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2. disease

Educational and Scientific Posters
Scientific Posters
March 11-14, 2012
Hyatt Regency Huntington Beach, Huntington Beach, CA
101
A Multimodality Imaging Approach to Differentiate Thymic Hyperplasia from Thymic Neoplasm
Shehrzad Rabbani, MD
RABBANI S, Suh R, Lee J, Gutierrez A, Brown K, Abtin F
102
Withdrawn
103
Magnetic Resonance Imaging in Nonischemic Cardiomyopathy: Making the Differential Diagnosis
Elena Scali, BA, MPhil
SCALI E, Leipsic J
104
Can Gender Predict the Appropriateness of Left Ventricular Mass in Normal Adolescents
and Young Adults?
AA Adamu, MD, PhD
ADAMU AA
105
Chest Pain Beyond Acute Coronary Syndrome: Cardiac and Non-cardiac Etiologies
David Juice, MD
JUICE D, Rubinowitz A, Oliva I
106
Unusual Devices and Hardware in the Chest - A Pictorial Review
Jubal Watts, MD
WATTS JR, Dartez D, Sonavane S, Terry N, Singh S
107
CT Features of Esophageal Malignancies - Pre and Post Treatment
Sushilkumar Sonavane, MBBS, DMRD
SONAVANE SK, Denham LW, Dartez D, Watts JR Jr, Terry N, Singh S
108
Posters
Society of Thoracic Radiology
The Pulmonary Embolism Predicament: Do Chest Radiographs Play a Part in Diagnosis?
Mollie Rashid, BA
RASHID MA, Wilcox A
109
Withdrawn
110
Multi Detector CT Evaluation of Airway Stents: What the Radiologist Should Know
David Saldana, MD
SALDANA DA, Ost D, Benveniste MK, Rao PP, Vlahos I, Marom EM, Erasmus JJ, Godoy MCB
111
The Use of Chest Radiography Following Percutaneous Tracheostomy
Julien Al Shakarchi, MBChB
SHAKARCHI JA, Janjua U, Kyi M
112
Lung Hernias of the Chest Wall
Iclal Ocak, Assistant Professor
OCAK I, Wang J, Bae KT
113
ALCAPA, A Rare but Serious Congenital Cardiac Anomaly
Neelum Mittal, MD
MITTAL N, Go BD
114
Incidence of Pulmonary Embolism in Oncologic Outpatients at a Tertiary Cancer Center
Mizuki Nishino, MD
NISHINO M, Shinagare AB, Guo M, Hatabu H, Krajewski KM, Andriole K, Van den Abbeele AD, DiPiro PJ
115
CT and MRI Features of Pseudoaneurysm of the Mitral-Aortic Intervalvular Fibrosa
Shoen CS Low, MBBS, FRCR
LOW SCS, Bach DS, Agarwal PP
25
Posters
Educational and Scientific Posters
116
Coronary Artery Conditions - More Than Just Stenosis
Adam Bernheim, MD
BERNHEIM A, Goyal N
117
Utility of Dual-Time-Point FDG PET/CT in Thoracic Disease
Nicholas Abel, MD
ABEL N, Nandalur K, Tien H
118
Multimodality Appearance of Radiation Changes to the Thorax: The Good, the Bad, and
the Ugly
Mina Zaki, MD
ZAKI M, Tien H, Nandalur K
119
Disease Progression Through Imaging: Idiopathic Pulmonary Fibrosis and Lung Cancer A Piloted Teaching Module
Jane L. Hur, BA
HUR JL, Shingala P, Hanna J, Johnson O, Vasani D, Awad S, Amorosa JK.
120
Multifaceted CT and MR Imaging for Planning, Execution and Outcome Assessment in
Pulmonary Vein Catheter Ablation for Atrial Fibrillation Treatment
Maya Galperin-Aizenberg, MD
GALPERIN-AIZENBERG M, Desjardins B
121
Case-based Review of Cryptogenic Organizing Pneumonia and Its Differential Diagnosis
Karen Naar, MD
NAAR K, Khan A
122
Unusual Intrathoracic Neoplasms: A Case-Based Review
Tami J. Bang, MD
BANG TJ, Sachs P, Suby-Long T, Restauri N
123
Errors as Opportunities: Spectrum of Cognitive Errors in Cardiothoracic Radiology
Prachi Agarwal, MD
AGARWAL PP, Quint LE
124
Diffuse Peribronchovascular Ground Glass Opacity or Consolidation: A Unique HRCT
Pattern Suggestive of Nitrofurantoin Toxicity
Steve Wilhelm, MD
WILHELM S, Teel G, Lalani T
125
Think Outside the Lungs: A Case Collection of Bone Findings on Chest Radiographs
Anusuya Mokashi, MD
MOKASHI A, Bernheim A, Goyal N
126
CT Features Distinguishing Pulmonary Arterial Neoplasms from Thromboemboli
Joseph Whetstone, MD
WHETSTONE J, Gosselin M
127
Imaging of Thoracic Manifestations of Scleroderma
Rafael Pacheco, MD
PACHECO R, Carlton M, Kaloudis E
128
Common Surgical Procedures for Congenital Heart Disease
Joseph Whetstone, MD
WHETSTONE J, Bardo DME
129
Chest HRCT Signs and Patterns: A Pictorial Essay
Ronak Talati, MD
TALATI R, Perone R, Chaudry A, Shroyer R
130
Bubbles of the Lung: Illustrative Review of Cavitary and Cystic Lesions at HighResolution CT
Ely R. Felker, MD
FELKER ER, Jude CM, Patel MK, Batra P
26
Educational and Scientific Posters
Multi-modality Imaging of Thoracic Manifestations of Sickle Cell Disease
Ashwin Nambiar, MD
NAMBIAR A, Pechersky D, Alpert J
132
Role of FDG PET/CT in Cardiovascular Masses
Amit Gupta, MD
GUPTA A, Shrikanthan S, Renapurkar R, Mohammed TL
133
Imaging Findings of Prosthetic Cardiac Valves: Normal Appearance, Complications, and
Associated Findings
Joseph T. Azok, MD
AZOK JT, Bhalla S, Gutierrez FR, Javidan-Nejad C, Woodard PK, Bierhals AJ
134
Anomalous Origin of the Right Coronary Artery with an Interarterial Course: 4 year
Experience at a Tertiary Care Center
Joseph T. Azok, MD
AZOK JT, Cummings KW, Raptis CA, Gutierrez FR, Javidan-Nejad C, Bierhals AJ, Woodard PK, Bhalla S
135
Cardiac Calcifications: Beyond the Coronaries
Vineeta Sethi, MBBS, MD
SETHI V, Dennie C, Penna E, Peterson R
136
Esophageal Cancer Staging Essentials: The New TNM Staging System (7th edition) and
Clinicoradiologic Implications
Tae Jung Kim, MD, PhD
KIM TJ, Hong SJ, Lee KW
137
Diastolic Function as Assessed by Cardiac MRI Using Longitudinal Left Ventricular
Fractional Shortening
Gurmohan Dhillon, B.Sc, B.Sc PT, MD
DHILLON GS, Thadani SR, Hope MD
138
Posters
131
Implantable Cardiac Conduction Devices on the Chest Radiograph - What Every Resident
Needs to Know
Anoma Lalani Dias, MA, MBBS
DIAS ALC, Hameed S, Hare SS, Ariff B, Mittal T, Kaneria S
139
CT Guided Percutaneous Core Needle Biopsy of Small Versus Larger Lung Nodules:
Diagnostic Accuracy and Complication Rates
L. John Fahrner, MD
FAHRNER LJ, Cockrell CH, Parker M, Yu J, Singh NS, Bajaj HS, Thacker LR
140
BAC is Dead! Acclimatization to the New Terminologies and the Radiological
Recommendations
Anand Gaikwad, MBBS, DMRD, DMRE, DNB
GAIKWAD A, Gupta A, Hare S, Gomes M, Sekhon H, Souza C, Lad S, Inacio J, Seely J
141
More Than Just a Veil of Ground-Glass: PneumoCystis Pneumonia (PCP) Unravelled
Shema Hameed, MBBS, BSc (Hons), MRCS, FRCR
HAMEED S, Abdullah S, Goncalves A, Gupta A, Hare S
142
The Fleischner Society’s Recommendations for the Follow Up of CT Detected Pulmonary
Nodules: A Program to Optimize Their Implementation
Joy Borgaonkar, MD, FRCPC
BORGAONKAR J, Manos D, Miller R, Gale J
143
Low Dose Chest CT: An Estimate of Radiation Dose Reduction Compared to Standard CT
JD Giardina, MD
GIARDINA JD, McGuire M, Rahmani N
144
Classic Radiographic Signs of Atelectasis: A Pictorial Essay
Robert Perone, MD
PERONE R, Talati RK, Chaudry A, Shroyer R
27
Posters
Educational and Scientific Posters
145
Bronchioloalveolar Carcinoma (BAC): A Diagnosis of the Past
Timothy Herbst, MD
HERBST T, Galperin-Aizenberg M, Deshpande C, Gupta N
146
Thoracic Diagnostic and Therapeutic Interventions - From Biopsies to Thermal Ablation
and Beyond! What the Radiologist Needs to Know
Mark Landis, MD, FRCPC
LANDIS M, Chung T, Nguyen E, Patsios D, Kachura J, Yasufuku K
147
Complications Following Various Esophageal Surgeries: Diagnostic Challenge and Pitfalls
Santosh Selvarajan, MBBS
SELVARAJAN S, Madan R, Trotman-Dickenson B, Hunsaker A
148
Radiological Spectrum of Assisted Heart Failure Therapy
Dharshan Vummidi, MRCP, FRCR
VUMMIDI D, Cascade P, Agarwal P
149
MR Imaging in Cardiac Amyloidosis: From Basic to Advanced
Elizabeth Weihe, MD
WEIHE E, Jeudy J, Kligerman S, Sosa F, White C
150
The Many Causes of Calcification in the Pleural Space
Leif Jensen, MD, MPH
JENSEN LE, Meyer CA, Yandow DR, Kanne JP
151
Malpositioning of Thoracic Lines and Tubes: A Pictorial Essay
Taruna Ralhan, MD
RALHAN T, Drosten R, Ornstein S, Trahan A
152
Multidetector Computed Tomography Imaging of Tumors of the Trachea and Central Bronchi
Maya Galperin-Aizenberg, MD
GALPERIN-AIZENBERG M, Herbst T, Gupta N
153
The Spectrum of Radiological Manifestations of Pulmonary Aspergillus Infection
Anoma Lalani Dias, MA, MBBS, MRCS
DIAS AL, Hameed S, Gupta A, Goncalves ATC, Gomes MM, Hare SS
154
Classic Chest Radiographic Localization Signs: A Teaching File
Robert W. Perone, MD
PERONE RW, Shroyer RJ, Talati R, Chaudry A, Lin CT
155
Quantitative Diagnostic Imaging of Lungs and Airways in Patient with Asthma: Modern
Imaging Techniques and Their Clinical Implications
Changhyun Lee, MD
LEE C, Laroia A, Hoffman E, Newell J, Thompson B, Stanford W, Mullan B
156
Anatomy and Pathology of Structures Related to the Aortic Root as Demonstrated by MRI,
Cardiac CT, and TEE
Michael A. Winkler, MD
WINKLER M, Attili A, Embertson R, Shah K, Hyde B, Sorrell V
157
Percutaneous CT-guided Sampling of Thoracic Lesions: A Comprehensive Review
Eric Schmidlin, MD
SCHMIDLIN E, Vummidi DR, Kazerooni EA, Sundaram B, Arenberg D, Reddy R
158
Metastatic Pulmonary Calcification: A Unique Presentation with Pictorial Review
Kathryn Olsen, MD
OLSEN KM, Henry DA
159
An Approach to Perioperative CT Imaging of Cardiac Valvular Disease
Nicoleta Anca, MD, MSc, FRCPC
ANCA N, Elliot T, Lydell C, Hutchinson S, Merchant N
28
Educational and Scientific Posters
T2 Weighted Imaging of the Heart: A Review
Nicoleta Anca, MD, MSc, FRCPC
ANCA N, Mikami Y, Lydell C, Elliot T, Howarth A, Merchant N
161
A Pictorial Review of Fatty Lesions of the Chest
Francisco Garcia-Morales, MD
GARCIA-MORALES F, Gupta P, Rice G, Donahue B
162
MR, CT, PET-CT and Echo-cardiography of Cardiac Tumors in the Adults
Francisco Garcia-Morales, MD
GARCIA-MORALES F, Abdullah SM
163
Not Just Blowing Hot Air: Primer on Pulmonary Function Testing in Lung Diseases for the
Radiologist
Jonathan H. Chung, MD
CHUNG JH, Al Qaisi M, Saettele M, Lynch DA, Kanne JP
164
Post- Lung Transplant Primary Graft Dysfunction: Distinctive Imaging Features
Shehrzad Rabbani, MD
RABBANI S, Belperio J, Suh R, Gutierrez A, Brown K, Abtin F
165
Withdrawn
166
Effect of Ambient Lighting on Optimal Viewing of Portable Chest X-ray Images
David Yankelevitz, MD
YANKELEVITZ D, Wang X, Foos DH, Jacobi AH, Henschke CI
167
Withdrawn
168
As Low as Reasonably Achievable: Radiation-Free Evaluation of Pulmonary and
Mediastinal Diseases Using MRI
Mustafa Al Qaisi, MD
AL QAISI M, Chung JH, Lichtenberger JP, Puderbach MU, Biederer J, Schroeder JD, Lynch DA
169
Posters
160
Make it Interactive: Adding Audience Response to Your paper or Electronic Poster
Gregory W. Gladish, MD
GLADISH GW
170
The Pulmonary Lymphoid System: A Review of Anatomy, Benign and Malignant Diseases
VA Lewis, MD
LEWIS VA, Dhand S, Sirajuddin A, Galvin JR, Franks TJ, White CS
171
MDCT Angiography in Pulmonary Hypertension: Pictorial Review
Archana Laroia, MD
LAROIA A, Laroia S, Lee CH, Thompson B, Mullan B, Stanford W
172
Impact of Maximum Intensity Projection Images in Thoracic Imaging Interpretation:
Lessons Learned
Tyler Ternes, MD
TERNES T, Martínez-Jiménez S, Rosado-de-Christenson M, Kunin J
173
Coronary Artery Luminal Area and Plaque Burden in South Asians and Non South Asians:
A Coronary CT Angiographic Assessment
Julie O’Brien, MB BCh BAO, FFR(RCSI)
O’BRIEN J, Wijesinghe N, Ramanathan K, Boone R, Taylor C, Hague C, Leipsic J
174
Lateral Chest Radiograph
Eil Seong Lee, Professor
LEE ES, Paik SH, You YW, Hwang DH, Lee KS
175
Isolated Branching Peripheral Opacity: A CT Finding Suggestive of Malignancy
Watson Blake, MD
WATSON B, Teel G, Loewen G
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101
A Multimodality Imaging Approach to Differentiate Thymic Hyperplasia from Thymic
Neoplasm
RABBANI S, Suh R, Lee J, Gutierrez A, Brown K, Abtin F
Purpose: Thymic lesions represent an unresolved diagnostic challenge that often requires surgical
intervention for an accurate diagnosis and staging. Noninvasive imaging may assist in diagnosing the
nature of thymic lesions, in turn helping to identify patients who are true candidates for surgery and
pre-plan a surgical approach.
