Supplement To    december 2012     THE JOURNAL OF PRACTICAL MEDICAL IMAGING AND MANAGEMENT  Transforming Patient Care Thro...
Strategies, solutions, success.Healthcare is in a state of transformation. Some only see the challenges. Philips Healthcar...
introduction                       Low dose and high quality:                       A delicate balance                    ...
Transforming Patient Care Through Patient Focus, Improved Productivity and Improved Clinical OutcomesIntroduction      1.....
Supplement at a glance                                                                                           CONTRIBUT...
Transforming Patient Care Through Patient Focus, Improved Productivity and Improved Clinical Outcomes                     ...
DXR                                             Table 1. Pros and cons of DR and CR DR		                                  ...
DXRsingle detectors. In addition, our satellites feature     examples show a reduction equal to or greatercombination RF/D...
clinical case: DXR                              Clinical Case                              Isolated non-osseous navicular-...
clinical case: DXR   A                                                            B                                       ...
Transforming Patient Care Through Patient Focus, Improved Productivity and Improved Clinical Outcomes                     ...
IXRFigure 1. 3D image demonstrating compression of the sub-            Figure 2. An XperGuide “target view” for a biopsy o...
IXRFigure 3. XperCT image following endoleak embolization               Figure 4. Intraprocedural XperCT with MR overlay d...
IXRRadiation dose                                            We regularly perform nephrostomy place-     Radiation exposur...
clinical case: IXR                                Clinical Case                                Treating recurrent pelvic c...
clinical case: IXR                                                                                                        ...
Transforming Patient Care Through Patient Focus, Improved Productivity and Improved Clinical OutcomesAmbient Experience fo...
Ambient Experiencethe uptake room are bathed in a warm-colored               “The fact that we have provided [patients]glo...
Transforming Patient Care Through Patient Focus, Improved Productivity and Improved Clinical Outcomes                     ...
MR                                         Table 1. 3T MRI protocol for Renal MassesSequence	 TR (msec)	 TE (msec)	 Flip A...
MR                                                                                      commonly demonstrates increased si...
THE JOURNAL OF PRACTICAL MEDICAL IMAGING AND MANAGEMENT
THE JOURNAL OF PRACTICAL MEDICAL IMAGING AND MANAGEMENT
THE JOURNAL OF PRACTICAL MEDICAL IMAGING AND MANAGEMENT
THE JOURNAL OF PRACTICAL MEDICAL IMAGING AND MANAGEMENT
THE JOURNAL OF PRACTICAL MEDICAL IMAGING AND MANAGEMENT
THE JOURNAL OF PRACTICAL MEDICAL IMAGING AND MANAGEMENT
THE JOURNAL OF PRACTICAL MEDICAL IMAGING AND MANAGEMENT
THE JOURNAL OF PRACTICAL MEDICAL IMAGING AND MANAGEMENT
THE JOURNAL OF PRACTICAL MEDICAL IMAGING AND MANAGEMENT
THE JOURNAL OF PRACTICAL MEDICAL IMAGING AND MANAGEMENT
THE JOURNAL OF PRACTICAL MEDICAL IMAGING AND MANAGEMENT
THE JOURNAL OF PRACTICAL MEDICAL IMAGING AND MANAGEMENT
THE JOURNAL OF PRACTICAL MEDICAL IMAGING AND MANAGEMENT
THE JOURNAL OF PRACTICAL MEDICAL IMAGING AND MANAGEMENT
THE JOURNAL OF PRACTICAL MEDICAL IMAGING AND MANAGEMENT
THE JOURNAL OF PRACTICAL MEDICAL IMAGING AND MANAGEMENT
THE JOURNAL OF PRACTICAL MEDICAL IMAGING AND MANAGEMENT
THE JOURNAL OF PRACTICAL MEDICAL IMAGING AND MANAGEMENT
THE JOURNAL OF PRACTICAL MEDICAL IMAGING AND MANAGEMENT
THE JOURNAL OF PRACTICAL MEDICAL IMAGING AND MANAGEMENT
THE JOURNAL OF PRACTICAL MEDICAL IMAGING AND MANAGEMENT
THE JOURNAL OF PRACTICAL MEDICAL IMAGING AND MANAGEMENT
THE JOURNAL OF PRACTICAL MEDICAL IMAGING AND MANAGEMENT
THE JOURNAL OF PRACTICAL MEDICAL IMAGING AND MANAGEMENT
THE JOURNAL OF PRACTICAL MEDICAL IMAGING AND MANAGEMENT
THE JOURNAL OF PRACTICAL MEDICAL IMAGING AND MANAGEMENT
THE JOURNAL OF PRACTICAL MEDICAL IMAGING AND MANAGEMENT
THE JOURNAL OF PRACTICAL MEDICAL IMAGING AND MANAGEMENT
THE JOURNAL OF PRACTICAL MEDICAL IMAGING AND MANAGEMENT
THE JOURNAL OF PRACTICAL MEDICAL IMAGING AND MANAGEMENT
THE JOURNAL OF PRACTICAL MEDICAL IMAGING AND MANAGEMENT
THE JOURNAL OF PRACTICAL MEDICAL IMAGING AND MANAGEMENT
THE JOURNAL OF PRACTICAL MEDICAL IMAGING AND MANAGEMENT
THE JOURNAL OF PRACTICAL MEDICAL IMAGING AND MANAGEMENT
THE JOURNAL OF PRACTICAL MEDICAL IMAGING AND MANAGEMENT
THE JOURNAL OF PRACTICAL MEDICAL IMAGING AND MANAGEMENT
THE JOURNAL OF PRACTICAL MEDICAL IMAGING AND MANAGEMENT
THE JOURNAL OF PRACTICAL MEDICAL IMAGING AND MANAGEMENT
THE JOURNAL OF PRACTICAL MEDICAL IMAGING AND MANAGEMENT
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THE JOURNAL OF PRACTICAL MEDICAL IMAGING AND MANAGEMENT

  1. 1. Supplement To december 2012 THE JOURNAL OF PRACTICAL MEDICAL IMAGING AND MANAGEMENT Transforming Patient Care Through Patient Focus,Improved Productivity and Improved Clinical Outcomes Sponsored by
  2. 2. Strategies, solutions, success.Healthcare is in a state of transformation. Some only see the challenges. Philips Healthcare Consultingsees the opportunities. We have helped many clients achieve improved performance and can do the samewith you. Our consultants can help you drive growth, solve complex workflow challenges, and deliver aquality healthcare experience. We provide objective, expert management advice and work with you toplan, create, and implement comprehensive strategies for managing ongoing change. We draw on ourextensive real-world experiences everyday and can help you developthe strategic and operational initiatives you need to succeed. Let ushelp you achieve new levels of financial and operational performance,visit www.philips.com/healthcareconsulting.
