Education Exhibits
Location: BR Community, Learning Center
Certificate of Merit
Participants
Emily Marie Brown MD (Presenter): Nothing to Disclose
Jason K. Mann MD : Nothing to Disclose
Sally Goudreau MD : Nothing to Disclose
Stephen Jacob Seiler MD : Nothing to Disclose
TEACHING POINTS
1. Fat injection (or lipofilling) is an increasing popular adjunct technique utilized by plastic surgeons to improve breast symmetry and contour following reconstruction.
2. Patients may have delayed symptoms following the procedure, including focal pain and/or a palpable lump.
3. Fat injections have a characteristic sonographic appearance of a complex ovoid mass with peripheral hyperechoic material and central anechoic fluid. Alternate findings mirror the classic spectrum of fat necrosis.
4. Knowledge of the characteristic features of fat injections permits a more confident diagnosis while relieving patient anxiety and avoiding unnecessary workup.
TABLE OF CONTENTS/OUTLINE
Overview of the surgical technique:
- Indications
- Illustration of procedure (to be created by our medical illustrator)
Review of the presenting signs/symptoms (at follow-up):
- Common symptoms
- Typical physical exam findings
Multimodality review of the imaging findings (with case examples):
- Ultrasound (the primary modality utilized for diagnostic evaluation)
- Mammography
- MRI
Clinical Implications
Summary
Education Exhibits
Location: BR Community, Learning Center
Certificate of Merit
Participants
Youe Ree Kim MD (Presenter): Nothing to Disclose
Hye-Won Kim MD : Nothing to Disclose
TEACHING POINTS
Irregular hypoechoic masses in breast do not always indicate malignancies. These lesions were assessed as BI-RADS Category
4a-to-4c suspicious malignancy on ultrasonography, resulting in US-guide biopsy. 1. There were many kinds of benign or borderline breast diseases representing irregular hypoechoic masses that can mimic carcinoma on ultrasonography. 2. Careful
US examination, history taking, and biopsy could help to differentiate them from malignancies.
TABLE OF CONTENTS/OUTLINE
Benign or bordeline breast lesions into 4 groups - Iatrogenic or trauma-related breast lesions Foreign body reaction Fat necrosis
Fibrotic scar - Proliferative disease - Benign breast tumors - Inflammation Abscess Idiopathic granulomatous lobular mastitis
Diabetic mastopathy Sclerosing adenosis Apocrine metaplasia Fibrocystic change Intraductal papilloma Fibroadenoma
Education Exhibits

Education Exhibits
Location: BR Community, Learning Center
Certificate of Merit
Participants
Christina Gkali MD (Presenter): Nothing to Disclose
Athanasios N. Chalazonitis MD, MPH : Nothing to Disclose
Zoi Antoniou BMedSc : Nothing to Disclose
Andromachi Zourla : Nothing to Disclose
Eleni Feida : Nothing to Disclose
TEACHING POINTS
1. To review the technique of both Strain Elastography (SE) and Acoustic Radiation Force Impulse Imaging (ARFI). 2. To suggest an appropriate breast SE and ARFI imaging examination protocol. 3. To demonstrate the elastographic imaging findings in benign and malignant breast lesions. 4. To review the potential elastographic pitfalls. 5. To suggest an appropriate reviewing method.
TABLE OF CONTENTS/OUTLINE
Both benign and malignant breast lesions were examined with SE and ARFI imaging in more than 50 consenting patients and can be displayed in details as a pictorial essay. All cases were paired with cytological or/and histological confirmation. Both SE and ARFI imaging were performed in benign and malignant breast lesions in order to depict the hardness of the examined lesion.
SE provides qualitative assessment of the tissue hardness. Strain ratio consist a quantification of this qualitative type of elastography. ARFI imaging is divided into two types: a) Virtual Touch Tissue Imaging (VTI) which provides the relative stiffness in qualitative way in the selected region of interest on a gray scale image and b) Virtual Touch Tissue Quantification (VTQ) which expresses the shear wave speed in solid materials as numeric values and describes quantitatively the hardness of tissue.
Education Exhibits
Location: BR Community, Learning Center
Participants
Emily Lorraine Sedgwick MD (Presenter): Nothing to Disclose
Sarah Louise Moorhead MD : Nothing to Disclose
Tamara Ortiz-Perez MD : Nothing to Disclose
Lilian O. Ebuoma MD : Nothing to Disclose
TEACHING POINTS
Teaching Points: Provide a pictoral review of the ultrasound lexicon in the BI-RADS 5th Edition, with emphasis on the changes in the lexicon, to promote appropriate use of the lexicon.
TABLE OF CONTENTS/OUTLINE
Studies have shown that focused teaching about the BI-RADS lexicon leads to improved appropriate use of the lexicon.
Ultrasound images demonstrating the lexicon characteristics will be displayed with the corresponding BI-RADS descriptors.
Images depicting the new BI-RADS descriptors (e.g. tissue composition, complex cystic and solid echo pattern) will be shown. A quiz will be provided following the instructive slides to reinforce the appropriate use of the BI-RADS lexicon. Outline Tissue
Composition Homogeneous background echotexture Heterogeneous background echotexture Masses Shape Orientation Margin
Echo pattern Posterior features Calcifications Calcifications in a mass Calcifications outside of a mass Intraductal calcifications
Associated features Architectural distortion Duct changes Skin changes Edema Vascular Elasticity Special cases Simple cyst
Clustered microcysts Complicated cyst Mass in or on skin Foreign body including implants Intramammary lymph nodes Axillary lymph nodes Vascular abnormalities Postsurgical fluid collection Fat necrosis Quiz
Education Exhibits
Location: BR Community, Learning Center
Participants
Erika Magdalena Meisen MD (Presenter): Nothing to Disclose
Maria Florencia Andraca : Nothing to Disclose
Laura Soledad Muscillo MD : Nothing to Disclose
Maria Emilia Diaz : Nothing to Disclose
Florencia Pia Sojo : Nothing to Disclose
Eduardo Pablo Eyheremendy MD : Nothing to Disclose
TEACHING POINTS
The purpose of this exhibit is: The objective of this paper is to describe the clinical and imaging features of cavernous hemangiomas, emphasizing those that allow it to differentiate themselves from angiosarcoma and other breast lesions. The major teaching points of this exhibit are: 1 - Nodules of solid appearance, usually hypo or hyperechoic and slightly heterogeneous. 2 - Classified as cavernous and capillary depending on the size of the vessels. Mixed are more common than pure capillaries. 3 - Usually are extraparenchymal (subcutaneous tissue) while angiosarcomas usually are intraparenchymal. 4 -
Unlike angiosarcoma, hemangioma show no flow on color doppler study. The flow inside the vascular structures is too slow to be demonstrated. 5-In mammograms, appears as a circumscribed, round, oval or lobulated, well-defined and high density lesion.
TABLE OF CONTENTS/OUTLINE
Cavernous hemangiomas are benign vascular tumors, usually located in the subcutaneous tissue. Classically, the diagnosis of cavernous hemangioma in adults was percutaneous biopsy, since it could be mistaken for a low-grade angiosarcoma (malignant lesion). However, there are imaging features of cavernous hemangiomas that allow us to differentiate them from angiosarcomas, avoiding unnecessary biopsies.

angiosarcomas, avoiding unnecessary biopsies.
Education Exhibits
Location: BR Community, Learning Center
Participants
Maria Florencia Andraca (Presenter): Nothing to Disclose
Erika Magdalena Meisen MD : Nothing to Disclose
Laura Soledad Muscillo MD : Nothing to Disclose
Maria Emilia Diaz : Nothing to Disclose
Florencia Pia Sojo : Nothing to Disclose
Eduardo Pablo Eyheremendy MD : Nothing to Disclose
TEACHING POINTS
The aim of this paper is to describe the clinical and imaging characteristics of childhood hemangiomas in the breast. The major teaching points of this exhibit are:1-Solid nodules with benign clinical features.2-Ultrasonography they may be echogenic or slightly heterogeneous.3-They have positive doppler flow in color doppler study, which is the fundamental pillar of this diagnostic entity.
TABLE OF CONTENTS/OUTLINE
The childhood capillary hemangiomas are benign vascular tumors that appear in the first months of life and are characterized by an initial proliferative phase and a later phase of regression. They are unusual lesions that may be located in both the breast parenchyma and the subcutaneous tissues surrounding the gland. The most important feature is their tendency to regression.
Lesions appear in the first weeks of life, grow for a few months and from the first year of life initiate a regression process leading to the total disappearance of the lesion in 95% of cases. There are ultrasound signs that force us to think about this entity, both in 2D and color doppler study, which correlate with histopathological findings. Treatment is expectant in the first place, unlike breast hemangiomas in adults, in which excision is recommended to avoid being confused with an underlying low-grade angiosarcoma, which invades the subcutaneous tissue.
Education Exhibits
Location: BR Community, Learning Center
Participants
Romuald Ferre (Presenter): Nothing to Disclose
Shaza Alsharif MD : Nothing to Disclose
Melanie Theriault MD : Nothing to Disclose
Valerie Blouin MD : Nothing to Disclose
Martine Pare RT : Nothing to Disclose
Benoit Delphin Mesurolle MD : Nothing to Disclose
TEACHING POINTS
The goals of the exhibits are: 1. To present and discuss the common errors encountered in breast US 2. Provide tips to limit the errors
TABLE OF CONTENTS/OUTLINE
Four scenarios that seem relevant in daily practice will be exposed: 1. Misinterpretation of "benign" appearing lesions (cancers displaying benign features: oval shape, circumscribed margins, hyperechoic echotexture) 2. Inadequate correlations between US
/ mammogram and US / physical exam 3. Value of a negative breast US 4. Underuse of available US settings particularly in interventional procedures 5. Misleading elastography (technique and results) US is an essential tool for breast imagers.
However, challenging situations can lead to misdiagnoses. Through various examples, practical tips and evidence-based algorithms will be proposed in this exhibit for better management of such situations in daily practise.
Education Exhibits
Location: BR Community, Learning Center
Participants
Irai Santana Oliveira MD (Presenter): Nothing to Disclose
Flavio Spinola Castro MD : Nothing to Disclose
Barbara Helou Bresciani MD : Nothing to Disclose
Luciano F. Chala MD : Nothing to Disclose
Vera Christina Camargo de Siqueira Ferreira MD : Nothing to Disclose
Nestor Barros : Nothing to Disclose
TEACHING POINTS
• To acknowledge the importance of ultrasound in breast imaging daily practice: may be problem solving, may outrule malignity, may detect subtle suspicious features • To understand ultrasound is an operator-dependant method: optimal scanning technique and accurate use of available resources is key for an appropriate examination and correct results • To accurately correlate ultrasound with other methods (mammography, MRI, CT): importance of positioning, anatomic landmarks and particular features of the lesion • To learn which mistakes are acceptable and how to avoid the unacceptable ones
TABLE OF CONTENTS/OUTLINE
• Breast ultrasound: background and importance in lesion characterization and assessment • Ultrasound technique: equipment,

• Breast ultrasound: background and importance in lesion characterization and assessment • Ultrasound technique: equipment, parameters and resources • Ultrasound technique: illustrative cases • Multimodality correlation: what must be regarded for an accurate correlation • Multimodality correlation: illustrative cases • Acceptable and unacceptable mistakes: a case-based review
• Conclusion
Education Exhibits
Location: BR Community, Learning Center
Certificate of Merit
Participants
Youichi Machida MD, PhD (Presenter): Nothing to Disclose
Mitsuhiro Tozaki MD, PhD : Nothing to Disclose
Akiko Shimauchi MD : Nothing to Disclose
Tamiko Yoshida : Nothing to Disclose
Yoshihide Kanemaki : Nothing to Disclose
TEACHING POINTS
1. It is importannt to recognize 'Ultrasound non-mass lesions (U-NML)" on breast ultrasound (US), which will become essential with increase in use of automated breast ultrasound (ABUS) imaging. 2. To detect and count suspicious features of U-NML helps interpreters assess possibility of malignancy.
TABLE OF CONTENTS/OUTLINE
Breast US is reported to detect incremental cancers that are negative on mammography, especially in women with dense breasts. ABUS enables radiologists to evaluate the breast comprehensively using three-dimensional sectional views, in a similar way to MRI. With a rising number of ABUS exams, it will become increasingly important to appreciate US lesions that would be observed as non-mass enhancements on MRI. Radiologists will be able to appreciate and evaluate "U-NML" properly after viewing this exhibit containing following topics; 1. U-NML in comparison with mammographic and MRI findings, as well as pathology results: what kind of lesions can appear as non-mass? 2. Categorization of U-NML based on scores of suspicious features.
Education Exhibits
Location: BR Community, Learning Center
Selected for RadioGraphics
Participants
Romuald Ferre (Presenter): Nothing to Disclose
Martine Pare RT : Nothing to Disclose
Lisa Smith : Nothing to Disclose
Shaza Alsharif MD : Nothing to Disclose
Melanie Theriault MD : Nothing to Disclose
Ann Elizabeth Aldis MD : Nothing to Disclose
Benoit Delphin Mesurolle MD : Nothing to Disclose
Pierre-Alain Goumot : Nothing to Disclose
TEACHING POINTS
The goals of the exhibit are: 1. To present and discuss the contributing factors in missed retro-areolar cancers on ultrasound 2.
To describe technical challenges, and propose management tips 3. To review the spectrum of retro-areolar lesions
TABLE OF CONTENTS/OUTLINE
1. Technical challenges of retro-arealar lesions: due to lesion position, lesion size 2. Management tips for challenging lesions: frequency, Doppler, elastography 3. Radio-pathologic correlation examples with management recommendations 4. False negatives: how to identify and prevent them US is an essential tool of the breast imager yet the technique remains challenging and imperfect to explore retro-areolar lesions. Challenges include technical considerations related to scanning adequately.
Through various examples using Doppler, elastography, this exhibit will offer practical tips to the radiologists as well as propose evidence-based algorithms for the diagnosis of retro-areolar lesions.
Education Exhibits
Location: BR Community, Learning Center
Participants
Megan Jenkins Kalambo MD (Presenter): Nothing to Disclose
Savitri Krishnamurthy MD : Nothing to Disclose
Sarah DeSnyder MD : Nothing to Disclose
Madeleine Duvic MD : Nothing to Disclose
Victor G. Prieto MD, PhD : Nothing to Disclose
Gary J. Whitman MD : Nothing to Disclose
TEACHING POINTS
Accurate classification and description of skin and superficial lesions of the breast will aid the radiologist in distinguishing benign

Accurate classification and description of skin and superficial lesions of the breast will aid the radiologist in distinguishing benign from suspicious imaging findings that warrant biopsy. In this presentation, we will provide a systematic approach to the evaluation of skin and superficial lesions of the breast on mammography and ultrasound and discuss distinctive imaging features of superficial breast lesions and indications for biopsy.
TABLE OF CONTENTS/OUTLINE
We will present a pictorial essay of our experience with superficial breast lesions at our institution, including management of challenging cases. Knowledge of the imaging features of superficial breast and skin lesions helps to guide appropriate management that includes annual mammography for benign lesions or biopsy for suspicious lesions. 1) Techniques that aid in identifying skin/superficial lesions. 2) Imaging features that aid in distinguishing benign superficial lesions from lesions that warrant biopsy. 3) Appropriate differential diagnoses for benign and malignant superficial lesions Top Differentials: Benign: epidermal inclusion cyst, nevus, hemangioma. Iatrogenic: scar,keloid Malignancy: breast cancer with direct skin involvement, angiosarcoma, metastases Hereditary: neurofibromatosis, steatocystoma multiplex
Education Exhibits
Location: BR Community, Learning Center
Participants
Brenna Ann Talkin Chalmers MD (Presenter): Nothing to Disclose
Linda Hovanessian-Larsen MD : Nothing to Disclose
Bhushan Desai MBBS, MS : Nothing to Disclose
Darryl Hwang PhD : Nothing to Disclose
Samantha Delapena : Nothing to Disclose
Sandy Chia-En Lee MD : Nothing to Disclose
Edward G. Grant MD : Research Grant, Bracco Group Research Grant, General Electric Company Medical Advisory Board,
Nuance Communications, Inc
TEACHING POINTS
1. To understand the basics of contrast enhanced ultrasound (CEUS) and Shear Wave Elastography (SWE). 2.To investigate the role of CEUS and SWE as a potential response assessment biomarker to neoadjuvant chemotherapy (NAC) in breast cancer by evaluating changes in tumor size, perfusion characteristics, and tissue stiffness before (baseline) and 2-3 weeks post-NAC initiation. 3. To assess the agreement between CEUS and SWE based classification rule and pathologically determined treatment response. 4. To determine the agreement between different imaging modalities (including conventional US, MRI, SWE). 5. To illustrate pictorial cases where CEUS and SWE are useful for therapy monitoring of breast cancer patients on NAC.
TABLE OF CONTENTS/OUTLINE
I. Background and Significance II. Literature review III. Limitations of conventional imaging modalities IV. Clinical utility of CEUS and SWE V. Technical note: Imaging data acquisition methodology (qualitative and quantitative) VI. Evaluating treatment response using different imaging modalities VII. Clinical case examples of studies done at our institution
Education Exhibits
Location: BR Community, Learning Center
Participants
Daniel Claudio Mysler MD (Presenter): Nothing to Disclose
Andres Kohan MD : Fellowship funded, Koninklijke Philips NV
Mora Amat : Nothing to Disclose fernando farache : Nothing to Disclose veronica fabiano : Nothing to Disclose
Ricardo D. Garcia-Monaco MD, PhD : Research Consultant, Siemens AG Research Consultant, BTG International Ltd federico colo : Nothing to Disclose
TEACHING POINTS
To review ultrasound imaging findings secondary to lipofilling To understand the impact this technique has on the adequate handling of patients with history of breast cancer To provide a decision tree upon ultrasound findings during the breast oncological control in patients that had a lipofilling treatment
TABLE OF CONTENTS/OUTLINE
Procedure : description of the lipofilling technique
Clinical Findings : during physical examination
Pathophysiology : Histopathologic findings, cascade of fat necrosis
Ultasound findings : review the different changes that happen in the breast and their visualization in ultrasound.
Tips and practical tricks : which associated ultrasound findings are suspicious for recurrent breast cancer and which ones discard it
Radiologic decision-tree
Education Exhibits
Location: BR Community, Learning Center
Selected for RadioGraphics

Participants
Matthew Cole Oliff MD (Presenter): Nothing to Disclose
Catherine Streeto Giess MD : Nothing to Disclose
Sughra Raza MD : Consultant, Seno Medical Instruments, Inc
Robyn L. Birdwell MD : Nothing to Disclose
TEACHING POINTS
1. To review the anatomy of the chest wall and axilla and to describe optimal ultrasound scanning techniques. 2. To present examples of non-mammary masses encountered during breast and axillary ultrasound with mammographic, CT, and/or MRI correlation 3. To outline imaging clues to the origin of non-mammary masses and to describe management strategies.
TABLE OF CONTENTS/OUTLINE
1. Review the anatomy of the axilla and chest wall and review the differential diagnosis of lesions in these regions. 2.
Demonstrate optimal ultrasound scanning techniques of the axilla to enable the breast imager to properly localize a lesion within the sometimes disorienting region of the axilla. 3. Present cases of ultrasound evident non-mammary masses with mammographic, CT, and/or MRI correlation 4. Describe clues and pitfalls in the diagnosis of non-mammary masses of the axilla and chest wall. 5. Review management strategies if a mass is thought to be non-mammary in origin.
Education Exhibits
Location: BR Community, Learning Center
Certificate of Merit
Selected for RadioGraphics
Participants
Mailan Melissa Cao MD (Presenter): Nothing to Disclose
Fan Yang MD, PhD : Nothing to Disclose
Heather I. Frimmer MD : Nothing to Disclose
TEACHING POINTS
This exihibit will teach participants: - subtle signs of architectural distortion on ultrasound, - troubleshooting techniques in hard-to-find lesions, - benefits and limitations of advanced ultrasound modes such as harmonics, spectral compound imaging, and other automated image optimization tools in the characterization of architectural distortion, - optimal techniques for ultrasound-guided biopsy of architectual disortion.
TABLE OF CONTENTS/OUTLINE
1. Indications for ultrasound in the work-up of architectural distortion detected with tomosynthesis 2. Sonographic imaging findings of architectural distortion with tomosynthesis correlation 3. Troubleshooting Techniques: using the parenchymal pattern seen on tomosynthesis to localize the lesion repositioning the patient imaging behind the nipple using advanced ultrasound modes such as harmonics, spectral compound imaging, and power Doppler 4. Techniques for successful ultrasound-guided biopsy of architectural distortion
Education Exhibits
Location: BR Community, Learning Center
Participants
Maria Florencia Andraca (Presenter): Nothing to Disclose
Erika Magdalena Meisen MD : Nothing to Disclose
Laura Soledad Muscillo MD : Nothing to Disclose
Maria Emilia Diaz : Nothing to Disclose
Florencia Pia Sojo : Nothing to Disclose
Eduardo Pablo Eyheremendy MD : Nothing to Disclose
TEACHING POINTS
The purpose of this exhibit is: 1-Describe the clinical and imaging characteristics of tumors phylloides, emphasizing those that allow differentiation of fibroadenoma, the main differential diagnosis. 2-Correlate these findings with histopathological diagnosis.
The major teaching points of this exhibit are: 1 - Solid nodules with benign clinical features, which usually appear in women aged 40-50 years, with rapid growth. 2 - On mammograms, appear as a well-defined lesion, round, oval or lobulated, circumscribed and with soft tissue density. 3 - Ultrasonography may be heterogeneous with anechoic areas inside. 4 - They can show positive doppler flow in color doppler study.
TABLE OF CONTENTS/OUTLINE
The phylloides tumors represent a heterogeneous group of biphasic neoplasms composed of stromal and epithelial components, which may be benign, borderline or malignant. They are unusual tumors constituting from 0.3 to 0.9% of all mammary tumors.
The average age of onset is around 40 -50 years old. There are ultrasound signs that force us to think about this entity, both in
2D and color doppler study, which correlate with histopathological findings. Definitive diagnosis is histopathological, and full resection with free margins is the main treatment of these lesions.
Education Exhibits

Location: NA
Participants
Moderator
Nirvikar Dahiya MD Nothing to Disclose
Kathryn Ann Robinson MD : Nothing to Disclose
Manjiri K. Dighe MD : Research Grant, General Electric Company
Jason Michael Wagner MD : Nothing to Disclose
Michael David Beland MD : Nothing to Disclose
Maitray D. Patel MD : Nothing to Disclose
Scott W. Young MD : Nothing to Disclose
Education Exhibits
Location: MS Community, Learning Center
Participants
Ignacio Martin-Garcia MD (Presenter): Nothing to Disclose
Rodrigo Blanco-Hernandez MD : Nothing to Disclose
Roberto Tabernero : Nothing to Disclose
Manuel Angel Martin Perez MD : Nothing to Disclose
Piedad Arias-Rodriguez : Nothing to Disclose
Jose Marin : Nothing to Disclose
TEACHING POINTS
-Review the role of radiology in the battery of tests in patients with suspicion of tularemia. -Show the radiological findings in the patient with positive serology results for Francisella Tularensis. -Present the typical spectrum of lesions in patients with a confirmed diagnosis of tularemia.
TABLE OF CONTENTS/OUTLINE
We performed a retrospective study taking a population of 172 patients who were treated in our centre between February 2008 and October 2009, with fever of unknown origin and adenopathies, and who underwent a specific serological analysis. We present the spectrum of radiological findings with CT, MR an US, with different clinical forms of presentation of tularemia.
According to our database, they correspond to: -Glandular tularemia: 23% (axillary, inguinal adenopathies). -Pharyngeal tularemia: 28% (cervical adenopathies and abscesses). -Typhoidal tularemia: 6% (splenic and hepatic involvement).
-Pneumonic tularemia: 40% (pleuropulmonary symptoms and mediastinic adenopathies) -and a rare case of spondylodiscitis:
3%.
Education Exhibits
Location: MS Community, Learning Center
Certificate of Merit
Participants
Sarah Kyung Oh MD (Presenter): Nothing to Disclose
Zina Joan Ricci MD : Nothing to Disclose
Jeffrey Harmon Roberts MD : Nothing to Disclose
Victoria Chernyak MD : Nothing to Disclose
Alla M. Rozenblit MD : Nothing to Disclose
Fernanda Samara Mazzariol MD : Nothing to Disclose
Milana Flusberg MD : Nothing to Disclose
Marjorie Werner Stein MD : Nothing to Disclose
Ellen Leslie Wolf MD : Nothing to Disclose
TEACHING POINTS
Teaching points: Review multimodality (CT, Ultrasound, and MRI) imaging of malignant disease in the abdomen which simulates benign conditions, raising awareness of overlapping features and highlighting key imaging pearls for correct diagnosis. 1.
Malignant disease can simulate benign conditions. 2. Superimposed infectious or inflammatory process may obscure the primary pathology. 3. Behavior on follow up exam can be helpful in distinguishing malignant disease from benign conditions.
TABLE OF CONTENTS/OUTLINE
A. Discuss differences between imaging modalities in the evaluation of tumor within the abdomen. B. Present cases where malignant disease simulates a benign condition. C. Present cases where a superimposed infectious or inflammatory process obscures the primary pathology. D. Highlight key features that may aid in correct diagnosis. E. Review imaging surveillance recommendations. Cases include but are not limited to the following: - Mucinous hepatic metastases as biliary hamartomas -
HCC as FNH - Scirrhous colon carcinoma as diffuse colitis with toxic megacolon - Mucinous appendiceal neoplasm as acute appendicitis - TCC as normal renal sinus fat - Seminoma as orchitis - Psammomatous ovarian calcification as fibroids -
Krukenberg tumors as tubo-ovarian abscesses - Buttock carcinoma as sacral decubitus ulcer
Education Exhibits
Location: MS Community, Learning Center

Participants
Nanda Venkatanarasimha MRCP, FRCR (Presenter): Nothing to Disclose
TEACHING POINTS
Familiarity afforded by recognition of a classic sign or Aunt Minnie on ultrasound allows for a more confident and accurate diagnosis Identification and understanding the pathophysiologic characteristics associated with these signs can facilitate timely patient management
TABLE OF CONTENTS/OUTLINE
Systematic review of signs in Hepatobiliary: • Starry sky, halo, target, reverse target, short gun, double duct, central dot, double barrel, gamna-gandy bodies • WES, comet tail, Champagne, Murphy's Genitourinary: • Renal sweat, dromedary hump, milk of calcium, mickey-mouse, Jack stone, cobra, ureteric jet • Filarial dance, onion skin Peritoneum & bowel • Cake and
Sandwich; pseudokidney Pelvis • Picket fence, tip of iceberg, string of pearls, feeding artery, ring of fire, bridging vascular, plug and mesh Doppler • Spoke wheel, whirl pool, Ying-yang, String of beads, visible thrill, mosaic • Reverse 'M', Parvus tardus, hepatofugal Correlative imaging Summary
Education Exhibits
Location: VI Community, Learning Center
Participants
Priyanush Kandakatla MD (Presenter): Nothing to Disclose
Anthony Edward Samir MD : Nothing to Disclose
TEACHING POINTS
1. To review the indications for FNA of thyroid nodule seen on ultrasound based on current society guidelines throughout the
World 2. comparing the similarities and differences between these guidelines.
TABLE OF CONTENTS/OUTLINE
1. Description of the following guidelines for FNA of thyroid nodules seen on ultrasound: 1.1. ATA (American Thyroid
Association) 1.2. AACE (American Association of Clinical Endocrinologists) 1.3. ETA (European Thyroid Association) 1.4. SRU
(Society of Radiologists in Ultrasound) 1.5. KSTR (Korean Society of Thyroid Radiology) 2. A comparison of society guidelines: quoted sensitivity and specificity ,similarities and differences, pros and cons. 3. Examples of cases where different guidelines may result in discordant actions.
Education Exhibits
Location: VI Community, Learning Center
Participants
Lelivaldo Antonio de Britto Neto MD : Nothing to Disclose
Carlos A P Ventura PhD : Nothing to Disclose
Thiago De Vasconcelos Saraiva : Nothing to Disclose
Diego Bortolazzi Bezerra Nunes MD : Nothing to Disclose
Priscila Pimentel Collier MD : Nothing to Disclose
Miguel Jose Francisco Neto MD (Presenter): Nothing to Disclose
Marcelo Buarque Gusmao Funari MD : Nothing to Disclose
TEACHING POINTS
To demonstrate the majors findings in carotid artery dissection on the Doppler ultrasonography. To review and illustrate role of
Doppler ultrasonography in carotid artery dissection and their complications. What cannot miss in the ultrasonography report of carotid dissection?
TABLE OF CONTENTS/OUTLINE
Cervical artery dissections (CAD) are more common in the internal carotid arteries (ICA), 70% in the cervical and petrous segments, mainly 2-3 cm distal to the carotid bulb. These segments are easily accessible by ultrasound. The Doppler ultrasound
(Doppler US) can make initial screening, diagnosis and monitoring of dissection in the proximal segments of the ICA. Computed tomography (CT) and magnetic resonance imaging (MRI) are the best methods in the evaluation of CAD. The present study aims to describe by practical cases the role and major abnormalities in the Doppler US of ICA dissections. Doppler US is a low cost exam that can assist in the diagnosis and monitoring of CAD. That can demonstrate the tapering column flow with abnormal pulsed wave Doppler up to 90% of cases of dissection. Moreover, it is able to determine the flow dynamics of the dissection. CT and MRI do not allow determining the flow dynamics It is important for all radiologist know the majors abnormalities in carotid artery dissection on the Doppler US.
Education Exhibits
Location: VI Community, Learning Center
Certificate of Merit
Participants

Participants
Patricia M. Carrascosa MD : Research Consultant, General Electric Company
Carlos Capunay MD (Presenter): Nothing to Disclose
Javier Vallejos MD, MBA : Nothing to Disclose
Alejandro Deviggiano MD : Nothing to Disclose
Gaston Rodriguez Granillo : Nothing to Disclose
TEACHING POINTS
1- To review the indications, diagnostic imaging, potential benefits and limitations of performing a dual-energy CT angiography with reduced iodine contrast volume. 2- To understand the advantages of dual energy CT in vascular imaging.
TABLE OF CONTENTS/OUTLINE
A. Introduction to dual energy CT. Physics B. Image analysis. Spectral imaging. Material decomposition. Calcium and bone subtraction. C. CT image acquisition. Technical parameters. Radiation issues D. Contrast injection protocol E. Diagnostic Imaging
F. Potential indications. Outcomes
Education Exhibits
Location: VI Community, Learning Center
Participants
Roberto Correa Soto (Presenter): Nothing to Disclose
Teresa Gonzalez De La Huebra Labrador : Nothing to Disclose
Aurymar Fraino : Nothing to Disclose
Percy Alexander Chaparro Garcia : Nothing to Disclose
Diego Sebastian Palominos Pose MD : Nothing to Disclose
Karin Daniela Muller MD : Nothing to Disclose
Cecilia Santos Monton : Nothing to Disclose
Heidy Saenz Acuna MD : Nothing to Disclose
TEACHING POINTS
The purpose of this exhibit is:
To explain the possible locations, orientations and physiology of the new transplanted organ (kidney, pancreas).
To review the methodology and temporal protocol of doppler ultrasound of patients transplanted pancreas-kidney.
To review the radiological findings indicating good and / or poor outcome.
TABLE OF CONTENTS/OUTLINE
Introduction
Transplanted organs (pancreas-kidney) location, orientation, relationships, physiology.
Imaging techniques and findings.
1.
2.
3.
Doppler ultrasound technique: protocol review, methodology, temporal protocol.
Radiological findings of good prognosis.
imaging findings of complications and poor prognosis
Common diagnostic pitfalls.
A useful radiological report.
Cases to illustrate the radiologic features.
Education Exhibits
Location: VI Community, Learning Center
Participants
Daniel Claudio Mysler MD : Nothing to Disclose
Andres Kohan MD (Presenter): Fellowship funded, Koninklijke Philips NV
Tiare Africa Pineiro MD : Nothing to Disclose
Monica Poclava MD : Nothing to Disclose
Adrian Nervo MD : Nothing to Disclose
Ricardo D. Garcia-Monaco MD, PhD : Research Consultant, Siemens AG Research Consultant, BTG International Ltd federico colo : Nothing to Disclose
TEACHING POINTS
To review clinical indications for lymph node biopsy To identify the different image guided biopsy techniques for lymph nodes To review ultrasound guided lymph node biopsy technique To review the different tips and tricks for a successful procedure and tissue sampling
TABLE OF CONTENTS/OUTLINE
Anatomy: location of the lymph nodes, best acoustic windows to image them and best point of acces for tissue sampling
Pathophysiology: metastatic pathways and where to go look for the most prpbably involved lymph nodes
Clinical Findings: tips from physical examination to help locate pathological lymph nodes

Ultrasound guided biopsy technique: a review step by step of the appropriate biopsy procedure
Indications and contraindications
Tips and tricks for succesful tissue sampling: experience based tips and tricks to maximize tissue sampling and obtain a representative biopsy
Possible complications and their treatment
Education Exhibits
Location: VI Community, Learning Center
Magna Cum Laude
Participants
Shilpa Nagarur Reddy MD (Presenter): Nothing to Disclose
Meghan Boros MD : Nothing to Disclose
Mindy Meislich Horrow MD : Spouse, Director, Merck & Co, Inc
TEACHING POINTS
1. Venous US is frequently the initial study requested to evaluate acute arm swelling in patients with dialysis access 2. While important to exclude DVT, , in the setting of swelling in an arm with chronic dialysis access, radiologists must consider a wide variety of other vascular and non-vascular causes for swelling, many of which can be appreciated or suggested using US 3. This exhibit will review anatomy of AV grafts and fistulas and how to evaluate them with US, demonstrate examples of alternative vascular and non-vascular diagnoses, and discuss when other modalities and interventions are necessary
TABLE OF CONTENTS/OUTLINE
1. Systematic approach using US for initial evaluation of swollen arm with chronic dialysis access a. History and physical examination of arm b. Type of access c. Relevant vascular anatomy with Doppler analysis d. Soft tissues 2. Venous related diagnoses a. Deep and superficial venous thrombosis b. Central venous stenosis or occlusion c. Large draining veins from fistula
3. Abnormalities intrinsic to chronic dialysis access a. Thrombosis of fistula or graft b. Steal syndrome c. PSA 4. Non-vascular diagnoses a. Soft tissue collections b. Other arm masses
Education Exhibits
Location: VI Community, Learning Center
Certificate of Merit
Participants
Amy Davis Haberman MD (Presenter): Nothing to Disclose
Erin Horsley DO : Nothing to Disclose
Steven David Herman MD : Nothing to Disclose
TEACHING POINTS
1. Learn the specific components of spectral waveforms and their meaning with respect to physiology.
2. Learn to maximize the ultrasound unit settings to guarantee accuracy of diagnosis.
3. Be able to recognize normal and abnormal waveforms specific to each organ and pathology.
TABLE OF CONTENTS/OUTLINE
1. Basic physiology of hemodynamics 2. Basic Doppler techniques 3. Dissection of a spectral waveform 4. Optimizing your
Doppler settings 5. Organ specific Doppler evaluation 6. Pathlogic Doppler waveforms 7. It doesn't look right but I'm not sure why. What do I do? 8. Post quiz
Education Exhibits
Location: VI Community, Learning Center
Participants
Ganesh Moreshwar Joshi MBBS (Presenter): Nothing to Disclose
Flavius F. Guglielmo MD : Nothing to Disclose
Lauren Lown : Nothing to Disclose
Roger Lown : Nothing to Disclose
Laurence Needleman MD : Nothing to Disclose
TEACHING POINTS
The purpose of this exhibit is: 1. Review all arteries outside of the brain that can be evaluated with Doppler ultrasound. 2. Learn imaging criteria for diagnosing significant stenosis in each artery. 3. Learn primary and secondary signs of arterial stenosis.
TABLE OF CONTENTS/OUTLINE
General principles 1. Waveform appearance within and adjacent to a significant stenosis 2. Optimizing color and spectral Doppler
Head and neck arteries 1. Internal carotid- non-operated, post CEA, and post stenting 2. Common and external carotid 3.
Subclavian- with TOS evaluation 4. Vertebral 5. Innominate Abdomen arteries 1. Abdominal aorta 2. Celiac- with MALC

evaluation 3. SMA, IMA 4. Renal- native and transplant renal artery evaluation 5. Iliac Upper extremity arteries 1. Axillary, brachial, ulnar 2. Radial- with evaluation for radial artery dependence Lower extremity arteries 1. CFA, SFA, DFA, popliteal 2.
PTA, ATA, peroneal 3. Bypass grafts, stents The major teaching points of this exhibit are: 1. There are general principles to know when evaluating arteries for stenosis within and proximal and distal to the stenosis. Adhering to them improves diagnostic accuracy. 2. Several arteries have unique imaging criteria when diagnosing stenosis. 3. In some arteries maneuvers can be performed to diagnose a stenosis.
Education Exhibits
Location: VI Community, Learning Center
Participants
Joao Rafael Terneira Vicentini MD (Presenter): Nothing to Disclose
Felipe Ribeiro Ferreira : Nothing to Disclose
Danilo Giorgio Oliveira Azevedo Medrado MD : Nothing to Disclose
Leina Ceravolo De Melo Zerey : Nothing to Disclose
Carlos A P Ventura PhD : Nothing to Disclose
Maria Cristina Chammas MD : Nothing to Disclose
TEACHING POINTS
- Recognize the importance of ultrasound as a diagnostic method in the evaluation of complications after endovascular aneurysm repair, particularly endoleak
- Key findings in ultrasound / Doppler examination of stents/grafts in peripheral arteries
- Discuss ways to improve Doppler ultrasound technique for better results in these patients
- Main advantages of ultrasound in the initial follow-up after aneurysm surgery over other imaging methods
TABLE OF CONTENTS/OUTLINE
- Sample of cases evaluated and monitored with Doppler ultrasound
- Special aspects of different arteries examination, such as the carotid and popliteal arteries
- Security and applicability of ultrasound following endovascular correction of aneurysms
- Correlation of sonographic findings and CT angiography (CTA)
- Literature review on use of ultrasound and CT scan for follow-up after endovascular aneurysm repair
Education Exhibits
Location: VI Community, Learning Center
Participants
Alexander Zachary Copelan MD (Presenter): Nothing to Disclose
Anindya K. Roy MD : Nothing to Disclose
Hanh Vu Nghiem MD : Nothing to Disclose
TEACHING POINTS
Advantages of ultrasound in cross-sectional intervention have been previously described. Utilizing case-based illustrations, we will not only substantiate these traditional advantages, but will also demonstrate additional advantages, including the use of ultrasound as a diagnostic, intra-procedural problem solving tool to prevent unnecessary procedures and potential complications.
TABLE OF CONTENTS/OUTLINE
Illustrate and Depict:
Traditional advantages of US as an image guidance tool: real-time nature, vessel visualization, portability, decreased procedure time and cost, and lack of ionizing radiation and use of iodinated contrast material
Expanded advantages: i. Biopsy of small lesions, lesions not readily accessible by CT guidance, trans-rectal, trans-vaginal, and trans-perineal approaches, and pediatric intervention ii. Use of US-guided direct compression to displace bowel loops to facilitate biopsy of deep lesions, to treat pseudo-aneurysm with or without thrombin injection, and to help minimize potential post-procedural bleeding complications iii. Use of US imaging as an intra-procedural problem solving tool to help prevent unnecessary procedures and potential complications, and to urge the interventionist to recognize such instances and take the appropriate steps to ensure the safety and efficacy of image-guided intervention
Education Exhibits
Location: VI Community, Learning Center
Participants
Jose Carmelo Albillos Merino MD (Presenter): Nothing to Disclose
Susana Hernandez Muniz MD : Nothing to Disclose
Javier Azpeitia Arman MD : Nothing to Disclose
Rosa M. Lorente-Ramos MD, PhD : Nothing to Disclose

Rosa M. Lorente-Ramos MD, PhD : Nothing to Disclose
Alvaro Paniagua MD : Nothing to Disclose
TEACHING POINTS
To describe the main thoracic interventions that can be achieved by ultrasound guidance. To propose a tailored approach with tips and tricks.
TABLE OF CONTENTS/OUTLINE
US-guided interventional procedures main advantages are that can be performed at the patient bed-side, permit a safe real-time control of the interventions without the use of ionizing radiation and are cost and time-effective. US has been considered to have a secondary role in interventions on the thorax. Nevertheless, most thoracic structures are adequately imaged by US and, as a result, interventional procedures can be safely performed with US-guidance. The main procedures that can be performed are biopsies (fine-needle and core biopsy) and drainage of fluid collections. The organs that can be reached by US are located in the chest wall, mediastinum, pericardium, pleura, pleural cavity and in the subpleural pulmonary parenchimas. We propose a guide to the interventions based on a tailored approach with real cases. Several steps must be followed: To depict the lesion with avalaible imaging techniques . To decide the best approach to the lesion. To verify correct visualization of the lesion with US. To perform the procedure with adequate technique and material. To assess absence of complications.
Education Exhibits
Location: VI Community, Learning Center
Participants
Ayman Sawas MD (Presenter): Nothing to Disclose
Devang Butani MD : Nothing to Disclose
TEACHING POINTS
Learn indications, benefits, interventional methods, and potential complications of utilizing ultrasound in interventional radiology procedures through case based presentation. This will include cases of performing direct intrahepatic protocaval shunt (DIPS) with intravascular ultrasound guidance, treating stenosis and thrombosiss of dialysis fistulas without fluroscopy, and percutaneous transhepatic cholangiogram (PTC).
TABLE OF CONTENTS/OUTLINE
A. Clinical scenerio.
B. Indication
C. Benefits of ultrasound pretaining to the case
D. Anatomy
E. Interventional methods
F. Outcomes including complications
Special Courses
PH US NM CT
AMA PRA Category 1 Credits ™ : 2.00
ARRT Category A+ Credits: 2.00
Sat, Nov 29 2:15 PM - 4:15 PM Location: E351
Participants
Moderator
Jerry A. Thomas MS : Stockholder, General Electric Company Stockholder, Hologic, Inc Stockholder, Stryker Corporation
Speaker, Medical Technology Management Institute
LEARNING OBJECTIVES
1) Understand the advanced capabilities of multi-spectral volumetric imaging in the major modalities of Ultrasound, MRI, CT and
Nuclear Imaging. 2) Appreciate the clinical capabilities of multi-spectral volumetric imaging and approach to utilizing advanced imaging applications with this technology.
Sub-Events
SPPH02A Dual Energy Imaging in Diagnostic Radiology
Jerry A. Thomas MS (Presenter): Stockholder, General Electric Company Stockholder, Hologic, Inc
Stockholder, Stryker Corporation Speaker, Medical Technology Management Institute
LEARNING OBJECTIVES
View learning objectives under main course title.
Hybrid Imaging in Ultrasound

SPPH02B
SPPH02C
Hybrid Imaging in Ultrasound
Evan Boote PhD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
View learning objectives under main course title.
ABSTRACT
Ultrasound imaging is a relatively inexpensive, low-risk application to patients, ubiquitously available in the health care setting. However, ultrasound presents a challenge to the novice user, particularly with regard to recognition of anatomic landmarks. In some situations, ultrasound imaging is not capable of resolving some structures, either due to spatial and/or contrast resolution limitations; in certain other situations, ultrasound offers a superior approach to visualizing abnormalities or the depiction of blood flow in the body. Hybrid ultrasound may be defined in a number of ways - the most likely definition would be what might be termed
'fusion' imaging, where a set of image data from a second modality is imported into the ultrasound system, anatomical landmarks are established, and a fused image is displayed in real-time. Hence the advantages of the other modalities would be gained during the use of the ultrasound system. Another definition of 'hybrid' may be the use of a device to depict a biopsy needle placement in real-time. A further extension of the word
'hybrid' might be to include real-time simultaneous imaging with another modality, even a non-traditional imaging modality. This presentation will review these variations of 'hybrid' ultrasound that are commercially available and in current clincal practice. However, the presentation will also cover those still in the development stage. The practical applications of these systems will be discussed, as will the limitations and restrictions on their use. Included in this will be an evaluation of cost of the system and a case-study on the use of hybrid imaging in a hospital setting.
Commercially Available Multi-spectral and Volumetric Imaging Systems
Sarah Eva McKenney PhD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
View learning objectives under main course title.
ABSTRACT
The price of purchasing and maintaining the latest imaging systems is on the order of millions; tight budgets in health care necessitate the ability to make smart purchases. This work identifies important considerations when purchasing an advanced imaging system, specifically in the context of dual energy and multi-modality volumetric imaging. The roles of imaging stakeholders are examined including: administrators, radiologists, technologists, medical physicists, IT specialists, clinical engineers, and vendors. A general overview of the strengths and weaknesses of volumetric commercially available imaging systems is also provided. Learning
Objectives • Identify the needs of the imaging cohort • Evaluate prospective systems for purchase
URL http://goo.gl/CB3Tgm
Scientific Papers
US BR
AMA PRA Category 1 Credits ™ : 1.50
ARRT Category A+ Credits: 1.50
Sun, Nov 30 10:45 AM - 12:15 PM Location: Arie Crown Theater
Participants
Moderator
Wendie A. Berg MD, PhD : Research Grant, Gamma Medica, Inc Research Grant, General Electric Company Equipment support, Gamma Medica, Inc Equipment support, General Electric Company
Moderator
Regina J. Hooley MD : Nothing to Disclose
Sub-Events
SSA01-01 Breast Imaging Keynote Speaker: State of the Art—Ultrasound for Breast Cancer Screening
Regina J. Hooley MD (Presenter): Nothing to Disclose
SSA01-03 The Connecticut Experiment Continues: Ultrasound in the Screening of Women with Dense Breasts
Years 3 and 4
Jean M. Weigert MD (Presenter): Stockholder, Tractus Company Limited

PURPOSE
To determine if the addition of screening breast ultrasound in women with mammographically normal but dense breasts in the 3rd and 4th year since the legislation was enacted has continued to improve breast cancer detection while demonstrating an improvement in PPV.
METHOD AND MATERIALS
The study utilized a retrospective chart review. Data collected included: (1) total number of screening mammograms; (2) total number of dense breast screening ultrasounds; (3) screening ultrasound Breast
Imaging Reporting Data System (BI-RADS) code results; (4) biopsy results; and (5) demographic data on women with malignant biopsies. Data was obtained from included sites throughout 2012 and 2013.
RESULTS
Data from 2 Connecticut radiology practices with 5 sites was collected. A total of 32230 screening mammograms and 4128 dense breast ultrasounds were performed in year 3 and 27937 screening mammograms and 3330 dense breast ultrasounds in year 4. In year 3, of the screening ultrasounds 148 were
BI-RADS 4 or 5, and 13 were found to have a cancer on biopsy. In year 4, there were 52 BI-RADS 4 or 5 ultrasounds and 10 cancers. The rate of detection is 3.1/1000 in year 3 and 3.0/1000 in year 4. The positive predictive value increased from 8.1% in year 3 to 16.1% in year 4. Of the women eligible for the screening ultrasound, 32% and 30% requested the test respectively in years 3 and 4.
CONCLUSION
Based on the data collected from these sites, screening breast ultrasound in women with dense breast parenchyma continues to detect mammographically occult malignancy in years 3 and 4 at the same rate as year 1 and 2. The rate of detection remains stable at 3.0/1000. However, the PPV increased in year 4 indicating that the selection of lesions biopsied was more accurate with fewer false positives. Of concern, the number of eligible women who elect to have the additional test remains low at about 30% which is due to several factors including education and cost.
CLINICAL RELEVANCE/APPLICATION
Adding screening breast ultrasound in patients with mammographically dense breasts continues to diagnose a significant number of additional cancers in the 3rd and 4th year since the legislation was enacted and the PPV has also improved.
SSA01-04 Impact of Breast Density Notification Law in the Detection of Breast Cancer: Initial 15 Months
Experience
Islamiat O. Ego-Osuala MD (Presenter): Nothing to Disclose , Kristin Elias MD : Nothing to Disclose ,
Sara Daniel Shaylor MD : Nothing to Disclose , Marissa Lauren Albert MD, MSc : Nothing to Disclose ,
Hildegard B. Toth MD : Nothing to Disclose , Linda Moy MD : Nothing to Disclose
PURPOSE
To determine the utilization and role of adjunct ultrasound (US) screening examination with the implementation of the breast density notification law.
METHOD AND MATERIALS
IRB approved retrospective review of women who underwent a hand held high resolution whole breast US exam performed by one of 11 experienced breast US technologists from Jan 1, 2013 to March 31, 2014. Screening mammogram and US exams were performed at a large academic center and two satellite private practices and evaluated by 1 of 16 breast imaging radiologists. The findings of the screening mammograms were known by the sonographer before the US exam was performed. Repeat scanning for lesions identified by the technologists was performed by the radiologists. The follow up rate, biopsy rates and added cancer detection rates were determined.
RESULTS
A total of 42,341 screening mammograms were performed in 36,523 women. Breast density was predominantly fatty in 3980 (9.4%), scattered fibroglandular tissue in 17,106 (40.4%), heterogeneously dense in 17,910
(42.3%) and extremely dense in 3345 (7.9%). Of 3044 women who underwent 3167 screening US exam, 2253
(74%) of women had dense breasts and 1857 (61%) had average risk for breast cancer. Screening US exam was performed within 1 month of the screening mammogram in 80.5% of the cases and 19.0% between 4-6 months from the mammogram. Of 3,167 US exams, 2614/3167 (82.5%) US exams were assessed as BIRADS 1 or 2, 276 (8.7%) as BIRADS 3, 277 (8.7%) as BIRADS 4 or 5. 18 biopsies were cancelled because the lesion was no longer seen or reassessed as benign. Biopsy was performed in 259 lesions, yielding 249 (96.1%) benign results, 5 high-risk lesions and 5 malignancies. Of 249 benign lesions, 109 (43.8%) were complex cyst and 59
(23.7%) were fibrocystic change. Of 10 lesions that underwent surgical excision, 6 were malignancies, 3 IDCs and 3 DCIS, yielding a PPV of 2.32%. 4 of 6 cancers were less than 1cm. 4 of 6 cancers were detected in women with abnormal mammographic finding. Screening US led to an additional cancer yield of 2/ 3167 (0.06%).
CONCLUSION
Supplemental whole breast US detects mammographically occult cancers, although our rate is much lower than previous studies.
CLINICAL RELEVANCE/APPLICATION
The low PPV of screening US in our study where most women had dense breast tissue and were average risk suggests further studies are necessary to identify the women who may benefit from the exam.

SSA01-05 Whole Breast US after Screening Breast Tomosynthesis: Initial Experience
Vera Lucia Nunes Aguillar MD (Presenter): Nothing to Disclose , Vera Christina Camargo de Siqueira Ferreira
MD : Nothing to Disclose , Erica Endo MD : Nothing to Disclose , Carla Basso Dequi MD : Nothing to
Disclose , Daniela Gregolin Giannotti MD : Nothing to Disclose , Giovanni Guido Cerri MD, PhD : Nothing to
Disclose
PURPOSE to determine performance of whole breast ultrassonography (US) in women who underwent additional breast
US during the first year of implementation of breast tomosynthesis (digital mammography - DM - plus tomosynthesis (BT), in a screening population
METHOD AND MATERIALS
Prospective study, including 1034 consecutive women, age 35-85 year-old, who underwent screening tomosynthesis for the first time: 2 views DM + 2 views BT of each breast, with sequential reading and consensus arbitration and, subsequently, had physician performed handheld whole breast US, from september/2011 through august/2012.
RESULTS
Twenty - six cases were classified as BI-RADS category 4 or 5 by screening BT and 24 were submitted to biopsy with 12 cancers found (4 DCIS and 8 invasive). In subsequent screening US, 09 lesions sere classified as
BIRADS category 4 , all submitted to FNA of biopsy and one cancer was found: lobular invasive carcinoma, HG1,
NH 1 , 6 mm, LS negative. Of 13 cancers detected in this screening population, with BT and additional US, 12 could be seen by tomosynthesis (4 DCIS and 8 invasive), while only 7 were detected by US (all invasive).
Cancer detection rate was 1,16% (12/1034) with breast tomosynthesis and increased to 1,26% (13/1034), with additional US. Adding US to BT increase the number of biopsies from 26 to 35. PPV3 for US only lesion detection was 1,1 (1/9) compared to 50% for lesions detected by tomossynthesis
CONCLUSION
Adding physician-performed handheld US to breast tomosynthesis had a little impact in cancer detection rate and a low overall PPV. Further clinical studies are needed with a large number of women, especially with dense breasts.
CLINICAL RELEVANCE/APPLICATION
Screening breast ultrasound
SSA01-06 Digital Breast Tomosynthesis (DBT) and Breast Ultrasound (US): Additional Roles in Dense Breasts with Category 0 at Conventional Digital Mammography (DM)
Jin Chung MD (Presenter): Nothing to Disclose , Eun-Suk Cha MD : Nothing to Disclose , Jee Eun Lee
MD : Nothing to Disclose , Jeoung Hyun Kim : Nothing to Disclose , Bo Bae Lee : Nothing to Disclose
PURPOSE
To compare the diagnostic performance of DBT and US for the dense breasts with category 0 at conventional
DM.
METHOD AND MATERIALS
From December 2012 to March 2013, DBT, breast US and DM were performed in 202 patients. Among them,
156 patients were dense breasts (ACR pattern 3 and 4) and 108 lesions of 108 patients were categorized as
BI-RADS 0 (asymmetry, 84; calcifications, 6; asymmetry with calcifications, 18). BI-RADS final assessment for
DBT and US were recorded. BI-RADS category 1-3 was considered benign, and BI-RADS category 4 and 5 were considered malignant. Sixty-two lesions underwent biopsy or surgical excision and others had at least 1 year of follow-up data.
RESULTS
Among 108 lesions, 17 (15.7%) were malignant and 91 (84.3%) were benign. Final assessments of US were categorized as follows: category 1 in 5, category 2 in 6, category 3 in 38, category 4a in 34, category 4b in 12, category 4c in 1 and category 5 in 12. For DBT, final assessments were categorized as follows: category 1 in
34, category 2 in 16, category 3 in 24, category 4a in 13, category 4b in 4, category 4c in 3, category 5 in 14.
The sensitivity and negative predictive value were 100% for both US and DBT. For US, specificity and positive predictive value were 53.9 and 28.8%. For DBT, specificity and positive predictive value were 81.3 and 50%.
Diagnostic accuracy of US and DBT were 61.1 and 84.3%. Benign biopsy rate of DBT (50%, 17/34) was lower than that of US (71.2%, 42/59).
CONCLUSION
For dense breasts, DBT showed better diagnostic performance than breast US. DBT may reduce the benign biopsy rate and short term follow-up.
CLINICAL RELEVANCE/APPLICATION
DBT is a beneficial method for dense breasts on DM, with reducing unnecessary breast biopsy and short-term follow-up.
SSA01-07 Comparison of Breast Digital Tomosynthesis and Full-field Digital Mammography: Ultrasonography
Detected Breast Cancer

SSA01-07
Detected Breast Cancer
Kyung Jin Nam MD (Presenter): Nothing to Disclose , Boo-Kyung Han MD, PhD : Nothing to Disclose , Eun
Sook Ko MD : Nothing to Disclose , Ji Soo Choi MD, PhD : Nothing to Disclose
PURPOSE
To compare the diagnostic performance of digital breast tomosynthesis (DBT) with that of conventional full-field digital mammography (FFDM) in a population of screening US-detected breast cancers.
METHOD AND MATERIALS
From January 2013 to June 2013, 865 women underwent both conventional FFDM and DBT imaging. Among them, 84 patients were classified as having screening US-detected cancers, which were initially detected by screening US in asymptomatic patients with negatively interpreted mammography. The cases with retrospectively seen, overt mammographic findings or incomplete datasets were excluded (n = 43). In the rest
41 women with US-detected mammographically occult cancers (hereafter, UDMOCs), three radiologists independently described the lesion type and location of the most actionable findings in both FFDM and DBT with
4-week interval, without knowledge of US findings. The lesion type was divided into: negative, mass, asymmetry, focal asymmetry, calcifications only, single view mass and mass with calcifications. The visibility score from 0 to 2 was given to each case.
RESULTS
Diagnostic performance when sum of visibility scores of three radiologists was equal to or more than score 4 was significantly different between DBT and FFDM ( 53.6% vs. 26.8%, P=0.013). Among 41 cases, all three readers detected cancers in 11 cases with DBT and 1 case with FFDM and no reader detected cancers in 6 cases with DBT and 16 cases with FFDM. We found significant difference of diagnostic performance between DBT and
FFDM in aspect of the individual visibility in two of three radiologists (63.4% vs. 31.7% for reader 1, p=0.008;
43.9% vs. 9.7% for reader 3, p =0.001). The dominant lesion type was "mass" on DBT (50%) and "focal asymmetry" on FFDM (57.1%).
CONCLUSION
This study has demonstrated improved diagnostic performance of DBT compared to FFDM in patients with
UDMOCs and increased accuracy for mass characterization of DBT compared to FFDM.
CLINICAL RELEVANCE/APPLICATION
When DBT is added to FFDM, cancer detection and mass characterization could be improved in the interpretation of mammographic abnormalities in women with mammographically occult breast cancer.
SSA01-08 Analysis of Missed Breast Cancers on Prior Screening US of Women Subsequently Diagnosed with
Breast Cancers
Sung Eun Song MD (Presenter): Nothing to Disclose , Nariya Cho MD : Nothing to Disclose , A Jung Chu
MD : Nothing to Disclose , Sung Ui Shin MD : Nothing to Disclose , Ann Yi MD, PhD : Nothing to Disclose
, Su Hyun Lee MD : Nothing to Disclose , Won Hwa Kim MD, PhD : Nothing to Disclose , Min Sun Bae
MD, PhD : Nothing to Disclose , Woo Kyung Moon : Nothing to Disclose
PURPOSE
To retrospectively investigate the presumptive reasons for a missed diagnosis on prior screening ultrasonography (US) examinations in women subsequently diagnosed with breast cancers.
METHOD AND MATERIALS
Between 2003 and 2011, 230 pairs of US examinations including prior images with negative or benign findings and subsequent images with developed cancers (mean interval, 11.2 months; range, 2- 24 months) were found. Mean size of detected cancers was 2.3 cm (range, 0.1 - 8.2 cm) for invasive cancers (n=182) and 2.4 cm
(range, 0.3 - 7cm) for DCIS (n=48). Mammographic density, background echotexture, lesion visibility, features on prior US, and reasons for missed diagnoses as well as their actionability were classified by two experienced radiologists in consensus. Differences between visible versus non-visible cases and actionable versus underthreshold findings were compared.
RESULTS
Of the 230 prior US images, 32% (74 of 230) had visible findings (mean size on US, 0.8cm; range, 0.2- 2.5
cm) correlated with subsequent cancers and 68% (156 of 230) did not. No differences were found in mammographic density (P=0.966) or background echotexture between visible and non-visible cases (P=0.229).
Of the 74 visible findings, reasons for missed diagnoses were misinterpretation (41%, 30/74), benign appearance (30%, 22/74), small lesion size < 5mm (9%, 7/74), multiple distracting lesions (8%, 6/74), stability
> 24 months (7%, 5/ 74), or missed core biopsy (5%, 4/74). Fifty-three percent (39/74) of them were classified as actionable and 47% (35/74) as underthreshold. Actionable findings showed more irregular shape
(P <0.001), non-circumscribed margin (P=0.004), non-parallel orientation (P =0.046), and larger lesion size (P
=0.049) than underthreshold findings.
CONCLUSION
Breast cancer findings on prior screening US are mainly missed due to misinterpretation (41%), benign appearance (30%), small size < 5mm (9%), or multiple distracting lesions (8%).

CLINICAL RELEVANCE/APPLICATION
To avoid missing early cancers on screening breast US, close attention should be paid to subtle suspicious findings as well as separate assessment of multiple findings.
SSA01-09 BI-RADS Differences in Lesion Assessment between Handheld Physician-Performed Whole Breast
Ultrasound (HHUS) and Supine Automated Ultrasound (AUS)
Ellen Bachman Mendelson MD (Presenter): Research support, Siemens AG Speakers Bureau, Siemens AG
Medical Advisory Board, Quantason, LLC Consultant, Quantason, LLC , Marcela Bohm-Velez MD : Consultant,
Koninklijke Philips NV Consultant, Matakina Technology Limited , Thomas S. Chang MD : Nothing to Disclose ,
Mariana Solari-Font MD : Nothing to Disclose , Sandra Sheila Rao MD : Nothing to Disclose , Erin Irene
Neuschler MD : Nothing to Disclose , Barbara H. Ward MD : Nothing to Disclose , Judith A. Wolfman MD :
Nothing to Disclose , Michelle Renee Straka MD : Nothing to Disclose , Andy Milkowski MS : Employee,
Siemens AG , Maria Kalata : Nothing to Disclose , Ingolf Karst MD : Nothing to Disclose , Mickey Woodard
RT : Nothing to Disclose
PURPOSE
To study equivalence in lesion detection & assessment between HHUS and whole breast AUS, independently interpreted.
METHOD AND MATERIALS
From 4/2012 to 2/2014, 505 pts. referred for breast US exams at 2 sites participated in this IRB-approved,
HIPAA-compliant prospective study. Physicians performed HHUS with a 18-6 MHz linear transducer using ACRIN
6666 documentation & assigning BI-RADS per lesion of 2 to 6, 1 (normal), or 0 (not seen) when HHUS and AUS were compared. For AUS, a sonographer positioned a wide 14-5MHz transducer for AP, lateral, and medial views. Transverse, coronal, and sagittal views were reviewed at a workstation by a 2nd breast imager blinded to HHUS. AUS and HHUS exams were integrated with clinical, mammography & MRI data. Where AUS and
HHUS BI-RADS were different, clinical significance was determined and explanation sought.
RESULTS
Age range: 19-92y. 505 pts. had 745 lesions. 87/505(17 %) had different HHUS and AUS lesion BI-RADS.
Mismatches were HHUS 0 (not seen) or 1 (negative) and AUS 4 (suspicious) in 29/87(33%); BI-RADS 2 on
HHUS and 4 on AUS in 16/87(18%); and 4 on HHUS with 0,1, or 2 on AUS in 26/87(30%). No BI-RADS mismatch resulted in cancer diagnosis. All lesions biopsied were benign. For BI-RADS HHUS 0/1 and AUS 4, many 4's had hypoechoic shadowing artifacts seen on one AUS view, often the lateral. Where HHUS was
BI-RADS 2 and AUS 4, oval masses <8mm had indistinct margins on the coronal and transverse views. Most
HHUS lesions not seen on AUS were found retrospectively on transverse but not coronal view.
CONCLUSION
HHUS and AUS lesion BI-RADS assessments differed in 18%, but no cancers were miscast as benign. For AUS success in breast imaging workflow, interpreters may benefit from knowing the AUS appearance of artifacts as well as lesions studied with HHUS.
CLINICAL RELEVANCE/APPLICATION
With concern for masking of cancers by dense breast tissue on mammography, a supine automated breast US scanner has been approved by the FDA for supplemental screening, only one of many indications for breast ultrasound. With experience in the similarities and differences between small FOV HHUS and AUS, automated scanners can be useful for diagnostic applications such as detection and follow-up of multiple benign-appearing masses.
Scientific Papers
PH US
AMA PRA Category 1 Credits ™ : 1.50
ARRT Category A+ Credit: 0
Sun, Nov 30 10:45 AM - 12:15 PM Location: S405AB
Participants
Moderator
Zheng Feng Lu PhD : Nothing to Disclose
Moderator
R. Jason Stafford PhD : Nothing to Disclose
Sub-Events
SSA21-01 Evaluation of Liver Viscoelasticity using Multi-frequency Transient Elastography: A New Approach
Based on Fractional Power Law Behaviour
Maelle Dejobert (Presenter): Nothing to Disclose , Patat Frederic MPH, MD : Nothing to Disclose ,
Jean-Pierre Remenieras : Nothing to Disclose

CONCLUSION
This project is a feasibility study of in vivo shear wave velocity measurements with a new processing algorithm.
Background
Non-alcoholic fatty liver disease (NAFLD) is emerging as a major cause of liver disease. The accurate assessment of the type of NAFLD is crucial for prognostic evaluation. The only parameter classically measured by the existing US elastography method is the stiffness of liver tissue. Elastographic analysis of excised liver tissues have demonstrated that the complex shear modulus G* follows, as a function of frequency, a power law in biological tissue. The goal of this study was to estimate the speed of shear wave dispersion using a modified
Fibroscan® in vivo.
Evaluation
Our work is a pilot study involving 10 healthy volunteers. We used a modified Fibroscan® research prototype based on transient elastography (Echosens company, France) to record shear wave dispersion at successive and different low frequency vibrations (25, 50, 75 and 100 Hz), and elastogram processing by using a new algorithm. For each volunteer, 40 transient vibrations were applied. We estimated the phase velocity dispersion cs(ω) of the shear wave as a function of the frequency in a 20-120 Hz bandwidth. The underlying premise for this work was to formulate the results with a fractional power law model cs(ω)= κcs*ω^γcs for which, the exponent coefficient γcs is a structure parameter of the liver, which is governed by viscosity and κcs is linked to elasticity. The comparison between experimental data and this fractional behaviour allowed us to determine these two biomechanical parameters of the liver, by solving an inverse problem. The measurement of cs(ω) was highly reproducible. For example, cs(50Hz) returned 1.44±0.20 m/s.
Discussion
No simple biomechanical model (like the Voigt model) could be used to explain the frequency dispersion of cs(ω). Therefore, the challenge is still to determine the most suitable parameters κcs and γcs through fitting with our data. A prospective study is currently underway to determine whether analysis of the phase velocity dispersion can be used as a reliable tool for the diagnosis of NAFLD.
SSA21-02 Thermoacoustic Imaging of Fresh Prostate Specimens – Preliminary Comparison to Histology
Sarah Kathryn Patch PhD (Presenter): Nothing to Disclose , David Hull MD : Nothing to Disclose , Majorca
Thomas : Nothing to Disclose , Stephanie Griep : Nothing to Disclose , Kenneth Jacobsohn MD : Nothing to Disclose , William See MD : Nothing to Disclose
CONCLUSION
If results of a larger study also support the hypothesis that the contrast mechanism is sensitive to cancer then development of a clinical prototype for in vivo imaging will be warranted.
Background
Prostate cancer is a good application for thermoacoustic imaging for several reasons. Mechanical properties of healthy and cancerous prostate tissue are well matched, so the assumption of constant sound speed is accurate.
Measurements represent integrals of the thermoacoustic source term over spheres centered at the transducer focus. Signal production by very high frequency irradiation is proportional to ionic content, and ionic content of prostatic fluids produced by healthy tissue in the peripheral zone is approximately three times higher than in blood and plasma whereas cancer suppresses ionic content. Signal strength is therefore expected to decrease with extent of cancerous involvement.
Evaluation
To test this hypothesis we imaged fresh human prostate specimens ex vivo and compared to the gold standard, histology. Over two-dozen specimens were imaged immediately after radical prostatectomy performed as part of normal care. Irradiation pulses with carrier frequency 108 MHz ensured excellent electromagnetic depth penetration. 700 ns pulses with power exceeding 20 kW propagated 20-25 mJ into a benchtop imaging system.
2.25 MHz focused single element transducers received the thermoacoustic pulses, which were amplified by 54 dB and signal averaged 64 times before recording to disc. Spatial encoding was performed in step-and-shoot mode, with 1.8-degree rotations between views and 3 mm translation between acquisition slices. Approximately
20 slices were acquired per specimen. Reconstruction was performed by filtered backprojection after extensive preprocessing. The peripheral zone was subdivided into regions of interest corresponding to tissue type
(Gleason grade, HGPin, inflammation, etc), as annotated on histology slides from three cases.
Discussion
Reconstructions revealed some common features: the verumontanum and urethra are frequently visualized.
Mean reconstruction values in cancer-free regions were four times greater than in regions with high percentage of cancer.
SSA21-03 Visualization of Breast Lesion Vasculature Using Three-dimensional (3D) Subharmonic Parametric
Maps
Anush Sridharan : Nothing to Disclose , John Robery Eisenbrey PhD : Nothing to Disclose , Flemming
Forsberg PhD (Presenter): Equipment support, Toshiba Corporation Research collaboration, General Electric
Company Research collaboration, Analogic Corporation Research collaboration, Toshiba Corporation Speakers
Bureau, Toshiba Corporation , Priscilla Machado MD : Grant, Toshiba Corporation Equipment support, Toshiba
Corporation , Kelly Dulin : Nothing to Disclose , Samantha Jaffe : Nothing to Disclose , Daniel Arthur
Merton : Nothing to Disclose , Haydee Ojeda-Fournier MD : Nothing to Disclose , Robert Frederick Mattrey
MD : Nothing to Disclose , Kirk Wallace PhD : Employee, General Electric Company , Carl Chalek PhD :
Employee, General Electric Company , Kai E. Thomenius PhD : Nothing to Disclose

PURPOSE
To investigate the feasibility of using contrast-enhanced 3D subharmonic ultrasound imaging (SHI) to visualize tumor vascularity, evaluate vascular heterogeneity and develop quantitative 3D parametric maps of vascularity in breast lesions.
METHOD AND MATERIALS
Patients (n = 134) identified with breast lesions on mammography were scanned using power Doppler imaging
(PDI), contrast-enhanced 3D harmonic imaging (HI) and 3D SHI on a modified Logiq 9 scanner (GE Healthcare,
Milwaukee, WI) equipped with a 4D10L probe. The contrast agent Definity (Lantheus Medical Imaging, N
Billerica, MA) was administered as a bolus of 0.25 ml for HI and as 20 μl/kg for SHI. All lesions were subsequently biopsied. A region-of-interest (ROI) corresponding to ultrasound contrast agent (UCA) flow was identified using 4D View (GE Healthcare) and mapped onto the raw slice data to generate a map of the time-intensity curve (TIC) for the lesion volume. Time-points corresponding to baseline, peak intensity and complete washout of UCA were identified to generate vascular heterogeneity plots of the lesion volume. This was subsequently broken down into central and peripheral lesion sections. Finally, 3D parametric volumes were produced for perfusion (PER) and area under the curve (AUC).
RESULTS
There were a total of 99 benign and 35 malignant lesions. Vascular activity was observed with PDI in 82 lesions
(61 benign and 21 malignant). UCA flow was observed in 8 (5 benign and 3 malignant) lesions for 3D HI and 68
(49 benign and 19 malignant) for 3D SHI. Analysis of vascular heterogeneity in 3D SHI volumes showed benign lesions to have a significant difference in vascularity between central and peripheral sections (1.71 ± 0.96 vs.
1.13 ± 0.79, p < 0.001) whereas malignant lesions showed no significant difference (1.66 ± 1.39 vs. 1.24 ±
1.14, p = 0.24), indicative of more vascular coverage, which was validated by the vascular visualization in the
PER and AUC parametric volumes.
CONCLUSION
Our preliminary results suggest that 3D SHI has improved sensitivity to UCA in vascular lesions compared to 3D
HI based on difference in the overall number of cases with UCA activity. Furthermore, 3D SHI is able to detect variations in vascular heterogeneity.
CLINICAL RELEVANCE/APPLICATION
Quantitative evaluation of vascular heterogeneity combined with vascular visualization of parametric volumes could aid in characterizing breast lesions.
SSA21-04 FITC-polylactide Nanoparticles Loaded on Albumin-coated Microbubbles: Preliminary In Vivo
Observations
Marianne Gauthier PhD (Presenter): Nothing to Disclose , Edward J. Roy PhD : Nothing to Disclose ,
William D. O'Brien PhD : Nothing to Disclose
PURPOSE
We tested in vivo a newly designed protocol to produce FITC-polylactide (PLA) nanoparticles (NPs) loaded on microbubble (MB) surfaces by comparing the fluorescent uptake in tumors after injecting NP-loaded MBs or NPs only in mice, and then imaging with ultrasound (US) at high mechanical index (MI).
METHOD AND MATERIALS
MBs (3.6 108 MB/mL, 1 mL) were produced from the sonication (70 s, 450 W) of a 5% bovine serum albumin and 15% dextrose solution. NPs (5 mg/mL, 1 mL) were produced by mixing FITC-PLA and PLA-PEG-COOH conjugates and covalently linking them to the surface of the pre-produced MBs via the carbodiimide technique.
Three BALB/c mice were subcutaneously injected with 4T1 breast tumor cells (105 cells) on both flanks. Each mouse was injected with 150 µL of NP-loaded MBs and NPs only, respectively, on right and left flanks. Each injection was followed by a 1-min US exposure at MI=1.0. Then, mice were euthanized and liver, and right and left tumors were snap-frozen in OCT medium for cryosectioning and immunostaining. 5-µm cryosections were fixed in cold 95% ethanol and blocked using Superblock. Sections were incubated with, respectively, collagen
IV and Cy-5 labeled donkey anti-rabbit IgG as primary and secondary antibodies, and then analyzed by fluorescence microscopy. For each mouse, tumors were imaged at 200x using FITC, DAPI and Cy-5 filters.
RESULTS
For each mouse, images showed the presence of the NPs in both tumors. However, right tumors (NP-loaded
MBs) always exhibited a much higher NP concentration than the corresponding left tumors (NPs only). In addition, from the collagen IV stain, it appeared that NPs detected from the right tumor were not only confined to the blood vessels but also spread to the surrounding tissues.
CONCLUSION
We tested in vivo our newly designed NP-loaded MBs. While undergoing high MI ultrasound, NP-loaded MBs exhibited a higher NP release into the tumor than NPs only: attaching NPs to the MB surface improved the local release of the NPs in tumors opening thus the way for future drug delivery techniques. This work was supported by NIH R37EB002641.
CLINICAL RELEVANCE/APPLICATION
Newly designed FITC-PLA NPs loaded on albumin-coated MBs undergoing high MI ultrasound improves the local

Newly designed FITC-PLA NPs loaded on albumin-coated MBs undergoing high MI ultrasound improves the local release of NPs in tumors.
SSA21-05 Numerical Modeling of the Dynamic of Ultrasound Contrast Agents in Vascular Network
Laure Delphine Boyer (Presenter): Nothing to Disclose , Stephen Randall Thomas PhD : Nothing to Disclose
, Ingrid Leguerney : Nothing to Disclose , Nathalie Brigitte Lassau MD, PhD : Speaker, Toshiba Corporation
Speaker, Bracco Group Speaker, Novartis AG Speaker, Pfizer Inc Speaker, F. Hoffmann-La Roche Ltd ,
Stephanie Pitre-Champagnat : Nothing to Disclose
CONCLUSION
NM with the Fluent software was validated to study blood and CA dynamics in simple geometries. Results obtained with realistic vascular networks composed of 25 to 137 vessels of 30 to 100µm diameter will be presented.
Background
Dynamic Contrast-Enhanced Ultrasonography (DCE-US) is a particularly attractive method to assess tumor microvasculature from the quantification of ultrasound contrast agents (CA) within lesion. This method does not yet benefit methodological tools imported from physics to characterize the ability of the quantification methods to evaluate tumor microcirculation. In this context, we developed the first numerical modeling (NM) based on
Computational Fluid Dynamics software to study the quantification methods to describe the tumor perfusion in a complex vascular network and to apprehend their variations according to tumor growth. The aim of this study was to validate this approach in comparison with DCE-US experiments on few characteristical geometries configurations and to extend to more realistic geometries of vascular network.
Evaluation
NM was performed with Fluent software (ANSYS, France), which modeled blood and CA flows in vascular network with laminar flow described by Poiseuille's law. Three geometries of numerical and experimental phantoms were a 2mm diameter tube representing respectively a single vessel, a bifurcation towards 2 parallel tubes and a serpentine. Volume of injected CA was 0.1mL with a blood flow of 41mL/min. Realistic injection of
CA by bolus was implemented in NM. DCE-US experiments were performed with an Aplio scanner (Toshiba,
Japan) and a 12MHz probe with SonoVue® (Bracco, Italy) as CA.
Discussion
Numerical time-concentration of CA curves were similar to those obtained experimentally for the three geometries.
SSA21-06 Investigations of the Radiographic Appearance of Surgical Mesh in Phantoms with Volumetric
Ultrasound and Magnetic Resonance Imaging
Matthew Allen Lewis PhD (Presenter): Nothing to Disclose , Beth A. Furey MD, BEng : Nothing to Disclose ,
Ananth Madhuranthakam PhD : Nothing to Disclose , April Alexander Bailey MD : Nothing to Disclose ,
Gaurav Khatri MD : Nothing to Disclose , Diane Mary Twickler MD : Nothing to Disclose
CONCLUSION
At our tertiary referral center, identifying the presence and extent of implanted mesh on clinical imaging has become paramount as patients are increasingly referred to us for complications including pain and infection after multiple surgical interventions and partial or incomplete mesh resection. Although surgical mesh is not readily apparent or differentiable from dense scar on clinical MR, it is identifiable in phantoms using US and
MRI. We are using phantoms to develop analysis tools to exploit the regular structure of these surgical devices with the goal of improving detection and localization.
Background
Imaging evaluation of surgical mesh implanted for repair of incontinence and pelvic organ prolapse is an important medical and legal problem. To date, the optimal modality for imaging evaluation of mesh in the pelvis has been ultrasound (US), but anatomic location and extent is limited on this modality. We sought to evaluate two approaches to improve post-surgical mesh evaluation including US with co-registered MRI for improved anatomic localization, and the development of US/MRI techniques that incorporate a priori information on the structure of the surgical mesh to improve detection. We describe preliminary experiments in phantoms containing surgical mesh.
Evaluation
Two surgical mesh samples (coarse and fine) were attached to 3D printed polymer supports using sutures and embedded in gelatin US phantoms. Both mesh phantoms were imaged simultaneously in a Philips Achieva 3T
MRI using various pulse sequences (T2W_TSE, T1W_FFE 3D, 3D_PD, FFE UTE). Phantoms were imaged serially with the Verasonics US research platform (Redmond, WA) using an L7-4 ultrasound transducer. Volumetric images were acquired through linear robotic motion in 1 mm steps. Visualization and analysis of the co-registered images were performed using OsiriX (Pixmeo, Geneva) and NIH ImageJ.
Discussion
In these studies, both meshes were readily apparent with both modalities (Figure 1). Only the US images

demonstrated the characteristic pearls-on-a-string appearance of mesh as described in the literature. Line profiles demonstrate periodicity associated with mesh and may provide insight for new in vivo detection methods.
SSA21-07 Characterization of Photoacoustic Thermography for Image-guidance and Monitoring of
Photothermal Ablations
Katherine Louise Dextraze MS (Presenter): Nothing to Disclose , Christopher J. MacLellan BS : Nothing to
Disclose , Trevor M. Mitcham BS : Nothing to Disclose , Marites Pasuelo Melancon PhD : Nothing to Disclose
, Richard R. Bouchard PhD : Nothing to Disclose
PURPOSE
Photoacoustic ultrasonic (PAUS) is capable of measuring temperature non-invasively while simultaneously providing anatomical images, making it a promising new technique for guiding and monitoring photothermal ablations. In order to assess the potential clinical role of PAUS imaging, the technique was validated against the clinically accepted magnetic resonance thermal imaging approach (MRTI).
METHOD AND MATERIALS
To facilitate co-registration between PAUS and MR images, a tissue-mimicking agar phantom was designed which had inclusions of gold nanoshells encapsulating super-paramagnetic iron oxide (SPIO) particles, where gold enhances the PA signal and SPIOs provide negative contrast on MRI. PA images were acquired on a Vevo
LAZR (FUJIFILM VisualSonics Inc., Toronto, Ontario) PA-ultrasound small-animal imaging system (21MHz) operating at 710nm. MRTI experiments were performed using a 6-channel flex coil (GE Healthcare, Waukesha,
WI) on a 3T MRI scanner (Discovery MR750, GE Healthcare, Waukesha, WI) using a fast multi gradient echo acquisition (16 echoes, 128x128 acquisition matrix, 25.6x25.6cm field of view, 3mm slice thickness, 60ms TR,
20� flip angle, 2.9ms minimum TE and 1.6ms echo spacing). The accuracy and spatio-temporal resolution of
PA thermography was cross-validated with both MRTI and a fluoroptic temperature sensor (LumaSense
Technologies, Santa Clara, CA) in the custom-designed phantom.
RESULTS
A thermally stable, dual-modality phantom was created for cross-validation of PA thermography and MRTI. PA thermography was characterized for thermal therapy guidance and compared to clinically-accepted MRI techniques and fluoroptic probe measurements. The PA signal was shown to change linearly across a temperature range of 35°C-55°C, within the limits of typical ablation temperature. Axial and lateral resolutions of PA images were sub-millimeter with a temporal resolution of 0.2s, which will accommodate precise real-time guidance and monitoring.
CONCLUSION
The sub-millimeter resolution and centimeter-order penetration depths achievable with PAUS imaging have the potential to deliver active monitoring of both a targeted tumor microenvironment and nearby healthy tissue during thermal ablation.
CLINICAL RELEVANCE/APPLICATION
The development of photoacoustic thermography as a precise, real-time technique for image-guidance and monitoring of thermal ablations will facilitate adaptive planning that may improve treatment efficacy.
SSA21-08 Methods of Measurement of Stiffness Value within a Thyroid Nodule on Shearwave Elastography
Manjiri K. Dighe MD (Presenter): Research Grant, General Electric Company , Jeff Thiel : Nothing to
Disclose , Daniel S. Hippe MS : Research Grant, Koninklijke Philips NV Research Grant, General Electric
Company
PURPOSE
To assess the difference in measurement of stiffness values within a thyroid nodule using Shear-Wave elastography with various regions of interest methods.
METHOD AND MATERIALS
After IRB approval, elastograms were obtained by Shear-wave elastography from 77 individuals, with a total of
88 thyroid nodules. Elastography data was acquired without any external compression using the Supersonics
Aixplorer machine. 1 reader blinded to the cytopathology or the final histopathology results was asked to draw regions of interest (ROIs) in the nodule. These included a 3mm ROI on the stiffest part of the nodule as seen on the elastogram image (3mm), ROI covering the whole nodule (WN), ROI covering the whole nodule and the margin of the nodule (WNM) and a circular ROI over the edge of the nodule (EN). The stiffness values were recorded for each of these measurements. Each nodule had multiple elastography images taken and an average value of the measurements (mean and max) for each nodule was calculated for various methods of measurement (3mm, WN, WNM and EN). Results were compared between the FNA + surgery and only surgery group as shown in the table
RESULTS
In the FNA + surgery group, the area under the curves (AUC) were similar for the various methods of measurement for both the mean and max kPa values. For the surgery only group, whole nodule ROI and whole nodule and the margin of the nodule ROI had marginally better AUCs compared to the 3mm ROI and the edge
ROI.
CONCLUSION

Our study indicates that measuring the stiffness in the whole nodule would be better than measuring the stiffest area since the variability in measurement would be less. This is likely because the reproducibility of measuring the ROI in the whole nodule would be better than picking out the stiffest area in the nodule.
CLINICAL RELEVANCE/APPLICATION
Decreasing the variability in measuring the stiffness within a nodule in thyroid elastography is important since the results would be much more accurate and more reproducible.
SSA21-09 O-mode Ultrasound, A New Novel Technique
Richard Gary Barr MD, PhD (Presenter): Consultant, Siemens AG Consultant, Koninklijke Philips NV Research
Grant, Siemens AG Research Grant, SuperSonic Imagine Speakers Bureau, Koninklijke Philips NV Research
Grant, Bracco Group Speakers Bureau, Siemens AG Consultant, Toshiba Corporation Research Grant, Esaote
SpA , Alex Lomes PhD : Stockholder, Orcasonix Ltd , Mati Shirizly PhD : Shareholder, Orcasonix Ltd
PURPOSE
Conventional US limitations and artifacts are related to the need for beam forming. O-mode introduces a novel approach that does not require a beam former, provides constant lateral resolution independent on depth of penetration and significantly decreases the shadowing from small pockets of gas allowing for new imaging windows to be utilized. The Doppler effect is evoked artificially by transmitting US signal from a "moving" transducer. Such transmitting scheme creates echo with different RF frequency shifts coming from different scatterers, which are located at the same depth, but at different lateral positions. This method provides exact lateral localization by exchanging the traditional focusing procedure (along line-of-sight) to signal processing of frequency-modulated signals coming from each depth, maintaining constant lateral resolution and improved shadowing performance. This is a pilot study to evaluate O-mode in a clinical setting.
METHOD AND MATERIALS
10 patients participated in an IRB approved, HIPPA compliant study to evaluate the possible potential advantages of the O-mode imaging. Patients received a complete abdominal exam on a conventional ultrasound system (Esaote, My Lab Twice, Genoa, IT; Philips IU22, Bothell, Wa, or Siemens S3000, Mountain View, Ca) in addition to the Orcasonix O-mode system. Comparison of the images was performed by visual inspection by a board certified Radiologists with 20 years experience in ultrasound imaging. Images were scored as to depth of penetration, shadowing artifacts, and overall acceptability of image quality.
RESULTS
In all 10 cases O-mode was able to visualize deep structures equally or better than conventional B-mode. In areas of shadowing from ribs or small pockets of gas O-mode was able to visualize structures deep to the bone or gas which were able to be visualized on B-mode.
CONCLUSION
Preliminary clinical validation of O-mode imaging is promising. Additional post processing is required to improve
O-mode image quality. O-mode imaging has several advantages over B-mode imaging including increased deep visualization, marked decreased shadowing and refractive artifacts. Without the need for a beam former smaller lighter ultrasound systems are possible.
CLINICAL RELEVANCE/APPLICATION
O-mode imaging can improve ultrasound imaging by significantly decreasing artifacts seen in B-mode imaging.
The lack of a beam former allows for smaller ultrasound systems.
Scientific Posters
BR
AMA PRA Category 1 Credits ™ : .50
Sun, Nov 30 12:30 PM - 1:00 PM Location: BR Community, Learning Center
Participants
Moderator
Elizabeth McDonald MD, PhD : Nothing to Disclose
Sub-Events
BRS237 Quantitative Lesion-to-fat Elasticity Ratio Measured by Shear-wave Elastography for the Diagnosis of Breast Cancers: Which Area Should be Selected as the Reference? (Station #1)
Ji Hyun Youk MD : Nothing to Disclose , Eun Ju Son MD, PhD : Nothing to Disclose , Ah Young Park MD :
Nothing to Disclose , Jeong-Ah Kim MD, PhD : Nothing to Disclose , Hye Mi Gweon MD (Presenter):
Nothing to Disclose
PURPOSE
To evaluate the diagnostic performance of lesion-to-fat elasticity ratio (Eratio) according to the location of the reference area in shear-wave elastography (SWE) for the diagnosis of breast cancers.

BRS238
METHOD AND MATERIALS
A total of 257 breast masses in 250 women who underwent SWE before core biopsy or surgery from February
2013 to August 2013 were retrospectively analyzed. For each mass, multiple quantitative Eratios were measured with a fixed region of interest (ROI) for the mass along with multiple ROIs for the surrounding normal fat in different locations. Logistic regression analysis with random effect was used to determine that Eratio was independently associated with breast cancers considering the location of ROI for the fat (depth, laterality, the actual or vertical distance from lesion, and the actual or vertical distance from the ROI of lesion). Quantitative mean (Emean) and maximum (Emax) elasticity values of the reference fat were divided into 4 groups according to their 25th percentile, median, and 75th percentile. Diagnostic performance of each group was evaluated using the area under the ROC curve (AUC).
RESULTS
At logistic regression analysis, Eratio showed a significant difference between benign and malignant lesions
(P<0.0001), irrespective of the location of ROI for the fat (depth, laterality, the actual or vertical distance from the lesion, and the actual or vertical distance from the ROI of lesion). The 25th percentile, median, and 75th percentile of elasticity values of fat were 11.5 kPa, 16.9 kPa, and 25.3 kPa for Emean and 16.3 kPa, 24.7 kPa, and 35.7 kPa for Emax, respectively. The AUC of each group (<25th percentile, 25th percentile~median, median~75th percentile, and ≥75th percentile) was 0.973, 0.982, 0.967, and 0.954 for Emean and 0.977,
0.967, 0.966, and 0.957 for Emax, respectively. There was no significant difference in AUC among different 4 groups.
CONCLUSION
Eratio was independently associated with breast cancers when considering the location of the reference area.
Eratio showed good diagnostic performance which was not influenced by the difference in elasticity value of reference fat.
CLINICAL RELEVANCE/APPLICATION
Eratio in SWE can be expected to reduce the effect of precompression. Eratio was useful for the diagnosis of breast cancers with good performance independent of the location of reference area.
Tumor Stiffness on Sonoelastography and the Risk of Recurrence in Early Breast Cancer Patients
(Station #2)
Ann Yi MD, PhD (Presenter): Nothing to Disclose , Woo Kyung Moon : Nothing to Disclose
PURPOSE
To evaluate whether the breast cancer stiffness according to the immunohistochemistric (IHC) subtypes is associated with the risk of recurrence in early breast cancer patients.
METHOD AND MATERIALS
Between January, 2006 and December, 2009, 164 consecutive women (mean age 50.5 years; range 27 - 78 years) who underwent ultrasound (US), sonoelastography and surgery for clinically T1-2 (mean US size 2.1
mm; range 5 - 40 mm), N0 breast cancers. Prospectively recorded elasticity scores of tumor (EST) were correlated with histopathology including IHC subtypes (luminal [ER+ and/or PR+], HER2 [ER- and PR-,
HER2+], triple negative [ER-, PR-, and HER2-]) using Fisher's exact test. Cox proportional hazards model was used to calculate adjusted hazard ratio (HR) of EST for recurrence after controlling for clinicopathologic variables including age, menopausal status, tumor size, tumor histology, nuclear grade, nodal status, lymphovascular invasion status, resection margin status, surgery type, and adjuvant treatment. Recurrence-free survival (RFS) outcomes estimated by Kaplan-Meier curve were compared between low EST (scores 1,2, and 3) and high EST (scores 4 and 5) groups using log-rank test.
RESULTS
Among 164 patients, 116 (70.7%) had luminal, 14 (8.5%) had HER2, and 34 (20.7%) had triple negative tumors. The mean value of ESTs were significantly different between IHC subtypes (4.22±0.94 in luminal,
3.71±0.99 in HER2, 3.82±0.99 in triple negative; P =.036), whereas recurrence rates were not (2.6% [3/116] in luminal, 14.3% [2/14] in HER2, 5.9% [2/32] in triple negative; P =.108). At multivariate cox analysis, high
EST was independently associated with worse RFS outcome (HR, 1.63; P =.032) in luminal subtype, whereas were not in HER2 (HR, 1.36; P =.696) and triple negative (HR, 0.75; P =.677) subtypes. 77 patients with luminal high EST tumors had 1.5 times (log rank, 1.51; P = .022) worse RFS outcome than 39 patients with luminal low EST tumors.
CONCLUSION
High elasticity score of luminal breast cancer might be a risk factor of recurrence in clinically T1-2, N0 breast cancer patients.
CLINICAL RELEVANCE/APPLICATION
Sonoelastography can be used to determine a subgroup of early breast cancer patients with a high risk of recurrence.

BRS239
BRS240
Do Women with an Abnormal Sonographic Axillary Lymph Node and no Breast Malignancy Need a
Biopsy? (Station #3)
Yoav Amitai MD (Presenter): Nothing to Disclose , Tehillah Menes MD : Nothing to Disclose , Orit Golan
MD, PHD : Nothing to Disclose
PURPOSE
Abnormal axillary lymph nodes on ultrasound are not a rare finding. We examined clinical and imaging characteristics, in order to define patients who may safely be followed.
METHOD AND MATERIALS
Clinical, imaging and pathology data were collected for 167 consecutive patients who underwent sonogaphic guided needle biopsy of an abnormal lymph node between 2008 and 2013. Malignancy rates were examined for different clinical settings: palpable axillary mass; history of breast cancer; findings suggestive of a systemic disease; and those with a breast finding of low suspicion or an incidental abnormal axillary lymph node. Patients with known breast cancer and those with a highly suspicious breast mass were excluded.
RESULTS
Thirteen patients (8%) were found to have a malignant result (10-carcinoma; 2-lymphoma; 1-malignant spindle cell tumor). Malignancy increased with age (Mean age in those with benign pathology was 54 vs. 69 in malignancy, P<0.001). Malignancy rates varied with clinical setting; Axillary mass (8, 26%); history of breast cancer (2, 11%); systemic disease (0%) and breast finding of low suspicion or incidental abnormal lymph node on screening (1, 1%). Malignancy was associated with lymph node size and cortical thickness. Low rates of malignancy were found when the cortex was<6mm (1, 0.8%). The most important imaging finding associated with malignancy was the lack of a preserved hilum, in which case almost a third (11, 31%) of the biopsies were malignant.
CONCLUSION
Only 1 of 85 women with a breast finding of low suspicion or an incidental abnormal axillary lymph node, was found to have malignancy. In this case the lymph node had no hilum. In women without breast cancer or a highly suspicious breast mass, more stringent criteria should be used when evaluating an abnormal axillary lymph node on sonography, as the malignancy rates are very low (1%).
CLINICAL RELEVANCE/APPLICATION
In women being evaluated for breast findings, such as a low suspicion breast mass, and in those undergoing screening studies, the finding of an abnormal axillary lymph node does not usually require a needle biopsy as long as the lymph node has a preserved hilum and cortical thickness is under 6mm.
Reducing False Positive Biopsy Rate of Screening Ultrasound Detected Breast Masses (Station #4)
Jennifer F. Wells MD (Presenter): Nothing to Disclose , Regina J. Hooley MD : Nothing to Disclose ,
Madhavi Raghu MD : Nothing to Disclose , Melissa Angeline Durand MD : Nothing to Disclose , Paul H.
Levesque MD : Nothing to Disclose , Liva Andrejeva-Wright MD : Nothing to Disclose , Laura Jean Horvath
MD : Consultant, Siemens AG , Liane Elizabeth Philpotts MD : Nothing to Disclose
PURPOSE
The positive predictive value (PPV) of biopsy of masses detected at screening breast ultrasound (SBUS) is low compared to masses at screening mammography. The purpose of this study was to determine if biopsy can potentially be avoided in some solid masses found at SBUS.
METHOD AND MATERIALS
An IRB approved retrospective chart review was performed on 100 BI-RADS 4 lesions in 91 patients detected only on SBUS during 10/15/2009 - 9/26/2012. Two radiologists blindly reviewed the sonographic images of each lesion, recorded BI-RADS features, and assigned each lesion a final assessment score.
RESULTS
The average patient age was 53 years (range 32 - 84). The average lesion size was 8.8 mm (range of 3-30).
80/100(80%) lesions were identified on a prevalence screening exam. 96 lesions were aspirated or biopsied, yielding 5 invasive ductal carcinomas and 1 DCIS for a PPV3 of 6.3%. All cancers (6/6) had indistinct, angular, or irregular margins and hypoechoic or heterogeneous echotecture. 5/6 cancers had a non-parallel orientation.
All malignancies were assessed as BI-RADS 4B or 4C, except for the one case of DCIS assessed as BI-RADS 3 by one reader. Of the 94 benign masses, 37(39%) were circumscribed, 56(60%) were hypoechoic, 64(68%) were oval or round, 53(56%) had a parallel orientation, and 68 (72%) had enhanced or no posterior acoustic features. The negative predictive value of an oval mass with circumscribed margins was 100%, regardless of echo pattern or posterior acoustic features. 7 retroareolar lesions were associated with a dilated duct and all were benign. 80/99 (81%) of cases were assigned a BI-RADS 2, 3, or 4A final assessment by at least one reader. If the lower BI-RADS score was used and these lesions were not biopsied, the PPV would have increased to 37.5% and one case of DCIS would have been downgraded to BI-RADS 3.
CONCLUSION
Retrospective blinded review showed many BI-RADS 4 lesions detected on SBUS have benign features and biopsy could probably have been avoided. Most cancers detected on SBUS have suspicious US features and are

BRE169
BRE109
BRE107 biopsy could probably have been avoided. Most cancers detected on SBUS have suspicious US features and are correctly identified by radiologists. Solid masses detected on SBUS require careful evaluation and may benefit from double reading in order to improve specificity.
CLINICAL RELEVANCE/APPLICATION
Screening breast US is being more widely performed in the United States. Strategies are needed to improve overall diagnostic performance and decrease false positive biopsies.
Tilting the Atlas: A Discussion of the Changes between the 4th and 5th Editions of BI-RADS
(Station #5)
Sadia Choudhery MD (Presenter): Nothing to Disclose , Stephen Jacob Seiler MD : Nothing to Disclose
TEACHING POINTS
1) Provide an overview of the changes recently implemented in the 5th edition of the Breast Imaging-Reporting and Data System (BI-RADS). 2) Present a variety of cases to highlight the changes in the reporting of mammography, breast ultrasound, and magnetic resonance imaging.
TABLE OF CONTENTS/OUTLINE
1) Mammography: • Removal of percentages from breast composition • A lobular mass is now oval • Isodensity re-termed equal density • Developing asymmetry added • Calcifications are benign or suspicious, without
"intermediate" or "high" probability of malignancy • Eggshell calcifications encompassed by rim calcifications •
Clustered calcifications re-termed grouped 2) Ultrasound: • Inclusion of tissue composition • A lobular mass is now oval • Re-categorization of margins to circumscribed and not circumscribed • Description of breast elasticity
3) MRI: • Non-mass-like enhancement re-termed non-mass enhancement (NME) • A lobular mass is now oval •
Mass margins reclassified into circumscribed and not circumscribed • Internal enhancement of a mass no longer includes enhancing septations and central enhancement • Ductal enhancement now incorporated into linear distribution of NME • Internal enhancement of NME no longer includes reticular/dendritic and stippled/punctate but clustered ring has been added 4) Uncoupling of assessment and management recommendation.
Pre-Operative Image Guided Breast Lesion Localization - A Pictorial Review of Technique (Station
#6)
Katrina Fern Lambert MD (Presenter): Nothing to Disclose , Lucy Boyd Spalluto MD : Nothing to Disclose ,
Erin Wyatt Kinney MD : Nothing to Disclose
TEACHING POINTS
To review indications and technique for image guided pre-operative breast lesion localization, including mammographic and sonographic guidance techniques and both standard wire localization and radioactive seed placement.
TABLE OF CONTENTS/OUTLINE
I. Review indications for wire localization
II. Illustrate technique for mammographic and sonographic guidance for wire localization with detailed photographs and diagrams to include:
1. Documenting patient history and confirming appropriate indication for procedure
2. Obtaining informed consent
3. Tray set up and needle/wire demonstration
4. Positioning patient appropriately and pre-procedural imaging
5. Needle/wire placement
6. Post-procedural imaging
7. Discussion of necessary information to relay to surgeon
III. Illustrate technique for mammographic and sonographic guided radioactive seed placement with detailed photographs and diagrams to include:
1. Documenting patient history and confirming appropriate indication for procedure
2. Obtaining informed consent
3. Tray set up and radioactive seed deployment device demonstration
4. Positioning patient appropriately and pre-procedural imaging
5. Seed placement
6. Post-procedural imaging
7. Discussion of necessary information to relay to surgeon
8. Discussion of management of radioactive material
Mastering the Challenges of MRI-guided Breast Interventions; MRI-guided Biopsy and Beyond
(Station #7)

BRE110
BRE159
Lumarie Santiago MD (Presenter): Nothing to Disclose , Mohammad Eghtedari MD, PhD : Nothing to
Disclose , H. Carisa Le-Petross MD : Nothing to Disclose
TEACHING POINTS
1) Review of various types MRI guided breast interventions and their indications 2) Review the technical aspects and step by step planning of MRI guided breast biopsy 3) Describe alternate techniques for challenging MRI guided interventions and how to anticipate their utilization 4) Understanding alternate techniques that may help the radiologist troubleshoot difficult cases and prevent false negative biopsies or potential surgical biopsies
TABLE OF CONTENTS/OUTLINE
We will present a pictorial essay of our experience performing MRI guided breast interventions over the last 10 years, including management of challenging cases 1) Variable appearance of the target lesion between the diagnostic and the intervention breast MRI 2) Planning schematics generated for MRI guided interventions with and without CAD 3) When MRI guided needle localization and bracketed needle localization are indicated 4)
When MRI guided marker clip placement is indicated 5) Alternate techniques addressing challenging interventions due to lesion location, presence of breast implants, multiplicity and bilaterality of lesions 5)
Determination of sampling adequacy and false negatives 6) How to address clip deployment failures or migration
Radioactive Seed Localization: Why to Start a Program, the Pros and Cons of RSL vs. Wire
Localization of Non Palpable Breast Lesions, How To Start a Program and How To Perform
Radioactive Seed Localizations under Mammographic and Ultrasound Guidance (Station #8)
Laurie R. Margolies MD (Presenter): Consultant, FUJIFILM Holdings Corporation Consultant, Konica Minolta
Group , Janet R. Szabo MD : Consultant, Siemens AG Consultant, FUJIFILM Holdings Corporation Consultant,
Konica Minolta Group , Emily B. Sonnenblick MD : Nothing to Disclose , Elisa Port MD : Nothing to Disclose
, Jacob Kamen PhD : Nothing to Disclose
TEACHING POINTS
1. Radioactive seed localizations are a relatively new way of localizing imaging detected breast abnormalities requiring surgical excison. They are often more convenient for the patient as well as physicians as the surgeon and radiologists schedules are uncoupled. Radioactive seed localizations also uncouple the surgeon's and radiologists pathway and multiple studies have shown a decrease in positive margin rate with seed localizations. The localization procedure is easy for the radiologist to learn. At the conclusion of this presentation the viewer will be familar with the concept of radioactive seed localization and its pros and cons.
TABLE OF CONTENTS/OUTLINE
A. Why to consider setting up a radioactive seed localization program
B. Ins and outs of begining a radioactive seedl localizaton program: regulatory requirements
C. Mammographic localization
D. Ultrasound localization
E. What can go wrong, how to prevent and what to do if there is loss of a seed or transection of a seed.
Blind Spots and Pitfalls in Breast Imaging (Station #9)
Rebecca Rakow-Penner MD, PhD : Nothing to Disclose , Jade De Guzman MD (Presenter): Nothing to
Disclose , Youn Jeong Kim MD : Nothing to Disclose , Ifeanyi C. Onyeacholem MD : Nothing to Disclose ,
Haydee Ojeda-Fournier MD : Nothing to Disclose
TEACHING POINTS
1. Differentiate perceptual versus cognitive errors in radiology 2. Review blind spots and pitfalls for screening and diagnostic exams on mammography, US and MRI with imaging correlation 3. Provide an algorithmic approach/checklist for reading screening and diagnostic mammograms, breast US and breast MRI 4. Test your knowledge with imaging case review in multiple choice format
TABLE OF CONTENTS/OUTLINE
Many radiologists, specifically those without breast imaging fellowship training, are apprehensive about reading breast imaging exams due to medical legal notoriety. That being said, most breast imaging exams in the United
States are still interpreted by radiologists without dedicated breast imaging training. This educational exhibit will review specific "blind spots" and common pitfalls on routine breast imaging. It will also provide a checklist for reading mammograms, breast US and breast MRI and provide an opportunity for self-assessment. 1.
Introduction 2. Errors in detection v. errors in interpretation a) limited detection secondary to technical factors, b) patient factors, c) human factor 3. Blind spots by a) mammogram, b) US and c) dynamic contrast enhanced breast MRI 4. Algorithmic approach to prevent missed cancer 5.Interactive multiple-choice case review 6.
Conclusion
Scientific Posters
ER

AMA PRA Category 1 Credits ™ : .50
Sun, Nov 30 12:30 PM - 1:00 PM Location: ER Community, Learning Center
Participants
Moderator
Savvas Nicolaou MD : Nothing to Disclose
Sub-Events
ERS203 Impact of CT on Geriatric Patients Presenting to the Emergency Department with Acute Abdominal
Pain (Station #1)
Carly Susan Gardner MD (Presenter): Nothing to Disclose , Tracy Anne Jaffe MD : Nothing to Disclose ,
Rendon C. Nelson MD : Consultant, General Electric Company Consultant, Nemoto Kyorindo Co, Ltd
Consultant, VoxelMetrix, LLC Research support, Bracco Group Research support, Becton, Dickinson and
Company Speakers Bureau, Siemens AG Royalties, Wolters Kluwer nv
PURPOSE
To evaluate the diagnostic yield of abdominopelvic computed tomography (CT) in geriatric patients presenting to the Emergency Department (ED) with acute abdominal pain and effect on management.
METHOD AND MATERIALS
Medical records search from 1/2004-1/2013 identified 327 geriatric patients (> 80 yo; 248 women, 79 men) undergoing abdominopelvic CT in the ED for acute abdominal pain. Cases were reviewed for study indication and pre-CT vs. post-CT diagnoses. Report interpretations were categorized into with and without acute findings.
Those with acute results were subdivided into medical and surgical diagnoses. Analysis of ED records was performed to determine whether results of the CT changed management, including medication treatment changes, referrals to a subspecialty, surgical operations and minimally invasive procedures. Anticipated admission status prior to imaging, actual disposition from the ED, and final disposition of those admitted were also recorded.
RESULTS
Of the 327 geriatric patients undergoing CT in the ED for acute abdominal pain, the most common indications for CT were small bowel obstruction (SBO) (66/327, 20%), abdominal aortic aneurysm rupture or dissection
(40/327, 12%), diverticulitis (37/327, 9%), and bowel ischemia or perforation (30/327, 9%). Most common CT diagnoses were gastrointestinal ischemia (28/249, 11%), diverticulitis/colitis (23/249, 9%) and SBO (22/249,
9%). Of all patients, 214 (65%) required hospital admission, of which results of CT determined admission in 144 patients (67%). 249 of 327 patients (77%) had acute or treatable positive findings on CT (119 medical, 130 surgical). CT changed management in 92 patients (37%); 10 medically and 82 surgically. Patients with surgical issues (82/130, 62%) were treated operatively (41/82, 50%) or with minimally invasive operations/procedures
(41/82, 50%).
CONCLUSION
Radiology interpretations from abdominopelvic CTs obtained in the ED have an impact on geriatric patient management, influencing primarily surgical rather than medical issues and subsequent treatment.
CLINICAL RELEVANCE/APPLICATION
The utilization of CT in the geriatric patient population will be an increasingly important issue for future health care management and cost.
ERS205 Decreased Birth Weight Associated with Administration of Intravenous Contrast for Computed
Tomography during Pregnancy (Station #3)
Jason Brett Hartman BA (Presenter): Nothing to Disclose , Alok Harwani : Nothing to Disclose , Nicholas
Bhojwani MD : Nothing to Disclose , Bahar Mansoori MD : Fellow, Sectra AB , Kelly Kuo : Nothing to
Disclose , Robert Morgan BA : Employee, Explorys Inc , Akshay Paspulati : Nothing to Disclose ,
Pablo Riera Ros MD, PhD : Medical Advisory Board, Koninklijke Philips NV Medical Advisory Board, KLAS
Enterprises LLC Medical Advisory Committee, Oakstone Publishing Departmental Research Grant, Siemens AG
Departmental Research Grant, Koninklijke Philips NV Departmental Research Grant, Sectra AB Departmental
Research Grant, Toshiba Corporation , Karin Anna Herrmann MD : Consultant, Koninklijke Philips NV
PURPOSE
Standard guidelines recommend that iodinated contrast media be avoided during pregnancy based on in vitro and animal studies but few reports have assessed its use clinically. We examined the risk of pregnancy complications associated with the use of intravenous iodinated contrast for CT in pregnant women.
METHOD AND MATERIALS
We retrospectively reviewed charts of pregnant women undergoing CT with or without iodinated contrast at our institution between February 2005 and December 2013. We divided patients into a study group that received contrast with CT and a control group that underwent CT without contrast. Patients were only included if their CT was negative and they were followed until delivery. Demographic and clinical data was recorded and compared

ERS206
ERE102 between the two groups using a two-tailed t-test.
RESULTS
336 pregnant women with CT during their pregnancy were recruited. 15 patients with positive CT results and
102 patients with poor follow-up were excluded. 128 patients received contrast with abdominal, pelvic, or chest
CT and 91 underwent non-contrast head CT. Mean birth weight was significantly lower in the contrast administered group (2679 g) versus the control group (3055 g) (p<0.01). There were no statistically significant differences between groups regarding mean age of the mother at the time of delivery, mean gestational age at delivery, or APGAR scores at 1 and 5 minutes (p>0.05). Mean gestational age at time of CT was significantly later in the contrast group (25 weeks vs. 22 weeks; p<0.05).
CONCLUSION
Based on this preliminary retrospective study it appears that the administration of iodinated contrast for CT during pregnancy may be associated with lower birth weight. Further studies are indicated to validate and understand this association.
CLINICAL RELEVANCE/APPLICATION
Findings from this study may further substantiate the recommendations for limiting the use of iodinated contrast media for CT in pregnant patients.
When the Appendix is not Seen on Ultrasound for RLQ Pain: Does the Interpretation of Emergency
Department Physicians Correlate with Diagnostic Performance? (Station #4)
Donald Le Ly MD, BEng (Presenter): Nothing to Disclose , Seng Thipphavong MD : Nothing to Disclose ,
Sara H. Gray MD, FRCPC : Nothing to Disclose , Anthony Edward Hanbidge MBBCh : Nothing to Disclose ,
Mostafa Atri MD : Nothing to Disclose , Korosh Khalili MD : Nothing to Disclose
PURPOSE
To determine the attitudes of emergency department (ED) physicians (MDs) towards non-visualization of the appendix (NVA) on ultrasound (US) scans for RLQ pain and to assess ultrasounds' diagnostic performance.
METHOD AND MATERIALS
A survey was administered to 166 ED MDs at several academic hospitals to determine their interpretation and practice after receiving an ultrasound report with NVA. Retrospective review of three large academic EDs revealed 1672 US scans performed for appendicitis in 2012. 291 (17.4%) explicitly indicated NVA and underwent a chart review of US findings, follow-up imaging, and surgical findings to determine the negative predictive value of NVA and utility of secondary findings. Univariate analysis was performed to determine which secondary signs of appendicitis were significant (P<0.05) predictors of a positive CT scan.
RESULTS
95/166 (57%) of ED MDs completed the survey; 53% had >10 years experience. After receiving an US report with NVA, 92% indicated re-examining the patient; 79% felt further imaging was required and 61% would proceed with CT. Only 18/95 (19%) of ED MD believed that follow up CT is positive for appendicitis in less than
10% of NVA; 71% agreed that a level of certainty scale would be helpful on radiology reports for appendicitis.
Of 291 US scans with NVA, 246 (85%) were female (mean age 31y). In 229/291 (79%), no alternate diagnosis was found and a CT was done in 94/229 (41%). Appendicitis was found in 13/229 (5.7%) patients with NVA and no alternate diagnosis; in 9/13 secondary signs of appendicitis were noted. Therefore negative predictive value (NPV) for NVA was 216/229 (94.3%). Inflammatory changes in RLQ (p=0.01) and focal tenderness
(p=0.02) noted on US were significant predictors of a positive CT scan.
CONCLUSION
Current perceptions and practice of some ED physicians equate NVA on US as an inadequate study to exclude appendicitis. However, NVA is itself a highly predictive sign (94.3%) of absence of appendicitis when an alternate cause of pain is not seen.
CLINICAL RELEVANCE/APPLICATION
Dissemination of the high NPV of ultrasound in RLQ pain among ED MDs may lead to diminished resource utilization. Radiologists can add value to ED MDs by providing an evidence-based level of certainty scale for US findings when assessing for appendicitis.
Bowel Pathology in Color versus Shades of Gray: Understanding Bowel Diseases with Use of Dual
Energy CT and Iodine Maps (Station #5)
Urvi Pravin Fulwadhva MD (Presenter): Nothing to Disclose , Jeremy Robert Wortman MD : Nothing to
Disclose , Aaron D. Sodickson MD, PhD : Research Grant, Siemens AG
TEACHING POINTS
1. Dual energy CT can help to enhance subtle tissue characteristics in the bowel in both benign and malignant disease processes (infectious, inflammatory, GI bleed, small bowel obstruction and neoplasms) with use of iodine map and iodine overlay images. 2. Use of dual energy CT protocols and post processing can be integrated in daily clinical routine to add further insights in bowel imaging.

