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

January 2018 Imaging Pearls - Learning Modules | CT Scanning | CT Imaging | CT Scan Protocols - CTisus
Imaging Pearls ❯ January 2018

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Cardiac

    • “It is estimated that in 2007, over 13 million chest CT examinations were performed, with less than 1 million being electrocardiogram-gated. Since CAC is often observed on standard non-contrast chest CT examinations performed without ECG gating, there is an opportunity to use this CAC information to implement preventive management in a large number of patients not known to have coronary atherosclerosis.” 


      Incidental coronary calcifications on routine chest CT: Clinical implications 
Pakdaman MN et al.
Trends in Cardiovascular Medicine , Volume 27 , Issue 7 , 475 - 480
    • “Of note, a true CAC score of 0 can only be reliably determined with gated studies, as studies using routine non-gated chest CT may show 0 among patients with CAC 0–9 on gated studies. Hutt et al. used ECG-gated CT as the gold standard to investigate the reliability of non-gated CT in detecting coronary calcification. They found a sensitivity of 96.4% and specificity of 100% for the detection of CAC. A review of four studies comprising 1153 subjects found a false-negative rate of 8.3%.”

      Incidental coronary calcifications on routine chest CT: Clinical implications 
Pakdaman MN et al.
Trends in Cardiovascular Medicine , Volume 27 , Issue 7 , 475 - 480

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Incidental coronary calcifications on routine chest CT: Clinical implications 
Pakdaman MN et al.
Trends in Cardiovascular Medicine , Volume 27 , Issue 7 , 475 - 480
    • “Unfortunately, cardiac findings are often overlooked on CT or may not be reported or adequately emphasized in the impression on the final report. Based on the high impact of incidental coronary calcifications on non-gated chest CT and the impact of CAC measurement on the management and outcome, we recommend increased attention be made to incidental coronary calcifications during the radiographic search pattern, with inclusion of positive findings in the impression of the final report.”

      
Incidental coronary calcifications on routine chest CT: Clinical implications 
Pakdaman MN et al.
Trends in Cardiovascular Medicine , Volume 27 , Issue 7 , 475 - 480
    • “While the reports from chest CT are likely, for at least the near future, to use the most basic of quantitative descriptors rather than scores such as the Agatston score, consideration might be given to the performance of ECG- gated CT scans in patients, unless the amount described is reported as extensive. Discussion with patients regarding preventive lifestyle modifications including a heart healthy diet and aerobic exercise programs would also be appropriate when any CAC is found.”

      
Incidental coronary calcifications on routine chest CT: Clinical implications 
Pakdaman MN et al.
Trends in Cardiovascular Medicine , Volume 27 , Issue 7 , 475 - 480
    • OBJECTIVES: The aim of this study was to investigate whether inclusion of simple measures of calcified plaque distribution might improve the ability of the traditional Agatston coronary artery calcium (CAC) score to predict cardiovascular events 


      BACKGROUND:
      Agatston CAC scoring does not include information on the location and distributional pattern of detectable calcified plaque. 


      CONCLUSIONS:
      The number of coronary arteries with calcified plaque, indicating increasingly “diffuse” multivessel subclinical atherosclerosis, adds significantly to the traditional Agatston CAC score for the prediction of CHD and CVD events. 


      Improving the CAC Score by Addition of Regional Measures of Calcium Distribution 
Blaha MJ et al.
J Am Coll Cardiol Img 2016;9:1407–16
    • “In our study of a well-defined multiethnic cohort free of baseline CVD, we have shown that measures of diffuse CAC distribution add predictive value to the Agatston CAC score, particularly when traditional CAC scores are in the intermediate range (1 to 300). This incremental predictive value is of similar magnitude to that commonly attributed to adding novel serum biomarkers to traditional risk factors in intermediate-risk patients.” 


      Improving the CAC Score by Addition of Regional Measures of Calcium Distribution 
Blaha MJ et al.
J Am Coll Cardiol Img 2016;9:1407–16
    • “We have shown that readily available measures of diffuse CAC distribution add to the traditional Agat- ston CAC score for the prediction of CHD and CVD events. While we await development of a new comprehensive CAC scoring algorithm, clinicians may consider reporting and interpreting the number of vessels with CAC in addition to a total CAC burden score on routine ungated and gated noncontrast chest and cardiac CT scans, particularly when CAC burden is intermediate.”

