2017 SUNDAYIMAGE INTERPRETATION SESSION
1938’s “Innovation”:
refresher courses
Desiree E. Morgan, MD
Vice Chair of Education
Professor of Radiology
University of Alabama at Birmingham
Desiree E. Morgan, MD
>100 peer-reviewed publications
>15 book chapters
>130 national & international invited lectures
Director MRI, Vice Chair Clinical Research, Director Human Imaging Shared Facility, Residency Program Director
Service: SAR, ABR, ACR, RSNA, ARRS, AUR, SCBTMR
>20 teaching & service awards
Brewer-Heslin Award for Professionalism, UAB
DESIREE E. MORGAN, MD
BS, Magna Cum Laude, Univ. of Georgia
MD, Medical College of Georgia
Residency, U. of Alabama at Birmingham
Faculty, UAB
Professor & Vice Chair Education, UAB
2017 RSNA IMAGE INTERPRETATION SESSION
Desiree E. Morgan, MD
RSNA SUNDAY AFTERNOON IMAGE INTERPRETATION SESSION 2017
RSNA Diagnosis LiveTM-
Go to: live.rsna.org → Sign on → Join session PS12
RSNA SUNDAY AFTERNOON IMAGE INTERPRETATION PANEL
• The PROCESS:
• Invite panelists, convince them this will be fun….
• Assure that cases will be gettable and once they agree- maybe not so much
• Gave panelists a single slide from each case as a sneak peek in June
• Provide full case material in July
• Hear the sweat, try to be supportive, work on nice photos, select dinner menu and wines
• The result: This afternoon’s adventure……..AND you will be a part of it!
RSNA Diagnosis Live - Go to: live.rsna.org → Sign on → Join session PS12
RSNA Diagnosis Live - Go to: live.rsna.org → Sign on → Join session PS12
RSNA SUNDAY AFTERNOON IMAGE INTERPRETATION PANEL
• The Theme: Mentoring
• A mentor is defined as “someone who teaches or gives help and advice to a less experienced and often younger person.”
• “The price of having an effective mentor or sponsor is an obligation to pay that forward.”
McGinty G. Choosing Wisely: Mentors, Sponsors, and Your Kitchen Cabinet
JACR 2017 DOI: http://dx.doi.org/10.1016/j.jacr.2017.07.006
RSNA Diagnosis Live - Go to: live.rsna.org → Sign on → Join session PS12
RSNA SUNDAY AFTERNOON IMAGE INTERPRETATION PANEL
• The Theme: Mentoring
• A mentor is defined as “someone who teaches or gives help and advice to a less experienced and often younger person.”
• “The price of having an effective mentor or sponsor is an obligation to pay that forward.”
McGinty G. Choosing Wisely: Mentors, Sponsors, and Your Kitchen Cabinet
JACR 2017 DOI: http://dx.doi.org/10.1016/j.jacr.2017.07.006
RSNA DIAGNOSIS LIVE
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Join session PS12
DIAGNOSIS LIVE QUESTION:
What is your subspecialty area of Radiology?
Molecular Imaging
Musculoskeletal
Neuro
Pediatric
Radiation Oncology
Other
General practice
Abdominal
Breast
Cardiothoracic
Emergency
Medical Physics
DIAGNOSIS LIVE QUESTION:
Which term best describes your practice?
A. Academic
B. Private
C. Government
D. Hybrid
THE PANELISTS:
All play a critical role in the development and mentoring of our trainees and beyond
ANGELISA PALADIN, MD, MS
• Program Director DR, U Washington since 2007
• Prof of Rad at U Washington and Children’s Regional Med Ctr
• BA, Smith College
• MS and MD, Chicago Medical School
• Diagnostic Radiology, UT Southwestern
• Pediatric Radiology Fellowship U Washington, Children’s Hospital and Regional Med Ctr
• ABR 1998; CAQ Peds in 2000; assistant PD U Wash 2000-2007
• Board of Directors, AUR, APDR; Exec Committee ACER, ARRS
• *Award-winning Educator and Mentor Extraordinaire!
ANGELISA PALADIN, MD, MS
• 2011- Mentor of the Year, U Wash Dept Radiology
• 2012- Stauffer Award, Academic Radiology, Co-author of Best Education Paper published in 2012
• 2013 American Roentgen Ray Society Distinguished Educator Award
• 2014 ACGME Parker J. Palmer Courage to Teach Award- Bestowed on 10 program directors (out of 9200 nationally!)
• 2014 Whitley Award (AUR) Co-author of Best Education Paper
• 2014 Gold Humanism Honor Society
• 2016 ACER Achievement Award
ANGELISA PALADIN, MD, MS
ANGELISA’S MENTOR
• My most influential mentor is Norm Beauchamp. He instills in everyone that works for him to strive for excellence and make an impact in everything they do. His leadership style is one inspired by confidence, humility and compassion.
PEDIATRICS CASE 1-NEWBORN GIRL
Difficulty breathing at birth
DIAGNOSIS LIVE QUESTION:
What would you do next?
