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Purpose The purpose of the study is to determine if a combination of dermal thickening and subcutaneous fluid honeycombing on non-contrast MRI, termed the dermal rim sign (DRS), can be diagnostically analogous to dermal backflow seen on lymphoscintigraphy in patients with secondary upper extremity lymphedema. Materials and methods Upper extremity MRI and lymphoscintigraphy were performed on patients referred to a multidisciplinary lymphedema clinic for suspicion of secondary lymphedema. Sensitivity, specificity, and positive and negative predictive values of DRS on MRI in detecting dermal backflow on lymphoscintigraphy and the correlation between DRS, Indocyanine Green (ICG) lymphography, bioimpedence L-Dex® ratio and MRI Lymphedema Staging were calculated. Weighted interobserver agreements on the presence and location of DRS on MRI were calculated. Results Of the 45 patients in the study, 91.1% (41/45) of patients had history of breast cancer. The average age was 58.4 ± 10.5 years, with a mean symptom duration of 4.7 ± 4.4 years. The mean BMI was 30.5 ± 7.0 kg/m2. Interobserver agreement on the presence and the extent of DRS on MRI was 0.93 [95% confidence-interval: 0.80–1]. DRS was present in 97% (32/33) of patients who demonstrated dermal backflow on lymphoscintigraphy. Sensitivity, specificity, PPV, and NPV of DRS were 96.6% [81.7%–99.9%], and 75.0% [47.6%–92.7%], 87.5% [74.9%–94.3%], and 92.3% [63.1%–98.8%]. DRS was associated with severity on ICG lymphography and bioimpedance (both p Conclusions DRS on non-contrast MRI is highly predictive of dermal backflow and correlates with clinical measures of lymphedema severity. DRS may be used as an independent diagnostic biomarker to identify patients who would benefit from dedicated exams.

Purpose: Pancreatic ductal adenocarcinoma (PDAC) remains a significant health issue. For most patients, there are no options for targeted therapy, and existing treatments are limited by toxicity. The HOPE trial (Harnessing Organoids for PErsonalized Therapy) was a pilot feasibility trial aiming to prospectively generate patient-derived organoids (PDO) from patients with PDAC and test their drug sensitivity and correlation with clinical outcomes. Experimental Design: PDOs were established from a heterogeneous population of patients with PDAC including both basal and classical PDAC subtypes. Results: A method for classifying PDOs as sensitive or resistant to chemotherapy regimens was developed to predict the clinical outcome of patients. Drug sensitivity testing on PDOs correlated with clinical responses to treatment in individual patients. Conclusions: These data support the investigation of PDOs to guide treatment in prospective interventional trials in PDAC.

Staging of upper extremity lymphedema is needed to guide surgical management, but is not standardized due to lack of accessible, quantitative, or precise measures. Here, we established an MRI-based staging system for lymphedema and validate it against existing clinical measures. Bilateral upper extremity MRI and lymphoscintigraphy were performed on 45 patients with unilateral secondary lymphedema, due to surgical intervention, who were referred to our multidisciplinary lymphedema clinic between March 2017 and October 2018. MRI short-tau inversion recovery (STIR) images were retrospectively reviewed. A grading system was established based on the cross-sectional circumferential extent of subcutaneous fluid infiltration at three locations, labeled MRI stage 0–3, and was compared to L-Dex®, ICG lymphography, volume, lymphedema quality of life (LYMQOL), International Society of Lymphology (ISL) stage, and lymphoscintigraphy. Linear weighted Cohen’s kappa was calculated to compare MRI staging by two readers. STIR images on MRI revealed a predictable pattern of fluid infiltration centered on the elbow and extending along the posterior aspect of the upper arm and the ulnar side of the forearm. Patients with higher MRI stage were more likely to be in ISL stage 2 (p = 0.002) or to demonstrate dermal backflow on lymphoscintigraphy (p = 0.0002). No correlation was found between MRI stages and LYMQOL. Higher MRI stage correlated with abnormal ICG lymphography pattern (rs = 0.63, p

BACKGROUND More than 100 million adults in the US suffer from prediabetes or type-2 diabetes. Noninvasive imaging of pancreas endocrine function might provide a surrogate marker of β-cell functional integrity loss linked to this disease. PURPOSE To noninvasively assess pancreatic blood-flow modulation following a glucose challenge using arterial spin labeling (ASL) MRI. STUDY TYPE Prospective. SUBJECTS Fourteen adults (30 ± 7 years old, 3M/11F, body mass index [BMI] = 24 ± 3 kg.m-2 ). FIELD STRENGTH/SEQUENCE 3T MRI / background-suppressed pseudocontinuous PCASL preparation with single-shot fast-spin-echo (FSE) readout before and after an oral glucose challenge using either fruit juice (n = 7) or over-the-counter glucose gel (n = 7). ASSESSMENT Subjects were fasting prior to initiation of oral stimulation, then dynamic perfusion measurements were performed every 2 minutes for 30 minutes. We quantified absolute blood flow at each timepoint. STATISTICAL TESTS Repeated-measures analysis of variance (ANOVA) followed by paired t-tests to assess for a significant effect of glucose challenge on measured perfusion. RESULTS Measured basal blood flow was 187 ± 53 mL/100g/min. A significant blood flow increase of +38 ± 26% was observed 10 minutes poststimulation (P < 0.05) and continuing until the end of the experiment. The gel stimulation provided the most consistent results, with an early rise followed by an additional later increase consistent with the known pancreatic insulin response to elevated blood glucose. Across-subject variations in blood flow increase were partially attributable to basal flow, with a negative correlation of r = -0.84 between basal and maximal relative flow increase in the gel group. DATA CONCLUSION ASL can be used to measure pancreatic flow in response to a glucose challenge, which could be linked to insulin release and secretion. This paradigm might be useful to characterize disorders of glucose regulation. LEVEL OF EVIDENCE 1 Technical Efficacy: Stage 3 J. Magn. Reson. Imaging 2020;51:854-860.