  3. 3. introduction Low dose and high quality: A delicate balance L ow radiation dose and high diagnostic image quality—it’s the delicate balance we all try to strike in radiology to provide the best possible care and improve patient out- comes. At Philips, we continue to make advances in establishing just the right balance in all of our products as we carry on our Imaging 2.0 vision, based on clinical integration and collaboration, patient focus, and improved economic value. We incorporate the principle of keeping radiation dose as low as reasonably achievable in every product we create. A prime example is our BrightView XCT, which provides high- quality images with less radiation dose than computed tomography (CT) scanners that lack Philips’ dose-reduction tools, while boosting reporting speed and accuracy. Additionally, our innovative iDose4 iterative reconstruction technique for Philips Ingenuity CT systems allows radiologists to manage dose without sacrificing image quality. Even for electrophysiology and angio procedures, which traditionally require high levels of radiation, Philips is constantly looking at ways to develop low-dose interventional X-ray systems that advance patient care. We Larry Dentice are incredibly excited about these products and how they are advancing the science of achieving the ideal balance of low radiation dose and high diagnostic image quality. Better patient At the same time, there is increasing pressure in the industry to improve productivity and keep healthcare costs down. Increased workflow demands on clinicians require the care is one of the ability to diagnose and collaborate virtually anytime, anywhere. That’s the principle behind Philips’ IntelliSpace Portal, a powerful thin-client solution for advanced image review driving forces and analysis offering a clinical solution that’s multi-specialty, multi-modality and multi- vendor—and accessible through iPad®*, laptop or smartphone*. behind what Better patient care is one of the driving forces behind what we do across the healthcare field, and these technologies offer enhanced diagnostic confidence to deliver improved care. we do. The following pages detail nine perspectives from experienced clinicians in various special- ties, reflecting how they are achieving better patient care in their specialty areas. Our hope is that their insights will inspire you with new ideas about the exciting possibilities within our field. We would like to extend Philips’ thanks for the collaboration and insights of all the physicians included in this special supplement to Applied Radiology as we work together to create the future of healthcare and save lives. Larry Dentice Senior Vice President, Imaging Systems Sales and Marketing Philips Healthcare North America *Note: Images are not for diagnosis except when using cleared software for mobile application. 1 ©December 2012 www.appliedradiology.com supplement to APPLIED RADIOLOGY n
  4. 4. Transforming Patient Care Through Patient Focus, Improved Productivity and Improved Clinical OutcomesIntroduction 1.......Low dose and high quality: A delicate balance Larry DenticeDXR 9.......The impact of digital radiography on the pediatric patient Richard Towbin, MD, and James Owen 12......Clinical Case: Isolated non-osseous navicular-medial cuneiform tarsal coalition Seth Vatsky, MD, and Richard Towbin, MDIXR 14......3D imaging in the angiography suite advances interventional patient care David Siegel, MD, FSIR 18......Clinical Case: Treating recurrent pelvic congestion David Siegel, MD, FSIRAmbient Experience 20......Ambient Experience for PET/CT: Reducing patient anxiety, improving the clinical process Joseph JalkiewiczMR 22......3T MR imaging protocol for characterization of renal masses Gaurav Khatri, MD, and Ivan M. Pedrosa, MD 27......Clinical Case: Metastatic workup of a morbidly obese patient with colorectal cancer Julia Grossman, MD, Gaurav Khatri, MD, and Ivan M. Pedrosa, MDIntelliSpace Portal 30......IntelliSpace streamlines the continuum of care Cristen BolanPET 32......Striking a balance in PET imaging transforms patient care Medhat M. Osman, MD, PhD 36......Clinical Case: Recurrent lymphoma in the left acetabulum Razi Muzaffar, DO, and Medhat M. Osman, MD, PhDSPECT 39......Low-dose, high-quality SPECT/CT imaging transforms patient care Medhat M. Osman, MD, PhD 46......Clinical Case: Osteomyelitis with associated fracture in the toe as seen on high-resolution SPECT/CT Razi Muzaffar, DO, and Medhat M. Osman, MD, PhDUltrasound 49......Improving patient outcomes with ultrasound elastography Richard G. Barr, MD, PhD, FACR 53......Clinical Case: Elastography in evaluation of musculoskeletal abnormalities Richard G. Barr, MD, PhD, FACRWomen’s Health 56......Transformation from film-screen to MicroDose digital mammography: Selection challenges, opportunity, and value Raymond Tu, MD, Riad Charafeddine, MD, Theodore Williams, MA, RT(R), and Steven Rothenberg 60......Clinical Case: Breast cyst and dermal calcification Raymond Tu, MD2 © n SUPPLEMENT TO APPLIED RADIOLOGY www.appliedradiology.com December 2012
  5. 5. Supplement at a glance CONTRIBUTING FACULTY Contributing Faculty Publisher O. Oliver Anderson Associate Publisher Kieran Anderson Richard G. Barr, MD, PhD, Bruce A. Cross, MD, Radiation Andrew J. Mullinix, MD, FACR, Professor of Radiology, Oncologist, Sparks Health Diagnostic Radiologist, Executive Editor Northeastern Ohio Medical System, Fort Smith, AR Franciscan St. Francis Health, University, and a Diagnostic Indianapolis, IN Cristen Bolan Radiologist at Radiology Consultants Inc., Youngstown, OH Contributing Editor Joseph Jalkiewicz Art Director and Production Barbara A. Shopiro Applied Radiology and this supple- ment, Transforming Patient Care Through Patient Focus, Improved Medhat M. Osman, MD, PhD, Ivan M. Pedrosa, MD, Chief- David Siegel, MD, FSIR, Productivity and Improved Clini- Program Director of the of-MRI, Associate Professor System Chief, Interventional cal Outcomes, are published by Division of Nuclear Medicine, of Radiology, Department of Radiology Services, North Shore Anderson Publishing, Ltd. The jour- Department of Radiology, LIJ Health System, and Associate Radiology, University of Texas nal does not warrant the exper- Saint Louis University Hospital, Southwestern Medical Center, Professor of Radiology, Hofstra tise of any author in a particular St. Louis, MO Advanced Imaging Research North Shore LIJ School of field, nor is it responsible for any Center, Dallas, TX Medicine, New Hyde Park, NY statements by such authors. The opinions expressed in this supple- ment are those of the authors. They do not imply endorsement of advertised products and do not necessarily reflect the opinions or recommendations of our sponsors or the editors and staff of Applied Radiology. Copyright © 2012 by Anderson Publishing, Ltd., 180 Glenside Avenue, Richard Towbin, MD, Radiol- Raymond Tu, MD, Chairman, Scotch Plains, NJ 07076. ogist-in-Chief, Department of Department of Radiology, United Radiology, Phoenix Children’s Medical Center and Clinical Asso- All rights reserved. Hospital, Phoenix, AZ ciate Professor of Radiology, The George Washington University School of Medicine and Health Sciences, Washington, DC2 Decembern 2 ©DecemberSUPPLEMENT TO APPLIED RADIOLOGY www.appliedradiology.comSUPPLEMENT TO APPLIED RADIOLOGY © n 2012 www.appliedradiology.com 2012
  6. 6. Transforming Patient Care Through Patient Focus, Improved Productivity and Improved Clinical Outcomes DXRThe impact of digital radiographyon the pediatric patientRichard Towbin, MD, and James Owen Dr. Towbin is Radiologist-in-I n the past three decades, the practice of radi- on a PACS for review and interpretation. This Chief, and Mr. Owen is PACS ology in general, and pediatric radiology in simplified and decreased the expense of the entire Administrator, Department of particular, has been transformed by imaging process, since no photographic development Radiology, Phoenix Children’stechnology. Ultrasound, computed tomography was needed; film processors, dark rooms and Hospital, Phoenix, AZ.