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Everything you need to know about Computed Tomography (CT) & CT Scanning

April 2018 Imaging Pearls - Educational Tools | CT Scanning | CT Imaging | CT Scan Protocols - CTisus
Imaging Pearls ❯ April 2018

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3D and Workflow

    • “Acute aortic injuries are not common in the setting of severe blunt trauma, but lead to significant morbidity and mortality. High- quality MDCT with 2D MPRs and 3D rendering are essential to identify aortic trauma and distinguish anatomic variants and other forms of aortic pathology from an acute injury. Misinterpretation of mimics of acute aortic injury can lead to unnecessary arteriography and thoracic surgery. Since most traumatic injuries occur in the distal arch, radiologists must be cognizant of the range of appearances of variants related to the ductus diverticulum. Cinematic rendering (CR) is a new 3D post-processing tool that provides even greater anatomic detail than traditional volume rendering. In this case series, CR is used to impart to radiologists a better understanding of various anatomic configurations that can be seen with a ductus diverticulum.”

      
MDCT of ductus diverticulum: 3D cinematic rendering to enhance understanding of anatomic configuration and avoid misinterpretation as traumatic aortic injury 
Steven P. Rowe1 & Pamela T. Johnson1 & Elliot K. Fishman
Emergency Radiology (2018) 25:209–213
    • “Postprocessing with 2D multiplanar reconstructions and 3D rendering has become standard of care in CT angiography. One of the advantages of volume rendering over maximum intensity projection is the ability to convey 3D anatomic relationships. For complex anatomic configurations like the thoracic aorta and pulmonary arteries, the lighting model in cinematic rendering adds even greater anatomic detail, as demonstrated by these cases.”


      MDCT of ductus diverticulum: 3D cinematic rendering to enhance understanding of anatomic configuration and avoid misinterpretation as traumatic aortic injury 
Steven P. Rowe1 & Pamela T. Johnson1 & Elliot K. Fishman
Emergency Radiology (2018) 25:209–213
    • “One of the most pronounced advantages of cinematic rendering is the production of realistic shadowing effects, allowing for very clear representation of the relative positions of objects within the imaged volume; this is well demonstrated in Fig. 1, where the shadowing from the aortic arch onto the underlying ductus diverticulum and pulmonary arterial vasculature allows the viewer to easily grasp the internal arrangement of these structures. Although the rate of incorrectly diagnosed traumatic aortic injuries was low even in the era when invasive aortography was the primary imaging modality, and has remained low with CT angiography as the frontline modality, the consequences of a missed diagnosis (potential death from massive hemorrhage) or an overcalled finding (unnecessary thoracotomy) underscore the importance of any new technique to improve diagnostic accuracy or diagnostic confidence.”


      MDCT of ductus diverticulum: 3D cinematic rendering to enhance understanding of anatomic configuration and avoid misinterpretation as traumatic aortic injury 
Steven P. Rowe1 & Pamela T. Johnson1 & Elliot K. Fishman
Emergency Radiology (2018) 25:209–213
    • “Since most traumatic injuries occur in the distal arch, radiologists must be cognizant of the range of appearances of variants related to the ductus diverticulum. Cinematic rendering (CR) is a new 3D post-processing tool that provides even greater anatomic detail than traditional volume rendering. In this case series, CR is used to impart to radiologists a better understanding of various anatomic configurations that can be seen with a ductus diverticulum.”


      MDCT of ductus diverticulum: 3D cinematic rendering to enhance understanding of anatomic configuration and avoid misinterpretation as traumatic aortic injury 
Steven P. Rowe1 & Pamela T. Johnson1 & Elliot K. Fishman
Emergency Radiology (2018) 25:209–213
    • “CR has the potential to improve visualization of subtle pancreatic neoplasms, differentiation of solid and cystic pancreatic neoplasms, assessment of local tumor extension and vascular invasion, and visualization of metastatic disease.” 


      Cinematic rendering of pancreatic neoplasms: preliminary observations and opportunities 
Linda C. Chu , Pamela T. Johnson, Elliot K. Fishman 
Abdom Radiol (2018)
https://doi.org/10.1007/s00261-018-1559-3
    • “Pancreatic cancer is the third most common cause of cancer death and CT is the most commonly used modality for the initial evaluation of suspected pancreatic cancer. Post-processing of CT data into 2D multiplanar and 3D reconstructions has been shown to improve tumor visualization and assessment of tumor resectability compared to axial slices, and is considered the standard of care. Cinematic rendering is a new 3D- rendering technique that produces photorealistic images, and it has the potential to more accurately depict anatomic detail compared to traditional 3D reconstruction techniques.”

      
Cinematic rendering of pancreatic neoplasms: preliminary observations and opportunities 
Linda C. Chu , Pamela T. Johnson, Elliot K. Fishman 
Abdom Radiol (2018)
https://doi.org/10.1007/s00261-018-1559-3
    • “Pancreatic cancer is the 12th most common cause of cancer and the 3rd most common cause of cancer death. It is estimated that 53,670 new pancreatic cancer cases will be diagnosed in the United States in 2017. CT is the most commonly used imaging modality for the initial evaluation of suspected pancreatic cancer.” 


      Cinematic rendering of pancreatic neoplasms: preliminary observations and opportunities 
Linda C. Chu , Pamela T. Johnson, Elliot K. Fishman 
Abdom Radiol (2018)
https://doi.org/10.1007/s00261-018-1559-3
    • “CR differs from traditional VR in the use of the lighting model. While VR uses a simple ray cast method to generate 3D images, CR uses Monte Carlo path tracing and global illumination model that takes direct and indirect illumination into account. With CR, each pixel is formed by thousands of rays passing through the volumetric dataset and includes effects of light rays from scatter and from voxels adjacent to the paths of the rays.” 


      Cinematic rendering of pancreatic neoplasms: preliminary observations and opportunities 
Linda C. Chu , Pamela T. Johnson, Elliot K. Fishman 
Abdom Radiol (2018)
https://doi.org/10.1007/s00261-018-1559-3
    • “The photorealistic quality of CR can accentuate subtle textural change of the pancreatic neoplasm compared to background pancreatic parenchyma, which can improve visualization of subtle cases. CR also provides greater appreciation of the global shape and size of the pancreas. This highlights parenchymal atrophy, which is a useful secondary sign associated with pancreatic adenocarcinoma. The photorealistic images of CR mimic real anatomic specimens that may be more intuitive for non-radiologists and may facilitate communication with referring clinicians and patients.”

      
Cinematic rendering of pancreatic neoplasms: preliminary observations and opportunities 
Linda C. Chu , Pamela T. Johnson, Elliot K. Fishman 
Abdom Radiol (2018)
https://doi.org/10.1007/s00261-018-1559-3
    • “Just as CR can highlight subtle hypoenhancement and textural change of pancreatic adenocarcinoma, the display settings can be modified to highlight structures with high Hounsfield units, such as neuroendocrine tumors. The wider dynamic range of color and depth helps to improve tumor conspicuity. CR improves depth perception, which can be particularly helpful in visualizing fine internal septations and mural nodularity in cystic pancreatic neoplasms. The improved appreciation of the internal architecture of the cystic pancreatic neoplasms may help in differentiating different types of cystic neoplasms.” 


      Cinematic rendering of pancreatic neoplasms: preliminary observations and opportunities 
Linda C. Chu , Pamela T. Johnson, Elliot K. Fishman 
Abdom Radiol (2018)
https://doi.org/10.1007/s00261-018-1559-3
    • “The exquisite vascular maps generated by CR can highlight the extent of vascular invasion (i.e., length of involved vessel, degree of luminal narrowing), which can assist in determining tumor resectability and in determining vascular reconstruction planning. The improved depth perception of CR can assist surgeons in visualizing the pancreatic tumor and the intrinsic vascular anatomy of the pancreatic bed. This is especially important if the patient may be a candidate for laparoscopic- or robot-assisted pancreatic surgery, since these minimally invasive surgery offer limited field of view compared with open surgery.” 