This review summarizes the relevant literature for the initial imaging of patients with symptoms of dysphagia. For patients with oropharyngeal dysphagia who have an underlying attributable cause, a modified barium swallow is usually appropriate for initial imaging but for those who have unexplained dysphagia a fluoroscopic biphasic esophagram is usually appropriate. Fluoroscopic biphasic esophagram is usually appropriate for initial imaging in both immunocompetent and immunocompromised patients who have retrosternal dysphagia. For postoperative patients with dysphagia, fluoroscopic single-contrast esophagram and CT neck and chest with intravenous (IV) contrast are usually appropriate for oropharyngeal or retrosternal dysphagia occurring in the early postoperative period where water-soluble contrast is usually preferred rather than barium sulfate. In the later postoperative period (greater than 1 month), CT neck and chest with IV contrast and fluoroscopic single-contrast esophagram are usually appropriate. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

This review summarizes the relevant literature regarding imaging of suspected diverticulitis as an etiology for left lower quadrant pain, and imaging of complications of acute diverticulitis. The most common cause of left lower quadrant pain in adults is acute sigmoid or descending colonic diverticulitis. Appropriate imaging triage for patients with suspected diverticulitis should address the differential diagnostic possibilities and what information is necessary to make a definitive management decision. Patients with diverticulitis may require surgery or interventional radiology procedures because of associated complications, including abscesses, fistulas, obstruction, or perforation. As a result, there has been a trend toward greater use of imaging to confirm the diagnosis of diverticulitis, evaluate the extent of disease, and detect complications before deciding on appropriate treatment. Additionally, in the era of bundled payments and minimizing health care costs, patients with acute diverticulitis are being managed on an outpatient basis and rapid diagnostic imaging at the time of initial symptoms helps to streamline and triage patients to the appropriate treatment pathway. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

We present a case report of a 24-year-old Caucasian man with mucopolysaccharidosis (MPS) type VI (Maroteaux-Lamy) who has documented progression of visual loss and corneal clouding over 18 years of follow-up. The MPSs are a group of inherited lysosomal storage disorders resulting from abnormalities

The range of pathology in adults that can produce abdominal pain is broad and necessitates an imaging approach to evaluate many different organ systems. Although localizing pain prompts directed imaging/management, clinical presentations may vary and result in nonlocalized symptoms. This review focuses on imaging the adult population with nonlocalized abdominal pain, including patients with fever, recent abdominal surgery, or neutropenia. Imaging of the entire abdomen and pelvis to evaluate for infectious or inflammatory processes of the abdominal viscera and solid organs, abdominal and pelvic neoplasms, and screen for ischemic or vascular etiologies is essential for prompt diagnosis and treatment. Often the first-line modality, CT quickly evaluates the abdomen/pelvis, providing for accurate diagnoses and management of patients with abdominal pain. Ultrasound and tailored MRI protocols may be useful as first-line imaging studies, especially in pregnant patients. In the postoperative abdomen, fluoroscopy may help detect anastomotic leaks/abscesses. While often performed, abdominal radiographs may not alter management. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Acute gastrointestinal (GI) immune-related adverse events (irAE) are commonly reported by patients with cancer undergoing treatment with immune checkpoint inhibitors (CPI); however chronic irAEs are rare. We present a case of a 71-year-old woman with metastatic gastro-oesophageal junction (GOJ) adenocarcinoma who developed delayed-onset chronic intestinal pseudo-obstruction (CIPO) while receiving second-line pembrolizumab. Repeated CT scans of the abdomen/pelvis found no small bowel obstruction, and evaluations for bowel inflammation, infection and paraneoplastic syndrome were negative. Bowel rest and glucocorticoids were associated with transient symptom resolution; however, symptoms recurred within 1 month. The patient was ultimately supported with total parenteral nutrition and intestinal motility agents. After 4 months, the GOJ cancer remained stable with no signs of progression. As CPI use expands, the incidence of rare irAEs, such as CIPO, may increase.

