A Guide to Penile Duplex Ultrasonographyarchive.rsna.org/2015/GenitourinaryRadiology.pdf · A Guide to Penile Duplex Ultrasonography All Day Location: GU/UR Community, Learning Center

Genitourinary Radiology

UR001-EB-X

A Guide to Penile Duplex Ultrasonography

All Day Location: GU/UR Community, Learning Center

ParticipantsBipin Rajendran, MD, Richmond, VA (Presenter) Nothing to DiscloseMichael Maldonado, MD, Richmond, VA (Abstract Co-Author) Nothing to DiscloseJohn T. Roseman, MD, Richmond, VA (Abstract Co-Author) Nothing to DiscloseUma R. Prasad, MD, Midlothian, VA (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

Penile duplex ultrasonography is a relatively safe, minimally invasive method for evaluation of a number of conditions, including butnot limited to Peyronie's disease as well as erectile dysfunction (ED) secondary to atherosclerotic or post-traumatic changes. Ourgoals are to highlight our experience with this modality by sharing our institution's protocol and to demonstrate a few select caseswhich highlight both normal sonographic findings as well as unique pathology.

TABLE OF CONTENTS/OUTLINE

1) Introduction to penile duplex ultrasonography2) Protocol3) Normal sonographic findings4) Sonographic findings associated withPeyronie's disease5) Sonographic findings associated with erectile dysfunction secondary to atherosclerosis6) Unique sonographicfindings in a patient with erectile dysfunction secondary to prior pelvic trauma

UR003-EB-X

Renal Tumors with Low Signal Intensity on T2-weighted MR Image; Radiologic-pathologic Correlation


ParticipantsYouyeon Kim, MD, Seoul, Korea, Republic Of (Presenter) Nothing to DiscloseDeuk Jae Sung, MD, Seoul, Korea, Republic Of (Abstract Co-Author) Nothing to DiscloseNa Yeon Han, Seoul, Korea, Republic Of (Abstract Co-Author) Nothing to DiscloseKi Choon Sim, Seoul, Korea, Republic Of (Abstract Co-Author) Nothing to DiscloseBeom Jin Park, MD, Seoul, Korea, Republic Of (Abstract Co-Author) Nothing to DiscloseMin-Ju Kim, MD, Seoul, Korea, Republic Of (Abstract Co-Author) Nothing to DiscloseSung Bum Cho, Seoul, Korea, Republic Of (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

1. To review variable renal tumors which show low signal intensity on T2-weighted image.2. To explain the histopathologic featuresthat create the specific appearance on the MR image.3. To discuss the practicality of the MRI findings for the differential diagnosisof the renal tumors.


Review of variable renal tumors with T2 low signal intensityImage findings of the tumors - AML - RCC Papillary RCC Clear cell RCC -other rare tumors TCC Hemangioma Leiomyoma OncocytomaHistopathologic features associated low T2 signal intensity Smoothmuscle component Papillary structure High N/C ratio Hemorrhage Use of the MRI finding for the differential diagnosisSummary anddiscussion

UR004-EB-X

Imaging of Renal Angiomyolipoma: It's Not All About Fat


AwardsCertificate of Merit

ParticipantsHaley R. Clark, MD, Dallas, TX (Presenter) Nothing to DisclosePayal Kapur, MD, Dallas, TX (Abstract Co-Author) Nothing to DiscloseIvan Pedrosa, MD, Dallas, TX (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

1. Technical considerations for US, CT, and MR when imaging renal angiomyolipoma (AML). 2. Correlation of histopatholgic subtypesof renal AML with imaging characteristics. 3. Diagnostic pitfalls, including other renal malignancies which have overlapping MRIimaging characteristics as renal AML.


Technical aspects: Ultrasound CT Non-contrast Contrast-enhanced Dual source MRI: 2D T1 IP/OP 3D T1 Dixon Spectral fatsuppression T2-weighted Contrast enhanced Diffusion-weighted Radiologic-Pathologic Correlation: WHO Classification of AML ClassicAML AML without visible fat AML with spontaneous hemorrhage AML status post embolization Enlarging AML Giant exophytic AMLMultiple AMLs in Tuberous Sclerosis AML in lymphangioleiomyomatosis AML with epithelial cyst (AMLEC) Epithelioid AML, pre and posttreatment with sirolimus Sclerosed epithelioid AML Diagnostic pitfalls: Fat containing clear cell renal cell carcinoma vs AML withminimal but visible fat Papillary renal cell carcinoma vs AML without visible fat Retroperitoneal liposarcoma vs exophytic AMLPseudo-angiomyolipoma after radiofrequency ablation Sclerosing extramedullary hematopoietic tumors

UR005-EB-X

Retroperitoneal Tumor and Retroperitoneal Fibrosis: CT and MR Characteristics and Pathological CorrelativeAnalysis


ParticipantsKeisuke Miyoshi, Ube, Japan (Presenter) Nothing to DiscloseNaofumi Matsunaga, MD, PhD, Ube, Japan (Abstract Co-Author) Nothing to DiscloseMasahiro Tanabe, MD, Ube, Japan (Abstract Co-Author) Nothing to DiscloseTakaaki Ueda, Ube, Japan (Abstract Co-Author) Nothing to DiscloseSei Nakao, Ube, Japan (Abstract Co-Author) Nothing to DiscloseYuko Harada, MD, Ube, Japan (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

The purpose of this exhibit is: 1. To review CT and MR imaging findings of various spectrum of retroperitoneal masses. 2. Tohighlight key differential diagnostic points of imaging findings with pathologic correlation.


1. Introduction - anatomy, cellular origin, malignant potential. 2. Clinical features - epidemiology, clinical symptoms and prognosis.3. Characteristic findings - neoplastic masses (mesodermal origin, neurogenic origin, germ cell origin, lymphoid or hematologic origin)and nonneoplastic masses. 4. Key points for the correlation of radiologic and pathologic features.

UR007-EB-X

Ultrasonographic Appearance of Testicular Tumors: Ultrasonographic-Pathologic Correlation


FDA Discussions may include off-label uses.

ParticipantsYong-Soo Kim, MD, PhD, Guri City, Korea, Republic Of (Presenter) Nothing to DiscloseSangjoon Lee, MD, Guri, Korea, Republic Of (Abstract Co-Author) Nothing to DiscloseSanghyeok Lim, MD, Gyeonggi-do, Korea, Republic Of (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

1. To understand the ultrasonographic features of testicular tumors on the pathologic basis. 2. To know ultrasonographic findings ofcharacteristic testicular tumors.


I. Germ cell neoplasm1. Seminoma2. Embryonal carcinoma3. Yolk sac tumor (adult, childhood type)4. Teratoma (Mature, Immature,With an overtly malignant component)5. ChoriocarcinomaII. Mixed germ cell tumorsIII. Sex cord-stromal neoplasms1. Leydig celltumor2. Sertoli cell tumorIV. Mixed germ cell-sex cord-stromal neoplasmsV. Tumors of "passenger" and non-Leydig, interstitialcells1. Lymphoma2. Leukemic infiltrates3. Miscellaneous others, including epidermoid cysts, mesenchymal tumors, and metastatictumors

UR008-EB-X

Cystogram "A Forgotten Study"


AwardsRSNA Country Presents Travel AwardCertificate of Merit

ParticipantsJulian Ramirez Arango, MD, Mexico City, Mexico (Presenter) Nothing to DiscloseMary C. Herrera-Zarza, MD, Mexico City, Mexico (Abstract Co-Author) Nothing to DiscloseLuis A. Ruiz Elizondo, MD, Mexico City, Mexico (Abstract Co-Author) Nothing to DiscloseAlin Marissa Becerril Ayala, MD, Mexico City, Mexico (Abstract Co-Author) Nothing to DiscloseJose L. Criales, MD, Huixquilucan, Mexico (Abstract Co-Author) Nothing to DiscloseKenji Kimura, MD, Mexico City, Mexico (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

Even though there are great advances in urologyc imaging, the cystogram continues to be the imaging method of choice for somepathologies, and its the radiologist duty to make a correct diagnostic impression through this method.Cystogram is highly efective,has easy access, low cost and is minimally invasiveThe correct interpretation of the cystogram by the radiologist decrease falsepositive results and increase our diagnostic ability.


Table of contents /OutlineIntroductionCorrect cystogram techniquesNormal anatomy and its anatomical variantsUses and utilities ofcystogramCommon pathologies diagnosed by this method

UR100-ED-X

Imaging of Gerota's Fascia


ParticipantsJun Isogai, MD, Asahi, Japan (Presenter) Nothing to DiscloseNaoki Harata, Asahi, Japan (Abstract Co-Author) Nothing to DiscloseKatsuya Yoshida, MD, Asahi, Japan (Abstract Co-Author) Nothing to DiscloseJun Kaneko, Hasuda, Japan (Abstract Co-Author) Nothing to DiscloseTassei Nakagawa, MD, PhD, Asahi, Japan (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

To understand interfascial spread of a wide variety of disorders in retroperitoneal Gerota's fascia.


Anatomy of retroperitoneal interfascial planes. CT or MRI findings of various interfascial disorders in Gerota's fascia.Pneumoretroperitoneum Pancreatic fluid / Bile / Urine collection Retroperitoneal hematoma Retroperitoneal abscess Tumor andinflammatory extension of renal, pancreatic and colon diseases Malignant lymphoma Retroperitoneal dissemination of thoracic tumorPrimary retroperitoneal tumor

UR101-ED-X

Genitourinary Applications of Spectral CT


ParticipantsNicholas L. Fulton, MD, Cleveland, OH (Abstract Co-Author) Nothing to DiscloseLuis A. Landeras, MD, Cleveland, OH (Abstract Co-Author) Institutional Grant support, Koninklijke Philips NVJason DiPoce, MD, Jerusalem, Israel (Abstract Co-Author) Nothing to DiscloseJacob Sosna, MD, Jerusalem, Israel (Abstract Co-Author) Consultant, ActiViews Ltd Research Grant, Koninklijke Philips NVPrabhakar Rajiah, MD, FRCR, Cleveland, OH (Presenter) Institutional Research Grant, Koninklijke Philips NV

TEACHING POINTS

Dual energy/spectral CT scanners provide material characterization capabilities which improve diagnostic accuracy, withoutincreasing radiation. There are several techniques of dual energy CT, including a dual layer technology Spectral detector CTenables retrospective generation of spectral images


-Spectral CT- Physics-Techniques of spectral CT-Phantom studies-Advantages and disadvantages of various implementations-Genitourinary applications of spectral CT with illustrations Stone characterization- Uric acid vs non uric acid Renal masscharacterization- virtual non contrast, iodine person, effective atomic number based images Adrenal mass characterizationImproved lesion detection and characterization Tumor perfusion and response to therapy Urinary stone in iodinated solution Virtualnon contrast in multiphasic studies- Radiation dose savings Urothelial tumor detection Artifact reduction

Honored Educators

Presenters or authors on this event have been recognized as RSNA Honored Educators for participating in multiple qualifyingeducational activities. Honored Educators are invested in furthering the profession of radiology by delivering high-qualityeducational content in their field of study. Learn how you can become an honored educator by visiting the website at:https://www.rsna.org/Honored-Educator-Award/

Prabhakar Rajiah, MD, FRCR - 2014 Honored EducatorJacob Sosna, MD - 2012 Honored EducatorJason DiPoce, MD - 2013 Honored Educator

UR102-ED-X

Eponyms in Urogenital Radiology: Old Names, But Still Golden Nuggets


ParticipantsDaniel M. Figueira, Niteroi, Brazil (Presenter) Nothing to DiscloseEmanuela T. Freitas, MD, Niteroi, Brazil (Abstract Co-Author) Nothing to DiscloseFelipe B. Afonso, MD, Niteroi, Brazil (Abstract Co-Author) Nothing to DiscloseJoao A. Vianna, Niteroi, Brazil (Abstract Co-Author) Nothing to DiscloseDaniel G. Neves, MD, Niteroi, Brazil (Abstract Co-Author) Nothing to DiscloseLeonardo K. Bittencourt, MD, PhD, Rio De Janeiro, Brazil (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

- Eponyms were historically used in medicine for honorary and educational purposes, but their importance has been questioned inthe present, in favor of a more anatomical description of findings and diseases. However, a number of eponyms and 'auntminnies'still constitute useful educational tools and mnemonics in radiology practice.- The urogenital system is rich in eponyms and'auntminnies', which translate a variable sort of anatomical structures and conditions, such as: Gerota´s fascia, Zuckerckandl sfascia, Denonvillier´s fascia, Bertin´s column, Malpighi s pyramid, Weigert-Meyer rule, Bricker surgery, Peyronie disease, etc.- Theobjective of this work is to review the most well-known and relevant eponyms in urogenital radiology, along with a didatic andillustrative approach, based on mnemonics and pattern recognition.


1 - What is an eponym? What is an 'auntminnie'?2 - The use of eponyms throughout medical history. Is there any role for themtoday?3 - Eponyms and 'auntminnies' in the urogenital system: an illustrative and mnemonical approach- Anatomy: Gerota´s fascia,Zuckerckandl s fascia, Denonvillier´s fascia, Bertin´s column, Malpighi s pyramid, Retzius´s space.- Malformations: Weigert - Meyerrule.- Diseases: Conn´s disease, Wilms tumor, Peyronie disease.- Syndrome: Zinner´s syndrome, Bourneville syndrome.- Surgery:Bricker Surgery.

UR103-ED-X

PIRADS v2: A Case-based Review of the New Categorization with Emphasis on Its Impact on MR GuidedBiopsy, Its Limitations and Pitfalls


ParticipantsVaraha Tammisetti, MD, Houston, TX (Presenter) Nothing to DiscloseBijan Bijan, MD, Sacramento, CA (Abstract Co-Author) Nothing to DiscloseSadhna Verma, MD, Cincinnati, OH (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

1. Review the new version of PIRADS with emphasis on changes from prior version and comparsion to similar other criteria. 2.Illustrate case based examples of each of the PIRADS categories and pitfalls in categorization and interpretation. This will be in aProstate MR Rad-Path correlation format. 3. Limitations of current PIRADS version. 4. Illustration and review of literature onutilization of PIRADS in each of the clinical settings with emphasis on its role in MR guided (direct or indirect by fusion) targetedbiopsy.


1. Clinical and technical considerations including 'clinically significant cancer', clinical scenarios and technical parameters2. Reviewof relevant normal anatomy with illustration of each of the lexicon of normal and pathological terms.3. Overview of PIRADS v.2 withreview of changes and comparison to other criteria.4. Case based examples of each of PIRADS categories in Peripheral andTransitional zones including benign findings such as prostatitis, asymmetric focal atrophy, periprostatic vessel, calcification, normalcentral zone. Presented in a quiz format with Rad-Path correlation.5. Limitations of current PIRADS and also pitfalls. Currentutility/status of DCE.6. Case based examples on utilization of PIRADS in each of the clinical settings with emphasis on its role in MRguided targeted biopsy.

Honored Educators


Sadhna Verma, MD - 2013 Honored Educator

UR104-ED-X

Prostate Cancer in the Transition Zone and the Anterior Fibromuscular Stroma: Clues to the Diagnosis inMultiparametric MRI with Emphasis on Intraprostatic Patterns of Spread and the Relative Frequency of theLocations


AwardsMagna Cum Laude

ParticipantsHiroshi Shinmoto, MD, Tokorozawa, Japan (Presenter) Nothing to DiscloseShigeyoshi Soga, MD, Tokorozawa, Japan (Abstract Co-Author) Nothing to DiscloseChiharu Tamura, Tokorozawa, Japan (Abstract Co-Author) Nothing to DiscloseKentaro Yamada, MD, Tokorozawa, Japan (Abstract Co-Author) Nothing to DiscloseTeppei Okamura, MD, Tokyo, Japan (Abstract Co-Author) Nothing to DiscloseHiroko Tomita, Tokorozawa, Japan (Abstract Co-Author) Nothing to DiscloseTatsumi Kaji, MD, Tokorozawa, Japan (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

Although the diagnostic performance of multiparametric MRI in peripheral zone (PZ) prostate cancer has been improved up toapproximately 80 to 90% sensitivity and specificity, the diagnosis of transition zone (TZ) prostate cancer is still challenging. Thus,the purpose of this exhibit is to present the patterns of intraprostatic spread and the relative frequency of the locations ofprostate cancer in the TZ and the anterior fibromuscular stroma (AFMS) based on 155 prostatectomy specimens withmultiparametric MRI data, and to provide diagnostic clues as to interpreting multiparametric MRI in TZ and AFMS prostate cancer.


Anatomy of the TZ and AFMS What is anterior prostate cancer (APC)? Clinical importance of APC Morphological features of TZ andAFMS prostate cancer The relative frequency of the locations of TZ and AFMS prostate cancer Atypical locations of TZ prostatecancer The non-cancerous AFMS and BPH mimicking TZ prostate cancer

UR106-ED-X

Multimodalityimaging Features of Sarcomas of the Abdomen and Pelvis with Radiologic-pathologic Correlation


ParticipantsKara D. Gaetke-Udager, MD, Ann Arbor, MI (Presenter) Nothing to DiscloseAaron M. Udager, MD, PhD, Ann Arbor, MI (Abstract Co-Author) Nothing to DiscloseKatherine E. Maturen, MD, Ann Arbor, MI (Abstract Co-Author) Consultant, GlaxoSmithKline plc; Medical Advisory Board,GlaxoSmithKline plcCorrie M. Yablon, MD, Ann Arbor, MI (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

After review of this exhibit, the viewer will be able to: List the types of sarcoma that can occur in the abdomen and pelvis Describeunique and shared imaging features of abdominal and pelvic sarcomas Identify imaging characteristics that aid biopsy planningExplain how the pathologic appearance correlates with the imaging findings Understand the surgical considerations for abdominaland pelvic sarcomas


Background Embryologic origin of soft tissue tumors Nomenclature of soft tissue tumors Surgical considerations Sarcomas of theabdomen and pelvis For each tumor below, we will discuss: Demographics Clinical presentation Pathologic features Multimodalityimaging features Treatment options Types of sarcomas Well-differentiated liposarcoma De-differentiated liposarcoma Pleomorphicliposarcoma Myxoid liposarcoma Undifferentiated high-grade pleomorphic sarcoma Leiomyosarcoma Extraskeletal osteosarcomaChondrosarcoma Ewing sarcoma Synovial sarcoma Alveolar soft part sarcoma Conclusions Challenge of overlapping imaging featuresPathologic features can be used to understand imaging and direct clinical management Imaging characteristics guide biopsydecisions Importance of surgical considerations in radiology report

Honored Educators


Katherine E. Maturen, MD - 2014 Honored Educator

UR107-ED-X

Sonographic Assessment of Tumour Margins at Partial Nephrectomy (PN) - Intraoperative and Ex-Vivo.Review of Technique


ParticipantsNaveed Altaf, MBBS, MRCS, Middlesbrough, United Kingdom (Presenter) Nothing to DiscloseGeoffrey P. Naisby, MBBS, Yarm, United Kingdom (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

1. To review the technique of ultrasound control of resection margins in Patients undergoing PN - Both Intraoperative and ex-vivo.2. To discuss the efficacy of this approach and its potential to demonstrate additional findings not seen on the preoperativeimaging which can modify surgery.


BackgroundIntraoperative ultrasound is a well-established technique routinely used to facilitate surgical resection during partialnephrectomy.Technique: Ultrasound was performed using a 12MHz probe after mobilisation of kidney and for laparoscopic cases, alaparoscopic USS probe was used. Tumour size and depth was mapped and area of excision marked with diathermy.Followingresection, the sample was evaluated in 3 dimensions, recording the closest margin between tumour and outer parenchymal edge.Margins were considered free of tumour when a rim of healthy renal parenchyma was seen completely without a gap or tumour wascontained within the pseudocapsule.Discussion:In line with a previous reports of surgical specimen (ex-vivo) ultrasound in assessingmargin status for PN, we confirm the safety and efficacy of this approach in our single institution series. Patient characteristics,operative indications, tumour and margin size were comparable to previous series.

UR109-ED-X

Multimodality Evaluation of Renal Transplant Vascular Complications



ParticipantsBehrad Golshani, MD, Sacramento, CA (Presenter) Nothing to DiscloseWonsuk Kim, MD, Sacramento, CA (Abstract Co-Author) Nothing to DiscloseDanny Cheng, MD, Sacramento, CA (Abstract Co-Author) Nothing to DiscloseCatherine T. Vu, MD, Denver, CO (Abstract Co-Author) Nothing to DiscloseGhaneh Fananapazir, MD, Sacramento, CA (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

The purpose of this exhibit is: To review common and uncommon renal transplant vascular complications across multiple imagingmodalities including ultrasound, MRI, CT, and conventional angiography. To discuss pearls and pitfalls related to uncommon renaltransplant vascular complications.


Background Renal transplant vascular anatomy Incidence of common and uncommon rental transplant vascular complicationsRepresentative ultrasound, CT, MRA and/or digital subtraction angiography images of the following entities will be presented:Tandem renal artery stenosis Renal vein stenosis Pseudo-renal artery stenosis External iliac artery stenosis External iliac veinstenosis Renal artery thrombosis Renal vein thrombosis Extrarenal pseudoaneurysm Intrarenal pseudoaneurysm Arteriovenous fistulaSubcapsular hematoma

UR110-ED-X

Staging of Prostate Cancer: Tips Not to Miss an Extracapsular Extension Reported Posteriorly by thePathologist


ParticipantsMarta Drake Perez, MD, Santander, Spain (Presenter) Nothing to DisclosePedro Lastra Garcia-Baron, MD, Santander, Spain (Abstract Co-Author) Nothing to DiscloseAlejandro Fernandez Florez, MD, Santander, Spain (Abstract Co-Author) Nothing to DiscloseAinara Azueta Etxebarria, Santander, Spain (Abstract Co-Author) Nothing to DiscloseElena Yllera Contreras, MD, Santander, Spain (Abstract Co-Author) Nothing to DiscloseElena Lopez Uzquiza, Santander, Spain (Abstract Co-Author) Nothing to DiscloseGerardo Lopez Rasines, MD, Santander, Spain (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

To summarize the MRI signs of prostate cancer with extracapsular extension, with the histopathologic outcomes as the referencestandard. To emphasize the correlation between the imaging findings and the histopathological results. To review the cases wherethe radiologic pathology correlation failed, giving a second look to the MRI and trying to figure out where the typical mistakes are.


- Importance of an accurate preoperative staging in prostate cancer.- MRI imaging protocol for prostate cancer in 3T magnetwithout endorectal coil.- MRI criteria to determine extracapsular extension, using radical prostatectomy histopathology as thereference standard. Irregular bulge in the prostatic capsule Broad capsular tumour contact (>12mm) Obliteration of therectoprostatic angle Obliteration of the vesiculoprostatic angle Asymmetry of the neurovascular bundle Evidence of direct tumorextension- Common mistakes from our daily practice

UR111-ED-X

Retrograde Urethrogram: Anatomy, Pathology, and Repair


ParticipantsFranco Verde, MD, Baltimore, MD (Presenter) Nothing to DiscloseLynda Mettee, Baltimore, MD (Abstract Co-Author) Nothing to DiscloseEdward J. Wright, MD, Baltimore, MD (Abstract Co-Author) Nothing to DiscloseMartin Auster, MD, Baltimore, MD (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

Knowing anatomy of male urethra is critical for operative repair Know the appearance of stricturesKnow the surgical approach tourethral disease and post-operative appearance on retrograde urethrograms


A. Technique a. Patient prep b. Equipment used c. Positioning and fluoro tipsB. Normal anatomyC. Pathology a. Stricture b.TraumaD. Surgical approachE. Post-operative appearance a. Normal postop retrograde ureterogram b. Leakage c. Followup d.Recurrent stricture

UR112-ED-X

Magnetic Resonance Imaging Evaluation of Urothelial Cell Carcinoma: Staging and Treatment Planning withHistopathological Correlation


ParticipantsPeter A. Harri, MD, Atlanta, GA (Presenter) Nothing to DiscloseCourtney A. Coursey Moreno, MD, Suwanee, GA (Abstract Co-Author) Nothing to DiscloseJuan C. Camacho, MD, Atlanta, GA (Abstract Co-Author) Nothing to DisclosePardeep K. Mittal, MD, Atlanta, GA (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

The purpose of this exhibit is: Review basic principles of urothelial cell carcinoma (UCC). Describe the use of magnetic resonanceimaging (MRI) to differentiate UCC in the urinary system from other malignant and benign lesions. Demonstrate the use of MRI toadequately stage UCC within the urinary tract and locate distant disease. Discuss the impact of MRI for accurate pre-surgicalevaluation and staging on management and treatment options.


Review common presentations of UCC, including key characteristics that define malignancy with histopathological correlations.Review of UCC staging with MRI imaging findings. Discuss the impact of MRI for accurate pre-surgical evaluation and staging onmanagement and treatment options. Important concepts are illustrated with schematic diagrams. Emphasis is placed on practicalapproaches and image pattern recognition. Conclusions: MRI plays a key role for noninvasive diagnosis of UCC and staging of thetumor, especially for smaller lesions where surgical management can differ depending on the extant of invasion. Adequateknowledge of UCC imaging features on MRI is crucial for appropriate and prompt patient intervention.

UR113-ED-X

Multiple Renal Masses: A Review of Causes with Emphasis on Differential Diagnosis


ParticipantsMariano Volpacchio, MD, Buenos Aires, Argentina (Presenter) Nothing to DiscloseChristine O. Menias, MD, Scottsdale, AZ (Abstract Co-Author) Nothing to DiscloseMario G. Santamarina, MD, Valparaiso, Chile (Abstract Co-Author) Nothing to DiscloseJoaquina Paz Lopez Moras, MD, Buenos Aires, Argentina (Abstract Co-Author) Nothing to DiscloseVeronica Rubio, Buenos Aires, Argentina (Abstract Co-Author) Nothing to DiscloseAntonio Luna, MD, Jaen, Spain (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

The goals of this presentation are: To review causes of multiple renal masses To discuss imaging findings of the different entitiesTo provide imaging-based clues useful to guide to the correct diagnosis


- Introduction- Etiology of multiple renal masses Hereditary Inflammatory and infectious Immunologic Vascular Neoplastic benign,primary malignant, secondary malignant- Imaging findings specific to the kidney and associated findings of each entity - Differentialdiagnosis cluesSummaryThe presence of multiple renal masses may be an isolated or dominant imaging finding as well as anadditional abnormality in the setting of multiorgan involvement.An imaging-based, multimodality approach may be crucial in thedifferential diagnosis process as well as in patient management.Awareness of the imaging appearance of the various causes indifferent imaging modalities and integration with other findings may result in a correct diagnosis in most cases as well as in assistingin proper patient work-up and management.

Honored Educators


Christine O. Menias, MD - 2013 Honored EducatorChristine O. Menias, MD - 2014 Honored EducatorChristine O. Menias, MD - 2015 Honored Educator

UR115-ED-X

Pharmakinetic, Gadolinium and Technical Parameters Affecting Bolus Geometry during Contrast EnhancedRenal MR Angiography: An Overview


ParticipantsCharbel Saade, PhD, Beirut, Lebanon (Presenter) Nothing to DiscloseGhina Al Fout, Beirut, Lebanon (Abstract Co-Author) Nothing to DiscloseBatoul Dorkmark, Beirut, Lebanon (Abstract Co-Author) Nothing to DiscloseFadi M. El-Merhi, MD, New York, NY (Abstract Co-Author) Nothing to DiscloseHussain M. Almohiy, PhD, Abha, Saudi Arabia (Abstract Co-Author) Nothing to DiscloseRayan Bou Fakhredin, Beirut, Lebanon (Abstract Co-Author) Nothing to DiscloseBassam El-Achkar, MD, Beirut, Lebanon (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

Optimal arterial hyperintensity is essential during MRA Matching scanning parameters such as TR, TE, Flip angle and parallel imagingwith with vessel dynamics significantly improves vessel hyperintensity This leads to increased arterial hyperintensity and reducedvenous hypointensity This can also lead to a reduced volume of Gadolinium based contrast agents. Reduced gadolinium-basedcontrast volume can reduce tissue, technique and motion related artefacts This can also lead to reduced specific absorption rate


A. Renal Vascular Anatomy and flow dynamics B. Scanning parameters C. Contrast media parametersD. Linear vs. MacrocyclicGadoliniumE. Parameters affecting bolus geomteryF. Transverse and Longitudinal relaxation ratio and its effect on signal intensityH.Comparison between 1.5T and 3.0T scanning parameters

UR116-ED-X

What's Going On With My Kidneys? When Diagnosis is Challenging: Multimodality Imaging in Atypical Nephritis



ParticipantsVirginia Gomez, San Sebastian, Spain (Presenter) Nothing to DiscloseJuan Vega Eraso, San Sebastian, Spain (Abstract Co-Author) Nothing to DiscloseMaria Carmen Biurrun Mancisidor, San Sebastian, Spain (Abstract Co-Author) Nothing to DiscloseGorka Arenaza Choperena, San Sebastian, Spain (Abstract Co-Author) Nothing to DiscloseGonzalo Vega-Hazas, San Sebastian, Spain (Abstract Co-Author) Nothing to DiscloseDiana Garcia Asensio, Donostia, Spain (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

To demonstrate the spectrum of imaging findings of upper urinary tract infections, with emphasis on certain rare entities wherelittle literature has been written about.To discuss the role of the different imaging techniques.To summarize the different riskfactors for developing UTI, describing some anatomical conditions mostly involved in recurrent nephritis.


While majority of UTIs are uncomplicated and can be diagnosed and treated based on clinical and laboratory data alone, imaging isrequired in some clinical scenarios.Different imaging modalities include US, IVU, CT, MRI and we have to be aware of their potentialbenefits and limitations.We will discuss some diagnostic classic signs and extrarrenal findings in typical scenarios. Thus, we willemphasize and illustrate with cases in which there is no or little literature written about. Such conditions include renal tumors withsuperimposed infection, atypical infection in kidney´s grafts, anaerobic germ infection associated to urinary stone, atypical form ofxantogranulomatous poyelonephritis, subcapsular abscesses...Finally, we will summarize the predisposing factors for developing UTIand recurrent infections with different cases: anomalies on the collecting system and ureter, and anomalies on the position androtation of the kidney.

UR118-ED-X

The Added Value of Functional and Molecular Imaging of the Scrotum


AwardsCum Laude

ParticipantsSandra Baleato Gonzalez, MD, PhD, Santiago, Spain (Presenter) Nothing to DiscloseRoberto Garcia Figueiras, MD, Santiago de Compostela, Spain (Abstract Co-Author) Nothing to DiscloseJoan C. Vilanova, MD, PhD, Girona, Spain (Abstract Co-Author) Nothing to DiscloseGabriel C. Fernandez-Perez, PhD, MD, Avila, Spain (Abstract Co-Author) Nothing to DiscloseNuria Escudero-Garcia, Santiago de Compostela, Spain (Abstract Co-Author) Nothing to DiscloseAnxo Martinez De Alegria, MD, Santiago de Compostela, Spain (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

The evaluation of scrotum has traditionally been made based on morphologic imaging. Recent developments in imaging techniqueshave improved the ability to evaluate scrotal entities. Beside this, multiparametric magnetic resonance imaging (MRI) may combinethe information from different anatomical, functional and molecular imaging techniques, thus allowing an improved understanding ofscrotal pathologies. The aim of this exhibit is: To emphasis the added information of functional and molecular imaging for evaluatingthe scrotum. To learn about the imaging findings of the scrotum based on different imaging techniques:dynamic contrast-enhancedMRI (DCE-MRI), dynamic contrast-enhanced ultrasound (DCE-US), diffusion-weighted MRI (DWI-MRI), MR spectroscopy imaging(MRSI),CT, PET, and US-elastography.


1.Clinical setting:1.1. Cryptorchidism1.2. Acute scrotum1.3. Non acute scrotum 1.3.1. Extratesticular lesion 1.3.2. Intratesticularlesions 2. Ultrasound utilities2.1. DCE-ultrasound: evaluate acute scrotum.2.2. Elastography: characterization of lesions 3. MRIutilities3.1. DCE-MRI: characterization of leisons3.2. DWI-W-BODY: staging and monitoring3.3 Spectroscopy: evaluatespermatogenesis

UR119-ED-X

The Nuts and Bolts of the Acute Scrotum: A Multiple Choice Question Case-Based Review of Acute ScrotalPathology



ParticipantsChristina Ma, MD, Los Angeles, CA (Presenter) Nothing to DiscloseAnokh Pahwa, MD, Los Angeles, CA (Abstract Co-Author) Nothing to DiscloseMichael J. Nguyen, MD, Santa Barbara, CA (Abstract Co-Author) Nothing to DiscloseMichael L. Douek, MD, MBA, Los Angeles, CA (Abstract Co-Author) Nothing to DiscloseSteven S. Raman, MD, Santa Monica, CA (Abstract Co-Author) Nothing to DiscloseMaitraya K. Patel, MD, Sylmar, CA (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

Acute scrotal abnormalities commonly present to the Emergency Department; several conditions require emergent surgicalexploration by the urologist. With the help of the clinical history and physical examination, the radiologist can offer a specificdiagnosis and guide decision-making particularly regarding surgical intervention. This multiple choice question case-based review willassist the radiologist at all levels of training better identify and diagnose these abnormalities and make appropriaterecommendations to the referring clinician.


Comprehensive multimodality imaging review of acute scrotal pathology in a multiple choice question format with pertinentdiscussion of clinical presentation, management, and differential diagnosis. Cases will include a spectrum of acute scrotalpathology: 1. Ischemia (testicular torsion, torsion of the appendix testis, testicular infarction); 2. Trauma (testicular rupture,intratesticular hematoma, testicular contusion, hematocele); 3. Infection (acute epididymitis including tuberculous epididymitis,abscess, Fournier's gangrene); 4. Testicular and extratesticular neoplasms (germ cell neoplasm, burned out germ cell tumor,lymphoma, metastasis, liposarcoma of the spermatic cord); 5. Enlarged scrotum (scrotal wall edema, hydrocele, spermatic cordhydrocele).

UR121-ED-X

Evaluation and Follow-up of the Complications of Urinary Tract Surgical Procedures: CT-urographic Patterns


ParticipantsGianpiero Cardone, MD, Milano, Italy (Presenter) Nothing to DiscloseMaurizio Papa, MD, Milan, Italy (Abstract Co-Author) Nothing to DisclosePaola Mangili, PhD, Milano, Italy (Abstract Co-Author) Nothing to DiscloseGiuseppe Balconi, Ornago, Italy (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

To review the most frequent urinary tract postoperative complications.To illustrate CT-Urographic patterns of urinary tractpostoperative complications.To describe the usefulness of CT-Urography in the diagnosis and follow-up of urinary tractpostoperative complications.


1) Most frequent urinary tract postoperative complications: Urinary leaks Uretero-vesical anastomosis dehiscence Ureterocutaneousfistulas Bleeding / hematomas Peritoneal and retroperitoneal fluid collections Urinary tract stenosis 2) Best CT techniques in theevaluation of urinary tract postoperative complications3) Conventional and urographic CT patterns of urinary tract postoperativecomplications4) CT imaging follow-up of urinary tract postoperative complications CONCLUSIONS1) Ureteral lesions, retroperitonealhematomas and/or bleeding and fluid collections are the most frequent urinary tract postoperative complications2) Urographicimages combined with conventional CT imaging allow an accurate diagnosis and follow-up of urinary tract postoperativecomplications3) Source axial images and MPR of the urographic acquisition show a better identification of urinary tract lesions4) 3DMIP reconstructions are useful in summarising urographic axial images

UR122-ED-X

Infiltrative Renal Lesions in Adults - Spectrum of Disease


AwardsCertificate of MeritIdentified for RadioGraphics

ParticipantsLori M. Gettle, MD, MBA, Hummelstown, PA (Presenter) Nothing to DiscloseUzma A. Rana, MD, MPH, Baltimore, MD (Abstract Co-Author) Nothing to DiscloseNabeel I. Sarwani, MD, Hummelstown, PA (Abstract Co-Author) Nothing to DiscloseCary L. Siegel, MD, Saint Louis, MO (Abstract Co-Author) Nothing to DiscloseBrent J. Wagner, MD, Reading, PA (Abstract Co-Author) Nothing to DisclosePerry J. Pickhardt, MD, Madison, WI (Abstract Co-Author) Co-founder, VirtuoCTC, LLC; Stockholder, Cellectar Biosciences, Inc;Research Consultant, Bracco Group; Research Consultant, KIT ; Research Grant, Koninklijke Philips NVThomas M. Dykes, MD, Hershey, PA (Abstract Co-Author) Researcher, Bayer AG

TEACHING POINTS

Review the differential diagnosis of infiltrative renal lesions in adults. Review imaging modalities and protocols used to evaluateinfiltrative renal lesions. Demonstrate the imaging features of benign and malignant infiltrative renal lesions.


Differential diagnosis of benign and malignant infiltrative renal lesions in adults. Imaging modalities and protocols to evaluateinfiltrative renal lesions. Ultrasound CT MRI PET-CT Imaging features of infiltrative renal lesions. Benign PyelonephritisAngiomyolipoma Infarct Contusion Malignant Urothelial carcinoma Lymphoma Less common renal carcinomas Metastases Renalsarcoma

Honored Educators


Perry J. Pickhardt, MD - 2014 Honored Educator

UR123-ED-X

Imaging Features of Paratesticular Masses


ParticipantsMustafa Secil, MD, Izmir, Turkey (Presenter) Nothing to DiscloseMichele Bertolotto, MD, Trieste, Italy (Abstract Co-Author) Nothing to DiscloseLaurence M. Rocher, MD, Kremlin Bicetre, France (Abstract Co-Author) Nothing to DiscloseGokhan Pekindil, MD, Manisa, Turkey (Abstract Co-Author) Nothing to DiscloseJonathan Richenberg, MRCP, FRCR, Brighton, United Kingdom (Abstract Co-Author) Nothing to DiscloseLorenzo E. Derchi, MD, Genova, Italy (Abstract Co-Author) Nothing to DiscloseParvati Ramchandani, MD, Merion Station, PA (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

1. To demonstrate the imaging findings of paratesticular masses 2. To illustrate the radiological features in correlation with thepathological findings


Paratesticular masses are relatively rare lesions which include the non-neoplastic lesions, and benign or malignant neoplasms. Non-neoplastic lesions of paratesticular area include the tunical cyst, epididymal cyst, spermatocele, fibrous pseudotumor, spermaticcord cyst, lipomatosis, and polyorchidism. Neoplastic lesions may either be benign or malignant. Benign neoplasms are lipoma,adenomatoid tumor, leiomyoma, angioleiomyoma, angiomyofibroblastoma-like tumor, hemangioma and papillary cystadenoma.Malignant neoplasms are mostly mesenchymal in origin, namely the rhabdomyosarcoma, liposarcoma, leiomyosarcoma, andundifferentiated pleomorphic sarcoma (malignant fibrous histiocytoma). Malignant mesothelioma, metastases due to variousprimaries, lymphoma/leukemia and plasmocytoma. Imaging findings of these lesions are going to be be presented.

UR125-ED-X

MRI of the Scrotum : A Complimentary Tool or A Necessary Diagnostic Step?


ParticipantsAhmed S. Soliman, MBBS, Doha, Qatar (Presenter) Nothing to DiscloseManeesh Khanna, MBBS, Doha, Qatar (Abstract Co-Author) Nothing to DiscloseSushila Ladumor, MBBS, MD, Doha, Qatar (Abstract Co-Author) Nothing to DiscloseAhmed M. Sherif, MBBCh, FRCR, Doha, Qatar (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

To understand the: Scrotal anatomy on MRI and its imaging protocol.A review of MRI appearnce of a wide spectrum of scrotaldisease . To understand the importance of MRI in problem solving situations such as: -Differentiating stromal from non stromaltumor. -Assessing tunica or epididymal involvement by the neoplastic lesion and evaluating retroperitoneum at the same time -Understand the difference of imaging caracteristics between different types of testicular neoplasm in dynamic post contrast studiesand diffusion WI.


A. MRI anatomy of the scrotum . B.Technique of MRI of the scrotum : sequences and aim of each. C. Scrotal pathologies : 1.Benign extratesticular lesions : Hematoma, Infection :TB epidydmoorchitis, Adenomatoid tumor, Dilatation of cowper gland etc. 2.Malignant extratesticular: Sclerosing Liposarcoma of epidydmis . 3. Benign testicular -Chronic infarction,Testicularabscess,Testicular contusion, tubular ectasia of rete testis, Stromal tumours such as Sertoli cell, Leydig cell and granulosa celltumour . Microlithiasis of the testis. 4. Malignant testicular : Seminomatous and non seminomatous germ cell tumour, lymphoma. D.Role of enhancement characterictics (DCE curves) and DWI in differentiating testicular neoplasms- review of data of a series ofmore than 10 intratesticular neoplasms .

UR126-ED-X

Ductal Adenocarcinoma of the Prostate: Imaging and Histopathological Features of this Unusual Suspect



ParticipantsAdam W. Jaster, MD, Dallas, TX (Presenter) Nothing to DiscloseDaniel N. Costa, MD, Dallas, TX (Abstract Co-Author) Nothing to DiscloseRonaldo H. Baroni, MD, Sao Paulo, Brazil (Abstract Co-Author) Nothing to DiscloseFranto Francis, MD, Dallas, TX (Abstract Co-Author) Nothing to DiscloseNeil M. Rofsky, MD, Dallas, TX (Abstract Co-Author) Nothing to DiscloseThais Mussi, MD, Sao Paulo, Brazil (Abstract Co-Author) Nothing to DiscloseIvan Pedrosa, MD, Dallas, TX (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

The purpose of this presentation is:1. To review the epidemiology, clinical findings and disease course of the ductaladenocarcinoma of the prostate (DAP) in comparison with the more common acinar adenocarcinoma of the prostate (AAP);2. Tocompare the unique and overlapping radiological (particularly MR imaging) features of DAP versus AAP with histopathologicalcorrelation.


1. Ductal Adenocarcinoma of the Prostate (DAP) Epidemiology Clinical Features Diagnosis and Staging Clinical Management andOutcomes2. MR Imaging of DAP and Histopathological Correlation Predominantly solid presentation Solid-cystic presentationPredominantly cystic presentation3. Differentiating DAP from AAP and Mixed Tumors Table and illustrations summarizing the imagingand histopathologic features common to both AAP and DAP and the findings favoring one subtype over the other4. ClinicalImplications Comparison of staging, clinical management, and outcomes of DAP and AAP (Table)5. Conclusions

UR127-ED-X

Calling All Kidneys! Sonographic Findings of Renal Pathology Beyond Hydronephrosis with CT and MRCorrelation


ParticipantsDana E. Amiraian, MD, Jacksonville, FL (Presenter) Nothing to DiscloseMelanie P. Caserta, MD, Jacksonville, FL (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

Ultrasound is an important imaging modality for evaluating the kidneys, and knowledge of sonographic abnormalities can help inidentifying and differentiating renal pathology. While not required for most uncomplicated cases of pyelonephritis, ultrasound canhelp identify complications of renal infection, some of which require emergent intervention. There are various types of renal masses,as well as many mass mimickers, and ultrasound is helpful in detecting and differentiating these entities. Ultrasound is useful foridentifying and localizing abnormal echogenic renal structures, which can usually be correlated on CT.


Review of renal ultrasound indications and normal anatomy on ultrasoundSonographic features of renal infection PyelonephritisEmphysematous pyelonephritis Pyonephrosis Xanthogranulomatous pyelonephritis Tuberculosis HIV nephropathy FungalApproach torenal masses Mimickers Renal cell carcinoma Transitional cell carcinoma Lymphoma AngiomyolipomaEvaluation of echogenicstructures Nephrolithiasis Medullary nephrocalcinosis Cortical nephrocalcinosis Papillary necrosisTake-home points

UR128-ED-X

Retroperitoneal Tumors: MR Imaging Characteristics, Diagnostic Clues, Differential Diagnosis andHistopathological Correlation


ParticipantsPardeep K. Mittal, MD, Atlanta, GA (Presenter) Nothing to DisclosePeter A. Harri, MD, Atlanta, GA (Abstract Co-Author) Nothing to DiscloseJuan C. Camacho, MD, Atlanta, GA (Abstract Co-Author) Nothing to DiscloseLauren F. Alexander, MD, Atlanta, GA (Abstract Co-Author) Spouse, Stockholder, Abbott Laboratories; Spouse, Stockholder, AbbVieInc; Spouse, Stockholder, General Electric CompanyWilliam C. Small, MD, PhD, Atlanta, GA (Abstract Co-Author) Nothing to DiscloseCourtney A. Coursey Moreno, MD, Atlanta, GA (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

1. To describe diagnostic challenges including localization of the retroperitoneal tumors, extent of invasion and characterization ofspecific pathology such as liposarcoma, leiomyosarcoma.,extragonadal germ cell, paragangliomas and sarcoma etc. 2. To illustratepatterns of spread, tumor components, tumor vascularity helping in narrowing the differential diagnosis.


Presentation will includes MRI characterization of retroperitoneal tumors using a dedicated less than 30 minute protocol ofabdominopelvic MRI without and with contrast.Primary retroperitoneal (RP) tumors originating in the retroperitoneum but outside themajor RP organs are uncommon. One of the challenges to radiologist is correct localization of the RP lesions, characterization aswell extent of the disease, involvement of adjacent structures, identifying the organ of origin.Hence MR imaging is valuable inevaluating RP tumors particularly in staging, assessment of vascular invasion and fat content due its excellent soft tissue contrast.Specific diagnosis might be difficult to achieve due to overlapping features but certain clues will help in narrowing the differentialdiagnosis such as liposarcoma,leiomysarcoma,solitary fibrous tumor, paraganglioma and lymphoma etc.

UR129-ED-X

Cysts of the Lower Male Genitourinary Tract, From the Prostate to the Penis



ParticipantsElena Lopez Uzquiza, Santander, Spain (Presenter) Nothing to DiscloseElena Yllera Contreras, MD, Santander, Spain (Abstract Co-Author) Nothing to DiscloseAlejandro Fernandez Florez, MD, Santander, Spain (Abstract Co-Author) Nothing to DisclosePedro Lastra Garcia-Baron, MD, Santander, Spain (Abstract Co-Author) Nothing to DiscloseMarta Drake Perez, MD, Santander, Spain (Abstract Co-Author) Nothing to DiscloseGerardo Lopez Rasines, MD, Santander, Spain (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

1. To review the embryologic development of the male genital tract (GT).2. To expose the normal anatomy and appearance of themale GT with different imaging techniques.3. To summarize the cystic lesions founded along the male GT, explaining the key findingsin order to elaborate an easy differential diagnose.


1. Embryologic development- Mesonephric (wolffran) ducts.- Paramesonephric (mullerian) ducts.2. Normal appearance- Ultrasound(transrectal, transperineal, testicular, transabdominal)- MRI3. Sample cases and mimics- Intraprostatic cysts (retention cyst, cysticdegeneration of BPH and tumours, abscess)- Extraprostatic cysts (seminal vesicle cyst, Cowper duct cyst)- Mimics of prostatic andextraprostatic cysts (urethral diverticulum)- Scrotal and testicular cysts- Mimics of scrotal and testicular cysts (hydrocele,hematocele, pyocele, varicocele)- Perineal cysts (epidermoid cyst of the median raphe)- Penis cysts

UR130-ED-X

Review of Retroperitoneal Fat-containing Tumors: Etiologies, Radiological Findings and Clinical Management



ParticipantsQiushi Wang, MD, Indianapolis, IN (Presenter) Nothing to DiscloseFatih Akisik, MD, Indianapolis, IN (Abstract Co-Author) Nothing to DiscloseTemel Tirkes, MD, Indianapolis, IN (Abstract Co-Author) Nothing to DiscloseMark Tann, MD, Indianapolis, IN (Abstract Co-Author) Nothing to DiscloseKumaresan Sandrasegaran, MD, Carmel, IN (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

1) To learn the differential diagnosis of retroperitoneal fat-containing tumors.2) To learn how to differentiate retroperitoneal fat-containing tumors using radiologic signs.3) To learn clinical management.


1) Contrast-enhanced CT and MRIs will be reviewed. 2) Brief discussion of how to detect macroscopic and microscopic fat on MRimaging.3) Review the spectrum of retroperitoneal fat-containing tumors.4) The classic and atypical appearances of a spectrum offat-containing tumors, including myelolipoma, angiomyolipoma, lipoma, liposarcoma, extramedullary hematopoiesis,neurofibromatosis, primary retroperitoneal teratoma, lipoblastomatosis, and hibernoma are discussed. 5) To discuss clinicalmanagement of different fat-containing tumors.

Honored Educators


Fatih Akisik, MD - 2014 Honored EducatorTemel Tirkes, MD - 2013 Honored EducatorTemel Tirkes, MD - 2014 Honored EducatorKumaresan Sandrasegaran, MD - 2013 Honored EducatorKumaresan Sandrasegaran, MD - 2014 Honored Educator

UR134-ED-X

Peripheral Zone Prostate Lesions: Differentiating Lesions with Prostate Magnetic Resonance Imaging UsingPI-RADS Version 2


ParticipantsDavid C. Gimarc, MD, Aurora, CO (Presenter) Nothing to DiscloseToshimasa J. Clark, MD, Denver, CO (Abstract Co-Author) Nothing to DiscloseJeffrey Meier, MD, Aurora, CO (Abstract Co-Author) Nothing to DiscloseNayana U. Patel, MD, Aurora, CO (Abstract Co-Author) Nothing to DiscloseSajal S. Pokharel, MD, PhD, Aurora, CO (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

After viewing the presentation, participants will be able to better understand the differentiation of prostate zonal anatomy,specifically the peripheral zone, and describe the different pathological diagnoses that occur within these zones. They will then beable to explain the utilization and categorization of PI-RADS version 2 with respect to peripheral zone lesions to distinguish benignand malignant etiologies based on findings in various sequences and technical factors.


Prostate Cancer Overview MR and Prostate Imaging: Pictorial Overview Basic Anatomy (Peripheral Zone - PZ) Essential Sequencesand Technical Aspects Multiparametric Imaging PI-RADS (version 2) Findings Differentiation of PZ lesions using PI-RADS v. 2 BenignEtiologies Malignant Etiologies Overall assessment (PI-RADS 1-5) Overall Limitations Recurrent Lesions or surveillanceExamples/Cases of PZ lesions (benign and malignant)

UR135-ED-X

Pitfalls and Mimickers on MDCTof the Kidney and Retroperitoneum


ParticipantsTakehiko Gokan, MD, Tokyo, Japan (Presenter) Nothing to DiscloseYoshimitsu Ohgiya, MD, Shinagawa-ku, Japan (Abstract Co-Author) Nothing to DiscloseMasanori Hirose, MD, Tokyo, Japan (Abstract Co-Author) Nothing to DiscloseNoritaka Seino, Tokyo, Japan (Abstract Co-Author) Nothing to DiscloseNobuyuki Takeyama, MD, Yokohama, Japan (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

In diagnosing MDCT of the kidney and the retroperitoneum, there are many pitfalls and mimickers, which may lead to misdiagnosisand erroneous patient management. In this exhibit, we show diagnostic pitfalls on MDCT of the kidney and the retroperitoneum aswell as show how to avoid these diagnostic pitfalls and differentiate the mimickers.


The cases will be presented in a quiz format. Key differential diagnostic points, pitfalls, and therapeutic management will behighlighted in the discussion of each case. Diagnostic PitfallsAdrenal pseudotumor due to surrounding normal anatomical structuresorextra-adrenal pathological conditionsMissed renal lesion due to evaluation with inappropriate phase after ivcontrast.ScanArtifacts: motion artifacts, partial volume artifacts, beam hardening artifacts.Miscellaneous: DiagnosticmimickersPapillary renal cell carcinoma vs. angiomyolipoma with minimal fatRetroperitoneal liposarcoma vs. exophytic growingangiomyolipomaIgG related disease vs. lymphomaTuberculous-like granuloma vs. renal cell carcinomaetc.

UR136-ED-X

The ABCs of BHD: An In-depth Review of Birt-Hogg-Dubé Syndrome


ParticipantsShiva Gupta, MD, Houston, TX (Abstract Co-Author) Nothing to DiscloseHyunseon C. Kang, MD, PhD, Houston, TX (Abstract Co-Author) Nothing to DiscloseDhakshina M. Ganeshan, MBBS, FRCR, Houston, TX (Abstract Co-Author) Nothing to DiscloseAjaykumar C. Morani, MD, Houston, TX (Abstract Co-Author) Nothing to DiscloseVikas Kundra, MD, PhD, Houston, TX (Presenter) License agreement, Introgen Therapeutics, Inc

TEACHING POINTS

Develop an understanding of: Molecular genetics of Birt-Hogg-Dubé Syndrome Histopathology of renal tumors in Birt-Hogg-DubéSyndrome Pertinent imaging findings and renal tumor subtypes of Birt-Hogg-Dubé Syndrome Treatment options for renal tumors inBirt-Hogg-Dubé Syndrome


I. Introduction to Hereditary Renal Cell Carcinomas (HRCCs) and Birt-Hogg-Dubé SyndromeII. Molecular Genetics of Birt-Hogg-DubéSyndromeIII. Histopathology of Renal Tumors in Birt-Hogg-Dubé SyndromeIV. Imaging of Birt-Hogg-Dubé Syndrome Renal Tumors:Hybrid Chromophobe Renal Cell Carcinoma (RCC)-Oncocytoma, Chromophobe RCC, Oncocytoma, Clear Cell RCC, Papillary RCCExtrarenal Abdominal Features Pulmonary Features: Pulmonary Cysts, Pneumothoraces Other Findings (e.g. skin lesions)V. SummaryRadiologists may be the first to suspect a HRCC syndrome. In-depth knowledge of Birt-Hogg-Dubé syndrome provides a frameworkfor differentiating it from other hereditary RCC syndromes, and understanding the precision therapies for treating RCCs.

UR137-ED-X

It's Not All About the Prostate! Incidental Extraprostatic Neoplasms and Clinically Significant Findings onMultiparametric Prostate MRI


ParticipantsRoss L. Eppelheimer, MD, Mineola, NY (Presenter) Nothing to DiscloseCorinne C. Liu, MD, Mineola, NY (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

Multiparametric prostate MRI plays a major role in the assessment and staging of prostate cancer. However, extraprostaticneoplasms and clinically significant incidental findings can be found on MRI. This exhibit will show specific examples of these findingsto demonstrate the importance of reviewing the extraprostatic regions of a prostate MRI in order to avoid missing potentiallysignificant findings.


The cases will be presented in an interactive quiz format. Specific cases will be presented to individuals viewing the exhibit. Correctanswers will be revealed and the rationale explained. Key differential diagnostic considerations will also be included, if applicable.The list of cases include: Schwannoma arising adjacent to seminal vesicleColon cancer in the setting of ulcerative colitisRightcommon iliac artery aneurysm with focal dissectionScrotal lipomaHorseshoe kidneyAvascular necrosis of the femoral heads

UR138-ED-X

The Treated Prostate on 3T Multiparametric Prostate MRI: An Interactive Quiz


ParticipantsRoss L. Eppelheimer, MD, Mineola, NY (Presenter) Nothing to DiscloseJohn Mattimore, Stony Brook, NY (Abstract Co-Author) Nothing to DiscloseCorinne C. Liu, MD, Mineola, NY (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

Multiparametric prostate MRI plays a major role in evaluating for recurrent disease in patients with biochemical relapse after radicalprostatectomy, radiation therapy and cryoablation. Anatomy of the pelvis is distorted after radical prostatectomy while radiationand cryoablation distorts the zonal anatomy. This exhibit will review the postsurgical and post-treatment changes of the prostateafter radical prostatectomy, radiation therapy and cryoablation. Participants will understand the pitfalls of the treated prostate thatcan be mistaken for recurrent disease. We also describe the limitations and strengths of certain sequences of multiparametricprostate MRI in the treated prostate.


The cases will be presented in an interactive quiz format. Specific cases post radical prostatectomy, radiation and cryoablation willbe presented to individuals viewing the exhibit. Correct answers will be revealed and the rationale explained.List of cases:Normalperiureteral enhancement versus recurrent disease after prostatectomy on prostate MRIImaging characteristics of the prostate andrecurrent prostate cancer post cryoablationImaging characteristics of the prostate and recurrent prostate cancer postBrachytherapy and Cyberknife therapy

UR139-ED-X

Non-invasive Radiological Manifestations of Obstructive Azospermia



ParticipantsWonsuk Kim, MD, Sacramento, CA (Presenter) Nothing to DiscloseArian Nikpour, MD, Sacramento, CA (Abstract Co-Author) Nothing to DiscloseBehrad Golshani, MD, Sacramento, CA (Abstract Co-Author) Nothing to DiscloseEugenio O. Gerscovich, MD, Sacramento, CA (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

Review the pertinent anatomy and embryogenesis of the male reproductive system with respect to obstructive azospermia. Reviewvarious acquired and congenital causes of obstructive azospermia. Review CT, ultrasound, and MR examples related to obstructiveazospermia.


Anatomy/Embrogenesis of the male ejaculatory system Clinical relevance Epidemiology Presentation Diagnosis ManagementPathophysiology of ejaculatory duct obstruction Acquired Epididymal obstruction Vas deferens obstruction Ejaculatory ductobstruction Congenital Epididymal obstruction Vas deferens obstruction Ejaculatory duct obstruction Review of imaging examples -Scrotal ultrasound Transrectal ultrasound CT MRI Summary

UR140-ED-X

Biochemical Recurrence of Prostate Carcinoma: A Multimodality Approach


ParticipantsMariano Volpacchio, MD, Buenos Aires, Argentina (Presenter) Nothing to DiscloseAntonio Luna, MD, Jaen, Spain (Abstract Co-Author) Nothing to DiscloseDiego M. Haberman, MD, Buenos Aires, Argentina (Abstract Co-Author) Nothing to DiscloseVictor Llanquipacha, Buenos Aires, Argentina (Abstract Co-Author) Nothing to DiscloseVeronica Rubio, Buenos Aires, Argentina (Abstract Co-Author) Nothing to DiscloseMario G. Santamarina, MD, Valparaiso, Chile (Abstract Co-Author) Nothing to DiscloseVictoria Franco, Buenos Aires, Argentina (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

The goals of this presentation are To review the concept of prostate carcinoma biochemical recurrence To review the diagnosticwork-up in patients with biochemical recurrence To discuss the merits and limitations of different imaging modalities in the approachto prostate biochemical recurrence To illustrate typical and atypical findings and patterns of recurrence on different imagingmodalities


IntroductionTreatment of prostate cancer and derived imaging findingsBiochemical recurrence concepts and work-upImagingmodalities: merits and limitations MDCT MRI Whole Body MRI SPECT PET/CTDiagnostic algorithm and therapeutic options afterrecurrenceSummaryBiochemical recurrence is a common clinical scenario after both local and systemic treatment.The treatingphysician is often faced with the challenge represented by a timely and proper diagnosis and localization of the site of recurrenceand the ensuing managment.A variety of morphologic, functional and metabolic imaging modalities are currently available and aproper, patient-adjusted and cost-effective approach is crucial in order to achieve adequate management.A rational use of thearray of diagnostic tools based on knowledge of their respective strengh and limitations is of paramount importance.

UR141-ED-X

Dynamic Voiding UrethroMR: A New Diagnostic Approach to Urethral Lesions


ParticipantsCarlos M. Araujo Junior, MD, Rio De Janeiro, Brazil (Presenter) Nothing to DiscloseJose Pedro R. Ravani, MD, Rio de Janeiro, Brazil (Abstract Co-Author) Nothing to DiscloseRomulo Varella, MD, Rio de Janeiro, Brazil (Abstract Co-Author) Nothing to DiscloseNara S. Astacio, MD, Rio de Janeiro, Brazil (Abstract Co-Author) Nothing to DiscloseLeonardo K. Bittencourt, MD, PhD, Rio De Janeiro, Brazil (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

In this article, we describe the protocol and the main findings of dynamic UrethroMR, while reviewing the appearance of urethralstrictures secondary to changes related to surgical procedures and STDs, demonstrating its importance in characterizingespongiofibrosis.


MATERIALS AND METHODSImages were acquired in a Siemens Aera 1.5-T Scanner, with multiplanar T1 and T2-weighted sequences,T2 with urographic effect by technical MIP obtained at rest and during voiding effort, SPACE, T1 fat-sat before and afteradministration of gadolinium.DISCUSSIONMR is a noninvasive imaging method with high spatial resolution, which allows multiplanarevaluation and good tissue characterization. Furthermore, it is highly accurate in the diagnosis of urethral strictures, enabling theidentification of lesions that are often underestimated in voiding uretrocistography, and allowing the physician a more accuratesurgical plan. MRI also allows complete assessment of the peri-urethral compartments, identifying risk factors and the presence ofassociated complications.CONCLUSIONUrethroMRI is a new imaging modality that shows potential to identify and quantify urethralstrictures, for which surgery remains the best treatment option, and the preoperative evaluation is crucial for success therapy inthese patients.

UR142-ED-X

Magnetic Resonance Imaging of Penile Diseases


ParticipantsVan Lai Nguyen, MD, Rotterdam, Netherlands (Presenter) Nothing to DiscloseMariska Rossius, Rotterdam, Netherlands (Abstract Co-Author) Nothing to DisclosePiotr Wielopolsky, Rotterdam, Netherlands (Abstract Co-Author) Nothing to DiscloseGert Dohle, MD, PhD, Rotterdam, Netherlands (Abstract Co-Author) Nothing to DiscloseGabriel P. Krestin, MD, PhD, Rotterdam, Netherlands (Abstract Co-Author) Consultant, General Electric Company; Research Grant,General Electric Company; Research Grant, Bayer AG; Research Grant, Siemens AG; Speakers Bureau, Siemens AGRoy S. Dwarkasing, MD, Rotterdam, Netherlands (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

MRI of the penis is challenging, mainly because of motion issues. In this exhibit we present our experience with dedicated MRIpenis, focus on the added value of MRI for penile diseases and conditions and propose recommendations for proper imaging.Teaching points: To describe technical challenges of state of the art MRI of the penis. To presents methods of MRI penis, includingapplication of pelvic phased array and other dedicated external surface receiver coils. To illustrate and describe the added value ofMRI for different penile disorders. To propose a practical MRI protocol, including scan parameters, for routine use with a pelvicphased array coil for both 1.5 and 3.0 T MR systems.


1. Introduction 2. Technical challenges for MRI penis 3. Clinical cases: Added values of MRI penis to clinical assessment and otherimaging modalities. 4. Limitations and pitfalls 5. Recommended imaging protocol (1.5 and 3.0T) 6. References.

UR143-ED-X

A Multimodality Review of Native Renal Vascular Pathology


ParticipantsSayf A. Al-Katib, MD, Royal Oak, MI (Presenter) Nothing to DiscloseMonisha Shetty, MD, Royal Oak, MI (Abstract Co-Author) Nothing to DiscloseMarco A. Amendola, MD, Coral Gables, FL (Abstract Co-Author) Nothing to DiscloseBeatrice L. Madrazo, MD, Miami, FL (Abstract Co-Author) Nothing to DiscloseSyed Zafar H. Jafri, MD, Royal Oak, MI (Abstract Co-Author) Nothing to DiscloseEmily Nghiem, Royal Oak, MI (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

To review the imaging features of common and uncommon pathology affecting the renal artery, renal vein and intraparenchymalvessels by multiple modalities including CT, US, MRI and angiography. To highlight the presentation and management of thisspectrum of native renal vascular pathology. To provide a framework to evaluate the native kidney for vascular pathology.


Renal Artery Pathology Renal artery aneurysm Renal arteriovenous fistula Renal arteriovenous malformation Fibromuscular dysplasiaaffecting the renal artery Spontaneous isolated renal artery dissection Renal artery stenosis Renal vascular pedicle injury in traumaRenal Vein Pathology Bland renal vein thrombosis Tumor thrombus secondary to renal cell carcinoma and adrenal cortical carcinomaRenal vein leiomyosarcoma Nutcracker phenomenon Renal Parenchymal Vascular Pathology Iatrogenic pseudoaneurysm Subcapsularhematoma after lithotripsy Page kidney Spontaneous parenchymal bleeds Renal cortical necrosis Renal infarction Renal lacerationPolyarteritis nodosa

UR144-ED-X

Computer-Aided Diagnosis of Prostate Cancer on Multi-parametric MRI: How I Do It


ParticipantsGe Gao, MD, Beijing, China (Presenter) Nothing to DiscloseXiaoying Wang, MD, Beijing, China (Abstract Co-Author) Nothing to DiscloseJue Zhang, Beijing, China (Abstract Co-Author) Nothing to DiscloseChengyan Wang, PhD, Beijing, China (Abstract Co-Author) Nothing to DiscloseJuan Hu, Kunming, China (Abstract Co-Author) Nothing to DiscloseXuedong Yang, Beijing, China (Abstract Co-Author) Nothing to DiscloseHe Wang, MD, Beijing, China (Abstract Co-Author) Research Grant, General Electric Company

TEACHING POINTS

1. To review the popular computer-aided diagnosis (CAD) system for identification and classification of prostate cancer(PCa) inclinical work. 2. To explain the workflow of CAD for localization of PCa that combines features derived from multi-parametric MRI(mp-MRI), and evaluate the performance of this system.


1. Clinical application of CAD for prostate cancer diagnosis2. Clinical promotion of mp-MRI for prostate cancer diagnosis is in adilemma3. Application and workflow of PCa CAD system for cancer localization Mp-MRI preprocessing Prostate segmentation Samplecollection Imaging features extraction Classification: system training and testing Outcome of the CAD system 4. Performance of thelesion localization by CAD system

UR145-ED-X

Abnormal Descent of the Testes


ParticipantsPankaj Nepal, MD, Doha, Qatar (Presenter) Nothing to DiscloseDevendra Kumar, MBBS, MD, Hamilton, ON (Abstract Co-Author) Nothing to DiscloseSubramaniyan Ramanathan, MD, MBBS, Doha, Qatar (Abstract Co-Author) Nothing to DiscloseHabeeba Hena, MD, Doha, Qatar (Abstract Co-Author) Nothing to DiscloseMahmoud Al Raheem Heidous, MD, Doha, Qatar (Abstract Co-Author) Nothing to DiscloseAtif Wasim Haneef Mohamad, MD, Doha, Qatar (Abstract Co-Author) Nothing to DiscloseManeesh Khanna, MBBS, Doha, Qatar (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

1) Undescended testes is the testes that fails to reach bottom of scrotum in expected location. 2) True undescended testesincludes intraabdominal testes or canalicular testes found in inguinal canal or superficial ring . 3) However ectopic testes is the onewhich has wandered from usual path due to abnormal gubernacular insertion and found in uncommon location. 4) Ultrasound is firstline of investigation to identify inguinal and superficial undescended testes. 5) MRI is reserved for the intraabdominal andundescended testes not visualized by ultrasound.


1) Pathway of testes descent in usual as well as unusual locations.2) Brief discussion on complications and clinical features.3)Judicious use of imaging modalities including ultrasound, MRI or laparoscopy for tracing intraabdominal testes and identifiyingtesticular vessels In imaging.4)Spectrum of demonstration:a) Ultrasound images of testes : in inguinal canal, superficial ring, leftiliac fossab) MRI images of testes: in left iliac fossa, superficial to rectus sheath ( ectopic), root of scrotum, inguinal canal,superficial ring and root of penis.c) CT image of testes: Calcified and high mesenteric (ectopic) with germ cell tumor.

UR146-ED-X

Pathways, Pearls and Pitfalls: An MR Feature-based Algorithm for Renal Mass Characterization


AwardsCum Laude

ParticipantsKristy Lee, MD, Boston , MA (Presenter) Nothing to DiscloseKatherine M. Troy, MD, Brookline, MA (Abstract Co-Author) Nothing to DiscloseLeo L. Tsai, MD, PhD, Boston, MA (Abstract Co-Author) Co-founder, Agile Devices Inc; Stockholder, Agile Devices Inc; ResearchConsultant, Agile Devices Inc; Karen S. Lee, MD, Boston, MA (Abstract Co-Author) Nothing to DiscloseMaryellen R. Sun, MD, Boston, MA (Abstract Co-Author) Research Grant, Glaxo SmithKline plc

TEACHING POINTS

1.Incidental renal masses are being discovered with increasing frequency due to the rising number of cross-sectional studies beingperformed. Although the vast majority of masses are incidental, many are incompletely characterized and indeterminate. MRI allowsfor accurate characterization which is essential to ensure appropriate medical versus surgical case management 2.Biopsy can play arole in many cases in which diagnosis is in question


Intro: MR imaging protocol; Algorithm: Utilizing characteristic lesion features at each pulse sequence, a stepwise approach todiagnosis of solid and cystic renal masses is presented. The algorithm incorporates factors such as the presence of cystic versussolid components, signal intensity at T2WI and T1WI, microscopic and macroscopic fat, hemorrhage, hemosiderin, restricteddiffusion and pattern of enhancement. We demonstrate the utility of this algorithm through a case-based approach and highlightpotential pitfalls and pearls. Cases include benign and malignant neoplasms (clear cell, papillary and chromophobe renal cell andurothelial carcinoma, metastases, lymphoma, typical and fat poor angiomyolipoma, oncocytoma, reninoma, and solitary fibroustumors, and non-neoplastic etiologies such as infectious and inflammatory lesions, infarct, hematoma, and xanthogranulomatouspyelonephritis.

UR147-ED-X

MR Imaging Spectrum of Penile Prosthesis and Its Complications


ParticipantsSubramaniyan Ramanathan, MD, MBBS, Doha, Qatar (Abstract Co-Author) Nothing to DisclosePankaj Nepal, MD, Doha, Qatar (Presenter) Nothing to DiscloseDevendra Kumar, MBBS, MD, Hamilton, ON (Abstract Co-Author) Nothing to DiscloseManeesh Khanna, MBBS, Doha, Qatar (Abstract Co-Author) Nothing to DiscloseNicola Schieda, MD, Ottawa, ON (Abstract Co-Author) Nothing to DiscloseAhmad Shamsodini, MS, Doha, Qatar (Abstract Co-Author) Nothing to DiscloseMahmoud Al Raheem Heidous, MD, Doha, Qatar (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

1) Penile prosthesis is ideal for patients with organic erectile dysfunction which is not responding to medications and non surgicaltreatments. 2) Types of prosthesis : malleable and inflatable penile prosthesis (IPP). 3) Various complications of prosthesis arepersistent pain, bending or deformity, mechanical malfunction, cross over and crural perforations. Complications of the reservoirinclude rupture, herniation and malfunction. 4) MR evaluation of penile prosthesis is superior due to its high soft tissuecontrast.Ultrasound can be used for initial evaluation and reservoir related complications.


1) Detailed MRI anatomy of normal penis, malleable and inflatable penile prosthesis. 2) Our institutional MRI protocol, commonindications. 3) Types of penile implants; malleable or semi rigid and inflatable penile prosthesis. 4) USG and MRI appearance of 3part IPP including penile cylinders, pump and reservoir. 5)Spectrum of complications for demonstration ( Images for exibits) : - MRimages of Buckling or S shaped deformity, displacement of the malleable rod - Cross-over of cylinders, - Reservoir leak, - Reservoirherniation into inguinal canal, - Prosthesis infection and erosion, - Ultrasound images of penile anatomy.

UR148-ED-X

Multiparametric MR Imaging of the Prostate and Prostatic Bed in the Evaluation of Cancer Recurrence


ParticipantsDafne D. Melquiades, Rio de Janeiro, Brazil (Presenter) Nothing to DiscloseErick S. Hollanda, Rio de Janeiro, Brazil (Abstract Co-Author) Nothing to DiscloseNatalia Sabaneeff, MD, Rio de Janeiro, Brazil (Abstract Co-Author) Nothing to DiscloseBruno R. Falcone, MD, Rio Dejjaneiro, Brazil (Abstract Co-Author) Nothing to DiscloseRomulo Varella, MD, Rio de Janeiro, Brazil (Abstract Co-Author) Nothing to DiscloseLeonardo K. Bittencourt, MD, PhD, Rio De Janeiro, Brazil (Abstract Co-Author) Nothing to DiscloseCarolina L. Vaz, Rio de Janeiro, Brazil (Abstract Co-Author) Nothing to DiscloseGuilherme M. Cunha, MD, San Diego, CA (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

1- Demonstrate that multiparametric pelvic MR imaging is a valuable tool in the diagnosis of the prostate cancer recurrence.2-Review the normal findings post-prostatectomy and post-radiation, as well as the findings suspicious for local and distant tumorrecurrence.3- Discuss the practical applications and decision algorithms for the management of prostate cancer recurrence, basedon the combination of imaging findings and clinical information.


1- Risk assessment, staging and treatment options for prostate cancer2- Multiparametric MR imaging protocol and post-processing3- Normal findings after radiotherapy and brachytherapy4- Normal findings after prostatectomy5- What is the availableclinical evidence on the performance of multiparametric MR imaging for detection of tumor recurrence?6- MR findings of tumorrecurrence:- Post-radiation;- Post-prostatectomy;- Nodal recurrence;- Distant metastases;7- How to use MR imaging informationwhen suspecting of prostate cancer recurrence?

UR149-ED-X

Staging of Prostate Cancer Using Multiparametric MR Imaging: A Practical Approach


ParticipantsDafne D. Melquiades, Rio de Janeiro, Brazil (Presenter) Nothing to DiscloseErick S. Hollanda, Rio de Janeiro, Brazil (Abstract Co-Author) Nothing to DiscloseNatalia Sabaneeff, MD, Rio de Janeiro, Brazil (Abstract Co-Author) Nothing to DiscloseGuilherme M. Cunha, MD, San Diego, CA (Abstract Co-Author) Nothing to DiscloseBruno R. Falcone, MD, Rio Dejjaneiro, Brazil (Abstract Co-Author) Nothing to DiscloseLeonardo K. Bittencourt, MD, PhD, Rio De Janeiro, Brazil (Abstract Co-Author) Nothing to DiscloseCarolina L. Vaz, Rio de Janeiro, Brazil (Abstract Co-Author) Nothing to DiscloseSabrina O. Bernal, MD, Rio de Janeiro, Brazil (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

• Demonstrate through a pictorial essay that multiparametric prostate MR can assist in a relevant way in the preoperative localstaging of PCa.• Review the main findings related to the PCa staging. We will briefly discuss the role of PI-RADS criteria in detectionand also recent evidence in disease staging.• Discuss about the performance and imaging criteria for the detection of extracapsularextension and seminal vesicle invasion, based on multiparametric MR imaging.• The main clinical signs described for extracapsularextension in T2WI are: nerurovascular bundle asymmetry or tumor involvement, focal bulging or irregularity in prostate contour,obliteration of the rectoprostatic angle, capsular retraction, contact of the tumor with the prostatic capsule and signs of capsulerupture with direct tumor extension to the periprostatic fat.


- Anatomy of the prostate gland and seminal vesicles.- Clinical staging of prostate cancer.- How does staging affect the treatmentoptions?- Multiparametric MR imaging protocol.- Typical MR imaging appearance of prostate cancer.- MR imaging findings forextracapsular extension.- MR imaging findings for seminal vesicle involvement.- MR imaging findings for bladder neck invasion.-Imaging pitfalls that may affect staging.

UR150-ED-X

MRI for the Diagnosis of Prostate Cancer: Basic Knowledge, Optimal Scan Protocols, Interpretations, and NewApplications


ParticipantsRyuji Akita, RT, MS, Hiroshima, Japan (Presenter) Nothing to DiscloseYukiko Honda, MD, Hiroshima, Japan (Abstract Co-Author) Nothing to DiscloseKazushi Yokomachi, RT, Hiroshima, Japan (Abstract Co-Author) Nothing to DiscloseYuji Akiyama, Hiroshima, Japan (Abstract Co-Author) Nothing to DiscloseMakoto Iida, Hiroshima, Japan (Abstract Co-Author) Nothing to DiscloseKazuo Awai, MD, Hiroshima, Japan (Abstract Co-Author) Research Grant, Toshiba Corporation; Research Grant, Hitachi, Ltd;Research Grant, Bayer AG; Reseach Grant, DAIICHI SANKYO Group; Medical Advisor, DAIICHI SANKYO Group; Research Grant, EisaiCo, Ltd; Research Grant, Nemoto-Kyourindo; ; ; ; ;

TEACHING POINTS

We present optimal MR protocols for the diagnosis of prostate cancer.Furtheremore, we demonstrate clinical utility of newapplications such as computed diffusion weighted imaging (cDWI) and high resolution 3D TSE T2-weighted imaging.The cDWI mayimprove sensitivity of prostate cancer and high resolution 3D TSE T2-weighted imaging may improve assessment of local invasion(extracapsular extension and seminal vesicle invasion).


1. Current diagnostic process 2. Optimal MRI protocol for diagnosing prostate cancer 3. Detectability of prostate cancer by MRI 4.Correlation between MR findings and the clinical T stage or Gleason score 5. Pitfalls of MRI interpretation: Artifacts and changesafter biopsy or treatment 6. New applications for MRI 6.1. cDWI 6.2. High resolution 3D TSE T2-weighted imaging

UR151-ED-X

New Concepts in Kidney Stone Characterization with CT


ParticipantsBlanca Pano Brufau, MD, Barcelona, Spain (Presenter) Nothing to DiscloseRafael Salvador Izquierdo, MD, Barcelona, Spain (Abstract Co-Author) Nothing to DiscloseJavier L. Moreno Negrete, MD, Barcelona, Spain (Abstract Co-Author) Nothing to DiscloseCarmen Sebastia Cerqueda, MD, Barcelona, Spain (Abstract Co-Author) Nothing to DiscloseLaura Bunesch Villalba, MD, Barcelona, Spain (Abstract Co-Author) Nothing to DiscloseCarlos Nicolau, MD, Barcelona, Spain (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

-To review relevant clinical concepts for radiologists regarding kidney stones, focusing in the fragility and stone burden concepts.-To discuss the CT and dual energy CT (DECT) findings to bear in mind when planning treatment .-To analyze current literatureregarding CT dose reduction and further classification based on calculi composition.


1. Introduction: clinical concepts of radiological interest-Composition-Treatment options and how radiological information can helpguide the appropriate treatment strategy: expectant attitude, active extraction and medical treatment 2. Contribution of CT intreatment planning2.1. Simple energy MDCT-Detection and localization: the halo and comet tail signs. The HIV Patient-Characterization -Size: Windowing, image magnification and stone burden -Composition (Stone Fragility): homogeneity, shape anddensity -Limitations in simple energy characterization2.2 DECT-Technique-Parameters for allow differentiation between uric andnon-uric acid composition-Post-processing Software3. Future Directions-Further classifications based on stones composition-Decreased radiation dose4. Structured radiological report. Summary of relevant data that CT and DECT can provide to guide theappropriate therapeutic management

UR152-ED-X

PI-RADS v2: MRI Imaging Features of Prostate Cancer and the Experience of an Active MRI SurveillanceProgram


ParticipantsRobert M. Marks, MD, San Diego, CA (Presenter) Nothing to DiscloseJohn R. Dryden, MD, SAN DIEGO, CA (Abstract Co-Author) Nothing to DiscloseJonathan Berger, MD, San Diego, CA (Abstract Co-Author) Nothing to DiscloseSean Stroup, MD, San Diego, CA (Abstract Co-Author) Nothing to DiscloseRichard S. Montgomery, MD, San Antonio, TX (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

This educational exhibit will 1) Discuss the role of MRI in Prostate Cancer 2) Discuss the MRI imaging technique at our institution 3)Review the categories of PI-RADS v2 with pathologically proven MRI cases 4) Discuss the role and clinical experience of an activeMRI surveillance program at a tertiary care hospital.


Overview of the indications for Prostate MRI in the diagnosis or surveillance of Prostate Cancer Discuss the imaging technique forProstate MRI at our institution Include table of MRI parameters Discuss the categories of both T2 and ADC findings of PI-RADS v2Chart of PI-RADS v2 categories Discuss lesion measurement guidelines for peripheral zone vs. transitional zone Discuss the role ofcontrast enhancement in PI-RADS v2 Pathologically proven MRI cases for each PI-RADS v2 category Discuss extracapsularextension with representative cases Discuss seminal vesicle invasion with representative cases Discuss the experience of an activeMRI surveillance program at a tertiary care medical center Discuss the role of an active MRI surveillance program Benefits ofobserving a lesion vs. prostatectomy Indication for MRI surveillance Discuss upstaging of tumors based on Prostate MRI after initialbiopsy

UR153-ED-X

Imagenological Review of the Key Findings in Retroperitoneal Fibrosis and its Complications


ParticipantsKarin Daniela Muller Campos, Santiago, Chile (Presenter) Nothing to DiscloseRoberto Correa Soto, Salamanca, Spain (Abstract Co-Author) Nothing to DiscloseJorge Ortiz Vega, MD, Santiago, Chile (Abstract Co-Author) Nothing to DiscloseIgnacio Maldonado, MD, Santiago, Chile (Abstract Co-Author) Nothing to DiscloseRodrigo Bazaes, MD, PhD, Santiago, Chile (Abstract Co-Author) Nothing to DiscloseCristian Varela, MD, Santiago, Chile (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

The purpose of this exhibit is:1. To understand the pathophysiology of retroperitoneal fibrosis and to know the typical clinicalmanifestation2. To characterize the typical imaging findings of the disease, with an emphasis on differential diagnosis withretroperitoneal malignancies3. To describe the most useful radiologic technique in this disease


- Introduction- Clinical presentation and pathophysiology of retroperitoneal fibrosis.- Imaging techniques and findings:1.Multidetector computed tomography and magnetic resonance2. Applications of Positron emission tomography 3. Radiological findingsindicating good prognosis4. Imaging findings of complications and markers of poor prognosis- Common diagnostic pitfalls anddifferential diagnoses.- Cases to illustrate the radiologic features.

UR154-ED-X

New Staging and Scoring Systems of Renal Cell Carcinomas: What the Radiologist Needs to Report


ParticipantsManjiri K. Dighe, MD, Seattle, WA (Presenter) Research Grant, General Electric CompanyJean H. Lee, MD, Seattle, WA (Abstract Co-Author) Nothing to DiscloseFunda Vakar-Lopez, Seattle, WA (Abstract Co-Author) Nothing to DiscloseRyan O'Malley, MD, Seattle, WA (Abstract Co-Author) Nothing to DiscloseSandeep Vaidya, MD, Seattle, WA (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

1. It is important for radiologists to be acquainted not only with the well widespread TNM staging system, but also with the newRCC scoring systems, since their conjoint use is crucial to manage the best treatment approach of renal masses. Since the adventof R.E.N.A.L., 3 more systems appeared and, although they have demonstrated to be reproducible inter-observer, they all haveinherent strengths and weaknesses. Because some difficulties have been detected when applying the renal scores, new scoringsystems are being developed in order to overcome those problems and to create more practical and simpler scores. 2. The aim ofthis educational poster is to review the imaging characteristics of various sub-types of renal cell carcinoma and to review thevarious imaging systems/algorithms used in deciding the appropriate method of treatment of RCC.


1. To understand the subtypes of renal cell carcinomas (RCCs) and their imaging characteristics 2. To review the new staging andscoring methods available including R.E.N.A.L, P.A.D.U.A, C-index scoring and A.B.L.A.T.E. algorithm. 3. To illustrate various renaltumors using the new scoring systems by means of pictorial examples. 4. To provide reporting macros that can be used for thevarious staging/scoring systems

UR155-ED-X

Crystal Clear or Somewhat Murky: A Pictorial Review of Imaging Biomarkers that are Predictive of CytogeneticAbnormalities in Clear Cell Renal Cell Carcinoma


ParticipantsJonathan R. Young, MD, Los Angeles, CA (Presenter) Nothing to DiscloseJocelyn A. Young, Los Angeles, CA (Abstract Co-Author) Nothing to DiscloseJiaoti Huang, Los Angeles, CA (Abstract Co-Author) Nothing to DiscloseSteven S. Raman, MD, Santa Monica, CA (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

1. Cytogenetics is becoming increasingly important in predicting patient prognosis in RCC because it can more accurately reflectcancer physiology in an individual patient. However, cytogenetic analyses require invasive procedures to obtain tissue samples. 2.Imaging features on multiphasic MDCT may potentially provide a non-invasive means of predicting cytogenetic information and thusinfluence how cytogenetic information is obtained and utilized to predict patient outcome. 3. For instance, enhancement on 4-phase MDCT can help predict the loss of chromosome 8p and the gain of chromosome 20, abnormalities that are associated with ahigher tumor grade and greater risk of recurrence.


1. Epidemiology of Renal Cell Carcinoma2. The Importance and Expanding Role of Cytogenetics in the Management of RCC3. CommonCytogenetic Abnormalities in Clear Cell RCC4. Cytogenetic Abnormalities in Clear Cell RCC with Prognostic Implications5. MultiphasicMDCT Imaging Biomarkers to Predict Cytogenetic Abnormalities with Prognostic Implications

UR158-ED-X

Multimodality Imaging of Non-Malignant Penile Disorders: A One-Stop Shop for Radiologists


ParticipantsStephanie A. Lee-Felker, MD, Los Angeles, CA (Presenter) Nothing to DiscloseEly R. Felker, MD, Los Angeles, CA (Abstract Co-Author) Nothing to DiscloseSteven S. Raman, MD, Santa Monica, CA (Abstract Co-Author) Nothing to DiscloseMaurice M. Garcia, MD, MS, San Francisco, CA (Abstract Co-Author) Nothing to DiscloseValdair F. Muglia, MD, PhD, Ribeirao Preto, Brazil (Abstract Co-Author) Nothing to DiscloseAntonio C. Westphalen, MD, Mill Valley, CA (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

The purpose of this exhibit is to:1. Review normal penile anatomy and physiology of erection2. Present the multimodality imagingappearances of an array of common, non-malignant penile disorders on ultrasound, cavernosagram, computed tomography,magnetic resonance imaging, and angiography3. Discuss which penile disorders require urgent urological intervention


1. Normal penile anatomy: structural, arterial, and venous anatomy2. Normal physiology of erection a. Normal color and spectralDoppler ultrasound of erection3. Multimodality imaging of erectile dysfunction a. Arterial insufficiency b. Venous incompetence,dorsal vein thrombosis c. Priapism i. Low flow priapism ii. High flow priapism: cavernosal artery pseudoaneurysm, cavernosoarterialfistula d. Color and spectral Doppler ultrasound, fluoroscopic cavernosagram, and CT cavernosagram evaluation4. Multimodalityimaging of common penile implants and devices, including related complications a. Device malposition b. Infection5. Infectiousconditions: abscess6. Inflammatory conditions: Peyronie's disease7. Trauma: penile hematoma, penile fracture

UR159-ED-X

Beyond Urothelial Bladder Cancers: Uncommon Players



TEACHING POINTS

1. To identify and illustrate the spectrum of primary bladder tumors other than urothelial carcinoma.2. To present typical andatypical radiologic findings of these tumors.3. To correlate radiologic findings with pathology.


1.The imaging findings on US, CT, MRI and PET of uncommon primary bladder tumors beyond urothelial bladder cancers arepresented, with particular attention to what the radiologist may add to diagnosis and help management.2.The tumors discussedinclude squamous carcinoma, adenocarcinoma, neuroendocrine carcinoma, carcinoid, melanoma, leiomyoma, fibroma, urachalcarcinoma, paraganglioma, hemangioma, pheochromocytoma, plasmacytoma, rhabdomyosarcoma, leiomyosarcoma, lymphoma,chloroma, neurofibroma, inflammatory myofibroblastic tumor, nephrogenic adenoma, and solitary fibrous tumor.

Honored Educators



UR160-ED-X

Adrenal Gland Abnormalities Associated with Systemic Conditions: A Pictorial Review of Clinical andRadiological Findings



TEACHING POINTS

1.Learn systemic conditions and associated imaging findings that can involve the adrenal glands.2.Abdominal radiologists need tosuspect the systemic conditions that can involve adrenal glands.

Honored Educators



UR161-ED-X

Multiparametric Ultrasonography of Scrotal Pathology: A Pictorial Review




ParticipantsDean Y. Huang, FRCR, London, United Kingdom (Presenter) Nothing to DiscloseEleni Konstantatou, MD, MSc, london, United Kingdom (Abstract Co-Author) Nothing to DiscloseRobert J. Eckersley, PhD, London, United Kingdom (Abstract Co-Author) Nothing to DiscloseMaria E. Sellars, MD, FRCR, London, United Kingdom (Abstract Co-Author) Nothing to DisclosePaul S. Sidhu, MRCP, FRCR, London, United Kingdom (Abstract Co-Author) Speaker, Bracco Group; Speaker, General ElectricCompany

TEACHING POINTS

Innovative ultrasonography techniques, such as contrast-enhanced ultrasonography (CEUS), and strain elastography (SE), haveallowed advanced imaging of scrotal pathology. When added to conventional grey-scale US and Doppler US as part of amultiparametric ultrasonography (MP-US) examination, each of these techniques provide information that could be useful whendiagnosing disorders within the scrotum. This exhibit aims to increase learners' familiarity with the appearances seen with thesetechniques, and to illustrate the usefulness of MP-US in imaging intra- and extratesticular pathology, particularly in the context ofconfirming benignity, for improved diagnostic confidence.


This exhibit aims to illustrate MP-US appearances of a spectrum of intra- and extratesticular pathology, including tumors such asseminoma, non-seminomatous germ cell tumors, sex-cord stromal tumors, lymphoma, metastasis, and sarcomas, as well as benignprocesses such as epidermoid cysts, venous infarction, intra-testicular hematoma, abscesses, segmental infarction, sarcoidosis,post-biopsy scar, testicular cysts, orchitis, adenomatoid lesions, and testicular torsion. The role of the newer techniques such asCEUS and SE in offering the means of better characterizing vascularity and inherent stiffness of lesions is also discussed.

UR162-ED-X

'The Ureter...Where Did You Come From? Where Did You Go?' An Interactive Teaching File


ParticipantsMegan T. Elgethun, MD, Pittsburgh, PA (Presenter) Nothing to DiscloseMatthew S. Hartman, MD, Pittsburgh, PA (Abstract Co-Author) Nothing to DisclosePaul R. Klepchick, MD, Pittsburgh, PA (Abstract Co-Author) Nothing to DiscloseMatthew T. Heller, MD, Pittsburgh, PA (Abstract Co-Author) Consultant, Reed Elsevier; Author, Reedl ElsevierDavid C. Reisner, MD, Pittsburgh, PA (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

The purpose of this exhibit is:1. To review the normal course, embryology and anatomy of the ureter. 2. Discuss the differentimaging modalities utilized for evaluation of the ureter.3. Demonstrate and review examples of pathology and surgical proceduresaffecting the course and appearance of the ureter. 4. To highlight the normal appearance, potential complications and imagingpitfalls of the ureter through the use of an interactive teaching file


This presentation will cover the following sections:1. Normal anatomy, embryology and course of the ureter.2. Review the commonimaging modalities used to evaluate the ureter.3. Demonstrate pathologic conditions that affects the normal course and appearanceof the ureter.4. Review common surgical procedures, interventions and post operative appearances of the ureter.5. InteractiveTeaching File6. Summary

UR163-ED-X

CT Findings in Long Term Peritoneal Dialysis


ParticipantsJoe Peltz, MD, Montreal, QC (Abstract Co-Author) Nothing to DiscloseShaza Alsharif, MD, Jeddah, Saudi Arabia (Presenter) Nothing to DiscloseCatherine Milne, Montreal, QC (Abstract Co-Author) Nothing to DiscloseArmen H. Attarian, MD, Mont-Royal, QC (Abstract Co-Author) Nothing to DiscloseBenoit D. Mesurolle, MD, Montreal, QC (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

The goals of this exhibit are:1. To present and discuss the complications of peritoneal dialysis (PD) catheters encountered in seriesof 133 patients during CT scan of the abdomen.2. To describe the associated abdominal finings during peritoneal dialysis and afterperitoneal dialysis catheter removal.


• Demographics of renal failure and types of dialysis.• Indications of abdominal CT in patients with PD catheters.• Factorscontributing to the development of PD related complications.• Review the imaging of complications expected in the long term ofperitoneal dialysis catheter, including those that develop after catheter removal based on two institutions experience.

UR165-ED-X

Role of MRI in Evaluation of Penile Carcinomas: Impact on Staging, Prognosis and Management Decisions



ParticipantsPriya Ghosh, MD, MBBS, Kolkata, India (Presenter) Nothing to DiscloseSaugata Sen, MBBS, MD, Kolkata, India (Abstract Co-Author) Nothing to DiscloseSumit Mukhopadhyay, MD, Kolkata, India (Abstract Co-Author) Nothing to DiscloseAditi Chandra, Kolkata, India (Abstract Co-Author) Nothing to DiscloseDayananda Lingegowda, MBBS, Kolkata, India (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

MRI can accurately delineate the anatomy of penis High contrast of a neoplastic lesion with normal tissue is obtained on T2-weighted images (T2WI) and post-gadolinium T1-weighted images (T1WI) Multiplanar imaging with MRI can provide adequateinformation required for loco-regional staging and prognostication of penile carcinomas as well as diagnose post-operativerecurrences


Background: Prognosis and treatment of penile carcinomas depend on local extent and regional nodal staging. Clinical examinationcan provide preliminary staging of penile neoplasms, but MRI is more accurate in loco-regional staging of penile cancer and has agood correlation with histologic staging Normal imaging anatomy: Corpora cavernosa, crura, corpus spongiosum, urethra, coveringlayers Technique and sequences Imaging appearance of carcinoma: Hypointense to corpora in T2WI and T1WI, enhances in post-gadolinium T1WI, but lesser than corpora Method of staging using MRI: TNM, Jackson staging T1: limited to the subcutaneoustissue T2: involvement of corpora T3: involvement of urethra or prostate T4: invasion of other adjacent structures Nodalassessment: superficial and deep inguinal, pelvic MRI evaluation: Impact on prognosis and management Other penile neoplasmsSummary and conclusion

UR166-ED-X

Array of Imaging Features in Tuberous Sclerosis Renal Disease with Histopathologic Correlation


ParticipantsJignesh N. Shah, MD, Memphis, TN (Presenter) Nothing to DiscloseHarris L. Cohen, MD, Memphis, TN (Abstract Co-Author) Nothing to DiscloseJohn Bissler, Memphis, TN (Abstract Co-Author) Nothing to DiscloseAsim F. Choudhri, MD, Memphis, TN (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

There are varied renal manifestations of tuberous sclerosis complex (TSC), which can be challenging to diagnose and characterizeon imaging. We will review the imaging appearance of different Tuberous Sclerosis renal findings on CT, MRI, angiography, andultrasound, based upon an imaging database of more than 500 patients with TSC renal disease. Imaging techniques will bereviewed, with an emphasis on MRI, and correlated with histology. The genetic and histologic basis for different imaging featureswill be reviewed.


1) Imaging features of various renal menifestations of Tuberous Sclerosis Complex (TSC) which will include:Angiomyolipoma- typical,with macroscopic fat- with microscopic fat but no macroscopic fat- with no microscopic or macroscopic fat- with hemorrhageRenalcystsAutosomal dominant polycystic kidney disease2) Genetic and histologic features reviewed include: Origin of renalangiomyolipoma from renal pericytes; Co-location of autosomal dominant polycystic kidney disease gene with TSC-2 gene

UR167-ED-X

"Imaging of Urinary Diversions and Postoperative Complications: What the Radiologist Needs to Know"


ParticipantsArvind Shergill, MBBS, Toronto, ON (Presenter) Nothing to DiscloseSeng Thipphavong, MD, Toronto, ON (Abstract Co-Author) Nothing to DiscloseAlexandre Zlotta, FRCPC, PhD, Toronto, ON (Abstract Co-Author) Nothing to DiscloseNasir M. Jaffer, MD, Toronto, ON (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

Both continent and incontinent diversions are available for urinary reconstruction after radical cystectomy. Ileal conduit is aprototype of incontinent diversions. Continent diversions include cutaneous catheterizable reservoirs and orthotopic neobladderformation. Surgical techniques alter normal anatomy and make imaging interpretation challenging if radiologists are unfamiliar withthese procedural details and postoperative imaging appearances. Imaging techniques including CT urogram, fluoroscopic loopogramand pouchography are used for routine follow up and tumor surveillance. Interventional radiological techniques like percutaneousnephrostomy and percutaneous ureteral stent placement are indispensible in the evaluation and treatment of urinary tract relatedcomplications.


Learning objectives Description and pictorial review of common surgical techniques Imaging techniques Imaging appearances withfocus on understanding complex postoperative anatomy Postoperative complications I. Early (<30 days): Intestinal complications:Ileus, Obstruction, Fistulas, Ischemia Collections: Hematoma, Lymphocele, Abscess Anastomotic leak Urinary Obstruction II. Late(>30 days): Infection Lithiasis Hydronephrosis Herniation Conduit stenosis/stricture Tumoral Recurrence 6. Conclusion

UR168-ED-X

Adrenal Mass Imaging: A Pictorial Review



ParticipantsMasahiro Tanabe, MD, Ube, Japan (Presenter) Nothing to DiscloseTakaaki Ueda, Ube, Japan (Abstract Co-Author) Nothing to DiscloseSei Nakao, Ube, Japan (Abstract Co-Author) Nothing to DiscloseKeisuke Miyoshi, Ube, Japan (Abstract Co-Author) Nothing to DiscloseNaofumi Matsunaga, MD, PhD, Ube, Japan (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

It is important that the radiologist be familiar with typical imaging features of adrenal masses and the imaging algorithm for adrenallesion characterization not only to make the correct diagnosis, but also to avoid unnecessary examinations. The purpose of thisexhibit is: 1.To understand an imaging algorithm for adrenal lesion characterization. 2.To review CT and MR imaging findings ofadrenal masses. 3.To highlight key differential diagnostic points of imaging findings with pathologic correlation.


1.Imaging algorithm for incidental adrenal lesion (tumor growth, CT densitometry, CT washouts, MR imaging)2.Characteristicfindings• Common lesions (adrenal cortical adenoma, pheochromocytoma, metastasis)• Unusual benign lesions (myelolipoma,ganglioneuroma, schwannoma, hemangioma)• Unusual malignant lesions (adrenal cortical carcinoma, lymphoma, leiomyosarcoma)

UR170-ED-X

Preoperative Assessment of "Zero Ischemia" Robotic-assisted Partial Nephrectomy Should be Performed with"Kidney Friendly' CT: What Radiologists and Technicians Need to Know about the Low-Energy Low-ContrastDose Renal CT



ParticipantsSatoru Takahashi, MD, Kobe, Japan (Presenter) Nothing to DiscloseYoshiko Ueno, MD, Kobe, Japan (Abstract Co-Author) Nothing to DiscloseUtaru Tanaka, Kobe, Japan (Abstract Co-Author) Nothing to DiscloseYuko Suenaga, Kobe, Japan (Abstract Co-Author) Nothing to DiscloseNoriyuki Negi, RT, Kobe, Japan (Abstract Co-Author) Nothing to DiscloseKiyosumi Kagawa, Kobe, Japan (Abstract Co-Author) Nothing to DiscloseKazuro Sugimura, MD, PhD, Kobe, Japan (Abstract Co-Author) Research Grant, Toshiba Corporation Research Grant, KoninklijkePhilips NV Research Grant, Bayer AG Research Grant, Eisai Co, Ltd Research Grant, DAIICHI SANKYO Group

TEACHING POINTS

Robotic partial nephrectomy can minimize ischemic damage to the kidney with super-selective renal artery clumping at the distalarterial branches. Low-energy contrast enhanced CT requires less contrast medium for the evaluation of both vessels and tumor.Because both procedures could reduce potential risk to renal function, low energy CT would be desirable for preoperativeassessment of robotic-partial nephrectomy.The purpose of this exhibit is:1. To review the procedures of robotic partialnephrectomy and understand vital structures/anatomies for the pre-operative assessment2. To explain CT techniques todemonstrate the required anatomies3. To discuss the usefulness of low-energy CT, particularly 3rd generation dual-source CT, inthe preoperative assessment4. To summarize the pros and cons of low-energy CT


Procedures of robotic partial nephrectomy -approach to the kidney -identification of tumor supplying arterial branchCT scanningtechnique - contrast injection - scan timing - image reconstructionPost processing -3D CTA -vessel tracking of tumor supplyingbranch -tumor segmentationPros and cons of low-energy CT -amount & rate of contrast injection -concentration of contrastmedium -beam-hardening artifact -Iterative reconstruction

UR171-ED-X

Imaging Characteristics of Central Gland Neoplasms on Multiparametric 3 Tesla MRI of the Prostate


ParticipantsRobert Villani, MD, Manhasset, NY (Presenter) Nothing to DiscloseEran Ben-Levi, MD, Roslyn, NY (Abstract Co-Author) Nothing to DiscloseArdeshir R. Rastinehad, DO, New Hyde Park, NY (Abstract Co-Author) Nothing to DisclosePnina Herskovits, MD, Manhasset, NY (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

1. The central gland of the prostate harbors at least 30% of all prostate gland malignancy. 2. Benign hypertrophic glandular andstromal nodules in the central gland may have many of the same characteristics as neoplasm in the peripheral zone. This results ineither overcalling of lesions in the central gland or conversely passing by lesions believing them to be benign. 3. This exhibit willdiscuss the characteristics of both benign and malignant lesions in the central gland of the prostate with the aim of improving areader's accurate detection of both.


Anatomy of the prostate gland. Pathophysiology of benign hyperplasia in the central glandReview of the common MRI appearancefor benign central nodular hyperplasiaReview of the characteristic MRI appearance of malignant central gland lesions. Artifacts andpitfalls when evaluating 3T multiparimetric MRI prostate imaging of the central gland of the prostate.Management of suspiciousfindings in the central gland on MRI of the prostate gland

UR172-ED-X

Study in Contrasts: A Resident's Guide to Contrast Media and Managing Contrast Related Emergencies


ParticipantsEvan Allgood, MD, Torrance, CA (Abstract Co-Author) Nothing to DiscloseJordan M. Anaokar, MD, Torrance, CA (Presenter) Nothing to Disclose

TEACHING POINTS

Radiology residents field questions related to the safety and appropriate use of intravenous contrast media and are often the firstto responders to emergencies in the radiology suite. The aim of this presentation is to help residents identify patients at risk foradverse reactions to intravenous contrast, understand precautions that can be taken to minimize these risks, and prepare them forhandling acute contrast reactions.


Risk factors for adverse events related to intravenous contrast media including allergy, renal insufficiency and other miscellaneousconditions Premedication strategies for patients with known contrast allergy Precautions for patients with renal insufficiency,including patients on acute or chronic hemodialysis, to avoid contrast-induced nephrotoxicity and nephrogenic systemic fibrosisSpecial considerations for women who are pregnant or breast feeding Common myths and misconceptions about intravenouscontrast Treatment of mild, moderate and severe contrast allergies and their mimics Self assessment questions

UR174-ED-X

Imaging of Penile Implant: What Can Go Wrong?


ParticipantsMariana D. Silva, MD, Sao Paulo, Brazil (Presenter) Nothing to DiscloseAroldo H. Ban, MEd, Sao Paulo, Brazil (Abstract Co-Author) Nothing to DiscloseFelipe R. Ferreira, Sao Paulo, Brazil (Abstract Co-Author) Nothing to DiscloseFernando I. Yamauchi, MD, Boston, MA (Abstract Co-Author) Nothing to DiscloseRonaldo H. Baroni, MD, Sao Paulo, Brazil (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

Although other imaging methods are sometimes used for the evaluation of penile prosthesis and other devices, MRI is the modalityof choice for investigating malfunctioning or painful penile implants. The purpose of this exhibition is to review all imaging aspects ofimplants and their different subtypes, including malleable and inflatable models; present a selection of cases to illustrate all majorcomplications such as migration, crossover, fracture, expelling, overlong prostheses and infection; and brief summary of penileimplants safety on the MR environment.


. Description of all types of malleable and inflatable penile implants and their aspects on the different imaging modalities, withemphasis on MRI;. Review MRI protocols to investigate painful penile implants and mechanical failures;. Illustrate several cases ofcomplications, including:1.migration;2.extrusion;3.fractures;4.overlong prosthesis;5.buckling;6.crossover;7.infection.8.fibrosis of thecorpora cavernosum.. Summary of MRI safety of penile implants

UR175-ED-X

DWI and the Male Pelvis: What This Technique Can Show Us


ParticipantsEdson D. Barbosa, Nova Iguacu, Brazil (Presenter) Nothing to DiscloseRachel F. Muffareg, Rio de Janeiro, Brazil (Abstract Co-Author) Nothing to DiscloseFelipe A. Mattos, Rio de Janeiro, Brazil (Abstract Co-Author) Nothing to DiscloseRomulo Varella, MD, Rio de Janeiro, Brazil (Abstract Co-Author) Nothing to DiscloseGabriella M. Borges, Rio de Janeiro, Brazil (Abstract Co-Author) Nothing to DiscloseLeonardo K. Bittencourt, MD, PhD, Rio De Janeiro, Brazil (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

- MRI is playing an increasingly important role in the avaliation of the diseases that compromise the male pelvis.- A DWI, in additionto being a rapid sequence and not needing the use of intravenous contrast, has become a useful and powerful tool, which has beenexpanding its borders and gaining new applicabilities, especially in the field of oncology, holding the promise for providing earliercancer detection and evaluation of treatment response and providing important information in a noninvasive manner.- The objectiveof this study is to analyze and illustrate some applications that DWI plays in the male pelvis and show the most common pitfalls inthe evaluation of the images, recalling also the principles of dwi and how to make the correct interpretation of this images.