      Cinematic rendering of pancreatic neoplasms: preliminary observations and opportunities 
Linda C. Chu , Pamela T. Johnson, Elliot K. Fishman 
Abdom Radiol (2018)
https://doi.org/10.1007/s00261-018-1559-3
    • “There are several limitations of CR technique. CR uses a more complex algorithm compared to VR and requires higher computational power. This requires more powerful workstations and network bandwidth. Each manipulation during interactive rendering requires a new set of calculations, which increases post-processing time. Second, the CR display needs to be optimized to depict the anatomy and pathology of interest. Therefore, CR needs to be performed by the radiologist and the display needs to be tailored to different clinical indications. Lastly, while CR dramatically improves photorealism of the CT images, it is currently unclear whether this photorealism improves diagnostic accuracy and/or patient outcomes. At the current time, the potential role of CR in pancreatic imaging remains speculative. These preliminary observations show potential application of CR in pancreatic imaging, which will require validation in future studies.”

      
Cinematic rendering of pancreatic neoplasms: preliminary observations and opportunities 
Linda C. Chu , Pamela T. Johnson, Elliot K. Fishman 
Abdom Radiol (2018)
https://doi.org/10.1007s00261-018-1559-3
    • “There are several limitations of CR technique. CR uses a more complex algorithm compared to VR and requires higher computational power. This requires more powerful workstations and network bandwidth. Each manipulation during interactive rendering requires a new set of calculations, which increases post-processing time. Second, the CR display needs to be optimized to depict the anatomy and pathology of interest. Therefore, CR needs to be performed by the radiologist and the display needs to be tailored to different clinical indications.” 


      Cinematic rendering of pancreatic neoplasms: preliminary observations and opportunities 
Linda C. Chu , Pamela T. Johnson, Elliot K. Fishman 
Abdom Radiol (2018)
https://doi.org/10.1007s00261-018-1559-3
    • “Lastly, while CR dramatically improves photorealism of the CT images, it is currently unclear whether this photorealism improves diagnostic accuracy and/or patient outcomes. At the current time, the potential role of CR in pancreatic imaging remains speculative. These preliminary observations show potential application of CR in pancreatic imaging, which will require validation in future studies.” 


      Cinematic rendering of pancreatic neoplasms: preliminary observations and opportunities 
Linda C. Chu , Pamela T. Johnson, Elliot K. Fishman 
Abdom Radiol (2018)
https://doi.org/10.1007s00261-018-1559-3
    • “An apparent limitation of CR is illustrated in the 2nd case. While the shadowing effects that arise from the global lighting model that is used contribute to the photorealistic quality of the images, shadowing can also potentially obscure important pathology. Therefore, as with any 3D rendering technique, it is important for the user to examine CR visualizations from multiple different views and to interactively alter the windowing settings to increase and decrease the transparency of overlapping anatomic structures, and to use CR in conjunction with axial display, 2D MPRs, MIP and VR. Other limitations of CR may come to light as the method becomes more widely clinically available.”

      
Cinematic rendering of cardiac CT volumetric data: Principles and initial observations 
Steven P. Rowe, Pamela T. Johnson, Elliot K. Fishman
Journal of Cardiovascular Computed Tomography 12 (2018) 56–59 

    • “CR is a promising method to enhance display volumetric CT data and should prove useful in diagnosis, treatment planning, surgical navigation, trainee education, and patient engagement. However, further study is needed to establish the advantaged and disadvantages of CR in comparison to other 3D methods.”

      
Cinematic rendering of cardiac CT volumetric data: Principles and initial observations 
Steven P. Rowe, Pamela T. Johnson, Elliot K. Fishman
Journal of Cardiovascular Computed Tomography 12 (2018) 56–59 

    • “Additional considerations that refine CR photorealism include the incorporation of shadowing effects that derive from assuming that the light source can be obscured by objects within the visualized volume. Such shadowing is not typically included in traditional VR, although it is possible to incorporate.8 Furthermore, while CR can use one or more unidirectional light sources as is done in VR, more typically an en- vironment map is used (i.e. texture maps that are related to the brightnesses of surfaces within a virtual scene and more accurately reflect realistic lighting scenarios).”

      
Cinematic rendering of cardiac CT volumetric data: Principles and initial observations 
Steven P. Rowe, Pamela T. Johnson, Elliot K. Fishman
Journal of Cardiovascular Computed Tomography 12 (2018) 56–59 

    • “Kawasaki’s disease (KD) is a vasculitis that predominantly affects children and can lead to the development of coronary artery aneurysms. These aneurysms can subsequently thrombose and occlude, which may lead to chest pain and other signs and symptoms of acute coronary syndrome in young patients. Coronary CT angiography, including 3D visualization techniques, is a common modality used in the follow-up of KD patients. In this series of three patients, we present the typical coronary artery imaging findings that can appear in these patients, with an emphasis on the use of the novel 3D technique of cinematic rendering (CR). CR utilizes a different lighting model than other 3D methods and is able to produce highly-detailed, photorealistic images. The potential advantages of CR images in understanding the complex mediastinal vascular anatomy and the relationships of coronary artery aneurysms to other anatomic structures are emphasized.”


      Evaluation of Kawasaki’s disease-associated coronary artery aneurysms with 3D CT cinematic rendering 
Steven P. Rowe1 & Stefan L. Zimmerman1 & Pamela T. Johnson1 & Elliot K. Fishman 
 Emergency Radiology (in press)
    • “The most important potential complication of KD is in- flammatory damage to the coronary arteries, which classically leads to the formation of coronary artery aneurysms. These aneurysms will often undergo vascular remodeling and partial 
thrombosis in order to produce a psuedonormal vascular lu- men. However, progressive thrombosis and other stenotic pro- cesses such as fibrosis can, over time, precipitate cardiac is- chemia that can lead to emergency room presentations for chest pain or other signs of acute coronary syndrome and necessitate invasive and/or surgical interventions. Of note, computed tomography (CT) angiography, including 3D methods such as volume rendering (VR), has been found to provide suitable non-invasive evaluation of the coronary arteries in patients with KD.”


      Evaluation of Kawasaki’s disease-associated coronary artery aneurysms with 3D CT cinematic rendering 
Steven P. Rowe1 & Stefan L. Zimmerman1 & Pamela T. Johnson1 & Elliot K. Fishman 
 Emergency Radiology (in press)
    • “As with other 3D visualization methods, CR would be expected to provide a global overview of the disease process that is not easily appreciated on 2D axial or multi-planar reformatted images. In particular, this may help to identify relatively distal, small caliber sites of aneurysmal enlargement, which stand out with high contrast on the 3D images but can be subtle when only 2D images are viewed. Given the anatomic complexity of the mediastinum with many adjacent vascular structures, it may be that CR has intrinsic advantages relative to other 3D methods in being able to accurately display the relative positions of those structures in a manner that may be more intuitively grasped in comparison to less photorealistic depictions.”


      Evaluation of Kawasaki’s disease-associated coronary artery aneurysms with 3D CT cinematic rendering 
Steven P. Rowe1 & Stefan L. Zimmerman1 & Pamela T. Johnson1 & Elliot K. Fishman 
 Emergency Radiology (in press)
    • “Even if CR demonstrates no, or only marginal, advantages relative to VR in terms of clinical applicability, the photorealistic appeal of these images will almost certainly lead to wide- spread use in trainee and patient education.”


      Evaluation of Kawasaki’s disease-associated coronary artery aneurysms with 3D CT cinematic rendering 
Steven P. Rowe1 & Stefan L. Zimmerman1 & Pamela T. Johnson1 & Elliot K. Fishman 
 Emergency Radiology (in press)
Adrenal

    • OBJECTIVE. The purpose of this study was to determine the rate of malignancy in inci- dentally detected bilateral adrenal masses in patients with no known history of cancer. 


      CONCLUSION. No case of malignancy was found in 322 incidentally detected bilateral adrenal nodules at CT of patients without known cancer. Imaging follow-up of such lesions may be unnecessary. 


      Incidentally Detected Bilateral Adrenal Nodules in Patients Without Cancer: Is Further Workup Necessary? 
Corwin MT et al.
AJR 2018; 210:780–784
    • “The differential diagnosis of bilateral adrenal masses without gross fat includes bilateral adenomas, metastases, infection, hemorrhage, lymphoma, pheochromocytoma, and adrenal cortical carcinoma. It is possible that the rate of malignancy could differ between incidentally detected unilateral and bilateral lesions. Adrenal metastases have been reported to occur bilaterally in 49% of cases and lymphoma in 43%.” 