The purpose of this article is to evaluate the image quality and added value of split-bolus contrast agent injection combining late arterial and portal venous phases compared with single-bolus contrast agent injection late arterial phase CT enterography.Consecutive patients who underwent CT enterography before and after implementation of a single-bolus CT enterography protocol were included. Attenuation and contrast-to-noise ratio (CNR) were assessed by ROI measurements of the bowel wall and arterial and venous structures. Subjective enhancement of the bowel wall (1, arterial; 2, mucosal; 3, transmural; 4, transmural with mucosal hyperenhancement) and bowel abnormalities were assessed by two independent readers. MR enterography examinations, endoscopy reports, and surgery reports within 30 days after CT enterography were used to produce a composite outcome.Sixty-six patients were included in our study: 33 (mean [± SD] age, 46.0 ± 19.8 years) who underwent split-bolus CT enterography and 33 (mean age, 49.9 ± 19.0 years) who underwent single-bolus CT enterography. Bowel wall attenuation and CNR were higher for split-bolus CT enterography than for single-bolus CT enterography at 120 kVp (enhancement, 98.7 ± 23.1 HU vs 85.1 ± 23.3 HU; CNR, 6.4 ± 2.5 vs 4.4 ± 2.3; p0.01). Subjective ratings of bowel wall enhancement were higher with the split-bolus CT enterography than the single-bolus CT enterography (2.6 ± 0.8 vs 2.3 ± 0.6; p0.001). Split-bolus CT enterography led to a higher detection rate of mucosal hyperenhancement than did single-bolus CT enterography in patients with active inflammatory bowel disease (100.0% [7/7; 95% CI, 59.0-100.0%] vs 33.3% [2/6; 95% CI, 4.3-77.7%]; p = 0.02), whereas both protocols had a specificity of 100.0% (9/9).Split-bolus CT enterography led to improved CNR (47%) compared with single-bolus CT enterography and significantly increased the detection rate of mucosal hyperenhancement in patients with active inflammatory bowel disease.

Spontaneous cancer regression is a rare event, scarcely reported among gastrointestinal malignancies. Pancreatic adenocarcinoma regression has been documented in five previous cases, none of which included liver metastases, and the mechanism by which this occurs is not known. A 56-year-old woman with history of discoid lupus, homocysteinemia and peripheral vascular disease was diagnosed with stage IV pancreatic ductal adenocarcinoma (PDA) metastatic to the liver. She received palliative chemotherapy with 5-fluorouracil, leucovorin, irinotecan and oxaliplatin (FOLFIRINOX) for 6 months, complicated by mucositis, diarrhoea, vomiting and twoClostridium difficilecolitis episodes. Cancer initially responded to chemotherapy. However, due to substantial toxicities, she decided to discontinue cytotoxic chemotherapy and focus on palliation alone. Thereafter, CT and carbohydrate antigen (CA) 19-9 showed further response and ultimately complete cancer regression that has persisted for 33 months after cessation of chemotherapy. This is the first report in the English literature showing spontaneous regression of a PDA with liver metastases. Two possible mechanisms are proposed: antitumoral autoimmunity and tumour hypoxia related to vascular disease.

Palpable abdominal masses may arise from the abdominal cavity or the abdominal wall. The differential diagnosis is broad for each variant ranging from benign lipomas, inflammatory processes, to malignant tumors. The imaging approach to diagnosis varies by location. For intra-abdominal masses, contrast-enhanced CT and ultrasound examination have demonstrated accuracy. For abdominal wall masses, which may arise from muscle, subcutaneous tissue, or connective tissue, MRI, CT, and ultrasound all provide diagnostic value. This publication reviews the current evidence supporting the imaging approach to diagnosis of palpable abdominal masses for two variants: suspected intra-abdominal neoplasm and suspected abdominal wall masses. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Rationale and Objectives Renal perfusion measurements using noninvasive arterial spin-labeled (ASL) magnetic resonance imaging techniques are gaining interest. Currently, focus has been on perfusion in the context of renal transplant. Our objectives were to explore the use of ASL in patients with renal cancer, and to evaluate three-dimensional (3D) fast spin echo (FSE) acquisition, a robust volumetric imaging method for abdominal applications. We evaluate 3D ASL perfusion magnetic resonance imaging in the kidneys compared to two-dimensional (2D) ASL in patients and healthy subjects. Materials and Methods Isotropic resolution (2.6 × 2.6 × 2.8 mm 3 ) 3D ASL using segmented FSE was compared to 2D single-shot FSE. ASL used pseudo-continuous labeling, suppression of background signal, and synchronized breathing. Quantitative perfusion values and signal-to-noise ratio (SNR) were compared between 3D and 2D ASL in four healthy volunteers and semiquantitative assessments were made by four radiologists in four patients with known renal masses (primary renal cell carcinoma). Results Renal cortex perfusion in healthy subjects was 284 ± 21 mL/100 g/min, with test-retest repeatability of 8.8%. No significant differences were found between the quantitative perfusion value and SNR in volunteers between 3D ASL and 2D ASL, or in 3D ASL with synchronized or free breathing. In patients, semiquantitative assessment by radiologists showed no significant difference in image quality between 2D ASL and 3D ASL. In one case, 2D ASL missed a high perfusion focus in a mass that was seen by 3D ASL. Conclusions 3D ASL renal perfusion imaging provides isotropic-resolution images, with comparable quantitative perfusion values and image SNR in similar imaging time to single-slice 2D ASL.

