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Infiltrative-appearance hepatocellular carcinoma presents a challenge to clinicians as diagnostic criteria continue to evolve and evidence-based treatment guidelines have yet to be established. While transarterial radioembolization has shown efficacy in hepatocellular carcinoma, many studies exclude infiltrative-appearance HCC in their analysis. The purpose of this study was to describe imaging features of infiltrative-appearance hepatocellular carcinoma and evaluate effects of radioembolization on survival. In a retrospective review, infiltrative HCC patients treated from 2008 to 2017 were identified. Patients were divided into two groups: TARE versus systemic therapy/palliative care. Demographics, dates of diagnosis/expiry, albumin, international normalized ratio (INR), sodium, alpha-fetoprotein (AFP), creatinine, Child-Pugh class, model for end-stage liver disease (MELD) score, bilirubin, radiation dose and volume were collected. Patients with bilirubin > 3 were excluded. Mann–Whitney U test and Fisher’s exact test assessed differences between groups. Kaplan–Meier survival and Cox proportional hazard analyses were performed. Fifty-three patients were identified, 15 underwent TARE while 38 served as control. Mean age was 60, 43 patients were male. The mean overall survival was 16.2 months for the TARE group and 5.3 months for the control group (Log-rank p

PURPOSE To demonstrate the feasibility of detecting patency, stenosis, or occlusion of transjugular intrahepatic portosystemic shunt (TIPS) with four-dimensional (4D) flow MR imaging. MATERIALS AND METHODS Sequential adult patients with TIPS were eligible for enrollment. Volumetric phase-contrast sequence was used to image TIPS. Particle tracing cine images were used for qualitative assessment of stenosis. TIPS was segmented to generate quantitative data sets of peak velocity. Segmentation and quantitative measurement of flow throughout an entire TIPS defined technical success. Doppler US was used for comparison. Venography, when available, and 6-month clinical follow-up were used as reference standards. RESULTS 4D flow MR imaging was performed in 23 patient encounters and was technically successful in 16/23 (69.6%) encounters. Three cases demonstrated both focal turbulence and abnormal velocities (> 190 cm/s or < 90 cm/s) on 4D flow and had venography-confirmed stenosis (true-positive cases). Seven cases had normal velocities and no turbulence on 4D flow, and all were confirmed negative with clinical follow-up or venography (true-negative cases). Six cases had discordant 4D flow results, with abnormal velocities but no turbulence or focal turbulence but normal velocities. All 6 discordant cases had no evidence of dysfunction during 6-month follow-up. CONCLUSION 4D flow MR imaging can detect TIPS patency and stenosis, but further investigation is required before it can be used to assess for TIPS dysfunction.

Infiltrative-appearance hepatocellular carcinoma presents a challenge to clinicians as diagnostic criteria continue to evolve and evidence-based treatment guidelines have yet to be established. While transarterial radioembolization has shown efficacy in hepatocellular carcinoma, many studies exclude infiltrative-appearance HCC in their analysis. The purpose of this study was to describe imaging features of infiltrative-appearance hepatocellular carcinoma and evaluate effects of radioembolization on survival.In a retrospective review, infiltrative HCC patients treated from 2008 to 2017 were identified. Patients were divided into two groups: TARE versus systemic therapy/palliative care. Demographics, dates of diagnosis/expiry, albumin, international normalized ratio (INR), sodium, alpha-fetoprotein (AFP), creatinine, Child-Pugh class, model for end-stage liver disease (MELD) score, bilirubin, radiation dose and volume were collected. Patients with bilirubin 3 were excluded. Mann-Whitney U test and Fisher's exact test assessed differences between groups. Kaplan-Meier survival and Cox proportional hazard analyses were performed.Fifty-three patients were identified, 15 underwent TARE while 38 served as control. Mean age was 60, 43 patients were male. The mean overall survival was 16.2 months for the TARE group and 5.3 months for the control group (Log-rank p 0.0001). Cox proportional regression analysis revealed significant associations between survival and albumin (HR 0.210, 0.052-0.839, p = 0.027), Child-Pugh class B (HR 0.196, 0.055-0.696, p = 0.012), sorafenib (HR 0.106, 0.031-0.360, p 0.001), and number of affected liver lobes (HR 1.864, 1.387-2.506, p 0.001).Transarterial radioembolization for infiltrative HCC improves life expectancy compared to treatment with comfort measures or systemic therapy.