      Incidentally Detected Bilateral Adrenal Nodules in Patients Without Cancer: Is Further Workup Necessary? 
Corwin MT et al.
AJR 2018; 210:780–784
    • “The most likely cause of the nodules in our study is adrenal adenoma. All nodules that were fully characterized at imaging proved to be adenomas in our study with the exception of two myelolipomas. Although the other nodules were presumed to be benign given imaging or clinical stability, the etiologic factors remained indeterminate because they were not further characterized and could represent other benign lesions, such as pheochromocytoma.” 


      Incidentally Detected Bilateral Adrenal Nodules in Patients Without Cancer: Is Further Workup Necessary? 
Corwin MT et al.
AJR 2018; 210:780–784
    • “Our study adds to the growing body of evidence that small incidentally detected adrenal nodules in patients without a history of cancer are highly likely benign and may require no further imaging follow-up. Specifically, our findings suggest this approach applies to the case of bilateral nodules. This finding of our study is important because the increased use and resolution of CT have led to an increase in incidental findings unrelated to the original clinical indication. This can lead to extensive further cascades of imaging and interventional workups that can be costly and cause morbidity and psychologic stress.”

      Incidentally Detected Bilateral Adrenal Nodules in Patients Without Cancer: Is Further Workup Necessary? 
Corwin MT et al.
AJR 2018; 210:780–784
    • “We found no cases of malignancy in 322 incidentally detected bilateral adrenal nodules at CT examinations of 161 patients who had no known cancer. Imaging follow-up of such lesions may be unnecessary.”

      
Incidentally Detected Bilateral Adrenal Nodules in Patients Without Cancer: Is Further Workup Necessary? 
Corwin MT et al.
AJR 2018; 210:780–784
Cardiac

    • “Additional considerations that refine CR photorealism include the incorporation of shadowing effects that derive from assuming that the light source can be obscured by objects within the visualized volume. Such shadowing is not typically included in traditional VR, although it is possible to incorporate.8 Furthermore, while CR can use one or more unidirectional light sources as is done in VR, more typically an en- vironment map is used (i.e. texture maps that are related to the brightnesses of surfaces within a virtual scene and more accurately reflect realistic lighting scenarios).”

      
Cinematic rendering of cardiac CT volumetric data: Principles and initial observations 
Steven P. Rowe, Pamela T. Johnson, Elliot K. Fishman
Journal of Cardiovascular Computed Tomography 12 (2018) 56–59 

    • “Kawasaki’s disease (KD) is a vasculitis that predominantly affects children and can lead to the development of coronary artery aneurysms. These aneurysms can subsequently thrombose and occlude, which may lead to chest pain and other signs and symptoms of acute coronary syndrome in young patients. Coronary CT angiography, including 3D visualization techniques, is a common modality used in the follow-up of KD patients. In this series of three patients, we present the typical coronary artery imaging findings that can appear in these patients, with an emphasis on the use of the novel 3D technique of cinematic rendering (CR). CR utilizes a different lighting model than other 3D methods and is able to produce highly-detailed, photorealistic images. The potential advantages of CR images in understanding the complex mediastinal vascular anatomy and the relationships of coronary artery aneurysms to other anatomic structures are emphasized.”


      Evaluation of Kawasaki’s disease-associated coronary artery aneurysms with 3D CT cinematic rendering 
Steven P. Rowe1 & Stefan L. Zimmerman1 & Pamela T. Johnson1 & Elliot K. Fishman 
 Emergency Radiology (in press)
    • “The most important potential complication of KD is in- flammatory damage to the coronary arteries, which classically leads to the formation of coronary artery aneurysms. These aneurysms will often undergo vascular remodeling and partial 
thrombosis in order to produce a psuedonormal vascular lu- men. However, progressive thrombosis and other stenotic pro- cesses such as fibrosis can, over time, precipitate cardiac is- chemia that can lead to emergency room presentations for chest pain or other signs of acute coronary syndrome and necessitate invasive and/or surgical interventions. Of note, computed tomography (CT) angiography, including 3D methods such as volume rendering (VR), has been found to provide suitable non-invasive evaluation of the coronary arteries in patients with KD.”


      Evaluation of Kawasaki’s disease-associated coronary artery aneurysms with 3D CT cinematic rendering 
Steven P. Rowe1 & Stefan L. Zimmerman1 & Pamela T. Johnson1 & Elliot K. Fishman 
 Emergency Radiology (in press)
    • “As with other 3D visualization methods, CR would be expected to provide a global overview of the disease process that is not easily appreciated on 2D axial or multi-planar reformatted images. In particular, this may help to identify relatively distal, small caliber sites of aneurysmal enlargement, which stand out with high contrast on the 3D images but can be subtle when only 2D images are viewed. Given the anatomic complexity of the mediastinum with many adjacent vascular structures, it may be that CR has intrinsic advantages relative to other 3D methods in being able to accurately display the relative positions of those structures in a manner that may be more intuitively grasped in comparison to less photorealistic depictions.”


      Evaluation of Kawasaki’s disease-associated coronary artery aneurysms with 3D CT cinematic rendering 
Steven P. Rowe1 & Stefan L. Zimmerman1 & Pamela T. Johnson1 & Elliot K. Fishman 
 Emergency Radiology (in press)
    • “Even if CR demonstrates no, or only marginal, advantages relative to VR in terms of clinical applicability, the photorealistic appeal of these images will almost certainly lead to wide- spread use in trainee and patient education.”


      Evaluation of Kawasaki’s disease-associated coronary artery aneurysms with 3D CT cinematic rendering 
Steven P. Rowe1 & Stefan L. Zimmerman1 & Pamela T. Johnson1 & Elliot K. Fishman 
 Emergency Radiology (in press)
    • OBJECTIVE. Previously published reports have shown that coronary CT angiography (CCTA) is a more efficient method of diagnosis than myocardial perfusion imaging (MPI) and stress echocardiography for patients presenting to emergency departments (EDs) with acute chest pain. In light of this evidence, the objective of this study was to examine recent trends in the use of these techniques in EDs. 


      CONCLUSION. Use of CCTA in EDs has increased rapidly, but far more MPI examinations are still being performed. This finding suggests that recently acquired evidence is not yet being fully acted upon.

      
Coronary CT Angiography: Use in Patients With Chest Pain Presenting to Emergency Departments 
Levin DC et al.
AJR 2018; 210:816–820
    • “ Chest pain is the second most com- mon cause of patient visits to emergency departments (EDs) in the United States. There are 8 million such visits annually, and they result in approximately $12 billion in costs . On arrival in the ED, patients with chest pain typically undergo ECG and cardiac enzyme determination. If these tests do not yield a diagnosis of acute coronary syndrome, the patient generally undergoes further observation and repeat testing. The testing often then includes imaging.”


      Coronary CT Angiography: Use in Patients With Chest Pain Presenting to Emergency Departments 
Levin DC et al.
AJR 2018; 210:816–820
    • “The American College of Radiology Ap- propriateness Criteria include a listing for chest pain suggestive of acute coronary syndrome. These criteria, which are well known to radiologists, rate various imaging tests on a scale of 1–9 with 7–9 considered appropriate, 4–6 possibly appropriate, and 1–3 usually not appropriate. In this particular clinical circumstance, MPI is rated 8, stress echocardiography 7, and CCTA 6. The reasons for the low rating of CCTA are not clear.”


      Coronary CT Angiography: Use in Patients With Chest Pain Presenting to Emergency Departments 
Levin DC et al.
AJR 2018; 210:816–820
    • “In view of what the aforementioned literature has shown, we believe the appropriateness criteria for chest pain suggestive of acute coronary syndrome should be revised to rate CCTA higher than both MPI and stress echocardiography. Radiologists, who interpret most CCTA examinations performed in EDs, should educate their emergency medicine colleagues about the greater utility of CCTA in the evaluation of patients with chest pain.”

