocellular
carcinoma (HCC) (34.5%), sixty-one had metastases of colorectal cancer (CRCM)
(41.2%), and thirty-six had metastases of others tumors (24.3%). The median
number of tumors treated per procedure was one tumor (range 1-7). The mean
lesion size was 2.2 cm (range, 0.4-5.1 cm). Follow-up evaluations were done with
CT, MRI and/or PET.
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Scientific and Educational Exhibits
Results: Local control rates were 89.2% (87.5% HCC, 91.7% CRCM and 87.5%
other metastases). Respective actuarial 1-, 2-, and 5-year survival rates were in
the HCC group 97.7%, 89.9 %, and 53.9%; in the CRCM 92%, 75.8%, and 35.8%;
and in the other metastases 93.7%, 77.9%, and 61.4%. And cumulative 1-, 2-, and
5-year disease-free survival rates (neither hepatic nor extrahepatic recurrence)
were in the HCC group 58%, 36.2%, and 14.4%; in the CRCM 43.9%, 20.1%,
and 13.6%; and in the other metastases 53.6%, 30%, and 22.5%. No mortality
was observed. Complications occurred and were easily solved in five patients
(pseudoaneurysm of the hepatic artery, liver abscess, thigh burning, biliar stenosis
and hepatic vein stenosis).
Conclusion: RFA enables adequate local control of non-resectable liver malignancies, achieving acceptable survival rates.
C-006
CT perfusion in evaluating therapeutic effect of transarterial
chemoembolization for hepatocellular carcinoma
G. Chen, H. Wen; Beijing/CN ([email protected])
Learning Objectives: To prospectively assess the changes in parameters of CT
perfusion pre- and post-TACE treatment of hepatocellular carcinoma (HCC) in
different treatment response groups.
Background: CT perfusion imaging provides a non-invasive and reproducible
technique for assessing tissue perfusion in locally advanced HCC.
Imaging Findings: 39 patients with HCC underwent pre-treatment CT perfusion
examinations (1 d before TACE) and post-treatment CT perfusion examinations (4
wk after TACE). The “response evaluation criteria in solid tumors” (RECIST) was
referred to when distributing of treatment responses. Wilcoxon signed ranks test
was used to compare the differences in CT perfusion parameters between pre- and
post-TACE in different treatment response groups. The result of this study: in the
PR treatment response group, HAP, HAF and HBV of viable tumor post-TACE were
reduced compared with pre-TACE, and their difference were statistically significant
between pre- and post-treatment (P = 0.001, 0.030 and 0.001, respectively); in
the SD group, all CT perfusion parameters were not significantly different between
pre- and post-TACE; and in the PD group, HAP, HAF, PVP and HBF of viable tumor
post-TACE were significantly increased compared with pre-TACE (P = 0.005, 0.012,
0.035 and 0.005, respectively), while other parameters were not significantly different between pre- and post- treatment.
Conclusion: The changes of CT perfusion parameters within viable tumor could
correlate different treatment response for HCC. Therefore, CT perfusion imaging
is a feasible technique for monitoring treatment response after TACE.
C-007
Pitfalls in CT and MRI differential diagnosis of focal liver masses with
central scar
S. Ghiea, M. Boros, C. Dobromir, I. Lupescu, S.A. Georgescu; Bucharest/RO
([email protected])
Usefulness of portal collateral volumetry in the course of liver
transplantation using 3-dimensional (3D) MSCT
H. Shishido, M. Ishifuro, M. Kiguchi, C. Fujioka, J. Horiguchi, K. Ito; Hiroshima/JP
([email protected])
Purpose: Due to severe portal hypertension, portal collateral circulation often
develops in patients with end-stage chronic liver disease. The purpose of this study
is to evaluate change in the collateral circulation volume between before and after
liver transplantation.
Methods and Materials: Using a phantom, we first investigated required enhancement (in CT value) of vessels for precise volumetry on volume rendered image.
In the clinical study (18 men and 7 women patients, age: 48p12), we measured
volumes of portal vein, splenic vein and portal collateral circulation.
Results: In the phantom study, accurate volumetry of vessel was possible with
vascular enhancement over 150 HU. However, with the enhancement under
150 HU, the volume was underestimated. In the clinical study, one of 25 subjects
with CT value in portal system of under 150 HU was excluded. For the remaining
24 subjects, the mean CT values were 233p20.6, 234p20.9 and 218p19.2 HU on
portal vein, splenic vein and portal collateral circulation, respectively. The volumes
measured before and after liver transplantation (30p2 days) were portal vein: 9.7p5.3
and 9.8p5.7 mm3 (p=0.91), splenic vein: 11.7p6.3 and 11.8p4.8 mm3 (p=0.71), and
portal collateral circulation: 86.6p60.0 and 35.6p20.0 mm3 (p 0.05).
Conclusion: Volumetry showed significant regression of portal collateral circulation
after liver transplantation, indicating favorable control of portal venous pressure.
C-009
Gd-EOB-DTPA-enhanced MR imaging of the liver: Overview from functional
and hemodynamic aspects of hepatocellular nodular lesions and pitfalls in
image interpretation
S. Kobayashi, O. Matsui, T. Gabata, J. Sanada, W. Koda, T. Minami, Y. Ryu,
K. Kawai, K. Kozaka; Kanazawa/JP
Learning Objectives: To provide the overview of functional liver MR contrast
agent, Gd-EOB-DTPA (EOB), and its significance on liver imaging. To familiarize
hepatobiliary phase EOB-enhanced MR image of various hepatocellular nodular
lesions. To understand the pitfalls of EOB-enhanced MR image in interpreting
findings of hepatocellular nodular lesions.
Background: EOB and hepatobiliary MR contrast agent enable us to perform both
the hemodynamic and the parenchymal functional analysis of hepatic lesions at the
same examination. On the hepatobiliary phase EOB-enhanced T1-weighted MR
image, we can depict focal parenchymal abnormalities, which show deterioration
of bile production/secretion, as hypo-intense lesions compared to background
liver. It means we can directly assess the functional state of hepatocytes and bile
secreting system with EOB-enhanced MR images.
Imaging Findings: Most of the hepatic tumors show hypo-intense compared to
background liver parenchyma on hepatobiliary phase EOB-enhanced T1-weighted
MR image. However, hepatocellular nodules, such as dysplastic nodule, welldifferentiated hepatocellular carcinoma (HCC) and moderately-differentiated HCC,
which are diagnosed based on angiography-assisted CT such as CTAP and CTHA,
might show hypo-, iso-, or hyper-intense compared to background liver parenchyma.
This diversity is attributed to the potential ability of cellular bile production/secretion,
and the findings are determined by the cellular functional state of bile production/
secretion, not by the grade of multi-step hepatocarcinogenesis process.
Conclusion: We should note that some of the hepatocellular nodules might show
iso- or hyper-intensity on hepatobiliary phase image of EOB-enhanced MRI, and
possibly it might confuse our diagnostic process.
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Vascular disorders of the liver: A systematic review on CT
M. Seco, L. Semedo, J. Costa, B. Gonçalves, B. Graça, F. Caseiro-Alves;
Coimbra/PT ([email protected])
Learning Objectives: To understand the pathophysiologic mechanisms underlying some vascular lesions of the liver. To review the CT findings of several hepatic
vascular disorders and perfusion abnormalities.
Background: In the past, vascular disorders of the liver did not constitute a major
primary indication for CT and were evaluated by duplex sonography or, in some
cases, by angiographic methods. With the development of the multi-detector technology, CT is now regarded as the primary imaging modality in this setting, since
it evaluates not only the vascular changes but also the liver parenchyma.
Imaging Findings: A systematic review and illustration of the spectrum of vascular
disorders of the liver as seen on CT (including perfusion abnormalities, portal vein
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Abdominal Viscera (Solid Organs)
Learning Objectives: To point out the imaging findings centered upon pitfalls
in differential diagnosis of histopathologically confirmed focal liver lesions with
central scar.
Background: Starting from a “puzzling case” of hepatic focal mass with central
scar - an extremely rare tumor, namely, solitary fibrous tumor of liver - we thought
important to find in our imaging database and medical literature if there are any
reliable imaging signs in differential diagnosis of such entities. We studied retrospectively (2005-2008) 1824 cases of liver masses: 1138 metastasis (62%), 217
hepatocarcinomas (11.9%), 205 abscesses (11.2%), 157 hemangioma (8.6%),
13 focal nodular hyperplasias (0.71%), 13 adenoma (0.71%), and 12 fibrolamelar
carcinomas (0.66%). We also found some very rare tumors (one solitary fibrous
tumor of liver and one hepatoblastoma).
Imaging Findings: Usually, scars within hepatic masses appear hypoattenuating
on unenhanced scans compared with normal liver parenchyma. After contrast
administration, the scar presents delayed enhancement if it is fibrous or it may be
hypoattenuating if it is necrosis. We discovered very similar CT and MRI imaging
findings between benign and malignant hepatic or nonhepatic origin lesions with
central scar (example: FNH very similar with HCC, metastasis with abscess or
solitary fibrous tumor of liver).
Conclusion: Imaging differential diagnosis in focal hepatic tumors with central
scar is difficult in most of the cases. Hepatic focal masses with central scar could
represent a broad spectrum of lesion, benign or malignant, originating in hepatic or
non hepatic tissue. Central scar in hepatic focal masses may be a pitfall by itself.
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Scientific and Educational Exhibits
and hepatic arterial thrombosis, hepatic venous outflow obstruction, hepatic infarction, hereditary hemorrhagic telangiectasia and peliosis hepatis) will be performed.
Vascular pseudo-lesions shall also be discussed.
Conclusion: Vascular disorders of the liver may not only mimic but also conceal
focal liver lesions. Awareness of the imaging spectrum and knowledge of the underlying mechanisms of vascular hepatic disorders can help avoid a substantial
amount of interpretative pitfalls, thereby increasing the diagnostic accuracy of CT
in this group of conditions.
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Clinical application of Gd-EOB-DTPA enhanced T1-weighted MRCP
N. Lee, S. Kim, J. Yeom, J. Lee, D. Kang, G. Kim, H. Seo; Busan/KR
Learning Objectives: To understand pharmacokinetics of Gd-EOB-DTPA. To list
disease entities that cause absent or delayed filling of the gallbladder and biliary
tract. To describe clinical applications of hepatobiliary MR using Gd-EOB-DTPA.
Background: Gadolinium ethoxybenzyl diethylenetriaminepentaacetic acid (GdEOB-DTPA) is a newly developed hepatobiliary MR contrast agent. Gd-EOB-DTPA
is gradually taken up by the hepatocyte and eventually excreted via the biliary
system, where it causes T1 shortening of bile. Because of these characteristics,
addition of Gd-EOB-DTPA enhanced T1-weighted MRCP may havepotential to
improve diagnostic limitations of standard MRCP.
Imaging Findings: We will illustrate clinical applications of Gd-EOB-DTPA enhanced T1-weighted MRCP. Clinical applications of Gd-EOB-DTPA include: 1)
visualization of biliary anatomy, 2) differentiation of biliary lesion from extrabiliary
lesion, 3) diagnosis of cholecystitis, 4) evaluation of filling defects in the biliary
tract and the degree of bile duct obstruction, and 5) post-operative complication
and post-procedure evaluation.
Conclusion: Gd-EOB-DTPA enhanced T1-weighted MRCP can increase diagnostic
performance for anatomical and functional biliary disorders.
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The application of single direction diffusion gradient DW-MRI in hepatic
metastases
Y. Cui, X. Zhang, Y. Sun, L. Tang, K. Cao, J. Li; Beijing/CN ([email protected])
Purpose: To evaluate the possibility of thin slice DW-MRI of whole liver in hepatic
metastases patients within one breath-hold via applying single direction diffusion
gradient sequence.
Methods and Materials: 30 locally gastro-intestinal cancer metastases patients (M/
F=19/11, mean age 57.5 years) were scanned by GE 1.5 T MR system. Transverse
plane DW-MR images were obtained by using single direction diffusion gradients
(diffusion gradients were applied in the S/I direction with b=0 and 800 sec/mm2;
slice thickness/slice gap=6/1 mm; slice number=28, scan time 22 sec) and three
direction diffusion gradients echo planar imaging sequence (diffusion gradients were
applied in the S/I, R/L and A/P direction with b=0 and 800 sec/mm2; slice thickness/
slice gap=6/1 mm; slice number=15, scan time 48 sec) separately. ADCs of lesions
were measured and artifact and distortion scale of lesions were evaluated.
Results: All the 30 patients acquired whole liver DW-MRI images within one breathhold by using single direction DW-MRI. At least two breath-holds were applied
when using three direction DW-MRI and the scan range could not cover the whole
liver. The ADCs of lesions obtained by single direction DW-MRI (mean =1.16×103
mm2/s) were correlated significantly (P=0.000) with ADCs acquired by DW-MRI
with three direction (mean =1.11×10-3 mm2/s). The scale of artifact and distortion
of lesions were significantly different between the two sequence (Farti=31.39,
Parti=0.000; Fdist=35.01, Pdist=0.000). Better DW-MR images were acquired by using
single direction DW-MRI.
Conclusion: By using single direction DW-MRI we can obtain whole liver thin slice
images as well as lesser artifact and distortion images.
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Prevalence and significance of hypoattenuating hepatic lesions deemed
too small to characterise: How are we following up these lesions and what
are the outcomes?
G.M. Jonathan Albuquerque, H. Khosa, P. McCarthy; Galway/IE
Purpose: To retrospectively determine the prevalence and significance of small
hypoattenuating hepatic lesions, in which follow-up imaging had been done, and
how this contributed to the diagnosis.
Methods and Materials: The authors retrospectively reviewed 1192 CT scans and
reports of patients undergoing CT thorax, abdomen and pelvis scans. The initial
and final CT scans were reviewed for hypoattenuating lesions less than 15 mm
that were reported as too small to characterise (TSTC). The primary diagnosis,
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treatment, number and size of lesions and their interval change were also reported.
Any additional investigations, such as ultrasound and MRI and their findings were
documented.
Results: Of 1192 CT scans, 564 (47%) patients were with multiple contrasted
scans. Of 564 patients, 96 (17%) patients had lesions deemed TSTC. 6 (6.3%) of
the 96 patients were excluded due to a short scan interval of 12 weeks. Follow-up
imaging of 90 (15.9%) patients revealed lesions were unchanged in 71 (78.9%),
increased size in 5 (5.6%), decreased in 3 (3.3%), and not seen in 9 (10%). 2
(2.2%) patients with multiple lesions, each had 1 lesion unchanged with the rest
either decreasing in size or not visualised.
The 5 enlarging lesions represented metastatic breast cancer in 3 (3.3%), dilated
hepatic ducts, and a simple cyst in 1 patient each (1.1%).
Conclusion: The prevalence of small hypoattenuating lesions in our study is 15.9%
with 3.3% proving to be metastases. Additional imaging with ultrasound or MRI did
not characterise the lesions in 69.6 and 40%, respectively, of the cases imaged.
C-015
Motionless T2 weighted magnetic resonance liver imaging using functional
residual capacity breath-hold
A. Tabuchi1, T. Katsuda2, R. Gotanda1, T. Gotanda1, M. Mitani1, Y. Takeda1;
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Okayama/JP, 2Hyogo/JP ([email protected])
Purpose: T2 weighted (T2W) liver images are often plagued by poor-image quality
due to respiratory motion artifact. The diaphragm moved during data acquisition
in spite of breath-hold (B-H). To reduce the motion artifact, the functional residual
capacity B-H technique was used and the diaphragmatic movement during B-H
was compared with voluntary expiration B-H.
Methods and Materials: Diaphragmatic movement during B-H were assessed
among three types: voluntary expiration without explanation and training beforehand
(VE-NEx B-H), VE B-H with explanation and training beforehand (VE-Ex B-H) and
functional residual capacity with explanation and training beforehand (FRC B-H)
in 25 healthy volunteers (12 males and 13 female, age 21 - 46, median age 24). In
clinical study, the qualitative analysis of the incidence rate of the respiratory motion
artifact was assessed in 60 patients (31 males and 29 female, age 37 - 88, median
age 65.5) between T2W whole liver images using VE-Ex B-H and FRC B-H.
Results: Diaphragmatic movement of VE-NEx, VE-Ex, and FRC B-Hs were
4.2 p 2.2, 3.4 p 1.6, and 1.6 p 1.2 (mm), respectively, (p 0.001). Diaphragmatic
movement of the FRC B-H was significantly smaller than the other B-H methods
(p 0.05). In clinical study, the incident rate of the motion artifact with FRC B-H was
significantly smaller than that of VE-Ex B-H (p 0.05).
Conclusion: The FRC B-H was a significantly effective method to reduce the
motion artifact during B-H. The FRC B-H should be applied to improve the image
quality of HCC diagnosis.
C-016
Characterisation of diffusion-weighted magnetic resonance imaging of
focal hepatic lesions
A. Pinardo Zabala, L. Gorospe Sarasus, M. Valle de Frutos,
T. Gómez San Roman, A. Palomar Estrada, V.R. Lara Mazenett; Puertollano/ES
([email protected])
Purpose: To analyse diffusion weighted magnetic resonance (DWMRI) in differential diagnosis of focal hepatic lesions, by using two b values, and determine an
apparent diffusion coefficient (ADC) threshold value to differentiate benign from
malignant lesions.
Methods and Materials: DWMRI was performed in 77 hepatic lesions, including
hepatocellular carcinoma (4 cases), hepatic metastases (9 cases), hemangioma
(30 cases), hepatic cyst (32 cases). Apparent diffusion coefficient (ADC) values
were evaluated using four different b values in different sequences. The ratio of
ADC values of lesion/liver in hepatocellular carcinoma and hepatic metastases
was also calculated.
Results: The mean ADC values of hepatic lesions were as follows: hepatocellular
carcinoma (0.91 p 0.22)×10-3 mm2/s, hepatic metastasis (1.14 p 0.12)×10-3 mm2/s,
hemangioma (1.64 p 0.42)×10-3 mm2/s, and hepatic cyst (3.18 p 0.21)×103 mm2/s. The ratio of ADC values in lesion/liver in hepatocellular carcinoma was
0.87 p 0.42, being significantly different from that in hepatic metastasis (1.41 p 0.17,
P 0.05).
Conclusion: Diffusion-weighted MR imaging can help differentiate benign from
malignant hepatic lesions. The use of two b values in one direction could be sufficient for the design of MR sequences in the liver.
Scientific and Educational Exhibits
C-017
Evaluation of hepatic lesions using diffusion-weighted echo-planar
imaging at 3 T MRI
T. Namimoto, K. Awai, T. Nakaura, Y. Yanaga, Y. Yamashita; Kumamoto/JP
Purpose: The purpose of this study was to determine apparent diffusion coefficients
(ADCs) of focal liver lesions on the basis of a diffusion-weighted single-shot echoplanar imaging (DWI) at 3 T magnetic resonance imaging (MRI) and to evaluate
whether ADC measurements can be used to differentiate between malignant and
benign masses in the liver.
Methods and Materials: One hundred forty-nine consecutive patients with focal
liver lesions (75 hepatocellular carcinomas (HCCs), 23 metastases, 15 cholangiocellular carcinomas (CCCs), 17 hemangiomas and 19 cysts) were evaluated in
this retrospective trial. DWI parameters at 3 T MRI were b values of 0 and 800 s/
mm2, TR/TE= 2200/68 ms, FA of 90° in the axial plane with chemical shift selective
fat suppression technique. Quantitative measurement of ADC was performed for
each liver lesion and liver parenchyma. Statistical analysis was applied to check
whether differences in mean ADC values were significant (p 0.05).
Results: The mean ADC values of HCCs, metastases, CCCs, hemangiomas
and cysts, were 1.08 p 0.24, 1.27 p 0.35, 1.43 p 0.42, 2.17 p 0.54, 3.06 p 0.29
× 10-3 mm2/s, respectively. Mean ADC values of normal and cirrhotic liver parenchyma were 1.33 p 0.27, 1.29 p 0.36 ×10-3 mm2/s, respectively. The mean ADCs
of malignant liver lesions were significantly lower than those of hemangiomas and
cysts (p 0.01), whereas no significant difference was seen for that of normal and
cirrhotic liver parenchyma.
Conclusion: Our preliminary results indicate that the ADC value has good potential
for differentiation between malignant and benign masses in the liver at 3 T MRI.
C-018
Progress in diagnosis of hepatic metastases in patients with colorectal
cancer: A prospective study of diffusion-weighted MR imaging combined
with gadolinium-enhanced dynamic study
Y. Kuroki1, K. Nasu2, S. Kuroki3, R. Sekiguchi1, Y. Yoshida1, Y. Yamabe1,
T. Yamamoto1; 1Utsunomiya/JP, 2Tsukuba/JP, 3Tokyo/JP
([email protected])
C-019
The mathematical model of chronic diffuse liver diseases differential
diagnosis based on 31P-MRS data
S.S. Bagnenko, G.E. Trufanov, V.A. Fokin, A.P. Kretsu; St. Petersburg/RU
([email protected])
Purpose: To design the mathematical model of chronic diffuse liver diseases differential diagnosis based on 31P-MRS data.
Methods and Materials: Ninety-four patients with diffuse liver diseases were
examined with 31P-MRS (1.5 T), which was performed in the right hepatic lobe.
Forty-three of them were with chronic viral hepatitis, 31 with cirrhosis and 20 with
steatosis of the liver. Reference data were acquired from 30 healthy volunteers. We
calculated the relative part of each metabolite (phosphomonoesters, inorganic phosphate, phosphodiesters and adenosine triphosphate) in total volume of phosphorus
chemical compounds and on the basis of acquired data designed the mathematic
model of differential diagnosis discussing pathological states.
C-020
Hepatic dysfunction: Evaluation by MRI with Gd-EOB-DTPA
Y. Nakamura1, T. Ohmoto1, E. Nishimaru2, T. Kajima1, K. Itoh2; 1Kure/JP,
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Hiroshima/JP ([email protected])
Purpose: Gd-EOB-DTPA exhibits high hepatic uptake and high T1 relaxivity in the
liver tissue. MRI with Gd-EOB-DTPA had the potential to evaluate hepatic dysfunction in animal studies. Our aim was to determine the potential of Gd-EOB-DTPA
for the evaluation of liver dysfunction clinically.
Methods and Materials: Between March 2008 and July 2008, 65 patients (39
men, 26 women; mean age 68.8 years, range 38 to 86 years) were examined
prospectively with abdominal MR imaging, using a 1.5 T MR imager (Hi-Speed;
General Electric Medical Systems, Milwaukee, WI) and torso phased array coil.
Fat-suppressed T1-weighted image was performed in the axial plane, before and
after (10 min, 20 min) administration of Gd-EOB-DTPA. The signal intensity (SI)
of the liver was measured by using a monitor-defined region of interest. Relative
enhancement (RE) of the liver was calculated with the following equation: RE (%)
= (SIpostcontrast - SIprecontrast)/SIprecontrast × 100. Hepatic dysfunction was classified with
Child-Pugh class.
Results: RE of the liver was on the decline with liver dysfunction. Also, there was
difference in RE increase pattern depending on the degree of liver dysfunction.
Conclusion: MRI with Gd-EOB-DTPA has the potential to evaluate liver dysfunction clinically.
C-021
Hepato-mesenteric index: A new Doppler index in the hepatic perfusion’s
study - comparison with Doppler perfusion index
P.V. Foti, R. Farina, M. Coronella, S. La Scola, R. Minardi, G. Riva, F. Pennisi,
G.C. Ettorre; Catania/IT ([email protected])
Purpose: To evaluate the diagnostic capabilities of a new Doppler index, the
hepato-mesenteric index (HMI), in the study of hepatic metastases from large bowel
tumours and to compare it with Doppler perfusion index (DPI).
Methods and Materials: HMI is calculated from the ratio between the hepatic
artery’s flow and the mesenteric artery’s one. 130 patients affected by colorectal
carcinoma, with or without hepatic metastases, underwent hepatic ultrasonographic
examination. HMI and DPI were obtained and compared. 50 patients without intestinal and hepatic disease represented the control group.
Results: Indexes analysis enabled identification of three groups of patients.
Group A: 41/130 patients (31.5%) with hepatic metastases showing HMI and DPI
higher than 0.50 and 0.30, respectively. Group B 24/130 patients (18.5%) without
hepatic lesions showing HMI and DPI higher than 0.50 and 0.30, respectively.
Group C 65/130 patients (50%) without hepatic metastases showing HMI and DPI
lower than 0.50 and 0.30, respectively. Control group’s patients showed HMI and
DPI lower than 0.50 and 0.30, respectively. These results show a perfect match
between DPI and HMI. HMI is easier to calculate than DPI. DPI evaluation shows
some difficulties owing to portal vein’s elliptic section and its movements with
respiratory excursion.
Conclusion: HMI is easy to perform; owing to its reproducibility it could replace
DPI in the hepatic evaluation of patients with colorectal cancer.
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Abdominal Viscera (Solid Organs)
Purpose: We prospectively examined the detectability of hepatic metastases
on diffusion-weighted images (DWI) in combination with Gadolinium-enhanced
dynamic (Gd-dynamic) study.
Methods and Materials: 24 patients with 60 metastatic nodules in all underwent
DWI and Gd-dynamic study prior to the resection of hepatic metastases of colorectal
cancer. We used a 1.5 Tesla MR scanner (Gyroscan Intera Master 1.5 T, Philips) and
SENSE-body coil. DWI was performed applying b factor 500 and then proceeded
to T2WI, T1WI, and Gd-dynamic study. The nodules that fulfilled all the following 3
conditions were diagnosed as hepatic metastases: nodules that showed high signal
intensity on DWI, nodules that were detected on T2WI or T1WI, and nodules that
showed a different contrast enhancement pattern from cavernous hemangiomas
and cysts on Gd-dynamic study. We analyzed the following 4 details: sensitivity,
positive predictive value (PPV), false positive (FP), and false negative (FN).
Results: 60 nodules, whose median diameter was 17 mm, were confirmed as
metastases pathologically. Of these, 13 nodules were 10 mm or under in diameter.
Overall sensitivity was 95%, PPV was 93%, FP was 4 nodules, and FN was 3
nodules. In cases of 10 mm or under, sensitivity was 85%, PPV was 73%, FN was
2 nodules, and FP was 4 nodules.
Conclusion: A combination of DWI with Gd-dynamic study accurately detected
hepatic metastases and showed its efficacy in preoperative diagnosis.
Results: The variance analysis showed the relative parts of PME, PCr, Y-ATP
in total volume of phosphorus chemical compounds and the PDE/Pi index were
the most informative criteria. On the assumption of equal probability the patient’s
belonging to all studying groups we received four linear classification discriminators: F1 (hepatitis)= -29.53+361.68* Y-ATP+66.23*PME+173.14*PCr+0.79*PDE/
Pi, F2 (cirrhosis)= -38.75+325.32* Y-ATP+146.39*PME+203.89*PCr+0.87*PDE/
Pi, F3 (steatosis)= -27.43+345.4* Y-ATP+31.5*PME+132.34*PCr+1.17*PDE/Pi,
F4 (control group)=-20.6+301* Y-ATP+58.76*PME+120.13*PCr+0.73*PDE/Pi. The
function with the largest value indicated the type of pathological process. Our model
demonstrated the total sensitivity for all kind of pathologies - 91%, differentiating
sensitivity - 77.6%, specificity - 78.3% and diagnostic efficacy - 77.8%.
Conclusion: As a result, we designed the efficient model of chronic diffuse liver
diseases differential diagnosis with satisfactory characteristics of sensitivity and
specificity. This model can assist in making decision when traditional MR-signs
are not obvious.
Scientific and Educational Exhibits
C-022
The role of imaging in the preoperative assessment of potential donors in
living donor-liver transplantation (LDLT)
S.E. Mc Sweeney, M. Staunton, T. Kim, K. Khalili; Toronto, ON/CA
([email protected])
Learning Objectives: 1) To discuss the role of imaging in the preoperative assessment of potential living donor-liver transplantations (LDLT). 2) To review and
illustrate with appropriate examples the role of cross-sectional imaging in donor
assessment.
Background: Liver transplants were originally obtained from cadevaric liver donors
but can now be harvested from living donors. This technique, called living-donor
liver transplantation (LDLT), expands the donor pool providing an effective alternative means of liver transplantation when the supply of organs for transplant from
cadevaric donors is inadequate. This procedure demands careful preoperative
evaluation to minimize morbidity to the healthy donor and recipient of the transplant
and cross sectional imaging is central to achieving this.
Procedure Details: There are relative and absolute contraindications to LDLT that
are primarily based on minimizing potential risk to the donor, but also ensuring
adequate graft survival. Exact preoperative anatomical knowledge required and
surgical technique varies between centers. Multidetector CT and MRI can assess
the liver parenchyma, relative and absolute lobar volumes and hepatic vascular
anatomy. Biliary anatomy can be determined with MRCP or CT cholangiography. In
this educational exhibit, the preoperative imaging evaluation of hepatic parenchymal,
biliary and vascular anatomy is described and illustrated in detail and the various
imaging protocols are reviewed.
Conclusion: Imaging plays a crucial role in living donor liver transplantation assessment and allows accurate evaluation of potential donors. This ensures selection
of only anatomically suitable donors without significant co-existing pathology and
allows detailed preoperative planning.
C-023
Ultrasound quantification of tissue strain properties: A way to overcome
subjectivity?
M. D’Onofrio, R. Malagò, F. Principe, R. Pozzi Mucelli; Verona/IT
([email protected])
Learning Objectives: To show the possibilities of Virtual touch Tissue imaging
(Siemens, Germany) in studying normal and pathological conditions of liver, pancreas, spleen and kidneys.
Background: Acoustic radiation force impulse (ARFI) imaging is a new and promising imaging modality that uses sound beams to evaluate the tissue strain properties.
Virtual touch Tissue imaging gives quantification of the responses.
Imaging Findings: The normal values found in 40 volunteers were: mean value of
1.37 m/s (1.02-2.63) in the liver; mean value of 1.2 m/s (0.90-1.42) in the pancreas;
mean value of 2.4 m/s (1.98-3.00) in the spleen; mean value of 2.2 m/s (0.803.47) in the kidney. In solid tumor, high values were found in hard tumors such
as pancreatic adenocarcinoma with mean value of about 4.5 m/s. Hepatocellular
carcinoma revealed value of about 3 m/s. In homogeneously fluid liquid structure
(gallbladder, simple cysts, serous lesions) no value (X-X-X-X) was obtainable owing to very high tissue motion. This was confirmed by testing ex vivo the probe in
the water with no value (X-X-X-X) obtainable. In inhomogeneous fluid structures
(mucinous lesions), the scanner measured a value from 1.39 to 3.93, owing to
viscous content. This was confirmed by testing ex vivo the probe in a gel-fluid
obtaining a value from 0.65 to 1.5m/s.
Conclusion: Tissue characterization could be possible with this new ultrasound
image method thus allowing differentiation between normal and pathologic tissues
or discrimination between different cystic content on the basis of fluid analysis. The
possibility of quantification should lead to an overcoming of subjectivity.
C-024
Ferucarbotran-enhanced diffusion-weighted MRI for assessment of small
hepatocellular carcinomas (HCCs) in the cirrhotic liver
D. Kim, J. Yu, J. Lim; Seoul/KR
Purpose: To retrospectively compare diffusion-weighted images (DWI) before
and after SPIO injection during MRI for assessment of small HCCs in the cirrhotic
liver.
Methods and Materials: Small HCCs (52 lesions, 29 patients) were detected at
1.5 T unit. Confidence score of each lesion on pre-contrast DWI (pre-DWI) and
SPIO-enhanced DWI (SPIO-DWI) were rated by two independent radiologists, using 5-grade scales. Lesions depicted on the SPIO enhanced T2* weighted images
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(SPIO-T2) were also scored by same method. All HCCs were divided to two groups
(Group 1, 1 cm; Group 2, 1-2 cm in maximum dimension). Cohen kappa test and
Wilcoxon signed rank test were used for statistical analysis.
Results: Comparing to pre-DWIs, SPIO-DWIs revealed no significantly different
confidence scores (p 0.05) in all small HCCs. Comparing to SPIO-T2, both of
pre-DWI and SPIO-DWI showed no significantly different confidence scores, regardless of b values (p 0.05), except SPIO-DWI with b value of 800 s/mm2 (p 0.05).
For group 1 lesions, SPIO-DWIs (mean = 4.28, 4.22, 4.11 for b = 50, 400, 800 s/
mm2, respectively) revealed higher confidence scores than pre-DWI (mean = 3.94,
3.89, 3.61 for b = 50, 400, 800 s/mm2, respectively) (p = 0.06, 0.08 and 0.02). Also
comparing to SPIO-T2 (mean = 3.83), SPIO-DWI with b value of 50 and 400 s/mm2
showed higher confidence scores (p = 0.05 and 0.09, respectively). Interobserver
agreement was substantial (k= 0.54-0.69).
Conclusion: SPIO-DWI is an easily applicable method and is superior to DWI for
detection of HCCs smaller than 1 cm.
C-025
Double contrast (DC) enhanced magnetic resonance imaging (MRI) of the
liver: Where do we stand today?
A.T.B. Almeida, K. Ganesan, Y. Lee, C. Sirlin; San Diego, CA/US
([email protected])
Learning Objectives: After reviewing this exhibit, the participants will know: 1.
What is DC MRI? 2. What are the indications? 3. How is it performed? 4. How is it
interpreted? 5. What are the advantages, disadvantages, and pitfalls?
Background: DC MRI consists of the sequential use of superparamagnetic iron
oxide (SPIO) and gadolinium (Gad) chelates. DC MRI techniques are based on the
following basic concepts: 1. SPIO and Gad have a synergistic effect on increasing
lesion-to-background contrast. The synergistic effect of SPIO and Gad is mainly
employed to evaluate hepatic fibrosis: SPIO selectively accumulates within Kupffer
cells, thereby reducing normal hepatic signal intensity while Gad accumulates
and enhances fibrotic hepatic tissue. 2. SPIO and Gad provide complementary
biological information: SPIO evaluates phagocytic function, while Gad evaluates
vascularity. In combination, SPIO and Gad increase sensitivity and specificity for
the diagnosis of focal hepatic lesions.
Imaging Findings: Combined contrast images exploit: 1. Synergist effects: on a
heavy T1W and T2*W sequence fibrosis appear as hyper-intense reticulations in a
background of dark liver. 2. Complementary biological information: SPIO-enhanced
T2*W images can be used to characterize lesions with atypical or indeterminate
gadolinium enhanced features, while Gad-enhanced dynamic acquisitions can be
used to detect and characterize lesions with preserved phagocytic function.
Conclusion: DC MRI exploits synergistic and complementary biological effects of
SPIO and Gad, and provides accurate identification, characterization and staging
of liver diseases.
C-026
Diffusion-weighted images of the liver at 3 T MRI: Comparison of apparent
diffusion coefficient before and after contrast enhancement with Gd-EOB-DTPA
T. Namimoto, K. Awai, T. Nakaura, Y. Yanaga, Y. Yamashita; Kumamoto/JP
([email protected])
Purpose: To compare the apparent diffusion coefficient (ADC) of the liver lesions
on diffusion-weighted images (DWI) before and after the administration of Gd-EOBDTPA for shortening the complete examination time.
Methods and Materials: Fifty-eight consecutive patients with focal liver lesions (25
hepatocellular carcinomas (HCCs), 11 metastases, 5 cholangiocellular carcinomas
(CCCs), 8 hemangiomas and 9 cysts) and liver parenchyma were evaluated in this
prospective trial. DWI with b values of 0 and 800 s/mm2 was performed before and
after the administration of Gd-EOB-DTPA at 3 T MRI. The ADC maps were derived
automatically pixel-by-pixel basis from the DWI. Quantitative measurement of ADC
was performed for liver lesions at each pre- and post- contrast. The paired Student’s
t-test was used to evaluate the difference between these two methods.
Results: The mean ADC values of liver parenchyma, HCCs, metastases, CCCs,
hemangiomas and cysts, were 1.16 p 0.19, 1.11 p 0.32, 1.27 p 0.42, 1.35 p 0.46,
2.25 p 0.50, 2.92 p 0.33 at pre-contrast, 1.23 p 0.21, 1.13 p 0.28, 1.27 p 038,
1.34 p 0.49, 2.18 p 0.537, 2.89 p 0.38 × 10-3 mm2/s at post-contrast, respectively.
The mean ADC of the liver parenchyma at post-contrast was significantly higher
than that of pre-contrast (p 0.01). However, no significant difference was seen for
the mean ADCs of all liver lesions between pre- and post-contrast.
Conclusion: Our preliminary results indicate that the ADC value of the liver lesions
at post-contrast of Gd-EOB-DTPA was comparable with that of pre-contrast.
Scientific and Educational Exhibits
C-027
T2-weighted images of the liver on 3 T MRI: Comparison of contrast before
and after the administration of Gd-EOB-DTPA
T. Namimoto, K. Awai, T. Nakaura, Y. Yanaga, Y. Yamashita; Kumamoto/JP
([email protected])
Purpose: To compare the T2-weighted image of the liver lesions before and after the
administration of Gd-EOB-DTPA for shortening the complete examination time.
Methods and Materials: Fifty-eight consecutive patients with focal liver lesions
(25 hepatocellular carcinomas (HCCs), 11 metastases, 5 cholangiocellular carcinomas (CCCs), 8 hemangiomas and 9 cysts) were evaluated in this prospective
trial. T2-weighted imaging was performed before and after the administration of
Gd-EOB-DTPA at 3 T MRI. The imaging parameters were TR/ TE=3354/75 ms, FA
90 degrees, ETL 25, SENSE factor of 2 with chemical shift selective fat suppression. The signal intensity (SI) of tumor on T2-weighted images was quantified as
the lesion-liver-contrast-ratio (CR) between lesion and liver by using the following
formula: (SIlesion - SIliver)/SIliver. Quantitative measurement of CR was performed for
liver lesions at each pre- and post- contrast. The paired Student’s t-test was used
to evaluate the difference between these two methods.
Results: The mean CRs of HCCs, metastases, CCCs, hemangiomas and cysts
were 1.67 p0.47, 2.28 p0.79, 2.58 p1.86, 2.45 p0.75, 3.27 p0.79 at pre-contrast,
1.74 p0.53, 2.37 p0.71, 2.80 p1.91, 2.81 p0.87, 2.99 p0.97 ×10-3 mm2/s at postcontrast, respectively. The CR of hemangiomas at post-contrast was significantly
higher than that of pre-contrast (p 0.01). However, no significant difference was
seen for the CRs of all other liver lesions between pre- and post-contrast.
Conclusion: Our preliminary results indicate that the T2-weighted imaging of the
liver lesions at post-contrast of Gd-EOB-DTPA was comparable with that of precontrast, except for hemangiomas.
C-028
Focal nodular hyperplasia (FNH) or hepatic adenoma (HA)? How MRI can
help us using liver-specific contrast agents
P. Paolantonio, R. Ferrari, M. Rengo, F. Vecchietti, P. Lucchesi, D. Bellini, A. Laghi;
Latina/IT ([email protected])
C-029
Value of mutlti-slice spiral CT in the diagnosis of manners of hepatic vein
reconstruction in adult living donor liver transplantation
W. Shen, C. Xie, J. Qi; Tianjin/CN ([email protected])
Purpose: To discuss the value of MSCT CTA in the diagnosis of hepatic vein
reconstructive manners in adult living donor liver transplantation (LDLT).
Methods and Materials: From May 2007 to August 2008, 84 recipients who had
underwent the LDLT with right lobe grafts did enhanced CT scan using MSCT after
operation, CTA of the hepatic veins were reconstructed with MPR, MIP and VR
techniques. All hepatic vein reconstructive manners were assessed. The results
of CTA were compared with that of surgical manners.
C-030
Dynamic contrast-enhanced ultrasonography with quantification for the
early evaluation of response to bevacizumab in advanced hepatocellular
carcinoma: A phase II study
L. Chami, M. Chebil, S. Koscielny, B. Benatsou, A. Roche, N. Lassau; Villejuif/FR
([email protected])
Purpose: To evaluate the efficacy of bevacizumab in patients with advanced hepatocellular carcinoma (HCC) using standard endpoints (i.e. objective response,
progression-free survival [PFS]), and to investigate whether there is any correlation
between these endpoints and tumor perfusion parameters measured using dynamic
contrast-enhanced Doppler ultrasonography (DCE-US).
Methods and Materials: Forty-two patients were enrolled and received intravenous
bevacizumab every 2 weeks. CT scans were performed before treatment and every
2 months thereafter. DCE-US was performed before treatment, on days 3, 7 and
15, at 2 months and every 2 months thereafter. Tumor perfusion parameters were
estimated quantitatively from contrast uptake curves constructed from raw linear
data. They were compared to CT-scans at 2 months and PFS. The ethics committee
approved the study and all patients gave written informed consent.
Results: A total of 262 DCE-US examinations were performed including 242 raw
linear data. Twenty-two patients were classified as good responders (i.e. partial
response/stable disease). Median PFS was 3 months. At day 3, total area under the
curve (AUC), AUC during wash-in (AUWI), and AUC during wash-out (AUWO) significantly correlated with response (p=0.03, p=0.03 and p=0.02, respectively), and AUC
and AUWO correlated significantly with PFS (p=0.02 and p=0.01, respectively).
Conclusion: DCE-US can be used to detect and quantify dynamic changes in
tumor vascularity as early as 3 days after initiation of bevacizumab therapy in
patients with HCC. These early changes in tumor perfusion are predictive of tumor
response and PFS and may be potential surrogate measures of efficacy for antiangiogenic therapy.
C-031
Neoplastic and non-neoplastic disorders of the periportal space: CT
imaging findings
S. Yeom, H. Kim, S. Lee, S. Park, P. Kim, M.-G. Lee; Seoul/KR
([email protected])
Learning Objectives: 1. To illustrate the spectrum of neoplastic and nonneoplastic
conditions that involve the periportal space and correlate them with histopathologic
findings. 2. To assess the differential diagnosis of periportal lesions according to
their origins and imaging features.
Background: Periportal region is an anatomic and potential space surrounding
portal vein, hepatic artery, bile duct, nerve and lymphatics. A variety of pathologic
conditions can occur in the periportal space via hematogenous, biliary, lymphatic,
and peritoneal routes and can be demonstrated with CT imaging. In this exhibit, we
describe the imaging features of a heterogeneous group of neoplastic and nonneoplastic periportal lesions and correlate them with histopathologic findings. We also
assess the differential diagnosis according to their origins and imaging features.
Imaging Findings: Periportal lesions may be classified on the basis of their
origins and imaging features as neoplastic iso-attenuating soft-tissue masses
(metastasis, direct tumor invasion, lymphoma, and inflammatory pseudotumor),
neoplastic low-attenuating soft-tissue masses (Langerhans’ cell histiocytosis),
nonneoplastic biliary and vascular lesions (congenital or acquired), and nonneoplastic low-attenuating lesions (periportal edema, hemorrhage, and inflammation).
Although the overlap of imaging findings among these diverse periportal lesions
exists, knowledge of the imaging features of periportal lesions may be helpful in
reducing the differential diagnosis.
Conclusion: Familiarity with the wide spectrum of pathologic conditions involving
the periportal space may facilitate making the differential diagnosis.
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Abdominal Viscera (Solid Organs)
Learning Objectives: To illustrate pharmacodynamic and pharmacokinetic properties of Gd-BOPTA, Gd-EOB-DTPA and ferucarbutran. To show pathological features
of FNH and HA with imaging correlation. To show typical and atypical features
of FNH and hepatic adenoma at MRI using different classes of hepatospecific
contrast agents.
Background: Differential diagnosis between FNH and HA is crucial for patient
management. An accurate and non-invasive differential diagnosis using MRI is
possible based on both dynamic imaging and functional information of liver-specific
contrast-agents.
Procedure Details: The identification and characterization of FNH and HA requires
an accurate dynamic study of the liver for the assessment of lesion vascularity.
Unfortunately, a definite differential diagnosis on the basis of morphology and lesion
vascularity is not always possible. Functional information offered by liver specific
contrast agent may help us in this diagnostic challenge.
Conclusion: The use of liver specific contrast agents offers functional information
on lesion cellularity that is extremely useful in differentiating FNH by HA. Information
on lesion bile ducts offered by hepatobiliary agents represents an accurate marker
of FNH nodule with respect to HA.
Results: CT images can display hepatic vein reconstructive manners. Bridge vein
transplant was used to reconstruct the tributaries of the middle hepatic vein and
inferior right hepatic vein (IRHV). Reconstructive types and numbers were listed:
RHV+MHV (n=22), RHV+MHV+ IRHV (n=5), RHV (n=22), RHV + IRHV (n=8), RHV
+ V5 (n= 3), RHV + V8 (n= 1), RHV + V5 + V8 (n= 23), among them 4 developed
thin, 2 became narrow, 4 cases (among RHV + V5 + V8) only showed right hepatic
vein and the tributaries (V8), the others displayed hepatic vein reconstructive manners and were correlated with that of surgical manners.
Conclusion: MSCT can clearly detect hepatic vein reconstructive manners, appear
bridge vein transplant used to reconstruct the tributaries of the middle hepatic vein
and inferior right hepatic vein, detect the track and distribution of vessels.
Scientific and Educational Exhibits
C-033
Liver tumour segmentation using contrast enhanced multidetector CT
data: Performance benchmarking of three semi-automatic methods
J. Zhou, Y. Qi, Q. Tian, S.K. Venkatesh, D.W.K. Wong, W. Xiong, T. Han, J. Liu,
W.-K. Leow, S.-C. Wang; Singapore/SG ([email protected])
Purpose: To quantitatively benchmark the performance of three semi-automatic
algorithms for 3D liver tumor segmentation.
Methods and Materials: We evaluated three segmentation methods in this study: (M1)
2D region growing with knowledge-based constraints, (M2) 2D voxel classification and
propagational learning, and (M3) Bayesian rule-based 3D region growing. The segmentation methods were tested on contrast enhanced multi-detector CT images of 30
liver tumors comprising of HCC and metastases. All tumors were manually segmented
by an experienced radiologist and confirmed by another radiologist, as the reference
for evaluation purposes. Data from 10 tumors were used for algorithm training and the
remaining 20 were used for testing. By calculating a set of complicated measures (volumetric overlap error, relative absolute volume difference, average symmetric absolute
surface distance, symmetric RMS surface distance and maximum symmetric absolute
surface distance) from reference and results, a score (ranged from 0 for total missing
to 100 for perfect matching) was assigned to each testing case. The total score of a
method was obtained by averaging the scores of all testing cases.
Results: The overall scores for the three methods were 64 for M1, 69 for M2 and
57 for M3. Major errors appear in tumors with poorly defined outline or isodense
to liver and in those with irregular shape.
Conclusion: Compared to expert’s recognition and interpretation, semiautomatic
liver tumor segmentation methods did not perform well in difficult cases; however,
the overall performance is promising. Further development and validation is needed
before it can be potentially used in clinical practice.
C-034
Gadoxate disodium-enhanced MRI of hepatic hemangiomas
S.-E. Baek, M.-J. Kim, J.-Y. Choi, J. Lim, Y.-E. Chung; Seoul/KR
([email protected])
Purpose: To determine whether the dynamic enhancement pattern of hemangiomas
on gadoxate disodium enhanced magnetic resonance imaging (MRI) are different
from conventional extracellular agents enhanced MRI.
Methods and Materials: After reviewing gadoxate enhanced MRI image from
2007.12 to 2008.03, 16 from 21 proven hepatic hemangiomas were included.
Multiphasic dynamic gadoxate enhanced T1W images were obtained in hepatic
arterial, portal, venous, equilibrium (5-min), 10-min and 20-min delayed phases.
The enhancement pattern of lesion was classified to homogeneous-high, iso
or hypo signal intensity (SI) to surrounding liver, rim enhancement, peripheral
nodular enhancement, and fill-in pattern. We also analyzed SI change of lesion
ROI in precontrast, 5 min, 10 min and 20 min delayed phases. Dynamic images
using a gadolinium-based extracellular agent was also obtained in two patients
one day ago.
Results: 14 lesions showed peripheral nodular enhancement in arterial phase,
and delayed fill-in, centripetal enhancement pattern at portal, venous, equilibrium
phases. 1 lesion showed rim enhancement in portal phase and 1 lesion was
homogenous-highly enhanced from arterial phase. 5 hemangiomas presented iso
SI in equilibrium phase. In ROI analysis, 15 hemangiomas depicted increasing SI
value at 5-min delayed phase and decreasing SI values at 10-min delayed phase.
Only 1 hemangioma showed slightly increased SI value at 10-min delayed phase
but, decreased SI value in 20-min delayed phase.
Conclusion: Early dynamic enhancement pattern of hemangiomas with gadoxate
enhanced MRI is similar to that with extracellular agent enhanced MRI, but central
pooling on the equilibrium phase images may be obscured by strong enhancement
of the surrounding liver.
C-036
Contrast-enhanced ultrasound versus gadolinium-enhanced magnetic
resonance for the evaluation of the response of hepatocellular carcinoma
to radiofrequency therapy: A concordance study
A. Sanchez-Montanez, D. Gil, J. Puig, J. Martin, A. Malet, A. Darnell; Sabadell/ES
([email protected])
Purpose: To compare contrast-enhanced ultrasound (CEUS) and gadoliniumenhanced magnetic resonance imaging (Gd-MRI) for assessing the response to
radiofrequency (RF) treatment of hepatocellular carcinoma (HCC) and high-grade
dysplastic nodules (HGDN).
Methods and Materials: We retrospectively studied 89 percutaneous therapeutic
procedures with RF in 50 patients. We treated 86 HCCs and 3 HGDNs diagnosed
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by imaging or biopsy. CEUS and Gd-MRI were performed 4-5 weeks after treatment. Signs of tumor persistence were: enhanced foci in the arterial phase and the
wash-out in the late phases. Neither CEUS nor Gd-MRI was considered the “gold
standard”. Imaging findings were classified into three categories: tumor persistence,
complete ablation, and undetermined. We distributed the results in concordance
tables, calculating the kappa statistic to eliminate random effects.
Results: From the total of 89 lesions, CEUS and Gd-MRI coincided in the diagnosis of complete ablation in 66 cases, and of tumor persistence in 4. In 9 cases,
CEUS diagnosed complete ablation and Gd-MRI tumor persistence. In 2 cases,
CEUS diagnosed tumor persistence and Gd-MRI complete ablation. CEUS was
inconclusive in 3 cases and Gd-MRI in 5. The techniques agreed in 86.4% of cases
and the kappa statistic was 0.36.
Conclusion: Agreement between the two techniques is only fair. We think GdMRI is better for assessing the response to RF treatment in HCC and HGDN
because it enables evaluation of the whole liver and all hepatic nodules with a
single contrast dose; CEUS has a secondary role when Gd-MRI is unable to reach
a definite diagnosis.
C-037
Multi-step changes of drainage vessels during hepatocarcinogenesis:
Imaging-pathological correlation
A. Kitao, Y. Zen, O. Matsui, T. Gabata, Y. Nakanuma; Kanazawa/JP
([email protected])
Purpose: To clarify the changes occurring in drainage vessels of dysplastic nodule
(DN) and hepatocellular carcinoma (HCC) during hepatocarcinogenesis.
Methods and Materials: This study focused on 46 surgically resected hepatocellular nodules. According to the findings of CT during arterial portography (CTAP)
and CT during hepatic arteriography (CTHA), we classified each nodule into three
types: type A (n=18), having equivalent or decreased portal perfusion compared
with background liver (CTAP), decreased arterial perfusion, and no corona enhancement (peri-nodular drainage of contrast material) (CTHA); type B (n=13), having
no portal perfusion, increased arterial perfusion, and thin corona enhancement (b
2 mm); type C (n=15), having no portal perfusion, increased arterial perfusion, and
thick corona enhancement ( 2 mm). We compared the histopathological features
and microangioarchitecture among these three types.
Results: Type A nodules histologically consisted of DN and well-differentiated
HCC; in contrast, type B/C nodules were moderately-differentiated HCC. Replacing growth was commonly observed in type A, whereas compressing growth was
more frequent in type B/C. Fibrous capsule was observed in 60% of type C nodules. Serial pathological sections demonstrated continuity between intra-nodular
capillarized sinusoids and hepatic veins in type A, and intra-nodular capillarized
sinusoids to surrounding hepatic sinusoids in type B. In type C, intra-nodular capillarized sinusoids were connected to extra-nodular portal veins directly, or via portal
venules within a fibrous capsule. Intra-nodular hepatic veins were significantly
decreased in type B/C.
Conclusion: Drainage vessels of DN and HCC change from hepatic veins to hepatic
sinusoids, and then to portal veins during multi-step hepatocarcinogenesis.
C-038
Ultrasound non-invasive methods for assessing liver cirrhosis in chronic
hepatitis C patients
H. Stefanescu, R.I. Badea, M. Lupsor, M. Grigorescu, Z. Sparchez, A. Serban,
H. Branda, A. Maniu; Cluj-Napoca/RO ([email protected])
Purpose: Liver lobes diameters, platelets to spleen size index (PSI) and liver
stiffness measurement (LSM) were validated as non-invasive liver cirrhosis (LC)
predictors in chronic hepatitis C (CHC) patients. The aim of this study was to
compare their diagnostic/prognostic performances.
Methods and Materials: 273 consecutive CHC patients - mean age 47.62 years,
63.4% females - were prospectively included. All of them underwent percutaneous
LB (METAVIR scoring system), LSM and ultrasound (US) examination. Left, caudate
and right lobe diameter, and spleen area were US measured and included into a
formula: liver size index (LSI)=[LL+CL]/RL, respectively, PSI=platelets count/spleen
area. The performance of LSI, PSI and LSM in diagnosing LC was assessed and
compared using sensitivity (Se), specificity (Sp) and AUROC using SPSS 15.0.
Results: The fibrosis stage distribution was: F1 -95 (34.8%), F2 -106 (38.8%), F3-35
(12.8%), F4 - 37 (13.6%). When LSI r0.96, LC patients were detected with Sn 47.2%,
Sp 91.9% and AUROC 0.705. When PSI b2.66, LC patients were detected with Sn
71.4%, Sp 86.3% and AUROC 0.816. When LSMr 13 Kpa, LC patients were detected
with Sn 83.3%, Sp 91.9% and AUROC 0.943. Comparing AUROCs, FibroScan proved
to be more accurate in diagnosing LC than LSI (p 0.001) and PSI (p=0.002), while
between LSI and PSI there was no significant difference (p=0.188).
Scientific and Educational Exhibits
Conclusion: LC can be accurately diagnosed using ultrasound derived non-invasive
methods in CHC patients. Among them, LSM is the best in identifying LC, while
LSI and PSI can be used in absence of FibroScan.
C-039
The diagnosis performance of ultrasonic transient elastography for
noninvasive assessment of liver fibrosis in 537 chronic hepatitis C patients
M. Lupsor, R.I. Badea, H. Stefanescu, Z. Sparchez, H. Branda, M. Grigorescu,
A. Serban, A. Maniu; Cluj-Napoca/RO ([email protected])
Purpose: The golden standard for fibrosis assessment in chronic hepatitis C (CHC) is
liver biopsy (LB), an invasive procedure with several limitations. We aim to assess the
performance of liver stiffness (LS) measurement through ultrasonic transient elastography (UTE) in quantifying liver fibrosis in a cohort of consecutive CHC patients.
Methods and Materials: 537 CHC patients were referred to LS measurement by UTE
(FibroScan®, EchoSens, Paris, France) 1 day before biopsy (which was interpreted
according to the METAVIR scoring system). Statistical analysis was performed using SPSS 15.0 for Windows. The diagnostic performance of LS was assessed using
sensitivity (Se), specificity (Sp), positive predictive value (PPV), negative predictive
value (NPV) and receiver operating characteristic curves (AUROC).
Results: LS values ranged from 2.90 to 75 kPa. Although there were a small correlation with steatosis (r=0.19, p 0.0005) and a medium one with necroinflmatory
activity (r=0.38, p 0.0005), LS values were significantly and strongly correlated
with fibrosis (r=0.73, p 0.0005).The diagnostic performances of LS in quantifying
each fibrosis stage was: for fibrosis stage F1 prediction AUROC= 0.890 (cutoff value
4.9 KPa, Se 83.77%, Sp 84.62%, PPV 99.07, NPV 20.96%); for F2 AUROC=0.829
(cutoff 75 KPa, Se 72.19%, Sp 80.90%, PPV 85.95%, NPV 64.24%); for F3 AUROC=0.915 (cutoff 9.1 KPa, Se 84.27%, Sp 87.98%, PPV 78.08%, NPV 91.66%)
and for cirrhosis (F4) AUROC=0961 (cutoff 13.2 KPa, Se 90%, Sp 93.40%, PPV
78.37%, NPV 97.23%)
Conclusion: Ultrasonic transient elastography is a promising noninvasive method
for detection of different fibrosis stages in CHC patients.
C-040
Gd-EOB-DTPA (Primovist®) MRI in evaluating residual liver tumor after
radiofrequency ablation (RFA)
S.V. Setola, A. Petrillo, O. Catalano, E. de Lutio di Castelguidone, M. Petrillo,
M. Mattace Raso, A. Siani; Naples/IT ([email protected])
C-042
Preoperative detection of colorectal liver metastases in fatty liver: MDCT
or MRI?
V. Kulemann, W. Schima, D. Tamandl, K. Kaczirek, T. Gruenberger, M. Weber,
A. Ba-Ssalamah; Vienna/AT
Purpose: To compare the sensitivity of MDCT and MRI in preoperative detection
of colorectal liver metastases after neoadjuvant chemotherapy resulting in diffuse
fatty infiltration of the liver.
Methods and Materials: Twenty preoperative tri-phasic MDCT (4-64-row, Siemens). and dynamic contrast-enhanced MRI (1.5 T or 3.0 T, Siemens) examinations of patients with colorectal cancer and liver metastases in diffuse steatosis
were retrospectively evaluated. All patients underwent surgical resection of liver
metastases (time interval 1- 60 days). The grade of fatty infiltration of the liver was
histopathologically proven and ranged from 25-75%.
Results: Overall, 51 metastases were found by histopathologic results of the
resected liver segments/lobes. The size of the metastases ranged from 0.4-13 cm;
with 18 (35%) being up to 1 cm in diameter. In overall rating, MDCT detected 33/51
lesions (65%) and MRI 45/51 (88%). For lesions up to 1 cm, MDCT detected
only 2/18 (11%) and MRI 12/18 (66%). One false positive lesion was detected by
MDCT. Statistical analysis showed that MRI is markedly superior to MDCT with a
statistical significant difference (p .001), particularly in detection of small lesions
(b1 cm; p .004). There was no significant difference between the two modalities
in detection of lesions 1 cm.
Conclusion: In the detection of colorectal liver metastases after neoadjuvant
chemotherapy and consecutive diffuse fatty infiltration of the liver, MRI is superior
to MDCT, especially for detection of small lesions.
Abdominal Viscera (Solid Organs)
Purpose: The aim of the study is evaluate the diagnostic efficacy of magnetic
resonance imaging (MRI) using the new liver-specific contrast agent gadoxetic-acid
(Gd-EOB-DTPA, Primovist®) after radiofrequency ablation (RFA) in the diagnosis
of residual liver tumor (hepatocellular carcinoma, HCC).
Methods and Materials: Twenty patients with known HCC (histologically proven)
underwent RFA after two diagnostic methodics: A contrast-enhanced triphasic
MDCT (Philips Brillance 16s, performed with pre-contrast, arterial, venous, interstitial and 5-min delayed phase) and a Gd-EOB-DTPA MRI (Siemens Symphony 1.5 T,
performed using dynamic phase and another acquisition, 20’ min delayed, during
the hepatocytic phase). Gd-EOB-DTPA MRI and MDCT were evaluated separately
by 2 blinded radiologists. All patients were followed up with both methodics at the
1st month and every 3 months during one year.
Results: MDTC detected 22 HCC lesions and after performing twenty-one RFA
treatments, 7 residual tumors and 3 new HCC foci were demonstrated. Dynamic-MRI
before RFA treatments detected 28 HCC and after RFA 10 residual tumors; delayed
MRI acquisition 5 new HCC foci; thus Gd-EOB-DTPA (Primovist®) MRI showed 3
residual tumor and 2 new HCC more than MDCT. In a patient, delayed phase (hepatocytic), acquired 20’ min after Gd-EOB-DTPA administration, showed a growing
lesion in its trasforming into an undifferentiated HCC, histologically proven.
Conclusion: The administration of Gd-EOB-DTPA (Primovist®), using both phases,
early (arterial) and delayed (hepatocytic) made we were able to identify at the same
time more residual HCC post-RFA and new undifferentiated HCC than MDCT.
Methods and Materials: We present the results of a pilot prospective study including 29 patients who had a recent liver biopsy (less than 3 months) and an MRI
(Avanto 1.5 T, Siemens). Each examination included DCE 3D VIBE acquisitions.
A late sequence was performed 1 hour after injection. DWI sequences were performed in breathold for different b values. ADC was measured on maps generated
by the Siemens console and with the Image J software based on the native DWI
sequences. Relative perfusion parameters were calculated from a dual-input onecompartmental model as proposed by the Van Beers group.
Results: Patients were classified according to Ishak. We found a significant difference (p 0.05) for the relative arterial perfusion between the different low grades
and for the other constants between patients with or without cirrhosis. Using b
values of 150 and 400 s/mm2, ADC measured with Image J in large ROIs was
more discriminant than with the other methods. We found that b values of 150 s/
mm2 are more significant for low grades discrimination and that b values of 400 s/
m2 are better for discrimination of cirrhosis from lower grades.
Conclusion: It seems possible to assess different grades of liver fibrosis using
DWI and DCE MRI (relative arterial perfusion and b=150 s/mm2 for low grades;
others perfusion parameters and b=400 s/mm2 to differentiate patients with cirrhosis or not).
C-041
Multiparametric MRI [diffusion-weighted imaging (DWI) and dynamic
contrast enhanced-MRI (DCE)] in liver fibrosis quantification in patients
with chronic hepatitis C
D. Olivié1, P.-a. Eliat1, P. Audet2, L. Lepanto2; 1Rennes/FR, 2Montreal, QC/CA
([email protected])
Purpose: To quantify the liver fibrosis in HCV+ patients by a multiparametric approach including diffusion weighted imaging and dynamic contrast enhanced MRI
with BOPTA-Gd.
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Abdominal Viscera (Solid Organs)
Pancreas
C-043
Accessory pancreatic duct and minor duodenal papilla: Visibility,
examination technique and imaging findings at secretin-enhanced
magnetic resonance cholangio-pancreatography
G. Restaino, M. Occhionero, M. Missere, E. Cucci, M. Ciuffreda, G. Sallustio;
Campobasso/IT ([email protected])
Learning Objectives: Many variants exist of accessory pancreatic duct (APD)
and minor duodenal papilla (MIP). Proper S-MRCP examination provides good
conspicuity of these structures. Morphological and functional evaluation of APD
and MIP adds important information regarding patients evaluated with S-MRCP
for pancreatic disease.
Background: APD, due to harder visibility and presumed lower clinical significance
S
than main pancreatic duct, is usually disregarded by
Oradiologists reporting MRCP.
Nevertheless, beside its role in pancreas divisum
EP(PD), its patency lowers the risk
to and after ERCP. MIP is difficult
of developing acute pancreatitis either spontaneous
d like several type of endocrine tumors,
to locate radiologically, but may host disease,
e
t
it
and its function is crucial in PD.
bm S-MRCP performed at our institution from
Procedure Details: We reviewedu300
S with regard to: visibility, type (long, intermediate,
2004 to 2008 and focused on APD
al end (stick, branch, saccular, spindle, cudgel),
short, ansa), morphology ofridistal
e
caliber and patency; on MIP
at with regard to visibility, location, size and morphology.
We also assessed the M
APD and MIP conspicuity in various S-MRCP sequences:
T2w-SSFSE, b-SSFP,
No 2D-MRCP w/o secretin, 3D-MRCP (with MIP, MPR) and
3D-LAVA (with minIP, MPR).
Conclusion: Morphological and functional evaluation of APD and MIP adds important information to those provided by S-MRCP. Newer MR sequences allow good
conspicuity of these structures. Knowledge of normal and variant morphology of
APD and MIP is crucial to correct image interpretation.
C-044
Malignant intraductal papillary mucinous neoplasm of the pancreas: A
comparison of the likelihood of invasiveness between 18 F-FDG PET/CT
and contrast enhanced MDCT findings
K. Takanami, T. Kaneta, M. Tsuda, S. Takahashi; Sendai/JP
([email protected])
Purpose: To evaluate the capability of 18 F-FDG PET/CT in determining the
likelihood of invasiveness of malignant intraductal papillary mucinous neoplasm
(IPMN) of the pancreas.
Methods and Materials: Sixteen patients with malignant IPMN (in situ carcinoma,
7; invasive carcinoma, 9) proved by a pathologic examination of surgically resected
specimens underwent surgery after both PET/CT and CE-CT were performed.
A nuclear medicine physician retrospectively evaluated the PET/CT images for
SUVmax of the lesions and a radiologist evaluated the CE-CT images for characteristics of the lesions. The results were compared between the in situ and invasive
carcinomas using Student’s t-test. Invasiveness was suspected when SUVmax r
2.5 was observed with PET/CT. Meanwhile, invasiveness was suspected when a
solid mass, or dilated main pancreatic duct (MPD r 10 mm diameter) was observed
with CE-CT.
Results: The SUVmax, the diameters of cystic tumor, and the diameters of MPD
of the in situ and invasive carcinomas were 2.18 p 0.66 vs. 5.68 p 3.27 (p .05),
31.1 p 8.63 vs. 34.4 p 8.08, and 4.88 p 2.30 vs. 8.67 p 3.84 (p .05), respectively.
Solid masses were observed in 0/7 and 5/9 patients with in situ and invasive
carcinomas, respectively. The sensitivity, specificity and accuracy for detecting
invasiveness were 1, 0.85 and 0.83 with PET/CT and 0.88, 1.00 and 0.75 with
CE-CT, respectively.
Conclusion: PET/CT provides useful information regarding the likelihood of invasiveness for malignant IPMN, which is almost equivalent to those provided by CE-CT.
C-045
Pancreatic-duodenal junction: Review of pathology by means of CT and MR
D. Hernandez, J. Pernas, C. Gonzalez Junyent, S. Gonzalez, J. Monill,
I. Corcuera, C. Perez-Martinez; Barcelona/ES ([email protected])
Learning Objectives: To review by means of CT and MR, the different pathologic
conditions tumoral, inflammatory or congenital origin in this specific anatomic area
that involve the pancreatic head, duodenum, duodenal ampulla, distal pancreatobiliary tract junction and retroperitoneum.
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Background: Pancreato-duodenal junction is a very small anatomical area
where pathologic processes converge that involve pancreatic head, duodenum,
distal pancreatobiliary tract, duodenal ampulla and retroperitoneum. Differential
diagnosis includes a spectrum of entities that ranges from anatomical variants
to malignancies.
Imaging Findings: CT and MR help us to identify specific radiologic signs that allow
to divide the pancreato-duodenal junction abnormalities into three cathegories: 1.
Normal variants and congenital anomalies (pancreas divisum, santorinicele, annular
pancreas, duodenal duplication cyst, choledocal cyst). 2. Acquired non tumoral:
traumatic, iatrogenic, inflammatory (duodenal hematoma, duodenal iatrogenic
perforation, groove pancreatiitis, gastroduodenal artery pseudoaneurysm). 3. Tumoral (pancreatic head adenocarcinoma, periampullary tumors, neuroendocrine
pancreatic tumors, duodenal adenocarcinoma). CT and MR images illustrate
morphologic aspects of these entities.
Conclusion: CT and MR are the most appropriated imaging modalities to evaluate
pancreato-duodenal junction. Knowing the imaging features is crucial to reach the right
diagnosis and treatment of the different entities that involve this anatomic area.
C-046
The postoperative residue or recurrence of pancreatic cancer: Comparison
of multi-detector row CT perfusion and PET-CT
L. Yu Bao; Guangzhou/CN ([email protected])
Purpose: To evaluate the postoperative residue or recurrence of pancreatic cancer by MDCT perfusion and PET/CT, to analyze whether any of the CT perfusion
parameters correlated with the postoperative residue or recurrence.
Methods and Materials: Perfusion CT of the postoperative patients with pancreatic
cancer was performed with 64-Detector row CT in 38 patients. A dynamic study (cine
mode) was acquired through the lesion following intravenous contrast administration (100 ml; 4-5 ml/s), and the data were analyzed using commercial software to
calculate tissue, BV, MTT, and vascular permeability surface area product (PS). All
S positron emission
the postoperative patients underwent fluorodeoxyglucoseO(FDG)
P
tomography CT (FDG-PET/CT) examinations and analyzed
whether any of the
E
perfusion parameters correlated with the postoperative
to residue or recurrence of
d
pancreatic cancer. Perfusion parameters of theeresidue
or recurrence and normal
pancreas tissue were compared.
itt
m residue or recurrence of pancreatic
Results: Thirty-two patients with postoperative
ub BF, BV, MTT and PS of postoperative
cancer were detected by PET/CT. The Smean
l cancer were 226.47p167.38 ml/min/100 g,
residue or recurrence of pancreatic
rs,ia 48.85p27.31
e
16.57p14.32 ml/100 g, 8.03p4.16
ml/min/100 g, respectively. The
t
mean BF, BV, MTT and PS M
ofa normal pancreas tissue were 362.47p142.31 ml/
min/100 g, 28.48p16.58 ml/100
g, 5.97p3.85 s, 26.33p21.42 ml/min/100 g, reNo
spectively. The mean BF, BV and PS between postoperative residue or recurrence
of pancreatic cancer and normal pancreas tissue were statistically significant
(p=0.015, p=0.006, p=0.002). The mean MTT between postoperative residue or
recurrence of pancreatic cancer and normal pancreas tissue were not statistically
significant (p=0.09).
Conclusion: MDCT perfusion can evaluate the postoperative residue or recurrence
of pancreatic cancer with significant BF, BV, and PS values, which can make differential diagnosis with postoperative residue or recurrence and normal tissue.
C-047
Characteristic MR features that are useful in differentiating between focal
autoimmune pancreatitis and pancreatic cancer
Y. Sugiyama, Y. Fujinaga, M. Kurozumi, K. Ueda, M. Kadoya, H. Hamano,
S. Kawa; Matsumoto, Nagano/JP ([email protected])
Purpose: Autoimmune pancreatitis, especially its localized form, has been frequently misdiagnosed as pancreatic cancer; this has led to unnecessary pancreatic
resections. We aimed to identify magnetic resonance (MR) imaging characteristics
that would be useful for differentiating between focal autoimmune pancreatitis and
pancreatic cancer.
Methods and Materials: We identified 27 patients with a focal pancreatic mass
from a patient database between 2002 and 2007. Thirteen of these patients had
autoimmune pancreatitis and 14 had pancreatic cancer. MR images were compared
between patients with focal autoimmune pancreatitis and those with preoperative
pancreatic cancer. MR imaging consisted of a respiratory-triggered fat-suppressed
T2-weighted turbo spin echo sequence, a breath-hold precontrast, and a dynamic
contrast-enhanced fat-suppressed T1-weighted gradient echo sequence, performed
on either a 1.5-T or a 3.0-T MR system.
Results: For differentiation between focal autoimmune pancreatitis and pancreatic cancer, we found that the following MR image characteristics are useful: (1)
speckled hyperintensity in a hypointense area on precontrast and arterial dominant
Scientific and Educational Exhibits
phase contrast-enhanced T1-weighted images, and (2) homogenous isointensity or
hyperintensity on equilibrium phase contrast-enhanced T1-weighted images. These
findings were observed significantly more frequently in autoimmune pancreatitis
than in pancreatic cancer, with a high accuracy of 74.1-85.2%. This suggested that
these characteristics would comprise a valuable diagnostic tool.
Conclusion: We identified two characteristic MR findings that are useful for the
differentiation between focal autoimmune pancreatitis and pancreatic cancer.
C-048
Pancreatic metastases: An imaging challenge
C. Triantopoulou, P. Maniatis, Z. Touloumis, E. Kolliakou, I. Siafas, C. Avgerinos,
J. Papailiou, C. Dervenis; Athens/GR ([email protected])
Learning Objectives: To describe the imaging features of pancreatic metastases
and present differential diagnostic criteria from other pancreatic tumors.
Background: Unlike primary pancreatic carcinoma, metastatic lesions of the pancreas are uncommon and account for approximately 2% of pancreatic malignancies.
A variety of extrapancreatic tumors can involve the pancreas secondarily and may
manifest with different clinical and imaging characteristics. Although many patients
have widespread disease, isolated metastases can be found. Surgical management
seems to be associated with improved survival in these cases.
Imaging Findings: Synchronous and metachronous cases were encountered. Hypovascular and hypervascular solitary or multiple lesions were found. In most cases, imaging appearance was related to the primary tumor. Metastases from renal cell carcinoma
and melanoma were hyperdense after contrast administration, while metastases from
lung, gastric and colon cancers appeared as hypodense lesions with a peripheral rim of
contrast enhancement in most patients on CT imaging. MRI was performed in a small
number of patients presenting diagnostic dilemmas and the enhancement pattern was
the same. Pancreatic duct showed no dilatation in all the cases. All surgical candidates
underwent partial pancreatectomy or enucleation of metastatic lesions. Imaging findings
correlated well with pathology results. Accurate diagnosis of metastases was possible
by imaging in all the patients. No surgical candidates received chemotherapy with
promising results in cases of colon and renal cancer metastases.
Conclusion: Preoperative diagnosis of a secondary pancreatic tumor is essential
for proper patient management. Radiologists should be familiar with the different
imaging appearance of pancreatic metastases.
C-049
IgG4-related sclerosing disease: Imaging findings of pancreatic and
extrapancreatic abnormalities
H. Irie, T. Nakazono, J. Nojiri, N. Kamochi, Y. Egashira, M. Nishihara, Y. Okajima,
S. Kudo; Saga/JP ([email protected])
C-050
Differentiation between autoimmune pancreatitis and other pancreatic
disorders on CT and MRI
H. Irie, T. Nakazono, J. Nojiri, N. Kamochi, Y. Egashira, M. Nishihara, Y. Okajima,
S. Kudo; Saga/JP ([email protected])
C-051
64-MDCT imaging of the pancreas: Scan protocol optimisation by different
scan delay regimes
M.S. Juchems, A.S. Ernst, H.-J. Brambs, A.J. Aschoff; Ulm/DE
Purpose: The purpose of this study was to compare different MDCT protocols to
optimize pancreatic contrast enhancement.
Methods and Materials: Forty patients (18 male, 22 female; ¶ 68.25y) underwent
biphasic CT (arterial and portal venous phase) using a 64-slice MDCT (Brilliance
64, Philips Medical Systems) after the injection of 1.2 ml/kg bodyweight of Iomeron
400 (Bracco) at rate of 4 ml/s. In 20 patients the scan protocol was adapted from
a previously used 40x CT scanner (Brilliance 40) with arterial phase scanning
initiated 11.1 s after a threshold of 150 HU was reached in the descending aorta
using automatic bolus tracking (protocol 1). This 11.1 s delay was changed to 15
s in the other 20 patients to reflect the shorter scanning times on the 64-channel CT compared to the previous 40x system (protocol 2). Hounsfield-units (HU)
were measured in the head and the tail of the pancreas in the arterial and portal
venous phases.
Results: Using a 11.1 s delay, 74.2 HU (head) were measured on average in the
arterial phase, while 111.2 HU (head) were measured using a 15 s delay (p=0.0001).
For the pancreatic tail, 76.73 HU (11.1s) and 99.89 HU (15s) were measured on
average (p=0.0002). HU values were also significantly higher in the portal venous
phase (pancreatic head: 67.5 HU (11.1 s) and 84.0 HU (15 s), p=0.0014; pancreatic
tail: 69.4 HU (11.1 s) and 99.9 HU 15 s), p=0.0071) using protocol 2.
Conclusion: In this study, we were able to demonstrate that the concept that
longer scan delays are required for faster CT scanners can be used to optimize
imaging of the pancreas.
C-052
Typical and atypical manifestation of serous cystadenoma of the pancreas
J.-Y. Choi, M.-J. Kim, J. Lee, J. Lim, J. Kim, H. Ko; Seoul/KR ([email protected])
Learning Objectives: 1. To review the typical imaging features of serous cystadenoma of the pancreas. 2. To discuss atypical manifestations of serous cystadenoma
and correlate with histopathology. 3. To discuss the differential points to diagnose
serous cystadenoma and its clinical significance.
Background: With the widespread use of cross-sectional imaging, cystic masses
in the pancreas are being detected with greater frequency. Among cystic pancreatic
tumors, serous cystadenomas (SCA) have characteristic imaging and histologic features that may differentiate them from other potentially malignant cystic tumors, such
as mucinous cystic tumors and intraductal papillary mucinous neoplasms. However,
various atypical features of SCA found on cross-sectional imaging may lead to incorrect diagnosis. Therefore, we illustrate in detail the various appearances of SCA.
Imaging Findings: 1. Imaging findings and histopathologic features of typical
serous cystadenoma-CT/EUS/MR. 2. Review of atypical manifestations of serous
cystadenoma-giant tumor with ductal dilatation, intratumoral hemorrhage, a solid
variant, unilocular cystic tumor, interval growth, and disseminated form. 3. Differential diagnosis of SCA.
Conclusion: Pancreatic SCA exhibit a wide range of imaging findings. Knowledge
of the spectrum of varied features observed in SCA is useful for differentiating this
lesion from other pancreatic tumors.
Learning Objectives: To review various CT and MRI findings of autoimmune
pancreatitis (AIP) and to classify AIP to three types: diffuse, segmental, and
multifocal type. To learn the crucial CT and MRI findings in differentiating AIP from
other pancreatic disorders.
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Learning Objectives: To recognize the concept of IgG4-related sclerosing disease.
To review imaging findings of IgG4-related sclerosing disease of various organs. To
learn diagnostic clues of IgG4-related sclerosing disease of various organs.
Background: IgG4-related sclerosing disease is a systemic disease that is characterized by extensive IgG4-positive plasma cells and T-lymphocyte infiltration of
various organs. Autoimmune pancreatitis (AIP) is thought to be pancreatic involvement of IgG4-related sclerosing disease. Besides pancreas, IgG4-related sclerosing
disease may affect bile duct, gallbladder, salivary gland, retroperitoneum, kidney,
lung, and prostate. Most IgG4-related sclerosing diseases have been found to
be associated with AIP, but also those without pancreatic involvement have been
reported, and diagnosis of such cases is often difficult.
Imaging Findings: This disease includes AIP, sclerosing cholangitis, cholecystitis, sialadenitis, retroperitoneal fibrosis, tubulointerstitial nephritis, interstitial
pneumonia, prostatitis, inflammatory pseudotumor and lymphadenopathy, all
IgG4-related. T2-weighted MR images and dynamic study are essential to diagnose this disease, since fibrosis with obliterative phlebitis is a characteristic
pathologic finding of this disease.
Conclusion: Since malignant tumors are frequently suspected on initial presentation, IgG4-related sclerosing disease should be considered in the differential diagnosis to avoid unnecessary surgery. Although the nomenclature differs, radiologists
should recognize this disease entity and its imaging findings.
Background: AIP is characterized by diffuse or segmental enlargement of the
pancreas with irregular narrowing of the main pancreatic duct, and fibrotic change
with lymphocyte infiltration histopathologically. Diagnosis of AIP is very important,
since it can be treated by steroid therapy. AIP can show various CT and MRI findings
and it is often difficult to differentiate AIP from other pancreatic disorders.
Imaging Findings: We reviewed CT and MRI findings of 39 cases of AIP, and
classified AIP to three types: diffuse, segmental, and multifocal type. The important
differential diagnosis of diffuse type AIP is mild acute pancreatitis and lymphoma.
Differentiating clues are main pancreatic duct change and enhancement pattern on
dynamic study. Differentiation between segmental type AIP and mass-forming pancreatitis or pancreas cancer is often difficult or may be almost impossible. Although
rare, AIP may show multifocal delayed enhanced masses within the pancreas.
Recognition of this type of AIP is mandatory in diagnosing pancreatic abnormalities.
The important differential diagnosis is lymphoma and metastases.
Conclusion: A capsule-like rim can play an important role in diagnosing AIP. A
smooth contour of the lesion without circumference fat tissue change is also considered to be characteristic for AIP. Differentiation between segmental type AIP
and pancreas cancer requires clinical information such as IgG4.
Scientific and Educational Exhibits
C-053
Abdominal disease in an adult population with cystic fibrosis: A pictorial
review
C.A. Ridge, S. McDermott, V. Chan, C. Hegarty, D.E. Malone; Dublin/IE
([email protected])
Learning Objectives: To illustrate the broad spectrum of abdominal imaging findings in an adult population with cystic fibrosis.
Background: With improvements in the management of the respiratory complications of CF, life expectancy in this population has increased. The abdominal manifestations of CF are common and may not present until adulthood. Consequently,
radiologist familiarity with the expected imaging appearances of CF abdominal
disease is paramount.
Imaging Findings: This pictorial review demonstrates the broad spectrum of
abdominal imaging findings in CF including: a. fatty infiltration of the liver, b. multinodular cirrhosis, c. portal hypertension and its complications, d. cholelithiasis, e.
microgallbladder, f. pancreatic cystosis, g. pancreatic atrophy and h. a rare case of
biopsy-proven hepatocellular carcinoma with underlying cirrhosis.
Conclusion: Abdominal disease in CF can be successfully evaluated by ultrasound, CT and MRI.
C-055
Computed tomodensitometry severity index of Balthazar or Mortele in
acute pancreatitis: From theory to practice
A.B. Faye, O. Craciun, M. Ben Hajmor, A.H. Tyazi, P. Etessami, M. Nowakowski,
A. Boruchowicz, P. Cuingnet; Valenciennes/FR ([email protected])
Learning Objectives: To review the best indications and technique of MDCT in the
early assessment of acute pancreatitis by using both classifications of Balthazar
and Mortele. To give the basic interpretation while assessing acute pancreatitis.
To describe and illustrate the spectrum of the radiological semiology of each state
in both classifications and to demonstrate the main difficulties encountered while
assessing acute pancreatitis, based on a series of 200 patients selected between
February 2005 and September 2008 in a general hospital.
Background: According to the best guidelines in Europe and America, computed
tomodensitometry is the gold standard in the early assessment of acute pancreatitis
by using Balthazar’s CTSI. It describes well inflammatory spectrum, early common and uncommon complications. There is a good correlation between CTSI of
Balthazar and the others clinical classifications like Ranson’s score. Nevertheless,
controversies persist between radiologists while assessing acute pancreatitis.
Recently, because of the complexity of the classification of Balthazar, Mortele
invented a new CTSI that seems to be interesting and more easy to practice but
needs further evaluations.
Imaging Findings: The author will illustrate the iconographic spectrum of the
radiological semiology of each stage in both classifications and demonstrate difficulties and limits by exciting examples.
Conclusion: CTSI of Balthazar needs to be well known in daily practice for each
radiologist in the early assessment of acute pancreatitis. The CTSI of Mortele is less
complex to use and seems to be more complete but needs furthers studies.
C-056
Hypotonic-MRCP combined with lava dynamic enhanced MRI in diagnosis
of periampullary diseases
X. Lin, N. Li; Jinan/CN ([email protected])
Purpose: To analyze the image features of the periampullary diseases by hypotonicMRCP and Propeller LAVA multi-phase dynamic enhanced sequence of the 3.0 T
MR, and the value of this technique in diagnosis and in preoperative evaluation
of excisability of tumors.
Methods and Materials: Forty-three patients suspected of periampullary diseases
underwent routine MRI including axial T1WI/T2WI and FS-T1WI/T2WI, coronal FIESTA
and 2D or 3D hypotonic-MRCP scanning. The maximum intensity projection (MIP) and
multi-planar reformation (MPR) were reconstructed and the time-signal curve was
drawn. The direct and indirect signs, diagnosis of the origin, feature, size and range of the
lesions were observed and compared with the clinical and histopathology findings.
Results: For calculus, inflammation and tumor lesions, the sensitivity and specificity
of hypotonic-MRCP combined with Propeller LAVA multi-phase dynamic enhanced
scan were 100 and 100%, 60 and 97.4%, 96.7 and 76.9%, respectively. In all the
30 tumors, the diagnostic accuracy rate of tissue origin was 93.3, 90.0 and 86.7%,
respectively. The diagnostic accuracy of tumor invasion was 83.3%. The accuracy
of preoperative evaluation of tumor excisability of pancreatic carcinoma, cholangiocarcinoma and ampullary carcinoma was 76.9, 85.7, and 88.9%, respectively.
S348
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Conclusion: Hypotonic-MRCP combined with Propeller LAVA multi-phase dynamic
enhanced scan can display the direct and indirect signs of periampullary lesions. It
is useful in identifying the origin and range of small periampullary lesions.
C-057
Autoimmune pancreatitis with multifocal mass-like lesions
Y. Fujinaga, M. Kadoya, K. Ueda, M. Momose, M. Kurozumi, S. Yanagisawa,
H. Hamano, S. Kawa; Matsumoto/JP ([email protected])
Purpose: Autoimmune pancreatitis (AIP) with multifocal mass-like lesions is a
rare form of AIP and only a few authors have been reported. The aim of this study
is to clarify the frequency and to analyze imaging findings of this unique form for
correct diagnosis.
Methods and Materials: We systematically reviewed CT, MRI, or gallium-67
(Ga-67) scintigraphy for 90 patients with AIP, 75 men and 15 women (median age,
63.1 years old), at Shinshu University Hospital. Diagnosis of AIP was based on the
diagnostic criteria for AIP proposed by the Japanese Pancreatitis Society. Among
these patients, we reviewed the diagnostic imaging, and analyzed frequency and
imaging findings of multifocal mass-like lesions of the pancreas.
Results: We identified 5 of 90 (5.6%) patients, 5 men (median age, 66.8 years old),
with multifocal mass-like lesions in the pancreas. MRI was performed in all patients
and fat saturated-T1-weighted images obviously showed all localized lesions as
hypointense lesions. MRCP was performed in 4 patients and showed irregular
main pancreatic duct narrowing in all patients, but multifocal lesions were unclear.
Dynamic contrast-enhanced CT was performed in 4 patients and all lesions but one
lesion showed hypovascular lesions. Ga-67 scintigraphy was performed in 4 patients
and all but one lesion that was unclear on dynamic contrast-enhanced CT, showed
increased uptake. All lesions disappeared after corticosteroid therapy.
Conclusion: A multifocal mass-like lesion was a rare form of AIP. It seems to be
important to know this unique form for differentiation of AIP from other focal lesions
such as pancreatic cancer.
C-058
Incidental pancreatic cysts are a frequent finding in liver
transplanted patients (LTPs) addressed to magnetic resonance
cholangiopancreatography (MRCP)
R. Girometti, L. Cereser, G. Como, M. Del Pin, A. Furlan, M. Bazzocchi, C. Zuiani;
Udine/IT ([email protected])
Purpose: To determine the prevalence of previously undiagnosed pancreatic cysts
in LTPs addressed to MRCP for suspected biliary complications.
Methods and Materials: 75 MRCPs performed on 49 LTPs over a 3-year period
were retrospectively reviewed by two radiologists, to assess the presence of pancreatic cysts, as far as their number, size (minimum detectable dimension=3 mm),
location (head/body/tail), relation with main pancreatic duct (MPD) (close/far, with/
without communication), and evolution over a minimum 6-month delay in 13 patients
with multiple examinations. Presence of cysts was also assessed in a control group
of 106 patients who underwent MRCPs for suspected biliary disease.
Results: Prevalence of pancreatic cysts was significantly higher in LTPs (61.2%)
compared to controls (30.2%) (p=0.0005; test of comparison of proportions). In
LTPs a total of 99 cysts were detected (per-patient mean=3.3), prevailing in the
head (43.4%), and ranging up to 16 mm in diameter. The majority of cysts (65.6%)
was close to MPD, only 24.2% showing evident communication. Four cases were
strongly suspected for intraductal-papillary-mucinous-tumors, including the only
patient showing cysts increase over a maximum 31-month follow-up. Cysts were not
associated (p=0.38-1.00; Fisher exact test) with pre- or post-transplantation factors
(including sex, age, type of bilio-pancreatic channel/biliary anastomosis, distance of
MRCPs from transplant, presence/type of biliary complications), except for alcoholic
etiology of cirrhosis (p=0.002) (Odds Ratio 9.71; 95% C.I. 1.90-49.6).
Conclusion: Incidental pancreatic cysts are frequent in LTPs. Clinical significance,
relation to liver transplant, and impact on patients’ management before and after
transplant are matters for debate.
Scientific and Educational Exhibits
C-059
Interventional radiologic management of severe acute pancreatitis
D. Leiva Pedraza, L. Martínez Carnicero, C. Valls Duran, S. Ruiz Osuna,
E. Alba Rey, F. García Borobia, A. Gumà Martínez; L’Hospitalet de Llobregat/ES
([email protected])
Purpose: To evaluate indications and results of interventional radiologic techniques
in the management of complications related to severe acute pancreatitis (SAP).
Methods and Materials: Twenty patients with SAP who required CT or US guided
FNA of necrotic tissue or drainage of fluid collection were reviewed over a 1-year
period (2006-2007). All patients were admitted to an intensive care unit and indications for percutaneous management were sepsis or organ failure.
S
Results: 40 procedures were performed in 20 patients:
O puncture of necrotic tissue
P
in 26 cases (11 patients), puncture of fluid collection
in
E 7 (5 patients) and drainage
of collection in 7 (4 patients). The procedures were
to performed under US-guidance
d
in 11 cases and CT-guidance in 29. FNA ofenecrosis
showed a sensitivity of 100%
tt patients). Patients with positive culand a positive predictive value of 87.5% i(8/11
m
ture underwent surgery. Mean time ofbinfection was 18.9 d. One culture positive for
Su at surgery. In 5 patients acute fluid collecStaphylococcus aureus was notlproved
a
i days) were suspected to correspond to abscesses.
tions in the initial period (11-20
er
Needle aspiration was positive
at for infection in 4 cases, and surgical debridement
M
was performed. Four patients
presented distant fluid collections (mean: 215 d)
consistent with infected
No pseudocysts and were treated percutaneously (n=3) or
surgically (n=1). Procedure-related complications were not observed.
Conclusion: FNA is useful for microbiological study of necrosis to detect infection, with a sensitivity of 100% and a positive predictive value of 87.5%. Infected
pancreatic necrosis must be managed surgically. Infected fluid collections may be
successfully managed percutaneously.
C-060
Relative accuracy of CT and MRI for the characterization of cystic lesions
of pancreas
H.-J. Lee, M.-J. Kim, J.-Y. Choi, H.-S. Hong, K.-A. Kim; Seoul/KR
C-061
Lymphoepithelial cyst of the pancreas: Morphologic features and
comparison with other cystic diseases of pancreas
W. Kim, J. Lee, H. Park, S. Kim, S. Kim, B. Choi; Seoul/KR
([email protected])
Purpose: To evaluate CT findings of lymphoepithelial cyst of pancreas (LEC) and
find differential points between LEC and other pancreatic cystic lesions.
S
Methods and Materials: Nine patients with surgicallyOproven
LECs and 39 patients
P
with pathologically confirmed cystic lesions including
E mucinous cystic neoplasms
to
(MCN, n=11), serous oligocystic adenomas (SOA,
d n=18), and chronic pseudocysts
e
(n=10) were included in this study. Two radiologists
analyzed CT images in terms of
t
it
size, location, shape, exophytic degree,mpresence of wall thickening and enhanceb
u calcification, pancreatic duct dilatation, and
ment, internal septum, mural nodule,
lS
internal debris. Comparative analysis
ir a was performed using C2 test.
e
Results: LECs occurred predominately
in male patients (88.9%) and varied in size
at
(38.2p17 mm). Most LECs M
were unilocular or multilocular and had smooth or slightly
o
lobulated margin. A fewNLECs had peripheral calcification, wall thickening, internal
septum, internal debris, and pancreatic parenchymal lining of exophytic portion. The
N
C-062
Contrast-enhanced ultrasound in the staging of acute pancreatitis
E. López-Pérez, T. Ripollés, M.J. Martínez-Pérez, F. Delgado, C. Leiva-Salinas,
I. Castelló; Valencia/ES ([email protected])
Purpose: To determine the diagnostic value of contrast-enhanced ultrasound
(CEUS) in the assessment of the severity of acute pancreatitis in comparison with
CT and clinical outcomes.
Methods and Materials: The study included 39 consecutive patients with a diagnosis of acute pancreatitis and clinical CT indication admitted to our hospital between
August 2006 and June 2008. Balthazar´s grading system and the modified severity
index of Mortelé were used to evaluate acute pancreatitis. Clinical variables were:
Ramson score, levels of C-reactive protein and duration of hospitalisation. Correlation between CEUS and CT severity indexes and between CEUS and clinical
parameters were tested by Spearman´s rank correlation coefficient. Based on CT
findings as the gold standard, the sensitivity, specifity, positive predictive value
and negative predictive value of CEUS were calculated for detecting severe acute
pancreatitis and pancreatic necrosis.
Results: 35 patients were analyzed (17 men, 18 women, median age 60.89 years,
range 23-87). A significant correlation between CT and CEUS was found for Balthazar (r= 0.894, p 0.01) and Mortelé severity indexes (r=0.957 p 0.01) and
for the detection of necrosis (Balthazar r= 0.851, p 0.01 and Mortelé r= 0.850,
p 0.01). The sensitivity, specifity, positive predictive value and negative predictive
value for detecting severe acute pancreatitis was 100% and for detecting pancreatic
necrosis were 73, 100, 100, and 89%, respectively.
Conclusion: Contrast-enhanced ultrasound is comparable to CT in the assessment
of severity of acute pancreatitis. It is a cheap, safe and portable method that could
be an alternative when CT is contraindicated.
C-063
Distinctive imaging features of solid pseudopapillary tumor of the
pancreas in male patients: Comparative study with CT and MR imaging
findings in female patients
J. Lee1, T. Kim1, J. Kim1, J.-S. Yu2, M.-S. Park2; 1Suwon/KR, 2Seoul/KR
([email protected])
Purpose: The purpose of this study was to describe the CT and MR imaging
features of solid pseudopapillary tumor (SPT) of the pancreas in male patients
and to compare with SPT in female patients.
Methods and Materials: Preoperative CT or MR images of pathology-proven
36 patients (men:women = 6:30) with SPT of the pancreas were retrospectively
reviewed. Images were retrospectively reviewed, including location of the tumor,
size, shape (round, oval, lobulated), capsule thickness, proportion of solid and
cystic component, and morphology of calcifications. Contrast enhancement patterns were also evaluated. Statistical differences of the imaging features between
male patients and female patients were analyzed.
Results: Mean age was higher in male SPT patients (male:female = 43.2:31.1
years) than in female patients with statistical significance (P=0.015). Lobulated
shape was comparably seen in both male SPT (50%) and female SPT (20%)
(P=0.438). Completely solid lesion was significantly more frequent in male SPT
patients (83.3%) than in female patients (26.7%) (P=0.049). Contrast enhancement
of progressive fill-in pattern was seen in all male SPT patients (100%), whereas it
was found in less than half of female SPT patients (44.8%) (P=0.044). No statistical differences were found with respect to tumor size, location, capsule thickness,
and shape of calcification.
Conclusion: In conclusion, completely solid pancreatic mass lesion with lobulated
shape and progressive fill-in contrast enhancement pattern in a middle-aged man
may suggest SPT in male patients. These imaging features may help distinguish
SPT from other pancreatic neoplasms, such as islet cell tumors or ductal adenocarcinoma.
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S349
Abdominal Viscera (Solid Organs)
Purpose: To define the relative performance of CT and MRI for the characterization
of cytstic lesions of pancreas.
Methods and Materials: We retrospectively analyzed 67 patients (M: F = 40:27,
age range, 12 - 79 years; mean, 55.2 years) with pancreatic cystic lesions who
underwent both multidetector CT and MRI. Three radiologists reviewed the CT and
MR images in random order and independently and recorded their confidence for
the benignity and malignancy of the lesions, the leading specific diagnosis for the
lesions. Area [Az] under receiver operating characteristic (ROC) curve was calculated to compare the diagnostic accuracy between CT and MRI.
Results: 6 lesions that were borderline lesions were excluded in the ROC analysis.
35 lesions were benign (57.4%), 26 lesions were malignant (42.6%). Az for differentiating benign from malignant lesions were comparable between two modalities in
each reviewer ([Az]=0.651, 0.764, 0.772 for reviewers 1, 2 and 3 at CT and 0.736,
0.762, 0.800 at MRI (p 0.05)). The leading diagnosis given by reviewers showed
no remarkable significance difference between the two modalites (Chi-square test
with Yates correction for continuity p 0.05; reviewers 1, 2, 3 were correct in 56.1,
71.2, and 59.1% at CT and 48.5, 71.2, and 57.6% at MRI, respectively).
Conclusion: CT and MRI were comparable for the characterization of benign and
malignant lesions.
most significant differential point of LEC from MCN and SOA
S was exophytic degree
O
(p=0.002 in MCN, p=0.000 in SOA). Most LECs wereP"mainly
exophytic" (77.8%) or
Eand just one SOA was "mainly
"partially exophytic" type (22.2%), whereas no MCN
o
t in other features. There was
exophytic" type. There was no statistical difference
d
te pseudocysts in exophytic degree.
also no significant difference between LECitand
m LEC such as absence of calcification
However, there were ancillary findings tobfavor
Su lining of exopytic portion.
and presence of pancreatic parenchymal
l
Conclusion: LECs appear as unilocular
or multilocular, smooth or slightly loburia
te male predominance. Most LECs revealed more
lated, exophtyic cystic lesionsawith
M
exophytic features than other
o cystic lesions.
Scientific and Educational Exhibits
C-064
Cross-sectional imaging of pancreas transplants and their complications
J.R. Dillman, K.M. Elsayes, J.D. Nadig, R.O. Bude, J.F. Platt, I.R. Francis;
Ann Arbor, MI/US ([email protected])
Learning Objectives: To discuss the recent advances in cross-sectional imaging for the evaluation of pancreas transplants. Illustrative examples of the normal
pancreas transplant, as well as a wide variety of transplant-related complications,
will be presented.
Background: Pancreas transplantation is currently performed for treatment of
insulin dependent diabetes mellitus. Therefore, radiologists must be familiar with
the normal imaging appearances of pancreas transplant and the wide variety of
transplant-related complications.
Imaging Findings: The exhibit begins with a brief explanation of the indications
and surgical techniques involved in pancreas transplantation. We then discuss the
various imaging modalities and parameters used in imaging pancreas transplants,
as well as indications for when to use a specific modality. The appearance of the
normal pancreas graft and complications will be discussed, including parenchymal
complications, vascular complications, various fluid collections, duodenal complications, and urethral complications, as well as post-transplant lymphoproliferative
disorder. Representative imaging examples are provided for each entity.
Conclusion: Pancreas transplantation has become much more commonplace over
the past several decades. Pancreas transplant grafts can be successfully evaluated
using multiple cross-sectional imaging modalities, including ultrasound, CT, and
MRI. Radiologist familiarity with the expected post-operative graft appearance and
possible transplant-related complications is of increasing importance.
C-065
Pictorial review of aggressive solid pseudopapillary tumours of the
pancreas
J. Lee1, T. Kim1, J. Kim1, M.-S. Park2, J.-S. Yu2, K. Kim2; 1Suwon/KR, 2Seoul/KR
([email protected])
Learning Objectives: The purpose of this exhibit is to discuss pathologic characteristics of aggressive solid pseudopapillary tumours (SPT) of the pancreas and to
illustrate imaging features of aggressive SPT compared with benign SPT.
Background: SPT of the pancreas are rare neoplasms, which mainly occur in
young woman. However, malignant behaviour does occur in 10-15% of cases.
Because of its rarity, there have been few reports about the imaging findings of
aggressive SPT.
Imaging Findings: Preoperative CT or MR images for 26 patients (8 patients with
aggressive SPT and 18 patients with benign SPT) were retrospectively reviewed
and imaging features were comparatively assessed. There were no significant differences between aggressive SPT and benign SPT with respect to the tumor size,
location, capsule thickness, internal composition, and pattern of calcification. Pancreatic duct dilatation was present in 4 of 8 aggressive SPT patients, while absent
in all benign SPT patients (p = .005). Vascular encasement by the tumor (n = 2)
and hepatic metastases (n = 2) were also exclusively demonstrated in aggressive
SPT patients. Multivariate logistic regression analysis showed that pancreatic duct
dilatation (p = .001), vessel encasement (p = .027) and metastasis (p = .027) were
the variables that can differentiate aggressive STP from benign SPT.
Conclusion: Aggressive SPT of the pancreas may show the imaging features of
aggressive behaviour of pancreatic duct dilatation, and vessel encasement with
or without extrapancreatic metastases. Recognition of the imaging features of aggressive SPT may help correct diagnosis and treatment planning.
C-066
Magnetic resonance cholangiopancreatography through the administration
of ilex paraguariensis
E.E. Martin, P. Battezzati, M. Bruno, D.F. Sarroca, M.A. Borensztein, C.H. Bruno;
Lomas de Zamora/AR ([email protected])
Purpose: To show the capability of Ilex paraguariensis as a negative oral contrast
agent to improve the quality of magnetic resonance cholangiopancreatography.
Methods and Materials: In the in-vitro preliminary phase, Ilex shortened T2
relaxation time and signal in SSh-TSE 2D, similar to the action of ferumoxil. Ilex is
a herb consumed as an infusion with 5.5 mg/dl manganese, responsible for these
properties. In this study, 30 consecutive patients were imaged with SSh-TSE 2D
sequences before and 10 minutes after administering Ilex. Two radiologists blindly
rated the contrast effect on the gastroduodenal signal using a scale from 1 (present)
to 4 (null); and on image quality of the biliary ductal system sections grading 1 (not
discernible) to 3 (wholly discernible). Results were analyzed statistically, with ANOVA
for repeated measures, with Friedman test for differences before and after the
contrast, and with weighted kappa coefficient values for interobserver variation.
S350
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F
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F
H
Results: Ilex was well-tolerated by all patients. Gastrointestinal signal was annulled
(p 0.001) in all patients; mean ratings with and without contrast agent were 2.0
and 3.95, respectively. Depictions of the common bile duct (p 0.01) and of the
pancreatic duct (p 0.001) were markedly improved, their mean scores being, respectively, 2.5 and 2.97 for the former, and 1.9 and 2.95 for the latter. Interobserver
agreement was high (k= 0.65) in the post-contrast images.
Conclusion: The elimination of the gastroduodenal signal was statistically significant (p 0.001) and all biliopancreatic structures were visually improved after
administering Ilex, proving to be an efficient and convenient alternative to negative
oral contrasts known.
C-067
Usefulness of MDCT perfusion measurement in patients with acute
pancreatitis
J.M. Pienkowska, E. Szurowska, J. Wierzbowski, M. Studniarek; Gdansk/PL
([email protected])
Purpose: Severe acute pancreatitis (AP) is a significant clinical problem, which is
associated with a highly mortality. The aim of this study was the analysis of usefulness of MDCT regional perfusion measurement in assessing the severity of acute
pancreatitis and its using for therapy planning.
Methods and Materials: 45 patients with clinical symptoms indicative of acute
pancreatitis underwent perfusion CT on 64-row MDCT scanner within 48 hours after
onset of symptoms of the AP. The follow-up examinations were performed after 4-6
weeks to detect progression of the disease. Dynamic perfusion CT was performed
after intravenous injection of a 40 ml bolus of contrast medium (injection rate 4 ml/
sec) at a 12-second scanning delay. Blood flow (BF), blood volume (BV), mean
transit time (MMT) and permeability-surface area product (PS) were calculated in
the three anatomic pancreatic subdivisions (head, body and tail).
Results: Perfusion parameters were significantly lower in 16 patients with acute
pancreatitis due to pancreatic ischemia. In 14 of these patients, severe complications (as pancreatic necrosis) would develop. There were no significant changes
in regional perfusion in patients with mild acute pancreatitis.
Conclusion: MDCT perfusion is a very useful indicator for selected patients in early
stages of acute pancreatitis who are at risk of developing severe complications and
can be used for therapy planning.
C-068
Intraductal papillary mucinous tumors of the pancreas (IPMTP): Assets of
MRI and 3D image review
C. Cotereau Denoiseux, L. Huwart, M. Louvet, I. Boulay-Coletta, M. Zins;
Paris/FR ([email protected])
Learning Objectives: 1. Knowing the elements of a positive diagnosis of IPMTP.
2. Understand the contribution of 3D MR imaging of the pancreas. 3. Evaluate MR
arguments of degeneration and knowing how to monitor an IPMTP. 4. Knowing the
differential diagnosis of cystic tumor of the pancreas.
Background: The diagnosis of IPMTP is affirmed by the identification of a communication between the secondary dilated duct and the main pancreatic duct.
Pancreatic 3D MR facilitates the identification of those communications. It is used
to monitor the IPMTP, search criteria of degeneration (pancreatic mass with endocanalar bud, majoration of the duct dilatation, calcifications, biliary fistula), and
evaluate recurrence or post-op complications.
Procedure Details: 1. The diagnosis of IPMTP is based on the identification of a
cystic dilatation of the pancreatic secondary ducts, communicating with the main
pancreatic duct. 2. 3D MR of the pancreas contains cholangio-wirsungography
sequences, T1 sequences with and without injection, and T2 sequences. 3. 3D
MR of the pancreas affirms cysts communication with the main pancreatic duct,
eliminating differential diagnoses (serous cystadénoma, false pancreatic cyst,
mucinous cystadénoma).
Conclusion: 3D MR is the method of choice for monitoring IPMTP.
Scientific and Educational Exhibits
Abdominal Viscera (Solid Organs)
Miscellaneous
C-069
Unusual extramedullary hematopoiesis sites shown by CT and MRI-scan
M. Albrizio, C. Peroni, C. Reduzzi, V. Piazza, A. La Fianza; Pavia/IT
([email protected])
Learning Objectives: The purpose of the exhibit is to present CT and MRI images
showing examples of extramedullary hematopoiesis (EMH).
Background: EMH is a peculiar condition that occurs in response to an insufficient
erythrogenesis in case of myelofibrosis, long standing anemia or chronic leukemia.
EMH can rarely be detected with CT or MRI-scan, the latter being able to show
erythropoietic activity only in very few cases.
Imaging Findings: From January 2004 to June 2008, 174 patients affected by
idiopathic myelofibrosis underwent a CT followed by an MRI examination at our
hospital. An IV contrast medium was always used (iodinated contrast medium for
CT and gadolinium for MRI). Only 14 patients presented EMH sites. EMH lesion
number, size and shape were evaluated. In case of MRI investigation, the presence
of contrast enhancement within a lesion was considered to be a sign of erythropoietic activity. EMH was found in peritoneal space, pelvicaliceal system, periportal
space, and extraperitoneal non lymphnodal sites. Imaging findings were confirmed
by CT-guided biopsy, follow-up or post-mortem examination. Only in 4 cases MRI
was able to detect evidences of erythropoietic activities.
Conclusion: CT and MRI can be successfully used to show EMH. In addition, gadolinium enhanced MRI scans can be useful in detecting erythropoietic activity.
C-070
Errors of a first year consultant radiologist
H.M. Imalingat, J. Smith; Leeds/UK ([email protected])
C-071
Imaging response patterns of malignant tumors treated with the
multitargeted tyrosine-kinase inhibitor (TKI) Sorafenib
O. Maksimovic, J.P. Pintoffl, J.T. Hartmann, C.D. Claussen, M. Horger; Tübingen/DE
([email protected])
Learning Objectives: To illustrate usual therapy-related imaging changes of
different tumors during therapy with Sorafenib as regarded by different imaging
modalities (contrast-enhanced ultrasound-CEUS, dynamic contrast-enhanced
CT-dynCECT, contrast-enhanced MRI with additional diffusion-weighted imagingDWI). To outline the advantages of the assessment of functional data contrary to
classical morphological therapy monitoring.
Background: Sorafenib demonstrates profound anti-tumor activity in different
tumors (e.g. hepatocellular carcinoma-HCC, renal cell carcinoma-RCC and others).
Since TKI inhibit angiogenesis, imaging tumor vascularization may allow assessment of treatment response. On the contrary, standard criteria in evaluating therapy
response are based on changes in size as defined by RECIST and do not address
functional parameters like tumor perfusion.
Imaging Findings: Examination of 35 patients and 76 lesions showed that tumor
size monitoring is unreliable as TKI generally do not induce tumor shrinkage. Tumor
size variations can occur and range from partial remission up to pseudo-progression
C-072
Diffusion weight imaging (DWI) in body district: From physics principles to
image interpretation
P. Paolantonio1, R. Ferrari1, M. Rengo1, F. Vecchietti1, P. Lucchesi1, F. Vasselli2,
A. Laghi1; 1Latina/IT, 2Rome/IT ([email protected])
Learning Objectives: To illustrate basic physics principles of DWI from image
acquisition to apparent diffusion coefficient calculation. To discuss peculiar technical
features of DWI in body applications To review the spectrum of potential clinical
application of DWI in body district. To show basics principles of qualitative and
quantitative image interpretations using DWI.
Background: DWI is a routinely used technique of neuro-MRI. DWI has shown
great chance in oncologic applications of body-MRI. DWI offers unique functional
information on water molecules diffusion; this information can be used study cellularity and integrity of cell’s membrane. Therefore, DWI can be used in a wide
spectrum of MR applications from lesion identification to characterization. Moreover,
DWI offers an unique chance to predict tumors response to therapy and to follow
neoadjuvant treatment.
Procedure Details: We will show how to optimize a DW sequence for body applications. In our experience, we used a SE-EPI-DWI sequence (TR 9000 msec;
TE: 87 msec; matrix 128x128 Fov 350x350 mm; slice thickness 5 mm; Nex 8 acq.
Time 2 min, 50 sec. b values: ranging 0-1000) acquired on a 1.5 T MR platform
(Signa Hde; GE, USA). We will show a spectrum of finding of DWI of liver lesions,
lymphnodes and neoplastic disease of abdomen and pelvis.
Conclusion: DWI is a feasible technique in body district. DWI offers a new parameter with respect to conventional T1 and T2 signal and contrast-enhancements.
Information of water diffusibility offered by DWI may be useful in tumor detection
and characterization as well as in prediction of tumor response to therapy and
tumor follow-up during neoadjuvant treatment.
C-073
Quantitative MR imaging in assessing the effect of different chelation
protocols in beta-thalassemic patients: A prospective long term trial
E.E. Drakonaki, S. Maragaki, A. Papadakis, T.G. Maris, A.H. Karantanas; Iráklion/GR
([email protected])
Purpose: To compare different chelation protocols on liver, spleen and bone marrow
siderosis in beta-thalassemic patients using quantitative MRI studies.
Methods and Materials: The study included 34 transfusion-dependent betathalassemic patients (age 25+7 years, 13/34 splenectomized) undergoing chelation
therapy (subcutaneous deferoxamine-DFX in 21/34 patients and combined therapy
with DFX and oral deferiprone in 13/34 patients). Liver, spleen and bone marrow
were prospectively assessed on two abdominal MR studies (time between scans
614.35+89 days) using T1GRE (120/4/90), PDGRE (120/4/20), T2*GRE (120/9/20)
and T1TSE (700/6.5/90) sequences. The signal intensity ratios of liver, spleen and
bone marrow to the paraspinous muscle (L/M, S/M, B/M, respectively) were calculated. The change (D) in ferritin (F), L/M, S/M, and B/M values were calculated in the
T1TSE sequence using the formula D=[(2d value-1st value)/1st value] x 100%.
Results: L/M, S/M and B/M correlated with ferritin values in all sequences (Pearson’s r-0.371, p~0). A reduction in iron load (negative DL/M, DS/M, DB/M value)
was found in 14/34 (41.17%), 7/21 (33.3%) and 14/34 (41.2%) patients, respectively,
greater in patients under combined therapy (t-test, p 0.05). A reduction in serum
ferritin (positive DF value) was found in 22/34 (95.6%) patients, greater in patients
under combined therapy (t-test p=0.03). Increased siderosis (positive DL/M, DS/M,
and DB/M value), was greater in the DFX group (t-test, p 0.05).
Conclusion: Ferritin values are an indicator of liver, spleen and bone marrow iron
load. Combined therapy is more effective than DFX alone in chelating liver, bone
marrow and spleen iron in transfusion-dependent beta-thalassemic patients.
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Abdominal Viscera (Solid Organs)
Learning Objectives: Self reflection and documentation of errors is recommended
by the General Medical Council and the Royal College of Radiologists as a part of
good clinical practice. We aim to demonstrate the important lessons that can be
learnt from reflection on one’s recorded practice.
Background: An observational prospective study of a number of errors made by
a first year consultant radiologist between January 2007 and December 2007 was
performed. Errors, either self observed or informed by consultant colleagues, were
documented. Details of error detection and patient impact were also recorded.
Imaging was reviewed with knowledge of the final diagnosis and correlated with
their pathological or operative findings and follow-up. Important learning points
were identified.
Imaging Findings: 8965 radiology studies were reported. 15 errors were observed,
incidence 0.2% (15/8965). 11 errors were recorded on imaging modalities and 4
errors occurred during interventional procedures. The impact of the errors observed
on patients included a negative laparotomy, delay in diagnosis and treatment plus
instigation of further imaging. 16 significant learning points were identified.
Conclusion: Recording one’s errors plays an important role in documenting performance. Learning from one’s mistakes is an important aspect of any individual’s
development.
due to increased volume secondary to tumor liquefaction. Perfusion imaging with
aid of both CEUS and dynCECT enable early assessment of therapy-induced
reduction in tumor perfusion. Additional abnormalities in tumor echogeneity and
attenuation (CT) reflecting accompanying necrosis can occur and be helpful for
diagnosis. On MRI, signal abnormalities generally occur early after therapy onset
and are supposed to reflect intratumoral hemorrhage and secondary necrosis.
Tumor necrosis can also be evaluated with the aid of DWI.
Conclusion: The use of functional imaging is beneficial and outclasses standard
response criteria and should therefore be implemented in response monitoring
protocols of TKI therapies irrespective of the modality to be used.
Scientific and Educational Exhibits
C-074
Spontaneous abdominal hemorrhage: Causes, CT findings and clinical
implications
A. Furlan1, S. Fakhran2, M. Federle3; 1Udine/IT, 2Pittsburgh, PA/US, 3Stanford, CA/US
([email protected])
Learning Objectives: To review the most common causes and imaging manifestations of spontaneous abdominal hemorrhage (SAH). To describe CT signs useful
for diagnosis and implications for patient’s management.
Background: SAH is defined as the presence of intra-abdominal hemorrhage from
a non-traumatic and non-iatrogenic cause. The clinical presentation is usually nonspecific, thus frequently the diagnosis is made on the basis of radiologic findings.
Because of its speed and widespread availability, CT plays an important role in the
assessment of presence and location of hemorrhage.
Imaging Findings: We will present the most common imaging manifestations of
the various etiologies of SAH. The following structure will be used: appearance
of hemorrhage on CT, coagulopathy related SAH, rupture of an abdominal aortic
aneurysm, visceral (hepatic, splenic, renal, adrenal and gastrointestinal) causes
(rupture of underlying tumor, infection, vasculitis) and gynecological causes (ruptured ovarian cyst or ectopic pregnancy, HELLP syndrome). For each point, we will
provide multiple images demonstrating the most typical and unique findings to aid
the radiologist in arriving at the correct diagnosis. In particular, we will discuss the
key CT findings to distinguish SAH due to coagulopathy from rupture of abdominal
aortic aneurysms or underlying visceral pathology, as well as the implications for
patient management.
Conclusion: CT is highly accurate for detection, quantification and localization
of SAH, having a direct impact on the clinical management and patient morbidity
and mortality. Radiologists should be familiar with the CT appearances of various
etiologies of SAH, as they may be life-threatening, requiring prompt diagnosis
and treatment.
C-075
Comparison of central and site review of RECIST data in an open
randomised phase II trial in advanced melanoma
D.C. Ghiorghiu1, K. Kemsley1, N. Schmitt1, D.J. Wilson1, H. Young1, O. Bohnsack2,
J.M. Kirkwood3, M. Cantarini1; 1Macclesfield/UK, 2Berlin/DE, 3Pittsburg, PA/US
([email protected])
Purpose: A 200 patient, Phase II multi-centre, open-label, randomised study was
conducted to compare the efficacy of AZD6244 (ARRY-142886) versus temozolomide (TMZ) in patients with advanced melanoma, assessed by progression-free
survival (PFS).
Methods and Materials: Scheduled tumour assessments were performed using
RECIST criteria until objective progression. All available radiological data was
collected by an independent review (IR) facility. Double read with adjudication
in case of discrepancies was performed in a blinded fashion for each subject.
Agreement between site measurements and independent central review of PFS
was assessed.
Results: Images were available for IR from 180 patients. Discordance was seen
between central and site data and on further investigation of these discrepancies,
imbalance was seen in favour of AZD6244 by the sites. Of the 22 patients whose
progression was recorded earlier by site than central review, 14 were on the TMZ
arm and of the 32 patients whose progression was recorded later by site than central
review, 20 were on the AZD6244 arm. In 20% of cases, discrepancy was due to
different assessments of % change of target lesions alone and 31% were due to
the identification of new lesions alone. There was large variability in the choice of
anatomical location of target lesions.
Conclusion: PFS using standard RECIST needs to be treated with caution in
advanced melanoma and consideration needs to be given to optimally define
lesion selection and radiological criteria. The potential for site bias in open label
trials supports use of central review of imaging data.