The HOPE trial (Harnessing Organoids for PErsonalized Therapy) was a pilot study to test the feasibility of generating patient derived organoids (PDOs) from patients with pancreatic cancer under real world conditions, test drug sensitivity against these PDOs, and correlate these findings with clinical outcomes. Biopsies were obtained primarily during routine clinical care from surgical specimens, ascites, fine needle biopsies (FNB) of primary tumors, and IR guided core biopsies of liver and lymph node metastases. PDOs were grown in WNT free media according to our previously published methods. PDO drug sensitivity testing was performed on a panel of drugs, AUC calculated, and sensitivity ranked. Patients were followed clinically and assessed for disease control. At data cutoff (January 2020), we enrolled a total of 76 subjects representing all stages of disease. Drug testing was performed successfully on PDOs generated from 12 of these subjects (16%). Factors contributing to success obtaining sufficient cells for PDO generation included modality, body part, and tumor cellularity. H&E and IHC corresponded in matched PDOs and donor tumors, as did DNA alterations. Transcriptomes of PDOs were classified as both ‘basal' and ‘classical' subtypes. When AUC values were annotated with clinical data, the Jenks break of 1.69 segregated matched PDO/AUC values into disease control and progressive disease. We estimated that a PDO AUC value 99% probability of disease control from a regimen that contains this drug, whereas if all drugs in a regimen had an AUC > 2.75 there is a > 80% probability of accurately predicting resistance. To illustrate the potential of PDO testing to tailor treatment for an individual patient, we described a case of a subject with stage IV PDAC with a KRAS mutation and ERBB2 amplification. The subject had disease control with FOLFIRINOX, which was held for toxicity. The PDO showed resistance to oxaliplatin and the patient subsequently had an extended period of disease control with regimens which did not include oxaliplatin, highlighting the potential of PDO drug sensitivity testing to exclude ineffective treatments from combination chemotherapy and limit toxicity. In conclusion, we have shown the feasibility of collecting material via real-world clinical practice sufficient to develop PDOs suitable for rapidly screening multiple drugs, and have shown a high degree of correlation between clinical outcomes in patients with PDAC and matched PDO drug sensitivity. We determined preliminary criteria based on the AUC of individual drugs in PDOs to predict drug sensitivity in subjects. These results highlight the potential of PDOs to personalize therapy and allow for the exclusion of ineffective drugs from combination regimens thereby reducing toxicity. We anticipate this approach will be used in future trials to prospectively inform treatment selection for patients with PDAC. Citation Format: Joseph Elan Grossman, Ling Huang, Lakshmi Muthuswamy, Sofia Perea, Dipikaa Akshinthala, Raul Gonzalez, Leo Tsai, Jonah Cohen, Mandeep Sawhney, Douglas Pleskow, Tyler M. Berzin, Bruno Bockorny, Andrea Bullock, Benjamin Schlechter, Mary Linton B. Peters, Catherine Conahan, Supraja Narasimhan, Christine Lim, Roger Davis, Robert Besaw, Martin Smith, Tara Kent, Mark Callery, Senthil K. Muthuswamy, Manuel Hidalgo. Organoid sensitivity in pancreatic cancer correlates with clinical response to treatment and reveals utility for reducing toxicity: Preliminary results from the HOPE trial [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr CT119.

Encapsulating peritoneal sclerosis (EPS) is a debilitating condition characterized by a fibrocollagenous membrane encasing the small intestine, resulting in recurrent small bowel obstructions. EPS is most commonly associated with long-term peritoneal dialysis, though medications, peritoneal infection, and systemic inflammatory disorders have been implicated. Many cases remain idiopathic. Diagnosis is often delayed given the rarity of the disorder combined with non-specific symptoms and laboratory findings. Although cross-sectional imaging with computed tomography of the abdomen can be suggestive of the disorder, many patients undergo exploratory laparotomy for diagnosis. Mortality approaches 50% one year after diagnosis. Treatment for EPS involves treating the underlying condition or eliminating possible inciting agents (i.e. peritoneal dialysis, medications, infections) and nutritional support, frequently with total parenteral nutrition. EPS-specific treatment depends on the disease stage. In the inflammatory stage, corticosteroids are the treatment of choice, while in the fibrotic stage, tamoxifen may be beneficial. In practice, distinguishing between stages may be difficult and both may be used. Surgical intervention, consisting of peritonectomy and enterolysis, is time-consuming and high-risk and is reserved for situations in which conservative medical therapy fails in institutions with surgical expertise in this area. Herein we review the available literature of the etiology, pathogenesis, diagnosis, and treatment of this rare, but potentially devastating disease.

The purpose of this study was to determine the incidence of nephrogenic systemic fibrosis (NSF) in patients with chronic kidney disease (CKD) and moderate-to-severe impairment of kidney function who had not previously been exposed to gadolinium-based contrast agents (GBCAs) or referred to undergo contrast-enhanced MRI with gadobenate dimeglumine or gadoteridol.Two multicenter prospective cohort studies evaluated the incidence of unconfounded NSF in patients with stage 3 CKD (estimated glomerular filtration rate [eGFR] in cohort 1, 30-59 mL/min/1.73 m(2)) or stage 4 or 5 CKD (eGFR in cohort 2,30 mL/min/1.73 m(2)) after injection of gadobenate dimeglumine (study A) or gadoteridol (study B). A third study (study C) determined the incidence of NSF in patients with stage 4 or 5 CKD who had not received a GBCA in the 10 years before enrollment. Monitoring for signs and symptoms suggestive of NSF was performed via telephone at 1, 3, 6, and 18 months, with clinic visits occurring at 1 and 2 years.For studies A and B, the populations evaluated for NSF comprised 363 and 171 patients, respectively, with 318 and 159 patients in cohort 1 of each study, respectively, and with 45 and 12 patients in cohort 2, respectively. No signs or symptoms of NSF were reported or detected during the 2 years of patient monitoring. Likewise, no cases of NSF were reported for any of the 405 subjects enrolled in study C.To our knowledge, and consistent with reports in the literature, no association of gadobenate dimeglumine or gadoteridol with unconfounded cases of NSF has yet been established. Study data confirm that both gadoteridol and gadobenate dimeglumine properly belong to the class of GBCAs considered to be associated with the lowest risk of NSF.

