Radiologists must be thorough when investigating malignant primary bone tumours

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Watch this session on ECR Live: Thursday, 16:00–17:30, Room E2
Tweet #ECR2014E2 #MS3

Malignant primary bone tumours like osteosarcoma and Ewing’s sarcoma are very serious diseases mainly affecting children and teenagers. General radiologists are not likely to see these patients every day at their practice, but when they do, they must know what they have to do to optimise patient care and improve outcomes. Experts will give instructions and share useful advice during the dedicated Multidisciplinary Session today at the ECR.

Conventional x-ray of a tumour in the knee (Image provided by Prof. Koenraad Verstraete)

Conventional x-ray of a tumour in the knee
(Image provided by Prof. Koenraad Verstraete)

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Experts explain how to avoid pitfalls in FDG PET/CT imaging

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Watch this session on ECR Live: Thursday, March 6, 16:00–17:30, Room I/K
Tweet #ECR2014IK #SF3

The demand for PET/CT studies is increasing and so is the need for radiologists to improve their knowledge of this important modality. One of the many areas that require their attention is the occurrence of pitfalls related to the uptake of Fludeoxyglucose (18F), commonly called FDG, the most commonly used tracer in PET/CT imaging. A dedicated Special Focus session at the ECR will offer attendees useful clues on how to avoid these pitfalls and correctly interpret images.

Katrine Åhlström Riklund is director of the medical school and deputy head of the department of radiation sciences at Umeå University, Sweden. She is 2nd vice-chairperson of the ESR’s Congress Committee.

Katrine Åhlström Riklund is director of the medical school and deputy head of the department of radiation sciences at Umeå University, Sweden. She is 2nd vice-chairperson of the ESR’s Congress Committee.

FDG uptake by tissue is also a marker for glucose uptake, which is closely correlated with certain types of tissue metabolism. This means that FDG can show not only disease-related changes but also normal, healthy metabolic changes in the body. “Not everything that shines is pathological. To know the difference, you have to train and learn what is really a disease and what is the physiological distribution of this tracer,” said Professor Katrine Åhlström Riklund, a radiologist specialised in nuclear medicine at Umeå, Sweden, who will moderate the session.
To help radiologists, speakers will share advice regarding FDG uptake in oncology, neurology and cardiology.

Most FDG PET/CT studies are currently being carried out to help stage cancer, and plan and follow-up therapy. The combination of FDG and PET/CT imaging is particularly useful in several different malignancies. Because a tumour cell divides rapidly and has a high rate of metabolism, FDG uptake usually corresponds to disease. Once physicians know the extent of the disease, they can make a more accurate diagnosis and treatment plan, especially in targeted therapies.

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Mar 2014
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Dr. Pepe’s Diploma Casebook: Case 52 – SOLVED!

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Dear Friends,

Today I am presenting radiographs of a 43-year-old woman with moderate dyspnoea. Disregard the widening of the right superior mediastinum, secondary to long-standing goiter. Leave me your thoughts and diagnosis in the comments sectiona and come back on Friday for the answer.

Diagnosis:
1. Thymoma
2. Heart disease
3. Lymphoma
4. None of the above

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ECR 2013 Rec: B. CT #E3920a #A225

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A-255 B. CT

J. Vilar | Saturday, March 9, 10:30 – 12:00 / Room A

Interpretation of chest images is fraught with errors. Confusing images may occur in chest CT and conventional radiography. Understanding the cause of the error and using some “ tricks” the radiologist may overcome these situations. Three aspects that may be of useful are: Gravity, Space and Time. Gravity may help the radiologist by using simple manoeuvres such as prone or lateral decubitus. Space relates to the location of the lesion. Upper or lower lobe locations are associated with certain pathologies. Time lapse is a major factor that may influence our diagnosis. Previous studies are essential. Fast growth or reduction of a lesion usually is associated with non-neoplastic disorders. Follow-up in acutely ill patients may be of great value and well as in lesions in oncologic patients. The lecture will present cases of variable difficulty where using these simple “tricks” the diagnostic problem can be solved.