(CT), and magnetic resonance imaging (MRI) associated personnel also were no longer neces-have all contributed immensely to the care of sary. This technology was widely accepted andchildren and led to a deeper understanding of utilized by radiology departments around theboth normal anatomy and disease processes. world. Once in a digital format, the images couldHowever, there has been no greater impact on be post-processed in a variety of ways to improvepediatric radiology than the development of the diagnostic abilities of the radiologist and todigital radiography (DR). promote rapid distribution of the imaging study Plain radiography has evolved considerably to be immediately available to local and wide-over the past 20 years. Film screen radiography area networks. In addition, once digitized, thewas the standard—the diagnostic centerpiece— images were immediately available on PACS andof radiology departments for decades. By could be reviewed by the pediatric radiologist,today’s standards, the technology was not who could assist the technologist with difficulttoo expensive and was able to create diagnos- cases and more rapidly provide a final reading totic images of good to excellent quality. But as physicians caring for the child. The shortened Richard Towbin, MDtechnology advanced it became clear that there turnaround time from image production to finalwere several issues, including the need for film reading improved patient care and radiology Digital radiogra-processing with the associated processing equip- workflow, leading to customer satisfaction andment, a dark room, chemicals and dedicated potentially increased business. phy has had adarkroom personnel. As a result, throughputwas slow, repeat rates at times exceeded 10%, Definitions of “DR” substantialand the pressure was on the technologists to The term ‘DR’ has two meanings in medical positive impactrestrain, position, and make exposures that min- imaging. The first is “digital radiography,” whichimized motion artifacts in children who could includes all methods of image acquisition, result- on pediatricbe crying and/or unwilling to cooperate. ing in an image that can be displayed in a digital imaging by In 1985, computed radiography (CR) was format. The hierarchy of digital radiography isintroduced, providing an alternative to film- divided into two major categories usually abbre- reducingscreen radiography. CR was able to use existing viated as ‘CR’ and ‘DR’. This second use of thex-ray equipment to create and retain an image abbreviation ‘DR’ refers to ‘direct radiography,’ radiation dose,on a phosphor plate. Once exposed, the CR cas- and it includes any system in which the image is imaging costs,sette was put into a reader, where a laser scanned created directly from a receptor. In direct radiog-the plate and converted the analog (A) image raphy systems, the image is sent directly from the and patientinto a digital (D) format. This A-to-D conver- receptor for processing. Computed radiography turnaround times.sion changed plain film radiography. The digital is also referred to as indirect radiography becauseimage could be fed into a computer and displayed the image is read off the imaging plate through a 9 ©December 2012 www.appliedradiology.com supplement to APPLIED RADIOLOGY n
  7. 7. DXR Table 1. Pros and cons of DR and CR DR CR Greater ease of use Unlimited manipulation and positioning of the image receptor for cross-table projections – useful in trauma cases. Elimination of cassette handling (-) Repetitive motion injuries b/c of long-term cassette handling Enhanced patient throughput (-) Slower, more complex workflow Potential for better IQ with lower radiation dose (-) Greater maintenance cost Faster workflow (-) More dose required Shorter turnaround time for viewing images Lower acquisition cost ( - ) Higher cost (-) Less integration to x-ray system Less patient movement (-) Need to move patient before viewing image Larger imaging area More latitude during image review More customizable imaging parameters Wireless transmission possible Ability for rapid exposures (multiple frames per second) Can track and QA images easier as well as exposure details (-) Higher start-up costs Key: (-) = cons discrete acquisition process. Generally speaking, authors have documented similar experiences. techniques used in CR imaging can be compared An unanticipated outcome of the faster TAT to a 200 speed film/screen system while DR tech- was demonstrated in the relationship between niques may be compared to a 400 speed or higher radiology and clinical services. For example, with film/screen system.1,5 Essentially, a DR system FSR or CR, the TAT was too slow to keep up requires approximately 50% or less technique with a busy orthopedic clinic, resulting in ten- than a CR system to produce a comparable image. sion between the two groups. In contrast, with Direct radiography was introduced in the late DR, the TAT is fast enough to keep up with the 1990s. The substantial impact of DR on daily demands of “herd-type” scheduling and multiple practice is multifaceted, and related in part to orthopedists seeing patients simultaneously. This the high percentage of case volume represented has dramatically improved relations between the by plain radiography. In our practice, and that two groups. of most departments, plain film radiography accounts for more than 50% of total imaging The Phoenix Children’s experience volume. As a result, this section of the depart- DR may be configured using single or dual ment employs the most technologists. The high detector systems. While both configurations efficiency and rapid turnaround time [TAT] work well and add efficiency at lower radia- of digital radiography often lead to a reduction tion doses, the technologists in our department in the number of technologists by significantly prefer the dual-detector configuration because increasing the number of studies performed per it is easier to position patients and requires technologist. To better understand the effect of fewer steps to complete a study with >2 views. direct radiography in the pediatric radiology set- However, this is not always a practical solu- ting, we did a time-motion study that contrasted tion, since it is more costly—about $100,000. film screen radiography (FSR) and DR. We In 2011 Phoenix Children’s Hospital opened found that the average TAT for a 3-view skeletal a new hospital building that included a new examination was approximately 12 minutes for radiology department fitted with Philips imag- FSR and 3 minutes for DR. The effect on exam ing equipment. We made a commitment to completion was more dramatic when all or part use DR only and installed three DR units, of an examination needed to be repeated. Other one with a dual-detector system and two with10 © n supplement to APPLIED RADIOLOGY www.appliedradiology.com December 2012
  8. 8. DXRsingle detectors. In addition, our satellites feature examples show a reduction equal to or greatercombination RF/DR rooms with single detectors. than 50% of patient dose. As a children’s hospital, our facility is a In most CR systems, technique tracking canstrong advocate of the Image Gently® move- only be achieved through exposure indicators inment with the goal of producing diagnostic the DICOM header. There is not an accuratestudies at the lowest possible radiation dose. way to track kVp, mA, or time. This is because aOur DR equipment supports these efforts by CR cassette has no connectivity to the x-ray gen-using lower mAs in most studies1 and reducing erator. Consequently, there is no way to transferthe repeat rate. Other positive features of DR study information from the x-ray generator to theinclude faster TAT, more flexibility of the imag- CR cassette. CR system exposure indicators caning device making it easier for the technologist be problematic. Every CR system manufacturerto position the child resulting in shorter imag- has a different methodology and scale to desig-ing times in our experience and that reported nate exposure indicator values. In addition, expo-in the literature.2,3 Compared to film/screen sure indicators are a reference value representingimaging, digital imaging systems are very forgiv- the relative amount of radiation hitting the plate.ing of both under- and overexposure. Severely Direct radiography systems do have the abilityunderexposed digital images can be grainy and to track technique factors. With DR, the x-rayunacceptable even after post-processing. In con- generator and receptor are part of a single, fullytrast, overexposed digital images can appear as integrated system. Technique factors [mA, kVp,if a correct technique had been used. This is a time] from the x-ray generator component of thedouble-edged sword, since it eliminates a second DR system are included in the DICOM header.exposure but may lead to exposure creep, one of Patient and study information from the work listthe major problems of DR. Exposure creep is a also becomes part of the DICOM header.tendency to increase technique to ensure that all The pros and cons of DR and CR are sum-images are diagnostic. Studies have shown DR marized in Table 1.images with exposure rates of 500% to 1000% In conclusion, DR has had a substantialcan still produce a diagnostic quality image.4 positive impact on pediatric imaging by reduc-Thus, a quality-assurance program that regu- ing radiation dose, imaging costs, and patientlarly monitors the technical output of DR to turnaround times. As a result of the image-ensure the highest-quality imaging at the lowest acquisition advantages, post-processing tool-possible dose is very important. box, and cost savings, we anticipate that over At Phoenix Children’s, the prevention of time, DR will replace all other forms of plainexposure creep has been addressed through two film pediatric imaging.simple but effective measures: Technique chartsand a film review program. Technique charts Referencesthat build in substantive reductions in dose are 1. Seibert JA. Medical Radiation Exposure Requirements for Digi-employed in all our imaging systems. Coupled tal Radiography. Presented: Digital Imaging Summit and Work- shop for Veterinary Radiologists. San Luis Obispo, Calif. Maywith the technique charts is a regular review of 29-31, 2008. randomly selected studies to ensure compli- 2. Hermann T. Computed radiography and digital radiography:ance with the charts. A few examples of DR A comparison of technology, functionality, patient dose, and image quality. eRadimaging.com http://www.eradimaging.techniques include: a neonatal chest radiograph com/site/article.cfm?ID=535. Accessed September 1, 2012.was typically obtained with CR using 58 Kvp 3. Reiner Bruce I, et al. Multi-institutional analysis of computedand 2.0 mAs. With DR, the same examination and direct radiography: Part I. Technologist, Productivity, Radi-is performed using 56 Kvp and 1.0-1.25 mAs. ology. 2005;236:413-419. Epub 2005 Jun 21. 4. Siebert J. The standardized exposure index for digital radi-A 3-view ankle scan on a teenager (15-19 years ography: An opportunity for optimization of radiation dose toold) on a CR system used 60 kVp at 4 mAs. The the pediatric population. Pediatr Radiol. 2011;41: 573–581.same study on DR uses 55 kVp at 1.5 mAs. An Published online 2011 April 14. doi:  10.1007/s00247-010- 1954-6.AP chest technique for a 6-month-old using CR 5. Willis, C. Computed radiography: A higher dose? SPRrequired 70 kVp at 2-3 mAs. The same study Seminar in Radiation Dose Reduction 2002. Ped Radiol.on our DR system uses 60 kVp at 0.8 mAs. All 2002;32:745-750. 11 ©December 2012 www.appliedradiology.com supplement to APPLIED RADIOLOGY n