C-076
Crossing diaphragmatic lesions: Imaging findings with emphasis on MDTC
and MRI
V.F. Muglia, H.S. Trad , M. Nader, M.K. Santos, R.R. Rosalen Jr,
M.H. Nogueira-Barbosa, J. Elias Jr.; Ribeirão Prêto/BR
Learning Objectives: To review the pertinent anatomy from diaphragm. To review
the spectrum of diseases that can grow through the diaphragm, either by anatomic
orifices or by invasion. To illustrate how MDCT and MRI can be used to assess
these lesions. To review imaging findings of 83 patients, with emphasis on MDCT
and MRI.
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Background: The diaphragm constitutes a striking boundary between chest and
abdomen. Some anatomic structures cross this border through anatomical orifices.
Several lesions also can cross from one cavity to another by using those orifices
or by direct invasion. We review 82 patients with lesions crossing the diaphragm.
Patients were evaluated by upper gastrointestinal series, ultrasound, sixteenchannel MDCT and 1.5 T-MRI.
Imaging Findings: Imaging findings were variable according to etiology of the
lesions and include diaphragmatic hernias, congenital or traumatic; infectious
lesions, with and without fluid collections; mass lesions either from thoracic or
abdominal organs.
Conclusion: Several lesions can extend through the diaphragm. The exquisite
anatomic details provided by MDCT and MRI, especially in sagittal and coronal
planes are essentials for correct diagnosis and planning surgical approach.
C-077
Imaging of the spleen: More than just size measurement
J. Ash-Miles, S. Morgan, M. Callaway, H. Roach; Bristol/UK
([email protected])
Learning Objectives: To describe the various anatomical anomalies and pathologies that can affect the spleen. To outline the imaging features of these conditions
in the common imaging modalities.
Background: Imaging assessment of the spleen is often limited to measuring its
size, and the spleen is often spared by many pathological conditions. There are
however several processes that can affect the spleen with characteristic imaging
features. It is important for the radiologist to recognise these.
Imaging Findings: In this presentation, we describe the imaging features of a
variety of anomalies and pathologies affecting the spleen, including anatomical
variations, cysts, haemangiomas, infections, abscesses, trauma, metastases, lymphoma and haematological disorders such as sickle cell disease. We also outline
some of the imaging guided interventions applicable to the spleen.
Conclusion: The spleen is an important organ, which can be affected by a variety of anomalies and pathologies, with characteristic imaging features that are
described here.
Scientific and Educational Exhibits
Breast
Digital Mammography
C-078
Computer-based generation of masses in digital mammograms
M.A. Berks, S. Astley, S. Caulkin, C. Rose, R. Rahim, C. Boggis; Manchester/UK
([email protected])
Purpose: Synthetic abnormalities provide a cost-effective substitute for real data
when testing and training radiologists or CAD software. A method of generating
synthetic masses based on learning the statistical variation in appearance of real
data is described.
Methods and Materials: A set of regions, each containing a biopsy-proven malignant mass, was sampled from a population of digitised screening mammograms.
Adaptive filtering and thin-plate spline interpolation were used to separate the
masses from the underlying breast tissue. Wavelet-decomposition was used to
build a hierarchical texture model of the breast tissue and a statistical appearance
model fitted to the separated masses. For synthesis, a normal mammogram region
is modified using the tissue model to match the appearance of a region associated
with a mass. A new mass is then generated from the mass model and superimposed
in the modified region.
Results: When 15 breast radiologists attempted to distinguish between 25 real and
synthetic masses, the mean area under the ROC was 0.69p0.13 (the goal being
0.5). The models used in this initial analysis have subsequently been optimised
(significantly reducing model fit error from 3.109 to 1.262; p 0.0001) and the
training set doubled. Preliminary results indicate masses generated by the new
models appear more realistic; an observer study is in progress.
Conclusion: Statistical appearance models successfully generate mammographic
masses that are indistinguishable from real examples. Unlike other methods, user
input is not required to synthesise each new mass. This allows large datasets to be
generated automatically, maximising the advantages of using simulated data.
C-079
Comparison between digital and screen-film mammography in a screening
program in Cantabria/ES
P. Merino, S. Sanchez, M. Sanchez, A. Vega, P. Alonso, E. Ortega; Santander/ES
([email protected])
Purpose: To compare results between the 4th (2003-2004) and 5th (2005-2006)
round of the screening program from Cantabria, Spain, after the introduction of
digital mammography.
Methods and Materials: The screening program studied women aged 50-65 years
with double projection. In the 4th round, only conventional mammography was used.
In the 5th round, women were studied with conventional mammography and digital
mammography, both direct (with soft copy reading) and indirect with CR (with
screen-film reading); the radiologists changed, having at least one year of training
in screening mammography reading. We compared these outcomes: participation,
recall for complementary projections and detection rates and percentage of in situ
and invasive carcinomas, pT1ab tumors, axillary lymph node involvement and
conservative surgeries.
Results: Rates of participation, recall for complementary projections and breast
cancer detection for 4th and 5th rounds were: 56.89 vs 64.53%, 7.2 vs 6.9% and 2.39
vs 4.69/1000 (p 0.001), respectively. The percentage of ductal in situ carcinomas,
invasive carcinomas, pT1ab tumors, tumors without axillary lymph node involvement
and conservative surgeries were 14 vs 18.71%, 86 vs 81.29% (p 0.001), 29.23
vs 34.35% (p 0.05), 75 vs 78.07%, and 76 vs 79.33%, respectively.
Conclusion: The introduction of digital mammography and the changes in the
screening program reading is supposed to double breast cancer detection rate in
the 5th round and specially an increase in the detection of ductal carcinoma in situ
in the counties where direct digital mammography was used.
C-080
Purpose: To compare observer performances using 3- and 5-megapixel (M)
liquid-crystal display (LCD) monitors for the detection and characterization of
microcalcifications and masses in digital mammograms.
Methods and Materials: Six radiologists assessed the 100 digital mammograms.
Of these, 28 mammograms depicted clustered microcalcifications (12 benign, 16
C-081
Computer-aided detection (CAD) in screening mammography: Analysis of
findings overlooked by the radiologist
S. Sanchez Gomez1, M. Torres-Tabanera2, A. Vega Bolívar1, M. Sainz Miranda3,
A. Baroja Mazo3, M. Ruiz Diaz3, P. Martinez-Miravete3, E. Lag Asturiano3;
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Santander/ES, 2Madrid/ES, 3Logrono/ES ([email protected])
Purpose: To analyze malignant lesions marked by CAD and overlooked in mammography interpretation.
Methods and Materials: We prospectively applied a CAD system to 21,855
screening mammograms for a 2-year period. Mammograms were interpreted by
one of six radiologists (two general and four breast radiologists). One hundred and
five cancers were detected in 94 women. After completing the series, we added
a 12-month follow-up period. Twenty-four additional carcinomas (false negative
interpretations by radiologists) were diagnosed during the follow-up period. Mammograms and CAD marks of these 24 cases were retrospectively analyzed by a
breast radiologist.
Results: General radiologists interpreted 15 (62.5%) of the 24 false-negative
mammograms. False-negative rates were 73.3% for general and 55.5% for breast
radiologists. Classification by lesion type was: 14 masses, 7 calcifications and
3 masses with calcifications. CAD system correctly marked 6 of the 24 lesions
overlooked by radiologists (2 minimal signs and 4 false negatives). CAD system
could have increased the detection rate of 4.65% if appropriate attention had been
paid to the marks.
Conclusion: Appropriate attention to CAD marks can reduce false negatives in
screening mammography, although more prospective studies and follow-up are
required.
C-082
Digital mammography self-assessment workshop
R. Holland, H.J.T.M. Rijken, J.H.C.L. Hendriks †; Nijmegen/NL
([email protected])
Learning Objectives: Participants should be more familiar with reading and
manipulating screening digital mammography cases and will have assessed their
reading skills to detect cancers in their early stage and to maintain a good balance
between recall- detection- and false-positive rates.
Background: A Dutch study (JNCI May 2005) on the review of advanced interval
and screen-detected cancers showed that a delicate balance exists between
recall-, detection-, and false-positive rates. At a low recall rate (i.e., 1%), when
only women with obvious mammographic abnormalities are recalled, a number of
cancers will surface as interval cancers or late screen-detected cancers at a more
advanced tumour stage. By lowering the threshold for recall by focusing on more
subtle mammographic abnormalities, a substantial number of cancers could be
detected earlier.
Procedure Details: This workshop gives participants the opportunity for hands-on
experience with digital mammography systems. Fourteen one-hour sessions will be
offered during two days. Each session starts with an introduction that includes the
learning objectives of the workshop, the method of reading and self-assessment
and instruction on how to use the system. Participants can read up to 10 different
modules, each one containing 30 selected screening mammography cases with a
mix of negatives and biopsy proven positives. At the end of each session, participants can assess their detection and false positive rates.
Conclusion: An optimal balance between detection- and false-positive rate can
be achieved with a recall rate of about 2 to 4%.
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3-mega versus 5-mega liquid-crystal displays for digital mammography: A
comparison of observer performance in the detection and characterization
of microcalcifications and masses
J. Cha, W. Moon, S.-Y. Chung, Y. Koh; Seoul/KR ([email protected])
malignant), 18 depicted masses (10 benign, 8 malignant), and 54 depicted no
apparent abnormality. The images were stored uncompressed as DICOM files
and randomized for two sessions of soft copy reading. The readers independently
read all cases displayed on two 3-M and two 5-M LCD monitors with an interval of
three months. Observers were asked to rate using a five-point scale the presence
or absence, and the probability of malignancy of microcalcifications and masses.
ROC analysis, the sensitivities and specificities were used to analyze results.
Results: For the detection of lesions, the mean Az was 0.986 for the 3-M, and
0.978 for the 5-M LCD session. The mean sensitivity and specificity was 97.1 and
80.8% for the 3-M, and 97.8 and 81.5% for the 5-M LCD session (p 0.5). For the
characterization of lesions, the mean Az was 0.954 for the 3-M, and 0.953 for the
5-M LCD session. The mean sensitivity and specificity was 94.4 and 67.1% for the
3-M, and 95.2 and 66.4% for the 5-M LCD session (p 0.5).
Conclusion: The 3-M and 5-M LCD monitors are comparable in terms of detection
and characterization of microcalcifications and masses in digital mammograms.
Scientific and Educational Exhibits
C-083
Digital breast tomosynthesis: Approaching mammographic challenges
C. Malhaire1, F. Thibault1, C. Dromain2, A. Tardivon1, C. Balleyguier2,
A. Athanasiou1, C. El Khoury1, L. Ollivier1; 1Paris/FR, 2Villejuif/FR
([email protected])
Learning Objectives: To learn the basic principle of digital tomosynthesis. To
understand the expected advantages and current clinical issues. To illustrate
these through a panel of clinical cases investigated in a research study in the
diagnostic setting.
Background: A limitation of mammography comes from the overlaid breast tissue
on projection views of the breast where a lesion may be obscured. Obtaining 3D
imaging of the breast may help visualize abnormal findings. A series of 150 patients
was prospectively investigated using one MLO-view digital breast tomosynthesis.
Diagnostic performance was compared with that of standard digital mammography
and breast ultrasound.
Imaging Findings: Tomosynthesis best helped characterize masses’ margins.
Asymmetric densities were well identified. Multiple, as well as one-view only, lesions
were more easily localized. Microcalcifications were correctly detected with perception of their distribution within the breast. As a limitation, lesion detection could be
impaired in very dense breast parenchyma with almost no fatty contrast.
Conclusion: Digital tomosynthesis offers a detailed 3D visualization of the breast,
thereby gaining useful information relative to standard mammography. Wider clinical
evaluation will define the situations best served by this new tool.
C-084
Mammographic density estimation: Comparison among BI-RADS
categories - a semi-automated software and a fully automated one
A. Tagliafico, G. Tagliafico, C. Martinoli, S. Tosto, M. Calabrese; Genoa/IT
([email protected])
Purpose: Although breast density is considered a strong predictor of breast cancer
risk, its quantitative assessment is difficult. The aim of our study is to calculate breast
density with a semi-automated and a fully automated software and compare it with
quantitative BI-RADS standards
Methods and Materials: A data set of 180 mammograms was evaluated with
the semi-automated software, the fully-automated one and BI-RADS quantitative
assessment. Intra- and inter-observer variability of three readers who used the
semi-automated software was calculated. The mean of these values was used
as a reference standard and correlated with BI-RADS evaluation made by two
blinded radiologists. Comparison between the semi-automated software and the
fully automated was studied with Bland-Altman statistics.
Results: Intra- (reader 1: k=0.73; reader 2: k=0.75; reader 3: k=0.65) and interobserver (reader 1 vs reader 2: k=0.75; reader 2 vs reader 3: K=0.81; reader 3 vs
reader 1: k=0.75) variability for the semi-automated software among three readers
were good and correlated with BI-RADS evaluation made by the two radiologists
(r=0.65 p 0.01). The fully automated software eliminated intra- and inter-observer
differences, correlated with BI-RADS categories (r=0.61 p 0.01) and can replace
the semi-automated one.
Conclusion: Our study demonstrates that automated estimation of breast density
is feasible, eliminates subjectivity and is more accurate than BI-RADS quantitative
evaluation. CLINICAL RELEVANCE/APPLICATION: A fully-automated estimation
of breast density is feasible, eliminates subjectivity and can be used not only for
research purposes but also in the daily practice.
C-085
Impact of the introduction of digital mammography and a computer-aided
diagnosis system (CAD), on a multidisciplinary breast unit
C. Romero, M. Gª-Hidalgo, C. Varela, A. Almenar, I. Herrera, J. Pinto; Toledo/ES
([email protected])
Purpose: To evaluate the impact that the introduction of digital mammography (DM)
first, and a computer-aided diagnosis (CAD) system later, had on breast cancer
diagnostic rate at a multidisciplinary breast unit.
Methods and Materials: We conducted a retrospective study that looked at 4164,
4204, and 4315 mammograms for 3180, 4034, and 4117 women for the first six
months of 2003, 2006, and 2007, respectively. We reviewed the images and reports
for all cases in the study. Only cases with diagnostic imaging features suggestive
of malignancy were included. #2 tests were carried out using SPSS after the
sample’s homogeneity was proved. We calculated total number of carcinomas
(including in situ carcinomas), their histological patterns and size, and interventional
procedures´ rate. We describe the comparative results for each of the three study
periods, which relate to diagnostic imaging by conventional mammography, DM,
and CAD with DM, respectively.
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Results: The introduction of DM meant a reduction in tumour size at diagnosis for
carcinomas T1 (p = 0.02). This was also the case following the addition of CAD.
There were no statistically significant differences between the three diagnostic
imaging techniques for the distribution of imaging findings, although a 9% increase
in the detection rate for microcalcifications was noted.
Conclusion: The digitalisation of mammography and the later introduction of CAD
meant a non significant improvement in breast cancer detection rate (p=0.06) at
our Unit. Nevertheless, a significant reduction in tumour size upon diagnosis was
observed with an overall increase in T1 carcinomas (p = 0.02).
Scientific and Educational Exhibits
Breast
MRI
C-086
Predictive value for malignancy of suspicious breast masses of BI-RADS
category 4-5 using ultrasound elastography and MRI diffusion-weighted
imaging
H. Satake, A. Nshio, M. Ikeda, S. Ishigaki, M. Kawamura, K. Shimamoto,
H. Kawai, S. Naganawa; Nagoya/JP
Purpose: To evaluate the predictive value for malignancy of ultrasound elastography
(USE) and MRI diffusion-weighted imaging (MRI-DWI) regarding breast mass of
BI-RADS category 4-5.
Methods and Materials: The subjects were consecutive 63 suspicious breast
masses classified as BI-RADS category 4 or 5. All patients were recommended
for biopsy and were confirmed pathologically (19 benign, 44 malignant). In addition
to the routine clinical examinations of mammography, ultrasound, and dynamic
contrast-enhanced MRI, USE and MRI-DWI were also obtained. Two radiologists
retrospectively evaluated elasticity score of USE, and calculated apparent diffusion coefficient (ADC) values on MRI-DWI. According to the several reports, the
cut-off levels of elasticity score was defined as between scores 3 and 4. Optimal
cut off levels of continuous ADC values were determined by estimating the receiver
operating characteristic curves. The diagnostic abilities to differentiate malignant
from benign lesions were analyzed by using univariate and multivariate logistic
regression analyses.
Results: The sensitivity, specificity, and accuracy were 84.0, 68.0, and 79.3% for
elasticity score and 75.0, 74.0, and 74.6% for ADC values, respectively. All four
cases with elasticity score 1 were proved to be benign pathologically. Although
both elasticity score and ADC values were shown to provide the significant criteria
for differentiating malignancy from benign in the univariate analysis, only elasticity
score was the significant predictor in the multivariate analysis.
Conclusion: Our results show that USE is the examination that can add more
reliable information to a recommendation for biopsy in the breast masses classified
as BI-RADS category 4-5, compared with MRI-DWI.
C-087
Evaluation of neoadjuvant chemotherapeutic effects of breast cancer by
MRI: Accuracy of MRI in predicting pathological complete response
N. Gomi, A. Khono, Y. Yamamoto; Tokyo/JP
Purpose: The importance of the evaluation of pathological complete response
(pCR) has been confirmed by the fact that there is a close correlation between pCR
to neoadjuvant chemotherapy (NAC) and prognosis for breast cancer. The objective
of our study was to evaluate the accuracy of MRI in predicting CR after NAC.
Methods and Materials: 305 women with stage IIB-III palpable solid breast cancer underwent dynamic contrast-enhanced T1WI of the entire breast, before and
after NAC. On imaging, complete response (iCR) was defined as no enhanced
tumor on all serial images. All patients underwent radical or conservative surgery
between Jan. 2005 and Dec. 2007, and imaging findings were compared with
pathologic findings.
Results: 43 out of 305 patients had iCR after NAC. 23 out of the iCR (53%) were
identified correctly with pCR (no histological evidence of invasive tumor cells). Yet
in 20 out of iCR patients (47%), MRI underestimated the residual tumor. In 17 out
of the 20 patients who were underestimated on MRI, resected specimens showed
marked response to chemotherapy and only a small amount of residual tumor
was detected. In 3 out of 20 patients who were underestimated on MRI, resected
specimens showed mild response to chemotherapy, and considerable amount of
residual tumor among fibrotic change was detected.
Conclusion: MRI seems to reflect pathological conditions after neoadjuvant chemotherapy effectively, and appears to provide good correlation with pCR. 53% of
the patients who were evaluated as iCR were pCR.
C-088
Morphological and kinetic characteristics of dynamic CE-MRI correlated
with histopathological factors of breast cancer: A potential prognostic role
of breast MRI?
T. Kanavou, M. Vlychou, A. Poultsidi, E. Athanasiou, M. Ioannou, I. Fezoulidis,
K. Vassiou; Larissa/GR ([email protected])
Purpose: To explore the correlation of morphological and kinetic DCE-MRI features
with histopathological prognostic factors of invasive breast cancer.
Methods and Materials: Fifty-one women with 57 cancerous lesions underwent
DCE-MRI prior to surgery. DCE-MRI findings were interpreted with a multifactorial
classification system that included morphological (shape, margins and pattern of
enhancement) and kinetic characteristics (initial signal increase and postinitial
behaviour of the time-signal intensity curve). Each morphological and kinetic parameter was scored with 0, 1 or 2 points and the total score was estimated. Finally,
each lesion was classified into one of the five categories that correspond to the five
ACR BI-RADS categories. Statistical analysis was performed to correlate DCE-MR
imaging parameters and histopathological findings using Fisher’s exact test and
stepwise multiple regression analysis.
Results: Increase of the signal intensity at the initial phase 100% was strongly
correlated with positive lymph nodes (p=0.008, OR 0.054). Types I and II time-signal
intensity curves at the postinitial phase were associated with a 4-fold increase in
the likelihood of progesterone receptors positivity (p=0.022, OR 4). Finally, high
total score was positively correlated with affected lymph nodes (p=0.033, OR
0.29). There was a statistically significant trend regarding ill-defined margins of
the tumor (p=0.08) and vascular infiltration and also high score and neural infiltration (p=0.072).
Conclusion: A multivariate interpretation model for DCE-MRI that includes
morphological and kinetic characteristics has prognostic value for invasive breast
cancer. Early initial contrast agent uptake and a high overall score are associated
with poor prognostic factors.
C-089
The factors influencing perifocal high signal intensity surrounding breast
lesions on T2-weighted images of breast MRI
K. Nakashima1, H. Ishimaru1, I. Isomoto2, K. Ishimaru3, T. Koshiishi1, N. Taura1,
S. Maeda1, H. Toyama1, M. Ito1, Y. Matsuoka1; 1Omura/JP, 2Nagasaki/JP,
3
Isahaya/JP ([email protected])
Purpose: Breast MRI often demonstrates perifocal high signal intensity (PH)
surrounding contrast-enhanced lesions, especially in breast carcinomas, on T2weighted images (WI). Some authors speculated that PH reflects edema due to
lymphatic involvement and one of the indicators of malignancy. However, the other
factors that may influence PH have not been established. Our purpose is to clarify
the factors influencing PH.
Methods and Materials: 131 patients with breast cancer and 48 patients with
benign lesion examined by MRI at 1.5 T were included. Coronal fat-suppressed
T2WI (section thickness 2-4 mm, matrix 512×512, field of view 25 cm), Gd-enhanced
dynamic T1WI, and postcontrast 3D T1WI were retrospectively evaluated to determine the presence of PH. Candidate factors including patient’s age, lesion’s signal
intensity on T2WI, homogeneity of enhancement, dynamic time course of enhancement, size, shape, margin, histopathology, and peritumoral lymphatic invasion (LI)
were evaluated with univariate and multivariate logistic regression analyses to find
the independent factors influencing PH.
Results: 2 of 9 factors (patient’s age and lesion’s margin) showing P 0.20 in
univariate analysis were excluded in multivariate analysis. LI [observed in 26/35
(74%) of lesions with PH vs 53/144 (37%) of lesions without PH; odds ratio, 3.6]
was the only valuable predictors for PH at multivariate analysis (p=0.006).
Conclusion: In 9 factors analyzed here, LI was the only valuable factor influencing PH.
Breast
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Scientific and Educational Exhibits
C-090
Correlation of breast ultrasound (US) elastography and MR imaging:
correlation of elastography score (ES) with short Tau inversion recovery
(STIR) MR images, enhancement ratio, apparent diffusion coefficient (ADC)
and fibrotic changes of breast disease
R.N. Matsubayashi, M. Imanishi, K. Yasumori, T. Muranaka, S. Momosaki;
Fukuoka/JP ([email protected])
Purpose: US elastography provides information regarding tissue hardness, and
is expected to become a novel diagnostic tool for breast disease. On the other
hand, MR images reflect the tissue characteristics. Fibrosis of the stroma of breast
diseases may affect the hardness of them. We investigated the correlation between
ES and signal-intensity (SI) of STIR MR images, enhancement ratio, ADC, and the
fibrosis in the breast lesions.
Methods and Materials: We reviewed the findings of US elastography and MRI
from 41 consecutive patients with breast lesions (25 invasive ductal carcinoma,
3 fibroadenoma, 1 phyllodes tumor, 2 ductal hyperplasia, 2 primary malignant
lymphoma, 3 mastopathy, 1 metastasis, 1 tubular adenoma, 1 ductal carcinoma
in situ, 1 diabetic matopathy and 1 intraductal papilloma). In each patient, elastography images were classified based on Tsukuba ES. We calculated the ratio of
SI of the lesion to muscle on STIR images (L/M ratio), enhancement ratio of early
to pre-contrast (E/P) and early to delayed (E/D) images and ADC for each lesion.
The ES and MR findings were correlated with the degree of fibrosis (based on
Masson trichrome stain).
Results: The ES significantly correlated with the L/M ratio (p=0.0306) and the ADC
(p=0.0256). The stromal fibrosis also correlated with ES (p=0.0023), the L/M ratio
(p=0.0344) and the E/D ratio (p=0.049).
Conclusion: The ES and L/M ratio are correlated significantly each other, and
they are correlated with the fibrosis. These results suggest that they will provide
the information of fibrosis, and may help the diagnosis of breast lesions.
C-091
Usefulness of diffusion-weighted imaging for detecting breast tumors as
screening modality: Comparing with breast US and dynamic contrastenhanced MRI
J.E. Lee, J.H. Lee, H.Y. Choi, S.Y. Baek; Seoul/KR
Purpose: To evaluate the usefulness of diffusion-weighted imaging (DWI) for
detecting breast tumors, as compared with breast ultrasound and dynamic contrastenhanced MRI.
Methods and Materials: Eighty-two patients who received mastectomy or breast
conserving surgery for breast cancer between February 2007 and April 2008 were
included. They had preoperative breast US and breast MRI within one month before
breast surgery. Dynamic contrast-enhanced images of MR were used as a reference
image for detecting tumor. We compared the detectability of breast lesions on DWI
with that of US. We also compared the detectability of coincidental probable benign
breast lesions for screening tool.
Results: Among 82 histopathologic proved malignant lesions, 80 lesions were
detected on DWI (detectability 97.6%) and 80 lesions were detected on US (detectability 97.6%). Of nine suspicious lesions for DCIS such as segmental or linear
clumped enhancement on dynamic contrast-enhanced images, 8 lesions (88.9%)
were found on DWI and 5 lesions (55.6%) were found on US. 35 lesions were noted
as coincidental probable benign lesions and 24 lesions were histopathologic proved
as benign lesions such as fibrocystic disease (12), fibroadenoma (5), fibrosis (4),
sclerosing adenosis (3) and the others are not confirmed by histopathology. Of
these, 34 lesions (97.1%) were detected on US, but only 18 lesions (51.4%) were
detected on DWI.
Conclusion: DWI had a high sensitivity for detecting malignant breast tumors
similar to US and dynamic contrast-enhanced images. However, benign lesions
on DWI were found with lower sensitivity than US. Then, DWI is not more sensitive
than US to detect breast tumors. We concluded that DWI is not useful for additional
screening modality.
C-092
Does breast MRI help us differentiate uncommon malignant breast tumors
from invasive ductal carcinoma?
O. Woo, S. Huh, A. Yi, K. Cho, B. Seo, A. Kim, E.-Y. Kang; Seoul/KR
([email protected])
Learning Objectives: To describe MRI findings of uncommon malignant breast
tumors, focusing on both the morphologic and dynamic enhancement patterns
with pathologic correlation. To identify MRI characteristics that aid in making a
correct diagnosis.
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Background: Although it is a challenging task for the radiologist to differentiate
pathologic subtypes of breast cancers owing to the overlap of radiologic findings
between them, certain types of uncommon malignant breast tumors have characteristic radiologic features that may help in the diagnosis of a specific subtype. This
exhibit illustrates the MRI findings of pathologically confirmed uncommon malignant
breast tumors of the breast and axilla.
Imaging Findings: We reviewed a wide spectrum of uncommon malignant
breast tumors: papillary carcinoma (n=13), mucinous carcinoma (n=7), medullary
carcinoma (n=3), tubular carcinoma (n=3), metaplastic carcinoma (n=4), apocrine
carcinoma (n=8), malignant phyllodes tumor (n=5) and primary breast lymphoma
(n=2). Mucinous, medullary, intracystic papillary carcinoma and metaplastic carcinoma showed benign morphologic characteristics. Mucinous and tubular carcinoma
present type I persistent enhancement pattern on MRI. Especially, internal cystic
portion of papillary carcinoma and mucinous carcinoma showed characteristic
high signal intensity on T2WI.
Conclusion: Breast MRI can help in the interpretation of specific pathologic
diagnosis, combining T2 high signal intensity, morphologic features and dynamic
enhancement pattern. Several subtypes of carcinomas may show persistent
enhancement pattern (tubular carcinoma) or benign morphologic characteristics
(mucinous and medullary carcinoma) on MRI, giving rise to possible diagnostic
pitfalls. Familiarity with radiologic findings of these tumors can aid in making the
correct diagnosis and avoiding misinterpretation of MRI findings.
C-093
Impact of the arterial input function assessment on the kinetic parameter
measurements and on the final response evaluation of breast cancer to
chemotherapy at contrast-enhanced MR imaging
C. de Bazelaire, C. Brunon, C. Farges, M. Albiter, L. Fournier, N. Siauve,
E. de Kerviler, O. Clément, C.A. Cuenod; Paris/FR
([email protected])
Purpose: To determine whether calculated or measured arterial-input-function
(AIF) at low-temporal-resolution dynamic-contrast-enhanced MRI (DCE-MRI)
yielded kinetic parameters that could be used to predict final pathologic response
to neo-adjuvant chemotherapy in breast cancer.
Methods and Materials: DCE-MRI were performed in women with breast cancer
before (n=35) and after treatment (n=24). High-spatial-resolution DCE-MRI included 8
series of 1.11 minute-acquisitions. Kinetic parameters (transfer constant, Ktrans; leakage
space, Ve) were calculated for tumors using measured or calculated-AIF. Differences
between the two AIFs and kinetics parameters issued from both AIFs were analyzed.
Changes in kinetic parameters after treatment obtained with both AIFs were correlated with final pathologic response and accuracies to identify non responders were
compared with area under receiver operating characteristic curves.
Results: Low-values of calculated-AIFs were overestimated whereas high-values
were underestimated. With calculated-AIF, similar errors were observed for Ktrans
values whereas Ve was globally overestimated. With measured-AIF, significant
changes in Ktrans and Ve were noted between non-, partial-, and complete responders
(Kruskal-Wallis test, P=0.0317 and P=0.0220, respectively). No differences in kinetic
parameters using calculated-AIF were seen with respect to response. A decrease
in Ve of less than -85% and less than -90% for Ktrans with measured-AIF resulted in
91% sensitivity for identifying non-responders (specificity=54%, area=0.83 for Ve;
specificity= 61%, area=0.80 for Ktrans). With calculated-AIF, these cutoff values had
lower accuracy (sensitivity=84%, specificity=23%, area=0.74 for Ve; sensitivity=55%,
specificity=46%, area=0.48 for Ktrans).
Conclusion: The use of measured-AIF rather than calculated-AIF tends to
improve accuracy in kinetic parameter measurements and treatment response
evaluation.
C-094
Molecular breast cancer subtypes: Accuracy of breast magnetic resonance
imaging predicting response to neoadyuvant chemotherapy
F. Jimenez Aragon, C. Bernal Lafuente, C. García Mur, M. Beltrán Marín,
L. Martínez Comín, R. Gomez Pereda; Zaragoza/ES ([email protected])
Purpose: Breast cancer is a clinically heterogeneous disease. A new molecular
classification based on gene expression studies divides it into three major subtypes:
triple negative (TN), HER2+, and luminal. Each one has shown different prognosis
and response to neoadjuvant chemotherapy (NAC). The objectives of this study
are: - To evaluate with magnetic resonance imaging (MRI) the response to NAC
of the three molecular subtypes of breast cancer. - To compare the radiological
response (RR) in MRI with the pathological response (pR), calculating the correlation index.
Scientific and Educational Exhibits
Methods and Materials: A total of 160 patients in whom core biopsy had confirmed
the presence of breast cancer underwent breast MRI prior to beginning NAC and
before surgical excision. Based on the MRI findings, patients were divided into
four groups: Non Response (NR), Major Parcial Response (MPR), Minor Partial
Response (mPR), and Complete Response (CR). The pR was based on the Miller
& Payne Scale, which divides the response into five categories (G1-G5).
Results: Of the 161 patients, 91 were into the luminal subtype, 39 HER2+ and
31TN. The MRI results showed 51.3% of RC in the HER2+ subtype and 41.9% in
the TN. The correlation index between the pR and RR was bigger in the TN (0.901
Pearson coefficient, p 0.0001).
Conclusion: There is a high correlation between PR and RR in all molecular breast
cancer subtypes. HER2+ and TN subtypes have the best rates of RC to NAC in
spite of their worse prognosis.
C-095
Apparent diffusion coefficient value and correlation with tumor grading
and histology in breast cancer patients undergoing DWI
E. Bufi, M. Costantini, P. Belli, C. Ierardi, R. Lombardi, L. Bonomo; Rome/IT
([email protected])
Purpose: To investigate the predictability of tumor grade, histology and invasivity in
breast cancer patients by means of the apparent diffusion coefficient (ADC) values
obtained with the DWI sequence.
Methods and Materials: From April 2005 to June 2008, 133 patients (a total of
160 breast lesions) with proven breast cancer underwent breast MRI including the
DWI sequence. For each breast lesion, the ADC value was calculated. Grading was
assessed by the Nottingham system. Kendall’s rank-correlation coefficient (tau) was
used to analyze the correlation between ADC and grading.
Results: Pathological analysis revealed invasive ductal carcinoma (CDI) in 123
cases (76.9%), invasive lobular carcinoma (CLI) in 14 cases (8.8%), in situ ductal
carcinoma in 16 (1%), invasive tubular carcinoma in 2 (1.3%) and mixed tubular and
lobular invasive carcinoma in 6 (3.8%). There were 20 (12.5%) grade 1, 68 (42.5%)
grade 2 and 72 (45%) grade 3 lesions. We observed a trend towards lower mean
ADC value for invasive carcinomas vs. in situ lesions (p=0.42, t-test) and a statistically difference between CDI and CLI (p=0.01, t-test). Mean ADC value for grade
1, 2 and 3 tumours was 1.17x10-3 mm2/s, 0.99x10-3 mm2/s and 0.89x10-3 mm2/s,
respectively (p 0.001 at one-way ANOVA). A statistically significant (p 0.001)
inverse correlation (Kendall's tau -0.279) was disclosed between the ADC value
and the tumor grading.
Conclusion: DWI and ADC provide consistent information to support MRI diagnosis
of breast cancer and are therefore promising parameters in the evaluation of the
tumor grading and histology.
C-096
The value of MR and MR-guided vacuum biopsy of the breast in selected
diagnostically difficult cases
S.D.F. Rego1, S.H. Heywang-Köbrunner2, A. Heinig3, B. Amaya3;
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Texture analysis of breast lesions enhancement kinetics in dynamic
contrast enhanced MRI: Correlation with histology
A. Karahaliou1, K. Vassiou2, T. Kanavou2, M. Vlychou2, N. Arikidis1,
S. Skiadopoulos1, L. Costaridou1; 1Patras/GR, 2Larissa/GR
([email protected])
Purpose: To investigate correlation between texture features extracted from
enhancement kinetics feature maps and histopathological prognostic factors in
invasive breast cancer.
Methods and Materials: 37 women with invasive breast cancer (40 lesions)
underwent preoperatively DCE-MRI, with 1.5 T system. Coronal 3D T1-weighted
spoiled gradient echo sequence was acquired before and five times after intravenous
administration of gadopenate dimeglumine (0.2 mmol/kg). For a selected slice, most
representative of the lesion, a bilinear model was fitted pixel-wise to corresponding time series and fitted parameters were used to create 3 kinetic feature maps:
peak-enhancement (PE-map), time-to-peak-enhancement (TPE-map) and wash-out
(W-map). 12 second order statistics texture features were extracted from each lesion
kinetic map and correlated with histopathological and immunohistochemical factors
employing univariate (Spearman rank-order correlation, binary logistic regression)
and multivariate (binary logistic regression and multiple regression with forward
selection) statistical analysis.
Results: Inverse-different-moment (W-map) was found to be a significant and
independent predictor of both histological grade (p=0.034) and estrogen receptors
(p=0.031). Difference-entropy (W-map) was independently associated with in situ
component (p=0.021). Sum-entropy (W-map) was found to be a significant and
independent predictor of both Her2/neu overexpression (p=0.046) and estrogen
receptors (p=0.044). Entropy (PE-map) and Sum-entropy (PE-map) were independently associated with tumor size (p=0.002) and progesterone receptors (p=0.046),
respectively. Information-measure-of-correlation-1 (TPE-map) and sum-entropy
(TPE-map) were found to be significant and independent predictors of lymph node
status (p=0.011) and neural infiltration (p=0.041), respectively.
Conclusion: These preliminary results suggest that texture analysis of breast lesions enhancement kinetics may contribute in preoperatively identifying malignant
lesions with different biological behaviour.
C-098
Pitfalls in breast MRI imaging
G. Argento, F. Capparella, C. Porcari, W. Calandro, E. Iannicelli, B. Sessa,
V. David; Rome/IT ([email protected])
Learning Objectives: MRI imaging of the breast has evolved into an important
adjunctive tool in breast imaging with multiple and ever increasing indications for
its use. As with other types of MRI imaging, there are a number of technical artifacts and pitfalls that can potentially limit interpretation of the images by masking
or simulating disease.
Background: Between Oct 2007 and Sept 2008 we studied 106 Pt, age 30-60 aa.
All of them came with a mammography and US imaging and a confirmed biopsy
diagnosis of breast cancer.
Imaging Findings: Most common pitfalls were: breast with BIRADS IV pattern with
high representation of fibroglandular tissue with poor adipose component; breast
volume exceeding breast coil dimension with tissue outside FOV; errors in contrast
venous administration: poor quantity or incorrect timing; poor fat saturation; bad
breast positioning inside coil; ipervascularity pattern in post-radiotherapy exams
or surgical granulation tissue.
Conclusion: A correct approach breast MRI imaging interpretation as to consider
pitfalls as potential causes of incorrect diagnosis or staging.
Breast
Purpose: To determine the value of MR in the diagnostic problem resolution in
cases that cannot be adequately solved by conventional imaging (mammography
and ultrasound) and clinical findings.
Methods and Materials: Between 1997 and 2001, 262 patients with alterations
that became evident in a mammography and without a correlation with additional
scans or ultrasound underwent breast contrast-enhanced MR.
Results: Among 262 patients, 145 did not show alterations; 27.5-month follow-up
was performed through MR (30 patients), MR/MM (14), MM (40), MM/US (35), US
(2), obit (3) and no control in 21 patients. In 117 patients with alterations, biopsy
was indicated in 73 cases (23-month follow-up), control through MR in 10 patients
(11.6-month follow-up) and through MM in 34 patients (27-month follow-up). Among
the 73 cases in which the histopathologic study was indicated, 58 patients did the
procedure (25 malignant, 1 LCIS, 32 found benign), in 3 patients the lesions were
not visible at the time of the biopsy and 12 did not undergo the procedure.
Conclusion: MR and MR-guided vacuum biopsy of the breast contributes towards
a correct diagnosis in problematic cases, which could not be clarified with only
mammography and ultrasound, 10% of these cases having been found to be
malignant.
C-097
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C-099
Metaplastic breast carcinoma: Radiologic findings with pathologic
correlation
J. Hernández Gañán, A. Gumà Martínez, R. Ortega Martínez, M. Lerin Martos,
M. Soler Monsó, L. Prieto Álvarez; L’Hospitalet de Llobregat/ES
([email protected])
Learning Objectives: To review mammographic, ultrasonographic and magnetic
resonance findings in 26 cases of metaplastic carcinoma of the breast (MCB). To
correlate the radiological features with clinical and histopathologic findings.
Background: MCB accounts for less than 5% of breast carcinomas. It is a rapidly
growing, palpable mass with mixed epithelial and mesenchymal differentiation. We
reviewed 26 metaplastic carcinomas diagnosed between 1996 and 2008. Patients’s
age ranged from 31 to 93 years (mean 53.2). Mammography was performed to
all 26, ultrasound to 23 and magnetic resonance to 6 cases. Radiologic findings
were classified according to the ACR BIRADS classification. Pathologically, size,
tumor type and presence of necrosis and osteoclast-like cells were assessed, and
immunostains for oestrogen and progesterone receptors, HER2, and markers of
mesenchymal, epithelial and myoepithelial cells were performed.
Imaging Findings: At mammography, 69% of tumors were round or lobular,
76.9 % had circumscribed or indistinct margins and only five had calcifications.
At ultrasound, 86.9% of tumors had circumscribed or microlobulated margins and
heterogeneous echogenicity with both solid and cystic areas and posterior acoustic
enhancement were seen in 56.5%. At MR, all tumors had type 2 or 3 enhancement
and four had cystic areas. At pathology, adenocarcinoma with squamous metaplasia, pure squamous carcinoma, spindle differentiation, chondroid elements and
osteoclast-like giant cells were seen.
Conclusion: Radiologists must be aware of these imaging findings, because
metaplastic carcinoma tends to show benign imaging features, such as round or
lobular shape with circumscribed margins, but biologically it is an aggressive tumor
with poor prognosis.
C-101
Benign breast lesions mimicking breast cancer: What do you need to know
A. Silva1, R. Sinnatamby2, P.D. Britton2, J. Venancio1, M. Ribeiro1; 1Matosinhos/PT,
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Cambridge/UK ([email protected])
Learning Objectives: Describe the various causes of benign breast lesions that
may mimic carcinoma on mammograms. Highlight the importance of an integrated
approach to these lesions that includes clinical presentation, imaging and cytology/histology to get to the correct diagnosis and prevent unnecessary surgical
intervention.
Background: Many benign breast lesions pose diagnostic challenges. It is important
for radiologists to be familiar with these benign lesions to avoid unnecessary surgery
on one hand or to plan the appropriate surgical procedure if needed.
Imaging Findings: This exhibit aims to do a pictorial review of the imaging features
of carcinoma-mimicking benign lesions with pathologic correlation. These lesions
include abscess, hematoma, radial scar, postsurgical scar, diabetic mastopathy, fat
necrosis, focal fibrosis, sclerosing adenosis, granular cell tumor, extraabdominal
desmoid tumor, medial insertion of pectoralis muscle or sternalis muscle, and axillary
lymphadenopathy for different causes other than breast disease.
Conclusion: Benign breast lesions are common and sometimes assume an aggressive appearance. Familiarity with its imaging findings and pathological correlation
is important to plan the appropriate plan of action.
C-102
Breast cancer in young women: Clinical, radiological and pathological
features
R. Lombardi, M. Costantini, P. Belli, M. Romani, G. Franceschini, L. Bonomo;
Rome/IT ([email protected])
Purpose: To study clinical, radiological and pathological findings of breast cancer
in women aged b 40.
Methods and Materials: We studied all the young women with pathological diagnosis of breast cancer who underwent radiological examinations and surgical
treatment in our hospital from March 2000 to June 2007. We describe clinical and
radiological patterns and we correlate imaging findings to histology and biological
markers.
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Results: We enrolled in this study 161 female patients b40 years with breast cancer.
We obtained a prevalence of 10.76%. An increase of breast cancer cases during
the considered period was noted. Mean age of our patients was 35.1 years. 24.3%
of patients had breast cancer familial history. At diagnosis, 96.27% of patients were
symptomatic: palpable mass or breast hardening was present in most cases. Mean
size of cancer at diagnosis was 26.10 mm. Diagnostic accuracy in breast cancer
detection and characterization was higher in ultrasonography than in mammography
(sensitivity, respectively, 67.08 and 90.06%). Histology revealed 77.64% cases of
IDC and most cases of grade 2 and 3 carcinomas. 55.3% of patients were lymph
nodes positives; 9 patients had metastases at diagnosis. Biological evaluation
revealed a high frequency of estrogen and progesterone receptor negatives and
frequent Ki67, c-erbB-2 and p53 positives. Statistical tests showed significant correlations between biological findings and radiological features.
Conclusion: Our study confirms the significant incidence and the high aggressiveness of breast cancer in young women. Our experience led us to reaffirm the importance of clinical examination and prompt imaging evaluation in young women.
C-103
Cancer detection in early recall patients in the all Wales breast screening
program (breast test Wales)
S.H. Bolt, P. Young; Cardiff/UK ([email protected])
Learning Objectives: To analyse the cancer detection rate and associated imaging features in patients placed on early recall in the Welsh screening program. To
review their management at the first assessment clinic.
Background: A search was made for all early recall episodes from 01/04/02 to
31/03/08. This yielded 754 women, 27 of whom developed breast cancer. NHS
BSP target standard requires less than 0.25% of women screened to be put on
early recall. Our rate was 0.14%.
Procedure Details: Of the 27 women with cancer, 17 were diagnosed within 12
months of the initial assessment. At the first visit, only 13 of the 27 had an attempt
at biopsy. Six of these were inadequate or technically difficult. Of the fourteen who
did not undergo biopsy at this first visit, thirteen had normal ultrasound scans; one
had neither. The mammographic appearances were varied with no trend identified.
Six of the 27 cancers required open surgical biopsy for diagnosis; four of these were
for calcification. Eighteen of the cancers were invasive, nine were DCIS.
Conclusion: Early recall can induce anxiety. It is therefore important to minimise
the number referred this way and optimise assessment at first visit. The cancer
detection rate was 3.6% in this cohort, compared with 0.8% for the general screening population. Early recall therefore remains a valid management option. We
recommend biopsy is attempted in all women, even if the ultrasound is normal,
before using early recall.
C-104
Flat epithelial atypia (FEA): Clinical-radiological and pathological
correlation
M. Cara García, M. Alvarez Benito, E. Fuentes Vaamonde, M. García Ortega,
J. Raya Povedano, B. Cajal Campo; Córdoba/ES ([email protected])
Purpose: Assess in patients with FEA: the clinical and radiological manifestations,
the accuracy of percutaneous biopsy, its association with other high-risk lesions or
carcinoma, and its prognosis, for the purpose of registering its management.
Methods and Materials: Retrospective study based on reviews of clinical histories
of patients with result of FEA in percutaneous breast biopsy (PB) and/or surgical
biopsy (SB) in the period April 05-May 08. The results of percutaneous biopsy and
surgical biopsy are correlated in order to calculate the rate of underestimation of
the percutaneous biopsy.
Results: 30 patients have been detected with result of FEA in mammary biopsy:
20 patients with result of FEA in PB. The SB confirmed the diagnosis of FEA in all
of them, demonstrating in addition another high-risk lesions in 8, and carcinoma
in 3. 4 with result of FEA and carcinoma in PB. 6 with diagnosis of FEA in SB (5
of them with percutaneous diagnosis of carcinoma). The majority of the patients
(83.33%) were `asymptomatic` at the moment of the diagnosis. The most frequent
radiological manifestation has been microcalcifications (80%). FEA has been associated with other high-risk lesions in 33.33%, and with carcinoma in 40%. Rate
of underestimation for patients with result of FEA in PB of 15%.
Conclusion: In patients with result of FEA in percutaneous mammary biopsy, surgical biopsy should be carried out. A specific monitoring is recommended for these
patients, some authors proposing prophylactic measures (chemoprevention).
Scientific and Educational Exhibits
C-105
Metastatic disease to the breast
A. Salgado, F. Pires, J. Loureiro, A. Aguiar, A. Guimarães, M. Gouvêa; Porto/PT
Learning Objectives: To recognize the clinical and imaging features of breast
metastasis from extramammary malignancies.
Background: Metastatic lesions to the breast are unusual. The most common
source is melanoma, but a wide variety of other tumors may secondarily involve
the breast. Although breast involvement occurs late in malignant disease, imaging
studies are indicated to reinforce the clinical suspicion of metastasis, to exclude a
primary breast tumor and to serve as a baseline for evaluation of therapy.
Procedure Details: We evaluated 17 cases of metastatic lesions of nonbreast origin
from our pathology database. The clinical and imaging features were retrospectively
reviewed and findings were correlated with pathology.
Conclusion: The radiologist is sometimes asked to evaluate breast masses discovered in patients with known extramammary malignancy. Thus, it is important
to recognize the clinical and radiographic distinctions between a metastasis and
a primary breast cancer.
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C-106
Mammographic and ultrasonographic findings after oncoplastic
techniques and breast reconstruction for breast cancer
A. Valdivielso Ortiz, P. Vera Aguila, A. Gumá Martinez, A. Lopez Ojeda,
A. Lopez Martinez, L. Prieto Alvarez; Barcelona/ES ([email protected])
Learning Objectives: To describe mammographic and ultrasonographic findings
in patients treated for breast cancer with oncoplastic techniques in conservative
surgery and with breast reconstruction techniques in mastectomy. We review normal
and pathologic findings and signs of recurrence.
Background: Oncoplastic techniques after breast-conserving therapy and breast
reconstruction techniques after mastectomy are a treatment choice for women with
breast cancer, being an alternative treatment to conventional surgery in specialized
centers. Both techniques include tissue expanders, prosthesis and autologous
tissue (latissimus dorsi, rectus abdominis, gluteus maximus myocutaneous flaps),
as well as remodeling and breast reduction in oncoplasty. We review exams performed in 355 patients treated between 2004 and 2007; 243 patients were treated
with mastectomy and breast reconstruction, and 112 with conserving therapy (20
hemimastectomy). Sixty-one patients had bilateral reduction mammoplasty, 17
tumorectomy and remodeling, 196 reconstructions with myocutaneous flaps only,
51 autologous flaps with implant, and 25 patients only implant.
Imaging Findings: Fat density surrounded by dense band and muscle fibers inside
is a normal finding of myocutaneous flaps. Implant wrinkles are seen with saline
implants. Parenchymal redistribution inferiorly, distortion and elevation of nipple
are normal findings in reduction mammoplasty. Abnormal findings are fat necrosis,
dystrophic calcifications, epidermal inclusion cysts and recurrent carcinoma.
Conclusion: Treatment of breast cancer with oncoplastic techniques has increased
in popularity. Mammography and ultrasound provide excellent visualization of
normal and pathologic findings in reconstructed breasts. For a better follow-up of
these patients, radiologists dedicated to breast pathology need to be familiarized
with these radiologic findings.
C-107
Automated breast ultrasound: A valid diagnostic tool in breast evaluation
D. Miranda1, R. Duarte2, J. Costa3; 1Matosinhos/PT, 2Vila Nova de Gaia/PT,
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Viana do Castelo/PT
Learning Objectives: To evaluate the accuracy of automated breast ultrasound
(ABUS) based on the literature review. To outline the advantages and limits of the
technique. To illustrate the spectrum of imaging findings of benign and malignant
breast disease.
Background: The ABUS provides 3D ultrasound images of breast tissue. The
integrated workstation allows the operator to select individual diagnostic planes,
S
including a high-resolution coronal view, not achievable onO
2D ultrasound. Handheld
P scanning practices are
breast ultrasound is significantly operator dependent Eand
highly variable. This technique allows a consistent and
to uniform approach of breast
dcomparisons of ultrasonography
scanning in reducing operator variability. Exact
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itt
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and follow-up of breast disease of the same
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permits a confident full coverage of the
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Imaging Findings: The imaging rfindings
obtained with ABUS presented a good
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correlation with conventionalasonography.
In this exhibit, we will illustrate the
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spectrum of breast abnormalities
(benign and malignant) acquired with ABUS
with 3D rendering.
No
Conclusion: The ABUS permits a uniform and consistent evaluation of breast
tissue, which adds confidence to ultrasound breast analysis. The quality of the
high-resolution images as well as 3D rendering images correlate well with the findings obtained with handheld ultrasonography. Based on this, ABUS is a valuable
diagnostic tool in evaluating breast abnormalities.
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C-108
Mimickers of malignancy and pitfalls in breast ultrasound
K.J. Jayapragasam, A. Yang Faridah; Kuala Lumpur/MY ([email protected])
Learning Objectives: To identify benign lesions that share malignant ultrasound
imaging features and to identify malignant lesions with atypical appearance.
Background: Analysis of the sonomorphology of breast nodules can permit their
classification into benign, malignant, and indeterminate categories. Nodules that
do not fulfill the strict criteria for benignity are considered either indeterminate or
malignant and biopsied. It is important for radiologists and clinicians to understand
the spectrum of imaging features to establish decision criteria for managing patients
Histopathology of indeterminate lesions was compared to the general sonographic
appearance based on its shape, margins, width-AP ratio, echogenicity, posterior
acoustic artifact, pseudocapsule and vascularity.
Imaging Findings: Presence of regular margins, gentle lobulations, posterior
acoustic enhancement, thin boundary and homogenous echo texture increases
the diagnostic confidence of a benign lesion. Atypical fibroadenomas, granulomatous mastitis radial scar, fat necrosis, papilloma, fibrocystic changes, sclerosing
adenosis, fibrosis, pseudoangiomatous stromal hyperplasia, show heterogeneous
internal echogenecity, microlobulations, thick boundary and posterior shadowing
mimicking breast carcinoma On the contrary, mucinous carcinoma with posterior
enhancement can mimic fibroadenoma or cyst. While echogenic or spherical breast
carcinomas are rare, such tumours do exist. Sonographic differentiation between
papillomas, papillary DCIS, and carcinomas are challenging when intraductal soft
tissue mass is seen. Color-flow or power Doppler imaging does not help distinguish
a cancer from benign lesions.
Conclusion: There is increased diagnostic confidence in using the sonographic features, when dealing with a typical lesion. For differentiation of malignant masses and
their mimikers, an objective sonographic criteria and core biopsy is warranted.
C-109
Relation of breast cancer vascularization pattern depicted by ultrasound to
axilary nodes status
F. Todua, T. Changelia, T. Daraselia; Tbilisi/GE ([email protected])
Purpose: The aim of the study was to assess possible correlation between power
Doppler sonographic data concerning vascularization pattern of the tumor and
histopathology results after lymphadenectomy in case of breast cancer.
Methods and Materials: 105 females with breast cancer were studied preoperatively by power Doppler sonography. Tumor size and number of tumor arteries
were correlated with axillary nodal status. Sonographic findings were compared
with tumor arteries with a diameter larger than 350 µm and with the density and
area of microvascularization.
Results: Good correlation of ultrasonographic and histopathologic results regarding number of tumor arteries (k=0.66, P 0.001) and tumor size (P=0.012) was
observed. Multivariate analysis showed an independent relationship between probability of axillary metastasis, number of tumor arteries (P=0.016), and sonographic
tumor size (P=0.035). A predictive model of axillary status was developed. The
receiver operating characteristic curve was used to determine 0.2324 as the score
to classify axillary nodal status. This score indicated high sensitivity (93.1%), low
specificity (49.4%), and high negative predictive value (96.1%).
Conclusion: The number of arteries in invasive breast carcinoma detected with
power Doppler sonography and sonographic tumor size are independent predictors
of axillary nodal status; these variables could contribute to reliable prediction of
absence of axillary involvement on the basis of a mathematic model.
C-110
Imaging aspects of papillary breast proliferations: From mammography to
free hand elastography
A.G. Maglas, A. Chiorean, M. Duma, T.S. Serb, S.M. Dudea, S. Sfrangeu;
Cluj Napoca/RO ([email protected])
Learning Objectives: To present imaging aspects encountered with breast papillary
proliferations. To highlight features that raise malignancy suspicion.
Background: A retrospective analysis of cases diagnosed between a 4 year interval
(2004-2008) in our radiology department was performed. Pathology was obtained
using core or excision biopsies. 58 cases were included. 33 were benign papillary
lesions and 25 were papillary carcinomas. Imaging examinations were carried out
in accordance with the ACR guidelines. Galactography was performed in 6 cases
and elastography in 12 cases.
Imaging Findings: The most frequent mammographic appearance of invasive papillary carcinomas was that of an opacity with imprecise deliniation. On ultrasound,
these tumours appeared as solid lesions (19), complex cysts (4) or intraductal
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proliferations (2). On ultrasound, the most frequent aspect of benign papillary lesions was that of dilated ducts with solid, intraductal component (21), followed by
the nodular solid appearance in 8 cases and intracystic proliferations in 4 cases.
Galactographically, there were visualized ductal obstruction, lacunary images or
parietal irregularities. All elastographically assessed papillary proliferations proved
to be more rigid than neighbouring breast parenchyma.
Conclusion: Ultrasound may enable us to detect and appreciate the extent of
disease in symptomatic and asymptomatic patients with negative standard mammographies. Differential diagnosis between benign or in situ papillary proliferations
and the invasive ones is often impossible from an imaging point of view. A close
appreciation of lesion’s delineation and degree of vascularization may up-grade
our level of suspicion. However, pathologic proof is mandatory for all papillary
proliferations.
C-111
3D and 4D ultrasound of the breast: What kind of additional information
can it provide over conventional 2D ultrasound in the diagnosis and
intervention of breast lesions?
O. Woo, K. Lee, A. Yi, Y. Kim, K. Cho, B. Seo, E.-Y. Kang; Seoul/KR
([email protected])
Learning Objectives: 1. To present variable techniques and differences in 3D and
4D ultrasound of the breast. 2. To demonstrate various breast lesions with pathologic correlation. 3. To evaluate the diagnostic accuracy of 3D and 4D ultrasound
in comparison with 2D ultrasound.
Background: 3D and 4D ultrasound may provide new perspectives in the field
of breast ultrasound. Consequently, we look forward to offering new diagnostic
information and potentially improved characterization of breast lesions.
Imaging Findings: 1. 3D and 4D ultrasound: techniques and differences. 2. 3D and
4D ultrasound images related normal anatomy. 3. Overview of 3D and 4D breast
ultrasound imaging. 1) Benign tumor: morphology, volume calculation. 2) Papillary
neoplasm: in association with adjacent duct. 3) Malignant tumor: morphology, extent
including adjacent duct involvement, staging. 4) Additional information provided over
2D ultrasound that aids in the diagnosis and intervention of breast lesions.
Conclusion: Major advantages of 3D and 4D ultrasound of the breast is its
capability to generate multi-sectional planes and provide volumetric data of the
lesion. Furthermore, the coronal plane provides additional information that assists
in differentiating benign and malignant tumors and in 3D targeting; it can provide
precise location of biopsy needles in all planes thus providing reassurance to the
radiologist.
C-112
Usefulness of sonographic findings for detection of extensive intraductal
component (EIC) around invasive breast cancer: Correlation with nuclear
grade of histopathology
K. Kim, H. Han, Y. Park, C. Hwang, Y. Cho, H. Yoo, D. Yoon, H. Seol, K. Kim;
Taejon/KR ([email protected])
Purpose: To investigate the efficacy of ultrasound in the detection of extensive
intraductal component (EIC) around invasive ductal cancer (IDC) and correlation
with histopathologic findings.
Methods and Materials: From January 2007 to September 2008, we retrospectively
evaluated 140 malignant confirmed breast nodules by operation. We classified
as IDC without EIC and IDC with EIC by histopathologic evaluation. Sonographic
finding were classified as hard finding (spiculation, thick halo, angulation, shadowS
ing), mixed finding (microlobulation, taller than wide, hypoechogenecity)
and soft
O
P
finding (calcification, duct extension and branching).
E We analyzed sonographic
o EIC lesions were evaluated
features between IDC without EIC and IDC with tEIC.
dgrade of DCIS.
pathologically and classified using the nuclear
e
itt
Results: Among 140 lesions malignant confirmed
lesions, 69 lesions were conm
b
firmed as IDC without EIC and 49 as IDC
with EIC. As comparison of sonographic
u
findings between IDC with EIC and without
l S EIC, calcification, duct extension, branch
ia In IDC with EIC, odds ratio of calcification
patterns were statistically significant.
r
e
(32.3), duct extension (7.4) and
at branching patern (13.3) were high. Odds ratio of
M
thick echogenic halo (0.2), angulation (0.4) and microlobulation (0.2) were low.
o
Among 23 EIC lesions,N
12 were classified as high nuclear grade, 10 as intermediate
grade, and 1 as low grade. Ductal extension and branch patterns were associated
with a high nuclear grade (p 0.05).
Conclusion: Soft suspicious findings were helpful findings for detection of EIC
around IDC. More ductal extension and branch patterns were associated with
high nuclear grade. High resolution US is useful in detection of EIC, especially
high grade.
Scientific and Educational Exhibits
C-113
Definition of tumor margins by high frequency ultrasound examination of
cancer tissue during breast conserving surgery
A. Hushmand Nia1, B. Dohmen2, F. Jahn1, E. Jung3, K. Scherer1, R. Kubale1;
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Pirmasens/DE, 2Kaiserslautern/DE, 3Regensburg/DE ([email protected])
Purpose: To assess the feasibility of high resolution ultrasound (US) examination
for defining free margins of tumour tissue during breast conserving surgery using
a novel tissue transfer and X-ray system (T-TRAX).
Methods and Materials: In 49 consecutive patients with malignant breast tumours
(0.4 to 2.2 cm) the specimens were examined, during surgery, using a 17 MHz US
probe with spatial compounding (SC) of different settings and THI i (Siemens Acuson
512 17L5) and compared to specimen mammographs (Hologic Lorad) measuring
the cranial, caudal, medial, lateral and dorsal free margins. For 3D correlation, the
specimens were fixed on T-TRAX.
Results: 41/49 of the tumours could be identified in mammographs, 47/49 in US
best seen with speckle reduction filters and a medium SC-level. In 3 cases, satellite
metastases were seen and resection of the correlating margins was performed.
In 19 patients, close margins (less than 5 mm) were identified and the correlating
margins were consequently removed. Compared to the pathological findings there
was a correlation of 0.86 to 0.91 in lateral, medial, caudal and cranial directions.
No second operation was necessary. Due to compression there was a sonographic
underestimation of the dorsal distance.
Conclusion: High-frequency US of surgically removed specimens is a valuable
tool for identifying tumour, microcalcifications and free margins avoiding repeated
surgery. In small tumours without calcifications it was superior to the specimen
mammograph.
Breast
Miscellaneous
C-114
Prospective multicentric observational registry on 900 ultrasound guided
vacuum-assisted breast biopsies: Towards a more wide-spread use of the
technique in daily medical practice
C.A.S. Labbe-Devilliers1, P. Meingan1, P. Lebas2; 1Nantes/FR, 2Orléans/FR
([email protected])
Purpose: The purpose of this national registry is to bring together professionals
using the Mammotome®EX breast biopsy system (Ethicon Endo-Surgery Cincinnati,
OH, USA) according to their type of practice and experience, and to demonstrate
the feasibility of the technique together with its impact on management of mastology patients.
Methods and Materials: The study is multicentric, prospective and non-randomised.
Between June 2006 and April 2008, 900 Mammotome®EX procedures were carried
out under ultrasound guidance in 25 different centres in France classed according
to their experience of breast biopsy and their type of practice: 17 private structures,
4 public establishments and 4 anti-cancer centres.
Results: We used an electronic registry to collect clinical data (age, past history
and risk factors), patient management prior to the procedure, type of lesion (BiRads classification, size), prior cytology or histology results, indication chosen
(for diagnostic purpose: discrepancy between radiology and pathology results,
technical reason; for strategic reasons: BI-RADS 5 lesion; or in order to excise a
benign lesion). Details of each procedure are given: 8 or 11 Gauge probe, number
of samples taken, tolerance (pain, anxiety) and any complications. The impact of
the Mammotome®EX was assessed using post-biopsy histology and the number
of surgical operations avoided.
Conclusion: The Mammotome®EX is a recent tool for mastology management
to be used as a complement to microbiopsy, and for which the indications have
been validated. Covering 900 procedures carried out in France, the EX registry is
a means for federating practices and demystifying the technique.
C-115
Imaging features of granulomatous mastitis
M.U. Manzoor, Z.S. Faruqui, N. Din; Lahore/PK
Learning Objectives: To highlight the clinical presentation and pattern of involvement in granulomatous mastitis and to review the imaging features of granulomatous
breast disease based on our case series.
Background: Granulomatous mastitis is a benign breast disease, which presents
as a breast mass in most of the cases. The clinical presentation and imaging
features of this benign breast disorder often mimics breast cancer. The purpose
of this educational exhibit is to highlight the key imaging features.
Imaging Findings: The most common presentation of granulomatous masttis
is an irregular hypoechoic mass. Breast abscess is the second most common
presentation. Axillary lymphnodes are enlarged in most of the cases and present
with thickened cortex. In some cases, isolated enlarged axillary lymphnodes are
the sole presentation, without any breast mass or abscess. Calcification can also
be seen in a few cases. Overall, the imaging features alone cannot distinguish
between granulomatous mastits and breast carcinoma. Clinical history, examination
and histological assessment are definitely required for the distinction.
Conclusion: Clinical presentation and imaging features of granulomatous mastitis
can mimic breast carcinoma in many cases and it is imperative to have fine needle
aspiration and/or core breast biopsy for definite diagnosis of the disease. Hunt for
malignant cells should continue in the presence of granulomatous picture, as the
co-existence has been documented in literature.
Breast
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Scientific and Educational Exhibits
C-116
Mammographic appearance of CAPSS and columnar cell lesions in a
screening population
K. Rahmat1, E. Wylie2; 1Kuala Lumpur/MY, 2Perth/AU ([email protected])
Purpose: Columnar alteration with prominent apical snouts and secretions
(CAPSS), a recently recognised breast pathology, is a spectrum of lesions bound
by columnar alteration at the low end and low grade ductal Ca in situ at the high
end. These lesions are being detected with increasing frequency in breast biopsies performed for microcalcifications in the breast assessment centre in Western
Australia. The spectrum of mammographic and ultrasound appearance of columnar
cell lesions and CAPSS lesions are reviewed.
Methods and Materials: We retrospectively reviewed our institution for records
of breast pathology obtained for columnar cell lesions performed for core needle
biopsies and surgical excisions from 2002 to 2006. A total of 65 patients were found
to have various types of columnar cell lesions. We identified 11 patients with CAPSS
lesions with a variety of histologies coexisting within the specimens.
Results: All 11 patients with CAPSS lesions underwent mammograms with and
without ultrasound. Of the 11 lesions, 10 lesions appeared as clusters of microcalcifications and 1 with a palpable non calcified mass. All patients underwent
diagnostic open biopsy following core biopsy.
Conclusion: CAPSS lesions usually present as non palpable suspicious clusters
of microcalcifications on mammograms. These lesions are indistinguishable from
other suspicious microcalcifications such as atypical ductal hyperplasia (ADH) or
ductal carcinoma in situ (DCIS). Current recommendation suggest that patients with
core needle biopsy showing CAPSS lesions with atypical features should undergo
surgical biopsy as they are more likely to be associated with a cancerous lesion.
C-117
Value of double reading and arbitration: Results based on 140944
screening mammograms, double read in 2005
S.H. Heywang-Köbrunner, A. Crispin, D. Hölzel, D. Möhrling; Munich/DE
Purpose: To assess the value of double reading and arbitration for QA in a
population-based screening project.
Methods and Materials: The Bavarian mammography screening program started
in 2003. Prior to being accepted as a reader, first readers had to have experience
with 1000 4-view mammograms performed/yr, second and third readers with more
than 2500 view mammograms performed/yr. Third reading was only performed by
the most experienced reader (s) per county.
Results: In 2005, a first reading was performed in 140944 women, a second reading
was performed in 138224 women in 2005, almost all remaining cases were double
read in 2006 (delay in first vs. second reading). When the first and second readers
rated the mammogram as BIRADS 1 or 2, the case was considered normal. A
third reading (abnormality reported by at least one reader) was performed in 9544
cases. The sensitivities and PPVs achieved by the first, second and third readers
(based on the initial evaluation of the 3 readers and histology confirmation in cases
rated suspicious by reader 3) were: 85 and 24% versus 91 and 17% versus 99.5
and 23%. Per county the gain in additional cancers from first reader to third reader
may be 25%. For single readers it may be even higher.
Conclusion: Double reading and arbitration allows to significantly increase the
detection rate, but does not lead to an increased rate of recalls.
C-118
Micro-CT as a tool to evaluate breast microcalcifications in 3D
I. Willekens1, T. Lahoutte1, A. Schiettecatte1, C. Breucq1, C. Bourgain1,
R. Deklerck2, A. Bossuyt1, J. de Mey1; 1Jette/BE, 2Etterbeek/BE
([email protected])
Purpose: The detection of microcalcifications on mammography is a unique sign
indicative of the presence of a breast lesion. The shape is of great importance for
the probability of malignancy. The purpose of this study was to evaluate the 3D
shape of breast microcalcifications using micro-CT in comparison with the anatomopathological analysis.
Methods and Materials: In this study, breast biopsy samples of 5 female patients
who showed suspicious microcalcifications on routine mammography were used.
The samples were imaged using a micro-CT (Skyscan 1076 micro-CT system;
Skyscan, Aartselaar, Belgium) at a resolution of 9 µm. Images were reconstructed
using filtered backprojection and viewed in 3D using CT-Volume software. The
samples were subsequently analyzed by the pathology service.
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Results: Anatomopathological analysis showed that 3/5 patients had a ductal
breastcarcinoma in situ. The micro-CT scans of the patients with no carcinoma
showed microcalcifications that were regularly shaped like tea cups. The 3D
analysis of the microcalcifications of the patients with carcinoma showed irregular
and angular shaped volumes.
Conclusion: This is the first analysis of microcalcifications in 3D using micro-CT.
The initial evaluation shows that benign and malign lesions could be distinguished
visually. This application opens up the possibility of 3D quantitative analysis and
automated detection of malign lesions.
C-119
Ultrasound and core needle axillary biopsy in patients with probable
malignant breast lesions
M. García Ortega, M. Alvarez Benito, M. Cara García, E. Fuentes Vahamonde,
P. Contreras Puertas; Córdoba/ES ([email protected])
Purpose: To assess the diagnostic accuracy of axillary percutaneous core needle
biopsy (CNB) in probable malignant breast lesions. To evaluate its impact on patient
management.
Methods and Materials: From October 2006 to July 2007, 257 patients (261
lesions) were evaluated retrospectively. CNB was performed in dominant or
suspicious lymph nodes. Patients with a malignant result in CNB were excluded
from the sentinel node procedure (SLNP) and treated with surgery or neoadjuvant
chemotherapy, but a benign result in CNB was treated with surgery and SLNP or
axillary dissection (AD). Results obtained with US and axillary CNB were correlated
with those obtained with SLNB and/or AD.
Results: 113 CNB were performed: negative in 63 patients, breast cancer metastases in 45, and metastases from other primaries in 5. The therapeutic approach
in patients with a positive result was: neoadjuvant chemotherapy in 15 patients
and surgery with AD in 29 patients (20 mastectomies and 9 tumorectomies). In
44 patients with a benign result in CNB, SLNP was performed, as well as 28 tumorectomies, 13 mastectomies with immediate reconstruction and 3 mastectomies
without reconstructive surgery. Diagnostic accuracy of axillary US: sensitivity 63%,
specificity 86%, positive and negative predictive values 75 and 78%. Diagnostic
accuracy of CNB: sensitivity 73%, specificity 100%, positive and negative predictive
values 100 and 77%, respectively.
Conclusion: CNB allows for a more precise therapeutic approach. 37% of the
patients have been spared from the SLNP and 60% of the patients treated with
mastectomy have been treated with immediate breast reconstruction.
C-120
The role of the radiologist in the planning of the oncoplastic surgery
J.J. Mosquera Osés, J.R. Varela Romero, C. Fernández da Ponte García,
A. Iglesias López, D. Fernández Alonso, A. Ríos Reboredo; A Coruña/ES
Learning Objectives: To review the different patterns of oncoplastic surgery
and the role of radiologist in delimitation of tumoral extension, multifocal or multicentric disease and postoperative results of surgery, particularly in case of wide
microcalcifications.
Background: Oncoplastic surgery refers to several surgical conservative techniques for which segments of malignant breast tissue are removed to achieve
wide surgical margins whereas the glandular remaining tissue is modified to obtain
the best possible cosmetic outcome simultaneously that looks for the symmetry
in another breast.
Procedure Details: We described the use of bracketing wires as markers for
optimal excision margins and to plan the surgical pattern, especially in troubled
cases. The number of bracketing wires to be used is determined by consultation
between the radiologist and the surgeon.
Conclusion: Oncoplastic surgery techniques improve the possibilities of breast conservative surgery in wide tumors. Bracketing wires may assist the surgeon to achieve
complete excision but do not ensure clear histologic margins of resection.
Scientific and Educational Exhibits
C-121
Mammography infection control: Should this be part of quality assurance
programmes?
D. O’Leary1, J. McCrann1, S. Lewis2, A. Poulos2; 1Dublin/IE, 2Sydney/AU
([email protected])
Purpose: The human skin has become reservoirs for exotic viruses and antibiotic
resistant bacteria and this is an increasing worldwide problem. During mammography, patients’ friable skin is in close contact with both equipment and hands
during positioning and the possibility of infection spread is highest where immunity
has been lowered by disease process. This research collaboration investigated
whether mammography units within New South Wales, Australia (NSW) and the
Republic of Ireland (ROI) have dedicated mammography-specific infection control
protocols and the extent of cleaning and disinfection. Possible vectors for increased
bio-load on hospitals/outpatient facilities specifically due to these mammography
units were also examined.
Methods and Materials: A questionnaire underpinned by worldwide infection
control guidelines was formulated and circulated to mammographers in symptomatic/asymptomatic mammography units within ROI and NSW. Observational
triangulation was also performed.
Results: Whilst mammography-specific infection control protocols were available
in fewer ROI (25%) than NSW (32%) units; NSW mammographers (43%) had
less access to documented protocols (vs. 94% ROI units). Significant variation
in cleaning methods, consistency and procedures resulted and was observed in
both regions. Infection control is not routinely included in the quality assurance
(QA) process of all units.
Conclusion: Many aspects of infection control procedures are less than satisfactory.
These procedures should be regulated with specific mammography infection control
protocols within the QA process to prevent patient cross-infection with a consequent
lowering of biological burden on hospitals and outpatient facilities.
C-122
Incidental 18 F-FDG uptake in breast tissue in PET/CT: A case series
C.S.H. Ng, T. Lynch; Belfast/UK ([email protected])
study. Women with both blue dye and radio-isotope underwent ANC as a second
procedure only if the SLNB was positive.
Results: Blue dye alone vs. blue dye and isotope, % SLN found: 90 vs. 99, % SLN
positive: 14 vs.16, % SLN negative: 86 vs. 83, % false negative: 3 vs. 0, average
no nodes: 2.3 vs. 2.13, range: 1-7 vs. 1-7.
Conclusion: Using blue dye alone it is possible to achieve the targets set by the
new UK start program, but there is a higher incidence of failure to find the sentinel
nodes than when used in combination with radio-isotope (90 vs. 99%). The use
of combined blue dye with radio-isotope is recommended as the best way to find
sentinel lymph nodes in women with breast cancer.
C-124
Breast screening assessment clinics: As easy as ABC
N.T.F. Ridley, S. Taylor, N. Gilhespy, S. Brown; Swindon/UK
([email protected])
Learning Objectives: To illustrate the introduction of a simple ABC classification
system for recall screening mammograms. A is the least and C the most suspicious. To describe the results of an audit of this and demonstrate how this can
improve clinic efficiency.
Background: There is an increasing workload in the UK National Breast Screening
programme. We have devised a simple ABC classification of recall mammograms
done at consensing. The classification correlates with the degree of suspicion of
significant pathology on the mammogram. We postulated that the time taken in the
clinic would relate to this. By allocating these patients evenly throughout our clinics
based on the ABC, grading efficiency has been improved.
Imaging Findings: We audited 30 of these patients to see if the ABC classification
correlated with number of biopsies, extra mammograhic views and final pathology.
Films per patient: A: 0.7, B: 1.9, C: 2.2; Biopsy rate per patient: A: 0, B: 0.27, C. 0.7;
Cancer diagnosis per patient: A: 0, B: 0.18, C: 0.44.
Conclusion: The results confirm that our grading system correlates with final
diagnosis, number of films and biopsy rate. A simple ABC grading method can be
introduced easily within the screening programme to improve assessment clinic
efficiency.
Learning Objectives: To recognise the importance of appropriate investigation and
follow-up of abnormal activity in breast tissue using 18F-FDG PETCT.
Background: 18F-FDG PETCT is increasingly being used to diagnose, stage,
restage and monitor malignant diseases. 18F-FDG is a radioactive positron emitter, which mimics cellular glucose utilization. Tumours such as lung cancer and
high grade lymphoma have a high glucose metabolic rate and are well identified
by PETCT. The role of PETCT in breast cancer is more limited as many malignant
breast lesions have relatively low glucose uptake and consequently show only
lowgrade uptake of radioactive tracer. 18F-FDG PETCT has been shown to be effective in differentiating postoperative fibrosis from malignant change in patients with a
history of breast cancer. In this exhibit, we will illustrate and describe the incidental
PETCT breast findings in patients with no previous history of breast cancer. We
consider the benefits of appropriate investigation and follow-up in such cases.
Imaging Findings: We illustrate and describe a series of cases where incidental
FDG activity was demonstrated in breast tissue in patients with no previous history
of breast cancer. Final diagnoses ranged from the benign (incidental fibroadenoma)
to malignant breast carcinomas.
Conclusion: Reporters of PETCT studies should be made aware of the malignant
potential of asymmetric, often low grade, increased FDG uptake in breast tissue
and should recommend appropriate investigation and follow-up.
C-123
Comparison of blue dye alone with blue dye and radioisotope combined
in the detection of axillary sentinel lymph nodes in women with invasive
breast cancer
D.J. Dasgupta, P. Jones, S. Jones, D. Fish, A.R. Sever, P. Mills, J. Donaldson;
Maidstone/UK ([email protected])
Breast
Purpose: Sentinel lymph node biopsy (SLNB) is established as a reliable method of
assessing the axillary nodal status in women with breast cancer. It can be performed
with blue dye or radio-isotope alone or in combination. This study compares the
blue dye alone with the combined blue dye and radio-isotope method.
Methods and Materials: 200 women with histologically confirmed invasive breast
cancer, and negative axillary assessment (ultrasound/FNA) underwent sentinel
lymph node biopsy. 100 had a sub-areolar injection of blue dye after induction of
anaesthesia, and 100 had an additional sub-areolar injection of radio-isotope the
day before surgery. Women receiving blue dye only went on to undergo a level 3
axillary node clearance (ANC) under the same anaesthetic as part of a validation
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Cardiac
Cardiomyopathies
C-125
Cardiomyopathies: The role of cardiac MRI
N. Galea, I. Carbone, E. Algeri, H. Grazhdani, D. Cannata, G. Cannavale,
C. Catalano, R. Passariello; Rome/IT ([email protected])
Learning Objectives: 1. To review classification and the main MR imaging findings
of various cardiomyopathies. 2. To explain the usefulness of cardiac MRI in the
diagnosis and proper management in patients with cardiomyopathy.
Background: Cardiomyopathies are an important and heterogeneous group of
myocardial diseases, including a large spectrum of different severity degree that
can lead to cardiovascular death or progressive heart failure. Cardiac MRI can
provide a lot of important information for the recognition and identification of the
CMP form, and for a proper patient management: morphological analysis of the
myocardium, evaluation of the impact on ventricular function, valvular dysfunction, characterization of pathological myocardium with an estimate of myocardial
damage extension.
Procedure Details: After a brief classification of non-ischemic cardiomyopathies,
we will illustrate a pictorial review of the various forms mainly focusing on dilated,
hypertrophic, restrictive and non-compaction cardiomyopathy, arrhythmogenic right
ventricular dysplasia and Tako-Tsubo disease. We will also describe MR strategies
employed to study different CMPs with particular emphasis on b-SSFP cine MRI,
T2w-STIR and DE-IR sequences, correlating with clinical data.
Conclusion: Cardiac MRI is a very useful imaging modality to assess various
cardiomyopathies, evaluating the degree of severity and giving important information for patient management.
C-126
Non-compaction of the myocardium: A distinct cardiomyopathy
R.J. Perea Palazon, T.M. de Caralt Robira, J.T. Ortiz Perez, M. Sitges Carreño,
C. Pare, J. Ramirez Ruz, P. Arguis Gimenez, M. Sanchez Gonzalez; Barcelona/ES
([email protected])
Learning Objectives: To present the MRI protocol for studying patients with noncompaction cardiomyopathy (NCC). To describe the MRI appearance of the NCC.
To review the embryology of the heart.
Background: Non-compaction of the myocardium is a recently recognized congenital cardiomyopathy. It may be an isolated finding or may be associated with
other congenital heart anomalies. Its diagnosis, however, is sometimes missed,
most often as a consequence of ignorance of the condition. NCC is diagnosed
accurately with MRI.
Imaging Findings: In this exhibit we describe and illustrate: 1.The new American
Heart Association (AHA) classification of cardiomyopathies. 2. The embryology
of the heart (focusing on the endomyocardial morphogenesis). 3. The clinical
presentations of NCC. 4. The MRI protocol for studying patients with NCC. 5. The
MRI diagnostic criteria of NCC. 6. Other imaging modalities to diagnose NCC:
echocardiography and multidetector computed tomography.
Conclusion: MRI morphologic findings and characteristic delayed enhanced images allow an accurate diagnosis of NCC.
C-127
Origin of ventricular arrhythmias by 12-Lead ambulatory ECG and
relationships with late enhancement cite in left ventricle by MRI and
multislice CT in hypertrophic cardiomyopathy and myocardial infarction
N. Funabashi, M. Ueda, T. Murayama, M. Uehara, H. Takaoka, I. Komuro; Chiba/JP
Purpose: We estimated the origin of ventricular-arrhythmias (VAs) from the morphology recorded by 12-lead ambulatory ECG and examined relationships to hypertrophic
or late enhancement (LE) cite in the left ventricle by MRI or MSCT in subjects with
hypertrophic-cardiomyopathy (HCM) or old myocardial infarction (OMI).
Methods and Materials: 30-subjects (24-male, 17-79 yrs, 20 with HCM and 10 with
OMI) underwent 12-lead ambulatory ECG-monitoring (24 hours), and MRI, and/
or MSCT. VAs were classified into 4-categories; right-superior (RS), left-superior
(LS), right-inferior (RI), and left-inferior (LI) axes. Furthermore, VAs with an RI or LI
axis-pattern without S-wave more than 0.1mV in the V6 lead were recognized as a
special-type of outflow (OF). If there were VAs in the same categories except OFtype, but obviously different configurations in a subject, this subject was recognized
as having multi-morphological VAs in one restrictive axis pattern.
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Results: Among 20-HCM-subjects, multi-morphological VAs in RI or LI categories
were observed in 11-subjects (Maron classification II or III) either with LE (5-subjects) or without LE (6-subjects) in MRI or MSCT. Nine subjects (Maron classification
I or V) had no multi-morphological VAs in one-restrictive-axis-pattern. Among 10
subjects with OMI, multi-morphological VAs in RS or LS categories were observed
in 6 subjects with extensive LE (5 antero-septal-apical and one lateral-posteriorinferior) exclusively. All MSCT-findings were coincident with MRI.
Conclusion: Multi-morphological VAs in one-restrictive-axis-pattern are related
to abnormal-myocardial-findings, i.e. broad-hypertrophy or extensive LE in the LV.
Presence of multi-morphological VAs in one-restrictive-axis pattern may suggest
abnormal findings in the LV myocardium, and MRI or MSCT should be taken into
consideration.
C-128
Cardiac magnetic resonance imaging of myocarditis
N. Galea, I. Carbone, E. Algeri, F. Ciolina, D. Cannata, A. Cannavale,
H. Grazhdani, C. Catalano, R. Passariello; Rome/IT ([email protected])
Learning Objectives: To illustrate the most relevant anatomo-pathologic features
of myocarditis. To be aware of cardiac MRI findings in patients with myocarditis. To
understand the role of cardiac MRI in patients with a suspicion of myocarditis.
Background: The clinical features of myocarditis are varied; so, the diagnosis of
myocarditis could be difficult at initial presentation. Cardiac MRI has the potentiality
to assess in the same session ventricular function, myocardial oedema and, using
contrast enhanced inversion-recovery late sequences, to evaluate the presence
end extent of myocardial injury. Knowledge of clinical, anatomo-pathological and
cardiac MRI technique and findings is essential when evaluating patients with a
suspected or known myocarditis. A precise knowledge of T2-w findings and especially of enhancement patterns observed in myocarditis is necessary to differentiate
it from other myocardial disease.
Procedure Details: In this exhibit, we will describe and illustrate: 1. The principal clinical and anatomo-pathologic features of myocarditis. 2a. MRI technique
that should be used in patients with a suspicion of or a known myocarditis. 2b.
T2-weighted sequences findings. 2c. Most frequent pattern of enhancement at
contrast-enhanced inversion recovery sequences.
Conclusion: Cardiac MRI plays a crucial role in diagnostic path, proper management and follow-up in patients affected by myocarditis.
C-129
Cardiac sarcoidosis: No longer “a hesitant art, an imperfect science”
Z.A. Khan, I. Barros D’Sa, A. Shimal; Birmingham/UK
Learning Objectives: To illustrate the range of the multi-modality imaging findings
for cardiac sarcoidosis. To emphasize the role of modern imaging techniques given
the crucial importance of early diagnosis of this illness.
Background: Traditionally difficult to diagnose, cardiac sarcoidosis has historically
been labelled as “a hesitant art, an imperfect science”. The first published death due
to cardiac sarcoidosis was in 1937. The disease is usually subclinical manifesting
only in 2-10% of cases of sarcoidosis. Cardiac involvement may be the sole or initial
presentation of the disease. It may involve any cardiac structure and hence can
present as arrhythmias, conduction defects, myocardial hypokinesia or ventricular
failure. Sudden cardiac death has also been described in up to 16% of patients.
We will describe the findings on plain film radiography, echocardiography, nuclear
cardiology, chest CT and cardiac MRI.
Imaging Findings: Plain films can show a spectrum of cardio-pulmonary findings.
Echocardiography provides both morphologic and functional data. Myocardial
perfusion studies show “reverse distribution” and left ventricular function. Cardiac
MRI can show myocardial or pericardial abnormalities with characteristic patchy
late gadolinium enhancement. CT supplements with abnormalities related to both
lungs and the heart.
Conclusion: Early diagnosis of cardiac sarcoidosis is possible allowing vital early
treatment initiation, profoundly affecting prognosis. New imaging techniques allow
better structural and functional cardiac assessment and a low index of suspicion
is required for investigation of symptoms.
Scientific and Educational Exhibits
C-130
Recreational and doping drugs induced cardiomyopathies
E. Algeri, I. Carbone, N. Galea, D. Cannata, F. Ciolina, C. Catalano,
R. Passariello; Rome/IT ([email protected])
Learning Objectives: To review the principal recreational and doping drugs
responsible for cardiac damage and to describe their effects. To illustrate the role
of MRI in evaluating cardiac morphological, structural and functional damage in
drug consumers.
Background: Most frequently used recreational and doping drugs are responsible
for cardiac structural and functional damage and should be considered especially
in young patients presenting with chest pain. Cardiac MRI has the potentiality to
assess in the same session right and left ventricular function, myocardial perfusion
and oedema and, using contrast enhanced inversion-recovery late sequences, to
evaluate the presence end extent of myocardial injury.
Procedure Details: In this exhibit, we describe and illustrate: 1a. The principal
recreational and doping drugs that can be responsible for cardiac damage (alcohol; cocaine; amphetamines; heroin and other opiates; dopes used by athletes).
1b. Pathophysiology and anatomic pathology of their cardiac effects. 2a. The MRI
technique that should be used in patients with a history of drug or dope abuse. 2b.
Most frequent MRI findings in patients with drug addiction.
Conclusion: Knowledge of cardiac side-effects of the most frequently used recreational and doping drugs and awareness of the role of MRI in the evaluation of the
impact of these substances on cardiac function and myocardial structure is essential
when evaluating patients with a known or suspected drugs and/or dope abuse.
C-131
Patterns of delayed-enhancement in MRI of ischemic and non-ischemic
cardiomyopathies
M. Natrella, D. Furfaro, E. Muraro, M. Cristoferi, M. Alessi, G. Fanelli, T. Meloni;
Aosta/IT ([email protected])
Learning Objectives: We describe characteristic enhancement pattern of various
cardiomyopathies.
Background: Myocardial diseases of varying etiology result in myocardial changes,
such as necrosis, fibrosis, edema and metabolite deposition, which can be visualized by DE-MRI. Acute and chronic ischemic diseases based on a coronary artery
disease as well as non-ischemic cardiomyopathies display DE. Cardiomyopathies
often show a characteristic enhancement pattern.
Imaging Findings: While ischemic lesions are localized in the subendocardium,
non-ischemic cardiomyopathies often display an intramyocardial or subepicardial
pattern. The typical pattern for dilated cardiomyopathies is band-like and intramyocardial with septal involvement. Arrhythmogenic right-ventricular dysplasias/
cardiomyopathies are frequently associated with right-ventricular DE. In the case
of amyloid cardiomyopathies that are often restrictive cardiomyopathies, subendocardial and circular DE is typically observed. Hypertrophic cardiomyopathies display
patchy intramyocardial DE usually in the anteroseptal region. Acute myocarditis is
typically accompanied by intramyocardial or subepicardial DE affecting the lateral
wall. In the case of chronic myocarditis, intramyocardial or subepicardial DE is
observed most frequently. Cardiac sarcoidosis typically entails patchy subepicardial
DE with right- and left-ventricular involvement. Since there is an overlap between
the enhancement patterns of cardiomyopathies, the diagnostic accuracy of DEMRI is limited and the diagnosis must be based on additional clinical and MRI
findings. The amount of DE often corresponds with cardiac functional parameters
as well as with the frequency of cardiac events so that DE-MRI may be useful for
risk stratification.
Conclusion: Furthermore, DE-MRI can be helpful in the planning and evaluation
of myocardial biopsies and electrophysiological examinations.
Cardiac
CT
C-132
Clinical significance of fat replacement in the moderator band of the
right ventricle in multislice CT in comparison with abnormal conduction
systems
N. Funabashi, M. Uehara, H. Takaoka, I. Komuro; Chiba/JP
Purpose: In MSCT, fat-replacement (FR) in the moderator-band (MB) of the
right-ventricle (RV) can often be observed. As the right-bundle-branch courses in
the MB, we evaluated the relationship of FR in the MB of the RV and conduction
abnormalities in ECG retrospectively.
Methods and Materials: 132 subjects (58-male, 59p27 years) who underwent
MSCT and without any findings of organic myocardium diseases in MSCT nor
echocardiogram were retrospectively analyzed. ECGs were also retrospectively
analyzed.
Results: FR in the MB was detected in 42-subjects (Group 1) and was not detected
in 90-subjects (Group 2). Complete and incomplete right-bundle-branch block
(RBBB) and complete left-bundle-branch-block (LBBB) were detected in 6, 8, and
1 subject, respectively. There were no significant differences about incidence of
complete or incomplete RBBB (9.6 versus 11.1%), mean QRS width (93.4p9.5
versus 94.5p17.7 msec), mean QRS axis (28.6 versus 33.2 degree), and standard deviation of QRS axis (32 versus 34 degree) suggesting presence of hemi
LBBB, among both groups. But age (64 versus 58 years) and ratio of female (66
versus 51%) were significantly higher in Group 1. In a logistic-model, only age
was associated with increased incidence of FR in the MB (relative-risk and 95%
confidential-interval were 1.03 and 1.001~1.053, respectively).
Conclusion: FR in the MB of the RV may not influence complete RBBB and
hemi LBBB, suggesting comprehensive abnormalities in myocardial conduction
systems but may be influenced by age. FR in the MB of the RV by MSCT may not
indicate organized abnormal myocardial conduction but only indicate degeneration by aging.
C-133
Usefulness of cardiac multidetector row CT (MDCT) before percutaneous
coronary intervention (PCI) as a treatment strategy for chronic total
occlusion
D. Kim1, E. Suk2, J. Seo1; 1Bucheon/KR, 2Seoul/KR ([email protected])
Learning Objectives: 1. To review the non-invasive imagings and pathophysiology
of chronic total occlusion. 2. To demonstrate the various imaging characteristics of
chronic total occlusion. 3. To explain the usefulness of multi-detector row CT (MDCT)
in the diagnosis and planning treatment of chronic total occlusion.
Background: In chronic total coronary occlusion (CTO), a common problem occurs in 10-15% of patients undergoing coronary angiography. Despite the development of interventional techniques, many clinicians prefer not to recanalize the
CTO because of the difficulty and low clinical success of percutaneous coronary
intervention. Under this circumference, MDCT is very useful to plan approach route
and to evaluate functional improvement after PCI.
Procedure Details: 64-slice CT (Siemens, Sensation 64, Erlangen, Germany)
was used for the evaluation of CTO. We included contents in this exhibit as follows:
1. Pathophysiology of chronic total occlusion; 2. Imaging findings and points that
should be checked on cardiac MDCT: a) site and detailed anatomy of occluded
stump, b) length of involved segment, c) amount of calcification within wall or occluded lumen, d) angulation of involved vessel, e) anatomy of collaterals, etc.; and
3. Review of imaging findings and discussion.
Conclusion: 1. Cardiac MDCT is a good image modality to assess the chronic
total occlusion. 2. Understanding of different imaging check points for chronic total
occlusion is important for accurate diagnosis and proper management.
Positive influence of aging on the occurrence of fat replacement in the
right ventricular myocardium determined by multislice-CT in subjects with
atherosclerosis
N. Funabashi, Y. Hori, M. Uehara, H. Takaoka, M. Ueda, I. Komuro; Chiba/JP
Purpose: We evaluated predictors of fat replacement (FR) in the right-ventricularmyocardium (RVM) determined by MSCT in atherosclerotics not receiving antiarrhythmia drugs and evaluated the relationship between the presence of FR in
the RVM and the occurrence of ventricular premature beats (VPB).
A
B
C
D
E
F
G
H
S365
Cardiac
C-134
Scientific and Educational Exhibits
Methods and Materials: 120-consecutive-atherosclerotics (101-males, 11-85
years) not receiving anti-arrhythmia drugs for VPB, who underwent MSCT (Light
Speed Ultra 16, GE) for evaluating atherosclerosis and Holter-ECG within onemonth were retrospectively analyzed for FR in the RVM and its relationship with
age, body mass index (BMI), and occurrence of VPB.
Results: 31-subjects had FR in RVM (18-males; median 67 years), and 89 did not
(53-males, median 56 years). Median age was significantly higher in subjects with
FR in RVM (P 0.01). The median BMI was 23.0 in subjects with FR and 23.0 in
those without (not significant). Average number of VPB by Holter-ECG was 1445
in 31 subjects with FR. Without FR, the average number of VPB was 995. The difference in the numbers of VPB was not significant (P=0.73). A logistic-regressionmodel using age, male sex and BMI indicated that age was associated with an
increased incidence of FR in the RVM (relative risk=1.055, 95% CI 1.019-1.092,
P 0.05).
Conclusion: Age but not BMI is significantly associated with the presence of FR
in the RVM. Aging might have a positive influence on the occurrence of FR in the
RVM as determined by MSCT in atherosclerotics, but FR in the RVM had no influence on the occurrence of VPB.
C-135
Comprehensive imaging of the heart in coronary artery disease by dual
energy CTA: Reconstruction and postprocessing strategies
F. Schwarz, B. Ruzsics, G. Bastarrika, J. Abro, R. Brothers, U. Schoepf;
Charleston, SC/US ([email protected])
Learning Objectives: To provide a step-by-step guide for the reconstruction and
postprocessing of ECG-gated dual energy datasets of the heart aiming at optimizing the visualization of coronary artery lumen, myocardial perfusion and regional
myocardial function.
Background: The principle of dual energy CT is that information about the absorption of X-rays with distinct energy spectra allows for the computation of average
atomic numbers for every voxel and iodine concentrations during steady states of
organ perfusion with iodine-containing contrast agents. Transfer of this technique to
cardiac CTA acquisitions permits a comprehensive diagnostic evaluation of the heart
in coronary artery disease: coronary artery stenoses, resulting perfusion defects of
the myocardium and myocardial function can be assessed based on a single CT
scan. With three primary datasets reconstructable from one CT scan, one for each
tube and a merged one, and specific myocardial perfusion series, reconstruction
and postprocessing have become confusing for inexperienced users.
Procedure Details: In this exhibit, we describe and illustrate based on our retrospective analysis of over 40 dual energy CTA acquisitions: 1. How the series for the
evaluation of coronary artery lumen, resulting perfusion defects of the myocardium
and myocardial function can be reconstructed from the same dual energy raw data.
2. How reconstruction and postprocessing parameters can be setup in a standardized and reproducible way to maximize gain of clinical information, reduce artifacts
and maximize reproducibility and oberserver-independence.
Conclusion: Knowledge of appropriate reconstruction and postprocessing parameters is most essential for a reproducible and observer-independent readout
of cardiac dual energy CTA datasets.
C-136
Characteristic cardiac MDCT findings of acute non-ST elevated myocardial
infarction (NSTEMI) without cardiac enzyme elevation in patients with
acute chest pain
D. Kim1, E. Chun2, S. Choi2, E. Suk3; 1Bucheon/KR, 2Bundang/KR, 3Seoul/KR
([email protected])
Purpose: To evaluate the characteristic imaging findings on ECG-gated MDCT in
patients with acute NSTEMI.
Methods and Materials: Among the consecutive 213 patients with acute chest
pain who underwent ECG-gated 64-slice MDCT, we retrospectively reviewed in
15 patients (13 men, 2 women, 64 p 9 years) with acute NSTEMI proved by ECG,
cardiac enzymes, and conventional angiography. We evaluated MDCT findings in
terms with plaque composition and density, lesion length, remodeling index (RI),
enhancement of vessel wall, density of infracted and remote normal myocardium,
regional wall motion abnormality (RWMA), and associated perfusion defect (PD).
Results: Initial ECG abnormality showed in 4 patients with ST-depression and
5 patients with T-inversion. Initial elevation of cardiac enzyme was seen in only
2 patients, even though all patients had elevated cardiac enzyme on follow-up
exam after MDCT. All patients showed intraluminal filling defect within coronary
lumen. Imaging findings of culprit coronary lesion on MDCT were as follows:
plaque composition (noncalcified: mixed = 13:2), plaque density (32p12 HU),
lesion length (8.2p6.9 mm), RI (1.46p0.16), type of enhancement at vessel wall
S366
A
B
C
D
E
F
G
F
H
(partial slight (n=5); concentric slight (n=6); concentric strong (n=4)). The density
of myocardium at infarct area and remote normal area is 38p19 and 115p15 HU,
respectively. RWMA and PD on corresponding vascular territory of culprit lesion
showed 13 in 15 patients (86%).
Conclusion: The characteristic imaging findings on MDCT in patients with acute
NSTEMI is discrete intraluminal filling defect with density of thrombus, severe
positive remodeling, and enhancement of vessel wall.
C-137
Cardiac assist devices at computed tomography and conventional
radiography
H. Scheffel, P. Stolzmann, M. Wilhelm, M. Lachat, L. Desbiolles, A. Plass,
S. Leschka, B. Marincek, H. Alkadhi; Zurich/CH ([email protected])
Learning Objectives: To learn about the imaging appearance of various cardiac
assist devices (CAD) using computed tomography and conventional radiography
and to learn about associated complications following their implantation.
Background: Circulatory support systems are able to act as a left ventricular assist
device (LVAD) supporting the left ventricle, as right ventricular assist device (RVAD)
supporting the right ventricle, or as biventricular assist device (BVAD) supporting
both ventricles. Patients receive mechanical circulatory support by implantation of
a CAD system for one of the three following intentions: (a) as a bridge-to-transplant
that provides circulatory assistance for the patient awaiting heart transplant; (b) as a
bridge-to-recovery that provides circulatory assistance allowing the heart to recover
or (c) as a long-term and permanent circulatory assistance being an alternative to
heart transplantation (so-called ‘destination therapy’). Because of the increasing
use of CAD systems, radiologists are confronted more and more often with such
devices in their daily clinical practice.
Imaging Findings: A thorough understanding of the cardiac anatomy and the
morphological features of various devices is a prerequisite for correct image
interpretation. Conventional radiography and computed tomography (CT) are the
most commonly used radiological techniques for imaging patients with a CAD. CT
is very useful to evaluate CAD systems and complications by using both two- and
three-dimensional reconstructions of the volumetric data sets.
Conclusion: Conventional radiography and CT allow for the comprehensive
assessment of patients with CAD by imaging the in- and outflow cannulae, the
anastomoses, the position of the pump, as well as associated complications.
C-138
Radiation dose and image quality using prospective electrocardiographtriggered coronary 64-MSCT angiography with different KV
G. Guo, C. Zhou, H. Cao, Y. Shen; Beijing/CN ([email protected])
Purpose: To evaluate radiation dose, image quality using prospective electrocardiograph (ECG)-triggered coronary 64-slice CT angiography (CTA) with different
KV and the clinical application of 1 mSv coronary scan.
Methods and Materials: 224 consecutive patients underwent 64-slice CTA using
prospective ECG-triggered axial scan protocol (mA tailored to Body Mass Index:
S
180~800 mA). 38 patients with low BMI were dividedOinto two groups: 20 were in
group A (BMI 21.5, 100 KV); 18 were in group B (BMI
EP 21.5, 120 KV). The other 186
patients were divided into group C (21.5bBMIb25,
to 120 KV), group D (25BMIb30,
d radiation dose was recorded and
120 KV) and group E (BMI 30, 120 KV).tThe
e
it
the image quality (excellent: 5; bad: 1) was
evaluated.
mB, C,blindly
b
Results: The radiation dose of groups
A,
D, E was 0.88 mSv (0.49~1.17 mSv),
u
1.47 mSv (0.91~2.02 mSv), 2.40 mSv
l S (1.10~3.39 mSv), 3.44 mSv (2.20~5.78 mSv)
ia respectively. There was no significant difference
and 4.45 mSv (3.82~5.68 mSv),
r
e
between image quality of group
at A with 100 KV (4.32) and that of groups B, C, D and
E with 120 KV (4.5). AndMradiation dose of the patient using axial scan protocol at
100 KV was decreased
No by 40% contrasted with that of group B at 120 KV.
Conclusion: Prospective ECG-triggered axial scan in 64-slice coronary CTA has
the ability to significantly reduce radiation exposure. For low-BMI ( 21.5) patients,
super low dose ( 1 mSv) at 100 KV using prospective ECG-triggered axial scan
could be selected and the image quality can fulfil clinical diagnostic needs.
Scientific and Educational Exhibits
C-139
The use of R-peak edit technique to improve image quality of 64-row MSCT
coronary artery angiography
B. Lv1, H. Cao1, Y. Zhou2; 1Beijing/CN, 2Hefei/CN ([email protected])
Learning Objectives: To demonstrate the value of R-peak edit technique on high
heart rate with fluctuation during the scanning in coronary artery angiography
using 64-row MSCT.
Background: Using application-specific ECG edit technique can improve image
quality of CCTA. GE VCT provides R-peak edit technique that radiologists can
correct wrong ECG trigger position manually. This study evaluates this technique
through both phantom and patient experiments.
S
Procedure Details: Helical scan of pulsating cardiac
phantom on the 70-110 bpm
PO
E
heart rate (10 bpm step) and different arrhythmia
was performed using ECG
to planAnd
gated 64-row 40 mm volume computed tomography.
50 patients who underd
e
went coronary artery CTA on high heart rate
itt were selected in this study. The image
m
quality of volume rendering (VR) andbmultiplanar
reformation (MPR) with/without
u using 5 point scoring (5: Excellent; 1: poor;
R-peak edit technology were analyzed
S
l
3: accepted diagnosis) in a blinded
ia fashion. For simulated coronary arteries of
cardiac phantom, mean scoring
er values (MSV) of the images with/without R-peak
t
a
edit including all heart rate
M is 4.03p0.45 and 3.09p0.7, respectively. The MSV on
the fluctuation of heart o
rate 10/min were significantly different with/without R-peak
N
edit (p 0.01). Coronary arteries of 50 patients were analyzed: MSV with/without
R-peak edit is 3.72p0.6 and 3.06p1.1 and MSV of 90% patients using R-peak edit
technique is larger than 3.0 (accepted diagnosis scoring).
Conclusion: The phantom experiment and patient’s analysis demonstrate R-peak
edit technique can reduce motion and stair-step artifacts and provide good image
quality on the high heart rate with fluctuation.
C-140
The evaluation of image quality using optimized low-dose contrast
injection protocols on 64-row MSCT in coronary artery angiography
Y. Wang, H. Cao, C. Zhou; Beijing/CN ([email protected])
Purpose: To compare the effect of a fixed contrast material injection dose protocol
and a dose tailored to patient body weight injection protocol on 64-row MSCT in
coronary artery angiography.
Methods and Materials: Two contrast material injection protocols were applied
in this study: protocol 1 - a fixed contrast material dose (69 mL of iopamidol 370)
with an injection rate of 5.0 mL/sec; protocol 2 - a dose tailored to the patient’s
S mL/sec. Prospective
body weight (0.8 mL/kg) with an injection rate of dose/12
O
P
ECG-triggered cardiac CTA was performed in 52Epatients (26 patients in each
protocol). The image quality of multiplanar reformation
to (MPR) was analyzed using
dmean cardiac artery enhancement
5 point scoring (5: Excellent; 1: poor;), and the
e
itt on image quality score, enhancement
was also measured. Statistical t test analysis
m
b
and dose of contrast material was performed.
u
Results: The mean image quality scores
l S of protocol 1 and protocol 2 were 4.13p0.23
a
i was no statistically difference (p 0.05). The
and 4.24p0.18, respectively. There
er
mean enhancement was 415p52
at Hu with protocol 1 and 350p31 Hu with protocol 2,
M difference. The mean contrast material dose showed
indicating significant statistical
statistical difference between
protocol 1 (69 mL) and protocol 2 (51.3 mL).
No
Conclusion: The dose and rate tailored to patient body weight injection protocol
can provide satisfactory quality and has the potential to significantly reduce contrast material injection dose compared with fixed contrast material injection dose
protocol. And it is very useful for obtaining better, homogeneous and consistent
contrast enhancement.
C-141
Dual-source coronary CT angiography: Radiation dose estimates in
different protocols tailored to patient specific parameters
S. Leschka, P. Stolzmann, H. Scheffel, S. Baumüller, L. Desbiolles, B. Marincek,
H. Alkadhi; Zurich/CH ([email protected])
C-142
The application of 64-section MSCT in diagnosing the coronary
atherosclerotic heart disease
L. Guo, W. Zhang; Suzhou/CN ([email protected])
Purpose: To evaluate the diagnostic performance of 64-MSCT in detecting different grades of coronary artery stenosis as well as the influence of image quality
in diagnosis.
Methods and Materials: A total of more than 600 patients underwent 64-MSCT,
out of which 78 patients who had undergone both MSCTA and selective coronary
angiography were taken into consideration. The sensitivity, specificity, positive
predictive value and negative predictive value of the 64-MSCT in detecting different
grades of coronary artery stenoses were calculated. The coronary segments were
divided into three groups according to the image score, followed by analyzing its
influence of the image quality on diagnosing stenosis in coronary segments. Then
the diagnostic performance of MSCT was compared with QCA in diagnosing the
stenosis of coronary artery quantitatively and qualitatively.
Results: Overall sensitivity, specificity, positive predictive value and negative predictive value of the 64-MSCT in detecting coronary artery stenosis were 93, 98, 88,
and 99%. The sensitivity in diagnosing mild, moderate and severe stenosis were
75, 77, 81, and specificity was 98%. There were 999 coronary segments that can
be assessed and 17 coronary segments could not be assessed due to poor image
quality. The kappa index was 0.7856, which indicated excellent agreement between
64-MSCT angiography and QCA. The correlation coefficient was 0.661.
Conclusion: Sixty-four MSCT angiography is an effective noninvasive diagnostic
tool for the detection of coronary artery stenosis, and the grade derived by CT
correlated well with QCA.
C-143
Coronary stenosis diagnosis accuracy and radiation dose of 64-row
cardiac CT with prospective ECG-triggered scan protocol and
retrospective ECG-gated scan mode: A pulsating cardiac phantom study
H. Cao, C. Zhou, Y. Shen; Beijing/CN ([email protected])
Purpose: To evaluate the accuracy of coronary stenosis measurement and radiation dose of prospective ECG-triggered and retrospective ECG-gated scan modes
using a pulsating cardiac phantom.
Methods and Materials: Simulated coronary arteries of 5 mm diameters with
three different stenosis rates (25, 50, and 75%) were scanned with both prospective ECG-triggered (Axial) and retrospective ECG-gated (Helical) modes. Different
heart rate plans were used: 1. 40~90 bpm, step 5 bpm;S2. 60 bpmp2, 60 bpmp5,
POaxial scan, dynamic padding
60 bpmp10 to simulate fluctuation of heart rate. During
E
technique was applied at irregular heart rate. ECG-driven
X-ray current modulation
to
and multi-sector reconstruction were utilized on
d helical scan. Accuracy of coronary
e
t
stenosis measurement and radiation dose
it was compared.
m
Results: There was no significant difference
on the measured stenosis rates
b
u rate below 70 bpm and at 60 bpmp2 heart
between axial and helical scan at heart
S
l
rate. But radiation dose of axialiaprotocol (2.4 mSv) was lower than that of helical
er ECG-driven current modulation). Helical scan
scan (8.0 or 13 mSv with/without
t
a
with multi-sector reconstruction
had better stenosis measurement at high heart
M
o
rate ( 70 bpm). At irregular
heart rate, there was significant difference with/without
N
dynamic padding technique on measured stenosis rates and radiation dose.
Conclusion: Axial protocol can significantly reduce radiation exposure. This protocol
is better used on stable heart rate up to 70 bpm and dynamic padding technique
is suitable for slightly irregular heart rate. ECG-driven current modulation helical
scan with multi-sector reconstruction is a better choice in cases of high heart rate
for both image quality improvement and radiation dose reduction.
A
B
C
D
E
F
G
H
S367
Cardiac
Purpose: To examine radiation dose estimates and image quality of different dualsource computed tomography coronary angiography (CTCA) protocols tailored to
heart rate (HR) and body mass index (BMI).
Methods and Materials: 200 consecutive patients (age 61p9 years) underwent either
helical CTCA (retrospective ECG-gating) or sequential CT (prospective ECG-triggering). CTCA protocols were tailored to HR and BMI: n=50 (any BMI, any HR) were
examined with a non-tailored CTCA protocol (helical CTCA, 120 kV/330 mAs), group A
(n=40, BMIb25 kg/sqm, HRb70 bpm) with sequential CTCA (100 kV/220 mAsref), group
B (n=43, BMIb25 kg/sqm, HR 70 bpm) with helical CTCA (100 kV/220 mAs), group C
(n=28, BMI 25 kg/sqm, HRb70 bpm) with sequential CTCA (120 kV/330 mAsref), and
group D (n=39, BMI 25 kg/sqm, HR 70 bpm) with helical CTCA (120 kV/330 mAs).
The radiation dose was calculated for each patient. Image quality was classified as
being diagnostic or non-diagnostic in each coronary segment.
Results: No significant differences in image quality were found among all five CTCA
protocols (p=0.78). Using the non-tailored CTCA protocol resulted in a radiation dose
of 9.0p1.0 mSv. This dose was significantly higher compared to that at sequential
CTCA (group A: 1.3p0.3 mSv, p 0.001; group C: 2.9p0.6 mSv, p 0.001), and
helical CTCA at reduced tube voltage and tube current (group B: 4.2p0.6 mSv,
p 0.01), but not significantly higher as compared to the non-tailored CTCA protocol
in patients with HR 70 bpm (group D: 8.5p0.9 mSv, p=0.51).
Conclusion: Dual-source CTCA is associated with average radiation doses between
1.3 and 9.0 mSv, depending on the protocol used. Tailoring of the protocol to the HR
and BMI results in dose reductions of up to 86%, while maintaining image quality.
Scientific and Educational Exhibits
C-144
Development of heart dynamic phantom usable with CT, MRI, nuclear
medicine and angiography (new type of phantom with ventriclemyocardium bicameral composition and artery valve movement)
K. Tsujioka, T. Goto, T. Sekitani, K. Asano, S. Shimizu, M. Tanase; Toyoake/JP
([email protected])
Purpose: In this report, we will discuss about our new type of phantom, the heart dynamic phantom, which can be used with CT, MRI, nuclear medicine, and angiography.
With our new heart dynamic phantom, we have succeeded in recreating the movement
of an actual human heart by making the myocardial pumping movement take place.
Methods and Materials: The phantom is made up of four segments: the driving
part, the transmitting part, the balloon, and the pool. The driving part, based on a
linear motor, can recreate actual human heart movement with computer-guided
assistance. The transmitting part allows this movement created by the driving part
to communicate with the balloon, which has a dual composition of cardiac muscle
and cardiac ventricle. A series of these movements appropriately imitates the
actual heart movement.
Results: We used the new phantom to conduct experiments on heart functions with
CT, MRI, and nuclear medicine scan. Our experiments found that ejection fraction
(EF), of which the true value is 55%, varied according to the type of scanning:
55% with CT, 54% with MRI, and 34% with nuclear medicine. As for myocardial
ischemia diagnosis, no difference was shown among all the modalities, resulting
in the accurate rate.
Conclusion: The new phantom we used was developed under a completely
new concept; it generates a movement closely resembling that of a human heart,
allowing the heart circulation and coronary artery movement. We believe that
the development of this type of phantom encourages further advances in the
cardiovascular field.
C-145
Role of CT angiography and cardiovascular magnetic resonance in the
selection of patients suitable for percutaneous aortic valve replacement
A. Rossi1, S.W. Kirschbaum1, F. Pugliese1, A. Moelker1, M.A. Cova2, P. de Feyter1,
P. de Jaegere1, G.P. Krestin1, R.J. van Geuns1; 1Rotterdam/NL, 2Trieste/IT
([email protected])
Learning Objectives: To illustrate the role and the advantages of CT angiography
(CTA) and cardiovascular magnetic resonance (CMR) in the selection of patients
for percutaneous aortic valve replacement (PAVR).
Background: In the past, surgical aortic valve replacement was the only effective
therapy for severe aortic stenosis (AS). Nowadays, a PAVR technique has been
in development. Important measurements before treatment are aortic valve area,
aortic annulus diameter, absence of severe peripheral arterial disease and favorable
coronary anatomy. CTA and CMR are useful tools in the evaluation of the selection
criteria for PAVR and one of them should be used in the preoperative screening of
patients who are candidates for PAVR.
Procedure Details: In this poster, we are going to describe the acquisitions protocols for CT and CMR in the evaluation of patients with aortic stenosis who are
candidates for PAVR, how to choose the best aortic annulus imaging plane for the
procedure, the anatomic relation between coronary ostia and annulus calcifications in relation to different types of percutaneous aortic valve prothesis and how
to evaluate proximal peripheral vessels by CTA and MRI.
Conclusion: CTA and CMR have an important role in the selection of patients for
PAVR giving important information to the execution of the procedure.
C-146
Congenital heart disease in adults: Role of MDCT
P. Orenes, M. Navallas, M. Sánchez Nistal, R. Cano, C. Jiménez López-Guarch,
T. Velázquez; Madrid/ES ([email protected])
Learning Objectives: 1. To show the role, clinical applications and advantages of
MDCT in the evaluation of adults with congenital heart diseases. 2. To illustrate the
radiological features and most representative findings of different CHD.
Background: Although echocardiography is the initial diagnostic modality for patients with suspected congenital heart disease, MDCT is a helpful complementary
imaging modality that overcomes the limitations of echocardiography, MRI and
heart catheterization.
Procedure Details: The most outstanding CT findings in congenital heart diseases
in adults are shown: atrial and ventricular septal defects, transposition of the great
arteries, solitary heart ventricle, tetralogy of Fallot, patent ductus arteriosus, anomalous pulmonary venous connection, Ebstein’s anomaly, pulmonary artery agenesis,
truncus arteriosus, etc. In some patients, more than one CHD are associated. Post-
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surgical findings are shown too. All patients were imaged on a sixteen-row MDCT
scanner without cardiac gating after the administration of iodinated contrast media.
A fast and simple postprocessing with MIP and VR reconstructions was performed.
Findings were compared with those of echocardiography, MRI and catheterism.
Conclusion: CT has become a useful imaging modality for the pre- and postsurgical evaluation of a wide variety of cardiac defects in adults. It is complementary to
echocardiography and heart catheterization, and can become a good alternative
to MRI because: spatial resolution, multi-phasic and functional studies, very fast,
availability, safe and effective in presence of metallic coils, pacemaker wires, valvular
prostheses, aneurysm clips, detection of extracardiac abnormalities (simultaneous
evaluation of airways and lung parenchyma).
C-147
Prognostic value of multislice computed tomography coronary
angiography and calcium scoring in patients without known coronary
artery disease
F. Cademartiri1, E. Maffei1, S. Seitun2, A.A. Palumbo1, C. Martini1, C. Saccò1,
A. Aldrovandi1; 1Parma/IT, 2Genoa/IT ([email protected])
Purpose: To determine the prognostic value of multislice computed tomography
coronary angiography (MSCT-CA) and coronary artery calcium scoring (CACS) in
patients without known coronary artery disease (CAD).
Methods and Materials: 511 patients (316 men, 61.5p11.2 years), who were
referred for suspected CAD, underwent MSCT-CA for CAD detection (normal vs.
non significant vs. significant CAD). CACS was categorized as normal/minimal
(0-10), mild (11-100), moderate (101-400), and severe/extensive ( 400). Patients
underwent follow-up for cardiac events.
Results: Normal coronary arteries were detected in 40%, non significant CAD
(b50% luminal narrowing) in 40%, and significant CAD ( 50%) in 20% of the
patients. Prevalence of significant CAD was 3.5% in the normal/minimal CACS,
21.5% in the mild CACS, 40% in the moderate CACS and 57% in the severe/
extensive CACS. At follow-up (19p4 months), 60 total events occurred (9 major).
In patients with normal coronary arteries on MSCT-CA, the major event rate was
0 vs. 1% in patients with non significant CAD, and 7.8% in patients with significant
CAD (p 0.0001). 1 major event occurred in a patient with normal/minimal CACS;
1 major event occurred in a patient with mild CACS. In multivariate analysis, CACS
was an independent outcome predictor over traditional risk factors, but when CAD
analysis by MDCT-CA were included into the model, significant predictors of events
remained the presence of diabetes (p 0.05), and obstructive CAD (p 0.01).
Conclusion: An excellent prognosis was noted in patients with a normal MSCTCA (0% major event rate). Importantly, normal/minimal CACS did not exclude the
presence of CAD and future events.
C-148
How to perform and to look at myocardial delayed enhancement with CT:
Impact of X-ray beam voltage/energy and contrast material volume
C. Martini1, E. Maffei1, A.A. Palumbo1, C. Saccò1, M.L. Dijkshoorn2,
A.C. Weustink2, N.R. Mollet2, F. Cademartiri1; 1Parma/IT, 2Rotterdam/NL
([email protected])
Learning Objectives: 1. To evaluate myocardial viability in myocardial infarction
using delayed-enhancement CT imaging. 2. To provide interpretation and scan
hints for the best visualisation of DE and no-reflow zone. 3. To show the effect of
different X-ray beam voltage/energy and contrast material volume.