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Mar 2014
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ECR 2013 Rec: A. Diagnosis #RC1601a #A545

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A-545 A. Diagnosis

M. Krokidis | Monday, March 11, 08:30 – 10:00 / Room E1

Oesophageal cancer is the sixth leading cause of death from cancer worldwide. More than 90 % of oesophageal cancers are either squamous-cell carcinomas or adenocarcinomas. Approximately, three quarters of all adenocarcinomas are found in the distal oesophagus, whereas squamous cell carcinomas are more evenly distributed between the middle and lower third. The cervical oesophagus is an uncommon site of disease. The pathogenesis of oesophageal cancer remains unclear. At the time of the diagnosis of oesophageal cancer, more than 50 % of patients have either unresectable tumours or visible metastases on imaging. The most common symptom of presentation is dysphagia which is present in >70% of the cases; odynophagia may also be present in a smaller percentage of patients. The patients are usually presented also with significant weight loss which appears to be also an important prognostic factor of the outcome of the disease. Diagnosis is based on the findings of a contrast swallow- which is usually the first exam to be performed; oesophageal cancer may present as polypoid, infiltrative, varicoid, or ulcerative lesions. Endoscopy usually confirms the findings of the swallow study, revealing the presence of a mass and offering the possibility of taking biopsy samples. Endoscopic ultrasound is the imaging method that is used for local staging and CT and PET-CT are used to determine the presence of metastatic disease. In case of presence of enlarged lymphnodes, fine needle aspiration or even open biopsy may be performed.

28
Feb 2014
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ECR 2013 Rec: High-resolution computed tomography (HRCT) of the lungs in brain dead pigs: a feasibility study #SS204 #B0169

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B-0169 High-resolution computed tomography (HRCT) of the lungs in brain dead pigs: a feasibility study

G. Bozovic, S. Steen, T. Sjöberg, C. Schaefer-Prokop, J. Verschakelen, Q. Liao, R. Siemund, I. Björkman-Burtscher | Thursday, March 7, 14:00 – 15:30 / Room D1

Purpose: Brain death has adverse effects on lung perfusion and ventilation with possible damage of lung parenchyma pre-transplantation. We wanted to assess brain dead subjects treated with a new drug regime with HRCT as a pre-transplant work-up.
Methods and Materials: Eleven pigs were decapitated (DC) assuring brain death, attached to ventilator and treated with a new drug regime optimising circulation thereby preventing lung edema. Thirteen non-decapitated pigs (N-DC) attached to ventilator, supported with conventional treatment served as controls. All were monitored 24h and thereafter examined with chest HRCT. Images were analysed by two radiologists using a pre-defined questionnaire assessing parenchymal and airway changes. In consensus, an overall conclusion inferred presence of edema, infection/atelectasis or airway pathology. Severity was estimated with a subjective scale.
Results: After 24h there were no significant differences between the groups regarding mean arterial pressure (MAP), arterial oxygen/fraction of inspired oxygen (PaO2/FiO2), amount of infused fluid, urine production or clinical signs of edema. Both groups showed parenchymal changes in a comparable extent (consolidation in 6/11 (DC) and 10/13 (N-DC) and GGO in 6/11 (DC) and 9/13 (N-DC), respectively). Overall conclusion appraised the presence of oedema in 2/11 (DC) but none of the N-DC pigs, signs of old/ recent infection in 6/11 (DC) and 7/13 (N-DC) and possible hypersensitive pneumonitis in 1/13 (N-DC).
Conclusion: After 24h, there were no significant differences in clinical and imaging findings between the groups supporting the successful hemodynamic optimising with the new drug regime. HRCT allows evaluation of pre-transplant lungs.

27
Feb 2014
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ECR 2013 Rec: Detection of HCC and liver metastases with BR14: final results of a multicentre phase IIA study #SS201b #B0232

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B-0232 Detection of HCC and liver metastases with BR14: final results of a multicentre phase IIA study

J. Hohmann, A. Müller, J. Skrok, K.-J. Wolf, A. Martegani, C.F. Dietrich, T. Albrecht | Thursday, March 7, 14:00 – 15:30 / Room I/K