  9. 9. clinical case: DXR Clinical Case Isolated non-osseous navicular-medial cuneiform tarsal coalition Seth Vatsky, MD, and Richard Towbin, MD Case summary Diagnosis An 11-year-old boy presented to an outpa- Isolated non-osseous coalition of the navic- tient orthopedics office for chronic foot pain. ular-medial cuneiform The otherwise healthy child was experiencingDr. Vatsky is a Fellow, and progressive right foot pain, localized to the prox- DiscussionDr. Towbin is Radiologist- imal medial aspect of the first metatarsal base, Tarsal coalition is an uncommon cause ofin-Chief, Department of over the previous 8 months.  foot pain, most frequently seen involving theRadiology, Phoenix The child had been regularly participating talo-calcaneal and calcaneo-navicular joint.1Children’s Hospital, in physical activity with a recreational baseball Symptoms typically present in late childhoodPhoenix, AZ. team. His symptoms had progressively gotten or early adolescence, depending on the level of worse throughout the baseball season. His pain activity of the individual. Frequently, there is was unresponsive to thermal treatment and the involvement of multiple joints in the same foot regular use of orthotic inserts. His pain at pre- or involvement of both feet (50% to 60%). sentation was rated 6/10. On exam there was The most extreme forms of coalition are associ- localized swelling over the medial aspect of the ated with syndromes such as Apert’s, where the right foot. The area was focally tender on palpa- coalitions result in the classic “mitten hand” or tion. A bilateral flexible pes planus foot defor- “stocking feet” appearance. Because of the dif- mity was present. However, both his range of ficulty of making the diagnosis on plain film motion and strength were intact bilaterally. radiographs, multiple radiographic signs have Initial treatment was instituted with the applica- been investigated and documented to assist tion of a walking boot for a period of 4 weeks. diagnosis.2,3 There has also been increased uti- Radiographs were obtained to evaluate for lization of magnetic resonance and computer underlying osseous abnormality (Figure 1).  tomography imaging to assist in diagnosis and surgical planning.4 Imaging findings The frequency of tarsal coalition in the Radiographic examination of the right foot general population has been reported to range demonstrated sclerosis and irregular narrow- from 1% to 6%. 5 There have been isolated ing of the inferior joint space at the articulation reports of an autosomal dominant inheritance between the navicular and medial-cuneiform. with variable penetration.6 Navicular-medial There was no evidence of mineralized bridging cuneiform tarsal coalition is a rarely described crossing the joint or early degenerative change. anomaly,7 but it is likely underreported in the The remainder of the examination was normal. literature.5 Traditionally, symptoms are treated12 © n supplement to APPLIED RADIOLOGY www.appliedradiology.com December 2012
  10. 10. clinical case: DXR A B C A B Figure 1. (A) AP radiograph of the right foot demonstrates non-osseous coalition of the medial cuneiform (MC) and the navicular (NAV). (B) Lateral radiograph of the right foot con- firms non-osseous coalition of the medial cuneiform (MC) with the navicular (NAV), limited to the inferior joint space.initially with conservative immobilization with Conclusiongraded return to activity through participa- The child’s pain responded well to conserva-tion in a physical therapy program. Failure to tive treatment. Physical therapy was initiated 2respond to these measures may result in surgical weeks after initial presentation. He was pain freeintervention, either fusing the joint or resecting after 4 weeks. While surgical consultation wasthe coalition with fat interposition to prevent obtained, surgical intervention was indefinitelyrecurrence.5,7 postponed, since the current interventions were The overall rarity of this form of tarsal coali- effective in relieving symptoms.tion in the population requires a high level ofsuspicion and knowledge of the radiographic References 1. Helms C. Fundamentals of Skeletal Radiology 3rd edition.findings of coalitions in this anatomically com- Elsevier Saunders 2005.plex region. While the visualization of joint 2. Crim J. Imaging of tarsal coalition. Radiology Clinics ofchange at the navicular-medial cuneiform is North America. 2008;46:1017-1026. 3. Crim J. Kjeldsberg KM. Radiographic diagnosis of tarsalrelatively simple and unobscured on AP radio- coalition. AJR Am J Roentgenol. 2004;182:323-328.graphs, the more common subtalar and calca- 4. Newman JS. Newberg AH. Congenital tarsal coalition:neal navicular coalitions can be challenging to Multimodality evaluation with emphasis on CT and MRidentify because of the complex anatomy. The imaging. Radiographics. 2000;20:321-332. 5. Morrissy RT, Weinstein SL. Tarsal Coalitions in Lovell &radiographic signs seen on conventional views: Winter’s Pediatric Orthopaedics, 6th Edition. Pittsburgh, PA:continuous C sign, talar beaking, absent middle Lippincott Williams & Wilkins 2006.facet, anteater, and reverse anteater sign, have 6. Leonard MA. The inheritance of tarsal coalition and itsvariable sensitivity and specificity, but their relationship to spastic flat foot. J Bone Joint Surgery. 1974 56B:520-525.presence must be suspected by the interpreting 7. Ross JR, Dobbs MB. Isolated navicular-medial cuneiformradiologist, to expedite further evaluation with tarsal coalition revisited: A case report. J Pediatric Orthope-cross-sectional imaging.3,4 dics. 2011;31:e85-e88. 13 ©December 2012 www.appliedradiology.com supplement to APPLIED RADIOLOGY n
  11. 11. Transforming Patient Care Through Patient Focus, Improved Productivity and Improved Clinical Outcomes 3D imaging in the angiography suite advances interventional patient care David Siegel, MD, FSIRDr. Siegel is System Chief,Interventional Radiology IServices, North Shore LIJ nterventional radiology has evolved rapidly injection, depending on the situation. This digi-Health System, and Associate over the last two to three decades, primarily tal image dataset is then processed in seconds;Professor of Radiology, due to refinements in catheters and catheter- depending on the technique utilized, the datasetHofstra North Shore LIJ based devices. These technological advances have provides interventionalists with a 3D vascular orSchool of Medicine, New allowed for the development of new techniques soft-tissue image for diagnosis and 3D road map-Hyde Park, NY. and applications of interventional therapy in terri- ping. Using the dedicated XperGuide software, tories previously not reachable. While image qual- this dataset also can be used to guide percuta- ity has improved and digital technology has been neous interventions with the aid of interactive used to its full advantage over time in the evolu- needle-path planning and guidance software. tion of angiography and interventional radiology This sophisticated software overlays a preplanned suites, until recently little had really changed with needle path, which the operator designs at an respect to the way imaging has been utilized to integrated workstation. Previously acquired CT guide these interventional procedures. scans and images from other modalities, such as Cone-beam computed tomography (CT), magnetic resonance imaging (MRI) and MR developed several years ago, has revolutionized angiography, can also be imported and superim- the way we guide procedures by allowing for soft- posed on a fluoroscopic image. tissue imaging in the angiography suite that can This article reviews the different abilities of be used with fluoroscopy. While rotating C-arms the 3D tools available in newer interventional and 3-dimensional (3D) acquisition techniques suites and provides an overview of their various David Siegel, MD, FSIR were developed nearly 20 years ago, current tech- clinical applications. nology