TABLE OF CONTENTS/OUTLINE
1. Brief primer of dual energy physics with attention to three-material decomposition and calculation of iodine content for display of iodine maps and virtual noncontrast images. 2. Case-based review of benign and malignant disorders of the bowel in both conventional gray-scale CT images and iodine maps. Emphasis on improved ability to detect and characterize bowel disease through use of dual-energy iodine content information, including the range of infectious, inflammatory, ischemic, and neoplastic bowel pathology. 3.
Potential use of dual energy CT and iodine maps in monitoring response to treatment and modulating therapy in patients with benign and malignant bowel diseases.
Scientific Posters
MK
AMA PRA Category 1 Credits ™ : .50
Sun, Nov 30 12:30 PM - 1:00 PM Location: MK Community, Learning Center
Participants
Moderator
Luke R. Scalcione MD : Nothing to Disclose
Sub-Events
MKS341 The Plantar Plate Complex of the First Metatarsophalangeal Joint: High Resolution MR Imaging at
11.7T and 3.0T with Anatomic and Histologic Correlation (Station #1)
Diego Avila Lessa Garcia MD (Presenter): Nothing to Disclose , Higor Grando MD : Nothing to Disclose ,
Eric Y. Chang MD : Nothing to Disclose , Sheronda Statum : Nothing to Disclose , Graeme M. Bydder
MBChB : Nothing to Disclose , Christine B. Chung MD : Nothing to Disclose
PURPOSE
There is discrepancy regarding the nomenclature and inconsistent anatomical descriptions in the literature with regard to the plantar plate of the first metatarsophalangeal joint (MTPJ). The purpose of the study is 1) to provide high and ultra-high resolution morphologic evaluation of the plantar region of the first MTPJ focusing on anatomic relationships and structural integrity and 2) to introduce the concept of the plantar plate complex.
METHOD AND MATERIALS
The first MTPJ of six fresh-frozen cadavers were used for this study. Imaging of the first MTPJ was performed on a 3.0T clinical MR system (General Electric Healthcare Medical Systems, Milwaukee, WI, United States) with a 2D intermediate-weighted sequence (TR 2000ms TE 35ms) and a 3D-FSPGR sequence (TR 50ms TE 5.2ms) as well as on an 11.7T MR system with a spin echo sequence (TR 5000ms TE 10ms). The plantar regions of each MTPJ were qualitatively analyzed on the MR images. Correlation with gross anatomic dissections and histology was performed.
RESULTS
Five ligaments, two sesamoids, a fibrous tissue pad, a capsule and six tendons compose the plantar plate region of the first MTPJ. The external and internal architecture of each of these structures is well demonstrated at both field strengths. Through anatomic and histologic correlation, it is evident that the first plantar plate is not a single structure, but rather a capsuloligamentous complex assisted by a dynamic musculotendinous apparatus.
CONCLUSION
MR imaging with gross and histologic correlation allows clarification of the previously confusing plantar plate complex of the first MTPJ.
CLINICAL RELEVANCE/APPLICATION
Dedicated coils and high resolution MRI allows for evaluation of the first MTPJ at a level never before seen.
Knowledge of the normal detailed anatomy of each component is important for radiological interpretation.
MKS342 Adult Acquired Flat Foot Deformity: Dynamic Ultrasound in the Evaluation of the Stabilizers of the
Medial Longitudinal Arch (Station #2)
Elena Gallardo MD, PhD (Presenter): Nothing to Disclose , Rosa Maria A. Landeras MD : Nothing to Disclose
, Eduardo Torres Diez : Nothing to Disclose , Rosario Garcia Barredo : Nothing to Disclose , Rosa De La
Puente : Nothing to Disclose , Gerardo Lopez Rasines MD : Nothing to Disclose
PURPOSE
To assess the role of the calcaneonavicular ligament in the peritalar destabilization in patients with acquired flat foot deformity.
METHOD AND MATERIALS
We performed a systematic exploration of the ankle with a high linear array transducer (8-13 MHz), focused on the evaluation of the medial stabilizers, posterior tibial tendon (PTT) and calcaneonavicular ligament or spring

MKS343
MKS344 the evaluation of the medial stabilizers, posterior tibial tendon (PTT) and calcaneonavicular ligament or spring ligament complex (SLC), in patients with the diagnosis of acquired flat foot deformity. We evaluated the presence of peritalar destabilization in all patients, measuring the medial talus bone motion from the sitting position to the standing position.
RESULTS
We reviewed 60 cases in 49 patients. Tendinosis ot PTT was visualized only in 59,5% of the ankles, whereas a significant degeneration of the SLC was demonstrated in 87% of the cases The most affected area of the SLC was the distal part of the superomedial component in all cases and we visualized a fibrillar disruption in almost one out of three of the cases. We assessed destabilisation more frequently in cases with both SLC degeneration and PTT tendinosis; additionally, in those patients with clear adduction of the talar head while standing, was more frequent the rupture of the SLC.
CONCLUSION
Ultrasound is an accurate technique in the evaluation of the spring ligament, and its signs of degeneration are more frequently visualized than PTT tendinosis in patients with acquired flat foot in their initial phases. Dynamic
US is a reliable method for measurement the peritalar desestabilization.
CLINICAL RELEVANCE/APPLICATION
The radiological literature of the acquired adult flat foot is based on the study of the posterior tibial tendon and
PTT insufficiency is considered the main cause of this disorder, however imaging techniques may show no abnormalities in this structure. This study shows that degeneration signs are more frequently visualized in SLC than in PTT, demonstrating the capital importance of this ligament complex on its own, in maintaining the normal alignment and height of the medial longitudinal arch.
Ligament Complex in the Carpometacarpal Joint of the Thumb: Assessment Using 3D Isotropic
T1-weighted Fast-spin Echo Indirect MR Arthrography (Station #3)
Hye Jung Choo MD (Presenter): Nothing to Disclose , Sun Joo Lee MD : Nothing to Disclose , Young Mi
Park MD, PhD : Nothing to Disclose , Dong Ho Ha MD, PhD : Nothing to Disclose , Seon-Jeong Kim MD :
Nothing to Disclose , Ok Hwa Kim : Nothing to Disclose
PURPOSE
The exact evaluation about the ligaments supporting the carpometacarpal joint (CMCJ) of the thumb is not easy on MRI, because the ligaments in the 1st CMCJ are complicated and the 1st CMCJ rests in a pronated and flexed position relative to the plane of the CMCJ of the other fingers. In this study, the ligament complex in the 1st
CMCJ was evaluated by using 3D isotropic T1-weighted fast spin-echo (3D T1 FSE) indirect MR arthrography.
METHOD AND MATERIALS
Three-dimensional T1 FSE indirect MR arthrography of the wrists was obtained from 26 patients (11 women, 15 men, and mean age, 39.9 years) without abnormality in the 1st CMCJ. On the reformatted axial, coronal and sagittal MR images according to the plane of the 1st CMCJ, the visibility, signal intensity, and thickness of the dorsoradial ligament (DRL), posterior oblique ligament (POL), superficial anterior oblique ligament (sAOL), deep anterior oblique ligament (dAOL) and ulnar collateral ligament (UCL) of the 1st CMCJ were evaluated by two musculoskeletal radiologists in consensus.
RESULTS
The DRL, POL, and dAOL were visualized in all the patients (100%), whereas sAOL was visualized in 12 (46%) and UCL in 24 (92%). The DRL showed low signal intensity in 77% of the patients, POL intermediate signal intensity in 77%, dAOL intermediate signal intensity in 100%, and UCL striated appearance in 83%. The POL was the thickest ligament (mean thickness, 2.3 mm; range, 1.7-3.4 mm) and the sAOL was the thinnest ligament (mean thickness, 0.5 mm; range, 0.4-0.8 mm).
CONCLUSION
The multiplanar reformatted 3D T1 FSE indirect MR arthrographic images according to the plane of the 1st CMCJ provided the high visibility and the detailed information about the ligament complex of the 1st CMCJ.
CLINICAL RELEVANCE/APPLICATION
The multiplanar reformatted 3D T1 FSE indirect MR arthrographic images provided the high visibility and the detailed information about the ligament complex of the 1st CMCJ.
Evaluation of Soft-tissue Sarcoma Response to Pre-operative Neoadjuvant Therapy: Added Value of
Functional MR Imaging Techniques at 3.0T (Station #4)
Theodoros Soldatos MD, PHD : Nothing to Disclose , Majid Chalian MD (Presenter): Nothing to Disclose ,
Michael Anthony Jacobs PhD : Nothing to Disclose , Laura Marie Fayad MD : Nothing to Disclose
PURPOSE
To determine the added value of functional magnetic resonance (MR) sequences (dynamic contrast-enhanced

MKS345
MKE191
[DCE] and quantitative diffusion-weighted imaging [DWI] with apparent diffusion coefficient [ADC] mapping) to conventional MR for assessing the response of soft tissue sarcomas (STS) to pre-operative neoadjuvant therapy.
METHOD AND MATERIALS
At 3T, 23 patients (13 males, 10 females, mean age 48±26 years, range 2-89 years) with high grade STS who underwent MR imaging with conventional (T1-weighted, fluid-sensitive, fat-suppressed static post-contrast
T1-weighted) and functional (DWI/ADC mapping, DCE-MR) sequences following neoadjuvant therapy, were included. Two readers evaluated all imaging independently (with resolved differences by consensus) for the presence of response by conventional imaging (response defined as ≤5% post-contrast enhancement within the tumor), DCE-MR (response defined as ≤5% of tumor enhancement on arterial phase images), and DWI
(response defined as ≤5% of tumor with ADC <1.0 mm2/sec). The presence of response by imaging was compared to the post-operative histologic response, (response defined as >95% non-viable tissue in the tumor), using Fisher's exact test. ROC analysis was performed to determine ADC threshold values that show adequate histologic response.
RESULTS
Of 23 tumors, 4 (17.4%) had adequate histologic response (≤5% viable tumor) in the form of necrosis and scar tissue (necrosis range 0%-95%, scar range 0%-100%), whereas the remaining 19 (82.6%) had a range of
10%-100% viable tumor. The sensitivity and specificity of imaging for determining adequate treatment response was 0% and 94.7% for conventional MR, 100% and 77.7% for DWI/ADC mapping, and 100% and
85.7% for DCE-MR, respectively. A threshold ADC for adequate treatment response was obtained with a minimum ADC>2.0 mm²/s (100% sensitivity, 61.1% specificity) or an average ADC>2.2 mm²/s (50% sensitivity, 77.8% specificity).
CONCLUSION
The addition of functional MR sequences to the conventional MR protocol increases the sensitivity of MR imaging for determining the presence of adequate treatment response in STS, particularly when the tumor undergoes histologic response by forming scar tissue rather than necrosis.
CLINICAL RELEVANCE/APPLICATION
Since STS may respond to neoadjuvant therapy with scar formation rather than necrosis, functional imaging may be used to improve the prediction of response by MR.
Characterization of Healthy and Symptomatic Patellar and Achilles Tendons by Shear Wave
Elastography (SWE) (Station #5)
Timm Dirrichs (Presenter): Nothing to Disclose , Christiane Katharina Kuhl MD : Nothing to Disclose ,
Simone Schrading MD : Nothing to Disclose
PURPOSE
Non-invasive evaluation of tendon elasticity may enhance diagnosis of tendon injury, and if so, could be used to monitor treatment effects. Shear wave elastography (SWE) has shown to be a powerful tool to estimate tissue stiffness. Aim of this study was to evaluate the feasibility and imaging findings of SWE in healthy and symptomatic patellar and achilles tendons.
METHOD AND MATERIALS
55 achilles tendons (35 symptomatic and 20 asymptomatic tendons) and 50 patellar tendons (30 symptomatic and 20 asymptomatic tendons) were systematically examined with SWE in the longitudinal and axial plane using a high-resolution linear 15 MHz probe (Aixplorer, Supersonic Imagine, Aix-en-Provence, France). In all tendons at least 3 SWE color maps were acquired in the distal, middle and proximal part of the tendon. A semi-quantitative analysis was done by analyzing the SWE color maps (homogenously blue = soft, turquoise=intermediate stiffness, yellow-red= high rigidity) (max. 180kPA). In addition, a quantitative,
ROI-based analysis of tendon elasticity was done. SWE values of symptomatic and healthy tendons were compared by using the student's t-test.
RESULTS
At semiquantitative analysis of the SWI color map, symptomatic tendons were rated as "soft" in 87.6% (57/65), as "intermediate" in 9.2% (6/65), and as "rigid" in 0.3% (2/65). In contrast, healthy tendons were rated as
"soft" in 10% (4/40), as "intermediate" in 37.5% (15/40), and as "rigid" in 52.5% (21/40). At quantitative analysis, the symptomatic tendons exhibited significantly lower mean SWE values (43 kPa, range 19-65 kPa) than healthy tendons (185 kPa, range 56-265 kPa) (p=0.0004). No differences were observed between SWE values of symptomatic achilles (40.2 kPa) vs. symptomatic patellar tendons (45.4 kPa).
CONCLUSION
SWE appears to be a simple and reproducible way to identify tendon pathology. Symptomatic tendons can be identified due to their reduced SWE rigidity. SWE may therefore prove to be a sensitive tool to monitor treatment effects.
CLINICAL RELEVANCE/APPLICATION
Shear wave elastography (SWE) is a simple and reproducible tool to identify tendon pathology in patellar and achilles tendons due to reduced tendon rigidity.
You've Got Nerve!: A Review of Entrapment Neuropathies of the Ankle and Foot (Station #6)

MKE234
MKE201
MKE211
Jessica Langer MD (Presenter): Nothing to Disclose , Daria Motamedi MD : Nothing to Disclose , Kira
Chow MD : Nothing to Disclose , Shahla Modarresi MD : Nothing to Disclose
TEACHING POINTS
The goal of this exhibit is to: (1) Review anatomy of nerves in the lower extremity, (2) Provide an overview of the common causes and imaging manifestations of entrapment neuropathies of the ankle and foot, and (3)
Discuss the imaging and clinical presentation of some of the most commonly encountered entrapment neuropathies in order to improve awareness and detection of these conditions.
TABLE OF CONTENTS/OUTLINE
Our exhibit will review the anatomy of nerves in the lower extremity, discuss the causes and clinical manifestations of common lower extremity entrapment neuropathies, and provide magnetic resonance imaging
(MRI) examples of each, including: (1) Superficial Peroneal Nerve Compression, (2) Deep Peroneal Nerve
Compression, (3) Sural Nerve Compression, (4) Tarsal Tunnel Syndrome, (5) Morton Neuroma, and (6) Baxter's
Neuropathy.
Greater Trochanteric Pain Syndrome: Anatomy, Pathology and Ultrasound Guided Interventions
(Station #7)
Eugene Maida MBChB (Presenter): Nothing to Disclose , Mary Margaret Chiavaras MD, PhD : Nothing to
Disclose , Jon A. Jacobson MD : Consultant, BioClinica, Inc Royalties, Reed Elsevier Equipment support,
Terumo Corporation Equipment support, Arthrex, Inc , Lisa Billone : Nothing to Disclose , Jay Smith MD :
Patent agreement, Tenex Health Inc Institutional license agreement, Tenex Health Inc Royalties, Tenex Health
Inc Stockholder, Tenex Health Inc
TEACHING POINTS
1. To review the anatomy of the greater trochanter and surrounding structures, and to emphasize the use of bone landmarks for accurate identification of specific tendons and burase. 2. To outline ultrasound techniques, including dynamic ultrasound examples of greater trochanteric pathology, such as tendinosis, tendon tears, bursitis and various snapping conditions with MRI correlation, as well as discussion of diagnostic pearls and pitfalls. 3. To provide a treatment algorithm which incorporates ultrasound as a diagnostic tool as well as ultrasound-guided treatment for both tendon and bursal abnormalities.
TABLE OF CONTENTS/OUTLINE
A. Objectives B. Anatomy C. Ultrasound Technique D. Ultrasound Evaluation E. Dynamic Ultrasound Evaluation
F. MRI Correlation G. Pathology H. Tendinosis I. Tendon Tears J. Trochanteric Bursitis K. Snapping Hip
Conditions L. Treatment Algorithm M. Take Home Points
Artifacts in Musculoskeletal Ultrasonography (Station #8)
Lana Hirai Gimber MD (Presenter): Nothing to Disclose , David Melville MD : Nothing to Disclose , Luke R.
Scalcione MD : Nothing to Disclose , Russell S. Witte PhD : Nothing to Disclose , Hina Arif Tiwari MD :
Nothing to Disclose , Mihra S. Taljanovic MD : Nothing to Disclose
TEACHING POINTS
1. Recognize the high-resolution ultrasonography (US) appearance of normal and injured musculoskeletal (MSK) structures including bone surface, muscle, tendon and ligament. 2. Recognize the US findings of common artifacts in MSK US with B-mode gray-scale and Doppler imaging that can be mistaken for pathology and several artifacts that frequently accompany pathologic conditions. 3. Learn techniques that can help avoid or minimize artifacts in MSK US.
TABLE OF CONTENTS/OUTLINE
1. MSK US Equipment and Technology 2. US findings of normal bone, muscle, tendon and ligament 3. US findings of injured bone, muscle, tendon and ligament 4. US artifacts with B-mode gray-scale imaging: side-lobe, beam-width, anisotropy, artifacts related to velocity errors (speed displacement and refraction), posterior acoustic shadowing, posterior acoustic enhancement/increased through transmission, posterior reverberation, and mirror image 5. US artifacts with Doppler imaging: transducer pressure, tissue strain, improper focus, motion, blooming, mirror image, background noise, aliasing, and twinkling 6. Techniques that can help avoid or minimize artifacts in MSK US.
Impingement Syndromes of the Lower Extremity: The Great Masqueraders (Station #9)
Gitanjali Bajaj MBBS (Presenter): Nothing to Disclose , Roopa Ram MD : Nothing to Disclose , Carey Lee
Guidry MD : Nothing to Disclose , Maharshi Harischandra Patel DO : Nothing to Disclose , Kedar
Jambhekar MD : Nothing to Disclose , Tarun Pandey MD, FRCR : Nothing to Disclose
TEACHING POINTS
1. Discuss the clinical presentation of lower extremity impingement syndromes. 2. Describe the imaging findings of lower extremity impingement syndromes. 3. Emphasize the diagnostic value of MR (Magnetic
Resonance) Imaging in the early diagnosis of these commonly misdiagnosed conditions.
TABLE OF CONTENTS/OUTLINE
1. Graphic illustrations showing impingement syndromes about the hip, knee, ankle and foot. 2. MR imaging correlation using case based scenarios. 3. Pearls and pitfalls to prevent diagnostic delay and inappropriate management of lower extremity impingement syndromes.

MKE310
MKE327
Bone Tumors, Their Reconstructive Options, and the Role of the MSK Radiologist in Their Assessment
(Station #10)
Joshua Zeidenberg BA, MD (Presenter): Nothing to Disclose , Juan Abelardo Augusto Pretell MD : Nothing to Disclose , Ty Kanyn Subhawong MD : Nothing to Disclose , Jean Jose MS, DO : Nothing to Disclose ,
Thomas Temple MD : Nothing to Disclose , Sheila Conway MD : Nothing to Disclose
TEACHING POINTS
1. Limb sparing reconstruction plays a major role in the treatment of orthopedic oncology patients. 2. Strategic choice of endoprosthesis, autograft, allograft, or allograft-prosthetic composites balance procedural complexity/morbidity with maximizing functional outcome. 3. Familiarity with these procedures facilitates early recognition of complications.
TABLE OF CONTENTS/OUTLINE
A. Limb sparing reconstructive options Determinants of limb-sparing feasibility -patient age -disease burden/overall prognosis -extent of neurovascular involvement -Advantages and disadvantages of
-Endoprosthesis -Autograft -Bulk allograft -Allograft-prosthetic composites B. Normal Findings -X-ray anatomy
-Assessment of positioning, stability, and fixation of the construct. C. Complications -Aseptic loosening
-Mechanical Failure -Nonunion -Infection -Fracture -Arthrosis D. Radiological features of recurrence/progression after reconstruction -Recurrence statistics -Characteristic locations, e.g. graft-native bone junction
-Manifestations as lytic bone lesion, soft tissue mass or calcification E. Conclusion -Variety of treatment options available -Choice of reconstruction influenced by multiple factors -Familiarity with techniques facilitates accurate and early identification of potential problems.
Myxoid Containing Tumors of Soft Tissues: MR Appearance with Radiologic-Pathologic Correlation
(Station #11)
Nicolas Alberti MD (Presenter): Nothing to Disclose , Agnes Neuville : Nothing to Disclose , Jean-Michel
Coindre : Nothing to Disclose , Xavier Buy MD : Proctor, Galil Medical Ltd , Jean Palussiere MD : Travel support, Bracco Group , Amandine Crombe : Nothing to Disclose , Bin Buih : Nothing to Disclose , Michele
Kind MD : Nothing to Disclose
TEACHING POINTS
Myxoid soft tissue tumors are a heterogeneous group of mesenchymal neoplasms with characteristic imaging features. Thus, MR results give the basis of decision-making by a multidisciplinary committee. The aim of this education exhibit was to identify specific MRI features and to correlate with pathology in a large series of histologically proven myxoid soft tissue tumours (STT) based upon our experience in a large tertiary referral centre.
TABLE OF CONTENTS/OUTLINE
I) MYXOMA II) MYXOID LIPOSARCOMA III) LOW-GRADE FIBROMYXOID SARCOMA IV) MYXOFIBROSARCOMA V)
EXTRASKELETAL MYXOID CHONDROSARCOMA
MKE233
Evaluation and Management of Ischiofemoral Impingement: A Radiologic and Therapeutic
Approach to a Complex Diagnosis (Station #12)
Moises Hernando MD (Presenter): Nothing to Disclose , Luis Cerezal MD : Nothing to Disclose , Luis Perez
Carro : Nothing to Disclose , Lourdes Guillen Vargas MD : Nothing to Disclose , Rosa Dominguez-Oronoz
MD : Nothing to Disclose , Ana Canga MD : Nothing to Disclose , Faustino Abascal : Nothing to Disclose ,
Raquel Prada MD : Nothing to Disclose , Maria Gonzalez Vazquez : Nothing to Disclose , Maria Costas
Alvarez : Nothing to Disclose
TEACHING POINTS
To describe in detail the anatomy of the ischiofemoral space. To assess the pathophysiological mechanisms and develop an understandable classification, particularly focusing on its etiology, predisposing factors and musculoskeletal associated abnormalities. To assess the role of radiologist in the diagnosis, treatment and postoperative evaluation in the ischiofemoral impingement, both primary and secondary
TABLE OF CONTENTS/OUTLINE
1.Anatomy 2.Clinical examination test and symptoms 3.Staging. Classification: Etiological: primary (orthopedic disorders) and secondary (traumatic, iatrogenic, tumor, pelvic instability, abnormal sagittal balance of the spine, imbalance abductors/adductors and hip dysplasia) Clinical: acute, chronic, transient/recurrent By location
(anterior, lateral) 4.Imaging Findings: Quantitative measurements Bone, muscle, tendon (typical and atypical), nerve, adipose tissue and bursae abnormalities Lower limbs, femoral, spine and pelvimetric measurements
(radiography, telemetry, fluoroscopy, CT, MRI) 5.MRI protocol. Significance of hip position: external rotation
6.Injection test: diagnostic and therapeutic 7.Diagnostic and therapeutic algorithm 8.Treatment: Endoscopic decompression of ischiofemoral space via deep gluteal space. Postoperative findings
MKE010-b Is a Soft Tissue Mass Involving the Tendon Sheath Always a Tenosynovial Giant Cell Tumor?
(hardcopy backboard)
Seun Ah Lee MD : Nothing to Disclose , Baek Hyun Kim MD : Nothing to Disclose , Seon Jeong Oh
(Presenter): Nothing to Disclose , Kyung-Sik Ahn MD : Nothing to Disclose , Suk-Joo Hong MD : Nothing to Disclose , Chang Ho Kang MD : Nothing to Disclose
TEACHING POINTS
1. To introduce tenosynovial giant cell tumor according to the 2013 WHO classification. 2. To review the radiologic and pathologic features of tenosynovial giant cell tumor in the extremities: localized and diffuse type.
3. To understand various other diseases that can occur in the extremities involving the adjacent tendon sheath.

TABLE OF CONTENTS/OUTLINE
Our exhibit will be divided into 4 sections and presented with relevant cases: 1. Revised nomenclature of tenosynovial giant cell tumor according to the 2013 WHO classification 2. Tenosynovial giant cell tumor in the extremities: radiologic and pathologic appearance. (1) Localized type: primary, recurred cases (2) Diffuse type
3. Other disease entities involving the adjacent tendon sheath of the extremities which mimic tenosynovial giant cell tumor: radiologic features with a brief disease review (1) Fibroma of tendon sheath (2) Fibromatosis of plantar fascia (3) Peripheral nerve sheath tumor such as schwannoma (4) Vascular leiomyoma (5) Synovial sarcoma (6) Alveolar rhadomyosarcoma (7) Others 4. Differential diagnostic considerations between tenosynovial giant cell tumor and other disease entities.
Scientific Posters
PH
AMA PRA Category 1 Credits ™ : .50
Sun, Nov 30 12:30 PM - 1:00 PM Location: PH Community, Learning Center
Participants
Moderator
Xiao Han MSc : Nothing to Disclose
Moderator
R. Jason Stafford PhD : Nothing to Disclose
Moderator
Lei Zhu MS : Advisory Board, RefleXion Medical Inc
Sub-Events
PHS125 Comparison of Standard and Water-exchange-modified Dual-input Pharmacokinetic Models for
DCE-MRI in Advanced Hepatocellular Carcinoma (Station #1)
Sang Ho Lee PhD (Presenter): Nothing to Disclose , Koichi Hayano MD : Nothing to Disclose , Dushyant V.
Sahani MD : Research Grant, General Electric Company , Andrew X. Zhu MD, PhD : Nothing to Disclose ,
Hiroyuki Yoshida PhD : Patent holder, Hologic, Inc Patent holder, MEDIAN Technologies
CONCLUSION
Parameter values differ substantially between standard and WX PKMs. The results suggest that DCE-MRI data are water-exchange sensitive.
Background
DCE-MRI data have often been analyzed using standard pharmacokinetic models (PKMs) that assume a fast water exchange limit (FXL). Recently, it has been demonstrated that deviations from the FXL model occur when contrast agent arrives at the target tissue. However, the analysis has not been reported in the liver tumor with dual blood supply. The aim of this study was to compare kinetic parameters between 5 different standard dual-input PKMs and their corresponding water exchange-modified (WX) versions obtained from DCE-MRI of advanced hepatocellular carcinoma (HCC).
Discussion
BF (P<0.003), BF
PV (P<0.03),
BV (P<0.001), and PS (P<0.022) were statistically significantly different for the pairwise comparison with all models except the AATH model, γ (P<0.023) with the TK and ETK models, BF
(P<0.008) with all models except the ETK model, MTT (P<0.05) with the 2CX and DP models, v with all models, and E (P=0.021) with only the DP model, respectively. No parameter was consistent over all
PKM pairs.
A
I (P<0.012)
Evaluation
T1-weighted DCE-MRI of 20 patients was performed on a Siemens Avanto 1.5T with 2 consecutive 7s acquisitions during breath-holds that repeated 10 times with a break of 21s between them over a 4 minute period. The arterial and portal input curves were modeled by a sum-of-exponentials function. Total hepatic blood flow ( ), arterial fraction ( γ ), arterial BF ( BF
A), portal BF (
BF
PV), blood volume (
( MTT ), permeability-surface area product ( PS ), fractional interstitial volume ( v
BV ), mean transit time
I), and extraction fraction (
E ) were estimated by fitting data to analytic solutions of 5 different FXL PKMs: the Tofts-Kety (TK), extended TK
(ETK), two compartment exchange (2CX), adiabatic approximation to the tissue homogeneity (AATH), and distributed parameter (DP) models, and their WX PKMs using a 2-site exchange model for the TK model and a
3-site 2-exchange model for the ETK, 2CX, AATH, and DP models. Paired comparison of parameters within HCC between FXL and WX PKMs was evaluated using Wilcoxon signed-rank test for each parameter and for each
PKM pair.
PHS126 Advanced Experience with a Semi-automatic, Customized Software Tool for Clinical MRI
Quantification of Visceral and Subcutaneous Adipose Tissue (Station #2)
Harald F. Busse PhD (Presenter): Nothing to Disclose , Alexander Schaudinn MD : Nothing to Disclose ,
Nicolas Linder : Nothing to Disclose , Gregor Thormer : Employee, Siemens AG , Thomas Kurt Kahn MD :
Nothing to Disclose , Nikita Garnov : Nothing to Disclose

PHS127
CONCLUSION
The presented software enables visualization and quantification of various fat depots and is considered a valuable tool to assess disease conditions and monitor related interventions.
Background
With obesity-related diseases, such as type 2 diabetes, on the rise, quantification of visceral and subcutaneous adipose tissue (VAT, SAT) volumes is becoming increasingly important as a diagnostic means for risk assessment. MRI-based analysis is common for that purpose but is either time-consuming with manual or error prone with automatic data processing. We report on our advanced experience, highlighting benefits and limitations of a customized semiautomatic fat quantification tool that has been used over the last three years for VAT and SAT analysis in obese patients.
Evaluation
The Matlab tool works with Dixon MR images, at our site, with 2-point acquisitions in supine position (1.5 T
Achieva XR, Philips, 50 slices, 10 mm thick, 0.5 mm gap, in 160 s plus breathing intervals). An active contour model is used to define inner and outer VAT and SAT boundaries. VAT volumes are quantified by histogram analysis of the MR signal intensities. Starting at an automatic threshold, the user has immediate visual feedback of the segmented VAT image as the threshold is adjusted until results are acceptable. Also, SAT and VAT outlines can easily be corrected manually. Work can be saved and retrieved at any time for later processing.
SAT and VAT total volumes and per slice are reported in common spreadsheet format.
Discussion
This tool has been used on over 500 datasets, originally covering 20 slices in the lumbar region and, for more than a year, � 40 slices across the whole abdomen. About 1 in 6 slices require minor and another 1/6 major corrections. Mean segmentation time for total VAT is � 24 min. Difficulties in automatic segmentation arise, e.
g., from liver or intestinal fat that is mistaken for VAT, fatty abdominal muscles with tissues mixed, a limited
FOV or artifacts occurring for BMIs > 40, and in regions like the minor pelvis or diaphragm dome where specific fat signals are missing. On the other hand, 4 in 6 slices can be left as is, and corrections for patients with intact abdominal muscle layers are minimal.
Preliminary Investigation of Diaphragmatic Motion-based Magnetic Resonance Elastography for
Assessing Liver Fibrosis (Station #3)
Allison Johnsen MD (Presenter): Nothing to Disclose , Jared Weis PhD : Nothing to Disclose , Abigail
Searfoss : Nothing to Disclose , Geoffrey Eugene Wile MD : Nothing to Disclose , Thomas Yankeelov PhD :
Research Consultant, Eli Lilly and Company , Michael Miga PhD : Nothing to Disclose , Richard Glenn
Abramson MD : Consultant, ICON plc Board Member, Partners in the Imaging Enterprise LLC
PURPOSE
Conventional magnetic resonance elastography (MRE) of the liver requires an external device for generating mechanical shear waves. We developed a novel MRE methodology that takes advantage of natural diaphragmatic respiratory motion to assess liver mechanical properties. The approach uses a model-based reconstruction algorithm to estimate mechanical elasticity using MR image volumes acquired under different states of deformation. The purpose of this initial investigation was to demonstrate this methodology for assessing liver fibrosis in cirrhotic and non-cirrhotic subjects.
METHOD AND MATERIALS
Technique was developed using normal volunteer subjects on a 3 T research scanner (Phillips Healthcare, Best,
The Netherlands) and subsequently deployed on a patient with cirrhosis undergoing clinical MR imaging on a
Phillips 1.5 T MR scanner. Each MR examination included breath-hold modified DIXON (mDixon) sequences acquired in sagittal plane at both end-inspiration and end-expiration (1.3 × 1.3 × 3.0 mm voxel resolution).
Post-processing elastography images were then generated through the use of a modality independent elastography (MIE) reconstruction optimized for liver parenchymal deformation induced by diagphragmatic respiratory motion.
RESULTS
Post-processing with a MIE reconstruction yielded a map of the spatial distribution of stiffness within the liver, kidney, and surrounding adipose tissue. The cirrhotic patient exhibited significant focal heterogeneity of liver stiffness with areas approximately two-fold greater than background liver stiffness values. Mean stiffness of the cirrhotic liver, normalized to fat, was 1.64 times greater than mean liver stiffness in a normal volunteer.
CONCLUSION
A MRE approach based on diaphragmatic motion yielded plausible results in this initial attempt to assess cirrhotic and non-cirrhotic livers. These preliminary results indicate the potential for this approach to provide non-invasive assessment of liver stiffness without the use of external hardware. Further study is warranted.
CLINICAL RELEVANCE/APPLICATION
Diaphragmatic motion-based magnetic resonance elastography has the potential to provide valuable information on liver stiffness without the use of external hardware.

PHS128
PHS129
PHS130
Effect of Iterative Model-based Reconstruction on the Sensitivity of Computed Tomography towards
Iodine and Gold Nanoparticle Contrast Agents (Station #4)
Ally Leigh Bernstein : Nothing to Disclose , Amar Dhanantwari : Employee, Koninklijke Philips NV ,
Thomas B. Ivanc MS : Employee, Koninklijke Philips NV , Efrat Shefer PhD : Employee, Koninklijke Philips
NV , David Peter Cormode DPhil, MS (Presenter): Research Grant, Koninklijke Philips NV Consultant,
Koninklijke Philips NV
CONCLUSION
IMR-based reconstruction techniques will allow contrast agents to be detected with greater sensitivity, potentially allowing lower contrast agent doses to be used.
Background
CT images have historically been reconstructed using filtered back-projection algorithms (FBP). Reconstructions via hybrid-iterative (ITER) and iterative model-based (IMR) algorithms have recently become available. These newer algorithms offer lower image noise than FBP. We therefore sought to determine whether newer algorithms would allow improved sensitivity of detection or reduced contrast agent doses via a phantom scanning study.
Influence of Acquisition Parameters on in Vivo X-ray Phase-contrast and Dark-field Radiographic
Imaging of Mice (Station #5)
Andre Yaroshenko (Presenter): Nothing to Disclose , Astrid Velroyen : Nothing to Disclose , Martin Bech :
Nothing to Disclose , Katharina Hellbach MD : Nothing to Disclose , Felix G. Meinel MD : Nothing to
Disclose , Maximilian F. Reiser MD : Nothing to Disclose , Franz Pfeiffer : Nothing to Disclose
PURPOSE
Recently first in vivo x-ray differential phase-contrast and dark-field radiographic images of a mouse were reported. It was noticed that the dark field yields much stronger signal for the lung tissue than the conventional absorption. The purpose of this study was to analyze how the lung dark-field signal depends on the scanning parameters like x-ray spectrum, detector pixel size and how much animal breathing affects the results.
METHOD AND MATERIALS
A compact small-animal preclinical scanner, which acquires conventional x-ray absorption simultaneously with phase-contrast and dark-field images, was used to acquire projection images of an in vivo 10-week-old
C57BL/6N mouse. The measurements were performed for three different spectra (35 kVp, 45 kVp and 50 kVp) and processed using different detector binning modes. During image acquisition the mouse was breathing freely.
Subsequently, the mouse was sacrificed and the measurements were repeated introducing different air volumes to the lung.
RESULTS
The processed dark-field images revealed that the best contrast-to-noise ratio was achieved for the 35 kVp spectrum, though other spectra also yielded significant signal. The lung could be clearly visualized for all three source settings. 200 x 200 �m pixel size was considered, applying a 4 x 4 detector binning. Hereby obtained images demonstrate that dark field gives a strong signal also for clinically compatible pixel sizes. Finally, comparison of the data acquired in vivo and ex vivo showed that breathing introduces only insignificant feature blurring due to motion.
CONCLUSION
This study analyzes different acquisition parameters for lung dark-field radiographic imaging. The results show that the high contrast for lung tissue can be achieved also for higher source voltages and clinically compatible pixel sizes. Furthermore, it is demonstrated that the animal breathing affects the image quality only negligibly.
The results of this study provide a rule of thumb for future choice of acquisition parameters for preclinical dark-field studies.
CLINICAL RELEVANCE/APPLICATION
The results of this study give an overview of how different acquisition parameters influence the imaging results for x-ray phase-contrast and dark-field radiographs. These results are of importance for future preclinical studies.
Standardization of Ultrasound Scanners for Dynamic Contrast-enhanced Ultrasonography (DCE-US)
(Station #6)
Stephanie Pitre-Champagnat (Presenter): Nothing to Disclose , Benedicte Coiffier : Nothing to Disclose ,
Laurene Jourdain : Nothing to Disclose , Laure Delphine Boyer : Nothing to Disclose , Ingrid Leguerney :
Nothing to Disclose , Nathalie Brigitte Lassau MD, PhD : Speaker, Toshiba Corporation Speaker, Bracco Group
Speaker, Novartis AG Speaker, Pfizer Inc Speaker, F. Hoffmann-La Roche Ltd
CONCLUSION
This new methodology of standardization was validated and its simplicity could facilitate the development of multicenter studies in DCE-US.
Background
The growing interest in DCE-US clinical studies to use quantitative imaging parameters to assess therapeutic

effects raises the problem of standardization of the ultrasound scanner to conserve the same dynamics and parameter thresholds in each clinical center. The aim of this study is to validate an original and fast method to establish the standardization in contrast mode of two different ultrasound scanners using settings initially defined for a French multicenter study.
PHE111 Novel Spectral Detector CT—Techniques and Clinical Applications (Station #7)
Maryam Etesami MD : Nothing to Disclose , Prabhakar Rajiah MD, FRCR (Presenter): Institutional
Research Grant, Koninklijke Philips NV
TEACHING POINTS
1) To explain basic principles of dual energy CT and different available methods with emphasis on the novel dual layer spectral detector CT technology (SDCT)
2) To discuss the advantages and disadvantages of SDCT compared to conventional CT and other dual energy methods
3) To review multiple specific clinical applications of SDCT for different organ systems
TABLE OF CONTENTS/OUTLINE
1) Basic principles of dual energy CT 2) Different methods of dual energy CT imaging 3) Single source, dual layer detector spectral CT technique 4) Advantages of SDCT • No need for pre-planning • Full availability of dose management tools;patient radiation dose • Elimination of time lag of sequential acquisitions, ideal for imaging moving tissue • Full field of view • Less artifact 5) Clinical advantages and applications • Increased sensitivity to contrast -Improved image quality -Less contrast media administration -Oncologic lesion characterization -Improved PE evaluation • Virtual non-contrast image • Material characterization - Kidney stone composition -Gout tophi characterization •Differentiation of calcium from iodine -Enhanced CTA and cardiac studies -Improved automated bone removal -Calcium quantification on CT angiogram • Metallic artifact reduction
• Molecular contrast agent imaging 6) Limitations
PHE010-b Real-time Demonstration of Simulated Low-dose Clinical CT Images (custom application computer demonstration)
Tomomi Takenaga (Presenter): Nothing to Disclose , Makoto Goto RT : Nothing to Disclose , Masahiro
Hatemura : Nothing to Disclose , Yoshikazu Uchiyama : Nothing to Disclose , Shigehiko Katsuragawa PhD
: Nothing to Disclose , Junji Shiraishi : Research Grant, Konica Minolta Group Research Grant, FUJIFILM
Holdings Corporation Research Grant, Nihon Medi-Physics Co, Ltd , Yu Narita : Nothing to Disclose
Background
Practical simulation of low-dose examinations is of immense value for optimization of CT. However, current methods are limited to specific vendor platforms, and generally rely on sinogram data that are difficult to access. We have developed a vendor-neutral computational scheme for producing simulated low-dose from standard dose CT images.
Evaluation
Interface: In this computer demonstration, we will present simulated low-dose clinical CT images. Examples will include brain, abdomen, and pelvic CT examinations. In a real-live presentation, any particular dose level or examination will be simulated and presented to the participant. The degree of dose reduction can be prescribed in 5% increments. The simulated CT images will be produced in real time and displayed on a side window of the standard dose CT images for comparison. Both the standard and the simulated CT images can be interpreted in scrolling mode. Methodology: Our methodology is based on adding noise to simulated sinogram data generated by Radon transform of the original CT dataset. The magnitude of noise addition is based on the difference between the tube current-exposure time product (mAs) of the original examination and the targeted reduced mAs. The approach was validated using images of the ACR CT phantom which indicated that the noise addition had the proper magnitude and texture (characterized in terms of the NPS) as those of real dose-reduced images with no negative impact on image resolution.
Discussion
The simulation of low-dose CT images is a highly powerful approach to address the need for optimization in CT.
However, current methods are limited to specific vendors and require access to sinogram data. Our technique eliminates these limitations with a simple methodology and a practical user interface. The approach is currently based on FBP reconstruction and needs to be extended to iterative reconstructions in the future.
CONCLUSION
We developed computer software for producing simulated low-dose CT images, which can be used for determining optimal dose setting of various CT examinations clinically without time-consuming experiments and risks in terms of increased patient dose.
PHE011-b Reliability of fMRI Experiments in the Setting of Neurovascular Uncoupling (hardcopy backboard)
Andrea Para MSc (Presenter): Nothing to Disclose , Julien Poublanc MSc : Nothing to Disclose , Joseph A.
Fisher MD : Stockholder, Thornhill Research Inc , David John Mikulis MD : Stockholder, Thornhill Research
Inc Research Grant, General Electric Company

Background
Activated neurons in the brain send a vasodilatory stimulus to surrounding blood vessels to increase supply of oxygen and glucose to meet metabolic demands. Functional magnetic resonance imaging (fMRI) uses blood oxygen level dependent (BOLD) contrast to detect changes in blood flow based on differences in the magnetic properties of oxygenated versus deoxygenated hemoglobin, and then infer neuronal activity from the observed changes in blood flow.
Cerebrovascular reactivity (CVR) is the ability of arterioles to increase blood flow in response to a global vasodilatory stimulus. CVR can be reduced or exhausted in steno-occlusive cerebrovascular disease resulting in blunted increases in blood flow, or even decreased blood flow due to steal physiology.
We hypothesize that in areas with exhausted vascular reserve and steal physiology there will be diminished blood flow response following neuronal activation, and that these areas would appear as false negatives on traditional BOLD fMRI.
Evaluation
Patients with unilateral steno-occlusive disease received a vasodilatory stimulus during BOLD MRI to generate
CVR maps. These were compared to traditional BOLD fMRI maps of neuronal activation in the motor cortex in response to a motor task. Neuronal activation from the motor task was found to be linearly correlated with CVR
(n=11 patients, R= 0.82). Patients with positive (normal) CVR showed positive activation on BOLD fMRI, while patients with negative CVR had decreased or absent neuronal activation on BOLD fMRI.
Discussion
Activated neurons send a vasodilatory stimulus to surrounding blood vessels, and the corresponding increase in oxyhemoglobin levels is the basis of the BOLD signal. In areas with cerebrovascular disease where CVR is impaired there is uncoupling of neuronal activation and blood flow that results in false negative errors on BOLD fMRI.
CONCLUSION
BOLD MRI CVR mapping can provide spatial information about the vascular reactivity of the brain that is essential to interpreting traditional BOLD fMRI studies in the setting of cerebrovascular steno-occlusive disease.
Scientific Posters
BR
AMA PRA Category 1 Credits ™ : .50
Sun, Nov 30 1:00 PM - 1:30 PM Location: BR Community, Learning Center
Sub-Events
BRS241 Lesion Stiffness Measured by Shear-wave Elastography: Preoperative Predictor of the Histologic
Underestimation of US-guided Core Needle Breast Biopsy (Station #1)
Ah Young Park MD : Nothing to Disclose , Ji Hyun Youk MD : Nothing to Disclose , Eun Ju Son MD, PhD :
Nothing to Disclose , Hye Mi Gweon MD : Nothing to Disclose , Jeong-Ah Kim MD, PhD : Nothing to
Disclose , Dahye Lee (Presenter): Nothing to Disclose
PURPOSE
To determine whether lesion stiffness measured by shear-wave elastography (SWE) could be used to predict the histologic underestimation of ultrasound (US)-guided 14-gauge core needle biopsy (CNB) for breast masses.
METHOD AND MATERIALS
This retrospective study enrolled a total of 99 breast masses including 40 high-risk lesions and 59 DCIS which were diagnosed at US-guided CNB and excised surgically. SWE was performed for all breast masses to measure quantitative elasticity values. To identify the preoperative factors associated with the histologic underestimation, patient age, symptom, lesion size, B-mode US findings, and quantitative SWE parameters were compared between the upgrade group and the non-upgrade group and estimated the predictive power for underestimation of each variable using univariate and multivariate logistic regression.
RESULTS
The overall underestimation rate was 28.3% (28/99) and the underestimation rate of high-risk lesion (ADH, phyllodes tumor and other atypia) and DCIS was 25.0% (57.1%, 16.7%, and 20.0%) and 30.5%, respectively.
Lesion size was larger (16.0 vs 10.0 mm, p=.016) and BI-RADS category was higher (p=.030) in the upgrade group than in non-upgraded group. The medians of all elasticity values of the upgrade group were significantly higher than those of the non-upgrade group (p<.0001): mean (Emean), 133.1 vs 57.4 kPa; maximum, 151.1 vs
66.6 kPa, minimum, 103.1 vs 43.6 kPa; the lesion-to-fat ratio, 7.8 vs 4.6. In subgroup analysis, high-risk

BRS242
BRS243 lesions which were upgraded to malignancy showed higher Emean than the non-upgrade lesions (ADH, p=.077; phyllodes tumors, p=.028; other atypia, p=.030) and as did DCIS upgraded to invasive cancer (p<.0001). In multivariate analysis, Emean was an independent predictor for underestimation of malignancy (odds ratio,
1.022; p<.0001).
CONCLUSION
Breast lesion stiffness quantitatively measured by SWE could be helpful to predict the underestimation of malignancy in US-guided CNB.
CLINICAL RELEVANCE/APPLICATION
For patients with high-risk lesions or DCIS after CNB which are sufficiently stiff on SWE, a one-step operation could be considered when surgical excision is performed.
Imaging and Histopathologic Features of BIRADS 3 Lesions Upgraded During Imaging Surveillance
(Station #2)
Aya Michaels MD (Presenter): Nothing to Disclose , Catherine Streeto Giess MD : Nothing to Disclose ,
Chris Sungwon Chung MD : Nothing to Disclose , Elisabeth P. Frost MD : Nothing to Disclose , Robyn L.
Birdwell MD : Nothing to Disclose
PURPOSE
To evaluate clinical or imaging differences between screen-detected benign and malignant upgraded lesions initially assessed as BIRADS 3 at diagnostic evaluation
METHOD AND MATERIALS
IRB approved retrospective review of the mammography database from 1/1/04-12/31/08 identified 1188
(1.07%) of 110,776 screening examinations assessed as BIRADS 3 following diagnostic evaluation at our academic center (staffed by breast specialists) or our outpatient center (staffed by general radiologists), 1017 with at least 24 months follow up or biopsy. Sixty (5.9%) BIRADS 3 lesions were upgraded to BIRADS 4 or 5 during imaging surveillance (the study population). Prospective reports, patient demographics, and clinical outcomes were abstracted from the longitudinal medical record.
RESULTS
Mean patient age was 54.1 years (range 35-85). Lesions consisted of 7 masses, 12 focal asymmetries (FAD), and 41 calcifications. Fifteen (25%) of 60 lesions upgraded from initial BIRADS 3 assessment were malignant
(1.47% of total; 15/1017 BIRADS 3 examinations). Breast imaging specialists interpreted 21 of 60 upgraded lesions, with 3 (14.3%) malignancies, compared to general radiologists who interpreted 39 of 60 upgrades, with
12 (30.8%) malignancies (p=0.160). Twelve (26.7%) of 45 benign upgraded lesions were masses or FADs, and
7 (46.7%) of 15 upgraded malignant lesions were masses or FADS (p=0.149). Six of 7 malignant upgraded masses/FADs had negative US at time of initial BIRADS 3 assignment. At initial assessment, prospective reports described features appropriate for BIRADS 3 classification in only 30/60 (50%). Mammographic development or change was reported in 18/60 (30%), increased prominence in 20/60 (33.3%) and stability in 1/60 (1.7%); change was not reported in 17/60 (28.3%), and 4/60 (6.7%) had no prior studies.
CONCLUSION
Most mammographic lesions upgraded from probably benign to suspicious had shown change or increased conspicuity at the time of initial BIRADS 3 assessment. Non breast imaging specialists had a higher malignancy rate among upgraded lesions compared to specialists. Masses and focal asymmetries represented a higher proportion of malignant than benign upgrades, and usually had no US correlate.
CLINICAL RELEVANCE/APPLICATION
Malignant masses and focal asymmetries mis-characterized as probably benign usually had no US correlate.
Careful utilization of BIRADS terminology will improve appropriate characterization.
Positive Predictive Value of Biopsy of Palpable Masses on the Mastectomy Side in Reconstructed and
Non-reconstructed Breasts (Station #3)
Sandra Brennan MBBCh, MSc (Presenter): Nothing to Disclose , Donna Danielle D'Alessio MD : Nothing to
Disclose , Jennifer Brisman Kaplan MD : Nothing to Disclose , Marcia Edelweiss MD : Nothing to Disclose ,
Alexandra Heerdt : Nothing to Disclose , Elizabeth A. Morris MD : Nothing to Disclose
PURPOSE
To determine the positive predictive value (PPV) of biopsy of palpable masses on the mastectomy (MX) side and to determine if there are patient or imaging features predictive of cancer.
METHOD AND MATERIALS
Following IRB approval, we performed a HIPPA-compliant retrospective review of 3,286 breast ultrasounds (US) performed from June 2008 to January 2013 to identify patients with MX presenting with palpable masses on the
MX side. We included reconstructed and non-reconstructed breasts and both prophylactic and therapeutic MX.

BRS244
BRE157
Medical records and imaging studies were reviewed. Statistical analysis was performed with Fisher's exact test.
95% confidence intervals (CI) were calculated.
RESULTS
69 patients with MX had targeted US of palpable masses. Age 25-82, mean 52 years. 43/69 (62%) underwent biopsy. 26/69 (38%) had follow-up and no biopsy; range of follow-up was 4-71, mean 21 months. 53/69 patients had a mass on US. 16/69 had no mass and the palpable was related to the implant in 7, clip/suture in
4, rib 1 and 4 had no finding on US. 12/43 (28%, 95% CI; 17-43) who underwent biopsy had cancer (age
35-68, mean 49 years), 31/43 (72%) were benign. All 12 cancers were on the original cancer side not the prophylactic MX side. 5/12 (42%) had received prior radiation and 6/12 (50%) hormonal therapy. Recurrences ranged from 0.6 to 4.5 cm maximum diameter, mean 1.6cm. Neither patient age (p=1.0), hormonal (p=0.14) or radiation therapy (p=0.7) had a statistically significant association with finding cancer on biopsy. Lesion shape (irregular versus oval/round) was very statistically significant (p=0.003) as was non-parallel orientation on US (P=0.01). Circumscribed versus non-circumscribed margins was not quite statistically significant
(p=0.08). Lesion size and presence of shadowing were not statistically significant (p=1.0). No cancers were found on follow-up.
CONCLUSION
The PPV of biopsy of palpable masses on the MX side in our study was 28% (95% CI; 17-43). Neither patient age, prior history of radiation or hormonal therapy had a statistically significant association with positive biopsy.
All recurrences were on the original cancer side. An irregular shape and anti-parallel orientation on US were significantly associated with cancer.
CLINICAL RELEVANCE/APPLICATION
The PPV of biopsy of palpable masses on the MX side is high at 28% with irregular shape and anti-parallel orientation on US significantly associated with cancer.
Outcomes of Probably Benign Lesions Detected on Screening Ultrasound in Women with Average and High Risk: Are We Recommending Unnecessary Follow Up Exams? (Station #4)
Kristin Elias MD : Nothing to Disclose , Islamiat O. Ego-Osuala MD (Presenter): Nothing to Disclose ,
Sara Daniel Shaylor MD : Nothing to Disclose , Marissa Lauren Albert MD, MSc : Nothing to Disclose ,
Hildegard B. Toth MD : Nothing to Disclose , Linda Moy MD : Nothing to Disclose
PURPOSE
The purpose of this study is to evaluate the prevalence and rate of malignancy of BI-RADS category 3 lesions detected on screening ultrasound in average and high risk patients.
METHOD AND MATERIALS
IRB approved retrospective review of consecutive technologist performed, hand-held screening ultrasound from
1/11 to 12/12 was performed. Patient characteristics, outcome, mammography results, and follow up of all
BI-RADS 3 cases were recorded and evaluated.
RESULTS
116/1937 screening US (6%) performed over a consecutive two year period were interpreted as BI-RADS category 3 with a total of 201 probably benign lesions. 53% of women had no known risk factors for breast cancer. 50% of the women were premenopausal and 78% had mammographically dense breasts.
Mammography was performed within 1 month in 84.5% of the cases. 108/116 (93%) US exams with 190 probably benign lesions had mean follow up of 15.7 months, range 5-36 months. On follow up, 141/190
(74.2%) lesions were downgraded to benign due to decrease in size, more definitive benign features, or stability over two years. 43/190 (22.6%) lesions remained stable and probably benign. Biopsy was performed of 6 (3.2%) lesions that demonstrated interval growth or suspicious change. One biopsy was performed due to patient preference. All 7 biopsies were benign with results including cysts, fibrocystic change, or fibroadenoma.
Two subsequent malignancies were detected in the contralateral breast on follow up within one year. The index lesions assessed as probably benign remained stable. Of the 108 cases with follow up no BI-RADS 3 lesions were found to be malignant.
CONCLUSION
In this study where 53% of women were average risk no subsequent cancers were detected in lesions assessed as probably benign on screening ultrasound.
CLINICAL RELEVANCE/APPLICATION
It is possible that with careful assessment some lesions may be interpreted as benign rather than probably benign in order to decrease unnecessary follow up exams without missing a malignancy, especially in an average risk population.
You will See it When you Know it: Clustered Ring Enhancement, a New Breast MRI BI-RADS
Descriptor for Internal Enhancement Pattern of Non-mass Enhancement (Station #5)
Youichi Machida MD, PhD (Presenter): Nothing to Disclose , Mitsuhiro Tozaki MD, PhD : Nothing to Disclose

BRE208
BRE219
BRE168
Youichi Machida MD, PhD (Presenter): Nothing to Disclose , Mitsuhiro Tozaki MD, PhD : Nothing to Disclose
, Akiko Shimauchi MD : Nothing to Disclose , Tamiko Yoshida : Nothing to Disclose , Yoshihide Kanemaki
: Nothing to Disclose
TEACHING POINTS
1. Clustered ring enhancement (CRE) becomes more distinct on delayed phase of dynamic contrast MRI following either a heterogeneous or clumped internal enhancement pattern on early phase. 3. When a non-mass enhancement (NME) bears both CRE internal pattern and segmental distribution, the lesion is highly predictive of malignancy. 4. While focal and regional distributions are descriptors of intermediate supicion, NMEs with such distributions are indicative of malignancy when CRE is observed, especially in combination with clumped internal pattern.
TABLE OF CONTENTS/OUTLINE
CRE has reported to be high predictive of malignancy. Although this descriptor will be more widely used after the revision of BI-RADS, employing it without knowledge of its definition or characteristics can lead to misinterpretation and undesiable outcomes. Radiologists engaged in breast imaging will be able to promote a better understanding of CRE through the following contents; 1. Reviewing the definition of CRE: how can we detect it? 2. Corresponding pathological findings and assumed pathophysiology 3. Examples of CRE: assessment in combination with distributions
Rare Breast Lesions: Correlation with Radiologic Imaging, Pathology, and Clinical Management
(Station #6)
Anjali Khurana MD (Presenter): Nothing to Disclose , Luke Mueller MD : Nothing to Disclose ,
Brian Samuel Englander MD : Nothing to Disclose
TEACHING POINTS
The purpose of this exhibit is to illustrate the varying rare entities occurring in the breast and to give a pictorial multimodality essay of these entities. Additionally, pathologic correlation and clinical management will be discussed.
TABLE OF CONTENTS/OUTLINE
There are multiple uncommon lesions of the breast that are encountered after biopsy. Characteristics of these rare entities will be discussed in a multimodality approach along with pathologic correlation and clinical management. Cases that will be included are entities such as sarcoid, lymphoma, angiosarcoma, phyllodes tumor, pseudoangimatous stromal hyperplasia, granular cell tumor, tubular adenoma, granulomatous inflammation, diabetic mastopathy, lipoma, and metastases.
A New Era in Axillary Management in Early Breast Cancer: The Gold Star is Ultrasound (Station #7)
Karina Pesce : Nothing to Disclose , Flavia Beatriz Sarquis MD (Presenter): Nothing to Disclose ,
Bernardo Oscar Blejman MD : Nothing to Disclose , Carlos Mariano Lamattina MD : Nothing to Disclose ,
Fabiana Gisela Vega MD : Nothing to Disclose
TEACHING POINTS
To analyze the history evolution of the management of the axilla in early breast cancer To discuss the diagnostic value of pre-surgery axillary ultrasound for nodal staging in patients with early breast cancer To define a sonographically normal anatomy and normal appearing axillary lymph node To describe the spectrum of sonographic findings in axillary pathologic lymphadenopathy To discuss false positive and negative value of axillary us.
TABLE OF CONTENTS/OUTLINE
1-Introduction 2-History evolution of the management of the axilla in early breast cancer 3-Ultrasound anatomy of the axilla and normal sonographic appearance of a lymph node 4-Differentiation of malignant vs. benign axillar nodes with imaging and pathological correlation will be illustrated 5-Limits, false positive and negatives of the axillary ultrasound 6-Role of the detection of axillary nodes in the staging of early breast cancer will be discussed 7- Conclusion
Three Heads Are Better than One: Unique and Complementary Strengths of Mammography,
Ultrasound and MRI in Achieving Optimal Evaluation of Breast Lesions (Station #8)
Morlie Ling Wang MD, MPH (Presenter): Nothing to Disclose , Marleine Tremblay MD, MSc : Nothing to
Disclose , Raffat Tahira Ahmad MD : Nothing to Disclose , Hiroyuki Abe MD : Consultant, Seno Medical
Instruments, Inc
TEACHING POINTS
1. To review the imaging lexicon and highlights from the 2013 5th Edition of the ACR BI-RADS Atlas. 2. To emphasize the complementary imaging information each modality provides using a pictorial review. a.
Mammography (MG): Evaluation of calcifications, breast symmetry, convenient study for overview of the breasts. b. Breast Ultrasound (US): Detailed evaluation of morphology, assessment of cystic/solid components, detection of vascularity, and real-time analysis. c. Breast MRI (MR): Visualization of angiogenesis, large field of view, accuracy in dense breasts, and detection of multifocal/multicentric disease. 3. To review potential pitfalls using a pictorial review: a. MG: Limited FOV, limited sensitivity in dense breasts, underestimation of extent. b.
US: Poor evaluation of deep structures, limited ability to evaluate calcifications, operator dependence. c. MRI:
Decreased sensitivity with background parenchymal enhancement, false positives, contraindications to MR, inaccuracies with lesion extent, and increased interpretation time.
TABLE OF CONTENTS/OUTLINE

BRE187
1. The imaging lexicon and highlights from the 2013 5th Edition of the ACR BI-RADS Atlas are central to the proficient practice of breast imaging. 2. Each modality provides unique and complementary information and has potential pitfalls.
How I Do It: The Diagnostic Breast Evaluation (Station #9)
Rebecca Rakow-Penner MD, PhD (Presenter): Nothing to Disclose , Jade De Guzman MD : Nothing to
Disclose , Ifeanyi C. Onyeacholem MD : Nothing to Disclose , Haydee Ojeda-Fournier MD : Nothing to
Disclose
TEACHING POINTS
After reviewing this exhibit the learner will 1. Review an algorithmic approach for callbacks from screening evaluation and for patients presenting with clinical symptoms; 2. Understand the rationale for specific imaging protocols for callbacks; 3. Present special considerations for unique situations including post-surgical, pregnant and nursing patient; 4. Discuss common pitfalls in the diagnostic workup; 5. Have an opportunity for self assessment with imaging case review in multiple choice format.
TABLE OF CONTENTS/OUTLINE
The approach to the diagnostic exam in breast imaging continues to be a source of much confusion due to lack of standardization and differences in approach that may be present even in an individual practice. The methodology and rationale for performing certain mammographic views in various situations and when and where to perform breast US is not well understood, especially in light of recent controversies. This educational exhibit will contain: Introduction; Rational and motivation for standardizing protocols; Algorithmic approach for clinical symptoms; Algorithmic approach for callback from screening mammogram; Special considerations including protocols for the post surgical breast, nursing or pregnant patient, others; Outline common pitfalls in the diagnostic evaluation; Conclusion; Test yourself
Scientific Posters
ER
AMA PRA Category 1 Credits ™ : .50
Sun, Nov 30 1:00 PM - 1:30 PM Location: ER Community, Learning Center
Sub-Events
ERS207
High-Dose Radiographic Examinations in the ED: Can We Justify Exposures in the Era of
Ultra-Low-Dose CT? (Station #1)
Elizabeth H. Y. Du BA, BSc : Nothing to Disclose , Amdad Mustafa Ahmed MBCHB, FRCR : Nothing to
Disclose , Savvas Nicolaou MD : Nothing to Disclose , Patrick McLaughlin FFR(RCSI) (Presenter): Nothing to Disclose
PURPOSE
Ultra-low-dose CT protocols at the authors' institution result in a mean effective dose of 0.1 mSv, 0.2 mSv and
0.4 mSv in the chest, abdomen/thoracic spine and pelvis/lumbar spine, respectively. Similar exposure levels have been reported in the literature by McLaughlin et al. (Insights Imaging, Nov 2013) and Hanna et al. (J.
Thorac. Cardiovasc. Surg., Jan 2014). We conducted a retrospective analysis of radiation exposure related to radiographic examinations of the chest, abdomen, thoracic spine, lumbar spine and pelvis in the ED of a level one trauma centre to determine the percentage of radiographs which exceeded mean exposure levels encountered at ultra-low-dose CT.
METHOD AND MATERIALS
Ethics approval was obtained. A total of 1261 radiographic examinations were included in this study (255 chest,
252 abdominal, 251 thoracic spine, 251 lumbar spine and 252 pelvic). Dose area product values (DAP, dGy•cm2) for each image were obtained for all datasets, as was the examination indication and report findings.
Individual DAPs were summed for multiple views to obtain a total DAP. Mean effective dose (MED, mSv) was calculated for each examination using published DAP-MED conversion factors (PA/lateral chest 0.012
mSv/dGy•cm2, AP chest 0.021 mSv/dGy•cm2, abdomen 0.026 mSv/dGy•cm2, thoracic spine 0.019
mSv/dGy•cm2, lumbar spine 0.021 mSv/dGy•cm2 and pelvis 0.029 mSv/dGy•cm2).
RESULTS
Mean and SD for the studies were: chest (0.061mSv, 0.107mSv), abdomen (1.025mSv, 1.152mSv), thoracic spine (1.124mSv, 1.045mSv), lumbar spine (1.074mSv, 1.087mSv) and pelvis (1.313mSv, 1.075mSv). MEDs for radiographs exceeded those for ultra-low-dose CT in 11% of chest, 96% of abdominal, 91% of thoracic spine, 81% of lumbar spine and 80% of pelvic examinations. Significant radiographic findings contributing to patient care were found in 32% of chest, 24% of abdominal, 22% of thoracic spine, 22% of lumbar spine and
35% of pelvic examinations.
CONCLUSION
This study demonstrates that a significant percentage of plain radiographs are performed at a greater radiation exposure than encountered in novel ultra-low-dose CT protocols, often with relatively low diagnostic yield. The

ERS204
ERS208 exposure than encountered in novel ultra-low-dose CT protocols, often with relatively low diagnostic yield. The context of our findings will be illustrated with clinical examples of ultra-low-dose CT images obtained in the ED at our institution.
CLINICAL RELEVANCE/APPLICATION
We believe these findings will contribute to a paradigm shift as to how we best deliver ionizing radiation in the
ED in future years.
Identifying Emergency Room Patients’ Understanding of Health Care Personnel Responsible for
Interpreting their Ultrasound Imaging (Station #2)
Samer Dabbo MD (Presenter): Nothing to Disclose
PURPOSE
To determine patients' understanding of the role and educational background of professionals performing emergency ultrasound (ERUS).
METHOD AND MATERIALS
This was a prospective IRB approved study where adult patients referred for ERUS to radiology department after-hours (5pm-8am and weekends) were approached to complete a one-page questionnaire following their ultrasound examination. Questionnaire focused on the professional responsible for interpreting examinations and their education. A non-random sampling approach was used in recruitment of patients based on patient's condition (i.e. only medically stable patients were approached). All examinations were performed by a sonographer and some patients were reexamined by a resident or staff radiologist. All accrued patients signed a consent.
RESULTS
271 surveys were completed with 68% of respondents being female. Patients' age ranged from 18-76 years old
(median 34 y.o). 76% of patients had a college degree. Patients identified the following health care providers as responsible for interpreting the images of their scan: radiologists (51%), emergency doctor (40%), family doctor (7%) and nurse (2%). Patients identified the following health care providers as most qualified for interpreting the images of their scan: radiologists (39%), emergency doctor (33%), family doctor (24%) and nurse (4%). The majority of patients (76%) recognized radiologists as medical doctors. Patient understood the role of the radiologist as the following: interpret the scan (51%), perform the scan (40%), consultant to your doctor (36%) and organize the scan (22%). The majority of patients (72%) wanted to speak directly with the individual who interpreted the images of their scan. There was no statistically significant association between gender, age or education level with respect to willingness to speak directly with the individual who interpreted the images (p>0.05).
CONCLUSION
The majority of patients recognize radiologists as medical doctor who primarily responsible for interpretation of the examination. In addition, the majority would prefer to speak directly with the individual who interprets their scan.
CLINICAL RELEVANCE/APPLICATION
Emergency room patients prefer to speak directly with individuals who interpret their ultrasound exam. The implications of this study may be to shift the paradigm towards a more visible role for radiologists.
Role of Neuroimaging in Patients Presenting with Headache in the Emergency Room (Station #2)
Mahbubul Patwary MD (Presenter): Nothing to Disclose , Daniel Fung MD : Nothing to Disclose
PURPOSE
Each year as many as 3 million patients present to an emergency department (ED) for treatment of headache.
With the rising use of imaging, neuroimaging has become an important financial and radiation safety issue. We investigated the diagnostic utility of computed tomography (CT) scans of the brain in patients with headache in order to propose a revised indication for neuroimaging in the community hospital emergency room setting.
METHOD AND MATERIALS
Electronic medical records from August 2013 to April 2014 were reviewed retrospectively from any patient who presented to the ED with a non-traumatic headache, as a primary or secondary diagnosis, who had a CT scan of the brain. Clinical stratification of headaches was not performed in order to exclude potential subjective data.
Quantifiable measures including vital signs, lab values and physical exams were reviewed in order to identify potential risk factors. Outcome of this study was defined as any positive finding on neuroimaging requiring hospital admission.
RESULTS
179 patients met the inclusion criteria and only two patients (1.1%) had neuroimaging findings requiring admission. The positive cases presented with focal neurological symptoms, hypertension greater than 140/90 mmHg, and age > 60. Non-contributory variables included sex, general appearance, other vital signs, and acute phase laboratory values. Furthermore, 27 patients with a known history of migraines (15.1%) did not demonstrate any positive neuroimaging findings.

ERS204
ERS208 demonstrate any positive neuroimaging findings.
CONCLUSION
The overwhelming majority of patients who presented to the emergency department with a headache had a neuroimaging study not requiring admission. The data suggests most of these scans are unnecessary and lead to increased radiation exposure and healthcare costs. This preliminary data is part of a longitudinal study, which can potentially set guidelines for appropriate neuroimaging in the ED.
CLINICAL RELEVANCE/APPLICATION
The benfit of neuroimaging in the setting of headache may be not be justified by the radiation risk and associated healthcare cost
Identifying Emergency Room Patients’ Understanding of Health Care Personnel Responsible for
Interpreting their Ultrasound Imaging (Station #2)
Mostafa Atri MD : Nothing to Disclose
PURPOSE
To determine patients' understanding of the role and educational background of professionals performing emergency ultrasound (ERUS).
METHOD AND MATERIALS
This was a prospective IRB approved study where adult patients referred for ERUS to radiology department after-hours (5pm-8am and weekends) were approached to complete a one-page questionnaire following their ultrasound examination. Questionnaire focused on the professional responsible for interpreting examinations and their education. A non-random sampling approach was used in recruitment of patients based on patient's condition (i.e. only medically stable patients were approached). All examinations were performed by a sonographer and some patients were reexamined by a resident or staff radiologist. All accrued patients signed a consent.
RESULTS
271 surveys were completed with 68% of respondents being female. Patients' age ranged from 18-76 years old
(median 34 y.o). 76% of patients had a college degree. Patients identified the following health care providers as responsible for interpreting the images of their scan: radiologists (51%), emergency doctor (40%), family doctor (7%) and nurse (2%). Patients identified the following health care providers as most qualified for interpreting the images of their scan: radiologists (39%), emergency doctor (33%), family doctor (24%) and nurse (4%). The majority of patients (76%) recognized radiologists as medical doctors. Patient understood the role of the radiologist as the following: interpret the scan (51%), perform the scan (40%), consultant to your doctor (36%) and organize the scan (22%). The majority of patients (72%) wanted to speak directly with the individual who interpreted the images of their scan. There was no statistically significant association between gender, age or education level with respect to willingness to speak directly with the individual who interpreted the images (p>0.05).
CONCLUSION
The majority of patients recognize radiologists as medical doctor who primarily responsible for interpretation of the examination. In addition, the majority would prefer to speak directly with the individual who interprets their scan.
CLINICAL RELEVANCE/APPLICATION
Emergency room patients prefer to speak directly with individuals who interpret their ultrasound exam. The implications of this study may be to shift the paradigm towards a more visible role for radiologists.
Role of Neuroimaging in Patients Presenting with Headache in the Emergency Room (Station #2)
Michael T. Mantello MD : Nothing to Disclose
PURPOSE
Each year as many as 3 million patients present to an emergency department (ED) for treatment of headache.
With the rising use of imaging, neuroimaging has become an important financial and radiation safety issue. We investigated the diagnostic utility of computed tomography (CT) scans of the brain in patients with headache in order to propose a revised indication for neuroimaging in the community hospital emergency room setting.
METHOD AND MATERIALS
Electronic medical records from August 2013 to April 2014 were reviewed retrospectively from any patient who presented to the ED with a non-traumatic headache, as a primary or secondary diagnosis, who had a CT scan of the brain. Clinical stratification of headaches was not performed in order to exclude potential subjective data.
Quantifiable measures including vital signs, lab values and physical exams were reviewed in order to identify potential risk factors. Outcome of this study was defined as any positive finding on neuroimaging requiring hospital admission.
RESULTS
179 patients met the inclusion criteria and only two patients (1.1%) had neuroimaging findings requiring admission. The positive cases presented with focal neurological symptoms, hypertension greater than 140/90

ERS209
ERS210 admission. The positive cases presented with focal neurological symptoms, hypertension greater than 140/90 mmHg, and age > 60. Non-contributory variables included sex, general appearance, other vital signs, and acute phase laboratory values. Furthermore, 27 patients with a known history of migraines (15.1%) did not demonstrate any positive neuroimaging findings.
CONCLUSION
The overwhelming majority of patients who presented to the emergency department with a headache had a neuroimaging study not requiring admission. The data suggests most of these scans are unnecessary and lead to increased radiation exposure and healthcare costs. This preliminary data is part of a longitudinal study, which can potentially set guidelines for appropriate neuroimaging in the ED.
CLINICAL RELEVANCE/APPLICATION
The benfit of neuroimaging in the setting of headache may be not be justified by the radiation risk and associated healthcare cost
CT Brain Perfusion (CTP): Do We Really is Useful in Ischemic Stroke? (Station #3)
Agustina Vicente Bartulos MD (Presenter): Nothing to Disclose , Michal Kawiorski ? : Nothing to Disclose ,
Daniel Lourido Garcia : Nothing to Disclose , Luis Gorospe Sarasua : Nothing to Disclose , Alfonso Muriel
Garcia : Nothing to Disclose , Maria Alonso de Lecinana Cases : Nothing to Disclose
PURPOSE
The mismatch hypothesis has been used to identify recoverable tissue in acute stroke. However, its utility has been questioned. We performed a study to determine whether CT perfusion (CTP) accurately identify salvable tissue and if the findings have a translation into clinic.
METHOD AND MATERIALS
Prospective registry of patients with severe anterior circulation stroke subjected to reperfusion therapies. We recorded clinical characteristics, urgent neuroimaging data (baseline multimodal CT, non-contrast CT at 24 hours), occurrence of recanalization and outcomes at three months(NIHSS and mRS). Volumetric measurement of infarct core (reduced blood volume) and at risk tissue (reduced blood flow with normal volume) in CTP were performed. In 24-h-CT total volume of lesion (TVL) and partial volume (PVL) of lesion in the slices corresponding to the perfusion acquisition cage, were measured. Percentage of at risk tissue not incorporated to the final lesion was estimated and correlated with outcomes
RESULTS
34 patients were included, median age 66.5 years (P25; P75: 60; 75). Baseline NIHSS 17 (14; 22). Location of the thrombus was: 21% Intracranial ICA, 62% M1 and 17% M2 segment of the MCA. Lesion volumes were:
Core: 10,6 mL (4;18); at risk tissue: 74.3 mL (56; 91); mismatch 89% (79; 95), TVL: 12.4 mL (8;54); PVL:
10.7 mL (5; 33). Percentage of at risk tissue that did not incorporate into the final lesion was reduced when recanalization occurred: 89 % (76; 94) vs 46 % (23; 86), p =0.0044). For every 10 % of preserved tissue,
NIHSS score improved by 3 points (95% CI: -4.9 - -0.8, p=0.007). Higher percentage of preserved tissue increased probability of independency (mRS 0-2) OR 1.15 (95% CI 1.04- 1.28).
CONCLUSION
CTP identify salvable tissue in acute stroke. Higher percentage of preserved at risk tissue is associated with better clinical outcome. The futile recanalization is associated with lower percentage of penumbra saved.
CLINICAL RELEVANCE/APPLICATION
This study helps us to determine the value of CT-Perfusion. Other parameters that may have clinical relevance are also being assessed (collateral, thrombus location .....). We are trying to obtain a predictive clinico-radiological scale to select patients who will benefit from reperfusion therapies.
ED CT of the Abdomen and Pelvis Utilization has Continued to Increase, Despite what Appears to be a Reduction in Procedures caused by Code Bundling (Station #4)
Santosh Kumar Selvarajan MD (Presenter): Nothing to Disclose , David C. Levin MD : Consultant,
HealthHelp, LLC Board of Directors, Outpatient Imaging Affiliates, LLC , Vijay Madan Rao MD : Nothing to
Disclose , Laurence Parker PhD : Nothing to Disclose
PURPOSE
Previous studies have shown that the all imaging utilization rates have been stable since 2006 except CT which has continued to grow (overall annual growth of 3.4% from 2007-2009). From 2011, CPT codes for CT scans of the abdomen and pelvis were bundled into a single new code. Our purpose was to determine what effect this policy had on recent trends in CT utilization in ED.
METHOD AND MATERIALS
The nationwide Medicare Part B databases for 2000-2012 were used. The codes for CT of the abdomen and CT of the pelvis were selected for all years of the study, and the bundled codes for CT abdomen/pelvis were selected for 2011 and 2012. Procedure volumes in ED and non-Ed (inpatient, office, and outpatient) settings were calculated. To understand the trends through the bundling years (2011 and 2012), we doubled the number of bundled codes, since these would have counted as 2 exams in 2010 and before.
RESULTS

ERE191
RESULTS
The nationwide Medicare utilization rates of both CT abdomen and CT pelvis grew from 2000 to 2007 (4.8 M. to
9.7 M.) Thereafter, from 2008 to 2010, growth had stabilized except in ED (Non-ED, 8.1 M. to 7.7 M.; ED, 1.7
M. to 2.0 M).
There is a dramatic drop off in 2011 due to bundling: non-ED, 7.7 M. 4.2 M., Ed, 2.0 to 1.2 M When the bundled exams are doubled, 2011 non-Ed is stable at 7.8 M. exams; ED increases substantially from 2010, to
2.3 M. exams. In 2012, again counting the bundled code as 2 exams, non-ED volume is stable, at 7.8 M., while
ED volume again increases substantially, to 2.6 M.
CONCLUSION
Medicare volumes of CT of the abdomen and CT pelvis show an apparent decline, but this is an artifact of code bundling. While procedure volume is stable in non-ED settings, volume of CT of the abdomen and pelvis continue to grow strongly in the ED.
CLINICAL RELEVANCE/APPLICATION
New guidelines are probably required to reduce the CT utilization rates in Emergency.
Imaging of Traumatic Preganglionic and Postganglionic Brachial Plexus Injuries (Station #5)
Yoshimi Endo MD (Presenter): Nothing to Disclose
TEACHING POINTS
1. To review the normal appearance of conventional and CT myelograms of the cervical spine.
2. To review the imaging features of preganglionic brachial plexus injuries, including conventional and CT myelographic features of both complete and partial cervical nerve root avulsions.
3. To identify traumatic injuries to the postganglionic brachial plexus, focused on MRI
TABLE OF CONTENTS/OUTLINE
Preganglionic nerve roots - Normal anatomy of the preganglionic nerve roots/rootlets - Normal appearance of the nerve roots/rootlets on conventional and CT myelography - Myelographic features of complete and partial nerve root avulsions with MRI correlation Postganglionic brachial plexus - Anatomy of the components of the brachial plexus - Imaging techniques on MRI and ultrasound of the plexus - Normal appearance of the brachial plexus on MRI and ultrasound - Traumatic postganglionic brachial plexus injuries on MRI, including avulsions from high-energy trauma, traction from sports-related injuries and shoulder dislocations, and plexus injuries as a complication of fractures.
Scientific Posters
MK
AMA PRA Category 1 Credits ™ : .50
Sun, Nov 30 1:00 PM - 1:30 PM Location: MK Community, Learning Center
Sub-Events
MKS346 Follow Up of Flexor Tendon Repair in the Hand: MR and US Imaging Assessment (Station #1)
Flore Viry MD (Presenter): Nothing to Disclose , Catherine Phan MD : Nothing to Disclose , Violaine
Beauthier : Nothing to Disclose , Lionel Arrive MD : Nothing to Disclose , Yves M. Menu MD : Nothing to
Disclose , Anne Miquel : Nothing to Disclose
PURPOSE
To compare contrast enhanced MR and ultrasound (US) performance in differentiating complications after repair of digital flexor tendon as tendon rupture (frank rupture or elongated callus) or adhesions, from normal post operative aspect.
METHOD AND MATERIALS
Sixteen consecutive patients with tendon rupture were included to be explored by MR ans US 3 months after surgery. 19 fingers, 25 tendons (16 Flexor Digitorum Profondis, 8 Flexor Digitorum Superficialis in zone 1 or 2
IFSSH and 1 Flexor Pollicis Longus) were explored by MR and US studies. Axial and sagittal spin echo sequences (T1, proton density and T1 with fat saturation and gadolinium injection) were performed. US included dynamic study. US and MR studies were blinded. The MR criteria for rupture was the complete lack of continuity of the tendon hyposignal on axial sequences. Standard of reference was either surgical results in case of reoperation or clinical status assessed by a senior surgeon 6-9 months after surgery.

MKS347
MKS348
RESULTS
The average time between surgery and imaging was 130 days (+/-109). Four tendons were reoperated with confirmation of frank rupture,10 had intensive reeducation for peritendinous adhesions and 11 had a normal outcome. MR and US depicted frank tendon ruptures in all 4 cases. False positive MR results for rupture was observed in two tendons and US was false positive for rupture in one of these 2 tendons. In these 2 cases, tendons were controlled very early after surgery (24/40 days). Gadolinium enhancement did not improve MR performance in assessing tendon continuity. In case of continuous tendon, the peritendinous scar tissue was depicted in all MR studies except 4 /11 normal outcome tendons controlled 350 days after surgery. US was more specific for peritendinous adhesions, showing the synchronous mobilisation of tendon and peritendinous tissue only in the 10 cases of peritendinous adhesions. In 2 normal outcome tendons xith suture in zone 1, dynamic US study was technically difficult.
CONCLUSION
MR and US study are complementary in the assessment of post operative flexor tendon. Special care should be taken in case of early post operative study, since immature connective healing tissue appears as a gap in the tendon continuity, especially in MR study.
CLINICAL RELEVANCE/APPLICATION
MR and US study are complementary in the assessment of post operative finger flexor tendon. Early control car lead to false positive results for tendon rupture.
Diffusion-weighted MR Imaging for Assessing Synovitis of Wrist and Hand in Patients with
Rheumatoid Arthritis: A Feasibility Study (Station #2)
Xubin Li MD, PhD (Presenter): Nothing to Disclose , Xia Liu : Nothing to Disclose , Xiangke Du : Nothing to Disclose , Zhao Xiang Ye : Nothing to Disclose
PURPOSE
The purpose of this study was to investigate the feasibility of diffusion-weighted imaging (DWI) in detecting synovitis of wrist and hand in patients with rheumatoid arthritis (RA) and evaluate its sensitivity, specificity and accuracy as compared to T2-weighted imaging (T2WI) with short tau inversion recovery (STIR) with the reference standard contrast-enhanced magnetic resonance imaging (CE-MRI).
METHOD AND MATERIALS
Twenty-five patients with RA underwent MR examinations including DWI, T2WI with STIR and CE-MRI. MR images were reviewed for the presence and location of synovitis of wrist and hand. The sensitivity, specificity and accuracy of DWI and T2WI with STIR were calculated respectively and then compared.
RESULTS
All patients included in this study completed MR examinations and yielded diagnostic image quality of DWI. For individual joint, there was good to excellent inter-observer agreement (k=0.62-0.83) using DWI images, T2WI with STIR images and CE-MR images, respectively. The k-values for the detection of synovitis indicated excellent overall inter-observer agreements using DWI images (k=0.86), T2WI with STIR images (k=0.85) and
CE-MR images (k=0.91), respectively. Overall, DWI demonstrated a sensitivity, specificity and accuracy of
75.6%, 89.3% and 84.6%, respectively, for detection of synovitis, while 43.0%, 95.7% and 77.6% for T2WI with STIR, respectively. DWI showed positive lesions much better and more than T2WI with STIR.
CONCLUSION
Our results indicate that DWI presents a novel non-invasive approach to contrast-free imaging of synovitis. It may play a role as an addition to standard protocols.
CLINICAL RELEVANCE/APPLICATION
It may play a role as an addition to standard protocols for assessing synovitis of wrist and hand in patients with rheumatoid arthritis.
Clinical Utility of Musculoskeletal Ultrasound in Foot and Ankle Pathology: How Ultrasound Imaging
Changes Diagnosis and Management (Station #3)
Benjamin Alan Tritle MD (Presenter): Nothing to Disclose , Michael C. Forney MD : Nothing to Disclose ,
Patricia Botti Delzell MD : Nothing to Disclose
PURPOSE
The foot and ankle are well suited for musculoskeletal ultrasound since many structures are superficial and able to be well seen. Clinicians have often narrowed the possibilities for a patient's symptoms to a limited differential or a specific anatomic location. In such situations, MRI may be an overly extensive and expensive test. Because of its usefulness and economic advantage, we sought to investigate the frequency with which musculoskeletal ultrasound supports or changes clinical management.
METHOD AND MATERIALS
After obtaining IRB approval, a retrospective review of 110 consecutive patients who underwent MSK ultrasound

MKS349
MKS350 of the foot or ankle was conducted (January 4, 2012-November 26, 2013). 98 of these patients had both a preand post-ultrasound clinical impression/plan documented in the medical record. The categories of the pre-ultrasound impressions included: Inflammatory conditions (36); Morton's Neuroma (16);
Traumatic/Mechanical conditions (15); Suspected mass (other than neuroma) (10); Foreign body (8);
Degenerative (7); Infectious (2). Note was made if the clinical diagnosis was changed or confirmed by ultrasound, and if treatment decisions were altered.
RESULTS
Ultrasound of the foot or ankle impacted diagnosis and or management for a large number of patients.
Diagnosis or management was influenced in 62 of 98 (63%; 95% CI: 53-72%) patients. In the majority of these cases, 68% (95% CI: 55-78%), both the diagnosis and the treatment were altered. In 36 patients whose diagnosis and treatment were not altered, ultrasound confirmed the initial clinical impression 97% of the time
(35/36; 95% CI: 85-100%).
CONCLUSION
Musculoskeletal ultrasound of the foot and ankle can play an important role in clinical decision making for a large group of patients. When musculoskeletal ultrasound did not change the diagnosis or management in this group of patients, it confirmed the initial clinical impression which may also be important to the clinician and the patient. In addition to being significantly lower in cost compared with MRI, ultrasound offers a more readily available test and may be better tolerated by some patients.
CLINICAL RELEVANCE/APPLICATION
Musculoskeletal ultrasound is a cost effective imaging modality which has become more readily available. Our data demonstrate ultrasound of the foot and ankle frequently impact clinical management.
Post-operative Follow-up MRI of Malignant or Locally Aggressive Tumors: Tissue 4D Perfusion and
Diffusion Weighted Images (Station #4)
In Sook Lee (Presenter): Nothing to Disclose , You Seon Song : Nothing to Disclose , Hie Bum Suh MD :
Nothing to Disclose , Se Kyoung Park : Nothing to Disclose , Jeung Il Kim MD, PhD : Nothing to Disclose ,
Jong Woon Song : Nothing to Disclose
PURPOSE
To evaluate the presence or absence of recurrent or remnant lesion during post-operative follow-up of malignant or locally aggressive tumors by using dynamic constrast enhanced (DCE, perfusion image) and diffusion weighted images (DWI).
METHOD AND MATERIALS
From January 2013 to February 2014, 24 patients (16 women, 8 men; age range, 18-84 years; mean age, 50 years) with 33 follow-up MR images performed DCE and DW images adding to conventional MR images after surgical removal of malignant or locally aggressie tumors. The day interval between first operation and follow-up date was ranged 7-439 days (mean 151 days). On conventional MR images, we evaluated the presence or absence of definite mass or nodule formation and focally fluid or hematoma formation at operation site, and edema and fascial thickening adjacent operation site. We measured apparent diffusion coefficient
(ADC) values on ADC maps calculated from DWI. On DCE images, we obtained the values of Ktrans, Kep, Ve, iAUC. And also, time-concentration curve (TCC) was automatically obtained with 7 types.
RESULTS
20 patients had malignant soft tissue tumors, two maligant bone tumors and two Langerhans cell histiocytosis.
Seven patients performed follow-up MR images of two-times and one performed three-times. Among 33 follow-up MR images, 12 cases had recurred or remnant lesions confirmed with re-operation. Only 4 cases were confirmed with no recurred or residual lesions through the re-operation and remaining 17 cases were determined with clinical and imaging follow-up more than 6 months. The factors evaluated on coventional MR images were all statistically insignificant (p < 0.05). On DCE images, the values of Ktrans and iAUC and TCC patterns were significant (p < 0.05). On DWI, the values of ADC were significant (p<0.05).
CONCLUSION
For evaluating the presence or absence of recurrence or remnant lesion at operation site after surgical removal of malignant or locally aggressive tumors, DCE and DWI were more effective than conventional MR images.
CLINICAL RELEVANCE/APPLICATION
In the cases that the determination of recurred or remnant lesion at previous operation site is difficult on follow-up MR images, these functional MR images might be helpful for avoiding unnecessary re-operation or procedures.
Non Invasive and Quantitative Evaluation of Muscle Damage has Important Clinical Application and a Crucial Role on Preclinical Research. Aim Was to Set Up and Validate an MR Based Non-invasive
Protocol for the Quantitative Assessment of Muscle Damage (Station #5)
Anna Palmisano MD (Presenter): Nothing to Disclose , Antonio Esposito MD : Nothing to Disclose ,

MKE146
MKE181
Tamara Canu RT : Nothing to Disclose , Francesco Maria Lo Russo : Nothing to Disclose , Francesco Aldo
De Cobelli MD : Nothing to Disclose , Alessandro Del Maschio MD : Nothing to Disclose
PURPOSE
Non invasive and quantitative evaluation of muscle damage has important clinical application and a crucial role on preclinical research. Aim was to set up and validate an MR based non-invasive protocol for the quantitative assessment of muscle damage/healing process in murine models of acute ischemic and non-ischemic damage.
METHOD AND MATERIALS
MR imaging was performed on a 7T magnet (Bruker): T2w-MSME sequences were acquired for the assessment of T2 relaxation time (T2-rt) and diffusion tensor images (EPI-DTI sequences) for the quantification of the fractional anisotropy (FA), in 24 C57BL/6N mice before intramuscle injection of cardiotoxin (CTX) and after 1, 3,
5, 7, 10, 15, 30 days. The same protocol was acquired 1,3,5,7,14,21 days after femoral artery ligation in 10 mice. Moreover, in these last group of mice DCE-MRI was performed and Ktrans and Ve evaluated. MRI parameters were compared to histological findings at each time point.
RESULTS
After i.m. injection of CTX: T2-rt peaked at day 3 followed by a progressive return to normal values; FA drops at day 1 with a progressive increase over normal values between day 7 and 15. A strong correlation was found between T2-rt and leukocyte infiltrates (r = 0.92 p<0.003), and between FA and the extent of tissue regeneration (% of regenerating fibres) (r = 0.88 p<0.001). In mouse model of acute ischemic damage we observed a trend similar to the previous but with a slower kinetics: T2-rt peaked between day 3 and 7 with a progressive return to basal value; FA drops between day 3 and 5 and reaches values higher than normal after day 14. DCE-MRI study showed a drop of k trans after damage, due to absent perfusion, with a progressive increase over normal value between day 7 and 14, paralleling to vascular regeneration. Ve increased at 24 hr after ischemic damage with a plateau till day 14-21, then return to normal values.
CONCLUSION
Multiparametric MRI offers an effective and complete evaluation of muscle damage/healing process.In
particular,T2-mapping e Diffusion Tensor Imaging allow an accurate quantitative monitoring of inflammatory infiltration and muscle regeneration occurring after acute muscle damage.
CLINICAL RELEVANCE/APPLICATION
Multiparametric quantitative MRI is a potentially powerful tool for the non invasive assessment of muscle damage/repair process also in clinical fiel.
Routine Knee MRI: T2 Black Lesions- Differential Considerations (Station #6)
Vibhor Wadhwa MBBS (Presenter): Nothing to Disclose , Gina Cho Sims MD : Nothing to Disclose ,
Avneesh Chhabra MD : Research Grant, Siemens AG Research Consultant, Siemens AG Research Grant,
Integra LifeSciences Holdings Corporation Research Grant, General Electric Company Consultant, ICON plc
TEACHING POINTS
1. Most lesions in the knee joint are T2 bright. 2. T2 dark lesions exhibit limited differential possibilities and their location in the knee joint and appearances are characteristic. 3. A diagnostic algorithm should be followed for arrivng at a definitive diagnosis of a T2 dark lesion.
TABLE OF CONTENTS/OUTLINE
1. Table of differential diagnosis of T2 dark lesions, such as vacuum phenomenon, blood clot or hemophilia, intraarticular body, discoid meniscus, displaced flap/bucket handle tears of meniscus, meniscal variants (oblique meniscomeniscal ligament, unilateral meniscomeniscal ligament, anterior and posterior transverse meniscomeniscal ligaments), thickened plica, displaced interference screw, particle disease from ACL graft, calcium hydroxyapatite deposition of posterior oblique ligament, gout, PVNS, lipoma arborescence and primary and secondary synovial osteochondromatosis.
2. Quiz format for the diagnosis of these lesions or lesion categories.
3. Diagnostic algorithm with summary of the salient features.
Posterior Ankle Impingement in Athletes: Pathogenesis, Imaging Features and Differential
Diagnoses (Station #7)
Daichi Hayashi MBBS, PhD (Presenter): Nothing to Disclose , Frank W. Roemer MD : Chief Medical Officer,
Boston Imaging Core Lab LLC Research Director, Boston Imaging Core Lab LLC Shareholder, Boston Imaging
Core Lab LLC , Pieter D'hooghe MD : Nothing to Disclose , Ali Guermazi MD, PhD : President, Boston
Imaging Core Lab, LLC Research Consultant, Merck KgaA Research Consultant, Sanofi-Aventis Group Research
Consultant, TissueGene, Inc
TEACHING POINTS
To review relevant anatomy of posterior ankle To describe different types of posterior ankle impingement syndromes due to traumatic and non-traumatic osseous and soft tissue pathology To describe the approach to imaging of these pathologies and illustrate their imaging features, including relevant differential diagnoses
TABLE OF CONTENTS/OUTLINE

MKE109
MKE159
MKE223
1. Introduction
2. Anatomy of posterior ankle
3. Imaging protocol for posterior ankle evaluation
4. Pathogenesis, clinical features, imaging findings and differential diagnoses
Bony lesions: fracture of posterolateral talar process; presence of os trigonum; osteophytes at the posterior margin of the tibial plafond and posteroinferior osteophytes of posterolateral talar process; loose bodies in the posterior recesses or posterior subtalar joint
Posteromedial soft tissue lesions: posterior tibiotalar ligament injury; posteromedial gutter synovitis and scar; avulsion fractures of posteromedial process of the talus at the insertion of posterior tibiotalar ligament
Posterolateral soft tissue lesions: posterior intermalleolar ligament injury; displaced distal tear of the calcaneofibular ligament
Anomalous and accessory muscles
5. Conclusion: Multimodality imaging readily identifies predisposing factors and distinct manifestations of posterior impingement syndromes
Update and Review of Dual-Energy CT Clinical Applications of the Gout (Station #8)
Xiaohu Li (Presenter): Nothing to Disclose , Bing Liu MD : Nothing to Disclose , Yu Yongqiang MD, PhD :
Nothing to Disclose
TEACHING POINTS
1. Review DECT technique and discuss clinically specific joints protocols 2.Apply various DECT imaging displays and advance post-processing techniques to detection of uric acid depositing in tophaceous gout
TABLE OF CONTENTS/OUTLINE
1.Dual energy implies at two different kV(80KV,140KV) levels simultaneously. The result is two spiral data sets acquired in a single scan providing information, which allows characterizing the imaged tissue or material.
2.Gout is characterized by the inflammatory response that results from the deposition of monosodium urate crystals in soft tissues and joints. 3.Dual source Dual-energy CT has been used to differentiate uric acid from calcium in musculoskeletal tissue, allowing gouty urate crystals to be distinguished from bone or dystrophic calcifications. 4.Dual-energy spectral CT can detect gout tophi within the peripheral joints of the patients. The quantitative measurement of the tophi concentration provides a new imaging method for quantitatively monitoring clinical outcomes of tophi.
Calcaneal Avulsion Fractures: Anatomy, Nuances, Mechanisms, and Pitfalls (Station #9)
Sarah M. Yu : Nothing to Disclose , Joseph Sekiguchi Yu MD (Presenter): Nothing to Disclose
TEACHING POINTS
1. To identify the vulnerable areas in the calcaneus that is susceptible to avulsion fractures. 2. To differentiate avulsion fractures from other fractures that affect the calcaneus. 3. To discuss imaging strategies and algorithms that facilitates diagnosis.
TABLE OF CONTENTS/OUTLINE
The calcaneus is the primary weightbearing bone in the heel. The morphology of this bone is complex and many of its surfaces serve as attachments to tendons, muscles, and ligaments. Radiographic imaging is difficult. The four articulating surfaces are oriented in different directions and the stabilizing ligaments that hold the calcenus in place occupy very specific locations. Avulsion fractures vary in size as well as in their mechanisms of injury. A proper search strategy allows recognition of these fractures and differentiation from normal variants in the foot.
Contents: 1. NORMAL OSSEOUS ANATOMY 2. NORMAL SOFT TISSUE ANATOMY 3. TYPES OF CALCANEAL
AVULSION FRACTURES 4. SITES OF VULNERABILITY a. Achilles tendon-calcaneal tuberosity b. Plantar fascia-middle calcaneal process c. Bifurcate ligament-anterior calcaneal process d. Extensor digitorum brevis-lateral cortex e. Calcaneocuboid ligament-cuboid articulating surface 5. PITFALLS a. Achilles tendon ossification b. Accessory ossicles c. Direct fractures
Run-ache: A Pictorial Review of the Most Common Injuries in Runners (Station #10)
Javier Fernandez Jara MD (Presenter): Nothing to Disclose , Arturo Alvarez-Luque : Nothing to Disclose ,
Marta Guirado Blazquez : Nothing to Disclose , Sonia Allodi De la Hoz : Nothing to Disclose ,
Daniel Taboada Bernabeu MD : Nothing to Disclose , Patricia Zuil Acosta : Nothing to Disclose , Ignacio
Acitores Suz : Nothing to Disclose
TEACHING POINTS
1. To review the most common injuries in runners. 2. To illustrate a wide spectrum of pathological situations in a case-based scenario.
TABLE OF CONTENTS/OUTLINE
1. Introduction 2. Background 3. Runners most common injuries: a. Pelvis, Hip and Thigh: - Hip adductor tendinopathy and muscle injury. - Iliac crest stress fracture - Hip stress fracture - Trochanteric Bursitis/ Great
Trochanteric pain syndrome b. Knee: - Iliotibial band syndrome - Hamstring tendinopathy and muscle injury -
Patellar tendinopathy - Infrapatellar bursitis - Patellofemoral syndrome - Tibial stress fracture - Knee sprain c.
Leg: - Gastrocnemius muscle injury - Medial tibial stress syndrome d. Ankle and foot: - Plantar fascitis - Achilles tendinopathy, bursitis and paratendinitis - Tibial posterior tendinopathy - Stress fractures - Morton neuroma -

MKE321
Ankle sprain 4. Take home messages 5. Conclusion
Imaging of Telangiectatic OS revisited: A Pattern Recognition Approach (Station #11)
Rammohan Vadapalli MD (Presenter): Nothing to Disclose , Harshavardhan KR MD : Nothing to Disclose ,
Prasad Guntuluri : Nothing to Disclose , Anuj Jain MD : Nothing to Disclose , Abhinav Sriram Sriram
Vadapalli : Nothing to Disclose , Rashmi Sudhir MBBS : Nothing to Disclose
TEACHING POINTS
Telangiectatic osteosarcoma was described by Paget in 1854 and was subsequently referred to by Gaylord as a
"malignant bone aneurysm" in 1903 . . This subtype of osteosarcoma is well recognized,representing
2.5%-12.0% of all lesions . Characteristically, telangiectatic osteosarcoma is primarily (>90%) composed of multiple aneurysmally dilated cavities that contain blood, with viable high-grade sarcomatous cells 1.To enlist the Non-Conventional Sub types of Osteo Sarcomas and discuss the characterstic features of TOS 2.To describe broadly the Imaging patterns of Telengiectatic OS on Radiography, CT and MRI and discuss the differential diagnosis
TABLE OF CONTENTS/OUTLINE
Content organization: -Radiography and CT patterns of TOS are discussed namely 1)Geographic bone destruction 2) Permeative Moth eaten Pattern 3) Expansile remodelling or aneurysmal remodelling.(ABC pattern) 4)Parallel Striation Pattern(due to Hyper trophied Veins- Venol's Sign) 5) Pathological fracture with
Advanced cortical destruction Pattern -MRI features of TOS are illustrated with Differential Diagnosis and radio
Pathological Correlation in typical and Uncommon sites. -Differentiation of TOS from ABC is discussed with
Helpful teaching points.
Scientific Posters
PH
AMA PRA Category 1 Credits ™ : .50
Sun, Nov 30 1:00 PM - 1:30 PM Location: PH Community, Learning Center
Sub-Events
PHS131 Prostate Cancer Localization in Multi-parametric MR Images Using Multimodality Image Fusion
(Station #1)
Julip Jung MS : Nothing to Disclose , Young Gi Kim BS : Nothing to Disclose , Helen Hong PhD
(Presenter): Nothing to Disclose , Sung Il Hwang MD : Nothing to Disclose
CONCLUSION
Our method can be used to improve the performance of localization, detection and staging of prostate cancer in multi-parametric MR images.
Background
Multi-parametric MR is increasingly mentioned in prostate cancer localization due to its possibility of combining anatomical information with functional information. T2wMR provides high spatial resolution and T1wMR provides good contrast for bleeding. In DWI, prostate cancer appears as high signal intensity while the ADC shows it as low signal intensity. Thus, we propose a multimodality image fusion on multiparametric MR images using signal correction, rigid and non-rigid registrations and color-coded mapping.
Evaluation
10 patients with prostate cancer were scanned using Philipse Achieva 3.0T TX MRI system. T2 Turbo Spin Echo images (TR/TE = 2500-3500/90-120 ms, flip angle = 90°, 512 x 512 matrix, slice thickness of 3 mm, 160 mm
FOV), T1 Turbo Spin Echo images (TR/TE = 500-570/9 ms, flip angle = 90°, 512 x 512 matrix, slice thickness of 3 mm, 160 mm FOV) and DWI (TR/TE = 6500/79 ms, flip angle = 90°, 256 x 256 matrix, slice thickness of 3 mm, 240 mm FOV, water excitation with b value of 1000 s/mm2) were obtained. To correct the signal intensity of bleeding within the prostate in T2wMR, the signal intensity of hemorrhage area within prostate of T2wMR is substituted for that of T1wMR. To align the prostate on DWI to T2wMR, the transformation parameters of DWI are estimated by normalized mutual information-based rigid registration. To align the prostate on ADC map to
T2wMR, the estimated transformation parameters are applied to ADC map. Then DWI and ADC map are color-coded and overlaid to T2wMR, respectively. To confirm prostate cancer localization, histopathology image is co-registered to T2wMR. For evaluation of our method, our result is visually compared with the location of prostate cancer indicated by a radiologist.
Discussion
Our signal correction can differentiate prostate cancer from hemorrhage area in T2wMR. Our multimodality image fusion can effectively localize the prostate cancer by providing complementary information and easily compare with ground-truth of histopathology image.