A. Resign from the film panel
B. Neck US
C. Neck/chest CT
D. Neck MRI
E. Lab test of some sort
PEDIATRICS CASE 1-NEWBORN GIRL
NECK SONOGRAPHY DAY 1
CONTRAST ENHANCED CT NECK AND CHEST, T2 MRI
LABS
AFP 45418 ng/mL
HCG 1.79 mIU/mL
SUMMARY OF FINDINGS
Right neck heterogeneous avascular mass involving thyroid
Deviates esophagus and trachea
Contains cysts and calcifications
SUMMARY OF FINDINGS
Thin septal enhancement
Normal AFP and HCG for a newborn
AFP 45418 ng/mL
HCG 1.79 mIU/mL
DIFFERENTIAL DIAGNOSISNEONATAL NECK MASS
Congenital
• Lymphatic malformation
Neoplastic
• Neuroblastoma
• Teratoma
DIFFERENTIAL DIAGNOSISNEONATAL NECK MASS
Lymphatic Malformation
Congenital neck mass
Cysts
Thin enhancing septa
Avascular
Calcification
Large solid components
Thyroid
DIFFERENTIAL DIAGNOSISNEONATAL NECK MASS
Neuroblastoma
Congenital neck mass
Calcifications
Elevated Catecholamines
Cysts
Vascular
DIFFERENTIAL DIAGNOSISNEONATAL NECK MASS
Teratoma
Congenital neck mass
Calcifications
Cysts
Avascular
Involves the thyroid
THYROID TERATOMA
Symptoms: Stridor, dyspnea, dysphagia and polyhydramnios (30%)
Germ cell tumors consist ectoderm, mesoderm and endoderm
Presence of multiple calcified foci and or fat highly suggestive of teratoma
THYROID TERATOMA
Serum alpha feta protein can be used as a marker of malignancy
Majority of neonate teratomas are mature or immature histology -benign
If cervical teratomas present within thyroid gland or if thyroid gland is continuous with tumor -thyroid origin
DR. PALADIN’S DIAGNOSIS
Cervical Teratoma of Thyroid Origin
THE DIAGNOSIS:
Right Thyroid Teratoma
THYROID TERATOMA
Origin:
• Cervical teratomas most common neck tumor in infants, but thyroid primary site of teratoma rare
• Conundrum- ? arising within or adjacent to thryroid gland
Intimate intermingling of thyroid tissue with teratoma and presence of a pseudocapsule = criteria for establishing thyroid origin
Neuroglial tissue predominates
Immaturity of histology NOT harbinger of adverse behavior as seen in adolescents and adults
Reidlinger et al. Am J Surg Pathol. 2005 May;29(5):700-6.
JIM ANDERSON, MD
• Program Director, Oregon Health & Science University since 2006
• Prof of Radiology, OHSU
• BS, University of Nebraska
• MD, University of Nebraska School of Medicine
• Diagnostic Radiology, University Kansas Med Center – Wichita
• Neuroradiology Fellowship Vanderbilt University Medical Center
• ABR 1997; CAQ Neuro 2002/2012; Assoc PD 2001-2006 + Neuro PD 2003-2017@OHSU
• Section Chief Neuroradiology since 2006
• *Chair, Radiology Review Committee ACGME
JIM ANDERSON, MD
• 2001 Radiology Teacher of the Year Award, Vanderbilt University Medical Center
• 2001 Silver Hammer Teaching Award, Department of Neurology, OHSU
• 2003 Outstanding Teacher of the Year Award, Diagnostic Radiology, OHSU
• 2004 Silver Hammer Teaching Award, Department of Neurology OHSU
• 2008 Chief Resident’s Teaching Award, Department of Internal Medicine OHSU
• Committees: ASNR (including Fellowship Directors Committee), ARRS, APDR
JIM ANDERSON, MD
2012 ACGME:
• RRC Diagnostic Radiology
• Chair, Residency Review Committee for Diagnostic Radiology
• Subcommittee on Program Requirement Development for Interventional Radiology/Diagnostic Radiology
• Chair, Milestones Writing Subcommittee for Neuroradiology
• Chair, Hospital Based Committee of RRC chairs
• Committee of Review Committee Chairs
JIM’S MENTOR
• Tom Dina, MD
• Radiology Program Director at Vanderbilt
• Inspired me to become a program director and commit to developing a strong program training excellent residents
NEURO CASE 1- 23 YEAR OLD MALE IN MVC
He sustained several fractures including left clavicle and femur; on arrival patient was conscious and oriented with a Glasgow Coma Scale 15/15
DIAGNOSIS LIVE QUESTION
Does the brain appear normal?
A. Yes
B. No
NEURO CASE 1- 23 YEAR OLD MALE IN MVC
He sustained several fractures including left clavicle and femur; on arrival patient was conscious and oriented with a Glasgow Coma Scale 15/15
INITIAL THOUGHTS
• No readily apparent intracranial injury
• History indicates significant other injuries. However, GCS is 15
• Subtle abnormality possible in frontal bone +/- scalp contusion
• Would need to see soft tissue and bone windows to see if that is real or something else
• At this point with no clinical findings to indicate neurological abnormality would get a standard "no acute intracranial abnormality" dictation
CHEST CT
The patient became short of breath within 24 hours and was intubated; mental status deteriorated→ coma
CHEST CT ?????
• Am I suppose to interpret this?