adds the ability to image soft tissue with CT, along with improvements in fluoroscopic 3D rotational angiography 3D angiographic and angiographic imaging of contrast-filled ves- and road mapping and CT imaging sels and other structures. Techniques for software Rotational angiography takes advantage reconstruction, manipulation, and analysis con- of the C-arm’s ability to rotate rapidly around with needle- tinue to be refined, and they now aid the inter- the patient and acquire angiographic images at ventional radiologist in guiding both vascular and numerous oblique projections around its arch. guidance nonvascular procedures in ways unimaginable as Contrast injection volume and duration must software brings recently as 5 to 7 years ago. be coordinated with the rotation speed and the At the forefront of the development of this desired images. Angiographers understand that us one step closer technology is Philips Healthcare, whose flag- the ability to see a vessel’s origination or the ship interventional suite is the Allura Xper FD exact point and angle of branching is essential to to the full-service, 20 system. Besides providing the high-quality planning procedures that require selective cath- image-guided fluoroscopy and digital x-ray acquisition systems eterization and precise endovascular therapy. now customary in modern interventional suites, The 3D reconstructed angiogram can also be procedure suite. the ceiling-suspended C-arm of the Allura Xper used for 3D road mapping. The 3D image FD 20 system can perform high-speed rotational can be superimposed on the live fluoroscopic scanning with or without simultaneous contrast image and manipulated together with the live14 © n supplement to APPLIED RADIOLOGY www.appliedradiology.com December 2012
  12. 12. IXRFigure 1. 3D image demonstrating compression of the sub- Figure 2. An XperGuide “target view” for a biopsy of a lesion in theclavian artery consistent with Paget-Schroetter syndrome. This iliac bone. Note the green circle over the lesion on the reconstructedcone-beam CT reconstruction was created from a single rota- image. This is superimposed on the live fluoroscopic image, indi-tional acquisition with contrast injection via 5-French cath- cating where the operator should place the needle. The insert in theeter positioned at the origin of the subclavian artery. Note: The right lower corner is one of several axial images used to plan theclavicle has been manually removed from the image so that the needle path.critical narrowing can be seen.fluoroscopic image. Oblique angles can be understanding the blood supply and drainageobtained, the patient can be moved, and the of various organs. In interventional oncologi-image can be magnified during endovascu- cal procedures, when caustic chemotherapeuticlar manipulations and interventions. Previ- preparations or radioactive particles are to beously, numerous stationary oblique “runs” were introduced into the liver vessels, confining therequired, using trial and error; once the appro- materials within the liver is essential, as non-tar-priate projection was determined, it was then get embolization can be catastrophic, especiallyemployed for treatment planning and guidance. when it involves the GI tract. If a vessel is opaci- With practice, interventionalists gain an fied during such a procedure and its vascular ter-understanding of when the added time, con- ritory is uncertain, XperCT can be performedtrast, and radiation of these rotational acquisi- during contrast injection, and the vascular dis-tions will ultimately lead to lower cumulative tribution identified on that soft-tissue imaging.procedural time, contrast use, and exposure. These techniques can be utilized outside the liver, as well. We often utilize cone-beam CTCone-beam CT before embolization to evaluate the potential Cone-beam CT employs image acquisition distribution of the embolic. Following emboli-similar to that of rotational angiography. Com- zation procedures, XperCT can assess the pre-puter software then performs a sophisticated cise territory embolized, making it clear whether3D reconstruction, resulting in images that further embolization is necessary.1can be viewed as a multiplanar reconstruction. Understanding the relationship of vesselsThese images can be manipulated, rotated and to surrounding structures can be essential tozoomed; adjustments in window and level also diagnosing different vascular conditions. Paget-can be made. Imaging soft tissue simultaneously Schroetter syndrome, or thoracic outlet syn-with opacified vessels can be essential to appre- drome, is a condition where the subclavian vesselsciating the relationship of these structures and are crushed between the first rib and the clavicle 15 ©December 2012 www.appliedradiology.com supplement to APPLIED RADIOLOGY n
  13. 13. IXRFigure 3. XperCT image following endoleak embolization Figure 4. Intraprocedural XperCT with MR overlay during injectionwith metallic coils, a vascular plug, and glue. Note the metal- sclerotherapy for treatment of a recurrent symptomatic left lowerlic coils and high-density tissue acrylic in the aneurysm sac, extremity venous malformation. Note the needle path designed withthe back disc of a vascular plug (grey arrow) used to seal the XperGuide to guide puncture of a previously suboptimally treatedpuncture site in the aneurysm sac, and the radiopaque glue portion of the lesion.(white arrow) used to embolize the lumbar vessels seen sup-plying the type 2 endoleak. and confined by the scalene muscles between and then to aid the operator in precisely placing those bony structures. This generally occurs the needle during a variety of interventional pro- when the affected arm is abducted and extended. cedures. The 3D CT image is first used to design Figure 1 is a cone-beam CT image that dem- the course of a needle or multiple needles that do onstrates Paget-Schroetter syndrome. On this not traverse any significant vascular or other dan- image, compression of the subclavian artery by gerous structures. The unit will then assume the the surrounding structures is beautifully depicted. necessary compound oblique positions based on XperCT can also be employed during inter- calculated coordinates. Initially, the C-arm will ventional procedures to locate and evaluate assume a “down the barrel” projection, or target devices. We have used cone-beam CT imaging to view, and superimpose a circle on the fluoro- guide filter placement in patients with severe con- scopic field where the needle should be placed. trast allergies or renal failure, to guide fenestration After fluoroscopically guided placement of the of aortic dissections by locating the appropriate needle, so that only a point is seen, the C-arm is point for flap puncture, and to evaluate the course then turned to an orthogonal view to monitor of catheters or guide wires when it is unclear if the progress of the advancing needle. When the unit true lumen of an occluded vessel was traversed or is turned to this orthogonal view, or to any posi- if a collateral vessel that would be dangerous to tion, the 3D soft-tissue image and needle path dilate was catheterized. The applications for this remain superimposed on the fluoroscopic image. technology continue to expand. Biopsies and other procedures requiring needle access can be performed more accurately and Interventional tools reliably, translating into fewer needle passes and for needle guidance lower complication rates, especially when related The 3D image dataset obtained by the to bleeding and post-procedure discomfort. cone-beam CT acquisition of the Philips FD20 Figure 2 is a target view for a biopsy of a 19-year- Allura Xper unit can be used with the dedicated old man with a benign cartilaginous lesion of the needle- guidance software to plan a needle path iliac bone. 16 © n supplement to APPLIED RADIOLOGY www.appliedradiology.com December 2012