Background: Myocardial infarct size is a predictor of clinical outcome in patients
suffering from AMI. We propose the delayed-enhancement CT imaging (DE-CT)
as non-invasive imaging modality for the detection of myocardial infarction. We use
different algorithms of dose and contrast material volume to evaluate the best way
to depict DE and no-reflow, in relation to remote myocardium.
Procedure Details: In domestic pigs (mean weight: 24 kg), an AMI was induced
and DE-CT imaging was performed 5 days later after administration of iodinated
contrast. Four scan protocols were performed in spiral cardiac mode at two tube current values (350/900 mAs) with two iodinated contrast material volume (30/100 ml).
The scans performed were: ART (CTA first-pass), DE1 (15 mAs/kg-1.25 gI/kg), DE2
(37.5 mAs/kg-1.25 gI/kg), DE3 (15 mAs/kg-3.75 gI/kg), DE4 (37.5 mAs/kg-3.75 gI/
kg). Also in humans, different protocols have been performed and different imaging
protocols are displayed.
Conclusion: The amount of contrast material is far more important than radiation
dose for the assessment of DE-CT.
Scientific and Educational Exhibits
C-149
Optimization of cardiac ECG-gated dose modulation techniques for
patients with high heart rates
T. Inoue1, K. Oosawa2, T. Nishida2, F. Uto1; 1Tenri/JP, 2Sakurai/JP
Purpose: Some of the major limitations in performing cardiac CTA examinations on
patients with high heart rates are challenges in obtaining consistent image quality
and implementing dose modulation techniques. An optimized scan technique that
will help better image these patients at lower radiation exposures is introduced.
Methods and Materials: Retrospective investigations of 571 cardiac CTA examinations were performed for physiological parameters and optimal cardiac phases
required for imaging of coronaries. Phantom tests were performed at different heart
rates (70, 80, 90 and 100 BPM) to compare performance between four different
dose modulation protocols (55% phase, combination of 50 & 60% phases, combination of 45 & 65% phases, and combination of 40 & 70% phases). Subsequently,
acquisitions were performed on patients to validate the optimized technique found
through phantom investigations.
Results: Evaluation of clinical scans indicated that optimal phases for coronary
visualization were between 30-50% and 70-80%, depending on heart rate. Detailed
analysis of phantom data for different heart rates revealed that the optimal phases
were 40 & 70% at 70 BPM, 45 & 65% at 80 BPM, 50 & 60% at 90 BPM, and 55% at
100 BPM. The radiation exposures when compared to those without dose modulation techniques were 20.1, 19.5, 18.8 and 18.4%, respectively. Overall, assessment
of clinical cases show an average heart rate of 84 BPM, resulting in dose of 18.7%
compared to that required without dose modulated techniques.
Conclusion: Optimized scanning techniques can enable considerable reductions
in X-ray radiation exposure for patients with high heart rates, while providing consistent diagnostic image quality.
C-150
Diagnostic performance of low-dose CT coronary angiography in the stepand-shoot mode
H. Scheffel, P. Stolzmann, S. Leschka, L. Desbiolles, A. Plass, T. Krauss,
B. Marincek, H. Alkadhi; Zurich/CH ([email protected])
Purpose: The purpose was to investigate the performance of low-dose dual-source
computed tomography (DSCT) coronary angiography in the step-and-shoot (SAS)
mode for the diagnosis of significant coronary artery stenoses in comparison with
conventional coronary angiography (CCA).
Methods and Materials: 120 consecutive patients (71 males, age 68p9 years, BMI
26.2p3.2 kg/m2) underwent both DSCT in the SAS mode and CCA within 14 days.
Twenty-seven patients were given IV beta-blockers for heart rate reduction prior to
CT. Patients were excluded if a target heart rate b70 bpm could not be achieved by
beta-blockers or when the patients were in non-sinus rhythm. Two blinded readers
independently evaluated coronary artery segments for assessability and for the
presence of significant ( 50%) stenoses. Sensitivity, specificity, negative (NPV)
and positive predictive value (PPV) were determined with CCA being the standard
of reference. Radiation dose values were calculated.
Results: DSCT coronary angiography in the SAS mode was successfully performed in all 120 patients. Mean heart rate during scanning was 59p6 bpm (range
44-69 bpm). 1773/1803 coronary segments (98%) were depicted with a diagnostic
image quality in 109/120 patients (91%). The overall patient-based sensitivity,
specificity, PPV, and NPV for the diagnosis of significant stenoses were 100, 93,
94, and 100%. The mean effective dose of the CT protocol was 2.5p0.8 mSv
(range 1.2-4.4 mSv).
Conclusion: DSCT coronary angiography in the SAS mode allows in selected
patients with a regular heart rate the accurate diagnosis of significant coronary
stenoses at a low radiation dose.
C-151
Dynamic visualization of the pulmonary valve at cardiac CT
E. Gassner1, Y.-S. Lee1, J. Abro1, W. Jaschke2, P. Costello1, U.J. Schoepf1;
1
Charleston, SC/US, 2Innsbruck/AT ([email protected])
C-152
Characteristics of early coronary artery plaque in Korean young adults
under 40 years: Findings of screening coronary CT angiography and
comparison with angiographic findings of acute coronary syndrome
patients
E. Ha, J. Cheung, Y. Kim, S. Shim; Seoul/KR ([email protected])
Purpose: We evaluated the characteristics of atherosclerotic plaque of early
coronary artery disease (CAD) in Korean young adults under 40 years old by
analysis of CT findings of coronary plaques detected on screening coronary CT
angiography (CCTA).
Methods and Materials: We analyzed screening CCTA obtained in 144 patients
who were younger than 40 years old in terms of the location, degree of stenosis,
and type of plaques and compared the results with angiographic findings of patients
who had acute coronary syndrome. We also compared the patients with CAD and
without CAD on CCTA in coronary risk factors.
Results: Eighteen patients had 22 coronary plaques on CCTAT,which were
located in proximal left anterior descending (LAD) (n=16), left main (LM) (n=4),
right (RCA) (n=2) coronary artery with the most common location of proximal left
anterior descending coronary artery (n=14). All patients had mid stenosis and
types of plaque included non-calcifying (n=7), mixed (non-calcifying component calcifying) (n=4), mixed (non-calcifying component calcifying) (n=6), calcifying
(n=5) plaque. Patients presented with acute coronary syndrome had 37 plaques
located in LAD (n=21), RCA (n=9), left circumflex (n=6), and LM (n=1) coronary
artery. The presence of obesity, smoking, hypertension, hypercholesterolemia,
and fatty liver was significantly higher in patients with CAD compared with patients
without CAD on CCTA.
Conclusion: In young adults, plaque of early coronary artery disease most commonly occurs in LAD, particularly in proximal segment, and non-calcifying plaque
is common.
C-153
Anatomy and variations of the arterial supply to the sinuatrial node:
Imaging with dual-source cardiac multidetector CT angiography
D. Yildirim, A. Agildere, S. Akpek, T. Gumus, M. Ucar; Istanbul/TR
([email protected])
Purpose: Our basic aim was to describe the sinus node artery (SAN) and to define
the typical anatomy and rare variations at this junction.
Methods and Materials: We retrospectively examined cardiac CT images of 98
patients (male: 85, female: 13, mean age: 48 years) acquired with dual source
multidetector system. Using the special software; three-dimensional and maximum
intensity projection and curved multiplanar images were generated. After depiction
of the sinuatrial node arterial supply: firstly, the trace of the artery was defined; secondly, calibration at the origin measured and then percentages were calculated.
Results: A single SAN arter originated from the proximal 35 mm of the right
coronary artery (RCA) in 89 (91%), from the proximal 40 mm of the left circumflex
artery in 4 (4%), directly from the RCA sinus in 3 (3%) and from the conal branch
of the RCA in 2 (2%) patients. Also, a typical trace of the SAN arterial supply was
detected in 43 patients who have similar anatomy.
Conclusion: The arterial blood supply to the SAN can be imaged easily with
dual-source multidetector CT examination by processing the routine cardiac CT
sections. Comparing with the literature reports, we can say that there is high variability between different races concerning the percentages of the different types
of arterial supply to the SAN.
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Learning Objectives: To demonstrate the feasibility, display techniques, and limitations of pulmonary valve imaging with retrospectively ECG-gated CT.
Background: Accurate visualization of the pulmonary valve remains challenging
for cross sectional imaging modalities. Recent developments in cardiac CT provide
unprecedented spatial and temporal resolutions for imaging rapidly moving structures, providing new opportunities for diagnosing valvular disease. This exhibit is
specifically aimed at CT diagnosis of pulmonary valve morphology and function
based on dedicated imaging planes. The current capabilities, limitations, and future
potential of cardiac CT for imaging the pulmonary valve are illustrated.
Imaging Findings: Imaging the pulmonary valve: current status and challenges.
Cross sectional anatomy of the right ventricular outflow tract, pulmonary valve, and
the pulmonary root. CT post-processing techniques and imaging planes for pulmonary valve display. Performance of dynamic CT imaging for visualizing pulmonary
valve anatomy and leaflet motion. CT imaging features of normal and diseased
valves. Current role of cardiac CT is compared to standard clinical modalities - advantages and disadvantages. Limitations: Anatomic conditions, technical pitfalls,
image noise, contrast medium delivery, heart rate, and temporal resolution.
Conclusion: High spatial and temporal resolution capabilities of cardiac CT
combined with postprocessing by interactive manipulation of 4D data sets allow
for high quality dynamic imaging of the pulmonary valve.
Scientific and Educational Exhibits
C-154
Quantitative analysis of the impact of nitroglycerin on coronary artery
imaging with 64-row CT
Y. Miao1, B. Wang1, Y. Shen2, J. Li2, Y. Guo2, H. Cao2; 1Hangzhou/CN, 2Beijing/CN
([email protected])
Purpose: Quantitatively evaluate the impact on image quality of using nitroglycerin
in coronary artery imaging with 64-row CT.
Methods and Materials: 100 patients who underwent 64-row CT coronary artery
imaging were divided into two groups of 50 each. Nitroglycerin was applied to
patients in one group (A) before the CT scans. CPR reconstructions of the anterior
descending, circumflex and right coronary branches were performed at their best
cardiac phases. Two experienced radiologists selected the middle points of the
proximal section of right coronary, left anterior descending, and circumflex branches,
and measured their diameters for the two groups of patients.
Results: The measured diameters of the proximal section of the right coronary,
left anterior descending, and circumflex branches were 3.92p0.72, 3.90p0.56,
3.59p0.81 mm and 3.41p0.99, 3.52p0.86, 3.28p0.56 mm for the groups of patients
with and without the use of nitroglycerin, respectively. The diameters increased by
15, 10.7 and 9.4%, respectively, for the three vessels with the use of nitroglycerin.
The mean values for these vessels were 3.83p0.52 and 3.40p0.72 mm, respectively,
with and without the use of nitroglycerin. The perceived image quality had marked
increase with the use of nitroglycerin.
Conclusion: The use of nitroglycerin is effective in increasing the diameters of
coronary arteries. It may improve the visualization of small coronary arteries and
their branches with the limited spatial resolution of the current CT system.
C-155
Imaging of left ventricular assist devices and possible device related
complications
B. Greiner, K. Wiebe, P. Heiss, C. Schmid, S. Feuerbach, O.W. Hamer;
Regensburg/DE ([email protected])
Learning Objectives: 1. Learn the imaging appearance of different types of
left ventricular assist devices (LVAD) on chest radiographs (CR) and computed
tomography (CT). 2. Learn which complications are associated with LVADs and
how to identify them on imaging.
Background: LVADs are increasingly used for the management of patients with
acute or chronic heart failure of various origins. The devices provide circulatory
support and are used as “bridge to transplant”, “bridge to recovery”, or permanent
alternative to transplant (“destination therapy”). LVADs are frequently associated with
device related complications that contribute to morbidity and mortality. Radiologists
should be aware of the normal imaging appearance of LVADs on CR and CT and
should be able to recognize device related complications.
Imaging Findings: Mechanical circulatory support is generally accomplished by
inserting cannulas in the heart and great vessels to divert blood from the failing
left ventricle back to the arterial circulation via a pump. Schematics as well as CR
and CT imaging findings (including multiplanar reformations) of different types of
LVAD are outlined. Potential device related complications, the most frequent being
hemorrhage, thrombembolism and air embolism, are discussed and illustrated.
Conclusion: LVADs are increasingly used in modern heart surgery. Radiologists
are required to recognize normal postoperative imaging appearances of the various
devices and to reliably identify potential complications.
C-156
Relative influence of plaque composition, arterial diameter and technical
adequacy on diagnostic performance of 64-row coronary CT angiography
(cCTA) using conventional quantitative coronary angiography (QCA) as
reference
A. Ascarelli, A. Napoli, M. Francone, F. Zaccagna, D. Geiger, P. Di Paolo,
C. Catalano, R. Passariello; Rome/IT ([email protected])
Purpose: Relative plaque composition, along with coronary diameter and image
quality, may affect the ability of cCTA in detecting significant stenoses. Thus, the
aim of our study was to determine whether composition of atherosclerotic plaques,
segmental coronary diameter and technical adequacy influence diagnostic performance of cCTA.
Methods and Materials: Seventy-eight patients underwent cCTA (64x0.6 mm
[Siemens]; 70 mL of 400 mgI/mL [Iomeprol; Bracco] at 4.5 ml/s) prior to QCA,
performed within 3 days. Data were analyzed using semi-automated quantitative
stenosis software (Vitrea 2). All segments 1.5 mm were analyzed. Two radiologists evaluated all cCTAs datasets concerning diagnostic image quality, presence
of significant coronary stenoses (validated against QCA), plaque composition and
segmental location.
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Results: In 77 of 78 patients, 64 cCTA enabled the visualization of the entire
coronary tree with diagnostic image quality in 925 segments. The overall sensitivity
for the detection of stenosis 70% was 93% (156-169), and specificity was 92%
(697-756). cCTA diagnostic accuracy (sensitivity, specificity[%]) was dominantly
dependant on plaque composition and progressively decreased with parallel increase of compositional density: 1, (soft plaque) 97-99; 2, (mixed) 97-96; p 0.01;
3, (predominantly calcified) 61-85; p 0.001. Inversely, diagnostic accuracy was
largely independent of image quality and segmental location (both p .05).
Conclusion: Plaque composition, and specifically high density lesions, significantly
affects diagnostic accuracy. In presence of soft plaque, the diagnostic accuracy
is consistently high irrespectively of coronary diameter and, at a lesser extent,
image quality.
C-157
How to assess various cardiac findings on non-gated routine chest CT:
Correlation with ECG-gated 64-slice MDCT - more to know, better to
understand!
S. Kim, E. Chun; Seoul/KR
Learning Objectives: Significant cardiac findings are common and it might be
easily-overlooked on non-gated routine chest CT. Therefore, systemic approach is
required for the evaluation of cardiac structure on non-gated CT. Also, radiologists
should know the significance and limitations for the assessment of various cardiac
findings on routine chest CT comparing with ECG-gated 64-slice MDCT.
Background: With recent advances of MDCT technology, temporal and spatial
resolution has been markedly improved. Therefore, cardiac structure on non-gated
CT is well visualized and it needs tailored evaluation for the accurate diagnosis of
various cardiac diseases.
Imaging Findings: 1. How to assess various cardiac findings on routine chest CT;
2. To demonstrate the various easily overlooked cardiac findings with significance
on routine chest CT correlated with ECG-gated 64-slice MDCT: 1) Myocardial
abnormality - acute or chronic myocardial infarction, DCMP, HCMP etc. 2) Valvular
heart disease - aortic, mitral, and pulmonary valvular heart disease. 3) Chamber
morphology such as ASD, D-shaped LV, and septal inversion. 4) Space occupying
lesions at heart structure - tumor or thrombus 5) Significant coronary atherosclerosis
including left main and proximal segment disease. 6) Pericardial disease such as
Tbc and tumor mimicking effusion; and 3. Limitation and Remedies of routine chest
CT for the assessment of cardiac findings.
Conclusion: Understanding of various cardiac findings on non-gated CT is important for the evaluation of chest pain or dyspnea as well as detection of subclinical,
but significant findings.
C-158
Diverticula of the heart in cardiac MSCT examination
E. Czekajska-Chehab, K. Rosinska-Bogusiewicz, E. Siek, S. Uhlig, A. Drop,
G. Staskiewicz, E. Wysokinska, J. Kobayashi; Lublin/PL
([email protected])
Purpose: Evaluation of the incidence, localization and morphology of heart diverticula (HD) in patients hospitalized in tertiary cardiology centre.
Methods and Materials: The study included 3266 ECG-gated MSCT examinations
of the heart in patients with acute or chronic heart diseases (8- and 64-row GE
Medical System LightSpeed).
Results: HDs were incidentally found in 46 (1.4%) patients aged from 10 to 76
years. Diverticula more frequently localized in the left ventricle (35 cases), especially
in its periseptal part. Nine lesions were discovered in the left atrium, one in the
right atrium and in one case both in the left atrium and ventricle. In 7 patients HDs
were seen multifocally. The size of HDs ranged from 4 to 30 mm (mean 7 mm). In
19 cases, diverticula were visible only in diastolic phase and almost completely
emptied during the systolic phase. In two cases, thrombus inside the diverticulum
was observed. HDs were associated with heart enlargement or hypertrophy in 34
patients, cardiac muscle hypokinesis or pathological mobility in 10 patients, other
congenital or acquired anomalies of the heart, cardiac or pulmonary vessels in 19
patients. Moreover, HDs coincided with cardiac focal lipomatosis in 14 patients.
Conclusion: The ECG-gated MSCT is an efficient method for detection and evaluation of both diverticula and other associated anomalies of the heart.
Scientific and Educational Exhibits
C-159
Evaluation of MDCT for the assessment of aortic disease: Pitfalls and
remedies
S. Kim, E. Chun; Seoul/KR
Learning Objectives: Rapid advances of MDCT technique have enabled correct
diagnosis of aortic disease. However, the proper understanding of the technique
and optimal enhancement is important for correct detection or characterization
of aortic disease. Therefore, it is necessary to understand the various pitfalls and
remedies of aortic disease on MDCT and to know the correct scanning protocols,
the optimal contrast enhancement, how to adjust the scan timing and appropriate
post processing method.
Background: The purpose of this exhibit is: 1. How to evaluate and measure various
aortic diseases using MDCT. 2. To demonstrate the various pitfalls and remedies
of aortic disease on MDCT. 3. To understand usefulness of state of art technology
and post-processing for the assessment of aortic disease.
Procedure Details: 1. Recent advances of techniques for the evaluation of aortic
disease on MDCT and post processing; 2. How to evaluate and measure various
aortic diseases; and 3. Common various pitfalls and remedies of aortic disease
on MDCT: 1) Acute aortic syndrome - technical factors, streak artifacts, periaortic
structures, aortic wall motion, and normal aortic sinuses. 2) Suboptimal enhancement of contrast media in patients with aortic dissection or aneurysm, 3) Accurate
measurement of maximum diameter before and after procedure in patient with
aortic aneurysm 4) Detection of impending or ruptured aneurysm. 5) Differentiation common aortic disease from unusual disease such as mycotic aneurysm,
vasculitis, and tumor.
Conclusion: Understanding of various pitfalls and remedies for the assessment
of MDCT is essential for accurate diagnosis and management in patients with
aortic disease.
C-160
Accuracy of 64-slice CT in assessment of coronary artery bypass grafts
and distal anastomoses
A. Arjmand Shabestari, M. Fatehi, S. Akhlaghpoor, M. Tehrai, M. Hashemian;
Tehran/IR ([email protected])
Purpose: This study was performed to determine diagnostic accuracy of MSCT
in assessment of patency of coronary artery bypass grafts (CABGs) and their
anastomoses.
Methods and Materials: Seventy-three patients with previous CABG who underwent both coronary CT angiography using 64-slice CT scanner and invasive coronary angiography were enrolled. Arterial and venous CABGs patency was graded
as: a-normal, b-insignificant ( 50% diameter reduction) stenosis, c-significant
(r50% diameter reduction) stenosis or d-totally occluded. Distal anastomoses were
graded as normal, stenotic or totally occluded. Negative results were considered
as either normal findings or presence of insignificant stenosis and positive results
were regarded as presence of r 50% diameter reduction stenosis, together with
total occlusion.
Results: In 73 patients (51 male, 22 female; mean age 64.9 p 8.6 years) totally 223
grafts (48 arterial and 175 venous) with the same number of distal anastomoses
were evaluated. In MSCT, 5 out of 223 bypass grafts (2.2%) patency could not be
evaluated; hence, finally 218 grafts (97.8%) were assessable. Assessability was
93.7 and 98.9% for arterial and venous grafts, respectively. Both normal patency
and total occlusion of SVGs in CTA were correctly reported in all venous grafts
(100%). Positive Predictive Value: General: 92.2%, Arterial: 84.6%, Venous: 94.1%;
Negative Predictive Value: General: 96.1%, Arterial: 93.8%, Venous: 96.7%.
Conclusion: Diagnostic accuracy of 64-slice MSCT in detecting normal patency,
non-significant stenoses, significant stenoses and total occlusion of arterial and
particularly venous CABGs is extremely high so that ICA may be eventually substituted by CTA in the near future.
C-161
Learning Objectives: Understanding the correlation of absorption changes in
correlation to temperature changes in CT imaging.
Background: Cardiac EP procedures are currently utilized using fluoroscopy and
3D mapping systems to visualize and control the positioning of the ablation catheter
in the heart dung the procedure. These imaging systems do not provide visualization
or control of ablation procedures and are strictly limited to catheter guidance and
positioning control. But a real time imaging of the developing tissue damage during
C-162
Dual source computed tomography angiography for detecting coronary
ostial lesions: Superior to conventional coronary angiography?
L.A. Neefjes1, E. Neoh1, M. Rengo2, S. Kyrzopoulos1, A.C. Weustink1,
N.R. Mollet1, G.P. Krestin1, P.J. de Feyter1; 1Rotterdam/NL, 2Latina/IT
([email protected])
Purpose: To evaluate the diagnostic performance of dual source multi-slice
computed tomography coronary angiography (CTCA) in detecting coronary ostial lesions in symptomatic patients, in comparison with conventional coronary
angiography (CAG).
Methods and Materials: 480 patients with CAG and CTCA were evaluated by an
independent observer. Of this group, 43 patients were suspected to have a coronary
ostial lesion. The CAGs and CTCAs of these patients were reviewed by, respectively,
a cardiologist and a radiologist. Afterwards, the cardiologist and radiologist formed
a consensus diagnosis by re-evaluating the CAG and the CTCA together. The
consensus diagnosis, considered as the standard of reference, was compared to
the first diagnosis made by the cardiologist and the radiologist separately.
Results: According to the consensus diagnosis, 26 ostial lesions were present in
24 patients. CTCA missed none of the severe ostial lesions and missed 1 moderate
lesion. CAG missed 5 lesions; 2 severe and 3 moderate ostial lesions. CTCA showed
a sensitivity of 96% up to 100% (depending on the stenosis degree; moderate/
severe and severe) in detecting coronary ostial lesions. Sensitivity of CAG was
75% up to 86% in detecting these ostial lesions.
Conclusion: CTCA appears to be an accurate imaging modality to detect coronary
ostial lesions. Compared to CAG, CTCA is more accurate in evaluating the coronary
ostium because of better 3D visualization of the ostia and no catheter related problems as passing the lesion with the cathetertip and catheter induced spasms.
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ECG-CT: A perfect diagnostic tool for detection and evaluation of coronary
artery aneurysms
S. Uhlig, E. Czekajska-Chehab, G. Staskiewicz, E. Siek,
K. Rosinska-Bogusiewicz, A. Drop; Lublin/PL ([email protected])
Purpose: Coronary artery aneurysm (CAA) is a rare complication of atherosclerosis or vasculitis, occurring in 1.5% of population. Initial symptoms are not
specific and the lesion may lead to serious clinical implications, including sudden
death. The aim of the study was to present possibilities of ECG-CT in detection
and evaluation of CAA.
Methods and Materials: ECG-CT examinations of 1700 patients were analyzed in
respect to detect CAA. The examinations were performed with 64-row scanner in the
years 2006-2008, in typical cardiac CT protocol. Multiplanar and 3D reconstructions
were used to evaluate coronary arteries. Localization and morphology of aneurysms,
as well as concomitant lesions of coronary arteries, were evaluated.
Results: CAA were detected in 25 patients (1.47% of investigated group; age
41-80, median 54.5), more frequently in males - 19 cases (76%). In 22 cases,
CAA was diagnosed for the first time. In 21 patients, one coronary artery was affected. Two and four arteries were involved in two cases each. CAA were revealed
in following vessels (number of aneurysms in brackets): RCA (14), LAD (5), LCX
(4), OM1 (4), LM (2), DIA1 (2), IM (1), posterolateral branch (1), (total number of
aneurysms - 33).
Diameter of aneurysms ranged from 3.8 to 15 mm (median 6.2) and the length
was 4-36 mm (median 11). In three cases, aneurysm contained thrombus. The
atherosclerosis was detected in 21 cases, and in 11 of them (44%) the stenoses
were hemodynamically significant.
Conclusion: ECG-gated CT, apart from being the valuable method of detection of atherosclerotic lesions in coronary arteries, enables an accurate diagnosis of CAA.
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Temperature monitoring in ablation procedures using computed
tomography
T.R. Fleiter, T. Dickfeld, K. Read; Baltimore, MD/US ([email protected])
the ablation procedure would be helpful to modulate ablation in order to maximize
the destruction of the targeted structure such as electrophysiologic active scars and
to minimize the damage of healthy tissue. Monitoring the temperature changes in
the effected tissue during the ablation would provide such information.
Procedure Details: The X-ray absorption of soft tissue varies with temperature.
Increasing temperature leads to decreased X-absorption and therefore decreasing HU values in CT. There is almost a linear correlation of temperature and HU
decrease in the typical EP ablation induced changes in the soft tissue. Measuring
the density changes over time using repeated CT scans therefore allows the monitoring of temperature changes and the size of the affected area in real time. The
measurements are relative and results depend on the content of the soft tissue.
Typical changes will be demonstrated in cardiac (swine model) and liver tissue - the
two main targets of interventional procedures.
Conclusion: CT monitoring of temperature changes has the potential to provide
real time monitoring of ablation procedures.
Scientific and Educational Exhibits
C-164
Artifacts in MDCT coronary angiography: How to recognize and avoid them
J.A. Fernandez Villameytide, P. Catalán Sanz, R. Gómez Illán, J. Longo Areso,
D. Barettino Coloma, J. Richard Rodriguez; Oviedo/ES ([email protected])
Learning Objectives: To illustrate the potential artifacts and pitfalls in MDCT coronary angiography and describe the potential solutions and tips to avoid them.
Background: MDCT coronary angiography is rapidly developing and its use is
becoming more prevalent, but artifacts and other pitfalls can cause significant
problems for the accurate diagnosis of coronary artery disease. Therefore, it is
important for the observers reporting these studies to be aware of the potential
artifacts and pitfalls and the different methods to minimize false-positive and falsenegative interpretations of coronary artery stenosis. We reviewed 285 64-MDCT
coronary angiography studies performed between September 2006 and September
2008 to illustrate the potential artifacts and pitfalls. Available solutions for avoiding
them are presented.
Imaging Findings: The pitfalls and artifacts are classified in: a) Motion related
artifacts caused by cardiac, respiratory or body motion; b) Partial volume averaging
effect; c) Streak artifacts; d) Technical artifacts, either during adquisition or reconstruction; e) Postprocessing artifacts and f) Artifacts derived from contrast material
enhancement and body habitus. Examples that may help to recognize these artifacts
are shown. Available solutions and tips to avoid them are presented.
Conclusion: Artifacts and other pitfalls can cause significant problems for the
accurate diagnosis of coronary artery disease. The most common artifacts are
motion-related.
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64-CT angiography for whole-body vascular imaging: In vivo quantification
of atherosclerotic burden and relation to traditional cardiovascular risk
index and 2-year follow-up
A. Napoli, M. Anzidei, D. Geiger, F. Zaccagna, C. Catalano, R. Passariello; Rome/IT
([email protected])
Purpose: Determine the value of whole-body CT angiography (WBCTA) for quantification of atherosclerosis burden and individual risk stratification.
Methods and Materials: Coronary and extra-coronary CTA was performed in a
single session using an adapted contrast injection protocol (70 + 50 mL at 4 and
3 mL/s [Iomeprol-400; 400 mgI]). The vascular system was evaluated on a segmental
basis. An atherosclerosis burden score (ABS) was generated for each individual
and correlated to traditional cardiovascular (CV) risk (Framingham risk index; FRI).
The prognostic value was determined on the basis of two years’ follow-up.
Results: 268 patients underwent WBCTA (190 with diabetes; 78 with metabolic
syndrome [MetS]). 113 patients were classified as high risk (FRI) and had higher
ABS (p=0.005); 155 patients were considered at mild risk for CV events; the ABS
varied between 5 and 63 (p 0.05). For ABS values greater than 35, the relative
risk for nonfatal myocardial infarction or coronary death was 2.2 (95% CI 1.4-3.6)
and the relative risk for any coronary event was 3.1 (CI 2.1-4.5) (P35 experienced
incident CV events.
Conclusion: WBCTA allows non-invasive, robust assessment of coronary and
extra-coronary vascular disease. ABS has a quantitative measure of whole-body
vascular pathology that compares with FRI for high risk individuals. ABS was
superior to FRI for risk stratification in patients at intermediate risk according to 2
year’ follow-up findings.
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What every radiologist should know about pharmacological management
in MDCT coronary angiography
J.A. Fernandez Villameytide, P. Catalán Sanz, R. Gómez Illán, J. Longo Areso,
D. Barettino Coloma, J. Richard Rodriguez; Oviedo/ES ([email protected])
Learning Objectives: To outline the pharmacological preparation of MDCT coronary angiography and the management of eventual complications.
Background: Best results in MDCT coronary angiography are obtained with low
and regular cardiac rhythm. In many cases drugs are needed to reach optimal
heart rhythm, mainly using beta-blockers. On the other hand, nitrates are frequently
used to improve the diameter of proximal coronary arteries. Therefore, radiologists
must be familiarized with these drugs, their contraindications and interactions
and the management of eventual complications. Between September 2006 and
September 2008, 285 MDCT coronary angiography studies were performed in
our department. The pharmacological preparation used and the complications
reported are described.
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Procedure Details: Patient’s history and vital signs are obtained on arrival. Potential
contraindications for the use of beta-blockers, nitrates and iodinate contrast are
specifically asked. Heart rhythm below 65 bpm is attended to optimize the results
of MDCT-coronary artery angiography. The determination to give beta-blockers,
their dosage and the way of administration to be used are individualized for each
patient on the basis of clinical setting and possible contraindications. Pharmacist
and referring physician consultation are done if alternative drugs are considered, as
calcium-channel blockers. None complication was described with the use of betablockers or with the alternative drugs used. Nitrates are used if heart rhythm is below
60 bpm. One case of hypotension and bradycardia was derived from its use.
Conclusion: The pharmacological preparation for MDCT coronary angiography on
an individualized basis and with awareness of potential complications is safe.
C-168
Acute chest pain and patent coronary arteries: What’s the next step?
V. Pineda, X. Merino, J. Rodriguez, H. Cuellar, S. Gispert, R. Domínguez-Oronoz;
Barcelona/ES ([email protected])
Learning Objectives: 1. To present a diagnostic algorithm in patients with acute
chest pain and patent coronary arteries. 2. To describe the usefulness of MRI in
such patients.
Background: The main cause of acute chest pain in patients with ECG changes and
elevated cardiac enzymes is coronary artery disease. However, some patients have
no coronary obstruction on angiography or MDCT, causing diagnostic uncertainty.
There are a number of potential causes for this situation and cardiac MRI helps to
clarify this diagnostic dilemma.
Imaging Findings: A broad spectrum of cardiovascular pathologies are considered
in the differential diagnosis of this scenario, including myocardial infarction, acute
myocarditis, tako-tsubo cardiomyopathy, apical hypertrophic cardiomyopathy,
coronary vasospasm, cardiac syndrome X, pericardial disease and acute aortic
syndrome. In these pathologies, cardiac MRI provides useful information to suggest
the correct diagnosis. The morphological and functional appearance in MR images
of these conditions will be described.
Conclusion: Cardiac MRI is a non-invasive powerful and clinically relevant tool
to distinguish between different cardiovascular aetiologies of acute chest pain in
patients with unobstructed coronary arteries.
C-169
Radiologic-pathologic correlation of imaging features of congenital heart
diseases using an ultra high-resolution flat-panel volume-CT: Pictorial
introduction
B. Reichardt1, C. Lang1, A. Juraszek2, P. Vock1, R. Gupta2; 1Berne/CH,
2
Boston, MA/US ([email protected])
Learning Objectives: 1. To demonstrate anatomical changes associated with
congenital heart disease. 2. To recognize the unique and novel imaging features
on ultra high resolution digital flat-panel CT that permit distinction among these
entities. 3. To demonstrate correlation between radiologic findings of congenital
heart disease and macroscopic pathological specimens.
Background: This educational exhibit will describe the morphologic changes of
20 excised and preserved hearts of children with congenital heart disease from
the cardiac registry of the Children´s Hospital Boston.
Procedure Details: Ten formalined excised hearts with common defects and ten
wax-fixated hearts with rare congenital heart defects were imaged on a prototype
of a digital flat-panel detector CT scanner with ultra high resolution (~200 µm) and
volumetric coverage.
Conclusion: We were able to demonstrate the benefits of the ultra high resolution CT
imaging features in observing the major types of congenital heart disease. We were
able to demonstrate clinically important relationships between the imaging findings
and macroscopic pathological findings even in small defects down to 0.2 cm.
C-170
Incidental findings noted on calcium scoring CT scans
M.D.B.S. Tam 1, T. Latham1, W. Howard2, A.B. Tanqueray2; 1Norwich/UK,
2
Southend/UK ([email protected])
Purpose: To determine the number of incidental non-cardiac abnormal findings
on calcium scoring cardiac CTs.
Methods and Materials: Triple-reading of 199 consecutive calcium scoring CT
scans was conducted. A consensus meeting was then held to review the detected
abnormalities, define the nature of the abnormalities, and to determine whether
patient recall for further investigations was required.
Scientific and Educational Exhibits
Results: 55 out of 199 CT scans (27.6%) were abnormal. 67 abnormalities were
detected across the 55 scans. Significant abnormalities included a squamous
carcinoma of the lung and indeterminate pulmonary nodules requiring follow-up.
Parenchymal lung abnormalities included a tumour, nodules, consolidation, emphysema and bronchiectasis. Pleural plaques and pleural effusions were identified.
Mediastinal abnormalities included lymphadenopathy and pericardial effusions.
Upper abdominal abnormalities were also detected and included ascites and
gallstones.
Conclusion: 28% of unenhanced calcium scoring CT scans show non-cardiac abnormalities. The interpretation of a large number of abnormalities is dependent upon
the clinical scenario. These findings raise the question whether these investigations
should be read by non-radiologists or specialists with no training in general CT.
C-171
Correlation of effective radiation dose and heart rate in dual-source CT
coronary angiography
F. Laspas, D. Tsantioti, A. Roussakis, N. Kritikos, R. Efthimiadou, D. Kechagias,
D. Savidou, V. Filippi, T. Georgiou, J. Andreou; Athens/GR ([email protected])
Purpose: To evaluate the relationship between radiation exposure and heart rate
(HR), in dual-source CT coronary angiography (CTCA).
Methods and Materials: Data from 187 CTCA examinations, performed with a
dual-source 64-slices scanner (Siemens Definition), were statistically evaluated.
Effective radiation dose (ERD), expressed in mSv, was calculated as the product
of the dose-length product (DLP) times a conversion coefficient for the chest
(mSv=DLPx0.017). Heart rate range and mean heart rate, expressed in beats per
minute (bpm) of each individual during CTCA, were also provided by the system.
Statistical analysis of ERD and HR data was performed by using Pearson correlation
coefficient, analysis of variance (AnOVa) and two-sample t-test.
Results: Mean HR and ERD were found to have a linear correlation. Each additional heart beat per minute was found to increase the total ERD by 0.138 mSv.
Individuals with a mean HR 70 bpm turned out to receive a statistically significant
higher ERD as compared to those with HRb70 bpm.
Conclusion: Dual-source CT scanners are considered to have the capability to
provide diagnostic examinations even with high HR and arrhythmias. However, it is
desirable to keep the HR below 70 bpm in order to reduce the ERD.
Cardiac
MRI
C-172
A modified rabbit model of reperfused myocardial infarction for cardiac MR
imaging research
Y. Feng, Y. Xie, H. Wang, F. Chen, G. Marchal, Y. Ni; Leuven/BE
([email protected])
Purpose: We sought to obtain a rabbit myocardial infarction (MI) model for research
with cardiac magnetic resonance imaging (cMRI) by overcoming a few technical
difficulties.
Methods and Materials: After systemic anesthesia, a newly developed endotracheal intubation method was applied for ventilation. Fourteen rabbits were divided
into group-1 (n=8) with open-chest occlusion of left circumflex coronary artery and
close-chest reperfusion, and group-2 (n=6) of non-ischemic control; all animals
received ECG-triggered cMRI at a 1.5 T clinical scanner. Left ventricular (LV)
functions were compared between two groups using two-tailed paired t-test. The
areas of MI in group-1 were morphometrically compared between delayed contrast
enhancement (DE-cMRI) and triphenyltetrazolium chloride (TTC) histochemically
stained specimens using Bland-Altman test and linear correlation analysis.
Results: The total success rate of intubation and reperfused MI was 14/14 and
6/8, respectively. Both global and regional LV functions significantly decreased
in group-1 as evidenced by significant hypokinesis of the lateral LV-wall and
statistical difference in wall thickening (P 0.001). In group-1, mean MI-area was
19.41p21.92% on DE-cMRI and 19.10p22.61% with TTC staining (r=0.985). Global
MI-volume was 17.92p7.42% on DE-cMRI and 16.62p7.16% with TTC (r=0.994).
Bland-Altman data showed a good agreement between DE-cMRI and TTC stained
specimens. The usefulness of this model was successfully tested for assessing a
new contrast agent.
Conclusion: We have introduced a practical rabbit model of reperfused MI, which
may offer a platform for more translational research using clinical MRI facilities.
C-173
Comparison with myocardial perfusion MRI and myocardial perfusion
SPECT in the diagnostic performance of coronary artery disease: A metaanalysis
K. Iwata1, M. Kubota1, K. Ogasawara2; 1Asahikawa/JP, 2Sapporo/JP
([email protected])
Purpose: To compare the diagnostic abilities of stress myocardial perfusion MRI
and myocardial perfusion SPECT, using a meta-analysis method.
Methods and Materials: We investigated the diagnostic abilities of MRI and SPECT
in the similar subject groups in reports written in English and Japanese. These
reports to be used for analysis were selected according to a “screening standard,”
which was established in advance. After consolidating the data from the selected
reports, we compared: (1) the integrated odds ratio, (2) the point estimation values
of sensibility/specificity, and (3) the summary ROC curve.
Results: For the analysis, six reports were selected (subjects: 153, coronary-artery
target sites: 447). Meta-analysis revealed that the diagnostic ability of myocardial
perfusion MRI was superior to that of myocardial perfusion SPECT regarding
the parameters (1)-(3): (1) the integrated odds ratio of MRI was 24.8 (95% CI
14.4-42.6) and SPECT was 9.2 (95% CI 5.6-15.1), (2) sensitivity were 75% (95%
CI 68-81%) and 64% (95% CI 57-71%), specificity were 89% (95% CI 85-93%)
and 83% (95% CI 77-88%), and (3) the summary ROC curve indicated statistical
significant difference (p 0.001).
Conclusion: The result of meta-analysis supports the previous reports concerning
the diagnostic abilities of the myocardial perfusion MRI and myocardial perfusion
SPECT are equal above. This is considered to be supportive evidence of the
usefulness of myocardial perfusion MRI.
Noninvasive measurement of cardiac high-energy phosphate metabolites
using 31P-spectroscopic chemical shift imaging
A. Hansch, R. Rzanny, J. Reichenbach, W.A. Kaiser; Jena/DE
Purpose: Cardiac diseases are commonly accompanied by structural abnormalities and impaired cardiac energy metabolism. Aim of this study was to investigate
whether the phosphocreatine/adenosine-triphosphate (PCr/ATP) ratio is reduced in
patients with different heart diseases by using spectroscopic chemical shift imaging
(CSI), and whether this ratio is a suitable indicator of disease severity.
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C-174
Scientific and Educational Exhibits
Methods and Materials: 59 patients were included: 20 patients with dilated
cardiomyopathy (DCM); 35 patients with hypertensive heart disease (HHD); and 4
patients with myocarditis (MyoC). Cardiac 31P-MR spectroscopy was performed
with a 1.5 T whole body scanner. Peak areas and ratios of different metabolites were
evaluated, including high-energy phosphates (PCr, ATP), 2.3-diphosphoglycerate
(2.3-DPG), and phosphodiesters (PDE). Correlation analyses were performed
between the metabolite ratios and the left ventricular ejection fraction (LVEF), an
established prognostic factor of heart failure.
Results: Spectral resolution and signal-to-noise ratio (SNR) of the CSI spectra were
sufficient to detect the multiplet structures of ATP and 2.3-DPG in all spectra and
to estimate the peak areas of 2.3-DPG+Pi, PDE, PCr and ATP in the myocardium
of all subjects. Patients with DCM, HDD and MyoC showed decreased PCr/ATP
ratios compared to healthy volunteers.
Conclusion: Magnetic resonance spectroscopy with standard CSI sequences is a
valuable tool for the non-invasive evaluation of myocardial structural alterations in
different cardiac diseases. The PCr/ATP ratio is a helpful parameter to evaluate the
severity of structural impairments of the myocardium in DCM, HDD and MyoC.
C-175
The role of transthoracic echocardiography and magnetic resonance imaging
for evaluation of heart echinococcosis
F. Todua, M. Razmadze, S. Kakhadze; Tbilisi/GE ([email protected])
Purpose: Analyze the role of transthoracic echocardiography (TE) and MRI in the
assessment of heart echinococcosis (HE).
Methods and Materials: 16 patients with HE were examined. The age of patients
varied from 11 to 55 years. The diagnosis of HE is based on serological reactions,
TE and MRI. TE was done in all cases followed by MRI to confirm TE data. Presenting symptoms have a wide variety, but the main symptom was precordial pain. 7
Patients had isolated heart echinococcosis, but most had concomitant damage of
other organs (lungs, liver, brain).
Results: The cysts were localized in the different sites of the heart: ventricular
septum-4 (the mean diameter of cystic mass 5.8 cm), LV apical segment (mean
diameter - 4.5 cm)-6, LV anteriolateral wall - 6 (mean diameter 8.7 cm). All masses
by TE presented either as solitary or multi-chambered cystic lesions with sharp
outlines. 11 patients underwent surgical treatment. During the operation was
found complete coincidence with TE data. Most of patients underwent multistep
hydatidectomy from heart, lungs, brain; in 3 patients was performed one-moment
cystectomy from heart and liver or lung. After the operation, all patients underwent
three or more courses of chemotherapy. 5 patients underwent conservative therapy
due to general condition; 3 of them died within 11 months.
Conclusion: TE is the primary modality for imaging of HE. It provides highresolution, real-time images. MRI is a useful method in differential diagnostics
of cysts providing additional information concerning relation of the cysts to the
adjacent structures.
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MR imaging of “no-reflow” phenomenon after PCI for acute myocardial
infarction
L. Natale1, A. Meduri1, A. Bernardini2, C. Liguori1, R. Marano1, L. Bonomo1;
1
Rome/IT, 2Teramo/IT
Learning Objectives: To demonstrate the appearance of no reflow with delayed
enhancement and with first pass perfusion imaging. To demonstrate differences
between the above mentioned techniques. To demonstrate the different impact on
prognosis of the two techniques.
Background: Even the complete restoration of epicardial blood flow could result in
an incomplete reperfusion of microvascular bed, causing hypoperfused zones within
the previously ischemic myocardial infarction. These phenomena were described as
“no-reflow”. New imaging modalities (such as myocardial contrast echocardiography,
magnetic resonance or scintigraphic techniques) allow to precisely assess perfusion
at microvascular level confirming the presence of myocardial areas with impaired
perfusion even with completely restored epicardial flow. Moreover, the amount of
no-reflow was found to significantly predict left ventricular segmental wall motion
dysfunction, ventricular remodeling and clinical outcome.
Imaging Findings: After introducing the pathophysiology of the “no-reflow phenomenon”, its impact on left ventricle remodeling is underscored. The appearance
of no-reflow is shown in both first pass and delayed enhancement MRI, with a
brief mention to other current techniques (other than MRI). Finally, differences
between first pass and delayed enhancement MRI in no-reflow assessment are
scrutinized.
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Conclusion: No-reflow reflects microvascular damage due to both infarction and
reperfusion. In segments with non transmural delayed enhancement, the presence of no-reflow is a negative prognostic factor for functional recovery. No-reflow
represents the major prognostic factor predicting left ventricle remodeling. Mild to
moderate rest perfusion defects at first pass MR represent no reflow phenomena
not visible at delayed enhancement, but significant for prognosis.
C-177
MR assessment of myocardial delayed hyperenhancement in hypertrophic
cardiomyopathy for stratification
O. Larina, O. Stukalova, V.E. Sinitsyn, M. Smirnova, S. Ternovoy, F. Ageev;
Moscow/RU ([email protected])
Purpose: To estimate the extent and distribution of focal myocardial hyperenhancement detected with delayed contrast-enhanced MR imaging (DCE MRI) in
patients with severe left ventricle hypertrophy caused by hypertrophic cardiomyopathy (HCP) and compare their occurrence with presence of clinical risk factors
of sudden death.
Methods and Materials: 18 patients with HCP were studied using 1.5 T MRscanner. Cine-MR was done using TrueFISP sequence. First-pass myocardial
perfusion assessment during bolus injection of Gd-DTPA-BMA (0.1 mmol/kg) was
followed (after 15 min) with studies of delayed contrast enhancement (DCE) using
segmented IR sequence.
Results: Three types of myocardial hyperenhancement were found: isolated focuses
(21%), multiple focuses (50%) and diffuse hyperenhancement (29%). There was
significant difference in myocardial end-diastolic thickness between hyperenhancing
and non-enhancing segments (19.0p6.4 vs. 10.6p4.7 mm, p 0.001). Significant
correlations were observed between end-diastolic segment's thickness and extent
of DCE (r=0.26, p 0.05), maximum values of hyperenhanced area were found in
segments with thickness 25 mm. Four patients (22%) had episodes of syncope,
and there was moderate correlation between volume of DCE and presence of
syncopes (r=0.53, p=0.04). No patient had episodes of ventricular tachycardia. In
the group studied, no correlation was found between extent of myocardial enhancement and presence of genetic markers of HCM.
Conclusion: In the group of HCM patients studied, correlation between the extent and
presence of DCE from one side, and extent of myocardial hypertrophy and presence
of syncopes from other side (possible risk factors of sudden death) was found.
C-178
Evaluating the enhancement of atherosclerotic plaque on contrastenhanced MRA: Comparison with CTA
T. Li, J.-h. Gao; Beijing/CN ([email protected])
Purpose: To evaluate the enhancement of coronary atherosclerotic plaque revealed
by CTA using pre- and post-contrast navigator-gated 3D-SSFP sequence and the
relationship between plaque enhancement and CT value of the plaque.
Methods and Materials: Nineteen patients with non-calcified plaques on the
proximal or middle segments of coronary artery detected by MDCT were studied.
The coronary MRA was acquired before and after Gd-DTPA administration using
S
navigator-gated 3D-SSFP sequence. The cross-section
O images perpendicular to
P
the long axis of coronary artery were reformatted
on
E MRA. Plaque enhancement
o was defined as enhancement.
was assessed using CNR. 50% increase oftCNR
The relationship between CNR incremented
and CT value was analyzed.
itt were identified on both pre- and postResults: Twenty-four plaques of 14 patients
m
contrast MRA. 11 plaques showed enhancement.
13 plaques showed no enhanceub
Sand
ment. CNR between 24 plaques
surrounding fat tissue were 10.29p4.28 and
l
ia
14.08p5.8 in pre- and post-contrast
MRA and there was a significant difference
er
(P 0.01). CNR was significantly
increased from 8.43p3.59 to 17.55p6.18 in 11
at
enhanced plaques andMno significant change (11.86p4.3 versus 11.15p3.48) in 13
non-enhanced plaques.
No There was no significant difference of CT value between
the enhanced plaques (68.44p24.72) and non-enhanced plaques (57.82p24.13).
There was no relationship between CNR increase of coronary atherosclerotic
plaque on MRA and CT value.
Conclusion: Enhancement of plaques can be demonstrated on CEMRA. The
enhancement of plaques on MRA has no relationship with CT value.
Scientific and Educational Exhibits
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The diagnostic role of cardiac 31P-MRS combined with transmitral MR-flow
measurements in patients with hypertensive heart disease without overt
systolic dysfunction
T. Burkhard, C. Herzog, F. Huebner, T.J. Vogl; Frankfurt a. Main/DE
Purpose: To evaluate the diagnostic role of 31P-MRS combined with transmitral
MR-flow measurements in hypertensive patients compared to echocardiography
and tissue Doppler.
Methods and Materials: 20 subjects (16 men and 4 women, mean age 57 p 13
years) were studied with echocardiography and 31P-MRS at 1.5 Tesla using an
ECG-gated CSI sequence with nuclear Overhauser effect. 12 subjects had a
diastolic dysfunction, 8 subjects served as control group in the following statistical
analysis. All patients underwent phase encoded MRI to obtain transmitral flow patterns to calculate E/A ratio and deceleration time of the early filling curve DT (E).
Comparison to echocardiographical results was performed. Statistical analysis was
made by using mean p SD for description of the data, Spearman correlation, BlandAltman- and Lin-correlation and 2-tailed student-t test for independent samples.
Results: No differences were found in weight, age, LVEF, endsystolic volume,
enddiastolic volume, cardiac output and BNP levels between patients and control
groups. Myocardial PCr/ATP-ratio in patients was significantly decreased compared
to controls (1.21 p 0.22 versus 1.54 p 0.24; p=0.006). Significant correlation existed
between echocardiographical and MR assessment of diastolic function. BlandAltman correlation was r=0.29, p=0.03, 95%-CI for r:[0.03; 0.52]; Lin-concordance
was: r=0.29, p=0.03, 95%-CI for r:[0.03; 0.52].
Conclusion: Cardiac 31P-MRS combined with MR assessement of transmitral flow
patterns correlate well with echocardiographical findings and could be a non invasive
means for detecting early states of heart failure in hypertensive patients.
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Usefulness of cardiac magnetic resonance (CMR) in the non-invasive
evaluation of the Fontan procedure (FP)
S. Navarro Herrero, P. Serrano Gotarredona, F.J. Jimenez Barros,
J.J. Cordones Guerrero; Seville/ES ([email protected])
Learning Objectives: To illustrate the FP and its variants in the univentricular heart.
To outline the advantages of CMR as a non-invasive technique in its evaluation. To
describe the postsurgical follow-up and our results in a series of 30 patients.
Background: The FP has achieved excellent results in patients with a univentricular
heart, though it can lead to several late complications. CMR proves to be essential
for excluding some of them, as pulmonary venous obstruction, ventricular outflow
obstruction, collateral vessels, stenosis and thromboembolic events. It is also a
priority to assess the ventricular contractile function, the competence of its inflow
valve and the width of its outflow tract.
Imaging Findings: CMR allows describing the congenital cardiopathy and associated anomalies. It depicts clearly the FP and its variants. CMR evaluates the
ventricular function and pulmonary perfusion. Contrast-enhanced 3D angiography
showed the cardiopulmonary flow paths and the 3D structure of the vascular
branches. CMR shows collateral vessels, stenosis, and anatomical study of pulmonary arteries. Cine-imaging allows to visualize the presence of flow in all the
postsurgical paths of FP.
Conclusion: CMR is an advanced technique in the non-invasive evaluation of FP.
Whichever the variant used, it is crucial to confirm the patency of the cavopulmonary
flow paths and to rule out stenosis. CMR gives us relevant information about the
pulmonary anatomy and perfusion, the ventricular function and the postsurgical
evaluation of FP.
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Role of cardiac magnetic resonance imaging in evaluation of hypertrophic
cardiomyopathy (HCM): A single-center experience
N. Galea, I. Carbone, E. Algeri, H. Grazhdani, G. Cannavale, C. Catalano,
A. Cannavale, R. Passariello; Rome/IT ([email protected])
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Utility of T2 weighted short-tau inversion recovery (STIR) sequences in
cardiac MRI: Clinical applications in acute ischemic (AI) and non-ischemic
(NI) heart disease
M. Francone, F. Calabrese, I. Iacucci, F. Vasselli, C. Catalano, R. Passariello;
Rome/IT ([email protected])
Learning Objectives: To become aware of the basic MRI design of a T2w-STIR
sequence and with possible edema artifact. To understand the pathophysiology and
significance of myocardial edema in different AI and NI settings. To correlate different
patterns of late enhancement with distribution and extent of T2w hyperintensity in
the clinical scenario of myocardial disease.
Background: To illustrate clinical use and spectrum of applications in cardiac MRI
of T2 weighted imaging using a short-tau inversion recovery technique (T2w-STIR)
in pts with AI and NI diseases.
Imaging Findings: Heart can be involved in a variety clinical disorders in which
heart muscle is preferentially involved or in which is a part of systemic diseases
(infectious, ischemic, tako-tsubo, pulmonary hypertension, myocardial hypertrophy).
Diagnosis is based on a clinically and compatible presentation, and technical investigations. Cardiac MR is an important tool for differential diagnosis, evaluation
of morphologic patterns of AI and NI diseases. MR can be useful in evaluating
activity of disease and determine treatment planning.
Conclusion: T2 weighted STIR represents an appealing and versatile technique
that can be applied in a wide variety of ischemic and non-ischemic conditions allowing detection of segmental or global increase of myocardial free water content
with high contrast difference between edematous myocardium and surrounding
tissues. Detection of edema is clinically relevant because it not only represents
an indicator of acute injury but should also be considered a prognostic marker in
numerous clinical settings potentially affecting ventricular contraction and relaxation,
initiating arrhythmias and inducing additional necrosis.
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Inflammatory whole heart diseases (IWHD): Cardiac MR role in
classification and differential diagnosis of infective non-infective heart
disease
F. Calabrese, M. Francone, I. Iacucci, F. Vasselli, C. Catalano, R. Passariello;
Rome/IT ([email protected])
Learning Objectives: To review the pathophisiology and clinical cardiac presentation of various IWHD. To understand the diagnostic role and strategies technique
of CMR in the evaluation of IWHD. To discuss morphological, functional and hyperenhancement findings and correlate them to clinical situations.
Background: To evaluate the advantages and limitation of cardiac MR in patients with clinical diagnosis of IWHD (endocardial, myocardial and pericardial
diseases).
Imaging Findings: Heart can be involved in a variety inflammation disorders in
which heart muscle is preferentially involved (myocardities) or in which is a part
of systemic diseases (infectious, metabolic or hymmunitary disorders). Symptom
onset is usually gradual but may be sudden and severe. Diagnosis is based on
a clinically compatible presentation, ECG, physical and technical investigations
(cardiac imaging, laboratory investigations). Cardiac MR is an important tool for
differential diagnosis, evaluation of morphologic patterns of IHD.MR can be useful
to evaluate activity of disease and determine treatment planning.
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Cardiac
Purpose: As HCM is a genetic disease whose initial manifestation can be sudden death (SD), it is essential to establish an early diagnosis, to proceed with risk
stratification and implementation of SD and cardiac failure prevention strategies.
CMR provides not only morphologic and functional information, but also detects
edema and, after gadolinium injection, perfusion defects and areas of fibrosis.
The aim of our study is to correlate MRI findings with clinical signs in patients
affected by HCM.
Methods and Materials: Thirty-five patients with a previous echocardiographic
diagnosis of HCM underwent CMR. They performed a cine study to assess free
wall and septal thickness, volumes, myocardial mass and outflow tract area in the
left ventricle and evidence of systolic anterior motion (SAM) of the anterior mitral
leaflet. CMR protocol included also T2-weighted sequences, First-pass perfusion
and DE-IR sequences. All data were correlated with clinical signs as chest pain
and ECG anomalies (atrial fibrillation, branch block, episodes of sustained VT
and/or VF).
Results: Delayed enhancement has been detected in 26/35 patients (74%). Edema
was present in 15/35 patients (43%) and perfusion defects in 8/35 (23%). 26 pts
presented outflow tract obstruction and in 14 cases there was SAM. Chest pain
and arrhythmias were significantly more frequent in pts with LV outflow obstruction,
SAM, edema and LE areas.
Conclusion: Cardio MRI offers a complete assessment of HCM in a one-stopshop procedure. CMR, with its capability to detect potentially arrhythmogenic
myocardial scarring, could provide additional information for the risk stratification
in selected patients.
Scientific and Educational Exhibits
Conclusion: MR demonstrates different imaging findings in patient in acute
(edema) or chronic phase. DE can demonstrate osmotic alterations of heart cells
in acute phase and the size, location and extent of fibrosis process in the chronic
phase. In conclusion, MRI is characterized by high tissue characterization and the
knowledge of location of CE delayed, of functional and clinical parameters can
allow a differential diagnosis of IWHD. Only in the valve leaflets evaluation case
MRI is inferior in morphologic analysis, but is superior in quantification of flow and
velocity in valve apparatus.
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Cardiac tumors
I. Santiago1, M. Portilha2, B. Gonçalves2, H. Rodrigues2, P. Donato2,
F. Caseiro-Alves2; 1Aveiro/PT, 2Coimbra/PT
Learning Objectives: To illustrate the CT and MR imaging findings of various types
of cardiac tumors diagnosed at our institution. To discuss the pertinent literature on
distinguishing clinical and imaging features of each type of cardiac tumor. To outline
the advantages and disadvantages of CT and MR for cardiac tumor diagnosis.
Background: Cardiac tumors are rare, often clinically non-specific and potentially
life-threatening. Early diagnosis is of utmost importance, since some are surgically
curable. CT and MR can accurately image the heart and surrounding structures
on multiple planes, providing important information regarding size, extension and
composition of heart tumors. In this exhibit, we will depict the CT and MR imaging
findings of selected cases of cardiac tumors from the pathology records of our
institution.
Imaging Findings: We selected histologically confirmed cases of benign and malignant heart tumors from the pathology records of our institution for which CT and/
or MR were performed, such as pericardial cysts, myxomas, hamartomas,fibromas,
metastasis and sarcomas; gathered and summarized the patients’ relevant clinical
information; depicted and described the differentiating imaging findings, namely
location, size, composition, patterns of enhancement, invasiveness and associated
findings; and overviewed the pertinent literature on each type of tumor described
and the main advantages and disadvantages of CT and MR.
Conclusion: CT and MR imaging findings help differentiate benign from malignant cardiac tumors, sometimes even further narrowing the differential diagnosis;
therefore, influencing their management.
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Cardiac cine MRI at 3 Tesla (comparision of SSFP and FLASH sequence)
J. Suyama, N. Seino, Y. Ohgiya, M. Hirose, T. Gokan; Tokyo/JP ([email protected])
Purpose: The aim of this study was to compare cardiac cine MRI using steadystate free precession (SSFP) and Fast Low Angle Shot (FLASH) at 3 T MRI about
contrast to noise ratio (CNR) and visual image quality assessment.
Methods and Materials: All images were acquired on a 3 T Siemens MAGNETOM
trio. Seven healthy volunteers underwent magnetic resonance imaging using SSFP
and FLASH sequence on the same day. For both SSFP and FLASH imaging,
8-mm thick short axis view and long axis view were acquired with equal matrix size
(192×192). CNR calculations were performed on the short axis images acquired
at end systole time point when myocardium has maximum thickness between left
ventricular blood and myocardiums, and compared between 2 sequences. And
visual image quality was assessed by three radiologists.
Results: In the CNR, SSFP images were better than FLASH images (SSFP:
7.14p2.16, FLASH: 3.57p1.83). Visual image quality also revealed that SSFP were
superior to FLASH in both short and long axis views. Although SSFP images contained dark blood artifact in 2 cases, these were improved by frequency offset.
Conclusion: SSFP sequences provided higher quality image than FLASH sequence and would be available for cardiac cine MRI at 3 T.
C-186
Sequential changes of myocardial microstructure in patients post
myocardial infarction by diffusion-tensor cardiac MR: Correlation with left
ventricular structure and function
M.-T. Wu1, M.-Y. Su2, W.-Y. Tseng2; 1Kaoshiung/TW, 2Taipei/TW
([email protected])
Purpose: To investigate the sequential changes of microstructure from recent to
chronic myocardial infarction (MI) using diffusion-tensor cardiac MR (DT-CMR).
Methods and Materials: Institutional review board approval and informed consent
were obtained. Seventeen patients from our previous study participated (age=55.1p11.5
years, all men). Myocardial microstructure, including tissue integrity (mean diffusivity
[MD], fractional anisotropy [FA]) and fiber architecture (helix angles [HA]), together with
myocardial viability by late gadolinium-enhancement and wall function by cine fast gradient echo image were measured at recent and chronic MI (interval=191p59 days).
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Results: As compared to the remote zone, the infarct-adjacent zone showed overall
increase of MD (two-way MANOVA, F1.16=36.3, P 0.001), decrease of FA (F1.16=5.8,
P=0.029) and decrease of mean HA (F1.16=62.0, P 0.001). From recent to chronic
MI, the differences of wall thickness and wall thickening between the remote zone
and infarct-adjacent zone progressed (P 0.001, P=0.020, respectively). There
was overall sequential decrease of MD (F1.16=22.6, P 0.001) and increase of FA
(F1.16=7.8, P=0.013). Multiple linear regression showed the improvement of wall
thickening in the infarct-adjacent zone correlated with decrease of MD in the infarctadjacent zone (r=-0.70, P=0.002) and increase of mean HA (i.e., more right-handed
helical myofiber reorientation) in the remote zone (r=0.60, P=0.011). Likewise, wall
thickening in the remote zone correlated with MD in the remote zone (r=-0.72,
P=0.001) and mean HA in the infarct-adjacent zone (r=0.72, P=0.001).
Conclusion: DT-CMR showed that zonal improvement of tissue integrity and fiber
architecture remodeling both contributed to zonal wall thickening recovery from
recent MI to chronic MI.
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MR imaging in endomyocardial fibrosis
S.N. Patro, T.R. Kapilamoorthy, N.K. Bodhey, A.K. Gupta, W. Sumnyan;
Trivandrum/IN ([email protected])
Purpose: 1. To study the extent and pattern of myocardial involvement in the
exclusive tropical endomyocardial fibrosis with delayed contrast enhancement.
2. To assess the feasibility of endocardiectomy and subsequent follow-up. 3. To
differentiate EMF from other non-ischemic cardiomyopathies.
Methods and Materials: 30 patients of EMF planned for endocardiectomy & valve
replacement on the basis of echocardiography were selected for MRI. Cine images,
SE T1WI, velocity-encoded MR and postprocessing on Argus were done to assess
the morphology, ventricular functions and vascular velocities. Pattern of enhancement was studied with phase shift IR scans performed at 10 - 60 mts.
Results: Myocardium involvement was seen with partial obliteration of ventricular cavity
predominantly in ventricular apex or in the inflow regions. Ventricular cavity showed characteristic crevices and outpouchings in cine images. AV valve incompetence was seen in
73% of cases due to plastering of leaflets. The LV ejection fraction (varied from 30 to 50%)
was a effective tool to suggest improvement in postsurgical cases. There was associated
thrombus (in 10%) and pericardial thickening/effusion (in 30%). The enhancement was
seen later (25-45 minutes) than that is seen in the cases of ischaemic heart disease. The
pattern of enhancement was irregular and bizarre unlike in ischaemic myocardium.
Conclusion: Due to the possible involvement of the RV also in EMF, MRI than just
echocardiography best studies this pathology. The timing and pattern of delayed
enhancement is different from other diseases. MRI gives a comprehensive assessment of the myocardial involvement.
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Role of cardic magnetic resonance (CMR) in the diagnosis and evaluation
of sinus venosus defect (SVD)
P. Serrano Gotarredona, S. Navarro Herrero, J. Cordones Gerrero,
B. Sobrino Guijarro, J. Jiménez Barro; Seville/ES ([email protected])
Learning Objectives: To depict morphologic findings of SVD with anomalous right
upper pulmonary venous connection (RUAPVC), by illustrating six such cases
referred for CMR in our institution. To describe study protocol, which also included
ventricular volumes and function quantification, as well as flow measurements to
assess pulmonary-to systemic flow ratio.
Background: SVD account for only 2 to 10% of atrial septal defects. High occurrence of presentation in adult age has been reported. The more common SVD
occurs in the upper atrial septum and is contiguous with the superior vena cava
(SCV). It is almost always associated with anomalous pulmonary venous drainage
of the right upper pulmonary vein (RUPV) to the SVC. Preoperative recognition
of the extraseptal nature of the interatrial communication is essential for surgical
planning. Echocardiography usually is sufficient for demonstrating RUAPVC in
younger children but may be missed in adolescent or adult patients.
Imaging Findings: This anomaly is recognized as a deficiency in the wall that
normally separates the left atrium and RUPV from the SCV, so that the pulmonary
vein is left unroofed, compelling it to drain into the SCV or into the superior dome
of the right atrium (RA) at the level of the caval atrial junction.
Conclusion: Cardiac MRI has to be considered as an adequate alternative method
for surgical planning of SVD repair, because it is able to accurately depict SVD
anomaly and associated RUAPVD, as well as to provide accurate quantitative
information on the hemodynamic burden.
Scientific and Educational Exhibits
C-189
Systemic vasculitis with cardiac involvement: Cardiovascular magnetic
resonance (CMR) findings
D. Piotrowska-Kownacka, L. Kownacki, D. Gawryluk, O. Rowinski; Warsaw/PL
([email protected])
Purpose: The aim of our study was CMR evaluation of cardiac function, rest perfusion and delayed enhancement pattern in patients with systemic vasculitis.
Methods and Materials: In the study, we included 13 patients with systemic vasculitis:
9 with Churg-Strauss syndrome (CSS) and 4 with Wegener’s granulomatosis (WG).
Cardiac involvement was suspected based on clinical symptoms and echocardiographic findings. All patients underwent CMR examination including function assessment, rest perfusion and delayed enhancement imaging. Perfusion defects and
delayed gadolinium enhancement were assessed using 17 segments model.
Results: Left ventricular (LV) ejection fraction ranged from 17.9 to 61.7% (mean
41.6 p14%). LV dysfunction was observed in all patients with Churg-Strauss syndrome (mean 34.4p11.2%, ranged from 17.9 to 48.9%) and in 1 with Wegener's
granulomatosis. In all studied patients delayed enhancement was observed 1020 minutes after Gd-DTPA administration (0.1 mmol/kg b.w). In CSS, delayed
enhancement was subendocardial (9/9 pts) or/and transmural (6/9 pts). The number
of affected segments ranged from 5 to 17 (median 10). In WG delayed enhancement was intramural or/and subepicardial. Perfusion deficits were detected in 3/9
patients with CSS and in 1 with WG.
Conclusion: CMR revealed crucial information in patients with systemic vasculitis.
Delayed enhancement pattern was typically subendocardial or partially transmural
in Churg-Strauss syndrome opposite to intramural and subepicardial in Wegener’s
granulomatosis.
C-190
Cardiac MRI: A survival guide
G. Tardaguila de la Fuente, F. Tardáguila Montero, R. Varela Ponte,
C. Trinidad López, G. Fernández Pérez; Vigo/ES ([email protected])
Learning Objectives: The objective of this exhibit is not to make a deep revision of
physics and specific pathology but to make a schematic and easy to understand review
of most common cardiac pathology that could be diagnosed with cardiac MRI.
Background: On one hand MRI physics is complicated. On the other, many radiologists are not familiarized with cardiac pathology as it is a relatively new field for them.
These two premises make cardiac MRI a subject that sometimes frightens radiologists who are not used to it. But the knowledge of the basic sequences, cardiac
planes and contrast enhancement patterns will allow non-specialised radiologists
and residents to diagnose the most prevalent cardiac pathologies.
Imaging Findings: We will illustrate and explain how to obtain the basic cardiac
planes (short axis, long axis, four chambers and left ventricle outflow tract). We
will use basic morphologic sequences to explain the most prevalent structural
cardiopathies. Cine sequences will be shown to explain valvular disease and contractility defects. T2 weighted images, first pass perfusion (with and without stress
with adenosine) and late enhancement (viability) will be explained to illustrate
ischemic cardiopathy and how to differentiate acute from chronic ischemic heart
disease including hibernated myocardium.
Conclusion: It is necessary for radiologist to be familiarized with terminology
and sequences used in cardiac MRI. Cardiac MRI is not as complicated as it is
often thought.
C-191
Is there a role for coronary MR angiography for the follow-up of patients
with Kawasaki disease?
E. Algeri, I. Carbone, N. Galea, G. Cannavale, D. Cannata, C. Catalano,
R. Passariello; Rome/IT
Results: Coronary-MR-angiography produced diagnostic images in 13/15 patients.
Information provided by coronary-MRA in the 13 diagnostic exams correlated well
with SCA and MDCT findings.
Conclusion: Coronary-MRA is a very useful diagnostic tool for the follow-up of pts
with KD. In order to reduce radiation dose, the decision to perform SCA or MDCT
can be based on coronary-MRA findings.
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Cardiac planes in tomography and magnetic resonance imaging in the
evaluation of double outlet right ventricle
L.M. Pabón, N. Pedreañez, C. Ng, M. Carrillo; Caracas/VE
([email protected])
Purpose: Defining the planes by magnetic resonance imaging (MRI) and computed
tomography (CT) in the double outlet right ventricle (DORV) diagnosis.
Methods and Materials: Cardiac CT and MRI revision with DORV diagnosis to
determine the planes characterizing the location of the ventricular septal defect
(VSD), the relationship of the great arteries and the outflow tract permeability,
confirming the findings with the echocardiogram.
Results: The total studies reviewed with DORV diagnosis by TC and IRM, included
3 CT and 12 MRI. The axial slices defined the relationship of the great arteries had
as result- according to GAR classification (great arteries relationship): 1 (GAR 1),
3 (GAR 2), 1 (GAR 3), 5 (GAR 4), 3 (GAR 5). The four-chamber planes and the
short axis in multiple slices determined the VSD type: they were 4 subaortic VSD,
3 subpulmonic and 2 doubly committed and 4 noncommitted. The short multiphase
- multislice permitted the evaluation of the ventricular function by MRI. The fourchamber planes and the long horizontal or vertical axis allowed to evaluate the
outflow, showing 7 pulmonary obstructions; 1 subaortic obstructions, 2 pulmonary
and subaortic obstruction, 2 cases with no obstruction and 3 pulmonary atresias.
The presence of associated anomalies was determinated with the vascular reconstruction by CT and the MRI-angio.
Conclusion: The MRI and the CT are complementary methods that not only allow
to make a diagnosis of vascular abnormalities associated to DORV but also are
useful to confirm intracardiac findings that determine in the surgical decision.
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Realistic visualization of DTI tractography of healthy and ischemic hearts
T.H.J.M. Peeters, A. Vilanova, G.J. Strijkers, B.M. ter Haar Romeny;
Eindhoven/NL ([email protected])
Purpose: We use DTI to improve the understanding of the structure of the muscle
fiber orientation in the heart wall, and how this changes with ischemia. Because
the heart wall is built from a vast amount of fibers, visualization is challenging.
We present a new photo-realistic rendering method, which greatly improves the
visual appearance.
Methods and Materials: Inspired by hair rendering methods, we use line illumination and shadowing of fibers to improve the perception of the shape of the fibers
and their mutual coherency. Color encodes the out-of-plane components of the
fibers, and fractional anisotropy.
Results: The new visualization methods are applied to a series of mouse models (9
Tesla small bore MRI) of healthy and ischemic hearts (7 days after the infarct). The
insight in the fiber structure becomes much better visible, in an intuitive way.
Conclusion: Proper illumination of lines improves the perception of fiber shapes.
Shadows improve the perception of coherencies among fibers. Our slice visualization allows for combined visualization of structure and function, and extra properties
such as fractional anisotropy.
Cardiac
Purpose: Kawasaki disease (KD) is an acute systemic vasculitis, often involving
coronary arteries with the development of aneurysms that may evolve to rupture,
thrombosis, up to complete occlusion. Since patients with KD need to be periodically
followed-up from the time of diagnosis to evaluate the evolution of CA disease, a
non invasive method, without any ionizing radiation employment is highly desirable.
The aim of our study was to test the ability of coronary-MR-angiography to identify
and follow-up CA lesions in patients with KD.
Methods and Materials: 15 patients with a previous diagnosis of KD underwent a
coronary-MRA. First a whole heart bSSFP acquisition was performed, then, after the
intravenous injection of 8 mL of a blood-pool contrast agent (Vasovist 0.25 mMol/mL,
Schering), a further steady state whole heart acquisition was performed. Images
were reconstructed on a dedicated software, using MPR, curved MPR and MIP.
Results were compared with findings at previously performed selective coronary
angiography (SCA) and/or multi detector computed tomography (MDCT).
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C-194
Chest
Three methods for quantification of mitral regurgitation fraction by
cardiovascular magnetic resonance
E.A. Mershina, V.E. Sinitsyn, G.A. Shiriaev; Moscow/RU
([email protected])
Learning Objectives: To remind the three methods for quantifying of mitral
regurgitation fraction (RF) with cardiovascular magnetic resonance (CMR) and
demonstrate their comparability.
Background: Velocity-encoded MRI has been reported to provide accurate
measurement of the volume of blood flow in the ascending aorta and through the
mitral annulus. 1. Biventricular volumetric analysis: RF (VOL) = [LVSV - RVSV],
where LVSV is left ventricular stroke volume and RVSV is right ventricular stroke
volume. 2. RF (FLOW) = [LVSV - aortic flow volume]. 3. RF (in/out) = [LV inflow
- aortic flow volume]. This method calculates the difference between LV outflow
and inflow. LV inflow is assessed by velocity mapping at the mitral valve annulus
during diastole.
Imaging Findings: We examined 10 healthy volunteers without cardiac valvular
disease confirmed with echocardiography. All subjects underwent LV and RV
volumetry, aortic flow and LV inflow measurements. There was good agreement
between aortic flow volume and RVSV (mean difference 3.5 p 1.8 ml), LVSV and
LV inflow (mean difference 2.8 p 3.2 ml).
Conclusion: All three methods are applicable. The most time-consuming and
sensitive to errors in RVSV visualization and regurgitation of other heart valves is
biventricular volumetric analysis. LV inflow calculation was the most difficult part
of this study because it acquires the flow at a fixed location during the cardiac
cycle, which is not necessarily the location of the mitral valve during the whole
cycle. Subtracting aortic flow volume from LVSV is the optimal CMR technique to
quantify mitral regurgitation.
Lung
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Imaging of lymphatics in the lung: From past to present
N. Nitta1, M. Takahashi1, Y. Nagatani1, H. Otani1, K. Shimoyama2, Y. Murakami1,
K. Murata1; 1Otsu/JP, 2Fukuchiyama/JP ([email protected])
Learning Objectives: To give an overview by describing research history of
lymphatics in the lungs. To learn about distribution of lymphatics and systematic
classification. To discuss anatomical problems of lymphatics. To review various lung
diseases invading the lymphatic system.
Background: Lymphatics are invisible to CT when there are no abnormalities. It
is important to know the distribution of lymphatics in the lungs.
Imaging Findings: Analysis of inflated, fixed lungs after contrast medial injection to
visualize lymphatics. Introduction of the two systems of lymphatic flow in the lungs
with a scheme: 1) Interstitium-pulmonary veins system and 2) Bronchi-pulmonary
arteries system. Exploration of anatomical problems of lymphatics in the lungs: 1)
Presence or absence of lymphatics in the alveolar regions; 2) Higher distribution of
lymphatics around pulmonary artery than bronchi and 3) Association of subpleural
with deep lymphatics. Studying how lung lesions invade the lymphatics, based on
HRCT findings and the discussions about concerning conditions, such as lymphangitis carcinomatosa, pulmonary edema, sarcoidosis, malignant lymphoma, acute
eosinophilic pneumonia and so on.
Conclusion: To enhance understanding of the complicated lymphatic system in
the lungs. To identify keys to solutions of anatomical problems based on previous
reports and our experience. To promote better understanding of lung lesions invading the lymphatic system based on anatomical findings.
C-196
Revision of the lung cancer TNM staging: Pictorial review of the proposed
changes and its limitations
J.V. Raj, A. Bajaj, J.J. Entwisle; Leicester/UK ([email protected])
Learning Objectives: 1. Review (pictorial) the proposed changes to the T, N and
M descriptors in the forthcoming (seventh) edition of the TNM classification of lung
cancer. 2. Highlight limitations of the proposed system.
Background: Non small cell lung cancer is the leading cause of cancer related
deaths. TNM staging of lung cancer plays a critical role in determining the therapy
and the prognosis of the disease. In 1996, the international association for the study
of lung cancer launched a worldwide TNM staging project to inform the next edition
of the staging system, which is due to be published in early 2009.
Imaging Findings: Changes to the T stage of the tumour: table and images. For ex:
T1 and T2 subclassified into a and b subgroups, nodule in the same lobe classified
as T3 instead of current T4. N stage of the tumour: table and images. Changes to
the M stage of the tumour: table and images. For ex: Subclassification of M1 into
1a and 1b. Limitations of the proposed system: lymphangitis carcinamatosa not
included. Different bulk of N2 disease not given sufficient importance.
Conclusion: The TNM staging is evolving to reflect the changing algorithms in
patient management worldwide. It is vital for all the radiologists to be well versed
with these proposed changes in the current system and appreciate its limitations.
C-197
Imaging findings of malignant pleural mesothelioma (MPM) in Japan
K. Kato1, T. Kishimoto1, K. Genba1, Y. Takeshima2, K. Inai2, S. Kanazawa1;
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Okayama/JP, 2Hiroshima/JP ([email protected])
Purpose: Our purpose is to evaluate the radiological findings of MPM by reviewing
the images of MPM cases in Japan.
Methods and Materials: Among 2742 mesothelioma death cases extracted by
“Vital Statistics of Japan 2003 to 2005”, we reviewed 211 MPM cases (182 men, 29
women; mean age, 69 years) in which the chest CT, XP and pathologic specimens
were obtained. 1. We reviewed whether there was pleural plaque, pleural effusion
and asbestosis or not on images. 2. Abnormal CT findings of the pleura were
categorized as follows: Category 1 (Cat-1), no thickening; Cat-2, smooth thickening; Cat-3, irregular thickening and Cat-4, mass formation. The categories of each
case were compared with T-stage according to IMIG. 3. We reviewed localization
of the pleural irregularity. We focused on three places as follows: mediastinal, fissural and basal pleura.
Results: 1. In all 211 cases, pleural plaque was present in 37% cases on CT and
in 12% cases on XP. Each pleural effusion and asbestosis was present in 93 and
3% cases on CT. 2. The ratio of each category was as follows: Cat-1 5%, Cat-2
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17%, Cat-3 35% and Cat-4 43% cases. As for correlation with T-stage, the majority
of patients of Cat-1 and Cat-2 were T1-2 (91%) and Cat-3 and Cat-4 were T3-4
(85%). 3. Location of pleural thickening was mediastinal in 78% cases, fissural 47%
cases and basal in 73% cases.
Conclusion: For early diagnosis of the MPM, it is necessary to pay attention to
slightly pleural irregularity, especially mediastinal pleura in persistent pleural effusion case with unknown cause.
C-198
Various imaging findings of pulmonary alveolar proteinosis
K. Kato, Y. Okumura, H. Hayashi, H. Yamamoto, S. Kanazawa; Okayama/JP
([email protected])
Learning Objectives: To demonstrate the wide spectrum of imaging findings of
pulmonary alveolar proteinosis (PAP) on CT/HRCT. To know imaging findings of
PAP on various stage (from early to advanced). To recognize the importance of the
finding “crazy-paving” to make a correct diagnosis of PAP.
Background: PAP presents various imaging findings on CT. On this exhibit we
show various cases from a typical to atypical and rare imaging findings of PAP
especially focusing on CT (including HRCT).
Imaging Findings: We show plain X-P and CT/HRCT images of the following
various impressive cases of PAP proven by pathological specimen: Subpleural and
apical distribution. We show localized ground-glass opacity and diffuse centrilobular
opacities. We follow, from very early to advanced stages, the course of showing
reticular opacities coexisting with ground-glass opacities, which is the so called
“crazy-paving”. We have migration of a lesion that underwent prone positioned CT.
We also show typical cases of PAP.
Conclusion: We will show the spectrum of disease in PAP by showing various
cases and emphasize the patterns most frequently associated with PAP. We could
find various degrees of “crazy-paving” like appearances in most PAP cases. We
should suspect PAP when we see such findings as “crazy-paving” like appearances,
which is therefore GGO with reticulation.
C-199
Imaging characteristics of the solitary pulmonary nodule
Y.M. Jones1, A.J. Clark2; 1Liverpool/UK, 2Stoke-on-Trent/UK
([email protected])
Learning Objectives: To describe and illustrate the salient imaging appearances
of a solitary pulmonary nodule that can aid the radiologist in differentiating benign
and malignant nodules.
Background: The incidental finding of a solitary pulmonary nodule is a frequent
clinical occurrence. With the advent of improved CT scanners and the possibility
of introducing screening for lung cancer it is becoming increasingly common, and
is likely to continue to do so. Until fairly recently, it had been widely accepted that
non-calcified pulmonary nodules should be considered to be malignant until proven
otherwise; however, current thinking has evolved from this.
Imaging Findings: Nodule contour, location, cavitation, attenuation, presence of
fat or calcification, size, volume doubling time, enhancement properties on CT and
MRI and metabolic activity on 18F-FDG PET are all valuable features in evaluating
the likelihood of malignancy within a solitary pulmonary nodule. We review these
imaging characteristics with illustrative examples.
Conclusion: The SPN often causes a clinical dilemma. Early detection and correct
management of malignant nodules is crucial, with the aim of minimising unnecessary
intervention and follow-up of benign lesions, while detecting malignant nodules at
the earliest opportunity. This review demonstrates, with examples, the key imaging appearances that can assist the radiologist in determining whether a solitary
pulmonary nodule is more likely to be benign or malignant.
C-201
Lymphoid lesions of the lung: Multidetector CT (MDCT) features and
pathologic correlations
C. Nedelcu, A.-L. Gourdier, S. Abi Khalil, M.-C. Rousselet, C.-M. Singeorzan,
C. Aubé; Angers/FR
C-202
A computed tomography (CT) score for sarcoidosis: Observer variation
and correlation with lung function
P.A. de Jong1, M. Nagtegaal2, H. de Jong1, J.C. Grutters2, J.M. van de Bosch2,
V. Karthaus2, H.W. van Es2, J.P. van Heesewijk2, S. Braak2, B. van Ginneken1,
M. Prokop1; 1Utrecht/NL, 2Nieuwegein/NL ([email protected])
Purpose: Chest CT can be used for obtaining prognostic information and phenotyping for genetic studies in sarcoidosis. A detailed CT-score for this purpose is
lacking. We developed such a CT-score and tested its reproducibility and correlation with lung function.
Methods and Materials: For a cohort study that correlates genotypes, phenotypes
and prognosis, we obtained HRCT, positron-emission-tomography, lung function
tests, blood samples, and broncho-alveolar-lavage in 135 sarcoidosis patients. In
order to perform detailed mapping of the CT phenotype, we established a CT-score
that included nodules, parenchymal, bronchial, air space, lymph node and pleural
involvement. The parameters were scored per lobe (except lymph nodes). One
observer scored 135 cases to correlate CT-scores with lung function (Spearman); a
second observer scored 50 scans to estimate reproducibility of the scoring system
(intraclass correlation).
Results: Patient age at HRCT was 44p12 yrs; the interval between HRCT and lung
function was 4p25 days. FVC, FEV1/FVC and DCLO were 96p19% pred, 77p10 and
78p15% pred, respectively. The most frequent findings on HRCT were lymphadenopathy (84%), nodules (61%), bronchial disease (46%) and parenchymal distortion
(44%). Intraclass correlation was excellent for the CT-score (R=0.89) and decreased
from 0.79 (septa and consolidations) to 0.44 (ground glass and mosaic pattern) for
the individual items. Significant negative correlation with lung function was found for
CT-score (0.44R 0.54, p 0.0001) and most CT items (0.22R 0.42, p 0.01)
except for nodules, ground glass and mosaic pattern.
Conclusion: In this pilot study, we found excellent reproducibility for our total CTscore and good reproducibility for most CT items. Total CT-score was significantly
related to lung function.
C-203
Disease-modifying antirheumatic drugs (DMARDs)-induced lung disease in
patients with rheumatoid arthritis: Chest radiographic and high-resolution
CT findings
S. Sakai, H. Yabuuchi, Y. Matsuo, T. Kamitani, T. Setoguchi, H. Honda;
Fukuoka/JP ([email protected])
Learning Objectives: To know the kinds of disease-modifying antirheumatic drugs
(DMARDs) causing lung diseases. To know the clinical criteria of drug-induced
lung disease. To demonstrate the image findings in patients with DMARDs-induced
lung disease.
Background: Recent progress in the development of DMARDs has greatly
improved the status of rheumatoid arthritis (RA) patients. However, adverse lung
reactions to DMARDs are potentially life-threatening. The diagnosis of DMARDsinduced lung disease is difficult because the clinical and radiological findings
are nonspecific and periods between the introduction of a drug and the onset of
symptoms are various in each patient. The recent studies reported that potential
predisposing factor for acute lung disease is pre-existing interstitial lung disease. The
aim of this educational exhibit is to show the chest radiographic and high resolution
CT (HRCT) findings in the patients with DMARDs-induced lung diseases.
Imaging Findings: Among DMARDs, injectable and oral gold, bucillamine, methotrexate, and leflunomide are able to cause potentially the adverse lung reaction.
Main histological types of these drugs-induced lung diseases are nonspecific
interstitial pneumonia, organizing pneumonia, and diffuse alveolar damage. However, these histological conditions are also seen as RA-related lung diseases.
Furthermore, DMARDs-induced lung diseases in rheumatoid arthritis patients
need to be differentiated from opportunistic infection because almost DMARDs
have immunosuppression effect.
Conclusion: DMARDs-induced lung disease shows various imaging findings.
HRCT for baseline examination is important for diagnosis of DMARDs-induced
lung disease on RA patients.
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Learning Objectives: To know the MDCT features of various lymphoid lesions
of the lung. To illustrate the etiologic diagnostic with clinical radiologic-pathologic
correlations.
Background: There is a large spectrum of lymphoid lesions of the lung: benign
reactive infiltrates as lymphoid interstitial pneumonia, follicular bronchiolitis, Castelman disease and intrapulmonary lymph nodes; malign primary lesions as lymphoid
granulomathosis and primary lymphoma (most frequently MALT); secondary malign
lesions as lung dissemination of a nodal lymphoma and neoplasic lymphangitis.
Imaging Findings: The MDCT scan features of those lesions are highly polymorphic, and clinical, biological and pathological correlations are necessary to reach
the diagnosis. The opportunist infections especially in immunosuppressed patients
are an important differential diagnostic and a classical pitfall.
Conclusion: The lymphoid lesions of the lung have various MDCT aspects and
different etiologies. The low of specificity of CT scan signs impose a clinical, biological and pathological correlation for a right diagnostic. Not to forget the opportunist
infections in immunosupressed patients.
Scientific and Educational Exhibits
C-204
C-207
Imaging findings in associated thoracic and renal adult diseases
M. Herraiz, R. Saiz, A. García-Layana, J. Bondia, J.J. Noguera, A. Villanueva,
J. Broncano; Pamplona/ES ([email protected])
Imaging the lungs in lymphoma
H. Vargas, F.A. Hampson, J.L. Babar, A.S. Shaw; Cambridge/UK
([email protected])
Learning Objectives: Recognize the findings of thoracic and renal associated
diseases in various imaging techniques (chest radiographs, MDCT, ultrasound
and MRI).
Background: Some findings in thoracic radiology are not specific. Knowing that a
patient has a specific renal disease is useful in the diagnosis of thoracic disease.
Imaging Findings: The imaging findings in thoracic and renal associated diseases
are shown. Cases of diseases that affect the kidneys and the lung, the mediastinum,
the skeletal system or the heart are shown. Cases are classified in: 1) chronic renal
failure (interstitial edema, metastatic pulmonary calcification, coronary disease); 2)
tumours: lung neoplasm spreading to the kidney and kidney neoplasm spreading
to the thorax; 3) kidney transplantation (infection, adverse drug reaction) and 4)
non-tumor-related systemic diseases with renal and thoracic affections (Wegener’s
disease, tuberous sclerosis).
Conclusion: Unspecific findings in the pulmonary parenchyma with CT (ground
glass opacities, “crazy-paving” pattern, interstitial pattern, pulmonary calcifications) might prove easier to diagnose if it is known that the patient has a specific
kidney disease (kidney failure, renal transplantation with opportunistic infection or
Everolimus side effect). Bone changes (increased vertebral density, erosions of
vertebral bodies) could be interpreted more effectively in oncology patients with renal
failure. Infrequent diseases of the heart or great vessels (myocardial hamartomas,
pulmonary artery stenosis) can be diagnosed more easily if it is known that renal
disease is present (tuberous sclerosis, Wegener’s disease).
Learning Objectives: 1. Illustrate the thoracic imaging findings of lymphoma and
the consequences of lymphoma treatment, including radiotherapy, chemotherapy
and bone marrow transplantation. 2. Highlight distinguishing features to aid differentiation between the types of lymphoma and other chest pathologies. 3. Provide
guidance on when, how and why tissue sample should be obtained.
Background: Pulmonary abnormalities are a frequent finding in patients with
lymphoma. Abnormalities may be due to the lymphoma itself, or a consequence
of the treatment regime. As radiologists, we are commonly asked to differentiate
between tumour, infection, drug reactions and post-radiotherapy changes. Patients
are also at increased risk of pulmonary emboli and, following transplantation, may
develop obliterative bronchiolitis.
Imaging Findings: Thoracic involvement is three times more common in Hodgkins
(HL) than non-Hodgkins (NHL) lymphoma. It is almost always associated with
mediastinal lymphadenopathy. In HL pulmonary involvement is most commonly
the result of direct extension from affected nodes; the parenchymal pattern may be
nodular, alveolar, bronchovascular or miliary. In NHL, pulmonary or pleural lesions
may present in the absence of mediastinal lymphadenopathy. Infective changes
may present with ground glass opacification, nodules, consolidation or cavitation,
whilst drug hypersensitivity may manifest in a number of ways.
Conclusion: Radiological evaluation of the lungs in lymphoma is a common and
potentially difficult problem. We will review the radiological features of these diseases
in order that the radiologist will be in a better position to aid clinical colleagues.
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C-208
Normal variants in the chest: Mimickers of disease
J.F.G.M. Costa, J. Brito, A. Costa, F. Caseiro-Alves, A. Bernardes; Coimbra/PT
Learning Objectives: 1. To review the most frequent normal anatomic variants in
the thorax. 2. To correlate them to the characteristic imaging findings of possible
differentials.
Background: There are innumerable anatomic variants involving the chest wall,
bronchi, lung and fissures, and systemic and pulmonary vessels. Familiarity with
these findings is essential to prevent errors in the interpretation of CT images.
Imaging Findings: In this exhibit, we review the imaging appearances of the most
common variants involving the chest wall, bronchi, lung and fissures, and systemic
and pulmonary vessels. Imaging modalities include chest X-rays, angiography,
CT and MRI. Anatomical correlation is also presented when possible. Each case
is accompanied by a brief history, an explanation of the findings and a list of the
appropriate differential considerations.
Conclusion: By reviewing this exhibit, users will be able to recognize both the
normal anatomy and anatomic variants of the chest, which is essential to avoid
misdiagnosis.
C-206
Bronchial carcinoid tumors: Factors that influence the rate of recurrence
and outcome
R. Duarte1, D. Miranda2, T. Pereira1, S. Gomes1, R. Couto1, P. Portugal1;
1
Vila Nova de Gaia/PT, 2Matosinhos/PT
Purpose: 1. To review the most common clinical symptoms and imaging findings
at radiography and computed tomography (CT) of bronchial carcinoid tumors. 2. To
correlate the imaging findings with the histologic features. 3. To determine how the
extent and histologic features of disease influence recurrence rate after surgery.
Methods and Materials: Bronchial carcinoid tumors are neuroendocrine neoS
plasms that have a broad spectrum of clinical andOhistologic
features. They are
rare primary thoracic neoplasms, representing only
EP 1-2% of all lung tumors. We
retrospectively reviewed the imaging and pathologic
to findings of bronchial carcinoid
dresection of bronchial carcinoid tumor
tumors in 29 patients who underwent surgical
e
t
itTumor size, histologic findings and nodal
at our institution between 2000 and 2006.
m influence
b
disease status were evaluated and their
in the recurrence of disease in
u
these patients was determined.l S
ia carcinoid tumors submitted to surgical resecResults: Patients with bronchial
er
tion have excellent outcome,
at with an overall survival rate near 90%. In our group
M
of patients, atypical histologic
pattern was the factor that most influenced local
recurrence.
No
Conclusion: Typical and atypical bronchial carcinoids have similar imaging features.
Patients submitted to surgical resection of bronchial carcinoid tumor with atypical
histologic findings were associated with higher rates of local recurrence than those
with typical histologic findings.
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Slowly growing malignant nodules and rapidly growing benign nodules:
Evaluation of the value of volume doubling time
Y. Zhao, Y. Wang, P.M.A. van Ooijen, M. Oudkerk; Groningen/NL
Learning Objectives: 1. To review the volume doubling time (VDT) of some
slowly growing malignant nodules and rapidly growing benign nodules on thoracic
CT images. 2. To outline other factors that should be taken into account in differentiation between malignant and benign lesions. 3. To discuss the benefits and
limitations of VDT.
Background: The VDT of lung nodules has been widely accepted as an index of
tumour growth rate. The prognosis of lung cancer correlates well with the tumour
VDT. The VDT of most benign pulmonary nodules is more than 450 days, whereas
the VDT of malignant lesions is usually less than 400 days. But a 2-year stability
did not always imply a benign state as it might also indicate malignant growth with
a long VDT.
Imaging Findings: We will present representative cases of slowly growing malignant nodules and rapidly growing benign nodules as found in a lung cancer screening setting. We will discuss the characteristics of these lesions. We will analyze
the pathologic results of slowly growing malignancies. We will also discuss how to
manage them in the follow-up and the benefits and limitations of VDT.
Conclusion: Evaluation of pulmonary nodules based on VDT alone sometimes
is complicated because the different natural histories. Malignant lesions can grow
fast, but may also have a long VDT. Malignant nodules may be stable for a long
period, and benign nodules may have rapid growth; the concept of lead-time should
be considered in managing these lesions.
C-209
Usefulness of the reversed halo sign on CT for the diagnosis of the
organizing pneumonia
V. Pérez Dueñas, I. Torres Sánchez, A. Bravo Soberón, L. Figueroa Nasra,
M. Pardo Rodríguez, M. Parrón Pajares; Madrid/ES ([email protected])
Purpose: The reversed halo sign has been recently described on lung CT as an
infrequent finding although specific for the diagnosis of organizing pneumonia (ON).
This exhibit will evaluate the prevalence of this sign in ON, describe its features
and its association with other ON findings.
Methods and Materials: High-resolution CT of 37 patients with histological
diagnosis of ON was reviewed by two experienced thoracic radiologist. 28 cases
(75.7%) were idiopathic and 9 (24.3%) were secondary (2 postchemotherapy of
breast cancer, 2 rheumatoid arthritis, 2 bone marrow transplantation, 1 polymyositis, 1 polymyalgia rheumatica, and 1 secondary to carbamazepine herpes zoster
treatment). HRCT was performed with a standard protocol (1 mm slice thickness,
10 mm table movement, high resolution reconstruction algorithm, and kV and mAs
adjusted to patient’s weight).
Scientific and Educational Exhibits
Results: Reversed halo sign was seen in 5 cases (prevalence 13.5%), 3 were cryptogenic, and 2 secondary (1 to chemotherapy for breast cancer and 1 to rheumatoid
arthritis). In 1 patient, the sign was identified in the superior lobes and in 4 in the
inferior lobes. It was unilateral in 1 case and bilateral in 4. Reversed halo sign was
the unique CT finding in 3 patients. In the other 2, additional ON signs were present
(peribronchovascular consolidations, bronchial dilatations, and multiple nodules
with halo sign in one case and centrilobular nodules in the other).
Conclusion: The reversed halo sign is not an exceptional lung CT finding in ON,
and so its knowledge and presence is a very useful imaging clue in the diagnosis
of this entity.
C-210
CT appearance of radiation injury of the lung after stereotactic body
radiation therapy (SBRT) for lung cancers: A pictorial review
A. Linda1, M. Tro vo2, C. Javidan-Nejad3, J. Bradley3; 1Udine/IT, 2Aviano/IT,
3
St.Louis, MO/US ([email protected])
Learning Objectives: To review the serial CT manifestations of radiation injury to
the lung after stereotactic body radiation therapy (SBRT) for lung cancers.
Background: SBRT is a recently introduced technique that allows the delivery of a
very high radiation dose to the target volume, while minimizing the dose to the adjacent
normal tissues. SBRT has been shown to be highly effective in the treatment of nonoperable stage I lung cancer or lung metastases. Considering its excellent results, it
is expected that an increasing number of patients will be treated with SBRT for lung
cancer. Therefore, an understanding of the SBRT-induced lung changes and CT findings is very beneficial to the radiologist, in particular in making the distinction between
radiation-injury and disease recurrence, and in the assessment of tumor response.
Imaging Findings: The complex distribution of radiation dose of SBRT and the very
high dose per-fraction result in patterns of lung injury that are different from those
of conventional radiation therapy (CRT). The most common early ( 6 months) CT
patterns are linear or diffuse consolidation, patchy consolidation and ground-glass
opacity (GGO), diffuse GGO, patchy GGO, no findings. The most common late ( 6
months) CT patterns are the "modified" conventional pattern (consolidation, volume
loss, bronchiectasis), mass-like pattern (focal consolidation), scar-like pattern (linear
opacity and volume loss), no findings. Infrequent complications of SBRT include
lobar collapse, parenchymal infection, rib fracture.
Conclusion: Lung injuries following SBRT are less evident than those following
CRT and have variable CT appearances according to the timing from treatment.
C-211
Postoperative bronchial stenosis in lung transplanted patients: Early
diagnosis with thoracic CT with multiplanar and 3D reconstruction
M. Martinez-Sapiña, P. Fernandez Suárez, O. Vazquez Muiños,
C. Fernandez Da Ponte, A. Iglesias Lopez, M. Delgado Roel; La Coruña/ES
([email protected])
Blunt chest trauma: A review with MDCT
P. Olmedilla, S. Hernandez, D. Exposito, V. Cuartero, S. Alonso, A. Sanz; Madrid/ES
([email protected])
Learning Objectives: Our purpose is to review the spectrum of imaging findings
in patients with blunt chest trauma evaluated with MDCT.
Background: MDCT is a relatively new modality that has come to occupy an important role in the evaluation of severely injured patients. Although isolated chest
injuries are not common, they are responsible for a high proportion of morbidity and
mortality. Therefore, a rapid and proper diagnosis is mandatory in these patients,
and contributes to the immediate treatment plan. After chest radiography, used
as initial tool for rapid triage, CT is the next most used imaging method. Technical capabilities of new generation MDCT scanners allow a prompt and accurate
diagnosis of major organ system disruption as well as subtle injuries.
Imaging Findings: In this exhibit we classify blunt-chest traumatic injuries, and we
show different cases of lung, pleura, mediastinum, diaphragm, aorta and thoracic
cage lesions. We also review the imaging findings in cardiac trauma, illustrated
with two additional examples. As this traumatic pathology is unusual and difficult to
identify, we emphasize its radiological presentation and clinical management.
Conclusion: Radiologist plays an important role in the evaluation of chest injuries
due to the development of MDCT. This modality allows an accurate and prompt
diagnosis, contributing to patient treatment. However, diagnosis of chest injuries is
not always easy. We review the spectrum of imaging findings in MDCT, especially
the more subtle ones. We believe that the reviewing of this topic will help us to
reduce overlooked lesions.
C-213
Role of MDCT in the management of blunt chest trauma
M. Febrer, M. Teixidor Viñas, L. Valls Masot, E. Gómez Roselló,
M. Osorio Fernández, S. Pedraza Gutiérrez; Girona/ES ([email protected])
Purpose: Thoracic injuries are frequent lesions in traumatic patients. The purpose
of our study is to review the spectrum of lesions in chest trauma and its association
with traumatic injuries in other locations using multidetector computed tomography
(MDCT).
Methods and Materials: We retrospectively reviewed whole-body MDCT studies
performed in our institution to polytraumatized patients over a 21 month period.
The analysis of the CT included multiplanar reformation (MPR) and two- or threedimensional postprocessing techniques of the entire data set at the workstation.
Results: 397 polytraumatized patients underwent standardized whole-body MDCT
scan. There were 305 males and 92 females with a median age of 38 years (range:
4-93). In 187 out of 397 patients (142 males and 45 females), a thoracic traumatic
injury was diagnosed (47%). The most frequent lesion was pulmonary contusion
(58.3%) associated or not with pulmonary laceration, followed by pneumothorax
(43.9%) and costal fractures (42.3%). Less prevalent injuries were hemothorax
(29.4%), athelectasis (17.1%), thoracic wall lesions (including subcutaneous
emphysema, hematoma and contusion) (11.2%), mediastinal hematoma (11.2%),
sternal fractures (including condrosternal articulations), clavical and scapular fractures and pneumomediastinum. Vascular, diaphragmatic and esophageal injuries
were infrequent findings.
Conclusion: Chest lesions are common injuries in polytraumatized patients. CT
is the election technique in clinical suspicion of severe trauma. MDCT improves
vascular injury assessment. The most frequent lesions are pulmonary contusions
(with or without associated laceration), pneumothorax and costal fractures. Radiologists play an important role in the management of traumatic patients, as an
accurate diagnosis will lead to proper therapeutic decisions.
C-214
Focal lung lesions that all radiologists should recognize as benign on CT
M. Seco, A. Canelas, B. Graca, L. Curvo-Semedo, F. Caseiro-Alves; Coimbra/PT
([email protected])
Learning Objectives: To know and illustrate the benign focal lung lesions whose
diagnosis can be specifically made by CT.
Background: The radiographic assessment of patients with a solitary or multiple
lung nodules, masses or cavities is a common clinical problem, which may require further characterization by CT. Primary or metastatic tumors usually are the
main diagnoses in patients with these findings. However, some other diseases or
abnormalities present with focal lung abnormalities, many of which have specific
appearances on CT that may suggest the correct diagnosis.
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Purpose: Lung transplant is the elective treatment in end-stage pulmonary
diseases. Advances on surgical techniques, donor organ preservation and immunosuppressant therapies have improved surveillance and lowered postoperative
complications. Stenosis of bronchial anastomosis is considered an important
morbidity. Its early detection allows an effective treatment.
Methods and Materials: Since January 1999 until May 2008, thoracic CT with
bronchial reconstruction was performed in 220 lung transplanted patients. CT
scans were realized between first and third month post-transplant. We have reviewed 320 anastomosis using thoracic CT with axial slides, multiplanar and 3D
reconstructions.
Results: Bronchial stenosis were minimal in 36 anastomosis, moderate in 3 and 12
were considered critical, appearing in these cases airway complications. All stenosis
were studied by broncoscopy and results were concordant with CT findings. Critical
stenosis was treated with balloon dilatation and bronchial stenting.
Conclusion: The use of thoracic CT with multiplanar and 3D reconstruction in lung
transplant follow-up protocol has supposed a great advance. It supports information
about longitudinal extension of bronchial narrowing area and distal airway space
orientation. It also allows higher clarity than axial slides and adequate calibration
of stenosis grade, which helps anastomosis dilatation and stenting planification.
Multiplanar and 3D reconstruction will permit us early bronchial stenosis detection
without the use of bronchoscopy.
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Scientific and Educational Exhibits
Imaging Findings: A systematic review with proper illustration of several entities
that have specific appearances on CT, including healed granulomas, hamartoma,
exogenous lipoid pneumonia, bronchocele, pulmonary arterio-venous malformations, sequestration, rounded atelectasis and loculated fluid collections, will be
performed.
Conclusion: The radiologist must be able to recognize the specific CT findings
of a wide spectrum of benign lung lesions, in order to avoid lung biopsies or other
invasive procedures in a considerable proportion of patients who present with focal
abnormalities on the chest plain film.
C-215
Upper lobe emphysema and concomitant lower lobe interstitial fibrosis:
The role of HRCT in the assessment of this distinct entity
E. Testempassi, S. Kopanakis, E. Lazaridou, M. Kalomenopoulou, D. Chondros;
Athens/GR
Purpose: Concomitant pulmonary fibrosis and upper lobe emphysema is a unique
entity that was recently characterized. This disorder is usually found in men who are
smokers. The purpose of this study is to present the imaging findings in patients
with combined pulmonary emphysema and fibrosis.
Methods and Materials: We analysed the chest HRCT findings in a retrospective series of 30 men patients ranged in age from 55 to 73 years. All patients had
dyspnea but they had almost normal spirometry. All patients had marked reduction
on pulmonary function tests.
Results: Lung volumes were preserved in almost all patients. All patients had
extensive upper lobe emphysema and diffuse interstitial fibrosis of the lower lobe.
All patients had dilatation of the central pulmonary vessels. The emphysema was of
bullous type in the 19 patients and of centrilobular type in 11 patients. All patients
had subpleural reticular abnormalities and honeycombing of lower lobes. Nine
patients had also ground glass opacities in the lower lobes.
Conclusion: The radiologist must be aware of this unique entity of combined
emphysema and interstitial fibrosis, which has almost normal spirometry. The early
diagnosis of the above syndrome affects the treatment, prognosis and outcome
of the disease.
C-216
The abnormality is on the lateral chest X-ray: What does the frontal chest
radiograph look like?
D.Y.F. Chung1, R.R. Misra2; 1Oxford/UK, 2High Wycombe/UK
Learning Objectives: To present a pictorial review of ‘abnormalities’ present on
a lateral chest X-ray (CXR), asking the question, ‘What does the abnormality look
like on the frontal radiograph?’ This is to emphasize the importance of the lateral
view in problem solving, without having to automatically recourse to CT, thereby
minimising patient dose wherever possible.
Background: The frontal CXR is an extremely commonly requested investigation.
By comparison, requests for lateral CXRs are in decline. The reasons can only be
surmised, but rapid access to CT, for a ‘CXR abnormality’, is likely the main driving
factor. We have a duty of care to minimize patient doses wherever possible, and
the Ionizing Radiation Regulations (UK) and media attention have made patients’
acutely aware of this. We present many examples where CT can be avoided, if a
lateral view is initially considered.
Imaging Findings: Firstly, we review the normal radiological anatomy of the lateral
CXR. We then review several ‘abnormal’ lateral views, asking the question ‘what
does the abnormality look like on the frontal view?’ Finally, we review the corresponding frontal CXR for each case, highlighting the lateral view appearances,
thereby demonstrating why diagnostic CT may be avoided.
Conclusion: This review should help the viewers reacquaint themselves with the
clinical usefulness of the lateral CXR, and to appreciate its value in dealing with an
‘abnormal’ frontal radiograph, thus avoiding unnecessary CT radiation exposure.
C-217
Hemoptysis assessment with multidetector CT
A. Sierra Vinuesa, M. Sanchez, I. Real, M. Burrel, P. Arguis, R. Perea,
T. De Caralt; Barcelona/ES ([email protected])
Learning Objectives: To describe the anatomy of the pulmonary and systemic
vasculature of the lungs. To assess the usefulness of multidetector CT (MDCT)
for the initial diagnostic evaluation in cases of acute hemoptysis and of recurrent hemoptysis following embolization. To suggest a hemoptysis management
guideline.
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Background: Massive hemoptysis has been defined as the expectoration of an
amount of blood ranging from 100 mL to more than 1000 mL over a period of 24
hours or any amount sufficient to cause a life-threatening condition. In 90% of
cases of hemoptysis, the bronchial arteries are responsible for the bleeding, and
nonbronchial systemic arteries and other pulmonary vessels the remaining 10%.
Imaging Findings: MDCT for initial evaluation of acute hemoptysis allows: (a)
the assessment of the severity of the hemorrhage and localization of the bleeding
site; (b) the identification of the origin and trajectories of the bronchial, systemic or
pulmonary vessels that may require embolization; (c) the detection of the underlying lung parenchima or mediastinic disease as potential sources of hemoptysis.
MDCT study of the bronchial arteries and pulmonary and systemic vasculature
increases the effectiveness of arterial embolization and decreases the extension
of the intervention by showing the precise hypertrophic or pathologic vessels. It
also studies underlying pathology in lung parenchima and mediastinum that might
be the primary cause of the hemoptysis.
Conclusion: MDCT improves the endovascular treatment procedures by providing
an accurate vascular map prior to embolization and allowing the correct identification
of the pathologic vessel or other underlying causes of hemoptysis.
C-218
Pulmonary abnormalities in HIV infected patients: An imaging review
A. Roque, T. Saldanha, C. Vasconcelos; Lisbon/PT ([email protected])
Learning Objectives: The aim of this pictorial essay is to review computed tomography (CT) pulmonary abnormalities in human immunodeficiency syndrome
(HIV) infected patients.
Background: Worldwide estimates suggest that, by November 2007, about 33.2
million people were HIV infected with 2.1 million deaths resulting from AIDS.
Pulmonary complications of AIDS that depend on the immunological competence
and CD4 level represent major causes of morbidity and mortality in HIV infected
patients and despite the advent of highly active antiretroviral therapy (HAART), the
lung continues to be the most frequently involved organ, although accompanied
by changes in frequency and nature of pulmonary findings. Imaging, mainly CT,
is an essential key in the diagnosis of pulmonary conditions (both infectious and
non-infectious), which occur at a higher rate in those patients.
Imaging Findings: Radiological features of infectious aetiologies such as fungal,
bacterial, mycobacterial (typical and atypical), viral and parasitic will be reviewed.
Non infectious conditions including Kaposi sarcoma, AIDS related lymphoma,
non specific interstitial pneumonitis, lymphocytic interstitial pneumonitis will be
discussed. The authors suggest a systematic approach of CT findings in HIV
patients based on imaging patterns and immunological parameters.
Conclusion: Pulmonary disorders are the most prevalent complication of HIV
infection, and it is imperative for the physician reporting CT studies to know full
pulmonary imaging spectrum enrolled since these conditions are associated with
high morbidity and mortality. Interpretation of imaging studies should integrate
clinical and laboratory information with radiographic pattern recognition.
C-219
Pneumomediastinum: Old signs in a refresher perspective
L.F.P. Gonçalves, S.C. Dias, P. Covas, C. Pina Vaz, V. Mendes; Braga/PT
([email protected])
Learning Objectives: We review imaging of pneumomediastinum and of the various conditions that can lead to it.
Background: Pneumomediastinum may constitute a diagnostic challenge due to
its wide spectrum of intra and extrathoracic causes and to similitude of its radiologic
findings with those of others entities. Good understanding of mediastinal anatomy
and of pneumomediastinum pathophysiology is crucial in this behalf. Although
pneumomediastinum is often asymptomatic, it may lead to chest pain, dyspnea,
and seldom hypotension due to impairment of venous return to the heart. Careful examination of radiographic findings is of utmost importance in the diagnosis
of pneumomediastinum. Computed tomography corroborates the diagnosis and
provides rapid and accurate evaluation of the organs involved, frequently leading
to a specific diagnosis. Correct assessment of the radiologic signs of pneumomediastinum strongly contributes to appropriate treatment planning.
Imaging Findings: We describe the radiographic signs of pneumomediastinum as
well as the imaging spectrum of its various intra and extrathoracic sources. Emphasis
is given to related diagnostic challenges, imaging pitfalls and differential diagnosis,
namely medial pneumothorax, pneumopericardium and spurious causes. The radiological findings were confirmed by reviewing clinical and pathological records.
Conclusion: Diagnosis of pneumomediastinum can be challenging and strongly
benefits from radiographic and tomographic findings, leading to accurate orientation.
Scientific and Educational Exhibits
C-220
Pulmonary and abdominopelvic imaging manifestations of complications
post haematopoetic stem cell transplantation
R. Dunne, P. Beddy, G. Murphy, R. Mc Dermott, G. Wilson, J.F. Meaney; Dublin/IE
([email protected])
Learning Objectives: To outline the temporal relationship between immune status
of the recipient and the development of complications post haematopoetic stem cell
transplantation (HSCT). To recognise the imaging patterns of such complications
on cross-sectional imaging of the thorax and abdomen.
Background: HSCT is frequently performed to restore immunologic and haematologic function in neoplastic conditions after myelosuppressive chemotherapy
and radiation therapy and in non-neoplastic conditions in which such function is
inadequate. Complications post HSCT are numerous and can be divided into three
phases based on the immunocompetency of the recepient: the pre-engraftment
or neutropenic period (days 0-30 after HSCT), the early post-engraftment period
(days 30-100), and the late post-engraftment period (after day 100). We performed
a retrospective 3 year review of all cross-sectional thoracic and abdominopelvic
imaging post HSCT patients with clinical and pathological correlation.
Imaging Findings: Acutely, the commonest complications were infection, iatrogenic and idiopathic pneumonitis and neutropenic enteero-colitis. In the late post
engraftment period, hepatic veno-occlusive disease, multisystem graft versus host
disease and secondary malignancy were most prevalent. CT was found to be the
most useful imaging modality in these patients with MRI and ultrasound aiding
diagnosis in certain situations.
Conclusion: With increasing use of and survival after HSCT, the prevalence of
complications related to HSCT is likely to increase, particularly in the adult population. Complications post HSCT are numerous and potentially devastating; therefore,
prompt recognition of their radiological features is essential.
C-221
Lymphoproliferative thoracic disease
S. Tripathi1, Y. Jones1, J. Curtis1, P. Janousek2, E. Marchiori3,
A. Soares Souza Junior4, M. Bertoni5, J. Gosney1, K. Irion1; 1Liverpool/UK,
2
Manchester/UK, 3Niteroi/BR, 4Sao Jose do Rio Preto/BR, 5West Yorkshire/UK
Learning Objectives: To review the key lymphoproliferative diseases of the thorax,
with pathological and imaging examples.
Background: The lymphoid tissue of the thorax is located in the lungs and mediastinum, including the thymus gland. Lymphoproliferation occurs in multiple and
varied conditions, for example, Castleman’s disease, infectious mononucleosis,
plasma cell granuloma and lymphoid interstitial pneumonia, and may involve lung
parenchyma, intra-thoracic lymph nodes or the thymus. The pathology of reactive and neoplastic proliferations of thoracic nodal lymphoid tissue is essentially
equivalent to that of extra thoracic lymph nodes; however, proliferations of thoracic
lymphoid tissue, particularly within the thymus, display various unique characteristics. Lymphoproliferative disorders are relatively infrequent findings within the thorax;
however, once identified clinical and radiological findings may allow distinction
between benign or malignant lymphoproliferative disorders, and also distinction
between these groups and lymphomas.
Imaging Findings: Lymphoproliferative disease of lung parenchyma, thymic tissue
and intra-thoracic lymph nodes are presented. We present the current radiological
trends for diagnosis and staging, including PET imaging, and pathological features
of a range of thoracic lymphoid diseases.
Conclusion: We present a comprehensive review of thoracic lymphoproliferative disease, including current diagnostic strategies, staging, imaging trends and
pathological features.
C-222
Cardiac silhouette findings and mediastinal lines and stripes: X-ray and
computed tomography correlation
R. Marano, G. Savino, C. Liguori, A. Meduri, L. Natale, L. Bonomo; Rome/IT
([email protected])
C-223
Diverticula of trachea vs main bronchus: MDCT with 1.25 mm thin section
W.-H. Lee, Y. Kim, S. Jou, W. Bae; Cheonan/KR ([email protected])
Purpose: To evaluate the incidence, size, number, location, and relation with
emphysema of tracheal and main bronchial diverticula on MDCT.
Methods and Materials: Consecutive 967 patients (mean age: 54 years, M:F
=600:367) underwent chest CT during 2 months were included. We reviewed CT
images reconstructed with 1.25 mm thickness, 1.25 mm interval. The incidence,
size, number and location of diverticula in trachea (group 1) and main bronchus
(group 2) were analyzed. The incidence of combined emphysema and diverticular
size with/without emphysema were analyzed.
Results: Of 967 patients, group 1 was 5.1% and group 2 was 5.2%. The diverticular
size was 6.4 mm (1.2-30 mm) in group 1, and 2.17 mm (1-15 mm) in group 2. In
group 1, all diverticula were in right posterolateral aspect of the trachea. In group 2,
91 of 94 diverticula were in inferior wall and 72 diverticula were in left main bronchus.
Diverticular number was one in group 1 and 1.8 (1-9) in group 2. 20 patients had
two or more diverticula. Emphysema was in 13 patients of group 1 and 18 patients
in group 2. Diverticular size in patients with emphysema was larger than without
emphysema in two groups (p 0.05).
Conclusion: On thin section MDCT, tracheal and main bronchial diverticula were
about 5%. The main bronchial diverticulum is smaller. All tracheal diverticula are
in right posterolateral aspect of the trachea, and most main bronchial diverticula
are the inferior wall of left main bronchus with one or more number. Diverticular
size is related with emphysema.