- Review the tecniques aspects involving DWI- Demonstrate the increased conspicuity and definition of malignant focal lesions inthe male pelvis, especially in the prostate- Predicting aggression, staging and evaluating response or tumor recurrence of cancersof the bladder, prostate, rectum and penile- Assisted in predicting which patients will have biochemical recurrence after radicalprostatectomy- Identify pelvic lymph nodes- Evaluation of pelvic collections- New insights- Common pitfalls for DWI imaging in thisanatomic region.

UR176-ED-X

Testicular Adrenal Rests Tumors: Imaging Appearance and Differential Diagnosis


ParticipantsSandra M. Tochetto, MD, Sao Paulo, Brazil (Presenter) Nothing to DiscloseOsmar C. Saito, MD, PhD, Sao Paulo, Brazil (Abstract Co-Author) Nothing to DiscloseRaquel A. Moreno, MD, Sao Paulo, Brazil (Abstract Co-Author) Nothing to DiscloseFernando L. Pereira, MD, Sao Paulo, Brazil (Abstract Co-Author) Nothing to DiscloseRonaldo H. Baroni, MD, Sao Paulo, Brazil (Abstract Co-Author) Nothing to DiscloseMaria Cristina Chammas, MD, Sao Paulo, Brazil (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

The purpose of this educational exhibit is to:1-Review the embryological development of the male gonad and the adrenal gland;2-Discuss the most common findings at US and MR imaging that can help to establish an accurate diagnosis;3-Report our experiencewith testicular adrenal rests tumors in patients with congenital adrenal hyperplasia;4-Discuss the differential diagnosis of a bilateraltesticular lesion.


The adrenal glands and the gonads share a common embryological origin. During the embryological development, some cells destinedto become adrenocortical cells may nestle within the descending gonad.Testicular adrenal rests tumors (TART) are benign lesionsthat develop due to overstimulation of this ectopic adrenal remnants within the testis. Imaging plays an important role in thedetection and surveillance of testicular adrenal rest tumors. US and MR imaging features are characteristic in the context ofelevated ACTH serum level (CAH). This exhibit will:1-Review the embryological development of the male gonad and the adrenalgland;2-Discuss the imaging findings (US and MR) of TART;3-Show examples of different presentations of TART with clinicalcorrelation;4-Discuss the implication for male fertility;5-Discuss the most important differential diagnosis.

UR177-ED-X

MR Imaging of Male-to-Female Sex Reassignment Surgery: A Comprehensive Review of Expected ImagingFindings in the Normal Post Operative and Common Complications


ParticipantsMarina A. Ferreira, Sao Paulo, Brazil (Presenter) Nothing to DiscloseFelipe R. Ferreira, Sao Paulo, Brazil (Abstract Co-Author) Nothing to DiscloseAroldo H. Ban, MEd, Sao Paulo, Brazil (Abstract Co-Author) Nothing to DiscloseFrancisco T. Denes, PhD, Sao Paulo, Brazil (Abstract Co-Author) Nothing to DiscloseBerenice B. Mendonca, Sao Paulo, Brazil (Abstract Co-Author) Nothing to DiscloseRonaldo H. Baroni, MD, Sao Paulo, Brazil (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

The purpose of this exhibition is: 1.Review and summarize the main surgical techniques in male-to-female sex reassignment surgery;2.Review the role of magnetic ressonance (MR) in the post-operative and the main expected imaging findings; 3. Review anddescribe the most commons complications after the male-to-female sex reassignment surgery and their presentations on differentimaging methods, focusing on magnetic ressonance (MR); 4.Present a sample of cases to illustrate normal expected findings andcomplications after surgery.


- Definition of transsexualism and its multidisciplinary approach and treatment modalities- The role of sex reassignment surgery forpatients in current society- Male-to-female sex reassignment surgery: summarizing the main steps and objectives- Describe theexpected imaging findings in the normal post-operative, focusing on MRI imaging (including a description of the suggestedprotocols)- Describe some of the most common complications after surgery and the imaging findings in those cases- Samples ofcases to exemplify normal post-operative MRI findings and common complications

UR178-ED-X

Eureka! Urachal Abnormalities Made Simpler


ParticipantsCarolina Parada, MD, Buenos Aires, Argentina (Presenter) Nothing to DiscloseSharon Z. Adam, MD, Chicago, IL (Abstract Co-Author) Nothing to DiscloseJulie Sanders, MD, Shreveport, LA (Abstract Co-Author) Nothing to DisclosePaul Nikolaidis, MD, Chicago, IL (Abstract Co-Author) Nothing to DiscloseVahid Yaghmai, MD, Chicago, IL (Abstract Co-Author) Nothing to DiscloseFrank H. Miller, MD, Chicago, IL (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

Understanding the different urachal abnormalities is based on understanding the embryonal development Imaging features of thedifferent abnormalities and the potential complications will be discussed


Embryonal development of the urachus Spectrum of urachal abnormalities including epidemiology Complications of urachalabnormalities Imaging appearance on sonography, CT and MRI of each abnormality - patent urachus, urachal cyst, urachal sinusand urachal diverticulum Imaging appearance on sonography, CT and MRI of associated complications - infection and carcinomaMimickers of urachal abnormalities

Honored Educators


Frank H. Miller, MD - 2012 Honored EducatorFrank H. Miller, MD - 2014 Honored EducatorVahid Yaghmai, MD - 2012 Honored EducatorVahid Yaghmai, MD - 2015 Honored Educator

UR179-ED-X

Multidetector CT Urography of 2015: Did the Current State of CTU Change? - Current Techniques, ClinicalUtility and New Applications


ParticipantsYukiko Honda, MD, Hiroshima, Japan (Presenter) Nothing to DiscloseToru Higaki, PhD, Hiroshima, Japan (Abstract Co-Author) Nothing to DiscloseYoko Kaichi, Hiroshima, Japan (Abstract Co-Author) Nothing to DiscloseChihiro Tani, MD, Hiroshima, Japan (Abstract Co-Author) Nothing to DiscloseMakoto Iida, Hiroshima, Japan (Abstract Co-Author) Nothing to DiscloseKazuo Awai, MD, Hiroshima, Japan (Abstract Co-Author) Research Grant, Toshiba Corporation; Research Grant, Hitachi, Ltd;Research Grant, Bayer AG; Reseach Grant, DAIICHI SANKYO Group; Medical Advisor, DAIICHI SANKYO Group; Research Grant, EisaiCo, Ltd; Research Grant, Nemoto-Kyourindo; ; ; ; ;

TEACHING POINTS

We focus on matters which have changed for these several years about CTU. First, we describe a current CTU method and variousguidelines critically. Second, we show the diagnostic capability of CTU when considering an exposed problem. Third, we introduceurothelial carcinoma(UC) staging criteria and pitfall with indicating several actual cases. We also make a clear when we shouldperform MR for detecting UC. Finally, we introduce and suggest new CT technologies and future perspective of CTU.


Critically review various multidetector CT urography (CTU) protocols and guidelines The current diagnostic capability of CTU whenconsidering an exposed problem Staging of urothelial carcinoma by using CT and pitfall When should we perform MR? Newtechnologies for CTU and future perspective of CTU

UR180-ED-X

Radiological Findings of the Normal and Pathologic Perirenal Space


ParticipantsJose A. Jimenez Lasanta SR, MD, Cerdanyola del Valles, Spain (Presenter) Nothing to DiscloseErika Normantas, Badalona, Spain (Abstract Co-Author) Nothing to DiscloseMonse Tenesa, Badalona, Spain (Abstract Co-Author) Nothing to DiscloseEva Barluenga, Badalona, Spain (Abstract Co-Author) Nothing to DiscloseJordi Bechini, Barcelona, Spain (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

1.-.To describe the normal anatomy of the perirenal space.2.- To present the radiologic features of perirenal space, its mainrelationships and boundaries.3-. To show the pathological processes that may involve this space4.- To compare the various imagingtechniques used in the evaluation of this anatomical region.


A detailed anatomic and pathological review of the perirenal space will be presented. Conditions to be considered are classifiedas,A. Inflammatory and infectious processes and collections: 1-pyelonephritis - abscess renal, •2. Xanthogranulomatouspyelonephritis, •3. Emphysematous pyelonephritis, •4. Pancreatitis, •5.Post-renal biopsy hematoma, •6. Post-renal trasnplantationhematoma.B. Neoplastic-paraneoplastic conditions: •1.Splenic angiosarcoma splenic, 2.Renal angiomyolipoma, •3. Renal cystictumor with solid area with enhancement, •4 Retroperitoneal mixoid liposarcoma, •5.Changes after tumor radiofrequency in perirenalspace, •6. Lymphoma with renal-perirrenal and mesenteric involvement (with PET-CT), •8. Splenic metastatic adenocarcinoma withperirenal extension, 8. Neuroblastoma with perirenal invasion, •10. Erdhein-Chester disease, •11. Renal Lymphangiectasia

UR181-ED-X

If It Aint broke, Don't Fix It. 'Utility of Ultrasound in Evaluation of Penile Pathology: A Pictorial Essay andReview of Literature.'


ParticipantsArtur Velcani, MD, Fairfield, CT (Abstract Co-Author) Nothing to DiscloseJonathan R. Weisiger, MD, New Haven, CT (Presenter) Nothing to Disclose

TEACHING POINTS

1. Provide basic understanding of the role of US in evaluation of the penis. Review of normal sonographic appearance of the penilesoft tissue and vasculature 2. Review non traumatic and traumatic penile pathologies while utilizing ultrasound imaging. 3. Discussclinical significance and management for each case.


Introduction General anatomy of the penile soft tissue. Review of normal US evaluation of penile vasculature and functional changeMost commonly encountered penile pathology: Vascular related abnormalities. Erectile dysfunction a- Normal parameters of penileDopplerb- Papaverine injection examination with duplex dopplerc- Pre/post injection evaluation of penale blood flow. 2. Priapism a-Slow flow and high flow variants.b- Arterial - arterial fistulac- Penile vein thrombosisd- Venous insufficiencye- Venous varixf-Pseudoaneurysm pre / post embolization Traumaa- Penile/corpus cavernous fracture Infectious a- Cellulitis b- Abscess Othera-Peyronie's disease

UR182-ED-X

Contrast-enhanced Ultrasound in Urology


ParticipantsNagaaki Marugami, Kashihara, Japan (Presenter) Nothing to DiscloseToshiko Hirai, MD, Kashihara, Japan (Abstract Co-Author) Nothing to DiscloseJunko Takahama, MD, Kashihara, Japan (Abstract Co-Author) Nothing to DiscloseAki Takahashi, MD, Kashihara, Japan (Abstract Co-Author) Nothing to DiscloseKimihiko Kichikawa, MD, Kashihara, Japan (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

1) To understand the principle of contrast-enhanced ultrasound (CE-US) compared with contrast-enhanced CT or MRI. 2) Todemonstrate the utility of CE-US in diagnosis of urologic disorders compared with multimodality imaging.


1, Introduction: the development of contrast medica of ultrasound, the principle of CE-US.2, Case presentations 1) Kidney: Renalinfarction, Renal cell carcinoma (clear cell RCC, papillary RCC, cystic RCC), Renal oncocytoma, Renal AML, Complicated cysts, etc.2) Testis: segmental testicular infarction, testicular torsion, testicular abscess, testicular trauma (hemorrhage),3, Discussion4,Summary: contrast-enhanced US can demonstrate high accuracy in the diagnosis of urologic disorders.

UR183-ED-X

Congenital Abnormalities of Kidney and Ureter: Embryology, Pathophysiology and Imaging with Emphasis onRole of Fetal MRI



ParticipantsJignesh N. Shah, MD, Memphis, TN (Presenter) Nothing to DiscloseSaurabh Gupta, MD, Milwaukee, WI (Abstract Co-Author) Nothing to DiscloseHarris L. Cohen, MD, Memphis, TN (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

• To review embryogenesis of kidneys and ureters and correlate the aberrant embryological pathways with anatomy of congenitalrenal and ureteric anomalies.• To review imaging findings of a wide spectrum of congenital renal and ureteric abnormalities withemphasis on role of fetal MRI.• To discuss the implications of imaging on management.


Normal embryogenesis of kidneys and ureters; Embryological basis of congenital renal and ureteric abnormalities including renalagenesis, renal ectopia, fusion and rotational abnormalities of kidneys, supernumery kidney, cystic renal disease (ADPKD, ARPKD,MCDK), congenital renal neoplasms (mesoblastic nephroma, wilm's tumor, rhabdoid tumor, clear cell sarcoma), retrocaval ureter,primary megaloureter, duplication of ureter, ectopic ureteric orifice, vesicoureteral reflux; Imaging findings of a wide spectrum ofcongenital renal and ureteric anomalies with emphasis on role of fetal MRI. Discuss implications of imaging on management.

UR184-ED-X

Genitourinary and Retroperitoneal Findings in 3 Neurocutaneous Syndromes: Tuberous Sclerosis,Neurofibromatosis, and Von Hippel-Lindau Disease


ParticipantsKatryana M. Hanley-Knutson, MD, Winston Salem, NC (Presenter) Nothing to DiscloseGeorge Athanasatos, MD, Winston Salem, NC (Abstract Co-Author) Nothing to DiscloseRaymond B. Dyer, MD, Winston Salem, NC (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

Identify the common and uncommon genitourinary and retroperitoneal radiographic manifestations of the presented neurocutaneoussyndromes. Understand the similarities and differences of the genitourinary and retroperitoneal manifestations of the presentedneurocutaneous syndromes.


Tuberous Sclerosis Angiomyolipomas (AML) Renal cysts Renal cell carcinomas (RCC) Retroperitoneal lymphangiomyomatosis(LAM)Neurofibromatosis-1 (NF-1) Retroperitoneal plexiform neurofibromas Renal artery stenosis PheochromocytomasVon Hippel-Lindau Disease Renal cysts Renal cell carcinomas Pheochromocytomas Papillary cystadenomas of the epididymis and broad ligament

UR186-ED-X

The Good, Bad and Ugly: Cross-Sectional Imaging Spectrum of Fat Containing Genitourinary Lesions andClinical Implications


ParticipantsYun S. Xie, MD, San Antonio, TX (Abstract Co-Author) Nothing to DiscloseAmeya J. Baxi, MBBS, DMRD, San Antonio, TX (Abstract Co-Author) Nothing to DiscloseAmol S. Katkar, MD, San Antonio, CO (Abstract Co-Author) Nothing to DiscloseArpit M. Nagar, MBBS, Columbus, OH (Abstract Co-Author) Nothing to DiscloseVijayanadh Ojili, MD, San Antonio, TX (Presenter) Nothing to Disclose

TEACHING POINTS

1. To describe the cross-sectional imaging findings of fat containing genitourinary lesions and discuss the clinical implications ofspecific imaging findings.2. To discuss the complications encountered with the fat containing lesions, role of imaging in detectingthese complications and image-guided interventions in the management of these patients.


1. Introduction, etiopathogenesis and clinical presentation of fat containing genitourinary lesions.2. Role of cross-sectional imagingmodalities (particularly CT).3. Imaging spectrum of fat containing genitourinary lesions (adrenal adenoma, adrenal myelolipoma, renalAML, renal liopma, clear cell RCC, bladder lipoma, ovarian teratoma, uterine lipoleiomyoma, extra-medullary hematopoiesis etc).

ED006-SU

Genitourinary Sunday Case of the Day

Sunday, Nov. 29 8:00AM - 11:59PM Location: Case of Day, Learning Center

GU

AMA PRA Category 1 Credit ™: .50

ParticipantsTheodora A. Potretzke, MD, Saint Louis, MO (Presenter) Nothing to DisclosePerry J. Pickhardt, MD, Madison, WI (Abstract Co-Author) Co-founder, VirtuoCTC, LLC; Stockholder, Cellectar Biosciences, Inc;Research Consultant, Bracco Group; Research Consultant, KIT ; Research Grant, Koninklijke Philips NVNaoki Takahashi, MD, Rochester, MN (Abstract Co-Author) Nothing to DiscloseMeghan G. Lubner, MD, Madison, WI (Abstract Co-Author) Grant, General Electric Company; Grant, NeuWave Medical, Inc; Grant,Koninklijke Philips NVAnup S. Shetty, MD, Saint Louis, MO (Abstract Co-Author) Nothing to DiscloseRichard Tsai, MD, Saint Louis, MO (Abstract Co-Author) Nothing to DiscloseGeorge A. Carberry, MD, Madison, WI (Abstract Co-Author) Nothing to DiscloseVincent M. Mellnick, MD, Saint Louis, MO (Abstract Co-Author) Nothing to DiscloseDavid U. Kim, MD, Madison, WI (Abstract Co-Author) Nothing to DiscloseYaseen Oweis, MD, MBA, Saint Louis, MO (Abstract Co-Author) Nothing to DiscloseZachary J. Viets, MD, Saint Louis, MO (Abstract Co-Author) Nothing to DiscloseBernard F. King JR, MD, Rochester, MN (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

1) Recognize imaging findings seen in disorders of the genitourinary systems. 2) Develop differential diagnosis based on the clinicalinformation and imaging findings. 3) Recognize the clinical importance of diagnosis.

Honored Educators


Perry J. Pickhardt, MD - 2014 Honored EducatorNaoki Takahashi, MD - 2012 Honored EducatorMeghan G. Lubner, MD - 2014 Honored EducatorMeghan G. Lubner, MD - 2015 Honored Educator

SSA09-01 Simultaneous Conventional Dynamic MR Urography and High Temporal Resolution Perfusion MRI ofBladder Tumors Using a Novel Free-Breathing Golden-Angle Radial Compressed-Sensing Sequence

Sunday, Nov. 29 10:45AM - 10:55AM Location: E351

SSA09-02 Magnetic Resonance Fingerprinting in Diagnosis of Prostate Cancer: Initial Experience


SSA09

Genitourinary (New Technologies for Imaging the Genitourinary Tract)

Sunday, Nov. 29 10:45AM - 12:15PM Location: E351

GU BQ MR US

AMA PRA Category 1 Credits ™: 1.50ARRT Category A+ Credits: 1.50


ParticipantsJulia R. Fielding, MD, Chapel Hill, NC (Moderator) Nothing to DiscloseErick M. Remer, MD, Cleveland, OH (Moderator) Nothing to Disclose

Sub-Events

ParticipantsNainesh Parikh, MD, New York, NY (Presenter) Nothing to DiscloseJustin M. Ream, MD, Ann Arbor, MI (Abstract Co-Author) Nothing to DiscloseHoi Cheung Zhang, New York, NY (Abstract Co-Author) Nothing to DiscloseKai Tobias Block, PhD, New York, NY (Abstract Co-Author) Royalties, Siemens AG; Hersh Chandarana, MD, New York, NY (Abstract Co-Author) Equipment support, Siemens AG; Software support, Siemens AG;Consultant, Bayer, AG; Andrew B. Rosenkrantz, MD, New York, NY (Abstract Co-Author) Nothing to Disclose

PURPOSE

To investigate the feasibility of simultaneous conventional dynamic MR urography (MRU) and high temporal resolution perfusion MRIof bladder tumors using a novel free-breathing golden-angle radial acquisition scheme with compressed sensing reconstruction

METHOD AND MATERIALS

22 patients with bladder lesions underwent MRU using the GRASP (Golden-angle RAdial Sparse Parallel) technique. Followingcontrast injection, GRASP was performed of the abdomen and pelvis during free breathing (voxel size 1.4x1.4x3.0 mm, 1,000 radialspokes, acquisition time 3:44 min). Two dynamic data-sets were retrospectively reconstructed from this single acquisition bycombining a distinct number of spokes into each dynamic frame: 110 spokes per frame to provide a resolution of approximately 30seconds, serving as conventional MRU for clinical interpretation, and 8 spokes per frame to provide 2 second resolution images forquantitative perfusion. Using the 2 second resolution images, ROIs were placed within the bladder lesion and normal bladder wall forall patients, an arterial input function was generated from the femoral artery, and the GKM perfusion model was applied.

RESULTS

Follow-up cystoscopy and biopsy demonstrated 16 bladder tumors (13 stage≥T2, 3 stage≤T1) and 6 benign lesions. All lesions werewell visualized using the conventional 25 second clinical dynamic images. Based on the 2 second resolution images, Ktrans wassignificantly higher in bladder tumors (0.38±0.24) than in either normal bladder wall (0.12±8, p<0.001) or in benign bladder lesions(0.15±0.04, p=0.033). The ratio between Ktrans of the lesion and of normal bladder wall in each patient was nearly double intumors than in benign lesions (4.3±3.4 vs. 2.2±1.6), and Ktrans was nearly double in stage≥T2 tumors than in stage≤T1 tumors(0.44±0.24 vs. 0.24±0.24), although these did not approach significance (p=0.180-0.209), likely related to small sample size.

CONCLUSION

GRASP DCE-MRI provides simultaneous conventional dynamic MRU and high temporal resolution perfusion MRI of bladder tumors.Quantitative evaluation of bladder lesions based on the 2 second temporal resolution reconstructions showed associations withpathologic findings in our preliminary cohort.

CLINICAL RELEVANCE/APPLICATION

The novel GRASP sequence allows quantitative perfusion evaluation of bladder lesions within the context of a clinical MRUexamination using a single contrast injection and without additional scan time.

ParticipantsShivani Pahwa, MD, Clevelnad, OH (Presenter) Nothing to DiscloseChaitra A. Badve, MD, MBBS, Cleveland, OH (Abstract Co-Author) Nothing to DiscloseYun Jiang, Cleveland, OH (Abstract Co-Author) Nothing to DiscloseAlice Yu, BS, MS, Cleveland, OH (Abstract Co-Author) Nothing to DiscloseMark D. Schluchter, PhD, Cleveland, OH (Abstract Co-Author) Nothing to DiscloseMark A. Griswold, PhD, Cleveland, OH (Abstract Co-Author) Research support, Siemens AG Royalties, Siemens AG Royalties, GeneralElectric Company Royalties, Bruker Corporation Contract, Siemens AGLee E. Ponsky, MD, Cleveland, OH (Abstract Co-Author) Nothing to DiscloseVikas Gulani, MD, PhD, Ann Arbor, MI (Abstract Co-Author) Research support, Siemens AG

PURPOSE

To describe initial experience in detecting prostate cancer (PCa) using quantitative MRI parameters - T1 and T2 relaxation times

SSA09-03 Contrast-enhanced Ultrasound for Renal Mass Characterization: Comparison of Low MI Time-intensity Curves and Destruction Reperfusion Techniques


SSA09-04 ARFI Evaluation of Small (<4 cm) Renal Masses. A Preliminary Study


To describe initial experience in detecting prostate cancer (PCa) using quantitative MRI parameters - T1 and T2 relaxation timesderived from magnetic resonance fingerprinting (MRF-FISP), in combination with conventional ADC maps.


63 patients with clinical suspicion of prostate cancer were imaged on 3T Siemens Skyra /Verio scanners. MRF has been shown tomeasure T1 and T2 relaxation times with high accuracy and precision2. In addition tothe standard multiparametric MRI exam, MRF-FISP was acquired (slice thickness: 6 mm, in-plane resolution:1×1 mm2,FOV:400 mm, TR:11-13 ms, flip angle:5-75 deg,duration:50s per slice).b-valuesfor DWI were0, 500, 1000 s/mm2.T1, T2 maps were generated from MRF-FISP dataand regions ofinterest (ROI)were drawn on T1, T2 and ADC maps in areas suspicious for cancer identified based on PIRADS score, and normalperipheral zone (NPZ). Matched pairs t-tests were used to compare T1, T2, ADC values in biopsy provenPCa and NPZ. Logisticregression model was applied to these parameters in differentiating PCa from NPZ. Receiver operating characteristic (ROC) analysiswas performed for the parameters singly and in combination and area under the curve (AUC) was calculated

RESULTS

29 patients were diagnosed with cancer on transrectal biopsy. T1, T2, ADC values were significantly lower in cancer compared toNPZ (p<0.0001). Mean T1, T2, ADC for prostate cancer were 1413±60ms, 66±3ms, 745±54 x 10-6mm2/s, respectively. For NPZ,these values were 2058±77ms, 165±8ms, 1736±37 x 10-6mm2/s.The AUC for T1, T2, ADC values in separating PCa from NPZ was0.978, 0.982, 0.801, respectively. The combination of T2 and ADC produced the most complete separation between cancer andnormal tissues, resulting in AUC of 0.995.

CONCLUSION

MRF-FISP is a novel relaxometry sequence that allows quantitative examination of prostate in a clinical setting. The T1 and T2relaxation times so obtained, in combination with ADC values show promising results in detecting prostate cancer.


Quantitative MR parameters can help identify prostate cancer non-invasively. This could have broad applications in diagnosis,guiding biopsy, and following treatment

ParticipantsWui K. Chong, MD, Chapel Hill, NC (Presenter) Nothing to DiscloseEmily Chang, MD, Chapel Hill, NC (Abstract Co-Author) Nothing to DiscloseSandeep Kasoji, Chapel Hill, NC (Abstract Co-Author) Nothing to DisclosePaul Dayton, PhD, Chapel Hill, NC (Abstract Co-Author) Co-founder, SonoVol LLC; Board Member, SonoVol LLCErsan Altun, MD, Istanbul, Turkey (Abstract Co-Author) Nothing to DiscloseJulia R. Fielding, MD, Chapel Hill, NC (Abstract Co-Author) Nothing to DiscloseKevin O. Herman, MD, Raleigh, NC (Abstract Co-Author) Nothing to DiscloseW K. Rathmell, Chapel Hill, NC (Abstract Co-Author) Research support, GlaxoSmithKline plcLee Mullin, PhD, Chapel Hill, NC (Abstract Co-Author) Nothing to Disclose

PURPOSE

To evaluate contrast enhanced US (CEUS) for renal mass characterization in chronic renal insufficiency (CRI), comparingnondestructive (low MI) and destruction-reperfusion techniques.


Prospective study comparing 48 subjects: 24 with normal function and renal masses scheduled for excision; 24 with CRI andindeterminate renal lesions on non-contrast US/CT.CEUS was performed on an Acuson Sequoia with CPS software. Perflutren(Definity) 1.3ml was administered IV. Lesions were imaged at a low MI of 0.2. A 3 minute videoclip was recorded. Time Intensitycurves (TICs) of the lesion and adjacent parenchyma were generated. After 30 minutes, a 2nd dose of Definity was given and aDestruction Reperfusion (DR) sequence performed on the same lesion. DR was performed under an IND exemption from the FDA.Bubble destruction was performed at an MI of 0.9. Reperfusion images were obtained using Motion Stabilized Persistence software(Siemens). A color-coded parametric map quantifying arrival time was generated in which Green=faster arrival, Red=slower,Black=no contrast. (Arrow=Bosniak IV mass).Reference standard was pathology, contrast CT/MR or absence of change on follow upimaging for benign lesions. Two blinded readers reviewed the low MI images and classified the lesions using Bosniak criteria.

RESULTS

Lesion size ranged from 1.7-7.6cm (mean 3.5cm). Histopathology of resected masses showed no cavitation or cellular injury fromhigh MI of DR. DR arrival times correlated with low MI TIC parameters. Sensitivity for distinguishing Bosniak I/II/IIF from III andhigher was: Reader 1-96%, Reader 2-100%. Specificity was 78% and 63%. Specificity is lower because CEUS detects smalleramounts of contrast than CT/MR, leading to 'overstaging' with standard Bosniak. Reduced time to peak and arrival time (p<0.05)was seen in the parenchyma of CRI subjects compared to parenchyma of those with normal renal function.

CONCLUSION

CEUS can characterize renal lesions, but Bosniak criteria must be modified because US is more sensitive to slight enhancement. DRdoes not cause tissue injury, correlates with low MI findings, and takes less time. The parenchyma in CRI showed reduced/ delayedcontrast uptake, suggesting CEUS may also be useful for renal functional imaging.


CEUS can evaluate indeterminate renal lesions and renal function in CRI, a population where CT and MR contrast arecontraindicated.

SSA09-05 Fusion Imaging of (Contrast-enhanced) Ultrasound with CT or MRI for Kidney Lesions


SSA09-06 Optimal Energy for Kidney Parenchymal Visualization in Monoenergetic Images Generated from DualEnergy CT

ParticipantsCostanza Bruno, Verona, Italy (Abstract Co-Author) Nothing to DiscloseAlessandra Bucci, MD, Verona, Italy (Presenter) Nothing to DiscloseMatteo Brunelli, PhD, Verona, Italy (Abstract Co-Author) Nothing to DiscloseSalvatore Minniti, MD, Verona, Italy (Abstract Co-Author) Nothing to DiscloseChiara Dalla Serra, Verona, Italy (Abstract Co-Author) Nothing to DiscloseRoberto Pozzi Mucelli, Verona, Italy (Abstract Co-Author) Nothing to Disclose

PURPOSE

To evaluate if ARFI can be a reliable technique in distinguish ccRCCS from other solid and fluid-containing small renal masses.


31 small (<4 cm) renal masses (27 were solid - 17/27 ccRCCs, 3/27 papillary RCCs, 2/27 chromophobe RCCs, 4 oncocytomas and 1angiomyolipoma - and 4 were cysts) were prospectively evaluated using US and ARFI. Each lesion was assigned an ARFI valueobtained from the average of 12 measurements.All the solid masses underwent resection; all the cystic lesions were Bosniak 2, sowere evaluated with follow up.The difference existing between the two groups was evaluated by means of Student's t test.A cutoff value was determined to distinguish between ccRCCs and other lesions and sensibility, specificity, PPV, NPV and accuracy weredetermined.

RESULTS

ccRCCs are characterized by an higher ARFI value and - when compared with all the other lesions - the difference existing betweenthe two groups was statistically significant (p<0.001). Considering a cut off value of 1.95 m/sec sensibility, specificity, PPV, NPVand accuracy were respectively 94.1%, 78.6%, 84.2%, 91.7% and 87.1%.

CONCLUSION

ccRCC is characterized by an higher ARFI value which can be used to distinguish it from other solid and fluid containing masses.


ARFI can be an useful tool in the evaluation of small renal masses, helping distinguish cc RCCs from other lesions.

ParticipantsThomas Auer, Innsbruck, Austria (Abstract Co-Author) Nothing to DiscloseTobias De Zordo, MD, Innsbruck, Austria (Presenter) Nothing to DiscloseDaniel Junker, Innsbruck, Austria (Abstract Co-Author) Nothing to DiscloseIsabel M. Heidegger, Innsbruck, Austria (Abstract Co-Author) Nothing to DiscloseWerner R. Jaschke, MD, PhD, Innsbruck, Austria (Abstract Co-Author) Nothing to DiscloseFriedrich H. Aigner, MD, Innsbruck, Austria (Abstract Co-Author) Nothing to Disclose

PURPOSE

The aim of the study was to evaluate the feasibility of fusion imaging (FI) of (contrast-enhanced) ultrasound (CEUS) with CT/MRIin localization of sonographically challenging kidney lesions and usefulness for assessment of indeterminate kidney lesions


From March 2013 to January 2014, 30 consecutive patients were included in this retrospective studyAll patients presented withpreviously in CT/MRI detected indeterminate kidney lesions that were either not detectable or hard to distinguish in conventionalgray-scale ultrasoundIn these patients additional FI was performed by fusion of ultrasound with CT/MRI datasets. In 26 (86.7%) ofthese patients FI and CEUS was simultaneously conducted

RESULTS

FI could be performed in all of the 30 patientsFI-indication: In 18 of 30 patients (60%) FI was performed because a lesion ofinterest could not clearly be allocated due to multiple and directly adjacent similar lesions within one kidney. In 12 of 30 patients(40%) the kidney lesions were solitary or at least isolated but could not be detected with gray-scale US alone.CEUS-indication:Insufficient CT protocol (without NECT) and a not-water-isodens lesion (>20 HU ) in 8 (30.8%) patients borderline CE in CT (10HU-20HU) in 11 (42.3%) patients non-conclusive CT/MRI studies in 5 (19.2%) patients CEUS for follow-up in 2 (7.7%)patients.Combined FI-CEUS: FI-CEUS could clearly differentiate between a surgical and non-surgical finding in 24 (80%) of 30patients In 2 (6.7%) of 30 patients with conducted FI-CEUS lesions remained indeterminateFinal dignosis: Histology revealed asurgical lesion in 6 (20%) patients, while in 18 (60%) patients a non-surgical lesion such as BII/BIIF cysts, abscess formations,cicatricial tissue and a pseudotumor could be found. FI-CEUS didn't determine a final diagnosis in 2 patients (6.7%) In one elderlypatient (3.3%) FI was conducted without CEUS because only size control of was demanded In 3 (10%) patients kidney lesions werenot confidently detected with FI due to general US limitations

CONCLUSION

Our data suggest that FI of the kidney is a feasible examination regarding the localization and further assessment of indeterminatekidney lesions.


The combination of FI with a synchronous CEUS examination can clarify indeterminate renal CT or MRI findings, reduce radiationexposure and is cost effective.


SSA09-07 The Use of New Tissue Strain Analytics Measurement in Testicular Lesions


ParticipantsJason DiPoce, MD, Jerusalem, Israel (Presenter) Nothing to DiscloseZimam Romman, Haifa, Israel (Abstract Co-Author) Employee, Koninklijke Philips NVJacob Sosna, MD, Jerusalem, Israel (Abstract Co-Author) Consultant, ActiViews Ltd Research Grant, Koninklijke Philips NV

PURPOSE

To evaluate image quality of kidney parenchyma in a spectrum of CT monoenergy levels and to select the optimal Monoenergylevels for visualization.


IRB approval was obtained. 30-corticomedullary phase, IV contrast-enhanced CT abdomen scans (18 males, 12 females, mean ageof 50 years) were evaluated. In each scan, kidney parenchyma (60 regions) was assessed. The scans were obtained from a 64-slice spectral detector CT prototype (Philips Healthcare, Cleveland, OH, USA) at 120 kVp with an average of 150 mAs. For eachscan, simultaneous conventional polyenergetic and monoenergetic image datasets at 50, 60, 70, 100, and 140 keV werereconstructed. Two experienced radiologists analyzed subjectively in consensus visualization of the kidney parenchyma andselected the optimal visualization dataset based on the conspicuity of the cortex and medulla and compared to the conventionalimages. Objective kidney signal-to-noise ratio (SNR) in the optimal monoenergy images was measured and compared to data fromthe conventional CT images.

RESULTS

Optimal image quality for kidney visualization was subjectively selected with 60 - 70 keV monoenergy images and was judged to bebetter than the conventional dataset. The kidney SNR values in optimal monoenergy were highly significantly different (p<0.01)from conventional CT images. Average SNR was 10.9 and 16.3 in the conventional and optimal monoenergy respectively.

CONCLUSION

Optimal visualization of the kidney parenchyma on dual energy CT images is achieved with monoenergy image reconstruction at 60 -70 keV based on both subjective and objective assessments and seems to improve image quality compared to conventional images.


Optimal image quality in monoenergy images may be supplemental to conventional polyenergetic images and potentially increase thediagnostic yield.

Honored Educators


Jason DiPoce, MD - 2013 Honored EducatorJacob Sosna, MD - 2012 Honored Educator

ParticipantsDirk-Andre Clevert, MD, Munich, Germany (Presenter) Speaker, Siemens AG; Speaker, Koninklijke Philips NV; Speaker, Bracco Group;Matthias Trottmann, Munich, Germany (Abstract Co-Author) Nothing to DiscloseJulian Marcon, Munich, Germany (Abstract Co-Author) Nothing to DiscloseMelvin D'Anastasi, MD, New York, NY (Abstract Co-Author) Nothing to DiscloseAlexander Karl, Munich, Germany (Abstract Co-Author) Nothing to DiscloseMaximilian F. Reiser, MD, Munich, Germany (Abstract Co-Author) Nothing to Disclose

PURPOSE

Virtual touch tissue imaging quantification (VTIQ) is a newly developed technique for the sonographic quantification of tissueelasticity. It has been used in the assessment of breast lesions. The purpose of this study was to determine the diagnosticperformance of VTIQ in unclear testicular lesions.


Twenty patients with known testicular pathology underwent conventional B-mode sonography with additional VTIQ of the testicularlesions using a Siemens Acuson S2000™ and S3000™ (Siemens Medical Solutions, Mountain View, CA, USA) system. Tissuemechanical properties were interpreted and compared in the VTIQ examination. The pathologic diagnosis was established aftersurgery or in the follow up examination in highly suspicious of benign lesions.

RESULTS

Over 36 months, 22 focal testicular lesions (median lesion size, 18 mm; range, 4-36 mm in 20 patients (median age, 43 years;range, 22-81 years) were examined. Lesions were hyperechoic (n = 1), hypoechoic (n = 14), isoechoic (n = 1), mixed echogenicity(n = 3) or anechoic (n = 3). Histological examination showed one benign lesion (6.25 %) with a mean size of 7 mm and 15 malignantlesions (93.75 %) with a mean size of 20 mm. The value of the shear wave velocity in normal testis tissue showed a mean shearwave velocity of 1.17 m/s. No value of the shear wave velocity could the measured in cystic lesions. The rest of the benign lesionsshowed a mean shear wave velocity of 2.37 m/s. The value of the shear wave velocity in germ cell tumours showed a mean shearwave velocity of 1.94 m/s and for seminoma it showed a mean shear wave velocity of 2.42 m/s.

CONCLUSION

VTIQ is a reliable new method for measuring qualitative and quantitative stiffness of testis lesions and tissue. The qualitative shear-

SSA09-08 One-stop-shot MRI for Infertility Evaluation: Comparison with US and CT-HSG

Sunday, Nov. 29 11:55AM - 12:05PM Location: E351

SSA09-09 4D Ultrasound Cistoscopy with Fly through in the Evaluation of Urinary Bladder Tumors PreliminaryExperience

Sunday, Nov. 29 12:05PM - 12:15PM Location: E351

wave elastography features were highly reproducible and showed good diagnostic performance in unclear testicular lesions. TheVTIQ technique is a useful in assessing small testicular nodules and pseudo lesions.


VTIQ is a reliable user independent new method for measuring qualitative and quantitative stiffness of different testis lesions andtissue. The VTIQ technique allows to distinguished different testis lesions and pseudo lesions.

ParticipantsJavier Vallejos, MD, MBA, Vicente Lopez, Argentina (Abstract Co-Author) Nothing to DiscloseJimena B. Carpio, MD, Buenos Aires, Argentina (Presenter) Nothing to DiscloseEzequiel Salas, MD, Buenos Aires, Argentina (Abstract Co-Author) Nothing to DiscloseCarlos Capunay, MD, Buenos Aires, Argentina (Abstract Co-Author) Nothing to DiscloseMariano Baronio, Buenos Aires, Argentina (Abstract Co-Author) Nothing to DisclosePatricia M. Carrascosa, MD, Buenos Aires, Argentina (Abstract Co-Author) Research Consultant, General Electric CompanyLorena I. Sarati, Vicente Lopez, Argentina (Abstract Co-Author) Nothing to Disclose

PURPOSE

Demonstrate the utility of MRI-HSG in the diagnosis of infertility, can through this method show uterine, tubal, ovarian and pelviccauses.


14 patients between 31 and 41 year-old diagnosed with infertility were studied. We performed a transvaginal ultrasound, virtual CT-HSG and MRI- HSG at the same day. MRI protocol include high-resolution T2 sequences, fat-suppressed T1, diffusion weightedimaging and contrast dynamic sequence (3D time-resolved imaging of contrast kinetics [TRICKS]). A contrast dilution of saline,iodine and gadolinium was instilled. Antral follicle counts, endometrial cavity findings, uterine wall pathology, tubal patency, andpelvic cavity findings were assessed with modalities.

RESULTS

In all cases it was observed more ovarian follicles on MRI-HSG than in US. In 65% of patients, Fallopian tubes were visualizedcompletely with MRI-HSG, whereas in the remaining 35% only look at its distal portion. In all cases was demonstrated tubal patencywith free peritoneal spillage. In 45% of patients, MRI-HSG showed endoluminal lesions, likes polyps and miomas, that werecorroborated with CT-HSG. In 14% of patients, MRI-HSG detected endometrial implants in pelvic cavity that could not becorroborated by the other methods.

CONCLUSION

MRI-HSG allows a comprehensive evaluation for infertility diagnosis, with visualization and quantification of antral follicles,endometrial cavity, uterine wall and fallopian tubes as well as pelvic cavity findings such as endometrial implants.


MRI techniques could be combined with HSG procedure in order to enables a one-step-shot imaging for evaluation of femaleinfertility with the advantages of causing less pain and avoidance of exposure to ionizing radiation.

ParticipantsVito Cantisani, MD, Roma, Italy (Abstract Co-Author) Speaker, Toshiba Corporation; Speaker, Bracco Group; Speaker, SamsungElectronics Co, Ltd; Nicola Di Leo, MD, Rome, Italy (Abstract Co-Author) Nothing to DiscloseValerio Forte, MD, Rome, Italy (Presenter) Nothing to DiscloseFlavio Malpassini, Rome, Italy (Abstract Co-Author) Nothing to DiscloseMauro Ciccariello, Rome, Italy (Abstract Co-Author) Nothing to DiscloseFrancesco Flammia, Rome, Italy (Abstract Co-Author) Nothing to DiscloseFrancesco M. Drudi, MD, Rome, Italy (Abstract Co-Author) Nothing to DiscloseCarlo Catalano, MD, Rome, Italy (Abstract Co-Author) Nothing to DiscloseFederica Flammia, Roma, Italy (Abstract Co-Author) Nothing to DiscloseGiuseppe Schillizzi, Roma, Italy (Abstract Co-Author) Nothing to DiscloseFerdinando D'Ambrosio, Rome, Italy (Abstract Co-Author) Nothing to Disclose

PURPOSE

To assess the feasibility and diagnostic efficacy 4D Ultrasound cystoscopy with Fly through as compared with trasditionalcystoscopy in evaluating Urinary Bladder tumors.


30 consecutive patients with previous detected urinary bladder lesions at cystoscopy were prospectively evaluated with 2Dbaseline US, and 4D Ultrasound with fly through (US virtual navigation system) by an expert radiologist blinded to cystoscopyresults. The two imaging modalities were compared with cystoscopy and surgical results (N=8 patients) in order to assess thesensitivity and specificity in tumor detection and characterization. The diagnostic performance of 2D features and 4D ultrasoundwere estimated and compared using ROC curve analysis.

RESULTS

24/33 and 31/33 urinary bladder lesions were detected by 2 D US and 4 D Ultrasound respectively. The latter was also able to

24/33 and 31/33 urinary bladder lesions were detected by 2 D US and 4 D Ultrasound respectively. The latter was also able toidentify two additional lesions not previously detected at traditional cystoscopy. The US features of the lesions were consistentwith the one provided at cystoscopy with not significant differences in term of characterization.Conclusion: Our preliminary resultsshows that 4 D ultrasound cystoscopy with fly through is more accurate than baseline 2D ultrasound to detect and characterizeurinary bladder lesions with results comparable with traditional cystoscopy.

CONCLUSION

Our preliminary results shows that 4 D ultrasound cystoscopy with fly through is more accurate than baseline 2D ultrasound todetect and characterize urinary bladder lesions with results comparable with traditional cystoscopy.


New ultrasound software such as 4 D ultrasound cystoscopy with fly through may help us to follow-up patients treatedconservatively for urinary bladder lesions.

SSA10-01 The Role of Peak Enhancement Values in Differentiating Pheochromocytomas from Adrenal Adenomason CT

Sunday, Nov. 29 10:45AM - 10:55AM Location: E353B

SSA10-02 Proton-Density Fat Fraction: A Viable Tool for Differentiating Adenomas from Nonadenomas inAdrenal Glands, Compared with In-phase and Out-of-phase MR Imaging


SSA10

Genitourinary (Adrenal and Renal Imaging)

Sunday, Nov. 29 10:45AM - 12:15PM Location: E353B

CT GU MR



ParticipantsSteven C. Eberhardt, MD, Albuquerque, NM (Moderator) Nothing to DiscloseClaudia P. Huertas, MD, Medellin, Colombia (Moderator) Nothing to DiscloseSeung Hyup Kim, MD, Seoul, Korea, Republic Of (Moderator) Nothing to Disclose

Sub-Events

ParticipantsMohammed F. Mohammed, MBBS, Vancouver, BC (Presenter) Nothing to DiscloseDavid Ferguson, MBBCh, Vancouver, BC (Abstract Co-Author) Nothing to DiscloseAlison C. Harris, MBChB, Vancouver, BC (Abstract Co-Author) Nothing to DiscloseWilliam C. Yee, MD,FRCPC, Vancouver, BC (Abstract Co-Author) Nothing to Disclose

PURPOSE

The purpose of this study is to establish the role of the peak enhancement Hounsfield Unit (HU) value of focal adrenal lesions indifferentiating potential pheochromocytomas from adrenal adenomas.


The peak enhancement HU values of histologically confirmed pheochromocytomas (n = 24) were retrospectively compared withthose of histologically confirmed adrenal adenomas (n = 28) on the 60-second contrast enhanced venous phase and comparedutilizing a chi-square test. The studies were performed over a period of 5 years (2009-2014) on multi-detector CT scanners(MDCT). HU values were also measured on unenhanced (n = 34) and 15-minute delayed contrast enhanced (n = 27) phases.Measurements were obtained by drawing a representative region of interest over the target lesion. Peak enhancement values wererecorded and absolute washout, relative washout and absolute enhancement (60-second enhanced minus unenhanced) were alsocalculated when available. Mass size was also recorded. The Student t test was used for comparing absolute enhancement andmass size.

RESULTS

83.3% (n = 20) of pheochromocytomas demonstrated a peak enhancement value of 85 HU or greater, compared to 10.7% (n = 3)of adrenal adenomas (p < 0.001, PPV = 86.96%, NPV = 86.2%). Absolute enhancement of pheochromocytomas was also higherthan that of adrenal adenomas (mean = 66.2 HU [range, 51-95 HU] vs. 48.1 HU [range, 18-74]; p < 0.005). Of thepheochromocytomas imaged with a triphasic protocol (n = 9), 77.8% (n = 7) met absolute and relative washout criteria for thediagnosis of a lipid-poor adenoma (>= 60% and >=40% respectively). Pheochromocytomas were significantly larger than adrenaladenomas (mean diameter, 4.5 cm [range, 1-8.3 cm] vs. 1 cm [range, 0.8-6.2 cm]; p < 0.0001).

CONCLUSION

Peak enhancement values of 85 HU or greater in an adrenal lesion on the 60-second post contrast phase strongly suggest adiagnosis of pheochromocytoma rather than adrenal adenoma, regardless of whether or not the lesion demonstrates absolute orrelative washout characteristics compatible with a lipid poor adenoma.


Peak enhancement values on the 60-second post contrast phase should be routinely assessed in the workup of an adrenal lesion toavoid missing a pheochromocytoma.

ParticipantsMeng Xiaoyan, BMedSc, Wuhan, China (Presenter) Nothing to DiscloseHu Daoyu, PhD, Wuhan, China (Abstract Co-Author) Nothing to DiscloseChen Xiao, Wuhan, China (Abstract Co-Author) Nothing to DiscloseZhen Li, MD, PhD, Wuhan, China (Abstract Co-Author) Nothing to DiscloseYanchun Wang, Wuhan, China (Abstract Co-Author) Nothing to Disclose

PURPOSE

To investigate the application of proton-density fat-fraction (PDFF) measurements for accurately quantifying the fat-content ofadrenal nodules, differentiating adenomas from nonadenomas, and compare with in-phase (IP) and out-of-phase (OP) MR imaging.


SSA10-03 Adrenal Calcifications on CT Associated with Familial Cerebral Cavernous Malformation Type I: AnImaging Biomarker for a Hereditary Cerebrovascular Condition


SSA10-04 Clinical Value of Dual-Energy Virtual Non-Contrast of Dual-Source CT for Adrenal Adenoma


This study was compliant with HIPAA and approved by the Institutional Review Board, with the waivers of informed consent. Theconsecutive research was performed between Aug 2013 to Aug 2014, 37 patients with 40 adrenal nodules (21 histopathologicallyproven adenomas, 13 proved pheochromocytomas and 6 clinically proven metastases) who underwent MRI scanning with T1independent volumetric multi-echo gradient-echo imaging with T2*correction (IDEAL-IQ), following with an axial 3D dual-echo Dixonsequence (LAVA-FLEX) which performed IP and OP images. All MRI examinations were performed on a 3.0-T MR scanner. PDFF, SIindex (SII), SI adrenal-to-liver ratio (ALR) and SI adrenal-to-spleen ratio (ASR) were calculated. All statistical analyses wereperformed by using statistical software SPSS 17.0.

RESULTS

PDFF of adenomas (21.39±10.09%)was significantly higher than of nonadenomas (2.25±2.73)(p=0.000, <0.05).PDFF was aneffective tool for distinguishing adenomas from nonadenomas with an area under the curve (AUC) of 0.982, higher than 3.20predicted adenomas with a sensitivity of 100% and a specificity of 89.5%.While,the sensitivities and specificities for adenomaswere 90.0% and 100%, both for SII, ALR and ASR on IP/OP images, with AUC of 0.942, 0.937, 0.932, respectively.

CONCLUSION

PDFF measurements provided a more accurate estimation for fat content in adrenal nodules than with IP/OP images, and it could bea precisely parameter for differentiating adenomas from nonadenomas.


In conclusion, IDEAL-IQ could be a valuable diagnostic tool for discriminating adenomas from nonadenomas with a high sensitivityand a relatively high specificity, avoiding radiation exposure, contrast media side-effect and complicated data calculation. IDEAL-IQwould be a prospective, reliable, and widely used method for diagnosing adrenal gland nodules in clinical study.

ParticipantsCorinne D. Strickland, MD, MS, Boston, MA (Presenter) Shareholder, Thayer Medical CorporationSteven C. Eberhardt, MD, Albuquerque, NM (Abstract Co-Author) Nothing to DiscloseLeslie Morrison, MD, Albuquerque, NM (Abstract Co-Author) Nothing to DiscloseLi Luo, PhD, Albuquerque, NM (Abstract Co-Author) Nothing to DiscloseBlaine L. Hart, MD, Albuquerque, NM (Abstract Co-Author) Nothing to Disclose

PURPOSE

Cerebral Cavernous Malformation Type I (CCM1) is an autosomal dominant disorder characterized by multiple cavernousmalformations in the brain that may cause seizures, cerebral hemorrhage, or focal neurologic deficits. Abdominal manifestations areunproven and poorly described. Individuals of Hispanic descent in the Southwestern US are disproportionately affected by thiscondition due to a founder mutation in the CCM1/KRIT1 gene. Our aim was to investigate whether adrenal calcifications on CT areassociated with CCM1 in carriers of the common Hispanic mutation (CHM).


In an IRB-approved, HIPAA-compliant study, abdomen CT scans of 23 CCM1 subjects (10 F, 13 M, mean 48 yrs, range 24-73 yrs)were retrospectively reviewed. All subjects had multiple CCM lesions on brain MRI; 11 had confirmed CHM genotype. As controls,abdomen CTs from 38 unaffected matched subjects (18 F, 20 M, mean 48 yrs, range 23-73 years) and 13 subjects with sporadic(non-familial) CCM (6 F, 7 M, mean 51 yrs, range 26-72 yrs) were reviewed. Size, location, number, laterality of calcifications, andadrenal morphology were recorded. Brain lesion count was recorded for CCM1 subjects. Statistical comparisons between groupswere calculated using Fisher exact test and two-sample t test.

RESULTS

15 of 23 CCM1 subjects (65%) had small (≤ 5mm), focal calcifications (SFC) in one or both adrenals, compared with 0 in unaffectedand sporadic CCM subjects (p<0.001). SFC were either left-sided or bilateral. Glands with SFC had normal adrenal morphology. Thepresence of SFC correlated positively with number of CCM brain lesions (p=0.048); bilateral SFC correlated positively with patientage (p=0.030).

CONCLUSION

SFC are found in a majority (65%) of adults with CHM-related CCM1 and may be a clinically silent disease manifestation. SFC in thispopulation are predominantly left-sided, more often bilateral with increasing age, and more common in patients with greater numberof brain lesions. These findings add to existing evidence that CCM1 is a multi-system disorder with effects beyond the centralnervous system. CCM1 should be considered in the differential diagnosis for focal adrenal calcifications encountered incidentally onCT.


Incidental adrenal calcifications on CT may detect unrecognized CCM1 and improve diagnostic confidence in equivocal cases.Recognition of this entity is important for management of neurologic manifestations and genetic counseling.

ParticipantsYang Shitong, Zhengzhou, China (Presenter) Nothing to Disclose

PURPOSE

To explore the feasibility of using virtual non-contrast (VNC) images in diagnosis of adrenal adenoma in dual-energy scans, andevaluate the sensitivity, specificity, and accuracy of VNC images for the lipid-poor adenoma.

SSA10-05 Characterization of Adrenal Lesions Using Rapid Kilovolt-Switching Dual Energy CT: Utility ofContrast-Enhanced Material Suppression Imaging


SSA10-07 MASS Criteria as a Predictor of Survival in Sunitinib Treated Metastatic RCC - A Secondary Post-hocAnalysis of a Multi-institutional Prospective Phase III Trial


The clinical manifestations and CT images for 30 patients with 31 lesions confirmed by pathological results from surgery werereviewed retrospectively. All of the patients were examined by a pre-contrast scan (true non contrast; TNC) and then arterial andvenous phase enhanced scan. Then enhanced examinations were performed with dual-energy scan mode (SOMATOM Flash,Siemens Healthcare, Forchheim, Germany). The dedicated post processing application Liver VNC was used to get VNC images at thearterial and venous phase respectively.Mean CT values, signal-to-noise ratio, subjective image quality, and radiation dose werecompared between routine TNC and VNC.The correlation between TNC and VNC images of the adrenal adenoma was evaluated.Sensitivity, specificity and accuracy of VNC images for the characterization of lipid-poor adenoma were calculated from chi-squaretables of contingency.

RESULTS

No significant differences were seen for mean CT values in normal adrenal tissue,adrenal adenoma and the muscles of posteriorspine between TNC and VNC images (p>0.05),except the abdominal aortic and spleen which the mean CT values in VNC images washigher than TNC image and the differences were statistically significant (p<0.05).SNR of all tissues in VNC images were higher thanthat in TNC image,and the differences were statistically significant (p<0.05) expect the abdominal aortic(p>0.05).The subjectivescore of VNC images was lower than that of TNC image, but the difference was no statistically significant(p>0.05).The radiationdose of VNC images was lower than that of TNC(p<0.05).A positive correlation was found for CT values of adrenal adenomabetween TNC and VNC images.Sensitivity,specificity,and accuracy from VNC images of arterial phase for the characterization oflipid-poor adenoma were 86.9%,100%,90.3% and from venous phase were 60.9%,87.5%,67.7%.

CONCLUSION

VNC images calculated from contrast-enhanced dual-energy CT have a potential to replace the TNC images to diagnose the adrenaladenoma and thus reduce the patient's radiation dose.


Dual-energy VNC have a potential to replace the TNC images to diagnose the adrenal adenoma and thus reduce the patient'sradiation dose.

ParticipantsJason A. Pietryga, MD, Birmingham, AL (Presenter) Nothing to DiscloseMark E. Lockhart, MD, Birmingham, AL (Abstract Co-Author) Nothing to DiscloseTherese M. Weber, MD, Birmingham, AL (Abstract Co-Author) Nothing to DiscloseLincoln L. Berland, MD, Birmingham, AL (Abstract Co-Author) Consultant, Nuance Communications, Inc; Stockholder, NuanceCommunications, Inc; Bradford Jackson, Birmingham, AL (Abstract Co-Author) Nothing to DiscloseDesiree E. Morgan, MD, Birmingham, AL (Abstract Co-Author) Research support, General Electric Company

PURPOSE

To characterize adrenal lesions as benign or malignant on contrast-enhanced dual energy CT using material suppression imaging(MSI) virtual unenhanced images and pseudo-unenhanced monoenergetic 140keV images.


IRB-approved HIPAA-compliant study. A retrospective search identified consecutive adult outpatients who had undergonemultiphasic dual energy CT(DECT) with an adrenal lesion (≥1cm) reported. Two patients weighing ≥300 lbs were excluded. A singleboard-certified radiologist reviewed the CTs and placed ROIs on the adrenal lesions on the noncontrast (NC) series andsimultaneously placed matching ROIs on MSI virtual unenhanced and virtual monoenergetic 140 keV images. The lesions werecharacterized by accepted clinical standards. Spearman rank correlation was performed to evaluate for associations between thevirtual unenhanced, pseudo-unenhanced HU and NC HU and t tests to evaluate means. Regression analysis was performed toidentify threshold values to characterize adrenal lesions as benign vs malignant. Myelolipomas were excluded from the regressionanalysis.

RESULTS

104 patients (52M,52F, mean age 62, weight 188 lb) with a total of 140 adrenal lesions were identified. 56%(78/140) of the lesionswere lipid-rich adenomas, 6%(9/140) lipid-poor adenomas, 20%(28/140) malignancies, 8%(11/140) myelolipomas and 10%(14/140)indeterminate. The mean HUs for adenomas were -6.5 (NC), 11.3 (MSI), 12.5 (140 keV); mean HUs for malignant lesions were 34.2(NC), 39.1 (MSI) 38.7 (140 keV), all p<0.0001. There were very strong Spearman correlations between NC and MSI HU (.83), NCand 140keV HU (.81) and MSI and 140keV HU (98). Excluding 1 obvious necrotic RCC metastasis, a threshold of 20 HU on MSI and16 HU on 140keV images correctly characterizes lesions as adenomas with a sensitivity of 68%(59/87) and 53%(46/87),respectively, both with specificity of 100%.

CONCLUSION

MSI virtual unenhanced and virtual 140keV monoenergetic contrast-enhanced DECT images can be used to characterize adrenaladenomas with a sensitivity of 72% and 59%, respectively, when using new HU threshold values of 20 and 16, respectively.Excluding an obvious necrotic RCC metastasis, both threshold values are 100% specific.


In this largest DECT series of adrenal lesions, new HU criteria are presented that can characterize lesions on contrast-enhancedDECT, potentially obviating the need for further imaging for most patients.


SSA10-08 Prediction of Survival in Patients with Metastatic Clear Cell Carcinoma Treated with Targeted Anti-angiogenic Agent Sunitinib via CT Texture Analysis

Sunday, Nov. 29 11:55AM - 12:05PM Location: E353B

ParticipantsAndrew D. Smith, MD, PhD, Jackson, MS (Presenter) Research Grant, Pfizer Inc; President, Radiostics LLC; President, LiverNodularity LLC; President, Color Enhanced Detection LLC; Pending patent, Liver Nodularity LLC; Pending patent, Color EnhancedDetection LLC; Frederico F. Souza, MD, Madison, MS (Abstract Co-Author) Nothing to DiscloseManohar Roda, MD, Jackson, MS (Abstract Co-Author) Nothing to DiscloseHaowei Zhang, MD, PhD, Jackson, MS (Abstract Co-Author) Nothing to DiscloseXu Zhang, PhD, Jackson, MS (Abstract Co-Author) Nothing to Disclose

PURPOSE

To validate MASS Criteria as a predictive imaging biomarker in metastatic RCC treated with anti-angiogenic therapy.


As part of a published multi-institutional prospective phase III trial, 375 adult patients with metastatic clear cell RCC were treatedwith sunitinib. In this secondary post-hoc retrospective analysis, initial post-therapy CT images were evaluated by RECIST, ChoiCriteria, and MASS Criteria in patients with DICOM format images. Comparison of PFS and OS among MSKCC risk and imagingresponse groups was evaluated using log-rank test. Inter-observer agreement between 3 readers was assessed in 21 randomlyselected cases using intra-class correlation coefficient (ICC).

RESULTS

Median PFS and OS of the full cohort (N=270) were 1.1 and 2.6 years, respectively. PFS and OS of all MASS Criteria objectiveresponse categories were significantly different from one another (p<0.0001 for each). By comparison, PFS of MSKCC low (N=186)and intermediate (N=84) risk groups, PFS of RECIST PR (N=33) and SD (N=228) groups, and OS of Choi Criteria SD (N=36) and PD(N=13) groups were not significantly different (p=0.225, 0.810 and 0.311, respectively). Median PFS for patients with baselineMSKCC Criteria low (N=186) and intermediate (N=84) risk were 1.2 and 0.9 years, respectively. By comparison, median PFS forpatients with MASS criteria FR (N=177), IR (N=84), and UR (N=9) were 1.4, 0.5, and 0.1 years, respectively. Inter-observeragreement among 3 readers interpreting 21 randomly selected cases using MASS Criteria was substantial (ICC=0.70).

CONCLUSION

In patients with metastatic RCC treated with sunitinib, MASS Criteria response on the initial post-therapy CT is predictive of PFSand OS.


MASS Criteria is currently the only quantitative biomarker for predicting response to anti-angiogenic therapy in metastatic RCC thathas been validated in a multi-institutional study and it may potentially be useful in guiding therapy, reducing drug toxicities andcosts, and planning adaptive design clinical trials.

ParticipantsMasoom A. Haider, MD, Toronto, ON (Presenter) Consultant, Bayer AG Alireza Vosough, MD, MRCP, Aberdeen, United Kingdom (Abstract Co-Author) Nothing to DiscloseFarzad Khalvati, PhD,MSc, Toronto, ON (Abstract Co-Author) Nothing to DiscloseAlexander Kiss, PhD, Toronto, ON (Abstract Co-Author) Nothing to DiscloseBalaji Ganeshan, PhD, London, United Kingdom (Abstract Co-Author) Scientific Director, TexRAD LimitedGeorg Bjarnason, MD, Toronto, ON (Abstract Co-Author) Nothing to Disclose

PURPOSE

To evaluate the role of CT Texture analysis in prediction of progression free and overall survival and assessment of response totreatment with Sunitinib in patients with metastatic clear renal cell carcinoma (RCC).


Contrast enhanced CT texture parameters were assessed in 40 patients with metastatic clear RCC who were treated with Sunitinib.Appropriate measurable lesions were selected based on RECIST criteria before and about two months after treatment with Sunitinib.Texture and histogram analysis of the lesions were performed using TexRad software. Using a Cox regression model, correlation oftexture parameters with measured time to progression and overall survival were assessed.

RESULTS

"Size normalized tumor Entropy" (NE) was found as an independent predictor of time to progression and overall survival and can addto Heng; a well-known prognostic model for metastatic RCC patients. Cox proportional hazards regression analysis (HR) showed thatNE was an independent predictor of time to progression. (HR = 0.01 and 0.02; 95% confidence intervals (CI): 0.00 - 0.29 and 0.00- 0.39; p=0.01 and p=0.01 for NE before and two months after treatment, respectively). NE was also shown to be an independentpredictor of overall survival. (HR = 0.01 and 0.01; 95% CI: 0.00 - 0.31 and 0.001 - 0.22; p=0.01 and p=0.003 for NE before andtwo months after treatment, respectively).

CONCLUSION

Tumor heterogeneity is a well-known feature of malignancy reflecting areas of increased cellular density, hemorrhage and necrosis.CT texture analysis can quantify heterogeneity by using a range of parameters including size normalized Entropy (NE) as a measureof texture irregularity. Our study showed that NE is an independent predictor of the outcome of treatment with Sunitinib in patientswith metastatic RCC and can be used for prediction of time to progression and overall survival in these patients. This can helpidentify non-responders from the outset with the potential to avoid unnecessary toxicity and to start alternative therapies earlier.

SSA10-09 Arterial Spin Labeling MR Imaging for Detecting Perfusion of Defect of Renal Cell Carcinoma Pseudo-capsule and Predicting Renal Capsule Invasion: Initial Experience

Sunday, Nov. 29 12:05PM - 12:15PM Location: E353B


The ability to identify poor responders early in the course of treatment or before starting the treatment can help patients be sparedfrom toxicity usually associated with these treatments and could potentially receive alternative therapies earlier. Using the costlydrugs of treatment only in patients who benefit from them will be a potential for cost-effectiveness improvement.

ParticipantsHanmei Zhang, Chengdu, China (Presenter) Nothing to DiscloseYinghua Wu, MD,PhD, Chengdu, China (Abstract Co-Author) Nothing to DisclosePanli Zuo, Beijing, China (Abstract Co-Author) Nothing to DiscloseNiels Oesingmann, PhD, Erlangen, Germany (Abstract Co-Author) Employee, Siemens AGBin Song, MD, Chengdu, China (Abstract Co-Author) Nothing to Disclose

PURPOSE

The defect of pseudo-capsule is tightly correlated with the invasiveness of tumors.This study aimed to prospectively evaluate theperformance of combining morphological imaging and functional imaging for detecting the defects of pseudo-capsule in renaltumors,and to predict renal capsule invasion which were confirmed histopathologically.


Twelve patients with suspicious renal tumors underwent T2-weighted imaging and contrast-free renal ASL imaging at a 3.0T MRscanner.Renal ASL was performed using a prototype flow-sensitive alternating inversion recovery trueFISP (FAIR-trueFISP)sequence with a TI of 1200 ms for perfusion images and without inversion for M0 images.A modified Look-Locker inversion-recovery(MOLLI) sequence was used for T1 mapping.Renal blood flow (RBF) was quantitatively measured on the perfusion images whichwere determined on a pixel by pixel basis.For T2-weighted images alone,the discontinuous hypo signal intensity rim was defined asthe defect of tumors' pseudo-capsule,for combination of T2-weighted images and ASL,the hypo signals in T2-weighted images aswell hyper signals in perfusion images was defined as the defect of tumors' pseudo-capsule.The diagnostic performance wasassessed using diagnostic test's index.

RESULTS

Twelve renal lesions (11 clear cell RCCs and 1 chromophobe RCC) were evaluated in 12 patients.All ccRCCs showed defect oftumors' pseudo-capsule on T2-weighted images.Of the 11 ccRCCs cases,10 cases showed blood flow right on the defect area oftumors' pseudo-capsule on perfusion images and 1 case did not.All the defect areas of tumors' pseudo-capsule seen in the surgeryoperation had renal capsule invasion.For defecting of tumors' pseudo-capsule,i.e. predicting renal capsuleinvasion,sensitivity,specificity,positive predictive value and negative predictive value were 100%,33.3%,81.8%,100% for T2-weighted images alone and 100%,66.7%,90%,100% for combination of T2-weighted images and ASL images.

CONCLUSION

The combination of T2-weighted images and ASL images produced promising diagnostic accuracy for predicting renal capsuleinvasion,which could offer additional imaging information for clinical diagnosis of renal tumors.


Noninvasively and prospectively evaluated the presence of the defect pseudo-capsule in renal tumors may help predict theinvasiveness of tumor and influence clinical therapy strategy.

GU200-SD-SUA1

Obstetrical Ultrasound Sweeps Show Promise for Point-of-Care Diagnosis in Resource-poor Areas

Station #1

GU201-SD-SUA2

Is PIRADs-score more Accurate versus DWI+T2w Based Data at 3T MRI: Analysis According to 189MR-guided Prostate Biopsies

Station #2

GUS-SUA

Genitourinary Sunday Poster Discussions

Sunday, Nov. 29 12:30PM - 1:00PM Location: GU/UR Community, Learning Center

GU


ParticipantsPaul Nikolaidis, MD, Chicago, IL (Moderator) Nothing to Disclose

Sub-Events

ParticipantsMatthew D. LeComte, PhD, Burlington, VT (Presenter) Nothing to DiscloseMary Streeter, RT, Burlington, VT (Abstract Co-Author) Nothing to DiscloseSarah Ebert, BS, Burlington, VT (Abstract Co-Author) Nothing to DiscloseBetsy L. Sussman, MD, Burlington, VT (Abstract Co-Author) Nothing to DiscloseDavid Jones, MD, Burlington, VT (Abstract Co-Author) Nothing to DiscloseAnne Dougherty, MD, Burlington, VT (Abstract Co-Author) Nothing to DiscloseKristen K. DeStigter, MD, Burlington, VT (Abstract Co-Author) Medical Advisory Board, Koninklijke Philips NV; Luminary, McKessonCorporation; Research collaboration, Koninklijke Philips NV;

PURPOSE

Resource-poor communities lack basic obstetrical (OB) imaging. Imaging the World's program integrates inexpensive ultrasound (US)technology with image compression and Internet data transfer to enable expert obstetrical evaluation. However, effectiveness ofthis system requires individuals minimally trained as sonographers to acquire images at the point-of-care. This study evaluateswhether these providers can acquire quality OB US images for later evaluation by trained readers.


Pregnant women were recruited after having a traditional OB US study performed by an expert sonographer (gold standard). Thenan individual taught to generate anatomically guided sweeps (scanner) with an ultrasound probe acquired images on consentingsubjects. These studies were evaluated by two obstetricians and one radiologist (readers) and compared to the gold standard. Thescanner and readers were blinded to the subjects' OB status. The studies were evaluated for visibility of maternal and fetalanatomy, gestational features, placental features and fetal biometry. The readers were asked to rank their confidence level foreach feature (confident, probable or uncertain).

RESULTS

61 individual studies evaluated by the three readers were included in this preliminary analysis. We found 62% of responsesdescribed the fetus as "well visualized" and 36% were "partially visualized" with high confidence. Additionally 97% of reports wererated as confident for intrauterine pregnancy and 98% of reports were rated as confident of fetal position. Placental position wasreported in 98% of reads. Features of biometry for dating and fetal cardiac, urinary, abdominal and neuro-anatomy were alsoappreciated in > 50% of reads. Image quality was also assessed by the readers.A thorough analysis of this data is warranted. Wewill report on concordance between the sweep and the gold standard diagnostic ultrasound reads as well as inter-observerreliability.

CONCLUSION

The preliminary data suggests that an individual minimally trained as a sonographer using only anatomical landmarks can generatediagnostic quality OB US images upon which clinical decisions can be made.


The ability to identify complications early with point-of-care obstetric ultrasound using a pre-prescribed protocol can directlyimprove perinatal outcomes in resource poor regions.

ParticipantsAnsgar Malich, MD, Nordhausen, Germany (Presenter) Nothing to DiscloseDino Kovacevic, Nordhausen, Germany (Abstract Co-Author) Nothing to Disclose

PURPOSE

PIRADS-score was established as the combination of T2w+DWI+contrast uptake analysis suggesting equivalent importance of allfeatures. Due to several contraindications of contrast agent application study aimed to verify, whether DWI+T2w are similaraccurate based on MR-guided prostate biopsy results.


213 prostatic lesions were MR-guided biopsied (3T MRI Philips Ingenia) after inconclusive ultrasound guided biopsy and aftermultiparametric MRI (T2w, dynamic analysis (>5min, single dynamic scan <13s, calculation using DynaCAD+Confirma-CAD) and DWI-analysis (b-value 0-1000). PI-RADs-scheme vs. T2w+DWI were matched to histopathologic outcome. At least 10pt. (DWI+T2w+CE-

GU204-SD-SUA5

Utility of CAD Derived Enhancement to Quantify Wash-out Characteristics of Clear Cell Renal CellCarcinoma Low Grade and High Grade Lesions at Four-Phase MDCT

Station #5

UR105-ED-SUA6

Interactive Experience with Prostate Imaging and Reporting and Data System Version 2

Station #6

MRI) or 7pt (DWI+T2w) were accepted as cut off for malignancy.

RESULTS

82/213 lesions were PCA and 17/213 ASAP (41/213 cases prostatitis, 35/213 hyperplasia, 32/213 dystrophic prostatic tissue, 6/189cases paraglandular tissue).Using PIRADS, 3/82 PCA had 9pt and 4 10pt (PIRADS-score 3); 9x11; 14x12; 12x13 (PIRADS-score 4)and 11x14 and 29x15pts (PIRADS-score 5).Using T2w+DWI only, 1 had 5pt; 1 6pt (PIRADS-equivalent 3), 8 7pts; 17 cases 8pts, 16cases 9pts and 39 10pts. Distribution of ASAP-lesions was: 1x6pt; 4x7pt; 7x8pt; 3x9pt; 2x10pt. Prostatitis was scored accordingto PIRADS: 2x14/15pt; 23x11-13pts.;15x10pts or less. Using T2w+DWI only, 4 had a sum of 9/10; 25 a score of 7/8 and 11 less.Hyperplastic nodules were scored according to PIRADs 3x14/15pts.; 20x11-13pts; 12xless points. Using DWI+T2w only 6 lesionswere scores with 9-10, 21x7/8 points and 8 with less points. Related PPV was: PIRADS: 95/184 (51.6%); DWI/T2w: 96/178(53.9%); Sensitivity: PIRADS: 95/99 (96.0%); Sens: DWI/T2w: 96/99 (97%).

CONCLUSION

Especially in case of contraindications for contrast agent application, reliable prostate diagnostic analysis can be obtained withoutdynamic contrast uptake using PIRADs-scheme without a lowered sensitivity, even for discrimination of prostatitis vs. cancer.Further dynamic parameter such as kep, slope and peak uptake might be of additional use for the diagnostic procedure but not yetembedded in the PIRADS-scheme.


In case of renal insufficiency reliable prostate MRI at 3T can be performed without contrast application. Point scale of contrastuptake of prostate lesions should be more precise and should include quantitative parameter.

ParticipantsHeidi Coy, Los Angeles, CA (Presenter) Nothing to DiscloseMichael L. Douek, MD, MBA, Los Angeles, CA (Abstract Co-Author) Nothing to DiscloseJonathan R. Young, MD, Los Angeles, CA (Abstract Co-Author) Nothing to DisclosePechin Lo, Los Angeles, CA (Abstract Co-Author) Nothing to DiscloseMatthew S. Brown, PhD, Los Angeles, CA (Abstract Co-Author) Nothing to DiscloseJonathan G. Goldin, MBChB, PhD, Los Angeles, CA (Abstract Co-Author) Nothing to DiscloseJames Sayre, PhD, Los Angeles, CA (Abstract Co-Author) Nothing to DiscloseSteven S. Raman, MD, Santa Monica, CA (Abstract Co-Author) Nothing to Disclose

PURPOSE

Although clear cell RCC (ccRCC) are typically detected incidentally by imaging, grading these lesions has only been possiblehistologically on biopsy or nephrectomy. A robust imaging based method to grade ccRCC correlating with established Furhman Grade(FG) would enable surveillance of low grade lesions and surgical or ablative treatment of high grade lesions.. The purpose of ourstudy was to assess wash-out characteristics of low grade and high grade ccRCC lesions on four-phase CT using a CAD algorithmto quantify lesion enhancement at each phase.


With IRB approval for this HIPAA-compliant retrospective study, our pathology and imaging databases were queried to obtain acohort of ccRCC with preoperative multiphasic multidetector CT imaged with a four-phase renal mass protocol (unenhanced (UN),corticomedullary (CM), nephrographic (NE), and excretory (EX)). A whole lesion 3D contour was obtained in all phases withproprietary software. The CAD algorithm determined a 0.5cm diameter region of peak enhancement <=300HU within the 3D lesioncontour. All contours were confirmed by a radiologist. Absolute wash-out was calculated using the adrenal wash-out formula: (CADlesion enhanced CT (HU) -CAD lesion Delayed CT (HU)/ (CAD lesion Delayed CT (HU)-CAD lesion Unenhanced CT (HU))* 100%). T-tests were used to compare % wash-out between low grade and high grade lesions. P values less than 0.05 were considered to besignificant.

RESULTS

107 patients (71 (64%) men and 40 (35%) women) with 111 unique ccRCC lesions (80 (72%) low grade (FG I and II) lesions and 31(28%) high grade (FG III and IV)) lesions were analyzed. Mean lesion size of the low grade lesions was 2.9 cm (range 0.8-6.4).Mean lesion size of the high grade lesions was 5.6 cm (range 1.6-14.4). . High grade lesions had a significantly higher washoutpercentage (60.2% vs 32.1% p=0.0047) as compared to low grade lesions from the CM to NE phase but similar wash out ratesbetween NE and EX phases (41.9% vs. 44.2%, p=0.6642).

CONCLUSION

High grade ccRCCs wash out at a significantly faster rate than low grade ccRCCs from the CM to NE phases


CAD derived ccRCC %wash-out was significantly greater in high grade vs. low grade ccRCC providing a non invasive method ofgrading at imaging, enabling more aggressive treatment for high grade lesions

AwardsCertificate of MeritIdentified for RadioGraphics

ParticipantsElmira Hassanzadeh, MD, Boston, MA (Presenter) Nothing to Disclose

UR157-ED-SUA7

Pitfalls of Adrenal and Renal Imaging: A Pictorial Review

Station #7

Erik Velez, BS, San Francisco, CA (Abstract Co-Author) Nothing to DiscloseFiona M. Fennessy, MD, PhD, Boston, MA (Abstract Co-Author) Nothing to DiscloseRuth M. Dunne, MBBCh, Aclare, Ireland (Abstract Co-Author) Nothing to DiscloseMukesh G. Harisinghani, MD, Boston, MA (Abstract Co-Author) Nothing to DiscloseClare M. Tempany-Afdhal, MD, Boston, MA (Abstract Co-Author) Nothing to DiscloseDaniel I. Glazer, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

The purpose of this exhibit is:•To describe the experience of using PIRADS v2 in a teaching hospital•To help readers identify variousPIRADS v2 scores with an interactive method•To discuss common challenges using PIRADS v2 in the clinical setting


•PIRADS v2 overview•Representative images of various PIRADS v2 scores•Challenges and pitfalls of PIRADS v2

ParticipantsMatthew J. Wu, MD, Halifax, NS (Abstract Co-Author) Nothing to DiscloseSeng Thipphavong, MD, Toronto, ON (Abstract Co-Author) Nothing to DiscloseMagdi A. Akl, FRCR, Halifax, NS (Abstract Co-Author) Nothing to DiscloseAndreu F. Costa, MD,FRCPC, Halifax, NS (Presenter) Nothing to Disclose

TEACHING POINTS

The learning objectives of this exhibit are: To present a variety of common renal and adrenal lesions with potential pitfalls indiagnosis To review how CT attenuation density, enhancement on CT and MRI, and the presence of fat on MRI, both intra-voxel fatand gross, will influence the diagnosis or differential diagnosis in the kidney and adrenal gland


1. Title slide2. Disclosures and target audience3. Case-based, image-rich review of common renal and adrenal lesions with potentialpitfalls in diagnosis. Cases will include but will not be limited to: Adrenal lesions with gross fat: myelolipoma, extramedullaryhematopoiesis, adrenal teratoma, and lipomatous degeneration of adenoma. Adrenal lesions with intra-voxel fat: adenoma, clear-cellRCC and HCC metastases0. Adrenal lesions measuring < 10 HU: adenoma, cyst and myelolipoma without gross fat on CT. Enhancingrenal lesions without gross fat: RCC, oncocytomas, lipid-poor angiomyolipomas. Renal lymphoma mimicking lobar pyelonephritis on CTRenal lesions with intra-voxel fat: clear cell RCC, AML, papillary RCC4. Summary5. References6. Author contact

GU205-SD-SUB1

"Surrounding Endometrium Sign" to Differentiate Eccentric Cornual Intra-uterine Pregnancies fromInterstitial Ectopic Pregnancy

Station #1

GU206-SD-SUB2

Utility of Using Abdominal Wall Thickness in Prenatal Ultrasound in Predicting Fetal Outcome forFetuses at Risk for Intrauterine Growth Restriction

Station #2

GUS-SUB

Genitourinary Sunday Poster Discussions

Sunday, Nov. 29 1:00PM - 1:30PM Location: GU/UR Community, Learning Center

GU


ParticipantsPaul Nikolaidis, MD, Chicago, IL (Moderator) Nothing to Disclose

Sub-Events

ParticipantsAllison L. Grant, MD, MSc, Toronto, ON (Presenter) Nothing to DiscloseAlly Murji, Toronto, ON (Abstract Co-Author) Nothing to DiscloseGlen Lo, MBBS,BMedSc, Toronto, ON (Abstract Co-Author) Nothing to DiscloseMostafa Atri, MD, Toronto, ON (Abstract Co-Author) Nothing to Disclose

PURPOSE

The aim of this study was to investigate whether a sign we have observed, "surrounding endometrium sign" (SES), can be used toreliably differentiate eccentric cornual intra-uterine pregnancy (IUP) from interstitial ectopic pregnancy (EP).


This was an REB approved retrospective review of all cases in our radiology database with keywords "interstitial" or "cornual"pregnancy from 2007 to 2015. Acquisition of consent was waived. One expert reader reviewed video-clips blindly using the SESsign, defined as extension of the endometrial lining to surround the eccentrically located gestational sac. Cases were calledeccentric IUP if SES was present and interstitial EP if SES was absent. Correlation with outcome was made.

RESULTS

Forty-four evaluable cases were included. Patients were 20 to 42 years old (mean 32.6±5.7). Twenty-four cases were negative forSES sign, supporting a diagnosis of interstitial EP. These cases were managed either with methotrexate (MTX), MTX and surgery, orexpectantly because of dropping β-hCG. None of 24 patients had passing of tissue vaginally.Twenty cases were positive for SES.Of those, 11 were prospectively called as eccentric IUPs and therefore appropriately managed. Six had spontaneous abortion, 4continued to pregnancy > 20 weeks, and one underwent DandC for a desired therapeutic abortion.The remaining 9 cases werecalled interstitial EP prospectively, and managed as such. Seven patients were treated with MTX, with some evidence in 4 of themof inappropriate management; 2 had f/u imaging which showed definite IUPs that had moved down the uterus, 1 had documentationof passed tissue per vagina (which should not occur with an interstitial ectopic), and one underwent a DandC that showed retainedproducts of conception (which again should not be possible with an interstitial pregnancy). Two patients underwent surgicalmanagement where pregnancy tissue was removed transcervically, again questioning the original diagnosis of interstitial pregnancy.

CONCLUSION

We propose the new 'surrounding endometrial sign' to accurately differentiate between eccentric cornual IUP and interstitial EP.


'Surrounding endometrial sign' on US can differentiate between eccentric cornual pregnancy and interstitial pregnancy, therebypotentially salvaging some pregnancies that may otherwise be terminated.

ParticipantsLei Wu, MD, Seattle, WA (Presenter) Nothing to DiscloseTheodore J. Dubinsky, MD, Seattle, WA (Abstract Co-Author) Stockholder Global Cancer Technology

PURPOSE

With 2nd or 3rd trimester prenatal ultrasound (US), fetal growth is routinely evaluated by calculating the estimated fetal weight(EFW). An EFW < 10th percentile for gestational age is defined as small for gestational age (SGA), and generally thought to beassociated with increased risk of IUGR. However, only a small number of these fetuses (5.2%) are affected by adverse perinataloutcome, and majority are constitutionally small. Besides abnormal UA doppler, other routinely measured biometric parameters donot accurately predict pathologic growth restriction (PGR) (1). Thus, there is a need for better predictors of PGR. Neonatesexposed to PGR tend to have lower percent body fat. Thus, we propose the measurement of abdominal wall thickness (AT) as ameasure of fetal metabolic reserve and as a possible predictor of PGR.


Our study population included singleton live IUP with gestational age (GA) > or = 28w0d based on 1st trimester US with EFW < 90thpercentile and no history of maternal diabetes. Fetuses are categorized as normal if the EFW is between 40th and 90th percentilesand no anatomic anomalies are present on US. Those with EFW < 10th percentile are considered SGA. 50 normal and 50 SGAfetuses are included in the study. Adverse perinatal outcome for SGA is evaluated and defined as admission to NICU or neonatal

GU207-SD-SUB3

Favorable Outcomes and Fertility Perspective in Women Treated by MRgFUS for Uterine Fibroids:Pregnancy Results

Station #3

GU208-SD-SUB4

Predictive Models for Lymph Node Metastases in Patients with Testicular Germ Cell Tumors

Station #4

death. AT is measured at its thickest portion in the same slice as the AC measurement. AT of SGA fetuses is compared to that innormal fetuses using a 2-tailed paired T-test. Chi-squared test was used to evaluate the relationship between mean AT in SGAfetuses and adverse outcome.

RESULTS

The mean GA is 32w0d for normal fetuses and 33w6d for SGA fetuses. The mean AT is 8mm for normal fetuses and 4mm for SGAfetuses (p<0.01). 6 of 50 SGA fetuses were lost to follow up prenatally. Overall, 28 of 44 (63.6%) remaining SGA neonates hadadverse outcome, 1 of which (2.2%) resulted in neonatal death. In those with AT > 3mm, 50.0% experienced adverse outcomecompared to 100% in fetuses with AT = 3 mm (p<0.01). AT of 3 mm had an OR of 25.0 for adverse outcome.

CONCLUSION

Using a cutoff value of 3mm, AT is a useful biometric parameter as a predictor of adverse outcome especially if IUGR is questioned.


Most biometric parameters on prenatal US do not accurately predict pathologic growth restriction. There is a need for betterpredictors such as our proposed abdominal wall thickness measurement.

Honored Educators


Theodore J. Dubinsky, MD - 2012 Honored EducatorTheodore J. Dubinsky, MD - 2013 Honored Educator

ParticipantsFabiana Ferrari, MD, L'Aquila, Italy (Presenter) Nothing to DiscloseFrancesco Arrigoni, Coppito, Italy (Abstract Co-Author) Nothing to DiscloseAnna Miccoli, MD, L'Aquila, Italy (Abstract Co-Author) Nothing to DiscloseFernando Smaldone, MD, L'Aquila, Italy (Abstract Co-Author) Nothing to DiscloseGiulio Mascaretti, MD, L'Aquila, Italy (Abstract Co-Author) Nothing to DiscloseCarlo Masciocchi, MD, L'Aquila, Italy (Abstract Co-Author) Nothing to Disclose

PURPOSE

The purpose of this study was to discuss about fertility perspective in women treated by MRgFUS and to report pregnancy afterthis treatment.


Fourteen patients, aged between 23 and 42 (mean age 32.5), affected by uterine fibroids, who wanted to get pregnant, weretreated in our department with MRgFUS. This study evaluates the findings on 14 patients presenting difficulties to conceive anduterine fibroids smaller than 6 cm. We preliminarily excluded the other causes of infertility with a gynaecological evaluation. Allpatients had only one treatment. We made a c.e. MRI, in order to control the Non-Perfused-Volume, immediately after treatment,and then after 3, 6 and 12 months from the treatment. After 17-20 months from the treatment, the patients started the course tobecome spontaneously pregnant.

RESULTS

After 12 months from treatment, 10 patients had a complete reabsorption of the necrotic areas and 4 had a partial reabsorption.Five months later, the patients started the course to become spontaneously pregnant. Two of them succeeded and 1 has alreadygiven birth at term to a healthy infant without any perinatal complications. Another patient with partial reabsorption of the necroticarea gave birth to a baby and another is now in her seventh month of pregnancy.

CONCLUSION

MRgFUS permits a significant reduction of the symptoms and is a valid alternative method to surgery in fertile women, without anycomplications in case of uterine implanting.


MRgFUS is a mini-invasive treatment that permits to save neighbouring healthy structures, and avoid post-surgical complicationsallowing the uterine implanting.

ParticipantsVishala Mishra, MBBS, Boston, MA (Presenter) Nothing to DiscloseYun Mao, MD, Chongqing, China (Abstract Co-Author) Nothing to DiscloseSandeep S. Hedgire, MD, Boston, MA (Abstract Co-Author) Nothing to DiscloseDuangkamon Prapruttam, MD, Boston, MA (Abstract Co-Author) Nothing to DiscloseMukesh G. Harisinghani, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose

PURPOSE

To develop predictive models for lymph node metastasis in testicular germ cell tumors.

GU209-SD-SUB5

Beyond Virtual Non-Contrast: Dual-Energy CT Fat Fraction for Differentiation Between Benign andIndeterminate Adrenal Nodules

Station #5

UR108-ED- PIRADS v2: A Case-Based Tutorial

To develop predictive models for lymph node metastasis in testicular germ cell tumors.


291 patients with testicular germ cell tumors were included, which were divided into seminomatous and nonseminomatous groups.For screening the risk factors for LN metastasis, the tumor-related characteristics (including histopathological information and tumormarkers) alpha fetoprotein and the lymph node-related features on CT were compared between metastatic cases andnonmetastatic cases. Two logistic regression models were built for each histological group, one depending on all tumor- and lymphnode-related risk factors (Model 1) and another only on tumor-related factors (Model 2). Receivers operating characteristic curveswere used to evaluate the predictive abilities of these models.

RESULTS

117 positive nodes/regions were identified in 68 patients, including 51 metastases and 17 occult metastases. Based on the selectedindependent risk factors, the sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of Model 1and 2 in senimomatous and nonseminomatous groups were (95.5%, 95.3%, 95.3%, 77.8%, and 99.2%), (63.6%, 83.6%, 80.7%,40.0%, and 93.0%), (93.5%, 94.7%, 94.3%, 89.6%, and 96.8%), and (89.1%, 44.2%, 58.9%, 43.6%, and 89.4%), respectively.

CONCLUSION

In our study, four models for predicting lymph node metastases in testicular cancer were established based on lymph node- andtumor-related risk factors. In patients without tumor-related factors, regular CT surveillance may be a good choice afterorchiectomy, while in patients without lymph node- and tumor-related factors, long interval-time CT follow-up could be considered.


The predictive abilities of LN-related CT factors (esp. SD) on LN involvement were obviously superior to those of tumor-relatedfactors. In patients without any IRF of Model 2, regular CT surveillance may be enough for predicting LN status, while in thepatients without any IRF of Model 1, a long interval-time CT follow-up could be considered. Additionally, right side tumors tend toinvolve contralateral LNs compared to left side ones, as well as positive inguinal LNs more frequently occur in patients with a historyof groin surgery.

ParticipantsGregory A. Bonci, MD, Boston, MA (Presenter) Nothing to DiscloseUrvi P. Fulwadhva, MD, Boston, MA (Abstract Co-Author) Nothing to DiscloseAaron D. Sodickson, MD, PhD, Wayland, MA (Abstract Co-Author) Research Grant, Siemens AG; Consultant, Bracco Group

PURPOSE

To evaluate whether dual-energy CT (DECT) can differentiate benign from indeterminate adrenal nodules based on the fat fractionderived from three-material decomposition.


The study included 22 patients with adrenal nodules detected on routine Emergency Department portal venous phase DECT scanswho also had gold standard non-contrast CT or MRI with chemical shift imaging. Adrenal nodules were categorized as benign if theydemonstrated attenuation <= 10 HU on non-contrast CT or loss of signal on chemical shift MR imaging. They otherwise remainedindeterminate. DECT scans were performed on a 128x2 slice dual-energy scanner (Siemens FLASH, Forchheim Germany) using tubecurrent modulation (CareDose4D) with reference mAs 400/155 at 80/Sn140 kVp or 201/155 at 100/Sn140 kVp, with the kVp pairselected based on patient size. Source images from each tube were reconstructed as 0.75 x 0.5 mm slices and used for post-processing on a thin-client server (Syngo via, version VA30). Nodule regions of interest (ROI) were placed to record HU values onthe mixed high/low kVp images, and the Liver Virtual Non-Contrast (VNC) application was used to calculate ROI VNC HU values andfat fraction (defined as 0 for a purely soft tissue attenuation lesion and 100% for a purely fat-containing lesion).

RESULTS

15 benign and 7 indeterminate adrenal nodules were identified based on gold standard imaging. Contrast-enhanced mixedattenuation values (HU ± STD) could not accurately differentiate between the lesions, with benign nodules measuring 39.9 ± 24.9and indeterminate nodules 61.6 ± 23.6 (t-test p = 0.07). However, benign and indeterminate lesions demonstrated significantlydifferent fat fraction values (33.5 ± 12.6% versus 6.8 ± 12.0%, p < 0.001) as well as VNC HU attenuation values (7.2 ± 16.2versus 38.6 ± 14.9, p < 0.001).

CONCLUSION

DECT fat fraction analysis shows promise in this proof-of-principle cohort for differentiating between benign and indeterminateadrenal nodules.


Adrenal nodule fat fraction derived from DECT three-material decomposition may provide additional information about nodule tissuecomposition to aid in differentiating benign from indeterminate lesions.

Honored Educators


Aaron D. Sodickson, MD, PhD - 2014 Honored Educator

SUB6Station #6

UR164-ED-SUB7

How to Optimize the Adquisition and Analysis of Diffusion-weighted Imaging in the Prostate forCancer Assessment

Station #7

ParticipantsDennis Toy, New Haven, CT (Presenter) Nothing to DiscloseJay K. Pahade, MD, New Haven, CT (Abstract Co-Author) Nothing to DiscloseMahan Mathur, MD, New Haven, CT (Abstract Co-Author) Nothing to DiscloseMike Spektor, MD, New Haven, CT (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

The objectives of the exhibit are to: 1. Familiarize trainees with the newly introduced scoring system that is aimed at standardizingprostate MRI performance and assessment. 2. Offer hands on experience scoring basic and challenging prostate MRI cases,highlight key findings, provide explanations and discuss pitfalls. 3. Provide tables and flow charts to assist in accurate scoring.


Table of contents/Outline:1. Normal prostate anatomy on MRI2. Overview of PIRADS v2 a. Patient preparation b. Technicalparameters and requirements c. Scoring d. Reporting3. Quiz format cases followed by labelled answers with explanations andrelevant teaching points a. Peripheral zone cases b. Transition zone cases c. Pitfalls d. PIRADS Assessment Category "X"4.Summary tables of scoring system algorithm


ParticipantsAntonio Luna, MD, Jaen, Spain (Abstract Co-Author) Nothing to DiscloseTeodoro Martin, MD, Jaen, Spain (Presenter) Nothing to DiscloseLidia Alcala Mata, MD, Jaen, Spain (Abstract Co-Author) Nothing to DiscloseJordi Broncano, MD, Cordoba, Spain (Abstract Co-Author) Nothing to DiscloseJavier Sanchez, MD, PhD, Madrid, Spain (Abstract Co-Author) Research Consultant, Koninklijke Philips NVMariano Volpacchio, MD, Buenos Aires, Argentina (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

1. Learn how to improve the sequence design of DWI in the prostate according to the clinical indication2. Analyze the differentmodels of analysis of diffusion signal decay in the prostate and enhance the most useful approach for cancer detection andcharacterization3. Enhance the current established indications to perform DWI in the prostate and review other new potential ones


1. Introduction2. DWI sequence design- b values according to analysis method- 1.5 and 3T protocol3. Quantification-Monoexponential model- IVIM- Kurtosis4. Clinical applications- Cancer detection according to PIRADS v2.0 criteria- Nodulecharacterization (cancer vs chronic prostatitis)- Locoregional staging- Therapy monitoring- Detection of recurrence- Screening ofcancer with DWI5. Conclusions

VSIO11-01 Updates in the Management of Small (T1a) Renal Masses: Resect, Ablate, or Follow?

VSIO11-02 Small Renal Mass (T1a): The Case for Ablation in 2015

Sunday, Nov. 29 1:30PM - 1:50PM Location: S405AB

VSIO11-03 Small Renal Mass (T1a): The Case for Resection in 2015


VSIO11-04 Small Renal Mass (T1a): Both Cases for Intervention are Weak. Active Surveillance Will Do Just asWell


VSIO11-05 Age Impacts Choice of Partial Nephrectomy vs. Percutaneous Ablation for Stage T1a Renal CellCarcinoma: a Surveillance, Epidemiology and End Results (SEER)-Medicare Population Study


VSIO11

Interventional Oncology Series: Percutaneous Management of Renal Tumors: Updates and OngoingControversies in 2015


GU IR OI RO



ParticipantsDebra A. Gervais, MD, Chestnut Hill, MA (Moderator) Nothing to Disclose

LEARNING OBJECTIVES

1) To review management options for small renal masses as well as indications for each. 2) To review the data supporting theenergy based thermal ablation modalities for ablation of renal masses. 3) To describe the role and limitations of biopsy of renalmasses. 4) To review the management of benign solid renal masses. 5) To describe the evidence for ablation of T1b renal masses.

Sub-Events

Participants

LEARNING OBJECTIVES

View learning objectives under main course title.

ParticipantsJeremy C. Durack, MD, New York, NY (Presenter) Scientific Advisory Board, Adient Medical Inc Investor, Adient Medical Inc

LEARNING OBJECTIVES


ParticipantsAdam S. Feldman, MD, Boston, MA (Presenter) Consultant, Olympus Corporation

LEARNING OBJECTIVES


ParticipantsStuart G. Silverman, MD, Brookline, MA, ([email protected]) (Presenter) Author, Wolters Kluwer nv

LEARNING OBJECTIVES


ParticipantsMinzhi Xing, MD, New Haven, CT (Presenter) Nothing to DiscloseNima Kokabi, MD, Atlanta, GA (Abstract Co-Author) Nothing to DiscloseDi Zhang, Pittsburgh, PA (Abstract Co-Author) Nothing to DiscloseHyun S. Kim, MD, Atlanta, GA (Abstract Co-Author) Nothing to Disclose

PURPOSE

To investigate survival outcomes in patients with stage 1a renal cell carcinoma (RCC) undergoing open or laparoscopic partialnephrectomy (PN) vs. percutaneous cryoablation (CRA) or radiofrequency ablation (RFA) in a large-scale population study.


The most recently updated SEER-Medicare linked database was queried for patients with T1aN0M0 RCC (≤4cm, ICD-O-3 C64.9)

VSIO11-06 Ablation for Renal Cell Carcinoma: Radiofrequency, Cryoblation, or Microwave?

VSIO11-07 Small Renal Mass (T1a): The Case for RFA in 2015


VSIO11-08 US-guided Percutaneus Radiofrequency Ablation of Renal Cell Carcinoma: Experience from Treating120 Renal Masses Over 7 Years


The most recently updated SEER-Medicare linked database was queried for patients with T1aN0M0 RCC (≤4cm, ICD-O-3 C64.9)diagnosed between 2000 and 2011 and followed to 2012. Patients who underwent therapy were selected from Medicare via CPTcarrier claim codes (percutaneous RFA 50592; percutaneous CRA 50593; open PN 50240; laparoscopic PN 50543). Mean overallsurvival (OS) from therapy was compared between patients who underwent percutaneous ablation vs. partial nephrectomy, withsubgroup survival analysis of individual therapies. Kaplan-Meier estimation and Cox proportional hazard models were used for survivalanalyses and to assess independent prognostic factors for OS.

RESULTS

A total of 5,983 T1a RCC patients underwent percutaneous ablation or PN within the study period, median age 72.0 yrs, 61.0%male. Of these, 3150 received open PN, 1785 received laparoscopic PN, 419 received CRA and 629 received RFA. Of these, 47.9%of patients undergoing PN were >72 yrs, vs. 67.1% of patients in the ablation group. Mean age of patients receiving ablation wassignificantly higher than that of the PN group, 80.1 vs. 70.6 yrs, p<0.001. Other factors including gender, ethnicity, mean indextumor size and tumor grade were not significantly different between comparison groups. Patients who underwent PN hadsignificantly higher mean OS compared to the ablation group, 128.7 vs. 75.5 months, p<.001. On Cox regression analysis, youngerage was the only independent prognostic factor for survival, HR 0.91 (0.87-0.93, p<0.001).

CONCLUSION

In T1aN0M0 RCC, patients undergoing ablation were significantly older compared to PN patients. Age was found to be anindependent prognostic factor for survival from treatment.


In T1aN0M0 RCC, age was found to be an independent prognostic factor for survival from treatment and may impact choice oftherapy.

Participants

LEARNING OBJECTIVES


ParticipantsDebra A. Gervais, MD, Chestnut Hill, MA (Presenter) Nothing to Disclose

LEARNING OBJECTIVES


Honored Educators


Debra A. Gervais, MD - 2012 Honored Educator

ParticipantsAdriana C. Montealegre Angarita, Barcelona, Spain (Abstract Co-Author) Nothing to DiscloseXavier Serres Creixams, PhD, Barcelona, Spain (Presenter) Nothing to DiscloseEnrique Trilla, Barcelona, Spain (Abstract Co-Author) Nothing to DiscloseMilton R. Villa III, Barcelona, Spain (Abstract Co-Author) Nothing to DiscloseJuan Halaburda Berni, Barcelona, Spain (Abstract Co-Author) Nothing to DiscloseEsteban Ramirez Pinto, MD, Barcelona, Spain (Abstract Co-Author) Nothing to DiscloseXavier G. Azogue JR, Barcelona, Spain (Abstract Co-Author) Nothing to Disclose

PURPOSE

Evaluate the efficacy and safet of ultrasound (US) guided percutaneous radiofrequency ablation (RFA) for small renal masses.Describe the complications of RFA guided by US. Evaluate the technique in their initial ablative capacity and rate of tumorrecurrence at one year minimum follow up. Illustrate postablation findings of residual or recurrent renal tumor by using Contrast-enhanced US (CEUS) Evaluate the effect of renal function in patients undergoing RFA guided by US


Over a 7 year 105 patients with 120 renal masses (tumor size averaged 2.7 cm) were reviewed treated with US-guidedpercutaneous RFA. Biopsy was performed at the same moment of the procedure from 2009. Cool-tip RFA system waspercutaneously inserted under ultrasound guidance. RF was emitted at 100-120 W for 12 minutes to attain temperatures sufficientto ensure tumor kill. The treatment response and technical success were defined by absence of contrast enhancement within thetumor on contrast enhanced CT and CEUS. The patients were followed up with CEUS and computed tomography at 3.6 months andevery 6 months thereafter. Multivariate analysis was performed to determine variables associated with procedural outcome.

RESULTS

VSIO11-09 Small Renal Mass (T1a): The Case for Cryoblation


VSIO11-10 Adjunctive Techniques to Improve Image-Guided Percutaneous Cyroablation of Renal Masses inDifficult Anatomic Locations: Quantifying Procedural Success and Long-term Outcomes


Follow-up ranged from 24 months to 84 months.The initial treatment success rate was 95.8%.Five of the remaining tumors weresuccessfully re-treated.Four tumors had recurrence (defined as the occurrence of contrast enhancing tumor 12 months aftercomplete ablation) three of whom required a second ablation and one nephrectomy.The overall technical success rate was 99%.Complications were seven self-limited included hematomas subcapsular or perirenal. In all 104 (99%) patients have preservation ofrenal function,only one patient developed significant renal function deterioration associated with perirenal hematoma. There wereno bowel complications despite the fact that 6 of the tumors were within 1 cm of bowel. Protective strategies progressed fromreliance on electrode positioning to hydro dissection.

CONCLUSION

Our experience to date suggests that US-guided RFA of small renal tumors is a safe and effective, minimally invasive technique inselected patients.


US-guided RFA of renal tumors can provide benefits compared to other techniques: Intraprocedural monitoring affords visualizationof the forming hot ball, helps detect proximity to surrounding structures and does not use ionizing radiation.

ParticipantsPeter J. Littrup, MD, Providence, RI (Presenter) Founder, CryoMedix, LLC; Research Grant, Galil Medical Ltd; Research Grant, EndoHealth Solutions Inc; Consultant, Delphinus Medical Technologies, Inc

LEARNING OBJECTIVES


ABSTRACT

Cryoablation of smaller renal cancers (i.e., T1a, or <4 cm) is an out-patient treatment that is safe, effective and flexibility fornearly any renal location. Major cryoablation benefits include its excellent visualization of ablation zone extent, low procedure painand flexible protection of tumor ablation sites near calyces, bowel and ureter. CT-guidance is the cryoablation guidance modality ofchoice due to circumferential visualization of low density ice and ready availability. US-guidance can augment renal cryoablation,especially for smaller visible masses and/or placement of interstitial metallic markers during biopsy for selected cases requiringbetter eventual CT localization. MR-guidance has little clinical benefit or cost-efficacy. For safety, cases will be considered foravoidance of direct calyceal puncture, selection of hydrodissection or balloon interposition for bowel protection, and protection ofthe uretero-pelvic junction by stent placement. Imaging outcomes of complications and their avoidance will be shown. For optimalefficacy, tumor size in relation to number and size of cryoprobes emphasize the "1-2 Rule" of at least 1 cryoprobe per cm of tumordiameter and no further than 1 cm from tumor margin, as well as cryoprobe spacing of <2cm. Thorough extent of visiblecryoablation margins beyond all apparent tumor margins produces very low local recurrence rates for tumors in nearly any renallocation, resulting in excellent cost-efficacy by minimizing the need for re-treatments.

ParticipantsAhmed Fadl, MD, Mineola, NY (Presenter) Nothing to DiscloseAndrew Ho, Bayside, NY (Abstract Co-Author) Nothing to DiscloseSamia Sayegh, DO, Mineola, NY (Abstract Co-Author) Nothing to DiscloseApril Griffith, Mineola, NY (Abstract Co-Author) Nothing to DiscloseSiavash Behbahani, MD, Mineola, NY (Abstract Co-Author) Nothing to DiscloseJason C. Hoffmann, MD, Mineola, NY (Abstract Co-Author) Consultant, Merit Medical Systems, Inc; Speakers Bureau, Merit MedicalSystems, Inc

PURPOSE

When performing renal mass cryoablation in difficult anatomic locations, adjunctive techniques such as retrograde pyeloperfusion,hydrodissection, and angioplasty balloon interposition can improve safety and technical success rates. Prior studies have reportedthe technical success of these techniques, but correlation with longer-term outcomes has not been reported in this specific patientpopulation. This study quantifies the success of these techniques, and correlates with long-term cross-sectional imaging outcomes.