Principal Information:
. We describe the imaging features of thymic hyperplasia, thymic neoplasm and common
differentials.
. Approach to characterization and differentiation of thymic pathologies, with focus on chemical
shift and dynamic respiration MRI protocols.
. Use of FDG-PET as an effective modality in differentiating thymoma from thymic hyperplasia and
thymic carcinoma from other entities within the thymus. Also the use of FDG-PET to direct biopsy
for optimal specimen yield.
. Technique of image guided biopsy approach for a thymic lesion and tips to avoid complications.
Conclusion: An organized approach to thymic imaging and tissue characterization improves presurgical planning and management of patients with thymic disease.
POSTERS
102
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103
Magnetic Resonance Imaging in Nonischemic Cardiomyopathy: Making the Differential
Diagnosis
SCALI E, Leipsic J
Purpose: The intent of this educational poster is to highlight the unique features of cardiac magnetic
resonance imaging in the diagnosis of nonischemic cardiomyopathies. Specific objectives include:
. To describe the current use of imaging in the evaluation of myocardial disease
. To present the etiology, histopathology and common clinical presentations of nonischemic
cardiomyopathies
. To describe and demonstrate representative MRI images of the major classes of nonischemic
cardiomyopathies
Methods: Cardiac magnetic resonance imaging, including the use of gadolinium enhancement, will
be used to showcase unique features of the most common nonischemic cardiomyopathies, including
heterotrophic, dilated, restrictive and arrhythmogenic right ventricular dysplasia.
Results: The etiology of nonischemic cardiomyopathies results in tissue characteristics that are best
characterized using cardiac MRI. Cardiac MRI’s ability to visualize the right ventricle and assess the
wall thickness of both sides of the heart, as well as the use of delayed gadolinium enhancement to
characterize patterns of myocardial scar, offer a substantial advantage over traditional imaging
techniques.
Conclusion: While echocardiography is well-suited to assess for ischemic change, cardiac MRI
provides additional information specific to nonischemic cardiomyopathies. Advantages of CMR
include the ability to obtain high spatial and temporal resolution images of the entire heart as well as
to demonstrate particular patterns of delayed contrast enhancement and other tissue characteristics.
These findings are essential to establishing the differential diagnosis and informing the clinical
management of this diverse group of diseases.
104
Can Gender Predict The Appropriateness of Left Ventricular Mass in Normal Adolescents and
Young Adults?
ADAMU AA
Purpose: The positive influence of body growth on cardiac development decreases with increasing
age and becomes insignificant after 20 years of age. The present study was undertaken to identify the
possible prognostic impact of gender on the appropriateness of LVM in normal individuals.
POSTERS
Materials and methods: 147 healthy individuals aged 17 to 23 years old volunteered for this study.
Seventy three were males. Anthropometry was performed using the method of R.N.Dorokhov and
V.G.Petrukhin (1989). For echocardiography, Acuson Aspen ultrasound scanner was used with 3.5
MHz cardiac probe.
Stroke work (g-m/beat) = Cuff systolic BP×stroke volume×0.014
Predicted LVM=55.37+6.64×H +0.64×SW-18.07×gender
Where H-height in meters, SW-stroke work, gender: male=1 and female=2.
Appropriateness of LVM was assessed as observed LVM (oLVM) divided by predicted LVM (pLVM)
and expressed as a percentage.
oLVM/pLVM > 128% is termed inappropriate, while < 72% is regarded low LVM.
Statistica 6.0 was used for statistical analysis.
Results: Individuals were grouped in order of increasing somatotype into nanosomatic, microsomatic,
micromesosomatic, mesosomatic, mesomacrosomatic, macrosomatic and megalosomatic.
Appropriateness of LVM correlated positively with body size in males (r=0.25; p<0.05), but
negatively in females (r=-0.35; p<0.01).
Conclusion: Male subjects have the tendency to develop inappropriately high LVM with increasing
body size.
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105
Chest Pain Beyond Acute Coronary Syndrome: Cardiac And Non-cardiac Etiologies
JUICE D, Rubinowitz A, Oliva I
Purpose: The purposes of this exhibit are: identify the cardiac and non-cardiac causes of chest;
discuss the plain film and cross-sectional imaging findings of the aforementioned processes;
succinctly summarize specific findings and how imaging can accurately help in the management of
these patients.
Material and Methods: Chest pain is one of the most common complains in the Emergency
Department accounting for approximately 6 millions of consults per year. Acute coronary syndrome is
a serious but treatable cause of acute chest pain but there are other as fatal and debilitating causes that
also need to be assessed to better guide patient’s management. These include but are not limited to
pulmonary embolism, pneumothorax, and acute aortic injury. There is a wide variety of different
treatment options for these patients depending mainly on the etiology of chest pain, such as antibiotic
administration, anticoagulation, or surgical intervention. Radiology plays an essential role in
accurately diagnosing the etiology of acute chest pain and therefore allowing timely implementation
of the appropriate management. Also, misinterpreting the radiological images will lead to inadequate
therapy with potential dire consequences for the patient. Thus it is important to be familiar with the
presentation and imaging findings of both cardiac and non-cardiac causes of chest pain to better triage
these patients, guide more appropriate therapy, or discharge efficiently.
Conclusion: Chest pain is a common complaint in patients presenting to the emergency department.
Etiologies of such symptom include cardiac and non-cardiac causes and radiology plays an essential
role in accurately diagnosing the etiology of acute chest pain allowing timely implementation of the
appropriate management.
106
Unusual Devices and Hardware in the Chest - A Pictorial Review
WATTS JR, Dartez D, Sonavane S, Terry N, Singh S
POSTERS
Purpose: A variety of hardware is routinely imaged in radiological examinations of the chest. We
have encountered several unusual and experimental devices in the thorax with which many general
and chest radiologists may not be familiar with. The objective of this educational exhibit is to
describe the typical appearance and purpose of several of these unusual devices with illustrative
examples.
Principal Information:This pictorial review will show examples of a variety of unusual devices in
the chest including:
Devices implanted within the pulmonary arteries (pulmonary artery pressure monitors such as the
CardioMEMS device, SynchroMed infusion pump catheter for pulmonary hypertension)
Heart failure devices (Paracor nitinol heart mesh, C-Pulse aortic balloon counterpulsation device,
ventricular assist devices including the minimally invasive Impella Cardiac Assist Device)
Left atrial occlusion devices for patients with atrial fibrillation
Unusal airway devices (Spiration endobronchial IBV valves for emphysema and trans-tracheal jet
ventilation catheters)
Additional examples include more commonly used hardware in unusual, but intended, locations
including dual lead pacing location in surgically corrected transposition, Amplatz occluder devices
used in unconventional locations, permanent epicardial pacing leads, and implanted chest wall
defibrillators)
Conclusion: Intrathoracic hardware is frequently encountered in imaging evaluations of the chest.
This pictorial review hopes to familiarize the chest or general radiologist with the appearance of
several of the newer and/or unusual devices that may be encountered.
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107
CT Features of Esophageal Malignancies- Pre and Post Treatment.
SONAVANE SK, Denham LW, Dartez D, Watts JR Jr, Terry N, Singh S
Purpose: Aim of this exhibit is to discuss the CT & PET-CT imaging features, staging, complications
of esophageal malignancies. The post treatment imaging appearances and complications will also be
discussed.
Principal information: As chest radiologists we often encounter CT scans performed to evaluate for
esophageal malignancies (e.g. adenocarcinoma, squamous cell carcinoma, lymphoma, metastasis,
leiomyosarcoma). In this exhibit we intend to discuss the imaging appearances esophageal
malignancies, staging of esophageal carcinoma, their complications (perforation, fistula formation) on
CT and PET-CT.
Various treatment options for esophageal carcinoma include surgery, radiation, chemotherapy,
palliative stenting. There is marked alteration in the anatomy especially after surgical procedures.
Expected post-surgical appearance as well as complications including but not limited to anastomotic
leaks, esophageal-pleural fistula, empyema, ischemic necrosis, recurrent tumor, and stricture will be
further illustrated on CT scans.
Conclusion:
As chest radiologist, it is important to be aware about CT and PET-CT appearances of esophageal
malignancies, staging, post treatment appearances and complications.
108
The Pulmonary Embolism Predicament: Do Chest Radiographs Play a Part in Diagnosis?
RASHID MA, Wilcox A
Purpose: This study was a retrospective review of CTPA and chest radiograph studies in patients with
clinical suspicion for pulmonary embolism. The purposes were to determine the negative predictive
value of diagnosing a PE, given grossly abnormal CXR findings that could account for the clinical
presentation, and to determine whether chest radiographs have a place in diagnosis.
POSTERS
Methods: This study was conducted as a retrospective review of contrast-enhanced CTPA studies and
corresponding chest radiographs ordered by the ED at our institution over 10 months. 494 study sets
qualified for inclusion, each containing a CXR and subsequent CTPA study. The studies were
reviewed for diagnosis and evidence of acute PE, specifically filling defects. Radiographs were
reviewed for evidence of abnormal pathology. Findings used to indicate abnormal pathology included
opacities, with clinical features of infection or inflammatory disease, possible infarcts and CHF.
Findings that were not considered abnormal included atelectasis and emphysematous changes.
Results: Of the 494 patients in the study, 28 had findings consistent with acute PE on CTPA. Of those
28, 3 had grossly abnormal CXR findings, while the remaining 25 did not. 77 other patients had
abnormal findings on CXR, but had no evidence of acute PE on CTPA. Using these findings, the NPV
of an abnormal chest radiograph in detection of PE was calculated to be 93.96%.
Conclusion: In our study, the NPV of chest radiographs was high, suggesting that abnormal findings
may indicate that a CTPA study is not needed for further evaluation if an explanation for symptoms is
apparent on radiograph and clinically. While CT is the gold standard for evaluating PE, the value of a
chest radiograph in diagnosis should not be discounted.
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Multi Detector CT Evaluation of Airway Stents: What the Radiologist Should Know
SALDANA DA, Ost D, Benveniste MK, Rao PP, Vlahos I, Marom EM, Erasmus JJ, Godoy MCB
POSTERS
Purpose: To review the different types of airway stents and indications for their use as well as the
role of multidetector CT (MDCT) in pre-procedure planning and evaluation of complications.
Principal Information: Airway stents are being increasingly used to treat symptomatic patients with
obstructive tracheo-bronchial diseases not amenable to surgical resection or when resection is
precluded by poor performance status. The most common conditions treated with trachea-bronchial
stents are primary lung cancer and metastatic disease. However, stents have also been used to manage
patients with airway stenosis related to benign conditions such as tracheobronchomalacia, relapsing
polychondritis, post-intubation tracheal stenosis, postoperative anastomotic stenosis and
granulomatous diseases. Additionally, airway stents can be used as a barrier method in the
management of esophagorespiratory fistulas. This educational exhibit reviews and illustrates the
different types of metallic and silicone stents, the indications for their use and the role of MDCT in
pre-placement planning. Furthermore, appropriate post-placement imaging for complications of stent
placement including stent malposition, migration, fracture and obstruction are reviewed.
Bronchoscopic correlation is provided.
Conclusions: Airway stents are being increasingly used in clinical practice and MDCT imaging
assists in both placement and diagnosis of stent-related complications. Knowledge of the stents most
frequently used together with an understanding of the criteria important in pre-procedure planning and
typical manifestations of stent-related complications are useful in ensuring appropriate treatment.
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111
The Use of Chest Radiography Following Percutaneous Tracheostomy
SHAKARCHI JA, Janjua U, Kyi M
Purpose: Tracheostomy is commonly used to assist weaning from mechanical ventilation in the
intensive care unit. It has shown benefits in improved airway suctioning, better patient comfort and
fewer laryngeal complications. Percutaneous tracheostomy (PT) has been shown to have some
benefits over the open technique and has become the procedure of choice in most intensive care units.
The possibility of pneumothorax or pneumomediastinum has led to the routine use of chest
radiography following the procedure. In our study, we aim to determine the need for routine chest
radiography following PT.
Using our tracheostomy database, we identified 50 patients who had PT since January 2010 in our
unit. A retrospective review of case notes and electronic patient records was performed for patient
demographics, reason for ITU admission, length of ITU stay, use of chest radiography post procedure
and finally any complications arising from the procedure.
The patients identified consisted of 31 males and 19 females with a mean age of 59 years (range 2484). The patient cohort consisted of a typical case mix of post surgical, trauma and medical patients.
46 patients (92%) had an x-ray to check for any complication from the procedure. However no
complications were reported clinically nor radiologically.
Chest radiography following percutaneous tracheostomy is necessary when there are clinical findings
suggesting pneumothorax or pneumomediastinum. However without clinical signs or symptoms of a
complication from the procedure, routine use of chest radiographs following percutaneous
tracheostomy does not seem to be necessary or cost effective.
112
Lung Hernias of the Chest Wall
OCAK I, Wang J, Bae KT
Purpose: To demonstrate significance and different type of lung hernias based upon etiologies
POSTERS
Material and Methods: Lung hernia of chest wall will be classified as Congenital
1. Supraclavicular
2. Intercostal
Traumatic
1. Blunt trauma
2. Penetrating trauma
2. Iatrogenic: secondary to standard thoracotomy, lung transplantation, after minor surgeries suc as
subsequent to harvesting LIMA, minimally invasive surgery for coronary artery disease, VATS.
Spontaneous lung herniation secondary to couging, sneezing and abnormal body motion Rare
pathologic conditions: empyema necessitatis.
Conclusion: Early diagnosis of lung herniation with chest X-ray and CT is crucial to prevent
devastation complication such as ischemia and necrosis of lung.
