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Radical Views...
from the Department of Radiology
Volume 5, Number 5
DECEMBER 2012
®
Beth Israel Deaconess
Medical Center
A teaching hospital of
Harvard Medical School
ACRONYMS: FYI
RSNA
In addition to our 4 RSNA Research & Education Foundation Awards*, BIDMC Radiology
acquitted itself well at the 98th Annual meeting of the Radiological Society of North America
in Chicago this year with department members presenting 32 talks and 32 posters, Moderating
10 sessions, and serving as faculty on 12 Refresher Courses. This year’s RSNA was particularly
successful for our Cardiothoracic Imaging section. Please see pg 4 for details!
FROM THE CHIEF
Jonathan B. Kruskal, MD PhD
2012
*
RSNA GRANTS
AND AWARDS
Personalizing DDP’s in PACS
Recently, I wrote to PACS genius Phil Purvis about how some of us (i.e., me) have no clue how
to set our own DDP’s (personalized DDP’s) on PACS such that they remain and work. As the
entire body reading room tried to do this week and failed, I think this is a great opportunity for
improving workflow! After speaking with Phil, who agreed with me that this task requires a bit
of training, we decided that he would put something together for us and set up meetings and
training sessions. So help is on the way!!
M*MODAL: Rolling our Front End Speech Recognition
Speaking of the need for new training, please see page 10 for a welcome and in-depth
Introduction of the new Front End Speech Recognition system from our Director of IT
Radiology, Dr. Jesse Wei.
Today’s Research, Tomorrow’s Practice
Harvard Professors at BIDMC Radiology:
Priscilla J. Slanetz,
MD MPH, & Ronald
Eisenberg, MD JD
- RSNA Education
Scholar Grant
Muneeb Ahmed, MD
- Silver Anniversary
Campaign Pacesetters
Research Seed Grant
Leo L. Tsai, MD
PhD MSc - Bracco
Diagnostics/RSNA
Research Resident
Grant
Olga R. Brook, MD
- RSNA Trainee
Research Prize
Nov. 13, 2012: Recommencing an old tradition of a black tie event at the Harvard Club to celebrate the appointment of
any new professor in our Department. With the recent promotions of Alex Bankier, Ron Eisenberg and Dave Alsop, it was
time to have a major celebration! This is an extremely impressive group and it was my pleasure spending the time
with all of you. - Jonny
cont’d on pg. 3
DEC 2012 Radical Views /1
Radiology Calendar December 2012
Mon
3
Weekly Mon Section Meetings:
3:00-4:00 ED section meeting
(monthly) [ED annex, WCC]
call Trish Gardner 4-2506
Tues
4
7:30 - 9:00
Adult Education
(Program Directors)
7:30 - 8:15
MSK - TBA (Jim Wu)
8:15 - 9:00
Guest Lecture & Case Conference
(Dr. Wing Chan, Dean, Taipei
Medical University)
7:30 - 8:15
Thyroid Imaging (Tony Parker)
8:15-9:00
Thyroid therapy (Tony Parker)
1:00-2:00
Body MRI meeting [Ansin 2]
17
7:30 - 8:15
Fellow Presentation (Som Mai Lè)
8:15-9:00
Cases (Som Mai Lè)
7:30 - 8:00
No conference 8 am start
31
7:30 - 8:00
No conference 8 am start
Weekly Wed Section Meetings:
11:00-12:00 MSK clinical conf
12:00-1:00 CardioThoracic,
GI/GU Oncology
3:00-4:00 Mammo [TCC-484]
8:15 - 9:00
Lymphangiography/case
conference (Barry Sacks)
11
7:30 - 8:15
Brain imaging (Kevin Donohoe)
8:15-9:00
Tagged RBC/GI Imaging
(Donohoe)
10:30-11:30
NMMI meeting [GZ-103]
18
7:30 - 8:15
ICU-Maladies (Paul Spirn)
8:15-9:00
Radiology of the Aorta - II (Diana
Litmanovitch)
8:00-9:00 IR Meeting
[West Recovery]
24
5
7:30 - 8:15
Endocrine interventions
(Barry Sacks)
12:00 - 1:00
Mentoring Meeting #5:
HMS Promotions & Your CV
(Debbie Levine) [TCC 484]
10
Wed
25
Christmas
10:30-11:30
No NMMI meeting [GZ-103]
12
7:30 - 8:15
Non-thyroid therapy (Tony Parker)
8:15-9:00
PET/CT (Tony Parker)
Thurs
Fri
6
7
Weekly Thurs Section Meetings:
12:00 - 1:30 Abd [WCC-354]
12:00-1:00 MSK
12:00-1:00
Chiefs’ Rounds
[Sherman Auditorium]
7:30 - 8:15 Congenital Spine
(Alice Fisher)
8:15-9:00 Congenital Brain (Peri)
2:00-3:00 West MedRads
- Body Senior [TCC 484]
13
14
20
21
7:30 - 8:15
Cardiac SPECT (Thomas Hauser)
8:15-9:00
Cardiac PET (Thomas Hauser)
12:00-1:00
Grand Rounds: Imaging Young
Patients with Inflammatory Bowel
Disease (Michael S. Gee, MGH)
[Sherman Auditorium]
7:15 - 8:00 US meeting
(WCC-304A Gallery)
5:00-6:00 Best in Practice: MRI
Research at BIDMC: An Overview
for MR Techs (David Alsop)
[TCC-10]
19
7:30 - 8:15
Endovenous ablation (Felipe
Collares)
8:15 - 9:00
Endovascular management of PE/
DVT (Salomao Faintuch)
7:30 - 8:15
Sella (Bhadelia)
8:15 - 9:00
Pineal region (Bhadelia)
No Grand Rounds
1:30-2:00 East MedRads
- Nukes Senior [TCC 484]
2:00-3:00 West MedRads
- Body Senior [TCC 484]
26
7:30 - 8:00
No conference 8 am start
27
28
7:30 - 8:00
No conference 8 am start
No Grand Rounds
1:30-2:00 East MedRads
- Nukes Senior [TCC 484]
ly
onth
the m ting:
s
s
i
e
tm
Don’ toring me ons
n
t
oi
me
Prom V
S
M
H
rC
& You Dec 3
a
d y
Mon 1:00 pm
12:00
*Consult the webpage for the most up-to-date schedule:
http://home.caregroup.org/departments/radiology/residency/scheduling/conferences/displayMonthNew.asp
DEC 2012 Radical Views /2
DEPARTMENTAL Grand Rounds
Friday, December 14, 2012
12 noon - 1:00 PM • Sherman Auditorium
Imaging Young Patients with Inflammatory Bowel Disease
Michael S. Gee, MD PhD - Associate Program Director in Radiology, Massachusetts General Hospital;
Assistant Professor of Radiology, Harvard Medical School.
Dr. Gee earned his MD in Medicine and PhD in Cell and Molecular Biology at the University of
Pennsylvania School of Medicine in Philadelphia in 2003. Coming to Boston for post graduate training,
he interned in General Surgery at Boston Medical Center and went on complete residency training
in Diagnostic Radiology which included a clinical focused year in abdominal imaging, interventional
radiology and pediatric radiology at Massachusetts General Hospital. Following completion of a
fellowship in Pediatric Radiology also at MGH, Dr. Gee joined the faculty as an Assistant Radiologist
in 2009. In 2011, he was promoted to his current rank of Assistant Professor of Radiology at Harvard Medical School. Dr. Gee
specializes in abdominal imaging and interventional radiology in pediatric patients and has been active in the development of a
pediatric PET-MRI program as well as the teaching of case-based learning sessions in pediatric radiology at the HMS CME level. We
are honored to have Dr. Gee presenting at Grand Rounds on Dec. 14. His most recent publications and presentations of his topic
include:
Gee MS, Nimkin K, Hsu M, Israel EJ, Biller JA, Katz AJ, Mino-Kenudson M, and Harisinghani MG. Prospective Evaluation of MR
Enterography as the Primary Imaging Modality for Pediatric Crohn Disease Assessment. AJR Am J Roentgenol 2011; 197:224-231.
Gee MS, Quencer KB, Mino-Kenudson M, Harisinghani M, and Nimkin K. Comparison of MR-E and CT-E for assessment of active
inflammation and fibrosis in pediatric Crohn’s disease. Scientific paper presented at the 2012 Society for Gastrointestinal Radiology
meeting, Scottsdale, AZ.
Learning Objectives for Participants: To be able to: 1) understand different IBD imaging modalities and their strengths and
weaknesses; 2) understand unique issues related to ionizing radiation exposure to young patients from imaging studies; 3) review
the spectrum of inflammatory bowel disease.
DEPARTMENTAL NEWS, AWARDS & HONORS:
RSNA 2012 Scrapbook
2012
RSNA GRANTS
AND AWARDS
Today’s Research, Tomorrow’s Practice
Above: Women’s Imaging AND CHIEF Fellow Olga Brook stands with her fellow
Trainee Research Prize winners at RSNA Chicago 2012! Right: Muneeb Ahmed,
Research Seed prize Winner also had the honor of being on the cover of the RSNA
Grants and Awards Guide!
DEC 2012 Radical Views /3
RSNA 2012 Scrapbook
This year’s RSNA was particularly successful for our Cardiothoracic Imaging section. At the conference, we were represented with 4
Refresher Courses, 4 Scientific Presentations, 4 Electronic Posters, 1 Print Poster, and 1 Session Moderation.
In addition, our contributions have received a series of awards:
RG
Magna Cum Laude Award + Invitation to submit to RadioGraphics
Litmanovich D, Boiselle PM, Eisenberg RL, Kulkarni N, Nemec SF, Bankier AA
Dose Reduction in Cardiothoracic CT: A Survival Guide (e-poster)
Certificate of Merits (3)
Litmanovich D, Boiselle PM, Eisenberg RL, Nemec SF, Kulkarni N, Bankier AA
“Two-in-one”: Safety Considerations for Cardiopulmonary Imaging in Pregnancy (e-poster)
Litmanovich D, Hagberg RC, Burke D, Boiselle PM, Bankier AA, Popma J, Raheem SZ
The Role of Imaging in Transcatheter Aortic Valve Implantation (TAVI): What the Radiologist Needs to Know (e-poster)
Kulkarni N, Petkovska I, Nemec SF, Litmanovich D, Boiselle PM, Bankier AA
To be or not to be … a Pulmonary Nodule (print poster)
RG
Invitation for submission to RadioGraphics
Kulkarni N, O’Donnell DH, Boiselle PM, Yildirim A,
Ridge CA, Litmanovich D, Bankier AA
Pulmonary Fissures and Their Importance for Novel
Respiratory Treatments - An Interactive MDCT Teaching
Atlas (e-poster)
Congratulations to all authors and co-authors! Thank you for
all the hard work. Finally, I would like to thank all those who
stayed home reporting and who have given valuable input
along the way, without necessarily being present on the
authorship lists – it is your success, too.
Thank you again,
Alex Bankier, Chief, Cardiothoracic Imaging
DEC 2012 Radical Views /4
RSNA 2012 Scrapbook:
In addition to Cardiothoracic Imaging, efforts in Neuroradiology, MRI and MSK were also recognized with the following awards:
LL-MKE3165
Mary G. Hochman
Jim S. Wu
Department of Radiology
Beth Israel Deaconess Medical Center
Harvard Medical School, Boston, MA
“Don’t Touch” Musculoskeletal Lesions:
ABDOMEN/PELVIS
Pararenal Fat Herniation
CHEST
Sternal Foramen
Radiologists play a key role in recognizing “don’t touch” bone lesions
on radiographs, i.e. findings that are so characteristic of benign entities
that additional work-up or biopsy is not considered necessary (1). Most
radiologists are very familiar with the spectrum of “don’t touch” bone
lesions seen on radiographs. However, there are analogous “don’t touch”
musculoskeletal lesions that are encountered on cross-sectional imaging
studies, in everyday practice, that can pose a greater challenge. This exhibit
reviews a spectrum of musculoskeletal lesions encountered on crosssectional studies that radiologists should recognize as benign or (expanding
the definition for this purpose) potentially benign. In general, these entities
include normal anatomic variants, sequella of prior trauma or surgery, and
recognized benign lesions. Lesions that are definitively benign should
not require additional work-up, while lesions that are potentially benign
may require further tailored assessment. The selection presented here is
illustrative, but cannot be considered exhaustive. Nonetheless, by becoming
familiar with these clearly or potentially benign lesions, the radiologist can
help prevent unnecessary imaging work-up or biopsy, saving patient distress
and health care costs.
Elastofibroma
The sternal foramen is a benign developmental
variant consisting of a 2-16 mm rounded lucency
in the lower third of the midline sternum that
occurs due to incomplete fusion of ossification
centers, found in 3-6.7% of patients. The
borders of the foramen should be well-defined,
smooth, and uniformly corticated, without an
associated soft tissue mass or reactive edema.
The sternal foramen is typically asymptomatic,
but should be reported due to potential
complications from bone marrow biopsy or
acupuncture.
b
a
(a) Coronal CT reformat,
(b) Axial CT, (c) Coronal CT
volume rendered reformat.
Note that the defect lies
midline, in the lower third of
the sternum and has smooth,
corticated borders.
Scapular Foramen
5.
Resnik CS, Brower AC. Midline circular defect of the sternum. Radiology.1979;130:657.
A scapular foramen is a benign normal variant radiolucent
defect in the scapula that can be mistaken for metastasis
or multiple myeloma. One study detected foramina in
29% (27/93) of specimens, most commonly in the body
of the scapula, inferior to the scapular spine. Foramina in
this location were irregularly shaped, ranging from 3-35
mm, and were occasionally multiple. Unlike scapular
b
a
foramina, metastases are often poorly marginated,
may have a soft tissue component, can occur at any site
(a) Axial CT, (b) Sagittal reformat.
Note well-marginated defect and lack of associated
in the scapula, and may involve other bones. Other
soft tissue mass.
sites of scapular foramina: the superior border of the
scapula at the junction with the coracoid process (due
to ossification of the superior transverse ligament); the superior fossa of the scapula, and along the superomedial
border. Scapular nutrient foramina (linear and branching) and, in osteopenia, thinning of the scapular body (large,
variably shaped, and blending gradually with surrounding bone) can also occur.
6.
Yakeler E, Tunaci M, Tunaci A, et al. Frequency of sternal variations and anomalies evaluated by MDCT. Am. J
Roentgenol. 2006;186:956–960.
Hibernoma
References
1.
Helms, CA. Fundamentals of Skeletal Radiology. Third edition. Philadelphia: Elsevier Saunders; 2005.
2.
Scott GS, Dizon LB. Pitfalls in MR Image Interpretation Prompting Referrals to an Orthopedic Oncology Clinic,
Radiographics 2007; 27:805-826.
3.
Wu JS, Hochman MG. Bone Tumors: A practical guide to imaging. New York: Springer; 2012.
4.
Ishii S, Shishido F. Causes of photopenic defects in the lower sternum on bone scintigraphy and correlation with
multidetector CT. Clin Nucl Med 2011; 36: 355–358.
7.
Pate D, Kursunoglu S, Resnick D, Resnick C. Scapular foramina. Skeletal Radiol 1985; 14(4):270-5.
8.
Lee JC, Gupta A, et al. Hibernoma: MRI features in eight consecutive cases. Clin Radiol. 2006; 61(12):1029-34.
9.
Dursun M, Agayev A, Makir B. CT and MR characteristics of hibernoma: six cases. Clin Imaging 2008; 32(1):42-7.
10. Smith CS, Teruya-Feldsteain J, Caravelli JF, Yeung HW. False-positive findings on 18F-FDG PET/CT: differentiation
of hibernoma and malignant fatty tumor on the basis of fluctuating standardize uptake values. AJR Am J
Roentgenol 2008; 190(4):1091-6.
11. Murphey MD, Carroll JF, Flemming DJ et al. From the archives of the AFIP: benign musculoskeletal lipomatous
lesions. Radiographics 2004; 24(5):433-66.
12. Fitzpatrick KA, Taljanovic MS, Speer DP et al. Imaging findings of fibrous dysplasia with histopathologic and
intraoperative correlation. AJR Am J Roentgenol 2004; 182:1389-98.
13. O’Sullivan P, O’Dwyer H, Flint J, et al. Soft tissue tumours and mass-like lesions of the chest wall: a pictorial
review of CT and MR findings. Br J Radiol 2007;80:574–580.
14. Battaglia M, et al. Imaging patterns in elastofibroma dorsi. European Journal of Radiology 2009; 72: 16-21.
15. Higuchi, T, Ogose A, Hotta T, et al. Clinical and imaging features of distended scapulothoracic bursitis:
spontaneously regressed pseudotumoral lesion. J Comput Assust Tomogr 2004; 28(2):223-8.
16. Richardson ML, Zink-Brody GC, et al. MR characterization of post-irradiation edema. Skel Radiol 1996; 25: 537-43.
17. May DA, Disler DG, Jones EA et al. Abnormal signal intensity in skeletal muscle at MR imaging: patterns, pearls,
and pitfalls. Radiographics 2000; 20:S295-315.
18. Stamatiou D, Skandalakis JE, et al. Lumbar hernia: surgical embryology, and technique of repair. American
Surgeon 2009; 75:202-7.
19. Murphey MD, Smith WS, Smith WE, Kransdorf MJ et al. Imaging of musculoskeletal neurogenic tumors:
radiologic-pathologic correlation. Radiographics 1999; 19:1253-1280.
20. Milgram JW. Intraosseous lipomas: radiologic and pathologic manifestations. Radiology 1988; 167:155-60.
21. Grangie C, Garcia J, Howarth NR, et al. Role of MRI in the diagnosis of insufficiency fractures of the sacrum and
acetabular roof. Skeletal Radiology 1997; 26: 517-524.