OBJECTIVE. The purpose of this article is to review infectious, inflammatory, and auto-immune-mediated processes in the gastrointestinal system where diffusion-weighted imaging can be helpful as well as pitfalls associated with its use. CONCLUSION. Diffusion-weighted imaging has become an important and widely used tool in abdominal and pelvic MRI, but it has been used primarily for oncologic applications. As more body MRI protocols are routinely including diffusion-weighted imaging, this sequence can be useful in evaluating an increasing number of nononcologic processes.

BACKGROUND AND PURPOSE: Gadobutrol (Gadavist) and gadoteridol (ProHance) have similar macrocyclic molecular structures, but gadobutrol is formulated at a 2-fold higher (1 mol/L versus 0.5 mol/L) concentration. We sought to determine whether this difference impacts morphologic contrast-enhanced MR imaging. MATERIALS AND METHODS: Two hundred twenty-nine adult patients with suspected or known brain tumors underwent two 1.5T MR imaging examinations with gadoteridol or gadobutrol administered in randomized order at a dose of 0.1 mmol/kg of body weight. Imaging sequences and T1 postinjection timing were identical for both examinations. Three blinded readers evaluated images qualitatively and quantitatively for lesion detection and for accuracy in characterization of histologically confirmed brain tumors. Data were analyzed by using the Wilcoxon signed rank test, the McNemar test, and a mixed model. RESULTS: Two hundred nine patients successfully completed both examinations. No reader noted a significant qualitative or quantitative difference in lesion enhancement, extent, delineation, or internal morphology (P values = .69–1.00). One hundred thirty-nine patients had at least 1 histologically confirmed brain lesion. Two readers found no difference in the detection of patients with lesions (133/139 versus 135/139, P = .317; 137/139 versus 136/139, P = .564), while 1 reader found minimal differences in favor of gadoteridol (136/139 versus 132/139, P = .046). Similar findings were noted for the number of lesions detected and characterization of tumors (malignant/benign). Three-reader agreement for characterization was similar for gadobutrol (66.4% [κ = 0.43]) versus gadoteridol (70.3% [κ = 0.45]). There were no significant differences in the incidence of adverse events (P = .199). CONCLUSIONS: Gadoteridol and gadobutrol at 0.1 mmol/kg of body weight provide similar information for visualization and diagnosis of brain lesions. The 2-fold higher gadolinium concentration of gadobutrol provides no benefit for routine morphologic imaging.

A 29-year-old woman presented with profound iron-deficiency anemia. Cross-sectional imaging identified a mass in the ileal mesentery. Surgical resection was curative and revealed a giant cystic arteriovenous malformation. Our report highlights the role of cross-sectional imaging in the evaluation and management of iron-deficiency anemia and obscure gastrointestinal hemorrhage.

Crohn's disease is a chronic inflammatory bowel disease (IBD) that can affect the entire GI tract, and adequate visualization of the small bowel is imperative for both diagnosis and management. Magnetic resonance and computed tomography enterography have gradually replaced barium-based studies. Magnetic resonance enterography has the distinct advantage of avoiding ionizing radiation to which many patients with IBD are overexposed. Endoscopy-based techniques, including capsule endoscopy and device-assisted enteroscopy, allow direct visualization of the small bowel mucosa. Deep enteroscopy has the additional benefit of allowing sampling of the mucosa for histological analysis. Small intestine contrast ultrasound is rapidly gaining credence as an excellent, radiation-free imaging technique, but is not available in all countries. Other imaging modalities, such as positron emission tomography and leucocyte scintigraphy, continue to be studied and may have a role in specific circumstances. This review summarizes the evidence for the various techniques for evaluating the small bowel in IBD.

Background: An abdominal phlegmon is an inflammatory mass that can develop in the setting of penetrating Crohn's disease (CD). Anti-tumor necrosis factor (TNF) antibody therapy is typically avoided in CD complicated by phlegmon because of concern for peritoneal infection but may offer an effective alternative to surgical resection after infection has been controlled with antibiotics. The aim of this study was to examine outcomes for patients with CD who developed an abdominal phlegmon that was subsequently treated with an anti-TNF antibody. Methods: We retrospectively reviewed the records of all CD patients attending Beth Israel Deaconess Medical Center between 2004 and 2010 with an abdominal phlegmon who were treated with an anti-TNF antibody in order to evaluate the safety and efficacy of this treatment regimen. Results: There were 13 patients with CD complicated by a phlegmon treated with antibiotics and an anti-TNF antibody at our center between 2004 and 2010. Ten were male. Median time (interquartile range) from diagnosis to development of the phlegmon was 5.9 (1.9–22.7) years. The phlegmon was associated with an abscess in 12 patients. In addition to anti-TNF therapy, all patients were treated with broad-spectrum antibiotics. Anti-TNF therapy was effective without complications in all subjects. Two patients eventually had surgery more than a year after initiating anti-TNF treatment. Conclusions: Penetrating CD complicated by phlegmon formation may be safely and effectively managed with a combination of antibiotics and anti-TNF therapy. Larger, prospective trials are required to confirm these initial findings. (Inflamm Bowel Dis 2011;)