      
Coronary CT Angiography: Use in Patients With Chest Pain Presenting to Emergency Departments 
Levin DC et al.
AJR 2018; 210:816–820
    • “An apparent limitation of CR is illustrated in the 2nd case. While the shadowing effects that arise from the global lighting model that is used contribute to the photorealistic quality of the images, shadowing can also potentially obscure important pathology. Therefore, as with any 3D rendering technique, it is important for the user to examine CR visualizations from multiple different views and to interactively alter the windowing settings to increase and decrease the transparency of overlapping anatomic structures, and to use CR in conjunction with axial display, 2D MPRs, MIP and VR. Other limitations of CR may come to light as the method becomes more widely clinically available.”


      Cinematic rendering of cardiac CT volumetric data: Principles and initial observations 
Steven P. Rowe, Pamela T. Johnson, Elliot K. Fishman
Journal of Cardiovascular Computed Tomography 12 (2018) 56–59 

    • “CR is a promising method to enhance display volumetric CT data and should prove useful in diagnosis, treatment planning, surgical navigation, trainee education, and patient engagement. However, further study is needed to establish the advantaged and disadvantages of CR in comparison to other 3D methods.”


      Cinematic rendering of cardiac CT volumetric data: Principles and initial observations 
Steven P. Rowe, Pamela T. Johnson, Elliot K. Fishman
Journal of Cardiovascular Computed Tomography 12 (2018) 56–59
Chest

    • “Acute aortic injuries are not common in the setting of severe blunt trauma, but lead to significant morbidity and mortality. High- quality MDCT with 2D MPRs and 3D rendering are essential to identify aortic trauma and distinguish anatomic variants and other forms of aortic pathology from an acute injury. Misinterpretation of mimics of acute aortic injury can lead to unnecessary arteriography and thoracic surgery. Since most traumatic injuries occur in the distal arch, radiologists must be cognizant of the range of appearances of variants related to the ductus diverticulum. Cinematic rendering (CR) is a new 3D post-processing tool that provides even greater anatomic detail than traditional volume rendering. In this case series, CR is used to impart to radiologists a better understanding of various anatomic configurations that can be seen with a ductus diverticulum.”


      MDCT of ductus diverticulum: 3D cinematic rendering to enhance understanding of anatomic configuration and avoid misinterpretation as traumatic aortic injury 
Steven P. Rowe1 & Pamela T. Johnson1 & Elliot K. Fishman
Emergency Radiology (2018) 25:209–213
    • “Since most traumatic injuries occur in the distal arch, radiologists must be cognizant of the range of appearances of variants related to the ductus diverticulum. Cinematic rendering (CR) is a new 3D post-processing tool that provides even greater anatomic detail than traditional volume rendering. In this case series, CR is used to impart to radiologists a better understanding of various anatomic configurations that can be seen with a ductus diverticulum.”

      
MDCT of ductus diverticulum: 3D cinematic rendering to enhance understanding of anatomic configuration and avoid misinterpretation as traumatic aortic injury 
Steven P. Rowe1 & Pamela T. Johnson1 & Elliot K. Fishman
Emergency Radiology (2018) 25:209–213
    • “Postprocessing with 2D multiplanar reconstructions and 3D rendering has become standard of care in CT angiography. One of the advantages of volume rendering over maximum intensity projection is the ability to convey 3D anatomic relationships. For complex anatomic configurations like the thoracic aorta and pulmonary arteries, the lighting model in cinematic rendering adds even greater anatomic detail, as demonstrated by these cases.”


      MDCT of ductus diverticulum: 3D cinematic rendering to enhance understanding of anatomic configuration and avoid misinterpretation as traumatic aortic injury 
Steven P. Rowe1 & Pamela T. Johnson1 & Elliot K. Fishman
Emergency Radiology (2018) 25:209–213
    • “One of the most pronounced advantages of cinematic rendering is the production of realistic shadowing effects, allowing for very clear representation of the relative positions of objects within the imaged volume; this is well demonstrated in Fig. 1, where the shadowing from the aortic arch onto the underlying ductus diverticulum and pulmonary arterial vasculature allows the viewer to easily grasp the internal arrangement of these structures. Although the rate of incorrectly diagnosed traumatic aortic injuries was low even in the era when invasive aortography was the primary imaging modality, and has remained low with CT angiography as the frontline modality, the consequences of a missed diagnosis (potential death from massive hemorrhage) or an overcalled finding (unnecessary thoracotomy) underscore the importance of any new technique to improve diagnostic accuracy or diagnostic confidence.”

      
MDCT of ductus diverticulum: 3D cinematic rendering to enhance understanding of anatomic configuration and avoid misinterpretation as traumatic aortic injury 
Steven P. Rowe1 & Pamela T. Johnson1 & Elliot K. Fishman
Emergency Radiology (2018) 25:209–213
Deep Learning

    • “In this paper, we adopt 3D CNNs to segment the pancreas in CT images. Although deep neural networks have been proven to be very effective on many 2D vision tasks, it is still challenging to apply them to 3D applications due to the limited amount of annotated 3D data and limited computational resources. We propose a novel 3D-based coarse- to-fine framework for volumetric pancreas segmentation to tackle these challenges. The proposed 3D-based framework outperforms the 2D counterpart to a large margin since it can leverage the rich spatial information along all three axes.”


      A 3D Coarse-to-Fine Framework for Automatic Pancreas Segmentation 
Zhuotun Zhu, Yingda Xia, Wei Shen, Elliot K. Fishman, Alan L. Yuille
arXiv:1712.00201v1 [cs.CV] 1 Dec 2017 

    • “In this work, we proposed a novel 3D network called “ResDSN” integrated with a coarse-to-fine framework to simultaneously achieve high segmentation accuracy and low time cost. The backbone network “ResDSN” is carefully designed to only have long residual connections for efficient inference. To our best knowledge, we are the first to segment the challenging pancreas using 3D networks which leverage the rich spatial information to achieve the state-of- the-art.”

      
A 3D Coarse-to-Fine Framework for Automatic Pancreas Segmentation 
Zhuotun Zhu, Yingda Xia, Wei Shen, Elliot K. Fishman, Alan L. Yuille
arXiv:1712.00201v1 [cs.CV] 1 Dec 2017 

    • “To address these issues, we propose a concise and effective framework based on 3D deep networks for pancreas segmentation, which can simultaneously achieve high seg- mentation accuracy and low time cost. Our framework is formulated in a coarse-to-fine manner. In the training stage, we first train a 3D FCN from the sub-volumes sampled from an entire CT volume. We call this ResDSN Coarse model, which aims to obtain the rough location of the target pancreas from the whole CT volume by making full use of the overall 3D context. Then, we train another 3D FCN from the sub-volumes sampled only from the ground truth bound- ing boxes of the target pancreas. We call this the ResDSN Fine model, which can refine the segmentation based on the coarse result.”


      A 3D Coarse-to-Fine Framework for Automatic Pancreas Segmentation 
Zhuotun Zhu, Yingda Xia, Wei Shen, Elliot K. Fishman, Alan L. Yuille
arXiv:1712.00201v1 [cs.CV] 1 Dec 2017 

    • “This work is motivated by the difficulty of small organ segmentation. As the target is often small, it is required to 
focus on a local input region, but sometimes the network is confused due to the lack of contextual information. We present the Recurrent Saliency Transformation Network, which enjoys three advantages. (i) Benefited by a (recurrent) global energy function, it is easier to generalize our models from training data to testing data. (ii) With joint optimization over two networks, both of them get improved individually. (iii) By incorporating multi-stage visual cues, more accurate segmentation results are obtained. As the fine stage is less likely to be confused by the lack of contexts, we also observe better convergence during iterations.”


      Recurrent Saliency Transformation Network: Incorporating Multi-Stage Visual Cues for Small Organ Segmentation 
Qihang Yu, Lingxi Xie, Yan Wang, Yuyin Zhou, Elliot K. Fishman, Alan L. Yuille
arXiv:1709.04518v3 [cs.CV] 18 Nov 2017
    • “This paper presents a Recurrent Saliency Transforma- tion Network. The key innovation is a saliency transfor- mation module, which repeatedly converts the segmentation probability map from the previous iteration as spatial weights and applies these weights to the current iteration. This brings us two-fold benefits. In training, it allows joint optimization over the deep networks dealing with different input scales. In testing, it propagates multi-stage visual information throughout iterations to improve segmentation accuracy.”