  14. 14. IXRRadiation dose We regularly perform nephrostomy place- Radiation exposure to the patient is cer- ment, biliary drainage, and complex fluid collec-tainly a factor in deciding how and when cone- tion drainage with Xper guide. Needle placementbeam CT and/or 3D angiography should be can be guided with the accuracy of CT imagingutilized in interventional practice. While rota- in an environment where subsequent cathetertional C-arm imaging techniques certainly manipulations and exchanges can be performeddeliver a greater radiation dose to the patient with high-quality fluoroscopic guidance. Needlethan does conventional fluoroscopy, in many guidance has significantly expanded our inter-situations, this technology can actually dramati- ventional armamentarium. For example, we havecally decrease the total fluoroscopy time and performed puncture and intubation of the pan-number of individual digital acquisitions— creatic duct for stenting of a persistent leak. Uti-therefore decreasing overall radiation exposure. lizing overlay of an MR image for targeting the When a needle can be advanced under real- cisterna chili, we were able to access the thoracictime fluoroscopic guidance after a single cone- duct and then embolize a postoperative leak. Fig-beam CT acquisition, the need for interval CT ure 4 demonstrates an intraprocedural XperCTscanning during manipulations and needle with MR overlay, obtained in a patient with apasses is eliminated. Even with the addition of venous malformation where recurrent symptomsan extra CT scan to confirm needle position, were related to a deeper, previously untreated loc-cumulative radiation dose to a patient during ulation. This deeper portion of the malformationa complex biopsy or other procedure requir- was targeted and successfully treated with sclero-ing CT guidance is usually decreased. For these therapy, resulting in complete symptom relief.situations, the Philips Allura Xper FD20 systemallows for a lower-dose cone-beam CT acquisi- Conclusiontion. This will produce an image of somewhat The availability of 3D angiographic and CTlower quality, but it can be used to determine imaging with needle-guidance software in theneedle position accurately. The overall decrease traditional interventional environment bringsin radiation to patients during biopsy proce- us one step closer to the full-service, image-dures has been validated in several published guided procedure suite, where interventionalstudies.2 radiologists can perform all procedures with the required technology at their disposal. FutureComplex interventional procedures developments in this technology should con- We now use XperGuide in many clini- tinue to enhance our precision and expand thecal situations where accurate CT-needle guid- role of interventional medicine.ance placement is needed in conjunction with Acknowledgement: The author would like toadditional vascular or nonvascular catheter and thank his colleague, Igor Lobko, MD, for his collabo-guide wire-based procedures. The combina- ration in much of the work discussed in this article.tion of soft-tissue CT imaging, needle-guidancesoftware, and 3D angiographic imaging can Referencesoften simplify what would be relatively com- 1. Tognolini Alessia, Louie John D., Hwang Gloria L., et al. Utility of C-arm CT in patients with hepatocellular carcinomaplex or cumbersome procedures; at times, it undergoing transhepatic arterial chemoembolization. J Vasceliminates the need to move a patient from one Interv Radiol. 2010;21: 339-347.suite to another where these different modalities 2. Braak Sicco J, Strijen van Marco JL, Es van Hendrik W, et al. Effective dose during needle interventions: Cone-beamare available. There are several reports of trans- CT guidance compared with conventional CT guidance.lumbar endoleak embolization utilizing cone- J Vasc Interv Radiol. 2011;22:455-461.beam CT guidance for sac puncture.3 Figure 3 3. Bindsbergen van Lars, Braak Sicco J, Strijen van Marco JL, de Vries Jean-Paul PM. Type II endoleak embolization afterdemonstrates an example of XperCT following endovascular abdominal aortic aneurysm repair with use ofendoleak embolization using coils, a vascular real-time three-dimensional fluoroscopic needle guidance.plug, and tissue acrylic. J Vasc Interv Radiol. 2010;21:1443-1447. 17 ©December 2012 www.appliedradiology.com www.appliedradiology.com supplement to APPLIED RADIOLOGY n
  15. 15. clinical case: IXR Clinical Case Treating recurrent pelvic congestion David Siegel, MD, FSIR Case summary for sclerotherapy. Figure 2 demonstrates a direct A 39-year-old female patient, SG, pre- puncture through the perineum, which was used sented with painful varices in the lower extremi- for access to some of the deep pelvic varices at a ties and pubic region after having several failed subsequent procedure. saphenous vein procedures. Following con- In this circumstance, direct access to a siz- sultation and venography, diagnoses of pelvic able pelvic vein for sclerotherapy would be quite congestion and iliac vein compression, or May- advantageous, but the issue is safely guiding a Thurner Syndrome, were made. The latter was needle to the mid-pelvis accurately and reliablyDr. Siegel is the System treated successfully with stenting of the iliac to avoid traversing any unwanted or dangerousChief, Interventional Radiol- vein; the gonadal veins were embolized bilater- pelvic structures. Figure 3, obtained at the lastogy Services, North Shore ally after venographic confirmation of reflux. procedure, is a venogrom obtained by directLIJ Health System, and Over the next 8 years, the patient underwent puncture of a posterior division branch of theAssociate Professor of 11 additional procedures to treat symptomatic left hypogastric vein using the planning func-Radiology, Hofstra-North recurrences. Although the patient’s symptoms tionality of XperCT and XperGuide. ContrastShore LIJ School of Medicine, completely or nearly completely resolved fol- injection beautifully demonstrates the symp-New Hyde Park, NY. lowing each successful procedure, they were tomatic pelvic venous plexi, including the peri- rarely in control for more than 6 to 8 months. uterine/periovarian plexus and the dilated veins surrounding the urinary bladder, communicat- Diagnosis ing with the deep peroneal veins. Following this Pelvic congestion syndrome venogrom, 3% sodium tetradecyl was injected through the needle and allowed to dwell in place Imaging findings with the patient in the semi-upright position As the patient’s varicosities recurred, it for 25 minutes. This procedure was performed became increasingly more difficult to obtain about 1 year prior to the preparation of this case access to them and to perform sclerotherapy, report and the patient has remained asymptom- especially when they began to develop in the infe- atic during that time, which is her longest symp- rior pelvis, causing pain and a burning sensation tom-free interval since presentation. involving the pelvic floor. Pudendal veins, cross pelvic collateral veins, recanalized portions of the Discussion saphenous vein and many unnamed veins were Pelvic congestion syndrome, or ovarian accessed and/or treated in subsequent sessions. venous incompetence, was originally described in An example is seen in Figure 1, a venogram from 19581 and the name pelvic congestion syndrome one of those procedures. Injection of contrast is first appeared in the literature in 1976.2 For many being performed via microcatheter, which was years, this was a misunderstood and underdiag- manipulated into the visualized pelvic floor veins nosed entity. The confusion is primarily due to via the vein of Giacomini. This was then used the variable clinical presentations and the wide18 © n supplement to APPLIED RADIOLOGY www.appliedradiology.com December 2012
  16. 16. clinical case: IXR CFigure 1. Contrast injection via microcatheter,which was manipulated into the visualized pel-vic floor veins via the vein of Giacomini. Thiswas then used for sclerotherapy.variations in response to endovascular therapy. Figure 2. Venogram performed through a trocar needle placed through theAs there are a myriad of etiologies for pelvic pain perineum using fluoroscopic landmarks only. Note the opacified deepand many patients are asymptomatic with respect pelvic varices and some extravasation of contrast from the prior nonguidedto their pelvic varices, treatment failures are not needle passes.uncommon. Additionally, many patients havesimple ovarian vein incompetence with involve-ment of one or both ovarian veins, while othershave some contribution from the internal iliacsystem.3 The latter situation can lead to treatmentfailures or incomplete symptom resolution fol-lowing gonadal vein embolization alone.Conclusion Pelvic congestion syndrome is a complexcondition, the hallmark of which is ovarian veinreflux and symptomatic pelvic varices. This caseof recurrent pelvic varices after embolotherapyillustrates how XperCT and XperGuide cansupport direct access for sclerotherapy afternumerous procedures have essentially elimi-nated the conventional vascular access routes.While this specific situation is quite rare, it is theauthor’s hope that practitioners will considercone-beam CT and dedicated needle guidancewhen faced with other situations where directdeep vascular access would be advantageous.References1. Topolanski-Sierra R. Pelvic phlebography. Am J Obstet Figure 3. Venogram obtained by contrast injection through a needle used toGynecl. 1958;76:44-45. puncture a posterior branch of the left hypogastric vein using XperCT and Xper-2. Hobbs JT. The pelvic congestion syndrome. Practitioner. Guide. The varicosities around the uterus, ovaries, bladder and pelvic floor are1976; 41:41-46.3. Ignacio EA, Dua R, Sarin S, et al. Pelvic congestion syn- opacified. This access was then used for injection of a sclerosing agent. The insertdrome: Diagnosis and treatment. Semin Intervent Radiol. in the left upper corner is one of several axial images used to plan the needle path2008;25:361-368. on the workstation. 19 ©December 2012 www.appliedradiology.com supplement to APPLIED RADIOLOGY n