Purpose: To develop a robust T2-weighted volumetric imaging technique with uniform water-silicone separation and simultaneous fat suppression for rapid assessment of breast implants in a single acquisition. Materials and Methods: A three-dimensional (3D) fast spin echo sequence that uses variable refocusing flip angles was combined with a three-point chemical-shift technique (IDEAL) and short tau inversion recovery (STIR). Phase shifts of −π/6, +π/2, and +7π/6 between water and silicone were used for IDEAL processing. For comparison, two-dimensional images using 2D-FSE-IDEAL with STIR were also acquired in axial, coronal, and sagittal orientations. Results: Near-isotropic (true spatial resolution—0.9 × 1.3 × 2.0 mm3) volumetric breast images with uniform water-silicone separation and simultaneous fat suppression were acquired successfully in clinically feasible scan times (7:00–10:00 min). The 2D images were acquired with the same in-plane resolution (0.9 × 1.3 mm2), but the slice thickness was increased to 6 mm with a slice gap of 1 mm for complete coverage of the implants in a reasonable scan time, which varied between 18:00 and 22:30 min. Conclusion: The single volumetric acquisition with uniform water and silicone separation enables images to be reformatted into any orientation. This allows comprehensive assessment of breast implant integrity in less than 10 min of total examination time. J. Magn. Reson. Imaging 2012;35:1216-1221. © 2012 Wiley Periodicals, Inc.

Objectives To assess the feasibility of low-dose time-resolved imaging of contrast kinetics (TRICKS) magnetic resonance (MR) angiography of the pedal vasculature at 3.0 Tesla (T) using a head coil. Materials and methods Eleven healthy volunteers were imaged using TRICKS MR angiography at 3.0 T with both feet positioned in a head coil. A dose of 7 mL was used for each of 3 acquisitions: images were obtained of each foot in the sagittal plane, and then both feet were imaged simultaneously in the transverse plane. The following parameters were used for acquisition: (TR/TE 4.7 milliseconds/ 1.3 milliseconds, field of view = 28 cm, Flip angle = 30 degrees, 384 x 256 matrix, section thickness = 1.6 mm, Bandwidth = 19.23). The dorsalis pedis, plantar arch, distal posterior tibial, lateral tarsal, and medial plantar arteries were graded for visualization, artifact, and overall image quality on a 4-point scale (1 = worst; 4 = best). Results Superior visualization trended towards separate sagittal acquisitions when compared with that of bilateral transverse acquisitions for most of the individual vessels of the foot. Overall, separate sagittal acquisitions (average score = 2.9) were superior to bilateral transverse acquisitions (average score = 2.6). The average image quality score reflecting the amount of artifact was 2.6 for studies obtained using bilateral transverse acquisitions and 3.1 for studies obtained using separate sagittal acquisitions. Conclusion Low-dose gadolinium multi-injection TRICKS and bolus-chase MR angiography at 3.0 T provides an effective and easily reproducible technique for imaging of the pedal vasculature in volunteers and has great potential for clinical application.

Magnetic resonance (MR) imaging can provide critical diagnostic and anatomic information while avoiding the use of ionizing radiation, but it has a unique set of safety risks associated with its reliance on large static and changing magnetic fields, high-powered radiofrequency coil systems, and exogenous contrast agents. It is crucial for radiologists to understand these risks and how to mitigate them to protect themselves, their colleagues, and their patients from avoidable harm and to comply with safety regulations at MR imaging sites. Basic knowledge of MR imaging physics and hardware is necessary for radiologists to understand the origin of safety regulations and to avoid common misconceptions that could compromise safety. Each of the components of the MR imaging unit can be a factor in injuries to patients and personnel. Safety risks include translational force and torque, projectile injury, excessive specific absorption rate, burns, peripheral neurostimulation, interactions with active implants and devices, and acoustic injury. Standards for MR imaging device safety terminology were first issued in 2005 and are required by the U.S. Food and Drug Administration, with devices labeled as "MR safe," "MR unsafe," or "MR conditional." MR imaging contrast agent safety is also discussed. Additional technical and safety policies relate to pediatric, unconscious, incapacitated, or pregnant patients and pregnant imaging personnel. Division of the MR imaging environment into four distinct, clearly labeled zones--with progressive restriction of entry and increased supervision for higher zones--is a mandatory and key aspect in avoidance of MR imaging-related accidents. All MR imaging facilities should have a documented plan to handle emergencies within zone IV, including cardiac arrest or code, magnet quench, and fires. Policies from the authors' own practice are provided for additional reference. Online supplemental material is available for this article.