• Looks worse, hope it doesn’t need some special pulmonary knowledge
• That knowledge jumped off the iceberg a long time ago
© Comstock Images/Jupiterimages
MENTAL STATUS CHANGE AND COMA
• With chest findings and clinical deterioration and the initial history of fractures I would be wondering about:
• Fat emboli – history is good for that
MENTAL STATUS CHANGE AND COMA
• Other thoughts …
• DAI
• Can have a normal appearance initially or not be detected on CT
• Would be highly unlikely with initial GCS of 15 (usually 8 or less)
• There could have been occult SAH with subsequent vascular spasm and infarct
• Vascular injury with subsequent intracranial findings
REPEAT NONCONTRAST HEAD CT, GADO MRI
24 hours
24 hours
BRAIN MRI, CONT
CT AND MR IMAGES – 24 HOURS LATER
• CT – still nothing
• MRI – T2 hyperintensities in white matter primarily in centrum semiovale, mostly a watershed distribution. Micro hemorrhages diffusely.
• No images suggesting corpus callosal injury or lesions predominately at grey/white junction
ANDERSON DIAGNOSIS: CEREBRAL FAT EMBOLISM SYNDROME
• Fat Embolism Syndrome:
• Often initially stable
• Pulmonary findings often precede neurological findings/symptoms
• Differential:
• DAI would still be a potential consideration however initial GCS, lack of CC involvement, and the concurrent pulmonary involvement suggest Fat Embolism Syndrome
CEREBRAL FAT EMBOLISM SYNDROME
• 2 mechanisms
• Fat emboli (fat globules) causing microinfarcts and potentially microhemorrhages
• Free fatty acids cause cytotoxic effects cause increased capillary permeability which can also lead to microinfarcts and microhemorrhages
• Findings often in watershed territories
DR. ANDERSON’S DIAGNOSIS
Cerebral Fat Embolism Syndrome
THE DIAGNOSIS:
Cerebral Fat Embolism Syndrome
CEREBRAL FAT EMBOLISM MRI
CFE
DAI
• Lesser # hemorrhages
• White/gray junction
• Small to medium linear foci
• Few scattered DWI abnormalities
• Greater # hemorrhages
• Predominantly frontal
• Punctate, round foci
• Confluent DWI abnormalities
Rutman et al. J Comput Assist Tomogr. 2017 Jul 13. Epub ahead of print PMID: 28708729
Goenka et al. N Engl J Med 2012; 367:1045September 13, 2012DOI: 10.1056/NEJMicm1100944
EVA LLOPIS, MD
• Facultad de Medicina, Valencia, Spain
• Radiology, Hospital La Fe de Valencia
• MD, Valencia University
• Diagnostic Radiology, Valencia University
• Chair MSK section, Hospital de la Ribera, Alzira, Spain
• President, of Spanish Musculoskeletal Radiology Society (2015-2019)
• Executive Board ERASMUS COURSES ON MRI
• 2017 Secretary of European Society of Musculoskeletal Radiology (ESSR)
• Scientific Committee: SERAM, ESR, ESSR
• ECR Program committee
• Faculty who started a new department in a new hospital and has 25 years of seeing it grow!
EVA LLOPIS, MD
EVA’S MENTORS
• Dr. Francisco Aparisi
• For involving me in skeletal radiology
• For inspiring me to keep innovating and enjoying work
• For teaching me a different way of interacting with clinicians
• Dr. Mario Padron
• For promoting me in the international societies and his continuous support
• Dr. Luis Cerezal
• To keep pushing to get the best out of me
MSK CASE 1- 23 YEAR OLD MAN
He awoke 3 weeks earlier with spontaneous swelling in his ankle, no injury recalled
US 4 WEEKS LATER- MORE ANKLE SWELLING AND CC “BLOOD COMING OUT OF MY ANKLE”
REPEAT RADIOGRAPHS AT TIME OF US
Presentation
4 weeks
ANKLE MRI NEXT DAY
CHEST CT- NONCONTRAST
He had been on therapy for a chronic skin condition, and a chest CT was obtained
CXR 5 years prior
Present CT chest
MSK CASE 1-FINDINGS
ANKLE
SOFT TISSUE & BONE
CHEST INTRAPULMONARY NODE
KIDNEY
US
CUTANEOUS LESIONS
MSK CASE 1-
ANKLE
•Lyticlesionwithscleroticborder&BME•
Rapidlyincreasingsofttissueswelling•
HeterogenouswithperipheraldopplerUS&thickwallenhancementonMR•
Inflammatorysignsinthesurroundingfat•
Fistulaopeningtotheskin•
Achillestendondisplaced
• Skin: ulcerations & bluish areas
CHEST CT
MSK CASE 1-CT FINDINGS
• Chest X-ray, 5 years ago, normal.
• Location
• Anterior mediastinum (lymph nodes, ectopic parathyroid, thymus)
• Intraparenchymal
• Solitary pulmonary nodule
• No calcifications, no fat
• Well defined
• Central low density (non contrast CT) thick wall
MSK CASE 1-FINDINGS
KIDNEY DISEASE
• Normal corticomedullary differentiation & shape
• Normal doppler, normal resistance index ratio, 0.59
• Abnormal location: too close to the skin
RENAL TRANSPLANT
IMMUNOSUPPRESSED PT
SKIN CONDITION
CUTANEOUS LESIONS
MSK CASE 1-
Immunosuppressed patient sec. to renal transplant medication
renal osteodystrophy vs steroids
• Horizontal metaphyseal line
• Rapidly progressive granulomatous lesion in the ankle in bone & soft tissue & skin
• Pulmonary solitary low density node
LESS PROBABLE
INFECTIONS
• Fungal
• Mycobacterias
• Other: nocardia, bacillary angiomatosis
TUMOUR
• Lymphoma
• Kaposi
INFLAMMATORY
• Sarcoid
• Wegener G
MSK CASE 1-
Complications in SOT
Skin & bone granuloma
Solitary nodule low density
FUNGAL, 47%
Blastomycosis, mucormycosis, coccidiodomycosis
FUNGAL, 33%
Actinomycosis, Aspergillus, coccidio., blasto.