      Recurrent Saliency Transformation Network: Incorporating Multi-Stage Visual Cues for Small Organ Segmentation 
Qihang Yu, Lingxi Xie, Yan Wang, Yuyin Zhou, Elliot K. Fishman, Alan L. Yuille
arXiv:1709.04518v3 [cs.CV] 18 Nov 2017
    • “Automatic segmentation of an organ and its cystic region is a prerequisite of computer-aided diagnosis. In this paper, we focus on pancreatic cyst segmentation in abdominal CT scan. This task is important and very useful in clinical practice yet challenging due to the low contrast in boundary, the variability in location, shape and the different stages of the pancreatic cancer. Inspired by the high relevance between the location of a pancreas and its cystic region, we introduce extra deep supervision into the segmentation network, so that cyst segmentation can be improved with the help of relatively easier pancreas segmentation.”


      Deep Supervision for Pancreatic Cyst Segmentation in Abdominal CT Scans 
Yuyin Zhou, Lingxi Xie, Elliot K. Fishman, and Alan L. Yuille 
(in) Medical Image Computing and Computer Assisted Intervention − MICCAI 2017
page 222-231
    • “This paper presents the first system for pancreatic cyst segmentation which can work without human assistance on the testing stage. Motivated by the high relevance of a cystic pancreas and a pancreatic cyst, we formulate pancreas segmentation as an explicit variable in the formulation, and introduce deep supervision to assist the network training process. The joint optimization can be factorized into two stages, making our approach very easy to implement. We collect a dataset with 131 pathological cases. Based on a coarse-to-fine segmentation algorithm, our approach produces reasonable cyst segmentation results. It is worth emphasizing that our approach does not require any extra human annotations on the testing stage, which is especially practical in assisting common patients in cheap and periodic clinical applications.”

      
Deep Supervision for Pancreatic Cyst Segmentation in Abdominal CT Scans 
Yuyin Zhou, Lingxi Xie, Elliot K. Fishman, and Alan L. Yuille 
(in) Medical Image Computing and Computer Assisted Intervention − MICCAI 2017
page 222-231
    • “In healthcare, faxes remain the most common method that practitioners use to communicate with each other, and therefore often contain important clinical information: lab results, specialist consult notes, prescriptions and so on. Because most healthcare fax numbers are public, doctors also receive scores of pizza menus, travel specials, and other “junk faxes.” Faxes don’t contain any structured text — so it takes medical practice staff an average of two minutes and 36 seconds to review each document and input relevant data into patient records. Through a combination of machine learning and business-process outsourcing that has automated the categorizing of faxes, we’ve reduced time-per-fax for our practices to one minute and 11 seconds. As a result, last year alone we managed to eliminate over 3 million hours of work from the healthcare system.”
    • “In healthcare, faxes remain the most common method that practitioners use to communicate with each other, and therefore often contain important clinical information: lab results, specialist consult notes, prescriptions and so on. Because most healthcare fax numbers are public, doctors also receive scores of pizza menus, travel specials, and other “junk faxes.” Faxes don’t contain any structured text — so it takes medical practice staff an average of two minutes and 36 seconds to review each document and input relevant data into patient records.”


      How AI Is Taking the Scut Work Out of Health Care
Jonathan Bush
Harvard Business Review (March 2018)
    • “Here’s just one example of the immediate opportunity: Each year, some 120 million faxes still flow into the practices of the more than 100,000 providers on the network of athenahealth, the healthcare technology company where I’m CEO. That’s right: faxes. Remember those?.”


      How AI Is Taking the Scut Work Out of Health Care
Jonathan Bush
Harvard Business Review (March 2018)
    • “We have a similar opportunity in medicine now with the application of artificial intelligence and machine learning. Glamorous projects to do everything from curing cancer to helping paralyzed patients walk through AI have generated enormous expectations. But the greatest opportunity for AI in the near term may come not from headline-grabbing moonshots but from putting computers and algorithms to work on the most mundane drudgery possible. Excessive paperwork and red-tape is the sewage of modern medicine. An estimated 14% of wasted health care spending — $91 billion — is the result of inefficient administration. Let’s give AI the decidedly unsexy job of cleaning out the administrative muck that’s clogging up our medical organizations, sucking value out of our economy, and literally making doctors ill with stress.”


      How AI Is Taking the Scut Work Out of Health Care
Jonathan Bush
Harvard Business Review (March 2018)
    • “Excessive paperwork and red-tape is the sewage of modern medicine. An estimated 14% of wasted health care spending — $91 billion — is the result of inefficient administration. Let’s give AI the decidedly unsexy job of cleaning out the administrative muck that’s clogging up our medical organizations, sucking value out of our economy, and literally making doctors ill with stress.”


      How AI Is Taking the Scut Work Out of Health Care
Jonathan Bush
Harvard Business Review (March 2018)
    • Open Radiology?

Kidney

    • “Despite the theoretical risk from ionizing radiation, CT is preferred over MR because of its higher spatial resolution and speed, and because it is less prone to artifacts. Compared to CT, MR angiography is much more prone to motion-related artifacts. Vascular calcification and urolithiasis are better depicted by CT than MR.”

      
CT evaluation of the renal donor and recipient 
 Vernuccio F et al.
Abdom Radiol (2018) (in press)
    • “Common reasons for potentially excluding a donor based on CT findings include renal anatomic variability (i.e., unilateral renal agenesis, renal ectopia, horseshoe kidney), complex vascular anatomy, urolithiasis, and malignancy. The presence of multiple renal arteries is considered a relative contraindication owing to longer operative times and higher risk of arterial thrombosis. Abnormalities of the collecting sys- tem might contraindicate transplant, including severe hydronephrosis, papillary necrosis, transitional cell carcinoma, or important anatomical variants such as ureteric duplication or ureteropelvic junction obstruction.”


      CT evaluation of the renal donor and recipient 
 Vernuccio F et al.
Abdom Radiol (2018) (in press)
    • “All measurements should be performed in the corti- comedullary phase. Kidney volume can be calculated by manually tracing the renal cortex on each image showing renal parenchyma and excluding the renal pelvis or it can be automatically estimated from bidimensional kidney measurements on axial images using predefined formulas. More recently, kidney volume can be measured with semiautomated or automated segmentation techniques that do not require manual tracing of the edges of the kidneys.”


      CT evaluation of the renal donor and recipient 
 Vernuccio F et al.
Abdom Radiol (2018) (in press)
    • “The vascular renal assessment is mandatory consid- ering that certain vascular anomalies may disqualify a potential donor. Arterial assessment is performed in the arterial phase and includes anatomic information with standardized measurements, delineation of vascular variants , and assessment for vascular diseases. In most individuals, the main renal artery originates between the upper margin of the L1 and the lower margin of the L2 vertebrae, with the right renal artery usually originating above the left renal artery with respect to the vertebral column.”


      CT evaluation of the renal donor and recipient 
 Vernuccio F et al.
Abdom Radiol (2018) (in press)
Pancreas

    • “CR has the potential to improve visualization of subtle pancreatic neoplasms, differentiation of solid and cystic pancreatic neoplasms, assessment of local tumor extension and vascular invasion, and visualization of metastatic disease.” 


      Cinematic rendering of pancreatic neoplasms: preliminary observations and opportunities 
Linda C. Chu , Pamela T. Johnson, Elliot K. Fishman 
Abdom Radiol (2018)
https://doi.org/10.1007/s00261-018-1559-3
    • “Pancreatic cancer is the third most common cause of cancer death and CT is the most commonly used modality for the initial evaluation of suspected pancreatic cancer. Post-processing of CT data into 2D multiplanar and 3D reconstructions has been shown to improve tumor visualization and assessment of tumor resectability compared to axial slices, and is considered the standard of care. Cinematic rendering is a new 3D- rendering technique that produces photorealistic images, and it has the potential to more accurately depict anatomic detail compared to traditional 3D reconstruction techniques.” 