Retrospective analysis of percutaneous renal mass cryoablation was performed from September 2011 through October 2014 at asingle, tertiary care institution. Cases using adjunctive techniques were analyzed. The diagnostic cross sectional imaging,procedural images and report, and follow-up multi-phasic cross-sectional imaging were reviewed by one radiology resident and oneinterventional radiology attending. The type of adjunctive technique used, reason for such utilization, and procedural outcome ofthe technique were recorded. Specifically, in cases of hydrodissection or balloon angioplasty interposition, measurements of thedisplacement distance were made. Minor and major complications were recorded, per Society of Interventional Radiology criteria.Longer-term outcomes were evaluated by review of follow-up cross-sectional imaging.

RESULTS

Out of 53 cryoablations during the study period, 9 utilized adjunctive techniques, including hydrodissection (n=8), retrogradepyeloperfusion (n=1), and angioplasty balloon interposition (n=1). Median greatest tumor dimension was 1.9cm (range 1.3-3.5cm).Prior to adjunctive technique, median tumor proximity to closest organ was 0.4cm (range 0.1-1.3cm). After technique was used,median distance to closest organ was 2.8cm (range 0.3-3.3cm). One hydrodissection was unsuccessful, thus angioplasty ballooninterposition was then performed. All cases had appropriate ablation zones and protection of adjacent critical structures. No minoror major complications were reported. No patients had evidence of residual or recurrent tumor on follow-up imaging, ranging from 3to 30 months.

VSIO11-11 Small Renal Mass (T1a): The Case for Microwave


VSIO11-12 Long-term Clinical Outcomes Following Radiofrequency and Microwave Ablation of Renal CellCarcinoma at a Single Large VA Medical Center


VSIO11-13 To Biopsy or Not Biopsy the Small Renal Mass before Ablation? That Is the Question

VSIO11-14 Biopsy or No Biopsy Before Ablation? Biopsy Every Renal Mass before Percutaneous Ablation

CONCLUSION

Adjunctive techniques to allow cryoablation of renal masses in difficult anatomic locations have excellent technical success ratesand long-term outcomes.


Improving outcomes of difficult renal mass cryoablations.

ParticipantsFred T. Lee JR, MD, Madison, WI (Presenter) Stockholder, NeuWave Medical, Inc; Patent holder, NeuWave Medical, Inc; Board ofDirectors, NeuWave Medical, Inc ; Patent holder, Medtronic, Inc; Inventor, Medtronic, Inc; Royalties, Medtronic, Inc

LEARNING OBJECTIVES


ParticipantsSalim E. Abboud, MD, Cleveland, OH (Presenter) Nothing to DiscloseTanay Y. Patel, MD, Cleveland, OH (Abstract Co-Author) Nothing to DiscloseStephanie Soriano, MD, Cleveland, OH (Abstract Co-Author) Nothing to DiscloseNannette Alvarado, MD, Cleveland, OH (Abstract Co-Author) Nothing to DisclosePreet S. Kang, MD, Pepper Pike, OH (Abstract Co-Author) Nothing to Disclose

PURPOSE

Earlier detection and a desire to preserve renal function and decrease surgical morbidity in the treatment renal cell carcinoma (RCC)has prompted increased use of percutaneous thermal ablation treatments such as radiofrequency ablation (RFA) and more recentlymicrowave ablation (MWA). MWA has the potential to provide more complete ablation compared to RFA in part due to more uniformand higher intra-tumoral temperatures, but only a few small studies have examined the short-and long-term outcomes of MWA forRCC. This retrospective review assesses the experience and technical short- and long-term success rates of using RFA and MWAfor RCC at a large VA medical center.


Patient and tumor characteristics (tumor size, nearness to collecting system, anterior/posterior location, location relative to polarline, and endophytic/exophytic predominance) were tabulated using descriptive statistics. Group comparisons were performed byusing univariate logistic regression analysis to determine factors impacting primary efficacy, secondary efficacy, and techniqueeffectiveness. Kaplan-Meier local tumor progression-free survival following ablation was calculated.

RESULTS

71 patients with 78 renal lesions underwent ablation. Mean, primary, and secondary mean follow-up were 35.1, 33.5, and 31.3months. Total, primary, and secondary technique effectiveness rates were 86%, 82%, and 4%, respectively. Primary efficacy andtotal technique effectiveness were associated with size, with p values of 0.02 and 0.001. There was no significant difference insurvival curves between MWA and RFA treated patients. MWA and RFA groups were not significantly different in terms of age, BMI,or tumor size. Complications occurred in 11.5% of patients, none resulting in death. More than 90% patients were done asoutpatients (sent home day of procedure) with moderate sedation. No cases used intubations or general anesthesia.

CONCLUSION

RFA and MWA both represent effective treatment modalities for RCC. Longer follow-up time and larger tumor size may be associatedwith the somewhat lower effectiveness rates; the comparable efficacy/complication rates compared to prior ablation studiesdemonstrate the feasibility of performing ablations on an outpatient basis.


Image guided percutaneous ablation is an effective and cost-effective treatment modality for RCC in patients that are not surgicalcandidates.

Participants

LEARNING OBJECTIVES


ABSTRACT

Characterization of small renal masses has proven challenging. However, with appropriate CT and MR protocols, the majority ofthese lesions can now be characterized pre procedurally, enabling a confident diagnosis. In this lecture, we will describe renal masscharacterization protocols and describe the common imaging signatures of RCC subtypes and their common mimics including lipidpoor AML and oncocytoma. This may eliminate need for preprocedural biopsy.


VSIO11-15 Biopsy or No Biopsy before Ablation? Don't Trouble Yourself or the Patient with the Renal MassBiopsy - Imaging Diagnosis Will Do Just as Well in 2015


VSIO11-16 Thermal Ablation of a Confluent Lesion in the Porcine Kidney with Magnetic Resonance Guided HighIntensity Focused Ultrasound (MR-HIFU)


VSIO11-17 Outside the Box: Is Ablation Effective for Masses other than T1a RCC

ParticipantsWilliam W. Mayo-Smith, MD, Boston, MA (Presenter) Author with royalties, Reed Elsevier; Author with royalties, CambridgeUniversity Press

LEARNING OBJECTIVES


ParticipantsSteven S. Raman, MD, Santa Monica, CA (Presenter) Nothing to Disclose

LEARNING OBJECTIVES


ParticipantsJohanna M. van Breugel, MSc, Utrecht, Netherlands (Presenter) Nothing to DiscloseMartijn de Greef, PhD, Utrecht, Netherlands (Abstract Co-Author) Nothing to DiscloseJoost W Wijlemans, MD,PhD, Utrecht, Netherlands (Abstract Co-Author) Nothing to DiscloseGerald Schubert, PhD, Vantaa, Finland (Abstract Co-Author) Employee, Koninklijke Philips NVChrit T. Moonen, PhD, Utrecht, Netherlands (Abstract Co-Author) Nothing to DiscloseMaurice V. Bosch, MD, PhD, Utrecht, Netherlands (Abstract Co-Author) Nothing to DiscloseMario G Ries, PhD, Utrecht, Netherlands (Abstract Co-Author) Nothing to Disclose

PURPOSE

To investigate if MR-HIFU can provide for a reliable confluent volumetric lesion in the renal cortex in a clinically relevant time-framein a porcine study.


Nine anesthetized pigs were placed on a clinical Philips Sonalleve MR-HIFU therapy system integrated with a 1.5T Achieva MRI. Bothacoustic energy delivery and MR-thermometry were respiratory gated and active surface cooling was employed to prevent near-field damage. A honeycomb pattern of at least seven ablation cells (9-25s, 450W acoustic power, 4x4x10 mm3 per cell) werepositioned in the cortex of the kidney. The therapeutic endpoint was evaluated by a non-perfused volume (NPV) measurementusing DCE-MRI. Subsequently, the animal was euthanized and the extent of induced necrosis was examined using a cellular viabilitystaining (NADH).

RESULTS

Confluent volumes on NPV-imaging (up ~3 mL) and NADH staining (up to ~4mL) were obtained and temperatures exceeding 60°Cwere reached in 6 pigs. I.e. heating of the false rib, poor respiratory correction, and a large incidence angle caused poor kidneyheating in 3 pigs.

CONCLUSION

These first results indicate that current clinical MR-HIFU equipment might be suitable for non-invasive therapy of renal masses.Positioning of the sonications and the subject based on anatomical scans is very important, as well as adequate motioncompensation. Future work will include a first clinical study on renal cell carcinomas.


There is an increasing interest in non-invasive kidney sparing therapy for renal cancer, since ~1.6% of men and women will bediagnosed with kidney and renal pelvis cancer during their lifetime, in 25% of all abdominal imaging sessions a renal lesion is found,partial nephrectomy - standard care for tumors <4cm - has a 15% complication rate, and the population is aging and known withcomorbidities and poor physical condition. Therefore, several patient studies investigated the feasibility of HIFU for the thermalablation of renal masses. Mainly a hand-held extracorporeal ultrasound device with US B-mode imaging for guidance or alaparoscopic approach was used. Disadvantages are i.e. the lack of respiratory motion compensation, no real-time visualization ofenergy deposition, and the complexity of the probe positioning. Alternatively, feasibility of MR-HIFU interventions on the kidney withrespect to motion compensated real-time thermometry and acoustic energy delivery was established, recently.

Participants

LEARNING OBJECTIVES


VSIO11-18 Percutantous Ablation for T1b Tumors


VSIO11-19 Percutantous Ablation for Angiomyolipomas


ParticipantsThomas D. Atwell, MD, Rochester, MN (Presenter) Nothing to Disclose

LEARNING OBJECTIVES


ParticipantsFred T. Lee JR, MD, Madison, WI (Presenter) Stockholder, NeuWave Medical, Inc; Patent holder, NeuWave Medical, Inc; Board ofDirectors, NeuWave Medical, Inc ; Patent holder, Medtronic, Inc; Inventor, Medtronic, Inc; Royalties, Medtronic, Inc

LEARNING OBJECTIVES


RC107

Renal Cell Carcinoma: How Imaging Can Be Used to Select among Treatment Options and Monitor Response

Sunday, Nov. 29 2:00PM - 3:30PM Location: N227

GU


ParticipantsErick M. Remer, MD, Cleveland, OH, ([email protected]) (Coordinator) Nothing to DiscloseSteven S. Raman, MD, Santa Monica, CA (Presenter) Nothing to DiscloseRaghunandan Vikram, MBBS, FRCR, Houston, TX (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) The attendee will learn how imaging can be used to predict renal tumor subtype and grade. 2) Imaging findings that guide renaltumor management toward percutaneous tumor ablation, partial, and radical nephrectomy will be described. 3) The use of imagingto evaluate patients after tumor ablation and nephrectomy will be reviewed. Assessment methods will be compared andcomplications will be illustrated. 4) Methods for assessing tumor response after chemotherapy such as RECIST, WHO, Choi /Modified Choi, SACT, and MASS criteria will be discussed with illustrative examples. Imaging appearances of post therapycomplications will be reviewed.

ABSTRACT

Honored Educators


Raghunandan Vikram, MBBS, FRCR - 2012 Honored Educator

RC110A Uterus and Endometrium

RC110B Ovarian Masses

RC110C Endometriosis

RC110

Gynecologic Ultrasound (An Interactive Session)

Sunday, Nov. 29 2:00PM - 3:30PM Location: E353B

GU OB US


Participants

Sub-Events

ParticipantsRuth B. Goldstein, MD, San Francisco, CA (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 torecognize a uterine abnormality in a postmenopausal woman that warrants further evaluation including tissue sampling or MRI. 3) Beable to recognize and diagnose adenomyosis.

Active Handout:Ruth Beth Goldstein

http://abstract.rsna.org/uploads/2015/15001988/RC110A.pdf

ParticipantsPhyllis Glanc, MD, Toronto, ON (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) Evaluate critical ultrasound features of adnexal masses that permit stratification into benign, indeterminate or suspicious formalignancy. 2) Incorporate the role of guidelines, consensus statements, risk prediction algorithms and serum biomarkers. 3)Consider the role of alternate imaging modalities such as MRI, CT, PET-CT. 4) Utilize appropriate management strategies.

ABSTRACT

There remains a gap between the state of the knowledge and translation into practice for the diagnosis and management ofadnexal masses. Pelvic ultrasound remains the primary imaging modality in the greater majority of cases. Most ovarian masses canbe correctly classified on the basis of their ultrasound characteristics, nonetheless many masses that are 'almost certainly benign'or even 'indeterminate' come to prompt surgical exploration, which is not always apprpriate or without its potential risks.. Thissession will explore further these characteristic findings but also will evaluate the role of serial ultrasound, additional modalities suchas MR or CT, serum biomarkers, strategies such as IOTA simple rules and optimization of referral patterns.

Active Handout:Phyllis Glanc

http://abstract.rsna.org/uploads/2015/15001989/RC110B.pdf

ParticipantsLuciana P. Chamie, MD, PhD, Sao Paulo, Brazil (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) Define clinical and epidemiological aspects of endometriosis. 2) Define the importance of imaging mapping for endometriosisbefore clinical counseling. 3) Apply the most appropriate technique to investigate endometriosis. 4) Define the bowel preparationrequired for the transvaginal ultrasound to investigate endometriosis. 5) Apply the imaging algorithm to map deeply infiltrativeendometriosis. 6) Assess the ultrasonographic findings of deeply infiltrative endometriosis in the most common sites such asbladder, vesicouterine pouch, retrocervical space, vagina, ureters, appendix and rectosigmoid colon. 7) Assess the ultrasonographicfindings of ovarian endometriomas and differentiate them from functional cysts.

ABSTRACT

Endometriosis is a very common gynecological disease affecting millions of women in their reproductive life, often causing pelvicpain and infertility. Clinical history and physical examination may suggest endometriosis, but imaging mapping is necessary toidentify the disease and mandatory for clinical couseling and surgical planning. Transvaginal ultrasound after bowel preparation isthe best imaging modality as the first-line technique to evaluate patients suspected of endometriosis. The bowel preparation isrelatively simple and include the day before and the day of the examination. This method is highly accurate to identify intestinalendometriosis and to determine which layers of the bowel wall are affected. In addition, it provides better assessment of smallperitoneal lesions of the retrocervical space, vagina and bladder. Pelvic adhesions can also be evaluated during the exam.

URL

http://chamie.com.br/download

Active Handout:Luciana Pardini Chamie

http://abstract.rsna.org/uploads/2015/15001990/Active RC110C.pdf

RC113-01 Fetal MRI of Genitourinary Tract Abnormalities


RC113-02 Novel Nanoparticle Gd Contrast Agent Does Not Penetrate the Placental Barrier


RC113-03 Normal and Abnormal Development of the Cerebellar Vermis - A Quantitative Fetal MRI Study

RC113

Pediatric Series: Fetal/Neonatal


GU OB MR PD


ParticipantsDaniela Prayer, MD, Vienna, Austria (Moderator) Nothing to DiscloseAmy R. Mehollin-Ray, MD, Houston, TX, ([email protected]) (Moderator) Nothing to Disclose

Sub-Events

ParticipantsAnn M. Johnson, MD, Philadelphia, PA, ([email protected]) (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) Learn basic fetal MRI techniques and relevent embryology. 2) Understand what fetal MRI can add in evaluation of genitourinary(GU) abnormalities. 3) Become familiar with patterns of fetal GU abnormalities with an emphasis on complex lesions affecting multipleorgan systems, such as cloacal malformation spectrum and exstrophy. 4) The purpose of the course is to understand the potentialrole of fetal MRI in the evaluation of fetal genitourinary tract abnormalities. There will be an emphasis on complex lesions affectingmultiple organ systems, such as cloacal malformation spectrum and exstrophy.

ParticipantsAnil N. Shetty, PhD, Houston, TX (Presenter) Nothing to DiscloseKetan B. Ghaghada, PhD, Houston, TX (Abstract Co-Author) Nothing to DiscloseRobia Pautler, PhD, Houston, TX (Abstract Co-Author) Nothing to DiscloseWesley Lee, MD, Houston, TX (Abstract Co-Author) Research support, General Electric Company Research support, KoninklijkePhilips NV Research support, Siemens AG Research support, Samsung Electronics Co Ltd Haijun Gao, PhD, Houston, TX (Abstract Co-Author) Nothing to DiscloseChandra Yallampalli, DVM,PhD, Houston, TX (Abstract Co-Author) Nothing to DiscloseDavid Rendon, PhD, Houston, TX (Abstract Co-Author) Nothing to DiscloseAnanth Annapragada, PhD, Houston, TX (Abstract Co-Author) Stockholder, Marval Pharma Ltd Stockholder, Alzeca Biosciences LLCStockholder, Sensulin LLC Stockholder, Abbott Laboratories Stockholder, Johnson & Johnson

PURPOSE

Gd contrast agent usage in placental imaging is generally contraindicated, for concerns related to fetal contrast agent exposure.We therefore developed a A novel liposomal Gd nanoparticle contrast agent for T1-MRI, retaining the Gd on the maternal side, thusshielding the fetus from potential toxicities. In this study, we tested this agent in placental imaging in a mouse model, andmeasured its transplacental permeability.


Female C57BL/6 mice, pregnant at gestational age E16.5±1 days, were imaged by T1-MRI on a 9.4T small animal MRI (BrukerInstruments) using a conventional contrast agent (Multihance, a meglumine salt of Gd-BOPTA chelate) (13 mice) and using thenovel nanoparticle Gd agent (9 mice). DCE-MRI was conducted using consecutive 3D-SPGRE sequences at a constant flip angle of16°, TE/TR=1.93ms/6ms, FOV = 3x3x2.5cm, matrix = 128x128x16. Each image was converted to a T1 map, and the contrast agentconcentration on a pixel-by-pixel basis, estimated from the known relaxivity. After imaging, the mice were sacrificed and the Gdcontent of the placenta and fetus measured using ICP-AES.

RESULTS

Image and data shown below are representative of each cohort. The placentae are rather small (2mmx3mm) but are still clearlydefined, and obviously not invasive into the uterine wall. Signal intensities in the placental and fetal ROI's, indicative of Gdconcentration in each compartment, clearly show that the conventional Gd chelate agent penetrates the placental barrier andenters the fetus. The nanoparticle agent however, does not do so, indicated by zero signal in the fetal compartment throughoutthe duration of this experiment. The ICP-AES study confirmed the imaging study results, with no detectable Gd in the fetalcompartment. A separate study in human placentae using an ex vivo perfused placenta preparation, also confirmed these results.

CONCLUSION

The nanoparticle contrast agent does not penetrate the placental barrier in a mouse model. The data are consistent with separatetests on a perfused human placenta model.


The incidence of placenta accreta has increased 8-fold in the last 30 years, and improved methods for placental imaging are sorelyneeded. Nanoparticle Gd contrast agents described in this work could be useful for placental imaging, while maintaining fetal safety.


RC113-04 MRI-US Fusion Imaging in Real-Time Virtual Sonography for the Evaluation of Fetal Anomalies:Preliminary Stud


ParticipantsGregor Kasprian, MD, Vienna, Austria (Presenter) Nothing to DiscloseGregor Dovjak, Vienna, Austria (Abstract Co-Author) Nothing to DisclosePeter C. Brugger, MD, PhD, Vienna, Austria (Abstract Co-Author) Nothing to DiscloseGerlinde Gruber, Vienna, Austria (Abstract Co-Author) Nothing to DiscloseGeorg Langs, Vienna, Austria (Abstract Co-Author) Nothing to DiscloseMichael Weber, Vienna, Austria (Abstract Co-Author) Nothing to DiscloseErnst Schwartz, MSc, Vienna, Austria (Abstract Co-Author) Nothing to DiscloseDieter Bettelheim, Vienna, Austria (Abstract Co-Author) Nothing to DiscloseDaniela Prayer, MD, Vienna, Austria (Abstract Co-Author) Nothing to Disclose

PURPOSE

Postnatal neurodevelopmental outcome of fetuses with hindbrain malformations is dependent on normal growth and development ofthe cerebellar vermis. This comparative in vivo and post mortem fetal MRI study aims to quantitatively assess the relativedimensions of respective vermian lobules between 18 to 32 gestational weeks (GW) in normal and pathological conditions.


75 fetuses (18-32 GW, mean 25.7GW) with normal brain development and 20 fetuses with different types of hindbrain malformationswere scanned prenatally (1.5T, T2-TSE, voxel size 0.72/0.72/4.4mm - 1.0/1.0/4.4mm) and seven fetuses (16-30GW, mean 21.9GW,3T, CISS sequence, resolution: 0.33/0.33/0.33mm) scanned within 24 hours postmortem were selected for postprocessing. A T2-weighted midline sagittal slice was identified and 2D vermian segmentation was performed using ITK snap (Figure).

RESULTS

The mean proportional size of 7/9 discriminable vermian lobules did not differ between in vivo and post mortem measurements. Therelative size of the following lobules increased during gestation (Pearson, p<0.05): Culmen (r²=.460) and Declive/Folium/Tuber(r²=.453). The proportions of Lingula (r²=-.439), Centrum (r²=-.554), Pyramis (r²=-.303) and Nodulus (r²=-.491) decreased withgestational age. The relative size of the Uvula did not show age specific changes (p=.201). Certain types of hindbrainmalformations showed common patterns of cerebellar lobular hypoplasia.

CONCLUSION

Fetal vermian lobulation can be accurately assessed by MRI between 18 and 32GW in normal and pathological conditions in vivo .Growth of specific vermian lobules is nonuniform during the second and third trimester. Distinct patterns of vermian lobularhypoplasia can be described antenatally.


Knowledge about the distinct growth patterns of specific vermian lobules is helpful in the prognostic classification of fetal hindbrainmalformations.

ParticipantsSilvia Bernardo, MD, Rome, Italy (Presenter) Nothing to DiscloseValeria Vinci, MD, Rome, Italy (Abstract Co-Author) Nothing to DiscloseMatteo Saldari, MD, PhD, Rome, Italy (Abstract Co-Author) Nothing to DiscloseAntonella Giancotti, Rome, Italy (Abstract Co-Author) Nothing to DiscloseCarlo Catalano, MD, Rome, Italy (Abstract Co-Author) Nothing to DiscloseLucia Manganaro, MD, Rome, Italy (Abstract Co-Author) Nothing to DiscloseCamilla Aliberti, Rome, Italy (Abstract Co-Author) Nothing to Disclose

PURPOSE

Magnetic resonance imaging (MRI) and ultrasound (US) scanning complement each other in the screening and diagnosis of fetalanomalies. Real-time virtual sonography (RVS) is a new technique that uses magnetic navigation and computer software for thesynchronized display of real-time US and multiplanar reconstruction MRI images. The purpose of this study was to evaluate thefeasibility and ability of RVS to assess the main pathologies in fetuses with suspected US anomalies.


This study was conducted over a two-month period march-april 2015 in 30 patients referred for a morphological fetal US-basedevaluation. Patients undergone Fetal MRI at 1.5 T for fetal anomalies were offered fusion imaging (Hitachi HI Vision Ascendus).TheMRI image dataset acquired at the time of the examination was loaded into the fusion system and displayed together with the USimage on the same monitor. Both sets of images were then manually synchronized and image were registered using multiple planesMR imaging.The ability of this combined image (RVS imaging) to assess the main anatomical sites and fetal anomalies was evaluatedand compared with standard B-Mode US and MRI images previously acquired.

RESULTS

In all cases RVS was technically possible, with a 100% match between MR images and US images. Data registration, matching andfusion imaging were performed in less than 15-20 minutes. On a total of 30 fetuses, 20 were for the encephalic district and 10 forthe body (8 thoraco- abdominal; 2 heart). In all cases RVS was technically possible, with a 100% match between MR images andUS images. In 10 cases of body abnormalities, fusion imaging helped the diagnosis in 20%. In the 10/20 cases of encephalicpathology, fusion imaging improved the diagnosis; in the other 10 cases MRI was superior to US even using the RVS.

CONCLUSION

The present work is a preliminary study on the feasibility and practical use of a Fetal MRI-US real-time fusion imaging. Thanks to

RC113-05 Predictive Value of the MRI-based Ratio of Fetal Lung Volume to Fetal Body Volume in CongenitalDiaphragmatic Hernia in Comparison to the MR Fetal Lung Volume and the Sonographic Lung-to-HeadRatio


RC113-06 Correlation between Fetal and Postmortem Magnetic Resonance Imaging and Conventional Autopsyin the Detection of Fetal Abnormalities


informations from both US and MRI, fusion imaging allows better identification of the different fetal pathologies and could improvethe performance of ultrasound examination.


Fusion imaging is feasible for the assessment of fetal abnormalities. Because it combines information from both US and MRItechniques, fusion imaging allows better identification of the different fetal pathologies.

ParticipantsClaudia Hagelstein, MD, Mannheim, Germany (Presenter) Nothing to DiscloseSilke von Mittelstaedt, Mannheim, Germany (Abstract Co-Author) Nothing to DiscloseMeike Weidner, Mannheim, Germany (Abstract Co-Author) Nothing to DiscloseChristel Weiss, Mannheim, Germany (Abstract Co-Author) Nothing to DiscloseRegine Schaffelder, MD, Mannheim, Germany (Abstract Co-Author) Nothing to DiscloseThomas Schaible, Mannheim, Germany (Abstract Co-Author) Nothing to DiscloseStefan O. Schoenberg, MD, PhD, Mannheim , Germany (Abstract Co-Author) Institutional research agreement, Siemens AGWolfgang Neff, MD, PhD, Alzey, Germany (Abstract Co-Author) Nothing to Disclose

PURPOSE

To evaluate prognostic accuracy of the MRI-based ratio of fetal lung volume to fetal body volume (MR-FLV/FBV) in fetuses withcongenital diaphragmatic hernia (CDH) and to compare it to established prognostic parameters (the observed-to-expected MR fetallung volume [o/e-MR-FLV] and the US-based observed-to-expected lung-to-head ratio [o/e-LHR]) with regard to survival,extracorporeal membrane oxygenation (ECMO) requirement and development of a chronic lung disease (CLD).


Fetal MRI was performed in 132 patients with isolated CDH (mean gestational age 32.8±3.8 weeks) to measure FLV and FLV/FBV.Sonographic assessment of the LHR was performed within three days before or after fetal MRI. To obtain parameters that wereindependent from gestational age, the o/e-MR-FLV and the o/e-LHR were calculated based on normal controls, whereas calculationof the MR-FLV/FBV is independent from normal controls.

RESULTS

91% of the neonates survived, 37% needed ECMO therapy and 45% developed a CLD. All prenatal parameters revealed an excellentcorrelation with patients´ clinical outcome. MR-FLV/FBV, o/e-MR-FLV and o/e-LHR were significantly higher in survivors (p always<0.0001). Patients with ECMO requirement and patients with CLD showed a significantly lower MR-FLV/FBV, o/e-MR-FLV or o/e-LHR(p always <0.0001). Prognostic accuracy regarding survival was quite similar for the three parameters (AUC MR-FLV/FBV : 0.830,AUC o/e-MR-FLV : 0.868, AUC o/e-LHR : 0.845). Regarding ECMO requirement (AUC MR-FLV/FBV : 0.844, AUC o/e-MR-FLV : 0.843,AUC o/e-LHR : 0.736) and development of CLD (AUC MR-FLV/FBV : 0.778, AUC o/e-MR-FLV : 0.795, AUC o/e-LHR : 0.738) the MR-FLV/FBV and o/e-MR-FLV showed a slightly better prognostic accuracy compared to the o/e-LHR.

CONCLUSION

In CDH, assessment of pulmonary hypoplasia based on the MR-FLV/FBV, the o/e-MR-FLV or the o/e-LHR is quite similar in predictingsurvival. Regarding ECMO requirement and development of CLD, the o/e MR-FLV and the MR-FLV/FBV showed a slightly betterprognostic accuracy compared to the US-based o/e-LHR. Compared to other prognostic parameters, MR-FLV/FBV has theadvantage of being independent from the reference to a normal control group.


In CDH, MRI-based MR-FLV/FBV and o/e-MR-FLV as well as US-based o/e-LHR are excellent and almost equivalent parameters topredict survival, ECMO-requirement and development of CLD.

ParticipantsMatteo Saldari, MD, PhD, Rome, Italy (Abstract Co-Author) Nothing to DiscloseSilvia Bernardo, MD, Rome, Italy (Presenter) Nothing to DiscloseCarlo Catalano, MD, Rome, Italy (Abstract Co-Author) Nothing to DiscloseValeria Vinci, MD, Rome, Italy (Abstract Co-Author) Nothing to DiscloseLucia Manganaro, MD, Rome, Italy (Abstract Co-Author) Nothing to Disclose

PURPOSE

To compare Fetal and postmortem MRI and conventional autoptic findings in cases of major pathological abnormalities.


In this prospective study we enrolled 128 fetuses with identified US findings of severe fetal malformations, with local researchethics committee approval. Among these, we performed 94 whole body Fetal MRI on 94 fetuses using a 1.5 T MR scanner and ofthese, only 89 women undewent termination of pregnancy because of the fetal abnormalities. Of the 89 patients, 80 (90%)consented to postmortem MRI alone; 59 (66%) women consented to both postmortem MRI and conventional autopsy and formedour study group. Following delivery, fetuses were stored in refrigerated compartments prior to MR imaging and autopsy. Also for thepost-mortem imaging evaluation we acquired whole body MR imaging using a 1.5 T MR scanner. MR images were reviewed by a teamof two radiologists blinded to the autoptic data. Pathologists who performed conventional autopsy were blinded to the MR data;autoptic data were considered the gold standard.

RC113-07 Imaging of Ambiguous Genitalia


RESULTS

Final autoptic diagnoses were: polycystic kidney disease (n=15), diaphragmatic hernia (n=10), lissencephaly (n=4), type-2 Arnold-Chiari malformation (n=6), Dandy-Walker syndrome (n=13), cloacal malformation (n=1), anencephaly (n=1), holoprosencephaly(n=4), rhombencephalosynapsis (n=2), Walker-Warburg syndrome (n=2), schizencephaly (n=1).MRI-autopsy provided additionalinformation in 10/59 (17%) compared to fetal MRI.In 6 cases (10%) conventional autopsy provided superior diagnostic informationcompared to MRI-autopsy. On the other hand, in 7 cases (12%) the disruption of the anatomy during autoptic dissection of thefetal body couldn't allow a correct identification of the pathology.

CONCLUSION

MR autopsy is accepted by nearly all mothers while conventional autopsy is accepted by about two-thirds of mothers, it providessimilar information compared to conventional autopsy in case of fetal malformations and it allows the evaluation of the pathology incase of tissue disruption during the autoptic evaluation.


Fetal MRI can add significant additional information and may be use to guide conventional autopsy

ParticipantsJeanne S. Chow, MD, Boston, MA (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) The purpose of this course is to understand the important role of the radiologists in infants with ambiguous genitalia. Imagingtechniques as well as important imaging findings will be detailed.

ABSTRACT

PS12A Report of the RSNA Research and Education Foundation

PS12B Image Interpretation Session

PS12

Sunday Afternoon Plenary Session

Sunday, Nov. 29 4:00PM - 5:45PM Location: Arie Crown Theater

CH GI GU MK NR ER


ParticipantsRonald L. Arenson, MD, San Francisco, CA (Presenter) Nothing to Disclose

Sub-Events

ParticipantsBurton P. Drayer, MD, New York, NY (Presenter) Advisor, Hologic, Inc

Abstract

The RandE Foundation - Our Future is Now This year marks the 100th anniversary of the RSNA's founding. As radiology looks towardthe future, one wonders what the next 100 years will look like for our specialty and whether the central role of radiologists inhealthcare will be sustained. Analogous to our clinical radiology mantra, if we are not at the radiology research table we will be onthe menu. As a leading global force in radiology, the RSNA is poised to lead the specialty into the next century and exceed theincredible success of the past 100 years. The RandE Foundation will play a key role in radiology's future by continuing its support ofinspiring investigators and those pursuing innovative approaches to education. To meet these research and education needs head-on, the Foundation launched Inspire-Innovate-Invest, The Campaign for Funding Radiology's Future® at last year's annual meeting.This bold campaign seeks to raise $17.5 million to fund grants in radiologic research and education, bridging the gaps in funding forpromising investigators and educators. To date our campaign has been a success with individuals, private practice and corporatedonors generously pushing us to the mid-way point in our goal. There is still a long way to go. The future of our specialty dependson the commitment and generosity of each of us, the members of the imaging community. This year, the Foundation will fund 92grants totaling $3.6 million. The RandE is funding 25% of our ever increasing number of excellent grant applications. While pleasedwith these achievements, imagine what the RandE Foundation could fund with additional support from all of us as radiologycolleagues? During the meeting week, please take time to visit the RandE Foundation Booth, located on Level 3 of Lakeside Centerto learn more about how you can be a part of the campaign and support the RandE Foundation and the future robustness of ourspecialty.

ParticipantsJonathan B. Kruskal, MD, PhD, Boston, MA (Presenter) Author, UpToDate, IncDonald P. Frush, MD, Durham, NC (Presenter) Nothing to DiscloseBruce B. Forster, MD, Vancouver, BC (Presenter) Travel support, Siemens AG; Travel support, Toshiba Corporation; Christine M. Glastonbury, MBBS, San Francisco, CA (Presenter) Author with royalties, Reed ElsevierMichelle M. McNicholas, MD, Dublin, Ireland (Presenter) Nothing to DiscloseMelissa L. Rosado De Christenson, MD, Kansas City, MO (Presenter) Author, Thieme Medical Publishers, Inc; Author, Reed Elsevier;Author, American Registry of Pathology; Author, Oxford University Press; ; ; ; Jorge A. Soto, MD, Boston, MA (Presenter) Nothing to Disclose

Honored Educators


Melissa L. Rosado De Christenson, MD - 2012 Honored EducatorJorge A. Soto, MD - 2013 Honored EducatorJorge A. Soto, MD - 2014 Honored EducatorJorge A. Soto, MD - 2015 Honored EducatorJonathan B. Kruskal, MD, PhD - 2012 Honored Educator

ED006-MO

Genitourinary Monday Case of the Day

Monday, Nov. 30 7:00AM - 11:59PM Location: Case of Day, Learning Center

GU



TEACHING POINTS


Honored Educators



SPSH20A PET/MRI of Gynecological Malignancies

SPSH20B Imaging of Prostate Cancer: Potential of PET/MRI with Tracers beyond FDG

SPSH20C Hyperpolarized 13C MR Clinical Trials of Prostate Cancer

SPSH20

Hot Topic Session: PET/MR and Hyperpolarized MR for GU Imaging

Monday, Nov. 30 7:15AM - 8:15AM Location: E450B

GU MR NM OI

AMA PRA Category 1 Credit ™: 1.00ARRT Category A+ Credit: 1.00

ParticipantsZhen J. Wang, MD, Hillsborough, CA, ([email protected]) (Moderator) Nothing to Disclose

LEARNING OBJECTIVES

1) To become familiar with current PET-MR imaging strategies. 2) To learn the current and future applications of PET-MR ingenitourinary oncology including gynecological cancers and prostate cancer. 3) To understand the principles of hyperpolarizedcarbon-13 MR metabolic imaging 4) To learn the clinical utility of hyperpolarized carbon-13 MR for measuring prostate canceraggressiveness and response to therapy

ABSTRACT

URL

Sub-Events

ParticipantsRaj M. Paspulati, MD, Cleveland, OH (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) PET-MRI protocol and workflow for Gynecological cancer. 2) Role of PET-MRI in Gynecological cancer staging, treatment planningand follow up for treatment response. 3) PET-MR Imaging pit falls and limitations.

ParticipantsMatthias Roethke, MD, Heidelberg, Germany (Presenter) Speaker, Siemens AG

LEARNING OBJECTIVES


Handout:Matthias Roethke

http://abstract.rsna.org/uploads/2015/15006404/Roethke Prostate RSNA handout.pdf

ParticipantsJohn Kurhanewicz, PhD, San Francisco, CA (Presenter) Nothing to Disclose

LEARNING OBJECTIVES


MSCM21A Musculoskeletal MRI of the Hip and Pelvis

MSCM21B MRI of Soft Tissue Masses of the Extremities

MSCM21C MRI of the Liver

MSCM21D MRI of the Female Pelvic Organs

MSCM21

Case-based Review of Magnetic Resonance (An Interactive Session)

Monday, Nov. 30 8:30AM - 10:00AM Location: S100AB

GI GU MK MR


ParticipantsJohn R. Leyendecker, MD, Dallas, TX (Director) Nothing to Disclose

LEARNING OBJECTIVES

1) Be familiar with the MRI appearance of common musculoskeletal derangements of the hip. 2) Develop a differential diagnosis formusculoskeletal soft tissue tumors based on MRI appearance. 3) Distinguish between common benign and malignant liver neoplasms.4) Be familiar with the typical MRI appearance of select female pelvic disorders.

ABSTRACT

This session will help attendees recognize and manage select, commonly encountered musculoskeletal and abdominopelvicabnormalities based on their MRI appearances using a case-based, interactive format.

Sub-Events

ParticipantsMini N. Pathria, MD, San Diego, CA (Presenter) Nothing to Disclose

LEARNING OBJECTIVES


Active Handout:Mini Nutan Pathria

http://abstract.rsna.org/uploads/2015/15002720/Active -MSCM21A.pdf

ParticipantsKirkland W. Davis, MD, Madison, WI, ([email protected]) (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) Distinguish characteristic extremity soft tissue masses on the basis of signal characteristics, such as high signal on T1-weightedimages or low signal on all sequences.

ABSTRACT

ParticipantsNicole M. Hindman, MD, New York, NY, ([email protected]) (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) Recognize and analyze benign but unusual liver lesions. 2) Analyze uncommon presentations of liver lesions. 3) Recognizeneoplastic mimics of benign lesions in the liver (eg, a colon metastasis mimicking a hemangioma) .

ABSTRACT

This session will cover common and uncommon presentations of liver lesions on several modalities (ultrasound, CT and MRI). A briefinteractive review of common, but atypical presentations of both benign and malignant liver lesions will be presented. Malignantmimics of benign liver lesions will also be shown, with features that should be analyzed in order to better characterize the lesion,and appropriately raise concern (eg, for a metastasis or intrahepatic cholangiocarcinoma instead of a benign hemangioma). Recentadvances in liver lesion characterization will be covered.

ParticipantsChristine O. Menias, MD, Scottsdale, AZ, ([email protected]) (Presenter) Nothing to Disclose

LEARNING OBJECTIVES


Honored Educators

Presenters or authors on this event have been recognized as RSNA Honored Educators for participating in multiple qualifyingeducational activities. Honored Educators are invested in furthering the profession of radiology by delivering high-quality

educational content in their field of study. Learn how you can become an honored educator by visiting the website at:https://www.rsna.org/Honored-Educator-Award/

Christine O. Menias, MD - 2013 Honored EducatorChristine O. Menias, MD - 2014 Honored EducatorChristine O. Menias, MD - 2015 Honored Educator

MSRO21

BOOST: Gynecology-Oncology Anatomy - Radiologic Evaluation of Pelvic Malignancies in the Era of ImagingBiomarkers (An Interactive Session)

Monday, Nov. 30 8:30AM - 10:00AM Location: S103AB

GU BQ RO



ParticipantsSaurabh Gupta, MD, Milwaukee, WI (Presenter) Nothing to DiscloseRobert S. Hellman, MD, Milwaukee, WI (Presenter) Nothing to DisclosePaul M. Knechtges, MD, Milwaukee, WI (Presenter) Nothing to DiscloseMark D. Hohenwalter, MD, Milwaukee, WI (Presenter) Nothing to DiscloseBeth A. Erickson, MD, Milwaukee, WI (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) Review uterine/cervical anatomy and current anatomic imaging methods for the evaluation of pelvic malignancy. 2) Review thecurrent role of PET in the imaging of pelvic malignancy. 3) Discuss the growing role of imaging biomarkers ( e.g. diffusion weightedimaging and perfusion imaging) in determining prognosis and treatment response for pelvic malignancies.

RC207-01 Intro to Prostate Cancer

Monday, Nov. 30 8:30AM - 8:55AM Location: N227

RC207-02 Detection and Characterization of Prostate Cancer with Multiparametric MRI (mpMRI): Do Learningand Experience Matter for Diagnostic Accuracy?


RC207

Genitourinary Series: Prostate MR 2015: Current Role in Staging and Surveillance and Intervention

Monday, Nov. 30 8:30AM - 12:00PM Location: N227

GU MR OI



ParticipantsPeter L. Choyke, MD, Rockville, MD, ([email protected]) (Moderator) Researcher, Koninklijke Philips NV Researcher, General ElectricCompany Researcher, Siemens AG Researcher, iCAD, Inc Researcher, Aspyrian Therapeutics, Inc Researcher, ImaginAb, IncResearcher, Aura Biosciences, Inc

LEARNING OBJECTIVES

1) To understand why prostate cancer is currently under- and over-diagnosed. 2) To understand the role of multiparametricprostate MRI in guiding biopsy of the prostate. 3) To understand the role in the diagnosis, surveillance and recurrence of cancer. 4)To review current progress in the focal treatment of prostate cancer.

ABSTRACT

The paradox of prostate cancer is that it is currently being overdiagnosed and underdiagnosed. PSA and blind biopsy has resulted inthe overtreatment of men with low risk disease and the undertreatment of men with intermediate high risk tumors that evade blindbiopsy. Multiparametric MRI is a major breakthrough in the diagnosis of prostate cancer. Moreover it can be used to monitorpatients for active surveillance and guide treatment. New standards for reporting of prostate MRI have been recently development.This course will not only review these important developments but will provide new research results to participants.

Sub-Events

ParticipantsPeter L. Choyke, MD, Rockville, MD, ([email protected]) (Presenter) Researcher, Koninklijke Philips NV Researcher, General ElectricCompany Researcher, Siemens AG Researcher, iCAD, Inc Researcher, Aspyrian Therapeutics, Inc Researcher, ImaginAb, IncResearcher, Aura Biosciences, Inc

LEARNING OBJECTIVES

1) To understand the limitations of PSA screening and random prostate biopsy. 2) To introduce the concepts of novel screeningtests and genomic analysis of prostate biopsies. 3) To review the importance of MRI in improving tumor localization, guiding biopsy,monitoring active surveillance and focally ablating prostate cancer.

ABSTRACT

See overview abstract

ABSTRACT

The diagnosis of prostate cancer is evolving quickly. There is increasing recognition that the combination of routine PSA screeningand random prostate biopsy overdiagnoses low grade disease and underdiagnoses high grade disease. Autopsy studies show thatthe normal prostate harbors many low grade and microscopic cancers that never becomes clinically apparent. On the other hand,random biopsies undersample the anterior prostate gland. More accurate screening tests (e.g. PCA-3) are under development fordetermining which men warrant biopsy. Genomic testing of prostate biopsy samples is also becoming more common and it is thoughtto improve the prediction of tumor aggressiveness. The increased use of genomics to guide therapy clearly requires that the biopsysample be representative of the tumor. MR guided biopsies, whether performed in gantry or using MR-US fusion, will improve thequality of the prostate biopsy specimen enabling more accurate genomic testing. Armed with more accurate and reliable tissuediagnosis, more rational decisions regarding active surveillance and/or focal therapy can be made. This course will review advancesin MR guided diagnosis, biopsy and therapy of prostate cancer.

ParticipantsRajan T. Gupta, MD, Durham, NC (Presenter) Consultant, Bayer AG; Speakers Bureau, Bayer AG; Consultant, Invivo CorporationDaniele Marin, MD, Cary, NC (Abstract Co-Author) Nothing to DiscloseBhavik N. Patel, MD,MBA, Durham, NC (Abstract Co-Author) Nothing to DiscloseKirema Garcia-Reyes, MD, Durham, NC (Abstract Co-Author) Nothing to DiscloseKingshuk Choudhury, PhD, Durham, NC (Abstract Co-Author) Nothing to DiscloseLisa M. Ho, MD, Durham, NC (Abstract Co-Author) Nothing to DiscloseTracy A. Jaffe, MD, Durham, NC (Abstract Co-Author) Nothing to DiscloseThomas J. Polascik, MD, Durham, NC (Abstract Co-Author) Nothing to Disclose

PURPOSE

To evaluate effect of dedicated reader education on accuracy/Gleason score estimation of index and anterior prostate cancer(PCa) diagnosis with mpMRI in attending radiologists compared to abdominal imaging fellows.

RC207-04 Abbreviated Prostate MRI (AP-MRI)


RC207-05 The Natural History of Low-grade Prostate Cancer: Lessons from an Active Surveillance Cohort



4 blinded attending abdominal imagers with 2-16 years of experience evaluated 31 prostate mpMRIs in this IRB-approved, HIPAA-compliant, retrospective study for index lesion and anterior PCa detection (including Gleason score estimation). Following dedicatededucation program, readers reinterpreted cases after a 2-4 month memory extinction period, blinded to initial reads. Referencestandard was established combining whole mount histopathology with mpMRI findings by a board-certified radiologist with 5 years ofprostate mpMRI experience. Multivariate analysis was performed to assess the effects of learning and reader experience. Results forattending radiologists were then compared with prior reader study results in radiology fellows (using the same set of cases).

RESULTS

Index cancer detection (attending vs. fellow): pre-education accuracy 64.5% vs. 74.2%; post-education accuracy 71.8% vs.87.7% (p=0.12 vs. p=0.003). Gleason score estimation (index): pre-education accuracy 46.8% vs. 54.8%; post-educationaccuracy 57.3% vs. 73.5% (p=0.04 vs. p=0.0005). Anterior PCa detection: pre-education accuracy 46.4% vs. 54.3%; post-education accuracy 75% vs. 94.3% (p=0.02 vs. p=0.001). Gleason score estimation (anterior): pre-education accuracy 42.9% vs.45.7%; post-education accuracy 67.9% vs. 80% (p=0.03 vs. p=0.002). These effects were all attributable to learning and not toreader experience based on multivariate analysis.

CONCLUSION

Accuracy of anterior PCa detection and Gleason score estimation for both index and anterior cancers significantly increasedfollowing dedicated reader education for both attendings and fellows. In addition, accuracy for index cancers was statisticallysignificantly improved for fellows post-education. The degree of statistically significant improvement was higher for fellows vs.attendings overall.


Performance in detection and characterization of PCa on mpMRI can be improved with dedicated reader education, however, it maybe that the earlier the educational intervention is done, the more significant the improvement.

AwardsRSNA Country Presents Travel Award

ParticipantsRobin Bruhn, Aachen, Germany (Presenter) Nothing to DiscloseSimone Schrading, MD, Aachen, Germany (Abstract Co-Author) Nothing to DiscloseChristiane K. Kuhl, MD, Bonn, Germany (Abstract Co-Author) Nothing to Disclose

PURPOSE

It has recently been shown that an Abbreviated MRI Protocol is suitable for breast cancer screening. Aim of this study was toinvestigate whether an Abbreviated Prostate MRI protocol (AP-MRI), consisting of 2 pulse sequences only (high resolution T2-TSEand DWI in a single plane), acquired without endorectal coil, is sufficient to diagnose prostate cancer (PCa) in men presenting withelevated PSA-levels.


Ongoing prospective reader study on 222 men (mean age 53.6 years) with median PSA of 7.1 who underwent multiparametric 3.0T-MRI with multi-element surface coil. The AP-MRI took a table time of just under 10 min. The full diagnostic protocol (FDP) took 30min and included the pulse sequences of the AP-MRI (0.4 mm in-plane axial T2-TSE and DWI with 4 b-values up to 1400 s/mm²),plus additional T2-TSE planes, coronal T1-TSE, and DCE. All MRI studies were read prospectively by two GU-radiologists inconsensus according to PIRADS 2.0. Readers first read the AP-MR images and made their diagnoses. Then, they read the FDP.Results of MR-guided biopsy, TRUS/saturation biopsy, and/or final surgical pathology, or MRI and PSA follow up of at least 24months served as SOR.

RESULTS

PCa was finally diagnosed in 85/222 men (38.3%), with median size 12 mm, classified as Gleason-6 in 25 patients, Gln-7 in 31, Gln ≥8 in 29. Diagnostic indices of the AP-MRI vs. the FDP were: Sensitivity: 93% (79/85) vs. 94% (80/85); Specificity: 89% (122/137)vs. 87% (120/137); PPV: 84% (79/94) vs. 82% (80/97), NPV: 95% (122/128) vs. 96% (120/125). The single cancer that wentundetected by AP-MRI was a Gln-6-cancer diagnosed by DCE. A total five additional cancers (Gln-6 in 3, and Gln-7 in 2 patients)went undetected by both, AP-MRI and FDP, and were detected by TRUS biopsy. NPV for biologically relevant prostate cancer (>Gln-6) was 98.8% (95%CI: 95.7%-99.9%) for both, AP-MRI and FDP.

CONCLUSION

Abbreviated prostate MRI allows diagnosis of biologically relevant PCa in under 10 minutes magnet time, without endorectal coil andwithout contrast agent, and offers a diagnostic accuracy that is equivalent to that of a full state-of-the-art multi-parametricprostate MRI protocol.


Abbreviated prostate MRI, if confirmed by further studies, may open the door for systematic MRI screening for prostate cancer.

ParticipantsFrancesco Giganti, MD, Milan, Italy (Presenter) Nothing to DiscloseNeophytos Petrides, London, United Kingdom (Abstract Co-Author) Nothing to DiscloseCaroline M. Moore, London, United Kingdom (Abstract Co-Author) Speakers Bureau, Myriad Genetics, Inc; Research Grant,

RC207-06 Multi-parametric MRI (including PIRADS)


RC207-07 Active Surveillance with MRI


GlaxoSmithKline plc; Consultant, STEBA Biotech NVMark Emberton, London, United Kingdom (Abstract Co-Author) Consultant, GlaxoSmithKline plc; Consultant, sanofi-aventis Group;Consultant, Glide Pharmaceutical Technologies Limited; Consultant, SonaCare Medical, LLCClare M. Allen, MBBCh, London, United Kingdom (Abstract Co-Author) Nothing to DiscloseAlex P. Kirkham, BMBCh, MD, London, United Kingdom (Abstract Co-Author) Nothing to Disclose

PURPOSE

To describe the natural history of low-grade prostate cancer by mpMRI changes in patients under active surveillance (AS).


This study had an authorization from our institutional ethics review board. From our database on patients with prostate cancer, atotal of 86 were enrolled in an AS program and had their first mpMRI in 2012 or before. The two reading radiologists, in consensus,knew tumor location and PSA but were blinded to both patient demographics and date of scan. The scans were reported randomly(reducing any bias assuming an increase in size with time). For each visible lesion we measured volume on the sequence bestshowing the tumor (the same for all scans), as well as attributing a score based on the European Society of Uroradiology -ESUR-2012 guidelines.

RESULTS

1. 66/86 patients had Gleason 3+3 and 20/86 Gleason 3+4 tumor. Median maximum cancer core lengths were 1 and 3.5 mm,respectively.2. 38/86 patients did not have a visible lesion on the initial MRI (< 3, ESUR criteria). Of these patients, none haddeveloped at a median of 3.56 years of follow up.3. 40/86 patients had a lesion scoring 3/5 or more (ESUR criteria) on more than 2scans, enabling an estimation of annual growth rate. 25 had Gleason 3+3, and 15 Gleason 3+4. Median monthly increase in volumewas 0.4% for Gleason 3+3 and 1.2% for 3+4 (p=0.049, Mann-Whitney test). No significant difference in the median monthly PSAincrease between these groups (0.9 vs 0.6%, p=0.42) was observed.4. In 38/40 patients having 2 scans separated by a median of1.19 years, 9/38 showed a decrease in lesion size between 5 and 50 %.

CONCLUSION

In a group of men on AS, we never observed development of a convincing lesion in those negative on the first scan. Conversely, itwas possible to measure a growth rate in visible tumors, and it was significantly different for Gleason 3+3 and 3+4. Finally, there isconsiderable inter-scan variability in volume: this must be taken into account when attrbuting a significant increase to a smalllesion.


The significant difference in rate of increase between small tumors of different grades under AS suggests that it is possible tomonitor their size on MRI.

ParticipantsClare M. Tempany-Afdhal, MD, Boston, MA (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) The state of the art mpMR protocols/sequences for prostate cancer imaging. 2) How to acquire and interpret high qualityimages. 3) What ACR-Pi-Rads is and how it can be implemented in clinical practice. 4) Current and future role of Prostate MR andACR- PiRads.

ABSTRACT

The current state of the art approaches to prostate cancer Multi-parametric MR(mpMR) Prostate imaging will be presented. MRItechniques at 1.5T and 3.0T and pulse seqeunce optimization for a state of the art mpMRI exam will be reviewed. The roles of eachseqeunce will be illustrated with clinical case examples to outline technical aspects and interpretative approaches. As theexaminations have become complex and the clinical demands are increasing there isa need for standarization of our techniques andinterpretative reporting. Thus in keeping with Bi-Rads and Li-Rads, we are developing Pi-Rads. The current ACR-PiRads will bereviewed - goals, methods and clinical applications will be presented and future vision for the role of prostate MR and ACR-PiRADSwill be presented

ParticipantsSadhna Verma, MD, Cincinnati, OH (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) What is active surveillance and how it is done. 2) Who is a candidate for active surveillance. 3) The role of mpMRI in riskstratification for active surveillance. 4) The relevance of mpMRI in addition to clinical parameters in disease management.

ABSTRACT

ABSTRACT

Active Surveillance with MRI Active surveillance is increasingly acknowledged as a preferred strategy for most men with low-riskdisease. This lecture will discuss low risk prostate cancer and how it is managed clinically. Role of mpMRI will be reviewed withclinical case examples to show selection, follow- up or possible removal of patients from active surveillance protocols.

Honored Educators

Presenters or authors on this event have been recognized as RSNA Honored Educators for participating in multiple qualifying

RC207-08 Longitudinal Follow-up Study of Prebiopsy Multiparametric MRI with Cancer- Negative Findings inPatients with Suspicious Prostate Cancer: A Single Institution Experience


RC207-09 Magnetic Resonance/Ultrasound (MR/US) Fusion Biopsy in Clinical Practice: Is Systematic Biopsy stillNeeded to Detect Clinically Significant Prostate Cancers?


educational activities. Honored Educators are invested in furthering the profession of radiology by delivering high-qualityeducational content in their field of study. Learn how you can become an honored educator by visiting the website at:https://www.rsna.org/Honored-Educator-Award/


ParticipantsJun Gon Kim, Seoul, Korea, Republic Of (Presenter) Nothing to DiscloseChan Kyo Kim, MD, PhD, Seoul, Korea, Republic Of (Abstract Co-Author) Nothing to DiscloseJung Jae Park, MD, Seoul, Korea, Republic Of (Abstract Co-Author) Nothing to DiscloseByung Kwan Park, MD, Seoul, Korea, Republic Of (Abstract Co-Author) Nothing to Disclose

PURPOSE

Few follow-up studies of prebiopsy prostate multiparametric MRI (mpMRI) with cancer-negative findings have been reported. Theaim of this study was to investigate the chance and characteristics of missing cancers on prebiopsy mpMRI with cancer-negativefindings based on Prostate Imaging Reporting and Data System (PI-RADS) in patients with suspicious prostate cancer (PCa).


584 consecutive patients (mean, 62.7 years; range, 30-86 years) with suspicious PCa who performed initial (n= 391) or repeatedprostate biopsies (n= 193) were enrolled in this retrospective study. All patients underwent prebiopsy 3-T mpMRI including T2-weighted, diffusion-weighted and dynamic contrast-enhanced imaging. Random systemic core biopsies and MR-targeted corebiopsies in cases of cancer-positive MRI findings were performed, while cases with cancer-negative MRI findings underwent randomsystemic core biopsies during subsequent follow-up. Biopsy-based definition of clinically significant cancer (CSC) was Gleason ≥ 3 +4 or Gleason 6 with maximal cancer core length (MCL) ≥ 4 mm. The likelihood of PCa on mpMRI was evaluated based on PI-RADSversion 2: score 4 or 5 was considered cancer positive.

RESULTS

Pathologically the cancers were found in 25% (146/584). The cancer-positive MRI findings were found in 17% (99/584) patientsand of these, 85.9% (85/99) had pathologically cancer cores. Of 485 patients with cancer-negative MRI findings, a total of 61(12.5%) had cancer cores [Gleason 6 (n= 42), 3 + 4 (n= 14), 4 + 3 (n= 2), 8 (n= 2), and 9 (n= 1)]: biopsy-naive patients (n= 38)and patients with negative previous biopsy (n= 23). The mean MCL was 3.4 mm (range, 1-12.6 mm). The CSCs were found in47.5% (29/61). Accordingly cancer-negative MRI findings missed 6% (29/485) CSCs: 4.1% (20/485) in biopsy-naive patients and1.9% (9/485) in patients with negative previous biopsy.

CONCLUSION

Prebiopsy 3-T mpMRI with cancer-negative findings misses approximately 12.5% PCa including 6% CSCs in a cohort of biopsy-naivepatients and patients with negative previous biopsy.


In a cohort of biopsy-naive patients or patients with negative previous biopsy, 3-T multiparametric MRI can improve the detectionof clinically significant prostate cancers, which can help to select optimal treatment strategies.

ParticipantsAndrei S. Purysko, MD, Cleveland, OH (Presenter) Nothing to DiscloseLeonardo K. Bittencourt, MD, PhD, Rio De Janeiro, Brazil (Abstract Co-Author) Nothing to DiscloseAntonio C. Westphalen, MD, Mill Valley, CA (Abstract Co-Author) Nothing to DiscloseAndrew J. Stephenson, MD, Cleveland, OH (Abstract Co-Author) Nothing to DiscloseErick M. Remer, MD, Cleveland, OH (Abstract Co-Author) Nothing to DiscloseBrian R. Herts, MD, Cleveland, OH (Abstract Co-Author) Research Grant, Siemens AGErika Schneider, PhD, Cleveland, OH (Abstract Co-Author) Stockholder, General Electric Company Stockholder, Pfizer IncStockholder, NitroSci Pharmaceuticals, LLCJennifer Bullen, MSc, Cleveland, OH (Abstract Co-Author) Nothing to DiscloseCristina Magi-Galluzzi, MD, PhD, Cleveland, OH (Abstract Co-Author) Nothing to DiscloseEric Klein, Cleveland, OH (Abstract Co-Author) Nothing to Disclose

PURPOSE

To compare the detection rates of clinically significant (CS) prostate cancer (PCa), herein defined as a tumor with Gleason score>= 3 + 4, by MR/US fusion biopsy and systematic extended-sextant TRUS (S-TRUS) biopsy.


IIRB-approved, HIPAA compliant retrospective study included 256 men (mean age: 62.3 yrs.) with either suspected PCa (n = 187)or enrolled on active surveillance (n = 69). All patients underwent multiparametric MRI (mpMRI) of the prostate on a 3.0 T magnetwithout endorectal coil as part of clinical care prior to biopsy, with T2, high B-value diffusion, and dynamic contrast enhancingimaging. Patients with potential tumor by mpMRI (n= 193) underwent MR/US fusion biopsy followed by 12-core systematic biopsy(SB) in the same procedure and performed by the same urologist who was aware of the location of the targets; those withnegative mpMRI underwent SB only (n = 63). The results of both biopsy techniques alone and combined were evaluated.

RESULTS

The overall detection rate of PCa in this population was 51.2% (131/256), and CS PCa was detected in 26.6% (68/256) of the men.

RC207-10 MR and MR-US Guided Biopsy


RC207-11 12 Months Follow-Up Results of MRI-Guided Transurethral Ultrasound Ablation for Treatment ofLocalized Prostate Cancer


The overall detection rate of PCa in this population was 51.2% (131/256), and CS PCa was detected in 26.6% (68/256) of the men.In those with positive mpMRI, there was no significant difference in the number of men with CS PCa detected by either biopsytechnique (MR/US fusion biopsy: 46 men [23.8%]; SB: 48 men [24.9%]), and both techniques combined detected more men withCS PCA (66 men [34.2%]). CS PCa was detected exclusively by MR/US fusion biopsy in 18 men (9.3%), and by SB in 20 men(10.4%). In most men with CS PCa exclusively detected by SB, the sextants involved were the same (n = 14) or the immediatelyadjacent ipsilateral sextant (n = 3) where the MRI target was described; in only 3 men (1.5%) the targets were located in a distantsextant from the site involved by CS PCa. PCa was detected in 28.6% (18/63) of the men with negative mpMRI, but only 2 cases(3.2%) were CS PCa.

CONCLUSION

More CS PCa was detected when MR/US fusion biopsy was combined with SB, with greater contribution from biopsies of the sameor immediately adjacent sextants of the MRI targets.


In clinical practice, MR/US fusion biopsy should be performed in conjunction with systematic biopsy of the same and immediatelyadjacent sextants of MRI-targets to ensure the detection of CS PCa detected by mpMRI.

ParticipantsDaniel J. Margolis, MD, Los Angeles, CA, ([email protected]) (Presenter) Research Grant, Siemens AG

LEARNING OBJECTIVES

1) List the indications for in-bore MR-guided and MR/US fusion-guided prostate biopsy. 2) Optimize the protocol and image post-processing of prostate MRI for lesion detection, selection, and delineation. 3) Understand the differences between in-bore MR-guided and MR/US fusion-guided prostate biopsy. 4) Describe the advantages and disadvantages of the different kinds of MR/USfusion-guided prostate biopsy. 5) Communicate with referrers to ensure all information is processed correctly for the biopsy session.

ABSTRACT

Interest in, and growth of, prostate MRI has been largely driven by increasing use of this technology for lesion detection ratherthan treatment planning. This shift in focus is accompanied by changes in the MRI protocol, and how this information is used. Agrowing number of opportunities for targeted biopsy, both in-bore direct MRI-guided and MRI-ultrasound image fusion targeting, isaccompanied by nearly as many different approaches. Each has advantages and disadvantages, some obvious, and some surprising.Awareness of these issues and how to master them is crucial for providing optimal patient care. These issues range from thehardware and software necessary to plan and perform the biopsy, to the intricacies of information and data communication, toreferral and follow-up. A comprehensive, service-line approach ensures patients are followed appropriately at all stages of thisprocess.

ABSTRACT

Multiparametric MRI has transformed from a tool primarily used for staging of known cancer into one for detection, localization, andsampling of suspected cancer. This has allowed for streamlining and simplifying the protocol use for imaging the prostate, whichpresents its own challenges, including managing decreased signal-to-noise ratios and interfacing with image-guided targeted biopsysoftware and hardware. The various platforms available for image-fusion targeted biopsy include in-bore MRI-directed, "cognitive-"or "mental-fusion" MRI-ultrasound targeted biopsy, software image fusion, articulated arm, and electromagnetic tracking. Attendeeswill learn how to incorporate image-guided targeted biopsy into their practice, how to interface with clinical collaborators andreferrers, and how image-guided targeted biopsy improves confidence in managing men with suspected or known prostate cancer.

URL

http://1drv.ms/1kzFy7W

ParticipantsMaya B. Mueller-Wolf, MD, Heidelberg, Germany (Presenter) Nothing to DiscloseSascha Pahernik, MD, Heidelberg, Germany (Abstract Co-Author) Nothing to DiscloseBoris Hadaschik, Heidelberg, Germany (Abstract Co-Author) Nothing to DiscloseTimur Kuru, MD, Heidelberg, Germany (Abstract Co-Author) Nothing to DiscloseIonel V. Popeneciu, MD, Heidelberg, Germany (Abstract Co-Author) Nothing to DiscloseGencay Hatiboglu, Heidelberg, Germany (Abstract Co-Author) Nothing to DiscloseJoseph Chin, MD, London, ON (Abstract Co-Author) Nothing to DiscloseMichele Billia, MD, London, ON (Abstract Co-Author) Nothing to DiscloseJames D. Relle, MD, West Bloomfield, MI (Abstract Co-Author) Nothing to DiscloseJason M. Hafron, MD, West Bloomfield, MI (Abstract Co-Author) Nothing to DiscloseKiran R. Nandalur, MD, Northville, MI (Abstract Co-Author) Nothing to DiscloseMathieu Burtnyk, DIPLPHYS, Toronto, ON (Abstract Co-Author) Nothing to DiscloseHeinz-Peter Schlemmer, MD, Heidelberg, Germany (Abstract Co-Author) Nothing to DiscloseMatthias Roethke, MD, Heidelberg, Germany (Abstract Co-Author) Speaker, Siemens AG

PURPOSE

MRI-guided transurethral ultrasound ablation (MR-TULSA) is a novel minimally-invasive technology to treat organ-confined prostatecancer (PCa), aiming to provide local disease control with a low side-effect profile. Directional plane-wave high-intensity ultrasoundgenerates a continuous volume of thermal coagulation to the prostate using real-time MR-thermometry control. A prospective,multi-institutional Phase I clinical study investigated safety, feasibility, and assessed efficacy of MR-TULSA treatment for PCa.

RC207-12 A Pilot Study to Evaluate Outpatient, Transrectal, Magnetic Resonance-guided Laser Focal Therapyfor Treatment of Localized Prostate Cancer


RC207-13 Focal Therapies

Monday, Nov. 30 11:35AM - 12:00PM Location: N227


30 patients with biopsy-proven, low-risk prostate cancer were enrolled: age>=65y, T1c/T2a, PSA<=10ng/ml, Gleason<=3+3 (3+4 inCanada only). Under general anaesthesia, the ultrasound device (TULSA-PRO, Profound Medical Inc., Canada) was positioned in theprostatic urethra with guidance from a 3T MRI (Siemens, Germany). Treatment planning was performed under MRI visualization withtherapeutic intent of whole-gland ablation. Treatment was delivered under continuous MRI thermometry feedback control.

RESULTS

MR-TULSA was well-tolerated by all patients without intraoperative complications. Median (5th-9th percentile) treatment time andprostate volume were 36 (24-54) min and 44 (30-89) ml, respectively. Maximum temperature measured during treatment depicted acontinuous region of heating shaped accurately to the prostate to within 0.1 ± 1.3 mm. CE-MRI confirmed the resulting conformalnon-perfused volume, and correlated well with the ablative temperatures on MR-thermometry. Successful treatment was furtherindicated by a median PSA decrease from 5.8 (2.8-8.9) ng/ml to 0.8 (0.1-3.2) ng/ml after one month remaining stable at 0.8 (0.1-3.7) ng/ml to 12 month. MRI and biopsy findings at 12 month show diminutive prostate volumes, averaging 51% fibrosis (n=29).Positive biopsies (55% of patients) demonstrate 61% reduction in total cancer length.

CONCLUSION

MRI-guidance enables accurate treatment planning, real-time dosimetry and control of the thermal ablation volume. Primaryoutcomes show that MR-TULSA is safe and precise for prostate ablation. Phase I data are sufficiently compelling to study MR-TULSA in a larger efficacy trial.


Whole-gland ablation can be safely and accurately achieved using MR-TULSA, which represents a minimally-invasive treatmentoption for organ-confined prostate cancer.

ParticipantsBernadette M. Greenwood, BS, RT, Indian Wells, CA (Abstract Co-Author) Nothing to DiscloseJohn F. Feller, MD, Indian Wells, CA (Presenter) Consultant, Koninklijke Philips NV Consultant, Visualase, Inc Stuart T. May Sr, MD, Indian Wells, CA (Abstract Co-Author) Nothing to DiscloseRoger McNichols, PhD, Houston, TX (Abstract Co-Author) Employee, BioTex, IncWes Jones, Indian Wells, CA (Abstract Co-Author) Nothing to DiscloseAxel Winkel, DiplEng, Schwerin, Germany (Abstract Co-Author) Employee, Koninklijke Philips NV

PURPOSE

In the United States alone, new prostate cancer cases for 2014 were estimated at 233,000 and deaths at 29,480. Focal therapiesfor low risk and intermediate risk localized prostate cancer are increasingly being explored. Our objective is to investigate the safetyand feasibility of using outpatient MR- (magnetic resonance) guided laser focal therapy for MR-visible prostate cancer utilizing atransrectal approach for laser applicator placement and therapy delivery.


All MR-guided therapy was delivered using a 1.5T Philips Achieva XR system (Philips Healthcare, Best, The Netherlands) for bothimage acquisition and real-time thermometry. Follow-up multiparametric MRI's (mpMRI) were performed on the same scanner aswere all follow-up MR-guided prostate biopsies. DynaCAD and DynaLOC (Invivo, Orlando, FL, USA) software were used for imageanalysis and interventional planning. Laser therapy was delivered using a Visualase (BioTex, Houston, TX, USA) 15W 980 nm laserapplicator introduced transrectally using the DynaTRIM (Invivo, Orlando, FL, USA)

RESULTS

34 men were treated. 45 cancer foci were treated. Total procedure time was between 1.5 and 4 hours. MRI volume of coagulationnecrosis ranged from 1.2-5.0cc. No serious adverse events or morbidity were reported. 7 treatment regions were positive at 6month biopsy, consistent with residual/recurrent cancer (23% of subjects, 15% of treated regions). 4 regions were retreated withlaser focal therapy. We observed a 35% decrease in mean PSA 1 year post-therapy and no statistically significant change is IPSSand SHIM scores at 6 months post-treatment. 4 patients went on to whole gland therapy: 3 incidence cancer patients (2 GleasonScore 4+4=8, 1 Gleason Score 4+3=7 multi-focal) elected radical prostatectomy (RP). No additional technical difficulty withdissection was reported by the surgeon performing RP. 1 Gleason 3+3=6 elected proton beam therapy (PBT) before undergoing 6month follow-up and biopsy. Incidence cancer rate was 10%.

CONCLUSION

Our data indicate that outpatient transrectally delivered MR-guided laser focal therapy for localized prostate cancer is both safeand feasible.


In the current climate of cost-reduction and emphasis on minimally-invasive treatment of cancer, focal treatment of prostacecancer with a precisely delivered energy source under MRI-guidance may have favorable results for cost control and quality of life.

ParticipantsAytekin Oto, MD, Chicago, IL, ([email protected]) (Presenter) Research Grant, Koninklijke Philips NV; ; ;

LEARNING OBJECTIVES

1) Emerging paradigm of focal therapy for early stage low risk prostate cancer. 2) Current status of different focal therapy methods

including laser ablation, high intensity focused US, electroporation and cryotherapy. 3) Challenges in patient monitoring followingfocal therapy. 4) Future developments in focal therapy of prostate cancer and the importance of radiologist's involvement.

ABSTRACT

TITLE: Image guided focal therapy of prostate cancer Focal therapy of low risk early stage prostate cancer is increasinglyimportant as a minimally invasive option for many patients. The rationale, patient selection criteria and challenges for image-guidedfocal prostate cancer therapy will be discussed. The essential technical details, advantages and disadvantages of clinicallyavailable focal therapy methods will be reviewed. Post-therapy patient monitoring options will be presented. Future developments inthe area of focal therapy of prostate cancer and opportunities for involvement of radiologists in focal therapy will be explored.

Honored Educators


Aytekin Oto, MD - 2013 Honored Educator

GU210-SD-MOA1

Got Stones? Utility of Kidney Graft Computed Tomography Prior to Transplantation

Station #1

GU213-SD-MOA4

Detection and Characterization of Prostate Cancer with Multiparametric MRI (mpMRI): Do Learningand Experience Matter for Diagnostic Accuracy?

Station #4

GUS-MOA

Genitourinary Monday Poster Discussions

Monday, Nov. 30 12:15PM - 12:45PM Location: GU/UR Community, Learning Center

GU



ParticipantsZhen J. Wang, MD, Hillsborough, CA (Moderator) Nothing to Disclose

Sub-Events

AwardsRSNA Country Presents Travel Award

ParticipantsMonserrat Reig Sosa, MD, Distrito Federal, Mexico (Presenter) Nothing to DiscloseJorge David Magana, MD, Mexico, Mexico (Abstract Co-Author) Nothing to DiscloseCarlos Mendez Probst, MD, Mexico, Mexico (Abstract Co-Author) Nothing to DiscloseJorge Vazquez-Lamadrid, MD, Mexico, Mexico (Abstract Co-Author) Nothing to Disclose

PURPOSE

To allow a complete evaluation of a cadaveric kidney graft prior to transplant To reduce the morbidity in kidney recipients causedby donor nephrolithiasis To encourage the use of non-enhanced kidney graft CT before transplant, and provide a preventivetreatment.


Prospective non-enhanced CT Scanners (Siemens Somatom 64, Munich and GE Lightspeed VCT 64, Milwaukee) ex vivo evaluation ofcadaveric renal allograft transplants from march 2013 through march 2015 in a reference transplant medical center. The protocolsof acquisition included one phase scan with 3 mm thickness cuts and reformatting in 0.6 mm in an overall time of 2 min. After thisthe scan was reviewed by a board certified radiologist evaluating the following: Presence, location, number, size and density(measured in Hounsfield Units) of the urinary stones.

RESULTS

32 cadaveric donors where enrolled in the period of time mentioned (22 males and 8 females), providing a total of 59 kidney grafts.Nine grafts reported stones, multiple stone disease was found in two grafts with 2 and 3 stones respectively, the latestcorresponding to one of the donors with bilateral disease The median kidney stone diameter was 2.8 mm (ED 1.03-3.74mm) with anaverage density of 198.5 HU (ED 51-919 HU) Four of the nine grafts underwent back table retrograde flexible nephroscopy andbasket stone removal while under cold ischemia, three out of these were considered successful; In a single unsuccessful case, a1.2 mm stone could not be located during the intervention, probably because of inadverted flushing The remaining five kidneys weretransplanted with a follow up CT performed 12 months after the transplantation in which four of the patients were negative fornephrolithiasis, the fifth patient corresponding to the horseshoe kidney developed new non obstructive stones under 2 mm diameter

CONCLUSION

This data supports the use of non enhanced MDCT scan kidney graft prior to transplantation to allow an accurate screening for thepresence of nephrolithiasis, rendering a helpful diagnostic tool to prevent further complications associated with nephrolithiasis.


Prevention and oportune tratment in renal ex vivo transplants to improve outcome

ParticipantsRajan T. Gupta, MD, Durham, NC (Presenter) Consultant, Bayer AG; Speakers Bureau, Bayer AG; Consultant, Invivo CorporationDaniele Marin, MD, Cary, NC (Abstract Co-Author) Nothing to DiscloseBhavik N. Patel, MD,MBA, Durham, NC (Abstract Co-Author) Nothing to DiscloseKirema Garcia-Reyes, MD, Durham, NC (Abstract Co-Author) Nothing to DiscloseKingshuk Choudhury, PhD, Durham, NC (Abstract Co-Author) Nothing to DiscloseLisa M. Ho, MD, Durham, NC (Abstract Co-Author) Nothing to DiscloseTracy A. Jaffe, MD, Durham, NC (Abstract Co-Author) Nothing to DiscloseThomas J. Polascik, MD, Durham, NC (Abstract Co-Author) Nothing to Disclose

PURPOSE

To evaluate effect of dedicated reader education on accuracy/Gleason score estimation of index and anterior prostate cancer(PCa) diagnosis with mpMRI in attending radiologists compared to abdominal imaging fellows.


GU214-SD-MOA5

Pathologic Correlation between Transperineal in-bore 3-Tesla MR Imaging-Guided Prostate Biopsyand Radical Prostatectomy

Station #5

GU215-SD-MOA6

Predicting Renal Calculus Composition: Does the Plane of Imaging Matter?

Station #6

4 blinded attending abdominal imagers with 2-16 years of experience evaluated 31 prostate mpMRIs in this IRB-approved, HIPAA-compliant, retrospective study for index lesion and anterior PCa detection (including Gleason score estimation). Following dedicatededucation program, readers reinterpreted cases after a 2-4 month memory extinction period, blinded to initial reads. Referencestandard was established combining whole mount histopathology with mpMRI findings by a board-certified radiologist with 5 years ofprostate mpMRI experience. Multivariate analysis was performed to assess the effects of learning and reader experience. Results forattending radiologists were then compared with prior reader study results in radiology fellows (using the same set of cases).

RESULTS

Index cancer detection (attending vs. fellow): pre-education accuracy 64.5% vs. 74.2%; post-education accuracy 71.8% vs.87.7% (p=0.12 vs. p=0.003). Gleason score estimation (index): pre-education accuracy 46.8% vs. 54.8%; post-educationaccuracy 57.3% vs. 73.5% (p=0.04 vs. p=0.0005). Anterior PCa detection: pre-education accuracy 46.4% vs. 54.3%; post-education accuracy 75% vs. 94.3% (p=0.02 vs. p=0.001). Gleason score estimation (anterior): pre-education accuracy 42.9% vs.45.7%; post-education accuracy 67.9% vs. 80% (p=0.03 vs. p=0.002). These effects were all attributable to learning and not toreader experience based on multivariate analysis.

CONCLUSION

Accuracy of anterior PCa detection and Gleason score estimation for both index and anterior cancers significantly increasedfollowing dedicated reader education for both attendings and fellows. In addition, accuracy for index cancers was statisticallysignificantly improved for fellows post-education. The degree of statistically significant improvement was higher for fellows vs.attendings overall.


Performance in detection and characterization of PCa on mpMRI can be improved with dedicated reader education, however, it maybe that the earlier the educational intervention is done, the more significant the improvement.

ParticipantsErik Velez, BS, San Francisco, CA (Presenter) Nothing to DiscloseChristopher B. Allard, Boston, MA (Abstract Co-Author) Nothing to DiscloseKemal Tuncali, MD, Boston, MA (Abstract Co-Author) Nothing to DiscloseAndriy Fedorov, PhD, Boston, MA (Abstract Co-Author) Nothing to DiscloseAdam Kibel, Boston, MA (Abstract Co-Author) Nothing to DiscloseClare M. Tempany-Afdhal, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose

PURPOSE

To evaluate the accuracy of in-bore transperineal 3-Tesla (T) magnetic resonance (MR) imaging-guided prostate biopsies forpredicting final Gleason grades among patients who underwent radical prostatectomy (RP).


We reviewed the records of 214 men who underwent transperineal MR imaging-guided biopsy (tpMRGB) from 2010-2015. All patientsreceived a baseline scan using 3-T multiparametric MRI (mpMR) with endorectal coil and were selected for biopsy based on findingsof a target to biopsy or having a high degree of clinical suspicion for cancer. The tpMRGB were performed in a 70-cm wide-bore 3-Tdevice. Patients who underwent RP within one year from biopsy were included. Descriptive statistics were performed to assess theconcordance between tpMRGB and final pathology among patients with and without previous transrectal ultrasound (TRUS)-guidedbiopsies.

RESULTS

A total of 24 men underwent tpMRGB with subsequent RP within one year. At the time of biopsy median age was 65 years(interquartile range [IQR] 11.7) and median PSA was 8.7 ng/mL (IQR 8.9). The median time between biopsy and RP was 85 days(IQR 50.5). Final pathology revealed Gleason 3+4=7 in 12 patients, 4+3=7 in 7 patients, and 4+4=8 in 2 patients. We observedconcordance between MR biopsy and RP in 21 cases (87.5%) in terms of summed Gleason scores. Pathologic Gleason upgradingoccurred in 3 cases (12.5%), all of which had final pathologic grades of 3+4=7.16 of the 24 patients had previously undergoneTRUS biopsies, of which 6 were negative and 10 were positive for Gleason ≤6. tpMRGB revealed Gleason upgrading in 8 of thepositive TRUS biopsies, all of which were concordant with RP pathology. Among all patients with negative TRUS biopsies, MR biopsydemonstrated evidence of cancer and was concordant with RP results in 83% of cases.

CONCLUSION

Gleason scores determined by tpMRGB at 3-T accurately correlate to final RP Gleason score. This may offer a more precise methodto diagnose and appropriately treat men with prostate cancer, especially in patients with negative or low-grade TRUS in whichclinically significant cancer is suspected.


Prostate cancer affects 1 in 7 American men. MR-guided prostate biopsies may offer a more accurate means of characterizingprostate pathology than conventional methods.

ParticipantsAri J. Spiro, MD, Bronx, NY (Presenter) Nothing to DiscloseAlla M. Rozenblit, MD, Bronx, NY (Abstract Co-Author) Nothing to DiscloseDavid Hoenig, MD, Bronx, NY (Abstract Co-Author) Nothing to Disclose

UR114-ED-MOA7

More Than Just a Stone: What Can be Hidden Behind a Renal Colic?

Station #7

UR169-ED-MOA8

Rare Sighting: A Review of Uncommon Renal Neoplasms and Mimics with Radiologic-PathologicCorrelation

Station #8

Victoria Chernyak, MD, Bronx, NY (Abstract Co-Author) Nothing to Disclose

PURPOSE

To compare accuracy of renal calculus attenuation values measured on axial vs coronal images in classifying stone composition.


This retrospective study included patients with nephrolithiasis who had non-contrast CT followed by percutaneous nephrolithotomy(PCNL) and stone composition analysis. By stone composition, patients were divided into Calcium group (with Ca-oxalatemonohydrate, Ca-oxalate dehydrate, Ca-apatite calculi), and Urate group ( with urate calculi). Largest size and attenuation ofcalculi were measured on coronal and axial images. Ability of maximum attenuation value measured on axial (Axial-Max) and coronal(Cor-Max) images to classify stone composition was assessed by receiver-operator curve.

RESULTS

There were 107 calculi, 16 (14.9%) in Urate group and 91 (85.1%) in Calcium group, with mean patient ages 52.8±14.9 and57.7±10.5 years (p=0.208), respectively. Median time intervals between CT and PCNL were 48 (IQR 31.5-76.5) and 58 (IQR 30-92)days in Urate and Calcium groups, respectively (p=0.588). Mean calculi sizes were 19.9±9.9mm and 18.2±6.7mm in Urate andCalcium groups, respectively (p=0.536). In Urate group, mean Axial-Max and Cor-Max were 576±162 HU and 621±184 HU (p=0.04),respectively. In Calcium group, mean Axial-Max and Cor-Max were 1,193±317 HU and 1,299±310 HU (p=0.0001), respectively. Areasunder the curve were 0.937 (95%CI 0.89-0.99) and 0.941 (95%CI 0.89-0.99) for axial and coronal images, respectively. Axial-Max≥670 HU has accuracy of 92.5% and LR+ of 7.5 for diagnosing calcium-containing calculi. Cor-Max≥773 HU has accuracy of 94.4%and LR+ of 7.6 for diagnosing calcium-containing calculi.

CONCLUSION

Maximum renal calculus attenuation values on coronal images are higher than those on axial, but are equally accurate in classifyingstone composition.


We confirm that despite the slight difference in values, coronal images can be used for predicting Ca-containing stones.

ParticipantsElena Inchausti, MBBS, Donostia, Spain (Presenter) Nothing to DiscloseJuan Vega Eraso, San Sebastian, Spain (Abstract Co-Author) Nothing to DiscloseCarmen Biurrun Mancisidor, MD, Donostia, Spain (Abstract Co-Author) Nothing to DiscloseMiren Zubizarreta, Donostia, Spain (Abstract Co-Author) Nothing to DiscloseVirginia Gomez, San Sebastian, Spain (Abstract Co-Author) Nothing to DiscloseAne Etxeberria, Donostia, Spain (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

- To understand and be concerned of the complications that can turn up from a simple renal colic. - To recognize other situationsthat because of their physiopathology (identical to nephritic colic) can simulate this entity.


Epidemiology of renal colic. Physiopathology. Diagnostic imaging. We present some cases in which a simple nephritic colic developeddifferent complications: Impaction of the stone along the ureter with hydroureter/hydronephrosis. Spontaneous rupture of renalpelvis(SRRP) with urinoma formation. Recurrent urinary tract infections/pyelonephritis and ureteritis.Other unusual complicationsexposed are: Spontaneous renal artery dissection with renal infarction. Acute cortical necrosis. Chronic infection:xantogranulomatous pyelonephritis. 5.Other situations mimicking renal colic are: Ureteral TBC. Primary carcinoma of the distal ureter/renal pelvis. Retroperitoneal fibrosis affecting both ureters formig renal abcesses. Peritoneal implant causing hydronephrosis. Bloodclot into the ureter, because of a renal AVM. Calcification of suture thread in the ureter (previous renal surgery).

ParticipantsLawrence J. Bahoura, MD, Royal Oak, MI (Presenter) Nothing to DiscloseDaniel L. George, MD, Royal Oak, MI (Abstract Co-Author) Nothing to DiscloseMonisha Shetty, MD, Royal Oak, MI (Abstract Co-Author) Nothing to DiscloseMitual B. Amin, MD, Royal Oak, MI (Abstract Co-Author) Nothing to DiscloseSyed Zafar H. Jafri, MD, Royal Oak, MI (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

Renal tumors are commonly encountered on imaging. Although the vast the majority of malignant kidney tumors are clear cell andpapillary renal cell carcinomas, there are many, much more rare neoplams, both malignant and benign, as well as mimics of neoplasmthat can be difficult to distinguish.This exhibit aims to:1. Present examples of extremely rare, pathologically proven renal neoplasms,mostly malignant, as well as select benign entities and mimics of neoplasm.2. Highlight specific clinical and imaging features, alongwith pathologic correlation, of the various rare entities to arm the radiologist with knowledge to expedite diagnosis and moreeffectively guide patient care.


I. ObjectivesII. Rare Renal Neoplasms-Collecting duct carcinoma-Birt-Hogg-Dube Syndrome with chromophobe cell carcinoma-Synovial sarcoma of the kidney-Mixed papillary and clear cell carcinoma-Plasmacytoma-Mixed epithelial and stromal tumor-Renal

medullary carcinoma-Capsular sarcoma-Capsular leiomyosarcoma-Mixed epithelioid malignant angiomyolipoma-Multilocular cysticnephroma with carcinoma-Metanephric adenoma-Squamous cell carcinoma of the collecting system-Rhabdoid tumorIII. Mimics ofneoplasm-Renal sarcoidosis-Hydatid cysts-Renal splenosisIV. DiscussionV. Conclusion

GU216-SD-MOB1

Mini-invasive Treatment of Uterine Adenomyosis Using MRgFUS: Success Rate and MRI ImagingFollow-up after 4 Years

Station #1

GU217-SD-MOB2

Voxel-Based Whole Lesion Enhancement Parameters: A New Approach to Discriminating Clear CellRenal Cell Carcinoma from Renal Oncocytoma

Station #2

GUS-MOB

Genitourinary Monday Poster Discussions

Monday, Nov. 30 12:45PM - 1:15PM Location: GU/UR Community, Learning Center

GU



ParticipantsZhen J. Wang, MD, Hillsborough, CA (Moderator) Nothing to Disclose

Sub-Events

ParticipantsFabiana Ferrari, MD, L'Aquila, Italy (Presenter) Nothing to DiscloseAnna Miccoli, MD, L'Aquila, Italy (Abstract Co-Author) Nothing to DiscloseFrancesco Arrigoni, Coppito, Italy (Abstract Co-Author) Nothing to DiscloseEva Fascetti, MD, L'Aquila, Italy (Abstract Co-Author) Nothing to DiscloseGiulio Mascaretti, MD, L'Aquila, Italy (Abstract Co-Author) Nothing to DiscloseCarlo Masciocchi, MD, L'Aquila, Italy (Abstract Co-Author) Nothing to Disclose

PURPOSE

To demonstrate the efficacy of uterine adenomyosis treatment using Magnetic Resonance imaging-Guided Focused Ultrasounds(MRgFUS) analyzing MRI imaging and success rate after 4 years.


A total of 21 patients aged between 28 and 51, affected by uterine adenomyosis (14 focal and 7 diffuse forms) were treated in ourdepartment with MRgFUS. We submitted the patients to the same MRI protocol, respectively before treatment and then after 1, 2and 4 years from the treatment. We analyzed the uterine wall morphology and the possible recurrence of the disease measuring thethickness of the junctional zone. Pre-treatment and post-treatment values were compared. Symptomatology was evaluatedthrough the symptom-severity-score questionnaire comparing the pre-treatment score with the one obtained after 1 and 4 yearsfrom the treatment. Patients were submitted to one treatment alone employing the specific therapeutic plan of high-energy-grid-sonication.

RESULTS

After 1 and 4 years from the treatment, 16 patients (76%) with focal adenomyosis did not present recurrence of pathology and agood recovery of the uterine wall morphology was observed. Only 5 (24%) out of 21 patients showed a recurrence of adenomyosisfocus after 1 year and were submitted to a second treatment. After 4 years from the treatment, 16/21 patients showed thicknessof the junctional zone less then 12 mm; 5/21 had a junctional zone more then 12 mm. After 1 year from the treatmentsymptomatology presented a reduction of about 80% if compared to the pre-treatment one with a progressive improvement after 4years.

CONCLUSION

In cases of focal adenomyosis, MRgFUS permits a good resolution of symptomatology maintaining the integrity of the uterus,without significant recurrence of the pathology. Differently, in the diffuse forms of adenomyosis, which are more difficult to betreated, it is possible to repeat the treatment. MRgFUS allows the control of the pathology which may recur.


The MRgFUS treatment of adenomyosis permits a significant reduction of the junctional zone thickness and a good resolution of thesymptoms especially in the focal forms with the possibility to repeat the treatment in case of recurrences.

ParticipantsFrank K. Chen, MD, Los Angeles, CA (Abstract Co-Author) Nothing to DiscloseDarryl Hwang, PhD, Los Angeles, CA (Abstract Co-Author) Nothing to DiscloseMittul Gulati, MD, Los Angeles, CA (Abstract Co-Author) Nothing to DiscloseSteven Cen, PhD, Los Angeles, CA (Abstract Co-Author) Nothing to DiscloseBhushan Desai, MBBS, MS, Los Angeles, CA (Abstract Co-Author) Nothing to DiscloseFelix Y. Yap, MD, Los Angeles, CA (Abstract Co-Author) Nothing to DiscloseMegha Nayyar, BA, Los Angeles, CA (Abstract Co-Author) Nothing to DiscloseInderbir Gill, MD, Los Angeles, CA (Abstract Co-Author) Nothing to DiscloseVinay A. Duddalwar, MD, FRCR, Aberdeen, United Kingdom (Presenter) Research Grant, General Electric Company

PURPOSE

Clear cell renal cell carcinoma (ccRCC) is the most common subtype of renal cell cancer, and renal oncocytoma (RO) is the secondmost common benign renal neoplasm after angiomyolipoma. Differentiating ccRCC from RO is often a diagnostic challenge given

GU218-SD-MOB3

Benign Enhancing Solid Components of Mature Ovarian Teratoma : MR Imaging Features andPathologic Correlation

Station #3

GU219-SD-MOB4

Clinical Impact of Prostate Cancer Detection with Extrapolated High b-value DWI

Station #4

similarities in epidemiology, presentation, and imaging. The purpose of our study is to evaluate the use of voxel-based whole lesionenhancement parameters on contrast enhanced computed tomography to discriminate ccRCC from RO.


In this institutional review board-approved study, we retrospectively queried the surgical database for post nephrectomy patientswho had pathology proven ccRCC or RO and had preoperative multiphase CECT of the abdomen between June 2009 and August2013. Preliminary evaluation of 69 patients (46 patients with ccRCC and 23 patients with RO) was performed. Multiphase CTacquisitions were transferred to a Synapse 3D workstation, and tumor regions of interest were manually segmented. Voxel-basedcontrast enhancement values were collected from the lesion segmentation and displayed as a histogram. Mean and medianenhancement, mean and median deenhancement, and histogram distribution parameters skewness, kurtosis, standard deviation, andinterquartile range were calculated for each lesion. Comparison between ccRCC and RO was made using each imaging parameter.For enhancement and deenhancement, which had normal distribution, independent t-test was used. For histogram distributionparameters, which did not have normal distribution, Wilcoxon rank sum test was used.

RESULTS

RO had significantly higher mean and median whole lesion enhancement (p < 0.01) on excretory phase than ccRCC while ccRCC hadsignificantly higher mean (p = 0.01) and median whole lesion deenhancement (p < 0.01). For histogram distribution parameters,ccRCC had significantly higher interquartile range on arterial (p < 0.01) and excretory phases (p = 0.03), significantly higherskewness on excretory phase (p = 0.02), and significantly higher standard deviation on arterial (p = 0.01) and nephrographicphases (p = 0.03) compared to RO.

CONCLUSION

Preliminary results from our study suggest that voxel-based whole lesion enhancement parameters can be used as a quantitativetool to discriminate ccRCC from RO.


While enhancement characteristics have been described to differentiate ccRCC from RO, this new method is an additional techniqueto categorize these lesions.

ParticipantsKyeong Ah Kim, MD, Seoul, Korea, Republic Of (Presenter) Nothing to DiscloseHoon Jung Shin, Seoul, Korea, Republic Of (Abstract Co-Author) Nothing to DiscloseChang Hee Lee, MD, Seoul, Korea, Republic Of (Abstract Co-Author) Nothing to DiscloseJae Woong Choi, MD, Seoul, Korea, Republic Of (Abstract Co-Author) Nothing to DiscloseYang Shin Park, MD, Seoul, Korea, Republic Of (Abstract Co-Author) Nothing to DiscloseCheol Min Park, MD, Seoul, Korea, Republic Of (Abstract Co-Author) Nothing to Disclose

PURPOSE

Mature teratoma (MT) is one of the most common benign ovarian neoplasm, but the tumor undergoes malignant transformation in 1-2% of cases. Squamous cell carcinoma is the most commonly associated malignancy. Enhancing portion of MT is known aspossibility of malignant transformation on contrast enhanced MR. We recently experienced the cases of benign MT with enhancingsolid component on pelvis MR. We have had a question about enhancing solid component within MT of ovary on MR always meansmalignant transformation. The purpose of this work is to evaluate the benign enhancing solid component within MT of ovary onpelvis MR and to correlate MR findings with pathology.


We retrospectively reviewed MR findings and pathologic reports of the 126 patients (n=154 masses) with pathologically confirmedbenign and malignant ovarian teratomas who underwent pelvis MR at our institution from January 2004 to January 2015. Weidentified 22 patients (n=24) who had benign enhancing solid components within MTs. MR images were reviewed for the followingcharacteristics: the largest diameter, appearance, and border of the enhancing solid components and presence of transmuralgrowth, lymphadenopathy, or metastasis. Pathologic analysis were also performed in available cases (n=13).

RESULTS

The ages of patients ranged from 6 to 68 years (mean; 28.5 years). The enhancing solid components were observed in 24 (18.8%)of 128 MTs. The largest diameter ranged from 5.9 - 42.2 mm (mean, 18 mm). The appearance was variable. 19 (79.2%) of 24 caseshad regular borders. No cases showed transmural growth, lymphadenopathy, or metastasis. In pathologic analysis, solid componentsof MT were confirmed as glial tissue (n=8), thyroid tissue (n=3), and fibrous stroma (n=2).

CONCLUSION

Enhancing solid component associated with MT of ovary is not infrequent. It does not necessarily indicate malignant transformation.Because of the size and complexity of ovarian MTs, surgical removal is usually recommended; however, excessive surgicalintervention can be potentially avoided with an accurate diagnosis.


Enhancing solid component associated with mature teratoma of ovary on pelvis MR is not infrequent. Excessive surgical interventioncan be potentially avoided with an accurate diagnosis.

Participants

GU220-SD-MOB5

Initial Application of T2* Mapping of the Uterine Fibroids in the Screening of MR-HIFU

Station #5

Sadhna Verma, MD, Cincinnati, OH (Presenter) Nothing to DiscloseJason W. Young, MD, Cincinnati, OH (Abstract Co-Author) Nothing to DiscloseSarad Sarkar, Grass Valley, CA (Abstract Co-Author) Employee, EigenRajesh Venkataraman, PhD, Grass Valley, CA (Abstract Co-Author) Employee, EigenXu Yang, Grass Valley, CA (Abstract Co-Author) Nothing to DiscloseKrishnanath Gaitonde, MD, CIncinnati, OH (Abstract Co-Author) Nothing to Disclose

PURPOSE

To assess the clinical impact of prostate cancer detection using acquired versus extrapolated high b-value diffusion weightedimaging (DWI) computed using 4 diffusion models.


50 sequential patients from 2013-2015 with pathologically proven prostate cancer (CaP) were chosen for analysis. 3TMultiparametric prostate MRI exams of the patients included one of 2 low b-value DWI protocols (b=100, 600, 1200 or b=15, 250,800, 1200) and a high b-2000 DWI. Additionally, high b-2000 DWI was extrapolated from the lower b-value images using 4 diffusionmodels - Monoexponential, IVIM, Stretched exponential and Kurtosis. All images were scored on subjective quality and readabilityindependently by 2 radiologists and 1 resident. Lesions were identified by consensus on all images by the 3 readers and subjectivelygraded for lesion conspicuity. Lesion-to-background contrast ratios were computed for each lesion on all images. Pathologicalground truth was established using MRI-Ultrasound fusion prostate biopsy of the identified lesions. Logistic regression analysis wasconducted to compare the CaP predictive capabilities of acquired b-2000 DWI versus computed b-2000 DWI from the 4 models.

RESULTS

All extrapolated b-2000 series demonstrated unanimously higher ratings for subjective quality and readability then acquired b-2000except the Kurtosis model (Wilcoxon Rank Test, p<0.0001). All extrapolated DWI (except Kurtosis) also demonstrated better lesionconspicuity in a direct comparison with acquired b-2000 DWI (T-test, p < 0.0001). Mathematical computation demonstrated higherlesion to background contrast ratio (LBCR) for all extrapolated DWI compared to acquired b-2000 DWI (ANOVA, p<0.0001). Logisticregression analysis determined that the LBCR of extrapolated b-2000 DWI was a better predictor of CaP than the LBCR of acquiredb-2000 DWI (p-value ~ 0.05). Receiver Operator Curve (ROC) analysis demonstrated higher area under the curve for exponential b-2000 DWI (72%) as compared to acquired b-2000 DWI (65%) or PSA (57%) alone

CONCLUSION

The increased lesion conspicuity of extrapolated DWI vs acquired high b-value DWI may be a major advantage in CaP detection.


The increased lesion conspicuity of extrapolated DWI vs acquired high b-value DWI may be a major advantage in CaP detection

Honored Educators



ParticipantsYing Zhu, MD, Bejing, China (Presenter) Nothing to DiscloseQueenie Chan, PhD, Hong Kong, China (Abstract Co-Author) Nothing to DiscloseXiaoying Wang, MD, Beijing, China (Abstract Co-Author) Nothing to Disclose

PURPOSE

In our short-term clinical study, we extracted T2* values from T2* map to investigate that if oxygenation of the fibroids correlatedwith the efficacy of sonication.


Eighteen patients with 25 uterine fibroids who received MR-HIFU treatment were included in our study. T2* mapping were achievedwhen screening. All data were acquired on a 3T MRI scanner , utilizing a 32-channel phased array coil. Multi echo gradient echosequence was used. T2* maps of the fibroids were processed by using the post processing software in a proprietary programmingenvironment. The T2* values of the gluteus muscles were also measured to check the stability of the images. Funaki classificationwas used to classify all fibroids into three types on T2WI as low signal intensity (SI) (type1), intermediate SI (type2), and high SI(type3). Non-perfused volume (NPV) was measured in the contrast-enhanced images immediately after treatment. The volumes ofthe whole fibroid and residual parts were also measured in the contrast-enhanced images at both post-treatment and three-monthfollow-up. The residual fibroid was defined as the non-necrotic part.

RESULTS

Among the 25 treated fibroids, 12 were type1 and 13 were type2. Independent samples t-test revealed that the mean T2* value oftype 2 fibroids (31.85±7.40ms) was significantly higher than that of type 1 (25.60±5.08ms, t=-2.28, P=0.032). However there wasno significant difference between the two types in the NPV (t=0.54, P=0.60). Spearman correlation analysis showed no significantcorrelation between the NPV and the T2* value (r=-0.24, P=0.24). We found the volume of residual fibroids was increasing in fourof the 25 fibroids, and their mean T2* value (37.40±6.57ms) was significantly higher than the others (27.40±5.89ms, t=-3.05,P=0.006), and the volume change of the residual fibroid had correlation with their T2* value (r=0.499, P=0.011).

CONCLUSION

Our study showed that the oxygenation might be different in fibroids with different Funaki classification. The four fibroids with

GU221-SD-MOB6

Quantification of Renal Stone Composition in Mixed Stones Using Dual-Energy CT: A Phantom Study

Station #6

UR117-ED-MOB7

Renal Papillary and Calyceal Lesions on CT Urography

Station #7

growing residual part suggested that T2* mapping may improve the criteria for selecting uterine fibroids amenable to treatment withMR-HIFU.


The four fibroids with growing residual part suggested that T2* mapping may improve the criteria for selecting uterine fibroidsamenable to treatment with MR-HIFU.

ParticipantsShuai Leng, PhD, Rochester, MN (Presenter) Nothing to DiscloseAlice Huang, Madison, WI (Abstract Co-Author) Nothing to DiscloseJuan Montoya, Rochester, MN (Abstract Co-Author) Nothing to DiscloseXinhui Duan, PhD, Rochester, MN (Abstract Co-Author) Nothing to DiscloseJames C. Williams, PhD, Indianapolis, IN (Abstract Co-Author) Nothing to DiscloseCynthia H. McCollough, PhD, Rochester, MN (Abstract Co-Author) Research Grant, Siemens AG

PURPOSE

To demonstrate the feasibility of using dual-energy (DE) CT to accurately quantify the percent composition of uric acid (UA) andnon-uric-acid (NUA) components of urinary stones having mixed composition.


A total of 24 renal stones were selected and analyzed with microCT to serve as the reference standard for UA and NUAcomposition. These stones were then placed in 6 water phantoms with lateral widths of 30, 35, 40, 45, 50, and 55 cm to simulatethe attenuation from slim to obese adults. The stone-containing phantoms were scanned on a third-generation dual-source CTscanner (Somatom Force, Siemens Healthcare, Germany) using dual-energy modes adaptively selected based on phantom size. Thelow energy beam was set to 70, 80, 90 or 100 kV, based on patient size, and the high energy beam was consistently set to150 kVplus a 0.6-mm tin filter. Dual energy analysis was performed using an in-house software package, in which the CT number ratio(CTR=low-energy CT number/high-energy CT number) was calculated for each pixel of the stones. Each pixel was then classified asUA or NUA by comparing the CTR with a single preset threshold, which was determined by finding the threshold with the lowestroot-mean-square error (RMSE) across all stones compared to the reference standard. Minimal and maximal absolute errors werethen calculated. A paired t-test was performed to compare the stone composition determined with DECT with the referencestandard of microCT.

RESULTS

Stone volume ranged from 75.3 to 319.1 mm3. Among these stones, 1 was pure UA, 1 was pure NUA, and the remaining 22 weremixed stones, with the percentage of UA ranging from 12% to 93% and the percentage of NUA ranging from 7% to 88%. Theoptimal CTR threshold ranged from 1.27 to 1.55, based on phantom size and tube potential. The RMSE was from 9.60% to 12.87%for all phantom sizes. The minimum absolute UA errors ranged from 0.04% to 1.24%, and the maximum absolute UA errors rangedfrom 22.05% to 35.46%. Paired t-tests showed no significant difference in the UA percentages estimated by DECT and microCT (pvalues ranged from 0.20 to 0.96).

CONCLUSION

Accurate quantification of UA and NUA composition in mixed stones is possible using DECT.


As most urinary stones have mixed compositions, accurate quantification of the composition of mixed stones is essential for clinicalapplication of dual-energy CT for stone composition analysis.

AwardsCum Laude

ParticipantsSatomi Kawamoto, MD, Baltimore, MD (Presenter) Research Grant, Siemens AG; ; Sheila Sheth, MD, Cockeysville, MD (Abstract Co-Author) Nothing to DiscloseElliot K. Fishman, MD, Owings Mills, MD (Abstract Co-Author) Research support, Siemens AG Advisory Board, Siemens AG Researchsupport, General Electric Company Advisory Board, General Electric Company Co-founder, HipGraphics, Inc

TEACHING POINTS

Renal papillary and calyceal lesions may cause hematuria, are occasionally encountered on CT urography, but they can be easilyoverlooked. They are often not seen or subtle on unenhanced or early contrast enhanced CT, and best seen in excretory phase CTurography. Routine use of wide window setting to view excretory phase CT is critical to detect subtle lesions in the renal papillaeand calyces. Normal anatomy and CT finding of renal papillae and calyces which should not be mistaken for pathology are alsodiscussed.


1. Anatomy and normal appearance of renal papillae and calyces on CT urography Simple calyx/compound calyx Anatomy andphysiology to explain the mechanism of papillary and calyceal pathology2. Papillary lesions: discuss etiology, typical and atypicalappearance on CT urography Papillary necrosis Renal tubular ectasia/medullary sponge kidney Medullary nephrocalcinosis3. Calyceallesions Calyceal diverticulum Small urothelial neoplasm Pyelitis Forniceal rupture - Physiologic/secondary to infection, fistulaformation4. Normal structures which potentially simulate pathology Prominent normal renal papilla which potentially simulatesabnormal filling defect Normal papillary blush

UR173-ED-MOB8

Imaging of the Postoperative Genitourinary Tract in Children and Adults

Station #8

Honored Educators


Elliot K. Fishman, MD - 2012 Honored EducatorElliot K. Fishman, MD - 2014 Honored Educator

ParticipantsDaniel Wannemacher, MD, Cincinnati, OH (Abstract Co-Author) Nothing to DiscloseJason W. Young, MD, Cincinnati, OH (Abstract Co-Author) Nothing to DiscloseChandana G. Lall, MD, Orange, CA (Abstract Co-Author) Nothing to DiscloseSadhna Verma, MD, Cincinnati, OH (Abstract Co-Author) Nothing to DiscloseHarsha V. Nalluri, MD, Cincinnati, OH (Abstract Co-Author) Nothing to DiscloseNabeel Arastu, MD, Cincinnati, OH (Abstract Co-Author) Nothing to DiscloseKyle M. Lewis, MD, Cincinnati, OR (Abstract Co-Author) Nothing to DiscloseRobert E. Hobohm, MD, Cincinnati, OH (Presenter) Nothing to Disclose

TEACHING POINTS

1. Understand the normal basic genitourinary tract anatomy. 2. Overview of common and uncommon GU procedures in children andadults and their multimodality imaging findings. 3. Discussion of complications of these procedures and multimodality imaging ofcomplications.