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113
ALCAPA, A Rare but Serious Congenital Cardiac Anomaly
MITTAL N, Go BD
Purpose: Anomalous left coronary artery from the pulmonary artery (ALCAPA) is a rare, but
important congenital cardiovascular entity to recognize on cardiac computed tomographic
angiography (CTA). People with this entity typically present with symptoms of congestive heart
failure in the first year of life and are evaluated and treated accordingly at that time. However,
patients with this syndrome who remained asymptomatic or escaped undetected clinically during
infancy may present later in childhood or adulthood with angina pectoris or cardiac arrest warranting
the need for workup including cardiac CTA. Recognizing the cardiac CTA features of this anomaly is
therefore critical in securing the diagnosis and directing the clinical team to the appropriate
management. By exhibiting a case of ALCAPA in a patient who presented to our institution as a
teenager, the pathophysiology, clinical history, imaging features by cardiac CTA, and management
will be reviewed.
114
Incidence of Pulmonary Embolism in Oncologic Outpatients at a Tertiary Cancer Center
NISHINO M, Shinagare AB, Guo M, Hatabu H, Krajewski KM, Andriole K, Van den Abbeele AD, DiPiro PJ
POSTERS
Purpose: Incidence of pulmonary embolism (PE) for different cancer types in oncology outpatients is
unknown. The purpose of the study is to determine the incidence of PE in oncology outpatients and to
investigate whether the incidence for PE is higher in certain cancers.
Methods/Materials: A cohort of oncology outpatients who had imaging studies at Dana-Farber Cancer
Institute from January 2004 through December 2009 was identified using research patient data registry.
Radiology reports were reviewed to identify patients who developed PE. Incidences of PE in the total
population and in each of 16 predefined cancer groups were calculated. Risk of PE for each cancer was
compared using Fisher exact test.
Results: A total of 13,783 patients was identified, of which 395 (2.87%; 95% CI, 2.59-3.16) developed PE.
The incidence of PE was highest in the central nervous system ([CNS] 12.90%; 95% CI, 8.45-18.59),
hepatobiliary (6.85%; 95% CI, 3.33-12.24), pancreatic (5.81%; 95% CI, 3.59-8.84), and upper gastrointestinal
(5.81%; 95% CI, 3.96-8.20) malignancies. The risk of PE was significantly higher for CNS (P < .0001; odds
ratio [OR], 5.28), pancreatic (P=.0027; OR, 2.15), upper gastrointestinal (P=.0002; OR, 2.18), and lung/pleural
malignancies (P=.0028; OR, 1.45). There was significantly lower risk of PE for hematologic (incidence,
1.16%; 95% CI, 0.79-1.64; P < .0001; OR, 0.35) and breast malignancies (incidence, 1.50%; 95% CI, 1.022.11; P < .0001; OR, 0.47).
Conclusions The incidence of PE in oncology outpatients in a tertiary cancer center during a 6-year period
was 2.87%. CNS, pancreatic, upper gastrointestinal, and lung/pleural malignancies had a significantly higher
risk for PE, whereas hematologic and breast malignancies had a significantly lower risk.
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115
CT and MRI Features of Pseudoaneurysm of the Mitral-Aortic Intervalvular Fibrosa
LOW SCS, Bach DS, Agarwal PP
Purpose: To describe the CT and MRI features of pseudoaneurysm of the mitral-aortic intervalvular
fibrosa (PMAIVF). Knowledge of PMAIVF is important as it can be life-threatening and lead to
complications including compression of and fistula formation into adjacent structures.
Materials and methods: In this retrospective study, we searched the institutional electronic medical
records database for patients who had ECG-gated CT and/ or MRI and had a diagnosis of PMAIVF
made on echocardiography between January 2000 and December 2008. CT and MRI images were
reviewed by two experienced cardiothoracic radiologists in consensus.
Results: Six patients (4 males, 2 females; mean age 50 ± 19 years) with PMAIVF formed the study
group; 4/6 had CT and 2/6 had MRI. Five of the 6 patients had prior aortic valve replacement surgery;
one patient had a presumed congenital PMAIVF. Of the 6 patients with PMAIVF, 4 were
asymptomatic while 2/6 presented with prosthetic aortic valve endocarditis. Maximum diameter of the
pseudoaneurysm in diastole was 31 ± 14 mm (range 19-52 mm). All patients with PMAIVF
demonstrated a characteristic location in the mitral-aortic intervalular fibrosa. Communication with
the left ventricular outflow tract was seen in 5 of 6 patients. Systolic expansion and diastolic collapse
were seen in 3 patients; the difference in size between systole and diastole ranged from 4 to 7 mm
with a mean of 6 mm. In one patient, cine MRI showed a jet of blood entering and exiting the
pseudoaneurysm.
Conclusion: PMAIVFs have a characteristic appearance on CT and MRI. Knowledge of this entity
and its imaging appearance is critical for proper patient care.
116
Coronary Artery Conditions - More Than Just Stenosis
BERNHEIM A, Goyal N
Purpose: The purpose of this exhibit is to review various coronary artery disease processes other than
stenosis. The objective will be to examine the relevant epidemiology, etiologies, clinical presentation,
and treatment options of patients with various coronary artery disease entities other than stenosis. An
aim will additionally be to present imaging findings of several example cases.
Conclusion: The key teaching points of this exhibit are that there are several important disease entities
that may affect the coronary arteries other than stenosis. Patterns on imaging examinations may be
recognized that are suggestive or diagnostic of various coronary artery disease processes. Finally,
medical and surgical treatment options are available for many of these entities.
POSTERS
Principal Information: Definitions, background, and relevant epidemiology of coronary artery diseases
will be presented. In addition, pathophysiology and clinical manifestations of several coronary artery
entities other than stenosis will be presented, including aberrant course, fistula, aneurysm and
pseudoaneurysm, dissection due to iatrogenic etiology, radiation-induced accelerated atherosclerosis, and
other rare entities. Imaging findings and example cases will be included.
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117
Utility of Dual-Time-Point FDG PET/CT in Thoracic Disease
ABEL N, Nandalur K, Tien H
Purpose: Dual-phase FDG PET-CT is performed in many institutions, largely on the basis of the
claim that malignant lesions demonstrate increased SUV over time and decreased or stable SUV over
time in benign lesions. The intent of our exhibit is to demonstrate the common and uncommon uses of
dual-time-point FDG PET/CT in thoracic disease.
Principal Information: Relevant findings from 50 cases from our institution of dual-time-point PETCT from the past 3 years including:
-Pathophysiological basis and current protocols -Indications including lung nodule characterization,
especially those with borderline levels of increased metabolic activity, mediastinal node staging in
non-small-cell lung cancer patients, and lymphoma -Case examples of false-positives such as
granulomatous disease and false-negatives with pathological correlation -Current evidence-based
analysis of usefulness
Conclusion: The role of dual-time-point PET-CT remains controversial in the evaluation of thoracic
disease, specifically lung nodule evaluation. However, some evidence suggests the protocol can
improve sensitivity and specificity for malignancy. Knowledge of dual-phase PET-CT is important for
thoracic radiologists and may improve patient care.
118
Multimodality Appearance of Radiation Changes to the Thorax: The Good, the Bad, and the
Ugly
ZAKI M, Tien H, Nandalur K
POSTERS
Purpose: Radiation therapy is often utilized to treat thoracic disease, including lung cancer, breast
cancer, and lymphoma. Most radiation therapy demonstrates minimal side effects and no significant
findings on imaging. However, it is not uncommon for thoracic injury to occur after radiotherapy. The
purpose of our study is to demonstrate the varying appearance of radiation-induced changes to the
thorax, with emphasis on acute and delayed complications.
Principal information: Relevant findings from 50 cases from our institution of radiation changes to
the thorax from the past 3 years including:
-Indications for radiation to the thorax -Plain film, CT, and MRI appearance of expected radiation
changes -Plain film, CT, and MRI appearance of recurrent disease and complications after radiation
therapy, including pulmonary necrosis, BOOP, thymic cysts, calcified lymph nodes, pericardial
disease, rib fractures, and post-radiation induced tumors such as sarcomas
Conclusion: Radiation therapy has become a mainstay in the treatment and palliation of various
diseases of the thorax. However, the treatment can be associated with several mild to severe
complications. Knowledge of the spectrum of the post-radiation appearance of the thorax is critical in
optimizing patient care.
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119
Disease Progression Through Imaging: Idiopathic Pulmonary Fibrosis and Lung Cancer - A Piloted
Teaching Module
HUR JL, Shingala P, Hanna J, Johnson O, Vasani D, Awad S, Amorosa JK
Purpose: Knowledge of the natural course of a disease is important in long-term management of patients
and informed clinical decision-making. Preclinical medical education focuses on snapshots of diseases at
a single time point. During clinical years, students also have limited ability to track patients’ long-term
progress due to constant rotation through clerkships.
Our objective is to introduce an interactive electronic module that educates students about radiologic and
clinical progression of idiopathic pulmonary fibrosis (IPF) and lung cancer. The goal is to increase
knowledge of disease progression to guide selection of diagnostic techniques and treatments. The module
has been piloted and assessed by medical students for educational value.
Principal Information: We use a dynamic timeline format to present progression of pulmonary cases.
IPF, the most common infiltrative lung disease, usually progresses to end-stage lung disease within several
years of diagnosis. IPF progresses through different stages on high resolution CT. Imaging findings
correlate with clinical severity and influence treatment options.
Lung cancer is the most common cancer worldwide and a leading cause of malignancy-related mortality.
Knowledge of its course is important to select therapies as well as imaging modalities to evaluate
metastases.
Our interactive cases incorporate imaging changes with physical exam and laboratory results, as well as
treatment options. They include built-in pre- and post-tests with which students actively assess their
knowledge. Medical students have piloted the module and been surveyed regarding its effectiveness.
Conclusion: We have developed an interactive module that is effective in teaching disease progression of
IPF and lung cancer to medical students.
120
Multifaceted CT and MR Imaging for Planning, Execution and Outcome Assessment in Pulmonary
Vein Catheter Ablation for Atrial Fibrillation Treatment
GALPERIN-AIZENBERG M, Desjardins B
POSTERS
Purpose: Over the last decade Pulmonary Vein Catheter Ablation (PVCA) has become an established
method for treatment of drug refractory and persistent atrial fibrillation. The intent of this exhibit is to
review a multifaceted role of CT and MR imaging in pre, intra and post procedural phases, as well as to
present emerging techniques facilitating selection of most appropriate candidates for PVCA.
Principal information: This exhibit will demonstrate the spectrum of imaging for:
Pre-ablation evaluation of (1) number, configuration and ostial diameters of the pulmonary veins (2) shape
and volume of the left atrium (3) esophagus location and its proximity to the ablation sites (4) pulmonary
arteries, airways and right phrenic nerve location. MR myocardial delayed enhancement evaluation prior to
PVCA is aiming to predict successful ablation in patients according to the distribution and amount of
preexisting fibrosis in the left atrium.
Intra-ablation integration of 3D maps obtained by MRI/CT with electroanatomic maps possibly improves
the clinical outcome and decreases procedure and fluoroscopy times.
Post-ablation assessment of (1) complications, such as pulmonary vein stenosis, thrombosis or dissection,
pulmonary infarction or hypertension, pleural/pericardial effusions and cardiac perforation (2) iatrogenic
scar in the left atrium or around the pulmonary veins ostia.
Conclusion: It is important for radiologists and interventional cardiologists to be cognizant of various
imaging techniques and findings before, during and after the PVCA in order to facilitate accurate planning,
safe and effective execution of the procedure and timely recognition of its complications.
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121
Case-based Review of Cryptogenic Organizing Pneumonia and Its Differential Diagnosis
NAAR K, Khan A
Purpose: Cryptogenic organizing pneumonia (COP) is one of the idiopathic interstitial pneumonia’s
which has various radiologic manifestations, both typical and atypical. This exhibit provides an
overview of the various radiologic manifestations of COP and its differential diagnoses, and helps the
reviewer to make a more accurate diagnosis.
Principal Information:
1. Discuss the clinical presentation and histological findings associated with COP.
2. Provide a case-based discussion of both the typical and atypical radiologic manifestations of COP.
3. Discuss ways to distinguish COP from other entities with similar radiologic manifestations,
including UIP, NSIP, chronic eosinophilic pneumonia, multifocal BAC and alveolar sarcoid.
4. Review treatment, management and follow-up imaging guidelines.
Conclusions: COP has both typical and atypical radiologic manifestations. A detailed knowledge of
the variable radiographic and HRCT findings is helpful for accurate diagnosis.
122
Unusual Intrathoracic Neoplasms: A Case-Based Review
POSTERS
BANG TJ, Sachs P, Suby-Long T, Restauri N
40
Purpose: Lung carcinoma is being diagnosed with increased frequency as imaging utilization has
evolved. (Lancet 1999; 354: 99-105). Additionally, in light of the recently reported National Lung
Cancer Screening Trial (NEJM 2011; 365: 395-409) results, rates of detection will likely rise.
However, multiple additional cell lines within the lungs give rise to neoplasms with variable biologic
behavior and the imaging appearance of these lesions may mimic primary lung carcinoma, often with
very different treatment protocols and prognosis. Although rare, these uncommon tumors are not
infrequently encountered at the University of Colorado Health System, a tertiary referral center for the
treatment of lung cancer.
Patients encountered through our multidisciplinary tumor board and large referral base provide a
unique opportunity to present eight cases of intrathoracic neoplasms with imaging findings which may
be indistinguishable from small cell /non small cell primary lung carcinoma. The following cases are
presented: pulmonary lymphoma, Kaposi’s sarcoma, atypical carcinoid, intrapulmonary schwannoma,
endobronchial thyroid metastases, mucoepidermoid, melanoma, and myofibrous tumor. This poster
serves as a review of the diversity of cell lines with the potential to mimic primary lung cancer in their
radiographic presentation.
123
Errors as Opportunities: Spectrum of Cognitive Errors in Cardiothoracic Radiology
AGARWAL PP, Quint LE
Purpose: To discuss different types of cognitive errors in cardiothoracic radiology with illustrated
examples
Principal Information: The different cognitive errors will be presented in a case based format.
Images (with relevant history) will be shown followed by a discussion of the error in question. Some
of the errors discussed will include:
• Satisfaction of search -Once a diagnostic finding is identified, the search stops and an additional
potentially important finding is missed
• Alliterative error- Bias from prior reports influencing the current reading. For instance, if a prior
report assigned incorrect significance to a finding, this may be propagated through multiple future
reports.