1
2
3
1
2
3
BACTERIA, 28%
• Mycobacteria
• Nocardia
BACTERIA, 22%
• Mycobacteria
• Nocardia
NEOPLASM, 30%
• Postranplant lymphoproliferative disorder
NEOPLASM, unknown%
• Postranplant lymphoproliferative disorder
• Others SCS, BCS, MELANOMA , KAPOSI
LYMPHOMA
1
• Less rapidly progressive• Lymph nodes• Homogenous attenuation
A
BACTERIA
• Nocardia
• Mycobacterias
2
• Indolent course, dot in circle• Solitary nodule: cavitation uncommon, calcium, lymph nodes• Extrapulmonary (ankle rare)
B
• Time elapsed & geographics• Target organ • Lung, mycetoma• Osteoarticular granulomas
FUNGAL
3
MSK CASE 1-
Post transplant invasive fungal infection
• Immunosuppression
• Time elapsed
• Early candida > aspergillus (90d)
• >6m (coccidioidomycosis; histoplasma; blastomycosis; cryptococcus)
• Medication
• Geographic location (coccidioidomycosis; histoplasmosis )
• Target organ: lung; CNS; osteoarticular; skin
DR. LLOPIS’ DIAGNOSIS
Post-Transplant Invasive Fungal Infection
THE DIAGNOSIS:
Post-Transplant Ankle Fat Pad Cryptococcosis
CRYPTOCOCCAL CELLULITIS
Fungal infections account for 5% of all infections in renal transplant recipients
Type of infection and risk factors differ depending on the period after the kidney transplant
Aspergillus species, Mucorales species, Candida species, and Cryptococcus neoformans are most common opportunistic fungi
Cryptococcal disease in solid organ transplant recipients:
disseminated or involves the CNS 53−72%
pulmonary 54%
skin, soft-tissue or osteoarticular 8.1%
Patel et al. Infections in solid-organ transplant recipients. Clinical Microbiology Reviews 1997; 10, (1), 86–124
Singh et al. Cryptococcosis in Solid Organ Transplant Recipients: Current State-of-the-ScienceClin Infect Dis. 2008 Nov 15; 47(10): 1321–1327
MARTA HEILBRUN, MD, MS
• Vice Chair for Quality Emory University (October 2017!!)
• Assoc Prof of Rad Emory University
• (Former) Program Director, U Utah 2014-2017
• BA, Amherst College
• MD, U Utah
• Abdominal Imaging Fellowship, U Utah
• Masters of Science in Clinical Investigation, U Utah
• ABR 2006; 2007 Assistant Prof Radiology; Adjunct Assist Prof Bioinformatics U Utah
• AUR Board of Directors, Executive Committee AAWR; Committees ABR, ACR, RSNA, AUR
• *Research mentoring of students and trainees!
MARTA HEILBRUN, MD, MS
• Research Focus: Works with data visualization scientists and experts in natural language processing and machine learning to explore and define the impact that diagnostic imaging tests have on disease outcomes
MARTA HEILBRUN, MD, MS
• 1993 Echoing Green Public Service Entrepreneur Fellowship
• 2005 American College of Radiology Thorwarth Award for Socioeconomic Research
• 2006 RSNA Roentgen Resident/Fellow Research Award
• 2006 Radiological Society of North America Trainee Research Prize
• 2007 GERRAF
• 2009 Scientific Paper Award Society of Uroradiology
• 2014 Fellow of the Society of Abdominal Radiology
MARTA’S MENTORS
• My mentors are those who have pushed me to go beyond learning and truly think about the problems we are being asked to solve.
• 1. Village concept- I have many many mentors, some have been in the institutions where I have trained and worked, and many I have met through my involvement in radiology professional societies: Limiting myself to radiologist mentors: Felix Chew, Ron Zagoria, Jeff Carr, Dave Avrin, Jerry Jarvik, Paula Woodward, Anne Kennedy, Akram Shaaban, Kathryn Morton, John Leyendecker, Julia Fielding, Mark Lockhart, Curt Langlotz, Chuck Kahn …. The list is truly endless. I am still meeting mentors and now growing the peer mentoring relationships, where we are supporting eachother in our research and academic career development, while increasing my role in mentoring others.
• 2: Paula Woodward. While I have certainly learned a tremendous amount of radiology from Paula, following in her footsteps as a GU imager, she has also strategically and actively pushed me outside of my comfort zone and into growth opportunities and my entire professional career.
ABDOMINAL CASE 1- 65 YEAR OLD WOMAN
She presented with pelvic pain and had history of a remote hysterectomy
DIAGNOSIS LIVE QUESTION:
What would you do next?