The postoperative imaging of the genitourinary tract in children and adults can be difficult to understand, as the native anatomyoften becomes distorted and unrecognizable following these procedures. Common complications of these procedures includehydronephrosis and stricture, which can lead to renal failure and long term morbidity. This exhibit will include a discussion of variouscommon and uncommon non-renal GU procedures in the pediatric and adult population with example cases for illustration. Thesecases include but are not limited to bladder augmentation surgery, Mitrofanoff appendicovesicostomy, Deflux procedure,cystectomy with urostomy formation, prostatectomy, and interventional recannalization of the distal ureter

Honored Educators


Sadhna Verma, MD - 2013 Honored EducatorChandana G. Lall, MD - 2013 Honored Educator

MSMI23A Overview of MI in Oncology

MSMI23B Hyperpolarized MRI of Prostate Cancer

MSMI23C Radiogenomics

MSMI23D Somatastatin Receptor Imaging

MSMI23

Molecular Imaging Symposium: Oncologic MI Applications

Monday, Nov. 30 1:30PM - 3:00PM Location: S405AB

GU MI MR OI RO



ParticipantsPeter L. Choyke, MD, Rockville, MD, ([email protected]) (Moderator) Researcher, Koninklijke Philips NV Researcher, General ElectricCompany Researcher, Siemens AG Researcher, iCAD, Inc Researcher, Aspyrian Therapeutics, Inc Researcher, ImaginAb, IncResearcher, Aura Biosciences, IncUmar Mahmood, MD, PhD, Charlestown, MA (Moderator) Research Grant, Sabik Medical Inc; Advisory Board, Blue Earth DiagnosticsLimited;

LEARNING OBJECTIVES

1) To understand the role of molecular imaging in cancer therapy. 2) To understand the impact that new molecular imaging agentscould have on drug development. 3) To understand the barriers facing the development of new molecular imaging agents.

ABSTRACT

Molecular Imaging is expanding in many new directions. Most research is being performed for PET and SPECT agents. However,optical and MRI agents are also being developed. Molecular Imaging can play a role in accelerating the development and approval ofnew cancer therapeutics by quantifying the impact drugs have in early Phase studies and by selecting the most appropriatepatients for trials. Molecular Imaging agents can be useful in determining the utility and mechanism of actions of drugs that arealready approved and may provide insights to oncologists regarding the best treatment combinations for individual patients.Molecular Imaging methods have already expanded our knowledge of cancer behavior and this will ultimately lead to new forms ofthe therapy that will one day cure this dreaded disease.

Sub-Events

ParticipantsPeter L. Choyke, MD, Rockville, MD, ([email protected]) (Presenter) Researcher, Koninklijke Philips NV Researcher, General ElectricCompany Researcher, Siemens AG Researcher, iCAD, Inc Researcher, Aspyrian Therapeutics, Inc Researcher, ImaginAb, IncResearcher, Aura Biosciences, Inc

LEARNING OBJECTIVES

1) To understand the broad spectrum of activities in molecular imaging including PET, SPECT, optical and MRI. 2) To understand thepotential impact of Molecular Imaging on cancer treatment.

ABSTRACT

Molecular Imaging is expanding at a rapid rate. This overview will provide a panoramic view of the field of Molecular Imaging andmajor trends that are emerging among the different modalities, PET, SPECT, optical, ultrasound and MRI that constitute molecularimaging.

ParticipantsDaniel B. Vigneron, PhD, San Francisco, CA (Presenter) Research Grant, General Electric Company

LEARNING OBJECTIVES


ParticipantsMichael D. Kuo, MD, Los Angeles, CA (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) To discuss the principles behind radgiogenomics and to highlight areas of clinical application and future development.

ABSTRACT

ParticipantsRonald C. Walker, MD, Nashville, TN, ([email protected]) (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) Describe the advantages of 68Ga-somatostatin PET/CT over 111In-DTPA-octreotide ]imaging. 2) Detect patients likely to benefit

MSMI23E Multimodal MI in Oncology

1) Describe the advantages of 68Ga-somatostatin PET/CT over 111In-DTPA-octreotide ]imaging. 2) Detect patients likely to benefitfrom peptide receptor radiotherapy (PRRT).

ABSTRACT

68Ga-labeled somatostatin analogs (DOTATATE, DOTATOC and DOTANOC) PET/CT imaging provides higher resolution scans than111In-DTPA-octreotide with less radiation, comparable cost, and imaging completion within 2 hours vs. 2-3 days. 68Ga-somatostatin analogs have a higher impact on care than 111In-DTPA-octreotide, including superior ability to identify patients likelyto benefit from PRRT. This activity will provide results from the literature and the author's experience to illustrate the advantages of68Ga-based PET/CT imaging of neuroendocrine tumors.

Active Handout:Ronald Clark Walker

http://abstract.rsna.org/uploads/2015/15003715/MSMI23D.pdf

ParticipantsUmar Mahmood, MD, PhD, Charlestown, MA (Presenter) Research Grant, Sabik Medical Inc; Advisory Board, Blue Earth DiagnosticsLimited;

LEARNING OBJECTIVES

1) To understand strengths of various imaging modalities for specific target/disease assessment.

ABSTRACT

Each imaging modality has a set of characteristics that helps define optimal use. These constraints include sensitivity, depth ofimaging, integration time for signal, and radiation dose, among other factors. Understanding when each modality can be used andwhen combining the relative strengths of differerent modalities can be synergistic allows greater molecular information to beacquired.

MSRO23

BOOST: Gynecology-Case-based Review (An Interactive Session)

Monday, Nov. 30 3:00PM - 4:15PM Location: S103AB

GU RO


ParticipantsKevin V. Albuquerque, MD, MS, Dallas, TX, ([email protected]) (Presenter) Nothing to DiscloseApril A. Bailey, MD, Dallas, TX (Presenter) Nothing to DiscloseStephen Thomas, MD, Chicago, IL (Presenter) Nothing to DiscloseYasmin Hasan, MD, Chicago, IL (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) Present the multimodality management of selected gynecolgic cancers including surgery, radiation and chemotherapy. 2)Highlight the importance of imaging in the diagnosis and followup of gynecologic cancers. 3) Highlight the importance of imaging inthe planning and delivery of radiation.

ABSTRACT

The care of patients with gynecologic cancers requires the collaboration of imaging specialists as well as gynecologic and radiationoncologists. Radiologic imaging is key in defining disease at diagnosis and following patients for detection of recurrence aftertreatment. In conjunction with computerised planning , sectional imaging allows for sophisticated planning of external beam andbrachytherapy and is key in maximizing the benefits of radiation while minimizing the risks. Case examples of the pivotal impact ofimaging and its importance in multidisciplinary care will be highlighted in this session

SSE10-01 Genitourinary Keynote Speaker: Renal Tumor Ablation-Current Status and Future Directions

Monday, Nov. 30 3:00PM - 3:10PM Location: E351

SSE10-02 Real-time MR-guided Renal Cryoablation: Technical Feasibility, Complications and Outcomes


SSE10-03 Single Institution Review of Percutaneous Cryoablation in the Horseshoe Kidney: An InitialExperience


SSE10

ISP: Genitourinary (GU Intervention)


GU CT IR MR



ParticipantsDouglas S. Katz, MD, Mineola, NY (Moderator) Nothing to DiscloseCary L. Siegel, MD, Saint Louis, MO (Moderator) Nothing to Disclose

Sub-Events

ParticipantsRonald J. Zagoria, MD, San Francisco, CA (Presenter) Nothing to Disclose

ParticipantsGeorgia Tsoumakidou, MD, Strasbourg, France (Presenter) Nothing to DiscloseHerve Lang, Strasbourg, France (Abstract Co-Author) Nothing to DiscloseGuillaume Koch, MD,MSc, Strasbourg, France (Abstract Co-Author) Nothing to DiscloseJulien Garnon, MD, Strasbourg, France (Abstract Co-Author) Proctor, Galil Medical LtdXavier Buy, MD, Bordeaux, France (Abstract Co-Author) Proctor, Galil Medical LtdAfshin Gangi, MD, PhD, Strasbourg, France (Abstract Co-Author) Nothing to Disclose

PURPOSE

At present, major improvements in device development, as well as modern special designed MR-suites (with MR-compatible lifesupport and anesthesia equipment) have made the performance of MR-guided percutaneous procedures not only feasible, but alsoattractive. We retrospectively reviewed our single institution experience with percutaneous MR-guided cryoablation of renaltumours for technical feasibility, complications and outcomes (oncologic, renal function).


Between April 2009 and March 2015, 68 patients underwent percutaneous MR-guided renal cryoablation. All procedures wereperformed in an MR-interventional unit, using a 1.5T large bore, supra-conductive system. Real-time BEAT IRTTT (3-simultaneous-plane sequence) and high-resolution T2-Blade/HASTE sequences were used for probe positioning and ice-ball monitoring.

RESULTS

A total of 79 lesions in 68 patients were treated. Four patients were excluded because of less than 3 month follow-up. Twenty-onepatients had a history of renal cancer (15 and 2 treated with total and partial nephrectomy, respectively, 4 with cryoablation).Mean maximal tumour diameter was 22mm (min 5, max 42). Biopsy results were available in 61 patients.Procedure related data(time, number-type of cryoprobes, ice ball size) were collected. Two freeze-thaw cycles were systematically performed.Hydrodissection was used in 37 patients.All procedures were technically successful. Local recurrent tumour was identified in sixpatients during the first six months of imaging follow-up. The local primary tumour control rate was 92%. One patient developed alate local recurrence at 3 years follow-up. Five out of six early and the late recurrence were treated percutaneously. Peri-operativemajor complication rate was 4.6% (one active bleeding necessitating embolization, one asymptomatic subcapsular hematoma, andone urothelial damage treated with ureteric catheter insertion). There was no procedural related death. Mean follow-up was 18 (3-70) months.

CONCLUSION

Percutaneous renal cryoablation can be performed with high technical and clinical success under MR-guidance. The real-time probeplacement, high soft tissue contrast, multi-planar imaging, and the lack of ionizing radiation are some of the advantages of MR vsthe CT-guidance.


Percutaneous cryoablation of T1a renal tumours can be perfromed safely and with high tecnical sucesss under MR-guidance.

ParticipantsJunjian Huang, MD, Rochester, MN (Presenter) Nothing to DiscloseThomas D. Atwell, MD, Rochester, MN (Abstract Co-Author) Nothing to DiscloseAnil N. Kurup, MD, Rochester, MN (Abstract Co-Author) Nothing to DiscloseStephen Boorjian, Rochester, MN (Abstract Co-Author) Nothing to DiscloseRobert Thompson, MD, Rochester, MN (Abstract Co-Author) Nothing to Disclose

SSE10-04 Placement of Essure Tubal Occlusion Coils by Fluoroscopy; An Option when Hysteroscopic PlacementFails


SSE10-05 Percutaneous Embolization of Varicocele By Steel and Platinum Coils


Grant D. Schmit, MD, Rochester, MN (Abstract Co-Author) Nothing to Disclose

PURPOSE

To present the initial case series of percutaneous cryoablation of tumors in a horseshoe kidney.


This is a single center retrospective review of 5 consecutive patients with a renal mass in a horseshoe kidney treated withpercutaneous image-guided cryoablation from June of 2006 to August of 2013. Patient and tumor characteristics were extractedfrom the electronic medical record. Oncologic outcomes were defined using standardized criteria.

RESULTS

Average age of patient was 59 years old(4M, 1F), tumor size was 3cm(±1cm), and serum creatinine was 1.1±0.4. Of the 5 patients,4 patients had biopsy proven clear cell renal cell carcinoma, and 1 patient had biopsy proven carcinoid. Technical success wasachieved in all patients. The median follow-up duration is 19 months. There were no major complications. Transient elevation ofcreatinine, not requiring dialysis, occurred following treatment in one patient which has since normalized to baseline. A singlepatient had inguinal nerve pain that resolved within 3 months. Mean creatinine at follow-up was 1.1±0.3. All patients remain free oflocal tumor progression. Two patients expired 46 months and 24 months after ablation due to unrelated disease.

CONCLUSION

There is a paucity of data with regard to the safety, efficacy, and long term outcome of percutaneous cryoablation in thehorseshoe kidney. From our initial series it seems that cryoablation is relatively safe in the treatment of small renal tumors, withoutimpact on renal function. This is the first reported series of cryoablation in the horseshoe kidney and, in select patients, maypresent an alternative to surgical management.


Percutaneous cryoablation represents an alternative treatment modality in patients with a small renal mass on a horseshoe kidney.

ParticipantsAmy S. Thurmond, MD, Portland, OR (Presenter) Nothing to Disclose

PURPOSE

Nonsurgical tubal occlusion by Essure coils was FDA (Food and Drug Administration) approved in 2002 for hysteroscopic placementby gynecologists. Occasionally hysteroscopic placement of one or both coils is not possible--or the coil perforates or is expelledfrom the tube. Fluoroscopic fallopian tube catheterization has been used since 1987 as a nonsurgical method for unblocking proximaltubal occlusion in women with infertility. The feasability of fluoroscopic fallopian tube catheterization for placement of Essure coilswas explored.


Women were referred by their gynecologists because of complications after hysteroscopic placement of the Essure device. No pre-medication, sedation, or anesthesia was given. Commercially available equipment was used to perform hysterosalpingogram,fallopian tube catheterization, and Essure placement. Equipment consisted of a 9 Fr balloon catheter for use in the cervix anduterus (Cook Medical), a 5 Fr catheter and 0.035 inch diameter hydrophilic guidewire for use in the fallopian tube (Cook Medical),and the Essure device and delivery system (Bayer Pharmaceutical).

RESULTS

Twelve women had attempt at fluoroscopic Essure placement in 14 tubes. Procedure was successful in 12/14 tubes (86%),including 5 tubes where hysteroscopic placement had failed, 2 tubes where hysteroscopic placement resulted in perforation, 3tubes in which device was expelled after hysteroscopic placement, and 2 tubes with hydrosalpinx. Fluoroscopic placement failed in2 tubes, in one because of severe tubal spasm which was also the reason for hysteroscopic failure, and in one tube (in whichdevice had been expelled) because of pain during the procedure attributed to severe endometriosis.There were no complications.Sixwomen have had post-procedure confirmation hysterosalpingograms required by the FDA and all 6 tubes with devices placedfluoroscopically were occluded (100%).

CONCLUSION

Ten of 12 high risk women (83%) who had failed Essure placement by hysteroscopy on one or both sides had subsequentsuccessful fluosocopic procedures allowing them to rely on the Essure devices for tubal occlusion. Twelve of 14 tubes (86%) wereamenable to fluoroscopic placement of the Essure device.


Ten of 12 women (83%) who would have been considered Essure failures and referred for tubal ligation, were converted to Essuresuccesses by fluoroscopic placement of the device.

ParticipantsSyed Muhammad Faiq, MBBS, Karachi, Pakistan (Presenter) Nothing to DiscloseKhair Muhammad, MBBS, Karachi, Pakistan (Abstract Co-Author) Nothing to DiscloseWaseem A. Mirza, MBBS, Karachi, Pakistan (Abstract Co-Author) Nothing to Disclose

PURPOSE

SSE10-06 Hysterosalpingo-foam Sonography (HyFoSy): A Prospective Observational Cohort Study of anInnovative, Radiation Free, Safe and Effective, Non(Embryo) Toxic Technique, to Visualize TubalPatency in an Outpatient / Office Setting


The goal of this study was to present our experience with percutaneous treatment of male varicocele in view of procedural, clinicalaspects in adult population.


45 male with clinical moderate to severe varicocele associated with scrotal swelling with "bag of worms" or discomfort in testes,such as heaviness or dull pain after standing all day, referred from urology outpatient department to Radiology Department, whereDoppler ultrasound was done which confirms the grade and patient underwent percutaneous varicocele embolization with coil.

RESULTS

The procedural success rate for spermatic vein occlusion was 93%. Follow-up, achieved of every patient after 6 month in urologyoutpatient department. Forty two patients (93%) reported disappearance of varicocele and as well as pain relief. In two patientspercutaneous embolization procedure failed due to internal jugular vein approach and congenital venous abnormality. None ofpatients reported a reappearance of their varicocele. No significant complications occurred in 42 patients except pain in twopatients and hematoma in two patients at femoral punctured site: none had any 6 months sequelae

CONCLUSION

Percutaneous embolization of varicocele carried out as outpatient procedure under local anesthesia and is more beneficial to patientin comparison to surgery. It has high procedural success rates, less recurrence rate, when performed by experience interventionalradiologist. We believed primary therapy for varicocele treatment should be embolization if we compared various risk factorsassociated with surgery.


Procedural and clinical success in elimination of varicocele by steel or platinum coils with low rate of failure and reappearance up to6 month. High failure rate was seen in our study through internal jugular vein approach for venous access. We believed primarytherapy for varicocele treatment should be embolization if we compared various risk factors associated with surgery.

ParticipantsAnurag Singh, MBBS,MD, Sharjah, United Arab Emirates (Presenter) Nothing to DiscloseTejashree Singh, Dubai, United Arab Emirates (Abstract Co-Author) Nothing to DiscloseKiran C. Patil JR, MD, Jalgaon, India (Abstract Co-Author) Nothing to Disclose

PURPOSE

This study was conducted to evaluate the efficacy and safety of HyFoSy as a first step routine office procedure for tubal patencytesting.


A prospective observational cohort study was conducted in a medical center from 26/11/2014 - 4/4/2015. 46 patients withsubfertility were examined. The mean age of patients was 31 years. The mean duration of subfertility was 2.2 years. The patientswere asked to report for the test, on days 7-9 of their menstrual cycle. All patients were at low risk for tubal disease and had nohistory of tubal surgery. A non(embryo) toxic foam was created by rigorously mixing 10 ml hydroxymethylcellulose glycerol gel(88.25% water) with 10 ml purified water to give a mixture containing 94.10% water in a 20 ml syringe, and was introduced into theuterine cavity with the help of a disposable 5F single balloon catheter. This foam had low viscosity and was sufficiently stable toshow echogenicity for at least 5 minutes. Tubal patency was determined by transvaginal ultrasound demonstration of echogenicdispersion of foam through the Fallopian tubes and the peritoneal spillage. The tubal contour, length and relation of spill withrespect to ipsilateral ovary, were also noted. The pain score was calculated. No precautions with regard to pregnancy wereadvised.

RESULTS

In 45/46 (98%) patients (except 1 case of cervical stenosis), a successful procedure was performed. In these cases, there was nofurther need for a hysterosalpingogram (HSG). 42 patients (94%) had bilateral patent tubes and 3 patients (6%) had unilateralpatent tubes. Only 1 patient (1/45; 2%) had mild vasovagal discomfort during the procedure that resolved spontaneously. Theaverage pain score was 2.2. All procedures were uneventful and no serious side-effects were observed. Furthermore, in 10 patients(22%) conception occurred within a median of 3 months after the procedure. Review of literature found our results comparable withother similar studies.

CONCLUSION

Thus, HyFoSy is a successful, less painful and radiatian free technique, easily performed in an office setting as a first step test fortubal patency.Comparison with other tubal patency tests was done as per the literature evaluation and our old experiences. Itshowed excellent findings in favor of HyFoSy.


HyFoSy is a radiation free, less painful, non(embryo) toxic, effective alternative to HSG and definitely has a potential to be the newgeneration patient friendly first step office test for tubal patency.

SSE11-01 In Vitro Imaging of Kidney Stones in Pig Kidneys Using Ultra-short Echo-time (UTE) MRI

Monday, Nov. 30 3:00PM - 3:10PM Location: E353B

SSE11-02 Low-dose Abdominal Computed Tomography for Urinary Stone Disease - Impact of AdditionalSpectral Shaping on Image Quality and Dosage


SSE11

Genitourinary (Renal Stone Imaging)


CT GU MR



ParticipantsNaoki Takahashi, MD, Rochester, MN (Moderator) Nothing to Disclose

Sub-Events

ParticipantsEl-Sayed H. Ibrahim, PhD, MSc, Ann Arbor, MI (Presenter) Nothing to DiscloseRobert A. Pooley, PhD, Jacksonville, FL (Abstract Co-Author) Nothing to DiscloseJoseph G. Cernigliaro, MD, Jacksonville, FL (Abstract Co-Author) Nothing to DiscloseMellena D. Bridges, MD, Jacksonville, FL (Abstract Co-Author) Nothing to DiscloseJamie G. Giesbrandt, MD, Jacksonville, FL (Abstract Co-Author) Nothing to DiscloseJames C. Williams, PhD, Indianapolis, IN (Abstract Co-Author) Nothing to DiscloseWilliam E. Haley, MD, Jacksonville, FL (Abstract Co-Author) Nothing to Disclose

PURPOSE

Ultra-short echo-time (UTE) MRI provides echo times (TE) in the range of tens of microseconds, which allows for effective imagingof tissues that have rapid signal decay, e.g., kidney stones. In this study, we investigate the imaging performance of UTE MRI forstones embedded within their usual milieu, the kidney, thus mimicking the in vivo situation.


24 kidney stones passed/extracted from patients were obtained. The stones represented 8 different types (confirmed by micro CT):calcium oxalate monohydrate (COM), calcium oxalate dehydrate (COD), brushite, apatite, uric acid (UA), struvite, cystine, andmixed-composition. Each stone type was represented by 3 stones in a range of sizes: small (2-3 mm), medium (4-6 mm), and large(7-10 mm). A total of 8 pig kidneys, purchased from a local meat store, were used in the experiments. Using small cuts, threestones (large, medium, and small) of the same type were inserted into each kidney, each into a different calyx (Fig 1a). Thekidneys were arranged in a small plastic container filled with water and covered with a sealed lid (Fig 1b), and then imaged on aSiemens 3T MRI scanner using an 18-channel body surface coil and an optimized 3D UTE pulse sequence.

RESULTS

All stones were successfully visualized. The resulting images clearly showed the stones' shapes with high resolution (Fig 1c).Although efforts were made to expunge air bubbles throughout the pre-scan process, air gaps still existed inside some of thekidneys, which resulted in some artifacts. Using the body surface coil and large FOV did not adversely affect stone visualization,which is promising for future in vivo imaging.

CONCLUSION

This study confirms the potential of MRI for in vitro imaging of stones in kidneys using the body surface coil, which is one stepcloser to in vivo imaging than phantom experiments with head or knee coils. If successful for true in vivo imaging, the UTEtechnique could serve as an alternative to CT for imaging patients for whom minimization of radiation exposure is desirable. Thesequence could be also added to abdominal MRI protocols for comprehensive evaluation of the genitourinary system.


Although CT is the modality of choice for imaging kidney stones, UTE MRI may provide an effective alternative when there areconcerns about radiation exposure.

ParticipantsPatricia Dewes, MD, Frankfurt, Germany (Presenter) Nothing to DiscloseClaudia Frellesen, Frankfurt, Germany (Abstract Co-Author) Nothing to DiscloseJan-Erik Scholtz, MD, Frankfurt, Germany (Abstract Co-Author) Nothing to DiscloseSebastian Fischer, MD, Frankfurt, Germany (Abstract Co-Author) Nothing to DiscloseThomas J. Vogl, MD, PhD, Frankfurt, Germany (Abstract Co-Author) Nothing to DiscloseRalf W. Bauer, MD, Frankfurt, Germany (Abstract Co-Author) Research Consultant, Siemens AG Speakers Bureau, Siemens AGBoris Schulz, MD, Frankfurt Am Main, Germany (Abstract Co-Author) Nothing to Disclose

PURPOSE

To evaluate a novel tin filter based abdominal CT technique for urolithiasis in terms of image quality and radiation exposure.


SSE11-03 Predictive Value of Low Dose and Dual-Energy CT for Successful Stone Disintegration in Shock WaveLithotripsy: An in-Vitro Study


SSE11-04 Feasibility of Split-filter Dual-energy CT for in-Vitro Differentiation of Urinary Stones by Using Dose-neutral (Compared with Single-energy CT) Protocol


130 consecutive patients with suspected urolithiasis underwent non-enhanced CT in our department with various techniques: 48patients were examined with a novel tin filtration (150kV Sn) method (group 1) on a third-generation dual-source-CT, 33 patientswere examined with automated kV-selection (80-140kV) based on the scout view with the same CT-device (group 2) and 49patients were examined on a second-generation dual-source-CT (group 3) also with automated kV-selection (80-140kV) based onthe scout view. Automated exposure control was active in all groups. Image quality was subjectively evaluated on a 5-point-likert-scale by two radiologists and interobserver agreement as well as signal-to-noise-ratio (SNR) was calculated. Dose-Length-Product(DLP) and volume based CT weighted Dose Index (CTDIvol) were used to analyze radiation exposure.

RESULTS

Image quality was rated in favour for the tin filter protocol with an excellent interobserver agreement (ICC=0.86-0.91). SNR wassignificantly better in group 1 and 2 compared to second-generation DSCT (p<0.001). On third-generation dual-source CT, therewas no significant difference in SNR between the 150 kV Sn and the CAREkV protocol (p=0.5). DLP of group 1 was significantlylower in comparison to group 2 and 3 by 23% and 27% (93 vs. 122 vs. 127mGycm; p<0.002). CTDIvol of group 1 was significantlower compared to group 2 (-36%) and 3 (-32%) (1.95 vs. 3.09 vs. 2.87 mGy; p<0.001).

CONCLUSION

Additional shaping of a 150kV spectrum by a tin filter substantially lowers patient exposure while improving image quality onabdominal Computed Tomography for urinary stone disease.


The novel tin filtered technique reduces radiation exposure and improves image quality in comparison to standard low- doseabdominal CT, thus serving to benefit the patient.

ParticipantsSebastian Winklhofer, MD, San Francisco, CA (Presenter) Nothing to DiscloseLargo Remo, Zurich, Switzerland (Abstract Co-Author) Nothing to DiscloseChristian Fankhauser, Zurich, Switzerland (Abstract Co-Author) Nothing to DiscloseCedric Poyet, Zurich, Switzerland (Abstract Co-Author) Nothing to DisclosePirmin Wolfsgruber, Zurich, Switzerland (Abstract Co-Author) Nothing to DiscloseTullio Sulser, MD, Zurich, Switzerland (Abstract Co-Author) Nothing to DiscloseHatem Alkadhi, MD, Zurich, Switzerland (Abstract Co-Author) Nothing to DisclosePaul Stolzmann, MD, Zurich, Switzerland (Abstract Co-Author) Nothing to Disclose

PURPOSE

Shock wave lithotripsy (SWL) represents the golden treatment for urinary stone disease. Failure of stone disintegration results inrepeated treatments or alternative procedures, thereby not only increasing medical costs. The ability to predict successful SWL willimprove the selection of patients suitable for SWL. This study investigates single energy computed tomography (SECT) and dual-energy computed tomography (DECT) to predict numbers of shock waves to stone disintegration in an in-vitro setting.


A total of 33 human urinary calculi (10 uric acid, 8 hydroxyapatite, 6 calcium oxalate monohydrate, 5 cysteine, 3 struvite, 1brushite stones, mean size 6±3 mm) were scanned using a 128-slice DECT machine (Somatom Force, Siemens Healthcare,Forchheim, Germany) with single- (120kVp) and dual-energy settings (80/150, 100/150kVp) resulting in 6 different SECT and DECTdata sets. Calculi were disintegrated using an electromagnetic Dornier DL50 lithotrypter (Dornier MedTech, Wessling, Germany) overa 2-mm mesh until succesful disintegration.

RESULTS

All stones were successfully disintegrated by applying a median of 72 shock waves (interquartile range 343). Regarding logisticregression analysis, CT numbers significantly (p<0.01) predicted fewer or more than median shock waves to successfuldisintegration and differed among data sets (p<0.05), both adjusted for stone composition (p<0.001) and size (p<0.001).Correlation coefficients ranged from rho=0.36 to 0.68 with best correlation for CT numbers and shock waves at 80 kVp (p<0.001).

CONCLUSION

Lower CT numbers are significantly associated with fewer shockwaves needed which is independent of stone composition and size.Optimal prediction of SWL success may be fascilated on the basis low-dose CT data which is paralleled by a low radiation dose.


Being able to predict the success of shock wave lithotripsy with low-dose computed tomography would be helpful to determine theoptimal management in patients with urinary calculi.

ParticipantsAnushri Parakh, MBBS,MD, Basel, Switzerland (Presenter) Nothing to DiscloseDaniel Boll, Basel, Switzerland (Abstract Co-Author) Nothing to DiscloseAndre Euler, MD, Basel, Switzerland (Abstract Co-Author) Nothing to DiscloseCaroline Zahringer, Basel, Switzerland (Abstract Co-Author) Nothing to DiscloseFabian Morsbach, Zurich, Switzerland (Abstract Co-Author) Nothing to DiscloseDaniel Mueller, Zurich, Switzerland (Abstract Co-Author) Nothing to Disclose

SSE11-05 Virtual Non-enhanced Images Generated from Spectral CT: Determinants of Detection of UrinaryCalculi in the Renal Collecting System


SSE11-06 Improved Differentiation between Uric Acid and Non-uric Acid Renal Stones Using DECTMonoenergetic Imaging

Geraldine Stadelmann, Basel, Switzerland (Abstract Co-Author) Nothing to DiscloseSebastian T. Schindera, MD, Basel, Switzerland (Abstract Co-Author) Research Grant, Siemens AG; Research Grant, Ulrich GmbH &Co KG; Research Grant, Bayer AG

PURPOSE

The study aimed to examine the efficacy of a novel split-filter (using gold and tin filters) single-source dual-energy CT (sf-DECT) incharacterizing renal stones as compared to second-generation dual-source dual-energy CT (ds-DECT) in intermediate-sizedphantoms using vendor-suggested and dose-neutral (to single-energy CT) protocols.


Urinary stones (n=65, size: 2.1-6.4mm) of known chemical composition (15 calcium, 15 struvite, 15 cystine and 20 urate) wereembedded in a custom-made kidney model and placed in a 30-cm cylindrical water-containing phantom simulating a medium-sizedpatient. Scans with vendor-recommended and dose-neutral protocols were performed on ds-DECT (SOMATOM Definition Flash,Siemens; protocol A (vendor-suggested) tube A, 100kVp, 210 reference mAs; tube B, Sn140kVp, 162 reference mAs; protocol B(dose-neutral) tube A, 100kVp, 65 reference mAs; tube B, Sn140kVp, 50 reference mAs) and sf-DECT (SOMATOM Definition Edge,Siemens; protocol C (vendor-suggested) AuSn 120kVp, 640 reference mAs; protocol D (dose-neutral) AuSn 120kVp, 235 referencemAs). Stones were assessed by a dedicated post-processing software. Positive (PPV) and negative (NPV) predictive values werecalculated. A comparison of radiation doses between both dual-energy techniques was made using CTDIvol parameter.

RESULTS

The CTDIvol (in mGy) for protocols A to D measured 13.7, 4.3, 11.2 and 4.4 respectively. Presence of all stones was detected bythe four protocols. The PPV of protocols A-D to characterize urate stones were 95.2, 95.2, 94.1 and 58.6 and for non-urate stoneswere 100, 100, 93.6 and 96.9, respectively. For clinically significant stones (>4 mm), the PPV for characterizing urate or non-uratestones (100 for both) by protocols A and B was not affected. For the same stone size, PPV of protocols C vs. D were 100 vs 76.9for urate and 96.4 vs. 96.0 for non urate stones. Dose-neutral sf-DECT was particularly inferior to ds-DECT in characterizing uratestones and stones which were less than 4 mm.

CONCLUSION

While dose-optimization is feasible in differentiation of urate from non-urate stones by ds-DECT for smaller stones, it is accurate forsf-DECT if they are greater than 4 mm in size.


Sf-DECT is a promising new tool for dual-energy evaluation with a benefit of reduced radiation dose as compared to second-generation dual-energy technique.

ParticipantsYan Chen, Zhengzhou, China (Presenter) Nothing to DisclosePeijie Lv, MMed, Zhengzhou, China (Abstract Co-Author) Nothing to DiscloseJianbo Gao, MD, Zhengzhou, China (Abstract Co-Author) Nothing to Disclose

PURPOSE

To determine which features of urinary calculi are associated with their detection on VNE images generated from Spectral computedtomograpic(CT) urography.


This retrospective study was approved by the insititutional ethics committee with waiver of informer consent.A total of53 patientswere examined with true nonenhanced (TNE) CT and Spectral CT urography in the excretory phase. Thecontrast medium wasvirtually removed from excretory-phase images by using material suppressed iodine(MSI),water-based (WB) and calcium-based(CaB) material decomposition (MD) analysis in the spectral imaging viewer.Thesensitivity regarding the detection of calculi on thesethree groups and the subjective scoring were determined byusing true non-enhanced (TNE) images as the reference standard , andinterrater agreement was evaluated byusing the Cohen k test.By using logistic regression, the influences of image noise,attenuation, and stone size, as well as attenuation of the contrast medium, on the stone detection rate were assessed on VNEimages.

RESULTS

169 stones were detected on the TNE images;149 stones were identified on CaB images (sensitivity,88.2%),145 stoneson WBimages(sensitivity, 85.7%),whlie 160 stones on MSI images(sensitivity,94.6%) with significant difference.Compared with the TNEimages,the relatively lower subjective scoring of the VNE images (P>0.05) and higher SNR,CNR(P<0.05)were identified. Size (long-axis diameter and short-axis diameter), and attenuation of the calculi,except for the image noise were significantly associated withthe detection rate on VNE images (P<0.05). As thresholdvalues on CaB, WB, MSI images, size larger than 2.68 mm , 3.01mm ,2.03mm,maximum attenuation of the calculigreater than 223 HU, 312HU and 203HU respectively were found.

CONCLUSION

After virtual elimination of contrast medium with material decomposition and MSI, large and high-attenuation calculi can bedetected with high reliability.


VNE images generated at excretory-phase Spectral CT can depict calculi larger than 2.03mm in the presence ofcontrast medium;however, small and hypoattenuating calculi may be missed.


ParticipantsFabio Lombardo, MD, Verona, Italy (Presenter) Nothing to DiscloseMatteo Bonatti, MD, Bolzano, Italy (Abstract Co-Author) Nothing to DiscloseGiulia A. Zamboni, MD, Verona, Italy (Abstract Co-Author) Nothing to DiscloseFederica Ferro, Bolzano, Italy (Abstract Co-Author) Nothing to DiscloseRoberto Pozzi Mucelli, Verona, Italy (Abstract Co-Author) Nothing to DiscloseGiampietro Bonatti, Bolzano, Italy (Abstract Co-Author) Nothing to Disclose

PURPOSE

To evaluate monoenergetic attenuation values of renal stones for discriminating between uric acid and non-uric acid stones.


IRB-approved retrospective study; need for informed consent was waived. We included in our study 37 patients (23M, 14F; meanage 54y) who underwent CT for symptomatic urolithiasis on our second-generation dual-source scanner. We performed a 120kVsingle-energy low-dose acquisition of the whole abdomen followed by one or more 100/140kV dual-energy acquisitions limited to theregions in which one or more stones were detected. All patients subsequently underwent stone extraction or they spontaneouslyexpelled the stone within 1 month from the examination; all the obtained stones were analyzed by means of infrared spectroscopyand classified, according to their prevalent composition, as uric acid or non-uric acid stones. When patients had >1 stone, theircomposition was considered the same for all the stones. Stones largest diameter was noted. One radiologist in training evaluated bymeans of a round ROI the monoenergetic attenuation values of the stones from 40 to 190 kV. 40/190kV monoenergetic attenuationratios were calculated. A qualitative analysis on the monoenergetic curves was also performed.

RESULTS

75 stones were detected in 37 patients; 36 stones were located in the urinary calices, 13 in the renal pelvis, 25 in the ureters and1 in the urinary bladder. Mean diameter was 6.1 mm (range 2-28 mm). At spectroscopy, 16/75 stones were prevalently composedby uric acid and 59/75 by cysteine or calcium oxalates/phosphates. Mean 40/190kV monoenergetic attenuation ratios were 0.82 foruric-acid stones (range 0.30-1.34) and 3.82 for non-uric acid stones (range 2.18-7.35)(p<0.0001). All uric-acid stones werecorrectly characterized using a cut-off of 1.5. Qualitative analysis of monoenergetic curves showed a different and easilyrecognizable shape both for uric acid and non-uric acid stones.

CONCLUSION

40/190 kV attenuation ratios accurately differentiate uric acid from non-uric acid stones. Furthermore, qualitative analysis ofmonoenergetic curves can be an easy method to rapidly assess stone composition.


40/190 kV monoenergetic attenuation ratio accurately predicts renal stone composition, even in small calculi, leading to a moreaccurate treatment planning.

ED006-TU

Genitourinary Tuesday Case of the Day

Tuesday, Dec. 1 7:00AM - 11:59PM Location: Case of Day, Learning Center

GU


ParticipantsTheodora A. Potretzke, MD, Saint Louis, MO (Presenter) Nothing to DisclosePerry J. Pickhardt, MD, Madison, WI (Abstract Co-Author) Co-founder, VirtuoCTC, LLC; Stockholder, Cellectar Biosciences, Inc;Research Consultant, Bracco Group; Research Consultant, KIT ; Research Grant, Koninklijke Philips NVNaoki Takahashi, MD, Rochester, MN (Abstract Co-Author) Nothing to DiscloseMeghan G. Lubner, MD, Madison, WI (Abstract Co-Author) Grant, General Electric Company; Grant, NeuWave Medical, Inc; Grant,Koninklijke Philips NVAnup S. Shetty, MD, Saint Louis, MO (Abstract Co-Author) Nothing to DiscloseRichard Tsai, MD, Saint Louis, MO (Abstract Co-Author) Nothing to DiscloseGeorge A. Carberry, MD, Madison, WI (Abstract Co-Author) Nothing to DiscloseVincent M. Mellnick, MD, Saint Louis, MO (Abstract Co-Author) Nothing to DiscloseDavid U. Kim, MD, Madison, WI (Abstract Co-Author) Nothing to DiscloseYaseen Oweis, MD, MBA, Saint Louis, MO (Abstract Co-Author) Nothing to DiscloseZachary J. Viets, MD, Saint Louis, MO (Abstract Co-Author) Nothing to DiscloseBernard F. King JR, MD, Rochester, MN (Abstract Co-Author) Nothing to DiscloseAkira Kawashima, MD, PhD, Phoenix, AZ (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS


Honored Educators



SPSC30

Controversy Session: Gadolinium Contrast Agents and Adverse Effects: Too Much Attention or Too Little?

Tuesday, Dec. 1 7:15AM - 8:15AM Location: E451A

GU MR SQ



ParticipantsHero K. Hussain, MD, Ann Arbor, MI (Moderator) Nothing to DiscloseEmanuel Kanal, MD, Pittsburgh, PA (Presenter) Consultant, Boston Scientific Corporation; Consultant, Medtronic, Inc; Consultant,St. Jude Medical, Inc; Consultant, Bayer AG; Investigator, Bracco Group; Royalties, Guerbet SA; Martin R. Prince, MD, PhD, New York, NY, ([email protected]) (Presenter) Patent agreement, General Electric Company;Patent agreement, Hitachi, Ltd; Patent agreement, Siemens AG; Patent agreement, Toshiba Corporation; Patent agreement,Koninklijke Philips NV; Patent agreement, Nemoto Kyorindo Co, Ltd; Patent agreement, Bayer AG; Patent agreement, LantheusMedical Imaging, Inc; Patent agreement, Bracco Group; Patent agreement, Medtronic, Inc; Patent agreement, Topspins, Inc;Stockholder, Topspins, IncRichard H. Cohan, MD, Ann Arbor, MI, ([email protected]) (Presenter) Consultant, General Electric Company; ; ; Matthew S. Davenport, MD, Cincinnati, OH, ([email protected]) (Presenter) Book contract, Wolters Kluwer nv; Bookcontract, Reed Elsevier;

LEARNING OBJECTIVES

1) To discuss associations of gadolinium based contrast agents (GBCA) and Nephrogenic Systemic Fibrosis (NSF). 2) To reviewrates and types of acute adverse reactions in patients receiving GBCA, and to place those in perspective with respect to the risk ofNSF. 3) To discuss several other potential safety factors about GBCA, and to compare and contrast incidence of new potentialsafety factors among the various CNS-approved GBCA. 4) To explain the current thinking regarding imaging patients with renalimpairment, and to define renal function thresholds that might be useful for operationalizing imaging in this patient population.

ABSTRACT

To review associations of gadolinium based contrast agents (GBCA) and Nephrogenic Systemic Fibrosis (NSF), and discuss currentpractice patterns that led to almost complete elimination of NSF. Speaker: Martin Prince.To review rates and types of acuteadverse reactions in patients receiving GBCA, discuss principles of premedication and treatment, and place the acute adversereaction rate in perspective with respect to the risk of NSF. Speaker: Richard Cohan. To list and integrate several other potentialsafety factors about GBCA, other than NSF and acute allergic type, into the clinical decision making process about whether or notto administer GBCA, and to compare and contrast incidence of new potential safety factors among the various CNS-approved GBCAavailable today. Speaker: Emanuel Kanal. To explain the current thinking regarding imaging patients with renal impairment, tohighlight the differences that exist between serum creatinine-based and eGFR-based screening, and to define the ranges of renalfunction thresholds for which caution might be advised to avoid potential harm that might result from the administration of iodinatedand gadolinium-based contrast media. Speaker: Matthew Davenport.

URL

RC307

GU Incidental Findings 2015 - What Is New and Helpful in Managing Them? (An Interactive Session)

Tuesday, Dec. 1 8:30AM - 10:00AM Location: E450B

GU


ParticipantsLincoln L. Berland, MD, Birmingham, AL, ([email protected]) (Coordinator) Consultant, Nuance Communications, Inc; Stockholder,Nuance Communications, Inc; Stuart G. Silverman, MD, Brookline, MA, ([email protected]) (Presenter) Author, Wolters Kluwer nvElaine M. Caoili, MD, MS, Ann Arbor, MI (Presenter) Nothing to DiscloseSusan M. Ascher, MD, Washington, DC (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) Appreciate the need for and value of recommendations for managing incidental findings. The participants should also be able tochoose from a variety of methods to bring these recommendations to the point of interpretation. 2) Identify incidental adnexalcystic lesions that require further evaluation to include the type and timing of follow up examinations. 3) Apply appropriate imagingcriteria and thresholds to better distinguish benign adrenal adenomas from more clinically important lesions. 4) Manage incidentalrenal masses, even when they are incompletely characterized, such as when they are too small to characterize or detected on anexamination that is not designed to evaluate them fully. Please bring your charged mobile wireless device (phone, tablet or laptop)to participate.

RC310A Ectopic Pregnancy

RC310B Diagnosis of Miscarriage

RC310C Mid-late First Trimester

RC310

First Trimester Ultrasound (An Interactive Session)

Tuesday, Dec. 1 8:30AM - 10:00AM Location: S402AB

GU OB US


Participants

Active Handout:Carol Beer Benson

http://abstract.rsna.org/uploads/2015/15001996/Active RC310.pdf

Sub-Events

ParticipantsAnne M. Kennedy, MD, Salt Lake City, UT (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) Diagnose tubal ectopic. 2) Differentiate Cesarean scar implantation from a normal, low-lying pregnancy. 3) Recognize the moreunusual sites of ectopic pregnancy (cervical, interstitial, abdominal). 4) Understand the indications for expectant vs. medical vs.surgical management .

ABSTRACT

Ectopic pregnancy can be a life-threatening condition for young, healthy women. The availability of senstive urine pregnancy testsmeans that we are seeing patients at a time when It may be very difficult to see any sonographic findings of pregnancy. Thesession will review and illustrate examples of the recommended descriptive terms 'pregnancy of unknown location',' probableectopic' and 'definite ectopic' both of which refer to tubal ectopics.We will also review the appearance of heterotopic pregnancyand non-tubal ectopics including Cesarean scar implantation, interstitial and cervical implantation, and abdominal and ovarianectopic with demonstration of the role of color Doppler, 3D ultrasound and other imaging modalities.Modern management of ectopicpregnacy has become much less aggressive, in part because the diagnosis is made so much earlier. The indications for the varioustreatment options will be outlined with illustrative case of local injection as well as intraoperative photos during laparoscopy.

Active Handout:Anne M. Kennedy

http://abstract.rsna.org/uploads/2015/15001997/RC310A.pdf

ParticipantsPeter M. Doubilet, MD, PhD, Boston, MA, ([email protected]) (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) Know the sonographic criteria for definite miscarriage and probable miscarriage in the early first trimester. 2) Understand thatany saclike intrauterine structure (rounded edges, no yolk sac or embryo) in a woman with a positive pregnancy test is highly likelyto 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 normal pregnancy.

ABSTRACT

This lecture will cover the diagnosis of early first trimester miscarriage in two settings: (i) ultrasound demonstrates no intrauterinegestational sac ('pregnancy of unknown location'); (ii) ultrasound demonstrates an intrauterine gestational sac but no embryo orheartbeat. In the first of these settings, the role of the quantitative hCG level will be discussed, including whether a singlemeasurement can be used to rule out a normal intrauterine pregnancy. In the second setting, the currently accepted criteria fordefinite miscarriage and for probable miscarriage will be presented. The lecture will also address findings that indicate a highlikelihood of impending pregnancy failure when an embryo with heartbeat is seen on ultrasound.

Active Handout:Peter Michael Doubilet

http://abstract.rsna.org/uploads/2015/15001998/RC310B Early1stTriMiscarriage--RSNA2015.pdf

ParticipantsCarol B. Benson, MD, Boston, MA (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) Recognize the importance of evaluating the developing fetal head during the late first trimester for early detection of large neuraltube defects. 2) Incorporate measurement of the nuchal translucency into their assessment of the fetuses of gestational age 11-14 weeks. 3) Recognize sonographic abnormalities of the ventral wall to distinguish normal physiologic bowel herniation from defectsincluding omphalocele and gastroschisis.

ABSTRACT

This lecture will discuss the sonographic appearance of fetal anatomy in the latter part of the third trimester in order to helpparticipants recognize abnormalities of the fetus at this early gestational age. While many anomalies cannot be detected until laterin pregnancy, the discussion will focus on those anomalies that can be detected in the first trimester. Specific topics covered willbe central nervous system anomalies, including anencephaly, encephalocele and holoprosencephaly, ventral wall defects includingomphalocele and gastroschisis, bladder outlet obstruction, and skeletal anomalies including skeletal dysplasias. Detection ofanomalies early in gestation, before the second trimester, permits time to assess the fetus for other anomalies, syndromes, andaneuploidy.

RC329A Overview of the Clinical Indications for Using MRI

RC329B Review of Scoring System for Complex and Sonographically Indeterminate Adnexal Masses (TheRULES)

RC329C Interactive Cases

RC329

Characterization of Complex and Sonographically Indeterminate Adnexal Masses (An Interactive Session)

Tuesday, Dec. 1 8:30AM - 10:00AM Location: E353B

GU MR US


Participants

Sub-Events

ParticipantsAndrea G. Rockall, MRCP, FRCR, London, United Kingdom (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) To be familiar with the typical clinical presentation of adnexal masses. 2) To understand the role role of ultrasound in the initialevaluation and diagnosis of adnexal masses. 3) To know the current indications for MRI in the characterisation of adnexal masses.

ABSTRACT

Clinical presentation of adnexal masses can be due to symptoms (such as acute or chronic pelvic pain or sepsis) or may beincidental. Ultrasound is the initial investigation in almost every case, although CT may be used initially in patients presenting withan acute abdomen. Ultrasound features that can differentiate benign from malignant adnexal masses are well defined and over 80%of cases can be confidently characterised on the basis of ultrasound findings. However, when the nature of a mass is indeterminateon ultrasound, MRI can be useful in further characterisation of the mass. This can be particularly useful in cases where fertilitypreservation is of paramount importance or where the risks of surgery are high due to other co-morbidities. This lecture will includea full discussion of the current indications for MRI in characterisation of adnexal masses.

ParticipantsIsabelle Thomassin-Naggara, MD, Paris, France (Presenter) Speakers Bureau, General Electric Company; Research Consultant, OleaMedical

LEARNING OBJECTIVES

1) To learn how to optimise the MRI protocol and how to improve the characterisation of indeterminate complex adnexal masses. 2)To understand the added value of functional sequences (DCE MRI and DWI) in diagnosing adnexal masses. 3) To present a noveldiagnostic score named ADNEX MR score for classified adnexal masses using MR imaging according to their positive predictive value.

ABSTRACT

For complex adnexal masses, MR imaging add to conventional criteria of malignancy common to all imaging modalities (bilaterality,tumor diameter larger than 4 cm, predominantly solid mass, cystic tumor with vegetations, and secondary malignant features, suchas ascites, peritoneal involvement, and enlarged lymph nodes) specific features based on the characterization of the solid tissue(including vegetation, thickened irregular septa and solid portion) of the adnexal tumor. Using ADNEX MR-SCORING system foradnexal masses, areas under the curve for diagnosis of malignancy is high both for experienced and junior reader(AUCR1/R2=0.980/0.961). A score is 4 or greater is associated with malignancy with a sensitivity of 93.5% (58/62) and specificityof 96.6% (258/267), the risk of malignancy is high, and the patient should be referred to a cancer center. When the diagnosticscore is 3 or less, the association with malignancy is minimal and the patient may benefit from more imaging follow-up orconservative treatment. Finally, if the diagnostic score is 2, the mass has a very low risk to be malignant (<2%). This new MRdiagnosis classification will be detailed with interactive clinical cases during this session

ParticipantsElizabeth A. Sadowski, MD, Madison, WI (Presenter) Nothing to DiscloseIsabelle Thomassin-Naggara, MD, Paris, France (Presenter) Speakers Bureau, General Electric Company; Research Consultant, OleaMedical

LEARNING OBJECTIVES

1) Develop a method for classifying adnexal masses on MRI by assessing their signal characteristics and enhancement patterns. 2)Assess the risk of ovarian cancer based on the MRI appearance of an adnexal lesion and clinical information. 3) Emphasize the roleof MRI in the evaluation of adnexal lesions.

ABSTRACT

ABSTRACT There is a spectrum of ovarian neoplasms ranging from benign to malignant. Identifying the MR imaging featuressuggestive of benign versus worrisome lesions can help appropriately triage adnexal lesions into follow up versus surgicalconsultation. The purpose of the interactive session is to review the imaging features of benign and worrisome adnexal lesions onMRI and to discuss the appropriate follow up in each case.

RC351A Practical Approach to Understanding Gene Mutations with Interpretation of Imaging in GynecologicMalignancy

RC351B Pearls and Pitfalls in Prostate MRI

RC351C How to Perform and Interpret MRI of the Bladder and Urethra: Anatomy, Technique, andApplications

RC351

Pelvic MRI in Oncology: Pearls for Practice

Tuesday, Dec. 1 8:30AM - 10:00AM Location: E350

GU MR OI RO


Participants

Sub-Events

ParticipantsPriya R. Bhosale, MD, Houston, TX (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) To learn the gentic mutations present in Endomtrial and Ovarian Cancer. 2) Pathogenesis of Ovarian Cancer. 3) Implications onimage interpretation.

ABSTRACT

Endometrial cancer is teh most common female gynecologic malignancy.Epithelial ovarian cancer is the most common cause ofgynecological cancer death in the United States. More recently epithelial ovarian tumors have been broadly classified into twodistinct groups. The type I tumors have low grade serous, clear cell, endometrioid, and mucinous histological features. Typically,these tumors are slow growing and confined to the ovary, and are less sensitive to standard chemotherapy. BRAF and KRASsomatic mutations are relatively common in these tumors, which may have important therapeutic implications. Type II tumors arehigh grade serous cancers of the ovary, peritoneum, and fallopian tube. These tumors are clinically aggressive and are often widelymetastatic at the time of presentation. We will discuss the gene mutations associated with different endometrial and epithelialovarian cancer, pathogenesis, implications on therapy and imaging.

Honored Educators


Priya R. Bhosale, MD - 2012 Honored Educator

ParticipantsAradhana M. Venkatesan, MD, Houston, TX, ([email protected]) (Presenter) Institutional research agreement,Koninklijke Philips NV

LEARNING OBJECTIVES

1) List the elements of common prostate MRI acquisition protocols, defining the roles for each pulse sequence in prostate cancerdetection. 2) List imaging findings critical to accurate prostate cancer detection and staging. 3) Identify imaging pitfalls in thedetection and staging of prostate cancer. 4) Describe common MRI findings of treated prostate cancer. 4) List the elements of theProstate Imaging-Reporting and Data System (PI-RADS) structured reporting scheme. 5) List the updated changes reflected in themost recent PI-RADSv2 structured reporting scheme.

ABSTRACT

Prostate cancer is one of the most frequently diagnosed cancers in the male population. It is the second most common type ofcancer detected in American men and their second leading cause of cancer death. The proposed refresher course will provide anoverview of MRI for prostate cancer imaging, including a discussion of salient imaging findings on multi-parametric MRI, pitfalls inimaging interpretation, and an overview of existing standardized reporting templates for prostate MR interpretation.

ParticipantsMukesh G. Harisinghani, MD, Boston, MA (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) MR techniques to image the bladder and urethra will be discussed. 2) Pointers for optimal MR evaluation will be discussed. 3)Pointers for accurate diagnosis on MRI will be discussed.

ABSTRACT

The propsed course will be provide an overview of applying MR for imaging the bladder and uretheral region

RC352

Carotid and Renal Doppler (Hands-on)

Tuesday, Dec. 1 8:30AM - 10:00AM Location: E264

GU VA US



ParticipantsGowthaman Gunabushanam, MD, New Haven, CT, ([email protected]) (Moderator) Editor, WebMD Health Corp ; Gowthaman Gunabushanam, MD, New Haven, CT, ([email protected]) (Presenter) Editor, WebMD Health Corp ; Mark E. Lockhart, MD, Birmingham, AL, ([email protected] ) (Presenter) Nothing to DiscloseShweta Bhatt, MD, MBBS, Rochester, NY (Presenter) Nothing to DiscloseWui K. Chong, MD, Chapel Hill, NC, ([email protected]) (Presenter) Nothing to DiscloseCorinne Deurdulian, MD, Los Angeles, CA (Presenter) Nothing to DiscloseVikram S. Dogra, MD, Rochester, NY (Presenter) Editor, Reed Elsevier Edward G. Grant, MD, Los Angeles, CA (Presenter) Research Grant, General Electric Company ; Medical Advisory Board, NuanceCommunications, IncUlrike M. Hamper, MD, MBA, Baltimore, MD (Presenter) Nothing to DiscloseFelix A. Hester, Helena, AL (Presenter) Nothing to DiscloseMichelle L. Robbin, MD, Birmingham, AL, ([email protected]) (Presenter) Consultant, Koninklijke Philips NV; Leslie M. Scoutt, MD, New Haven, CT (Presenter) Consultant, Koninklijke Philips NVRavinder Sidhu, MD, Rochester, NY, ([email protected]) (Presenter) Nothing to DiscloseSadhna Verma, MD, Cincinnati, OH (Presenter) Nothing to DiscloseMargarita V. Revzin, MD, Wilton, CT, ([email protected]) (Presenter) Nothing to DiscloseDavida Jones-Manns, Hampstead, MD (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) Describe the technique and optimally perform carotid Doppler ultrasound. 2) Describe the technique and optimally perform renalDoppler ultrasound. 3) Review qualitative and quantitative criteria for diagnosing abnormalities in carotid and renal ultrasoundDoppler examinations.

ABSTRACT

This hands-on course will provide participants with a combination of didactic lectures and an extended 'live' scanning opportunityon normal human volunteers, as follows: Didactic lectures (30 minutes): 1. Carotid Doppler Ultrasound: scanning technique,diagnostic criteria and interesting teaching cases. 2. Renal Doppler Ultrasound: scanning technique, diagnostic criteria andinteresting teaching cases. Mentored scanning (60 minutes): Following the didactic lectures, the participants will proceed to ascanning area with normal human volunteers and ultrasound machines from different manufacturers. Participants will be able toperform live scanning with direct assistance (if needed) by faculty. Faculty will be able to offer feedback, help participants improvetheir scanning technique as well as answer any questions. Faculty will also be available to answer general questions relating to allaspects of vascular Doppler, not limited to carotid and renal Doppler studies.

Honored Educators


Leslie M. Scoutt, MD - 2014 Honored EducatorSadhna Verma, MD - 2013 Honored Educator

SSG06-01 Genitourinary Keynote Speaker: Gynecologic Cancer Imaging-Present and Future

Tuesday, Dec. 1 10:30AM - 10:40AM Location: N229

SSG06-02 High Grade Serous Ovarian Cancer: BRCA Mutation Status and CT Imaging Phenotypes


SSG06

ISP: Genitourinary (Imaging Gynecological Malignancy)

Tuesday, Dec. 1 10:30AM - 12:00PM Location: N229

GU MR OI BQ


ParticipantsSusanna I. Lee, MD, PhD, Boston, MA (Moderator) Nothing to DiscloseAndrea G. Rockall, MRCP, FRCR, London, United Kingdom (Moderator) Nothing to Disclose

Sub-Events

ParticipantsSusanna I. Lee, MD, PhD, Boston, MA (Presenter) Nothing to Disclose

ABSTRACT

The past decade has seen the development of MRI and FDG PET-CT, both of which now play central and complementary roles intreatment planning and followup of women with uterine, ovarian and vulvar cancer. Ongoing investigations of novel techniques suchas diffusion and perfusion imaging, and of PET tracers capable of targeting hypoxia and hormone receptors, will push cancerradiology firmly into the realm of the molecular, quantitative and predictive in the coming decade. PET-MRI, capable of concurrentmulti-modality functional imaging, will likely prove to be a mainstay in personalized gynecologic cancer care.

Honored Educators


Susanna I. Lee, MD, PhD - 2013 Honored Educator

ParticipantsStephanie Nougaret, MD, New York, NY (Presenter) Nothing to DiscloseYuliya Lakhman, MD, New York, NY (Abstract Co-Author) Nothing to DiscloseHebert Alberto Vargas, MD, New York, NY (Abstract Co-Author) Nothing to DiscloseMaura Micco, MD, Rome, Italy (Abstract Co-Author) Nothing to DiscloseMelvin D'Anastasi, MD, New York, NY (Abstract Co-Author) Nothing to DiscloseSarah A. Johnson, MD, Toronto, ON (Abstract Co-Author) Nothing to DiscloseRamon E. Sosa, BA, New York, NY (Abstract Co-Author) Nothing to DiscloseKrishna Juluru, MD, New York, NY (Abstract Co-Author) Nothing to DiscloseNoah Kauff, New York, NY (Abstract Co-Author) Nothing to DiscloseHedvig Hricak, MD, PhD, New York, NY (Abstract Co-Author) Nothing to DiscloseEvis Sala, MD, PhD, New York, NY (Abstract Co-Author) Nothing to Disclose

PURPOSE

To investigate the associations between BRCA mutation status and preoperative CT imaging phenotypes in women with high-gradeserous ovarian cancer (HGSOC).


115 patients with HGSOC (76 BRCA mutation-positive and 39 BRCA mutation-negative) and CT scans prior to the primarycytoreductive surgery were included in this retrospective HIPAA-compliant study. Two radiologists (R1 and R2) independentlyreviewed all CT scans and R1 determined total measurable peritoneal tumor volume (TPTV) for each patient. Associations betweenBRCA mutation status, CT imaging features, and TPTV were analyzed using Fisher exact test and Mann Whitney test. Inter-readeragreement was assessed with the Cohen's kappa. Kaplan-Meier and Cox proportional hazards regression survival analyses wereperformed.

RESULTS

BRCA mutation-positive HGSOC had less frequent peritoneal disease, mesenteric infiltration, and lymphadenopathy at CT (p =0.0002, < 0.0001-0.03, 0.03 for both readers, respectively). Furthermore, the pattern of peritoneal implants was correlated withthe BRCA mutation status: nodular pattern was more common in BRCA-associated tumors whereas infiltrative pattern was morefrequent in sporadic tumors (p = 0.0009 and p = 0.0005 for R1 and R2, respectively). BRCA mutation-positive HGSOC had highermean TPTV (125 cm3 ± 171) than sporadic tumors (56 cm3 ± 95) (p<0.001). Irrespective of BRCA mutation status, mesentericinvolvement by tumor was associated with shorter progression-free survival (p <0.0001 for both readers) and overall survival(p<0.0002 and p<0.0001 for R1 and R2, respectively).

CONCLUSION

BRCA mutation status in HGSOC was linked to the distinct CT imaging phenotypes. Mesenteric disease at CT was an independent

SSG06-03 Advanced Cervical Cancer: Quantitative Assessment of Early Response to Neoadjuvant Chemotherapywith Intravoxel Incoherent Motion Diffusion-weighted Magnetic Resonance Imaging


SSG06-04 Prognostic Value of Diffusion-weighted MRI and PET/CT During Concurrent Chemoradiotherapy inUterine Cervical Cancer


predictor of reduced survival in both BRCA mutation-positive and sporadic tumors.


BRCA-associated HGSOC have characteristic prognostically significant morphology on CT.

Honored Educators


Stephanie Nougaret, MD - 2013 Honored EducatorEvis Sala, MD, PhD - 2013 Honored Educator

ParticipantsYanchun Wang, Wuhan, China (Presenter) Nothing to DiscloseDao Y. Hu, MD, PhD, Wuhan, China (Abstract Co-Author) Nothing to Disclose

PURPOSE

To investigate the utility of intravoxel incoherent motion (IVIM) diffusion-weighted magnetic resonance imaging (MRI) for predictingand monitoring the response of cervical cancer to neoadjuvant chemotherapy (NACT).


This prospective study was approved by an institutional review board, and informed consent was obtained from all patients. A totalof 42 patients with primary cervical cancer were recruited into this study. IVIM diffusion-weighted MRI was performed on allpatients at three time points (prior to NACT, 3 weeks after the first NACT, and 3 weeks after the second NACT).The response totreatment was determined according to the Responded Evaluation Criteria in Solid Tumors (RECIST) three weeks after the secondNACT treatment, and the subjects were categorized into responders and non-responders. The standard ADC, true diffusioncoefficient (D), perfusion-related pseudo-diffusion coefficient (D*), and perfusion fraction (f) values were determined.

RESULTS

Patients were divided into responders (n=24) and non-responders (n=18) according to the RECIST guidelines. Before treatment, theD and standard ADC values were significantly higher in responders than in non-responders (both p<0.01). No significant differenceswere observed in D* and f . Analysis of the receiver operating characteristic (ROC) curves indicated that the threshold ofD<0.93×10-3mm2/s and the standard ADC<1.11×10-3mm2/s could be used to differentiate responders from non-responders,yielding area under curve (AUC) values of 0.804 and 0.768, respectively. Three weeks after both the first and second NACTtreatments, the D and standard ADC values in the responders were still significantly higher than those in the non-responders.D*and f values still showed no significant differences.The ROC curve analysis indicated that the AUC values for D and standard ADCwere 0.823 and 0.763 for the second time point and 0.787 and 0.794 for the last time point.

CONCLUSION

IVIM may be useful for predicting and monitoring the efficacy of NACT in cervical cancer. D and standard ADC values couldrepresent reliable early predictors of the NACT response prior to treatment. Furthermore, these parameters can be used to monitorNACT responses during and after therapy.


These results should be useful for both patients and clinical doctors. Patients who are unsuitable for NACT could be given radiationor surgical treatment in a more timely manner.

ParticipantsJung Jae Park, MD, Seoul, Korea, Republic Of (Presenter) Nothing to DiscloseChan Kyo Kim, MD, PhD, Seoul, Korea, Republic Of (Abstract Co-Author) Nothing to DiscloseByung Kwan Park, MD, Seoul, Korea, Republic Of (Abstract Co-Author) Nothing to Disclose

PURPOSE

To evaluate the prognostic value of diffusion-weighted MRI (DWI) and PET/CT during concurrent chemoradiotherapy (CCRT) ofcervical cancer for predicting disease progression.


This retrospective study included 67 consecutive patients (median age, 55 years; range, 28-78 years) who received CCRT forlocally advanced cervical cancer. All patients underwent both 3T-DWI and PET/CT before and during (at 4 weeks) treatment. Themean apparent diffusion coefficient (ADC) and maximum standardized uptake value (SUVmax) were measured on the tumors and thepercentage changes of each parameter between the two time points (ΔADC and ΔSUVmax) were calculated. In the prediction ofdisease progression, the diagnostic performance of tumor ΔADC and ΔSUVmax was evaluated using the time-dependent receiveroperating characteristics (ROC) curve analysis. The relationship between disease progression and clinical and imaging parameterswas investigated using univariate and multivariate Cox regression analyses.

RESULTS

SSG06-05 Application of Non-Gaussian Water Diffusional Kurtosis Imaging in the Assessment of UterineTumors: A Preliminary Study


SSG06-06 Clinical Value of Proton (1H-) Magnetic Resonance Spectroscopy (MRS) Using Body-phased ArrayCoil at 3.0 T in Pretreatment Assessment for Cervical Cancer Patients


During a mean follow-up of 2.7 years, disease progression was identified in 16 patients (23.9%): local recurrence (n= 7), distantmetastasis (n= 8) and both local recurrence and distance metastasis (n= 1). During treatment, the mean ADC and SUVmaxsignificantly increased and decreased, respectively (both P < 0.001). The mean ΔADC and ΔSUVmax were 42.6 ± 17% and 67.6 ±16.5%, respectively. In the prediction of disease progression, the integrated area under the curve of ΔADC (0.791) and ΔSUVmax(0.781) were not significantly different ( P = 0.88) and the optimal cut-offs of ΔADC and ΔSUVmax were 35.1% and 60.7%,respectively. On multivariate Cox regression analysis, the ΔADC (< 35.1%) and ΔSUVmax (< 60.7%) were the only independentpredictors of disease progression after treatment (hazard ratio, 4.1 and 4.5; P , 0.04 and 0.03, respectively).

CONCLUSION

The percentage changes of DWI and PET/CT parameters during CCRT offer similar prognostic value for the prediction of post-treatment disease progression in patients with cervical cancer.


DWI, as a noninvasive tool, can be used in the prediction of therapeutic outcomes following concurrent chemoradiotherapy inpatients with cervical cancer, instead of PET/CT with the risk of ionizing radiation exposure.

ParticipantsAliou A. Dia, MD, Suita, Japan (Presenter) Nothing to DiscloseMasatoshi Hori, MD, Suita, Japan (Abstract Co-Author) Nothing to DiscloseHiromitsu Onishi, MD, Suita, Japan (Abstract Co-Author) Nothing to DiscloseMakoto Sakane, MD, Suita, Japan (Abstract Co-Author) Nothing to DiscloseTakahiro Tsuboyama, MD, Suita, Japan (Abstract Co-Author) Nothing to DiscloseNoriyuki Tomiyama, MD, PhD, Suita, Japan (Abstract Co-Author) Nothing to DiscloseMitsuaki Tatsumi, MD, PhD, Suita, Japan (Abstract Co-Author) Nothing to DiscloseTomoyuki Okuaki, RT, Chuo-Ku, Japan (Abstract Co-Author) Employee, Koninklijke Philips NV

PURPOSE

To retrospectively evaluate the feasibility and the value of diffusional kurtosis imaging (DKI) in the assessment of uterine tumorscompared with that of conventional diffusion weighted imaging (DWI) and with pathological findings as gold-standard.


Sixty-one women (mean age: 54.85 years ±14.09, range 26-89 years) with histopathologically proven uterine cancers (51 cervicalcancers and 10 corpus cancers) underwent 3-T MR imaging using DKI with high b values (b=700, 1000, 1700 and 2500 s/mm2) andDWI (b=0 s/mm2, b=700 s/mm2). Thirteen of the 61 patients (21.3 %) had coexisting leiomyomas.ROI-based measurements ofdiffusivity (D), kurtosis (K) and ADC of the uterine cancers, leiomyomas, healthy myometrium and endometrium were performed.Theareas under the ROC curve (AUC) in differentiating malignant from benign lesions were also compared.

RESULTS

Mean D of uterine cancers (0.879 mm/s2 ± 0.30) was significantly lower than that of the leiomyomas (1.174 mm/s2±0.43)(P=0.006), the healthy myometrium (1.178 mm/s2± 0.27) (P=0.000) and the healthy endometrium (1.308 mm/s2±0.5) (P=0.013).Mean K of uterine cancers (0.754 mm/s2± 0.22) was moderately higher than that of leiomyomas (0.686 mm/s2± 0.24), the healthymyometrium (0.708 mm/s2± 0.19) and the healthy endometrium (0.568mm/s2± 0.25).No significant difference was found betweenthe mean K of the uterine cancers, the leiomyomas, the healthy myometrium and endometrium (P=0.33, 0.27 and 0.23).There wasno significant difference in AUC between D and ADC.

CONCLUSION

D is not superior or inferior to the conventional ADC in the differentiation between benign and malignant uterine lesions. The K thatis related to the microstructural complexity was higher in uterine cancers than that of leiomyomas but without any significantdifference, opposite to K values in white matter tissue of the brain, in breast or prostate cancers where the mean K of malignantlesions was significantly higher than of the benign lesions.


The D, in non-Gaussian DKI, is equal to the conventional ADC in differentiating benign from malignant uterine lesions. The K ofuterine malignant tumors was not significantly higher than that of the benign lesions, unlike in breast or prostate cancers.

ParticipantsGigin Lin, MD, Guishan, Taiwan (Presenter) Nothing to DiscloseYu-Ting Huang, Guishan, Taiwan (Abstract Co-Author) Nothing to DiscloseKoon-Kwan Ng, Guishan, Taiwan (Abstract Co-Author) Nothing to DiscloseYu-Chun Lin, MSC, Taoyuan, Taiwan (Abstract Co-Author) Nothing to DiscloseTzu-Chen Yen, MD, PHD, Taoyuan, Taiwan (Abstract Co-Author) Nothing to DiscloseHung-Hsueh Chou, MD, Taoyuan, Taiwan (Abstract Co-Author) Nothing to DiscloseAngel Chao, MD, Taoyuan, Taiwan (Abstract Co-Author) Nothing to DiscloseChiun-Chieh Wang, Guishan, Taiwan (Abstract Co-Author) Nothing to DiscloseChyong-Huey Lai, Guishan, Taiwan (Abstract Co-Author) Nothing to DisclosePen-An Liao, MD, Taipei City, Taiwan (Abstract Co-Author) Nothing to Disclose

PURPOSE

To determine the clinical value of proton (1H-) magnetic resonance spectroscopy (MRS) using body-phased array coil at 3.0 T, in

SSG06-07 Impact of Multiparametric MRI (mMRI) on the Therapeutic Management of Suspicious AdnexalMasses Detected by Transvaginal Ultrasound (TVUS)


SSG06-08 Preoperative Tumor Texture Analysis from MRI Predicts Deep Myometrial Invasion and High RiskHistology in Endometrial Carcinomas


To determine the clinical value of proton (1H-) magnetic resonance spectroscopy (MRS) using body-phased array coil at 3.0 T, inpretreatment assessment for cervical cancer patients.


We prospectively enrolled 52 histology proven cervical cancer patients (age 27-80 years) and 30 age-matched surgical candidatesfor benign uterine myoma without evidence of cervical cancer. Pretreatment MR study plus MRS and diffusion weighted imaging(DWI) sequences were carried out at a 3.0 T system using body-phased array coil for the pelvis. PRESS localized 1H-MRS wasapplied to cervical tumor or normal tissue, with resonances analyzed by using the LC-Model algorithm. Cramer-Rao lower bound(CRLB) threshold of 20% was used as quality control. We compared resonances based on: (1) tumor vs normal cervical tissue, (2)histopathology type (squamous vs adenocarcinoma) (3) T stage = IIb (4) nodal metastasis (5) distant metastasis using Mann-Whitney test.

RESULTS

Cervical tumor showed a lower 1.3-ppm lipid level (0.30 vs 1.01μM, P < .05), as compared with normal cervical tissue. Squamouscell carcinoma demonstrated lower levels in 1.3-ppm lipid (0.17μM vs 0.59μM, P < .05) and 0.9-ppm lipid (0.04μM vs 0.16μM, P <.05), as compared with adenocarcinoma. Tumor with T stage >= IIb had lower levels in 1.3-ppm lipid (0.15μM vs 0.53μM, P < .05),0.9-ppm lipid (0.04μM vs 0.15μM, P < .05) and total choline (0.04μM vs 0.16μM, P < .05). Tumors with nodal metastasis containedlower levels of 1.3-ppm lipid (0.16μM vs 0.44μM, P < .05) and glutamine (0.01μM vs 0.02μM, P < .005), whereas tumors withdistant metastasis contained a lower level of 1.3-ppm lipid (0.12μM vs 0.50μM, P < .05). However, resonances from cervical tumorwere independent to maximal tumor size or ADC value on MRI.

CONCLUSION

1H-MRS using body-phased array coil at 3.0 T in cervical cancer patients is useful in differentiating tumor, histopathology type, Tstage >= IIb, nodal or distant metastasis, and is independent to maximal tumor size or ADC value on MRI.


1H-MRS using body-phased array coil at 3.0 T added additional dimensions for pretreatment assessment in cervical cancer patients.

ParticipantsSimone Schrading, MD, Aachen, Germany (Presenter) Nothing to DiscloseSabine M. Detering, Aachen, Germany (Abstract Co-Author) Nothing to DiscloseDirk Bauerschlag, Aachen, Germany (Abstract Co-Author) Nothing to DiscloseChristiane K. Kuhl, MD, Bonn, Germany (Abstract Co-Author) Nothing to Disclose

PURPOSE

Incidental adnexal masses at TVUS are common and diagnostically challenging. The primary goal of imaging is accurate tissuecharacterization to guide further management, i.e. the choice between plain follow-up vs laparoscopic surgery vs. open surgery.Aim of this study was to evaluate the diagnostic utility of mMRI for further management stratification in patients with such adnexalmasses


Prospective IRB-approved trial on 126 women (mean age 54.6 years) with inconclusive adnexal masses at TVUS. All womenunderwent conventional work up, including pelvic examination, TVUS, and CA-125 levels. In addition, all women underwent mMRI at3T with high resolution T2-TSE in three planes, DWI (max. b-800) and DCE. Likelihood of malignancy and appropriate management(i.e. follow-up vs. laparoscopic vs. open surgery) was first determined based on results of conventional methods, and then,independently, based on mMRI. Then, all methods were reviewed in synopsis. Final surgical pathology served as standard-of-reference or clinical and imaging follow-up of at least 24 months

RESULTS

In 65% (82/126) of patients the adnexal mass finally classified as benign, in 29% (36/126) as malignant and in 6% (8/126) asborderline. The diagnostic indices for TVUS+CA-125 alone vs. MRI alone vs. all methods combined were as follows: Sensitivity: 86%(31/36) vs. 97% (35/36) vs. 100% (36/36); Specificity: 32% (29/90) vs. 83% (75/90) vs. 80% (68/90); PPV: 34% (31/91) vs. 70%(35/50) vs. 74% (40/54), NPV: 65% (29/44) vs. 98% (75/76) vs. 100% (72/72). After mMRI, the therapeutic management waschanged in 41/126 (34%) of patients. In 30 patients in whom surgery had been recommended based on conventional assessment,mMRI correctly diagnosed typical benign findings; these patients underwent follow-up instead of surgery. None of these womendeveloped malignancy during follow-up. In another 11 patients, mMRI results correctly suggested malignancy such that opensurgery was performed instead of laparoscopic surgery

CONCLUSION

Compared with conventional assessment (pelvic exam, TVUS, CA-125), mMRI correctly changed the management in one-third ofwomen with incidental adnexal masses. It helps avoid unnecessary surgery, or unnecessary surgical steps (conversion fromlaparoscopic to open surgery)


Pelvic mMRI helps to significantly improve clinical management of asymptomatic women with incidental adnexal masses identified onTVUS

Participants

SSG06-09 Endometrial Cancer MR Staging Accuracy in a Large Multi-site UK Cancer Network Over Three Years:Can the Reported Single Centre Staging Accuracies be Met in Clinical Practice?

Tuesday, Dec. 1 11:50AM - 12:00PM Location: N229

Sigmund Ytre-Hauge, MD, Bergen, Norway (Presenter) Nothing to DiscloseErik Hanson, PhD, Bergen, Norway (Abstract Co-Author) Nothing to DiscloseArvid Lundervold, MD, PhD, Bergen, Norway (Abstract Co-Author) Nothing to DiscloseJone Trovik, MD, Bergen, Norway (Abstract Co-Author) Nothing to DiscloseHelga Salvesen, MD, PhD, Bergen, Norway (Abstract Co-Author) Nothing to DiscloseIngfrid S. Haldorsen, MD, PhD, Bergen, Norway (Abstract Co-Author) Nothing to Disclose

PURPOSE

Tumor heterogeneity is a key feature of malignant disease. Heterogeneity in MR images can be quantified by texture analysis. Weaimed to explore whether high risk histological features are reflected in texture parameters derived from preoperative MRI inendometrial carcinomas.


Preoperative pelvic contrast-enhanced MRI (1.5T) including diffusion-weighted imaging (DWI) was prospectively performed in 99patients with histologically confirmed endometrial carcinomas. Tumor region of interest (ROI) was manually drawn encircling theuterine tumor on axial T1-weighted contrast-enhanced (CE) series on the slice displaying the largest cross-section tumor area.Histogram based texture features (standard deviation, skewness and kurtosis) were calculated from these tumor ROIs. Textureparameters were analyzed in relation to established histological subtype and grade, surgicopathological staging parameters (deepmyometrial and cervical stroma invasion and lymph node metastases) and MRI based tumor volume and tumor apparent diffusioncoefficient (ADC) value using Mann-Whitney U test, Jonckheere-Terpsta trend test and Pearson's bivariate correlation test.

RESULTS

Large standard deviation (SD) in the tumor ROIs was significantly associated with presence of deep myometrial invasion (p=0.009).Lower values for skewness were observed in the tumor ROIs from endometrioid high grade tumors (p=0.012) and from non-endometrioid tumors (by definition always high grade lesions, p=0.020). Kurtosis was positively correlated to tumor volume (r= 0.27;p=0.006) and negatively correlated to tumor ADC value (r=-0.28; p=0.006).

CONCLUSION

MRI derived tumor texture features reflecting tumor heterogeneity are significantly related to high risk histology and predict deepmyometrial invasion in endometrial carcinomas. Thus, tumor texture features based on MRI represent promising biomarkers to aidpreoperative tumor characterization for risk stratified surgical treatment.


Tumor texture features derived from MRI reflect high risk endometrial carcinoma and may aid preoperative risk classification forstratified surgery.

ParticipantsNeil Soneji, BSC, MBBS, London, United Kingdom (Abstract Co-Author) Nothing to DiscloseAnnarita Ferri, MD, Chieti, Italy (Presenter) Nothing to DiscloseVictoria Stewart, London, United Kingdom (Abstract Co-Author) Nothing to DiscloseRoberto Dina, MD, London, United Kingdom (Abstract Co-Author) Nothing to DiscloseNishat Bharwani, MBBS, FRCR, London, United Kingdom (Abstract Co-Author) Nothing to DiscloseAndrea G. Rockall, MRCP, FRCR, London, United Kingdom (Abstract Co-Author) Nothing to Disclose

PURPOSE

To determine the radiological staging accuracy of endometrial cancer (EC) from images acquired from multiple MR scanners across a10 centre UK cancer network over three years.


Retrospective study of 382 consecutive patients with EC imaged in 9 external hospitals and 3 internal hospital sites discussed atour tertiary gyne-oncology centre between October 2011-October 2014. All patients with tertiary centre reports for both finalhistology and MRI were included (n=270). The radiological stage provided at MDT discussion was compared to the 'gold standard'histological report. Parameters assessed included depth of myometrial invasion, cervical and nodal stage. The use of DWI or DCEand the site for incorrect staging were recorded. MedCalc statistical software version 15.2.2 was used.

RESULTS

242 of 270 MRI reports (90%) included a final FIGO stage; of these 147 scans were performed internally and 95 at an externalhospital. Accuracy of the reported depth of invasion was 72.7% for all cases (72.8% for internal and 72.6% for external scans).Sensitivity, specificity, positive and negative predictive values & accuracy with DWI (n=204) were 67%, 77%, 64%, 79%, 73% andwithout DWI (n=38) were 75%, 69%, 53%, 86%, 71% (p>.05). Accuracy with DCE (n=109) was 72% and without (n=130) was73%. For cervical stromal invasion, sensitivity, specificity, PPV, NPV and accuracy for all scans were 59%, 94%, 64%, 93% and89%. As a percentage of all causes of staging error, depth of invasion accounted for 41-52%, cervix stromal invasion 20-32% andnodal stage 8-16% depending on whether the patient was scanned internally or externally, or whether DWI or DCE were included(p>.05).

CONCLUSION

Staging accuracy in a large multi-site cancer network over three years does not meet the reported staging accuracies in meta-analyses of smaller single centre published research (pooled sensitivity/specificity of 86-90%). DWI and DCE did not affect stagingaccuracy, although only a small number of cases did not have these. The underlying causes for the reduction in sensitivity andspecificity need to be evaluated in order to translate the highest achievable MR staging accuracy to long term routine practice.


Accuracy of MR staging of endometrial cancer in a multi-site cancer network over three years does not reach single centre studyresults. The causes for staging inaccuracies need to be understood.

SSG09-01 First Clinical Trial on Ultrasound Molecular Imaging Using KDR-Targeted Microbubbles in Patients withBreast and Ovarian Lesions

Tuesday, Dec. 1 10:30AM - 10:40AM Location: S504CD

SSG09-02 Imaged EGFR Expression Level Reflects Inhibited Growth-Pathway Node in Model of Triple-NegativeBreast Cancer


SSG09

Molecular Imaging (Gynecologic Oncology)

Tuesday, Dec. 1 10:30AM - 12:00PM Location: S504CD

BR GU MI MR RO



ParticipantsKathryn A. Morton, MD, Salt Lake City, UT (Moderator) Nothing to DiscloseZaver M. Bhujwalla, PhD, Baltimore, MD (Moderator) Nothing to Disclose

Sub-Events

ParticipantsJuergen K. Willmann, MD, Stanford, CA (Presenter) Research Consultant, Bracco Group; Research Consultant, Triple RingTechnologies, Inc; Research Grant, Siemens AG; Research Grant, Bracco Group; Research Grant, Koninklijke Philips NV; ResearchGrant, General Electric CompanyLorenzo Bonomo, MD, Rome, Italy (Abstract Co-Author) Nothing to DiscloseAntonia Testa, Rome, Italy (Abstract Co-Author) Nothing to DisclosePierluigi Rinaldi, MD, Rome, Italy (Abstract Co-Author) Nothing to DiscloseGuido Rindi, Rome, Italy (Abstract Co-Author) Nothing to DiscloseSanjiv S. Gambhir, MD, PhD, Stanford, CA (Abstract Co-Author) Board Member, Enlight Biosciences; Board Member, ImaginAb, Inc;Board Member, FUJIFILM Holdings Corporation; Board Member, ClickDiagnostics, Inc; Consultant, FUJIFILM Holdings Corporation;Consultant, Gamma Medica, Inc; Speaker, ImaginAb, Inc; Stock, Enlight Biosciences; Stock options, Enlight Biosciences; Travelsupport, Gamma Medica, Inc

PURPOSE

To assess if clinical ultrasound molecular imaging (USMI) using a novel clinical grade human kinase domain receptor (KDR)-targetedmicrobubble (BR55, Bracco) is safe and allows assessment of KDR expression in patients with breast and ovarian lesions, usingimmunohistochemistry (IHC) as gold standard.


21 women (34-66 yrs) with focal breast lesions and 24 women (48-79 yrs) with focal ovarian lesions were injected IV with BR55(0.03-0.08 mL/kg bw) and 2D USMI of the target lesions was performed dynamically every 2 min starting 5 min after injection up to29 min, using the linear 15L8 probe (Siemens) or the endocavitary 1123 probe (Esaote). Normal breast tissues surrounding thelesion or the contralateral presumed normal ovary served as intra-patient controls. Blood pressure, EKG, oxygen levels, heart rate,CBC, and metabolic panel were obtained before, and 30 min, 1h, 24h after BR55 administration. Persistent focal BR55 binding onUSMI was visually assessed in consensus by 2 blinded offsite radiologists as none, possibly or definitely. Patients underwent surgicalresection of the target lesions and tissues were stained for CD31 and KDR. A pathologist assessed vascular KDR expression using a4-point scale (none, weak, intermediate, high). Adjudication was performed in consensus (offsite radiologists and pathologist) tomatch clinically.

RESULTS

USMI with BR55 was well tolerated by all patients at all doses, without safety concerns. Among the 40 patients included in theanalysis, KDR expression was higher in malignant breast and ovarian lesions (score 2.40±0.63 and 2.08±0.64, respectively)compared to benign breast and ovarian lesions (2.08±0.64 and 1.33±0.50). KDR expression matched well with presence of focalBR55 binding on USMI in malignant breast (13/15; 86.7%) and ovarian (11/13; 84.6%) lesions, as well as benign breast (2/3;66.7%) and ovarian (8/9; 88.9%) lesions. Focal USMI signal could be detected up to 29 min after injection.

CONCLUSION

Use of BR55 in USMI of breast and ovarian lesions is safe and effective and preliminary data indicate that KDR-targeted USMI signalmatches well with vascular KDR expression on IHC.


This study provides proof of principle on feasibility and safety of KDR-targeted USMI in patients with breast and ovarian lesions andlays the foundation for further clinical trials.

ParticipantsEric Wehrenberg-Klee, MD, Boston, MA (Presenter) Nothing to DiscloseNafize S. Turker, PhD, Boston, MA (Abstract Co-Author) Nothing to DisclosePedram Heidari, MD, Boston, MA (Abstract Co-Author) Nothing to DiscloseMauri Scaltriti, PhD, New York, NY (Abstract Co-Author) Nothing to DiscloseUmar Mahmood, MD, PhD, Charlestown, MA (Abstract Co-Author) Research Grant, Sabik Medical Inc; Advisory Board, Blue Earth

SSG09-03 FACBC PET/CT Before and After Neoadjuvant Therapy in Locally Advanced Breast Cancer: AProspective Pilot Clinical Trial


SSG09-04 Operation-naive Invasive Ductal Carcinoma of the Breast. Comparison of Staging Performed with

Diagnostics Limited;

PURPOSE

Triple-negative breast cancer (TNBC) is an aggressive breast cancer subtype for which targeted inhibitors of theRTK/PI3K/AKT/mTOR growth pathway have demonstrated early treatment success. The surface receptor EGFR is one of thedominant RTKs mediating downstream growth signals along this pathway and changes in EGFR expression may be predictive oftherapeutic inhibition. We sought to demonstrate that the changes in EGFR expression predictive of treatment response could benon-invasively assessed.


64Cu-DOTA-cetuximab F(ab´)2 was prepared from cetuximab monoclonal antibody and probe affinity for EGFR assessed. A panel ofTNBC cell lines (MDMBA468, MDMBA231, HCC70) was treated with the AKT inhibitor GDC-0068 or the PI3K inhibitor GDC-0941 forone day at a range of concentrations. Following treatment, we assessed in vitro EGFR probe uptake. In vitro uptake study resultswere compared to protein quantification as assessed by Western blot. After treatment of HCC70 mouse xenografts with control,GDC-0068, or GDC-0941 for two days, PET-CT imaging of HCC-70 tumors with 64Cu-DOTA-EGFR F(ab´)2 was performed.

RESULTS

In vitro treatment with GDC-0068 resulted in increased EGFR Probe uptake of 25%, 139%, and 16% for MDAMB468, MDMBA231, andHCC70, respectively. In vitro treatment with GDC-0941 resulted in increased EGFR uptake of 6%, 87%, and 88%, for the samepanel of cell lines. In vitro uptake studies demonstrate close correlation with changes in EGFR expression as assessed by Westernblot. In vivo imaging of HCC70 mouse xenografts with EGFR PET Probe after treatment with control, GDC-0068, or GDC-0941demonstrate SUVmean of 0.32 (±0.03), 0.50 (±0.01), 0.62 (±0.01), with all comparisons significant (p<0.01).

CONCLUSION

We demonstrate in a murine model of triple-negative breast cancer that changes in EGFR expression induced by targetedtherapeutics can be non-invasively assessed using a 64Cu-DOTA-EGFR F(ab´)2 PET imaging probe. We demonstrate that changesin the level of EGFR expression, potentially indicative of therapeutic response, differ depending on the growth-pathway inhibited.


Noninvasive assessment of changes in EGFR expression could be a valuable clinical tool for rapid assessment of therapeutic efficacyof targeted growth pathway inhibitors in TNBC, allowing for dynamic clinical decision making in response to imaged resistanceprofiles.

ParticipantsGary A. Ulaner, MD, PhD, New York, NY (Presenter) Research support, General Electric Company; Research support, F. Hoffmann-LaRoche LtdSerge Lyashchenko, New York, NY (Abstract Co-Author) Nothing to DiscloseHanh Pham, New York, NY (Abstract Co-Author) Nothing to DiscloseJason S. Lewis, PhD, New York, NY (Abstract Co-Author) Nothing to Disclose

PURPOSE

Genes for amino acid transport proteins are highly upregulated in both invasive ductal carcinoma (IDC) and ILC, as compared tonormal breast epithelium. This molecular phenotype may allow for the development of imaging agents based on amino acidmetabolism. We evaluated whether Fluorine-18 labeled 1-amino-3-fluorocyclobutane-1-carboxylic acid (FACBC), an amino acidanalog labelled with fluorine-18, could be used as an imaging agent for local staging of locally advanced breast cancer before andafter neoadjuvant therapy.


This prospective clinical trial is being performed under IRB approval. In this trial, newly diagnosed breast cancer patients that areplanned for neoadjuvant systemic therapy followed by surgical resection undergo FACBC PET/CT prior to systemic therapy and thenagain following completion of systemic therapy. Maximum Standardized Uptake Values (SUVmax) and other quantitative measures ofFACBC-avidity are measured for the primary breast tumor and nodal metastases before and after systemic therapy. Followingsurgery, FACBC results are correlated with postoperative histopathologic results.

RESULTS

Of 28 planned patients, we have currently accrued 23. All 23 accrued patients have undergone the pre-neoadjuvant therapy FACBCPET/CT. All 23 primary breast lesions were FACBC avid with SUVmax values of 2.3 to 17.5. 18 of 23 patients (78%) had FACBC avidaxillary nodes with SUVmax values of 1.2 to 14.6. In 2 of 23 patients (9%), an unsuspected extra-axillary local nodal metastasiswas detected on the pre neoadjuvant therapy FACBC PET/CT. SUVmax of these nodes was 2.1 and 2.2, and both werepathologically proven to be metastases. 15 of 23 patients (65%) have completed both pre- and post-neoadjuvant PET/CT scansand histological analysis following surgical resection. In 13 of these 15 patients (87%), a reduction of SUVmax in the primary breastcancer of greater than 90% could accurately identify the presence or absence of complete response/near complete response asdefined by post surgical histologic analysis.

CONCLUSION

This pilot trial of FACBC PET/CT in locally advanced breast cancer demonstrates potential uses of FACBC PET/CT before and afterneoadjuvant therapy.


Further work on FACBC as a radiotracer in locally advanced breast cancer is warranted.

Whole Body DWI, PET, PET-CT, and PET-MR


SSG09-05 Multiparametric 18F-FMISO PET/MRI for Assessment of Treatment Response to Chemo-radiation andHypoxia Monitoring in Cervix Cancer Patients: A Feasibility Study


ParticipantsOnofrio A. Catalano, MD, Napoli, Italy (Presenter) Nothing to DiscloseBruce R. Rosen, MD, PhD, Charlestown, MA (Abstract Co-Author) Research Consultant, Siemens AGAngelo Luongo, Napoli, Italy (Abstract Co-Author) Nothing to DiscloseMark Vangel, PhD, Charlestown, MA (Abstract Co-Author) Nothing to DiscloseMarco Catalano, Napoli, Italy (Abstract Co-Author) Nothing to DiscloseUmar Mahmood, MD, PhD, Charlestown, MA (Abstract Co-Author) Research Grant, Sabik Medical Inc; Advisory Board, Blue EarthDiagnostics Limited; Emanuele Nicolai, Napoli, Italy (Abstract Co-Author) Nothing to DiscloseAndrea Soricelli, MD, Napoli, Italy (Abstract Co-Author) Nothing to DiscloseMarco Salvatore, MD, Napoli, Italy (Abstract Co-Author) Nothing to Disclose

PURPOSE

To compare the performance of whole body (WB) DW, WB-PET, WB-PETCT, and WB-PETMR in patients with newly diagnosedinvasive ductal breast cancer, before undergoing treatment.


49 consecutive women with newly diagnosed invasive ductal carcinoma of the breast underwent WB-DWI, WB-PET, WB-contrastenhanced (CE) PETCT and WB-CE-PETMR before treatment. A radiologist and a nuclear medicine physician evaluated in consensusthe studies and searched for occurrence, number, and location of metastases. Final staging and number of lesions, according toeach technique, were compared. Pathology and imaging follow up were used as the ground truth reference.

RESULTS

All the techniques correctly staged 32/49 patients: stage2b in 8, 2c in 7, 3c in 4, 4 in 13. They provided discordant stages in 17/49patients: 1 (stage 2a): staged-4 by WB-PET; 4 (stage 2b): 3/4 staged-2a by WB-PET and WB-PETCT, 1/4 staged-4 by WB-DWI;3(stage 3a): 2/3 staged-2b by WB-PET and WB-PETCT, 1/3 staged-4 by WB-DWI;3(stage 3c): 2/3 staged-2a by WB-PET and WB-PETCT, 1/3 staged-4 by WB-PET and WB-PETCT;6 (stage 4): 1/6 staged-3a by WB-PET, WB-DWI, and WB-PETCT, 1/6 staged-2bby WB-PET and WB-PETCT, 1/6 staged-2b by WB-PET, WB-DWI, and WB-PETCT, 1/6 staged-3a by WB-DWI, 1/6 staged-3c byWB-DWI, and 1/6 staged-3a by WB-PET, WB-PETCT and 3c by WB-DWI. Staging performance of WB-PETMR (49 correctly staged)was significantly better than WB-PETCT (38 correctly staged) (P=0.001, chi square-test).The best performing modality formalignant lymph-node detection was WB-PETMR (47 of 49 patients), followed by WB-DWI (37/49), followed by WB-PET and WB-PETCT (15 patients each). Significantly more malignant nodes were detected by WB-PETMR (P<0.0001, paired t-tests). At least asmany true-positive lesions were detected by WB-PETMR than by any of the other three modalities for 46 patients. Thecorresponding number of patients for WB-PET, WB-PETCT, and WB-DWI were 40, 39 and 34, respectively.

CONCLUSION

PETMR allows a better accuracy in initial staging of surgical-naive ductal invasive breast cancer. The higher performance is likelyrelated to the additive information of PET, DWI, as well as of the other sequences (STIR, T1-weighted Dixon, HASTE, ADC maps,and CE-T1-weighed images) of WB-PETMR


When available WB-PETMR should be considered for proper staging of naive ductal invasive breast cancer.

ParticipantsPetra Georg, MD,PhD, Wiener Neustadt, Austria (Abstract Co-Author) Nothing to DisclosePiotr Andrzejewski, MA, Vienna, Austria (Abstract Co-Author) Nothing to DisclosePascal A. Baltzer, MD, Vienna, Austria (Abstract Co-Author) Nothing to DiscloseStephan H. Polanec, MD, Vienna, Austria (Abstract Co-Author) Nothing to DiscloseWolfgang Wadsak, Vienna, Austria (Abstract Co-Author) Speaker, General Electric Company; Consultant, THP Medical; ResearchGrant, ABX GmbH; Research Grant, Rotem GmbHAlina Sturdza, MD, Vienna, Austria (Abstract Co-Author) Nothing to DiscloseGeorgios Karanikas, MD, Vienna, Austria (Abstract Co-Author) Nothing to DiscloseStephan Polterauer, MD, Vienna, Austria (Abstract Co-Author) Nothing to DiscloseRichard Poetter, MD, Vienna, Austria (Abstract Co-Author) Nothing to DiscloseThomas H. Helbich, MD, Vienna, Austria (Abstract Co-Author) Research Grant, Medicor, Inc; Research Grant, Siemens AG; ResearchGrant, C. R. Bard, IncDietmar Georg, PhD, Vienna, Austria (Abstract Co-Author) Nothing to DiscloseKatja Pinker, MD, New York, NY (Presenter) Nothing to Disclose

PURPOSE

To demonstrate feasibility of combined multiparametric positron emission tomography/magnetic resonance imaging at 3T (3T MPPET/MRI) and to assess treatment response and hypoxia monitoring in cervix cancer patients undergoing chemo-radiation therapy.


In this IRB-approved prospective study 7 patients underwent sequential 3T MP 18F-FMISO PET/MRI at baseline; 2 and 5 weeks (w)after start and 3 months (FU) after treatment. MRI protocol consisted of a high-resolution isotropic T2-w SPACE, a DWI EPI(b=50/850 sec/mm²) and a high-resolution contrast-enhanced (CE) T1-w VIBE sequence. Patients were injected with 330 MBq18F-FMISO and scanning was started 240 min after injection. CT data was used for attenuation correction. PET and MR imageregistrations were performed using Mirada RTx (Mirada Medical, Oxford, UK , ver. 1.4.0.23) software. Gross tumour volume (GTV)

SSG09-06 Correlation of PET-MR Biomarkers with Breast Cancer Molecular Subtypes, Grading and Presence ofDistant Metastases at Time of Presentation


SSG09-07 Impact of Estrogen Receptor Gene Mutations on [18F]-Fluoroestradiol Uptake in Breast Cancer


was contoured by an experienced radiation oncologist on PET/MRI data sets. The volume of GTV was assessed for tumor size, CE-kinetics, restricted diffusivity and 18F-FMISO-avidity using SUVmax and SUV (SUVnorm ) normalized to gluteal muscle uptake. Atfollow up, cervix was contoured, since all patients showed clinically complete remission.

RESULTS

3T MP 18F-FMISO PET/MRI was successfully performed in all patients at every time-point. Median GTV volume was 43.9cc atbaseline, 22.4cc after 2w (20-25Gy) and 7.7cc after 5w (40-45Gy). Mean ADC values were 1.02x10-3mm2/sec increasing to1.18x10-3mm2/sec after 2w and to 1.27x10-3mm2/sec after 5w and to 1.37x10-3mm2/sec at FU. All GTVs showed mean initial-enhancement (IE) followed by a plateau with an increasing IE at 2w and 5w and wash-out at 5w. At FU, there was a persistentenhancement. The mean 18F-FMISO SUVnorm was 3.1 at baseline and decreased to 2.3 at 2w and 2.0 at 5w and follow-up. In allpatients there was never the whole tumor 18F-FMISO-avid, but 18F-FMISO-avid spots within the tumor indicative of hypoxia couldbe identified before and during the course of therapy.

CONCLUSION

MP 18F-FMISO PET/MRI in cervix cancer patients at 3T is feasible and enables non-invasive monitoring of morphological andfunctional changes during treatment.


3T MP 18F-FMISO PET/MRI can depict areas of tumor hypoxia during therapy and thus identify patients at risk who need anaggressive treatment approach.

ParticipantsOnofrio A. Catalano, MD, Napoli, Italy (Presenter) Nothing to DiscloseBruce R. Rosen, MD, PhD, Charlestown, MA (Abstract Co-Author) Research Consultant, Siemens AGCarlo Iannace, MD, San Leucio del Sannio, Italy (Abstract Co-Author) Nothing to DiscloseAngelo Luongo, Napoli, Italy (Abstract Co-Author) Nothing to DiscloseMarco Catalano, Napoli, Italy (Abstract Co-Author) Nothing to DiscloseMark Vangel, PhD, Charlestown, MA (Abstract Co-Author) Nothing to DiscloseUmar Mahmood, MD, PhD, Charlestown, MA (Abstract Co-Author) Research Grant, Sabik Medical Inc; Advisory Board, Blue EarthDiagnostics Limited; Maria Lepore, MD, Avellino, Italy (Abstract Co-Author) Nothing to DiscloseBethany L. Niell, MD, Boston, MA (Abstract Co-Author) Nothing to DiscloseEmanuele Nicolai, Napoli, Italy (Abstract Co-Author) Nothing to DiscloseAndrea Soricelli, MD, Napoli, Italy (Abstract Co-Author) Nothing to Disclose

PURPOSE

To evaluate if PET-MR biomarkers correlate with molecular genetic subtypes, grading, and presence of distant metastases at timeof presentation in naïve ductal invasive breast cancers.


21 consecutive patients with naïve ductal invasive breast cancer and genetic molecular subtype profiling underwent whole-bodycontrast enhanced FDG-PET-MR (Biograph mMR, Siemens). Two readers, using commercially available software, measured thefollowing PET-MR biomarkers: ADC, Ktrans, Ve, Kep, IAUC, SUVmax, SUVmean, and MTV. They were correlated with geneticmolecular subtypes, grading and occurrence of distant metastases.

RESULTS

Genetic molecular subtypes were as follows: ER-7, ER+14; PR-8, PR+13; HER2-11, HER2+10; Ki67-low (<=35%), Ki67 medium/high(>35%). Grading was G2 in 14 and G3 in 7. Six patients had distant metastases. The following biomarkers were higher in the ER-and PR- compared to ER+ and PR+ patients: Kep (9234±1320 versus 6492 ±2358, p0.01), SUVmax (14.19±7.17 versus 6.17±4.24,p0.004), and SUVmean (8.44±4.01, p0.004). ADC directly correlated with the degree of Ki67 expression (1019±256 for Ki67<=35%,1338±105 forKi67>35%, p0.002). The following biomarkers were lower in HER2- patients compared to HER2+ cases: ADC (1050±280versus 1306±122, p0.009), Kep (6726±2240 versus 8599±2122, p0.028), SUVmax (6.29±4 versus 11.8±7.65, p0.046), andSUVmean (3.72±2.28 versus 7.03±4.43, p0.04).G2 patients experienced lower Kep (6638±2391 versus 8944±1764, p0.04) and lowerSUVmax (6.83±4.73 versus 12.89±8.07, p 0.04) than G3 patients.No biomarkers correlated with presence of distant metastases.

CONCLUSION

In naïve ductal invasive breast cancers, PET-MR biomarkers correlate with molecular genetic subtypes and with grading, but notwith the presence of distant metastases.


PET-MR biomarkers might have prognostic and therapeutic implications on patients' management.

ParticipantsManoj Kumar, MS, Madison, WI (Abstract Co-Author) Nothing to DiscloseGinny L. Powers, PhD, Madison, WI (Abstract Co-Author) Nothing to DiscloseJustin Jeffery, Madison, WI (Abstract Co-Author) Nothing to DiscloseYongjun Yan, PhD, Madison, WI (Abstract Co-Author) Nothing to DiscloseAmy M. Fowler, MD, PhD, Saint Louis, MO (Presenter) Nothing to Disclose

SSG09-08 Imaging Patients with Breast and Prostate Cancers Using Combined 18F NaF/18F FDG and TOFsimultaneous PET/ MRI


SSG09-09 In Vivo Assessment of Ovarian Tumor Response to Tyrosine Kinase Inhibitor Pazopanib usingHyperpolarized 13C-Pyruvate MRS and 18F-FDG PET/CT Imaging in a Mouse Model

PURPOSE

Accurately predicting therapeutic responsiveness in women with breast cancer remains challenging. Positron emission tomography(PET) imaging using [18F]-16alpha-17beta-fluoroestradiol (FES) provides a way to non-invasively and longitudinally examine thesubset of tumors expressing estrogen receptor alpha (ERα) which comprise approximately 70% of all breast cancers. However, theeffect of mutations in the gene encoding ERα, recently identified in patients with endocrine-resistant, metastatic breast cancer, onFES uptake is unknown. We developed a model system to test how mutations in ERα influence the uptake of FES.


Stable cell lines expressing either wild-type ERα (231-ER) or a point mutation in the ligand-binding pocket, G521R (231-G521R),were created in the ERα-negative human breast cancer cell line MDA-MB-231. ERα-positive MCF7 human breast cancer cells wereused as a positive control and parental MDA-MB-231 cells were used as a negative control. Cell uptake of FES was measured invitro with microPET/CT imaging and gamma counting. In addition, in vivo FES uptake was measured in MCF7 and 231-ER tumorsgrown as xenografts in athymic nude mice.

RESULTS

FES uptake was observed both in vitro and in vivo in the MCF7 and 231-ER cells/tumors. However, there was no significant FESuptake in the 231-G521R cells or parental MDA-MB-231 cells. The 231-ER cells had a similar dose response curve to MCF7 incompetition assays using increasing doses of cold estradiol, and as consistent with the uptake data, 231-G521R binding was notaltered by cold competition.