PHS132
PHS134
PHS135
Measurement of Noise Power Spectrum for CT Image: Importance of Low Frequency Component and
Methods to Achieve Its Accuracy (Station #2)
Mitsunori Goto MMedSc, RT (Presenter): Nothing to Disclose , Masaaki Taura BMedSc, RT : Nothing to
Disclose , Kazuhiro Sato MMedSc, RT : Nothing to Disclose , Noriyasu Homma PhD : Nothing to Disclose ,
Issei Mori : Nothing to Disclose
CONCLUSION
ROI must be reasonably large for low frequency accuracy even with proper windowing. If ROI needs to be very small, deconvolution is a choice.
Background
To evaluate noise reduction performance of iterative reconstruction (IR), noise standard deviation is not a good noise indicator and noise power spectrum (NPS) analysis is needed. For the evaluation of low-contrast detection performance, low-frequency component of NPS is crucially important because signal exists only at low frequency region. On the other hands, NPS measurement of CT image is inaccurate at low frequency due to frequency leakage problem. We show the low-frequency error of NPS quantitatively in association with the size of region of interest (ROI) and usage of windowing. We further show that the frequency leakage can be corrected by a deconvolution.
Discussion
Overestimate of low frequency NPS worsens with smaller ROI. The frequency leakage problem is dominated by the length of short side of rectangular ROI. Windowing is effective to suppress this error, but becomes almost powerless if ROI is 32x32 pixels or smaller. Among several window functions, we judged Welch type is the most preferable. When ROI is 32x32 pixels, MFSNR for 10 or 20mm object size is underestimated by a factor of more than 10% even with windowing. This error can be made virtually zero by deconvolution.
Evaluation
We generated 512 independent noise images by PC simulation. Their true NPS is theoretically known and statistically identical with that of clinical 512x512 matrix images of 320 mm FOV using Shepp-Logan kernel.
Rectangular ROIs of various sizes are set, and 2-dimensional NPS of each ROI is obtained. All 2D-NPSs are transformed to 1-D NPS by circumferential averaging. The average NPS is obtained from 512 NPSs for each ROI size. Windowing is performed by multiplying a window function to pixel values within ROI before applying to
2D-FT. A Richardson-Lucy type deconvolution is applied to 2-D NPS. Deconvolved 2-D NPS is then converted to
1-D NPS. For the deconvolution, the kernel was designed such that it approximates macroscopic frequency leakage effect. The matched filter SNR (MFSNR) was calculated for each of non-windowed, windowed, and deconvolved NPS.
Impact of Tube Current Modulation on Lesion Detectability as a Function of Patient Size (Station #4)
Justin Bennion Solomon MSc (Presenter): Nothing to Disclose , Daniel Jack Frush BS : Nothing to Disclose ,
Baiyu Chen : Nothing to Disclose , Juan Carlos Ramirez Giraldo PhD : Employee, Siemens AG , Ehsan
Samei PhD : Research Grant, Siemens AG Research Grant, General Electric Company Research Grant,
Carestream Health, Inc
PURPOSE
To assess the impact of tube current modulation (TCM) on detectability as a function of patient size using phantom measurements.
METHOD AND MATERIALS
The task-based Mercury 3.0 phantom, composed of cylindrical sections of 12, 18, 23, 30 and 37cm diameters, and connected through tapered sections, was imaged on a modern dual-source CT scanner (Flash, Siemens) using fixed tube current-time product (fixed mAs) and TCM. An abdominal protocol was used with 120 kVp and pitch = 1.0 with comparable radiation output (CTDIvol) values. Image series were reconstructed using filtered back projection at 0.6 mm. The task transfer function (TTF), the noise power spectrum (NPS), and the detectability index (d') for a 10 mm- 50 HU designer lesion were estimated as a function of phantom size. The results were compared in terms of the impact of TCM on detectability and phantom-size relationship.
RESULTS
For both TCM and fixed tube-current scans, d' decreased with increasing phantom size. However, the magnitude of detectability change was reduced with the use of TCM. For TCM scans, d' decreased on average by 75%, when comparing the largest and smallest phantom sections. For fixed mAs scans, d' decreased on average by 90%.
CONCLUSION
TCM reduces the degradation of image quality with phantom size, but it does not eliminate that dependency.
The data can be used to design and optimize CT protocols as a function of patient size.
CLINICAL RELEVANCE/APPLICATION
The use of the tube current modulation can lead to an improvement in image quality consistency across patient sizes. However, larger patients still have a lower level of image quality.
Quality Assessment of Mobile Fluoroscope Fleet for Budget and Resource Planning (Station #5)
Jaydev Kardam Dave PhD, MS (Presenter): Nothing to Disclose , Eric Laurence Gingold PhD : Nothing to
Disclose

PHS136
PHE123
Disclose
CONCLUSION
Routine performance evaluations by a medical physicist can provide valuable data for imaging equipment budgeting and resource planning, and avenues for data-driven decision making for such tasks.
Background
Fifteen mobile c-arm fluoroscopes (nine 9" x-ray image intensifiers (XRII) and six 12" XRIIs) at a tertiary healthcare center were evaluated. Five of these units (four 9' XRII and one 12' XRII) were to be identified for replacement. An ojective criteria was developed to guide the selection of the units to be replaced. Improvement in the variation within the fleet was assessed after replacement with five new XRII units.
Quantifying Tumor Neovascularity with Immunohistochemical Markers Compared to Subharmonic
US Imaging (Station #6)
Aditi Gupta : Nothing to Disclose , Kelly Dulin : Nothing to Disclose , Samantha Jaffe : Nothing to Disclose
, Mark Forsberg : Nothing to Disclose , Jaydev Kardam Dave PhD, MS : Nothing to Disclose , Flemming
Forsberg PhD (Presenter): Equipment support, Toshiba Corporation Research collaboration, General Electric
Company Research collaboration, Analogic Corporation Research collaboration, Toshiba Corporation Speakers
Bureau, Toshiba Corporation , Manasi Dahibawkar BSc : Nothing to Disclose , Valgerdur Halldorsdottir MSc
: Nothing to Disclose , Anya Isabelle Forsberg : Nothing to Disclose , Andrew Marshall : Nothing to Disclose
, Priscilla Machado MD : Grant, Toshiba Corporation Equipment support, Toshiba Corporation , Traci B. Fox
MS, RT : Nothing to Disclose , Ji-Bin Liu MD : Research Grant, GluMetrics, Inc
PURPOSE
To compare different methods for quantifying tumor neovascularity based on immunohistochemical markers of angiogenesis to contrast-enhanced subharmonic ultrasound imaging (SHI).
METHOD AND MATERIALS
Twenty-eight (28) athymic, nude, female rats were implanted with 5 x 106 breast cancer cells (MDA-MB-231) in the mammary fat pad. The ultrasound contrast agent Definity (Lantheus Medical Imaging, N Billerica, MA) was injected in a tail vein (dose: 36 μl) and pulse-inversion SHI was performed in triplicate using a modified Sonix
RP scanner (Analogic Ultrasound, Richmond, BC, Canada) with a L9-4 linear array (transmitting and receiving frequencies of 8 and 4 MHz, respectively). Specimens were extracted and sliced corresponding to the imaging planes and stained for endothelial cells (CD31), vascular endothelial growth factor (VEGF), and cyclooxygenase-2 (COX-2). Tumor neovascularity was quantified in 3 different ways 1) over the entire tumor 2) in small sub-regions of interest (ROIs) and 3) in the tumor periphery (within 2 mm of the margin) and centrally.
Results from specimens and SHI were compared using a linear regression analysis.
RESULTS
Of the 28 rats implanted 23 (82 %) exhibited tumor growth and were successfully studied. SHI depicted the tortuous morphology of tumor neovessels and delineated small areas of necrosis. The angiogenic expression in the tumor periphery was consistently higher than in the center for all 3 immunohistochemical markers (p <
0.014). SHI measures of tumor vascularity did not correlate with the immunohistochemical markers when assessed over the entire tumor area or over sub-ROIs (p > 0.3). However, when the specimens were divided into a central and a peripheral region VEGF was found to correlate with SHI in both areas (r = 0.45 and r =
0.56; p < 0.04). The strongest correlation in this model was between SHI and COX-2 in the periphery of the tumors (r = -0.61; p = 0.004).
CONCLUSION
When comparing quantitative measures of tumor neovascularity derived from immunohistochemical markers to
SHI from xenograft models, sub-ROIs corresponding to the biologically active region (i.e., the tumor periphery) appear to account for tumor heterogeneity.
CLINICAL RELEVANCE/APPLICATION
In the future SHI may be used to monitor response for patients treated with anti-COX-2 therapies.
Virtual Monochromatic Imaging Using Dual Energy CT—Principles and Clinical Applications (Station
#7)
Abed Ghandour MD : Nothing to Disclose , Rong Rong MD : Institutional Grant support, Koninklijke Philips
NV , Prabhakar Rajiah MD, FRCR (Presenter): Institutional Research Grant, Koninklijke Philips NV
TEACHING POINTS
1. With dual energy CT, virtual monochromatic images of any energy can be generated from low and high energy data 2. Generation of virtual monochromatic images can be performed either in the projection or image domains (projection domain- rapid kv switching, dual layers; image domain- dual source) 3. There are several clinical applications of virtual monochromatic imaging- including artifact reduction and optimizing contrast 4.
Equivalent monochromatic images- with same mean energy and radiation of polychromatic image, has higher image quality and lower artifacts
TABLE OF CONTENTS/OUTLINE

- Virtual monochromatic imaging- Definition, physics
- Generation of virtual monochromatic images from different technologies, including dual layer
- Projection vs. image based methods- Technique, advantages, disadvantages
- Phantom studies illustrating the concept of virtual monochromatic images
- Clinical applications with illustrative cases
- Monochromatic low keV images- For boosting contrast in vascular structures- with suboptimal bolus/decreased contrast dose
- Monochromatic high keV imaging- For reducing artifacts- Beam hardening, metal artifact, calcium blooming
- Virtual non contrast using material decomposition- Radiation dose saving
- Virtual calcium score
- Material differentiation
PHE005-b Modular Near Real-time Quality Control Analysis for Neuroimaging Data (hardcopy backboard)
Gregory A. Book MS (Presenter): Nothing to Disclose , Michael Stevens : Nothing to Disclose , Michal
Assaf : Nothing to Disclose , Godfrey Pearlson : Nothing to Disclose
Background
Functional MRI and other neuroimaging modalities are susceptible to normal MR artifacts including RF spikes and coil failures, however the most common artifacts are from motion. Real-time motion detection is necessary to allow the scanner operator a chance to repeat a series if motion exceeds a certain limit, and this capability is not available on all MRI scanners. We seek to solve these problems by creating an automated near real-time system to identify and flag potential quality control issues in neuroimaging data. We additionally introduce an algorithm to quantify motion in 3D structural images.
Evaluation
The QC system was built upon the existing Neuroinformatics Database (NiDB) system, and is modular because new QC protocols can be included. Upon receipt of a complete series, the system runs multiple QC checks in parallel by submitting the jobs to a compute cluster, with the results then stored and displayed on a webpage for each imaging study. QC checks include timeseries motion estimation of functional MRI, SNR calculation of timeseries and 3D volumes, and motion detection in 3D structural volumes. fMRI motion estimation and SNR are calculated using FSL. The 3D volume motion detection algorithm calculates the radial average of the FFT of each slice of an image, then takes the average of the linear regression of the resulting power spectra plots, where a more negative R2 value indicates less high frequency signal and therefore more motion.
Discussion
The NiDB instance in which the QC system was tested stores 43,855 fMRI series and 18,371 3D structural volumes, including the QC results for the respective series. QC results are available 5-10 minutes after the completion of a series. Timeseries motion estimation allowed scan repeats, SNR values indicated coil failures, and R2 value from 3D volumes was consistent with operator identified motion.
CONCLUSION
Having near real-time QC metrics available allows the MR operator to repeat a scan while the patient is still in the scanner if artifacts are found. Motion detection in 3D images is most useful when collecting multiple structural images within the same scanning session to identify which images should be excluded from further analysis.
Refresher/Informatics
US MR CT GU US MR CT GU
AMA PRA Category 1 Credits ™ : 1.50
ARRT Category A+ Credits: 1.50
Sun, Nov 30 2:00 PM - 3:30 PM Location: N228
Participants
Moderator
Julia R. Fielding MD : Nothing to Disclose
Maitray D. Patel MD (Presenter): Nothing to Disclose
Reena Chetna Jha MD (Presenter): Consultant, CeloNova BioSciences, Inc
LEARNING OBJECTIVES
1) Describe current best practice recommendations for management of adnexal asymptomatic, incidental, and/or potentially physiologic findings on pelvic US, CT, and MR based on lesion characteristics and patient clinical factors. 2) Understand the reference lines and angles in pelvic MRI that are used in the evaluation of pelvic floor disorders. 3) Understand the typical imaging characteristics of the endometrium and myometrium according to patient age and stage of the reproductive cycle, and review associated benign pathology.

Refresher/Informatics
US GI
AMA PRA Category 1 Credits ™ : 1.50
ARRT Category A+ Credits: 1.50
Sun, Nov 30 2:00 PM - 3:30 PM Location: E451A
Sub-Events
RC110A Contrast Ultrasound of the Liver and Gallbladder
Hans-Peter Weskott MD (Presenter): Luminary, General Electric Company Speaker, Bracco Group
LEARNING OBJECTIVES
1) Understanding the indications of contrast enhanced ultrasound (CEUS) in focal liver and gallbladder diseases.
2) Learning about the importance of the three contrast phases and how CEUS performes in detecting and characterizing focal liver lesions and to characterize inflammatory and tumorous changes of the gallbladder wall.
3) Learning about the potential value as well as the limitations of CEUS in liver an gallbladder diseases. 4)
Learning how CEUS performs when compared to B-mode and Color Doppler ultrasound, CT and MRI imaging.
ABSTRACT
Liver: In patients with favorable scanning conditions CEUS is at least as sensitive as contrast enhanced CT
(CECT) in detecting malignant liver lesions. Due to its high temporal resolution even a short hyperenhancement of a few seconds can reliably be detected this improving the characterization of focal liver lesions (FLL). A majority of FLL can therefore be characterized as iso- or hyperenhancing. During the arterial phase the tumor vessel supply and the tumor`s vessel architecture and direction of contrast filling is important in characterizing
FLL. Due to a high spatial resolution novel contrast imaging techniques allow detection of washed out lesions down to 3mm in size. CEUS characterizes FLL with a much higher confidence than conventional US techniques and is comparable to CECT and CEMRI. CEUS also improves intraoperative tumor detection and characterization. Using time intensity analysis a change in contrast enhancement over time helps in estimating tumor response to chemotherapy. CEUS is also used to monitor local ablation therapy and is useful to early detect local tumor recurrence. Gallbladder: CEUS can be used to better visualize ulceration, perforation and tumors of its wall. It thus helps to improve the patient`s clinical management including timing for surgery.
CEUS does not affect renal or thyroid function and is therefore helpful in older patients and should be the first line contrast imaging technique in patients with impaired renal function.
RC110B Liver Elastography
Paul Singh Sidhu MRCP, FRCR (Presenter): Speaker, Bracco Group Speaker, Siemens AG Speaker, Hitachi, Ltd
LEARNING OBJECTIVES
1) Understand the concept of measuring liver stiffness with elastography, methods of elastography in clinical use. 2) Understand the need for the clinical application of liver stiffness measurements in disease management.
3) Review the different techniques available and review evidence of their accuracy. 4) Consolidate knowledge on application, accuracy and position in clinical practice of liver elastography.
ABSTRACT
Chronic liver disease is a major health problem, representing the end stage of a number of pathological processes arisng from a variety of causative factors. Alcohol misuse remains an important cause but the increasing prevalence of viral hepatitis (Hepatitis B and C) worldwide represents a healthcare issue. Early stages of chronic liver disease, fibrosis prior to the development of cirrhosis, is important to establish as this influences medical mamgement, aimed at halting or slowing the progression to irreversable cirrhosis. Non-invasive markers are often used to predict the presence of liver fibrosis, but ultimately a liver biopsy is needed to stage the degree of fibrosis (usually the METAVIR or ISHAK scores). A liver biopsy is associated with morbidity and mortality, and samples a small volume of the liver, in a disease process that is often patchy. The need for an accurate non-invasive imaging method of assessing the degree of liver fibrosis, in essence the
#39;stiffness#39; of the liver, has encouraged the use of elastography to grade liver stiffness by either
#39;compression#39; assessment or using shear wave technology. The principles of the different types of elastography will be discussed, the application in assessing chronic liver disease, the evidence for accuracy and the future in clinical practice will be discussed.Chronic liver disease is a major health problem, representing the end stage of a number of pathological processes arising from a variety of causative factors. Alcohol misuse remains an important cause but the increasing prevalence of viral hepatitis (Hepatitis B and C) worldwide represents a healthcare issue. Early stages of chronic liver disease, fibrosis prior to the development of cirrhosis, is important to establish as this influences medical management, aimed at halting or slowing the progression to irreversible cirrhosis. Non-invasive markers are often used to predict the presence of liver fibrosis, but ultimately a liver biopsy is need
RC110C Gallbladder and Biliary Disease
Anthony Edward Hanbidge MBBCh (Presenter): Nothing to Disclose
LEARNING OBJECTIVES

1) Discuss the value of ultrasound when assessing the gallbladder and bile ducts. 2) Identify the imaging features of acute conditions of these structures and complications. 3) Recognize common pitfalls to avoid misinterpretation. 4) Briefly describe other conditions of the gallbladder and bile ducts including sclerosing cholangitis, cholangiocarcinoma, IgG4 associated cholangitis, adenomyomatosis, gallbladder polyps and gallbladder cancer.
ABSTRACT
Acute cholecystitis is the most common cause of acute pain in the right upper quadrant (RUQ), and urgent surgical removal of the gallbladder is the treatment of choice for uncomplicated disease. However, cross-sectional imaging is essential because more than one-third of patients with acute RUQ pain do not have acute cholecystitis. In addition, patients with complications of acute cholecystitis, such as perforation, are often best treated with supportive measures initially and elective cholecystectomy at a later date. Ultrasound (US) is the primary imaging modality for assessment of the gallbladder and bile ducts; US is both sensitive and specific in demonstrating gallstones, biliary dilatation, and features that suggest acute inflammatory disease. It is sensitive at detecting abnormalities of the wall of the gallbladder and bile ducts. Often, additional imaging modalities are indicated. Computed tomography (CT) is valuable, especially for confirming the extent and nature of the complications of acute cholecystitis. Magnetic resonance (MR) cholangiopancreatography is helpful in complicated ductal disease (eg, recurrent pyogenic cholangiohepatitis) when more detailed diagnostic information is required for treatment planning, whereas endoscopic retrograde cholangiopancreatography is used when biliary intervention is required (eg, treatment of choledocholithiasis). Both CT and MR are accurate when staging malignancies of the gallbladder and bile ducts. Successful imaging with all modalities requires familiarity with both the characteristic and the unusual features of a wide variety of pathologic conditions. In addition, potential pitfalls must be recognized and avoided.
Refresher/Informatics
US OI MR MI
AMA PRA Category 1 Credits ™ : 1.50
ARRT Category A+ Credits: 1.50
Sun, Nov 30 2:00 PM - 3:30 PM Location: S504CD
Participants
Moderator
Fabian Kiessling MD : Advisor, invivoContrast GmbH Co-owner, invivoContrast GmbH Advisor, Molecular Targeting
Technologies, Inc Researcher, Bayer AG Researcher, Bracco Group Researcher, Merck KgaA Researcher, AstraZeneca PLC
Researcher, Koninklijke Philips NV Researcher, FUJIFILM Holdings Corporation
LEARNING OBJECTIVES
1) Attendees will learn the principles and applications of molecular imaging using ultrasound and photoacoustic imaging techniques. 2) Principles and applications of ultrasound molecular imaging will be reviewed. 3) Principles and applications of molecular imaging using photoacoustic imaging techniques will be presented. 4) Ultrasound guided drug delivery approaches will be reviewed. 5) At the end of this course, the attendees will understand the principles and potential clinical applications of ultrasound and optoacoustic molecular imaging as well as of ultrasound guided drug delivery.
Sub-Events
RC117A Photoacoustic Imaging
Stanislav Emelianov PhD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Understand the fundamental principles of photoacoustic imaging and major components of photoacoustic imaging system. 2) Knowing how photoacoustic images are formed and how to interpret photoacoustic images.
3) Understand how imaging contrast agents or imaging probes affect contrast, penetration depth and specificity in photoacoustic imaging. 4) Understand the ability of photoacoustic imaging system to visualize anatomical, functional and molecular properties of imaged tissue. 5) Identify the role of photoacoustic imaging in pre-clinical and clinical applications.
ABSTRACT
Photoacoustic imaging or tomography - a non-ionizing, non-invasive, real-time imaging technique capable of visualizing optical absorption properties of tissue at reasonable depth and high spatial resolution, is a rapidly emerging biomedical and clinical imaging modality. Photoacoustic imaging is regarded for its ability to provide in-vivo morphological and functional information about the tissue. With the recent advent of targeted contrast agents, photoacoustics is capable of in-vivo molecular imaging, thus facilitating further molecular and cellular characterization of tissue. This presentation is designed to provide both a broad overview and a comprehensive understanding of photoacoustic imaging. With a brief historical introduction, we will examine the foundations of photoacoustics, including relevant governing equations, optical/acoustic properties of the tissues, laser-tissue interaction, system hardware and signal/image processing algorithms. Specifically, penetration depth and spatial/temporal resolution of photoacoustic imaging will be anlyzed. Integration of photoacoustic and ultrasound imaging systems will be discussed. Techniques to increase contrast and to differentiate various tissues in photoacoustic imaging will be presented. Furthermore, design, synthesis and optimization of imaging probes (typically, nanoconstructs or dyes) to enable molecular/cellular photoacoustic imaging will be presented.
Special emphasis will be placed on contrast agents capable of multiplexed imaging, multi-modal imaging and

RC117B
RC117C
RC117D image-guided therapy including drug delivery and release. The presentation will continue with an overview of several commercially available and clinically-relevant systems capable of photoacoustic imaging. Regulatory aspects of photoacoustic imaging systems and imaging contrast agents will be presented. Finally, current and potential biomedical and clinical applications of photoacoustics will be discussed.
Ultrasound Molecular Imaging
Juergen Karl Willmann MD (Presenter): Research Consultant, Bracco Group Research Grant, Siemens AG
Research Grant, Bracco Group
LEARNING OBJECTIVES
1) To understand the acquisition and quantification principles of ultrasound molecular imaging. 2) To understand the characteristics and biodistribution of molecularly targeted ultrasound contrast agents. 3) To understand the role of ultrasound molecular imaging in preclinical and clinical applications.
ABSTRACT
Ultrasound imaging is a widely available, relatively inexpensive, and real-time imaging modality that does not expose patients to radiation and which is the first-line imaging modality for assessment of many organs.
Through the introduction of ultrasound contrast agents, the sensitivity and specificity of ultrasound for detection and characterization of focal lesions has been substantially improved. Recently, targeted contrast-enhanced ultrasound imaging (ultrasound molecular imaging) has gained great momentum in preclinical research by the introduction of ultrasound contrast agents that are targeted at molecular markers over-expressed on the vasculature of certain diseases. By combining the advantages of ultrasound with the ability to image molecular signatures of diseases, ultrasound molecular imaging has great potential as a highly sensitive and quantitative method that could be used for various clinical applications, including screening for early stage disease (such as cancer); characterization of focal lesions; quantitative monitoring of disease processes at the molecular level; assisting in image-guided procedures; and, confirming target expression for treatment planning and monitoring.
In this refresher course the concepts of ultrasound molecular imaging are reviewed along with a discussion on current applications in preclinical and clinical research.
Sonographically-guided Drug Therapy
Alexander L. Klibanov PhD (Presenter): Research Grant, Koninklijke Philips NV Co-founder, Targeson, Inc
Stockholder, Targeson, Inc Institutional research collaboration, AstraZeneca PLC
LEARNING OBJECTIVES
1) To identify the basic principles of ultrasound energy deposition as applied to molecular imaging and image-guided therapeutic interventions. 2) To combine the general physical principles of ultrasound-microbubble interaction, drug-carrier systems pharmacokinetics and ultrasound contrast imaging, apply this knowledge for the development of triggered delivery approaches in the setting of personalized medicine. 3) To understand advantages and disadvantages of ultrasound application in the potential image-guided intervention designs. 4) To identify and compare potential clinical applications of ultrasound-guided drug delivery.
ABSTRACT
The reason of ultrasound use in drug delivery is to enhance drug action specifically in the area of disease. The design of such therapeutic intervention should assure that drug deposition or action enhancement take place only in the disease site, with the general goal to improve the therapeutic index. There are several approaches to ultrasound-assisted drug delivery. The first approach, closest to clinical practice, takes advantage of existing ultrasound contrast agents (intravenous gas microbubbles approved in US for cardiac imaging). When these bubbles are co-injected intravenously with the drugs, and ultrasound energy applied to the areas of disease, localized energy deposition leads to endothelium activation or transient "softening" of blood brain barrier (BBB).
Drugs (including antibodies or liposomes) can thus transit BBB and achieve therapeutic action. Ultrasound imaging can be used for targeted focusing of ultrasound energy in the areas of disease. Second approach suggests attaching microbubbles to the drug or a drug carrier (including nucleic acid drugs). Microbubbles can be complexed with drug or gene carrier nanoparticles, so that local action of ultrasound would result in triggered drug release/deposit or transfection in the ultrasound-treated area. Third approach involves targeted microbubble design, as in ultrasound molecular imaging. Combination of targeted microbubbles with drug carrier makes possible unfocused ultrasound use, to act only in the areas of the target receptor expression, where microbubbles adhere and ultrasound energy is then deposited. Lately, formulation moved from microbubbles to smaller nanodroplet drug carriers, to reach interstitium, where drug release could take place upon ultrasound treatment. Overall, combination of ultrasound imaging, including contrast (molecular) imaging, focused ultrasound, and drug carrier systems will lead to novel image-guided therapies, especially applicable in the era of personalized medicine.
Magnetic Resonance Molecular Imaging
Moritz Florian Kircher MD, PhD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
View learning objectives under main course title.
ABSTRACT
The field of molecular MRI has exploded in the last decade, with hundreds of different concepts and probe designs developed and tested in vitro and in vivo. This talk will attempt at giving a structured overview over this vast arsenal of potentially useful approaches by focusing on those that have the highest potential for clinical translation. The approaches will be grouped into 6 major categories and their principles explained and illustrated with key examples: 1) Multimodal nanoparticles; 2) Activatable MRI probes; 3) Targeted superparamagnetic iron oxide nanoparticles; 4) non-targeted superparamagnetic iron oxide nanoparticles; 5)

MRI-based Radiogenomics; and 6) Hyperpolarized magnetic resonance spectroscopic imaging.
Refresher/Informatics
BQ US PH
AMA PRA Category 1 Credits ™ : 1.50
ARRT Category A+ Credits: 1.50
Sun, Nov 30 2:00 PM - 3:30 PM Location: E353A
Sub-Events
RC125A Elasticity and Backscatter Related Measures
Timothy J. Hall PhD (Presenter): Equipment support, Siemens AG Advisory Board, Siemens AG
LEARNING OBJECTIVES
1) Describe the various approaches and history of Quantitative Ultrasound. 2) Understand the difference in system-dependent and system-independent backscatter parameters. 3) Understand the benefits of system-independent backscatter parameters. 4) Describe the state of the art in elasticity imaging and quantitative ultrasound from backscattered echoes.
ABSTRACT
There is a long history of attempts to use the backscattered echo signals from medical ultrasound to describe disease conditions of various tissue types. For example, from the initial application of ultrasound in breasts, the investigators attempted to differentiate benign from malignant disease based on characteristics of the echo signals. Along the way, there have been substantial successes. For example, it was only 30yrs ago that we debated how to estimate blood flow based on ultrasound echo signals and how to interpret that data. Just over
20yrs ago we began to display flow dynamics with color flow imaging. More recently, elasticity imaging methods, which also began in the "tissue characterization" or "quantitative ultrasound" community, have become commercially viable products with clear diagnostic potential. These were "tissue characterization" methods in their early days. Now they are recognized as specific procedures with quantifiable diagnostic merit.
Numerous other "quantitative ultrasound" (QUS) methods have been proposed, developed, tested and have demonstrated varying degrees of success. Many of these methods are still under development. This presentation will discuss "quantitative ultrasound" methods based on backscattered echo signals focusing on the most recent techniques that are either commercially available or that show the greatest potential as diagnostic tools.
RC125B Volume Flow and Measures From Contrast Agents
Oliver D. Kripfgans (Presenter): Research support, General Electric Company Equipment support, General
Electric Company
LEARNING OBJECTIVES
1) Understand the pitfalls of ultrasound based blood flow acquisition, analysis, and interpretation. 2) Become familiar with current approaches of quantitative estimation of blood flow and learn how to minimize associated errors. Understand how volumetric blood flow estimation can become a biomarker. 3) Obtain an overview of current commercial ultrasound contrast agents as well as their availability in the US. 4) Learn about contrast agent enhanced measurements in a clinical setting and potential use of ultrasound contrast as a therapy agent.
ABSTRACT
Clinical ultrasound scanners typically offer three methods of blood flow acquisition, namely pulse wave, color flow and power Doppler. While real-time blood flow visualization is one of the perks of ultrasound, standardized quantitative methods are still unavailable to the radiologist. Pulse wave offers volumetric flow computation based on assumptions that are often violated. Color flow has never been directly quantitative as no angle correction can be dialed-in. The advent of 2D ultrasound arrays (electronic or mechanically swept) has enabled color flow and power Doppler acquisition in the coronal plane thus yielding Doppler angle as well as geometry independent flow information for direct quantification of in situ real-time volumetric flow. The RSNA's QIBA
(Quantitative Imaging Biomarker Alliance) effort is targeting quantitative blood volume flow as a possible future biomarker. Ultrasound contrast agents have been approved for many clinical applications in Europe, Asia and
Canada. The FDA has limited the use of ultrasound contrast agents in the US and essentially only cleared ultrasound contrast agents for cardiac applications. However, off-label application is practiced in the US. Its extend and benefits will be discussed in this course along with current approaches for ultrasound contrast agents based clinical measurements. Also included will be the use of contrast agents in enabling and quantifying therapeutic interventions.
URL's www.ultrasound.med.umich.edu/ODK/RSNA2012
RC125C Ultrasound Measurements and FDA Criteria for Display of New Quantitative Measures

Brian Stephen Garra MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Review the main types of quantification of Ultrasound images. 2) Review some recent examples exploring sources of error in ultrasound morphometric quantification. 3) Summarize new ultrasound based parameters that might be displayed. 4) Discuss the formation of the Ultrasound QIBA Technical Committee and its objectives. 5) Review recent changes in FDA policy regarding display of quantitative features on ultrasound images.
ABSTRACT
Ultrasound images are probably the most frequently measured images and extensive literature on a wide variety of ultrasound image measurements exists going back to the 1960's. Most morphometric and Doppler measurements are well documented and are at a mature stage. Automated measurements of volume and structures such as arterial intimal medial thickness are also finding increasing clinical application but each method of image segmentation and quantification has its own characteristic problems and sources of error.
Some newer measurements including measurement of tissue strain (elastography) and strain rate and one of the newest, shear wave speed, are the subject of considerable research activity and the sources of error and bias are just now being identified and quantified. The RSNA Quantitative Imaging Biomarker Alliance (QIBA) has recently undertaken the task of developing standardized protocols for measurement of ultrasound related parameters. The first project of the US QIBA technical committee is to develop a profile for measurement of shear wave speed in tissue using ultrasound. The FDA has long allowed many types of measurements to be displayed as part of the ultrasound image. A demonstration of reasonable accuracy and precision important for obtaining clearance to display a new measurement. Display of measurement accuracy may also be required and users should be informed of situations where the measurement may be inaccurate. The efforts of the QIBA may provide data that in the future will help to speed up FDA clearance for display of new types of measurements.
Refresher/Informatics
US IR US IR
AMA PRA Category 1 Credits ™ : 1.50
ARRT Category A+ Credits: 1.50
Sun, Nov 30 2:00 PM - 3:30 PM Location: E264
Participants
Stephen Clifford O'Connor MD (Presenter): Nothing to Disclose
William Eugene Shiels DO (Presenter): President, Mauka Medical Corporation Royalties, Mauka Medical Corporation Patent holder, Mauka Medical Corporation
Alda Felicita Cossi MD (Presenter): Nothing to Disclose
Michael V. Krasnokutsky MD (Presenter): Nothing to Disclose
Mark LeRoy Lukens MD (Presenter): Nothing to Disclose
Kenneth S. Lee MD (Presenter): Research Consultant, SuperSonic Imagine Speakers Bureau, Medical Technology Management
Institute
Manish Natvarlal Patel DO (Presenter): Nothing to Disclose
Hollins P. Clark MD, MS (Presenter): Nothing to Disclose
Mark Joseph Hogan MD (Presenter): Nothing to Disclose
Carmen Gallego MD (Presenter): Nothing to Disclose
Mabel Garcia-Hidalgo Alonso MD (Presenter): Nothing to Disclose
John David Lane MD (Presenter): Nothing to Disclose
Andrew Jered Rabe DO (Presenter): Nothing to Disclose
Humberto Gerardo Rosas MD (Presenter): Nothing to Disclose
Kristin Marie Dittmar MD (Presenter): Nothing to Disclose
Nicholas Andrew Zumberge MD (Presenter): Stockholder, Covidien AG Stockholder, Abbott Laboratories Stockholder, Abbvie
Inc Stockholder, Mallinckrodt plc Stockholder, Dexcom, Inc Stockholder, Merck & Co, Inc Stockholder, Gilead Sciences, Inc
Stockholder, Exact Sciences Corporation Stockholder, Cerner Corporation
LEARNING OBJECTIVES
1) Identify basic skills, techniques, and pitfalls of freehand invasive sonography. 2) Discuss and perform basic skills involved in thermal tumor ablation in a live learning model. 3) Perform specific US-guided procedures to include core biopsy, abscess drainage, vascular access, cyst aspiration, soft tissue foreign body removal, and radiofrequency tumor ablation. 4) Incorporate these component skill sets into further life-long learning for expansion of competency and preparation for more advanced interventional sonographic learning opportunities.
Special Courses
US MR MK
AMA PRA Category 1 Credits ™ : 1.00
ARRT Category A+ Credit: 1.00
Mon, Dec 1 7:15 AM - 8:15 AM Location: E351
Participants
Moderator
Laura W. Bancroft MD : Royalties, Wolters Kluwer nv
Jon A. Jacobson MD (Presenter): Consultant, BioClinica, Inc Royalties, Reed Elsevier Equipment support, Terumo Corporation

Jon A. Jacobson MD (Presenter): Consultant, BioClinica, Inc Royalties, Reed Elsevier Equipment support, Terumo Corporation
Equipment support, Arthrex, Inc
Theodore T. Miller MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Describe the indications for shoulder US. 2) Desribe the advantages and disadvantages of US for evaluating the shoulder. 3)
Describe the indications for shoulder MRI. 4) Describe the advantages and disadvantages of MRI for evaluating the shoulder.
Refresher/Informatics
US OB GU
AMA PRA Category 1 Credits ™ : 1.50
ARRT Category A+ Credits: 1.50
Mon, Dec 1 8:30 AM - 10:00 AM Location: E450B
Sub-Events
RC210A Diagnosis of Early Nonviable Pregnancy
Peter Michael Doubilet MD, PhD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Know the sonographic criteria for definite miscarriage and probable miscarriage in the early first trimester.
2) Understand that any saclike intrauterine structure (rounded edges, no yolk sac or embryo) in a woman with a positive pregnancy test is highly likely to be a gestational sac. 3) Understand that nonvisualization of an intrauterine gestational sac in a woman with hCG above the "discriminatory" level (2000 mIU/ml) does not exclude the possibility of a viable pregnancy.
ABSTRACT
I. Sonographic Criteria for Diagnosing Pregnancy Failure (Miscarriage) in an Intrauterine Pregnancy of Uncertain
Viability [Note: an intrauterine fluid collection with rounded edges in a woman with positive hCG is almost certainly a gestational sac; it is definitely a gestational sac if it contains a yolk sac or embryo.] 1. Criteria for definite miscarriage (i) CRL =2 weeks after a scan that showed a gestational sac without yolk sac; (iv) Absence of embryo with heartbeat >=11 days after a scan that showed a gestational sac with yolk sac 2. Criteria suspicious for miscarriage (i) CRL =6 weeks after LMP; (vi) Empty amnion (amnion seen adjacent to yolk sac, with no visible embryo); (vii) Enlarged yolk sac (>7 mm); (viii) Small gestational sac size in relation to the embryo : II. Guidelines Related to the Possibility of a Viable Intrauterine Pregnancy in a Pregnancy of Unknown
Location (positive pregnancy test and no intrauterine or ectopic pregnancy seen on ultrasound) 1. A single hCG, regardless of its level, does not reliably distinguish between ectopic and intrauterine pregnancy (viable or nonviable) 2. If a single hCG is =3000 mIU/ml, a viable intrauterine pregnancy is possible but unlikely.
However, the most likely diagnosis is nonviable IUP, so it is generally appropriate to get at least one followup hCG before treating for ectopic pregnancy.
Active Handout http://media.rsna.org/media/abstract/2014/13010306/RC210A sec.pdf
RC210B Diagnosis and Treatment of Ectopic Pregnancy
Hope Elizabeth Peters MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Recognize the spectrum of findings at transvaginal ultrasound in ectopic pregnancy. 2) Report TVUS findings in suspected ectopic pregnancy when a non-specific intrauterine fluid collection is present. 3) Differentiate usual vs. "unusual" ectopic pregnancies and understand their different treatment algorithms. 4) Understand the limitations of ultrasound related to maternal and technical factors. 5) Assist clinicians with appropriate follow up/management recommendations in excluding and diagnosing ectopic pregnancy.
ABSTRACT
Transvaginal ultrasound is the primary imaging modality to evaluate suspected ectopic pregnancy, performed in patients with a positive pregnancy test and pain or bleeding. The diagnosis is most commonly made when ultrasound demonstrates no intrauterine gestational sac and an extraovarian adnexal mass is found. Ectopic pregnancies occur in the ampulla of the fallopian tube >90% of the time and therapy is well established including systemic methotrexate and/or salpingectomy. When attempting to exclude or diagnose ectopic pregnancy, TVUS may demonstrate a non-specific intrauterine fluid collection. The term "pseudogestational sac" should not be used to describe an intrauterine fluid collection as this term can be confusing and improperly imply ectopic pregnancy prompting premature treatment. Rather, any intrauterine fluid collection should be regarded as a potential intrauterine pregnancy and reported as such. Ectopic pregnancies may also occur in
"unusual" locations such as: the cervix, a cesarean section scar, the interstitial portion of the fallopian tube, within the ovary or concomitant with an intrauterine pregnancy. These "unusual" ectopic pregnancies are a unique subset of ectopic pregnancies requiring prompt diagnosis and alternative treatment options. Ultrasound does carry with it some limitations in the diagnosis of ectopic pregnancy related to both maternal and technical factors. Prompt diagnosis of all types of ectopic pregnancy and recognizing potential early intrauterine pregnancies will allow for appropriate follow up, optimal treatment and improve outcomes for these patients.

RC210C Fetal Anatomy in the First Trimester
Phyllis Glanc MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Improve knowledge of first trimester anatomic development. 2) Compare indications for transabdominal versus transvaginal imaging in first trimester. 3) Recognize anomalies which typically present in first trimester.
4) Demonstrate understanding of the implications and management of common first trimester anomalies.
ABSTRACT
As sonographic technology has improved, diagnosticians have gained the ability to visualize more fetal structures during the first trimester than used to be possible with older equipment. Because of this, it is important that practitioners who perform and interpret first trimester ultrasound understand how the fetus develops and recognize the sonographic appearance of fetal structures as they become apparent at different gestational ages during the first trimester. Some fetal structures are only visible in the first trimester fetus, but are no longer apparent after that. These include the nuchal translucency and physiologic bowel herniation. The nuchal translucency is a hypoechoic band behind the fetal neck, that, when thickened, is associated with increased risk of aneuploidy and cardiac anomalies. Physiologic bowel herniation is a normal protrusion of bowel into the base of the umbilical cord that can usually be distinguished from abnormal herniations through the ventral wall, such as omphalocele and gastroschisis. The fetal cranium and brain can be evaluated during the latter half of the first trimester, and anomalies such as anencephaly and holoprosencephaly can often be diagnosed. Likewise, other anomalies of the fetus can sometimes be diagnosed during the first trimester, including amniotic band syndrome, posterior urethral valves, and cardiac anomalies. Recognition of these anomalies in the first trimester will assist in early detection of fetal abnormalities, allowing for earlier and improved counseling for patients.
Active Handout http://media.rsna.org/media/abstract/2014/13010308/RC210C sec.pdf
Refresher/Informatics
PH US MR
AMA PRA Category 1 Credits ™ : 1.50
ARRT Category A+ Credits: 1.50
Mon, Dec 1 8:30 AM - 10:00 AM Location: S504CD
Participants
Moderator
Juergen Karl Willmann MD : Research Consultant, Bracco Group Research Grant, Siemens AG Research Grant, Bracco Group
LEARNING OBJECTIVES
1) To understand the principle technical aspects of ultrasound and MR elastography. 2) To learn clinical applications of elastography. 3)To learn the advantages and disadvantages of ultrasound and MR elastography for assessing tissue stiffness in various organs.
Sub-Events
RC217A US Elastography of the Liver
Richard Gary Barr MD, PhD (Presenter): Consultant, Siemens AG Consultant, Koninklijke Philips NV Research
Grant, Siemens AG Research Grant, SuperSonic Imagine Speakers Bureau, Koninklijke Philips NV Research
Grant, Bracco Group Speakers Bureau, Siemens AG Consultant, Toshiba Corporation Research Grant, Esaote
SpA
LEARNING OBJECTIVES
1) To describe the clinical need for liver stiffness evaluation. 2) To describe the principles of ultrasound shear wave liver elastography To review the technique of shear wave liver elastography. 3) To discuss pitfalls in performing and interpreting ultrasound liver elastography To describe the basic approach to interpret ultrasound liver elastography.
ABSTRACT
Diffuse liver disease is one of the major health problems in the world. Hepatitis C (HCV) and Hepatitis B (HBV) viruses are the leading causes of chronic liver disease. It is estimated that 180 million and 350 million people worldwide are chronically infected with HCV and HBV respectively. In western countries, liver disease caused by HCV is the main indication for liver transplantation. Liver biopsy has been considered the reference standard for fibrosis assessment and stage classification. However, biopsy is invasive, with potential complications that can be severe in up to 1% of cases. In addition, a liver biopsy represents roughly 1/50,000 of the liver volume

RC217B
RC217C and there is interobserver variability at microscopic evaluation. Elastography is a non-invasive method for liver fibrosis assessment and has been an area of intense research. With ultrasound elastography systems now widely available worldwide this technique is beginning to replace liver biopsy as method for diagnosis and follow-up of liver fibrosis. This technique is easy to perform but requires attention to detail. This course will review the principles of shear wave elastography (SWE) for liver fibrosis assessment. A review of the technique and pitfalls will be presented. The literature will be reviewed as well as published guidelines on the use of SWE for liver fibrosis assessment. A discussion of the clinical applications of this technique and future potential applications will be discussed.
Active Handout http://media.rsna.org/media/abstract/2014/14001183/RC217A sec.pdf
Non-liver Applications of US Elastography
Anthony Edward Samir MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Identify non-liver applications for shear wave elastography. 2) Understand typical disease appearances of non-liver pathologies on elastography. 3) Understand valid indications for sonoelastography.
MR Elastography
Richard L. Ehman MD (Presenter): CEO, Resoundant, Inc
LEARNING OBJECTIVES
1) To describe the rationale for tissue elasticity imaging. 2) To describe the basic physical approach for
MRI-based elasticity imaging. 3) To describe the most common indications for MR elastography of the liver. 4)
To describe the basic approach to interpretation of hepatic MR elastography exams. 5) To describe pitfalls in interpretation of hepatic MRE. 6) To describe other potential applications of MRE.
ABSTRACT
Many disease processes cause profound changes in the mechanical properties of tissues. This accounts for the efficacy of palpation for detecting abnormalities and provides motivation for developing practical methods to assess tissue elasticity. Magnetic Resonance Elastography (MRE) is a new commercially-available MRI-based technique that can quantitatively image the mechanical properties of tissue.
The most advanced current application of MRE is for diagnosing hepatic fibrosis. Chronic liver disease is serious worldwide problem, and hepatic fibrosis is the most important consequence, which if not detected and treated, eventually leads to cirrhosis which is irreversible and associated with high mortality.
MRE can be readily implemented on a standard MRI system. A device is used to generate vibrrations in tissue.
The waves are imaged with a special MRI pulse sequence. Acquistion time for liver MRE is approximately 15 seconds. Because the incremental imaging time is so small, MRE can readily added to standard abdominal MR imaging protocols. The data are automatically processed generate quantitative images showing the elasticity of the liver and other tissues in the upper abdomen.
Clinical studies by multiple investigators have now established that MRE is an accurate method for diagnosing hepatic fibrosis. MRE-measured hepatic stiffness increases systematically with fibrosis stage. Growing clinical experience indicates that MRE is at least as accurate as liver biopsy for this diagnosis, while also being safer, more comfortable, and less expensive.
Human studies have demonstrated that it is feasible to apply MRE to quantitatively assess other tissues and organs such as brain, breast, heart, and kidney. MRE may be helpful in differentiating between benign and malignant neoplasms. New research has shown that MRE is helpful in the preoperative assessment of patients with brain tumors such as menigiomas.
Refresher/Informatics
US PH
AMA PRA Category 1 Credits ™ : 1.50
ARRT Category A+ Credits: 1.50
Mon, Dec 1 8:30 AM - 10:00 AM Location: S403B
Sub-Events
RC221A Ultrasonography Perspective
Paul L. Carson PhD (Presenter): Research collaboration, General Electric Company Research collaboration,
Light Age, Inc
LEARNING OBJECTIVES

RC221B
RC221C
1) Understand the roles of medical physicists and other providers of ultrasound system QC, performance evaluation and user education. 2) Gain an understanding of the longer term potential of medical ultrasound to aid in medical physics planning and training.
ABSTRACT
A very brief overview is given of the innovations that have led to current medical ultrasound systems and QC thereof. A clear connection to clinical performance/cost effectiveness has not been established, but the ratio is improving. To aid in medical physics planning and training, more distant (beyond 10 years) and less robust predictions are ventured than in Dr. Hangiandreous' talk. The reduction in artifacts and improvement in resolution will be surprisingly large. It is posed that ultrasound will be headed toward almost ubiquitous use in personal hands as well as those of medical personnel, for monitoring and control of chronic conditions, for direct treatment and for precisely localized drug delivery and enhancement of radiation therapy. Medical physicists who can help keep the computer controls integrated, the systems properly calibrated and the users properly trained will find a substantial role in society.
Active Handout http://media.rsna.org/media/abstract/2014/13010884/RC221A sec.pdf
Ultrasonography 1.0
Zheng Feng Lu PhD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Describe the current role of ultrasound medical physics in clinical practice. 2) Explain the ultrasound image quality metrics utilized in current ultrasound QA/QC testing. 3) Outline the methods and tools available for ultrasound system QA/QC in current clinical practices. 4) Survey the available standards and voluntary accreditation guidelines for medical ultrasound imaging systems. 5) Understand the need for QC at different levels of time and financial investment.
ABSTRACT
This talk will focus on the present role of ultrasound medical physics in clinical practices. It will review the ultrasound image quality metrics currently utilized in ultrasound QA/QC testing. It will describe testing procedures required and/or recommended by accreditation programs and advisory organizations. General guidelines and available standards will be discussed regarding tolerances for acceptance testing and commissioning of these devices, as well as periodic quality control tests, as applicable to diagnostic B-mode imagers. A brief review of ultrasound phantoms used in these testing procedures will be presented.
Active Handout http://media.rsna.org/media/abstract/2014/13010885/RC221B sec.pdf
Ultrasonography 2.0
Nicholas James Hangiandreou PhD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Identify the roles expected for medical physics to play in future clinical ultrasound practices. 2) Demonstrate understanding of emerging ultrasound imaging performance metrics that are expected to be in routine practice in the future. 3) Demonstrate understanding of emerging ultrasound imaging technologies that are expected to be in routine practice in the future. 4) Identify approaches for implementing comprehensive medical physics services in future clinical ultrasound practices.
ABSTRACT
Ultrasound imaging is evolving at a rapid pace, adding new imaging functions and modes that continue to enhance its clinical utility and benefits to patients. This talk will look ahead 10-15 years and consider how medical physicists can bring maximal value to the clinical ultrasound practices of the future. The roles of physics in accreditation and regulatory compliance, image quality and exam optimization, clinical innovation, and education of staff and trainees will all be considered. A detailed examination of expected technology evolution and impact on image quality metrics will be presented. Clinical implementation of comprehensive physics services will also be discussed.
Active Handout http://media.rsna.org/media/abstract/2014/13010886/RC221C sec.pdf
Refresher/Informatics

US MK US MK
AMA PRA Category 1 Credits ™ : 1.50
ARRT Category A+ Credits: 1.50
Mon, Dec 1 8:30 AM - 10:00 AM Location: E258
Participants
Marnix T. van Holsbeeck MD (Presenter): Consultant, General Electric Company Consultant, Koninklijke Philips NV
Stockholder, Koninklijke Philips NV Stockholder, General Electric Company Grant, Siemens AG Grant, General Electric Company
Kenneth S. Lee MD (Presenter): Research Consultant, SuperSonic Imagine Speakers Bureau, Medical Technology Management
Institute
Catherine J. Brandon MD (Presenter): Stock options, VuCOMP, Inc
Michael A. Dipietro MD (Presenter): Nothing to Disclose
Alberto Stefano Tagliafico MD (Presenter): Nothing to Disclose
Joseph Hudson Introcaso MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Recognize and identify pitfalls of scanning that lead to false positive or false negative musculoskeletal ultrasound results. 2)
Perform skills for scanning difficult patients. 3) Follow rigorous protocols for the examination of different anatomic regions. 4)
Position patients for more complicated musculoskeletal ultrasound examinations. 5) Recognize and integrate the importance of tissue movement in judging the functionality of the extremities.
ABSTRACT
In this Musculoskeletal Ultrasound Master class, an opportunity will be given to participants to start a written dialogue in advance to RSNA 2012. The electronically submitted questions will be sorted by instructors and organized per topic. A select number of recurrent themes in these questions will be prepared for dialogue on stage. When the questions focus on a particular scanning skill, the authors of the questions will be invited on the examination platform to show problems they encounter in their practice. By using a step-by step approach in solving the scanning issues, all who are present should benefit from the technical interactions on stage. Cameras will project scanning details on large screens. The seating in the master class will guarantee close proximity for an enriching interaction between audience and stage. At the end of the master class, the audience will be broken up in smaller groups for a more personal interaction with the instructors with the intent of improving scanning skills on an individual level.
Refresher/Informatics
US BR US BR
AMA PRA Category 1 Credits ™ : 1.50
ARRT Category A+ Credits: 1.50
Mon, Dec 1 8:30 AM - 10:00 AM Location: E264
Participants
Gary J. Whitman MD (Presenter): Nothing to Disclose
Annamaria Wilhelm MD (Presenter): Research Grant, Merck & Co, Inc
Richard Merrell Chesbrough MD (Presenter): Consultant, C. R. Bard, Inc Consultant, Radnet, Inc
Michael N. Linver MD (Presenter): Nothing to Disclose
Paula Beth Gordon MD (Presenter): Stockholder, OncoGenex Pharmaceuticals, Inc Scientific Advisory Board, Hologic, Inc
Consultant, Seno Medical Instruments, Inc
Stamatia V. Destounis MD (Presenter): Investigator, FUJIFILM Holdings Corporation Investigator, Seno Medical Instruments,
Inc
Anna Irene Holbrook MD (Presenter): Nothing to Disclose
Alice S. Rim MD (Presenter): Nothing to Disclose
Alda Felicita Cossi MD (Presenter): Nothing to Disclose
Eren D. Yeh MD (Presenter): Nothing to Disclose
Gary W. Swenson MD (Presenter): Nothing to Disclose
Catherine Welch Piccoli MD (Presenter): Stockholder, VuCOMP, Inc Consultant, Real Time Tomography, LLC Stockholder, Real
Time Tomography, LLC
Michael Patrick McNamara MD (Presenter): Stockholder, Apple Inc Stockholder, General Electric Company
Selin Carkaci MD (Presenter): Consultant, Hologic, Inc
Jean M. Seely MD (Presenter): Nothing to Disclose
Phan Tuong Huynh MD (Presenter): Research Grant, Siemens AG Consultant, Siemens AG
H. Carisa Le-Petross MD (Presenter): Nothing to Disclose
Basak Erguvan Dogan MD (Presenter): Nothing to Disclose
Jay Alan Baker MD (Presenter): Research Consultant, Siemens AG
Tanya W. Stephens MD (Presenter): Nothing to Disclose
Jiyon Lee MD (Presenter): Nothing to Disclose
Alexis Virginia Nees MD (Presenter): Nothing to Disclose
William R. Poller MD (Presenter): Consultant, Devicor Medical Products, Inc
LEARNING OBJECTIVES
1) Describe the equipment needed for ultrasound guided interventional breast procedures. 2) Review the basic principles of ultrasound guidance and performance of minimally invasive breast procedures. 3) Practice hands-on technique for ultrasound guided breast interventional procedures.
ABSTRACT
This course is intended to familiarize the participant with equipment and techniques in the application of US guided breast biopsy and needle localization. Participants will have both basic didactic instruction and hands-on opportunity to practice biopsy techniques on tissue models with sonographic guidance. The course will focus on the understanding and identification of: 1) optimal positioning for biopsy 2) imaging of adequate sampling confirmation 3) various biopsy technologies and techniques 4) potential problems and pitfalls

Series Courses
US OI MR IR GI
AMA PRA Category 1 Credits ™ : 3.25
ARRT Category A+ Credits: 4.00
Mon, Dec 1 8:30 AM - 12:00 PM Location: E350
Participants
Moderator
Mark Elwood Lockhart MD : Nothing to Disclose
Moderator
Kathryn Jane Fowler MD : Research support, Bracco Group
Sub-Events
VSGI21-01 MRI and MR Elastography
Frank H. Miller MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Discuss the role of conventional MRI in the diagnosis of HCC and benign hepatic nodules. 2) Use of gadoxetate and diffusion weighted imaging in characterizing focal liver lesions in cirrhotic patients. 3) MR elastography in the assessment of fibrosis.
ABSTRACT
MR imaging plays in important role in the diagnosis of cirrhosis. The classic and atypical MR imaging features of hepatocellular carcinoma and the distinction from benign hepatic nodules will be discussed. The use of ancillary features of HCC will be discussed including the utility of gadoxetate and diffusion weighted imaging in characterizing focal hepatic lesions in cirrhotic patients. MR elastography, a relatively new technique will be emphasized for the staging of fibrosis and diagnosis of cirrhosis.
Active Handout http://media.rsna.org/media/abstract/2014/14000543/VSGI21-01 sec.pdf
VSGI21-02 The Outcome of Hypovascular and Hypointense Nodules on Hepatocyte-phase Gadoxetic
Acid-enhanced Magnetic Resonance Imaging; When Does It become a Conventional HCC?: 5 Years'
Experience
Katsuhiro Sano MD,PhD (Presenter): Nothing to Disclose , Utaroh Motosugi MD : Nothing to Disclose ,
Tomoaki Ichikawa MD, PhD : Consultant, DAIICHI SANKYO Group , Shintaro Ichikawa MD : Nothing to
Disclose , Hiroyuki Morisaka MD : Nothing to Disclose , Kojiro Onohara MD : Nothing to Disclose ,
Tomohiro Takamura : Nothing to Disclose , Hiroshi Onishi : Nothing to Disclose
PURPOSE
Nodules that appear hypointense on hepatocyte phase of gadoxetic acid-enhanced magnetic resonance imaging
(EOB-MRI) and hypovascular on arterial-phase are often encountered in clinical practice. Such nodules cannot be diagnosed using routine imaging criteria. The pupose of this study was to elucidate the natural history over a long period of hypovascular nodules that appear hypointense on hepatocyte-phase EOB-MRI by focusing on hypervascularization.
METHOD AND MATERIALS
In this study, 235 such nodules in 84 patients were examined. Hypovascularity of the nodules was confirmed using dynamic CT. All nodules were retrospectively examined using serial follow-up CT and MRI. examinations until hypervascularity was observed on arterial-phase dynamic CT or EOB-MRI, or CT during hepatic arteriography.
RESULTS
The mean follow-up duration was 702 days (range: 69 to 2085 days). Of the 235 nodules, 148 (63%) developed hypervascularization. The optimal cut off value of the size of hypervascularization was 10mm. Of the
102 nodules (=10mm or >10mm), 81 (79%) developed hypervascularizaion. The size of the nodules (=10mm or >10mm) and increase in size of the nodules were independent risk factors of hypervascularization by multivariate analysis. The 1-year cumulative risks of hypervascularization were 20% (=10mm or >10mm).
These values were significantly differences.
CONCLUSION
About 80% of hypovascular and hypointense nodules on EOB-MRi (=10mm or >10mm) progressed to conventional hepatocellular carcinoma. Large nodular size (=10mm or >10mm) and increase in size of the nodules is the MR imaging findings that higher risk of hypervascularization.
CLINICAL RELEVANCE/APPLICATION

About 80% of hypovascular and hypointense nodules on EOB-MRI with the size equal to 10mm or larger 10mm.
Large nodular size (=10mm or >10mm) and increase in size of the nodules are the MR imaging findings that indicate higher risk of hypervascularization.
VSGI21-03 Texture Analysis of Non-enhanced and Gadoxetate Disodium-enhanced MR Images of the Liver: A
Comparison with Histological Grade of Liver Fibrosis
Akira Yamada MD (Presenter): Nothing to Disclose , Kazuhiko Ueda MD : Nothing to Disclose , Yasunari
Fujinaga MD : Nothing to Disclose , Masahiro Kurozumi MD : Nothing to Disclose , Shinichi Miyagawa :
Nothing to Disclose , Masumi Kadoya MD : Nothing to Disclose
PURPOSE
To evaluate value of gadoxetate disodium on noninvasive diagnosis of liver fibrosis by texture analysis of MR images.
METHOD AND MATERIALS
Consecutive 46 patients who underwent preoperative gadoxetate disodium-enhanced MR imaging using 3 Tesla
MR system were included in this retrospective study. The grade of liver fibrosis (the fibrosis score: F) was histologically diagnosed by surgical specimen in all patients. Pre-contrast respiratory-gated 2D fast spin echo
T2-weighted images (voxel size = 0.7 x 0.7 x 5 mm), pre- and post-contrast (20 minutes after venous administration) breath-hold 3D gradient recalled echo T1-weighted images (voxel size = 0.7 x 0.7 x 3 mm) were used for evaluation. Fat-suppression was applied to all images. Region of interests sized 60 x 60 pixels were located in the liver avoiding major vessels and hepatic lesions in each MR image. Four feature values
('contrast', 'correlation', 'energy', and 'heterogeneity') of the liver were determined by texture analysis of region of interests. A stepwise liner regression analysis of the fibrosis score on the feature values obtained from texture analysis was performed using 3 different image sets (pre-contrast MR images, post-contrast MR images, and the both). ROC analysis of obtained 3 regression models in differentiation of liver fibrosis (F1-4) from normal liver (F0) was performed.
RESULTS
The area under ROC of obtained 3 regression models in differentiation of liver fibrosis from normal liver was
0.64 for pre-contrast MR images, 0.83 for post-contrast MR images, and 0.85 for the both. Two feature values
(x1: 'correlation' in post-contrast T1-weighted images, P < 0.0001; x2: 'energy' in pre-contrast T2-weighted images, P = 0.017) were significant predictors for the fibrosis score in eventual regression model (y =
-31.232x1 - 10.39x2 + 32.137, R = 0.63, P < 0.0001).
CONCLUSION
Gadoxetate disodium can add value on noninvasive diagnosis of liver fibrosis by texture analysis of MR images.
CLINICAL RELEVANCE/APPLICATION
The degree of liver fibrosis especially at its early stage can be predicted non-invasively by texture analysis of non-enhanced and gadoxetate disodium-enhanced MR images.
VSGI21-04 State-of-Art Sonography
Stephanie R. Wilson MD (Presenter): Research Grant, AbbVie Inc Grant, Johnson & Johnson Consultant,
Lantheus Medical Imaging, Inc Equipment support, Siemens AG Equipment support, Koninklijke Philips NV
LEARNING OBJECTIVES
1) The attendee will appreciate the unique contribution of contrast enhanced ultrasound (CEUS) to imaging of
HCC in terms of its real time dynamic performance, superior spatial and temporal resolution, and incomparable vascular sensitivity. 2) The attendee will analyze the imaging performance of microbubble contrast agents for liver mass characterization with CEUS, which are purely intravascular, as compared to the interstitial agents commonly used for CT and MR scan.
VSGI21-05 Assessment of Hepatic Vascular Network Connectivity by Automated Graph Analysis of Dynamic
Contrast Enhanced Ultrasound to Evaluate Portal Hypertension in Patients with Cirrhosis: A Pilot
Study
Ivan Amat-Roldan PhD (Presenter): Nothing to Disclose , Annalisa Berzigotti MD, PhD : Nothing to Disclose
, Rosa Gilabert MD : Nothing to Disclose , Jaime Bosch MD : Nothing to Disclose
PURPOSE
The liver vascular network is characterized by a highly organized structure. This is progressively deranged due to fibrosis and hepatocyte drop-out in patients with chronic liver diseases, leading to portal hypertension. We hypothesised that graph analysis of vascular images obtained by dynamic contrast-enhanced ultrasound
(DCE-US), would allow calculating the hepatic vascular network connectivity, which would predict the degree of organization of the liver circulation, and that this would mirror the severity of portal hypertension.
METHOD AND MATERIALS
This pilot study includes 4 healthy subjects and 15 well characterized patients with liver cirrhosis who underwent DCE-US and hepatic venous pressure gradient measurement (HVPG; gold standard method to assess portal hypertension in cirrhosis). Individual graph models ('vascular connectomes') were computed based on time series analysis of video sequences of DCE-US examination (disruption-reperfusion technique).
Graph analysis was carried out by calculation of clustering coefficient; according to graph theory a higher clustering coefficient indicates a more organized network. Based on clustering coefficient we calculated

clustering coefficient indicates a more organized network. Based on clustering coefficient we calculated statistical models to predict HVPG from DCE-US video sequences.
RESULTS
Healthy subjects had a high clustering coefficient of vascular connectome suggesting a highly organized liver vascular network. Patients with cirrhosis showed a lower clustering coefficient indicating disruption of normal anatomy. Clustering coefficient decreased as HVPG increased. The correlation between the best model derived from distribution of clustering coefficient (10 bins) of vascular 4 connectome and HVPG had a Pearson's correlation of 0.977 and a root mean square error of 1.57 evaluated by leave one out cross-validation.
CONCLUSION
Computer based graph-analysis of video sequences generated by DCE-US permits to calculate a vascular connectome that reflects the degree of organization of hepatic microvascular network
CLINICAL RELEVANCE/APPLICATION
This non-invasive method is able to quantify automatically the degree of liver vascular derangement and accurately mirrors the severity of portal hypertension in patients with cirrhosis.
VSGI21-07 LIRADS and UNOS Classifications of Liver Lesions
Cynthia Sawhney Santillan MD (Presenter): Consultant, Robarts Clinical Trials Research Group
LEARNING OBJECTIVES
1) To demonstrate the use of the LI-RADS and UNOS imaging categorization systems for observations seen in patients at risk for hepatocellular carcinoma with sample cases. 2) To highlight the different purposes of each categorization system. 3) To illustrate the differences and similarities in how observations are categorized with each system.
VSGI21-08 A Review of LI-RADS Categorization in 201 Pathology Proven Hepatocellular Carcinomas
Eric Christopher Ehman MD (Presenter): Nothing to Disclose , Spencer Caton Behr MD : Research Grant,
General Electric Company , Rizwan Aslam MBBCh : Research support, Bayer AG , Benjamin M. Yeh MD :
Research Grant, General Electric Company Consultant, General Electric Company , Linda Ferrell MD :
Nothing to Disclose , Thomas A. Hope MD : Speaker, Guerbet SA Research Grant, General Electric Company
PURPOSE
To explore the trends in imaging appearance and differences in findings by modality for the new LI-RADS v2014 definitions in a large group of pathology proven cases of hepatocellular carcinoma.
METHOD AND MATERIALS
Pathology reports from liver specimens (explants and partial hepatectomies) of 605 sequential patients with cirrhosis were reviewed to identify specimens with at least one focus of viable hepatocellular carcinoma, then cross-correlated with pre-operative CT and MR imaging. Patients with completely necrotic treated tumor, those without available prior pre-treatment multiphase imaging and tumors smaller than 1 cm were excluded. Each lesion was examined, the imaging features recorded, and the lesion retrospectively graded using the LI-RADS
2014 criteria.
RESULTS
147 patients with a total of 201 hepatocellular carcinomas diagnosed between 12/2008 and 10/2013 were analyzed. Average time between the most recent pre-treatment prior imaging study and surgery was 13 months. 150 (75%) lesions were imaged by multiphase CT, and 51 (25%) lesions by MRI. Overall, 64 (32%) lesions measured ≥1cm and <2cm, while 137 (68%) were ≥2cm. There were 21 (13%) LIRADS-3 lesions, 75
(37%) LIRADS-4 lesions and 102 (50%) LIRADS-5 lesions. 171 (85%) of lesions exhibited arterial hyperenhancement, 136 (68%) demonstrated washout and 29 (14%) showed evidence of capsule. At CT, the rate of LIRADS-3, -4 and -5 lesions was 13%, 37% and 50% respectively. At MR, these rates were 4%, 39% and 55%. At CT, 13% of 1-2 cm lesions were graded LIRADS-5, and at MR, 38% were graded LIRADS-5.
Arterial phase hyperintensity and washout appearance rates were equivalent between MR and CT, but capsule appearance was more common on MR (29%) imaging than at CT (10%), with χ2 = 10.7 (p<0.05).
CONCLUSION
The rate of arterial enhancement and portal venous or delayed washout are similar between lesions diagnosed via CT and those diagnosed with MR. Capsule appearance was seen significantly more frequently at MR, resulting in a higher rate of LIRADS-5 lesions measuring 1-2 cm at MR compared to CT.
CLINICAL RELEVANCE/APPLICATION
Differences in sensitivity for LI-RADS 5 lesions exist for MR and CT, which may support the use of MR imaging for the evaluation of HCC over that of CT in the pre-transplant population
VSGI21-09 Performance of LI-RADS Criteria for Diagnosis of Pathologically Proven Hepatocellular Carcinoma

VSGI21-09
Using Gd-EOB-DTPA, and Comparisons with the Japan Society of Hepatology 2010 Criteria
Stephanie Channual MD (Presenter): Nothing to Disclose , Anokh Pahwa MD : Nothing to Disclose ,
Katrina Richards Beckett MD : Nothing to Disclose , James Sayre PhD : Nothing to Disclose ,
David Shin-Kuo Lu MD : Consultant, Covidien AG Speaker, Covidien AG Consultant, Johnson & Johnson
Research Grant, Johnson & Johnson Consultant, Bayer AG Research Grant, Bayer AG Speaker, Bayer AG ,
Steven Satish Raman MD : Consultant, Bayer AG Consultant, Covidien AG
PURPOSE
Only recently has LI-RADS (LR) expanded to apply to hepatobiliary (HB) contrast agents, with lesion appearance on the HB phase considered to be an ancillary feature that favors the diagnosis of hepatocellular carcinoma (HCC). In contrast, the Japan Society of Hepatology (JSH) includes lesion appearance on the HB phase as a major criteria that favors the diagnosis of HCC. The purpose of our study was to determine the performance of LI-RADS v2014 and Japan Society of Hepatology (JSH) 2010 criteria for the non- invasive diagnosis of HCC.
METHOD AND MATERIALS
This was an IRB approved, HIPAA compliant retrospective study with 131 consecutive suspected HCC nodules in
114 patients confirmed by percutaneous biopsy, resection, or explant within 90 days of Gd-EOB-DTPA MRI.
Nodule size, presence of a capsule, and enhancement patterns were recorded. The nodules were then categorized as LR3, LR4, or LR5 based on the LI-RADS major criteria, and categorized as either meeting or not meeting the JSH criteria (defined as arterial enhancement and venous wash out, or arterial enhancement and lack of Gd-EOB-DTPA uptake on HB phase imaging).
RESULTS
Of the 131 nodules, 116 were pathologically confirmed HCC (88.5%). Of 131 nodules, 23 (18%), 41 (31%), and 67 (51%) were categorized as LR3, LR4, and LR5 respectively. Of these, 15/23, 37/41, and 64/67 LR3,
LR4 and LR5 nodules were pathologically proven as HCC, respectively (sensitivities, 13%, 32%, and 55%, respectively; specificities, 47%, 73%, and 80%, respectively). The PPV of LR3, LR4, and LR5 were 65%, 90%, and 96%, respectively. The sensitivity, specificity, and PPV for the JSH criteria were 72.4%, 53.3%, and
92.3%, respectively. The accuracy of LR4 and LR5 combined was 83% (109/131), while the accuracy for the
JSH criteria was 70.2% (92/131).
CONCLUSION
Although use of LI-RADS with Gd-EOB-DTPA yields a high PPV and accuracy for diagnosing HCC, moderate sensitivity and specificity suggest that further refinement of the criteria may be necessary and percutaneous nodule biopsy may be complementary for diagnosis. However, LR4 and LR5 combined was more sensitive and accurate for diagnosing HCC compared to the JSH criteria.
CLINICAL RELEVANCE/APPLICATION
The use of hepatobiliary specific MR contrast agents, such as Gd-EOB-DTPA, is becoming more prevalent, and understanding its applicability with LI-RADS is essential for the noninvasive evaluation of nodules in cirrhotic livers.
VSGI21-10 Ablation of Liver Lesions
Fred T. Lee MD (Presenter): Stockholder, NeuWave Medical, Inc Patent holder, NeuWave Medical, Inc Board of Directors, NeuWave Medical, Inc Patent holder, Covidien AG Inventor, Covidien AG Royalties, Covidien AG
LEARNING OBJECTIVES
1) Understand the basic rationale for ablation of liver lesions. 2) Understand the differences between ablation of liver tumors in cirrhotic and non-cirrhotic livers. 3) Understand the differences between the different ablation technologies.
VSGI21-11 Imaging Evaluation of Ablative Margin and Index Tumor Immediately after Radiofrequency Ablation for Hepatocellular Carcinoma: Comparison between Multi-detector CT and MR Imaging
Jin Woong Kim MD : Nothing to Disclose , Sang Soo Shin MD (Presenter): Nothing to Disclose , Suk Hee
Heo MD : Nothing to Disclose , Hyo Soon Lim MD : Nothing to Disclose , Sung Mo Kim : Nothing to
Disclose , Yong-Yeon Jeong MD : Nothing to Disclose , Heoung-Keun Kang MD : Nothing to Disclose
PURPOSE
To prospectively compare multi-detector CT and MR imaging in assessment of ablative margin (AM) and index tumor within ablation zones immediately after radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC).
METHOD AND MATERIALS
Based on our preliminary data, necessary number of patients was estimated to be at least 30 when an α error of 0.05 and a β error of 0.2 were applied. A total of 33 consecutive patients with 42 HCCs, who had successfully undergone contrast-enhanced CT and MR imaging after RFA, was enrolled in this study. CT and MR imaging

were performed within 3 and 7 hours after completion of RFA, respectively. Both CT and MR images were reviewed in consensus by two radiologists in two separate sessions regarding visual discrimination between AM and index tumor and status of AM within ablation zones. The status of AM was classified as AM plus (AM completely surrounded tumor), AM zero (AM was partly discontinuous, without protrusion of tumor beyond postulated border of ablated area) and AM minus (AM was partly discontinuous, with protrusion of tumor). Any ablation zone with AM plus or AM zero was considered as imaging evidence to predict technical effectiveness, which was based on one-month follow-up CT, as well as to represent technical success.
RESULTS
With CT and MR imaging, visual discrimination between AM and index tumor was possible in 4 (9.5%) and 34
(81%) of 42 ablation zones, respectively (P< .001). Among 4 and 34 ablation zones in which status of AM could be evaluated on CT and MR imaging, respectively, all of 4 ablation zones were classified as AM plus on CT images, whereas 34 ablation zones were categorized into AM plus (n=28), AM zero (n=5) and AM minus (n=1) on MR images. Based on CT and MR imaging, technical success was determined to be achieved in 4 (9.5%) and
33 (78.6%), respectively (P< .001). The technical effectiveness was noted in all of ablation zones on one-month follow-up CT. CT and MR imaging predicted technical effectiveness in 4 (9.5%) and 33 (78.6%), respectively, (P< .001).
CONCLUSION
MR imaging was superior to multi-detector CT for assessment of ablative margin and index tumor within ablation zones immediately after RFA.
CLINICAL RELEVANCE/APPLICATION
MR imaging performed immediately after RF ablation can provide sufficient information regarding necessity of additional ablation after RF ablation with more confidence than contrast-enhanced CT.
VSGI21-12 Thermal Ablation in the Treatment of Hepatocellular Carcinoma (HCC): Radiofrequency Ablation
(RFA) vs. Microwave Ablation (MWA)
Thomas Josef Vogl MD, PhD (Presenter): Nothing to Disclose , Stefan Zangos MD : Nothing to Disclose ,
Jorg Trojan MD : Nothing to Disclose , Nagy Naguib Naeem Naguib MD, MSc : Nothing to Disclose ,
Nour-Eldin Abdelrehim Nour-Eldin MD, MSc : Nothing to Disclose
PURPOSE
To prospectively evaluate and compare the therapeutic response of radiofrequency ablation (RFA) and microwave ablation (MWA) therapy of hepatocellular carcinoma (HCC).
METHOD AND MATERIALS
Institutional review board approval was obtained prior to this prospective study and written informed consent was obtained from all patients included in the study for both the ablation procedure and anonymous use of their data for research purposes. From September 2008 to December 2011, 53 consecutive patients (42 males/11 females; mean, 59 years; range 40-68; SD, 4.2) underwent CT-guided percutaneous RFA and MWA of 68 HCC lesions. The inclusion and exclusion criteria were in accordance with the Barcelona Clinic Liver Cancer (BCLC) criteria for indications and contraindications for ablation therapy of HCC. The morphologic tumor response
(number, location and size) was evaluated by MRI. Follow-up protocol was 24 hours post ablation, then in
3-month intervals post ablation in the first year and in 6-month intervals thereafter.
RESULTS
Complete therapeutic response was documented in 84.4% (27/32) of lesions treated with RFA and in 88.9%
(32/36) of lesions treated with MWA (p=0.6). Complete response was achieved in all lesions ≤2.0 cm in diameter in both groups. There was no significant difference in rates of residual foci of HCC lesions between RFA and MWA groups (p=0.15, Log-rank test). Recurrence rate for 3, 6, and 9 months in patients with HCC who underwent RFA vs. MWA were 6.3%, 3.1%, 3.1% vs. 0%, 5.6%, 2.8%. Time-to-progression in patients treated with RFA compared with MWA was 6.6 vs. 8.3 months. Progression-free-survival rate for patients treated with
RFA was 96.9%, 93.8% and 90.6% at 1, 2, and 3 years, for patients treated with MWA it was 97.2%, 94.5%, and 91.7%, respectively (p=0.98).
CONCLUSION
In conclusion, RFA and MWA therapy showed no significant difference in the treatment of HCC regarding complete response, rates of residual foci of untreated disease and recurrence rate.
CLINICAL RELEVANCE/APPLICATION
RFA or MWA can be used with similar results concerning local tumor control of HCC
Scientific Posters

BR
AMA PRA Category 1 Credits ™ : .50
Mon, Dec 1 12:15 PM - 12:45 PM Location: BR Community, Learning Center
Participants
Moderator
Debra Somers Copit MD : Scientific Advisory Board, Hologic, Inc
Sub-Events
BRS245 On the Statistical Relationships Between Quantitative DCE-, DW-, and APT-CEST-MRI: A Hypothesis
Generating Study (Station #1)
Elizabeth Vera Gadwood MD (Presenter): Nothing to Disclose
PURPOSE
New MRI techniques are being developed to quantitatively evaluate breast tumors in the diagnostic and prognostic settings. One such method is amide proton transfer (APT), a type of chemical exchange saturation transfer (CEST) imaging. APT provides information about protein content and distribution in tumors. Studies have shown that APT can distinguish healthy tissue from tumor and may be sensitive enough to detect subtle changes related to chemotherapy. This study aims to evaluate APT-CEST-MRI in relation to diffusion weighted
MRI (DW-MRI) and dynamic contrast enhanced MRI (DCE-MRI) in breast cancer patients.
METHOD AND MATERIALS
12 patients with invasive mammary carcinoma underwent MR imaging prior to therapy, which included DW-,
DCE-, and APT-CEST-MRI. Analysis of the DCE-MRI data returned the volume transfer constant (Ktrans), extravascular extracellular volume fraction (ve), efflux constant (kep), and blood plasma volume fraction (vp).
The apparent diffusion coefficient (ADC) was estimated from the DW-MRI data, while the mean APT was calculated from the CEST data. The Spearman's rank correlation coefficient was calculated to test for a significant statistical relationship between all of these parameters at the whole tumor region of interest level.
RESULTS
APT and Ktrans demonstrated a strong and significant correlation (r2=0.82, p=0.002) while a modest but non-significant correlation was seen between APT and vp (r2=0.6, p=0.051). There was no correlation between
APT and ADC (r2=0.08, p=0.8).
CONCLUSION
The significant correlation between APT and Ktrans, a marker of tumor vessel perfusion and/or permeability, suggests that protein synthesis may be related to tumor associated angiogenesis. This hypothesis is strengthened by the positive correlation between APT and vp. Lack of correlation between APT and ADC suggests that APT is a stronger marker of extracellular protein, rather than intracellular protein, as it appears to be independent from tumor cell density.
CLINICAL RELEVANCE/APPLICATION
Initial results suggest APT is independent from DW-MRI and complimentary to DCE-MRI. If this can be validated in a larger patient set, measurements of APT could impact standard MRI breast protocols.
BRS246 Initial Testing of an In-bore MRI-guided Real-time Breast Biopsy System (Station #2)
Frederick Kelcz MD, PhD (Presenter): Nothing to Disclose , Raymond Harter MS : President, Marvel
Medtech, LLC , Ethan K. Brodsky PhD : Nothing to Disclose , Walter F. Block PhD : Research support,
General Electric Company , Roberta Marie Strigel MD, MS : Speaker, Bracco Group , Graham T. Reitz :
Research funded, Marvel Medtech, LLC , Sergey N. Kuro : Employee, Marvel Medtech, LLC
PURPOSE
The current method of MRI-assisted breast biopsy requires that the patient be moved into the bore for planning and verification, then out of the bore for the biopsy procedure. This approach is subject to error due to patient motion or trocar-induced lesion displacement between image sets. We are developing an in-bore system for robotic interactive MR image guided interventions (iMR-IGI) using MRI-compatible actuators and a ceramic trocar. This will allow the radiologist to efficiently and rapidly control, in real time, all aspects of the intervention process.
METHOD AND MATERIALS
We have developed a multi-degree-of-freedom robotic proof-of-concept prototype system for in-bore MR image guided biopsy (IGB) trocar placement. The MRI-compatible system configuration is not limited to lateral or medial access to the breast and is constructed so as to permit a real-time imaging interface to the MRI scanner. The system also has its own integrated radiofrequency (RF) breast coil to maximize signal to noise ratio (SNR) and uses piezoelectric actuators. The in-bore tool positioner is mounted on a circular track surrounding the breast cup and RF coil.
RESULTS

BRS247
BRS250
Video will be presented, taken during real-time MR imaging, demonstrating robotic controlled insertion of the fluid filled, MR visible ceramic trocar into a gel breast phantom. We tested SNR levels using phantoms with all electronics unpowered (SNR = 44) vs. a fully activated state (SNR=31) using an 8 channel commercial receive breast coil (GE Healthcare, Waukesha, WI). While SNR degradation is measurable in this early prototype, it is modest and acceptable given the clinical requirements for identifying and tracking a known lesion.
CONCLUSION
We have demonstrated proof-of-concept novel in-bore actuation capability with concurrent real-time imaging.
Our proposed system will provide a rapid, interactive method for placing diagnostic and therapeutic tools into the breast under real-time MRI guidance.
CLINICAL RELEVANCE/APPLICATION
Some literature has used the term "real-time" to simply describe a surgery that can be completed entirely within the MR suite. In such cases, the imaging guidance itself is not in real-time and device guidance is performed by iterating between diagnostic imaging and discrete device manipulations. We have demonstrated novel true in-bore actuation capability with concurrent real-time imaging, now to be applied to the breast, but with potential for use in other body regions.
Heterogeneity of Background Parenchymal Enhancement on MRI Strongly Predictive of Breast
Cancer Molecular Subtypes (Station #3)
Jeff Wang (Presenter): Nothing to Disclose , Fumi Kato : Nothing to Disclose , Kohsuke Kudo MD :
Nothing to Disclose , Hiroko Yamashita : Nothing to Disclose , Hiroki Shirato MD, PhD : Nothing to Disclose
PURPOSE
Despite many efforts having studied lesion texture as imaging biomarkers of breast cancer (BC) subtypes, it appears none have yet been published assessing the same of background parenchymal enhancement (BPE).
This study aims to determine the prognostic ability of BPE texture surrogates with molecular subtypes of BC.
METHOD AND MATERIALS
Building evidence continues to show BC is a diverse disease. Molecular subtyping based on estrogen (ER), progesterone (PgR), and human epidermal growth factor 2 (HER2) receptor expression provides valuable information for treatment.
Dynamic contrast-enhanced (DCE)-MRI is standard in diagnostic breast imaging, known for its high sensitivity.
Increased BPE on DCE-MRI has been associated with higher rates of abnormal interpretation and obscured breast masses. There is also evidence it may provide insight with BC risk.
This retrospective study included 64 women with 69 invasive mass carcinomas, who had DCE-MRI. ER, PgR, and
HER2 receptor expression of the lesions were determined by immunohistochemistry in specimens. The cancers were also categorized triple-negative (TN) or Luminal A (LumA), as clinically significant.
Segmentation of parenchyma tissue was performed from DCE-MRI of the affected breast and BPE texture was then quantified as first and second-order statistical features of pharmacokinetic parameter maps calculated from the tissue compartment.
Logistic regression models were learned, using reduced BPE texture features to classify receptor status.
Accuracy (ACC), sensitivity (TPR), specificity (TNR), and area under the ROC curve (AUC) of performance were calculated from leave-one-out cross-validation.
RESULTS
TN BC were classified with ACC of 95%, TPR of 89%, TNR of 97%, and AUC of 0.89. ER BC were classified with
ACC of 88%, TPR of 67%, TNR of 96%, and AUC of 0.81. PgR BC were classified with ACC of 68%, TPR of 42%,
TNR of 86%, and AUC of 0.61. HER2 BC were classified with ACC of 83%, TPR of 36%, TNR of 94%, and AUC of
0.63. LumA BC were classified with ACC of 61%, TPR of 65%, TNR of 57%, and AUC of 0.66.
CONCLUSION
BPE texture is demonstrated as able to predict TN and ER BC with great accuracy and discriminative ability;
PgR, HER2, and LumA BC to lesser degrees.
CLINICAL RELEVANCE/APPLICATION
BPE heterogeneity can extend the diagnostic ability of DCE-MRI, as it is strongly predictive of some molecular subtypes of breast cancer, particularly the more aggressive triple-negative subtype.
Incidental Findings on Breast MRI: The Added Value of Second-look Digital Breast Tomosynthesis
(Station #4)
Paola Clauser MD (Presenter): Nothing to Disclose , Luca Alessandro Carbonaro MD : Research Consultant, im3D SpA , Martina Pancot : Nothing to Disclose , Massimo Bazzocchi MD : Nothing to Disclose , Chiara
Zuiani MD : Nothing to Disclose , Francesco Sardanelli MD : Speakers Bureau, Bracco Group Research
Grant, Bracco Group Speakers Bureau, Bayer AG Research Grant, Bayer AG Research Grant, IMS International
Medical Scientific
PURPOSE

BRS248
To assess the clinical utility of second-look digital breast tomosynthesis (SL-DBT) to look for lesions detected initially on MRI and to compare SL-DBT with second-look ultrasound (SL-US).
METHOD AND MATERIALS
This multicentric retrospective study included 143 patients with biopsy-proven breast cancer that underwent both BT and MRI as staging. The study obtained IRB approval and patients signed the informed consent for the examinations. Four readers with experience in breast imaging reviewed MRI examinations to find incidental lesions not suspected on the basis of previous imaging. MRI lesions characteristics were evaluated: morphology
(mass like enhancement ML, non mass like enhancement NML or foci), dimensions (≤10 mm or > 10 mm) and
ACR BIRADS classification (3 or 4-5). DBT was then re-evaluated looking for MRI findings. Data on SL-US were also collected for all incidental findings. Standard of reference was biopsy, surgical excision or follow up (≥1 year).
RESULTS
Eighty-two MRI incidental findings were detected in 51 patients. At SL-DBT a correlation was made in 40 cases
(49%) including 29 malignant lesions and 11 benign lesions. At SL-US a correlation was made in 41 (50%) including 25 malignant and 16 benign lesions. Overall, 61 (74.4%) of the lesions were visible with at least one technique other than MRI, including 40 malignant and 21 benign lesions. Of the 21 lesions non-visible at second look, 17 were malignant and 4 were benign. When analysing the type of lesion found at SL-DBT, no significant differences were found regarding morphology (ML vs NML vs foci), dimensions (≤10 mm or > 10 mm) and
BIRADS classification (3 vs 4-5). Though the difference was not significant, SL-DBT found more frequently NML lesions compared to SL-US (44% vs 28%).
CONCLUSION
SL-DBT allowed to add almost 25% additional lesions in adjunct to SL-US, and it could be particularly helpful for areas of NML enhancement. The absence of a DBT or US correlate does not warrant to avoid MR-guided biopsy for suspicious findings.
CLINICAL RELEVANCE/APPLICATION
With the introduction of systems to perform biopsy under Tomosynthesis guidance, the use of SL-DBT could help avoiding MR-guided biopsy, thus reducing costs and discomfort for the patients.
Usefulness of Combined Diffusion-weighted Imaging to Dynamic Contrast-enhanced Breast MRI for
Diagnosis of the Multifocal and Multicentric Breast Cancer (Station #5)
Eun Kyung Park MD (Presenter): Nothing to Disclose , Kyu Ran Cho MD, PhD : Nothing to Disclose , Bo
Kyoung Seo MD, PhD : Nothing to Disclose , Ok Hee Woo MD : Nothing to Disclose , Sung Bum Cho :
Nothing to Disclose , Kyung Hwa Park : Nothing to Disclose
PURPOSE
The purpose of this study was to investigate the diagnostic value of an imaging protocol that addition of diffusion-weighted imaging (DWI) to dynamic contrast-enhanced breast MRI (DCE-MRI) for diagnosis multifocal and multicentric breast cancer.
METHOD AND MATERIALS
The prospective study included 82 consecutive women with 136 enhancing lesions on DCE-MRI for preoperative staging in breast cancer. Morphologic and kinetic assessments were performed on DCE-MRI and findings were classified according to the Breast Imaging Reporting and Data System (BI-RADS) lexicon. Apparent diffusion coefficient (ADC) values were compared for benign and malignant lesions. For the combined MRI protocol, lesions which were classified as BI-RADS 4a and had an ADC value more than the calculated cutoff value were considered as benign. Sensitivity (SE), specificity (SP) and positive predictive value (PPV) were evaluated for
DCE-MRI alone and combined MRI protocol for unexpected additionally detected lesions on DCE-MRI. Results were further compared by lesion size (>1cm or ≤1cm).
RESULTS
Of the 136 lesions, 26 were benign and 110 were malignant (15 ductal carcinoma in situ, 95 invasive carcinoma). The malignant lesions (mean ADC, 0.93±0.22×10-3 mm2/s) exhibited lower mean ADC than benign lesions (1.20±0.24×10-3 mm2/s, P <0.01). Of the 136 lesions, 49 lesions were additionally detected lesions on DCE-MRI. DCE-MRI alone showed 97% SE, 18% SP, and 69% PPV. The combined MRI protocol produced 97% SE, 71% SP, and 86% PPV, and showed statistically significant increase of SP ( P <0.01) and PPV
( P =0.02). PPV of combined MRI protocol for larger lesions (100%) was higher than that of smaller lesions
(76%), however, combined DWI increased PPV similarly for larger lesions and small lesions.
CONCLUSION
The combined DWI to DCE-MRI has the potential to increase the SP and PPV to diagnose multifocal and multicentric breast cancer.
CLINICAL RELEVANCE/APPLICATION
The addition of DWI can decrease the false positive diagnosis and this is recommended in preoperative staging of breast cancer.

BRS249
BRE235
BRE200
Incidence of Internal Mammary Lymph Nodes on Breast MRI Following Oncoplastic Surgery (Station
#6)
Elizabeth Jennifer Watson MD, MPH : Nothing to Disclose , Elizabeth J. Sutton MD (Presenter): Nothing to
Disclose , Girard Gibbons BA : Nothing to Disclose , Elizabeth A. Morris MD : Nothing to Disclose
PURPOSE
Breast cancer oncoplastic surgery allows a tandem approach to treatment and reconstruction, which may involve silicone implant placement. Postoperatively, magnetic resonance imaging (MRI) can diagnose silicone implant rupture. Enlarged internal mammary lymph nodes (IMLN) can develop after silicone implant placement but inaccessibility makes tissue diagnosis difficult. The purpose of this study was to assess among women with a history of breast cancer and silicone implant placement, the incidence of benign and malignant internal mammary lymph nodes on MRI.
METHOD AND MATERIALS
This retrospective study received institutional review board approval and need for informed consent waived.
Between 2000-2013, we identified women who had: a) breast cancer, b) oncoplastic surgery, c) postoperative implant protocol MRI. Clinical and pathologic data were collected. Short and long axis measurements of the largest IMLN, per side, were recorded. A benign IMLN was defined as having, at minimum, two years of either:
1) imaging stability and/or 2) no clinical evidence of recurrent disease. A malignant IMLN was defined if patient had biopsy proven metastatic disease.
RESULTS
956 women with breast cancer were identified who underwent oncoplastic surgery and a postoperative implant protocol MRI (n=552 bilateral and n=404 unilateral). The mean time between surgery and MRI was 84.4
months (range 0.5-512 months). 32 percent of patients (n=306) had IMLN. Mean short and long axis measurements were 0.5 cm (SD 0.2) and 0.7 cm (SD 0.3), respectively. ILMN were significantly more likely to be benign than malignant (p<0.05). Less than 5% of IMLN were metastatic.
CONCLUSION
IMLN identified on silicone implant protocol breast MRI following oncoplastic surgery for breast cancer are significantly more likely to be benign than malignant. The results support imaging follow-up instead of immediate metastatic work-up
CLINICAL RELEVANCE/APPLICATION
IMLN identified on implant protocol MRI are probably benign and imaging follow-up should be considered instead of an immediate work-up to exclude metastatic disease.
The Sonographic Appearance of Benign Masses of the Breast in Children and Adolescents (Station
#7)
Karina Pesce : Nothing to Disclose , Flavia Beatriz Sarquis MD (Presenter): Nothing to Disclose , Monica
Colombo : Nothing to Disclose , Eun Ae Park : Nothing to Disclose , Bernardo Oscar Blejman MD : Nothing to Disclose
TEACHING POINTS
1-To recognize the normal ultrasound appearance of the breast in children and adolescents 2- To describe benign masses of the breast in children and adolescents 3- To recognize the ultrasound characteristics of the benign breast masses in children and adolescents.
TABLE OF CONTENTS/OUTLINE
1-Introduction 2- Normal Breast Development. Stages of Tanner 3- Sonographic normal appearance of the breast in children and adolescents 4- Spectrum of benign masses of the breast in children and adolescents: the sonographic appearance. 5-Clinical cases 6-Conclusion
Nipple Discharge: Evaluation, Diagnosis, and Management (Station #8)
Lilian Wang MD (Presenter): Nothing to Disclose , Ellen Bachman Mendelson MD : Research support,
Siemens AG Speakers Bureau, Siemens AG Medical Advisory Board, Quantason, LLC Consultant, Quantason, LLC
TEACHING POINTS
The purpose of this exhibit is to review the causes, imaging findings, and management of benign and malignant nipple discharge. In patients with negative mammography and ultrasound and unsuccessful ductography, MRI is an important adjunct imaging modality in nipple discharge evaluation.
TABLE OF CONTENTS/OUTLINE
1. Distinguish clinically benign and suspicious nipple discharge. 2. Discuss pathologic entities responsible for nipple discharge. 3. Review imaging modalities used in nipple discharge evaluation with sample cases: a.
Mammography b. Ultrasound c. Ductography d. MRI 4. Discuss management of nipple discharge with review of current literature.