A. Doppler US to detect presence or absence of flow
B. Review of prior imaging
C. Surgical consultation before pelvic MRI
D. Check CA-125
E. Find out why she had hysterectomy
65 YEAR OLD WOMAN WITH PELVIC PAIN
2015
CONTRAST ENHANCED ABDOMINOPELVIC CT
2015
She developed gross hematuria and was scanned 2 weeks later
Cystoscopic biopsy/TUR: benign urothelial tissue, no malignancy; chronic inflammation; pelvic mass biopsy: similar histomorphology to a 2012 pelvic massCD 10 and ER positivity
MRI 3 MONTHS LATER, PERSISTENT HEMATURIA
2015
COMPARISONS
In total, there were four biopsies, two of them surgical excisions, from 2012-2015
A definitive procedure was performed in 2016
2016
2012
FINDINGS
• Initial 2015:
• US: 7 cm hetergeneous cystic and solid adnexal mass with vascular flow
• CT: Mass is inseparable from vaginal cuff on L, L ureter is encased but no hydro
• MRI: Mass has grown rapidly, no fat is present in lesion
• Comparisons
• 2012: More solid, clearly arising from L vaginal fornix, not ovarian/tubal
• 2016: Recurrence along laparotomy incision
• Clinical: Post menopausal, remote hysterectomy, mass is ER+/CD10+
• Recommendations: Surgical consultation/resection
DISCUSSION: WHERE DID THE MASS START?
• If Adnexa: What benign/low malignant potential lesions could this be?
• Endometrioma with malignant transformation: Most commonly will be clear cell carcinoma
• Will be CD10+/ER+
• Tends to occur in younger women, need a hx of endometriosis
• If Uterine: What benign/low malignant potential lesions could this be?
• Endometrial Stromal Sarcoma
• Will be CD10+/ER+
• Tends to occur in younger women, with late recurrences
• Cervical CA/Endometrial Ca/Uterine carcinosarcoma
• Will be aggressive
DR. HEILBRUN’S DIAGNOSIS
• Surgical lesion: Will need detailed histopathology to determine the etiology
• My best assessment, based on all the imaging:
Late Recurrence of Endometrial Stromal Sarcoma
THE DIAGNOSIS:
Müllerian Adenosarcoma Arising From Endometriosis
MÜLLERIAN ADENOSARCOMA
Müllerian adenosarcoma was first reported in 1974 by Clement and Scully
Mixture of a benign glandular epithelium and malignant sarcomatousstroma, mainly in the uterus of postmenopausal♀
Extrauterine Müllerian adenosarcoma is rare, arises in ectopic foci of endometriosis
This patient had TAH BSO for endometriosis 15 years earlier
Huang et al. Extragenital adenosarcoma: a case report, review of the literature, and management discussion. Gynecol Oncol. 2009;115:472–475
Clement PB, Scully RE. Müllerian adenosarcoma of the uterus. A clinicopathologic analysis of ten cases of a distinctive type of müllerian mixed tumor. Cancer. 1974;34:1138–1149.
FRANK RYBICKI, MD, PHD
• Chair and Prof of Radiology U of Ottawa Faculty of Medicine andThe Ottawa Hospital
• BA, Univ of Pennsylvania
• MD PhD, Harvard-MIT(Division of Health Sciences and Technology)
• Diagnostic Radiology, Brigham and Women’s Hospital
• Brigham and Women’s Cardiovascular Imaging- Section Chief
• Founder and Director, Applied Imaging Science Laboratory
• Board of Directors, NASCI
• Fellow AHA, ACR, NASCI
• Founder and first Chair, RSNA Special Interest Group on 3D Printing
• 2004 RSNA Cum Laude Education Award for globally introducing standard-compliant AR
• * Mentor and teacher of physicians and physician scientists world wide!
FRANK RYBICKI, MD, PHD
• Started off as a Quincy House Tutor
• 1999 Resident Research Trainee Prize RSNA
• 2001 Roentgen Research Award RSNA
• Numerous individual awards for research, education, mentored research:
• RSNA Medical Student Research Grant 2005, 2006
• RSNA Resident Research Trainee Prize 2010, 2011
• RSNA Fellow Student Research Trainee Prize 2012, 2014 x 2
• RSNA Honored Educator Award 2016
• 25 Course Director roles, plus 2 multiyear course directorships
• Chair, ACR Quality and Safety Commission – Appropriateness Criteria©, involved since 2007
• Active grant reviewer since 2007, including RSNA R&E Foundation
• Reviews for every journal related to CV imaging; Editor in chief 3D Printing in Medicine
• Introduced wide area detector CT in radiology RSNA 2007; 1st described “CT flow” RSNA 2008
FRANK RYBICKI, MD, PHD
CARDIOTHORACIC CASE 1- 39 YEAR OLD WOMAN
4-6 mm
Transfer from another hospital in respiratory failure and malignant hypertensive urgency
MALIGNANT HYPERTENSION39 YEAR OLD FEMALE
+ “small caliber aorta” + cardiomyopathy
Kidney Injury/ Renal Artery Stenosis
Aortic pathology (coarctation, dissection, vasculitis)