Abdominal and pelvic pain are common reasons for pregnant women to present to the emergency department, and can pose a diagnostic dilemma due to overlap in the symptoms of a normal pregnancy and non-obstetric pathology. A nonspecific presentation with signs and symptoms, such as nausea, vomiting, and leukocytosis, may necessitate diagnostic imaging for further characterization. Ultrasonography (US) is often the best initial modality for imaging pregnant patients in the emergency department setting due to its wide availability, lack of ionizing radiation, and diagnostic versatility. However, ultrasound may not fully characterize non-obstetric pathology and can have high inter-user variability. Magnetic resonance imaging (MRI), with its lack of ionizing radiation and excellent soft-tissue contrast, is preferred over CT for assessing the pregnant patient but may have limited availability, especially in the acute setting or after hours. This includes weekends, evening, 3 am, etc. Computed tomography (CT) has the downside of ionizing radiation to the fetus, but can provide useful information in certain gastrointestinal or urinary tract pathology that can be difficult to characterize with ultrasound or MR.

Background Hepatobiliary contrast enhanced MRI is known to be the most sensitive imaging modality for detection of colorectal hepatic metastasis. To date no study has investigated the rate of disappearing lesions with gadoxetic acid MR (Eovist/Primovist), or characterized the pathologic response of lesions which disappear on gadoxetic acid MR. Methods Retrospective review of hepatic resections for colorectal metastases between 01/2008 and 01/2014 was performed to evaluated the rate of disappearance of lesions on gadoxetic acid MR and the rate of complete pathologic response in the lesions that disappear. “Disappearing lesions” were lesions on baseline imaging that were not identifiable on pre-operative Eovist MRI. Complete pathologic response was defined as no viable tumor on pathology or by lack of recurrence within 1 year. Results In 23 patients, 200 colorectal metastases were identified on baseline imaging. On pre-operative Eovist MR 77 of the 200 lesions (38.5%) were “disappearing” lesions. At surgical pathology or 1 year follow-up imaging, 42 of 77 lesions (55%) demonstrated viable tumor (21) or recurrence (21). Thirty of 77 lesions (39%) were nonviable at pathology (10) or without evidence of recurrence at 1 year (20). 5 lesions were indeterminate. Discussion Despite disappearance on Eovist MR imaging (the most sensitive available imaging modality), 38.5% of all colorectal metastases disappeared and of those, 55% were viable.

Transarterial radioembolization (TARE) is one of the few treatment options available for infiltrative hepatocellular carcinoma with tumor in vein. This is backed by the published data showing marginally favorable toxicity profile compared with other locoregional and systemic therapies. Although lung shunt fraction studies are performed to prevent radiation injury to the lungs, TARE-induced embolization/metastasis to the lungs has not been reported before. We report an intriguing case of new lung metastases within 1 month after TARE for infiltrative hepatocellular carcinoma with a tumor in the vein, with only a slightly elevated but acceptable lung shunt fraction. This report brings to light the possibility of such a complication and argues for improved preprocedural assessment of a tumor in vein burden and embolization potential.

The manifestations of endometriosis commonly present a diagnostic challenge to the gynecologist and radiologist. Familiarity with its varied presentations may allow for a more accurate diagnosis. The goal of this review is to the present the imaging spectrum of endometriosis, less common sites of involvement as well as the potential rare complications. Relevant surgical and histopathological correlation is also provided. In addition to clinical evaluation and sonography, MRI is a highly accurate imaging modality in the diagnosis of endometriosis. It possesses a distinctive advantage over other modalities in that it allows a complete survey of the pelvic compartments. The potentially devastating effects of endometriosis include pelvic pain and even infertility. Since standard treatment is surgical, the radiologist needs to be familiar with the various manifestations in order to aid diagnosis for appropriate management.