• Watching the grass grow- The finding is compared only to the most recent previous exam and not
to older exams, thereby missing slow growth over a long period of time
• Ascertainment bias – Personal bias towards certain patient characteristics
• Anchoring – Early determination of diagnosis and ‘fitting the findings’ to the diagnosis
• Gambler’s fallacy: Thinking that if one has recently seen several patients with certain pathology,
the chances that the next patient has the same pathology are slim.
• Availability bias – Recent exposure to a diagnosis, especially a missed call, increases sensitivity to
that abnormality, leading one to overcall this entity in the future
• Framing bias: Misdirection by clinical history
• Distraction – Distraction during the interpretation of a case can interfere with the search pattern
and increase the chances of missing relevant findings.
Conclusion: Errors discussed in this presentation are common in day-to-day cardiothoracic radiology
interpretations. We hope that this exhibit will help elucidate causes of human errors and thereby
enhance individual performance.
124
Diffuse Peribronchovascular Ground Glass Opacity or Consolidation: A Unique HRCT Pattern
Suggestive of Nitrofurantoin Toxicity
WILHELM S, Teel G, Lalani T
Purpose: To describe a unique pattern of HRCT abnormalities highly suggestive of nitrofurantoin toxicity.
Results: Over a 6 year period, 11 cases presented to our service that proved to have nitrofurantoin toxicity.
The patient age ranged from 46 to 86, with an average age of 66. All but one patient were female. Of the 11
cases, 8 had a pattern of symmetric diffuse peribronchovascular ground glass opacity extending from the hila
to the lung periphery described prospectively by the original interpreting radiologist. Three of the 8 cases
with peribronchovascular ground glass opacity also had peribronchovascular consolidation. Diffuse
peribronchovascular ground glass opacity was described in one patient in the same time period who did not
prove to have nitrofurantoin toxicity. In 7 out of 8 patients on nitrofurantoin with this pattern, the diagnosis
of nitrofurantoin toxicity was prospectively suggested, including 4 where the interpreting radiologist had no
prior knowledge of the patient’s drug exposure.
POSTERS
Methods: Chest imaging (x-ray and CT, including high-resolution CT when available) was retrospectively
reviewed for all recorded cases of proven nitrofurantoin-induced lung disease at our institution over the last 6
years. The review included imaging findings (with follow-up when available), original interpretation, patient
medications, and clinical course. A literature search analysis was then performed to review the findings
associated with nitrofurantoin-induced lung disease.
Conclusion: Diffuse peribronchovascular ground glass opacity, with or without peribronchovascular
consolidation, is an HRCT pattern highly suggestive of nitrofurantoin toxicity and can be used to diagnose
this condition even in the absence of prior knowledge of nitrofurantoin exposure.
41
125
Think Outside the Lungs: A Case Collection of Bone Findings on Chest Radiographs
MOKASHI A, Bernheim A, Goyal N
Purpose: The purpose is to heighten awareness amongst radiologists as to the importance of
evaluating osseous structures on routine chest radiographs. The objective is to foster an understanding
that the chest radiograph can be an initial and often critical clue in recognizing significant
musculoskeletal pathology.
Principal Information: A multitude of bony pathologies can be diagnosed from a chest radiograph.
These include diseases of traumatic and degenerative etiology, those of metabolic origin (such as
sickle cell anemia and renal osteodystrophy), and entities related to neoplastic etiology (including
primary and metastatic disease). Several example cases will be presented.
Conclusion: The chest radiograph, often thought of as the primary initial imaging examination for
pulmonary pathology, can be an important study for recognizing important musculoskeletal pathology
as well. The radiologist’s familiarity with these entities and their presentation on chest radiography is
important to identifying many of these important diseases.
126
CT Features Distinguishing Pulmonary Arterial Neoplasms from Thromboemboli
WHETSTONE J, Gosselin M
POSTERS
Purpose: In this exhibit, cases of pathologically confirmed primary and metastatic intraluminal
pulmonary arterial neoplasms are contrasted with examples acute and chronic bland pulmonary
emboli to highlight distinguishing CT features.
Principal Information: Intraarterial pulmonary neoplasms include pimary malignancy, such as
angiosarcoma, and tumor emboli. Extrapulmonary sources of pulmonary tumor emboli are
uncommonly encountered; reported etiologies include renal, hepatocellular, breast, and gastric
carcinoma as well as osteosarcoma, atrial myxoma, and choriocarcinoma. On CT, the appearance of
these lesions is dependent on the order of the pulmonary artery branch in which they are located. In
central lesions, we have observed an abrupt tapering of the pulmonary artery distal to neoplastic
filling defects which is not evident with thromboemboli. Central neoplastic filling defects also often
demonstrate internal enhancement. Higher order branch lesions give rise to a multinodular or
“beaded” appearance of the artery. Most distally, small vessel tumor emboli have a “tree-in-bud”
appearance. These imaging features can be used to suggest a diagnosis of neoplasm rather than
thromboembolism.
Conclusion: Although pulmonary artery neoplasms are rare, there are imaging features which, when
present, should alert the radiologist to consider the diagnosis. This poster will familiarize viewers with
the CT appearance of pulmonary arterial neoplasms by contrasting cases of bland thromboemboli,
tumor emboli, and primary neoplasms.
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127
Imaging of Thoracic Manifestations of Scleroderma
PACHECO R, Carlton M, Kaloudis E
Purpose: The intent of this exhibit is to demonstrate and discuss the thoracic imaging findings
characteristic of scleroderma.
Principal information: Radiology plays a significant role in the evaluation of scleroderma. Often,
imaging may be used to support its diagnosis in cases with an equivocal or subclinical presentation.
In the case of scleroderma sine scleroderma, in which patients develop visceral sclerosis, but no
sclerosis of the skin, radiographic findings can be paramount to making a timely diagnosis.
Radiography, high resolution chest CT and Cardiac MRI are presented and described for the various
thoracic manifestations of scleroderma, including diffuse interstitial lung disease, esophageal
hypomotility and reflux, mediastinal lymphadenopathy, bony resorption, soft tissue calcification,
pleural effusion, pulmonary vascular disease, and myocardial disease, including cardiomegaly,
pericardial effusion and myocardial fibrosis. Characteristic findings are identified and discussed, and
their reported frequency as seen in the literature is presented. Pathophysiologic mechanisms are
explored when they are known.
Conclusion: Thoracic manifestations of scleroderma can be demonstrated using many common
modalities and can provide an important adjunct in the consideration and diagnosis of scleroderma.
Radiologists should be aware of imaging manifestations of this important, yet rare, disorder, to assist
our clinical counterparts with early and effective intervention.
128
Common Surgical Procedures for Congenital Heart Disease
WHETSTONE J, Bardo DME
Purpose: In this exhibit we review the history and development of surgical procedures for correction and
palliation of congenital heart disease (CHD), current surgical approaches, and the pre and postoperative
anatomy of CHD using diagrams, cardiac computed tomography (cardiac CT) and cardiac magnetic
resonance imaging (CMR).
POSTERS
Principle Information: Preoperative and postoperative imaging evaluation and long term follow-up of
patients with CHD is challenging due to the nature of complex anatomy and may be further obfuscatory by
the preponderance of eponyms when naming surgical techniques.
Surgical success now allows patients with CHD to live well into adulthood. General and subspecialist
radiologists alike must now possess a working knowledge of current and historical surgical techniques and
anatomy in order to make accurate diagnoses.
Preoperative and postoperative anatomy and imaging findings which indicate the need for reoperation will
be illustrated with schematic diagrams and cardiac CT and CMR images.
CHD lesions including atrial and ventricular septal defects, patent ductus arteriosus, tetralogy of Fallot,
transposition of the great arteries, coarctation and hypoplasia of the aorta, hypoplastic left heart syndrome
as well as surgical procedures including transannular patch, Blalock-Taussig and Glenn shunts, Fontan,
Jatene, Norwood, Damus-Kaye-Stansel, LeCompte, Rastelli, Mustard, Senning, Ross, and others will be
reviewed.
Conclusion: Knowledge of the anatomy and the surgical treatment of CHD is necessary for pediatric and
adult radiologists alike. This poster will familiarize viewers with the most common CHD lesions, and the
pre and post operative imaging findings.
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129
Chest HRCT Signs and Patterns: A Pictorial Essay
TALATI R, Perone R, Chaudry A, Shroyer R
Purpose: The purpose of this exhibit is to visually delineate common and important signs and
patterns in Chest HRCT imaging using a case based format. Recognition of these signs and
patterns are critical to the accurate detection and characterization of pulmonary disease. It is our
intent that after reviewing this educational exhibit, the reader will become familiar with many of
these classic and important HRCT signs and patterns thus strengthening his or her diagnostic
interpretive skills.
Methods: High resolution MDCT images as well as chest radiographs will be presented as
unknowns followed by a discussion of the related sign or pattern being illustrated. The discussion
will include a visual description of the radiologic findings as well as the diagnosis and differential.
Results: Identification of the classic imaging signs and patterns of Chest HRCT are critical to the
successful detection and characterization of pulmonary disease.
Conclusion: Accurate interpretation of HRCT of the chest is dependent on a strong visual
vocabulary of the classic signs and patterns presented in this educational exhibit. It is our goal that
by the end of the review of this exhibit, the viewer will have acquired a stronger diagnostic acumen
of pulmonary disease facilitating the expeditious delivery of excellent patient care.
130
Bubbles of the Lung: Illustrative Review of Cavitary and Cystic Lesions at High-Resolution CT
POSTERS
FELKER ER, Jude CM, Patel MK, Batra P
Purpose: Pulmonary cavities and cysts are frequently seen on high-resolution CT (HRCT) in a variety
of diseases. Radiologic features and associated abnormalities, when correlated with clinical
presentation, can help narrow the differential diagnosis.
After reviewing this presentation, participants will be able to: 1) Describe the HRCT appearance of
cavitary and cystic lesions; 2) Understand the pathogenesis of disorders which result in cavity and
cyst formation; 3) Appreciate the spectrum of diseases manifested by lung cavities and cysts; 4)
Correlate clinical factors, radiologic characteristics and associated abnormalities, which lead to a more
specific diagnosis.
Principal information: This exhibit will review cases of: 1) Cavitary lung lesions: a. Infection bacterial, mycobacterial, fungal; b. Neoplastic - bronchogenic carcinoma, metastases, tracheobronchial
papillomatosis; c. Vascular - septic emboli, pulmonary infarct; d. Immunologic/autoimmune Wegener’s granulomatosis, rheumatoid arthritis. 2) Cystic lung lesions: Diffuse cystic lung disease: a.
Lymphangioleiomyomatosis; b. Pulmonary Langerhans cell histiocytosis. Multifocal and focal cystic
lung disease: a. Infection - cystic bronchiectasis, pneumatocele; b. Interstitial lung disease lymphocytic interstitial pneumonia, desquamative interstitial pneumonia; c. Neoplastic - cystic
metastases; d. Congenital - bronchogenic cyst, congenital cystic adenomatoid malformation.
Conclusion: There is a wide spectrum of diseases which present with pulmonary cavitary or cystic
lesions on HRCT. Correlation of clinical factors and radiologic characteristics provide important clues
to diagnosis.
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131
Multi-modality Imaging of Thoracic Manifestations of Sickle Cell Disease
NAMBIAR A, Pechersky D, Alpert J
Purpose: A comprehensive review of the thoracic imaging findings of sickle cell disease.
Principal information: Sickle cell disease is one of the most prevalent genetic disorders, affecting
approximately 250 million people globally, resulting from a single gene mutation in hemoglobin A.
Sickle cell disease affects multiple organ systems, and while clinical and laboratory data often leads to
diagnosis, imaging findings may further facilitate diagnosis and patient care. This presentation will
illustrate and describe the underlying pathology associated with both classic and less commonly
recognized imaging manifestations of sickle cell disease as it affects multiple organ systems:
pulmonary disease such as acute chest syndrome and interstitial disease, cardiovascular disease
including pulmonary hypertension, musculoskeletal and upper abdominal findings. Multiple imaging
modalities will be utilized.
Conclusion: Sickle cell disease affects several thoracic organ systems. Understanding the various
radiologic manifestations of sickle cell disease can assist in diagnosis and patient care.
132
Role of FDG PET/CT in Cardiovascular Masses
GUPTA A, Shrikanthan S, Renapurkar R, Mohammed TL
Purpose: FDG PET/CT is widely used for staging and analysis of disease burden in known cancer
patients and to aid in determining the nature (benign or malignant) of a newly diagnosed
indeterminate lesion. However, only a little is known about the use of FDG PET/CT in the analysis of
suspected primary or metastatic cardiovascular lesions. We aim to illustrate the FDG uptake pattern in
some of the cardiovascular masses.
POSTERS
Methods: 14 patients (8 females and 6 males) with either biopsy proven or suspected cardiovascular
malignancy underwent FDG PET/CT. The cardiovascular malignancy was suspected based on
imaging characteristics on CT or MRI scans. The amount of FDG injected was based on the patient
weight and ranged from 7.1 mCi to 16.0 mCi. The imaging was performed one hour after intravenous
injection of FDG, to allow clearance of FDG from blood pool. The amount of FDG uptake is
proportional to the metabolic activity of the cells, resulting in higher FDG uptake in the cancer cells
compared to normal cells. FDG uptake pattern in the cardiovascular lesions was analyzed visually and
intensity of FDG uptake was measured using standard uptake values (SUV).
Conclusions: FDG PET/CT is a useful diagnostic tool for characterization of cardiovascular masses.
Based on the intensity and pattern of FDG uptake, it can be predicted if the lesion is benign or
malignant. In newly diagnosed cases of cardiovascular malignancy, it can be used for staging and
analysis of disease burden. In known cases of cardiovascular malignancy, it is a useful diagnostic tool
to assess treatment response.
Key Words: PET/CT, Cardiovascular tumors.
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133
Imaging Findings of Prosthetic Cardiac Valves: Normal Appearance, Complications, and
Associated Findings
AZOK JT, Bhalla S, Gutierrez FR, Javidan-Nejad C, Woodard PK, Bierhals AJ
Purpose: 1. Review the expected post-operative appearance of prosthetic cardiac valves 2. Review
complications associated with prosthetic cardiac valves
Principal Information:1. Introduction 2. Imaging features of prosthetic cardiac valves on the chest
radiograph 3. Cross-sectional imaging features of prosthetic cardiac valves 4. Complications and
assessment of suspected prosthetic valve dysfunction
Conclusion: Prosthetic cardiac valves are commonly encountered in radiology. Knowledge of the
expected position on chest radiographs, the normal appearance on cross-sectional imaging, and
commonly encountered complications and associated findings is important for the radiologist. Clinical
examples of each of these topics will be presented. In addition, examples of abnormalities on gated
cardiac CT examinations such as pannus and thrombus formation and CT fluoroscopy will be
provided. Magnetic resonance imaging, although somewhat limited by metallic artifact, can also be
used to assess prosthetic valves. For purposes of infection, nuclear medicine studies can be helpful.