Eclampsia
Hypercalcemia
Hyperthyroidism and Thyrotoxicosis
Pheochromocytoma
Subarachnoid Hemorrhage
Drugs
VASCULITIS
LARGE VESSEL VASCULITIS
Medium
vessel
Small
vessel
Large
vessel
Kawasaki
PAN
ANCA
Immune
complex
Takayasu: <40 yo, granulomatous inflamm of Aoand major branches, hypertension w emergencies
Giant Cell: >50 yo, Ao and extracranial carotid (temporal), polymyalgia rheumatica
No size predominance
“Complicated”
Watts RA et al. Rheumatology 50:643 (2011)
CHEST CT ANGIOGRAM SAME DAY
ROLE OF RADIOLOGY IN TAKAYASU
• Secure diagnosis – histopathology can be contraindicated
• Differentiate inflammatory versus atherosclerotic disease
• Determine if a vascular lesion is active
• Evaluate downstream ischemia & complications
ABDOMINOPELVIC CT ANGIOGRAM SAME DAY
Lactic Acid: 2.8;
hypertension persisted; patient remained minimally responsive
2 WEEKS LATER: POSTERIOR REVERSIBLE ENCEPHALOPATHY SYNDROME (PRES)
Predominant parieto-occipital subcortical vasogenic edema
Intraparenchimal / subarachnoid hemorrhage* in/ along edema
Restricted diffusion* 11% - 26% of cases
Contrast enhancement (gyriform / leptomeningeal)
Reversibility 70%- 90% cases
*Poorer outcomes
DR. RYBICKI’S DIAGNOSIS
Takayasu’s Arteritis and
Posterior Reversible Encephalopathy Syndrome
THE DIAGNOSIS:
Takayasu’s Arteritis
+
MidAortic Syndrome
MID AORTIC SYNDROME
Mid Aortic Syndrome = Middle Aortic Syndrome = Abdominal Coarctation
Congenital- abn fusion of dorsal aortas in 4 week embryo
Acquired: Takayasu, Giant Cell arteritis, NF, FMD, William’s syndrome, Alagille syndrome, RPF
Inter-renal > suprarenal > infrarenal > diffuse
Life expectancy if untreated = 30-40 years
Death due to cardiovascular complications of progressive hypertension
Treatment is surgical
Bhatti et al. JPMA 2011;61(10):1018-1020
Delis et al. Perspect Vasc Surg Endovasc Ther 2005;17:187-203
Gornik et al. Aortitis. Circulation 2008;117:3039-51
WHERE ARE YOU FROM?
Downloaded from: https://visibleearth.nasa.gov/view.php?id=73580 and https://visibleearth.nasa.gov/view.php?id=73751 on 11.6.2017
DIAGNOSIS LIVE QUESTION: WHERE ARE YOU FROM?(TOUCH YOUR HOME ON THE WORLD IMAGE AND HIT “SUBMIT”)
Downloaded from: https://visibleearth.nasa.gov/view.php?id=73580 and https://visibleearth.nasa.gov/view.php?id=73751 on 11.6.2017
PEDIATRICS CASE 2- 7 YEAR OLD GIRL
Palpable upper abdominal mass discovered at pediatrician’s office during well child visit
ABD US, CT ANGIOGRAM
ABDOMINAL ULTRASOUND AND CT ANGIOGRAM
CT ANGIOGRAM
SUMMARY OF FINDINGS
11 cm well circumscribed mass with uniform density
Separate from liver, stomach, spleen and kidneys
Large draining veins into IVC
PERTINENT NEGATIVES
• No Calcifications
• No Cysts
• No Central scar
• No Necrosis
• No Abnormal arteries from aorta
DIFFERENTIAL DIAGNOSIS
• Extralobar pulmonary sequestration
• Pedunculated FNH
• Ectopic liver
DIFFERENTIAL DIAGNOSIS
Extralobar pulmonary sequestration
Solid mass
Systemic venous drainage
Systemic arterial supply
Near diaphragm
DIFFERENTIAL DIAGNOSIS
Pedunculated FNH
Solid mass
Systemic venous drainage
Enhancement pattern
Completely separate liver
Central Scar
DIFFERENTIAL DIAGNOSIS
Ectopic liver
Solid mass
Systemic venous drainage
Similar enhancement
Completely separate liver
ECTOPIC LIVER
J. Visceral Surgery (2014) 151, 451-455
ECTOPIC LIVER
Histological findings = liver: regular lobules, central vein and normal portal spaces
Increase in number of blood vessels on the outer surface
Higher risk of torsion
Higher risk of HCC
DR. PALADIN’S DIAGNOSIS
Ectopic Liver
THE DIAGNOSIS:
Accessory Lobe of Liver
ACCESSORY LOBE OF LIVER
Extremely rare condition
• “Bulky” (>31gm) and connected to liver by a stalk (typically perihepatic)
• “Small” (10-30 gm) and connected on wide base to liver (typically R lobe)
• Not connected to liver (thorax or pelvis)
• Pinpoint and located around gallbladder
Complications: torsion, infarction, hemorrhage, acromphalusSymptoms: Most asymptomatic and discovered at surgery. If torsion, acute stomachaches, abdominal distension, nausea, vomiting, or shock
Treatment: surgical resection if pedunculated
Wang et al. Intractable & Rare Diseases Research. 2012; 1(2):86-91
ACCESSORY LOBE OF LIVER
414 g 11.5 x 9.8 x 5.7 cm
Pathological slides courtesy David R. Kelly MD, The Children’s Hospital of Alabama
NEURO CASE 2- 15 YO FEMALE W/ CEREBRAL PALSY
She developed spastic paraplegia
DIAGNOSIS LIVE QUESTION:
Where is the abnormality?