      
Improving the CAC Score by Addition of Regional Measures of Calcium Distribution 
Blaha MJ et al.
J Am Coll Cardiol Img 2016;9:1407–16
    • “In patients for whom the development or progression of CAC would support intensification or alteration in preventive management, it may be appropriate to consider repeat CAC scanning at an interval of 5 years for patients with 0 CAC and a 3-5 year interval for patients with >0 CAC.”


      Clinical indications for coronary artery calcium scoring in asymptomatic patients: Expert consensus statement from the Society of Cardiovascular Computed Tomography 
Hecht h et al.
Journal of Cardiovascular Computed Tomography 11(2017) , 157 - 168
    • “It may be appropriate to include CAC scanning in CCTA protocols in symptomatic patients without established CAD undergoing CTA, and in high risk asymptomatic individuals for whom the CCTA appropriateness criterion is uncertain, as well as in asymptomatic patients referred for preoperative evaluation prior to major surgery.”


      Clinical indications for coronary artery calcium scoring in asymptomatic patients: Expert consensus statement from the Society of Cardiovascular Computed Tomography 
Hecht H et al.
Journal of Cardiovascular Computed Tomography 11(2017) , 157 - 168
    • “Consistent with a prior guideline from the SCCT/STR, CAC scoring of noncontrast chest CT scans is appropriate in all lung cancer screening patients and patients greater than 40 years of age without established ASCVD. The presence of CAC should be noted in the report of all NCCT studies.”


      Clinical indications for coronary artery calcium scoring in asymptomatic patients: Expert consensus statement from the Society of Cardiovascular Computed Tomography 
Hecht H et al.
Journal of Cardiovascular Computed Tomography 11(2017) , 157 - 168
    • CAD-RADS: Coronary Artery
Disease - Reporting and Data System. 
An Expert Consensus Document of the Society of Cardiovascular Computed Tomography (SCCT), the American College of Radiology (ACR) and the North American Society for Cardiovascular Imaging (NASCI). Endorsed by the American College of Cardiology 


      Cury RC et al.
J Am Coll Radiol 2016;13:1458-1466

    • The proposed reporting system for coronary artery disease is?
      A. BI-RADS
      B. LI-RADS
      C. Lung-RADS
      D. PI-RADS
      E. CAD-RADS

    • BI-RADS (breast for screening mammography)
      LI-RADS (standardization reporting in patients with chronic liver disease)
      Lung-RADS (standardization reporting of high-risk smokers undergoing CT lung screening)
      PI-RADS (multi-parametric MR imaging in the context of prostate cancer)
      CAD-RADS (standardized reporting system for coronary CTA results on a per-patient basis.)
    • “The suggested CAD-RADS classification is applied on a per-patient basis and represents the highest-grade coronary artery lesion documented by coronary CTA. It ranges from CAD-RADS 0 (Zero) for the complete absence of stenosis and plaque to CAD-RADS 5 for the presence of at least one totally occluded coronary artery and should always be interpreted in conjunction with the impression found in the report.”


      CAD-RADS: Coronary Artery
Disease - Reporting and Data System. 
Cury RC et al.
J Am Coll Radiol 2016;13:1458-1466
    • “The main goal of CAD-RADS is to standardize reporting of coronary CTA results and to facilitate communication of test results to referring physicians along with suggestions for subsequent patient management. In addition, CAD-RADS will provide a framework of standardization that may benefit education, research, peer-review and quality assurance with the potential to ultimately result in improved quality of care.”


      CAD-RADS: Coronary Artery
Disease - Reporting and Data System. 
Cury RC et al.
J Am Coll Radiol 2016;13:1458-1466
    • “The majority of coronary arterial anomalies do not have clinical repercussions and do not need intervention. However, some anomalies can intermittently or chronically impede myocardial perfusion, leading to clinical manifestations such as angina, myocardial infarction, congestive heart failure, ventricular aneurysms, or sudden cardiac death.”