  17. 17. Transforming Patient Care Through Patient Focus, Improved Productivity and Improved Clinical OutcomesAmbient Experience for PET/CT: Reducing patientanxiety, improving the clinical processJoseph Jalkiewicz “the whole gamut of cancers,” including lym- phomas and cancers of the head and neck, lung, and breast. Patient anxiety: A PET/CT imaging challenge Yet getting patients’ anxiety under control is crucial to the success of PET/CT scanning, which requires injections of 18F fluorodeoxy- glucose (18F-FDG) and relies heavily on the patient to remain quiet and still for up to 90 minutes or more. That’s a challenging task for anyone, much less a patient dealing with the emotional turmoil accompanying a cancer diag- nosis, said Dr. Cross. “You are asking [patients] to wait while you inject them with radioactive material, and they are already pretty nervous to start with because F ew words strike fear into a person like the words, “You have cancer.” An estimated 1.64 million people will hear they have cancer, and on top of that they have to be quiet. That is incredibly difficult for people to do,” he said. those words this year as they receive a diagnosis of “When you inject the patient with FDG, breast cancer, prostate cancer, head/neck cancer, you want patients to be relaxed so they don’t or any one of the many other forms of the sec- produce false positives in the images, which may ond-leading cause of death in the United States.1 be caused by motion, either from humming, As part of their treatment, many of these talking or just moving about,” he said, explain- patients will undergo positron emission tomog- ing that such motion can cause extra dye uptake raphy and computed tomography (PET/CT) and metabolization by the muscles, leading to scanning, one of the most powerful and effective false positive results. imaging technologies available to help radiation Administering sedatives like diazepam to Bruce A. Cross, MD oncologists diagnose, stage, and monitor cancer- help patients relax is an option, but various stud- ous lesions and their response to treatment. ies have produced mixed results on their effective- We do a “PET scanning has revolutionized scanning for treatment of cancer,” said Bruce Cross, MD, ness, in addition to other drawbacks, such as the inability of outpatients to drive home and poten- better job citing head/neck cancer as just one example. tial interactions with other drugs.2 “Before, we had assumed that if you had a large Radiation oncologists like Dr. Cross use here at Sparks lymph node, you had to treat the entire lymph a variety of techniques to relax patients and in part node. With PET scanning, you can distinguish which lymph nodes are involved and which ones enhance the clinical process. because of are not. We have been able to tailor our treatment The Ambient Experience solution fields to [target] only the areas involved and to Ambient Experience is Philips’ strategy for Ambient protect, for example, the salivary glands.” creating a patient-friendly, soothing environ- Experience. As a radiation oncologist in the Sparks Health System in Fort Smith, AR, Dr. Cross ment for those undergoing PET/CT imaging procedures. To calm nervous patients during said he uses PET/CT to help treat adults with radiopharmaceutical injection, the walls of20 © n supplement to APPLIED RADIOLOGY www.appliedradiology.com December 2012
  18. 18. Ambient Experiencethe uptake room are bathed in a warm-colored “The fact that we have provided [patients]glow, and patients are provided with a comfort- with a distraction or entertainment … to takeable chair. Patients entering the exam room, their mind off the radioactive agent is a reallymeanwhile, can select from several different positive thing,” he said. “It gives them some-room themes by using a touchscreen tablet PC. thing else to focus on.”The selected theme is reflected in immediate He also said the tropical beach scenes arechanges to the room environment, including especially popular with his adult patients. “Thecolored lighting from a skylight and animated beach, with palm trees and the ocean, is a clas-projected images accompanied by soothing sic mental getaway for adults. If the only thingmusic and other sounds. available were cartoon characters, not many An Ambient Experience suite is also adults would want to see them. That’s why thedesigned to promote operational efficiency that, choice [that the Ambient Experience] offers Referencescombined with more relaxed patients, helps makes them very happy,” he said. 1. American Cancer Society. Can-improve patient compliance and streamlines Dr. Cross said he is “convinced that we do cer facts and figures 2012: Leading new cancer cases and deaths-2012PET/CT examinations by reducing patient a better job here” at Sparks in part because of estimates. http://www.cancer.org/anxiety.3 Ambient Experience. acs/groups/content/@epidemiology- “I’ve been very impressed that Sparks went surveilance/documents/document/Audiovisual intervention: all out on with the Ambient Experience. I am acspc-032012.pdf. Last accessed Aug. 28, 2012.A sound solution convinced, from my 25 years of experience read- 2. Vogel, Wouter V, Valdes Olmos A recent study concluded that “audiovisual ing PET scans, that we do a better job here. How Renato A, Tijs Tim JW, et al. “Inter-intervention” can help to reduce patient anxiety much of that is patient cooperation or the excel- vention to lower anxiety of 18F-FDGin the PET uptake room and reduce false positive lent algorithms in the technology is hard to tell, PET/CT patients by use of audiovisual imagery during the uptake phase18F-FDG uptake in brown adipose tissue (BAT) but I feel very secure that we’re doing a better job.” before imaging.” J Nucl Med Technol.“without the disadvantages associated with phar- 2012:40;1-7. *It is important to note that this study was per-macologic interventions.”2 formed with a prototype configuration that is not com- 3. Philips Website. Ambient Experi- “Throughout the stay in the uptake room, a ence. PET/CT. http://www.healthcare. mercially available. Ambient Experience as a product/ philips.com/us_en/products/ambi-significant decrease in overall anxiety was found, service has not been designed nor has it been approved by ent_experience/clinical_solutions/together with several other significant changes Philips to have capability to provide the effect described pet_ct/index.wpd. Accessed Aug. 28,in patient physiology. In the cohort with audio- in the study. 2012.visual intervention, however, the decrease inpatient anxiety was significantly larger. Thecohort with intervention also showed signifi-cantly lower 18F-FDG uptake in BAT, but notin muscles,” the researchers reported.2 The results of the study of 101 patients werepublished in the June 2012 issue of the Journalof Nuclear Medicine Technology.* The study results are no surprise to MedhatM. Osman, MD, ScM, PhD, Associate Pro-fessor and Medical Director of the Division ofNuclear Medicine and PET/CT, Saint LouisUniversity School of Medicine, St. Louis, Mo. “Strategies such as Ambient Experience canlead to improved patient management becausecalmer patients are better able to cooperate,which can impact many aspects of the clinicalprocess,” Dr. Osman said. “And that meanshappier referring physicians.” In the opinion of Dr. Cross, the value of Ambient Experience can help anxious, unsure patientsAmbient Experience lies in delivering a moresuccessful PET/CT examination because you feel a sense of ease and relaxation in a welcominghave a calm, relaxed, and cooperative patient. environment that soothes and calms. 21 ©December 2012 www.appliedradiology.com supplement to APPLIED RADIOLOGY n
  19. 19. Transforming Patient Care Through Patient Focus, Improved Productivity and Improved Clinical Outcomes 3T MR imaging protocol for characterization of renal masses Gaurav Khatri, MD, and Ivan M. Pedrosa, MD R enal cell carcinoma (RCC) is the third supine with arms placed above his head using most common genitourinary tumor a 16-channel phased-array torso coil. Each and seventh most common cancer in the sequence is obtained as a breathhold acquisition United States. Radical or partial nephrectomy has during patients’ end-expiration, which allows historically been the standard treatment; however, for more reproducible anatomic co-registra- given the trend towards earlier diagnosis, less inva- tion.2 Breath-hold times range from 16 to 22 sive treatment options are feasible in appropriate seconds. Coaching prior to actual image acqui- cases.1 Imaging plays a vital role in detection of sition helps improve breath-hold consistency renal lesions, in assessing local stage, providing with resultant successful postprocessing of the crucial information for planning surgical resection subtraction images.2 A gadolinium-based con- and predicting prognosis, thus contributing to trast agent (GBCA) is administered to patients management decision making. Although ultraso- with baseline estimated glomerular filtration nography and computed tomography (CT) have rate (eGFR) >30 mL/min/1.73 m2 and with- been used for evaluation of renal lesions, magnetic out evidence for acute exacerbation of renal dis- resonance (MR) imaging offers certain advantages ease. The GBCA is administered intravenously Ivan M. Pedrosa, MD over these modalities. via power injector at a dose of 0.1mmol/Kg or 0.1mL/Kg followed by a bolus of 20 mL of Technology saline, both at an injection rate of 2 cc/second. Parallel imaging MR imaging possesses higher inherent The protocol is detailed in Table 1. strategies, such as contrast resolution than CT or ultrasound. In addition, it has a high sensitivity for detect- T2-weighted sequences SENSE, with ing tissue enhancement when gadolinium is Half-fourier T2-weighted single shot turbo administered. It is free of known pitfalls, such spin echo (SS TSE) images provide excellent the mDIXON as pseudoenhancement, seen routinely on image quality due to faster acquisition times than technique, allow CT.2-4 MR imaging with 3.0 Tesla (3T) sys- that of conventional multislice echo-train imag- tems, high-density phased-array coils, and newly ing offering a virtual breath-hold independent for fast volumetric developed sequences, such as multiecho Dixon imaging strategy.2 However, breath-hold imag- acquisition of the (mDIXON),5 offers robust image quality and ing or respiratory triggering with respiratory bel- excellent spatial resolution. 