Women commonly present to the emergency room with subacute or acute symptoms of gynecologic origin. Although a pelvic exam and ultrasound (US) are the preferred initial diagnostic tools for gynecologic entities, a CT is often the first line imaging modality in the emergency department. We will provide a review of normal uterine enhancement and normal pregnancy related findings, and then familiarize radiologists with the CT appearances of gynecologic entities classically described on ultrasound that may present to the emergency department.

Magnetic resonance (MR) imaging can be used as a primary or secondary modality in the evaluation of acute pelvic pain in women. MR avoids the ionizing radiation exposure of computed tomography (CT) and provides a larger field of view with greater detail than ultrasound. This chapter first addresses practical considerations including scanner strength, intravenous gadolinium contrast use, and essential MR sequences. Then pelvic inflammatory disease, ectopic pregnancy, and ovarian torsion are reviewed with an emphasis on the MR imaging findings. At the end of this chapter, the reader should be able to structure an MR protocol, implement it in an emergency department setting, and recognize the common causes of acute pelvic pain on MR.

To determine the degree of interradiologist agreement between the MRI features of appendicitis during pregnancy, the outcomes associated with an indeterminate interpretation and the negative predictive value of non-visualization of the appendix.Our study was approved by the institutional review board at the Washington University in St. Louis, Missouri (WUStL) and was HIPAA (Health Insurance Portability and Accountability Act of 1996)-compliant. The informed consent requirement was waived. Cases of suspected appendicitis during pregnancy evaluated using MRI were retrospectively identified using search queries. Scans were re-reviewed by two radiologists (7 and 9 years experience, respectively) to evaluate the interradiologist agreement of different MRI features of appendicitis during pregnancy (visualization of the appendix, appendiceal diameter, appendiceal wall thickening, periappendiceal fat stranding, fluid-filled appendix and periappendiceal fluid). The radiologists were blinded to patient outcome, patient intervention, laboratory data, demographic data and the original MRI reports. Clinical outcomes were documented by surgical pathology or clinical observation. Interradiologist agreement was analysed using Cohen's κ, while patient demographic and clinical data was analysed using Student's t-testing.233 females with suspected appendicitis during pregnancy were evaluated using MRI over a 13-year period (mean age, 28.4 years; range, 17-38 years). There were 14 (6%) positive examinations for appendicitis during pregnancy, including 1 patient whose MRI was interpreted as negative, proven by surgical pathology. The presence of periappendiceal soft-tissue stranding and the final overall impression had the most interradiologist agreement (к = 0.81-1). There were no pregnant patients found to have acute appendicitis who had an indeterminate MR interpretation or when the appendix could not be visualized.The final impression by the two retrospectively reviewing radiologists of MR examinations performed for suspected appendicitis during pregnancy had near-perfect agreement. In patients where the appendix could not be visualized or in patients that were interpreted as indeterminate, no patients had acute appendicitis. Advances in knowledge: MR impression for suspected appendicitis in the pregnant patient has high interradiologist agreement, and a non-visualized appendix or lack of inflammatory findings at the time of MR, reliably excludes surgical appendicitis.

Mesenteric ischemia and ischemic colitis are uncommon but potentially life-threatening causes of acute abdominal pain. Portal venous phase computed tomography (CT) is routinely ordered in the emergency room setting for abdominal pain, but subsequent MR angiography may be requested for additional evaluation of the mesenteric vasculature. We compare the concordance of CT and magnetic resonance angiography (MRA) for acute bowel ischemia. Thirty-two patients who underwent contrast-enhanced MRA for bowel ischemia after having undergone CT evaluation within the preceding 2 weeks were identified. A retrospective review of imaging, treatment history, surgical, and pathology reports was conducted. Two radiologists each reviewed the imaging studies in a blinded fashion. Ten cases of bowel ischemia were confirmed by endoscopy and/or surgical pathology. CT correctly identified bowel findings in all cases. Intraobserver agreement between CT and MRA for all vessels was 0.68 and 0.63, highest for the superior mesenteric artery. Interobserver agreement was 0.74 for MRA and 0.78 for CT. Vascular findings were only directly mentioned in 10 of 32 CT reports (and 7 of 10 cases with confirmed bowel ischemia). MRA only detected two additional or alternative diagnoses. Portal venous phase CT and MRA demonstrate a high degree of concordance for vascular evaluation. Reviewed CT examinations were sufficient to assess the patency of the mesenteric vasculature, but vascular findings were not reported in most cases. A direct description within the report may have obviated the request for further MR imaging. MRA adds little value after portal venous CT in assessing bowel ischemia.