      Cinematic rendering of pancreatic neoplasms: preliminary observations and opportunities 
Linda C. Chu , Pamela T. Johnson, Elliot K. Fishman 
Abdom Radiol (2018)
https://doi.org/10.1007/s00261-018-1559-3
    • “Pancreatic cancer is the 12th most common cause of cancer and the 3rd most common cause of cancer death. It is estimated that 53,670 new pancreatic cancer cases will be diagnosed in the United States in 2017. CT is the most commonly used imaging modality for the initial evaluation of suspected pancreatic cancer.” 


      Cinematic rendering of pancreatic neoplasms: preliminary observations and opportunities 
Linda C. Chu , Pamela T. Johnson, Elliot K. Fishman 
Abdom Radiol (2018)
https://doi.org/10.1007/s00261-018-1559-3
    • “CR differs from traditional VR in the use of the lighting model. While VR uses a simple ray cast method to generate 3D images, CR uses Monte Carlo path tracing and global illumination model that takes direct and indirect illumination into account. With CR, each pixel is formed by thousands of rays passing through the volumetric dataset and includes effects of light rays from scatter and from voxels adjacent to the paths of the rays.” 


      Cinematic rendering of pancreatic neoplasms: preliminary observations and opportunities 
Linda C. Chu , Pamela T. Johnson, Elliot K. Fishman 
Abdom Radiol (2018)
https://doi.org/10.1007/s00261-018-1559-3
    • “The photorealistic quality of CR can accentuate subtle textural change of the pancreatic neoplasm compared to background pancreatic parenchyma, which can improve visualization of subtle cases. CR also provides greater appreciation of the global shape and size of the pancreas. This highlights parenchymal atrophy, which is a useful secondary sign associated with pancreatic adenocarcinoma. The photorealistic images of CR mimic real anatomic specimens that may be more intuitive for non-radiologists and may facilitate communication with referring clinicians and patients.” 


      Cinematic rendering of pancreatic neoplasms: preliminary observations and opportunities 
Linda C. Chu , Pamela T. Johnson, Elliot K. Fishman 
Abdom Radiol (2018)
https://doi.org/10.1007/s00261-018-1559-3
    • “Just as CR can highlight subtle hypoenhancement and textural change of pancreatic adenocarcinoma, the display settings can be modified to highlight structures with high Hounsfield units, such as neuroendocrine tumors. The wider dynamic range of color and depth helps to improve tumor conspicuity. CR improves depth perception, which can be particularly helpful in visualizing fine internal septations and mural nodularity in cystic pancreatic neoplasms. The improved appreciation of the internal architecture of the cystic pancreatic neoplasms may help in differentiating different types of cystic neoplasms.”

      
Cinematic rendering of pancreatic neoplasms: preliminary observations and opportunities 
Linda C. Chu , Pamela T. Johnson, Elliot K. Fishman 
Abdom Radiol (2018)
https://doi.org/10.1007/s00261-018-1559-3
    • “The exquisite vascular maps generated by CR can highlight the extent of vascular invasion (i.e., length of involved vessel, degree of luminal narrowing), which can assist in determining tumor resectability and in determining vascular reconstruction planning. The improved depth perception of CR can assist surgeons in visualizing the pancreatic tumor and the intrinsic vascular anatomy of the pancreatic bed. This is especially important if the patient may be a candidate for laparoscopic- or robot-assisted pancreatic surgery, since these minimally invasive surgery offer limited field of view compared with open surgery.” 


      Cinematic rendering of pancreatic neoplasms: preliminary observations and opportunities 
Linda C. Chu , Pamela T. Johnson, Elliot K. Fishman 
Abdom Radiol (2018)
https://doi.org/10.1007/s00261-018-1559-3
    • “There are several limitations of CR technique. CR uses a more complex algorithm compared to VR and requires higher computational power. This requires more powerful workstations and network bandwidth. Each manipulation during interactive rendering requires a new set of calculations, which increases post-processing time. Second, the CR display needs to be optimized to depict the anatomy and pathology of interest. Therefore, CR needs to be performed by the radiologist and the display needs to be tailored to different clinical indications. Lastly, while CR dramatically improves photorealism of the CT images, it is currently unclear whether this photorealism improves diagnostic accuracy and/or patient outcomes. At the current time, the potential role of CR in pancreatic imaging remains speculative. These preliminary observations show potential application of CR in pancreatic imaging, which will require validation in future studies.” 


      Cinematic rendering of pancreatic neoplasms: preliminary observations and opportunities 
Linda C. Chu , Pamela T. Johnson, Elliot K. Fishman 
Abdom Radiol (2018)
https://doi.org/10.1007s00261-018-1559-3
    • “There are several limitations of CR technique. CR uses a more complex algorithm compared to VR and requires higher computational power. This requires more powerful workstations and network bandwidth. Each manipulation during interactive rendering requires a new set of calculations, which increases post-processing time. Second, the CR display needs to be optimized to depict the anatomy and pathology of interest. Therefore, CR needs to be performed by the radiologist and the display needs to be tailored to different clinical indications.” 


      Cinematic rendering of pancreatic neoplasms: preliminary observations and opportunities 
Linda C. Chu , Pamela T. Johnson, Elliot K. Fishman 
Abdom Radiol (2018)
https://doi.org/10.1007s00261-018-1559-3
    • “Lastly, while CR dramatically improves photorealism of the CT images, it is currently unclear whether this photorealism improves diagnostic accuracy and/or patient outcomes. At the current time, the potential role of CR in pancreatic imaging remains speculative. These preliminary observations show potential application of CR in pancreatic imaging, which will require validation in future studies.” 


      Cinematic rendering of pancreatic neoplasms: preliminary observations and opportunities 
Linda C. Chu , Pamela T. Johnson, Elliot K. Fishman 
Abdom Radiol (2018)
https://doi.org/10.1007s00261-018-1559-3
    • “Generally, accepted chemotherapy combinations for pancreatic adenocarcinoma include FOLFIRINOX (leucovorin, fluorouracil, irinotecan, and oxaliplatin) and gemcitabine-based chemotherapy. Since FOLFIRINOX has found to improve overall survival of patients with metastatic pancreatic adenocarcinoma when com- pared with gemcitabine, the same multidrug chemotherapy regimen became a rational choice to treat borderline and locally advanced pancreatic adenocarci- noma to render patients with locally advanced cancer resectable. Gemcitabine have been the most widely used agents along with 5-fluorouracil for patients with pancreatic adenocarcinoma. Gemcitabine with nabpaclitaxal chemotherapy including nab-paclitaxal-pacrotaxine and other regimen are being tested, and their efficacies are being investigated.”


      Assessment of iodine uptake by pancreatic cancer following chemotherapy using dual- energy CT 
Satomi Kawamoto,1 Matthew. K. Fuld, Daniel Laheru, Peng Huang, Elliot K. Fishman
Abdom Radiol (2018) (in press)
    • “Conventional anticancer chemotherapy may affect tumor vascularization. Previous studies have shown reduction in CT perfusion parameters after conventional chemotherapy in various types of tumors including rectal cancer and non-small cell lung cancer . Many of the conventional chemotherapeutic agents are cytotoxins that are capable of damaging the vascular endothelium. These observations might be based on the loss of angiogenic cytokine support after cell death.”


      Assessment of iodine uptake by pancreatic cancer following chemotherapy using dual- energy CT 
Satomi Kawamoto,1 Matthew. K. Fuld, Daniel Laheru, Peng Huang, Elliot K. Fishman
Abdom Radiol (2018) (in press)
    • “In conclusion, iodine uptake by pancreatic adenocarcinoma using DECT may add supplemental information for assessment of treatment response, although tumor iodine uptake by pancreatic adenocarcinoma is small, and it may be difficult to apply to each case. Normalized tumor iodine uptake might be more sensitive than iodine concentration to measure treatment response. More data are necessary to confirm these observations.”