3T magnets have the lows (when necessary) is recommended to ensure abdomen with advantage of higher signal-to-noise, which can proper anatomic registration of the images and be used to yield shorter acquisition times and/or coverage. Visualization of renal lesions can be decreased motion increased image resolution.2 Multiplanar imag- optimized by improving the dynamic range when artifacts due ing, homogeneous fat suppression, and dynamic utilizing fat-suppression techniques. contrast-enhanced imaging are also routinely to shorter achievable on 3T MR platforms, all of which aid Echo-planar with diffusion-weighted imaging breath-hold times. in lesion detection and characterization. Echo-planar imaging (EPI) is utilized to Our institutional 3T renal-mass evalua- obtain diffusion-weighted images (DWI) that tion protocol is performed with the patient allow for detection and characterization of22 © n supplement to APPLIED RADIOLOGY www.appliedradiology.com December 2012
  20. 20. MR Table 1. 3T MRI protocol for Renal MassesSequence TR (msec) TE (msec) Flip Angle (o) Bandwidth Section FOV (cm) Matrix (Hz/pix) Thickness/Gap (mm)Coronal T2-weighted 960 80 90 652 5/1 40 × 45 312 × 279SS TSEAxial T2-weighted 920 80 90 543 5/1 40 × 30 304 × 168fat suppressed SS TSEAxial DWI 1060 53 90 36.5 7/1 44 × 35 144 × 115Axial 2D T1-weighted 120 2.3/1.15 55 1215 5/1 40 × 38 400 × 269dual echo IP/OP GRECoronal mDIXON 3.8 1.7/2.1 10 1923 3/-1.5 39 × 40 260 × 223Sagittal mDIXON 3.7 1.32/2.3 10 1568 3/-1.5 30 × 30 248 × 230Axial mDIXON 3.3 1.16/2.1 10 1852 3/-1.5 38 × 33 252 × 218lesions based on degree of restriction of water images (ie, fat saturated), which are used formotion. The authors acquire images using the dynamic contrast-enhanced portion of therespiratory triggering and multiple b values: b0, study. Pre-contrast mDIXON acquisitions areb50, b400, b800. Apparent diffusion coefficient obtained in oblique sagittal orientation along(ADC) maps are generated based on the diffu- the long axis of each kidney and also in the coro-sion images. nal plane. Coronal ‘fat-saturated’ T1-weighted spoiled gradient-echo images (mDIXON) areT1-weighted sequences then acquired during a properly timed cortico- Pre-contrast T1-weighted images include medullary phase using a real-time bolus track-2-dimensional (2D) dual echo in-phase (IP) ing technique (BolusTrack, Philips Healthcare),and opposed-phase (OP) gradient-echo (GRE) and then during the early and late nephro-images acquired in the axial plane. graphic phase at 40 and 90 seconds after the Although dynamic imaging was tradition- initiation of the corticomedullary phase. Sagit-ally performed utilizing 3-dimensional (3D) tal oblique mDIXON images are again acquiredT1-weighted fat-saturated spoiled gradient- along the long axis of each kidney during theecho images, recently developed DIXON-based excretory phase after the coronal dynamic acqui-acquisitions, such as the mDIXON sequence, sition. Finally, an axial mDIXON acquisition isallow for more robust fat saturation (ie, fat- obtained and ‘water only’ and ‘fat only’ imagewater separation) than traditional sequences datasets are generated. Subtraction of the pre-that utilize frequency selective fat saturation contrast images from each of the post-contrasttechniques. 6,7 The combination of parallel images produce subtracted volumetric image Dr. Khatri is an Assistantimaging strategies, such as SENSE, with the datasets, which are useful for assessing the pres- Professor of Radiology,mDIXON technique allows for a fast volumet- ence of enhancement in a renal lesion. Body/Body MRI Section,ric acquisition of the abdomen with decreased and Dr. Pedrosa is Chief-motion artifacts due to shorter breath-hold Clinical applications of-MRI, Associate Professortimes. Furthermore, the mDIXON tech- T2-weighted images of Radiology, Departmentnique offers the possibility of reconstructing Simple cysts appear as homogeneously of Radiology, University ofthe acquired data set as T1-weighted IP, OP, hyperintense thin-walled structures on Texas Southwestern Medicaland fat-only images (without penalty of added T2-weighted images, while septations or solid Center, Advanced Imagingacquisition time) in addition to the water-only elements appear hypointense relative to the Research Center, Dallas, TX. 23 ©December 2012 www.appliedradiology.com supplement to APPLIED RADIOLOGY n
  21. 21. MR commonly demonstrates increased signal inten- A B sity relative to the normal renal parenchyma on T2-weighted images.9 Intralesional necrosis, common in clear cell RCC,11 appears as mod- erate to high signal intensity on T2-weighted images, although it can occasionally appear hypointense.12 Intratumoral hemorrhage and fibrosis can be present and exhibits variable sig- nal on T2-weighted images. Clear-cell RCC may present with a capsule or pseudocapsule, which is hypointense on T2-weighted images and discontinuity of the capsule suggests inva- sion of the perirenal fat and higher grade.9,13 Papillary RCC, accounting for approximately C D 10% to 15% of all RCC,14 demonstrate homo- geneous low signal intensity on T2-weighted images,11 although it may also exhibit foci of hemorrhage and necrosis resulting in a more heterogeneous appearance.9 Predominantly fat-containing lesions, such as some angio- myolipomas (AMLs), appear hyperintense on T2-weighted images, and exhibit lower signal on T2-weighted fat-suppressed images. AMLs with minimal fat on the other hand, exhibit homoge-Figure 1. Figure 1 demonstrates multiple lesions in the right kidney in a patient neous hypointense signal relative to renal paren-with Von-Hippel Lindau (VHL). Two clear-cell renal cell carcinomas (white arrow, chyma on T2-weighted images, but should notwhite arrowhead) demonstrate predominant hyperintense signal with numerous demonstrate necrotic elements.9thick septations on coronal T2-SS TSE image (A), and hypointense signal on coro- In situations where administration of con-nal mDIXON pre-contrast image (B). The coronal mDIXON post-contrast image trast is contraindicated, T2-weighted images(C) shows enhancement of the septations, which is confirmed on the coronal may demonstrate the presence of tumor throm-mDIXON subtraction image (D). A smaller lesion in the lower pole (black arrow) bus in the renal veins and IVC as a filling defectis hyperintense on the coronal T2-SS TSE image (A) and hyperintense on coro- of increased signal intensity against backgroundnal mDIXON pre-contrast image (B). Although a majority of the lesion does not of dark flow voids.appear to enhance on the coronal mDIXON post-contrast image (C), there is asubtle central hyperintense nodule. The coronal mDIXON subtraction image (D)confirms enhancement of this central nodule within a predominantly hemor- Diffusion-weighted imagesrhagic lesion. Another small lesion along the lateral cortex (black arrowhead) is DWI allows for characterization of renalhyperintense on the coronal T2-SS TSE image (A), and does not enhance on the lesions as either solid or cystic based on theircoronal mDIXON post-contrast image or on the subtraction image (C and D). This degree of restriction of water motion.15 Thislesion is isointense to the surrounding parenchyma on the coronal mDIXON pre- may be particularly helpful when intravenouscontrast image (B) and is consistent with a cystic lesion containing hemorrhagic contrast cannot be administered (allergies,or proteinaceous debris. renal failure, etc.), precluding evaluation for hyperintense fluid (Figure1). Numerous thick- enhancement. A lesion that remains hyperin- ened septations increase the likelihood of lesions tense on high b-value images and demonstrates being malignant. 8 Hypointense lesions on low signal on ADC maps is more indicative of T2-weighted images may represent solid lesions a solid rather than cystic lesion. 15 However, or cystic lesions with hemorrhagic or protein- restricted diffusion may be seen in hemorrhagic aceous contents.9 Signal characteristics of solid non-neoplastic contents within a cystic lesion. lesions on T2-weighted images may suggest Although some authors have shown utility of specific histologic subtyping. Clear-cell RCC, ADC values in differentiation of benign lesions accounting for 65% to 80% of RCC,10 most and RCC 16 or between subtypes of RCC,1724 © n supplement to APPLIED RADIOLOGY www.appliedradiology.com www.appliedradiology.com December 2012

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