When applicable, correlation with echocardiography will be presented.
134
Anomalous Origin of the Right Coronary Artery with an Interarterial Course: 4 year Experience at a
Tertiary Care Center
AZOK JT, Cummings KW, Raptis CA, Gutierrez FR, Javidan-Nejad C, Bierhals AJ, Woodard PK, Bhalla S
POSTERS
Purpose: Anomalous origin of the right coronary artery with an interarterial course has been associated with
sudden cardiac death. Reported high-risk CT features include a slit like orifice, acute angle of origin, and an
intramural segment. Treatment is controversial. Identification of an intramural course is important as these
patients can undergo an unroofing procedure rather than coronary artery bypass.
Methods/Materials: 25 patients with anomalous origin of the right coronary artery with an interarterial course
who underwent a gated coronary CT angiogram were identified. Of these, 11 underwent surgery. The angle of
origin of the right coronary artery, the presence of a slit like origin, and the height to width ratio of the
interarterial segment were measured. These findings were correlated with the presence or absence of an
intramural course at surgery. Data was also collected from available stress tests and catheterization procedures.
Results: Of the 11 patients who underwent surgery, 6 had an intramural course, 2 did not, and in 3 the course
was unknown. All 6 patients with an intramural course underwent an unroofing procedure. The remaining
patients underwent coronary artery bypass (5) or a LeCompte maneuver (1). Patients found to have an
intramural course were more likely have a slit like orifice, an elliptical shape within the interarterial segment,
and an acute angle of origin. Three patients prior to surgery had positive stress tests in the right coronary artery
distribution.
Conclusions: CT findings suggestive of an intramural segment include an acute angle of origin, a slit like
orifice, and an elliptical shape of the interarterial segment. Not all patients with an interarterial anomalous right
coronary artery undergo surgery.
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135
Cardiac Calcifications: Beyond the Coronaries
SETHI V, Dennie C, Penna E, Peterson R
Purpose: Calcifications may develop in the cardiac valves, mitral annulus, myocardium and
pericardium. These are commonly encountered on imaging studies. This educational exhibit focuses
on recognizing the location and shape of these calcifications to help pinpoint their etiology and
potential clinical significance.
Educational Goals and Teaching Points:
-To illustrate the types of cardiac calcification based on shape and location on plain films and MDCT.
-To provide imaging clues to help differentiate each type of calcification.
-To discuss the potential clinical relevance of each type of calcification.
Key Imaging Points:The typical imaging features of calcification affecting the aortic and mitral valves
as well as the mitral annulus will be reviewed and illustrated to emphasize their clinical significance.
Imaging clues to differentiate pericardial from myocardial calcification will be illustrated through case
examples.
Less common types of cardiac calcification which may be encountered on cross-sectional imaging
will be shown such as calcification in cardiac tumors, intracardiac thrombi and diffuse calcification of
the myocardium post-sepsis, after prolonged severe hypotension or in the setting of renal failure.
Conclusion: Cardiac calcification can be a marker of increased risk of cardiovascular
morbidity/mortality. The amount of calcification may also predict the extent of underlying disease
.The radiologist should be aware of the significance of these imaging findings as they can have
important implications on patient management.
136
Esophageal Cancer Staging Essentials: The New TNM Staging System (7th edition) and
Clinicoradiologic Implications
KIM TJ, Hong SJ, Lee KW
Purpose: The intent of this exhibit is to review the new 7th edition of the TNM staging system of
esophageal cancer and its clinicoradiologic implications.
Results: Improvements in staging include new definition of Tis, T4, regional lymph node, N
classification, and M classification, and addition of the nonanatomical cancer characteristics:
histopathologic cell type, histologic grade, and cancer location. Stage groupings were constructed by
adherence to principles of staging, including monotonic decreasing survival with increasing stage
group, distinct survival between groups, and homogeneous survival within groups.
POSTERS
Methods: The diagnostic findings of esophageal cancer at CT, endoscopic US, and PET/CT were
reviewed, with emphasis on the advantages and limitations of these modalities in pretreatment staging.
Changes incorporated into TNM-7 for staging of esophageal cancer are discussed with particular
emphasis on clinicoradiologic implications.
Conclusion: Chest radiologists must understand the details set forth in the TNM staging system of
esophageal cancer and be familiar with the changes in the 7th edition, which attempts to better
correlate disease with prognostic value and treatment strategy.
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137
Diastolic Function as Assessed by Cardiac MRI Using Longitudinal Left Ventricular Fractional
Shortening
DHILLON GS, Thadani SR, Hope MD
Purpose: Diastolic dysfunction has been shown to predict cardiovascular events in multiple studies.
Although cardiac magnetic resonance (CMR) is the gold standard for determining left ventricular
volumes and systolic function, it is not routinely used to assess left ventricular diastolic dysfunction
(LVDF). Midwall longitudinal fractional shortening (MLFS) is a simple parameter that has been
shown to correlate with LVDF by echocardiography. We sought to assess this parameter in the
evaluation of LVDF with echocardiography measures as a reference.
Methods: 61 adult patients without congenital heart disease or prosthetic heart valves underwent
transthoracic echocardiography (TTE) and CMR. Diastolic function was graded by standard
echocardiography criteria as normal (0), impaired relaxation (I), pseudo-normal (II), or restrictive
(III). CMR analysis of MLFS was performed with steady-state free precession cine sequences in the 4
chamber plane by measuring changes in the distance between the base of the anterior mitral leaflet
and the apical endocardium.
Results: MLFS was 16.0% ± 5.3% in the 49 patients with grade 0 or I LVDF compared to 10.0% ±
6% in the 12 patients with grade II or III LVDF (p=0.001). Amongst 54 patients with a left
ventricular ejection fraction of at least 45%, the MLFS was 16.8% ± 4.5% in the 45 patients with
grade 0 or I LVDF compared to 12.0% ± 5.7% in the 9 patients with grade II or III LVDF (p=0.008).
Conclusions: In patients with normal or mildly reduced left ventricular systolic function, MLFS can
differentiate between those with significant diastolic dysfunction and those who have normal or
mildly impaired diastolic function.
138
Implantable Cardiac Conduction Devices on the Chest Radiograph - What Every Resident
Needs to Know
DIAS ALC, Hameed S, Hare SS, Ariff B, Mittal T, Kaneria S
POSTERS
Purpose: There are now a vast range of implantable cardiac conduction devices that radiologists
frequently encounter on chest radiographs. Often radiologist reports will make note of their presence,
however it is necessary that radiologists perform an accurate and scrupulous assessment in the early
correct placement and in the long term follow up of these objects including evaluation of any potential
complications.
Principal Information: This exhibit will educate the reader regarding:
1) The range of currently available and commonplace devices with a pictorial review of their normal
appearances:
a. Pacemakers - different types: single and dual chamber, biventricular b. Automatic implantable
cardioverter defibrillators(AICDs) c. Implantable cardiac monitors (e.g.Reveal devices)
2) What needs to be assessed?
a. Lead and generator placement with review of relevant cardiac anatomy
b. Lead integrity
c. Review areas
3) The awareness of, and how to review for complications with selected radiographic examples:
a. Acutely - e.g inadequate lead position, lead damage, signs of cardiac rupture,
pneumo/haemothorax
b. Longer term - e.g ‘Twiddlers’ syndrome, lead fractures, damage to insulation, lead displacement,
‘subclavian crush’ syndrome causing lead damage
Conclusion: Resident radiologists will come across cardiac conduction devices commonly in their
every day practice. The importance of their critical assessment in initial placement and long term
follow up of these objects is of paramount importance. This exhibit will make the reader more
confident in providing that accurate evaluation.
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139
CT Guided Percutaneous Core Needle Biopsy of Small versus Larger Lung Nodules: Diagnostic
Accuracy and Complication Rates
FAHRNER LJ, Cockrell CH, Parker M, Yu J, Singh NS, Bajaj HS, Thacker LR
Purpose: The purpose is to determine the diagnostic accuracy and complication rate of CT-guided
core-needle biopsy (CNB) for lung nodules less than 15 mm versus that of nodules larger than 15 mm
in diameter.
Methods/Materials: This study was granted an exemption by the institutional review board. 284 CTguided transthoracic lung nodule biopsies were performed from March, 2008 to January, 2011 using a
20-gauge or 18-gauge automated coaxial cutting needle device (Temno®, Cardinal Health, Inc,
Dublin, OH). 55 biopsies were performed on nodules less than or equal to 15 mm in dimension (mean
diameter 11.2 mm). 197 biopsies were performed on nodules greater than 15 mm in dimension (mean
diameter 35.8 mm). 32 biopsies were excluded. Biopsies were performed by radiology residents with
varying levels of experience and were supervised by attending radiologists with 6-23 years of
experience. Biopsy accuracy was determined by final pathology results, imaging findings, and a
retrospective review of clinical notes and patient charts. Complication rates were assessed with
follow-up imaging findings, and a retrospective review of clinical notes and patient charts.
Results: Overall biopsy accuracy was 81.8% for nodules less than or equal to 15 mm in diameter, and
97.0% for nodules greater than 15 mm (P=0.0002). Pneumothorax rate was 30.9% for small nodules,
and 19.3% for large nodules (P=0.0651). Thoracostomy tube insertion rate was 10.9% following CNB
of small nodules, and 8.6% following that of large lesions (P=0.6037).
Conclusion: CT-guided CNB of lung nodules smaller than 15 mm in diameter has a diagnostic
accuracy slightly less than that of larger nodules. The complication rates are similar for CNB of both
small and larger lung nodules.
140
BAC Is Dead! Acclimatization to the New Terminologies and the Radiological
Recommendations.
GAIKWAD A, Gupta A, Hare S, Gomes M, Sekhon H, Souza C, Lad S, Inacio J, Seely J
Purpose: International multidisciplinary classification of lung adenocarcinoma has introduced major
changes in terminology, the most important being discontinuation of the term bronchioloalveolar
carcinoma ‘BAC’. New terminology has been introduced and the purpose of this educational exhibit is
to review these changes from the radiologist’s perspective. Imaging spectrum of CT findings
according to histologic subtypes is displayed.
POSTERS
Principal Information: Recommended terms for the classification of adenocarcinoma and typical
corresponding radiological pattern:
1. Atypical adenomatous hyperplasia (AAH) commonly appears as pure ground glass opacity (GGO)
<5 mm.
2. Adenocarcinoma in situ (AIS) is usually seen as pure GGO > 5 mm.
3. Minimally invasive adenocarcinoma (MIA) commonly presents as a predominant GGO and a small
central solid component &#8804; 5mm.
4. Lepidic predominant adenocarcinoma (LPA) most often appears as subsolid lesion with solid
component measuring >5 mm.
5. Invasive adenocarcinoma, usually presents as solid nodule.
6. Invasive mucinous adenocarcinoma has spectrum of appearances and overlaps with nonmucinous
variety, but the non-solid component typically presents as consolidation (or airspace disease).
One important recommendation is to measure the size of solid component as well as total tumor size
of a part-solid lesion which has potential implications for TNM staging
Conclusions:
1. Adenocarcinoma has been better characterized and classified into new categories with different
prognosis and management.
2. The different types of adenocarcinoma present typical corresponding radiological features 3.Total
tumor size and size of solid component should be recorded.
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141
More Than Just a Veil of Ground-Glass: PneumoCystis Pneumonia (PCP) Unravelled
HAMEED S, Abdullah S, Goncalves A, Gupta A, Hare S
Purpose: To review:1. Historical changes in terminology reiterating that despite reclassification of
Pneumocystis Carinii to Pneumocystis Jirovecii, PCP remains the term of choice. 2. Critical
differences in clinical presentation of PCP in AIDS and non-AIDS immunosuppressed patients. 3.
Typical and atypical MDCT manifestations of PCP, using a temporal classification. 4. Imaging
findings in immune reconstitution inflammatory syndrome (IRIS) secondary to PCP.
Principal Information: 1. Overview of the opportunistic infection PCP with a discussion of recent
changes in nomenclature and changing epidemiological trends.
2. Pathophysiology of PCP infection using biopsy proven cases.
3. Pictorial review of acute, subacute and chronic PCP, including end-stage manifestations such as
interstitial fibrosis and cystic lung disease.
4. Pathology and imaging of IRIS, which classically presents with an organizing pneumonia pattern
on MDCT.
Conclusion: Despite re-classification of the human-specific pathogen Pneumocystis Carinii to
Pneumocystis Jirovecii, PCP remains the term of choice - however the term now refers to
PneumoCystis Pneumonia. Whilst the incidence in AIDS patients decreases, it is on the rise in the
non-AIDS-immunocompromised patient population, with a significantly variable clinical presentation.
This exhibit demonstrates the range of imaging findings in PCP including PCP-related IRIS, with an
emphasis on the temporal classification of MDCT findings, which enable a presumptive radiological
diagnosis in the appropriate clinical context.
142
The Fleischner Society’s Recommendations for the Follow Up of CT Detected Pulmonary
Nodules: A Program to Optimize their Implementation
BORGAONKAR J, Manos D, Miller R, Gale J
POSTERS
Purpose: The Fleischner recommendations for the follow up of CT detected pulmonary nodules are
based on nodule size and patient risk status (high or low risk of developing lung cancer). We observed
that risk status was rarely known by the reporting radiologist therefore the guidelines could not be
utilized accurately. The solution: Develop a program which allows the recommendations to be
applied.
Methods: A questionnaire to determine risk status was administered to all patients having thoracic CT
scans. When follow up was indicated, the patient was automatically booked for the follow up
appointment. Reports of approximately 1500 thoracic CT scans done before and after implementation
of the program were reviewed to assess the program’s impact.
Results: Prior to implementation of the program, when pulmonary nodules were detected, 2 options
for follow up were given in 21.4% of cases. Single recommendations were provided that were often
not in accordance with the Fleischer Society’s recommendations. Following implementation, a single
follow up recommendation in accordance with the guidelines was provided in 95% of cases. Patients
returned for follow up at the recommended interval 74.3% of the time versus 54.8% in the pre
program group. The patients lost to follow up decreased from 26.7% to 15.5%.