      Assessment of iodine uptake by pancreatic cancer following chemotherapy using dual- energy CT 
Satomi Kawamoto,1 Matthew. K. Fuld, Daniel Laheru, Peng Huang, Elliot K. Fishman
Abdom Radiol (2018) (in press)
    • OBJECTIVE. The purposes of this study were to assess whether CT texture analysis and CT features are predictive of pancreatic neuroendocrine tumor (PNET) grade based on the World Health Organization (WHO) classification and to identify features related to disease progression after surgery. 

      CONCLUSION. CT texture analysis and CT features are predictive of PNET aggressiveness and can be used to identify patients at risk of early disease progression after surgical resection. 


      Prediction of Pancreatic Neuroendocrine Tumor Grade Based on CT Features and Texture Analysis 
Canellas R et al.
AJR 2018; 210:341–346
    • “Although PNETs can be grouped by cell type of origin and the presence of symptoms (functional and nonfunctional), the most important differentiation is tumor grade. According to the World Health Organization (WHO) classification system, PNETs can be classified as low grade (less aggressive with the highest 5-year survival rate, 85%), intermediate grade, and high grade (most aggressive with the lowest 5-year survival rate,9%).”

      

Prediction of Pancreatic Neuroendocrine Tumor Grade Based on CT Features and Texture Analysis 
Canellas R et al.
AJR 2018; 210:341–346
    • “The results of our study showed that CT texture analysis and CT features can be used to predict PNET grade. The odds of having an intermediate- or high-grade tumor in a tumor larger than 2.0 cm were 3.3 times as high as those in smaller tumors; in tumors associated with vascular involvement, 25.2 times as high as those in tumors without vascular involvement; in tumors associated with pancreatic duct dilatation, 6 times as high as those in tumors without pancreatic duct dilatation; in tumors associated with lymphadenopathy, 6.8 times as high as those in tumors not associated with lymphadenopathy; and in tumors with high entropy values, 3.7 times as high as those in tumors with low entropy values.”


      Prediction of Pancreatic Neuroendocrine Tumor Grade Based on CT Features and Texture Analysis 
Canellas R et al.
AJR 2018; 210:341–346
    • “Our results are in accordance with findings in the literature. The texture parameter entropy, which is thought to reflect tissue heterogeneity, has previously been reported as one of the best quantitative parameters for differentiating benign from neoplastic thrombi, assessing glioma grade, and assessing patient outcome in colorectal cancer.”


      Prediction of Pancreatic Neuroendocrine Tumor Grade Based on CT Features and Texture Analysis 
Canellas R et al.
AJR 2018; 210:341–346
    • “CT texture analysis and CT features can be used to predict PNET grade according to the WHO classification. They also can be used to identify patients at risk of early recurrence or progression after surgical resection.”


      Prediction of Pancreatic Neuroendocrine Tumor Grade Based on CT Features and Texture Analysis 
Canellas R et al.
AJR 2018; 210:341–346
    • “Therefore, the texture parameter entropy and the CT features (vascular involvement, pancreatic duct dilatation, lymphadenopathy, and size greater than 2.0 cm, which has already been adopted by some institutions) can be used as imaging biomarkers to identify patients who would bene t from surgery, from the watch-and-wait approach, or from postoperative adjuvant therapy. More-over, there has been much interest in creating Radiomics models to predict tumor aggressiveness and patient outcomes for multiple tumors. The results of our study may contribute to the development of a robust predictive model that combines quantitative and qualita- tive imaging parameters (e.g., texture parameters) and clinical predictors.”

      
Prediction of Pancreatic Neuroendocrine Tumor Grade Based on CT Features and Texture Analysis 
Canellas R et al.
AJR 2018; 210:341–346
    • “Second-opinion review by subspecialized oncologic radiologists can impact patient care, specifically in terms of management decision.”

      
Does Second Reader Opinion Affect Patient Management in Pancreatic Ductal Adenocarcinoma? 
 Corrias G et al.
Academic Radiology (in press)
    • “Cancer staging differed in 13% (9 of 65) of cases for surgeon 1 and in 18.4% (12 of 65) for surgeon 2. Patient management changed in 38.4% (25 of 65) of cases for surgeon 1 and in 20% (13 of 65) for surgeon 2. When compared to the pathologic staging gold standard, second opinion was correct in 85.7% (six of seven) of the time for both surgeons. Recommended patient management from second-opinion reports showed good agreement with the reference standard (weighted K = 0.6467 [0.4014–0.892] and weighted K = 0.6262 [0.3954–0.857] for surgeon 2).”

      
Does Second Reader Opinion Affect Patient Management in Pancreatic Ductal Adenocarcinoma? 
 Corrias G et al.
Academic Radiology (in press)
    • “In conclusion, our results indicate that second-opinion review by subspecialized oncology radiologists can impact patient care, specifically in terms of management decision. Our findings support the notion that subspecialty radiologic training and subspecialty expertise influence patient care in the setting of multidisciplinary, disease-specific, team-based medicine. Moreover, second-opinion consultations should be viewed as a valuable and reimbursable clinical service within the field of radiology.”

      
Does Second Reader Opinion Affect Patient Management in Pancreatic Ductal Adenocarcinoma? 
 Corrias G et al.
Academic Radiology (in press)
    • “Pancreatic cancer (PC) has a poor prognosis due to delayed diagnosis. Early diagnosis is the most important factor for improving prognosis. For early diagnosis of PC, patients with clinical manifestations suggestive of PC and high risk for developing PC need to be selected for examinations for PC. Signs suggestive of PC (e.g., symptoms, diabetes mellitus, acute pancreatitis, or abnormal results of blood examinations) should not be missed, and the details of risks for PC (e.g., familial history of PC, intraductal mucin producing neoplasm, chronic pancreatitis, hereditary pancreatitis, or life habit) should be understood. Multidetector computed tomography (MDCT) and magnetic resonance imaging (MRI) can be performed for diagnosing PC, but the diagnostic ability of these examinations for PC is limited. Endoscopic diagnostic procedures, such as endoscopic ultrasonography, including fine-needle aspiration, and endoscopic retrograde pancreatocholangiography, including Serial Pancreatic-juice Aspiration Cytologic Examination (SPACE), could be recommended for a detailed examination to diagnose pancreatic carcinoma earlier.”


      Early Diagnosis to Improve the Poor Prognosis of Pancreatic Cancer 
Masataka Kikuyama et al.
Cancers 2018, 10, 48; doi:10.3390/cancers10020048
    • “Pancreatic cancer (PC) has a poor prognosis due to delayed diagnosis. Early diagnosis is the most important factor for improving prognosis. For early diagnosis of PC, patients with clinical manifestations suggestive of PC and high risk for developing PC need to be selected for examinations for PC. Signs suggestive of PC (e.g., symptoms, diabetes mellitus, acute pancreatitis, or abnormal results of blood examinations) should not be missed, and the details of risks for PC (e.g., familial history of PC, intraductal mucin producing neoplasm, chronic pancreatitis, hereditary pancreatitis, or life habit) should be understood. Multidetector computed tomography (MDCT) and magnetic resonance imaging (MRI) can be performed for diagnosing PC, but the diagnostic ability of these examinations for PC is limited.”


      Early Diagnosis to Improve the Poor Prognosis of Pancreatic Cancer 
Masataka Kikuyama et al.
Cancers 2018, 10, 48; doi:10.3390/cancers10020048
    • “Signs suggestive of PC (e.g., symptoms, diabetes mellitus, acute pancreatitis, or abnormal results of blood examinations) should not be missed, and the details of the risks for PC (e.g., familial history of PC, intraductal mucin producing neoplasm, chronic pancreatitis, hereditary pancreatitis, or life habit) should be understood in order to diagnose PC at an early stage to improve its prognosis.”


      Early Diagnosis to Improve the Poor Prognosis of Pancreatic Cancer 
Masataka Kikuyama et al.
Cancers 2018, 10, 48; doi:10.3390/cancers10020048
Spleen

    • Purpose: To evaluate whether an incidentally noted splenic mass at abdominal computed tomography (CT) requires further imaging work-up. 

      Conclusion: In an incidental splenic mass, the likelihood of malignancy is very low (1.0%). Therefore, follow-up of incidental splenic masses may not be indicated. 