BRE183
From Lymphoma to Melanoma: Metastatic Disease to the Breast and Axilla from Extramammary
Malignancies (Station #9)
Kopal Shama Kulkarni MD (Presenter): Nothing to Disclose , Ashley Cimino-Mathews MD : Nothing to
Disclose , David J. Eisner MD : Nothing to Disclose , Ergeba H. Sheferaw MD, MPH : Nothing to Disclose ,
Bonmyong Lee MD : Nothing to Disclose , Susan Caroline Harvey MD : Nothing to Disclose , Dorothy Amy
Sippo MD : Nothing to Disclose
TEACHING POINTS
The purpose of this exhibit is:
1) To review the sources of metastatic disease to the breast and axilla.
2) To explain how metastatic disease can spread to the breast via either hematogenous or lymphatic routes.
3) To review the clinical and imaging presentations of metastatic disease to the breast and axilla.
TABLE OF CONTENTS/OUTLINE
Overview of metastatic disease to the breast and axilla: -Frequency of occurrence -Sources of metastatic malignancy -Routes of spread -Hematogenous -Lymphatic Clinical presentation Review of imaging findings
Sample cases -Lung cancer -Adenocarcinoma -Squamous cell carcinoma -Lymphoma/leukemia -Melanoma
-Ovarian cancer -Plasmacytoma -Renal cell carcinoma Other breast lesions that may have imaging features similar to metastatic disease -Complicated cyst -Invasive ductal carcinoma -Invasive lobular carcinoma
Summary
BRE008-b When Cancer's Not the Answer: A Radiologic Review of Infectious and Inflammatory Breast
Pathologies (hardcopy backboard)
Nancy Anne Resteghini DO, MS (Presenter): Nothing to Disclose , Sue A. MacMaster MD : Nothing to
Disclose , Rebecca Hultman DO : Nothing to Disclose
TEACHING POINTS
1. To review imaging presentations of commonly encountered breast infections in both healthy and immunocompromised women. Cases will include: subareolar abscess, infected sebaceous cyst, mastitis, fat necrosis, post-biopsy infection, and Filariasis. 2. To review imaging presentations of inflammatory breast conditions such as Granulomatous Mastitis, Breast Amyloidosis and Diabetic Mastopathy. 3. To present imaging features that are important for the radiologist to be able to identify to characterize infectious and inflammatory lesions. 4. To provide a multimodality pictorial review of pathologies of the infected or inflamed breast, while highlighting optimal imaging modalities.
TABLE OF CONTENTS/OUTLINE
1. Overview of multimodality imaging appearance of common infectious and inflammatory breast pathologies. 2.
Present imaging examples of infectious and inflammatory breast pathologies: Subareolar abscess, infected sebaceous cyst, cellulitis, mastitis, fat necrosis, post-biopsy infection and Filariasis Granulomatous Mastitis,
Breast Amyloidosis and Diabetic Mastopathy 3. Review relevant clinicopathologic features and radiologic manifestations of each pathologic process. 4. Discuss the diagnostic value of each modality, and the importance of differentiating infection and inflammation from breast malignancy
Scientific Posters
GI
AMA PRA Category 1 Credits ™ : .50
Mon, Dec 1 12:15 PM - 12:45 PM Location: GI Community, Learning Center
Participants
Moderator
Rizwan Aslam MBBCh : Research support, Bayer AG
Sub-Events
GIS337 Reducing Beam Hardening Artifact by Monochromatic Images with CT Spectral Image: Comparison with Traditional Polychromatic X-ray Imaging—Quantitative Study in Phantom (Station #1) chunwu zhou : Nothing to Disclose , Xinming Zhao MD : Nothing to Disclose , Liming Jiang MD : Nothing to Disclose , Ning Guo : Nothing to Disclose , Zheng Zhu : Nothing to Disclose , Jing Zhao (Presenter):
Nothing to Disclose
PURPOSE
Use a quantitative phantom to evaluate the ability of beam hardening artifact (BHA) reduction by monochromatic images with CT spectral image by comparison with traditional polychromatic X-ray imaging
(TPXI).

GIS338
METHOD AND MATERIALS
A cyclical phantom with diameter of 25cm (Quantitative Standard Pulsating Phantom QSP-1, Fuyo Corporation) was used. Three fresh pig humerus bones and three 10mm-diameter tubes filled with iodine contrast were placed in the center of periphery of the phantom to mimic human's bones and arteries. The phantom with bones and tubes was immersed in a water tank. Under the condition of helical scan with 120kVp, the CT value of three bones were 1025Hu, 905Hu and 770Hu respectively, the CT value of three tubes were 1200Hu, 1000Hu and 840Hu respectively. Both CT spectral imaging mode (protocol A) and routine CT mode (protocol B) with
120kV and 600mA were used. The other scan parameters were the same for two protocols, including FOV of
25.0cm, slice thickness of 5mm, rotation speed of 0.8s/r and pitch of 0.984. Both the monochromatic images
(40-140keV, interval of 10keV) and 120kV TPXI images were reconstructed. Beam hardening artifact index was calculated for each image, according the fomular: BHA index=SQRT(ROIa^2-ROIb^2), where ROIa denotes to the SD value of water in the region adjacent to tubes with obvious BHA, ROIb denotes the SD value of water in the region far away from tubes and bones without obvious BHA. The area of ROIa and ROIb were both about
50mm2. Data was compared with rank sum test.
RESULTS
The BHA index of 120kV TPXI image was 20.45±6.30. The BHA index of each monochromatic image set
(ranging from 1.17±0.86 to 9.72±1.32) was lower than that of 120 TPXI image (p<0.001). Monochromatic images at 80keV had the lowest BHA index (1.17±0.86). The variation of BHA index at 90keV to 140 keV(3.13±0.46 to 4.71±1.03) was smaller than that at 40keV to 70keV(9.72±1.32 to 3.28±0.26)(p<0.01).
CONCLUSION
Monochromatic images have less beam hardening artifact than TPXI images, high keV images(80keV-140keV) are superior to low keV images(40keV-70keV).
CLINICAL RELEVANCE/APPLICATION
CT spectral image provides less beam hardening artifact and more accurate CT attenuation number, which may help clinical diagnosis.
Imaging Outcomes of Liver Imaging Reporting and Data System (LI-RADS) 2, 3 and 4 Categories on
CT and MR Examination (Station #2)
Masahiro Tanabe MD (Presenter): Nothing to Disclose , Eduardo Almeida Cunha Costa MD : Nothing to
Disclose , Marilia Fortes MD : Nothing to Disclose , Omid Yeganeh MD : Nothing to Disclose , Tanya
Wolfson MS : Nothing to Disclose , Claude B. Sirlin MD : Research Grant, General Electric Company
Speakers Bureau, Bayer AG Consultant, Bayer AG , Michael Simca Middleton MD, PhD : Consultant, Allergan,
Inc Institutional research contract, Bayer AG Institutional research contract, sanofi-aventis Group Institutional research contract, Isis Pharmaceuticals, Inc Institutional research contract, Johnson & Johnson Institutional research contract, Synageva BioPharma Corporation Institutional research contract, Takeda Pharmaceutical
Company Limited Stockholder, General Electric Company Stockholder, Pfizer Inc Institutional research contract,
Pfizer Inc
PURPOSE
The Liver Imaging Reporting and Data System (LI-RADS) released by the ACR is a comprehensive system for standardized interpretation and reporting of CT and MR examinations performed in patients at risk for hepatocellular carcinoma (HCC). The purpose of this study was to assess imaging outcomes of LR-2 (probably benign), LR-3 (intermediate probability for HCC) and LR-4 (probable HCC) observations. Specifically, we sought to determine the proportion of LR-2, LR-3, and LR-4 observations that, during clinical imaging follow-up and in the absence of treatment progress regress or remain stable in category code.
METHOD AND MATERIALS
This was a retrospective, observational, longitudinal, single-center study of patients who underwent clinical CT or MRI examinations for surveillance for or diagnosis of HCC.
RESULTS
The final study cohort had 158 patients (87 men, 71 women; mean age 59.0 years). All patients had chronic liver disease, and most had cirrhosis. The patients had a total of 284 observations (LR-4 [n = 53], LR-3 [n =
170], and LR-2 [n = 61]). Among the 53 LR-4 observations, 18 (34%) progressed to LR-5 during follow-up (15 within six months, one within 12 months, two at more than 12 months), 25 (47%) remained stable, and 9
(17%) regressed in category. Among 170 LR-3 observations, 7 (4%) progressed to LR-5 during follow up (0 within six months, two within 12 months, and five at more than 12 months), 10 (6%) progressed to LR-4, 47
(28%) remained stable, and 106 (62%) regressed to LR-1 or LR-2. All 61 LR-2 observations remained stable or regressed during follow-up.
CONCLUSION
LR-2, LR-3, and LR-4 observations have different imaging outcomes. One-third of LR-4 observations progressed to LR-5 within 6 months. Most LR-3 observations remained stable or regressed. All LR-2 observations remained stable or regressed.
CLINICAL RELEVANCE/APPLICATION

GIS339
GIS341
The LI-RADS categories were developed mainly by expert opinion. This study provides preliminary validation of the LR-2, LR-3, and LR-4 categories by showing that they have different imaging outcomes.
Locally-advanced Pancreatic Adenocarcinoma: Reassessment of Response with CT Scan after
Neoadjuvant Chemoradiotherapy (Station #3)
Christophe Cassinotto MD (Presenter): Nothing to Disclose , Jean-Pierre Lafourcade : Nothing to Disclose ,
Amaury Mouries : Nothing to Disclose , Bruno Lapuyade : Nothing to Disclose , Eric Terrebonne : Nothing to Disclose , Herve Trillaud MD : Nothing to Disclose , genevieve belleannee : Nothing to Disclose ,
Laurence Chiche MD : Nothing to Disclose , christophe laurent : Nothing to Disclose , Michel Montaudon
MD : Nothing to Disclose
PURPOSE
To prospectively evaluate the ability of CT scan to determine tumor response and predict resectability after neo-adjuvant chemo-radiotherapy (CRT) in patients with non-metastatic locally-advanced pancreatic cancer
(LAPC).
METHOD AND MATERIALS
This study received ethics approval, and all participants provided written informed consent. We prospectively enrolled consecutive patients with cephalic LAPC who underwent surgical exploration and/or resection following neoadjuvant CRT from June 2009 to May 2013. Two radiologists independently analyzed the baseline and post-CRT CT scans recording the size, attenuation, and circumferential vascular contacts of the tumor.
Associations between the post-operative histological grade of tumor response (pTNM) and the clinical, biological and CT scan criteria were assessed using Spearman's correlation coefficients. CT scan criteria related with the presence of R0 resection were assessed using logistic regression.
RESULTS
Forty-seven patients were included, 33 with R0 resection, and 14 with R1 or no resection. Variables demonstrating a significant correlation with the histological tumor classification of tumor response were: post-CRT CA19-9 level (r=0.46), post-CRT tumor largest axis (r=0.44), post-CRT largest+small axis (r=0.46), change in largest axis (r=0.31), change in largest+small axis (r=0.39), change in SMV/Portal vein contact
(r=-0.38), and post-CRT SMA contact (r=0.34). Partial regression of tumor contact with the SMV/Portal vein was associated in all cases with R0 resection (10/10 patients, PPV = 100%), and partial regression of tumor contact with any peripancreatic vascular axis was associated with R0 resection in 91% of cases (20/22 patients,
PPV = 91%). Persistence of SMV/Portal vein stenosis after CRT was not predictive for R1 resection.
CONCLUSION
Partial regression of tumor-vessel contact indicates suitability for surgical exploration, irrespective of the degree of decrease in tumor size or the degree of residual vascular involvement.
CLINICAL RELEVANCE/APPLICATION
CT criteria based on the degree of tumor to vessel contact could provide valuable assistance in making decisions about therapy after completion of neo-adjuvant chemo-radiotherapy.
Evaluation of Tumor Recurrence after Whipple Surgery Using ssDECT (Station #4)
Manuel Patino MD (Presenter): Nothing to Disclose , Jorge Mario Fuentes MD : Nothing to Disclose ,
Pritesh Patel MD : Nothing to Disclose , Avinash Ranesh Kambadakone MD, FRCR : Nothing to Disclose ,
Dushyant V. Sahani MD : Research Grant, General Electric Company
PURPOSE
To evaluate performance of Single source Dual-energy CT (ssDECT) in detection of local recurrence on post
Whipple patients compared to conventional single-energy CT scans.
METHOD AND MATERIALS
Thirty-five patients (17 males; 18 females) with history of pancreatic adenocarcinoma and Whipple procedure
(0.1 to 5 years after the procedure) underwent a follow up ssDECT (GE-CT750 HD, 140/80 kV). Two blinded radiologists independently reviewed the 140 kVp and DECT processed iodine and monochromatic images in a separate session for the presence of local recurrence, liver metastasis, and surgical complications and provided recommendations. Multiple follow up studies, tumor markers (CA-19.9) and histology served as standard reference. Quantitative analysis of the iodine concentration in the surgical bed was performed, and subsequently compared for post-operative changes and recurrence using t-test.
RESULTS
15 patients had local recurrence and 20 showed expected post-operative changes. The sensitivity and specificity for SECT for local recurrence was 75% and 65% for R1, and 70% and 65% for R2 and for DECT it was 86% and 75% for R1, and 83% and 70% for R2. Interobserver agreement for DECT was good with a kappa value of
0.7. Iodine concentration was different in patients with local recurrence vs. those with expected changes (p
CONCLUSION ssDECT shows higher sensitivity and specificity for diagnosing local recurrence detection after Whipple surgery compared to SECT. Tumor recurrence can be differentiated from normal post operatory changes based on iodine quantification.
CLINICAL RELEVANCE/APPLICATION
Distinction between normal postoperative changes vs. tumor recurrence after Whipple procedure impacts

GIS343
GIS345 patient management, and can be challenging on conventional CT. DECT have potential to overcome these limitations by mapping the iodine distribution within tumor and normal tissue.
Spectral CT in Rabbit VX2 Liver Tumors: Image Fusion Technology Associated with Monochromatic
Image (Station #6)
Wang Mingyue (Presenter): Nothing to Disclose , Jianbo Gao MD : Nothing to Disclose , Zhou Yue :
Nothing to Disclose
PURPOSE
To evaluate the value of image fusion technology associated with monochromatic image of spectral CT
METHOD AND MATERIALS
Twenty-four rabbits with VX2 liver tumors underwent spectral CT, On the 8th day after implantation. The conventional 140kVp polychromatic images (QC) and monochromatic images with energy level from 40 to 14o keV were generated. In the arterial phase the optimal CNR keV (OP) and 70keV were choosen and the fusion image (OP+70)keV was generated from OP plus 70keV. The tumor-to-liver contrast-to-noise ratio (CNR) and image noise 0f the four groups were calculated. The lesion conspicuity scores(LCS) and overall image quality scores(OQS) in the four groups were recorded.
RESULTS
The CNR of the group (OP+70) had no significant differences from that of the group OP, but the image noise of group (OP+70) was significantly lower than that of group OP (2.63±2.59vs2.81±2.74,p=0.288;9.12±1.28
vs7.89±1.35,p=0.002),the CNR of the OP and (OP+70) were significantly higher than that of group
70(1.92±2.39,p
CONCLUSION
Image fusion technology associated with monochromatic image of spectral CT which combine the advantage of high CNR and the advantage of low noise, improve the lesion detection and image quality.
CLINICAL RELEVANCE/APPLICATION improve the lesion detection and image quality
Hepatic Steatosis after Percutaneous Intraportal Pancreatic Islet Transplantation (PIPIT) in 108
Allo-and Auto-Transplanted Patients: Can Ultrasound Predict the Clinical Outcome? (Station #8)
Giulia Agostini (Presenter): Nothing to Disclose , Massimo Venturini MD : Nothing to Disclose , Giulia
Querques : Nothing to Disclose , Paola Maffi : Nothing to Disclose , Antonio Secchi : Nothing to Disclose ,
Alessandro Del Maschio MD : Nothing to Disclose
PURPOSE
PIPIT is a less invasive, repeatable therapeutic option in brittle type 1 diabetes, compared to surgical pancreas transplantation: it can be performed after kidney-transplantation (IAK), alone (ITA) in type-1 diabetic pts without chronic renal insufficiency, or as an autotransplantation (IAT) after pancreatectomy
(immunosuppression unnecessary). Steatosis is a consequence of the islets' engraftment: its meaning is controversial. Our retrospective longitudinal study aimed to assess hepatic steatosis incidence at ultrasound
(US) after islet auto- and allotransplantation, and to identify any relationship with graft function.
METHOD AND MATERIALS
From 1989 to 2012, 108 pts (33 IAK, 50 ITA, 25 IAT) underwent PIPIT, which is performed under a combined
US and fluoroscopic guidance. US was performed at baseline/6/12/24 months. Steatosis first detection/prevalence/duration/distribution were recorded. Steatosic (S) and non-steatosic patients (NS) were compared for the following parameters at baseline/6/12/24 months: insulin-independence-rate, ß-score,
C-peptide, glycated-hemoglobin, exogenous-insulin-requirement, fasting-plasma-glucose, infused-islet-mass.
C-peptide is the traditional marker of islet function, but ß-score is a more comprehensive parameter, including all the previously mentioned ones.
RESULTS
Steatosis was found in 21/108 pts, 24% (20/83) allotransplanted, 4% (1/25) autotransplanted (better outcome), with first detection at 6 months, highest prevalence at 1 year (18 cases). Infused-islet-mass was significantly higher in S than NS patients (IE/kg: S=10.822; NS=6.138). Metabolically, S pts had worse basal conditions (ß score: S=1.7 ± 1.6; NS=2.8 ± 2.8), but better islet function at the time of steatosis first detection
(ß score: S=3.9 ± 2.0; NS=2.9 ± 2.3), after which a progressive islet exhaustion, along with steatosis disappearance, was observed. Conversely, in NS pts these parameters remained more stable in time.
CONCLUSION
Steatosis at US seems to be related to islet mass and overworking activity. Presence of steatosis precedes metabolic alterations, can predict graft dysfunction addressing therapeutic decisions before islet exhaustion.
Absence of steatosis doesn't allow any conclusion.
CLINICAL RELEVANCE/APPLICATION
Steatosis at US precedes metabolic alterations and can predict graft's dysfunction addressing to therapeutic decisions before islet exhaustion. If steatosis doesn't appear, no conclusion can be drawn.

GIE197
GIE179
GIE267
GIE144
Liver Imaging: Review of Commonly Used and Developing MRI Techniques (Station #9)
Wirana Angthong MD (Presenter): Nothing to Disclose , Vithya Varavithya : Nothing to Disclose ,
Panitpong Maroongroge : Nothing to Disclose , Wichet Piyawong MD : Nothing to Disclose , Kaan
Tangtiang MD : Nothing to Disclose , Surachate Siripongsakun MD : Nothing to Disclose
TEACHING POINTS
The purpose of this exhibit is:
- To review the clinical usefulness of commonly used MRI techniques and provide the indication/ limitation for those sequences
- To explain the utility of developing MRI techniques and their application in clinical practice
- To review common pitfalls and problem solving in interpretration of liver imaging
TABLE OF CONTENTS/OUTLINE
1. Overview commonly used MRI techniques - In/ opposed-phase images Detection chemical shift cancellation artifact Pronounce T2* and susceptibility artifacts on images with long TE - T2W Multishot T2W (FSE) with respiratory trigger Single shot T2W (ssFSE) - Balanced gradient echo - Pre-and dynamic post contrast 3D-GE
T1W/FS - Hepatocyte-specific contrast agent Characterization of focal hepatic lesions Interpretation challenge in cirrhotic nodules 2. Developing MRI techniques - Diffused weighted imaging Qualitative and quantitative assessment Cirrhotic patient for HCC detection and evaluation of response to treatment - High flip-angle
Gadoxetic acid imaging
The Powerful Role of of Barium Esophagorgraphy in Detection of Important Thoracic Esophageal
Pathologies (Station #10)
Babak Maghdoori BEng, MD (Presenter): Nothing to Disclose , Nasir M. Jaffer MD : Nothing to Disclose ,
Seng Thipphavong MD : Nothing to Disclose
TEACHING POINTS
1. Anatomy: review of esophagography specific anatomy 2. Barium esophagography: understanding of proper technique & correct imaging acquisition 3. Esophageal structural disorders: systematic approach to important structural pathologies, barium esophagography imaging of select diseases, & their corresponding radiological interpretations 4. Esophageal motility disorders: systematic approach to important motility pathologies, barium esophagorgraphy imaging of select pathologies, & their corresponding radiological interpretations
TABLE OF CONTENTS/OUTLINE
1. Esophageal anatomy a. Normal & barium esophagography-specific anatomy 2. Barium Esophagography a.
Appropriate Contrast agents barium b. Proper technique, image acquisition, & appropriate/timely utilization 3.
Structural esophageal disorders a. Important cases of thoracic esophagus structural pathologies i.
Pathophysiology, epidemiology, & clinical context ii. Pertinent barium esophagorgraphy interpretations & caveats/pitfalls 4. Motility esophageal disorders a. Important cases of thoracic esophagus motility pathologies i.
Pathophysiology, epidemiology, & clinical context ii. Pertinent barium esophagorgraphy interpretations & caveats/pitfalls 5. Summary
Radiology for Dysphagia: When the Endoscopy Cannot Help (Station #11)
Alberto Ivo Carbo MD (Presenter): Nothing to Disclose , Sana Naeem MD : Nothing to Disclose , Meghna
Chadha MD, MBBS : Nothing to Disclose
TEACHING POINTS
• To discuss causes and pathophysiology of dysphagia that can be diagnosed by radiology. Pharynx: motility disorders. Upper esophageal sphincter: diminished opening, delay opening, early closing. Esophagus: webs, motility disorders, severe strictures, perforations, extrinsic compressions • To analyze the contribution of radiology in the diagnosis of causes of dysphagia that cannot be solved by endoscopy
TABLE OF CONTENTS/OUTLINE
• The symptom of dysphagia • Anatomy and pathophysiology of dysphagia • Imaging techniques • Pharyngeal swallowing abnormalities • Cricopharyngeal dysmotilities • Pharyngoesophageal webs • Esophageal motility disorders • Pharyngoesophageal tears and perforations • Severe pharyngeal and esophageal strictures •
Extrinsic compressions • Conclusions
Three-Dimensional Ultrasonography of Biliary Tract Disorders (Station #12)
Jessica Kurian MD (Presenter): Nothing to Disclose , Susan Judith Frank MD : Nothing to Disclose ,
Benjamin Taragin MD : Nothing to Disclose
TEACHING POINTS
The purpose of this exhibit is to describe the use of three-dimensional ultrasonography (3DUS) in diagnosis of congenital and acquired biliary tract disorders. Teaching points include: 1. Review the current literature pertaining to 3DUS and the biliary tract 2. Review the basic technical aspects of 3DUS 3. Understand the normal appearance of the biliary tract on 3DUS 4. Illustrate the 3DUS features of various biliary tract disorders 5. Using examples, discuss the role of 3DUS in biliary tract imaging, including advantages and disadvantages, comparison to CT, MRCP and ERCP, and potential future directions
TABLE OF CONTENTS/OUTLINE

GIE015-b
TABLE OF CONTENTS/OUTLINE
1. 3DUS technique 2. 3DUS of the normal biliary tract 3. Case examples of biliary pathology illustrated by 3DUS.
The entities presented will include but are not limited to: Cholelithiasis and choldeocholithiasis, cholangiocarcinoma and gallbladder carcinoma, adenomyomatosis, gallbladder polyps, choldeochal cyst 4.
Future directions and summary
Use of a Staged US and CT Protocol to Diagnose Acute Appendicitis in Adults (hardcopy backboard)
Menaka Nadar MD (Presenter): Nothing to Disclose , Arun Krishnaraj MD, MPH : Nothing to Disclose
TEACHING POINTS
1. To review the current ACR guidelines for imaging in patients with suspected acute appendicitis. 2. To review the US findings of acute appendicitis. 3. To explain the role of US in diagnosing acute appendicitis in appropriately selected adults.
TABLE OF CONTENTS/OUTLINE
1. Presentation/workup of acute appendicitis 2. ACR guidelines for imaging patients with suspected acute appendicitis 3. US findings in acute appendicitis 4. Staged US and CT protocol for imaging appropriately selected adults with suspected appendicitis -US evaluation of the appendix can be effective at diagnosing appendicitis in a variety of patients -US first can avoid unnecessary radiation and is lower cost than CT -In cases of a nonvisualized appendix, but inflammatory changes in the right lower quadrant (i.e. free fluid or increased echogenicity within the surrounding fat), CT is recommended for further evaluation. -In cases of equivocal ultrasound, further evaluation with CT or other imaging can be performed as clinically indicated. 5. Limitations of ultrasound in imaging adults with suspected appendicitis -BMI
Scientific Posters
MK
AMA PRA Category 1 Credits ™ : .50
Mon, Dec 1 12:15 PM - 12:45 PM Location: MK Community, Learning Center
Participants
Moderator
Soterios Gyftopoulos MD : Nothing to Disclose
Sub-Events
MKS351 Long Head of Biceps Tendon (LHBT) Instability Due to Biceps Pulley Lesion of the Shoulder:
Arthro-MRI including “Functional” Images vs Arthroscopy (Station #1)
Silvia Mariani MD (Presenter): Nothing to Disclose , Alice La Marra MD : Nothing to Disclose , Emanuele
Costantini MD : Nothing to Disclose , Francesco Arrigoni : Nothing to Disclose , Antonio Barile MD :
Nothing to Disclose , Carlo Masciocchi MD : Nothing to Disclose
PURPOSE
To evaluate the added value of the internal and external rotation and abduction and external rotation (ABER) images during arthro-MRI in identifying the LHBT instability and the possible development of an antero-superior impingement (ASI).
METHOD AND MATERIALS
We retrospectively analyzed MRI exam of 70 patients who underwent arthro-MRI (1.5T) and arthroscopy within the following 7-45 days. Patients had clinical suspicion of biceps pulley lesions. The shoulder was studied (with dedicated coil) in neutral position, in internal and external rotation and ABER position in all patients.
RESULTS
Patients were divided in 4 groups (Habermayer classification) and evaluated for an unstable LHBT:10 patients had superior gleno-humeral ligament (SGHL) tear (Type I),16 patients SGHL and supraspinatus (SSP) tendon tears (Type II),21 patients SGHL and subscapularis (SSC) tendon tears (Type III) and 23 patients SGHL, SSP and SSC tears (Type IV). At arthroscopy 2 patients were negative,8 patients had Type I,16 patients Type II,19 patients Type III and 25 patients Type IV lesions. MRI internal and external rotation showed an initial anteromedial subluxation of the LHBT in 8 patients with Type II lesion and an anteromedial subluxation of the
LHBT in all patients with Type III and Type IV lesions. ABER position showed gleno-humeral antero-superior malalignment in 14 cases. The dynamic tests during arthroscopy, confirmed LHBT instability and ASI features in patients with Type III and Type IV lesions and antero-superior malalignment only in 9 cases.
CONCLUSION
Only high grade lesions of the biceps pulley can be associated with LHBT instability and antero-superior gleno-humeral malalignment. MRI external and internal rotation led to a better identification of structures of the biceps pulley and the detection of LHBT instability could suggest the presence of ASI.
CLINICAL RELEVANCE/APPLICATION

MKS352
MKS353
"Functional" MRI images allow a dynamic evaluation of the LHBT and of the antero-superiror aspect of the gleno-humeral joint; these structures often result unstable in presence of an ASI type III and type IV confirmed by arthroscopic dynamic tests.
Delaminated Tears of the Rotator Cuff: Prevalence, Characteristics and Diagnostic Accuracy on
Indirect MR Arthrograph (Station #2)
Hye Jung Choo MD : Nothing to Disclose , Gi Won Shin MD (Presenter): Nothing to Disclose , Sun Joo
Lee MD : Nothing to Disclose , Young Mi Park MD, PhD : Nothing to Disclose , Young Jun Cho : Nothing to Disclose , Seok Jin Choi : Nothing to Disclose
PURPOSE
The presence of delaminated tears of the rotator cuffs has been reported as a negative prognostic factor after rotator cuff repairs. However, there are a few radiologic reports about delaminated tears of the rotator cuff. In this study, the prevalence, characteristics, and diagnostic accuracy of delaminated tears at the supraspinatus-infraspinatus tendons (SST-IST) were evaluated on indirect MR arthrography.
METHOD AND MATERIALS
Indirect MR arthrography of 231 shoulders with tears at the SST-IST were included. On MR images, the delaminated tears at the SST-IST, defined as an intratendinous horizontal splitting between the articular and bursal layers of the SST-IST and/or different degree of retraction between the two layers, were identified and classified into six types: articular-delaminated full-thickness tear, bursal-delaminated full-thickness tear, interstitial-delaminated full-thickness tear, articular-delaminated partial-thickness tear, bursal-delaminated partial-thickness tear and interstitial-delaminated partial-thickness tear. Other radiologic findings such as the presence of intramuscular cysts and footprint tears were evaluated. Based on the review of video records of 127 arthroscopic surgeries, the diagnostic accuracy of indirect MR imaging for the detection of the delaminated tears was determined.
RESULTS
On MR imaging, 56% (129/231) of shoulders with SST-IST tears had delaminated tears. Articular-delaminated full-thickness tears (n = 58) and articular-delaminated partial-thickness tears (n = 64) were the most common types. About 82% (36/44) of articular-delaminated full-thickness tears occurring at the SST were combined with articular-delaminated partial-thickness tears at the IST. SST-IST footprint tears and intramuscular cysts were significantly more common in the shoulders with delaminated tears ( p = 0.007 and 0.01 respectively).
The sensitivity and specificity of indirect MR arthrography for detection of delaminated tears were 93% and
95%, respectively.
CONCLUSION
On MR imaging, about half of the shoulders with SST-IST tears were combined with delaminated tears. The diagnostic accuracy of indirect MR arthrography for detection of delaminated tears was high.
CLINICAL RELEVANCE/APPLICATION
On MR imaging, about half of the shoulders with SST-IST tears were combined with delaminated tears. The diagnostic accuracy of indirect MR arthrography for detection of delaminated tears was high.
Serial Ultrasonography after Arthroscopic Repair of Rotator Cuff Tear: Temporal Evolution of
Sonographic Findings (Station #3)
Hye Jin Yoo MD (Presenter): Nothing to Disclose , Ja-Young Choi MD : Nothing to Disclose , Sung Hwan
Hong MD : Nothing to Disclose , Yusuhn Kang MD : Nothing to Disclose , Jina Park MD : Nothing to
Disclose , Ji Young Kim MD : Nothing to Disclose
PURPOSE
To evaluate the serial changes in the sonographic findings of repaired tendon after rotator cuff repair with serial ultrasound examinations
METHOD AND MATERIALS
Sixty five arthroscopically repaired rotator cuff tears (44 full-thickness tears, 21 partial-thickness tears) were retrospectively included in this study. Serial ultrasound examinations were performed at 5 weeks, 3 months, and 6 months after surgery. Sonographic findings of the repaired tendon were assessed in terms of presence of retear, tendon thickness, morphologic tendon characteristics, and vascularity, bursitis at each time point.
RESULTS
Four recurrent tears were occurred within 3 months of surgery. Postoperative tendon thickness decreased from
5 weeks to 6 months following surgery (r=-0.245; p=0.001). There were significant changes in the morphologic tendon characteristics including echotexture, fibrillar pattern, and surface irregularity of repaired tendon from 5 weeks to 6 months following surgery. The subacromial subdeltoid(SDAD) bursitis and vascularity of repaired tendon were also decreased postoperatively over time.

MKS354
MKS355
CONCLUSION
Serial ultrasound examinations after arthroscopic rotator cuff repair were useful to monitor the postoperative changes of repaired tendon. Morphologic appearances of repaired tendon and peritendinous soft tissue changes were improved over time and nearly normalized within 6 months of surgery.
CLINICAL RELEVANCE/APPLICATION
Serial ultrasound examinations can monitor the postoperative changes of repaired tendon and is recommended as a follow-up imaging modality in the early postoperative period after arthroscopic rotator cuff repair
Ultra-high Field Analysis of Knee Cartilage in a Sheep Model by Means of Quantitative T2 Mapping
Using 7T MRI and Histological Validation (Station #4)
Milena L. Pachowsky MD (Presenter): Nothing to Disclose , Siegfried Trattnig MD : Nothing to Disclose ,
Kolja Gelse MD : Nothing to Disclose , Joachim Friske : Nothing to Disclose , Martin Brix : Nothing to
Disclose , Goetz Hannes Welsch MD : Nothing to Disclose
PURPOSE
T2 mapping at 7T might help to understand the development of osteoarthritis (OA) and of integration processes after cartilage repair procedures, i.e. autologous chondrocyte transplantation (ACT). Purpose of this study is to determine biochemical properties of cartilage in a sheep model, using biochemical MRI by means of quantitative
T2-mapping and establish a histological validation.
METHOD AND MATERIALS
Three groups of sheep (healthy cartilage, n=30, a model of osteoarthritis (post meniscectomy), n=30, and sheep with cartilage defects at the femoral condyle treated by ACT, n=15) were examined. MR scans were achieved at 7T MR whole body system (Magnetom, Siemens Healthcare, Erlanen, Germany) using a 28-channel transmit/receive knee array coil. T2 relaxation maps were measured by a sagittal multi-echo spin sequence. TR
5260ms; TE 12, 24, 36, 48, 60, and 72ms; FOV 145x145mm, 716x869 matrix size; BW 180 Hz/pixel, slice thickness 2mm; flip angle 145°. Semi-automatic region-of-interest analysis was performed. For stratification with regards to anatomical (collagen) structure, subregional analysis was done (deep - superficial cartilage layer). Results were compared to histological findings. Statistical analysis-of-variance was performed.
RESULTS
In healthy cartilage, T2 values averaged 41,92ms (SD 11,7) in the superficial layer and 32,69ms (SD 9,74) in the deep layer. OA showed results of 60,90ms (SD 14,34) in the superficial layer and 47,28ms (SD 13,54) in the deep layer. After ACT results averaged at 58,41ms (SD 15,53) in the superficial and 45,66 (SD 20,81) in the deep layer. Increase of T2 values between deep and superficial zone was highly significant in the group with healthy cartilage, significant in the OA model and the ACT group. OA and ACT group showed significantly higher values compared to healthy cartilage. Comparison between histological scoring and MR findings showed a significant correlation.
CONCLUSION
The sheep model shows differences between healthy cartilage, OA and cartilage repair sites in T2 mapping. Our new approach at 7T gives additional information about the imaging techniques of the ultra-structure of cartilage and provides one of the very few histological validations of T2 mapping in vitro.
CLINICAL RELEVANCE/APPLICATION
The presented study of T2 mapping in a sheep model and histological validation is an important approach towards establishing T2 mapping of articular cartilage in clinical appplication.
Diffusion Tensor Imaging, T2 Mapping, and Various Fat Suppression Imaging in Early State of
Denervated Skeletal Muscle: Experimental Study in Rats (Station #5)
Dong-Ho Ha (Presenter): Nothing to Disclose , Hwan Tae Park : Nothing to Disclose , Sunseob Choi MD,
PhD : Nothing to Disclose
PURPOSE
To simultaneously evaluate the sequential alteration of the DTI indices, T2 values and subjective visual signal intensity change on various fat suppression techniques in the early state of denervated skeletal muscle in the rat model.
METHOD AND MATERIALS
Institutional animal use and care committee approval was obtained. Complete neurotmesis of the sciatic nerve of 8 white rats was performed. We examined MR studies of the normal muscle and follow-up studies at 3 days,
1 week, and 2 weeks after surgery. FA, mADC and T2 values ware measured at the calf muscles. We also subjectively graded visual signal intensity change on CHESS, STIR and IDEAL imaging. Statistical significances were obtained.
RESULTS
FA values at 3 days (0.35±0.06, P=0.012), 1 week (0.29±0.04, P=0.017), 2 weeks (0.34±0.05, P=0.017)

MKS356
MKS357 were significantly lower than that in control group (0.54±0.17). The mADC of the all follow up periods decreased, but statistically insignificant. T2 values began to increase at three days without statistical significance (34.08±1.42, P=0.069), significantly increased at 2 weeks (38.11±6.41, P=0.017) and marked increased at 2 weeks (46.53±5.17, P=0.012), compared with control group (32.71±1.33). Visual signal intensity changes were variously at 1 week and more prominent at 2 weeks. Grading the lesions was identical in all cases.
CONCLUSION
FA and T2 values will be effective parameters to observe the early state of denervated skeletal muscle.
CLINICAL RELEVANCE/APPLICATION
The calculation of FA and T2 value wiil be effective noninvasive methods for the evaluation of acute skeletal deneravated muscle, even though it has various limitations. Fat suppression techniques did not affect the early detection of high signal abnormality on T2 weighted image and grading of lesion.
Tarsal Navicular Bone Size in Diabetics: Radiographic Assessment (Station #6)
Elie Harmouche (Presenter): Nothing to Disclose , Douglas D. Robertson MD, PhD : Nothing to Disclose ,
Geza Kogler PhD, DPhil : Nothing to Disclose , Minzhi Xing MD : Nothing to Disclose , Tharwat Mahmoud
El Zahran MD : Nothing to Disclose , Michael R. Terk MD : Nothing to Disclose
PURPOSE
To test the anecdotal observation that isolated navicular collapse is associated with diabetes mellitus, we quantified the size of the tarsal navicular in subjects with and without diabetes and tested for association of size with age, height, weight, body mass index (BMI), gender, smoking, bone mineral density (BMD), duration and level of control of diabetes.
METHOD AND MATERIALS
Ankle radiographs of 200 patients (122 females; 78 males; mean age 58 years [27-89]), 100 with type II diabetes and 100 age-gender matched controls were selected and reviewed. The anteroposterior (AP) dimension of the mid navicular bone was measured from lateral radiographs. For standardization, the superoinferior (SI) dimension of the calcaneal was measured and the navicular-calcaneus ratio calculated.
Statistical evaluation included independent sample t- tests and linear regression analyses.
RESULTS
Diabetic subjects had a significantly smaller navicular AP dimension and navicular-calcaneus ratio compared to controls (p=0.02 and p=0.0001, respectively). Age, gender, height and duration of diabetes had no association with the navicular-calcaneus ratio. Navicular-calcaneus ratio was inversely correlated with weight (p=0.01) and
BMI (p<0.001) and directly correlated with smoking (p=0.04).
CONCLUSION
The navicular anteroposterior dimension is smaller in type II diabetic subjects compared to age-gender matched controls. We hypothesize that this is due to navicular collapse whose cause is multifactorial.
CLINICAL RELEVANCE/APPLICATION
This study associates diabetes with dimensional changes in the tarsal navicular and expands our knowledge of the effect diabetes on the bony foot.
Evaluation of a Simplified Version of the Rheumatoid Arthritis Magnetic Resonance Imaging Score
(RAMRIS) Comprising 5 Joints (RAMRIS5) (Station #7)
Christoph Schleich (Presenter): Nothing to Disclose , Falk Roland Miese MD : Nothing to Disclose , Philipp
Sewerin : Nothing to Disclose , Benedikt Ostendorf : Nothing to Disclose , Gerald Antoch MD : Speaker,
Siemens Medical AG Speaker, Bayer AG Speaker, BTG International Ltd , Christian Buchbender : Nothing to
Disclose
PURPOSE
Semi-quantitative measurement of inflammatory pathologies of the hand in magnetic resonance images (MRI) is a mandatory, but time-consuming task for MRI controlled studies in Rheumatoid Arthritis (RA). The objective of this study was to evaluate a simplified version of the Rheumatoid Arthritis Magnetic Resonance Imaging Score
(RAMRIS) reduced to five joints of the hand (RAMRIS5).
METHOD AND MATERIALS
94 patients with rheumatoid arthritis (62 female, 32 male; age 59 ±12 years, range 25 - 83 years; disease duration 5 ±7.5 years) from the REMISSION PLUS study cohort who had complete files on C-reactive protein
(CRP) levels and Disease Activity Score of 28 joints (DAS28) and completed MRI of the clinical dominant hand at baseline and after one year under anti-rheumatic therapy (follow-up time 12.5 ± 3.5 months) in a dedicated extremity MRI scanner at 0.2T were included in this retrospective study. MR images were scored according the
RAMRIS criteria by two readers in consensus. Spearman correlations of the RAMRIS sum-score, subscores for
RAMRIS of the metacarpophalangeal joints (RAMRISMCP), wrist (RAMRISWrist) and a reduced score comprising the MCP 2 - 5 and the intercarpal joint were assessed. Additionally, Spearman correlations of MRI scores, CRP

MKE230
MKE304 the MCP 2 - 5 and the intercarpal joint were assessed. Additionally, Spearman correlations of MRI scores, CRP levels and DAS28 were calculated.
RESULTS
There was a strong correlation between RAMRIS5 and the RAMRIS sum-score for all patients (r =0.88, p<0.05) at baseline and follow up (r =0.83, p< 0.05). Among the subscores there was a good correlation between
RAMRIS5 and RAMRISMCP (baseline: r=0.64, p<0.05; follow-up: r=0.74, p< 0.05) as well as between
RAMRIS5 and RAMRISwrist (baseline: r=0.75, p< 0.05, follow-up: r = 0.63, p<0.05) at baseline and follow up.
The correlation between RAMRIS5 and CRP (baseline: r=0.13, p<0.05; follow-up: r=0.03, p<0.05) or DAS28
(baseline: r=0.15, p<0.05; follow-up: 0.30, p<0.05) were weak, just like it was observed for regular RAMRIS
(CRP baseline: r=0.18, p<0.05; follow-up: r=0.11, p<0.05; DAS28 baseline: r=0.21, p<0.05; follow-up: r=0.33, p< 0.05).
CONCLUSION
RAMRIS5, a modified shorter RAMRIS score based on five joints of the hand is a viable tool for semi-quantitative assessment and monitoring of joint damage in RA.
CLINICAL RELEVANCE/APPLICATION
RAMRIS5 can be used as a time and resource saving alternative for semi-quantitative description of inflammatory joint changes and therapy monitoring in MRI-controlled studies in RA and for clinical therapy response assessment in RA .
What’s In a Name? Review of Specialized Radiographic Views and Stress Radiography for
Musculoskeletal Trauma (Station #8)
Chris R. Smith MD (Presenter): Nothing to Disclose , Robert J. Talbert MD : Nothing to Disclose , Sanjeev
Bhalla MD : Nothing to Disclose , Michael V. Friedman MD : Nothing to Disclose , Travis J. Hillen MD :
Consultant, Biomedical Systems Consultant, Vidacare Corporation , Jonathan Craig Baker MD : Research
Consultant, Biomedical Systems
TEACHING POINTS
The standard radiographic series is not always sufficient to diagnose and characterize subtle musculoskeletal injuries. Specialized views and stress radiography help to detect and delineate subtle fractures, ligament injuries, and joint abnormalities. Radiologists should be familiar with these important but less common examinations, which yield valuable supplemental information that affects treatment decisions. Teaching Points:
Review the limitations of the standard musculoskeletal radiographic examination and frequently missed injuries.
Review important supplemental views, many of which are known by eponyms, and stress radiographic examinations. Review proper positioning and technique for each view, including important landmarks radiologists can use to assess the quality of the study. Understand key anatomy through 3D surface-rendered
CT images. Review the additional clinical information each specialized study provides over the standard radiographic series through illustrative cases.
TABLE OF CONTENTS/OUTLINE
Review of commonly missed injuries
Specialized radiographic views and stress radiography
When to use each view
Patient positioning and technique
3D surface-rendered CT images of anatomic landmarks
Cases illustrating clinical utiility of each specialized study
Summary
Ultrasound-guided Gadolinium Joint Injections for Magnetic Resonance Arthrography: A
Step-by-Step Approach (Station #9)
Kimberly Ruth Gardner MD (Presenter): Nothing to Disclose , Brian Manfredi MD : Nothing to Disclose ,
Hsiu Su MD : Nothing to Disclose
TEACHING POINTS
At the conclusion of this presentation, the learner should be able to:
1. Recognize the advantages of ultrasound-guided over landmark-based or fluoroscopically-guided approaches to joint injection with gadolinium prior to arthrography.
2. Gain knowledge of pre-procedural considerations and contraindications.
3. Become familiar with the step-by-step procedure for ultrasound-guided gadolinium shoulder, elbow, wrist, hip and knee injections prior to magnetic resonance arthrography, including technical factors such as ultrasound probe selection and imaging parameters.
TABLE OF CONTENTS/OUTLINE
1. Introduction: The Increasing Role of Sonography in Musculoskeletal Diagnostics and Therapeutics 2.
Advantages of Ultrasound-guided over Landmark-based or Fluoroscopically-guided Approaches 3.
Pre-Procedural Considerations a) Clinical History b) Prior Imaging c) Current Medications and Allergies d)

MKE128
MKE313
MKE286
MKE246
Contraindications 4. Technical Factors a) Probe Selection b) Imaging Parameters 5. Injection Preparation 6.
Step-by-Step Procedure for Ultrasound-guided Hip, Knee, Shoulder, Elbow and Wrist Injections a) Patient
Position b) Needle Approach c) Joint Space Injection under Direct Sonographic Visualization 7. Post-Procedure
Considerations/Complications including suboptimal gadolinium injection
MSK Imaging: Manifestations of Granulomatous Disease (Station #10)
Mariko Fitzgibbons MD (Presenter): Nothing to Disclose , Kira Chow MD : Nothing to Disclose , Sulabha
Masih MD : Nothing to Disclose
TEACHING POINTS
1) Review the immunologic basis of granulomas 2) Review of the pathogens and immune processes leading to granuloma formation 3) Case-based review of musculoskeletal manifestations of granulomatous disease such as sarcoidosis, tuberculosis, coccidioidomycosis, and epidermal inclusion cysts.
TABLE OF CONTENTS/OUTLINE
Discussion will begin with the definition of a granuloma and a discussion of the types of granulomatous disase.
This will be a case based presentation of various MSK granulomatous process. Imaging modalities: XR, US,
PET/CT, CT, MRI 1) Sarcoidosis Bone marrow, soft tissue changes 2) Atypical Mycobacterial Septic arthritis 3)
Tuberulosis Various manifestations including: Dactylitis, osteomyelitis, Pott's disease, soft tissue infections 4)
Coccidioidomycosis Septic arthritis, lytic lesions 5) Epidermal inclusion cyst
Dermatofibrosarcoma Protuberans, A Rare Skin Lession That Radiologists Should Think about
(Station #11)
Claudia Leticia Hernandez Mejia (Presenter): Nothing to Disclose , JESUS JIMENEZ DEL RIO : Nothing to
Disclose , Maria Isabel Fernandez Martinez : Nothing to Disclose , Angeles Ramirez Escobar : Nothing to
Disclose , MARIA SANCHEZ PEREZ : Nothing to Disclose , Johanna Marisol Silva MD : Nothing to Disclose
TEACHING POINTS
To review the dermatofibrosarcoma protuberance tumor and discuss its key radiological findings. To explain the role of radiology in the follow-up and gain awareness of skin lesions found in different imaging techniques.
TABLE OF CONTENTS/OUTLINE
When we come across a soft tissue mass identifying its origins (epidermis, dermis or hypodermis) can be of help. Also we have to consider the location within the body and the age of the patient in order to narrow down the differential diagnosis. Dermatofibrosarcoma protuberance (DFSP) is the most common mesenchymal superficial malignancy. It originates from the dermis. The peak age is between 20 and 40 years old. It affects more frequently men than woman (not in our series) and is most commonly seen on the trunk. It can recur and rarely metastasizes. We will show its key feature image on MR, CT and ultrasonography with a series obtained at our institution. We reviewed 40 cases from January 1998 until mars 2014. We found 20 males and 20 females (mean age 44 years, age range 22 to 71 years). Only 1 recurrence has been reported (9 years after the original lesion). It is important to have free margins after resections otherwise a recurrence could happen and long term follow up is needed. That is why we need to understand post treatment imaging changes and differentiate it from local recurrence.
Maneuvering Around Metal: Total Joint Arthroplasy Imaging and MR Metal Suppression Sequences
(Station #12)
Brett S. Talbot MD (Presenter): Nothing to Disclose , Eric P. Weinberg MD : Nothing to Disclose
TEACHING POINTS
The purpose of this educational exhibit is to:
1) Provide an overview of current metal suppression sequences, including a discussion of key concepts in the associated MR physics.
2) Demonstrate an extensive series of cases where metal suppression plays a key role in the diagnosis of total arthroplasty complications.
3) Place emphasis on specific findings in total knee and total hip arthroplasty on metal-suppressed MR imaging.
TABLE OF CONTENTS/OUTLINE
-Basic approaches to metal suppression such as metal artifact reduction sequence (MARS). -Discussion of more contemporary approaches including WARP (MARS with view angle tilting - VAT), SEMAC, and MAVRIC. -MR physics discussion including limitations (inability to perform fat saturation, possibility of increased imaging time). -Field strength comparison including degrees of susceptibility artifact at 1.5 and 3.0 T. Specific complications to be discussed include: Metallosis Particle Disease Infection (acute and chronic) Loosening
Tendon injury Muscle injury
Evaluation of the Intraarticular Portion of the Biceps Brachii Tendon at the Shoulder with
Ultrasound: Anatomy, Pathology and New Maneuver of Mick Jagger Position (Station #13)
Guillermo Andres Azulay MD : Nothing to Disclose , Patrick Omoumi MD (Presenter): Nothing to Disclose ,
Daniel Postan : Nothing to Disclose , Gabriel Hector Aguilar MD : Nothing to Disclose , Rafael Barousse
MD : Nothing to Disclose , Ignacio Rossi : Nothing to Disclose , Ariel Franz Gonzales Nogales MD, PhD :
Nothing to Disclose
TEACHING POINTS

It is essential to understand the dynamics of the intraarticular portion of the biceps tendon in relation to shoulder movement for the ultrasound examination. A maneuver in abduction and internal rotation (Mick Jagger position) can help to visualize the intraarticular portion of the biceps tendon and its pathology.
TABLE OF CONTENTS/OUTLINE
1. Anatomy: - Cadaveric study illustrating the anatomy of the intraarticular portion of the biceps tendon, the relationship between the tendon and its surrounding structures, the position of the technique in relationship to the shoulder movements. 2. Detailed ultrasound technique: - Description of the Mick Jagger position - Optimal acoustic window 3. Normal ultrasonographic aspects 4. Pathological ultrasonographic aspects
MKE018-b Basic Principles and Applications of Dual Energy Computed Tomography (DECT) in Gout (hardcopy backboard)
Shima Aran MD (Presenter): Nothing to Disclose , Frank J. Simeone MD : Nothing to Disclose ,
Khalid Walid Shaqdan MD : Nothing to Disclose , Elmira Hassanzadeh MD : Nothing to Disclose ,
Efren Jesus Flores MD : Nothing to Disclose , Hani H. Abujudeh MD, MBA : Research Grant, Bracco Group
Consultant, RCG HealthCare Consulting Author, Oxford University Press
TEACHING POINTS
There are many exciting new applications for advanced imaging in gout. Dual energy CT (DECT) can differentiate urate crystals from calcium by using specific attenuation characteristics and reveal even small occult tophaceous deposits. DECT can also be used for serial volumetric quantification of subclinical tophi to evaluate response to treatment. We plan to expose radiologists to a series of challenging cases to understand how this unique and clinically relevant modality can facilitate diagnosis and management of gout.
TABLE OF CONTENTS/OUTLINE
1. Physical principles of DE or spectral CT on basis of photoelectric and Compton interactions as well as material decomposition. 2. Available techniques of DE data acquisition, for example, dual source CT scanners, fast kilovoltage switching and sandwich detector tech¬niques. 3. Image processing and reconstruction of DECT data. 4. Clinical application of DECT for diagnosis and management of gout. 5. Sample cases. 6. Limitations of
DECT in the musculoskeletal imaging such as the effects on image quality, artifacts and radiation dose.
Education Exhibits
OT
AMA PRA Category 1 Credits ™ : .50
Mon, Dec 1 12:15 PM - 12:45 PM Location: MS Community, Learning Center
Sub-Events
MSE013-b 105 Years of Conventional Dacryocistography Nowdays Technique and Advances (hardcopy backboard)
Felipe Aluja MD (Presenter): Nothing to Disclose , Rodolfo Alberto Mantilla Espinosa MD : Nothing to
Disclose , Jorge O. Suarez MD : Nothing to Disclose
TEACHING POINTS
Review the technique of dacryocystography that was originally described by Ewing in 1909 using bismuth subnitrate as contrast media. It was the first method used to evaluate the lacrimal drainage system. Describe the lacrimal drainage system anatomy in dacryocystography including essential structures as Rosenmüller valve, Krause valve and Hasner valve. Recognize nasolacrimal drainage system pathologies, specially causes of obstruction as infectious, inflammatory, congenital, tumoral and traumatic. Discusses and illustrate other imaging methods including ultrasound, computed tomography, magnetic resonance imaging and nuclear medicine.
TABLE OF CONTENTS/OUTLINE
Introduction
Anatomy of the lacrimal drainage system
Conventional dacriocystography technique
Obstruction of the lacrimal drainage system
Other imaging methods
Conclusions
MSE102 Fungus Among Us: Spectrum of Imaging Findings in Coccidiomycosis (Station #1)
Asha Goud MD (Presenter): Nothing to Disclose , Neil Patel MD : Nothing to Disclose
TEACHING POINTS
Coccidioidmycosis, commonly known as Valley Fever, is caused by a fungus found in the soil of dry areas and is endemic to the southwestern United States. At least 30-60% of people who live in an endemic area are infected

at some point in their lives. The infection is spread through inhalation of particles and travelers passing through endemic areas may also contract the disease. Clinical manifestations range from minor respiratory illness that clears on its own to severe multi-organ system disseminated disease. The goals of this exhibit are to become familiar with the clinical manifestations be able to identify the spectrum of multi organ system imaging findings
TABLE OF CONTENTS/OUTLINE
1. Background 2. Clinical manifestations and laboratory/imaging findings of Valley Fever. 3. An emphasis is placed on wide range of imaging findings and dissemination patterns to various organ systems on mutliple modalities (CT, US, NM, and MRI) including: pulmonary musculoskeletal ocular gastrointestinal lymphatic systems. 4. Conclusion: Each year there are over 150,000 cases of Valley Fever, however, there is little public awareness of this disease. Knowledge of the wide spectrum of imaging findings are essential in the diagnosis and management
Scientific Posters
PH
AMA PRA Category 1 Credits ™ : .50
Mon, Dec 1 12:15 PM - 12:45 PM Location: PH Community, Learning Center
Participants
Moderator
Paul L. Carson PhD : Research collaboration, General Electric Company Research collaboration, Light Age, Inc
Moderator
Patrick J. La Riviere PhD : Research funded, Toshiba Corporation
Sub-Events
PHS137 Dual-sided Breast Ultrasound in Mammographic Positions and Potential Spatial Correlation with
Digital Breast Tomosynthesis (DBT) (Station #1)
Won-Mean Lee MS (Presenter): Nothing to Disclose , Eric D. Larson : Nothing to Disclose , Mitchell M.
Goodsitt PhD : Research collaboration, General Electric Company , Oliver D. Kripfgans : Research support,
General Electric Company Equipment support, General Electric Company , Marilyn A. Roubidoux MD :
Research Consultant, Delphinus Medical Technologies, Inc , Sushma Alvar PhD : Nothing to Disclose ,
Heang-Ping Chan PhD : Institutional research collaboration, General Electric Company , Paul L. Carson PhD
: Research collaboration, General Electric Company Research collaboration, Light Age, Inc
PURPOSE
We describe a prototype dual-sided breast ultrasound system 'BLUCI' that scans the compressed breast in the same orientations as clinical mammograms. We report 1) BLUCI design and performance, 2) technologist technique and gel containment apparatuses and 3) image processing techniques to segment, register, and combine BLUCI ultrasound (US) and digital breast tomosynthesis (DBT) volumes.
METHOD AND MATERIALS
Women with breast masses are imaged in two separate systems. BLUCI is a modified commercial mammography system with ultrasound-compatible fabric compression paddles. BLUCI acquires two US volumes, top-down and bottom-up, that provides greater lesion conspicuity throughout the breast as compared to single-sided US. Each frame is acquired 800 µm apart and is spliced into a single volume of 200 mm x 70 mm x 80 mm. A combined single-sided US and DBT system, or 'CINDI', generates co-registered single-sided US and
DBT volumes. When scanning, the technologist compresses the breast in the same position for both systems and applies ultrasound coupling gel using rubber gel dams and gel-filled cloth rolls. Dual-sided US, single-sided
US, and DBT volumes are registered automatically using calibrated mechanical offsets and manually by a simple translation. These two alignment methods were compared to determine whether registration offers a significant advantage over mechanical offsets to radiologists locating homologous lesions.
RESULTS
Preliminary results show that the registration offsets needed to align a homologous lesion between all three volumes are often large and quite variable. Registering dual-sided US and DBT volumes from two separate systems required 8.3±12.0 mm, 22.4±27.3 mm, and -7.0±8.0 mm in the anterior-posterior, transverse, and cranial-caudal axes, respectively (n = 8).
CONCLUSION
The BLUCI-CINDI workstation allows viewing of three image volumes in two modalities side-by-side with registered region-of-interest tools. Preliminary results indicate that image registration is often needed to align a homologous lesion among all three image volumes. Automated probe alignment and reader study graphical user interface are currently being developed.
CLINICAL RELEVANCE/APPLICATION
We aim to refine and evaluate a dual-sided breast ultrasound system that can provide an additional imaging modality for radiologists as an adjunct clinical mammography or DBT.

PHS138
PHS139
Using Multiresolution Texture Analysis of B-mode Ultrasound Images to Identify Vulnerable
Asymptomatic Plaque (Station #2)
Spyretta Golemati (Presenter): Nothing to Disclose , Symeon Lehareas : Nothing to Disclose , Nikolaos
Tsiaparas : Nothing to Disclose , Achilleas Chatziioannou : Nothing to Disclose , Despina Perrea : Nothing to Disclose , Konstantina Nikita PhD : Nothing to Disclose
CONCLUSION
Ultrasound-image-based texture is promising toward improved assessment of cardiovascular risk.
Background
Valid identification of the vulnerable asymptomatic carotid atherosclerosis remains a crucial clinical issue.
Multiresolution texture analysis has been shown to characterise atheromatous tissue, especially in terms of horizontally oriented texture in longitudinal B-mode sections. We investigated these texture properties at three distinct areas of the diseased arterial wall (the plaque, the wall adjacent to it and the plaque shoulder, i.e. the boundary between plaque and wall), in an attempt to describe tissue discontinuities along the asymptomatic arterial wall.
Evaluation
We interrogated 25 arteries, 11 with low (50-69%) and 14 with high (70-100%) stenosis degrees. The two groups had similar ages. Multiresolution analysis was performed using wavelet packets and the coiflet1 wavelet, for three levels of decomposition. At the first decomposition level, four subimages were derived, including one approximation and three detail subimages (horizontal, vertical and diagonal). At each subsequent level, four subimages were derived from each subimage of the previous level. Seven horizontal detail subimages were retained and their mean and standard deviations were the derived texture features, yielding a total of fourteen features, each estimated at systole and diastole. Between high and low stenosis cases, 9 features were statistically different (Wilcoxon rank sum test, p-value<0.05) in the plaque shoulder at systole and 4 at diastole. No differences were observed for the site of the plaque nor for the wall adjacent to it. Texture differences along the wall (wall - shoulder - plaque) were more pronounced in high stenosis cases; in these cases, the plaque had significantly different texture compared to its shoulder and the adjacent wall.
Discussion
The plaque shoulder provides valuable information about the pathophysiology of atherosclerosis. Cardiac systole highlights better tissue texture properties. Texture variability along the atherosclerotic wall, which is indicative of tissue discontinuities, and proneness to rupture, can be quantitatively described with texture indices.
Capability of 3D Ordered Subset Expectation Maximization (OSEM) Reconstruction Algorithm in
Performing Half-time Myocardial Perfusion Imaging Studies (Station #3)
Chung Ting Tang MSc, BSC : Nothing to Disclose , Martin Wai-Ming Law PhD (Presenter): Nothing to
Disclose , Cheuk Man Tong : Nothing to Disclose , Ting Kun Au Yong MBChB : Nothing to Disclose , K. K.
Wu MBChB : Nothing to Disclose , Y H Hui MBChB : Nothing to Disclose
PURPOSE
This study is to investigate the capability of the compensate of the collimator detector response embedded in the 3D OSEM reconstruction algorithm and whether the compensation would allow the acquisition time of the
Myocardial Perfusion Imaging Studies to be halved.
METHOD AND MATERIALS
An Anthropomorphic torso phantom and a cardiac phantom were used in this study. The cardiac phantom have three defects, the first defect, volume 5.1ml is located in between the mid/basal anterolateral region, the second defect, volume 2.9ml is in the mid inferoseptal region and the third defect is an air bubble, volume about 2ml, located in between the apex and apical anterior region. The cardiac phantom and the liver compartment of the Torso phantom were injected with 0.25mCi of Tc99m and SPECT images were acquired using different scanning protocol (Full-time and Half-time) with Low energy high resolution (LEHR) and Low energy all purpose (LEAP) collimators. The measurement was repeated using TI-201. Acquired data were reconstructed using Filtered Back Projection (FBP) and 3D OSEM and were analyzed by two Nuclear Medicine
Physicians.
RESULTS
For the SPECT images acquired using both LEHR and LEAP collimators, defects in the cardiac phantom were more visible in the half-time SPECT images reconstructed using 3D OSEM compared to the images reconstructed with Full-time FBP for both Tc99m and TI-201 using LEHR and LEAP collimators.
CONCLUSION
3D OSEM has showed its capability to perform half-time Myocardial Perfusion Imaging studies. The quality of the Half-time Myocardial Perfusion Images reconstructed using 3D OSEM is equally relevant or better to
Full-time images reconstructed using FBP.
CLINICAL RELEVANCE/APPLICATION
The examination time and the examination waiting time of Myocardial Perfusion Imaging could be shorten.

PHS140
PHS141
In Vivo Proof of Principle: X-ray Dark-field Radiography for Diagnosis of Lung Fibrosis (Station #4)
Katharina Hellbach MD (Presenter): Nothing to Disclose , Andre Yaroshenko : Nothing to Disclose , Oliver
Eickelberg : Nothing to Disclose , Martin Bech : Nothing to Disclose , Maximilian F. Reiser MD : Nothing to
Disclose , Ali Onder Yildirim : Nothing to Disclose , Franz Pfeiffer : Nothing to Disclose , Felix G. Meinel MD
: Nothing to Disclose
PURPOSE
The aim of this study was to evaluate whether it is possible to visualize pulmonary fibrosis in vivo using X-ray dark-field imaging and whether dark-field radiography has incremental diagnostic value in diagnosing fibrosis compared to conventional transmission images.
METHOD AND MATERIALS
Pulmonary fibrosis was induced by orotracheal injection of bleomycin (2.5U/kg BW, n=6). Control mice (n=5) received orotracheal injection of PBS. All mice (female C57Bl/6N) were examined 14 days after application of bleomycin or PBS. A prototype grating-based small animal scanner was used for image acquisition. Images were processed using Fourier decomposition thus generating transmission as well as dark-field radiographs.
Mice were breathing freely during image acquisition. Before sacrificing the animals pulmonary function tests were performed. Lungs were obtained for further histopathological analysis (e.g. tissue ratio).
RESULTS
As confirmed by histopathological analysis and pulmonary function tests mice in the bleomycin group had developed fibrosis: Tissue ratio was significantly higher for fibrotic (51.8% ± 9.6) than for control lungs (37.7%
± 1.7; p < 0.05). Dynamic compliance was significantly lower for the bleomycin (0.0121 ml/cmH2O ± 0.0022) than for the PBS group (0.0214 ml/cmH2O ± 0.0003; p < 0.001). Correspondingly, tissue elastance was significantly higher for mice suffering from fibrosis (85.0 cm H2O/ml ± 15.7) compared to healthy mice (37.7
cm H2O/ml ± 9.6; p < 0.01). Fibrotic areas within the lungs resulted in a strong decrease in dark-field signal intensity (figure1). This change in signal intensity was easier to detect in dark-field than in transmission images.
CONCLUSION
With this study we were able to show for the first time that in vivo visualization of pulmonary fibrosis is feasible using dark-field radiography. Moreover, changes in dark-field signal intensity can be detected more readily than corresponding changes in transmission signal strength.
CLINICAL RELEVANCE/APPLICATION
Dark-field imaging yields a stronger contrast for lung imaging than conventional absorption and has, therefore, a high potential for pulmonary imaging. This study reveals that it is easier to detect pulmonary fibrosis relying on dark-field images, when compared to conventional absorption-based imaging. With further technical development this implies that fibrosis could be detected at early stages without the use of CT.
Contrast-to-Noise Ratio Comparison in Single and Dual-energy Mono-energetic CT Imaging (Station
#5)
Joshua Grimes PhD (Presenter): Nothing to Disclose , Gregory James Michalak PhD : Nothing to Disclose ,
Ahmed Halaweish PhD : Employee, Siemens AG , Joel Garland Fletcher MD : Grant, Siemens AG ,
Cynthia H. McCollough PhD : Research Grant, Siemens AG
PURPOSE
The purpose of this study was to a) determine the improvement in the maximum iodine CNR when images are processed with the Mono-energetic Plus (Mono+) algorithm compared to the previous mono-energetic algorithm
(Mono), and b) compare the maximum achievable CNR with Mono+ with that obtained using single-energy (SE) scans.
METHOD AND MATERIALS
Objects containing various concentrations of iodine and calcium hydroxyapatite were placed within torso-shaped water phantoms ranging in lateral width from 15 to 45 cm and scanned on a dual-source CT system (Siemens
Somatom Force). Single energy scans were performed at x-ray tube potentials from 70-150 kV, and dual energy (DE) scans were performed using a tube potential paring of 90/150Sn kV. Mono-energetic images were generated using commercial software (syngo Via Dual Energy, VA30) at energies of 40-110 keV using both
Mono and Mono+. Iodine contrast to noise ratio (CNR) was calculated using the mean (and standard deviation) of the CT numbers in iodine and water from respective regions-of-interest in 10 consecutive images.
RESULTS
Mono+ increased the maximum achievable CNR by an average of 45% as compared to Mono by causing an increase in CNR with a decrease in photon energy below 70 keV. However, the maximum CNR was achieved at
70 kV (SE) in the 15-35 cm phantoms, and 80 kV (SE) in the 45 cm phantom. Mono+ achieved the maximum
CNR (30% higher than that of SE) in the 45 cm phantom. CNR obtained using Mono (DE) was on average 67% of that achieved with SE (range 53-91%), while the CNR achieved using Mono+ (DE) was on average 97% of that achieved with SE (range 78-130%).
CONCLUSION
The use of Mono+ greatly increased the CNR of mono-energetic images compared to Mono at each mono-energetic setting (keV value), but especially for settings below 70 keV. The maximum achievable CNR in
DE images was improved such that it nearly matched that achievable in SE scanning.

PHS142
PHS143
DE images was improved such that it nearly matched that achievable in SE scanning.
CLINICAL RELEVANCE/APPLICATION
Mono+ can be used to achieve a CNR that is comparable to optimized SE scanning, while allowing the flexibility to perform material discrimination or decomposition tasks.
Dual-energy Subtraction Radiography in Cystic Fibrosis (Station #6)
Verena Obmann MD (Presenter): Nothing to Disclose , Zsolt Szucs-Farkas MD, PhD : Nothing to Disclose ,
Andreas Christe : Nothing to Disclose , Sebastian Ott : Nothing to Disclose , Enno Stranzinger MD :
Nothing to Disclose
PURPOSE
Imaging plays a crucial role in the evaluation and management of patients with cystic fibrosis. More accurate assessment of the disease state enables a targeted therapy of this chronic lung disease. The primary goal is the improvement of the quality of life and prolongation of the life expectancy. The aim of the study is to evaluate the diagnostic benefit of Dual-Energy subtraction (DE-) radiography in comparison with conventional radiographs (CR) in adult patients with cystic fibrosis (CF).
METHOD AND MATERIALS
49 DE-radiographs of 24 adult patients (16 males, 8 females) with cystic fibrosis (median age 32 years, range
18-71 years) were included in the study. Lung function tests (FEV1%/predicted and FVC%/predicted) were performed within 10 days of the radiography. Two radiologists (13 and 3 years of experience) evaluated all CR
(PA view only) in a blinded and randomized order. In a second reading all DE-radiographs were evaluated together with the CR one month later. The modified Chrispin Norman score (CNS), including the extend of over inflation, bronchial line, ring, mottled and large shadows, was used to assess changes in the lung parenchyma.
A five point score was used to determine the diagnostic confidence of all pulmonary findings. The Wilcoxon statistics and the Spearman's rank-test were used to compare the CNS of conventional and DE-radiographs and to correlate CNS with the lung function tests.
RESULTS
CNS of both the CR images and DE-radiographs correlated significantly with FEV1% (R= -0.729 and -0.659;
P<0.001) and FVC% (R= -0.709 and -0.628; P<0.001), differences between correlation coefficients of CR and
DE were not significant (P= 0.113 and 0.174, respectively). A higher confidence was achieved with
DE-radiographs compared to radiographs alone (median, 3.6 vs 3.4; P= 0.01).
CONCLUSION
DE-radiographs are well suited for the evaluation of patients with CF. A good correlation with the clinical parameters was observed. The confidence of the readers to interpret pulmonary changes in CF is significantly higher with DE radiographs. However, considering the higher radiation dose of DE radiographs, the diagnostic benefit for the patients with cystic fibrosis compared to CR was statistically not significant.
CLINICAL RELEVANCE/APPLICATION
DE-subtraction radiography provides lung images without the superimposition of the bones. Pulmonary changes in cystic fibrosis can be detected with higher diagnostic confidence than with CR.
Automatic Detection of Bladder Mass Lesions within Contrast Enhanced Region in CTU (Station #7)
Kenny Heekon Cha MSc (Presenter): Nothing to Disclose , Lubomir M. Hadjiiski PhD : Nothing to Disclose ,
Heang-Ping Chan PhD : Institutional research collaboration, General Electric Company , Richard H. Cohan
MD : Consultant, General Electric Company Consultant, Medscape, LLC , Elaine M. Caoili MD, MS : Nothing to
Disclose , Jun Wei PhD : Nothing to Disclose
PURPOSE
To develop a computer-aided diagnosis system for bladder lesion detection in CT urography, which potentially can assist radiologists in detecting bladder cancer.
METHOD AND MATERIALS
Initially, the bladder was automatically segmented by our previously developed Conjoint Level set Analysis and
Segmentation System (CLASS). In this preliminary study, we focused on detecting mass lesions within the contrast-enhanced (C) region of the bladder as a prescreening step. The C region was delineated from the segmented bladders using a method based on maximum intensity projection. The bladder wall of the C region was extracted by using adaptive thresholding to remove the contrast material, and transformed into a profile of wall thickness normal to the wall surface. The morphology and voxel intensity along the profile were analyzed and suspicious locations were labeled as lesion candidates. With IRB approval, a data set of 70 patients with
102 biopsy-proven bladder lesions within the C region was collected. All lesions were marked by experienced radiologists in the CTU volumes as reference standard and rated by their conspicuity. The cases were split evenly into independent training and test sets. The training set contained 30 subjects having 37 malignant and
9 benign lesions with average size of 20.1 mm (range: 4.2-61.7 mm). The test set contained 33 subjects having 47 malignant and 9 benign lesions with average size of 18.8 mm (range: 1.4-61.1 mm). The average lesion conspicuity rating in both sets was 2.2 (scale 1 to 5, 5 very subtle).

PHS144
RESULTS
Our system detected 78% (36/46) of the bladder lesions with 3.5 (123/35) false positives per patient in the training set, and 77% (43/56) of bladder lesions with 4.4 (155/35) false positives per patient in the test set.
The false negatives were mainly caused by the non-uniformity of the contrast material, camouflaging the lesions as a part of the bladder wall.
CONCLUSION
Our study demonstrates the feasibility of our method for detection of bladder lesions within the contrast-enhanced region of the CTU for lesions of a variety of shapes and sizes. Further work is underway to increase the sensitivity and reduce the false positives, and to detect lesions in the entire bladder.
CLINICAL RELEVANCE/APPLICATION
Early detection of bladder cancer is crucial for improved patient survival. This study shows a CAD system useful for automatic bladder cancer detection within the contrast-enhanced region of CTU.
Web-based Nuclear Medicine Quality Assurance Tool (Station #8)
Paul Stauduhar (Presenter): Nothing to Disclose , Osama R. Mawlawi PhD : Research Grant, Siemens AG
Research Grant, General Electric Company
CONCLUSION
We have developed a unique QA program and website in order to remotely monitor nuclear medicine scanners.
The tool, which is freely available, aids in the assessment of system performance and error prediction in order to take pre-emptive action.
Background
The quantification and standardization of quality assurance are necessary for error prediction and performance assessment so that pre-emptive actions can be taken. Currently there are no tools that easily consolidate and present daily or other QC data for PET/Gamma Cameras (GC) which allow remote viewing or trend analysis. We believe that by making use of data that exist on PET/GC, an internal webpage and analysis program can be developed in order to facilitate the monitoring of these systems.
Scientific Posters
MK
AMA PRA Category 1 Credits ™ : .50
Mon, Dec 1 12:45 PM - 1:15 PM Location: MK Community, Learning Center
Sub-Events
MKS358 Quantification of Rotator Cuff Muscle Atrophy: A Retrospective Study Comparing Ultrasound to MRI
(Station #1)
Christian Sander Geannette MD : Nothing to Disclose , Yoshimi Endo MD (Presenter): Nothing to Disclose ,
Ronald Steven Adler MD, PhD : Nothing to Disclose
PURPOSE
Assessment of echogenicity provides a measure of muscle atrophy during routine shoulder US. However, muscle echogenicity is subjective with significant inter- and intra-observer variability. This study sought to determine the value of quantifying muscle echogenicity in order to estimate the degree of rotator cuff atrophy as determined by MRI.
METHOD AND MATERIALS
This was a retrospective review of patients who underwent ultrasound and MR shoulder examinations. The supraspinatus (SSM), infraspinatus (ISM) and teres minor (TM) muscles were evaluated. Muscle echogenicity was quantified using image analysis software and represented as dB (decibels)/mm2. 5 mm ROIs were randomly placed in the short-axis view of each muscle group, avoiding the myotendinous junction. On MR, muscle atrophy was scored in two ways: degree of fatty infiltration (Goutallier classification) and loss of muscle bulk (occupational ratios), provided by consensus of two musculoskeletal radiologists.
RESULTS

MKS359
MKS360
A total of 27 SSM, 32 ISM, and 32 TM muscles were evaluated. Goutallier scores were scored: 0: normal, 1: more muscle than fat, 2:equal muscle and fat, 3: more fat than muscle. Muscle echogenicity means were: SSM
(mean: 42.7), ISM (53.81) and TM (46.89) dB/mm2. Spearman's rank correlation coefficient demonstrates moderate positive correlation between SSM and ISM gray values and Goutallier scores (0.54). Spearman's rank correlation coefficient demonstrates weak positive correlation between TM and Goutallier score (0.33).
Spearman's rank correlation was weak between SSM and ISM gray value and occupational ratio.
CONCLUSION
Muscle echogenicity on US demonstrates moderate correlation of the supraspinatus and infraspinatus muscles when compared to MRI Goutaillier classification.
CLINICAL RELEVANCE/APPLICATION
Muscle echogenicity on US relates in part to rotator cuff fatty infiltration and may provide valuable information during routine shoulder ultrasound. The paucity of Goutallier grade 2 and 3 muscles may account for the absence of a stronger correlation with muscle echogenicity and should be further investigated.
Longitudinal Follow-up of Incidentally Detected Pseudotumors in Patients with Metal on Metal
Implants: A Prospective Study (Station #2)
Khushboo Pilania MD (Presenter): Nothing to Disclose , Bhavin Jankharia MD : Stockholder, Pfizer Inc
Stockholder, Cipla Ltd Stockholder, Glenmark Pharmaceuticals Ltd , Rishab Bilala MBBS : Nothing to Disclose
PURPOSE
The purpose of this study is to describe the significance and temporal evolution of incidentally detected, presumed, metal induced reactive periprosthetic masses in patients with metal on metal (MoM) hip arthroplasty and thus help decide the further plan of management.
METHOD AND MATERIALS
Patients with MoM hip replacements fitted with a recalled implant (ASR, DuPuy) often undergo MRI with metal artifact reduction sequences (MARS) to look for complications. From a cohort of 136 asymptomatic patients, with
181 MoM hips, patients with a mention of periprosthetic soft tissue mass in their reports at first presentation were selected. Ethics committee approval is not required in our institution for retrospective studies. Eighty patients were selected. Those with complex masses and complications like loosening, osteomyelitis, focal particle disease, tendon tear were excluded. A search was then made amongst the rest for those who had a repeat scan within 6 months to 2 years. Twenty patients with 23 MoM hips fit these criteria. The two scans were then compared by two expert radiologists and all findings were arrived at by consensus. Progression was defined as increase in the size of collection or change in morphology i.e. increase in wall thickness, development of septae or altered signal intensity. Meticulous review for any new collection or complication in the interim was also made.
RESULTS
Twenty asymptomatic patients with 23 MoM hips and 25 periprosthetic masses were evaluated. Comparison revealed that 13 of 25 reactive masses remained unchanged in shape, size and morphology over time. Eight of the 25 masses regressed, 2 of which completely resolved. Only 4 of the 25 lesions showed an increase in size.
New periprosthetic mass was found in only 1 of the 23 hips. No significant new complication was noted in any of the patients. None of the patients turned symptomatic.
CONCLUSION
Periprosthetic soft tissue masses are not uncommon in patients with MoM hips. The majority of them in asymptomatic individuals remain stable or regress in the short to medium term and close follow-up or decisions on revision surgery may not be warranted in asymptomatic patients.
CLINICAL RELEVANCE/APPLICATION
Our study reveals that most of pseudotumors in patients with MoM hips, remain stable or regress, thereby stressing that decisions on revision may not be warranted in asymptomatic patients.
The Incipient Breach of the Midline Pubic Plate: Is this MRI Finding Key to Early Diagnosis and
Prevention of Athletic Pubalgia? (Station #3)
Jordan Gold MD (Presenter): Nothing to Disclose , William Clark Meyers MD : Nothing to Disclose ,
Johannes B. Roedl MD, PhD : Nothing to Disclose , William B. Morrison MD : Consultant, General Electric
Company Consultant, AprioMed AB Patent agreement, AprioMed AB Consultant, Zimmer Holdings, Inc , Adam C.
Zoga MD : Nothing to Disclose
PURPOSE
Anecdotally, we noted a focal soft tissue breach located anterior to the midline pubic symphysis with horizontal orientation on sagittal MR imaging in patients with clinical athletic pubalgia. We sought to establish the incidence of this "incipient breach" and explore its clinical and MR associations, as well as explore its role in the evolution of athletic pubalgia injuries.
METHOD AND MATERIALS

MKS361
MKS362
80 consecutive cases referred for MR from an athletic pubalgia specialty clinic were reviewed. The presence of an incipient breach, as well as any rectus abdominis/adductor (RA-AL) aponeurosis or midline pubic plate lesion were recorded and localized, as were presence of a secondary cleft, subapophyseal defect and osteitis pubis
(classified as mild, moderate, severe). Age and gender were recorded along with any athletic activity, clinical examination findings and treatment planning, and all were correlated with the presence of an incipient breach.
A control group of 20 subjects imaged for hip lesions was reviewed.
RESULTS
79/80 study subjects had athletic pubalgia lesions at MRI. The incipient breach was identified on sagittal images in 61% (49/80) of study subjects. In patients with primary midline pubic plate lesions, 82% (42/51) showed an incipient breach. In patients with a primary unilateral RA-AL aponeurosis lesions, the incidence of an incipient breach was 21% (6/28). Moderate or severe osteitis pubis was identified in 49% of patients with an incipient breach (24/49), compared with 35% of patients without the lesion (11/31). 20/25 patients with an incipient breach were also noted to have a secondary cleft by MR. Football players accounted for majority of referred patients at 45% with 25/36 (69%) showing an incipient breach, while baseball and soccer players each accounted for 7.5% of the study group with 66% and 50% having incipient breaches respectively. 44/49 of patients with an incipient breach were treated with surgical pelvic floor repair.
CONCLUSION
An incipient breach is a common and potentially important observation in an athletic pubalgia patient population. This finding should be observed on sagittal imaging at midline and reported.
CLINICAL RELEVANCE/APPLICATION
The genesis of athletic pubalgia is long debated with many focusing on a musculoskeletal source. The incipient breach may reflect this initial injury, particularly in patients with midline lesions.
The Different Changes of Running and Stair Activity on Knee Articular Cartilage: Quantitative MRI
Using T1 rho and T2 Mapping (Station #4)
Meng Chen (Presenter): Nothing to Disclose , Sirun Liu : Nothing to Disclose , Lin Qiu : Nothing to
Disclose , Xiang-Ran Cai : Nothing to Disclose , Si Shen : Nothing to Disclose , Fei Wang : Nothing to
Disclose , Jing Zhang : Nothing to Disclose , Cici Zhang : Nothing to Disclose
PURPOSE
To measure the changes on T1 rho and T2 relaxation times of knee articular cartilage immediately after 30 minutes running and stair activity
METHOD AND MATERIALS
3.0T MRI scans were performed in thirty young healthy adults immediately after 30 minutes rest and running respectively. After a week, 3.0T MRI scanswere performed again after 30 minutes stair activity. The T1 rho and
T2 mapping sequences were used to evaluate the knee articular cartilage. The cartilage was divided into 6 regions: media and lateral femoral condyle, medial and lateral tibial plateau, patella and trochlea. The patella cartilage was further divided 2 regions: superficial and deep parts.Analysis of variance for random block design data and paired samples t test were performed to estimate the changes on T1 rho and T2 relaxation times.
RESULTS
The T1 rho and T2 value after running and stair activity showed consistent decrease in all region of the knee articular cartilage. The superficial parts of patella cartilage, the lateral trochlea cartilage and the medial tilial plateau cartilage showed significant reduction. The superficial parts oflateral patella cartilage (T1 rho value after
30 min rest, running and stair activity were 54.411±4.159,,48.130±2.17 and 45.734±1.821
respective,p=0.011) , the lateral trochlea cartilage(p=0.000) and the posterior part of medialtibialplateau cartilage(p=0.017) experienced the greatest reduction. The T1 rho and T2 value after stair activity had reduction when compared with the condition after running, but the data did not have statistic significance. The
T1 rho and T2 value of the superficial parts experienced significant reduction when compared with the deep parts(p=0.000).
CONCLUSION
T1 rho and T2 value on knee articular cartilage showed reduction consistently after running and stair activity, suggesting running and stair activity had consistent load distribution on knee articular cartilage. The changes after stair activity were more obvious than running. The lateral patella cartilage, the lateral trochlea cartilage and the posterior part of media tibial plateau cartilage experienced greater reduction, suggesting greater loads were shared in these areas during running and stair activity.
CLINICAL RELEVANCE/APPLICATION
The research exploited articular cartilage changes and loads distribution to physiologic exercise.The study results would be valuable in sports medicine, osteoarthritis and chondromalacia patellae.
Shinkie (Nerve-Sheath Signal Increased with Inked Rest-Tissue Rare Imaging) — Novel 3D Isotropic
MR Neurography (MRN) Technique for Lumbosacral Plexus Evaluation (Station #5)
Avneesh Chhabra MD (Presenter): Research Grant, Siemens AG Research Consultant, Siemens AG Research
Grant, Integra LifeSciences Holdings Corporation Research Grant, General Electric Company Consultant, ICON plc , Jared Kasper MD : Nothing to Disclose

MKS363
MKS364 plc , Jared Kasper MD : Nothing to Disclose
PURPOSE
Evaluate relative merits of SHINKIE over conventional 3D inversion recovery (IR) turbo spin echo (TSE) imaging used for LS plexus MRN.
METHOD AND MATERIALS
Prospectively acquired 21 consecutive LS MRN exams on 3 Tesla scanner using both 1.5mm isotropic 3DIRTSE and SHINKIE techniques were analyzed. Two trained observers evaluated all images for motion and pulsation artifacts, nerve signal to noise (SNR), contrast to noise (CNR), nerve-fat ratio, quality as well as degree of fat suppression (muscle-fat ratio) and depiction of various segments of the LS plexus.
RESULTS
4 exams were excluded due to prior spine surgery. Bowel motion artifacts, pulsation artifacts, inhomogeneous fat saturation and patient motion were seen in 16/17, 0/17, 17/17, 2/17 in 3DIRTSE and 0/17, 0/17, 0/17,
1/17 in SHINKIE, respectively. The p values were significant in SHINKIE for nerve SNR (<0.01), CNR (<0.01), nerve to fat (<0.01) and degree of fat saturation, muscle to fat ratio (p<0.01). Both 3D IRTSE and SHINKIE showed all LS plexus nerve roots, sciatic and femoral nerves universally. Smaller branches including obturator nerves, ilioinguinal and iliohypogastric were seen in 10/17, 5/17, 1/17 in 3DIRTSE and 17/17, 16/17, 7/17 in
SHINKIE exams, respectively.
CONCLUSION
In addition to the benefit of effective vascular signal and bowel artifact suppression, the SHINKIE MRN technique demonstrates increased conspicuity of smaller LS plexus branches.
CLINICAL RELEVANCE/APPLICATION
SHINKIE sequence should be incorporated in LS plexus imaging for better nerve identification and pre-surgical planning.
Early Findings of Charcot Arthropathy on MR Imaging (Station #6)
Lodewijk Jules van Holsbeeck MD (Presenter): Nothing to Disclose , William B. Morrison MD : Consultant,
General Electric Company Consultant, AprioMed AB Patent agreement, AprioMed AB Consultant, Zimmer
Holdings, Inc , Viviane Khoury MD : Nothing to Disclose , Paula Gangopadhyay BS : Nothing to Disclose
PURPOSE
To identify early findings of Charcot arthropathy on MR imaging.
METHOD AND MATERIALS
The MR imaging reports database was searched for the words "Charcot" and "Neuropathic"; resultant patient list was reviewed for the following inclusion criteria: 1) documented early Charcot arthropathy by clinical exam; or 2) follow-up imaging showing evolution into classic Charcot arthropathy. Images were reviewed for location of Charcot, as well as marrow, articular, ligamentous, tendinous and soft tissue findings on the initial MR exam.
Findings on follow-up were documented.
RESULTS
Results: Fifteen feet in fourteen patients were identified with MR imaging of early Charcot. Seven were located at the Lisfranc joint and eight at the Chopart joint. Initial findings included subchondral bone marrow edema in
10/15; subchondral fracture in 3/15; tear of a supporting ligament in 10/15; tendinopathy in 5/15; and muscle atrophy in 7/15. In cases of early Charcot at the Lisfranc joint, tearing of the inferior capsule of the first TMT joint was followed by midfoot collapse; in cases of early Charcot at the Chopart joint, tearing of the spring ligament was followed by hind foot collapse.
CONCLUSION
MRI can be successfully used to predict future risk for rapidly progressive arthropathy at both the Chopart and
Lisfranc joints.
CLINICAL RELEVANCE/APPLICATION
Identification of initial ligamentous injuries preceding Charcot arthropathy in the diabetic population could assist surgeons in early intervention and prevention of late deformity.
Dorsovolar Position of the Distal Radius and Ulna at the Distal Radioulnar Joint in Asymptomatic
Volunteers on MRI (Station #7)
Seema M. Meraj MD (Presenter): Nothing to Disclose , Nidhi Jain MD : Nothing to Disclose ,
Catherine Niyada Petchprapa MD : Nothing to Disclose
PURPOSE
Evaluate the dorsovolar position of the distal radius and ulna at the distal radioulnar joint (DRUJ) in forearm pronation, supination, and neutral in asymptomatic volunteers on MRI.
METHOD AND MATERIALS

MKE152
MKE258
MKE135
METHOD AND MATERIALS
Twenty wrists in ten asymptomatic volunteers (five men, five women; mean age 29.6 years; range 27-32 years), without history of pain, prior trauma or previous hand/wrist surgery were imaged utilizing axial proton density weighted MRI with the wrist pronated, supinated, and in the neutral position. Three methods were used to quantify the presence/absence/degree of subluxation of the DRUJ: Mino criteria, subluxation ratio, and radioulnar ratio.
RESULTS
None of the volunteers had clinical DRUJ instability. Using the Mino criteria, DRUJ instability was suspected in
55% (11/20) of the wrists in pronation, 45% (9/20) in neutral, and 45% (9/20) in supination. Using the subluxation ratio method, only 2 of the wrists fit the criteria for subluxation in pronation and 1 in supination.
Only 1 wrist fit the criteria for subluxation using the radioulnar ratio method in supination. The ulna was dorsally positioned in 7/20 with respect to the radius in pronation and volarly positioned in 5/20 in supination. The mean values for the radioulnar ratio method were 0.530 in pronation and 0.481 in supination.
CONCLUSION
Established methods for evaluating DRUJ alignment were abnormal in our study of asymptomatic subjects, raising concern for their reliability for detecting true DRUJ instability.
CLINICAL RELEVANCE/APPLICATION
There is some degree of normal dorsovolar translation between the radius and ulna in pronation and supination.
Further study of normal wrists is necessary to avoid overdiagnosing DRUJ instability on cross sectional imaging.
US of the Knee: What to Look for (Station #8)
Maria Dolores Lopez Parra MD (Presenter): Nothing to Disclose , Jose Acosta Batlle : Nothing to Disclose ,
Blanca Palomino : Nothing to Disclose , Catalina Maria Garcia Barrio : Nothing to Disclose , Belen Lopez
Parra MS : Nothing to Disclose
TEACHING POINTS
-to review the sonographic anatomy and scanning technique knee. -to describe those pathological conditions in which ultrasound (US) has a similar or even higher sensivity and specificity than MRI
TABLE OF CONTENTS/OUTLINE
Understanding of the anatomy, scanning technique and appearance of pathological conditions is essential for proper interpretation of US findings. We review US and MRI studies performed in 245 patients with symptoms referred to a specific knee area; those patients with diffuse or meniscal symptoms were excluded. We describe the songraphic appearance of the four anatomic compartments in which knee is divided: anterior, medial, lateral and posterior. We explain how to perform a dynamic US study (with active and passive mobilization) and to obtain images of the full course of the tendons and collateral ligaments in different planes. Illustrative examples of main tendinous , ligaments and recess diseases are shown. US imaging of other structures, such as patellar cartilage, supra patellar recess and peroneal/ tibial nerve. We emphazise the advantages of US exam compared to MRI. US is especially useful in the study of tendons of anterior compartment, particularly in child in which MRI will be subject to the effects of anisotropy and in the evaluation of posterior compartment and collateral ligaments.
The Postoperative Shoulder: A Meeting Point between Radiologists and Orthopedic Surgeons
(Station #9)
Maria Jose Ereno Ealo MD (Presenter): Nothing to Disclose , Alberto Sanchez Sobrino : Nothing to Disclose
, Oscar Luis Casado Verdugo : Nothing to Disclose , Rosa Monica Rodrigo Del Solar : Nothing to Disclose ,
Estibaliz Montejo : Nothing to Disclose , Begona Sancho Garaizabal : Nothing to Disclose
TEACHING POINTS
1. Describe in a didactic way the main surgical procedures used for the treatment of shoulder pathology 2.
Explain the imaging findings in each post-operative situation 3. Review the most common post-operative complications
TABLE OF CONTENTS/OUTLINE
Postoperative imaging of the shoulder is challenging. In order to reduce the distance between radiologists and orthopedic surgeons it is important to know the main shoulder surgical procedures. We describe in a didactic way the techniques, indications and contraindications, normal temporal evolution and complications from the point of view of the image and from arthroscopic or surgical perspective. Our topics will be: 1. Rotator cuff
Surgery a. Subacromial decompresion - Anterior acromioplasty - Mumford procedure b. Rotator cuff repair 2.
Biceps Tendon Surgery a. Biceps tenodesis b. Biceps tenotomy 3. Labral-Ligamentous Complex Surgery a.
SLAP repair b. Bankart repair c. Capsular shift 4. Shoulder Arthroplasty
Do They Follow Rules and Regulations? Association of Soft Tissue Injury and Bone Edema Patterns in
Acute Knee Injuries (Station #10)
Sridhar Devu DMRD, FRCR (Presenter): Nothing to Disclose , Umamahesh Matapathi MBBS,MD : Nothing to Disclose , venkata rama subramanyam muddana MBBS : Nothing to Disclose
TEACHING POINTS
The intention of the exhibit : 1.To understand the dynamic anatomy of knee joint 2.To organise the pattern of bone contusions and fractures in acute injuries around the knee joint 3.To evaluate the stabilising structures of

bone contusions and fractures in acute injuries around the knee joint 3.To evaluate the stabilising structures of the knee joint. 4.To correlate the specific patterns of bone and soft tissue injuries 5.To establish a protocol of reporting in acute injuries of knee joint
TABLE OF CONTENTS/OUTLINE
Complex anatomy of knee joint -Bones -Stabilising structures of the joint Applying principles of dynamics to knee joint Various patterns of injury —Pivot shift injury —Clip injury —Hyperextension injury —Dashboard injury
—Lateral patellar subluxation —Unclassifiable injury Representative cases Summary Future directions
MKE108
MKE257
Sonography and Ultrasound Interventions in Gout (Station #11)
Alberto Andres Simoncini MD (Presenter): Nothing to Disclose , Guillermo P. Sangster MD : Nothing to
Disclose , Carlos Humberto Previgliano MD : Nothing to Disclose , Cinzia Andrea Bartoletti MD : Nothing to
Disclose , Anne Hollister MD : Nothing to Disclose , Justin Wayne Skweres MD : Nothing to Disclose
TEACHING POINTS
The purpose of this exhibit is:
1- To review the pathophysiology of gout and the resulting specific and nonspecific sonographic findings.
2- To analyze the value of ultrasound interventions to confirm the disease.
3- To discuss the roll of ultrasound to monitor disease activity and treatment response.
4-To compare ultrasound with other imaging modalities.
TABLE OF CONTENTS/OUTLINE
1) Pathophysiology of gout. 2) Non-specific sonographic findings: -Soft tissue edema. -Synovitis ( Joint effusion,.h yperemia, s ynovial proliferation). -Hyperechoic foci. -Erosions. 3) Specific sonographic findings:
-Double contour sign. -Tophus. 4 )Ultrasound as a tool to evaluate disease activity and monitoring treatment.
5) Ultrasound guided interventions in gout. 6) Differential diagnosis. 7) Comparison between ultrasound, radiography and other advanced modalities (CT, Dual Energy CT, MRI). 8) Summary.
The Posterior Rotator Interval of the Shoulder, Normal Anatomy and MR Findings (Station #12)
Yoav Morag MD (Presenter): Nothing to Disclose , David Alexander Jamadar MBBS : Nothing to Disclose ,
Asheesh Bedi MD : Nothing to Disclose , David R. Lucas MD : Nothing to Disclose , Bruce Miller : Nothing to Disclose , Elaine M. Caoili MD, MS : Nothing to Disclose , Lucas Gama Lobo MD : Nothing to Disclose ,
Corrie Marlene Yablon MD : Nothing to Disclose , Jon A. Jacobson MD : Consultant, BioClinica, Inc Royalties,
Reed Elsevier Equipment support, Terumo Corporation Equipment support, Arthrex, Inc
TEACHING POINTS
Appreciate the anatomy of the posterior rotator interval Recognize posterior rotator interval MR signal abnormalities Appreciate the configuration of posterior rotator interval signal abnormalities in light of the underlying anatomy
TABLE OF CONTENTS/OUTLINE
Anatomy of the posterior rotator interval Review of current literature Cadaver dissection with histologic slides
Sample MRI and MR arthrogram cases Discussion of the signal abnormalities in the posterior rotator interval as seen on MRI and their potential association with the anatomy of the posterior rotator interval.
MKE019-b Challenges in Imaging a Post Surgical Meniscus - Where Do We Stand Today? (hardcopy backboard)
Monika Rowe MD, PhD (Presenter): Nothing to Disclose , Adam W. Mitchell FRCR : Nothing to Disclose ,
Gajan Rajeswaran MBBS, FRCR : Nothing to Disclose , Jeremiah Christopher Healy MBBCHIR, FRCR :
Nothing to Disclose , Justin Charles Lee MBBS, FRCR : Nothing to Disclose , Andrew Williams MBBS :
Nothing to Disclose
TEACHING POINTS
The purpose of this exhibit is: 1. To review the morphology of the normal post surgical meniscus on imaging and how it differs to the normal meniscus. 2. To discuss the utility and imaging findings in assessment of post surgical meniscal tears/ retears. 3. To discuss the utility and imaging findings in assessment of meniscal implants.
TABLE OF CONTENTS/OUTLINE
1. Review of the normal meniscal anatomy, including normal morphology and capsular and bony attachments.
2. Review of the nomenclature and MRI criteria for a tear in a non-surgical meniscus. 3. Role and use of MRI in assessment of the post surgical meniscus: a) When to image the post surgical meniscus. b) Optimal MRI sequences to improve assessment of the post surgical meniscus, including a review of the utility of direct and indirect MR arthography. c) Normal appearances of the post surgical meniscus. d) Features consistent with a post surgical tear/ retear (with sample cases). e) Pitfalls in assessment. 4. Role of CT arthrography in assessing post surgical retears: a) When and how to use CT arthrography. b) Normal appearances of the post surgical meniscus. c) Features consistent with a post surgical tear/retear (with sample cases). d) Pitfalls in assessment.
5. Use of MRI in assessing the meniscal transplant (with sample cases). 6. Summary.