C-224
Cryptogenic organizing pneumonia: Typical and atypical imaging features
on high resolution computed tomography
C. Dornia1, D. Manos2, J.L. Babar3, S. Feuerbach1, O.W. Hamer1;
1
Regensburg/DE, 2Halifax, NS/CA, 3Cambridge/UK ([email protected])
Learning Objectives: 1. Learn the pathophysiological basis and clinical background
of cryptogenic organizing pneumonia (COP). 2. Learn the classical HRCT appearance of COP. 3. Learn how to recognize unusual patterns and avoid diagnostic
pitfalls. 4. Learn how to work up difficult cases.
Background: Organizing pneumonia (OP) occurs without any identifiable cause
(“cryptogenic organizing pneumonia”, COP) as well as secondary to a multitude of
disorders of various origins (“secondary organizing pneumonia”). Possible triggers
are infections, drugs, collagen vascular disease, transplantations and radiation
directed to the chest. Common symptoms include cough, fever, and dyspnea. In the
vast majority, OP shows an excellent response to corticosteroid treatment with rapid
clinical improvement and resolution of radiological findings. Radiologists should
be aware of the typical and atypical imaging features of OP to prevent diagnostic
errors and guide appropriate work-up and management.
Imaging Findings: High resolution computed tomography (HRCT) is the modality
of choice if OP is suspected. The classical HRCT features of OP are consolidations
and ground glass opacities in a predominantly peripheral or peribronchovascular
distribution; an air bronchogram is common. Less common or atypical findings
include perilobular opacities, crazy paving, nodules, linear opacities and the
reversed halo sign. Cryptogenic and secondary OP cannot be distinguished on
the basis of imaging.
Conclusion: The classical HRCT features of OP are well known. However,
numerous atypical patterns have meanwhile been described. A profound knowledge of the various appearances of OP is a prerequisite for an accurate image
interpretation.
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Chest
Learning Objectives: To illustrate the CXR and CT imaging correlation of the mediastinal lines and stripes and cardiac silhouette concepts. The knowledge and the capability
to recognize the thickening, displacement or deletion of one of these mediastinal lines
or stripes as well as the presence/absence of the cardiac silhouette finding support the
appropriate request of CT examination. To help identify the CXR abnormal appearances
to perform differential diagnosis prior to obtaining information with chest CT.
Background: Chest X-ray (CXR) still represents the first diagnostic tool in patient
with suspected lung or mediastinal disorders, providing useful information. Most
of this information is mostly based on the compositions and relationships of the
anatomic structures in mediastinum, pleura, and lungs determining the so called
mediastinal lines and stripes and cardiac silhouette concepts, which may play an
important role in establishing or ruling-out a diagnosis before proceeding to CT. The
knowledge and the capability to recognize the thickening, displacement or deletion
of one of these mediastinal lines or stripes as well as the presence/absence of the
cardiac silhouette finding support the request of valuable CT examination.
Imaging Findings: CXR and CT anatomy of mediastinal lines and stripes and
cardiac silhouette. Relationship of lung and mediastinal diseases to mediastinal
lines and stripes and cardiac silhouette. Sample cases and differential diagnosis.
Conclusion: Radiologists must be familiar with these anatomical concepts and
be able to identify their normal and abnormal appearances to perform differential
diagnosis prior to obtaining additional information with chest CT.
Scientific and Educational Exhibits
C-225
Density-based MDCT quantification of lung volumes: An inter and intraoperator reproducibility study
F. Molinari1, M. Amato1, A. Macagnino1, G. Serricchio1, T. Pirronti1, M.U. Puderbach2,
L. Bonomo1; 1Rome/IT, 2Heidelberg/DE ([email protected])
Purpose: Density-based MDCT quantification (q-MDCT) of lung volumes can be
relevant in patients undergoing surgery for severe emphysema or lung cancer. The
inter- and intra-observer variabilities of q-MDCT were assessed in this study.
Methods and Materials: From the institution database, we identified 23 chest examinations obtained on a 16-MDCT scanner (slice thickness and interval = 1.25 mm;
pitch = 1.5) and showing signs of emphysema. After applying a semi-automatic
procedure for lung segmentation and delimiting manually the lobes through the
fissures, mean densities (MD) and volumes (V) were calculated for both lungs
and each lobe. A threshold of -950 HU was used to obtain mean densities and
volumes of the areas of emphysema (MDE; VE). All four parameters were calculated independently by two operators in two sessions one month apart. Inter- and
intra-observer differences were expressed as percentages over the means. Mean
percent differences with confidence intervals were assessed.
Results: Inter-observer mean percent differences for both lungs were: MD=0.04p1.1;
V=-0.19p3.4; MDE=-0.1p0.5; VE=-4.4p17.9; intra-observer mean percent differences were: MD=0.08p1; V=-0.17p3.45; MDE=-0.08p0.5; VE=3.6p16.4. Confidence
intervals ranges (p) obtained from each lobe were MD=1.4-3.9; V=13.3-98.3;
MDE=0.6-1.4; VE=29.6-137.6 for the inter-observer, and MD=0.4-0.7; V=3.7-10.6;
MDE=0.4-0.8; VE=17.3-32.9 for the intra-observer analyses.
Conclusion: Very accurate assessment of mean density and volume of normal
and emphysematous parenchyma can be obtained applying q-MDCT to both lungs.
Results are less reproducible if the analysis is performed lobe-wise using manual
delimitation along fissures.
C-226
Side effects of chest radiotherapy: MDCT findings
A.F.L. Carneiro, P.G.F. Sousa, A.S. Preto, J.M.T. Campos; Porto/PT
([email protected])
Learning Objectives: To describe the most common CT findings complications
after chest radiotherapy.
Background: Radiotherapy is a widely used curative or palliative technique and
recent advances have rendered it progressively more effective and less aggressive.
Still, unwanted ill-effects are still commonly found in follow-up chest examinations
of irradiated patients. Their differential diagnosis can be
S a challenge.
O of the chest have different
Imaging Findings: The different structures and tissues
P
E in more or less characteristic
radiation tolerances and are affected accordingly,
to
patterns, over time. Lung damage may bed evident
as early as six weeks after
te
treatment with standard doses as acute tradiation
pneumonitis, which presents as
i
air-space consolidation with geometric
bmboundaries. This may resolve successfully
or progress over 12 to 18 months u
to a more chronic, organized and fibrotic form,
S
l
with lung volume loss and retraction.
Both forms of injury are characteristic in that
ia
they conform to the radiation
er field and in their timing. Pneumothorax and pleural
t
a
effusion are rarely seen. Airways
are inevitably included in the radiations ports and
MIrradiation
may be affected as well.
of the heart may cause pericardial effusions or
o
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thickening or scarring of the myocardium. Bone may become osteoporotic or develop
osteoradionecrosis. Soft tissue calcifications are common. Acute esophagitis is
frequent and may be followed by stricture or fistula formation.
Conclusion: Awareness of the possible CT findings allows correct recognition of
these radiation-associated entities and better management of irradiated patients.
C-227
Thoracic CT in the intensive care unit: Does it alter the management?
Z.H. Aldin, N. Tunariu, J. Hollway; London/UK ([email protected])
Purpose: To determine the clinical value of thoracic computed tomography (CT) in
comparison with conventional in patients in a general intensive care unit (ICU).
Methods and Materials: We retrospectively reviewed the thoracic CT studies
and the associated bedside chest radiographs in 108 ICU patients scanned over
4 year period (age range 23- 87 years). The time interval between the CT scan
and the chest radiograph was not more than 24 hours. We analyzed the additional
information provided by CTs and the diagnostic and therapeutic relevance of
these findings.
Results: CT revealed new findings in 47 of the 108 patients (43.4%). However,
CT provided unsuspected significant diagnostic information that changed the
management of the patient in only 19 of the 108 patients (17.5%). Examples of
correctable lesions include malpositioned or occluded chest tube, unsuspected
S384
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large pleural effusion, empyema, pneumothorax, lung abscess, and postoperative
mediastinal collections. There were no significant complications during transport
for CT-examination.
Conclusion: Our experience suggests that although chest CT does not change the
management significantly in the majority of ICU patients, it is tremendously helpful
in patients whose clinical course is not explained by the available information or
whose chest radiographs are difficult to interpret. Therefore, careful selection of
patients who require CT examination can reduce time and cost incurred by transferring patients to and from radiology department.
C-228
Inflammatory pseudotumor: Radiological manifestations from head to toe
J. Quintero1, G. Valderas2, I. Guasch1, S. Ruiz2, I. Urra1, M. Pujol2; 1Badalona/ES,
2
Hospitalet de Llobregat/ES ([email protected])
Learning Objectives: To describe to spectrum of clinical and radiologic features
of inflammatory pseudotumor. To identify the various treatment options for inflammatory pseudotumor.
Background: Inflammatory pseudotumor is a quasineoplastic lesion that most
commonly involves the lung and the orbit, but it has been reported to occur in nearly
every site in the body. Because inflammatory pseudotumors mimic malignant tumors
both clinically and radiologically, the radiologist should be familiar with this entity
and help avoid unnecessary radical surgery when possible. Clinically, patients with
inflammatory pseudotumor tent to have varying degrees of fever, growth impairment,
iron deficiency anemia, thrombocytosis, and hypergammaglobulinemia.
Imaging Findings: We presented thirteen cases with histological proven or clinical
diagnosed of inflammatory pseudotumor: lung (2), spleen (2), liver (4), gastrointestinal tract (2), orbit (2) and adrenal gland (1). But in the literature also described in:
heart, pancreas, gastrointestinal tract, kidney, retroperitoneum, mesentery, urinary
tracts. Inflammatory pseudotumor is the most common primary lung mass seen in
children (50% of benign intrapulmonary tumors seen in pediatric patients). Orbital
pseudotumor is a common cause of unilateral proptosis in adults (constitutes about
6% of all orbital lesions).
Conclusion: Inflammatory pseudotumor can both radiologically and clinically
mimic a malignant process. They involve many anatomic sites. If this diagnosis is
considered, unnecessary radical surgery may be avoided. The treatment options
are varied and consist of surgery, high-dose steroids, irradiation, and chemotherapeutic agents.
C-229
Acute and chronic cardiothoracic manifestations of illicit use
S. Akers, H. Litt; Philadelphia, PA/US ([email protected])
Learning Objectives: To review the common cardio-pulmonary effects of illicit
drug abuse. To illustrate the common imaging findings of pathology related to illicit
drug abuse. To discuss interactions between drug-related and non-drug related
diseases.
Background: Illicit drug use is a major societal problem worldwide. Many of the
most commonly used illicit drugs have acute and chronic
S cardiopulmonary effects
with imaging manifestations. In this exhibit, we will demonstrate
many of the most
PO
E
common conditions related to drug use which oaffect the heart, lungs, and other
t
intrathoracic structures, and discuss the effects
d of drug-related disease on nonte
drug related pathology. This is particularlyitimportant
in the acute setting, where the
m underlying disease.
psychomotor effects of drug use may mask
b
Imaging Findings: Conditions to S
beu illustrated include: cocaine related acute and
l
chronic lung disease, IV drug related
ir a talcosis, emphysema, and vanishing lung, as
well as cocaine induced coronary
vasospasm, IV drug related valvular disease,
e
at may cause acute and chronic symptoms, which can
among others. These conditions
M
interact with and maskoother underlying diseases, for example causing or worsening
N
acute coronary syndrome in patients with underlying coronary artery disease.
Conclusion: Illicit drugs have wide ranging effects on the cardiopulmonary system, with a myriad of imaging manifestations. Appreciating these manifestations
can lead the radiologist to the appropriate diagnosis and suggest other potential
clinical findings.
C-230
CT halo sign: Differential diagnosis
N.J.F.P. Silva1, M. Castro2, L. Melão2, B. Viamonte2, R. Cunha2;
1
V.N. Famalicão/PT, 2Porto/PT ([email protected])
Learning Objectives: Learn differential diagnosis of the entities associated with
the CT “halo sign”. Learn clinical characteristics and other imaging features that
help narrowing the differential diagnosis.
Scientific and Educational Exhibits
Background: The halo sign refers to a CT finding of ground glass opacity area
surrounding a nodule or a mass. It is commonly present in leukemic patients with
invasive aspergilosis as a sign of perilesional hemorrhage; however, its presence is
nonspecific and has been demonstrated in several other clinical entities associated
with pulmonary hemorrhagic nodules like hypervascular tumor metastases, Kaposi
sarcoma, Wegener granulomatosis or in patients submitted to a transbronchial
biopsy. It is also documented in patients with other infections (like tuberculosis
or mycobacterium avium complex), chronic eosinophilic pneumonia, cryptogenic
organizing pneumonia and in some tumors, particularly adenocarcinoma or bronchioloalveolar carcinoma.
Procedure Details: A didactic format will be used and organized based on imaging
findings and clinical features. Differential diagnosis with a discussion of specific
entities will follow.
Conclusion: Understanding the imaging findings and the clinical spectrum of the
diseases associated with the CT halo sign may allow a more precise diagnosis,
optimizing patient management, particularly in the setting of severely immunocompromised patients.
C-231
Lipoid diffuse lung disease: A pictorial review
R.M. Maia, M. Gomes, R. Themudo, L. Sousa, J. Reis, M. Ribeiro; Oporto/PT
Learning Objectives: To illustrate the imagiologic spectrum of lipoid diffuse lung
disease (pulmonary alveolar proteinosis and exogenous lipoid pneumonia) and
describe the classic radiographic and HRCT findings based on a series of patients
diagnosed in our institution.
Background: Pulmonary alveolar proteinosis is a very rare condition that is characterized pathologically by filling of the alveoli with a PAS-positive proteinaceous
material rich in lipid. It is considered idiophatic. Exogenous lipoid pneumonia is an
uncommon condition resulting from aspirating or inhaling fatlike material that elicits
a foreign body reaction and proliferative fibrosis in the lung. Because symptoms are
absent or nonspecific and the roentgenographic findings simulate other diseases,
exogenous lipoid pneumonia is often unrecognized.
Imaging Findings: Radiographic manifestations of pulmonary alveolar proteinosis include bilateral, patchy, diffuse or para-hilar air-space consolidation or hazy
ground-glass opacity that is more severe in lung bases and resembles pulmonary
edema. HRCT shows bilateral areas of ground glass opacity, smooth interlobular
septal thickening in lung regions showing ground-glass opacity (crazy paving), consolidation and a patchy or geographic distribution. Radiographic manifestations of
exogenous lipoid pneumonia include consolidation, ill-defined masses with variable
amounts of low attenuation fat and sometimes fibrosis, with a typical lower-lobe
distribution. HRCT shows well or ill-defined masses or areas of consolidation in
a dependent location.
Conclusion: Staining of BAL fluid can be diagnostic if the radiologist has considered clinical information and imagiologic patterns of lipoid diffuse lung disease
and alerts the pathologist.
C-232
HRCT features of ATRA syndrome
E.M. Di Maggio, M.C. Inserra, M. Floridia, M. Russo, M. Raimondo, P. Romeo;
Taormina/IT ([email protected])
Pathology
C-233
IgG4-related lung disease: CT findings with pathological correlations
D. Inoue1, Y. Zen1, H. Abo2, T. Gabata1, H. Demachi2, T. Kobayashi1, J. Yoshikawa3,
S. Miyayama3, Y. Nakanuma1, O. Matsui1; 1Kanazawa/JP, 2Toyama/JP, 3Fukui/JP
([email protected])
Purpose: To retrospectively analyze radiological findings of IgG4-related lung
disease as correlated with pathological specimens.
Methods and Materials: This study focused on 13 patients with IgG4-related
lung disease (nine males and four females; age, 43-76 years). We retrospectively
analyzed CT images with regard to the characteristics, shapes and distribution of
radiological findings and correlated them with surgically resected or biopsied lung
specimens in seven patients.
Results: IgG4-related lung disease manifested a variety of radiological features.
Pulmonary lesions could be classified into four types based on the presence of
major radiological abnormalities: solid nodular type having solitary mass forming
or discrete nodules resembling primary lung cancer in four cases, local groundglass opacity (GGO) type characterized by multiple round-shaped GGO resembling
bronchioloalveolar carcinoma in two patients, alveolar interstitial type showing
honeycombing, bronchiectasia, and diffuse GGO resembling interstitial pneumonia
in two patients, and bronchovascular type showing thickening of bronchovascular
bundles and interlobular septa in five patients. Pathologically, solitary nodules consisted of diffuse lymphoplasmacytic infiltration with fibrosis. GGO was histologically
characterized by inflammatory cell infiltration in thickened alveolar interstitium. In
the advanced lesions, alveolar structures were disrupted and peri-pleural air spaces
were dilated. These histological findings corresponded to the radiological findings
of honeycombing. Thickened bronchovascular bundles or interlobular septa on CT
histologically showed lymphoplasmacytic infiltration with fibrosis along peribronchiolar or interlobular connective tissue.
Conclusion: IgG4-related lung disease manifested four types of radiological features on chest CT. Radiological findings corresponded to IgG4-related sclerosing
inflammation along the intrapulmonary connective tissue.
C-234
Diagnosis of malignant pleural mesothelioma on CT
S. Haque, M. Singh, B. Rajashanker, P.M. Taylor; Manchester/UK
([email protected])
Purpose: Computed tomography (CT) is the primary imaging modality used for the
diagnosis of malignant pleural mesothelioma (MPM). We carried out a review to
determine the appearances of MPM on CT in 15 histologically confirmed cases.
Methods and Materials: CT performed prior to biopsy was retrospectively reviewed using a grading system ranging from 0 - 4, depending on the degree of
suspicion of MPM. Initial CT reports were assessed to determine whether MPM
was suspected prior to biopsy.
Results: All cases were proven MPM on histology; 6/15 cases also diagnosed
on cytology. A third of cases had no suspicious features (Grade 0) or a low index
of suspicion (Grade 1). 3/15 patients had borderline appearances (Grade 2) with
minor pleural thickening. 3/15 patients had a high degree of suspicion (Grade 3)
including nodular, circumferential pleural and interlobar fissure thickening. 4/15
patients had typical findings of MPM with local invasion (Grade 4). Unilateral pleural
effusion demonstrated in 11/15 and pleural plaques in 20%. 6/15 had lymph node
involvement. 2/15 patients had originally been suspected of MPM prior to biopsy
and 6/15 were presumed pleural metastases.
Conclusion: There is a wide spectrum of findings on CT in MPM and the initial
diagnosis was only suspected in two cases. Despite retrospective review, 5/15 cases
did not demonstrate any suspicious features. However, the presence of a unilateral
pleural effusion with nodular pleural and interlobar fissure thickening should raise
the suspicion of MPM and requires careful assessment for local invasion.
Chest
Learning Objectives: To discuss and to illustrate the occurrancy of pulmonary
hemorrhage in all trans retinoic acid syndrome even without haemoptysis as strictly
related clinical finding. To understand the HRCT aspects of this syndrome.
Background: ATRA syndrome is a complication (16%) of the use of all trans
retinoic acid, which may develop 5-21 days after the accepted treatment of acute
promyelocytic leukaemia. Diagnosis can be made by the presence of three of the
following symptoms: fever, dyspnea, weight gain, hypotension, renal failure, pulmonary infiltrates, pleural effusion, and pericardial effusion; anaemia with haemoptysis
when pulmonary haemorrhage occurred.
Imaging Findings: Out of 3 cases of ATRA syndrome observed during the last
year, one occurred also with anaemia and pulmonary haemorrhage but without
haemoptysis. Diagnosis was made by HRCT that showed diffuse alveolar damage:
poorly defined centrilobular nodules, coalescent nodules associated to bilateral
diffuse air space consolidation of posterior lung zones with relatively sparing of
the anterior lung fields and patchy zone of GGO. At complete remission on bone
marrow examination, final HRCT after treatment showed no evidence of pulmonary
damage.
Conclusion: Early recognition of ATRA syndrome is important: tempestive intervention with high doses of corticosteroid appeared in fact to abort the progression
of this syndrome.
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Scientific and Educational Exhibits
C-235
Chest
A great unknown diaphragm call: Normal anatomy and pathology
J. Quintero, S. Mourelo, E. Barluenga, D. Hernández, I. Guasch, C. Pozuelo;
Badalona/ES ([email protected])
Learning Objectives: To describe the normal anatomy, variants of normality and
pathology of the diaphragm and peridiaphragmatic structures, emphasizing CT.
Illustrating the importance and advantages of the reconstructions with multidetector
CT and magnetic resonance imaging in the evaluation of the diaphragm.
Background: For the role of the diaphragm is generally regarded as a structure
intrathoracic albeit for their integration across the diaphragmatic crura also are
regarded as a structure intraabdominal. Become familiar with the embryological
development of the diaphragm will facilitate know the anatomy, pathology and
periprhagmatic processes.
Imaging Findings: Normal anatomy: diaphragmatic hiatuses and inserts.
Variants of normalcy: diaphragmatic pillars, pseudotumor diaphragmatic, arched
lateral ligaments, retrocrural air. Diaphragmatic defects: Bochdalek hernia, hernia
Morgagni, hiatus hernia and traumatic hernia. Peridiaphragmatic pathology: yuxtadiaphragmatic and retrocrural. Transdiaphragmatic processes: subphrenic, liver
(hydatid cyst, amebian abscess, iatrogenic) and lymphatic channels. Diaphragmatic
tumors: they are very rare, most of those are malignant sarcomas, while the highlight
of benign lipoma. Diaphragmatic elevation: unilaterally or bilaterally.
Conclusion: Given the shape and thinness of the diaphragm it is difficult to visualize
a structure in its entirety. For its structural complexity anatomical structures with
multiple ligaments and connections to the chest and abdomen is more than just a
border between the two cavities. Technological advances with teams’ multidetector CT with multiplanar reconstructions have improved markedly display normal
diaphragm and the pathology of the area and diaphragmatic peridiaphragmatic.
PET
C-236
PET/CT depiction of ATS mediastinal nodal stations: What every
radiologist should know - diagnostic strategies and potential pitfalls
J.V. Raj1, J. Birchall2; 1Leicester/UK, 2Derby/UK ([email protected])
Learning Objectives: To understand the importance of using ATS (American
Thoracic Society) nodal stations in staging lung cancer. Appreciate PET/CT depiction of these nodal stations and be aware of diagnostic strategies and potential
pitfalls of the technique.
Background: Accurate staging of lung cancer is critical due to its therapeutic and
prognostic implications. It is vital that radiologists, nuclear medicine physicians,
pulmonologists, thoracic surgeons and the oncologists speak the same language
when it comes to nodal staging. This can only be achieved by universal use of ATS
system. Recent advances in PET/CT have led to its increased use in staging, but
it has its own advantages and limitations which we will address.
Imaging Findings: Pictorial depiction of: ATS nodal stations on PET/CT. Diagnostic
strategies: Normal vs abnormal node characteristics. Importance of PET and CT
integration. Pitfalls: Differential diagnosis of PET positive node. Implication of N3
positive node on PET/CT without N1/N2 disease-radical therapy should not be denied without exploring these nodes. Spatial resolution of PET component of CT.
Conclusion: As time goes by, PET/CT and ATS nodal staging will become part and
parcel of lung cancer staging. Every radiologist therefore should be well versed with
ATS nodal stations and appreciate the importance and limitations of PET/CT.
C-237
Evaluation of the accuracy of PET/CT in determining the size of the
primary tumour in T1 and T2 non-small cell lung cancers
D. Pawaroo1, N. Cummings2, P. Musonda1, R. Rintoul2, C. Beadsmoore1;
1
Norwich/UK, 2Cambridge/UK ([email protected])
Purpose: To compare measurements of T1 and T2 primary non-small cell lung
cancer tumours (NSCLC) on CT and PET and determine which modality correlates
most accurately with histological tumour size.
Methods and Materials: Retrospective study of 58 patients with surgical resection of T1 and T2 NSCLC at Papworth Hospital between 2005 and 2007 in whom
pre-operative PET/CT scanning was performed. The maximum measurement of
the primary lung tumour was recorded on the PET scan and unenhanced CT (soft
tissue and lung windows) in whichever plane was largest. Comparison was made
with the maximum dimensions of the histological specimen.
Results: Linear correlation with the histology specimen maximum dimension was
greatest for PET (0.82), followed by CT soft tissue (0.70) and CT lung (0.67). The
greatest linear correlation was between measurement on CT soft tissue and lung
windows indicating these can be used interchangeably. The Bland and Altman
method showed CT soft tissue window measurements demonstrated highest
concordance with histology (mean -0.225; standard deviation 1.5) but PET had a
lower standard deviation (mean -0.29; standard deviation 0.99). PET measurements
were discordant with histology in 3 patients, CT in 5.
Conclusion: PET is better at delineating the primary tumour volume in NSCLC if
there is surrounding collapse/consolidation; otherwise, CT using either soft tissue
or lung windows is accurate. PET tumour volume measurements can be inaccurate
in alveolar cell carcinoma and atypical adenomatoid hyperplasia due to low FDG
accumulation. CT is more accurate in these cases.
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Detection of second primary malignancies with integrated PET/CT in the
staging of non-small-cell lung cancer (NSCLC)
D. Leiva Pedraza, C. Gámez Cenzano, S. Guirao Marín, E. Andía Navarro,
Á. Fernández León, I. Puig Povedano, F. Martínez Torrens, I. Martínez Ballarín,
S. Padrones Sánchez; Hospitalet de Llobregat/ES ([email protected])
Purpose: To assess retrospectively the additional value of PET/CT in the detection of unsuspected second primaries in the staging of patients diagnosed with
OS
non-small-cell lung cancer and other extrathoracic
EPlesions including metastatic
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itte a pathological proven lung tumour
Methods and Materials: 379 patientsmwith
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staging was established. All extrathoracic
temetabolic
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obtained from the medical records (follow-up 12 mo).
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Results: Extrathoracic hypermetabolic lesions were detected in 23% of the patients
(88/379) and 75% of these lesions (66/88) were proved to be malignant: 51 patients
with metastasis (77%) and 15 patients with second primaries (23%). Simultaneous malignancies, observed in 4% of the patients (15/379), were more frequently
colorectal tumours in an early stage (10/15) and 1 of those patients presented a
S
double synchronous colorectal cancer. Other primaries O
included
head and neck
P
cancer (1), renal cancer (1), pancreatic cancer (1) and
o Elymphoma (1). Extrathoracic
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benign foci observed in the remaining 25% iof
ttethe patients (22/88) were localized
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variants and adenomas.
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Conclusion: PET/CT for staging
rianon-small-cell lung cancer patients was able to
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assess local involvement M
o and detect unsuspected distant metastases and second
primaries in a singleNstudy. Most extrathoracic hypermetabolic lesions resulted
malignant (75%): metastasis (77%) and second malignancies (23%). The results
of our study suggest that second primary tumours can be detected in 4% of
patients with primary lung cancer (most of them are detected as an early stage
colorectal tumor).
C-239
Solitary pulmonary nodule: Role of combined morphological and
metabolic imaging
A. Reginelli, M. De Rimini, M.G. Pezzullo, A. Russo, F. Lassandro, P. Muto,
A. Rotondo; Naples/IT
Purpose: To determine the complementary diagnostic value of morphological and
metabolic studies obtained with 18 F-FDG-PET/CT and contrast enhanced MDCT
in solitary pulmonary nodule (SPN) characterization.
Methods and Materials: 34 patients with SPN from 10 to 30 mm in size were
studied with 18 F-PET/CT and MDCT with iv contrast. Data analysis on dedicated
workstations provided the semi-quantitative parameter of 18 FDG uptake (standardized uptake value-SUV) and morphological, volumetric and densitometric data of
MDCT with iv contrast. The results so obtained were compared with histological
and citological responses.
Results: Of the 34 SPN, 23 were malignant and 11 were benign at histopathological examination. 18 F-FDG-PET/CT correctly identified 21 (91%) malignant lesions
(SUV 3) and 10 (90%) benign lesions with 2 false negative and 1 false positive.
MDCT with morphological and densitometric evaluation identified 19 (82.6%)
malignant lesions and 11 (100%) benign lesion with 4 false negative.
Conclusion: Combined study with 18 F-FDG-PET/CT and MDCT with iv contrast
optimizes the global information with morphological and metabolic parameters and
so it improves the specificity in SPN characterization.
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Standardized perfusion value (SPV): A semi-quantitative approach between
MSTC and 18f-FDG pet in evaluating solitary pulmonary nodules (SPN)
A. Reginelli, S. Cappabianca, G. Rossi, M. Petrillo, C. Varelli, R. Muto,
A. Rotondo; Naples/IT
Technical Aspects
C-241
Multi-detector row CT (MDCT) and post-processing techniques in the
diagnosis of diffuse lung disease
J. Ciampi, J. Alarcón, J. de la Torre, M. Santillana, A. Aguado, F. Pla; Madrid/ES
([email protected])
Learning Objectives: To illustrate the multi-detector row CT (MDCT) and postprocessing techniques in the diagnosis of diffuse lung disease. To demonstrate the
benefits of MDCT versus high-resolution CT of the chest (HRCT).
Background: HRCT is the imaging technique widely accepted for evaluation of
diffuse lung disease. However, the main limitations of HRCT are that only 10%
of lung parenchyma is scanned, and the difficulties to obtain high quality images
in severely dyspneic or non collaborative patients. The generation of isotropic
volumetric high-resolution data obtained with MDCT has supposed the possibility
of visualizing the lung parenchyma in contiguous high quality images, with the
option of creating two-dimensional (2D) and three-dimensional (3D) reformatted
images. These studies are obtained at much shorter scanning times without losing
spatial resolution.
Procedure Details: In this exhibit we describe the different reconstruction techniques available with MDCT, and their application to the different patterns of diffuse
lung disease. In the first part we discuss the wide spectrum of post-processing tools,
including 2D reformation (multiplanar reconstruction, maximum intensity projection
(MIP), minimum intensity projection (minIP)) and 3D reformation (volume intensity
projection (VIP) and volume rendering (VR)). In the second part we illustrate the
MDCT findings in the major patterns of infiltrative lung disease (reticular, nodular,
and increased-decreased lung attenuation), with special emphasis in the most
frequent pathological entities.
Conclusion: The numerous reformation tools and the shorter scanning times of
MDCT suppose an actual benefit over HRCT in the evaluation of infiltrative diffuse
lung disease.
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The preliminary study on 64-detector CT perfusion imaging in guiding
biopsy of pulmonary lumps
L.-Q. Kang, Z.-W. Song, Y.-F. Chen; Cangzhou/CN
Purpose: To explore the value of 64-detector CT perfusion imaging in guiding
biopsy of pulmonary lumps.
Methods and Materials: CT guided biopsy was performed on 147 patients with
pulmonary lumps between February 2005 and June 2007. The patients were divided
into 3 groups: 33 cases guided by CT perfusion imaging as group I, 45 cases guided
by contrast-enhanced CT as group II, and 69 cases guided by plain CT as group
III. The achievement ratio of biopsy, the accuracy in grouping and grading of lung
cancer and the incidence of complication were compared.
Results: The achievement ratio of biopsy from group.i. to III was 100% (33/33),
91.1% (41/45), and 79.7% (55/69), respectively, and the difference was statistically
significant between group.i. and III (P 0.05). The accuracy in grouping and grading
of lung cancer from group.i. to III were 100% (27/27), 91.2% (31/34), and 71.7%
(33/46), respectively, and the difference was statistically significant between group.i.
and III and between group II and III (P 0.05). The incidence of complication from
group.i. to III was 15.2% (5/33), 26.7% (12/45), and 43.5% (30/69), respectively, and
the difference was statistically significant between group.i. and III (P 0.01).
Conclusion: CT perfusion imaging guided biopsy of pulmonary lumps using 64-detector CT has a potential to improve the accuracy of histopathological diagnosis
with lower risk and higher achievement ratio, but more research and technical
improvements are needed before it is widely used.
C-243
Feasibility of in vivo proton magnetic resonance spectroscopy of lung
cancer
C. Park, C. Lee, I. Song, J. Goo, H. Lee; Seoul/KR ([email protected])
Purpose: To investigate the feasibility of in vivo proton magnetic resonance spectroscopy (MRS) for assessment of lung cancer.
Methods and Materials: In this prospective study, 10 consecutive patients (7
men and 3 woman; mean age, 64.4 years) with pathologically-proven lung cancer
(mean size, 56.8 mm, range, 44-77 mm), were subjected to MRS using PRESS in
breath hold and continued respiration-triggered acquisition. All MRS examinations
were performed using a 1.5 T scanner. We assessed technical success rate and
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Purpose: In order to correlate MSCT standardized perfusion value (SPV) and
obtain 18 F-FDG PET standardized uptake value (SUV) in the characterization of
solitary pulmonary nodules.
Methods and Materials: We studied 29 patients (52 - 74 years old) with proven
solitary pulmonary nodule (SPN) (n = 21) or in follow-up for previously identified
SPN of unknown nature (n=8). In all patients, both CT scan after intravenous
administration of contrast medium and PET-CT were performed. In all SPN perfusional values quantified with semi-quantitative method and elaborated as SPV
and SUV were calculated and the obtained values were matched and correlated
with cytological specimens.
Results: Seventeen patients with SPN had malignant lesions while in four, benign
nodules were found. They were computed, respectively, a specificity SPV/SUV of
75% and 83%, a sensitivity SPV/SUV equal to 88% and an accuracy of 85%. Both
SPV and SUV had the same positive predictive value (PPS) (94%) but different
negative predictive value (NPV) (60 vs. 67%). The relationship among the specificity,
sensitivity and accuracy was 90% (r=0.90), 100% (r=1) and 100% (r=1).
Conclusion: Being histological bioptic evaluation the only certain response, the
SPV is potentially able to offer, with a single MSCT acquisition, an information data
pool easy to be compared with both routine studies, made by MSCT and 18 F-FDG
PET, gaining a lower global patient exposition to the radiant doses.
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Scientific and Educational Exhibits
investigated the reason of the technical failure in those cases. The peak areas
of the choline (Cho) and lipid were measured in the lung mass and expressed
the relative signal-to-noise ratio (SNR) of Cho to the background noise level. The
Cho-to-lipid ratio was measured by dividing the peak area of Cho at 3.2 ppm by
the peak area of lipid at 1.3 ppm.
Results: Of the 10 lung cancers, spectra of analyzable quality were obtained from
8 tumors (technical success rate, 80%). Two MRS data sets from tumors had poor
spectroscopic resolution or impaired signal-to-noise ratio for analysis. The mean
Cho SNR of lung cancers was 10p14.43 (range, 0-31.2). The mean Cho-to-lipid
ratio of lung cancers was 0.2p0.34 (range, 0-0.96).
Conclusion: In vivo proton MRS in breath hold and continued respiration-triggered
acquisition is technically feasible for the evaluation of lung cancer.
C-244
Ground-glass nodule volume - influence of the tube current on automated
measurements: A chest CT phantom study
L. E, D. Ma; Beijing/CN ([email protected])
Purpose: The purpose of our study was to evaluate the effect of various tube
currents on the accuracy of volumetric measurement of ground-glass nodules by
using a chest phantom.
Methods and Materials: A chest phantom containing 13 artificial ground-glass
nodules (8~15 mm in diameter) with known volume was scanned using a 64-section computed tomography (CT) scanner at different tube currents (210, 180, 150,
120, 90, 60, 30 mA). All data were reconstructed with slice thickness of 0.625 mm
and bone algorithm. Automated nodule volume measurements were performed by
using computer-assisted volume measurement software. The relative percentage
error (RPE) and the absolute percentage error (APE) between the CT measured
volume and the reference-standard volume of ground-glass nodules was measured.
RPEs and APEs obtained at each current were compared respectively by the use
of two-way ANOVA.
Results: There was substantial underestimation of volume of ground-glass nodules
measured at 30, 60, 90 mA, the mean RPE of the software-calculated volume of
ground-glass nodules were -5.63p8.60, -6.07p7.49, and -5.50p8.31%, respectively.
And there was substantial overestimation of volume at 120, 150, 180 and 210 mA,
the mean RPE were 2.32p8.05, 3.06p8.18, 4.71p7.63, and 3.05p7.79%, respectively. But there was no statistically significant difference in APEs across the seven
tube currents (p=0.876).
Conclusion: Computer-assisted volume measurement is a promising method for
quantification of ground-glass nodule volume. It is important to know the effect
of different tube currents on the accuracy of volumetric measurement during the
follow-up of ground-glass nodule volume.
C-245
Low dose chest CT in the preoperative evaluation in patients with pectus
excavatum: Clinical utility for surgical plan
K. Lee, M.-Y. Kim, H. Park, E.-Y. Kang, Y. Oh, B. Seo, S. Lee, B. Je; Ansan/KR
([email protected])
Purpose: Individual patients with pectus excavatum (PE) may have chest characteristics that impact the result of repair. This study was conducted to assess
the usefulness of low-dose multidetector row computed tomography (MDCT)
depiction of various deformities that would have an impact on the choice of pectus
bar shaping.
Methods and Materials: This study included 185 consecutive patients (135 men
and 50 women; age, 3-30 years; mean age, 10 years) who underwent low dose
MDCT and had surgical correction of their PE between March 2007 and March 2008.
All the patients underwent low dose multidetector (MDCT) before surgical procedure.
MDCT scans were obtained by using a sixty four-channel MDCT with 120 kVp and
30-35 mAs. Morphological variations of chest wall deformity were evaluated based
on symmetricity of deformity and broad or deep focal depression.
Results: 105 (56.8%) patients had the typical deep symmetrical depression of
the lower sternum (focal type; 74, broad type; 31). 80 (43.2%) patients had asymmetrical depression, which is the maximal depression is in the cartilage off to one
side (focal type; 33, broad type; 20). 27 patients (14.6%) revealed the unbalanced
type (variant of asymmetric depression), which describes the center of the depression is in the midline but one side of the wall of the depression is more severely
depressed than the other.
Conclusion: Low dose chest CT is useful in the identification of morphological
variations of PE that is helpful in the preoperative shaping of the pectus bar prior
to surgical repair.
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Whole-lung xenon ventilation CT using a dual energy technique with dualsource CT
Y. Watanabe1, T. Nakazawa2, M. Higashi2, T. Itoh3, K. Ohtani3, S. Sase3,
Y. Ohnishi2, H. Naito2; 1Chuo/JP, 2Suita/JP, 3Tokyo/JP ([email protected])
Purpose: To evaluate whether whole lung xenon-ventilation CT by dual energy (DE)
CT is a useful diagnostic tool for regional lung ventilation evaluation.
Methods and Materials: Six healthy volunteers inhaled 30% stable xenon for
2 min. Whole-lung CT (baseline native and dynamic enhanced) was performed
during wash-in (7 times) and wash-out (2 times) by dual-source CT (SOMATOM
Definition; Siemens, Germany) in the low-dose DE mode (140 kV, 6 eff.mAs and
80 kV, 26 eff.mAs). Xenon images were obtained using commercial DE software
(Siemens, Germany) to extract lung perfused blood volume images and xenon
ventilation analysis software (Anzai, Japan). Time-attenuation curves were fitted
by non-linear least square curve fitting to a single-compartment exponential model.
K (rate constant of enhancement), A (amount of enhancement) and EMS (error
mean square) maps from xenon images or combined images (140 kV and 80 kV
data) were obtained. The lung was divided into upper, middle, and lower fields and
K-values of these fields were compared.
Results: Xenon images and whole lung ventilation maps from DE CT data were
successfully obtained in all volunteers. Average EMS from the xenon images
(77.5p9.0) was significantly lower than those from the fused images (133.5p14.1).
K-values from the xenon images were significantly larger in the lower lung fields,
but this difference was not detected in K-values from the combined images.
Conclusion: The xenon ventilation map was calculated more accurately from xenon
images extracted from DE CT data than from combined images. Whole-lung regional
ventilation function can be displayed with DE xenon ventilation CT.
C-247
Comparison of STIR turbo SE imaging and diffusion-weighted imaging of
the lung: Capability for detection and subtype classification in pulmonary
adenocarcinomas
H. Koyama, Y. Ohno, N. Aoyama, M. Nogami, D. Takenaka, Y. Onishi,
K. Matsumoto, S. Matsumoto, K. Sugimura; Kobe/JP
([email protected])
Purpose: To evaluate the capabilities of DWI for detection and differentiation of
subtype classification in patients with pulmonary adenocarcinoma, and to directly
compare those capabilities with STIR.
Methods and Materials: Thirty-two patients (14 men and 18 women; mean age,
65.2 years) with 33 adenocarcinomas were enrolled in this study. All MR examinations were performed on a 1.5 T scanner. To determine the capability for detection, detection rates of both sequences were compared by using McNemar’s test.
ADC values on DWI and contrast ratio between cancer and muscle (CR) on STIR
were measured for comparison with histological subtypes, and these values were
compared with subtype classifications by using ANOVA. Finally, ROC-based positive tests were performed to differentiate subtype classifications, and differentiate
capabilities were compared with each other by using McNemar’s test.
Results: Detection rate of DWI (85% [28/33]) was significantly lower than that of
STIR (100% [33/33], p 0.05). There were no significant differences between ADC
values and subtype classifications; however, CRs of BAC were significant lower
than other types (p 0.05). When threshold values for differentiating BAC from
others (ADC=0.0012, CR=0.8) were adapted, sensitivity (56.5% [13/23], p 0.05)
and accuracy (63.6% [21/33], p 0.05) of DWI were significantly lower than those
of STIR (sensitivity: 95.7% [22/23] and accuracy: 90.9% [30/33]). When threshold
values (ADC=0.0014, CR=1.2) for differentiating adenocarcinoma with mixed
subtypes from that except BAC component, there were no significant difference
among two sequences.
Conclusion: The capabilities of DWI for detection and subtype classification were
lower compared with STIR.
C-248
Virtual bronchoscopy-guided transbronchial lung biopsy in the diagnosis
of peripheral lung cancer
S. Iwano, K. Imaizumi, T. Okada, Y. Hasegawa, S. Naganawa; Nagoya/JP
([email protected])
Purpose: Multidetector computed-tomography (MDCT) with 0.5 mm x 64 detector
rows enables the high quality virtual bronchoscopic (HQVB) image of whole bronchial trees. Therefore, we have applied HQVB for the navigation of transbronchial
biopsy in the diagnosis of lung cancer since 2006. The aim of this study was to
evaluate the clinical value of HQVB for the assistance of peripheral lung cancer
diagnosis by transbronchial lung biopsy (TBLB).
Scientific and Educational Exhibits
Methods and Materials: Eighty patients of peripheral lung cancer (50 males and 30
females, mean age 67; range from 38 to 84) confirmed by pathology were reviewed.
For all patients, an experienced radiologist planned one or two suitable HQVB
paths on a workstation before the real bronchoscopy and the expert physicians of
respiratory internal medicine underwent TBLB navigated by them. The factors for the
performance in the HQVB-guided TBLB (character of patients, CT reconstruction
protocols, feature of tumor) were analyzed by logistic regression analysis.
Results: In 62 patients, specimens obtained by HQVB-guided TBLB showed
pathologic findings and sensitivity was 78%, which is at least concordant with
the previously reported value in the literature. Furthermore, the size (13-55 mm),
location, the leading bronchial generation (4th - 8th), internal opacities (Solid or
GGO) and the pathology of the lesion were independent of performance of HQVBguided TBLB.
Conclusion: HQVB-guided TBLB could contribute to accurate diagnosis of peripheral lung cancer regardless of feature of tumor.
C-249
Small animal imaging of lung cancer: Comparison of different imaging
modalities exemplified by SPC-myc and SPC-raf transgenic mouse models
T. Rodt, C. von Falck, R. Halter, C. Boehm, C. Tillkorn, J. Lotz, M. Galanski,
J. Borlak; Hannover/DE ([email protected])
Learning Objectives: To present different small animal imaging modalities for
imaging of lung cancer. To compare the advantages and disadvantages of the
different modalities.
Background: Small animal imaging allows in-vivo assessment of lung cancer. It
can be used for further examination of molecular carcinogenesis mechanisms and
evaluation of novel treatment strategies. Different modalities including microCT,
microPET, MRT and optical imaging have been applied. As in human imaging, the
individual modalities have different advantages and disadvantages for particular
diagnostic questions. Furthermore, the specific requirements that come along with
the changes in physiological parameters and spatial dimension in small animal
imaging have to be taken into consideration.
Imaging Findings: Exemplified by SPC-myc and SPC-raf transgenic mouse
models, microCT, microPET, MRT and optical imaging techniques are presented.
Imaging findings are correlated to necropsy and histology findings. Technical considerations such as anesthesia, gating and the choice of tracers are addressed.
The advantages and disadvantages of the different modalities are further discussed
by the literature on small animal imaging in lung cancer.
Conclusion: Small animal imaging of lung cancer can be obtained using different
imaging modalities that have specific advantages and disadvantages. Morphology
is best appreciated by microCT while microPET and optical imaging allow obtaining functional and metabolic information. MRT bridges the gap allowing imaging
of morphology as well as function or metabolism.
C-250
Role of dual energy subtraction in the detection of bone abnormalities:
Looking beyond the conventional chest radiography
D. Castellon, J. Calatayud, G. Tardaguila, J. Aguilar, R. Prada, E. Santos,
F.M. Tardaguila; Vigo/ES ([email protected])
Dynamic contrast-enhanced 3D magnetic resonance with automatic
subtraction in the follow-up of lung tumors treated with radiofrequency
ablation
P. Arguis, M. Sánchez, L. Bianchi, A. Borrat, R.J. Perea, T.M. De Caralt;
Barcelona/ES ([email protected])
Learning Objectives: To describe the dynamic contrast-enhanced 3D magnetic
resonance with automatic subtraction in the follow-up of lung tumors treated with
radiofrequency ablation (RFA). To illustrate the MRI findings of lung tumors after
RFA.
Background: RFA is a treatment option for nonsurgical patients with primary
and metastatic lung tumors. The follow-up is important because some of treated
patients will demonstrate local residual viable tumor with potential reintervention.
CT is the technique for follow-up. The enhancement pattern and the size of the
change in the ablated lesion are the most important CT findings of lung tumors
for determining whether a complete ablation has been achieved. As at MRI images the ablation zone is usually seen with high signal on T1, it may be difficult to
recognize enhanced areas.
Imaging Findings: On immediate MRI images, the ablation zone is iso/hypointense on T1 and the reactive rim is hyperintense on T2 with peripheral enhancement post-gadolinium administration. On follow-up, the central part of the lesion
becomes hyperintense on T1. Treated areas without contrast enhancement on
post-gadolinium enhanced T1-weighted images are suggestive of complete ablation. Subtraction, obtained between noncontrast and contrast enhanced images
at dynamic gadolinium-enhanced MR imaging, may be more sensitive detecting
very small enhanced areas representing viable residual tumor.
Conclusion: Dynamic contrast-enhanced 3D magnetic resonance with automatic
subtraction may be useful in the follow-up of lung tumors treated with RFA.
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The impact of post-processing of chest DR on detection of simulated lung
lesions: A phantom study
L. Zhao, W. He, K. Wang; Beijing/CN ([email protected])
Purpose: To compare three parameters sets of post-processing in DR chest radiology for the detection of simulated lung lesions (nodules, reticular, ground-glass,
linear and miliary patterns).
Methods and Materials: Simulated nodules, including ground-glass, linear and
reticular patterns were superimposed over a authropomorphic chest phantom
(KAGAKU, Kyoto, Japan). DR radiography was performed with different three postprocessing parameters sets (default, low pass and high pass enhanced, Digital
Diagnost, Release 1.3, Philips Medical Systems, Hamburg, Germany). Screen
reading was performed by four radiologists. The detection performance of three
parameter sets was compared by using receiver operating characteristic (ROC)
analysis involving 36,000 observations.
Results: By using default, high and low pass enhanced processing parameter sets,
the Az value for detection of ground-glass were 0.780, 0.737 and 0. 865, better at
low pass, p 0.05; linear pattern: 0.898, 0.935, 0.912, better at high pass, p 0.01;
and nodule pattern: 0.826, 0.825, 0.840, better at low pass, p 0.01.
Conclusion: The diagnostic performance of chest DR was changed in different
types of post-processing. The low pass image was better for detection of groundglass and nodule patterns whereas high pass image better for linear and reticular
patterns. This study is helpful to define some post-processing protocols to increase
detection of certain chest lesion patterns, such as nodule, reticular, ground-glass,
linear and miliary patterns.
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Clinical applications and diagnostic role of dual energy subtraction in the
evaluation of thoracic disease: A pictorial essay
D. Castellon, J. Calatayud, J. Aguilar, G. Tardaguila, R. Prada, C. Delgado,
F.M. Tardaguila; Vigo/ES ([email protected])
Learning Objectives: 1) To review the basic principles of dual energy subtraction.
2) To illustrate the spectrum of diseases that can be demonstrated by this technique.
3) To provide a practical approach to clinical applications. 4) To highlight technical
limitations and imaging pitfalls.
Background: Chest radiography still represents the most common tool in diagnostic
radiology due to its simple application, low dose and low cost. Dual energy subtraction takes advantage of the difference in the energy dependence of attenuation
between soft tissue and bone. These differences are used to generate tissueselective images. This ability of dual energy technology to remove overlying bony
structures has markedly improve the detection of pulmonary nodules. Although the
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Learning Objectives: 1. To review the basic principles of dual energy subtraction. 2.
To illustrate the broad spectrum of skeletal pathology and their radiological imaging
patterns. 3. To discuss the role of dual energy subtraction chest radiography in the
detection and characterization of bone lesions.
Background: Skeletal abnormalities are common findings on chest radiography.
Despite recent advances in MDCT, chest radiography remains the most common
tool used to make an initial diagnosis approach of many thoracic diseases. In its
conventional form, anatomic features overlay each other and anatomical noise
can reduce the capacity of observer to detect abnormalities of concern. In dual
energy, tissue-selective images are generated removing overlying structures,
which may help the radiologists to detect lesions that could not be identified on
conventional X-ray.
Imaging Findings: Representative cases of thoracic bone diseases found on dual
energy chest radiography are shown and classified into five groups to facilitate learning: 1) congenital abnormalities, 2) inflammatory/infectious pathology, 3) bone neoplasms (primary tumors and metastases), 4) extension by contiguity and 5) traumatic
lesions. Imaging features are illustrated using a multimodality approach (plain film,
dual energy chest radiography, ultrasound and MDCT). Usefulness of bone-selective
image in the identification of chest wall abnormalities is emphasized.
Conclusion: Dual energy subtraction chest radiography has been recognized as a
promising technique in the evaluation of cardiothoracic disease and bone-selective
image is a helpful modality in the detection and characterization of thoracic bone
lesions, especially in the diagnosis of metastastatic bone disease.
C-251
Scientific and Educational Exhibits
majority of the published literature on dual energy subtraction chest radiography
has focused on the improved detection of lung nodules, we will illustrate many other
dual energy clinical applications in this pictorial essay.
Imaging Findings: Representative cases are shown in this exhibit to illustrate
the expanded diagnostic role in the assessment of cardiothoracic disease with
dual energy subtraction digital chest radiography. These are classified into different groups to facilitate learning: 1) calcified and noncalcified nodules, 2) pleural
disease, 3) pneumothorax, 4) hilar and mediastinal masses, 5) airway pathology,
6) bone abnormalities, 7) cardiovascular disease and 8) indwelling devices and
foreign bodies.
Conclusion: Dual energy subtraction chest radiography improves the radiologist’s
ability to diagnose a wide variety of cardiothoracic pathology. Major teaching point
is familiarizing the viewer with dual energy subtraction images of different abnormalities beyond lung nodules.
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Patent foramen ovale and expiratory scans: Importance in CT pulmonary
angiography
R.S. Kashyape, H. Choudhury, A. Kohli, D. Rajput; Mumbai/IN
([email protected])
Purpose: Evaluation of expiratory scans for adequate opacification of pulmonary
arteries during CT pulmonary angiography of patients with intra-cardiac shunts.
Methods and Materials: 30 patients who underwent CT pulmonary angiography
for suspected pulmonary embolism during a period of six months were evaluated
retrospectively. In all patients, the scan was taken after inspiration using standard
recorded API. A second scan was performed with the patient holding his breath in
expiration if adequate opacification of pulmonary arteries was not obtained in the
first scan, due to a suspected right to left intra-cardiac shunt.
Results: Out of a total of 30 patients, in 4 patients adequate opacification of pulmonary arteries could not be achieved in the first run. In two of these, there were
technical problems including failure of injector in one and extravasation of contrast
in another patient. In the remaining two, a patent foramen ovale was suspected due
to simultaneous dense opacification of superior vena cava and ascending aorta
with relative non opacification of pulmonary arteries. In these two patients, repeat
scans taken in expiration with all other parameters remaining the same yielded
adequate pulmonary artery opacification. These two patients were later proved to
have a patent foramen ovale on 2D echo studies.
Conclusion: Since the prevalence of patent foramen ovale has been estimated to
be about 25% in the general population, additional scans in expiration should be
taken in all patients suspected to have patent foramen ovale.
C-257
Needle image plates compared to conventional CR in chest radiography:
How much dose reduction is possible?
V. Kulemann, S. Pötter-Lang, M. Gruber, R. Berger, K. Vonbank, M. Weber,
M. Uffmann; Vienna/AT
Purpose: To compare image quality of standard-dose computed radiography and
dose reduced needle-technology CR for supine CXR in a clinical setting.
Methods and Materials: We prospectively evaluated 128 radiographs of 32 immunocompromised patients. For each patient, four clinical CXR were performed
within one week, two with powder image plates (PIP; Fuji ST-V) and two with
needle image plates (NIP; Agfa DXS) at standard and half doses, respectively.
One experienced radiologist and two residents blinded to dose level and kind of
imaging system rated different anatomical structures, image noise, tubes/lines
and abnormalities on a image quality scale from 1 to 10 (1=poor, 10=excellent).
The rating scores were tested for statistical differences using analysis of variance
with repeated measures.
Results: A statistical difference (p 0.05) was found for the two systems as well as
for the two dose levels. Overall rating scores were 6.5 for PIP with full dose, 6.2 for
PIP with half dose, 7.6 for NIP with full dose and 7.4 for NIP with half dose. There
was a significant difference in favour of the NIP system at the same dose level. Also,
the NIP images obtained at half dose were ranked significantly better compared to
the PIP images at standard dose. The differences in ranking of anatomical structures
and abnormalities were more pronounced in low absorption areas (pulmonary vessels, parenchyma) than in high absorption areas (mediastinum, spine).
Conclusion: For supine chest radiographs, the NIP technology allows for a dose
reduction of 50% compared to PIP while providing higher image quality.
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C-258
Clinical attitudes to diagnosis of PE: The unknown unknowns!
N. Askari Haider1, S. Haider2, S. Kennish1, M. Darby1; 1Leeds/UK, 2Hull/UK
([email protected])
Purpose: Diagnosis of pulmonary embolism (PE) requires clinical suspicion and
appropriate investigation. This audit determines junior doctors’ awareness of and
adherence to British Thoracic Society (BTS) guidelines for PE.
Methods and Materials: Review of all CTPA request cards over a 45 day period to
determine the indications and results. Junior doctors in two big teaching hospitals
responded to an online survey exploring whether clinical suspicion of PE translated
to appropriate investigations.
Results: Request cards: 237 CTPA were performed; 16% were positive for PE. Only
36% of request cards provided adequate details. Survey response: 115 doctors
responded, 92% were confident that they could competently assess the clinical
probability of PE, still 62% do not always assess it. 75% correctly identified that Ddimers should be performed in intermediate/low clinical probability patients. Despite
this, 57% would still consider performing CTPA in patients with negative D-dimer.
The majority of doctors would inappropriately request V/Q scans for patients with
significant cardio-pulmonary disease. 51% believed that normal V/Q scan did not
reliably exclude PE. 70% of junior doctors have not read BTS guidelines.
Conclusion: A low positive pick-up rate for CTPA and poor understanding of appropriate investigative pathways for PE amongst junior doctors suggests that many
patients are being imaged inappropriately. This has important radiation protection
and financial implications. We propose to: 1. Introduce PE teaching into junior
doctor’s induction and e-learning modules. 2. Display summary of BTS guidelines
in CT department. 3. Introduction of request cards specific for CTPA/VQ involving
tick boxes for appropriate clinical details and D-dimer result.
C-259
CT angiography in suspected pulmonary embolism: Impact of patient
characteristics and different venous lines on vessel enhancement and
image quality
C.M. Heyer, D. Roggenland, S.P. Lemburg, S.A. Peters, V. Nicolas; Bochum/DE
([email protected])
Purpose: To compare image quality, patient characteristics, and different types of
contrast application in pulmonary CT angiography (pCTA) in patients with suspected
pulmonary embolism.
Methods and Materials: 126 patients were investigated with pCTA including bolus
tracking and automated tube current modulation (ATCM). Patient characteristics,
type (peripheral or central venous line), position (cubital vein or vein on forearm/
hand), size (18- or 20-gauge), and side of venous access were documented.
Pulmonary vessel enhancement and image noise were quantified; signal-to-noise
ratio (SNR) and contrast-to-noise ratio (CNR) were calculated. Subjective vessel
contrast was assessed by two radiologists in consensus.
Results: Patient age showed a significant positive correlation to mean (Pearson’s
coefficient=.266; p=.003) and peak vessel enhancement (PC=.244; p=.006), CNR
(PC=.178; p=.046), and subjective image quality (PC=.344; p .001), whereas patient weight revealed a significant negative correlation to mean (PC=-.473; p .001)
and peak vessel enhancement (PC=-496; p .001), SNR (PC=-.446; p .001), CNR
(PC=-.425; p .001), and subjective image quality (PC=-.422; p .001). In univariate
analysis, SNR and CNR were significantly higher in patients who received contrast
medium through a peripheral catheter (30p13 and 27p13, respectively) compared
to those in whom contrast agent was applied via a central line (22p8 and 19p7;
p=.041 and p=.029, respectively). Sex, size, position, or side of venous access had
no significant impact on vessel enhancement or image quality.
Conclusion: Patient age and weight showed significant impact on vascular attenuation and image quality in pCTA, whereas sex and different peripheral venous routes
did not significantly influence image parameters. Contrast injection through central
catheters carries the risk of sub-optimal pulmonary artery contrast.
Scientific and Educational Exhibits
C-260
Pulmonary hypertension: Role of MDCT
M. Navallas, M. Sánchez Nistal, E. Álvarez Moreno, A. Arenas de Pablo,
C. Jiménez López-Guarch, T. Velázquez; Madrid/ES ([email protected])
Learning Objectives: To show the role, clinical applications and advantages of
MDCT in the evaluation of pulmonary hypertension. To distinguish primary from
secondary PH. To illustrate the radiological features and most representative findings of different causes of PH, with a special mention of chronic thromboembolic
pulmonary hypertension (differentiation of chronic from acute pulmonary embolism
and evaluation of the extension and distribution of thrombi to select candidates
for surgery).
Background: It is important to be aware of the different causes of PH because
some of them are treatable like chronic thromboembolism. Thromboendarterectomy
improves symptomatology, increases survival, improves the clinical condition of
patients, and diminishes the quantity of drugs for maintenance.
Procedure Details: The utility of MDCT to evaluate other causes of PH such
as congenital heart diseases, Rendu-Osler syndrome, veno-occlusive disease,
connective tissue disorders, pulmonary fibrosis, and chronic thromboembolism
is shown. The most outstanding CT findings in chronic thromboembolism are illustrated. A comparison between acute and chronic pulmonary embolism is done.
Our findings are compared with those of classical techniques: echocardiography
and catheterism.
Conclusion: MDCT is an easy to perform technique that helps in diagnosing PH
while it makes a differential diagnosis of its causes. Chronic pulmonary embolism
is an uncommon cause of pulmonary hypertension. An important difference with
other causes of pulmonary hypertension is that it has a surgical treatment. MDCT
is useful in the diagnosis, location and extension evaluation of the thrombi, as
well as to assess thromboendarterectomy results. MDCT is complementary to
echocardiography and right heart catheterization.
C-261
Role of computed tomography after pulmonary endarterctomy
P. Diez, A.M. Sanchez Nistal, R. Cano, M. Navallas, L. Ibañez, M.J. Ruiz-Cano,
P. Escribano Subias; Madrid/ES ([email protected])
Purpose: To evaluate the potential of multidetector-CT and search for new signs
in the assessment after pulmonary thromboendarterectomy (PTE) in patients with
chronic thomboembolic pulmonary hypertension (CTEPH).
Methods and Materials: We analyzed hemodynamic parameters (PVR, right atrial
pressure (RAP)), and we correlated it with MDCT findings (mosaic parenchyma,
pattern score (MPP), pericardial and pleural changes, collateral systemic circulation (CSC), pulmonary artery (PA) to aorta artery ratio (PAR) PA score (PAS), right
and left ventricles diameter ratio and interventricular septum position) before and
6 months after PTE. PAS was obtained by giving, to every affected PA, n points
(x2 if completed obstruction) according to the number of branches that originate
from it (max score (100%)= 40).
Results: 10 patients were studied (48p15 years, 7 males). 6MWT (345p138 vs
502p89 meters), hemodynamic paramenters (PVR (968p386 vs 351p229 dinas/
cm-5)), and CT findings (PAR (1.3p0.2 vs 1.0p0.2) and PAS (42p18% vs 21p19%))
significantly improved (p 0.05) after surgery. There were changes but not significant
changes in other CT variables (CSC and MPP).
Conclusion: PTE is the primary treatment of CTPH. From our knowledge, there is
no compendium that shows the radiological parameters after PTE. We think that the
whole study of these parameters in MDCT is helpful before and after PTE, mainly
pulmonary artery/aorta ratio and pulmonary artery score. Future works in this direction may get that CT is an indispensable tool to evaluate these patients.
C-262
Can CT parameters predict clinical course in patients with pulmonary
embolism? A retrospective analysis of 152 patients
D. Roggenland, S.P. Lemburg, S.A. Peters, V. Nicolas, C.M. Heyer; Bochum/DE
([email protected])
C-263
Diagnosis of chronic pulmonary embolism with dual source dual energy CT
Y. Nishimoto, S. Miura, S. Kitano, J. Takahama, N. Marugami, K. Kichikawa;
Kashihara/JP
Purpose: To investigate the usefulness of dual source dual energy CT in the
diagnosis of chronic pulmonary embolism (CPE).
Methods and Materials: Nine patients with clinical suspicious of CPE underwent
a dual energy CT angiogram of the lung (SOMATOM Definition, Siemens) using
the following acquisition parameters (140 and 80 kV tube voltage, 1:4 tube current ratio, 64x0.6 mm collimation and 0.5 sec gantry rotation time). Contrast agent
(100 ml@370I 65 kg and 300I 65 kg for patients, respectively) was injected at
a rate of 4 ml/s. Perfusion defects were evaluated with lung perfused blood volume
algorism (Lung PBV). Lung PBV images were generated with commercial software
(Siemens, Germany). We evaluated: (a) the depiction of endoluminal clots on
transverse CT scans (contiguous 1-mm thick composite images from both tubes)
and (b) the pattern of perfusion defects on Lung PBV images.
Results: (a) Two patients showed CT features of PE with depiction of clots within
trunk (n=2), lobar (n=1), segmental (n=1). All clots were identified as incomplete
filling defects. 3 patients had lobar artery stenosis. (b) The pattern of perfusion
defects: segmental perfusion defect and shift to upper lung field (n=3), segmental
perfusion defect (n=2), shift to upper lung field (n=1), decrease for whole lung field
(n=1) and no perfusion defect except emphysema/honeycombing (n=2).
Conclusion: Dual source dual energy CT is useful for the diagnosis of CPE. It
enables detection of the endoluminal clots, perfusion defects and redistribution
at the same time.
C-264
Role of multidetector CT pulmonary angiography in the diagnostic
algorithm of pulmonary hypertension
V.M. Suárez-Vega, I. Torres Sánchez, J. Ríos Blanco, S. Alcolea Batres,
A. Alonso Torres, C. Fernández Capitán; Madrid/ES ([email protected])
Purpose: To describe the prevalence of right ventricular dysfunction signs. To
establish the usefulness of MDCT angiography versus ventilation/perfusion (V/Q)
scintigraphy in the diagnostic algorithm.
Methods and Materials: Between November 2006 and May 2008, the MDCT
angiographies of 47 patients were recorded. The inclusion criterion was a threshold
of systolic main pulmonary artery (MPA) pressure of 40 mm Hg or higher at rest.
Moreover, in 23 of these patients (48.9%) the V/Q scintigraphies were available.
MDCT pulmonary angiographies were evaluated for right ventricle (RV) dysfunction
signs (RV/LV ratio 1, left bowing of interventricular septum) and vascular prognostic
ratios. Patients were divided into two groups (A pulmonary artery 29 mm and
B 29 mm) for the statistical analysis. The non-parametric test of U Mann-Whitney
was used. V/Q scintigraphies were classified according to high, medium or low
probability for pulmonary thromboembolic disease.
Results: The mean and standard deviations of MPA and RV were recorded, being
higher on the B group. The RV/LV and the MPA/Aorta ratios were significantly higher
on the B group (p 0.001). Sixteen patients (69.5%) presented a correct match
between the MDCT angiography and the V/Q scintigraphy. Four negative V/Q scintigraphies presented signs of chronic thromboembolism in the MDCT angiography,
which also made the alternative diagnosis of interstitial disease.
Conclusion: MDCT angiography is an accurate tool depicting RV dysfunction signs.
It has also proven signs of chronic thromboembolism in patients with negative V/Q
scintigraphies and made the alternative diagnosis of parenchymal diseases. Hence,
it might be a first-line-tool in the diagnostic approach of PH.
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Purpose: To establish CT parameters in patients with pulmonary embolism (PE)
predictive for clinical course and mortality.
Methods and Materials: Between 5/2004 and 10/2007, all patients with CT diagnosis of PE were retrospectively identified and included in the study. Analysis of
axial 16-slice CT scans was performed by two radiologists in consensus including
documentation of diameter of RV, LV, SVC, Ao, PA, ventricular septal bowing and
contrast reflux into IVC and/or azygos vein. Pulmonary obstruction index (POI)
and RV/LV- and Ao/PA-ratio were calculated. Patient characteristics and clinical
course including ICU treatment, mechanical ventilation, thrombolysis, days of
hospitalization, and mortality were documented. Multivariate logistic regression
was performed with a p-value of 5%.
Results: 152 patients (62p17 years, 55% male) were enrolled in the study. Mean
duration of hospitalization was 21p24 days. 66 patients (42%) were treated on ICU
and mechanical ventilation was necessary in 20 patients (13%). 11 patients received
thrombolysis. Mortality rate was 8%. Significant positive correlations between both
POI (p=.037; OR=1.020) and IVC reflux (p=.018; OR=2.894) and ICU treatment were
present. Furthermore, significant positive correlation between IVC reflux (p=.005;
OR=10.494) and mechanical ventilation could be documented. POI revealed a
positive correlation to necessity of thrombolysis (p=0.037; OR=1.114). RV/LV-ratio
significantly correlated to mortality rate (p=.042; OR=6.275). No other imaging
parameter showed significant impact on the clinical course of affected patients.
Conclusion: RV/LV-ratio is a predictive parameter for mortality in patients with PE.
POI and IVC reflux are predictive for necessity of ICU treatment and mechanical
ventilation. Length of hospital treatment cannot be predicted by CT parameters.
Scientific and Educational Exhibits
C-265
C-268
Purpose: To compare the results obtained with MDCT and TTCE grades in the
screening of PAVMs in patients with HHT.
Methods and Materials: 84 patients (45% males; mean age 46 years) with HHT
studied with MDCT and TTCE. MDCT scans were performed with 3 mm collimation
and 1.5 mm reconstruction thickness. TTCE was performed by IV injection of 5 ml
of agitated saline. The test was considered positive when contrast was visualized
in the left atrium after a delay of at least 4 cardiac cycles. The studies were classified into grade 1 to 4 according to ventricular opacification. Positive predictive
values (PPV) and 95% confidence intervals (CI) of TTCE using CT as the reference
standard were calculated.
Results: 17 of 84 patients had PAVMs on MDCT. All patients with negative TTCE
had a negative MDCT for PAVMs. 65.5% patients had a positive TTCE, 44% were
considered as grade 1, 31% grade 2, 18% grade 3, and 7% grade 4. There was
a significant association between TTCE grades and detection of PAVM on MDCT
(p 0.0001). None of the patients with grade 1 had PAVM on the MDCT. PPV were
0% for grade 1, 24% (95%CI 5-46%) for grade 2, 90% (95%CI 70-100%) for grade
3, and 100% for grade 4.
Conclusion: TTCE grades are useful to select patients for MDCT in the screening of PAVMs in patients with HHT. These findings suggest that in the presence of
TTCE grade 1, further MDCT studies may not be necessary.
Learning Objectives: To review the potential sources of systemic arterial supply
(SAS) to the lung and the spectrum of associated congenital or acquired conditions.
To present CT, MR, conventional angiography or chest X-ray images from cases
of our experience that illustrate the imaging findings that allow the recognition of
these vessels and associated processes.
Background: SAS may take place through hypertrophied normal systemic arteries, most commonly bronchial arteries, or through abnormal vessels, already
present at birth, such as major aortopulmonary collaterals (MAPCs), also called
aberrant arteries. These are more frequently related to congenital lung processes
(sequestration syndrome), although they can also be a source of collateral flow
in some congenital heart disease (CHD). Hypertrophied systemic arteries supply
the lung also in some cases of CHD as well as in acquired lung diseases such us
bronchiectasis, tuberculosis and other lung infections, pulmonary thromboembolism
and other causes of chronic pulmonary arterial obstruction.
Imaging Findings: Hypertrophied bronchial or other systemic arteries are usually
recognized as tubular, tortuous enhancing structures originating from descending
thoracic aorta or its branches. Aberrant vessels take their origin directly from the
aorta apart from the normal origin of bronchial arteries.
Conclusion: SAS to the lung may be associated to congenital cardiac and lung
diseases or to acquired disease, and can be the source of significant hemoptysis.
MR and CT angiography are non-invasive techniques that allow accurate recognition of aberrant vessels and hypertrophied bronchial or other systemic arteries, as
well as cardiac and lung associated anomalies.
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Contribution of MDCT and transthoracic contrast echocardiography
grades in the screening of pulmonary arteriovenous malformations
(PAVMs) in patients with hereditary hemorrhagic telangiectasia (HHT): An
ongoing study
J. Parra1, J. Bueno2, J. Zarauza2, J. Cuesta2, R. Zarrabeitia2, M. Fariñas Alvarez2;
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Santander/ES, 2Torrelavega/ES ([email protected])
Pre-operative evaluation for the interventional treatment of hemoptysis
patients using 64-slice computed tomography angiography
L. Liu1, H. Yang1, X. Wang1, H. Cao2; 1Changchun/CN, 2Beijing/CN
([email protected])
Learning Objectives: To demonstrate the clinical value of multi-slice computed
tomography angiography (MSCTA) in pre-operative evaluation for the interventional
treatment of hemoptysis patients.
Background: CTA techniques based on dynamic enhancement CT exams could
effectively promote the specificity and accuracy diagnosis. This study evaluates the
S
value of CTA in diagnosis and treatment of hemoptysis
O patients.
Procedure Details: Twenty-one hemoptysis patients
EP underwent MSCTA before the
digital subtraction angiography (DSA) and intervention
treatment. The parameters of
to
d
the CT scan protocol were: 64x0.625 collimation,
120 Kv, rotation time 0.4s. Volume
e
t
it multiplanar reformation were used to depict
rendering, maximal intensity projection, and
m were
b
the lesion. The findings of CT angiography
compared with those of DSA. Feeding
Supatients were revealed clearly by CTA. There was
arteries and their origin in 19 ofl 21
a
no statistically significant difference
in detecting abnormal arteries between CTA and
ri
te
DSA (P 0.05). All of theafeeding
arteries were treated by interventional methods and
M time was shortened guided by the information of CTA. In
the interventional treatment
the reexamined CTA
Noimages, the abnormal arteries were seen embolised.
Conclusion: From the comparative study between CTA and DSA on examination
of hemoptysis patients, it was proved that CTA had a high sensitivity in revealing
the feeding arteries. It can help doctors to make more confirmable diagnosis and
to promote the success rate of the operation.
C-267
Thoracic vascular anomalies detected on CT scan: A pictorial review
Y. Kim, S. Song, O. Woo, H. Yong, E.-Y. Kang; Seoul/KR ([email protected])
Learning Objectives: 1. To discuss embryogenesis of vascular structures in thorax.
2. To classify developmental vascular anomalies detected on thoracic CT scan.
3. To recognize the imaging characteristics of pulmonary and systemic vascular
anomalies in adult.
Background: Various congenital anomalies may affect the pulmonary and systemic
vessels in adult thorax. These are usually found incidentally at chest radiography
or CT. An awareness of various pulmonary and systemic vascular anomalies can
be helpful for making precise diagnosis.
Procedure Details: 1. Embryology of thoracic vessels 2. Incidence and category of
developmental vascular anomalies in thorax. 3. Imaging characteristics of pulmonary
and systemic vascular anomalies.
Conclusion: An awareness of various pulmonary and systemic vascular anomalies
can be helpful for making precise diagnosis.
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Systemic arterial supply to the lung
P. Serrano Gotarredona, S. Navarro Herrero, E. Merchante García,
J. Manzanares Vargas, B. Sobrino Guijarro; Seville/ES ([email protected])
When to suspect pulmonary vasculitis: Radiologic and clinical clues
A. Alguersuari1, E. Castaner1, E. Ballesteros1, M. Andreu1, X. Gallardo1,
Y. Pallardo2, J.M. Mata1; 1Sabadell/ES, 2Alzira/ES ([email protected])
Learning Objectives: To review the causes of diffuse pulmonary hemorrhage
and the types of vasculitis that most frequently affects the respiratory system. To
familiarize radiologists with CT findings and clinical features that can help in the
differential diagnosis.
Background: The diagnosis and management of a systemic vasculitis affecting
the lungs is difficult. The vasculitis are rare and their signs and symptoms are nonspecific. Although the clinical presentation can be highly variable, the identification
of particular combinations of findings (radiological and clinical) should suggest the
possibility of vasculitis.
Procedure Details: We reviewed the CT findings and clinical features of 35 patients
with pulmonary vasculitis. We classified vasculitis in: 1) Small-vessel (ANCA-associated Wegener granulomatosis, microscopic polyangiitis, Churg-Strauss Syndrome).
2) Medium vessel (polyarteritis nodosa). 3) Large-vessel (Takayasu, Behçet). 4)
Primary immune complex-mediated vasculitis. 5) Secondary vasculitis (systemic
lupus erythematosus). We classified radiological findings in: 1) Pulmonary signs:
cavitary or nodular disease; infiltrates (consolidation, ground-glass); centrilobular
nodules; bronchial disease; 2) Vascular signs: vessel wall thickening; aneurysm;
stenosis; pulmonary hypertension. We will also review the clinical scenarios suggestive of vasculitis (i.e. sinous troubles, mononeuritis).
Conclusion: The diagnosis of vasculitis is often delayed because a number of other
disorders can mimic the clinical manifestations. CT is valuable in the non-invasive
diagnosis of patients with pulmonary vasculitis; certain CT signs in combination
with clinical features enable an earlier diagnosis.
C-270
Does widening of coronary sinus indicate right ventricular dysfunction
in patients with acute pulmonary embolism assessed with multislice
computed tomography?
G.J. Staskiewicz, E. Czekajska-Chehab, J. Przegalinski, A. Tomaszewski,
S. Uhlig, K. Torres, A. Torres, A. Drop; Lublin/PL
([email protected])
Purpose: Right ventricular dysfunction (RVD) may occur in the course of acute
pulmonary embolism (PE). Patients with RVD need more intensive treatment, and
the prognosis is more severe. Radiological parameters of RVD assessed in MSCT
are not satisfactory at present. The aim of the study was to evaluate usefulness
of measurement of coronary sinus (CS) in assessment of RVD in patients with
acute PE.
Scientific and Educational Exhibits
Methods and Materials: Retrospective assessment of 55 MSCTPA examinations
with signs of acute PE (8- and 64-row scanner) was performed. Quantification of
pulmonary vascular obstruction was performed according to Mastora et al. Pulmonary artery systolic pressure (PASP) was echocardiographically assessed in
all patients. Width of CS was measured in axial plane in a standardized location.
Specificity and sensitivity of CS measurement were calculated.
Results: Median width of CS in patients with increased PASP was 16 mm (range: 12
- 24 mm) and 10 mm (range: 7 - 22 mm) in patients with normal PASP (p=0.001). Best
cutoff value was assessed at 12.5 mm, with sensitivity of 0.94 and specificity of 0.75.
Conclusion: Width of CS seems to be a promising parameter for identification of
RVD in patients with acute PE. A prospective study of this parameter should be
undertaken to further assess its accuracy.
C-271
Clot burden score at CT angiography predicts short-term mortality risk
after acute pulmonary embolism
E. Kamel, E. Rizzo, G. Adler-Etechami, P. Schnyder, S. Qanadli; Lausanne/CH
([email protected])
Purpose: To investigate the potential prognostic value of quantifying the clot burden
at CT angiography in patients with acute pulmonary embolism (PE).
Methods and Materials: Six hundred ninety patients were enrolled. For each
patient, the arterial obstruction index (OI) was quantified. Three month mortality
rate was requested for the entire study population that was sub-divided into 2
groups according to the presence (group A) or absence (group B) of pre-existing
cardiopulmonary diseases (CPD). A threshold value of 40% for the arterial OI was
set to stratify patients into high (r40%) or low ( 40%) risk; then, mortality rates
were compared accordingly for both groups.
Results: The mean arterial OI for the whole study cohort was 23p19% (range, 2.5
to 67.5%). Mortality rate at 3 month was 5% (34/690 patients). Of those 34 patients,
19 (56%) were in group A, whereas, 15 (44%) belonged to group B. Arterial OI
threshold of 40% failed to predict the risk of mortality from acute PE in group A
patients since 16 (84%) out of 19 deaths occurred in patients with a relatively low
( 40%) arterial OI. On the other hand, there was a significant difference of mortality
risk between group B patients who had high (10 deaths) and those who presented
with relatively lower (5 deaths) arterial OI.
Conclusion: In patients without pre-existing CPD, quantifying the clot burden
upon CT angiography has the potential to predict the risk of short-term mortality
from acute PE.
C-272
CT pulmonary angiography for evaluation of pulmonary embolus in
patients with elevated BMI: Predicting and preparing for the “habituslimited” study based upon evaluation of body mass index
S.M. Brannan, V. Ramakrishnan, N. Naveed, M.A. Berner, Q.A. Rao,
S.C. Williams, G. Marinan; Bridgeport, CT/US ([email protected])
C-273
Robust modeling of time intensity curves
A. Maciak1, D. Mayer2, A. Kronfeld1, K. Mayer-Wiethe3, G. Seidel3, T. Vomweg2;
1
Mainz/DE, 2Ingelheim/DE, 3Lübeck/DE ([email protected])
Purpose: This abstract shows a robust and fast method of describing TICs in
utrasound-based BHI and CE-MRI based on a physical model. The model has similar
robust properties to a gamma-variate function, but an accurate bolus flow shape.
Methods and Materials: The model is based on the physical behavior of bolus
fluids. It is data driven and does not require any further knowledge about tissue
compartments. It describes pharmacokinetics qualitatively. The model consists of
three parts. The first one describes the signal baseline and the second parameter
describes the uptake behavior of the contrast agents by a logistic function. The third
parameter gives the wash-out characteristic by an exponential term.
Results: The model has been validated in two different types of clinical settings.
Perfusion sonography is heavily affected by noise, movement and low SNR. The
model substituted a gamma variate function in a software system for automatically
detecting perfusion reduced brain tissue. This setting was validated on 26 patients.
In MR-mammography the challenges are to describe the uptake and washout of
contrast agents with few data points. In this setting, the model has substituted a
two-compartment model. This setting was validated on 142 patients. The Akaikeinformation-criterion has shown an improvement in modeling TICs comparing to
gamma-variate functions.
Conclusion: The advantages of the presented model are the simplicity, the behavior
of modeling TICs having only very few data and the models accuracy even if the
data is strongly affected by noise. The model can be computed very fast and gives
a robust estimation of the kinetic of contrast agents.
C-274
“Virtual projection radiography”: A novel teaching tool to improve
understanding of radiology basics
C. von Falck, T. Rodt, S. Waldeck, M. Galanski, H.-O. Shin; Hannover/DE
([email protected])
Learning Objectives: To demonstrate a novel teaching tool for improved understanding of projection effects based on post-processed CT-datasets.
Background: The accurate interpretation of plain-film radiographs demands not
only a profound knowledge of normal anatomy and typical pathologic changes but
also a conceptional understanding of projection effects. In radiological student and
resident education, direct correlation of plain-film radiographs and cross-sectional
images in the same patient is helpful to facilitate the understanding of basic projection principles. Based on this cross-modality teaching approach, we propose
the use of “virtual projection radiographs” based on post-processed CT datasets.
These virtual radiographs are interactively created in a step-by-step approach and
thus help to develop a conceptional model of image generation. In this exhibit, we
illustrate the possible use of this technique in the various pathologies of the chest,
the wrist and the ankle.
Procedure Details: The CT datasets were retrospectively chosen from the hospital’s
PACS archive. CT scans were acquired on a 64-slice MDCT (GE Lightspeed VCT)
with a slice collimation of 0.625-1.25 mm. “Virtual projection radiography” images
were interactively created using thick-slab and ray-sum post-processing techniques
on a dedicated multi-modality workstation (GE Advantage Workstation 4.4). The
CT datasets were aligned according to the standard radiographic projections and
the “virtual radiographs” were created step-by-step. For evaluation purposes, the
resulting images were compared to true radiographs of the same patient.
Conclusion: Post-processing of CT-datasets using thick-slab techniques can be
readily applied to create “virtual radiographs” that facilitate the understanding of
projection effects.
C-275
Development of software for automatic measurement of Cobb angle and
quantitative assessment method for follow-up in radiographs of patients
with scoliosis
E. Omoto1, O. Wakamatsu1, S. Sanada2; 1Tokyo/JP, 2Kanazawa/JP
([email protected])
Purpose: Cobb’s method is a standard technique for measurement of the degree
of scoliotic curvature in patients with scoliosis. However, some error is introduced
in the manual procedure. Cobb’s method and observation of the whole-spine morphology are required at periodic follow-ups. In the present study, we developed
a computer-aided algorithm for automatic measurement of the Cobb angle and a
method for quantitative assessment of radiographs.
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Purpose: CTPA for evaluation of pulmonary embolism is frequently limited in obese
patients, due to issues of beam attenuation and scatter. Using chart review, we
attempted to determine a cut-off range of body mass index at or above which the
effects of scatter and attenuation render the diagnostic utility of standard protocol
CTPA predictably limited.
Methods and Materials: Charts of 1000 recent CTPA studies were reviewed.
BMI was calculated based on admission height and weight. Those with BMI 25
were excluded. Studies limited by technical factors other than beam attenuation
and scatter were excluded. Final study group comprised 208 patients (BMI 25-46).
Reports and images for the 208 study members were reviewed by two BC radiologists, blinded to BMI calculations.
Results: Patients with BMI 38 were more likely to have an exam interpreted as
"habitus-limited" than those patients with BMI 38 (odds ratio = 12). Beginning at
BMI 34, there is a direct relationship between increased BMI and risk of "habituslimited" interpretation.
Conclusion: CTPA for evaluation of pulmonary embolism utilizing standard imaging
protocol in our institution is frequently limited in obese patients. Standard protocol
CTPA studies performed on patients with a body mass index 38 have a high likelihood of "habitus-limited" interpretation, which may result in subsequent utilization
of alternative diagnostic modalities. Clinical application: establish a BMI at which
modifications to standard protocol must be made to optimize CTPA. Assist referring
physicians to optimize diagnostic algorithm for PE in morbidly obese patients and
manage expectations for CTPA in the morbidly obese.
Computer Applications
Scientific and Educational Exhibits
Methods and Materials: In manual analysis, the Cobb angle was measured as
the degree of scoliotic curvature in original images. In automatic analysis, the
original images were processed by median filter, Gaussian filter, subtraction and
binarisation. Automatic measurement of the Cobb angle was performed using a
fourth-order multinomial equation. In addition, the whole-spine morphology curve
was obtained by connecting the central point of the adjacent spine in the processed
image for observation of interval changes on whole-spine radiographs in ten patients.
To avoid positional changes of the spine induced by tilting, Y-axis adjustment of
the curve was performed.
Results: A good correlation (r=0.9724, P 0.01) between the manual and automatic measurements was found, especially in the processed images. In the ten
patients, the interval changes were observed quantitatively by superimposition of
each whole-spine morphology curve.
Conclusion: Computer-aided automatic measurement of the Cobb angle is a reliable method for clinical evaluation of patients with scoliosis, and the whole-spine
morphology curve is useful for quantitative observation of interval changes.
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www.PubmedReader.com: A custom-defined tool for instant literature
updates
R. Talanow1, I. Timofte2, F. Giesel3; 1Cleveland, OH/US, 2East Cleveland, OH/US,
3
Heidelberg/DE ([email protected])
Learning Objectives: To provide a program that provides immediate and easy
access from PubMed to specific medical topics, independent from location, and
without the need to redefine search criteria repeatedly to accelerate the physician’s
workflow in research and daily work.
Background: PubMed is the most used literature database for researching newest
knowledge in Medicine. However, it does not provide the possibility to customize
the search to the individual user’s needs.
Procedure Details: The information is obtained via RSS feed on-the-fly from the
PubMed database and provided to the user as HTML code in the form of a customdefined website. The user may create multiple search criteria and save them in a
personal profile. The inividualized information is stored on the server. The program
may be used in different modes for a broad overlook about all defined search criteria
with access to the PubMed information and another mode for on-the-fly access
to the information directly from the user’s computer. By using the latter mode, the
user receives an instant access to custom defined search criteria with literally a
click of the mouse.
Conclusion: This web-based program provides PubMed information to specific
medical topics on-the-fly without need for reentering frequent search criteria. It
offers individualized user accounts, easy to use and is free of charge. The user
stays always up-to-date and by individualization of the search criteria, access and
layout of information presentation, the user is provided with a flexible and practical
tool to facilitate the physician’s workflow in research and daily work.
C-277
RadLex for dummies: A how-to tutorial and practical example for
integrating RadLex for individual needs
R. Talanow; Cleveland, OH/US ([email protected])
Learning Objectives: To provide a tutorial for even less computer experienced
users to understand how to implement a RadLex interface for individual purposes
such as integration into websites.
Background: RadLex is a lexicon for uniform indexing and retrieval of radiology
information resources. It offers users and developers to share the information via
several ways. One way is the possibility to retrieve the information directly from the
user’s website. However, for less computer experienced users this may become
a difficult task to perform.
Procedure Details: We provide a tutorial on how to create an interface to use the
RadLex information from the user’s own website. Step by step, the tutorial explains
the requirements that are needed to perform this task and explains the individual
steps with explanatory text and images. This tutorial demonstrates also a working
and useful example. After this tutorial, even a not well experienced computer user
should be able to integrate a RadLex interface into the own website.
Conclusion: This tutorial explains in an - even for a less computer experienced
user - understandable way how to create a working RadLex interface for individual
purposes such as integrating into the own website.
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C-278
Evaluation of availability of radiology e-learning material in the internet
and concepts for improvement
R. Talanow1, D. Ketelsen2, M. Grunewald3; 1Cleveland, OH/US, 2Tübingen/DE,
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Erlangen/DE ([email protected])
Learning Objectives: The aim of the study was to analyze the availability of published radiological e-learning tools and to find solutions for quality assurance.
Background: Multiple (not) peer-reviewed websites exist, which offer links to online radiologic-educational material. However, not uncommonly, websites change
location, contents or shut down completely. Consequently, these link lists contain
increasingly dead links, which deteriorate the value of these resource link lists.
Procedure Details: Two educational resource link databases were evaluated (Compare, n=435 links and TNT-Radiology, n=1078 links). 56.4% (102/181) of links were
accessible. A subgroup analysis of programs published 5 to 8 years ago showed
significantly inferior availability to programs published 3 to 5 years ago (p 0.01).
The analysis of external links showed between 49.2 and 61.0% accessible links.
As a consequence, a solution is needed, which allows near-automatic evaluation
and control of existence and quality of educational resources. Authors should be
able to submit their educational programs and users themselves should be able to
evaluate these programs depending on several criteria including existence of the
links. Furthermore, the program has to check validity of resources to guarantee
high quality and reliability of the provided resources.
Conclusion: More than 50% of investigated radiological e-learning tools on the
Internet were not accessible after a period of 5 to 8 years. It is not feasible for single
providers of educational resource lists to guarantee the availability of the links. As
a consequence, an independent and peer-reviewed tool for quality assurance is
necessary to shift this responsibility to the users themselves.
C-279
Three radiology workflow changes over three years and the resultant
radiology report turnaround times (RTAT)
M.M. Conlon1, M. Mc Entee2; 1Galway/IE, 2Dublin/IE
([email protected])
Purpose: This study investigates the effects of outsourced transcription, paper
request scanning and voice recognition on report turnaround times (RTAT) in a
radiology department over a 3 year period.
Methods and Materials: A customised report named ‘Elapsed times report’
extracted study data from the RIS. This report captured significant times in the
reporting process. Each workflow change resulted in a new phase and data for
each of the 4 phases was analysed using a student t-test.
Results: In phase 1, radiology reports were typed in-house and the RTAT was
22:33:49 hours (SD 38:51 Hrs). A change to outsourced transcription in Phase 2
resulted in a RTAT of 95:58:40 hours (SD 108:19 Hrs). In Phase 3, all requests
were scanned to PACS (picture archive and communication system) and RTAT was
62:59:17 hours (SD 51:26 Hrs). Phase 4 introduced VR (voice recognition) and
saw a decrease in RTAT to 10:09 hrs (SD 8:51 Hrs).
Conclusion: Outsourcing of report transcription resulted in an increase of +325%
in the RTAT as it increased the times taken to input draft reports and the time taken
for radiologists to sign reports. The scanning of paper request saw a decrease
in the RTAT (pb 0.001). The RTAT was decreased by 45% on the original RTAT
following implementation of voice recognition. In phase 4, radiologists generate
and sign reports concurrently thus eliminating the elapsed time between draft
and signed states. Of the three workflow changes, VR had the greatest positive
impact on RTAT.
C-280
Computer-aided-diagnosis (CAD) for brain, breast, and eye diseases: Three
‘knowledge cluster’ projects in Japan
H. Fujita1, G.N. Lee1, Y. Uchiyama1, D. Fukuoka1, Y. Hatanaka2, T. Hara1, Y. Ikedo1,
C. Muramatsu1, T. Morita3, T. Endo3; 1Gifu City/JP, 2Shiga/JP, 3Aichi/JP
([email protected])
Learning Objectives: To introduce 3 CAD systems that are dedicated to: (a)
brain MRI for the detection of cerebral diseases; (b) breast ultrasound for women
with dense breast; (c) retinal fundus images for the early detection of some ocular
diseases.
Background: The above 3 CAD projects are part of the ‘Knowledge Cluster
Initiative’ project, which is a national wide, multi-project, multi-center initiative by
the Japanese government. The projects emerged as a respond to the Japanese
health care needs.
Scientific and Educational Exhibits
Procedure Details: The following three CAD systems are presented: (1) The brain
CAD system detects cerebral vascular diseases on MRI images featuring the novel
selMIP technique; recognition of the eight neuro arteries; and diagnosis of unruptured aneurysm, arterial occlusion and lucunar infarct. (2) The breast CAD system
detects breast cancer on 3D full-breast ultrasound images acquired with the use of
a prototype scanner. (3) The eye CAD system detects ocular diseases on retinal
fundus images, which enables diagnosis of glaucoma with stereo imaging.
Conclusion: Three CAD systems for the Japanese health-care needs are introduced with the following features: (1) novel selMIP introduced in the brain CAD
system, which enables the visualization of interested-vessels-only and facilitates
the diagnosis of many cerebral vascular diseases; (2) 3D full-breast ultrasound
data in the breast cancer CAD system, which enables breast ultrasound screening;
(3) stereo images and 3D analysis of the optic nerve head, which improves the
accuracy in glaucoma diagnosis.
C-281
E-NUCS: Online evaluation and skills development in nuclear medicine
with a focus on hybrid modalities such as PET/CT and SPECT/CT
M. Grunewald1, R. Talanow2, R. Heckemann3, D. Ketelsen4, M. Middendorp5,
T. Kuwert1; 1Erlangen/DE, 2Cleveland, OH/US, 3London/UK, 4Tübingen/DE,
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Frankfurt/DE ([email protected])
Learning Objectives: Creation of an internet resource of cases and assessment
tools in nuclear medicine, with a focus on hybrid modalities including PET-CT and
SPECT-CT.
Background: Case reports were selected for educational value as part of the reporting routine and entered into a database structured by modality, pathological entity and
anatomical region. Cases are presented as multiple choice questions with brief clinical
information and three or more images. Answer choices vary according to three levels
of difficulty, targeting senior undergraduates, junior residents in nuclear medicine, and
certified nuclear medicine/radiology practitioners, respectively. Configurable time limits
simulate realistic pressure. In addition to in-house cases, teaching cases published
elsewhere were added with authors’ permission. Hyperlinks lead to explanations on
the originating sites and to other sources of relevant in-depth material.
Procedure Details: Approximately 500 cases have been peer-reviewed and published in E-NUCS. Learners can choose between a textbook learning mode and a
quiz mode. After solving a block of 5, 10 or 20 questions, brief explanatory notes
are presented for each case. A full history of users’ answers and performance is
gathered for later analysis and plotting as “learning curves”.
Conclusion: E-NUCS (http://nuk.elera.de/) combines existing teaching and learning resources from the internet with cases collected at our institution and presents
them in a multifunctional fashion, emphasizing hybrid modalities and addressing
learners of various experience levels and disciplines. Learners can assess their
own and others’ expertise in nuclear medicine and plot learning curves that evaluate their progress.
C-282
Public web-version of an anatomical-radiological structured database for
standard values in structured reporting
M. Simon1, A. Bischof1, K. Ziehe2, J. Klueter1, J. Barkhausen1; 1Lübeck/DE,
2
Rostock/DE ([email protected])
Semi-automated assistant system of chest CT diagnosis using contentbased retrieval of CT images with structured report
M. Endo1, A. Osawa2; 1Shizuoka/JP, 2Tokyo/JP ([email protected])
Purpose: To evaluate the system that assists a radiologist in the diagnosis of chest
CT, using content-based retrieval of CT images with structured report.
Methods and Materials: With the approval of the IRB, we prepared a server client
system with a database containing 247 lung cancers and 60 pulmonary inflammations, each consisting of CT images, structured radiologic diagnostic reports
and definitive diagnosis based on pathology and/or clinical follow-up. This system
automatically calculates quantitative characteristics of the lesion when a radiologist
clicks on an abnormal pulmonary lesion on CT images, and retrieves CT images
of four cases most similar to it. And then the system semi-automatically creates a
new diagnostic report using the structured report of the most closely matched CT
image selected by the radiologist in four cases. One radiologist read 30 cases (23
lung cancers and 7 inflammations) and evaluated the accuracy rate of differential
diagnosis, confidence of malignant/benign discrimination, and report creation time
with or without our system.
Results: The accuracy rate of differential diagnosis changed from 86.7 (26/30)
to 90.0% (27/30) with the use of this system. Az value of malignant/benign differentiation had no significant difference. Furthermore, the radiologist required
less time to create the 27 reports, (average time 106.9 sec) compared to without
the system (142.2 sec).
Conclusion: We have considered that this system is clinically useful as it reduces
report creation time without compromising accuracy of image diagnosis or confidence and improves the efficiency of radiologist workflow.
C-284
A new image processing filter for the automatic extraction of organs’
internal structures: Application to liver tumors
F. Pizzorni Ferrarese1, N. Moretto1, D. Botturi1, A. Choudhary2, G.A. Zamboni1;
1
Verona/IT, 2Kharagpur/IN ([email protected])
Purpose: To propose a new image filter for the detection and extraction of the
internal structure of organs from liver CTs, and to assess its accuracy.
Methods and Materials: Our approach is based on automatic multi-thresholding
of images obtained through the minimization of the relative entropy between the
original and the thresholded image, i.e., the system extracts only the structures
that convey information, maintaining the overall content. We applied the proposed
filter on 10 CT datasets with 20 metastatic lesions to be segmented.
Results: We evaluated filter accuracy by comparing the segmentation results with
the manual segmentation by 2 experienced radiologists. We used state-of-the-art
image processing filters evaluation parameters, analyzing both volume and surface
differences, errors and mismatches. The filter is capable to accurately extract both
hypo- and hyper-attenuating lesions. From the quantitative analysis, the accuracy
is greater (84%, with 9.52% of volume difference and 0.77 mm of average surface
distance between the segmented region and the gold standard) for homogeneous
and small tumors ( 3 cm), whereas for larger tumors the accuracy is lower (70%)
mainly due to their wider range of attenuation.
Conclusion: We developed a new filter that extracts both hypo- and hyperattenuating tumors using minimum cross entropy multi-thresholding. Since multithresholding techniques could be computationally expensive, we will optimize our
system using genetic algorithms. We are investigating the use of textures modeling
to better discriminate the liver from other organs. Furthermore, we are currently
studying the application of our approach to the segmentation of other abdominal
structures, such as the pancreas.
C-285
Computer-aided detection (CAD) applied to chest X-rays: Radiologic
characterization of false positive markers
A. Malich1, M. Klima1, D. Hentrich1, P. Hannemann2; 1Nordhausen/DE, 2Neustadt/DE
([email protected])
Purpose: Recently, CAD-systems were developed to analyze conventional chest
X-ray being the most common imaging performed to detect lung cancer. Its clinical application is limited by the number of false positives (FP)/image. The study is
aimed to characterize FP and their most characteristic locations.
Methods and Materials: X-rays from 205 patients (171 malignant cases, 23 proven
benign cases, 11 CT-proven unsuspicious cases) were retrospectively analyzed
by CAD (OnGuard™Europe4.0, Riverain, USA). CAD-marks were matched to CT/
histology in consensus by two radiologists. Analysis included total number of placed
markers and characteristics of FP and its location.
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Learning Objectives: It can be difficult for radiologists to determine whether anatomical structures are normal, anatomical variations, or pathological. The result is
often an inconclusive report providing a non-specific finding.
Background: We consider it essential to have a reference database accessible
whilst report writing in order to identify whether a finding is normal, a variation
or pathological. A comprehensive literature and internet search could not offer
complete papers addressing standard values. Only individual regions or organs
were discussed and available overviews did not confirm the origin and validity of
the value or they originate from the early time of diagnostics.
Procedure Details: The “iQ-ANATOMY” database is PostgreSQL based and
available in German and English; access without registration. The web-database
can search for anatomical patterns structured by region or functionality as well as
regions based on CT/MRI and US examination. The user-friendly search criteria
make finding any value easy, e.g. “Show all standard values for CT Abdomen”. All
values reference original literature and where available, information pertaining to
patient numbers, age and sex variations and the range is also provided. Currently,
it contains around 450 referenced standard values. The application is available via
our intranet and offers all departments involved in diagnostic imaging a quick tool
assisting in the decision of whether a finding is normal or abnormal.
Conclusion: By using the web-database, we significantly improved the quality of
radiology reports and assist radiologists in providing more definite findings and
conclusions. The public web-version will be available in 2009.
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Scientific and Educational Exhibits
Results: 541/777 set markers (69.6%) were FP. 146/171 (85.4%) conventionally
detected malignant cases were correctly highlighted by CAD (some BC were
highlighted more than once). Most common FP-markers were on vessels (218/541;
40.3%), bone crossings (140/541; 25.9%) and hilar structures (75/541; 13.9%).
Pneumonic structures were highlighted 9 times, periphrenic structures 22 times,
hypoventilated areas 38 times, external materials 11 times, whereas nipple was
wrongly highlighted 9 times, effusion 3 times. Other FP were uncharacteristic
and occasionally off the thorax. Most common FP-location were bone crossings
of the clavicle, hilar/perihilar region ( 75%). Detection rate was nearly perfect in
peripheral nodules sized 15 mm. The FP-rate varied (malignant: 2.57/image;
benign: 3.13/image).
Conclusion: Among those nodules of conventional imaging being visible, CAD
detected a sufficiently high number to be clinically useful. The detection of nodules
in the lung periphery is highly sensitive and sufficiently specific using CAD. Further
software upgrades should focus on a reduction of FP-markers especially on vessels and bone crossings.
C-286
CT based texture analysis of the lung parenchyma
W. Recheis1, R. Huttary1, A. Ruiu2, N. Sverzellati2, M. Zompatori2, W. Jaschke1;
1
Innsbruck/AT, 2Parma/IT ([email protected])
Purpose: Texture analysis of the lung parenchyma, based on CT imagery, is a new
method to detect and quantify various disease patterns. The purpose of this study
was to test whether texture analysis based software can discriminate between
multiple pulmonary patterns occurring in the main interstitial lung diseases.
Methods and Materials: Two experienced thoracic radiologists retrospectively and independently analyzed 25 thorax CT datasets (0.5 mm slice thickness, low-dose protocol,
native, Siemens Sensation 64, 17 male, 8 female, 52 p 11.7 years) with different lung
diseases such as emphysema and fibrotic interstitial lung disease. Subsequently, the
same records were examined by the texture analysis algorithm 3D-AMFM (Adaptive
Multiple Feature Method, University of Iowa, Iowa City) concerning currently 4 diseasespecific pathological parenchymal textures (normal, groundglass, honeycombing,
emphysema, nodular). This system had been previously trained by the same radiologists
defining over 2000 regions of interest with specific pathologic patterns.
Results: 93% of known lung pathologies, measured in volumes of interest
(15x15x15 voxel), were clearly identified by the software. In 22 out of 25 cases,
texture analysis provided relevant additional information such as mixtures of
emphysema and ground glass opacity. In 5 cases, mixtures of honeycombing and
ground glass were clearly discriminated.
Conclusion: The mixtures of pathologies can be differentiated and were confirmed by a second analysis of the radiologists. The disadvantage of the method
presented is the absence of a “ground truth”. Nevertheless, the method seems
to be capable of being employed in the separation and differentiation of several
pathological patterns.
C-287
A new concept of interactive journal publication: The journal of radiology
case reports
R. Talanow; Cleveland, OH/US ([email protected])
Learning Objectives: To develop an interactive journal that is able to increase
the educational and practical value of case reports by resembling the “real life” at
the radiologist’s workstation.
Background: Traditionally, case reports provide only selected images, which demonstrate only the pathology or pertinent findings. This has limited educational and
practical value, because users only receive selected information and cannot “find
out” the answer on their own. It does not resemble the “real life” at the radiologist’s
workstation where the entire stack of images needs to be scrolled through and
the examiner has to find the pathology himself. Furthermore, scrolling through the
stack of images helps to obtain an overview of the entire environment, including
the anatomical relationship.
Procedure Details: The peer review and editorial process conforms to international standards of peer reviewed, scientific journals. Peer review is blinded and
exceptional by taking usually no more than 7 days. Each article receives a DOI
and is fully citable. Interactivity is unique and allows viewing the cases as seen on
workstations - with scroll functions and the ability to window and level. The articles
are available in multiple formats (Abstract, HTML, PDF, Interactive) to allow interactivity as well as printing as hardcopy. This journal is dedicated to radiology case
reports but also accepts review articles and original research.
Conclusion: The “Journal of Radiology Case Reports” (www.RadiologyCases.com)
is a new generation of interactive journals, which is dedicated to radiology case
reports and offers unique interactivity as known from radiological workstations.
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Guidelines for diagnostic imaging: The initiatives and the issues
M. Reed; Winnipeg, MB/CA ([email protected])
Learning Objectives: To familiarize radiologists with: 1. The reasons for diagnostic
imaging (DI) guidelines. 2. The available guidelines. 3. The issues related to DI
guidelines.
Background: The utilization of diagnostic imaging (DI) is increasing rapidly in many
countries, and there is growing concern that a significant number of DI studies
are not contributing to the management of patients. These inappropriate studies
often subject patients to unnecessary radiation. There may be unexpected findings
(incdentalomas) which subject patients to additional investigations. They also add
further strain to the already strained resources of many health care systems.
Procedure Details: In response to this situation several radiological associations,
including the Royal College of Radiologists, the American College of Radiology and
the Canadian Association of Radiologists, have developed guidelines for DI. Other
organizations are also developing DI guidelines, usually as part of clinical practice
guidelines. Although the development of guidelines for DI is essential, there are four
important issues related to their development: 1. Difficulties in finding the evidence
for evidence-based guidelines. 2. Fostering interspeciality collaboration, which is
essential for their development. 3. The development of two separate streams of DI
guidelines: guidelines incorporated into clinical practice guidelines and guidelines
produced by radiological societies and the necessity of merging these. 4. Their
implementation in a way that they will be used.
Conclusion: The development of guidelines is imperative to control the inappropriate use of DI. However, there are important issues related to their development.
Radiologists need to be aware of these and the available guidelines.
C-289
Computed radiography implementation: A statewide experience from
Australia
T.J. Oliver; Brisbane/AU ([email protected])
Purpose: Queensland Health (QH) provides public health services to a highly
decentralised population base across the state of Queensland. Medical imaging is
provided at 130 facilities; Licensed X-ray operators perform the image acquisition at
77 sites in rural and remote locations where there are no diagnostic radiographers
available. In July 2008, QH successfully completed the ‘j.net’ project and in doing
so became the first state health service in Australia to provide digital acquisition of
general radiographic examinations at all of its medical imaging facilities.
Methods and Materials: The aim of the j.net project was to establish a minimum
level of digital image capture and processing equipment at all 130 facilities. This
involved installation or upgrade of computed radiography (CR) equipment at a
total of 86 sites.
Results: The project was completed within the proposed timelines. A follow-up
survey of CR users indicated a high satisfaction rate (90% of respondents). This is a
reflection of the quality of the project processes and the attention paid to the change
management aspects associated with the introduction of this new technology.
Conclusion: Rural and remote image acquisition sites in QH are now well positioned to employ the advantages of the digital imaging paradigm. As QH’s Radiology Informatics Program continues to establish full wide area network connectivity
for these sites, all of QH’s image acquisition facilities will have equitable access
to specialist services and the consequent improvement to healthcare delivery for
their communities.
C-290
Efficiency of DICOM image compression algorithms for reducing file
transfer time for teleradiology
D. Ustyuzhanin, O. Pianykh, V.E. Sinitsyn, S. Ternovoy; Moscow/RU
([email protected])
Purpose: To assess applicability of ZIP, JPEG-LS, JPEG2000, JPEG image compression algorithms (time of image transfer, size of image files) for DICOM image
transfer in teleradiology.
Methods and Materials: Brain MR images of 30 patients with different pathologies (vascular white matter lesions, multiple sclerosis) were included in the study.
MRI scans of each patient contained 175 slices. Images were transferred via
the Internet (by DICOM protocol) between two medical centers in the same city
(Moscow). Internet speed at both sites was 2.8-3.0 Mbit/sec. Images of each patient were transferred 5 times with different compression algorithms integrated in
DICOM format (without compression, lossless ZIP, JPEG-LS, JPEG2000, JPEG).
Image quality loss for lossy JPEG-LS, JPEG2000, JPEG algorithms was chosen
to maintain diagnostic image quality.
Scientific and Educational Exhibits
Results: Use of lossless compression (ZIP) leads to 55% reduction of images
transfer time (203.1p6.9 vs. 92.4p2.2 sec) and 63% reduction of files size (63.2p0.1
vs. 23.7p0.4 MB). Lossy image compression algorithms provided shorter images
transfer times and decreased file size (66 and 74% for JPEG-LS, 69 and 81% for
JPEG-2000, 79 and 79% for JPEG, respectively). All differences were statistically
significant (p 0.01).
Conclusion: Using of lossless DICOM images compression (ZIP) algorithm allowed 2.2-fold reduction of image transfer time. Lossy compression algorithms
can provide shorter transfer time (3.0-4.7 fold) and can be used for slow satellite
Internet and transfer of large studies.
C-291
Advent of 3D printing based on MDCT data
P.M. Berman, J. Sosna; Jerusalem/IL ([email protected])
Learning Objectives: To introduce the concept of 3D printing in image postprocessing and to demonstrate useful applications for this technology.
Background: While 3D printing (3DP) is widely used in industrial design, it has
enjoyed only limited use in the medical field and in radiology. Despite having welldocumented benefits, certain technical and cost issues have effectively prevented
3DP from enjoying wider use. However, recent developments have paved the way
for 3DP to become a viable component in medical imaging.
Procedure Details: While standard imaging workflow consists of MDCT scanners
for the acquisition of source data and dedicated post-processing workstations for
generation of 2D and 3D reconstructions, we have added 3D printing capabilities for improved visualization of complex anatomical structures. The 3D printer
produces highly-accurate, physically three-dimensional plastic models that can
be held in one’s hands, examined from all angles, and even dissected. This allows
one to interact with imaging data in a way that was difficult, unlocking a wealth of
information that is contained in our everyday CT exams.
Conclusion: 3D printing is a compelling technology, which is now technically
feasible and has a potential role in state-of-the-art 3D visualization.
C-292
Custom implant design and surgical pre-planning using rapid prototyping
and anatomical models for the repair of orbital floor fractures
M.T. Elgalal, M. Kozakiewicz, M. Olszycki, B. Walkowiak, L. Stefanczyk; Lodz/PL
([email protected])
C-293
Semi-automated volumetric analysis of lymph nodes during follow-up
M. Fabel1, H. Bolte1, H. von Tengg-Kobligk2, L. Bornemann3, V. Dicken3,
B. Geisler3, J. Biederer1, M. Heller1; 1Kiel/DE, 2Heidelberg/DE, 3Bremen/DE
([email protected])
Purpose: Therapy monitoring in oncological patients requires accurate and reliable imaging and post-processing. RECIST criteria are the current standard for
therapy monitoring with inherent disadvantages. The aim of this study was to
compare semi-automated volumetric analysis of lymph node metastases during
follow-up to RECIST.
C-294
From DICOM to print: A guide to importing, converting, editing, annotating,
and exporting DICOM images to make them suitable for publication
G. Rajeswaran, N. Chew, D.R. Tsukagoshi, J.C. Healy, J.C. Lee; London/UK
([email protected])
Learning Objectives: To explain how to import and convert DICOM (Digital Imaging
and Communications in Medicine) images using the freely available OsiriX software
and how to edit and annotate these images to make them suitable for print using
Adobe Photoshop CS3 software.
Background: DICOM is the accepted standard file format for medical images. However, the majority of scientific journals require submitted images to be anonymised,
annotated and converted into a more widely accepted format such as TIFF or JPEG.
We explain how to do this using widely available software.
Procedure Details: Using OsiriX to: import and view DICOM files, convert (export)
DICOM files into a variety of image formats suitable for print (e.g. TIFF, JPEG, etc).
Using Adobe Photoshop CS3 to: crop the image to an appropriate size, Optimise
the colour balance, brightness and contrast for print, Annotate the image with text,
arrows, etc. Reconvert the image file into a format suitable for print.
Conclusion: We have shown the reader how to use widely available and commonly
used software to import, convert, edit, annotate and export a DICOM image into
an image format suitable for publication.
C-295
Integrating PACS, pathology findings, multidisciplinary team meetings and
digital patient management records as effective tools for problem based
learning in radiology
S. Krishan, R. Briggs, A. Chalmers, D. Tolan; Leeds/UK
([email protected])
Learning Objectives: 1. To learn how electronic patients records and multidisciplinary team (MDT) meetings can be integrated with radiopathologic correrelation
database. 2. To know the software and hardware components involved. 3. To be
aware of steps in implementation and potential hurdles in creating such a database.
4. To appreciate how effective PBL sessions can be created for radiology teaching
from such a database.
Background: Current trends in medical education focus on outcome and PBL as
a means to facilitate student learning. MDT meetings provide a wealth of training
to the radiology residents in clinico-pathological correrelation and clinically oriented
interpretation of imaging findings. We envisage integration of PACS, MDT meetings
and digital patient management records as a means for providing a teaching mine
for structured PBL modules in radiology.
Procedure Details: Simple data warehouse can be constructed using digital MDT reports,
PACS images and relevant digital patient management records using a combination open
source software, XML version of reports and MIRC software. Structured PBL sessions can
be created by retrieving cases using flexible queries. This can further be incorporated in
creating competency based assessment systems in radiology. We describe the design,
steps in implementation and potential hurdles in creating such a database.
Conclusion: Such systems have immense potential in providing a vast range of
clinicopathologically oriented radiological case material. PBL in radiology however
needs to be validated further before it can be universally adopted. Whether such
a database can replace or complement traditional time tested didactic teaching
remains to be seen.
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Computer Applications
Purpose: Orbital floor fractures are a common complication of facial trauma. Surgical repair is challenging due to complex anatomy of the orbit and limited operating
field. Rapid prototyping can provide virtual and physical anatomical models based
on MDCT imaging for accurate surgical pre-planning and fabrication of patient
specific 3 dimensional preformed implants.
Methods and Materials: 12 patients with facial trauma and orbital floor fractures
were included in the study. DICOM data sets from MDCT were prepared and exported
to specialist software. 3D virtual models of the unaffected orbit were created and
mirrored onto the contralateral side; producing models that represented premorbid
anatomy of the fractured orbit. Physical models were built using a photopolymer rapid
prototyping system and used as templates to cut and form standard titanium mesh,
creating implants with a 3 dimensional ‘true-to-original’ shape. Postoperatively, MDCT
was used to assess implant placement and orbital dimensions.
Results: Study group: 3 retreatments, 3 inveterate fractures, 6 acute fractures.
Significant improvement in four cases and total recovery in eight cases were
observed after surgery, on the basis of ortoptic examination. Pre-formed custom
implants accurately reflect the shape and dimensions of the orbital floor and
resulted in reduced operating times -15 to 20 min, less soft tissue manipulation,
fewer trial fittings, decreased likelihood of damaging intraorbital structures, more
precise fit and repair.
Conclusion: Rapid prototyping can be used to create accurate anatomical models
on the basis of CT imaging. The mirroring method is a valuable technique for creating templates used to fabricate custom implants.
Methods and Materials: Multislice-CT data were acquired in 50 patients with
malignant melanoma stage III/IV during follow-up covering chest, abdomen and
pelvis with thin-slice collimation in clinical routine. Volumetric analysis was performed
using semi-automated software (OncoTreat, MeVis Research, Germany). 174 lymph
node metastases were evaluated by two independent readers regarding manual
RECIST measurements and effective diameters (DM) (computed from volume (ml)
into mm to allow direct comparison to RECIST max. DM). Further segmentation
time, need for corrections and obtained quality were recorded.
Results: The software demonstrated feasibility of robust volumetric analysis for lymph
node metastases. Quality of segmentation was rated acceptable to excellent in ~85%
per reader. Time spent per lymph node (for search, segmentation, optional correction
and manual RECIST measurements) averaged ~40-60 sec. In 20%, manual corrections
were needed. In about 1 out of 5 cases, differences regarding therapy response classifications (partial response, progressive disease or stable disease) were found between
RECIST and volumetry. Tumor growth rate showed a significantly higher variation with
RECIST (27.5% standard deviation) than for volumetry (10.6%). Variability of the size
measurements was 0.94 mm for eff. DM and about 3 mm for max. DM.
Conclusion: Semi-automated 3D-volumetric analysis software allows a reliable,
fast and convenient segmentation of lymph node metastases during follow-up.
Scientific and Educational Exhibits
C-296
Contrast Media
Indexing of radiological reports: Moving the human-computer language
barrier
T. Voet, P. Devolder, P. Duyck; Gent/BE ([email protected])
Purpose: When using a computerised index of words originating from a large collection of radiological reports, users tend to encounter a human-computer language
barrier. This obstacle arises whenever a complex query cannot be adequately
formulated in the language required by the computer interface. This study seeks
to alleviate this interface problem.
Methods and Materials: Since its conception in 2004, the indexing system
developed at the Ghent University Hospital covers 130 million words originating from 2 million reports. The index contains 350,000 unique words and results
are typically returned within 31 ms. To counter the problems related to complex
queries, we educated the users regarding basic search engine features: word
grouping, wildcards, and binary logic. We also implemented word stemming in
four European languages, automatic rewriting of queries for common synonyms,
and contextual searching.
Results: Following education, users started to pick up search engine features:
phrases (3.0%), wildcards (2.9%), binary operator “and” (4.6%), “not” (1.7%), “or”
(1.2%), and parentheses (0.6%). Both the word stemming and the automatic inclusion of synonyms received positive feedback. However, only administrators used
contextual searching because of the composite syntax.
Conclusion: The search engine features we implemented helped to move the interface language barrier away from our users. These 45 radiologists and researchers
use the integrated indexing system on a daily basis as a convenient way of quickly
finding radiological studies.
C-297
Computer-aided diagnostic tools in cancer detection and therapy using
statistical modeling of normal torso FDG-PET scans
T. Hara1, T. Katafuchi2, S. Ito3, D. Fukuoka1, G.N. Lee1, T. Kobayashi1, X. Zhou1,
H. Fujita1, K. Doi4; 1Gifu/JP, 2Seki/JP, 3Ichinomiya/JP, 4Chicago, IL/US
Purpose: To develop an automated software to visualize the temporal changes of
SUV, and to provide the SUV score of abnormality based on 95% confidence interval
(CI) calculated by using normal FDG-PET scan cases for male and female.
Methods and Materials: FDG-PET scans (male: 143, female: 54) interpreted as
normal were collected to calculate the CI of SUV. For each male and female, the
torso regions were registered into one standard physique shape by using body
region recognition, liver and bladder detection. Surface deformation using thin-platespline was also applied to register the scans to the standard physique. The mean
and standard deviations of SUV in each voxel in the assembled normal scans were
stored as a three dimensional statistical model (3D-model). Current and previous
patient scans were registered to the 3D-model to calculate the score of SUV. The
score shows the distance from normal cases. Both of the difference of SUV and
the score were visualized in a color scale to show the changes.