International audience; BACKGROUND AND PURPOSE:Gadobenate dimeglumine (MultiHance) has higher r1 relaxivity than gadoterate meglumine (Dotarem) which may permit the use of lower doses for MR imaging applications. Our aim was to compare 0.1- and 0.05-mmol/kg body weight gadobenate with 0.1-mmol/kg body weight gadoterate for MR imaging assessment of brain tumors.MATERIALS AND METHODS:We performed crossover, intraindividual comparison of 0.1-mmol/kg gadobenate with 0.1-mmol/kg gadoterate (Arm 1) and 0.05-mmol/kg gadobenate with 0.1-mmol/kg gadoterate (Arm 2). Adult patients with suspected or known brain tumors were randomized to Arm 1 (70 patients) or Arm 2 (107 patients) and underwent 2 identical examinations at 1.5 T. The agents were injected in randomized-sequence order, and the 2 examinations were separated by 2-14 days. MR imaging scanners, imaging sequences (T1-weighted spin-echo and T1-weighted high-resolution gradient-echo), and acquisition timing were identical for the 2 examinations. Three blinded readers evaluated images for diagnostic information (degree of definition of lesion extent, lesion border delineation, visualization of lesion internal morphology, contrast enhancement) and quantitatively for percentage lesion enhancement and lesion-to-background ratio. Safety assessments were performed.RESULTS:In Arm 1, a highly significant superiority (P < .002) of 0.1-mmol/kg gadobenate was demonstrated by all readers for all end points. In Arm 2, no significant differences (P > .1) were observed for any reader and any end point, with the exception of percentage enhancement for reader 2 (P < .05) in favor of 0.05-mmol/kg gadobenate. Study agent-related adverse events were reported by 2/169 (1.2%) patients after gadobenate and by 5/175 (2.9%) patients after gadoterate.CONCLUSIONS:Significantly superior morphologic information and contrast enhancement are demonstrated on brain MR imaging with 0.1-mmol/kg gadobenate compared with 0.1-mmol/kg gadoterate. No meaningful differences were recorded between 0.05-mmol/kg gadobenate and 0.1-mmol/kg gadoterate.

Crohn disease is a chronic inflammatory disorder involving the gastrointestinal tract, characterized by episodic flares and times of remission. Underlying structural damage occurs progressively, with recurrent bouts of inflammation. The diagnosis and management of this disease process is dependent on several clinical, laboratory, imaging, endoscopic, and histologic factors. In recent years, with the maturation of CT enterography, and MR enterography, imaging has played an increasingly important role in relation to Crohn Disease. In addition to these specialized examination modalities, ultrasound and routine CT have potential uses. Fluoroscopy, radiography, and nuclear medicine may be less beneficial depending on the clinical scenario. The imaging modality best suited to evaluating this disease may change, depending on the target population, severity of presentation, and specific clinical situation. This document presents seven clinical scenarios (variants) in both the adult and pediatric populations and rates the appropriateness of the available imaging options. They are summarized in a consolidated table, and the underlying rationale and supporting literature are presented in the accompanying narrative. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every three years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Diffusion-weighted imaging (DWI) has become an increasingly used tool in abdominal and pelvic magnetic resonance imaging (MRI), primarily in the oncologic setting. DWI sequences are being added to routine MRI protocols at many institutions, and as its use has spread, more non-oncologic applications have been explored. The purpose of this article is to provide a review of DWI applications in inflammatory, infectious, autoimmune-mediated, and ischemic processes affecting the genitourinary system.

The most common cause of acute right lower quadrant (RLQ) pain requiring surgery is acute appendicitis (AA). This narrative's focus is on imaging procedures in the diagnosis of AA, with consideration of other diseases causing RLQ pain. In general, Computed Tomography (CT) is the most accurate imaging study for evaluating suspected AA and alternative etiologies of RLQ pain. Data favor intravenous contrast use for CT, but the need for enteric contrast when intravenous contrast is used is not strongly favored. Radiation exposure concerns from CT have led to increased investigation in minimizing CT radiation dose while maintaining diagnostic accuracy and in using algorithms with ultrasound as a first imaging examination followed by CT in inconclusive cases. In children, ultrasound is the preferred initial examination, as it is nearly as accurate as CT for the diagnosis of AA in this population and without ionizing radiation exposure. In pregnant women, ultrasound is preferred initially with MRI as a second imaging examination in inconclusive cases, which is the majority.The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every three years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Colorectal cancer is the third leading cause of cancer deaths in the United States. Most colorectal cancers can be prevented by detecting and removing the precursor adenomatous polyp. Individual risk factors for the development of colorectal cancer will influence the particular choice of screening tool. CT colonography (CTC) is the primary imaging test for colorectal cancer screening in average-risk individuals, whereas the double-contrast barium enema (DCBE) is now considered to be a test that may be appropriate, particularly in settings where CTC is unavailable. Single-contrast barium enema has a lower performance profile and is indicated for screening only when CTC and DCBE are not available. CTC is also the preferred test for colon evaluation following an incomplete colonoscopy. Imaging tests including CTC and DCBE are not indicated for colorectal cancer screening in high-risk patients with polyposis syndromes or inflammatory bowel disease. This paper presents the updated colorectal cancer imaging test ratings and is the result of evidence-based consensus by the ACR Appropriateness Criteria Expert Panel on Gastrointestinal Imaging. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Acute right upper quadrant pain is a common presenting symptom in patients with acute cholecystitis. When acute cholecystitis is suspected in patients with right upper quadrant pain, in most clinical scenarios, the initial imaging modality of choice is ultrasound. Although cholescintigraphy has been shown to have slightly higher sensitivity and specificity for diagnosis, ultrasound is preferred as the initial study for a variety of reasons, including greater availability, shorter examination time, lack of ionizing radiation, morphologic evaluation, confirmation of the presence or absence of gallstones, evaluation of bile ducts, and identification or exclusion of alternative diagnoses. CT or MRI may be helpful in equivocal cases and may identify complications of acute cholecystitis. When ultrasound findings are inconclusive, MRI is the preferred imaging test in pregnant patients who present with right upper quadrant pain. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Bilateral facial nerve paralysis is an uncommon presentation and even more so in children. There are reports of different causes of bilateral facial nerve palsy. It is well-established that hypertension and chickenpox causes unilateral facial paralysis and the importance of checking the blood pressure in children with facial nerve paralysis cannot be stressed enough. The authors report a boy with bilateral facial nerve paralysis in association with hypertension and having recently recovered from chickenpox. The authors review aspects of bilateral facial nerve paralysis as well as hypertension and chickenpox causing facial nerve paralysis.