Scientific Posters
PH
AMA PRA Category 1 Credits ™ : .50
Mon, Dec 1 12:45 PM - 1:15 PM Location: PH Community, Learning Center
Sub-Events
PHS145 "All That Blue Is Not Malignant " — Role of Ultrasound Elastography in the Evaluation of Cervical
Lymph Nodes (Station #1)
Rahul Rajendra Arkar MBBS, DMRD, DNB (Presenter): Nothing to Disclose , Venkatesh Kasi Arunachalam
MBBS, DMRD : Nothing to Disclose , R Rupa MBBS, DMRD : Nothing to Disclose , Tejas Mohan Kalyanpur
DMRD : Nothing to Disclose , Mathew Cherian MD : Nothing to Disclose , Pankaj Mehta MD : Nothing to
Disclose , Rajesh Kumar Vartharajaperumal MBBS, DMRD : Nothing to Disclose
PURPOSE
To differentiate benign and metastatic cervical lymph nodes with B-mode and sonoelastography separately and combined with histopathologic findings as reference standard.
METHOD AND MATERIALS
Two hundread patients were assessed with B-mode sonography and sonoelastography. B-mode characteristics include - short axis dimension, short axis to long axis ratio, fatty hilum, calcification and vascularity.
Elastographic pattern of lymph node after adequate compression was evaluated and categorized to one of the five groups as categorized by Ahuja A. T. et.al. (Ultrasound of malignant cervical lymph nodes, 2008
International Cancer Imaging Society). All patients underwent FNAC of the enlarged lymph node.The results of
B-mode ultrasonography and sonoelastography were compared with histopathology and analysed statistically.
RESULTS
Histopathology: Prevalence of malignant and benign lymph nodes was 64% and 36% respectively. B- mode sonography showed 32 false positive cases which include 8 of acute suppurative inflammation, 16 of tuberculosis and 8 of reactive hyperplasia. Elastography: 40 out of 72 benign cases showed patterns I and II
(reactive). Remaining 32 cases were falsely reported as metastatic and include 20 of tuberculosis, 4 of necrotizing histiocytic lymphadenopathy (Kikuchi lymphadenopathy), 5 of chronic non-specific lymphadenitis and 3 of reactive hyperplasia. Among 128 histopathologically proven metastasis cases, 120 cases were metastatic on elastogram. Diagnostic performance:The diagnostic performance of B-mode USG showed sensitivity, specificity and diagnostic accuracy of 84.4%, 55.6% and 74.0% respectively and Elastography showed sensitivity, specificity and diagnostic accuracy of 93.8%, 55.6% and 80 % respectively. The diagnostic performance of combined B-mode USG and Elastography showed sensitivity, specificity and diagnostic accuracy of 96.9%, 33.3% and 74% respectively.
CONCLUSION
1.Ultrasound elastography increases the sensitivity in detecting metastatic cervical lymph nodes. 2.The
specificity however is significantly lower than the western literature; probably due to significant number of patients having tuberculous cervical lymphadenopathy.
CLINICAL RELEVANCE/APPLICATION
In view of high false positve results with ultrasound elastography evaluation of cervical lymph nodes in countries where infections like tuberculosis are more prevalent, ultrasound elastography should be used very cautiously in characterising cervical lymphadenoapthy.
PHS146 Accuracy of the Measurement of CT Numbers of Dual-energy Spectral CT Imaging under Beam
Hardening Conditions (Station #2)
Wei Tang MD (Presenter): Nothing to Disclose , Zukun Xiong : Nothing to Disclose , Yao Huang MD :
Nothing to Disclose , Ning Guo : Nothing to Disclose , Ning Wu MD : Nothing to Disclose
PURPOSE
To compare dual-energy spectral computed tomography (CT) imaging and conventional CT imaging in terms of accuracy of the measurement of CT numbers under beam hardening conditions with phantoms.
METHOD AND MATERIALS
A circular phantom (QSP-1, Fuyo Corporation) was used. Eight 20mm-diameter tubes filled with water
(condition1) or iodine contrast medium at 20mg/ml (condition2,weak beam hardening) or iodine contrast medium at 50mg/ml (condition3, severe beam hardening) were placed in peripheral holes of the phantoms. One test tube of filled with iodine contrast media solutions at various concentration levels
(0,0.1,0.5,1,2,5,10,20,50mg/ml) were placed in the phantoms. At each condition and test tube of each iodine concentration, the phantom was scanned by both conventional CT and dual energy spectral CT. Conventional CT was performed at tube voltage of 80kVp, 100 kVp, 120 kVp and 140 kVp. Virtual monochromatic (VNC) images from 40 to 140 keV (interval of 10keV) were obtained by dual-energy CT spectral imaging. For each concentration of the test tube, the CT number of each iodine tube. The delta CT number were calculated

PHS147
PHS148 according to the formulas: ΔCT=CTcondition2-CTcondition1 or ΔCT=CTcondition3-CTcondition1. The results were compared with one-way ANOVA analysis.
RESULTS
At condition2, the mean ΔCT of VNC images (40keV to 140keV) varies from (-3.72±3.63) to (5.50±1.83) , lower than that of conventional CT images(80kVp, -39.05±16.90; 100kVp, -33.14±15.82;120kVp,
-22.80±14.08; 140kVp, -25.89±12.81) (p<0.001). At condition3, the mean ΔCT of VNC images (40keV to
140keV) varies from (-62.72±25.14) to (22.29±4.40), lower than that of conventional CT images(80kVp,
-163.08±44.79; 100kVp, -129.39±37.40;120kVp, -111.86±33.24; 140kVp, -99.70±29.96) (p<0.001); the mean ΔCT of VNC images (60keV to 140keV) varies from (-17.12±6.59) to (22.29±4.40), lower than that of
VNC images (40keV, -62.72±25.14;50keV. 38.04±4.65) (p<0.001).
CONCLUSION
At both weak and severe beam hardening conditions, dual-energy CT spectral imaging provides more accurate
CT numbers, at severe beam hardening condition, the CT numbers of VNC images at high keV levels are accurate than those in low keV levels.
CLINICAL RELEVANCE/APPLICATION
At both weak and severe beam hardening conditions, dual-energy CT spectral imaging provides more accurate
CT numbers, at severe beam hardening condition, the CT numbers of VNC images at high keV levels are accurate than those in low keV levels.
Determining the Effect of Advanced Reconstruction Algorithms on Standardised Uptake
Measurements of the Normal Adrenal Gland Using 18F-FDG PET/CT (Station #3)
Heok Cheow MBBCh, MSc (Presenter): Nothing to Disclose , Mark Gannon : Nothing to Disclose , Sarah
Heard : Nothing to Disclose
CONCLUSION
There were significant difference between SUVmax measurements and visual appearance of the adrenal gland using the three reconstuction algorithms. Readers of PET/CT should be aware the normal range of adrenal uptake is dependant on reconstruction algorithm used.
Background
Characteristation of adrenal incidentalomas found during 18F-FDG PET/CT imaging is important for clinical management. Many clinicians interpreting adrenal uptake use established SUV ranges of the normal adrenal gland or visually compared it with liver to aid their decision. These SUV ranges were often determined from data processed using noncurrent iterative reconstruction algorithms. Contemporary commercial reconstruction utilise advanced algorithms which offer improved image quality (contrast, resolution) but may affect measured
SUV. The purpose of the current study was to describe and compare normal adrenal 18F-FDG uptake between
GE's proprietary iterative reconstruction software VUE Point HD (V-HD) and their advanced VUE Point FX (V-FX) and VUE Point FX - Sharp IR (V-SIR) algorithms which utilise time of flight (TOF) and TOF with point spread function (PSF) corrections respectively.
Evaluation
A retrospective audit of 23 patients referred for lymphoma staging was performed with the expectation that adrenal uptake for this cohort would be representative of a normal patient population. All images were reconstructed using V-HD, V-FX and V-SIR algorithms. Quantitative analysis was performed by measuring
SUVmax. Qualitative adrenal uptake was measured by visually comparing it to hepatic uptake (0 = no visualisation, 1 = activity less than liver, 2 = activity equal to liver, 3 = activity greater than liver).
Discussion
There were statistically significant differences between reconstructed data for SUVmax and visual score results as determined by one-way ANOVA (F(2,99) = 32.16, p < 0.01 and F(2,99) = 9.69, p < 0.01 respectively). The range of SUVmax for all adrenal glands was 1.3 - 3.5, 1.5 - 4.5 and 2.5 - 7.9 for V-HD, V-IR and V-SIR respectively. Visual score correlated poorly with SUVmax (slope = 0.05, R = 0.04 slope = 0.24, R = 0.21 and slope = 0.83, R = 0.45) for V-HD, V-FX and V-SIR respectively.
Quantitative in Vivo X-ray Dark-field Radiography for Early Pulmonary Emphysema Diagnosis
(Station #4)
Katharina Hellbach MD (Presenter): Nothing to Disclose , Andre Yaroshenko : Nothing to Disclose , Oliver
Eickelberg : Nothing to Disclose , Martin Bech : Nothing to Disclose , Maximilian F. Reiser MD : Nothing to
Disclose , Ali Onder Yildirim : Nothing to Disclose , Franz Pfeiffer : Nothing to Disclose , Felix G. Meinel MD
: Nothing to Disclose
PURPOSE
The aim of this study was to evaluate whether x-ray dark-field radiography can be used for early diagnosis of pulmonary emphysema in in vivo mice.
METHOD AND MATERIALS
Emphysema was induced by orotracheal injection of porcine pancreatic elastase (80U/kg BW, n=30). Control

PHS149
PHS150 mice (n=11) received orotracheal injection of PBS. To ensure the development of different stages of emphysema mice (female C57Bl/6N) were imaged 7, 14 and 21 days after application of elastase or PBS.
Images were acquired with a prototype grating-based small animal scanner and processed using Fourier decomposition to generate transmission as well as dark-field radiographs. During image acquisition the anaesthetized mice were breathing freely. In vivo pulmonary function tests were performed before sacrificing the animals. Lungs were obtained for further histopathological analysis (e.g. mean cord length (MCL) quantification). Three blinded readers, all of them experienced radiologists and familiar with dark-field imaging, were asked to rate the severity of emphysema for both dark-field and transmission images.
RESULTS
Different stages of emphysema could be clearly visualized on the dark-field radiographs, contrary to the conventional absorption-based imaging. As confirmed by MCL-quantifications murine lungs in the elastase group had developed different stages of emphysema (figure 1). Correlation between MCL and dark-field signal intensity (r=0.85) was significantly higher than correlation between MCL and transmission signal intensity
(r=0.37). Visual ratings for dark-field images (r=0.85) correlated significantly better with MCL than visual ratings for transmission images (r=0.36). Quantitative and qualitative diagnostic accuracy as well as interreader agreement were significantly higher for dark-field imaging than for conventional transmission images.
CONCLUSION
Using X-ray dark-field radiography it is possible to visualize and reliably diagnose different stages of emphysema in vivo with a projection imaging method.
CLINICAL RELEVANCE/APPLICATION
Small structural changes in the lung can be visualized with the x-ray dark-field imaging. Using this imaging method it is possible to diagnose early emphysema using a projection imaging method, which offers the change to start therapy even before clinical symptoms occur. With further technical developments X-ray dark-field radiography could be used for emphysema screenings and follow-up imaging without the use of CT.
Impact of Spectra Separation for Monoenergetic Extrapolation Using Dual-energy Dual-source CT in
Pediatric-sized Phantoms (Station #5)
Juan Carlos Ramirez Giraldo PhD (Presenter): Employee, Siemens AG , Marilyn J. Siegel MD : Research
Consultant, Siemens AG Speakers Bureau, Siemens AG , Bernhard Schmidt PhD : Employee, Siemens AG
PURPOSE
To evaluate the effect of spectra separation in the image quality of monoenergetic images estimated from dual-energy CT data acquired in pediatric-sized phantoms
METHOD AND MATERIALS
Three phantoms representing small (12 x 8 cm), medium (16 x 12 cm), and large (27 x 18 cm) pediatric sizes were scanned using second generation dual-source CT (Somatom Flash) with a thoracic DECT protocol at
100/140 kVp (default) and 80/140kVp; and with a third generation dual-source CT (Somatom Force) with DECT protocol using 70/150 kVp. All scans used additional tin filtration in the high energy tube to increase spectra vol) was recorded.
Monoenergetic images were calculated between 40 and 85 keV, in 5 keV steps, using commercially available software (Syngo DE Monoenergetic). To assess the impact of the spectra separation in image quality, the image noise, contrast, contrast-to-noise ratio (CNR), and dose-weighted CNR [CNRD = CNR/sqrt(CTDIvol)] were calculated. Parameters were compared with paired t-test.
RESULTS
For the 70/150, 80/140, and 100/140 kVp protocols, the radiation output values were 0.40, 0.52, 0.49 mGy
(small phantom); 1.33, 1.42, 1.50 (medium phantom); and 1.96, 2.32, 2.24 mGy (large phantom); respectively. Image noise in monoenergetic images decreased significantly in the 70/150 kVp protocol, relative to both the 80/140 and 100/140 kVp protocols (P < .05); and also decreased significantly when comparing the
80/140 kVp relative to the 100/140 kVp (P < .05). Image contrast values measured in monoenergetic images were comparable for all kVp protocols and independent of phantom size, with contrast differences which were consistently less than 17.6% (range 0.3 to 17.6%). CNR and CNRD significantly increased with use of the
70/150 kVp protocol relative to the 80/140 and 100/140 kVp protocols (P < .05), and also increased with use of
80/140 kVp relative to 100/140 kVp protocol (P < .05).
CONCLUSION
In pediatric sizes, kilovoltage pairs for dual-energy CT leading to larger x-ray spectra separation result in a significant decrease of image noise in synthetized monoenergetic images, with a corresponding improvement in
CNR and dose tradeoff.
CLINICAL RELEVANCE/APPLICATION
For contrast-enhanced DECT imaging in pediatric patients this study favors the use 70/150 kVp (with tin) for third generation DSCT, and of 80/140 kVp (with tin) for the second generation.
Effects on Image Quality of a 2D Anti-scatter Grid in X-ray Breast Tomosynthesis (DBT): Initial
Experience Using the Dual Modality Breast Tomosynthesis (DMT) Scanner (Station #6)
Tushita Patel BS (Presenter): Institutional research agreement, Hologic, Inc , Heather Renee Peppard MD :
Consultant, Siemens AG Research Grant, Hologic, Inc , Andrew Polemi : Institutional research agreement,

PHS151
PHS152
Consultant, Siemens AG Research Grant, Hologic, Inc , Andrew Polemi : Institutional research agreement,
Hologic, Inc , Zongyi Gong BS, PhD : Institutional research agreement, Hologic, Inc , Mark Bennett Williams
PhD : Institutional research agreement, Hologic, Inc.
CONCLUSION
A 2D anti-scatter grid can be usefully incorporated in DBT systems using fully isocentric tube-detector rotation to improve image quality, especially for thicker breasts.
Background
Radiation scattered from the breast in mammography causes image degradation, including loss of contrast between cancerous and background tissue. Scatter increases with increasing compressed thickness. Unlike in
2D mammography, an anti-scatter grid cannot readily be used in tomosynthesis since the changing tube-detector orientation would result in unacceptable loss of primary radiation. However, in the DMT scanner, which combines digital breast tomosynthesis (DBT) and molecular breast tomosynthesis (MBT) on a single gantry, the tube and detector rotate around a common axis. This C-arm geometry raises the possibility of using a 2-dimensional (cellular) focused anti-scatter grid. The purpose of this study is to assess the improvement in image quality when using an anti-scatter grid in the DBT portion of a DMT scan.
Computer Aided Detection of Ureter Wall Thickening in Multi-detector Row CT Urography (Station
#7)
Lubomir M. Hadjiiski PhD (Presenter): Nothing to Disclose , David Zick : Nothing to Disclose , Heang-Ping
Chan PhD : Institutional research collaboration, General Electric Company , Elaine M. Caoili MD, MS :
Nothing to Disclose , Richard H. Cohan MD : Consultant, General Electric Company Consultant, Medscape,
LLC , Chuan Zhou PhD : Nothing to Disclose , Kenny Heekon Cha MSc : Nothing to Disclose
PURPOSE
To develop a CAD system for automated detection of ureter abnormalities in multi-detector row CT urography
(CTU), which potentially can assist radiologists in detecting ureter cancer.
METHOD AND MATERIALS
Our CAD system consists of two stages. In the first stage, tracking of the ureter is performed by previously developed COmbined Model-guided Path-finding Analysis and Segmentation System (COMPASS). After a user-input starting point, the ureter is automatically tracked by COMPASS based on anatomical knowledge and feature analysis of the contrast-filled lumen. In the second stage, the ureter wall is detected by using a polar transformation and tandem gray level thresholding to separate the ureter wall from the lumen and the background beyond the ureter wall. The ureter wall is considered abnormal if the wall thickness is greater than
1 mm. An upper limit of the wall thickness is imposed to reduce false positives. Finally, if the width of the thickened region extends to larger than 1/3 of the entire ureter wall circumference on a given slice it is considered a site of ureter wall thickening. In this pilot study, a limited data set of 38 patients (25 malignant and 13 benign) with biopsy-proven ureter wall thickenings was collected with IRB approval. Experienced radiologists identified 45 locations of ureter wall thickenings (28 cancers and 17 benign) on the CTU images as reference standard. The average lesion thickness was 4.0 mm (range: 1.8-9.2 mm). The average conspicuity rating was 3.1 (range: 2 to 5) on a scale of 1 to 5 (5 very subtle).
RESULTS
The COMPASS successfully tracked the ureters in all patients. 98% (44/45) of the ureter wall thickenings including 100% (28/28) of the ureter cancers were detected with 1.5 (55/38) false positives per patient. The missed benign wall thickening was a small lesion with thickness of 1.9 mm.
CONCLUSION
Our COMPASS and CAD system can track the ureter and detect ureter cancer of medium conspicuity and relatively small size. Further study is underway to collect a larger data set and improve the detection performance. This pilot study is a first step towards the development of a CAD system for detection of malignancy manifested as ureter wall thickening in CTU.
CLINICAL RELEVANCE/APPLICATION
An accurate CAD system has the potential to assist radiologists in detection of ureter cancers at an early stage which usually are subtle in appearance.
Feasibility and Accuracy of Bone Density Measurement by CT Spectral Imaging: An in Vitro Study on
Sheep Bone (Station #8)
Nan Yan MMed (Presenter): Nothing to Disclose , Wang Chenwei PhD : Nothing to Disclose
PURPOSE
Gemstone spectral CT can be substitute method for bone mineral density measurement.
METHOD AND MATERIALS
5 isolated fresh sheep lumbar vertebral body bone, including 4 vertebras for each bone, were used in this study.

Each bone was scanned with both gemstone spectral CT (Discovery CT 750HD, GE healthcare) and DXA (Dual energy X-ray absorptiometry). Then, each bone got high temperature incineration and weighed, bone density was calculated. For CT data, monochromatic images were reconstructed; the bone calcium content was measured on quantitative calcium/water-based material decomposition images with a dedicated software (GSI
Viewer). Using calcium content of bone ash as the gold standard, pearson correlation analysis was taken for the calcium content of GSI and BMD value of DXA are respectively.
RESULTS
Both calcium content of GSI and BMD value of DXA had high positive-correlation with calcium content of bone ash (both P<0.01). The correlation efficient of calcium content of GSI (r=0.888) was slight higher than that of
BMD value of DXA(r=0.845).
CONCLUSION
Quantitative calcium content measurement by gemstone spectral CT provide compatible accuracy with bone mineral density measurement of DXA.
CLINICAL RELEVANCE/APPLICATION
Gemstone spectral CT can be substitute method for bone mineral density measurement.
PHE001-b A Low Dose, High Resolution Digital Radiography Sensor by Using an Electron-Blocking Electrode
(hardcopy backboard)
Wei-Ben Wang (Presenter): Nothing to Disclose , Bo-Wen Xiao : Nothing to Disclose , Chien-Ju Lee :
Nothing to Disclose , Ming Hua Yeh : Nothing to Disclose , Wen-Tung Wang : Nothing to Disclose ,
Ming-Huan Yang : Nothing to Disclose
Background
A low dose, high resolution digital radiography sensor (DRS) is proposed herein. By using an electron-blocking electrode of poly(3,4-ethylene-dioxythiophene)-poly-(styrenesulfonate) (PEDOT) coupling with a 2T-1C pixel circuit, a 70-um pixel size of DRS is suitable for overcoming the drawbacks in conventional flat-panel X-ray detector, who suffer from limited resolution and sensitivity as the pixel size reduces to sub-100-μm as the prominent need for X-ray tomosynthesis, such as mammography.
Evaluation
Fig. 1 shows the pixel structure with 1-um thickness amorphous selenium (α-Se) as the conversion layer and
PEDOT as the conducting electrode. By overlaying a-Se with 100% effective fill factor, the DRS could perform high resolution and low dose benefits. The blue-light is excited from phosphor with x-ray irradiating and then be absorbed by the a-Se. As shown in Fig. 2, the Se-containing photodiode consisted of an indium tin oxide
(ITO) electrode, a Se layer and a PEDOT electrode.
Discussion
The DRS with a flexible characteristic is demonstrated as shown in Fig. 3. The sensor could be still operated after a repeated bending test with 1.5 cm curvature radius and 2,000 bending times. The X-ray image obtained by full system is shown in Fig. 3 which the phantom image with circle profile could be observed. The image quality could be enhanced by implementing image processing algorithm in the future.
Fig. 4 shows the current results in a Se-containing photodiode. As seen, by using PEDOT to be an electron-blocking electrode, the device exhibits higher current than that of an Ag-containing counterpart under an emission of a 470 nm blue light. Nevertheless, without any emission, the PEDOT-containing device possesses the lowest current among all.
CONCLUSION
The 70-um pixel size of high resolution DRS is fabricated. Under a low dose X-ray emission, a preliminary image of a phantom appearance could be obviously shown in the sensor.
Flat-panel amplified pixel sensor array can be integrated into digital X-ray imaging systems for mammography, breast tomosythesis, fluoroscopy, dental imaging, and cone-beam CT applications.
Plenary Sessions
US
AMA PRA Category 1 Credits ™ : 1.25
ARRT Category A+ Credit: 1.00
Mon, Dec 1 1:30 PM - 2:45 PM Location: Arie Crown Theater
Participants
Presiding
N. Reed Dunnick MD Nothing to Disclose President, Radiological Society of North America

Sub-Events
PS20B
PS20C
Presentation of Honorary Membership
Zheng Yu Jin MD (Presenter): Nothing to Disclose , Markus Schwaiger MD (Presenter): Research Grant,
Siemens AG , Kaori Togashi MD, PhD (Presenter): Research Grant, Bayer AG Research Grant, DAIICHI
SANKYO Group Research Grant, Eisai Co, Ltd Research Grant, FUJIFILM Holdings Corporation Research Grant,
Nihon Medi-Physics Co, Ltd Research Grant, Shimadzu Corporation Research Grant, Toshiba Corporation
Research Grant, Covidien AG , N. Reed Dunnick MD Nothing to Disclose
New Horizons Lecture: Future of Ultrasound
Jonathan Matthew Rubin MD, PhD (Presenter): Equipment support, General Electric Company Equipment support, Siemens AG , Jon A. Jacobson MD Consultant, BioClinica, Inc Royalties, Reed Elsevier Equipment support, Terumo Corporation Equipment support, Arthrex, Inc
Ultrasound is considered useful because it is safe, fast, and easy to perform. However, these mainly passive attributes will be and are being augmented by new quantitative methods that are nearly unique to ultrasound, giving ultrasound a new life and increased relevance in the medical imaging armamentarium. The first of these is elasticity imaging. Many flavors of this extremely robust new imaging and diagnostic method are now becoming standard fare in the literature. The general implementations of elastography have been strain and shear wave speed (SWS) imaging. However, these are now augmented by shear viscosity imaging, non-linear strain and non-linear shear wave imaging. The applications are expanding rapidly, and the impact will almost certainly be major. The leading application and the one getting the most notice has been assessing liver fibrosis/cirrhosis. The standard method is biopsy, which is invasive with real risks. Biopsies are also highly localized and represent a very poor sample of the underlying disease. SWS imaging is a more global measure, and it is totally benign. For these two reasons alone, SWS will likely replace liver biopsies for fibrosis/cirrhosis assessment. Other applications are being developed, and are already having impact. These include breast cancer differentiation, thyroid nodule characterization, cardiac function and conduction analysis, deep venous thrombosis aging, and Crohn's disease stricture evaluation. The second application is volume flow estimation.
Using 3D and 4D sampling, volume flow becomes quite simple to measure. The technique is based on what is known as Gauss's Theorem. This relation states that volume flow is equal to the total integrated flux over any surface cutting across a conduit with flow. The method is angle independent, flow profile independent, and vessel geometry independent. Using 2D ultrasound arrays, these measurements can be performed in real-time.
The applications are nearly limitless. A good approximation of its potential utility corresponds to the number times parameters such as resistive indices and pulsatility indices are now being applied. Volume flow would replace them. Such measurements would significantly affect transplant evaluations, cardiac output measurements, fetal evaluation through umbilical cord blood flow measurements, carotid artery flow, and cerebral perfusion. Direct perfusion estimates defined by flow per unit mass would become standard by estimating organ weight with 3D imaging and direct measurements of blood flow. Finally, there are a whole new variety of applications for contrast agents, some of which will almost certainly be employed. Given the fact that ultrasound contrast agents are gas bubbles, it is possible to vary the composition of the shells that stabilize these gas bubbles, making these gas bubbles not only contrast agents but delivery agents. Investigators have already placed drug compounds or chemotherapeutic agents into bubble shells and bubbles have been used to facilitate gene transfection. Some of the more novel applications include manipulation of perflourocarbon droplets that contain chemotherapeutic agents that can be made to boil in ultrasound fields at desired target locations, thus depositing its agents at precise points in the body.
Special Courses
US OI NM MR CT BQ US OI NM MR CT BQ
AMA PRA Category 1 Credits ™ : 1.50
ARRT Category A+ Credits: 1.50
Mon, Dec 1 4:30 PM - 6:00 PM Location: N227AB
Participants
Moderator
Daniel C. Sullivan MD : Nothing to Disclose
LEARNING OBJECTIVES
1) Understand the activities that RSNA supports to help move the profession of radiology from a primarily qualitative interpretation paradigm to a more quantitative-based interpretation model. 2) Describe the challenges of extracting uniform, standardized quantitative measures from clinical imaging scans. 3) Describe the benefits of implementing more quantitative image interpretation in clinical radiology practice, including quality assurance activities and for the development of decision-support tools. 4) List an example of an imaging biomarker from CT, MR, PET and ultrasound scans that are needed in clinical practice.
ABSTRACT
In response to the need for reliable and reproducible quantification of biomedical imaging data, the RSNA in 2007 organized the
Quantitative Imaging Biomarkers Alliance (QIBA, http://rsna.org/QIBA_.aspx) whose mission is to improve the value and practicality of quantitative imaging biomarkers by reducing variability across devices, patients and time. QIBA participants span a wide range of expertise including clinical practice, clinical research, physics, statistics, engineering, marketing, regulatory, pharmaceutical, and computer science. QIBA employs a systematic, consensus-driven approach to produce a QIBA Profile that includes one or more Claims and specifications for the image acquisition and processing necessary to achieve that Claim. QIBA
Profiles are based on published data whenever such data are available and on expert consensus opinion for specifications where no data exist. Thus there are several sources of variability in the quantitative results obtained from clinical images, which can

no data exist. Thus there are several sources of variability in the quantitative results obtained from clinical images, which can be grouped into three categories: (1) the image acquisition hardware, software and procedures; (2) the measurement methods used; and (3) the reader variability. Examples of QIBA Profiles for CT volumetry, DW-MR, FDG-PET and ultrasound for liver elastography will be discussed.
Sub-Events
SPSI22A Introduction
Daniel C. Sullivan MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
View learning objectives under main course title.
SPSI22B
SPSI22C
CT for Lung Cancer Screening
James L. Mulshine MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
View learning objectives under main course title.
DW-MR for Cancer Staging and Monitoring
Mark Alan Rosen MD, PhD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
View learning objectives under main course title.
SPSI22D FDG-PET for Cancer Staging and Monitoring
Richard L. Wahl MD (Presenter): Patent holder, Naviscan, Inc Patent holder, GlaxoSmithKline plc Patent holder, Spectrum Pharmaceuticals, Inc Research Consultant, GlaxoSmithKline plc Research Consultant, Nihon
Medi-Physics Co, Ltd Research support, General Electric Company Research support, Molecular Insight
Pharmaceuticals, Inc Research support, Cell Point LLC
LEARNING OBJECTIVES
View learning objectives under main course title.
SPSI22E US Elastography for Liver Fibrosis Diagnosis and Monitoring
Anthony Edward Samir MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
View learning objectives under main course title.
Special Courses
US MR IR MK
AMA PRA Category 1 Credits ™ : 1.00
ARRT Category A+ Credit: 1.00
Tue, Dec 2 7:15 AM - 8:15 AM Location: E351
Participants
Moderator
Mark Richard Robbin MD : Nothing to Disclose
Sub-Events
SPSH30A Update on Osteoid Osteoma Radiofrequency Ablation
Mark Richard Robbin MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES

1) Understand the current practice and literature of Osteiod Osteoma ablation. 2) Discuss different techniques of Osteoid Osteoma ablation. 3) Review techniques of ablation of other benign Bone Tumors.
SPSH30B Cryoablation and Microwave Treatment of Metastatic Disease to Bone
Damian E. Dupuy MD (Presenter): Research Grant, NeuWave Medical Inc Board of Directors, BSD Medical
Corporation Stockholder, BSD Medical Corporation Speaker, Educational Symposia
LEARNING OBJECTIVES
1) Review the current microwave and cryoablation technology. 2) Understand the current clinical indications and how both thermal technologies are applied to patients with osseous metastatic disease. 3) Learn the pearls and pitfalls of implementation through clinical examples.
SPSH30C MR-guided Focused Ultrasound Treatment of Painful Bone Metastases
David C. Gianfelice MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Introduce technology of MR Guided focused ultrasound ablation 2) Specific application of this technology for painful bone metastases 3) Review of the literature and definitive Phase 3 study 4) Possible future applications
Refresher/Informatics
US OB GU US OB GU
AMA PRA Category 1 Credits ™ : 1.50
ARRT Category A+ Credits: 1.50
Tue, Dec 2 8:30 AM - 10:00 AM Location: N228
Participants
Mindy Meislich Horrow MD (Presenter): Spouse, Director, Merck & Co, Inc
Paula J. Woodward MD (Presenter): President, Amirsys, Inc
LEARNING OBJECTIVES
1) The learner will be made aware of the importance of acute kidney injury (AKI) and associated ultrasound findings. 2)
Ultrasound criteria of cystic adnexal masses will be reviewed. 3) Testicular and scrotal pathology and the importance of ultrasound will be explained.
ABSTRACT
Ultrasound has taken on new importance in the evaluation of the kidney, female pelvis and the scrotum/ testicles. We will explain the ultrasound findings of acute kidney injury (AKI), the evaluation of pelvic masses and the necessary follow-up.
Finally, a review of the testicle and ultrasound findings will complete the course.
Refresher/Informatics
US OB GU
AMA PRA Category 1 Credits ™ : 1.50
ARRT Category A+ Credits: 1.50
Tue, Dec 2 8:30 AM - 10:00 AM Location: E450B
Active Handout http://media.rsna.org/media/abstract/2014/13010309/RC310 sec.pdf
Sub-Events
RC310A Fetal Genitourinary Anomalies
Roya Sohaey MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Diagnose and offer a management plan for mild fetal hydronephrosis (pelviectasis). 2) Differentiate between different causes of significant hydronephrosis using ultrasound and MRI. 3) Develop an approach to differential diagnosis for renal cystic dysplasia.

RC310B
RC310C
ABSTRACT
This lecture will discuss the approach to fetal GU anomalies. Mild and significant hydronephrosis differential diagnoses and associations will be stressed. Strategies for imaging with MR and need for follow up imaging or further diagnostic testing will be disussed. Finally, the differential diagnosis of renal cystic dysplasia will be explored as it relates to etiology and associations with genetic disorders.
Active Handout http://media.rsna.org/media/abstract/2014/13010310/RC310A sec.pdf
Multiple Gestations
Anne M. Kennedy MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Determine chorionicity and amnionicity and understand why it is important to do so in all multiple gestations.
2) Understand and diagnose specific complications of monochorionic twinning such as twin to twin transfusion syndrome and twin reversed arterial perfusion. 3) Recognize the indications for more frequent surveillance and intervention in complicated twin pregnancies.
ABSTRACT
This lecture will review how to determine chorionicity and amnionicity with emphasis on doing so in the first trimester. Monochorionic pregnancies require increased surveillance because of specific complications relating to shared placental vasculature. We will review the imaging findings of twin to twin transfusion syndrome and twin reverse arterial perfusion sequence as the prognosis is very poor if untreated. Early recognition and prompt referral is essential for pregnancy management.
Active Handout http://media.rsna.org/media/abstract/2014/13010311/RC310B sec.pdf
Obstetrical Emergencies
Carol Beer Benson MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Diagnose and differentiate causes of bleeding in pregnancy based on sonographic findings. 2) Apply transvaginal and translabial techniques to assess the cervix and placenta. 3) Use ultrasound to diagnose causes of pain in pregnancy. 4) Recognize the sonographic appearance of uterine incarceration during pregnancy and its clinical significance. 5) Understand how to interpret fetal umbilical artery Doppler in the assessment of fetal well-being.
ABSTRACT
This lecture will discuss how ultrasound is used to assess acute problems in pregnancy during the second and third trimesters, including symptoms of pain and bleeding, abnormal findings at physical examination, and concerns for fetal well-being. Techniques for assessing cervical length and placenta previa will be discussed, including transvaginal and translabial scanning. Also included will be a discussion about when and how to use fetal umbilical artery Doppler for assessing fetal well-being. Sonographic assessment of abnormal fetal heart rate patterns will also be covered.
Refresher/Informatics
US VA GI US VA GI
AMA PRA Category 1 Credits ™ : 1.50
ARRT Category A+ Credits: 1.50
Tue, Dec 2 8:30 AM - 10:00 AM Location: E264
Participants
Shweta Bhatt MD, MBBS (Presenter): Nothing to Disclose
Wui Kheong Chong MD (Presenter): Nothing to Disclose
M. Robert Dejong (Presenter): Advisory Board, Koninklijke Philips NV Speakers Bureau, Koninklijke Philips NV
Vikram Singh Dogra MD (Presenter): Editor, Reed Elsevier
Corinne Deurdulian MD (Presenter): Nothing to Disclose

Edward G. Grant MD (Presenter): Research Grant, Bracco Group Research Grant, General Electric Company Medical Advisory
Board, Nuance Communications, Inc
Gowthaman Gunabushanam MD (Presenter): Editor, WebMD Health Corp
Ulrike M. Hamper MD, MBA (Presenter): Nothing to Disclose
Felix A. Hester (Presenter): Nothing to Disclose
Mark Elwood Lockhart MD (Presenter): Nothing to Disclose
Michelle Lavonne Robbin MD (Presenter): Consultant, Koninklijke Philips NV
Leslie M. Scoutt MD (Presenter): Consultant, Koninklijke Philips NV
Sadhna Verma MD (Presenter): Nothing to Disclose
Ravinder Sidhu MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Understand basic concepts associated with abdominal and visceral Doppler. 2) Describe ultrasound techniques, protocols, and diagnostic criteria for evaluation of abdominal and visceral arteries. 3) Gain experience in Doppler techniques through personalized hands-on scanning of models with a variety of ultrasound machines. 4) Describe common pitfalls in Doppler examinations.
ABSTRACT
This hands-on course will focus on the details that constitute good Doppler technique in the evaluation of vascular flow within the abdomen and pelvis. Technical considerations for optimization of Doppler images will be discussed and the concepts will be applied to abnormalities commonly encountered in patients. Initial two brief lectures will begin by discussing important aspects of abdominal and visceral Doppler. The majority of the session will give participants an opportunity to scan live models to improve technical skills in color and spectral Doppler. Faculty will be available at multiple stations using a variety of ultrasound machines. Participants will be encouraged to inquire about specific arterial territories of interest in the abdomen and pelvis during the hands-on component of the course.
Series Courses
US MK US MK
AMA PRA Category 1 Credits ™ : 3.25
ARRT Category A+ Credits: 3.50
Tue, Dec 2 8:30 AM - 12:00 PM Location: E450A
Participants
Moderator
Marnix T. van Holsbeeck MD : Consultant, General Electric Company Consultant, Koninklijke Philips NV Stockholder,
Koninklijke Philips NV Stockholder, General Electric Company Grant, Siemens AG Grant, General Electric Company
Moderator
David Paul Fessell MD : Nothing to Disclose
LEARNING OBJECTIVES
The 'Ultrasound' Series Course will review musculoskeletal sonography through live instruction by expert refresher course instructors, interspersed with scientific presentations.
Sub-Events
VSMK31-01 Shoulder Ultrasound (Demonstration)
Jon A. Jacobson MD (Presenter): Consultant, BioClinica, Inc Royalties, Reed Elsevier Equipment support,
Terumo Corporation Equipment support, Arthrex, Inc
LEARNING OBJECTIVES
1) Be familiar with ultrasound examination and anatomy of the shoulder and common pathology.
ABSTRACT
The goal of this live demonstration is to review shoulder ultrasound technique, which will be completed in 5 steps. The first step evaluates the long head of the biceps brachii tendon in short and long axis with the shoulder in neutral position. Step #2 with external rotation of the humerus evaluates the subscapularis in long and short axis, as well as the biceps brachii tendon for subluxation or dislocation. Step #3 evaluates the supraspinatus in long and short axis, as well as the distal infraspinatus tendon. Understanding the greater tuberosity facets is helpful in distinguishing between the supraspinatus and infraspinatus. Step #4 evaluates the acromioclavicular joint. With humerus abduction, the shoulder is also evaluated for subacromial impingement.
Step #5 with the shoulder in neutral position evaluates the posterior glenohumeral joint recess, the posterior labrum, the spinoglendoid notch, and the infraspinatus muscle for fatty degeneration and atrophy. A comprehensive evaluation is essential to accurately diagnose shoulder pathology.
VSMK31-02 Sonographic Median Nerve Cross Sectional Area Measurement in CTS Patients: Can Delta and Ratio
Calculations Predict Severity Compared to Nerve Conduction Studies?
Mohamed Mahmoud Hamdy Abd Ellah MD (Presenter): Nothing to Disclose , Thomas Auer MD : Nothing to
Disclose , Eberle Gernot MD : Nothing to Disclose , Lenka Gerencerova MD : Nothing to Disclose , Sylvia
Strobl MD : Nothing to Disclose , Christian Kremser PhD : Nothing to Disclose , Gudrun Feuchtner MD :
Nothing to Disclose , Fabian Plank MD : Nothing to Disclose , Mihra S. Taljanovic MD : Nothing to Disclose
, Werner R. Jaschke MD, PhD : Nothing to Disclose , Andrea Klauser MD : Nothing to Disclose
PURPOSE
To evaluate the role of high resolution US in prediction of carpal tunnel syndrome (CTS) severity compared to nerve conduction studies.

nerve conduction studies.
METHOD AND MATERIALS
643 wrists of 427 CTS patients (325 females and 102 males), age ranged between 17-90 years (57.9+/-14.7, mean+/-Std) were included in this study. CTS was diagnosed clinically and confirmed by nerve conduction studies (NCS). US was performed using a 14-8-MHz (LA424, 14-8 MPX; Esaote, Genoa-Firenze, Italy) or
18-6-MHz (LA435, MyLab90; Esaote) linear array transducer. CTS severity was classified according to NCS.
Cross sectional measurements (CSA) of the median nerve was done at the level of the carpal tunnel (CSAc) and more proximally at the level of the pronator quadratus muscle (CSAp). Two parameters were calculated; Δ-CSA which is the difference between the proximal and distal measurements, and R-CSA which is the ratio calculated by dividing the distal over the proximal CSA.
RESULTS
Patients were classified into three groups (mild, moderate, and severe) according to severity by NCS. The mean
CSA was (12.5, 14.7, and 18.8), mean Δ-CSA was (4.2, 6.95, and 10.7), and mean R-CSA was (1.5, 1.95, and
2.4) in all groups respectively with a significant difference between all groups (p<0.001). The cut off value was
5.5, and 8.5 between groups 1 and 2, and groups 3 and 4 respectively for Δ-CSA, while it was 1.7 and 2.2
between the same groups for R-CSA.
CONCLUSION
By implementing cut off values for the calculated parameters (Δ-CSA and R-CSA), high resolution US showed ability to predict CTS severity compared to NCS.
CLINICAL RELEVANCE/APPLICATION
1. The difference between cross-sectional areas of the median nerve measured at the level of the carpal tunnel
(CSAc) and at the level of the pronator quadratus muscle (CSAp) - Δ-CSA - and the ratio between the two values - R-CSA - increases with the severity of Carpal tunnel syndrome (CTS). 2. Those parameters showed significant difference between different patient groups, which were classified according to nerve conduction study results (mild, moderate, and severe). 3. Better severity determination with Δ-CSA and R-CSA is obtained with better sensitivity and specificity values compared tp measured CSAc alone especially for the differentiation between mild and moderate groups. 4. Cut off values were obtained for each parameter (Δ-CSA and R-CSA) between the different CTS severity groups.
VSMK31-03 Diagnostic Performance of Ultrasound, MR Imaging, and MR Arthrography after Rotator Cuff Repair
Qian Dong MD (Presenter): Nothing to Disclose , Bo He : Nothing to Disclose , Jon A. Jacobson MD :
Consultant, BioClinica, Inc Royalties, Reed Elsevier Equipment support, Terumo Corporation Equipment support, Arthrex, Inc , Catherine J. Brandon MD : Stock options, VuCOMP, Inc , Corrie Marlene Yablon MD :
Nothing to Disclose , David Alexander Jamadar MBBS : Nothing to Disclose , Yoav Morag MD : Nothing to
Disclose , Girish Gandikota MBBS : Nothing to Disclose
PURPOSE
To evaluate the diagnostic performance of ultrasound (US), magnetic resonance imaging (MRI), and magnetic resonance arthrography (MRA) in patients with recurrent rotator cuff tear after rotator cuff repair, using revision surgery as the standard of reference.
METHOD AND MATERIALS
Institutional review board approval was obtained and informed consent was waived. This retrospective study included 104 consecutive patients (111 shoulders, 63 men, 41 women; mean age, 54.5 years) with recurrent and/or persistent symptoms after rotator cuff repair and subsequent revision surgery from January, 2004 to
November, 2013. Reports of US in 52 patients (54 shoulders), MRI in 63 patients (68 shoulders), MRA in 17 patients were reviewed with consensus to determine the presence or absence of recurrent full thickness rotator cuff tear. The imaging results were then compared with the operative reports.
RESULTS
Over all, sensitivity, specificity, accuracy, positive predictive value and negative predictive value in detection of recurrent rotator cuff full-thickness tear in postoperative shoulder were of 90.0%, 87.5%, 94.4%, 90.0% and
87.5% by US, respectively; 82.5%, 92.9%, 86.8%, 94.3% and 86.8% by MRI, respectively. MRA had 100% in all values. The differences in performance of MRI and US for detecting recurrent rotator cuff full-thickness were not statistically significant.
CONCLUSION
MRI, US and MRA in particular, are highly accurate means for assessing recurrent full thickness tears in postoperative shoulders.
CLINICAL RELEVANCE/APPLICATION
For detection of rotator cuff tear in shoulders that have not undergone surgery, ultrasound (US), magnetic resonance imaging (MRI), and magnetic resonance arthrography (MRA) are all accurate methods with high sensitivity and specificity. However, imaging assessment of rotator cuff in postoperative shoulders can be challenging.

VSMK31-04 Sonographic-guided Procedures (Demonstration)
Marnix T. van Holsbeeck MD (Presenter): Consultant, General Electric Company Consultant, Koninklijke Philips
NV Stockholder, Koninklijke Philips NV Stockholder, General Electric Company Grant, Siemens AG Grant, General
Electric Company , Kathy Quenneville BS, RT (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) To demonstrate optimal techniques for performing sonographic-guided procedures.
VSMK31-05 May Intratendinous US-guided Platelet Rich Plasma (PRP) Injection Modify the Natural History of
Degenerative Tendinopathy of Rotator Cuff Tendons of the Shoulder? Results of 4 years of Clinical and MRI Follow-up
Francesco Arrigoni (Presenter): Nothing to Disclose , Lorenzo Maria Gregori : Nothing to Disclose , Alice La
Marra MD : Nothing to Disclose , Luigi Zugaro : Nothing to Disclose , Antonio Barile MD : Nothing to
Disclose , Carlo Masciocchi MD : Nothing to Disclose
PURPOSE
There is currently no literature describing the diagnostic imaging of the long-term outcomes in case of
US-guided PRP injection of the supraspinatus tendon. The aim of this study was to evaluate the evolution of the degenerative tendinopathy of the rotator cuff from the morphological (MRI images) and clinical point of view 4 years after treatment with US-guided PRP injection of the supraspinatus tendon, compared with patients submitted to medical and physical therapy alone.
METHOD AND MATERIALS
We retrospectively evaluated 240 patients (all patients with history of trauma or surgery during the follow-up were excluded), 120 treated 4 years before with US-guided PRP injection of the supraspinatus tendon (group 1,
G1) and 120 submitted, over a 4 year period, to medical and physical therapy alone (group 2, G2). For each patient, 2 radiologists independently evaluated the MRI performed before and 4 years after the injection (G1) or, in the G2, 2 MRIs performed at the distance of 4 years from each other, dividing the results into 3 categories for each group: improvement, stationary findings or worsening. A clinical and functional evaluation was also performed (VAS and Constant scale).
RESULTS
We recorded an improvement in the MRI appearance of the supraspinatus tendon in 31.7% of the G1 and only in 3.3% of G2; stationary findings were found in 48.3% in the G1 and in 34.2% in the G2, while worsening was of 20% in G1 and 62.5% in G2. Clinical evaluation: the mean VAS values showed improvement of 74.5% for the G1 and of 16.2% for G2; mean Constant values showed improvement of 56% (G1) and 9% (G2).
CONCLUSION
This study suggests that the US-guided PRP injection can be effectively used in the rotator cuff tendinopathy.
Our results show the ability to regenerate and delay the degenerative processes: not only there is a higher percentage of patients with an improvement of the MRI appearance of the supraspinatus tendon 4 years after
PRP injection, but also the number of patients that show a worsening of the MRI findings is lower in the G1 than in the G2. The clinical findings reflect positive outcomes in terms of pain relief and functional improvement.
CLINICAL RELEVANCE/APPLICATION
To evaluate, with a 4 year follow-up, clinical and functional effects and imaging findings of US-guided PRP injections of the supraspinatus tendon compared with natural history of tendinopathy.
VSMK31-06 Ultrasound-guided Perineural Injection of Upper Extremity and Sciatic Nerves: Does Single Needle
Position Produce Circumferential Nerve Coverage?
Ogonna Kenechi Nwawka MD (Presenter): Nothing to Disclose , Theodore T. Miller MD : Nothing to Disclose
, Gregory Roy Saboeiro MD : Research funded, Terumo Corporation Speakers Bureau, Bioventus LLC ,
Shari Tamar Jawetz MD : Nothing to Disclose
PURPOSE
Our current clinical technique for ultrasound-guided perineural injection consists of placing the needle along both the superficial and deep surfaces of the nerve to obtain circumferential distribution of the injectate. This study aims to determine if a single needle position will produce circumferential coating of a nerve.
METHOD AND MATERIALS
For this IRB approved study, 6 upper extremity and 3 pelvic fresh cadaveric specimens were obtained. For the upper extremity, a 25 gauge hypodermic needle was positioned along the deep surface of the median nerve in the carpal tunnel, the radial nerve in the radial tunnel, and the ulnar nerve in the cubital tunnel, and 2 ml of dilute Omnipaque-300 contrast was injected for each nerve. In the pelvis, a 22 gauge spinal needle was positioned deep to the sciatic nerve, and 5 ml of contrast was injected. Thus, 18 upper extremity nerves (6 median, 6 radial, 6 ulnar) and 6 sciatic nerves were injected. All needle placements and injections were performed under ultrasound guidance by two experienced musculoskeletal radiologists. The specimens then underwent CT scanning, and the distribution of perineural contrast was assessed by a musculoskeletal radiologist not involved in the injections.
RESULTS

6/6 radial and 6/6 ulnar nerves demonstrated circumferential distribution of injectate on CT. Only 3/6 median nerves had circumferential coverage. 6/6 sciatic nerves demonstrated circumferential coverage on CT. The average length of spread for the upper extremity perineural injectate was 12.5 cm, with a range of 5.5 cm to
20 cm. For the sciatic nerves, the average length of spread was 10.3 cm, ranging from 6.4 cm to 15.5 cm.
CONCLUSION
Using the clinical volumes of injectate that we use for upper extremity nerves and the sciatic nerve, positioning adjacent to the deep surface of each nerve was sufficient to produce circumferential coating of the nerve, except in the tight fibroosseus space of the carpal tunnel.
CLINICAL RELEVANCE/APPLICATION
We no longer try to position the needle adjacent to two opposite sides of a nerve during ultrasound-guided perineural injections, except in the carpal tunnel.
VSMK31-07 Evaluating Bone Neoplasia: Ultrasound-guided Biopsy vs. Computed Tomography-guided Biopsy
Rounak R. Bafana MD (Presenter): Nothing to Disclose , Nick Ryan Reeser MD : Nothing to Disclose , Kevin
McGill MD, MPH : Nothing to Disclose , Marnix T. van Holsbeeck MD : Consultant, General Electric Company
Consultant, Koninklijke Philips NV Stockholder, Koninklijke Philips NV Stockholder, General Electric Company
Grant, Siemens AG Grant, General Electric Company
PURPOSE
To compare the diagnostic accuracy of ultrasound (US)-guided biopsy with computed tomography (CT)-guided biopsy, regarding primary and metastatic bone lesions.
METHOD AND MATERIALS
A retrospective review was performed on 116 patients presenting with lesions of the appendicular skeleton and shoulder girdle that were suspicious for primary or metastatic bone malignancy. All patients underwent percutaneous needle core biopsy and/or fine needle aspiration (FNA) using CT (n = 83 ) or ultrasound (n = 33) guidance. Samples obtained by CT and ultrasound were then stratified by lesion characteristics (size, radiographic features, location), biopsy type (core vs FNA), and categorized as either Group A - Diagnostic or
Group B - non-diagnostic. Diagnostic accuracy was based on comparison to surgical pathology and clinical outcome.
RESULTS
Overall accuracy of US-guided cases was 87.9% (29/33) whereas for CT-guided cases it was 87.9% (72/83).
Biopsy results were further broken down by lesion size. For US, 88.9% of lesions 0-3cm were diagnostic, 85.7% of lesions 4-6cm were diagnostic, and 90% of lesions greater than 6cm were diagnostic. For CT, 80.0% of lesions 0-3cm were diagnostic, 92.9% of lesions 4-6cm were diagnostic and 81.3% of lesions greater than 6cm were diagnostic.
CONCLUSION
Ultrasound and CT have comparable diagnostic accuracy in the sampling of bone lesions, regardless of size.
CLINICAL RELEVANCE/APPLICATION
With comparable accuracy to CT and the benefits of lower cost, lack of radiation, and the ability to perform procedures at bedside, ultrasound is an ideal method for clinicians to investigate suspicious osseous lesions.
VSMK31-08 Sonography for Evaluation of Arthritis (Demonstration)
Etienne Cardinal MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) To demonstrate comprehensive methods to evaluate joints for arthritis.
VSMK31-09 Ultrasound Findings in Hand Joints Involvement in Patients with Psoriatic Arthritis and Its
Correlation with Clinical DAS28 Score
Priyanka Mahadeorao Naranje MBBS, MD (Presenter): Nothing to Disclose , Mahesh Prakash MBBS, MD :
Nothing to Disclose , Aman Sharma : Nothing to Disclose , Sunil Dogra MBBS, MD : Nothing to Disclose ,
Niranjan Khandelwal MD : Nothing to Disclose
PURPOSE
To evaluate the ultrasound findings in hand joints in patients with psoriatic arthritis and correlate grayscale and power Doppler ultrasonography findings with Disease Activity Score 28.
METHOD AND MATERIALS
This prospective study was performed in 30 patients. Ultrasound evaluation of 28 joints of both hands was undertaken and various findings were recorded including synovial hypertrophy, power Doppler abnormality, soft

tissue thickening, tendonitis, joint effusion, periosteal reaction and erosions. Composite ultrasound scores and
Disease Activity Score 28 were calculated and compared.
RESULTS
Ultrasound detected more abnormalities in the hand joints than did clinical examination. The frequency of various ultrasound abnormalities were as follows: Synovial hypertrophy was seen in 100%, power Doppler abnormality suggesting hypervascularity in 36.7%, soft tissue thickening in 66.7%, periosteal reaction in
33.3%, erosions in 30% (mostly in DIP and PIP joints) and flexor tendonitis in 6.7% of patients. Significant correlation was found between Disease activity score 28 and gray-scale joint score (GSJS) (Spearman's ρ:
0.499, P: 0.005), gray-scale joint count (GSJC) (ρ: 0.398, P: 0.029) and power Doppler joint score (PDJS) (ρ:
0.367, P: 0.046). There was a statistically significant difference between remission and low disease activity group, and moderate disease activity group in terms of GSJC, GSJS, PDJC and PDJS (P<0.05). These ultrasound measures were higher in moderate disease activity zone patients.
CONCLUSION
Ultrasound is a useful modality for the objective assessment of psoriatic arthritis, which can detect joint inflammation to a larger extent than clinically expected. Ultrasound including power Doppler can be used as a modality for assessment of severity of psoriatic arthritis as it correlates with the clinical scoring.
CLINICAL RELEVANCE/APPLICATION
Ultrasound including power Doppler is a very good modality for assessment of severity of psoriatic arthritis.
VSMK31-10 Rhumatoid Arthritis: Correlations betwween Ultrasound and Radiograpic Images and betwween
Ultrasound and Clinical Findings
Manel Limeme : Nothing to Disclose , Neila Benzina : Nothing to Disclose , Moncef Allegue MD : Nothing to Disclose , Houneida Zaghouani Ben Alaya : Nothing to Disclose , Senda Majdoub : Nothing to Disclose , habib amara : Nothing to Disclose , dejla bakir : Nothing to Disclose , Chakib Kraiem MD, DMD
(Presenter): Nothing to Disclose
PURPOSE
To evaluate concordance between clinical examination and ultrasound of joints (hands) in an heterogeneous group of patients with rheumatoid arthritis (RA). To compare sonography with conventional radiography for the detection of erosions in the metacarpophalangeal (MCP) joints of patients with RA.
METHOD AND MATERIALS
Forty patients were included in a prospective, transversal, single-center study, whatever disease activity, duration or treatment. In each patient, both hands were evaluated for a total of 960 joints. Synovitis was scored using clinical examination, B-mode and power Doppler. Concordance between swelling joint by clinical examination, synovitis thickening by B-mode (grade 1 or higher) and inflammation by power Doppler (grade 1 or higher) was assessed by computing the kappa coefficient. Erosion sites were recorded using radiography and sonography and subsequently compared using each modality.
RESULTS
Clinical joint examination and ultrasound concordance was very low at the metacarpophalangeal joints (κ < 0.1) and was low at wrists (κ: 0.23 to 0.30). B-mode and power Doppler found 350 more synovitis than swollen joint count using clinical examination and up to 228 times more at metacarpophalangeal joints. Sonography detected 127 definite erosions in 56 of 100 RA patients, compared with radiographic detection of 32 erosions
(26 % of which coincided with sonographic erosions) in 17 of 100 patients (P < 0.0001). The mean duration from the onset of symptoms was 3.46 months. Based on the clinical, biochemical and US scores the patients from our study presented early stages of RA. Also, statistically significant correlations were observed between the time elapsed from the onset, the changes highlighted by ultrasound and the stage of the disease.
CONCLUSION
Our study confirms that US evaluation of changes in the joints of the hand offers useful information for staging the diagnosis of RA as it determines the activity of the disease thanks to Doppler parameters. It is a reliable technique that detects more erosions than radiography, especially in early RA. This technology has potential in the management of patients with early RA and is likely to have major implications for the future practice of rheumatology.
CLINICAL RELEVANCE/APPLICATION
US evaluation of changes in the joints of the hand offers useful information for staging the diagnosis of RA as it determines the activity of the disease thanks to Doppler parameters.
VSMK31-11 Supersonic Shear Imaging Identifies Potential Evidence of Localized Changes in Achilles Tendon
Compliance in Middle-aged Adults
Laura Slane PhD (Presenter): Nothing to Disclose , Ryan J. DeWall PhD : Nothing to Disclose , Jack Martin
: Nothing to Disclose , Kenneth S. Lee MD : Research Consultant, SuperSonic Imagine Speakers Bureau,
Medical Technology Management Institute , Darryl Thelen : Nothing to Disclose
PURPOSE

Middle-aged adults exhibit increased incidence of Achilles tendon and calf muscle strain injuries. Age-related changes in tendon compliance are hypothesized to be a contributing factor, but assessing tissue compliance in vivo remains challenging. Supersonic Shear Imaging is an ultrasound elastography approach that noninvasively evaluates tissue compliance by measuring shear wave propagation speed (SWS). The purpose of this study was to compare spatial variations in SWS within the Achilles tendons of young and middle-aged adults.
METHOD AND MATERIALS
We recruited ten healthy young (27±4 yrs) and middle-aged adults (49±4 yrs). SWS images were collected from regions of the Achilles tendon, including the free tendon, the soleus aponeurosis and the medial gastrocnemius aponeurosis, at three ankle angles: resting (R), dorsiflexed (R-15 deg) and plantarflexed (R+15 deg). SWS data were evaluated post-hoc at regions of interest defined within tendon boundaries.
RESULTS
Achilles tendon SWS varied significantly with imaging location, with the greatest speeds measured in the free tendon. Ankle posture had a significant effect on SWS, with speed progressively increasing with ankle dorsiflexion along the entire tendon length. A significant, inverse relationship between resting gastrocnemius aponeurosis SWS and age (R2=0.34, p<0.01) was observed, but there were no age-effects in the free tendon or soleus aponeurosis. A similar relationship existed in the gastrocnemius aponeurosis in the dorsiflexed posture
(R2=0.55, p<0.01).
CONCLUSION
We observed age-related changes in Achilles tendon SWS to be location dependent, with evidence of a significant increase in compliance in the gastrocnemius aponeurosis of middle-aged adults. Our results suggest that Achilles tendon compliance increases in a distal-to-proximal fashion, with greater compliance at the muscle-tendon junction. Middle-aged adults seem to exhibit greater tendon compliance near the muscle-tendon junction, which could give rise to localized tissue stain concentrations and hence injury risk.
CLINICAL RELEVANCE/APPLICATION
These results demonstrate the potential for Supersonic Shear Imaging to quantitatively characterize spatial variations in tendon elasticity that may be affected by aging, injury and disease processes.
VSMK31-12 Evaluation of the Median Nerve and Carpal Tunnel Tendons in Patients with Carpal Tunnel Syndrome using Transient Elastography
Renata La Rocca Vieira MD (Presenter): Nothing to Disclose , Ronald Steven Adler MD, PhD : Nothing to
Disclose , Kiril Kiprovski : Nothing to Disclose , James S. Babb PhD : Nothing to Disclose
PURPOSE
Carpal tunnel syndrome (CTS) is caused by compression or irritation of the median nerve (MN) within the carpal tunnel (CT). The diagnosis of CTS might be challenging given the lack of typical clinical or EMG findings. We aim to prospectively determine whether shear wave analysis provides useful adjunctive and quantitative information regarding the diagnosis of CTS
METHOD AND MATERIALS
This prospective work in progress included 5 patients-10 wrists (5 F, age range 41-70y, mean 55.6y) with clinically proven CTS and 4 healthy volunteer- 8 wrists (4 f, age range 32-45y, mean 39y). In both groups, the following measurements were performed: MN cross-sectional areas (CSA) in the CT and in the pronator quadratus (PQ); shear wave velocities in the longitudinal and axial planes (SWV) for MN and CT tendons. The differences between CTS patients and controls with regards to MN CSA and MN and tendon velocities were assessed with 9MHz linear transducer and S3000 scanner (Siemens, Mountainview, CA). A 2-dimension parametric SWV image was generated, from which selective SWV could be calculated
RESULTS
The CSA in the patients with CTS was significantly higher than those in the volunteers (p<0.001). In the CTS group, the difference between MN CSA in CT and PQ was significant (p=0.006). The tendon velocity was significantly higher in the CTS group compared to controls, in both axial (P <0.017) and longitudinal (p<
0.001) planes. No significant difference was found between the velocities of the MN in any plane between CTS and volunteers. The mean velocities/SD of the MN in the axial and longitudinal planes in the CTS group and volunteers are respectively 6.13/2.55 and 7.97/2.12 and 7.21/1.67 and 7.59/0.83. The difference between the velocities of the MN in the longitudinal versus axial planes is significant (p=0.011) in the CTS group
CONCLUSION
The stiffness of the CT tendons is significantly higher in patients with CTS. Preliminary data did not find significant difference between the velocities of the MN between CTS and volunteers, likely due to small sample size. Interestingly, the difference between the velocities of the MN in the longitudinal versus axial planes is significant probably due to anisotropy
CLINICAL RELEVANCE/APPLICATION
The pathophysiology of CTS is a combination of increased CT pressure and ischemic injury in the MN. Our results suggest the same theory can be applied to the tendons in the CT in patients with CTS

VSMK31-13 Superb Microvascular Imaging (SMI) and Detection of Low Grade Musculoskeletal Inflammation
Adrian Kuok Pheng Lim MD, FRCR (Presenter): Luminary, Toshiba Corporation , Keshthra Satchithananda
MBBS : Committee member, Johnson & Johnson , Sonya Abraham : Nothing to Disclose , Elizabeth Ann
Dick MD, FRCR : Nothing to Disclose , David Owen Cosgrove MBBCh, FRCR : Research Consultant,
SuperSonic Imagine Research Consultant, Bracco Group Speakers Bureau, Toshiba Corporation
PURPOSE
To assess the efficacy of Superb Microvascular Imaging (SMI) in detecting low grade inflammation in joints and tendons compared with conventional Power Doppler ultrasound (PDUS).
METHOD AND MATERIALS
SMI is a new and sensitive Doppler technology designed to detect slow flowing microvasculature. We assessed it in patients who presented for routine MSK ultrasound (Aplio 500, Toshiba Medical Systems). The grey-scale,
PDUS and SMI findings of each study were recorded on video clips. The joints and tendons which demonstrated an abnormality or vascular signal on either grey-scale appearance, PDUS or SMI were included in the analysis.
Three radiologists with over 10 years experience individually in MSK ultrasound assessed the images and scored whether there were grey-scale changes, signal on PDUS and/or SMI within the joints or tendons examined. If signal was detected on PDUS and SMI, they also scored a four point scale comparing the two
Doppler techniques (no difference, mildly, moderately or markedly better)
RESULTS
50 cases have been analyzed to date, comprising of 36 joints, 9 tendons, and 5 superficial lumps. In all cases, patients were symptomatic with joint pain or a palpable lump and 12 had a history of an inflammatory arthropathy. There was very good agreement between the readers (Κappa = 0.85). 29 cases demonstrated vascular flow with both PD and SMI while in 5 cases, no flow was detected with either technique. In 16 cases, vascularity was detected with SMI but not with PDUS (Fisher's exact test: p = 0.02). Out of the 29 patients with vascularity on SMI and PDUS, 3 showed no difference; while SMI scored moderately or markedly better in 20 cases (Chi2: p<0.02). In 12 patients, the SMI findings altered patient management where they either received an ultrasound guided steroid injection or started oral analgesia and/or disease modifying treatment.
CONCLUSION
SMI is a revolutionary Doppler technique which not only improves the visualisation of the microvasculature but allows detection of low grade inflammation not previously visualised with Power Doppler. This has significant clinical impact leading to a change in management in 25% of the patients in this study population.
CLINICAL RELEVANCE/APPLICATION
The improved sensitivity of SMI compared with the current 'gold standard' Power Doppler, allows the detection of low grade inflammation not possible with Power Doppler which would significantly influence patient treatment.
VSMK31-14 Interesting Musculoskeletal Ultrasound Cases
Benjamin David Levine MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Be familiar with important topics in musculoskeletal ultrasound.
ABSTRACT
The goal of this presentation is to emphasize important teaching points through a series of interesting musculoskeletal ultrasound cases. Ultrasound imaging features of various musculoskeletal disease processes will be highlighted, along with review of case specific anatomy and technique.
Scientific Papers
ER CT GU GI
AMA PRA Category 1 Credits ™ : 1.50
ARRT Category A+ Credits: 1.50
Tue, Dec 2 10:30 AM - 12:00 PM Location: E352
Participants
Moderator
Michael Nathan Patlas MD, FRCPC : Nothing to Disclose
Moderator
Mariano Scaglione MD : Nothing to Disclose
Sub-Events
SSG03-01 Rapid Acquisition Axial and Coronal T2 HASTE MR in the Evaluation of Acute Abdominal Pain

SSG03-01
Sam Byott MBChB (Presenter): Nothing to Disclose , Ian Harris MBBCh, FRCR : Nothing to Disclose
PURPOSE
To assess MR in acute abdominal imaging and ascertain if it is a reliable alternative to CT in patients under 60
METHOD AND MATERIALS
Four year prospective analysis from January 2009 - December 2013. In patients under 60 presenting with acute abdominal pain, MR was used either as a primary investigation, or following ultrasound when there was ongoing clinical concern. Rapid acquisition HASTE (Half Fourier Acquisition Single Shot Turbo Spin Echo) coronal and axial sequences without intravenous contrast. Patients were followed up for minimum of 3 months.
RESULTS
468 cases included in the study. 349 negative for acute abdominal pathology 116 positive for acute abdominal pathology 3 indeterminate MR Negative: 324 had uneventful follow up 22 had negative laparoscopies 3 had subsequent appendectomies, appendicitis on histology (3 days, 10 days and 2 months post scan) MR Positive:
64 had surgery confirming MR findings: 34 appendicitis, 14 SBO, 3 Ovarian torsion, 3 LBO, Intussusception,
Ovarian carcinoma, Ovarian dermoid, 2 Pelvc inflammatory disease, Diverticular abscess, Crohns, 4 Endoscopy for acute bowel pathology 1 had surgery for MR diagnosis of appendicitis, sigmoid diverticular perforation identifed at surgery 51 were treated conservatively with concordant follow-up: 4 SBO, 11 diverticulitis, 6 Pelvc inflammatory disease, 7 Inflammatory bowel disease, 7 Colitis, 6 Pyelonephritis, 2 Cholecystitis, Renal abscess,
Pseudomembranous colitis, Splenic heamatoma, Mesenteric adenitis, 2 Pancreatitis, Lymphoma, Epiploic appendagitis MR indeterminate: 1 treated conservatively, 1 had laparoscopic appendendectomy, normal appendix on histology, 1 had laparoscopic appendendectomy with acute appendicitis on histology Overall diagnostic accuracy of 99% (463/468), with respect to correlation between MR diagnosis and clinical/surgical follow up Negative laparoscopy rate: 4.9%
CONCLUSION
This study demonstrates that rapid acquisition axial and coronal T2 HASTE MR is a practical, safe and effective method in the diagnosis of acute abdominal pain. MR is the preferred option to CT in patients of an age prone to radiation with a potential surgical diagnosis.
CLINICAL RELEVANCE/APPLICATION
MRI in acute abdominal imaging is both effective and practical and is the preferred imaging option in patients of an age prone to radiation with a potential surgical diagnosis.
SSG03-02 Ureteral Stone Detection Using Virtual Nonenhanced Images in Enhanced Spectral CT Imaging: A
Preliminary Study
Duan Haifeng MMed (Presenter): Nothing to Disclose , He Taiping MMed : Nothing to Disclose , Yang
Chuangbo MMed : Nothing to Disclose , Ma Guangming MMed : Nothing to Disclose , Guo Youmin MD :
Nothing to Disclose , Lei Yuxin MMed : Nothing to Disclose , Yu Yong MMed : Nothing to Disclose
PURPOSE
To evaluate the clinical value of detecting ureteral stones with the virtual nonenhanced (VNE) images generated in the enhanced spectral CT imaging.
METHOD AND MATERIALS
38 adults (21 males and 17 female, ages: 24-76years) with positive calculi in the urinary system found during abdominal CT for lesion diagnosis or clinical emergency were retrospectively analyzed. True nonenhanced (TNE)
CT was performed with 120kVp with noise index of 12 at 5mm slice thickness. Contrast-enhanced scans in the venous phase (VP) and delayed phase (DP) were performed with spectral CT mode. VNE images were generated from the 2 enhanced phases. 2 board-certified radiologists reviewed both TNE and VNE images for image quality and stone detection rate. Mean CT number, size and contrast-noise-ratio (CNR) of stones were measured.
RESULTS
52 stones were detected from TNE images, including 11 in the renal parenchyma, 25 in the renal pelvises, 4 in the ureters of abdominal segments, 7 in the ureters of pelvis segments and 5 in the bladder; 51 and 52 stones were detected with VNE images at VP and DP, respectively. The missed stone at VP located in renal parenchyma with diameter less than 0.8mm and low CT number of 86HU, similar to that of renal parenchyma.
The mean CT number (in HU) for the stones from TNE was 310.15±154.85, higher than the 244.33±153.20
from VNE at VP and 251.78±155.73 at DP (p<0.05). The maximum stone areas (in mm2) determined from
VNE images were 39.0±32.7 and 38.8±33.4, within 83% of the 47.0±36.8 determined by TNE images. The 3 sets images produced similar image quality scores and CNR values at 22.51±12.99, 19.25±15.69 and
20.91±17.71, respectively with no difference. The dose reduction achieved by omitting TNE scan was 21.4%.
CONCLUSION
The use of VNE images generated from the enhanced spectral CT provides very high sensitivity in detecting ureteral stones with good image quality and 21% dose reduction compared with the TNE images. There is good correlation in stone CT number and size measurement between TNE and VNE images.
CLINICAL RELEVANCE/APPLICATION
VNE images from enhance spectral CT may be used to replace TNE for ureteral stone detection with excellent

sensitivity and dose reduction.
SSG03-03 Direct Comparison of Contrast-Enhanced MRI with Contrast-Enhanced CT to Diagnose Appendicitis
Michael D. Repplinger MD (Presenter): Nothing to Disclose , Perry J. Pickhardt MD : Co-founder, VirtuoCTC,
LLC Stockholder, Cellectar Biosciences, Inc , Douglas Robert Kitchin MD : Nothing to Disclose , Jessica B.
Robbins MD : Nothing to Disclose , Timothy J. Ziemlewicz MD : Nothing to Disclose , Scott Brian Reeder
MD, PhD : Institutional research support, General Electric Company Institutional research support, Bracco
Group
PURPOSE
To determine the accuracy of an MRI protocol (with and without contrast plus DWI) when compared with a
CE-CT protocol for the detection of acute appendicitis.
METHOD AND MATERIALS
This is a HIPAA-compliant, IRB-approved prospective study of patients presenting to the emergency department with abdominal pain. Patients were eligible for enrollment if they were over 11 years old and had a CT ordered to evaluate for appendicitis. After consent was obtained, patients underwent CT and MR imaging in tandem.
Three attending radiologists interpreted all MR and CT images independently. Image sets were de-identified.
Multiple parameters were documented for each image set including characteristics of the appendix (size, location, etc), the likelihood of appendicitis, possible alternative diagnoses, and the time required to interpret the images. Follow-up consisted of a chart review for pathological/surgical findings or follow-up phone interview/chart review. Continuous variables were summarized with descriptive statistics using means and 95% confidence intervals. Receiver operating characteristic (ROC) curves for the likelihood of appendicitis were drawn. Pair-wise comparisons of AUCs were obtained. Cohen's kappa with quadratic weights was used to assess inter-reader agreement.
RESULTS
We enrolled 93 patients from 2/2012-7/2013, including 60 women (64.5%), with a mean age of 33.3 years
(30.5, 36.2). The incidence of appendicitis was 37.6%. Sensitivity and specificity were 0.94 (0.79, 0.99) and 1
(0.91, 1) for unenhanced MRI/DWI, 0.94 (0.79, 0.99) and 0.92 (0.91, 0.98) for CE-MRI, and 1 (0.88, 1) and
0.98 (0.89, 1) for CT. The ROC curves had AUCs of 0.868 (0.784, 0.953), 0.885 (0.814, 0.956), and 0.903
(0.832, 0.973) for unenhanced MRI/DWI; 0.864 (0.782, 0.947), 0.867 (0.795, 0.938) and 0.9 (0.823, 0.976) for CE-MRI; and 0.947 (0.899, 0.996), 0.959 (0.915, 1), and 0.961 (0.915, 1) for CT. The mean time to read the MR images was 4.45 minutes (4.23, 4.67) compared with 2.04 minutes (1.91, 2.17) for CT. Kappa values were 0.643-0.805 for unenhanced MRI/DWI, 0.722-0.778 for CE-MRI, and 0.769-0.976 for CT.
CONCLUSION
The accuracy of this MRI protocol approached that of CT for the diagnosis of appendicitis, with substantial inter-rater agreement.
CLINICAL RELEVANCE/APPLICATION
MRI may be a suitable first-line imaging test to diagnose appendicitis in the general population.
SSG03-04 Usefulness of Low-Dose Non-enhanced CT with Coronal Reformations in Patients with Suspected
Acute Appendicitis: Comparison with Standard-Dose Non-enhanced CT
Seong Jong Yun (Presenter): Nothing to Disclose , Hyun Cheol Kim : Nothing to Disclose , Sang Won Kim
MD : Nothing to Disclose , Dal Mo Yang : Nothing to Disclose , Woo Jin Yang : Nothing to Disclose , Kyung
Jin Lee MD : Nothing to Disclose , Ji Su Kim : Nothing to Disclose
PURPOSE
To evaluate usefulness of low-dose (LD) non-enhanced CT (NECT) with coronal reformation to diagnose acute appendicitis in comparison with standard-dose (SD) NECT and SD contrast-enhanced CT (CECT).
METHOD AND MATERIALS
The institutional review board approved this retrospective study and waived the informed consent. This study population included 452 adult patients (age range, 18-89 years) who underwent CT performed by using a SD
(SD NECT and SD CECT1, n = 182) or a LD protocols (LD NECT and SD CECT2, n = 270) for suspected acute appendicitis. Two reviewers independently interpreted the axial and the coronal reformatted images of NECT and CECT scans during separate sessions. They assessed appendix visualization and proposed a diagnosis of appendicitis using a 4-point scale. Diagnostic performance and interobserver agreement for diagnosing acute appendicitis were compared between SD NECT and SD CECT1, LD NECT and SD CECT2, and LD NECT and SD
NECT, respectively.
RESULTS
The frequencies of appendix visualization of reviewers 1 and 2 were 95.6% (174/182) and 94.5% (172/182),
98.4% (179/182) and 98.9% (180/182), 90.7% (245/270) and 90% (243/270), and 98.9% (267/270) and
98.1% (265/270) for SD NECT, SD CECT1, LD NECT, and SD CECT2, respectively. Areas under the curves
(AUCs) of reviewers 1 and 2 for SD NECT (0.97 and 0.96, respectively) were not significantly lower than those of SD CECT1 (0.99 and 0.97) (P = 0.19 and 0.64, respectively). AUCs of reviewers 1 and 2 for LD NECT (0.95

and 0.95) were significantly lower than those of SD CECT2 (0.99 and 0.98) (P = 0.002 and 0.02, respectively).
However, AUCs of reviewers 1 and 2 for LD NECT (0.95 and 0.95) were not significantly lower than those of SD
NECT (0.97 and 0.96) (P = 0.18 and 0.92, respectively). All of the values for interobserver agreement of SD
NECT, SD CECT1, LD NECT, and SD CECT2 were excellent (k = 0.84, 0.84, 0.85, and 0.86, respectively).
CONCLUSION
LD NECT with coronal reformation was not inferior to SD NECT for the initial evaluation of acute appendicitis.
CLINICAL RELEVANCE/APPLICATION
LD NECT can be used as the first-line imaging tool in the workup of patients with suspected acute appendicitis.
SSG03-05 CT Features of Small Bowel Closed Loop Obstruction in Emergency Room: Comparison between
Patients Groups according to Treatment Strategies
Cherry Kim MD (Presenter): Nothing to Disclose , Choong Wook Lee MD : Nothing to Disclose , Mi-Hyun
Kim : Nothing to Disclose , Gil-Sun Hong MD : Nothing to Disclose
PURPOSE
To assess CT features of small bowel closed loop obstruction (CLO) in patients who need emergency operation within 24 hours, and to compare CT features between patients who need delayed operation and who were recovered by conservative treatment.
METHOD AND MATERIALS
From 2009 to 2013, 187 patients were diagnosed as having CLO based on CT results in the emergency room
(ER). Among them, 135 patients were enrolled using the exclusion criteria as follows; (a) CLO by peritoneal seeding, (b) CT images without coronal images, and (c) patients who were immediately transferred to other hospital. Clinical decision for treatment strategy was made based on both clinical and CT findings: 51 patients
(Group A) were treated surgically within 24 hours and the remaining 84 patients (Group B) were initially decided to be conservatively treated. Among the 84 patients, 27 patients (Subgroup B1) underwent operation after 24 hours due to aggravation of clinical signs, and 57 patients (Subgroup B2) were recovered with conservative treatment only. CT images were analyzed regarding CT features as follows; pre-contrast bowel wall (BW) attenuation, BW enhancement, BW thickening, mesenteric edema, whirling sign, shape of entrapped mesenteric vessels, distance between beaked bowel loops, mesenteric vascular collapseness, and vascular enhancement of mesenteric arteries and veins. CT features were compared between group A and B, and between subgroup B1 and B2 using Fishers exact test and Student t-test.
RESULTS
CT features of group A showed significantly increased pre-contrast BW attenuation, decreased BW enhancement, decreased vascular enhancement of mesenteric arteries and veins, increased BW thickening, severe mesenteric edema and severe mesenteric vascular collapseness than those of group B (all, p<0.001). In subgroup analysis between B1 and B2, all CT features didn't show any significant differences (all, p>0.05).
CONCLUSION
In patients who admitted ER with CLO, CT features were quite different between the groups who need emergency operation or not. However, there were no significant CT findings to differentiate the patients who need delayed operation from the patients who were completely recovered with conservative treatment.
CLINICAL RELEVANCE/APPLICATION
In patients with small bowel closed loop obstruction, some CT features could be important factors for clinical decision about emergency operation or initial conservative treatment.
SSG03-06 Virtual Monochromatic Reconstruction of Contrast-enhanced Dual-energy CT at 70 keV Maximizes the Conspicuity of Mucosal Enhancement in Acute Small Intestinal Obstruction
Kathryn Darras MD (Presenter): Nothing to Disclose , Patrick McLaughlin FFR(RCSI) : Nothing to Disclose ,
David M. Thomas BSC : Nothing to Disclose , Shamir Rai BSC : Nothing to Disclose , Luck Jan-Luck Louis
MD : Nothing to Disclose , Tim O'Connell MD, Meng : President, Resolve Radiologic Ltd , Silvia D. Chang
MD : Nothing to Disclose , Alison Clare Harris MBChB : Nothing to Disclose , Savvas Nicolaou MD :
Nothing to Disclose
PURPOSE
To evaluate the role of virtual monochromatic imaging (VMI) to maximize the conspicuity of mucosal enhancement in computed tomography (CT) of the abdomen and pelvis for acute small intestinal obstruction and to compare this technique to conventional polychromatic imaging (PCI).
METHOD AND MATERIALS
Institutional review board approval was obtained, with no informed consent required, for this retrospective

analysis. 20 consecutive patients with acute small intestinal obstruction were scanned using a 128-section dual source, dual energy CT system using a standardized protocol (100-140 kV, ref mAs of 115-89, 32x0.6mm).
Scans were retrospectively reconstructed at VMI energy levels from 40 - 150 keV in 10 keV increments and were analyzed both quantitatively and qualitatively. SNR and CNR values for mucosal enhancement in collapsed segments were recorded using region of interest (ROI) analysis at each energy level for all VMI datasets and compared to PCI. Subjective analysis of mucosal enhancement was performed by two independent, blinded readers.
RESULTS
The SNR and CNR for mucosal enhancement at the different VMI levels were compared using ANOVA with posthoc analysis with Newman-Keuls Multiple Comparison Test, demonstrating statistical significance (p <
0.05). Optimal SNR and CNR for small intestinal mucosal enhancement was observed at 80 keV and 70 keV, respectively. Qualitatively, both readers reported increased conspicuity of mucosal enhancement at the 70keV level.
CONCLUSION
VMI reconstruction of contrast enhanced dual energy CT scans of the abdomen and pelvis at 70 keV maximizes the conspicuity of mucosal enhancement in computed tomography (CT) of the abdomen and pelvis for acute small intestinal obstruction. At this level, conspicuity was improved for all readers.
CLINICAL RELEVANCE/APPLICATION
VMI reconstruction of contrast enhanced dual energy CT scans of the abdomen and pelvis at 70 keV maximizes the conspicuity of mucosal enhancement in acute small intestinal obstruction.
SSG03-07 Usability of Ultrasound for the Diagnosis of Acute Appendicitis Correlated to Patients BMI and the
Severity of Inflammation
Sebastian Bickelhaupt (Presenter): Nothing to Disclose , Sandra Tschirky : Nothing to Disclose , Michael A.
Patak MD : Nothing to Disclose
PURPOSE
The clinical diagnosis of acute appendicitis in emergency departments is often backed by ultrasound (US) or/and computed tomography (CT). US is commonly the initial modality as an inexpensive and fast tool avoiding ionizing radiation. The increasing number of patients with a high body mass index (BMI) might limit the use of
US. Our study investigated the accuracy of US for the diagnosis of appendicitis correlated to the patients BMI, the severity of inflammation and the need for additional CT-examinations.
METHOD AND MATERIALS
716 patients with suspected acute appendicitis(mean age 40.33, 309 female, 408 male)were included in this
IRB-approved, retrospective study between 2005-2011. Inclusion criteria:clinically suspected acute appendicitis, data of body mass index(BMI),leukocytes,c-reactive protein and a consecutive surgical intervention with histopathologically proven appendicitis. Patients grouping followed WHO definitions(BMI<18.5;18.5-24.9;25.0-29.9;>30).Correlations between the BMI, ultrasound-ability in detecting acute appendicitis, the necessity for CT examinations(Siemens Somatom 64, Erlangen, Germany) and the level of inflammation were calculated using Spearmans-rank-correlation. .
RESULTS
Ultrasound-usage decreased with increasing BMI from 65.5%(BMI<18.5)and 67.11%(18.5-24.9) to
54.6%(25.0-29.9) and 45.6%(>30) in a significant negative correlation(r=-0.1,p=0.006). Vice versa initial CT usage increased from 7.82% to 18.5% (r=0.2,p<0.05). The need for additional CT after US significantly correlated with the BMI(r=0.1,p=0.005) (3.4%;10.7%;11.6%;26.5%). The diagnostic certainty of ultrasound significantly decreased with increasing BMI from 48.27% and 45.8% to 38% and 30.8% (r=-0.097,p=0.006), that did not correlate with levels of inflammatory markers(p>0.05) which did not differ between the groups.
CONCLUSION
The diagnostic certainty for the diagnosis of acute appendicitis significantly correlates with the BMI of the patients, leading to an increasing need for additional CT in obese patients. This finding was independent of the severity of inflammation with no correlation between the level of inflammatory markers and the diagnostic certainty of the ultrasound examination.
CLINICAL RELEVANCE/APPLICATION
Our study revealed a significant and robust negative correlation between the diagnostic certainty and an increasing BMI in the patients which helps to assess the appropriateness of initial ultrasound in patients depening on the BMI.
SSG03-08 Evaluation of the Distribution of Enteral Contrast in ED Patients Undergoing Abdominal-Pelvic CT:
Does It Get Where It Is Supposed to Go and What Is the Added Value?
Tarek Noel Hanna MD : Nothing to Disclose , Seyed Amirhossein Razavi MD : Nothing to Disclose ,
Drew Anthony Streicher MD, MBA (Presenter): Nothing to Disclose , Jamlik-Omari Johnson MD : Nothing to
Disclose , Kimberly E. Applegate MD, MS : Co-editor, Springer Science+Business Media Deutschland GmbH
Advisory Board, WellPoint, Inc

PURPOSE
Current oral prep for adult abdominal-pelvic CT (AP CT) has shortened to one hour to facilitate faster
Emergency Department (ED) patient care. How often does oral contrast optimally opacify the gastrointestinal tract? Does this contrast reach the site of pathology or assist in diagnosis?
METHOD AND MATERIALS
All adults undergoing AP CT exams in the ED at two university-affiliated urban hospitals were identified via the healthcare database over a 3-month period in 2012. Two raters reviewed CTs for the proximal and distal location of enteric contrast. Presence, site, and type of bowel pathology as well as prior gastrointestinal surgery were documented. When applicable, the site of bowel pathology was evaluated for the presence or absence of enteric contrast.
RESULTS
Of 1349 patients, 530 (39%; 61% female, mean age 50+/- 19 years) were administered oral contrast. In
321/530 (61%), oral contrast reached the terminal ileum (TI). Bowel pathology was present in 31% of these cases (165/530). When small or large bowel pathology was present, 47% (77/165) of cases had oral contrast present at the bowel pathology site. When the bowel was categorized into 4 anatomic segments, there was a significant difference (p<0.001) in oral contrast reaching the site of bowel pathology based on location: stomach and duodenum (84%), jejunum to TI (35%), proximal colon (57%), and distal colon (28%). In 8% of cases (41/530), the original interpretation was equivocal for bowel pathology. 59% (24/41) of these equivocal cases had oral contrast present at the site of pathology. Of all 530 oral contrast cases, in only 84 cases (16%) did contrast extend from the stomach to the distal colon.
CONCLUSION
Only 61% of adults in the ED that undergo CT achieve oral contrast passage to the TI. 16% had complete stomach to distal colon contrast distribution. Oral contrast was present at the possible pathology site in equivocal reports (59%) in a similar frequency to positive cases (47%). These results raise questions about the use of oral contrast to facilitate identification and characterization of bowel pathology, unless prep time is lengthened.
CLINICAL RELEVANCE/APPLICATION
ED length of stay time pressures continue to intensify, leading to shorter prep times for oral contrast administration. As a result, optimal CT bowel prep is not achieved in many patients.
SSG03-09 A New Technique for the Diagnosis of Acute Appendicitis: Abdominal CT with Compression to the
Right Lower Quadrant
Erhan Akpinar MD : Nothing to Disclose , Abidin Kilincer MD (Presenter): Nothing to Disclose , Bulent
Erbil : Nothing to Disclose , Volkan Kaynaroglu : Nothing to Disclose , Deniz Akata MD : Nothing to
Disclose , Mustafa Nasuh Ozmen MD : Nothing to Disclose
PURPOSE
To determine the diagnostic accuracy of abdominal CT with compression to right lower quadrant in adults with acute appendicitis.
METHOD AND MATERIALS
Institutional review board approved this prospective study, and compression group patients gave written informed consent. The study included 168 patients (age range, 18-78 years) who underwent contrast enhanced
CT for suspected appendicitis performed either by using compression to the RLQ (n = 71) or by standard protocol (n = 97). Compression was applied to RLQ with 1000cc saline bag and an elastic belt. All compression group patients had abdominal US examination before CT to exclude conditions like abdominal aortic aneurysm, etc. Two radiologists reviewed in consensus CT images; receiver operating characteristic (ROC) analysis, Fisher exact tests, and Mann-Whitney U tests were used to compare diagnostic accuracy between the two groups.
RESULTS
Fifty-nine patients (23 in compression group and 36 in standard protocol) had pathologically proven acute appendicitis. Median (min-max) outer diameter of appendix was 10 mm (7-15 mm), 10.5 mm (7.1-17.6 mm), 5 mm (4-7.5 mm) and 6.3 mm (4.8-10.3 mm) among patients with appendicitis in compression and standard-CT, and without appendicitis in compression and standard-CT, respectively. While appendix diameter was not significantly different among patients with appendicitis undergoing CT with or without compression, there was a significant difference across other groups in pairwise comparisons (p<0.01). In patients without appendicitis, filling of contrast material to the appendiceal lumen was statistically higher in compression group when compared to standard protocol (p<0.01). Area under the ROC curve of compression and standard CT were
0.997 and 0.979, respectively. Using a cut-off value of 6.75 mm for outer appendiceal diameter, the sensitivity and specificity for diagnosing appendicitis was 100% and 67.3% with standard CT, while the specificity increased to 94.9% with preservation of sensitivity at 100% with compression CT.
CONCLUSION
Normal appendix diameter was significantly smaller in compression-CT group when compared to standard-CT group, increasing the diagnostic accuracy of CT performed by abdominal compression.
CLINICAL RELEVANCE/APPLICATION

Abdominal CT with compression to right lower quadrant, which can be considered as a CT counterpart of graded compression US, has a high diagnostic accuracy in the setting of acute appendicitis.
Scientific Papers
US CT NR HN
AMA PRA Category 1 Credits ™ : 1.50
ARRT Category A+ Credits: 1.50
Tue, Dec 2 10:30 AM - 12:00 PM Location: N226
Participants
Moderator
Jenny K. Hoang MBBS : Nothing to Disclose
Moderator
Ashok Srinivasan MD : Author, Amirsys, Inc
Sub-Events
SSG10-01 Lifetime Attributable Risk of Cancer from Radiation Exposure during Parathyroid Imaging:
Comparison of 4DCT and Sestamibi Scintigraphy
Jenny K. Hoang MBBS (Presenter): Nothing to Disclose , Robert E. Reiman MD : Nothing to Disclose ,
Giang Huong Nguyen MD, PhD : Nothing to Disclose , Natalie Januzis : Nothing to Disclose , Carolyn R.
Lowry BS : Nothing to Disclose , Bennett B. Chin MD : Nothing to Disclose , Terry T. Yoshizumi PhD :
Nothing to Disclose
PURPOSE
The aim of this study was to measure the effective dose and organ doses for parathyroid 4DCT and sestamibi scintigraphy, and to estimate the lifetime attributable risk (LAR) of cancer incidence based on the measured radiation doses.
METHOD AND MATERIALS
We measured the organ radiation doses for 4DCT and sestamibi scintigraphy (with SPECT-CT) based on scanning with our institution's protocols. An anthropomorphic phantom with MOSFET detectors was scanned to measure radiation dose from CT. Organ doses from the radionuclide for scintigraphy were based on
NUREG/CR-6345. Effective dose was calculated for 4DCT and scintigraphy, and used to estimate the LAR of cancer incidence for patients differing in age and gender with the approach established by the Biologic Effects of
Ionizing Radiation VII report. A 55-year-old female was selected as the standard patient based on demographics of patients with primary hyperparathyroidism.
RESULTS
The organs that received the highest radiation dose for 4DCT were the thyroid (150 mGy), salivary glands (137 mGy) and the esophagus (87 mGy). For sestamibi scintigraphy, the highest organ doses were to the colon (42 mGy), gall bladder (35 mGy) and the kidneys (32 mGy). The effective dose was 26 mSv for 4DCT compared to
12 mSv for sestamibi scintigraphy. The baseline lifetime incidence of any cancer in the unexposed standard patient.was 46438/100,000. In the exposed patient, the LAR for cancer incidence was 172/100,000 for 4DCT and 66/100,000 for sestamibi scintigraphy. This resulted in an increase in lifetime incidence of cancer over baseline risk of 0.46% for 4DCT and 0.18% for sestamibi scintigraphy. In a 25-year-old female (nonstandard) the increase in the lifetime incidence of cancer over baseline risk was higher at 0.94% for 4DCT and 0.36% for sestamibi scintigraphy.
CONCLUSION
Effective dose from 4DCT is double that of sestamibi scintigraphy, but both studies cause negligible increases in lifetime risk of cancer. Clinicians should not allow concern for radiation-induced cancer influence decisions regarding workup in older patients with primary hyperparathyroidism. In younger women, 4DCT should not be the first-line imaging modality given a substantially higher LAR from 4DCT compared to scintigraphy.
CLINICAL RELEVANCE/APPLICATION
Clinicians should not allow concern for radiation-induced cancer influence decisions regarding workup in older patients (≥ 55 years) with primary hyperparathyroidism.
SSG10-03
TIRADS and Ultrasound Elastography: Useful Tools in Recommending Repeat FNA for Solid Thyroid
Nodules with Nondiagnostic Fine Needle Aspiration Cytology
Vivian Youngjean Park MD (Presenter): Nothing to Disclose , Eun-Kyung Kim : Nothing to Disclose , Jin
Young Kwak MD : Nothing to Disclose , Jung Hyun Yoon MD : Nothing to Disclose , Hee Jung Moon MD :
Nothing to Disclose
PURPOSE

PURPOSE
We aimed to evaluate the role of the thyroid imaging reporting and data system (TIRADS) and elastography in recommending repeat fine-needle-aspiration (FNA) for solid thyroid nodules with nondiagnostic FNA cytology.
METHOD AND MATERIALS
A total of 143 solid thyroid nodules in 141 patients were included. Each was classified according to the TIRADS; solid component, hypoechogenicity or marked hypoechogenicity, microlobulated or irregular margins, microcalcifications, and taller-than-wide shape were considered suspicious US features. Nodules with one, two, three or four, or five suspicious US features were classified as category 4a, 4b, 4c or 5 respectively.
Elastography scores were classified according to the Rago and Asteria criteria. We investigated the malignancy risk for each TIRADS category and the corresponding sensitivity, specificity, negative predictive value, positive predictive value and accuracy of elastography.
RESULTS
Of 141 nodules, 25 were malignant, 79 were benign, and 39 were not confirmed. None of the US features, frequencies of TIRADS categories or classification according to the Rago and Asteria criteria significantly differed between benign and malignant nodules. The malignancy risk for TIRADS category 4a, 4b, 4c and 5 were 6.7% (1/15), 15.8% (6/38), 20.7% (17/82) and 12.5% (1/8) respectively, when including nonconfirmed nodules in the denominator. When analyzing confirmed nodules, elastography showed the highest negative predictive value for TIRADS category 4a; sensitivity, specificity, negative predictive value, positive predictive value and accuracy were 0% (0/1), 85.7% (6/7), 85.7% (6/7), 0% (0/1), 75% (6/8) for the Rago criteria and
100% (1/1), 85.7% (6/7), 100 (6/6%), 50% (1/2) and 87.5% (7/8) for the Asteria criteria. The Asteria criteria accurately classified the 1 malignant nodule in the TIRADS category 4a as malignant.
CONCLUSION
Observation may be considered for solid thyroid nodules with nondiagnostic cytology that are classified as
TIRADS category 4a and benign based on Asteria criteria, due to their low malignancy risk and high negative predictive value of elastography. Repeat FNA is warranted for TIRADS category 4b, 4c or 5, regardless of elastography features.
CLINICAL RELEVANCE/APPLICATION
Elastography is a useful tool in recommending repeat FNA for solid thyroid nodules with initial nondiagnostic cytology, when no other suspicious US features are present.
SSG10-04 Ultrasound Elastography Using Carotid Artery Pulsation in Differential Diagnosis of Sonographically
Indeterminate Thyroid Nodules
Bongguk Yim (Presenter): Nothing to Disclose , Woo Jung Choi MD : Nothing to Disclose , Jeong Seon
Park MD : Nothing to Disclose , Hye Ryoung Koo MD : Nothing to Disclose , Soo-Yeon Kim : Nothing to
Disclose
PURPOSE
The purpose of this study was to evaluate the diagnostic performance of gray-scale ultrasound (US) and a new method of thyroid US elastography using carotid artery pulsation in the differential diagnosis of sonographically indeterminate thyroid nodules.
METHOD AND MATERIALS
A total of 102 thyroid nodules with indeterminate gray-scale US features from 102 patients (20 men and 82 women; age range, 16-74 years, mean age: 51 years) were included. Gray-scale US images were reviewed and scored from 1 (low) to 5 (high) according to the possibility of malignancy. US elastography was performed using carotid pulsation as a compression source. The elasticity contrast index (ECI), which quantifies local strain contrast within a nodule, was automatically calculated. The radiologist reassessed scores after concurrently reviewing gray-scale US and elastography. Receiver operating characteristic curve analysis was used to evaluate the diagnostic performances of each data set and to compare the Az values of gray-scale scoring, ECI, and combined assessment scoring.
RESULTS
Malignant thyroid nodules were more hypoechoic than benign nodules. The ECI was significantly higher in malignant nodules than in benign thyroid nodules. The Az values of each data set were 0.755 (95% CI,
0.660-0.835) for gray-scale, 0.835 (95% CI, 0.748-0.901) for ECI, and 0.853 (95% CI, 0.769-0.915) for combined assessment. The Az value for the combined assessment of gray-scale and ECI was significantly higher than for gray-scale alone (p = 0.022).
CONCLUSION
Combined assessment with gray-scale US and elastography using carotid artery pulsation is helpful for differentiating sonographically indeterminate thyroid nodules.
CLINICAL RELEVANCE/APPLICATION

CLINICAL RELEVANCE/APPLICATION
Thyroid US elastography using carotid artery pulsation may be a useful adjunctive parameter for the differential diagnosis of sonographically indeterminate thyroid nodules.
SSG10-05 Parathyroid Adenomas and Hyperplasia on 4DCT: Grading System for Degree of Confidence
Manisha Bahl MD, MPH (Presenter): Nothing to Disclose , Ali R. Sepahdari MD : Nothing to Disclose ,
Julie A. Sosa MD : Nothing to Disclose , Jenny K. Hoang MBBS : Nothing to Disclose
PURPOSE
Prior to performing minimally-invasive parathyroidectomy, preoperative imaging is required to localize parathyroid adenomas with a high degree of confidence. Several signs on 4DCT can be used to determine degree of confidence. The purpose of this study is to evaluate the performance of a confidence grading system for parathyroid lesions on 4DCT.
METHOD AND MATERIALS
We retrospectively reviewed preoperative 4DCT scans in 63 consecutive patients from November 2012 to
December 2013 with pathologically-proven parathyroid adenomas or hyperplasia. Two radiologists reviewed the
CT images to localize parathyroid lesions. Lesions detected on imaging and confirmed by surgery were categorized by a three-category confidence grading system based on four enhancement patterns (Types A-D) and three secondary signs. "Consistent with" was defined as Type A/B enhancement with >/=1 secondary findings. "Suspicious" was Type A/B enhancement without secondary findings or Type C/D enhancement with
>/=1 secondary findings. "Possible" was Type C/D enhancement without secondary findings. The enhancement patterns required the lesion to be lower in attenuation than the thyroid gland on the noncontrast phase but differed on the arterial and delayed phases. Secondary findings were size >/=1 cm, a cystic component, and the polar vessel sign. We calculated and compared the prevalence and positive predictive values (PPV) of each grading system category.
RESULTS
63 patients had 75 lesions. 54 patients had single adenomas and nine patients had multigland disease with 21 lesions. The sensitivities for single gland and multigland disease were 94% and 52%, respectively. 74 lesions
(including four false positives) could be categorized by the grading system. "Consistent with" was seen in 51% of lesions and had 100% PPV. "Suspicious" represented 37% of lesions and had 96% PPV. Finally, "possible" represented 11% of lesions and had the lowest PPV (73%).
CONCLUSION
A grading system allows radiologists to communicate the degree of confidence when a lesion is detected on
4DCT, which is valuable for preoperative planning. The proposed system performs as intended in that the highest confidence grade has the highest PPV and the lowest grade has the lowest PPV.
CLINICAL RELEVANCE/APPLICATION
A 4DCT grading system can communicate degree of confidence for parathyroid adenomas, and detection of a lesion with the highest confidence grade may reduce the need for further imaging.
SSG10-06 Intra-reader Agreement for Color Based Elastograms in Thyroid Elastography
Manjiri K. Dighe MD (Presenter): Research Grant, General Electric Company , Jeff Thiel : Nothing to
Disclose , Theodore J. Dubinsky MD : Nothing to Disclose
PURPOSE
To assess intra-reader agreement in evaluation of the color elastograms in thyroid elastography using
Shear-Wave elastography
METHOD AND MATERIALS
After IRB approval, elastograms were obtained by Shear-wave elastography from 77 individuals, with a total of
96 thyroid nodules. Elastography data was acquired without any external compression using the Supersonics
Aixplorer machine. Each nodule had multiple color elastograms saved per nodule. 1 reader blinded to the final cytopathology results was asked to score the elastogram images based on a standard 5-point scale. The reader was then asked to rescore the elastograms after a period of 15 days and was also blinded to the prior results.
Results were also compared to the cytopathology diagnosis based on Bethesda classification. In addition, since each nodule had multiple images, variability of scoring within a single nodule was also evaluated.
RESULTS
There was overall good intra-reader agreement in scoring the elastograms with a concordance correlation coefficient of 0.83, a weighted kappa of 0.71 with a 95% confidence interval of 0.66 to 0.76 and a mean
Intraclass correlation coefficient (ICC) of 0.83 and 0.90. The Area under the curve for accurate diagnosis of the nodule as being benign or malignant was 0.82. The variability in the scoring between the benign nodules was less than that in the malignant nodules with a variance of 0.64 and 1.38 respectively.