Results: In a colon cancer case, for example, the current SUV was 1.57, but the
score using the 3D-model was 3.58. The abnormal accumulation was also verified
on the subtraction image. The means of SUVs from abnormal spots in lung and
liver are statistically different from the means of the corresponding regions in 3D
normal model by using the T-test (p 0.001).
Conclusion: Temporal subtraction and scoring approach has the potential to
greatly assist radiologists. We will begin a prospective clinical study for evaluating
the utility of the system developed.
C-298
Are radiologists ready to care for acutely ill patients? The standard of adult
CPR amongst UK radiologists
A.D. Culverwell1, C.R. Tapping2; 1Leeds/UK, 2Hull/UK
([email protected])
Purpose: To assess the attitudes and ability of radiologists to manage adult life
support in cardio-pulmonary arrest and acute anaphylaxis reactions.
Methods and Materials: A questionnaire survey assessing the knowledge and
confidence managing an adult cardio-respiratory arrest scenario was sent to 165
radiology consultants and registrars in 6 NHS trusts in Yorkshire, 106 participated.
The questionnaire included basic demographic details and 9 questions to assess
recent training, knowledge and confidence in adult resuscitation as per the Resuscitation Council (UK) 2005 guidelines and management of acute anaphylaxis.
Results: Despite the fact that 90% of participants stated they would feel confident
to initiate life support, the average score from the questions assessing life support
procedure was 2.3 out of 5, with only 13% of participants answering all questions
correctly. There was no correlation between the grade of radiologist and likelihood of
a correct answer, nor was there a correlation between feeling confident and knowing
the correct life support procedure. Flaws in training were highlighted with only 61%
of radiologists having attended a life support course in the last 4 years. Those who
had attended a course more recently were more likely to perform CPR correctly
(p=0.02). Individuals who were confident in initialising CPR were more likely to be
confident that other members of staff could assist them (p=0.028).
Conclusion: This study emphasises the need for regular life support training and
the need to alter the attitude of radiologists who must consider it their role to initiate
effective life support in the radiology environment.
C-299
Apoptotic and antiproliferative effects of the iso-osmolar contrast medium
iodixanol on renal proximal tubular cells in vitro
M.C. Heinrich, M. Scheer, M. Heckmann, M. Küfner, W. Bautz, M. Uder;
Erlangen/DE
Purpose: The mechanisms of contrast-medium-induced tubulotoxicity are incompletely understood. In particular, the tubulotoxic effects of iso-osmolar contrast
media, which were often used in patients at the highest risk of contrast-mediuminduced nephropathy, have barely been investigated. Thus, the aim of our study
was to evaluate the cytotoxic effects of iso-osmolar iodixanol on renal tubular cell
cultures.
Methods and Materials: LLC-PK1-cells (a well-established, proximal tubular
epithelial cell line) were incubated with iodixanol or isotonic NaCl (18.75-75 mg I/
ml, 1-24 hours). Necrotic cell death was assessed by trypan blue exclusion test.
The number of trypan-blue positive, non-viable cells was determined using a
hemocytometer. To assess apoptosis mono- and oligonucleosomes of cell lysates
were determined based on a quantitative sandwich-enzyme-immunoassay-principle
using monoclonal antibodies directed against DNA and histones. Measurement of
BrdU (5-bromo-2’-deoxyuridine) incorporation into the DNA by means of an ELISA
was used for quantification of cell proliferation.
Results: Iodixanol induced no significant increase in the number of necrotic cells
(8 and 9% at 37.5 and 75 mg I/ml vs. 8% for control, p 0.05). In contrast, iodixanol
increased significantly the number of oligonucleosomes indicating induction of
apoptosis (125p4% of control, p 0.05). Iodixanol induced a significant, dose- and
time-dependant inhibition of BrdU-incorporation indicating inhibition of cell proliferation (92p2 and 79p2% of control at 18.75 and 37.5 mg I/ml, p 0.001).
Conclusion: Apoptosis without significant necrosis contributes to the renal tubular
toxicity of iodixanol. Additionally, we demonstrated for the first time an antiproliferative effect of iodixanol on renal tubular cells.
C-300
Contrast induced nephropathy (CIN): Differences between isosmolar
(IOCM) and low osmolar contrast media (LOCM) in patients evaluated for
peripheral arterial occlusive disease (PAOD): A prospective multicenter
study
R.P. Karlsberg, S.Y. Dohad, V. Multicenter Group; Beverly Hills, CA/US
([email protected])
Purpose: To compare the incidence of CIN following administration of IOCM
(iodixanol-GE Healthcare, Princeton, NJ), versus LOCM (iopamidol-Bracco Diagnostics, Princeton, NJ; ioversol-Mallinckrodt, St. Louis, MO; iohexol-GE Healthcare,
Princeton, NJ; iopromide-Berlex, Montville, NJ).
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Methods and Materials: 253 patients (mean age: 64.4 p 10.8, 63.2% male)
underwent invasive digital subtraction angiography (DSA) for PAOD following
washout of 72 hours to 14 days after intravenous iodixanol (320 mg I/mL) computed tomography (CTA) of the abdominal aorta with runoff. Contrast agent for
DSA was each center's normal practice. Serum creatinine (SCr) levels at baseline
and 24 hours following DSA were measured. CIN was defined as a SCr increase
of r25% from baseline.
Results: 148 (58.5%) received IOCM and 105 (41.5%) LOCM (iopamidol 92
subjects, ioversol 8, iohexol 3, and iopromide 2). Baseline risk factors and average contrast dose and hydration protocols were comparable between the IOCM
and LOCM groups except for renal function: Prior to DSA, 8.1% IOCM patients
(12/148) versus 2.9% LOCM patients (3/105) had renal dysfunction ( 1.5 ml/dl).
Overall, 22 of 253 patients (8.7%) experienced CIN: 8 (8/148, 5.4%) from IOCM
and 14 (14/105, 13.3%) from LOCM. Of the 14 patients with CIN receiving LOCM,
13 had iopamidol and 1 had ioversol. CIN difference was statistically significant
between IOCM (iodixanol) and LOCM (p=0.027) and between IOCM (iodixanol)
and iopamidol (p=0.020).
Conclusion: In patients suspected of PAOD undergoing DSA after CTA, the
incidence of CIN was significantly less for patients who received IOCM for DSA
rather than LOCM.
C-301
Nephrogenic systemic fibrosis: A prospective follow-up methodology
for patients with suspected brain tumors and chronic kidney disease
undergoing MRI with gadolinium contrast agent
N.S. Mamilla palli1, M.J. Kuhn1, M. Minn1, K. Vallurupalli1, A.R. Kuhn2;
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Springfield, IL/US, 2Chicago, IL/US ([email protected])
Purpose: To evaluate the incidence of nephrogenic systemic fibrosis (NSF) in
patients with stages 3 to 5 chronic kidney disease (CKD) undergoing MRI with
gadobenate dimeglumine.
Methods and Materials: As part of a prospective multi-center study, patients
referred for MR neuroimaging with contrast were screened with a calculated
eGFR (MDRD method) from a serum creatinine value obtained within 24 hours
prior to MRI. Patients with eGFR 30-59 mL/min/1.73 m (2) were categorized as
cohort 1 and eGFR 30 mL/min/1.73 m (2) as cohort 2. Patients who received
any gadolinium agent within the previous year were excluded. Eligible patients
signed the informed consent and received 0.1 mmol/kg gadobenate dimeglumine
(MultiHance). Patients are followed up to two years with scheduled telephone calls
and office visits to evaluate for any signs of nephrogenic systemic fibrosis. A skin
biopsy by a dermatologist is part of the protocol for any suspected cases. To date,
we have enrolled 14 patients over 6 months at our site and enrolment is ongoing
at our center and other sites participating in this multi-center study.
Results: No confirmed cases of NSF have been seen so far in the group of 14
patients enrolled at our site. One patient was lost to follow-up and another patient
died of unrelated causes.
Conclusion: A prospective study to evaluate the incidence of NSF in patients
undergoing gadolinium enhanced MRI has not been previously accomplished. The
methodology of our study may serve as a model for other institutions.
C-302
Contrast enhanced harmonic sonography (CEUS) of focal liver lesions:
Discordant enhancement pattern with contrast enhanced MDCT and MR
P. Cabassa, E. Brunelli, S. Mombelloni, M. Narbone, E. Gatti, R. Maroldi; Brescia/IT
([email protected])
C-303
Comparison of intravenous (IV) isosmolar contrast (IOCM) vs. intraarterial
(IA) IOCM or low osmolar contrast media (LOCM): A prospective
multicenter trial
R.P. Karlsberg, S.V. Dohad, V. Multicenter Group; Beverly Hills, CA/US
([email protected])
Purpose: IV contrast administration differs from IA and may be further confounded
by the use of isosmolar (IOCM) or low osmolar contrast media (LOCM). We studied
the incidence of CIN following IV IOCM (iodixanol, 320 mg-I/m), for computed tomography (CTA) versus IA IOCM or IA LOCM for IA digital subtraction angiography
(DSA) in the same patient population.
Methods and Materials: First patients with suspected peripheral arterial occlusive
disease underwent CTA with IV IOCM. After 72 hours to 14 days, DSA was performed with contrast chosen by clinical practice. CIN was defined as SCr increase
r25% from baseline after 24 hours.
Results: 265 CTA patients (mean age: 64.7 p 10.9, 63.8% male) with IV IOCM and
253 DSA patients (mean age: 64.4 p 10.8, 63.2% male) with IA IOCM or IA LOCM
had complete SCr levels. Of the DSA patients, 148 (58.5%) received IA IOCM and
105 (41.5%) received IA LOCM (iopamidol, 92; ioversol, 8; iohexol, 3; iopromide
2). Contrast volume for CTA and DSA was comparable. CIN developed in 20 of
265 patients (7.5%) post-CTA and 22 of 253 patients (8.7%) post-DSA (p = NS).
Of those with CIN following DSA, 14 (14/105, 13.3%) received IA LOCM compared
to fewer patients (8/148, 5.4%) receiving IA IOCM (p=.027).
Conclusion: The incidence of CIN following CTA with IV IOCM was not statistically
different from that following DSA with IA administration of various contrast media.
However, when CIN occurred with DSA and IA administration of contrast it was
less frequent with IOCM.
C-304
Contrast-enhanced ultrasound (CE-US) of kidney transplantation and
correlation with clinical-laboratory data: Diagnosis of early renal allograft
dysfunction
N. Caproni, A. Grossi, I. Mancarella, P. D’Alimonte, G. Cappelli, P. Torricelli;
Modena/IT ([email protected])
Purpose: Compare CE-US with spectral-Doppler-US (sD-US), s-creatinine clearance level and GFR in the assessment renal graft function.
Methods and Materials: 56 renal transplanted patients (62 kidneys) underwent
s-creatinine (mg/dL) and GFR (ml/min) evaluation, CE-US and sD-US at day 15
post-transplant. At CE-US, it was quantitatively analyzed the CE peak intensity
(PI%) and the regional blood flow (RBF ml/sec). At sD-US, it was evaluated the
median resistance index (RI).
Results: 47 patients (52 kidneys) had an uneventful clinical course, 9 patients (10
kidneys) had acute renal rejection, confirmed by biopsy. In the control group, the
mean s-creatinine, GFR, PI, RBF and RI were 1.93, 58.9, 61.87, 80.45 and 0.78,
respectively. In the other 9 patients, the mean s-creatinine, GFR, PI, RBF and RI
were 5.34, 19.2, 40.16, 53.7 and 0.95. A high correlation was found between the
s-creatinine and PI and RBF both in the control group and in the reject group (r
=-0.478, p 0.001; r =-0.42, p 0.01; r =0.844, p 0.001; r =0.828, p 0.01).
There was high correlation between GFR and PI and RBF in the reject group (r
=-0.77, p 0.01; r =-0.78, p 0.01) and between GFR and PI in the control group
(r =0.32, p 0.5), but not between GFR and RBF. No correlation was found between IR e CE-US parameters. Significant correlation exists between s-creatinine
and RI (r =-0.67, p 0.05) and between GFR and IR (r =0.65, p 0.5) only in the
reject group, but not in the control group. The sensibility, specificity, accuracy and
predictive value negative (PVN) of PI and RBF was calculated (respectively, 90,
86, 86, 97% and 80, 86, 85, 95%).
Conclusion: CE-US allows the evaluation of renal transplanted perfusion, with
high accuracy and PVN. Clinical laboratory parameters correlate better with CE-US
parameters, especially in cases of acute rejection than with sD-US parameters.
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Contrast Media
Purpose: To evaluate frequency, type and possible causes of discordant enhancement patterns between CEUS and CT/MR during vascular phases.
Methods and Materials: From our database of focal liver lesions studied with
CEUS, we reviewed retrospectively 338 patients who underwent CEUS and at least
one cross sectional contrast enhanced imaging (CT or MR). CEUS was performed
with Sonovue at the standard dose of 2.4 ml with continuous real time scanning at
low mechanical index (0.1-0.2). Arterial, portal and late phases for each imaging
modality were assessed comparing the ecogenity/attenuation/intensity of the lesion
relatively to the adjacent liver. Final diagnosis was obtained histologically (surgical/
biopsy) or with clinical and imaging follow-up of at least 6 months.
Results: Final diagnosis was: 125 HCCs, 58 metastases, 20 colangiocarcinomas,
46 hemangiomas, 40 FNH and 49 others. 125/338 (36.9%) lesions showed discordance with CT or MR imaging. Discordant enhancement was found in: 73/125 HCC,
17/58 metastases, 19/20 colangiocarcinomas, 16/46 hemangiomas and 23/40 FNH.
Discordant pattern in portal phase was found especially in HCCs (63/73) result-
ing isoechoic at CEUS and hypodense on CT/RM. Discordant pattern in arterial
phase was more frequent for metastases (13/17). Possible explanations of these
findings are: 1. Microbubbles are purely intravascular agents; 2. Timing to peak of
enhancement can be missed with CT/MR, not with CEUS; 3. CEUS is extremely
sensible to depict micro and macrovasculature of focal lesions.
Conclusion: Discordances are relatively frequent; their recognition is useful for a
correct characterization of focal liver lesions.
Scientific and Educational Exhibits
C-305
C-307
Purpose: In order to detect the BOLD effect, T2*-sequences are used. Their limitations could be overcome by using a T1-sequence with the coincident intravenous
administration of a blood-pool contrast medium (cm). It has been shown in vessel
trials that gadofosveset significantly shortens relaxation values for a period of 4
hours (h). The aim of this study was to determine the optimal time point for the
dynamic T1 functional imaging.
Methods and Materials: For each of the 10 healthy subjects, T1 sensitive 3D
GR sequences were carried out (TR=8.5 ms/TE=3.14 ms/FA=10 deg) with forty
3 mm thick slices and 1.8 mm in plane resolution, immediately after administration (0.03 mmol/kg) of VASOVIST (Schering) and after 2, 4 and 6 h. Subjects
performed block type challenging paradigm with 30 finger tappings in 30 s length
‘on’ periods followed with this same length ‘off’ resting periods. Ten repetitions of
above conditions took 600 s giving as a result 100 volumes. SPM5 software was
used for statistical analysis.
Results: Exactly the same localization of activation areas was found in all subjects
in all examinations. The increase of the signal intensity in primary motor cortex
(hand knob) was determined using RFX group analysis: T-value (p 0.001) for the
right hand- 0 h-12.62, 2 h-8.82, 4 h-9.18, 6 h-7.8, for the left- 0 h-7.34, 2 h-7.14,
4 h- 8.34, 6 h- 7.23.
Conclusion: Dynamic T1 fMRI is a reliable and sensitive technique to detect
cortical activations in 6 h after the blood-pool agent administration. This technique
should be carried out directly after cm administration; however, it is possible to get
satisfactory results up to 4 h afterwards.
Purpose: Subcutaneous extravasation is a well-recognized complication of intravenous administration of iodinated contrast media. Local toxicity effects can range
from minor erythema and swelling to extensive tissue necrosis. The objective of this
presentation is to establish the frequency and clinical effects of extravasation of
iodinated contrast media related to mechanical power injection during CT exams.
Methods and Materials: During a 2-year period, 11,520 patients underwent
contrast media-enhanced CT studies at our institution. In all exams a mechanical
power injector was used for infusion of ionic and non-ionic iodinated contrast media
through a plastic cannula in an upper extremity.
Results: Extravasation was detected in 26 (0.2%) patients. Nineteen patients had
extravasation of less than 10 mL and only referred minor symptoms. Six patients
had extravasation of at least 30 mL, and referred mild to moderate pain, swelling,
erythema and skin changes at the injection site without severe or permanent effects.
One patient had a severely damaged with tissue necrosis that required surgical
intervention. The mean contrast media volume used per exam was of 105 mL.
The mean infusion rate was 2.6 mL/seg. The principal causes of extravasation
were noncommunicative patients (elderly, infants) and chronically ill patients with
debilitated veins. No correlation was found between amount of contrast media or
infusion rate and frequency of extravasation.
Conclusion: The frequency of extravasation of contrast media after mechanical
bolus injection is higher that reported for hand-injection, but similar to that of other
studies using power injectors. Adequate treatment should be applied to prevent
severe effects.
Dynamic T1 Functional MRI examinations with use of blood pool contrast
agent: An approach to optimization of the technique
A. Majos1, T. Wolak2, P. Bogorodzki2, E. Piatkowska-Janko2, L. Stefanczyk1;
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Lodz/PL, 2Warsaw/PL ([email protected])
C-306
Temporal aspects of contrast-induced nephropathy (CIN): Considerations
for future trials
C. Davidson1, W. Laskey2, M. Rudnick3, P. Sherwin4, J. Stafford5, G. Stevens6;
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Chicago, IL/US, 2Albuquerque, NM/US, 3Philadelphia, PA/US,
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Princeton, NJ/US, 5Baltimore, MD/US, 6Bastrop, TX/US ([email protected])
Purpose: Examine temporal aspects (time to onset; by-day incidence and prevalence; duration) of contrast-induced nephropathy (CIN; 0.5 mg/dL serum creatinine
(SCr) increase) in chronic kidney disease patients undergoing coronary angiography
randomized to low-osmolar (LOCM) or iso-osmolar (IOCM) contrast medium.
Methods and Materials: Post-hoc, hypothesis-generating analyses of data from the
68 CIN patients (23%, 68/299; 34/CM group) in a prospective double-blind CIN trial
(VALOR) comparing LOCM ioversol 320 mg-I/mL versus IOCM iodixanol 320 mg-I/
mL were conducted for: CIN incidence on days 1, 2, and 3 after administration; CIN
prevalence over 28 days (7 visits); and CIN duration.
Results: By-day CIN incidences overall and by CM (ioversol, iodixanol) were: day
1, 20 (29%) (13 [38%], 7 [21%]); day 2, 35 (51%) (15 [44%], 20 [59%]); day 3, 13
(19%) (6 [18%], 7 [21%]). CIN prevalence rose rapidly days 1 and 2 and peaked
on day 2 (iodixanol and overall) or 3 (ioversol). Numbers of subjects with CIN of
1, 2, and 3 days duration overall and by CM (ioversol, iodixanol) were: 1 day, 31
(46%) (13 [38%], 18 [53%]); 2 days, 26 (38%) (12 [35%], 14 [41%]); 3 days, 11
(16%) (9 [26%], 2 [6%]).
Conclusion: In this study CIN rates varied by day. This suggests that multiple
post-dose SCr assessments in clinical trials that investigate CIN will provide
greater accuracy in overall CIN reporting than trials that employ a single post-dose
measurement over a wide time period.
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Extravasation of iodinated contrast media in CT studies: Frequency and
effects
P. Carrascosa, J. Vallejos, C.M. Capuñay, E. Martin Lopez, J. Carrascosa;
San Isidro/AR
Scientific and Educational Exhibits
Genitourinary
Female
C-308
Magnetic resonance imaging of deep and visceral pelvic endometriosis:
Examination technique and imaging findings
G. Restaino, M. Missere, M. Ciuffreda, E. Cucci, M. Occhionero, G. Sallustio;
Campobasso/IT ([email protected])
Learning Objectives: MRI provides the best preoperative assessment of pelvic
endometriosis. MRI technique must be adapted to the typical appearance of the
disease, with emphasis on T1-W fat suppressed and on T2-W high resolution images. Typical MRI features are T1-hyperintensity with shading in T2-W images for
endometriomas and low-intermediate SI with regions of signal hyperintensity in
T1-W images and uniform low signal intensity on T2-W images for deep lesions.
Background: Endometriosis represents a common and important clinical problem
of childbearing age women. Accurate preoperative assessment of extension of
pelvic endometriosis is required for planning surgical excision, but is difficult with
physical examination. US lacks panoramic evaluation. Exploratory laparoscopy
cannot accurately demonstrate endometriotic lesions hidden by adhesions or
located in the subperitoneum.
Imaging Findings: The MRI findings in deep and visceral pelvic endometriosis
vary with the type of lesions: infiltrating small implants, solid deep lesions in the
anterior or posterior cul-de-sac and involving the uterosacral ligaments and torus
uterinus, ovarian or extraovarian endometrioma, visceral endometriosis involving
the bladder or sigmoid and rectal wall, laminar lesions, cystic lesions, complex
lesions and adhesions. Endometriomas show high SI at T1- and T2-W sequences
persisting at fat-suppressed T1-W images, often with gradual variation of SI at
T2-W images. Solid deep lesions show low to intermediate SI with punctate
regions of signal hyperintensity on T1-w images, uniform low signal intensity on
T2-W images, and enhancement, corresponding to the abundant fibrous tissue
seen in these lesions.
Conclusion: MRI provides best preoperative assessment of pelvic endometriosis.
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Imaging appearances of the post-operative and post-radiotherapy pelvis
H.C. Addley, A.H. Vargas, E. Sala; Cambridge/UK
([email protected])
MRI and CT findings after uterine fibroid embolization
S.K. Verma, D. Bergin, O.H. Baltarowich, C. Gonsalves, A.S. Lev-Toaff,
D.G. Mitchell; Philadelphia, PA/US ([email protected])
Learning Objectives: 1. To identify the spectrum of findings on magnetic resonance
imaging (MRI) and computed tomography (CT) of 74 women performed after uterine
fibroid embolization (UFE) 2. To illustrate UFE associated common and uncommon
MRI and CT appearances 3. To discuss post UFE complications that require urgent
medical or surgical intervention.
Background: UFE is an effective treatment for symptomatic uterine fibroids as a
good alternative to surgical management. Major complications
following UFE are
S
O
rare. MRI and CT are typically employed to evaluatePthe uterus following UFE for
E
fibroid infarction, size, location change, persistent
to enhancement and changes in
adenomyosis or to assess complications thatd may require intervention in acute
e
phase. Variable pattern of calcification on CT
ittcan differentiate embolic particles and
m and uterine vessels following UFE is
fibroid involution. Visualization of gas inbuterus
u misinterpreted as a sign of infection.
an expected finding that should notSbe
l
Imaging Findings: MRI and CT
ir afindings includes post procedural appearances,
e after UFE: sterile and infectious, fibroid location
patterns of calcification, gas
at
changes, fibroid vascularity,
M adenomyosis following UFE, fibroid recurrence, uterine
necrosis and ovarian dysfunction.
No
Conclusion: MRI and CT appearances vary depending upon time interval after
UFE and success of the procedure. CT following UFE may be requested because
of acute pelvic pain or pyrexia or for an unrelated indication. Awareness of expected
and abnormal imaging findings is essential for correct diagnosis and treatment.
Radiologists should be familiar with the range of post UFE appearances on MRI
and CT to better aid clinicians in correct diagnosis and treatment.
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Pitfalls in staging uterine neoplasm with MRI: Recognize and avoid them
M.A. Portilha, B. Graca, A. Canelas, C. Marques, F. Caseiro-Alves; Coimbra/PT
([email protected])
Learning Objectives: To review pitfalls in pretreatment staging of endometrial and
cervical cancers with MRI.
Background: Accurate assessment of the extent of uterine neoplasm on preoperative MRI is expected to greatly optimize surgical procedure and therapeutic strategy.
However, possible misdiagnoses in defining the extent of uterine neoplasms by
MRI have been reported.
Procedure Details: We present a series of cases from our MRI department that
demonstrate the following aspects: 1) Summary of MRI technique and FIGO staging
system; 2) Endometrial cancer: 2.1 Pitfalls in the diagnosis of myometrial invasion;
2.2 Pitfalls in the diagnosis of cervical invasion; 3) Cervical cancer: 3.1 Pitfalls in the
diagnosis of stromal invasion; 3.2 Pitfalls in the diagnosis of parametrial invasion;
and 4) Common aspects: 4.1 Pitfalls in the diagnosis of bladder and rectal wall
invasions; 4.2 Pitfalls in lymph node assessment.
Conclusion: Although pitfalls in staging endometrial and cervical cancers have
been reported, MRI remains the optimal imaging technique compared with CT or
ultrasound. This presentation provides a review of these pitfalls in analyzing patient,
technique and tumor-related reasons to allow improvement of routine clinical staging
of uterine neoplasms with MRI.
C-312
Acute female pelvic disease: Role of MDCT in emergency radiology with
emphasis on gynecologic and obstetric disorders
R. Cano Alonso, P. Díez Martínez, M. Navallas Irujo, L. Ibañez Sanz,
J. Gómez Herrera, S. Borruel Nacenta; Madrid/ES ([email protected])
Learning Objectives: To highlight the role of multidetector CT (MDCT) in emergency radiology as a useful tool in the diagnosis and management of acute female
pelvic disease. To describe key radiologic signs to narrow differential diagnosis.
Background: We retrospectively reviewed imaging findings of acute pelvic disease
in women reporting to the emergency room at our institution from December 2006
to August 2008. MDCT was essential in the management of patients in which
gynecologic exploration was not confluent or undone since it was not the initial
suspicion.
Imaging Findings: We focus on gynecologic and obstetric disorders such as
hemorrhagic ovarian cysts, ovarian torsion, pelvic inflammatory disease, ruptured
ectopic pregnancy, complicated uterine myomas, intravascular leiomyomatosis,
traumatic hematocolpos, blunt maternal trauma, postpartum complications (rectus
sheath hematoma, pelvic abscess and hematoma, endometritis) and post-cesarean
section complications (uterine perforation, uterine dehiscence at the incision site
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Learning Objectives: To illustrate the normal imaging appearance of the female
pelvis following surgery and radiotherapy. To demonstrate the appearance of important post-operative and post-radiotherapy complications. To demonstrate the
imaging findings in disease recurrence.
Background: Hysterectomy p bilateral salpingoophorectomy (BSO) is used in
the treatment of malignant and benign gynaecological disease. Trachelectomy is
a fertility sparing treatment option for small cervical cancers. Radiotherapy is also
a treatment for malignant gynaecological disease. The CT and MR appearances
following these treatments are used to determine disease recurrence and future
management.
Imaging Findings: The CT and MR appearances following surgery depend on the
treatment (trachelectomy, hysterectomy or pelvic exenteration) as do the complications seen, which include lymphocoeles and pelvic haematoma. Radiation changes
in the pelvis include bone changes (from signal alteration to sacral insufficiency
fractures), bowel changes (radiation colitis and proctitis), bladder changes (cystitis)
as well as fistulae either to the bowel or bladder. Local disease recurrence can
be demonstrated as a mass, as signal change on MR and can involve the ureter
causing hydronephrosis.
Conclusion: Imaging of the female pelvis following treatment for malignancy
(whether surgical or radiotherapy) will guide the future management of the patient.
Disease recurrence can be subtle and in the post-operative and post-radiotherapy
pelvis difficult to detect due to loss of anatomical tissue planes and changes in
signal intensity. There are benign and malignant complications of surgery and
radiation to the pelvis, which are important to recognise both on early and further
follow-up imaging in these patients.
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Scientific and Educational Exhibits
of caesarean section, ovarian vein thrombosis, colovaginal fistula). We also briefly
review gastrointestinal entities that may mimic these conditions such as appendicitis,
diverticulitis, intestinal inflammatory disease, neoplasms and pelvic abscesses as
a complication of any of the previous entities.
Conclusion: Although ultrasound (US) is the imaging modality of choice for the
evaluation of female pelvic pain, the role of MDCT remains important if US findings
are equivocal or the abnormality extends beyond the field of view achievable with
the endovaginal probe and further characterization is required. Many gynecologic
and gastrointestinal disorders present with typical MDTC findings that radiologists
must recognize to improve the diagnosis and management of these patients.
C-313
Threatened abortion: Early diagnostic tools
I. Tsikhanenka; Minsk/BY ([email protected])
Purpose: To evaluate uterine blood flow and circulation in corpus luteum in early
pregnancy complicated with threatened abortion.
Methods and Materials: Ultrasound and color Doppler data of blood flow in uterine,
spiral arteries and corpus luteum at 5-11 weeks of pregnancy were obtained in 80
women with threatened abortion (1 group), in 30 women of 2 (control) group. Data
were combined with biochemical markers (progesterone,
S b-hCG and trophoblastic
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glycoproteid).
P
E in 86.25% in 1 group and in
Results: Intervilluos blood circulation was registered
to ipsilateral in 71.25% in 1 group
100% in 2 group. Chorion and corpus luteum
were
ed flow was presented as single color
and in 53.3% in control group. Corpus luteittblood
i
locus in 43.75% in group 1 and just inm20% (p 0.05) in control group. Resistant
b group comparing with 2 group (p 0.05).
indices of spiral arteries were higher
Su in 1hCG,
l
Serum concentration of progesterone,
and rophoblastic glycoproteid were
ia to control group
decreased in group 1 if compared
(p 0.005), and changes were
er
t
a having genital infections. There was inverse correlation
more significant in patients
M
between IR in spiral arteries
and hCG concentration (R 0.24, p 0.04).
No blood flow probably present in normal and complicated
Conclusion: Intervilluos
early pregnancy. Absence of peripheral vascular ring in corpus luteum can be
considered as a sign of complications. Changes in resistant indices of spiral arteries in combination with biochemical markers can define patients with a high risk
of early pregnancy loss.
C-314
MR imaging diagnosis of dilated fallopian tubes
P. Papadopoulou, N. Michailidis, I. Kalaitzoglou, A. Haritanti,
P. Psychidis-Papakyritsis, D. Goulis, D. Rousso, A.S. Dimitriadis; Thessaloniki/GR
([email protected])
Learning Objectives: To illustrate and discuss the MR imaging features and differential diagnosis of dilated fallopian tubes.
Background: Dilated fallopian tubes are a common finding in female pelvis
imaging, often associated with pelvic inflammatory disease or endometriosis.
Although endovaginal ultrasound is the primary diagnostic tool, MR imaging is
an invaluable complementary method, especially in complex lesions that may
simulate malignancy.
Procedure Details: We retrospectively reviewed sixty-two cases of dilated fallopian
tubes from our database. Diagnosis was confirmed clinically or surgically. Lesion
size, shape, multiplicity, presence of complete or incomplete septa, haemorrhage,
shading and presence or absence of solid portion or mural nodules was recorded.
The commonest configuration was that of a folded tubular structure, often C or S
shaped. The finding of incomplete mural folds or plicae was highly specific. Twentyfour cases were attributed to endometriosis, thirty-one to pelvic inflammatory
disease including six tuboovarian abscesses, two to extrauterine pregnancy, two to
benign ovarian neoplasm, one to malignancy, and two to previous surgery.
Conclusion: Dilated fallopian tubes can be correctly identified in MR imaging
on the basis of morphology. The signal intensity of the contents may be used to
further characterize the lesion and the underling pathology, most commonly pelvic
inflammatory disease or endometriosis.
C-315
MR imaging of vulval cancer
M.Y. Kataoka1, E. Sala1, P. Baldwin1, A. Farhadi2, C. Reinhold2; 1Cambridge/UK,
2
Montreal, QC/CA ([email protected])
Purpose: Little is studied about the optimal sequence and contrast-enhanced
(CE) MRI for vulval cancer so far. The purpose of our study is to retrospectively
evaluate the diagnostic ability of MRI in vulval cancers and to examine the added
value of CE imaging.
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Methods and Materials: MRIs of 39 patients who had been diagnosed with vulval
cancer (mean age 70 years) from two institutions were evaluated by three radiologists using five-point scoring for recognition of the main vulva lesion and degree
of enhancement on CE-MRI. Lymph nodes of more than 5 mm in short axis were
measured and scored for margin, necrosis, loss of fatty hilum, signal intensity
compared to the main vulval lesion, and diagnostic confidence for presence of
metastasis. The scorings were repeated for CE-MRI (n=26). The above evaluations
were compared to pathological findings.
Results: MRI accurately categorized size of vulva lesions in 81% of patients.
Evaluation changed after CE-MRI in 19 patients and recognition of the main vulval lesion improved in 7 cancer lesions. Ratio of short to long (S/L) axis of lymph
nodes was the best quantitative criteria to predict tumour involvement (area under
curve: 0.84). Diagnostic confidence by radiologist accurately predicts groin nodal
metastasis in 87% of groins. Using the combined criteria of “S/L of 0.8 or above”
or “with spiculated margin”, 82% of groins can be diagnosed correctly.
Conclusion: MRI can be useful in predicting size of the vulval cancer and groin
lymph node metastasis. CE-MRI can improve recognition of vulval lesion.
C-316
Long echo time diffusion-weighted imaging (long TE-DWI) in diagnosing
female pelvic tumors
A. Tamura, H. Tanaka, C. Ishii, R. Asai, S. Katano, M. Nakano, M. Sakamoto;
Tokyo/JP ([email protected])
Learning Objectives: To learn the role of DWI in offering additional information for
the diagnosis of female pelvic tumors. To investigate the usefulness of long TE-DWI
(TE 200 msec) in tumor characterization.
Background: Although most malignant tumors in the female pelvis tend to show
high intensity on DWI with short echo time (about 70 msec), which is considered
to reflect high cellular density in the tumors, borderline tumors and benign tumors
also can show high intensity. Accurate preoperative diagnosis is desired to take an
appropriate management. We hypothesized that not cellular density but relaxation
time of water protons in the cells is different among malignant tumor, benign tumor
and normal tissues. The difference could be emphasized by long TE-DWI because
of prolonged T2 of water molecules in malignant tumors.
Imaging Findings: Many malignant tumors (leiomyosarcoma, endometrial cancers,
cervical cancers, tubal cancer, ovarian surface epithelial-stromal malignant tumors,
dysgerminoma, metastasis and dissemination) remained high intensity on long TEDWI. Smooth muscle tumor with unknown malignant potential kept high intensity on
long TE-DWI. Cellular leiomyomas that showed high intensity on short TE-DWI lost
intensity on long TE-DWI. Degenerated leiomyoma and thecofibroma diminished
intensity on long TE-DWI. Granulosa cell tumor, ovarian surface epithelial-stromal
borderline tumor reduced intensity on long TE-DWI. Two major pitfalls are also
demonstrated. Mature cystic teratoma with less fat component maintains very high
intensity on long TE-DWI. Hemorrhagic component affects the intensity on DWI.
Conclusion: Female pelvic tumors can be qualitatively diagnosed by a long
TE-DWI.
C-317
Ovarian borderline tumors of MRI: Imaging findings and radiologicpathologic correlation
R.N. Matsubayashi1, Y. Matsuo2, T. Nakazono3, Y. Okajima2, T. Muranaka1;
1
Fukuoka/JP, 2Tokyo/JP, 3Saga/JP ([email protected])
Learning Objectives: To illustrate the MR imaging features of ovarian borderline
tumors. To learn the essential diagnostic clues based on the histologic features
of borderline tumors.
Background: Ovarian tumors are classified as benign, borderline, and malignant.
Borderline tumors have a relatively good prognosis and originate in younger patients
compared with malignant tumors, and it is important to diagnose them correctly for
adequate treatment. In this exhibit we show MR images of surface epithelial-stromal
borderline tumors and correlate the findings with histologic features. Additionally,
granulosa cell and carcinoid tumors are also shown.
Imaging Findings: Serous borderline cystic tumor showed polypoid excrescenses
in the cyst. On T2-weighted images (T2WI), these excrescenses showed a ‘broccoli’like appearance, and had low signal-intensity (SI) stalk with delicate branching.
This reflected the histologic ‘hierarchical branching’. Mucinous borderline tumor of
intestinal type had many loculi with partly thickened walls. Mullerian mucinous/mixed
epithelial borderline tumors (MMBT/MEBT) often originate in endometriotic cysts in
young women, and they showed a very high SI of the outer part on T2WI (cotton
ball-like). The very high SI reflected severe edematous stroma. Rare borderline
endometrioid adenofibroma was shown as a slowly enhanced mass in endometriotic
cyst. Borderline Brenner tumor is very rare. Benign Brenner tumor shows a very
low SI, but the borderline tumor showed relatively high SI on T2WI.
Scientific and Educational Exhibits
Conclusion: It is important to know the characteristics of ovarian borderline tumors
to distinguish them from highly malignant tumors. In particular, in cases of tumors
associated with endometriosis careful interpretation is recommended.
C-318
MR imagings of sex cord-stromal tumors of the ovary: Usual and unusual
appearances and their mimickers
Y. Okajima1, T. Nakazono1, H. Irie1, Y. Matsuo1, M. Nishihara1, A. Tamura2,
Y. Saida2, F. Yamasaki1, S. Kudo1; 1Saga/JP, 2Tokyo/JP ([email protected])
Learning Objectives: To demonstrate MR imaging findings of sex-cord stromal
tumors of the ovary and their mimickers with pathological correlation.
Background: Sex cord-stromal tumors are uncommon ovarian tumors, representing
less than 8% of all ovarian neoplasms. Some of these rare tumors show characteristic imaging findings representing abundant stroma; however, they may also
show unusual imaging findings due to degeneration. Sex cord-stromal tumors have
good prognosis compared to malignant epithelial tumors. Therefore, recognition
of various imaging findings is essential for the accurate preoperative diagnosis, to
avoid excessive surgical intervention and to preserve infertility.
Imaging Findings: Thecoma-fibroma group typically show hypointense solid
masses on T2WI with gradual enhancement. Cystic degeneration and edema can
be seen in larger tumors. Chemical shift MRI can be useful to identify intracellular
lipid of the cells. Fibromas can be associated with torsion and Meigs syndrome.
Adult granulosa cell tumors usually show solid masses with a various amount
of cystic components and hemorrhage. They may be associated with rupture.
Sclerosing stromal tumors demonstrate hyperintense cystic components and
heterogenous solid components with thick peripheral hypointense rim on T2WI. On
dynamic contrast study, the solid components show peripheral early enhancement
with centripetal progression. Sertoli-stromal tumors and steroid cell tumors are
also demonstrated. Brenner tumors, adenofibromas, malignant epithelial tumors,
metastatic tumors, subserosal and broad-ligament leiomyomas, and rare sertoliform
endometrioid carcinomas will be demonstrated as mimickers.
Conclusion: To differentiate sex cord-stromal tumors of the ovary from other tumors,
detailed evaluation of T2WI and dynamic contrast study can be useful.
C-319
MR inter-observer agreement in the analysis of endometriosis
L. Saba1, S. Guerriero1, B. Virgilio1, R. Sulcis2, M. Gerada1, G. Melis1, G. Melis1,
G. Mallarini1; 1Cagliari/IT, 2Muravera/IT ([email protected])
C-320
Cystic pelvic masses of non-ovarian origin
P.L. Moyle1, M.Y. Kataoka1, A. Nakai2, A. Takahata2, C. Reinhold3, E. Sala1;
1
Cambridge/UK, 2Kyoto/JP, 3Montreal, QC/CA ([email protected])
Learning Objectives: To recognise the main causes and differential diagnoses
for non ovarian cystic lesions in the female pelvis.
Background: Cystic masses in the female pelvis are common. The majority of
cystic lesions originate from the ovary but there are other causes of cystic masses
within the pelvis, which may be mistaken for ovarian pathology. This may lead to
C-322
Comparative efficacy of uterine artery embolization (UAE) and MR-guided
focused ultrasound surgery (MRgFUS)
T. Sycheva, V.E. Sinitsyn, A.E. Bugerenko, E.A. Mershina, K.V. Lyadov,
Y.B. Kurashvili, A.V. Stepanov; Moscow/RU ([email protected])
Purpose: To compare results of organ-saving methods for treatment of females
with uterine fibroids (UAE and MRgFUS).
Methods and Materials: UAE was used for treatment of 85 women (mean age 36p5.8 years). Average uterine size (long axis) was 89.3p19.4 mm, average size
of myomas was 56.4p28.9 mm. The focused ultrasound system was used to ablate
tissue in combination with on-going magnetic resonance imaging, 1.5 T. MRgFUS
was performed in 40 women (mean age 37.6p5.6 years). Average uterine size was
85.2p28.1 mm, size of myomas - 40.7p20.9 mm. Both groups were comparable by
main clinical symptoms (lower abdominal pain, pelvic organs dysfunction, menorrhagia, menometrorrhagia, anemia) and concomitant gynecological diseases
(endometrial polyps, infection, cervical erosion).
Results: Good results were obtained in both groups. 1. Severity of clinical symptoms
was reduced in 89% of women after UAE and in 76.2% after MRgFUS. 2. Average
uterine size has been reduced in 1.4 and 1.22 times after UAE and MRgFUS,
respectively. Uterine size became normal in 33% and 25% cases, respectively.
Average size of myomas reduced in 2 and 1.5 times after UAE and MRgFUS,
respectively. 3. Technical success was achieved in 99.2% (UAE) and 95% (MRgFUS) cases. Complications after UAE were noted in 4.7% cases, after MRgFUS
no complications were registered.
Conclusion: Both methods of uterine fibroid treatment were effective and organsaving. MRgFUS is a noninvasive alternative to surgical treatment (hysterectomy,
myomectomy) and minimally invasive operation (embolisation of uterine arteries).
MRgFUS allows reducing morbidity attributable to other methods.
C-323
Many faces of adenomyosis: Usual, unusual MR manifestations, pitfalls
and problem-solving techniques
M. Takeuchi, K. Matsuzaki, H. Nishitani; Tokushima/JP
([email protected])
Learning Objectives: To demonstrate various MR manifestations of adenomyosis.
To describe problem-solving MR techniques for the diagnosis of adenomyosis:
diffusion-weighted imaging (DWI), susceptibility-weighted imaging (SWI), 1H-MR
spectroscopy (MRS), cine-MRI, and high resolution MRI at 3 T.
Background: Typical adenomyosis shows characteristic MR imaging: diffuse or
focal thickening of junctional zone, or ill-demarcated low intense myometrial lesion
on T2-weighted images. However, adenomyosis may exhibit various MR manifestations and mimic benign or malignant gynecologic pathologies.
Imaging Findings: Various physiologic or pathologic states may influence MR
appearances of adenomyosis; amount of functional endometrial tissue, phase of
the menstrual cycle, endogenous hormonal abnormality, and exogenous hormonal
stimulation. Abundant endometrial tissue, hemorrhage, edema, and decidualization
may cause complex MR appearances mimicking malignancy. Atypical morphologic
appearances of adenomyosis should be recognized; solid mass-like “adenomyoma”,
hemorrhagic cyst-forming “adenomyotic cyst”, polypoid “adenomyomatous polyp”,
and endometrial lesion-like “pseudowidening”. Benign and malignant adenomyosis
mimickes; physiological myometrial contraction, myometrial involvement of pelvic
endometriosis, low-grade endometrial stromal sarcoma, and myometrial metas-
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Purpose: The purpose of this work was to evaluate inter-observer agreement in the
evaluation of the deep pelvic endometriosis by using magnetic resonance (MR).
Methods and Materials: From June 2006 to August 2007, two radiologists evaluated 47 women (mean age 38; range 23-49) who underwent MR study for suspected
endometriosis. MR was at 1.5 Tesla. Exams were completed with Gadolinium. Each
dataset was independently evaluated by the radiologists for the presence or absence
of deep pelvic endometriosis and localization (utero-sacral ligaments (USLs), pouch
of Douglas, the vagina, the rectosigmoid, rectovaginal septum and the bladder) of
suspected lesions was recorded. Cohen kappa statistic was performed in order to
calculate agreement between measurements.
Results: We observed an inter-observer agreement of 89.36% and the kappa
value was 0.635. In the USLs, the inter-observer agreement was 85.11% and the
kappa value 0.571. In the pouch of Douglas, the inter-observer agreement was
82.98% and the kappa value 0.552. In the vagina, the inter-observer agreement
was 91.49% and the kappa value was 0.552. In the rectosigmoid, the inter-observer
agreement was 91.49 % and the kappa value 0.725. In the rectovaginal septum, the
inter-observer agreement was 91.49% and the kappa value 0.746. In the bladder,
the inter-observer agreement was 93.62% and the kappa value 0.538.
Conclusion: Results of our study indicate that MR has a high inter and intraobserver agreement in the identification of endometriosis located in the rectosigmoid and in the rectovaginal septum, whereas the agreement is sub-optimal in the
endometriosis located in the USLs.
inappropriate management. The anatomical location of lesions, identification of
normal ovaries, and clinical history are important clues to the diagnosis. We illustrate
imaging findings of non-ovarian cystic lesions using US, CT and MRI.
Imaging Findings: Tubal lesions such as hydrosalpinx, haematosalpinx, and
pyosalpinx can mimic ovarian cystic mass. Sausage-, C-shaped mass separate
from ovary is a key finding. Another common cystic lesion is peritoneal inclusion
cyst, which occurs among pre-menopausal women with peritoneal adhesions and
is characterized by a cystic lesion conforming to pelvis with entrapped normal ovary.
Cystic masses of gastrointestinal origin include appendiceal mucocele, which can
be traced back to the caecal pole. Sacral meningocele can present as a cystic
pelvic mass. Cross-sectional imaging demonstrates continuation to sacral area.
Lymphocele is a thin-walled cyst commonly encountered after pelvic surgery. It can
have thickened wall when infected and may be confused with ovarian malignancy.
Haematoma, abscess, pelvic lymphangioleiomyomatosis, and cystic degeneration
of leiomyoma are also discussed.
Conclusion: Not all cystic disease in the female pelvis is of ovarian origin. Understanding the anatomical location of a lesion, combined with clinical history, is
the key to avoid this pitfall.
Scientific and Educational Exhibits
tases should be differentiated. DWI with ADC measurement, detection of small
hemorrhagic foci by SWI, evaluation of the choline peak by MRS, demonstrating
morphologic changes on cine MRI, and revealing detailed internal structures on high
resolution MRI are helpful for differential diagnosis. DWI is also useful in evaluating myometrial invasion of endometrial cancer with co-existing adenomyosis, and
malignant transformation of adenomyosis.
Conclusion: Recognizing various MR manifestations of adenomyosis and making accurate diagnosis by using problem-solving MR techniques are important for
appropriate management of the patients.
C-324
Clinical application of susceptibility-weighted MR imaging in gynecologic
diseases
M. Takeuchi, K. Matsuzaki, H. Nishitani; Tokushima/JP
([email protected])
Learning Objectives: To demonstrate the role of susceptibility-weighted MR imaging (SWI) in diagnosing various gynecologic diseases.
Background: SWI combines magnitude and phase information from fully velocity
compensated gradient-echo sequence, and visualizes the susceptibility effects
caused by local inhomogeneity of the magnetic field as signal voids. SWI has exquisite sensitivity to the blood products such as hemosiderin and deoxyhemoglobin,
and may contribute to the diagnosis of various gynecologic pathologies with fresh
or obsolete hemorrhage.
Imaging Findings: Punctate or curved linear signal voids along the cyst wall due to
hemosiderin deposition as a result of repeated hemorrhages are characteristic for
endometrioma, and useful sign for differentiating from non-endometrial hemorrhagic
cyst. The presence of signal voids due to hemosiderin deposition in extra-ovarian
endometriosis (i.e. urinary bladder, abdominal wall and peritoneal implants), and
in adenomyosis is also diagnostic. SWI is sensitive to a small amount of hemorrhagic contents, and can differentiate mucinous cysts from hemorrhagic cysts both
exhibiting high signal intensity on T1-weighted images. SWI can also demonstrate
fresh hemorrhage, and is helpful for detecting ectopic pregnancy, small hemorrhagic necrosis in uterine sarcomas, hemorrhagic infarction in red degenerated
leiomyomas, and placental polyp with hemorrhagic foci. The signal voids on SWI
are demonstrated more prominent at 3 T than at 1.5 T reflecting the higher sensitivity of 3 T to the magnetic susceptibility effect. Calcification and intestinal gas may
cause susceptibility artifacts on SWI as pitfalls.
Conclusion: SWI is sensitive for the presence of hemorrhage within various gynecologic pathologies, and provides helpful information for the differential diagnosis.
C-325
Staging of endometrial cancer: Role of diffusion-weighted MR imaging in
comparison with T2-weighted and dynamic gadolinium-enhanced images
G. Rechichi, D. Ippolito, S. Galimberti, P. Perego, M. Signorelli, S. Sironi;
Monza/IT ([email protected])
Purpose: To compare the reliability of MR diffusion weighted with background body
signal suppression images (DWIBS) with T2-weighted and dynamic Gadoliniumenhanced imaging in the pre-operative local staging of endometrial cancer.
Methods and Materials: The study group consisted of 40 patients with proved endometrial adenocarcinoma, who underwent pre-operative MR staging. In addition to
the standard MR protocol imaging, including T2-weighted and Gadolinium-enhanced
sequences, we performed DWIBS obtained with b-value of 0 and 1000 s/mm2. All
the patients underwent radical hysterectomy; the imaging findings were compared
with histopathological results to evaluate the sensitivity of the three different MR
sequences used. We considered as superficial invading tumors those cases staged
as FIGO IA/IB (confined to endometrium/invading 50% of myometrium) and as
deep invading tumors all FIGO IC cases (invading 50% of myometrium).
Results: A significant difference (p 0.005) for sensitivity was found for each of
the sequences employed, having the histopathological findings as standard (39
cases of superficial invading cancer vs 9 of deep invading cancer). The sensitivity
we obtained for DWIBS, T2-weighted and Gadolinium-enhanced images was of 92,
100 and 75%, respectively. Statistical analysis showed that T2-weighted images
are the most accurate in local staging of endometrial cancer, followed by DWI and
then Gadolinium-enhanced sequences.
Conclusion: Due to their sensitivity, the association between T2-weighted images
and DWIBS could represent the most reliable MR imaging protocol in pre-operative
local staging of endometrial cancer.
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Mid-trimester anomaly screening: A resident’s guide
S.S. Hedgire, K. Narsinghpura, P. Gupta, T. Kalyanpur, S. N, R. Krishnan,
S. Pene, R. Renganathan, P. Mehta; Coimbatore/IN ([email protected])
Learning Objectives: To formulate an approach for fetal anomaly screening in
second trimester.
Background: Use of a systematic approach to fetal anomaly screening and why
a mid-trimester scan is preferred.
Imaging Findings: 1. Technique. 2. Normal and abnormal findings in the head and
neck, thorax, heart, abdomen, pelvis, limbs and spine. 3. Pitfalls.
Conclusion: Antenatal anomaly screening assumes importance as it enables
the radiologist to detect lethal anomalies and aids in counselling the patients.
We attempt to formulate a systematic approach to the mid-trimester detection of
various anomalies.
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Magnetic resonance imaging appearances of borderline ovarian tumours
H. Sbano, R. Williamson, M. El-Bahrawy, S. Babar; London/UK
([email protected])
Purpose: To describe the MRI appearances of borderline ovarian tumours, and
the frequency of MR features indicative of malignancy.
Methods and Materials: MRIs from 27 patients with 31 histologically confirmed
borderline ovarian tumours were reviewed. Mass size, signal intensity on T1, T2,
T1 WATTS, septal thickness, nodules, papillary projections, solid elements, haemorrhage, ascites, peritoneal and mesenteric nodules, omental thickening and
lymphadenopathy were recorded.
Results: 31 tumours (19 serous and 12 mucinous) were diagnosed in 27 patients.
Each mass ranged from 3 - 31 cm (mean 13 cm). 27/31 (87%) of the tumours
were cystic. 4/31 (13%) were cystic with solid components. Multiple septa were
demonstrated in 25/31 (81%). 8/31 (26%) had thickened septa ( 3 mm). The range
of septal thickness was 1 - 6.3 mm (mean 2.9 mm). Solid components including
nodules and papillary projections were noted in 26/31 (84%). The range of diameters of the largest solid components was 2.4 - 33 mm, with multiple solid elements
demonstrated in 19/31 (61%). 4/31 (13%) had ascites. Omental thickening was
demonstrated in 2/31 (6.5%). Mesenteric deposits were observed in 1/31 (3.2%).
6/31 (19%) had completely benign appearance (4, serous and 2 mucinous). One
malignant feature was observed in 14/31 (45%); 9 serous, 5 mucinous. 10/31 (32%)
had 2 malignant features (5 serous and 5 mucinous). 3 malignant features were
observed in 1/31 (3.2%) (Serous).
Conclusion: Borderline ovarian tumours remain a diagnostic challenge with 81%
displaying features on MRI indicative of malignancy. Such features were observed
in 79% of the serous and 83% of the mucinous subtypes.
C-328
Uncommon ovarian teratomas: Imaging findings and pathologic
correlation
S. Motoshima, H. Irie, T. Nakazono, Y. Okajima, T. Otsuka, S. Kudo; Saga/JP
([email protected])
Learning Objectives: 1. To review imaging findings of uncommon ovarian teratomas and correlate them to pathologic findings. 2. To illustrate various imaging
findings of uncommon ovarian teratomas and to discuss the cause of atypical
presentations. 3. To learn the crucial imaging findings in differentiating from other
ovarian masses.
Background: 1. Presenting cases: various types of mature cystic teratomas (typical,
torsion, ruptured, without intracystic lipid material, malignant transformation, with
massive hemangiomatous element), immature teratoma, struma ovarii, carcinoid
tumor, etc. 2. Review of CT and MRI findings. 3. Imaging-pathologic correlation.
Imaging Findings: Imaging findings of torsion of teratoma include deviation of
uterus and absence of enhancement of the mass. Rupture of teratoma causes
leakage of sebaceous content into the peritoneum. Mature cystic teratoma with
malignant transformation and immature teratoma appear to be fat-containing mass
with a solid component. The former occur in the 6th or 7th decade of life, the latter
occur in the 1st or 2nd decade of life. Struma ovarii and carcinoid tumor are classified
monodermal teratoma, which have strong contrast enhancement.
Conclusion: It is important to be familiar with the variety of imaging appearance of uncommon ovarian teratomas to distinguish them from other significant
diseases.
Scientific and Educational Exhibits
C-329
Patients with ovarian lesions: spectrum of diseases evaluated with
contrast enhanced ultrasound (CEUS)
F. Lacelli1, L.M. Sconfienza2, M. Bertolotto3, N. Gandolfo4, C. Murolo2, G. Serafini1;
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Pietra Ligure/IT, 2Genua/IT, 3Trieste/IT, 4Sanremo/IT ([email protected])
Learning Objectives: To illustrate the spectrum of ovarian pathologies that can
be effectively evaluated with CEUS.
Background: Transvaginal US is the first imaging modality of choice in evaluating
ovarian diseases. Color Doppler analysis allows detecting intralesional flow in a
relevant number of situations. However, it is often inadequate in the detection of
small perfusion abnormalities, being almost useless to differentiate poorly vascular
from avascular lesions. The detection of microvascularization is particularly important in complex lesions, giving a relevant aid in the differential diagnosis between
benign or malignant features.
Imaging Findings: CEUS was used to assess a wide range of adnexal affections.
Cases of ovarian torsion, ovarian fibroids, hemorrhagic lesions, complex masses
with papillary projections, solid tumors, paraovarian lesions and pseudotumors
peritonei are presented, both in standard conditions and during CEUS evaluation.
Differences between findings on conventional ultrasound examination and CEUS
assessment will be highlighted.
Conclusion: CEUS allows detection of microcircle perfusion abnormalities in
patients affected by a wide range of pathology. This information is mandatory in
obtaining a correct differential diagnosis and in many cases is significant to modify
the therapeutic approach.
C-330
Signs in imaging of the female pelvis: A pictorial review
M. Takeuchi, K. Matsuzaki, H. Nishitani; Tokushima/JP
([email protected])
Learning Objectives: To demonstrate various diagnostic signs in imaging of the
female pelvis with pathologic correlation.
Background: Various diseases may occur in the female pelvis from not only reproductive organs but also intestinal, mesenteric, urinary, or extra-peritoneal organs.
Imaging Findings: Signs associated with signal intensity pattern on MRI: “Shading sign” for endometrioma (T2-shortening by repeated hemorrhagic contents),
“Stained-glass appearance” for mucinous tumors (various contents in loculi), “Hyperintense rim sign” for red degenerated leiomyoma (T1-shortening by Methemoglobin),
“Black sponge-like appearance” for ovarian cystadenofibroma (fibrous mass with
multiple tiny glands), “Black garland” for ovarian fibromatosis (fibrous cortical thickening), “Black rim sign” for polypoid endometriosis (surrounded by adhesive fibrous
tissue), “Mural Othello pieces” for malignant Brenner tumor (combination of benign
fibrous hypointense nodule and malignant hyperintense nodule on T2WI). Signs
associated with morphologic appearances: “Bridging vascular sign” (feeding arteries) and “Beak sign” for subserosal leiomyoma, “Preserved follicle sign” for benign
enlarged ovaries (polycystic ovaries; massive edema; torsion; oophoritis), “Floating
fat balls” for mature cystic teratoma, “Uterine scalloping” for pseudomyxoma peritonei, “Marginal crescent sign” for ancient schwannoma (residual solid component),
“Target sign” for urethral clear cell carcinoma (preserved urethra as central dot),
“Centripetal replacement sign” for extra-peritoneal tumors (anterior replacement of
rectum; inward replacement of iliac vessels and ureter), “Black worms” for low-glade
endometrial stromal sarcoma (preserved muscular bandles).
Conclusion: Diagnostic signs in imaging are helpful for the differential diagnosis in
the routine clinical practice, and recognition of characteristic signs in imaging may
form an important part of the training process for diagnostic radiologist.
C-331
Learning Objectives: To demonstrate various benign physiologic conditions and
tumor-like lesions simulating neoplasms in the female pelvis, and to describe clues
to the differential diagnosis.
Background: Physiologic conditions may affect the morphologic appearances of
female reproductive organs. Benign physiologic conditions and tumor-like lesions
may mimic neoplasms in the female pelvis.
Imaging Findings: Non-neoplastic ovarian enlargement mimicking solid or multilocular cystic tumors may occur under various conditions: Massive ovarian edema
following chronic incomplete torsion, polycystic ovaries/ovarian fibromatosis with
stromal proliferation, Hyperreactio luteinalis/ovarian hyperstimulation syndrome
C-332
Differential diagnosis of uterine myometrial masses: Clinical challenge by
diffusion-weighted MR imaging and in-vivo 1H-MR spectroscopy
M. Takeuchi, K. Matsuzaki, H. Nishitani; Tokushima/JP
([email protected])
Learning Objectives: To demonstrate the feasibility of diffusion-weighted MR
imaging (DWI) and in-vivo 1H-MR spectroscopy (MRS) in differentiating benign
myometrial lesions from malignancy.
Background: Hyperintense leiomyomas on T2-weighted MR images have a
diagnostic dilemma in the differentiation from uterine sarcomas. Adenomyosis
may show various signal intensity and mimic malignancy. It is occasionally difficult
to differentiate these benign myometrial lesions from sarcomas on the basis of
morphologic appearances.
Imaging Findings: Uterine sarcomas show high signal intensity on DWI with
significantly lower ADC (0.79p0.26, n=7) compared with benign myometrial lesions (1.34p0.29, n=60) due to high cellularity of malignant tumor cells. In benign
hyperintense leiomyomas on T2-weighted images, cellular leiomyomas show higher
signal intensity with relatively low ADC (1.18p0.16, n=6) compared with degenerated
leiomyomas (1.60p0.30, n=21). Hydropic/myxomatous degeneration in leiomyomas,
and edema/decidualization in adenomyosis may increase the signal intensity on
T2-weighted images; however, high ADC in such benign lesions is helpful for the
differential diagnosis. High choline peaks are observed in sarcomas by MRS reflecting their prominent cellular proliferating activity, whereas moderate to low choline
peaks are observed in benign myometrial lesions. High-grade sarcomas tend to
show higher choline peaks by MRS.
Conclusion: DWI and MRS can provide useful information for the differential
diagnosis of hyperintense myometrial masses on T2-weighted images.
C-333
Ovarian lesions: MRI findings with histopathological correlation
P.V. Foti, R. Farina, D. D’Aniello, M. Coronella, E. Fisichella, G. Politi, G.C. Ettorre;
Catania/IT ([email protected])
Learning Objectives: To show the diagnostic performance of magnetic resonance
imaging (MRI) in the characterization of ovarian lesions: we illustrate typical and
atypical MRI findings of adnexal lesions and correlate them with histopathologic
findings.
Background: 20 women (age range, 26-65 years) with 24 ovarian lesions underwent MR imaging before surgical excision. MR protocol included FSE T2-weighted
and plain and gadolinium-enhanced T1-weighted sequence. MR images were
correlated with histologic findings.
Imaging Findings: The lesions observed were as follows: 4 functional cysts, 4
endometrial cysts, 4 fibromas, 4 mature cystic teratomas, 7 serous cystadenocarcinoma, and 1 tubo-ovarian abscess. Functional cysts show low signal in T1-weighted
sequence and high signal in T2-weighted sequence. Endometrial cysts show high
signal in both sequence T1-weighted and T2-weighted. Fibromas have extremely
low signal intensity on T1- and T2-weighted MRI, as does muscle, with moderate
contrast enhancement. Mature cystic teratomas can contain variable cystic and solid
components (adipose and ectodermal structures). Solid component do not enhance
when the lesion is benign, and in cases of malignant degeneration enhancement
of these solid component will be observed. Malignant tumors typically appear as
complex solid/cystic adnexal masses; any solid components will enhance following administration of contrast. Inflammatory lesions can mimic an ovarian cancer,
clinical correlation is essential for diagnosis.
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Benign physiologic conditions and tumor-like lesions simulating
neoplasms in the female pelvis: Clues to the differential diagnosis
M. Takeuchi, K. Matsuzaki, H. Nishitani; Tokushima/JP
([email protected])
caused by the endogenous or exogenous hormonal stimulation, and Oophoritis/
tubo-ovarian abscess due to infection. Recognition of preserved follicles on imaging and understanding of clinical information are important for the diagnosis.
Endometriosis may occasionally mimic neoplasms: decidualization associated
with pregnancy/polypoid endometriosis may mimic malignancies in ovaries, vagina
or peritoneal cavity. High ADC due to their vascularized edematous nature on
diffusion-weighted imaging is diagnostic. Endometriosis may involve intestine, bladder, and abdominal wall, and simulate cancers. Revealing hemosiderin-deposition
by susceptibility-weighted imaging is helpful for the diagnosis. In the uterus, deep
nabothian cyst and adenoma malignum, edematous/decidualized adenomyosis and
sarcomas, adenomyotic cyst and uterine/ovarian malignancy, myometrial contraction and leiomyomas should be differentiated by characteristic MR manifestations,
sequential morphologic changes and clinical information of physiologic conditions.
Urethral diverticulum mimics clear cell carcinoma, and contrast-enhanced MRI
can differentiate them.
Conclusion: Recognition of imaging manifestations of normal organs and benign
tumor-like lesions under various physiologic conditions is important for making
accurate diagnosis and appropriate management of the patients.
Scientific and Educational Exhibits
Conclusion: MR showed high diagnostic accuracy and sensibility in the diagnosis
of endometrial cysts and mature cystic teratomas; it moreover can help distinguish
among benign and malignant tumors, though a degree of overlap remains.
C-334
Evaluation of histological type in uterine endometrial cancer by threedimensional MRI in which CO2 gas was infused into the uterine cavity
D. Kakizaki, S. Xu, K. Saito, S. Akata, M. Yoshimura, J. Park, K. Tokuue; Tokyo/JP
([email protected])
Purpose: We conducted MRI by 3D-VIBE (3 dimensional image with volumetric
interpolated breath-hold examination) method in which CO2 gas was infused into
the uterine cavity, and created an endoscopic image (MR hysteroscopy) and multiplannar reconstruction (MPR) of the uterine cavity. And we performed evaluation
of histological type and clinical stage in uterine endometrial cancer.
Methods and Materials: The pulse sequence of MR imaging was 3D-VIBE method.
CO2 gas was pumped into a catheter inserted in the uterine cavity and images were
taken by 3D-VIBE. MPR and endoscope image processing were then performed.
There were 36 cases of cancer of uterine body.
Results: Based on the FIGO classification, the cancer of uterine body types were
15 cases of Ia, 15 cases of Ib, 7 cases of Ic, 6 cases of IIa and 7 cases of IIb.
The histological type were 50 cases: 29 adenocarcinoma, 5 adenoacanthoma, 6
adenosquamous, 3 serous (papillary serous), 1 mutinous, 1 clear cell, 2 squamous
cell, 1 mixed and 2 undifferentiated.
Conclusion: CO2 gas infusion into the uterine cavity made it possible for MRI
intrauterine endoscopy and MPR. And the most important conclusion that emerged
from the research is that this study will surely contribute to determine the histological
type of uterine endometrial cancer.
C-335
Hysterosalpingography (HSG) anatomy, imaging and pathology revisited
A.M. Browne, E. DeLappe, H. Khosa, G. Colleran, K. Cronin, C. Roche;
Galway/IE ([email protected])
Learning Objectives: We provide an interesting, informative and concise radiological guide of HSG technique, anatomy and pathology.
Background: HSG is the radiographic evaluation of the uterus and fallopian tubes
with the use of radiographic contrast medium. The most common indications for
performing HSG are infertility, recurrent abortion and evaluation of the uterus and
fallopian tubes post tubal surgery. We provide an educational exhibit of the presentation and imaging findings of uterine and tubal pathology identified on HSG
in our institution and correlate imaging findings with clinical features. We illustrate
characteristic appearances and differentiate these from other pathologies where
appropriate.
Imaging Findings: We illustrate, using imaging findings, normal uterine and fallopian tube anatomy. We demonstrate the characteristic appearances of a wide
spectrum of uterine and tubal pathologies including acquired and congenital anomalies. We also briefly discuss HSG technique and potential complications. Uterine
abnormalities demonstrated include congenital abnormalities, polyps, leiomyomas,
surgical changes, synechiae and adenomyosis. Tubal abnormalities demonstrated
include tubal occusion, polyps, hydrosalpinx and peritubal adhesions.
Conclusion: HSG is a valuable imaging modality in the evaluation of the uterus and
fallopian tubes. A wide variety of uterine and tubal abnormalities can be demonstrated with hysterosalpingography. Accurate diagnosis allows for early management
of treatable conditions including those affecting patient fertility.
C-336
Diffusion-weighted MR imaging of endometrial cancer: Differentiation from
benign endometrial lesions and evaluation of myometrial invasion
M. Takeuchi, K. Matsuzaki, H. Nishitani; Tokushima/JP
([email protected])
Purpose: To demonstrate the feasibility of diffusion-weighted MR imaging (DWI) in
differentiating benign endometrial lesions from malignancy, and in evaluating the
depth of myometrial invasion by endometrial cancer.
Methods and Materials: Pathologically proven 67 uterine endometrial lesions
including 22 benign lesions (polyps/hyperplasia) and 45 endometrial cancers
were evaluated on DWI (b=800 seconds/mm2). The ADCs (x 10-3 mm2/seconds)
in all lesions were measured. In 33 endometrial cancers the histologic findings
were compared with DWI and contrast-enhanced T1-weighted images. The depth
of myometrial invasion was classified as stage S (superficial invasion/ limited to
endometrium) and stage D (deep invasion: tumor invades more than 50% of the
myometrium). The staging accuracies of each sequence were assessed.
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Results: Endometrial cancer show high signal intensity on DWI with significantly
(p 0.01) lower ADC (0.84p0.19) compared with benign endometrial lesions
(1.58p0.36) due to high cellularity of cancer cells. The staging accuracy on DWI and
contrast-enhanced T1-weighted images were 94 and 88%, respectively. The depth
of invasion was overestimated in three patients with co-existing adenomyosis and
underestimated in one patient with infiltrative tumor growth on contrast-enhanced
T1-weighted images. DWI could accurately evaluate the tumor extent in three of
these four patients.
Conclusion: DWI can provide useful information for the differential diagnosis of
endometrial masses and for the evaluation of the depth of invasion by endometrial
cancer. Especially, when adenomyosis co-exists with endometrial cancer at the
same site, DWI improves the accuracy of staging.
C-337
Virtual hysteroscopy: A promise less invasive method
P. Carrascosa1, M. Baronio2, C.M. Capuñay1, J. Vallejos1, E. Martín López1,
M. Borghi2, C. Sueldo2, S. Papier2; 1San Isidro/AR, 2Caba/AR
Purpose: To evaluate the accuracy of virtual hysteroscopy (VH) for the evaluation
of cervical and uterine pathology in comparison with hysteroscopy (H).
Methods and Material: Twenty-five patients with diagnosis of infertility were
studied. All patients underwent VH with a 64 row multidetector CT. A volume of
10-15 ml of a dilution of low-osmolality iodine contrast agent was instilled into the
uterine cavity. All patients were derived to H after VH. The studies were performed
and evaluated independently and in a blinded way. The diagnostic accuracy for
VH and H were calculated.
Results: Three of 25 patients presented cervix pathology in VH (2 with polyps and
1 with folds thickening). Two lesions (1 polyp and 1 synechiae) were detected by H
and not by VH (false negatives for VH). However, in a second evaluation they were
identified. Twenty patients presented elevated lesions in uterine cavity. Both VH
and H detected 19 polyps, 3 submucosal myomas, 1 cesarean scar and 1 patient
with septate uterus. Two polyps were detected by VH and not by H in a first lecture
but confirmed by the second look (false negative findings for H). Both VH and H
had the same sensitivity, specificity, positive and negative predictive values of 92,
100, 100 and 92%, respectively.
Conclusion: VH result exceeds those of H for the evaluation of uterine pathology,
identifying two polyps overlooked in the first H exam. The false negative findings
of the cervical region were retrospectively seen in VH studies.
Scientific and Educational Exhibits
Genitourinary
Kidney
C-338
Effect of acquisition duration on parameters measurement of CT perfusion
in rabbit kidney
L. E 1, D. Ma1, Z. Wu2, J. Li2; 1Beijing/CN, 2Taiyuan/CN ([email protected])
Purpose: To evaluate if there is a significant change in the parameter of CT perfusion of kidney when differing scan acquisition times are used with the objective
of reducing radiation dose and examination duration, while not compromising on
parameter estimation accuracy.
Methods and Materials: CT perfusion of kidneys was studied by a 64-row multidetector CT in eight male New Zealand white rabbits. Acquiring time is 60 seconds,
and these raw data could subsequently be subdivided into 3 different acquisition
times (30, 45 and 60) by selecting a specified number of images to be loaded up
into the workstation. The mean values of renal cortex (BV, BF and MTT) were
compared using the two-way analysis of variance.
Results: There was no significant difference between values obtained at the 3
different acquisition times for BV (p=0.056), BF (p=0.184) and MTT (p=0.675). The
absolute values of BF and BV have a large variability.
Conclusion: There was no significant difference in rabbit kidney BV, BF and MTT for
any of the scan times studied. Data acquired in the period of first pass is sufficient
to calculate BV, BF and MTT. The advantages of a reduction in total acquisition
time include reduced likelihood of patient movement and may enable perfusion
studies in a single breath hold, and the more important thing is that radiation dose
can be reduced greatly. Our study also revealed that the measured BF and BV in
the renal cortex have a larger variability in absolute values.
C-339
Imaging aspects of urachal remnant pathology
S. Palma, J. Inácio, J. Leitão, L. Lobo, M. Abecasis, I. Távora; Lisbon/PT
([email protected])
Learning Objectives: The authors propose an embryologic and anatomic features
review of the urachus, regarding the two major group anomalies (congenital/acquired). This review will be illustrated by CT and MRI images of our department.
Background: The urachus is a remnant of the intraembryonic portion of the allantois. This is an extraperitoneal structure that typically closes at birth. Congenital
anomalies include patent urachus, urachal sinus/cyst, vesicourachal diverticulum
and umbilical-urachal sinus. Acquired anomalies concern infectious complications
of congenital anomalies and a broad spectrum of very rare benign and malignant
tumors.
Imaging Findings: TC and MRI imaging techniques give an important contribution
to differentiate urachal from bladder apex pathologies. According to several authors,
the extension of urachal carcinoma through the space of Retzius, the midline position
and calcifications in a midline supravesical mass are considered nearly diagnostic
for urachal carcinoma. Usually this is a silent pathology, and so the radiologist must
be aware if a midline supravesical mass is diagnosed.
Conclusion: Understanding the anatomy and the imaging features of urachal remnant diseases, along with the typical locations and distributions of these diseases,
is essential for correct diagnosis and proper management.
C-340
Study of renal MR perfusion weighted imaging
H. Shi, H.-Y. Ding; Jinan/CN ([email protected])
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Beyond renal cell carcinoma - expanding the differential for solid renal
masses: A series of unusual, pathologically proven renal masses
N.P. Hanson, A. Hawari, W.D. Boswell, V.A. Duddalwar; Los Angeles, CA/US
([email protected])
Learning Objectives: To review differentiating imaging characteristics of unusual
renal masses. To correlate clinical and radiological findings for unusual and rare
renal masses as well as unusual imaging appearances of common renal masses. To
provide multi-modality correlation of imaging findings for renal masses. To discuss
imaging protocols and follow-up in the management of these renal masses.
Background: There is significant overlap in the appearance of both benign and
malignant masses in the kidney. This presentation provides pathologically proven
examples of unusual renal masses such as metastatic lesions, granulomas, leiomyoma, focal infiltrations, inflammatory pseudotumor and others. The goal is to
provide visual examples to the radiologist in order to allow consideration of both
clinical factors and differentiating imaging characteristics to provide a narrow but
accurate differential diagnosis for an unusual renal mass. We also discuss unusual
imaging appearances of common renal masses.
Imaging Findings: Multi-modality imaging findings will be provided for each of the
different cases including CT, MRI and US. These findings will be compared and
their value in differentiating various pathologies discussed.
Conclusion: Differentiating between solid renal masses can be difficult. Using
clinical factors and imaging characteristics to narrow the differential diagnosis
prior to invasive procedures may improve patient care by avoiding unnecessary
procedures, or allowing nephron sparing procedures to be performed.
C-342
Contribution of diffusion-weighted MR imaging for predicting benignity of
complex adnexal masses
I. Thomassin-Naggara, I. Toussaint, C.A. Cuenod, E. Darai, C. Marsault,
M. Bazot; Paris/FR ([email protected])
Purpose: To prospectively assess the contribution of diffusion-weighted MR imaging
(DWI) for characterizing complex adnexal masses.
Methods and Materials: Seventy-seven women (22 to 87 years old) with complex adnexal masses underwent MR imaging including DWI before surgery. In
cases of bilateral tumors, the most complex tumor was analyzed (30 benign and
47 malignant). Conventional morphological criteria of malignancy (size, papillary
projections, thickened irregular septa, solid portion and T2-signal intensity within
solid component) were recorded in addition to b1000 signal intensity and apparent
diffusion coefficient (ADC) measurements of cystic and solid components. Statistical
descriptive analysis was performed using Mann-Whitney test and Fisher’s exact
test. Positive likelihood ratios (PLR) were calculated for predicting benignity and
malignancy.
Results: The most significant criteria for predicting benignity were low b1000 signal
intensity within solid component (PLR=10.9), low T2 signal intensity within solid
component (PLR=5.7), absence of solid portion (PLR=3.1), absence of ascites or
peritoneal implants (PLR=2.3) and absence of papillary projections (PLR=2.3). All
masses that displayed simultaneously low signal intensity within solid component
on T2 weighted and on b1000 diffusion weighted images were benign. Alternatively,
the presence of a solid component with intermediate T2 signal and high b1000
signal intensity was associated with a PLR of 4.5 for a malignant adnexal tumor.
Calculated ADC values, however, did not contribute to differentiating benign from
malignant adnexal masses.
Conclusion: DWI is an accurate tool for predicting benignity of complex adnexal
masses. DWI should have a role for selecting treatment strategy in women with
complex adnexal masses.
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Purpose: To study the method and findings of MR perfusion weighted imaging
(PWI) in normal kidney and renal diseases.
Methods and Materials: Thirty-three cases, including 9 volunteers, 14 cases with
renal carcinoma, 6 cases with renal cyst, 2 cases with renal angiomyolipoma and
2 cases with renal tuberculosis were examined with T1WI, T2WI and PWI. The data
from the cases were processed with workstation to obtain time-signal intensity
curves, color perfusion maps and relative perfusion value. The relative renal blood
volume (rRBV), the relative renal blood flow (rRBF), the mean Transition Time
(MTT) and the time to peak (TTP) in the normal renal cortex and medulla and the
renal lesions were calculated.
Results: After the treatment of statistics, the results showed that rRBV and rRBF
of the cortex was greater than that of the medulla in the normal kidneys (p 0.01
and p 0.01); MTT and TTP of the cortex was shorter than that of the medulla in
the normal kidneys (p 0.01 and p 0.05). The values of rRBF and TTP of the renal
carcinoma were evidently higher than the normal tissues (p 0.01). The values
of rRBV and rRBF of the renal cysts distinctly decreased (p 0.01) and MTT and
TTP lengthened (p 0.01). The value of rRBV of the renal angiomyolipoma and
the renal tuberculosis was distinctly decreased (p 0.01).
Conclusion: PWI can demonstrate the hemodynamic and the functional states of
the normal renal tissues and the renal lesions and will become an ideal method for
showing the morphological and functional changes of the kidney.
Scientific and Educational Exhibits
C-343
Incidental adrenal adenomas: Are we doing the right thing?
N. Schembri, G. Lamb; Liverpool/UK ([email protected])
Purpose: To evaluate the local practice of reporting incidental adrenal masses.
Methods and Materials: The initial report of adrenal adenomas picked up incidentally on CT or MR between January and December 2006 at the Royal Liverpool
University Hospital was looked at retrospectively. The contents of the initial report
were analysed for documentation for the need of biochemistry assessment, size,
morphology, HU or signal drop of the lesion, and follow-up imaging.
Results: 56 CT and 31 MR adrenal scans were analysed. Female to male ratio was
38:49, mean age of 55 years. 40 scans were carried out as follow-up investigations
of a previous incidental finding. Adrenal masses picked up as part of abnormal
biochemistry work-up or if malignancy was suspected were excluded. The National
Institutes of Health (NIH) Consensus Development Panel on Management of the
Clinically Inapparent Adrenal Mass (2002) was referred to as a standard. Differences emerged when compared with standard: biochemistry investigations were
suggested in only 37.5% of cases, morphological description was documented in
42.5%, size of the lesion was measured in 87.5% and HU/signal drop was documented in 40%. Follow-up imaging was advised in 67.5%, although the majority
did not specify a time interval. Follow-up imaging suggested varied among CT
(42.5%), MR (27.5%) and US (5%). 17.5% of scans were requested by clinicians
despite contrary advice given by the reporting radiologist.
Conclusion: In the absence of official UK national guidelines, we propose recommendations for reporting incidental adrenal adenomas to advise appropriate
management aimed at eliminating unnecessary over-investigation.
C-344
Infrarenal retroperitoneum: Detailed anatomy and various pathologic
conditions
J. Sung, S. Lee, Y. Ku, Y. Won, I. Hwang, K. Chun; Uijongbu/KR
([email protected])
Learning Objectives: To review embryogenesis and layered anatomy of infrarenal extraperitoneal space. To demonstrate various kinds of pathologic conditions
involving infrarenal retroperitoneum.
Background: The retroperitoneum is divided into the retroperitoneal space
and retroperitoneal plane. The retroperitoneal space at the level of the kidney is
subdivided into great vessels space, posterior renal space, perirenal space, and
anterior pararenal space (pancreaticoduodenal compartment and colonomesocolic
compartment). The retroperitoneal plane at the level of kidney is subdivided into
retromesenteric, retrorenal, lateral conal plane, and sufascial plane. But, below
the level of renal fascial cone, perirenal space and pancreaticoduodenal compartment of the retroperitoneal space disappear. The retromesenteric and retrorenal
planes are combined and make a combined interfascial plane. Then, infrarenal
retroperitoneum is composed of three spaces (colonomesocolic compartment of
the retroperitoneum, posterior pararenal space, and great vessel space) and two
interfascial planes.
Procedure Details: We divide infrarenal retroperitoneal space into 4 layers, from
ventral to dorsal aspect. Layer 1 colonomesocolic compartment: colon cancer,
lymphoma, diverticulitis. Layer 2 interfascial plane compartment: pancreatitis,
mesenteric hematoma, round ligament hematoma, ovarian vein thrombosis. Above
the level of iliac crest: retromesenteric plane, perirenal space, retrorenal plane.
Below the level of iliac crest: combined interfascial plane. Layer 3 great vessel
compartment: rupture of abdominal aortic aneurysm, May Thurner syndrome,
paraganglioma of organ, Zukerkandle. Layer 4 posterior pararenal space and
muscular compartment: schwannoma, psoas abscess.
Conclusion: The knowledge of layered anatomy of infrarenal retroperitoneum
is helpful in diagnosing and understanding the spread of the diseas involving
retroperitoneal space.
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MDCT is very useful to indicate the appropriate management of adrenal
hemorrhage in patients with severe blunt trauma
A. Pinto, S. Merola, A. Sparano, C. Stavolo, S. Daniele, T. Cinque, L. Romano;
Naples/IT ([email protected])
Purpose: To describe the management and the outcome of 35 cases of MDCTdetected adrenal hemorrhage in patients with severe blunt trauma.
Methods and Materials: We reviewed 35 patients who suffered from severe
traumatic adrenal hemorrhage after motor vehicle collisions (n = 20), falls (n = 9)
and sports-related (n = 6). MDCT images were analyzed for multi-organ traumatic
injury and at the level of the adrenal gland the following CT findings were searched:
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indistinct or enlarged adrenal gland, focal hematoma expanding and distorting the
adrenal gland, gross or focal adrenal hemorrhage in an otherwise normal-sized
gland and active adrenal bleeding.
Results: All 35 patients manifested multi-organ traumatic injuries. On MDCT images, adrenal gland hemorrhage appears as focal hematoma ranging from 20 to
60 mm in length and from 12 to 55 mm in width expanding and distorting the adrenal
gland (n=16), enlarged adrenal gland (n= 9), gross or focal adrenal hemorrhage
in an otherwise normal-sized gland (n=7) and active adrenal bleeding (n=3) with
pseudoaneurysm formation in one patient. Thirty-two patients were followed without
any intervention; two patients with active adrenal bleeding were submitted to surgery
and the last patient with active adrenal bleeding and pseudoaneurysm received
transarterial embolization. Follow-up CT scans obtained in all patients 3-90 days
after the trauma showed various degrees of resolution of the adrenal injury.
Conclusion: MDCT can accurately indicate the size of the hematoma and the
presence of extravasation helping in determining the appropriate management of
patients with traumatic adrenal hemorrhage.
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The volume of adrenal glands and its impact factors of average human
adults on 64-slice MSCT
X. Wang, H. Xue, W. Liu, Z. Jin; Beijing/CN ([email protected])
Purpose: To measure volume and other parameters of normal adrenal glands in
human adults and to correlate these measurements to age, sex and descriptors
of body size.
Methods and Materials: Measurements of adrenal glands were obtained from
computed tomographic images in 81 patients (M:F=1.5:1, age: 20-76, mean=48
y) who underwent enhanced 64-slice abdominal CT scan for routine clinical
indications. Patients with conditions known to affect the size of adrenal glands or
cases with focal adrenal enlargement suggesting a mass were excluded. Images
of portal phase were studied. Both the reconstruction interval and thickness were
1.5 mm. Adrenal gland was outlined by hand on each slice with computer-assistant
technology to calculate its volume. The maximal sectional area, length, width and
thickness of each adrenal gland were also measured.
Results: The average measurements for left/right adrenal gland were: mean
volume 4.23 cm³ (2.85-5.83, SD: 0.74)/4.26 cm³ (2.59-6.56, SD: 0.86); maximal
sectional area 1.86/2.22 cm², length 3.93/3.76 cm, width 2.52/3.33 cm and thickness
0.97/0.76 cm. The volumes slightly correlates with weight (L:r=0.2777, P=0.0174;
R:r=0.3417, P=0.0033) and BSA (L:r=0.3019, P=0.0094; R:r=0.3453, P=0.0030).
There was no significant difference in adrenal volume with regard to sex after
applying GLM procedure to reduce the impact of weight, nor did volume change
significantly with age. Length has a stronger correlation with volume than other
parameters in both left (r=0.4176, P=0.0001) and right (r=0.5157, P 0.0001)
adrenal glands.
Conclusion: Body size, rather than age and sex, affects the volume of adrenal
gland in human adults. Length has a stronger correlation with volume than other
parameters in both adrenal glands.
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Bosniak categorisation of renal cysts using gadolinium-enhanced 3-D
flash MRI
A. Snow, E. Ward, D. Halpenny, G. McNeill, N. Swan, W.C. Torreggiani; Dublin/IE
([email protected])
Learning Objectives: To illustrate the use of gadolinium-enhanced 3D fast low
angle single shot (FLASH) MRI in the categorisation of renal cysts according to the
Bosniak classification system. To correlate these findings with histology.
Background: Renal cysts seen on imaging commonly present a prognostic dilemma for the reporting radiologist. The Bosniak system of cyst classification is a
well-recognised, usually CT-based, method that provides a guide as to the need for
further imaging or intervention. MRI has previously been shown to be a valuable tool
in the assessment of renal masses, including cystic lesions. In this exhibit, we will
describe the imaging protocol used and demonstrate the ability of 3D FLASH MRI
to easily and accurately categorise renal cysts according to the Bosniak system.
In addition, we will provide histological correlation.
Imaging Findings: 3D FLASH MRI provides excellent detail of cystic renal masses
through the whole spectrum of Bosniak categories, including small lesions that may
be poorly seen using other imaging modalities. We give examples of all categories
(I, II, IIF, III and IV). Gadolinium administration further assists in the differentiation of
benign from malignant lesions by enhancing soft tissue structures within the mass
and is routinely used in appropriate patients in our department.
Conclusion: We demonstrate that gadolinium-enhanced 3D FLASH MRI allows
clear differentiation of all categories of Bosniak cysts and is a useful tool in the
workup of such masses.
Scientific and Educational Exhibits
C-348
Ormond’s disease or secondary retroperitoneal fibrosis: An overview of
retroperitoneal fibrosis
M. Heckmann, M. Uder, W. Bautz, M.C. Heinrich; Erlangen/DE
Learning Objectives: This poster illustrates the spectrum of retroperitoneal fibrosis
(RF) and describes how to assess its activity. It should help to differentiate between
malignant and benign RF.
Background: RF represents a rare inflammatory disease. About two-thirds seem
to be idiopathic (=Ormond’s disease). One-third is secondary to infections, traumata, radiation-therapy, malignant diseases or the use of certain drugs. The clinical
symptoms are non-specific.
Imaging Findings: On sonography, RF appears as a hypoechoic mass that can
involve the ureters and cause hydronephrosis. IVU and MRU can demonstrate the
triad of medial deviation, extrinsic compression of the ureters and hydronephrosis.
The lesion typically begins at the level of the forth or fifth lumbar vertebra, encasing the aorta and often displacing the ureters medially. On unenhanced CT, RF is
isodense with muscle. On MRI, the mass is hypointense on T1-weighted images. On
T2-weighted images, it may be hyperintense at early stages, and at late stages its
signal may be low. After administration of contrast-media, enhancement is greatest
in the early inflammatory phase and minimal in the late fibrotic phase. To differentiate
retroperitoneal masses diffusion-weighted MRI may provide useful information.
Conclusion: RF is a rare, but complex condition in which the role of the radiologist
is essential, both in suggesting the diagnosis and in aiding management. Therefore,
CT and MRI play an important role. T2-weighted images and dynamic enhancement can help in assessing activity, monitoring response to therapy and detecting
relapse. ADC-values may provide useful information in differentiating benign and
malignant retroperitoneal masses.
C-349
The enhancement parameters of renal tumours with reference to
opacification of aorta in multiphase CT examination
L. Grzycka-Kowalczyk, E. Czekajska-Chehab, G. Staskiewicz, S. Wojtaszko,
K. Bar, A. Drop, D. Skomra, E. Korobowicz; Lublin/PL ([email protected])
Purpose: Precise prediction of tumor type may be helpful for treatment planning.
The aim of the study was to evaluate MSCT imaging of renal tumors, estimate a
pattern of tumor enhancement with the reference to abdominal aorta and measure
the differences in attenuation values according to grade of differentiation (G) among
clear cell subtype.
Methods and Materials: 61 CT examinations with pre-contrast and contrastenhanced acquisition on arterial (AP), corticomedullary (CMP) and excretory
phase (EP), with subsequently confirmed 45 clear cell renal carcinomas (including
5 cystic type); 6 papillary renal cell tumors, 4 oncocytomas, 4 cystic nephromas,
2 uroepithelial carcinomas. The attenuation in three regions of interest (ROI) was
measured on pre-contrast scanning and after IV administration of contrast agent
on all phases.
Results: Pairwise comparison showed different attenuation values on AP between
clear cell and papillary subtypes - with predominance of clear cell tumor; stronger
enhancement of oncocytoma than relevant part of clear cell tumor and higher attenuation values of all RCC subtypes than cystic nephroma. The attenuation values
among G-1, G-2 and G-3 clear cell subtypes differ on CMP, in central parts of G-2
and G-3 tumors and during EP, in central parts of G-2 and G-3. Tumor density
with reference to aorta showed higher enhancement value (on CM phase) among
oncocytomas than clear cell and RCC tumors.
Conclusion: The degree of enhancement during post-contrast scanning can be
a valuable parameter for differentiating among renal tumors and evaluating grade
of differentiation among clear cell subtype.
Urolithiasis: Toward more comprehensive radiological reporting
W. Shabana, R.P. Galwa; Ottawa, ON/CA ([email protected])
Learning Objectives: To illustrate the role of different imaging modalities and recent
updates in urolithiasis with emphasis on the reported findings that are crucial in
clinical decision making.
Background: Flank pain is a common presentation in the emergency department.
Diagnostic imaging plays a crucial role in detection of urolithiasis and exclusion of
other etiologies as well as choosing the best treatment plan. Factors such as stone
size, stone location and urinary tract anatomy significantly influence the decision
between invasive and noninvasive treatments.
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Spectrum of CT and MR findings in disease of the adrenal gland
A. Perez Martinez, Y. Herrero Gomez, M.J. Adan Martin, R. Juarez Tosina,
C.N. Cereceda Perez, J.M. Pinto Varela, C.R. Caracela Zeballos,
P.M. Aguilar Angulo; Toledo/ES ([email protected])
Learning Objectives: The aim of this teaching exhibit is to illustrate the imaging
findings obtained with computed tomography (CT) and magnetic resonance imaging
(MRI) in a wide spectrum of usual and unusual adrenal diseases.
Background: The adrenal gland is a common site of disease. Adrenal disease
is often discovered incidentally during the evaluation of a variety of abdominal
complaints. CT and MRI play a significant role not only in the detection of adrenal
abnormalities but also in characterizing them as benign or malignant. The imaging
findings of patients with disorders involving the adrenal were reviewed from our
database of abdominal pathology. CT was performed in all cases, while MRI was
performed in all masses and whenever TC images were not conclusive. The key
findings at each imaging modality are shown and compared with the underlying
pathologic features when available.
Imaging Findings: Abnormalities of the adrenal gland include adrenal hyperplasia,
traumatic haemorrhage, benign masses (functional and non-functional adenomas,
cysts, myelolipoma, angioma pheochromocytoma, ganglioneuroma), malignant
masses (carcinoma, metastases), infections and Addison disease. In addition, we
describe the normal adrenal anatomy with CT and MR imaging, and some usual
pitfall of adrenal masses.
Conclusion: Evaluation of patients with adrenal disorders frequently requires
multiple imaging modalities for diagnosis and surgical management planning.
Because many of these disorders have characteristic imaging appearances, this
exhibit will help the practicing radiologist to better understand and recognize the
pathologic processes affecting the adrenal gland.
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Retroperitoneal liposarcoma: Imaging findings
M.M.M.D. Djosev1, M.M.M.S. Stojanovic1, J.J.S.I. Ilic1, B.B.O.R. Begenisic1,
N.N.M.D. Djuric1, D.D.J.L. Lalosevic1, S.S.M.A. Arsenovic1, M.M.N.D. Djuric2,
M.M.Z.G. Glumac2; 1Belgrade/RS, 2Sombor/RS ([email protected])
Learning Objectives: In this exhibit, we will illustrate and discuss the imaging
findings in MSCT of retroperitoneal liposarcoma.
Background: Liposarcoma is the second commonest malignant retroperitoneal
soft-tissue tumor in adults and classically presents as a large mass with minimal
symptoms and a high local recurrence rate. It is a slow growing tumor that displaces
rather than infiltrates surrounding tissue and may attain enormous size before it
is detected.
Imaging Findings: Computed tomography scanning plays an important role in
the diagnosis of lipomatous and myxoid tumors of soft tissue. We reviewed the CT
findings of patients with retroperitoneal liposarcoma. Because the tumorous mass
may consist predominantly of fat or soft-tissue components, depending on its grade
and histology, CT findings demonstrate 3 distinct patterns, as follows: solid pattern
(inhomogenous, poorly marginated infiltrating mass with contrast enhancement
( 20 HU)); mixed pattern (focal fatty areas (-40 to -20 HU) with areas of higher
density ( 20 HU)); pseudocystic pattern (water density mass -20 to +20 HU).
Conclusion: Preoperative diagnosis of retroperitoneal liposarcoma is a common
problem due to lack of characteristic clinical presentations. CT is used to diagnosis
and assess the size and extent of retroperitoneal tumors, as well as assess the
involvement of organs and vasculature. Different subtypes of retroperitoneal liposarcoma show different CT features relating to their major histologic component.
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C-350
Imaging Findings: Plain radiography (KUB): The maximum renal stone diameter
on KUB is the standard used by the urology guidelines for stone management.
Sensitivity and specificity of KUB for detecting renal stones will be discussed.
Ultrasonography: The sensitivity, specificity, various factors that contribute to urolithiasis detection and new techniques (e.g. twinkling) will be discussed. Intravenous
urogram: It is considered by urologists as the gold standard in treatment planning.
However, currently it is a suboptimal modality for urolithiasis. Unenhanced CT: It
replaced urogram with sensitivity and specificity of 95-100%. The clinical relevance
of ureterolithiasis depiction with respect to the anatomical landmarks used by urologists is still lacking in radiology reports. The use of multiformatted CT images is also
underutilized despite its high potential in stone size assessment.
Conclusion: Unenhanced CT is currently the gold standard for urolithiasis. The
radiology report should include the stone size, location and detailed urinary tract
anatomy, which are significant factors in treatment planning and approach.
Scientific and Educational Exhibits
C-354
Imaging of renal infections: A pictorial review
M. Franca, B. Ramos, J. Pires, R. Maia, M. Certo, P. Varzim; Porto/PT
([email protected])
Learning Objectives: To review the role of imaging in the evaluation of renal infections and related complications. To show its imaging findings, focusing on ultras
sonography (US) and computed tomography (CT). To present manifestations of
unusual infections, as emphysematous pyelonephritis and xantogranulomatous
pyelonephritis.
Background: Although not routinely indicated in noncomplicated pyelonephritis,
imaging plays a significant role to assess clinically equivocal cases, to evaluate
high risk patients, to determine the extent of inflammatory process and to depict
its complications.
Imaging Findings: US is frequently used in evaluation of suspected pyelonephritis
and has a major role in pregnant women. It can identify areas of renal infection,
abscesses, pyonephrosis and extension to perinephric space. Doppler-US improves
its sensitivity in detecting parenchymal infection. CT is the modality of choice to
image pyelonephritis. The presence of gas, calculi, haemorrhage or masses can
be revealed with unenhanced CT. Administration of contrast demonstrates areas of
abnormal nephrogram, obstruction to renal excretion, and identifies complications.
The authors review the imaging findings of renal infections and its complications,
exemplifying with representative cases. They pay attention both to typical and
more unusual forms of pyelonephritis, such as emphysematous pyelonephritis and
xantogranumolatous pyelonephritis.
Conclusion: The role of imaging is fundamental in patients with pyelonephritis and
recurrent, equivocal or persistent symptoms despite adequate treatment, and in
evaluation of patients with high-risk factors to renal infection. Familiarity with imaging
findings of typical and unusual forms of renal infections, as well of its complications,
is crucial to make the correct diagnosis.
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Diagnostic features and follow-up of complicated pyelonephritis on
second generation contrast ultrasound
T. Fontanilla, J.M. Arriaga, C. García Roch, J. Hernanz, R. Pérez Arangüena,
I. Rivera, E. Van denBrule; Madrid/ES ([email protected])
Purpose: Our objectives are to describe the diagnostic features of complicated
pyelonephritis on contrast enhanced ultrasound (CEUS), to distinguish focal
pyelonephritis from abscess, and to describe the findings during the follow-up of
these patients.
Methods and Materials: Baseline grey scale, power Doppler and contrast enhanced ultrasound (CEUS) were performed in 23 patients (mean age 27 years),
suspects of complicated pyelonephritis. Contrast specific programs were used
after an intravenous bolus 2.4 ml dose of a sulphur hexafluoride contrast agent
(SonoVue). Follow-up was done in 10 patients.
Results: CEUS showed: No findings (n=5 patients), focal pyelonephritis (n=14)
and abscess (n=8). In 4 cases, there were both abscess and focal pyelonephritis.
Pyelonephritis and abscess showed distinctive enhancement patterns. Focal
pyelonephritis appeared as a focal hipoenhanced lesion in cortical and late corticomedular phase; iso or hipoenhanced on early corticomedular phase. Abscesses
appeared as focal areas of absence of enhancement in all phases. Follow-up
showed rapid healing of focal pyelonephritis, and a much slower resolution of the
sonographic findings in abscesses. 3 patients developed hipovascular cortical
scars; one of them developed arterial hypertension.
Conclusion: CEUS improves the diagnostic performance of baseline sonography
in the detection of complications of pyelonephritis. It provides enhancement features
that make possible to distinguish abscess from focal pyelonephitis. Due to the
absence of radiation, CEUS may be considered as a first line tool in the follow-up
of these usually young patients.
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Imaging of complex cystic lesions of the kidney with contrast-enhanced
ultrasonography
H. Moschouris1, M.G. Papadaki1, A. Foteinos1, P. Goutzios2, D. Matsaidonis1;
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Piraeus/GR, 2Athens/GR ([email protected])
Learning Objectives: To illustrate the findings of contrast-enhanced ultrasonography (CEUS) in the main types of complex cystic renal masses. To demonstrate
the advantages and limitations of this method and assess its role in the diagnostic
work up of these lesions.
Background: Complex cystic renal masses often pose diagnostic and therapeutic
problems. CEUS can be utilised immediately after the sonographic detection of a
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complex renal mass in order to evaluate the vascularity of the lesion and increase
the yield of information provided by baseline US.
Imaging Findings: Several cases of complex cystic renal masses studied by
ultrasound before and after the i.v. administration of a last generation ultrasound
contrast agent (SonoVue, Bracco) are demonstrated: Cystic renal cell carcinomas
(unilocular with mural nodule, multilocular with thickened irregular septa, heterogeneous with microcystic and solid components), benign cystic renal tumor (cystic
multilocular nephroma), complicated non neoplastic renal cysts, renal abscesses,
liquefied renal hematoma with cystic morphology and renal hydatid cyst. The high
sensitivity of CEUS in detecting blood flow in the neoplastic or inflammatory tissue
is demonstrated and several patterns of enhancement are described. The ability
of CEUS to differentiate hemorrhagic (non-enhancing) cysts from semi-solid renal
tumors is underlined. The findings of CEUS are correlated with those of grey-scale
and color Doppler ultrasonography and with CT and MRI.
Conclusion: CEUS can increase the diagnostic efficiency of US in the assessment of complex cystic renal masses and may, in a few cases, obviate the need
for further imaging investigation.
C-357
Chronic renal infections in the third world: Spectrum of imaging findings
Z.A. Khan, S. Ahmad; Karachi/PK ([email protected])
Learning Objectives: 1. To understand the imaging characteristics of renal infections. 2. To outline salient differentiating features of various renal infections.
Background: Diagnosis of renal infection particularly in its chronic stage is often
challenging. Clinical presentation is usually non-specific and often confusing resulting in delay in the diagnosis and initiation of proper therapy. Often the diagnosis is
first suggested on imaging done for workup of non-specific abdominal complaints.
On imaging these infections could have varied features. In developing countries
where a large segment of population has limited access to medical care, diagnosis of these infections is even more difficult because of the late presentation and
advanced nature of the disease.
Imaging Findings: In this exhibit, we will present typical and atypical characteristics of different kinds of renal infections presenting in a tertiary care center of a
third world country. These include acute and chronic pyelonephritis, pyonephrosis,
renal tuberculosis, hydatid, fungal infection (candidiasis, aspergillosis etc)., and
xanthogranulomatous pyelonephritis etc.
Conclusion: Diagnosis of chronic renal infections is a challenging task due to
non-specific clinical presentation and more varied imaging characteristics. Awareness of the complete spectrum of imaging finding of different kinds of infection is
important to arrive at a correct diagnosis.
C-358
Renal oncocytomas: computed tomography (CT) and magnetic resonance
(MR) patterns
G. Cardone, C. Iabichino, P. Mangili, G. Guazzoni, G. Balconi; Milan/IT
([email protected])
Learning Objectives: To illustrate the most frequent CT and MR patterns of renal
oncocytomas. To evaluate the most effective CT and MR imaging examination
techniques in the diagnosis of renal oncocytomas.
Background: Renal oncocytoma, a subgroup of renal adenoma, is a benign neoplasm that arises from tubular epithelial cells of the kidney. 22 patients with renal
oncocytomas were evaluated by means of both CT and MR examinations.
Procedure Details: MDCT were performed using unenhanced and post-contrast
scans, followed by urographic acquisition. MR was performed using pyelographic,
urographic and conventional GRE-T1w, TSE-T2w and ce-GRE FS-T1w sequences.
Ce-T1w MR images were also obtained before and after digital subtraction.
Conclusion: The most frequent CT patterns were isodensity on pre-contrast images, hyperdensity on early ce images and relative hypodensity on late ce images.
The most frequent MR patterns were hypointensity with a hyperintense central
scar on T2w images, hyperintensity with a hypointense central scar on early ce
images and hyperintensity on late ce-images. The most effective CT technique
was multiphasic acquisition. The most effective MR techniques were TSE T2w and
dynamic ce-FS-GRE T1w sequences.
Scientific and Educational Exhibits
C-359
Laparoscopic cryoablation (LC) of small renal tumors imaging follow-up:
Comparison between magnetic resonance (MR) and multi-detector row
computed tomography (MDCT) imaging patterns
G. Cardone, A. Cestari, P. Mangili, G. Guazzoni, G. Balconi; Milan/IT
([email protected])
Learning Objectives: To illustrate the differences between MR and MDCT patterns
in patients treated with LC for small renal tumors. To show the advantages of MR
imaging in the follow-up of patients treated with LC.
Background: LC is considered a minimally invasive approach for the treatment
of small renal masses. Since it is not possible to document histopatologically the
complete tissue necrosis after cryoablation, an adequate radiological follow-up
is mandatory. We reviewed 2 year MR and CT imaging follow-up of 5 pts, who
performed abdominal MR follow-up for LC of small renal tumors and whole body
MDCT follow-up due to concomitant neoplastic pathologies.
Imaging Findings: On MR and CT imaging 24h after treatment all cryolesions
were more than 1 cm larger than the original masses. Cryolesions decreased in
size by an average of 38% at 1 month, 80% at 12 months and 88% at 24 months
following cryoablation. Postprocedural MR ce-T1w and ce-MDCT images showed
complete ischemia of the cryolesions. Retroperitoneal and pleural effusion was
found in all cases 24 h after surgery. On CT images, cryolesion was isodense with
respect to perilesional effusion.
Conclusion: LC is a safe and minimally invasive therapy for small renal tumors. MR
is an effective tool in the imaging follow-up of renal lesions treated with LC. MDCT
can be used as alternative choice to MR, but lower contrast resolution compared
to MR imaging makes it difficult to differentiate cryolesion from the surrounding
perilesional collections.
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Laparoscopic cryoablation (LC) of renal carcinomas: Medium term
outcome after 7 years MR imaging follow-up
G. Cardone, A. Cestari, L. Nava, P. Mangili, G. Guazzoni, G. Balconi; Milan/IT
([email protected])
Purpose: This study aims to determine the safety and efficacy of LC in the management of small renal carcinomas and assess its medium term outcome.
Methods and Materials: 67 pts underwent LC of 82 renal carcinomas between
July 2000 and December 2007. All treatment was administered under laparoscopic
US guidance. Pts were followed up clinically, biochemically and by MR imaging
24 hours after surgery, and subsequently at 1, 3, 6, 12, 18, 24, 36, 48, 60 and 84
months. All MR examinations were performed with a 1.5 T MR system using GRE
T1w, TSE T2w and ce -dynamic GRE FS-T1w sequences.
Results: 24 hours after treatment all cryolesions were more than 1 cm larger
than the original masses; cryolesions decreased in size by an average of 38% at
1 month, 64% at 6 months, 80% at 12 months and 93% at 84 months following
cryoablation. Postprocedural MR ce-T1w images showed complete ischemia of
cryolesions. Follow-up revealed no evidence of local recurrence in 65/67 pts (97%).
2 pts showed local recurrence at 12 and 24 months. 8/67 (12%) pts demonstrated
metachronous nodules in the same or in the contralateral kidney at 12-24 months.
7/67 pts died for metastasis of a previous malignancy. After surgery, 21% of the
cases showed a small intralesional haematoma and 11% of the cases a small
perilesional haematoma.
Conclusion: Our medium term experience suggests that LC is a safe, well tolerated
and minimally invasive therapy for small renal carcinomas, and MR is an effective
imaging technique in the follow-up of renal lesions treated with LC.
C-361
Learning Objectives: To illustrate the spectrum of genitourinary tuberculosis in a
tertiary care centre of a third world country where the disease is endemic.
Background: Tuberculosis (TB) is a global emergency particularly with the growing
infection rate of AIDS worldwide. Genitourinary tuberculosis (GUTB) is an example
of secondary tuberculosis and is the third commonest extra pulmonary lesion. The
incidence of GUTB is also increasing especially in the developing countries where
the incidence can be five times higher than in the western countries. This could be
a reflection of the social deprivation, poor diet and over crowded living conditions
that have a direct effect on the disease by increasing the susceptibility.
Imaging Findings: In this exhibit, we present imaging features in 122 patients who
have tuberculous involvement of various parts of genitourinary tract including kidney,
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Ultrasound and contrast-enhanced ultrasound in the management and
follow-up of percutaneous radiofrequency ablation of renal tumors
C. Hoeffel1, O. Helenon2, F. Tranquart3, A. Méjean2, A. Khairoune1, J.-M. Correas2;
1
Reims/FR, 2Necker/FR, 3Tours/FR ([email protected])
Learning Objectives: To illustrate the role of ultrasound (US) and contrastenhanced ultrasound (CEUS) during percutaneous radiofrequency ablation of renal
tumors (RFA). To illustrate the spectrum of CEUS findings in renal tumors successfully treated and to show typical patterns of residual tumor after RFA. To highlight
pitfalls that may be encountered in assessing residual tumor with CEUS.
Background: Between January 2006 and June 2008, 65 tumors in 43 patients
(mean age 61, range 24-90) were treated and prospectively followed-up with CT
and/or MR examinations the day after the RFA procedure, at six weeks, four months,
one year and each year subsequently. 17 patients had Von Hippel Lindau (VHL)
disease. Seven tumors were retreated at least once.
Imaging Findings: This exhibit illustrates the major value of US and CEUS for
guiding biopsy and electrode placement, as well as for immediate assessment
of renal RFA and electrode repositioning on residual tumor. CEUS role in the
follow-up is crucial as CEUS allows real time identification of a residual or recurrent
tumor in the RF ablation zone when an enhancing nodule or crescent, most often
peripheral, is seen. Comparison of follow-up CEUS with CEUS of the renal tumor
before treatment is mandatory.
Conclusion: CEUS has an important role to play in the immediate and mid term
follow-up of RFA procedures, particularly for detection of a residual tumor. It is
an interesting complement to CT or MRI as it can be easily performed (no renal
toxicity).
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Pearls and pitfalls in the MR imaging and CT evaluation of renal tumors
treated with percutaneous radiofrequency ablation (RFA)
C. Hoeffel1, A. Khairoune2, S. Merran2, O. Helenon2, A. Méjean2, J.-M. Correas2;
1
Reims/FR, 2Paris/FR ([email protected])
Learning Objectives: To illustrate the spectrum of CT and MRI findings in renal
tumors successfully treated using percutaneous RFA and to show typical patterns
of residual tumor. To illustrate the spectrum of complications. To highlight pitfalls that
may be encountered in assessing residual tumor after RFA. To suggest guidelines
for an accurate imaging diagnosis of residual tumor.
Background: Between January 2006 and June 2008, 65 tumors in 43 patients
(mean age 61, range 24-90) were treated and prospectively followed-up with CT and
/or MR examinations the day after the RFA procedure, at six weeks, four months,
one year and each year subsequently. 17 patients had a Von Hippel Lindau (VHL)
disease. Seven tumors were retreated at least once.
Imaging Findings: Differential diagnosis of residual disease is illustrated, including presence of devascularized renal parenchyma, arteriovenous fistula, vessels,
detached renal parenchyma. The following issues are highlighted: Comparison of
follow-up imaging with initial imaging pattern is mandatory. Analysis of unenhanced,
arterial, tubular and delayed phases after contrast administration is essential for
evaluation of residual tumor and complications (urinomas, hematomas and hemorrhages, bowel perforation, and vascular disorders). MDCT multiplanar reformats
may prove useful, as well as subtraction between enhanced and unenhanced fat
suppressed T1- weighted sequences.
Conclusion: MDCT is the reference imaging modality in the evaluation of renal
tumors after RFA. MRI is an alternative modality in case of renal insufficiency or
may be performed in addition to MDCT when assessment of residual disease is
difficult.
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S411
Genitourinary
Imaging spectrum of genitourinary tuberculosis: Our experience at a
tertiary care centre of a third world country
Z.A. Khan, S. Ahmad; Karachi/PK ([email protected])
ureter, urinary bladder, prostate and urethra. These patients were diagnosed and
treated at Sindh Institute of Urology and Transplantation, Karachi over a period of 10
years. The diagnosis was based on microbiological and histopathological grounds. In
a few cases, the diagnosis was presumptive where clinical and radiological features
were suggestive and anti tuberculous treatment resulted in improvement.
Conclusion: Genitourinary tuberculosis remains a significant diagnostic problem especially in developing countries. Imaging studies are only suggestive or
compatible for the disease and should not be used for confirmation or exclusion
of the disease.
Scientific and Educational Exhibits
C-364
Functional VCT XT 80 mm perfusion imaging simultaneously with dynamic
CTA for diagnosis of the stenosis of renal artery
X. Ye, C . Zhou, H. Cao; Beijing/CN ([email protected])
Purpose: To evaluate the value of functional VCT XT 80 mm perfusion imaging
simultaneously with dynamic CTA for diagnosis of the stenosis of renal artery.
Methods and Materials: Functional 80 mm perfusion imaging with dynamic CTA
was performed in 30 patients with stenosis of renal artery using VCT XT. One 49.4
s (include 18 pass) axial scanning was performed in each case. Dynamic scanning
material. Total 288
started at the 8th second after injection of a bolus of contrast
S
images with 5 mm slice thickness were obtained through
PO the kidneys. All images
E
were reconstructed at 0.625 mm slice thickness.
The perfusion images and the
to
dynamic renal artery CTA (include 3D MIPdand MPVR) of different phase at an
e
interval of 2.8 s were obtained on workstation.
itt
m
Results: Satisfying dynamic CTA images
of renal artery were obtained in 30 paub and degree of the stenosis of renal artery.
tients, which clearly showed the location
S
Degree of stenosis b50% in 13alcases (group A), 51~75% in 10 cases (group B),
i
75% in 7 cases (group C).tComparing
with the intact kidney, the value of BF and
er
a
BV of the affected kidney
M were decreased, but the value of MTT was increased.
There was significantodifference of these values between bilateral kidneys in group
N
B and group C.
Conclusion: The functional 80 mm perfusion images simultaneously with dynamic
CTA clearly show the hemodynamic information of the kidney and the morphological
change of the renal artery. It is useful for diagnosis and follow-up of the stenosis of
renal artery and function of the kidneys.
C-365
Transdiaphragmatic decompression pathways of pneumomediastinum and
pneumoretroperitoneum
J. Isogai, J. Kaneko, S. Maejima; Hasuda/JP
Learning Objectives: 1. To describe transdiaphragmatic pathways of compressed
air in the pneumomediastinum and pneumoretroperitoneum based on 9 and
12 patients, respectively. 2. To illustrate each compartment of retroperitoneal
interfascial spaces into which air is dissected. 3. Not to mistake extraperitoneal
infradiaphragmatic air for intraperitoneal air in order to avoid unnecessary exploratory surgeries.
Background: It has been mentioned the retroperitoneal fascia has potential space
and its continuity among compartments by the direct injection of contrast materials.
Since compressed air dissects into interfascial spaces more physiologically, we can
easily understand the continuity between mediastinum and retroperitoneum.
Imaging Findings: 1. CT features of air distribution in the extraperitoneal and
extrapleural spaces via diaphragm. 2. To illustrate anterior and posterior transdiaphragmatic pathways of compressed air.
Conclusion: Radiologists must be aware of extraperitoneal infradiaphragmatic
air to avoid unnecessary exploratory surgeries and recognize decompression
pathways to select an appropriate drainage route if abscess formation occurs in
the periphrenic space.
C-366
When the kidney is bleeding: A review of traumatic and not traumatic acute
renal bleeding
M.I. Rossi Prieto, E. Monedero Martínez- Pardo, P. Díez Martínez,
J.J. Gómez Herrera, A. Marín Toribio, S. Borruel Nacenta; Madrid/ES
([email protected])
Learning Objectives: To explain the different causes of acute renal bleeding
(ARB). To correlate and illustrate the findings in ultrasound, CT and arteriography.
To assess the role of the radiologists in the management of these patients and the
different possibilities of treatment.
Background: The ARB is an emergency situation and can lead to a hemodynamic
failure. A proper and fast management of these cases allows a good prognosis
overall in politrauma patients. While ultrasound only gives us indirect signs, CT
can provide anatomic and pathologic information required to determine the management of ARB. Patients in stable condition should be referred for angiographic
embolization, while life-threatening bleeding is the only absolute indication for
surgical exploration.
S412
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Imaging Findings: We show numerous cases of active kidney bleeding. The causes
were traumatic and nontraumatic. In most cases, we have correlated US and CT
images as well as those obtained by angiography. We have made a follow-up of
the treatment given to the different cases evaluating the possible complications
(urinome, rebleeding, renal ischemia, parenchymatous hematoma and venous
thrombosis). CT is the best initial method to diagnose ARB and in most cases to
identify the underlying complications.
Conclusion: CT is the technique of choice in the initial management of patients
with active bleeding, showing great efficacy and good correlation with angiography.
If the renal bleeding is important, nephrectomy is the best treatment with the less
number of complications.
C-367
Clinical practice results of new CT urography protocols
V. Taboada, B. Suárez, C. Rodríguez Paz, A. Fabbricatore, M. Otero; Vigo/ES
([email protected])
Learning Objectives: 1. Practical CTU protocols technique adapted from the ESUR
consensus. 2. Selection of the CTU protocol depending on the clinical suspicion. 3.
Optimization of radiation dose and results on every CTU protocol.
Background: CTU Working Group of the European Society of Urogenital Radiology
(ESUR) proposal on indications and technique for CTU was the first consensus
reached on the application of this technique. We have adapted our CT protocols
according to this consensus and present our results.
Procedure Details: We assessed renal function with creatinine clearance value. All
protocols include furosemide use (10 mg/1 min previous contrast injection). Single
phase: Congenital anomalies, traumatic lesions, complicated urinary infections,
haematuria (low risk of TCC), percutaneous nephrolithotomy planning, urinary
diversions. Split-bolus single CTU: Nephrographic-Excretory phase. Triple-bolus
single CTU: Corticomedullary-nephrographic-excretory phase. Dual Phase: Haematuria (high risk of TCC), invasive extraurinary tumor, papillary and medullar
necrosis. Single-bolus CTU: Portal or nephographic phase and excretory phase.
CT exploration systems: 16 and 64 detectors CT with appropriated reconstruction
parameters for each model and multiplanar and 3D post-processing imaging. We
have evaluated the radiation dose with the CTDI, DLP and effective dose parameters
in each one of the news protocols.
Conclusion: 1. We have achieved a relievable and reproducible CTU technique. 2.
The adaptation of the CTU protocol depending on the clinical suspicion improves
diagnostic efficiency and the decreases the global radiation dose. 3. We review the
radiation dose parameters values in every CTU protocol.
C-368
Metastatic renal cell carcinoma: Assessment of tumour response to
targeted therapy
N. Bharwani, N. Griffin, M. Gore, S.A. Sohaib; London/UK
Learning Objectives: 1. To review the CT appearances of advanced metastatic
renal cell carcinoma (mRCC) at presentation and following treatment. 2. To highlight
the potential pitfalls in image interpretation that can occur following treatment with
targeted therapy.
Background: Metastatic disease occurs in a significant proportion of patients with
RCC. Recent advances in systemic treatments for mRCC using targeted therapy
have shown a significant increase in progression-free survival. These new drugs are
cytostatic and inhibit growth rather than induce tumour regression. Therefore, the
use of accepted tumour response criteria (WHO and RECIST) has limitations and
potential pitfalls. This pictorial review will discuss and illustrate the post-treatment
appearances and highlight possible misinterpretations.