NEURO CASE 2- 15 YO FEMALE W/ CEREBRAL PALSY
She developed spastic paraplegia
INITIAL THOUGHTS
• Findings:
• Indentation along the posterior cord in the upper thoracic region
• Increased posterior epidural fat, however this does not appear to be causing thecal sac compromise and isn’t uncommon in this area
• If real: This could represent spinal lipomatosis or less likely, given the relative uniform appearance, spinal angiolipoma
INITIAL THOUGHTS
• I think the epidural fat is just that and the real finding is the displaced cord; so I would primarily consider:
• Arachnoid cyst (intradural) or arachnoid web
• Anterior cord herniation
• Less likely: other extra-medullary, intradural mass that is iso-intense to CSF such as epidermoid
SPINE MRI
MORE THOUGHTS
• Axial T2 image shows area of relatively higher signal intensity posterior to cord with lack of any CSF pulsation artifact. Nothing traversing through this area
• Cord is focally displaced on sagittal and there may be a syrinx or minimal central cord edema in cord superior to displacement
• Neither image shows the cord abutting the ventral thecal sac or herniating through the dura
POSSIBLE NEXT STEPS
• Could do a CSF flow study to look at CSF motion in this area
• Hi-res thin T2 images might help to define or indicate if walls/septations are present
• FLAIR or DWI might be helpful to help exclude epidermoid or other non-CSF containing mass
ADDITIONAL IMAGES NEURO CASE 2
1.4mm
4mm
1.4mm
ANDERSON DIAGNOSIS: ARACHNOID CYST
• This is pretty typical of every proven arachnoid cyst I have come across and fits with descriptions in literature
• Can occur at any age
• Variable clinical presentation. Spastic paraplegia is one possible presenting symptom
DR. ANDERSON’S DIAGNOSIS
Intradural Spinal Arachnoid Cyst
THE DIAGNOSIS:
Arachnoid web/adhesion along the dorsal aspect of the upper cord
ARACHNOID WEB
Intradural extramedullary bands of arachnoid tissue that can extend to the pial surface of the spinal cord
Produce focal dorsal indentation of the cord
Upper thoracic location is typical
Characteristic deformity of spinal cord termed “scalpel sign”
May also have T2 signal-intensity changes in cord, syringomyelia
17 yo girl’s life was changed with this Dx-walked after surgery
Reardon et al. AJNR Am J Neuroradiol 2013;34:1104 –10
MSK CASE 2- 45 YEAR OLD MAN WITH KNEE PAIN
No history of trauma
SAME DATE RADIOGRAPHS
OUTSIDE MRI THREE WEEKS EARLIER
A PROCEDURE WAS PERFORMED
MSK CASE 2-SUMMARY
Bone tumor with large soft tissue mass
Central area in the mid diaphysis of the femur lowSI on MR, heterogeneous calcifications on CT
1
2
3
4
5
No matrix, osteoid or chondral
Marked cortical destruction
Proximal skip metastasis
MSK CASE 2-DDX, AGRESSIVE BONE TUMOUR
• UNDERLYING BONE INFARCT
• Malignant fibrous histiocytoma, fibrosarcoma (WHO 2013)
• Osteosarcoma
• Others, angiosarcomas ….
• Dedifferentiated Chondrosarcoma
• Osteomyelitis
No chondroid
Soft tissue mass….
FINDINGS,
infarct-associated bone sarcomas
NO OSTEOID
SKIP METASTASIS
NO OSTEOID
SKIP METASTASIS
FIBROSARCOMA
OSTEOSARCOMA
DIAGNOSIS LIVE QUESTION:
• What is the diagnosis?
A. Osteosarcoma
B. Fibrosarcoma
C. Angiosarcoma
DIAGNOSIS
1. Skip metastasis
2. No osteoid, fibrohistiocytic
3. Less frequent!
FIBROSARCOMA
OSTEOSARCOMA
DR. LLOPIS’ DIAGNOSIS
Osteosarcoma arising in bone infarct
THE DIAGNOSIS:
Osteosarcoma arising in bone infarct
BONE INFARCT OSTEOSARCOMA
Secondary sarcoma arising in association with a preexisting bone infarct is extremely rare
Malignant fibrous histiocytoma >> osteosarcoma > angiosarcoma
M > F, 5th -6th decade
Typical location is about the knee
More than 50% of patients die of their disease; majority of patients who die do so within 2 years
Domson et al. Clin Orthop Relat Res. 2009 Jul; 467(7): 1820–1825
ABDOMINAL CASE 2- 54 YEAR OLD WOMAN
She presented for outpatient Barium esophagram for gastric sleeve planning
DIAGNOSIS LIVE QUESTION:
Where is the abnormality?
ABDOMINAL CASE 2- 54 YEAR OLD WOMAN
ABDOMINAL CASE 2- 54 YEAR OLD WOMAN UNDERGOING PRE-BARIATRIC SURG ESOPHAGRAM
SHE REPORTED PRIOR SWALLOWING AND BREATHING ISSUES…….
2014
FINDINGS
• Esophagrams
• Smoothly marginated mass near the level of the vallecula.
• Does not appear to infringe upon swallow
• On double contrast esophagram, a Schatzki ring is noted. No intrinsic or extrinsic lesions. No achalasia or otherwise patuluous esophagus
• Findings on swallow were present previously
• Radiographs
• Bulky hilar adenopathy and right paratracheal adenopathy
• No definite pulmonary abnormality. Normal heart size.