      The Incidental Splenic Mass at CT: Does It Need Further Work-up? An Observational Study 
 Siewert B et al.
 Radiology 2018; 287:156–166
    • “Follow-up of splenic masses inci- dentally detected at CT (i.e., in patients with no evidence of previous or newly diagnosed malignancy and no systemic symptoms or localized pain) does not appear to be indicated.”


      The Incidental Splenic Mass at CT: Does It Need Further Work-up? An Observational Study 
 Siewert B et al.
 Radiology 2018; 287:156–166
    • “This study included 379 patients, 214 (56.5%) women and 165 (43.5%) men, with a mean age 6 standard deviation of 59.3 years 6 15.3 (range, 21–97 years). There were 145 (38.3%) patients in the malignancy group, 29 (7.6%) patients in the symptomatic group, and 205 (54.1%) patients in the incidental group. The incidence of malignant splenic masses was 49 of 145 (33.8%) in the malignancy group, eight of 29 (27.6%) in the symptomatic group, and two of 205 (1.0%) in the incidental group (P , .0001). The incidental group consisted of new diagnoses of lymphoma in one (50%) patient and metastases from ovarian carcinoma in one (50%) patient. Malignant splenic masses in the incidental group were not indeterminate, because synchronous tumors in other organs were diagnostic of malignancy.”


      The Incidental Splenic Mass at CT: Does It Need Further Work-up? An Observational Study 
 Siewert B et al.
 Radiology 2018; 287:156–166
    • “Such incidental findings include masses in the spleen, which have been reported as inciden- tal findings in greater than 14% of autopsies, and most commonly represent hemangiomas, cysts, hamartomas, lymphangiomas, or granulomas.”
 The Incidental Splenic Mass at CT: Does It Need Further Work-up? An Observational Study 
 Siewert B et al.
 Radiology 2018; 287:156–166
      “While the ACR white paper represents a consensus opinion of experts in the field, the follow-up recommendations for splenic masses are based on personal experience of the expert panel, and the panel acknowledged that there were not enough scientific data on which to base this decision. The purpose of our study was, therefore, to evaluate whether an incidentally noted splenic mass at abdominal CT requires further imaging work-up.”


      The Incidental Splenic Mass at CT: Does It Need Further Work-up? An Observational Study 
 Siewert B et al.
 Radiology 2018; 287:156–166
    • “The initial “white paper” from the American College of Radiology (ACR) incidental findings committee recommends further evaluation and/or follow-up imaging for all incidental splenic masses greater than 1 cm that do not have clearly benign features at imaging at the time of detection. The majority of such solid splenic nodules and masses are benign, with hemangioma being the most frequent diagnosis. However, CT imaging characteristics of benign and malignant splenic masses often overlap, making definitive differentiation difficult.”


      The Incidental Splenic Mass at CT: Does It Need Further Work-up? An Observational Study 
 Siewert B et al.
 Radiology 2018; 287:156–166


    • The Incidental Splenic Mass at CT: Does It Need Further Work-up? An Observational Study 
 Siewert B et al.
 Radiology 2018; 287:156–166


    • The Incidental Splenic Mass at CT: Does It Need Further Work-up? An Observational Study 
 Siewert B et al.
 Radiology 2018; 287:156–166
    • “In conclusion, in patients with an incidental splenic mass identified at imaging and with the absence of a history of malignancy, fever, weight loss, or pain in the left upper quadrant or epigastrium, such masses are highly likely to be benign regardless of their appear- ance. Additional imaging or follow-up is not warranted, even if the mass does not show the appearance of a simple cyst. Further work-up is only needed if the splenic mass is seen in conjunction with other findings worrisome for malignancy.”


      The Incidental Splenic Mass at CT: Does It Need Further Work-up? An Observational Study 
 Siewert B et al.
 Radiology 2018; 287:156–166
    • “In patients with known malignancy or with constitutional symptoms and/or pain localized to the left upper quadrant or epigastrium, although most masses will also be benign, such patients require further assessment.”


      The Incidental Splenic Mass at CT: Does It Need Further Work-up? An Observational Study 
 Siewert B et al.
 Radiology 2018; 287:156–166
    • SANT-Sclerosing Angiomatoid Nodular Transformation
      SANT is a benign nonneoplastic vascular lesion of the spleen. This lesion is thought to arise from a response of the red pulp to underlying stromal inflammation or vascular injury. On pathology, there are dense areas of fibrosis and angiomatoid nodules. SANT usually presents as a solitary lesion. Although patients with SANT are typically asymptomatic, SANT has been associated with pancytopenia and an in- creased erythrocyte sedimentation rate.
    • SANT-Sclerosing Angiomatoid Nodular Transformation
      The imaging findings of a solitary splenic lesion, old hemorrhage, dense fibrosis, and centripetal enhancement should lead to suspicion of SANT.
Trauma

    • “Acute aortic injuries are not common in the setting of severe blunt trauma, but lead to significant morbidity and mortality. High- quality MDCT with 2D MPRs and 3D rendering are essential to identify aortic trauma and distinguish anatomic variants and other forms of aortic pathology from an acute injury. Misinterpretation of mimics of acute aortic injury can lead to unnecessary arteriography and thoracic surgery. Since most traumatic injuries occur in the distal arch, radiologists must be cognizant of the range of appearances of variants related to the ductus diverticulum. Cinematic rendering (CR) is a new 3D post-processing tool that provides even greater anatomic detail than traditional volume rendering. In this case series, CR is used to impart to radiologists a better understanding of various anatomic configurations that can be seen with a ductus diverticulum.”


      MDCT of ductus diverticulum: 3D cinematic rendering to enhance understanding of anatomic configuration and avoid misinterpretation as traumatic aortic injury 
Steven P. Rowe1 & Pamela T. Johnson1 & Elliot K. Fishman
Emergency Radiology (2018) 25:209–213
    • “Since most traumatic injuries occur in the distal arch, radiologists must be cognizant of the range of appearances of variants related to the ductus diverticulum. Cinematic rendering (CR) is a new 3D post-processing tool that provides even greater anatomic detail than traditional volume rendering. In this case series, CR is used to impart to radiologists a better understanding of various anatomic configurations that can be seen with a ductus diverticulum.”

      
MDCT of ductus diverticulum: 3D cinematic rendering to enhance understanding of anatomic configuration and avoid misinterpretation as traumatic aortic injury 
Steven P. Rowe1 & Pamela T. Johnson1 & Elliot K. Fishman
Emergency Radiology (2018) 25:209–213
    • “Postprocessing with 2D multiplanar reconstructions and 3D rendering has become standard of care in CT angiography. One of the advantages of volume rendering over maximum intensity projection is the ability to convey 3D anatomic relationships. For complex anatomic configurations like the thoracic aorta and pulmonary arteries, the lighting model in cinematic rendering adds even greater anatomic detail, as demonstrated by these cases.”


      MDCT of ductus diverticulum: 3D cinematic rendering to enhance understanding of anatomic configuration and avoid misinterpretation as traumatic aortic injury 
Steven P. Rowe1 & Pamela T. Johnson1 & Elliot K. Fishman
Emergency Radiology (2018) 25:209–213
    • “One of the most pronounced advantages of cinematic rendering is the production of realistic shadowing effects, allowing for very clear representation of the relative positions of objects within the imaged volume; this is well demonstrated in Fig. 1, where the shadowing from the aortic arch onto the underlying ductus diverticulum and pulmonary arterial vasculature allows the viewer to easily grasp the internal arrangement of these structures. Although the rate of incorrectly diagnosed traumatic aortic injuries was low even in the era when invasive aortography was the primary imaging modality, and has remained low with CT angiography as the frontline modality, the consequences of a missed diagnosis (potential death from massive hemorrhage) or an overcalled finding (unnecessary thoracotomy) underscore the importance of any new technique to improve diagnostic accuracy or diagnostic confidence.”


      MDCT of ductus diverticulum: 3D cinematic rendering to enhance understanding of anatomic configuration and avoid misinterpretation as traumatic aortic injury 
Steven P. Rowe1 & Pamela T. Johnson1 & Elliot K. Fishman
Emergency Radiology (2018) 25:209–213
© 1999-2018 Elliot K. Fishman, MD, FACR. All rights reserved.