Conclusions: The program resulted in a statistically significant improvement in our ability to provide
a single follow up recommendation in accordance with the Fleischner Society’s recommendations and
in patients returning at the recommended interval. The number of patients lost to follow up also
significantly decreased. This program was established using existing resources and has been positively
received by physicians and staff.
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143
Low Dose Chest CT: An Estimate of Radiation Dose Reduction Compared to Standard CT.
GIARDINA JD, McGuire M, Rahmani N
Purpose: Recent studies recommend the use of low dose technique in chest CT, which has been
shown to provide sufficient diagnostic quality for many indications. In our outpatient imaging center,
we routinely use low dose CT in patients who require follow-up for intrapulmonary findings. Here,
we compare the reported dose-length product (DLP) of standard and low dose techniques in the same
patient, and estimate the effective dose reduction.
Methods and Materials: We retrospectively reviewed the CT dose reports of 50 patients who
underwent standard dose chest CT, and subsequent follow-up with low dose CT. All studies were
performed with GE Lightspeed scanners, with the generated dose reports based on a 32cm phantom.
The standard dose studies were performed with the following parameters: kVp120, auto mA, exposure
time 0.7. Low dose studies were performed with kVp 120. Selected mAs was based on patient weight
as follows: <135lbs - 60mAs; 135-200 lbs - 80mAs, >200lbs-120mAs. An estimate of effective dose
was calculated from DLP using the relatively conservative conversion factor of 0.017. The percent
dose reduction was calculated for each patient.
Results: Using DLP as a proxy for effective dose, 49 of 50 patients had a decrease in radiation
exposure from standard to low-dose technique. The median dose reduction was 43.7%.
Conclusion: Reducing patient exposure to ionizing radiation should be a top priority for all
radiologists. The use of low dose techniques in chest CT is an effective method for achieving this
goal without sacrificing diagnostic accuracy. Our data show that patients in routine follow-up can, on
average, benefit by a 43% reduction in dose by using relatively modest dose-reduction techniques.
144
Classic Radiographic Signs of Atelectasis: A Pictorial Essay
PERONE R, Talati RK, Chaudry A, Shroyer R
Purpose: The purpose of this exhibit is to visually delineate the classic radiographic signs of
atelectasis in the form of a pictorial essay. Recognition of the signs of atelectasis are critical to the
accurate interpretation of chest radiographs which remain an important initial imaging modality in the
radiologic workup. It is our intent that after reviewing this educational exhibit, the reader will
become familiar with many of the classic and important chest radiographic signs of atelectasis thus
strengthening his or her diagnostic interpretive skills.
POSTERS
Principal Information: In this educational exhibit we will summarize the important chest
radiographic signs of atelectasis. This will be accomplished in the form of a pictorial essay utilizing
chest radiographic imaging followed by a discussion of the related sign being illustrated. The content
of the discussion will include a visual description of the radiologic hallmarks of the sign as well as, if
appropriate, a differental diagnosis.
Conclusion: Chest Radiographs remain an important first line imaging modality in the radiologic
workup of a patient. The successful interpretation of chest radiographs is crucial and dependent on the
aquisition of a strong visual vocabulary of the classic chest radiographic signs and patterns of
pulmonary disease. It is our goal that by the end of the review of this educational exhibit, the viewer
will be familiar with the various presentations of atelectasis hence improving their diagnostic acumen
and facilitating the delivery of superior patient care.
51
145
Bronchioloalveolar Carcinoma (BAC): A Diagnosis of the Past
HERBST T, Galperin-Aizenberg M, Deshpande C, Gupta N
Purpose: Radiologic and pathologic pictorial summary of the new classification strategy of lung
adenocarcinoma and its effect on the practice of thoracic radiology.
Principal Information: The International Association for the Study of Lung Cancer/American
Thoracic Society/European Respiratory Society reclassified lung adenocarcinoma, and pathologic and
radiologic recommendations were made in early 2011. The term BAC is no longer used in this new
system. The new classification instead describes preinvasive lesions as either atypical adenomatous
hyperplasia (AAH) or adenocarcinoma in situ (AIS, formerly BAC). AAH is the earliest preinvasive
lesion for lung adenocarcinoma detectable by CT and appears as a small groundglass nodule (GGN).
Nonmucinous AIS typically presents as a pure GGN though sometimes as a semi-solid or
occasionally solid nodule. Mucinous AIS presents as a solid nodule or consolidation. Minimally
invasive adenocarcinoma (MIA) has a variable imaging presentation and has not been fully
characterized, though has been described as a partially solid nodule with a predominant GGN and a
small central solid component of &#8804; 5mm. Mucinous MIA appears as solid or part-solid
nodule. Invasive adenocarcinoma is often a solid nodule. Invasive mucinous adenocarcinoma
(formerly mucinous BAC) typically presents as a range of disease from nodules to lobar replacement.
Conclusions: It is important for radiologists to be aware of the new multidisciplinary classification
scheme of lung adenocarcinoma and the absence of the term “bronchioloalveolar carcinoma” from
this system. In addition to standardizing the terminology across medical disciplines, the classification
is important for biopsy planning and to support research investigation and clinical trials.
146
Thoracic Diagnostic and Therapeutic Interventions - From Biopsies to Thermal Ablation and
Beyond! What the Radiologist Needs to Know
POSTERS
LANDIS M, Chung T, Nguyen E, Patsios D, Kachura J, Yasufuku K
52
Purpose: Thoracic intereventions have long included diagnostic procedures such as percutaneous CTguided lung biopsies and some therapeutic procedures such as pleural drainage under sonographic/CT
and fluroscopic guidance.
With the development of newer minimally invasive techniques and partnering with other divisons such
as thoracic surgery and respirology, further image guided procedures have evolved. These now include
microcoil placement for preoperative localization of pure ground-glass nodules, thermal ablative
techniques for neoplasm (either primary or for solitary or oligometastatic disease) and endobronchial
ultrasound-guided biopsy techniques for mediastinal nodes and peripherally-located tumors.
In this exhibit, we will present: 1. our institutions experience with all of these established and
emerging techniques, 2. review the indications and periprocedural issues for each technique, 3. inform
the radiologist of how these emerging techniques currently and in the future may fit in to a patient’s
treatment algorithm.
147
Complications Following Various Esophageal Surgeries: Diagnostic Challenge and Pitfalls
SELVARAJAN S, Madan R, Trotman-Dickenson B, Hunsaker A
Purpose: Illustrate imaging appearances of normal post-operative appearance and complications
following various esophageal surgeries and discuss interdisciplinary management of common and
uncommon complications.
Extensive nature of esophageal surgery is associated with variety of complications which require
prompt diagnosis to avoid mortality and improve long term prognosis. We will illustrate the range of
expected post operative appearances following various types of esophageal resections like
pseudotumors, fluid collections, pulmonary edema, atelectasis, and hematoma. Additionally,
immediate and delayed complications like anastomotic site injuries including leaks and strictures,
mediastinitis, pneumonia, adult respiratory distress syndrome, chylothorax, hemothorax, various
fistulas (most commonly fistula between the trachea and gastric pull up and also rarer fistulas like
aorto-esophageal and esophageoperciardial fistulas) will be discussed. Various infectious
complications like osteomyelitis, discitis, mediastinal abscesses, empyemas requiring Claggett
window procedure will be illustrated. Finally, we will discuss our institutional imaging protocol to
address suspected early and delayed post operative complications.
Conclusion: Understanding imaging findings of normal post operative appearance following
esophageal surgery will prevent unnecessary further investigation and early diagnosis of various
complications will guide interdisciplinary management and improve morbidly and mortality.
Radiological Spectrum of Assisted Heart Failure Therapy
148
VUMMIDI D, Cascade P, Agarwal P
POSTERS
Purpose: There are several treatment options for cardiac failure unresponsive to medical therapy particularly
given the large number of patients awaiting cardiac transplantation. We would like to illustrate these innovative
treatment modalities, with potential complications. Key issues, imaging findings & techniques Multiple options
are available for treating advanced cardiac failure including mechanical cardiac assist devices, surgical procedures
designed to reduce wall stress, biventricular pacing, gene therapy and autologous cell transplantation to promote
cardiac repair. The role of radiology (radiographs, CT, MR& PET) in the assessment of ventricular assist devices,
surgical therapy and biventricular pacing will be discussed.
Format and organizational structure: This principles, radiologic appearances and complications of the following
techniques will be discussed:
I. Mechanical
For acute cardiogenic shock
IABP, Tandem heart (extracorporeal centrifugal continuous flow pump that withdraws blood from the left atrium
and pumps it into femoral arteries), Axial Flow pumps
For chronic decompensated heart failure
1. Extracorporeal
2. Intracorporeal
3. New advances- smaller, more compact devices
Axial Flow pumps
Centrifugal pumps
4. Total artificial Heart
II. Surgical reshaping of the dilated heart decreases wall stress thereby promoting reverse remodeling.
A. Batista procedure, Dor procedure.
B. Cardiomyoplasty
C. Mitral valve repair/replacement to reduce regurgitant volume.
III.
Biventricular pacing for patients with heart failure & intraventricular conduction delay
Conclusion: Increasing number of patients are being offered these therapeutic options as a bridge to transplant
given the relative stagnation in the number of donor hearts available. It is therefore imperative that all practicing
radiologists involved in cardiothoracic imaging are familiar with their appearances and complications.
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149
MR Imaging in Cardiac Amyloidosis: From Basic to Advanced
WEIHE E, Jeudy J, Kligerman S, Sosa F, White C
Purpose: Cardiac amyloidosis is a rare subset of diseases which involve extracellular deposition of
insoluble fibrillary protein precursors in the heart. This often results in a heterogeneous clinical
appearance of the disease that can confound diagnosis and delay appropriate therapy.
MRI has emerged as a powerful tool in the evaluation of cardiac amyloidosis. In addition to late
gadolinium enhancement, additional MR techniques such as T1 mapping and T2*, have been studied
to help further refine diagnosis. However, little is known as to whether the extent of findings on
cardiac MR in cardiac amyloidosis correlates with the clinical severity of disease and prognosis of the
patient.
This presentation will provide a state-of-the-art review of the MR assessment of cardiac amyloidosis,
including a discussion of basic and advanced MR techniques, and common MR findings in both
symptomatic and asymptomatic patients. Additionally, we provide our experience correlating imaging
findings alongside clinical biomarkers for further stratification of patient prognosis. This presentation
will be enhanced with links to web-based multimedia, providing interactive engagement with the
exhibit audience.
Conclusion: Cardiac MR imaging has an important role in the diagnosis and management of cardiac
amyloidosis with delayed enhancement being the principal finding in supporting the diagnosis.
Additional imaging findings may provide clinical information to better assess the patient’s risk
stratification and overall prognostic outcome.
150
The Many Causes of Calcification in the Pleural Space
POSTERS
JENSEN LE, Meyer CA, Yandow DR, Kanne JP
54
Purpose: This poster will provide a comprehensive review of entities associated with calcification in
the pleural space. Common causes reviewed include organizing hematoma, asbestos related pleural
plaque, and pyothorax. Tuberculosis and associated historical therapies - oleothorax and thoracoplasty
result in striking pleural calcification. Neoplastic processes that will be discussed include: fibrous
tumor of the pleura, osteosarcomatoid mesothelioma, and calcified metastases. Finally, unusual causes
of pleural calcification, pleurolith, and post-cholecystectomy intrathoracic gallstones are described.
Upon completion of this exhibit, the reviewer will be able to provide a thorough differential diagnosis
of entities associated with pleural calcification and possible distinguishing features.
151
Malpositioning of Thoracic Lines and Tubes: A Pictorial Essay
RALHAN T, Drosten R, Ornstein S, Trahan A
Purpose: Imaging serves as an important diagnostic tool for evaluating the position of various lines,
tubes and other thoracic devices and detecting related complications. Although malpositioning of
many lines and tubes may not be immediately life-threatening, some require rapid detection and
correction to avoid adverse outcomes. It is therefore important for Radiologists to know the function
as well as common complications associated with the various thoracic lines and tubes.
Principal Information: Chest X-ray and CT imaging features will be described that demonstrate
malpositioning or malfunctioning of commonly seen thoracic lines and tubes such as endotracheal
tubes, central vascular catheters, chest tubes, cardiac pacemakers, Swan-Ganz catheters and intraaortic
balloon pump catheters.
Conclusion: It is important to monitor the various indwelling thoracic catheters used in patients. A
systematic approach and knowledge of the radiographic features and complications of the common
indwelling lines and tubes is of the utmost importance.
152
Multidetector Computed Tomography Imaging of Tumors of the Trachea and Central Bronchi
GALPERIN-AIZENBERG M, Herbst T, Gupta N
Purpose: Pictorial summary of the heterogeneous benign and malignant tumors of the trachea and
main bronchi with emphasis on Multidetector Computed Tomography (MDCT) imaging.
POSTERS
Principal Information: Primary tumors of the trachea and main bronchi constitute only 1% to 2% of
all respiratory tract tumors. Presentation of these tumors is variable with symptoms of dyspnea,
cough, hemoptysis, asthma, stridor, hoarseness and dysphagia. Attributing these symptoms to other
etiologies cause delay in diagnosis, further compounded by missing the subtle findings on imaging.
Plain chest radiographs are insensitive and diagnose less than 50% tracheal tumors. Planar
tomography has a better sensitivity but MDCT has become standard to localize lesions and to institute
prompt treatment before the disease is advanced. Bronchoscopy depending on MDCT findings can
provide definitive airway assessment and can obtain tissue diagnosis. This exhibit aims to detail a
pictorial review of various MDCT techniques for acquisitions and post-processing. Imaging of
various malignant and benign tumors will be illustrated including common lesions as squamous cell
carcinoma, adenoid-cystic carcinoma and not so common lesions including mucoepidermoid
carcinoma, and carcinoids. Examples of secondary malignant involvement of trachea and benign
tracheal lesions will be illustrated.
Conclusion: MDCT has revolutionized the tracheobronchial imaging for noninvasive assessment of
tumor extent within the lumen, airway wall, and surrounding structures. Imaging plays a pivotal role
in the evaluation of the tracheal and central bronchial neoplasms in diagnosis and treatment planning
and radiologists should be cognizant of imaging appearance of various tracheobronchial tumors.