Imaging Findings: RCC metastases are typically vascular, enhancing lesions.
Following treatment with targeted therapy, responders show a decrease in lesion
attenuation. This may be accompanied by a decrease in size, although most lesions
show disease stabilisation by CT size criteria. A common pitfall is the apparent
detection of “new” visceral lesions on post-treatment imaging, e.g., within the liver.
We will also demonstrate the evolution in appearances of disease response within
different organs.
Conclusion: Tumour size response criteria have limitations in mRCC in patients
on targeted therapies. With increasing use of these new systemic treatments, radiologists should be aware of typical post-treatment appearances and the potential
pitfalls in interpretation.
Scientific and Educational Exhibits
C-369
Renal cell carcinoma: Hunt the metastasis
N. Bharwani, N. Griffin, M. Gore, S.A. Sohaib; London/UK
Learning Objectives: a) To illustrate the typical CT appearances of RCC metastases. b) To determine common sites of metastatic disease and identify important
review areas.
Background: Metastatic disease is seen in approximately 25-30% of patients
presenting with RCC. In patients presenting with early stage disease, approximately
50% will develop recurrent or metastatic disease, usually within 3 years of initial
nephrectomy. With increasing treatment options available for patients with metastatic
RCC, knowledge of the imaging patterns is essential. We have reviewed the imaging
of 70 patients with metastatic RCC presenting for treatment targeted therapies to
identify the common sites of disease and highlight the frequently missed lesions.
Imaging Findings: RCC metastases have typical appearances within the thorax,
abdomen and pelvis. This pictorial review will discuss and illustrate the pattern and
characteristic features of recurrent and metastatic disease in our patient population.
Common sites of disease are the lung (83%), lymph nodes (73%), liver (34%) and
bone (31%) where lesions are typically lytic and expansile. Frequently overlooked
sites of disease include the pancreas, thyroid and subcutaneous tissues.
Conclusion: Imaging has a pivotal role in assessment of disease extent and
evaluation of treatment response in patients with metastatic RCC. With the advent
of new systemic therapies for metastatic RCC, the reporting radiologist needs to
be aware of the patterns of disease spread as imaging has an ever increasing role
in informing management decisions.
C-370
To illustrate pathophysiology and CT imaging features of various ureteric
colic mimics
M. Sreenivas, A. Razack; Hull/UK
Learning Objectives: To illustrate the pathophysiology and CT imaging features
of various ureteric colic mimics. To emphasise the importance of reviewing every
CT KUB study systematically.
Background: Ureteric colic secondary to a stone disease is one of the most common urological emergencies. In many centres, plain CT KUB has become a wellestablished technique in the investigation of ureteric colic. Our institutional review of
780 consecutive CT KUB studies revealed about 4% of acute non-urological surgical
emergency conditions. In addition, another 4% of cases were non emergency but
significant pathological conditions. In this exhibit, we describe the pathophysiology
and plain CT features of various ureteric colic mimics.
Imaging Findings: Images were reviewed on a dedicated CT workstation with mutliplanar reformatting and using various window settings. Presence of free gas and
fluid, and inflammatory fat stranding were noted. Inflammatory or tumour features
involving particular organ system were analysed. Examples include diverticulits,
appendicitis, pancreatitis, panniculitis/epiploic appendagitis, bowel perforation,
intussussception, gall stone ileus, dermoid cyst, renal cell carcinoma, carcinoid
tumour and complex ovarian cyst.
Conclusion: A number of non-urological conditions mimic ureteric colic and can
be detected on CT KUB. It is important to beware of these conditions so that the
patients can be appropriately managed.
C-371
An illustration of the MR appearances of renal lesions treated with
radiofrequency ablation in patients suffering from Von Hippel Lindau
syndrome
D.J. Alcorn; Glasgow/UK
C-372
Complex renal stones: The benefit of a pre-operative planning with 3D CT
A. Magnusson1, M. Brehmer2, M. Beckman2; 1Uppsala/SE, 2Stockholm/SE
([email protected])
Purpose: To evaluate the impact of an extended preoperative radiological planning
with 3D CT in patients with complex renal stones.
Methods and Materials: 31 consecutive patients with complex renal stones were
included. Initially, the patients were examined with excretory urography or abdominal
CT. In consensus, an endourologist and a radiologist decided an optimal track from
these images. All patients were then examined with CT with thin slices ( 1 mm)
and 3D reconstructions of the collecting system and the stone/stones. In order to
simulate positioning during surgery, the patients were scanned in a prone position
and with a wedge cushion under the lower part of the abdomen. In consensus and
blinded for the result from the initial decision, a track was estimated from the 3D
CT. All patients underwent percutaneous nephrolithotripsy (PCNL).
Results: From the initial examination, a track was planned in 24 patients. The decision was changed in 14 patients after the 3D CT. With 3D CT, it was possible to
estimate a track for all patients. In 9/10 patients, a track for PCNL was established
in agreement with the decision from the initial examination and in 20/21 patients
in agreement with the 3D CT examination. 24 patients (78%) were stone free with
one PCNL session, and in 21 of these patients only one track was established. 7
patients required further treatment with ESWL (4), PCNL (1) or ureteroscopy (2).
Conclusion: An extended preoperative planning with 3D CT resulted in successful
treatment of most complex renal stones through one track.
C-373
Malignancy after kidney transplantation: A radiological approach
J. Quintero, P. Puyalto, J. Jiménez, S. Mourelo, E. Barluenga, B. Bayès;
Badalona/ES ([email protected])
Learning Objectives: To review the spectrum of malignancies occurred after
kidney transplantation. To shows their typical and atypical radiological features,
not commonly seen in not transplanted patients.
Background: After cardiovascular disease, cancer is the second cause of death
following renal transplantation. The aetiology of post transplant malignancy is
unknown, it might probably be multifactorial. Advancements in immunosuppressive therapy have significantly improved patient and graft survival following renal
transplantation. This is paralleled by an increasing occurrence of post transplantation malignancy.
Imaging Findings: We reviewed retrospectively 29 patients (19 men and 10
women) with cancer diagnosed after renal transplantation. In our institution the
incidence of cancer after renal transplantation is 5.7%. 54% developed cancer
within the first 5 years after transplantation, and 46% did after 10 years or more.
In our series linfoproliferative disease was the most frequent cancer (7), followed
by renal cell carcinomas (6), lung cancer (5), and liver metastasis (2). Isolated
cases of skin carcinoma, bladder carcinoma, breast carcinoma, prostatic cancer,
meningioma, peritoneal carcinomatosis, cholangiocarcinoma, iliopsoas liposarcoma
and melanomas were also seen.
Conclusion: Radiologists should be aware of the higher incidence of malignancies in inmunocompromised patients after renal transplantation and their special
radiologic appearances due to their more aggressive behaviour. Follow-up of renal
transplant patients must include screening tests directed at tumor detection. Imaging
studies and other tests in this patient group should be interpreted by physicians
who are familiar with transplant related peculiarities.
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S413
Genitourinary
Purpose: To illustrate the spectrum of MR appearances of renal lesions treated with
radiofrequency ablation in patients suffering from Von Hippel Lindau Syndrome.
Methods and Materials: Von Hippel Lindau syndrome is an autosomal dominant
inherited neurocutaneous dysplasia complex. Multiple bilateral renal cell carcinomas
arise in 50% of the patients usually developing in cyst wall. Previously treatment
was largely surgical. From 2005 to 2008, 5 patients with VHL with enlarging renal
cysts were referred for radiofrequency ablation & lesion were ablated using Boston
Scientific bipolar leveen probe. All patients had pretreatment MR and post treatment
MR scans at 3 monthly intervals (mean 18 months).
Results: The appearances of the 7 lesions before and after treatment are compared including the enhancement during dynamic contrast enhanced acquisitions.
No evidence of progressive disease is seen in any lesion. 2 treatment related
complications are illustrated.
Conclusion: The treatment of enlarging cystic lesions in patients with VHL using
radiofrequency ablation appears successful at least in the short term with no radiological evidence of continued cyst enlargement in any patient. The MR appearances
are illustrated along with the 2 treatment related complications.
Scientific and Educational Exhibits
C-374
Genitourinary
New concepts of renal tumors: Histopathology-radiologic correlations
J. Hayoun, D. Eiss, S. Merran, V. Vasiliu, O. Helenon; Paris/FR
Purpose: To describe the radiological features of the new entities of renal tumors
of the 2004 World Health Organisation (WHO) classification of the adult renal
neoplasms and new concepts of renal tumors that appeared recently.
Methods and Materials: A multicentric retrospective study during 5 years (January
2002- September 2007) in the departments of uroragiology.
Results: We describe the imaging features with macroscopic and histologic features
of new entities of the 2004 World Health Organisation (WHO) classification of the
adult renal neoplasms such as: mixed epithelial and stromal tumor of the kidney
(n=1), mucinous tubulocystic renal carcinoma with fusiform cells (n=1), cystic
multilocular renal cell carcinoma (n=21), renal cell carcinomas associated with
Xp11.2 translocations (n=5), épithelioid angiomyolipoma (n=2), and two interesting
new concepts not yet described in the WHO classification: hybrid oncocytoma and
chromophobe renal cell (n=7) and tubulocystic carcinoma (n=1).
Conclusion: The radiologists should know these new and rare renal tumors for
implications in patients’ clinical management.
C-375
The use of dynamic contrast enhanced MRI (DCE MRI) with quantitative
data analysis in the differentiation between RCC and AML
M.M.H. Abd Ellah, L. Pallwein, C. Kremser, R. Peschl, M. Elsharkawy, G. Mikuz,
W. Jaschke, F. Frauscher; Innsbruck/AT ([email protected])
Purpose: We aimed to evaluate DCE MRI with quantitative data analysis using
tracer kinetic modeling for studying the microvasculature differences between
RCC and AML.
Methods and Materials: We examined 20 patients with small renal masses. A
T1-map dynamic contrast perfusion MR imaging was done for all patients using
1.5T Magnetom VISION (Siemens, Erlangen, Germany). All the obtained data were
analyzed using the software program Matlab (MathWorks, Inc, USA). Different
standard tracer kinetic parameters, as blood perfusion, blood volume, extraction
fraction and permeability surface area product were calculated. The different obtained parameters were compared with the different tumor types. Final diagnosis
was confirmed by histopathology in 18 patients and by follow up in 2 patients.
Results: Of the totally examined patients 16 showed clear cell RCC, 4 AML (2 of
them were low fat containing). Among the variously calculated tracer kinetics, the
extraction fraction showed significant differences between both types (p <0.001)
(3.1/3.5 for RCC) and (median/range, 0.09/0.26 for AML). Also the permeability
surface area product (PSS) showed increase in RCC compared to AML, but it
was not significant.
Conclusion: DCE MRI using quantitative data analysis through tracer kinetic modeling showed significant differences between RCC and AML in two parameters PSS
(non significant) and extraction fraction (significant). It could be a useful method
differentiating both tumors especially low fat AML from RCC.
Male
C-376
Prostate cancer after treatment; imaging modalities at follow-up:
What to do?
A.L. Valentini, B. Gui, A. Latini, A. Caulo, E. Mazzeo, L. Bonomo; Rome/IT
([email protected])
Learning Objectives: To discuss the role of different imaging modalities in patients
with prostate cancer undergoing radiotherapy/hormone deprivation therapy (RT/
HT) or submitted to radical prostatectomy (PRAD).
Background: Patients with prostate cancer treated with RT/HT or PRAD are
monitored by the PSA test and digital rectal examination (DRE). However DRE
sensitivity is low and a PSA test might show a low level even in the case of
progression of the disease. In the past, US and MRI have been used in prostate
cancer at follow-up. However, parenchyma changes due to HT and RT result in an
alteration of echogenity or signal intensity that makes difficult to correctly assess
the status of the disease. In addition, both US and MRI are scarcely useful after
PRAD in small lesions.
Imaging Findings: A series of US, MRI, spectroscopic MRI (MRSI) and dynamic
contrast enhanced (DCE) MRI pictures are employed to explain how and why
MRSI and DCE are mandatory for the correct assessment of the disease. MRSI is
necessary to monitor the response to therapy, especially in long term conservative
treatments, and can also identify a recurrent cancer. DCE is helpful particularly
in differentiating small local recurrence from a normal residual prostatic tissue
after PRAD.
Conclusion: The imaging modality usually employed in the follow-up of prostate
cancer is analyzed, together with their disadvantages/diagnostic advantages, in a
complete pictorial review. The role of MRSI in long term therapeutic modalities and
the usefulness of DCE in PRAD cases are especially stressed.
C-377
The change of ADC value by different high-b value in prostate cancer and
normal prostate
T. Yoshizako, A. Wada, A. Kobayashi, M. Nakamura, K. Uchida, H. Kitagaki;
Izumo Shimane/JP ([email protected])
Purpose: To evaluate the change of ADC value by different high-b value for prostate
lesions and normal prostate.
Methods and Materials: This study included thirty-six cancers in 30 patients with
radical-prostatectomy. The ADC values were measured: 1) normal peripheral zone
(PZ), 2) normal transitional zone (TZ), 3) cancer: 36 lesions, and 4) non-malignant
lesion (NML): 27 lesions (inflammation 4, hyperplasia 23). 1.5 T MR unit was used.
The DWI were obtained by single shot echo planner image (b=0, 1000 and 2000
sec/mm²). The ADC values of each b factor were calculated and compared cancer
with NML and normal tissue.
Results: In b=1000, the ADC values (10³mm²/s) were: 1) 1.671 + 0.279, 2) 1.152
+ 0.222, 3) 0.923 + 0.146, and 4) 1.123 + 0.066. In b=2000, the ADC values were:
1) 1.049 + 0.123, 2) 0.821 + 0.161, 3) 0.666 + 0.071, and 4) 0.782 + 0.061. The
ADC value in each b factor was the significant difference between cancer and
normal tissue (P 0.05). In TZ, the ADC value in each b factor was the significant
difference between cancer and NML (P 0.05). But the ADC value in each b factor
was not significantly different between cancer and NML in PZ.
Conclusion: Both the ADC values of b=1000 and b=2000 were the same trends
for distinguishing of prostate lesions. In TZ, the ADC value might be useful for
detecting cancer from NML.
C-378
Prostate cancer detection and localization: T2-weighted and diffusionweighted endorectal MRI
B. Yagci, N. Ozari, Z. Aybek, E. Duzcan, N. Karabulut; Denizli/TR
Purpose: To evaluate T2-weighted imaging (T2WI), diffusion-weighted imaging
(DWI), and the combination of these MR techniques in the detection and localization of prostate cancer.
Methods and Materials: A total of 22 patients with serum prostate specific antigen
levels of 2.5 ng/mL were evaluated by T2WI and DWI (b value = 800 s/mm2) using
an endorectal coil at 1.5 T, before a systematic 12-core biopsy. The peripheral zone
of the prostate was divided into base, mid, and apex and left and right halves, thus
yielding six regions (n=132). Minimum apparent diffusion coefficient (ADC) values
of each region in the peripheral zone were measured. Two core biopsies were
obtained from each sextant under transrectal ultrasound guidance.
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Scientific and Educational Exhibits
Results: Prostate cancer was pathologically detected in 12 of the 22 patients, and
in 46 of 132 sextants. The receiver operating characteristic curve analysis revealed
an optimal cut-off ADC value of 1.25 x 10-³ mm²/s to predict prostate cancer. The
sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for the detection and localization of prostate cancer within peripheral zone
were 72, 74, 60, 83, and 73% for T2WI; 85, 77, 66, 90, and 80% for DWI; 83, 83,
72, 90, and 83% for the combined T2WI+DWI, respectively.
Conclusion: Compared with T2WI, use of DWI improved accuracy in prostate
cancer localization. The combination of T2WI and DWI may be a valuable tool
for detecting and localizing prostate cancer within the peripheral zone and may
potentially reduce false-negative biopsy rates and unnecessary biopsies.
C-379
2D and 3D T2-weighted MR sequences for the assessment of
neurovascular bundles changes: After nerve-sparing radical retropubic
prostatectomy with erectile function correlation
M. Osimani, V. Panebianco, D. Lisi, L. Di Mare, S. Bernardo, R. Passariello;
Rome/IT ([email protected])
Purpose: Aim of this study is to assess, in patients submitted to a bilateral nervesparing radical retropubic prostatectomy (RRP), the capability of a dedicated 3D
isotropic MRI T2 weighted sequence (3D T2 ISO) in the depiction of post surgery
changes of neurovascular bundles (NVBs) formation. Furthermore, our aim is also
to introduce a new morphologic MRI classification score of the NVBs alteration
patterns, using the International Index Erectile Function 5-item (IIEF-5) questionnaire as standard of reference for correlation analysis.
Methods and Materials: Fifty-three consecutive patients were post-operatively
submitted to two MR examinations, including both a 2D TSE T2-weighted (2D T2)
and 3D T2 ISO sequences. Images findings were scored using a relative five-point
classification and correlated with post-operative IIEF-5 score.
Results: Both radiologists enclosed 13.2 % patients in class 0, 11.3% in class
I, 34% in class II, 24.5% in class III and 16.9% in class IV. With 3D T2 ISO images, the same radiologists enclosed 43.3 % in class 0, 32% in class I, 11.4%
in class II, 7.5% in class III and 5.7% in class IV. In all cases, the correlation and
regression analysis between the 3D T2 ISO and IIEF-5 score resulted in higher
coefficients values.
Conclusion: Our study confirmed the major correlation level with IIEF-5 score of
3D T2 ISO sequence in the morphologic MR depiction of NVBs alterations after a
bilateral nerve sparing RRP.
C-380
Inflammation, high grade prostatic intraepithelial neoplasia (HGPIN) and
prostate cancer: Evidence for a link at spectroscopic magnetic resonance
and dynamic contrast enhanced MR
D. Lisi, V. Panebianco, M. Osimani, E. Santucci, A. Sciarra, R. Passariello; Rome/IT
([email protected])
Role of multimodality imaging in penile carcinoma
R. Kochhar, B. Taylor, V. Sangar; Manchester/UK ([email protected])
Learning Objectives: To illustrate the role of magnetic resonance imaging (MRI)
in local staging of penile carcinoma. To outline the use of non invasive imaging
techniques for assessment of regional lymph nodes. To highlight the potential of
novel techniques.
Background: Penile cancer is a rare neoplasm in the developed world affecting
1 per 100,000 males per annum in the UK. Assessment on the basis of clinical
findings alone can often result in inaccurate staging. Our hospital is the referral
centre for penile cancer for a population of about 7 million, with 55 new cases
being imaged each year. The various radiological techniques, their advantages
and limitations, and imaging appearances of penile cancer are described and
illustrated in this exhibit.
Imaging Findings: MRI depicts penile anatomy in detail. It is the most accurate
technique to define the local extent, to determine depth of tumour invasion and
for postoperative follow-up. Ultrasound with Doppler is useful for FNAC of suspicious nodes but unreliable for nodal staging. It helps to select patients suitable for
lymphoscintigraphy and is used for follow-up. Preoperative lymphoscintigraphy with
sentinel node biopsy is used to predict lymphogenous metastases in occult inguinal
disease. Novel imaging techniques like PET-CT and nano-particle enhanced MRI
have a high sensitivity and specificity for lymphogenous metastases but their clinical
utility has not been established.
Conclusion: Imaging has an important role in the management of penile cancer.
MRI accurately assesses local invasion and novel imaging techniques have shown
potential in accurate prediction of metastatic lymph nodal disease.
C-382
Prostatic carcinoma (PC) treated with cryosurgical ablation: Medium term
outcome after 3-year magnetic resonance (MR) imaging follow-up
G. Cardone, A. Losa, L. Nava, P. Mangili, G. Guazzoni, G. Balconi; Milan/IT
([email protected])
Purpose: To determine the safety and efficacy of cryosurgical ablation in the
management of PC and to assess its medium term outcome after 3-year MR
imaging follow-up.
Methods and Materials: 12 patients with PC underwent cryosurgical ablation.
Patients were followed-up clinically, biochemically and by MR imaging 24 hours
after surgery, and subsequently at 3, 6, 12, 24 and 36 months. MR examinations
were performed with a 1.5 T MR system using TSE T1w, TSE T2w and ce-FS
TSE T1w sequences; ce-T1w images were also evaluated before and after digital
subtraction.
Results: No significant rise in PSA was noted post-procedurally in all the cases.
On MR images, 24 hrs after treatment the prostate was 59% larger than the original
volume of the gland; the treated gland decreased in size of an average of 41, 52
and 65% at 3, 6 and 12 months, respectively. Ce-FS TSE T1w and subtracted MR
images showed complete ischemia of the gland in all the cases, with periurethral
zone sparing to preserve the urethra. Follow-up revealed no evidence of local or
distant recurrence in all the patients. After surgery, 2 patients showed little areas
of perilesional enhancement due to perilesional haematomas, disappearing 3
months after surgery.
Conclusion: Our medium term experience suggests that cryosurgical ablation
is a safe, well tolerated and minimally invasive therapy for localized PC, and MR
is an effective imaging technique in the follow-up of PC treated with cryosurgical
ablation, in the early evaluation of the efficacy of the treatment and in the evaluation of complications.
C-383
Local recurrence of prostate cancer (PC): Usefulness of keyhole
subtracted dynamic contrast-enhanced (KSDce) MR sequence
G. Cardone, C. Iabichino, L. Nava, M. Freschi, P. Mangili, G. Guazzoni,
G. Balconi; Milan/IT ([email protected])
Purpose: The aim of this study is the evaluation of the usefulness of digital
subtracted-keyhole-GRE sequence in the study of local recurrence of prostate
cancer using ce-dynamic MR imaging.
Methods and Materials: We retrospectively reviewed 34 patients treated with
radical prostatectomy for prostatic cancer with a rise in PSA level (0.2 to 7 ng/
ml) and subsequently biopsy proven local recurrence. All the patients underwent
MR examinations, performed with a 1.5 T MR system and an endorectal coil, using multiplanar TSE T2w, dynamic ce-keyhole-GRE T1w and digitally subtracted
dynamic ce-keyhole-GRE T1w sequences. All data sets were qualitatively and
quantitatively evaluated.
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Genitourinary
Purpose: Recent evidences suggest a link between inflammation and prostate
cancer. Aim of this study was to determine and to compare magnetic resonance
spectroscopic imaging (MRSI) and dynamic contrast-enhanced magnetic resonance
(DCEMR) features in histologically confirmed prostatic inflammation, high grade
prostatic intraepithelial neoplasia (HGPIN), low grade (LGPC) and high grade
(HGPC) prostate cancers.
Methods and Materials: The present prospective study comprised a group of
32 men who showed at histology a diagnosis of inflammation (Group B), HGPIN
(Group C) or prostate adenocarcinoma (LGPC = Group D and HGPC = Group E).
The protocol included all patients who merited a prostate biopsy because of an
increased serum PSA level (greater than 4 ng/ml). All 32 cases were submitted to
MRSI and DCEMR 2 weeks before biopsy.
Results: ANOVA analysis shows that a constant and significant (P 0.05) difference in almost all metabolic assessments (MRSI) exists between controls (group
A) and the other groups (Group B, C, D, E). Moreover, inflammation (Group B)
showed no significantly (p 0.05) different choline and citrate levels when compared
to HGPIN and LGPC. The results of the ratio analysis were consistent with no
significant (p 0.05) differences between inflammation and HGPIN and between
LGPC and HGPC.
Conclusion: This is the first study in the literature in which a quantitative analysis of
individual metabolites concentration at MRSI has been specifically used to sustain
the hypothesis for a link among inflammation, HGPIN and PC.
C-381
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Results: On T2w MR images neoplastic lesions were evident in 61% of the cases.
On dynamic ce-GRE T1w MR images neoplastic lesions were evident in 79% of the
cases. On subtracted dynamic ce-keyhole-GRE T1w MR images neoplastic lesions
were evident in 91% of the cases. The keyhole technique allowed acquisition time
reduction, with improvement in time resolution. Subtracted images showed higher
contrast resolution in the focal early enhancement areas evaluation compared to
the conventional dynamic images. Local recurrences were evident on subtracted
ce T1w images only in 4 cases. Digital subtraction technique minimized the high
signal intensity of perirectal and perianastomotic fat and improved the evaluation
of the focal areas of contrast enhancement.
Conclusion: In our study, subtracted dynamic ce-keyhole-GRE T1w MR sequence
allowed better results compared to the T2w and conventional dynamic MR sequences, and can be successfully employed in the evaluation of local recurrence
of prostate cancer.
C-384
Can diffusion-weighted MR imaging reduce unnecessary prostate biopsy?
New strategy employed high b value diffusion-weighted imaging (DWI) for
patients with elevated PSA
Y. Yamabe1, Y. Kuroki1, K. Nasu2, Y. Yoshida1, R. Sekiguchi1, T. Yamamoto1;
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Utsunomiya/JP, 2Tsukuba/JP ([email protected])
Purpose: We analyzed whether patients with elevated PSA could be stratified
depending on therapeutic necessity by non-contrast MR imaging including high
b value DWI.
Methods and Materials: The subjects were 130 patients with elevated PSA whose
serum PSA levels were 4 ng/ml or more. They were obtained by MR images prior
to prostate biopsy. We used an MR scanner (Gyroscan Achieva 1.5 T, Philips) and
SENSE-body coil. Images used for this study were trans axial section of DWI (b
value: 1500 and 2000), ADC map (b value: 1500), and T2WI. We classified the
subjects into 2 groups. Group A showed high signal intensity area on DWI with
unclear or disappear normal prostate gland pattern on T2WI. Group B showed
any signal intensity on DWI with normal prostate gland pattern. It was speculated
that Group A needed prostate biopsy and group B was recommended watchful
waiting. We compared MRI diagnosis with pathological diagnosis by biopsy as
reference standard.
Results: Of 130 cases, 78 cases were diagnosed as Group A and 52 cases as
Group B. Group A consisted of 53 cases of significant cancer, 8 cases of insignificant
cancer, and 17 cases without cancer. Group B consisted of 1 case of significant
cancer, 2 cases of insignificant cancer, and 49 cases without cancer.
Conclusion: It was speculated that using of non-contrast MR imaging with high
b value DWI enabled stratification depending on therapeutic necessity of the PSA
group.
C-385
High-b-value diffusion-weighted imaging at 3T for detection of prostate
cancer
Y. Ohgiya, T. Hashizume, J. Suyama, N. Seino, M. Hirose, T. Gokan; Tokyo/JP
Purpose: The purpose of this study was to investigate usefulness of high-b-value
diffusion-weighted imaging (DWI) in combination with T2-weighted imaging (T2WI)
for detection of prostate cancer.
Methods and Materials: Seventy-three patients underwent T2WI and DWI (b =
50, 500, 1000, and 2000) at 3T. Three independent observers reviewed images
obtained from combination of T2WI and DWI (b = 500) (protocol A), combination
of T2WI and DWI (b = 1000) (protocol B), combination of T2WI and DWI (b = 2000)
(protocol C), and combination of T2WI, DWI (b = 50, 500, 1000, and 2000), and
ADC maps (protocol D). Area under the receiver operating characteristic (ROC)
curve (Az) was calculated under results of systemic biopsy as the standard of
reference. Significant difference was defined as a P value less than 0.05 for the
Az tested with a two-tailed paired Student t test.
Results: Prostate cancer was pathologically detected in 55 of the 73 patients. The
sensitivity, specificity, accuracy, and Az for the detection of prostate cancer were
as follows: 19, 86, 69%, and 0.591, respectively, in protocol A; 43, 83, 73%, and
0.667, respectively, in protocol B; 39, 87, 75%, and 0.742, respectively, in protocol
C; 54, 77, 71%, and 0.804, respectively, in protocol D. Mean Az in protocol A was
significantly lower than in the other protocols.
Conclusion: Combined reading of DWI with b value more than 1000 or 1000 and
T2WI showed higher accuracy in the detection of prostate cancer than combined
reading of DWI (b = 500) and T2WI.
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C-386
Prostatic endorectal magnetic resonance: Recent changes in clinical
indications
S. Cirillo, M. Petracchini, T. Gallo, D. Campanella, A. Macera, F. Russo,
D. Molinar, S. Debernardi, D. Regge; Candiolo/IT
Purpose: The aim of the present study was to summarize recent changes in the
indication for endorectal magnetic resonance (eMR) starting by our database of
the last 46 months.
Methods and Materials: From August 2004 to May 2008 in our institute, 880 eMR
examinations were performed in 856 consecutive male patients. Patients were
scheduled for eMR by urologists from collaborating institutions with different clinical
indications. We considered the indications in two different periods of 23 months
each one (August 2004 - June 2006 and July 2006 - May 2008); chi square test
were performed to assess differences in frequency for each indication between
the two different periods.
Results: Four hundred and twenty eMR examinations were executed in the first
period and 460 in the second period. In the first and in the second periods, respectively, 46.90 and 30.21% of eMR were executed for local staging of prostate
cancer, 27.85 and 20.65% for localizing local recurrence after primary treatment;
25.23 and 49.13% for the evaluation of prostatic glands in patients with previous
negative biopsies and increased PSA values. A statistical difference was found
for the first (C2 =53.34, p-value 0.001) and for the third indication (C2 =25.90,
p-value 0.001). No statistical difference was found for the second indication (C2
=6.23, p-value: 0.012).
Conclusion: The use of new functional studies (such as magnetic resonance
spectroscopy, dynamic contrast enhancement and diffusion weighted imaging)
increased eMR accuracy in detecting cancer tissue and consequently led to a
change in the clinical indications.
C-387
Tumors and tumor-like conditions of the testis: Gray-scale and color
Doppler US findings with radiologic-pathologic correlation
E. Xinou, K. Lytras, S. Iosifidou, M. Gialamoudi, F. Patakiouta, D. Doula,
E. Karoglou, D. Anestakis, L. Grassos; Thessaloniki/GR ([email protected])
Learning Objectives: 1. To illustrate the spectrum of gray-scale and color Doppler
US findings of usual and unusual testicular tumors. 2. To correlate these imaging
features with pathologic findings. 3. To describe conditions that can mimic such
tumors. 4. To delineate which imaging findings can be used to help differentiate
tumors from tumor-like conditions.
Background: Ultrasonography (US) is the initial imaging modality for investigating
testicular tumors. The ability of color Doppler US to demonstrate testicular perfusion aids in reaching a specific diagnosis. With rare exception, solid intratesticular
masses should be considered malignant. The sonographic appearance of testicular
tumors reflects their gross morphology and underlying histologic characteristics.
Imaging Findings: Approximately 95% of malignant testicular tumors are germ cell
tumors, of which seminoma is the most common histologic subtype. Rare malignant
conditions that can also manifest as testicular masses include leukemia, lymphoma,
plasmacytoma and metastases. A variety of benign intratesticular processes, such
as hematoma, orchitis, abscess, infarction, and granuloma, can mimic testicular
malignancy and must therefore be considered in the differential diagnosis. Grayscale and color Doppler US imaging features of a wide variety of testicular tumors
are presented and correlated with their pathologic findings, emphasizing those
features that can help establish a specific diagnosis.
Conclusion: The use of color Doppler US can help to establish the correct diagnosis of a variety of testicular tumors, appropriately guiding treatment. A short-term
follow-up US examination can help exclude acute conditions, which can occasionally appear as a mass.
C-388
Prostate ultrasound elastography in cancer detection
E. Panfilova, A. Emelyanenko, S. Alferov, A. Zubarev; Moscow/RU
([email protected])
Purpose: To evaluate the diagnostic possibilities of ultrasound (US) elastography
imaging in diagnosis of prostate cancer in patients with elevated PSA level or with
palpable prostate nodules.
Methods and Materials: 400 consecutive patients underwent TRUS (gray scale,
color Doppler, elastography) with the EUB 900 (Hitachi Medical, Japan) using
EUP-V53 W of 6.5 MHz transduser (PSA level 4-14 ng/ml, prostate volume 4095 cm³, mean age 63p9). Sonoelasticity score of the suspicious for prostate cancer
lesions were evaluated (from 1 to 4). Prostate sexstant biopsies were performed in
Scientific and Educational Exhibits
all cases. Sensitivity, specificity, accuracy, positive predictive value (PPV), negative
predictive value (NPV) were calculated in all cases.
Results: 301 patients using sonoelastography were suspected to have prostate
cancer. The sonoelastography was in agreement with histopathology results in
278 cases. Prostate cancer were characterized of 3.8p0.8 sonoelasticity score,
compared to prostatitis - 1.7p0.9 (p 0.001), and BPH - 2.5p1.1 (p 0.05). Our
study shows sensitivity - 97.4%, specificity - 75.4%, accuracy - 90.75%, PPV 97.0%, NPV - 75.4%.
Conclusion: US elastography shows high potential in prostate cancer diagnostics. It offers additional information that increased the sensitivity of conventional
ultrasound methods.
C-389
Imaging of bulbo-urethral glands pathology
M. Valentino, M. De Matteis, C. Poggi, M. Casadio Baleni, P. Pavlica, L. Barozzi;
Bologna/IT ([email protected])
Learning Objectives: To illustrate the imaging findings of the pathology of bulbourethral glands.
Background: Bulbo-urethral glands or Cowper’s glands are accessory sexual
glands and are made of a main gland situated on either side of the bulbar urethra
at the level of the urogenital diaphragm. Their long ducts are drained into the
bulbar urethra by small paramedian orifices. The glands can be the site of cystic
dilatation or inflammation and their ducts can show a dilatation that can produce
voiding obstruction.
Imaging Findings: 23 adult patients with bulbo-urethral glands pathology were
observed. Sonography was used in 16 cases, radiography in 23 and cystoscopy in
7. The most common symptoms (15 pts) were stranguria and post-urinary dribbling,
two with perineal pain during straining and six were asymptomatic and investigated
for different pathology. In two cases, small calcifications were detected at the level
of the urogenital diaphragm on the plain film and transrectal sonography. Abscess
of the gland was observed in 1 patient and cystic dilatation in 2 cases. The dilated
bulbo-urethral duct or syringocele was the most frequent pathology.
Conclusion: Bulbo-urethral glands pathology is considered rare but the diagnosis
should be entertained in any male presenting with long standing irritative or obstructive symptoms when no other explanation is found. The diagnosis is obtained only
with voiding or retrograde urethrography. Transperineal sonourethrography is very
helpful in all cases prior to any therapeutic procedure.
C-391
Is real-time elastography targeted biopsy able to enhance prostate cancer
detection? An analysis of detection rate using an elasticity-scoring system
L. Pallwein, F. Aigner, V. Spiss, M. Mitterberger, W. Jaschke, F. Frauscher;
Innsbruck/AT ([email protected])
Purpose: Real-time elastography (RTE) has already shown its ability to detect
PCa. This prospective study was performed to evaluate RTE for targeted prostate
biopsy in a PSA screening population in comparison to cancer detection rate of
systematic biopsy.
Methods and Materials: Included were 383 patients with elevated PSA (mean:
7.0p 13.8) and scheduled for systematic biopsy. Before systematic approach, a
targeted biopsy with a limited number of cores (maximum 5) was performed. Targeted biopsy was based on findings in RTE. Stiff lesions were considered malignant.
Appearance of elasticity of outer gland areas was divided into: score 1- normal
(regular stiffness), score 2- indeterminate (inhomogeneously increased stiffness),
and score 3- suspicious (homogeneously increased stiffness). PCa detection rates
of each stiffness grades were compared with findings of systematic biopsy.
Results: Sensitivity for PCa detection (134 of 383 patients; 35%) was 91.0%
(122/134) for RTE targeted biopsy and 76.9% (103/134) for systematic biopsy. Score
1 elasticity pattern was found in 129 patients, 3 of them (2.3%) showed cancer,
score 2 elasticity pattern in 146 patients, 42 of them (28.8%) showed cancer, and
score 3 elasticity pattern in 108 patients, 89 of them (82.4%) showed cancer. The
correlation between stiffness grade and Gleason Score was significant. The prostate
volume and the PSA also were correlated with the stiffness grades.
Conclusion: RTE has already shown its value for PCa detection. The use of a
stiffness grading system seems to be able to further enhance the PCa detection
rate and can increase the diagnostic accuracy of RTE.
C-390
Prostate cancer (PCa) detection in patients with a total PSA (tPSA) 10 ng/
ml: Targeted biopsy with a sonographic triple approach and a reduced
number of cores vs systematic 10 core biopsy
F. Aigner, L. Pallwein, V. Spiss, M. Mitterberger, W. Jaschke, F. Frauscher;
Innsbruck/AT ([email protected])
Genitourinary
Purpose: Results of a targeted biopsy approach based on findings in grey scale
(GS), color Doppler (CD) and real-time elastographical (RTE) imaging were compared with systematic biopsy findings for detection of prostate cancer.
Methods and Materials: 94 patients (mean age: 61.8; range: 42-86) with a tPSA
serum value lower than 10 ng/ml (mean: 5.1; range: 1.3-10) underwent a 5 core
targeted biopsy by an uroradiologist. Targeted cores only were taken from areas
with pathologic patterns in GS, CD, or RTE imaging (Hitachi EUB-8500). In the
same session, a 10 core systematic biopsy was performed by a blinded urologist.
PCa detection rates were compared.
Results: 28/94 patients showed PCa (mean gleason score: 6.3; range: 5-9).
Systematic approach detected 18/28 (64.2%), targeted biopsy approach detected
23/28 (82.1%). In the group of patients with a tPSA of 4 ng/ml, 12 patients showed
cancer and targeted biopsy was able to detect 10 and systematic biopsy 7 of these
12. The detection rate in the group with tPSA of 4-10 ng/ml was 15/16, for targeted
biopsy and 11/16 for systematic biopsy.
Conclusion: The targeted biopsy based on a sonographical triple approach with
a reduced number of cores seems to increase PCa detection rate even in patients
with a tPSA of 10 ng/ml. Therefore, the targeted technique may be able to reduce
costs and complications of prostate biopsy.
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C-394
GI Tract
Gastrointestinal (GI) tract perforation: Accuracy of CT in prediction of
presence, site and cause
J. Mendiola Arza, I. Arrieta Artieda, M. Carreras Aja, A. Dolado Llorente,
I. Terreros Bejo, M. Berástegui Imaz; Baracaldo/ES ([email protected])
Acute Abdomen
C-392
Radiological review of acute and chronic mesenteric ischaemia: How to
image, diagnose and treat
P.L. Skippage, M. Ingram, G. Bydawell, G. Munneke; London/UK
Learning Objectives: 1) To review the pathophysiology and aetiology of both acute
and chronic mesenteric ischaemia. 2) To discuss the imaging modalities available:
what should be used and when. 3) To discuss treatment options that are available,
with a particular emphasis on percutaneous interventional procedures.
Background: Acute and chronic mesenteric ischaemia can present with differing
clinical scenarios. As radiologists we should be aware that imaging findings, although
classical, can be subtle and therefore we should also know how to tailor imaging
techniques for individual cases to ensure that an accurate and timely diagnosis is
made. Treatment options should always include discussion around interventional
radiological techniques.
Imaging Findings: We will present cases collected from our institution of imaging
findings in both acute and chronic mesenteric ischaemia. This will focus on CT
appearances, in particular the role of MDCT, but will also include other imaging
modalities such as angiography. We will also discuss and show examples of treatment of mesenteric ischaemia, emphasising radiological interventional techniques
that can be used.
Conclusion: Radiologists must be aware of how to image the different clinical entities of acute and chronic mesenteric ischaemia. Specific imaging findings should
be sought and investigations tailored to provide optimal results. The treatment of
both types should always include discussions with interventional radiologists as
percutaneous techniques provide a good alternative to standard open surgical
procedures.
C-393
Abdominal plain film versus multi-detector CT in the evaluation of
nonspecific abdominal pain in the emergency department: A model for
evaluating process, cost and effectiveness
M. O’Brien1, L. Milne2, T. Ptak2; 1Amherst, MA/US, 2Boston, MA/US
([email protected])
Purpose: To construct a simple model to assess the role and impact of diagnostic
imaging in abdominal pain. Scenarios employing a combination of modalities are
analyzed with respect to length of stay, cost, and radiation dose.
Methods and Materials: A Markov model was constructed for abdominal pain
in the emergency department (ED). Diagnostic decisions are directed through an
observation pathway or MDCT, abd plain film (ABX) or ultrasound. Models were
constructed for two paradigms, one with ABX and one without. Model data were
from 2724 adult patients presenting to our ED with abdominal pain between 1/1
and 31/12/2007. Expected values were calculated for time (hrs), cost (dollars)
and radiation exposure (mGy) in each paradigm. Cost-effectiveness and sensitivity analyses were performed for change in the preferred scenario. Monte Carlo
simulation estimated scenario specific cost.
Results: Values favored no-ABX pathway for cost and time analysis, but favored
ABX pathway in the radiation exposure analysis. Sensitivity analyses revealed an
ABX preferred pathway in time and cost only when diagnostic efficiency of ABX was
elevated and MDCT severely reduced. Radiation dose model consistently favored
ABX scenario in all analyses. Values in cost-effectiveness models favored ABX
scenario, but were essentially collinear using dollar cost and time.
Conclusion: MDCT is favored over ABX in the initial ED evaluation of abdominal
pain in simple models using dollar cost and ED time metrics. ABX scenario is favored
only when the sole consideration was radiation exposure. All cost-effectiveness
models favor ABX scenario, but are nearly collinear in dollar cost and length-ofstay (time) models.
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Purpose: The purpose of this study was to review the accuracy of CT for determination of the GI tract perforation and to emphasize the most characteristic findings
that indicate the site and cause of perforation.
Methods and Materials: We prospectively studied 65 patients with abdominal
pain, pneumoperitoneum and surgically proven GI tract perforation. Two emergency radiologists evaluated the images and both completed a questionnaire on
the presence or absence of seven CT findings indicative of acute bowel disease
and gastrointestinal perforation. The seven CT findings evaluated were: focal defect in the bowel wall, segmental bowel wall thickening, perivisceral fat stranding,
abscess, extraluminal fluid, few bubbles of extraluminal air concentrated in close
proximity of the bowel wall and extraluminal air in both abdomen and pelvis. After
reviewing these findings the two radiologists predicted site and cause of perforation. Fisher´s exact test and contingency tables were performed to assess the
significance of CT findings.
Results: The presence of concentrated extraluminal air bubbles (p 0.001) and the
perivisceral fat stranding (p=0.002) are the best predictors of the site of perforation.
The cause of GI tract perforation was predicted in 49 of 65 patients (75%).
Conclusion: CT has high performance in diagnosing the presence, site and cause
of GI tract perforation. The presence of concentrated extraluminal air bubbles and
the perivisceral fat stranding are the best predictors of the site of perforation. Correct
diagnosis of the presence, level and cause of perforation are essential for appropriate management and surgical planning in patients with GI tract perforation.
C-395
Abdominal gossypiboma: A pictorial review
A. Canelas, M. Seco, B. Graça, F. Cavalheiro, L. Curvo-Semedo, L. Teixeira,
F. Caseiro-Alves; Coimbra/PT ([email protected])
Learning Objectives: To describe the clinical and radiologic spectrums of abdominal and pelvic gossypibomas.
Background: A retained surgical sponge or swab is also known as a gossypiboma,
derived from gossypium (Latin, cotton) and boma (Swahili, place of concealment).
Gossypiboma occurs with a frequency of one in 100-5000 operations and accounts
for 50% of malpractice claims for retained foreign bodies. Clinically, retained sponges
may be asymptomatic or result in a granulomatous response with abscess development, intestinal obstruction or fistula formation. The aim of this pictorial essay is
to provide an update review of the radiologic findings of retained surgical sponges
in the abdomen and pelvis.
Imaging Findings: Several cases of abdominal and pelvic gossypibomas will be
illustrated using a multimodality approach - X-ray, ultrasound, CT and MRI.
Conclusion: Awareness of the typical radiologic appearances is critical to the
diagnosis of retained surgical sponges or swabs. Inadvertently retained sponges
are often clinically unsuspected and may be first recognized by imaging. A high
index of suspicion is required because a history of an incorrect sponge count is
frequently lacking and because a radiopaque marker is not always visible. CT or
MR imaging may be helpful in problematic cases.
C-396
Use of abdominal X-ray in accident and emergency departments
I. Din, J. Rathore, H. Aniq; Liverpool/UK ([email protected])
Purpose: Abdominal X-ray involves exposure to significant amount of radiation. The
Royal College of Radiologists (RCR) UK has published guidelines on the appropriate use of abdominal X-rays. We aimed to find out the extent to which unnecessary
abdominal X-rays are requested based on RCR guidelines.
Methods and Materials: We retrospectively audited 200 patients in whom
abdominal X-ray was performed in accident and emergency of Royal Liverpool
University Hospital (between August and November 2007). Only first 50 cases from
each month were selected. Clinical notes and X-ray request forms were reviewed
separately against the guidelines.
Results: There were 106 females and 94 males. The mean age of patients was
52.51 (range 16-94). Clinical impression/diagnosis was not made in 29% of the
cases. Based on clinical notes, only 45% of the abdominal X-rays were requested
appropriately. Based on the information given on request forms, 75.5% of the Xrays appeared to be appropriately requested. 70% of the abdominal X-rays were
reported normal by radiologist.
Scientific and Educational Exhibits
Conclusion: The results suggest that significant number of abdominal X-rays
were requested inappropriately. In a few cases, there was marked discrepancy
between clinical notes and the information provided on radiology request forms.
Increased awareness of local/national guidelines is essential to prevent unnecessary exposure of patients to radiation. Accurate and honest information should
be provided on request forms to help our radiology colleagues and to avoid any
medico-legal problems.
C-397
Believe it or not: Unusual abdominal diseases diagnosed with CT in
emergency room
L. Figueroa Nasra, A. Verón Sánchez, E. Valbuena Durán, E. Alonso Gamarra,
A. Diez Tazcón, G. Gallardo-Madueño; Madrid/ES ([email protected])
Learning Objectives: To discuss the use of CT in the evaluation of patients with
nonspecific abdominal complaints. To recognize the CT findings of various uncommon abdominal diseases that can cause acute abdominal pain in the emergency
room.
Background: Acute abdominal pain in adults is a nonspecific but common clinical
complaint in emergency room. In these cases, the clinical presentation is often
confusing and ultrasound has been used with a poor degree of success in the
diagnosis, but the CT findings are characteristic and allow early recognition and
often decide on operative versus nonoperative therapy.
Imaging Findings: Appendicitis is the most common cause of the acute abdomen.
Numerous other entities (epiploic appendagitis, omental infarction, intussusception, gallstone ileus, inferior mesenteric venous thrombosis, small bowel torsion,
perforated small bowel diverticulitis, typhlitis, hepatic hydatid cyst rupture) are
relatively uncommon, but taken as a whole they make up a substantial number of
patients who present with acute abdominal pain. In this exhibit all these entities will
be discussed, stressing their key CT findings and the differential diagnoses.
Conclusion: CT plays a pivotal role in establishing the diagnosis and in deciding on
operative versus nonoperative therapy in a patient with abdominal pain of uncertain
etiology in the emergency room.
C-398
Imaging of perforation as a result of GI tract endoscopy
P. Steyerova, J. Horejs; Prague/CZ ([email protected])
Learning Objectives: To learn about usual and less common appearance of perforation on different levels of GI tract resulting from GI tract endoscopy procedures.
To highlight important features of clinical importance.
Background: Perforation is a quite uncommon complication of endoscopy, encountered in 0.03 to 0.11% of patients undergoing endoscopy. The significance of
radiologist is to provide early and accurate information whether the perforation is
present, to reveal its location and evaluate its extent and other possible complications. In our presentation, we would like to show series of images of perforation
resulting from upper GI tract endoscopy, ERCP, trans-esophageal echocardiography
and colonoscopy encountered in our clinic during last 4 years of cooperation with
endoscopic centre.
Imaging Findings: Patients were indicated for imaging because of previous
endoscopic procedure and either suspected perforation or clinical/laboratory
disturbances following the endoscopy. Though some of the patients underwent
conventional X-ray first, the main technique for imaging of these patients was CT.
CT usually revealed different amount of free air outside the GI tract with maximum
in the vicinity of the perforation site; sometimes we observed the perforation directly
with leak of contrast media which was administered orally prior to scanning. In a
case of ERCP stent migration with perforation of duodenal wall, we observed a
covered perforation with creation of a small fistula.
Conclusion: Imaging techniques are crucial for evaluation of GI tract perforation
as a result of endoscopic procedure. Early and precise recognition and description
is necessary for subsequent management of the patient.
C-399
Learning Objectives: 1. To illustrate the various imaging features of mesenteric
ischemia (MI) on multidetctor computed tomography (MDCT). 2. To depict the
anatomy of mesenteric vasculature. 3. To relate the etiology and pathogenesis of
mesenteric ischaemia to the different imaging patterns seen on MDCT.
C-400
Diagnosis in active abdominal bleeding: Importance of MDCT and
correlation with arteriography
E.I. Monedero Martínez-Pardo, M.I. Rossi Prieto, P. Diez Martínez,
A. Alcalá-Galiano Rubio, E. Salvador Álvarez, S. Borruel Nacenta; Madrid/ES
([email protected])
Purpose: To compare the diagnostic capacity of MDCT and arteriography to demonstrate active abdominal bleeding. To make a correlation between both techniques
showing the findings obtained in each one. To show the important role of MDCT in
the management of this emergency.
Methods and Materials: We have revised patients with active abdominal bleeding
studied at our hospital during one year, collecting those that required both urgent
MDCT and arteriography. There were a variety of different etiologies found in the
group of patients included in our study: traumatisms, focal lesions, iatrogenesis and
spontaneous bleeding. We could classify the origin in hepatic, pancreatic, renal,
splenic, from lumbar vessels or pelvic structures. We only considered a positive
active bleeding in MDCT in those cases where we could see leak of contrast
(although there were indirect signs in all of them).
Results: We have observed an important correlation between MDCT and arteriography (72%). We found more discrepancy in splenic location, where nearly
60% of the results were false negative for MDCT (the general rate was 17%).
Renal origin was the location with the highest agreement (83% of correlation, no
false negatives).
Conclusion: There is an important correlation between the direct signs of active
abdominal bleeding in MDCT and arteriography (apart from splenic bleeding, where
indirect signs become of greater importance). According to this, we recommend
MDCT as the technique of choice in these patients’ management.
C-401
Acute abdominal and pelvic pain in pregnancy
G. Murphy, P. Beddy, R. Dunne, M. Keogan; Dublin/IE
Learning Objectives: 1. Outline aetiology and incidence of common pathology
that presents as an acute abdomen in pregnancy. 2. Retrospectively assess the
imaging findings of pregnant patients presenting with acute abdominal or pelvic
pain. 3. Review the imaging modality of choice for pregnant patients.
Background: The incidence of the acute abdomen during pregnancy is 2%. Non
obstetric surgical intervention will be required in 0.5%. The role of imaging is to
distinguish between cases requiring urgent intervention and those that can be
managed conservatively. The anatomical and physiological changes of pregnancy
render the diagnosis and management of abdominal pain challenging. Non-ionising
modalities including ultrasound and MRI are preferred due to concerns regarding
radiation dose to the foetus. This article reviews and illustrates both common and
rare conditions presenting as acute abdominal pain during pregnancy.
Imaging Findings: The following cases are presented: Hepatobiliary, Acute cholecystitis, Biliary obstruction, Biliary colic. Ascending cholangitis Pancreatic, Acute
pancreatitis, Pancreatic carcinoma. Intestinal: Small bowel obstruction due to a
spigelian hernia, acute appendicitis, acute Crohn’s colitis. Renal: Renal obstruction. Pelvic: Dermoid cyst torsion, Ovarian torsion, Degenerating fibroid, Benign
and malignant ovarian masses. Trauma: Domestic violence with splenic laceration.
Musculoskeletal: Sacral stress fracture.
Conclusion: This comprehensive case series illustrates the spectrum of conditions
presenting as an acute abdomen in the pregnant patient.
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A practical approach in diagnosing mesenteric ischemia using
multidetector computed tomography
A. James, J.H. Chauh, B. Thomas, V. Rudralingam, S.A. Sukumar;
Manchester/UK ([email protected])
Background: Mesenteric ischemia is one of the most common causes of an
acute abdomen in patients over 50 years of age and is potentially life threatening.
MI can affect the large or small bowel, may be segmental or diffuse and varies
in extent from partial mural to transmural ischemia. Surgical resection is still the
mainstay of treatment for bowel ischemia and may be combined with mesenteric
endarterectomy in select cases. Correct diagnosis and timely intervention determine
the clinical outcome.
Imaging Findings: The MDCT findings vary with the degree, distribution, cause
and severity of MI and include: Bowel wall thickening - hypoattenuaton (oedema)
or hyperattenuation (intramural haemorrhage); “Paper-thin” dilated bowel; Specific
sites such as splenic flexure. Hyperenhancement or hypo/non enhancement of the
bowel wall depending on the extent and cause of MI and the presence of superadded
infection. Fat stranding and ascites; Pneumatosis intestinalis, portomesenteric air
and perforation; Primary cause of MI such as arterial or venous thrombosis.
Conclusion: In practice, diagnosing MI is challenging due to the variable clinical
and radiological features, especially in the absence of classical features. A combined systematic clinical and radiological approach is vital for accurate diagnosis
and prompt intervention.
Scientific and Educational Exhibits
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MDCT differential diagnosis of acute colonic conditions
S. Romano, G. Tortora, F. Maisto, A. Russo, L. Romano; Naples/IT
([email protected])
Learning Objectives: To illustrate the spectrum of MDCT findings of common and
rare acute colonic conditions giving some “key points” to consider for an effective
differential diagnosis.
Background: Acute disease of the colon could be due to various and different
pathologic entities, ranging from occlusion to the endoluminal transit to parietal
vascular affections from arterial origin or impaired venous drainage, to “flogosis”,
which could represent manifestations of different etiologies causing similar (but
not equal) bowel damage and imaging findings. MDCT scanning with i.v. contrast
medium administration, without any endoluminal opacification or distension represents a common diagnostic method to perform in Emergency in patients with
suspected acute colonic condition.
Imaging Findings: MDCT findings related to the following acute disease of the
colon will be considered, illustrated and evaluated for criteria of differential diagnosis
with correlation to the bowel wall appearance (thickening, stratification with focused
attention to mucosal and submucosal feature, density, enhancement, air or fluid
distension, presence of pneumatosis): Ischemia from arterial occlusion or low-flow
state, disease from impaired venous drainage, alterations from chemiotherapics,
hemorrhage, appendicitis, diverticulitis, alterations from haematological disorders,
occlusions and obstructions.
Conclusion: MDCT examinations could represent a good tool for an effective differential diagnosis of acute disease of the colon from various origins.
Colon
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Evaluation of preoperative staging and resectability of colon cancer using
CTC: Correlation with surgical results
A. Stagnitti, A. Marini, L. Testaverde, F. Iafrate, M. Marini, A. Pichi, A. Laghi;
Rome/IT ([email protected])
Purpose: To evaluate the diagnostic performance of CTC in the evaluation of
preoperative staging and resectability of colon cancer.
Methods and Materials: Fifty-eight patients with colon cancer who underwent
surgical treatment and had available preoperative CTC with i.v. contrast were
included in the study. All the images of preoperative CTC were independently
analyzed by two radiologists with different experience and the differences in their
assessment were analyzed by consensus using MPR reconstructions and VR
images. The radiologists were asked to determinate the depth of invasion of the
colon wall (T stage) classifying into bT2, T3 and T4; involvement of loco-regional
nodes (N stage) and distant metastasis (M stage). TNM staging with CTC were
correlated with surgical results.
Results: The overall accuracy values for T staging of reviewer 1, reviewer 2 and
consensus reading were 91.6, 86.2 and 92.8%, respectively; 92.2, 79.8 and
92.5% for bT2; 88.1, 85.5, and 89.7% for T3; and 94.5, 93.5 and 96.2% for T4.
Three out of 14 T4 lesions were understaged due to inadequate distension (n=1)
and misinterpretation of adjacent organ involvement as partial volume averaging
(n=2).The accuracy values for N staging and M staging were 81.8 and 94.0% for
reviewer 1; 78.2 and 88.1% for reviewer 2; and 81.8 and 94.0% for consensus
reading, respectively.
Conclusion: Contrast enhanced CTC shows good performance in the preoperative
evaluation of staging and resectability of cancer colon.
C-404
Diagnosis of uncomplicated stercoral colitis: CT findings
A. Linda1, J. Heiken2; 1Udine/IT, 2St. Louis, MO/US ([email protected])
Learning Objectives: 1. To review the pathophysiology of stercoral colitis. 2. To
discuss the importance of early recognition of uncomplicated stercoral colitis. 3. To
review the risk factors and clinical presentation. 4. To illustrate the CT findings.
Background: Stercoral colitis is an inflammatory disease of the colon due to the
persistent pressure over the bowel wall by hard stools, in patients with chronic
constipation. The fecal mass may cause pressure necrosis of the wall leading to
perforation of the colon, which is a life-threatening condition. It is crucial to recognize
clinical and CT findings suggestive of stercoral colitis and treat it before it results
in perforation. Risk factors are immobilization, diseases predisposing to constipation, and drugs reducing bowel mobility. Patients can present with abdominal pain,
vomiting, abdominal distention, or be asymptomatic.
Imaging Findings: CT findings of uncomplicated SC are: 1. fecal impaction with
overdistention of the involved colonic segments, 2. thickened and strongly enhancing colonic wall, and 3. pericolonic fat stranding.
Conclusion: Knowledge of risk factors, clinical presentation and imaging features
of uncomplicated stercoral colitis allows prompt diagnosis and treatment, before
the development of life-threatening complications.
C-405
Cytomegalovirus enterocolitis in non-AIDS patients: Evaluation of CT
findings and clinical features
E. Chae, S. Lee, H. Kim, S. Park, A. Kim, H. Ha; Seoul/KR ([email protected])
Purpose: To evaluate CT findings and clinical features of cytomegalovirus (CMV)
enterocolitis in non-AIDS patients.
Methods and Materials: Twenty-two non-AIDS patients (eleven women, eleven
men; mean age, 55 years) with pathologically proven CMV enterocolitis were included. Medical records were reviewed for immune status, presenting symptoms,
clinical courses. CT scans were retrospectively reviewed for the location of involved
bowel (i.e. small bowel, colon, and both), maximal bowel thickness, pattern of bowel
wall enhancement (i.e. single ring, double ring, and homogeneous), the presence
of ascites and pericolic/perienteric infiltration.
Results: Five patients were apparently immunocompetent, whereas 17 had
medical conditions that may alter immune status including chemotherapy (n=5),
immunosuppression (n=4), blood dyscrasia (n=2), diabetes mellitus (n=3), recent
major surgery (n=2), and renal failure (n=1). The presenting symptoms were abdominal pain (n=14), hematochezia (n=12), diarrhea (n=11), and fever (n=3). On
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CT, all patients, except one, showed bowel wall thickening (mean maximal thickness, 8.8 mm for the colon and 6.3 mm for the small bowel) involving both small
bowel and colon (n=5) or limited to the colon (n=11) or small bowel (n=5). Bowel
wall enhancement pattern was single ring (i.e. strong enhancement of inner layer)
in 13 patients, double ring in five, and homogenous in three. Bowel involvement
was continuous in 14 patients. Ascites was present in 10 patients and pericolic/
perienteric infiltration in fourteen. Four patients with delayed diagnosis underwent
surgery due to bowel perforation or refractory GI bleeding.
Conclusion: CMV enterocolitis can develop in immunocompetent as well as
immunocompromised hosts, and is characterized by mild continuous bowel wall
thickening with single or double ring enhancement. Delayed diagnosis may lead
to serious complication.
C-406
Accuracy of CT in colonic obstruction: Analysis and review
I. Terreros, A. Dolado, J. Mendiola, I. Arrieta Artieda, M. Carreras, G. Iglesias;
Barakaldo/ES ([email protected])
Purpose: 1. To determine the accuracy of computed tomography (CT) in diagnosing
colonic obstruction and recognizing the location and severity of this entity. 2. We
evaluate and show the different causes of colonic obstruction dividing these into
intraluminal, intrinsic and extrinsic.
Methods and Materials: We analyzed prospectively 58 patients with clinical or
radiologic colon obstruction suspicion, to whom a Helicoidal CT was performed in
our Emergency Radiology Section. CT results were compared with surgery, endoscopy or clinical evolution. We studied the ability of CT for diagnosing mechanic
colonic obstruction, and also the location, cause and complications (ischemia or
perforation) of each obstruction.
Results: CT diagnosed correctly 46 of the 47 mechanic obstructions (sensibility of
97.9%) and 10 of the 11 non obstructive diffuse dilatations (specificity of 90.9%). The
point of obstruction was satisfactorily located in 45 of the 47 obstructions (95.8%)
and the specific cause in 43 of them (91.5%). The complications were correctly
determined in 7 of the 10 cases in which surgery was finally performed. We analyze
several of these data by mean of kappa index. Causes of colonic obstruction include
the following: intraluminal (25.5%), intrinsic (57.4%) and extrinsic (17%).
Conclusion: CT is the diagnostic technique of election for patients with clinical or
radiologic suspicion of colonic obstruction, with great effectiveness for diagnosis
(differentiating among intraluminal, intrinsic and extrinsic causes), location and
possible complications in order to contribute information enough for an optimum
therapeutic management.
C-407
Perfusion CT using 64-channel slice MDCT in colorectal cancer:
Comparison of perfusion parameters with tumor grade and angiogenesis
using microvessel count (MVC)
J. Kim1, Y. Jeong1, S. Heo1, S. Shin2, J. Lee1, H. Kang2; 1Jeollanam-do/KR,
2
Kwangju/KR ([email protected])
DWI of the post-operative colon
T. Gerukis, D. Voultsinou, A. Papachristodoulou, A. Pantazopoulou, E. Vafiadis,
A. Petridis, V. Kalpakidis, P. Palladas; Thessaloniki/GR ([email protected])
Purpose: To investigate the value of diffuse-weighted imaging (DWI) with the use of
apparent diffusion coefficient (ADC) measurements in the post-operative follow-up
of patients with primary colon malignancy.
Methods and Materials: We examined 17 patients (7 males, 10 females) with
single-shot echo-planar diffusion-weighted MR imaging (DWI) in addition to the
routine MR protocol for the abdomen in a 1.5 T MR unit. All patients were subjected
in the past (3 months to 3 years) to colectomy for large bowel adenocarcinoma.
Images were obtained in 3 b-values (0, 400, 800 s/mm2) with generation of ADC
maps. Quantitative analysis was performed in regions of interest, placed on normal
and pathologic tissue at the corresponding ADC maps.
Results: 7 patients presented with relapse (5 local relapse and 2 presented
pathologic periregional lymph node), 5 with post-radiation fibrosis and 5 with normal findings. The ADC values of carcinoma relapse were from 0.95 to 1.17, with
a mean value of 1.08 (x 10-3 mm2 sec-1). Post-radiation changes (edema, fibrosis)
showed significant higher ADC values (1.85 p 0.13).
Conclusion: DWI with ADC measurements can give valuable additional information during the post-operative follow-up of patients with colon malignancies and
may be used (in adjunction to the other available sequences and techniques) for
discrimination of post-radiation changes from relapse. Thus, we believe that it must
take a permanent place in the routine abdominal MR examination protocols.
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Colon CAD: What the radiologists need to know
R. Ferrari, P. Paolantonio, M. Rengo, F. Vecchietti, P. Lucchesi, M. Maceroni,
A. Laghi; Latina/IT ([email protected])
Learning Objectives: To provide basic and advanced description of colon CAD
software, concerning technical basis and principal pitfalls; to understand what are
the benefits and the disadvantages of using it in the clinical workflow; to review
results of the most recent literature.
Background: Colon CAD softwares are promising diagnostic tools in helping
radiologists reporting virtual colonoscopy and they are now being integrated in
the main 3d reconstruction workstations. It is widely demonstrated in literature that
experience is one of most factors that affects results in reporting virtual colonoscopy.
And in the recent literature, CAD software seems to be useful in reducing the gap
between expert and inexpert readers.
Procedure Details: This exhibit describes the technical basis of colon CAD software and the advantages or disadvantages of using them as primary, secondary
or concurrent reader. It provides knowledge on the main false positives and how
to discriminate.
Conclusion: Colon CAD softwares are now integrated in the major 3D reconstruction workstations; knowing what are the main benefits of using CAD software in
your clinical workflow is a primary goal for the radiologist who approaches this
technique and seems to reduce gap between inexpert and expert radiologists. It
is still debated in literature if the best use is as secondary reader or concurrent
reader. The number of false positives in the recent softwares’ versions is not so
high and most of them are easily discriminated.
GI Tract
Purpose: To correlate CT perfusion parameters with tumor grade, and to assess
CT perfusion for evaluation of angiogenesis of rectal adenocarcinoma.
Methods and Materials: Preoperative perfusion CT was performed with 64-channel
volume CT (Lightspeed VCT, GE Healthcare Technologies, WI, USA) in 20 patients
(12 women, eight men; age range, 32-82 years). Dynamic CT perfusion was performed in rectal carcinoma for 65 seconds after injection of contrast medium. One
radiologist analyzed tumor blood flow (BF), blood volume (BV), mean transit time
(MTT), and permeability surfaces (PS) on GE workstation (GE Healthcare Technologies, Milwaukee, WI, USA). CT perfusion parameters were compared among
tumors of different grades and correlated with microvessel count (MVC).
Results: In 20 patients with colorectal cancer, histologic grade was well-differentiated (n=9), moderately-differentiated (n=11), and poorly-differentiated adenocarcinoma (n=2). BF was higher in moderately-differentiated adenocarcinoma
than in well-differentiated tumors (p .05). MTT was shorter in moderately- than
well-differentiated adenocarcinoma (p .05). However, there were no significant
differences in other CT perfusion parameters between well- and moderatelydifferentiated colorectal adenocarcinomas. There was no significant correlation
between CT perfusion parameters and MVC.
Conclusion: BF and MTT on perfusion CT provide useful information for histological grade of rectal adenocarcinoma. However, CT perfusion parameter was not
correlated to MVC.
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ESGAR CT colonography database
E. Neri1, S. Halligan2, J. Stoker3, D. Burling4, P. Lefere5, S.A. Taylor6, P. Rogalla7,
A. Laghi8; 1Pisa/IT, 2London/UK, 3Amsterdam/NL, 4Harrow/UK, 5Roeselare/BE,
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Northwick Park/UK, 7Berlin/DE, 8Latina/IT ([email protected])
Purpose: The European Society of Gastrointestinal and Abdominal Radiology
(ESGAR) organizes CT colonography (CTC) workshops that consist in hands-on
training on dedicated workstations. The purpose of this study (carried out by the
ESGAR CTC working group) was provide to the course participants a teaching
resource available after the course for training in CTC.
Methods and Materials: To reach this objective, 73 endoscopically verified CTC
cases have been collected by multiple European centers of reference and a database has been developed to allow the remote access. The CTC cases, used also
for the training during the workshops, have been stored in a DICOM web server,
accessible through the Internet. Once entered in the database, a DICOM browser
allows to search the cases and visualize the full dataset; dedicated remote clients
can also browse and retrieve the DICOM study.
Results: The CTC cases are classified according to the C-RADS (CTC Reporting and Data System) and consist in 26 C-RADS-4 (35%), 23 CRADS-3 (31%),
11 CRADS-2 (15%), 10 CRADS-1, 1 CRADS-0 (1%) and 4 flat lesions (5%). The
internal search tool, based on the C-RADS, allows stratifying the cases in the different clinical situations that the radiologists need to know. The first access to the
database has been provided to 90 radiologists who attended the 9th ESGAR CTC
workshop in Berlin (Sept. 2008).
Conclusion: The database represents a valuable teaching tool for training in CTC
and a source of high quality CTC datasets compliant with the C-RADS.
Esophagus
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Eosinophilic oesophagitis
S. Morgan, J. Ash-Miles, H. Roach, M. Callaway, J. Virjee; Bristol/UK
([email protected])
Learning Objectives: To describe the clinical manifestations and epidemiology
of eosinophilic oesophagitis (EO), and to illustrate its typical radiological findings
on upper gastro-intestinal barium studies.
Background: EO is a chronic and benign condition increasingly being recognised
as a distinct form of oesophagitis. It usually presents as food bolus obstruction in a
young adult and is therefore important for the general radiologist to be aware of the
diagnosis and recognise the typical radiological features. Barium swallow examination is often the first diagnostic test, and can demonstrate features diagnostic of EO.
This may obviate the need for more invasive and expensive investigations.
Imaging Findings: We present a collection of subtle yet typical radiological signs
of EO. We will illustrate these and provide endoscopic and pathological correlations.
Conclusion: EO is often an unrecognised diagnosis in young adults. There are
subtle yet typical radiological findings of this increasingly prevalent disease that are
important for the general radiologist to be aware of and recognise.
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Imaging findings in esophageal carcinoma: Diagnosis, follow-up and
complications
A.F.L. Carneiro, P.F.G. Sousa, D.M. Rocha, A.S. Preto; Porto/PT
([email protected])
Learning Objectives: To describe the imaging findings in MDCT and MRI of
esophageal carcinoma.
Background: Esophageal carcinoma is a common and deadly cancer, usually
diagnosed with endoscopic or fluoroscopic studies. Advances in MDCT and MRI
techniques, combined with use of oral or multiphasic IV contrast media improve
the detection, staging and monitoring of esophageal carcinoma and its complications.
Imaging Findings: Esophageal carcinoma most commonly presents in CT studies
as a wall thickening or mass, most conspicuous in the arterial or venous phase.
The latter phase is also optimal for detection of local nodal involvement or distant
(thoracic or abdominal) metastasis. Similar findings can be expected, and, as such,
characterized, following local cancer recurrence after surgery. CT is also useful for
detection of complications such as mediastinitis, fistulous tracts and monitoring of
endoluminal stents. Suspected fistulas, not apparent in fluoroscopy, may be better
delineated with CT after oral contrast. MRI studies best depict the esophageal
layers in T2w sequences. In selected cases, mucosal thickening not visible in CT
will be apparent in MRI and more accurately staged accordingly.
Conclusion: Current CT and MRI techniques for examination of the esophagus
allow diagnosis of most cases of esophageal carcinoma, as well as confident
staging and follow-up.
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The accuracy evaluation of FDG-PET for the diagnosis of lymph node
metastasis of esophageal cancer and relationship between cancer amount
in lymph node and the FDG uptake
S. Okazumi1, K. Shuto2, K. Narushima2, R. Kato1, H. Matsubara2; 1Sakura/JP,
2
Chiba/JP ([email protected])
Purpose: Currently, diagnosis of lymph node metastasis by FDG-PET is considered
to show high specificity and low sensitivity. In this study, the relationship between
FDG uptake of metastatic lymph nodes and the amount of metastatic cells in each
node was investigated by dissected lymph nodes specimen and its significance
was estimated.
Methods and Materials: 83 cases with esophageal cancer (which included 40
cases with preoperative chemoradiation and 43 cases with no adjuvant therapy) who
underwent esophagectomy with 3 field lymph node dissection. The total number of
dissected nodes was 3434 including 124 metastatic nodes. 370 MBq of FDG was
administered intravenously and whole body PET (GE Advance NXi) was done before
esophagectomy. Lymph nodes uptakes of FDG were evaluated by standardized
uptake value (SUV) and SUV r3.0 was used as the index of preoperative diagnosis of metastatic node. After operation, the accuracy of preoperative FDG-PET
was estimated in each node, and then the diameter and occupying ratio of cancer
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cells in each metastatic node on the pathological specimen was examined and
compared with its FDG uptake.
Results: The sensitivity, specificity and accuracy of the preoperative PET diagnosis were 96.3, 16.8 and 99.3%, respectively. The uptakes (SUV) and the
diameter:cancer occupying ratios were significantly correlated (r=0.47, p 0.001),
and the uptake of the SUV 3.0 needed the diameter (mm):cancer occupying
ratio 3.0.
Conclusion: FDG-PET diagnosis for lymph node metastasis of esophageal
cancer depends on the diameter:cancer occupying ratio of the lymph node and its
diagnostic index is over 3.0.
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Ultrasonographic evaluation of coronary veins as an esophageal varices
predictor
O. Persiva1, X. Serres1, M. Sarrias2, S. Roche1, C. Vilà1, J. Genescà1;
1
Barcelona/ES, 2Sant Pere de Ribes/ES ([email protected])
Purpose: To assess ultrasound as an esophageal varices presence predictor in
chronic hepatopathy patients on the basis of coronary/left gastric veins evaluation
by using endoscopy as the reference standard.
Methods and Materials: Ultrasound data in 274 patients are included and correlated to endoscopy findings. Sonographic parameters include: spleen size, portal
vein velocity and diameter, liver parenchyma characteristics and coronary veins
presence, size and flux direction. Endoscopy evaluation assessed presence and
severity of esophageal varices. Multivariate statistical analysis is calculated and receiver operating characteristic (ROC) curves are constructed for these variables.
Results: Results are shown as area under ROC curves (AUC) with 95% confidence
interval (CI). Portal vein diameter (AUC 0.68 [95% CI: 0.621, 0.750]), spleen size
(AUC 0.66 [95% CI: 0.606, 0.72]), liver characteristics (AUC 0.70 [95% CI: 0.646,
0.755]) and coronary veins size and flux direction (AUC 0.69 [95% CI: 0.631, 0.748])
are statistically significant non-invasive predictors of esophageal varices.
Conclusion: Sonographic assessment of size and flux direction in coronary/left
gastric veins is a useful non-invasive test to predict the presence of esophageal
varices in chronic hepatopathy patients.
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64-MDCT perfusion of esophageal carcinoma with 40-mm tumor coverage
A. Djuric-Stefanovic, D. Saranovic, D. Masulovic, A. Ivanovic; Belgrade/RS
([email protected])
Purpose: 64-MDCT enables quantitative assessment of the perfusion parameters
(BF, BV, MTT and PS) within 40-mm length of the tumor volume. In the majority of
the available studies, perfusion parameters were calculated for the 5- or 10-mm
thick part of the tumor. Therefore, we analyzed the differences in the values of the
perfusion parameters between 5- and 40-mm esophageal tumor coverage.
Methods and Materials: CT perfusion studies were performed in 24 patients using
the following protocol: 50 ml contrast, flow 4 ml/s, delay 5 s, cine mode acquisition
of 8 contiguous 5-mm axial images/1 s, scan duration 50 s. Perfusion CT study
was loaded into the software (Perfusion 3, GE) and perfusion parameters (BF, BV
and MTT) were calculated for each of 8 tumor levels scanned. The average values
of BF, BV and MTT for 40-mm long tumor volume were statistically compared with
values of single 5-mm axial image at the level of maximal tumor diameter, for each
patient (paired-sampled T test).
Results: The average values of BF and BV in 40-mm long part of tumor were
significantly different in comparation with single 5-mm thick slice at the level of
maximal tumor diameter (BF- 89 ml/min/100 g: 96 ml/min/100 g, p 0.01; BV 4.97 ml/100 g: 5.51 ml/100 g, p 0.05). No significant difference was find for MTT
(6.31 s: 6.39 s, p 0.05).
Conclusion: 64-MDCT with 40-mm tumor coverage could improve quantitative
assessment of esophageal carcinoma perfusion parameters, if each of eight 5-mm
thick tumor levels is analysed by perfusion software.
GI Tract
Peritoneum
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Abdominal tuberculosis: A reemerging disease
C. Pérez, M. Sola, M. Menso, X. Salvador, J. Pernas, D. Hernandez,
E. Montserrat, P. de la Torre; Barcelona/ES ([email protected])
Learning Objectives: To review the abdominal tuberculosis physiopathology. To
review by means of CT, MR, US and barium studies several cases of abdominal
tuberculosis involving liver, pancreas, kidney, bladder, mesentery, peritoneum,
esophagus, colon and ileocecal area. To emphasize, especially for new radiologist
generations, that tuberculosis is still an important diagnostic.
Background: Due to several factors, tuberculosis has experienced a new increase
in our population. Tuberculosis is well known for its mimicking abilities and is often
confused with neoplastic processes. Its diagnosis can be very difficult and often
requires invasive procedures.
Procedure Details: Several cases of, histologically or culture positive proven,
abdominal tuberculosis involving liver, pancreas, genitourinary, mesenteric, peritoneum, esophagus and ileocecal area by means of CT, MR, US and barium studies
are used to illustrate the many faces of this infectious entity.
Conclusion: The increase in abdominal tuberculosis in general population, due
to several demographic changes, obliges to include this entity in the differential
diagnosis of several abdominal pathologies, especially in atypical cases. Knowing
the different presentations helps, especially for younger radiologists, to reach the
diagnosis.
C-417
Peritoneum: Anatomy, physiology and pathology
C.L. Fernandez Rey, I. Gutierrez Lopez, E. Montes Perez, S.M. Costilla Garcia,
D.J. Gonzalez Suarez, A. Alvarez Cofiño; Oviedo/ES
([email protected])
Learning Objectives: To describe the normal anatomy and the pathology of the
peritoneum. To discuss the usefulness of multidetector CT with multiplanar reformation in the evaluation of peritoneal pathologies.
Background: Peritoneum is a large and thin serous membrane that lines peritoneal
cavity and involves most abdominal viscera. Therefore, peritoneum and peritoneal
spaces are commonly affected in many primary and second pathologies. Radiologists must be familiar with the anatomy and physiology of the peritoneum, as well
as the spectrum of peritoneal pathologies.
Imaging Findings: 1. Anatomy: We review the anatomy of the peritoneum: peritoneal spaces, omentum, ligaments and mesenteries. 2. Physiology: We discuss the
physiological factors that determine the location and the dissemination of peritoneal
diseases: anatomic boundaries and physiologic flow of peritoneal fluid. 3. Pathology:
We present a diverse spectrum of both primary and second peritoneal pathologies
including inflammatory conditions, tumor and tumor-like lesions, systemic diseases,
traumatic and vascular processes, and internal hernias. We also discuss the key
concepts in the diagnosis of the peritoneal diseases: characteristics of peritoneal
fluid and collections (density, location, mass effect), malignant ascitis versus bening
ascitis, and disproportionate fat stranding.
Conclusion: Knowledge of anatomy and physiology is important to determine the
origin, cause and extent of the peritoneal pathologies. Multidetector CT with multiplanar reformation improves the resolution of peritoneal spaces and the detection
of pathologic conditions.
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Purpose: Although peritoneal metastases are commonly encountered in patients
with pelvic malignancies, their diagnosis with conventional imaging modalities (US,
CT, MRI), especially during early peritoneal spread, is challenging. The aim of this
retrospective study is to assess the value of [18 F]FDG-PET/CT in the identification
of radiologically occult peritoneal carcinomatosis.
Methods and Materials: From July 2007 to June 2008, 17 patients with known
pelvic malignancy (7 with colorectal cancer, 8 with ovarian cancer and 2 with cervical
cancer), status post-treatment, 39-78 years old (mean age: 60 years) underwent
[18 F]FDG-PET/CT at our institution for suspected recurrence because of asymp-
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[18 F]FDG-PET/CT diagnosis of radiologically occult peritoneal
carcinomatosis in asymptomatic patients with suspected recurrent pelvic
malignancies based on elevated tumor marker serum levels
M.G. Skilakaki, D.N. Exarhos, E.V. Skoura, S. Tsolaki, P. Rondogianni,
I.E. Datseris; Athens/GR ([email protected])
Scientific and Educational Exhibits
tomatically elevated tumor marker serum levels (CEA, CA-125, CA 19-9). All patients
had previously performed - within less than a month - negative conventional imaging
tests: CT of the chest and CT and/or MRI of the abdomen and pelvis.
Results: Peritoneal infiltration was revealed in 12 of 17 patients (70%). Peritoneal
metastatic disease was present in 5 men with colorectal cancer, 6 women with
ovarian malignancy and 1 woman with cervical cancer. In 8 of 17 patients (47%), the
presence of peritoneal metastases was the only finding indicative of recurrence.
Conclusion: In this study, [18 F]FDG-PET/CT had increased sensitivity for diagnosis of peritoneal metastases compared to conventional imaging modalities. We think
that at the appropriate clinical setting, 18 F]FDG-PET/CT could be incorporated in
the diagnostic work-up of suspected peritoneal carcinomatosis. Further investigation
with prospective studies is needed to address this hypothesis.
C-419
The different types of internal hernia after laparoscopic Roux-En-Y gastric
by-pass for morbid obesity: MDCT features
A. Kawkabani Marchini, A. Paroz, S. Romy, M. Sutter, A. Denys, P. Schnyder,
S. Schmidt; Lausanne/CH
Learning Objectives: 1. To provide an overview of the different types of internal
hernia (IH) occurring after laparoscopic Roux-en-Y gastric bypass (LRYGBP) for
morbid obesity. 2. To describe correspondent MDCT features in relation with the
underlying anatomical landmarks in order to differentiate their localisation and to
direct the surgeon during following laparoscopic closure of mesenteric defects.
Background: LRYGBP for morbid obesity is associated with less perioperative
complications, shorter hospital stay and a more rapid recovery compared with the
open surgical procedure. However, a relatively high incidence of IH is seen that
may be due to the laparoscopic approach, but also caused by rapid weight loss
with consecutive loosening of the mesenteric sutures.
Procedure Details: After briefly reviewing the surgical procedure of LRYGBP
(ante- versus retrocolic), we describe the exact anatomical landmarks of the different types of IH occurring at any time after operation: They are caused by surgical
defects at the level of the transverse colon mesentery, at the Petersen’s space,
which represents an opening between the mesocolon and jejunal mesentery, or
at the entero-enterostomy site. Typical MDCT features of each IH type in axial and
coronal planes as well as targeted vascular reconstructions are demonstrated.
Conclusion: Exact knowledge about underlying pathophysiology and anatomical
landmarks is essential for distinguishing the different types of IH occurring after
LRYGBP on MDCT, since radiological features are difficult to recognize and may
even overlap. The radiologist should be aware of the potential anatomic sites to
ensure subsequent straightforward laparoscopic exploration.
C-420
A myriad of mesenteric masses
S.P. Ramachandra, M. Bydder, S. Vessal; Stoke-on-Trent/UK
([email protected])
Learning Objectives: The aim of this article is to describe the CT features of various mesenteric tumours, tumour like conditions and also to discuss the approach
to differential diagnosis.
Background: The primary mesenteric neoplasms are rare. However, small bowel
mesentery is a major route for the tumour dissemination. CT is the imaging modality of choice for identifying these lesions. CT features along with clinical history
may guide towards the diagnosis, although image guided/surgical open biopsy
is often required to confirm the diagnosis. Due to the clinical symptoms being
non-specific, CT plays an important role towards the diagnosis and management
of the patient.
Imaging Findings: In this article, we discuss the characteristic CT features of
primary mesenteric tumours, metastases as well as conditions mimicking the
tumours.
Conclusion: CT remains the dominant imaging modality for the diagnosis of
mesenteric masses. As there is an overlap of radiology and pathologic features,
knowledge of these neoplastic and inflammatory conditions is important for the
diagnosis and appropriate management of the patient.
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C-421
Peritoneal carcinomatosis: Pathways of disease spread and spectrum of
imaging findings in MDCT
D. Miranda1, R. Duarte2, A. Salgado3, A. Salgueiro1, M. Ribeiro1; 1Matosinhos/PT,
2
Vila Nova de Gaia/PT, 3Porto/PT
Learning Objectives: To review the anatomy of the peritoneal spaces. To describe
the mechanisms and pathways of disease spread through the peritoneal cavity. To
illustrate the imaging findings of malignant peritoneal seeding on MDCT, based
on 50 pathologic proved cases.
Background: The peritoneal recesses are important anatomic boundaries that
define the dynamic routes of peritoneal fluid circulation. The normal ascendant flow
of the peritoneal fluid, which depends on the negative pressure gradient between
the abdomen and pelvis, is arrested by these peritoneal reflections. Malignant
peritoneal seeding tends to accumulate in four major dependent sites due to these
anatomic landmarks: pouch of Douglas, left lower quadrant, right lower quadrant
and right paracolic gutter.
Imaging Findings: The presence of peritoneal carcinomatosis significantly influences tumor staging, prognosis and patient management. Thus, an early and
accurate recognition of this entity is essential. Peritoneal carcinomatosis can
have a variety of appearances, including ascites, pseudomyxoma peritonei and
peritoneal implants.
Conclusion: The recognition of peritoneal carcinomatosis is essential in tumor
staging and patient management. A comprehensive knowledge of the peritoneal
anatomic landmarks and pathways of seeding provides a systematic review approach, improving the accuracy in peritoneal metastases detection.
C-422
Update in mesenteric and omental disease: CT and MR findings
M. Fernández López-Peláez, M. García Isidro, F. Bergaz Hoyos,
E. Ayerbe Unzurrunzaga, M. Parras Jurado, E. De Luis Pastor, A. Duque Taurá,
J. Cobo Soler; Madrid/ES ([email protected])
Learning Objectives: To update a review of pathologies, which may involve
mesentery and omentum. To approach differential diagnosis based on CT and
MR images. To illustrate common and unusual radiological findings. To discuss or
illustrate radiopathological correlation.
Background: Mesentery and omentum may be involved in many systemic processes, but less commonly, they present as isolated disease. Differential diagnosis,
initially based on imaging techniques, is crucial for management and prognosis.
Procedure Details: We show an interesting review of diffuse and focal involvement
from primary or secondary etiology, diagnosed in our department with multislice-CT
or MR. Confirmation was made by cytology or biopsy.
Conclusion: Mesentery and omentum may be involved in many systemic processes. However, differential diagnosis with primary diseases is important for their
management and prognosis. This exhibit illustrates a current review of several
diseases, which may involve primarily or secondly mesentery and omentum, with
special emphasis on multislice-CT and MR radiological findings.
C-423
Tumour seeding: Spectrum of imaging findings and clues to diagnosis
S.V. Setola, O. Catalano, A. Nunziata, A. Siani; Naples/IT ([email protected])
Learning Objectives: The aim of this exhibit is to illustrate the imaging findings in
patients with tumour seedings and to review their causes.
Background: Tumour seeding is the consequence of an iatrogenic transport of
tumour cells during open surgery, laparoscopic procedures (port tracks), or percutaneous procedures (biopsy, drainage, and ablation therapy). In most cases, tumour
seeding appears few months after the procedure as a single, vascularised nodule
within the abdominal wall, placed along a surgical scar or along the presumptive
path of a percutaneous procedure. The underlying tumour mass is typically located
in proximity to the seeding site with a superficial location. Risk factors include
metastatic mass nature, poor differentiation grade, large instrumentation calibre,
repeated percutaneous procedures, and scarce operator skill.
Imaging Findings: We show a variety of tumour seeding locations (chest wall,
abdominal wall, liver parenchyma, etc). as imaged by several modalities (sonography, colour-Doppler, CT, and MRI). The presumptive path of the needle or any
other percutaneous instrument is considered. Differential diagnosis mostly includes
non-iatrogenic tumour spread, infection, granulomas, and fluid collections.
Conclusion: Knowledge of patient history is important to detect a tumour seeding developed at level of surgical scars, laparoscopic accesses, or percutaneous
accesses. Early diagnosis is important because frequently patients with tumour
seeding can still be treated radically (surgery or ablation therapy).
Scientific and Educational Exhibits
C-424
Appliance of the new Choi CT response patterns to the MR evaluation of
patients affected by advanced GIST during molecular targeted therapy
(imatinib mesylate)
A. Messina, C. Morosi, P. Casali, A. Gronchi, E. Fumagalli, M. Raciti,
D. Vergnaghi; Milan/IT ([email protected])
Purpose: To evaluate the applicability of the new Choi CT patterns of tumor
response to molecular targeted therapy in advanced GIST to MR imaging, with
correlation to Recist criteria.
Methods and Materials: 25 pts with abdominal advanced GIST (225 liver lesions and 75 peritoneal lesions) underwent therapy with imatinib mesylate. All pts
performed MR examinations at baseline and then at 2, 4, 6, 8, 10 and 12 months
during treatment with a 1.5 T system using TSE T2w and dynamic ce 3D-GRE
T1w sequences. MR pattern in responsive patients according to Recist criteria
was tumor decrease in size. MR pattern in responsive patients according to the
new Choi criteria was the decrease of vascularization 15% on semiquantitative
perfusional evaluation.
Results: On morphologic MR evaluation, using dimensional criterion, 14/25 pts
had a RECIST “Partial Response”, 5/25 pts had a RECIST “Stable Disease” and
6/25 pts had a RECIST “Progression Disease”. On MR vascularization, evaluation
20/25 pts had an MR “Partial Response” pattern, 3/25 had an MR “Stable Disease”
pattern and 2/25 had an MR “Progression Disease” pattern.
Conclusion: Through the morphologic RECIST criteria, we were able to appreciate
only a portion of pathologically responsive patients. The assessment of vascularization on MR imaging may usefully integrate the dimensional data, in order to clinically
predict the pathologic tumor response.
C-425
Abdominal wall mass: Evaluation with CT and USG
Y. Lee, Y. Kang, E. Heo, Y. Sohn; Iksan/KR ([email protected])
Learning Objectives: 1. To understand the anatomy of abdominal wall for differential diagnosis of abdominal wall masses. 2. To review the spectrum of imaging
findings of high resolution ultrasonography and multi-detector CT of various palpable
or non-palpable abdominal masses.
Background: In many clinical practices, abdominal wall masses can be detected
by patient’s symptoms or physical examination. However, without the typical clinical manifestation, it is difficult to detect or characterize various abdominal masses.
Ultrasonography is an easy and convenient method to determine the presence or
absence of abdominal wall lesions and it is useful for differential diagnosis with its
characteristic imaging findings. Recent development of multi-detector CT technology allowed high resolution body imaging; it can detect more small masses of
abdominal wall and it can also evaluate peritoneal pathology.
Imaging Findings: In this exhibit, we will illustrate the CT and US imaging findings
of various pathologic conditions of abdominal wall such as hernia, variable solid
and cystic tumors, hematoma, infectious diseases, endometriosis, and vascular
diseases. The clinical history, location of the lesion and characteristic imaging features are key points to reach the correct diagnosis. We also perform the radiologicpathologic correlations, if they are surgically confirmed cases.
Conclusion: 1. Abdominal wall masses are not uncommon diseases that manifest with solitary or multiple, palpable or non-palpable lesions, can be associated
intraperitoneal disease processes. 2. Imaging diagnosis including CT and ultrasonography can play an important role to detect and characterize the various
abdominal wall masses.
gists to know what is important to evaluate in those patients affected by peritoneal
carcinomatosis. Distinct patterns appear to predict the presence of either nodular
or diffuse peritoneal pathology. MDCT is one of most suitable imaging modality in
patients with high tumor markers in selecting patients for complete cytoreduction
and perioperative intraperitoneal chemotherapy.
Conclusion: 64 rows MDCT imaging in the detection and staging of peritoneal
carcinomatosis and is a useful diagnostic tool in evaluating peritoneal carcinomatosis, monitoring response to therapy and in long follow-up.
C-427
Exploring peritoneal cavity: Practical approach to peritoneum visualized in
multi slice computed tomography
E. Czekajska-Chehab, G. Staskiewicz, S. Uhlig, E. Siek, A. Drop; Lublin/PL
([email protected])
Learning Objectives: To review normal anatomy of peritoneum, particularly for
identification of ligaments, recesses and vessels. To remind main pathologies and
their potential routes of spread in relation to communication of parts of peritoneal
cavity.
Background: The peritoneum serves not only as a support for abdominal organs,
but also forms a complex communication system of blood and lymph vessels,
ligaments and recesses that determines specific pathologies of peritoneum and
potential routes of spread of diseases such as inflammations or neoplasms. The
familiarity with normal anatomy of peritoneum is essential for correct comprehension
of pathophysiology of these processes. The authors realized that this knowledge is
limited among young residents, who consider it exceptionally difficult. Therefore, an
attempt of clear and short explanation anatomy and the review of most common
pathologies of peritoneum was made.
Procedure Details: Axial scans as well as VR, multiplanar and MIP reformations
were used for visualization of peritoneum. Colored segmentation technique was
applied for clear presentation of separate structures of peritoneum paying special
attention for its possible involvement in selected pathologies. The most common
diseases affecting peritoneum are presented.
Conclusion: Multi slice computed tomography allows detailed visualization of
peritoneum and its substructures and appropriate knowledge of anatomy is useful
in evaluation of pathologies of abdominal cavity, especially diffused ones. Postprocessing techniques are extremely useful in explaining the complex anatomy of blood
vessels, spaces and ligaments especially for inexperienced readers.
C-426
Imaging of peritoneal carcinomatosis with 64-MDCT: What radiologists
need to know now - diagnostic patterns, case examples and pitfalls
F. Iafrate1, A. Stagnitti1, A. Pichi1, D. Caruso2, F. Vecchietti1, D. Geiger1, A. Laghi2;
1
Rome/IT, 2Latina/IT ([email protected])
GI Tract
Learning Objectives: Early diagnosis of peritoneal spread in malignant disease
is essential to prevent unnecessary laparotomies and to select the patients in
whom complete cytoreduction and perioperative intraperitoneal chemotherapy
is feasible.
Background: Although anatomic imaging is the mainstay for evaluating peritoneal seeding, small neoplastic implants can be difficult to detect with CT and MR
imaging.
Results: 64 rows MDCT with I.V. contrast has the potential by using thin slice
(625 mm) and MPR reconstructions to improve detection of peritoneal metastases.
In this poster, we review different appearances, diagnostic patterns of peritoneal
spread after dividing abdomen into 9 anatomical regions. It is important for radiolo-
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Scientific and Educational Exhibits
GI Tract
Rectum
C-428
Dynamic MRI assessment of rectocele in obstructed defecation: Evaluation
of symptoms related to the evacuation dynamics, expulsion times and
associated pelvic floor disorders
A. Salzano1, V. Nocera2, V. Cavallo2, A. Nunziata2, E. Montemarano2, P. De Feo 2;
1
Frattamaggiore/IT, 2Naples/IT
Learning Objectives: A series of 68 female patients (mean age of 61 years)
suffering from obstructed defecation were studied by dynamic MRI. Our objective
is to evaluate the main shape changes of rectum as rectocele in order the whole
pelvic floor dynamics, the size of rectocele during evacuation phases and expulsion times, the association with rectal prolapses, and their relationship with pelvic
floor disorders.
Background: MRI was carried out in breathe hold with T2-weighted scans at supine
patient, previously investigated by defecography. To better understand the functional
mechanism of rectocele in order to obstructed defecation, dynamic MRI scans were
acquired during different manoveurs of pelvic floor. This is to depict well the size
and MRI appearance of rectocele during pelvic floor excursion.
Imaging Findings: We recognized 56 perineal descent syndromes, 52 rectoceles,
48 rectal mucosal and wall prolapses, 29 cystoceles, 17 rectal intussusceptions,
15 puborectalis muscle syndromes and 14 urethroceles. In 39 patients with large
rectoceles (mean diameter of 5.6 cm), we observed blockage sensation of evacuation, subjective sensation of incomplete defecation, long evacuation times (up to
5 minutes), prevailing more than of 67% of perineal descent syndromes and rectal
prolapse pathologies.
Conclusion: Thanks to dynamic MRI of pelvic floor, we focused a correlation between MR features and obstructed defecation, suggesting that in patients with large
rectoceles the symptomatology is worsened by rectal wall prolapse and rectal intussusception. In fact, in the other cases of rectoceles with low percentage and entity
of rectal prolapse, the treatment of symptoms improved defecation difficulties.
C-429
A pain in the butt: An MRI pictorial review of benign anorectal conditions
with clinical correlation
N. Chew, K. Shahabuddin, N. Khan; London/UK ([email protected])
Learning Objectives: To review the anatomy, pathophysiology and MRI appearances of benign conditions affecting the ano-rectal region. To understand the
central role of imaging in these benign anorectal conditions in terms of patient
management.
Background: Benign anorectal conditions can be painful and debilitating. Broadly,
it divides into 2 categories: 1. Infective conditions: Condyloma acuminata, perianal abscess and fistulae. 2. Non-infective/ Iatrogenic conditions: Anal fissures,
haemorrhoids including thrombosed haemorrhoids, solitary rectal ulcer syndrome,
rectal prolapse, proctitis.
Imaging Findings: Imaging findings on MRI in benign anorectal pathology are
diverse. We illustrate these conditions with real life examples and line drawing
correlation.
Conclusion: We describe clinically and illustrate on MRI a spectrum of benign
anorectal diseases.
C-430
High-field (3 T) magnetic resonance defecography with functional
assessment of the evacuation phase: A pictorial essay
A. Anaye, V. Goncalves-Matoso, J.-Y. Meuwly, P. Schnyder, S. Schmidt;
Lausanne/CH
Learning Objectives: 1. To describe the adequate technique of dynamic highfield MRI (3 T) in assessing pelvic floor disorders. 2. To provide an overview of the
most common pathologies occurring during the evacuation phase, especially in
comparison with results of conventional defecography.
Background: Dynamic high-field magnetic resonance (MR) defecography including
the evacuation phase is a promising tool for the assessment of functional pelvic disorders, nowadays seen with increasing frequency in elderly women in particular.
Procedure Details: After description of the ideal technical parameters of MR
defecography performed in supine position after gel rectal filling with a 3 Tesla unit
and including the evacuation phase, we stress the importance of using a standardized evaluation system for the exact assessment of pelvic floor pathophysiology.
The typical pelvic floor disorders occurring before and/or during the evacuation
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phase, such as sphincter insufficiency, vaginal vault and/or uterine prolapse,
cystourethrocele, peritoneo-/entero-/ sigmoïdocele or rectal prolapse are demonstrated. The difference between the terms “pelvic floor descent” and “pelvic
floor relaxation” are pictorially outlined. MR results are compared with these of
conventional defecography.
Conclusion: Exact knowledge about the correct technique including the evacuation
phase and the use of a standardized evaluation system in assessing pelvic floor
disorders by dynamic high-field MRI is mandatory for accurate and reproducible
diagnosis.
C-431
Perianal fistulae: MRI appearance and classification
K. Au Yong, N.J. Coupe, G. Tony, S. Vessal; Stoke-on-Trent/UK
([email protected])
Learning Objectives: 1. A pictorial review of the complex anatomy of the perianal
region and how the organization of anatomy dictates the course of fistulous tracts.
2. Illustration of the MRI appearance of perianal fistulae and associated complications. 3. Description and demonstration of imaging classification and the relevance
to surgical planning.
Background: Perianal fistula is a relatively uncommon GI condition but associated
with high morbidity. A previous anorectal abscess usually causes the condition but
fistulae can develop secondary to trauma, Crohn’s disease, fissures, carcinoma,
radiation therapy and infections. MRI is excellent in demonstrating the anatomy of
the perianal region including the extent of fistulous tracts and their relationship to
the sphincter complex and ischiorectal fossae. This is important for correct surgical management and MRI has been shown to provide 80-90% concordance with
operative findings.
Imaging Findings: Our exhibits use a variety of MRI sequences and post-processed images to demonstrate the spectrum of imaging findings in perianal fistulae
with specific emphasis on the relationship of fistula extent to the normal anatomy
and the appearance of complications. We will also relate the imaging findings to
the Parks surgical classification system.
Conclusion: MRI is excellent in the diagnostic work-up of patients with perianal
fistula. It is able to demonstrate secondary extension of the primary fistulae and
any complicating pathology. The recognition of fistulae and accurate imaging classification will allow appropriate surgical planning and management.
C-432
MR imaging classification of perinal fistulas: All that the radiologist need
to know
J. de Miguel Criado, M. Diez de Vacas, F. Aguilera del Hoyo,
L. Gutierrez Velazquez, L. Garcia del Salto, A. Marco Sanz, C. Cristos Alvaro,
E. Cuevas, P. Fraga Rivas; Coslada/ES ([email protected])
Learning Objectives: To illustrate the MRI spectrum of perianal fistulas. To explain
the essential teaching points and its important implications for surgical management
and outcome. To describe the MRI anatomy of the perianal region.
Background: Perianal fistulization is an uncommon but important condition of the
gastrointestinal tract that causes a substantial morbidity. To understand the surgical
options for treating fistulous disease, it is necessary to demonstrate accurately the
anatomic relationship between the perianal fistula and the anal sphincters. In this
exhibit, we will review the anatomy of the perianal region, the surgical management
and the useful MR imaging protocols.
Imaging Findings: MR imaging examinations was performed with a body-array coil,
without patient preparation. We used T1 and T2-weighted sequences in sagital and
axial planes and T1-weighted contrast-enhanced sequences in axial and coronal
planes. We used an MR imaging-based grading system for perianal fistulas (St
James’s University Hospital classification) to characterise the perianal fistulas.
Conclusion: We show the essential key points in the assessment of perianal fistula
and their surgical implications as well as examples of the imaging findings of St
James’s University Hospital MR imaging classification of perianal fistula.
C-433
Rectal cancer: The role of MR imaging
S.C.P. Costa Dias, L. Gonçalves, S. Kurochka, H. Torrão, V. Mendes; Braga/PT
([email protected])
Learning Objectives: To review the MR anatomy of the rectal region and the
imaging features of rectal cancer. To discuss the advantages and limitations of MR
imaging in this pathology. To systematize the information that the radiologist should
provide in the report, presenting practical cases.
Scientific and Educational Exhibits
Background: Rectal cancer is a common disease with a high mortality rate. Imaging plays a fundamental role in the preoperative evaluation, providing local and
distant staging. In the local staging, MR has clearly gained advantage to endorectal
ultrasound due to its large field of view, being more suitable for staging advance
rectal cancer. In the distinction among T1 or T2 stage tumors, endorectal ultrasound
remains the more accurate technique, offering better spatial resolution.
Imaging Findings: The evaluation of the involvement of the mesorectal fat and
mesorectal fascia is now considered the cornerstone for treatment planning,
even more important that T staging. The assessment of the distance between the
tumor and the mesorectal fascia is a valid criterion to predict the infiltration of the
circumferential recession margin, defining which patients benefit from preoperative treatment or direct surgery. Another parameter that has to be analyzed is the
sphincteral involvement in order to consider a sphincter-sparing surgery. This
review will be documented with cases of our institution, providing an overview of
the different tumor stages and illustrating the mentioned crucial points in the MR
evaluation of the rectal cancer.
Conclusion: MR imaging in rectal cancer is a very powerful instrument, improving
the management of these patients.
C-434
MRI evaluation of extra mural vascular invasion in rectal cancer
P.L. Perera, S. Patel, J. Sington, S.M. Williams; Norwich/UK ([email protected])
Learning Objectives: To present a pictorial representation of the appearances of
extramural vascular invasion (EMVI) in rectal cancer as seen on MRI and histology.
To demonstrate the signs of EMVI on MRI. To evaluate the accuracy of detection
of EMVI on MRI in a non-specialist centre.
Background: Treatment of rectal cancer includes surgery p pre and/or post operative chemo-radiotherapy. The advent of improved neo-adjuvant therapies has
called for accurate preoperative staging to enable optimal timing and combination
of treatment. For example, presence of EMVI is one of the factors that would favour
pre operative therapy. Compared to previously used imaging techniques, such as
endorectal US and CT, MRI demonstrates greater accuracy in identifying EMVI,
depth of invasion, nodal status and circumferential resection margin (MERCURY
project).
Imaging Findings: 12 patients who had histologically proven EMVI were selected
and their MRI reports reviewed. The scans were reviewed to look for radiological
signs of invasion. None of the 12 patients was reported as having definite EMVI
on MRI. In retrospect, four of these patients could be identified on MRI. Selected
MRI images with corresponding histology slides are presented.
Conclusion: The detection rate of EMVI on MRI is poor. This could be due to
several reasons including inadequate imaging protocols and reporter dependant
factors. Reiteration of MERCURY guidelines on the radiological signs of EMVI and
reviewing imaging protocols will be of value.
C-435
Perfusion CT of rectal cancer: How to perform it and information we can get
L. Curvo-Semedo, M. Seco, F. Cavalheiro, F. Caseiro-Alves; Coimbra/PT
([email protected])
Preoperative T and N staging of colorectal cancer with fusion imaging
between diffusion-weighted imaging and 3D fat suppressed contrastenhanced T1-weighted imaging (FDWI)
H. Horikoshi, T. Akiyoshi, N. Oya, A. Okayama; Ota/JP ([email protected])
Purpose: To prospectively determine diagnostic performance of predictive criteria
for T and N staging with FDWI in primary colorectal cancer patients, with histopathologic findings as reference standard.
Methods and Materials: Seventy-two colorectal cancer patients (39 men and 33
women, mean age; 62 years) underwent preoperative whole abdominal MRI using
1.5 T MRI (Magnetom Avanto, Siemens, Erlangen, Germany) with total imaging
matrix (Tim) and surgical resection. DWI and 3D fat-suppressed contrast-enhanced
T1WI were obtained in the axial plane. DWI was performed with respiratory gating
EPI-CHESS sequence and high b-value of 1000 s/mm2. FDWI was obtained by
workstation. T staging of FDWI was evaluated by one radiologist and surgeon by
consensus preoperatively. T and N staging were determined and correlated with
histopathologic results.
Results: Histologically, tumors were classified as T1 in 1 patient, T2 in 8, T3 in 61,
and T4 in 2, and T staging was correctly determined with FDWI in 52 patients (82%).
The sensitivity, specificity, positive predictive value, negative predictive value, and
accuracy of N staging on FDWI were 71, 58, 60, 69, and 64%, respectively.
Conclusion: FDWI may have an acceptable diagnostic ability for T and N staging
of colorectal cancer.
C-437
High resolution MRI for rectal cancer: Primer for radiology residents
S. Krishan, R. Briggs, A. Chalmers, D. Tolan; Leeds/UK
([email protected])
Learning Objectives: 1. To understand the relevant local anatomy with emphasis on
fascial planes. 2. To correlate appearances on MRI with surgical planes of excision.
3. To be able to appreciate how the imaging findings relate to pathology specimens.
4. To understand the pearls and pitfalls in the various imaging techniques. 5. To
know what the surgeons and oncologists expect from radiologists.
Background: En bloc surgical excision of rectal cancer with lymph nodes has
been proven to reduce recurrence. High resolution Imaging plays a key role in local
staging and providing the surgeons with a roadmap for their operation.
Imaging Findings: We provide a pictorial review of the common imaging findings
in high resolution MR of rectum. We further describe radiolopathologic correrelation
with demonstration of various facial planes. Finally, common pearls and pitfalls are
presented that can be used as a ready reckoner by radiology residents.
Conclusion: High resolution rectal MRI can provide vital anatomic information
important to a good surgical outcome. It is very important in planning surgery,
deciding resectability and assessing benefit from pre-operative neo adjuvant
chemotherapy.
C-438
Making sense of MR imaging of perianal fistulae, fissures, and abscesses:
A gentle algorithm for beginners
P. Khatri, N. Chew, C. Davies, N. Khan; London/UK
Learning Objectives: 1. To illustrate the normal MR anatomy of the anal canal and
ischioanal fossa, correlated with line drawings. 2. Describe a simple algorithmic
approach in the MR interpretation of perianal fistulae, fissures and abscesses with
emphasis on what the surgeon needs to know. 3. Understanding the management
of these diseases and their follow-up imaging.
Background: The interpretation of perianal fistulae, fissures and abscesses on MR
can be complex and confusing. Clear understanding of the anatomy is essential
in delineating the pathology on MRI and hence for planning further medical and
surgical management.
Imaging Findings: Pictorial review with illustration of the normal pelvic anatomy
with emphasis of the anal canal and ischioanal fossa on MRI is demonstrated.
Further examples of perianal fistulae (simple and complex), fissures and abscesses
are included with a systematic approach illustrated.
Conclusion: Understanding the anatomy and pathophysiology of periananl fistulae,
fissures and abscesses aids the accurate diagnosis of these conditions. These
provide the surgeons with essential information to plan further management.
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GI Tract
Learning Objectives: To explain how to perform a perfusion CT examination
for the study of rectal cancer. To discuss the functional information that could be
derived from such a study.
Background: In the Western world, colorectal cancer is one of the most frequently
diagnosed tumours and is among the highest mortality rates due to neoplastic
causes. The 5-year survival depends on tumor stage at the diagnosis: tumours with
advanced stage at presentation are associated with poor outcome. Accordingly, the
tumor stage guides treatment options. Some therapies created a need for functional
assessment of tumour response and this purpose has driven the development of
perfusion CT examinations.
Imaging Findings: Perfusion CT is obtained through acquisition of a series of images at the same location over a period of time from which it is possible to generate
a time-attenuation curve displaying the temporal changes in iodine concentration
resulting from the contrast injection. With appropriate mathematical modelling of
data from tissue and the vascular systems, quantitative functional information can
be derived. It allows measurement of tumour vascular physiology and provides
quantitative information on perfusion parameters including blood flow, blood volume,
mean transit time, and vascular permeability-surface area product.
Conclusion: Functional perfusion CT measurements are increasingly used to
monitor changes in tumour perfusion in response to chemotherapy and radiation
therapies. These measurements provide an in vivo biomarker of tumor angiogenesis
and may obviate invasive histological analysis. Assessment of tumour vascularity by perfusion CT suggests that perfusion parameters could be important in
prognostic terms.
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Scientific and Educational Exhibits
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GI Tract
Pearls and pitfalls of magnetic resonance staging of rectal carcinoma,
post-downsizing chemoradiotherapy
M. Anderson; Oxford/UK ([email protected])
Learning Objectives: To review the role of MR in the staging of rectal cancer and
planning of total mesorectal excision. To understand and illustrate the changes
in the appearance of rectal tumours caused by neoadjuvant chemoradiotherapy
(CRT), with pathologically staged examples. To highlight the common features that
prevents accurate image interpretation.
Background: Downsizing chemoradiotherapy has transformed the treatment
of locally advanced rectal cancers. Sphincter sparing surgery is increasingly
practised.
Imaging Findings: The main teaching points are: 1. The appearance of tumours
and lymph nodes after CRT and how to assess disease response both for preoperative and palliative treatment. 2. Features that indicate a threatened resection
margin post CRT and the role of MRI in surgical planning. 3. Features that indicate
complete clinical response to CRT. 4. The difficulties of imaging and planning treatment of low rectal tumours.
Conclusion: The imaging of rectal tumours post downsizing chemoradiotherapy
is important in surgical planning but is limited by the variability of the tumour
response.
Small Bowel
C-440
Feasibility of MRI in experimentally induced inflammatory small bowel
disease: A pilot study in a porcine model
A. Negaard, E.-M. Loeberg, P. Naess, N.-E. Klow; Oslo/NO
([email protected])
Purpose: To compare macroscopic and microscopic findings of experimentally
induced inflammatory lesions in jejunum and ileum with magnetic resonance imaging (MRI) findings.
Methods and Materials: In six pigs, inflammatory small bowel lesions were
experimentally induced. Segments in jejunum and ileum were isolated and trinitrobenzenesulfonic acid and ethanol (TNBS-EtOH) solution was installed. MRI of
the small bowel was performed 7 days after the surgery. Before the MRI, a 6%
mannitol solution was installed through a nasogastric tube. The MRI protocol consisted of T2, BFFE and T1 weighted sequences with intravenous contrast. Bowel
wall thickness (BWT), bowel wall enhancement (BWE) and bowel stenosis (BWS)
were evaluated. After the MRI, the animals were sacrificed. The small bowel was
removed and inspected macroscopically and microscopically.
Results: Inflammatory lesions developed in jejunum and ileum. The lesions were
visible macroscopically and microscopically. The microscopic findings consisted
of variable degrees of inflammation, ulcer formation and fibrosis. In jejunum the
inflammatory lesions had normal bowel wall thickness and were not diagnosed with
MRI, except in one pig with a bowel necrosis probably caused by an intramural
injection or leakage of the TNBS-EtOH solution. In ileum, the bowel wall thickness
was increased and the inflammatory lesions were diagnosed with MRI.
Conclusion: The inflammatory lesions were visible macroscopically and microscopically. Lesions in ileum had increased BWT and were possible to image with
MRI. Lesions in jejunum had normal BWT and were not diagnosed with MRI, except
in one pig with increased BWT probably caused by complications.
C-441
A comprehensive pictorial review of inflammatory bowel disease with
pathological correlation
P. Balan1, G. Griffiths1, E. Morris2, R. Winter2, R. Owen1, G. Davies2; 1Cardiff/UK,
2
Llantrisant/UK ([email protected])
Learning Objectives: 1. Review the pathophysiology of inflammatory bowel
disease. 2. Review the imaging findings. 3. Review the differentiating features and
complications. 4. Highlight the potential pitfalls in diagnosis.
Background: Inflammatory bowel disease is a common condition encountered
in routine radiological practice. It could be due to infective, ischaemic, vasculitic
and other rare causes.
Procedure Details: We describe the pathophysiology of inflammatory bowel disease and present a comprehensive pictorial review of findings on different imaging
modalities, including ultrasonography, 64 MDCT, MRI, nuclear medicine and barium
studies to demonstrate the differentiating features and various complications. The
imaging findings are correlated with pathological findings. This review is also used
to highlight potential pitfalls.
Conclusion: Accurate diagnosis of inflammatory bowel disease and identification
of complications is essential for appropriate management of patients. Knowledge
of the pathophysiology, imaging findings, differential diagnosis and awareness of
potential complications is important for useful interpretation of images.
C-442
Complications of Meckel’s diverticulum: Imaging diagnosis
R. Iwasa, K. Itoh, M. Hino, H. Ueda, T. Shibata, M. Hashimoto, Y. Imai; Hyogo/JP
([email protected])
Learning Objectives: To illustrate multimodality imaging for diagnosis of Meckel’s
diverticulum and its complications, and to provide surgical correlation and pathologic findings.
Background: Meckel’s diverticulum is the most common malformation of the
gastrointestinal tract, and clinical symptoms arise from complication of the diverticulum. Preoperative diagnosis of the diverticulum is sometime difficult despite the
availability and wide use of various imaging techniques. Recently as multidetector
computed tomography (MDCT) has become widespread, it allowed rapid, highresolution imaging of the entire abdomen and pelvis, and multiplanar reformation
(MPR) images give the best visualization of Meckel’s diverticulum often concealed
by overlying small-bowel loops.
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Imaging Findings: We will illustrate the following: 1. incidentally detected Meckel’s
diverticulum without complications, 2. hemorrhagic ulcer in the diverticulum, 3.
ileal strangulation associated with the diverticulum, 4. intussusception caused by
inverted diverticulum, and 5. diverticulitis and perforation. Some cases mimic such
disorders as appendicitis, peptic ulcer disease, and small intestinal lipoma. The
imaging features of these diseases will be presented on different types of imaging
modalities, including ultrasonography, MDCT, barium examination, endoscopy and
scintigraphy with surgical and pathologic correlation. Usefulness of MPR images
obtained by MDCT and specificity of scintigraphy will be discussed, and the relative
advantage and indication for the various imaging procedures will be assessed.
Conclusion: Knowledge of the clinical and radiologic characteristics of Meckel’s
diverticulum will aid in the early and accurate diagnosis of cases with complications. The imaging evaluation of patients should be tailored to their age and clinical
presentation.
C-443
Diagnosing small bowel carcinoid tumor with MDCT enteroclysis
G. Tóth1, L. Tóth2, E. Turupoli1; 1Budapest/HU, 2Miskolc/HU ([email protected])
Learning Objectives: To show the usefulness of MDCT enteroclysis in the diagnosis of carcinoid tumor. To show the different types of carcinoid tumor in the
small bowel.
Background: MDCT enteroclysis has proved to be useful for evaluating minimal bowel
wall thickening, stenosis and dilatations of the small bowel, and also we can study the
pathological changes of mesentery. Our goal was to localise exactly the site of carcinoid
tumor, if other examinations were negative. We present the typical imaging findings of
our experience of MDCT enteroclysis. We demonstrate some of our cases.
Imaging Findings: From December 2005 to September 2008, 38 CT enteroclysis
were performed to find carcinoid tumor in the small bowel. Positive findings were
demonstrated in 7 of 38 patients. CT enteroclysis were performed using the following parameters: slice 2 mm, with overlap scans, reconstruction interval 2 mm,
after administration of methylcellulose by nasojejunal tube, before and after infusion
of 120 ml iv. contrast agent, at a rate of 4 ml/s with a scan delay of 35 seconds.
In all cases, multiplanar reformatted images were performed. Collimation was
16x0.75 mm. We found soliter, and multiplex lesions with polipoid, annular stenosing, and infiltrating appearances with typical mesenterial reactions. In 3 cases
patients already had a liver mets.
Conclusion: MDCT enteroclysis is a good tool in detecting carcinoid tumor in
the small bowel.
C-444
Is there a good correlation between perfusion of enlarged lymph nodes
and CDAI in active Crohn’s disease?
G. Tóth1, E. Turupoli1, L. Tóth2; 1Budapest/HU, 2Miskolc/HU ([email protected])
Multidetector-CT (MDCT) with polyethylene glycol (PEG) solution versus
multidetector-CT enteroclysis in small bowel disease
L.M. Minordi, A. Vecchioli, L. Verrastro, G. Poloni, L. Bonomo; Rome/IT
([email protected])
Purpose: The aim of the study is to evaluate multidetector-CT with polyethylene
glycol solution (PEG) (PEG-CT) as an alternative technique to multidetector-CT
enteroclysis (E-CT) in patients with suspected small bowel disease.
Methods and Materials: 145 patients underwent abdominal contrast-enhanced
16-row multidetector-CT after administration of 2000 mL of PEG by mouth (n=75)
or after administration of 2000 mL of methylcellulose by naso-jejunal tube (n=70).
Small bowel distention, luminal and extraluminal findings were evaluated and compared with small bowel follow-through examination in 60 patients, barium enema
in 50, surgery in 25 and endoscopy in 35. Statistical evaluations were carried out
by C2 test with Yates correction.