23. Lagier R, et al. Osteopoikilosis: A radiological and pathological study. Skeletal Radiology 1984; 11(3):161-8.
24. Theodorou DJ, Theodorou SJ, Kakitsubata Y et al. Imaging of Paget disease of bone and its musculoskeletal
complications: a review AJR Am J Roentgenol 201; 96(6):S64-75.
25. Wunderbaldinger P, Bremer C, et al. Imaging features of iliopsoas bursitis. Eur Radiol 2002; 12:409-415.
26. Magee T, Hinson G. Association of Parabral Cysts with Acetabular Disorders. AJR Am J Roentgenol 2000; 174:1381-4.
27. Pitt MJ, Graham AR, et al. Herniation pit of the femoral neck. AJR Am J Roentgenol 1982; 1138:1115-21.
28. Greenspan A. Steiner G. Knutzon R. Bone Island (enostosis): clinical significance and radiologic and pathologic
correlations. Skeletal Radiology 1991; 20:85-90.
29. Chung CB, Gentili A, Chew FS. Calcific tendinosis and periarthritis: classic magnetic resonance imaging
appearance and associated findings. J Comput Assist Tomogr 2004; 28:390-396.
30. Flemming DJ, Murphey MD, Shekitka KM, Temple HT, Jelinek JJ, Kransdorf MJ. Osseous involvement in calcific
tendinitis: a retrospective review of 50 cases. AJR Am J Roentgenol 2003; 181:965-972.
31. Siegal DS, Wu JW, Newman JS, del Cura JL, et al. Calcific Tendinitis: A Pictorial Review. Canadian Association of
Radiologists Annual 2009; 60:263-272.
32. Parikh J, Hyare H, Saifuddin A. The imaging features of post-traumatic myositis ossificans, with emphasis on MRI.
Clin Radiol 2002;57:1058–1066.
33. International Agency for Research on Cancer. Fletcher CDM, Krishnan Uni K, Mertens F, Eds. Pathology and
genetics of tumours of soft tissue and bone. 3rd edition. World Health Organization; 2006.
34. Wu JS, Hochman MG, Soft-tissue tumors and tumorlike lesions: a systematic imaging approach. Radiology 2009;
253: 297-316.
d
Elastofibromas are benign slow-growing tumors comprised of elastin and collagen, almost always (>90%)
arising between the inferior scapula and posterior chest wall, and bilateral in up to 50% of cases. They are more
common after the age of 50 and in women, with reported incidence of 2-17%. They may be asymptomatic or
present with mass effect or pain. The typical appearance is a lenticular mass that mimics muscle on CT and on
T1W MRI, and contains feathery strands of fat. Elastofibromas may have edema-like signal and enhancement on
MRI and may be hypermetabolic on FDG PET. Although the differential diagnosis includes benign and malignant
soft tissue masses, the location, feathery appearance, and, especially, bilaterally support a presumptive
diagnosis.
Scapular Bursitis
Rarely, an adventitial bursa
can arise deep to the scapula,
between the serratus
anterior muscle and the
chest wall. Scapulothoracic
bursae range from 5.5 -12
cm, with variable T1 and
high T2 signal, and may
have fluid levels. Bursae
a
b
c
are cystic. Walls and
internal septae can be
(a) Axial STIR, (b) Axial post-contrast fat saturated T1, (c) Sagittal T1. The
moderately thick and can
lesion lies between the scapula and posterior chest wall. T1 signal can range
enhance, but should be
from isointense to muscle to high T1 signal and fluid levels can occur. Walls
smooth and even, without
and internal septae enhance, but are smooth and even. Here, the lesion was
focal nodular thickening
caused by a scapular osteochondroma (arrowhead). Malignant degeneration
or enhancement. If not
of the cartilage cap should be excluded.
treated, confirmation of
stability or resolution is recommended. Some scapulothoracic bursae arise due to a scapular osteochondroma.
If so, malignant degeneration of the cartilage cap should be excluded. Features concerning for malignant
degeneration are: cap > 2cm thick in adult, indistinct cap margins, soft tissue mass with or without chondroid
calcification, and bone destruction.
Hibernoma is an uncommon benign neoplasm
comprised of brown fat that can present as a painless,
slow-growing , 5-10 cm mass , often presenting in
a
the 3rd or 4th decade. It is most commonly found
b
in the thigh or in areas of residual brown fat such
(a) Axial T1, (b) Coronal STIR
as the neck, axilla, back and mediastinum and can
(c) Axia l post-contrast fat
be located in the subcutaneous fat or within or
saturated T1.
between muscles. A fatty lesion containing a large
c
branching vessel is suggestive of hibernoma.
Location in subcutaneous fat about the neck and
The differential diagnosis does include other benign
shoulders is common. Note that the lesion is not
and malignant neoplasms. Given its vascularity, core
isointense to subcutaneous fat and that it has multiple
needle biopsy has been discouraged. On MRI, the
enhancing internal septations.
typical hibernoma is a well-defined mass, isointense
or slightly hypointense to subcutaneous fat on T1W and isointense or slightly hyperintense on T2W images, with
prominent thin, low signal internal vascular and septal bands and variable enhancement. On CT, hibernomas often
are slightly hyperdense compared to normal subcutaneous fat. Hibernomas can demonstrate increased FDG
activity on PET scan, with SUV similar to liposarcoma, but hibernoma SUVs can vary over time due to changes in
metabolic activity.
Post-Radiation Myositis
Fibrous Dysplasia of Rib
22. Cabarrus MC, Ambekar A, Lu Y, Link TM. MRI and CT of Insufficiency Fractures of the Pelvis and Proximal Femur.
AJR Am J Roentgenol 2008; 191:995-1001.
c
b
a
(a) Axial CT, (b) Axial T1, (c) Axial T2, (d) Axial fat saturated T2. The lesion lies between the serratus anterior
muscle and the posterior chest wall (arrow). It is lenticular in shape and isointense to muscle with feathery
internal fat. Associated edema and enhancement is variable.
c
Fibrous dysplasia is the most common
benign lesion in ribs. While classically
“ground glass”, it also can have cystic,
chondroid or osseous constituents, so
CT density and MRI signal can vary. It
b
a
d
c
tends to be elongated and can cause
Patient 1 - (a) Coronal CT reformat, (b) Axial CT. Rib is expanded. Note
rib expansion and cortical thinning.
involvement of long segment of rib. A small pathologic fracture is present.
Unless there is a fracture, there
Patient 2 - (c) Axial post-contrast fat saturated T1. (d) Radionuclide bone
should be no cortical interruption,
scan. Most cases show increased bone scan activity, often quite marked.
periosteal new bone, or surrounding
soft tissue abnormality. Metastases
and myeloma are also common in ribs, but tend to involve shorter segments, appear more aggressive, and may have
soft tissue extension. All three lesions can involve one or more ribs. Both fibrous dysplasia and metastases can be
positive on bone scan, but the pattern of bone involvement may help in making the distinction.
Sacral Insufficiency Fracture
Lumbar hernia, i.e. protrusion of
intra- or retroperitoneal contents
through a congenital or acquired
defect in the posterolateral
abdominal wall, is a rare entity.
The majority (80%) are acquired
hernias. Of these, most are primary
and spontaneous and occur in
the upper lumbar triangle on the
a
b
left. The remainder of acquired
(a) Axial T1. Fat herniates through a defect in the
hernias are secondary and are
musculature of the posterior abdominal wall, contiguous
related to prior surgical incision,
with pararenal fat. (b) Axial CT. Retroperitoneal
trauma, or lumbar abscess.
liposarcoma with hazy and more confluent soft tissue
Approximately 20% are congenital
density. Note that the hernia exerts traction on abdominal
and may be associated with other
contents while the liposarcoma exerts mass effect,
abnormalities. Lumbar hernias
displacing the kidney anteriorly.
should be distinguished from
well-differentiated retroperitoneal liposarcomas, because liposarcomas are one of the most
common primary retroperitoneal neoplasms. Retroperitoneal liposarcomas typically occur in
patients 50-70 years old. Benign lipomas rarely occur in the retroperitoneum. Lumbar hernias
should demonstrate continuity with the retroperitoneal fat and should not have thickened
septae (>2mm) or nodular soft tissue components. A history of prior surgery or local insult is
supportive. Care should be taken to ensure that the hernia has not developed due to mass effect
from a retroperitoneal mass.
The Cross-sectional Edition
Although not commonly reported, muscle
edema (and sometime enhancement) due
to muscle necrosis (radiation myositis) can be
seen following radiation treatment. While
the muscle edema itself is nonspecific in
appearance, the abnormality may conform to
the sharp, straight borders of the radiation
portal, with sharply demarcated signal
b
a
abnormalities extending beyond the muscle
into surrounding tissues. Awareness of the
(a) Coronal T1, (b) Coronal STIR. Edema and fatty
history of radiation treatment is central
atrophy in the anterior wall musculature due to radiation
to providing this diagnosis. Muscle edema
treatment. Unlike other forms of myositis, post-radiation
peaks at approximately 6 months following
change has sharp borders, conforming to the margins of
neutron radiation therapy and at 12-18 months
the radiation portal.
following photon therapy, and lasts longer
following neutron therapy: complete resolution
of photon-induced myositis tends to occur within 2-3 years (50% of patients) whereas <20% of the patients
treated with neutron therapy showed resolution in 3-4 years. Radiation myositis should be distinguished from
residual or recurrent enhancing tumor nodules in the surgical bed.
Peripheral Nerve Sheath Tumor (PNST)
Peripheral nerve sheath tumors are
often benign, but can be malignant
and that distinction is not necessarily
evident at imaging. However, PNSTs
have characteristic imaging features
that allow the diagnosis of nerve
sheath tumor to be suggested based
on imaging:
• location along the course of a
nerve
• thickened nerve seen entering
and exiting the lesion (tail sign)
• central low T2 signal with
peripheral high T2 signal (target
sign)
• when intramuscular, a rim of fat
surrounding the lesion (split fat
sign).
Patient 1- (a) Axial CT,
(b) Coronal CT reformat.
Patient 2 - (c) Axial STIR,
(d) Radionuclide bone scan.
Fractures may be unilateral
or bilateral. The key is
recognizing that the major
fracture lines run vertically
through the sacral ala.
b
a
c
d
Sacral insufficiency fractures can occur in osteoporotic individuals and can be seen following radiation
therapy to the sacrum. Early fractures may be radiographically occult, but may be visible on MRI or
bone scan. A lucent fracture line may be visible on CT, but when the bone is osteopenic and there
is sclerosis due to healing, the fracture may be difficult to distinguish from tumor, particularly with
known malignancy. The key is recognizing the vertical orientation of the abnormality (equivalent
to the “Honda sign” on bone scan, though transverse fracture component is not always seen). On
CT, thin sections and oblique coronal reformats can help to highlight the vertical fracture line. Stress
fractures may involve multiple contiguous bones, which is less common for metastases unless there is
widespread metastatic disease. The presence of a fracture line, absence of a soft issue mass, and
evidence of healing on sequential studies supports the diagnosis of sacral insufficiency fracture.
Paget Disease
Paralabral Cyst
Fibrous Dysplasia of Femur
Paget disease,
which occurs due to
abnormal, excessive
remodeling of
bone, is a relatively
b
common disorder in
some populations,
though its overall
a
prevalence is thought
to be decreasing.
Skull, spine, pelvis,
(a) Coronal CT reformat,
c
and long bones are
(b) Axial CT, (c) Axial CT.
common sites. Lytic,
Blastic phase of Paget disease in the left iliac bone and right
mixed, and blastic
proximal femur. Note asymetric appearance. Key features are
(sclerotic) phases
cortical and trabecular thickening and enlargement of the bone.
have distinctive
findings and can
coexist in one individual. Patients may be asymptomatic and the disease found incidentally due
to an elevated serum alkaline phosphatase or an abnormal imaging study. Radionuclide bone
scans can show marked activity in Pagetic bone, but not all lesions are “hot” on bone scan. On
CT, the hallmarks of the blastic phase of Paget disease are thickening of cortex and trabeculae
and bony enlargement. MR appearance is variable, but quiescent disease should demonstrate
fatty marrow.
Synovial cysts or ganglia can arise from
the hip joint, occasionally as paralabral
cysts associated with acetabular
labral tears. Lesions appear as wellcircumscribed, rounded, ovoid, or
lobulated, periarticular cystic masses,
consisting of simple or proteinaceous
fluid, with a thin enhancing rim of
intravenous contrast. With sufficient
spatial resolution, communication with
the joint is often visualized, but this
cannot always be established, even when
intra-articular contrast is employed.
Fibrous dysplasia (FD) is a benign
lesion resulting from failure of
normal maturation of bone,
composed of dysplastic fibrous
tissue and immature trabeculae,
b
a
c
sometimes with cystic, chondroid
or osseous components. The
(a) AP radiograph of proximal femur, (b, c) Axial CT. Mixed
proximal femur is the most
lucent and sclerotic lesion, with ground glass density and
common site. Most cases are
sclerotic rim. Fibrous dysplasia can be expansile with endosteal
monostotic, but FD can occur
scalloping (arrow), but it should not have periosteal new bone
as part of McCune-Albright
formation unless fractured and it does not have a soft tissue
syndrome (with café-au -lait spots
component.
and endocrine disorders such as
precocious puberty) or as part of the extremely rare Mazabraud syndrome (intramuscular myxomas).
In the proximal femur, the lesion is often rounded or ovoid, with a thick sclerotic rim, classically
a “long lesion in a long bone”, with a ground glass density, and it can demonstrate endosteal
scalloping, slight bone expansion, and bowing. The MRI appearance is variable. Monostotic
lesions are typically asymptomatic and should not have periosteal new bone formation (unless
fractured) or a soft tissue component. Bone scan often shows marked activity and, in polyostotic
disease, can demonstrate multiple lesions in a characteristic distribution to help support the diagnosis.
Liposclerosing myxofibrous tumor (LSFMT) can have a similar appearance in the proximal femur, but is
rarer, tends to have higher T2 signal intensity, and may contain small speckles of internal fat.
Brown tumors (osteoclastomas)
are accumulations of fibrous tissue
Coronal CT reformat.
and giant cells occurring due to
Lytic lesions are seen
microfracture and hemorrhage from
in the left iliac bone
bone resorption and can occur in all
and proximal femur.
forms of hyperparathyroidism. When
Notwithstanding
multiple lytic lesions are present, Brown
their aggressive
tumors should be considered in the
appearance, these
differential, even when aggressive in
proved to be benign
appearance. Diagnosis is based on
brown tumors.
history (renal failure, malabsorption);
lab findings (elevated serum calcium
and/or parathyroid hormone); other
imaging findings of hyperparathyroidism; and, in 1° hyperparathyroidism, parathyroid adenoma
found on ultrasound or sestamibi scan. Brown tumors should become sclerotic with treatment; lack
of healing with treatment should prompt concern for another diagnosis.
b
Lipoma of Bone
An intraosseous lipoma
is a benign neoplasm
of mature adipocytes
and usually occurs
as an asymptomatic,
incidental finding.
a
The true incidence
is controversial. An
intraosseous lipoma
c
appears as a wellPatient 1 - (a) Coronal reformat,
defined, lucent lesion
(b) Axial CT.
with a sclerotic rim.
Patient 2 - (c) Axial CT.
Common locations
include the proximal
Lucent lesions with wellfemur and ilium. CT
circumscribed borders, sclerotic
is diagnostic due
rims, fat density, and central
b
to fat attenuation.
calcification (arrow).
Fat within the lesion
may be slightly lower
attenuation on CT – and
higher signal intensity on T1W images -- than normal fatty marrow, due to the absence of cellular
elements within the lipoma. The lipoma often has central or peripheral ossification or calcification,
fibrous tissue, and central cystic change. As a result, the MRI appearance can be confusing, without
an accompanying radiograph or CT. Peripheral mineralization results in pathognomonic “bull’s
eye” appearance.
Acknowledgements
Sincere and hearty thanks to Donna Wolfe, Clotell Forde, and Carol Wilcox for their
assistance in the preparation of this project.
Synovial Herniation Pit
Calcific Tendinitis
b
a
c
Patient 1 - (a) AP radiograph, (b) Coronal CT reformat, (c) Axial CT.
c
a
d
(a) Axial CT at level of joint, (b) Axial CT at
level of lesser tuberosity, (c) Axial T1,
(d) Axial fat saturated T2. The bursa
communicates with the joint and, here,
contains multiple dense, high T1, low T2
loose bodies.
b
Note that the bursa follows the iliopsoas tendon, lying immediately anterior to the
anterior column of the acetabulum and hip joint and extends toward the lesser
tuberosity, with a tapered appearance.
The iliopsoas bursa courses along the tendon and can become distended due to fluid from the
hip joint (bursa communicates with joint in 15%) or due to primary inflammation of the bursa.
The key to diagnosis is following the course of the tendon from the abdomen/pelvis, as it
crosses anterior to the hip joint and inserts onto the lesser tuberosity.