55
153
The Spectrum of Radiological Manifestations of Pulmonary Aspergillus Infection
DIAS AL, Hameed S, Gupta A, Goncalves ATC, Gomes MM, Hare SS
Purpose: Pulmonary aspergillosis is a fungal infection which may be associated with high mortality.
It encompasses a complex disease spectrum dependent on host immunity and pre-existing lung
disease. This review demonstrates the constellation of imaging findings in pulmonary Aspergillus
infection with clinicopathological correlation.
Principal Information:
1) Overview of clinical and histopathological features of pulmonary aspergillosis:
• Aspergilloma and its complications
• Bronchocentric granulomatosis
• Allergic bronchopulmonary aspergillosis (ABPA)
• Chronic necrotizing aspergillosis (CNA)
• Invasive pulmonary aspergillosis (IPA): Airways invasive, including aspergillus bronchiolitis,
and angioinvasive disease
2) Pathophysiology of the intimate relationship between host immunity and each of the above clinical
subtypes
3) Discussion of the changing epidemiological trends of Aspergillus infection
4) Pictorial review of typical and atypical findings on radiographs and MDCT for each clinical entity
5) Relationship to underlying lung disease with imaging examples:
• Mycetomas in pre-existing cavity (TB, sarcoid, lung resection)
• ABPA in asthma and cystic fibrosis
• CNA in chronic lung diseases such as COPD, TB, radiotherapy
6) Rationale for image-guided intervention in aspergilloma treatment with radiological examples of
intracavitary antifungal injection and arterial embolization
Conclusion: The clinical and radiological presentation of pulmonary aspergillosis is varied and
should be correlated with immune status and pre-existing lung disease. An awareness of the range of
imaging manifestations and complications is crucial to enable presumptive radiological diagnosis,
especially in the context of increasingly prevalent immune compromise.
154
Classic Chest Radiographic Localization Signs: A Teaching File
PERONE RW, Shroyer RJ, Talati R, Chaudry A, Lin CT
POSTERS
Purpose: This educational exhibit reviews the classical radiographic appearance of various
localization signs within the thoracic space. These localization signs highlight the knowledge
necessary for quick, accurate interpretation of thoracic imaging studies. This poster serves as an
important review for all radiology residents and junior attending radiologists. The information
presented is particularly relevant for those residents pursuing ER, Chest, or Body Radiology
fellowships.
Principal Information: Chest radiographs demonstrate numerous well-described signs which aid in
the three dimensional localization of pathology within the compartments of the thorax. Radiographic
signs indicative of pathology within the chest wall, pleural space, pulmonary parenchyma,
mediastinum, and hila will be discussed. A brief description of each sign and differential, where
appropriate, will be given.
Conclusion: Chest radiographs continue to be an important first line screening modality in the
detection of intrathoracic pathology. The chest is a complex three dimensional structure containing
many compartments; and, it is essential for the radiologist to have a thorough understanding of the
numerous chest radiographic localization signs for successful disease detection, characterization and
localization within the thorax.
56
155
Quantitative Diagnostic Imaging of Lungs and Airways in Patient with Asthma: Modern Imaging
Techniques and Their Clinical Implications
CHANGHYUN LEE, Laroia A, Hoffman E, Newell J, Thompson B, Stanford W, Mullan B
Purpose: Imaging techniques such as computed tomography, magnetic resonance imaging, and positron
emission tomography are providing metrics which may serve to identify new phenotypes associated with
asthma. The purpose of this presentation is to describe and illustrate examples of some of these modern
imaging techniques. Their clinical implications in patients with asthma will be explored and illustrated.
Principal information: # Modern imaging techniques
A. MDCT
- Central airway imaging
Quantitative airway measurement such as wall thickening, wall area, and wall area fraction
- Parenchymal density based imaging
- % Low attenuation area and air trapping
- Ventilation imaging
- Xenon-enhanced CT imaging using single and dual energy techniques
- Clinical implications
B. Functional MRI
- Hyperpolarized helium ventilation imaging
- Diffusion MR imaging
- Clinical implications
C. Other imaging modalities including PET-CT, SPECT and EBUS
Conclusion: Quantitative modern imaging techniques can provide useful data leading to an improved
understanding of pathophysiology of asthma. Knowledge of the clinical implications of quantitative radiologic
imaging techniques is helpful both to the radiologists and physicians in establishing new guidelines for the
clinical assessment of asthma.
156
Anatomy and Pathology of Structures Related to the Aortic Root as Demonstrated by MRI,
Cardiac CT, and TEE
WINKLER M, Attili A, Embertson R, Shah K, Hyde B, Sorrell V
Purpose: To demonstrate the importance of multimodality evaluation of the aortic root prior to
invasive therapies.
POSTERS
Principle information: The aortic root and extends from the aortic annulus to the sinotubular
junction and includes both the aortic valve and the ostia of the coronary arteries. It has both
complicated function and a complex three dimensional anatomy. Pathology processes in this region,
whether due to infection, congenital defect, or other cause, have both structural and physiological
components. These must be understood before treatment decisions are made.
Three robust and complementary imaging modalities, MRI, Cardiac CT, and TEE, can be used to
characterize the aortic root. The suitability and value of each modality varies somewhat from patient
to patient. However, for the most part, data from these studies are both complementary and
confirmatory. The risks associated with invasive therapies in this anatomic region are so great that
multimodality imaging is the best care for most patients.
In this exhibit a gamut of aortic root pathologies will be presented with multimodality imaging
correlation and discussion in each case of how each modality contributed to the management of the
case. Gross pathological and intraoperative images will accompany some of the cases.
Conclusion: MRI, Cardiac CT, and TEE are valuable and complementary modalities for the
evaluation of diseases of the aortic root.
57
157
Percutaneous CT-guided Sampling of Thoracic Lesions: A Comprehensive Review
SCHMIDLIN E, Vummidi DR, Kazerooni EA, Sundaram B, Arenberg D, Reddy R
Purpose: To comprehensively review CT-guided sampling procedures of thoracic lesions.
Principal Information: We will discuss the following topics.
1. Indications, contra-indications, tools and technical aspects of the procedures.
2. Compare the technique, success rates and complication rates of core biopsy and fine needle
aspiration and discuss the advantages and disadvantages to each.
3. Approaches to sample difficult lesions.
4. Techniques to enhance the diagnostic yield of the procedure.
5. Common and rare complications, techniques to reduce complications and management of
complications.
6. Performance figures for CT-guided sampling of both lung and mediastinal lesions.
7. Alternatives to CT-guided sampling such as video-assisted thoracic surgery (VATS) sampling and
navigational bronchoscopy.
8. Preoperative localization of nodules using both methylene blue dye and wire localization.
9. Radiation dose considerations to the patient and operator during the procedure.
Conclusion:It is important that the operator be familiar with the many dimensions involved in CTguided sampling of thoracic lesions. Utilizing proper technique to increase diagnostic yield and
minimize complications is necessary to have a successful procedure. Prompt diagnosis and proper
management of complications will decrease patient morbidity and mortality.
158
Metastatic Pulmonary Calcification: A Unique Presentation with Pictorial Review
POSTERS
OLSEN KM, Henry DA
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Purpose: The goal of this exhibit is to highlight an unreported presentation of metastatic pulmonary
calcification (MPC). We showcase a biopsy proven case of MPC presenting as diffuse, discrete treein-bud centrilobular nodules without definitive increased attenuation in a renal transplant patient,
mimicking endobronchial tuberculosis or atypical infection. Four additional cases of tree-in-bud
patterned MPC are presented, one of which evolved into and other which evolved from a well
described pattern of MPC. This new presentation is contrasted to the three well-documented CT
presentations of MPC: ill-defined, high density nodules; diffuse or patchy ground glass opacities,
usually high in attenuation; and high attenuating consolidation. A pictorial comparison between
MPC, pulmonary ossification, and dystrophic calcification is also demonstrated and clarified.
Additionally, we illustrate the radiologic spectrum of asymptomatic MPC to MPC leading to
respiratory failure, underscoring the clinical importance of this finding. We conclude that the
presentation of tree-in-bud nodules in patients with a predisposition to the development of MPC,
following exclusion of TB or other atypical infections, should include MPC, despite lack of
radiologically detectable calcium.
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An Approach to Perioperative CT Imaging of Cardiac Valvular Disease
ANCA N, Elliot T, Lydell C, Hutchinson S, Merchant N
Introduction: Echocardiography and MRI examinations remain the main examinations for structural
and functional cardiac valve assessment. Echocardiography is dependent on the operator and
interpreter skill and experience as well as it is limited by poor acoustic windows in a subset of
patients.
Purpose: To introduce a structured approach to the cardiac CT examination of cardiac valves, with an
emphasis on the preoperative requirements of value to the cardiac surgeon. CT imaging of the
postoperative complications of valve surgery will also be discussed.
Principal information: Contrast enhanced gated cardiac CT angiography (CTA) offers an invaluable
complementary evaluation given its larger field of view and spatial resolution. This additional
information can be invaluable for preoperative planning particularly in that subset of patients with
contraindications or limited echocardiographic and MR examinations.
Not only does CTA depict the structural features of the cardiac valves, it also allows for functional
characterization of the cardiac valves and left ventricle. It offers a detailed understanding of its
relation with the adjacent structures.
CTA also provides an opportunity to simultaneously assess the coronary arteries, where due to valve
pathology, a conventional angiogram may be relatively contraindicated. We also review the
postsurgical complications of valvular replacement such as perivalvular leaks, psuedoaneurysms or
perivalvular pannus.
Conclusion: This pictorial review presents an approach to perioperative CT imaging of cardiac
valves.
160
T2 Weighted Imaging of the Heart: A Review
ANCA N, Mikami Y, Lydell C, Elliot T, Howarth A, Merchant N
I n t r od u ct ion : Spin-echo techniques in CMR have been used for over two decades, primarily to image
cardiac anatomy. More recently, T2 weighted (T2W) CMR imaging has seen an increase in utilization
in CMR protocols, especially in the evaluation of myocardial tissue characterization of acute
myocardial processes. T2W imaging is sensitive to both regional as well as global increases in
myocardial water content.
Purpose: The purpose of this educational exhibit is to review T2W imaging in the heart.
POSTERS
P r in cip a l in for m a t ion : This discussion will initially review current methodologies of cardiac T2W
acquisition, the limitations of T2W techniques, and approaches to semi-quantitative and quantitative
analysis. The remainder of this review will demonstrate the appearance and clinical utility of T2W in
various myocardial processes such as acute myocardial infarction, acute viral myocarditis, Takotsubo
cardiomyopathy, cardiac transplant rejection and certain cardiomyopathies such as sarcoid and
hypertrophic cardiomyopathy.
C on clu sion : This educational exhibit will help the participant to better understand the implementation
of cardiac T2W imaging and its application in a number of clinical conditions.
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161
A Pictorial Review of Fatty Lesions of the Chest
GARCIA-MORALES F, Gupta P, Rice G, Donahue B
Purpose: The intent of this exhibit is to illustrate the imaging features of a variety of fat-containing
lesions of the chest primarily by anatomic distribution.
Methods: CT, MRI, PET-CT and plain film imaging features are described for fat-containing lesions
in the lung parenchymal, pleural cavity, heart, esophagus, rest of the mediastinum and chest walls.
Results: Fatty lesions by anatomical presentation: Mediastinal: neoplastic: lipoma, thymic tumors,
teratomas, and non neoplastic: mediastinal lipomatosis.Esophagus: Giant fibrovascular tumor with
predominantly fatty component. Cardiac: lipomatous metaplasia in ischemic cardiomyopathy,
lipomatous hypertrophy of the inter-atrial septum, Arrhytmogenic right ventricular dysplasia, .
Neoplastic mimics including prominent crista falciformis, juxtacaval fat. Lung parenchyma:
neoplastic: hamartoma, lipoma . Non neoplastic: lipoid pneumonia.Pleural lesions: Lipomas,
extrapleural fat.
Chest wall and MSK : elastofibroma dorsi, fatty metaplasia of the shoulder, lipomas.
Fat containing wall defects: Morgagni, Bochdalek and hiatal hernias.
Metabolically active brown fat: hibernomas, lipomatous hypertrophy of the interatrial septum,
paraspinal fat.
Conclusion: The identification of macroscopic fat within a thoracic lesion along with its specific
location within the chest reduces the differential diagnosis and usually leads to a more specific
imaging diagnosis avoiding additional diagnostic tests.
162
MR, CT, PET-CT and Echo-Cardiography of Cardiac Tumors in the Adults
GARCIA-MORALES F, Abdullah SM
Purpose: The intent of this exhibit is to demonstrate the imaging characteristics and locations of
cardiac tumors and their frequency as well as to understand the indications of the different imaging
modalities to assess cardiac tumors and non-neoplastic masses.
POSTERS
Methods: MR, CT, PET-CT, echocardiography and plain film imaging features are described for
various cardiac tumors of the adults , benign and malignant as well as non-neoplastic masses and
mimics.
Results: The prevalence of cardiac tumors by age, chamber location will be provided for benign and
malignant pathologies including myxomas, fibroelastomas, lipomas, primary angiosarcoma,
lymphoma, metastasis, etc. Mimics and non-neoplastic lesions will include intracavitary thrombus,
anatomical variants, asymmetric hypertrophic cardiomyopathy, pseudoaneurysm of saphenous venous
bypass grafts, etc.
Conclusion: Although primary cardiac tumors are rare, their location, size and imaging features can
help to provide an imaging diagnosis. The most frequent secondary malignancies of the heart can
usually be suspected by associated nearby or distant primary malignancies.
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163
Not Just Blowing Hot Air: Primer on Pulmonary Function Testing in Lung Diseases for the
Radiologist
CHUNG JH, Al Qaisi M, Saettele M, Lynch DA, Kanne JP
Purpose: 1. Review indications for pulmonary function testing (PFT).
2. Summarize the technical aspects of PFT.
3. Review the different categories of spirometric flow curves and quantization.
4. List differential diagnoses for various pulmonary conditions with case examples correlating HRCT
appearance and PFT.
Principal Information:
1. A low FEV1/FVC ratio indicates an obstructive pattern, whereas a normal value indicates either a
restrictive pattern or a normal test.
2. A normal FEV1/FVC ratio with a low FVC indicates a restrictive pattern; a normal value suggests a
normal pattern.
3. Decreased DLCO results from conditions which either decrease the exchange of oxygen at the
surface level of alveoli (emphysema, pulmonary fibrosis, pulmonary emboli) or interfere with
RBCs’ ability to bind oxygen (anemia).