Purpose: The study was primarily designed to find the optimal dose range of BR14 to detect malignant focal liver lesions. Secondary objectives were the evaluation of the safety profile and comparison with contrast-enhanced MRI (CE MRI).
Methods and Materials: 25 patients (9f, 16m, mean age: 66y) with known HCC or liver metastases were examined in three centres during a time period of three months. Each patient underwent a baseline and at least three contrast-enhanced US (CEUS) with ascending dose levels (0.25ml, 1.0ml, 4.0ml) of BR14. CE MRI was done 4 weeks prior or post-study examination. Lesions were recorded in on a liver map, with respect to localisation, size and suggested lesion type. Examination quality was documented and safety parameters were assessed.
Results: The number of lesions detected with BR14 CEUS increased with dose, while the number of missed lesions and the lesion size decreased. Despite the increasing contrast enhancement no other image quality parameter showed a substantial difference. No significant changes were found for the analysed safety parameters and no serious adverse events were reported.
Conclusion: We finally conclude that the recommended dose level of BR14 is between 1.0 ml and 4.0 ml for which the lesion detection was comparable to the CE MRI. In addition, we found a higher number of especially small lesions with higher doses of BR14 which might be due to a higher sensitivity of CEUS for the detection of liver metastases. However, this is an interesting and debatable finding.

Caceres’ Corner Case 87 (Update: Solution)

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Dear Friends,

Our next case is that of a 60-year-old male with intermittent chest pain for the last year. If it is of any help, Muppet made the wrong diagnosis in this case. His mind was probably still in Mexico.

What do you see? What would be your diagnosis? Check the images below, leave your thoughts in the comments section, and come back on Friday for the answer.

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24
Feb 2014
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ECR 2013 Rec: Bon appétit! Starters”: cystic fibrosis, pneumonia and pulmonary embolism #SF4a #A083

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A-083 Bon appétit! Starters”: cystic fibrosis, pneumonia and pulmonary embolism

M.U. Puderbach | Friday, March 8, 08:30 – 10:00 / Room F2

CF: MRI is comparable to CT with regard to the detection of relevant morphological changes in the CF lung. Compared to CT, the strength of MRI is the additional assessment of “function”, i.e. perfusion, pulmonary haemodynamics and ventilation. In CF, regional ventilatory defects cause changes in regional lung perfusion due to the hypoxic vasoconstriction response or tissue destruction. Using dynamic contrast-enhanced MRI, these perfusion changes can be assessed. Pulmonary embolism: The current imaging reference technique in evaluation of acute pulmonary embolism is helical computed tomography. To be competitive with CT, an abbreviated MR protocol focusing on lung vessel imaging and lung perfusion may be accomplished within 15 min in-room time. As a first step, a steady-state GRE sequence acquired in two or three planes during free breathing enables a non-contrast-enhanced detection of large central emboli. As a second step, the protocol continues with the contrast-enhanced steps including first pass perfusion imaging, high spatial resolution contrast-enhanced (CE) MRA and a final acquisition with a volumetric interpolated 3D FLASH sequence in transverse orientation. Pneumonia: The potential of MRI to replace chest radiography, particularly in children, was already investigated several years ago. The experience from this work may be considered valid for the suggested protocols for 1.5-T scanners since image quality has significantly improved. Therefore, T2-weighted fat-suppressed as well as dynamic contrast-enhanced T1-GRE sequences are applied with a slice thickness between 5 and 6 mm. Disease entities encompassing community-acquired pneumonia, empyema, fungal infections and chronic bronchitis are detectable.

24
Feb 2014
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ECR 2013 Rec: Can non-invasive techniques as CTA and MRA replace catheter angio for diagnostic work-up? #SF8a #A205

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A-205 Can non-invasive techniques as CTA and MRA replace catheter angio for diagnostic work-up?

L. van den Hauwe, M. Voormolen, T. van der Zijden, R. Salgado, J. Van Goethem, P.M. Parizel | Saturday, March 9, 08:30 – 10:00 / Room B

Although catheter angiography remains the gold standard for cerebrovascular imaging, in recent years, it has been replaced to some extent by less-invasive techniques, such as CTA, MRA, and ultrasound. Some of these techniques allow for cerebrovascular imaging without exposure to ionizing radiation, and/or without requiring an exogenous contrast agent that could cause nephrotoxicity, allergic reaction, or other adverse effects. Moreover, all of these techniques avoid the extra time, expense, and possibility of complications that are associated with arterial catheterization. Ongoing developments in CT- and MR-based angiography continue to improve the effectiveness of these techniques, and to expand the clinical roles that they can fulfill. Nowadays, these noninvasive techniques not only provide images with high spatial resolution, but also offer time-resolved images, in which arterial and venous phases can be distinguished, and can provide selective visualization of vessels supplied by a single supplying artery. This presentation will review the latest developments in CT- and MR-based cerebral angiography, and illustrate the use of these CT- and MR-techniques in the diagnosis of cerebral aneurysms and vascular malformations.

22
Feb 2014
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