Osteopoikilosis
Osteopoikilosis is a rare sclerosing
bone dysplasia that manifests as
multiple, small (2-10 mm), round
or oval, periarticular sclerotic foci.
b
Osteopoikilosis can be scattered in
the axial and appendicular skeleton,
(a) Coronal reformat CT,
however, foci are often seen about the
(b) Axial CT. Multiple sclerotic
pelvic and shoulder girdles. Unlike
lesions distributed about
a
multiple metastases, osteopoikilosis
the hip joints, typical for
osteopoikilosis.
is usually asymptomatic, symmetric
in distribution, should not be
associated with bone destruction or periosteal new bone formation, does not typically show
uptake on bone scan, and may have characteristic involvement of the metacarpal bones or may
have skin lesions (dermatofibrosis lenticularis disseminata). Unfortunately, on occasion, small sclerotic
metastases might “hide” within osteopoikilosis. Mastocytosis and tuberous sclerosis are also in the
differential.
b
Iliopsoas Bursitis
Brown Tumor
a
(a) Coronal T1, (b) Sagittal T2,
(c) Close-up sagittal T2. Ovoid
mass, oriented along the
course of a nerve. Note central
low signal and peripheral high
T2 signal (opposite of necrosis)
and thickened segment of
nerve entering and exiting the
nerve (arrows).
c
a
(a) Coronal T1, (b) Axial STIR close-up. A lobulated
well-circumscribed mass (arrows) demonstrates
fluid signal and hugs the hip joint, consistent with
a paralabral cyst. The lesion may not necessarily fill
with contrast on a hip arthrogram.
Ischiogluteal Bursitis
Ischiogluteal bursitis is an
uncommon condition, resulting
in accumulation of bursal fluid
between the ischial tuberosity and
overlying musculature. Reported
cases have been associated with
repetitive trauma (“weavers
bottom”), gout, and mechanical
irritation due to metastasis. The
a
b
inflamed bursa can be mistaken
for a mass or abscess on physical
(a) Axial STIR. (b) Axial post-contrast fat saturated T1.
exam or on an imaging study.
There is a fluid collection along the posterior edge of
Patients present with buttock
the ischial tuberosity. The bursa typically originates
pain which may radiate into the
between the ischial tuberosity and gluteus maximus
posterior leg and be mistaken
muscle. While the fluid collection itself is nonspecific,
for sciatica or hamstring
the location is highly suggestive of fluid in an inflamed
tendinopathy. Imaging findings
bursa.
are consistent with bursae seen
elsewhere. Knowledge of the
entity, its characteristic location, and the relevant clinical scenarios can help to prevent
misdiagnosis.
The classic synovial
herniation pit is a rounded,
< 1 cm, lucent focus at the
anterior femoral head-neck
junction, but can be larger
or posterior. It invariably
communicates with the
surface of the bone.
b
a
d
c
Patient 1 - (a) Coronal STIR, (b) Post-contrast fat saturated T1. MRI shows prominent edema
and enhancement in the region of the right gluteus medius tendon. This could be mistaken for
inflammation or infection because the small focus of hydroxyapatite (arrow) is not readily visible.
a
Patient 2 - (c) Axial CT, (d ) Sagittal CT reformat. Hydroxyapatite at the insertion of the gluteus
maximus tendon onto the posterior femur. Calcific tendonitis can cause bone erosion and be
mistaken for an aggressive lesion. The key is seeing the calcification on radiographs or CT and
recognizing the association with a tendon.
b
Patient 2 - (c) Axial T1, (d) Axial fat saturated T2.
Synovial herniation pits (Pitt’s pit) have traditionally been considered an incidental, asymptomatic
finding, though more recently some authors have posited an association with femoro-acetabular
impingement. These lesions are quite common. They are typically small (<1 cm) rounded lucencies
with a sclerotic rim, found in the anterosuperior femoral neck, at the proximal femur headneck junction. However, they can grow to 2-3 cm and become multi-lobulated and they can
sometimes occur posteriorly. Cross-sectional images should help demonstrate continuity with the
cortical surface of the femur. The characteristic location and presence of a sclerotic rim should help
distinguish a synovial herniation pit from a metastasis.
Calcific tendinitis, caused by calcium hydroxyapatite crystal deposition in tendons, is a common
cause of peri-articular pain and is common at the shoulder and hip. Calcific tendinitis typically affects
patients 30-60 years old and is slightly more common in women. It appears as a focal calcification
adjacent to the joint, but can be easily overlooked on MRI unless there is concomitant edema.
However, when accompanied by soft tissue or marrow edema or by bone erosion, calcific tendinitis
can be mistaken for an aggressive infection or neoplasm. For MRI, a correlative radiograph can
help to demonstrate the calcification within the tendon and guide the proper diagnosis. In the
resorptive phase, calcifications appear fluffy and amorphous, are often associated with acute onset of
pain and decreased mobility, and can raise clinical concern for septic arthritis or fracture.
Bone Island
Myositis Ossificans (MO)
Bone islands (enostoses) are
extremely common, asymptomatic,
normal variants (hamartomas)
consisting of cortical bone arising
within the medullary cavity.
Classically, a bone island is an oval
c
b
or rounded sclerotic focus, <1 cm, a
with a spiculated “brush border” Patient 1 - (a) Axial CT.
(short spicules), that occurs near
Patient 2 - (b) Coronal reformat CT, (c) Axial CT. A bone island
a joint and aligns parallel to the
had a characteristic spiculated “brush border,” lies near a joint,
long axis of the bone. On MRI, a
aligns along the long axis of the bone, and is homogeneously
bone island is low signal on T1- and low signal on all MRI sequences, without reactive edema. It
occasionally has a lucent center.
fat saturated T2-weighted images,
similar to cortical bone, and
does not have surrounding marrow edema. On CT, the lesion may be uniformly dense or may have a
lucent center. In patients with prostate or sclerotic metastases, the differential diagnosis could include
a sclerotic metastasis, but bone islands should be asymptomatic and should not have reactive marrow
edema or bone scan activity. (Bone scan activity is extremely rare, though has been described in a large
or actively growing bone island.) Although sclerotic metastases may have an irregular border, they do
not usually have the typical spiculated brush border of a bone island. Moreover, prostate metastasis is
unlikely if the PSA is <10 ng/mL (unless the patient is s/p prostatectomy, in which case any detectable
serum PSA would be suspicious). Low grade osteosarcoma can present as focal sclerotic intramedullary
lesion, but is usually larger and painful. Consider biopsy if the lesions grows > 2 5% in 6 months or
>50% in 1 year.
a
b
c
d
Myositis ossificans. (a) Axial T1, (b) Axial STIR, (c) Coronal post-contrast fat saturated T1, (d) Axial
CT reformat with femur abducted. Myositis ossificans can be mistaken for a mass lesion on MRI
(arrows). Radiographs or (more sensitive) CT show ossification with characteristic “zoning,” i.e.,
increased density peripherally. In paraplegics, patients with traumatic brain injury, or a history of
direct trauma, the index of suspicion should be high.
Myositis ossificans is a benign ossifying soft tissue mass that occurs in muscle, usually in the large
muscles of the extremities, including the thigh and upper arm. Patients may be asymptomatic or may
present with pain and swelling, with or without a recalled history of trauma. Calcification becomes
evident several weeks after onset and is characterized by a “zonal pattern,” starting peripherally
and progressing centrally. The calcification evolves from faint irregular densities to dense
calcification to a rim of mature lamellar bone with central osteoid matrix. Mature MO parallels bone
on MRI, low signal peripherally and isointense to fat centrally, with no surrounding edema. However,
early stage MO can be mistaken for sarcoma, as it presents with irregular borders, heterogeneously
low T1/ high T2 signal, internal enhancement, and surrounding edema. In paraplegics, patients
with traumatic brain injury, or a history of direct trauma, the index of suspicion should be high
and radiographs or CT should be obtained to assess for the zonal pattern of mineralization that
could be easily overlooked on MRI.
Imaging Evaluation of Orbital Reconstruction with a Clinical Perspective.
Daniel T. Ginat, Suzanne K. Freitag, Mary E. Cunnane, Gul Moonis
RG
“Don’t Touch” Musculoskeletal Lesions: The Cross-sectional Edition.
Mary G. Hochman, Jim S. Wu
The following posters were also presented
at RSNA and are notable for being genderspecific and we include them here for your
information and appreciation:
State-of-the-Art MRI for Chronic Pancreatitis: Spectrum of Findings and
Proposal of New Noninvasive Scoring System.
Daniel A.T. Souza, Koenraad J. Mortele
Finding a Voice: Imaging Features after Phonosurgical Procedures for Vocal
Cord Paralysis Rehabilitation. Behroze Vachha, Mary E. Cunnane, Pavan
Mallur, Gul Moonis
RG
Revised Atlanta Classifi cation of Acute Pancreatitis: Imaging
Features, Standardized Reporting Nomenclature, and Potential
Complications. Peter E. Humphrey, Steven C. Eberhardt, Scott C.
Carter, Koenraad J. Mortele
Stress Fractures in Female Athletes:
LL-MKE3153
Stress Fractures in Female
Athletes
Purpose: To present the clinical hallmarks and
supporting imaging findings specifically relevant to
musculoskeletal injuries in female athlete triad.
2
1
Fig 4. Left hip MRI
coronal T1W(a) and fatsaturated T2W(b) images
and axial T1W(c) and
fat-saturated T2W (d)
images demonstrating
linear low T1 and
T2 signal in the left
inferior pubic ramus
with surround high
T2 signal, consistent
with a nondisplaced
fracture (red arrows).
• Discusses the unique physiologic aspects of female
athlete triad relating to specific sports injuries,
specifically stress fractures
• Demonstrates relevant imaging findings in DEXA
scan and MRI that aid in the diagnosis of female
athlete triad and associated injury of stress fracture
Optimal Energy
Availability
Reduced Energy Availibility
with or without
Disordered Eating
Low Energy Availablity
with or without
an Eating Disorder
Functional
Hypothalmic
Amenorrhea
Subclinical
Menstrual
Disorders
Optimal Bone
Health
Low
BMD
a
a
b
b
d
c
a
b
Fig 3. Bilateral calf MRI T1W (a) and fat-saturated T2W (b) coronal images as well as right (c) and left
(d) sagittal fat-saturated T2W images with foci of low T1 signal and high T2 signal, consistent with
bilateral tibia stress reaction (red arrows).
Fig 2. Right tibia and fibula
AP radiograph (a) and lateral
radiograph (b) demonstrating
focal cortical thickening of the
lateral proximal fibula diaphysis
(red arrows), consistent with a
healing stress fracture.
• Female athlete triad (FAT) is syndrome of decreased energy
availability, menstrual dysfunction, and/or decreased bone
density in the female athlete.
• Female athlete triad causes considerable health risks to the
female athlete that may not be reversible.
This exhibit:
• Defines female athlete triad, an interrelated
spectrum of disordered eating, irregular menstrual
cycles, and low bone density
Summary: Female athlete triad requires a multidisciplinary
team for treatment and diagnosis, including but not limited
to the sports medicine physician and musculoskeletal
radiologist. DEXA and MRI play an important role in the
diagnosis of female athlete triad and its related injuries.
Summary:
2
Manjiri M. Didolkar , Bridget J. Quinn , Mary G. Hochman
1
Conclusions:
Dept. of Radiology, Beth Israel Deaconess Medical Center
Dept. of Orthopaedics, Beth Israel Deaconess Medical Center;
Division of Sports Medicine, Boston Children’s Hospital
Harvard Medical School, Boston, MA
1
Clinical Presentation & the Role of Imaging in Female Athlete Triad
There is additional
surrounding edema
(surrounding high
T2 signal).
c
Fig 1. Female Athlete Triad. The female athlete
triad refers to the interrelated relationship of energy
availability, menstrual function, and bone health.
Athletes can move anywhere along the spectrum
depending on their diet and exercise habits. They may
not show all clinical conditions simultaneously.
Energy availability refers to the amount of dietary
energy remaining for body functions after exercise. An
athlete does not need to be diagnosed with an eating
disorder to have low energy availability. Athletes may
reduce their energy availability by disordered eating
such as restricting calories, increasing their exercise
energy expenditure, fasting, binge-eating and purging,
diet pills, laxatives, diuretics, and enemas. Some athletes
have clinical eating disorders such as anorexia nervos
or bulimia nervosa. Athletes at risk are those who
participate in sports that emphasize leanness, such as
distance running, light-weight rowing, dance, figure
skating, and gymnastics. Low energy availability affects
bone health indirectly by causing menstrual dysfunction
and directly by suppressing bone forming metabolic
hormones.
Menstrual function refers to the range between normal
menstrual cycles that occur every 28 days + 7 days
(eumenorrhea) to the absence of menstrual cycles
lasting more than 3 months (amenorrhea). Functional
hypothalamic amenorrhea results from low energy
availability and a disruption in the hypothalamicpituitary axis. This decrease in estrogen’s restraint on
bone resoprtion can lead to a decrease in bone density.
Bone health refers to the accumulation and maintenance
of bone, including the quality of bone protein, internal
bone mineral structure, and bone mineral density (BMD).
Bone is influenced by energy availability, menstrual
status, genetics, behavior, and environment. The current
method for evaluating bone health is by measuring
BMD with dual energy x-ray absorpitometry (DEXA). The
International Society for Clinical Densitometry (ISCD)
recommends that BMD in children, adolescence, and
premenopausal women be expressed as Z-scores to
compare age and sex-matched controls. Since athletes
in weight-bearing sports typically have higher BMD than
non-athletes, the American Academy of Sports Medicine
(ACSM) recommends that a Z-score <1.0 be further
investigated. The ACSM classifies low bone density for
age and activity level as a Z score between -1.0 and -2.0
with secondary risk factors for fracture. Osteoporosis
in athletes is defined as a Z-score < -2.0 with secondary
clinical risk factors for fracture.
The female athlete triad can significantly impact an
athlete’s reproductive and musculoskeletal health.
These athletes are at increased risk of fractures,
injuries, infertility, and depression/anxiety.
c
Table 1. Bone Density:
Region
PA Spine / L1-L4
Left Hip /
Femoral Neck
Exam
Date
07/30/12
BMD
(g/cm2)
0.866
T-Score
-1.6
PR
83
Z-Score
-1.6
AM
83
07/30/12
0.704
-1.3
83
-1.2
84
World Health Organization criteria for BMD interpretation classify patients as Normal (T-score
at or above -1.0), Osteopenic (T-score between -1.0 and -2.5), or Osteoporotic (T-score at or
below -2.5).
Fig 2c and Table 1. DEXA study demonstrating increased fracture risk and low bone
density for age and activity level in the lumbar spine and the left femoral neck with Z
scores < -1.0.
•
•
•
Nutrition:
•
29 yo F distance runner
Completed the Boston Marathon in 3:38. Initially decreased mileage
after, and then rapidly ramped up mileage from 30 to 60 miles/week
Presented with right lateral calf pain with running and walking
•
•
History of restrictive eating patterns in college with weight loss, no
history of anorexia or bulimia
Focused on eating a “healthier” diet by eating less carbs
Takes Vit D 400 IU daily
Menstrual
Hx:
•
•
Onset of menses at age 12, occurring ~28 days
Currently taking OCPs, never missed a cycle for > 3 mos
Bone Hx:
•
Prior history of a left tibia stress fracture associated with running
•
•
•
•
•
Height 5 ft 2 in, Weight 109 lbs, BMI 19.9
Well-developed, well-nourished, healthy-appearing
BLE exam - no redness, warmth, swelling, bruising, or bony deformity
Positive hop test, heel strike, and three-point bend test
Point tender over the proximal aspect of her fibula
Diagnosis:
•
•
Right proximal fibular stress fracture
Concern for female athlete triad
Treatment:
•
•
6 weeks of relative rest, avoided impact, was allowed to cycle and swim
Pain-free on f/u evaluation and placed on a return-to-running program
and gait analysis under guidance of a sports physical therapist
Returned to running
Physical
Exam:
•
Nutrition:
Table 2. Bone Density:
Region
PA Spine / L1-L4
Left Hip / Femoral
Neck
Exam
Date
11/11/11
BMD
(g/cm2)
0.828
T-Score
-2.0
PR
79
Z-Score
-1.9
AM
80
11/11/11
0.778
-0.6
92
-0.6
92
World Health Organization
criteria for BMD interpretation
classify patients as Normal
(T-score at or above -1.0),
Osteopenic (T-score between
-1.0 and -2.5), or Osteoporotic
(T-score at or below -2.5).
Patient 2
Patient 1
History:
e
•
•
All labs (hemoglobin/hematocrit, Ca, vit D, PTH, Mg, Phos, alb/total
protein levels, TSH/free T4, chem, celiac panel) WNL
Sports nutritionist evaluation, recommended increase protein; also GI
evaluation, diagnosed with bacterial overgrowth of small intestine
Strong emphasis placed on maintaining energy availability
Menstrual
Function:
•
Continue OCP
Bone:
•
•
•
History:
•
•
•
•
Denies restrictive eating
Denies history of anorexia, bulimia, or purging
Nutrition:
•
•
•
•
Placed on Caltrate after diagnosis of her stress fracture
Not getting a lot of Ca and vit D
Admits to calorie restriction and restrictive eating with recent weight loss
•
•
History of irregular cycles, onset of menses at age 11
Menses after age 18 became sporadic, placed on OCP
Stopped OCP during increased running period, cycles again became sporadic
Gone > 3 mos without a cycle, has been amenorrheic in the past
Menstrual
Hx:
Bone Hx:
•
No history of prior fractures
•
•
•
•
Onset of menses at age13-14
Started OCPs at age 14 due to menstrual irregularity
At age 22 she was taken off OCP; cycles were regular
During marathon training, stops getting her period; this can persist for > 3 mos
•
•
•
•
Height 5 ft 2 in, Weight 116 lbs, BMI 21.2
Well-developed, well-nourished, healthy-appearing
BLE exam - positive hop test, heel strike test, three-point bend test
Point tender over mid antero-medial tibias
Bone Hx:
Diagnosis:
•
•
Bilateral tibia stress reaction
Concern for female athlete triad
Treatment:
•
•
Relative period of rest, allowed to cycle, swim, and ambulate as tolerated
6 week f/u and began a gradual return to running program
•
•
Sports nutrition evaluation to optimize energy availability
BMI 21.2 considered healthy; however, counseled on energy availability and
concern regarding further weight loss
All labs (Hemoglobin/hematocrit, Ca, vit D, PTH, Mg, Phos, chem, alb/total
protein) WNL
•
Menstrual
Function:
•
•
•
placed on holiday from norethindrone to evaluate menstrual cycle
Labs (LH, FSH, estradiol, prolactin, TSH/free T4) WNL
With decrease in energy expenditure during relative period of rest, patient
resumed menses every 28 days
•
BMD - low bone density for age and activity level in the spine
Bone density tends to be higher in the hips of runners due to the impact nature
of their sport but lower in the spine
4.