CONCLUSION

These data support the use of stable cell lines expressing variant forms of ERα as models for demonstrating the effects of ERα genemutations on FES uptake. Ongoing studies are focusing on the effects of recently identified clinically-relevant ERα mutations on FESuptake and on the prediction of response to ER-targeted therapies.


FES-PET imaging provides a non-invasive way to probe ERα function and may prove useful in identifying the development of ERαgene mutations and thus predicting endocrine resistance in ERα-positive breast cancer patients.

ParticipantsRyogo Minamimoto, MD, PhD, Stanford, CA (Presenter) Nothing to DiscloseAndreas M. Loening, MD, PhD, San Francisco, CA (Abstract Co-Author) Nothing to DiscloseValentina Taviani, PhD, Stanford, CA (Abstract Co-Author) Nothing to DiscloseSanjiv S. Gambhir, MD, PhD, Stanford, CA (Abstract Co-Author) Board Member, Enlight Biosciences; Board Member, ImaginAb, Inc;Board Member, FUJIFILM Holdings Corporation; Board Member, ClickDiagnostics, Inc; Consultant, FUJIFILM Holdings Corporation;Consultant, Gamma Medica, Inc; Speaker, ImaginAb, Inc; Stock, Enlight Biosciences; Stock options, Enlight Biosciences; Travelsupport, Gamma Medica, IncShreyas S. Vasanawala, MD, PhD, Palo Alto, CA (Abstract Co-Author) Research collaboration, General Electric Company;Consultant, Arterys; Research Grant, Bayer AG; Andrei Iagaru, MD, Stanford, CA (Abstract Co-Author) Research Grant, General Electric Company; Research Grant, Bayer AG

PURPOSE

We previously reported the pilot evaluation of a simultaneous PET/MRI scanner with TOF capability, as well as the use of combined18F NaF/18F FDG PET/CT in cancer patients. Here we prospectively compared the combined 18F NaF/18F FDG PET/ MRI against99mTc-MDP in patients with breast and prostate cancers for the detection of metastatic disease.


Fifteen patients referred for 99mTc-MDP bone scans were prospectively enrolled from Oct 14 - Mar 15. The cohort included 7 menwith prostate cancer and 8 women with breast cancer, 41 - 85 year-old (average 61 ± 13). 18F NaF (0.7-2.2 mCi, mean: 1.2 mCi)and 18F FDG (3.8-5.2 mCi, mean: 4.2 mCi) were subsequently injected from separate syringes. The PET/MRI was done 6-30 days(average 9.3 ± 3.2) after bone scan. The whole body MRI protocol consisted of T2-weighted, DWI, and contrast-enhanced T1-weighted imaging. Lesions detected with each test were tabulated and the results were compared.

RESULTS

All patients tolerated the PET/MRI exam, and PET image quality was diagnostic despite the marked reduction in the administereddosage of radiopharmaceuticals (80% less for 18F NaF and 67% less for 18F FDG compared to standard protocols). Five patientshad no bone metastases identified on either scans. Bone scintigraphy and PET/MRI showed osseous metastases in 9 patients, butmore numerous bone findings were noted on PET/MRI than on bone scintigraphy in 3 patients. One patient had negative bone scan,but bone metastases were seen on PET/MRI. Lesions outside the skeleton were identified by PET/MRI in 3 patients.

CONCLUSION

The combined 18F NaF/18F FDG PET/MRI is superior to 99mTc-MDP scintigraphy for evaluation of skeletal disease extent. Further, itdetected extra-skeletal disease that may change the management of these patients, while allowing a significant reduction inradiation exposure from lower dosages of PET radiopharmaceuticals administered. A combination of 18F NaF/18F FDG PET/MRI mayprovide the most accurate staging of patients with breast and prostate cancers prior to the start of treatment.


The combined 18F NaF/18F FDG PET/MRI is superior to 99mTc-MDP scintigraphy for evaluation of skeletal disease extent.

Tuesday, Dec. 1 11:50AM - 12:00PM Location: S504CD

ParticipantsMurali Ravoori, Houston, TX (Abstract Co-Author) Nothing to DiscloseSheela Singh, Houston, TX (Abstract Co-Author) Nothing to DiscloseJaehyuk Lee, Houston, TX (Abstract Co-Author) Nothing to DiscloseJames Bankson, PhD, Houston, TX (Abstract Co-Author) Nothing to DiscloseVikas Kundra, MD, PhD, Houston, TX (Presenter) License agreement, Introgen Therapeutics, Inc

PURPOSE

Early response measures for ovarian cancer are needed to common targets such as tyrosine kinases. Via effects on signaling withintumor cells or via effects on angiogenesis, such inhibitory drugs have the potential to alter tumor metabolism. 18Fluorodeoxyglucose(18F-FDG) mimics glucose and can be used to evaluate early glycolysis. Hyperpolarization magnetic resonance spectroscopy (MRS)imaging can be used to study pyruvate, which can be produced by glycolysis and other pathways and sits at a decision point foraerobic versus anaerobic metabolism. Our purpose was to assess whether either early or late components of metabolism can serveas indicators of response of ovarian cancer to tyrosine kinase inhibitor (including angiogenesis inhibitor via VEGF receptor inhibition)Pazopanib.


Seventeen days after injection of 2 x 106 human ovarian SKOV3 tumors cells into female nude mice, treatment with vehicle orPazopanib (2.5 mg/mouse po) was initiated. Longitudinal T2-weighted MR, hyperpolarized pyruvate MRS, and 18F-FDG PET/CTimaging were performed pre-treatment as well as 2 days and 2 weeks after treatment.

RESULTS

Pazopanib was effective in inhibiting ovarian tumor growth compared to control (p<0.05). Significantly higher pyruvate to lactateconversion (lactate/pyruvate+lactate ratio) was found 2 days after treatment with pazopanib compared to pre-therapy (p<0.005,n=8). This was not seen with control or with 18F-FDG PET/CT imaging.

CONCLUSION

Findings suggest that later metabolic events (pyruvate to lactate conversion) may serve as as an early indicator of response ofovarian cancer to tyrosine kinase (angiogenesis) inhibitor pazopanib in mouse models, even when early glycolytic events do not.


Hyperpolarized 13C-Pyruvate MRS may serve as an early indicator of response to tyrosine kinase (angiogenesis) inhibitors such aspazopanib in ovarian cancer even when 18F-FDG PET/CT does not.

GU223-SD-TUA2

NSsaFe study: An Observational Study on the Incidence of Nephrogenic Systemic Fibrosis in RenalImpaired Patients Following Gadoterate Meglumine Administration

Station #2

GU224-SD-TUA3

Quantitative Enhancement Analysis in Small Renal Mass: Differentiation of Clear Cell Carcinoma fromOther Subtypes and Angiomyolipoma with Minimal Fat at Three-phase Multi-detector CT

Station #3

GUS-TUA

Genitourinary Tuesday Poster Discussions

Tuesday, Dec. 1 12:15PM - 12:45PM Location: GU/UR Community, Learning Center

GU



ParticipantsAntonio C. Westphalen, MD, Mill Valley, CA (Moderator) Nothing to Disclose

Sub-Events

ParticipantsJennifer V. Frabizzio, MD, Abington, PA (Presenter) Consultant, Guerbet SA

PURPOSE

: To determine the incidence of nephrogenic systemic fibrosis (NSF) in patients with renal impairment after administration ofgadoterate meglumine (DOTAREM®) and to collect data on the safety profile of gadoterate meglumine in a post-marketingobservational study.


: Safety data are being collected worldwide for hundreds of patients with moderate to severe renal impairment undergoingcontrast-enhanced magnetic resonance with gadoterate meglumine. At inclusion, clinical history, indication for MR imaging and renalfunction are recorded, and patients are followed up for over 2 years with 3 visits separated by at least 3 months. During follow-upvisits, adverse events (AEs) are recorded with particular focus on any symptoms related to NSF. If NSF is suspected then biopsy isperformed for confirmation.

RESULTS

As of February 10, 2015, the safety data of 512 patients (mean age: 69.5 years (range: 21-95); male: 59.8%) were available forreview. The mean eGFR was 37.3 ±15.9 ml/min/1.73m2 (range: 4.0-74.2) including 68.4% of moderate, 16.2% of severe, 12.7% ofend-stage renal insufficiency and 2.7% of kidney transplanted patients. To date, 288 patients attended the first follow-up visit(between 3 and 12 months after MRI), 176 patients attended the second follow-up visit (between 13 and 21 months after MRI) and114 patients the third follow-up visit (between 22 and 27 months after MRI). No AEs related to DOTAREM® were reported. Sevenpatients (1.4%) had serious adverse events due to underlying disease that were not related to gadoterate meglumine. Not a singlecase of NSF has been observed.

CONCLUSION

: This interim analysis of the NSsaFe study records no cases of NSF in patients with moderate to severe renal impairment after theadministration of gadoterate meglumine.


A gadolinium agent with no incidence of NSF could allow for patients with renal impairment to obtain constast could provide moreaccurate diagnosis and potentially eliminate the need to obtaining GFR laboratory values pre MRI.

ParticipantsSee Hyung Kim, Daegu, Korea, Republic Of (Presenter) Nothing to DiscloseJung Hee Hong, Daegu, Korea, Republic Of (Abstract Co-Author) Nothing to Disclose

PURPOSE

To quantitatively assess whether enhancement characteristics at three-phase MDCT can help differentiate clear cell RCCs frompapillary, chromophobe RCCs and AMLs with minimal fat.


IRB approved this retrospective study. A total of 409 clear cell, 62 papillary, 41 chromophobe RCCs and 51 AMLs with minimal fatwere included. Mean attenuations between clear cell RCC and the other three groups in each phase were compared using t-test.Enhancement values, such as percentage enhancement ratio (PER), enhancement change (EC) and absolute washout ratio (AWR),were calculated and compared using cutoff analysis with optimal threshold level among four groups.

RESULTS

Mean attenuation of clear cell RCCs was significantly greater than papillary and chromophobe RCCs in corticomedullary and earlynephrographic phases, and AMLs with minimal fat in corticomedullary phase. AMLs with minimal fat were significantly great in non-enhanced phase. There were significant differences in PER, EC and AWR of clear cell RCC, compared with those of papillary (148.8vs. 262.5, P=0.002, 0.581 vs. 1.285, P=0.001, and 37.1 vs. -70.5, P=0.001), chromophobe RCCs (148.8 vs. 169.8, P=0.02, 0.581

GU225-SD-TUA4

Clinical Value of Proton (1H-) Magnetic Resonance Spectroscopy (MRS) using Body-phased ArrayCoil at 3.0 T in Pretreatment Assessment for Cervical Cancer Patients

Station #4

GU226-SD-TUA5

Post Ablation MRI Evaluation of the Prostate and Predictors of Local Tumour Recurrence

Station #5

vs. 0.751, P=0.02, and 37.1 vs. 28.8, P=0.03) and AMLs with minimal fat (148.8 vs. 194.2, P=0.01, 0.581 vs. 0.981, P=0.02, and37.1 vs. 13.4, P=0.008). Diagnostic performances to differentiate clear cell RCCs from papillary, chromophobe RCCs and AMLs withminimal fat had accuracies, ranging 80.9% (399/471) to 88.5% (417/471), 70.2% (321/457) to 74.1% (339/457) and 80.6%(371/460) to 85.0% (391/460).

CONCLUSION

Enhancement values may help differentiate clear cell RCCs from papillary RCCs, chromophobe RCCs and AMLs with minimal fat.


Enhancement characteristics of three phase MDCT are helpful for differentiating clear cell RCCs from other subtypes and AMLs withminimal fat.

ParticipantsGigin Lin, MD, Guishan, Taiwan (Presenter) Nothing to DiscloseYu-Ting Huang, Guishan, Taiwan (Abstract Co-Author) Nothing to DiscloseKoon-Kwan Ng, Guishan, Taiwan (Abstract Co-Author) Nothing to DiscloseYu-Chun Lin, MSC, Taoyuan, Taiwan (Abstract Co-Author) Nothing to DiscloseTzu-Chen Yen, MD, PHD, Taoyuan, Taiwan (Abstract Co-Author) Nothing to DiscloseHung-Hsueh Chou, MD, Taoyuan, Taiwan (Abstract Co-Author) Nothing to DiscloseAngel Chao, MD, Taoyuan, Taiwan (Abstract Co-Author) Nothing to DiscloseChiun-Chieh Wang, Guishan, Taiwan (Abstract Co-Author) Nothing to DiscloseChyong-Huey Lai, Guishan, Taiwan (Abstract Co-Author) Nothing to Disclose

PURPOSE

To determine the clinical value of proton (1H-) magnetic resonance spectroscopy (MRS) using body-phased array coil at 3.0 T, inpretreatment assessment for cervical cancer patients.


We prospectively enrolled 52 histology proven cervical cancer patients (age 27-80 years) and 30 age-matched surgical candidatesfor benign uterine myoma without evidence of cervical cancer. Pretreatment MR study plus MRS and diffusion weighted imaging(DWI) sequences were carried out at a 3.0 T system using body-phased array coil for the pelvis. PRESS localized 1H-MRS wasapplied to cervical tumor or normal tissue, with resonances analyzed by using the LC-Model algorithm. Cramer-Rao lower bound(CRLB) threshold of 20% was used as quality control. We compared resonances based on: (1) tumor vs normal cervical tissue, (2)histopathology type (squamous vs adenocarcinoma) (3) T stage = IIb (4) nodal metastasis (5) distant metastasis using Mann-Whitney test.

RESULTS

Cervical tumor showed a lower 1.3-ppm lipid level (0.30 vs 1.01μM, P < .05), as compared with normal cervical tissue. Squamouscell carcinoma demonstrated lower levels in 1.3-ppm lipid (0.17μM vs 0.59μM, P < .05) and 0.9-ppm lipid (0.04μM vs 0.16μM, P <.05), as compared with adenocarcinoma. Tumor with T stage >= IIb had lower levels in 1.3-ppm lipid (0.15μM vs 0.53μM, P < .05),0.9-ppm lipid (0.04μM vs 0.15μM, P < .05) and total choline (0.04μM vs 0.16μM, P < .05). Tumors with nodal metastasis containedlower levels of 1.3-ppm lipid (0.16μM vs 0.44μM, P < .05) and glutamine (0.01μM vs 0.02μM, P < .005), whereas tumors withdistant metastasis contained a lower level of 1.3-ppm lipid (0.12μM vs 0.50μM, P < .05). However, resonances from cervical tumorwere independent to maximal tumor size or ADC value on MRI.

CONCLUSION

1H-MRS using body-phased array coil at 3.0 T in cervical cancer patients is useful in differentiating tumor, histopathology type, Tstage >= IIb, nodal or distant metastasis, and is independent to maximal tumor size or ADC value on MRI.


1H-MRS using body-phased array coil at 3.0 T added additional dimensions for pretreatment assessment in cervical cancer patients.

ParticipantsTristan Barrett, MBBS, BSc, Guildford, United Kingdom (Presenter) Nothing to DiscloseMasoom A. Haider, MD, Toronto, ON (Abstract Co-Author) Consultant, Bayer AG John Trachtenberg, MD, Toronto, ON (Abstract Co-Author) Nothing to DiscloseSangeet Ghai, MD, Toronto, ON (Abstract Co-Author) Nothing to Disclose

PURPOSE

To determine the morphologic changes in the prostate gland after focal laser ablation therapy for prostate cancer and to assessthe value of different MRI sequences for the detection of recurrent/residual disease


Nineteen patients undergoing focal ablation therapy for prostate cancer were followed up clinically and with MRI at 3-7 months posttherapy, with findings correlated to subsequent biopsy. The overall gland volume was compared to baseline size and morphologicalfeatures were assessed on anatomical T2 imaging including signal intensity, atrophy, capsular retraction, and loss of zonal anatomy.Diffusion-weighted imaging was quantitatively assessed using apparent diffusion co-efficient (ADC) maps and dynamic-contrast-enhanced (DCE) MRI uptake curves were calculated for treatment regions.

GU227-SD-TUA6

Incidental Ovarian Lesions on CT in Post-menopausal Women with a History of Non-ovarianMalignancy: Can We Tell Benign from Malignant?

Station #6

UR120-ED-TUA7

Decoding MR Defecography: A Case-Based Approach

Station #7

RESULTS

At follow-up biopsy, 8 patients (42.1%) had no evidence of prostate cancer in the region of the gland treated, and 11 (57.9%)demonstrated recurrent/residual disease. Prostate gland volume reduced in 17/19, with a median decrease of 11.6% and astatistically significant correlation between the size of ablation zone decrease in volume. There was no significant difference in ADCvalues, nor in any of the T2-weighted imaging signs assessed between the groups. 7/8 patients with no disease demonstrated typeI enhancement curves on DCE-MRI, and none had a type III curve. 4/11 patients with recurrent/residual disease demonstrated atype III enhancement curve; 3 of these patients had Gleason 3+4 disease on biopsy and there was a significant correlationbetween the type of enhancement curve and post-treatment Gleason score.

CONCLUSION

The prostate gland undergoes expected atrophy following focal ablation therapy. Diffusion-weighted imaging and T2-weightedimaging do not accurately distinguish residual disease. DCE-MRI enhancement curves show promise for differentiating residualdisease from fibrosis, making it the optimal sequence for follow-up assessment in this patient cohort.


Multi-parametric MRI of the prostate and DCE in particular are helpful in evaluating presence of residual disease post focal ablationfor PCa and may be used for follow up of pateints to detect recurrence of significant disease, rather than subjecting the patientsto repeated biopsies.

ParticipantsAkshay D. Baheti, MBBS, Seattle, WA (Presenter) Nothing to DiscloseKiran Gangadhar, MD, Seattle, WA (Abstract Co-Author) Nothing to DiscloseDaniel S. Hippe, MS, Seattle, WA (Abstract Co-Author) Research Grant, Koninklijke Philips NV; Research Grant, General ElectricCompanyRyan O'Malley, MD, Seattle, WA (Abstract Co-Author) Nothing to DiscloseCarolyn L. Wang, MD, Seattle, WA (Abstract Co-Author) Nothing to Disclose

PURPOSE

Determine whether the ACR white paper on managing incidental adnexal lesions seen on CT (based on SRU guidelines)can be used ina high-risk population of late postmenopausal women (>55 years)with known non-ovarian cancer and whether CT morphology of thelesions can be used to discriminate benign from malignant


IRB and HIPAA compliant retrospective review was performed of 140 patients with 158 adnexal lesions,classified as simplecystic,complex cystic,solid-cystic and solid based on CT morphology and features described in the ACR paper. Lesions werecategorized as benign,indeterminate or malignant based on pathology,imaging stability(median f/u 34 months)or response totherapy.Intergroup comparison was done based on patient and lesion features with Fisher's exact test and permutation tests toaccount for dependence between bilateral lesions in same patient.

RESULTS

20/158(13%) malignant, 44/158(28%) indeterminate and 94/158(59%) benign lesions were noted.19/20 malignant lesions weremetastases while 1 was indeterminate for colorectal metastasis vs ovarian primary. 0/105 simple cysts,2/27 complex cysts,15/21solid-cystic and 3/5 solid lesions were malignant.Cysts classified complex due to high HU(>20) without septations orcalcifications(16/27) were all benign.Compared to benign lesions, malignant ones were more likely to have a solid component(M:18/20 vs B:4/94,OR=202,p<0.001) rather than purely cystic features.Enhancing components and septae were more common inmalignant lesions(p<0.001). Overall, 61/140(44%)patients had metastases.Presence of peritoneal metastases significantlycorrelated with ovarian involvement by malignancy(OR=30.9,p<0.001). Malignancy in adnexal lesions was significantly associatedwith primary tumor type(p=0.02),with breast and colorectal cancers most common to metastasize to ovaries(5 each).

CONCLUSION

Our study supports the ACR recommendations on incidental adnexal lesions even in patients with known non-ovarianneoplasm.Simple adnexal cysts are highly unlikely to be malignant,while lesions that are not simple cystic should be viewed withsuspicion.Peritoneal metastases have a significant correlation with ovarian involvement.


The current ACR white paper on managing incidental adnexal lesions on CT extrapolates US-based criteria.We endorse the sameusing a high-risk cohort.We also evaluate them further based on CT morphology,primary tumor and metastatic pattern.

ParticipantsGuangzu Gao, MD, New Haven, CT (Presenter) Nothing to DiscloseSamira Rathnayake, MD, New Haven, CT (Abstract Co-Author) Nothing to DiscloseMike Spektor, MD, New Haven, CT (Abstract Co-Author) Nothing to DiscloseSteffen Huber, MD, New Haven, CT (Abstract Co-Author) Nothing to DiscloseJay K. Pahade, MD, New Haven, CT (Abstract Co-Author) Nothing to DiscloseMahan Mathur, MD, New Haven, CT (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

Magnestic resonance (MR) defecography can pose a challenge to the uninitiated for a variety of reasons, often related to

UR185-ED-TUA8

Neoplastic and Non-neoplastic Proliferative Diseases of the Perinephric Space

Station #8

unfamiliarity with the relevant pelvic anatomy, confusion regarding the parameters used to measure organ descent and/or limitedknowledge of the pathologic entities themselves. The purpose of this exhibit is to help the viewer master these concepts, providingthe relevant information in a simple, yet comprehensive, quiz-based approach.


Cases will be presented in a quiz format followed by a brief explanation of the answer, highlighting the relevant concepts. We willpresent a summary slide at the end of all the cases which will provide the relevant information in a tabulated form. The followingare the list of cases that will be presented/discussed: Normal anatomy Example of normal images at different phases rest, squeeze,evacuation). Normal parameters (PCL line, H line, M line, anorectal angle) will also be showcased Abnormal entities: Anteriorcompartment (cystocele, urethral hypermobility)- Middle compartment (uretrovaginal prolapse, enterocele, sigmoidocele,peritoneocele) Posterior comparemtent (anterior and posterior rectocele, rectal intussusceptions, rectal prolapse) Descendingperineal syndrome Spastic pelvic floor syndrome (dyssynergic defecation) Summary tables

ParticipantsMorooj Al Subhi, MD, Montreal, QC (Presenter) Nothing to DiscloseMaria Tsatoumas, MD, Outremont, QC (Abstract Co-Author) Nothing to DiscloseVipul Bist, Montreal, QC (Abstract Co-Author) Nothing to DiscloseAmer Alaref, MD, Montreal, QC (Abstract Co-Author) Nothing to DiscloseBenoit P. Gallix, MD, PhD, Montpellier, France (Abstract Co-Author) Nothing to DiscloseCaroline Reinhold, MD, MSc, Montreal, QC (Abstract Co-Author) Consultant, GlaxoSmithKline plc

TEACHING POINTS

1. To review the cross-sectional anatomy of the perirenal space. 2. To describe the interlacing network through which variouspathologic processes infiltrate and spread within the perirenal space.3. To illustrate the specific imaging findings of neoplastic andnon-neoplastic processes of the perirenal space.


OUTLINE• Cross-sectional anatomy of perirenal space Anatomic borders Pathways of spread via interlacing network• Neoplasticconditionso Lymphomao Plasma-cell neoplasmo Metastaseso Primary renal cell carcinomao Retroperitoneal malignancies• Non-neoplastic conditionso Fluid (hematoma, urinoma, abcess, cysts, lymphangioma)o Inflammatory (pancreatitis, xanthogranulomatouspyelonephritis)o Proliferative (retroperitoneal fibrosis, amyloid, extramedullary hematopoisis, rosai-dorfman and erdheim-chesterdisease)CONCLUSION1. Cross-sectional imaging is crucial in diagnosing pathologic processes of the perirenal space. 2. Althoughconsiderable overlap of the imaging findings exist, specific imaging features in combination with clinical history, can help suggestthe correct diagnosis. 3. Imaging-guided percutaneous biopsy can be performed to establish the diagnosis in indeterminate casesallowing for accurate patient management.

Honored Educators


Caroline Reinhold, MD, MSc - 2013 Honored EducatorCaroline Reinhold, MD, MSc - 2014 Honored Educator

GU228-SD-TUB1

Incidence of Contrast-Induced Nephropathy, Dialysis, and Renal Graft Loss after Transplant RenalAngiography

Station #1

GU252-SD-TUB3

70 kV renal CT Angiography with 3rd Generation Dual-source CT for the Preoperative Assessment ofRobotic-assisted Laparoscopic Partial Nephrectomy: Preliminary Study

Station #3

GUS-TUB

Genitourinary Tuesday Poster Discussions

Tuesday, Dec. 1 12:45PM - 1:15PM Location: GU/UR Community, Learning Center

GU



ParticipantsAntonio C. Westphalen, MD, Mill Valley, CA (Moderator) Nothing to Disclose

Sub-Events

ParticipantsGhaneh Fananapazir, MD, Sacramento, CA (Presenter) Nothing to DiscloseBehrad Golshani, MD, Sacramento, CA (Abstract Co-Author) Nothing to DiscloseMichael T. Corwin, MD, Sacramento, CA (Abstract Co-Author) Nothing to DiscloseSima Naderi, MD, Sacramento, CA (Abstract Co-Author) Nothing to DiscloseChris Bent, MD, SACRAMENTO, CA (Abstract Co-Author) Nothing to DiscloseRamit Lamba, MD, Sacramento, CA (Abstract Co-Author) Nothing to Disclose

PURPOSE

To report the incidence of contrast-induced nephropathy (CIN), dialysis, and renal graft loss attributable to direct intraarterialinjection of the transplanted renal artery in renal allograft recipients.


Our institutional review board approved this retrospective health insurance portability and accountability act complaint study. One-hundred patients underwent conventional transplant renal arteriography. Serum creatinine levels were recorded at baseline, prior tothe arteriogram, and within the 24-72 hours after the angiogram. CIN was assessed on those patients who had a serum creatininewithin the 24-72 hour window. CIN was defined as an increase in serum creatinine of > 0.5 mg/dL and/or 1.5 times the pre-arteriogram creatinine. In those patients with CIN, as well as those who did not meet the criteria for assessing the creatinine in the24-72 hour window, clinical outcomes of need for dialysis and renal allograft loss 30 days after angiography were evaluated.

RESULTS

Thirty-seven patients met the criteria for assessing for CIN, of which three patients (8%) demonstrated CIN after arteriogram.None of the patients with CIN or those who did not meet the criteria to assess for CIN required dialysis or had graft failure at 30days.

CONCLUSION

Even in patients with a single renal allograft, the risk of CIN appears to be low, with no subsequent need for dialysis or graft loss.


Caution regarding administration of iodinated contrast to renal transplant recipients may have been previously overstated andadministration may be performed safely.

Honored Educators


Ramit Lamba, MD - 2014 Honored Educator

ParticipantsSatoru Takahashi, MD, Kobe, Japan (Presenter) Nothing to DiscloseYoshiko Ueno, MD, Kobe, Japan (Abstract Co-Author) Nothing to DiscloseYuko Suenaga, Kobe, Japan (Abstract Co-Author) Nothing to DiscloseUtaru Tanaka, Kobe, Japan (Abstract Co-Author) Nothing to DiscloseNoriyuki Negi, RT, Kobe, Japan (Abstract Co-Author) Nothing to DiscloseKiyosumi Kagawa, Kobe, Japan (Abstract Co-Author) Nothing to DiscloseKazuro Sugimura, MD, PhD, Kobe, Japan (Abstract Co-Author) Research Grant, Toshiba Corporation Research Grant, KoninklijkePhilips NV Research Grant, Bayer AG Research Grant, Eisai Co, Ltd Research Grant, DAIICHI SANKYO Group

PURPOSE

Robotic partial nephrectomy can minimalize the volume of ischemia during procedure with super-selective renal artery clumping at

GU231-SD-TUB4

Diagnostic Accuracy of MRI and Diffusion-weighted Magnetic Resonance Imaging in PredictingResponse to Neo-adjuvant Chemo-radiotherapy (nCRT) in Patients with Locally Advanced CervicalCarcinoma (LACC): Correlation with Pathological Response

Station #4

GU232-SD-TUB5

Diagnostic Accuracy of PI-RADS v2: Validation with Targeted In-Bore MRI-Guided Prostate Biopsy

Station #5

Robotic partial nephrectomy can minimalize the volume of ischemia during procedure with super-selective renal artery clumping atthe distal arterial branches. Although meticulous evaluations of intra-renal arterial are warranted, the evaluation is challenging oncurrent renal CT angiography (CTA) because of limited contrast between the intra-renal arterial branches and the renal cortex.Since low-energy CT radically improve contrast enhancement in CTA, we evaluated the ability of 70 kV renal CTA with 3rdgeneration dual-source CT for depicting intra-renal arterial branches.


We retrospectively evaluated 23 patients who underwent renal CTA for suspicious renal neoplasm on 192-slice 3rd generation dual-source CT scanner at 70 kV. All patients were given 510 mgI/Kg of contrast media (CM) with an injection rate of 5 mL/s and CTAwas acquired using bolus-tracking technique. CT values of the abdominal aorta, the main trunk of the renal artery, and the renalcortex were measured. The most distal artery detected on 0.6 mm slice images was recorded for each patient. The images wereevaluated using semi-automatic vessel tracking between the main trunk of the renal artery and the proximal interlobar artery.Success rate of vessel tracking was recorded for each patient. These results were compared with historical control scanned inconventional multi-slice CT at 120 kV.

RESULTS

CT values of the abdominal aorta, renal artery, and the renal cortex at 70 kV (793, 737, 326 HU respectively) were statisticallygreater than those at 120 kV (330, 321, 154 HU; p<.0001). Although CT value differences between the artery and the renal cortexwere greater at 70 kV protocol, CT value ratio were not significantly different. 70 kV protocol could demonstrate the distalinterlobar artery in most of cases (86%), while the proximal part of interlobar artery were barely depicted at 120 kV. Consequently,success rates of semi-automatic vessel tracking at 70 kV were greater than those at 120 kV (89 % vs. 30 %).

CONCLUSION

70 kV renal CTA with 3rd generation dual-source CT could successfully demonstrate the intra-renal branches of the renal artery,leading to easy and reliable assessment of the tumor-supplying arterial branches.


70 kV renal CTA with 3rd generation dual-source CT is of great use for the preoperative assessment of robotic-assisted partialnephrectomy by demonstrating the tumor supplying arteries.

ParticipantsErsilia Devicienti, Rome, Italy (Presenter) Nothing to DiscloseAnna Lia Valentini, MD, Rome, Italy (Abstract Co-Author) Nothing to DiscloseBenedetta Gui, MD, Rome, Italy (Abstract Co-Author) Nothing to DiscloseElena Rodolfino, Rome, Italy (Abstract Co-Author) Nothing to DiscloseMaura Micco, MD, Rome, Italy (Abstract Co-Author) Nothing to DiscloseLorenzo Bonomo, MD, Rome, Italy (Abstract Co-Author) Nothing to Disclose

PURPOSE

To assess diagnostic accuracy of MRI and diffusion-weighted magnetic resonance imaging (DWI) in predicting response to neo-adjuvant chemo-radiotherapy (nCRT) in patients with locally advanced cervical carcinoma (LACC) and subsequently treated withradical hysterectomy, in correlation with pathological response


70 women (mean age: 52.6 years) with histologically proven cervical cancer and stage FIGO>IB bulky underwent 1.5 T conventionalMRI and DWI, before (pre-nCRT MRI) and at the end of nCRT (post-nCRT MRI). Tumor volume and mADCs (calculated at b=0 and800 s/mm2) were measured at each assessment in order to assess imaging-response to treatment. Radical hysterectomy wasperformed 4 weeks after post-nCRT MRI. Treatment response was classified, according to histopathological results, as completeresponse (CR), microscopical residual disease (microRD<3mm) and macroscopical residual disease (macroRD>3mm). Sensitivity,specificity, positive predictive value (PPV) and negative predictive value (NPV) of MRI were calculated at first groupinghistopathology microRD as CR and also grouping histopathology microRD as macroRD

RESULTS

According to histopathology, 33/70 patients showed CR, 21/70 had microRD and 16/70 showed macroRD. At MRI 46 patientsshowed complete response and 24 patients showed partial response to nCRT. Diagnostic accuracy, sensitivity, specificity, PPV andNPV of MRI were respectively 82,86%, 87,50 %, 81,48%, 58,33 % and 95,65% when grouping histopathology microRD with CR and70,00%, 54,05%, 87,88%, 83,33% and 63,04% when grouping histopathology microRD with macroRD

CONCLUSION

MRI and DWI imaging showed high diagnostic accuracy and in particular high VPN in evaluation of tumor response to nCRT inpatients with LACC. However its diagnostic accuracy is limited in patients with histopathological microRD (< 3mm) because ofintrinsic limit of MRI in spatial resolution


In this study, in which we enrolled a large number of patients with LACC proven by pathological results, MRI shows high diagnosticaccuracy in the evaluation of tumor response to nCRT and it is a reliable tool for surgery modulation

Participants

GU233-SD-TUB6

Evaluation for Reliability and Validity of Newly Developed MRI-based Radiological Scoring System forInvasive Placenta Previa

Station #6

Ely R. Felker, MD, Los Angeles, CA (Presenter) Nothing to DiscloseStephanie A. Lee-Felker, MD, Los Angeles, CA (Abstract Co-Author) Nothing to DiscloseDaniel J. Margolis, MD, Los Angeles, CA (Abstract Co-Author) Research Grant, Siemens AGDavid S. Lu, MD, Los Angeles, CA (Abstract Co-Author) Consultant, Medtronic, Inc Speaker, Medtronic, Inc Consultant, Johnson &Johnson Research Grant, Johnson & Johnson Consultant, Bayer AG Research Grant, Bayer AG Speaker, Bayer AG Robert A. Princenthal, MD, Thousand Oaks, CA (Abstract Co-Author) Employee, Koninklijke Philips Electronics NVJohn F. Feller, MD, Indian Wells, CA (Abstract Co-Author) Consultant, Koninklijke Philips NV Consultant, Visualase, Inc Martin I. Cohen, MD, Thousand Oaks, CA (Abstract Co-Author) Nothing to DiscloseBernadette M. Greenwood, BS, RT, Indian Wells, CA (Abstract Co-Author) Nothing to DiscloseHyung J. Kim, PhD, Los Angeles, CA (Abstract Co-Author) Nothing to DiscloseSteven S. Raman, MD, Santa Monica, CA (Abstract Co-Author) Nothing to Disclose

PURPOSE

To evaluate the diagnostic performance of the recently proposed PI-RADS v2 scoring system, using in-bore magnetic resonance(MR) guided biopsy (MRGB), and to determine the correlation between PI-RADS v2 score and biopsy Gleason score (GS).


IRB-approved, HIPAA-compliant, retrospective study of 153 consecutive patients (102 men with elevated PSA and suspected PCa,and 51 men on active surveillance; mean age 65.6 +/- 8.5 years, median PSA 7.8 ng/mL) with 191 lesions referred for mpMRI(T2WI, DWI, DCE) at 3T followed by MRGB.Targets were originally selected by one of four experienced genitourinary radiologists andthen re-scored using PI-RADS v2 criteria by a fifth radiologist who was blinded to clinical information and biopsy histology. Testcharacteristics, including sensitivity and specificity, were calculated. Clinically significant disease (CSD) was defined as GS 7 orhigher. PI-RADS v2 scores were compared among CSD, clinically insignificant PCa, and benign targets. Spearman Rank test wasused to assess correlation between PI-RADS v2 score and biopsy GS.

RESULTS

Biopsies were clinically significant PCa, insignificant PCa and benign in 63 (33%), 37 (19%) and 91 (48%) patients, respectively.CSD had significantly higher mean PI-RADS v2 score (4.49 +/- 0.56) than insignificant PCa (3.97 +/- 0.79) and benign targets (2.96+/- 0.73) (p < 0.0001). There was a positive correlation between PI-RADS v2 score and GS (r = 0.64, p < 0.0001). Sensitivity,specificity, accuracy, PPV, and NPV of PI-RADS 5 for CSD were: 52%, 93%, 80%, 79%, and 80%; of PI-RADS 4 or higher for PCawere: 90%, 75%, 83%, 80%, and 87%. The NPVs of PI-RADS < 4 for PCa and CSD were 88% and 97%, respectively.

CONCLUSION

PI-RADS v2 performs well as a predictor of MRGB outcome and has moderate to good correlation with biopsy GS.


MRGB is high-yield for detection of CSD in patients with PI-RADS v2 4 and 5 targets.The high NPV of PI-RADS v2 < 4 for CSDsuggests that monitoring of these lesions, rather than immediate targeted biopsy, may be a consideration for management.

ParticipantsYoshiko Ueno, MD, Kobe, Japan (Presenter) Nothing to DiscloseTetsuo Maeda, Kobe, Japan (Abstract Co-Author) Nothing to DiscloseKazuhiro Kitajima, MD, Nishinomiya, Japan (Abstract Co-Author) Nothing to DiscloseSatoru Takahashi, MD, Kobe, Japan (Abstract Co-Author) Nothing to DiscloseUtaru Tanaka, Kobe, Japan (Abstract Co-Author) Nothing to DiscloseYuko Suenaga, Kobe, Japan (Abstract Co-Author) Nothing to DiscloseKazuro Sugimura, MD, PhD, Kobe, Japan (Abstract Co-Author) Research Grant, Toshiba Corporation Research Grant, KoninklijkePhilips NV Research Grant, Bayer AG Research Grant, Eisai Co, Ltd Research Grant, DAIICHI SANKYO Group

PURPOSE

To examine the reliability and validity for a newly developed MRI-based radiological scoring system for invasive placenta previa


This study was based on the retrospective review of prenatal MR images of 70 patients (median age: 35 years) who underwent MRexamination at 1.5 T for the screening of invasive placenta previa. Eighteen out of 70 patients were pathologically diagnosed withinvasive placenta previa. MR imaging included axial, coronal and sagittal T2-weighted half-Fourier single-shot turbo spin echosequence and sagittal T1-weighted gradient echo sequence. Cumulative radiological score (CRS) was defined as a sum of Likert 5-point agree/disagree scale for six MR features: T2 dark band, intraplacental abnormal vascularity, uterine bulging, heterogeneousplacenta, myometrial thinning and placental protrusion sign. Two expert radiologists (reader A and B) and two inexperiencedresidents (reader C and D) who were blinded to the patient's outcome independently calculated their CRS (range 5-30). The inter-rater reliability of the CRS was assessed by intraclass correlation coefficient (ICC) measurement. The correlation between the CRSand invasive placenta previa was assessed by logistic regression analysis. For evaluation of the diagnostic performance of the CRSfor invasive placenta previa, the receiver operating characteristic (ROC) analysis was performed.

RESULTS

The inter-rater reliability was excellent for the expert radiologists (ICC: 0.85), fair-to-good among all four readers (ICC: 0.72) andthe inexperienced residents (ICC: 0.66). In logistic regression analysis, there was a significant correlation between the CRS andinvasive placenta previa for all readers (R2, A: 0.57, B: 0.61, C: 0.45, D: 0.55, p<0.05). ROC analysis showed the cut off value was17 (Sensitivity: 88.9%, Specificity: 92.3%, Accuracy: 91.4%; for reader A, Sensitivity: 83.3%, Specificity: 92.3%, Accuracy:90.0%; for reader B, Sensitivity: 83.3%, Specificity: 92.3%, Accuracy: 90.0%; for reader C, Sensitivity: 50.0%, Specificity: 98.0%,Accuracy: 85.7%; for reader D).

CONCLUSION

UR124-ED-TUB7

Hypovascular Focal Lesions of the Kidney: Imaging Spectrum with CT, CEUS, MR and PathologyCorrelation

Station #7

UR002-EB-TUB

Top Ten Pearls and Pitfalls of Magnetic Resonance Urography (MRU)

Hardcopy Backboard

We have developed a new MRI-based radiological scoring system that demonstrates excellent or fair-to-good inter-rater reliability,significant association, and high diagnostic performance with invasive placenta previa.


This new MRI-based radiological scoring system is suitable for the diagnosis of invasive placenta previa.

ParticipantsJavier L. Moreno Negrete, MD, Barcelona, Spain (Presenter) Nothing to DiscloseBlanca Pano Brufau, MD, Barcelona, Spain (Abstract Co-Author) Nothing to DiscloseLaura Herrero, MD, Barcelona, Spain (Abstract Co-Author) Nothing to DiscloseRafael Salvador Izquierdo, MD, Barcelona, Spain (Abstract Co-Author) Nothing to DiscloseCarmen Sebastia Cerqueda, MD, Barcelona, Spain (Abstract Co-Author) Nothing to DiscloseCarlos Nicolau, MD, Barcelona, Spain (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

-Recognize the multiple differentials of a hypovascular renal focal lesion, point out the imaging features of the most frequentetiologies and review the diagnostic keys of the least frequent causes.-Review the Bosniak classification (with particular emphasisin CEUS and CT), the management of renal cysts and the correlation between the different imaging techniques.-Propose adiagnostic approach for hypovascular renal lesions.


Introduction Introduction. CT, MR and CEUS protocols and technical issues. Avascular (Cystic) lesions. Review of Bosniak'sClassification by CT. Evaluation of CEUS and MR for Cyst Classification. Benign (Bosniak I-II) Indeterminate (Bosniak IIF) Malignant(Bosniak III-IV) Hypovascular lesions. Benign. Infections, vascular causes, fatty AMLs, granulomatous diseases (Sarcoid) Malignant

ParticipantsMarc Dilauro, MD, MSc, Ottawa, ON (Abstract Co-Author) Nothing to DiscloseNicola Schieda, MD, Ottawa, ON (Presenter) Nothing to DiscloseNajla Fasih, MBBS, Ottawa, ON (Abstract Co-Author) Nothing to DiscloseKrishna Prasad Shanbhogue, MD, New York, NY (Abstract Co-Author) Nothing to DiscloseTrevor A. Flood, MD, FRCPC, Ottawa, ON (Abstract Co-Author) Nothing to DiscloseEvan S. Siegelman, MD, Philadelphia, PA (Abstract Co-Author) Consultant, BioClinica, Inc; Consultant, ICON plc; Consultant, ACRImage Metrix

TEACHING POINTS

1. Understand how to design and implement a comprehensive MRU protocol 2. Appreciate common technical pitfalls and how todetect and avoid them 3. Develop an approach to the diagnosis of urothelial pathologies with MRU and understand commoninterpretive pitfalls


Technical Pitfalls/Pearls1. Insufficient distention mimics/obscures pathology; Saline/Furosemide improves distention 2. Peristalsismimics strictures; Thick-slab heavily T2W TSE dynamic sequences capture peristalsis 3. TSE flow artifact mimics filling defects;Acquire orthogonal TSE and balanced SSFP 4. T2* effects overwhelm T1 shortening; Dilute gadolinium concentration or useGadoxetic acid Interpretive Pitfalls/Pearls1. Hemorrhage may demonstrate restricted diffusion; Do not rely solely on DWI fordiagnosis2. Not all hilar masses are urothelial cell carcinoma (UCC); Hilar RCC mimics UCC 3. Infiltrative lesions are not always UCC;Other malignancies (e.g. lymphoma) and benign (e.g. pyelonephritis, contusion) causes should be considered4. Not all bladder wallthickening is malignant; Benign etiologies preserve the bladder wall layers5. Not all venous tumor thrombus is from RCC; UCC rarelycauses venous thrombosis6. Satisfaction of search is critical in MRU; UCC often demonstrates multifocality

Honored Educators


Evan S. Siegelman, MD - 2013 Honored EducatorKrishna Prasad Shanbhogue, MD - 2012 Honored EducatorKrishna Prasad Shanbhogue, MD - 2013 Honored Educator

MSCC33

Case-based Review of Nuclear Medicine: PET/CT Workshop-Cancers of the Abdomen and Pelvis (InConjunction with SNMMI) (An Interactive Session)

Tuesday, Dec. 1 1:30PM - 3:00PM Location: S406A

GI GU CT NM


ParticipantsJanis P. O'Malley, MD, Birmingham, AL (Director) Nothing to DiscloseCiaran J. Johnston, MD, Dublin, Ireland (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) Identify the utility of PET CT in staging a wide variety of primary and recurrent GI, GU and gynecological cancers. 2)Differentiate patterns of physiological FDG uptake from pathologic processes. 3) Expalin the importance of CT correlation forselected cancer subgroups. 4) Describe the role of PET CT in assessing patient response to radiation therapy and chemotherapy,including early assessment and PET influenced treatment strategies.

SSJ10-01 MR-guided In-bore versus MRI/Ultrasound Fusion Plus TRUS-guided Prostate Biopsy: A ProspectiveRandomized Trial in Patients with Prior Negative Biopsies

Tuesday, Dec. 1 3:00PM - 3:10PM Location: E353C

SSJ10-02 Accuracy of Targeted Prostate Biopsy Using MR-ultrasound Fusion to Guide Biopsies Directed to FocalLesions Suspicious for Malignancy: A Retrospective Study of 286 Patients


SSJ10

Genitourinary (Prostate Intervention)


GU IR MR US



ParticipantsAytekin Oto, MD, Chicago, IL (Moderator) Research Grant, Koninklijke Philips NV; ; ; Temel Tirkes, MD, Indianapolis, IN (Moderator) Nothing to Disclose

Sub-Events

AwardsTrainee Research Prize - Resident

ParticipantsLars Schimmoeller, MD, Duesseldorf, Germany (Presenter) Nothing to DiscloseMichael Quentin, MD, Dusseldorf, Germany (Abstract Co-Author) Nothing to DiscloseChristian Arsov, MD, Duesseldorf, Germany (Abstract Co-Author) Nothing to DiscloseDirk Blondin, MD, Duesseldorf, Germany (Abstract Co-Author) Nothing to DiscloseRobert Rabenalt, Duesseldorf, Germany (Abstract Co-Author) Nothing to DiscloseGerald Antoch, MD, Duesseldorf, Germany (Abstract Co-Author) Nothing to DiscloseAndreas Hiester, Dusseldorf, Germany (Abstract Co-Author) Nothing to DiscloseErhard Godehardt, Duesseldorf, Germany (Abstract Co-Author) Nothing to DiscloseHelmut Erich Gabbert, D-40225 Dusseldorf, Germany (Abstract Co-Author) Nothing to DisclosePeter Albers, MD, PhD, Duesseldorf, Germany (Abstract Co-Author) Nothing to Disclose

PURPOSE

This study prospectively compares the PCa detection rate (PCa-DR) of MR-guided in-bore biopsy (IB-GB) alone and MRI/ultrasoundfusion-guided biopsy combined with a systematic TRUS-GB (FUS+TRUS-GB) in patients with at least one negative TRUS-GB and PSAlevel ≥4ng/ml.


253 patients were included in this study. After multiparametric prostate MRI (T2WI, DWI, DCE-MRI) at 3T patients with any PI-RADS sum score ≥10 were prospectively randomized to IB-GB or FUS+TRUS-GB. Analysis of detection rates for PCa and significantPCa (Gleason score ≥7), highest Gleason score, number of biopsy cores to detect one (significant) PCa, positivity rate of biopsycores, and tumor involvement per biopsy core were performed.

RESULTS

210 patients met all study requirements and were prospectively randomized, 106 patients receiving IB-GB and 104 patientsFUS+TRUS-GB (age 65.3±7.1 vs. 66.7±6.8 years; median PSA 10.0 vs. 10.8 ng/ml, IQR 7.8-14.9 vs. 7.4-15.5 ng/ml). Mean numberof cores was 5.61±0.80 vs. 17.38±1.17; p<0.001. PCa-DR for IB-GB was 36.8% (29.2% for significant PCa) and for FUS+TRUS-GB39.4% (31.7%); p=0.776 and p=0.765. Mean highest Gleason score of 7.24±0.96 vs. 7.46±1.01; p=0.233. Positivity rate per biopsycore was 20.7% (123/595) vs. 11.6% (210/1,808); p<0.001. Number of biopsy cores needed to detect one PCa or one significantPCa was 15.3 vs. 44.1 and 19.2 vs. 54.8.

CONCLUSION

The combined biopsy approach did not significantly improve the overall PCa-DR compared to targeted IB-GB alone, but requiredsignificantly more cores. A prospective comparison of MR-targeted biopsy alone to systematic TRUS-GB is justified.


We did not observe a difference between IB-GB and FUS+TRUS-GB to detect PCa.

ParticipantsGuilherme C. Mariotti, MD, Jundiai, Brazil (Presenter) Nothing to DiscloseTatiana Martins, MD, Belo Horizonte, Brazil (Abstract Co-Author) Nothing to DiscloseMarcos R. Queiroz, MD, Sao Paulo, Brazil (Abstract Co-Author) Nothing to DiscloseThais Mussi, MD, Sao Paulo, Brazil (Abstract Co-Author) Nothing to DiscloseRodrigo Gobbo, Sao Paulo, Brazil (Abstract Co-Author) Nothing to DiscloseRonaldo H. Baroni, MD, Sao Paulo, Brazil (Abstract Co-Author) Nothing to Disclose

PURPOSE

Demonstrate an increase in the accuracy of targeted prostate biopsy using MR-ultrasound fusion to guide biopsies directed to focal

SSJ10-03 Targeted MR-guided Prostate Biopsy: Are Two Biopsy Cores per MRI Lesion Required?


SSJ10-04 Prostate Cancer Aggressiveness: Correlation Between Multiparametric MRI and Molecular StaggingUsing the CCP Score (Prolaris™ test)


Demonstrate an increase in the accuracy of targeted prostate biopsy using MR-ultrasound fusion to guide biopsies directed to focallesions suspicious for malignancy in a retrospective study of 286 patients.


A single-institutional, IRB approved retrospective analysis of 286 patients in our database, which underwent targeted prostatebiopsies using MR-ultrasound fusion from August 2013 to January 2015.We included all patients with suspected prostatic cancerbased on clinical or laboratory findings (positive digital rectal examination or high PSA) submitted to multiparametric MRI and US-MRIfusion prostate biopsy.We excluded 7 patients with MRI-biopsy interval >= 6 months, 17 patients that underwent biopsy for stagingof known cancer or active surveillance and 1 patient for whom clinical data was unavailable.

RESULTS

A total of 261 patients were included. Of these, 45 patients (17%) underwent previous negative transrectal US-guided biopsies.Table 1 summarizes demographic data of our casuistic.Pre-procedure MRI followed a Likert scale for suspition: Likert 1: 1 patient(0,4%); Likert 2: 18 patients (6,9%); Likert 3: 100 patients (38,3%); Likert 4: 75 patients (28,7%); Likert 5: 67 patients(25,7%).Overall positivity of the biopsies for tumors was 59% (154 cases), with 79% (123 cases) significant cancer (Gleason>=7),19% (30 cases) non-significant cancer (Gleason 6) and 1 case of STUMP. Analyzing only the Likert 4 and 5 cases, in a total of 142cases, the overall positivity was 76% (108 cases), with 90% (96 cases) significant cancer (Gleason>=7), 10% (11 cases) non-significant cancer (Gleason 6) and 1 leiomyoma. In our institution, the positivity of US-guided random biopsies, in a large sample ofother patients in the same period (331 patients), was around 52%.

CONCLUSION

Our study demonstrates a significant improvement in the performance of prostate biopsy with US- MRI fusion compared to randomUS-guided biopsies, with potential clinical impact.


Random prostate biopsies performed on a sextant-basis have a high incidence of false-negative results, and often diagnosemicrofocal lesions with low clinical significance. Targeted prostate biopsies using MR-ultrasound fusion have shown to detectclinically significant lesions and increase the accuracy of the procedure, with better clinical outcomes.

ParticipantsLars Schimmoeller, MD, Duesseldorf, Germany (Presenter) Nothing to DiscloseMichael Quentin, MD, Dusseldorf, Germany (Abstract Co-Author) Nothing to DiscloseChristian Arsov, MD, Duesseldorf, Germany (Abstract Co-Author) Nothing to DiscloseFrederic Dietzel, Dusseldorf, Germany (Abstract Co-Author) Nothing to DiscloseDirk Blondin, MD, Duesseldorf, Germany (Abstract Co-Author) Nothing to DiscloseGerald Antoch, MD, Duesseldorf, Germany (Abstract Co-Author) Nothing to DiscloseAndreas Hiester, Dusseldorf, Germany (Abstract Co-Author) Nothing to DiscloseRobert Rabenalt, Duesseldorf, Germany (Abstract Co-Author) Nothing to DisclosePeter Albers, MD, PhD, Duesseldorf, Germany (Abstract Co-Author) Nothing to Disclose

PURPOSE

This study evaluates the efficiency and potential benefit of taking two biopsy cores per MRI lesion when performing targeted MR-guided prostate biopsy.


1545 biopsy cores of 774 intraprostatic lesions (two cores per lesion) in 290 patients (66.2±7.8 years; median PSA 8.2 ng/ml; IQR6.0-12.0 ng/ml) were retrospectively evaluated regarding PCa detection, Gleason score, and tumor infiltration of the first (FBC)compared to the second biopsy core (SBC). All patients received previously a multiparametric (mp)-MRI (T2WI, DWI, DCE) of theprostate at 3T and all lesions were histologically verified by MR-guided in-bore biopsy.

RESULTS

491 biopsy cores were prostate cancer (PCa) positive, 239 of 774 (30.9%) FBC and 252 of 771 (32.7%) SBC (p=0.446). 61 FBC vs.78 SBC detected significant PCa with a Gleason score ≥4+3=7 (25.5% vs. 31.0%; p=0.125). 687 SBC (89.1%) showed no histologicdifference to the FBC. 74 SBC resulted in a higher tumor involvement per core when detecting the same Gleason sore (38.1%). Intotal 29.9% of the PCa lesions were Gleason-upgraded by SBC. 40 SBC detected PCA by negative FBC (5.2%). 43 SBC resulted in aGleason upgrade (5.6%). 20 SBC showed a Gleason upgrade from a Gleason score 3+3=6 to ≥3+4=7 (2.6%) and 4 SBC to a Gleasonscore ≥4+3=7 (0.5%). 14 SBC showed a Gleason upgrade from 3+4=7 to ≥4+3=7 (1.8%).

CONCLUSION

The benefit of a second targeted biopsy core per suspicious MRI lesion is likely minor, especially regarding a significant Gleasonupgrade. Therefore a further reduction of biopsy cores is feasible when performing a targeted MR-guided in-bore prostate biopsy.


Provided a correct biopsy position was documented a second biopsy core per MRI lesion may be omitted for targeted MR-guided in-bore biopsy.

ParticipantsRaphaele M. Renard-Penna, Paris, France (Presenter) Nothing to DiscloseGeraldine Cancel-Tassin, Paris, France (Abstract Co-Author) Nothing to Disclose

SSJ10-05 Multi-parametric MRI (MpMRI) Findings after Focal Laser Ablation for Prostate Cancer (Pca)


Eva M. Comperat, MD, Paris, France (Abstract Co-Author) Nothing to DiscloseJustine Varinot, Paris, France (Abstract Co-Author) Nothing to DisclosePierre Mozer, MD, PhD, Paris, France (Abstract Co-Author) Nothing to DiscloseMorgan Roupret, Paris, France (Abstract Co-Author) Nothing to DiscloseMarc O. Bitker, Paris, France (Abstract Co-Author) Nothing to DiscloseOlivier Lucidarme, MD, Paris, France (Abstract Co-Author) Consultant, Bracco Group Consultant, F. Hoffmann-La Roche LtdConsultant, Boehringer Ingelheim GmbH Olivier Cussenot, Paris, France (Abstract Co-Author) Nothing to Disclose

PURPOSE

To correlate the ESUR-PI-RADS components as prognostic imaging biomarkers in localized prostate cancer to the Gleason score andthe molecular CCP score (Prolaris™) .


107 patients who had a multiparametric (mp) MRI before (RP) were selected. The largest lesion (index lesion) was measured on T2-MRI (Fig 1A) and ADC map and was classified with the ESUR-PI-RADS scoring system. A region of interest (ROI) was drown in thecenter of each target, on the ADC map . A single ADC ROI was correlated to histologically index proven lesion. The index lesionspointed out by mp MRI were matched on RP specimens and were run in Myriad's Research Laboratory in accordance with theProlaris™ protocol in order to perform CCP score

RESULTS

For each index lesion the Pearson's correlations between, pretherapeutic CAPRA score, compoments of the ESUR-PIRADS score,including the maximal diameter (Tmax) and the topography of the index tumor were compared with the histo-pathologicalobservations on the RP specimen.ESUR-PI RADS score and its components were tested with logistic regression model in oreder toassess their predictive value for Gleason's grade 4, CCP score value on the index lesion.On one hand, significant negativecorrelation was found between mean ADCs and diameter of the index lesion with Gleason's grade 4 ( p=0.0078). The logisticregression model including Tmax (over 10mm) and ADC (under 800) predict with confidence Gleason'grade 4 in the index lesion (Fig3). On the other hand, The Tmax or ADC size of the index lesion, remains unable to point out the aggressiveness of 7 tumoursdefined by CCP score. Among those, six were Gleason 6 (3+3) with a median Tmax of 8mm, and one of 8 mm was Gleason 7(3+4)

CONCLUSION

By mapping image features to gene expression data we were able to show that diffusion imaging and tumor size offer a potential forin vivo non invasive assessment of prognostic cancer aggressiveness.However CCP score related to high risk of lethal cancer didnot, completely match with the mpMRI tumour map and Gleason score in 7% of patients. These results previosuly suggested bylarge scale genomic analysis suggest that the further management of early stages PCa could strongly beneficed of targeted biopsywith moelcular analysis


This radio genomic correlation suggest that management of PCa could strongly benefit from both MRI targeted biopsy andsubsequent molecular analysis.

ParticipantsAytekin Oto, MD, Chicago, IL (Presenter) Research Grant, Koninklijke Philips NV; ; ; Shiyang Wang, PhD, Chicago, IL (Abstract Co-Author) Nothing to DiscloseXiaobing Fan, PhD, Chicago, IL (Abstract Co-Author) Nothing to DiscloseStephen Thomas, MD, Chicago, IL (Abstract Co-Author) Nothing to DiscloseAmbereen Yousuf, MBBS, Chicago, IL (Abstract Co-Author) Nothing to DiscloseGregory S. Karczmar, PhD, Chicago, IL (Abstract Co-Author) Nothing to DiscloseTatjana Antic, Chicago, IL (Abstract Co-Author) Nothing to DiscloseScott Eggener, Chicago, IL (Abstract Co-Author) Research Grant, Visualase, Inc Speakers Bureau, Johnson & Johnson

PURPOSE

To describe the quantitative and qualitative MpMRI findings following focal laser ablation of Pca


27 patients with 36 cancer foci on baseline MRI, underwent MRI guided focal laser ablation were prospectively followed with,immediate (36/36 sites), 3-month (36/36 sites) and 12-month (24/36 sites) post-procedure 3T MpMRI and TRUS guided biopsy at12 months. Qualitative and quantitative MpMRI findings including size and appearance of ablation defect, ADC, K(trans) and Vewere recorded and compared between the follow-up studies and between patients with and without residual disease.

RESULTS

36 cancer foci were ablated in 27 patients. Ablation defect was clearly visible on 36/36, 11/36 and 0/24 sites on the immediate, 3-month and 12-month post-contrast DCE-MR images respectively, with a gradual decrease in size on 3 month MRI even in visiblecases. Focal atrophy/scarring was noted at the site of ablation in 10/36 and 20/24 sites on 3-month and 12-month MRI. MeanK(trans) values were significantly lower on post-procedure MRI`s compared to baseline values (p<0.05). Mean ADC values on 3-month MRI were significantly higher than the baseline ADC values (p<0.05). There was not significant change in Ve (p>0.05). In 2/4cases with residual cancer, focal early enhancement was noted on 12-month DCE-MR Images. Other than 1 case with residualcancer, no focal lesion (other than diffuse and ill-defined changes secondary to ablation) was noted at the ablation site on 12-month T2 and ADC images.

CONCLUSION

Immediate post-contrast MR images are helpful for identification of the ablation defect. Quantitative MR parameters such as ADCand K (trans) change significantly following ablation. Early focal enhancement on DCE-MR Images at the ablation zone at 12-month

SSJ10-06 Primary and Secondary Prostate Biopsy Settings: Differences When Performing Targeted MR-guidedBiopsies


MRI is a suspicious finding for residual tumor.


Follow-up MR images can be obtained at 12 months after laser ablation and early focal enhancement at the ablation zone can beconsidered suspicious for residual cancer.

Honored Educators



ParticipantsFrederic Dietzel, Dusseldorf, Germany (Presenter) Nothing to DiscloseLars Schimmoeller, MD, Duesseldorf, Germany (Abstract Co-Author) Nothing to DiscloseMichael Quentin, MD, Dusseldorf, Germany (Abstract Co-Author) Nothing to DiscloseDirk Blondin, MD, Duesseldorf, Germany (Abstract Co-Author) Nothing to DiscloseChristian Arsov, MD, Duesseldorf, Germany (Abstract Co-Author) Nothing to DiscloseGerald Antoch, MD, Duesseldorf, Germany (Abstract Co-Author) Nothing to DiscloseAndreas Hiester, Dusseldorf, Germany (Abstract Co-Author) Nothing to DiscloseRobert Rabenalt, Duesseldorf, Germany (Abstract Co-Author) Nothing to DiscloseErhard Godehardt, Duesseldorf, Germany (Abstract Co-Author) Nothing to DisclosePeter Albers, MD, PhD, Duesseldorf, Germany (Abstract Co-Author) Nothing to Disclose

PURPOSE

This study evaluates the MR-guided in-bore biopsy (IB-GB) in patients, who were either biopsy naive (primary biopsy) or who hadundergone at least one previous negative trans-rectal ultrasound-guided biopsy (secondary biopsy) with regard to cancer detectionrate, tumor localization and lesion size.


In total, 1,602 biopsy cores from 297 patients (66.1±7.8y; median PSA 8.2ng/ml; prostate volume 58±30ml) in primary (n=160) andsecondary (n=137) prostate biopsies settings were evaluated in this retrospective study. All patients received diagnostic prostateMRI (T2WI, DWI, DCE) at 3T. All lesions described on MRI were biopsied with IB-GB and examined histologically.

RESULTS

In 148 patients 511 cores were positive for prostate cancer (PCa). Clinically significant PCa was found in 82.4% (any Gleasonpattern ≥4). PCa detection rate for patients with primary biopsies was 55.6% and 43.1% for secondary biopsies. In patients withprimary vs. secondary biopsies, PCa was located peripherally in 62.5% vs. 49.5% (p=0.04), in the transition zone in 27.3% vs.27.5% (p=0.53), and in the anterior stroma in 10.2% vs. 22.9% (p<0.01). Higher grade PCa (Gleason score ≥4+3=7) occurredapically in 38.5% (p=0.01). PCa detection rates for patients with smaller prostate volumes (<30ml vs. 30-50ml vs. >50ml; p<0.01)or larger lesion sizes (>0.5cm3 vs. 0.5-0.25cm3 vs. <0.25cm3; p<0.01) were significantly higher.

CONCLUSION

In primary and secondary prostate biopsies PCa detection rates were significantly higher for larger lesions and smaller prostateglands. In secondary biopsies, PCa was anteriorly located at a significantly more frequent rate. Higher grade PCa was detected inboth settings in an apical location more often.


MRI-guided in-bore biopsy led to high detection rates, especially of clinically significant PCa, in primary and secondary prostatebiopsies.

SSJ11-01 Dynamic Contrast-enhanced MRI Combined with Diffusion Weighted Imaging in Differential Diagnosisof Malignant Gestational Trophoblastic Neoplasia and Postpartum Retained Placental

Tuesday, Dec. 1 3:00PM - 3:10PM Location: E353B

SSJ11-02 Variable Sonographic Features and Imaging Underdiagnosis of Partial Molar Pregnancy


SSJ11

Genitourinary (Multimodality Imaging of Pregnancy and Pelvic Floor)


GU MR US


ParticipantsElizabeth A. Sadowski, MD, Madison, WI (Moderator) Nothing to DiscloseMary C. Frates, MD, Sharon, MA (Moderator) Nothing to Disclose

Sub-Events

ParticipantsKangkang Xue, Zhengzhou, China (Presenter) Nothing to DiscloseJingliang Cheng, MD, Zhengzhou, China (Abstract Co-Author) Nothing to DiscloseYong Zhang, DO, Zhengzhou, China (Abstract Co-Author) Nothing to DiscloseTianxia Bei, Zhengzhou, China (Abstract Co-Author) Nothing to Disclose

PURPOSE

To explore the application value of dynamic contrast-enhanced MRI (DCE-MRI) combined with diffusion weighted(DW-MRI) in thedifferential diagnosis of malignant gestational trophoblastic neoplasia(MGTN) and postpartum retained placental tissue(RPT).


The institutional review board approved this retrospective stuty and waived the requirement for informed consent. 74 cases(medianage, 30.6 years; age range, 20-48 years) of MGTN and RPT confirmed clinically were retrospectively analyzed, all patientsunderwent DCE-MRI and DW-MRI(500 and 1000 mm²/s) at 3.0T. Types of time signal-intensity curves(TIC) and quantitativeanalysis of time to peak(TTP), maximum contrast enhancement ratio(MCER) and ADC values of each case were performed.Differences in TTP, MCER, and ADC values between MGTN and RPT were evaluated using the independent samples t-testrespectively.The sensitivity, specificity and accuracy of dynamic contrast-MRI, DW-MRI and combination of the two methods indiagnosing MGTN and RPT were calculated.

RESULTS

There were 39 MGTN, of which 13 lesions were invasive mole and 26 lesions were choriocarcinoma. There were 35 RPT, of which 14lesions were normal retained placenta, 6 lesions were adherent placenta and 15 lesions were implanted placenta. The mean ADCvalue and TTP of MGTN(1.38±0.11×10-3mm²/s, 37.84±3.73 s) were significantly different( p<0.01 ) from that ofRPT(2.03±0.56×10-3mm²/s, 102.11±9.14 s).The MECR of MGNT(248.58±19.28%) was not significantly different (P>0.05) from thatof RPT(236.45±16.77%) statistically. The sensitivity, specificity and accuracy in diagnosing MGTN and RPT was 84.62%, 85.71%,85.13% for DCE-MRI; 89.74%, 88.57%, 89.19% for DW-MRI; 94.87%, 94.29%, 94.59% for combination of the two methods.

CONCLUSION

MGTN and RPT has different features in DCE-MRI and DW-MRI respectively, and the combination of the two methods can providehigh application value for the differential diagnosis of MGTN and RPT.


The clinical issues and standard imaging features of malignant gestational trophoblastic neoplasia and postpartum retained placentaltissue are similar, and the combination of DWI and dynamic-enhanced MRI can help clinician distinguish them, so as to decidetreatment plans.

ParticipantsJulia Savage, MD, Ann Arbor, MI (Presenter) Nothing to DiscloseKatherine E. Maturen, MD, Ann Arbor, MI (Abstract Co-Author) Consultant, GlaxoSmithKline plc; Medical Advisory Board,GlaxoSmithKline plcErika Mowers, MD, Ann Arbor, MI (Abstract Co-Author) Nothing to DiscloseKatherine Pasque, MD, Ann Arbor, MI (Abstract Co-Author) Nothing to DiscloseAshish P. Wasnik, MD, Ann Arbor, MI (Abstract Co-Author) Nothing to DiscloseVanessa Dalton, MD, Ann Arbor, MI (Abstract Co-Author) Nothing to DiscloseJason Bell, MD, Ann Arbor, MI (Abstract Co-Author) Nothing to Disclose

PURPOSE

The goal of this study is to describe the ultrasound findings in histopathologically proven molar pregnancies and to correlate thesefindings with clinical parameters including serum beta-hCG levels and partial vs. complete molar pregnancy.


Retrospective chart review revealed 72 women with failed pregnancy or elective termination with histopathologic diagnosis of molar

SSJ11-03 Performance of Translabial Ultrasound versus Pelvic Floor MRI in the Detection of Transvaginal MeshImplant Complications


pregnancy and available ultrasound images between January 1, 2001 to December 31, 2011. Clinical data, ultrasound images andreports were reviewed.

RESULTS

Mean age of women was 30.45 ± 6.97 years of age (range: 16-49), with 1.25 ± 1.49 prior pregnancies (range: 1-11). Meangestational age (GA) by last menstrual period was 74.45 ± 19.07 days (range: 39-138) and median serum beta-hCG was 64,400(range: 447-662,000), with expected positive correlations between mean sac diameter (MSD) vs. beta-hCG (r=0.45, p=0.004) andMSD vs. GA (r=0.54, p<.0001). Pathologic results showed 49 partial and 23 complete moles. By imaging, partial moles were morecommonly described as having a discrete gestational sac (85.7 vs 21.7%, p<.0001), yolk sac (48.9 vs. 4.6%, p=0.0003), or fetalpole (57.1 vs. 0%, p<.0001), while complete moles were more likely to show clearly abnormal tissue in the uterus (82.6 vs. 20.8%,p<.0001) and to be prospectively diagnosed as molar pregnancy by the dictating radiologist (86.9 vs. 40.82%, p=0.0002).

CONCLUSION

Partial molar pregnancy is associated with a highly variable sonographic appearance and frequent detection of recognizableproducts of conception, which may contribute to its underdiagnosis by imaging. Complete molar pregnancy is more strikinglyabnormal and thus recognizable by imaging, and commonly diagnosed prospectively.


Suspicion of hydatidiform mole in failed pregnancy has impacts on clinical management including: need for uterine evacuation,submission of products of conception to pathology, and serum b-hCG surveillance; failure to prospectively suggest or diagnosemolar pregnancy may negatively impact patient care.

Honored Educators



ParticipantsKaroly Viragh, MD, Los Angeles, CA (Presenter) Nothing to DiscloseSeth A. Cohen, MD, Los Angeles, CA (Abstract Co-Author) Nothing to DiscloseShlomo Raz, MD, Los Angeles, CA (Abstract Co-Author) Nothing to DiscloseSteven S. Raman, MD, Santa Monica, CA (Abstract Co-Author) Nothing to Disclose

PURPOSE

The goal of the study was to determine the efficacy of 2D and 3D dynamic translabial ultrasound versus pelvic floor MRI in thedetection of transvaginal mesh implant complications.


With IRB approval and HIPAA compliance, a retrospective observational study was performed to correlate the intraoperative findingsof transvaginal mesh implant complications (perforation, extrusion, fluid collections) with the standard pre-operative translabialultrasound and pelvic floor MRI evaluations in women who were treated with suburethral transvaginal mesh implant for stress urinaryincontinence or pelvic organ prolapse. The pre-operative translabial ultrasound and MRI examinations were reviewed with attentionto technical details. The sensitivity of ultrasound in identifying complications was calculated. The location of the transvaginal meshwith respect to the bladder and urethra was also evaluated (extraluminal, intramural, intraluminal). Factors for technicalimprovement were identified.

RESULTS

The study cohort included 200 women (mean age 55 years) with transvaginal mesh implants for who underwent 2D and 3D dynamictranslabial ultrasound, pelvic floor MRI and mesh excision at our institution between 2007 and 2013. Descriptive statistics wereprovided. 17 patients were found to have perforation into the urethra and/or bladder during surgery. None were found to haveextrusion or significant fluid collections. Translabial ultrasound had a sensitivity of (12/17) 70.5%, whereas detection of meshfragments by MRI was challenging even in retrospect. Limitations were due to suboptimal visualization of the mesh fragments, whichcould be improved with pre-procedural hydration for bladder distention and the use of vaginal gel to better image the suburethralspace.

CONCLUSION

2D and 3D dynamic translabial ultrasound is a powerful real-time method for transvaginal mesh localization and for visualizingcomplications, most importantly perforation into the urethra and/or bladder, which allows for better surgical planning and pre-operative patient counseling.


Translabial ultrasonography is a powerful real-time diagnostic technique for the evaluation of female pelvic floor dysfunction and ismore sensitive than MR in detecting transvaginal mesh perforation.

SSJ11-04 To Determine the Ultrasound Predictors of Successful Treatment of Ectopic Pregnancy Using a SingleDose Methotrexate Protocol: Preliminary Results


SSJ11-05 Accuracy of MRI in the Prenatal Diagnosis of the Abnormally Adherent Placenta: Comparison withFindings at the Time of Delivery


ParticipantsMargarita V. Revzin, MD, Wilton, CT (Presenter) Nothing to DiscloseDennis Toy, New Haven, CT (Abstract Co-Author) Nothing to DiscloseRegina J. Hooley, MD, New Haven, CT (Abstract Co-Author) Nothing to DiscloseLeslie M. Scoutt, MD, New Haven, CT (Abstract Co-Author) Consultant, Koninklijke Philips NV

PURPOSE

Uncomplicated ectopic pregnancy (EP) usually is managed with methotrexate (MTX) and other non-surgical interventions. There islimited data on the expected US findings of MTX treated EPs. The aim of the present study is to identify US predictors ofsuccessful treatment with MTX.


This is a retrospective IRB approved and HIPAA compliant cohort study, exempt from informed consent. The medical records of 121women (mean age of 29 + 5.3 years) who were diagnosed with an EP and underwent a single dose treatment with MTX werereviewed. Only those subjects who had a visible EP without heart activity on US prior to treatment and who had a follow up USafter treatment were included in the study (n=52). Post treatment EP were evaluated with respect to the change in size, shape,echogenicity of the EP, presence of a gestational and yolk sac, fetal heart rate, vascularity, and hemoperitoneum after treatment.Results were correlated with patient b-hCG levels, clinical symptoms and necessity for surgical intervention. Qualitative andquantitative parameters were analyzed using parametric and nonparametric tests.

RESULTS

Separate assessment of the US findings with respect to their sensitivity(Ss), specificity (Sp), NPV and PPV respectively are asfollows: EP change in size 53%, 57%, 45%, 55%, shape 89%, 75%, 85%, 78%, echogenicity 87%, 78%, 85%, 90%, avascularity79%, 90%, 85%, 88%; and absent or small hemoperitoneum 90%, 86%, 87%, 78% ; A combination of at least three of thesefindings was most accurate with Ss 95%, Sp 96%, PPV 95%, NPV 90%.Presence of fetal heart activity, increased size of yolk sacand gestational sac, large amount of hemoperitoneum were strong US predictors of failure of MTX treatment with Ss 100%, Sp100%, PPV 100%, NPV 99%

CONCLUSION

A combination of at least three US findings including stable shape and echogenicity, avascularity and absence or small amount ofhemoperitoneum are best US predictors of successful MTX treatment of EPs. Detection of fetal heart activity, largehemoperitoneum, and increase in size of gestational and yolk sac are strong US predictors of a failure of MTX treatment. Change insize of the EP after MTX treatment is not a reliable predictor of either treatment success or failure.


US findings aid in prediction of successful treatment of ectopic pregnancy using a single dose methotrexate protocol

Honored Educators


Leslie M. Scoutt, MD - 2014 Honored Educator

ParticipantsSherelle L. Laifer-Narin, MD, Englewood, NJ (Presenter) Nothing to DiscloseSidney Z. Brejt, MD, New York, NY (Abstract Co-Author) Nothing to DiscloseSarah Goodman, MD, New York, NY (Abstract Co-Author) Nothing to DiscloseJason Wright, New York, NY (Abstract Co-Author) Nothing to DiscloseJeffrey H. Newhouse, MD, Bronxville, NY (Abstract Co-Author) Research Consultant, PAREXEL International Corporation

PURPOSE

To evaluate the accuracy of magnetic resonance imaging in diagnosing invasive placentation.


A retrospective review of all patients referred for MRI of the placenta from December 2004 to December 2014 was performed.Indications for MRI included abnormal appearance of the placenta on ultrasound, history of prior cesarean delivery, and history ofprior uterine surgery. MRI reports were reviewed for placental location, presence or absence of abnormal placentation according toestablished MRI findings, and suspicion for parametrial involvement. Criteria included the presence of dark intraplacental bands,heterogeneous signal intensity, abnormal vascularization and thickened nodular contour along the urinary bladder surface, uterinebulging into the bladder, and loss of the myometrial margin. MRI was considered positive even if only one of these criteria werepresent. Comparison was made with findings at either delivery or operation, and pathology reports.

RESULTS

256 MRI exams were reviewed. 144 exams were negative both on MRI and delivery/pathology. 8 exams interpreted as normal on MRIunderwent hysterectomy with pathology demonstrating placenta accreta. 80 exams were interpreted as positive for abnormal

SSJ11-06 3T Pelvic MRI Thresholds for Pelvic Organ Prolapse before and after First Childbirth


placentation, and were diagnosed as accreta, increta, or percreta on delivery/pathology. 24 cases interpreted as positive on MRIhad normal placental delivery and pathology. MR diagnosis of abnormal placentation had a sensitivity of 91%, specificity of 86%,PPV of 77%, NPV of 95%, and an accuracy of 87.5%.

CONCLUSION

Placental adhesive disorder is a significant cause of maternal morbidity and mortality. Prenatal MRI is accurate in evaluating invasiveplacentation in patients at high risk for this condition.


MRI can provide topographic information specifically in cases with lateral extension into the parametrical regions. Identification ofabnormal placentation assists the clinician in planning the mode of delivery, extent and location of surgical incision, and determiningthe need for multidisciplinary involvement and assistance.

ParticipantsMark E. Lockhart, MD, Birmingham, AL (Presenter) Nothing to DiscloseHolly Richter, MD, Birmingham, AL (Abstract Co-Author) Research Grant, Pelvalon, Inc; Consultant, Pelvalon, Inc; Consultant,Kimberly-Clark Corporation; Royalties, UpToDate, IncGordon W. Bates, MD, Birmingham, AL (Abstract Co-Author) Nothing to DiscloseTimothy M. Beasley, PhD, Birmingham, AL (Abstract Co-Author) Nothing to DiscloseDesiree E. Morgan, MD, Birmingham, AL (Abstract Co-Author) Research support, General Electric Company

PURPOSE

To evaluate the usefulness of published 3T MRI parameters suggesting pelvic organ prolapse before and after first childbirth


In this IRB-approved HIPAA-compliant prospective cohort study, patients presenting for reproductive assistance were recruited tocomplete validated questionnaires, clinical pelvic exams, baseline dynamic 3T MRI, and repeat MRI 6 months after delivery. Subjectswere nulliparous women, at least 19 years age, and asymptomatic by Pelvic Floor Distress Inventory-20. Predetermined publishedthresholds or 2 SD beyond means in the literature for pelvic prolapse on MRI were evaluated. Also, a 10% change from baseline topostpartum was considered a significant change. Using 120 cc rectal gel and pelvic phased array coil over the pelvis, static 3mmaxial and coronal T2 FSE sequences were followed by 10 mm thick dynamic sagittal HASTE at rest and during strain. The 10 mmsagittal sequence then evaluated pelvic floor mobility during evacuation of the rectal gel. MRI parameters were measured by afellowship-trained radiologist, blinded to clinical data.

RESULTS

19 subjects (mean age 31 years) completed baseline clinical and MRI studies, and 10 (mean age 30.5 years) of them completedpostpartum clinical and MRI studies. None developed significant pelvic floor symptoms by the PFDI-7 and PISQ-12 questionnairesafter childbirth. None had levator tears at baseline; two subjects developed tears postpartum. Mean pelvic floor mobility wasincreased in patients after childbirth and 17 pelvic soft tissue parameters increased by greater than 10% postpartum. At baseline7/133 (5.3%), 8/209 (3.8%), and 79/209 (37.8%) of pelvic soft tissue measurements exceeded published thresholds (indicatingprolapse) at rest, strain, and evacuation, respectively, majority in the anterior compartment. After pregnancy and childbirth, 4/70(5.7%), 6/110 (5.5%), and 51/110 (46.4%) exceeded thresholds at rest, strain, and evacuation, respectively, in this asymptomaticpopulation. Osseous parameters remained unchanged.

CONCLUSION

Although published soft tissue parameters work well for rest and strain MR imaging, their values in evacuatory series are frequentlyexceeded, even in asymptomatic nulliparous and primiparous women.


In nulliparous and primiparous women, the evacuatory phase will commonly exceed published MRI thresholds for pelvic organprolapse and therefore results should be used with caution.

SSJ14-01 Promising Role of Ga-68 PSMA PET/CT over Conventional Imaging in Staging and Restaging ofCarcinoma Prostate

Tuesday, Dec. 1 3:00PM - 3:10PM Location: S504CD

SSJ14-02 18F-fluoro-4-thia-palmitate (18F-FTP) PET Imaging for Evaluation of Exogenous Fatty AcidMetabolism in Prostate Cancer: Implications for Treatment Optimization


SSJ14

Molecular Imaging (Prostate/Neuroendocrine Tumors)


GU BQ MI MR



ParticipantsPeter L. Choyke, MD, Rockville, MD (Moderator) Researcher, Koninklijke Philips NV Researcher, General Electric Company Researcher,Siemens AG Researcher, iCAD, Inc Researcher, Aspyrian Therapeutics, Inc Researcher, ImaginAb, Inc Researcher, Aura Biosciences,IncVikas Kundra, MD, PhD, Houston, TX (Moderator) License agreement, Introgen Therapeutics, Inc

Sub-Events

ParticipantsVenkatesh Rangarajan, MBBS, Mumbai, India (Presenter) Nothing to DiscloseArchi Agrawal, MBBS, Mumbai, India (Abstract Co-Author) Nothing to DiscloseRasika Kabnurkar, MBBS, Mumbai, India (Abstract Co-Author) Nothing to DiscloseNilendu C. Purandare, DMRD, Mumbai, India (Abstract Co-Author) Nothing to DiscloseSneha A. Shah, Mumbai, India (Abstract Co-Author) Nothing to Disclose

PURPOSE

1) To study the utility of Ga-68 Prostate Specific Membrane Antigen (PSMA) Positron Emission Tomography/Computed Tomography(PET/CT) for staging and restaging of Carcinoma Prostate (CaP).2) To compare the efficacy of Ga-68 PSMA PET/CT with ContrastEnhanced Computed Tomography (CECT) and F18 Sodium Fluoride (NaF) PET/CT for lesion detection


Retrospective audit of prospectively maintained data of 25 patients of CaP (3 for staging and 22 with biochemical failure forrestaging) who underwent Ga-68 PSMA PET/CT, CECT and F18 NaF PET/CT scan. The imaging findings were analyzed on lesion-lesion and patient-patient basis for concordance and discordance.

RESULTS

All the 3 cases imaged for staging evaluation demonstrated Ga-68 PSMA uptake at the site of primary while CECT demonstratedlesion in only 1 patient. In cases with suspected biochemical failure, local recurrence was detected in 59% (13/22) patients on Ga-68 PSMA PET/CT as against 9 % (2/22) detected on CECT. In 25 patients studied, Ga-68 PSMA PET/CT detected 43 metastaticnodes compared to 29 detected on CECT. Ga-68 PSMA detected additional metastases in sub cm sized nodes in 24% (6/25)patients. Ga-68 PSMA had incremental value in detecting occult extranodal metastases involving urinary bladder, pararectal noduleand peritoneal deposit in 8% (2/25) patients .In 25 patients, 109 skeletal lesions were detected on Ga-68 PSMA while F18 NaFPET/CT demonsrated147 lesions. Concordance in imaging findings of Ga-68 PSMA PET/CT and F 18 Fluoride PET/CT was noted in68% (17/25) patients. Ga-68 PSMA PET/CT had an incremental value in staging of 1 patient where it detected lytic and marrowmetastases. In restaging group, 7 patients showed additional lesions on F18 NaF PET/CT.

CONCLUSION

Ga-68 PSMA PET/CT is superior in detection of primary, nodal and soft tissue metastases as compared to conventional imagingtechniques. However, F18 NaF PET/CT appears to detect more skeletal lesions in patients with biochemical failure in our study andfurther prospective trials are warranted to confirm these findings.


Ga-68 PSMA PET/CT has an incremental value as a one stop shop in staging and restaging of carcinoma prostate

ParticipantsPedram Heidari, MD, Boston, MA (Presenter) Nothing to DiscloseShadi A. Esfahani, MD, MPH, Boston, MA (Abstract Co-Author) Nothing to DiscloseGiorgia Zadra, PhD, Boston, MA (Abstract Co-Author) Nothing to DiscloseMichael S. Placzek, PhD, Charlestown, MA (Abstract Co-Author) Nothing to DiscloseBenjamin Larimer, PhD, Charlestown, MA (Abstract Co-Author) Nothing to DiscloseJacob M. Hooker, PhD, Charlestown, MA (Abstract Co-Author) Nothing to DiscloseMassimo Loda, MD, Boston, MA (Abstract Co-Author) Nothing to DiscloseUmar Mahmood, MD, PhD, Charlestown, MA (Abstract Co-Author) Research Grant, Sabik Medical Inc; Advisory Board, Blue EarthDiagnostics Limited;

PURPOSE

Upregulation of de novo lipogenesis is a major metabolic change in PCa development, and correlates with tumor progression and

SSJ14-03 Feasibility of Hyperpolarized 13C-Pyruvate Magnetic Resonance Spectroscopy for Pancreatic CancerDiagnostic Imaging


SSJ14-04 Evaluation of Fast Non-enhanced PET/MR Examination Protocols in a Fully Integrated PET/MR

Upregulation of de novo lipogenesis is a major metabolic change in PCa development, and correlates with tumor progression andpoor prognosis. Differentiation of diet-derived versus de novo fatty acid (FA) utilization in PCa is essential in designing anti-lipogenictherapeutics. We aim to evaluate the use of 18F-fluoro-4-thia-palmitate (18F-FTP) PET for assessment of exogenous FA utilizationby PCa.


14C incorporation into lipids of LNCaP cells by a glucose donor (marker of de novo lipogenesis) was measured by a beta-counterafter treatment with vehicle, IPI-9119, or C75. Growth inhibition rescue of LNCaP cells was performed using Cell Titer Glo assayafter incubation with IPI-9119 alone or in the presence of BSA or of BSA-conjugated palmitate. For in-vitro 18F-FTP uptake studyLNCaP cells were incubated with IPI-9119, C75, Etomoxir, SSO, DMSO, and combination of IPI-9119 with Etomoxir or C75 for 24hours. The cells were then incubated with 18F-FTP and harvested to measure retained activity corrected for cell count. IACUCapproval was obtained. Mice with subcutaneous LNCaP xenografts were fasted. PET data was acquired in list mode after injectionof 18F-FTP. The SUVmean and tracer influx constant were measured.

RESULTS

14C incorporation in lipids decreased to approximately 25% of control using both IPI-9119 and C75 indicating FASN inhibition. LNCaPgrowth inhibition was aborted by BSA-conjugated palmitate. 18F-FTP uptake significantly increased with IPI-9119 treatment, whileC75, etomoxir, SSO treatment reduced 18F-FTP uptake. 18F-FTP PET demonstrated significantly decreased uptake in LNCaP tumorsfollowing treatment with C75 and etomoxir compared to control (SUVmean=0.20±0.01, 0.25±0.2, and 0.40±0.02, respectively).

CONCLUSION

We demonstrated that metabolic imaging using 18F-FTP can be used to assess the exogenous FA utilization by PCa. As expected,IPI-9119 (selective FASN inhibitor) increased the exogenous FA (18F-FTP) uptake while C75, which induces a host of metabolicmodulations other than FASN inhibition paradoxically reduces 18F-FTP uptake. Etomoxir (FAO inhibitor) and SSO (FA transporterinhibitor) reduce 18F-FTP uptake as expected.


Understanding the effect of exogenous lipid availability on therapeutic potential of targeting de novo lipogenesis is critical inprostate cancer treatment. This could lead to treatment strategies that result in maximal efficacy.

ParticipantsStephanie K. Carlson, MD, Rochester, MN (Presenter) Royalties, Medspira, LLCAlan Penheiter, PhD, Rochester, MN (Abstract Co-Author) Nothing to DisclosePrasanna K. Mishra, PhD, Rochester, MN (Abstract Co-Author) Nothing to DiscloseFergus J. Couch, PhD, Rochester, MN (Abstract Co-Author) Nothing to DiscloseSlobodan I. Macura, PhD, Rochester, MN (Abstract Co-Author) Nothing to DiscloseJohn D. Port, MD, PhD, Rochester, MN (Abstract Co-Author) Nothing to DiscloseMalgorzata Marjanska, PhD, Minneapolis, MN (Abstract Co-Author) Nothing to DiscloseClaire E. Bender, MD, Rochester, MN (Abstract Co-Author) Nothing to Disclose

PURPOSE

Hyperpolarized (HP) 13C magnetic resonance spectroscopic imaging (MRSI) is a recently developed technique that allows thedetection of injected 13C-labeled agents and their metabolites in real-time. The purpose of this study was to identify and explorepotential metabolic pathways in pancreatic ductal adenocarcinoma (PDAC) that could be targeted with HP-13C MRSI to increasethe diagnostic accuracy of pancreatic cancer imaging.


We performed gene expression profiling using laser capture microdissection and RNAseq on histologically-confirmed primary PDACtumors and normal pancreas tissue from 21 patients. A promising, highly upregulated and imageable metabolic pathway (theconversion of pyruvate to lactate) was identified. To further explore this pathway in vivo, mice bearing genetically-engineeredPDAC tumors were injected with 200 microliters of 80 mM [1-13C]-pyruvate. Tumors were quench-frozen and excised 30 s post-injection. Spectroscopic data on tumor lysates was obtained using 1H and 13C nuclear magnetic resonance. Studies were approvedby our IRB and IACUC.

RESULTS

Gene expression studies showed that transcripts encoding transporters and enzymes responsible for cellular import of pyruvate,export of lactate, and conversion of pyruvate to lactate are almost universally upregulated in PDAC compared to normal pancreas,while competing pathways of mitochondrial pyruvate metabolism and cytoplasmic pyruvate to alanine conversion are consistentlylow. NMR analysis of PDAC tumors showed a tumor metabolic signature consistent with a very high lactate concentration and highlactate-to-alanine ratio. Quantitative analysis after injection of [1-13C]-pyruvate showed a 4.8-fold enrichment of intratumoral [1-13C]-lactate over natural abundance, indicating that ~5% of the total lactate in the tumor at 30 s post-injection was derived fromthe injected [1-13C]-pyruvate.

CONCLUSION

PDAC tumors have a pyruvate-lactate metabolic signature that can be quantitated with 13C-pyruvate NMR. Further exploration ofHP-13C-pyruvate MRSI for PDAC is warranted.


A new molecular imaging strategy for PDAC used in conjunction with existing morphological imaging could transform patientmanagement in clinically-challenging scenarios.

System for Patients with Neuroendocrine Tumours: Direct Comparison to Multiphase Contrast-enhanced PET/CT


SSJ14-05 Qualitative and Quantitative Comparison of 68Ga-DOTATATE PET/CT and PET/ MRI inNeuroendocrine Tumours


ParticipantsFerdinand F. Seith, BSC, Tuebingen, Germany (Presenter) Nothing to DiscloseChristian la Fougere, Munich, Germany (Abstract Co-Author) Nothing to DiscloseChristina Pfannenberg, MD, Tuebingen, Germany (Abstract Co-Author) Nothing to DiscloseKonstantin Nikolaou, MD, Tuebingen, Germany (Abstract Co-Author) Speakers Bureau, Siemens AG Speakers Bureau, Bracco GroupSpeakers Bureau, Bayer AGNina Schwenzer, MD, Tuebingen, Germany (Abstract Co-Author) Nothing to DiscloseCornelia Brendle, MD, Tubingen, Germany (Abstract Co-Author) Nothing to DiscloseChristina Schraml, MD, Tuebingen, Germany (Abstract Co-Author) Nothing to Disclose

PURPOSE

In patients with neuroendocrine tumours (NET), kidney failure is a common complication of radionuclide therapy. It is known thatmultiphase contrast-enhanced PET/CT is superior to non-enhanced PET/CT in diagnosing metastases with low or no tracer uptakeas well as small lesions especially in the liver. However, due to the superior soft tissue contrast of MRI it is possible that non-enhanced PET/MR offers the same information as contrast-enhanced PET/CT. The aim of the study was therefore to evaluate afast protocol in PET/MR without contrast agent in direct comparison to multiphase contrast-enhanced PET/CT as gold standard.


39 Patients (22 female, 58±13 years) were examined in multiphase contrast-enhanced 68Ga-DOMITATE-PET/CT in a clinical setupand in PET/MR subsequently. 2 blinded readers investigated PET/MR examinations of the abdomen with 3 different setups:T2HASTE+PET (30min), T2HASTE+TSET2+PET (35min) and T2HASTE+TSET2+DWI+PET (35min). The T2HASTE was acquired underfree breathing with continuous table move. DWI was acquired with two b-values (0, 800 s/mm2). Metastatic lesions were definedas functional and/or morphological suspicious lesions or lymph nodes. The results were compared with the contrast-enhancedPET/CT, follow-up examinations and histopathology, if available.

RESULTS

T2HASTE sequences were of diagnostic quality in all patients. DWI suffered from artefacts especially in the upper regions of theliver. Compared with contrast-enhanced PET/CT high agreement was found with T2HASTE+TSET2+DWI+PET.

CONCLUSION

A protocol for PET/MR including T2HASTE, TSET2, DWI and PET seems to provide comparable results compared with multiphasecontrast-enhanced PET/CT. With an estimated time of 35 min for a whole body examination, this might serve as a legitimatealternative to contrast-enhanced PET/CT for patients with kidney failure in the future.


In patients with neuroendocrine tumours (NET) and kidney failure, fast non-enhanced PET/MR protocols can serve as a legitimatealternative to multiphase contrast-enhanced PET/CT examinations.

ParticipantsFrancesco Fraioli, MD, London, United Kingdom (Presenter) Nothing to DiscloseAlshaima Alshammari, London, United Kingdom (Abstract Co-Author) Nothing to DiscloseEvangelia Skoura, Athens, Greece (Abstract Co-Author) Nothing to DiscloseRizwan Syed, MBBS, FRCR, London, United Kingdom (Abstract Co-Author) Nothing to DiscloseSofia Michopoulou, London, United Kingdom (Abstract Co-Author) Nothing to DiscloseJamshed Bomanji, London, United Kingdom (Abstract Co-Author) Nothing to DiscloseAshley M. Groves, MBBS, Hitchin, United Kingdom (Abstract Co-Author) Investigator, GlaxoSmithKline plc; Investigator, GeneralElectric Company; Investigator, Siemens AG; ; ;

PURPOSE

Many Neuroendocrine tumours (NET) show high somatostatin receptor avidity. The aim of this study is to compare 68Ga-DOTATATEPET/CT with 68Ga-DOTATATE PET/MRI imaging in patients with known NET, and assess the confidence in anatomic lesion detectionand localization. Furthermore, the value of each sequence of MRI was separately evaluated.


We analysed the data of 38 NET patients. Cross over of both 68Ga-DOTATE PET/CT and PET/MRI scans were performed. MRprotocol was as follow: T1 MPR, pre and post gadolinium injection, T2 haste, DW1 (b0, 500, 1000). Two observers for 68Ga-DOTATATE PET/MRI and one observer for 68Ga-DOTATATE PET/CT, independently, reviewed the images and inter observer andinter modality correlation was assessed by using interclass correlation.

RESULTS

Our initial data showed good inter modality correlation between 68Ga-PET/CT and PET/MRI. All lesions considered as malignant inPET/CT were equally depicted in PET/MRI in the compared regions. Both modalities, revealed liver metastases in the same numberof patients (18 patients), and bone metastases in 7 patients. However, counting the number of liver lesions in each patient, 68Ga-DOTATATE PET/MRI was able to recognize more lesions in 3 patients. On the other hand, more lung lesions were detected in thelung in the CT component compared to MRI component (7 lesions versus 4). The contrast and DWI sequence of PET/MRI did nothave a significant effect on final outcome, but in a selected number of cases these images confirmed and helped to furthercharacterize and detect more lesions. Inter observer reliability was equally very good in both modalities.

SSJ14-06 68Ga-DOTATOC Uptake in Somatostatin Expressing Tumors is Directly Related to Specific Activity:Implications for Receptor Quantitation Imaging


CONCLUSION

This study demonstrates the potential of 68Ga-DOTATOC PET/MRI in patients with NET, with special advantages in thecharacterization of liver lesions.


68Ga-DOTATOC PET/MRI can help in diagnosis and staging of patients with NET, with special advantages in the characterization ofliver lesions.

ParticipantsPedram Heidari, MD, Boston, MA (Presenter) Nothing to DiscloseDominik Berzaczy, MD, Vienna, Austria (Abstract Co-Author) Nothing to DiscloseAlicia Leece, Boston, MA (Abstract Co-Author) Nothing to DiscloseShadi A. Esfahani, MD, MPH, Boston, MA (Abstract Co-Author) Nothing to DiscloseUmar Mahmood, MD, PhD, Charlestown, MA (Abstract Co-Author) Research Grant, Sabik Medical Inc; Advisory Board, Blue EarthDiagnostics Limited;

PURPOSE

The importance of specific activity (SA) has been previously shown in functional PET imaging studies. We hypothesized that traceruptake, measured using semiquantitative (SUV) or quantitative (Patlak plot) parameters, would vary considerably according to SA incancer receptor imaging. This study aims to evaluate the effect of SA on PET parameters used for quantitation of 68Ga-DOTATOCuptake in somatostatin receptor (SSTR) tumor models.


In-vitro, SSTR2 expression level was assessed using Western blot across multiple cancer lines including IMR32, Capan1, A549 andAR42J, and was normalized for Β-actin expression. The SSTR2/Β-actin ratio was correlated to in-vitro 68Ga-DOTATOC uptakenormalized for cell counts. AR42J and IMR32 normalized 68Ga-DOTATOC uptake was plotted against 68Ga-DOTATOC SA rangingfrom 0.2 to 20 Ci/g and correlation was assessed. The in-vitro studies were performed in triplicate. For in-vivo studies InstitutionalAnimal Care and Use Committees approval was obtained. Subcutaneous AR42J xenografts were implanted in Nu/Nu mice. DynamicPET scans in list mode were acquired following injection of 68Ga-DOTATOC with a wide range of SAs (0.3 - 50 Ci/g). Net tracerinflux (Ki), SUVmax and SUVmean were plotted against the SA to establish the correlation between quantitative parameters and SA.Patlak-plot was used to calculate the tracer influx constant for the tumor ((Ki= (k1 × k3 / k2 + k3)).

RESULTS

We observed a consistent ratio between 68Ga-DOTATOC uptake per cell and SSTR2/Β-actin level across the cell lines (R2=0.95,p<0.024). In-vitro we demonstrated a linear correlation between SA and 68Ga-DOTATOC uptake per cell in IMR32 (R2=0.98,P<0.015) and AR42J (R2=0.99, P<0.005). We found that Ki, SUVmax, and SUVmean decreased in a linear fashion with reduction inSA. Quantitative 68Ga-DOTATOC PET parameters had a direct linear correlation with SA (R2=0.89, p<0001 for Ki, R2=0.66,p<0.0001 for SUVmax and R2=0.82 and p<0.0001 for SUVmean).

CONCLUSION

68Ga-DOTATOC uptake is strongly correlated to SSTR2 expression for each given SA. However, 68Ga-DOTATOC uptake in SSTR-expressing tumors increases in a linear fashion with increase in SA, over the range studied.


68Ga-DOTATOC uptake by tumors can vary widely with change in specific activity. Quantitation for radiotherapy dosimetry andresponse assessment is improved with correction for specific activity.

RC407

Quality and Safety in GU Radiology: Update on Best Practices, Contrast Material, and Radiation Dose

Tuesday, Dec. 1 4:30PM - 6:00PM Location: E350

GU SQ


ParticipantsGiles W. Boland, MD, Boston, MA (Coordinator) Principal, Radiology Consulting Group; Royalties, Reed ElsevierRichard H. Cohan, MD, Ann Arbor, MI, ([email protected]) (Presenter) Consultant, General Electric Company; ; ; James A. Brink, MD, Boston, MA (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) Understand the background and current status of best practice clinical and workflow management and its imperitive for improvingpatient outcomes. 2) To review indications for premedication prior to contrast material administration. To summarize the currentunderstanding of iodinated contrast media nephrotoxicity. To describe common errors made in treating contrast reactions. 3) Tounderstand the requirement to match radiation dose according to the individual patient, clinical question and modality used. Tooutline meaningful radiation metrics including organ dosages and the overall radiation absorbed to estimate patient risk.

ABSTRACT

BEST PRACTICES: Increasingly medicine is being defined and evaluated based on patient outcomes rather than procedural events.While best practices are evolving and sometimes incomplete, many do exist, yet there is marked departmental variation from oneorganization to another. This session will outline why and how best practice implementation, particularly as it relates to IV contrastuse and radiation dose, is essential to achieve better patient outcomes. This will require evaluation of current practices andcomparison to nationally driven guidelines, with subsequent compliance to guidelines where they exist. CONTRAST SAFETY: Somepatients have contrast reactions despite premedication. Patients who have repeated reactions in this setting tend to havereactions of similar severity. Studies performed with control groups suggest that there is minimal to no increased risk of contrast-induced renal failure in patients who receive iodinated contrast material; however, the control groups likely included patients atincreased risk of acute kidney injury. Some errors treating contrast reactions relate to failure to administer epinephrine or using thewrong dose / wrong route. The act of administering this drug can also be problematic. RADIATION DOSE: In all radiologicalexaminations that utilize x-rays, there are always three important issues that must be taken into consideration. The first relates tothe appropriate amount of radiation to be used, which must always explicitly take into account the imaging task at hand as well asthe physical characteristics of the patient undergoing the CT examination. The second issue is how to transform the radiationincident on the patient into the organ doses received which are essential to understanding (any) patient risks. The finalconsideration is to understand the radiological significance of the radiation absorbed by the patient, and to estimate (any)radiological risks, as well as the corresponding uncertainties.

RC410A Thyroid Elastography

RC410B Renal Elastography: Where Are We?

RC410C Liver Elastography

RC410

Ultrasound Elastography

Tuesday, Dec. 1 4:30PM - 6:00PM Location: S406B

GI GU HN NR US


Participants

Sub-Events

ParticipantsRichard G. Barr, MD, PhD, Campbell, OH (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; SpeakersBureau, Siemens AG; Consultant, Toshiba Corporation; Research Grant, Esaote SpA

LEARNING OBJECTIVES

1) Explain the difference between strain and shear wave elastography. 2) Understand the techniques to be able to perform thyroidultrasound elastography. 3) Apply ultrasound elastography into routine clinical practice of thyroid nodules.

ABSTRACT

Thyroid nodules are very common and work-up of these nodules remains challenging. Fine needle aspiration has been the method ofchoice for diagnosing suspicious lesions with a sensitivity of 54%-90% and specificity of 60-96% for detection of malignant lesions.Malignant thyroid lesions are statistically stiffer than benign lesions. Ultrasound elastography can assess the stiffness of thyroidlesions. Several studies have been performed evaluating strain and shear wave elastography to characterize thyroid nodules. Strainelastography is qualitative while shear wave elastography is quantitative. These studies suggest that ultrasound elastography mayimprove sensitivity and specificity of characterizing thyroid lesions over B-mode imaging alone. There is a learning curve forperforming adequate thyroid ultrasound elastography. Both cystic lesions and calcified lesions are difficult to evaluate withelastography. There is some overlap of stiffness values between benign and malignant thyroid nodules and elastography should noteliminate biopsy of suspicious lesions based on B-mode imaging. Stiff lesions on elastography should increase the suspicion formalignancy. This presentation will discuss the differences between strain and shear wave elastography, discuss technique andpitfalls in performing the examination, review the literature, and discuss published guidelines.

ParticipantsNicolas Grenier, MD, Bordeaux CEDEX, France, ([email protected]) (Presenter) Advisory Board, Supersonic Imagine;Travel support, Guerbet SA

LEARNING OBJECTIVES

1) To become familiar with the advantages and limits of the different elastography technologies applied to kidney. 2) To understandthe factors affecting reliability and reproducibility of elasticity measurement within the kidney. 3) To learn about the intrarenalchanges responsible for elasticity changes. 4) To learn about the clinical impact of elasticity measurement in renal parenchymaldiseases. 5) To learn about the clinical impact of elasticity measurement in renal tumors.

ABSTRACT

Ultrasound elastography is a new imaging technique under development that provides information about renal stiffness. Kidneyelasticity quantification with ultrasound should be better performed with a quantitative technique, based on shear wave velocitymeasurements (ARFI or SSI methods). Kidney stiffness changes can be affected by mechanical factors such as external pressureinduced by the probe and intrarenal characteristics such as tissue anisotropy, which is high in renal medulla, vascularization, whichis high within the cortex, and hydronephrosis. Chronic kidney disease (CKD) incidence and prevalence are increasing in Westerncountries, due particularly to diabetes mellitus and hypertension-related nephropathies. During progression of such renalparenchymal diseases, cellular density may increase, mainly during acute inflammatory phases, and the interstitial matrix may beinvaded by fibrosis. All components of these tissue changes may induce an increase of renal elasticity which is not specificallyrelated to fibrosis. Tubular, glomerular, interstitial and vascular changes may also be responsible for an increase of stiffness. This iswhy, further studies are now necessary before to understand the real impact of elastography measurement in clinical nephrology.Considering characterization of renal tumors with elastography, clinical experience is still limited. Preliminary results show thatbenign tumors seem to have lower values of elasticity than malignant ones, but, here too, more experience is also necessary.