Results: Crohn’s disease was diagnosed in 64 patients, neoplasms in 16 (6 with
lymphoma non Hodgkin, 3 with carcinoid, 2 with Peutz-Jeghers syndrome, 2 with
adenocarcinoma, 2 with lypoma, 1 with metastasis from melanoma), adhesions
in 6. Distension of the proximal and distal jejunum was found to be significantly
better in patients studied with E-CT than those studied with PEG-CT, as confirmed
by the C2 test with Yates correction (p 0.05: statistically significant difference). No
significant difference was present for others sites (p 0.05). Evaluation of pathological ileal loops was good with both techniques. The values of sensitivity, specificity
and diagnostic accuracy were, respectively, 94, 100 and 96% with E-CT and 93,
94 and 96% with PEG-CT.
Conclusion: PEG-CT is a good alternative technique to E-CT in patients with
suspected small bowel disease.
C-446
Carcinoid tumours: A pictorial review
K. Slaven, P. Healey; Liverpool/UK ([email protected])
Learning Objectives: To recognize common radiological presentations of carcinoid
tumours and metastases.
Background: Neuro-endocrine tumours (NETs) develop from enterochromaffin
cells and can be divided into gastroenteropancreatic and carcinoid tumours. Carcinoid tumours arise from the embryonic gut and are found incidentally in 1:300 of
autopsies. They are classified either by organ of origin (embryonic foregut, midgut or
hindgut) or by a histological-based system. Although typically slow growing, all have
a malignant potential and the ability to metastasize. 10% of metastatic carcinoids
(predominantly those of a mid-gut origin) secrete the hormone serotonin (5-HT),
which causes the symptoms of carcinoid syndrome.
Imaging Findings: When imaging a suspected carcinoid tumour, contrast enhanced CT,
radionuclide imaging (octreotide) and fused imaging (SPECT/CT) are used. While it may
be difficult to identify the primary tumour, appearances of metastatic disease can assist
with diagnosis. Typical findings in metastatic disease include enhancement, calcification
within the tissue mass (70%) and adjacent desmoplastic reactions. Routine follow-up
includes interval CT or MRI, although further radionuclide imaging may be required.
Conclusion: Although relatively rare, tumours imaging is crucial in the initial assessment and follow-up of carcinoid tumours. Knowledge of the diversity of imaging
presentations and use of different modalities is essential in diagnosing, staging
and following up these patients.
C-447
Semi-quantitative assessment of enhancement in contrast-enhanced
ultrasound in patients with Crohn’s disease: Comparison with Crohn’s
disease activity index
M. Jedrzejczyk, K.T. Szopinski, A. Cybulska; Warsaw/PL ([email protected])
Purpose: To evaluate the usefulness of semi-quantitative parameters of sonographic contrast enhancement in the assessment of activity of Crohn’s disease (CD).
Methods and Materials: Enhancement curves of the bowel and iliac artery were
calculated in 52 contrast-enhanced ultrasound examinations performed in 36 patients with confirmed CD (22 males, 14 females, mean age 32 years). The Crohn’s
disease activity index (CDAI) was calculated in all patients. The bowels were imaged
on a Voluson 730 Expert (General Electric) machine using a 2-5 MHz convex probe.
Contrast-enhanced images were obtained after intravenous administration of 1.2 ml
of SonoVue (Bracco). Maximal signal intensity (Imax), area under curve (AUC), mean
transit time (mTT), time-to-peak (TTP), and rise time (RT) were calculated, and the
results obtained in patients with active and inactive disease were compared and
assessed using Student t test.
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Purpose: The purpose of this study was to measure the perfusion of enlarged
lymph nodes in Crohn’s disease, and to compare results with CDAI.
Methods and Materials: We examined 35 patients with known Crohn’s disease.
These patients had thickened wall small or large bowel with lymph nodes 1 cm.
26 patients had clinically suspected exacerbation of Crohn's disease. Region of
interest were placed over the biggest lymph node near the inflamed bowel segment.
We measured the perfusion of lymph nodes. We administered 1.5 ml/kg i.v. contrast
material. The flow was 3.5 ml/s. Acquisition started after 20 sec of administration
of the contrast material and lasted for 45 sec at a rate of one image per 1.5 sec.
Collimation was 8x3 mm. The slope of enhancement, perfusion (P) ml/100 ml/min,
peak enhancement intensity (PEI), time to peak enhancement (TTP), and blood
volume (BV) ml/100 g were determined. These results were compared with CDAI.
Statistical analysis was performed using the Wilcoxon rank sum test.
Results: The signal intensities of the perfusion scans were measured and displayed
in a graph. The graphs showed a typical enhancement pattern in patients with CDAI
higher than 350. A good correlation was found between CDAI and P, TTE and BV
(0.913, 0.942, 0.961), p 0.009.
Conclusion: Measuring the perfusion in enlarged lymph nodes can be a valuable
tool in assessing Crohn’s disease activity.
C-445
Scientific and Educational Exhibits
Results: In patients with CDAI 150 (n=27), the mean ratio of Imax in the bowel and
in the iliac artery was -5.1 dB, and in patients with CDAIb150 (n=25) the mean ratio
of Imax was -7.3 dB (p 0.01). In patients with CDAI 150, the mean ratio of AUC
in the bowel and in the iliac artery was -7.4 dB, and in patients with CDAIb150 the
mean ratio of AUC was -11.6 dB (p 0.05). mTT, TTP and RT were not statistically
different in patients with active and inactive Crohn's disease.
Conclusion: Ratio of the maximal signal intensity and ratio of the AUC, measured
in the bowel wall and in the iliac artery, are suitable parameters in the assessment
of the activity of Crohn’s disease.
C-448
Contrast-enhanced ultrasound (CEUS) in Crohn’s disease: Technique,
image interpretation, and clinical applications
T. Ripollés, M.J. Martinez-Perez, F. Delgado, E. López-Pérez, G. Figueres,
J.M. Paredes; Valencia/ES
Learning Objectives: To describe the technique of the CEUS in the evaluation of
patients with Crohn´s disease. To illustrate the sonographic findings and clinical
applications, including complications and assessment of disease activity. To provide
examples of CT or MR correlation.
Background: Recent meta-analysis has demonstrated no significant differences
in diagnostic accuracy among different imaging techniques in the evaluation of
CD. Ultrasound is now established as a valuable technique in the diagnosis and
follow-up of patients with CD. The use of echo-contrast agents provides accurate
depiction of bowel wall perfusion due to the high sensitivity in the detection of
microvascularization. This method permits real-time examination of the bowel wall
perfusion with similar contrast resolution than CT and MR.
Imaging Findings: Contrast-specific US techniques allow continuous imaging
evaluation of the bowel wall and the perienteric tissues after IV administration of
second generation contrast agent (Sonovue®). The introduction of imaging quantification techniques enables objective quantitative measurement of enhancement.
Current CEUS applications: to characterise inflammatory masses distinguishing
phlegmons from abscesses; to differentiate fibrotic from inflammatory stricture; CD
activity assessment (evaluation of pattern of enhancement or quantitative measure
of increase in wall brightness); prognostic value to detect relapses; to monitor efficacy of drug treatments.
Conclusion: Ultrasound now has clearly defined roles in the diagnosis and follow-up
of CD. CEUS is part of the entire sonographic evaluation and its results are comparable with other modalities, such as CT or MR. Familiarity with the technique will
extend its use in clinical practice.
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Stomach
C-449
The role of gastric distention with additional water in differentiating locally
advanced gastric carcinomas from physiological uptake in the stomach on
FDG PET
K. Kamimura1, S. Nagamachi1, H. Wakamatsu1, S. Fujita1, S. Ueno1,
Y. Umemura1, M. Ogita1, T. Fujimoto1, M. Nakajo2; 1Miyazaki/JP, 2Kagoshima/JP
Purpose: In the current study, we investigated the role of gastric distention with
additional water to determine whether it is beneficial for the differentiation of locally advanced gastric carcinomas from physiological FDG uptake in the stomach
and to characterise the FDG uptake of gastric carcinomas by relating it to the
histopathological properties of the tumours.
Methods and Materials: Sixteen patients with locally advanced gastric carcinomas
and 20 control subjects were studied by FDG PET. After whole-body PET imaging,
the patients drank 400 ml of water, and then spot imaging, with additional water, of
the stomach was performed. The final diagnosis was determined from the results of
surgery. The gastric areas were divided into the upper, middle, and lower parts. The
degree of FDG uptake in the stomach was qualitatively evaluated by visual grading
into 3 degrees. For quantitative analysis, the regional tumour uptake was measured
by mean standardised uptake values using a region of interest technique.
Results: In visual analysis, the sensitivity, specificity, positive predictive value,
negative predictive value, and accuracy of PET without additional water ingestion
were 100, 50, 62, 100, and 72%, respectively, and those of PET with additional
water ingestion were 88, 100, 100, 91, and 94%, respectively. Using spot imaging
under the condition with additional water ingestion, four gastric carcinomas were
depicted more clearly.
Conclusion: Gastric distention as a result of patients drinking a glass of water is
a simple and noninvasive method for improving the diagnostic accuracy of FDG
PET in patients with locally advanced gastric carcinoma.
C-450
CT evaluation of gastric lymphoma with drug induced hypotonia and water
filling of the stomach
A. Gligorievski; Skopje/MK ([email protected])
Purpose: The purpose of our study was to determine the value of computed
tomography (CT) with a drug-induced hypotonia and water filling in diagnosis and
preoperative staging of 27 patients with gastric lymphoma (GLy) confirmed by
endoscopic biopsy.
Methods and Materials: CT scans were performed in supine and prone positions
with drug induced hypotonia and water filling of stomach with 500-700 ml., and
intravenous administration of non-ionic contrast agent. Prone position and druginduced hypotonia allowed visualization of the whole gastric wall and prevented
gas artifacts, commonly present during supine imaging.
Results: CT scans were analyzed with respect to the thickness of the stomach
wall, rugal thickening, presence of wall infiltration, mucosal nodularity, ulcerations
and tumor masses, regional tumor spread, lymph node deposits and presence
of distant metastases. The most common findings in GLy was ulcers of variable
size, depth and number in 43% of cases, a mass with or without an ulcer in 36%
of cases, and rugal thickening in 21% of cases. According to CT results, GLy was
staged in four groups: IE, IIE1, IIE2, IIIE and IVE. Precise preoperative staging was
achieved in 73%, overstaging in 18% and understaging in 9% of patients. Sensitivity
and specificity of the technique was 93 and 85%, respectively. Low grade MALT
lymphoma was in 69% and high grade MALT lymphoma in 31% of cases.
Conclusion: We believe that CT performed with this method is a useful noninvasive
method for preoperative evaluation and staging of gastric lymphoma and should
be used before surgery is planned.
Scientific and Educational Exhibits
C-451
Staging of gastric cancer: A comparative study with 64-MDCT and 1.5 T MRI
B. Cavallo Marincola, A. Napoli, M. Anzidei, F. Zaccagna, C. Catalano,
R. Passariello; Rome/IT ([email protected])
Purpose: compare the usefulness of MRI with T2-weighted turbo spin-echo and
fast T1-weighted 3D gradient-echo sequences with 64-DCT in the staging of
gastric carcinoma.
Methods and Materials: Thirty patients with gastric carcinoma underwent MRI
and MDCT. MR (1.5 T) and 64-MDCT (200 mA, 120 kv, thickness 1.25 mm, rec.
int. 0.6 mm) were performed after i.m. injection of scopolamine and water distension of the stomach. In the MRI protocol True-FISP T2-weighted sequences, turbo
spin-echo T2-weighted sequences (TR 4000 ms, TE 100 ms, thickness 3 mm,
matrix 384x384, TA 30) and gadolinium-enhanced fat-suppressed 3D gradientecho sequences (TR 5.8 ms, TE 2.75 ms, thickness 3 mm, matrix 384x384, TA
18) were included. 64-MDCT was performed 60 sec after contrast agent injection
(3.5-4 ml/sec). Two groups each of two radiologists independently analyzed MRI
and 64-MDCT images; results were compared with pathologic findings.
Results: MR accuracy was higher than 64-MDCT (85 and 79%, respectively) in
the differentiation of T1-T2 stages; the accuracy of MR and CT was not significantly
different in the differentiation of T2-T3 and T3-T4 stages (p 0.05). Overstaging was
noted in 6% of cases with MRI and 10% with 64-MDCT. Understaging was noted
in 15% of cases with MR and 18% with 64-MDCT.
Conclusion: MRI and 64-MDCT accuracies were not different in advanced stages,
while MRI was superior in the differentiation of early stages of gastric cancer.
GI Tract
Miscellaneous
C-452
Gastrointestinal imaging findings in collagen vascular diseases
T. Ichikawa, J. Koizumi, Y. Nagata, H. Yamamuro, Y. Imai; Isehara/JP
([email protected])
Learning Objectives: To illustrate abdominal imaging features in collagen vascular
diseases on CT and barium study.
Background: Collagen vascular diseases are known to present with various
gastrointestinal manifestations classified as: 1) gastrointestinal damage due to the
collagen vascular disease itself; 2) adverse events by pharmacotherapies; or 3)
gastrointestinal infections secondary to corticosteroid administration. The first group
includes lupus enteritis in systemic lupus erythematosus (SLE), pneumatosis cystoides intestinalis (PCI) in scleroderma, and ileocecal ulcer in Bechet disease.
Imaging Findings: This exhibit illustrates specific imaging findings on CT and
barium study in collagen vascular diseases. The target sign on contrast enhanced
CT is observed in vasculitis such as SLE and Henoch-Schonlein purpura. PCI
characterized by intramural air in the intestine is associated with scleroderma, mixed
connective tissue disease and SLE. The demonstration of cystic gas collection in
the intestinal wall and pneumoperitoneum are detected with highest sensitivity using CT. Lupus cystitis is a rare manifestation associated with hydronephrosis and
lupus enteritis. Small aneurysms and stenosis of vessels in polyarteritis nodosa are
demonstrated on MDCT as well as angiography. Barium study is useful to detect
esophageal dysmotility and small intestinal dilatation in scleroderma, thumb-printing
sign consistent with intestinal edema or hemorrhage in SLE and Henoch-Schonlein
purpura and multiple ulcers in SLE and Bechet disease.
Conclusion: To recognize image findings on CT and barium study is important in
correct diagnosis and treatment in patients with collagen vascular diseases.
C-453
Abdominal endoscopic procedures complications: Spectrum of imaging
findings
P.A.A.F. Santos, J. Pires, M. Gomes, M. França, F. Reis; Porto/PT
([email protected])
Learning Objectives: To highlight the role of different imaging techniques in the
assessment of complications arising from endoscopic procedures (diagnostic and/
or therapeutic). Several cases will be illustrated, representative of complications
resulting from upper endoscopy, colonoscopy and ERCP, and demonstrated by
conventional radiography, ultrasound and CT.
Background: The complications arising from endoscopic procedures are in
decline at present thanks to improvements in technology and greater experience
of endoscopists. However, the increasing number in the therapeutic endoscopic
procedures, which leads to many complications such as perforation and bleeding,
continue to occur with a frequency not negligible.
Imaging Findings: From the list of complications associated with these techniques,
special emphasis will be given to parietal perforation (leading to pneumomediastinum, pneumoperitoneum and pneumoretroperitoneum), bleeding (including
hemoperitoneum as a result of direct trauma or stretching of splenic vessels),
parietal hematomas from more invasive procedures and acute pancreatitis in the
setting of ERCP. CT scan was shown to be the most valuable technique in this
context, because of its greater sensitivity and specificity in the evaluation of the
clinical entities mentioned above.
Conclusion: It is important to be aware of potential risks of endoscopic procedures
as these can represent a life-threatening event. The role of imaging techniques is
very important in this setting, since early diagnosis may provide a favorable clinical
outcome to the patient.
C-455
Learning Objectives: 1. To present the definitions of evidence-based medicine.
2. To show how abdominal imaging and intervention decisions in patient groups
or individual patients must be based on the best available current evidence. 3. To
describe how evidence-based medicine can change the current and the future
abdominal imaging practice.
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How can evidence-based medicine change abdominal imaging practice?
A.N. Chalazonitis1, G. Tsimitselis2, J. Tzovara1, G. Neofytou1, F. Laspas1,
N. Ptohis1; 1Athens/GR, 2Larissa/GR ([email protected])
Scientific and Educational Exhibits
Background: Abdominal radiology is a rapidly evolving field, with new diagnostic
methods and interventional techniques continuously replacing the previously accepted. Traditionally radiologists were taught how to practice their specialty through
textbook memorization and copying the behavior from acknowledged experts. The
remodeling of the today’s radiological practice requires new skills that are not usually part of medical training.
Procedure Details: We will demonstrate how EBM can change the way abdominal
radiologists look after their patients by accessing and applying valid and relevant
summaries of guidelines and systematic reviews. We will also provide guidelines
how and where to use appropriate, ‘technology assessment’ principles to find answers that are based on the best current evidence for problems arising in current
imaging or interventional practice.
Conclusion: Today there is a powerful demand for ways of getting evidence into
radiological practice in the most efficient way. EBM can change the way abdominal
radiologists look after their patients by accessing and applying valid and relevant
summaries of guidelines and systematic reviews.
C-456
The Iliopsoas compartment: A pictorial review of anatomy and common
pathologies
M.J. Kaduthodil, H. Ganesh S. Rajaram, R. Vijay; Sheffield/UK
([email protected])
Learning Objectives: To review the anatomy and the spectrum of pathologies
affecting the iliopsoas compartment with emphasis on cross sectional imaging.
Background: The iliopsoas compartment is an important anatomical landmark in
the abdomen and can be the site of a variety of pathological processes. A detailed
knowledge of the anatomy and imaging appearances can help increase diagnostic
accuracy, and CT in particular is useful not only in delineating pathology but also
can help in image guided intervention.
Procedure Details: We review the detailed cross sectional anatomy and the common disease processes affecting the iliopsoas compartment using cross-sectional
as well as diagrammatic images.
Conclusion: A combination of detailed knowledge of anatomy and pathologies
and the advanced imaging techniques that are available now will enable clearly
defining disease processes affecting the iliopsoas compartment.
C-457
Usefulness of [18 F]FDG-PET/CT for assessment of recurrent pelvic cancer
in patients with rising tumor serum markers and negative conventional
imaging tests
M.G. Skilakaki, E.V. Skoura, P. Rondogianni, C. Giannopoulou, D.N. Exarhos,
I.E. Datseris; Athens/GR ([email protected])
Purpose: To determine the ability of [18 F]FDG-PET/CT in detection of recurrence
in patients with previously treated pelvic malignancies who have elevated tumor
marker serum levels and negative results on conventional imaging.
Methods and Materials: 17 patients (6 men, 11 women) aged from 39 to 78 years
(mean age: 60 years) who underwent [18 F]FDG-PET/CT at our institution between
July 2007 and June 2008 were included in the study. Inclusion criteria were: known,
post-treatment pelvic cancer, increased serum tumor markers (CEA, CA-125, CA
19-9) and recent negative conventional imaging evaluation: CT of thorax, CT and/
or MRI of abdomen and pelvis. Of the 17 patients, 7 had colorectal cancer, 8 had
ovarian and 2 cervical cancer.
Results: Recurrent disease was revealed in all 17 patients: of 7 patients with
colorectal cancer, 4 had peritoneal metastases, 2 had lymphadenopathy (1
paraaortic and common iliac and 1 mediastinal lymph nodes) and 1 patient had
both peritoneal infiltration and iliac lymph nodes. Of 8 women with ovarian cancer,
3 had peritoneal carcinomatosis, 2 had intraabdominal lymphadenopathy and the
rest 3 had peritoneal disease in association with: intraabdominal lymphadenopathy
(2), supraclavicular lymph nodes (1), inguinal lymph nodes (1), axillary lymphadenopathy (1), and hepatic lesions (1). Finally, the 2 women with cervical cancer had
mediastinal lymph nodes and peritoneal carcinomatosis, respectively.
Conclusion: Although further confirmatory work is needed, [18 F]FDG-PET/CT
seems to be a very important tool in the assessment of recurrent disease suggested by rising tumor serum markers in patients with pelvic cancer and negative
conventional imaging tests.
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C-458
CT appearance of abdominal liposarcoma
P. Sadaba, I. Aloa, I. Aguirre, S. López, A. Cancho, K. Armendariz, Z. Fernandez,
N. Serrano, I. Iraola; Galdakao/ES
Learning Objectives: To illustrate CT features of different types of abdominal
liposarcomas.
Background: Abdominal liposarcomas are uncommon; nevertheless, they are the
second commonest malignant retroperitoneal soft-tissue tumor in adults. CT is an
excellent tool for diagnose this entity, with high sensitivity and specificity, allowing
a precise anatomical localization. There are four histological types recognized, the
myxoid being the most common.
Imaging Findings: We reviewed clinical and radiological data of 12 patients, 7
women and 5 men (age range: 42-80 years; mean: 61 years) with histologically
proven abdominal liposarcoma diagnosed at our institution from 1995 to august
2008. Abdominal liposarcomas were found in retoperitoneum (10) and mesentery
(2). The size of the tumours ranged from 8 to 35 cm. CT appearance of the liposarcomas vary on different histologic subtypes.
Conclusion: CT provides accurate information regarding abdominal liposarcomas.
Knowledge of their radiological characteristics is essential in the diagnosis and
patient´s management.
C-459
A free and customized online tool to facilitate quick and accurate staging
of common gastrointestinal malignancies
R. Talanow; Cleveland, OH/US ([email protected])
Learning Objectives: To create a free, web-based and customized cancer staging tool for common gastrointestinal malignancies, which easily integrates into the
radiologist’s daily work from any monitor or PACS station.
Background: Complex cancer staging systems describe the anatomic spread
of a particular malignancy. Staging provides prognostic information and is vital
in guiding appropriate therapy. However staging can be difficult to perform for the
inexperienced physician and inaccurate staging can lead to unnecessarily adverse patient’s outcome. The author provides a free, comprehensive, web-based,
on-the-fly solution that is easy to use and aids in accurate staging of common
gastrointestinal malignancies.
Procedure Details: The tumor classification information is based on the Collaborative Staging Network. On-the-fly staging is done by calculating and comparing the
information provided by the user with the tumor classification database saved on the
server. The staging tool can be used in several modes for the user’s convenience.
Output of information is also offered in several modes to increase flexibility and
better integration into the reader’s workflow.
Conclusion: This free, web-based and customized program easily integrates
into the radiologist’s daily work from any monitor or PACS station. The interface is
flexible and easily adapts to the individual physician’s preferences by seamlessly
incorporating into the workflow. It is an intuitive, user friendly educational program
that makes staging of common gastrointestinal malignancies easy and accurate.
C-460
Diffusion Wi in abdominal MRI: PET CT is threatened!
P.A. Ganne, O. Bruot, J. Mathias, V. Laurent, D. Régent;
Vandoeuvre Les Nancy/FR ([email protected])
Purpose: We performed diffusion Wi in MRI abdominal imaging in different clinical
backgrounds, and we fusioned DW images with T1 or T2W images to obtain “virtual
PET-MRI” images. We tried to know if such images can be helpful in tumoral and
inflammatory GI tract disease.
S
Methods and Materials: We retrospectively studiedODWi in different GI tract tumoral
P
or inflammatory pathologies (Crohn’s disease, pancreatic
cancer, peritoneal carcinoE
matosis, lymphoma, rectal cancer). Thanks to
toOsirix software, DW and anatomical
images were fusioned. Results were compared
with clinical and surgical data.
ed
itt detection and a better small tumoral
Results: Virtual PET-MRI allows a better
m
b This technique is indeed quite efficient to
lesions localisation before treatment.
Su Furthermore, this functional and anatomical
detect small carcinomatosis nodules.
l
ia approach of digestive inflammatory disorders. This
imaging allows a physiological
er
non-irradiant exam mayatbe an interesting choice to assess GI tract inflammatory
M suffering from Crohn’s disease.
activity in young patients
Conclusion: Virtual
No PET MRI imaging is a non irradiant, non invasive and non
expansive efficient technique that is sensible in tumoral and inflammatory GI tract
disease, but has to be evaluated with larger studies and compared with PET-CT
in terms of specificity.
Scientific and Educational Exhibits
C-461
Advanced gastrointestinal stromal tumors in treatment with imatinibmesylate: Response evaluation with CT and MRI
E.R. Amador, G. Alonso, E. Usamentiaga, L. Picó, P. Lopez, J. Martin;
Palma de Mallorca/ES ([email protected])
Learning Objectives: To illustrate response with CT or MRI to imatinib-mesylate
treatment in advanced GIST. To correlate tumour response assessment with the
prognosis of the disease. To review the CT technique and method to quantify the
response.
Background: Gastrointestinal stromal tumours (GIST) are primary mesenquimal
tumours of the gastrointestinal tract, mesentery or retroperitoneum, CD117 positive. Malignant GIST account for the majority of gastrointestinal sarcomas. 61% of
them being advanced at diagnosis. Imatinib-mesylate is highly effective in advanced
disease with response of nearly 50%. CT is adequate to assess tumour response.
In addition to RECIST criteria, density and enhancement variations correspond
better to clinical outcome. Between 2002 and 2008, CT/MR images of 44 lesions
(liver, lung, mesentery, peritoneum and gastrointestinal tract) in 13 patients with
advanced GIST on glivec therapy were reviewed. These were classified according
to responders (stable and remission disease) and non-responders (progressive
disease); we illustrated treatment response and analysed technique influence.
Imaging Findings: Multiphase MDCT were carried out in all patients. One patient
with pelvic recurrence was studied with MRI. Tumour control was achieved in 72.7%
of the cases; a quarter of them attained complete remission. The average follow-up
period was 33.5 months. All patients were alive at the moment of the study. A possible false positive due to a deficient bolus technique was reviewed. Arterial phase
did not contribute to decide treatment.
Conclusion: Optimal tumour evaluation response with CT requires a standardized and comparative method of lesion analysis, based on an adequate IV bolus
portal phase.
C-462
CT-colonography (CTC): Which are the right scanner parameters to use?
P. Paolantonio, R. Ferrari, M. Rengo, F. Vecchietti, P. Lucchesi, M. Maceroni,
A. Laghi; Latina/IT ([email protected])
Learning Objectives: To describe acquisition parameters of CT-colonography
protocols using different scanners generations moving to single slice spiral CT
to the 64-MDCT.
Background: Nowadays, the “panorama” of technical approaches for CTC is expanding offering a wide spectrum of different possibilities. As technology continues
to advance, there will be a continuing need to reassess the relative tradeoffs between
scan width, image noise, patient dose, image artefacts, breath-hold times, and the
number of reconstructed images to be viewed and archived.
Procedure Details: We will discuss the relationship among collimation, tube current settings, patient dose exposure and accuracy in polyp detection of various
CTC protocols valid for different scanner generation. We will offer some practical
guidelines for CTC technique based on evidences of literature and on our personal
experience of more than 800 CTC examinations performed on different scanners
generation including a 64-MDCT (VCT; GE).
Conclusion: A single scanning protocol with identical parameters for all scanners
and patients cannot be recommended due to technological differences as well
as different clinical indications to CTC. What is possible to do is to offer general
guidelines according to the consensus statement on CTC. Collimation should not
be larger than 5 mm for SSCT and no larger than 3 mm for MDCT. With the advent
of 64-slice MDCT, sub-millimeter collimation will be mandatory, although clinical
benefits are still unclear.
C-463
Mesenteric venous thrombosis: MDCT features according to the
underlying etiology
R. Duran, A. Denys, P. Schnyder, S. Schmidt; Lausanne/CH ([email protected])
C-464
Principles of computed tomographic enterography and recent trends in
interpreting imaging findings
K.M. Elsayes, J.D. Nadig, M. Al-Hawary, J. Platt; Ann Arbor, MI/US
([email protected])
Learning Objectives: To discuss the imaging techniques, clinical indications,
and utility of computed tomographic enterography (CTE) in diagnosing various
gastrointestinal diseases. Characteristics of these diseases will be illustrated with
representative examples. Special emphasis will be placed on the recent trends in
interpreting the imaging findings.
Background: The introduction and continuing technical improvements in CTE
technique have increased its utility as an effective, efficient, and non-invasive tool
in the diagnosis and management of a variety of gastrointestinal disorders. Subsequently, an increasing number of CTE examinations are performed. Therefore,
the radiologist must be familiar with the technique and imaging findings relevant
to various gastrointestinal diseases.
Imaging Findings: The exhibit begins with a short introduction of CTE followed by
discussion of the imaging parameters, patient preparation, and types of negative
oral contrast. We then discuss the utility of CTE in diagnosing various gastrointestinal diseases and review the imaging findings according to the recent trends in
interpretation. The exhibit concludes with sample cases illustrating the diagnostic
role of CTE and imaging findings of a spectrum of diseases including inflammatory bowel disease, mesenteric ischemia, gastrointestinal bleeding, small bowel
obstruction, and gastrointestinal tumors.
Conclusion: CTE is frequently performed with modern equipment. When performed
appropriately, it is a powerful tool capable of characterizing small bowel pathology,
identifying lesions within the stomach, duodenum and colon, and providing an
opportunity to evaluate both extraluminal and extraintestinal tissues. Radiologists
need to be able to recognize and interpret the relevant findings in CTE and apply
them to the various gastrointestinal diseases.
C-465
The post-operative abdomen: A diagnostic challenge for the radiologist
A. James, J.H. Chauh, F. Grieve, B. Thomas, V. Rudralingam, S.A. Sukumar;
Manchester/UK ([email protected])
Learning Objectives: 1. To review the normal post operative appearances on
multi detector abdominal computed tomography (CT). 2. To depict the numerous
immediate and late complications of abdominal surgery ranging from trivial to
catastrophic.
Background: Suspected post operative complications are a common indication for
CT imaging. Interpreting the post operative abdomen is challenging to the radiologist
as knowledge of the surgical technique is vital in understanding the new anatomy.
Also the postoperative changes in the mesentery, omentum and bowel may lead
to diagnostic pitfalls and hence clinical correlation is of utmost importance. CT is a
powerful tool for identifying the early and late post operative complications.
Imaging Findings: The spectrum of imaging features of the post operative abdomen
includes the following: Expected features - omental and mesenteric fat stranding,
oedema, ascites, free gas and ileus. Wound sepsis - dehiscence and abdominal
wall collections. Intra abdominal sepsis- collections, abscesses, retained surgical
foreign bodies and dropped gallstones. Anastomotic leak and peritonitis. Vascular- massive intra abdominal haemorrhage, vessel injury and ischemia. Bowel
obstruction and due to acute and late onset adhesions. Organ injury- ureters and
bowel. Hernias- incisional, parastomal and internal.
Conclusion: Radiologists are frequently asked to assess the post operative abdomen. Radiological findings should be interpreted in conjunction with knowledge of
the surgical technique and the clinical picture. Timely and accurate diagnosis is
the key to optimal management.
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GI Tract
Purpose: To work out certain, well-defined aetiologies frequently associated with
mesenteric venous thrombosis (MVT) in order to predict a typical population at
risk, since MVT is nowadays often incidentally detected on cross-sectional imaging. To demonstrate the MDCT features, frequency and extent of associated bowel
ischemia according to the underlying pathology.
Methods and Materials: Our electronic database revealed 71 patients (25 women,
mean age 55) with thrombosis of the superior and/or inferior mesenteric vein
detected by MDCT between 2000 and 2008. Two radiologists jointly reviewed the
corresponding MDCT features including intraluminal extension, underlying aetiology
and associated bowel ischemia, if present.
Results: MVT was associated with carcinoma in 31 (43.7%) patients (pancreas
21.1%, liver 9.9%, others 12.7%). Concomitant inflammation was seen in 15
(21.1%) patients (pancreatitis 11.3%, diverticulitis 4.2%, others 5.6%), whereas
coagulation/hematologic disorders were found in 7 (9.9%) patients, liver cirrhosis
in 6 (8.5%), mixed/miscellaneous causes in 5 (7%) and still unknown aetiologies in
5 patients (7%). MVT resulted from recent operations in 2 (2.8%) patients. MDCT
features of venous bowel ischemia were present in 15 patients (21.1%). 46.5% of
MVT were (sub)acute, while 53.5% chronic. The luminal extension was complete in
52.1%, subtotal ( 50% of lumen) in 22.5% and partial ( 50% of lumen) in 25.4%
of patients, consisting either of blood clots (76.1%) or tumoral tissue (23.9%), the
latter mainly due to pancreas adenocarcinoma (76.4%).
Conclusion: MDCT features of MVT are seen with a wide range of underlying
diseases. Signs of intestinal ischemia are infrequently associated, mostly occurring
with coagulation/hematologic disorders (40%).
Scientific and Educational Exhibits
C-466
Head and Neck
Postsurgical changes in abdominal CT: Where to look
B. López-Botet Zulueta, I. Pena Fernández, M. Manzano Paradela,
T. Presa Abós, C. Andreu Arasa, L. Del Campo Del Val; Madrid/ES
([email protected])
Learning Objectives: To review the most common abdominal surgical procedures.
To describe the anatomical changes occurring after the surgical procedures and
radiological findings in abdominal CT.
Background: In different procedures of abdominal surgery, the normal anatomy
is substantially altered. In many occasions, these variations can make the image
interpretation difficult for the radiologist. The knowledge of the spectrum of postsurgical changes is indispensable for a correct discrimination between normal
and pathological findings, to find out surgical complications or for the follow-up of
oncological patients.
Procedure Details: We have retrospectively reviewed abdominal CT performed
in our hospital in patients who previously underwent abdominal surgery because
of diverse reasons (oncological, inflammatory, bariatric). We show different CT
protocols employed according to what pathology the patient presented and we used
multiplanar reconstructions that may be extremely useful to recognise postsurgical
changes. We have classified the surgical procedures in three groups: gastrointestinal
tract, genitourinary tract, and other surgery.
Conclusion: Because of its high frequency and its clinical importance, radiologists
must be familiar with the different abdominal surgical procedures, the anatomical
changes and its manifestations in CT.
Anatomy
C-467
Micro-CT of the hyoid-larynx complex: A new tool in forensic pathology
B. Ilsen, D. Van Varenbergh, I. Willekens, J. de Mey; Brussels/BE
([email protected])
Learning Objectives: The aim of this study is to determine the feasibility of detecting hyoid-larynx fractures with micro-CT in post mortem specimens and to better
understand the complex anatomy of the laryngeal skeleton.
Background: Examination of the hyoid-larynx complex is part of the routine procedure of the medico-legal autopsy. Hyoid-larynx complex injuries occur in different
causes of death. Strangulation is the most common cause of a fractured laryngeal
skeleton. Post-mortem detection of fractures is relevant in interpreting homicide
by strangulation, because of the difficult interpretation of skeletal abnormalities
due to the misleading polymorphism of the hyoid-larynx complex. Because of this
need of accurate documentation in medico-legal examination, we evaluated a new
technique for the detection of traumatic lesions using post-mortem radiological
micro-CT-studies (spatial resolution of 83 µm) on excised specimens. 10 datasets
were analysed with a 3D volume rendering program in order to examine shape,
ossification, fusion of synchondroses and fracture site.
Imaging Findings: In all cases, the shape, ossification and eventual synchrondroses were nicely depicted. Analysis of our 3D-data resulted in 32 synchondroses
and 25 ossifications (fusions). Two fractures of the superior corn of the thyroid
cartilage were easily depicted in one patient. Medico-legal anatomopathological
examination of the laryngeal skeleton confirmed these last findings.
Conclusion: Our study presents the first radiological images of fractured hyoidlarynx complex. Micro-CT of the hyoid-larynx complex is a promising new method
for the detection of post-traumatic lesions in post-mortem specimens. It could be a
new helpful tool in forensic pathology. Further investigation is warranted.
C-468
Head and neck spaces: Where and what?
K. Au Yong, N.J. Coupe, V. Chidambaram, C.K. Jadun; Stoke-on-Trent/UK
([email protected])
Learning Objectives: 1. To revisit the anatomy of spaces in the neck as demonstrated by cross-sectional imaging. 2. How the different spaces give rise to
different pathologies and why knowledge of the anatomy is important for accurate
differential diagnosis.
Background: Head and neck lesions are a very challenging subject for radiologists
due to the complex anatomy and wide ranging pathology. Cross sectional imaging
is now commonly used to assist the clinical evaluation of head and neck lesions.
The anatomical location and borders of head and neck lesions are vital in narrowing radiological differential diagnosis and allowing formation of an appropriate
clinical management plan.
Imaging Findings: We present normal cross sectional images using CT and MRI
to demonstrate the boundaries, contents and relationships of the many spaces in
the neck. Pathological imaging is also presented to demonstrate how this knowledge
aids formation of an appropriate differential diagnosis.
Conclusion: A working understanding of the location, borders and contents of
the spaces in the head and neck is vital to the role of the radiologist in accurate
determination of the location of head and neck mass lesions. This in turn enables
appropriate subsequent management and intervention.
C-469
Interactive anatomy of the skull base
F.A. Gomes de Almeida, V.M. Fernandes, G.G. Cerri, E.M.M.S. Gebrim;
São Paulo/BR ([email protected])
Learning Objectives: To present in a didactic and interactive way the complex
anatomy of the skull base with images acquired in the new generation of multidetector computed tomography scanners (MDCT) with post-processing techniques
of volume rendering, three-dimensional reconstructions and maximum intensity
projections (MIP).
Background: As a transitional zone, the skull base has a complex anatomy and,
besides its inherent pathologies, is affected by extension both by neurological processes coming from the skull as well as by head and neck diseases. Understanding
its anatomy is the key to identify the pathologic process that may involve it.
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Scientific and Educational Exhibits
Procedure Details: Our presentation begins with an introductory overview of
the skull base anatomy, focusing on its divisions, anatomic structures and bone
landmarks. Then, we proceed to a stepwise interactive quiz of enhancing complexity presenting multiple choice questions based on the relations between different
structures and the pathways of pathologic entities of different sites. All this richly
illustrated with volume rendering reformats acquired in a 64-channel MDCT.
Conclusion: The skull base houses innumerous pathways of disease spreading.
With the advent of MDCT, it became much easier to find its lesions and to track
down the original sites of these disorders. But first it is necessary to understand
its complex anatomy, its different connections and how they present at MDCT
examination.
C-470
Static and dynamic evaluation with MRI of larinx and oro-pharingeal cavity
in professional opera singers
M. Di Girolamo, F. Assael, G. Scavone, K. Piccotti, V. David; Rome/IT
([email protected])
Purpose: To assess the anatomy of phonetic organs by MRI in professional opera
singers with different vocal ranges.
Methods and Materials: 26 opera singers 7 tenors, 5 basses, 8 sopranos and
6 mezzosopranos were evaluated with MRI. We performed static study to evaluate the area of superior surface of vocal cord, and the dynamic study during the
prolonged vocalization of the vowel a, measuring the mouth area and pharyngeal
lumen. These data considered: 1) vocal tessitura; 2) vocal cord size; 3) mouth area
and pharyngeal lumen.
Results: The average size of the vocal cord was: 0.71 cm2 for sopranos; 1.20 cm2
for mezzosopranos; 1.58 cm2 for tenors; 2.88 cm2 for basses. The average area of
mouth and pharyngeal lumen during the vocalization was: 15.8 cm2 for sopranos;
14.6 cm2 for mezzosopranos; 23.6 cm2 for tenors; 32.2 cm2 for basses. The differences in vocal cord size between sopranos and mezzosopranos (P: 0.0641) and
between tenors and basses (P: 0.0833) are tendentially and statistically significant.
The size variation during the vocalization between tenors and basses is tendentially and statistically significant (P: 0.0833) while is it not between sopranos and
mezzosopranos (P: 0.6434).
Conclusion: Our results demonstrate a correlation between the surface of the
vocal cord, the vocal tract and the tessitura of a singer. Long vocal cord and wide
vocal tract characterize low-pitched voice types (bass, baritone, contralto, mezzosoprano) while short vocal cord and narrow vocal tract characterize high-pitched
voice types (tenor, soprano).
C-472
Web-based tutorial of oral cavity MRI anatomy
A. Lo Casto, P. Purpura, F. Ganguzza, V. Giacalone, G. La Tona, S. Vitabile;
Palermo/IT ([email protected])
Learning Objectives: To review the MR imaging anatomy of oral cavity, supplying
an easy access web-based tutorial. After viewing this exhibit, the reader will be
able to recognize the main anatomic structures and spaces of the oral cavity as
displayed on MRI multiplanar sections.
Background: Oral cavity diseases can involve different anatomic structures and
spread through the deep facial spaces. Therapeutic choices for oral cavity diseases
are managed also on the basis of MR imaging findings that allow to precisely depict
the local extension of the diseases. This is possible thanks to the superior soft
tissue contrast resolution of MRI. A good knowledge of the anatomic structures
and spaces of the oral cavity is thus fundamental to report an MRI study of this
anatomic region.
Imaging Findings: A pictorial review of T1, T2 weighted, and contrast enhanced
multiplanar MR imaging was used as learning material for the tutorial. Web-based
infrastructure allows for a fast and intuitive investigation. Web interface is organized
in frames and each section has been developed following the WBC guidelines for
web content accessibility. By using a mouse to select specific parts on MR images,
the user can recognize single normal anatomic structures or identify the boundaries
of deep spaces within the oral cavity.
Conclusion: This custom-developed interactive MRI tutorial software should be
useful in assisting even those new to MR imaging of oral cavity with a friendly
interface tool.
C-471
Important vascular anomalies of head and neck vessels
G. Sarti, S. Cappabianca, L. Casale, R. Fenza, M. Montemarano, A. Rotondo;
Naples/IT ([email protected])
Head and Neck
Learning Objectives: The aim of the study is to illustrate normal vascular anatomy
and most common anomalies of the head and neck vasculature in normal subjects
and in patients with head and neck neoplasm in order to define clinical concern of
them in presurgical assessment.
Background: 97 studies of head and neck performed with 32 slices MDCT were
retrospectively reviewed. In all cases, CT study was performed using a standardized 3 phase protocol and both the arterial and venous phases were successively
employed in order to obtain 3D and MIP post-processing reconstructions. Anatomic
distribution of principal arteries and veins of the face were evaluated in order to
define normal and not-significant clinical variants.
Imaging Findings: The major variations observed were the following: low bifurcation of common carotid artery and anomalous branching of external carotid artery,
lateral position of external carotid artery facial vein continuing as external jugular
vein after receiving retromandibular and submental veins, low bifurcation of common
carotid artery and anomalous branching of external carotid artery, lateral position
of external carotid artery, common facial vein draining into external jugular vein,
anomalous formation of external jugular vein.
Conclusion: Knowledge superficial venous system variations and of the arteries
and their branch anomalies seems to be extremely important in the assessment of
patients with surgical treatable head and neck neoplasms; their recognition during
diagnostic imaging are moreover important before vascular surgical procedures both
in patients with anomalous development of facial vasculature and in pre-treatment
assessment of patients with important facial trauma.
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Scientific and Educational Exhibits
Head and Neck
Head and Neck Cancer
C-473
Extranodal primary non-Hodgkin lymphomas of the head and neck: CT and
MRI findings
S. Capurro, L. Oleaga, M. Squarcia, F. Calaf, M. Olondo, J. Berenguer, T. Pujol;
Barcelona/ES
Learning Objectives: 1. To describe the most common imaging findings. 2. To
show the most frequent sites of involvement. 3. To depict the differences on imaging
between carcinomas and lymphomas in this location.
Background: NHL of the head and neck arises in lymph nodes in 65% of cases
and in extranodal sites in 25 to 30% of cases. Extranodal primary NHL are classified based on cell of origin in B-cell lymphomas, T-cell and natural killer- (NK-)
cell lymphomas. They occur predominantly in patients between the ages of 50 and
60 years. The primary site of involvement is the Waldeyer’s ring, representing 5 to
10% of all lymphoma patients; they can also occur in the nasopharynx, oral cavity,
nasal cavity, orbit and larynx.
Imaging Findings: CT is the primary modality for the assessment of tumoral
masses in the head and neck. Extranodal lymphomas manifest as submucosal
masses covered by intact mucosa, frequently associated with enlarged lymph nodes
in the neck, with moderate enhancement after the introduction of contrast. Unlike
carcinomas ulceration is rare. Occasionally, high grade aggressive lymphomas can
present with bone destruction mimicking infiltrating carcinomas. On MR imaging
they display low in signal intensity on T1-weighted images and intermediate on
T2-weighted images with low enhancement after gadolinium injection.
Conclusion: CT and MRI represent useful tools in the staging of extranodal primary
NHL; staging is important to select the appropriate therapy. Imaging characteristics
can help differentiate extranodal primary NHL of the head and neck form carcinomas in this location.
C-474
Perineural spread in extracranial head and neck malignancies - MDCT or
MR imaging: Which is better?
H.V. Vadodaria, M.K.N. Neelagiri, P.B. Vasani, K.G. Goswami; Ahmedabad/IN
([email protected])
Purpose: 1. To study the incidence and pattern of perineural spread (PNS) in
various extracranial head and neck malignancies with CT and MR imaging. 2. To
compare the efficacies of MDCT and MRI in the assessment of PNS.
Methods and Materials: 189 cases of extracranial head and neck malignancies
were studied with 6 slice MDCT and 0.4 T MRI. Both plain and contrast enhanced
scans were performed with FOV of 16-18 cm and 3 mm thick slices along with high
resolution reconstruction algorithm and fat suppressed post contrast sequences.
The primary features of PNS like extent, enhancement, skip lesions and changes
in neural foramina, and secondary features like muscle atrophy were studied. The
results of both imaging techniques were compared.
Results: A total of 24 cases of PNS were detected of which 23 were detected on
MRI and 17 on MDCT. MRI was especially useful in detecting the obliteration of fat
planes and early denervation changes, whereas MDCT was helpful in detecting
subtle bone erosions.
Conclusion: MRI was found to be clearly superior to MDCT in detecting and
delineating the extent of PNS and thus should be the primary imaging modality.
However, MDCT is a useful adjunct to rule out doubtful bony involvement.
C-475
Metastatic salivary gland tumors: A pictorial review of an infrequent finding
R. Cano Alonso, M. Navallas Irujo, P. Díez Martínez, L. Ibáñez Sanz,
I. Arribas García, A. Alcalá-Galiano Rubio; Madrid/ES ([email protected])
Learning Objectives: To review our series of patients with malignant salivary gland
tumors (MSGT). To describe epidemiologic characteristics, treatment results and
prognosis, with emphasis on local recurrence and distant metastases and their
imaging findings.
Background: We designed a retrospective analysis of 86 patients diagnosed of MSGT
between 1991 and 2001, with a mean follow-up time of 75 months. Thirteen patients
diagnosed of metastatic-SGT were included in our study.The aim of this work is to describe
epidemiologic characteristics, surgical management and imaging findings of these tumors
and their distant metastases by means of multidetector TC (MDTC) and/or MR.
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Procedure Details: An exhaustive analysis of clinical onset, diagnostic and surgical management was performed, with emphasis on local recurrence and distant
metastases rates. Thirteen patients (15, 11%, mean age 52.3 years) developed
one or more distant metastases, with a mean survival rate of 73 months. The most
frequent histologic type was adenoid cystic carcinoma (50%, 7 cases), followed
by terminal duct carcinoma (18%, 2 cases), ex-pleomorphic carcinoma (1), poorly
differentiated epidermoid carcinoma (1), ex-pleomorphic carcinosarcoma (1) and
undifferentiated tumor (1). The most frequent locations for distant metastases in
our study population were lung (50%, 7 cases), bone (21%, 3), liver (14%, 2),
intraocular (7%, 1) and cavernous sinus (7%, 1).
Conclusion: SGT account for less than 3% of all neck and head tumors. MetastaticSGT is an infrequent finding, with a small number or reported cases. Knowledge of
their main characteristics may help in the management of these patients.
C-476
Head and neck cancers: Comperative evaluation by CT, MRI and FDG-PET
M. El-Kholy1, A.A. Zytoon1, O. Ebied1, K. Murakami2; 1Shebin El-Koom/EG,
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Tochigi/JP
Purpose: To investigate the diagnostic accuracy of head and neck cancers, lymph
node metastasis, and local tumor recurrence by FDG-PET compared with CT and
MRI, and to validate the results with the histopathological data.
Methods and Materials: Forty-one patients with head and neck cancers were
enrolled. Our patients presented for primary staging of head and neck cancers
(n=23) or monitoring after therapy (n=18). The three imaging modalities (FDG-PET,
MRI and CT) were compared.
Results: Overall, 82 head and neck regions were analyzed for detection of malignancy (for primary tumors, n = 23; for lymph node metastasis, n = 41; for local tumor
recurrence after therapy, n = 18). The overall sensitivity and specificity were: CT 88.9
and 89.2% (95% CI; 80.2-94.9%, r = 0.7791, P 0.0001), MRI 88.9 and 91.9% (95%
CI; 81.9-95.8%, r = 0.8049, P 0.0001), and FDG-PET 97.78 and 86.49% (95%
CI; 84-96.9%, r = 0.8551, P 0.0001). Only FDG-PET by its unique advantage as
a whole-body examination could detect distant metastases in 4/41 (9.8%) patients,
all outside the head and neck regions (liver, lung, paraortic lymph nodes, and bone
metastases), and synchronous breast cancer in 1/41 (2.4%) patients.
Conclusion: Compared with CT and MRI, FDG-PET was found to have the highest sensitivity with lower specificity than CT and MRI. Moreover, the whole-body
FDG-PET imaging proved a useful tool for detection of distant metastasis and
synchronous tumors.
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The diagnostic value of computed tomography in invasion of carotid and
jugular vessels by head and neck malignant tumors
L. Aghaghazvini, H. Sharifian, H. Mazaher; Tehran/IR ([email protected])
Purpose: In head and neck malignancies, awareness of invasion to cervical vessel
walls is greatly important before surgery because it could severely affect patients’
management. This study was designed to assess the diagnostic value of computed
tomography (CT) in determining the presence and extent of carotid artery (CA) and
jugular vein (JV) invasions by head and neck malignant tumors.
Methods and Materials: Contrast enhanced CT was performed on 46 patients with
head and neck malignant tumors before surgery. Five abnormal CT findings were
considered for CA invasion: I) tumor encasement greater than 180°; II) compression; III)
displacement; IV) ill-defined wall of CA and V) deletion of fat planes between tumor and
CA. Five abnormal CT findings were considered for JV invasion: I) tumor encasement
greater than 180°; II) compression; III) segmental thrombosis; IV) deletion of fat planes
between tumor and JV and V) segmental obliteration of JV. The CT appearances of
all tumors were prospectively compared with surgical and pathology findings as gold
standard. The diagnostic indices (sensitivity, specificity, positive predictive value and
negative predictive value) were calculated for all variables separately.
Results: Surgical findings revealed invasion to CA in 13 of 40 tumors and to JV
in 22 of 46 tumors. The specificity of finding IV was 0.9 for CA (95% confidence
interval [CI]=0.73-0.99) and sensitivity of finding V was 1 for CA (% CI=.9-1). The
sensitivity of finding IV was 0.95 for JV (CI=0.87-1).
Conclusion: CT should be considered as a good diagnostic staging method and
could be helpful in determining cervical vessel invasions but it is not as a definite
method in all patients.
Scientific and Educational Exhibits
C-478
Malignant laryngeal neoplasms: CT and MR pictorial reviews
R.M. Maia, A. Salgado, M. França, J. Pires, J. Reis, M. Ribeiro; Oporto/PT
Learning Objectives: To illustrate the imagiologic spectrum of malignant laryngeal
neoplasms and describe the classic findings in CT and MR imaging.
Background: Squamous cell carcinoma is the most common malignant tumor in
the larynx. The risk factors for cancer of the larynx are considered to be smoking
and alcohol. They are more common in men, especially after 50 years of age.
Mucosal abnormalities can be evaluated by the clinician, but these tumors spread
submucosally. Non-squamous cell carcinomas typically grow beneath an intact
mucosal layer and biopsy results inconclusive or negative. The tumor extension of
malignant laryngeal neoplasms must be evaluated by CT or MR, which demonstrate
local tumor and lymphatic extension.
Imaging Findings: Criteria used for tumor involvement are soft tissue thickening,
presence of a bulky mass, abnormal contrast enhancement, infiltration of fatty
tissue or a combination of these. The authors reviewed CT and MR exams of
malignant laryngeal tumors performed in their institution and illustrate the general
imaging findings.
Conclusion: CT and MR are useful cross-sectional imaging of the head and
neck to delineate the extent of primary disease, the presence of bone or cartilage
invasion and the presence of nodal disease. The head and neck radiologist plays
a very important role in assessing the extent of disease and therefore influences
the appropriate selection from the available treatment options.
C-479
Cystic masses of the head and neck: A pictorial essay
V.M. Joshi; Hyderabad/IN ([email protected])
Learning Objectives: To describe and illustrate the spectrum of cystic lesions of
the extracranial head and neck on CT and MRI scans. To help formulate a comprehensive list of differential diagnosis for such lesions based on their characteristic
locations and imaging features.
Background: The gamut of cystic lesions of the extracranial head and neck is not
extensive. Many of these lesions are rare, but their radiologic features often permit
definitive diagnosis to be rendered by the radiologist. We present CT and/or MRI
findings of 17 patients with such lesions.
Imaging Findings: The following masses are described - first, second and third
branchial cleft cysts, lymphangiomas, Tornwaldt’s cyst, thyroglossal duct cyst, abscesses, ranula, epidermoid, laryngocele, cystic schwanoma, thyroid cyst, jugular
vein thrombosis and necrotic adenopathy. Two cases of “clinically cystic” lipoma and
carotid artery pseudoaneurysm are illustrated. Characteristic locations, imaging
features and brief description of the pathology is provided.
Conclusion: 1. CT and MRI scans optimally depict the entire spectrum of cystic
lesions of the extracranial head and neck. 2. The true nature of “clinically cystic”
lesions can be optimally delineated on imaging. 3. A thorough knowledge of the
characteristic locations and imaging appearances of these masses gives the radiologist the advantage of describing both the deep tissue extent and the probable
histopathology to the clinician.
C-480
The added value of 18 F-FDG-PET CT for diagnosing occult primary
tumours in head and neck cancer
R. Hanlon, H. Lewis-Jones, D. White, N.H. Wieshmann; Liverpool/UK
([email protected])
C-481
The frequency and characteristics of posterior fossa lesions that are
missed on CT
J. Ni Mhuircheartaigh, O. Carney, M. Browne, E. DeLappe, T. Walshe,
D. O’Keeffe; Galway/IE
Purpose: The reduced sensitivity of CT compared with MRI in evaluating posterior
fossa lesions is an oft quoted axiom of radiology. When asked to support this statement with evidence from the literature, it is extremely difficult to justify. The aim of
this study was to identify how many lesions are missed on CT and to characterise
the nature of these lesions.
Methods and Materials: We reviewed all the MRI brain or MR skull base studies
performed and identified any studies where posterior fossa lesions were identified.
These were reviewed to identify which patients had also a CT brain performed
within 8 weeks. The number and nature of lesions were recorded. Patients with
demyelination were excluded as this would not be identifiable outside of the posterior fossa either.
Results: 2,678 patients underwent 2,860 MRI scans. Of these, 158 studies on 120
patients had demonstrated posterior fossa lesions. Within this group, 55 patients
had a CT brain within 8 weeks. The only cases where neoplastic lesions were not
identifiable on CT were those in which it was not possible to administer intravenous
contrast. The non-neoplastic lesions not identified on CT were small infarcts in the
cerebellum and brainstem and 2 cases of central pontine myelinolysis.
Conclusion: While much emphasis has been placed on the limited usefulness of
CT in the evaluation of posterior fossa lesions, these findings indicate that CT is
sensitive in detection of significant lesions. Furthermore, the importance of intravenous contrast to improve the sensitivity should not be underestimated.
C-482
Nasopharyngeal carcinomas: Clinical and radiologic assessment
A. Salgado, R. Maia, F. Pires, P. Oliveira, M. Bacelar, M. Gouvêa; Porto/PT
Learning Objectives: To describe the CT and MRI features of nasopharyngeal
carcinomas (NPCs). To present the role of MRI in the staging and follow-up. To
describe the different ways that this tumor can spread.
Background: NPC is a relatively rare cancer and represents 0.2% of malignant
disease in the white population. Undifferentiated carcinoma is the most common
histopathologic type and is associated with EBV. The principal presenting symptom is
a nodal neck mass. Imaging manifestations of NPCs are variable and optimally evaluated by CT and MR imaging. The most reliable imaging finding is that of an aggressive,
often enhancing mass, centered in the lateral pharyngeal recess, that infiltrates the
deep fascial planes about the nasopharynx. Nodal metastases are present in 90%
of cases at presentation and distant metastases in less than 10%.
Procedure Details: We retrospectively reviewed the clinical and imaging findings
of NPCs and present the most representative cases. We show the essential role
of the CT and MRI in staging and treatment of patients with NPC.
Conclusion: Imaging is vital for tumor mapping and recurrence assessment. MR
imaging provides excellent visualization of nasopharynx soft-tissue planes and
enhanced MR imaging is the best tool for evaluation of intracranial extent via direct,
perivascular and/or perineural routes. Both CT and MRI may be used for identifying
skull base involvement. CT is superior to MRI for identifying early cortical invasion,
while MRI is superior to CT for detecting marrow involvement.
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Head and Neck
Purpose: To establish the added value of 18 F FDG-PET CT imaging for diagnosing
occult primary tumours in head and neck cancer patients.
Methods and Materials: Data was collected from all patients who presented to
the Regional Head and Neck Cancer Multidisciplinary meeting with metastases
to cervical lymph nodes from an unknown primary origin (September 2003 and
November 2007). Patients with negative conventional imaging and clinical examination were referred for 18 F FDG-PETCT scan. The results of the PETCT scan
were compared with biopsy results and with cross sectional imaging. The clinical
outcome of the patients was recorded.
Results: 2022 patients with head and neck cancer were reviewed between September 2003 and November 2007. 42/2022 patients had metastatic squamous
cell carcinoma to cervical nodes of unknown primary origin. 20 of 42 patients with
an unknown primary were referred for an FDG-PETCT. In 4/20 patients, the FDGPET CT indicated an occult primary tumour at the base of the tongue. This was
confirmed by biopsy in 3 patients but in 1 there was no histological confirmation.
In 6/20 patients, the FDG-PETCT demonstrated asymmetrical FDG activity in the
tonsils but subsequent histology was negative. In 10/20 patients, the FDG-PETCT
was negative and blind biopsies were negative. Follow-up to date has not identified
a primary. All patients have survived to date.
Conclusion: 18 F-FDG-PETCT scanning can be useful in the detection of occult
primary tumors presenting with metastases to cervical lymph nodes. In our practice,
it is used when clinical examination and conventional imaging are negative.
Scientific and Educational Exhibits
C-483
Head and Neck
Role of dynamic susceptibility contrast perfusion MR imaging in
differentiation of recurrent head and neck tumors from post radiation
changes
A.A.A. Abdel Razek, W. Rudwan, M. Amer; Mansoura/EG ([email protected])
Purpose: To assess the role of dynamic susceptibility contrast perfusion MR imaging echo-planar MR imaging for differentiation recurrent head and neck tumors
from post radiation changes.
Methods and Materials: Prospective study was conducted on 33 consecutive
patients (21 M, 12 F aged 39-73 ys: mean 51 ys) with head and neck cancer after
complete course of radiotherapy. Multislice dynamic contrast enhanced single shot
echoplanar T2*-weighted MR imaging was done after bolus infusion of GadoliniumDTPA at a dose of 0.2 ml mol/kg BW after 8 seconds. Image acquisition was repeated every 2 seconds for 120 seconds. The images were processed and lesion
signal intensity versus time curve was created.
Results: The mean percentage of maximum signal intensity loss of recurrent tumor
was 38.6% and of post radiation changes was 15.55%. There was statistical difference in the maximum percentage of signal intensity loss between recurrent tumor
and post radiation changes (p 0.03). Selection of maximum signal intensity loss
of 25.6% as the thresholds to predict recurrence has sensitivity of 91%, specificity
of 93%, accuracy of 92%, positive predictive value of 63.6, negative predictive
value of 100% and area under the curve was 0.956.
Conclusion: We concluded that dynamic susceptibility contrast enhanced
echoplanar MR imaging increased diagnostic performance of MR imaging in
differentiation recurrent tumor from post radiation changes in patients with head
and neck cancer.
C-484
Enhancing lesions of the tongue and floor of mouth on fat-suppressed
contrast-enhanced MR images: Normal and abnormal findings
I.M. Brennan, G. Murphy, J.F. Meaney; Dublin/IE
Learning Objectives: To illustrate the spectrum of normal and abnormal enhancing
lesions within the floor of mouth on contrast-enhanced MR imaging. To highlight
the pitfalls in interpretation of areas of increased enhancement and to correlate the
findings with T2W images. To demonstrate correct tumour staging with MRI.
Background: Detection of primary tumours within the tongue and floor of mouth
is frequently difficult for many reasons, including image degradation due to
dental amalgam and mucosal opposition. This leads to poor lesion conspicuity.
Fat-suppressed contrast enhanced T1W imaging is the optimal method for lesion
detection and is superior to T2W imaging. However, accurate tumour staging is
complicated by the presence of multiple sites of focal enhancement within the
normal oral lymphoid and salivary gland tissues.
Imaging Findings: We illustrate non-contrast (T2W) pre and post-contrast MR
imaging in normal subjects, benign and malignant tumours, and inflammatory
lesions of the tongue and floor of mouth in a cohort of patients presenting to a
tertiary referral centre. We present the normal spectrum of enhancement within
the tongue and floor of mouth. We illustrate the differing patterns of enhancement
amongst these processes that aid in confident identification and accurate staging
of malignant disease.
Conclusion: MR is a valuable modality for the local staging of primary tongue
and floor of mouth tumours. Knowledge of the spectrum of normal enhancement
is essential to allow accurate staging and planning.
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Maxillofacial Imaging
C-485
Pearly whites and pearly cysts: A review of maxillary, mandibular and
dental lesions
E.K. Dillon, R. Chinn, R.P. Barker; London/UK ([email protected])
Learning Objectives: To review important and common radiological pathology
seen in the mandible and maxilla.
Background: Maxillary and mandibular radiological abnormalities may have odontogenic and nonodontogenic origins and are not uncommonly encountered in
both the paediatric and adult populations. Comprising both benign and aggressive
lesions, they may present acutely, more indolently, or be imaged incidentally.
Imaging Findings: 1) Benign cystic lesions of the mandible and maxilla (periapical,
dentigerous, and odontogenic keratocysts and fibrous dysplasia). 2) Benign solid
lesions (ameloblastomas, odontomas, ossifying fibromas, periapical cemental dysplasia and neurofibromas). 3) Malignant solid lesions (squamous cell carcinomas,
osteosarcomas and metastatic tumours). 4) Lesions associated with teeth and their
support structures. 5) Craniofacial syndromes affecting this region.
Conclusion: Mandibular and maxillary lesions may present in a variety of ways.
Whilst biopsy is often required ultimately to make the diagnosis, it is important that
radiologists recognise the abnormality and suggest a likely cause.
C-486
Ultrasound diagnostics of children’s maxillofacial area vascular
malformations
A. Vasylev, M. Vykluk; Moscow/RU ([email protected])
Purpose: Optimization of ultrasound diagnostics of children’s maxillofacial area
vascular malformations.
Methods and Materials: High resolution ultrasound examinations were performed
in 243 children (with the age from 2 months to 14 years) with vascular malformations of maxillofacial area.
Results: Capillary cavernous hemangiomas were detected in 85 children as
inhomogeneous structure formations with areas of liquid genesis (caverns) and
vascular component and primarily arterial flow. Arterial-venous communications
were found in 12 cases as additional vascular structures with non-linear course in
jaws projections; were characterized by high linear velocities (up to 100 - 150 cm/s)
and fistulas. In 39 children, venous angiodysplasia was found as heterogeneous
formations with dilated veins. Angiofibromas were found in 35 children as formations
with capsules and consisting of several nodules separated by fibrous septas. In 26
cases, hypervascularisation of formations were found in other observations and
single vessels were detected in projections. Lymphangiomas were diagnosed in 72
patients as avascular formations with average echogenicity with hypoechoic areas of
a small size (cavernous component) and anechoic cavities with incomplete septas
(cystous component). At the period of inflammation (22 observations), increase of
formations size, increase of cystous cavities, appearance of suspension septas
thickening and foliation was noted.
Conclusion: Ultrasonic examinations allow determining the character of vascular
malformations of children’s maxillofacial area. This adequately influences the
choice of treatment tactics.
Scientific and Educational Exhibits
C-487
Is it so important to differentiate the cysts and cystic lesions of the jaw?
The role of MDCT in the diagnosis
R. Prada, E. Santos, J. Aguilar, G. Tardáguila, F. Tardáguila; Vigo/ES
([email protected])
Learning Objectives: 1. To review the different types of cysts and cystic lesions of
the jaw. 2. To describe the characteristic imaging patterns useful for narrowing the
differential diagnosis. 3. To outline the value of MDCT in their diagnosis.
Background: Cysts and cystic lesions of the jaw are common in our daily practice.
The understanding of the main pathological processes and of whatever the clinician needs to know about them ought to make easier the study of these lesions
for radiologists.
Imaging Findings: Although cysts in the jaws are commonly diagnosed and treated
by general dental specialists, MDCT is being increasingly used to evaluate this
pathology. Jaw cystic lesions can be odontogenic or nonodontogenic. We present a
range of richly illustrated cases with the help of 64-MDCT images so as to provide
radiologists with an excellent opportunity to become familiar with odontogenic and
nonodontogenic lesions alike. Odontogenic cysts include follicular and radicular
cysts, residual and paradental cysts, odontogenic keratocysts and ameloblastomas.
Nonodontogenic cysts are mainly traumatic bone cysts, incisive canal cysts and
benign fibro-osseous lesions. The location of the lesion within the jaw, its borders,
its internal architecture, as well as its effects on adjacent structures makes generally possible the narrowing of their differential diagnosis.
Conclusion: The definitive diagnosis of cysts and cystic lesions of the jaw relies
on a constellation of clinical and radiological findings. Although the imaging appearance can be non-specific, certain MDCT patterns should allow us to make
an accurate diagnosis.
Head and Neck
Temporal Bone
C-488
Increased signal intensity of the cochlea on pre- and post-contrast
enhanced 3D-FLAIR in patients with vestibular schwannoma
M. Yamazaki, S. Naganawa, H. Kawai, T. Nihashi, H. Fukatsu; Nagoya/JP
([email protected])
Purpose: To evaluate the signal intensity of the cochlear fluid on pre- and postcontrast enhanced thin section three dimensional fluid attenuated inversion recovery
(3D-FLAIR) in patients with vestibular schwannoma.
Methods and Materials: Twenty-seven patients with vestibular schwannoma who
underwent MR imaging of inner ear between January 2006 and June 2008 were
retrospectively analyzed. 3D-heavily T2 weighted images (T2WI), 3D-T1 weighted
images (T1WI) and 3D-FLAIR images were obtained in all patients. In 18 patients,
post-gadolinium enhanced 3D-T1WI and 3D-FLAIR were also obtained. Slice
thickness of all images was 0.8 mm. Region of interest (ROI) of both cochlea (C)
and medulla oblongata (M) were determined on 3D-FLAIR images by referring to
3D-heavily T2WI at workstation. Signal intentisy ratio between C and M on 3D-FLAIR
(CM ratio) was defined as follows: signal intensity (SI) of C divided by SI of M. In 20
patients, correlation between CM ratios and hearing level was also evaluated.
Results: CM ratios of affected side were significantly higher than those of unaffected
side (p 0.001). In affected sides, post contrast signal elevation was observed
(p 0.005). CM ratios were correlated with hearing level (p 0.05).
Conclusion: The results of the present study suggest the alteration of cochlear
fluid composition and the disruption of blood-labyrinth-barrier in the affected sides.
Furthermore, the positive correlation between cochlear signal intensity and hearing
level was shown. These warrant further study to clarify the relationship of 3D-FLAIR
findings and prognosis of hearing preservation surgery.
C-489
Temporal bone fractures: CT findings
S. Rosa, E. Domènech, M. Larios, C. Delgado, D. Villa, T. Sempere; Tarragona/ES
Learning Objectives: To review the anatomic relationships of temporal bone and
adjacent structures (blood vessels and nerves), since petrous bone is the most
common place for fractures of the skull base. To identify and describe CT findings
of 3 types of fractures of petrous bone (longitudinal, transverse and oblique) and
to know complications associated to them.
Background: There are three types of petrous bone fracture depending on the way
of the fracture line: 1 - horizontal or longitudinal (70-80%) 2 - vertical or transverse
and 3 - oblique or mixed. Transverse processes are less frequent but more serious
ones, because they often affect the inner ear structures and cause total sensorineural deafness, as well as 50% of the cases that are accompanied by permanent
facial paralysis. Intracranial complications that can arise from these fractures are:
meningitis, injury to adjacent venous sinuses with accumulation of blood or extraaxial
thrombosis, traumatic meningoencefalocele and leak of LCR.
Imaging Findings: CT imaging findings.
Conclusion: Petrous bone fractures are relatively frequent and important to be
taken into account in patients with cranial trauma because they can have serious
consequences. It is important to recognize anatomic structures in order to make a
correct diagnosis of petrous bone fractures.
Head and Neck
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Scientific and Educational Exhibits
C-490
Head and Neck
Magnetic resonance imaging of temporomandibular joints in patients
treated for internal derangement
L. Gentile, F. Molinari, E. Faloni, P. Manicone, L. Raffaelli, R. Ursini, A. D’Addona,
T. Pirronti, L. Bonomo; Rome/IT ([email protected])
Learning Objectives: To illustrate the spectrum of magnetic resonance imaging
(MRI) findings of the temporomandibular joint (TMJ) in patients treated for internal
derangements.
Background: Internal derangements of the TMJ may be treated conservatively
with long-term use of splints. The potential changes in condilar-disc relationship
and position induced by such devices are rarely understood by radiologists. In this
exhibit, we show the normal, pathological and post-treatment MRI findings of the
TMJ in patients with internal derangement.
Imaging Findings: Normal MR images of TMJ with anatomic schemes. Static and
dynamic MR images showing all the grades of internal derangement of the TMJ
disc. MRI studies obtained in patients treated with the use of splits.
Conclusion: Treatment-related remodeling of the TMJ may be understood and
described when patient’s clinical condition and history are known. Dynamic imaging
offers the opportunity to visualize the spontaneous range of TMJ motion, which might
be normal even when extensive alterations are detected by static images.
Miscellaneous
C-491
Magnetic resonance ophthalmoscopy: The usefulness of half-Fourier
single-shot rapid acquisition with relaxation enhancement sequence with a
microscopy coil in the morphologic evaluation of eyeballs
K. Tanitame, K. Sasaki, T. Sone, M. Sumida, T. Ichiki, K. Ito; Hiroshima/JP
([email protected])
Purpose: The first purpose of this study was to compare half-Fourier single-shot
rapid acquisition with relaxation enhancement (RARE) sequence with balanced
steady-state free precession (b-SSFP) sequence in the evaluation of eyeballs using a microscopy coil. The second purpose was to clarify the usefulness of RARE
magnetic resonance (MR) imaging in the evaluation of glaucoma eye, retinal
detachment and postoperative eye.
Methods and Materials: 1-mm and 2-mm section thickness images of half-Fourier
single-shot RARE sequence and b-SSFP sequence with a 1.5-T MR unit and
a 23 mm microscopy coil were obtained in 8 healthy volunteers. In addition to
spatial and temporal resolutions, the visualization of the eyeball’s morphological
features was assessed among those images. Furthermore, RARE MR imaging
was performed in 21 glaucoma patients including 6 patients after surgical treatment, 1 patient with retinal detachment and 2 patients who underwent cataract
surgery. These results were compared with those of established ophathalmological
examinations.
Results: The best image quality was achieved by half-Fourier single-shot RARE
sequence with 2-mm section thickness in the morphologic evaluation of the
eyeballs (P .01). There was excellent agreement between RARE MR imaging
and slit-lamp biomicroscopy in the classification of the anterior chamber angles
as narrow or open in glaucoma patients (K=0.90 [95% CI: 0.70, 1.09]) and RARE
MR imaging corresponded to optical coherence tomography in the patient with
retinal detachment. Moreover, RARE MR imaging was useful in the evaluation of
postoperative eyes.
Conclusion: Half-Fourier single-shot RARE MR ophthalmoscopy using a microscopy coil delineates the details of the eyeball’s anatomy.
C-492
MR imaging of the neck at 3 Tesla using T2-weighted BLADE compared
with T2-weighted fast spin-echo sequence
Y. Ohgiya, T. Hashizume, J. Suyama, N. Seino, M. Hirose, T. Gokan; Tokyo/JP
Purpose: BLADE and PROPELLER (periodically rotated overlapping parallel lines
with enhanced reconstruction) techniques have been proposed to reduce the effect
of head motion. The purpose of this study was to evaluate T2-weighted BLADE
(T2W-BLADE) compared with T2-weighted fast spin-echo (T2W-FSE) regarding
motion artifacts, tissue contrasts, and lesion detectability.
Methods and Materials: Forty-six patients (31 men, 15 women; mean age, 57.2
years) referred for MR imaging of the neck were included in a comparison of
T2W-BLADE and T2W-FSE. All examinations were performed at 3 T in the axial
image orientation using the same parameters and spatial resolution. Two observers evaluated unlabelled images for motion artifacts (ghosting and pulsation
artifacts), the preferred image quality, and lesion detectability. ROI-based quantitative measurements were performed to assess tissue contrasts. The frequency of
occurrence of the different assessed motion artifacts was tested using McNemar’s
test. Reader agreement was assessed using Cohen’s kappa test. Tissue contrasts
were compared using paired Student’s t-tests. Lesion detectability was compared
by using Chi-Squared test.
Results: T2W-BLADE showed less ghosting and pulsation artifacts than T2W-FSE
(P 0.01). T2W-BLADE images were rated as better than or equal to T2W-FSE
images in the majority of cases (93.5%; kappa = 0.60). There was no significant
difference in tissue contrasts between T2W-BLADE and T2W-FSE. Thirty two
lesions were present in 32 patients and equally well seen on T2W-BLADE and
T2W-FSE.
Conclusion: T2W-BLADE imaging for the neck is applicable at 3 T. T2W-BLADE
sequence can reduce motion artifacts and provide tissue contrasts and lesion
detectability equivalent to T2W-FSE sequence.
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C-493
Rapid prototyping in manufacturing of external auditory canal model for a
hearing aid device
R. Chrzan1, A. Urbanik1, S. Miechowicz2, O. Markowska2, T. Kudasik2;
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Krakow/PL, 2Rzeszow/PL ([email protected])
Learning Objectives: To illustrate the possibilities of modern biomedical engineering in ENT patients. To describe the steps of hearing aid manufacturing, using rapid
prototyping based on CT data.
Background: Rapid prototyping is the automatic construction of physical objects
from virtual CAD (computer aided design) models. For medical objects, the models
may be created using data from CT or MR examinations. In ENT patients with
impaired hearing, an intracanal hearing aid is commonly adjusted by taking direct
external auditory canal impression. In many cases it results in an inaccurately fitted
device and patient’s discomfort. However, currently it is possible to quickly manufacture perfectly fitted hearing aids using rapid prototyping based on CT data.
Procedure Details: CT of external auditory canal was performed using dedicated
high resolution protocol. Virtual CAD model was generated based on CT data.
Location of hearing aid electronic elements was planned based on CAD model.
Material model of external auditory canal with hearing aid was produced using
stereolitography. Finally, hearing aid was manufactured using vacuum casting
based on stereolitography model.
Conclusion: Rapid prototyping may utilize data obtained from commonly used spiral
CT scanners. This technology may help in manufacturing biomedical prostheses,
reducing time of device production and improving its fitting.
C-494
Brain and head and neck protocols on multi-detector row CT (MDCT): Eye
lens dosimetry and clinical implications
J.S.P. Tan, K.-L. Tan, J.C.L. Lee, C.-M. Wan, J.-L. Leong, L.-L. Chan;
Singapore/SG ([email protected])
Learning Objectives: To understand dosimetric differences between identical
neuroimaging studies on multi-detector row CT (MDCT) of different numbers of
detectors and their clinical implications.
Background: CT examination is a high radiation dose imaging modality. The rapid
advancement in MDCT technology has paralleled the exponential increase in the
number of CT examinations performed. The eye lens is especially susceptible to
radiation-induced cataracts. However, the dosimetric differences between identical neuroimaging studies on MDCT using different numbers of detectors are not
well known.
Procedure Details: Six cadaveric CT scans were performed on a 64-slice MDCT
for each of the following clinical studies, viz, brain, paranasal sinus and temporal
bone/orbits, and the eye lens dose measured using thermoluminescent dosimeters
(TLDs). The studies were repeated on a 16-slice MDCT using identical protocols.
The dose length product, volume CT dose index and TLD readings for each CT
protocol were tabulated and compared between scanners and protocols.
Conclusion: CT brain in tilted axial mode on the 16-slice MDCT imparts the
lowest radiation dose to the eye lens due to deliberate angulation of the radiation
beam out of the eyes. Conversely, when CT gantry tilt is impossible, hyperflexion
of the neck is an alternative. For paranasal sinuses and temporal bone/orbits CT
protocols, eye lens radiation doses delivered by 64-slice MDCT are significantly
lower than 16-slice MDCT, partly due to improvements in automatic tube current
modulation technology.
C-495
Learning Objectives: To illustrate how educational theory on teaching for transference (i.e. teaching strategies to promote the ability of students to apply case based
learning to new clinical problems) can be applied in the use of the compartment
model for orbital imaging in postgraduate education and training of ophthalmology
and radiology residents and fellows.
Background: Many radiologists are unaware of best practices in teaching and
particularly evidence based educational theory, which can be immediately and
effectively applied to postgraduate training. As a consequence, current practices
in radiology education follow a see one do one approach.
C-496
The capability of microfocal radiography during intraoperational stage of
stomatological implantation
I.N. Gipp, N.S. Serova, A.Y. Vasiliev, A.I. Ushakov; Moscow/RU ([email protected])
Purpose: Evaluation of microfocal radiography possibilities at the intraoperational
stage of stomatological implantation.
Methods and Materials: 60 patients were examined (27 female and 33 male) with
age from 19 to 62. Mandibular implantation was performed to 37 patients, maxillary
- 23 patients. All examinations were performed in the operation room with portable
digital microfocal radiography unit. The following exposition parameters were used:
60 kV, 0.1 mA, exposure time - 0.2 s.
Results: Obtained data had allowed evaluation of the correct relationship of implantation space and surrounding anatomical structures in the course of operation
procedures. 26 mandibular patients had indicated impermissible distance between
the lower wall of implantation space and the mandibular canal (less than 1.8 mm)
and in 3 patients distance to foramen mental was less than 1.4 mm. Maxillary bone
tissue volume among the examined group was sufficient enough for implant installation. Intraoperational microradiography had allowed surgeons to make decisions
on implantation technique that differed from preplanned ones based on preoperative
radiology examinations (orthopantomography and spiral CT): in 9 cases, decision
was made to decrease the depth of implant installation and in 6 cases to install an
implant of a smaller size, compared to the one preplanned.
Conclusion: Use of portable digital microfocal radiography equipment in the intraoperative stage of stomatological implantation allows making final decision during
the operation about the tactic and its performance. This significantly increases the
quality of treatment procedures.
C-497
Multidetector computerized tomographic (MDCT) findings during and
following osteo-odonto-keratoprosthesis (OOKP) surgery
L.L. Chan, C.M. Wan, J. Tan, Y.M. Por, W. Lim, D. Tan; Singapore/SG
Purpose: Osteoodontokeratoprosthesis surgery (OOKP) is a two-stage sightrestoring procedure for patients with refractory corneal blindness. The purpose of
this exhibit is to report: 1) the complex CT findings at each stage of the surgery
and 2) the serial post stage 2 CT findings of the prosthesis on multi-detector computerized tomography (MDCT).
Methods and Materials: The 2 stages of the OOKP surgery are spaced about
4 months apart. Tooth harvest for prosthesis formation and ocular resurfacing
preparations are performed during the first stage. The keratoprosthesis is then
implanted onto the neo-ocular surface during the second stage. Measurements of
the keraotprosthesis on baseline and follow-up CT scans in our patient cohort are
recorded and compared for resorption and tilting.
Results: The CT findings at each stage of surgery are explained with intraoperative
photographic correlation. To date, three of 21 patients (11 women, 18 - 58 years)
have shown resorption of at least 25% of the baseline prosthetic dimensions, and
at as early as five months follow-up. One patient demonstrated significant tilting of
the prosthesis with respect to the optic nerve.
Conclusion: MDCT scans graphically demonstrate the stages of the complex
OOKP surgery. Prosthetic resorption and tilting are detectable on early serial
MDCT imaging.
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Head and Neck
Application of educational theory regarding teaching for skill transference
using the compartment model for orbital imaging in postgraduate
education and training: Assessment and evaluation of a group of
ophthalmology and radiology residents and fellows
P.-S. Goh; Singapore/SG ([email protected])
Procedure Details: This exhibit will present key research regarding transference,
show its relevance to postgraduate training applying the compartment model for
orbital imaging with a group of ophthalmology and radiology residents and fellows,
as well as present data to show its effectiveness in postgraduate education. In
particular, a combination of: a) presenting paired examples, asking students to
work out underlying principle, then presenting principle, b) mixed practice - i.e.
presenting two contrasting cases, asking students to work out differences, then
presenting principle, and c) distributed practice will be shown to be the best method
for encouraging transference of skills.
Conclusion: Application of educational theory regarding teaching for skill transference can significantly improve radiology training and educational efforts as
illustrated in this presentation using the compartment model for orbital imaging.
Scientific and Educational Exhibits
C-498
Conclusion: 1. Paragangliomas, aneurysms and pseudoaneurysms have classic locations and imaging features that are exquisitely depicted on CT and MRI
studies permitting a definitive diagnosis. 2. Imaging studies accurately depict the
location and extent of involvement and help determine the surgical approach in
treating these lesions.
Learning Objectives: To review the head and neck infections at the emergency
room. To suggest the most likely source of infection. To describe possible complications and typical pathways of extension, following head and neck spaces on CT.
Background: Head and neck anatomy is usually a long and wearisome chapter
of any radiologist resident’s book. Nevertheless, studying lesions following cervical
spaces can help us make a better approach to their possible source. CT is widely
used to diagnose head and neck infections, and usually the medical management
or surgical intervention is based on imaging findings.
Procedure Details: 81 patients with neck infections were studied with CT in the
last two years in our emergency department. Our image protocol depends on the
type of infection, physical examination being the first diagnosis step. If mediastinal
or vascular involvement is suspected, thoracic structures must be included in the
study. We will discuss, with imaging examples, the most common infections arising in each facial compartment, and their typical spread pathways. The radiologist
should communicate if the infection is presented as cellulitis or as an abscess,
its size and space location. A delay in diagnosis can lead to fatal complications,
such as descending mediastinitis, jugular vein thrombosis, or even systemic dissemination.
Conclusion: After reviewing this exhibit, a radiologist in training will be able to: A.
Realize the importance of the head and neck infections. B. Suggest the possible
source of infection following cervical spaces description. C. Optimize the patient’s
outcome by a correct team-work with head and neck surgeons.
C-501
I cannot swallow, doctor: What is wrong with me? Head and neck
infections in the emergency room
E. Alonso Gamarra, F. Guerra Gutiérrez, P. García Raya, M. Parrón,
V. Pérez Dueñas; Madrid/ES ([email protected])
C-499
MR imaging of common and uncommon extraocular orbital lesions
C.L. Fernandez Rey, A. Saiz Ayala, E. Santamarta Liebana, E. Montes Perez;
Oviedo/ES ([email protected])
Learning Objectives: To illustrate the compartmental anatomy of the orbit. To
discuss radiological findings of both common and uncommon extraocular orbital
lesions.
Background: MR imaging is often used in the detection and differential diagnosis
of orbital pathology. We show some key facts to help us to detect usual orbital
diseases and to familiarise with some unusual lesions.
Imaging Findings: 1. Anatomy: We describe the anatomy of the orbit and illustrate
the principal lesions that can involve the major anatomic orbital spaces. 2. Pathology:
We have made a pictorial review showing the wide spectrum of lesions that can
involve the extraocular orbit including primary and secondary neoplasms, vascular
malformations, pediatric tumors and inflammatory conditions.
Conclusion: Multiple pathological conditions can involve the extraocular orbit.
The location, MR imaging characteristics and clinical history can help narrow the
differential diagnosis.
C-500
Pulsatile vascular masses of the extracranial head and neck: CT and MRI
features
V.M. Joshi, U.K. Nayak; Hyderabad/IN ([email protected])
Learning Objectives: To illustrate the imaging features of pulsatile vascular masses
of the extracranial head and neck.
Background: Paragangliomas are the commonest causes of pulsatile vascular
masses in the extracranial head and neck. Paragangliomas of the head and neck
have characteristic distribution, originating from the paraganglia or glomus cells
within the carotid body, vagal nerve, middle ear and jugular foramen. Carotid or
vertebral artery aneurysms and pseudoaneurysms are the other rarer causes of
such masses. Contrast CT and/or MRI findings in 15 patients who presented to
our imaging department with pulsatile swellings of the extracranial head and neck
are presented.
Imaging Findings: Characteristic locations and the striking imaging features of
the paragangliomas are illustrated and described in detail. All paragnagliomas
were seen as intensely enhancing soft-tissue masses in the carotid space, jugular
foramen, or tympanic cavity at CT and a salt-and-pepper appearance at standard
spin-echo magnetic resonance imaging. A classic permeative pattern of bone
destruction was seen in jugular foramen paraganglioma. Contrast CT with sagital
and coronal reformations in two patients with aneurysms and pseudoaneurysm of
the carotid artery are illustrated with brief description about the pathology.
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MR cisternography with fast imaging employing steady-state acquisition
(FIESTA)
P.V. Foti, R. Farina, S. Palmucci, M. Coronella, D. D’Aniello, D. Bellomia, G. Politi,
G.C. Ettorre; Catania/IT ([email protected])
Learning Objectives: To illustrate the main features of FIESTA sequence, and
its advantages over other MR imaging sequences in imaging cisternal parts of
cranial nerves V-VII-VIII.
Background: FIESTA sequence generates T2/T1 contrast because of its short
repetition time (TR) and the symmetrical and balanced gradient around the echo
time (TE). It provides very high signals from tissues with large T2/T1 ratios, such as
fluid, blood and fat. Scanning time is shorter than in conventional CISS and FISP,
and movement and flow artifacts occur less often than with other sequences. The
contrast to noise ratio (CNR) is higher. Blurring artifacts occur less often because
the MR signal is always achieved in a coherent state. Magnetic susceptibility artifacts
occur with lower frequency due to very short TE and wide band thickness.
Imaging Findings: We assessed FIESTA sequence’s performance in patients with
V-VII-VIII cranial nerve’s related symptoms. In cases of posterior fossa tumors,
FIESTA sequence depicted clearly tumor’s extension and facilitated a superior
assessment of tumor’s effect on cranial nerve anatomy. When a neuro-vascular
conflict was suspected, FIESTA identified in all patients the anatomical relationship
between vascular structures and trigeminal, facial and cochleovestibular nerves.
Moreover, volumetric 3D acquisition allowed very high quality from multiplanar
reformations using minimum intensity projection algorithm.
Conclusion: 3D FIESTA sequences are superior to other heavily T2-weighted
sequences in visualizing cisternal parts of the posterior fossa cranial nerves for the
following reasons: high-resolution, short acquisition time, less artifacts from CSF
pulsation and magnetic susceptibility. Thus, high quality images can be obtained.
C-502
Denervation cervical muscular atrophy: CT and MR evaluations
A. Piscopo, R.L.E. Gomes, E.M.M.S. Gebrim, L.N. Silva, F.K.I. Cevasco,
M.M. Daniel, G.G. Cerri; Sao Paulo/BR ([email protected])
Learning Objectives: To illustrate the spectrum of cervical muscular atrophy after
nerve injury. Computed tomography (CT) and magnetic resonance (MR) studies
were selected to exemplify the denervation muscular atrophy by lesions of V, VI,
VII, X, XI and XII nerves.
Background: Patients with denervation cervical muscular atrophy usually have a
prior history of tumoral resection and radical neck dissection, tumor invasion and
radiation neuropathy.
Imaging Findings: The sequence of events has been divided into the acute, the
subacute and the chronic phases. During the acute phase, the MR appearance of
muscle is frequently normal. More recent works have shown that signal changes
and contrast enhancement can be detected as early as 24 h. The subacute phase
is characterized by a relative increase in the extracellular water compared with the
intracellular water. There is a high signal intensity within the denervated muscle on
T2 weighted and STIR images and may occur enhancement with contrast. Chronic
denervation is best seen on T1-weighted images, and show as a loss of muscle bulk
with diffuse areas of increased signal intensity within the muscle corresponding to
fatty replacement, fibrosis and atrophy.
Conclusion: It is important to become familiar with acute, subacute and chronic
changes of muscle denervation because neoplastic and inflammatory processes
may have a similar imaging appearance. Head and neck clinically silent tumors
can signal its presence only as a cranial nerve dysfunction through the denervated
muscle. Therefore, in denervated muscle, we must evaluate the entire course of
the cranial nerve searching for a lesion.
Scientific and Educational Exhibits
C-503
Vascular lesions of the orbit: A pictorial review
C.L. Fernandez Rey, A. Saiz Ayala, E. Santamarta Liebana, E. Montes Perez,
P. Sanchez Lopez, I. Noval Tuñón; Oviedo/ES ([email protected])
Learning Objectives: To illustrate the spectrum of vascular lesions that can involve
the orbit. To discuss and emphasize the role of MR angiography.
Background: Multiple vascular lesions can affect the orbit including neoplasms,
malformations and shunts. These lesions can manifest with proptosis or diplopia.
Imaging differentiation is essential because the management and prognosis vary
greatly. MR angiography provides useful information in the preoperative evaluation
of these lesions.
Imaging Findings: The spectrum of vascular lesions that can involve the orbit
include hemangiomas, cavernous malformations, orbital varices, venous lymphatic
malformations, hemangiopericytomas, hemangioblastomas, vascular metastases,
etc. We have made a pictorial review showing the more significant cases and describe the specific imaging features that can help us in their diagnosis.
Conclusion: Imaging studies are essential for the evaluation of the vascular processes affecting the orbit. Location, age patient and characteristics on MR imaging
are key facts that can help narrow the differential diagnosis, thereby helping to
guide patient treatment.
C-504
Dental CT: Substantial findings the radiologist needs to communicate to
the clinician
A. Gahleitner, U. Kuchler, F. Kainberger; Vienna/AT
([email protected])
Learning Objectives: Unfortunately, most radiologists have had little experience
with dental-CT and many of the findings remain undescribed. Our objective, therefore, was to determine the CT appearance of dental related diseases of the jaws
and to demonstrate typical and frequent findings.
S
Omethod for anatomic imaging
Background: Dental-CT has become an established
P
E
of the jaws prior to dental implant placement. oMore recently, this high-resolution
t
imaging technique has gained importance in d
diagnosing dental associated diseases
e
of the mandible and maxilla.
itt
m
Imaging Findings: Dental-CT investigations
using the usual high resolution protocol
ubfeed) were performed and reconstructed on a
(1 mm slice thickness, 1.0 mm table
S
l placement as well as patients with cysts, oroworkstation). Patients prior to implant
ia
rmaxillary
antral fistulas, odontogenous
sinusitis, impacted teeth and dental fractures
e
at
have been investigated.M
Anatomic
and pathologic conditions of the jaws are clearly
visualized and serve oas an aid to the clinician for therapeutic management.
N
Conclusion: This exhibit reviews our experiences from over 24000 CT investigations and will summarize the imaging possibilities and indications, which dental-CT
is able to cover.
Interventional Radiology
Vascular
C-505
Central venous occlusion: Back to the heart of the matter
D.A. Covarrubias, D.M. Flamini, R.F. Leonardo, J.M. Martino; Brooklyn, NY/US
([email protected])
Learning Objectives: To review the anatomy and physiology of the central veins
of the upper extremity and the major clinical etiologies of occlusion. To demonstrate
a variety of cases that depicts the typical imaging appearance of central venous
occlusion across multiple modalities and address pertinent aspects of imagingguided management options.
Background: As the number of patients requiring extended central venous access continues to rise, central venous thrombosis of the upper body has become
an increasingly common clinical dilemma. Diagnosis and often management of
these conditions depends heavily on multi-modality imaging. The purpose of this
exhibit is to review the relevant anatomy of the venous system of the upper torso
and extremities and to portray the imaging findings of both primary and secondary causes of central venous occlusion as well as present a brief examination of
significant collateral pathways and their imaging manifestations. Finally, treatment
options will also be discussed.
Imaging Findings: Examples of imaging findings of central venous occlusion using multiple imaging modalities will be presented, including venography, computed
tomography, and magnetic resonance angiography/imaging. Brief examples of
imaging-guided therapeutic interventions will also be presented.
Conclusion: The goal is to develop a confident approach to the diagnosis of central
venous occlusion and an understanding of relevant clinical aspects of the condition
as well as available treatment options.
C-506
The role and method for performing fistuloplasty on a poorly functioning
haemodialysis fistula
S. Stuart, A. Hameeduddin, P. Boavida, B. Roberton; London/UK
([email protected])
C-507
Evaluation of vascular supply with angio-CT during intra-arterial
chemotherapy for advanced maxillary cancer
N. Kashiwagi, K. Nakanishi, M. Koyama, Y. Satou, K. Yoshino, H. Uemura; Osaka/JP
([email protected])
Learning Objectives: To identify the feeding arteries of advanced maxillary cancer
and illustrate these supplying territories using angio-CT.
Background: Combined therapy with radiotherapy and superselective intra-arterial
chemotherapy for advanced maxillary sinus carcinoma has been recently attempted
in many institutions to preserve the organ and improve poor prognosis. Understanding the tendency of the feeding arteries of advanced maxillary cancer could aid in
appropriately performing this interventional procedure and in shortening its time.
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S443
Interventional Radiology
Learning Objectives: To explain when fistuloplasty is an appropriate technique
for managing poorly functioning haemodialysis fistulae. To describe the technique
of fistuloplasty for managing poorly functioning haemodialysis fistulae. To outline
the possible complications of fistuloplasty.
Background: The number of patients with end stage renal failure is increasing
worldwide. Haemodialysis is one of the main methods of renal replacement therapy
and the use of haemodialysis is increasing. Formation and maintenance of a functioning arterio-venous fistula is vital for long term haemodialysis. Unfortunately,
complications with the fistula such as thrombosis and stenosis can render the fistula
unsuitable for use. Fistuloplasty is a technique that can help improve the function
of a fistula and allow it to be used for haemodialysis once again.
Procedure Details: The multimodality methods of imaging a non functioning fistula
and their relative advantages and disadvantages are illustrated. The role of fistuloplasty in the management of a non functioning haemodialysis fistula is explained.
The method of performing fistuloplasty and the equipment needed is carefully explained and illustrated. The possible complications of fistuloplasty including contrast
extravasation, fistula rupture and pseudoanuerysm formation is covered along with
the role of interventional radiology in managing these complications.
Conclusion: Fistuloplasty is a safe and effective method for treating a non functioning haemodialysis fistula. Fistuloplasty can be associated with complications that
may be treated using interventional radiology.
Scientific and Educational Exhibits
Imaging Findings: We studied 13 patients with maxillary cancer by angio-CT. The
clinical T factors for these patients were T3 (N=6) and T4 (N=7). Feeding arteries
were as follows: 13 via the maxillary artery, 6 via the orbital artery, 6 via the facial
artery, 4 via the transverse facial artery, 4 via the ascending palatine artery, 1
via the ascending pharyngeal artery, and 1 via the middle meningeal artery. The
supplying territories of feeding arteries were as follows: The maxillary arteries
supplied the tumors in the maxillary sinus, its wall, and the pterygopalatine fossa.
Other arteries supplied the tumor, which extended to the extra maxillary sinus as
follows: the tumors with an upward extension were supplied by the orbital arteries,
medial frontal tumors were by the facial arteries, lateral frontal tumors were by the
transverse facial arteries, those extending downward were supplied by the ascending palatine arteries, and those towards posterior were supplied by the ascending
pharyngeal artery or middle meningeal artery.
Conclusion: The parasitic supplying arteries of the maxillary cancer exhibited
uniform tendencies depending on the tumor site.
C-508
The role and contributable factors for preservation of long term patency in
stent assisted subintimal angioplasty in a patient with a critical lower limb
ischemia
S. Lee, Y. Cho, Y. Choi, H. Kim, J. Woo, J. An, Y. Jeong, C. Han; Seoul/KR
([email protected])
Learning Objectives: To illustrate variable features of stent-assisted subintimal
angioplasty for severe stenosis of multifocal infrapopliteal arteries in a critical limb
ischemia. To analyse contributable factors of preservation of long term patency of
stent-assisted subintimal angioplasty between angioplasty alone and combined
stent placement in infrapopliteal arteries.
Background: Percutaneous intentional subintimal angioplasty has become an
accepted and successful method of treatment for chronic atherosclerotic occlusive
disease in femoropopliteal and infrapopliteal arteries. But, there are few studies
and reported literature for analysis of factor for preservation of long term patency of treated infrapopliteal arteries and role of additional stent after subintimal
angioplasty.
Procedure Details: A total 36 patients were treated with subintimal angioplasty
for segmental occlusion of superficial femoral artery only (15/36), superficial
femoral artery combined infrapopliteal artery (12/36) and infrapopliteal artery only
(9/36) during the last three years. The percutaneous subintimal angioplasty only
was performed in 10 patients in 21 patients of treated infrapopliteal arteries and
combined stent assisted angioplasty was performed in 14 patents in severe occlusive infrapopliteal arteries.
Conclusion: The stent assisted subintimal angioplasty may be helpful in preserving
long term patency and successful recanalization after angioplasty than subintimal
angioplasty alone, but adequate anticoagulation medication, serial follow-up Doppler ultrasonograpy and additional angioplasty are needed in continuing initial
patency.
C-509
Management of intractable bladder and prostate hemorrhage with selective
arterial embolization: Short- and long-term outcomes
R. Loffroy, A. Delgal, B. Guiu, F. Michel, I. Kermarrec, J.P. Cercueil, D. Krausé;
Dijon/FR
Purpose: To evaluate the efficacy and outcomes of transcatheter arterial embolization as an alternative therapeutic option in the control of intractable hematuria of
vesical or prostatic origin after failed conservative treatment.
Methods and Materials: Retrospective study of 22 consecutive embolization procedures in 19 patients (17 men, 2 women, mean age 73p17.2 years) with refractory
bladder or prostate hemorrhage referred from 1999 to 2008 for selective pelvic
angiography after failed conventional therapy. Vascular embolization was performed
uni- (n=5) or bilaterally (n=12) as follows: superselective distal particulate or glue
embolization of the vesical or prostatic arteries in 10 patients, selective proximal
coil occlusion of the anterior division of internal iliac artery in 2 patients, both in 3
patients, and coil blockade technique in 2 patients. Success was monitored with
postembolization angiography and cessation of hematuria clinically.
Results: The technical success rate was 89.5% (17 of 19 patients). The primary
clinical success rate was 82.3% (14 of 17 patients). Secondary clinical success
occurred in one additional patient (88.2%). The periprocedural mortality rate was
21% (4 of 19), mostly related to underlying conditions. No major complications
related to catheterization occurred. Late bleeding recurrence was reported in 4
(23.5%) of 17 patients. Median follow-up postembolization was 7 months (range,
7 days-56 months). Six additional patients died during follow-up, but none of the
deaths were due to re-bleeding.
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Conclusion: Selective angiographic embolization is safe and effective for controlling
chronic life-threatening bladder or prostate hemorrhage regardless of the cause,
and should be considered as the treatment of choice, usually obviating the need
for emergency surgery in critically ill patients.
C-510
Transarterial management of renal angiomyolipomas in elective and
emergency settings
E.T.H. Liu, S.K. Venkatesh, K.Y. Seto, L.K.A. Tan; Singapore/SG
([email protected])
Learning Objectives: To describe the indications, methods, efficacy and complications of transarterial management of renal angiomyolipomas (AMLs) in both
elective and emergency settings.
Background: Renal AMLs are uncommon benign hamartomas composed of fat,
smooth muscles and aggregates of thick-walled blood vessels with incomplete
elastic layers. The incomplete elastic layers make the tumor blood vessels prone to
aneurysmal formation and bleeding. Indications for embolization include symptomatic tumours, high risk of morbidity or mortality due to surgery and patients’ desire to
obviate surgery. Large tumours ( 4 cm) are more likely to present with spontaneous
hemorrhage and therefore candidates for elective management to prevent bleeding
and associated complications. The treatment options include surgery and transarterial embolization where the latter is preferred as it is minimally invasive. Surgery is
performed when transarterial management fails to control the bleeding.
Imaging Findings: We describe the imaging appearances of renal AMLs on ultrasound, CT, MRI and catheter angiography. The angiographic appearances and
transcatheter management of the AMLs with different embolic materials will be
illustrated with examples. The present accepted strategy of renal AML embolization
is preservation of the normal renal parenchyma by super selective embolization
of tumor vessels only. The various embolic agents used include gelfoam, poly
vinyl alcohol (PVA) particles, metallic coils, absolute alcohol, and iodized oil. The
reported complication rate with transarterial embolization is about 10% and most
commonly is an abscess formation.
Conclusion: Transarterial management of renal AMLs is an effective and safe
procedure in both elective and emergency settings.
C-511
Drug eluting stents for the treatment of small caliber obstructive
femoropopliteal artery disease: A clinical trial, early and mid term results
F.Z.H.M. Moukhtar, A.M.A. El Marakbi; Jiddah/SA
([email protected])
Purpose: The study is designed to review our experience with endovascular therapy
using coronary drug eluting stents in obstructive femoropopliteal segments.
Methods and Materials: Angioplasty and selective stenting of femoropopliteal
occlusive disease was performed in 33 limbs in 28 patients using coronary drugeluting stents from April 2005 to Jan 2007. All patients who had endovascular
therapy for intractable lower limb ischemia due to TASC 2000 A, B and C lesions
pass through our routine surveillance protocol that includes a clinical evaluation,
an ABI, and a color-flow duplex scan at 24 hours, 1 month, 6 months, and 1 year
after the procedure.
Results: Selective stenting were done in 33 limbs, either due to residual stenosis
more than 30% or flow limiting dissection of the artery. Single stent was used in 14
limbs (42%), while using more than one stent in 19 limbs (58%). Mean lesion length
52 mm p.053 mm. mean diameter of the obstructive lesion 3.22 mm. Endovascular
therapies was technically successful in all patients. During follow-up, stenosis free
patency was 100, 86, and 77% by 1, 6, and 12 months intervals, respectively.
Conclusion: Drug eluting coronary stenting can be used exceptionally at proximal
SFA with small caliber artery 3.5 mm with good short and mid term patency
rates and with better results in TASC A&B. In our series, endovascular therapy
proved technically feasible and safe modality for small caliber femoropopliteal
arterial segment.
C-512
Management of peripheral venous malformations
C.B. Hernandez, B. Zudaire, M.J. Herraiz, J. Arias, M. Arraiza,
A. Martinez-Cuesta; Pamplona/ES ([email protected])
Learning Objectives: 1. To describe the classification system of vascular anomalies in order to differentiate between benign tumors (hemangiomas) and vascular
malformations. 2. To show our experience in the treatment of peripheral venous
malformations with ultrasound-guided microfoam sclerotherapy.
Scientific and Educational Exhibits
Background: We present our experience as a major referral center for vascular
anomalies. We have reviewed the most representative cases treated in our center
with ultrasound-guided microfoam sclerotherapy. Marked improvement is shown
using advanced imaging techniques (Doppler ultrasound, angio-computerised
tomography, angio-magnetic resonance, and angiographic techniques). Treatment
with ultrasound-guided microfoam sclerotherapy may be considered the first choice
treatment for venous malformations.
Procedure Details: Particular emphasis is made on the application of new diagnostic techniques (CT and MR venography) used to depict with greater precision
the extension of the lesions and involvement of anatomical structures. We also
describe the combination of sclerotherapy with other interventional techniques in
order to obtain better results.
Conclusion: Venous malformations are congenital lesions that usually manifest
in childhood or early adulthood and can experiment growth causing serious complications such as functional limitation, ulceration, and haemorrhage. Their clinical
presentation is variable depending on the size and location. Surgical resection is
often contraindicated as complete excision is difficult or impossible, particularly
when the malformation is diffuse.
C-513
Intracranial aneurysms volume and coil packing density: The impact of the
measurement method
D. Knap1, M. Zbroszczyk1, K. Gruszczynska1, W. Wawrzynek2, M. Korzekwa1,
P. Bazowski1, J. Baron1; 1Katowice/PL, 2Piekary Slaskie/PL ([email protected])
Purpose: To check if different techniques of intracranial aneurysms volume measurement in 3D rotational DSA can impact the calculated coil packing density during
intravascular aneurysm embolisation.
Methods and Materials: 35 patients with intracranial aneurysms underwent
intravascular embolisation. Aneurysm volume was measured three times: first
with dedicated software on workstation with 3D DSA data. Then with the formula
for ellipsoid volume, with two diameters measured on DSA, and third with three
diameters measured on DSA. Calculated data were used to generate coil packing
density of embolised aneurysms. Anova statistics was used to compare values
obtained with the three techniques.
Results: Mean aneurysm volume, obtained with dedicated software, was 0.517 ml,
SD 1.02 ml, with three diameters: 0.548 ml, SD 1.18 ml. Largest volumes were
obtained with two diameters method: mean 0.624 ml, SD 1.33 ml. Coil packing
density calculated with dedicated software was: mean 19.9%, SD 13.3%; with two
diameters: mean 23.8%, SD 16.6%; and for 3 diameters: mean 28.4%, SD 20.1%.
Differences among aneurysm volumes obtained with three methods were not statistically significant (p= 0.928); however, differences among coil packing densities
based on aneurysm diameters were statistically significant (p=0.002).
Conclusion: Different measurement techniques used for calculation of intracranial aneurysm volume resulted in statistically significant differences in calculated
coil packing densities. Technique of aneurysm measurement on 3D DSA images
should be taken into consideration in the evaluation of intravascular embolisation
results.
C-514
Learning Objectives: To understand the physiopathogenesis of superior vena
cava syndrome (SVCS). To recognize the early clinical and radiological signs of
SVCS. To report the critical usefulness of radiological pre/post procedure means.
To describe the technical key points of SVC stenting. To recognize and treat post
operative complications.
Background: SVCS is associated to a malignancy in more than 90% of cases.
SVC obstruction causes elevated venous pressure upstream and creation of a
third compartment (Interstitial Space). Percutaneous endovascular stenting can
be performed as a first or second option procedure. Clinical complications include
SVCS recurrence and cardio respiratory impairment. Early clinical symptoms include
headache when leaning, hoarseness and supra clavicular fossa swelling.
Imaging Findings: The impact in the diagnosis and follow-up of Chest X-ray (body
habitus, body mass index, central line, cardiomegaly, pleural effusion), Doppler
ultrasound (subclavian, jugular and internal thoracic veins), MDCT venography
(location, length, severity of the stenosis/thrombosis; pericardial/pleural effusion,
radiation therapy sequellae, subclavian/inominate/SVC involvement)) and MR
venography will be presented and discussed.
C-515
Endovascular management of intracranial aneurysms: Resident’s guide to
ABC of hardware
S.S. Hedgire, K. Narsinghpura, D. Raja, R. Krishnan, P. Mehta, M. Cherian;
Coimbatore/IN ([email protected])
Learning Objectives: To highlight the importance of correct hardware selection
in the treatment of varieties of intracranial aneuryms.
Background: Endovascluar coiling is high acuity level treatment modality for
ruptured and unruptured intracranial aneurysms. Complete filling, promotional
thrombosis or redirection of flow into the parent artery are goals of endovascular
treatment. To achieve this one should be aware of available hardware.
Procedure Details: Location and morphology of aneurysm as well as tortuosity of
vasculature decide the basic hardware required. Neck of the aneurysm, i.e. wide or
narrow, decides whether auxillary therapy (stent, balloon etc) is to be used or not.
An easy step-by-step selection of hardware starting from the sheath to the coils
ensures completeness of the procedure in short time.
Conclusion: Apt selection of hardware is key to successful embolization of intracranial aneurysms.
C-516
Higher incidence of complication in valved than in non-valved chemoport:
By referral rates to interventional radiology
A. Choi1, E.-Y. Jeon1, H. Kim2; 1Anyang/KR, 2Goyang/KR ([email protected])
Purpose: To compare the complication rates of traditional non-valved chemoport
and valved chemoport, according to the referral rates to interventional radiology
department because of problem using the chemoports.
Methods and Materials: During 5 years, 438 cases of chemoport insertion through
internal jugular vein under US guidance were done in angiographic suite in 410
patients. The position of chemoports was right (289 cases) and left (149 cases)
side chest wall. The purpose of chemoport insertion was for chemotherapy and
intravenous fluid infusion. We used valved chemoport in 109 cases and non-valved
chemoport in 329 cases. A total of 30 cases of problematic chemoports referred to
interventional radiology were included in this study. The problems were classified
as sepsis, pocket infection, catheter migration, occlusion with thrombus, leakage,
rotation, skin necrosis, cannulation difficulty, and fibrin sheath formation by retrospective review of medical records according to the types of chemoports.
Results: The complication rates related to chemoport is higher in valved (11.93%)
than non-valved (5.17%) chemoports. Also the complication rates related to position
of chemoport is higher in left (13.42%) than right (3.46%) side chest wall.
Conclusion: The higher referral rates to interventional radiology were present in
valved than non-valved chemoports. When there is a need to insert valved chemoport, a different method of insertion and management seems to be necessary
compared with those of non-valved chemoports.
C-517
Embolization of wide neck intracranial aneurysms
N. Limbucci, A.V. Giordano, M. Gallucci; L’Aquila/IT ([email protected])
Learning Objectives: To review the available techniques for embolization of wide
neck aneurysms. To underline the growing number of indications for endovascular
treatment of brain aneurysms.
Background: Coiling is becoming the favourite treatment for brain aneurysms in
many institutions. However, treatment of wide neck aneurysms often requires the
use of more complex techniques.
Procedure Details: Here, we review the procedural steps, advantages, complications and controversies of the main techniques used for wide neck aneurysms
embolization, including balloon assisted coiling, stent assisted coiling, intrastent
remodelling and liquid polymer embolization.
Conclusion: Confidence with complex embolization techniques allows treatment
of most cases of wide neck intracranial aneurysms.
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Interventional Radiology
Superior vena cava syndrome: What the radiologist needs to know
P.-Y. Marcy, L. Gastaud, V. Mari, C. Hebert, N. Amoretti, M. Poudenx; Nice/FR
([email protected])
Conclusion: Patients presenting with tumors that respond well to chemotherapy
need a central I.V. line to be inserted to start treatment. Otherwise, percutaneous
stenting can be performed and reaches a high rate of efficacy. The Lanciego scale
(clinical status), chest X-ray, Doppler ultrasound and Stanford classification are useful tools to assess the patient’s condition. The physiopathogenesis and treatment
of cardiac shock with jugular vein distension (pulmonary embolism, pericardial
tamponnade, overload syndrome) will be highlighted.
Scientific and Educational Exhibits
C-518
Management of life-threatening pelvic hemorrhage by emergency uterine
artery embolization
L. Flors, E. Lonjedo, C. Leiva-Salinas, G. Figueres, E. López-Pérez, A. Ruiz,
J. Martínez-Rodrigo; Valencia/ES ([email protected])
Purpose: To evaluate the efficacy and safety of emergency selective uterine artery
embolization and its role as an alternative to surgery (hysterectomy or arterial ligation) in the management of intractable pelvic hemorrhage.
Methods and Materials: Sixteen patients with life-threatening hemorrhage underwent uterine hemostatic uterine embolization in our institution during a 2 year
period. The pelvic hemorrhage was related to uterine atony (10 patients), bleeding
tumour (3 patients), false aneurysm (2 patients) and pelvic hematoma (1 patient).
The approaches employed were: 13 right-side unifemoral, 2 bilateral femoral and
1 radial. After selective uterine arteries catheterization (cobra shaped or vertebral
catheter, 4 F or 5 F), the embolization was performed with absorbable gelatine
sponge and/or particles of polyvinyl alcohol (PVA) depending on the case.
Results: The procedure consisted of embolization under angiographic guidance
of both uterine arteries (n =32), and vaginal (n =2) or anterior division of internal
iliac artery (n = 1). In all patients, pelvic hemorrhage was successfully controlled.
One patient needed repeated embolization the next day. Angiographic embolization
allowed preservation of the uterus. Embolization controlled the vaginal hemorrhage
in a previously hysterectomized patient. No major complication related to embolization therapy was observed.
Conclusion: Emergency arterial embolization is a safe and effective means of
controlling pelvic hemorrhage. The procedure avoids high risk surgery in an unstable
patient and allows maintenance of reproductive ability.
C-519
Pulmonary artery pseudoaneurysms related to Swan-Ganz catheter
placement: CT findings and embolization with vascular plugs
M. Burrel, M. Real, M. Sanchez, P. Arguis, A. Sierra, M. Barrufet, X. Montañá;
Barcelona/ES ([email protected])
Learning Objectives: 1. To describe radiological findings on CT images and vascular reconstructions of pulmonary artery pseudoaneurysms related to Swan-Ganz
catheter placement. 2. To introduce the use of the amplatzer vascular plug and
describe the technique for embolization of pulmonary artery pseudoaneurysms.
Background: Perforation of a pulmonary artery after placement of a Swan-Ganz
catheter is a serious complication that requires immediate management. Exact
description of size and anatomic localization of a pulmonary pseudoaneurysm
is crucial for planning further therapy. Multidetector CT has proved not only to
correctly demonstrate the anatomic location of the pseudoaneurysm but also to
be able to directly visualize the feeder vessel and its connection to the aneurysm.
The amplatzer vascular plug is an embolization device that has been increasingly
applied for various vascular embolization procedures.
Procedure Details: 64-row Multidetector CT angiography was performed to evaluate three patients who presented massive hemoptysis after placement of a SwanGanz catheter for monitoring during cardiac surgery. MDCT detected the presence of
a pseudoaneurysm in all cases, as well as depicted the feeding vessel on MIP and
MPR reconstructions. The information obtained was essential for the endovascular
management. The embolization was performed successfully using an amplatzer
vascular plug; the technical aspects of the procedure are described.
Conclusion: MDCT is essential for subsequent superselective angiographic visualization of the feeder vessel and for successful embolization. The vascular plugs
allow a rapid, safe and effective occlusion of the bleeding artery.
C-520
Multimodality evaluation of consecutive patients with abdominal aneurysm
treated with endovascular graft: Color-Doppler-US vs low-MI CEUS
compared with 64-slice-CTA and MRA
V. Cantisani, E. Marotta, G. Menichini, L. Coletta, P. Ricci, R. Passariello; Rome/IT
([email protected])
Purpose: To evaluate the efficacy of color-Doppler-US and low-MI CEUS in the
assessment of endovascular graft treatment for abdominal aneurysm as compared
with 64-slice-angio-CT and angio-MRI.
Methods and Materials: From February 2006 to June 2008, 120 consecutive
patients (90 M; 30 F - mean age: 63aa) treated with endovascular aortic graft
underwent color-Doppler-US, low-MI CEUS, 64-slice-angio-CT, angio-MRI and
angiography if re-treatment was indicated. Sensitivity and specificity of ultrasound
examinations were compared with CT and MRI as the reference standards or when
available with the angiography. McNemar test was then calculated.
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Results: Twelve true endoleaks (type II: 10, Type III: 2) were identified (10%) by
the FU or by angiography. Sensitivity and specificity of color-doppler-US, CEUS,
angio-CT, and angio-MRI were: 50, 100, 83, 92% and 60, 100, 100, 100%, respectively. CEUS was significantly more accurate than US (p 0.001) and highly
comparable to angio-CT and angio-MRI. Consequences to treatment occurred in
6 patients (50%).
Conclusion: CEUS is a feasible tool in follow-up of endovascular aortic aneurysm
treatment since it may identify endoleaks missed at other imaging techniques.
C-521
Endovascular repair for thoracic aortic disease involving aortic arch using
curved nitinol stent-graft: An early experience with midterm follow-up
N. Hongo, R. Shuto, T. Kono, S. Matsumoto, S. Miyamoto, H. Mori; Oita/JP
([email protected])
Purpose: The purpose of this study was to report the mid-term feasibility, efficacy,
and durability of endovascular repair of aortic disease involving aortic arch such as
thoracic aortic aneurysm (TAA) and DeBakey type III aortic dissection (AD).
Methods and Materials: Between February 2007 and August 2008, 50 patients
with aortic disease including TA and AD involving aortic arch were enrolled and
evaluated for a curved nitinol stent-graft (Matsui-Kitamura stent-graft). As control
subjects, an open surgical group of 58 patients enrolled. Just before stentgrafting,
32 patient received debranching bypass to create a proximal landing zone: 20 were
subclavian debranching, 9 were carotid and subclavian debranching and 3 were
three vessel debranching.
Results: 50 patients had successfully implanted of the stentgraft. The median
follow-up was 8.3 months (range 1-19.5 months). Perioperative mortality rate in
the endovascular versus open surgical group was 6 (n=3) versus 6.8% (n=4).
Neurological complication rate were 8 (n=4) versus 8.6% (n=5), while the rate of
pulmonary or cardiac complications in endovascular group is significantly lower
than that in open surgical group. Median hospital stay was 16.5 versus 27.95 days.
A type I or II endoleak was detected in 3 cases on the 1 month follow-up CT scan,
but there were no cases with secondary endoleak and with significant enlargement
of the aneurysms.
Conclusion: The treatment of aortic disease involving aortic arch using curved
nitinol stent-graft is technically feasible. Considering the lower complication and
midterm results, this series can be valid therapy for TAA or AD.