CONCLUSION
Our study indicates that there was good overall intra-reader agreement for qualitative scoring of the elastograms. The overall variance in the scoring of benign nodules was less than that in the malignant nodules.
There could be bias in this since the number of malignant nodules in our study was smaller than benign nodules. Since Shearwave elastography provides quantitative values for the stiffness in the nodule, there would be less of a discordance and less variance compared to scoring color elastograms for thyroid nodule elastography.
CLINICAL RELEVANCE/APPLICATION
Decreasing the intra-reader variability in thyroid elastography is important. We also evaluated the variance in scoring each individual nodule since in every exam multiple images are acquired per nodule and it is important to know which particular score should be assigned to a nodule to be able to provide accurate diagnosis.
SSG10-07 Preoperative Differentiation of Thyroid Adenomas and Thyroid Carcinomas Using High Resolution
Contrast-enhanced Ultrasound (CEUS)
Ernst Michael Jung MD (Presenter): Nothing to Disclose , Stefan Schleder MD : Nothing to Disclose , Lena
Dendl : Nothing to Disclose , Christian Roland Stroszczynski MD : Nothing to Disclose
PURPOSE
To evaluate the impact of high-resolution contrast-enhanced ultrasound (CEUS) in combination with Color
Coded and Power Doppler Sonography (CCDS/PD) in the preoperative differentiation of thyroid adenomas and thyroid carcinomas.
METHOD AND MATERIALS
A total of 111 patients (60 female, median age 54 years) underwent surgery for thyroid adenoma and thyroid carcinoma. CCDS/PD and CEUS were performed in all patients by an experienced examiner using amultifrequency linear transducer (6-9 MHz) and were digitally stored.Reading of the ultrasound images was performed by two experienced radiologistsin consensus. For CEUS a bolus injection of 1 ml
Sulfurhexaflouride-Microbubbles (SonoVue®) was used. A histopathological evaluation was obtained as standard of reference in all patients.
RESULTS
80 thyroid adenomas and 31 thyroid carcinomas were detected. Mean diameter of thyroid adenomas and thyroid carcinomas was 27 mm and 25 mm, respectively. The differences in microcirculation of thyroid adenomas and thyroid carcinomas werestatistically highly significant (p <0.01). Representative features for thyroid adenomas were either no wash-out or wash-out with persisting edge in late phase, for thyroid carcinomas a complete wash-out in late phase. Thus, calculation of the sensitivity, specificity, positive and negative predictive value of
82%, 91%, 96% and 63%, respectively, for the differentiation of benignity and malignancy was possible.
CONCLUSION
Dynamic evaluation of microcirculation using CEUS and CCDS/PD enables a more reliable preoperative discrimination between thyroid adenomas and thyroid carcinomas.
CLINICAL RELEVANCE/APPLICATION
CEUS enables a more reliable preoperative discrimination between thyroid adenomas and thyroid carcinomas
SSG10-08 Dual-energy Multiphasic CT Scan for Localization of Discrepant or Unlocalized Parathyroid
Adenomas
Reza Forghani MD, PhD (Presenter): Nothing to Disclose , Michael Roskies MD : Nothing to Disclose ,
Michael Hier MD : Nothing to Disclose , Alex Mlynarek : Nothing to Disclose , Mark Levental MD :
Nothing to Disclose
PURPOSE
Accurate pre-operative localization of parathyroid adenomas (PAs) is essential for successful minimally invasive surgery, and is typically based on two concordant studies. 4-dimensional MDCT is increasingly used for localization of PAs. There are also isolated reports of dual-energy CT (DECT) for localization of PAs but no systematic evaluation of this technique. DECT has the potential to increase accuracy of PTA detection by enabling more accurate iodine content evaluation and to eliminate the need for an unenhanced scan, reducing radiation exposure. In this study, we evaluated the utility of multiphasic DECT for PA localization in a group of patients having discrepant or unidentified PAs.
METHOD AND MATERIALS
20 patients with primary hyperparathyroidism having either discrepant or unlocalized PAs underwent a multiphasic DECT in a 64-slice scanner (GE Discovery CT750HD). Scans were obtained at 25, 55, and 85 sec after injection of 80 mL of iopamidol at 3.5 mL/sec. DECT scans were reconstructed as 70 keV monochromatic images and source images transferred to a dedicated workstation for reconstruction of virtual monochromatic

images and source images transferred to a dedicated workstation for reconstruction of virtual monochromatic images. The scans were prospectively reviewed by 2 attending head and neck radiologists. The final results were compared with localization during minimally invasive surgery and histopathologic confirmation.
RESULTS
Out of 20 patients, 11 had negative and 9 discordant standard imaging. DECT identified PAs in 8 of 11 and 7 of
9 patients, respectively. Of the 15 PAs, 7 were prospectively identified as PA candidates but characterized as atypical, based on absence of rapid arterial phase enhancement and early washout and/or presence of internal low attenuation areas. 7 patients have so far undergone surgery, and DECT correctly localized the PA in 6 of 7 patients, for a total of 7 PAs (one patient had bilateral PAs).
CONCLUSION
3-phase DECT without an unenhanced scan can accurately localize PAs in a significant proportion of unlocalized or discrepant cases. Although perfusion characteristics are important, a high proportion of PAs lacked typical perfusion characteristics in this patient population but were identifiable based on other features.
CLINICAL RELEVANCE/APPLICATION
Multiphasic DECT without an unenhanced scan can accurately localize a significant number of PAs not localized by conventional imaging enabling successful minimally invasive surgery with reduced surgical exploration and associated patient morbidity.
SSG10-09 4DCT in the Evaluation of Hyperparathyroidism: Predictors of Parathyroid Single Gland and
Multigland Disease
Ali R. Sepahdari MD (Presenter): Nothing to Disclose , Manisha Bahl MD, MPH : Nothing to Disclose ,
Jenny K. Hoang MBBS : Nothing to Disclose
PURPOSE
Parathyroid multigland disease (MGD) is a challenging problem for radiologists. Other lesions in the patient may be missed after the first lesion is detected because they are small or not suspected. We aim to compare 4DCT findings of single gland (SG) and MGD to identify findings that may predict MGD.
METHOD AND MATERIALS
We retrospectively reviewed 35 patients with MGD and 129 patients with SG lesions who had preoperative 4DCT scans at two institutions between September 2011 and December 2013. The following data were recorded: presurgical calcium and PTH levels, number of candidate lesions identified with 4DCT, and longest measurement of abnormal glands seen on CT. Parametric and non-parametric statistical tests were applied in order to determine features or combinations of features that could predict MGD.
RESULTS
Mean size of MGD was 8.8 mm and significantly smaller than mean size 11.8 mm for SG lesions (p .001). MGD also had lower serum PTH (P=.03). Fisher's exact test showed that identification of only 1 abnormal gland, versus no abnormal glands or multiple abnormal glands, was strongly predictive of single gland disease
(P<.0001, likelihood ratio [LR] = 5). The finding of only 1 abnormal gland was 86% specific for single gland disease (14% missed MGD). Adding the requirement that the abnormal gland measure at least 10 mm in maximal dimension resulted in 94% specificity for SG disease (6% missed) (P<.0001, LR 8.5).
CONCLUSION
Identification of a single abnormal gland measuring at least 10 mm on 4DCT is highly specific for single gland disease. Conversely, when the candidate lesion is less than 1cm, the radiologists should be more suspicious for
MGD and review the scan closely for another lesion. This information can help radiologists to improve the sensitivity of future 4DCT interpretations for MGD.
CLINICAL RELEVANCE/APPLICATION
Improving the detection of MGD or raising suspicion for MGD to the surgeons allows for a more informed clinical management plan and appropriate selection of patients for minimally invasive surgery.
Scientific Posters
IR VA
AMA PRA Category 1 Credits ™ : .50
Tue, Dec 2 12:15 PM - 12:45 PM Location: VI Community, Learning Center

Tue, Dec 2 12:15 PM - 12:45 PM Location: VI Community, Learning Center
Participants
Moderator
Hyeon Yu MD : Nothing to Disclose
Sub-Events
VIS235 Protection Against Radiation-induced Brain Tumors in Interventional Professionals (Station #1)
Luke Anthony Byers DO (Presenter): Nothing to Disclose , William Werner Orrison MD : Consultant, RadSite
Consultant, World Wide Innovations & Technologies , Peter Cartwright BS : Nothing to Disclose
PURPOSE
Individuals involved in interventional procedures are chronically exposed to ionizing radiation, the only unequivocal risk factor for developing intracranial neoplasms. A recent report identified 31 interventionalists who developed brain cancer with the concern that physicians performing interventional procedures have disproportionate left-sided brain tumors. This study was designed to evaluate the effectiveness of using a novel personal cranial radiation protection surgical cap as a means of reducing the risk of radiation induced cerebral neoplasms.
METHOD AND MATERIALS
Following IRB waiver disposable surgical caps containing various levels of protective lead-free radiation shielding
(No Brainer -RADPAD, Kansas City, KS) were used to protect the cranium in one interventionalist and one assistant during multiple fluoroscopic procedures. Radiation monitoring during the fluoroscopic procedures was accomplished using real-time radiation detectors (UNFORS, Billdal, Sweden). Simultaneous monitor recordings were performed with radiation detectors positioned identically above and below the protective material at the level of the anterior left cranium (above the left eye). Four levels of radiation protection were tested (lead equivalency at 90 kVp): 1) Red - 0.375 mm, 2) Orange - 0.25 mm, 3) Yellow - 0.125 mm and 4) Blue - 0.07
mm.
RESULTS
A total of 34 patient procedures were completed. Average distance from the calvarium to the Image intensifier was approximately 1 meter. The interventionalist and the assistant reported that the surgical caps were minimally different from those typically worn for interventional procedures and there was no reported discomfort even after multiple hours (day long) wearing. Dose reductions for the procedures are as follows:
Overall (92%), Red (100%), Orange (100%), Yellow (96%) and Blue (78%).
CONCLUSION
The "No Brainer"is aptly named, as this simple inexpensive approach to cranium protection is easy to use, comfortable and highly effective at decreasing brain radiation exposure. This device should stem the increasing number of interventionalists reported with cerebral malignancies.
CLINICAL RELEVANCE/APPLICATION
Comfortable disposable surgical caps containing a lead-free radiation protection barrier can serve as a means of reducing the risk of radiation induced cerebral neoplasms.
VIS236 Incidence of Significant Non-vascular Findings (Neoplastic and Non-neoplastic) in Patients Who
Have Undergone Endovascular Aortic Aneurysm Repair (EVAR) (Station #2)
Mark Quentin Smith MD (Presenter): Nothing to Disclose , W. Brian Hyslop MD, PhD : Nothing to Disclose ,
Louise Michelle Henderson : Nothing to Disclose , Hyeon Yu MD : Nothing to Disclose , Julia R. Fielding MD
: Nothing to Disclose
PURPOSE
To determine the incidence of clinically significant non-vascular findings on contrast-enhanced CT angiography in patients who have undergone EVAR.
METHOD AND MATERIALS
We retrospectively reviewed the radiology reports of the initial abdominopelvic contrast-enhanced 64-slice
MDCT scans in 1000 patients who presented with an abdominal aortic aneurysm between January 1, 2008 and
December 31, 2011. We followed the imaging results for a minimum of two years to determine the significance of each finding. Incidental findings that were benign or unlikely to undergo follow-up were placed into the low significance group. Benign findings that had the potential to warrant medical or surgical intervention were classified as having moderate importance. Findings that required specialized imaging, biopsy or therapeutic intervention as well as indeterminate findings were placed within the high significance category. We examined the proportion of incidental findings in each of these categories by age and location and calculated the 95% confidence intervals to assess differences among subgroups.
RESULTS
There were a totla of 2374 incidental findings in 847 patients: 1877 were of low significance, 357 were of moderate significance, and 140 were grouped in the high significance category. There were no differences in the proportion within each category of incidental findings by age group (<65 versus 65+). Of the high significance findings, 32 incidental malignancies (3.2%, 95% CI: 2.3-4.5%) were found, with renal cell carcinoma being the most common (n=11), followed by metastatic disease (n=5). 22 of the 32 patients had N0M0 disease at initial staging.

VIS237
VIS234
CONCLUSION
Our rate of incidental cancers found on abdominopelvic imaging of 3.2% is low, but is greater than the
0.56-1.25% reported in virtual colonoscopy studies. This may be secondary to the older mean age of this population. In addition, contrast-enhanced scans allow for definitive diagnosis of malignant lesions.
CLINICAL RELEVANCE/APPLICATION
The presence of incidental cancers on endovascular CT angiography highlights the need for careful radiologic review of all vascular imaging studies.
Realizing Radiation and Iodine Dose Reduction in Coronary CT Angiography by Using Adaptive
Statistical Iterative Reconstruction (Station #3)
Xiao-ying Wang (Presenter): Research Grant, General Electric Company , Mengxi Jiang : Research Grant,
General Electric Company , Mingyu Zou PhD : Research Grant, General Electric Company , Chuang Yi :
Research Grant, General Electric Company , Gang Hu : Research Grant, General Electric Company , Rui
Wang : Research Grant, General Electric Company , He Wang MD : Research Grant, General Electric
Company , Baocui Zhang : Research Grant, General Electric Company , Fusheng Gao MD : Research Grant,
General Electric Company , Jian Luo : Research Grant, General Electric Company , Jian Jiang : Research
Grant, General Electric Company , Chenglin Zhao : Research Grant, General Electric Company
PURPOSE
To investigate the feasibility of low kVp and low iodine scan protocol in coronary computed tomography angiography (CCTA) to reduce radiation dose without undermining image quality.
METHOD AND MATERIALS
200 consecutive patients with body mass index (BMI) 20-25 kg/m2 undergoing prospectively electrocardiogram-triggered CCTA were randomized into four groups at 4 sites. Group A: using 80kVp and iodixanol 270 mgI/mL with 60% adaptive statistical iterative reconstruction (ASiR); group B: using 100kVp and iodixanol 270 mgI/mL with 30-40% ASiR; group C: using 100kVp and iodixanol 320 mgI/mL with 30-40% ASiR; group D: using 120kVp and iopromide 370 mgI/mL with filtered back projection. 60 ml contrast was given at 5 ml/s intravenously. CT values of 18 coronary artery segments were measured. Image quality was assessed by 2 experienced radiologists blinded to examination, using a 4-point scale (1-4: nondiagnostic-excellent). An assigned score of 1 in any segments was graded the image as nondiagnostic. Noise, contrast-to-noise (CNR), signal-to-noise ratio (SNR) and size-specific dose estimate (SSDE) were also calculated.
RESULTS
163 subjects completed study. CT values of all segments in all groups met clinical diagnostic requirement. There was no significant difference in image quality among the four groups (3.4 ± 0.7, 3.5 ± 0.5, 3.6 ± 0.4, 3.6 ± 0.3
respectively).The average CT value in group A (n=37) was higher than that in group B (n=45), C (n=40) and D
(n=41) (all p < 0.05). Noise in group A (40.6 ± 8.5 HU) was significantly higher than that in group B (28.8 ±
6.7 HU), C (28.5 ± 4.6 HU) and D (29.1 ± 4.8 HU) (all p < 0.001), while CNR and SNR in group A was lower than that in group C and D (both p < 0.001). Compared with group D, the mean SSDE was reduced by 56.2%,
34.7%, and 34.3% in group A, B, C respectively.
CONCLUSION
All low kVp scans achieved a good image quality with significantly reduced radiation dose. 80 kVp with iodixanol
270 mgI/mL in prospectively electrocardiogram-triggered CCTA for patients with a normal BMI is practicable.
CLINICAL RELEVANCE/APPLICATION
With a prospective comparison, the study result has solidified the use of low tube voltage and low iodine enhancement in CCTA. It is time to promote 80 kVp CCTA protocol in clinical to benefit patients from 50% reduction of radiation dose.
Prophylactic Temporary IVC Filter Retrieval following Major Spinal Reconstruction Surgery:
Comparison between Scoliosis and Non-scoliosis Patients (Station #5)
Hilary A. Brazeal MD (Presenter): Nothing to Disclose , Jay Desai MD : Nothing to Disclose , Carlos Javier
Guevara MD : Nothing to Disclose , Seung Kwon Kim MD : Nothing to Disclose
PURPOSE
Prophylactic IVC (inferior vena cava) filter placement was initiated for all 'high-risk' spinal surgery patients after a pilot study demonstrated decreased VTE-related morbidity and mortality . Given increased angulation of the
IVC filter in patients with scoliosis, there is higher chance of IVC filter tilting, leading to increased difficulty of
IVC filter retrieval. The purpose of this study is to compare filter retrieval between scoliosis and non-scoliosis patients who had temporary IVC filter placement before major spinal reconstructive surgery.
METHOD AND MATERIALS
Patients were identified by a computerized search of the radiology information system for prophylactic temporary IVC filter placement before major spinal reconstructive surgery and filter retrieval after surgery from

VIS238
VIE125
2005 to Jan 2014. These patients were divided into two groups: a scoliosis surgery (SS) group and a non-scoliosis surgery (NSS) group. Type of filter, attempted filter retrieval, indwelling time of filter, sedation time of the filter retrieval procedure, and success of attempted filter retrieval were compared between the two groups.
RESULTS
From 2005 to Jan 2014, 134 IVC filters were placed prior to spine surgery. 116 (84.9%) of those were retrievable filters. Retrieval was attempted on 53 (45.7%) of the retrievable filters. Retrieval was successful in
45/53 (84.9%) of those attempts, including a single case that was successful on the second attempt.
Indwelling time of IVC filter at time of attempted retrieval was significantly higher in the SS group (SS group =
59.4 days, NSS group = 31 days) (p=0.006). Success rate of attempted filter retrieval in the SS group (78.1%
(25/32)) was lower than the NSS group (95.2% (20/21)) (p=0.13). Average retrieval sedation time of a successful retrieval in the SS group (44.8 minutes) was higher than the NSS group (28.2 minutes) (p= 0.15).
Type of filters in failed retrievals were Günther Tulip (4/25) and Option (4/17).
CONCLUSION
IVC filter retrieval requires increased procedure time and has decreased success rates in the SS group compared with the NSS group.
CLINICAL RELEVANCE/APPLICATION
Longer IVC filter indwelling time in scoliosis surgery patients leads to increased difficulty and decreased success of IVC filter retrieval.
Transarterial Chemoembolization (TACE) as a Palliative Treatments Option for Liver Metastases from
Lung Cancer: Indications, Outcomes and Role in Patient’s Management (Station #6)
Tatjana Gruber-Rouh (Presenter): Nothing to Disclose , Nagy Naguib Naeem Naguib MD, MSc : Nothing to
Disclose , Nour-Eldin Abdelrehim Nour-Eldin MD, MSc : Nothing to Disclose , Martin Beeres MD : Nothing to
Disclose , Julian Lukas Wichmann MD : Nothing to Disclose , Stefan Zangos MD : Nothing to Disclose ,
Thomas Josef Vogl MD, PhD : Nothing to Disclose
PURPOSE
To evaluate local tumor control and survival data after TACE with three different chemotherapeutic protocols in the palliative treatment of patients with liver metastases from lung cancer
METHOD AND MATERIALS
The study protocol was approved by the ethical committee, and informed consent was obtained from all patients prior to treatment. A total of 44 patients (mean age, 55.2 years; range, 42-78 years) with unresectable liver metastases of lung cancer who did not respond to systemic therapy were repeatedly treated with TACE in
4-week intervals. In total, 176 chemoembolization procedures were performed (mean, 4 sessions per patient; range, 3-6 sessions). The local chemotherapy protocol consisted of mitomycin alone (22.7%; n=10), mitomycin with gemcitabine (22.7%; n=10) or mitomycin, gemcitabine and cisplatin (54.6%, n=24). Embolization was performed with lipiodol and degradable starch microspheres. Local tumor response was evaluated by MRI according to the RECIST criteria. Survival data were calculated according to the Kaplan-Meier method.
RESULTS
The local tumor control was: partial response (PR) in 15.9% (n=7), stable disease (SD) in 56.8% (n=25) and progressive disease (PD) in 27.3% (n=12) of patients. The 1-year survival rate after chemoembolization was
70%, and the 2-year survival rate was 38%. The median and mean survival times from the start of TACE treatment were 20 and 31.8 months. There was no statistically significant difference between the three treatment protocols.
CONCLUSION
Chemoembolization is a potentially palliative treatment option in achieving local control in selected patients with liver metastases from lung cancer.
CLINICAL RELEVANCE/APPLICATION
Chemoembolization is a potentially palliative treatment option in achieving local control in selected patients with liver metastases from lung cancer.
Popliteal Artery Entrapment Syndrome (PAES): Types and Dynamic Imaging Protocol (Station #7)
Karel F. Wallecan MD (Presenter): Nothing to Disclose , Mohamed Ouhlous MD, PhD : Nothing to Disclose ,
Adriaan Moelker MD : Nothing to Disclose
TEACHING POINTS
1. To describe normal anatomy of the popliteal fossa 2. Current classification of anatomic and functional popliteal artery entrapment 3. To assess weaknesses and strengths of different imaging modalities 4. Discuss emerging role of dynamic contrast enhanced CTA for diagnosing PAES.

VIE101
VIE021-b emerging role of dynamic contrast enhanced CTA for diagnosing PAES.
TABLE OF CONTENTS/OUTLINE
Normal anatomy of the popliteal fossa Anatomic versus functional popliteal entrapment Radiographic evaluation of PAES with Ultrasound, MRI/MRA and Angiography Dynamic CTA for suspected PAES: - Advantages - how we do dynamic scanning on CT Clinical cases Summary
Selective Internal Radiation Therapy (SIRT) – A Review on the Principle, Work-up and Overview of
Published Data in Selective Internal Radiation Therapy with Yttrium-90 Microspheres (Station #8)
Henry Ho Ching Tam MBBS (Presenter): Nothing to Disclose , Ying Chen MBBS : Nothing to Disclose ,
Dow-Mu Koh MD, FRCR : Nothing to Disclose , Adil Al-Nahhas : Nothing to Disclose
TEACHING POINTS
The incidence of both primary and secondary liver malignancies is increasing. Although surgery or minimally invasive intervention e.g. radiofrequency ablation results in the best outcomes, these approaches are limited by the burden and site of disease. Selective internal radiation therapy (SIRT) is a promising technique in patients deemed unsuitable for surgery. Despite its increasing popularity, radiologists may not be familiar with this treatment. Review the principle of SIRT with yttrium-90 (90Y) microspheres Review the literature with regards to treatment outcomes. Although morphological imaging is usually used to assess disease burden and treatment response, the potential for functional imaging techniques is discussed.
TABLE OF CONTENTS/OUTLINE
Physics and biological basis of SIRT with yttrium-90 Comparison of the properties of SIR-spheres with
Theraspheres Patient selection/contraindications Patient preparation: visceral angiography (Fig. 1); hepatopulmonary shunt (Fig. 2 and 3); dosimetry Adverse reactions and complications Special consideration in patients with portal vein thrombosis and malignant biliary obstruction Morphologic and functional imaging techniques for response assessment and prediction (Fig. 4 and 5) Review of published data supporting use of
90Y-SIRT: response rate and long-term outcome
Ultrasound Guided Percutaneous Thrombin Injection for Treating Femoral Artery Pseudoaneurysms:
When and How to Do it; When Not to Do it (hardcopy backboard)
Eleni Antypa : Nothing to Disclose , Demosthenes D. Cokkinos MD (Presenter): Nothing to Disclose ,
Konstantinos Iosifidis MD : Nothing to Disclose , Kalliopi Melaki : Nothing to Disclose , Despina Kriketou
MSc, MD : Nothing to Disclose , Ploutarhos A Piperopoulos MD, PhD : Nothing to Disclose
TEACHING POINTS
To present a guide to ultrasound (US) guided percutaneous injection of thrombin for the treatment of femoral artery pseudoaneurysms. To review the indications, technique, possible complications and limitations. To assess relevant guidelines in order to seek alternative treatment when this technique fails.
TABLE OF CONTENTS/OUTLINE
Description of predisposing factors for femoral artery pseudoaneurysm formation, clinical features and Doppler
US diagnosis. Meticulous description of the technique, including step by step US guided femoral artery catheterisation, thrombin preparation and administration, variation of the procedure according to the size, form and number of the pseudoanurysm's lobes. Specific points that should be kept in mind in order to maximise success rates and avoid complications. Outline of post procedure follow up, need for possible repetition of treatment and guideline flowchart in order to abandon the technique for surgical repair when needed are also explained. US images from our Institution's experience.
Scientific Posters
MK
AMA PRA Category 1 Credits ™ : .50
Tue, Dec 2 12:45 PM - 1:15 PM Location: MK Community, Learning Center
Sub-Events
MKS372 Performing Lumbar Sympathetic Blocks: A New Technique (Station #1)
Humberto Gerardo Rosas MD (Presenter): Nothing to Disclose
PURPOSE
Injury to the genitofemoral nerve and unsuccessful blockade of the lumbar sympathetic chain are the most common complications following lumbar sympathetic blocks (LSB). Prior studies have shown that conventional techniques lead to either anterior or lateral placement of the needle in respect to the sympathetic ganglia, or placement within the psoas muscle itself leading to suboptimal flow of the injectate. A transdiscal approach was recently advocated to avoid these complications, however the potential for discitis, and accelerated disc degeneration must be considered. The purpose of the study was to evaluate a new paradiscal, extraforaminal technique to perform fluoroscopically directed lumbar sympathetic blocks that would avoid transgression of vital

MKS373
MKS374 technique to perform fluoroscopically directed lumbar sympathetic blocks that would avoid transgression of vital structures and allow appropriate needle placement along the anterolateral aspect of the vertebral body.
METHOD AND MATERIALS
IRB approval and a waiver of consent were obtained for this retrospective HIPAA compliant study. Fluoroscopic spot views and medical records from 73 (45 females, 28 males; mean age 46.3) consecutively performed lumbar sympathetic blocks dating back to March 13, 2008 were retrospectively reviewed. Patients meeting the diagnostic criteria for complex regional pain syndrome with symptoms lasting greater than 6 months refractory to conservative measures were included in the study. Utilizing the transverse process as a guide, the needle was advanced under fluoroscopic guidance to the anterolateral aspect of the vertebral body. Contrast was administered to confirm appropriate needle placement and skin surface temperatures monitored to document the sympathetic response. The response to the injection was determined utilizing a 10 point Visual Analog
Score (VAS).
RESULTS
No major complications occurred defined as death, neurovascular injury, injury to the visceral organs, and infection. Minor complications included a single vasovagal response. All 73 injections resulted in a greater than
3 oC increase in skin temperature indicating appropriate blockade of the sympathetic ganglia. VAS scores demonstrated a statistically significant reduction in symptoms from baseline to the postprocedure period.
CONCLUSION
This study describes a safe alternative method for performing LSB.
CLINICAL RELEVANCE/APPLICATION
The technique described allows placement of the needle subjacent to the sympathetic ganglia while avoiding transgression of vital structures.
US-guided Block of Suprascapular Nerve as a Treatment of Adhesive Capsulitis: Indications,
Technique and Early Results (Station #2)
Francesca Lacelli MD : Nothing to Disclose , Chiara Martini MChir : Nothing to Disclose , Davide Orlandi
MD (Presenter): Nothing to Disclose , Giovanni Serafini MD : Nothing to Disclose
PURPOSE
Adhesive capsulitis (AC) is characterized by pain and stiffness in external rotation and abduction of the upper limb; physiatric rehabilitation (PR) is often difficult.The suprascapular nerve (SN) supplies70% of shoulder sensitive innervation.US visualizes the SN at the level of the spine of the scapula.The purpose of this work is to show that SN block makes a more lasting pain decrease than the intra-articular treatment of capsulitis and makes the PR easier
METHOD AND MATERIALS
20 patients with clinical diagnosis of adhesive capsulitis were randomized in 2groups (A=10F, y=45±3.2;
B=10F, y=44±3.6).Group A was treated with US-guided intra-articular injection of 5cc of hydrocloride mepivacaine2%, 40mg of methylprednisolone and 6ml(90mg) of hyaluronate.In group B the US-guided perineural (at the level of the spine of the scapula) injection of 5cc of hydrocloride mepivacaine2% was added to the treatment.All patients began PR the day of treatment. All patients underwent clinical (VAS scale and ROM index) both before than immediately after the treatment, at 1week and 1month.
RESULTS
VAS before: 8.9 (A), 9.1 (B); immediately after: 5.0(A), 4.8(B); at 1week: 6.2 (A), 4.5 (B); at 1month: 6.1 (A),
4.0 (B) (p<0.01). ROM before: 100°(A), 95°(B); immediately after: 120°(A,B); at 1week: 130°(A), 150°(B); at
1month: 135°(A), 170°(B).We had not complications, in particular no deficit of motion. In all patients of group B we visualized the SN by ultrasound.
CONCLUSION
The role of physiatry in rehabilitation and reduction of pain is fundamental.The SN block associated with intra-articular treatment allows an improvement of PR.The SN block has a more lasting effect than intra-articular treatment.
CLINICAL RELEVANCE/APPLICATION
Ultrasound guided SN block is recommended to improve efficency of rehabilitation in patient with shoulder capsulitis.
Imiglucerase Shortage: Effects in Patients with Gaucher Disease (Station #3)
Jose Manuel Morales MD, PhD (Presenter): Nothing to Disclose , Antonio Cano-Rodriguez MD : Nothing to
Disclose , Victor Manuel Encinas MD : Nothing to Disclose

MKS375
MKS376
PURPOSE
To study the reversibility of therapeutic effects upon interruption of enzymatic therapy after a prolonged shortage of human recombinant glucocerebrosidase treatment (Imiglucerase, Cerezyme® Sanofi), and to determine the posterior replacement by physiological lipids after the restart of it.
METHOD AND MATERIALS
Fourteen patients with Gaucher's disease underwent long-term enzyme replacement therapy in our hospital. All of them had been clinically, biochemically and radiologically stable for at least four years before production of the enzyme was abruptly interrupted. Of these fourteen patients, six were excluded from the study for not having had a previous MRI scan, or for displaying results with artifacts. In the remaining eight, the last MRI scan prior to the beginning of the supply shortage (A: "baseline MRI" scan) was compared with the first of the scans performed when the shortage ended (B: "post-deprivation MRI" scan). To assess the reversibility of the pathological infiltration following the resumption of treatment, we compare this second study with a third MRI scan, performed after the restart of the therapy (C: "post-resumption" MRI).
RESULTS
In seven of these eight patients, a diffuse progression was confirmed in the infiltration of vertebral marrow by pathological Gaucher tissue when the post-deprivation images were compared with images corresponding to the baseline studies In all of these seven cases, the post-resumption MRI showed a tendency to recover the basal state, following the restoration of the usual enzyme dose.
CONCLUSION
The forced deprivation of enzyme treatment in the population of patients with Gaucher's disease caused by the global enzyme supply shortage which followed the interruption of its production from September 2009 to
October 2010, allowed us to confirm, in the majority of our patients, both the reversibility of the therapeutic effects of imiglucerase on bone marrow once its periodic administration is interrupted, and the tendency of this pathological infiltration to disappear following re-administration of this enzyme.
CLINICAL RELEVANCE/APPLICATION
To our knowledge, the accidental world shortage of the enzyme replacement therapy, allows for the first time to prove the reversibility of the therapeutic effects of imiglucerase on bone marrow.
The Iliotibial Band in Acute Knee Trauma: Patterns of Injury on MR Imaging (Station #4)
David McKean BMBCh, FRCR (Presenter): Nothing to Disclose , Philip Yoong FRCR : Nothing to Disclose ,
James Teh MD : Nothing to Disclose , Ramy Mohamed Mansour MBBCh : Nothing to Disclose
PURPOSE
The appearance of the iliotibial band (ITB) is rarely described in MRI of acute knee trauma. The purpose of our study is to investigate the characteristic patterns of injury seen with injury of the ITB. We hypothesize that injury of the ITB on MRI is associated with internal derangement, in particular anterior cruciate ligament (ACL) tears and posterolateral corner disruption.
METHOD AND MATERIALS
A retrospective review was completed of 200 MRI scans performed for acute knee trauma. Patients were excluded if there was a history of injury over 4 weeks from the time of the scan, septic arthritis, inflammatory arthropathy, previous knee surgery or significant artefact. In each scan, the ITB was scored as normal, minor sprain (Grade 1), severe sprain (Grade 2) and torn (Grade 3). The menisci, ligaments and tendons of each knee were also assessed.
RESULTS
The mean age was 27.4 years (range 9-69). 71.5% (n = 143) patients were male. The ITB was injured in 115 cases (57.5%). The next most common soft tissue structure injured was the ACL in 53.5% (n=107). Grade 1
ITB injury was seen in 90 of these cases (45%), Grade 2 injury in 20 cases and Grade 3 injury in only 5 cases.
There is a significant association between ITB injury and ACL rupture (P
CONCLUSION
ITB injury is strongly associated with significant internal derangement of the knee, especially cruciate ligament rupture, posterolateral corner injury and patellar dislocation.
CLINICAL RELEVANCE/APPLICATION
Injury of the iliotibial band on MRI is associated with internal derangement, in particular anterior cruciate ligament (ACL) tears and posterolateral corner disruption.
Pelvic Morphology in Ischiofemoral Impingement (Station #5)
Miriam Antoinette Bredella MD (Presenter): Nothing to Disclose , Debora Cristina Azevedo MD : Nothing to
Disclose , Adriana Maria De Lima Oliveira MD : Nothing to Disclose , Frank J. Simeone MD : Nothing to
Disclose , Connie Y. Chang MD : Nothing to Disclose , Ambrose J. Huang MD : Nothing to Disclose , Martin
Torriani MD : Nothing to Disclose
PURPOSE
Ischiofemoral impingement (IFI) is associated with abnormalities of the quadratus femoris muscle and

MKS377
MKS378 narrowing of the ischiofemoral (IF) and quadratus femoris (QF) spaces. Anatomic variations in pelvic morphology such as a wider inter-ischial distance and femoral neck anteversion may predispose patients to IFI.
The purpose of our study was to assess new MRI measures to quantify pelvic morphology which may predispose to IFI. We hypothesized that patients with IFI have a wider inter-ischial distance and increased femoral neck anteversion compared to normal controls.
METHOD AND MATERIALS
The study was IRB approved and complied with HIPAA guidelines. The study group comprised 78 patients with
IFI (mean age: 52.2±15.6 y, 68 f, 10 m) and 51 age and gender matched controls. Control subjects underwent
MRI of the hip for acute trauma but were otherwise asymptomatic. Two MSK radiologists independently measured IF and QF distance , femoral cross sectional area (CSA) at the level of the lesser trochanter, the ischial angle as a measure of inter-ischial distance, and femoral neck angle as a measure of femoral anteversion. The quadartus femoris was evaluated for edema and atrophy. Groups were compared with ANOVA.
RESULTS
All patients with IFI and none of the controls subjects had abnormalities of the quadratus femoris muscle
(p<0.0001). Out of the 78 patients, 14 (18%) had bilateral MRI findings of IFI. Patients with IFI had decreased
IF and QF distance (p<0.0001) compared to controls. Patients with IFI had increased ischial angle (p=0.04) and increased femoral neck angle (p=0.03) compared to controls. There was a trend toward decreased femoral
CSA (p=0.08) in IFI compared to controls.
CONCLUSION
Patients with IFI have increased ischial and femoral neck angles compared to controls. These anatomic variations in pelvic morphology may predispose to IFI. MRI is a useful method to not only assesses the osseous and soft tissue abnormalities associated with IFI but also to quantify anatomic variations in pelvic morphology that can predispose to IFI.
CLINICAL RELEVANCE/APPLICATION
MRI can be used to assess osseous and soft tissue abnormalities associated with IFI and to quantify anatomic variations in pelvic morphology that can predispose to IFI.
Osteoporosis Screening with Computed Tomography: Contrast Media Significantly Affects Bone
Signal (Station #6)
Esther Pompe MD (Presenter): Nothing to Disclose , Martin J. Willemink MD : Nothing to Disclose ,
Gawein Reinout Dijkhuis MD : Nothing to Disclose , Harald Verhaar : Nothing to Disclose , Firdaus
Mohamed Hoesein MD : Nothing to Disclose , Pim A. De Jong MD, PhD : Nothing to Disclose
PURPOSE
Osteoporosis could be detected by determining the bone density (BD) in a region of interest (ROI) within a lumbar vertebra on CT. The effect of intravenous contrast media on BD measurements on computed tomography (CT) examinations performed for other indications was evaluated.
METHOD AND MATERIALS
152 subjects (99 without and 53 with malignant renal neoplasm) who underwent both un-enhanced and two contrast-enhanced (arterial and portal venous phase) abdominal CT exams in a single session between June
2011 and July 2013 were included. BD was evaluated on the three exams as CT-attenuation values in
Hounsfield Units (HU) in the first lumbar vertebra (L1).
RESULTS
Subjects were stratified based on the presence of malignancies, because BD measurements were significantly higher in the group without malignancies. Mean ± standard deviation (SD) differences in BD measurements were 27.5±56.4 HU (p<0.01) in the un-enhanced phase, 23.6±59.9 HU in the arterial phase (p<0.01) and
19.8±56.5HU (p<0.01) in the portal phase. CT-attenuation values were significantly higher in contrast-enhanced phases, compared to the un-enhanced phase (p<0.01). In patients without malignancies,
HU-values increased from 128.8±48.6 HU for the unenhanced phase to 142.3±47.2 HU for the arterial phase and 147.0±47.4 HU for the portal phase (p<0.01). In patients with malignancies, HU-values increased from
112.1±38.1 HU to 126.2±38.4 HU and 130.1±37.3 HU (p<0.02), respectively. With thresholds of ≤110 HU,
≤135 HU, ≤160 HU to define osteoporosis, measurements in the arterial phase and portal phase resulted in
7-25% false negatives.
CONCLUSION
Our study showed that intravenous contrast injection substantially affects BD-assessment on CT and taking this into account it may improve opportunistic screening for osteoporosis.
CLINICAL RELEVANCE/APPLICATION
An overestimation of bone density due to contrast injection in clinical CT scans could lead to false negative results if used in a screening setting for osteoporosis.
Ultrasound of Morton’s Neuroma: What Are We Really Looking At? (Station #7)
Stuart Lance Cohen MD (Presenter): Nothing to Disclose , Theodore T. Miller MD : Nothing to Disclose ,
Edward F DiCarlo : Nothing to Disclose , Scott J Ellis : Consultant, Integra LifeSciences Holdings Corporation
Educator, Integra LifeSciences Holdings Corporation Consultant, OrthoHelix Surgical Designs, Inc , Matthew
Roberts MD : Nothing to Disclose
PURPOSE

MKE299
MKE114
MKE266
To correlate the appearance of preoperative ultrasounds of Morton's neuromas with the surgical specimens.
METHOD AND MATERIALS
Nine Morton's neuromas excised between July, 2013 and March, 2014 that had preoperative ultrasounds were evaluated with approval of the IRB. Preoperative ultrasounds were evaluated for neuroma size and appearance.
The resected surgical specimens were sonographically evaluated for size and appearance immediately following excision. All pre- and postoperative scans were performed using Philips IU-22 scanners. Specimens were then evaluated pathologically. The appearance and size of the neuromas were compared between the preoperative and postoperative images, and were correlated to the surgical and pathologic appearances.
RESULTS
All specimens were pathologically proven as Morton's neuromas; they showed focal thickening of the nerve at gross examination, and sclerosis and mucoid degeneration of the nerve fascicles and fibrotic thickening of the perineurium histologically. Longitudinal sonography of the specimens demonstrated echogenic focal enlargement of the nerve at the site of the neuroma, measuring 6.9 mm average (range 4 mm to 11 mm).
Preoperative images in the longitudinal plane showed a normal fibrillar echogenic nerve extending to a focal heterogenous hypoechoic mass within the webspace which measured 14.3 mm average (range 9 mm to 24 mm). Surgically, all cases had thickened or scarred bursal tissue around the nerve, and interdigital vessels that had to be disentangled from the nerve.
CONCLUSION
The heterogenous hypoechoic intermetatarsal mass that is sonographically considered a "Morton's neuroma" is actually a "neuroma-bursal complex" consisting of the thickened nerve, tangled vessels, and scarred/thickened bursa, that is much larger than the neuroma itself.
CLINICAL RELEVANCE/APPLICATION
Sonographically, Morton's neuromas are actually neuroma-bursal complexes, larger than the neuroma itself.
Ultrasound Guided Lumbar Spine Facet Injections (Station #8)
Randy Dewain Balmforth DO (Presenter): Nothing to Disclose , Marnix T. van Holsbeeck MD : Consultant,
General Electric Company Consultant, Koninklijke Philips NV Stockholder, Koninklijke Philips NV Stockholder,
General Electric Company Grant, Siemens AG Grant, General Electric Company
TEACHING POINTS
After a short anatomic review of the posterior lumbar spine , introduce the idea that facet joints can be identified and ultrasound guided facet injections performed.
TABLE OF CONTENTS/OUTLINE
I. Sonographic and pictorial anatomic review of the lumbar spine II. Introduction of Ultrasound guided facet injections. A. Reasons why this procedure will be beneficial in the future: III. Research/ procedure confirming location in the facet joint. IV: Discussion
Hand & Wrist Masses: MR Imaging with Pathologic Correlation (Station #9)
Cody Jackson Morris MD (Presenter): Nothing to Disclose , Gina Johnson : Nothing to Disclose ,
Adam Daniel Singer MD : Nothing to Disclose , Elie Harmouche : Nothing to Disclose , Abhijit Datir MD :
Nothing to Disclose
TEACHING POINTS
1. To discuss a practical approach for MRI evaluation of hand and wrist masses, including optimal sequences and the use of intravenous contrast. 2. To present the characteristic MRI findings of hand and wrist masses, ranging from common to uncommon, and benign to malignant lesions. 3. To emphasize the understanding of
MRI tissue characteristics of hand and wrist masses in correlation with underlying pathologic findings.
TABLE OF CONTENTS/OUTLINE
1. Introduction to MRI protocols in imaging of hand and wrist masses 2. Utility of contrast in the evaluation of hand and wrist masses 3. Spectrum of common to uncommon, and benign to malignant lesions in hand and wrist 4. Understanding of MRI tissue characteristics in correlation with pathologic findings 5. Individual examples with explanation based on histopathology, including but not limited to - Ganglion cyst Abscess Lipoma
Peripheral nerve sheath tumor Epidermal inclusion cyst Glomus tumor Adamantinoma Giant cell tumor of tendon sheath Synovial osteochondromatosis Lipofibrous hamartoma Soft tissue sarcoma, including undifferentiated pleomorphic sarcoma, liposarcoma, and spindle cell sarcoma 6. Conclusion
Imaging of Low Back Pain in Adult and Pediatric Populations: Red Flags, Educational Intervention, and Outcomes (Station #10)
Dennis Parhar BSc (Presenter): Nothing to Disclose , Ismail Tawakol Ali MBChB, MD : Nothing to Disclose ,
Savvas Nicolaou MD : Nothing to Disclose
TEACHING POINTS
The purpose/aim of this exhibit is to:
1.
2.
Demonstrate when low back imaging should be ordered in adult and pediatric populations and to present guidelines with an underlying rationale
Review the benefits, drawbacks, and controversies of the various imaging modalities used in the

3.
4.
investigation of low back pain
Identify the radiologic findings of red flags of low back pain in various imaging modalities along with their clinical correlations
Understand the utility of educational intervention as opposed to imaging in patient satisfaction and outcome
TABLE OF CONTENTS/OUTLINE
Review the necessity of guidelines in determining the need for diagnostic imaging of low back pain
Review of imaging modalities used in the investigation of low back pain (plain film, CT, MRI, myelography, bone scintigraphy) including their benefits and drawbacks
Review of clinical red flags in the adult and pediatric populations
Outline an algorithm to identify presentations meriting early diagnostic imaging
Demonstrate image examples and clinical correlation of diagnoses meriting early diagnostic imaging
Discuss the efficacy of educational intervention compared to imaging in patient satisfaction and outcome
Summary points and future directions
MKE112
Extrinsic Wrist Ligaments for Dummies: Detailed Anatomy on Dissection, Function, and MR
Imaging (Station #11)
Annemieke Milants (Presenter): Nothing to Disclose , Maryam Shahabpour MD : Nothing to Disclose ,
Michel De Maeseneer MD : Nothing to Disclose
TEACHING POINTS
To discuss detailed anatomy of the extrinsic wrist ligaments, illustrated by anatomical dissection. To discuss function and clinical relevance of the different ligaments. To present standard and 3D MR images with thin sections of the extrinsic ligaments.
TABLE OF CONTENTS/OUTLINE
1. The palmar extrinsic ligaments - radioscaphocapitate (RSC) - radiolunotriquetral (RLT) - short radiolunate
(SRL) - radioscapholunate/ligament of Testut (RSL) - palmar ulnotriquetral (pUT) - ulnolunate (UL) ulnocapitate (UC) 2. The dorsal extrinsic ligaments - dorsal radiotriquetral (dRT) - dorsal ulnotriquetral (dUT) 3.
The midcarpal ligaments (combining extrinsic and intrinsic ligaments) - palmar scaphotriquetral/ ligament of
Sennwald (pST) - arcuate ligament: triquetrohamatocapitate (THC) and scaphocapitate (SC) - dorsal scaphotriquetral (dST) - triquetrotrapeziotrapezoidal (TTT) - distal part of RSC - scaphotrapeziotrapezoidal complex (STT) 4. Stabilizing function of the extrinsic ligaments 5. MR Imaging of the extrinsic ligaments
(standard and thin section 3D DESS)
MKE164
Current Concepts of Total Ankle Arthroplasty for Radiologists (Station #12)
Hyojeong Mulcahy MD (Presenter): Nothing to Disclose , Felix Sze-Kway Chew MD : Nothing to Disclose ,
Jack Anthony Porrino MD : Nothing to Disclose
TEACHING POINTS
Total ankle arthroplasty is becoming the definitive treatment for end-stage, symptomatic arthritis of the tibiotalar joint. More sophisticated designs, stronger materials, improved surgical technique, and broader indications have led to an increased use. This educational exhibit will: 1. Review the current concepts of ankle replacement including various designs and modern surgical techniques. 2. Explain and illustrate the expected imaging appearances. 3. Demonstrate complications, and explain how such failures occur.
TABLE OF CONTENTS/OUTLINE
1. Types and prosthetic designs of ankle replacement 2. Current surgical techniques 3. Radiologic assessment
4. Complications a. Infection, b. Loosening c. Polyethylene wear d. Osteolysis, e. Periprosthetic fractures f.
Component fractures g. Hypertrophic ossification h. Dislocation
MKE005-b Trapped in a Tunnel: Ultrasound Imaging of Peripheral Nerve Entrapment Neuropathies (hardcopy backboard)
Srinadh Boppana MD (Presenter): Nothing to Disclose , Eshwar Chandra Nandury MD : Nothing to Disclose
, Kamlesh M Chawda MD : Nothing to Disclose , Prashanth Kumar Karnati MD : Nothing to Disclose , Jyothi
Reddy MD : Nothing to Disclose , Annapurna Srirambhatla MD : Nothing to Disclose , Balaji Varaprasad
Mallula MD : Nothing to Disclose
TEACHING POINTS
Describe the anatomy and imaging of various osteofibrous tunnels in the body using ultrasound. Recognise the normal ultrasound appearances of peripheral nerves. Identification of peripheral nerve entrapments, their location and causes.
TABLE OF CONTENTS/OUTLINE
Introduction: Anatomy , imaging technique and normal appearances Various nerve entrapments (carpal tunnel, guyons canal ,cubital tunnel, radial groove, suprascapular notch, inguinal ligament (meralgia paresthetica), fibular neck, popliteal fossa,tarsal tunnel). Causes including anatomical variants, retinaculae, ligaments, tenosynovitis, bone and joint abnormalities, masses and masslike lesions( neural and perineural). Conclusion

Scientific Papers
US GI
AMA PRA Category 1 Credits ™ : 1.00
ARRT Category A+ Credit: 1.00
Tue, Dec 2 3:00 PM - 4:00 PM Location: E353A
Participants
Moderator
Michael Austin Blake MBBCh : Editor with royalties, Springer Science+Business Media Deutschland GmbH
Moderator
Vamsi Rao Narra MD, FRCR : Consultant, Biomedical System Medical Advisory Board, Guerbet SA
Sub-Events
SSJ07-01 Biphenotypic Intrahepatic Cholangiocarcinoma and Hepatocellular Carcinoma: Imaging Features on
MRI, CT, Ultrasound and PET
Michael Leigh Wells MD (Presenter): Nothing to Disclose , Sudhakar Kundapur Venkatesh MD, FRCR :
Nothing to Disclose , Geoffrey Bates Johnson MD, PhD : Nothing to Disclose , Jeff L. Fidler MD : Nothing to
Disclose , David Maitland Hough MD : Nothing to Disclose , Joel Garland Fletcher MD : Grant, Siemens AG ,
Vishal Chandan MBBS : Nothing to Disclose
PURPOSE
Biphenotypic primary hepatic neoplasms characterized by both hepatocellular carcinoma (HCC) and cholangiocellular carcinoma (CCA) differentiation are rare. We performed a retrospective study to review the imaging and laboratory findings in 47 patients.
METHOD AND MATERIALS
In this institutional review board approved study, we retrospectively searched our institutional electronic medical records for patients with pathologically confirmed biphenotypic tumors. Clinical data and serum tumor markers were recorded. Two reader consensus of imaging features obtained for computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET) and ultrasound.
RESULTS
Chronic liver disease (CLD) was present in 36% of subjects; cirrhosis in 28%. Serum AFP was elevated in 29/42
(69%), CA 19.9 in 21/35 (60%) and both AFP and CA 19.9 were elevated in 16/34 (47%). On MRI, tumors were T2 hyperintense in 18/19 (95%) and T1 hypointense in 19/19 (100%). Only 1/27 (4%) exhibited classic
HCC feature of arterial hyperenhancement followed by washout. On CT and MRI, nearly three quarters (20/27,
74%) had peripheral hyperenhancement followed by peripheral washout or fade coupled with gradual central enhancement. Other patterns included persistent peripheral enhancement on all phases (n =3), separate foci of arterial and delayed enhancement (n=2), and hypoenhancement (n=1). Pseudocapsule was present in 6; biliary obstruction in 3 and liver capsule retraction in 8. Peripheral hypoechogenicity and central hyperechogenicity was the most common ultrasound feature, 5/12 (43%). PET demonstrated hypermetabolism in 9/11 (82%).
CONCLUSION
Biphenotypic tumors do not show strong association with CLD and serum tumor markers are inconsistently elevated. They exhibit variable imaging characteristics on CT and MRI, but classic features of HCC are usually not seen. Most have enhancement patterns which may suggest alternative diagnoses such as biphenotypic tumor, CCA or metastasis. Two distinct tumor components are rarely seen. Discordance between imaging findings and laboratory tumor markers should raise suspicion of biphenotypic tumor. Mixed tumors tend to be very metabolically active at FDG PET. Ultrasound is not specific.
CLINICAL RELEVANCE/APPLICATION
Suggesting an etiology other than HCC may be an important role of imaging in these patients given the significant differences in management of HCC compared with biphenotypic tumors, CCA or metastases.
SSJ07-02 Evaluation of a New Manganese-based Orally-Administered Hepatobiliary MR Contrast Agent
Rendon C. Nelson MD (Presenter): Consultant, General Electric Company Consultant, Nemoto Kyorindo Co,
Ltd Consultant, VoxelMetrix, LLC Research support, Bracco Group Research support, Becton, Dickinson and
Company Speakers Bureau, Siemens AG Royalties, Wolters Kluwer nv , Kohkan Shamsi MD, PhD : Research
Consultant, CMC Contrast AB
PURPOSE
To determine the qualitative and quantitative efficacy of orally-administered manganese chloride tetrahydrate
(CMC-001) for the evaluation of focal liver lesions (FLL) by MRI.

METHOD AND MATERIALS
Unenhanced alone and combined unenhanced and CMC-001 enhanced T1- and T2-weighted images at 1.5T of
30 healthy volunteers and 134 patients included in five Phase I and II trials or for compassionate use were evaluated separately by one independent reader who was blinded to patient information, contrast agent dose and clinical diagnosis. Region-of-interest signal intensity (SI) measurements were acquired from the non-tumorous liver parenchyma, common bile duct (CBD), portal vein (PV), paraspinous muscle and FLL, when present. FLL were also scored for visualization, delineation, detection confidence and characterization. Mean signal intensity measurements and lesion contrast-to-noise ratios (CNR) were compared between pre- and post-contrast images. The detection of benign and malignant-appearing lesions were compared between unenhanced alone and combined unenhanced and CMC-001 enhanced images.
RESULTS
178 unenhanced and CMC-001 enhanced image pairs were available for evaluation (some patients were imaged more than once). Comparing T1-weighted unenhanced to enhanced images, there was a significant increase in the SI of both liver parenchyma and CBD (37% and 412%, respectively; p<.0004). There was also a statistically significant improvement in the lesion-to-liver CNR after CMC-001 administration (median: pre:
4.22, post: 12.12; p<.0001). Compared to unenhanced images alone, the combination of unenhanced and
CMC-001enhanced images demonstrated 13% more malignant-appearing lesions. Also for malignant-appearing lesions, confidence in lesion localization in the 'high' category increased from 41% to 56% (p<.0001), while confidence in lesion visualization and delineation in the 'excellent' category increased from 32% to 44%
(p<.0001) and from 18% to 36% (p<.0001), respectively.
CONCLUSION
This initial analysis shows that orally-administered manganese chloride tetrahydrate provides qualitative and quantitative improvement over unenhanced MRI for visualization and detection of focal liver lesions.
CLINICAL RELEVANCE/APPLICATION
Manganese chloride tetrahydrate could be an alternative contrast agent for patients with known or suspected focal liver lesions in whom gadolinium-based contrast agents are contraindicated, particularly in patients with renal insufficiency.
SSJ07-03
SSJ07-04
Diagnostic Management of Benign Hepatocellular Lesions Imaged atMR - Hepatobiliary Phase versus
CEUS
Lambros Charles Tselikas MD (Presenter): Nothing to Disclose , Frederic Pigneur MD : Nothing to Disclose ,
Marion Roux : Nothing to Disclose , Vincent Roche : Nothing to Disclose , Laurence Baranes MD : Nothing to Disclose , Julien Calderaro : Nothing to Disclose , Charlotte Costentin : Nothing to Disclose , Damien
Medico : Nothing to Disclose , Marjan Djabbari : Nothing to Disclose , Alexis Laurent : Nothing to Disclose
, Ariane Mallat : Nothing to Disclose , Alain Rahmouni MD : Nothing to Disclose , Alain Luciani MD, PhD :
Nothing to Disclose
PURPOSE
To compare the added value of contrast-enhanced ultrasound (CEUS) and delayed hepatobiliary phase (HBP) imaging using Gd-BOPTA enhanced MRI in patients with atypical benign hepatocellular lesions (BLT).
METHOD AND MATERIALS
Sixty four BLT -37 focal nodular hyperplasia (FNH) and 27 hepatocellular adenomas (HCA)- with atypical presentation on liver MR using extracellular Gd chelates (EC-MRI) in 41 patients where retrospectively included in this IRB approved study. All patients underwent HBP MRI and CEUS. Two radiologists independently reviewed
2 sets of images: set 1 EC-MRI and HBP MRI; set 2 EC-MRI and CEUS. All HCA and 38% of all FNH were documented on pathology, the remaining FNH being diagnosed in board decisions and a median 18 months follow-up. Sensitivity (Se) specificity (Spe) were compared between the two sets, and subgroup analysis according to lesion's size were performed.
RESULTS
Regardless of lesion size, the respective Se and Spe of both data sets were not statistically different (94 and
100% vs. 78 and 92% respectively; p=0.11 and p=0.48). For lesions larger than 35mm, although both sets had similar excellent specificity (100%, p = 1) the sensitivity was higher for EC- MRI+HBP set (100% vs. 33%; p=0.04).
CONCLUSION
Although the overall performances of EC-MRI + CEUS and EC-MRI + HBP MRI are similar, the use of HBP should be advocated over CEUS in larger than 35mm large benign hepatocellular lesions.
CLINICAL RELEVANCE/APPLICATION
Size influences HBP and CEUS diagnostic performances. the use of HBP should be advocated over CEUS in larger than 35mm large benign hepatocellular lesions.
Detection of Liver Metastases Using a High Spatial Resolution Ultrasound Contrast Mode: Impact of
Small Liver Metastases in Different Primary Malignancies
Hans-Peter Weskott MD (Presenter): Luminary, General Electric Company Speaker, Bracco Group , Michael
Hoepfner MD : Nothing to Disclose , Carsten Bohm : Nothing to Disclose

SSJ07-05
PURPOSE
Retrospective evaluation of the number and size distribution of liver metastases of different primaries by analyzing digitally stored triphasic CEUS loops of the liver in a two center study
METHOD AND MATERIALS
201patients with 287 CEUS examinations were included. US basic examination prior and after CEUS examination of 1.2mL Sonovue™ bolus injection (Bracco, Milan, Italy) in patients with metastatic liver disease.
CEUS was performed in a pulse inversion technique (LOGIQ E9, GE Healthcare, Milwaukee, IL,USA). Patients were referred for CEUS with intention to treat,or for staging/restaging after chemotherapy or tumor resection.
Representative loops of all triphasic CEUS examinations were digitally stored. At late phase, metastases were defined as washed out lesions and measured on still frames. Most frequent primaries: GI tract tumors (n=76, including 9 follow ups), breast cancer (n=89, 41 follow ups), melanoma (n=32, 9 follow ups). Size distibution was defined in 4 groups: Group 1: <5mm, group 2: 5.1mm -10mm, group 3: 11mm-20mm, group 4: >20mm.
RESULTS
In 287 examinations 3264 metastases were detected. Size distribution of all included patients: Group 1: 14.0%,
2: 37.9%, 3: 28.3%, 4: 19.8%. Patients with GI tract metastases (76 exams in 52 patients, 313 metastases) showed the largest metastases: Group 1: 4.0%, 2: 28.9%, 3: 31.1%, 4: 37.3%. Size distribution in breast cancer according to the four groups ( n=89 exams in 41 patients, 1526 metastases): Group 1: 22.5%, 2:
45.2%, 3: 22.2%, 4: 10.3%. Size distribution in melanoma group (32 exams in 20 patients, 337 metastases):
Group 1: 19.2%, 2: 38.9%, 3: 31.5%, 4: 10.6%. Using high resolution CEUS technique small metastases down to 3mm in size could be detected.
CONCLUSION
CEUS is capable to detect also small metastases below 10mm accounting for 1/3 (GI tract) to 2/3 (breast cancer) of all metastases.
CLINICAL RELEVANCE/APPLICATION
Detection of especially small metastases is most important for the management of metastatic diseases. In patients with a high likelihood of liver metastases high resolution CEUS should be included early in the diagnostic work up.
Contrast-enhanced Sonography (CEUS) Assessment of Dirty, Cystic-like Focal Liver Lesions (FLLs)
Orlando Catalano MD : Nothing to Disclose , Pietro Paolo Saturnino MD (Presenter): Nothing to Disclose ,
Antonio Nunziata MD : Nothing to Disclose , Sergio Venanzio Setola MD : Nothing to Disclose , Fabio
Sandomenico MD : Nothing to Disclose , Antonella Petrillo MD : Nothing to Disclose
PURPOSE
Dirty liver cysts at US represent a challenge, since true cysts can mimic a solid FLL while solid FLLs may be confused with cysts. Our single-cancer centre study analyses the additional value of microbubbles contrast injection in cancer patients with "dirty" cysts at baseline US.
METHOD AND MATERIALS
In a 7-year period we identified 48 patients with 50 "dirty" cysts (hypoechoic content in 24 lesions, lack of posterior enhancement in 10 lesions, both findings in 16 lesions) at US. These subjects were imaged for cancer staging/follow-up and had no previous study for comparison. They prospective underwent sulphur hexafluoride-based contrast medium injection. Diagnosis was confirmed by further imaging in 30 lesions, follow-up in 18, and biopsy in 2.
RESULTS
US was indeterminate, by definition, in all lesions (9-39 mm, mean 20). The liver echotexture was fatty in 37 patients and normal in the others. An inhomogeneous content was more predictive for solid nature than lack of dorsal enhancement did. CEUS correctly diagnosed all 24 true cysts (100%) in 24 patients and 25/26 solid lesions (96%, 18 metastases and 7 hemangiomas) in the remaining 24. One deeply located metastasis was incorrectly diagnosed as cyst by CEUS.
CONCLUSION
CEUS allows achieving a definitive diagnosis in patients with US findings of "dirty" liver cyst. CEUS allows ruling out a solid FLL and characterizing truly solid FLLs. This is of special value in countries where US is regarded as the first modality for liver survey.
CLINICAL RELEVANCE/APPLICATION
It is not uncommon that liver cysts show an atypical appearance at US. In these cases CEUS allows to solve the diagnostic pitfall avoiding further imaging with more expensive and invasive modalities.
SSJ07-06 Contrast-enhanced Hepatic Angiography: A Novel CEUS Technique to Image Intrahepatic Arteries
Hans-Peter Weskott MD (Presenter): Luminary, General Electric Company Speaker, Bracco Group ,
Shanshan Yin MD : Nothing to Disclose

PURPOSE
To evaluate the arterial hepatic architecture including diameter, course and branching by using a pulse inversion technique in patients with either diffuse and/or focal liver disease.
METHOD AND MATERIALS
For detection or characterization of focal liver lesions (FLL) in normal/or diffuse liver disease 137 patients underwent CEUS. With arrival of the first bubbles (contrast agent Sonovue, Bracco Company, Milan,Italy) a sweep of the right or left liver lobe was performed using a low MI harmonic imaging technique (pulse inversion,
Logiq E9, C1-5, GE Healthcare, Milwaukee, USA). Cine capture was started to visualize the vascular continuity of intrahepatic arteries. Average accumulation time for a cine capture sequence was 6.5s ±1.8s. A successful examination was defined when at least three main branches of the right or left hepatic artery were imaged.
Loops were reviewed to compare course and size of intrahepatic arteries, including 44 patients with liver metastases,28 within liver cirrhosis and 65 patients without cirrhosis and malignant FLL among them 18 patients with benign FLL
RESULTS
The success rate was 88%. In cirrhotic patients 78% had a tortuous course and dilated arteries including at least three main arterial branches. The mean diameter of the right or left main tortuous artery was
3.36±0.92mm. The smallest arterial branches measured 0.4mm. Compared to patients without collateral circulation (n=24), diameters were thinner in patients with collateral circulation (n=4) (3.39±0.96mm vs.
2.58±1.15mm , p=0.138). In non-cirrhotic patients, 54% showed corkscrew arteries involving no more than two main arterial branches, mostly seen in patients under chemotherapy. In comparison the mean diameter of the non-cirrhotic liver was thinner (2.32±0.89mm, p=0.000). Curly arteries were seen more often in the elderly
(r=0.285). In metastatic disease, 45.4% patients had curly arteries. Tortuous feeding arteries were seen in all
FNH and HCC. Arterial stenosis was seen in a patient with lung cancer without liver metastasis.
CONCLUSION
CEHA is capable to image changes of the intrahepatic arterial architecture and thus contributes to characterize the vascular status in patients with diffuse or focal liver diseases.
CLINICAL RELEVANCE/APPLICATION
CEHA shows differences in in the arterial architecture of patients with diffuse liver disease, especially in patients under or after chemotharapy, it helps to image tumor supplying arteries in benign FLL and HCC.
Refresher/Informatics
VA US GU
AMA PRA Category 1 Credits ™ : 1.50
ARRT Category A+ Credits: 1.50
Tue, Dec 2 4:30 PM - 6:00 PM Location: E450B
Sub-Events
RC410A Masses and Parenchymal Diseases
Michael David Beland MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Identify the imaging features of a variety of etiologies of renal masses and understand the potential overlap between malignancy, non-malignant mass-like lesions and pseudomasses. 2) Recognize the potential limitations of ultrasound in the identification of renal masses and learn to maximize technique. 3) Demonstrate the wide range of appearances of parenchymal diseases on ultrasound and develop an approach to evaluation.
ABSTRACT
Renal masses are a common finding on ultrasound. While the vast majority are cysts, solid appearing lesions are also frequently encountered. Not all 'masses' are cancer and there are numerous mimicers of malignacy on renal ultrasound. Numerous cases will be shown of various malignant and non-malignant etiologies of renal masses. Factors impacting the sensitivity of renal ultrasound for detection of masses will be reinforced. Finally, renal parenchymal diseases can demonstrate a wide variety of sonographic appearances. Multiple examples will be shown as well as the importance of developing a systematic evaluation of the patient with parenchymal disease.
RC410B Renal Doppler
John Stephen Pellerito MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Learn techniques and protocols for Doppler evaluation of the renal arteries. 2) Optimize abdominal Doppler

RC410C
1) Learn techniques and protocols for Doppler evaluation of the renal arteries. 2) Optimize abdominal Doppler studies. 3) Recognize the role of Doppler in evaluation of renal stents.
ABSTRACT
Evaluation of the renal arteries and kidneys is an integral component of the workup of renal insufficiency and hypertension. Doppler ultrasound examination is proven valuable in the detection of renal artery stenosis and occlusion. Doppler ultrasound has multiple advantages over CT or MR angiography: noninvasive, no radiation and does not require administration of contrast material. This program will discuss the techniques and protocols needed for successful renal artery evaluation with Doppler ultrasound. Tips to optimize the examination will be provided. There will also be a discussion of the evaluation of renal artery stents.
Renal Transplants
Deborah J. Rubens MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Review the normal parenchymal and vascular anatomy of renal transplants including their normal Doppler parameters. 2) Identify the most common causes of renal transplant complications and criteria for their diagnosis. 3) Outline some of the pitfalls in transplant ultrasound imaging and when to use CT, MR and/or angiography in addition to ultrasound.
ABSTRACT
This lecture will review the anatomy and pathophysiology of renal transplants. The role of ultrasound imaging in assessment of acute as well as chronic renal transplant dysfunction will be elucidated. The performance of
Doppler ultrasound will be highlighted regarding vascular stenosis and occlusion, parenchymal perfusion, and planning and assessing organ biopsy. Doppler techniques to avoid false negative and false positive studies will be emphasized. Controversial parameters will be stressed, in particular the use of absolute velocities versus ratios in the diagnosis of renal artery stenosis. Surgical emergencies will be highlighted, and the role of correlative imaging with CT, MR and/or angiography will be addressed.
Active Handout http://media.rsna.org/media/abstract/2014/13010304/RC410C sec.pdf
Refresher/Informatics
US NR MK US NR MK
AMA PRA Category 1 Credits ™ : 1.50
ARRT Category A+ Credits: 1.50
Tue, Dec 2 4:30 PM - 6:00 PM Location: E264
Participants
Carlo Martinoli MD (Presenter): Nothing to Disclose
J. Antonio Bouffard MD (Presenter): Nothing to Disclose
Catherine J. Brandon MD (Presenter): Stock options, VuCOMP, Inc
Etienne Cardinal MD (Presenter): Nothing to Disclose
Mary Margaret Chiavaras MD, PhD (Presenter): Nothing to Disclose
Joseph Gerard Craig MD (Presenter): Nothing to Disclose
Michael A. Dipietro MD (Presenter): Nothing to Disclose
David Paul Fessell MD (Presenter): Nothing to Disclose
Ghiyath Habra MD (Presenter): Nothing to Disclose
Andrea Klauser MD (Presenter): Nothing to Disclose
Marnix T. van Holsbeeck MD (Presenter): Consultant, General Electric Company Consultant, Koninklijke Philips NV
Stockholder, Koninklijke Philips NV Stockholder, General Electric Company Grant, Siemens AG Grant, General Electric Company
Rachel Beth Hulen MD (Presenter): Nothing to Disclose
Marina Kislyakova MD (Presenter): Nothing to Disclose
Joseph Hudson Introcaso MD (Presenter): Nothing to Disclose
Jon A. Jacobson MD (Presenter): Consultant, BioClinica, Inc Royalties, Reed Elsevier Equipment support, Terumo Corporation
Equipment support, Arthrex, Inc
Kenneth S. Lee MD (Presenter): Research Consultant, SuperSonic Imagine Speakers Bureau, Medical Technology Management
Institute
Humberto Gerardo Rosas MD (Presenter): Nothing to Disclose
Matthieu Rutten MD (Presenter): Nothing to Disclose
Alberto Stefano Tagliafico MD (Presenter): Nothing to Disclose
Ximena Loreto Wortsman MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Describe the ultrasound anatomy and scanning technique for examination of neck (i.e. brachial plexus, spinal accessory, long thoracic, phrenic, vagus) and shoulder (i.e. suprascapular, axillary, musculocutaneous) nerves. 2) Illustrate the main anatomic landmarks to identify these nerves. 3) Master technical approaches to nerve ultrasound including the recognition of pitfalls.
ABSTRACT
In recent years, ultrasound of the musculoskeletal and peripheral nervous systems is becoming an increasingly imaging tool with an expanding evidence base to support its use. However, the operator dependent nature and level of technical expertise

required to perform an adequate ultrasound assessment means that appropriate training is required. For this purpose, the present course will demonstrate the basic principles of musculoskeletal ultrasound with a special focus on the examination of small (<1mm thick) and difficult-to-study nerves. The standardized techniques of performing an adequate ultrasound study of the axillary nerve in the shoulder, the musculocutaneous nerve in the arm and the anterior interosseous nerve in the proximal forearm will be illustrated. Similarly, the examination technique to image the lateral femoral cutaneous nerve in the inguinal area and the saphenous nerve throughout the lower extremity will be described. The hands-on workshops will provide the opportunity to interactively discuss the role of ultrasound in this field with expert instructors. Participants will be encouraged to directly scan model patients. A careful ultrasound approach with thorough understanding of soft-tissue planes and extensive familiarity with anatomy are prerequisites for obtaining reliable information regarding the affected structure and the site and nature of the disease process affecting it.
Special Courses
US
AMA PRA Category 1 Credits ™ : 1.00
ARRT Category A+ Credit: 1.00
Wed, Dec 3 7:15 AM - 8:15 AM Location: S404CD
Participants
Moderator
William Eugene Shiels DO : President, Mauka Medical Corporation Royalties, Mauka Medical Corporation Patent holder, Mauka
Medical Corporation
Brian D. Coley MD (Presenter): Author with royalties, Reed Elsevier
David Bahner MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Describe the differences between focused and comprehensive ultrasound in the clinical setting. 2) Determine the differences between sonography and sonology and how clinicians are using ultrasound in medical decision making 3) Delineate the barriers associated with teaching ultrasound in medical school and how medical education is preparing the next generation of clinicians to use this tool in their practice.
Special Courses
US MR IR GU US MR IR GU US
AMA PRA Category 1 Credits ™ : 1.00
MR IR GU
ARRT Category A+ Credit: 1.00
Wed, Dec 3 7:15 AM - 8:15 AM Location: E351
Participants
Moderator
Peter L. Choyke MD : Researcher, Koninklijke Philips NV Researcher, General Electric Company Researcher, Siemens AG
Researcher, iCAD, Inc Researcher, Aspyrian Therapeutics, Inc Researcher, ImaginAb, Inc Researcher, Aura
Moderator
Julia R. Fielding MD : Nothing to Disclose
LEARNING OBJECTIVES
1) Learn current clinical applications for MR/US fusion biopsy of the prostate. 2) Describe elements of 2 fusion systems important to the radiologist. 3) Compare use of MR/US fusion systems with visual targeting of prostate cancers.
Sub-Events
SPSH40A Fused MR/US Prostate Biopsy with a Single Vendor System: How and When to Use It
Andrew B. Rosenkrantz MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
View learning objectives under main course title.
SPSH40B Prostate Biopsy Using Two Fused MR/US Systems: Clinical Use and Comparison
Daniel Jason Aaron Margolis MD (Presenter): Research Grant, Siemens AG
LEARNING OBJECTIVES
View learning objectives under main course title.
Active Handout http://media.rsna.org/media/abstract/2014/14019807/SPSH40B sec.pdf

Multisession Courses
ER US OB GU
AMA PRA Category 1 Credits ™ : 1.50
ARRT Category A+ Credits: 1.50
Wed, Dec 3 8:30 AM - 10:00 AM Location: S100AB
Sub-Events
MSES41A Arterial Doppler Waveforms around the Body
Mindy Meislich Horrow MD (Presenter): Spouse, Director, Merck & Co, Inc
LEARNING OBJECTIVES
1) Analyze the difference between high resistance and low resistance arterial waveforms and where they normally occur. 2) Demonstrate an understanding of the parvus tardus waveform and the situations in which it occurs. 3) Demonstrate an understanding of Doppler waveforms related to stenosis, pseudoaneurysm and arterio-venous fistula.
ABSTRACT
This lecture will review the basic types of normal arterial waveforms throughout the body including carotid, vertebral, visceral organ and peripheral vessels. Further discussion will include general and specific changes related to stenosis, occlusion, pseudoaneurysms and arterial venous fistulas with some cases related to pitfalls and quality assurance.
MSES41B
MSES41C
First Trimester US
John Stephen Pellerito MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Recognize sonographic features and landmarks of a normal first trimester pregnancy. 2) Interpret sonographic findings and hCG measurements to determine a normal or abnormal gestation. 3) Analyze diagnostic criteria for nonviable first trimester pregnancy. 4) Apply sonographic findings to clarify a pregnancy of uncertain viability or unknown location.
ABSTRACT
First Trimester US John S Pellerito, MD FACR This presentation highlights the sonographic presentations of normal and abnormal first trimester pregnancy. We will discuss the normal landmarks that are visualized during the first weeks of life. Expected hCG titers are reviewed for each landmark and discrepancies between sonographic findings and hCG levels will be discussed. The diagnostic criteria for normal and nonviable early pregnancy will be established. There will be case discussions to evaluate the findings associated with an intrauterine pregnancy of uncertain viability as well as how to assess a pregnancy of unknown location
US of OB Emergencies
Oksana Helena Baltarowich MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) List the main placental causes of significant bleeding in the third trimester of pregnancy. 2) Explain the causes of false sonographic diagnosis of placenta previa. 3) Explain the differences among placenta accreta, increta, and percreta. 4) List the complications of cervical incompetence.
ABSTRACT
This lecture will review the sonographic findings seen in obstetrical emergencies in the second and third trimesters of pregnancy. The diagnosis of placenta previa will be discussed along with the pitfalls in the sonographic diagnosis. Differences between placenta accreta, increta and percreta will be highlighted. Examples of placental abruption will be shown. Cervical incompetence and its complications will be discussed along with several other abnormalities that constitute emergent situations.
Active Handout http://media.rsna.org/media/abstract/2014/14000994/MSES41C.sec.pdf

Refresher/Informatics
ER US MR CT OB GU
AMA PRA Category 1 Credits ™ : 1.50
ARRT Category A+ Credits: 1.50
Wed, Dec 3 8:30 AM - 10:00 AM Location: E450B
Sub-Events
RC508A US of Obstetrical Emergencies
Ana P. Lourenco MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Recognize the sonographic appearance of common and uncommon obstetric emergencies. 2) Demonstrate understanding of management for emergent obstetric diagnoses. 3) Identify those cases requiring additional imaging, beyond US, for definitive diagnosis.
RC508B
RC508C
RC508D
ABSTRACT
In this refresher course focused on US of Obstetrical Emergencies, we will review the key imaging findings and management of both common and uncommon obstetrical emergencies. As many hospitals and radiology practices may not routinely evaluate pregnant patients, these are particularly important topics to review. Timely and accurate diagnosis is critical to improved outcomes for both the mother and fetus. The range of topics to be reviewed will cover the first, second, and third trimester, as well as the immediate post-partum period.
Diagnoses will include ectopic pregnancy, with a focus on the less commonly encountered types of ectopics cervical, C-section scar, interstitial, and ovarian ectopics. We will also review the imaging findings of ovarian hyperstimulation as well as associated complications, which can be potentially life-threatening. Ovarian torsion in pregnancy will be discussed, as the hormonal changes of pregnancy and mass effect from corpus luteal cysts of pregnancy or other masses may predispose patients to torsion. Furthermore, the non-specific clinical presentation often makes the diagnosis challenging. Similarly, the presentation of acute appendicitis in pregnancy may be non-specific. Imaging findings of acute appendicitis in pregnancy will be reviewed, as accurate diagnosis prior to appendiceal rupture can markedly improve outcomes for both mother and fetus.
Placental abnormalities will be reviewed, including placenta previa, placental abruption, and abnormal placentation (accreta, increta, percreta). Imaging findings of cervical incompetence will be reviewed, as well as important next steps in clinical management once this diagnosis is discovered. We will also review the sonographic findings of uterine dehiscence, which although rare, is potentially catastrophic to both mother and fetus. Lastly, we will review the imaging findings of retained products of conception, most commonly presenting in the immediate post-partum period.
Active Handout http://media.rsna.org/media/abstract/2014/14002058/RC508A sec.pdf
US of Gynecological Emergencies
Robin Beth Levenson MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Discuss gynecologic causes of acute female pelvis and the role of ultrasound in evaluation. 2) Identify important gynecologic ultrasound findings in the acute setting and recognize pearls and pitfalls in diagnosis. 3)
Illustrate examples demonstrating range of imaging findings. 4) Recognize the key ultrasound features in gynecologic emergencies.
Active Handout http://media.rsna.org/media/abstract/2014/14002059/RC508B sec.pdf
CT of the Acute Female Pelvis
Anjali Agrawal MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Highlight the importance of recognition of acute gynecologic conditions on CT. 2) Outline the physiologic processes that may present as acute pelvic pain and their CT findings. 3) Describe the CT features of various pathologic causes of the acute female pelvis. 4) Illustrative case examples with correlative imaging findings on sonography or MRI to improve the understanding of the anatomy and pathology on CT.
MRI of the Acute Female Pelvis
Stephan W. Anderson MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES

1) The participant will review the etiologies of acute pelvic pain for which MRI may be effectively employed in the diagnostic evaluation. 2) The participant will be able to apply an MRI-based approach to certain etiologies of acute abdominal pain at their own institution. 3) The participant will review the current pertinent literature in the application of MRI in acute pelvic pain.
Refresher/Informatics
US OB GU
AMA PRA Category 1 Credits ™ : 1.50
ARRT Category A+ Credits: 1.50
Wed, Dec 3 8:30 AM - 10:00 AM Location: S404CD
Sub-Events
RC510A 3D Ultrasound in Gynecology
Beryl R. Benacerraf MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) To learn about the multiplanar reconstruction technique in scanning the pelvis, including its usefulness of looking at the coronal view of the uterus to evaluate the endometrium for polyps, fibroids and mullerian duct anomalies. 2) To learn to use 3D to determine the position of an IUD in the uterus. 3) To learn how 3D can help on detecting the causes of pelvic pain.
ABSTRACT
Three-dimensional (3D) ultrasound allows us to acquire a volume and display any plane of section within that volume regardless of the scanning orientation. The ability to display a 3D image of any type or plane has been one of the most powerful recent advances in sonography, particularly in the field of obstetrics and gynecology.
In gynecology, 3D has allowed visualization of coronal view of the uterus, enabling us to diagnose mullerian duct anomalies without using MRI. We can also easily diagnose malpositioned IUDs (a common cause of pelvic pain and bleeding), polyps, submucous fibroids and other abnormalities related to the uterine cavity. 3D ultrasound also greatly facilitates the correct diagnosis of hydrosalpinges because of the infinite planes in which the tubal areas can be displayed.
RC510B Ovarian Masses and Cysts
Douglas L. Brown MD (Presenter): Author with royalties, UpToDate, Inc Author with royalties, Reed Elsevier
Editor with royalties, Reed Elsevier
LEARNING OBJECTIVES
1) Demonstrate understanding of what ovarian features are normal or inconsequential, so as to not over-diagnose ovarian cysts or masses. 2) Be able to recognize sonographic features that reliably predict benign and malignant ovarian cysts. 3) Understand the appropriate imaging follow-up of benign and indeterminate ovarian masses.
RC510C Uterus and Endometrium
Ruth Beth Goldstein MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Be able to state the acceptable standards for endometrial assessment in women with abnormal vaginal bleeding. 2) Be able to recognize a uterine abnormality in a postmenopausal woman that warrants further evaluation including tissue sampling or MRI. 3) Be able to recognize and diagnose adenomyosis.
Refresher/Informatics
PD US
AMA PRA Category 1 Credits ™ : 1.50
ARRT Category A+ Credits: 1.50

Wed, Dec 3 8:30 AM - 10:00 AM Location: S102AB
Sub-Events
RC513A Contrast Enhanced US and Elastography?
Nancy A. Chauvin MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Understand the principles of contrast enhanced ultrasound and ultrasound elastography and how to perform both techniques. 2) Apply contrast enhanced US and elastography in their practice in order to evaluating pathology.
RC513B
RC513C
Pediatric Doppler
Brian D. Coley MD (Presenter): Author with royalties, Reed Elsevier
LEARNING OBJECTIVES
1) Understand the basics of blood flow and hemodynamics, and how they are reflected in the Doppler waveform. 2) Apply the understanding of these changes to clinical cases involving the liver, kidney, and vasculature in children.
Challenging Pediatric US Examinations
Lynn A. Fordham MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Review challenging cases. 2) Discuss strategies to recognize and evaluate challenging cases. 3) Review diagnoses and pertinent alternative diagnoses
ABSTRACT
In this session we will review selected challenging pediatric ultrasound cases, discuss some of the issues that make the case challenging, review the diagnoses and review alternate diagnoses
Refresher/Informatics
US MR DM BR
AMA PRA Category 1 Credits ™ : 1.50
ARRT Category A+ Credits: 1.50
Wed, Dec 3 8:30 AM - 10:00 AM Location: E450A
Sub-Events
RC515A Mammography
Murray Rebner MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) To educate the attendees with the use of the audience response system regarding the changes to the mammography section in the new 5th edition of the BI-RADS atlas.
ABSTRACT
The new edition of the BI-Rads atlas contains changes in the various sections. The purpose of this presentation is to highlight the major additions and revisions to the mammography section of the document. These points will be made with slides and with illustrations. Theey will be emphasized with the use of the audience response system. The participants should obtain an understanding of the major changes and this will enable them to incorporate these modifications in their practice.
RC515B Ultrasound
Mary C. Mahoney MD (Presenter): Scientific Advisory Board, Hologic, Inc Research support, Hologic, Inc

RC515C
Mary C. Mahoney MD (Presenter): Scientific Advisory Board, Hologic, Inc Research support, Hologic, Inc
Consultant, Devicor Medical Products, Inc
LEARNING OBJECTIVES
1) To review the BI-RADS lexicon for breast US. 2) To identify recent changes to the US BI-RADS lexicon. 3)
To discuss the incorporation of BI-RADS into breast US interpretation.
MRI
Carol H. Lee MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) To review the BI-RADS lexicon for breast MRI. 2) To identify recent changes to the MR BI-RADS lexicon. 3)
To discuss the incorporation of BI-RADS into breast MRI interpretation.
Refresher/Informatics
US IR US IR
AMA PRA Category 1 Credits ™ : 1.50
ARRT Category A+ Credits: 1.50
Wed, Dec 3 8:30 AM - 10:00 AM Location: E263
Participants
William Eugene Shiels DO (Presenter): President, Mauka Medical Corporation Royalties, Mauka Medical Corporation Patent holder, Mauka Medical Corporation
Peter L. Cooperberg MD (Presenter): Nothing to Disclose
Veronica Josephine Rooks MD (Presenter): Nothing to Disclose
Alda Felicita Cossi MD (Presenter): Nothing to Disclose
Nathalie J. Bureau MD (Presenter): Equipment support, Siemens AG
James Walter Murakami MD (Presenter): Nothing to Disclose
Paolo Minafra MD (Presenter): Nothing to Disclose
Paula Beth Gordon MD (Presenter): Stockholder, OncoGenex Pharmaceuticals, Inc Scientific Advisory Board, Hologic, Inc
Consultant, Seno Medical Instruments, Inc
Hollins P. Clark MD, MS (Presenter): Nothing to Disclose
Carmen Gallego MD (Presenter): Nothing to Disclose
Mabel Garcia-Hidalgo Alonso MD (Presenter): Nothing to Disclose
Michael A. Dipietro MD (Presenter): Nothing to Disclose
Horacio Munsayac Padua MD (Presenter): Nothing to Disclose
Patrick Warren MD (Presenter): Nothing to Disclose
Robert Douglas Lyon MD (Presenter): Nothing to Disclose
Stephen Clifford O'Connor MD (Presenter): Nothing to Disclose
Michael Andrew Mahlon DO (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Identify basic skills, techniques, and pitfalls of freehand invasive sonography, with specific focus on small part applications.
2) Define and discuss technical aspects, rationale, and pitfalls involved in musculoskeletal, breast, head and neck, and pediatric interventional sonographic care procedures. 3) Successfully perform basic portions of hands-on US-guided procedures in a tissue simulation learning model, to include core biopsy, small abscess coaxial catheter drainage, cyst and ganglion aspiration, lymphatic malformation macrocyst access, soft tissue foreign body removal, and intraarticular steroid injection. 4) Incorporate these component skill sets into further life-long learning for expansion of competency and preparation for more advanced interventional sonographic learning op
Refresher/Informatics
US MK US MK
AMA PRA Category 1 Credits ™ : 1.50
ARRT Category A+ Credits: 1.50
Wed, Dec 3 8:30 AM - 10:00 AM Location: E264
Participants
Viviane Khoury MD (Presenter): Nothing to Disclose
Etienne Cardinal MD (Presenter): Nothing to Disclose
Jon A. Jacobson MD (Presenter): Consultant, BioClinica, Inc Royalties, Reed Elsevier Equipment support, Terumo Corporation
Equipment support, Arthrex, Inc
J. Antonio Bouffard MD (Presenter): Nothing to Disclose
Joseph Gerard Craig MD (Presenter): Nothing to Disclose
David Paul Fessell MD (Presenter): Nothing to Disclose
Ghiyath Habra MD (Presenter): Nothing to Disclose
Joseph Hudson Introcaso MD (Presenter): Nothing to Disclose

Joseph Hudson Introcaso MD (Presenter): Nothing to Disclose
Marnix T. van Holsbeeck MD (Presenter): Consultant, General Electric Company Consultant, Koninklijke Philips NV
Stockholder, Koninklijke Philips NV Stockholder, General Electric Company Grant, Siemens AG Grant, General Electric Company
Kenneth S. Lee MD (Presenter): Research Consultant, SuperSonic Imagine Speakers Bureau, Medical Technology Management
Institute
Humberto Gerardo Rosas MD (Presenter): Nothing to Disclose
Catherine J. Brandon MD (Presenter): Stock options, VuCOMP, Inc
Kambiz Motamedi MD (Presenter): Nothing to Disclose
Mary Margaret Chiavaras MD, PhD (Presenter): Nothing to Disclose
Andrea Klauser MD (Presenter): Nothing to Disclose
Mark Cresswell MBBCh (Presenter): Nothing to Disclose
Robert R. Lopez-Ben MD (Presenter): Nothing to Disclose
Colin Daniel Strickland MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Identify anatomic structures which can impinge or move abnormally in the upper extremity causing pain during normal range of motion. 2) Describe the ultrasound anatomy and scanning technique for a dynamic examination of these lesions. 3)
Position patients optimally for the dynamic evaluation of the upper extremity respecting ergonomics.
ABSTRACT
This course will demonstrate standardized techniques of performing the dynamic examination of upper extremity conditions that are only or best demonstrated dynamically. These include shoulder impingement syndrome, acromioclavicular joint instability, long head of biceps dislocation, medial elbow joint instability, extensor carpi ulnaris dislocation, median nerve movement, and trigger finger.
In the first portion of the course, probe positioning will be demonstrated on a model patient with overhead projection during live scanning. In the second portion of the course, an international group of expert radiologists will assist participants in learning positioning and scanning of the shoulder, elbow, and wrist/ finger lesions described. An emphasis on dynamic maneuvers and ergonomic documentation of tissue dynamics will be taught. Participants will be encouraged to directly scan model patients.
Active Handout http://media.rsna.org/media/abstract/2014/4426454/RC552 sec.pdf
Scientific Posters
BR
AMA PRA Category 1 Credits ™ : .50
Wed, Dec 3 12:15 PM - 12:45 PM Location: BR Community, Learning Center
Participants
Moderator
Catherine M. Tuite MD : Nothing to Disclose
Sub-Events
BRS271 Diagnostic Performance of Shear-wave Elastography (SWE) in Complex Cystic Breast Lesions in
Comparison with Conventional Ultrasound (Station #1)
Boeun Lee (Presenter): Nothing to Disclose , Eun-Suk Cha MD : Nothing to Disclose , Jin Chung MD :
Nothing to Disclose , Jee Eun Lee MD : Nothing to Disclose , Jeoung Hyun Kim : Nothing to Disclose
PURPOSE
To evaluate the diagnostic performance and usefulness of SWE for differential diagnosis of complex cystic breast lesions, in comparison with conventional ultrasound (US).
METHOD AND MATERIALS
From January 2013 to November 2013, of 140 women who had been performed conventional US and SWE, 140 complex cystic breast lesions were included in this study. All patients underwent US-guided core biopsy or surgical excision. BI-RADS US final assessment and SWE parameters (qualitative maximum elasticity using a six-level visual color scale, homogeneity of elasticity, color pattern) were recorded for each lesion. Final assessment of SWE with US was based on BI-RADS US lexicon, however, the final assessment was downgraded for dark blue and light blue lesions and upgraded for orange and red lesions. Sensitivity and specificity were calculated, while category 4b, 4c or 5 indicated malignancy and category 3 or 4a was regarded as a benign interpretation. Histopathologic diagnosis was used as reference standard.
RESULTS
Of the 140 complex cystic lesions, 30 lesions (21.4%) were malignant. Large size (22.7mm vs. 14.8mm), old age (52.7 years vs. 43.6 years), symptomatic lesions (70% vs. 31.8%) and final assessments for US and SWE with US were significant with malignancy (P<0.05). Of group of 30~70% cystic portion, malignancy rate was significant as 37.8%. Mean maximum elasticity of malignant lesions (187.75kPA) was significantly higher than that of benign (46kPa) (P<0.001). Homogeneity of elasticity and color pattern were significantly different from malignancy and benign lesions (P<0.05). Sensitivity of US and SWE with US were 33.3% and 93.3% (P<
0.001, Kappa =0.069) and specificity of US and SWE with US were 94.5% and 96.4% (P=0.687, kappa=0.373).
Diagnostic accuracy was improved after adding SWE (21.4% to 86.4%). Using SWE with US, we could reduce benign biopsy rate from 100% to 16.4% (18/110) and 74.4 % (93/125) of category 4a lesions were downgraded to category 3.

BRS272
BRS273
CONCLUSION
For complex cystic breast lesions, SWE is able to increase in the accuracy and sensitivity in distinguishing benign from malignant lesions and to avoid unnecessary benign biopsy.
CLINICAL RELEVANCE/APPLICATION
The combination of US and SWE is useful in differential diagnosis of complex cystic breast lesions with reducing benign biopsy rate.
Management of Radial Scar/Radial Sclerosing Lesions Diagnosed on Image-guided Biopsy of the
Breast (Station #2)
Beatriu Reig MD, MPH (Presenter): Nothing to Disclose , Tova C. Koenigsberg MD : Nothing to Disclose ,
Sanjita Ravishankar MD : Nothing to Disclose , Susan Fineberg MD : Nothing to Disclose
PURPOSE
Radial scars and radial sclerosing lesions (RSL) of the breast are benign lesions that may present with mammographic distortion or may be incidentally identified on core needle biopsy. Patients with RSL on core biopsy usually undergo excisional biopsy due to the concern for undersampling of an associated malignancy.
There are conflicting data in the literature regarding the upgrade rate of radial scar found on core needle biopsy, with the upgrade to malignancy ranging from 0% to 40% of cases. We seek to expand on this literature with the largest case series to date that evaluates outcomes in patients with radial scar without atypia on core biopsy.
METHOD AND MATERIALS
The pathology database of breast core biopsy results was searched for words 'radial scar,' 'complex sclerosing lesion' or 'radial sclerosing lesion' for years 2003 through 2014. Inclusion criteria for this study were: (1) RSL diagnosed as the highest-grade lesion on imaging-guided core needle biopsy specimens; and (2) surgical excision, or, if excision was not recommended, two-year imaging or clinical follow without evidence of malignancy. Patients with any finding of malignancy or atypia (atypical ductal hyperplasia, atypical lobular hyperplasia, flat epithelial atypia, cytologic atypia or lobular carcinoma in situ) in the needle core biopsy specimen were excluded.
RESULTS
100 lesions in 100 patients met criteria for inclusion. Patients ranged in age from 25 to 89 years. 89 patients had surgical excision and 11 patients had imaging or clinical follow up for at least two years. Complete imaging information was available for 93 patients. Of these, 40 underwent stereotactic core needle biopsy, 50 underwent ultrasound-guided core biopsy, and 3 underwent MRI-guided core biopsy. In the 100 patients, there were two cases of upgrade to malignancy on the surgical excision specimen, both of which yielded low-grade
DCIS (spanning 3 mm and 1 cm in each case). There were no cases upgraded to invasive carcinoma.
CONCLUSION
The cancer upgrade rate of RSL is 2%, with two cases that were low grade DCIS. There were no upgrades to invasive carcinoma. This suggests that surgical excision could be obviated in RSL cases without atypia on imaging-guided core needle biopsy.
CLINICAL RELEVANCE/APPLICATION
Careful radiologic-pathologic correlation of benign findings and close imaging follow up may be a safe alternative to surgery in patients with RSL without atypia diagnosed on needle core biopsy.
Almost a Wonder: Ultrasound-guided Sclerosis with Alcohol in Breast Fistulas; A New Treatment
(Station #3)
Ana Maria Fernandez Martinez MD (Presenter): Nothing to Disclose , Laura Lopez : Nothing to Disclose ,
Iria Alvarez Silva : Nothing to Disclose , Jose Daniel Samper Wamba MD : Nothing to Disclose , Teresa
Cuesta : Nothing to Disclose
PURPOSE
Breast fistulas are defined as communication between one or more ducts and the skin. The disease affects young women and it is an insidious clinical pathology, usually with long evolution and with a major impact on daily life. The treatment has traditionally been surgical with a high rate of recurrence. We propose to study the clinical utility of ultrasound-guided sclerosis with alcohol as an alternative treatment to surgery in breast fistulas.
METHOD AND MATERIALS
A retrospective study based on data collected during 3 years, from January 2011 to December 2013. All breast fistulas diagnosed and treated with ultrasound-guided sclerosis with alcohol were reviewed. The technique of ultrasound-guided sclerosis with alcohol consists of introducing a solution of pure alcohol reduced to 50% with an anesthetic agent. The result of the percutaneous treatment was recorded as bad (partial response, secretion persists), good (partial response, low discharge) or excellent (complete response, absence of secretion, complete closure).