Nattiv A, Loucks AB, et al. ACSM position stand: the female athlete triad. Med Sci Sports
Exerc. 2007; 39 (10):1867 – 82.
Deimel JF, Dunlap BJ. The female athlete triad. Clin Sports Med. 2012; 31: 247-254.
Iwatomo J, Sato Y, et al. Analysis of stress fractures in athletes based on our clinical
experience. World J Orthop. 2011; 2 (1): 7-12.
Khan AA, Bachrach L, et al. Standards and guidelines for performing central dual-energy
x-ray absorptiometry in premenopausal women, men, and children. J Clin Densitom. 2004;
7 (1): 51-63.
Bonnick SL. Current controversies in bone densitometry. Rheumatol. 2002; 14: 416-420.
26 yo F runner
Increased milage from 3-4 days/week to 5 days/week training for the San Diego
marathon
Initially diagnosed with proximal hamstring syndrome
Referred for probable left hip inferior pubic ramus stress fracture which she
sustained while training
•
•
Bone:
BMD - low bone density for age and activity level
Sports nutritionist counseled on optimizing energy availability and
micro/macro nutrients while training
25 yo F distance runner
Increased her running distance from 2-3 miles 3x/week to 4-7 miles 4x/week
Presented with bilateral tibia pain
Positive recent weight loss
Menstrual
Hx:
Nutrition:
2.
3.
5.
Nutrition:
Physical
Exam:
1.
Patient 3
History:
•
•
•
•
References:
f
e
• Initially, a female athlete may seek specialty care for
injuries. While female athlete triad may be a consideration,
imaging is used first to diagnosis the injuries, including
stress fractures and fractures.
• The diagnosis of fractures or stress fractures in these
athletes may lead to the initial evaluation of female
athlete triad. Of equal importance is the awareness
and correct reporting of the Z-scores on DEXA scans
in addressing the bone mineral density component of
female athlete triad.
DEXA study
demonstrating
normal bone
density of the
lumbar spine (e)
and femoral
necks (f).
Fig 3e, Table 2. DEXA study demonstrating an increased fracture risk and low bone density for age
and activity level in the lumbar spine with a Z score <1.0 and no increased fracture risk and normal
bone density of the left femoral neck.
• A symbiotic relationship between the sports medicine/
orthopaedic physician and radiologist would best serve
the female athlete.
For the radiologist:
d
f
Multidisciplinary approach needed:
• This should lead to the investigation of female athlete triad
including energy availability, menstrual function, and bone
mineral density.
Osteoporosis
Nattiv A, et al. ACSM Position Stand. The Female Athlete Triad.
Med Sci Sports Exerc. 2007; Oct (10) 39:1867-82
• Severe undernutrition impairs reproductive and skeletal
heath; menstrual irregularities and low bone mineral
density increase stress fracture risk.
•
•
No prior stress fracture
Prior traumatic fractures to wrist and ankle
Physical
Exam:
•
•
•
•
•
Height 5 ft 3 in, weight 130 lbs, BMI 23.0
Well-developed, well-nourished, healthy-appearing
Positive hop test on the left
Point tenderover the left inferior pubic ramus
Pain with resistive hamstring and adductor testing
Diagnosis:
•
•
Nondisplaced left inferior pubic ramus fracture
Concern for female athlete triad
Treatment:
•
Activity modification and relative period of rest with swimming and aquatic
running
Repeat MRI revealed healing stress fracture
•
Nutrition:
•
•
Menstrual
Function:
Bone:
•
•
Nutrionist evaluation due to restrictive eating and lack of food with Ca and vit D,
incorporated variety of protein, dairy, multivitamin
Received counsel on energy availability
•
During relative period of rest, resumption of menses
Serologic evaluation normal thus diagnosis made of functional hypothalamic
amenorrhea
Counseled on optimal energy availability and nutrition
•
BMD - Normal for age and activity level
a
b
c
d
Fig 5. Pelvis MRI coronal T1W (a) and fat-saturated T2W (b) images
and axial T1W (c) and fat-saturated T2W (c) images demonstrating
linear low T1 and T2 signal in the left inferior pubic ramus with cortical
thickening and decreased surrounding high T2 signal, consistent with
a healing nondisplaced fracture (red arrows).
DEC 2012 Radical Views /5
RSNA 2012 Scrapbook:
Interventional Radiology in Men’s Health
ABSTRACT: The interventional radiologist can take on a growing role
in men’s health issues with a working knowledge of several common
conditions, for which the epidemiology, diagnostic work-up, imaging
findings, and endovascular management are presented here.
Erectile Dysfunction
Priapism
Erectile dysfunction is the inability to achieve and maintain penile erection sufficient for
sexual intercourse. It affects over 16% of men, increases in prevalence with aging and can be
classified as organic or psychogenic. Risk factors include obesity and smoking. Drug side effects
cause up to 25% of ED.
Priapism is a persistent erection of the penis not associated with sexual stimulation. The incidence
is 2.9 per 100,000 person-years, being more prevalent in men with sickle cell disease or those
using intracorporal injections for erectile dysfunction. Based on the pathophysiology, priapism
is classified as low-flow and high-flow. The low-flow type (aka veno-occlusive type) is the most
common, and occurs due to venous thrombosis leading to decreased venous outflow. This
results in a compartment-like syndrome and significant risk of tissue necrosis; hence, it is a surgical
emergency. The high-flow type is almost always seen in the traumatic setting, typically from a
straddle injury, leading to fistula formation.
CAVERNOUS
BRANCH
CORPUS CAVERNOSUM
DORSAL ARTERY
BULB
BU
LB
BULBOUS
O
AR -UR
BRANCH
TE ET
RY HR
AL
ANTERIOR
BRANCH
GLANS PENIS
2a
2b
2c
Fig 3. Arterial anatomy of the penis
Fig 7: Selective
internal pudendal
arteriograms
before and after
embolization of
the cavernosal
artery with Gelfoam
demonstrates
continued flow to the
dorsal penile artery
but no flow to the
deep penile artery
2d
Fig 2.
a) Internal iliac arteriogram
b) Selective arteriogram of the inferior vesical/prostatic artery trunk
c) Super selective arteriogram of the prostatic branches
d) Selective arteriogram before and after embolization of the prostatic branches
Fig 4. Internal iliac anterior division arteriogram
Varicocele
Fig 6: Internal
pudendal arteriogram
demonstrating the
cavernosal blush, a
bilateral, symmetric
stain at the base of
the penis that washes
out and should not
be mistaken for
extravasation
CORPUS SPONGIOSUM
INTERNAL PUDIC
ARTERY
Fig 1. Gross pathology of the arterial supply of the prostate with selective iliac arteriogram correlate
Beth Israel Deaconess Medical Center
Harvard Medical School, Boston, MA
Evolving Applications
Benign Prostatic Hypertrophy
BPH affects 40-50% of men aged 51-60, and 80% of men over 80. Most frequently, patients
present with decreased urinary stream, increased frequency and urgency.
LL-VIE1147
Sahil V. Mehta, Salomao Faintuch
Fig 5. Selective right internal pudendal arteriogram
Varicocele, described 2,000 years ago by Celsus as decreased testicular size with an enlarged hemiscrotum,
is caused by dilated scrotal veins. Its prevalence is as high as 20%; the majority being left sided (90%). The
presence of isolated right sided varicoceles should prompt evaluation for an obstructing mass.
Internal
appearance
of dilated
veins
Copyright © 2003 Society of Interventional Radiology
Anatomic Considerations
Pathophysiology
Procedural & Technical Considerations
Pathophysiology
BPH develops primary in the peri-urethral or transitional
zones of the prostate. Prostatic enlargement depends
on the potent androgen dihydrotestosterone (DHT).
In the prostate, type II 5-alpha-reductase metabolizes
circulating testosterone into DHT, which works locally.
Microscopically, BPH is a hyperplastic process resulting in
prostate enlargement, leading to urethral compression
which may restrict urine flow from the bladder. Besides
extrinsic urethral compression, there is also excessive
smooth muscle contraction causing additional urine flow
restriction.
The prostatic artery has variable origins, ranging from
the anterior (gluteal-pudendal) trunk, umbilical artery,
internal pudendal artery, inferior gluteal artery or the
obturator artery. In most cases (41.5%–74.3%) the
prostate gland is supplied by a common arterial trunk
(prostate-vesical) that gives rise to the inferior vesical
artery and the prostatic artery.
Organic causes of ED can be classified into vascular,
neurogenic, anatomic and endocrine. Vascular
causes of ED are either arterial or venous.
Atherosclerotic or traumatic arterial occlusive
disease can decrease the perfusion pressure and
arterial inflow, thus increasing the time to maximal
erection and decreasing rigidity. On arteriography,
bilateral diffuse disease of the internal pudendal,
common penile, and cavernosal arteries has been
found in impotent patients with atherosclerosis. On
the other hand, focal stenosis of the common penile
or cavernosal artery is most often seen in young
patients who have sustained blunt pelvic or perineal
trauma. Failure of adequate venous occlusion has
been proposed as one of the most common causes of
vascular impotence. Veno-occlusive dysfunction may
result from acquired venous shunts (surgical correction
of priapism), degenerative changes (Peyronie’s disease,
old age, and diabetes) or traumatic injury to the tunica
albuginea.
The internal pudendal artery divides into the dorsal
penile and the cavernosal (deep) arteries of the penis.
The bulbo-urethral artery supplies the bulb of the
urethra, the corpus spongiosum and the glans penis.
It may arise from the cavernosal, dorsal or accessory
pudendal arteries.
High-flow priapism results from unregulated blood
flow from to the lacunar spaces of the corpora
cavernosa. There is constant inflow and outflow as there
is no venous obstruction.
Prior to the procedure, effort should be made to identify
the side of the fistula with Doppler ultrasound. Selective
arteriography of both external and internal pudendal
arteries should be performed. Embolization should be
performed in a highly selective fashion in the minor
arterial branches (usually deep penile or cavernosal)
to avoid ischemic complications. After treatment of
the fistula, the contralateral side should be imaged to
look for additional fistula. If small, it may be treated
expectantly.
The primary etiologic factor is a right-angle entry of
the left spermatic vein into the high pressure system of
the left renal vein. This creates a hydrostatic column of
pressure against which the pampiniform plexus must
function to allow testicular venous outflow in the upright
position. Other factors include congenital absence of
valves and extrinsic compression.
Clinical Presentation & Management
Although nearly all men develop histological BPH, the
degree of prostatic enlargement and resulting symptoms
is quite variable. The severity of lower urinary tract
symptoms (LUTS) is best quantified using the American
Urological Association (AUA) symptom index.
The effectiveness of medical therapy such as 5-alpha
reductase inhibitors and selective alpha blockers
has replaced surgical treatment in most cases of
symptomatic BPH. However, transurethral resection or
prostatectomy remain the gold standard for patients who
develop complications of BPH or who are refractory to
medical therapy (approx. 25% of patients). Bleeding,
infection, urethral strictures, prolonged pain, incontinence
or urinary retention and sexual dysfunction are
complications associated with surgical treatments.
The Role of the Interventional Radiologist
In the past, prostatic artery embolization (PAE) was
only utilized for prostatic bleeding after biopsy or surgical
intervention. Recently, animal studies and preliminary
clinical trials suggest that PAE can be a promising
treatment alternative to surgery for BPH. Animal studies
demonstrated marked volume reduction in treated
prostates. Initial reports in humans have shown not only
gland volume reduction, but also improvement in
symptom scores and peak urinary flow.
LL-BRE3193
Procedural & Technical Considerations
Most of the patients described in the literature, treated by
a single research team, underwent embolization of the
bilateral prostatic arteries with nonspherical 200-micron
PVA particles. The endpoint chosen for embolization was
slow flow or near-stasis, and absence of prostatic gland
opacification.
Outcomes
In the largest study to date, PAE was technically successful
in 14/15 patients (93.3%). Mean follow-up = 7.9 months.
International Prostate Symptom Scores decreased 6.5
points, quality of life improved 1.14 points, International
Index of Erectile Function increased 1.7 points, and
peak urinary flow increased 3.85mL/sec. There was a
mean PSA antigen reduction of 2.27ng/mL and a mean
prostate volume decrease of 29mL by MRI. There was one
reported major complication (bladder wall ischemia) and
four clinical failures (28.6%). More studies are needed to
establish the future role of prostatic artery embolization in
the treatment of benign prostatic hyperplasia.
References
1. Pisco JM, Pinheiro LC, Bilhim T, Duarte M, Mendes JR,
Oliveira AG. Prostatic arterial embolization to treat
benign prostatic hyperplasia. J Vasc Interv Radiol. 2011
Jan;22(1):11-9; quiz 20.
2. Bilhim T, Pisco JM, Furtado A, Casal D, Pais D, Pinheiro LC,
O’Neill JE. Prostatic arterial supply: demonstration by
multirow detector angio CT and catheter angiography.
Eur Radiol. 2011 May;21(5):1119-26.
Role of the Interventional Radiologist
The majority of erectile dysfunction can be
managed with non-endovascular treatments such as
phosphodiesterase inhibitors (sildenafil, vardenafil,
tadalafil). However, in the presence of a fixed arterial
obstruction, enhanced smooth muscle relaxation may
not be met with an increase in arterial infow to the
corpora cavernosa, resulting in a suboptimal response
to phospodiesterase inhibitor therapy. Therefore,
endovascular treatment (angioplasty or stent
placement) of atherosclerotic disease in the internal
iliac and internal pudendal arteries may be indicated.
Also, diagnostic arteriography and endovascular
intervention can play a role in patients with focal
arterial stenosis secondary to perineal trauma.
Endovascular treatment has been used for both
arterial and venous problems. Babaev et al.
reported three patients treated with endovascular
revascularization by stent placement, each with
improvement in their erectile function. The ZEN trial
designed to treat ED in 50 patients with drug eluting
stent placement is currently underway.
On the venous side, numerous techniques have been
proposed to reduce leakage. Miwa et al. treated 10
patients with pelvic venoablation using ethanol. At
short-term follow-up (<6 months), 7 patients (70%)
reported erections sufficient for vaginal insertion; at
the long-term follow-up visit (mean 32 months), 5 men
(50%) reported sustained, sufficient potency and
5 (50%) reported persistent erectile dysfunction.
Currently, as no consensus exists on the treatment of
either arterial insufficient ED or venous leakage ED,
additional studies are needed.
1. Babaev A, Jhaveri RR. Angiography and endovascular
revascularization of pudendal artery atherosclerotic
disease in patients with medically refractory erectile
dysfunction. J Invasive Cardiol. 2012 May;24(5):23640.
2. Heidelbaugh JJ. Management of erectile
dysfunction. Am Fam Physician. 2010 Feb
1;81(3):305-12. Review.
Jordana Phillips MD, Priscilla J. Slanetz MD MPH, Tejas S. Mehta MD MPH,
Nancy Littlehale NP, Shambhavi Venkataraman MD, Valerie J. Fein-Zachary MD
Beth Israel Deaconess Medical Center • Harvard Medical School, Boston, MA
In this exhibit, we aim to:
1. Clarify the use of transgender terminology
2. Identify breast health issues and barriers faced by transgender
patients
3. Review current breast screening recommendations for transgender
patients
4. Discuss expected imaging findings and common abnormal imaging
findings in this population
Terminology
Provider education regarding correct terminology is crucial to eliminating
stigma, improving access, and providing quality care.
Sex
Gender identity
Gender expression
Gender nonconformity
Transgender
Gender dysphoria
Transsexual
MTF: Male to Female
transsexual
(aka Transwoman)
FTM: Female to Male
transsexual
(aka Transman)
Passing
Getting Read/Clocked/
Spooked
Stealth
Intersex
Androgyne
Cross-dresser
The designation of a person as male or
female at birth – natal male or natal female
– based on anatomic and biologic markers,
eg genitalia or chromosomes
Identification as man, woman, or
something else which may or may not
coincide with the person’s natal sex
The external manifestation of a person’s
gender identity, which may or may not
conform to societal norms of masculine and
feminine
A person’s gender identity differs from the
cultural norms prescribed for people of that
particular sex
An umbrella term for any person defying
their prescribed gender role but not
necessarily desiring to alter their natal sex
Distress caused by discrepancy between
one’s gender identity and natal sex
A person whose gender identity differs
from their natal sex and may medically
alter their sex to live life as their identified
gender by using hormonal therapy and
possibly sex reassignment surgery
A natal male whose gender identity is
female and presents socially as a woman
often after medical intervention
A natal female whose gender identity is
male and presents socially as a man often
after medical intervention
When someone is perceived as the gender
they are presenting in their manner and
dress
When a stranger sees through the gender
someone is trying to portray
When a transgender person has
transitioned into a different gender and
lives as if born that gender
A person born with genitalia that are
neither exclusively male nor female or that
are inconsistent with chromosomal sex
Someone whose gender identity is both
female and male, or neither
A person who dresses in clothing not
associated with their natal sex, but may not
want to change gender
Transgender patients face multiple barriers to quality health care many of which were
identified in the recent National Transgender Discrimination Survey collected from
6,450 self- identified transgender and gender-nonconforming people around the
United States. These barriers include:
1. Social stigma –
o 25% have experienced some form of harassment in the medical setting.
o Up to 71% hide their gender identity so as to avoid discrimination.