e15591 Background: Infiltrative-appearance hepatocellular carcinoma (IHCC), also known as diffuse HCC, presents a distinct challenge to clinicians as evidence-based treatment guidelines have yet to be established. While transarterial radioembolization (TARE) has shown efficacy in HCC, many studies exclude IHCC in their analysis. The purpose of this study was to evaluate whether TARE of IHCC improves survival. Methods: With IRB approval, patients with IHCC were identified. Patient were divided into two groups: TARE versus systemic therapy/palliative care. Demographics, date of diagnosis, date of expiry, albumin, international normalized ratio (INR), sodium, alpha-fetoprotein (AFP), creatinine, Child-Pugh class, model for end-stage liver disease (MELD) score, and bilirubin were collected. Patients with bilirubin >3 were excluded. Mann-Whitney U test and Fisher’s exact test assessed for differences between groups. Kaplan-Meier survival analysis and Cox proportional hazard analysis were performed. Results: Forty-one patients were identified, 10 underwent TARE while the remaining 31 served as a control. Mean age was 62, 30 patients were male. The mean overall survival of the TARE treatment group was 16.6 months (506 days) and the mean overall survival of the control group was 5.6 months (170 days) (Log-rank p < 0.004), with a combined overall survival of 8.5 months (259 days). Cox proportional regression analysis revealed statistically significant associations between survival and albumin (hazard ratio 0.12, 0.032-0.41, p < 0.001), Child-Pugh class B (hazard ratio 0.25, 0.064-0.941, p < 0.041), and sorafenib therapy (hazard ratio 0.246, 0.071 – 0.847, p < 0.026). Conclusions: Transarterial radioembolization for patients with IHCC improves life expectancy compared to treatment with comfort measures or systemic therapy.[Table: see text]

Review the current literature, focusing on potential clinical applications of time-resolved 3-dimensional phase contrast imaging (4D flow) in the thorax. Magnetic resonance imaging has become an important diagnostic tool in the evaluation of the heart and great vessels, complimenting echocardiography in routine clinical practice. Advances in 4D flow now allow for comprehensive modeling of blood flow in the thorax in a single ECG-gated and respiratory-gated volumetric acquisition. 4D Flow modeling of preferential flow through shunts, eccentric jets related to valvular disease, helical flow in aneurysms, shear wall stress around atherosclerotic plaque, and pulse wave pressures within the aorta is now possible, and may lead to improved prognostication and management of complex cardiovascular pathology. The physiologic data obtained with 4D flow MR has provided new insight into a wide range of cardiovascular pathology, from congenital heart disease, bicuspid aortopathy, and aortic coarction to aortic aneurysms, atherosclerotic plaque, and aortic dissection.

Imaging plays an increasingly important role in the staging and management of colorectal cancer. In recent years, magnetic resonance imaging (MRI) has supplanted transrectal ultrasound as the preferred modality for the locoregional staging of rectal cancer. Furthermore, the advent of both diffusion-weighted imaging and hepatobiliary contrast agents has significantly enhanced the ability of MRI to detect colorectal liver metastases. In clinical practice, MRI routinely provides prognostic information, helps to guide surgical strategy, and determines the need for neoadjuvant therapies related to both the primary tumor and metastatic disease. Expanding on these roles for MRI, positron emission tomography (PET)/MRI is the newest clinical hybrid imaging modality and combines the metabolic information of PET with the high soft tissue contrast of MRI. The addition of PET/MRI to the clinical staging armamentarium has the potential to provide comprehensive state-of-the-art colorectal cancer staging in a single examination.

Radiofrequency ablation (RFA) has become an accepted first-line treatment for osteoid osteomas. Ablation of spinal osteoid osteomas has presented a particular challenge because of their proximity to delicate neural structures. Although many case series have reported multiple successfully treated spinal osteoid osteomas, there are no reports of thermal injury or insufficiency fracture associated with RFA of spinal osteoid osteomas. We report the management of complications that result from treating a spinal osteoid osteoma within a pedicle.