BRS274
BRS275
RESULTS
Ten fistulas were identified in nine women. The median age was 35 years old (interquartile range was 18.5
years). The median time for the clinical evolution of the disease was 24 months. In five patients, fistulas were caused by recurrent mastitis (50%), in four patients fistulas were attributed to previous surgery (40%) and in one case to breastfeeding (10%). Patients reported clinical exacerbation in winter (78%), symptoms associated with menstruation (33%) and symptoms associated with stressful situations (22%). Nipple inversion existed in
45% of the patients. 78% of patients were smokers. No immediate complications were noted. The procedure was well tolerated in most cases (9 out of 10 patients scored 1 or 2 on the visual analogue scale of pain).
During the follow-up time there has not been evidence of recurrence in any of them. The response to the treatment was excellent in eight fistulas (80%) and good in two of them (20%).
CONCLUSION
Ultrasound-guided sclerosis with alcohol is a therapeutic alternative to surgery that shows favorable clinical results in the treatment of breast fistulas.
CLINICAL RELEVANCE/APPLICATION
The biggest problem of fistulas breast is the high rate of recurrence after surgical treatment. We propose a new treatment, less aggressive, with favorable clinical results as a therapeutic alternative.
A Comparison of FFDM Screening Recall Rates Before and After the Addition of 2D/3D Digital Breast
Tomosynthesis: Is there a “trickle-down” Effect? (Station #4)
Nicole Nakyung Lee MD (Presenter): Nothing to Disclose , Tracy Frazee : Nothing to Disclose , Zhongze Li
: Nothing to Disclose , Steven P. Poplack MD : Research Grant, Hologic, Inc
PURPOSE
To determine if 2D (FFDM) screening recall rates have been impacted by the clinical implementation of 2D/3D digital breast tomosynthesis (DBT).
METHOD AND MATERIALS
Our institution initiated use of 2D/3D DBT as a screening modality in February 2012 in one of three screening mammography units. A retrospective review of screening mammography was performed for a two-year period before and after the introduction of tomosynthesis. Aggregate FFDM recall rates from February 2010-January
2012 were compared to aggregate FFDM recall rates from February 2012-January 2014 using a Chi-square test.
Both sets of recall rates (before vs after DBT) were stratified by density and a three dimensional analysis was performed using a Cochran-Mantel-Haenszel test.
RESULTS
A total of 24,384 FFDM screening mammograms were performed in the two years before implementation of
2D/3D DBT; 17,210 FFDM screening mammograms were performed in the two years after the addition of 2D/3D
DBT to the screening practice. The aggregate FFDM recall rate was significantly lower after implementation of
2D/3D DBT, decreasing from 8.75% to 7.76% (p=0.0003). When stratified by density, recall rates for each time period (before vs after, respectively), were: extremely dense 9.41% vs 9.47%; heterogeneously dense
10.64% vs 9.25%; scattered 8.49% vs 7.71%; fatty 4.67% vs 4.96%. The p-value from the
Cochran-Mantel-Haenszel test was 0.008.
CONCLUSION
The recall rate of FFDM may be positively influenced by the partial implementation of 2D/3D DBT in screening mammography. The etiology of this effect is unclear, but may be related to a learning curve from experience with 2D/3D DBT.
CLINICAL RELEVANCE/APPLICATION
Addition of 2D/3D DBT to clinical screening practice may indirectly result in a reduction of 2D (FFDM) screening recall rates, which would contribute further to the beneficial effect of DBT implementation in a breast cancer screening program.
Atypical Lobular Hyperplasia at MRI Guided Vacuum Assisted Biopsy: Is Surgery Necessary? (Station
#5)
Sandra Brennan MBBCh, MSc (Presenter): Nothing to Disclose , Manuela Durando : Nothing to Disclose ,
Adriana D. Corben MD : Nothing to Disclose , Elizabeth A. Morris MD : Nothing to Disclose
PURPOSE
To evaluate MRI characteristics and upgrade rate to cancer of atypical lobular hyperplasia (ALH) diagnosed at
MRI guided vacuum-assisted biopsy (MRI-VAB).
METHOD AND MATERIALS
A HIPAA compliant retrospective study was performed by collecting consecutive MRI-VABs yielding ALH between January 2003-December 2012. ALH was divided into 2 groups 1) pure ALH and 2) ALH associated with

BRS276
BRS277 other high risk lesions (atypical ductal hyperplasia (ADH), papilloma, radial scar or columnar cell changes)(noted
ALH/HR). Patients with incomplete data or with synchronous ipsilateral cancer were excluded. ALH that yielded cancer at surgery was defined as upgrade. Statistical analysis was performed (p<0.05) and 95% CI were calculated.
RESULTS
196 consecutive MRI-VABs yielded atypical lesions; 54/196 (27.6%) were ALH. 2/54 cases were excluded for incomplete data and 7/54 for synchronous ipsilateral cancer, leaving 43 patients with 45 ALH (mean size 11.7
mm; range: 3-40). 33/45 (73%) were pure ALH and 12/45 (27%) were ALH/HR (5/45 (11%) associated with
ADH. Patients (mean age 53 years; range: 34-72) were predominantly post-menopausal (51.2%), with previous history of breast cancer (41.9%) or high risk lesions (20.9%) and underwent MRI mostly for screening (69.8%).
No difference in size, T2 appearance or type of enhancement was noted between pure ALH and ALH/HR. Both pure ALH 24/33 (73%) and ALH/HR 8/12 (67%) showed predominantly progressive kinetics (p=0.95). Surgical excision was performed on 39/45 ALH lesions. The remaining 6/45 lesions underwent imaging follow-up (mean
20 months (range: 12-48)). Malignancy (low grade DCIS) was found in 1/39 (2.6%; CI 95%: 0.1-13.5%) undergoing biopsy or 1/45 (2.2%; CI 95%: 0.1-11.8%) of all cases. The single upgrade occurred in the ALH/HR group associated with ADH. No pure ALH lesions were upgraded at surgery.
CONCLUSION
ALH represented 27.6% of atypical lesions identified at MRI-guided VABs performed in our high risk population.
Upgrade rate to cancer of MRI-VABs yielding ALH was low (2.6% and 2.2%) and was found with ALH associated with ADH only. Pure ALH without associated atypia may not necessitate surgical removal.
CLINICAL RELEVANCE/APPLICATION
Upgrade rate to cancer of MRI-VABs yielding ALH was low (2.6% and 2.2%) in our study and was found with
ALH associated with ADH only, therefore pure ALH without associated atypia may not necessitate surgical removal.
Ultrasound Predicts Residual Disease in Triple Negative and ER+ Breast Cancer but not in HER2+
Breast Cancer (Station #6)
Rosalind Pitpitan Candelaria MD (Presenter): Nothing to Disclose , William Frazer Symmans MD :
Co-founder, Nuvera Biosciences, Inc Scientific Advisor, Nuvera Biosciences, Inc , Maheshwari Ramineni MD :
Nothing to Disclose , Wei Tse Yang MD : Researcher, Hologic, Inc
PURPOSE
The purpose of this study is to determine if ultrasound (US) tumor response measurements during neoadjuvant chemotherapy (NAC) predicts residual cancer burden (RCB), which is a significant predictor of distant relapse-free survival.
METHOD AND MATERIALS
Patients with primary invasive breast cancer, who had ultrasound performed before and after NAC, were included in this HIPAA-compliant retrospective study from a single institution. Patients were treated with paclitaxel followed by fluorouracil, doxorubicin and cyclophosphamide (FAC) or fluorouracil, epirubicin and cyclophosphamide (FEC). Human epidermal growth factor receptor 2 positive (HER2+) patients received concomitant trastuzumab. US measurements were obtained in three dimensions. All patients underwent mastectomy or segmentectomy and sentinel node biopsy or axillary node (AXLN) dissection. RCB was calculated based on area of primary tumor bed, overall cancer cellularity as percent (%) of area, % of in situ cancer, number of positive lymph nodes and diameter of largest metastasis. Regression analysis was performed for RCB versus % change in the following tumor measurements: 1) largest dimension, 2) bi-dimension and 3) volume.
RESULTS
160 breast cancer patients [69 triple receptor negative (TRN), 45 estrogen receptor positive (ER+) and 46
HER2+] were included. Median age at diagnosis was 50, range 30-76; median tumor size was 3.4 cm, range
0.9-10.4. 63% of patients were AXLN positive at diagnosis; 30% of this subset became node negative at surgery. TRN tumors showed 38% pCR (pathologic complete response), 9% RCB-I, 32% RCB-II and 22%
RCB-III; ER+ 11% pCR, 13% RCB-I, 58% RCB-II and 18% RCB-III; HER2+ 57% pCR, 15% RCB-I, 26%
RCB-II and 2% RCB-III. There were significant associations between RCB and % change in tumor largest dimension, bi-dimension and volume for TRN (p<0.001) and ER+ (p<0.05) but not in HER2+ breast cancer
(p>0.05).
CONCLUSION
US tumor response measurements are significant predictors of RCB in TNBC and ER+ but not in HER2+ breast cancers. This may contribute to the monitoring of TNBC and ER+ breast cancer response to targeted therapies and drug development.
CLINICAL RELEVANCE/APPLICATION
US has differential capacities of measuring tumor response based on molecular phenotype; alternate imaging is needed to adequately measure response of HER2+ tumors to better identify chemoresistance.
Stereotactic Biopsy of Segmental Breast Calcifications: Is Sampling of Anterior and Posterior

BRS277
BRE192
BRE176
Components Necessary? (Station #7)
Sean D. Raj MD (Presenter): Nothing to Disclose , Emily Lorraine Sedgwick MD : Nothing to Disclose ,
Frederick Joseph Severs MD, MS : Nothing to Disclose , Karla A. Sepulveda MD : Nothing to Disclose
PURPOSE
Pathology from biopsy of a large area of segmental calcifications on mammography can have direct impact on surgical management. Although dependent on breast size, cancer spanning greater than 5 cm is usually treated with mastectomy and cancer less than 5 cm is managed with lumpectomy. There is insufficient data on whether a single central biopsy of calcifications that assumes homogeneity of disease in the imaging abnormality is adequate to establish need for mastectomy, or if pathologic proven cancer in the anterior and posterior components defining extent of disease is required. This study aims to evaluate concordance rates of paired biopsies of suspicious segmental mammographic calcifications.
METHOD AND MATERIALS
From a 5 year review of our imaging database, 66 subjects with BI-RADS® 4 or 5 segmental calcifications on mammography that underwent anterior and posterior stereotactic biopsies were identified. The paired biopsy results were analyzed for concordance in benign, high risk and malignant pathology.
RESULTS
Of the 66 cases, there was strong agreement (Kappa=0.88, p<0.001) in anterior and posterior pairs in benign, high-risk and malignant findings with 92% concordance (61/66 cases; 95% CI=83-97%). In 3 cases of discordance involving high risk (ADH) and malignancy (DCIS), management did not change, as surgery was required at both sites. In 2 cases with discordant benign and high risk (few foci of ALH) management did not change as observation was performed rather than surgery.
CONCLUSION
The absence of data on pathologic concordance in anterior and posterior aspects of segmental calcifications has led to a varied clinical approach to biopsy. In our study, the sampling of 2 components of segmental calcifications spanning more than 5 cm on mammography yielded high concordance, and there was no change in surgical management in the discordant results. Although further prospective investigation is warranted, this data suggests that a single central biopsy of suspicious segmental calcifications would be adequate for diagnosis and representative of the whole imaging abnormality. This approach reduces potentially unnecessary biopsies, associated morbidity and health care costs.
CLINICAL RELEVANCE/APPLICATION
Greater than 90% concordance of pathology in biopsies of anterior and posterior aspects of segmental calcifications suggests a single central biopsy would be adequate to establish diagnosis of a large segmental mammographic abnormality.
Invasive Carcinoma of Special Subtypes: Rad-Path Correlation (Station #8)
Tomie Heldt Ichihara MD : Nothing to Disclose , Luciano F. Chala MD : Nothing to Disclose , Bruna Maria
Thompson MD (Presenter): Nothing to Disclose , Barbara Helou Bresciani MD : Nothing to Disclose , Nestor
Barros : Nothing to Disclose , Carlos Shimizu MD : Nothing to Disclose
TEACHING POINTS
To review WHO classification and molecular taxonomy of special subtypes invasive carcinomas To learn about imaging features particularities of special subtypes invasive carcinomas and their histological basis To identify differences and similarities in presentation of non special subtype and most common special subtypes of the invasive carcinoma
TABLE OF CONTENTS/OUTLINE
WHO classification of special subtype invasive carcinoma Associations between the molecular taxonomy of breast cancer and histological special types Frequency and epidemiology of special subtype invasive carcinoma
Case based review illustrating: Imaging features and histological basis of special type invasive carcinoma
Diferences and similarities in presentation of non special subtype and most common special subtypes of the invasive carcinoma Special type invasive carcinomas that can mimic benign lesion Conclusion
Breast Findings in Systemic Diseases: A Pictorial Review (Station #9)
Ivan Carrion MD (Presenter): Nothing to Disclose , Luis Martin MD : Nothing to Disclose , Luz Elena
Guerrero MD : Nothing to Disclose , Lina K. Rojas MD : Nothing to Disclose
TEACHING POINTS
The objective of this educational exhibit is making a pictorial review of systemic diseases with findings in mammography and US breast studies emphasizing in the differential diagnosis with malignant and benign specific breast pathology.
TABLE OF CONTENTS/OUTLINE
The exhibit will be presented in an electronic slide quiz format. Spectrum of systemic diseases with breast findings images with pathology images correlation will be exhibit and most important clinical features of each one and key differential diagnostic points will be highlighted in the discussion part. The exhibit will show the next cases: - Malignancies: o Metastases o Hematology malignancies - Cardiovascular: o Arterioesclerosis o
Vascular congestion (agenesia of ICV, compression of SVC,…) - Endocrinology diseases: o Diabethic mastopathy o Hyperparathyroidism - Inflamatory disease: o Granulomatous diseases. o Rheumatoid arthitis o Systemic

o Hyperparathyroidism - Inflamatory disease: o Granulomatous diseases. o Rheumatoid arthitis o Systemic lupus erythematosus o Scleroderma - Other entities: o Amyloidosis o Sarcoidosis o Collagen vascular disease o
Mondor disease o Poland syndrome - Infections diseases: o Widespread infections o Phylariasis
BRE006-b Imaging Features of Metastatic Lesions to the Breast: Pictorial Essay (hardcopy backboard)
Luciana Graziano MD : Nothing to Disclose , Almir Bitencourt MD (Presenter): Nothing to Disclose ,
Gislaine Cristina Lopes Machado Porto MD : Nothing to Disclose , Camila Guatelli : Nothing to Disclose ,
Juliana Alves Souza : Nothing to Disclose , Elvira Ferreira Marques : Nothing to Disclose , Mirian Rosalina
Brites Poli MD : Nothing to Disclose
TEACHING POINTS
The purpose of this exhibit is: 1. To review the incidence, epidemiology, diagnosis and treatment of metastatic lesions to the breast. 2. To present the imaging appearances of secondary breast tumors at mammography, ultrasound (US), magnetic resonance imaging (MRI), computed tomography (CT) and positron emission tomography (PET)/CT. 3. To evaluate the use of imaging methods, including PET/CT, on the staging and therapeutic evaluation of patients with metastatic lesions to the breast.
TABLE OF CONTENTS/OUTLINE
Metastatic lesions to the breast - Incidence - Epidemiology - Diagnosis - Treatment Imaging Features -
Mammography - Ultrasound - MRI - CT - PET/CT
Scientific Posters
GI
AMA PRA Category 1 Credits ™ : .50
Wed, Dec 3 12:15 PM - 12:45 PM Location: GI Community, Learning Center
Participants
Moderator
Jinxing Yu MD : Nothing to Disclose
Sub-Events
GIS366 Feasibility of Using MR Elastography to Differentiate Benign and Malignant Masses in Pancreas
(Station #1)
He An (Presenter): Nothing to Disclose , Yu Shi PhD : Nothing to Disclose , Qiyong Guo MD : Nothing to
Disclose
PURPOSE
Differential diagnosis of pancreatic masses remains as an important clinical challenge nowadays. Recently, we conducted a prospective study to assess the ability of MR Elastography (MRE) to evaluate the shear stiffness in patients with pancreatic benign and malignant masses. Hence, the purpose of this study was to evaluate the potential value of MRE in the characterization of pancreatic tumors.
METHOD AND MATERIALS
22 patients with pancreatic tumors and 10 healthy volunteers underwent 3.0T MRE exam using echo planar imaging (EPI) pulse sequence with low-frequency vibrations (40Hz) between December 2013 and March 2014.
The patients included 9 cases with pancreatic benign masses and 13 cases with pancreatic cancer (PC).Cyst
with pure liquid and lesion with diameter less than 1.5cm were excluded due to fail for algorithm or detection on elastogram. Except for 5 cases with PC proven by extra-pancreatic metastasis, all the other cases were proven by surgery and pathology. Of the 9 benign cases, 5 were diagnosed with mass-forming pancreatitis
(MFP), 2 with cystadenoma, 1 with islet cell adenoma and 1 with pancreatic lipoma. Of the 13 malignant cases, all were diagnosed with Pancreatic Ductal Adenocarcinoma (PDAC).Stiffness was calculated with a 3D direct inversion algorithm. Statistical analysis was performed on the stiffness values for differentiation of normal pancreas, benign tumors and malignant tumors.
RESULTS
Malignant liver tumors had significantly greater mean shear stiffness than both benign tumors (2.04±0.52kPa
vs 1.19±0.24kPa,p=0.038) and normal pancreas (2.04±0.52kPa vs 1.21 ±0.08kPa,p=0.001). Benign tumors had similar stiffness values to normal pancreas (1.19±0.24kPa vs 1.21 ±0.08kPa,P=0.07).Within the benign lesions, the MFP had a little greater stiffness than other types of tumors (1.22~1.47kPa vs.
0.67~1.14kPa,P=0.025).
CONCLUSION
MR Elastography has the unique ability to define benign/healthy pancreas and malignant masses. A hallmark of
PDAC is the presence of 'desmoplasia', a process in which massive fibrous tissue infiltrates and envelops neoplasm, which might contribute the tumor much harder than the healthy pancreatic tissues. Different types of benign tumors might have varied stiffness due to their diverse mechanical properties.
CLINICAL RELEVANCE/APPLICATION

GIS368
GIS369
MR Elastography has the unique ability to define benign/healthy pancreas and malignant tumors and is recommended for the diagnosis of pancreatic masses in clinic.
Feasibility of Volumetric Contrast-Enhanced US and Tumor Volume Measurement Using 3D
Transducer in Therapeutic Response Evaluation after Targeted Therapy in Rabbit Hepatic VX2
Carcinoma Comparison with 2D-CEUS (Station #3)
Jung Hoon Kim MD (Presenter): Nothing to Disclose , Jeehyun Kim : Nothing to Disclose , Hyo Won Eun
MD, PhD : Nothing to Disclose , Joon Koo Han MD : Nothing to Disclose , Byung Ihn Choi MD, PhD :
Research Consultant, Samsung Electronics Co Ltd
PURPOSE
Tumor size and vascularity are most important parameters for therapeutic response evaluation. This study is to assess the feasibility of tumor volume measurement and volumetric contrast-enhanced US using 3D transducer in therapeutic response evaluation after treatment in VX2 rabbit hepatic tumor comparison with 2D-CEUS.
METHOD AND MATERIALS
Rabbit hepatic VX2 carcinoma with targeted therapy(n=22, 30mg/kg/day of Sorafenib for 7-day) and control group(n=13) were performed CEUS using 2D(12MHz, PLT-1204MV) and 3D transducer(12MHz, PLT-1204BT) baseline and one day after first treatment. Three different tumor volumes(calculated volume from 2D US;
2D-Vol, 3D volume identified on non-contrast US; 3D-Vol, 3D volume identified on CEUS; e3D-Vol) and seven
US perfusion parameters were obtained. Tumor volume using MDCT as a reference standard, we compared the change of each different tumor volumes. Therapeutic efficacy was estimated using necrotic fraction, MVD, and apoptosis of tumor after treatment. Correlation between tumor volume and US perfusion parameters was analyzed.
RESULTS
According to pathology, there were significant different between baseline and after treatment. Tumor volume showed no statistical difference between baseline and one day after first treatment(299.9 ±140.6 vs 283.7
±118.1, mm3, p=.108), however, in treatment group, both 3D and 2D US perfusion parameters, including peak intensity(33.2±19.9 vs 16.6±10.7, 63.7±20.0 vs 30.1±19.8), slope(15.3±12.4 vs 5.7±4.5, 37.3±20.4 vs
15.7±13.0), AUC(1004.1±560.3 vs 611.4±421.1, 1332.2±708.3 vs 670.4±388.3), had significantly decreased one day following first treatment(p=.00). e3D-Vol showed no statistical difference comparison with tumor volume using MDCT(299.9± 140.6mm3 vs 283.7±118.1, p= .108), however 2D-Vol(1933.7±1250.4, p= .00) and 3D-Vol(236.8±118.0, p=.00) had significant difference comparison with tumor volume using MDCT.
CONCLUSION
CEUS using 3D transducer was useful for predicting early therapeutic response one day after targeted therapy using US perfusion parameters. In addition to, CEUS using 3D transducer is accurately measure the tumor volume.
CLINICAL RELEVANCE/APPLICATION
CEUS using 3D transducer is feasible to predict therapeutic response evaluation after targeted therapy because it is not only useful for perfusion evaluation but also accurate tumor volume measurement.
The Application Value of the CT Perfusion Imaging in the Diagnosis of Autoimmune Pancreatitis
(Station #4)
Huiping Shi MD (Presenter): Nothing to Disclose , Xiaoxuan Ma : Nothing to Disclose , Minxia Qiao :
Nothing to Disclose , Fan Yang : Nothing to Disclose , Shibo Dong : Nothing to Disclose
PURPOSE
To investigate the application value of the whole pancreas CTperfusion imaging in the diagnosis of autoimmune pancreatitis (AIP) and the differential diagnosis between the AIP and pancreatic carcinoma.
METHOD AND MATERIALS
Seven cases of autoimmune pancreatitis and 8 pancreatic carcinoma underwent the whole pancreas perfusion
CT imaging. The 18-gauge intravenous needle was placed into right antecubital vein and contrast medium
Ultravist 40 ml(370 mg iodine/ml,6ml/s)was injected following normal saline 30 ml at the same speed.
Perfusion scan and injection started at the same time. Total acquisition time lasted for 60s with 19 times volume CT scan and 6080 pictures. The CT findings and perfusion parameters of all cases were analysed and compared,such as,diffuse enlargement/focal lesion of pancreas,pancreatic duct changes such as its' stricture, expansion or truncation,adjacent blood vessels involvement, the features of the time-density curve, characteristics of the perfusion pseudo-color pictures and perfusion parameters,other autoimmune diseases manifeastion.
RESULTS
In 7 AIP cases, the lesions in 5 located at the head of the pancreas,2 body and tail, and 5 accompanied with pancreatic duct dilatation, 4 extrahepatic bile duct dilation, one ulcerative colitis. No blood vessels invasion was found in all cases. In 8 cases of pancreatic carcinoma,3 located at the pancreatic head,5 the body and tail, and
4 accompanied with dilation of pancreatic duct, 6 adjacent vascular invasion, and 2 extraheptic bile duct dilatation. Time-density curve analysis showed the enhancement pattern of AIP was similar to that of the normal pancreatic tissue, but the degree of the enhancement was significantly reduced. The shape of the time-density

GIS371
GIS372 pancreatic tissue, but the degree of the enhancement was significantly reduced. The shape of the time-density curve had a significantly difference between pancreatic carcinoma and the normal pancreatic tissue in which the former demonstrated a much lower enhancement pattern than the letter. The mean AF value had a stistically significant difference(p<0.05) between AIP and pancreatic carcinoma (82.6 vs 69.7ml/min/100ml) in statistical analysis of Variance.
CONCLUSION
As a supplement method of routine CT examination, CT perfusion imaging could demonstrate characteristics of
AIP, and would play an important role in the diagnosis and differential diagnosis of AIP.
CLINICAL RELEVANCE/APPLICATION
CT perfusion can demonstrate the blood supply features of the pancreas disease and helpful for the diagnosis of autoimmune pancreatitis.
Pre-operative Staging of the CT Colonography for Patients with Colorectal Cancer: Effect of Low
Tube Voltage and Iterative Reconstruction (Station #6)
Sadahiro Yamamura (Presenter): Nothing to Disclose , Masanori Imuta MD : Nothing to Disclose , Seitaro
Oda MD : Nothing to Disclose , Daisuke Utsunomiya MD : Nothing to Disclose , Yasuyuki Yamashita MD :
Consultant, DAIICHI SANKYO Group
PURPOSE
The purpose of our study was to assess the accuracy of the pre-operative staging of the CT colonography (CTC) in patients with colorectal cancer with decreasing in tube voltage from 120- to 100-kVp with iterative reconstruction (IR).
METHOD AND MATERIALS
Scanning was performed with 24 consecutive patients who had a diagnosis of colorectal carcinoma in the supine
(120-kVp with FBP) and prone (100-kVp with IR) positions, with other parameters unchanged. Two readers visually assessed image quality and the k coefficients were calculated for interobserver agreement. The average image quality ratings were compared using the Wilcoxon signed rank test. We also evaluated the accuracy of the CTC for staging colorectal cancer in both 120-kVp with FBP and 100-kVp with IR.
RESULTS
No significant differences were found in the visual score for the image quality between 120-kVp with FBP and
100-kVp with IR. The interobserver agreement was substantial. CTC with a 100-kVp with IR algorithm identified all the carcinomas and had an overall accuracy of 85%, 64% and 100% for the evaluation of tumor depth, lymph nodes and metastases respectively, and CTC with a 100-kVp with FBP algorithm had an overall accuracy of 81%, 62% and 100%. No significant differences were found in the accuracy of the staging between 120-kVp with FBP and 100-kVp with IR.
CONCLUSION
CTC with a 100-kVp with IR algorithm proved useful for the pre-operative evaluation of patients with a diagnosis of colorectal carcinoma with substantial radiation dose redcution.
CLINICAL RELEVANCE/APPLICATION
CTC with a 100-kVp with IR algorithm proved useful for the pre-operative evaluation of patients with a diagnosis of colorectal carcinoma with substantial radiation dose redcution.
Radio-pathological Correlation in HCC Treated by Transarterial Chemoembolisation: Comparison between RECIST, mRECIST and EASL Criteria (Station #7)
Maxime Ronot MD (Presenter): Nothing to Disclose , Marco Dioguardi Burgio MD : Nothing to Disclose ,
Onorina Bruno MD : Nothing to Disclose , Claire Francoz : Nothing to Disclose , Valerie Paradis MD :
Nothing to Disclose , Francois Durand : Nothing to Disclose , Laurent Castera : Nothing to Disclose ,
Valerie Vilgrain MD : Nothing to Disclose
PURPOSE
To compare the diagnostic performance of RECIST1.1, mRECIST, and EASL criteria for assessing tumor necrosis in a consecutive series of patients treated with transarterial chemoembolisation (TACE) before liver transplantation (LT) for hepatocellular carcinoma (HCC).
METHOD AND MATERIALS
Between 2006 and 2012, all patients treated with at least one session of TACE before LT for HCC were included.
Response to treatment was evaluated by two independent readers on the last MDCT before LT according to
RECIST1.1, mRECIST, and EASL criteria. Tumor response on imaging was compared to the tumor necrosis assessed on pathologic examination of the liver explant. Major necrosis was defined as the presence of more than 90% of necrosis. Necrosis between 50-90% and < 50% were defined as intermediate and minor necrosis, respectively. Inter-reader agreement for the tumor response was evaluated by the kappa statistic. Factors

GIS373
GIE251 associated with a major (>90%) necrosis were tested by multivariate analysis.
RESULTS
58 patients with 88 HCC treated with 94 TACE sessions (53 male (91%) were included. Before TACE, patients had a mean 1.6 (range 1-4)of HCC with a mean 25mm diameter (range 10-80 mm). HCC was unique in 30 patients (52%). All HCCs were hypervascular on arterial phase MDCT acquisition. 51 nodules (58%) showed major necrosis. Among them, lesions were classified as complete response according to RECIST1.1, mRECIST and EASL in 2 (4%), 47 (92%) and 47(92%) for reader 1, respectively, and 1 (2%), 45 (88%) and 45 (88%) for reader 2, respectively. Despite similar performances with mRECIST and EASL, only mRECIST was correlated with major necrosis on multivariate analysis for both readers (p<0.0001). Inter-observer agreement was substantial for RECIST1.1 (k=0.65 +/- 0.08), mRECIST (k=0.78+/-0.07), and EASL (k=0.75+/-0.07).
CONCLUSION mRECIST and EASL criteria showed better correlation with major tumor necrosis than RECIST1.1. mRECIST showed better correlation with tumoral major necrosis and should be used to evaluate response to TACE.
CLINICAL RELEVANCE/APPLICATION
Patients with HCC treated by TACE should be evaluated with mRECIST criteria.
Barium Swallow Is Insensitive in Diagnosing Clinically Significant Anastomotic Leaks Following
Esophagectomy (Station #8)
Simon Roh MD (Presenter): Nothing to Disclose , Mark Iannettoni MD : Nothing to Disclose , John Keech
MD : Nothing to Disclose , Peter Gruber MD, PhD : Nothing to Disclose , Kalpaj Parekh MBBS : Nothing to
Disclose
PURPOSE
The standard of practice following esophagectomy is to evaluate the anastomosis by a barium swallow for detection of leaks. The aim of this study was to evaluate the reliability of the barium swallow study compared to clinical evaluation in diagnosing anastomotic leaks following esophagectomy.
METHOD AND MATERIALS
We studied all consecutive patients with either transhiatal or transthoracic esophagectomy between January
2000 and December 2013 at our institution. Patients were evaluated for anastomotic leak by routine barium swallow study on post-op day 5. These results were compared to clinically determined leaks (defined by neck wound infection requiring jejunal feeds and or parenteral nutrition) during the postoperative period. The sensitivity and specificity of barium swallow in diagnosing clinically significant anastomotic leaks was determined.
RESULTS
A total of 382 esophagectomies were performed [mean age 62.1 (21-88) years], [malignancy (n=313), high grade dysplasia (n=15), benign stricture/perforation (n=35), and other (n=19)]. A variety of techniques were used including transhiatal (n=341), McKeown (n=34), and Ivor Lewis (n=7) esophagectomies. Operative mortality was 2.9% (n=11). 356 patients (93%) underwent barium swallow study after esophagectomy [mean postoperative day 6.4 (3-75)]. Clinically significant anastomotic leak was identified in 32 (9.0%) patients
[malignancy 84% (n=27), high grade dysplasia 13% (n=4), benign stricture/perforation 3% (n=1)]. The sensitivity of the swallow in diagnosing a leak was 35% and specificity was 98%. The positive and negative predictive values of barium swallow study in detecting leaks were 58% and 94%, respectively.
CONCLUSION
Barium swallow is an insensitive but specific test for detecting leaks at the cervical anastomotic site after esophagectomy.
CLINICAL RELEVANCE/APPLICATION
Our practice has evolved to resume oral intake two weeks after the surgery even in the case barium swallow is negative for a leak.
Fluoroscoping Esophageal Trauma (Station #10)
Merav Galper BA, MD (Presenter): Nothing to Disclose , Christopher D'Arcy Scheirey MD : Nothing to
Disclose , Francis Joseph Scholz MD : Owner, FSpoon Company
TEACHING POINTS
1) Prompt recognition of esophageal injury is critical for clinical management 2) Suspected esophageal trauma producing dysphagia warrants urgent fluoroscopic examination 3) Special techniques must be employed for optimal visualization of injuries 4) Fluoroscopic staging of esophageal trauma differs from the AAST and other esophageal injury scales and is based on degree of mural damage
TABLE OF CONTENTS/OUTLINE

GIE124
GIE315
GIE025-b
1) Background of esophageal trauma 2) Perforation etiologies a. Instrumentation b. Ingestion/vomiting c.
Fragile mucosa (e.g. bullous dermatoses, eosinophilic esophagitis) d. Radiation stricture e. Caustic agents 3)
When/Why fluoroscopy? a. Signs and symptoms: odynophagia, neck crepitus, abnormal breath sounds b.
Symptomatic: fluoroscopy is best first test for subtle injuries and staging c. Critically ill: CT and/or surgery d.
Pneumomediastinum without odynophagia: no benefit from esophagography; Macklin effect is discussed 4)
Technique a. Water-soluble, 90 cc, 4/s AP pharynx; 1/s AP esophagus b. If negative: barium Pharynx: 4/s AP,
Lateral Esophagus: 1/s, upright AP, LAO and prone LPO 5) Esophageal Trauma Staging a. Mucosal - "Taco
Tear," Mallory-Weiss Syndrome b. Intramural - "Esophageal tear drop" sign c. Transmural - Boerhaave
Syndrome d. Intramural Hematoma - "Ribbon" sign
“Biliary Diseases with Pancreatic Counterparts”: Evolving Concepts in Pathogenesis and
Cross-sectional Imaging Findings (Station #11)
Venkata S. Katabathina MD (Presenter): Nothing to Disclose , Erin Flaherty MD : Nothing to Disclose ,
Nicole Riddle MD : Nothing to Disclose , Anil Kumar Dasyam MD : Nothing to Disclose , Narayan Lath :
Nothing to Disclose , Srinivasa R. Prasad MD : Nothing to Disclose
TEACHING POINTS
Review anatomy and embryology of biliary tract with emphasis on peribiliary glands List select inflammatory and neoplastic diseases of biliary tract that have pancreatic counterparts Discuss evolving concepts regarding pathogenesis along with molecular and cytogenetic abnormalities Describe CT/MRI findings and role of imaging in diagnosis and management
TABLE OF CONTENTS/OUTLINE
Introduction Anatomy and development of biliary tract Inflammatory diseases: IgG4 sclerosing cholangitis-autoimmune pancreatitis; primary sclerosing cholangitis-idiopathic duct centric chronic pancreatitis
Neoplasms: Cholangiocarcinoma-pancreatic adenocarcinoma; Intraductal papillary mucinous neoplasm of bile duct (IPMN-B)- IPMN of pancreas (IPMN-P); Biliary mucinous cystic neoplasm (MCN) and IPMN-B with cystic change-pancreatic MCN and IPMN-P with cystic changes Recent advances in pathogenesis, molecular biology and cytogenetics Conclusion Biliary tract and pancreas develop from endoderm, peribiliary glands demonstrate remnants of pancreatic tissue. Select biliary pathologies show similar pathogenesis and imaging findings to their pancreatic counterparts; this has lead to proposal of a new disease concept 'biliary diseases with pancreatic counterparts'. This unified concept will assist in understanding pathogenesis of pancreatico-biliary diseases and developing novel therapeutic strategies.
MR Enterography: Application in Non-Inflammatory Diseases of the Gastrointestinal Tract (Station
#12)
Stephanie Soriano MD (Presenter): Nothing to Disclose , Raj Mohan Paspulati MD : Research grant from
Philips Healthcare
TEACHING POINTS
• With the greater demand, the radiologist should be familiar with the proper technique, applications, and imaging features of MR enterography. • MR provides improved tissue contrast, greater transmural and extramural detail, and function information, facilitating diagnosis of non-inflammatory small bowel disease.
TABLE OF CONTENTS/OUTLINE
Imaging modalities available for the evaluation of small bowel disease Rationale for the use of MR enterography for evaluation of noninflammatory bowel disease Lack of ionizing radiation Improved tissue contrast
Visualization of the entire bowel Greater endoluminal, mural, and extramural enteric detail Functional information
The POEM Procedure (Peroral Endoscopic Myotomy): Current Role and Experience, Imaging
Findings, and Potential Complications (hardcopy backboard)
Stavros Stavropoulos : Nothing to Disclose , Rani J. Modayil MD : Nothing to Disclose , Sharon Taylor MD
: Nothing to Disclose , Ahmed Fadl MD : Nothing to Disclose , Nikhil K. Jain MD, MBA : Nothing to Disclose
, Douglas S. Katz MD (Presenter): Nothing to Disclose , Mariam Moshiri MD : Consultant, Reed Elsevier
Author, Reed Elsevier , Galina Levin MD : Nothing to Disclose , Sushma Gaddam BS : Nothing to Disclose
TEACHING POINTS
First described in Japan in 2008, and then first performed in the United States in 2009, the POEM procedure
(peroral endoscopic myotomy) is a 'miminally invasive' approach to replace the Heller myotomy for achalasia and other related disorders, where conservative management has failed or is not indicated. A form of NOTES, the POEM is performed via endoscopic access to the gastroesophageal junction, via a submucosal tunnel approach, which allows rapid secure closure with clips placed at the mucosotomy site. POEM is now used at multiple centers with similar outcomes to date as with surgical myotomy. The purpose of this exhibit is therefore to review the world-wide experience, as well as our extensive institutional experience; to demonstrate the expected and unexpected imaging findings following POEM; to explain the procedure and its indications and contra-indications; and to review the relevant current clinical and limited imaging literature.
TABLE OF CONTENTS/OUTLINE
- Indications, contra-indications, and current status/role of POEM - What the endoscopist needs to know from the radiologist before and after the POEM procedure - Expected and unexpected imaging findings before and after the procedure (radiography, fluoroscopy, and CT) - Outcomes/review of the literature - Early and late potential adverse events: recognition and management

Scientific Posters
MK
AMA PRA Category 1 Credits ™ : .50
Wed, Dec 3 12:15 PM - 12:45 PM Location: MK Community, Learning Center
Participants
Moderator
Jenny T. Bencardino MD : Nothing to Disclose
Sub-Events
MKS379 Imaging and Clinical Features of Lesions Suspicious for Malignant Transformation in
Neurofibromatosis Type 1 (NF1) Associated Plexiform Neurofibromas (PNs) (Station #1)
Srivandana Akshintala MBBS, MPH : Nothing to Disclose , Sucharita Bhaumik MD : Nothing to Disclose ,
Aradhana Mukherjea Venkatesan MD : Institutional research agreement, Koninklijke Philips NV , Andrea
Baldwin : Nothing to Disclose , Seth M. Steinberg PhD : Nothing to Disclose , Eva Dombi (Presenter):
Nothing to Disclose , David Liewehr : Nothing to Disclose , James Reynolds : Nothing to Disclose , Markku
Miettinen : Nothing to Disclose , Brigitte Widemann : Nothing to Disclose
PURPOSE
Malignant Peripheral Nerve Sheath Tumors (MPNSTs) in NF1 often arise in preexisting PNs. Neurofibromas with histologic atypia (atypical neurofibromas or ANFs) have been described as potential precursors for MPNSTs. Our goal is to identify precursors for MPNSTs based on MRI and FDG-PET imaging and tumor growth characteristics.
METHOD AND MATERIALS
Patients with NF1 and PN were followed longitudinally with MRI using volumetric analysis of tumor burden
(MEDx v3.44), and underwent FDG-PET when clinically indicated. Nodular lesions within or outside a PN defined as well-demarcated encapsulated lesions > 3 cm lacking a central dot sign on MRI and often associated with
FDG avidity were considered suspicious for malignancy. Growth rate (% change in tumor volume per year) was calculated for nodular lesions and PNs. Histology from either biopsy or resection of nodular lesions was obtained in a subset of patients.
RESULTS
Of 140 patients followed, 56 had suspicious nodular lesions. Tumor growth rates based on ≥1 year of follow up
(median follow-up 2.3 yrs; range 1-11.5) with no PN-directed treatment during this interval could be calculated for 73 PNs and 29 nodular lesions from a total of 68 patients (41 male). The median age at the start of growth rate analysis was 8.9 yrs (range 0.7 to 40.2) for PNs and 18.9 yrs (range 8.1 to 45.3) for nodular lesions. The median growth rate was 13% per year (range -14 to 247) for PNs and 22% per year (range -10 to 273) for nodular lesions. In PNs, the highest growth rates were observed in young patients but no age relationship was noted for nodular lesions. Histology was obtained in 20 nodular lesions from 15 patients. 9 were benign, 10 ANF and 1 MPNST. One patient with ANF developed a high grade MPNST after 10 years of observation.
CONCLUSION
ANFs and MPNSTs may be identified based on MRI findings and FDG-PET avidity. Nodular lesions appear to develop at a later age compared to PNs, and growth rates are independent of patient age. We are evaluating additional imaging modalities (MRI diffusion weighted imaging, MR perfusion and 18Fluoro-thymidine PET), which may have further utility in identifying malignant transformation in NF1 PNs.
CLINICAL RELEVANCE/APPLICATION
MPNSTs are highly malignant sarcomas that require complete surgical removal for cure. Identification of precursor lesions for MPNST on imaging will facilitate successful treatment.
MKS380 Histogram Analysis of Iodine Maps from Dual Energy CT: Evaluation of an Objective Response
Criterion for Monitoring Targeted Therapy of Melanoma Patients (Station #2)
Monika Uhrig MD, DIPLPHYS (Presenter): Nothing to Disclose , David Simons MD : Nothing to Disclose ,
Marika Ganten MD : Nothing to Disclose , Jessica Hassel : Nothing to Disclose , Heinz-Peter Schlemmer
MD : Nothing to Disclose
PURPOSE
Radiologic monitoring of molecular targeted therapy is essential. Routine CT-follow only focuses on the quantification of tumor size changes, a method which is known to be limited. Contrast-enhanced dual energy CT
(DECT) enables additionally within one single examination quantitative assessment of contrast media uptake of tumors. Our purpose was to investigate patterns of contrast media enhancement under targeted therapy by performing histogram analyses (HA) of iodine maps based on DECT.
METHOD AND MATERIALS
11 stage IV-melanoma patients underwent DECT at baseline, follow up (FU) 1 and FU 2. Volume segmentation of 28 metastases was performed semi-automatically. Iodine uptake (IU) and HA including standard deviation

MKS383
MKS381
(STD), maximum (max) and mean of 8 RECIST-responders (4 male, 4 female, mean age 63) to BRAF-inhibitor
(BRAF-I) therapy was investigated. Furthermore one mixed responder to BRAF-inhibitor as well as two patients under ipilimumab (IPI)-therapy (1 responder, 1 non-responder) are presented.
RESULTS
In general, histograms of responder reveal a characteristic pattern including narrower shape and means moving towards origin. For BRAF-responder mean, max and STD of the iodine histograms decrease significantly (p
CONCLUSION
HA of iodine maps based on DECT revealed a typical pattern of contrast media enhancement. It has potential to add an objective and functional criterion to traditional size measurements of standard CT examinations without additional radiation exposure to the patient. DECT can therefore contribute to accurate response assessment of targeted therapies in clinical routine.
CLINICAL RELEVANCE/APPLICATION
DECT enables quantification and histogram analysis of contrast media which allows for accurate response assessment of targeted therapy in order to avoid potential toxicity and escalating costs.
National Trends in the Management of Outpatients with Non-traumatic Knee Symptoms Over a
Decade (Station #3)
Patricia Silveira MD (Presenter): Nothing to Disclose , Ivan Ip MD, MPH : Nothing to Disclose , Michael J.
Healey MD : Nothing to Disclose , Elizabeth G. Matzkin MD : Nothing to Disclose , Stacy Elaine Smith MD :
Nothing to Disclose , Ramin Khorasani MD : Consultant, Medicalis Corp
PURPOSE
To examine trends in the management of outpatients with nontraumatic knee symptoms from January 2001 to
December 2010.
METHOD AND MATERIALS
Design: Retrospective study using nationally representative data from the National Ambulatory Medical Care
Survey and the National Hospital Ambulatory Medical Care Survey.
Setting and Participants: All adult outpatients presenting with nontraumatic knee symptoms from January 2001 to December 2010.
Main Outcome Measures: Number of clinic visits, radiographs, computed tomography (CT) and magnetic resonance imaging (MRI) utilization rates, pain medication prescription, and referral to other physician or physical therapy.
Statistical analysis: Linear and logistic regressions were performed. Multiple variable regression was conducted to control for confounders.
RESULTS
We identified 7847 patient-visits with nontraumatic knee symptoms, which are a representative sample of an estimated 172 million outpatient visits in the United States over the study period. The average age of patients was 57.5 years; 64.3% female. The proportion of pre- and post-operative visits did not change over time.
Radiograph utilization remained stable at approximately 28%, while CT and MRI utilization increased from 5% in 2001 to 8.3% in 2010 (p<0.001). Non-steroidal anti-inflammatory drugs and acetaminophen use decreased from 35.3% in 2001 to 30.6% in 2010 (p=0.001), while narcotic use increased from 5.2% to 15.2%
(p<0.001). Physical therapy and other physician referral rates increased from 5.7% in 2001 to 14.1% to 2010
(p<0.001) and from 9.7% in 2001 to 15.9% to 2010 (p<0.001), respectively.
CONCLUSION
While the proportion of pre- and post-operative visits and radiograph utilization remained stable, advanced imaging increased over 60%, and referral rates to physical therapy and other physicians increased 147% and
64%, respectively. The largest increase was in narcotic use - nearly 3-fold over the decade. These findings suggest an emerging need for evidence-based guidelines regarding the use of advanced imaging and narcotic prescription for patients presenting with knee symptoms, which could reduce costs, radiation exposure, and overdose rates, and improve quality of care.
CLINICAL RELEVANCE/APPLICATION
This is the first nationally representative study of ambulatory patients presenting with knee-related symptoms, the most common musculoskeletal reason for US ambulatory visits in 2009 and 2010.
Reading of the Sacroiliac Joints on Plain Radiographs in Undifferentiated Spondyloarthropathies:
Agreement between Local Reading and Trained Central Reading in a Cohort of 708 Patients (Station
#4)
Rosaline Van Den Berg MSc : Nothing to Disclose , Gregory Lenczner MD : Nothing to Disclose , Antoine A.
Feydy MD (Presenter): Nothing to Disclose , Desiree M. F. M. Van Der Heijde MD, PhD : Nothing to Disclose
, Monique Reijnierse MD : Nothing to Disclose , Alain Saraux : Nothing to Disclose , Pascal Claudepierre :
Nothing to Disclose
PURPOSE
In daily practice, local radiologists/rheumatologist judge sacroiliac joints on X-rays (X-SI), while in cohorts the

MKS382
MKE263 scoring is done by trained readers. Our aim was to compare the local scores to centralized scores.
METHOD AND MATERIALS
Patients with back pain from the 25 participating centers were included in the DESIR cohort (n=708). Baseline
X-SIs were scored by the local reader, according to a scoring method derived from the modified New York
(mNY) criteria1 (local score). Grade 2 and 3 from the original mNY were pooled together in one combined grade 'DESIR-2'. Sacroiliitis was defined by at least unilateral grade ≥DESIR-2. In addition, two centralized readers independently scored all X-SIs according to the original mNY criteria. In case of disagreement, a radiologist experienced in SpA imaging served as adjudicator. An X-SI was marked positive for sacroiliitis if 2/3 readers agreed on bilateral ≥mNY-2 or unilateral ≥mNY-3.
RESULTS
Inter-reader agreement between the two centralized readers was moderate (Kappa 0.54), while percentage agreement (84.3%) was good. However, the adjudicator needed to score 108/689 (15.7%) X-SIs because of disagreement among the two centralized readers. Overall, more radiographs were scored positive by the local readers (n=184) than by the centralised readers (n=145). In 77 patients, the X-SI was scored positive by the local reader but negative by the centralized readers.
CONCLUSION
Agreement between the centralized score and local score, also the inter-reader agreement between the two centralized readers, was moderate. The role of X-SI as diagnostic criterion for axial SpA should be re-evaluated.
CLINICAL RELEVANCE/APPLICATION
The role of X-Ray of SI Joints as diagnostic criterion for radiographic axial SpA should be re-evaluated.
Osteoarthritis of the Knee Treated with Intra-articular Hyaluronic Acid (HA) and Platelet-rich Plasma
(PRP) Injection: Clinical, Functional and MRI Evaluation of 1 year Follow-up (Station #5)
Alice La Marra MD (Presenter): Nothing to Disclose , Silvia Mariani MD : Nothing to Disclose , Andrea
Mancini MD : Nothing to Disclose , Luigi Zugaro : Nothing to Disclose , Antonio Barile MD : Nothing to
Disclose , Carlo Masciocchi MD : Nothing to Disclose
PURPOSE
To compare long-term results of PRP and HA intra-articular therapy, in patients with osteoarthritis of the knee.
METHOD AND MATERIALS
On the basis of clinical and radiological diagnosis of OA of the knee we selected 223 patients treated in our department with intra-articular injection of HA (105 pts: Group A) and PRP (118 pts: Group B). Exclusion criteria were rheumatic and /or hematology diseases. All patients were submitted to MRI before and 1 year after infiltrative treatment. To homogenize the results we divided the patients into 2 subgroups on the basis of the age and gender: group Aa (70 pts aged between 62/81; 36 males and 34 females) and Ab (35 pts aged between 36/61; 19 males and 16 females). Group Ba (38 pts aged between 62/81; 20 males and 18 females) and Bb (80 pts aged between 37/61; 42 males and 38 females ). In all patients clinical (VAS 0-10) and functional (WOMAC 0-240) evaluations were performed, before and 1 year after treatment. We created an imaging scale ranging from a minimum of 0 to a maximum score of 11, on the basis of the distribution of the joint effusion (articular recesses, periarticular bursae), the side of the chondral damage (medial and lateral compartments, patello-femoral compartment), and the presence or not of subchondral edema .
RESULTS
Statistically significant age-related differences were observed in our study. Group Aa: MRI showed an improvement of about 60% (10 pre-treatment and 4 after treatment; P < 0.01), with VAS improvement of about 40% and Womac of about 65%; Group Ab: MRI showed an improvement of about 29% (7 pre-treatment and 5 after treatment; P< 0.01) with VAS improvement of about 52% and Womac of about 42%. Group Ba:
MRI showed an improvement of about 30% ( 10 pre-treatment and 7 after treatment; P
CONCLUSION
Our result show improvements in symptomatology, function, and imaging in all patients, with better results in young pts treated with PRP (37-61 years) and in older pts treated with HA (62-82).
CLINICAL RELEVANCE/APPLICATION
Our study shows that in cases of OA, MRI can be a valid technique both to document the improvement of the patients after infiltrative treatment and to plan their subsequent management.
Disco Inferno: A Rapid Review of Lumbar Discography (Station #6)
Jordan Gold MD (Presenter): Nothing to Disclose , Kristen Elizabeth McClure MD : Nothing to Disclose ,
Adam C. Zoga MD : Nothing to Disclose , Christopher Geordie Roth MD : Author, Reed Elsevier
TEACHING POINTS
The purpose of this exhibit is: 1. Review the indications for lumbar discography, including using MRIgadolinium based discography. 2. Review technique and interpretation of CT and MR discography, including potential pitfalls. 3. Review potential complications related to CT and MR discography. 4. Discuss potential benefit of MR Discography compared with conventional CT-discography.

MKE111
MKE119
MKE287
MKE320
TABLE OF CONTENTS/OUTLINE
Lumbar Discography: Background and History - Conventional CT Discography - MR Discography Anatomy of the
Intervertebral Disc Pathophysiology of Degenerative Disc Disease Indications for Lumbar Discography
Comparison of MR Discography - Advantages of MR Discography compared with conventional MRI and CT
Discography - Disadvantages MR Discography Technique - Intradiscal Injection Technique - Gadolinium
Preparation for MR Discography - MRI Sequences and Imaging Techniques Interpretation of Lumbar Discography
Potential Pitfalls - Incorrect Gadolinium Concentration - Annular Injections Complications - Post-procedural
Infection: Discitis - Intervertebral Disc Herniations: Acute Schmorl's Node - Gadolinium Induced Reactions and
Venous Intravasation Conclusion
Elbow Injuries in Adult and Pediatric Overhead Athletes (Station #7)
Dana Lin MD (Presenter): Nothing to Disclose , Jonathan Khedoori Kazam MD : Nothing to Disclose ,
Tony T. Wong MD : Nothing to Disclose
TEACHING POINTS
1. To review common injuries in the pediatric overhead athlete
2. To review common injuries in the adult overhead athlete
3. Use powerpoint based animations to explain mechanisms of all discussed injuries in both populations
TABLE OF CONTENTS/OUTLINE
1. Pre-test questions 2. Phases of pitching 3. Pediatric injuries - Medial epicondyle apophysitis - Medial epicondyle avulsion - Capitellar osteochondral lesion - Panner disease - Olecranon apophysitis 4. Adult injuries -
Ulnar collateral ligament injury - Valgus extension overload - Medial epicondylitis - Olecranon stress fracture -
Ulnar neuritis 5. Answers and review to pre-test questions
Non-Neoplastic Masses of the Hand and Wrist (Station #8)
Maryann Ro MD (Presenter): Nothing to Disclose , Sarah Vanderlinde Mijangos MD : Nothing to Disclose ,
Carlos Luis Benitez MD : Nothing to Disclose , Robert Daniel Irish MD : Nothing to Disclose
TEACHING POINTS
1. Many palpable masses of the hand and wrist are of non-neoplastic origin.
2. The differential diagnosis of palpable masses of the hand and wrist can be narrowed by identifying their relationship to surrounding structures and defining the signal characteristics on MR imaging.
3. A more definitive diagnosis can be reached when the physical exam findings and previous medical conditions are known.
TABLE OF CONTENTS/OUTLINE
Exhibit Organization: I. Brief Overview of Hand Anatomy II. Acquired non-neoplastic masses of the hand and wrist 1. Arthropathies • Gout • Rheumatoid arthritis 2. Tendinopathy and Synovitis • Diffuse pigmented villonodular synovitis • Nodular tenosynovitis • DeQuervain's tenosynovitis • Tenosynovial chondromatosis •
Calcific tendinitis 3. Post-traumatic Lesions • Flexor tendon bursitis • hematoma 4. Cysts • Ganglion cyst 5.
Other • Nora's lesion III. Developmental non-neoplastic masses 1. Vascular • Arteriovenous malformations •
Varix 2. Accessory Muscles • Extensor digitorum manus brevis 3. Bony excrescences • Carpal boss • melorrheostosis 4. Other • Fibrolipomatous hamartoma
MR Imaging of BioCartilage Augmented Microfracture Surgery (Station #9)
Nicholas Mark Gutierrez MD (Presenter): Nothing to Disclose , Jean Jose MS, DO : Nothing to Disclose ,
Ty Kanyn Subhawong MD : Nothing to Disclose , James Banks MD : Nothing to Disclose , Bryson Lesniak
MD : Nothing to Disclose , Michael Baraga : Nothing to Disclose , Thomas Temple MD : Nothing to
Disclose
TEACHING POINTS
Focal full-thickness articular cartilage defects are prevalent in young active patients and often result in significant morbidity. The use of BioCartilage as an adjunct to standard microfracture surgery has emerged as a promising technique for cartilage restoration. A description of BioCartilage and its post-operative MR imaging appearance are provided in this exhibit. It is essential that the musculoskeletal radiologist becomes familiar with this surgical technique and its post-operative MR imaging findings including potential complications.
TABLE OF CONTENTS/OUTLINE
- Indications - Surgical technique - What is BioCartilage? • Dehydrated, micronized allogeneic cartilage extracellular matrix containing proteoglycans and type II collagen among other matrix elements. - What is the role of BioCartilage? • Primarily provides scaffolding over a microfracture defect and promotes regeneration of more hyaline-like cartilage in conjunction with platelet-rich plasma (PRP). - Post-operative MR imaging • Fast spin echo, gradient echo, and T2 mapping • Signs of incomplete incorporation and other complications with illustrative cases
Imaging of Soft tissue Tumors Clues and Tricks for Decision Making (SLAM Approach) (Station #10)
Rammohan Vadapalli MD (Presenter): Nothing to Disclose , Harshavardhan KR MD : Nothing to Disclose ,
Lalitha Palle : Nothing to Disclose

MKE333
MKE205
Lalitha Palle : Nothing to Disclose
TEACHING POINTS
To make an algorithmic diagnostic imaging approach for characterization of soft tissue masses ( SLAM approach: S-Signal and Signs, L-Location A-Age group M-Multiplicity/Morphology)
TABLE OF CONTENTS/OUTLINE
SLAM approach :Signal morphology on T1 and T2, Location clues, Age group clues, Multiplicity are discussed with clinical examples. The Key Imaging Signs are illustrated with examples Triple sign: Synovial sarcoma
Lasagne sign: Elastofibroma Broccoli sign: Lipoma arborescence Fascicular sign: Neurogenic tumours Comet Tail sign: Neurogenic tumors Target sign/Bulls eye sign: Neurogenic tumours Dot in circle sign: Mycetoma Foot
Coaxial cable sign: Lipo fibromatous Hamartoma Median nerve/Neural Fibrolipoma Location clues along a vein , along a nerve, along a tendon to name a few. Multiplicity and causes of multiple and symmetrical soft tissue mass lesions are illustrated The M Rule or MI7 for the Morphology of the lesions is highlighted: Morphology (MI
7 Rule) Melanin :Clear cell Sarcoma Met haemoglobin: Haemorrhage in a tumour/Haematoma Mucin: Metastatic adenocarcinoma Mycelia(septal hyphae):Fungal pathology-Mycetoma MatrixMix:
Calcium,Phleboliths,haemosiderin,Fat,Cellularity Makkan(Fat) :Lipoma,Lipoblastoma Myxoid: Myxoma, Myxoid
Liposarcoma
Sacrumology 101 - Benign and Malignant Primary Tumors (Station #11)
Mital Kishor Patel MD (Presenter): Nothing to Disclose , Ricki Upendra Shah MD : Nothing to Disclose ,
Andrew Lee Chiang MD : Nothing to Disclose
TEACHING POINTS
-Multimodality imaging review of benign and malignant primary sacral tumors. -Brief review of the safety, efficacy, and technical aspects of CT guided biopsies of these tumors
TABLE OF CONTENTS/OUTLINE
Purpose/Aim: The detection and imaging workup of sacral tumors often crosses multiple radiology subspecialties including musculoskeletal, neuroradiology, and body imagers. As each subspecialist may have a tendency to limit their differential based on their scope of practice, we hope to provide an electronic educational exhibit that broadens their perspectives and highlights the full spectrum of both benign and malignant primary sacral tumors. Table of Contents: Case based review (list below) - brief pertinent patient history and symptomatology - multimodality imaging review - discussion of role of CT guided biopsy in each case treatment and management Benign Tumors - Myxopapillary Ependymoma -Schwannoma -Giant Cell Tumor
-Large Tarlov Cyst Maligant Tumors -Plamacytoma -Chondrosarcoma -Chodroma -Myeloid Sarcoma -Ewings
-Non-Hodgkins Lymphoma
Brachial Plexus: MRI and Ultrasound Evaluation and the Clinical Impact. Demonstrating Imaging
Technique, Anatomy & Pathology. Six Year Review of Both Ultrasound and MRI Findings of the
Brachial Plexus in the Same Patients (Station #12)
Mark Cresswell MBBCh (Presenter): Nothing to Disclose , Mary Margaret Chiavaras MD, PhD : Nothing to
Disclose , Jon A. Jacobson MD : Consultant, BioClinica, Inc Royalties, Reed Elsevier Equipment support,
Terumo Corporation Equipment support, Arthrex, Inc , Darra Thomas Murphy MD, FRCPC : Nothing to
Disclose , Roberta Dionello MBBS, FRCR : Nothing to Disclose
TEACHING POINTS
Imaging technique of the Brachial Plexus using both ultrasound and MRI
Step by step approach to ultrasound technique to assess the Brachial Plexus.
Understand the relative merits and pitfalls of both MRI and ultrasound
Anatomic review of the brachial plexus
Pathology of the Brachial Plexus reviewed by case examples
TABLE OF CONTENTS/OUTLINE
A. Objectives
B. Anatomy
C. Ultrasound technique
D. MRI evaluation
E. Advantages: MRI vs US
F.Advantages: US vs MRI
G. Pathology: Roots
H. Pathology: Trunks
I.Pathology: Cords
J: Six year imaging experience results
Summary

MKE027-b Paraspinal Musculature Anatomy and Pathology: A Pictorial Essay (hardcopy backboard)
Maria Del Rocio Iniguez-Rodriguez MD (Presenter): Nothing to Disclose , Juan Eugenio Cosme MD :
Nothing to Disclose , Jorge Vazquez-Lamadrid MD : Nothing to Disclose
TEACHING POINTS
The purpose of this exhibit 1. Review the basic anatomical of the paraspinal musculature. 2. Describe and illustrate landmark that aid during the interpretation of MRI spine. 3. Describe and illustrate pathology in the paraspinal musculature.
TABLE OF CONTENTS/OUTLINE
1. Define anatomical landmarks useful in the interpretation of the MRI spine. 2. Examine normal anatomy of the paraspinal muscles. I. Deep Muscles and fascia of the neck. II. Fascies and muscles of the trunk. III. Deep muscles and fascia of the Back. IV. Normal Anatomy - Cervical Spine. - Thoracic Spine. - Lumbosacral Spine. V.
Relationship with compartment to the chest, retroperitoneum and musculoskeletal system. 3. Ilustrates the utility of CT and MRI in detecting pathology of the paraspinal musculature. I. Neoplastic disease. II. Infection.
III. Trauma. IV. Miscellaneous Pathology.
Scientific Posters
MK
AMA PRA Category 1 Credits ™ : .50
Wed, Dec 3 12:45 PM - 1:15 PM Location: MK Community, Learning Center
Sub-Events
MKS384 Diffusion of Non-fatty Soft Tissues Tumors though Magnetic Resonance Imaging: Impact of ROI
Positioning and Lesion Morphology in the Performance of ADC Value Analysis (Station #1)
CHLOE BONARELLI (Presenter): Nothing to Disclose , PEDRO TEIXEIRA : Nothing to Disclose , GABRIELA
HOSSU : Nothing to Disclose , CHEN BAILIANG : Nothing to Disclose , Alain Gilbert Blum MD : Research
Consultant, Toshiba Corporation Research Consultant, General Electric Company
PURPOSE
Highlight the impact of the ADC calculation method on the performance of diffusion weighted imaging in soft tissue tumors' characterisation. Assess two practical methods of ADC calculation in the tumour characterisation of soft tissue lesions.
METHOD AND MATERIALS
69 consenting patients displaying a soft tissue tumour with histological proof have been included prospectively between November 2009 and October 2012. The study had been approved by the local ethical committee. Two radiologists calculated several ADCs (minimal: ADCmin and average: ADCavg) for each lesion according to two methods (manual and semi-automated).
RESULTS
We demonstrated a significant relationship between the ADC value and the lesion's nature (malignant or benign), regardless of the ADC calculation method chosen (p = 0.02). A significant difference emerged between
ADC values of benign tumours and malignant ones (p < 0.01), and between the ADCmin values obtained manually versus the ones obtained through the semi-automated method (p < 0.0001). The inter-observer reproducibility was excellent for ADCmin (ICC = 0.82) and good for ADCavg (ICC = 0.77). The manually obtained ADC yielded the best results for tumour characterisation (Se = 83%, NPV = 88%). The manually obtained ADCavg yielded the best results in the solid-lesion subgroup (Se = 80%, NPV = 92%), while the
ADCmin obtained though semi-automated method yielded the best results for mixt lesions (Se = 80%, NPV =
93%).
CONCLUSION
The choice of ADC has a significant impact on the method's performance and is influenced by the tumour's own morphology. The manually-obtained ADCmin has yielded the best results overall.
CLINICAL RELEVANCE/APPLICATION
Correlate the ADC calculation method with the tumor morphology to improve the performance of diffusion weighted imaging and increase diagnostic confidence.
MKS385 Quantitative Measurement of Tumor Cecrosis Does Not Correlate with Tumor Volume Changes:
Preliminary Results (Station #2)
Ty Kanyn Subhawong MD (Presenter): Nothing to Disclose , Mark D. Barton MBA, BS : Nothing to Disclose ,
Juan Abelardo Augusto Pretell MD : Nothing to Disclose , Juan Infante MD : Nothing to Disclose , Jean
Jose MS, DO : Nothing to Disclose , Sheila Conway MD : Nothing to Disclose , H. Thomas Temple :
Consultant, Stryker Corporation

MKS386
MKS387
PURPOSE
Soft tissue sarcomas are often treated with neoadjuvant chemo- or radiation therapy; determining when treatment effect has plateued has important treatment implications for timing of surgery. Such decisions are often based on radiologic imaging parameters but these remain suboptimally defined. We correlated quantitative measurements of tumor volume to quantitative and qualitative assessments of percent tumor necrosis.
METHOD AND MATERIALS
In this IRB-approved retrospective review, we identfied 23 patients with both pre- and post-neoadjuvant therapy MRI available for volumetric tumor assessment. Tumor volume was calculated using OsiriX by drawing a region of interest, which outlined the tumor margins across multiple contiguous slices; a pixel-thresholding technique was used to identify solidly enhancing tumor, and the percentage of necrosis from the total tumor volume was calculated using the MATLAB programming language. Subjective assessment of percent tumor necrosis was performed on a randomly selected subset of 8 patients and compared to quantitative results.
RESULTS
Subject mean age was 53.6 years, range 15-88, 13 males). Relative change in tumor volume correlated poorly with change in percentage necrosis, as calculated quantitatively and subjectively (Pearson r = 0.15 and -0.21, respectively). There was good correlation in absolute assessments of percent necrosis between subjective and quantitative methods (Pearson r = 0.87). Correlation between subjective and quantitative assessments of change in tumor necrosis was fair (Pearson r = 0.48).
CONCLUSION
Changes in tumor volume show little correlation with changes in percent tumor enhancement assessed subjectively and quantitatively.
CLINICAL RELEVANCE/APPLICATION
Clinical decisions based on changes in soft tissue sarcoma tumor volume as a surrogate for treatment response should be made with caution; subjective assessments correlate well with more labor-intensive quantitative techniques.
Diagnostic Impact of Echo Planar Diffusion-weighted Magnetic Resonance Imaging (DWI) in
Musculoskeletal Neoplastic Masses Using Apparent Diffusion Coefficient (ADC) Mapping as a
Quantitative Assessment Tool (Station #3)
Sherif Abdelfattah MD, PhD (Presenter): Nothing to Disclose , Hassan Kassem MD : Nothing to Disclose
PURPOSE
To evaluate the diagnostic impact of echo planar DW imaging in distinguishing benign from malignant musculoskeletal soft-tissue masses using ADC mapping as a quantitative assessment tool.
METHOD AND MATERIALS
We evaluated 73 tumors (21 bone tumors and 52 soft-tissue tumors). MR examinations were performed with a
1.5-T system. Diffusion-weighted single-shot EPI images were obtained in all patients. Apparent diffusion coefficients (ADCs) were calculated by using b factorsof 0 and 1000 s/mm2. ADC value measurements were compared with the histopathological findings.
RESULTS
The average ADC of benign tumors was 1.86 ±0.67 • 10_3 mm2/s, and that of malignant soft-tissue tumors was 0.97 ±0.35 • 10_3 mm2/s. ADC value of malignant tumors was significantly lower than that of the benign tumor group (p< 0.0001). The highest ADC value was seen in the case of ganglion cyst (2.8 ± 0.23 • 10_3 mm2/s) and cystic neurofibroma (2.5 ± 0.04 • 10_3 mm2/ s), and juxta cortical enchondroma (2.65 ± 0.36 •
10_3 mm2/s) while the lowest one was seen in aggressive fibromatosis (0.37± 0.05 • 10_3 mm2/s). For malignant soft-tissue masses, the highest ADC value was seen in mesenchymal chondrosarcoma (2.1 ± 0.32) liposarcoma (intermediate grade) (1.4 ± 0.21) while the lowest ADC value was seen in fibrosarcoma (high grade) (0.78± 0.14).
CONCLUSION
MR diffusion provides additional information to the routine MRI sequences rendering it an effective non-invasive tool in differentiating between benign and malignant soft-tissue tumors
CLINICAL RELEVANCE/APPLICATION
MR diffusion provides additional information to the routine MRI sequences rendering it an effective non-invasive tool in differentiating between benign and malignant soft-tissue tumors
Prevalence of MRI Spinal Lesions Typical for Axial Spondyloarthritis in Patients with Inflammatory
Back Pain (Station #4)

MKS388
Manouk de Hooge : Nothing to Disclose , Jean-Baptiste Pialat MD : Nothing to Disclose , Antoine A. Feydy
MD (Presenter): Nothing to Disclose , Monique Reijnierse MD : Nothing to Disclose , Maxime Dougados :
Nothing to Disclose , Desiree M. F. M. Van Der Heijde MD, PhD : Nothing to Disclose
PURPOSE
Background: Since 2012, a cut-off value of ≥3 inflammatory lesions was suggested by the ASAS/OMERACT group, as positive MRI of the spine (MRI-spine). Moreover, fatty lesions on MRI-spine are associated with axial
Spondyloarthritis (axSpA). Objectives: To determine the prevalence of inflammatory (BME) and fatty lesions on
MRI of the spine in patients with and without axSpA.
METHOD AND MATERIALS
Patients aged 18-50 with inflammatory back pain (≥3 months, ≤3 years) from 25 centres in France were included in the DESIR-cohort (n=708). All available baseline MRIs were independently scored by 2 well-calibrated readers, blinded to any other data. In case of disagreement, an experienced radiologist served as adjudicator. BME and fatty lesions typical for axSpA were scored when visible on ≥2 consecutive slices.
Prevalence of MRI lesions was calculated based on several cut-offs and lesions were considered present if 2/3 readers agreed.
RESULTS
All patients with symptom onset <45 y with MRI-spine (n=549) were included in the analyses. Patients fulfilling the ASAS criteria could either fulfill both arms, only the imaging arm or only the clinical arm. The first 2 groups were subdivided; patients with radiographic sacroiliitis (mNY+) and sacroiliitis on MRI (MRI+), patients with mNY+ and no sacroiliitis on MRI (MRI-), patients without radiographic sacroiliitis (mNY-) and MRI+. BME lesions occur in all different subgroups of the ASAS criteria and in patients without axSpA. The prevalence in no SpA group (which can be seen as false positives) is only 6.1%. With a cut-off ≥2 BME lesions false positives drop below 5% while the prevalence in the ASAS axSpA groups is still reasonable. Especially prevalence in patients with mNY+ and MRI+ is very high; 61.9% (both arms positive) and 43.8% (imaging arm only positive). Fatty lesions are seen slightly less often seen in all patient groups.
CONCLUSION
In a low percentage of patients without axSpA BME and fatty lesions is found indicating that spinal BME and fatty lesions are specific for patients with axSpA. These lesions are especially prevalent in patients with sacroiliitis on imaging. In this cohort, a cut-off ≥2 or ≥3 BME lesions and similarly ≥2 or ≥3 fatty lesions discriminate best between patients with and without axSpA.
CLINICAL RELEVANCE/APPLICATION
Spinal BME and fatty lesions on MRI are especially prevalent in patients with sacroiliitis on imaging.
Baastrup Disease (Kissing Spine Syndrome): Safety and Efficacy of Imaging- Guided Infiltrations
(Station #5)
Maria Tsitskari MD (Presenter): Nothing to Disclose , Dimitrios Filippiadis MD, PhD : Nothing to Disclose ,
Lazaros Reppas BS : Nothing to Disclose , Efthimia Alexopoulou : Nothing to Disclose , Nikolaos L. Kelekis
MD : Nothing to Disclose , Alexios Kelekis MD, PhD : Consultant, Benvenue Medical, Inc
PURPOSE
Baastrup disease refers to pathology of adjacent spinous processes of degenerative origin resulting in back pain with central distribution. Purpose of this study is to assess safety and efficacy of percutaneous, fluoroscopy-guided infiltrations in a consecutive series of patients suffering from symptomatic Baastrup disease.
METHOD AND MATERIALS
During the last 4 years, 55 patients suffering from Baastrup disease (diagnosed clinically and by imaging findings) underwent percutaneous, fluoroscopy-guided infiltration. Diagnosis was performed both clinically and with imaging studies (x-ray or Computed Tomography or Magnetic Resonance Imaging). The position of the needle (22 Gauge spinal needle) was fluoroscopically verified at the level of interspinous-midspinous ligament.
Once in proper position, a mixture of long acting glucocorticosteroid with local anesthetic (1.5/1 cc) was injected. A questionnaire with NVS scale helped assessing pain relief degree, life quality and mobility improvement.
RESULTS
A total of 67 sessions was performed in our patient sample (1.21 infiltration /patient). In 12/55 patients
(21.8%) a second infiltration was performed within 7-10 days apart from the first one. Comparing the pain scores prior (mean value 8.18±1.44 NVS units) and after (mean value 0.62±0.93 NVS units) there was a mean decrease of 7.56±1.686 NVS units units (p<0.001) on terms of pain reduction, effect upon mobility and life quality. There were no clinically significant complications noted in our study.
CONCLUSION
Fluoroscopy-guided infiltrations seem to be a feasible, efficacious and safe approach for pain reduction and mobility improvement in patients with Baastrup disease. Imaging guidance ensures proper needle positioning as well as enhances efficacy and safety.
CLINICAL RELEVANCE/APPLICATION

MKS389
MKE261
MKE184
Corticosteroid infiltration for Baastrup disease is a safe and efficient therapy for pain reduction and mobility improvement; imaging guidance ensures accurate needle placement and augments safety and efficacy.
Reliability of sterEOS 3D Scoliosis Measurements Using a 5 Fold Reduction in Radiation (Station #6)
Peter Newton : Research Grant, EOS imaging SA , Fredrick Reighard : Institutional Research Grant, EOS imaging SA , Quinn Colin Meisinger MD (Presenter): Nothing to Disclose , Carrie Bartley MA : Institutional
Research Grant, EOS imaging SA , Tracey Bastrom : Institutional Research Grant, EOS imaging SA , Burt
Yaszay : Institutional Research Grant, EOS imaging SA
PURPOSE
To evaluate the reliability of 3D spinal reconstructions from EOS x-rays utilizing a 5-fold reduction in radiation dosage compared to standard EOS images utilized for evaluating patients with adolescent idiopathic scoliosis
(AIS).
METHOD AND MATERIALS
After IRB approval, 30 AIS patients (20 non-op, 10 post-op) who received "standard", biplanar, anteroposterior and lateral spine x-rays in our EOS imaging unit (~ 0.31mGy) as part of their routine care, also underwent an additional set of "microdose" EOS x-rays (~ 0.06 mGy) using a new protocol. All subjects had a major Cobb angle greater than 20° (non-operative cohort) or a prior posterior spinal fusion with instrumentation
(post-operative cohort). A single reviewer created full 3D reconstructions once of each set of images using sterEOS software. Coronal (Cobb angles), sagittal (T1-T12, T4-T12, L1-L5, L1-S1), and apical axial rotation measurements were obtained. Intraclass correlations (ICC) and the 95% confidence intervals for the differences between the standard and microdose EOS image measurements were compared.
RESULTS
The average ICC was 0.95 for both the non- and post-operative groups (range 0.89-0.99). The calculated differences for all coronal and sagittal measurements were statistically similar in the non-operative group
(p>0.05). In the post-operative group, all measurements were statistically similar, with the exception of T1-T12 kyphosis, which measured greater in the microdose x-rays (45° vs 42°, p=0.001). The error in measurement between standard and microdose images can be found in the Table.
CONCLUSION
Good reliability was found between 3D measurements of the standard x-rays and the microdose x-rays in patients with idiopathic scoliosis. A small difference in measurements was observed for T1-T12 kyphosis in the post-operative group possibly suggesting slightly greater difficulty in visualizing the spine in patients after spinal fusion with instrumentation. Further study is underway with a goal of 30 subjects per group; however there is a strong suggestion that radiation exposure can be further reduced with EOS imaging in scoliosis patients.
CLINICAL RELEVANCE/APPLICATION
For scoliosis patients, standard EOS imaging offers reduced radiation exposure; it appears further reduction by another 5-fold is possible while maintaining reliability of 3D deformity measurements.
“Bending over Backwards”: Dual-Energy CT Assessment of the Spine (Station #7)
Neal C. Chhaya MBBS, FRCR (Presenter): Nothing to Disclose , Brathaban Rajayogeswaran MBBCh :
Nothing to Disclose , Paul Ian Mallinson MBChB : Nothing to Disclose , Peter L. Munk MD : Nothing to
Disclose
TEACHING POINTS
Dual-energy computed tomography - how does it work Recognizing hardware or soft tissue complications such as fracture or loosening Optimize acquisition and reconstruction parameters to minimize artifact whilst maximizing soft tissue resolution Help problem solve by identifying vertebral marrow edema in trauma and perivertebral urate deposition in gout Tips and tricks for using the monoenergetic spectrum to your advantage
TABLE OF CONTENTS/OUTLINE
The advent of dual-energy technology is changing the way we utilize computed tomography. A variety of conditions affecting the spine may present themselves on CT such as traumatic or osteoporotic vertebral fracture, spondylo-lysis/listhesis or even gout. This exhibit demonstrates how to evaluate accurately and effectively using dedicated algorithms. However a big challenge for the Radiologist remains when evaluating the spine in the presence of high atomic number (high-Z) materials. Traditionally CT imaging has proved inadequate in these situations due to excessive spray and streak artifact resulting from a variety of factors including beam hardening, detector photon starvation and inherent quantum noise. With our ability to manipulate the parameters of the dataset acquired as well as apply specific reconstruction algorithms, comes more accurate evaluation of both the osseous and soft tissue structures.
The Forgotten Bone: An Overdue Review of Lesions Which May Arise In the Fibula (Station #8)
Barry Glenn Hansford MD (Presenter): Nothing to Disclose , Gregory Scott Stacy MD : Research agreement,
Biomet, Inc
TEACHING POINTS
The purpose of this exhibit is: 1. To the best of our knowledge, there is no discussion in the radiology literature dedicated solely to lesions which may arise in the fibula. Hence, our aim is to provide a differential diagnostic overview of lesions which one may encounter in the fibula based on histologically-proven cases encountered at our institution 2. To review how anatomy of the fibula influences the form of primary fibular lesions (e.g.,

MKE218
MKE322
MKE269
MKE132 benign lesions may be more likely to appear expansile and therefore aggressive than in other bones) 3. To simplify the differential diagnosis based on key imaging findings and clinical clues 4. To briefly review important lesion-specific "pearls" as well as options for clinical management
TABLE OF CONTENTS/OUTLINE
Introduction Discussion of how fibular anatomy influences lesion appearance Review of fibular lesions and their imaging appearance, including benign and malignant intramedullary and surface tumors, tumor-like lesions, and tumor mimics. This review will include: --Clinical clues --Key imaging findings with pathology specimens
--Multi-modality approach to imaging work-up --High yield "pearls" and management considerations Summary
Nerve Entrapment of the Upper Extremity: A Closer Look with High-resolution MRI from the Nerve
Roots to the Hand (Station #9)
Niyata Chitrapat MD (Presenter): Nothing to Disclose , Karen Chi-Lynn Chen MD : Nothing to Disclose ,
Eric Y. Chang MD : Nothing to Disclose , Richard Znamirowski : Nothing to Disclose , Sheronda Statum :
Nothing to Disclose , Christine B. Chung MD : Nothing to Disclose
TEACHING POINTS
Review the various types and severity of peripheral nerve injury. Review the MR appearance of peripheral nerves in health and disease. Review patterns of denervation changes in musculature on MRI. Detail potential sites of nerve entrapment of the upper extremity with high resolution MRI.
TABLE OF CONTENTS/OUTLINE
1. Define: a. Neurapraxia b. Axonotmesis c. Neurotmesis 2. Review the normal and pathologic appearance of the peripheral nerve. 3. Highlight common sites of nerve entrapment and potential causes of nerve entrapment of the upper extremity with high-resolution MRI. a. Brachial Plexus i. Interscalene ii. Costoclavicular iii.
Retropectoralis Minor b. Suprascapular Nerve i. Suprascapular notch ii. Spinoglenoid notch c. Axillary Nerve i.
Quadrilateral space d. Musculocutaneous Nerve i. Coracobrachialis Muscle e. Ulnar Nerve i. Cubital Tunnel ii.
Guyon's canal f. Median Nerve i. Pronator Syndrome ii. Anterior Interosseous Nerve Syndrome iii. Carpal Tunnel g. Radial Nerve i. Spiral Groove of the Humerus ii. Arcade of Frohse iii. Extensor carpi radialis brevis h.
Superficial Radial Nerve Compression i. Posterior border of the brachioradialis 4. Review muscle denervation patterns in the upper extremity
Imaging Signs of Nerve Sheath Tumours and Tumour Like Masses on Conventional MRI and MR
Neurography Revisited (Station #10)
Rammohan Vadapalli MD (Presenter): Nothing to Disclose , Meena Ak MD, DPhil : Nothing to Disclose ,
Harshavardhan KR MD : Nothing to Disclose , Abhinav Sriram Sriram Vadapalli : Nothing to Disclose ,
Pramod Kumar Reddy Kaila MD : Nothing to Disclose , Abhijit Roychowdhury MD : Nothing to Disclose
TEACHING POINTS
-enlist the signs commonly used in characterization of neural sheath masses -illustrate each Imaging sign with clinical examples -The Pathological correlates of Imaging signs used to identify neural sheath neoplasm and
Tumour like masses
TABLE OF CONTENTS/OUTLINE
A. Signs and Patterns in Neurogenic Tumours 1.Target sign 2.Split Fat sign 3. Comet tail sign 4. Fascicular sign
5 .Bag of Worms Pattern 6. Co Axial Cable sign. B. Signs and Patterns in Non Neurogenic Pathology -Segmental nerve enlargement,Displacement - Perineural Cuffing -Comet tail Sign -Nerve Edema sign -Entrapment -Bon fire
Sign (pattern) Tumours: Lymphoma, Leukaemia Peri-neural Capillary haemangioma ,Bone lesions invading the neural sheath, Superior Sulcus Tumour, Ovarian neoplasms and Sacral GCT/Metastases Tumour Like masses:
Sarcoid , Tuberculosis, Hansen's Disease,Amyloid,GCT of Tendon sheath, Localized PVNS, Varices in Tarsal tunnel Each sign is defined, Illustrated diagrammatically and with clinical MRI and MR Neurography (STIR
MRN/PROSET MRN,DTI based MR neurography) Pathological correlates like biopsy features are highlighted
MR Imaging of Spinal Marrow: Normal and Abnormal Patterns (Station #11)
Chandan Kakkar MBBS, MD (Presenter): Nothing to Disclose , Satwant Singh Khela MBBS : Nothing to
Disclose , Kavita Saggar MD : Nothing to Disclose , RITU GALHOTRA MD : Nothing to Disclose ,
Prakashini Koteshwara MD : Nothing to Disclose , Rajagopal KV MD, FRCR : Nothing to Disclose
TEACHING POINTS
To discuss the role of MR imaging in spinal marrow with emphasis on physiological changes and various pathologies involving the spinal marrow.
TABLE OF CONTENTS/OUTLINE
1) To discuss the role of MRI in spinal marrow assessment with optimal use of sequences. 2) To illustrate the physiological changes in the marrow with advancing age 3) To illustrate the patterns of marrow involvement in reconversion process in haemolytic anemias and haematological malignancies. 4) Patterns of marrow infiltration and replacement in primary and secondary malignancies. 5) Patterns of marrow depletion in post therapy patients. 6) Considerations like marrow involvement in HIV, vertebral fractures, infectious and degenerative processes , spinal flurosis
Are New MRI Techniques Useful for Knee Evaluation? (Station #12)
Teodoro Martin MD (Presenter): Nothing to Disclose , Antonio Luna MD : Nothing to Disclose , Joan C.
Vilanova MD, PhD : Nothing to Disclose , Maria Jose Romero Rivera : Nothing to Disclose , Fernando Caro
Mateo : Nothing to Disclose , Jordi Broncano MD : Nothing to Disclose , Pilar Caro Mateo : Nothing to

Mateo : Nothing to Disclose , Jordi Broncano MD : Nothing to Disclose , Pilar Caro Mateo : Nothing to
Disclose , Lidia Alcala Mata MD : Nothing to Disclose
TEACHING POINTS
1. Review the technical adjustments necessary to perform, in the knee, functional sequences such as DWI,
DCE-MRI, DWI and DTI-based neurography, multiecho TSE T2-weighted sequence for T2 mapping of the cartilage, 3D and 4D angiography and MR lymphography. 2. Analyze the impact of all these new techniques in the evaluation of normal structures and pathological conditions.
TABLE OF CONTENTS/OUTLINE
CONTENT ORGANIZATION 1. Introduction 2. Technical basis and adjustments of advanced MRI sequences a.
DWI b. DCE-MRI c. MR neurography: STIR, DWI and DTI d. MRI angiography: 3D, 4D e. MRI lymphography 3.
Clinical applications a. Bone and soft tissue tumors b. Cartilage quantification c. Vascular disease (venous, arterial and lymphatic) d. Nerve pathology (tumoral and non-tumoral) SUMMARY Functional MRI permits to obtain quantifiable information in several clinical scenarios in the knee
Multisession Courses
US
AMA PRA Category 1 Credits ™ : 1.50
ARRT Category A+ Credits: 1.50
Wed, Dec 3 1:30 PM - 3:00 PM Location: S406A
Sub-Events
MSCU41A Contrast Enhanced US as a Problem Solving Technique
Stephanie R. Wilson MD (Presenter): Research Grant, AbbVie Inc Grant, Johnson & Johnson Consultant,
Lantheus Medical Imaging, Inc Equipment support, Siemens AG Equipment support, Koninklijke Philips NV
LEARNING OBJECTIVES
1) The attendee will comprehend the value of CEUS in terms of its high temporal resolution, allowing for real time dynamic demonstration of blood flow in neoplasms of the abdominal solid organs, especially the liver and the kidney. 2) The attendee will analyze the value of CEUS for tumor characterization based on its incomparable vascular sensitivity and superior spatial and temporal resolution.
MSCU41B Test Your Transplant IQ
Michelle Lavonne Robbin MD (Presenter): Consultant, Koninklijke Philips NV
LEARNING OBJECTIVES
1) Discuss common and uncommon complications in renal, pancreas and liver transplantation. 2) Describe pitfalls encountered in transplant evaluation. 3) Review the imaging algorithm when a complication is suspected.
MSCU41C Vascular Ultrasound
Laurence Needleman MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) The attendee will describe the major duplex findings of stenosis and of acute, residual and recurrent DVT.
Scientific Papers
US BR
AMA PRA Category 1 Credits ™ : 1.00
ARRT Category A+ Credit: 1.00
Wed, Dec 3 3:00 PM - 4:00 PM Location: Arie Crown Theater
Participants

Moderator
Catherine Streeto Giess MD : Nothing to Disclose
Moderator
Mary S. Newell MD : Nothing to Disclose
Sub-Events
SSM01-01 The Additive Role of 3D Reconstructed Ultrasound to the New Technologies of Digital Mammography in the Proper Assessment of Breast Cancer
Maha Hussein Helal MD (Presenter): Nothing to Disclose , Dorria Saleh Salem MD : Nothing to Disclose ,
Basma El Kalaawy MBBCh : Nothing to Disclose , Lamia Adel MD : Nothing to Disclose , Sahar Mansour
MD : Nothing to Disclose , Nadia Mokhtar MD : Nothing to Disclose , Nelly Alieldin MD : Nothing to
Disclose , nagat mansour khalifa : Nothing to Disclose , Noha Abdel Shafey MD : Nothing to Disclose ,
Rasha Mohamed Kamal MD : Nothing to Disclose , Omnia Mokhtar MD : Nothing to Disclose
PURPOSE we aimed to elucidate the role of recent advances in digital mammography, versus 3D breast ultrasound in the staging of breast cancer prior management.
METHOD AND MATERIALS
This retrospective analysis with ethics committee approval included 115 masses in 103 cases. Evaluation methods included regular digital mammography, 3-D tomosynthesis, contrast enhanced mammography and 3D breast ultrasound. For mammography acquisition, a combined technique (2D+3D imaging) that acquires a traditional digital mammogram and a tomosynthesis scan in the same compression is performed. For applying contrast-enhanced images: low and high energy exposures were taken in the same projections after IV injection of contrast agent. Evaluated masses were biopsied and proved malignancy (70 masses) were further evaluated regarding lesions' extension, size, multiplicity and related calcifications in correlation with data provided with 2D and automated 3D ultrasound examinations. Pathological specimen was the standard reference.
RESULTS
Comparable estimation to the pathology extension was provided by tomosynthesis (n=58, 83%) and 3D ultrasound (n=56, 80%) followed by contrast-enhanced (n=32, 46%) and regular mammography (n=51, 73%).
Contrast-enhanced mammography presented the least assessment for calcifications, yet the most accurate size estimation with a median value of 0.4 compared to 0.5 and 1.5 for tomosynthesis and regular mammography respectively. Multiplicity was better demonstrated by contrast mammography with sensitivity of 92% followed by 3D ultrasound (87%), then tomosynthesis (77%) and regular mammography (54%). An accuracy of 92% presented by combined analysis of the advanced mammography applications and the 3D automated ultrasound in the pre-operative evaluation of breast cancer.
CONCLUSION
Digital mammogram with advanced applications (tomosynthesis and contrast-enhanced imaging) together with
2D and 3D automated ultrasound provide an utmost evaluation and proper staging of breast cancer.
CLINICAL RELEVANCE/APPLICATION
Digital mammography (DM) is still limited by overlapped densities that may provide false negative/positive diagnosis. Advanced applications of DM: tomosynthesis and contrast-enhanced mammography aided by the application of 2D and automated 3D ultrasound imaging represent the perfect mélange for proper prognosis assessment and prior management precise estimation.
SSM01-02 Quantitative Lesion Characterization Using Whole Breast Ultrasound Tomography: Initial Results from an ongoing Clinical Study
Neb Duric PhD (Presenter): Officer, Delphinus Medical Technologies , Peter John Littrup MD : Founder,
CryoMedix, LLC Research Grant, Galil Medical Ltd Research Grant, Endo Health Solutions Inc Officer, Delphinus
Medical Technologies, Inc , Cuiping Li PhD : Employee, Delphinus Medical Technologies, Inc , Mark J. Krycia
BS : Nothing to Disclose
PURPOSE
We evaluated whether quantitative tissue parameters, obtained from whole-breast ultrasound tomography
(UST), could enhance discrimination of breast masses, using automated regions-of-interest (ROI).
METHOD AND MATERIALS
This HIPAA compliant, IRB approved trial accrued 100 patients having breast masses identified on palpation, mammography or US, for a UST scan. Pathological correlation was based on biopsy results and standard imaging results (simple cysts). A sequential stack of full-breast, coronal B-mode images as well as quantitative sound speed (SS=m/sec) and attenuation (AT=dB/cm/MHz) images were generated. Identified areas of suspicion were outlined by a radiologist using an ROI ellipse, for which 10 progressive peritumoral and 10 intratumoral ellipses were then automatically generated for evaluation of quantitative trends in relative reflectivity, SS and ATT between the mass and its immediate surrounding peritumoral region.
RESULTS
27 palpable regions had no imaging findings on either standard imaging or UST. Of the remaining 73 subjects,

26 cancers, 16 Fibroadenomas, 20 Cysts and 11 miscellaneous benign histologies were noted. As seen in the figure, the full coronal B-mode image shows a ~1.5 cm hypoechoic mass at 1:00, overlaid by progressive intra-and peritumoral ROI's. Radial trends in the reflectivity, SS and ATT of the ROIs from the tumor epicenter to the furthest peritumoral ellipse show a classic pattern for cysts with both low central reflectivity and attenuation [B], whereas malignant masses showed inverted ATT pattern with the highest values at the tumor center. In combination with a trinary (sharp/indistinct/irregular) tumor margin assessment, cysts and fibroadenomas and cancers showed quantitative separation [C]. This resulted in positive predictive values (PPV) for UST of 93%, compared with standard US BI-RADS of 59%.
CONCLUSION
The addition of through transmission provides a substantial increase in the PPV of UST over standard ultrasound
BI-RADS criteria. A larger UST mass study of 300 patients is ongoing to validate these results.
CLINICAL RELEVANCE/APPLICATION
Whole breast UST provides quantitative evaluations of a tumor and its immediate surroundings, producing characteristic tissue trends that may aid rapid mass evaluations in larger trials.
SSM01-03 Breast Ultrasound After A Normal Mammographic Work-up: More Harm than Benefit
Betty Tuong MD (Presenter): Nothing to Disclose , Supriya Ravindra Kulkarni MD, DMRD : Nothing to
Disclose , Derek Muradali MD : Nothing to Disclose
PURPOSE
Abnormal screening mammograms are often further evaluated with spot compression views. If the abnormality does not persist on spot views, it is usually presumed that the lesion was artifactual from overlapping normal tissue, and the assessment is deemed negative. However, there is a trend to perform breast ultrasound (US) despite a negative mammographic work-up. The objective of this study was to determine if the addition of US after negative spot views could detect breast cancers missed at initial assessment.
METHOD AND MATERIALS
Retrospective chart review was performed from 2004 to 2013. Patients with abnormal mammograms, negative follow-up spot views, and concomitant breast US were identified. Abnormalities detected on US and the final
BIRADS classification were reviewed. Pathology from BIRADS 4/5 cases was recorded. Follow-up imaging recommended after a benign biopsy or BIRADS 3 assessment were reviewed to a final diagnosis of benign or cancer.
RESULTS
1860 patients were enrolled with US classified as BIRADS 1/2 (1588), BIRADS 3 (210) or BIRADS 4/5 (62). Of the BIRADS 4/5 cases, patients were initially referred for asymmetry (32), focal asymmetry (16), architectural distortion (8) or a mass (6). US showed a region of shadowing (26) or a mass (36). Final pathology was invasive ductal carcinoma (7), invasive lobular carcinoma (1), DCIS (2), fibrocystic change (10), fibroepithelial lesion (5), radial scar (2), fat necrosis (2), papillary lesion (2) and benign breast tissue (31). In total, 10/1860
(0.5%) cases had a final diagnosis of cancer. For benign biopsies, follow-up was recommended for up to 2 years and initiated 61 additional studies (23 US, 21 MRI and 17 mammograms). For BIRADS 3 cases, 213 additional studies were performed for up to 3 years (113 US, 1 MRI and 99 mammograms). 274 additional studies were performed in total and all cases were benign at the completion of follow-up.
CONCLUSION
In patients with negative spot views at assessment, the prevalence of a mammographically occult cancer that can be detected by US is very low. The addition of US results in a substantial number of unnecessary biopsies and imaging tests. Therefore, in patients with negative spot views at assessment, an additional US should not be performed routinely.
CLINICAL RELEVANCE/APPLICATION
It appears that on a population basis, more harm than good is caused by the addition of breast ultrasound after a negative mammographic work-up.
SSM01-04 Outcomes of Breast MRI-detected Suspicious Non-mass Enhancement (NME): Correlation with
Second-look Ultrasound (US) and Frequency of Malignancy
Adrienne Rebecca Newburg MD (Presenter): Nothing to Disclose , Chloe Muy-Chou Chhor MD : Nothing to
Disclose , Leng Leng Young Lin BA, MD : Nothing to Disclose , Jennifer Gillman : Nothing to Disclose , Jin
Ah Kim MD : Nothing to Disclose , Hildegard B. Toth MD : Nothing to Disclose , Linda Moy MD : Nothing to Disclose
PURPOSE
Prior studies have shown that MRI-detected malignant lesions are more likely than benign to have sonographic correlates, as are masses and foci compared to NME. The purpose of this study is to determine frequency of US correlate for NME, and to assess malignancy rate for NME with an US correlate versus NME without.
METHOD AND MATERIALS
An IRB-approved, retrospective review of 5,837 consecutive breast MRIs performed from 2005-2011 identified
928 NME lesions for which follow-up or biopsy was recommended. Two fellowship-trained breast radiologists

evaluated these using 5th edition BI-RADS lexicon to define lesion type, distribution, and internal enhancement pattern. Patient demographics and pathology results, including frequency of malignancy, were recorded.
Of the 928 NME lesions, 332(36%) were recommended for second-look US. 284/332 (86%) had the recommended second-look US. 48/332(14%) of lesions did not have recommended second-look US, for reasons including loss to follow-up (29/48, 60%), subsequent surgery (18/48, 38%), and proceeding directly to
MRI-guided biopsy (1/48, 2%).
RESULTS
In 64/284(23%), an US correlate was seen. US-guided biopsy was recommended for 43/64(67%) lesions. Of the 43 recommended US biopsies, 39/43(91%) were performed yielding: 7/39(18%) malignancies (4 IDC, 2
ILC, 1 DCIS), 6/39(15%) high risk (HR) lesions or atypia (3 papillomas, 3 atypia), and 24/39(62%) benign.
1/39 (3%) US biopsy was non-diagnostic but ultimately yielded DCIS on MRI biopsy. Pathology was not available for 1/39(3%).
Of the remaining 21/64(33%) cases in which a correlate was seen, 4/21(19%) were recommended for surgery/surgical consultation (2 IDC, 1 ILC, 1 papilloma), 4/21(19%) for 6-month follow-up US (no malignancy detected on f/u), and 13/21(62%) for 6-month f/u MRI (no malignancy on f/u).
In 220/287(77%) no US correlate was seen. MRI biopsy was performed on 107/220(48%) of these lesions which yielded 13/107(12%) malignancies (3 IDC, 7 DCIS, 3 ILC), 15/107(14%) HR lesions/atypia (3 papilloma,
4 LCIS, 5 radial scar/sclerosing lesion, 3 atypia), and 79/103(77%) benign pathology. 1/15(7%) HR lesion was upgraded at surgery to ILC.
CONCLUSION
The yield for detecting an US correlate for MRI-detected NME is low (23%) with an 18% rate of malignancy, compared with 12% of NME without US correlate.
CLINICAL RELEVANCE/APPLICATION
All suspicious NME should undergo biopsy, regardless of whether a sonographic correlate is identified.
SSM01-05 Rim and other Patterns of Stiffness on ShearWave™ Elastography (SWE) as Predictors of Malignancy in the BE1 Trial
Ellen Xiameng Sun (Presenter): Nothing to Disclose , Wendie A. Berg MD, PhD : Research Grant, Gamma
Medica, Inc Research Grant, General Electric Company Equipment support, Gamma Medica, Inc Equipment support, General Electric Company , Joel Gay : Employee, SuperSonic Imagine , Claude Cohen-Bacrie MD,
PhD : Executive Vice President, SuperSonic Imagine Officer, SuperSonic Imagine
PURPOSE
Stiffness within a mass ± surrounding tissue on ShearWave elastography (SWE) correlates with increasing risk of malignancy; we sought to determine if stiffness distribution was predictive of malignancy.
METHOD AND MATERIALS
From 9/2008 to 9/2010, at 16 centers in Europe and USA, 1647 women with breast masses consented to repeat US and SWE imaging (SuperSonic Imagine, Aix-en-Provence, France). 1562 women/masses had acceptable reference standard; 37 were excluded due to artifacts. Uniplanar SWE images were reviewed for visual and quantitative stiffness as well as pattern of maximum stiffness: rim, scattered foci within and adjacent to mass, only within mass, adjacent region, adjacent focus, stiffness neither within nor adjacent to mass, or no stiffness. We also evaluated BI-RADS 3/4a masses for any rim stiffness.
RESULTS
1525 women (median age 50 yrs, mean 51.8, range 21-94) and masses (median 12 mm, mean 14, range 1-53) were evaluated, including 494 (32.4%) malignant. Maximum stiffness as a rim was seen with 342 (22.5%) of masses: 177 (51.7%) malignant (odds ratio, OR, 19, 95%CI 6.2-55, after correcting for grayscale BI-RADS assessment). Other patterns also correlated with increased risk of malignancy, including within mass (OR 17), adjacent region or focus (OR 18 and 11 respectively), and scattered foci within or adjacent to mass (OR 10).
Stiffness not within or immediately adjacent to mass was not predictive of outcome, with 5/97 (5.2%) of such masses malignant (OR 1.8, 95%CI 0.4-8.3); this likely represents artifact. Of 254 masses without any stiffness,
6 (2.4%) were malignant. Of 428 BI-RADS 3 lesions, 9 (2.1%) were malignant; 8/105 (7.6%) with stiff rim were malignant. Among 390 BI-RADS 4a lesions, 40 (10%) were malignant; 27/110 (24.5%) with stiff rim were malignant; 4/62 (6.5%) soft masses with any SWE rim were malignant; and 5/31 (16%) otherwise stiff masses were malignant. 4/187 (2.1%) soft BI-RADS 4a masses without any stiffness or rim were malignant.
CONCLUSION
Among BI-RADS 3 masses, 1/323 (0.3%) lacking a stiff rim on SWE were malignant. Among BI-RADS 4a masses, any pattern of SWE stiffness in or around the mass, or, for soft masses, a rim, would have identified
36/40 (90%) malignancies, leaving 4 (2.1%) malignancy rate among 187 remaining BI-RADS 4a masses.
CLINICAL RELEVANCE/APPLICATION
The presence of absolute ± rim SWE stiffness among probably benign or low suspicion masses seen on breast
US should prompt biopsy.

SSM01-06 Clinical Value of Relative Quantification Ultrasound Elastography in Characterizing Breast Tumors
Alice Carboni (Presenter): Nothing to Disclose , Alfonso Fausto MD : Research Consultant, General Electric
Company , Cosimo Damiano Forte : Nothing to Disclose , Luca Volterrani : Nothing to Disclose
PURPOSE
To evaluate ultrasound elastography using strain ratio (SR), a relative quantification approach for breast lesions characterization.
METHOD AND MATERIALS
One hundred forty-seven consecutive patients (52±14 years) with a total of 156 breast lesions underwent to ultrasound elastography. For each lesion evaluation, a movie of at least 5 seconds was recorded. Technical accuracy was assessed automatically. To obtain dynamic SR evaluation a rounded small region of interest was depicted inside the fat tissue (F), in the glandular tissue (G) and the in the lesion (L), preferably at the same depth. Mean value of the ratio between G and F resulted in background tissue composition elasticity: R1; mean value of L/F resulted in lesion elasticity: R2, both evaluated in arbitrary unit (au). A two-years follow-up and pathology results were the standard of reference. Discordances between BI-RADS classification and R2 values were also evaluated. Mann-Whitney test, ROC analysis and Chi-square with Yates correction were used.
RESULTS
A high technical accuracy was obtained in all examinations. Twenty-seven out of 156 lesions were cysts, 25 with a typical three-layer artifact. Seventeen were malignant lesions (13 IDC, 2 IDC+DCIS, 1 DCIS and 1 ILC) and
112 benign lesions (90 fibroadenomas, 7 lymph nodes, 5 fat necrosis, 5 sclerosing adenosis, 2 adenosis, 2 mastitis, 1 radial scar). R1 values were 1.6±0.7au and 1.2±0.9au (mean±SD); R2 values were 6.1±2.5au and
1.9±1.3au for malignant and benign lesions, respectively (P
CONCLUSION
Relative quantification of ultrasound elastography allows to find high levels of diagnostic accuracy in characterizing breast tumors above all in downgrading BI-RADS 3 and 4 lesions.
CLINICAL RELEVANCE/APPLICATION
A high specificity is found using a relative quantification ultrasound elastography despite of background tissue composition. The application of this technique could reduce useless biopsy.
Multisession Courses
ER US GU
AMA PRA Category 1 Credits ™ : 1.50
ARRT Category A+ Credits: 1.50
Wed, Dec 3 3:30 PM - 5:00 PM Location: S406A
Sub-Events
MSCU42A GYN Challenging Cases
Oksana Helena Baltarowich MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Recognize the sonographic features of various manifestations of gynecological pathologies. 2) Discuss the differential diagnosis for each entity.
ABSTRACT
A variety of sonographic images of gynecological pathologies will be shown as unknowns. Differential diagnoses will be discussed for each entity. The most likely diagnosis will be revealed in the context of the clinical setting in which it was presented.
MSCU42B Acute Abdomen: Diagnosis and Intervention
Michael David Beland MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Recognize when ultrasound is an appropriate first line imaging modality for the patient presenting with acute abdominal pain. 2) Be able to recognize the pertinent postive and negative findings on ultrasound when evaluating common and occasionally uncommon causes of acute abdominal pain. 3) Learn when to consider ultrasound as a modality for performing interventions to treat the patient presenting with acute abdominal pain.

MSCU42C
ABSTRACT
Ultrasound is often the first line imaging modality for the patient presenting with acute abdominal pain. This is particularly true when there is a high clinical suspicion of biliary or renal etiologies. Through multiple case presentations, this session will review the ultrasound findings one may encounter when working up acute abdominal pain. In addition,cases where ultrasound guided interventions may be appropriate in patients present with abdominal pain will be shown. Audience involvement will be encouraged through the use of audience response.
Head to Toe: Small Parts Matter!
Deborah J. Rubens MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Review some of the common pathologic entities involving superficial glands and structures. 2) Emphasize the unique technical parameters which are critical to optimize imaging of small parts. 3) Test the attendant's knowledge of some critical decision pathways in superficial pathology.
ABSTRACT
High frequency ultrasound is a powerful tool to assess superficial structures including the neck (thyroid, parathyroid, other neck masses) chest and abdominal wall, extremities and the scrotum. Accurate performance requires optimizing scanning frequency for adequate tissue penetration as well as Doppler sensitivity to differentiate fluid collections from tumors, to assess organs for blood flow and to diagnose inflammatory conditions. Cases will be selected to emphasize thyroid, neck, testicular and extra-testicular pathology, particularly those cases which require urgent surgical or medical intervention such as incomplete or partial torsion, hernias and testicular ischemia. Additional cases will include symptomatic lumps and bumps as well as the incidentalomas one commonly encounters in superficial scanning.
Active Handout http://media.rsna.org/media/abstract/2014/14001451/MSCU42C sec.pdf
Multisession Courses
US MR CT US MR CT
AMA PRA Category 1 Credits ™ : 1.00
ARRT Category A+ Credit: 1.00
Wed, Dec 3 3:40 PM - 4:40 PM Location: N230AB
Participants
Karen Letourneau (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Identify the role of diagnostic imaging in the diagnosis and treatment in Tuberous Sclerosis Complex (TSC). 2) Recognize the limitations of various modalities in the diagnosis of specific pathologies. 3) Compare the utility and efficacy of CT, MR, ultrasound and plain films in identification of the common pathologic conditions associated with TSC. 4) Gain understanding of the patient's and the family perspective in diagnostic imaging departments.
ABSTRACT
ABSTRACT We present a case report of a patient with all the typical lesions of tuberous sclerosis complex(TSC); renal angiomyolipoma, renal cysts, cardiac rhabdomyoma cortical tubers and subependymal nodules. Our case also demonstrates atypical findings in TSC; abdominal aortic aneurysm and renal cell carcinoma. A brief overview of the disease will be presented however, we have limited the majority of the discussion to the aspects of this disease in which diagnostic imaging, i.e.; CT, MR, ultrasound and plain films plays a vital role in the diagnosis and treatment planning of this complex disease.
Refresher/Informatics
US NR HN
AMA PRA Category 1 Credits ™ : 1.50
ARRT Category A+ Credits: 1.50
Thu, Dec 4 8:30 AM - 10:00 AM Location: N227AB
Sub-Events
RC610A Thyroid Nodules: When and What to Biopsy
Jill Eve Langer MD (Presenter): Consultant, BioClinica, Inc

RC610B
RC610C
LEARNING OBJECTIVES
1) Discuss the sonographic characteristics that are associated with a high probability that a thyroid nodule is likely malignant or likely benign. 3) Gain an understanding of the rationale of the current guidelines for recommending thyroid fine needle aspiration.
ABSTRACT
As an overview, this presentation will review the epidemiology of thyroid nodules and correlate the sonographic findings with the risk of malignancy or the likelihood that the appearance represents a benign hyperplastic thyroid nodule rather than a true neoplasm. Additionally, the rationale for current guidelines for recommending thyroid fine needle aspiration will be discussed. The prevalence of palpable thyroid nodules is estimated to be
6.4% in women and 1.5% in men between 30 to 60 years of age, living in iodine-sufficient regions. However, high resolution sonography of the neck has been shown to be a much more sensitive technique than palpation, detecting nodules in 19 to 67% of randomly selected adults, with detection rates greater in women and increasing with age for both genders. Fortunately the vast majority of sonographically detected thyroid nodules are benign, hyperplasic regions of the thyroid. Fine-needle aspiration biopsy (FNA) is still considered the most reliable diagnostic test to determine if a thyroid nodule is malignant. Malignant nodules account for approximately 5% of all nodules that undergo palpation-guided FNA and approximately 10 to 15% of nodules that undergo sonography-guided FNA procedures. Analysis of the sonographic features of thyroid nodules has become the preeminent non-invasive tool for analyzing the risk of malignancy of thyroid nodules and aids in selecting which nodules should undergo fine needle aspiration (FNA). A number of recently published guidelines and consensus statements emphasize that the sonographic appearance of a nodule is a superior predictor of malignancy compared with nodule size or palpability and that when sonographic features of malignancy are noted, the nodule should undergo FNA. A number of sonographic features have shown a high specificity for the diagnosis of thyroid cancer and include marked hypoechogenicity, the presence of microcalcifications, infiltrating or micro-lobulated borders, and a taller-
Post-Thyroidectomy Neck
Carl C. Reading MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Recognize the sonographic appearance of recurrent and metastatic disease, and other abnormalities, in the post-operative neck.
ABSTRACT
In the post-thyroidectomy neck, ultrasound surveillance is a highly effective method to evaluate for residual and recurrent disease. Recurrence can occur anywhere within the neck, but typically is located in the mid and low internal jugular chains and thyroid bed region. Abnormal cervical lymph nodes can be recognized with a high degree of accuracy due to abnormal size, shape, internal architecture, and color Doppler appearance. In patients with suspected metastatic papillary cancer, the presence of internal fluid or calcifications is highly predictive of malignancy. Abnormal nodal color Doppler flow including peripheral (non-hilar), increased, and irregular flow is highly predictive of malignancy. Within the post-operative thyroid bed, itself, residual thyroid tissue, tumor recurrence, and suture granulomas can occur. FNA for cytologic analysis of suspected abnormalities can be performed, and the addition of thyroglobulin and calcitonin assay of the specimen, for papillary and medullary cancer, respectively, adds a high degree of accuracy to this procedure.
Parathyroid and Other Neck Masses
Mary Catherine Frates MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Understand the best method to detect abnormalities of the parathyroid gland. 2) Gain understanding of the wide variety of lesions that can be found in the neck outside of the thyroid gland. 3) How to differentiate between these lesions based on their sonographic characteristics.
Refresher/Informatics
US BR
AMA PRA Category 1 Credits ™ : 1.50
ARRT Category A+ Credits: 1.50
Thu, Dec 4 8:30 AM - 10:00 AM Location: E450A
Sub-Events
RC615A High-quality Breast US
Janice S. Sung MD (Presenter): Nothing to Disclose

RC615B
RC615C
Janice S. Sung MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) To review basic ultrasound principles used to create high quality images. 2) To understand appropriate breast ultrasound technique and documentation. 3) To improve knowledge regarding breast ultrasound accreditation, including image evaluation and biopsy case assessment.
Challenging Cases
Bruno D. Fornage MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) To review common and less common causes of artifacts, diagnostic errors, and pitfalls, and ways to identify them. 2) To describe tips and tricks to optimize the acquisition and interpretation of sonograms of the breasts and nodal basins.
Whole Breast Screening
Stamatia V. Destounis MD (Presenter): Investigator, FUJIFILM Holdings Corporation Investigator, Seno
Medical Instruments, Inc
LEARNING OBJECTIVES
1) Review of current screening breast ultrasound legislation and the impact on breast imaging centers. 2) To review and discuss available automated breast ultrasound technologies utilized for screening ultrasound. 3)
Discussion of clinical experience with handheld screening ultrasound.4) Review of current published literature.
Refresher/Informatics
IR US MR
AMA PRA Category 1 Credits ™ : 1.50
ARRT Category A+ Credits: 1.50
Thu, Dec 4 8:30 AM - 10:00 AM Location: S504CD
Participants
Moderator
Pejman Ghanouni MD, PhD : Research Grant, General Electric Company Research Grant, InSightec Ltd
Sub-Events
RC617A Body Applications of MR-Guided High Intensity Focused Ultrasound
Wladyslaw Michal Witold Gedroyc MBBS, MRCP (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Where Can FUS be applied. 2) What are the current and future applications of FUS in the general body area.
3) What are the technological problems of FUS in this field. 4)How may these problems be overcome. 5) What requirements does a prostate FUS system require for safe and effective application. 6) What are the potential complications of prostate MR guided FUS. 7) What are the technological requirements necessary to improve MR guided focused ultrasound therapy to the liver. 8) What other areas can MR guided focused ultrasound potentially be applied to in the body.
ABSTRACT
The largest area of FUS application has been of uterine fibroids but this application has shown the potential for similar procedures to be carried out in other areas of the body.. Because of the outpatient non-invasive nature of the procedure FUS becomesa highly cost-effective method of achieving destruction of abnomal tissue without invasion. Percutaneous destruction of liver tumours in a completely non-invasive manner would change therapy to the liver radically. FUS holds out such a prospect but the technological improvements required to our current machinery are substantial. The barrier of the FUS absorbing rib cage is hard to overcome and to date MR guided focused ultrasound has only been able to reach lesions that are not covered by ribs. The movement produced by respiration presents a significant problem currently addressed by controlled ventilation during FUS
. Technological improvements are slowly being implemented to address these areas. Similar constraints apply to other upper abdominal organs which move with respiration and technological improvements to allow liver
FUS equally apply to kidneys and spleen. New endorectal MR guided transducers which can ablate areas of the prostate under accurate MR targeting and thermal control are in phase 1 studies treating low risk prostate carcinoma and looking at safety and early efficacy. These results will be discussed. A brief discussion of MR guided focused ultrasound application to the breast and soft tissue tumours will also be presented as well as the possibility of FUS utilisation in soft tissues.