C-522
Clinical presentation and management of spinal dural arteriovenous fistula
in 20 consecutive cases
A.K. Gupta, A.L. Periakaruppan, N.K. Bodhey, S.N. Patro, J. Saini; Trivandrum/IN
([email protected])
Purpose: To evaluate the efficacy of the endovascular embolisation of spinal
dural AV fistulas.
Methods and Materials: In this retrospective study between 1998 and 2008, 20
patients were included. The presenting symptoms in these patients were consistent with progressive myelopathy, and included lower extremity weakness (52%),
paraesthesias (30%), back pain (24%), and urinary symptoms (6%). All the patients
were diagnosed to have spinal dural AVF based on imaging and angiographic findings. All the patients underwent endovascular embolisation of the fistula. Varying
concentrations of the glue (NBCA) was used for embolisation.
Results: Endovascular treatment resulted in a significant symptomatic improvement
in all the treated patients. No technical/procedural failures were documented in any
of the patients. Total obliteration of the fistulae was achieved in all the patients. No
procedural morbidity/mortality was documented. On follow-up 6-132 months, all
patients have shown clinical improvement.
Conclusion: Endovascular embolisation is an alternative treatment of choice for
spinal dural AV fistulae. It is safe and efficacious and complete occlusion can be
obtained in all the patients.
C-523
How to manage pelvic arterio-venous malformation
H. Rikimaru1, A. Sato2; 1Ichinoseki/JP, 2Sendi/JP ([email protected])
Learning Objectives: To learn clinical feature of pelvic arterio-venous malformation (AVM). To learn imaging feature of pelvic AVM. To learn treating strategies. To
learn complication and outcome of each treatment.
Background: Pelvic AVM is a rare, but known as a difficult-to-treat disease. It has
been treated with surgery, by IVR, or by combination of both techniques, although
high-incidence of recurrence still remain even in these days. On IVR technique,
transarterial embolotherapy has been used for long years using absolute ethanol,
Scientific and Educational Exhibits
microcoil, NBCA, etc. Recently, however, transvenous treatment was introduced in
manner of balloon occluded-retrograde trasvenous obliteration (BRTO).
Procedure Details: On transvenous embolotherapy, drainage vein should be
obstructed by balloon catheter initially. Next, microcatheter should be inserted
and left in place near the nidus. Then, ethanolamin oleate (EO) should be injected
intermittently to expose EO to the nidus effectively. Balloon should be deflated
after few hours. We completely cured a patient of recurrent huge pelvic AVM using aforementioned transvenous technique. Furthermore, we treated four more
patients of pelvic AVM in these 10 years by transarterial approach: One of them
was completely cured in one session by using NBCA; other three patients have
gone through years of cure and recurrence.
Conclusion: The choice of therapy for pelvic AVM should be based on their types:
Localized pelvic AVM can be treated with surgery or by embolotherapy irrespective
of transareterial or transvenous approach. Large and widely-spreading AVM should
be treated by transarterial embolotherapy in a repetitive manner. Finally, recurrent
pelvic AVM can be treated by transevenous embolotherapy.
C-524
Retrograde transpopliteal approach for subintimal recanalization of SFA in
patients with complex vessels anatomy
R. Gandini, E. Pampana, M. Stefanini, C.A. Reale, L. Di Vito, S. Spano,
G. Simonetti; Rome/IT
Purpose: The aim of the study was to evaluate efficacy of subintimal angioplasty
by retrograde transpopliteal approach in patients, unsuitable for antegrade or
controlateral approach, with CLI and candidates to amputation.
Methods and Materials: From January 2006 to January 2007, 13 patients (10
male, 3 female) 8 with SFA occlusion at the origin and undetectable ostium of
SFA, 5 with femoro-femoral by-pass create a misunderstanding for the origin of
SFA, underwent to intentional subintimal angioplasty through ultrasound-guided
retrograde popliteal approach. All the patients were preliminarily evaluated with US
Doppler and angio-MRI. Ultrasound evaluation of the popliteal fossa was carried
out after the procedure to exclude local complications.
Results: Technical success was obtained in 92.3% with resolution of pain and
limb salvage. In one case, the subintimal dissection was carried out at the origin
of profunda artery causing occlusion and thrombosis of this; so the complication
was solved with surgery intervention. There were no puncture site hematomas or
popliteal arteriovenous fistulae.
Conclusion: Subintimal angioplasty with trans-popliteal approach is a safe and
effective technique, especially in patients with multivessel disease poor candidate
to surgery. It should be considered for SFA occlusions or CFA disease where the
contralateral femoral or antegrade ipsilateral femoral approach is often technically
or anatomically difficult.
C-525
Evaluation of cost and fluoroscopy’s time in subintimal recanalization of
SFA using true lumen re-entry device or “double approach” technique
R. Gandini, E. Pampana, C.A. Reale, L. Di Vito, S. Spano, L. Boi,
G. Anghelopulos, G. Simonetti; Rome/IT
Non-Vascular
C-526
Minimally invasive management of biliary complications after partial liver
transplantation in adult and pediatric patients with two separate biliary
anastomoses
R. Miraglia, L. Maruzzelli, S. Caruso, M. Milazzo, G. Marrone, G. Mamone,
V. Carollo, A. Luca; Palermo/IT
Learning Objectives: To describe the anatomical variants of the donors’ bile ducts
with significant impact on partial liver transplantation. To describe the minimally
invasive management of biliary complications after adult and pediatric partial liver
transplantation in patients with two separate biliary anastomoses.
Background: Liver transplantation is the standard of care for adult and pediatric
patients with end-stage liver diseases and unresectable primary hepatic tumors. Due
to the insufficient number of livers from deceased donors, partial liver transplantation from deceased donors or living related has become an important therapeutic
option. For possible anatomical variants of the donors’ bile ducts, in partial liver
transplantation, two separate biliary anastomoses are performed in up to 45% of
cases. Biliary complications are seen in 20 to 40% of recipients and are responsive
of graft dysfunction and significant morbidity and mortality. Interventional radiology
is often the first choice of treatment.
Procedure Details: Diagnosis and treatment of the most frequent biliary complications as anastomotic bile ducts strictures and anastomotic large bile leak are
discussed. Indications, possible complications and results achievable of interventional radiology procedures and combined radiological-endoscopic procedures
(rendezvous technique) utilized in the minimally invasive management of patients
with two separate biliary anastomoses are described.
Conclusion: Radiologists play a key role in early diagnosis and non-surgical treatment of biliary complications after partial liver transplantation.
C-527
The synergic effect of radiofrequency and embolization in the treatment of
HCC: More responses and fewer recurrences
J. Urbano, J. Cabrera, A. Glez-Guirado, B. Polo Lordiu, S. Albertos, S. Vazquez;
Madrid/ES ([email protected])
Purpose: To show our experience in percutaneous treatment of HCC with a synchoric combination of radio frequency and hepatic embolization.
Methods and Materials: Since 2001, 115 nodular, low or intermedial stage HCC
were treated in 80 child A and B cirrhotic patients. All patients were non surgical
candidates for hepatic resection. 26 women and 54 men had a mean age of 65.6
years (43 - 84). Average tumors size was of 33.2 mm (10 - 150). If tumor was
3 cm we performed TAE. For the recurrences or tumors 3 cm we did TAQE. A
combination of fluoroscopy and ultrasound guidance was used for tumoral puncture.
Treatment response evaluation follows EASL and RECIST criteria.
Results: Mean follow-up is of 29.1 months (1 - 85). Complete response was 100%
in tumors 3 cm, 94% in tumors 3 5 cm and 23% in tumors 5 cm. There
is 0% of local recurrence during the FU in tumors 3 cm. Distant metachronic
nodule recurrence occurred in 47% during FU. One patient died of colon perforation. There were a 6.9% of readmissions because of severe pain or fever. Specific
HCC survival was 91, 70 and 46% at 12, 24 and 36 months, respectively. Logrank
test shows non significative differences in survival between tumors of 3 cm and
tumors of 3 5 cm.
Conclusion: There is a synergy effect between RF and embolization. A very good
local control of HCC is achieved by this combined treatment.
C-528
Balloon kyphoplasty for treatment of vertebral compression fractures:
Outcomes at 2 years
M. Runge, D. Wendling, J.-F. Bonneville; Besançon/FR ([email protected])
Purpose: To evaluate the clinical and radiographic efficacy of balloon kyphoplasty
in the treatment of VCF caused by osteoporosis, myeloma, osteolytic metastasis
and hemangioma. To describe the clinical and radiographic outcomes with 2 years
follow-up.
Methods and Materials: 80 consecutive patients with 86 vertebral fractures
(T4-L5) were treated with balloon kyphoplasty. All patients were included after an
identification of symptomatic levels by clinical and imaging evaluation (X-ray, CT
scan, magnetic resonance imaging) regardless of the underlying pathologic cause.
Clinical and imaging follow-up were performed for each patients at 3, 6, 12 and 24
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Interventional Radiology
Purpose: Assessment of difference of cost and fluoroscopy’s time in the treatment of long obstruction of superficial femoral artery in unsuccessful true lumen
re-entry after subintimal revascularization using two different technique: “double
approach”(femoral and popliteal puncture)and re-entry device outback catheter.
Methods and Materials: From June 2006 to June 2007, 128 patients with CLI
and long obstruction of SFA were treated with intentional subintimal angioplasty.
In 40 patients after 15 minutes it was not possible to re-entry the true lumen with
standard technique and so we randomized the patients in two different groups: 20 of
them were treated with "double approach" technique, others with outback catheter
re-entry device. The “Outback” group had mean time fluoroscopy of 14p8 min, the
"double approach" technique group of 26p12 min.The mean cost of procedure was
4025_ for the "Outback" group and 2025_ for the other group.
Results: Technical success was 100% in the "double approach" group, and in the
other group is 95% due to high calcification. In the "Outback" group it was necessary to place stent in the site of re-entry in the 60%, whereas in “double approach”
group stent was necessary in the 20%. Three complications were detected in the
“double approach” group: one arteriovenous fistulae and two haematoma in site
of puncture.
Conclusion: Both techniques are safe and effective, despite the shortest time of
fluoroscopy in the Outback group, the "double approach" technique group presented
lower cost and much discomfort for the patients.
Interventional Radiology
Scientific and Educational Exhibits
months after the procedure. Evaluation at each follow-up time point included pain
reponse (VAS), change in pain usage, pre and post operative imaging outcome (CT
or MRI). Vertebral body height and kyphotic deformity were measured by comparing
pre and postoperative measurements.
Results: Pain score decreased significantly and immediately in all patients after
the procedure with reduction (21.1%) or stopping (82.9%) of analgesic drugs and
persisted through the follow-up. Imaging studies demonstrated a stabilization of vertebral body height and no complications were related. 3 patients (3.75%) sustained
fracture in the first 2 months after the procedure at the adjacent above level. With
medical treatment, pain disappeared without loss of vertebral body height.
Conclusion: According to our results, kyphoplasty has a high success rate (pain
reduction and vertebral body height restoration) and low complication rate. The
prevalence of a new vertebral fracture in the adjacent level is low. These results
remain stable for 2 years following treatment.
C-529
The post radiofrequency ablation scar or tumor tissue of hepatocellular
carcinoma: Comparison of 3.0 T MR diffusion-weighted imaging and PET-CT
L. Yu Bao; Guangzhou/CN ([email protected])
Purpose: To evaluate the post radiofrequency ablation scar or tumor tissue of
hepatocellular carcinoma (HCC) by 3.0 T MR diffusion-weighted imaging (DWI)
and PET/CT, to analyze whether the value of ADC correlated with the post radiofrequency ablation (RFA) scar or tumor tissue.
Methods and Materials: Thirty-eight patients with HCC were enrolled in our
study. All the patients underwent RFA. 3.0 T MR diffusion weighted imaging was
performed with b value of 600 s/mm2. An echo-planar sequence was performed.
S
The ADC values of the lesion after RFA were measuredOin diffusion weighted images. All the patients underwent fluorodeoxyglucose
EP(FDG) PET/CT (FDG-PET/
to analyzed whether the value
CT) examinations after the MR examinations. It was
d of HCC after RFA. The scar or
of ADC correlated with the scar or tumor tissue
e
t
it
tumor tissue of HCC after RFA was confirmed
m by PET/CT and clinical follow-up.
b
The values of ADC of the scar or tumor
tissue
and normal liver tissue were comSu
pared. The data were analyzed by SPSS13.0
statistical software, and p 0.05 was
l
ia
considered to be significant.
er
Results: Thirty-six patients with
at post RFA scar or tumor tissue of HCC were conM with the results of PET/CT, the mean ADC of tumor
firmed by PET/CT. Compared
No2/sec, The mean ADC of scar tissue was 5.96×10-3 mm2/
tissue was 1.81×10-3 mm
sec. The mean ADC between scar and tumor tissue were statistically significant
(p=0.015).
Conclusion: Compared with PET/CT, the ADC value of DWI is a promising functional MRI tool for prediction of therapeutic response to radiofrequency ablation,
DWI is useful in the differential diagnosis of scar tissue and tumor tissue in patients
with HCC after RFA.
C-530
Paravertebral nerve block for transhepatic percutaneous interventional
procedures
J.J. Echevarria, J.L. Miguélez, P. Makua, J. Aguirre, I. Aloa, A. Cancho; Galdakao/ES
([email protected])
Purpose: Intravenous sedation often leads to the appearance of deep breaths that
hinder the realization of percutaneous interventional procedures of hepatobiliary
territory. We present our experience in implementing paravertebral nerve block
(PNB) as a technique of selective analgesia in carrying out upper abdominal percutaneous procedures that allow the collaboration of the patient during the practice
of the therapeutic interventional procedure.
Methods and Materials: We have practiced using PNB 12 percutaneous interventional procedures: five ablations of malignant liver masses (three thermal ablations
and two ethanolizations), six transhepatic biliary drainages motivated by common
bile duct stenosis (five malignant and one postsurgical) and one extraction of choledocholithiasis. PNB was carried out by local infiltration of 0.75% ropivacaine at
the level of T6-T9. Both in the percutaneous approach as during the implementation
of the procedures, response to pain was evaluated using visual analog pain score.
The hemodynamic response was controlled too.
Results: The quality of analgesia was satisfactory in all patients, not requiring
general anesthesia in any case. All patients were able to collaborate properly on
controlling ventilatory movements, when it was indicated by the radiologist. Adverse
effect was found with the onset of episodes of hypotension in two patients, and
symptoms of epidural extension of the anesthetic drug, manifested by paresis of
both lower limbs, in one patient.
Conclusion: PNB provides adequate analgesia allowing the comfortable practice
of percutaneous interventional procedures of the hepatobiliary territory, and enables
the active collaboration of the patient to facilitate the work of the radiologist.
S448
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C-531
Depiction of the feeding artery of hepatocellular carcinoma in the caudate
lobe using flat panel detector C-arm cone-beam CT images
M. Honda1, T. Gokan1, T. Kitanosono2; 1Tokyo/JP, 2Rochester, NY/US
Purpose: The feeding artery of hepatocellular carcinoma (HCC) in the caudate
lobe (S1) is often difficult to recognize on digital subtraction angiography (DSA). We
conducted this study to evaluate the ability of flat panel detector C-arm cone-beam
CT (CBCT) in detection of feeding arteries of HCCs arising in S1.
Methods and Materials: In fourteen patients with HCC in S1, the combination of
CBCT during arterial portography (CBCTAP) and CBCT during hepatic arteriography
(CBCTHA) was performed using a single plane C-arm angiography system with
a flat panel detector. We evaluated visualization of feeding arteries of the HCCs
on CBCT and compared with the DSA images. The location and size of the HCC,
intrahepatic metastasis, portal vein invasion, and the success rate of superselective
catheterization into the feeders were also evaluated.
Results: Identification of origin of the feeding artery was possible in four patients
with DSA (28.6%) and 14 patients (100%) in CBCT. The feeding arteries originating from the right, left or middle hepatic artery were detected in 11, 1, 1 patients,
respectively. In one patient, right inferior phrenic artery fed the HCC. The mean
long axis length of an HCC nodule was 27.5 mm (range, 10-80 mm). Intrahepatic
metastasis was seen in 13 patients (92.9%). Three patients (18.8%) had portal
vein invasion. The success rate of superselective microcatheter feeder selection
was 92.9% (13/14).
Conclusion: CBCT images are able to depict the feeding artery of HCC in S1. CBCT
images are helpful in selecting the feeding artery of HCC for chemoembolization.
C-532
Stents implantation as complementary treatment in thrombosed
haemodialysis vascular accesses
J. García-Medina, N. Lacasa, S. Muray, I. Pérez-Garrido, V. Garcia; Murcia/ES
([email protected])
Purpose: To communicate our experience with the implantation of stents in haemodialysis vascular accesses in cases in which they were thrombosed.
Methods and Materials: We treated 40 dialysis accesses in which we inserted 45
covered stents (3 Passager, 14 Wallgraft, 5 Viabahn and 19 Fluency) and 4 noncovered stents (Wallstent) in 38 patients. The accesses were 10 radial fistulas, 18
brachial fistulas, and 12 grafts.
Results: All cases except one (thrombosis during another stent implantation) came
in with total or partial thrombosis. So, we use manual catheter-directed thromboaspiration in all cases. Stent indications were: non-controlled venous rupture post
angioplasty (n=3; 7.5 %), pseudoaneurysms with attached thrombotic material in
the lumen (n=30; 75%), and grafts boucles and irregularities (n=7; 17.5%). The
clinical success rate was 95%. Median follow-up was 11.43 p 9.3 months (r=0-35
months). Primary patency rate was 65 p 7% at 6 months, 37 p 7% at 12 months
and 7 p 4% at 24 months. Secondary patency rate was 70 p 7% at 6 months,
45 p 8% at 12 months and 10 p 4% at 24 months. Better patencies found in radiocephalic fistulas (40 p 15% and 50 p 15% at one year in primary and secondary
patencies, respectively).
Conclusion: Metallic stents are useful to treat lesions in thrombosed haemodialysis
accesses in selected cases.
C-533
Radiofrequency ablation of hepatic tumors: Effect of post-ablation margin
on local tumor progression
C.-H. Liu1, R.S. Arellano2, R.N. Uppot2, A.E. Samir2, D.A. Gervais2, P.R. Mueller2;
1
Taipei/TW, 2Boston, MA/US ([email protected])
Purpose: To retrospectively evaluate the relationship between post-ablation margins
and local tumor progression following radiofrequency ablation (RFA) of hepatocellular carcinomas and colorectal liver metastases.
Methods and Materials: Institutional review board approval with waived informed
consent was obtained for this HIPAA-compliant study. Eighty-three patients (66
men and 17 women) with 107 hepatic tumors who underwent RFA during a 7-year
period were divided into two groups: hepatocellular carcinoma group (HCC) (55
patients with 69 lesions) and the colorectal liver metastases group (28 patients
with 38 lesions). Post-ablation margins were calculated on one-month follow-up
contrast-enhanced computed tomography (CT) or magnetic resonance imaging
(MRI) studies. Efficacy was evaluated at one-month post ablation, then at 3-month
intervals for the first year and biannually thereafter. The Kaplan-Meier method and
a Cox model were used for the analyses.
Scientific and Educational Exhibits
Results: The results of the log-rank test showed that the minimum threshold postablation margin of 0.4 cm (P =.020) and the tumor size smaller than 2.5 cm (P
=.001) significantly correlated with local control for the HCC group. Cox regression
analysis showed that the minimum threshold post-ablation margin of 0.4 cm and
tumor size smaller than 2.5 cm were independent factors (P =.036 and.017). In
the colorectal liver metastases group, the result of the log-rank test showed that
the minimum threshold post-ablation margin of 0.4 cm (P =.345) did not correlate
with local control.
Conclusion: Percutaneous RFA is more effective in achieving local control in
patients with HCC than with colorectal liver metastases.
enhanced CT was performed after the electrode removal to evaluate the immediate
lesion’s response to the ablation and to detect any local complication. Follow-up was
performed at 1, 3, and 6 month’s post-RFA and every 6 months afterwards.
Results: 14/21 (66.6%) patients showed complete response. 7/21 (33.4%) patients
showed partial necrosis and in those a second RFA following the same protocol
was performed. 4/21 patients showed a local recurrence and they also underwent
a second RFA. Major complications did not occur. 5/21 patients suffered from post
ablation syndrome.
Conclusion: RFA of adrenal metastasis seems to be a promising alternative treatment in cases of adrenal metastases.
C-534
C-537
Selective and super selective chemoembolization (TACE) for advanced
stage hepatocellular carcinoma (HCC): 5 years follow-up
G. Moggio, C. Castagnolo, A. Sorbo, F. Maisto, G. Belfiore; Caserta/IT
([email protected])
Purpose: To report the experience of 5-years follow-up in selective and superselective chemioembolization (TACE and precision TACE) of HCC.
Methods and Materials: From 2001 to 2006, 30 patients with 50 HCC nodules
3 cm and non resectable (range 3-7 cm) underwent TACE and pTACE. Patients
were all affected by cirrhosis (18 HCV, 12 HBV-related) with class A child-pugh in
23 cases and B in 7. All treatments were executed with selective or superselective
catheterism of segmental branch of liver artery using a coaxial technique and 2.7 F
microcatheter. Imaging checks with triphasic CT were made at 1, 3, 6 months, every
6 months for the first 2 years and every year for the next 5 years. The response
was considered complete when no area of nodular enhancement was evident, and
incomplete when a nodular portion was still appreciable.
Results: Initial success was 100% of cases and there were no major peroprocedural complications observed. Of 9 cases treated with non superselective TACE
(conventional TACE), only 4 cases reported post embolization syndrome, while
the remaining 21 treated with pTACE experienced this syndrome. CT control after
1 month showed complete necrosis in 16 (54%) and partial necrosis of 14 (46%).
The remaining cases were reprocessed with a new pTACE obtaining complete
necrosis in 1/3 and persistence of nodular residual in 2/3; all the complete necrosis
persisted even in a 5-year follow-up.
Conclusion: Treatment with TACE of HCC, according to our experience, if properly
executed is still today a safe and effective method for tumor necrosis.
C-535
CT guided placement of fiducials in malignant lesions: Presentation of the
technique
E. Sotiropoulou, O. Konstantinopoulos, A. Manataki, K. Verigos, N. Salvaras,
L. Thanos; Athens/GR ([email protected])
C-536
Treatment of adrenal metastases originating from primary lung cancer with
radiofrequency ablation
E. Seferos, E. Sotiropoulou, A. Manataki, O. Konstantinopoulos, I. Tsangaridou,
L. Thanos; Athens/GR ([email protected])
Purpose: The purpose of this presentation is to evaluate the feasibility, efficacy
and safety of CT guided RFA of adrenal metastatic lesions in patients with primary
lung cancer.
Methods and Materials: Over a 2 year period, a total of 32 RFA sessions was
performed at our institution in 21 patients with adrenal metastatic neoplasms using
expandale needle electrodes. After CT-guided insertion of the electrode, a pulsed RF
energy was applied for 12 to 15 min in every case. A dual-phase dynamic contrast
Purpose: To evaluate the technical usefulness of ultrasound (US) guided percutaneous drainage treatment for haematomas in the musculoskeletal system. To define
which factors predict the evolution of haematomas.
Methods and Materials: We reviewed all the US-guided interventional procedures
carried on musculoskeletal system from April 2004 to September 2007 in Basurto
Hospital. We selected those who received a fibrilolityc treatment (urokinase). In
the study were included 91 procedures carried on 79 patients (aged 12-98, mean
64). We have recorded the localization and cause of the haematomas, duration
of drains, the necessity of hospitalization of the patients and how long it was, and
if the patients had been treated with anticoagulant drugs or not. We have registered the failure and complication rates and which factors can influence them.
We evaluate which factors can modify the admission time and the duration of the
catheter drainage.
Results: The drainage was effective in 89% of the haematomas, and complications
presented in 9.9%. Patients treated as outpatients were 39.6%, whilst 40.7% required hospitalization because of the haematoma. Another 19.8% were hospitalized
for other pathologies not related with the haematoma. Failure and complication rates
were higher in younger patients and in patients without anticoagulant treatment.
Time of drain was significantly higher for haematomas located in articulations
compared to those located in soft tissues.
Conclusion: US-guided percutaneous drainage with intracavitary fibrinolytic
treatment is simple, fast, safe and an efficacious alternative for the treatment of
the musculoskeletal system haematomas. Failure and complication rates are not
linked to age.
C-538
Ventilation causes heat-sink effect in laser ablation of lung tumors
A. Vietze1, F. Koch1, U. Laskowski2, S. Fillmer1, A. Linder2, N. Hosten1;
1
Greifswald/DE, 2Hemer/DE ([email protected])
Purpose: To evaluate in an ex-vivo lung model whether ventilation has a similar
heat sink effect as perfusion on the temperature development during laser ablation of tumors.
Methods and Materials: Sixty-one resected specimens were ventilated and perfused in an isolated human lung perfusion model (IHLP) immediately after surgery.
This model offers the opportunity of keeping the lobes under almost physiological
conditions for 6 hours. Laser ablation in the model was performed using a Nd:YAG
laser. The effects of perfusion and ventilation on temperature development were
evaluated by selectively turning these off for 6 minutes each in 5 specimens (n=5).
The standard procedure started with a steady state at 60 °C 10 mm away from the
laser fiber before ventilation was turned off. Invasive temperature measurement
allowed recording slope, peak and the following decrease at a distance of 10 mm
from the laser fiber.
Results: As expected, discontinuation of perfusion caused a significant increase
in temperature (2.86 °C over 6 minutes, p 0.05). This phenomenon is known as
the heat sink effect. The effect was even greater after discontinuation of ventilation
(increase of 9.01 °C over 6 minutes, p 0.05).
Conclusion: Ventilation has an even greater impact on temperature development
during thermal ablation than perfusion. This may influence the extent of necrosis
and has to be considered while planning ablation of lung tumors.
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S449
Interventional Radiology
Learning Objectives: To describe the technique of positioning gold fiducials as
tumor landmarks under CT guidance to facilitate treatment with Cyberknife system
of malignant lesions.
Background: Cyberknife is a new robotic radiosurgery system, allowing maximum
concentration of the beam on the target lesion with minimum damage on the surrounding tissues. To achieve this, fiducials are used as tumor landmarks and they
are advanced inside/around the lesion percutaneously.
Procedure Details: To discuss the indications for fiducial positioning, namely the
lesions at which site are indicated for Cyberknife treatment. To describe the implantation technique: kind of needle used, how to deliver fiducials and where should they
be placed relative to the tumor in order to achieve optimal result with Cyberknife
stereotactic radiosurgery. To present the complications that may be encountered
as well as their management, depending on the tumor site.
Conclusion: Fiducial positioning inside malignant tumors under CT guidance
seems to be a safe and efficient procedure.
Utility of ultrasound-guided interventional procedures as a treatment for
haematomas in the musculoskeletal system and predictor factors during
their evolution
I. Corta, S. Cisneros Carpio, I. Lauzirika, L. Alvarez de Eulate Santacara,
J. Del Cura Rodriguez, D. Grande Icaran; Bilbao/ES ([email protected])
Scientific and Educational Exhibits
C-539
Interventional procedures in obstetrics and gynecology: An overview
S.T. Laroia, H. Abada, M. Sharafuddin, A.T. Laroia, S. Sun; Iowa City, IA/US
Learning Objectives: The purpose is to review the various interventional radiology
procedures in current obstetrics and gynecological practice.
Background: The interventional radiologist can now offer many services to
the obstetrician-gynecologist. This exhibit will highlight various applications and
techniques.
Imaging Findings: The exhibit will be organized under following headings: Embolization for post partum and post surgical bleeding, uterine artery embolization,
percutaneous drainage of uterine abscesses, cervical stenting, fallopian tube
recanalization, radiofrequency ablation of pelvic and vaginal tumors, drainage of
pelvic fluid collections, transvaginal biopsy. All the topics will be well illustrated with
images and relevant line diagrams.
Conclusion: The attendee will be able to review the state of art radiological intervention techniques in current obstetric-gynecological practice.
C-540
Percutaneous ethanol lipiodol injection therapy of recurred hepatocellular
carcinoma after trans-arterial chemoembolization in high-risk locations
H.-K. Ko, L. Jong Tae, J. Won, S. Choi; Seoul/KR ([email protected])
Purpose: To evaluate the safety and effectiveness of percutaneous ethanol lipiodol
injection therapy (PELIT) of hepatocellular carcinoma (HCC) after trans-arterial
chemoembolization (TACE) in high-risk locations.
Methods and Materials: Between April 2006 and March 2008, 22 patients with 22
recurred HCC nodules after repeated TACE underwent PELIT. Repeated TACE was
impossible to treat recurred nodules due to hypovascularity (n=12) and rudimentary
feeding artery after repeated embolization (n=10). All lesions were impossible to
be treated with radiofrequency ablation (RFA) due to high-risk location. PELIT was
performed under real time fluoroscopy guidance and cone-beam CT (Dyna-CT;
Siemens Medical Solution, Forchheim, Germany). Complications, effectiveness of
PELIT, and prognosis of the patients were evaluated.
Results: 31 PELIT sessions were performed for 22 nodules. Apparent tumor
necrosis after first PELIT was noted at follow-up CT in 15 nodules (68.2%). During follow-up (mean, 14 months p 6 [SD]), local recurrence was seen in 7 nodules
(31.8%). Four of seven recurred lesions were performed repeated PELIT (mean
session; 2.4) and two of them showed complete necrosis during follow-up. Five
patients with progressive disease after first and repeated PELIT received conservative treatment. All of the patients survived during follow-up period. There was
no major complication.
Conclusion: PELIT under fluoroscopy and cone-beam CT guidance is safe and
effective for the treatment of recurred HCC after TACE especially in high-risk
locations.
C-541
Fluoroscopic placement of self-expanding metallic stent for the treatment
of obstructing left-sided colorectal cancer
H.-P. Hong1, P. Kang1, S. Kim2; 1Seoul/KR, 2Saint Louis, MO/US
([email protected])
Purpose: To evaluate the feasibility and effectiveness of fluoroscopic placement
of self-expanding metallic stent for the preoperative colonic decompression or
palliative treatment of obstructing left-sided colorectal cancer.
Methods and Materials: From January 2004 to December 2007, 92 fluoroscopic
placement of self-expanding metallic stents were attempted in 87 patients (M:F=
40:47, mean age: 65 years) with malignant colonic obstruction. Sites, purpose of
the stent insertion, type, technical clinical success rates and complication rates of
the stent were evaluated.
Results: Site of the stent placement were rectum (n=33), rectosigmoid junction
(n=16), sigmoid colon (n=34) and descending colon (n=4). 60 cases (65.2%) of
stent insertion were done for preoperative colonic decompression and 32 cases
(43.8%) were done for palliative purpose. 87 uncovered and 5 covered metallic
self-expanding stents were used. Technical success rate of stent placement was
95.6% (88/92). In 81 out of 92 cases, symptoms of the colonic obstruction were
relieved, giving clinical success rate of 88.04%. Among 60 cases of preoperative
decompression, 55 cases underwent elective operation with primary anastomosis
(91.7%). In the palliative group, the patency rates were 87.9% at 3 months, 75.2%
at 6 months and 75.2% at 12 months. Complications associated with stent insertion
were minor bleeding (67.4%), severe pain (18.5%), migration (4.34%), and tumor
ingrowth (3.26%). No procedure related mortality was noted.
S450
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Conclusion: Fluoroscopic placement of self-expanding metallic stent for the treatment of obstructing left-sided colorectal cancer is feasible and effective. Also, this
procedure gives good clinical results for both preoperative colonic decompression
and palliative purposes.
C-542
Ultrasound guided fine-needle aspiration biopsies: Comparison of sample
adequacy with different needle sizes and with/without onsite cytologic
analysis
R. Erman Yalcin, C. Yucel, P. Uyar Göcün, A. Poyraz, F. Taneri, H. Özdemir;
Ankara/TR ([email protected])
Purpose: The aim of this study was to compare the adequacy of samples obtained
with different sized needles and with/without onsite cytologic analysis.
Methods and Materials: Two hundred patients (169 women and 31 men; age
range, 17-80 years; mean, 49 years) with solitary (n=65) or multiple (n=135) thyroid
nodules underwent ultrasound (US) guided fine-needle aspiration biopsies (FNAB).
Nodule diameters were between 6-45 mm (mean: 15.2 mm). Patients were randomly divided into four groups according to needle size (NS) and whether onsite
cytologic analysis (OCA) was performed or not. Group I: NS=21 gauge, OCA (-),
Group II: NS=27 gauge, OCA (-), Group III: NS=21 gauge, OCA (+) and Group IV:
NS=27 gauge, OCA (+). Each group consisted of 50 patients. Sample adequacy
rates and number of needle passes were calculated for each group and compared
with chi-square test.
Results: The number of needle passes were 1-4 (mean: 2.20) in Group I, 1-4 (mean:
2.48) in Group II, 1-4 (mean 2.38) in Group III and 1-4 (mean 2.44) in Group IV.
In Group I, significantly less passes were performed. Sample adequacy rates for
different groups were 96, 90, 100 and 98%, respectively. There was no significant
statistical difference between groups. In Groups I and III, hematoms were developed
in three cases after the procedures.
Conclusion: Best results were obtained with thicker needles and onsite cytologic
evaluation. However, the use of 21 gauge needles carries higher risk for complications. Our experience shows that, for high adequacy rates and patient comfort
at the same time, thinner needles and onsite cytologic analysis should be the
preferred approach.
C-543
Is doxorubicin the most effective drug for chemoembolization?
B. Guiu, B. Chauffert, S. Guiu, R. Loffroy, J.-P. Cercueil, D. Krausé,
M.-H. Guignard, L. Bedenne, M. Boulin; Dijon/FR ([email protected])
Purpose: Lipiodol emulsions of anticancer drugs with faster and higher activity could
be more efficient than the classical doxorubicin-Lipiodol for chemoembolization. The
aim of our study was to evaluate the in vitro cytotoxicity of different anticancer drugs
in the presence or not of amiodarone on three digestive human cell lines.
Methods and Materials: The three cell lines we used were HepG2 (hepatoma
cells), HCT8 and HT29 (colic cells). Tested drugs were cisplatin, daunorubicin,
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doxorubicin, epirubicin, idarubicin, mitomycin C and mitoxantrone.
Confluent cells
O
P
were washed, resuspended in 100µl of HAM culture
E medium and exposed to the
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1 hour in a CO2-incubator
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days at 37 °C in 200 µl MNC
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i a classical colorimetric assay. Cell
culture medium. Cytotoxicity was measured
m byuntreated
bcontrol
survival was expressed as a percent of
cells. Each point was the
u
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i effective drug in inducing cytotoxicity in the
Results: Idarubicin was the most
er
three cell lines. The efficacy
at of idarubicin was already observed at the lowest
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concentration (31 µg/ml) whereas
the activity of doxorubicin, for example, seemed
to be dependent on its
Noconcentration. On the HepG2 hepatocarcinoma cell line,
the three less effective drugs were doxorubicin, cisplatin and mitomycin C. The
concentration of three drugs causing a 50% decrease in viability of these cells
was around 500 µg/ml.
Conclusion: Our results show that idarubicin could be a better choice than doxorubicin for chemoembolization.
C-544
CT evaluation after radiofrequency ablation of hepatic tumors
M. Fatehi, S. Akhlaghpoor, A. Arjmand Shabestari, F. Fattahi,
M. Shojae Moghadam; Tehran/IR ([email protected])
Learning Objectives: To illustrate CT findings after radiofrequency ablation of
hepatic mass lesions, to review signs of treatment success or failure and to overview
follow-up protocols for liver RF ablation based on the experience of 108 cases.
Scientific and Educational Exhibits
Background: Three phase contrast enhanced CT scan is the most widely used
method for follow-up of RF ablated hepatic tumors that are usually performed within
1 month after intervention and repeated after 3 months. Those radiologists who
are not familiar with typical changes after RF of liver may misinterpret the CT scan
resulting in disappointment of clinician and patient. The radiologist should be aware
of change in size, enhancement pattern and evolution of ablated areas and also
residual/recurrent tumor or added metastatic deposits. The paper reflects findings
of 211 RF ablated hepatic tumors in 108 cases.
Imaging Findings: The first CT scan performed after RF ablation may show
ring like enhancement around ablated area, which actually reflects hyperemia
and should not be mistaken for residual or recurrent tumor. The scan may show
changes attributable to complications of intervention. Another important issue in
post-RF scans is apparent increase in size of the lesion since a larger area is ablated to secure safe margins. The size of ablated area will show gradual decrease
over time. Any enhancing structure in previously sharp ablation area should be
considered as recurrence.
Conclusion: Clear understanding of typical and atypical findings after RF ablation of liver tumors will help radiologists and referring clinicians correctly assess
response to treatment.
C-545
Ultrasound guided fine-needle aspiration biopsy of the thyroid: Experience
from an oncologic hospital
I. Georgiou, H. Tsokou, N. Paximadakis, S. Karvelas; Athens/GR ([email protected])
Purpose: We reviewed the “St. Savvas” Anticancer Hospital of Athens’ experience
with ultrasound fine-needle aspiration biopsy (FNAb) of the thyroid and correlate
the results with sonographic and color Doppler characteristics of thyroid nodules
to predicting risk of malignancy.
Methods and Materials: 932 ultrasound guided FNAbs of thyroid nodules performed at our institution during the last three years were reviewed. We retrospectively analyzed the following sonographic parameters: size, number, echogenicity,
echo structure, shape, margin regularity, presence of calcifications, presence of
a hypoechoic rim and internal vascularity. Individual features and combination of
features were analyzed for their correlation with benign and malignant diseases.
Results: FNA diagnosis included 93% benign and 7% malignant nodules. The
probability of malignancy was higher in solitary nodules. The size did not show
any significant difference between benign and malignant nodules in this study. The
sonographic features significantly associated with malignancy were: hypoechogenicity, irregular margins, absence of hypoechoic rim and intranodular vascular
nodes. Presence of “snowstorm” pattern of calcification was 100% specific for
malignancy.
Conclusion: Fine-needle aspiration biopsy of the thyroid has proved to be an
excellent diagnostic tool in the initial management of thyroid nodules, with high
sensitivity and specificity in diagnosing malignant tumors and well accepted by
patients because of minimal discomfort and complication. However, its effectiveness is highly dependent on the expertise of the operator performing the procedure
and the adequacy of the cytological specimen. Ultrasound guided FNAb should be
performed on thyroid nodules with diameter greater than 8 mm and sonographic
characteristics suspicious for malignancy.
C-546
Purpose: MR-guided interventions on mammographically/sonographically occult
lesions are still time consuming, and depend critically on the experience of the
radiologist. The study is aimed to analzye imaging characteristics of those lesions
visible in MRI only and the feasibility of MR-guided interventions.
Methods and Materials: 130 MR-guided interventions on enhancing lesions
were performed at our hospital between 12/06 and 9/08. All cases were analyzed
retrospectively regarding dynamic/morphological data, histopathology, and size. All
images were done using the same standardized protocol (1.5 T Achiva, Philips;
0.1 mmol Gd-DTPA/kgbw; same slice thickness, dynamic analyses by CAD (Confirma), intervention planning by SureLoc (Confirma), intervention positioning by
Noras positioning aid, Suros-biopsy kid).
Results: 35/130 interventions were histologically malignant/premalignant. Mean
size was 4 mm. Contrast uptake of benign vs. malignant lesions 4 mm did not differ.
Morphology did differ in lesions sized 4 mm (irregular edge, subtle spiculations,
hypointense T2 in malignancies). Most common benign lesions were papillomata
(21%), fibroadenoma (24%), sclerosing adenosis (19%). Most common malignant
entity was DIN3. Planning of the intervention was highly accurate. 14 further planned
C-547
Clinical and radiological characteristics of hepatocellular carcinoma that
enable performing radiofrequency ablation as a single-treatment: A 2-year
follow-up result
W. Jeong, P. Kim, K. Kim, Y. Shin, H. Won; Seoul/KR ([email protected])
Purpose: To predict whether radiofrequency ablation as a single-treatment of
hepatocellular carcinomas will be possible by pre-procedural examinations.
Methods and Materials: A total of 343 consecutive patients diagnosed with
hepatocellular carcinomas (HCC) following percutaneous radiofrequency ablation
and followed up for more than 6 months were enrolled. Considered pre-procedural
factors were as follows: 1) larger than 3 cm of a HCC size, 2) more than three of
number of HCC, 3) encapsulation, 4) extranodular extension, 5) duct invasion, 6)
adjacent vessel larger than 4 mm, 7) subcapsular location, 8) previous history of
transarterial chemoembolization (TACE), 9) marginal recurrence of treated HCC if
undergoing TACE previously, 10) viral induced HCC, and 11) more than 300 ng/ml
of serum alpha-fetoprotein level. For the comparison of each cumulative ablationmaintenance rate and multivariate analysis, Log-rank test and stepwise Cox hazards
model were performed.
Results: In 134 patients, treatment methods changed to TACE (n=130) or surgery
(n=4), and radiofrequency ablation was maintained as a single-treatment in 209
patients. Mean follow-up period was 17.7 months (range, 6-36 months) and mean
interval in which the treatment method changed was 8.6 months (range, 0-31
months). Log-rank test revealed that significantly contributing factors were tumor
size, non-encapsulation, extranodular extension, duct invasion, adjacent vessel,
subcapsular location, history of TACE and level of alpha-fetoprotein (p .05). Cox
hazard model showed that history of TACE was the most significant factors (odds
ratio =3.02; p .05).
Conclusion: Several meaningful radiologic and laboratory findings of pre-procedural examination help to decide radiofrequency ablation as a single-treatment
of the HCC.
C-548
Challenging bone tumors management
A. Gangi, G. Bierry, X. Buy; Strasbourg/FR ([email protected])
Learning Objectives: To know the different techniques to manage bone tumors
percutaneously in challenging cases (location, proximity to nerve roots, cord, loop).
To understand when and how to use each ablation technique (alcool, laser, RF,
or cryoablation). To know all protective techniques (insulation, thermal monitoring,
fluid injection) to reduce complications of percutaneous procedures.
Background: Percutaneous bone tumor management is now recognized and some
tumors as osteoid osteoma are treated in the majority of cases percutaneously.
Other primary or metastatic tumors can be also treated percutaneously. The purpose of this exhibit is to report the challenging situations with difficult location, large
extension of the tumor, proximity to root, cord, loop and to describe how to avoid
complications using combination of different techniques. Emphasis is put on the
insulation techniques, thermal monitoring and protection of surrounding organs.
Procedure Details: Description of different technique in challenging tumors and
when and how to use them: Tumor ablation, tumor consolidation, tumor cavitation,
combination of different techniques, and thermal insulation.
Conclusion: Interventional radiology allows percutaneous management of the
majority of metastatic bone tumors, and of some primary ones, even in difficult
location.
C-549
Percutaneous removal of biliary foreign bodies: A pictorial review
H. Baek1, Y. Lee1, A. Park1, J. Juhn1, J.-I. Bae2; 1Busan/KR, 2Suwon/KR
Learning Objectives: To illustrate techniques for percutaneous removal of biliary
foreign bodies.
Background: Presence of a foreign body in biliary tree is known to act as a nidus
for sludge and microlithiasis formation. With increasing number of hepatobiliary
surgery and non-surgical endoscopic or percutaneous interventions, many unexpected foreign bodies in the biliary tract are encountered. In this exhibit, we will
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Interventional Radiology
MR-guided interventions on only MR-detectable lesions in breast MRI:
A pathologic-radiologic comparison
A. Malich, A. Kott, J. Feger, R. Gorna; Nordhausen/DE ([email protected])
interventions were not realizable due to non enhancing (during interventional procedure) of those enhancing pattern in dynamic diagnostic breast-MRI, due to inoptimal
localization of lesions. No technical problems occurred during intervention.
Conclusion: The ratio of up to 30% (pre)malignant findings of MR-guided intervention of enhancing small lesions support clinical relevance of this procedure even on
subtle lesions. Due to time consuming procedure, MR-guided interventions should
be done only on those lesions being not otherwise visualizable.
Scientific and Educational Exhibits
describe the spectrum of biliary foreign bodies and techniques for their retrieval.
Foreign bodies were fractured external internal drainage catheter, malfunctioning
plastic stent, detached olive tip of stent delivery sheath, migrated bare metallic
stent, migrated covered metallic stent, and broken stone basket, broken tooth of
biopsy forcep, etc.
Procedure Details: Percutaneous transhepatic biliary drainage was performed
through a bile duct suitable for the easiest access to the foreign bodies. Initially,
an adequate size sheath was introduced. Coaxially various kinds of devices were
used to capture and retrieve the foreign body to avoid bile duct injury.
Conclusion: Percutaneous approach is a safe and effective method for removal
of biliary foreign bodies alternative to endoscopic management.
C-550
Blunt tip coaxial introducer: Spectrum of indications in various
interventional procedures in the chest and abdomen
C. de Bazelaire, C. Farges, J. Frija, E. de Kerviler; Paris/FR
([email protected])
Learning Objectives: To outline the advantages of the blunt tip coaxial introducer.
To exhibit the wide spectrum of indications of the blunt tip coaxial introducer in
different interventional radiology procedures.
Background: Coaxial introducers are widely used in interventional radiology for
biopsy or drainage accesses. However, they are often provided with a sharp stylet,
requiring careful manipulation. The use of a blunt tip stylet allows easy access to
difficult targets, and safe manipulation in the chest or in the abdomen.
Procedure Details: We routinely use blunt tip coaxial introducers for CT-guided
procedures. The kit is composed of a 17G external canula fitted with a sharp stylet,
replaceable by a second one having a blunt tip. The coaxial introducer may give
access to 18G biopsy guns, or 0.35 guide wires for the purpose of percutaneous
drainages or nephrostomies. We have started using the technique when no clear
path to work through was seen on the images, taking advantage of the capability
of the blunt tip to bounce off the great vessels, ureters, bowel loops, the capsule of
the liver and kidneys. In difficult nephrostomies, the sharp tip enters the cavities and
the blunt tip helps navigating within renal cavities, i.e., among calculus, reaching
the ureter when necessary.
Conclusion: The alternating use of the 2 stylets facilitates difficult biopsies, drainages or nephrostomies. This technique has become the method of choice for most
of our procedures in the chest and abdomen. Examples of various procedures will
be shown in the exhibit.
C-551
Evaluation of therapeutic response and major complications after imageguided radiofrequency ablation of liver tumors: A pictorial review
P.A.A.F. Santos, M. Gomes, M. França, R. Themudo, R. Maia, F. Reis; Porto/PT
([email protected])
Learning Objectives: Description of both typical and atypical imaging findings
after liver tumor radiofrequency (RF) ablation, concerning with therapeutic response
and complications.
Background: Image-guided RF ablation has been used increasingly during the past
decade to treat hepatic tumors. After the procedure, a close radiologic follow-up
is mandatory, in order to exclude both immediate and delayed complications and
tumor response to the treatment. Contrast-enhanced ultrasonography, computed
tomography (CT) and magnetic resonance imaging all can be useful for this assessment. At most institutions, a dynamic CT-scan is preformed within the first 24
hours to evaluate immediate complications and after 1 month to assess technical
success. If this is achieved, CT may be repeated every 3 months for evaluation
of tumor recurrence.
Imaging Findings: The overall complication rate for RF is low and ranges from
minor complications (pleural effusion, self-limited hemobilia, thermal skin injury
and minimal perihepatic fluid), to major complications (intraperitoneal hemorrhage,
hepatic infarction, hepatic abscess formation, intestinal perforation, bile peritonitis
and delayed tumor seeding). Post-treatment CT should show a completely nonenhancing hypodense area with diameter larger or equal to the pretreatment
diameter and with no enhancing focus, although early in the course, a peripherally
enhancing rim may be seen due to inflammatory response of the normal tissue.
Conclusion: RF of liver tumours has many advantages over surgery, including
low complication rate, reduced cost and increased patient compliance. However,
radiologists should be aware of both the typical and the atypical CT findings in the
RF ablation zone and their clinical significance.
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C-552
Absolute and relative contraindications of radiofrequency ablation of focal
liver tumors
F. Vandenbroucke, J. de Mey; Brussels/BE ([email protected])
Learning Objectives: To outline the relative and absolute contraindications of
image-guided percutaneous radiofrequency ablation (RFA) in the liver. To describe
the major and fatal complications after a series of 146 RFA procedures and to look
for possible risk factors.
Background: RFA is increasingly used for the treatment of focal tumors in the
liver. The indications of these procedures on the basis of tumor size, number and
location are well established. In this exhibit, we will describe the contraindications
that can lead to major complications or even death. Between March 1999 and
September 2008, a total of 156 RFA procedures of the liver were performed in our
department. We counted 2 patients who died within one month after RFA. Another
two patients had a major complication, one liver abscess and one peritoneal bleeding. We analyzed the patients’ records and looked for risk factors that could have
attributed to those events.
Procedure Details: The RFA procedures were performed under general anesthesia, or conscious sedation combined with local anesthesia. A cool-tip electrode
was introduced under CT-guidance for lesion ablation. We ablated up to 5 lesions
in a single patient during one procedure. Clinical and radiological feedback was
used to determine unsuitable candidates after registration of direct and long term
complications.
Conclusion: A profound preliminary examination of the history and previous images of candidates for RFA leads to better patient selection, and will minimize the
risk in future procedures.
C-553
Percutaneous cryoablation of renal tumors: Initial experience in 20 patients
X. Buy, G. Bierry, D. Szwarc, H. Lang, C. Roy, A. Gangi; Strasbourg/FR
([email protected])
Purpose: To evaluate the feasibility, safety and efficacy of percutaneous cryoablation for the management of renal tumors.
Methods and Materials: From May 2007 to June 2008, 21 renal tumors in 20
non surgical patients (mean age 65) were treated with cryoablation. Mean tumor
size was 26 mm (13-52). 13 tumors were endophytic and 7 were abutting the
renal pelvis. 6 lesions were in close contact with the bowel. All procedures were
performed percutaneously under CT guidance, with biopsy performed during the
same session. Up to four cryoprobes were used simultaneously for the biggest
tumor. For bowel insulation, thermal protection technique with CO2 insufflation and
temperature monitoring with thermocouple was used. Minimum follow-up with MRI
and creatinin was 4 months.
Results: No complication occurred. The first patient in the series required an additional session due to insufficient freezing time protocol. All others were treated in
a single session with no evidence of residual tumor on follow-up. CT control allowed
precise monitoring of the ice ball and CO2 insulation. Pain was minimal with majority
of the procedures performed under low sedation. All patients could be discharged
within two days. Creatinin remained unchanged after 4 months.
Conclusion: Percutaneous cryoablation is a promising low-pain alternative
technique for the management of renal tumors in non surgical patients. The intent
is curative in a single session for tumors less than 4 cm. For central tumors, the
risk of thermal damage to the pyelic structures seems to be reduced compared to
radiofrequency ablation.
C-554
Percutaneous cryoablation of painful musculoskeletal tumors: Initial
experience in 32 patients
X. Buy, S. Daniel, G. Bierry, A. Gangi; Strasbourg/FR
([email protected])
Purpose: To evaluate the feasibility, safety and efficacy of percutaneous cryoablation for the management of painful musculoskeletal tumors.
Methods and Materials: From June 2007 to August 2008, 32 patients suffering from
painful non surgical musculoskeletal tumors underwent CT-guided percutaneous
cryoablation. All patients were refractory to morphine medication and radiotherapy.
Cementoplasty was combined during the same session if weight bearing bone was
involved with risk of pathological fracture. In case of close contact with sensitive
structures, particularly nerves, thermal protection techniques (CO 2 insulation,
continuous monitoring with thermocouple) were used. Pre- and post-procedural
pain was evaluated with VAS pain score and medication.
Scientific and Educational Exhibits
Results: All procedures were technically successful. CT guidance allowed a
precise visual control of the ice ball. Peri- and post-procedural pain was hardly
reduced compared to similar procedures performed with radiofrequency ablation.
88% (28/32) patients reported a major reduction of pain. One transient crural paresis occurred after cryoablation of a painful L3 osteoblastic metastasis. No other
complication occurred. 8 patients died within 8 weeks due to advanced disease
but without significant recurrence of pain at the treated area.
Conclusion: Percutaneous cryoablation of painful musculoskeletal tumors is a
promising technique when conventional therapies have failed. Peri- and postprocedural pain is low and majority of procedures are performed under conscious
sedation. The visual control of the ice ball with sharp margins gives a high safety
when performing cryoablation close to sensitive structures. However, a good knowledge of thermal protection techniques is mandatory to avoid complications.
C-555
Reducing risk and stabilizing the vertebral body in advanced metastatic
spine lesions: A combined approach using plasma-mediated tumor
ablation and cement augmentation
B. Georgy; Escondido, CA/US ([email protected])
Purpose: Combining percutaneous plasma-mediated radiofrequency ablation
with cement augmentation offers a less invasive treatment option for advanced
metastatic lesions of the spine while providing immediate pain relief. The treatment
is particularly useful for cases with cortical destruction and/or epidural extension.
This study evaluated bone cement deposition patterns and leakage rate in relation
to the metastatic lesion after using this combined approach.
Methods and Materials: A void is created in the anterior portion of the tumorinfiltrated vertebral body using a bipolar plasma radiofrequency-based device
(ArthroCare Corp., Austin, TX), followed by cement augmentation. Retrospective
assessments of CT images performed before/after the procedures were evaluated
in 37 patients (44 levels) with advanced metastatic lesions. All patients reported
pain status (VAS) pre-procedure and 2-4 weeks afterwards.
Results: Assessment found that 90-100% cement was deposited in the anterior 2/3
of the vertebral body in 19 levels (43%), while 75-90% of the cement was deposited
in this region in 16 levels (36%). In 13 of 15 levels with posterior lesions (86%),
cement deposited anterior to the lesion. 13 levels showed no leakage (29.5%).
Two clinically insignificant incidences of epidural cement leakage recorded. 25 of
28 patients (89.5%) reported pain relief post-procedure.
Conclusion: Plasma-mediated radiofrequency ablation allows greater control of
cement deposition, increases likelihood of stabilizing the anterior 2/3 of the vertebral
body, and may replace extensive anterior surgical stabilization techniques. This
combined technique appears particularly useful in cases with posteriorly-located
lesions. Cement leakage using this approach is clinically insignificant, while postprocedure pain relief is excellent.
C-556
Complications of percutaneous lung radiofrequency ablation
A. Afaq, S. Khan, U. Patel, E. Leen; London/UK
Laser, radiofrequency and microwave ablation therapy of lung tumors:
Qualitative and quantitative analysis
N.-E.A. Nour-Eldin, N.N.N. Naguib, M.G. Mack, T.J. Vogl; Frankfurt a. Main/DE
([email protected])
Learning Objectives: To provide a qualitative description of principle and basic
physics of most applicable tools of ablation (LASER, radiofrequency and microwave)
and quantitative analysis of the advantages and limitations of each modality to
make maximal benefit on clinical practice.
Background: Ever since its introduction in the management of lung tumors,
thermal ablation became a promising minimal invasive therapy of lung tumors,
opening new horizons in pulmonary neoplastic therapy. The potential advantages
of local tumor ablation therapy over surgical resection might include: 1) selective
damage, 2) minimal treatment morbidity and mortality, 3) less breathing impairment in patients with borderline lung function through sparing healthy lung tissue,
4) repeatability, 5) fairly low costs, 6) excellent imaging during the procedure and
for follow-up and last but not least 7) the gain in quality of life with less pain, much
shorter hospitalization times with the interventions performed on an outpatient base
or with overnight stays and thus a quicker re-access to social life. For oncology
interventionists, physical background advantages and limitations of the therapeutic
ablative tools represent the backbone of successful treatment representing a non
avoidable learn demand.
Procedure Details: Description of the terminology of the thermal ablation of lung
tumors, principle of function, indications and contraindications, advantages and
disadvantages of LASER, radiofrequency and microwave regarding ablation capabilities and potential complications associated with reference of each qualitative
and quantitative item to literature and institutional experience.
Conclusion: The pulmonary thermal ablation therapy is an operator dependant
procedure that requires comprehensive understanding of how, what and when
to apply.
C-558
Imaging and intervention in unstable pelvic trauma
N. Fotiadis, C. Bent, I. Ahmed, I. Renfrew, K. Brohi, M. Matson; London/UK
([email protected])
Learning Objectives: This presentation aims: To review the normal CT and angiographically vascular anatomy of the pelvic vessels. To reveal the spectrum of
imaging findings in arterial and venous injuries encountered in severe pelvic trauma.
To present ways of successful endovascular treatment of pelvic bleeding.
Background: Arterial hemorrhage is one of the most serious problems associated with pelvic fractures, and it remains the leading cause of death attributable
to pelvic fracture. Early detection of arterial bleed at CT angiography can lead
to prompt performance of angiographic embolization, which can be lifesaving. A
pictorial review, based on the authors’ extensive experience, is used to present a
representative series of vascular injuries seen in severe pelvic trauma.
Imaging Findings: Arterial injuries and extravasation of the iliolumbar artery, lateral
sacral arteries, the superior and inferior gluteal artery, the internal pudendal artery
and the obturator artery are illustrated with CT and angiographic images. Different
embolization approaches are discussed.
Conclusion: Pelvic multidetector CT and classic angiography have a cardinal role
in the management of patients with severe pelvic trauma and vascular injuries.
Interventional Radiology
Learning Objectives: A review of the complications of radiofrequency ablation
(RFA) use in lung tumour management.
Background: Radiofrequency ablation (RFA) is gaining increasing popularity in
the management of unresectable lung tumours. Feasibility and safety continues
to be supported with continuing trials. However, further study is also necessary in
order to minimise the recognised complications.
Procedure Details: Recognised commoner minor adverse effects and complications include pain, subcutaneous emphysema, hemoptysis, pyrexia, pleural effusions, small pneumothorax and skin burn. Less common major complications include
large pnemothorax requiring drainage, abscess, intrapulmonary hemorrhage and
air embolism. Death has been reported from intractable pneumothoraces/massive
hemoptysis and from interstitial pneumonitis - the latter being related to previous
external beam radiotherapy and larger tumor size.
Conclusion: As the technique develops and knowledge of higher risk profiles
improves, complications are likely to reduce in the future. However, of the limited
relatively small studies on complications, adverse symptoms have occurred in approximately a third whereas minor complications in up to a half and major complications in less than a quarter. The procedure continues to gain recognition as a safe
and effective minimally invasive treatment option for unresectable lung tumors.
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Scientific and Educational Exhibits
Molecular Imaging
C-559
First-pass CT perfusion of FN13762 murine breast cancer: Region-byregion correlation with histological vascular parameters
C. Park1, J. Goo1, H. Lee1, M. Kim1, K. Kim2, C. Lee1; 1Seoul/KR, 2Gyeonggi-Do/KR
([email protected])
Purpose: To investigate the correlation between first-pass CT perfusion indices and
histological vascular parameters using region-by-region correlation methods.
Methods and Materials: The institutional animal care and use committee of our
institute approved this study. FN13762 murine breast cancer cells were implanted
in 14 female Fischer rats and first-pass perfusion CT was performed. Tumor perfusion maps including blood flow (BF), blood volume (BV), mean transit time (MTT)
and permeability-surface-area product (PSA) were generated using commercial
perfusion software. The entire tumor area was divided into 6 separate regions on
perfusion maps, and the regional perfusion indices were quantified. Histological
vascular parameters including microvessel density (MVD), luminal vessel number (LVN), luminal vessel area (LVA), and luminal vessels perimeter (LVP) were
measured in the corresponding histological region to perfusion maps. Correlation
analysis was performed between regional tumor perfusion indices and histological
vascular parameters of the corresponding tumor region. Additionally, mean perfusion values of entire tumor were correlated with histological vascular parameters
of the hottest spot within the entire tumor.
Results: In region-by-region correlation manner, regional BF (r=0.476), BV
(r=0.348), and MTT (r=-0.506) was significantly correlated with MVD in the corresponding tumor region (P 0.01). Also in each Fischer rat, MVD showed significantly
good correlations with BF, BV, and MTT (P 0.01). Correlation analysis between CT
perfusion indices of entire tumor and histological vascular parameters of the hottest
spot within entire tumor did not show significant correlations (P 0.05).
Conclusion: Regional BF, BV, and MTT are significantly correlated with MVD in
the corresponding tumor region.
C-560
Phosphorus: 31 magnetic resonance spectroscopy of skeletal muscle
in maternally inherited diabetes and deafness A3243G mitochondrial
mutation carriers
S.G.C. van Elderen, J. Doornbos, E.H.R. van Essen, H.H.P.J. Lemkes,
J.A. Maassen, J.W.A. Smit, A. de Roos; Leiden/NL ([email protected])
Purpose: To investigate high-energy phosphate metabolism in striated skeletal
muscle of patients with the maternally inherited diabetes and deafness (MIDD)
syndrome.
Methods and Materials: Patients were recruited from the local MIDD database
of the diabetes mellitus (DM) outpatient clinic of our institution. In 11 patients with
the MIDD mutation (6 with DM and 5 non-DM) and 8 healthy subjects, phosphocreatine (PCr) and inorganic phosphate (Pi) in the vastus medialis muscle was
measured immediately after three minutes of repeated knee extension by using
³¹P-magnetic resonance spectroscopy (MRS). The half time of recovery (t½) of
mono-exponentially fitted (PCr+Pi)/PCr was calculated from spectra obtained every
four seconds after cessation of exercise. A multiple linear regression model was
used for statistical analysis.
Results: Patients with the MIDD mutation showed a significantly prolonged t½
(PCr+Pi)/PCr) after exercise as compared to controls (13.6p3.0 vs. 8.7p1.3 s,
p=0.01). No association between the presence of DM and t½ (PCr + Pi)/PCr was
found (p=0.382).
Conclusion: MIDD patients showed impaired mitochondrial oxidative phosphorylation in skeletal muscle shortly after exercise, irrespective of the presence of
diabetes mellitus.
C-561
Quiz yourself in lymph node characterization with lymphotropic
nanoparticle-enhanced MRI using superparamagnetic iron oxides!
T. Islam, M. Braschi, G.R. Oliveira, M.G. Harisinghani; Boston, MA/US
([email protected])
Learning Objectives: The purpose of this educational exhibit is to familiarize viewers with various patterns of enhancement in lymphotropic nanoparticle-enhanced
MRI (LNMRI) with ferumoxtran-10 using test cases.
Background: Evolving technologies such as LNMRI with ferumoxtran-10 improve
the accuracy in distinguishing benign from malignant lymph nodes. However, accurate nodal characterization requires reader training and experience. This exhibit
will showcase the variations in signal intensity changes with ferumoxtran-10 in
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benign and malignant nodes. Multiple histologically proven lymph nodes from
various primary tumors will be shown pre and post contrast enhancement in a quiz
manner followed by the correct answers.
Procedure Details: This technique employs superparamagnetic iron oxide
nanoparticles targeted at the reticuloendothelial system.They are phagocytozed
by macrophages that accumulate within lymph nodes. Disturbances in lymph
flow or in nodal architecture caused by metastases lead to abnormal patterns
of accumulation of the particles, which are detectable by MRI. On post contrast
T2- and T2*-weighted MRI benign lymph nodes show a drop in signal intensity
and homogenous darkening whereas areas of malignant infiltration show lack of
nanoparticle uptake and remain signal-intense.
Conclusion: Taking this quiz, the viewer will acquire confident knowledge of the
features of benign versus malignant lymph nodes in lymphotropic nanoparticleenhanced MRI.
C-562
Limitations of 18FDG-PET/TC in oncology: False positive and false negative
findings
A. Díez Tascón, I. Pinilla Fernandez, M. Hernández Maraver, J. Coya Viña,
B. Rodríguez-Vigil Junco, N. Gómez León; Madrid/ES ([email protected])
Learning Objectives: To review the spectrum of potential pitfalls and limitations
of whole-body 18FDG-PET/CT scans in oncologic patients with emphasis on false
positive and false negative interpretations, and how some of them can be avoided
or appropriately interpreted.
Background: Accurate diagnosis and staging are essential for an adequate
management of oncologic patients. 18FDG-PET/CT has emerged as a powerful
imaging tool in oncology. The combined acquisition of morphologic and functional
images has synergistic advantages and minimizes their limitations, resulting in a
more accurate test than either of its constituents. However, there remain potential
pitfalls the interpreters must be aware of.
Imaging Findings: 18FDG is not a cancer specific tracer and is physiologically taken
up by various organs making difficult identification of lesions in these localizations.
There are also benign pathologic causes of 18FDG uptake that can mimic malignant
neoplasm (infectious, inflammatory processe, benign tumors). Other limitations are
related to the variable 18FDG avidity of several types of cancers. Tumors exhibiting
very low 18FDG uptake may lead to false negative interpretations. In addition, there
are potential pitfalls related to technical factors or the timing of the study that can
compromise the sensitivity of 18FDG-PET/CT for detecting tumors.
Conclusion: 18FDG-PET/CT plays an important role in the management of cancer
patients. Despite its benefits, 18FDG-PET/ CT has recognized limitations. This
exhibit will help to identify physiologic variants and benign pathologic conditions
with increased 18FDG uptake that can be confused with malignant neoplasm,
to increase awareness of potential false negative findings, and to reduce false
interpretations.
C-563
Macrophage imaging by USPIO-enhanced MR for the differentiation of
infectious osteomyelitis and aseptic vertebral inflammation
G. Bierry1, F. Jehl1, N. Boehm1, P. Robert2, J.-L. Dietemann1, S. Kremer1;
1
Strasbourg/FR, 2Roissy/FR ([email protected])
Purpose: To prospectively evaluate macrophage imaging using USPIO enhanced
MRI for the differentiation of vertebral infectious osteomyelitis and sterile inflammation.
Methods and Materials: Vertebral osteomyelitis and sterile vertebral inflammation were induced in two groups of 6 rabbits. MRI examinations were performed
in the 12 rabbits twice a week including unenhanced and gadolinium-enhanced
SE T1w sequences. Once endplates enhancement was observed on gadoliniumenhanced MR sequence, a second MRI examination (FS SE T1w sequence) was
performed in the 12 rabbits 24 hours after USPIO administration (Sinerem, 45 µmol
Fe/kg). MR imaging were correlated with histopathologic findings (macrophage
immunostaining and Perls blue staining). Endplates signal-to-noise ratio (SNR)
changes after gadolinium and after USPIO administration were calculated and
compared in two groups.
Results: On gadolinium-enhanced T1 sequences, a significant SNR enhancement
of vertebral endplates was present in both groups without significant difference
between the two groups (p=0.26). On USPIO-enhanced T1 sequences, a significant SNR enhancement was only observed in the infection group (p=0.03) with a
significant difference of SNR between the infection and the sterile inflammation
groups (p=0.002). Infected areas presented a replacement of bone marrow by an
intense macrophage infiltration. On Perls blue stain, some of those macrophages
Scientific and Educational Exhibits
were iron-loaded. At the opposite, sterile inflammation showed a replacement of
bone marrow by an inflammatory tissue with only rare macrophages; no staining
was observed on Perls stain.
Conclusion: USPIO-enhanced MR imaging can distinguish infectious osteomyelitis
from sterile vertebral inflammation because of a different macrophages distribution
between the two types of lesions.
C-564
FDG PET/CT in the primary staging evaluation of adenocarcinoma of lung
R. Talanow, S. Shrikanthan, T.-L. Mohammed; Cleveland, OH/US
([email protected])
Purpose: Purpose of this study was to analyze prevalence, patterns and factors
associated with FDG uptake in lung adenocarcinoma and to investigate association
of FDG uptake with metastatic disease.
Methods and Materials: FDG-PET/CT findings of 132 patients (42-86 years, 50
males, 82 females) with lung adenocarcinoma at initial staging were analyzed.
Maximum standard uptake value (SUV) of primary lesion was correlated with
lesion size, presence of nodal or distant metastasis and histology. Histology was
further investigated for differentiation and presence of coexisting bronchoalveolar
cell (BAC) component. Patients were divided into 3 groups based on SUV of the
primary: low (SUV 2), intermediate, (SUV 2-4) and high (SUV 4).
Results: There were 18 cases with SUV 2 (14%), 21 with SUV 2-4 (16%) and
93 had SUV 4 (70%). Among the 18 with SUV 2, there was coexistent BAC
component in 12 (67%) and 14 were well differentiated with metastasis in only 3
(17%). Primary lesion was 1.5 cm in 7 (39%) of these cases. Among the 21 with
SUV 2-4, BAC component was present in 9 (43%), 18 (86%) were well differentiated and metastasis was present in 10 (48%). 7 (33%) were less than 1.5 cm.
Among the 93 with SUV 4, BAC component was present in only 10 (11%), 57
(61%) were differentiated and metastasis was present in 38 (41%). Only 6 (6%)
were less than 1.5 cm.
Conclusion: Majority of lung adenocarcinomas were FDG avid, with low FDG
avidity likely to have a BAC component and less likely to have metastasis. FDG
avid lesions were larger, tended to have metastasis and less likely to have a BAC
component.
C-565
Comparison of Tc-99m sestamibi and Tc-99m tetrofosmin for preoperative
localization in primary hyperparathyroidism
R. Talanow, D. Neumann; Cleveland, OH/US ([email protected])
Ga-68 labelled peptides for PET/CT imaging of neuroendocrine tumors
C. von Falck, T. Rodt, S. Waldeck, W.H. Knapp, H.-o. Shin, M. Galanski;
Hannover/DE ([email protected])
Learning Objectives: To outline the advantages and limitations of 68Ga-labelled
somatostatin analogues for PET/CT imaging. To illustrate the spectrum of PET/
CT imaging findings of various neuroendocrine tumors. To demonstrate potential
pitfalls and artefacts.
Background: The detection of neuroendocrine tumors using morphologic imaging modalities can be challenging. PET/CT with 68Ga-labelled somatostatin
analogues is a valuable imaging modality for this tumor entity that combines the
high sensitivity and specificity of PET with the superior morphologic information
provided by CT. It is valuable for staging, restaging, surgical planning and the
evaluation of patients scheduled for internal radiotherapy. Profound knowledge of
the physiological tracer distribution and potential pitfalls and artefacts is essential
to minimize false findings.
Imaging Findings: PET/CT using 68Ga-labelled somatostatin analogues shows
physiological tracer uptake in the pituitary gland, the liver, the spleen, the adrenal
glands and the urinary tract. Notably, only a minor anatomic background is provided
by somatostatin-receptor PET alone and correlation of focal uptake with morphologic information is essential. In this exhibit, typical examples of different benign
and malignant neuroendocrine tumors in somatostatin-receptor PET are presented
and correlated with the corresponding CT and MR imaging findings. Typical pitfalls
and artefacts are presented and commented.
Conclusion: Combined PET/CT using 68Ga-labelled somatostatin analogues
allows for highly sensitive and specific detection and precise anatomic localization of neuroendocrine tumors and should be considered as the primary imaging
modality in these patients.
C-567
Fever of unknown origin, a value of hybrid 18F-FDG PET/CT imaging
E. Ferdová, J. Ferda; Plzen/CZ ([email protected])
Purpose: The aim of presented work is to evaluate the clinical value of 18F-FDGPET/CT in patients with fever of unknown origin (FUO) and to compare PET/CT
finding with the results of the following investigation.
Methods and Materials: 48 patients (24 men, 24 women, mean age 57.6 years with
range 15 - 89 years) underwent 18F-FDG-PET/CT due to the fever of unknown origin.
All examinations were performed using complex PET|/CT protocol combined PET
and whole diagnostic contrast enhanced CT with sub-millimeter spatial resolution
(except patient with history of iodine hypersensitivity or sever renal impairment). CT
data contained diagnostic images reconstructed with soft tissue and high-resolution
algorithm. PET/CT finding were compared with results of biopsies, immunology,
microbiology or autopsy.
Results: The cause of FUO was explained according to the PET/CT findings and
followed investigations in 44 of 48 cases - 18 cases of microbial infections, nine
cases of autoimmune inflammations, four cases of non-infectious granulomatous
diseases, eight cases of malignancies and five cases of proved immunity disorders
were found. In 46 cases, the PET/CT interpretation was correct. Only in one case,
the cause was overlooked and the uptake in atherosclerotic changes of arteries
was misinterpreted as vasculitis in the other. The reached sensitivity was 97%
(43/44), and specificity 75% (3/4), respectively.
Conclusion: In patients with fever of unknown origin, 18F-FDG-PET/CT might enable the detection of its cause.
C-568
Imaging of neuroendocrine tumors
N.H. Wieshmann1, R. Hanlon1, D. Cuthbertson1, S. Hughes2, A. Groves3;
1
Liverpool/UK, 2Belfast/UK, 3London/UK ([email protected])
Purpose: This pictorial review aims to familiarize the general radiologist with the
increasing choice of the hybrid imaging techniques and the imaging patterns seen in
common and uncommon neuroendocrine tumours (NETs). We also aim to emphasize
the complementary role of hybrid molecular imaging to conventional radiological
workup and the important role of nuclear medicine in the management of NETs.
Methods and Materials: NETs derive from diffuse endocrine cells dispersed
throughout the respiratory and gastrointestinal tract although they can arise anywhere in the body. Common sites include the adrenal medulla, pancreas, pituitary,
thyroid and parathyroid glands. NETs are generally small, tend to progress slowly
(but inexorably) and can be difficult to localize with routine imaging. Identification
and staging of NETs with conventional morphological imaging methods such as
sonography, computerized tomography and magnetic resonance imaging can be
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Molecular Imaging
Purpose: Both Tc-99m sestamibi and Tc-99m tetrofosmin have been used for the
preoperative detection of parathyroid lesions in patients with hyperparathyroidism.
The purpose of this study was to compare the diagnostic utility of these radiopharmaceuticals in the evaluation of patients with primary hyperparathyroidism.
Methods and Materials: 130 consecutive patients with primary hyperparathyroidism underwent SPECT imaging preoperatively. Each patient received I-123 NaI
orally, followed by Tc-99m sestamibi IV in 64 patients and and Tc-99m tetrofosmin IV
in 66. Simultaneous, dual-isotope SPECT of the neck and chest was then obtained.
Normalization/subtraction of I-123 SPECT from the Tc-99m SPECT was performed,
and the resultant SPECT images were interpreted for focal residual Tc-99m activity.
SPECT results were compared to surgical and histopathological findings.
Results: In the Tc-99m sestamibi group, 55 single parathyroid adenomas, 4 double
parathyroid adenomas, and 7 hyperplastic parathyroids were found; surgery was
unsuccessful in 2 patients. Sestamibi SPECT had 60 true positive findings, 12
false positives, 14 false negatives and 6 true negatives (81% sensitivity). In the
Tc-99m tetrofosmin group, 57 single parathyroid adenomas, 6 double parathyroid
adenomas, and 3 hyperplastic parathyroids were found; surgery was unsuccessful
in 2 patients. Tetrofosmin SPECT had 50 true positive findings, 9 false positives,
22 false negatives, and no true negatives (69% sensitivity).
Conclusion: Sensitivity of dual-isotope subtraction Tc-99m sestamibi SPECT
was greater than that for Tc-99m tetrofosmin. Tc-99m sestamibi might be superior
to Tc-99m tetrofosmin for detection of parathyroid lesions in patients with primary
hyperparathyroidism and the preferred radiopharmaceutical for preoperative localization.
C-566
Scientific and Educational Exhibits
difficult and sometimes unreliable. Many NETs express specific receptors for peptides and increased molecular uptake mechanisms. This is the foundation of the
expanding use of molecular imaging techniques which utilise the specific properties
of NETs by using specific radiolabelled molecules/tracers.
Results: Depending on the molecular properties of the tumor, radiopharmaceuticals
such as meta-iodobenzylguanidine (MIBG), somatostatin receptor scintigraphy
(SRS) and positron emission tomography combined with CT (PETCT) using [18F]
Fluoro-deoxy-glucose, [18F] dihydroxyphenylalanine and 68Ga-DOTATATE/DOTATOC
play an increasingly important part in the management of NETs.
Conclusion: Molecular imaging aims to overcome some of the weaknesses of
routine radiological imaging with the use of radiolabelled tracers and hybrid imaging
with increased accuracy of localization, staging and characterization of NETs.
C-569
PET/CT: Artifacts and pitfalls in oncologic diagnosis
E. Fdez. Delgado, R. Sáiz Martínez, A. Olavarría Delgado, L. Gorospe Sarasúa,
V. García Blázquez, V. Segur Nieto; Madrid/ES ([email protected])
Learning Objectives: The aim of this poster is to review and illustrate some of the
most frequently encountered artifacts and pitfalls in PET/CT imaging since their
detection and accurate interpretation is essential for the optimal management of
patients with cancer.
Background: Accurate diagnosis and precise staging (or restaging) of cancer
patients is essential in the management of oncologic patients. The use of combined
equipments allows for an accurate fusion and correlation of anatomic and metabolic activity images. In order to make the most of the PET/CT study, a thorough
understanding of the physiopathology of cancer, physiological distribution of F-18
fluorodeoxyglucose (FDG), recognition of frequently encountered physiologic variations in FDG distribution and possible causes of non-malignant non-physiologic
FDG uptake is required. In addition, there may be specific artifacts that could lead to
important therapeutic consequences. These artifacts occur because the combined
PET/CT units use the CT information to correct the attenuation of the PET emission
data, and for reconstruction of the PET images.
Imaging Findings: We present images that illustrate the most frequent pitfalls in
PET/CT and that are explained by variable physiologic uptake, benign pathologic
FDG uptake, malignant tumoral lesions with low FDG uptake, and technical artifacts
(breathing artifacts, attenuation correction artefacts).
Conclusion: A thorough understanding of the cancer physiopathology and of PET/
CT technique is necessary for the correct reading and reporting of the PET/CT
scans in order to avoid interpretation errors.
C-570
Impact of differently functionalized gold nanoparticles on endothelial cells
in culture
I. Müller1, C. Rosman2, C. Sönnichsen2, W.A. Kaiser1, I. Hilger1; 1Jena/DE, 2Mainz/DE
Purpose: The interest in applications of nanoparticles for diagnostic and therapeutic
purposes is increasingly growing. For example, functionalized gold nanoparticles
(GNP) have been proposed as optical/thermal probes for cancer detection or as
contrast agents for magnetic resonance imaging. Considering that nanoparticles
are mostly applied intravasally, we investigated the impact of differently functionalized GNP on endothelial cells by determining the IC50 (inhibitory concentration)
values.
Methods and Materials: Murine endothelial cells (SVEC4-10) were incubated
with spherical gold nanoparticles (Ø 40 nm, 0.06 mg/mL gold) functionalized
with polyethylenglycol (SH-PEG-NH2; SH-PEG-COOH; SH-PEG-OCH3) or cetyl
trimetylammonium bromide (CTAB, a cationic surfactant) at concentrations of
0.003 to 30 µg/mL or to 240 µg/mL, respectively. Cell viability was measured after
24, 48 and 72 h of GNP incubation using a colorimetric cytotoxicity assay for
mitochondrial activity.
Results: CTAB-modified GNP showed an IC50 value in a concentration range of
0.03 to 0.3 µg/mL gold (24-72 h of incubation). In contrast to this, PEG-functionalized
GNP was comparatively less cytotoxic. The IC50 value of SH-PEG-NH2 (cationic)
and SH-PEG-COOH (anionic) nanoparticles were higher than 0.003 to 30 µg/mL
gold, the SH-PEG-OCH3 (neutral) derivatization was non-toxic up to 240 µg/mL
gold (24-72 h of incubation).
Conclusion: Cytotoxicity assays revealed the impact of surface functionalization of
GNP on endothelial cells. The nanoparticle modification with the surfactant CTAB
seems to be cytotoxic. This effect can be prevented by the use of PEG independently
from the respective functional groups. Our results basically demonstrate the potential
of intravasal applications of functionalized GNPs in the long term.
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C-571
Patterns of FDG uptake seen in the brain PET/CT scan for different
dementias
A. Nasoodi, S.J. Hughes; Belfast/UK ([email protected])
Learning Objectives: To understand the difference in performing a combined
positron emission tomography and computed tomography (PETCT) scan for dementia and oncology. To understand the patterns seen in the normal aging brain.
To understand the patterns seen in the common and uncommon dementias.
Background: PETCT with [F18] 2-fluoro-2-deoxy-D-glucose (FDG) is well established for routine oncological investigations but not for the assessment of early
dementia. FDG PET is better than perfusion scintigraphy for the assessment of
early dementia. The patterns of disease seen in early dementia assessment in FDG
PETCT are sometimes different from those seen in perfusion studies.
Imaging Findings: We will show the indicators of a high quality FDG PETCT
brain scan. We will show normal brain patterns and patterns seen in the normal
aging brain. We will show the patterns of disease seen in Alzheimer’s disease,
frontotemporal dementia, Lewy body dementia, vascular dementia, mixed dementia
and Creutzfelt-Jacob disease. We will discuss the possible benefit of the combined
findings of the FDG distribution and the unenhanced CT which can be obtained
from the PETCT scan. We will discuss the accuracy and reliability of this scanning
technique in these different diseases. We will discuss the problems with using this
technique in mild cognitive impairment (MCI) as opposed to early dementia.
Conclusion: The delegate should feel more confident in recognising the patterns
of disease seen in dementia scanned with FDG PETCT and realise the advantages
and shortcomings of this exciting technique.
Scientific and Educational Exhibits
Musculoskeletal
Bone
C-572
How not to miss a fracture: Assessing the impact of focused radiological
teaching
D.Y.F. Chung, R.R. Misra; High Wycombe/UK ([email protected])
Purpose: To evaluate whether formal teaching of radiographic ‘rules’ improves
the diagnostic accuracy of trauma radiographs reported by emergency department officers.
Methods and Materials: Nine emergency department officers, of varied experience, reported thirty radiographs of the upper limb, in three separate reporting
tests. It was clarified that the assessment included both normal and abnormal
cases. They were asked to comment on the presence of an abnormality and its
nature. Sensitivity, specificity and overall accuracy were assessed. Once phase 1
was completed, formal teaching of radiographic ‘rules’ was given under consultant
radiologist guidance. A new reporting test was conducted as previously, immediately
post teaching. After 2 weeks, a final reporting test was conducted. All radiographs
used were independently reported by two consultant radiologists. Paired sample
t-test was used to compare data to assess for statistical significance.
Results: Statistically significant improvement (p=0.0055) in the mean value sensitivities was seen between phase 2 (81.00p12.91) and phase 1 (64.33p17.37).
Likewise, a significant improvement (p=0.0022) was also seen in mean value
sensitivities between phase 3 (75.78p14.06) and phase 1. No significant difference
in sensitivity was identified (p=0.3043) between phases 2 and 3, indicating that
the 'rules' were being appropriately maintained. Overall accuracy also improved
throughout the study.
Conclusion: Formal radiological guidance has demonstrated significant improvement in the identification of abnormal radiographs despite limited radiological
training. This study supports education in radiograph interpretation for emergency
officers prior to clinical practice, which will have a positive impact on patient management in a busy accident and emergency department.
C-573
Semi-automating bone segmentation from MRI wrist images: Application
in clinical trials in rheumatoid arthritis (RA)
A. Rastogi, K. Leung, C. Foley, L.V. Krasnosselskaia, E.J. Hughes, N. Saeed,
J.S. Angwin, M.H. Binks, K. McLeish, D. Hill, J.V. Hajnal, P.C. Taylor; London/UK
([email protected])
Interventional radiology in the treatment of the osteoid osteoma (OO)
J. Alvarez-Tutor1, E. Alvarez-Tutor1, J. Sauret, M.D.2; 1Pamplona/ES, 2Buffalo, NY/US
Purpose: To validate the development of CT-guided percutaneous procedures,
such as percutaneous resection with trephine (PR), and the radiofrequency ablation (RF). To remove the core of the lesion and therefore relieve the symptoms in
a considerably less invasive way.
Methods and Materials: We treated 65 lesions in 60 patients with a presumptive
diagnosis of osteoid osteoma. We performed 49 PRs and 16 RFs. Of the 49 PRs, 5
S
required curettage. One required an ethanol injection. The procedures
were guided
O
by CT imaging under general or spinal anesthesia with
EP24 hour hospitalization.
Tumor samples were taken for anatomical pathologyto
analysis (AP).
dIn 5 of them it was necessary
Results: All lesions were accessed successfully.
e
t
it
to broaden the resection due to a possible insufficient
In 38 of the 65 lem in 6/65margin.
b
sions (58.5%), AP confirmed the OO diagnosis;
(9.2%) of them, AP found
u
other specific lesions, such as enostoma
l S (n=2), bone cyst (n=1), inclusion cyst
ia osteitis (n=1); and in the rest of the cases
(n=1), chondroma (n=1), and chronic
r
e
the findings were unspecified. All
at patients (60/60) showed no pain within 24-48
M (8.3%) received further treatment due to recurhours of the procedure, and 5/60
ring symptoms.
No
Conclusion: The percutaneous procedure has shown to be an effective technique for the treatment of OO. Compared to surgical excision, the percutaneous
technique is less invasive, requires less anesthesia and hospitalization time, and
allows an earlier return to active life. PR is less expensive than RF, but it requires
a wider bone incision.
C-575
Magnetic resonance imaging in bone abnormalities of the forefoot:
A pictorial review
M. Vilagran, P. Melloni, A. Sanchez-Montañez, L. Riera, A. Marín, M. Veintemillas,
R. Valls; Sabadell/ES ([email protected])
Learning Objectives: To provide a comprehensive overview of normal and
pathologic findings in the bones of the forefoot and discuss the differential diagnosis of forefoot abnormalities. To describe and illustrate the bone abnormalities
of the forefoot: osteochondral lesions, necrosis, bruises, occult or stress fractures,
necrosis, diabetic osteitis, tumours, etc.
Background: Over a five-year period, 848 feet in 796 patients were examined using
1.0T MRI at our centre. All patients had previously undergone X-ray and some US
and/or CT as well. We used T1-weighted density and T2-weighted spin-echo or fast
spin-echo sequences in the sagittal and coronal planes, together with gradient-echo
and occasionally spin-echo T1-weighted sequences in the axial plane. STIR or fatsuppressed T1-weighted sequences were also used in some cases. Intravenous
gadolinium contrast was administered when necessary.
Imaging Findings: We present illustrative cases of bone abnormalities, such as
osteochondral lesions, bruises, fractures (occult or not), stress fractures, necrosis,
sesamoiditis, osteomyelitis, diabetic osteitis, erosive arthritis, intraosseous tumour
(cyst, enchondroma) and others. When useful, we also show with plain-film and/or
CT images to help to better appreciate the MR findings.
Conclusion: Plain films are essential for the evaluation of osseous abnormalities.
They should be the initial imaging study performed and may be helpful in excluding
other etiologies of forefoot pain. MRI is a powerful noninvasive method for detecting
and diagnosing many causes of abnormalities in the forefoot.
C-576
Don’t put your foot in it: Pitfalls and pearls in the diagnosis of mid-foot
fractures and dislocations
P.A. Tyler, C. Thorning, W.M.W. Gedroyc, E.A. Dick, C. Burnett; London/UK
Learning Objectives: To allow viewers to identify and categorise this unusual and
frequently missed group of injuries of the foot using anatomical illustrations and
multimodality imaging of a range of examples.
Background: Foot and ankle injuries account for many accident and emergency
radiographs performed in the UK. With several common patterns of injury accounting for the majority of radiographic abnormalities, it is important to maintain
vigilance for the more subtle and unusual injuries. Failure to recognise and treat
these injuries can result in the development of serious complications, including
compartment syndrome, ischaemia, neurological compromise and later Charcot’s
joints and osteoarthritis.
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Musculoskeletal
Purpose: We present a semi-automated method of measuring bone volume and
compare it with manual delineation on a cohort of normal and RA subjects in a
longitudinal trial.
Methods and Materials: 2 patients and 2 healthy volunteers (n=4) enrolled in a
longitudinal RA MRI study were scanned on a Philips Achieva 3 T MR scanner with
a dedicated wrist coil. T1w FFE water select images (TE/TR/FA: 2.3 ms/11 ms/20º,
0.5 mm3 isotropic resolution) were used for the analysis. The hamate bone was
segmented by two methods: manual and semi-automatic. The former method was
performed using a tablet laptop and interactive viewing tool. The latter used region
growing based on voxel intensity thresholding technique (s/w from: http://www.doc.
ic.ac.uk/~dr/software/index.html). The performance of two independent observers
(O1 and O2) was compared using difference in bone volumes (VD) (%) (meanpSD)
and similarity index (SI) (meanpSD) (2x intersection/union of regions).
Results: The total time taken for manually segmenting hamate bones (n=4) were
similar between observers (263 vs 288 minutes for approx. 384 total slices); corresponding times for semi-automated method were 8 and 10 minutes. SI and VD
for manual inter-rater technique were 0.95p0.01 and 8.07p1.71, and for manual
intra-rater O1 was 0.97p0.01 and 2.08p1.97, respectively. SI and VD comparisons
between O1 manual vs semi-automatic were 0.93p0.02 and 8.1p7.9; for O2
0.93p0.02 and 10.6p5.7, respectively.
Conclusion: The semi-automated method is less labor intensive and performs well
in extracting bone volumes when evaluated against the manual technique, the latter
having good intra and inter-observer reproducibility but being time consuming.
C-574
Scientific and Educational Exhibits
Imaging Findings: We illustrate the relevant anatomy and review a range of
fractures and dislocations of the mid-foot, using plain radiographs, computed
tomography and magnetic resonance imaging. Guidelines for reporting to reduce
errors are described and illustrated, with recommendations about how to minimise
common errors and classify these injuries into their various categories.
Conclusion: This exhibit will allow the viewer to recognise and classify an important
but frequently missed group of traumatic injuries to the foot.
C-577
Dual X-ray absorptiometry (DXA): A comprehensive review
R.M. Lorente-Ramos, Y. del Valle-Sanz, F. Azpeitia-Armán, J. Acosta-Batlle;
Madrid/ES
Learning Objectives: To review DXA procedure in terms of proper positioning and
analysis in order to achieve correct interpretation. To describe potential artifacts and
disorders that can affect bone mineral density (BMD) measurements.
Background: DXA is the technique of choice in the assessment of bone mineral
density (BMD). Multiple conditions may affect BMD measurements, being the most
important inappropriate patient positioning. Artifacts that should be excluded from
the analysis, and disorders previously diagnosed or that require further exams,
may also be identified. Excluding artifacts from the ROI in densitometry analysis
is essential for adequate assessment.
Imaging Findings: We review appropriate positioning for DXA scans and emphasize potential mistakes due to incorrect positioning. We also present artifacts
such as dense objects (catheters, piercing), surgical material (spine fixations,
meshes), contrast media, calcification (hydatid cyst, lymph nodes, dermatomyositis).
Multiple disorders may also appear: osteoarthosis, osteopetrosis, fractures, lytic
or sclerotic bone lesions (metastasis, lymphoma, bone island, Paget´s disease,
hemangioma).
Conclusion: The major teaching point of the exhibit is to be familiar with DXA
analysis ad interpretation. The radiologist should be able to recognize and avoid
pitfalls due to inappropriate positioning, artifacts or disorders and to be aware of
possible lesions sometimes previously undiagnosed.
C-578
Fluid-fluid levels in bone tumors: A pictorial review
L. Figueroa Nasra, C. Martín Hervás, M. Tapia-Viñé, D. Bernabeu Taboada,
F. López Barea, V. Pérez Dueñas; Madrid/ES ([email protected])
Learning Objectives: To describe the features fluid-fluid levels (FFL) on bone
tumors with various imaging modalities, highlighting the value of this sign. To review
the bone tumors that may present FFL, emphasizing their most important imaging
findings, differential diagnoses, and pathologic correlation.
Background: FFL are not a frequent finding in bone tumors and are an important sign that can be useful in the differential diagnosis. They have been usually
reported as being strongly suggestive of aneurysmal bone cysts, but have been
also seen in other entities. These can be studied with CT, but MR is the most
useful technique.
Imaging Findings: We reviewed our experience with bone tumors that showed
FFL on CT or MR. They can be present in several tumors: aneurysmal bone cysts,
telangiectatic osteosarcoma, chondroblastoma, osteoblastoma, brown tumor, giant
cell tumor, condromixoid fibroma, fibrous dysplasia, simple bone cyst, metastases, and intraosseous lipoma. Typical signs and morphological features of these
tumours will be reviewed. MR plays the main role detecting FFL and their features,
but CT can also contribute with valuable information. FFL indicates extracellular
methemoglobin (relatively recent hemorrhage) and not indicate aggressiveness.
Pathologic correlation, including results of the dissection of gross specimens and
examination of the fluid within cavities, was available in all patients.
Conclusion: FFL is a non-specific finding but its presence can significantly aid in
formulating a limited differential diagnoses, in combination with clinical and other
imaging findings. They are related to prior hemorrhage, and cannot be considered
indicative of malignancy.
C-579
Diabetic foot - comparison of MR and SPECT/CT with 99mTc-HMPAO
labeled leucocytes in osteomyelitis: Preliminary study
E. Vano-Galvan, E. Capilla, J. Cardona, M. Moreno Casado, M. Vega Gonzalez;
Madrid/ES
Purpose: To check the efficacy of MR and SPECT/CT to diagnose and stage
osteomyelitis in diabetic foot. To graphically show semiologic criteria in MR and
SPECT/CT that proved to be more specific for osteomyelitis in diabetic foot.
S458
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Methods and Materials: In 14 patients with diabetic foot and suspicion of osteomyelitis an MR at least with Fat Sat CE T1WI sequence was performed. In the following
10 days a SPECT/CT with 99mTc-HMPAO labeled leucocytes. A comparison and
qualitative analysis of both tests were made in each patient. Gold standard was
clinical follow-up of 1-10 months.
Results: In all cases uptake regions in SPECT/CT correlated with soft tissue abscesses, edema, cortical destruction and enhancement in MR. On the other hand,
the patients who showed in MR edema and enhancement not always correlated
with positive SPECT/CT, probably caused by edema of the neuropathic arthropathy.
The most specific criteria that we found in MR for osteomyelitis were fistulae and
abscesses plus bone abnormalities at pressure points. Clinical follow-up demonstrated greater efficacy of SPECT/CT in the staging of osteomyelitis.
Conclusion: Both techniques are supposed to show similar efficacy evaluating
osteomyelitis in diabetic foot, but, in our preliminary study, gadolinium enhancement was not always specific for osteomyelitis, and so other semiologic criteria
must be considered. SPECT/CT with 99mTc-HMPAO labeled leucocytes may be
useful in evaluating the extension of osteomyelitis in diabetic foot, thus improving
their therapeutic management.
C-580
Magnetic resonance imaging of abnormalities of the nonosseous
structures of the forefoot: A pictorial review
L. Riera, P. Melloni, M. Veintemillas, A. Marin, A. Sanchez-Montañez, M. Vilagran;
Sabadell/ES ([email protected])
Learning Objectives: To catalogue the wide spectrum of forefoot injuries depicted
by MRI by means of a pictorial review of the findings in abnormalities of the tendons,
ligaments, nerves, and soft tissues and to discuss the differential diagnoses.
Background: Over a five-year period, we examined 848 feet in 796 patients using
1.0 T MRI. All patients had previously undergone X-ray and some US and/or CT as
well. We used T1-weighted density and T2-weighted spin-echo or fast spin-echo
sequences in the sagittal and coronal planes, together with gradient-echo and
occasionally spin-echo T1-weighted sequences in the axial plane. STIR or fatsuppressed T1-weighted sequences were also used in some cases. Intravenous
gadolinium contrast was administered when necessary.
Imaging Findings: Abnormalities were classified into: musculotendinous abnormalities, such as tenosynovitis; nerve abnormalities, such as Morton’s neuroma,
schwannoma; synovial abnormalities, such as arthritis; soft-tissue abnormalities,
such as abscesses, bursitis, vascular tumours (haemangioma, arteriovenous
malformation), fibroblastic tumours (Ledderhose), fibrohistiocytic tumours (giantcell tumour, proliferative fascitis), soft-tissue mass (sarcoma), adipocytic tumours
(lipoma), pericytic tumours (glomus tumour), chondro-osseous tumours (chondroid
metaplasia), tumours of uncertain differentiation (angiomyxolipoma), etc.
Conclusion: MRI can provide high-quality multiplanar images useful in the evaluation of forefoot pathology. MRI has proven especially useful in detecting the numerous soft-tissue and joint processes occurring in the forefoot that are not depicted
or not as well characterized on other modalities. MRI often enables a specific
diagnosis based on the location, signal intensity characteristics, and morphologic
features of the abnormality. Consequently, MR imaging is increasingly being used
to evaluate patients with forefoot complaints.
C-581
Steroid-induced musculoskeletal changes
C. Paulino, L. Rodrigues, F. Cavalheiro, A. Canelas, M. Goncalo, M. Ferreira,
F. Caseiro-Alves; Coimbra/PT ([email protected])
Learning Objectives: To provide a pictorial review of the musculoskeletal changes
induced by corticosteroids, identifying their characteristic features at multimodality
imaging. To discuss their pathophysiology and the factors that increase their risk
and review therapeutic options for their prevention and treatment, with special attention to osteoporosis since it is the most common change and has an important
morbidity.
Background: Corticosteroids use is widespread in medicine. They are used to
treat a wide variety of autoimmune and inflammatory diseases. While they are often
life-saving, side-effects are well known. The most common side-effect of corticosteroids is osteoporosis, which can be avoided or minimized by being aware of its
pathophysiology and predisposing factors. Other side-effects are unavoidable but
their resolution may be aided by early diagnosis and appropriate treatment.
Imaging Findings: Patients on long-term steroid treatment show varied musculoskeletal changes with osteoporosis and its insufficiency fractures being the most
common. Other changes include avascular necrosis, acute and chronic myopathy,
excessive callus formation and musculoskeletal infections (such as septic arthritis,
osteomyelitis and pyomyositis).
Scientific and Educational Exhibits
Conclusion: Radiologists should be familiar with the various musculoskeletal
changes induced by corticosteroids. Awareness and early identification of those
side-effects allow appropriate management. Regarding steroid-induced osteoporosis, its recognition and identification of patients with additional risk factors for bone
loss are extremely important, given the availability of effective therapeutic options
for its treatment and prevention.
C-582
Imaging findings in musculoskeletal paracoccidioidomycosis
L.M. Monsignore, S.R. Teixeira, M.N. Simao, R. Martinez, J. Elias Jr.,
M.H. Nogueira-Barbosa; Ribeirao Preto/BR ([email protected])
Purpose: To retrospectively review imaging findings of musculoskeletal (MSK)
paracoccidioidomycosis (PCM).
Methods and Materials: After institutional board approval, medical records of
patients with MSK PCM were reviewed (1980 to 2008). Cases were included when
positive culture or typical fungal cells were obtained from MSK tissues or when
imaging evidence of MSK infection was present and the pathogen isolated from
other tissues. Radiographs were available in 17/18 patients, ultrasound in 3/18,
computed tomography in 5/18, and magnetic resonance (MRI) in 4/18.
Results: The mean age was 15 p 8.7 years (ranging from 4 to 33) and 55.6% were
male. In 6/18 patients (33.3%), MSK was the exclusive system involved. Osseous
lesions were the most common in 17/18 (94.4%). Fifty-four osseous lesions were
identified. The usual manifestation was a well-defined lytic lesion (64.8%), without
marginal sclerosis (81.5%) and without periosteal reaction (88.9%). Articular involvement was present in 3/18 (16.7%), with one case of primary arthritis. Soft tissue
involvement was identified in 5/18 (27.8%), and exclusive muscular involvement
in 1/18. Ultrasound showed fluid collections with debris in 3/3 cases, one in soft
tissue and two adjacent to cortical bone destruction. All cases evaluated by MRI
showed soft tissue involvement with high signal intensity in T1-weighted images
and peripheral contrast enhancement.
Conclusion: MSK PCM is rare, but could be the first and/or the only presentation
of the disease. MSK lesions described here should raise the possibility of PCM
in the differential diagnosis, mainly if the patient had visited or lived previously in
an endemic region.
C-583
Diagnostic dilemma in sicklers with acute bone crisis: Role of
subperiostael fluid collection on MRI in resolving this issue
S. Ahmad, Z.A. Khan; Al-Ahsa/SA ([email protected])
C-584
Evaluation of proton MR diffusion with selection of different areas for
characterization of musculoskeletal tumours
B. Osemont, D. Roch, R. Detreille, M. Louis, S. Lecocq, J. Wassel, T. Batch,
A. Blum; Nancy/FR ([email protected])
Purpose: Evaluate the interest of MR diffusion by using ADC values in selected
areas for differentiating benign and malignant musculoskeletal tumours.
Methods and Materials: Magnetic resonance imaging (MRI) at 1.5 and 3 T including echo-planar DWI sequences was performed prospectively in 50 patients with
musculoskeletal tumours; 24 were malignant and 26 were benign. The b values
were 0 and 600 s/mm2. For each tumour, the apparent diffusion constant (ADC)
C-585
An MR study of osteoporotic compression fractures: Correlation between
proton MR spectroscopy, in-phase/opposed-phase imaging and perfusion
indices at 3 Tesla
A. Regis Arnaud, D. Ben Salem, N. Trodi, F. Ricolfi, D. Krausé, P.M. Walker;
Dijon/FR
Purpose: To improve MR performance in compression fractures, various techniques
have been proposed. In our study, proton magnetic resonance spectroscopic
imaging (1H MRSI), quantified in-phase/opposed-phase imaging (In-Out MRI)
and dynamic contrast-enhanced (DCE) MRI were performed to evaluate vertebral
marrow fat in acute and chronic lesions.
Methods and Materials: Fourteen patients were evaluated for vertebral collapse due to osteoporosis. MR imaging and spectroscopy were performed at 3
Tesla. Marrow fat content (% fat fraction: FF) estimated through spectroscopy was
compared with fat quantification using In-Out imaging. Supplementary analyses
on DCE-MR images yielded maximum percentage of enhancement and enhancement slope. Data were acquired in lumbar marrow; a multivoxel spectroscopy was
acquired on and around the fracture. We compared acute compression (15), chronic
compression (9) and non-compressed vertebrae (47). Pearson’s correlation and
non-parametric statistics were used.
Results: In order to validate the In-Out imaging, we used a dual flip angle algorithm (20°, 70°) for the identification of the dominant constituent (water or fat). We
illustrated an age-dependent correlation for estimated FF. We found statistically
significant differences between the FF of normal vertebrae and chronic compressed
fractures with respect to acute lesions (p 0.002). For DCE-MRI, we found significant
differences between non-compressed, acute and chronic compression fractures.
Conclusion: Fat quantification and perfusion analysis of vertebral bone marrow
can represent a new approach compression fracture studies and may help us to
study potential risks for compression fracture.
C-586
Stature estimation on the basis of sacrum beam distance in Anatolian
Caucasians: The use of volumetric MDCT scanning in forensic
anthropometry
H.M. Karakas1, O. Celbis1, A. Harma1, B. Alicioglu2; 1Malatya/TR, 2Edirne/TR
([email protected])
Purpose: The accurate estimation of stature is a cardinal milestone to establish
an individual’s identity in medicolegal investigations involving skeletal remains.
Intact long bones have been used in the derivation of regression equations for
the estimation of stature in different population groups. The present work was
performed to investigate the possibility of estimation of stature from sacrum beam
distance (SBD).
Methods and Materials: SBD was visualized and measured on 2D maximum intensity projection computed tomographic images of pelvic bone. Data was obtained
using 64-channel multi-detector computed tomography (MDCT) with an isotrophic
resolution of 500 micron. Sixty-six males (41.56 p 14.86 years of age) and 43
females (41.14 p 14.15 years of age) were investigated. Sacrum was visualized
on sagittal plane, and was measured electronically.
Results: SBD is measured 89-138 mm (108.8p11.2) in Anatolian Caucasians.
The parameter is not significantly related to age (p=.175). A significant correlation
is found between the stature and SBD (r=0.481, p 0.0001). Regression formula
[SBD x 0.374] + 126.741 was developed to estimate stature.
Conclusion: Sacrum is usually a well protected compact bone. SBD is a stable
parameter, unrelated to age. Incomplete skeletons even if sex is unknown, SBD is
helpful to estimate sex. This study is the unique use of SBD parameter to determine
stature also demonstrates the use of MDCT in forensic medicine to collect data on
different populations to determine geographical, racial and diachronic variances as
well as revealing contemporary anthropometric data of the population.
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Musculoskeletal
Purpose: To establish MRI criteria to diagnose early osteomyelitis in sickle cell
disease patients with acute bone crisis. To differentiate it from normally occurring
ischemic changes in these patients
Methods and Materials: MRI study with and without Gadolinium contrast was
carried out in 56 sickle cell disease patients with acute bone crisis and clinical
suspicion of osteomyelitis. The diagnostic criteria included: 1) Marrow edema, 2)
Periosteal thickening, 3) Subperiosteal or soft tissue fluid collection and 4) Soft
tissue edema. Our emphasis was mainly on subperiosteal fluid collection as this is
the solely finding which is not seen in ischemic crisis. Diagnosis was confirmed on
pathological grounds in most of the patients and on clinical basis in few cases where
fluid could not be aspirated and antibiotic treatment resolved the condition.
Results: Depending on these criteria, we diagnosed early osteomyelitis in 32
cases out of 56 patients who were clinically confirmed and treated accordingly
and improved. Sixteen cases were diagnosed as ischemic changes/avascular
necrosis. Two cases showed soft tissue changes. Six cases were equivocal for
infection/ischemia.
Conclusion: Early osteomyelitis is a challenging diagnosis clinically and radiologically in patients with sickle cell disease, which can be diagnosed on MRI if special
emphasis is put on subperiosteal fluid collection.
was calculated in the different area of the lesions, highlighted by the colour mapping of the lesion reflecting the different ADC values as well as the T2 and T1 after
Gadolinium injection pattern.
Results: The different area of the tumours exhibit significantly different ADC values.
Although, there is an overlap of some values, mostly due to giant cell tumours, the
minimal ADC value is the most important one to differentiate benign from malignant tumours. The mean ADC values of benign lesion (2.12 x 10-3 mm2/s) and of
malignant lesions (1.35 x 10-3 mm2/s) are significantly different. The maximal ADC
value is dependant on the myxoid nature of the tumour or of necrosis or haemorrhagic changes within the lesion.
Conclusion: The ADC value could be used to differentiate benign from malignant
tumours but a thorough selection of the different tumour areas is necessary.
Scientific and Educational Exhibits
C-587
Who is who in bone tumours
E. Pluot, S.L.J. James, A.M. Davies; Birmingham/UK ([email protected])
Learning Objectives: To provide the reader with a specific insight into medical
history through potted biographies of some of the physicians whose names have
become eponymous or synonymous with bone tumours and tumour-like conditions of bone.
Background: Over the past 300 years, the medical fraternity has enthusiastically
named diseases, symptoms and tests after their supposed discoverers. A number
of physicians from many different areas of expertise have contributed to our understanding of tumours and tumour-like lesions of bone.
Imaging Findings: Listed in alphabetical order are illustrated biographies of those
whose names are used to define or characterise numerous signs, syndromes or
diseases associated with tumours and tumour-like conditions of bone.
Conclusion: It is still much debated whether these eponyms provide a less than
truthful account of how diseases were discovered and should therefore be abandoned in the daily practice, or are a rather practical form of medical shorthand as
well as a tribute to our glorious forefathers. However, the spectrum of all these
colourful characters, from different medical and cultural backgrounds, may mirror
the complexity of bone tumours and tumour-like conditions in today’s medicine.
C-588
Renal osteodystrophy: Radiological manifestations in adults
O. Abeyakoon, R. Senasi, M. Kaduthodil, S. Morcos; Sheffield/UK
Learning Objectives: To illustrate the spectrum of common radiological manifestations of what is collectively often known as renal osteodystrophy (ROD), which
develops in patients with end stage renal disease (ESRD).
Background: Bony changes in patients with ESRD result from a combination
of different pathological processes that include secondary hyperparathyroidism,
osteomalacia, osteosclerosis, arthropathy, amyloidosis and avascular osteonecrosis.
Imaging Findings: Secondary hyperparathyroidism (subperiosteal/subchondral/
subligamentous bone resorption, generalised loss of bone density, brown tumours,
periosteal reaction, vascular and soft tissue calcification). Osteoslerosis (e.g. rugger jersey spine). Osteomalacia (Looser’s zones, bone deformity e.g., kyphosis,
triradiate pelvis, bell shaped thorax, bowing of the legs, osteopenia). Amyloidosis
(loss of bone density, lytic lesions, soft tissue masses and extensive joint destruction). Crystal deposition (chondrocalcinosis). Aseptic spondylitis (irregular disc
narrowing, destruction of adjacent bone). Avascular osteonecrosis, which could be
secondary to corticosteroid therapy, micro emboli and vascultitis (patchy sclerosis
and radiolucent areas, collapse of the articular surface, dense irregular calcific
areas in the shafts of long bones).
Conclusion: Knowledge of the radiological appearances of ROD is important for
the long term management of patients with ESRD.
C-589
Conventional osteosarcoma: The most common primary malignant bone
tumor in adolescents - imaging features on radiography, CT and MRI
J. Campos, A. Preto, D. Rocha, M. Pimenta, P. Sousa, A. Vieira; V. Castelo/PT
([email protected])
Learning Objectives: Discuss the imaging findings of conventional osteosarcoma
in radiography, CT and with a special focus in MRI. Comment on the differential
diagnostics.
Background: Conventional osteosarcoma comprises 75% of all osteosarcomas,
being more common in the adolescent age group (10-25 years). It is commonly of
metaphyseal origin, frequently crossing the physeal plate. It is usually located about
the knee, but can occur in other long bones as proximal humerus. It is a highly aggressive lesion with permeative change, cortical breakthrough and soft-tissue mass.
Periosteal reaction is usually present (sunburst or Codman´s triangle pattern).
Imaging Findings: Osteoid matrix is produced in 90% of the osteosarcomas,
which is visible on radiography or CT images. The amount of matrix changes
the radiographic appearance from densely blastic to nearly completely lytic. The
findings of conventional osteossarcoma also vary according to the mineralization
S460
A
B
C
D
E
F
G
F
H
of the matrix. In a highly dense matrix, the signal will be low in every sequence.
If less dense, there will be low heterogeneous signal on T1 and heterogeneous
high signal on T2. Skip lesions will be present in 1-10% of cases. Metastases are
common, with hematogenous spread to lungs or bone and lymphatic spread locally. The differential diagnosis includes Ewing´s sarcoma, cortical desmoid and
myositis ossificans.
Conclusion: Radiology plays an important role in diagnosing and staging the
disease. MRI is essential to evaluate the local extent, plan the biopsy and the
definitive therapy.
C-590
Cierny-Mader classification of chronic osteomyelitis: Preoperative
evaluation with cross-sectional imaging
M. Wisniewska, I. Babiak, P.D. Palczewski, J. Swiatkowski, M. Golebiowski;
Warsaw/PL ([email protected])
Learning Objectives: To know the anatomical part of Cierny-Mader classification
of chronic osteomyelitis. To understand the role of cross-sectional imaging in pretreatment staging of osteomyelitis.
Background: Cierny-Mader classification is an anatomico-physiological staging
system of chronic osteomyelitis that defines the extent of bone infection and immunological status of the host. Widely used by orthopedic surgeons, it is seldom
mentioned in radiologic literature. The anatomical staging distinguishes four stages
of disease with different treatment options. Stage 1 is a contained intramedullary
process. Stage 2 represents superficial infection caused by penetrating soft-tissue
injury. Stage 3 corresponds to full-thickness cortical sequestration that can be
removed without comprising bone stability, while stage 4 lesions are diffuse and
require intercalary bone resection.
Imaging Findings: Plain film features of stage 1 osteomyelitis may be subtle and
resemble acute osteomyelitis with soft-tissue swelling, periosteal elevation, and later
sclerosis. Stage 2 manifests with thickening of outer cortex and sclerosis. Stages 3
and 4 osteomyelitis are difficult to assess with plain film radiography due to abundant
sclerosis. CT allows precise visualization of bone destruction and sequestra, which
helps in differentiating stages 3 and 4 disease. MRI is indispensable in defining
the extent of bone marrow involvement and soft tissue extension. PET/CT, which
is increasing in availability, allows the precise gradation of inflammatory changes
intensity, both in axial and longitudinal planes.
Conclusion: Staging of osteomyelitis according to Cierny-Mader classification
can be performed with a combined use of CT and MRI, improving communication
between the radiologist and clinician and facilitating treatment planning.
C-591
Interpretation of radiographs in emergency department: Impact of missed
diagnosis
V.B. Pakala, A. Kirwadi, D. Kumar, P. Evans; Swansea/UK
([email protected])
Purpose: To assess the impact of errors by emergency doctors in interpreting
emergency radiographs on patient management.
Methods and Materials: A retrospective study conducted over 13 month period in
a teaching hospital emergency unit. Clinical notes of the patients recalled to casualty based only on radiology reports were reviewed. Non radiological and planned
elective recalls were excluded. All the X-rays were independently reassessed by
a musculoskeletal radiologist.
Results: 100 patients were included in the study. After radiologist review, a total
of 88 cases were considered as true or strongly suspicious abnormalities in which
one is an incidental finding and 12 were considered false positive. Out of twelve,
eight were reported by consultant, three by radiographers and one by a trainee.
Among the true positive abnormalities, 58 patients were seen by junior doctors,
25 by middle grade doctors, 3 by nurse practitioners and 2 by consultants. In 68
patients, there was change in management (further imaging-26, specialist referral-37 and follow-up only-5). All patients were managed conservatively, except two
patients who needed surgical intervention. One of them was a fracture fixation and
the other was a foreign body removal.
Conclusion: Considering the huge number of patients (approximately 75,000 per
year) reviewed by emergency doctors, the errors were few. Significant change in
management happened only in fewer cases. Lack of adequate clinical information to
the reporting radiologist might have contributed to the false positive reports. Further
training for junior doctors is needed in interpreting emergency radiographs.
Scientific and Educational Exhibits
C-592
Differentiation of normal and neoplastic bone tissue in dynamic
gadolinium-enhanced magnetic resonance: Validation of a semi-automated
technique
F. D’Agostino, C. Quattrocchi, F. Occhicone, P. Dell’Aia, R. Del Vescovo,
R. Grasso, B. Beomonte Zobel; Rome/IT ([email protected])
Purpose: To clinically validate accuracy of a semi-automated software tool in the
analysis of the enhancement curve in focal malignant bone lesions.
Methods and Materials: 23 patients affected by cancer with malignant focal bone
lesions underwent dynamic gadolinium enhanced MRI performed using the following protocol: T1 weighted TSE sequences (TR 600 msec, TE 8.6 msec, FOV 40 x
40), before and after intravenous injection of contrast agent containing gadolinium.
Images post-processing was performed using the software DyCoH. Each region of
interest (ROI), drawn to include the area of the lesion with the highest values of the
AUC (area under curve) map, was analyzed to obtain time-intensity curves and relative perfusional parameters: time to peak (TTP), Peak Intensity (PI), slope (60’’slope)
and intensity (60’’I) after contrast agent injection, and final intensity (FI).
Results: Data were obtained by analysis of 86 malignant lesions and 86 apparently
normal bone regions. PI, 60’’slope, 60’’I and FI were significantly different between
neoplastic and apparently normal (p 0.001) samples. Sensitivity, specificity and
accuracy were, respectively, 94, 93 and 94% at a PI threshold of 100 (SNR), with
positive and negative predictive values of 93 and 94%. At a threshold value of
0.85 for 60''slope, sensitivity, specificity, accuracy, positive and negative predictive
values were both 91%.
Conclusion: The semi-automated technique we present appears to be accurate
for identification of neoplastic tissue and for mapping perfusion parameters, with
the added value of a consistent measurement of perfusion parameters on color
coded maps.
C-593
Radiographic findings in imaging of ochronosis
G. Argento, G. Fabbri, F. Caporilli Razza, C. Porcari, F. Capparella, W. Calandro,
G. Scavone, I. Pochesci; Rome/IT ([email protected])
Learning Objectives: We describe the radiographic findings in ochronotic patients
with acute arthritis.
Background: Alkaptonuria is a rare disorder of phenylalanine and tyrosine metabolic pathway, inherited as an autosomic recessive trait and characterized by a
defect of the homogentisic acid oxidase enzyme. As a consequence, the pool of
homogentisic acid is increased which this results in alkaptonuria (i.e. increased
excretion of the acid in urine) and ochronosis (i.e. the deposit of grossly bluishblack and microscopically ochre pigmented polymer of the sclera, skin connective
tissues and cartilage).
Imaging Findings: Ochronosis leads to a disabling degenerative arthropathy in
the advanced stages of the disease. Knees, hips, shoulders and spine, mainly at
dorsal and lumbar levels are involved. A progressive calcification of intervertebral
discs occurs, sometimes with narrowing, resorption and fusion of adjacent vertebral
bodies, vertebral osteophyte formation and intervertebral ligament calcification.
Conclusion: Conventional X-ray images are still considered to be the gold standard
in this rare arthropathy. Nevertheless, non-contrast CT scanning and in some cases
even contrast-enhanced MRI may introduce new evaluation elements.
Musculoskeletal
Joints
C-595
Tears of rotator cuff: What has happened? Revisiting with pathologic
correlation
M.L.A.D. Pimenta, A. Vieira, M.A. Pereira Gutierres, J.M.C. Ferrera Torres;
Porto/PT ([email protected])
Learning Objectives: The aims of this study are to discuss the clinical and radiologic features of rotator cuff tears, and to compare the imaging findings with
arthroscopy findings as well as to improve the relevance of radiology reporting of
shoulder MRI in surgical decision-making.
Background: Shoulder injuries are common among all ages, but tend to be more
widespread with growing age. MRI is an important tool in the diagnosis of rotator
cuff tears. Arthroscopic techniques can evaluate the entire shoulder joint and can
usually fix the tear.
Imaging Findings: The MR characteristics of rotator cuff tears, based on our
hospital data base, are compared with the arthroscopic features to allow a more
comprehensive approach to this entity. All patients underwent an MR investigation
performed using 3 T MR device, and had arthroscopy confirmation.
Conclusion: Correlation be