CHALLENGE: How best to identify transgender patients so as to properly educate
regarding their breast cancer risk which may be elevated due to higher levels of
smoking, alcohol consumption, obesity, and nulliparity as well as long duration of
exogenous hormone use.
2. Lack of provider knowledge and training o 50% transgender respondents worked with health care providers who lacked
knowledge of their health care needs.
The majority of fistulae are unilateral and singular
(80-90%) in adults. Children are known to have a high
incidence of multiple fistulae (50%). The classic
anatomic descriptions of arterial supply to the penis
are identified in less than 20% of patients, making
knowledge of the anatomy and variants imperative.
Outcomes
Selective embolization studies report resolution of
priapism in 79%, with subsequent erectile dysfunction
in 39%. These results are clearly better than those
encountered with surgery (see above). Gelfoam-specific
results have up to 74% resolution rates and substantially
lower erectile dysfunction rates of 5%.
References
1. O’Sullivan P, Browne R, McEniff N, Lee MJ. Treatment
of “high-flow” priapism with superselective
transcatheter embolization: a useful alternative
to surgery. Cardiovasc Intervent Radiol. 2006 MarApr;29(2):198-201.
2. Volkmer BG, Nesslauer T, Kuefer R, Kraemer S, Goerich
J, Gottfried HW. High-flow priapism: a combined
interventional approach with angiography and colour
Doppler. Ultrasound Med Biol. 2002 Feb;28(2):165-9.
CLINICAL TEACHING POINT: Breast augmentation has not been shown to increase a
patient’s risk for breast cancer in natal female population and therefore is not considered
likely to increase the risk in the transgender population. Imaging may detect implant
rupture (either intracapsular or extracapsular) which can be detected on mammography,
ultrasound and/or MRI.
Fig 1: 25-year-old MTF
patient treated with
estradiol 0.5 mg daily
and spironolactone
150 mg daily for one
year had a baseline
mammogram for
unilateral nipple
discharge(1a) and a
follow-up six months
later (1b) showing
increasing retroareolar
breast tissue.
Role of the Interventional Radiologist
The interventional radiologist can be called upon to
perform percutaneous embolotherapy in patients
requiring treatment. Surgical ligation is an alternative
option.
• For patients with a history of prior or current exogenous hormone use,
annual mammography beginning at age 50 years if the patient has one of the
following additional risk factors : estrogen and progestin use for >5 years, BMI
> 35, and/or family history.
• For patients without a history of hormone use, clinical breast exam and breast
self-exams are advised for educational benefit only, unless the patient has
other known risk factors, eg Klinefelter’s for which screening mammography
may be performed.
Success rates after embolization range between 9097%, without significant differences between embolics.
Improvement in semen parameters range from 27-78%.
Small randomized trials have demonstrated comparable
results after embolization and surgical therapy.
Embolotherapy clearly has a faster recovery compared to
surgery, and lower incidence of complications (hematoma,
pain). The most feared surgical complications (hydrocele,
epididymitis and arterial injury) are not seen after
embolotherapy.
Anatomic Considerations
Venous blood drains from each testicle into the pampiniform
plexus. The plexus coalesces to form the ISV (internal spermatic
vein). On the left, the ISV drains into the renal vein. On the right,
it drains directly into the inferior vena cava. This pattern is seen
in 79% of patients on the left and 78% of patients on the right.
The most common anatomic variations are the presence of
multiple veins terminating in the renal vein on the left (20%),
and the termination of the ISV in the renal vein on the
right (8%). In addition to the ISV, other veins (external pudendal,
References
1. Iaccarino V, Venetucci P. Interventional Radiology of Male
Varicocele: Current Status. Cardiovasc Intervent Radiol.
2012 Mar 2. Epub ahead of print.
2. Diegidio P, Jhaveri JK, Ghannam S, Pinkhasov R, Shabsigh
R, Fisch H. Review of current varicocelectomy techniques
and their outcomes. BJU Int. 2011 Oct;108(7):1157-72. doi:
10.1111/j.1464-410X.2010.09959.x. Epub 2011 Mar 24.
Review.
TRANSGENDER MEN
5a
5b
Fig 5: Ultrasound in a 41-year-old MTF patient shows silicone granulomas,
some of which are hyperechoic superficially with marked posterior shadowing
(a) while others look more hypoechoic (b) with variable posterior acoustic
enhancement.
General Health Concerns
Transgender men who have not had sex reassignment surgery, regardless of whether
they take hormonal supplementation, have a similar lifetime risk for breast cancer
as natal women of approximately 12.4%. Once a transman undergoes bilateral
subcutaneous mastectomies as part of sex reassignment surgery, the breast cancer
risk decreases by nearly 90% (similar to that seen in natal women with moderate
to high risk of breast cancer), although the risk remains higher than a natal man.
Although there are a few case reports, studies have not shown an increased risk of
testosterone-related breast cancer.
Screening Recommendations, with or without testosterone use
• For transmen who have retained their natal anatomy or have undergone
reduction surgery, annual screening mammography starting at age 40 years
or sooner, based on risk assessment, should be performed.
5. Fibrocystic changes (Fig 6) and benign neoplasms such as fibroadenomas
(Fig 7) can develop with imaging appearances being similar to that in natal
women.
1a
1b
Fig 6: Ultrasound in a 28-year-old MTF patient on hormonal therapy for one
year reveals fibrocystic changes.
• Hematomas and seromas may be seen in the immediate postoperative period
(Fig 9).
• Abscesses can form and may necessitate percutaneous image guided drainage
for symptomatic relief (Fig 10).
• Breast malignancy in transmen who have not undergone surgery presents
with similar appearance as in natal women. In transmen treated with bilateral
mastectomies, malignancy most often presents as a palpable mass and
ultrasound-guided percutaneous core biopsy is the preferred diagnostic tool.
7a
2a
2b
Fig 2: 43-year-old MTF patient treated with hormonal therapy for 10 years and with bilateral
retropectoral saline implants. Routine (2a) and implant displaced views (2b) demonstrate
heterogeneously dense breast parenchyma.
7b
7c
Fig 9: Ultrasound of a 21-year-old FTM patient with a history of bilateral
mastectomy shows a postoperative seroma that was subsequently drained.
Fig 7: 39-year-old MTF patient on hormonal therapy for 3 years has a
circumscribed hypoechoic mass with no internal vascularity on ultrasound
(7a) that correlates with a circumscribed enhancing lesion with nonenhancing
internal septations on MRI (7b) that is T2 bright (7c) consistent with a
fibroadenoma.
6. Breast malignancy can occur (Fig 8) and especially should be considered in
transwomen on hormones for more than 5 years who present with a new
palpable mass.
3a
3b
Fig 10: Ultrasound of a 48-year-old FTM patient status post bilateral breast
reduction reveals an abscess in the residual breast tissue.
Fig 3: 41-year-old MTF patient treated with injectable estrodiol 20mg IM once every 2 weeks for
20 years and with bilateral retropectoral silicone implants. Routine (3a) and implant displaced
views (3b) demonstrate dense parenchyma.
CONCLUSION
4. Free silicone injections carry risks of disfigurement with hard, lumpy breasts making breast
cancer detection challenging and may be associated with more emergent complications
such as infection, pulmonary embolism and even death.
• Breast imagers should become more knowledgeable and sensitive to specific
needs of the transgender community so they can provide better and more
individualized care for their patients.
CLINICAL TEACHING POINT: Free silicone injections present as high attenuation masses
on mammography (Fig 4), echogenic, hypoechoic and/or snow-storm appearance on
sonography (Fig 5), and low signal on T1-weighted fat-suppressed images, high signal
on T2 water-suppressed images, and high signal on silicone selective MR sequences.
• Barriers to quality health care for transgender patients include social stigma,
lack of provider knowledge and training, health insurance coverage, and
structural layout of physician practices.
8a
Imaging Findings
There are a variety of expected breast imaging findings in transwomen taking
hormones, some of which are more pronounced with longer duration of use. These
findings include:
• Transgender patients face a variety of breast problems ranging from benign
changes related to hormonal use to breast malignancy. Mammography,
ultrasound and MRI are useful tools to help detect and diagnose these
problems.
References:
1. Increasing glandular density of breast tissue is associated with more pronounced
nipple areolar complex related to prolonged hormonal use (Figs 1-3). This should
be referred to as breast tissue, rather than gynecomastia, as lobules begin to form as
seen in natal women’s breast.
CLINICAL TEACHING POINT: Development of lobules in breasts of transwomen
may result in development of entities not typical in natal men, such as cysts,
fibroadenomas, and lobular carcinoma.
Outcomes
• Pre-chest surgery mammography is only indicated if the patient meets the
usual natal female requirements.
TRANSGENDER WOMEN
Screening Recommendations
Embolization of the ISV and its contributory channels is
performed under fluoroscopy, above the inguinal canal.
The endpoint is complete occlusion of the ISV.
Imaging Findings
The most common breast imaging findings in transmen relate to post mastectomy
complications. These findings include:
CHALLENGE: How can practice settings be re-designed to respectfully
provide care to this population
General Health Concerns
Although there are case reports of breast cancer in transgender patients, a few studies
in this population have not demonstrated any increased risk. However, many believe
that feminizing hormones, such as exogenous estrogen and progestin, may increase
these patients’ risk for breast cancer, especially as these patients may be exposed
to hormonal therapy from adolescence into later life, beyond the age natal women
typically go through menopause.
Selective catheterization of the left renal vein, and of the
orifice of the left ISV is performed. After injection of 1020 ml of contrast during Valsalva, venous incompetence
and reflux in the ISV is confirmed. Diffeerent embolic
and sclerosant agents have been used for varicocele
embolization (coils, glue, plugs, boling contrast, sotradecol).
• For transmen with bilateral mastectomies, clinical breast exam and self-exams
should be considered. Screening mammography is not recommended.
3. Health insurance coverage –
o Majority are uninsured due to higher levels of unemployment, poverty,
and inability to access coverage through life partners and spouses.
o Those with insurance often have policies that do not cover routine
screening procedures or sex reassignment treatments.
4. Structural layout of physician practices –
o Lack of comfortable space for natal men and transgendered men to wait for
breast imaging studies.
o Patient medical record may not reflect the patient’s chosen gender or name
leading to patient discomfort at the time of the health care visit.
Patients can be treated on an outpatient basis with
conscious sedation. Given the relatively healthy and
young population, extreme care should be taken to
reduce gonadal radiation doses. A right femoral or right
jugular approach can be used.
Commonly used grading system: grade 0 - nonpalpable,
grade 1 - palpable with the patient standing and performing
Valsalva, grade 2 - palpable without Valsalva and grade 3 visible. It should be noted that only palpable varicoceles have
been documented to be associated with infertility.
CHALLENGE: How to best educate providers about transgender patients and
their specific health needs
CHALLENGE: How to effectively change health care insurance coverage for this
population so as to better address specific health needs
Procedural & Technical Considerations
Common presenting symptoms and signs include
testicular atrophy, enlarged hemiscrotum and pain.
Varicocele’s role in infertility is controversial, but it is the
most often intervened upon abnormality in infertile men
(up to 40% of infertile men have a varicocele). Indications
for treatment of a varicocele include 1) subfertility
or infertility in adult males, 2) absence of any other
identifiable or correctable causes of infertility and 3) a
female partner with normal fertility.
CLINICAL TEACHING POINT: Unilateral bloody spontaneous nipple discharge in a
transwoman warrants imaging evaluation to exclude other pathology, such as intraductal
papillomas or malignancy, although to our knowledge, there are no case reports in the
literature. Imaging should start with US if under 30 years old.
3. Breast augmentation (either saline or silicone implants) may be seen secondary to sex
reassignment surgery.
vassal and cremasteric) contribute to the drainage of the
testes, but to a much smaller extent.
Clinical Presentation & Management
2. Development of clear bilateral non-spontaneous nipple discharge related to hormone use.
Barriers to Health Care
Limited information exists regarding breast health in the transgender
population, primarily due to historical bias that has permeated through
the health care system. As a consequence, there are essentially no
scientific publications attending to the specific needs of this patient
demographic. The Institute of Medicine’s March 2011 report and Healthy
People 2020, a government sponsored 10-year agenda for improving the
nation’s health, have included transgender people’s health as a major goal.
The interventional radiologist can be called upon to
manage cases of high-flow priapism. Patients who do
not have spontaneous recovery are obvious candidates,
but some advocate for earlier intervention fearing
worsening prognosis for erectile recovery. Embolization
is preferred over surgery due to its higher success rate
(79% with embolization versus 63% with surgery)
and lower rate of erectile dysfunction (39% with
embolization versus 50% with surgery).
Anatomic Considerations
References
Breast Imaging in the Transgender Patient
INTRODUCTION
Role of the Interventional Radiologist
Controversies exist over the embolic material used.
Permanent material, such as microcoils, have the
disadvantage of irreversible occlusion and potentially
higher erectile dysfunction rates. Gelfoam allows
recanalization of the artery after a few weeks, allowing
a higher rate of preservation of erectile function, but
possibly higher recurrence rates. N-butylcyanoacrylate
(glue) is not frequently used due to its cost and
technical procedural challenges.
Fig 11. Venogram of the left spermatic vein before and after
sclerotherapy
Fig 10. Venogram before and after coil embolization
of the spermatic vein
Pathophysiology
Priapism often becomes evident in a delayed fashion,
up to 72 hours after the initial injury. Because the
venous outflow is not obstructed, there is no
compression and thus, no ischemia. High-flow priapism
is typically painless. Current management guidelines
from the American Urological Association suggest initial
conservative management. More than 60% of cases
resolve spontaneously, but 33% of those develop
erectile dysfunction.
Copyright © 2003 Society of Interventional Radiology
Fig 9. Coil embolization of the varicocele
Anatomic Considerations
Clinical Presentation & Management
Coil placed in vein
Fig 8. Surface anatomy of the male varicocele demonstrating palpable
engorged veins
Pathophysiology
Current Literature
Varicocele Embolization
Varicocele
External
appearance
of dilated
veins
8b
Fig 4: Mammogram in a 45-year-old MTF patient treated with silicone injections shows
innumerable bilateral silicone granulomas.
Fig 8: 50-year-old MTF patient treated remotely with hormonal therapy for 5
years presented with a palpable left breast mass seen on mammograhy (8a) and
a complex cystic mass seen on ultrasound (8b). Biopsy revealed invasive ductal
carcinoma.
1.
Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities, Board on the
Health of Select Populations, Institute of Medicine. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a
Foundation for Better Understanding. Washington, DC, The National Academies Press, 2011.
2.
Glossary of Gender and Transgender Terms. Fenway Health. January 2010; http://www.fenwayhealth.org/site/DocServer/
Handout_7-C_Glossary_of_Gender_and_Transgender_Terms__fi.pdf?docID=7081.
3.
The World Professional Association for Transgender Health. Standards of Care for the Health of Transsexual, Transgender, and
Gender Nonconforming People. 7th version, July 2012. http://www.wpath.org/documents/SOC%20V7%2003-17-12.pdf.
4.
Grant JM, Mottet LA, Tanis J, Harrison J, Herman JL, and Keisling M. Injustice at Every Turn: A Report of the National
Transgender Discrimination Survey. Washington: The National Gay and Lesbian Task Force and the National Center for
Transgender Equality, 2011.
5.
Makadon HJ, Mayer KH, Potter J. Fenway Guide to Lesbian, Gay, Bisexual & Transgender Health, 1st Edition. American College
of Physicians 2007,
DEC 2012 Radical Views /6
RSNA 2012 Scrapbook: Alumni Party
. . . and then on Tuesday night, it
was time to party at the
17th Annual BIDMC Alumni Cocktail
Reception at the
University Club of Chicago
Special thanks to Sam Yam and Jonny
Kruskal for the photos!
Michelle Browne (Fellow 2012), Carole Ridge (Fellow 2011), our Chief,
and fellow South African Leon Van Rensburg, Chair of the Radiological
Society of South Africa.
Vice Chair for Community Network Services Peter Gordon at his first RSNA with
his predecessor Max Rosen.
DEC 2012 Radical Views /7
RSNA 2012 Scrapbook: Alumni Party
L to R: Justin Kung, Moritz Kircher (Resident 2009),
Bettina Siewert, Muneeb Ahmed and Ferris Hall.
L to R:
Priscilla
Slanetz,
Ferris Hall,
Jeanne
Ackman,
and Carol
Hulka,
BIDMC
faculty
alumnus
2001.
Current fellow Jennifer Nì Mhuircheartaigh with residents Seth
Berkowitz and Leo Tsai. Special thanks to Jenny for volunteering to
transport posters back to BIDMC!
Above and right:
Debbie Levine and
Thomas Vrachliotis
(Fellow 2001)
Ihab Kamel (Fellow 2000), Max Rosen and Marc Rothenberg, former BIDMC
HMFP Business Mgr.
DEC 2012 Radical Views /8
RSNA 2012 Scrapbook: Alumni Party
Above: Karen Lee and Katie Krajewski (resident/
fellow 2009)
Left: Vandana Dialani, Shambhavi
Venkataraman, Rola Shaheen (faculty alumnus
2012), and Karen Lee.
Koenraad Mortele and Jonathan Kruskal.
Diana Litmanovich, Olga Brook, Jacob Sosna (Fellow 2003) and Liat Applebaum (Fellow 2005).