4. Airway obstruction may be present in sarcoidosis, hypersensitivity pneumonitis, or collagen
vascular diseases (obliterative bronchiolitis).
5. An increased alveolar-arterial gradient can be found in many lung diseases and is greatest in UIP
and least in sarcoidosis. Smoking-related lung disease, berylliosis, and asbestosis demonstrate an
intermediate increase in alveolar-arterial gradient.
Conclusion: 1. PFT is a valuable tool in diagnosing and monitoring patients with lung diseases. 2.
Knowledge of abnormal PFT patterns and their concomitant differential diagnoses can help
radiologists in image interpretation.
164
Post- Lung Transplant Primary Graft Dysfunction: Distinctive Imaging Features
RABBANI S, Belperio J, Suh R, Gutierrez A, Brown K, Abtin F
Purpose: Primary graft dysfunction (PGD) is a more recognized complication following lung
transplant. It is a severe lung injury and major cause of early mortality. Its imaging features may
closely resemble more commonly diagnosed complications such as acute rejection or infection. This
exhibit will illustrate distinctive imaging features of primary graft dysfunction and features which
help in the differentiation of PGD from other complications after lung transplant.
POSTERS
Principal Information:
. Primary graft dysfunction is a form of acute complication post lung transplant which is potentially
treatable. On imaging it may resemble acute rejection or infection but the underlying etiology
differs.
. Imaging appearance is distinct. Knowledge of the imaging findings allows for correct pretreatment
diagnosis, as the clinical management differs from acute rejection, infection and other less common
complications during the acute phase of post lung transplant.
. Review of CXR and CT findings of primary graft dysfunction.
. Imaging differentiation between primary graft dysfunction and other complications following lung
transplant.
. Clinical and imaging outcome following treatment of primary graft dysfunction.
Conclusion: Knowledge of the distinctive radiologic appearance of primary graft dysfunction may
help refine diagnostic efforts by radiologists and aid in therapeutic efforts.
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Effect of Ambient Lighting on Optimal Viewing of Portable Chest X-ray Images
YANKELEVITZ D, Wang X, Foos DH, Jacobi AH, Henschke CI
POSTERS
Purpose: To quantify differences in optimal presentation of information content in portable chest
radiographs under different reading room ambient lighting conditions.
Methods: Forty digital radiographs captured in a surgical ICU were presented to readers who were
instructed to adjust brightness, latitude, and signal equalization to optimize overall quality. This
process was performed twice. In the first instance the radiologist performed readings in a darkened
room, typical of reading conditions for radiologists. In the second instance, readings were performed
in a lighted room such as is typical in the ICU suite where monitors are present at a nursing station.
Results: When images of large patients were viewed in the lighted room as compared to the darkened
room, readers increased image brightness by the equivalent of 0.13 film density units, decreased
latitude by 8%, and increased signal equalization gain by 8%. For images of thin patients, brightness
was increased by 0.20 film density units, latitude was decreased by 15%, and signal equalization gain
was increased by 18%.
Conclusion: The consistent preference for a brighter image with less latitude but greater degree of
signal equalization in the lighted room implies that a single standard automated display setting for
chest radiographs as is now commonly done is suboptimal. Depending on where the images are being
viewed, different settings should be used. The consistent increase in signal equalization gain to
achieve higher local contrast implies a loss of information content in the lighted room setting.
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As Low As Reasonably Achievable: Radiation-Free Evaluation of Pulmonary and Mediastinal
Diseases Using MRI
AL QAISI M, Chung JH, Lichtenberger JP, Puderbach MU, Biederer J, Schroeder JD, Lynch DA
Purpose: 1. Discuss the risks of ionizing radiation, particularly in regards to chest CT.
2. Summarize a proton MRI protocol optimized to evaluate lung parenchyma and the mediastinum. 3.
Demonstrate the multiple non-vascular conditions which can be diagnosed and followed using proton
MRI.
POSTERS
Principal Information: 1. Introduction
2. Risks related to iatrogenic radiation exposure 3. MRI protocol for pulmonary and mediastinal
assessment a. Coronal HASTE b. Coronal TrueFISP c. Axial BLADE d. Axial DWI e. Axial post
contrast VIBE 4. MRI imaging findings of various thoracic diseases with comparison to CT a.
Indeterminate pulmonary nodules. b. Lung cancer c. Sarcoidosis d. Cystic fibrosis e. Atypical
mycobacterial pneumonia f. Pleural and mediastinal diseases
Conclusion:
1. Iatrogenic radiation, particularly CT, is a useful tool but exposes patients to ionizing radiation,
which may potentially induce cancer based on the linear, no-threshold model.
2. MRI is a viable tool in assessing the thorax, including the lungs.
3. Given the lack of ionizing radiation, MRI is an ideal tool to follow patients with chronic lung
disease.
4. A potentially specific finding of sarcoid involvement of lymph nodes is the reversed target sign.
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169
Make it Interactive: Adding Audience Response to Your paper or Electronic Poster
GLADISH GW
Purpose: Generating and maintaining interest in a static exhibit is challenging. Methods for
improving interest include visual effects such as images and bold design elements. Electronic exhibits
can add movies and animation. However the widely available presentation systems focus on a linear
presentation and provide no method for assessing the readers understanding. Audience response
systems of have become widely available in oral presentations and are known to improve audience
attention and knowledge retention. This exhibit describes the use of a web-based audience response
system that can be run in parallel with an electronic or paper poster to provide an interactive
experience and assess user engagement and learning.
Principal information: The audience response systems typically used in meetings require specialized
hardware and support personnel. They are limited to a small number of questions per lecture to
maximize time for presentation of the material. These systems are not usable in conjunction with a
poster exhibit. Software audience response systems are available but may require a specific hardware
device and software installation. They may also require integration into the exhibit presentation
software. A free teaching oriented service called Socrative requires only a smartphone device with
Web access to allow reader participation. This exhibit describes the use of the Socrative software and
includes examples of implementing questions to provide interactivity in an educational or scientific
exhibit.
Conclusions: Use of Socrative software provides a method of adding audience response to an
electronic or paper poster through an easy web interface requires only a web connected smartphone
for reader interaction.
170
The Pulmonary Lymphoid System: A Review of Anatomy, Benign and Malignant Diseases.
LEWIS VA, Dhand S, Sirajuddin A, Galvin JR, Franks TJ, White CS
POSTERS
Purpose: To review the components of the normal lymphoid anatomy of the lung parenchyma as well
as the multi-detector CT imaging features of the major benign and malignant pulmonary lymphoid
diseases.
Principal Information: The pulmonary lymphoid system is a complex infrastructure composed of
lymphatics, intrapulmonary lymph nodes, bronchus-associated lymphoid tissue (BALT) and lymphoid
aggregates. Additionally, many different types of cells are involved in the pulmonary lymphoid system
including lymphocytes, plasma cells, and phagocytic cells.
Although lymphoid diseases involving the lung parenchyma are considered uncommon, they are
becoming increasingly recognized with the growing number of post transplant patients as well as
patients who are on immunosuppressive therapies. There is a large spectrum of lymphoid diseases
involving the lung parenchyma, ranging from benign to malignant, the majority of which arise from
BALT. These diseases are best evaluated with multi-detector CT in correlation with clinical
information and pathology. In this exhibit, the normal lymphoid anatomy as well as the major benign
and malignant pulmonary lymphoid diseases involving the lung parenchyma will be demonstrated.
Conclusions: The pulmonary lymphoid system is a complex system that gives rise to a large spectrum
of both benign and neoplastic pulmonary lymphoid disorders. Cross-sectional imaging with multidetector CT is helpful in the evaluation and diagnosis of these lesions.
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171
MDCT Angiography in Pulmonary Hypertension: Pictorial Review
LAROIA A, Lee CH, Laroia S, Thompson B, Stanford W, Mullan B
Purpose: Pulmonary hypertension is associated with poor prognosis if remains undiagnosed and
untreated. The radiologist plays a key role in both the diagnosis of pulmonary hypertension and
determining its etiology. The purpose of this study is to present a pictorial review of the MDCT
angiography findings seen in pulmonary hypertension.
Principal information: Definition and classification of Pulmonary Hypertension
Diagnostic tests including chest radiography, CT, HRCT, MR, echocardiography
MDCT angiography findings of pulmonary arterial hypertension including idiopathic pulmonary
arterial hypertension, chronic thromboembolic pulmonary hypertension, pulmonary hypertension
associated with lung disease, cardiac disease, AV shunts, HIV infection connective tissue disease.
Rarer causes including hepatopulmonary syndrome /portopulmonary hypertension and pulmonary
sarcoma. Pulmonary venous hypertension associated with cardiac disease and pulmonary venoocclusive disease.
What the clinicians wants to know from radiologist in a patient with dyspnea of unknown origin and
in a patient with known pulmonary hypertension.
Conclusion: MDCT angiography is useful for identifying underlying disorders and differentiating
among the wide variety of causes of pulmonary hypertension. Therefore, with the knowledge of its
imaging findings, radiologists can assist in management and improving outcomes.
172
Impact of Maximum Intensity Projection Images in Thoracic Imaging Interpretation: Lessons
Learned
TERNES T, Martínez-Jiménez S, Rosado-de-Christenson M, Kunin J
Purpose: To illustrate the value of maximum intensity projections (MIPs) in thoracic imaging
interpretation.
POSTERS
Principal Information: MIP images are created by summation of higher attenuation voxels from
groups of stacked images to generate single two-dimensional reformations. Such images are widely
used in vascular CT imaging but are not typically reconstructed in other protocols, as they may not be
deemed useful or practical (given the need to interpret additional images and the increased image
storage requirements). Three years ago, we began to routinely use coronal 10 mm thickness MIPs for
all thoracic CT studies. In our experience, beyond the routine use in vascular imaging, MIPs are also
useful in the evaluation and characterization of parenchymal, mediastinal and chest wall abnormalities
and can bring value to interpretation of chest CT in routine and emergent settings. Some examples
include: evaluation of pulmonary nodules for identifying calcification when not apparent on axial
images, highlighting different patterns of small lung nodules (e.g. bronchiolitis), fracture
characterization in the setting of trauma (e.g. costochondral and non-displaced sternal fractures), and
enhancing visualization of vascular abnormalities (e.g. pulmonary arteriovenous malformations, active
bleeding). In this exhibit we illustrate findings that could be overlooked on conventional CT imaging
but are clearly demonstrated on MIP reformations.
Conclusions: MIP imaging is useful in the daily evaluation of a variety of thoracic abnormalities.
Because of the limited number of generated images (approximately 20-30 per exam), the increased
time investment and image storage requirements are not significant.
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173
Coronary Artery Luminal area and Plaque Burden in South Asians and Non South Asians: A
Coronary CT Angiographic Assessment
O’BRIEN J, Wijesinghe N, Ramanathan K, Boone R, Taylor C, Hague C, Leipsic J
Purpose: Introduction: South Asians (SA) have reported higher prevalence of coronary artery
disease, higher mortality from myocardial infarction and a poorer outcome from coronary bypass
surgery compared to Non South Asians (NSA). Smaller coronary artery size in SA has been proposed
as a potential contributing factor for these adverse outcomes, although this has not been established.
Our aim was to evaluate coronary artery luminal area and atherosclerotic disease burden between SA
and NSA using CCTA.
Methods: Self-identified SA individuals and matched NSA individuals underwent 64-detector CCTA.
Patients were matched for gender, age, body surface area, and coronary dominance. Each received 0.4
mg sublingual nitroglycerin prior to the CCTA. 2 radiologists, blinded to details, measured ostia and
luminal areas of proximal coronary arteries as well as the presence of disease.
Results: 88 subjects were included in both groups. There was no difference in incidence of
dyslipidemia, diabetes, hypertension and smoking history. SA individuals had smaller mean coronary
artery areas for all vessels: Left main coronary artery: 17.4+/-4.7 mm2 v 18.3+/-4.2 mm2 (p= 0.2),
LAD: 12.0+/-3.5 mm2 v 13.3+/-3.6 mm2 (p =0.02). LCX: 10.6+/-3.7 mm2 v 11.9+/-4.1 mm2
(p=0.03), RCA: 12.5+/-5.0mm2 v 13.9+3.8 mm2 (p=0.03). Both cohorts had the same burden of
obstructive disease; SA 11.5% v NSA 11.5% (p=1.0), however SA had a higher prevalence of
atherosclerosis SA 62.2% v NSA 44.8% (p=0.04).
Conclusions: SA individuals have significantly smaller coronary artery diameters and prevalence of
coronary atherosclerosis then matched NSA. These findings may play a role in the higher CAD
related rate of morbidity and mortality experienced by South Asians as compared to Non South
Asians.
174
Lateral Chest Radiograph
LEE ES, Paik SH, You YW, Hwang DH, Lee KS
Purpose: The intent of this exhibit is to demonstrate various thoracic lesions encountered on lateral
chest radiograph.
POSTERS
Conclusion: Some of thoracic diseases not well seen on frontal chest radiograph. But lateral chest
radiograph can help in diagnosing some thoracic abnormalities and exhibiting extent of the lesions. In
this exhibition, the authors tended to describe various thoracic abnormalities best seen on lateral chest
radiograph.
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175
Isolated Branching Peripheral Opacity: A CT Finding Suggestive of Malignancy
WATSON B, Teel G, Loewen G
Introduction: The purpose of this study was to review a series of cases with the chest CT finding of
isolated peripheral branching opacity (bronchocele) and determine the significance of this finding
with relation to pathologic diagnosis.
Methods/Materials: Retrospective review was performed of 9 cases involving the chest CT finding of
isolated peripheral bronchocele in which a pathologic diagnosis was obtained. Case review included
CT findings, initial imaging interpretation, biopsy technique used to secure tissue, and pathologic
diagnosis. Time interval and tumor staging between initial imaging and final diagnosis was also
reviewed. A literature search and analysis was then performed to support or refute conclusions.
Results: 6 of 9 cases reviewed had a pathologic diagnosis of malignancy, and 83% of those
malignancies were of neuroendocrine origin, with 3 cases of small cell carcinoma, 1 case of mixed
small cell and non-small cell carcinoma, and 1 case of carcinoid. There was 1 case of squamous cell
carcinoma.
Conclusion: Peripheral airway bronchiectasis with mucoid impaction is a common imaging finding in
benign small airways disease. However, when isolated to a single subsegmental airway, this finding
may signify an endobronchial tumor, most likely of neuroendocrine origin. This represents a specific
radiologic presentation of endobronchial malignancy that has not been previously described in the
literature.
POSTERS
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