ParticipantsPaul S. Sidhu, MRCP, FRCR, London, United Kingdom, ([email protected]) (Presenter) Speaker, Bracco Group; Speaker, GeneralElectric Company

LEARNING OBJECTIVES

1) To understand the concept of liver fibrosis grading and the implications for healthcare management. 2) To review the basis forthe assessment of liver fibrosis using elastography, with emphasis on the different techniques. 3) To understand the differences inthe techniques and the variability in measurement assessment. 4) To achieve an overview of the need and position of thistechnique in clinical care.

ABSTRACT

Liver fibrosis and cirrhosis from many causes is an important cause of long term morbidity and mortlaity. Most cases are aconsequence of chronic viral disease (Hepatitis B and C) with alcoholic lever disease an important ethiological factor. The degree ofliver fibrosis, and the presence of established cirrhosis confer differnet mamangement stratergies, with imaging playing an importantrole in the non-invasive assessment of patents with chronic liver disease. Fibrosis grading traditionally performed using the Metaviror Ishak scoring system is essentially a hiistological grading system. Ultimately the possibility to avoid a liver biopsy is the aim, if anon-invasive technique can stage the grade of fibrosis, establishing correct patient management. Liver ultrasound elastography is adeveloping technique that offers this possibility, with varying methods of aassessment ranging form strain methods and shear wavemethods. These techniques will be explained, the status of the current standing of the techniques will be summarised, and the levelof technology offered by differnet machines will be reviewed. An overall summary of the current status and the implications forclinical practice will be discussed.

ED006-WE

Genitourinary Wednesday Case of the Day

Wednesday, Dec. 2 7:00AM - 11:59PM Location: Case of Day, Learning Center

GU



TEACHING POINTS


Honored Educators



SPSH40A Ra-223 Therapy for Skeletal Metastases from Prostate Cancer

SPSH40B Comparison of Ga-68 and F-18 Labeled Small Molecule PSMA Tracers for Prostate Cancer Imaging

SPSH40C PSMA Ligands for Imaging and Therapy of Prostate Cancer

SPSH40

Hot Topic Session: Molecular Imaging and Radionuclide Therapy for Prostate Cancer

Wednesday, Dec. 2 7:15AM - 8:15AM Location: E451A

GU MI OI RO



ParticipantsUwe Haberkorn, MD, Heidelberg, Germany, ([email protected]) (Moderator) Nothing to DiscloseEric M. Rohren, MD, PhD, Houston, TX (Moderator) Nothing to DiscloseAlexander Drzezga, MD, Cologne, Germany (Moderator) Research Grant, Eli Lilly and Company; Speakers Bureau, Siemens AG;Speakers Bureau, General Electric Company; Speakers Bureau, Piramal Enterprises Limited; Research Consultant, Eli Lilly andCompany; Research Consultant, Piramal Enterprises Limited; ; ; ; ; ;

ABSTRACT

Radium-223 is a recently approved therapy for treatment of bone metastases in patients with metastatic prostate carcinoma. As analpha-emitting radioisotope, radium has the potential to be a powerful therapy for treatment of a variety of skeletal malignancies.In this presentation, the use of radium-223 in the treatment of prostate cancer will be reviewed through a case-based format.Future directions in radium-223 therapy will be discussed.

URL

Sub-Events

ParticipantsEric M. Rohren, MD, PhD, Houston, TX (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) Review the chemical and physical features of radium-223 dichloride. 2) Discuss the clinical utility of radium-223 therapy. 3)Understand the technique for radium-223 administration. 4) Review the anticipated outcomes of radium-223 therapy through case-based review.

ABSTRACT

Radium-223 is a recently approved therapy for treatment of bone metastases in patients with metastatic prostate carcinoma. As analpha-emitting radioisotope, radium has the potential to be a powerful therapy for treatment of a variety of skeletal malignancies.

URL

Honored Educators


Eric M. Rohren, MD, PhD - 2015 Honored Educator

ParticipantsCarsten Kobe, Cologne, Germany (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) Understand the concept of PSMA PET-imaging in the diagnosis of prostate cancer in general and in comparison to conventionalmethods. 2) Learn about the currently available alternatives for radiolableling of PSMA-tracers, e.g. 68-Gallium and 18F-Fluoride andtheir characteristics. 3) Gain insights from first comparative studies about the clinical value of the availble tracers with regard totheir sensitivity, specificity and practicability.

ParticipantsUwe Haberkorn, MD, Heidelberg, Germany (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) Understand the background and pharmacokinetics of PSMA ligands for PET/CT. 2) Estimate the value of PSMA-based imaging incomparison to choline-based imaging. 3) Assess the value of PSMA-targeting for diagnosis and therapy. 4) Estimate the effects andside effects of endoradiotherapy with PSMA ligands

ABSTRACT

The prostate-specific membrane antigen (PSMA) is frequently over-expressed in prostate cancer (PCa) which led to the

The prostate-specific membrane antigen (PSMA) is frequently over-expressed in prostate cancer (PCa) which led to thedevelopment of several PSMA-targeting molecules are for the detection and therapy of metastatic castration resistant prostatecancer (mCRPC).In a first diagnostic study 82.8% of 319 patients investigated with 68Ga-PSMAHBED-PET/CT at least one lesionindicative for PCa was detected. Amongst lesions investigated by histology, 30 were false-negative in 68Ga-PSMAHBED-PET/CT, allother lesions (n=416) were diagnosed true-positive or -negative. Fifty of 116 patients available for follow-up received a localtreatment after 68Ga-PSMAHBED-PET/CT. A comparison of the 68Ga-PSMA-ligand with 18F-fluoromethylcholine PET/CT revealed 78PC-suspicious lesions in 32 patients using 68Ga-PSMA-PET/CT and 56 lesions in 26 patients using Choline-PET/CT (significant withp=0.04). All lesions detected by 18F-fluoromethylcholine-PET/CT were also seen by 68Ga-PSMA-PET/CT. Since the ligand bound toPSMA is internalized, the target may also be used for endoradiotherapy. We used a small molecule inhibitor of PSMA MIP-1095 fortherapy in 25 men with final stage mCRPC. PSA values decreased by >50% in 60.7% of the men treated. 84.6 % of men with bonepain showed complete or moderate reduction in pain. Hematological toxicities were mild. 25% of men treated had a transient slightto moderate dry mouth. No adverse effects on renal function were observed.In order to increase the therapeutic flexibilty atheranostic PSMA ligand coupled to DOTA was synthesized which allows coupling to Ga-68 for diagnostic use or to Lu-177 or Ac-225 for therapy. Initial experience in 30 patients shows promising results concerning antitumor activity with mild side effects.

URL

MSCP41A Fetal Thoracic and Abdominal Anomalies

MSCP41B Pediatric Abdominopelvic Tumors

MSCP41C Congenital Disorders of the Genitourinary Tract

MSCP41

Case-based Review of Pediatric Radiology (An Interactive Session)

Wednesday, Dec. 2 8:30AM - 10:00AM Location: S406A

CH GI GU OB PD


ParticipantsSudha A. Anupindi, MD, Philadelphia, PA (Director) Nothing to Disclose

LEARNING OBJECTIVES

1) To apply a systematic approach in the evaluation of pediatric diseases. 2) To identify essential imaging features of variouspediatric congenital, musculoskeletal, abdominal and neurological diseases using a multimodality approach. 3) To understand anddevelop best imaging practice for various pediatric diseases.

ABSTRACT

To apply a systematic approach in the evaluation of pediatric diseases To identify essential imaging features of various pediatriccongenital, musculoskeletal, abdominal and neurological diseases using a multimodality approach To understand and develop bestimaging practice for various pediatric diseases

Sub-Events

ParticipantsChristopher I. Cassady, MD, Houston, TX (Presenter) Nothing to Disclose

LEARNING OBJECTIVES


ParticipantsM. Beth McCarville, MD, Memphis, TN (Presenter) Support, General Electric Company

LEARNING OBJECTIVES


ParticipantsTracy N. Kilborn, MBChB, Cape Town, South Africa (Presenter) Nothing to Disclose

LEARNING OBJECTIVES


MSES41A Catching Ovarian Cancer

MSES41B US and MRI: Imaging of Chronic Pelvic Pain in Women

MSES41C Imaging of the Bladder and Ureters

MSES41

Essentials of Genitourinary Imaging

Wednesday, Dec. 2 8:30AM - 10:00AM Location: S100AB

GU MR US


Participants

Sub-Events

ParticipantsElizabeth A. Sadowski, MD, Madison, WI (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) Review the types of ovarian epithelial neoplasm seen on imaging. 2) Assess the risk of ovarian cancer based on imagingappearance of an adnexal lesion and clinical information. 3) Emphasize the role of MRI in further evaluation of adnexal lesions.

ABSTRACT

There is a spectrum of ovarian epithelial neoplasms ranging from benign to malignant. Current theories regarding the precursorlesions are debated; however, the pathway from benign epithelial neoplasm to low grade carcinoma follows an indolent course andis distinctly different from the aggressive evolution of high grade carcinoma. An understanding of the pathogenesis of low gradeversus high grade ovarian epithelial neoplasms can be helpful to radiologists, when they are faced with an adnexal lesion.Identifying the imaging features suggestive of benign, intermediate and worrisome lesions can triage adnexal lesions into follow upversus treatment. The purpose of this presentation is to review the imaging features of benign, indeterminate and worrisomeadnexal lesions and to discuss the appropriate follow up in each case.

ParticipantsMostafa Atri, MD, Toronto, ON (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) To review MRI and US features of adenomyosis and their correlation with pathology. 2) To discuss staging and US and MRIfeatures of endometriosis and their role in the management of this condition. 3) To familiarize imagers with US features ofdiverticulosis/diverticulitis and how to differentiate it from colitis.

ABSTRACT

Chronic pelvic pain constitutes 10-40% of gynecology visits at a total cost of 39 billion dollars/year in USA. The most commonetiologies are gynecological with GI, urology and MSK conditions being the other causes. During this presentation, imaging featuresof adenomyosis, endometriosis, pelvic congestion, and US features of diverticulosis/diverticulitis are reviewed. Both adenomyosisand endometriosis are common conditions affecting women. They are frequently seen as an incidental finding that can beaccurately evaluated by MRI and US in symptomatic patients. There is close correlation between pathology and imaging features ofadenomyosis. The main role of imaging in the evaluation of endometriosis is in the staging of the disease to plan for surgery. USfeatures of uncomplicated diverticulitis are discussed. Transvaginal US can accurately diagnose diverticulosis/diverticulitis thatshould be sought for in women undergoing US to evaluate for chronic pelvic pain.

Handout:Mostafa Atri

http://abstract.rsna.org/uploads/2015/15001868/IMAGING CHRONIC PELVIC PAIN FINAL RSNA 2015 FINAL.pdf

ParticipantsManjiri K. Dighe, MD, Seattle, WA (Presenter) Research Grant, General Electric Company

LEARNING OBJECTIVES

1) Review embryology and discuss congenital anomalies of the bladder and ureter. 2) Classify and discuss imaging appearance ofureteric and bladder disease. 3) To discuss the protocols and imaging appearance of bladder and ureteric pathology on variousmodalities. 4) Review the staging of bladder and ureteric malignancies. 5) Discuss the imaging appearance of various stages ofbladder and ureteric cancer. 6) Illustrate the newer techniques for imaging of bladder and ureter.

ABSTRACT

The ureter is an extra-peritoneal structure surrounded by fat.; The ureter is divided into three portions: the proximal ureter (upper)is the segment that extends from the ureteropelvic junction to the area where the ureter crosses the sacroiliac joint, the middleureter courses over the bony pelvis and iliac vessels, and the pelvic or distal ureter (lower) extends from the iliac vessels to thebladder. It is a dynamic organ and not a simple conduit through which urine flows. Benign and malignant lesions can affect theureter and these maybe due to contiguous involvement from the kidney or bladder. The ureter can be imaged by a variety ofmodalities including computed tomography (CT), magnetic resonance imaging (MR), direct pyelography (DP) both antegrade (AP)and retrograde (RP), nuclear medicine diuretic scan and voiding cystourethrography (VCUG). Benign lesions like endometriosis,

Ureteritis, Ureteritis cystica can affect the ureter as well. Transitional cell carcinoma in the ureter is usually diagnosed on imaging.Bladder carcinoma is the fourth most common cancer in men and women. Knowledge of imaging options and appearance isnecessary for both radiologists and urologists. Transitional cell carcinoma (TCC) is the most common bladder neoplasm withsquamous cell and adenocarcinoma found in less than 10% of cases.; Benign lesions are uncommon but some can be suggested bytheir imaging appearance. Cystoscopy allows tissue diagnosis and treatment of superficial lesions. Although magnetic resonanceimaging (MRI) and computed tomography (CT) both have limitations in detailing depth of muscle invasion, both have a prominentrole helping to define the lesion and in staging. This presentation illustrates the role of MR and CT in evaluating bladder and ureterwith a discussion of the newer techniques of MR Diffusion Weighted Imaging (DWI) and virtual cystoscopy by CT or MR.

MSRO41

BOOST: Genitourinary-Oncology Anatomy (An Interactive Session)

Wednesday, Dec. 2 8:30AM - 10:00AM Location: S103CD

GU RO



ParticipantsJelle O. Barentsz, MD, PhD, Nijmegen, Netherlands (Presenter) Nothing to DiscloseAlbert J. Chang, MD, PhD, San Francisco, CA (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) Introduce imaging anatomy relevant to prostate cancer and review imaging issues for contouring primary tumors, nodal regions,and adjacent critical structures. 2) Review how the integration of different imaging modalities can affect tumor delineation. 3) Howto choose appropriate imaging methods for specific purposes and to discuss the significance of certain imaging findings.

RC507

Bladder, the Forgotten Organ: Role of CT, MRI, and PET in Diagnosis, Staging, and Surveillance of Cancer

Wednesday, Dec. 2 8:30AM - 10:00AM Location: N229

GU CT MR NM


ParticipantsStuart G. Silverman, MD, Brookline, MA, ([email protected]) (Coordinator) Author, Wolters Kluwer nvAndrew B. Rosenkrantz, MD, New York, NY (Presenter) Nothing to DiscloseHomer A. Macapinlac, MD, Houston, TX (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) Learn the latest developments on the role of CT, MRI, and PET/CT in the detection, diagnosis, staging, and surveillance ofpatients with bladder cancer. 2) Learn currently recommended CT, MRI, and PET/CT techniques and protocols and how toimplement them in clinical practice. 3) Learn how to interpret CT, MRI, and PET/CT scans of the bladder with an emphasis on casereview and diagnostic pitfalls.

ABSTRACT

The urinary bladder is the most common site of malignancy of the urinary tract and is imaged by radiologists on many abdominalimaging exams. However, historically the bladder has been a 'forgotten' organ and thought to be largely the purview of the urologistdue to the central role that cystoscopy has played in both the diagnosis and local staging of bladder cancer. Recent advances inCT, MRI, and PET have emerged that now allow radiologists to play an important role in the detection, diagnosis, staging, andsurveillance of patients with or suspected of having bladder cancer. This course will detail these advances and explain how, when,and why radiologists should be using these three modalities in clinical practice today. Using illustrative case examples, advances inknowledge such as how CT urography can be used to detect bladder cancer, how MR urography can be used to distinguish muscle-invasive from superficial tumors and evaluate the upper tracts, and how PET/CT (and the newly introduced PET/MRI) can be usedto stage and follow patients. With additional advances in low dose CT, emerging MRI techniques, and novel PET agents, radiologywill play an increasingly vital role in the care of patients with bladder cancer in the future.

RC510A 3D Ultrasound in Obstetrics

RC510B Fetal Genitourinary Anomalies

RC510C Placenta

RC510

Second and Third Trimester Obstetrical Ultrasound (An Interactive Session)

Wednesday, Dec. 2 8:30AM - 10:00AM Location: E450B

GU OB US


Participants

LEARNING OBJECTIVES

Please bring your charged mobile wireless device (phone, tablet or laptop) to participate.

Sub-Events

ParticipantsBeryl R. Benacerraf, MD, Brookline, MA (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) To learn the principles of 3D sonography and the applications for fetal scanning. To evaluate clinical situations where 3Dscanning is helpful and where it is not useful beyond the 2D examination. 2) To see examples of fetal malformations scanned in 3Dusing surface rendering and multiplanar reconstruction. 3) To learn how to use volume scanning to dramatically reduce scan timeand improve you scanning efficiency by rescanning stored volumes of complete fetal anatomy.

ABSTRACT

Three-dimensional (3D) ultrasound allows us to acquire a volume and display any plane of section within that volume regardless ofthe scanning orientation. The ability to display a 3D image of any type or plane has been one of the most powerful recent advancesin sonography, particularly in the field of obstetrics and gynecology. In imaging of the fetus, 3D ultrasound is advantageous indemonstrating many types of fetal defects and dysmorphologic facial features using surface rendering. The fetal brain is also one ofthe areas where 3D ultrasound has been most helpful, since the reconstruction of the third non-scanning plane is crucial indemonstrating planes of section not previously visible sonographically. The corpus callosum is an example of one area not readilyimaginable in standard imaging planes. The fetal sutures are also easy to image with 3D, which is particularly helpful in fetuses withsuspected craniosynostosis. 3D ultrasound is key for imaging fetal skeletal abnormalities, providing additional information onaffected fetuses as compared to 2D. Evaluation of the spine using 3D has been helpful to determine the level of spina bifida, thusproviding crucial information regarding prognosis. Evaluation of the fetal heart is an intense area of research interest, and the heartcan be imaged in realtime 3D (4D) using a method called STIC. This method provides the ability to obtain a full volume of thebeating heart to evaluate in detail off line with or without color Doppler and while it is beating.Volume imaging is also key inimproving efficiency of the ultrasound department. The entire fetus can be imaged easily by acquiring and archiving a few volumes.This way, the patient can spend far less time in the ultrasound room and the entire scan can be done remotely and virtually usingthe stored volumes. This techniques reduces operator dependency usually associated with 2D ultrasound.

ParticipantsRoya Sohaey, MD, Portland, OR (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) Apply the Urinary Tract Dilation classification system to fetal imaging practice. 2) Develop an anatomic approach for differentialdiagnosis of urinary tract obstruction. 3) Develop an understanding of which cases would benefit from fetal MR.

ABSTRACT

By the conclusion of this course, the participant will be able to apply the prenatal UrinaryTract Dilation (UTD) classification systemfor diagnosis and follow-up planning. The learner will develop an anatomic approach towards differential diagnosis for obstructivecauses of UTD, renal cystic dysplasia and complex genitourinary anomalies. In addition, a fetal sex-based approach for analysis ofcomplex lower tract anomalies will be discussed. The course will demonstrate how fetal MR is useful as a problem solving tool incertain complex cases. The lecture is didactic and case-based in format.

ParticipantsSara M. Durfee, MD, Boston, MA (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) Identify the cause of vaginal bleeding in patients with placental abnormalities that include placenta previa and placentalabruption. 2) Describe the sonographic features of placenta accreta. 3) Define trophotropism and describe how this process leadsto both normal and abnormal placentation.

ABSTRACT

After this presentation, the participant will understand how the normal placenta develops and how factors such as trophotropismlead to placental abnormalities. Specific abnormalities such as placenta previa, placental abruption and placenta accreta will be

addressed in detail. In addition, first trimester abnormalities such as the chorionic bump and subchorionic hematomas will bediscussed. The presenter will describe the sonographic appearance of succenturiate lobe, circumvallate placenta and sonolucencieswithin the placenta and will comment on placental masses.

RC550

Fallopian Tube Catheterization (Hands-on)

Wednesday, Dec. 2 8:30AM - 10:00AM Location: E260

GU OB


ParticipantsAmy S. Thurmond, MD, Portland, OR (Moderator) Nothing to DiscloseRonald J. Zagoria, MD, San Francisco, CA, ([email protected]) (Presenter) Nothing to DiscloseLindsay S. Machan, MD, Vancouver, BC (Presenter) Nothing to DiscloseA. Van Moore JR, MD, Charlotte, NC (Presenter) Nothing to DiscloseAnne C. Roberts, MD, La Jolla, CA (Presenter) Nothing to DiscloseDavid M. Hovsepian, MD, Stanford, CA (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) Obtain hands-on experience with fallopian tube catheterization using uterine models and commercially available catheters andguidewires. 2) Review the evolution of interventions in the fallopian tubes. 3) Learn safe techniques for fallopian tube recanalizationfor promoting fertility, and fallopian tube occlusion for preventing pregnancy. 4) Discuss the outcomes regarding pregnancy rateand complications. 5) Appreciate ways to improve referrals from the fertility specialists and expand your practice.

ABSTRACT

Fallopian tube catheterization using fluoroscopic guidance is a relatively easy, inexpensive technique within the capabilities ofresidency trained radiologists. Fallopian tube cathterization can be used to dislodge debris from the tube in women with infertility,orto place FDA-approved tubal occlusion devices in women who do not desire fertility. The fallopian tube is the 1 mm gatewaybetween the egg and the sperm. Noninvasive access to this structure for promoting, and preventing, pregnancy has been soughtfor over 160 years. This hands-on course allows participants use commercially available catheters and devices in plastic models forfallopian tube catheterization, and to speak directly to world experts about this exciting procedure.

MSRO42-01 Invited Speaker:


MSRO42-02 A Phase I Dose Escalation Study of Hypofractionated Radiation Therapy for Favorable Risk ProstateCancer: Acute Toxicity and Early Efficacy


MSRO42-03 Robotic Stereotactic Body Radiation Therapy for Organ Confined Prostate Cancer


MSRO42

BOOST: Genitourinary-Integrated Science and Practice (ISP) Session

Wednesday, Dec. 2 10:30AM - 12:00PM Location: S103CD

GU OI RO



ParticipantsStanley L. Liauw, MD, Chicago, IL (Moderator) Nothing to DiscloseGeorge B. Rodrigues, MD, London, ON (Moderator) Nothing to Disclose

Sub-Events

ParticipantsRodney J. Ellis, MD, Pepper Pike, OH (Presenter) Nothing to Disclose

ParticipantsNicholas J. Sanfilippo, MD, New York, NY (Presenter) Nothing to DiscloseWilliam C. Huang, MD, New York, NY (Abstract Co-Author) Nothing to DiscloseHerbert Lepor, MD, New York, NY (Abstract Co-Author) Nothing to DiscloseSilvia C. Formenti, MD, New York, NY (Abstract Co-Author) Nothing to DiscloseBenjamin Cooper, New York, NY (Abstract Co-Author) Nothing to DiscloseSmith Beverly, New York, NY (Abstract Co-Author) Nothing to DiscloseBarry Rosenstein, New York, NY (Abstract Co-Author) Nothing to DiscloseSamir S. Taneja, MD, New York, NY (Abstract Co-Author) Consultant, Eigen Consultant, GTx, Inc Consultant, Bayer AG Consultant,Healthtronics, Inc Speaker, Johnson & Johnson Investigator, STEBA Biotech NV Royalties, Reed Elsevier

ABSTRACT

Purpose/Objective(s): The optimal radiation schedule for the curative treatment of prostate cancer remains unknown. Prostatecancer patients receiving definitive external beam radiation therapy (EBRT) are typically treated 5 days per week for 7-9 weeks.This prolongation of treatment time increases healthcare costs and is less convenient for patients. There is data supporting thenotion that the a/ß ratio for prostate cancer cells is between 1 and 3, suggesting a clinical benefit to hypofractionation. Wetherefore conducted a Phase I dose escalation trial in men with low to low-intermediate risk prostateadenocarcinoma.Materials/Methods: All men with clinical T1-2c, Gleason Score (GS) 6, prostate cancer with a prostatic specificantigen (PSA) less than 10 ng/dL were eligible for this trial. Men with clinical T1-2c, GS 7 prostate cancer and/or PSA 10 - 20ng/dL were included provided the biopsy demonstrated low volume disease (Results: From June, 2012 to December, 2014, 9patients were accrued to the three dose cohorts with a median follow-up of 11 months (range: 2 – 30). Patients had a median ageof 63, pre-treatment PSA of 4.9 ng/dL, and pre-treatment AUA score of 10. Four patients had a GS of 7. The maximum tolerateddose (MTD) was 57.6 Gy with all patients completing treatment with less than or equal to grade 2 maximum gastrointestinal,genitourinary, dermatologic or fatigue related toxicity (Table 1). Six patients have at least 1 PSA post-treatment (3 months aftercompletion) with a median PSA decrease of 65%. One patient of the six with > 11 month follow-up had grade 2 rectaltelangiectasia requiring minor endoscopic cautery. The remaining 5 patients had no grade 2 toxicity thus far.Conclusion: All threedose levels were well tolerated with no MTD identified. Further follow-up is warranted for long term toxicity and efficacy.Table 1:Acute toxicity in patients undergoing hypofractionated radiation.Grade of ToxicityCTCAE v. 4.0Dose Level 154 Gy/ 18 Fxn = 3DoseLevel 255.8 Gy/ 18 Fxn = 3Dose Level 357.6 Gy/ 18 Fxn =3Gastrointestinal023011032000Genitourinary000212312100Dermatitis0333Fatigue03111022

ParticipantsJonathan A. Haas, MD, Mineola, NY (Presenter) Speaker, Accuray IncorporatedAaron E. Katz, MD, Garden City, NY (Abstract Co-Author) Nothing to DiscloseSeth Blacksburg, MD, MBA, New York, NY (Abstract Co-Author) Speakers Bureau, Bayer AG; Owen Clancey, PhD, Mineola, NY (Abstract Co-Author) Nothing to DiscloseMichael Santoro, MD, East Meadow, NY (Abstract Co-Author) Nothing to DiscloseRichard Ashley, MD, Garden City, NY (Abstract Co-Author) Nothing to DiscloseDimitri Kessaris, MD, Manhasset, NY (Abstract Co-Author) Nothing to DiscloseRobert Mucciolo, MD, Massapequa, NY (Abstract Co-Author) Nothing to DiscloseAstrid Sanchez, Mineola, NY (Abstract Co-Author) Nothing to DiscloseDiane Accordino, RN, Mineola, NY (Abstract Co-Author) Nothing to DiscloseSusan Lowery, BA, Mineola, NY (Abstract Co-Author) Nothing to DiscloseWilliam Macmelville, Mineola, NY (Abstract Co-Author) Nothing to DiscloseChristopher Mendez, BA, Mineola, NY (Abstract Co-Author) Nothing to DiscloseMatthew R. Witten, PhD, Mineola, NY (Abstract Co-Author) Nothing to Disclose

MSRO42-04 The Effect of Radiation Timing on PSA Reduction in High Risk Prostate Cancer Patients Treated withDefinitive Radiation Therapy


MSRO42-05 Patient Inversion Therapy for Bowel (PITB) to Achieve Maximum Displacement in Radiotherapy forProstate Cancer


ABSTRACT

Purpose/Objective(s): The unique radiobiology of prostate cancer supports a hypofractionated as opposed to a conventionallyfractionated dose regimen with a potential for improved outcomes and reduced toxicities. We report on our continued experienceusing a robotic linear accelerator to deliver stereotactic body radiation therapy for localized prostate cancer.Materials/Methods:From April 2006 through December 2014, a total of 1207 patients with localized carcinoma of the prostate were treated with roboticstereotactic body radiation therapy at a single institution. All patients had T1c to T2b disease. 493 patients had low risk disease.548 patients had intermediate risk disease. 166 patients had high risk disease. Pretreatment PSAs ranged from .77 to 205. 126patients received hormonal therapy prior to treatment at the discretion of their urologist. Treatment planning was done with CTscans fused with an MRI scan except in 31 cases where an MRI scan could not be done for medical reasons such as a pacemaker.Dose was prescribed to the 83% to 87% line, 5 mm beyond the capsule except posteriorly 3 mm. 1037 patients with low andintermediate risk disease received CyberKnife only to a dose of 3500 to 3625 cGy over 5 fractions. All patients received 1500 mg ofamifostine intrarectally 50 minutes prior to each treatment fraction.Results: The median initial PSA was 6.2. The median follow-upwas 33 months. The median post treatment PSA is 0.35. At the time of last follow-up, 12 patients have had a PSA failure byPhoenix biochemical definition. 1 patient with low risk disease failed. 7 patients with intermediate risk disease failed and 4 patientswith high risk disease failed. There were 136 patients with a minimum follow up of at least 36 months and 56 patients with aminimum follow up of at least 48 months. There are 26 patients with a minimum follow up of 60 months. 272 patients achieved aPSA below 0.2 and 413 patients reached a PSA below 0.4. The median treatment PSA at 12 months is 0.90. The median PSA at 24months is 0.45. The median PSA at 36 months is 0.40. the median PSA at 48 months is 0.25. The median treatment PSA at 60months is 0.20. With a median follow up of 33 months, the biochemical disease free survival for low risk, intermediate risk, and highrisk was 99.7%, 98.7%, and 97.5% respectively. 2 patients had symptomatic hematuria which resolved with hyperbaric oxygen. 2patients required green light laser for urinary retention. 1 patient has required catheterization. 3 patients had rectal bleeding whichresolved with rowasa enemas and hyperbaric oxygen.Conclusion: Stereotactic body radiation therapy using a robotic linearaccelerator continues to be extremely well tolerated and efficacious in the management of localized prostate cancer. High rates oflocal control can be achieved while also achieving low rates of bladder and rectal toxicity. This study confirms prior reported serieswith a larger number of patients.

ParticipantsApar Gupta, Boston, MA (Presenter) Nothing to DiscloseSteven Vernali, Boston, MA (Abstract Co-Author) Nothing to DiscloseAnkit Agarwal, BS, Boston, MA (Abstract Co-Author) Nothing to DiscloseMuhammad M. Qureshi, MBBS,MPH, Boston, MA (Abstract Co-Author) Nothing to DiscloseAlexander E. Rand, BA, Boston, MA (Abstract Co-Author) Nothing to DiscloseAriel E. Hirsch, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose

ABSTRACT

Purpose/Objective(s): We previously found that neither time to treatment (TTT) nor elapsed time of treatment (ETT) had anyeffect on PSA velocity in patients with low- and intermediate-risk prostate cancer. In this analysis, we sought to examine theeffects of TTT and ETT on PSA change in patients with high-risk prostate cancer.Materials/Methods: We performed a retrospectivereview of 1,584 patients who were diagnosed with prostate cancer at our institution between January 2005 and December 2013,and found 412 patients with non-metastatic disease who completed treatment with definitive external beam radiation therapy(EBRT). A total of 146 patients who also received concurrent androgen-deprivation therapy (ADT) were included in the analysis.TTT was calculated as days between positive prostate biopsy and EBRT start date, and ETT was calculated as days between EBRTstart and stop date. Demographic data on race/ethnicity, primary language spoken, insurance status, marital status, and age werealso collected. Analysis of variance was performed to analyze the relationship of these factors with absolute and percentagechange in pre- and post-EBRT PSA levels. Data were analyzed using a 0.05 level of significance.Results: Median age at diagnosiswas 67 years (range 50-85 years); 11% had a Gleason score (GS) of 6, 49% GS 7, and 40% GS 8-10. Median TTT was 134 daysand median ETT was 62 days. No demographic variable was found to be significantly related to absolute or percentage change inPSA. No optimal threshold of days from diagnosis to treatment (TTT) was identified to predict change in PSA level. ETT wassignificantly related to PSA change, after adjusting for demographic variables. Those who fell in the upper quartile of ETT (>64days) were found to have a 94.2% decline in PSA, compared to 98.0% for those who fell in the lower three quartiles(p=0.03).Conclusion: A delay in treatment prior to starting EBRT did not have an effect on post-EBRT PSA level, relative to initialPSA level. However, a delay during EBRT was related to a lesser reduction in PSA decline. Further research is warranted in this areato elucidate the clinical significance of differences in PSA reduction.

ParticipantsGordon L. Grado, MD,PhD, Scottsdale, AZ (Abstract Co-Author) Nothing to DiscloseDavid Constantinescu, Charleston, IL (Presenter) Nothing to DiscloseScott Thompson, CMD, Scottsdale, AZ (Abstract Co-Author) Nothing to DiscloseCarrie S. Petrone, RN, Scottsdale, AZ (Abstract Co-Author) Nothing to DiscloseMary M. Grado, BSN,MS, Scottsdale, AZ (Abstract Co-Author) Nothing to DiscloseMichael C. Grado, BA, Scottsdale, AZ (Abstract Co-Author) Nothing to DiscloseThayne Larson, MD, Scottsdale, AZ (Abstract Co-Author) Research Consultant, NxThera, Inc

PURPOSE

The purpose of this study was to evaluate a new and novel approach to the valuation and reduction of small bowel volume from theirradiated fields in the treatment of prostate cancer. This technique utilizes inversion therapy to either completely displace small orlarge bowel from the irradiated field or to significantly reduce the volume of bowel irradiated in the PTV. This procedure haspotential application in multiple areas of abdominal and pelvic radiation therapy.


MSRO42-06 Institutional Experience of Long-term (10-15 Years) Results with High Dose Rate (HDR) SalvageTherapy for Recurrent Prostate Cancer


MSRO42-07 Designing and Implementing an Innovative Phantom-Based Simulator Training Program for ProstateBrachytherapy Using Advanced Magnetic Resonance Imaging


Between January 2014 and March 2015, 14 consecutive patients were identified where small or large bowel was directly within theirradiated PTV. Patients were evaluated with bladder distention, patient positioning, and inversion therapy to displace bowel fromthe irradiated PTV. Inversion therapy had the greatest effect in displacing and maintaining displacement of bowel from theirradiated volume. Several inversion tables were evaluated prior to the procedure and the two safest devices with the most clinicalexperience for inversion therapy were selected for this trial. Dose volume histograms were compared with and without inversion.

RESULTS

Patients were identified with loops of bowel directly within the radiated field due to previous surgery or anatomy. Standardtechniques for bowel displacement (patient positioning, bladder distention, belly-board), were ineffective at displacing sufficientbowel from the irradiated volume to affect greater radiation dose delivery. Inversion therapy was selected for bowel displacementwhich when combined with bladder distention maintained the displacement during the course of radiation therapy. 13/14 patientswere found to have sufficient bowel displacement to allow greater radiation dose delivery to the PTV without compromising fieldsize or prescribed dose. 1/14 patients did not benefit from this technique.

CONCLUSION

Patient inversion therapy for bowel (PITB) achieved excellent bowel displacement for radiation therapy to the pelvis. In thesepatients, neither the radiation therapy field nor the prescribed dose had to be compromised. Patients also had fewer bowel andbladder symptoms during the pelvic radiation therapy. This technique is determined to be useful, easily applicable, and welltolerated by patients.


This procedure permits higher radiation therapy dose delivery to the PTV with fewer side effects and morbidity due to lesssmall/large bowel volume irradiated.

ParticipantsNevine M. Hanna, MD, Sandy, UT (Presenter) Nothing to Disclose

ABSTRACT

Purpose/Objective(s): Limited treatments are available for recurrent prostate cancer patients. Modality selection can be challengingfor both the patient and their physicians. HDR brachytherapy has been used extensively as a boost after external beam radiationtherapy, but is increasingly being tested as salvage treated for locally recurrent prostate cancer. We report our long-term resultsfor HDR salvage brachytherapy in patients with initially low, intermediate, and high risk prostate cancer.Materials/Methods: Patients(n=27) with a median age of 71 (57-84) years at recurrence with low- (n=10), intermediate- (n=8), and high-risk prostate cancer(n=9) treated at the California Endocurietherapy (CET now at UCLA) between 1991 and 2009 were analyzed. Median HDRbrachytherapy dose prescription was 36 (22-46) Gy in 6 (3-8) fractions. Five patients did receive additional external beam radiationtherapy (EBRT) after HDR brachytherapy to an EBRT dose of 36 (36-50) Gy. Presenting disease characteristics were medianrecurrent PSA 8.1 (1.4-86.7) ng/mL, Gleason Score 7 (5-10), median prostate volume 23.2 (0-80) cc. Androgen deprivation therapy(ADT) was administered in 68% for a median of 6 (3-96) months. Risk groups were defined according to the NCCN guidelines.Sustained PSA nadir+2 was used to define biochemical relapse. Statistical analyses being performed are to include Kaplan-Meieranalyses and univariate and multivariate Cox proportional analyses.Results: Preliminary analysis shows that the median overallfollow-up time was 6.90 (0.30-15.92) years. The 5, 10 and 15 year overall survival (OS) rates were 86%, 36% and 11%,respectively. The 5, 10 and 15 year distant metastases-free survival (DMFS) rates were 68%, 29% and 11%, respectively.Biochemical progression free survival (BPFS) for the initially presenting low, intermediate and high grade patients is 122, 59, and 41months, respectively. On univariate analyses, BPFS after salvage HDR was most significantly impacted by PSA at recurrentdiagnosis (p=0.007) but not significantly affected by risk group at initial diagnosis (P>0.05). Univariate Cox analyses andmultivariate analyses are currently underway to determine the impact of ADT on these parameters.Conclusion: Our long-term datavalidates HDR salvage brachytherapy in recurrent prostate cancer patients as a standard treatment option which offers excellentrates of disease control.


ParticipantsNikhil G. Thaker, MD, Houston, TX (Presenter) Nothing to DiscloseTze Yee Lim, Houston, TX (Abstract Co-Author) Nothing to DiscloseRajat Kudchadker, Houston, TX (Abstract Co-Author) Nothing to DiscloseTharakeswara K. Bathala, MD, Houston, TX (Abstract Co-Author) Nothing to DiscloseThomas Pugh, Houston, TX (Abstract Co-Author) Nothing to DiscloseUsama Mahmood, Houston, TX (Abstract Co-Author) Nothing to DiscloseDeborah A. Kuban, MD, Houston, TX (Abstract Co-Author) Nothing to DiscloseTeresa Bruno, Houston, TX (Abstract Co-Author) Nothing to DiscloseJihong Wang, PhD, Houston, TX (Abstract Co-Author) Nothing to DiscloseR. Jason Stafford, PhD, Houston, TX (Abstract Co-Author) Nothing to DiscloseThomas A. Buchholz, MD, Houston, TX (Abstract Co-Author) Nothing to DiscloseS J. Frank, MD, Houston, TX (Abstract Co-Author) Board Member, C4 Imaging LLC; Stockholder, C4 Imaging LLC; Advisory Board,Elekta AB

PURPOSE

Prostate brachytherapy (PB) is a well-established treatment for localized prostate cancer and has the potential to deliver excellent

MSRO42-09 Stereotactic Body Radiation Therapy for Primary Lesion of Renal Cell Carcinoma

Wednesday, Dec. 2 11:50AM - 12:00PM Location: S103CD

outcomes at low cost. However, high-quality PB requires hands-on training and expertise in image-guidance, which is minimallyemphasized in current radiation oncology training. Additionally, MRI holds promise of improving target delineation over CT imaging.Our objective was to design and implement a unique pilot training program that utilizes advanced MRI and a phantom simulatorapproach to improve the quality of PB education.


Our existing PB phantom simulator program was adapted to introduce MRI treatment planning and post-implant evaluation. Thesimulator program emphasized six core areas: patient selection, simulation, treatment planning, implantation, treatment evaluation,and outcome assessment. Trainees in the simulator program were residents, fellows, or physicists. The program utilized the Iodine-125 pre-operative planning technique and a transrectal ultrasound device to implant prostate phantoms. MRI markers weresubstituted for spacers to allow for visualization.

RESULTS

Forty one trainees have completed the phantom simulator program to date. Ten implants were successfully conducted during theMRI-phantom simulator pilot program. MRI 3DT2 CUBE sequence could adequately delineate the prostate, seminal vesicles, rectumand bladder in the CIRS 053MM phantom. Dummy seeds could be well-visualized with post-implant CT scans. However, seedidentification on MRI required a learning curve due to the need to identify MRI markers, which flanked each dummy seed (Figure).The MRI markers facilitated detection of up to 97% of seeds in implanted phantoms by identifying the signal voids between MRImarkers.

CONCLUSION

This proof-of-principle educational curriculum successfully adapted a phantom simulator training program to implement advancedMRI simulation, treatment planning, and post-implant dosimetry. Analysis of implants showed that most organs could be adequatelyvisualized with MRI and that most seeds could be identified with the aid of MRI markers. Phantom-based simulator training programscan provide a valuable educational opportunity to learn the PB process and to learn how to implement advanced image-guidance.


Phantom-based simulator training can enhance practical expertise with advanced imaging technology and image-guide therapies.

ParticipantsHotaka Nonaka, Chuo, Yamanashi, Japan (Presenter) Nothing to Disclose

ABSTRACT

Purpose/Objective(s): We assessed the efficacy and toxicity of stereotactic body radiation therapy (SBRT) for primary lesion ofrenal cell carcinoma (RCC).Materials/Methods: We retrospectively reviewed 9 patients (7 male and 2 female) with stage I RCCtreated with SBRT between 2007 and 2014. The diagnosis of RCC was judged according to imaging. The median age was 73 yearsold (range, 59-79). Three patients had high serum creatinine level before SBRT. Four patients had history of prior contralateralnephrectomy. The median diameter of tumor was 18 mm (range, 9-26). A total dose of 60-70 Gy in 10 fractions was administeredat the 95% of planning target volume or internal target volume. Median biologically effective dose was 119 Gy (range 96-119),using an a/ß value of 10 Gy. Overall survival (OS) and local progression-free survival (LPFS) were based on Kaplan Meier estimates.Toxicity was scored according to NCI-CTCAE, version 4.0. Renal disorder was graded by referring to pretreatment renalfunction.Results: The median follow-up duration after SBRT was 28 months (range, 11-89). Clinical response was partial response(PR) in 5 tumors, stable disease (SD) in 4 tumors. Five tumors with PR has decreased gradually in size for 11-56 months (median,42) after SBRT. Three patients developed distant metastases. The 2- and 3- year OS rate were 85.7% and 64.3%, respectively(median survival time, 44 months). The 3- year LPFS rate was 100%. In a case of a patient with SD tumor, autopsy was performedat 29 months after SBRT, and it showed almost complete necrosis of tumor tissues with a small amount of viable renal carcinomacells. Three patients developed Grade 3 chronic kidney disease (CKD), 1 had Grade 2 CKD. All patients with Grade 3 CKD had highserum creatinine level before SBRT, and 2 of these patients had prior contralateral nephrectomy before SBRT. Severe toxicity forother organs at risk was not observed.Conclusion: SBRT for primary lesion of RCC resulted in acceptable LPFS and toxicity. Becauseof slow tumor response, we need long-term follow up to observe the effect of SBRT for RCC. Multicenter prospective study ismandatory to evaluate true local effect and toxicity and to compare SBRT versus other local treatment modalities for RCC.

SSK08-01 Assessing the Role of Quantification of Shear Wave Velocity and Tissue Elasticity in the Detection ofInterstitial Fibrosis within the Transplant Kidney


SSK08-02 Improved Temporal Resolution and Image Contrast for Kidney DCE-MRI by 3D Spoiled Gradient-recalled Echo Sequence with Compressed Sensing


SSK08

Genitourinary (Functional Imaging of the Kidneys)

Wednesday, Dec. 2 10:30AM - 12:00PM Location: E450B

GU MR US


ParticipantsHarriet C. Thoeny, MD, Bern, Switzerland (Moderator) Nothing to DiscloseZhen J. Wang, MD, Hillsborough, CA (Moderator) Nothing to Disclose

Sub-Events

ParticipantsDavid Ferguson, MBBCh, Vancouver, BC (Presenter) Nothing to DiscloseAmdad M. Ahmed, MBChB, FRCR, Birmingham, United Kingdom (Abstract Co-Author) Nothing to DiscloseMohammed F. Mohammed, MBBS, Vancouver, BC (Abstract Co-Author) Nothing to DiscloseCaitlin Schneider, Vancouver, BC (Abstract Co-Author) Nothing to DiscloseChristopher Nguan, Vancouver, BC (Abstract Co-Author) Nothing to DiscloseAlison C. Harris, MBChB, Vancouver, BC (Abstract Co-Author) Nothing to Disclose

PURPOSE

Novel ultrasound techniques allow for the assessment of tissue fibrosis. One such technique ('Virtual Touch IQ') allows for bothqualitative and quantitative measurement of shear wave velocity to assess tissue strain and detect underlying fibrosis. Using thistechnique, in the setting of renal allograft failure, we aim to compare the gold standard of renal biopsy and histological grade withthat of shear wave velocity measurement to evaluate for potential underlying interstitial fibrosis.


Patients undergoing renal biopsy for renal graft dysfunction within the ultrasound department were enrolled prospectively over aneight-month period. In addition to routine routine renal ultrasound with Doppler imaging, shear wave velocity measurements using'Virtual Touch IQ' were obtained from the target area for renal cortical biopsy. Sufficient magnitude of the shear wave wasconfirmed on quality display. Biopsies were performed and reviewed by a nephropathologist, blinded to the imaging results, withhistological categorization according to the Banff classification.Shear wave velocities and histological grade were compared todetermine significance. Statistical analysis was performed using the Mann Whitney test and Spearman-correlation-coefficient (rho).

RESULTS

Fourteen patients were identified and subcategorized according to the Banff category with respect to interstitial fibrosis as normal(n=4), grade 1(n=4), grade 2 (n=3) and grade 3(n=3). Median shear wave velocity was demonstrated to be significantly higher inrenal transplants with biopsy proven interstitial fibrosis (median=2.512m/s) than those without interstitial fibrosis(median=1.925m/s) (Mann Whitney U=4, n1=4, n2=10, p<0.05). Positive correlation was also identified between the mean shearwave velocity and Banff categories (rho= 0.731, p=0.003).

CONCLUSION

Preliminary data indicates that shear wave velocity within cortex of the transplant kidney correlates significantly with interstitialfibrosis in the context of renal allograft failure.


Shear wave velocity analysis is a potentially valuable non-invasive tool to assess for renal allograft interstitial fibrosis.

ParticipantsKai Zhao, PhD, Beijing, China (Presenter) Nothing to DiscloseBin Chen, Beijing, China (Abstract Co-Author) Nothing to DiscloseJue Zhang, Beijing, China (Abstract Co-Author) Nothing to DiscloseXiaoying Wang, MD, Beijing, China (Abstract Co-Author) Nothing to Disclose

PURPOSE

To verify the feasibility of combine Compressed Sensing (CS) technique in dynamic contrast-enhanced magnetic resonance imaging(DCE-MRI) of kidney


Nine healthy New Zealand rabbits underwent kidney DCE-MRI studies on a clinical 3.0T MR scanner. 3D spoiled gradient-recalledecho sequence modified with CS scheme was scanned before and after the administration of 0.05 mmol/kg of Gd-DTPA with thefollowing parameters: TR = 3.3ms, TE = 1.3ms, FA = 15°, slice thickness = 3 mm, matrix =128×128, FOV = 180mm and 16 sliceswere acquired. Four accelerations (2-x, 3-x, 4-x, 8-x) were scanned as well as the fully sampling every other day for each animal in

SSK08-03 Noninvasive Evaluation of Stable Renal Allograft Function Using Shear-Wave Elastography


SSK08-04 Assessment of Renal Allograft Function Early after Transplantation Using Renal IVIM with Healthy asControl


DCE MR imaging. The contrast-to-noise ratio (CNR) and signal-to-noise ratio (SNR) of the reconstructed images of the kidney wereanalyzed and compared to that of the fully sampled images separately.

RESULTS

The images with 2-X, 3-X, 4-X, 8-X CS acceleration and fully sampled results were shown from row 1 to row 5. The 8-Xaccelerated images appeared blurring which may due to the loss of a mass of high frequency information (Figure 1).Signal intensitycurves of cortex and medulla were represented in Figure 2. The reconstructions of 8-X were also blurring.Superior CNR performancebetween cortex and tissue CNR_ct, and medulla and tissue CNR_mt were found for all the time points after contrast administration.CNR_ct of CS reconstructed images were significantly larger than that of the conventional fully sampled images at all accelerationsthroughout the enhancement (p<.01 for 2-X; p<.001 for 3-X and 4-X). CNR_mt of CS reconstructed images were also significantlylarger than that of the fully sampled images (p<.01 for 2-X; p<.001 for 3-X and 4-X). CNR_cm measured from cortical and medullaryregions were larger in CS reconstructed images, especially at the initial time of enhancement: 44.00 10.0 for 2-X, 43.30 8.0 for 3-Xand 49.78 14.9 for 4-X vs. 15.28 6.7 for 1-X (p<.001 for all) (Table 1).In SNR analysis, SNR-cortex (SNR_c) and SNR-medulla(SNR_m) of CS reconstructed images were all found statistically different from conventional fully sampled images (p<.001) (Table2).

CONCLUSION

Compressed sensing is a feasible and promising acceleration method to improve temporal resolution and image contrast in renalDCE-MRI.


CS is a promising imaging method with both improved temporal resolution and image contrast, which will be widely used in thefuture.

ParticipantsJung Jae Park, MD, Seoul, Korea, Republic Of (Presenter) Nothing to DiscloseChan Kyo Kim, MD, PhD, Seoul, Korea, Republic Of (Abstract Co-Author) Nothing to DiscloseBeom Jun Kim, Seoul, Korea, Republic Of (Abstract Co-Author) Nothing to DiscloseByung Kwan Park, MD, Seoul, Korea, Republic Of (Abstract Co-Author) Nothing to Disclose

PURPOSE

Protocol renal allograft biopsies improve outcomes via early detection and treatment of subclinical rejection (SCR). Shear-waveelastography (SWE) assesses quantitatively the tissue elasticity. The aim of our study was to investigate the feasibility of SWE inevaluating patients with stable renal allograft function who underwent protocol biopsies.


95 patients (mean age, 48.3 years; range, 21-73 years) with stable renal allograft function who underwent ultrasound (US)-guidedprotocol biopsies at 10 days or 1 year after transplantation were enrolled in this retrospective study. All US and elasticityexaminations of renal allograft were performed by a commercial scanner using a convex transducer (C5-1 ElastoPQ, Philips iU 22).SWE was performed immediately before protocol biopsies. Tissue elasticity (kPa) in the cortex was measured for all renal allografts.Clinical and US variables were compared between patients with SCR and without SCR using the Student t -test. The correlationbetween estimated glomerular filtration rate (eGFR) and tissue elasticity was evaluated in all patients by Pearson correlation.Diagnostic performance of tissue elasticity to distinguish between patients with SCR and without SCR was analyzed using a receiveroperating characteristics (ROC) curve analysis.

RESULTS

Acute rejection (AR) was pathologically confirmed in 34 patients. The mean tissue elasticity of ARs (31.0 ± 12.8 kPa) wasstatistically greater than that no ARs (24.5 ± 12.2 kPa) ( P < 0.001), while the resistive index values did not show statisticaldifference between ARs and no ARs ( P = 0.112). Clinical variables including age, kidney size, creatinine and eGFR revealedstatistical differences between ARs and no ARs ( P < 0.05). Tissue elasticity demonstrated a moderate negative correlation witheGFR (correlation coefficient= -0.604, P < 0.001). At ROC curve analysis, the area under the curve (AUC) of tissue elasticity was0.651 and followed eGFR (AUC= 0.728).

CONCLUSION

SWE, as a noninvasive tool, may be feasible in distinguishing between allograft with SCR and without SCR in patients with stablerenal function. Moreover, it may demonstrate functional state of renal allografts.


As a feasible technique, shear-wave elastography may help to noninvasively assess functional state of patients with stable renalallograft function.

ParticipantsLihua Chen, Tianjin, China (Presenter) Nothing to DiscloseTao Ren, Tianjin, China (Abstract Co-Author) Nothing to DiscloseWen Shen, Tianjin, China (Abstract Co-Author) Nothing to DisclosePanli Zuo, Beijing, China (Abstract Co-Author) Nothing to Disclose

PURPOSE

Graft dysfunction is a common complication following transplantation,which is associated with allograft survial. Intravoxel incoherent

SSK08-05 Renal Hemodynamics and Oxygenation Evaluated by ASL, BOLD and Oxygen Extraction Fraction(OEF) Imaging in Animal Model of Diabetic Nephropathy


SSK08-06 Diffusion Weighted Imaging and Diffusion Tensor Imaging for Detection of Acute Kidney Injury inPatients Following Lung Transplantation

Graft dysfunction is a common complication following transplantation,which is associated with allograft survial. Intravoxel incoherentmotion (IVIM) has potential to assess renal function in patients with renal and allograft dysfunction. The purpose of the currentstudy in renal allografts early after transplantation was to investigate relationship between estimated glomerular filtration rate(eGFR) and diffusion and perfusion parameters calculated using IVIM imaging, compared with healthy kidney, and to gain thesensitive IVIM parameters for monitoring allograft function.


A total of 71 subjects were performed on a 3.0T MRI scanner (MAGNETOM Trio, a Tim system, Siemens AG, Erlangen, Germany)using IVIM sequence with 11 b values( 0, 10, 20, 40, 60, 100, 150, 200, 300, 500, and 700 s/mm2 ). Subjects were divided into 3groups: group 1, healthy volunteers (n=19); group 2, allografts with good allograft function(eGFR≥60mL/min/1.73m2, n=33); group3, allografts with impaired allograft function(eGFR<60mL/min/1.73m2, n=19).To separate the perfusion and diffusion, a bi-exponential fit was used to calculate the diffusion coefficient of slow (ADCslow); the diffusion coefficient of fast (ADCfast) andperfusion fraction (FP). Differences in IVIM parameters between the cortex and medulla in each group were compared using pairedsamples t test. Differences of IVIM parameters between three groups were compared using LSD test.Relationships between eGFRand IVIM parameters were assessed using spearman correlation coefficient.

RESULTS

The ADC, ADCslow, Fp values of renal cortex were significantly higher in group 1 and group 2 compared to group 3(all p<0.01). TheADC, ADCslow values of renal medulla were significantly higher in group 1 and group 2 compared to group 3(all p<0.01). Forallografts, significant differences in ADC, ADCslow, FP values of renal cortex and ADC, ADCslow values of renal medulla wereobserved between group 2 and group 3. In renal allografts, there was a significant positive correlation between eGFR and ADC,ADCslow , Fp value of cortex, ADC, ADCslow value of medulla(all p<0.05).

CONCLUSION

The ADC, ADCslow, FP values of renal cortex and ADC, ADCslow values of renal medulla may be useful for detect renal allograftdysfunction. IVIM technique is a reliable imaging for evaluating and monitoring allograft function.


IVIM technique can be used to evaluate and monitor allograft function

AwardsTrainee Research Prize - Medical Student

ParticipantsRui Wang, PhD, Beijing, China (Presenter) Nothing to DiscloseXiaoying Wang, MD, Beijing, China (Abstract Co-Author) Nothing to DiscloseXuedong Yang, Beijing, China (Abstract Co-Author) Nothing to DiscloseKai Zhao, PhD, Beijing, China (Abstract Co-Author) Nothing to DiscloseXueqing Sui, Beijing, China (Abstract Co-Author) Nothing to DiscloseZhiyong Lin, Beijing, China (Abstract Co-Author) Nothing to Disclose

PURPOSE

To investigate the feasibility of evaluating renal hemodynamics and oxygenation changes by arterial spin labeling (ASL), bloodoxygen level dependent (BOLD) and oxygen extraction fraction (OEF) imaging in diabetic nephropathy (DN) rabbits.


Seventeen New Zealand rabbits were divided into 2 groups: DN group, 12 rabbits with intravenously injection of alloxan at 100mg/kg; and control group, 5 rabbits with injection of same dosage of 0.9% saline. At 72hr after the injection, blood glucose levelwas tested for all. Rabbits with blood glucose level higher than 16.0 mmol/L were considered as successfully established of diabetesmellitus (DM) model. MR examination was performed at 3T MR scanner (GE) with an 8-channel knee coil. For each rabbit, 2 times ofMR exam were performed: baseline (before injection) and 72hr after model established successfully. ASL imaging was conductedwith the labeling strategy of flow-sensitive alternating inversion recovery (FAIR) and BOLD was conducted with multiple gradientecho (mGRE) sequence. The measurement of renal OEF was derived from Yoblonsky's model with multi-echo gradient and spin echo(MEGSE) sequence. Then the rabbits were sacrificed for pathological study of the kidney. Quantitative RBF, R2* and OEF valueswere obtained within manually drawn ROIs, including cortex (CO) and outer medulla (OM). One-way ANOVA and paired-sample Ttest was performed to test the differences of RBF, R2* and OEF for inter- and inner-group.

RESULTS

Ten of 12 rabbits in DN group were successfully established DM model and renal pathological damages can be observed in theserabbits. There was no statistically significant difference of RBF, R2* or OEF between two groups at baseline (p>0.05). Comparedwith baseline, R2* and OEF in OM at 72 hr was significantly increased in DN group (p=0.018 and 0.048, respectively), while thecontrol group was not (p>0.05). In CO, R2* also elevated significantly at 72 hr compared with baseline (p=0.04). For control group,there was no significant difference in CO or OM between baseline and 72 hr (p>0.05).

CONCLUSION

The combination of ASL, BOLD and OEF MRI may enable a comprehensive assessment of the functional status of early DNpathophysiological changes.


It would be valuable for clinicians to early detect renal pathophysiological changes for diabetes without symptoms.


SSK08-07 Evaluation of Ultra-fast, Single Breath-Hold Renal ASL Perfusion-Preliminary Results of HealthyVolunteers


ParticipantsSusanne Tewes, MD, Hannover, Germany (Presenter) Nothing to DiscloseGregor Warnecke, Hannover, Germany (Abstract Co-Author) Nothing to DiscloseMi-Sun Jang, Hannover, Germany (Abstract Co-Author) Nothing to DiscloseDagmar Hartung, MD, Hannover, Germany (Abstract Co-Author) Nothing to DiscloseMatti Peperhove, MD, Hannover, Germany (Abstract Co-Author) Nothing to DiscloseMarcel Gutberlet, Dipl Phys, Hannover, Germany (Abstract Co-Author) Nothing to DiscloseChristine Fegbeutel, Hannover, Germany (Abstract Co-Author) Nothing to DiscloseBjoern Juettner, Hannover, Germany (Abstract Co-Author) Nothing to DiscloseAxel Haverich, Hannover, Germany (Abstract Co-Author) Nothing to DiscloseFrank K. Wacker, MD, Hannover, Germany (Abstract Co-Author) Research Grant, Siemens AG Research Grant, Pro Medicus Limited Faikah Gueler, MD, Hannover, Germany (Abstract Co-Author) Nothing to DiscloseKatja Hueper, Hannover, Germany (Abstract Co-Author) Nothing to Disclose

PURPOSE

Loss of renal function is a frequent complication after lung transplantation (lutx) and is associated with higher morbidity. Thus,imaging biomarkers to noninvasively monitor renal damage and to guide treatment strategies to preserve renal function are ofclinical relevance. The purpose was to evaluate diffusion weighted imaging (DWI) and diffusion tensor imaging (DTI) for detection ofrenal impairment in lutx-patients.


54 patients 14±2 days after lutx and 12 healthy volunteers underwent MRI on a 1.5T scanner. Respiratory-triggered DWI (10 b-values, 0-1000 s/mm²) and DTI sequences (20 diffusion direction, b=0,600 s/mm²) were acquired. Maps of apparent diffusioncoefficient (ADC) and fractional anisotropy (FA) were calculated. Renal function was monitored daily and acute kidney injury (AKI)was defined according to AKIN-criteria within 48h after surgery. Factors contributing to AKI such as duration of surgery,immunosuppressive drugs and blood product infusion were documented. Statistical analysis comprised ANOVA and correlationanalysis. Values are given as mean±SEM.

RESULTS

59% (32/54) of lutx-patients developed AKI. ADC of renal medulla was significantly lower in patients with AKI compared to patientswithout AKI (2.07±0.03 vs 2.17±0.04*10-³ mm²/s, p<0.05) and to healthy volunteers (2.07±0.03 vs 2.21±0.03*10-³ mm²/s,p<0.01). FA-values of renal medulla were significantly reduced compared to healthy volunteers in both groups (AKI: 0.27±0.01, noAKI: 0.28±0.01, healthy: 0.33±0.02, p<0.001), and did not differ between patients with and without AKI. ADC and FA negativelycorrelated with the amount of blood product infusion (r=-0.41 and r=-0.42, p<0.01) and ADC was correlated with eGFR at the dayof MRI (r=-0.52, p<0.001). No correlations with duration of surgery and tacrolimus levels at the day of the MRI were observed.

CONCLUSION

Diffusion imaging showed significant renal changes in lutx-patients compared to healthy volunteers irrespective of whether AKI wasdiagnosed according to standard criteria. ADC reduction was stronger in patients with AKI. Amount of blood product infusioncorrelated with MRI parameters and may be a contributing factor to renal damage following major surgery.


Diffusion imaging detects renal damage following major surgery and may help to improve patient management to prevent furtherrenal damage.

ParticipantsMelissa Ong, MD, Mannheim, Germany (Presenter) Nothing to DiscloseThorsten Honroth, Bremen, Germany (Abstract Co-Author) Research funded, Siemens AGGuenther Matthias, Bremen, Germany (Abstract Co-Author) Research funded, Siemens AGBernd Kuehn, PhD, Erlangen, Germany (Abstract Co-Author) Nothing to DiscloseStefan O. Schoenberg, MD, PhD, Mannheim , Germany (Abstract Co-Author) Institutional research agreement, Siemens AGDaniel Hausmann, MD, Mannheim, Germany (Abstract Co-Author) Nothing to Disclose

PURPOSE

Evaluation of 3D ultra-fast, single breath-hold arterial spin labeling magnetic resonance imaging (ASL MRI) for the measurement ofrenal perfusion.


We included 7 (5 male, mean age 29) healthy volunteers who did not suffer from any medical condition. A single-shot pulsed ASL(PASL) prototype sequence with a 3D GRASE readout using background suppression was implemented on a 3.0 Tesla MagnetomSkyra MRI scanner (Siemens Healthcare, Erlangen, Germany). 24 slices with a resolution of 4.7mm x 4.7mm x 4mm were acquired for4 different inflow times (TI = 750ms, 1000ms, 1250ms, 1500ms) within a single breath-hold of 23s, including an integratedcalibration scan (M0). The prototype sequence allowed a multi-slice measurement of the whole kidney in one exam. The exam wasperformed using a standard 18-channel body matrix coil. No contrast agent was applied. Subjective image quality was rated by tworadiologists according to a 5-point Likert-scale (5=excellent; 1=non-diagnostic). Mean renal cortical and medullary blood flow wasmeasured in the upper and lower pole of the kidney.

RESULTS

All images were rated as diagnostic. Overall image quality was rated as good (4; 25-75% quartile 3-4). Mean cortical perfusionvalues were 224±28 mL/100mL/min for the upper and 224±37 mL/100mL/min for the lower pole, mean medullary perfusion value

SSK08-08 Diffusion-weighted Magnetic Resonance Imaging of Kidneys in Patients with Chronic Kidney Disease


SSK08-09 Intravoxel Incoherent Motion MRI for Differentiating Renal Hypoperfusion from Increased Cellularityafter Ischemia-Reperfusion

Wednesday, Dec. 2 11:50AM - 12:00PM Location: E450B

ranged between 107±16 mL/100mL/min and 101±14 mL/100mL/min for the upper and lower pole, respectively.

CONCLUSION

Ultra-fast, single breath-hold renal ASL perfusion in healthy volunteers shows promising results regarding image quality andfeasibility.


Ultra-fast, single breath-hold ASL perfusion facilitates contrast-free creation of parametric perfusion maps, which can be repeatedarbitrarily and hence potentially serve to monitor therapy.

ParticipantsKatarzyna M. Sukowska, MD, Warsaw, Poland (Presenter) Nothing to DisclosePiotr Palczewski, MD, Warsaw, Poland (Abstract Co-Author) Nothing to DiscloseAgnieszka Furmanczyk-Zawiska, Warsaw, Poland (Abstract Co-Author) Nothing to DiscloseWojciech Szeszkowski, Warsaw, Poland (Abstract Co-Author) Nothing to DiscloseDorota Piotrowska-Kownacka, Warsaw, Poland (Abstract Co-Author) Nothing to DiscloseMagdalena Durlik, Warsaw, Poland (Abstract Co-Author) Nothing to DiscloseMarek Golebiowski, Warsaw, Poland (Abstract Co-Author) Nothing to Disclose

PURPOSE

To assess the apparent diffusion coefficient (ADC) values of renal parenchyma in patients in different stages of chronic kidneydisease (CKD). To correlate ADC measurements with creatinine blood level, estimated glomerular filtration rate (eGFR), and ADCvalues obtained from healthy subjects.


20 healthy volunteers and 34 patients in different stages of CKD were examined on a 1.5 unit (Ingenia, Philips, The Netherlands).The inclusion criteria for patients with CKD were: biopsy proven CKD and no hydronephrosis or renal artery stenosis. Blood samplesto assess the serum creatinine level were taken immediately before examination. The MR examination included two diffusionweighted sequences: one with 16 b values uniformly distributed from 0 to 750; the other one with 10 b values including 6 low (0-150) and 4 high (300-900) b values. ADC values were measured with whole-kidney manually placed region of interest. Statisticalanalysis was performed using the Statistica software (version 10.0; Statsoft, Inc., US). Unpaired Student's t-test were used toevaluate the differences in ADC. ROC curves were drawn to find out area under the curve for differentiation of CKD groups and cut-off ADC values were calculated so as to achieve the highest average sensitivity and specificity. To investigate the relationshipbetween ADC values and serum creatinine / eGFR, Pearson's correlation coefficient was calculated by bivariate correlation. All Pvalues <0.05 were taken as statistically significant.

RESULTS

A significant positive correlation between ADC and eGFR and a negative correlation between ADC and creatinine blood level wasobserved. There were statistical differences between ADC values in healthy individuals and patients in moderate and severe stageof CKD. Based on ADC measurements cut-off values were established allowing for identification of patients with eGFR higher than 60ml/min/1.73m2 and lower then 30ml/min/1.73m2.

CONCLUSION

The DWI has a potential role in assessing renal function as ADC values correlate with eGFR and the level of renal damage in severestages of CKD.


The ability of DWI to noninvasively assess eGFR may provide an additional tool for monitoring the course of disease and forstratifying the risk of contrast medium administration in patients with CKD.

ParticipantsMike Notohamiprodjo, Munich, Germany (Presenter) Nothing to DiscloseKatharina Stella Winter, Munich, Germany (Abstract Co-Author) Nothing to DiscloseMichael Staehler, MD, Munich, Germany (Abstract Co-Author) Nothing to DiscloseAndreas D. Helck, MD, Munich, Germany (Abstract Co-Author) Nothing to DiscloseOlaf Dietrich, PhD, Munich, Germany (Abstract Co-Author) Nothing to DiscloseMoritz Schneider, Munich, Germany (Abstract Co-Author) Nothing to Disclose

PURPOSE

To differentiate hypoperfusion from inflammatory hypercellularity after renal ischemia-reperfusion due to partial nephrectomy usingIntravoxel Incoherent Motion MRI.


This IRB approved prospective study was performed according to the declaration Helsinki. 15 patients with renal tumors underwentMR at 3T (Magnetom Verio, Siemens Healthcare) directly before and one week after partial nephrectomy. Diffusion weighted imagingwas acquired with an EPI-sequence (10 b-values 0-800 s/mm2, 3 averages, 6 directions). IVIM-analysis was performed with home-built software (PMI 0.4, IDL) by biexponential fitting of the tissue Dslow (mm2/s*10-3) and the pseudo-diffusion Dfast (mm2/s*10-3) as well as the perfusion component f (%). Apparent diffusion coefficient (ADC; mm2/s*10-3) was derived from monoexponential

analysis. To compare parameters between baseline and follow-up the paired Wilcoxon signed-rank test and to compare non-nephrectomized and partially nephrectomized kidneys the non-paired Mann-Whitney U test was used.

RESULTS

In the baseline examination prior to partial nephrectomy there were no significant differences between tumor bearing andcontralateral kidney, whereas the follow-up measurement showed significant differences for ADC (p<0.001), Dfast (p=0.02) andmost pronounced for f (p<0.001). Partially nephrectomized kidneys showed a significant decrease of ADC (2.5±0.3 vs. 2.3±0.2,p<0.01), Dfast (8.6±1.8 vs. 7.3±1.7, p = 0.02) and again most pronounced for f (19.2±3.0 vs. 13.7±4.4 p < 0.01). There were nosignificant differences for Dslow (operated kidney 2.0±0.2 vs. 2.0±0.2; contralateral kidney 2.1±0.2 vs. 2.0±0.1) Non-nephrectomized contralateral kidneys expressed a significant increase of ADC (2.5±0.2 vs. 2.7±0.3, p < 0.01), and f (19.3±2.6 vs.21.5±4.0, p = 0.03). There was no significant correlation of the alteration of each parameter to clamping time.

CONCLUSION

IVIM detects significant changes, particularly of the perfusion fraction in the operated and contralateral kidney after partialnephrectomy suggesting that ischemia-reperfusion associated diffusion restriction is correlated to hypoperfusion rather thanincreasing inflammatory cellularity.


IVIM MRI suggest that renal ischemia-reperfusion associated diffusion restriction is correlated to hypoperfusion rather thanincreasing inflammatory cellularity.

SSK09-01 Computed Very High B-Value Diffusion-Weighted Imaging of the Prostate: How High Should We Go?


SSK09-02 Utility of Apparent Diffusion Coefficient (ADC) in Intermediate Grade (Gleason score 3+4=7) ProstateCancer Diagnosed at Non-targeted TRUS-guided Needle Biopsy


SSK09

Genitourinary (Prostate Imaging and Staging)

Wednesday, Dec. 2 10:30AM - 12:00PM Location: N228

GU MR OI


ParticipantsAndrew B. Rosenkrantz, MD, New York, NY (Moderator) Nothing to DiscloseAntonio C. Westphalen, MD, Mill Valley, CA (Moderator) Nothing to DiscloseRonaldo H. Baroni, MD, Sao Paulo, Brazil (Moderator) Nothing to Disclose

Sub-Events

ParticipantsNainesh Parikh, MD, New York, NY (Presenter) Nothing to DiscloseJustin M. Ream, MD, Ann Arbor, MI (Abstract Co-Author) Nothing to DiscloseAndrea S. Kierans, MD, New York, NY (Abstract Co-Author) Nothing to DiscloseMax X. Kong, MD, New York, NY (Abstract Co-Author) Nothing to DiscloseSamir S. Taneja, MD, New York, NY (Abstract Co-Author) Consultant, Eigen Consultant, GTx, Inc Consultant, Bayer AG Consultant,Healthtronics, Inc Speaker, Johnson & Johnson Investigator, STEBA Biotech NV Royalties, Reed ElsevierAndrew B. Rosenkrantz, MD, New York, NY (Abstract Co-Author) Nothing to Disclose

PURPOSE

To assess the impact of a broad range of computed b-values (1,500-5,000 s/mm2) on prostate cancer detection.


49 patients undergoing 3T prostate MRI before radical prostatectomy were included. Exams included DWI with a maximal acquiredb-value of 1,000 s/mm2, from which six computed DWI image sets (b-values ranging from 1,500-5,000 s/mm2) were generated.Two radiologists [R1 (attending), R2 (fellow)] independently evaluated the ADC map as well as each DW image set, blinded to theb-value, to assess dominant lesion location. Pathologic findings from radical prostatectomy served as the reference standard.

RESULTS

Sensitivity for tumor: R1-82% (ADC), 80% (b1000), 86% (b1500), 88% (b2000), 86% (b2500), 84% (b3000), 76% (b4000), 65%(b5000); R2-71% (ADC), 63% (b1000), 76% (b1500), 71% (b2000), 70% (b2500), 65% (b3000), 57% (b4000), 37% (b5000).Sensitivity for Gleason score≥7 tumor: R1-83% (ADC), 80% (b1000), 93% (b1500), 93% (b2000), 90% (b2500), 90% (b3000), 80%(b4000), 65% (b5000); R2-75% (ADC), 68% (b1000), 80% (b1500), 78% (b2000), 78% (b2500), 70% (b3000), 60% (b4000), 38%(b5000). PPV for tumor: R1-95% (ADC), 95% (b1000), 93% (b1500), 96% (b2000), 98% (b2500), 93% (b3000), 95% (b4000), 87%(b5000); R2-85% (ADC), 82% (b1000), 93% (b1500), 88% (b2000), 92% (b2500), 94% (b3000), 93% (b4000), 75% (b5000).Dominant lesion visual conspicuity (1-5 scale): R1-3.4±1.5 (ADC), 2.5±1.2 (b1000), 3.3±1.4 (b1500), 3.2±1.3 (b2000), 3.2±1.4(b2500), 3.1±1.4 (b3000), 2.8±1.4 (b4000), 2.7±1.5 (b5000); R2-3.2±1.6 (ADC), 2.1±1.1 (b1000), 3.2±1.5 (b1500), 3.1±1.6(b2000), 3.0±1.6 (b2500), 2.5± 1.5 (b3000), 1.8±1.0 (b4000), 1.3±0.6 (b5000). Reader confidence (1-5 scale): R1-3.2±1.5 (ADC),2.6±1.3 (b1000), 3.1±1.4 (b1500), 3.1±1.4 (b2000), 3.1±1.5 (b2500), 3.1±1.5 (b3000), 3.0±1.6 (b4000), 2.8±1.7 (b5000); R2-3.3±1.7 (ADC), 2.2±1.2 (b1000), 3.2±1.6 (b1500), 3.4±1.7 (b2000), 3.4±1.8 (b2500), 3.1± 1.8 (b3000), 2.6±1.6 (b4000), 1.9±1.3(b5000).

CONCLUSION

Computed b-values in the range of 1,500-2,500 s/mm2 were optimal for prostate cancer detection, comparing favorably with theADC map. b-values of 1,000 or 3,000-5,000 exhibited lower performance.


Computed b-values of 1,500-2,500 s/mm2 (but not higher) help optimize prostate DWI, thereby facilitating targeted prostate biopsyand tailored treatments based on imaging guidance.

ParticipantsRadu Rozenberg, MD, Ottawa, ON (Abstract Co-Author) Nothing to DiscloseNicola Schieda, MD, Ottawa, ON (Abstract Co-Author) Nothing to DiscloseShaheed Hakim, Ottawa, ON (Abstract Co-Author) Nothing to DiscloseTrevor A. Flood, MD, FRCPC, Ottawa, ON (Abstract Co-Author) Nothing to DiscloseRebecca Thornhill, PhD, Ottawa, ON (Abstract Co-Author) Nothing to DiscloseChristopher Lim, MD, Ottawa, ON (Presenter) Nothing to Disclose

PURPOSE

To determine the ability of ADC analysis to predict Gleason score (GS) upgrading of tumor and extra-prostatic extension (EPE) afterradical prostatectomy (RP) in 3+4=7 prostate cancer (PCa).

SSK09-03 High Resolution 3-Tesla Endorectal Prostate MR Imaging: A Multireader Study of RadiologistPreference and Perceived Interpretive Quality of 2D and 3D T2-weighted FSE MR Images


SSK09-04 Multi-Parametric MRI Performance in Prostate Cancer Detection: Stratified by Gleason Scores andTumor Size on Whole Mount Histopathology



With REB approval, 54 men with GS 3+4=7 PCa at non-targeted TRUS-guided biopsy underwent 3-Tesla MRI and RP between 2012-2013. Outcomes at RP included: A) upgrading to GS 4+3=7 and B) organ confined disease (OCD). >0.5 mL tumors were contouredby a blinded GU radiologist by correlating ADC to RP histopathology map. Mean ADC, ADC ratio (normalized to peripheral zone),histogram analysis (10th, 25th and 50th centile ADC) and texture analysis features were compared between groups using multi-variate analysis, regression modeling and ROC analysis.

RESULTS

25.9% (14/54) patients were upgraded to GS 4+3=7 and 51.9% (28/54) patients had EPE after RP. There was no difference in age(p=0.38, 0.85), PSA (p=0.96, 0.95) or % of core biopsies with Gleason pattern 4 (p=0.56, 0.89) between groups. Mean ADC(mm2/sec), ADC ratio, 10th, 25th and 50th centile ADC were similar between GS 3+4=7 (0.94 ± 0.24, 0.58 ± 0.15, 0.77 ± 0.31,0.94 ± 0.28 and 1.15 ± 0.24) and GS 4+3=7 tumors (0.96 ± 0.20, 0.55 ± 0.11, 0.71 ± 0.26, 0.89 ± 0.19 and 1.11 ± 0.16), p>0.05.10th centile ADC was lower in tumors with EPE (0.69 ± 0.31 versus 0.82 ± 0.28), p=0.02; with no difference comparing all otherconventional ADC parameters, p>0.05. Regression models combining texture features improved prediction of GS upgrade: A)Kurtosis+Entropy+Skewness (AUC 0.76 [SE=0.07], p<0.001; sensitivity 71%, specificity 73%) and B)Kurtosis+Heterogeneity+Entropy+Skewness (AUC 0.77 [SE=0.07], p<0.001); sensitivity 71%, specificity 78%).

CONCLUSION

Amongst Gleason score 3+4=7 prostate cancers diagnosed at TRUS-guided biopsy, mean ADC and ADC histogram analysis is notpredictive of upgrading after RP, while ADC texture-analysis improves accuracy. 10th centile ADC is predictive of EPE.


Conventional ADC analysis cannot predict upgrading of Gleason score 3+4=7 prostate cancer diagnosed at TRUS-guided biopsy;however, ADC texture-analysis improves accuracy and 10th centile ADC can predict organ confined disease.

ParticipantsAntonio C. Westphalen, MD, Mill Valley, CA (Presenter) Nothing to DiscloseSusan M. Noworolski, PhD, San Francisco, CA (Abstract Co-Author) Nothing to DiscloseSaunak Sen, San Francisco, CA (Abstract Co-Author) Nothing to DiscloseMukesh G. Harisinghani, MD, Boston, MA (Abstract Co-Author) Nothing to DiscloseKartik S. Jhaveri, MD, Toronto, ON (Abstract Co-Author) Speaker, Bayer AGSteven S. Raman, MD, Santa Monica, CA (Abstract Co-Author) Nothing to DiscloseAndrew B. Rosenkrantz, MD, New York, NY (Abstract Co-Author) Nothing to DiscloseZhen J. Wang, MD, Hillsborough, CA (Abstract Co-Author) Nothing to DiscloseRonald J. Zagoria, MD, San Francisco, CA (Abstract Co-Author) Nothing to DiscloseJohn Kurhanewicz, PhD, San Francisco, CA (Abstract Co-Author) Nothing to Disclose

PURPOSE

The goal of this study was to compare the perceived quality of 3-Tesla axial T2-weighted high-resolution 2D and high-resolution 3DFSE endorectal MR images of the prostate.


We studied 85 men (median age=65 years, 46 to 83) with proven or suspected prostate cancer who had endorectal MR imagingwith 2D and 3D T2-weighted FSE MR images. Six radiologists from various institutions independently reviewed axial T2 weighted MRimages shown individually and paired. Readers identified their preferred images and scored using a 5-point scale their confidence inidentifying tumor. They also scored the delineation of the zonal anatomy and capsule, tumor conspicuity, and image quality(artifacts, distortion, and sharpness) using a 3-point scale. We used a meta-analysis routine to calculate pooled estimates basedon a random-effects model. A formal analysis of heterogeneity was also done. The presence of heterogeneity is consistent withdifferences in the readers' scores. We used a mixed effect logistic regression, taking into account the clustering effect, todetermine if prior treatment and number of years of reader's experience were predictors of the option for 2D or 3D images.

RESULTS

Each reader had a strong preference for a given T2-weighted MR sequence, favoring one of the two techniques in at leastapproximately 70% of cases; but the choices were evenly distributed between the two sequence options. The pooled estimateshows that the 3D image is preferred in about 47% of the times (95% CI=20% to 74%). The choice for one or other techniqueswas not associated with prior treatment or readers' years of experience. There was no significant difference in confidence in tumoridentification (p=0.16 to 1.00). There was no difference in delineation of the zonal anatomy (p=0.19), prostatic capsule (p=0.14),and tumor conspicuity (p=0.89). Similarly, no difference was found when assessing motion artifact (p=0.48) and distortion(p=0.41). 2D FSE images were significantly sharper than 3D FSE (p<0.001), but also more likely to exhibit artifacts not related tomotion (p=0.002).

CONCLUSION

There are strong individual preferences for the 2D or 3D FSE MR images, but a wide variability among radiologists. There weredifferences in image quality, but not in the sequences' ability to delineate the glandular anatomy and depict cancer.


2D and 3D FSE techniques appear to be equally adequate fro clinical use.

SSK09-05 Distortion in Diffusion-Weighted Prostate MRI: Readout-Segmented EPI DWI vs. Single-Shot EPIDWI


ParticipantsPooria Khoshnoodi, MD, Los Angeles, CA (Presenter) Nothing to DiscloseDaniel J. Margolis, MD, Los Angeles, CA (Abstract Co-Author) Research Grant, Siemens AGHector E. Alcala, MPH, Los Angeles, CA (Abstract Co-Author) Nothing to DiscloseNelly Tan, MD, Los Angeles, CA (Abstract Co-Author) Nothing to DiscloseWei-Chan Lin, MD, Taipei, Taiwan (Abstract Co-Author) Nothing to DiscloseDavid Y. Lu, MD, Los Angeles, CA (Abstract Co-Author) Nothing to DiscloseJiaoti Huang, Los Angeles, CA (Abstract Co-Author) Nothing to DiscloseRobert E. Reiter, MD, Los Angeles, CA (Abstract Co-Author) Nothing to DiscloseDavid S. Lu, MD, Los Angeles, CA (Abstract Co-Author) Consultant, Medtronic, Inc Speaker, Medtronic, Inc Consultant, Johnson &Johnson Research Grant, Johnson & Johnson Consultant, Bayer AG Research Grant, Bayer AG Speaker, Bayer AG Steven S. Raman, MD, Santa Monica, CA (Abstract Co-Author) Nothing to Disclose

PURPOSE

To evaluate the prostate cancer (CaP) detection rate by multi-parametric MR imaging (MP-MRI) confirmed by whole mounthistopathology (WMHP) stratified by Gleason Scores (GS) and tumor size.


A HIPPA-compliant, IRB-approved study of 290 consecutive men who underwent prostate MP-MRI before radical prostatectomy(RP) from October 2010 to January 2015 was performed. Clinical, MP-MRI (T2W, DWI and DCE) and pathologic features (WMHPslides, GS, maximal diameter) were obtained. The index tumor was defined as the pathological lesion with the highest GS or largesttumor when multiple foci had identical GS. A genitourinary (GU) radiologist and a GU pathologist reviewed each case. Each tumorfocus on WMHP which matched with concordant target on MP-MRI was considered detected tumor. Chi-squared tests were used totest difference in MRI tumor detection rates by tumor grade (GS=3+3 defined as low grade vs. GS>6 as high grade) and tumor size(<1 cm defined as small vs. ≥ 1cm as large tumor). Logistic regression was used to test a tumor grade by tumor size in MRIdetection. Statistical analyses were conducted using Stata 12.1. P-values below .05 were considered significant.

RESULTS

290 patients had 639 unique CaP foci on WMHP. Of 639 total tumors foci on pathology, 310 (48.5%) and of 290 total index lesions,224 (77.2%) were detected on MP-MRI. MRI detected 86/326 (26.4%) of low grade tumors vs. 223/313 (71.2%) of high gradetumors, and 56/257 (21.8%) of small vs. 253/382 (66.2%) large tumors. MRI detected 44/212 (20.8%) of low grade small tumorsvs. 12/45 (26.7%) of high grade small tumors, and 42/114 (36.8%) low grade large tumors vs. 211/268 (78.7%) of high grade largetumors. (p<.05)

CONCLUSION

We found that MP-MRI missed 51.6% of all CaP. However, when CaP stratified by size and GS, larger tumors were associated withincreased detection rate for both high and low grade tumors. There was also a significant size by grade interaction, such that thedifference in detection rates by grade was much larger among tumors 1cm or larger. These findings suggest that the MP-MRI tendsto detect larger with higher grade CaP lesions. In our study, MP-MRI detected 78.7% of all high grade large CaP foci.


MP-MRI which combines anatomic with functional and physiologic assessment of prostate cancer has substantially improveddiagnostic capabilities of detecting clinically significant prostate tumors.

ParticipantsIvan Platzek, MD, Dresden, Germany (Presenter) Nothing to DiscloseAngelika Borkowetz, MD, Dresden, Germany (Abstract Co-Author) Nothing to DiscloseMarieta Toma, MD, Dresden, Germany (Abstract Co-Author) Nothing to DiscloseThomas Brauer, MD, Dresden, Germany (Abstract Co-Author) Nothing to DiscloseHagen H. Kitzler, Dresden, Germany (Abstract Co-Author) Nothing to DiscloseVerena Plodeck, MD, Dresden, Germany (Abstract Co-Author) Nothing to DiscloseManfred Wirth, Dresden, Germany (Abstract Co-Author) Nothing to DiscloseMichael Laniado, MD, Dresden, Germany (Abstract Co-Author) Reviewer, Johnson & Johnson

PURPOSE

The aim of this study was to evaluate the utility of segmented-readout echo planar diffusion-weighted imaging (SR EPI DWI) forprostate imaging in comparison to conventional single shot EPI DWI (SS EPI DWI), with an emphasis on distortion artifacts.


Sixty-eight patients with suspected prostate cancer were included in this prospective study. Patient age varied between 46 and 77y (65 y on average). All patients underwent multiparametric prostate MRI (mpMRI) at 3T, which included T2-weighted images,dynamic contrast-enhanced (DCE) images, and both SR EPI DWI and SS EPI DWI. Apparent diffusion coefficient maps (ADC) mapswere generated for both SR EPI DWI and SS EPI DWI. Overall lesion classification was based on the PI-RADS scoring systemproposed by the European society of Urogenital Radiology (ESUR). Distortion on ADC maps was classified on a five point scale.Furthermore, the maximum distortion in the anteroposterior direction was measured in each patient for both SR EPI DWI and SS EPIDWI.

RESULTS

ADC maps based on SR EPI DWI showed no evidence of distortion in 58/68 patients (85%), while ADC maps based on SS EPI DWIshowed no distortion in 42/68 patients (61.7%). Distortion scores were higher (indicating stronger distortion) for SS EPI DWI ascompared to SR EPI DWI in 19/68 patients (27.9%) and lower in only one patient (1.5%). Visual evaluation showed significantly lessdistortion for SR EPI DWI in comparison to EPI DWI (p = 0.0001). Average maximum distortion (1.5 ± 2.6 mm) was significantly lower

SSK09-06 Accuracy and Inter-Observer Variability of Prostate Imaging-Report and Data System (PI-RADS)Version 2.0 for Characterization of Lesions Identified on Multiparametric Magnetic ResonanceImaging of the Prostate


SSK09-07 Predicting Organ-confined Prostate Cancer in the Era of Multiparametric MRI: Comparing theAccuracy of the Partin Tables and mpMRI


in SR EPI DWI in comparison to SS EPI DWI (4.9 ± 9.7 mm) (p < 0.0001). Ninety-six prostate lesions were detected with mpMRI intotal. PI-RADS scores did not differ significantly between mpMRI including SR EPI DWI and mpMRI including SS EPI DWI (p = 0.464).Mean ADC values based on SS EPI DWI (0.93 ± 0.21) were slightly lower than those based on SR EPI DWI (0.96 ± 0.22)(p = 0.047).

CONCLUSION

SR EPI DWI of the prostate has significantly less pronounced distortion artifacts compared to SS EPI DWI. As prostate lesiondetection and lesion classification based on PI-RADS scores do not change significantly when SR EPI DWI is used instead of SS EPIDWI, SR EPI DWI is a promising alternative to conventional diffusion-weighted sequences.


The use of SR EPI DWI instead of conventional SS EPI DWI in prostate MRI reduces distortion and can help improve correlationbetween DWI and T2-weighted images.

ParticipantsAndrei S. Purysko, MD, Cleveland, OH (Presenter) Nothing to DiscloseLeonardo K. Bittencourt, MD, PhD, Rio De Janeiro, Brazil (Abstract Co-Author) Nothing to DiscloseBrian R. Herts, MD, Cleveland, OH (Abstract Co-Author) Research Grant, Siemens AGAntonio C. Westphalen, MD, Mill Valley, CA (Abstract Co-Author) Nothing to DiscloseErick M. Remer, MD, Cleveland, OH (Abstract Co-Author) Nothing to DiscloseAndrew J. Stephenson, MD, Cleveland, OH (Abstract Co-Author) Nothing to DiscloseJennifer Bullen, MSc, Cleveland, OH (Abstract Co-Author) Nothing to DiscloseCristina Magi-Galluzzi, MD, PhD, Cleveland, OH (Abstract Co-Author) Nothing to DiscloseEric Klein, Cleveland, OH (Abstract Co-Author) Nothing to Disclose

PURPOSE

To measure the accuracy and inter-observe variability of PI-RADS version 2.0 for the characterization of prostate lesions identifiedon mpMRI.


IRB-approved, HIPAA compliant retrospective study including 171 men (mean age: 61.5 yrs.) either being investigated for prostatecancer (n = 128) or enrolled in active surveillance (n =43), who were examined on a 3.0 T magnet without endorectal coil, andwere found to have potential targets for biopsy. Two readers with 8 yrs. of experience in abdominal imaging independently reviewedand assigned a PI-RADS V.2 assessment category to the dominant MRI targets. The reference standard was the combined resultsfrom the MR/US fusion biopsy and transrectal ultrasound guided 12-core systematic biopsy (SB) performed in all the patients and inthe same procedure. Clinically significant (CS) PCa was defined as tumors with Gleason score >= 3 + 4. Receiver operatingcharacteristic (ROC) analysis was performed.

RESULTS

PCa was detected in 49.1% (84/171) and CS PCa was detected in 32.3% (55/171) of the men. Using PI-RADS category > 3 todiscriminate any PCa from non-cancerous lesions, the sensitivity (Sen), specificity (Sp) and area under the ROC curve (AUC) were77.4%, 84.9% and 85.7% for reader 1 and 69.1%, 87.2%, and 77.9% for reader 2. Using PI-RADS category > 3 to discriminate onlyclinically significant PCa from clinically insignificant prostate cancer and benign lesions, the Sen, Sp, and AUC were 98.2%, 79.1%,and 91.1% for reader 1 and 92.7%, 84.4%, and 90.4% for reader 2. The inter-observer agreement coefficient was 0.68 (95% CI:0.61- 0.75).

CONCLUSION

PI-RADS V.2 had high sensitivity, specificity and accuracy for the discrimination of clinically significant PCa from other pathology,with good inter-observer agreement.


Lesions with a PI-RADS V.2 assessment category > 3 should be considered for targeted biopsy, while avoiding the biopsy of lesionswith a category < 3 reduces the number of negative biopsies and/or detection of clinically insignificant lesions.

ParticipantsAlison F. Brown, BA, Durham, NC (Presenter) Nothing to DiscloseThomas J. Polascik, MD, Durham, NC (Abstract Co-Author) Nothing to DiscloseRachel K. Silverman, MS, Chapel Hill, NC (Abstract Co-Author) Nothing to DiscloseKae Jack Tay, MBBS,MMed, Durham, NC (Abstract Co-Author) Nothing to DiscloseRajan T. Gupta, MD, Durham, NC (Abstract Co-Author) Consultant, Bayer AG; Speakers Bureau, Bayer AG; Consultant, InvivoCorporation

PURPOSE

To investigate the accuracy of the Partin tables and multiparametric magnetic resonance imaging (mpMRI) in predicting organ-confined (OC) prostate cancer (PCa) after radical prostatectomy (RP), and to determine if radiologic staging information frommpMRI versus digital rectal exam (DRE) to augment the Partin tables increases the predictive accuracy of this widely usednomogram.

SSK09-08 Diagnostic Differentiation of Prostate Cancer from Prostatic Hyperplasia: What Diffusion KurtosisImaging Can Help Us?


SSK09-09 Incidental Bone Lesions on Staging MRI for Prostate Cancer: Prevalence and Clinical Importance

Wednesday, Dec. 2 11:50AM - 12:00PM Location: N228


In this retrospective, HIPAA-compliant, IRB-approved study, 157 patients underwent 3T mpMRI with endorectal coil before RP.MpMRI was used to assess clinical stage and an updated version of the Partin tables was used to calculate the probability of eachpatient to harbor OC disease. Logistic regression models predicting OC disease were created using mpMRI staging alone and withPSA as a covariate. Two sets of probabilities were obtained from the Partin tables, using clinical staging from either DRE or mpMRI.The area under curve (AUC) was used to calculate the predictive accuracy of each of these four predictive methods.

RESULTS

The predictive accuracy of mpMRI alone in predicting OC disease on pathological analysis is greater (AUC=0.86) than the Partintables (AUC=0.70), and is further improved when combined with PSA values (AUC=0.88). The accuracy of the Partin nomogram inpredicting OC disease decreases (AUC=0.59) when clinical stage is based on mpMRI versus DRE.

CONCLUSION

The superior predictive accuracy of mpMRI compared to Partin tables in predicting OC disease on pathological analysis validatesresults of smaller previously published studies, including one from our group. Partin table probabilities are calculated using clinicalstage based on DRE result, a less sensitive test than mpMRI; therefore, this frequently leads to disease understaging.Consequently, although mpMRI has been shown to more accurately predict clinical stage than DRE, using mpMRI stage in the Partinnomogram does not improve its accuracy. In conclusion, mpMRI staging information is valuable as a stand-alone test when availablebased on its AUC value, but should not be applied to the Partin nomogram in its existing form.


As more accurate clinical staging information is becoming available due to mpMRI, nomograms that incorporate mpMRI stage areneeded to better predict OC PCa and assist in surgical planning prior to RP.

ParticipantsChen Lihua, Dalian, China (Presenter) Nothing to DiscloseAilian Liu, MD, Dalian, China (Abstract Co-Author) Nothing to DiscloseQingwei Song, MD, Dalian, China (Abstract Co-Author) Nothing to DiscloseMa Chunmei, MD, Dalian, China (Abstract Co-Author) Nothing to DiscloseMeiyu Sun, Dalian, China (Abstract Co-Author) Nothing to DiscloseZibin Tong, Dalian, China (Abstract Co-Author) Nothing to DiscloseYe Li, Dalian, China (Abstract Co-Author) Nothing to Disclose

PURPOSE

To evaluate the feasibility of the typical parameters of DKI in diagnositic differentiation of prostate carcinoma from prostatichyperplasia.


One hundred and thirteen patients with the suspicion of prostate disease were recruited in the study. All the patients, with writteninformed consent obtained, were performed MRI exams on a 3.0T scanner in a protocol containing the routine T1WI, T2WI,contrast-enhanced MRI, DWI and DKI. From the following histopathological examination, it was confirmed that prostate carcinomawas in 30 and prostatic hyperplasia in 29. MR images were reviewed and analyzed by author and one experienced radiologist whohas five years experience in prostate diagnosis, using a dedicated software in Functool on GE ADW4.4 workstation. For each focus,the mean value of the parameters of DKI (MK, Ka, Kr, FA, MD, Da, Dr) and DWI(ADC) was measured: in PCa group, the area whereshows low signal on T2WI image, high signal on MK image and histopathological positive was the focus, regions of interest (ROIs)drew three times in the tumor, the size of the ROI was chosen to cover the 2/3 of the tumor(fig 1) , then the average value wasused in statistics. In BPH group, three identical ROIs (70mm2)were drew in the central zone, the average value was used instatistics. The type of time-signal intensity curve(TIC) was observed by two observers collectively. ICC test was used to examinethe consistency of the measurements, Pearson test was used to examine the relevance between MD and ADC value,and student'st-test was executed to compare the obtained parametric values with p> 0.05 concerned statistical significant. The ROC curve of allthe parameters were drew and analyzed.

RESULTS

The ICC value of the DKI parameters and DWI parameter in the PCa group and BPH group were respectively,0.963,0.935,0.959,0.905,0.970,0.909,0.967,0.977and 0.804,0.899,0.913,0.901,0.923,0.902,0.911,0.931, exhibiting an amenableconsistency. The mean MK, Ka, Kr of PCa were significantly higher (p < 0.01) than the BPH, while the mean MD, Da, Dr ofcancerous tissue was found to be significantly lower (p < 0.01) than the hyperplasia tissue. No statistically significant differencewas observed between FA values of two groups (p >0.05). The area under the ROC curve of all parameters were higher than 0.9.

CONCLUSION

DKI demonstrated can supply many meritorious parameters, with most useful in diagnostic differentiation of prostate cancer fromprostatic hyperplasia. Combining with the routine prostate MRI, DKI may help in increasing the sensitivity and specificity of cancerdetection.


Combining with the routine prostate MRI, DKI may help in increasing the sensitivity and specificity of cancer detection.

Participants

Rachel Schor-Bardach, MD, New York, NY (Presenter) Nothing to DiscloseNiamh M. Long, MD, New York, NY (Abstract Co-Author) Nothing to DiscloseJane D. Cunningham, FFRRCSI, New York, NY (Abstract Co-Author) Nothing to DiscloseAnna Kirzner, MD, Brooklyn, NY (Abstract Co-Author) Nothing to DiscloseRamon E. Sosa, BA, New York, NY (Abstract Co-Author) Nothing to DiscloseDebra A. Goldman, MS, New York, NY (Abstract Co-Author) Nothing to DiscloseChaya Moskowitz, New York, NY (Abstract Co-Author) Nothing to DiscloseHedvig Hricak, MD, PhD, New York, NY (Abstract Co-Author) Nothing to DiscloseDavid M. Panicek, MD, New York, NY (Abstract Co-Author) Nothing to DiscloseHebert Alberto Vargas, MD, New York, NY (Abstract Co-Author) Nothing to Disclose

PURPOSE

To evaluate the prevalence of bone lesions identified on prostate MRI and determine the associations between their imagingfeatures, clinical/pathologic characteristics and the presence of prostate cancer (PCa) bone metastases.


In this IRB approved, retrospective study, the medical records of 3765 patients undergoing staging prostate MRI for newly-diagnosed (PCa) between 2000-2014 were reviewed. Amongst these, the MRI exams of all patients with bone metastases and arandom selection of patients without bone metastases (matched with a 3:1 ratio to patients with bone metastases) were reviewedby 2 independent readers (R1 and R2) for presence, size and signal characteristics of bone lesions on T1-weighted sequences alongwith their subjective level of suspicion (1-5 Likert scale) for the likelihood of bone metastases on MRI. Prostate-specific antigenlevels, biopsy Gleason Score, clinical stage and National Comprehensive Cancer Network (NCCN) risk categories were recorded. Thereference standard was bone biopsy and/or at least 1-year follow-up after MRI. Associations between MRI and clinical/pathologicfindings were tested using Fisher's exact and Wilcoxon Rank Sum tests. Inter-reader agreement and diagnostic accuracy for bonemetastases detection were assessed using Cohen's simple Kappa statistic and areas under the receiving operating characteristicscurve (AUC).

RESULTS

57 out of 3765 patients (1.5%) had bone metastases. None of the patients with low-risk PCa according to the NCCN criteria hadbone metastases. Inter-reader agreement on MRI was fair to substantial (k=0.26-0.70). There was at least 1 bone lesion presenton MRI in 72% (95% CI: 0.66-0.78) and 70% (95% CI: 0.64-0.76) of patients according to R1 and R2. The AUC for detecting bonemetastases on MRI was 0.97 (95% CI: 0.94-1.00) and 0.90 (95% CI: 0.84-0.95) for R1 and R2. Larger lesion diameter (p<0.0001for both) and absence of intratumoral fat (p=0.0013-0.0020) were significantly associated with bone metastases for both readers.

CONCLUSION

Bone lesions in prostate MRI are present in the majority of patients undergoing initial staging for PCa, and infrequently representmetastatic disease.


MRI findings should be interpreted in the context of clinical features which increase the likelihood of metastatic disease.

GU234-SD-WEA1

Dose 70 kV CT Imaging with 3rd Generation Dual-source CT Simply Increase Pseudo-enhancement ofRenal cyst? Importance of Considering Reduced Requirement of Contrast Dosage: A Phantom Study

Station #1

GU251-SD-WEA2

Multiphasic MDCT Imaging Features Can Help Discriminate Sarcomatoid RCC and Collecting DuctCarcinoma from Clear Cell RCC

Station #2

GUS-WEA

Genitourinary Wednesday Poster Discussions

Wednesday, Dec. 2 12:15PM - 12:45PM Location: GU/UR Community, Learning Center

GU


ParticipantsSusanna I. Lee, MD, PhD, Boston, MA (Moderator) Nothing to Disclose

Sub-Events

ParticipantsSatoru Takahashi, MD, Kobe, Japan (Presenter) Nothing to DiscloseNoriyuki Negi, RT, Kobe, Japan (Abstract Co-Author) Nothing to DiscloseKiyosumi Kagawa, Kobe, Japan (Abstract Co-Author) Nothing to DiscloseErina Suehiro, RT, Kobe, Japan (Abstract Co-Author) Nothing to DiscloseWakiko Tani, RT, Kobe, Japan (Abstract Co-Author) Nothing to DiscloseToshinori Sekitani, MS, Kobe, Japan (Abstract Co-Author) Nothing to DiscloseHideaki Kawamitsu, MD, Kobe, Japan (Abstract Co-Author) Nothing to DiscloseKazuro Sugimura, MD, PhD, Kobe, Japan (Abstract Co-Author) Research Grant, Toshiba Corporation Research Grant, KoninklijkePhilips NV Research Grant, Bayer AG Research Grant, Eisai Co, Ltd Research Grant, DAIICHI SANKYO Group

PURPOSE

Thanks to improved iodine absorption of lower kV, attenuation of iodine contrast medium (CM) at 70 kV is 2.0-time greater thanthose at 120 kV with 3rd generation dual-source CT scanner. Although identical HU values could be theoretically achieved with halfdose of CM at 70 kV comparing to 120 kV, diagnostic ability would be impaired with increased beam hardening effect at lower kVimaging. The purpose of this phantom study is to compare the degree of pseudo-enhancement under identical surroundingattenuation at different energy CT scan, assuming contrast enhanced CT protocols of 70 kV CT with half dose CM and 120 kV CTwith full dose.


Circular phantom (26 cm in diameter) filled with different concentration of diluted CM (240 HU or 116 HU at 120 kV) and equippedwith 7 cylindrical inserts of water and various concentration of CM (0.4, 4.5, 10.7, 24.8, 63.6, 127.6 HU at 120 kV, respectively)was scanned at 70 kV or 120 kV with identical radiation dose (CTDIvol of 7.6 mGy) using 3rd generation dual-source CT scanner.HU values of inserted water, representing pseudo-enhancement due to beam-hardening artifacts, as well as those of diluted CM incylindrical inserts, indicating slightly enhancing lesions, were measured. Pseudo-enhancement and contrast to noise ratio (CNR) ofthe phantoms with surrounding 116 HU CM scanned at 70 kV were compared to those of 240 HU at 120 kV to simulate contrastenhanced CT protocols of 70 kV with half dose CM and 120 kV with full dose CM.

RESULTS

Diluted CM of 116 HU at 120 kV demonstrated HU value of 234±18 at 70 kV, while 240 HU CM showed 501±29 HU at 70 kV. Pseudo-enhancement of water insert with 240 HU phantom at 120 kV scan (23.9±0.3 HU) were significantly greater than those with 116 HUat 70 kV scan (12.4±0.7 HU, p<.0001). At 120 kV scan with surrounding 240 HU diluted CM, CNR of 24.8 HU or greater phantomshowed significant difference from water, while 4.5 HU or greater phantom showed significantly different CNR from water at 70 kVscan with 116 HU diluted CM.

CONCLUSION

To consider double HU values of iodine CM at 70 kV compared to 120 kV scans, a half contrast dose CT at 70 kV causes lesspseudo-enhancement and better CNR for subtle enhancement.


Considering pseudo-enhancement of renal cyst, contrast enhanced CT protocol of 70 kV with half dose CM would be more desirablethan 120 kV with full dose CM.

ParticipantsJonathan R. Young, MD, Los Angeles, CA (Presenter) Nothing to DiscloseJocelyn A. Young, Los Angeles, CA (Abstract Co-Author) Nothing to DiscloseDaniel J. Margolis, MD, Los Angeles, CA (Abstract Co-Author) Research Grant, Siemens AGMichael L. Douek, MD, MBA, Los Angeles, CA (Abstract Co-Author) Nothing to DiscloseSteven Sauk, MD, Saint Louis, MO (Abstract Co-Author) Nothing to DiscloseMargaret Hsu, MD, Sacramento, CA (Abstract Co-Author) Nothing to DiscloseSteven S. Raman, MD, Santa Monica, CA (Abstract Co-Author) Nothing to Disclose

PURPOSE

To investigate whether imaging features on multiphasic MDCT can discriminate sarcomatoid RCC (sRCC) and collecting duct

GU236-SD-WEA3

CT Findings of Advanced Papillary Renal Cell Carcinoma Type-2: Comparison with Advanced ClearCell Renal Cell Carcinoma

Station #3

GU237-SD-WEA4

Is it Possible to Indicated Renal Function by Virtue of Iodine Concentration Derived from DECT RenalImaging?

Station #4

carcinoma (CDC) from clear cell RCC (ccRCC). sRCC and CDC are rare, aggressive variants of RCC. In the setting of metastasis,upfront cytoreductive nephrectomy has survival benefit in ccRCC. However, for sRCC and CDC, upfront cytoreductive nephrectomyhas little or no survival benefit, as it delays the administration of systemic therapy.