Mel Couse with Jim Busch (resident/fellow 2004)
L to R: Ammar Sarwar, Leo Tsai, Colm McMahon (Faculty alumnus 2011) and Mai-Lan Ho.
DEC 2012 Radical Views /9
RESIDENCY NEWS
 What’s New in Residency Accreditation? - Priscilla J. Slanetz MD, MPH
As the July 2013 start date for the new accreditation system approaches, the residency leadership would
like members of our department to understand the major changes that will soon be in place regarding
accreditation of our ACGME residency and fellowship programs. The new accreditation process is
comprised of two main components: the CLER visit (clinical learning environment review) and the
continuous accreditation process.
During the next 18 months, all Institutions with accredited training programs will undergo a CLER visit.
This visit is designed to assess the learning environment on a global scale with particular attention being
paid to how trainees are integrated into departmental and hospital-wide processes related to patient
safety and quality, supervision, transitions in care, duty hours, and honesty/professionalism. During the CLER visit, site visitors will
meet with the hospital CEO, program directors, DIO, and multiple residents and fellows across departments. The goal of this visit is
to ensure a effective and safe learning environment in order to maximize the education of future physicians.
Priscilla J. Slanetz, MD, MPH
Dir., Radiology Residency
Program & Dir., Breast MRI
The continuous accreditation process consists of several different parts. The hope is that based on an analysis of trends in a
training program, programs will innovate and constantly improve the educational experiences of their trainees. Working with
the GME and our core departmental faculty, the residency program leadership will be responsible for submitting annual program
updates. These annual updates entail reporting on specific performance parameters including:
•
•
•
•
•
•
•
Program attrition (residents, fellows, and program leadership)
Specific program characteristics
Scholarly activity of trainees and core faculty
Board pass rate
Trainee clinical experiences (case logs and annual survey data)
Faculty survey of the training programs
Semi-annual trainee evaluation and feedback based on the new radiology milestones
Fortunately for radiology, the ABR milestones committee has created only 12 specific milestones based on the ACGME core
competencies:
6 ACGME Core Competencies
12 ABR Milestones
Patient care and technical skills: Consultant
Competence in procedures
Medical knowledge: Protocol selection and optimization of images
Interpretation of examinations
Professionalism: Professional values and ethics
Interpersonal and communication skills: Effective communication with patients, families, and care givers
Effective communication with members of the health care team
Systems-based practice: Quality improvement
Healthcare economics
Practice-based learning and improvement: Patient safety (contrast agents, radiation safety, MR safety and sedation)
Scholarly activity
Self-directed learning
Due to the short duration of most fellowships, there is a plan to condense the milestones for fellows such that they will
predominantly focus on medical knowledge and patient care. As a result of this new approach, faculty should expect to see some
changes in our evaluation forms in the next 6 months. We also will be creating a new clinical competency committee which will
be responsible for overseeing the submission of the semi-annual report for each trainee to the ACGME. Please let us know if you
would be interested in serving on this new committee.
Finally, every 10 years, the program will be expected to undergo an extensive self-study similar to what medical schools undergo
during an LCME visit. At present, BIDMC is currently scheduled for this self-assessment in 2016.
DEC 2012 Radical Views /10
RESIDENCY NEWS (cont’d)
Ammar Sarwar, 4th yr Resident in the news:
Ammar Sarwar, was one of two residents nationwide, selected to visit the
American College of Radiology (ACR) headquarters in Reston, Virginia as
the James Moorefield fellow in Healthcare Policy and Economics in October.
He worked with the ACR Economics staff as well as members of the Harvey
Neiman Health Policy Institute, learning about issues affecting radiology
currently. He also spent time at the Brookings Institution, Center for Medicaid
and Medicare Services (CMS) and on Capitol Hill interfacing with thought
leaders regarding the implementation of the Affordable Care Act (ACA).
Ammar will continue work started during the fellowship by serving on
the Episodes of Care Committee of the ACR Commission on Economics
to structure radiologist payments in the accountable care organizations
and on the Hospital and Outpatient Prospective Payment System (HOPPS)
committee lobbying CMS for appropriate valuation of outpatient radiology
reimbursements.
*Ammar was also quoted in the December issue of Boston Magazine in the article “Boston’s Best Doctors: Top Docs 2012”:
In many ways, the ground is shifting under the feet of our physicians, forcing them to ask a
lot of hard questions. The answers to those questions, 12 of which we explore here, reveal a
lot about the kind of healthcare you and your family will receive in the years ahead.
Are med students learning enough?
Doctors in training work fewer hours than ever before, thanks to new regulations, but
that’s forcing them to adapt to new ways of practicing medicine.
It used to be that medical residents routinely worked 30-hour shifts and 100-hour
weeks. A kind of boot-camp ethos prevailed: Only total immersion could produce
doctors who were truly ready to serve on medicine’s front lines. But the hours took
their toll: Residents made mistakes in care, crashed their cars on the way home, and
snapped at patients in need of emotional support.
What’s On Your Doctor’s Mind?
And what does it mean for the future of medicine?
By Casey Lyons (ED)
BOSTON MAGAZINE, DECEMBER 2012
Medicine is changing fast, especially right here in Massachusetts. As the rest of the nation
continues to debate universal healthcare, we’re already six years into our own experiment. It’s been
a great success: Today 98 percent of our residents are insured. But to contain the costs associated
with the program, state legislators recently passed a controversial law altering the way medicine is
practiced here. And that’s just one of the many ways in which the ground is shifting under the feet
of our physicians, forcing them to ask a lot of hard questions. The answers to those questions, 12 of
which we explore below, reveal a lot about the kind of healthcare you and your family will receive
in the years ahead.
So in 2003, in response to mounting pressure from the Accreditation Council for
Graduate Medical Education, hospital duty for residents was capped at 80 hours per
week. And in 2011 the state followed the Institute of Medicine’s recommendation to
restrict single workdays to no more than 16 hours (down from 24).
Some doctors and trainees think the pendulum has now swung too far, limiting
what residents can learn.
“There was a period of exploitation,” says Ammar Sarwar, a radiology resident
at Beth Israel Deaconess. He’s glad that’s over, but Sarwar also thinks medical
education has been harmed.
With a 16-hour shift limit, three different residents might wind up in charge of a
single patient’s care. That’s a problem, because it increases the chance that important
information isn’t shared during patient handoff. It also limits the residents’ ability to
connect with patients.
However, Russell Phillips, the director of the Center for Primary Care at Harvard
Medical School, argues that the handoff is precisely what trainees need to learn.
Medicine is moving toward a team-care model, he says, and doctors need to learn to
do it better—even if, like their predecessors, they have to learn on the fly.
—Karen Weintraub
Top Docs Survey
Click on a question to find out how Boston’s best doctors answered the questions posed here.
1. Am I a fool for becoming a general practitioner?
2. What if I could have fewer patients?
3. Should I tell my patients what I would do in their place?
4. How do I say I’m sorry?
5. Should I worry about what it costs?
6. Am I burned out?
7. Do I need a robot?
8. What can I do to make patients follow my instructions?
9. Can I trust the drug companies?
10. Are med students learning enough?
11. Should I treat only healthy patients?
12. Should I e-mail with my patients?
http://www.bostonmagazine.com/articles/2012/11/boston-bestdoctors-how-doctors-think-top-docs/#answer10
DEC 2012 Radical Views /11
Introducing ...Baby Nour (“Light”)
Research fellow Dr.
Marwan Moussa is
pleased to announce
the birth of his daughter Nour
on Saturday, Nov. 24, 2012. At 7.9 lbs (3.5 kg), she
is beautiful and healthy. Mom is well but Dad was
a bit sleep-deprived. Special thanks to co-author
Dr. Muneeb Ahmed who presented Marwan’s 2
talks at RSNA this year so that Dad could be there
for Nour’s arrival!
DEC 2012 Radical Views /12
DEPARTMENTAL NEWS, AWARDS & HONORS: Introducing . . .
Radiology
Patient
Satisfaction
Surveys are
up!
In Radiology we are committed to providing
the best possible care for our patients.
In order to continuously improve your experience …
Radiology wants to know
“How was your visit?”
Can you spare 2 minutes
to answer a few questions?
- Aideen Snell, MSW
Service Excellence
Program Manager
The Radiology Patient Satisfaction Survey for all of
our outpatients is now up and running on our new
touch screen kiosks located on TCC4, WCC3, GZ3 and
West MRI Suite. Check them out! When talking to the patients,
encourage them to use the kiosk and take the survey on their way out.
Let them know how important their feedback is to Radiology and how
committed we are to improving the patient experience. If they don’t tell
us, we’ll never know!
Please use the kiosk or log on
using the barcode or URL
to let us know how we are doing:
http://www. Radiologywants2know.com
If you don’t tell us, how will we know?
Introducing . . .
Ghada Almakhaita, MD, our second observer in our International Visiting Observership for Body
MR. Ghada is a resident in King Abdulaziz Medical City, Riyadh, Saudi Arabia. She most recently was
a Clinical Fellow in Body Imaging at Dalhousie University, Halifax, Canada. After attending our CME
course, Practical MR Imaging of the Abdomen and Pelvis at the Marriott Long Wharf Hotel, Ghada
became aware of our International Vising Observership program and immediately enrolled.
We are delighted to have Ghada as an international observer and value her presence in our
department. Ghada will be with us from November 20, 2012 until April 30, 2013.
New Voice Recognition System Training:
We are currently preparing to implement voice recognition as a department (you may have
noticed a 4th monitor at your PACS workstation). In preparation, our support team will be
providing group and individual (on-site) training of the new voice recognition software.
Individual, training dates and times are provided below:
B. James Hamilton
Radiology Information
System (RIS)
Application Specialist
Monday, December 3, 2012
Tuesday, December 4, 2012
Wednesday, December 5, 2012
Thursday, December 6, 2012
Friday, December 7, 2012
9:00am – 3:00pm
8:30am – 3:00pm
9:00am – 3:00pm
8:30am – 3:00pm
8:30am - 3:00pm
The duration of an individual training is approximately 30 minutes. Please email James
Hamilton at [email protected] as soon as possible to schedule a training date and time
that is convenient for you.
Thank You!
DEC 2012 Radical Views /13
BIDMC Front End Speech Recognition & Rollout Plan
Part I
INTRODUCTION
Jesse Wei, MD
Physician Director,
IT Radiology
By now you have undoubtedly noticed additional computer monitors and Rad Mics showing
up at PACS workstations. Aside from nuclear medicine as well as some community sites,
the software and hardware has been deployed throughout the department. These have
been installed in conjunction with the impending widespread rollout of “front-end speech
recognition” (i.e., voice recognition) for transcription of radiology reports. Many questions have
been raised in conjunction with the rollout, and I’m writing to introduce the system and answer
some of these questions.
As an introduction to the system, our front-end speech recognition solution is based on
technology and a speech engine by M*Modal (http://www.mmodal.com <http://www.mmodal.com> ). The
M*Modal speech engine is a licensed technology which must be integrated by clients into custom software
solutions rather than a pre-built product which is “plugged into” the radiology information system (RIS). This
technology was chosen over available stand-alone alternatives because it allows our (BIDMC) programmers to
create a solution which fits as closely as possible into our current academic workflow.
The current rollout is a “Phase I” rollout. In this phase, the front-end voice recognition is serving as a
replacement for the RTAS dictaphone and eScription for BIDMC (Boston) studies. The benefits of this phase of rollout include
immediate report turnaround for editing as well as integration with PACS to reduce the chances of CLIP# mismatches.
The time line for rollout follows:
•
First week of December: “Official rollout” begins - formal training sessions will be provided both in a lecture-type setting, as
well as in the reading rooms. Training materials will also be distributed at this time.
•
December-January: Continued encouragement to use the front-end voice recognition. During this time frame, RTAS will
remain as a fall-back as people learn to use the front-end VR, and in case of unanticipated technical problems.
•
Middle of February: We will begin to remove RTAS dictaphones from reading areas in order to further encourage migration
to the front-end voice recognition. While many or most RTAS machines will be removed, a few will be remain in place
during the extended transition. As RTAS dictaphones get removed, the support for the Front-end Speech Recognition will
transition to 24/7 coverage.
•
Extended transition: An extended phase of transition will occur as we ensure high-volume sections can handle the workload
using the Front-End Speech Recognition. We recognize that a robust utilization of macros and templates (which only
currently have primitive handling) will be needed before some of these sections can fully migrate off of eScription and onto
front-end speech recognition. During this extended transition, we will also ensure that potential planned downtimes such
as CCC downtimes can also be mitigated.
As this first phase of rollout is happening, we will embark on the next phase of software development. In the Phase II of
development, we expect that many of the additional functions which our alpha testers have requested (and are frequently seen
features within other products) will be implemented, including:
•
•
•
•
•
More intuitive mechanism to insert templates and use macros.
Better utilization of buttons on the Rad Mic or addition of customization options for Rad Mic buttons.
Addition of structured reporting rules (as requested by individual sections).
Improved robustness of fallover for the scenario of CCC downtime.
Allowance for use of local transcriptionists to assist in editing of select reports.
The infrastructure to send reports to BIDMC-Needham has not yet been created, and will happen concurrently with Phase II
software refinements. This infrastructure will require work and cooperation between BIDMC IS, BID-Needham IS, and Meditech.
DEC 2012 Radical Views /14
BIDMC Front End Speech Recognition
Part II: FAQ
Frequently asked questions
Q: Can I use VR?
A: Yes. Official training starts in December.
Q: What about Needham?
A: The ability to dictate Needham reports is in the roadmap, pending success of the Phase I deployment at BIDMC. This will require
coordination between IS at BIDMC, BIDMC-Needham, and Meditech and therefore may take some time to implement.
Q: What is the difference between “Dictate” and “Voice Edit”?
A: In “Dictate” mode, you dictated in the same manner as current RTAS dictations. The report will not be transcribed while you
dictate, but the recording is being streamed live to the M*Modal servers which is doing the transcription in the background.
When you are done with the report, you click the “EOL” button on the Rad Mic, and in a few seconds your transcribed report will
appear.
In “Voice Edit” mode, the local recognizer engine on your PACS workstation (i.e., the processor on your PACS workstation) is doing
the voice recognition, which potentially results in slightly lower accuracy, and slightly slower learning. Words and phrases pop up
on the screen as you dictate, in the same manner typically seen when using Powerscribe or Radwhere.
Q: Should I use “Dictate” or “Voice Edit”?
A: We prefer that you use “Dictate” for the reasons above. Learning should be faster using the Dictate mode. You can listen to your
own dictation using the Dictate mode.
Q: What is the difference between “Dictate” and “Dictate Minimized”?
A: “Dictate Minimized” reduces the size of the VR window while dictating, in order to reduce distractions of a bright blank screen.
Q: If my dictation is being streamed to a M*Modal server, what happens if the network goes down?
A: There is an automatic fallover to “Voice Edit” mode on your local machine if the connection between BIDMC and M*Modal is
lost. However, if there is a CCC downtime, you should fallover to RTAS until this scenario can be handled. Our current speech
recognition implementation will not work if there is not a valid CLIP# accessible in the RIS (which is based on CCC).
Q: Does this slow down my dictation?
A: Typically, users do not need to dictate slower than you in normal speech--speed of dictation does not significantly affect
accuracy of the speech engine, and in fact the speech engine is optimized for transcribing a normal speech pattern. However,
slurring words together or mumbling while dictating (which frequently happens during rapid dictation) will likely reduce
accuracy. Once a simple mechanism for using macros and templates is implemented, front-end speech recognition should be at
least as fast as traditional dictating.
Q: Is there an idle-timeout period?
A: Yes, your report will timeout if it is inactive for 20 minutes.
Q: Is my report saved in the case of a timeout?
A: Your voice dictation up to timeout is saved. The handling of timeout differs between the “Dictate” mode and the “Voice Edit”
mode.
In “Dictate” mode: a timeout will occur if there is no use of the Rad Mic over 20 minutes. In this case, there is an Auto-Suspend
which saves your voice file. Assuming that you enter the same CLIP# on the same workstation, you will receive the option to
Resume your dictation. While you may resume where you left off, you will not be able to rewind to the portion of your dictation
which was prior to the Auto-Suspend. However, after finishing the dictation with EOL button, you will still be able to do a Voice
Edit of the entire report as if you were not interrupted. You can also force a suspend in the middle of a dictation by clicking on the
“Suspend” button.
In “Voice Edit” mode: an autosave snapshot occurs every 5 minutes. At worst, 5 minutes of work may be lost if there is a network
problem or in an uncontrolled exit from the application (such as if Internet Explorer is manually closed). In the case of a 20-minute
timeout, a snapshot is typically taken so edits made to that point are saved. In either of these scenarios, edits to the most recent
autosave can be retrieved on re-entering the software (on the same computer).
Q: Can I resume after Auto-Suspend or Auto-Save on another computer?
A: This has not been tested and is not guaranteed to work.
DEC 2012 Radical Views /15
BIDMC Front End Speech Recognition
Part II: FAQ (cont’d)
Q: Can I listen to what I’ve dictated?
A: Yes, you can use the Rewind (left-arrow), Playback (triangle), and Fast-Forward (right arrow) buttons on the dictataphone. Like
on RTAS, by default, continued dictation will overwrite where your dictation is stopped ([OVR] button is boxed). Like on RTAS, the
behavior can be changed to insert a recording by clicking on the [INS] button.
Q: How to I move between sections (HISTORY, TECHNIQUE, FINDINGS, IMPRESSION, etc)?
A: You just say the section name like in a dictation. E.g., “Impression colon” and it will automatically move to that section. Certain
sections have synonyms. For instance, History = History, Indication, Indications, Clinical History, Clinical Indications. Impression =
Impression, Impressions, Results, Summary, Conclusion.