To assess the value of dynamic contrast-enhanced (DCE) combined with T2-weighted (T2W) endorectal coil (ERC) magnetic resonance imaging (MRI) at 3 T for determining extracapsular extension (ECE) of prostate cancer.In this IRB-approved study, ERC 3-T MRI of the prostate was performed in 108 patients before radical prostatectomy. T2W fast spin-echo and DCE 3D gradient echo images were acquired. The interpretations of readers with varied experience were analysed. MRI-based staging results were compared with radical prostatectomy histology. Descriptive statistics were generated for prediction of ECE and staging accuracies were determined by the area under the receiver-operating characteristic curve.The overall sensitivity, specificity, positive predictive value and negative predictive value for ECE were 75 %, 92 %, 79 % and 91 %, respectively. Diagnostic accuracy for staging was 86 %, 80 % and 91 % for all readers, experienced and less experienced readers, respectively.ERC 3-T MRI of the prostate combining DCE and T2W imaging is an accurate pretherapeutic staging tool for assessment of ECE in clinical practice across varying levels of reader experience.• Endorectal coil (ERC) magnetic resonance imaging is widely used for imaging prostatic disease. • ERC 3-T MRI is reasonably accurate for local prostate cancer staging. • High diagnostic accuracy is achievable across different levels of reader experience. • MRI facilitates therapeutic decisions in patients with prostate cancer.

The Third International Symposium on Advancing Science and Elimination of the Use of Laboratory Animals for Development and Control of Vaccines and Hormones, organized by the National Institute of Public Health and the Environment (RIVM, The Netherlands) under the auspices of the International Association for Biologicals (IABS), was held in Utrecht, The Netherlands, 12–14 November 2001.

A comprehensive overview of the current status of magnetic resonance imaging (MRI) in the locoregional assessment and management of rectal adenocarcinoma is presented. Staging systems for rectal cancer and treatment strategies in its management are discussed to give the reader the context that shapes MRI acquisition techniques and interpretation. Findings on MRI are detailed and their accuracy reviewed based on currently available evidence. Optimization of MRI acquisition and relevant pelvic anatomy are reviewed. A detailed description of our approach in interpreting MRI for locoregional staging of rectal cancer is given and future directions are also introduced.

Perianal fistula is an abnormal communication between the anal canal and perianal skin. The majority of perianal fistulous disease results from either cryptoglandular inflammation or Crohn's disease. These groups differ in pathophysiology, prognosis, and strategies for imaging and treatment. Endoanal ultrasound and magnetic resonance imaging represent current imaging strategies for evaluating perianal fistulas and may be used alone or in combination. The use of three-dimensional technique and peroxide fistulography optimize the ultrasound evaluation of perianal fistula. The use of multiple imaging planes and sequences including fat suppression and contrast enhancement optimize the magnetic resonance imaging protocol. Examples of the imaging appearance of perianal fistulas and a proposed flowchart for imaging modality selection are provided.

ObjectivesWe sought to determine the prevalence of noncardiac pathology in a large consecutive series of patients referred for clinical cardiac magnetic resonance (CMR) studies.BackgroundThe imaging field for many CMR sequences extends outside of the heart border. As a result, noncardiac pathology may be identified. These noncardiac findings have clinical significance because they often lead to subsequent imaging/testing and intervention. The prevalence of noncardiac findings on clinical CMR studies has not been well described.MethodsThe reports of all 1,534 (62% male, age 50 ± 15 years) clinical CMR studies performed at an academic medical center during calendar years 2002 to 2006 were reviewed. All studies had been interpreted by both a staff cardiologist (level III trained in CMR) and a board-certified radiologist (with fellowship training in CMR). For each study, sex, age, indication for CMR study, and reported noncardiac pathology were extracted. Follow-up for each major noncardiac pathology was evaluated by reviewing the patient's medical center electronic medical record. These noncardiac pathologies were then categorized as significant if an intervention or change in the patient's management ensued.ResultsA total of 116 (7.6%) studies had at least one noncardiac finding. These findings included 55 major findings (e.g., lymphadenopathy, lung abnormalities, mediastinal masses) in 48 distinct reports (prevalence of 3.1%) and 74 minor findings (e.g., small pleural effusions, liver cysts, renal cysts) in 70 distinct reports (prevalence of 4.6%). The majority (62%) of major findings were previously known, with only 8 findings in 6 (0.4%) of 1,534 reports ultimately deemed to be new and clinically important/significant. The age of those with noncardiac pathology was greater (54 ± 16 years vs. 49 ± 16 years, p < 0.001).ConclusionsIn this large series of consecutive clinical CMR studies interpreted by both staff cardiologists and radiologists, noncardiac pathology is uncommonly reported. When reported, the majority of major findings are previously known. New major findings were detected in