With IRB approval for this HIPAA-compliant retrospective study, we derived a cohort of 166 ccRCCs, 7 sRCCs, and 4 CDCs withpreoperative multiphasic MDCT with up to four phases (unenhanced, corticomedullary, nephrographic, and excretory). Each lesionwas reviewed by two fellowship-trained GU radiologists with 7 and 12 years experience for contour, spread pattern, pattern ofenhancement, neovascularity, and calcification until a consensus was reached.

RESULTS

sRCCs were more likely than ccRCCs to have an irregular contour (57% v 2%, p<0.001) and an infiltrative spread pattern, definedas infiltration into adjacent renal parenchyma, collecting system, or neighboring structures, (71% v 10%, p<0.001). CDCs were alsomore likely than ccRCCs to have an irregular contour (75% v 2%, p<0.001) and an infiltrative spread pattern (100% v 10%,p<0.001). An infiltrative spread pattern has a specificity of 90% and sensitivity of 71% in discriminating sRCC from ccRCC and aspecificity of 90% and sensitivity of 100% in discriminating CDC from ccRCC. An irregular contour has a specificity of 98% andsensitivity of 57% in discriminating sRCC from ccRCC and a specificity of 98% and sensitivity of 75% in discriminating CDC fromccRCC.

CONCLUSION

Solid renal lesions with an irregular contour or an infiltrative spread pattern are suspicious for sRCC or CDC. Lesions with theseimaging features should be biopsied first rather than taken directly to nephrectomy, as upfront cytoreductive nephrectomy has littleor no survival benefit and delays the administration of systemic therapy.


An infiltrative spread pattern and irregular contour have a relatively high specificity and sensitivity in discriminating sRCC and CDCfrom ccRCC. Lesions with these imaging features should be biopsied first rather than taken directly to nephrectomy, as upfrontcytoreductive nephrectomy has little or no survival benefit and delays the administration of systemic therapy.

ParticipantsNagaaki Marugami, Kashihara, Japan (Presenter) Nothing to DiscloseToshiko Hirai, MD, Kashihara, Japan (Abstract Co-Author) Nothing to DiscloseJunko Takahama, MD, Kashihara, Japan (Abstract Co-Author) Nothing to DiscloseAki Takahashi, MD, Kashihara, Japan (Abstract Co-Author) Nothing to DiscloseKimihiko Kichikawa, MD, Kashihara, Japan (Abstract Co-Author) Nothing to Disclose

PURPOSE

Papillary renal cell carcinoma (papRCC) type-2 is categorized as a subtype with worse prognosis. Advanced papRCC type-2 is likelyto show heterogeneous and ill marginated mass mimicking advanced clear cell renal cell carcinoma (ccRCC). The purpose of thisstudy is to clarify the features of the CT findings of papRCC type-2 and to compare between advanced papRCC type-2 (over T3a)and advanced ccRCC.


The materials ware 19 papRCC and 44 ccRCC (over T3a) histologically proven in 256 consecutive patients with RCC undergoingpreoperative CT and nephrectomy. Before and after injection of contrast media, CT images were obtained at plain,corticomedullary, and nephrogenic phases. For visual assessment, the tumor size, heterogeneity, tumor margin, calcification, renalvein invasion, lymph node/ distant metastasis and degrees of enhancement at corticomedullary phase (type A: same or less thanrenal medulla enhancement, type B: less than renal cortex enhancement, type C: same as renal cortex enhancement). Forquantitative assessment, CT values at each phase were measured. We compared between papRCC and ccRCC for these factors.

RESULTS

Among all papRCC, 11 advanced papRCC (T3a over) were evaluated: the mean tumor size (7.3cm), heterogeneity (8/11), ill margin(8/11), calcification (2/11), renal vein invasion (7/11), metastases (3/11), enhancement type (type A; 4, type B; 5, type C; 2).The mean CT values were 34.0, 64.7 and 60.2 HU at plain, corticomedullary, and nephrogenic phases, respectively. Compared withadvanced ccRCC, there were significant difference only in CT values at corticomedullary phase (papRCC vs.cc RCC:64.7 vs. 104.7HU) and degrees of enhancement (type A; 4, B; 5, C; 2 vs. type A; 0 ,B; 8,C; 36).

CONCLUSION

Although advanced papRCC type-2was morphologically similar to advanced ccRCC, the degree of enhancement of papRCC type-2 atcorticomedullary phase was significantly less than that of advanced ccRCC.


For the patient with unresectable advanced RCC, contrast-enhanced CT findings may help us to determine whether it isconventional ccRCC or papRCC type-2 and to select the appropriate drug for molecular targeting therapy as part of a personalizedtreatment plan.

Participants

GU239-SD-WEA6

Single-phase Split-bolus Dual-energy CT Urography after Furosemide Intravenous Injection forEvaluating Urinary Stones and Bladder Tumors

Station #6

Min Li, Shenyang, China (Abstract Co-Author) Nothing to DiscloseKe Ren, MD, ShenYang, China (Abstract Co-Author) Nothing to DiscloseYangyang Kan, Shenyang, China (Abstract Co-Author) Nothing to DiscloseYu Zhao, Shenyang, China (Abstract Co-Author) Nothing to DiscloseKe Xu, MD, Shenyang, China (Abstract Co-Author) Nothing to DiscloseLong Cui, MD, PhD, Shenyang, China (Presenter) Nothing to Disclose

PURPOSE

This study aims at assess the feasibility of using quantified iodine concentration derived from DECT renal imaging to reflect renalfunction.


78 patients who underwent enhanced DECT abdominal scanning in our hospital were enrolled in this study. According to the renalfunction results, they were divided into healthy group and abnormal group given serum creatinine, blood urea and cysteine-c levelseparately. Enhanced renal images were derived at arterial phase, nephrographic phase and late phase respectively, and the Iodineconcentration was determined by virtue of the dual energy material decomposition algorithm. However, to avoid the acrossdifferences, the iodine enhancement level were normalized by divide the iodine concentration in renal cortex with the iodineconcentration in the aorta at arterial phase. The normalized iodine concentration (NIC) level between normal and abnormal renalfunction group were compared to analysis the difference.

RESULTS

Out of the 78 patients (Age: 59.6±10.4, Male: 53), there were 3, 15 and 42 patients whose blood urea, cys-c and serum creatininelevel were out of the healthy range. NIC difference analysis based on serum creatinine was neglect due to limited abnormalitycases. NIC in the abnormal blood urea group were 0.59±0.12, 1.22±0.23 and 1.17±0.16 for arterial, nephrographic and late phaserespectively; while in the normal blood urea group were 0.60±0.21, 1.40±0.34 and 1.30±0.25. The difference between these twogroups was significant at late phase (t=-1.992, P=0.05). NIC in the normal cys-c group were 0.56±0.12, 0.66±0.15, 0.61±0.08respectively, while in the abnormal cys-c group they were 0.64±0.26, 0.71±0.18, 0.68±0.14. The difference between two groups isalso significant at late phase (t=-2.688, P<0.01).

CONCLUSION

It is feasible to indicate serum creatinine abnormality and cys-c abnormality given the late phase NIC derived from dual energy.


Dual energy scanning is able to not only provide the anatomical details but also reflect the functionality of the kidney.

ParticipantsJun Gon Kim, Seoul, Korea, Republic Of (Presenter) Nothing to DiscloseChan Kyo Kim, MD, PhD, Seoul, Korea, Republic Of (Abstract Co-Author) Nothing to DiscloseSohee Song, Seoul, Korea, Republic Of (Abstract Co-Author) Nothing to DiscloseJung Jae Park, MD, Seoul, Korea, Republic Of (Abstract Co-Author) Nothing to DiscloseByung Kwan Park, MD, Seoul, Korea, Republic Of (Abstract Co-Author) Nothing to Disclose

PURPOSE

To investigate the feasibility of single-phase split-bolus dual-energy CT (DECT) after furosemide intravenous injection for evaluatingurinary stones and bladder tumors, and to measure the potential radiation dose reduction.


A total of 218 consecutive patients (mean age, 53 years; range, 28-77 years) who underwent split-bolus DECT urography afterfurosemide intravenous injection were enrolled in this retrospective study. The protocol included true noncontrast (TNC) and single-phase (combined nephrographic-excretory) postcontrast DECT scans. Virtual noncontrast (VNC), linearly blended and iodine overlay(IO) images were reconstructed from postcontrast DECT scans. The number and size of urinary stones were assessed on TNC andVNC images. Image quality of VNC and TNC was qualitatively evaluated using a 5-point scale. The CT numbers of bladder tumorswere also analyzed on TNC and reconstructed image. The potential dose reduction of a single-phase from dual-phase protocol wasmeasured.

RESULTS

169 urinary stones (mean size, 7.58 mm; range, 2-32.2 mm) in 56 patients and 19 bladder tumors (mean size, 12.7 mm; range, 4-56mm) in 10 patients were analyzed. On VNC images, 98.2% (149/169) stones were detected and the remaining 11.8% (20/169)stones were missed. The mean size of the missed stones on VNC image was 2.33 mm (range, 1.6-3.4 mm), but all stones ≥ 3.5 mmwere detected. For bladder tumors, the CT numbers on TNC and VNC images were 34.0 HU and 32.9 HU, respectively ( P = 0.754);the enhancement values of linearly blended and IO images were 68.2 HU and 78.2 HU, respectively ( P = 0.023); and accordingly,all tumors were characterized on IO images. The overall imaging quality of the VNC was significantly inferior to the TNC images (P=0.012), but the quality scales of the VNC were fair or more. The mean dose of single-phase DECT acquisition was 4.23 mSvcomparing with 7.08 mSv of the dual-phase study, resulting in about 40% reduction of radiation exposure by omitting TNC.

CONCLUSION

Single-phase split-bolus DECT urography using furosemide intravenous injection appears to be feasible for evaluating clinicallysignificant stones and bladder tumors, with potentially reduced radiation exposure.


Single-phase split-bolus DECT urography after furosemide intravenous injection can be used to evaluate clinically significant stonesand bladder tumors.

UR131-ED-WEA7

Optimizing Renal Transplant Ultrasound Parameters

Station #7

ParticipantsRajiv Rao, MD, Sacramento, CA (Presenter) Nothing to DiscloseGhaneh Fananapazir, MD, Sacramento, CA (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

Teaching Points for this Exhibit:1. Optimization: To discuss the technical principles that contribute to optimal ultrasound imaging ofrenal transplants.2. Artifacts: To review the major imaging artifacts that the radiologist commonly encounters when interpreting apost-operative renal transplant ultrasound.


1. Probe selection: use of high frequency probes2. Pressure artifact and its effect on resistive indices3. Gain settings on grayscale,color and spectral Doppler images4. Wall filter settings: masking true arcuate artery resistive indices5. Velocity scale settings: colorand spectral Doppler6. Angle of Insonation Optimization to eliminate false spectral broadening Optimization to eliminate directionalambiguity Optimization to obtain accurate velocity measurements 7- Aliasing Physical principles behind the phenomenon Artifactscreated on color and spectral Doppler settings Clinical use of the artifact to demonstrate stenosis Fixing aliasing artifact8- Spectralbroadening9- Color Doppler findings in nonvascular structures

GU240-SD-WEB1

Diffusion Kurtosis Imaging of Uterine Endometrial Cancer: Preliminary Study

Station #1

GU241-SD-WEB2

Prediction of Disease Progression after Concurrent Chemoradiotherapy in Uterine Cervical Cancer:Value of Diffusion-weighted Imaging

Station #2

GUS-WEB

Genitourinary Wednesday Poster Discussions

Wednesday, Dec. 2 12:45PM - 1:15PM Location: GU/UR Community, Learning Center

GU


ParticipantsSusanna I. Lee, MD, PhD, Boston, MA (Moderator) Nothing to Disclose

Sub-Events

ParticipantsShigeaki Umeoka, MD, Osaka City, Japan (Presenter) Nothing to DiscloseAkira Yamamoto, MD, PhD, Kyoto, Japan (Abstract Co-Author) Nothing to DiscloseKoji Sakai, Kyoto, Japan (Abstract Co-Author) Nothing to DiscloseAki Kido, MD, Kyoto, Japan (Abstract Co-Author) Nothing to DiscloseThorsten Feiweier, DIPLPHYS, PhD, Erlangen, Germany (Abstract Co-Author) Employee, Siemens AG Stockholder, Siemens AG Patentholder, Siemens AGKaori Togashi, MD, PhD, Kyoto, Japan (Abstract Co-Author) Research Grant, Bayer AG Research Grant, DAIICHI SANKYO GroupResearch Grant, Eisai Co, Ltd Research Grant, FUJIFILM Holdings Corporation Research Grant, Nihon Medi-Physics Co, Ltd ResearchGrant, Shimadzu Corporation Research Grant, Toshiba Corporation Research Grant, Covidien AG

PURPOSE

1.To investigate the feasibility and utility of DKI for the assessment of uterine endometrial cancer2.To correlate ADC, D and Kvalues with histologic subtypes of endometrial lesion


A total of twenty-nine patients (age 28-86) with clinically suspected endometrial lesions prospectively underwent MR imaging at3T, including DKI ( b-factors 0, 100, 500, 1000, 1500, 2000, 2500s/mm², Three orthogonal MPG directions with monopolar scheme(prototype sequence)). D (diffusion coefficient) and K (Kurtosis; the deviation of tissue diffusion from a Gaussian pattern) mapimages were generated on a voxel-by-voxel basis with in-house software. ADC map images were also calculated based on diffusion-weighted images with b-factors of 0, 500 and 1000 s/mm². Obtained ADC, D, and K values of the endometrial lesions werecorrelated with histological findings, subdivided into three categories (1. No malignant endometrial lesion, 2. Low-grade (grade 1)endometrial cancer, 3. High-grade (grade 2 or 3) endometrial cancer) using student t-test.

RESULTS

Histologically, 17 patients had endometrial carcinoma (11 low grade, 6 high grade) and 12 patients had benign conditions. 26 of 29endometrial lesions (89.7%) could be successfully visualized as lower signal intensity areas compared to the myometrium on ADC, D,and K map images. Of these 26 cases, the D, ADC (10-3mm2/s) and K values were 1.65±0.72, 1.52±0.50 and 0.64±0.11 for non-malignant endometrial lesion, 0.79±0.13, 0.67±0.11 and 0.87±0.08 for low-grade endometrial cancer, 0.81±0.16, 0.73±0.11 and1.10±0.08 for high-grade endometrial cancer, respectively. All K-, D- and ADC-values of the tumor show significant differencesbetween non-malignant and malignant lesion. Although no significant differences of D- and ADC-values between low- and high-grade cancer are observed, the K-value tends to be significantly higher in high-grade cancer than in low-grade cancer..

CONCLUSION

DKI seems an effective, non-invasive method for the assessment of endometrial lesions. ALL D-, K-, and ADC-values are helpful forthe differentiation between benign and malignant endometrial lesion. Only the K-value shows an excellent correlation withhistological subtypes of uterine endometrial cancer, and may serve as a new, useful prognostic biomarker.


Diffusion kurtosis imaging is well related to histological characteristics, including tumor cellularity and architectural distortion.

ParticipantsJung Jae Park, MD, Seoul, Korea, Republic Of (Presenter) Nothing to DiscloseChan Kyo Kim, MD, PhD, Seoul, Korea, Republic Of (Abstract Co-Author) Nothing to DiscloseByung Kwan Park, MD, Seoul, Korea, Republic Of (Abstract Co-Author) Nothing to Disclose

PURPOSE

To investigate the value of diffusion-weighted imaging (DWI) as a predictor of disease progression after concurrentchemoradiotherapy (CCRT) in uterine cervical cancer.


Our retrospective study included 100 consecutive patients (median age, 55 years) who received CCRT for locally advanced cervicalcancer. All enrolled patients underwent 3T-MRI including T2-weighted imaging (T2WI) and DWI at 1 month after completion ofCCRT. The presence or absence of residual tumor on T2WI and DWI was determined using a 5-point probability scale. For predicting

GU242-SD-WEB3

Percutaneous and Laparoscopic Cryoablation (CA) of Renal Carcinomas: Mid-term CT and MRImaging Follow-up

Station #3

GU243-SD-WEB4

Correlation of Renal IVIM Diffusion Parameters to DCE-MRI Perfusion Parameters from a Three-Compartment Model

Station #4

disease progression after completion of CCRT, the diagnostic performance of the presence of residual tumor on T2WI and DWI wasevaluated using the time-dependent receiver operating characteristics (ROC) curve analysis. The relationship between MR(presence of residual tumor on T2WI and DWI, and tumor size) and clinical variables (age, FIGO stage and histologic type) anddisease progression was investigated using the Cox regression analysis.

RESULTS

After a mean follow-up of 2.6 years, disease progression developed in 24 patients (24.0%): local recurrence (n= 10), distantmetastasis (n= 11) and both local recurrence and distance metastasis (n= 3). At ROC curve analysis, the integrated area under thecurve was significantly greater on DWI (0.751) than on T2WI (0.659) for predicting disease progression ( P = 0.009). For predictingdisease progression, the positive predictive values of DWI versus T2WI were 54.4% versus 32.7% at the first, 73.0% versus 37.2%at the second, and 72.7% versus 39.3% at the third year after CCRT, respectively, which were statistically different (all P -values<0.03). On univariate analysis, the presence of residual tumor on T2WI or DWI, and non-squamous cell carcinoma were significantlyassociated with disease progression ( P < 0.01). However, the presence of residual tumor on DWI was the only independentpredictor of disease progression (hazard ratio, 6.34; P < 0.0001) on multivariate analysis.

CONCLUSION

The presence of residual tumor on DWI at 1 month after completion of CCRT appears to be the only independent predictor fordisease progression in patients with locally advanced cervical cancer.


As an imaging marker, the presence of residual cervical cancer on DWI at 1 month after completion of CCRT may help to predicttherapeutic outcomes, which may play a crucial role in developing a personalized treatment.

ParticipantsGianpiero Cardone, MD, Milano, Italy (Presenter) Nothing to DiscloseMaurizio Papa, MD, Milan, Italy (Abstract Co-Author) Nothing to DiscloseAndrea Losa, MD, Milano, Italy (Abstract Co-Author) Nothing to DiscloseTommaso Maga, MD, Milan, Italy (Abstract Co-Author) Nothing to DisclosePaola Mangili, PhD, Milano, Italy (Abstract Co-Author) Nothing to DiscloseGiuseppe Balconi, Ornago, Italy (Abstract Co-Author) Nothing to Disclose

PURPOSE

This study aims to determine the safety and efficacy of CA in the management of small renal carcinomas and to assess its mediumterm outcome.


We report the mid-term CT/MR imaging follow-up in 115 pts who gained at least 5 years follow-up after CA of 96 renal carcinomas.Treatment was administered under laparoscopic US guidance in 101 pts and using percutaneous CT guidance in 14 pts. Pts werefollowed up clinically, biochemically and by imaging 24 hours after surgery, and subsequently every 6 months. Imaging follow-upwas obtained using a 1,5T MR system in 104 cases and using CT in 11 pts with contraindications to MR.

RESULTS

24 hours after treatment all cryolesions were more than 1 cm larger than the original masses; cryolesions decreased in size by anaverage of 38% at 1 month, 64% at 6 months, 80% at 12 months and 93% at 84 months following LC. Early postprocedural MR andCT ce- images showed complete ischemia of cryolesions. Follow-up revealed no evidence of local recurrence in 111/115 pts (96%).4 pts showed local recurrence at 12, 24 and 96 months. 12/115 pts (9%) demonstrated metachronous nodules in the same or inthe contralateral kidney at 12, 24 and 48 months. 2 pts showed a pancreatic metastatic nodule at 12 and 24 months. 11/115 ptsdied for metastasis of a previous malignancy. 1 pt showed ureteral fistula and 1 pt showed proximal ureteral stenosis. No significantrise in creatinine level was noted postprocedurally. After surgery 11% of the cases showed small perilesional haematomas.

CONCLUSION

Our experience suggests that CA is a safe, well tolerated and minimally invasive therapy for small renal carcinomas. MR is aneffective tool in the imaging follow-up of renal lesions treated with CA, and the high contrast resolution of MR allows a betterevaluation of vascularization of treated areas on subtracted ce images compared to CT. CT can be used as an alternative choice toMR, but lower contrast resolution of CT to MR makes it difficult to differentiate the cryolesion from the surrounding perilesionalcollections.


CA is a safe, well tolerated and minimally invasive therapy for small renal carcinomas. MR and CT are effective imaging techniques inthe follow-up of renal lesions treated with CA.

ParticipantsOctavia Bane, PhD, New York, NY (Presenter) Nothing to DiscloseMathilde Wagner, MD,PhD, Paris, France (Abstract Co-Author) Nothing to DiscloseHadrien Dyvorne, PhD, New York, NY (Abstract Co-Author) Nothing to DiscloseHenry Rusinek, PhD, New York, NY (Abstract Co-Author) Nothing to DiscloseJeff L. Zhang, PhD, Salt Lake Cty, UT (Abstract Co-Author) Consultant, Bristol-Myers Squibb CompanyBachir Taouli, MD, New York, NY (Abstract Co-Author) Consultant, Guerbet SA

GU244-SD-WEB5

Texture Analysis on T2-weighted MRI to Evaluate for Biochemical Recurrence in Prostate CancerPatients

Station #5

PURPOSE

To correlate cortical and medullary intravoxel-incoherent motion diffusion-weighted imaging (IVIM-DWI) parameters to DCE-MRIparameters using a validated three-compartment model.


IVIM-DWI and DCE-MRI data were analyzed in 20 patients (M/F 14/6, age 58±7 y; serum eGFR=85± 26 ml/min) with liver diseasewho underwent abdominal MRI at 1.5T. A bipolar diffusion sequence with single-shot EPI readout and spectral fat saturation wasacquired in 17 interleaved slices in the coronal plane with respiratory triggering and 16 b-values. 64 coronal 3D FLASH DCE-MRIvolumes were acquired over repeat breath-holds with a mean temporal resolution of 2.7 sec, during injection of 0.05 mmol/kg of Gd-BOPTA at 3 ml/sec.ROIs were placed on the motion-corrected IVIM images (FireVoxel) in the renal cortex and medulla, avoidingmajor vessels, lesions and fat. Mean ROI signal was fitted to the IVIM model.The cortex and medulla in each kidney, as well as theaorta at the level of the renal arteries, were semi-automatically segmented from the DCE-MRI volumes using validated software(Perf4DSegm).GFR, whole kidney, cortical and medullary renal plasma flow (RPF), as well as mean transit times (MTT) for thecompartments and the whole kidney, were calculated.

RESULTS

Renal IVIM parameters obtained were in accordance with previous studies; cortical ADC and perfusion fraction (PF) weresignificantly higher compared to medulla (p=0.0005 and p=0.0007, respectively). DCE-MRI parameters obtained in 18/20 patients(due to truncated arterial input function in 2 patients) were in agreement with previous studies using the three-compartmentmodel. DCE-MRI eGFR was significantly correlated with serum eGFR (Spearman r=0.595, p=0.011), but under-estimated serum eGFR(slope = 0.47, p = 0.005; intercept = 14.12, p = 0.279). RPF values were significantly higher in the cortex than in the medulla(p<10^-6). Significant correlation was observed for pooled cortical and medullary PF and ADC with RPF (Fig.1; PF r=0.327,p=0.005, ADC r=0.387, p=0.001). Cortical RPF correlated with ADC (r=0.49, p=0.003), but not with PF. No other DCE-MRI and IVIMparameters were correlated.

CONCLUSION

Cortical and medullary ADC and PF were moderately correlated with RPF in this initial ongoing study.


IVIM diffusion cannot be substituted for DCE-MRI in the evaluation of renal plasma and tubular flow. The techniques providecomplementary information on renal function.

ParticipantsAnna M. Brown, BEng, Bethesda, MD (Presenter) Nothing to DiscloseSandeep Sankineni, MD, Bethesda, MD (Abstract Co-Author) Nothing to DiscloseJoanna Shih, Bethesda, MD (Abstract Co-Author) Nothing to DiscloseRichard Ho, Bethesda, MD (Abstract Co-Author) Nothing to DiscloseMaria Merino, MD, Bethesda, MD (Abstract Co-Author) Nothing to DisclosePeter Pinto, Bethesda, MD (Abstract Co-Author) Nothing to DisclosePeter L. Choyke, MD, Rockville, MD (Abstract Co-Author) Researcher, Koninklijke Philips NV Researcher, General Electric CompanyResearcher, Siemens AG Researcher, iCAD, Inc Researcher, Aspyrian Therapeutics, Inc Researcher, ImaginAb, Inc Researcher, AuraBiosciences, IncBaris Turkbey, MD, Ankara, Turkey (Abstract Co-Author) Nothing to Disclose

PURPOSE

To assess whether texture analysis can evaluate whole-prostate T2-weighted MRI scans for biochemical recurrence (BCR) in post-prostatectomy patients.


Initially 337 patients who underwent prostate multi-parametric MRI (mpMRI) followed by radical prostatectomy between 5/2007 -3/2014 were included in this study, all with ≥1 year follow-up. In this cohort, 21 patients were determined to have BCR based onthe American Urologic Association definition. One patient was excluded for having brachytherapy seeds present on his baselinempMRI. A matched cohort analysis was performed on the basis of age, pre-treatment prostate specific antigen (PSA), and race,and 18/20 patients were able to be matched with controls (recurrence-free prostate cancer patients). Ultimately, 36 patients wereincluded in the study (n=18 BCR, n=18 matched controls).Pre-treatment T2-weighted turbo-spin echo MRI scans were acquired at3T using an endorectal coil and a 16-channel surface/cardiac coil. Whole-prostate contour voxels of interest (VOIs) were assessedusing the texture analysis program MaZda (Technical University of Lodz, Poland). Feature reduction was performed using the MutualInformation method in MaZda, resulting in seven texture features that were incorporated into a linear discriminant analysis (LDA)model. Receiver-operator characteristic (ROC) curve analysis was then used to evaluate the LDA model.

RESULTS

For the BCR patients, mean age and PSA were 59 yrs (range 41-73) and 19.2 ng/mL (range 4.5-51.1), respectively. The mean ageand PSA for the matched control patients were 60 yrs (range 51-76) and 19.1 ng/mL (range 2.62-55.7), respectively. ROC analysisof the LDA model of the seven texture features resulted in an area under the curve (AUC) of 0.87 and p=0.00017 in distinguishingBCR from matched control whole-prostate VOIs. Using a cutoff MDF1 of 3.01, the sensitivity was 89% and specificity was 78%, and30/36 (83%) patients were classified correctly.

CONCLUSION

The LDA model separates BCR from matched control patients with reasonably high accuracy. Our approach can potentially be usedto predict BCR candidates at the pre-treatment phase. Further work is now needed to prospectively test this model.


GU245-SD-WEB6

Single Phase Enhanced CT for the Detection of Urolithiasis: Can It be an Alternative to NonenhancedCT or Muliphase Protocols?

Station #6

UR132-ED-WEB7

PI-RADS v2.0 - An Atlas and Illustrated Manual

Station #7

Texture analysis shows potential to distinguish prostate cancer patients with biochemical recurrence from a matched cohort ofrecurrence-free patients based on baseline T2-weighted MRI features.

ParticipantsChristelle Chedrawy, MD, Chicago, IL (Presenter) Nothing to DiscloseGirish Kumar, MD, Stickney, IL (Abstract Co-Author) Nothing to DiscloseNancy Wilkins, Glenview, IL (Abstract Co-Author) Nothing to DiscloseAnita H. Kelekar, MD, Palatine, IL (Abstract Co-Author) Nothing to DiscloseDheeraj Reddy Gopireddy, MD, MPH, Chicago, IL (Abstract Co-Author) Nothing to DiscloseRita Agarwala, MD, Oak Brook, IL (Abstract Co-Author) Nothing to Disclose

PURPOSE

To determine the usefulness of enhanced CT for detection of renal and ureteral calculi. To determine the usefulness of enhancedCT in identifying alternate diagnosis if not suspected.


Between January 2014 and December 2014, 70 CT scans performed in the outpatient center for renal stone detection, hematuria orflank pain were randomly reviewed. 69 were performed with at least 2 phases, including a noncontrast examination. One study wasperformed with contrast only. 27 studies positive for renal calculi were reviewed independently by two radiology residents. Thenumber of stones seen on enhanced examinations was then compared to the number detected on the nonenhaned studies.

RESULTS

Stones were not seen in 7 studies (26 %) and 9 (33%) studies by observer 1 and 2 respectively. At least 66 % of the missedstones were less than 3 mm in size. Nearly all of the stones were calyceal. None of the stones that were not detected on theenhanced study were associated with hydronephrosis, hydroureter, perinephric stranding or other secondary signs. The studiesnegative for urolithiasis demonstrated on the enhanced examination significant pathology such as prostatomegaly and bladdercancer, accounting for patient's presenting symptoms.

CONCLUSION

Enhanced CT can be used in the detection of urolithiasis. Missed stones on enhanced CT were not associated with significantobstructive changes and may be questionably clinically significant.


Although nonenhanced CT has been proven to be the most accurate diagnostic study with a high sensitivity (95-96%) andspecificity (98%) , enhanced CT performed in the nephrographic phase may present an alternative to detection of urolithiasis.Additionally, it increases a physician diagnostic certianty by identifying alternate significant pathology not initially suspected.

ParticipantsErick S. Hollanda, Rio de Janeiro, Brazil (Presenter) Nothing to DiscloseDafne D. Melquiades, Rio de Janeiro, Brazil (Abstract Co-Author) Nothing to DiscloseFernanda Miraldi, MD, Rio de Janeiro/Niteroi, Brazil (Abstract Co-Author) Nothing to DiscloseAndrei S. Purysko, MD, Cleveland, OH (Abstract Co-Author) Nothing to DiscloseNatalia Sabaneeff, MD, Rio de Janeiro, Brazil (Abstract Co-Author) Nothing to DiscloseLeonardo K. Bittencourt, MD, PhD, Rio De Janeiro, Brazil (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

The joint initiative for standardization of the interpretation and communication of multiparametric prostate MR findings hasculminated on the development of the second version of PI-RADS. In this presentation, we demonstrate the typical imaging findingsin each assessment category, underscoring the main changes over the previous PI-RADS version. Of note, we highlight theadoption of a 'dominant' parameter for each zonal compartment of the prostate, corresponding to DWI for the peripheral zone andT2WI for the transition zone. DCE is now only applied to differentiate between scores 3 and 4 in the peripheral zone. The notion oflesion size was now incorporated to DWI and T2WI criteria, using a threshold of 1.5 cm to differentiate between scores 4 and 5 forhighly-suspicious lesions.


Why and when to use Multiparametric prostate magnetic ressonace imaging (mpMRI).PI-RADS v2 vs. PIRADS v1. Brief history andevolution. Rationale for the imaging criteria.mpMRI protocols and functinal sequences.The 'dominant' sequence based on zonalanatomy, a recent implementation from PI-RADS v2.Sample cases, with assessment categories and troubleshooting.How to usempMRI with PI-RADS in routine clinical practice. Decision making and risk stratification.Besides detection, is PI-RADS any good fortumor staging?

MSSR43A Abdominal Injuries

MSSR43B The Enemy Within, Non-Traumatic Abdominal Emergencies

MSSR43C Interactive Case Discussion

MSSR43

RSNA/ESR Emergency Symposium: Abdominal Emergencies (An Interactive Session)

Wednesday, Dec. 2 1:30PM - 3:00PM Location: S402AB

GI CT ER


ParticipantsRonald J. Zagoria, MD, San Francisco, CA, ([email protected]) (Moderator) Nothing to DiscloseAndras Palko, MD, PhD, Szeged, Hungary (Moderator) Medical Advisory Board, Affidea Group;

Sub-Events

ParticipantsAndras Palko, MD, PhD, Szeged, Hungary, ([email protected]) (Presenter) Medical Advisory Board, Affidea Group;

LEARNING OBJECTIVES

1) To explain the significance of injury mechanism and its role in the formation of consequent abdominal lesions and theircomplications. 2) To outline the role of proper imaging technique and diagnostic algorithm in the sufficiently fast diagnosis ofabdominal injuries. 3) To learn more about the typical and unusual findings of various abdominal traumatic conditions.

ABSTRACT

Abdominal injuries require a timely and reliable diagnosis in order to prevent the potentially lethal outcome. The armory of clinicaltools (physical examination, lab tests) does not fulfill these criteria, since they are either not fast, or not reliable. Imagingdiagnostic modalities help the clinician to acquire the necessary amount of information to initiate focused and effective treatment.However, the selection of the appropriate imaging algorithm, modality and technique, as well as the precise detection andinterpretation of essential imaging findings are frequently challenging, especially because the circumstances, under which theseexaminations are performed (open wounds, bandages, non-removable life-supporting equipment, lack of patient cooperation, etc.),are frequently less than optimal. Knowledge of critical imaging signs, symptoms and the role they play in the evaluation of thepatient's condition, but also fast decision-making and ability to closely cooperate with the clinicians are skills of key importance forradiologist members of the trauma team.

ParticipantsRonald J. Zagoria, MD, San Francisco, CA, ([email protected]) (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) Attendees will be able to better analyze CT scans for non-traumatic causes of abdominal pain. 2) Attendees will learn the CTsigns and causes of bowel ischemia. 3) Attendees will learn the CT findings of common causes of an "acute" abdomen. 4) Attendeeswill learn the imaging findings of acute, nontraumatic urinary tract and GI tract emergencies.

ABSTRACT

This segment of the course will go over the optimal imaging approach for patients presenting with acute abdominal pain. CT findingswill be emphasized. Key imaging findings of nontraumatic causes of acute abdominal pain including gastrointestinal tract and urinarytract pathology will be explained. A systematic approach for the imaging evaluation of patients wih abdominal emergencies will beillustrated and explained including proper scan protocols and analysis of imaging findings. Imaging diagnosis of urinary tractobstruction, infection, bowel obstruction, and ischemia will be emphasized.

ParticipantsAndras Palko, MD, PhD, Szeged, Hungary (Presenter) Medical Advisory Board, Affidea Group; Ronald J. Zagoria, MD, San Francisco, CA, ([email protected]) (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) Attendees will be able to better analyze CT scans for traumatic and non-traumatic causes of abdominal pain. 2) Attendees willlearn the CT signs and causes of bowel ischemia and injuries. 3) Attendees will learn the CT findings of common causes of atraumatic and non-traumatic 'acute' abdomen. 4) Attendees will learn the imaging findings of acute, traumatic and nontraumaticurinary tract and GI tract emergencies.

ABSTRACT

Using cases and an audience response system, this segment of the course will go over the optimal imaging approach for patientspresenting with acute abdominal pain and abdominalk injuries. CT findings will be emphasized. Key imaging findings of traumatic andnontraumatic causes of acute abdominal pain including gastrointestinal tract and urinary tract pathology will be explained. Asystematic approach for the imaging evaluation of patients wih abdominal emergencies will be illustrated and explained includingproper scan protocols and analysis of imaging findings. Imaging diagnosis of blunt an penetrating abdominal injuries, urinary tractobstruction, infection, bowel obstruction, and ischemia will be emphasized.

MSRO43

BOOST: Genitourinary-Case-based Review (An Interactive Session)

Wednesday, Dec. 2 3:00PM - 4:15PM Location: S103CD

GU RO


ParticipantsSpencer C. Behr, MD, Burlingame, CA (Moderator) Research Grant, General Electric Company; Consultant, General Electric CompanyPaul Nguyen, Boston, MA (Moderator) Consultant, Medivation, Inc; Consultant, GenomeDx Biosciences IncDaniel J. Margolis, MD, Los Angeles, CA, ([email protected]) (Presenter) Research Grant, Siemens AGGeorge B. Rodrigues, MD, London, ON (Presenter) Nothing to DiscloseTodd Morgan, MD, Ann Arbor, MI (Presenter) Research funded, Myriad Genetics, Inc; Research funded, MDxHealth SARussell Szmulewitz, MD, Chicago, IL (Presenter) Advisory Board, Pfizer Inc; Advisory Board, Bayer AG

LEARNING OBJECTIVES

1) To apply oncologic decision making in prostate cancer. 2) To recognize critical clinical manifestations of prostate cancer. 3) Todiscern clinically significant from insignificant signs and findings in prostate cancer.

SSM11-01 Genitourinary Keynote Speaker: Safety and Efficacy of Corticosteroid Prophylaxis

Wednesday, Dec. 2 3:00PM - 3:10PM Location: E352

SSM11-02 The Effect of IV Contrast on Renal Function in Patients on Metformin


SSM11-03 The Presence of a Solitary Kidney is not an Independent Risk Factor for Acute Kidney InjuryFollowing Contrast-enhanced CT


SSM11

ISP: Genitourinary (Intravenous Contrast Issues and CT Dose Reduction)


CT GU SQ


ParticipantsMatthew S. Davenport, MD, Cincinnati, OH (Moderator) Book contract, Wolters Kluwer nv; Book contract, Reed Elsevier; Dean A. Nakamoto, MD, Beachwood, OH (Moderator) Research Grant, Galil Medical Ltd; Research agreement, Toshiba Corporation

Sub-Events

ParticipantsMatthew S. Davenport, MD, Cincinnati, OH (Presenter) Book contract, Wolters Kluwer nv; Book contract, Reed Elsevier;

ParticipantsCody W. McHargue, BA, San Francisco, CA (Presenter) Nothing to DiscloseArti D. Shah, MD, San Francisco, CA (Abstract Co-Author) Nothing to DiscloseJudy Yee, MD, Clayton, CA (Abstract Co-Author) Research Grant, EchoPixel, IncPriyanka Jha, MBBS, Sacramento, CA (Abstract Co-Author) Nothing to DiscloseIsabel Allen, San Francisco, CA (Abstract Co-Author) Nothing to DiscloseDonald Chau, BA, San Francisco, CA (Abstract Co-Author) Nothing to DiscloseRobert Rushakoff, MD, San Francisco, CA (Abstract Co-Author) Nothing to Disclose

PURPOSE

Due to concerns of acute kidney injury and the theoretical risk of lactic acidosis with metformin, the Food and Drug Administrationmandates that metformin be held for two days after intravenous (IV) contrast until renal function is checked and in an acceptablerange. However, there is minimal evidence to support this practice. Further investigation is warranted.


We conducted a retrospective cohort study of 130 adult outpatients at the San Francisco Veterans Affairs Medical Center todetermine if there was a change in renal function in diabetic patients on metformin who underwent computed tomography (CT)scans with IV contrast between 2007-2014. Patients were excluded if immediately hospitalized after the CT scan. The generalizedestimating equations method was used to determine whether IV contrast and pre-contrast creatinine (Cr; or pre-contrastestimated glomerular filtration rate [eGFR]) were associated with a change in Cr (or eGFR). Covariates included: age, gender, BMI,diabetes (DM) duration and HbA1c.

RESULTS

In our cohort, mean age was 67±10 years, 119 (91%) were male, 71 (55%) were Caucasian, and 63 (49%) were higher risk (pre-contrast eGFR <60 ml/min/1.73m2). Mean DM duration was 6.5±6.0 years and mean HbA1c was 7.1±1.3%. Mean pre- and post-contrast Cr were 1.13±0.25 mg/dL and 1.09±0.26 mg/dL; p=0.02 (overall t-test). Mean pre- and post-contrast eGFR were 72±24ml/min/1.73m2 and 75±26 ml/min/1.73m2; p=0.006 (overall t-test). In fully-adjusted models, there was a significant decrease in Crpost-contrast: β-coefficient -0.24 (95% confidence interval [CI] -0.35 to -0.12), p<0.001. There was no significant change ineGFR post-contrast: β-coefficient -0.06 (95% CI -0.16 to 0.03), p=0.19. A subgroup analysis of patients with pre-contrast eGFR <60 ml/min/1.73m2 showed similar results.

CONCLUSION

There is no evidence of deterioration in renal function in outpatients on metformin who receive IV contrast, even in a cohort with alarge proportion of higher risk patients. Therefore, our results suggest that the current practice of holding metformin after IVcontrast should be re-evaluated.


The practice of holding metformin and checking Cr two days after IV contrast should be re-evaluated as there was no evidence tosuggest a decline in renal function in a cohort with high risk patients.

ParticipantsJennifer S. McDonald, PhD, Rochester, MN (Abstract Co-Author) Research Grant, General Electric CompanyRichard W. Katzberg, MD, Sacramento, CA (Abstract Co-Author) Research Grant, Siemens AG Research Grant, Bayer AGInvestigator, Siemens AG Investigator, Bayer AGRobert J. McDonald, MD, PhD, Rochester, MN (Presenter) Nothing to DiscloseEric E. Williamson, MD, Rochester, MN (Abstract Co-Author) Research Grant, General Electric CompanyDavid F. Kallmes, MD, Rochester, MN (Abstract Co-Author) Research support, Terumo Corporation Research support, Medtronic, Inc

SSM11-04 New Insights in the MRI Excretory Phase: The Use of Gd-EOB-DTPA for the Evaluation of theExcretory System


SSM11-05 Feasibility and Image Quality of Reduced Dose CT Intravenous Pyelogram Using Model-BasedIterative Reconstruction in Patients with Hematuria


Research support, Sequent Medical, Inc Research support, Benvenue Medical, Inc Consultant, General Electric Company Consultant,Medtronic, Inc Consultant, Johnson & Johnson

PURPOSE

To determine whether patients with a solitary kidney are at higher risk for contrast-induced acute kidney injury (AKI) than matchedcontrol bilateral kidney patients.


This retrospective study was HIPAA compliant and approved by our Institutional Review Board. Adult patients with bilateral kidneysor a solitary kidney from unilateral nephrectomy who received a contrast-enhanced computerized tomography (CT) scan at ourinstitution from January 2004 to August 2013 were identified. The effects of contrast exposure on the rate of AKI (defined as a risein maximal observed serum creatinine (SCr) of either 1) > 0.5 mg/dL or 2) > 0.3 mg/dL or 50% over baseline within 24-72 hours ofexposure), and 30-day post-scan emergent dialysis and death were determined following propensity score-based 1:3 matching ofsolitary and control bilateral kidney patients.

RESULTS

Propensity score matching yielded a cohort of 247 solitary kidney patients and 691 bilateral kidney patients. The rate of AKI wassimilar between the solitary and bilateral kidney groups [SCr > 0.5 mg/dL AKI definition odds ratio (OR) = 1.11 (95% confidenceinterval (CI) 0.65 - 1.86); p = 0.70; SCr > 0.3 mg/dL or 50% AKI definition OR = 0.96 (95% CI 0.41 - 2.07). p = 0.99]. The rate ofemergent dialysis was rare and also similar between cohorts (OR = 1.87 (0.16-16.4), p=.61). Though the rate of mortality washigher in the solitary kidney group (OR = 1.70 (1.06-2.71), p=.0202), chart review found that no death was attributable to AKI.

CONCLUSION

This study did not detect any significant differences in the rate of AKI, dialysis, or death attributable to contrast-enhanced CT inpatients with solitary versus bilateral kidneys.


Contrast-enhanced CT protocols can be guided by image optimization, rather than contrast-induced nephropathy risk in solitarykidney patients.

ParticipantsCaterina Colantoni, MD, Milan, Italy (Presenter) Nothing to DiscloseAntonio Esposito, MD, Milan, Italy (Abstract Co-Author) Nothing to DiscloseAnna Palmisano, MD, Milan, Italy (Abstract Co-Author) Nothing to DiscloseFrancesco A. De Cobelli, MD, Milan, Italy (Abstract Co-Author) Nothing to DiscloseAlessandro Del Maschio, MD, Milan, Italy (Abstract Co-Author) Nothing to Disclose

PURPOSE

Excretory MR urography is a useful complementary technique in many MR imaging studies of the abdomen to assess kidneyexcretion and the urinary collecting system. However, after the injection of a standard dose gadolinium-based contrast media,frequently, the collecting system is unassessable for T2* effect due to very high concentration of Gd in the urine. Aim of thepresent study was to compare the enhancement of the urinary collecting system after the injection of a single standard dose ofGd-based contrast media known for different renal excretion rates: Gadobutrol, Gadobenate dimeglumine, and Gd-EOB-DTPA.


In 60 patients (pts) with normal creatinine clearance and without urinary tract dilatation, mean signal intensities (pixel values) ofthe renal pelvis and of the paravertebral muscles for the calculation of renal pelvis/skeletal muscle ratio, were evaluated on 3D fastT1-weighted gradient-echo sequences with fat suppression obtained during excretory phase after intravenous injection of 0.1mmol/kg contrast media: 20pts were studied with Gadobutrol, 20pts with Gadobenate dimeglumine, and 20pts with Gd-EOB-DTPA,respectively. Urinary collecting system was considered assessable/not-assessable according to the presence of T2* effect.

RESULTS

The mean signal intensities of renal pelvis were 1954±1368.5 (pixel values) for Gadobutrol, 2488±843.8 for Gadobenate dimeglumine,and 3605±1025.3 for Gd-EOB-DTPA, respectively. The mean signal intensity ratio was 2.2±1.59 for Gadobutrol, 2.7±0.88 forGadobenate dimeglumine, and 3.8±1.46 for Gd-EOB-DTPA. No significant differences were found between the mean signal intensityratio of Gadobutrol and that of Gadobenate dimeglumine (p>0.05); significant differences were found between the mean signalintensity ratio of Gadobutrol and of Gd-EOB-DTPA (p<0.005), and that of Gadobenate dimeglumine and of Gd-EOB-DTPA (p<0.001).Urinary collecting system was considered not-assessable in 8/20pts for Gadobutrol, in 1/20pt for Gadobenate dimeglumine, and in0/20pts for Gd-EOB-DTPA.

CONCLUSION

The urinary collecting system was considered assessable in all pts studied after injection of a standard dose of Gd-EOB-DTPA, andthis could be due to the low urine excretion rate.


The use of Gd-EOB-DTPA in the excretory MR urography can improve the assessability of the excretory system, with no evidence ofT2* shortening effects.

SSM11-06 Reduced Radiation Dose with Iterative Reconstruction in 100 kVp CT Urography: With differentIodine Dosage


ParticipantsIsabelle Boulay-Coletta, MD, Paris, France (Abstract Co-Author) Nothing to DiscloseLinda N. Morimoto, MD, Stanford, CA (Presenter) Nothing to DiscloseDominik Fleischmann, MD, Palo Alto, CA (Abstract Co-Author) Research support, Siemens AG; Lior Molvin, Stanford, CA (Abstract Co-Author) Speakers Bureau, General Electric CompanyLu Tian, Stanford, CA (Abstract Co-Author) Nothing to DiscloseJuergen K. Willmann, MD, Stanford, CA (Abstract Co-Author) Research Consultant, Bracco Group; Research Consultant, Triple RingTechnologies, Inc; Research Grant, Siemens AG; Research Grant, Bracco Group; Research Grant, Koninklijke Philips NV; ResearchGrant, General Electric Company

PURPOSE

To evaluate the feasibility and image quality of Reduced Dose (RD) CT Intravenous Pyelogram (IVP) using Model-Based IterativeReconstruction (MBIR) compared to Standard Dose (SD) CT IVP using Adaptive Statistical Iterative Reconstruction (ASIR) inpatients referred for work-up of hematuria.


In this IRB approved and HIPAA compliant study, 66 consecutive patients (44 males and 22 women; mean age, 62 years; mean BMI,27 kg/m²) referred for a dual phase CT IVP (non-contrast and combined split-bolus nephrographic-excretory phase) wereprospectively included and either imaged with SD CT IVP with 40% ASIR technique (n=34) or RD CT IVP with MBIR technique (n=32)on a 64-slice CT scanner (GE Discovery 750 HD). Quantitative measurements of image noise on both non-contrast and post-contrast imaging in addition to radiation dose and patients' BMI were recorded by one reader. Two independent, blinded readersassessed subjective image quality, including image noise, sharpness of the renal cortex and collecting system (calyces, renal pelvis,ureters, and bladder), presence of artifacts, and overall image quality impression on non-contrast and post-contrast images utilizing4 or 5-point grading scales.

RESULTS

Both patient groups were not significantly different (26.8 +/- 7.8 kg/m² versus 27.5 +/- 4.8 kg/m²) in regards to BMI. Radiationdose was reduced by an average of 49% (p<0.01) on RD CT IVP (CTDI vol = 7.7 +/- 2.8 mGy) compared to SD CT IVP (CTDI vol=15.1 +/- 4.8 mGy) on post-contrast imaging. Overall dose reduction averaged 36% with non-contrast and contrast-enhancedimaging (RD CT IVP CTDIvol =15.31 +/- 2.8 mGy versus SD CT IVP CTDI vol = 23.91 +/- 5.3 mGy). Overall image quality impressionof the collecting system, artifacts, and image sharpness were not significantly different (p>0.05) between RD CT IVP and SD CTIVP. Subjective image noise was significantly lower (p<0.01) in RD CT IVP, which was also reflected by a quantitative reduction ofimage noise by an average of 44% (p<0.01) on non-contrast imaging and 37% (p<0.01) on post-contrast imaging.

CONCLUSION

RD CT IVP is feasible and allows for a substantial dose reduction compared to SD CT IVP protocol without compromising imagequality.


Introduction of iterative reconstruction algorithms which can be implemented with routine clinical CT IVP protocols to reduceradiation exposure while yielding diagnostic quality images.

ParticipantsHuihui Wang, MD, Beijing, China (Presenter) Nothing to DiscloseJuan Hu, Kunming, China (Abstract Co-Author) Nothing to DiscloseXuedong Yang, Beijing, China (Abstract Co-Author) Nothing to DiscloseXiaoying Wang, MD, Beijing, China (Abstract Co-Author) Nothing to DiscloseHe Wang, MD, Beijing, China (Abstract Co-Author) Research Grant, General Electric CompanyJian Jiang, MD, Beijing, China (Abstract Co-Author) Research Grant, General Electric Company

PURPOSE

To evaluate the image quality and radiation dose in CT urography at 100kVp with iterative reconstruction, combining a differentiodine dosage.


This study was approved by the institutional review board. From March to June 2012, 45 consecutive patients who underwent CTUfor hematuria were divided into 3 groups: group A, 100kVp and 0.9mL/kg contrast material (CM) (9 men, 6 female; mean age 49.4years; mean BMI 22.6kg/m2); group B, 100kVp and 1.1mL/kg CM (8 men,7 female; mean age 50.1years; mean BMI 22.6kg/m2);group C, 120kVp and 1.1mL/kg CM (13men, 2 female; mean age 58.5 years, mean BMI 23.5kg/m2). Automatic tube current wasused in all groups. The 100kVp images (group A and B) were reconstructed with 80% adaptive statistical iterative reconstruction(ASiR), while filter back projection (FBP) for 120kVp images (group C). Urinary tract was divided into 11 segments, and mean CTvalues and contrast-to-noise ratio (CNR) of each segment in the excretory phase were measured respectively in 3 groups. Theradiation dose in excretory phase was compared (volume computed tomography dose index, CTDIvol; size-specific dose estimate,SSDE and estimated effective dose, ED).

RESULTS

There were no significant differences among group A, B and C for age, BMI and transverse circumstance (all P>0.05). Allexaminations were considered to be of acceptable image quality and inter-observer agreement was good (K=0.717, P<0.001). Therewere no significant differences in mean attenuations of all urinary segments among 3 groups (P>0.05). Image noise was much lessin group A and B (both P<0.001) than that of group C, but there was no significant difference between group A and B (P=0.934).CNRs in most segments were higher in group B than group C(P=0.001~0.062) and similar between group A and C(P=0.024~0.896),but there were no notable differences in CNRs between group A and B (P>0.05). Mean CTDIvol, SSDE and ED in excretory phase in

group A and B were significantly lower than those of group C(P<0.05). Iodine dosage was reduced by 18.2% in group A than groupB and C.

CONCLUSION

Given subjective and objective image quality, CTU at 100 kVp with 80% ASiR resulted in reduction of radiation dose, and 0.9mL/kgCM (320mgI/ml) iodine dosage was workable.


High radiation exposure and Contrast-Induced Nephropathy for CTU have drawn much attention and anxiety, 100kVp with 80% ASiRand 0.9mL/kg CM may offer a means of resolution.

SSM24-01 Evaluation of Changes in Quality of Life Related to Uterine Fibroid Embolization (UFE): PreliminaryResults of the French SFICV EFUZEN Study

Wednesday, Dec. 2 3:00PM - 3:10PM Location: E450B

SSM24-02 Vascular/Interventional Keynote Speaker: Current Status of Prostate Artery Embolization as aTreatment for BPH


SSM24-03 Percutaneous Ablation of Oligometastatic Prostate Cancer: Oncologic Outcomes and Safety


SSM24

ISP: Vascular/Interventional (Gentiourinary Interventions-Treating Conditions of the Prostate and Uterus)


GU IR



ParticipantsSandeep Bagla, MD, Woodbridge, VA (Moderator) Consultant, Hansen Medical Inc; Consultant, NeuWave Medical, Inc; Consultant,CeloNova BioSciences, Inc; Consultant, Medtronic, Inc; Consultant, DFINE, Inc'; Consultant, Boston ScientificCharles T. Burke, MD, Chapel Hill, NC (Moderator) Nothing to Disclose

Sub-Events

ParticipantsHelene Kovacsik, MD, PhD, Montpellier, France (Abstract Co-Author) Nothing to DiscloseSebastien Bommart, MD, Montpellier, France (Abstract Co-Author) Nothing to DiscloseMarc R. Sapoval, MD, PhD, Paris CEDEX 15, France (Abstract Co-Author) Nothing to DiscloseDenis Herbreteau, MD, Tours, France (Presenter) Nothing to DiscloseJean-Paul Beregi, MD, Nimes, France (Abstract Co-Author) Nothing to DiscloseJean-Michel Bartoli, MD, Marseille, France (Abstract Co-Author) Nothing to Disclose

PURPOSE

Main goal:- To evaluate quality of life before and one year after UFESecondary goals:- To determine impact of imaging findings(MRI data) before and 3-6months after UFE on changes in quality of life


Study design: prospective, multicenter (25 centers) French observational studyPatients: 264 consecutive symptomatic womenreferred in the center for UFE using EmbozeneÒ (Celonova) particles. Methods:Clinical data: the quality of life score was calculatedusing the previously validated UFS-QOL by Spies, before and one year after UFE.Imaging data: MRI were performed before and 3-6months after UFE. Data recorded were uterine and main fibroid volume, percentage of fibroid enhancement after injection ofgadolinium. Impact of imaging data before and after UFE on QOL scores was searched.

RESULTS

189 patients (85.9%) showed monorrhagia at baseline. This was reduced to 39 patients (18%) at 1 year of follow up. 171 patients(78.1%) had pelvic pressure symptoms at baseline. This was reduced to 42 patients (19.4%) after 1 year of follow up.CompleteQOL study was obtained in 192 women. Improvement of QOL score at one year after UFE a was found 183/203 (90.2%) for HRQL,163/192 (84.9%) for Symptoms Severity. The probability of presenting a profuse bleeding was significantly reduced (by 62%)among patients with high reduction of fibroid volume (>=30%), as compared to patients with low fibroid volume reduction (<30%)(OR=0.38; 95%CI: [0.18;0.80]) (p = 0.011) The Impact of percentage of uterine volume or main fibroid reduction and decrease offibroid enhancement on change in post embolization global UFS-QOL score was not established.

CONCLUSION

At one year post embolization, UFE improves significantly quality of life


UFE is not only an effective technique but is also considered highly satisfactory by women

ParticipantsSandeep Bagla, MD, Woodbridge, VA (Presenter) Consultant, Hansen Medical Inc; Consultant, NeuWave Medical, Inc; Consultant,CeloNova BioSciences, Inc; Consultant, Medtronic, Inc; Consultant, DFINE, Inc'; Consultant, Boston Scientific

ParticipantsAndrew Erie, MD, Rochester, MN (Presenter) Nothing to DiscloseJonathan M. Morris, MD, Rochester, MN (Abstract Co-Author) Nothing to DiscloseBrian T. Welch, MD, Rochester, MN (Abstract Co-Author) Nothing to DiscloseAnil N. Kurup, MD, Rochester, MN (Abstract Co-Author) Nothing to DiscloseAdam J. Weisbrod, MD, Rochester, MN (Abstract Co-Author) Nothing to DiscloseThomas D. Atwell, MD, Rochester, MN (Abstract Co-Author) Nothing to DiscloseGrant D. Schmit, MD, Rochester, MN (Abstract Co-Author) Nothing to Disclose

SSM24-04 Frequency of Penile and Rectal Collateral Flow from Prostatic Arteries during Prostatic ArteryEmbolization


Eugene D. Kwon, MD, Rochester, MN (Abstract Co-Author) Nothing to DiscloseMatthew R. Callstrom, MD, PhD, Rochester, MN (Abstract Co-Author) Research Grant, Thermedical, Inc Research Grant, GeneralElectric Company Research Grant, Siemens AG Research Grant, Galil Medical Ltd

PURPOSE

To determine the oncologic outcomes and safety of percutaneous ablation in the treatment of oligometastatic prostate cancer.


This is a retrospective, single-institution review of 31 patients with oligometastatic prostate cancer who underwent 43percutaneous ablations of their limited (≤5) metastatic sites. Eight patients (26%) were antigen deprivation therapy-naïve (ADT-naïve) and received ablation with the purpose of delaying ADT. Twenty-three patients (74%) underwent ablation either because ofresistance to systemic therapies or a more aggressive multimodal treatment approach was preferred. Study endpoints includedprocedural complications, local control, progression free survival (PFS), and androgen deprivation therapy-free survival (ADT-FS).ADT-FS was defined as the time between percutaneous ablation and the initiation of ADT.

RESULTS

Local control was achieved in 35 (81.4%) of 43 tumors with a median follow-up of 8 months (range, 3-60 mo) after ablation. Tumorrecurrence was found in 8 (18.6%) of 43 tumors at a median follow-up of 6 months (range, 2-38 mo). Median prostate-specificantigen (PSA) measurements were significantly lower approximately 2 months after ablation compared to before ablation (0.27 ng/dl[range <0.01 to 7.7] and 1.5 ng/dl [range <0.01 to 72.0], respectively (p=0.02)). Estimated PFS rates for all patients at 6 and 12months after ablation were 65% (95% CI, 44-80) and 45% (95% CI, 24-64), respectively. Of the 8 ADT-naïve patients whounderwent ablation with purpose to delay ADT, all (100%) achieved local control and the ADT-FS at 12 months was approximately70%. None of the ablations were associated with major complications.

CONCLUSION

Percutaneous ablation of oligometastatic prostate cancer appears safe, achieves acceptable local control rates, and can delaydisease progression when used in combination with other therapies. Percutaneous ablation may be particularly valuable in ADT-naïve patients who do not tolerate or prefer to delay ADT.


Percutaneous ablation can be used as part of a multimodal treatment approach for oligometastatic prostate cancer and can delayhormone therapy in ADT-naïve patients.

ParticipantsAri J. Isaacson, MD, Chapel Hill, NC (Abstract Co-Author) Advisory Board, BTG International LtdCharles T. Burke, MD, Chapel Hill, NC (Presenter) Nothing to Disclose

PURPOSE

The most common mechanism of complication during prostatic artery embolization (PAE) is non-target embolization. Avoidance ofbranches supplying the bladder is commonly described. Less commonly discussed are intra-prostatic collaterals supplying the penisand rectum, although they are frequently seen during PAE. Because of the risks associated with non-target embolization as a resultof these shunts, it would be beneficial to have an understanding of their incidence, as well as from what prostatic artery branchesthey arise. The purpose of this study was to retrospectively determine the frequency of rectal and penile collateral flow from eachprostatic artery branch as seen during PAE.


DSA images from PAEs performed between April 2013 and March 2015 were evaluated by two interventional radiologists experiencedin performing PAE. A consensus determination was made about which arteries were catheterized (the anterolateral prostatic artery(ALPA), the posterolateral prostatic artery (PLPA) or a common trunk (CT) of the two) and about the presence of collateral flow tothe arteries supplying the penis and/or the rectum from each catheterized artery. The overall incidence of such collaterals wascalculated as well as the frequency in which they arose from each prostatic artery branch.

RESULTS

During 26 PAEs, 58 prostatic arteries were catheterized (36 ALPAs, 10 PLPAs and 12 CTs). Collateral flow to arteries supplying thepenis or rectum was identified in 18/26 PAEs (69%). Flow to the penile arteries was seen in 13/36 (36%) ALPA catheterizations andin 5/12 (42%) CT catheterizations. Flow to rectal branches was seen in 8/10 (80%) PLPA catheterizations and in 4/12 (33%) CTcatheterizations. No flow to penile branches was observed from a PLPA, nor was there flow to a rectal branch seen from an ALPA.

CONCLUSION

Shunting to the penis and/or rectum was present during the majority of PAEs. Collateral flow to the rectum from the PLPA or from aCT was seen quite frequently and collateral flow to the penis from an ALPA or CT was seen with moderate frequency duringprostatic artery catheterization.


Understanding the incidence of rectal and penile collateral pathways from the specific branches of the prostatic arteries will allowfor greater detection of these findings during PAE in order to avoid complications.

SSM24-05 Prostate Cancer Treatment with Irreversible Electroporation (IRE): Experience, Safety and Efficacyafter 4.5 Years in 222 Patients


SSM24-06 Phase II Clinical Trial for Evaluation of MRI-guided Laser Induced Interstitial Thermal Therapy(LITT) for Low-to-intermediate Risk Prostate Cancer


ParticipantsMichael K. Stehling, MD, PhD, Offenbach, Germany (Presenter) Nothing to DiscloseEnric Guenther, Dipl Phys, Frankfurt, Germany (Abstract Co-Author) Nothing to DiscloseNina Klein, MSc, Offenbach am Main, Germany (Abstract Co-Author) Nothing to DiscloseStephan Zapf, Frankfurt, Germany (Abstract Co-Author) Nothing to DiscloseDucksoo Kim, MD, Boston, MA (Abstract Co-Author) Nothing to DiscloseBoris Rubinsky, PhD, Berkeley, CA (Abstract Co-Author) Nothing to Disclose

PURPOSE

Irreversible Electroporation (IRE) is a novel tissue ablation method. It selectively destroys cells whilst preserving tissueinfrastructure and is hence an ideal method for focal prostate cancer (PCa) therapy. It preserves (or allows regeneration of) vitalsurrounding structures such as neurovascular bundle, inferior sphincter and rectum, thus minimizing the side-effects of PCatherapy, mainly being impotence and incontinence.


We have employed IRE for the treatment of 222 patients with primary (stages T1-T4) and recurrent PCa after surgery (18/222),radiation therapy (4/222) and HIFU (3/222). All patients underwent mp-MRI prior to and after IRE (T2, diffusion, perfusion, inselected cases 1H spectroscopy). 44% of patients underwent additional 3D-transperineal biopsy before IRE. Treatment was carriedout by rectal US-guided transperineal IRE-electrode insertion under general anesthesia and deep muscle relaxation. 161 patientshad focal and 61 whole gland ablations. All patients had follow-ups with PSA and mp-MRI for documentation of local tumor control.

RESULTS

Initial tumor control was achieved in all patients. Within the follow-up period of up to 4y, the recurrence rates were 0/45 (Gleason<7), 4/103 (Gleason 7) and 5/54 (Gleason >7). There were no IRE-related complications and toxicity was extremely low: 16patients reported a transient reduction of erectile function (EF) (recurred after 6-8m), 5 a permanent reduction and 2 a permanentloss of EF. There were no cases of IRE-related incontinence, even when the lower urinary sphincter was included in the treatmentfield; a partially included rectum also remained intact. Treatment was completed within 24h in all patients with a single overnightstay in the clinic. Patients had no wound pain.

CONCLUSION

IRE treatment of PCa is safe. In the short-term follow-up with MRI and PSA (maximum 4.5y) it is effective. Toxicity is significantlylower compared to other PCa treatments. Based on our data incontinence can be avoided altogether. MRI and 3D-biopsy aresuitable for pre-treatment work-up and MRI for post-treatment follow-up. IRE has the potential to become an important tool forPCa therapy.


IRE treatment is an alternative to the current treatment options for PCa, with much lower invasiveness and toxicity. It is effectivein all stages of PCa and offers treatment options in advanced and recurrent PCa not amenable to other therapies.

ParticipantsAytekin Oto, MD, Chicago, IL (Presenter) Research Grant, Koninklijke Philips NV; ; ; Shiyang Wang, PhD, Chicago, IL (Abstract Co-Author) Nothing to DiscloseAmbereen Yousuf, MBBS, Chicago, IL (Abstract Co-Author) Nothing to DiscloseSydeaka Watson, PhD, Chicago, IL (Abstract Co-Author) Nothing to DiscloseTatjana Antic, Chicago, IL (Abstract Co-Author) Nothing to DiscloseScott Eggener, Chicago, IL (Abstract Co-Author) Research Grant, Visualase, Inc Speakers Bureau, Johnson & Johnson

PURPOSE

To assess the oncologic efficacy and safety of MRI-guided laser-induced interstitial thermal therapy of biopsy confirmed and MR-visible prostate cancer.


27 patients with biopsy proven low-to-intermediate risk prostate cancer underwent MRI-guided laser ablation of the cancer usingVisualase laser ablation device. All patients had a pre-procedure endorectal MRI which showed suspicious foci concomitant with thepositive sextant on TRUS-guided biopsy. The area of interest was targeted transperineally using 1.5 T Philips MRI scanner andVisualase ablation device. Ablation was monitored by real time MR thermometry using Visualase MRI thermometry software.Perioperative, early and late complications and adverse events were recorded. Follow-up was performed with 3-month MRI and MR-guided biopsy, 12-month MRI and TRUS guided biopsy and validated quality of life questionnaires to assess urinary and sexualfunction.

RESULTS

MRI-guided laser ablation of prostate cancer was successfully performed in all 27 patients without significant peri-proceduralcomplications. All patients were discharged home the same day. Average duration of the procedure was 3 hours 17 minutes andaverage duration of a single laser ablation was 1 minute 22 seconds. Total number of ablations per patient ranged from 2-8, with amedian of 4. The treatment created an identifiable hypovascular defect in all cases. Post procedure complications were minor andincluded urinary symptoms, perineal bruising and erectile dysfunction, all of which self- resolved. Validated quality of life urinary andsexual questionnaires obtained before and 12 months after the procedure did not reveal any significant differences (p≥0.05). 1/27and 3/17 patients had residual cancer in the ablation zone at 3 months and 12 months respectively.

CONCLUSION

Short-term follow-up results of MRI-guided focal laser ablation for treatment of clinically localized, low-to-intermediate risk prostatecancer appear promising. It may offer a minimally invasive procedure for select patients that does not appreciably alter sexual orurinary function.


Short-term results of our phase II trial show that MRI-guided focal laser ablation can be a safe and feasible option for treatment oflow-to-intermediate risk prostate cancer.

Honored Educators



MSCU42A Challenging Abdominal Cases

MSCU42B Acute Pelvic Pain

MSCU42C Superficial Ultrasound Imaging: Head to Toe

MSCU42

Case-based Review of US (An Interactive Session)

Wednesday, Dec. 2 3:30PM - 5:00PM Location: S406A

GI GU US


ParticipantsDeborah J. Rubens, MD, Rochester, NY (Moderator) Nothing to Disclose

LEARNING OBJECTIVES

1) Recognize the diverse applications of ultrasound throughout the body and when it provides the optimal diagnostic imagingchoice. 2) Understand the fundamental interpretive parameters of ultrasound contrast enhancement and its applications in theabdomen. 3) Know the important factors to consider when choosing ultrasound vs CT for image guided procedures and how tooptimize ultrasound for technical success.

ABSTRACT

Ultrasound is a rapidly evolving imaging modality which has achieved widespread application throughout the body. In this course wewill address the major anatomic areas of ultrasound use, including the abdominal and pelvic organs, superficial structures and thevascular system. Challenging imaging and clinical scenarios will be emphasized to include the participant in the decision-makingprocess. Advanced cases and evolving technology will be highlighted, including the use of ultrasound contrast media as a problemsolving tool, and the appropriate selection of procedures for US-guided intervention.

Active Handout:Deborah J. Rubens

http://abstract.rsna.org/uploads/2015/15002752/Active MSCU42.pdf

Sub-Events

ParticipantsOksana H. Baltarowich, MD, Philadelphia, PA (Presenter) Nothing to Disclose

LEARNING OBJECTIVES


ABSTRACT

View abstract under main course title.

ParticipantsLeslie M. Scoutt, MD, New Haven, CT, ([email protected]) (Presenter) Consultant, Koninklijke Philips NV

LEARNING OBJECTIVES


Honored Educators


Leslie M. Scoutt, MD - 2014 Honored Educator

ParticipantsDeborah J. Rubens, MD, Rochester, NY (Presenter) Nothing to Disclose

LEARNING OBJECTIVES


MSRT46

ASRT@RSNA 2015: Prostate Cancer and MR Imaging: What Do We Want to See and How to Get It

Wednesday, Dec. 2 3:40PM - 4:40PM Location: N230

GU MR OI


ParticipantsJames Stirling, DCR, DMS, Middlesex, United Kingdom, ([email protected] ) (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) To learn the anatomy and comon pathology of the prostate gland. 2) To learn the factors and how to optimise prostatesequences eg. T1, T2 and STIR whole pelvis sequences, small field of view T2 axial, sagital and coronal sequences, diffusionweighted imaging, contrast enhanced T1 and T2* dynamic sequences. 3) To learn how different sequences are used with primary,secondary and metastatic prostate cancer. 4) To give a taste of hybid PET/MR 18F Choline imaging.

ABSTRACT

Over the last couple of years MRI of prostate cancer has moved from just T1 and T2 imaging to multi-parametric, multi-modalityimaging. To produce high quality imaging, sequence parameter factors have to be optimized, balancing clinical requirements withpatient comfort, total on-table time, scanner capabilities and limitations. The lecture will include prostatic anatomy and howdifferent sequences can characterize benign and malignant disease. The talk will show the sequences that are needed and how tooptimize them. This will include T2 small field of views, diffusion weighted imaging, T1 and T2* dynamic contrast enhancedsequences and intrinsic susceptibility weighted imaging. As prostate cancer develops and is treated the imaging protocols change.The protocols include surveillance and staging and then progress to recurrence and metastatic whole body imaging. MRI is nowbeing complemented with PET in hybrid machines combining the strengths of both modalities. This lecture will show how MR imagingof malignant prostate disease changes as the disease progresses.

SPSC44A Introduction to Session and Overview of Multiparametric Prostate MRI

SPSC44B 1.5T vs 3T Imaging: Pros and Cons

SPSC44C Diffusion Weighted Imaging

SPSC44D Dynamic Contrast Enhanced Imaging

SPSC44E Imaging of Recurrence in Prostate Cancer

SPSC44

Controversy Session: Prostate Imaging: Just What MR Technique is Best?

Wednesday, Dec. 2 4:30PM - 6:00PM Location: E450A

GU MR


ParticipantsRajan T. Gupta, MD, Durham, NC (Moderator) Consultant, Bayer AG; Speakers Bureau, Bayer AG; Consultant, Invivo Corporation

LEARNING OBJECTIVES

1) The goal of this session is to explore the different techniques that comprise high quality multiparametric MRI of the prostate.More specifically, we will deal with some of the key protocol questions that one must tackle in order to set up mpMRI in their ownpractice. Examples of the topics to be discussed include 1.5T vs. 3T imaging; endorectal coil vs. phased array body coil use; theoptimal diffusion weighted metrics to be used to assess lesion aggressiveness, etc.; the changing role of dynamic contrastenhanced MRI in prostate imaging, especially in light of the recent release of PI-RADS version 2; and finally, the optimal techniquesto evaluate for disease recurrence after therapy. The format of the session will be both didactic and interactive with audienceparticipation.

Sub-Events

ParticipantsRajan T. Gupta, MD, Durham, NC (Presenter) Consultant, Bayer AG; Speakers Bureau, Bayer AG; Consultant, Invivo Corporation

LEARNING OBJECTIVES


ParticipantsRajan T. Gupta, MD, Durham, NC (Presenter) Consultant, Bayer AG; Speakers Bureau, Bayer AG; Consultant, Invivo CorporationFrancois Cornud, MD, Paris, France (Presenter) Nothing to Disclose

LEARNING OBJECTIVES


ParticipantsAndrew B. Rosenkrantz, MD, New York, NY (Presenter) Nothing to Disclose

LEARNING OBJECTIVES


ParticipantsSadhna Verma, MD, Cincinnati, OH (Presenter) Nothing to Disclose

LEARNING OBJECTIVES


Honored Educators



ParticipantsAdam Froemming, MD, Rochester, MN (Presenter) Nothing to Disclose

LEARNING OBJECTIVES


SPSC46

Controversy Session: Ultrasound versus CT for Suspected Renal Colic: Which Modality Rocks in the ER?

Wednesday, Dec. 2 4:30PM - 6:00PM Location: S404CD

GU CT US ER


ParticipantsJudy Yee, MD, San Francisco, CA (Moderator) Research Grant, EchoPixel, IncMitchell E. Tublin, MD, Pittsburgh, PA (Presenter) Nothing to DiscloseAaron D. Sodickson, MD, PhD, Wayland, MA, ([email protected]) (Presenter) Research Grant, Siemens AG; Consultant,Bracco GroupD. Mark Courtney, MD, MSc, Chicago, IL (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) Describe the advantages of ultrasound and present a cost effective, rational algorithm for its use in the evaluation of ERpatients with potential renal colic. 2) Understand the benefits of CT over ultrasound in ER imaging of suspected renal colic. 3)Understand the perspective and preferences of the ER physician for the workup of renal colic and the effect on clinical workflow.

Honored Educators


Aaron D. Sodickson, MD, PhD - 2014 Honored Educator

ED006-TH

Genitourinary Thursday Case of the Day

Thursday, Dec. 3 7:00AM - 11:59PM Location: Case of Day, Learning Center

GU



TEACHING POINTS


Honored Educators



SPSH50A Principles of DECT

SPSH50B DECT of GU Masses-2015 Update

SPSH50C Establishing DECT in Your Practice: Nuts and Bolts

SPSH50

Hot Topic Session: Dual-energy CT for GU Imaging

Thursday, Dec. 3 7:15AM - 8:15AM Location: E350

GU CT


ParticipantsHersh Chandarana, MD, New York, NY (Moderator) Equipment support, Siemens AG; Software support, Siemens AG; Consultant,Bayer, AG;

LEARNING OBJECTIVES

1) This course will cover the basics and application of Dual Energy CT in GU Radiology.

ABSTRACT

Sub-Events

ParticipantsDaniel T. Boll, MD, Durham, NC (Presenter) Research Grant, Siemens AG; Research Grant, Koninklijke Philips NV; Research Grant,Bracco Group

ParticipantsTerri J. Vrtiska, MD, Rochester, MN (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) Discuss DECT advantages for renal mass evaluation. 2) Describe useful DECT applications for renal mass characterization. 3)Summarize recent literature and future opportunities of DECT of renal masses.

ABSTRACT

Application of DECT to renal mass evaluation and improved characterization.

URL

ParticipantsAvinash R. Kambadakone, MD, Boston, MA (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) Describe the basic principles, technique and clinical applications of DECT. 2) Identify and appraise the different technologies,workflow implications and challenges of DECT in day-to-day practice. 3) Apply and incorporate the most appropriate DECT protocolsinto routine practice.

ABSTRACT

URL

RC607

A Case-based Audience Participation Session (Genitourinary) (An Interactive Session)

Thursday, Dec. 3 8:30AM - 10:00AM Location: E352

GU


ParticipantsPaul J. Chang, MD, Chicago, IL, ([email protected]) (Coordinator) Co-founder, Stentor/Koninklijke Philips NV;Researcher, Koninklijke Philips NV; Medical Advisory Board, lifeIMAGE Inc; Medical Advisory Board, Merge Healthcare IncorporatedWilliam W. Mayo-Smith, MD, Boston, MA (Presenter) Author with royalties, Reed Elsevier; Author with royalties, CambridgeUniversity PressAndrea G. Rockall, MRCP, FRCR, London, United Kingdom (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) The participant will be introduced to a series of Genitourinary case studies via an interactive team game approach designed toencourage "active" consumption of educational content. 2) The participant will be able to use their mobile wireless device (tablet,phone, laptop) to electronically respond to various Genitourinary case challenges; participants will be able to monitor their individualand team performance in real time. 3) The attendee will receive a personalized self-assessment report via email that will review thecase material presented during the session, along with individual and team performance. Please bring your charged mobile wirelessdevice (phone, tablet or laptop) to participate.

ABSTRACT

The extremely popular audience participation educational experience is back! :GU Diagnosis Live is an expert-moderated sessionfeaturing a series of interactive Genitourinary case studies that will challenge radiologists' diagnostic skills and knowledge. Buildingon last year's successful Diagnosis Live premiere, GU Diagnosis Live is a lively, fast-paced game format: participants will beautomatically assigned to teams who will then use their personal mobile devices to test their knowledge of GU radiology in a fast-paced session that will be both educational and entertaining. After the session, attendees will receive a personalized self-assessment report via email that will revview the case material presented durinig the session, along with individual and teamperformance. :

RC610A Renal Masses

RC610B Contrast Ultrasound of the Liver and Gallbladder

RC610C Contrast Ultrasound of Bowel

RC610

Ultrasound Contrast (An Interactive Session)

Thursday, Dec. 3 8:30AM - 10:00AM Location: S402AB

GI GU US



Participants

Sub-Events

ParticipantsEdward G. Grant, MD, Los Angeles, CA (Presenter) Research Grant, General Electric Company ; Medical Advisory Board, NuanceCommunications, Inc

LEARNING OBJECTIVES

1) Understand the indications for the use of contrast enhanced ultrasound in renal masses. 2) Be familiar with the advantages anddisadvantages of contrast enhanced ultrasound in comparison to other forms of cross sectional imaging with regard to itsapplication to renal masses. 3) Be able to analyze contrast enhanced ultrasound images of the kidney. 4) Understand the basics ofquantitative contrast imaging of renal masses.

ABSTRACT

Contrast enhanced ultrasound (CEUS) has numerous applications in the imaging of renal masses. It has the particular advantage inthis population of being able to be used in patients with renal failure which is not the case with either CT or MRI. Obviously CEUSdoes not use ionizing radiation and is less expensive than other techniques. A further advantage is the fact that ultrasound is a realtime technique and vascular characteristics of lesions can be evaluated throughout the examination. Applications of CEUS in thekidney include imaging of complex cysts (flow in wall, septae etc.) and evaluation of pseudolesions (column of Bertin, infarct,scars). It can also be used to further characterize indeterminate masses on CT/MR and may be able to classify some lesions asbenign versus malignant, or suggest their actual histology. The diagnostic capability of CEUS is facilitated by its ability to providequantitative information. Given the lack of ionizing radiation and absence of nephrotoxicity CEUS is ideal for patients undergoingactive surveillance of a renal mass or post resection/RFA.The evaluation of complex renal cysts is one of the most commonindications for CEUS. Observed features at CEUS are typically similar to those of the Bosniak classification and this has now beenadapted for use with ultrasound contrast. In solid renal masses CEUS may provide information that can help determine the nature ofthe mass and its anatomy as well as the number of individual lesions. This is particularly valuable in patients in whom other contrastagents are contraindicated. One notable example is the characteristic enhancement pattern of papillary versus clear cell renal cellcarcinoma. The former typically enhances less than the surrounding parenchyma throughout the examination while the latterdramatically hyperenhances in the arterial phase. Again, quantitative imaging can further add to the confidence of the diagnosis insuch cases.

ParticipantsHans-Peter Weskott, MD, Hannover, Germany, ([email protected]) (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 aboutthe importance of the three contrast phases and how CEUS performes in detecting and characterizing focal liver lesions and tocharacterize inflammatory and tumorous changes of the gallbladder wall. 3) Learning about the potential value as well as thelimitations of CEUS in liver an gallbladder diseases. 4) Learning how CEUS performs when compared to B-mode and Color Dopplerultrasound, CT and MRI imaging.

ABSTRACT

Liver: In patients with favorable scanning conditions CEUS is at least as sensitive as contrast enhanced CT (CECT) in detectingmalignant liver lesions. Due to its high temporal resolution, even a hyper-enhancement of a few seconds can reliably be detected,thus improving the characterization of focal liver lesions. A majority of malignant lesions can therefore be characterized as hypo-,iso- or hyper-enhancing. During the arterial phase the tumor`s vessel architecture and direction of contrast filling is important forcharacterizing a lesions character. Due to a high spatial resolution, novel contrast imaging techniques allow detection of washedout lesions down to 3mm in size. CEUS characterizes focal liver lesions with a much higher diagnostic confidence than conventionalUS and is comparable to CT and MRI. CEUS also improves intraoperative tumor detection and characterization. Using time intensityanalysis a change in contrast enhancement and kinetics helps in estimating tumor response to chemotherapy. CEUS is also used tomonitor local ablation therapy and is a useful imaging tool to detect early tumor recurrence. Gallbladder: CEUS can be used tobetter visualize ulceration, perforation, and tumors of its wall. It thus helps in optimizing clinical management, including timing forsurgery. CEUS does not affect renal or thyroid function and is therefore helpful in older patients and the preferred imagingtechnique in young patients and those with impaired renal function.

Participants

Stephanie R. Wilson, MD, Calgary, AB (Presenter) Research Grant, Lantheus Medical Imaging, Inc; Equipment support, Siemens AG;Equipment support, Koninklijke Philips NV

LEARNING OBJECTIVES

1) Attendees will recognize the association of hypervascularity with inflammatory processes in the bowel on the basis ofneoangiogenesis. 2) They will appreciate the value of CEUS of the bowel, with provision of both subjective and objective blood flowdeterminations, useful in determining disease activity and in assessing response to therapy. . 3) They will apply the commoninterpretations of time itensity curves to obtain peak enhancement and area under the curve information, recognizing their directrelationship to inflammatory disease with increasing parameters.

ABSTRACT

RC629A Introduction to PI-RADS

RC629B Technical Considerations

RC629C How to Use PI-RADS

RC629D Interactive Clinical Case Review

RC629

Prostate MRI Using PI-RADS (Prostate Imaging Reporting and Data System) (An Interactive Session)

Thursday, Dec. 3 8:30AM - 10:00AM Location: E450B

GU MR


Participants

LEARNING OBJECTIVES

1) Describe the clinical indications for prostate MRI and MRI-targeted interventions. 2) Assess technical considerations forperformance of multi-parametric prostate MRI, including pulse sequences, coils, contrast administration, magnetic field strength. 3)Integrate information from T2, DCE, and DWI to analyze and report prostate MRI exams using new ACR-PIRADS methodology. Pleasebring your charged mobile wireless device (phone, tablet or laptop) to participate.

Sub-Events

ParticipantsJeffrey C. Weinreb, MD, New Haven, CT (Presenter) Nothing to Disclose

LEARNING OBJECTIVES


ParticipantsClare M. Tempany-Afdhal, MD, Boston, MA (Presenter) Nothing to Disclose

LEARNING OBJECTIVES


ParticipantsJelle O. Barentsz, MD, PhD, Nijmegen, Netherlands (Presenter) Nothing to Disclose

LEARNING OBJECTIVES


Active Handout:Jelle O. Barentsz


Participants

LEARNING OBJECTIVES


SSQ09-01 Genitourinary Keynote Speaker: Contemporary Challenges of Imaging Renal Masses


SSQ09-02 Do Incidental Hyperechoic Renal Lesions Measuring ≤ 1cm Warrant Further Imaging? Outcomes of161 Lesions


SSQ09-03 Post-operative Outcomes of Cystic Renal Cell Carcinomas Defined on Pre-operative ComputedTomography: A Retrospective Study in 1315 Patients


SSQ09

ISP: Genitourinary (Renal Mass Evaluation)

Thursday, Dec. 3 10:30AM - 12:00PM Location: E353B

GU CT MR


ParticipantsRaghunandan Vikram, MBBS, FRCR, Houston, TX (Moderator) Nothing to DiscloseDaniele Marin, MD, Cary, NC (Moderator) Nothing to Disclose

Sub-Events

ParticipantsJohn R. Leyendecker, MD, Dallas, TX (Presenter) Nothing to Disclose

ParticipantsAbimbola Ayoola, MD, New York, NY (Presenter) Nothing to DiscloseAndrew B. Rosenkrantz, MD, New York, NY (Abstract Co-Author) Nothing to DiscloseAnkur Doshi, MD, New York, NY (Abstract Co-Author) Nothing to Disclose

PURPOSE

Although follow-up CT or MRI has been advised for further evaluation of incidental hyperechoic renal lesions on ultrasound (US),this approach is variably followed in clinical practice given the lack of robust data to guide optimal follow-up recommendations.Thus, the purpose of our study was to determine the outcomes of incidental hyperechoic renal lesions measuring ≤ 1cm based on alarge single-center cohort in order to better inform management strategies for such lesions.


We retrospectively identified 161 hyperechoic renal lesions on US measuring ≤ 1cm (mean size 0.7 ± 0.2 cm) that had either (a) afollow-up CT or MRI or (b) at least 2 year follow-up by US. Mean patient age was 63 ±13 years (range 30-88 years). The initial USand follow-up imaging were reviewed to assess for a change in size or definitive lesion characterization.

RESULTS

Follow-up imaging consisted of US in 23.0% (37/161), CT in 45.3% (73/161) and MRI in 31.7% (51/161). 57.1% (92/161) of lesionswere confirmed as angiomyolipomas on CT or MRI. 19.9% (32/161) showed less than 4mm growth on long-term US follow-up (mean62±26 months, range 24-110 months). 11.8% (19/161) had no correlate on CT or MRI. 6.2% (10/161) were too small to definitivelycharacterize on CT. 3.1% (5/161) were not visualized on follow-up US. CT characterized one lesion (0.6%) as a stone and onelesion (0.6%) as a hyperdense cyst. One lesion (0.6%) on CT was an enhancing solid mass without macroscopic fat, presumed torepresent an RCC, although was lost to follow-up. This lesion was not as hyperechoic as the renal sinus fat on the initial US.

CONCLUSION

The overwhelming majority of hyperechoic renal lesions ≤ 1cm with the classic US appearance of an angiomyolipoma were benign orstable on follow-up imaging. Thus, these lesions may not warrant any further imaging evaluation.


To our knowledge, we have provided the largest study to date to assess outcomes of small hyperechoic renal lesions on follow-upimaging that support the benignity of this US finding.

ParticipantsJung Jae Park, MD, Seoul, Korea, Republic Of (Presenter) Nothing to DiscloseChan Kyo Kim, MD, PhD, Seoul, Korea, Republic Of (Abstract Co-Author) Nothing to DiscloseByung Kwan Park, MD, Seoul, Korea, Republic Of (Abstract Co-Author) Nothing to DiscloseByong Chang Jeong, Seoul, Korea, Republic Of (Abstract Co-Author) Nothing to DiscloseSeong Il Seo, Seoul, Korea, Republic Of (Abstract Co-Author) Nothing to Disclose

PURPOSE

Post-operative outcomes of cystic renal cell carcinomas (RCCs) defined on preoperative imaging were not widely investigated andthe cut-off of cystic proportion is arbitrary. We aimed to evaluate the post-operative outcomes of cystic RCCs defined on pre-operative computed tomography (CT) and to identify the optimal cut-off of cystic proportion in association with patients' prognosis.


SSQ09-04 The Radiogenomic Risk Score: Construction of a Prognostic Quantitative, Noninvasive Image-basedMolecular Assay for Renal Cell Carcinoma


SSQ09-05 CAD Derived Absolute Attenuation Discriminates Clear Cell Renal Cell Carcinoma from Benign Mimicsand RCC Subtypes at Four-Phase MDCT

Our retrospective study included 1315 consecutive patients who received surgery for single sporadic RCC and had adequate pre-operative CT for analysis. The cystic proportion of RCC was calculated on pre-operative CT by a radiologist. The optimal cut-off ofcystic proportion in RCC was explored by locating the minimum P value on log rank test regarding cancer-specific survival. The RCCswere categorized as cystic and non-cystic groups according to (1) conventional cut-off (i.e. proportion of cystic component≥75%) and (2) the optimal cut-off, and then cancer-specific and recurrence-free survival rates were compared between the twogroups. The clinical, pathologic, and imaging variables were analyzed using the Cox regression analysis to determine theindependent predictor of cancer-specific survival.

RESULTS

Of the 1315 RCCs, 107 (8.1%) were identified as cystic RCCs using the conventional cut-off. During a median follow-up of 4.9years, patients with cystic RCC revealed neither metastasis nor recurrence after surgery. The cancer-specific and recurrence-freesurvival rates of cystic RCCs were significantly better than those of non-cystic RCCs (both P < 0·001). In association with cancer-specific survival rate, the optimal cut-off of cystic proportion in RCC was 45%, and 197 (15.0%) patients were defined as cysticRCCs accordingly. On multivariate Cox regression analysis, cystic RCC defined by the optimal cut-off (45%) was one of theindependent predictors of cancer-specific survival (hazard ratio, 0.34; P = 0.03).

CONCLUSION

Cystic RCCs defined on pre-operative CT are associated with low metastatic potential and favorable outcomes after surgery.Furthermore, the optimal cut-off of cystic proportion in association with cancer-specific survival is 45%.


Cystic renal cell carcinomas (RCCs) defined by preoperative CT may be managed differently from non-cystic RCCs for selectingoptimal treatment methods.

ParticipantsNeema Jamshidi, MD, PhD, Los Angeles, CA (Presenter) Nothing to DiscloseEric Jonasch, MD, Houston, TX (Abstract Co-Author) Consultant, Pfizer Inc Consultant, Novartis AG Consultant, GlaxoSmithKline plcConsultant, AstraZeneca PLC Research funded, Pfizer Inc Research funded, GlaxoSmithKline plc Research funded, Bristol-MyersSquibb Company Research funded, Novartis AG Research funded, Exelixis, Inc Research funded, Onyx Pharmaceuticals, Inc Matthew A. Zapala, MD,PhD, Boston, MA (Abstract Co-Author) Nothing to DiscloseRonald L. Korn, MD, PhD, Scottsdale, AZ (Abstract Co-Author) Chief Medical Officer, Imaging Endpoints; Founder, ImagingEndpoints; Shareholder, Imaging EndpointsLejla Aganovic, MD, La Jolla, CA (Abstract Co-Author) Nothing to DiscloseHongjuan Zhao, Stanford, CA (Abstract Co-Author) Nothing to DiscloseT S. Raviprakash, Umea, Sweden (Abstract Co-Author) Nothing to DiscloseRobert Tibshirani, Stanford, CA (Abstract Co-Author) Nothing to DiscloseSudeep Banerjee, BA, Los Angeles, CA (Abstract Co-Author) Nothing to DiscloseJames Brooks, Stanford, CA (Abstract Co-Author) Nothing to DiscloseBorje Ljungberg, MD, San Diego, CA (Abstract Co-Author) Nothing to DiscloseMichael D. Kuo, MD, Los Angeles, CA (Abstract Co-Author) Nothing to Disclose

PURPOSE

Quantitative multi-gene assays are effective clinical decision making tools in oncology, however cost, risks associated with tissueprocurement, and difficulty in framing subcellular information within a larger physiological context limits their overall utility. Weevaluated the feasibility of reconstructing quantitative non-invasive molecular assays (NIMA) in clear cell renal cell cancer (ccRCC)using data extracted from a single computed tomography (CT) scan.


In this IRB approved study, gene expression profile data and contrast enhanced CT scans from 70 ccRCC patients in a training setwere initially analyzed. A NIMA for a previously validated ccRCC-specific SPC prognostic gene signature was constructed termedthe Radiogenomic Risk Score (RRS), using the microarray data and a 28 trait image array to evaluate each CT scan using multipleregression of gene expression analysis. The predictive power of the RRS NIMA was then prospectively validated in an independentdataset (n=77) to confirm its relationship to the SPC gene signature and to quantify individual risk.

RESULTS

Our quantitative NIMA faithfully represents the tissue-based molecular assay it models. The RRS scaled with the SPC genesignature (R=0.57, p=6.2e-4, classification accuracy 70.1%, p<0.001) and predicted disease-specific survival (log rank p<0.001).Independent validation confirmed the relationship between the RRS and the SPC gene signature (R=0.45, p=1.3e-4, classificationaccuracy 68.6%, p<0.001) and disease-specific survival (log-rank p<0.001) and that it was independent of stage, grade andperformance status (multivariate Cox model p<0.05, log-rank p<0.001).

CONCLUSION

A NIMA for the ccRCC-specific SPC prognostic gene signature that is predictive of disease-specific survival and independent ofstage was constructed and validated confirming that quantitative NIMA construction is feasible.


Non-invasive molecular assays can be constructed that efficiently capture both pre-specified quantitative molecular phenotypes aswell as systems-level phenotypes not accessible by genomic-based tests alone, with a range of potential clinical applicationsincluding prognostication and patient stratification in human clinical trials.


SSQ09-06 Prognostic Value of Newly Proposed Response Criteria in Assessing Tumor Response in AdvancedRenal Cell Carcinoma


ParticipantsHeidi Coy, Los Angeles, CA (Presenter) Nothing to DiscloseJonathan R. Young, MD, Los Angeles, CA (Abstract Co-Author) Nothing to DiscloseMichael L. Douek, MD, MBA, Los Angeles, CA (Abstract Co-Author) Nothing to DiscloseMoe Moe Ko, Los Angeles, CA (Abstract Co-Author) Nothing to DiscloseWar War Ko, Los Angeles, CA (Abstract Co-Author) Nothing to DisclosePechin Lo, Los Angeles, CA (Abstract Co-Author) Nothing to DiscloseMatthew S. Brown, PhD, Los Angeles, CA (Abstract Co-Author) Nothing to DiscloseJames Sayre, PhD, Los Angeles, CA (Abstract Co-Author) Nothing to DiscloseSteven S. Raman, MD, Santa Monica, CA (Abstract Co-Author) Nothing to Disclose

PURPOSE

Currently, all solid enhancing non-fatty renal neoplasms are presumed to be malignant. Up to 30% of these lesions are benign, mostcommonly oncocytoma. Renal Cell Carcinoma (RCC) subtypes are a heterogeneous group treated by surgery, ablation or activesurveillance with a prognosis based on histology. The purpose of our study is to determine if peak enhancement derived fromvolumetric 3D lesion contour and a Computer Aided Diagnostic (CAD) algorithm can discriminate clear cell RCC (ccRCC) from benignRCC mimics and RCC subtypes.


With IRB approval for this HIPAA-compliant retrospective study, our pathology and imaging databases were queried to obtain acohort of RCC, oncocytoma, and lipid-poor angiomyolipoma (AML) with preoperative multiphasic multidetector CT imaged with afour-phase renal mass protocol (unenhanced, corticomedullary (C), nephrographic (N), and excretory (E)). A whole lesion 3Dcontour was obtained in all phases with proprietary software. The CAD algorithm determined a 0.5cm diameter region of peakenhancement ≤300HU within the 3D lesion contour. All contours were confirmed by a radiologist. T-tests were used to comparepeak multiphasic enhancement. P values <0.05 were considered significant.

RESULTS

206 patients (65% men, 35% women) with 223 unique renal masses (105 (47%) ccRCC, 41(18%) oncocytoma (O), 18 (8%)chromophobe RCC (chRCC), 45 (20%) papillary RCC (pRCC), 14 (6%) lipid-poor AML) were analyzed. In the C phase, CAD absolutepeak attenuation of the ccRCC (174 HU) was greater than that of O (167 HU, p=0.333), chRCC (136 HU, p=0.007), pRCC (85 HU,p<0.0001), and lipid-poor AML (144 HU, p=0.004). In the N phase, CAD absolute peak attenuation of the ccRCC (144 HU) wasgreater than that of O (132 HU, p=0.015), chRCC (106 HU, p<0.0001), pRCC (103 HU, p<0.0001), and lipid-poor AML (115 HU,p<0.0001). In the E phase, CAD absolute peak attenuation of the ccRCC (118 HU) was greater than that of O (104 HU, p=0.001),chRCC (86 HU, p<0.0001), pRCC (86 HU, p<0.0001), and lipid-poor AML (98 HU, p=0.001).

CONCLUSION

CAD derived absolute attenuation discriminates ccRCC from indolent RCC subtypes and benign RCC mimics at four-phase MDCT


CAD enhancement is a robust method to discriminate clear cell RCC from RCC subtypes and benign mimics, enabling clinicians tostratify patients to active surveillance, preoperative biopsy or surgical therapy.

ParticipantsHyunseon C. Kang, MD, PhD, Houston, TX (Presenter) Nothing to DiscloseShiva Gupta, MD, Houston, TX (Abstract Co-Author) Nothing to DiscloseWei Wei, Houston, TX (Abstract Co-Author) Nothing to DiscloseLina Lu, MS, Houston, TX (Abstract Co-Author) Nothing to DiscloseMarc Matrana, MD, New Orleans, LA (Abstract Co-Author) Nothing to DiscloseNizar M. Tannir, MD, Houston, TX (Abstract Co-Author) Consultant, Onyx Pharmaceuticals, Inc; Consultant, Bayer AG; Consultant,Pfizer Inc; Speakers Bureau, Bayer AG; Speakers Bureau, Onyx Pharmaceuticals, Inc; Speakers Bureau, Pfizer Inc; Research funded,Pfizer Inc; Research funded, Eli Lilly and Company; Research funded, F. Hoffmann-La Roche Ltd; Spouse, Stockholder, Merck & Co,IncHaesun Choi, MD, Houston, TX (Abstract Co-Author) Nothing to Disclose

PURPOSE

Several new solid tumor response criteria have been proposed to overcome the limitations of traditional size based criteria. Thisstudy examines the prognostic value of these criteria, and the additive value of clinical risk factors, in patients with advanced renalcell carcinoma (RCC) treated with pazopanib.


Fifty-seven patients with metastatic RCC, who were treated with pazopanib after progression with other targeted therapies, werestudied retrospectively. Two sets of CTs (pre- and 1-3.5 months post-treatment) were reviewed by 2 abdominal radiologists.Tumor response on the post-therapy scan was evaluated with RECIST, Choi, modified Choi, MASS, the 10% threshold criteria, aswell as a consensus subjective reader assessment, simulating radiologists' clinical interpretation. In addition to these criteria,combined criteria incorporating MSKCC risk factors + imaging criteria were used to define response groups. Response evaluationswere correlated with overall survival (OS) and progression-free survival (PFS) using the log-rank test. Only patients with partialresponse (PR) or stable disease (SD) were included in the analysis of PFS.

RESULTS

The 6 patients with progressive disease (PD) by RECIST, and the 22 patients with PD by the subjective reader assessment, had

SSQ09-07 Diagnostic Accuracy of Unenhanced MRI for Suspicious Malignant Renal Lesions Inend Stage RenalFailure Patients with Acquired Cystic Disease


SSQ09-08 Impact of Imaging and Histological Findings on the Prognosis of xp-11 Translocation Renal CellCancer


significantly worse OS compared to patients with SD or PR. There was no significant difference in OS between responders andnonresponders by Choi, modified Choi, or MASS criteria. When MSKCC risk factors were combined with imaging criteria, thecombined criteria defined groups of patients with significantly worse OS. Patients with PR by modified Choi criteria showedsignificantly longer PFS compared to those with SD (p=0.033). PR and SD groups defined by other criteria did not show a significantdifference in PFS. The MSKCC risk factors did not improve the prognostic ability of imaging-based criteria to predict patients withlonger PFS.

CONCLUSION

Patients with PD by either RECIST or the subjective reader assessment had significantly worse survival compared to SD or PRgroups. The addition of MSKCC risk factors significantly increased the predictive value of all criteria for OS. This effect wasdominated by the MSKCC criteria, which were strongly correlated with survival.


In the salvage therapy setting, the addition of clinical risk factors improves the predictive value of imaging-based tumor responsecriteria.

ParticipantsRafel Tappouni, MBBCh, FRCPC, Winston-Salem, NC (Presenter) Nothing to DiscloseDavid D. Childs, MD, Clemmons, NC (Abstract Co-Author) Research Grant, Endocare, IncShadi Qasem, Winston-Salem, NC (Abstract Co-Author) Nothing to DiscloseKeyanoosh Hosseinzadeh, MD, Winston-Salem, NC (Abstract Co-Author) Consultant, Bayer AG

PURPOSE

To determine sensitivity, specificity and accuracy of unenhanced MRI in detecting malignant lesions in end stage renal failurepatients with acquired renal cystic disease (ARCD). To assess added value of diffusion weighted imaging (DWI) in characterizinglesions. To identify MRI features associated with malignant lesions.


Unenhanced renal MRIs of 55 patients with ARCD were retrospectively reviewed in consensus by two blinded radiologists. Lesionsless than 1 cm were excluded. Lesions were scored based on size, T1 and T2 signal, homogeneity, hemosiderin, and DWI on a 5point scale: 1 as definitely benign, 2 as probably benign, 3 as indeterminate, 4 as probably malignant and 5 as definitely malignant.Preliminary scoring was performed without DWI and repeated with DWI. Scores 1-2 were grouped as benign and 3-5 asmalignant.Sensitivity, specificity and accuracy of diagnosis was calculated by comparing to nephrectomy samples performed within6 months of the MRI in 40 patients and five year imaging and clinical follow up in 15 patients. Stability over a 5 year period wasdeemed benign. Chi square test assessed the imaging features. Scores were renumbered to a 3-level confidence score: 0,indeterminate; 1, probably benign and malignant; 2, definitely benign and malignant, and a paired t-test was performed to compareconfidense levels.

RESULTS

There were 26 cysts (8 nephrectomy, 18 imaging follow up) and 34 solid lesions including 1 urothelial carcinoma, 2 oncocytomasand 31 renal cell carcinomas. Lesion size ranged from 1-17cm.MRI features suggestive of malignancy included T1 iso orhyperintensity (p=0.0003), T1 heterogeneity (p=0.0037), T2 heterogeneity (p=0.0092), and presence of hemosiderin (p=0.0034).The sensitively, specificity and accuracy for preliminary diagnosis versus final diagnosis using DWI were 82, 69, 77 and 82, 73, 78respectively. The area under the receiver operator curve for the diagnosis with DWI was 0.8512. The addition of DWI resulted in anincrease of the confidence score (p=0.001).

CONCLUSION

Unenhanced renal MRI is an accurate modality in characterizing lesions in ARCD. DWI can increase the confidence for the diagnosisof malignant renal lesions. T1 iso and hyperintensity, T1 and T2 signal heterogeneity and the presence of hemosiderin areassociated with malignant lesions.


Unenhanced renal MRI is accurate in the detection of malignant lesions in ARCD.

ParticipantsPauley T. Gasparis, MD, Indianapolis, IN (Presenter) Nothing to DiscloseKumaresan Sandrasegaran, MD, Carmel, IN (Abstract Co-Author) Nothing to DiscloseKevin A. Parikh, Indianapolis, IN (Abstract Co-Author) Nothing to DiscloseKunal B. Gala, MBBS, MD, Mumbai, India (Abstract Co-Author) Nothing to DiscloseClinton D. Bahler, MD, Indianapolis, IN (Abstract Co-Author) Nothing to DiscloseChandru P. Sundaram, Indianapolis, IN (Abstract Co-Author) Nothing to Disclose

PURPOSE

Xp11 translocation renal cell cancer (Xp11RCC) is an uncommon RCC (<1%) in the general population but accounts for 30% of RCCpresenting under the age of 18 years. We wanted to identify imaging features at presentation and histological findings of theresected tumor that predicted overall survival (OS), progression-free survival (PFS), and the occurrence of local and distantmetastases.

SSQ09-09 How Does the Surrounding Background Fat Affect Enhancement of Exophytic Renal Lesions? APhantom Study



Retrospective review of pathology database from Jan 2001 to Mar 2015 revealed 22 cases with Xp11RCC. Imaging findings atpresentation were available in 18 of these cases. Detailed analysis of imaging findings for tumor size, calyceal invasion, necrosis,hemorrhage, exophytic growth, presence of local or distant metastases at presentation were recorded. Pathological findingsincluding T-staging, margin positivity, Fuhrman grade and immunostain positivity were recorded. Clinical and imaging databases wereused to determine OS, and PFS. Multivariate regression analysis and Kaplan-Meier survival statistics were performed.

RESULTS

Mean age at surgery was 40.2 (range 10-83) years. 15 of 22 patients were over 18 years. 1-, 2- and 3-year survivals were 88%,79%, and 73% respectively. On CT / MRI, the majority of tumors enhanced to a lesser degree than adjacent cortex (13/18), wereheterogeneous (11/18) and exophytic (14/18). Necrosis was seen in 5 tumors and correlated with larger tumor size (p<0.01), whilecalyceal invasion (seen in 6 tumors) did not (p=0.07). On multivariate logistic regression analysis, PFS correlated only with Fuhrmangrade (p=0.04) and calyceal invasion (p=0.05) and recurrence of metastatic disease correlated only with initial tumor size (p=0.05).Age and gender at presentation, tumor heterogeneity, and necrosis did not correlate with prognosis. On analysis of overall survival,tumors > 5 cm had a substantially worse outcome than those < 5 cm (log rank test, Chi Square 6.73, p<0.01).

CONCLUSION

For staging scans of Xp11RCC, radiologists should assess tumor size and calyceal invasion as these have the most impact onsurvival. Unlike previous studies, we did not find younger patients to have better clinical outcomes.


Calyceal invasion by tumor and tumor size > 5cm predict adverse outcome in Xp11 RCC.