Q: What happens if I accidentally deleted a mandatory section header (such as “FINDINGS” or “IMPRESSION”)?
A: You can either undo the deletion, or double click on the missing section title in the left column, and that header will reappear.
Q: Is there a list of voice commands?
A: Yes, these will be by the PACS workstations and are on the Department Intranet (under “PACS” in the left column) under
“MModal VR Commands”
Q: Can mammograms and breast ultrasounds be dictated on Front-End Speech Recognition.
A: Yes, but as BI-RADS handling has not yet been coded, you will not be able to approve the report directly from the application,
and it will need to be saved to RISweb for signing.
Q: The speech recognition usually works very well for me. Why did it suddenly start returning gibberish?
A: The most common cause of this problem is that the gain on your microphone has changed, or you are holding it differently.
Try re-running the Gain Wizard (see Part 3) in order to optimize the microphone gain. Just like the radiology image you look at on
a PACS workstation has to be properly windowed and leveled to be properly interpreted, the gain level on the microphone has
to be properly set so that the speech recognition software can best try to interpret what you’re saying. Another thing you might
consider is to listen to your dictation (if you used the “Dictate” mode rather than the “Voice Edit” mode) -- if you think that you
are speaking clearly and clearly understandable in the recording, but being recognized poorly, please let us know. Email RISWeb
Feedback with the clip number and the problem. We can forward these cases to M*Modal to review if we find an unexplainable
recurring problem.
Q: Numbers come out wrong. It spells out the numbers when I want it Arabic, it’s Arabic when I want it Roman, and it’s
Roman when I want it spelled out.
A: Numbers are particularly difficult to deal with. We are allowed to set some rules on how numbers are transcribed but there are
always exceptions to the rule. Current settings (which apply to the entire department) include:
• Cranial Nerves are currently Arabic (but can be set to be Roman if there is a consensus).
• Numbers at the start of the sentence are currently numeric rather than spelled out.
• Ordinals are abbreviated: 1st, 2nd, etc.
Please send to RISWeb feedback cases where you think the numbers should be done a different way from the way they’re being
transcribed. Please provide specifics (provide a clip # as well as a description of how it’s coming out and how you want it to come
out). These will be reviewed and summary feedback provided to M*Modal.
Q: Why is my Speech Recognition always crashing?
A: This is unfortunately a sporatic problem which has not been reliably reproducible. It is unclear to us whether the crashing
is with specific machines or users, or if it is a problem with our local implementation or the M*Modal components, or with the
deployment process. We’re actively working on this problem. Please let us know when your Speech Recognition crashes (please
email RISWEB Feedback with: the Clip#, which reading room you’re in, the phone# next to your PACS workstation, and what you
were doing when it crashed) so we can tell how widespread this problem is.
Q: Why and when are you going to take away RTAS machines?
A: We are currently paying for two transcription services (RTAS/Escription and M*Modal). To encourage the transition to front-end
speech recognition, we will (starting in February) gradually decrease the number of RTAS machines available. Once Needham
workflow is integrated with this dictation system, and a fallback plan is available for CCC downtimes, the remainder of RTAS
machines will be removed (date indeterminate).
DEC 2012 Radical Views /16
BIDMC Front End Speech Recognition
Part III: Gain Wizard & Enrollment
Two commonly overlooked features may impact the quality of speech recognition: Gain Wizard and Enrollment. The Gain Wizard
is a 20 second process which adjusts the “volume” dial on your microphone so that the dynamic range picked up by the computer
is optimized for speech recognition.
•
•
Gain which is set too low is analogous to a microphone which is left off at a public event: nothing can be heard from the
speech recognition software and what is picked up is recognized and transcribed as gibberish.
Gain which is set too high is analagous to a microphone which is turned too high at a public event and the squeal of
feedback is heard: the speech recognition software can not properly recognize areas which are clipping.
In order to provide the most accurate speech recognition, Gain Wizard should be run once per user per machine, or as needed as
described below in the “Gain Wizard” section.
Enrollment is a method of “jump-starting” the speech recognition engine’s accuracy for an individual user, and while it takes a few
minutes, Enrollment only needs to be run one time per user. If you have not run enrollment since Thursday 11/15/2012, when
our speech recognition environment moved to a production server, you may consider running (or re-running) this to help with the
recognition accuracy. See the “Enrollment” section below, and be sure to run the Gain Wizard prior to running Enrollment.
Gain Wizard:
The first time you log into a machine you will see a warning next to your username: “Please run Gain Wizard under Setup.” Anytime
you see this warning, it would be best to run the Gain Wizard.
Click on Setup:
Special thanks to Sonographer Practitioner
Laurie Sammons for demonstrating the new
voice recognition system.
DEC 2012 Radical Views /17
Click on Gain Wizard:
After you run the Gain Wizard you will
be prompted to click the Save button
and this should save your microphone
gain settings on that computer. The
Gain Wizard warning illustrated above
will then go away.
While dictating, you should see
the color bar (below) moving with
fluctuations of voice. It should be
dominantly green and going into the
yellow zones.
If the color stays green all the time and
never reaches yellow, the gain is too
low. Move the microphone closer to
your mouth or re-run the gain wizard.
If the color frequently goes to red
and you get the Clipping message
below, the gain is too high. Move the
microphone away from your mouth or
re-run the gain wizard.
Enrollment:
Enrollment only needs to be performed one time per user (after 11/15/2012) in order to help the speech recognition engine figure
out the nuances of an individual user’s speech. This may be particularly helpful for those of you who might be accused of having
an accent.
Please ensure that you have run Gain Wizard prior to running Enrollment (Garbage in, Garbage out!).
Click on the Setup button as described above, and then click on “Enrollment” and follow the directions:
DEC 2012 Radical Views /18
MRI Case of the Month
Dec 2012
Clinical History: 30 year old male, active recreational soccer player with chronic left groin pain,
radiating into the thigh. (Fig 1)
MR Case of the Month A new educational tool
for technologists:
Background: Monthly
case presentations
highlighting an exam
that has been done
particularly well and/
or illustrates a teaching
point. Exams can be
chosen for a variety of
reasons. It could be an
excellent exam where
the imaging was done
really well; it could be a
new type of exam not
previously performed;
the technologist
altered the exam in
some way to improve
the imaging quality;
or maybe the patient
was difficult and the
technologist pulled
out all the stops to
get the exam done.
These cases have great
learning potential for
all technologists.
Thanks to MSK Chief
and faculty, Mary
Hochman and Jim Wu,
for contributing this MR
Case of the Month Dec
2012.
- Jeremy Stormann
B.S., RT(R) (CT) (MR)
MRI Clinical Instructor
a
b
c
Fig 1. a) Axial Fat Saturated T2. Linear high T2 signal at the left adductor tendon insertion site represents a tear
(arrow). Normal right adductor tendon appears black (dotted arrow). Note edema in adductor muscles (curved
arrow). Pubic symphysis (asterisk). P, Pubic bone. IT, ischial tuberosity. b) Sagittal Fat Saturated T2. Linear high
T2 signal at the left adductor tendon insertion site represents a tear (arrow). P, Pubic bone. B, bladder. S1, S1
vertebral body. c) Coronal Fat Saturated T2. Linear high T2 signal at the left adductor tendon insertion site
represents a tear (arrow). Normal right adductor tendon appears black (dotted arrow). P, Pubic bone.
Discussion:
Sports hernia or athletic pubalgia refers to groin injuries that occur in athletes, typically associated with
sudden changes in direction, twisting at the waist, or side-to-side ambulation (e.g. soccer, ice hockey,
football, fencing, high jumping and other track and field events, and baseball.) Patients often present
with pain in the inguinal region, which may radiate to the adductor muscles of the thigh, the lower
abdominal muscles, perineum, and/or scrotum. Symptoms may be unilateral or bilateral, are often
insidious in onset, are exacerbated by activity, and can become quite debilitating. The injury occurs
most commonly in men under the age of 40.
Despite the name sports hernia, there is no actual hernia. Instead, the injury involves the musculotendinous attachments upon the pubic symphysis and adjoining pubic ramus bones, with tendon
degeneration or tears and sometimes with bone marrow and muscle edema. The lower abdominal
muscles (external and internal oblique, transversus abdominis, and rectus abdominis) insert onto
the pubic symphysis from above and the adductor muscles of the thigh (pectineus, gracilis, adductor
longus, adductor brevis, and adductor magnus) insert onto the pubic symphysis from below. The
rectus abdominis and adductor longus tendon fibers merge to form a common fibrous aponeurosis
that courses along the anterior surface of the pubic symphysis to create a single continuous structure
(Fig 2).). In a severe injury, the tendons may be completely avulsed from the pubic bone. As in the
shoulder or ankle, tendon degeneration appears high signal on proton density or T1W images and
tendon tears appear high signal on T2W and fat saturated T2W or STIR images. Conservative treatment
and steroid injection may be attempted, but definitive treatment often requires surgery.
There are many causes of groin pain (Table 1). Because the differential diagnosis based on clinical
exam can be difficult, MRI plays an important role. While many causes of groin pain can be identified on
a routine screening musculoskeletal pelvis or unilateral hip MR study, diagnosis of true “sports hernia”
require a specialized MRI examination.
DEC 2012 Radical Views /19
MR Imaging Technique:
Fig 2. Normal Sagittal
Midline Anatomy. Note
that the rectus abdominis
muscle of the anterior
abdomen is confluent
with the adductor longus
tendon and muscle of the
proximal thigh, forming a
single fibrous aponeurosis
centered on the anterior
surface of the pubic bone.
RA, Rectus Abdominis. AL,
Adductor Longus. P, Pubic
bone. Bl, Bladder.
The exam is a multiplanar non-contrast exam, performed using the
body array coil. The first part of the exam is comprised of larger field of
view (FOV) images that help screen for other kinds of pathology, while
the second part of the exam employs smaller FOV images targeted to
the area of interest about the pubic symphysis (Fig 3). Coil coverage
should run from the iliac crest to proximal femoral diaphyses, centered
at or just above the pubic symphysis, to ensure good coverage both
above and below the pubic symphysis. A specialized oblique axial
plane helps to nicely lay out all the muscles and tendons that insert on
the anterior pubic rami. To be useful for diagnosis, this plane must be
optimally positioned – parallel to the ilio-pubic cortex or arcuate line of
the pelvic inlet. If necessary, the radiologist can help to confirm proper
positioning. Additional details are provided in the Teaching Points.
Table 1. Clinical Differential Diagnosis of
Groin Pain
Sports Hernia
Degeneration or tear involving the Rectus
Abdominis–Adductor Longus tendons or their
combined aponeurosis
Pubic Symphysis
Pubic Ramus Stress Fracture
Osteitis pubis
Apophysitis (teenager with unfused apophyses)
Hip
Arthritis
Septic Arthritis
Osteonecrosis (AVN or avascular necrosis)
Stress fracture
Inguinal hernia
Fig 3a. Localizer for Axial Images.
Center right/left on pubic symphysis.
Scan from supra-acetabular iliac bone
to below the pubic symphysis, along
perineal subcutaneous fat.
Scrotum
Epididymitis and orchitis
Testicular Torsion
Referred pain
Lumbar spine sciatica
Knee pain
Fig 3b. Localizer for Targeted Images.
Center right/left on pubic symphysis.
Scan from medial femur to medial
femur. FOV should include from
fat anterior to pubic symphysis to
posterior to ischial tuberosities.
Sagittal images should be aligned
along the pubic symphysis. . Coronal
images should be aligned along the
anterior surface of the pubic bones.
Nerve Entrapment
Piriformis syndrome (sciatic nerve)
Pudendal, obdurator, or femoral nerves
r
Fig 3c-d. c. (midline), d (lateral). Localizer for Targeted Oblique Axial Plane. Images are
aligned perpendicular to the pubic ramus (midline) and parallel to iliopubic cortex (lateral).
Scan from anterosuperior to pubic symphysis through posteroinferior to hip joint.
Fig 3e. Resultant oblique axial PDW image
shows normal muscles about the pubic
symphysis (arrow). P, pubic bone. AB, adductor
brevis. AM, adductor magnus. AL,adductor
longus. OE, obdurator externus. OI, obdurator
internus. PEC, pectineus.
DEC 2012 Radical Views /20
Sports Hernia Teaching Points:
•
Sports hernia, also known as athletic pubalgia because
there is no actual hernia, refers to an injury of the rectus
abdominis-adductor longus tendons and/or their
aponeurosis. The aponeurosis is dense fibrous tissue
formed by the tendon fibers as they join, attach, and
pass over the anterior surface of the pubic symphysis
and the adjoining portion of the pubic bones.
•
The exam is composed of two parts:
i) Relatively routine pelvic images (slightly smaller
than normal FOV): Coronal T1, Coronal STIR and
axial FS-T2W images
ii) Targeted small FOV (20-22 cm) images centered
about the pubic symphysis: Sagittal FS-T2W,
Oblique Axial T2W, and Oblique Axial PDW images
•
•
The MRI examination is performed as a non-contrast
exam using the body array coil. A smaller high quality
coil, such as the cardiac coil, could be employed for the
targeted portion of the exam, but would require optimal
placement and would risk signal loss posteriorly in most
patients, unless it could be combined the posterior array.
The patient should empty his/her bladder prior to the
exam to minimize motion artifact. Although the study is
usually done with the patient supine, prone positioning
– if tolerated -- may help in cases of “belly breathing”.
Save the Date
June 17-19, 2013
ABDOMINAL & PELVIC IMAGING 2013
Imaging Review of GI and GU Tracts
All Imaging Modalities Included
Get ready for your MOC exam
Course Director: Koenraad J. Mortele, MD
The Boston Marriott Long Wharf, Boston, MA
For More Information, Contact:
Lois Gilden
617-667-0299
Email: [email protected]
http://radnet.bidmc.harvard.edu/education/cme/cme.asp
HARVARD
Beth Israel Deaconess
Department of Continuing Medical Education
Department of Radiology
MEDICAL SCHOOL
Medical Center
•
Unlike other MSK studies of the hip or pelvis, the
targeted images are centered on the pubic symphysis, in
both craniocaudad and sagittal planes.
•
Good coil placement is very important. The second,
targeted part of the exam may require re-positioning of
the coil (both anterior and posterior portions of the coil).
BIDMC Radiology is proud to present
A smaller field of view is employed for the targeted
portion of the exam because many tendons are crowded
in a small area and the smaller FOV helps to detect small
tendon or aponeurotic tears.
MRI Research at BIDMC:
•
•
•
The oblique axial plane is positioned parallel to the
ilio-pubic cortex, extending from anterior to the pubic
symphysis and overlying tendons posteriorly to include
the proximal adductor muscles. It extends parallel to the
arcuate line of the pelvic inlet. It nicely lays out all the
muscles centered in the area.
Pathology appears similar to tendon pathology
elsewhere: high PD/low T2 signal for tendon
degeneration and high PD/high T2 signal for tendon
tears.
References (available free online):
1.
Omar IM, et al., Athletic Pubalgia and “Sports Hernia”: Optimal MR
Imaging •Technique and Findings. RadioGraphics 2008; 28:1415–1438.
2.
Zoga AC, et al. Athletic pubalgia and the “sports hernia”: MR imaging
findings. Radiology 2008; 247(3):797–807
Best in Practice BIDMC MRI
Lecture Series 2012
An Overview for MR Techs
Moderator: David Alsop, PhD
David Alsop, PhD
Pofessor of Radiology
Vice Chairman & Director of
Radiology Research
Wednesday, December 12, 2012
5:00 pm - 6:00 pm
Rabkin Board Rm, Shapiro 10
Local Organizing Committee: Jeremy Stormann B.S. RT (R), (MR); Steve
Flaherty, MBA, RT (R), (MR); Ines Cabral-Goncalves, RT (R), MR; David Alsop,
PhD and Koenraad J. Mortele, MD
Event Coordinator: Lois Gilden, Tel: 7-0299 / [email protected]
DEC 2012 Radical Views /21
Mc
Ke
Kathleen West
HMFP contracts with McKesson for Revenue Cycle Management services
including diagnosis coding, claims scrubbing, allowables monitoring, accounts
receivable and insurance denial management, compliance and reporting. We offer this
column by Kathleen West,, McKesson’s Senior Director of Account Management for Radiology,
as an opportunity to keep you informed. During this time of revenue and utilization reductions,
compliance scrutiny and increased payer denials, our partnership with McKesson has been vital to
our ability to maintain our financial stability. Feel free to contact [email protected] should you
have any specific questions or concerns related to the Revenue Cycle Management process.
ss
on
Radiology
Co
r
ne
r
Annual CPT Code Updates and Changes
2010
-
54 Updates & Changes
2011
-
56 Updates & Changes (including creation of Bundled CT Abdomen & Pelvis codes)
2012
-
46 Updates & Changes (including creation of Bundled CTA codes)
2013
-
41 Updates & Changes
Procedures reported together 75% or more result in bundled procedures
Top 5 Changes for 2013:
•
Aortography & Angiography
o
•
Intravasular Thrombolysis
o
•
Bundled codes include catheterization, contrast, flouro, RS&I
Bundled codes include thrombolytic infusion, RS&I, repeated imaging and catheter exchanges on same day,
moderate sedation
Thorocentesis
o
Bundled codes to include Image Guidance
•
Nuclear Medicine
o Combined single and multiple determinations for thyroid imaging
o Single parathyroid imaging code deleted and now broken out into two codes
•
Diagnostic
o
o
Cervical codes revised to list number of views
Several descriptor changes
Annual Medicare Physician Fee Schedule Update:
•
RVU Changes
o Year over year impact (1.5%)
o Adjustments to Conversion Factor (2012 = $34.0376)
• Subject to SGR (26.5%)
•
GPCI Floor
o Subject to expire on 12/31 unless acted on to extend
•
“Sequestration”
o Covered under the budget control act (BCA of 2011)
o All Departments to receive an 8% cut
o Medicare payments will be reduced by 2% unless 111thCongress acts
DEC 2012 Radical Views /22
Ho Ho Ho!