• Adenopathy is minimally improved since initial workup
DISCUSSION
• Radiography suggests Sarcoid (ah – she knows that I have more thoracic radiology experience than flouroscopy, even though I am an abdominal imager)
• Other in DDX includes TB, Metastatic dz, Lymphoma, Multicentric Castleman’s
• These would not be expected to have such an indolent course, with persistent and mildly improved adenopathy 2-3 years later.
• Sarcoid is known to occur in larynx, usually with other manifestations of the disease
DR. HEILBRUN’S DIAGNOSIS
SARCOID
THE DIAGNOSIS:
Epiglottic Sarcoidosis
EPIGLOTTIC SARCOIDOSIS
Sarcoidosis- multisystem disorder characterized by noncaseating granulomas, most commonly involving pulmonary system
Upper airway is involved 6% of cases; laryngeal in 1.2%
Laryngeal sarcoidosis more commonly supraglottic: epiglottis, arytenoids and false vocal cords -rich lymphatic supply
Symptoms: dysphonia, irritating dry cough and dysphagia
DDx: relapsing polychondritis, granulomatosis with polyangiitis (GPA), papillomatosis, amyloidosis, histoplasmosis, blastomycosis, tuberculosis, syphilis, lymphoma, squamous cell carcinoma and cartilaginous tumors
Treatment: systemic steroids; combined modalities include intralesional steroids with mucosa sparing laser surgery or laser surgery
CARDIOTHORACIC CASE 2- 32 Y.O. WOMAN IN MVC
Figure courtesy Joao Inacio, MDSeptal PatternLymphaticsVenulesInterstitium
She developed a headache after a low impact motor vehicle collision and came to the emergency department
CARDIOTHORACIC CASE 2- 32 Y.O. WOMAN IN MVC
Septal Pattern
Lymphatics
Venules
Interstitium
Figure courtesy Joao Inacio, MD
She developed a headache after a low impact motor vehicle collision and came to the emergency department
CARDIOTHORACIC CASE 2- 32 Y.O. WOMAN IN MVC
2015
2015
COMPARISONS
Her pulmonary complaints began in 2005 with “choking sensation”
2014
2015
2005
DIFFERENTIAL FOR SEPTAL/ LINEAR PATTERN
* rare
Pulmonary edema
Lymphangitic spread of tumor
Chronic / recurrent pulmonary hemorrhage
Pulmonary fibrosis (e.g. sarcoidosis)
* Pulmonary venocclusive disease
* Lymphoproliferative disease
* Lymphangiomatosis
* Metabolic lung disease (e.g. amyloidosis, Niemann-Pick)
* Histiocytic Disorders (e.g. Erdheim-Chester)
DIFFERENTIAL FOR SEPTAL/ LINEAR PATTERN
* rare
Pulmonary edema
Lymphangitic spread of tumor
Chronic / recurrent pulmonary hemorrhage
Pulmonary fibrosis (e.g. sarcoidosis)
* Pulmonary venocclusive disease
* Lymphoproliferative disease
* Lymphangiomatosis
* Metabolic lung disease (e.g. amyloidosis, Niemann-Pick)
* Histiocytic Disorders (e.g. Erdheim-Chester)
T SPINE, SAME POST TRAUMA CT EXAMGORHAM-STOUT DISEASE
Findings
Nonaggressive bone loss
“Vanishing”
Cortex preserved
Vertebral heights preserved
Lymphangiomatosis (lymphangiectasia)
Erdheim-Chester disease
Gorham-Stout disease (GSD), aka vanishing bone disease …is a rare bone disorder characterized by progressive bone loss and the overgrowth of lymphatic vessels.
SHE HAS MULTIPLE MEDICAL PROBLEMS: IN 2011, EVALUATED FOR DIPLOPIA
2011
Progressive bone loss, very thin bones
2015 (at time of MVC)
2012: EVALUATED FOR DECREASED HEARING AND TRIGEMINAL MUSCLE WASTING
Carlos Torres, MD
No retro-orbital mass
Bilateral petrous apex cephalocele
Borderline low lying cerebellar tonsils
GORHAM STOUT SYNDROME
Diffuse or multicentric proliferation of sinusoidal channels of lymphatic origin and progressive destruction of the bone
Multiple lytic lesions, heterogeneous bone density, osteopenia
Interstitial thickening at lung bases. Chylous pleural effusions
Cystic lesions in visceral organs (e.g. spleen)
Lymphangiomatosis of the petrous apex - lymphatic communication with the CSF containing space (CSF leak)
Multiple infiltrating lesions in the soft tissues
Kotecha R et al. Clinical Radiology 67:782 (2012)
Cushing SL et al. Otology & Neurotology 31:789 (2010)
DR. RYBICKI’S DIAGNOSIS
Gorham Stout Syndrome
THE DIAGNOSIS:
Gorham Stout Disease
GORHAM STOUT DISEASE
Dr. Rybicki already said it all……………………..
MENTOR
“The delicate balance of mentoring someone is not creating them in your own image, but giving them the opportunity to create themselves.”
— Steven Spielberg
DIAGNOSIS LIVE QUESTION:
Please type the name of your most influential MENTOR or great TEACHER in the space provided and hit “SUBMIT”.
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