Honored Educators


Kumaresan Sandrasegaran, MD - 2013 Honored EducatorKumaresan Sandrasegaran, MD - 2014 Honored Educator

ParticipantsAdeel R. Seyal, MD, Chicago, IL (Presenter) Grant, Siemens AGAtilla Arslanoglu, MD, Chicago, IL (Abstract Co-Author) Grant, Siemens AGFaezeh Sodagari, MD, Chicago, IL (Abstract Co-Author) Grant, Siemens AGYuri Velichko, PhD, Chicago, IL (Abstract Co-Author) Nothing to DisclosePaul Nikolaidis, MD, Chicago, IL (Abstract Co-Author) Nothing to DiscloseVahid Yaghmai, MD, Chicago, IL (Abstract Co-Author) Nothing to Disclose

PURPOSE

To evaluate the effect of surrounding tissue composition on renal lesion enhancement at multidetector computed tomography.


Two phantoms (A and B) simulating renal lesions were constructed with 15 test tubes (1.5 cm in diameter) each. For phantom A,the tubes were embedded in fat (-90 HU); and for phantom B, the tubes were embedded in agar gel (neutral medium; 7.3HU). Thetubes were filled with a serial dilution of iodinated contrast [iohexol (300mg/mL)]. Both phantoms were scanned twice using a 64-slice scanner at 120kVp and constant 150mAs. Attenuation was calculated by a centrally placed region-of-interest within each testtube and the surrounding medium and averaged over five slices for each acquisition. Mean of measurements from both acquisitionswere used for analysis. The amount of contrast needed to attain an enhancement of 10HU and 20HU were determined. Regression,paired t and Wilcoxon signed rank tests were used for analysis.

RESULTS

Iodine concentration of 0.285 and 0.675 mg/mL resulted in enhancement of 10 HU and 20 HU, respectively, for a lesion surroundedby fat and 7.3 HU and 16.62 HU when lesion surrounded by neutral medium. At any given iodine concentration, the contrastenhancement was significantly greater for a lesion surrounded by fat when compared with the lesion surrounded by neurtal medium(P<0.0001).

CONCLUSION

A renal mass surrounded by fat tends to show greater enhancement compared with one surrounded by a neutral medium.


Thresholds for enhancement may be different for renal lesions surrounded by fat when compared to intraparenchymal or partiallyexophytic lesions.

Honored Educators


Vahid Yaghmai, MD - 2012 Honored EducatorVahid Yaghmai, MD - 2015 Honored Educator

SSQ10-01 Fractal Analysis of the Leiomyoma before Uterine Artery Embolization Using Contrast-Enhanced MRIand Its Effect on the Outcome


SSQ10-02 Color Doppler Evaluation Of Utero-Ovarian Circulation In Polycystic Ovarian Syndrome and ItsCorrelation With Hormonal and Biochemical Parameters


SSQ10

Genitourinary (Benign and Malignant Gynecological Diseases)


GU MR


ParticipantsHarris L. Cohen, MD, Memphis, TN (Moderator) Nothing to DiscloseMindy M. Horrow, MD, Philadelphia, PA (Moderator) Spouse, Director, Merck & Co, Inc

Sub-Events

ParticipantsNagy N. Naguib, MD, MSc, Frankfurt Am Main, Germany (Presenter) Nothing to DiscloseNour-Eldin A. Nour-Eldin, MD,PhD, Frankfurt Am Main, Germany (Abstract Co-Author) Nothing to DiscloseTatjana Gruber-Rouh, Frankfurt Am Main, Germany (Abstract Co-Author) Nothing to DiscloseThomas Lehnert, MD, Frankfurt Am Main, Germany (Abstract Co-Author) Nothing to DiscloseRenate M. Hammerstingl, MD, Frankfurt Am Main, Germany (Abstract Co-Author) Nothing to DiscloseStefan Zangos, MD, Frankfurt Am Main, Germany (Abstract Co-Author) Nothing to DiscloseThomas J. Vogl, MD, PhD, Frankfurt, Germany (Abstract Co-Author) Nothing to Disclose

PURPOSE

To test whether fractal analysis of the leiomyoma using contrast-enhanced MRI correlates with the leiomyoma volume before andafter uterine artery embolization (UAE) and with the percentage change at 3 month follow-up enabling its usage as a prognosticfactor for treatment success.


The study was retrospectively performed on 33 females (Mean Age: 44.85 +/- 3.95) with 64 leiomyomas. For fractal analysis; MRIimages were exported and converted into 8-Bit greyscale images. The greyscale images were then loaded into the computerprogram ImageJ and analysis was performed using the FracLac plugin. The analysis was performed using the differential-box-counting method at 12 different grid positions. The Mean Fractal dimension for each leiomyoma was calculated by drawing a ROIaround each leiomyoma. On the other hand the volume of each leiomyoma was calculated before and 3 months after UAE usingcontrast-enhanced MRI. The correlation between the mean Fractal dimension of each leiomyoma and its volume before and afterUAE as well as the percentage change in leiomyoma volume was tested for statistical significance using Spearman-Rank Correlationtest.

RESULTS

The mean Fractal Dimension of all leiomyomas was 1.0622 +/- 0.1472 (Range: 0.74 - 1.31). The mean leiomyoma volume beforeUAE was 97.38 ml +/- 160.86 (Range: 1.65 - 987.34). At follow-up the mean leiomyoma volume was 68.08 ml +/- 138.3 (Range:0.15 - 875.05). The mean percentage volume change at follow-up was 52.54% [reduction] +/- 26.99 (Range: 40.05%[increase] -96.57%[reduction]). A statistically significant strong positive correlation between the mean fractal dimension of each leiomyomaand its volume before and after UAE was observed (rho = 0.77, p<0.0001 and rho = 0.78, p<0.0001 respectively). A statisticallysignificant strong negative correlation between the mean fractal dimension of each leiomyoma and its percentage volume change at3 month follow-up was noted (rho = -0.68, p<0.0001).

CONCLUSION

The smaller the mean fractal dimension of a leiomyoma before UAE the higher will be the percentage volume reduction at 3 monthfollow-up after UAE.


Leiomyomas with low mean fractal dimension tend to have a significantly better response at 3 month follow-up following UAE.Hence fractal dimension can be used as a prognostic factor for patient selection.

ParticipantsShivi Jain, MD, Varanasi, India (Presenter) Nothing to DiscloseAkanksha Singh, MD, Varanasi, India (Abstract Co-Author) Nothing to DiscloseMadhu Jain, MD, Varanasi, India (Abstract Co-Author) Nothing to DiscloseRam C. Shukla, MD, MBBS, Varansi, India (Abstract Co-Author) Nothing to DiscloseAshish Verma, MBBS,MD, Varanasi, India (Abstract Co-Author) Nothing to DiscloseArvind Srivastava, Varanasi, India (Abstract Co-Author) Nothing to Disclose

PURPOSE

To find out the variations in utero-ovarian circulation and their association with various endocrinal and biochemical parameters inwomen with Polycystic Ovarian Syndrome (PCOS).

SSQ10-03 Contrast Enhanced 3D STIR T2-Weighted SPACE in Evaluating Sacral Nerve Plexus in PelvicEndometriosis: Compared with Conventional 2D Sequence


SSQ10-04 MRI-US Fusion Imaging in Real-Time Virtual Sonography for the Evaluation of Pelvic Endometriosis:Preliminary Study



65 patients of reproductive age group who had clinical and biochemical findings suggestive of PCOS by Rotterdam criteria (2003)were selected for TVS with Color Doppler study in early follicular phase (3rd-5th day of menstrual cycle). 58 age-matched womenwith normal clinical and biochemical parameters were taken as controls. The RI (Resistance Index), PI (Pulsatility Index) and PSV(Peak Systolic Velocity) of ovarian stromal and uterine arteries were assessed after the estimation of LH, LH: FSH ratio, freetestosterone level, fasting Insulin level and fasting glucose:insulin ratio.

RESULTS

The mean value of LH, LH: FSH, free testosterone and fasting glucose:insulin ratio was significantly higher (p<0.001) in PCOSpatients in comparison to control (LH 7.95 ± 1.34 vs 5.60 ± 0.51; LH: FSH=1.93 ± 0.17 vs 1.16 ± 0.22; free testosterone 3.63 ±0.40 vs 1.71 ± 0.31; fasting glucose:insulin ratio 4.0 ± 0.60 vs 7.51 ± 0.49). The mean ovarian stromal RI, PI and PSV in PCOS wassignificantly lower (p<0.001) as compared to control (0.43 ± 0.08, 0.58 ± 0.10, 11.41 ± 2.53 vs 0.79 ± 0.21, 0.86 ± 0.03, 9.40 ±0.73 respectively). Similarly, uterine artery PI was significantly higher (p<0.001) in PCOS when compared to control (3.05 ± 0.45 vs2.43 ± 0.31). There was significantly negative correlation of ovarian stromal RI with serum LH: FSH ratio(r=0.617.p< 0.01). TheUterine artery PI positively correlated with LH: FSH ratio(r=0.548, p<0.01), free testosterone (r=0.532, p< 0.01), fastingInsulin(r=0.414, p< 0.01), fasting glucose:insulin ratio (r=0.484, p<0.01) and inversely with ovarian stromal RI (r=0.410, p<0.01).

CONCLUSION

Hormonal dysfunction is responsible for hemodynamic changes in utero-ovarian circulation in patients with PCOS. Ultrasonographyalong with color Doppler plays a significant role in the diagnosis and monitoring of Polycystic Ovarian Syndrome.


The decreased PSV and increased PI and RI of uterine artery may explain recurrent early abortions in PCOS. Significant negativecorrelation between ovarian stromal RI and LH: FSH ratio confirms hormonal dysfunction.

ParticipantsXiaoling Zhang, Guangzhou, China (Presenter) Nothing to DiscloseMeizhi Li, Guangzhou, China (Abstract Co-Author) Nothing to DiscloseJian Guan, MD, Guangzhou, China (Abstract Co-Author) Nothing to DiscloseMingjuan Liu, MMEd, Guangzhou, China (Abstract Co-Author) Nothing to DiscloseShurong Li, GuangZhou, China (Abstract Co-Author) Nothing to DiscloseYan Guo, MD, Guangzhou, China (Abstract Co-Author) Nothing to DiscloseHuanjun Wang, MD, GuangZhou, China (Abstract Co-Author) Nothing to Disclose

PURPOSE

To prospectively evaluate microstructural abnormalities in sacral nerve plexus in women with pelvic endometriosis at 3.0T MRI.


Twenty women with clinically diagnosed pelvic endometriosis and 20 age-matched healthy women were enrolled in this study. Inaddition to conventional coronal 2D T2WI TSE imaging, contrast enhanced coronal 3D STIR T2-weighted SPACE was obtained toproduce multiplanar (MPR) images. All examinations were assessed independently by two radiologists for the infiltration of the sacralplexus by endometriotic lesions and the abnormal anatomical features of the sacral plexus. Agreement between 2D- and 3D-sequences and inter-observer-agreement was evaluated using kappa-statistics.

RESULTS

The sacral nerve roots in healthy subjects and patients were clearly visualized on both sequences. The diameter of the sacralnerve roots in patients was larger than in the control group. Most of the patients with endometriosis displayed local thickening orindistinction in the fibers of sacral plexus. There were no significant difference between the results of the 2 radiologists (F=2.563,P=0.086). Contrast enhanced 3D STIR T2-weighted SPACE was preferable in evaluating sacral nerve plexus in pelvic endometriosisthan regular 2D sequences.

CONCLUSION

Changes of the microarchitecture of the sacral nerve plexus were revealled in the patients with pelvic endometriosis on MRI.Contrast enhanced 3D STIR T2-weighted SPACE can display the infiltration of scaral nerve fibers by endometriotic lesions and theabnormal anatomical features of scaral nerve plexus.


Contrast enhanced 3D STIR T2-weighted SPACE was applied as a method of magnetic resonance neurography to reveal thecorrelation between the changes of scracal plexus and chronic pelvic pain in patients with pelvic endometriosis .

ParticipantsValeria Vinci, MD, Rome, Italy (Abstract Co-Author) Nothing to DiscloseLucia Manganaro, MD, Rome, Italy (Abstract Co-Author) Nothing to DiscloseSilvia Bernardo, MD, Rome, Italy (Presenter) Nothing to DiscloseMatteo Saldari, MD, PhD, Rome, Italy (Abstract Co-Author) Nothing to DiscloseMaria Eleonora Sergi, MD, Rome, Italy (Abstract Co-Author) Nothing to DiscloseCarlo Catalano, MD, Rome, Italy (Abstract Co-Author) Nothing to Disclose

SSQ10-05 Diagnostic Value of MR Imaging to Diagnose Adnexal Torsion


SSQ10-06 Can Diffusion-weighted MR Imaging Differentiate Uterine Sarcomas from Leiomyomas?


Federica Capozza, Rome, Italy (Abstract Co-Author) Nothing to Disclose

PURPOSE

Real-time virtual sonography (RVS) is a new technique that uses magnetic navigation and computer software for the synchronizeddisplay of real-time US and multiplanar reconstruction MRI images. The purpose of this study was to evaluate the feasibility andability of RVS to detect pelvic endometriosis.


This study was conducted over a two-month period in march-april 2015 on 25 patients referred for a Clinical and US suspect ofendometriosis. Patients underwent pelvic MRI at 3 T and fusion imaging was offered (Hitachi HI Vision Ascendus) . The MRI imagedataset acquired at the time of the examination was loaded into the fusion system and displayed together with the US image onthe same monitor. Both sets of images were then manually synchronized and image were registered using multiple planes MRimaging.

RESULTS

2patients had endometriosis of the vescico-uterine pouch, with urinary symptoms associated.7patients had endometriosis of themiddle compartment mainly shown as ovarian endometriomas in 6 cases and adenomyosis in 3 cases.19had signs of endometrioticimplants in the posterior compartment shown as fibrotic plaque over the serosal surface of the uterus and rectum in 12 cases. In 1case there was a deep infiltrating intestinal endometriosis over the rectum. A retroflexed uterus was associated in 6 cases. 6 casesshowed fibrotic strands between the uterus and the rectum with thickening of the uterosacral ligaments.Regarding endometriosis ofthe medial compartment, there was an overlap of data of 100% between MRI and RVS, both appearing superior to a standard USevaluation.Endometriosis of the vescico-uterine pouch was better visualized in MRI.Fibrotic strand were displayed in both methodswith an overlap of 100%; on the contrary, relying on RVS it was more difficult to differentiate between active plaque andpredominantly fibrotic plaque because of the difficulty in visualizing the hemorrhagic foci. However the infiltration of the bowel wallwas better undressed in RVS.

CONCLUSION

Thanks to information from both US and MRI, fusion imaging allows better identification of the pelvic implants, superior to thestandard US evaluation.


Thanks to information from both US and MRI, fusion imaging allows better identification of the pelvic implants, superior to thestandard US evaluation.

ParticipantsSophie Beranger-Gibert, Paris, France (Abstract Co-Author) Nothing to DiscloseHajer Sakly, Paris, France (Abstract Co-Author) Nothing to DiscloseMarcos Ballester, MD, Paris, France (Abstract Co-Author) Nothing to DiscloseMarie Bornes, Paris, France (Abstract Co-Author) Nothing to DiscloseMarc J. Bazot, MD, Paris, France (Abstract Co-Author) Nothing to DiscloseEmile Darai, Paris, France (Abstract Co-Author) Nothing to DiscloseIsabelle Thomassin-Naggara, MD, Paris, France (Presenter) Speakers Bureau, General Electric Company; Research Consultant, OleaMedical

PURPOSE

To retrospectively evaluate the diagnostic performance of MR imaging for the diagnosis of adnexal torsion (AT) in a series ofpatients with an equivocal adnexal mass at ultrasonography in a context of acute or sub acute pelvic pain.


Our institutional ethics committee approved the study and granted a waiver of informed consent. All patients with acute or sub-acute pelvic pain undergoing MR exam for the exploration of an equivocal adnexal mass (January 2007 to December 2012) withsurgical exploration or clinical and radiological follow up at least of 3 months were retrospectively included (n=58). Threeradiologists blinded to the clinical, ultrasonographic and surgical data retrospectively and independently reviewed MR images.Features associated with AT were identified using univariate and recursive partitioning multivariate analysis.

RESULTS

Twenty-two patients (38%) had a diagnosis of AT. The accuracy of MR image interpretation by each reader was 83.8% (26/31),90.3% (28/31), 83.8% (26/31) in a context of acute pelvic pain and 92.5% (25/27), 88,8% (24/27), 81.5% (22/27) in a context ofsub acute pelvic pain for reader 1, 2 and 3 respectively. On multivariate analysis, whirlpool sign (OR=6.5 [1.36-31], p=0.01) and athickened tube (OR=8.2 [1.2-56.8], p=0.03) were associated with adnexal torsion, with substantial inter-reader agreement (kappa0.71-0.84, and 0.82-0.86, respectively). The presence of adnexal hemorrhagic content helps to predict ovarian viability (p=0.009)

CONCLUSION

MR imaging is an accurate technique for the diagnosis of adnexal torsion in the setting of patients with adnexal mass having acuteor sub acute pelvic pain.


MR imaging is an accurate second line technique to diagnose adnexal torsion without any pelvic irradiation with the ability to predictovarian viability without any gadolinium injection.

SSQ10-07 Variations in Reporting Recommendations for Son Graphically Evaluated Endometrial Stripe in PostMenopausal Bleeding in a Subspeciality Practice


ParticipantsJun Gon Kim, Seoul, Korea, Republic Of (Presenter) Nothing to DiscloseChan Kyo Kim, MD, PhD, Seoul, Korea, Republic Of (Abstract Co-Author) Nothing to DiscloseJung Jae Park, MD, Seoul, Korea, Republic Of (Abstract Co-Author) Nothing to DiscloseByung Kwan Park, MD, Seoul, Korea, Republic Of (Abstract Co-Author) Nothing to Disclose

PURPOSE

Differentiation uterine sarcoma from leiomyoma is a major challenge. The aim of this study was to investigate the utility of diffusion-weighted imaging (DWI) in differentiating uterine sarcomas from leiomyomas.


Between January 2010 and August 2014, 188 patients with surgically confirmed 38 uterine sarcomas (16 leiomyosarcomas, 12malignant mixed Mullerian tumors, 9 endometrial stromal sarcomas, and 1 undifferentiated pleomorphic sarcoma) and 150 leiomyomaswere enrolled in this retrospective study. All patients underwent preoperative routine pelvic MR imaging at 3T, including DWI. DWIwas obtained using a STIR single-shot echo-planar imaging technique with background suppression (b= 0 and 1000 s/mm2). Theapparent diffusion coefficient (ADC) and signal intensity on T2-weighted imaging (T2SI) were calculated in the tumors, normalmyometrium and gluteus muscle. In the differentiation of sarcomas from leiomyomas, various parameters (ADC, diffusion restriction,tumor-myometrium or gluteus muscle contrast ratio [TCRm or TCRg] on T2-weighted imaging, necrosis, hemorrhage, and size) wereevaluated.

RESULTS

The mean ADC values of sarcomas (0.939 ± 0.253) were statistically lower than those of leiomyomas (1.347 ± 0.327 × 10-3mm2) (p < 0.001). For differentiating sarcomas from leiomyomas, the parameters including diffusion restriction, T2SI, TCRm, TCRg, necrosisand hemorrhage were statistically significant (all p -values < 0.001). At receiver operating characteristics curve analysis, the areaunder the curves of diffusion restriction and ADC in differentiating sarcomas from leiomyomas were 0.902 and 0.860, respectivelyand were statistically greater than other parameters (TCRm, TCRg, necrosis, hemorrhage and size) ( p < 0.05): with a cutoff ADCvalue of 1.111 × 10-3mm2, the sensitivity and specificity were 79% and 80%, respectively. For the degree of diffusion restriction,sarcomas showed moderate or strong in 97% (37/38), while leiomyomas revealed absent or mild in 69% (104/150).

CONCLUSION

DWI at 3T may be a useful technique for the differentiation of uterine sarcomas from leiomyomas.


As a noninvasive technique, preoperative DWI at 3T can be used to predict sarcomas in patients with uterine myometrial masses,which may give potential for planning treatment strategies.

ParticipantsAoife Kilcoyne, MBBCh, Boston, MA (Presenter) Nothing to DiscloseAvinash R. Kambadakone, MD, Boston, MA (Abstract Co-Author) Nothing to DiscloseColin J. McCarthy, MD, Boston, MA (Abstract Co-Author) Nothing to DiscloseGiles W. Boland, MD, Boston, MA (Abstract Co-Author) Principal, Radiology Consulting Group; Royalties, Reed ElsevierSusanna I. Lee, MD, PhD, Boston, MA (Abstract Co-Author) Nothing to DiscloseDebra A. Gervais, MD, Chestnut Hill, MA (Abstract Co-Author) Nothing to Disclose

PURPOSE

Endometrial cancer is the most common gynecologic cancer in the United States. Early diagnosis and intervention is imperative toimprove prognosis and survival. In the setting of postmenopausal vaginal bleeding (PMB), sonographically determined endometrialstripe thickness is an established criteria for predicting risk of cancer and thereby serving as a guide to trigger endometrialsampling. Current guidelines recommend tissue sampling for endometrial stripe measuring >5mm, however, there is limited data onadherence to these guidelines. The purpose of this study was to evaluate the variability in reporting recommendations forsonographically determined endometrial stripe thickness measuring 5mm in patients with PMB at a subspecialty practice in anacademic teaching institution.


In this ongoing study, we performed a review of the 'RENDER' radiology database to identify pelvic ultrasound exams performed onwomen aged 18-80years between January 1st 2009 and December 31st 2014 for evaluation of PMB. Using natural languageprocessing, the radiology reports of these exams were then analysed for endometrial stripe thickness, reporting patterns in thebody, impression of radiology report and the recommendations, if any. The search terms used for the focused search included'endometrial stripe', '5mm', 'postmenopausal'. The variations in the reporting recommendations based on the endometrial stripethickness were then evaluated.

RESULTS

Of the 253 reports reviewed, 58 (24.6%) were not relevant - the search identified patients with an endometrial stripe of greater orless than 5mm. In 74 reports (29.2%), no recommendation was made. In 73 reports (28.8%), endometrial biopsy was recommended.Other recommendations included: biopsy or imaging 14 (6%), no intervention 11 (4%), further imaging 8 (3%), gynaecology review4 (2%), gynaecology review and biopsy 4 (2%), follow-up imaging 2 (1%).

CONCLUSION

In a subspecialty abdominal imaging practice at an academic institution, considerable variation exists on the reportingrecommendation for evaluation of PMB with endometrial stripe thickness measuring 5mm with only 30% of reports adhering toestablished guidelines.

SSQ10-08 Cystic Adnexal Lesions Analyzed by International Ovarian Tumor Analysis (IOTA) Criteria in RoutineClinical Practice


SSQ10-09 MR Imaging and Semi-automated Texture analysis for Differentiating Atypical Appearing UterineLeiomyomas from Leiomyosarcomas



The findings of this study highlight the need for development of standardised approaches/tools to bring about clarity in terms ofmanagement options/further investigation of abnormal endometrial thickening in the setting of postmenopausal bleeding.

Honored Educators


Debra A. Gervais, MD - 2012 Honored EducatorSusanna I. Lee, MD, PhD - 2013 Honored Educator

ParticipantsClaire E. Beaumont, MD, Madison, WI (Abstract Co-Author) Nothing to DiscloseJessica B. Robbins, MD, Madison, WI (Abstract Co-Author) Nothing to DiscloseElizabeth A. Sadowski, MD, Madison, WI (Presenter) Nothing to DiscloseMark A. Kliewer, MD, Madison, WI (Abstract Co-Author) Nothing to DiscloseLisa Barroilhet, MD, Madison, WI (Abstract Co-Author) Nothing to DiscloseLaura Huffman, MD, Madison, WI (Abstract Co-Author) Nothing to DiscloseKatherine E. Maturen, MD, Ann Arbor, MI (Abstract Co-Author) Consultant, GlaxoSmithKline plc; Medical Advisory Board,GlaxoSmithKline plc

PURPOSE

The simple rules developed by the IOTA group direct management of adnexal cysts based on sonographic imaging features. Thediagnostic performance of these criteria in routine practice has not been formally evaluated since the original study was publishedin 2010. The goal of our research is to determine how well the IOTA simple rules criteria perform in stratifying cystic lesions anddetecting ovarian cancer in routine radiology practice.


Patient consent was waived for this IRB approved retrospective review of transvaginal US studies on non-pregnant post-menarchalwomen performed between January-March 2011. Adnexal cysts larger than 3 cm were evaluated according to the IOTA rules. Theincidence of benign adnexal lesions, borderline tumors and ovarian carcinoma was calculated. Surgical pathology, resolution onfollow-up imaging and/or normal gynecological pelvic examination at 2 years were the accepted end points.

RESULTS

108 lesions in 104 women met inclusion criteria. Mean age=41±14 years; range=13-84. 3 lesions (2.8%) met simple rule 1(malignant): 30% (1/3) were cystadenomas and 30% (1/3) carcinoma, with no borderline tumors. 95 lesions (88%) met simple rule2 (benign): 10.5% (10/95) were benign ovarian neoplasms (dermoids=2; cystadenomas=8), with no borderline tumors orcarcinomas. 10 lesions (9.2%) met simple rule 3 (indeterminate): 20% (2/10) were benign ovarian neoplasms, 20% (2/10) borderlinetumors, and 10% (1/10) carcinoma. Thus, the IOTA rules gave a definitive (non-indeterminate) result in 98/108 (90.7%) of casesand correctly triaged 100% of borderline and malignant neoplasms either to further imaging evaluation or surgery.

CONCLUSION

The results of this pilot study indicate that the IOTA rules successfully detect borderline and malignant neoplasms. However, thevast majority of lesions in routine practice are benign in both sonographic appearance and clinical behavior. Full and nuancedevaluation of diagnostic performance in routine clinical practice will require a larger number of cancers, to be evaluated in ourongoing research.


The IOTA simple rules were able to detect borderline and malignant ovarian neoplasms in our clinical practice and aided in directingwomen with such lesions to oncologic specialists.

Honored Educators



ParticipantsYuliya Lakhman, MD, New York, NY (Presenter) Nothing to DiscloseJoshua L. Chaim, DO, New York, NY (Abstract Co-Author) Nothing to DiscloseHarini Veeraraghavan, New York, NY (Abstract Co-Author) Nothing to DiscloseDiana S. Feier, MD, Cluj-Napoca, Romania (Abstract Co-Author) Nothing to DiscloseHebert Alberto Vargas, MD, New York, NY (Abstract Co-Author) Nothing to DiscloseRamon E. Sosa, BA, New York, NY (Abstract Co-Author) Nothing to Disclose

Debra A. Goldman, MS, New York, NY (Abstract Co-Author) Nothing to DiscloseChaya Moskowitz, New York, NY (Abstract Co-Author) Nothing to DiscloseRobert Soslow, New York, NY (Abstract Co-Author) Nothing to DiscloseNadeem Abu-Rustum, New York, NY (Abstract Co-Author) Nothing to DiscloseHedvig Hricak, MD, PhD, New York, NY (Abstract Co-Author) Nothing to DiscloseEvis Sala, MD, PhD, New York, NY (Abstract Co-Author) Nothing to Disclose

PURPOSE

To investigate whether qualitative magnetic resonance (MR) imaging features and texture analysis (TA) can distinguish betweenatypical appearing uterine leiomyomas (ALM) and leiomyosarcomas (LMS)


Forty-one women with ALM (n=22) or LMS (n=19) at histopathology and MRI between January 1, 2007 and December 31, 2013were included in this retrospective study. Two readers (R1 and R2), blinded to histopathologic diagnoses, independently evaluatedall cases. R2 manually segmented each tumor on axial T2-weighted image. Intensity based gray scale correlation matrix (GLCM)textures and Gabor edge based GLCM textures were computed for each segmented tumor. Relationships between clinicalcharacteristics, imaging features, and histopathology were tested with Fisher's exact test. Each tumor was assigned a score of 0to 4 based on the total number of most statistically significant features present. Diagnostic accuracy with exact 95% confidenceintervals was calculated for each feature and score. Texture features were analyzed with a random forest (RF) classifier toautomatically distinguish ALM from LMS. RF classifier was optimized by varying the number of decision trees and its performancewas tested with five-fold cross validation.

RESULTS

Nodular borders, hemorrhagic foci, "T2 dark" areas, and central (±peripheral) unenhanced area(s) were significant predictors of LMS(p<0.0001 for each feature and reader). Sensitivity and specificity of each feature for LMS were 0.84/0.74 and 0.91/0.86 fornodular borders, 0.95/1.0 and 0.82/0.95 for hemorrhagic foci, 0.84/0.79 and 0.86/0.86 for "T2 dark" areas, and 0.95/1.0 and0.73/0.68 for central (±peripheral) unenhanced area(s) for R1/R2, respectively. When any 3 of these features were detected in alesion, the sensitivities and specificities were 1.0/0.95 and 0.95/1.0 for R1/R2, respectively. The best classification accuracy ofcomputer-generated image features was achieved with 25 decision trees (AUC=0.86, sensitivity=0.95, specificity=0.69). The Gaboredge-based texture features were more relevant than the intensity based texture features for the classification.

CONCLUSION

Presence of certain qualitative MRI features can reliably distinguish ALM from LMS. Texture analysis as a semi-automated adjunctmay add certainty to the diagnosis of LMS.


MR imaging and semi-automated texture analysis are useful in distinguishing atypical appearing leiomyomas from leiomyosarcoma.

Honored Educators


Evis Sala, MD, PhD - 2013 Honored Educator

MSRT54

ASRT@RSNA 2015: Renal and Urographic CT Imaging

Thursday, Dec. 3 11:45AM - 12:45PM Location: N230

GU CT


ParticipantsRobert C. Chatelain, RT, Ottawa, ON (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) To identify normal anatomy and its variants demonstrated by CT of the urinary system. 2) To explain the value of having specificdedicated protocols for the renal and urographic imaging. 3) To differentiate renal and urographic pathologies by origin (congenital,neoplastic, vascular etc.)

ABSTRACT

The urinary system is subject to a wide variety of pathological processes and anatomical variants. Fortunately, it lends itself well tobeing imaged by a range of modalities. This presentation will focus on the imaging of the urinary system using ComputedTomography (CT). Due to high spatial resolution, CT is an excellent tool to evaluate stones, masses, traumatic injuries andinfections. Non contrast CT is the procedure of choice to evaluate kidney stones. CT is also used to differentiate malignant fromnonmalignant renal masses, to evaluate the local spread of a renal malignancy and CT angiography (CTA) is an excellent tool todefine the anatomy of the renal arteries and veins.

GU246-SD-THA1

Volumetric Stone Burden Measurement by 3D Reconstruction on NCCT is not a more AccuratePredictor of Stone Free Status after PCNL than 2D Stone Burden Measurements

Station #1

GU248-SD-THA3

Detecting the Main Composition of Urinary Stones with Dual-source Dual-energy ComputedTomography in Vivo

Station #3

GUS-THA

Genitourinary Thursday Poster Discussions

Thursday, Dec. 3 12:15PM - 12:45PM Location: GU/UR Community, Learning Center

GU


ParticipantsDean A. Nakamoto, MD, Beachwood, OH (Moderator) Research Grant, Galil Medical Ltd; Research agreement, Toshiba Corporation

Sub-Events

ParticipantsBrandon Nadeau, MD, London, ON (Presenter) Nothing to DiscloseThomas Tailly, London, ON (Abstract Co-Author) Nothing to DisclosePhilippe Violette, London, ON (Abstract Co-Author) Nothing to DiscloseYige Bao, London, ON (Abstract Co-Author) Nothing to DiscloseJustin Amann, MD, London, ON (Abstract Co-Author) Nothing to DiscloseHassan Razvi, London, ON (Abstract Co-Author) Research Consultant, Olympus Corporation; Research Consultant, HistoSonics, Inc ;Royalties, Cook Group Incorporated ; ; ; John D. Denstedt, MD, London, ON (Abstract Co-Author) Royalties, Cook Group Incorporated

PURPOSE

Stone burden has been reported as an independent predictor of post-operative outcomes for percutaneous nephrolithotomy (PCNL).We aimed to identify the optimal method for imaging quantification of stone burden to predict residual stone at 3 months postpercutaneous nephrolithotomy (PCNL).


We identified 246 patients from a prospective database of PCNL procedures performed at a single tertiary center between January2006 and December 2013. Pre-operative stone burden was assessed by three different methods on reformatted coronal CT images:1) estimated elliptical surface area (SA) calculated as longest perpendicular diameter * π /4; 2) manual surface area measurementwith digital calipers; 3) 3D volume rendering using automated CT software. SA's were reported in increments of 500mm². Logisticregression, receiver operative characteristics (ROC) curve analysis and area under the curve (AUC) were used to evaluate thepredictive value of each method. Primary outcome was stone-free status (SFS) at discharge. Secondary outcomes included SFS at3 months post-procedure, and operative time.

RESULTS

Our cohort had a mean age of 55.7 years, was 40.9% female and had an 19.2% incidence of residual stone. All measurementmethods accurately predicted stone-free status at discharge; OR1: 1.47, CI 1.16-1.86; OR2: 1.51, CI 1.12-2.05, OR3: 1.20, CI:1.04-1.38 respectively. Areas under the curve of ROC analysis were 0.661, 0.658 and 0.662 respectively, demonstrating almostequivalent predictive value of each measurement method. Similar results were seen for predicting stone-free rate at 3 months post-procedure.

CONCLUSION

Our results indicate that the use of complex techniques to measure pre-operative stone burden on CT including manually-derivedsurface area or 3D volumetric reformations provide no added value in predicting post-operative outcomes for PCNL when comparedto traditional 2D measurements based on maximum diameter.


Volumetric measurement of renal stone burden on CT by automated 3D rendering provides no added value in predicting operativeoutcomes for percutaneous nephrolithotomy compared to traditional 2D measurements.

ParticipantsGu Mu Yang Zhang, MD, Beijing, China (Presenter) Nothing to DiscloseHao Sun, MD, Beijing, China (Abstract Co-Author) Nothing to DiscloseHuadan Xue, MD, Beijing, China (Abstract Co-Author) Nothing to DiscloseZheng Yu Jin, MD, Beijing, China (Abstract Co-Author) Nothing to Disclose

PURPOSE

To evaluate the accuracy of dual-source dual-energy computed tomography (DSDECT) in predicting the main composition of urinarycalculi in vivo


Patients with suspected urolithiasis from March of 2014 to Februrary of 2015 underwent DSDECT for urinary stone compositionanalysis before percutaneous nephrolithotomy or ureterorenoscopy. All patients were scanned by DSDECT using the dual-energy

GU235-SD-THA6

Prostate Imaging Reporting and Data System Version 2 Improves Diagnostic Performance ofMultiparametric MR Imaging of the Prostate for Experienced and Unexperienced Reader

Station #6

UR133-ED-THA7

Scrotal Ultrasound versus MRI: The Ball is in your Court

Station #7

renal stone protocol. Material-specific chromatic images were made using dedicated post-processing software. Two radiologistsinterpreted the images and analyzed the composition of stones independently. The final determination of the composition of stoneswas made by fourier transform infrared spectrometry postoperatively. The accuracy of DSDECT in evaluating stone composition wasanalyzed.

RESULTS

A total of 81 urinary calculi from 67 patients(50 male, 17 female, mean age: 50 years) were included in this study. There are 43stones with single composition (uric acid n=5, cystine n=2, hydroxylapatite n=5, calcium oxalate n=31) and 38 stones with mixedcomposition(uric acid/calcium oxalate n=4, cystine/hydroxylapatite n=1, calcium oxalate/hydroxylapatite n=33). The accuracy fordetecting uric acid, cystine, hydroxylapatite and calcium oxalate were 77.8%(7/9), 100%(3/3), 97.4%(38/39) and 98.5%(67/68).As for detecting the main composition of stones, DSECT correctly identified 7 of the 9 calculi mainly composed of uric acid and allthe rest of 64 calculi mainly composed of calcium oxalate, 3 calculi mainly composed of cystine and 5 calculi mainly composed ofhydroxylapatite. The overall accuracy of DSDECT in predicting the main composition of stones was 97.5%(79/81).

CONCLUSION

DSDECT could accurately distinguish the four stone composition and accurately predict the main composition of urinary calculi.


DSDECT could facilitate the optimization of clinical management of urolithiasis by accuratley predicting the main composition ofstones in vivo

ParticipantsMoritz Kasel-Seibert, Jena, Germany (Presenter) Nothing to DiscloseRene Aschenbach, MD, Jena, Germany (Abstract Co-Author) Nothing to DiscloseMarcus Horstmann, Jena, Germany (Abstract Co-Author) Nothing to DiscloseMarc-Oliver Grimm, Jena, Germany (Abstract Co-Author) Nothing to DiscloseUlf K. Teichgraeber, MD, Jena, Germany (Abstract Co-Author) Research Consultant, W. L. Gore & Associates, Inc; ResearchConsultant, Siemens AG; Research Consultant, CeloNova BioSciences, Inc ; Research Consultant, General Electric Company; Tobias Franiel, Jena, Germany (Abstract Co-Author) Nothing to Disclose

PURPOSE

This study evaluates the diagnostic performance of the multiparametric magnetic resonance imaging (mpMRI) based ProstateImaging Reporting and Data System (PI-RADS) version 2, in comparison to version 1.


138 lesions in 82 consecutive patients with elevated PSA and at least one negative transrectal ultrasound guided systematic biopsywere retrospectively evaluated and scored according to PI-RADS V1 and V2 by an experienced and unexperienced blinded reader.All patients underwent endorectal mpMRI (T2-weighted imaging + diffusion weighted imaging + dynamic contrast enhanced MRI) at1.5T. Results of targeted in-bore MRI guided biopsy were used as reference standard. Diagnostic parameters were calculated on aper lesion basis.

RESULTS

For the experienced reader scoring with PI-RADS V2 and a threshold of ≥ 4 increased specificity (0.81 vs. 0.67), positive predictivevalue (0.63 vs. 0.48) and negative predictive value (0.90 vs. 0.88) while maintaining sensitivity of 0.77 in comparison to PI-RADSV1. For the unexperienced reader all diagnostic parameters improved respectively as follows: sensitivity 0.79 vs. 0.67, specificity0.78 vs 0.68, positive predictive value 0.60 vs. 0.46, negative predictive value 0.90 vs. 0.84. The use of PI-RADS V2 with athreshold of ≥ 3 resulted in 39 more lesions for the experienced and 9 more lesions for the unexperienced reader which would havebeen correctly classified as benign. Inter-reader agreement improved for PI-RADS V2 (κ=0.51) compared to V1 (κ=0.25).

CONCLUSION

PI-RADS V2 compared to PI-RADS V1 led to an improvement of diagnostic parameters. Inter-reader agreement betweenexperienced and unexperienced reader increased from fair to moderate.


PI-RADS V2 compared to V1 improves diagnostic accuracy for the detection of prostate cancer while higher inter-reader reliabilitysuggests a more replicable and understandable reporting system.


ParticipantsIan Mills, MD, New Haven, CT (Presenter) Nothing to DiscloseMike Spektor, MD, New Haven, CT (Abstract Co-Author) Nothing to DiscloseSteffen Huber, MD, New Haven, CT (Abstract Co-Author) Nothing to DiscloseJay K. Pahade, MD, New Haven, CT (Abstract Co-Author) Nothing to DiscloseMahan Mathur, MD, New Haven, CT (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

Magnetic resonance (MR) interpretation of scrotal pathology can present a unique challenge for the unintiated, particularly since

ultrasound (US) is often the first, and many times the only, imaging study that is required. Nevertheless, MR imaging is useful in thissetting, potentially serving as a problem solving tool for indeterminate lesions seen on US. The purpose of this exhibit is toshowcase the MR imaging appearance of a variety of neoplastic and non-neoplastic conditions of the scrotum. Specific imagingfeatures which facilitate differentiation of these conditions will be discussed and MR/US imaging correlatation will be emphasized.


MRI technique and indications Normal anatomy Non-neoplastic conditions Epididymo-orchitis (including TB) Testicular hematomaTubular ectasia of the rete testis Polyorchidism Cryptorchidism Hydrocele, hematocele/pyocele Epididymal cyst, spermatocele Focaltesticular infarct Adrenal rests Testicular prosthesis Extra-testicular lipoma Inguinal hernia Neoplastic conditions Seminoma Mixedgerm cell tumor Lymphoma Adenomatoid tumor of the epididymis Spermatic cord sarcoma Summary/Conclusion

GU230-SD-THB1

Innovative Single Acquisition Split Bolus Dual Energy CT (SBDECT) Protocol for ComprehensiveEvaluation of Renal Masses: Preliminary Results of Prospective Randomized Trial

Station #1

GU254-SD-THB3

Prostate Cancer: Correlation of Intravoxel Incoherent Motion MR Parameters with Gleason Score

Station #3

GUS-THB

Genitourinary Thursday Poster Discussions

Thursday, Dec. 3 12:45PM - 1:15PM Location: GU/UR Community, Learning Center

GU



ParticipantsDean A. Nakamoto, MD, Beachwood, OH (Moderator) Research Grant, Galil Medical Ltd; Research agreement, Toshiba Corporation

Sub-Events


ParticipantsDinesh Manoharan, MBBS, New Delhi, India (Presenter) Nothing to DiscloseSanjay Sharma, MD, FRCR, New Delhi, India (Abstract Co-Author) Nothing to DiscloseChandan J. Das, MD, MBBS, New Delhi, India (Abstract Co-Author) Nothing to DiscloseRajeev Kumar, MD,MChir, New Delhi, India (Abstract Co-Author) Nothing to DiscloseGeetika Singh, MBBS, MD, New Delhi, India (Abstract Co-Author) Nothing to DisclosePratik Kumar, MSc, PhD, New Delhi, India (Abstract Co-Author) Nothing to DiscloseArun K. Gupta, MBBS, MD, New Delhi, India (Abstract Co-Author) Nothing to Disclose

PURPOSE

To evaluate the diagnostic accuracy of single acquisition SBDECT compared to standard triple phase MDCT in evaluation ofsuspected renal masses.


The study was approved by institutional review board. Eighty consenting adults (>18y, 52M,28F) from April 2014 to March 2015,with suspected renal mass(es) on ultrasound requiring further evaluation by CT were randomly assigned into two groups: singleacquisition SBDECT (n=41, Gp A) or standard triple phase MDCT (n=39, Gp B). Patients were scanned in Siemens Somaton DefinitionFlash 2x128 slice scanner. Gp A protocol consisted of 40 ml iodinated IV contrast hand injected at 0s, 45ml @ 4ml/s at 820s and60ml @ 3.5ml/s at 852s with single dual energy CT image acquisition after the end of third bolus. Gp A scan parameters tubepotential/ref mAs were 100kVp/230mAs and Sn140kVp/178mAs). In Gp B protocol, single energy CT images were acquired in noncontrast (0s), corticomedullary (28s), nephrographic (80s) and delayed (15min) phase. Histopathology /FU were used as thereference standard. Two readers in consensus qualitatively rated vascular, parenchymal enhancement and urinary tractopacification. Effective radiation dose was calculated.

RESULTS

Overall 169 masses (36 malignant, 133 benign) were analyzed in Gp A. All 36 malignant and 130/133 of benign masses (sens 100%,spec 97.74%, PPV 92.31% , NPV 100%, Acc 98.22%) were correctly diagnosed. Three were false positive. In Gp B, total 93 masses(28 malignant, 65 benign) were analyzed. It diagnosed correctly 26/28 malignant and 64/65 benign masses (sens 92.86%, spec98.46%, PPV 96.29% and NPV 96.96%, Acc 96.72%). Two were false negative and one was false positive. Arterial and venousenhancement was excellent in 88% and 86% respectively. Renal parenchymal enhancement was excellent in 69%. Intrarenalcollecting system and upper ureter showed complete opacification in 72%. Mean effective dose was 8.7 mSv and 23.9 mSv in Gp Aand Gp B respectively (p<0.05).

CONCLUSION

The accuracy of single acquisition SBDECT is comparable to the standard triple phase MDCT in characterizing renal masses. It is adose efficient protocol providing adequate image quality of renal parenchyma, vascular anatomy and pelvicalyceal system.


Proposed CT protocol can be effectively used for routine evaluation of renal masses with much lower radiation dose to a patient.

ParticipantsDal Mo Yang, Seoul, Korea, Republic Of (Abstract Co-Author) Nothing to DiscloseHyun Cheol Kim, Seoul, Korea, Republic Of (Abstract Co-Author) Nothing to DiscloseSang Won Kim, MD, Seoul, Korea, Republic Of (Abstract Co-Author) Nothing to DiscloseGeon-Ho Jahng, PhD, Seoul, Korea, Republic Of (Abstract Co-Author) Nothing to DiscloseYe Na Son, Seoul, Korea, Republic Of (Abstract Co-Author) Nothing to DiscloseWoo Jin Yang, Seoul, Korea, Republic Of (Presenter) Nothing to Disclose

PURPOSE

To evaluate the potential of IVIM imaging to predict histologic prognostic parameters by investigating whether IVIM parameters

GU255-SD-THB4

Characterization of Renal Masses in MR Reporting: Pathologic Correlation as Part of a PerformanceQuality Review at an Academic Center

Station #4

GU256-SD-THB5

Imaging Features of Abdominal Wall Endometriosis

Station #5

correlate with Gleason score.


A total of 41 patients with histologically-proven prostate cancer who underwent prostate MR imaging using a 3T MRI machine wereincluded in this study. For the eight DWI b-values (0, 10, 20, 50, 100, 200, 500, and 800 sec/mm2), the spin-echo echo-planarimaging (EPI) sequence was performed. The D, f, D*, and ADCfit values were compared between three different groups of prostatecancer: Gleason score 6 (n = 9), Gleason score 7 (n = 16), and Gleason score 8 or higher (n = 16). Receiver operatingcharacteristic (ROC) curves were generated for D, f, D*, and ADCfit to assess the ability of each parameter to distinguish cancerswith low Gleason scores from cancers with intermediate or high Gleason scores.

RESULTS

Pearson's coefficient analysis revealed significant negative correlations between the Gleason score and ADCfit (r = -0.490, P =0.001) and the Gleason score and D values (r = -0.514, P = 0.001). On the other hand, the Gleason score was poorly correlatedwith the f (r = 0.168, P = 0.292) and D* values (r = -0.108, P = 0.500). The ADCfit and D values of prostate cancers with Gleasonscores of 7 or ³ 8 were significantly lower than those of prostate cancers with a Gleason score of 6 (P < 0.05). ROC curves wereconstructed to assess the ability of the IVIM parameters to discriminate prostate cancers with a Gleason score of 6 from thosewith Gleason scores of 7 or ³ 8. The areas under the curve (AUCs) ranged from 0.671 to 0.974. ADCfit and D yielded the highest Azvalue (0.960-0.956), whereas f yielded the lowest Az value (0.633).

CONCLUSION

The pure molecular diffusion parameter, D, was the best IVIM parameter for discriminating prostate cancers with low Gleason scoresfrom prostate cancers with intermediate or high Gleason scores.


The accurate assessment of prostate cancer aggressiveness is important for deciding the most appropriate initial treatmentstrategy. We believe Intravoxel incoherent motion (IVIM) imaging may provide information about tumor aggressiveness withoutprostate biopsy determination.

ParticipantsHelen S. Xu, BA, Boston, MA (Presenter) Nothing to DiscloseLeo L. Tsai, MD, PhD, Boston, MA (Abstract Co-Author) Co-founder, Agile Devices Inc; Stockholder, Agile Devices Inc; ResearchConsultant, Agile Devices Inc; Eric U. Yee, MD, Boston, MA (Abstract Co-Author) Nothing to DiscloseMaryellen R. Sun, MD, Boston, MA (Abstract Co-Author) Research Grant, Glaxo SmithKline plc

PURPOSE

To evaluate the accuracy of MR diagnosis of renal masses through retrospective review of MRI reports from an academic medicalcenter with pathologic correlation as gold standard.


A retrospective review of MRI reports from MR renal mass examinations performed at a single site was correlated with pathologicaldiagnosis. 100 renal masses were assessed with dedicated contrast-enhanced renal mass protocol MR examinations prior tobiopsy/surgical resection from August 2013-November 2014. All imaging was performed on-site and reported by abdominal imagingradiologists with fellowship training in body MRI. Pathologic diagnoses included clear-cell renal cell carcinoma (ccRCC) (n=62),papillary RCC (n=11), chromophobe RCC (n=6), RCC with papillary and oncocytic features (n=1), unclassified RCC (n=1),oncocytoma (n=13), oncocytic neoplasm with papillary features (n=1), AML (n=4) and AML with papillary adenoma (n=1). Theleading diagnosis, differential diagnoses, and descriptors (such as T2 signal intensity and enhancement pattern) from the MRreports were compared to the pathological diagnosis of each lesion.

RESULTS

The sensitivity and specificity of a primary MRI diagnosis of ccRCC was 83% and 58%, for papillary RCC 91% and 98%, and forangiomyolipoma 75% and 99%, respectively. Only 8% of oncocytomas were primarily diagnosed on MRI, with the remainderprospectively reported as likely ccRCC. No chromophobe RCC was the primary diagnosis on MRI, with only 1 (17%) included in thedifferential. 50% of ccRCCs and 77% of oncocytomas were described as T2-hyperintense with 65% and 69% respectively havingenhancement similar-to or greater-than the renal cortex. 73% of papillary RCCs were described as T2-hypointense, and 73% werehypoenhancing.

CONCLUSION

Papillary RCCs were diagnosed with the greatest accuracy, likely due to its unique MR characteristics. Lower specificity for ccRCC isdue in part to overlap of MR characteristics with other lesions, posing a particular diagnostic challenge for less-common lesionssuch as oncocytomas and chromophobe RCC.


While MRI can accurately diagnose many renal masses to aid treatment planning, challenges remain in differentiating lesions thathave similar MR features as ccRCC, in particular oncocytic neoplasms.

ParticipantsGail Yarmish, MD, New York, NY (Presenter) Nothing to Disclose

GU257-SD-THB6

Virtual Non-contrast Imaging for CT Urography with Third-generation Dual-source Dual-energy CTScanner

Station #6

Evis Sala, MD, PhD, New York, NY (Abstract Co-Author) Nothing to DiscloseHedvig Hricak, MD, PhD, New York, NY (Abstract Co-Author) Nothing to DiscloseRobert Soslow, New York, NY (Abstract Co-Author) Nothing to DiscloseYuliya Lakhman, MD, New York, NY (Abstract Co-Author) Nothing to DiscloseDebra A. Goldman, MS, New York, NY (Abstract Co-Author) Nothing to DiscloseChaya Moskowitz, New York, NY (Abstract Co-Author) Nothing to DiscloseHebert Alberto Vargas, MD, New York, NY (Abstract Co-Author) Nothing to Disclose

PURPOSE

To assess the utility of various morphologic and quantitative CT features in differentiating abdominal wall endometriosis from othermasses of the abdominal wall.


Institutional review board approval and waiver of informed consent were obtained for this HIPAA compliant study. CT studies of 105female patients with histologically evaluated abdominal wall masses were reviewed (median age of 41 years with range: 21 - 55years); 24.8% (26/105) had histologically proven endometriosis. The other most common diagnoses included desmoid (13.3%;14/105), leiomyosarcoma (7.6%; 8/105), adenocarcinoma (5.7%; 6/105), clear cell adenocarcinoma (4.8%; 5/105), serouscystadenocarcinoma (3.8%; 4/105) and fibromatosis (2.9%; 3/105). Two radiologists blinded to the final histopathologic diagnosisindependently evaluated all cases and recorded their CT imaging features: size, number, location, density, enhancement,heterogeneity, presence of calcifications, associated scars, intraperitoneal disease, and the newly described "comet-tail" sign.Histopathologic specimens served as a gold standard. Associations between CT features and endometriosis were tested using theFisher exact and the Wilcoxon Rank Sum tests. P-values were adjusted for multiple testing using the false discovery rate approach.Inter-reader concordance was also calculated.

RESULTS

The CT features significantly associated with endometriosis were location below the umbilicus (p=0.0264), homogeneity (p=0.0264),and "comet tail" sign (p<0.0001). Inter-reader agreement ranged from slight for mass enhancement (k=0.20) to almost perfect oncalcifications (k=0.85), comet tail sign (k=0.97), cystic density (k=0.85), position above or below umbilicus (k=0.97), intraperitonealdisease (k=0.97), multiple abdominal wall masses (k=0.94), association with scar (k=0.88), mass heterogeneity (k=0.90), and masslocation (k=0.90).

CONCLUSION

CT features are helpful in distinguishing abdominal wall endometriosis from other abdominal wall soft tissue masses.


Abdominal wall endometriosis is often misinterpreted when encountered on CT, however there are discriminating imaging featureswhich can assist the radiologist in making this diagnosis.

Honored Educators


Evis Sala, MD, PhD - 2013 Honored Educator

ParticipantsSatoru Takahashi, MD, Kobe, Japan (Presenter) Nothing to DiscloseYoshiko Ueno, MD, Kobe, Japan (Abstract Co-Author) Nothing to DiscloseKiyosumi Kagawa, Kobe, Japan (Abstract Co-Author) Nothing to DiscloseYuko Suenaga, Kobe, Japan (Abstract Co-Author) Nothing to DiscloseKazuhiro Kitajima, MD, Nishinomiya, Japan (Abstract Co-Author) Nothing to DiscloseNoriyuki Negi, RT, Kobe, Japan (Abstract Co-Author) Nothing to DiscloseUtaru Tanaka, Kobe, Japan (Abstract Co-Author) Nothing to DiscloseKazuro Sugimura, MD, PhD, Kobe, Japan (Abstract Co-Author) Research Grant, Toshiba Corporation Research Grant, KoninklijkePhilips NV Research Grant, Bayer AG Research Grant, Eisai Co, Ltd Research Grant, DAIICHI SANKYO Group

PURPOSE

Virtual non-contrast (VNC) imaging with dual energy CT has been expected to replace true non-contrast imaging. In the excretoryphase of CT urography (CTU), however, VNC images are of suboptimal quality because of the densely opacified urine in thecollecting system, even with 2nd generation dual source CT (DSCT) scanner. The purpose of this study is to investigate the abilityof VNC imaging in CTU with 3rd generation DSCT compared with those with 2nd generation scanner.


We retrospectively compared 33 consecutive patients who underwent CTU with 192-slice 3rd generation DSCT scanner using adual-energy combination of 100 & 150Sn kV, with 19 historical controls with 128-slice 2nd generation DSCT scanner using a 100 &140Sn kV. CT values of the renal pelvis and the urinary bladder were measured on both mixed images and VNC images of excretoryphase CTU. On mixed images, CT values of the area with suboptimal iodine suppression (any pixel that showed >40 HU on VNCimages) were compared between 2nd and 3rd generation DSCT. Subjective assessment of the ability of iodine suppression on VNCwas scored on a 5-point scale. The ability of detecting urinary stones was also compared. Radiation dose (CTDIvol) was recorded ineach case.

RESULTS

UR156-ED-THB7

Male Factor Infertility: Role of Imaging

Station #7

There were no statistically significant differences in CT values of the renal pelvis and the urinary bladder between 2nd and 3rdgeneration DSCTU on mixed images (renal pelvis, 528 HU vs. 756 HU; urinary bladder, 282 HU vs. 273 HU), as well as VNC images(renal pelvis, 44 HU vs. 42 HU; urinary bladder, 20 HU vs. 8.8 HU). However, mean CT values of the area with suboptimal iodinesuppression were lower with 2nd generation (457±177 HU) than 3rd generation DSCT (686±161 HU; p<.0001). No statisticallysignificant differences were found between subjective assessments of VNC with 2nd and 3rd generation DSCT. Renal stones greaterthan 2-mm in diameter were detected on VNC with both 2nd and 3rd generation DSCT. CTDIvol of the excretory phase CTU wassignificantly greater with 2nd generation DSCT than 3rd generation (2nd, 10.4±2.0 mGy; 3rd, 7.7± 1.7 mGy; p<.0001).

CONCLUSION

3rd generation DSCT could provide more optimal iodine suppression on VNC for the excretory phase CT urography.


VNC imaging with 3rd generation DSCT is effective for suppressing iodine attenuation of densely opacified urinary tract in CTurography.

AwardsIdentified for RadioGraphics

ParticipantsPardeep K. Mittal, MD, Atlanta, GA (Presenter) Nothing to DisclosePeter A. Harri, MD, Atlanta, GA (Abstract Co-Author) Nothing to DiscloseJuan C. Camacho, MD, Atlanta, GA (Abstract Co-Author) Nothing to DiscloseNima Kokabi, MD, Atlanta, GA (Abstract Co-Author) Nothing to DiscloseMatthew S. Hartman, MD, Pittsburgh, PA (Abstract Co-Author) Nothing to DiscloseCourtney A. Coursey Moreno, MD, Suwanee, GA (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

-Demonstrate role of imaging to identify correctable causes of male infertility.-Describe imaging is critically important in diagnosis ofpre-testicular, testicular and post-testicular conditions causing infertility in males as well as assessment of obstructive causes ofazoospermia.-Demonstrate basic concepts in male reproduction, differential diagnosis and clinical evaluation.


Infertility failure to conceive after regular unprotected sexual intercourse in the absence of known reproductive pathology over aperiod of 1-2 years. According to WHO 20% causes of infertility are due to male factors where as 27% abnormalities are found inboth partners thus male factors are almost in 50% of casesMale factors:Pretesticular: hypogonadism, pituitary failure, estrogenexcess, cortisol excess/ deficiency. Testicular: varicocele, rete testis, cryptorchidism, tumors, granulomatous diseaseetc.Posttesticular: congenital absence of vas deferens, utricular / Müllerian duct cyst, ejaculatory duct obstructionetc.Abnormalities causing testicular failure and impaired spermatogensis cannot be corrected whereas obstructive processes arepotentially correctableSummary: Radiologists should be familiar with evaluation of infertility and common radiological findings anddisease processes associated with male factor infertility

MSCA51A Hepatic Tumor Imaging

MSCA51B Abdominal Trauma Imaging

MSCA51C Acute Abdomen Imaging

MSCA51

Case-based Review of the Abdomen (An Interactive Session)

Thursday, Dec. 3 1:30PM - 3:00PM Location: S406A

GI GU OB ER


ParticipantsDouglas S. Katz, MD, Mineola, NY, ([email protected]) (Director) Nothing to Disclose

LEARNING OBJECTIVES

1) To review a series of clinically relevant, abdominal imaging cases, with audience participation. 2) To review important conceptsand potential pitfalls of: the liver on sonography; the acute abdomen on US, CT, and MR; liver transplants on multi-modalityimaging; genitourinary imaging; and trauma imaging 3) To provide take home points for the audience based on specific actual casematerial which was instructional or problematic for the presenters.

ABSTRACT

Sub-Events

ParticipantsPuneet Bhargava, MD, Shoreline, WA (Presenter) Editor, Reed Elsevier

LEARNING OBJECTIVES

1) Review imaging appearances of common hepatic tumors. 2) Review key imaging findings that aid in differential diagnosis.

ABSTRACT

Honored Educators


Puneet Bhargava, MD - 2015 Honored Educator

ParticipantsSavvas Nicolaou, MD, Vancouver, BC (Presenter) Institutional research agreement, Siemens AG

LEARNING OBJECTIVES

1) Review the technique and protocols, with an emphasis on MDCT, for imaging of blunt and penetrating abdominal and pelvictrauma. 2) Demonstrate examples of the spectrum of injuries and the accompanying management associated with abdominaltrauma, including hepatic and hepatobiliary (gallbladder) injuries, bowel and mesenteric injuries, and pelvic injuries including bladderand vascular injuries. 3) Demonstrate significance of arterial and portal venous phase imaging in the setting blunt abdominal andpelvic trauma, and the utility of whole body imaging. 4) Review new imaging applications and techniques such as iterativereconstruction and dual-energy CT, which can help better image abdominal and pelvic injuries post-trauma.

ABSTRACT

ParticipantsStephan W. Anderson, MD, Boston, MA (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) The participant will be exposed to the current literature related to imaging of acute abdominal pain using CT. 2) The participantwill be able to apply an evidence-based approach to CT protocol development in the imaging of acute abdominal pain. 3) Theparticipant will be able to independently evaluate the published literature in this area in a critical fashion and continue to applyrecent developments to their own practice.

RC707

GU Ultrasound 2015: The Expert's Update on Kidney, Gynecologic and Testicular US

Thursday, Dec. 3 4:30PM - 6:00PM Location: N227

GU OB US


ParticipantsJohn J. Cronan, MD, Providence, RI (Coordinator) Nothing to DiscloseMindy M. Horrow, MD, Philadelphia, PA, ([email protected]) (Presenter) Spouse, Director, Merck & Co, IncPaula J. Woodward, MD, Salt Lake City, UT (Presenter) Vice President, Reed Elsevier

LEARNING OBJECTIVES

1) The learner will be made aware of the importance of acute kidney injury (AKI) and associated ultrasound findings. 2) Ultrasoundcriteria of cystic adnexal masses will be reviewed. 3) Testicular and scrotal pathology and the importance of ultrasound will beexplained.

ABSTRACT

Ultrasound has taken on new importance in the evaluation of the kidney, female pelvis and the scrotum/ testicles. We will explainthe ultrasound findings of acute kidney injury (AKI), the evaluation of pelvic masses and the necessary follow-up. Finally, a reviewof the testicle and ultrasound findings will complete the course.

Honored Educators


Mindy M. Horrow, MD - 2013 Honored Educator

RC807

GYN and Pelvic Floor 2015: Latest Imaging Guidelines and Angles Simplified!

Friday, Dec. 4 8:30AM - 10:00AM Location: N227

GU CT MR US


ParticipantsMark E. Lockhart, MD, Birmingham, AL, ([email protected]) (Coordinator) Nothing to DiscloseReena C. Jha, MD, Washington, DC (Presenter) Nothing to DiscloseMaitray D. Patel, MD, Phoenix, AZ (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) Describe current best practice recommendations for management of adnexal asymptomatic, incidental, and/or potentiallyphysiologic findings on pelvic US, CT, and MR based on lesion characteristics and patient clinical factors. 2) Understand thereference lines and angles in pelvic MRI that are used in the evaluation of pelvic floor disorders. 3) Understand the typical imagingcharacteristics of the endometrium and myometrium according to patient age and stage of the reproductive cycle, and reviewassociated benign pathology.

ABSTRACT

This session will present on topics related to pelvic imaging. At the conclusion of the three presentations, the participants shouldhave an improved understanding of imaging characteristics of the ovaries and uterus, including endometrium. Also, the imagingparameters used in evaluation of pelvic floor abnormalities such as organ prolapse and structural abnormalities related toincontinence will be reviewed. In each lecture, the imaging characteristics of a variety of disease processes will be covered.

Active Handout:Maitray D. Patel

http://abstract.rsna.org/uploads/2015/14000842/RC807.pdf

RC808A Pitfalls in Right Upper Quadrant Ultrasound

RC808B Pediatric Abdominal Ultrasound Pitfalls

RC808C Non-obstetrical Gynecologic Ultrasound Pitfalls

RC808D First Trimester Ultrasound Pitfalls

RC808

Emergency Ultrasound Pitfalls (An Interactive Session)

Friday, Dec. 4 8:30AM - 10:00AM Location: E353C

GI GU OB US ER


Participants

Sub-Events

ParticipantsMindy M. Horrow, MD, Philadelphia, PA, ([email protected]) (Presenter) Spouse, Director, Merck & Co, Inc

LEARNING OBJECTIVES

1) Describe technical factors that may improve visualization of cholelithiasis including appropriate frequency transducer andidentification of gallbladder neck. 2) Identify non biliary causes of gallbladder wall thickening. 3) Recognize causes for non-visualization of a fluid filled gallbladder and how to differentiate the gallbladder from other fluid filled structures in the right upperquadrant. 4) Describe situations in which color Doppler is essential to detect renal causes of right upper quadrant pain.

Honored Educators


Mindy M. Horrow, MD - 2013 Honored Educator

ParticipantsSusan D. John, MD, Houston, TX (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) Use optimal protocols for performing abdominal US in infants and children. 2) Avoid diagnostic errors in pediatric gastrointestinalUS caused by common artifacts and variables in exam performance. 3) Recognize variations in pathology and important secondaryfindings that are helpful for the diagnosis of acute or emergent conditions in the pediatric abdomen.

ABSTRACT

ParticipantsAna P. Lourenco, MD, Providence, RI, ([email protected]) (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) Recognize commonly encountered gynecological ultrasound pitfalls. 2) Describe strategies to avoid these pitfalls.

ABSTRACT

This session will review common pitfalls encountered in gynecologic ultrasound and highlight strategies for avoiding such pitfalls.Case-based presentations will illustrate the varied presentations of ovarian torsion, non-gynecologic etiologies for acute pelvic painincluding ureteral calculi and acute appendicitis, and a variety of uterine, ovarian and adnexal abnormalities. The benefits andlimitations of transabdominal and transvaginal imaging, as well as color Doppler, will be highlighted with examples to demonstratethe utility of each technique.

Active Handout:Ana P. Lourenco


ParticipantsMariam Moshiri, MD, Seattle, WA (Presenter) Consultant, Reed Elsevier; Author, Reed Elsevier

LEARNING OBJECTIVES

1) To review the relatively recent report of the Society of Radiologists in Ultrasound, on new ultrasound criteria for evaluation offirst trimester pregnancy. 2) To demonstrate potential pitfalls of sonographic performance and interpretation in the first trimester ofpregnancy, and to discuss how to avoid them. 3) To review other relevant, very recent literature on first trimester pregnancyultrasound performance and interpretation.

Honored Educators


Mariam Moshiri, MD - 2013 Honored EducatorMariam Moshiri, MD - 2015 Honored Educator

RC818A Functional and Molecular Imaging at Oxford University

RC818B Lessons Learned from the National Irish Breast Screening Program: The First 12 years-One MillionMammograms On

RC818C MRI of Pelvic Malignancy-The View from Down Under

RC818

Global Cancer Imaging-Insights from Overseas

Friday, Dec. 4 8:30AM - 10:00AM Location: E261

GU MI MR OI



Participants

Sub-Events

ParticipantsFergus V. Gleeson, MBBS, Oxford, United Kingdom (Presenter) Consultant, Alliance Medical Limited; Consultant, Blue EarthDiagnostics Limited; Consultant, Polarean, Inc;

LEARNING OBJECTIVES

1) To learn about the functional and molecular imaging research being conducted within the Radiology Department of OxfordUniversity Hospitals NHS Trust.

ABSTRACT

There is increasing functional and molecular imaging being performed in medicine. The Radiology department at the Churchill Hospitalin Oxford is conducting a number of trials in these areas, and has designed these trials around interventions to measure the effectof these new techniques. It has also taken the opportunity to raise the profile of Radiology within the University, to promotegreater collaboration with basic scientists, attracting increased funding, and opportunities for scientists and physicians.

ParticipantsMichelle M. McNicholas, MD, Dublin, Ireland (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) To review the results of the Irish National Breast Screening Program following 12 years of screening with over 1,000,000mammograms performed. 2) To understand the essential components of setting up and maintaining a national breast screeningprogram in Ireland. This includes the rationale for the decisions made at the outset, such as age range, frequency of screens,centralisation of service and responsibility of the screening process to the end of primary surgery. 3) To understand the need forand the mechanism of developing a national registry of eligible women in the absence of a national unique identifier. 4) Tounderstand the need for a client charter which sets out client guarantees, objectives and goals around issues of consent,timeliness of screening results and recall to assessment, biopsy results and admission for surgery and further treatment whereindicated. 5) To understand the necessity of national guidelines, annual reports and external accreditation. 6) To demonstrate theessential need for ongoing review of key performance indicators (recall rate, biopsy rate, cancer detection rate, DCIS rate, openbiopsy rate, false negative rate, interval cancer rate) as surrogates of program success. 7) To understand the importance ofcommunication and feedback to clients, units, practitioners and media in maintaining uptake. 8) To understand the reportingstructure and the composition of various roles within the multidisciplinary medical and surgical teams. 9) To understand therequirements for ongoing training and education of all staff - physicians, technologists, nurses, physicists, administrative staff. 10)To understand the factors affecting radiation dose to the screened population and the over-riding responsibility of the ALARAprinciple, such as: role of physics team, mammographic technique, equipment choice, technologist expertise and training, qualityassessment. 11) To understand the operational issues of different screening units, double reading, discrepancy cases, dealing withinterval cancers, dealing with outliers in key performance parameters. 12) To understand the positive spinoff s from the programincluding increased awareness, improving national standards in the screening and the symptomatic population and the contributionto improved diagnostic and treatment options. 13) To understand how the program achieved, maintained, and monitoredperformance and how it adapted to changes in practice as issues or controversies arose. 14) To discuss whether this populationscreening program has been a successful and cost effective health care initiative for Ireland. 15) Ultimately, to understand whetherthe Irish National Breast Screening Program has led to improved survival in women with breast cancer in Ireland.

ParticipantsNicholas J. Ferris, MBBS, Clayton, Australia, ([email protected]) (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) To learn about the local availability and funding of MRI in investigating pelvic malignancy that is unique to Australia.2) Tounderstand the current usage of Pelvic MRI in investigating pelvic malignancy in the Australian population.3) To review some typicalexamples of Pelvic MRI in Oncology that illustrate the advantages of MRI in the assessment of pelvic malignancies and impact MRIhas on patient management in the multidisciplinary setting.

ABSTRACT

Most medical imaging tests in Australia are heavily subsidized by the Federal government as part of the 'Medicare' national health

RC818D Imaging of HCC-A Korean Perspective

insurance system.Prostate cancer is a common problem in Australian men, and MRI appears to be a very useful tool in itsassessment and management, however it remains unfunded in the Medicare system. To remedy this, a group of clinicians has madeapplication to the Medicare Services Advisory Committee (MSAC) for inclusion of the test on the Medicare Benefits Schedule. Stepsin the recently revised MSAC procedure will be reviewed, with reference to the current application for prostate MRI.The impact ofits current unfunded status on the uptake of prostate MRI will be briefly reviewed.Despite the lack of government support, therehas been considerable experience with the technique 'Down Under', leading to some important publications in the internationalliterature about the role of MRI in selection of patients for biopsy, and the choice of biopsy target.

ParticipantsByung Ihn Choi, MD, PhD, Seoul, Korea, Republic Of (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) To learn recent imaging techniques for the qualitative and quantitative diagnosis, selection of treatment methods, andevaluation of monitoring after treatment for HCC. 2) To understand the imaging findings of hepatocarcinogenesis from regeneratenodule going through low and high grade dysplastic nodule, early HCC and finally to advanced HCC. 3) To review current clinicalpractice guidelines including role of imaging for the diagnosis and treatment for HCC with focus on recent change of guidelines byrapid progression of imaging biomarkers.

ABSTRACT

RC829A Imaging Perianal Fistulae

RC829B Pelvic Endometriosis

RC829C Cholangiocarcinoma Diagnosis and Staging: What the Surgeon Needs to Know

RC829

Body MRI: Clinical Challenges (An Interactive Session)

Friday, Dec. 4 8:30AM - 10:00AM Location: E450A

GI GU MR OI


Participants

Sub-Events

ParticipantsDamian J. Tolan, MBBCh, FRCR, Leeds, United Kingdom, ([email protected]) (Presenter) Speaker, Bracco Group; Speaker, Merck& Co, Inc

LEARNING OBJECTIVES

1) To understand how to describe the different types of fistula. 2) To learn how to perform, interpret and report MRI for the initialassessment of fistula in ano. 3) To learn the implications of MR findings in planning surgical treatment.

ParticipantsEvan S. Siegelman, MD, Philadelphia, PA (Presenter) Consultant, BioClinica, Inc; Consultant, ICON plc; Consultant, ACR ImageMetrix

LEARNING OBJECTIVES

1) Review the theories concerning the pathogenesis of endometriosis. 2) Discuss the clincial indications that may indicate the useof pelvis imaging to diagnose endometriosis. 3) Assess the current MR techniques used in the detection and characterization ofendometriosis. 4) Describe the imaging features of endometriomas and deeply infiltrative endometriosis.

ABSTRACT

Endometriosis is defined as the presence of ectopic endometrial glands and stroma outside the uterus. Endometriosis is a commoncause of pelvic pain and infertility, affecting as many as 10% of premenopausal women. Radiologists should be familiar with thevarious imaging manifestations of endometriosis, especially those that allow its differentiation from other pelvic lesions. The MR'pearls' offered here apply to the detection and characterization of pelvic endometriosis. The inclusion of T1-weighted fat-suppressed sequences is recommended for all MR examinations of the female pelvis because such sequences facilitate the detectionof small endometriomas and aid in their differentiation from mature cystic teratomas. Benign endometriomas can exhibit restricteddiffusion and should not be confused with ovarian cancer. Although women with endometriosis are at risk for developing clear celland endometrioid epithelial ovarian cancers (ie, endometriosis-associated ovarian cancers), imaging findings such as enhancingmural nodules should be confirmed before a diagnosis of ovarian malignancy is suggested. The presence of a dilated fallopian tube,especially one containing hemorrhagic content, is often associated with pelvic endometriosis. Deep (solid infiltrating) endometriosiscan involve the pelvic ligaments, anterior rectosigmoid colon, bladder, uterus, and cul-de-sac, as well as surgical scars; the lesionsoften have poorly defined margins and T2 signal hypointensity as a result of fibrosis. The presence of subcentimeter foci with T2hyperintensity representing ectopic endometrial glands within these infiltrating fibrotic masses may help establish the diagnosis.

Honored Educators


Evan S. Siegelman, MD - 2013 Honored Educator

ParticipantsEduard E. De Lange, MD, Charlottesville, VA, ([email protected]) (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) To learn about staging cholangiocarcinoma. 2) To understand how the tumor is classified surgically. 3) To get insight into thevarious surgical procedures for tumor resection. 4) To understand the importance of vascular involvement for determining tumorresectability.

ABSTRACT

Active Handout:Eduard E. De Lange

http://abstract.rsna.org/uploads/2015/15002799/RC829C.pdf

Handout:Eduard E. De Lange

http://abstract.rsna.org/uploads/2015/15002799/Course RC829C- de Lange EE - Cholangiocarcinoma - What the surgeon needs to

know.xps

RC851A How to Perform DWI - Principles and Protocol

RC851B Interpretation of DWI - How to Create and Use ADC Maps in Your Practice

RC851C Applications of DWI in Clinical Practice - When It Does and Doesn't Help

RC851

Imaging in Practice: DWI in the Abdomen and Pelvis

Friday, Dec. 4 8:30AM - 10:00AM Location: S406A

GI GU MR


Participants

Sub-Events

ParticipantsShreyas S. Vasanawala, MD, PhD, Palo Alto, CA (Presenter) Research collaboration, General Electric Company; Consultant, Arterys;Research Grant, Bayer AG;

LEARNING OBJECTIVES

1) Understand basic principles of contrast formation in diffusion weighted MRI. 2) Understand sources of artifacts in diffusionweighted MRI. 3) Know techniques to reduce artifacts to produce diagnostic quality diffusion weighted images.

ABSTRACT

Diffusion-weighted imaging is being used with increasing frequency in body MRI. The basic mechanism of contrast generation is theuse of large motion-sensitizing gradients such that water molecules undergoing random motion are dephased, resulting in signalloss. Tissues and lesions with high cellularity have reduced diffusive motion of water, which results in relatively high signal.However, a number of issues make diffusion-weighted imaging in the body challenging relative to neurological applications. First, thevast majority of clinical DWI is performed with an echo-planar technique, which suffers from image distortions due to fieldinhomogeneity. These become problematic particularly where there are gas-tissue interfaces, such as at the dome of the liver andnear gas-filled bowel. The presentation will discuss methods to minimize these distortions. Second, the T2 relaxation rates ofabdominal tissues are less than that of pelvic viscera and much less than that of the brain, whereas normal water diffusivity ishigher; as the choice of diffusion sensitivity (b value) heavily influences the echo time, lower b values must be used. Third, motionfrom cardiac pulsations, respiration, and peristalsis produce artifacts, some of which are easily recognizable, and others which cansubtly hide pathology. Techniques to minimize these pitfalls will be presented. Finally, issues of reproducibility that affect thepractical clinical use of DWI for lesion characterization in body MRI will be discussed, along with approaches to improve reliability.

ParticipantsThomas A. Hope, MD, San Francisco, CA, ([email protected]) (Presenter) Advisory Committee, Guerbet SA; Research Grant,General Electric Company

LEARNING OBJECTIVES

1) Understand the principles of calculating ADC. 2) Understand the effect of b-value selection and weighting on diffusioncalculations. 3) Explore the value of IVIM and other parameters.

ABSTRACT

In order to incorporate diffusion weighted imaging into clinical practices, it is important to understand how diffusion data isevaluated. Qualitatively, one can simply say that lesions are "bright" on diffusion, but intensity on high b-value imaging is notalways equal to a lesion that has reduced diffusion. The understanding and implementation of quantitative analysis is thereforecritical for both research and everyday clinical practice. The first step is the calculation of the apparent diffusion coefficient (ADC)map, which is used to help tease out the differences in intrinsic T2 hyperintensity and diffusivity. The calculation of the ADC map isgreatly affected by the methodology used as well as the selection of b-values acquired. The ADC of a tissue describes how quicklysignal decreases as the b-value is increased. Those lesions with high diffusivity will have high ADC values, while those lesions withreduced diffusion will have lower ADC values. In addition to ADC, other parameters have been describe that affect the measureddiffusivity. The most commonly discussed is intravoxel incoherent motion (IVIM) that is thought to represent the random movementof blood within the capillary system, often called pseudodiffusion. This parameter has its greatest effect on diffusion weightedimages at low b-values.

URL

ParticipantsFrank H. Miller, MD, Chicago, IL (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) Demonstrate the utility of diffusion weighted imaging in the abdomen. 2) Show advantages and limitations of diffusion weightedimaging in the abdomen.

ABSTRACT

Diffusion weighted imaging (DWI) has been used in neuroimaging for many years. It has only more recently become feasible in theabdomen. The objective of this talk is to emphasize the important role that diffusion-weighted imaging can have in your practice

and that it can be used routinely without difficulty in the abdomen and pelvis. DWI potentially can detect additional lesions anddirect the radiologist to lesions that are not as well seen on conventional imaging. DWI helps in characterization of lesions but doeshave limitations in specificity which will be discussed. Qualitative and quantitative evaluation can be performed and the applicationsof these techniques clinically will be described. The strengths and limitations of DWI in multiple organs including the liver, pancreas,adrenal gland, kidney, and evaluation for metastases and infections will be discussed. DWI is especially helpful for identify lymphnode and peritoneal metastases. Emerging techniques include the use of diffusion weighted imaging to assess response to therapyfollowing liver-directed therapy will also be discussed. In summary, DWI should be used routinely if not being used at yourinstitution. This talk will show benefits and limitations of DWI in a number of organs in the body.

Honored Educators


Frank H. Miller, MD - 2012 Honored EducatorFrank H. Miller, MD - 2014 Honored Educator

SST07-01 Quantitative Assessment of Voxel-wise Apparent Diffusion Coefficient using K-means Clustering toPredict and Assess Chemotherapeutic Response in Bladder Cancer


SST07-02 MDCT Urography Using a 320-detector Row Scanner: Comparison of the Wide Volume (W-V) ScanMode and Conventional Helical Scan Mode in Terms of Radiation Dose and Image Quality


SST07

Genitourinary (MR and CT of the Urothelium)

Friday, Dec. 4 10:30AM - 12:00PM Location: E351

GU CT MR



ParticipantsDavid D. Childs, MD, Clemmons, NC (Moderator) Research Grant, Endocare, IncPaul Nikolaidis, MD, Chicago, IL (Moderator) Nothing to Disclose

Sub-Events

ParticipantsHuyen T. Nguyen, PhD, Columbus, OH (Abstract Co-Author) Nothing to DiscloseAmir Mortazavi, MD, Columbus, OH (Abstract Co-Author) Nothing to DiscloseKamal S. Pohar, MD, Columbus, OH (Abstract Co-Author) Nothing to DiscloseZarine K. Shah, MD, Columbus, OH (Abstract Co-Author) Nothing to DiscloseGuang Jia, PhD, Baton Rouge, LA (Abstract Co-Author) Nothing to DiscloseMichael V. Knopp, MD, PhD, Columbus, OH (Abstract Co-Author) Nothing to DiscloseDebra Zynger, MD, Columbus, OH (Abstract Co-Author) Nothing to DiscloseHendrik Von Tengg-Kobligk, MD, Bern, Switzerland (Presenter) Research Grant, W. L. Gore & Associates, Inc

PURPOSE

To evaluate the value of k-means clustering of voxel-wise Apparent Diffusion Coefficient (ADC) in the assessment ofchemotherapeutic response in bladder cancer.


10 bladder cancer patients who received neoadjuvant chemotherapy were included in this initial study. Patients were scanned on a3T multi-transmit system (Achieva, Philips Healthcare) using a 32-channel phased-array surface coil. Each patient had a baseline(before chemotherapy) MRI and a post-chemotherapy MRI, followed by radical cystectomy. High resolution T2W imaging wasperformed prior to DWI. DWI data were processed on in-house software written in IDL (Exelis, VIS) to acquire voxel-wise ADC foreach tumor. The k-means clustering was implemented to segment each tumor in three clusters (labeled as clusters 1, 2, 3 with low,intermediate, high ADC). The volume fractions (VFs) of three clusters in a tumor at baseline and post-chemotherapy werecorrelated with the tumor response. P<0.05 was considered to be statistically significant. Color cluster maps were overlaid on ADCmaps to visualize the cluster distribution.

RESULTS

Using pathological findings and radiologic volume estimation of bladder tumors, 6 patients were defined as responders and 4 as non-responders. At baseline, responders showed a significantly higher VF of cluster 1 and lower VF of cluster 2 (all P<0.04) than non-responders (Figure 1). In contrast with resistant cases, responsive tumors showed a decrease in VF of cluster 1 and an increase inthat of cluster 3 after chemotherapy. These differences in the post-chemotherapy changes of cluster VFs were found to bestatistically significant (all P<0.04) between responders and non-responders.

CONCLUSION

As ADC characterizes the micro-cellularity in body tissues, the heterogeneity of tumor micro-cellularity can be quantified using k-means clustering of voxel-wise ADC to enable the early assessment and predication of chemotherapeutic response in bladdercancer.


k-means clustering of voxel-wise ADC can be useful in predicting chemotherapeutic response at baseline and assessingchemotherapy-induced changes of micro-cellularity in bladder cancer.

ParticipantsCatherine Roy, MD, Strasbourg, France (Presenter) Nothing to DiscloseRaphael Quin, Strasbourg, France (Abstract Co-Author) Nothing to DiscloseMickael Ohana, MD, MSc, Strasbourg, France (Abstract Co-Author) Nothing to DiscloseGuillaume Alemann, MD, MS, Strasbourg, France (Abstract Co-Author) Nothing to DiscloseAissam Labani, MD, Strasbourg, France (Abstract Co-Author) Nothing to DisclosePierre G. Leyendecker, MD, Strasbourg, France (Abstract Co-Author) Nothing to Disclose

PURPOSE

To prospectively compare the conventional helical scan mode and W-V scan mode in CT Urography examinations using a 320-

SST07-03 Comparison between Conventional Cystourethrography and MRI with Voiding MR-cystourethrography in the Evaluation of Male Urethral Strictures


SST07-04 Efficiency of Diffusion-weighted (DW) MRI to Evaluate the Excreto Urinary Wall Lesions: AProspective Study of 95 Patients

detector row scanner in terms of image quality, radiation dose and accuracy of the automatic stitching for alignment of ureteralsegments in the W-V scan mode.


A cohort of 70 patients underwent a multiphasic CT Urography examination using a 320-detector CT scanner (Aquilion ONE, ToshibaMedical Systems) including a medullary phase using the helical scan mode(collimation:80x0.5mm, rotation:0.5s,1mm/0.8mm,acquisition time:4-6s) and an excretory phase using the W-V scan mode (collimation:200x0.5mm, rotation:0.5s,1mm withoutoverlapping and 4 to 5 volumes to cover the entire urinary tract, acquisition time:6-7s). Adaptative blending was used to stitch thewide volumes. Both scans modes were performed at 120kVp with the same FOV, length of coverage and iterative reconstruction(AIDR 3D). The Body Mass Index (BMI) of each patient and the dose-length product (DLP) was also recorded.For the quantitativeanalysis, the signal to noise ratio (SNR) was calculated in the iliopsoas muscle. For qualitative analysis, two independentexperienced readers were asked to subjectively assess the presence of motion artefacts as well as the quality of the volumesmatching by analysis the continuity of the ureter on the excretory phase, using a four-point scale.

RESULTS

The mean DLP was significantly lower for the W-V acquisition than for the helical acquisition (136.8+/-28mGy·cm vs 232.8+/-41mGy·cm,respectively) equal to 42.53% (p<0.05), regardless of the patient's BMI. The SNR was quite similar with W-V and helicalscan mode (15.3+/-1.9 vs 17.3+/-2.5, respectively). No significant difference was noted for the presence of motion artifactsbetween both modes.In 85% of cases, there was no disruption of the continuity of the ureter with the W-V scan mode afterstitching of the volumes. In 12% of cases, there was minimal discontinuity of one segment and in 3% of cases there was aninadequate matching of the volumes.

CONCLUSION

Wide Volume scanning using a 320-MDCT allows a significant radiation dose reduction (42%) while preserving image quality incomparison to helical scanning. The lack of overranging with minimal overbeaming explain those results.


Wide volume scanning allows a significant reduction of radiation dose with a perfect continuity of the ureter and an excellent imagequality .

ParticipantsMarco Di Girolamo, MD, Rome, Italy (Presenter) Nothing to DiscloseInes Casazza, Rome, Italy (Abstract Co-Author) Nothing to DiscloseSimone Mariani, Rome, Italy (Abstract Co-Author) Nothing to DiscloseFrancesco Carbonetti, MD, Rome-Roma, Italy (Abstract Co-Author) Nothing to DiscloseGiulia Francione, Rome, Italy (Abstract Co-Author) Nothing to DiscloseVincenzo David, MD, Rome, Italy (Abstract Co-Author) Nothing to Disclose

PURPOSE

To evaluate the accuracy of conventional retrograde and voiding cystourethrography and MRI together with voiding MR-cystourethrography in the evaluation of male urethral strictures.


We evaluated 39 male patients with urethral strictures diagnosed with urine flow velocity recording and conventional retrograde andvoiding cystourethrography. All these patients underwent MRI and voiding MR-cystourethrography using a 1.5T superconductivemagnet. The patients had urine-filled bladders and high-resolution sagittal TSE T2-weighted scans were performed (TR:6250ms;TE:90ms;sl.thick.:3mm; acq.time:3'38"). Voiding MR-cystourethrography was performed with T1-weighted spoiled 3D gradient-echoacquisitions on sagittal plane (TR:12ms; TE:2,7ms; flip-angle:40°; sl.thickness: 2mm; acq.time:12s) after the filling of bladderlumen with contrast-material-enhanced urine obtainded by the i.v administration 20 mg of furosemide followed by ¾ of the normaldose of a paramagnetic contrast agent (Magnevist, Bayer Pharma, Germany). After micturition high-resolution coronal TSE T2-weighted scans were performed at the level of the stenosis. Two radiologists in consensus evaluated the morphology and length ofthe urethral stenosis with the two modalities and with MRI the entity and the site of spongio-fibrosis was assessed.

RESULTS

3 patients were not able to perform voiding MR-cystourethrography. In 36 patients evaluated with two imaging modalities 32 singleand 4 double urethral strictures were detected. The measurement of the stenosis length was equal or superior with voiding MRcystourethrography and the analysis of 3D sagittal scans allowed a better evaluation of the morphology of the urethral strictures incomparison with conventional cystourethrography. Spongio-fibrosis was found in 30 patients (83%). The site of spongio-fibrosiswas always assessed with MRI (dorsal, ventral, dorsal and ventral and circular fibrosis).

CONCLUSION

MRI with voiding MR-cystourethrography shows the morphology and the length of the urethral strictures better than conventionalcystourethrography and allows the detection and site of spongio-fibrosis, avoiding radiation exposure to the gonads and urinarycatheterization.


MRI could be proposed as all-in-one technique for the evaluation of urethral stenosis, allowing their detection and lengthassessment and determining the presence and site of spongiofibrosis.


SST07-05 ADC as a Novel Biomarker to Predict the Local Stage and Tumor Grade of Bladder Cancer


ParticipantsCatherine Roy, MD, Strasbourg, France (Presenter) Nothing to DiscloseAissam Labani, MD, Strasbourg, France (Abstract Co-Author) Nothing to DiscloseMickael Ohana, MD, MSc, Strasbourg, France (Abstract Co-Author) Nothing to DiscloseGuillaume Alemann, MD, MS, Strasbourg, France (Abstract Co-Author) Nothing to DiscloseGuillaume Bierry, MD, PhD, Strasbourg, France (Abstract Co-Author) Nothing to DiscloseHerve Lang SR, MD, Strasbourg, France (Abstract Co-Author) Nothing to Disclose

PURPOSE

The purpose was to investigate the reliability of DW-MRI in differentiating malignant from benign thickening or masses of the entireurinary excretory wall.


We prospectively evaluated 95 patients referred for 52 upper urinary tract (UUT) and 43 bladder (Bl) lesions during a period of 5years (from january 2010 to january 2015) . MR examinations were performed on a 3T unit (Achieva, Philips Medical System)including to our conventional protocol using T2 and T1 sequence before and after contrast media injection an axial DWI (TR/TE :7000/55, FOV : 250-300, ETL : 53, slice thickness : 4 mm, acquisition time : 4 min, Sense factor : 2, b =0 and 1000 mm2/sec)under free breathing with a respiratoy compensatory device (navigator echo) for UUT. The final diagnosis and standard of referencewas the pathological analysis performed after MR examination, obtained either after surgery (74 cases) or by selective cytology andendoscopic biopsy (21 cases) with a follow up imaging (at least one year) for 11 of them. Mann-Whitney test and Student -t testwere used to determine the efficiency of the mean ADC value.

RESULTS

Maximal axial diameter was 34±24mm for malignant (39 UUT; 33 Bl) and 15±5mm for benign lesions (13 UUT; 10 Bl), respectively.For UUT, the mean ADC value in the malignant lesions was significantly lower than that in the benign lesions: 0.99+0.27 x10-3mm2/s against 1.54+0.43 x10-3mm2/s, respectively (p=0.0005). Thirty-three malignant lesions had an ADC value inferior to 1 x10-3mm2/s and only one benign lesion. There was a significant difference among the mean ADC values of different grades of malignanttumors, corresponding to 0.84 ± 0.12 x10-3mm2/s-1 and 1.0 ± 0.20 x10-3mm2s-1 (p<0.01) in high-grade and low-grade excretoryepithelioma, respectively For bladder, the mean ADC value in the malignant lesions was not significantly inferior to that of benignlesions (1.22 ± 0.3 x10-3mm2/s against 1.32± 0.2x10-3mm2/s, p=0.41)

CONCLUSION

DW-MRI is efficient in the differentiation between benign from malignant lesion located on the upper urinary tract. It does not seemaccording those data reliable for bladder tumors. DW sequence must be included in MR protocols for exploration of upper urinarytract.


DW must be included in MR protocols for exploration of upper urinary tract. DW-MRI is efficient in the differentiation between benignfrom malignant lesion only in the upper urinary tract.

ParticipantsChandan J. Das, MD, MBBS, New Delhi, India (Presenter) Nothing to DiscloseT. Razik, New Delhi, India (Abstract Co-Author) Nothing to DiscloseSanjay Sharma, MD, FRCR, New Delhi, India (Abstract Co-Author) Nothing to DiscloseDeepnarayan Srivastava, Delhi, India (Abstract Co-Author) Nothing to DiscloseAmlesh Seth, MBBS, MCHIR, New Delhi, India (Abstract Co-Author) Nothing to DiscloseArun K. Gupta, MBBS, MD, New Delhi, India (Abstract Co-Author) Nothing to Disclose

PURPOSE

To evaluate the role of ADC as a novel biomarker to predict the local stage and tumor grade of bladder cancer using histopathology(of post TURBT/cystectomy specimen) as the gold standard.


The study was approved by the local institutional ethics committee. MRI of 25 patients were performed in a 3 Tesla imaging system(Achieva, Philips). Routine T1W and T2W images were obtained, followed by Diffusion Weighted Imaging in four b values (b0, 500,1000, and 1500). All the patients had their surgery done within 1 month of performing MRI. Tumour staging was assessed with thecriteria used byTakeuchi et al,( 2009). For the tumour grade, freehand ROI values were obtained from the ADC map and their meancalculated. Images were reviewed by two experienced radiologists in consensus, both blinded to the histopathology report.Subsequently, the sensitivity, specificity, positive and negative predictive values were assessed using standard statistical tests.Results were compared with the histopathology.

RESULTS

DWI had a sensitivity of 76.9% in detecting muscle invasion with a high specificity of 91.7%. The positive and negative predictivevalues were 90.9 and 78.6% respectively. The ADC values were (0.786 + 0.045) x 10-3 for high grade lesions and (1.049 + 0.113) x10-3 for low grade lesions, with a significant difference between the two (p< 0.05). We could not found any additive value of T2weighted imaging when combined with DWI. DWI images acquired in coronal and sagiital plane were better for evaluation of bladderdome lesion whereas axial plane DWI were best for rest of the lesions.

CONCLUSION

DWI showed a high specificity and positive predictive value in identifying muscle invasion. ADC values showed significant correlationwith the tumor grade and can be used as novel imaging biomarker for predicting redict the local stage and tumor grade of bladder

SST07-06 Detection of Urothelial Carcinomas: Comparison of Reduced-dose Based Iterative Reconstructionwith Standard-Dose Filtered Back Projection


SST07-07 Recurrence Patterns in Transitional Cell Carcinoma of the Upper Urinary Tract


cancer..


ADC can be used as a noninvasive tool to evaluate bladder tumor and may avoid repeated cystoscopy or biopsy during follow up oflow grade lesions following TURBT. DWI at 3T is superior to T2WI for evaluating the T stage of bladder cancer, particularly indifferentiating T1 tumors from those T2 or higher, and in detecting stalks of papillary bladder tumors.

ParticipantsSee Hyung Kim, Daegu, Korea, Republic Of (Abstract Co-Author) Nothing to DiscloseJung Hee Hong, Daegu, Korea, Republic Of (Presenter) Nothing to Disclose

PURPOSE

To retrospectively assess radiation dose, image quality and diagnostic performance of CT urography detecting urothelial carcinomasfor performing reduced-dose with iterative reconstruction (IR) in comparison to standard-dose with filtered back projection (FBP).


Institutional review board approved this study. 2163 patients (age range, 28-81years; 1452 male) at high-risk for urothelialcarcinomas randomly underwent standard-dose scanning with FBP (120kVp for >80kg, 100kVp for 50-80kg) or reduced-dosescanning with IR (100kVp for >80kg, 80kVp for 50-80kg) according to the body weight. Objective and subjective image qualitybetween the two groups with same weight scope was compared, using two-way analysis. The predictive accuracy detectingurothelial carcinomas were also calculated by using as standard reference.

RESULTS

Mean effective dose was 26% (15.5mSv vs. 11.1mSv) and 30% (7.91mSv vs. 5.01mSv) lower with the reduced-dose scanning.Objective image noise had no significant difference, except for 120kVp with FBP and 80kVp with IR (ranging from 7.2 to 7.9 vs. 9.4to 9.9, P <.0102). SNR and CNR had no significant difference. Subjective image quality had no significant difference in visual imagenoise, artifacts, ureter depiction and overall image quality, except for artifacts in 100kVp with FBP and 80kVp with IR (5 [4-5] vs. 4[3-4]) (P >.05). Diagnostic accuracies on lesion level were 89.6% (89/98, 120kVp with FBP), 91.3% (105/115, 100kVp with FBP),92.9% (79/85, 100kVp with IR) and 88.8% (111/125, 80kVp with IR), respectively.

CONCLUSION

Reduced-dose images with IR showed radiation dose reduction and equivalent image quality with ensuring diagnosis detectingurothelial carcinomas as compared with standard-dose images with FBP, thus these robust capabilities may use in clinical practice.


Reduced-dose images with IR could be of help to reduce radiation dose with equivalent image quality for detecting urothelialcarcinomas as compared with standard-dose images with FBP.

ParticipantsBetsa Parsa, Boston, MA (Presenter) Nothing to DiscloseVishala Mishra, MBBS, Boston, MA (Abstract Co-Author) Nothing to DiscloseSandeep S. Hedgire, MD, Boston, MA (Abstract Co-Author) Nothing to DiscloseYun Mao, MD, Chongqing, China (Abstract Co-Author) Nothing to DiscloseDuangkamon Prapruttam, MD, Boston, MA (Abstract Co-Author) Nothing to DiscloseMukesh G. Harisinghani, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose

PURPOSE

This study included patients diagnosed with UT-TCC who underwent nephroureterectomy between 2003-2008. Tumor location,morphology, TNM staging and histologic grade were recorded based on radiological examinations . The pattern and timing ofrecurrence was evaluated at 3, 6, 12, 24, 36 and 60 months in a five-year imaging and clinical follow up period (2008-2013).


This included patients diagnosed with UT-TCC who underwent nephroureterectomy between 2003-2008. Tumor location,morphology, TNM staging and histologic grade were recorded based on radiological examinations and clinical notes. The pattern andtiming of recurrence was evaluated at 3, 6, 12, 24, 36 and 60 months in a five year follow up period (2008-2013).

RESULTS

68 patients with an average age of 77.5 yrs were included in this study. At initial work-up, renal, ureteric and renal plus uretericlesions were present in 34, 25 and 9 patients respectively. Of 59 patients for whom tumor morphology was available, 34 had mass-forming lesions and 25 were seen as filling defects. The majority of patients had a T-stage of Ta (n=28) or T3 (n=23), while nodalinvolvement was mostly absent. Tumors were grade 3 in 44.1% and grade 2 in 33.8%.Most recurrences were noted at 3 and 24months. Patients with bilateral tumors had a higher recurrence rate at 3, 12, and 24-month follow-ups while for unilateral tumorsthe chance was higher at 36-month follow-up. Recurrence rate was also higher in patients with T2, N1 and pathologic grade 3 andin patients with T2, N1 and N2 at 3- and 12-month follow-ups, respectively. Pathological grade 1 tumors showed late recurrence at5-yr follow up. Overall, recurrence occurred in 20 cases during the 5-yr follow-up, which was commonly located in lymph nodes,bladder. Multivariate analysis showed T-stage and location of primary tumor were independent predictors of tumor-free survival(p=0.021, 0.038 respectively). Average tumor-free survival time was 56.5 months.

CONCLUSION

SST07-08 The Incremental Value of Diffusion-Weighted MR Images in the Tumor Detection and the Staging ofPreoperative T Categorization in Renal Pelvic Carcinoma: Effect of Reader Experience


SST07-09 Organ Confined Urinary Bladder Carcinoma: A Comparative Analysis for "Submucosa LinearEnhancement" Sign on Early Phase of DCE-MRI and the "Inchworm" Sign on DWI

Friday, Dec. 4 11:50AM - 12:00PM Location: E351

Nodal, bladder, hepatic and bone metastasis are common in UT-TCC with most of them occurring at 3 and 24 months. T-stage andlocation are independent predictors of tumor-free survival. Tumors confined to either kidney or ureter, lower T, N stage andhistologic grade were associated with longer survivals.


Information on the pattern of recurrence in UT-TCC patients can lead to more effective planning of imaging surveillance strategy.

ParticipantsRika Yoshida, MD, Izumo, Japan (Presenter) Nothing to DiscloseTakeshi Yoshizako, MD, Izumo, Japan (Abstract Co-Author) Nothing to DiscloseHiroshi Mori, Izumo, Japan (Abstract Co-Author) Nothing to DiscloseMinako Maruyama, Izumo, Japan (Abstract Co-Author) Nothing to DiscloseTakashi Katsube, Izumo City, Japan (Abstract Co-Author) Nothing to DiscloseShinji Andou, MD, Izumo, Japan (Abstract Co-Author) Nothing to DiscloseTomonori Nakamura, Izumo, Japan (Abstract Co-Author) Nothing to DiscloseNobuko Yamamoto, MD, Izumo, Japan (Abstract Co-Author) Nothing to DiscloseMegumi Nakamura, Izumo, Japan (Abstract Co-Author) Nothing to DiscloseHajime Kitagaki, MD, Izumo, Japan (Abstract Co-Author) Nothing to Disclose

PURPOSE

The purpose of this study is to retrospectively assess the incremental value of diffusion-weighted MRI (DWI) to T2-weighted image(T2WI) in the tumor detection and the staging of preoperative T categorization in renal pelvic carcinoma by readers of differentexperience levels.


Thirty-two urothelial carcinoma in 32 patients underwent preoperative MRI examination, including T2WI and DWI (b=0, 800 s/mm)and contrast-enhanced imaging (CEI). All patients had total nephrectomy within 1 month of MRI. Two radiologists (reader 1 had 5years and reader 2 had 18 years of experience) independently reviewed three image sets (T2WI alone, T2WI plus DWI, and T2WIplus CEI) regarding tumor detection and the discrimination of locally advanced tumors.

RESULTS

The pathologic T category was T1 in 5 (15.6%), T2 in 6 (18.8%), T3a in 9 (28.1%), T3b in 11 (34.4%), and T4 in 1 (3.1%).T2WIplus DWI enabled a high detection rate (97%, 31/32) without significant differences.In reader 1, for the diagnosis of T3 or highercategories, the accuracies were relatively low in all three image sets (75.0% each for T2WI alone and T2WI plus CEI and 71.9% forT2WI plus DWI). For discriminating tumors with macroscopic renal invasion from those with microscopic renal invasion or less, T2WIplus DWI (90.6%) was significantly more accurate than T2WI alone (68.8%) (p < 0.05), with with areas under receiver operatingcharacteristic curves (AUC) of 0.82 and 0.73, respectively.In reader 2, for the diagnosis of T3 or higher categories, the accuracieswere relatively low in all three image sets (each sets were 71.9%). For discriminating tumors with macroscopic renal invasion fromthose with microscopic renal invasion or less, the accuracies were relatively high in all three image sets (84.3% for T2WI alone,94.8% for T2WI plus CEI and 90.6% for T2WI plus DWI), with AUC of 0.88, 0.95, and 0.93, respectively.For the diagnosis of Tcategorization, T2WI added DWI improved interobserver agreement from fair (κ = 0.21, 0.32) to substantial (κ = 0.60, 0.73).

CONCLUSION

DWI improved the tumor detection rate and the diagnostic performance for T categorization of renal pelvic cancer without contrastmaterial, especially for the relatively inexperienced reader.


DWI improved the tumor detection rate and the diagnostic performance for T categorization of renal pelvic cancer without contrastmaterial.

ParticipantsHuanjun Wang, MD, GuangZhou, China (Presenter) Nothing to DiscloseJian Guan, MD, Guangzhou, China (Abstract Co-Author) Nothing to DiscloseYan Guo, MD, Guangzhou, China (Abstract Co-Author) Nothing to Disclose

PURPOSE

To investigate the pathogenetic mechanism of "submucosa linear enhancement" and to further evaluate its application value inpreoperative staging of organ confined bladder carcinoma.


The examination protocol was approved by the institutional medical ethics committee and informed consent was obtained from allpatients. 59 patients with suspected or confirmed urothelial bladder cancer and no renal function impairment were enrolled in thestudy. All patients underwent MRI within 2-weeks before surgery. Two image sets of T2WIandDW-MRI and T2WIandDCE-MRI wereindependently interpreted by two readers at 2-week intervals by analyzing whether there were "inchworm" sign on DWI and"submucosa linear enhancement" sign on early phase of DCE-MRI, which were further comparatively analyzed with pathology. Tumorsize was also compared.

RESULTS

92 carcinomas (79 T1, 13 T2) were analyzed. 58 presented "submucosa linear enhancement" on early phase of DCE-MRI whichmanifested three types as follow: continuous linear enhanced submucosa gathering toward into the center of tumor (39),continuous straight and no gathering linear enhanced submucosa(14) and interrupted linear enhanced submucosa(5) respectively,and the remaining 34 lesions presented no significant linear enhanced submucosa. 42 carcinomas (38 T1, 4 T2) presented"inchworm" sign on DWI, with the remaining 50 lesions (41 T1, 9 T2) shown not. Statistical significance were found for tumor sizebetween carcinomas presented "inchworm" sign and those without, which had a median of 21.5mm for the former, and 13.0mm forthe latter.

CONCLUSION

Presentation of "submucosa linear enhancement" under the tumor base on DCE-MRI is a significant imaging sign which can beapplied in preoperative staging of organ confined bladder carcinoma. Presentation of either straight or gathered continuous"enhanced submucosa line" often suggests bladder muscle wall have not been involved.


DCE-MRI and DWI can supply us an optimal imaging tool for preoperative staging of organ confined bladder carcionoma and is highlyrecommended.

Documents

A Guide to Penile Duplex Ultrasonographyarchive.rsna.org/2015/GenitourinaryRadiology.pdf · A Guide to Penile Duplex Ultrasonography All Day Location: GU/UR Community, Learning Center