Thank you, Sheila Nadeau! At this time of
year, anyone who visits the West Campus
Clinical Center 3rd floor will notice the
holiday-wrapped doors brightening the
Ultrasound/Vascular Division, thanks to
sonographer Sheila Nadeau. Her efforts
above and beyond her clinical duties
contribute to a cheerful environment for
both patients and staff!
Best
Wishes for
a Happy
Holiday
Season
to our
Radiology
Community
and
beyond!
DEC 2012 Radical Views /23
2012 BIDMC Radiology Publications [New Citations in Blue*]. We do a monthly PubMed search for new BIDMC publications
and may miss those in which your affiliation is not noted. If we miss your paper, please send the reference to [email protected].
Note that publications do not always appear in Pubmed in the same month they are actually published and publications listing an Epub date may
be updated in the new year, thus their paper publication will appear in 2013.
Aberle DR, Henschke CI, McLoud TC, Boiselle PM. Expert Opinion: Barriers
to CT Screening for Lung Cancer. J Thorac Imaging. 2012 Jul;27(4):208.
Adeyiga AO, Lee EY, Eisenberg RL. Focal hepatic masses in pediatric
patients. AJR Am J Roentgenol. 2012 Oct;199(4):W422-40.
Agrawal JR, Travis AC, Mortele KJ, Silverman SG, Maurer R, Reddy SI,
Saltzman JR. Diagnostic yield of dual-phase computed tomography
enterography in patients with obscure gastrointestinal bleeding and
a non-diagnostic capsule endoscopy. J Gastroenterol Hepatol. 2012
Apr;27(4):751-9. doi:10.1111/j.1440-1746.2011.06959.x.
Ahmed M, Moussa M, Goldberg SN. Synergy in cancer treatment
between liposomal chemotherapeutics and thermal ablation. Chem Phys
Lipids. 2012 May;165(4):424-37. Review.
Akçakaya M, Basha TA, Chan RH, Rayatzadeh H, Kissinger KV, Goddu B,
Goepfert LA, Manning WJ, Nezafat R. Accelerated contrast-enhanced
whole-heart coronary MRI using low-dimensional-structure self-learning
and thresholding. Magn Reson Med. 2012 May;67(5):1434-43. doi:
10.1002/mrm.24242. PMC3323762.
Akçakaya M, Rayatzadeh H, Basha TA, Hong SN, Chan RH, Kissinger KV,
Hauser TH, Josephson ME, Manning WJ, Nezafat R. Accelerated Late
Gadolinium Enhancement Cardiac MR Imaging with Isotropic Spatial
Resolution Using Compressed Sensing: Initial Experience. Radiology. 2012
Sep;264(3):691-9. PMC3426855.
Arbab-Zadeh A, Miller JM, Rochitte CE, Dewey M, Niinuma H, Gottlieb I,
Paul N, Clouse ME, Shapiro EP, Hoe J, Lardo AC, Bush DE, de Roos A, Cox C,
Brinker J, Lima JA. Reply. J Am Coll Cardiol. 2012 Aug 14;60(7):642-3.
Asch E, Levine D, Robens J. Cornual ectopic pregnancy of dichorionic
diamniotic twins, with one live fetus and co-twin demise. Ultrasound Q.
2012 Sep;28(3):189-91.
Ashitate Y, Kim SH, Tanaka E, Henary M, Choi HS, Frangioni JV,
Flaumenhaft R. Two-wavelength near-infrared fluorescence for the
quantitation of drug antiplatelet effects in large animal model systems.
J Vasc Surg. 2012 Jul;56(1):171-80. PMC3389273
Ashitate Y, Lee BT, Laurence RG, Lunsford E, Hutteman M, Oketokoun R,
Choi HS, Frangioni JV. Intraoperative Prediction of Postoperative Flap
Outcome Using the Near-Infrared Fluorophore Methylene Blue. Ann Plast
Surg. 2012 Mar 6. PMC3371147.
Ashitate Y, Stockdale A, Choi HS, Laurence RG, Frangioni JV. Real-time
simultaneous near-infrared fluorescence imaging of bile duct and arterial
anatomy. J Surg Res. 2012 Jul;176(1):7-13. PMC3212656.
Ashitate Y, Vooght CS, Hutteman M, Oketokoun R, Choi HS, Frangioni JV.
Simultaneous assessment of luminal integrity and vascular perfusion of
the gastrointestinal tract using dual-channel near-infrared fluorescence.
Mol Imaging. 2012 Jul-Aug;11(4):301-8. PMC3439161.
Alemozaffar M, Chang SL, Kacker R, Sun M, Dewolff WC, Wagner AA.
Comparing Costs of Robotic, Laparoscopic, and Open Partial
Nephrectomy. J Endourol. 2012 Nov 7.
Balbir-Gurman A, Brook OR, Chermesh I, Braun-Moscovici, Y. Pneumatosis
cystoides intestinalis in scleroderma-related conditions: A report of
three cases and review of the literature. Internal Medicine Journal. 2012
Mar;42(3):323-9.
Anderson ME, Goldsmith JD, Hochman MG, Taghinia A. Orthopaedic
Case of the Month: Pulsatile Soft Tissue Mass. Clin Orthop Relat Res. 2012
Nov;470(11):3275-9. doi: 10.1007/s11999-012-2518-x.
Bamberg F, Boiselle PM, Choe YH, Funabashi N, Schoepf UJ. Expert
Opinion: Should Coronary CT Angiography be Used as a Screening Test? J
Thorac Imaging. 2012 Nov;27(6):339. doi: 10.1097/RTI.0b013e31826b4866.
Akuthota P, Litmanovich D, Zutler M, Boiselle PM, Bankier AA, Roberts
DH, Celli BR, Decamp MM, Berger RL. An Evidence-Based Estimate on the
Size of the Potential Patient Pool for Lung Volume Reduction Surgery. Ann
Thorac Surg. 2012 Jul;94(1):205-11.
Bankier AA, Kressel HY. Through the Looking Glass Revisited: The Need
for More Meaning and Less Drama in the Reporting of Dose and Dose
Reduction in CT. Radiology. 2012 Oct;265(1):4-8.
Aberle DR, Henschke CI, McLoud TC, Boiselle PM. Expert Opinion: Barriers
to CT Screening for Lung Cancer. J Thorac Imaging. 2012 Jun 12.
Alsop DC. Arterial spin labeling: its time is now. MAGMA. 2012
Apr;25(2):75-7.
Appelbaum L, Ben-David E, Sosna J, Nissenbaum Y, Goldberg SN. US
Findings after Irreversible Electroporation Ablation: Radiologic-Pathologic
Correlation. Radiology. 2012 Jan;262(1):117-25.
Appelbaum E, Maron BJ, Adabag S, Hauser TH, Lesser JR, Haas TS,
Riley AB, Harrigan CJ, Delling FN, Udelson JE, Gibson CM, Manning WJ,
Maron MS. Intermediate-signal-intensity late gadolinium enhancement
predicts ventricular tachyarrhythmias in patients with hypertrophic
cardiomyopathy. Circ Cardiovasc Imaging. 2012 Jan 1;5(1):78-85.
Arbab-Zadeh A, Miller JM, Rochitte CE, Dewey M, Niinuma H, Gottlieb I,
Paul N, Clouse ME, Shapiro EP, Hoe J, Lardo AC, Bush DE, de Roos A, Cox
C, Brinker J, Lima JA. Diagnostic Accuracy of Computed Tomography
Coronary Angiography According to Pre-Test Probability of Coronary
Artery Disease and Severity of Coronary Arterial Calcification The CORE64 (Coronary Artery Evaluation Using 64-Row Multidetector Computed
Tomography Angiography) International Multicenter Study. J Am Coll
Cardiol. 2012 Jan 24;59(4):379-87.
Bedayat A, Rybicki FJ, Kumamaru K, Powers SL, Signorelli J, Steigner ML,
Steveson C, Soga S, Adams K, Mitsouras D, Clouse M, Mather RT. Reduced
exposure using asymmetric cone beam processing for wide area detector
cardiac CT. Int J Cardiovasc Imaging. 2012 Feb;28(2):381-8. PMC3111872.
Ben-David E, Appelbaum L, Sosna J, Nissenbaum I, Goldberg SN.
Characterization of irreversible electroporation ablation in in vivo porcine
liver. AJR Am J Roentgenol. 2012 Jan;198(1):W62-8.
Berg WA, Zhang Z, Lehrer D, Jong RA, Pisano ED, Barr RG, Böhm-Vélez
M, Mahoney MC, Evans WP 3rd, Larsen LH, Morton MJ, Mendelson EB,
Farria DM, Cormack JB, Marques HS, Adams A, Yeh NM, Gabrielli G; ACRIN
6666 Investigators (Fein-Zachary V). Detection of breast cancer with
addition of annual screening ultrasound or a single screening MRI to
mammography in women with elevated breast cancer risk. JAMA. 2012
Apr 4;307(13):1394-404.
Bhatia S, Frangioni JV, Hoffman RM, Iafrate AJ, Polyak K. The challenges
posed by cancer heterogeneity. Nat Biotechnol. 2012 Jul 10;30(7):604-10.
doi: 10.1038/nbt.2294.
DEC 2012 Radical Views /24
Bloch BN, Genega EM, Costa DN, Pedrosa I, Smith MP, Kressel HY, Ngo L,
Sanda MG, Dewolf WC, Rofsky NM. Prediction of prostate cancer
extracapsular extension with high spatial resolution dynamic contrastenhanced 3-T MRI. Eur Radiol. 2012 Jun 3.
Boiselle PM. A New JTI Milestone. J Thorac Imaging. 2012 Jan;27(1):1.
Boiselle PM. “Readers’ opinion”. J Thorac Imaging. 2012 Mar;27(2):72.
Boiselle PM. Jeff kanne appointed as consulting editor for electronic
media. J Thorac Imaging. 2012 Mar;27(2):71.
Boiselle PM. “Quality matters”. J Thorac Imaging. 2012 May;27(3):137.
Boiselle PM. A Fond Farewell to JTI Case Reports. J Thorac Imaging. 2012
Nov;27(6):337-8. doi: 10.1097/RTI.0b013e31826f3b0b.
Boiselle PM, Abbara S, Blanke P, A Leipsic J, Sundaram B, Quint LE. Expert
Opinion: MDCT Aortic Root Measurements for Transcatheter Aortic Valve
Implantation. J Thorac Imaging. 2012 May;27(3):140.
Boiselle PM, Collins J, Dodd JD, Herold CJ, Leung AN. Expert Opinion:
What are the Greatest Challenges and/or Barriers to Applying Evidencebased Medicine in the Daily Practice of Cardiopulmonary Radiology? J
Thorac Imaging. 2012 Sep;27(5):271.
Boiselle PM, Goodman LR, Litmanovich D, Rémy-Jardin M, SchaeferProkop C. Expert Opinion: CT Pulmonary Angiography in Pregnant
Patients With Suspected Pulmonary Embolism. J Thorac Imaging. 2012
Jan;27(1):5.
Boiselle PM, Michaud G, Roberts DH, Loring SH, Womble HM, Millett ME,
O’Donnell CR. “Dynamic expiratory tracheal collapse in COPD: Correlation
with clinical and physiological parameters”. Chest. 2012 Jun 21.
Boiselle PM, Nikolaou K, Schoepf UJ, Seo JB. Expert Opinion: Dual Energy
CT: Most and Least Relevant Cardiopulmonary Imaging Applications.
J Thorac Imaging. 2012 Jan;27(1):6.
Boiselle PM, Reddy GP. Editors’ recognition awards for distinction in
reviewing in 2011. J Thorac Imaging. 2012 Jan;27(1):2.
Bollen TL, Singh VK, Maurer R, Repas K, van Es HW, Banks PA, Mortele KJ.
A comparative evaluation of radiologic and clinical scoring systems in the
early prediction of severity in acute pancreatitis. Am J Gastroenterol. 2012
Apr;107(4):612-9. doi: 10.1038/ajg.2011.438.
Brennan IM, Ahmed M. Portal vein thrombosis following percutaneous
transhepatic cholangiography-An unusual presentation of Prothrombin
(Factor II) gene mutation. World J Radiol. 2012 May 28;4(5):224-7.
PMC3386535.
Brodoefel H, Tognolini A, Zamboni GA, Gourtsoyianni S, Claussen
CD, Raptopoulos V. Standardisation of liver MDCT by tracking liver
parenchyma enhancement to trigger imaging. Eur Radiol. 2012
Apr;22(4):812-20.
Brook OR, Gourtsoyianni S, Mendiratta-Lala M, Mahadevan A, Siewert
B, Sheiman RR. Safety profile and technical success of imaging-guided
percutaneous fiducial seed placement with and without core biopsy in
the abdomen and pelvis. AJR Am J Roentgenol. 2012 Feb;198(2):466-70
Brook OR, Gourtsoyianni S, Brook A, Mahadevan A, Wilcox C,
Raptopoulos V. Spectral CT with Metal Artifacts Reduction Software for
Improvement of Tumor Visibility in the Vicinity of Gold Fiducial Markers.
Radiology. 2012 Jun;263(3):696-705.
Bulman JC, Toth R, Patel AD, Bloch BN, McMahon CJ, Ngo L, Madabhushi
A, Rofsky NM. Automated Computer-derived Prostate Volumes from
MR Imaging Data: Comparison with Radiologist-derived MR Imaging
and Pathologic Specimen Volumes. Radiology. 2012 Jan;262(1):144-51.
PMC3262981.
Canto MI, Hruban RH, Fishman EK, Kamel IR, Schulick R, Zhang Z, Topazian
M,Takahashi N, Fletcher J, Petersen G, Klein AP, Axilbund J, Griffin C, Syngal
S,Saltzman JR, Mortele KJ, Lee J, Tamm E, Vikram R, Bhosale P, Margolis D,
Farrell J, Goggins M; American Cancer of the Pancreas Screening (CAPS)
Consortium. Frequent detection of pancreatic lesions in asymptomatic
high-risk individuals. Gastroenterology. 2012 Apr;142(4):796-804.
PMC3321068.
Chansakul T, Lai KC, Slanetz PJ. The postconservation breast: part 1,
expected imaging findings. AJR Am J Roentgenol. 2012 Feb;198(2):321-30.
Review.
Chansakul T, Lai KC, Slanetz PJ. The postconservation breast: part 2,
imaging findings of tumor recurrence and other long-term sequelae. AJR
Am J Roentgenol. 2012 Feb;198(2):331-43. Review.
Chen PH, Ghosh ET, Slanetz PJ, Eisenberg RL. Segmental breast
calcifications. AJR Am J Roentgenol. 2012 Nov;199(5):W532-42. doi:
10.2214/AJR.11.8198.
Chou CP, Chiou SH, Levenson RB, Huang JS, Yang TL, Yu CC, Chiang AJ,
Pan HB. Differentiation between pelvic abscesses and pelvic tumors with
diffusion-weighted MR imaging: a preliminary study. Clin Imaging. 2012
Sep;36(5):532-8.
Chuang ML, Gona P, Hautvast GL, Salton CJ, Blease SJ, Yeon SB, Breeuwer
M, O’Donnell CJ, Manning WJ. Correlation of Trabeculae and Papillary
Muscles With Clinical and Cardiac Characteristics and Impact on CMR
Measures of LV Anatomy and Function. JACC Cardiovasc Imaging. 2012
Nov;5(11):1115-23. doi: 10.1016/j.jcmg.2012.05.015. PMC3502069.
Chuang ML, Gona P, Salton CJ, Yeon SB, Kissinger KV, Blease SJ, Levy D,
O’Donnell CJ, Manning WJ. Usefulness of the left ventricular myocardial
contraction fraction in healthy men and women to predict cardiovascular
morbidity and mortality. Am J Cardiol. 2012 May 15;109(10):1454-8.
Collins KC, Odell DD, Sheiman RG, Gangadharan SP. Critically
compromised airway secondary to expanding esophageal mucocele. Ann
Thorac Surg. 2012 Aug;94(2):635-6.
Corwin MT, Smith AJ, Karam AR, Sheiman RG. Incidentally detected misty
mesentery on CT: risk of malignancy correlates with mesenteric lymph
node size. J Comput Assist Tomogr. 2012 Jan-Feb;36(1):26-9.
Cullen G, Vaughn B, Ahmed A, Peppercorn MA, Smith MP, Moss AC,
Cheifetz AS. Abdominal phlegmons in Crohn’s disease: outcomes
following antitumor necrosis factor therapy. Inflamm Bowel Dis. 2012
Apr;18(4):691-6. doi: 10.1002/ibd.21783.
Cypess AM, Chen YC, Sze C, Wang K, English J, Chan O, Holman AR, Tal
I, Palmer MR, Kolodny GM, Kahn CR. Cold but not sympathomimetics
activates human brown adipose tissue in vivo. Proc Natl Acad Sci U S A.
2012 Jun 19;109(25):10001-5.
Dai W, Robson PM, Shankaranarayanan A, Alsop DC. Reduced resolution
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DEC 2012 Radical Views /29
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Note that publications with PMCID numbers denote NIHfunded author manuscripts. (PMCIDs are also required
by BIDMC grant administration policy for further funding
applications and are included in this bibliography for your
convenience.)
DEC 2012 Radical Views /30