RC617B
RC617C
RC617D
Neurologic Applications of MR-guided HIFU
Max Wintermark MD (Presenter): Research Grant, General Electric Company Research Grant, Koninklijke
Philips NV
LEARNING OBJECTIVES
1) To understand the neuro applications of HIFU. 2) To understand the challenges of applying HIFU for neuro applications. 3) To review the ongoing trials of neuro applications of HIFU.
Treatment of Fibroids with MR-guided HIFU
Matthias Matzko MD (Presenter): CEO, Imaging Service AG Shareholder, Imaging Service AG
LEARNING OBJECTIVES
1) To become familiar with the basic physical principles of HIFU and the potential of MR guidance. 2) To approach selection criteria in MRI screening examinations for accurate indications and identify contraindications and non-suitable patients. 3) To appreciate current results and potential therapy regimens. 4) To understand recent technical developments and their potential.
Palliation of Painful Metastases to Bone
Pejman Ghanouni MD, PhD (Presenter): Research Grant, General Electric Company Research Grant,
InSightec Ltd
LEARNING OBJECTIVES
1) Therapeutic options for palliation of painful metastases to bone. 2) Patient selection for MR guided focused ultrasound palliation of painful bone metastases. 3) Results of Phase III pivotal study of ExAblate MR guided focused ultrasound for palliation of painful bone metastases. 4) Technical aspects of successful patient treatment. 5) Immediate post-treatment imaging-based assessment of results. 6) Future applications of MR guided focused ultrasound for the management of osseous metastatic disease.
ABSTRACT
Cancer patients commonly have metastases to bone; as the survival of cancer patients is prolonged by more effective therapies, the prevalence of patients with metastases to bone is also increasing. Bone metastases are often painful, and often diminish the quality of life. Radiation therapy (RT) is the standard of care for the treatment of bone metastases, but a significant subset of patients do not respond to RT. MR guided focused ultrasound non-invasively achieves localized tissue ablation and provides a proven method of pain relief in patients who do not respond to radiation therapy. MR imaging provides a combination of tumor targeting, real-time monitoring during treatment, and immediate verification of successful treatment. The results of the pivotal Phase III trial that led to FDA approval of the ExAblate MR guided focused ultrasound device for the palliation of painful metastases to bone will be reviewed. In particular, patient selection, the technical aspects of successful patient treatment, and post-treatment assessment of results will be described. Concepts for future development of this technology with regard to the management of osseous metastatic disease will also be presented.
Refresher/Informatics
IR US IR US
AMA PRA Category 1 Credits ™ : 1.50
ARRT Category A+ Credits: 1.50
Thu, Dec 4 8:30 AM - 10:00 AM Location: E264
Participants
Patrick Warren MD (Presenter): Nothing to Disclose
William Eugene Shiels DO (Presenter): President, Mauka Medical Corporation Royalties, Mauka Medical Corporation Patent holder, Mauka Medical Corporation
Veronica Josephine Rooks MD (Presenter): Nothing to Disclose
Humberto Gerardo Rosas MD (Presenter): Nothing to Disclose
Corrie Marlene Yablon MD (Presenter): Nothing to Disclose
Andrada Roxana Popescu MD (Presenter): Nothing to Disclose
Linda J. Warren MD (Presenter): Shareholder, Hologic, Inc
Hisham A. Tchelepi MD (Presenter): Nothing to Disclose
John Miras Racadio MD (Presenter): Research Consultant, Koninklijke Philips NV Travel support, Koninklijke Philips NV
Neil T. Specht MD (Presenter): Nothing to Disclose
Mahesh M. Thapa MD (Presenter): Nothing to Disclose
Kristin Marie Dittmar MD (Presenter): Nothing to Disclose
James Walter Murakami MD (Presenter): Nothing to Disclose
Neil David Johnson MD (Presenter): Royalties, Merge Healthcare Incorporated
Stephen Clifford O'Connor MD (Presenter): Nothing to Disclose

LEARNING OBJECTIVES
1) Identify basic skills, techniques, and pitfalls of freehand invasive sonography. 2) Discuss and perform basic skills involved in thermal tumor ablation in a live learning model. 3) Perform specific US-guided procedures to include core biopsy, abscess drainage, vascular access, cyst aspiration, soft tissue foreign body removal, and radiofrequency tumor ablation. 4) Incorporate these component skill sets into further life-long learning for expansion of competency and preparation for more advanced interventional sonographic learning opportunities.
Scientific Papers
US MR CT GU
AMA PRA Category 1 Credits ™ : 1.50
ARRT Category A+ Credits: 1.50
Thu, Dec 4 10:30 AM - 12:00 PM Location: E353B
Participants
Moderator
Hakmin Park MD : Nothing to Disclose
Moderator
Ruth P. Lim MBBS, MMed : Nothing to Disclose
Sub-Events
SSQ09-01 Genitourinary Keynote Speaker: Renal CTA and MRA—When and How?
Ruth P. Lim MBBS, MMed (Presenter): Nothing to Disclose
SSQ09-02 Cortical and Medulla Oxygenation Evaluation of Kidneys with Renal Artery Stenosis by BOLD MRI
Comparing with Healthy Volunteers
Zhao Long (Presenter): Nothing to Disclose , Jiayi Liu : Nothing to Disclose , Zhanming Fan : Nothing to
Disclose
PURPOSE
The purpose of this study was to compare R2* value of renal artery stenosis (RAS) patients with the degree of
RAS of its own and R2* value of control group respectively, and therefore evaluate different levels of renal hypoxia by BOLD MRI.
METHOD AND MATERIALS
We compared 51 renal arteriosclerosis kidneys with 32 healthy kidneys of volunteers. We also compared 4 subgroups of renal arteriosclerosis kidneys, 16 without obvious RAS, 6 with mild RAS, 9 with moderate RAS and
20 with severe RAS. BOLD signal was measured in the cortex and medulla by a 3.0T MR scanner. The severity of vascular occlusion was determined by intervention.
RESULTS
For all groups, medulla R2* values, reflecting the deoxyhemoglobin, were higher than cortex R2* values. Both cortex and medulla R2* values of renal arteriosclerosis kidneys (21.14±4.90/s, 36.25±8.04/s) were higher than corresponding R2* values of control group (18.23±1.77/s, 29.61±2.26/s) (P<0.05), and a more sensitive change was found in medulla. For RAS subgroups, medulla R2* values for severe RAS (44.20±6.01/s) elevated as compared with unobstructed, mild, moderate stenosis subgroups (29.87±3.92/s, 33.15±2.42/s,
31.98±4.28/s) (P<0.05), but cortex R2* values for severe RAS(24.06±5.94/s) were found no significant difference from mild, moderate stenosis subgroups(20.20±2.01/s, 19.14±1.86/s) while it was higher than unobstructed subgroup(18.96±3.62/s) (P<0.05). Besides, combing mild and moderate RAS as one group, both cortex and medulla R2* values of this group (19.56±1.92/s, 32.44±3.59/s) elevated as compared with control group (P<0.05).
CONCLUSION
This study shows that BOLD MR can noninvasively detect different levels of renal hypoxia induced by RAS with different severities of vascular occlusion. It can play an important role in estimation of kidney oxygenation changes when vascular occlusion overwhelms the capacity of the kidney to adapt to reduced blood flow. R2* value may become an index to identify the severity of renal hypoxia and parenchymal injury.
CLINICAL RELEVANCE/APPLICATION
BOLD MRI is an effective and noninvasive method to evaluate the oxygenation state of kidney. It can play an important role in estimation of kidney oxygenation changes when RAS exists. BOLD MRI is a sensitive tool which can be used to detect ischemia and anoxia of medulla of kidney.
SSQ09-03 The Comparative Study on Image Quality of Renal Artery CT Angiography by Iterative
Reconstructions and Filtered Back Projection

SSQ09-04
Pinggui Lei (Presenter): Nothing to Disclose , Xiaoying Wang MD : Nothing to Disclose , Yufeng Xu :
Nothing to Disclose , He Wang MD : Research Grant, General Electric Company , Xiaochao Guo MD :
Nothing to Disclose , Jianxin Liu : Nothing to Disclose
PURPOSE
The purpose of this study was to evaluate the image quality and image noise of artery CT angiography with iterative reconstructions which based on the original data from dual-source dual-energy CT.
METHOD AND MATERIALS
Fourteen consecutive patients underwent dual-energy (DE) renal artery CTA examination [Somatom Definition
FLASH, (Siemens Healthcare, Germany)] were analyzed retrospectively. Tube voltage 80 kV and Sn140kV; tube current 250mAs and 106mAs; collimation 128×0.6mm. Data sets were reconstructed with Sinogram Affirmed
Iterative Reconstruction (SAFIRE) and filtered back projection (FBP) base on original data.CTDI vol and SSDE were recorded and calculated. Image quality was evaluated by two experienced radiologists. For qualitative assessment, the whole quality of imaging, detail quality of imaging (sharpness of main renal artery and segmental vessels, segmental vessels displayed in MPR and MIP) were evaluated with 5 scale method (1=poor to 5=excellent). For quantitative assessment, attenuation values were measured in the vascular lumen of aorta, renal arteries and erector spinae major at almost same level, and contrast-to-noise ratio (CNR), signal-to-noise ratio (SNR) were calculated.
RESULTS
The mean value of CTDIvol and SSDE of renal CTA were (10.15±2.32) mGy and (12.93±1.82) mGy. There was significant difference in the whole imaging quality between 2 groups (Z=-3.61, P<0.05). There was no significant difference in the sharpness of vessels between the 2 groups(Z=-2.00, P=0.05); Whereas the segmental vessels displayed in MPR and MIP were not statistically different(Z=-0.00, P>0.05; Z=-0.00,
P>0.05), respectively. The attenuation values of abdominal aorta and renal artery in two groups were
[(211±34) HU vs. (213±34) HU, P>0.05] and [(196±38) HU vs. (193±36) HU, P0.05]. The CNR and SNR in two groups were (14±6 vs. 9±4, P
CONCLUSION
Compared with standard FBP reconstruction, SAFIRE improve image quality and has the potential to decrease radiation dose.
CLINICAL RELEVANCE/APPLICATION
Compare with FBP, SAFIRE reconstruction can achive better image quality, which help its clinical diagnosis and treatment.
Non Invasive Evaluation of Elasticity of Renal Parenchyma by Acoustic Radiation Force Impulse
Imaging
Vivek Kishor Pargaonkar MBBS (Presenter): Nothing to Disclose , Sudhakar K : Nothing to Disclose
PURPOSE
Prospective evaluation of diagnostic efficacy of acoustic radiation force impulse(ARFI) imaging to test the elasticity of renal parenchyma by measuring the shear wave velocity(SWV) which might be used to detect chronic kidney disease(CKD).
METHOD AND MATERIALS
Fifty patients(age range 18-78yrs)with CKD were enrolled.Seventy three subjects(age range 18-71 yrs) without clinical, biochemical or ultrasound evidence of renal disease were also included and served as control group.An
ARFI value, expressed as speed (m/s) of wave propagation through the tissue,was calculated for each patient by calculating the mean of values obtained in both kidneys.The results were compared with the subjects in the control group.The potential influencing factors and measurement reproducibility were evaluated.Correlations
between SWV and laboratory tests were analyzed in CKD patients.Receiver-operating characteristic curve (ROC) analyses were performed to assess the diagnostic performance of ARFI.P value < 0.05 was considered statistically significant.
RESULTS
The mean SWV in control group was 2.93±0.58m/s,while 1.95±0.21,1.6±0.62,1.78±0.42,1.81±0.36 and
1.63±0.27m/s for stage 1,2,3,4 and 5 CKD patients respectively.The SWV was significantly higher for subjects in the control group compared with each stage in CKD patients.ARFI could not predict different stages of
CKD.The SWV of subjects in control group differed significantly between men and women(2.82±0.61vs3.08±0.50m/s,P=0.025,n=73).In CKD group also, the mean SWV was higher in women compared to men(1.83±0.32vs.1.71±0.40m/s,P=0.35,n=50).The SWV showed negative correlation with age in the control as well as CKD group.The Inter-observer agreement expressed as intraclass coefficient correlation was 0.65(95% CI 0.4368-0.8054, P=< 0.05,n=40).In CKD patients, SWV correlated to e-GFR(r=0.113,p=0.435),urea nitrogen (r=-0.155,p=0.283), and creatinine (r=-0.240,p=0.093).ROC analyses indicated that the area under the ROC curve was 0.974 (95% CI: 0.952-0.997,P< 0.001).The cut-off value for predicting CKD was 1.85m/s(sensitivity 97.3 %,specificity 64%).
CONCLUSION
A significant difference in the SWV in the control group compared to CKD group by ARFI indicates its potential role in the detection of CKD.
CLINICAL RELEVANCE/APPLICATION

SSQ09-05
SSQ09-06
ARFI can be a potential diagnostic,prognostic,simple,inexpensive,easily available,repeatable and accurate tool for non invasive evaluation of CKD.
Radiation Dose and Contrast Reduction during UFE Using 3D MRA Guidance versus Conventional 2D
Technique
Nishad Nadkarni MD (Presenter): Nothing to Disclose , Vikram S. Dravid MD : Nothing to Disclose , Anil
Syal MD : Nothing to Disclose , Atul Gupta MD : Nothing to Disclose
PURPOSE
To compare physician dose, patient dose, procedure time, contrast and fluoro time using the conventional 2D technique for uterine fibroid embolization (UFE) versus a novel 3D MRA guided UFE technique.
METHOD AND MATERIALS
Ten UFE procedures were performed at 2 hospitals in the same health system by 2 interventional radiologists, each with over 10 years of experience using the same imaging equipment and protocols. 5 of these cases were performed using the conventional 2D guidance technique and 5 were performed using a novel 3D MRA guidance technique, which allows real time fusion of a preexisting MRA with the live fluoroscopy stream to create a visual roadmap during UFE. The physician dose (�Sv), patient dose (DAP), procedure time (min), non-embolic contrast (mL), and fluoro time (min) were compared.
RESULTS
There was a 94% reduction in average physician dose using 3D MRA guidance (18.6 �Sv) versus the conventional 2D technique (308.6 �Sv). There was an 83% reduction in average patient radiation dose using
3D MRA guidance (68.5 Gy.cm2) versus 2D technique (401.6 Gy.cm2). A 49% reduction in procedure time was noted using 3D MRA guidance (40 min) versus 2D technique (78 min). A 55% reduction was noted in non-embolic contrast utilized using 3D MRA technique (39 ml) versus 2D technique (86 ml). There was a 57% reduction in fluoroscopy time using 3D MRA guidance (10.8 min) versus 2D technique (24.9 min).
CONCLUSION
There is a notable and statistically significant reduction (p < 0.05) in physician and patient radiation dose, procedure time, non-embolic contrast utilized and fluoro time using 3D MRA guidance for UFE.
CLINICAL RELEVANCE/APPLICATION
Radiation exposure not only to patient, but also to physician is of great concern. The Novel 3D MRA guidance technique not only reduces radiation to physician and patient, but also reduces procedure time, contrast utilized and fluoroscopy time.
Refining the Role of Contrast Enhanced Ultrasound in the Characterisation of Renal Lesions
Claire Cuscaden MBBS (Presenter): Nothing to Disclose , Alain M. Lavoipierre MD : Nothing to Disclose ,
Mark Frydenberg MBBS : Nothing to Disclose , Daniel Moon MBBS : Nothing to Disclose , Mark Smyth :
Nothing to Disclose , Melissa Scott : Nothing to Disclose
PURPOSE
The aim of this study was to assess further the role of contrast enhanced ultrasound (CEUS) in the characterisation of renal lesions, with an emphasis on Bosniak 2F lesions.
METHOD AND MATERIALS
Over a 40 month period, a total of 90 CEUS examinations were performed at our institution, involving 65 patients with a total of 77 lesions. All patients had had prior CT, MRI or, less commonly, US examinations. All patients were examined on Philips iU22 equipment, with the administration of intravenous boluses of intravenous perflutren (Definity TM). The examinations were all performed by a single radiologis. In those patients who subsequently underwent core biopsy 18G Bard Biopty equipment was used. Sonographically, the lesions were classified as cystic or solid, and the cysts characterised according to the Bosniak classification.
RESULTS
In total, 77 lesions were examined after CT Bosniak grading. Of these, the CT graded Bosniak 2F lesions comprised 32% (n=25). All were reclassified according to imaging characteristics on CEUS with 28% downgraded to Bosniak 1 and 2 (confirmed stability with 2 year follow up). 40% were upgraded to Bosniak 3 and 8% remained as Bosniak 2F. 16% (n=12) were CT graded as Bosniak 3 on CT. 60% contained features consistent with Bosniak III. 20% were upgraded to Bosniak IV (confirmed with histology) and 20% were downgraded to Bosniak II. All CEUS graded Bosniak 4 lesions were confirmed to be malignant on histology. Of the solid, malignant appearing lesions examined with CEUS, 94% were confirmed as such with histology.
CONCLUSION
CEUS offers improved contrast resolution relative to CT or MRI and plays an important role in the characterisation of renal lesions by • Helping to visualise vascularity in solid lesions or in solid components of cystic lesions with borderline or difficult to assess enhancement on CT or MRI • Upgrading or downgrading lesion as a consequence of the improved contrast resolution which therefore allows better visualisation of lesion vascularity
CLINICAL RELEVANCE/APPLICATION
• Virtually abolishing the Bosniak 2F category • Allowing assessment or follow up of renal lesions, particularly in patients with impaired renal function or allergy to iodinated contrast medium, and also to avoid excessive radiation in patients requiring longer term follow up.

SSQ09-07 Perfusion-CT as a Potential Predictor for Response to Antiangiogenic Therapy with Multikinase
Inhibitors in Patients with Metastatic Renal Cell Cancer: Preliminary Results of a Pilot Study
Alexander Sterzik (Presenter): Nothing to Disclose , Michael Staehler MD : Nothing to Disclose , Jozefina
Casuscelli : Nothing to Disclose , Martina Karpitschka MD : Nothing to Disclose , Florian Schwarz MD :
Nothing to Disclose , Maximilian F. Reiser MD : Nothing to Disclose , Anno Graser MD : Speakers Bureau,
Siemens AG Speakers Bureau, Bracco Group Speakers Bureau, Pfizer Inc Consultant, Bayer AG Grant, Bayer AG
PURPOSE
To evaluate the role of dynamic contrast-enhanced computertomography (DCE-CT, perfusion CT) as a potential biomarker in predicting response to antiangiogenic therapy with multikinase inhibitors (MKI) in patients with metastatic renal cell carcinoma (mRCC). ).
METHOD AND MATERIALS
48 mRCC patients were prospectively enrolled of which 38 were included in the current study. CT perfusion imaging of representative metastatic lesions was performed before and 8 weeks after start of treatment with
Sunitinib (n=28) or Pazopanib (n=10). The DCE-CT protocol included a targeted dynamic acquisition starting 4
- 8 s after injection of 50 ml of contrast media at 6 ml/s using a 4D spiral mode technique (10 cm z-axis coverage, scan duration 44sec, 100 kVp (abdomen), 80 kVp (chest), 100 mAs) on a dual source scanner
(Siemens Somatom Definition Flash). Blood flow (BF), blood volume (BV) and permeability-surface area product
(PS) were calculated for the entire tumor volume. DCE-CT results were correlated with Response Evaluation
Criteria in Solid Tumors response (RECIST) and with progression-free interval (PFI) using Spearman rank correlation, Wilcoxon test, Mann-Whitney U test and Kaplan-Meier statistics.
RESULTS
Responders (n=14) - defined by their best overall response according to RECIST - showed significantly higher baseline values of BF and BV as well as a significantly higher reduction of BF/BF parameters after 8 weeks of
AAT than those with stable disease (n = 21) or progressive disease (n=4), (all p-values <0.05). A definition of
>50% reduction of BF and BV after 8 weeks of antiangiogenic therapy as a cut-off value was identified to optimally discriminate patients with favorable outcome (median PFI of 10 months) from those with early progression (median PFI of 4 months) and enabled with a sensitivity and specificity of 75%, respectively 90% identification of poor responders with a PFI of < 7 months.
CONCLUSION
In patients with mRCC relative changes of tumor BF and BV assessed with CTP after 8 weeks of antiangiogenic
MKI-treatment may allow prognostic estimations of early therapy failure.
CLINICAL RELEVANCE/APPLICATION
Perfusion-CT predicts reponse to MKI-therapy in patients with mRCC allowing identification of poor responders with early therapy failure and therefore might help to optimize oncologic treatment in this tumor entity.
SSQ09-08 Analysis of 4-years Experience of Renal Transplant Colour Flow Ultrasonography (CFUS) and Renal
Arterial Resistive Index (RI) Measurement to Determine the Optimum Post-operative Renal
Transplant Imaging Protocol
Christopher Beirne MBBCh, MRCS (Presenter): Nothing to Disclose , Aisling Courtney MRCP, MBBCh :
Nothing to Disclose , John Trevor Lawson MD : Nothing to Disclose
PURPOSE
Ultrasonography is routinely performed following renal transplantation to assess for early complications including acute tubular necrosis, accelerated rejection, obstruction or collections and renal vein/renal artery thrombosis. The schedule of scans has been based on historical practice and many patients have multiple scans.
The resistive index, which is a measure of pulsatile flow affected by vascular resistance, heart rate and pulse pressure, is measured in all patients however its predictive relationship to post-operative complications has been debated and we have also assessed the value of routine RI measurement.
METHOD AND MATERIALS
Data from a prospectively maintained transplant surgery database was analysed and correlated with the ultrasound scan findings over a 4-year period January 2010 to December 2013. Initially a retrospective audit of all data was performed between January 2010 and December 2012. This was used to identify potential areas for service improvement. This included a review of the referral pattern and development of an optimal schedule for imaging as well as issues such as patient transportation and service provision in the out-of-hours setting.
These factors were subsequently addressed by a prospective audit performed immediately over the following 4 month period. As a consequence of this second audit, a protocol was then introduced to optimise service provision for all renal transplant patients. All subsequent transplant patients up until December 2013 were prospectively audited to ensure protocol safety. The timing of renal transplant ultrasonography (by post-operative day), CFUS, R.I. and significant renal and extra-renal findings were recorded. The R.I. of patients requiring post-operative biopsy, post-operative haemodiaysis or prolonged sonographic investigation
(>5 days) were also analysed for significance.
RESULTS
Total number of patients (n=324). Mean age = 44 years (range 3-73 years). Living related/unrelated donor
(n=204) versus cadaveric donor (n= 120). Within the initial audit period January 2010 -December 2013:

SSQ09-09
Transplant cases, n = 223. Mean number of ultrasound exams performed per patient, n=6.1 (4 - 14). Number of acute transplant rejections (n=3, 1.6%), RI >1 (n=2). There was no significant difference in RI within surviving grafts (live or cadaveric donor) assessed at days 1, 3, 4 or 5 (p=0.69, 0.5, 0.71 or 0.83 respectively).
RI was not significantly different in patients requiring biopsy or post-operative haemodialysis (p=0.71, 0.82).
During the first prospective audit January 2013 - April 2013: Transplant cases, n= 36. Mean number of ultrasound exams performed per patient, n=4.19 (2 - 9). Number of acute transplant rejections (n=0), RI >1
(n=1). With the protocol implemented during May 2013 - December 2013: Transplant cases, n = 65. Mean number of ultrasound exams performed per patient, n = 3.4 (2 - 12). Number of acute transplant rejections (n
= 1, 1.5%), R.I. >1 (n=0). During both the re-audit and protocol implemented period the R.I was not found to be significantly different between patients who had a satisfactory post-transplant course and those patients who were not progressing satisfactorily and required biopsy or post-operative haemodialysis (p=0.64, 0.5). There was also a marked reduction in examinations performed within both the re-audit and protocol period, when the patients were imaged according to an agreed schedule and directed referral pattern.
CONCLUSION
Renal transplant patients in the immediate post-operative period do not routinely require multiple CFUS with RI calculation. RI does not reliably predict patients requiring biopsy or prolonged post-operative dialysis. Patients with elevated RI's (>1) have an increased association with acute rejection, and a low threshold for performing ultrasound is indicated when graft rejection is suspected. In those patients who have undergone uncomplicated surgical and who have a smooth post-operative course we have successfully introduced a protocol within our institution to perform CFUS on Day 1 and 5 (living donor) and Day 1, 3 and 5 (cadaveric donor). This enables a more efficient use of the ultrasound department and our out of hours service with no detriment to patient care.
Those patients who are at increased risk are also better identified as the request forms have been re-designed to ensure that all relevant clinical details are available to the radiologist. An additional benefit is a significant cost saving (annual reduction in CFUS examinations of approximately 2.7 scans per patient with approximately
100 transplants per year), with much of the reduction being in out of hours scanning.
BMI-based Tube Kilovolt Selection Combined with Iodixanol (270 mg I/mL) and Iohexol (350 mg
I/mL) in Achieving Coherent Vascular Enhancement in Renal Artery CT Angiography
Yan Liang MMed (Presenter): Nothing to Disclose , Zhiren Chen MD : Nothing to Disclose , Chuang Yi :
Research Grant, General Electric Company , Bin 00617875. Li : Nothing to Disclose , Dongbin Shi : Nothing to Disclose , Yongfang Yin : Nothing to Disclose
PURPOSE
To compare vascular enhancement between a low-kilovoltage renal artery CT angiography (CTA) protocol using a low-concentration iodixanol(270mgI/mL) and routine 120kV protocol with high-concentration iohexol(350 mg
I/mL) contrast medium .
METHOD AND MATERIALS
30 patients (body mass index, ≤ 23 kg/m(2)) with suspected renal artery stenosis underwent renal artery CTA with a 64-MDCT scanner using a tube voltage of 80 kV. Patients were received 70 mL of iodixanol (270 mg
I/mL) injected at a rate of 5 mL/s. And 32 patients(BMI>23 kg/m(2)) were administered an equal volume of iomeprol (350 mg I/mL) at a delevery rate of 5 mL/s. Images of 80kVp group were post-processed with adaptive statistical iterative algorithm(50%ASiR).For both groups, the CT values and SD values of aorta, subcutaneous fat and the erector spine muscle were measured, and the averaged SD value was calculated as the image noise. The signal-noise-ratio (SNR) and contrast-noise-ratio (CNR) for aorta, artery and left renal artery and right renal artery were calculated respectively.
RESULTS
For low-kVwith ASiR group, the enhancement of aorta , artery and left renal artery and right renal artery
(223.4±23.8, 261.0±32.2 and 267.2±31.0) were compatible with those in routine120 kV group(271.3±30.4,
223.9±25.6 and 256.3±32.1)(each p>0.05). The CNR of aorta , artery and left renal artery and right renal artery (32.1±7.8, 32.4±6.7 and 31.8±4.7) in low-kVCTA group was slightly higher than those in conventional
CTA group(28.6±6.4,29.9±6.1 and 29.3±9.4)(each p>0.05). Enhancement homogeneity was good with both contrast agents, with no statistically significant difference between them (p>0.05)
CONCLUSION
In 80-kV renal artery CTA of lean patients, higher intravascular enhancement can be achieved with iodixanol(270 mg I/mL),with good vessel conspicuity down to the sub-segmental level.
CLINICAL RELEVANCE/APPLICATION
In patients of BMI<=23 with reduced contrast medium, low-kV (80kV) renal artery CTA provides compatible image quality with conventional (120kV) renal artery CTA.
Scientific Papers
US MR IR GU
AMA PRA Category 1 Credits ™ : 1.50
ARRT Category A+ Credits: 1.50
Thu, Dec 4 10:30 AM - 12:00 PM Location: E450B

Thu, Dec 4 10:30 AM - 12:00 PM Location: E450B
Participants
Moderator
Cary Lynn Siegel MD : Nothing to Disclose
Moderator
Parvati Ramchandani MD : Nothing to Disclose
Sub-Events
SSQ10-01 Genitourinary Keynote Speaker: Fibroid Expert Topic—MR Guided Focal Cryoablation for Native and
Recurrent Prostate Cancer
David Arthur Woodrum MD, PhD (Presenter): Nothing to Disclose
Abstract
In 2014, the American Cancer Society (ACS) estimates that 233,000 new cases of prostate cancer will be diagnosed in the United States. Most men are managed with either radiation therapies or surgery with recurrence rates as high as 25-40%. No matter how expertly done, these therapies carry significant risk and morbidity to the patient's health related quality of life with impact on sexual, urinary and bowel function. For this reason, focal or regional treatments for low risk native and recurrent prostate cancer patients are beginning to be adopted. Although questions remain, focal therapies are becoming more attractive to patients who are demanding more options. MR imaging provides the best lesion visualization for both native and recurrent prostate cancer. However, until recently treatment in the MR suite has not been possible. Now MR guided cryoablation, laser ablation and focused ultrasound are possible. We will discuss the use of MR guided cryoablation in treatment of native and recurrent prostate cancer.
SSQ10-02 MRI-Guided Transurethral Ultrasound Ablation for Treatment of Localized Prostate Cancer
Maya B. Mueller-Wolf MD (Presenter): Nothing to Disclose , Matthias Roethke MD : Nothing to Disclose ,
Sascha Pahernik MD : Nothing to Disclose , Boris Hadaschik : Nothing to Disclose , Timur Kuru MD :
Nothing to Disclose , Gencay Hatiboglu : Nothing to Disclose , Ionel Valentin Popeneciu MD : Nothing to
Disclose , Joseph Chin MD : Nothing to Disclose , Michele Billia MD : Nothing to Disclose , James D. Relle
MD : Nothing to Disclose , Jason M. Hafron MD : Nothing to Disclose , Kiran R. Nandalur MD : Nothing to
Disclose , Mathieu Burtnyk DIPLPHYS : Nothing to Disclose , Heinz-Peter Schlemmer MD : Nothing to
Disclose
PURPOSE
MRI-guided transurethral ultrasound ablation (MR-TULSA) is a novel minimally-invasive technology to treat organ-confined prostate cancer (PCa), aiming to provide local disease control with a low side-effect profile.
Directional plane-wave high-intensity ultrasound generates a continuous volume of thermal coagulation shaped accurately to the prostate using real-time MR-thermometry and active temperature feedback control. A prospective, multi-institutional Phase I clinical study investigated safety, feasibility, and assessed efficacy of
MR-TULSA treatment for PCa.
METHOD AND MATERIALS
30 patients with biopsy-proven, low-risk prostate cancer (age ≥ 65y, T1c/T2a, PSA ≤ 10ng/ml, Gleason 6
(3+3)) were enrolled. MR-TULSA was performed for whole-gland prostate ablation using the PAD-105 (Profound
Medical Inc., Canada) and a 3T MRI (Siemens, Germany). One treatment session was delivered under general anaesthesia and 3D active MR-thermometry feedback control. Thermal coagulation was confirmed on CE-MRI immediately after MR-TULSA and at 12 months.
RESULTS
MR-TULSA was well-tolerated by all patients. There were no intraoperative complications. Normal micturition resumed after catheter removal. Median (range) treatment time and prostate volume were 36 (24-61) min and
44 (21-95) ml, respectively. Maximum temperature measured during treatment depicted a continuous region of heating shaped accurately to the prostate to within 0.1 ± 1.3 mm, with average over- and under-targeted volumes of 0.8 and 1.0 ml, respectively. Immediate post-treatment cell kill, visualized by the peripheral region of enhancement surrounding the non-perfused volume, correlated well with the acute cell kill regions on
MR-thermometry. Successful treatment was further indicated by a median PSA decrease from 5.8 to 0.7 ng/ml at 1 month (n=24), remaining stable to 0.7 ng/ml at 6 months (n=12).
CONCLUSION
MRI-guidance enables accurate treatment planning, real-time dosimetry and control of the thermal ablation volume. The Phase I clinical trial showed that whole-gland ablation of the prostate for localized PCa is feasible, safe, and accurate using MR-TULSA.
CLINICAL RELEVANCE/APPLICATION
Whole-gland ablation can be safely and accurately achieved using MR-TULSA, which represents a minimally-invasive treatment option for organ-confined prostate cancer.
SSQ10-03 Non-invasive Focal Therapy of Organ Confined Prostate Cancer: Phase I Study Using Magnetic
Resonance Guided Focused Ultrasound Technology and Excision Pathology for Efficacy Assessment
Pier Luigi Di Paolo MD (Presenter): Nothing to Disclose , Gaia Cartocci MD : Nothing to Disclose , Fulvio
Zaccagna MD : Nothing to Disclose , Gianluca Caliolo : Nothing to Disclose , Valeria Panebianco MD :
Nothing to Disclose , Alessandro Napoli MD : Nothing to Disclose

PURPOSE
To assess safety and initial effectiveness of non-invasive high intensity 3T MR guided focused Ultrasound
(MRgFUS) treatment of localized prostate cancer in a phase I, treat and resection designed exploratory study.
METHOD AND MATERIALS
On the basis of a power analysis, 11 patients with biopsy proven focal T2 prostate cancer (low-to-intermediate risk: PSA max 12 and Gleason max 3+4), confirmed on a previous multiparametric MR exam (Discovery 750,
GE) including dynamic contrast enhanced (DCE) imaging (Gd-BOPTA, Bracco), underwent MRgFUS ablation
(ExAblate, InSightec). All patients were scheduled to radical laparoscopic prostatectomy; MRgFUS treatment was carried out on the MR identifiable lesion (max 2) using a patient specific energy (3000-8500 J) and real time MR thermometry monitor for correct treatment location. Non-perfused volume (NPV) in the post-ablative
MRI was than compared with excision pathology for necrosis assessment.
RESULTS
No significant complications were observed in all subjects during or immediately after the procedure. Procedure was validated by pathologist, that demonstrated extensive coagulative necrosis at the site of sonication surrounded by normal prostatic tissue with inflammatory changes; these features positively compared with immediate post-ablative MRI scan and NPV. At histology 10 patients were free of residual viable tumor within the treated area; in the remaining patient, 10% of residual tumor was observed within the NPV. There was a variable amount of isolated cancer tissue (Gleason max 7, 3+4) within the non-treated parenchyma that was neither identifiable at MRI nor at biopsy.
CONCLUSION
Results of our Phase I study suggest MR guided Focused Ultrasound as a safe and effective modality to determine >90% necrosis of identifiable prostate cancer; other prospective studies are needed to extend success rate in larger cohort.
CLINICAL RELEVANCE/APPLICATION
MR guided Focused Ultrasound is a safe and effective modality to determine >90% necrosis of identifiable prostate cancer.
SSQ10-04 Long Term Results Of Optimized Focal Therapy Of Prostate Cancer: Average 10-Year Follow-up in 70
Patients
Gary Mark Onik MD (Presenter): Nothing to Disclose
PURPOSE
Following the lead of lumpectomy for breast cancer, focal therapy for prostate cancer was introduced in order to limit morbidity while providing good cancer control. Focal therapy is now an established trend in prostate cancer management, but long term data has not been available. This report presents results on 70 patients treated with focal cryoablation, followed for an average of 10 years.
METHOD AND MATERIALS
Between May 7, 1996 and December 28, 2005 70 patients were treated with focal cryoablation. All patients were staged using an additional prostate biopsy. Transperineal 3D Prostate Mapping Biopsy (3D-PMB) was used in 63 patients. All patients were then treated with percutaneous focal cryoablation of all known tumor(s). All known cancers regardless of tumor size or Gleason score were treated. Biochemical disease free status was determined by the Phoenix criteria. Potency was determined by ability to have vaginal penetration and satisfaction with sexual functioning. Continence was determined by pad free status.
RESULTS
Disease specific survival was 64/64(100%). Overall biochemical disease free survival (BDFS) was 62/70 (89%).
BDFS results stratified according to the D'Amico criteria were: 8/9 (89%) high risk; 28/32 (88%) medium risk;
26/29 (90%) low risk. There was no statistically significant difference between the risk levels. 19/20 (95%) bilaterally but focally treated patients were BDF. In total 10/70 (14%) patients had a local recurrence that needed re-treatment (none in the treated area), and 9/10 (90%) remain BDF. Continence after the first treatment was 100% (no pads). Potency including re-treatments was 74%. No other complications occurred.
There was no instance of significant bleeding and no instance of rectal damage.
CONCLUSION
Within the limitations of our study, the long term cancer control results of focal therapy using cryoablation appears competitive with radical whole gland treatments in low risk patients and superior in medium and high risk patients in achieving cancer free status . It achieves this with extremely low morbidity compared to whole gland treatments. If these results are confirmed, focal therapy as we have outlined could significantly lower the morbidity and mortality associated with prostate cancer.
CLINICAL RELEVANCE/APPLICATION
Focal therapy has the potential to completely change the paradigm of prostate cancer management.
SSQ10-05 Cryotherapy for Renal-cell Cancer: Evaluation of the Efficacy of the Treatment with
Contrast-Enhanced Ultrasonography (CEUS)

Michele Bertolotto MD (Presenter): Nothing to Disclose , Fulvio Stacul MD : Nothing to Disclose , Calogero
Cicero : Nothing to Disclose , Francesca Cacciato : Nothing to Disclose , Salvatore Siracusano MD :
Nothing to Disclose , Maria Assunta Cova MD : Nothing to Disclose , Matilde Cazzagon : Nothing to Disclose
, Antonio Celia : Nothing to Disclose
PURPOSE
To evaluate the diagnostic accuracy of contrast enhanced ultrasound (CEUS) in the early detection of residual tumor after cryoablation.
METHOD AND MATERIALS
Twenty-six patients with 31 renal tumors (20 men, 6 women; mean age, 69 years; range, 52-81 years) underwent percutaneous cryoablation between August 2011 and July 2013. All tumors were treated with CT guidance. Patients underwent CEUS before, within 1 day (early follow-up CEUS), 1 month and 3 months after the ablation. In patients with persistent lesion vascularity at early follow-up CEUS the test was repeated also 1 week after the treatment. Reference standard was MRI/CT performed every 6 months after cryoablation for the first two years, and then yearly.
RESULTS
The mean tumor size was 20 mm (range, 6-37 mm). One patient was lost to follow up. Twenthy-five patients with 30 renal tumors were followed-up for at least 6 months and all underwent CEUS. MRI was perfomed in 21 patients, CT in 4 patients who had contraindications to MR scanning. The mean follow-up period was 15 months
(range, 6-24 months). Early CEUS follow-up displayed a completely avascular lesion in 24/30 renal lesions.
Minimum to mild perilesional enhancement was present in 4 cases, which disappeared progressively during the follow-up. One type IV cystic tumor had two intralesional vegetations (10 and 20 mm, respectively), which were still vascularized early after cryoablation and during the follow-up and were categorized as residual tumor.
Severe comorbidities precluded from repeated cryoablation. Two lesions were vascularized in the early CEUS follow-up while the CEUS investigation repeated 1 week and 1 month after the treatment documented progressive devascularization of the mass.
CONCLUSION
CEUS is an effective alternative to CT and MRI for the early diagnosis of residual tumour after renal percutaneous cryoablation. Care should be taken, however, in interpreting persistent vascularity in the early
CEUS follow-up as residual tumor. Repeated CEUS investigations allow to differentiate between a late devascularization of a successfully ablated tumor and persistent disease.
CLINICAL RELEVANCE/APPLICATION
CEUS is able to monitor the result of cryoablation of renal tumors. Early features after the treatment, however, should be interpreted with caution to avoid misdiagnosis of persistent disease.
SSQ10-06 CT-guided Biopsy for the Entirely Endophytic Small Renal Mass: Comparison of Diagnostic Rate and
Complication between Standard-dose and Low-dose Protocol Group
Mi-Hyun Kim (Presenter): Nothing to Disclose , Jeong Kon Kim MD : Nothing to Disclose , Myung-Won
You MD : Nothing to Disclose , Hyuck Jae Choi MD : Nothing to Disclose , Kyoung-Sik Cho MD : Nothing to Disclose
PURPOSE
To compare the diagnostic rate and complication between standard-dose and low-dose protocol group in the
CT-guided biopsy for the entirely endophytic small renal masses (SRM)
METHOD AND MATERIALS
A total of 56 patients underwent CT-guided biopsy for the entirely endophytic SRM (≤ 4 cm) from May 2011 to
March 2014. Biopsy was performed with standard-dose protocol (reference mAs, 210) in 37 patients and low-dose protocol (reference mAs range, 40-80; mean±standard deviation, 43±9.5) in 19 patients. The diagnostic rate, histologic finding, radiation dose, complication rate, and procedure time were assessed from the retrospective chart and image reviews and compared between two groups.
RESULTS
In the low-dose protocol group, all 19 patients had diagnostic results (14 renal cell carcinomas, 2 metastases, 1 urothelial carcinoma, 1 oncocytic neoplasm, and 1 angiomyolipoma). In the standard-dose protocol group, 36
(97%) patients had diagnostic results (24 renal cell carcinomas, 2 metastases, 1 lymphoma, 4 angiomyolipomas, 4 inflammations, and 1 cyst) and one patient had non-diagnostic result. No serious complication such as active bleeding was occurred in two groups. The standard-dose protocol group had statistically greater value of the dose length product (DLP) than low-dose protocol group (560±221 vs. 180±61 mGy*cm, P < .05). Mean procedure time was equally 21 minutes in two groups.
CONCLUSION
Low-dose protocol CT-guided biopsy for the entirely endophytic SRM has comparable diagnostic result to the standard-dose protocol group without increasing complication rate or procedure time.
CLINICAL RELEVANCE/APPLICATION

Endophytic renal tumors have been related to higher surgical complexity and higher postoperative complication rate than exophytic lesions, and the number of biopsies in these endophytic lesions is increasing in our institution. Low dose protocol CT-guided biopsy may be sufficient for the histologic diagnosis of the endophytic
SRM and can reduce the radiation dose to the patient.
SSQ10-07 Ultrasound-guided Transvaginal Core Biopsy of Pelvic Masses: Feasibility, Safety and Short-term
Follow-up
Jung Jae Park MD (Presenter): Nothing to Disclose , Chan Kyo Kim MD, PhD : Nothing to Disclose , Byung
Kwan Park MD : Nothing to Disclose
PURPOSE
Although several previous studies reported the utility of transvaginal approach for endometrial biopsy or fine needle aspiration of pelvic lesions, few studies have demonstrated the feasibility of transvaginal technique for biopsy of pelvic masses. The aim of our study was to evaluate the diagnostic accuracy and safety of ultrasound
(US)-guided transvaginal core biopsy for pelvic masses.
METHOD AND MATERIALS
Forty-nine pelvic masses (mean size, 4.2 ± 2.8 cm) in 49 women (median age, 59 ± 12.7 years) who received
US-guided transvaginal core biopsy between 2009 and 2013 were enrolled in this retrospective study. On pre-biopsy CT or MR imaging, the lesions were identified in vaginal stump (n = 25), rectovaginal or vesicovaginal pouch (n = 11), adnexa (n = 8), or distal ureter (n = 5). The biopsy was performed using a probe equipped with a guide and an 18 gauge Tru-cut needle with an automatic biopsy gun (Ace-cut) after local anesthesia. We evaluated the diagnostic accuracy and complication rate of the procedure.
RESULTS
All acquired specimens were adequate and sufficient for pathologic analysis. Overall diagnostic accuracy of
US-guided transvaginal core biopsy was 91.8% (45/49 patients). Of these, 39 lesions were diagnosed as malignancies and five lesions that revealed active or chronic inflammation without evidence of malignancy regressed spontaneously on follow-up imaging. The remaining one lesion was diagnosed as ovarian sex cord-stromal tumor. Of the four non-diagnostic lesions, two were identified as fibrothecoma and recurrent leiomyosarcoma after surgery, respectively and the remaining two were clinically regarded as recurrent ovarian and endometrial cancer due to increases in size on follow-up imaging, respectively. None of these biopsies resulted in major complications. As minor complications, vaginal bleeding immediately after the biopsy and gross hematuria were found in 10 patients (20.4%) and three patients (6.1%), respectively, but these complications were stopped spontaneously in all 13 patients without further treatment or transfusion.
CONCLUSION
US-guided transvaginal core biopsy appears to be reliable and safe procedure for the histologic diagnosis in patients with pelvic masses.
CLINICAL RELEVANCE/APPLICATION
As a reliable and safe technique, US-guided transvaginal core biopsy can be used for clinical decision making and selecting optimal treatment strategies in patients with pelvic masses.
SSQ10-08 Retrospective Study of Uterine Fibroid Treatment Using MRgFUS: Correlations between Age,
Recurrence Rate and Clinical Outcomes
Fabiana Ferrari MD (Presenter): Nothing to Disclose , Anna Miccoli MD : Nothing to Disclose , Francesco
Arrigoni : Nothing to Disclose , Eva Fascetti MD : Nothing to Disclose , Antonio Barile MD : Nothing to
Disclose , Carlo Masciocchi MD : Nothing to Disclose
PURPOSE
To evaluate the efficacy of MRgFUS in the uterine fibroids treatment analysing the recurrence rate after 12 months from the treatment. This study correlates the age of patients to the clinical and imaging results.
METHOD AND MATERIALS
38 patients, with symptomatic uterine fibroids were treated using MRgFUS from September 2011 to December
2012. Twenty-two of them were aged between 40 and 50 (group 1), 10 patients between 30 and 40(group 2) and 6 patients between 20 and 30 (group 3). Single fibroids were found in 13 patients while 25 patients presented multiple fibroids. Patients were submitted to one treatment alone. We submitted the patients to c.e.
MRI respectively before treatment, after 10 days, 3 months, 6 months and 12 months. We made a morphological analysis of the images, an evaluation of the treated volume extension and the possible recurrence of the pathology in the area of the treatment. Clinical evaluation was performed by
SSS-questionnaire, comparing the pre-treatment score to the one obtained after 12 months.
RESULTS
All patients had a non-perfused-volume mean value of 91.5 %. Thirty-four women belonging to Group 1, Group
2 and Group 3 (89.5% of patients) showed a complete reabsorption of the necrotic area without any fibrotic tissue in the treatment area after 12 months. Four younger women (10.5 % of patients) belonging to Group 3, aged between 24 and 30 years, showed hypointense tissue in the peripherical part of the treated area after 3-6 months from the treatment. One of them, who underwent myomectomy, showed a mixed tissue made of necrotic cells and fibrotic tissue. Clinically, after 12 months from the treatment, Group 1, Group 2, and Group 3 showed a SSS-Q mean value of 7.8, 8.1, and 6.4, respectively. We did not appreciate clinical differences of

statistical relevance between the groups.
CONCLUSION
MRgFUS is an effective technique in younger and older women. We found excellent morphological results and clinical outcomes in patients belonging to group 1 and 2. In Group 3, the excellent clinical response was not associated to significant morphological results, this however not impairing the final response to the treatment.
CLINICAL RELEVANCE/APPLICATION
We evaluate the efficacy of the uterine fibroid treatment using MRgFUS correlating the morphological and clinical results in younger and older women obtaining in both groups good therapeutic results.
SSQ10-09 Genitourinary Keynote Speaker: Oncologic Applications of HIFU in 2014—Current State-of-the Art and Future Directions
Aradhana Mukherjea Venkatesan MD (Presenter): Institutional research agreement, Koninklijke Philips NV
Abstract
High intensity focused ultrasound (HIFU), also known as focused ultrasound (FUS) is a non-invasive image-guided therapy, which has been primarily employed in the clinical realm for non-invasive thermal ablation of benign and malignant neoplasms. Real time imaging guidance, treatment monitoring and therapy control is achieved with ultrasound (US) or magnetic resonance imaging (MRI) guidance. Clinical experience in the GU tract has been described in the treatment of leiomyomata, adenomyosis, prostate and renal tumors, although, to date, widespread adoption of HIFU thermoablation remains limited. Ongoing technical challenges include the feasibility of treating large tumors within a finite treatment time, treating targets prone to motion or those for which the acoustic window is restricted by intervening anatomy. A range of provocative bio-effects of therapeutic ultrasound beyond thermoablation also have the potential to be leveraged in the care of the oncology patient. Hyperthermic effects can potentiate the release of thermosensitive drugs, enhance the permeability and retention of chemotherapeutic agents, and potentially enable gene delivery within tumors.
Mechanical effects of HIFU, including stable and inertial cavitation play a role in heat sensitive drug and gene delivery and have the potential to be employed as adjuvant effects for more efficient ablation of large tumors.
Ongoing and promising oncologic research is directed toward optimization of HIFU's thermoablative capabilities and greater elucidation of its non-thermal effects. This keynote presentation will describe the principles governing oncologic applications of HIFU and present current state-of-the art and future GU interventional applications of this innovative image-guided therapy.
Scientific Posters
ER
AMA PRA Category 1 Credits ™ : .50
Thu, Dec 4 12:15 PM - 12:45 PM Location: ER Community, Learning Center
Participants
Moderator
Clint W. Sliker MD : Nothing to Disclose
Sub-Events
ERS233 Revised Criteria for Ultrasound Diagnosis of Appendicitis: Importance of Hyperechoic Fat in Adult and Pediatric Patients with Appendices Measuring 6-8 mm in Diameter (Station #1)
Stephanie T. Chang MD (Presenter): Nothing to Disclose , R. Brooke Jeffrey MD : Research Consultant,
InnerVision Ultrasound , Jarrett Rosenberg PhD : Nothing to Disclose , Eric West Olcott MD : Nothing to
Disclose
PURPOSE
To determine whether the ultrasound (US) presence of hyperechoic fat, hyperemia or an abnormal submucosal layer (SML) may be additionally predictive with appendiceal diameter in diagnosing acute appendicitis among pediatric and adult patients.
METHOD AND MATERIALS
A total of 381 patients (292 pediatric patients and 89 adults defined as greater than 18 years in age) between the ages of 2-40 years undergoing US evaluation for appendicitis between December 2011-January 2013 with visualized appendices were included. US cases were retrospectively reviewed by two independent readers for the presence of hyperechoic fat (absent, unilateral, or circumferential), loss of the SML, or increased Doppler blood flow. Acute appendicitis was ascertained by surgery or clinical follow-up.
RESULTS
In a multivariate model including sex, age, maximum anterior-posterior diameter, fat, SML loss, and Doppler flow, only appendiceal diameter (OR 2.7, p<0.001), unilateral fat (OR 4.1, p=0.039), and circumferential fat
(OR 7.7, p<0.001) demonstrated significant independent predictive value for diagnosing acute appendicitis in a population of adult and pediatric patients. Specifically, for borderline appendices measuring between 6-8 mm in

ERS234
ERS235 diameter, the presence of circumferential fat significantly increased the likelihood of appendicitis (OR 9.0, p=0.006).
CONCLUSION
The US presence of hyperechoic fat, particularly circumferential fat, is the most important secondary finding to appendiceal diameter for diagnosing appendicitis in both pediatric and adult patients.
CLINICAL RELEVANCE/APPLICATION
The presence or absence of hyperechoic fat on US evaluation for appendicitis is the most important finding for improving sensitivity and specificity in appendices between 6-8 mm in diameter.
Imaging of Postcoital Pelvic Pain and/or Vaginal Bleeding (Station #2)
Ajay K. Singh MD (Presenter): Nothing to Disclose , Hani H. Abujudeh MD, MBA : Research Grant, Bracco
Group Consultant, RCG HealthCare Consulting Author, Oxford University Press
PURPOSE
The aim of the study was to study the evaluate features of female patient's presenting with postcoital acute or subacute pelvic pain and/or bleeding
METHOD AND MATERIALS
248 patients (17-74 years; Avg 35.2 years) with history of pelvic pain and/or bleeding after coitus were included in this study. There were 246 ultrasound, eight CT and oneMR studies were performed in the 247 patients.
There were 80 patients with vaginal bleeding (40 with pelvic pain and 40 without pelvic pain). Rest of the patient's (n = 167) presented with pelvic pain without bleeding. 32 patient had history of intrauterine device insertion in the past.
RESULTS
Out of the 168 patients who were imaged for postcoital pain, 80 (47.6%) patients had a positive imaging study.
In this group 24 had uterine fibroids, and 32 had an ovarian cyst measuring at least 2.5 cm in diameter. The other findings in the patients included 1 hydronephrosis, 1 hematometra, 1 malpositioned IUD, 7 adenomyosis
(one with fibroid), 4 hemoperitoneum, 1 pelvic inflammation, 3 polycystic ovarian disease, 2 polyps, and 4 suspected adenomyosis. In the 40 patients with pain and vaginal bleeding 40% of the patients had a positive imaging finding, while in patients with vaginal bleeding only 47.5% (19/40) patients had a positive imaging finding. Amongst the 247 patients, there were 4 patients with significant hemoperitoneum, 1 patient with vaginal perforation and 2 patients with ovarian neoplasm.
CONCLUSION
Pelvic imaging for postcoital pain and/or bleeding has a high rate of positive results which justify its use in patient management. Although the most common findings of postcoital pain and/or vaginal bleeding are uterine fibroids and functional ovarian cysts, the most clinically significant result which can potentially require emergent intervention is intraperitoneal bleeding and vaginal vault perforation.
CLINICAL RELEVANCE/APPLICATION
The study justifies the use of pelvic imaging for postcoital pain and/or bleeding based on high positivity rate.
The study concludes that the most common findings of postcoital pain and/or vaginal bleeding are uterine fibroids and functional ovarian cysts,which do not require emergency surgery. It enumerates the serious causes which need urget management..
Performance of Automated 3D-rendering of Ribs in Polytrauma Patients: Clinical Experience in 110
Patients (Station #3)
Suonita Khung : Nothing to Disclose , Pauline Masset : Nothing to Disclose , Jean-Baptiste Faivre MD :
Nothing to Disclose , Nunzia Tacelli MD : Nothing to Disclose , Jacques Remy MD : Research Consultant,
Siemens AG , Martine J. Remy-Jardin MD, PhD (Presenter): Research Grant, Siemens AG
PURPOSE
To evaluate the diagnostic performance of virtually-rendered unfolded views of the ribs.
METHOD AND MATERIALS
110 consecutive adult patients referred for polytrauma underwent a chest CT examination, retrospectively reviewed for specific detection of rib fractures according to two independent approaches: (a) analysis of transverse CT sections, completed with multiplanar reformats whenever deemed necessary by the reader
(Group 1) ; (b) analysis of unfolded ribs as proposed by the software « CT Bone Reading » that generated a virtually-rendered unfolded view of the ribs and spine, with the possibility of rib analysis along their long axis and creation of standard orthogonal views in different orientations of any area suspected of fracture (Group 2).
The gold standard for the diagnosis of rib fractures was established by the combined analysis of Group 1 and
Group 2 images. Image analysis was obtained as follows: (a) separate reading of Group 1 and Group 2 images by two independent readers (a junior reader and a senior reader); (b) consensus analysis of Group 1 and Group
2 images by the two readers to establish the final diagnosis of rib fractures.

ERS236
ERE201
RESULTS
From the gold standard analysis, 44 patients had rib fractures (mean number of fractures per patient: 2.85) with a total of 266 ribs fractured and a total of 314 fractures (222 undisplaced; 92 displaced). The "CT bone reading" provided a complete reconstruction of the whole ribcage in 94 patients (85.5%) and partially incomplete reconstructions (1- 5 ribs inadequately reconstructed) in 16 patients (14 .5%). The software performance was established as follows: (a) diagnosis of rib fracture (sensitivity: 0.84; specificity: 1); (b) number of ribs fractured (sensitivity: 0.77; specificity: 0.99); (c) number of displaced fractures (sensitivity:
0.92; specificity: 1). Group 2 analysis allowed detection of 38.6% of rib fractures missed in Group 1 and significantly reduced the junior reader's reading time (p<0.0001).
CONCLUSION
This software has the potential to help detect rib fractures in polytrauma patients.
CLINICAL RELEVANCE/APPLICATION
The detection of rib fractures in a polytrauma patient, often difficult and time consuming, can be helped by the evaluated system.
Does Distance Matter? Effect of Having a Dedicated CT Scanner in the Emergency Department on
Completion of CT Imaging and Final Patient Disposition Times (Station #4)
Wilfred Dang BS (Presenter): Nothing to Disclose , Ania Zofia Kielar MD : Nothing to Disclose , Angel Yi
Nam Fu BSC : Nothing to Disclose , Suzanne T. Chong MD : Nothing to Disclose , Matthew Donald Fernand
McInnes MD, FRCPC : Nothing to Disclose
PURPOSE
To evaluate whether the presence of a CT scanner in the emergency department (ED) improves ED workflow by decreasing the time between imaging requisition and completion, as well as potentially impacting patient outcomes by shortening time to final disposition.
METHOD AND MATERIALS
IRB approval was obtained for this retrospective study conducted on 2,142 consecutive, acute thoracic, abdominal and pelvic imaging requests from two affiliated academic EDs from August 1 to October 31, 2012. At one institution, the CT scanner is in the ED; in the other it is located in the radiology department 300m away from the ED. Patients were stratified based on acutity of CT indication, interpreting radiologist training level, and the time of day of scanning. Three time points were compared between hospitals: 1) The time the CT requisition was received to the time the CT scan was initiated (ΔTime 1), 2) the time from CT scan initiation to the time the CT was reported preliminarily by a resident/fellow, or verbally reported by staff to the ED (ΔTime
2), and 3) the time the CT requisition was received to the time of final patient disposition (ΔTime 3).
RESULTS
Decreases in time, favouring the institution with the ED CT scanner, are 16 (P<0.0001), 15 (P<0.0001), and 19 minutes (P<0.04). Significant differences were also seen in morning and overnight shifts (P<0.0001, P<0.0001,
P=0.002, and P<0.0001, P=0.04, P=0.001) and for CT reporting times in higher radiology levels of training
(P=0.04 and 0.0001 for Staff and PGY 5, respectively). No significant differences were seen for hyperacute patients.
CONCLUSION
The presence of an ED CT scanner is associated with decreases time to CT scan completion, radiological interpretation and patient disposition.
CLINICAL RELEVANCE/APPLICATION
A CT scanner in the Emergency department reduces: time from request to scan initiation, time from CT request reception to interpretation, and time of patient disposition for acute-care patients.
Spectrum of CT Appearance of Traumatic Venous Injuries (Station #5)
Suresh Cheekatla MBBS (Presenter): Nothing to Disclose , Nagaramesh Chinapuvvula MBBS : Nothing to
Disclose , Susanna Claire Spence MD : Nothing to Disclose
TEACHING POINTS
1. To know the spectrum of traumatic venous injuries. 2. To know how to recognize these injuries on CT.
TABLE OF CONTENTS/OUTLINE
1. CT signs that are definitive for venous injury: a) Intraluminal filling defect or thrombus seen on venous and delayed phases. b) Venous pseudoaneurysm seen on venous and delayed phases. c) Venovenous fistula seen on venous and delayed phases. d) Arteriovenous fistula seen on arterial phase. e) Active contrast extravasation seen on venous and/or delayed phases. 2. CT signs that are suggestive but not definitive for venous injury: a)
Hematoma, stranding, or fluid around the vein. b) Contour irregularity. c) Luminal narrowing.

Scientific Posters
GI
AMA PRA Category 1 Credits ™ : .50
Thu, Dec 4 12:15 PM - 12:45 PM Location: GI Community, Learning Center
Participants
Moderator
Michael Stanley Gee MD, PhD : Nothing to Disclose
Sub-Events
GIS382 DCE-MRI-based Pharmacokinetic Biomarker for Predicting Survival of Patients with Advanced
Hepatocellular Carcinoma Treated by Sunitinib: Fast-Water-Exchange-Limit-Constrained Analysis
(Station #1)
Sang Ho Lee PhD (Presenter): Nothing to Disclose , Koichi Hayano MD : Nothing to Disclose , Dushyant V.
Sahani MD : Research Grant, General Electric Company , Andrew X. Zhu MD, PhD : Nothing to Disclose ,
Hiroyuki Yoshida PhD : Patent holder, Hologic, Inc Patent holder, MEDIAN Technologies
PURPOSE
To compare five different standard dual-input pharmacokinetic models (PKMs) with the fast water exchange regime for the analysis of baseline DCE-MRI data in the prediction of 1-year survival (1YS) and its association with overall survival (OS) in advanced hepatocellular carcinoma (HCC) treated by sunitinib.
METHOD AND MATERIALS
Twenty patients with advanced HCC underwent DCE-MRI at baseline, and received sunitinib daily by mouth for
28 days followed by 14 days of rest in 6-week cycles. The baseline DCE-MRI data were analyzed retrospectively by using five different standard dual-input PKMs: the Tofts-Kety (TK), extended TK, two compartment exchange, adiabatic approximation to the tissue homogeneity (AATH), and distributed parameter (DP) models.
Kinetic parameters consisted of total hepatic blood flow (BF), arterial flow fraction ( ), arterial BF ( BF
A), portal
BF, blood volume, mean transit time, capillary permeability-surface area product ( PS ), fractional interstitial volume ( v
I), and extraction fraction (
E ). Following receiver operating characteristic analysis with additional leave-one-out cross-validation, parameters of the different kinetic models were compared in terms of 1YS discrimination using cross-validated Kaplan-Meier analysis, and association with OS using a univariate
Cox-proportional hazard model, with additional permutation testing.
RESULTS
For 1YS prediction, the TK-model-derived v
I (P=0.037), the AATH-model-derived
(P=0.027), and E (P=0.033), and the DP-model-derived γ (P=0.012) and BF
BF
A (P=0.019),
PS
A (P=0.041) had statistically significant predictability after cross-validation and permutation testing, all of which were lower in the high-risk group. For OS, the increase of the AATH-model-derived PS and the DP-model-derived BF
A were statistically significantly associated with the increase of OS with hazard ratios of 0.766 (P=0.023) and 0.809 (P=0.025) after permutation testing, respectively.
CONCLUSION
The AATH-model-derived PS and the DP-model-derived BF
A were effective biomarkers for both the prediction of
1YS and the association with OS. Among the standard models, the AATH and DP were favorable models in survival analysis.
CLINICAL RELEVANCE/APPLICATION
Kinetic parameters derived from dual-input PKMs with the fast water exchange regime based on baseline
DCE-MRI data can provide effective prognostic imaging biomarker.
GIS383 Is Iodine Quantification Able to Reflect Early Chemotherapy Response of Liver Metastases
Origination from Rectal Cancer?—Preliminary Results (Station #2)
Rui Qi (Presenter): Nothing to Disclose , Zhenlin Li MD : Nothing to Disclose , Xiaohui Zhang : Employee,
Siemens AG
PURPOSE
To evaluate the value of iodine quantification by dual-source dual-energy computed tomography(DSDECT) in appraising chemotherapy effect of liver metastases of rectal cancer.
METHOD AND MATERIALS
A total of 7 patients (2 female, 5 male, mean age 52y) with liver metastases from unresectable rectal cancer were retrospectively analyzed. 37 lesions were evaluated, range 4-7 lesions each. In all cases, a first line therapy with oxaliplatin was stopped and second line therapy with Zaltrap+FOLFIRI was initiated. Time interval between first cycle of second line and stop of last cycle of primary therapy was minimum 1 month each.

GIS384
GIS385
DSDECT scans were performed (SOMATOM Definition Flash, Siemens) before application of second line therapy as base line and directly after end of each cycle according to clinical standards. Iodine quantification was based on portal venous phase (PVP, standardized iodine load and injection rate). According to RECIST criteria, number of patients classified as partial response / progressive disease (PR/PD) were 4/3 (total number of metastases per group 23/14). Iodine quantification was performed on the manufactures workstation (MMWP, Siemens) and region of interest to evaluate the iodine concentration (standardized iodine value used, SIV, normalization by iodine uptake of surrounding liver parenchyma) were placed in areas with maximal enhancement within solid tumor tissue. A two sample t-test was used for statistical analysis.
RESULTS
SIV for PR (0.46±0.24) and PD(0.71±0.28)group in DSDECT before chemotherapy were significantly different in the PVP scan(P=0.011). The change of SIV between pre-chemotherapy and first cycle of the chemotherapy for
PR group (0.13±0.20) were significantly different with that in PD group (-0.12±0.14)(P=0.00). The change of
SIV between pre-chemotherapy and second cycle of the chemotherapy for PR group (0.19±0.19) was also significantly higher than that in PD group (-0.19±0.28)(P=0.00). For PR group the SIV increased in most target lesions after chemotherapy, while for PD group the SIV decreased.
CONCLUSION
SIV provided information in the base line scanning and reflected the early response on second line chemotherapy in liver metastases of advanced rectal cancer. This preliminary study may be a robust and simple parameter for therapy assessment.
CLINICAL RELEVANCE/APPLICATION
SIV may be a easy obtained parameter to therapy follow-up and predication for second line chemotherapy of liver metastases.
A Preliminary Study on Multislice-Based CECT Texture Analysis in Differential Diagnosis of Pyogenic
Hepatic Abscess and Malignant Mimickers (Station #3)
Shiteng Suo (Presenter): Nothing to Disclose , Zhi Guo Zhuang : Nothing to Disclose , Mengqiu Cao :
Nothing to Disclose , Jianrong Xu : Nothing to Disclose
PURPOSE
To establish the utility of multislice-based texture analysis on contrast-enhanced computed tomography (CECT) in discrimination of pyogenic hepatic abscess and malignant mimickers.
METHOD AND MATERIALS
This retrospective study included 25 abscesses in 20 patients and 33 tumors in 26 patients who underwent
CECT, and for further comparison, 19 hepatic simple cysts in 19 patients were also reviewed. Multislice-based texture analysis was assessed for CECT images using a Laplacian of Gaussian band-pass filter (5 filter levels with sigma weighting ranging from 1.0 to 2.5), with quantification of uniformity, entropy, kurtosis and skewness. Statistical significance for these parameters was tested by one-way ANOVA followed by Tukey honestly significant difference (HSD) test. Diagnostic performance was evaluated using the receiver operating characteristics (ROC) curve analysis.
RESULTS
There were significant differences in entropy and uniformity at all sigma weightings (P < 0.001), and in kurtosis and skewness only at sigma 1.8 and 2.0 weightings (P = 0.002-0.006) when hepatic abscess, malignant mimickers and simple cysts were compared. Tukey HSD test showed that abscess had a significantly higher entropy and a significantly lower uniformity than malignant mimickers (P = 0.000-0.004). Entropy (at a sigma
2.0 weighting) had the largest area under the ROC curve of 0.888 in distinguishing abscess from malignant mimickers, with a sensitivity of 81.8% and a specificity of 88.0% using a threshold of 3.64.
CONCLUSION
Multislice-based texture analysis may be useful for differentiating pyogenic hepatic abscess and malignant mimickers. Entropy and uniformity are helpful to distinguish the two entities. Larger prospective studies with histopathological results are needed to further confirm the relationship between CECT texture features and disease microenvironment characteristics.
CLINICAL RELEVANCE/APPLICATION
Multislice-based texture analysis quantifies the routinely acquired CECT data in clinical practice without additional imaging and may provide a potential tool to bridge radiologic data with intrinsic tissue characteristics.
The Usefulness of Gadoxetic Acid-Enhanced Dynamic Magnetic Resonance Imaging in Hepatocellular
Carcinoma: Toward Improved Staging (Station #4)
Sang Hyun Choi (Presenter): Nothing to Disclose , Jae Ho Byun MD : Nothing to Disclose , Heon-Ju Kwon
MD : Nothing to Disclose , Hong-Il Ha MD : Nothing to Disclose , So Jung Lee : Nothing to Disclose ,
Hyung Jin Won MD : Nothing to Disclose , Pyo Nyun Kim MD : Nothing to Disclose
PURPOSE
To evaluate the usefulness of gadoxetic acid-enhanced dynamic magnetic resonance imaging (MRI) in staging hepatocellular carcinoma (HCC).

GIS386
GIS387
METHOD AND MATERIALS
Two investigators independently and retrospectively reviewed dynamic computed tomography (CT) and gadoxetic acid-enhanced dynamic MRI obtained from July to September 2011 in 195 patients with HCC (158 men, 37 women; mean age, 57.1 years). The diagnostic performances of dynamic CT and MRI were evaluated.
Barcelona Clinic Liver Cancer (BCLC) stages were determined before and after gadoxetic acid-enhanced dynamic
MRI and according to final diagnosis. Change in BCLC stage was evaluated after adding gadoxetic acid-enhanced dynamic MRI to dynamic CT. The consistency between final BCLC stage and each of these two modalities was compared. Diagnostic performance and BCLC staging between gadoxetic acid-enhanced dynamic MRI and dynamic CT was compared using the McNemar test.
RESULTS
Final BCLC stage was classified as stage 0 (12.8%), A (60.5%), B (16.9%), C (8.7%), and D (1.0%), respectively. Gadoxetic acid-enhanced dynamic MRI showed significantly higher diagnostic performance than dynamic CT for HCC, including significantly greater sensitivity (observer 1, 90.6% [203/224] versus 79.5%
[178/224]; observer 2, 88.4% [198/224] versus 63.8% [143/224]; P<.05), and significantly more accurate
BCLC staging (observer 1, 92.8% [181/195] versus 80.5% [157/195]; observer 2, 89.2% [174/195] versus
68.2% [133/195]; P<.05). Gadoxetic acid-enhanced dynamic MRI showed higher interobserver agreement for the diagnosis (k = 0.630 versus 0.485) and staging (k = 0.851 versus 0.601) than dynamic CT. BCLC stage was changed correctly after gadoxetic acid-enhanced dynamic MRI in the patients showing differences between CT and final BCLC stages (observer 1, 71.1%; observer 2, 71.0%).
CONCLUSION
Gadoxetic acid-enhanced dynamic MRI provided important additional information compared with dynamic CT during initial staging HCC. Gadoxetic acid-enhanced dynamic MRI showed higher diagnostic performance and more accurate BCLC staging than dynamic CT.
CLINICAL RELEVANCE/APPLICATION
Gadoxetic acid-enhanced dynamic MRI is important during initial staging HCC as it shows significantly more accurate BCLC staging and is more consistent with final BCLC stage than dynamic CT.
Radiation Reduction in Reproductive-Aged Women for Suspected Acute Appendicitis: A Look at
Ultrasound versus Computed Tomography (Station #5)
Darren Lu MD (Presenter): Nothing to Disclose , Hisham A. Tchelepi MD : Nothing to Disclose
PURPOSE
To recognize ultrasound (US) as the first step in evaluating reproductive-aged women with suspected acute appendicitis and to stress its role in eliminating the need for unnecessary radiation exposure.
METHOD AND MATERIALS
A retrospective review was conducted of women ages 14 to 45 (mean of 28.4) presenting with right lower quadrant pain suspicious for acute appendicitis. All cases had an initial right lower quadrant ultrasound.
Subsequent CT scans were performed as clinically indicated by the ordering physicians. All cases that proceeded to surgery had pathologic confirmation.
RESULTS
158 cases were reviewed. In 23 cases (14.6%), a normal appendix was identified on US. 2 of those cases had a follow up CT performed, both showing a normal appendix. 27 cases (17.1%) demonstrated a dilated, noncompressible appendix consistent with acute appendicitis on US. 8/27 (29.6%) had follow up CT, 7 of which confirmed acute appendicitis. One case proved to be cecal diverticulitis with a normal appendix. All cases of acute appendicitis were confirmed on pathology except one, which was perforated and managed medically. 108 cases (68.3%) were non-diagnostic in which the appendix was not identified. 34 of those had a CT demonstrating a normal appendix. 17/34 (50%) had alternative diagnoses including pyelonephritis, hemorrhagic/ruptured ovarian cysts, teratoma, fibroids, and hydrosalpinx. Our results demonstrate that US has a positive predictive value of 95.8% and a negative predictive value of 100% when an appendix was identified, which are similar to the previously reported data for CT. None of the patients with a non-diagnostic US were subsequently diagnosed with acute appendicitis on CT or clinically. Using the calculator from www.xrayrisk.com, for a female with an average age of 28.4 and DLP of 790 mGy-cm (values from our study population), the total effective dose of a CT abdomen and pelvis is 14.22mSv causing a 1/499 additional risk of cancer.
CONCLUSION
This study demonstrates that US plays a significant role in the reduction of radiation dose to our study population of reproductive-aged women. Additionally, US of the appendix in patient presenting with acute right lower quadrant pain can be dependable and reliable for diagnosis.
CLINICAL RELEVANCE/APPLICATION
Ultrasound should be considered for the initial evaluation of suspected acute appendicitis, especially in reproductive-age women to decrease radiation exposure.
Parallel-transmit-accelerated Spatially-selective Excitation MRI for Reduced-FOV Diffusion-weighted
Imaging of the Pancreas (Station #6)
Kolja Thierfelder MD, MSc (Presenter): Nothing to Disclose , Wieland H. Sommer MD : Nothing to Disclose ,

GIS388
Kolja Thierfelder MD, MSc (Presenter): Nothing to Disclose , Wieland H. Sommer MD : Nothing to Disclose ,
Olaf Dietrich PhD : Nothing to Disclose , Felix G. Meinel MD : Nothing to Disclose , Maximilian F. Reiser
MD : Nothing to Disclose , Konstantin Nikolaou MD : Speakers Bureau, Siemens AG Speakers Bureau,
Bracco Group Speakers Bureau, Bayer AG
PURPOSE
Diffusion-weighted imaging (DWI) of the pancreas often suffers from susceptibility and distortion artifacts. Our aim was to evaluate the use of 2D-selective parallel-transmit accelerated excitation MRI for diffusion-weighted
EPI (pTX-EPI) of the pancreas and to compare it to conventional single-shot EPI (c-EPI).
METHOD AND MATERIALS
The MRI examinations of 32 consecutive patients were evaluated in this prospective and IRB-approved study. All examinations were performed on a 3-T MRI system equipped with two independent transmit channels. PTX-EPI was performed with a (zoomed) Field-of-View (FOV) of 230 × 118mm2, whereas c-EPI used a full-FOV of 380 ×
285mm2. The 2D-RF pulse of pTX-EPI was shortened by a factor of 1.7 (TX-acceleration factor). In a qualitative analysis, two blinded and experienced readers evaluated 3 different aspects of image quality on 3- to 5-point
Likert scales. Additionally, apparent diffusion coefficients (ADCs) were determined in both c-EPI and pTX-EPI in normal-appearing pancreatic tissue using regions of interests (ROIs). Mean ADC values and standard deviations were compared between the two techniques.
RESULTS
The zoomed pTX-EPI was superior to c-EPI with respect to overall image quality (3.10 ± 0.65 vs. 2.45 ± 0.77, p < 0.0001) and identifiability of the pancreatic ducts (1.03 ± 0.81 vs. 0.45 ± 0.69, p < 0.01). Artifacts were significantly less severe in pTX-EPI than in c-EPI (1.06 ± 0.77 vs 1.61 ± 0.84, p < 0.01). The mean ADC values of c-EPI (1.29 ± 0.19 × 10-3 mm2/s) and pTX-EPI (1.27 ± 0.17 × 10-3 mm2/s) did not differ significantly (p =
0.44). The variation within the ROIs as measured by the standard deviation was significantly lower in pTX-EPI
(0.095 ± 0.035 × 10-3 mm2/s) than in c-EPI (0.135 ± 0.075 × 10-3 mm2/s), p < 0.05.
CONCLUSION
TX-accelerated spatially-selective EPI leads to substantial improvements in DWI of the pancreas with respect to different aspects of image quality without significantly influencing the ADC values.
CLINICAL RELEVANCE/APPLICATION
PTX-accelerated EPI has the potential to overcome some of the limitations of conventional DWI techniques in
MRI of the pancreas. Further studies might show whether the use of parallel-transmit enables a more accurate differentiation of pancreatic lesions.
Added Value of Diffusion-weighted MR Imaging to T2-weighted and Dynamic Contrast-enhanced MR
Imaging in T Staging of Gastric Cancer (Station #7)
Song Liu (Presenter): Nothing to Disclose , Jian He MD, PhD : Nothing to Disclose , Wenxian Guan :
Nothing to Disclose , Qiang Li : Nothing to Disclose , Haiping Yu : Nothing to Disclose , Zhuping Zhou :
Nothing to Disclose , Shanhua Bao : Nothing to Disclose , Zhengyang Zhou : Nothing to Disclose
PURPOSE
The objective of this study was to confirm whether diffusion-weighted (DW) magnetic resonance (MR) imaging has some added value to T2-weighted (T2W) and dynamic contrast-enhanced (CE) MR imaging in T staging of gastric cancer on 3 T MR scanners.
METHOD AND MATERIALS
Fifty-one patients (age range, 28-82 years; mean, 62 years; 33 men and 18 women) with a total of 51 gastric cancers underwent axial T2W, dynamic CE and DW (b, 0 and 1000 s/mm²) MR imaging. Two radiologists independently interpreted the images for T staging of the tumors. The tumors were staged based on the histopathological findings that assign the tumor stage according to TNM classification of American Joint
Committee on Cancer (AJCC, 7th edition). McNemar test was used to check the differences among three MR image sets (T2W+CE, T2W+DW, T2W+CE+DW) in the diagnostic accuracy with the reference of post-operative histopathological results. Inter-observer agreement was calculated by using kappa statistics.
RESULTS
The overall accuracy of T staging in pT1-4 gastric cancers by T2W+CE+DW (88.2%) was significantly higher than that by T2W+CE and T2W+DW (both 76.5%, P=0.031). For advanced lesions (pT2-4), T staging accuracy by T2W+CE+DW (92.3%) was significantly higher than that by T2W+CE (76.9%, P=0.031). There were no significant differences of T staging accuracy in pT1-4 and pT2-4 gastric cancers between T2W+CE and
T2W+DW (P=1.000, 0.125). Kappa values in inter-observer agreement test were 0.855, 0.826 and 0.578 in
T2W+DW, T2W+CE+DW and T2W+CE.
CONCLUSION
DW adds useful information to T2W and CE MR imaging in T staging of gastric cancer, especially in advanced lesions.
CLINICAL RELEVANCE/APPLICATION

GIS389
GIE127
GIE169
DW can be routinely added into MR imaging for preoperative T staging of gastric cancer without much time consuming. In patients who fail to fulfill CE imaging, DW may replace CE to ensure successful MR examinations.
Role of Initial Imaging in Risk Stratification for Suspected Choledocholithiasis in Hospitalized
Patients (Station #8)
Stella Kang MD : Nothing to Disclose , Laura Heacock MS, MD (Presenter): Nothing to Disclose
PURPOSE
The American Society of Gastroenterology (ASGE) guidelines on evaluation of suspected choledocholithiasis generally support MRCP for intermediate risk patients, and direct evaluation with ERCP for high-risk patients.
However, frail patients at high risk of choledocholithiasis but also procedural complications may benefit from
MRCP, with the tradeoff of possible delay in necessary stone extraction. We evaluated the predictive utility of
ASGE guideline variables and imaging parameters in risk stratification as a potential decision aid for choosing
MRCP or ERCP.
METHOD AND MATERIALS
We retrospectively reviewed inpatient cases at our institution with clinically suspected choledocholithiasis.
Included patients had US or CT of the abdomen followed by MRCP within 48 hours. Reference standard included
ERCP, endoscopic ultrasound, intraoperative cholangiogram, or documented clinical resolution. We used binary logistic regression to test 5 variables in ASGE risk assessment (total bilirubin, age, common duct (CD) dilatation, pancreatitis, liver function test (LFT) abnormality) according to published guidelines, as well as CD size at US/CT, for prediction of choledocholithiasis.
RESULTS
78 cases were included in regression analysis with 25 cases of CD stones. Among ASGE variables for risk assessment, abnormal LFT and CD dilatation were significant predictors of choledocholithiasis (p = 0.031,
0.017). Inclusion of all ASGE variables was slightly more accurate than the two-variable model (77 vs 75% accuracy). Within the ASGE high risk group, CD dilatation was a significant predictor of choledocholithiasis. In the ASGE high risk class, CD stone prevalence was 53%, and CD dilatation had positive predictive value (PPV) of 75%; meanwhile, ASGE intermediate risk patients had 22% CD stone prevalence, and CD dilatation had a
PPV of only 26%.
CONCLUSION
For acutely ill patients, CD dilatation is the strongest predictor of choledocholithiasis and may aid the decision for MRCP versus ERCP. Patients classified as ASGE high risk for choledocholithiasis with CBD dilatation on initial imaging have high pretest probability not warranting MRCP. ASGE intermediate risk patients cannot be reclassified to high risk using CD dilatation.
CLINICAL RELEVANCE/APPLICATION
CD dilatation at initial imaging is the strongest predictor of choledocholithiasis in hospitalized patients and use with established clinical guidelines aids the decision for MRCP versus ERCP.
Duct, Duck, Goose: MRCP Search Pattern and Findings, an Interactive Quiz Game! (Station #9)
David Nguyen MD : Nothing to Disclose , Mittul Gulati MD (Presenter): Nothing to Disclose
TEACHING POINTS
Using quiz based format, a range of MRCP findings and associated pathology will be reviewed, including variant anatomy, common conditions, duct pathology, neoplasms, and miscellaneous cases/ mimics.
TABLE OF CONTENTS/OUTLINE
1. Introduction: MRCP technique and sample search pattern 2. Duct anatomy and common variants a. normal anatomy and MRCP search pattern b. pancreas divisum c. low insertion cystic duct d. aberrant anatomy hepatic ducts (direct insertion right on left, etc). 3. Common conditions a. choledocholithiasis b. acute cholecystitis c.
acute pancreatitis 4. Bile duct pathology a. Primary sclerosing cholangitis b. HIV cholangitis c. chronic pancreatitis d. choledochal cysts 5. Neoplasm a. cholangiocarcinoma b. gallbladder carcinoma c. ampullary/ duodenal carcinoma d. pancreatic carcinoma e. pancreatic cystic neoplasms- serous and mucinous 6.
Miscellaneous and mimics a. duodenal diverticulum b. peribiliary cysts c. choledocholithiasis after bowel diversion d. groove pancreatitis
Beyond Recurrence: Recognizing the Pathologies of the Post-operative Groin (Station #10)
Joseph Michael Miller MD, MS (Presenter): Nothing to Disclose , Shirin Towfigh MD : Nothing to Disclose ,
Rola Saouaf MD : Nothing to Disclose
TEACHING POINTS
Modern hernia repair involves placement of mesh within the inguinal canal. Mesh repairs are associated with more complications than primary tissue repairs and can often lead to a chronic pain syndrome known as inguinodynia. Diagnosis benefits considerably from cross-sectional imaging, however our internal data show

GIE319
GIE321 inguinodynia. Diagnosis benefits considerably from cross-sectional imaging, however our internal data show that radiologists perform this task poorly. We conducted a retrospective review of 322 patients presenting to a specialty hernia surgeon from 2008-2013. Of the 56 patients with history of inguinal mesh, we identified 19 patients operated on for mesh-related complication with pre-operative cross-sectional imaging available.
Radiologists only correctly reported mesh-related abnormalities in 32% of cases (compared to 79% success rate by a blinded expert reader, p = 0.0081).
Evaluation of the post-operative groin is difficult. In addition to reviewing the CT and MRI findings of these surgically-confirmed complications, we intend to highlight the frequent causes of misdiagnosis found in our series. Relying on intraoperative correlation, we hope to illustrate the relevant devices and techniques involved in modern herniorrhaphy.
TABLE OF CONTENTS/OUTLINE
Techniques - Anterior repair - Pre-peritoneal repair Devices - Flat Mesh - Sandwich - Plugs Complications -
Malpositioning - Migration - Meshoma - Infection - Neuroma
Pull Me Up: A Review of Esophagectomy and Gastric Pull-though Procedures, Their Radiographic
Features and Complications (Station #11)
Jennifer Flanagan (Presenter): Nothing to Disclose , Shaun Michael Nordeck MS, RRA : Research Grant,
Toshiba Corporation , Vasantha Vasan MD : Nothing to Disclose , Richard Charles Batz MD : Nothing to
Disclose
TEACHING POINTS
With the incidence of esophageal carcinoma continuing to increase, esophagectomy and gastric pull-through surgeries for these patients are also on the rise. It is important for radiologists to be able to recognize the different surgical techniques and their radiographic presentations as well as potential complications. This education exhibit will discuss the different surgical techniques (i.e. Ivor lewis, modified Ivor Lewis, modified
McKeown approach, vagal-sparing esophagectomy, transthoracic esophagectomy, transhiatal esophagectomy, bloc esophagectomy, endoesophageal pull through, gastric pull-up and bowel interposition), their radiographic presentation and associated complications.
TABLE OF CONTENTS/OUTLINE
I. Introduction II. Review of normal anatomy of GI tract with special emphasis on esophagus and stomach. III.
Review of esophagectomy and gastric pull-through procedures including different surgical techniques IV. Review post-op radiographic features and associated complications V. Summary of teaching points
Small Bowel Tumors: Multi-technical Radiological Approach with Emphasis on CT and MRI and with
Endoscopic and Pathologic Correlation (Station #12)
Jose Gutierrez Chacoff MD (Presenter): Nothing to Disclose , Juan Ramon Ayuso MD : Nothing to Disclose ,
Giancarlo Schiappacasse MD : Nothing to Disclose , Mario Pages MD : Nothing to Disclose , Daniel Barnes
MD : Nothing to Disclose
TEACHING POINTS
Small bowel tumors are uncommon lesions whose the incidence have increased, so its diagnostic imaging is of paramount importance to accelerate the therapeutic process. The presence of a stenotic lesion in the duodenum or in the jejunum is highly suggestive of adenocarcinoma. The presence of an intestinal mass associated with the affected loop aneurysmal dilation, suggest lymphoma or GIST. Lymphoma present an homogeneous low contrast enhancement, while the GIST is hypervascular with areas of necrosis.
TABLE OF CONTENTS/OUTLINE
Introduction Study Techniques - Double contrast radiology - Ultrasound and endosonography - MDCT and
MDCT-enterography - MRI-enterography - PET-CT - Endoscopy and Endoscopic capsule Benign tumors -
Radiologic Semiology - Lypoma - Hemangioma - Adenomatous polyp - Hamartomatous polyp - Leiomyoma
Malignancies - Radiologic Semiology - Adenocarcinoma - Carcinoid - Lymphoma - GIST - Sarcoma - Metastasis
Diseases associated with intestinal tumors - Peutz-Jegers - Gardner Syndrome - Blue nevus syndrome - Lynch
Syndrome - Crohn's Disease - Celiac Disease Diagnostic Approach
Multisession Courses
US OI GU GI
AMA PRA Category 1 Credits ™ : 1.50
ARRT Category A+ Credits: 1.50
Thu, Dec 4 3:30 PM - 5:00 PM Location: S406A
LEARNING OBJECTIVES
Several speakers will be presenting case-based reviews of topics of relevance for imaging of the abdomen and pelvis. Brief discussions with focused reviews of the literature will follow for each case.

Sub-Events
MSCA52A Pitfalls and Pearls in Abdominal Sonography
Terry S. Desser MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Correctly identify common and uncommon sonographic pathology in the abdomen. 2) Use your understanding of basic sonographic and physiologic principles to infer the correct diagnosis in unusual ultrasound cases.
MSCA52B Genitourinary Tract Imaging
Julie H. Song MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Apply practical approach to diagnose common and uncommon pathology of genitourinary tract. 2) Learn to avoid pitfalls and misdiagnosis of genitourinary tract pathology.
MSCA52C Abdominal Oncologic Imaging
Matthew Thomas Heller MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Summarize imaging findings of complications of abdominal malignancies due to direct tumor effects and treatment effects. 2) Discuss the role imaging in determining treatment regimens.
ABSTRACT
Imaging plays a central role in the detection, diagnosis and treatment planning of abdominal malignancies.
Proper imaging begins with protocol selection. Knowledge of imaging pitfalls helps the radiologist avoid diagnostic errors. Recognition of complications due to tumor effects and treatment effects is important to minimize morbidity and mortality in patients undergoing treatment for abdominal malignancies. Through case-based discussion, we will review tactics to optimize imaging and management for patients with abdominal malignancies.
Active Handout http://media.rsna.org/media/abstract/2014/14001464/MSCA52C sec.pdf
Refresher/Informatics
US
AMA PRA Category 1 Credits ™ : 1.50
ARRT Category A+ Credits: 1.50
Thu, Dec 4 4:30 PM - 6:00 PM Location: E353C
Sub-Events
RC710A The Painful Scrotum
Thomas Charles Winter MD (Presenter): Speakers Bureau, General Electric Company
LEARNING OBJECTIVES
1) Describe the normal anatomy of the scrotum. 2) Describe proper technique for grey-scale and Doppler examination of the scrotum. 3) List common etiologies for the acute, painful scrotum.
ABSTRACT
This didactic lecture will describe the proper sonographic technique for scrotal examination, review normal anatomy of the scrotum as demonstrated by ultrasound, and will then progress to a description of the common pathologic conditions that may present emergently with acute scrotal pain.
RC710B Diagnosing Hernias
Gandikota Girish MBBS, FRCR (Presenter): Nothing to Disclose

RC710C
LEARNING OBJECTIVES
1) Describe the sonographic technique of evaluating hernias. 2) Identify sonographic features which help differentiate epigastric, direct, indirect and femoral hernias. 3) Understand some of the common pitfalls when using sonography to evaluate patients with inguinal hernias.
ABSTRACT
Inguinal hernias are a common clinical condition which may present with inguinal discomfort, and Ultrasound is a useful means for making a definite diagnosis. Ultrasound is most helpful in diagnosing Subtle hernias which are often difficult to diagnose clinically. Understanding the sonographic anatomy of the inguinal canal and femoral triangle and dynamic evaluation using valsalva, is the key to diagnosing different types of inguinal hernias. However, there are a number of concepts which help the practitioner maximize the utility of the technique, including understanding the relationship between the deep ring and the inferior epigastric artery, and being aware of the pitfalls like the 'thin man' pitfall and the normal movement of the spermatic cord, to name a few.
Assessment of Lumps and Bumps
Ronald Steven Adler MD, PhD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Describe sonographic appearance of common soft tissue masses. 2) List the current roles and indications of sonography as a screening tool and for sonographic characterization of soft tissue masses, which can further aid in diagnosis and therapy.
Refresher/Informatics
US NR HN OI US NR HN OI
AMA PRA Category 1 Credits ™ : 1.50
ARRT Category A+ Credits: 1.50
Thu, Dec 4 4:30 PM - 6:00 PM Location: E263
Participants
Jill Eve Langer MD (Presenter): Consultant, BioClinica, Inc
Kathryn Ann Robinson MD (Presenter): Nothing to Disclose
Sheila Sheth MD (Presenter): Consultant, Star Scientific, Inc
LEARNING OBJECTIVES
1) Describe the sonographic characteristics of thyroid nodules that are suspicious for malignancy. 2) a. Discuss the Bethesda
Cytology Classification of Thyroid FNA results and the risk of malignancy associated with each category. b. Describe the indications for two new genetic tests that may be performed on FNAs obtained from thyroid nodules with indeterminate cytology. 3) a. Describe the technique of US-guided biopsy of thyroid nodules and cervical lymph nodes in patients who have undergone thyroidectomy for thyroid cancer. b. Discuss the rationale and method of performance of US-guided ethanol ablation of malignant cervical adenopathy in post thyroidedctomy patients.
ABSTRACT
This presentation will consist of a three individual presentations. The first will review the sonographic characteristics of thyroid nodules that are suggestive of malignancy. Recommendations for selecting which thyroid nodules require ultrasound-guided biopsies which have been provided by both Radiology consensus conferences and published Endocrinology guidelines will be discussed. The second presentation will review with the Bethesda Cytology Classification of Thyroid FNA results and the risk of malignancy associated with each category. Additionally this presentation describes the indications for two new genetic tests that may be performed on FNAs obtained from thyroid nodules with indeterminate cytology. The last presentation will provide a detailed description of the technique for performing ultrasound guided biopsy of thyroid nodules and cervical lymph nodes.
Various methods will be discussed and required equipment outlined. Possible complications, though rare, will be described. A comparison of the typical sonographic features of normal versus abnormal lymph nodes will be presented in an effort to identify those patients in whom sonographic follow up can be used instead of biopsy. A discussion of the possible advantages of adding thyroglobulin assay to cytologic evaluation will be provided. The rationale for and technique of performing ultrasound guided ethanol ablation of malignant cervical lymph nodes in patients with thyroid cancer will be undertaken.
Refresher/Informatics
US IR BR US IR BR
AMA PRA Category 1 Credits ™ : 1.50
ARRT Category A+ Credits: 1.50
Thu, Dec 4 4:30 PM - 6:00 PM Location: E264

Participants
Jocelyn A. Rapelyea MD (Presenter): Research Consultant, Siemens AG Consultant, General Electric Company
Margaret M. Szabunio MD (Presenter): Nothing to Disclose
Liane Elizabeth Philpotts MD (Presenter): Nothing to Disclose
Shambhavi Venkataraman MD (Presenter): Nothing to Disclose
Angelique C. Floerke MD (Presenter): Nothing to Disclose
Rachel Frydman Brem MD (Presenter): Board of Directors, iCAD, Inc Board of Directors, Dilon Technologies LLC Stock options, iCAD, Inc Stockholder, Dilon Technologies LLC Consultant, U-Systems, Inc Consultant, Dilon Technologies LLC Consultant, Dune
Medical Devices Ltd
Karen S. Johnson MD (Presenter): Research Consultant, Siemens AG
Nicole Sondel Lewis MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Describe the equipment needed for ultrasound guided interventional breast procedures. 2) Review the basic principles of ultrasound guidance and performance of minimally invasive breast procedures. 3) Practice hands-on technique for ultrasound guided breast interventional procedures.
ABSTRACT
This course is intended to familiarize the participant with equipment and techniques in the application of US guided breast biopsy and needle localization. Participants will have both basic didactic instruction and hands-on opportunity to practice biopsy techniques on tissue models with sonographic guidance. The course will focus on the understanding and identification of: 1) optimal positioning for biopsy 2) imaging of adequate sampling confirmation 3) various biopsy technologies and techniques 4) potential problems and pitfalls
Refresher/Informatics
US MR CT GI
AMA PRA Category 1 Credits ™ : 1.50
ARRT Category A+ Credits: 1.50
Fri, Dec 5 8:30 AM - 10:00 AM Location: N230AB
Sub-Events
RC809A Pitfalls in Bowel Imaging
Douglas S. Katz MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) To briefly overview the problem of correct interpretation of the bowel on 'routine' abdominal and pelvic CT.
2) To demonstrate cases of pitfalls and pearls of interpretation of bowel findings on abdominal and pelvic CT. 3)
To briefly review the limited literature on this topic.
RC809B Atypical Liver Lesions
Rendon C. Nelson MD (Presenter): Consultant, General Electric Company Consultant, Nemoto Kyorindo Co,
Ltd Consultant, VoxelMetrix, LLC Research support, Bracco Group Research support, Becton, Dickinson and
Company Speakers Bureau, Siemens AG Royalties, Wolters Kluwer nv
LEARNING OBJECTIVES
1) To understand the typical imaging appearance of various focal liver lesions on CT and MR and how they can present in an atypical fashion (i.e. the imaging spectrum).
RC809C
RC809D
Pitfalls in Hepatic Doppler Sonography
Jonathan B. Kruskal MD, PhD (Presenter): Author, UpToDate, Inc
LEARNING OBJECTIVES
1) Discuss the common technical pitfalls that occur when performing the liver Doppler examination, and how these can be mitigated. 2) Discuss the perceptual and interpretive errors that occur when performing the liver
Doppler examination, and how these can be minimized. 3) Describe the clinical impact of technical and interpretive errors.
Pearls and Pitfalls in Pancreatic Diseases
Benjamin M. Yeh MD (Presenter): Research Grant, General Electric Company Consultant, General Electric
Company
LEARNING OBJECTIVES
1) Understand critical ductal and parenchymal anatomic variants that affect the appearance of the pancreas

affected by cancer. 2) Describe the appearance of pancreatic adenocarcinomas and how to report critical structures for local staging of malignancy. 3) Review mimics of pancreatic adenocarcinoma and how to distinguish between benign and malignant disease.
ABSTRACT
Pancreatic cancer remains a devastating disease with a poor general prognosis. Understanding of the typical radiological features of pancreatic cancer helps in the detection of early disease that may be curable. While surgical resection carries the hope of cure in patients with resectable disease, accurate radiological interpretation and staging is critical for the appropriate triage of patients with suspected adenocarcinoma and provides the roadmap for surgical intervention. Imaging interpretation also guides palliative therapy that may improve the quality of life. In this course we will cover important anatomical considerations at CT and MRI that allow for rapid accurate interpretation of images in patients with suspected adenocarcinomas. We will review important mimics of malignancy that may require different treatment and improved prognosis. The staging of adenocarcinoma, including structural landmarks important for pre surgical planning will be discussed.
Refresher/Informatics
VA US
AMA PRA Category 1 Credits ™ : 1.50
ARRT Category A+ Credits: 1.50
Fri, Dec 5 8:30 AM - 10:00 AM Location: E353C
Sub-Events
RC810A Challenges in Carotid Doppler
Edward G. Grant MD (Presenter): Research Grant, Bracco Group Research Grant, General Electric Company
Medical Advisory Board, Nuance Communications, Inc
LEARNING OBJECTIVES
1) Understand the various forms of extracranial pathology affecting the arteries serving the brain and their diagnostic appearance/criteria as seen by the ultrasound examination. 2) Be familiar with the indications for a cerebrovascular examination and its relationship to correlative imaging. 3) Know the criteria set forth by the
Society of Radiologists in Ultrasound Consensus Conference for internal carotid artery stenosis and their rationale.
active handout http://media.rsna.org/media/abstract/2014/13010314/RC810-a Sec .pdf
RC810B
RC810C
Vertebral Artery Ultrasound: A Gateway to the Great Vessels
Mindy Meislich Horrow MD (Presenter): Spouse, Director, Merck & Co, Inc
LEARNING OBJECTIVES
1) Describe normal anatomy and spectral Doppler of the vertebral arteries. 2) Describe the spectrum of Doppler findings of the subclavian steal phenomenon: pre, partial and complete steal. 3) Detect proximal disease in the innominate vessels and aorta using vertebral artery waveforms in combination with carotid waveforms.
ABSTRACT
This lecture will demonstrate normal and variant duplex Doppler imaging of the vertebral artery. It will analyze the anatomy of the vertebral-basilar circulation and how it explains the spectrum of subclavian steal syndrome.
It will further demonstrate the combination of findings in vertebral and carotid circulations that indicates brachiocephalic disesase.
Upper and Lower Extremity Veins
Leslie M. Scoutt MD (Presenter): Consultant, Koninklijke Philips NV
LEARNING OBJECTIVES
1) Describe the US criteria for diagnosis of DVT in the upper and lower extremities. 2) Discuss common pitfalls in US evaluation of DVT. 3) Discuss current controversies in the US evaluation of DVT such as: acute vs chronic
(residual) DVT; use of the D-dimer assay; should the calf veins be evaluated; is it appropriate to do unilateral exams. 4) Describe the role of US in identifying other causes of extremity pain and swelling.
ABSTRACT
This lecture will describe the technique and diagnostic criteria for the US diagnosis of DVT in the upper and

This lecture will describe the technique and diagnostic criteria for the US diagnosis of DVT in the upper and lower extremities. Common pitfalls in sonographic assessment of DVT will be described as well as current clinical questions in US evaluation of patients suspected of harboring DVT such as: what is the importance of pre-test probability?, what is the role of the D-dimer assay?, how to differentiate acute from chronic DVT?, and should the calf veins be routinely examined? In addition, the US appearance of other causes of extremity pain and swelling will be described as US has been shown to be useful in making alternative diagnoses, which are often important for patient management, in up to 10% of cases.
Refresher/Informatics
US IR US IR
AMA PRA Category 1 Credits ™ : 1.50
ARRT Category A+ Credits: 1.50
Fri, Dec 5 8:30 AM - 10:00 AM Location: E264
Participants
Christopher Allen Molvar MD (Presenter): Nothing to Disclose
Kent T. Sato MD (Presenter): Nothing to Disclose
Albert A. Nemcek MD (Presenter): Consultant, B. Braun Melsungen AG
Robert J. Lewandowski MD (Presenter): Advisory Board, Nordion, Inc Advisory Board, BTG International Ltd Advisory Board,
Boston Scientific Corporation Consultant, Cook Group Incorporated
Ramona Gupta MD (Presenter): Nothing to Disclose
Terry David Wilkin MD (Presenter): Nothing to Disclose
Kevin Lee Keele MD (Presenter): Nothing to Disclose
Michael Henderson Hamblin MD (Presenter): Nothing to Disclose
Terence Albert S. Matalon MD (Presenter): Nothing to Disclose
Elias Hohlastos MD (Presenter): Nothing to Disclose
Andrew James Lipnik MD (Presenter): Nothing to Disclose
Christopher Baron MD (Presenter): Nothing to Disclose
Parag M. Amin MD (Presenter): Nothing to Disclose
LEARNING OBJECTIVES
1) Acquire the skill to direct a needle to a target for diagnostic or therapeutic purposes with Real-time US-guidance.
ABSTRACT
Participants will have the opportunity to hone their skills in ultrasound guided interventions using phantoms. Experienced practitioners in ultrasound guided intervention will serve as faculty.