      Anomalous Coronary Arteries That Need Intervention: Review of Pre- and Postoperative Imaging Appearances 
 Agarwal PP et al.
 RadioGraphics 2017; 37:740–757
    • “In a data analysis from a large U.S. national registry of competitive athletes, spanning a period of 27 years (1980–2006), anomalous coronary arteries were the second most common causeof SCD, accounting for 17% (119 of 1049) of SCDs, after hypertrophic cardiomyopathy, which accounted for 36%.”


      Anomalous Coronary Arteries That Need Intervention: Review of Pre- and Postoperative Imaging Appearances 
 Agarwal PP et al.
 RadioGraphics 2017; 37:740–757
    • “The RCA and LCA fistulas most commonly drain into the right heart with common sites being the right ventricle, right atrium, pulmonary artery, and coronary sinus. Drainage into the left heart is rare, with drainage into the left atrium being slightly more common than into the left ventricle.”


      Anomalous Coronary Arteries That Need Intervention: Review of Pre- and Postoperative Imaging Appearances 
 Agarwal PP et al.
 RadioGraphics 2017; 37:740–757
    • “CAFs are unlikely to close spontaneously (1%– 2% spontaneous closure rate) .Therefore, transcatheter or surgical closure may be considered in childhood even in asymptomatic patients, to avoid complications in adult life. Current recommendations include closure of large CAFs irrespective of symptoms, and treatment of small- to-medium stulas when the patients become symptomatic .”


      Anomalous Coronary Arteries That Need Intervention: Review of Pre- and Postoperative Imaging Appearances 
 Agarwal PP et al.
 RadioGraphics 2017; 37:740–757
    • “Surgical options are usually reserved for cases where transcatheter treatment cannot be completed due to high-risk proximity to an adjacent coronary artery, multiple stulous 
 connections, or difficult access to the abnor- mal coronary artery or its branches. Surgery may also be preferred if there is a coexisting condition that warrants surgical management. Options include external ligation of the CAF, internal patch, or suture closure of the ori ce of the fistulous communication.”


      Anomalous Coronary Arteries That Need Intervention: Review of Pre- and Postoperative Imaging Appearances 
 Agarwal PP et al.
 RadioGraphics 2017; 37:740–757
    • “As coronary artery calcification (CAC) represents direct evidence of coronary atherosclerosis with excellent negative predictive values in patients without presence of CAC, it suggests itself to be beneficial for risk stratification of patients with suspected ACS and potentially advantageous as opposed to clinical risk scores alone. In fact, in this low-intermediate risk population only 10% of patient.” 


      Identification of coronary artery calcification can optimize risk stratification in patients with acute chest pain 
 Bittner DO et al
 International Journal of Cardiology 249 (2017) 473–478
    • “In this large real-world clinical scenario of patients with acute chest pain, we could demonstrate a strong association of the extent of CAC to the severity of CAD and the incidence of ACS. Identification of CAC in addition to clinical risk assessment using TIMI risk score provides an excellent negative predictive value to identify patients at low risk for obstructive CAD and ACS. The clinical value of this combined effort might improve patient management in settings where more advanced imaging is not available.”

      
Identification of coronary artery calcification can optimize risk stratification in patients with acute chest pain 
 Bittner DO et al
 International Journal of Cardiology 249 (2017) 473–478
    • “The inclusion of CAC, in combination with clinical risk assessment, has high clinical value in patients with acute chest pain, as it identifies patients at low risk for ACS and obstructive CAD more accurately as com- pared to clinical risk assessment alone.” 


      Identification of coronary artery calcification can optimize risk stratification in patients with acute chest pain 
 Bittner DO et al
 International Journal of Cardiology 249 (2017) 473–478
    • “Whereas conventional risk factors can indicate the likelihood of CAD, coronary artery calcification (CAC) represents direct evidence of coronary atherosclerosis and thus can significantly improve 10-year CHD risk prediction in combination with traditional risk factors. As shown in asymptomatic patients, CAC scoring has been studied extensively and is well established by using non-contrast ECG-gated computed tomography of the heart. Although the negative predictive value (NPV) was consistently demonstrated to be high, in symptomatic patients the assessment of CAC does not play a major role, as obstructive CAD cannot be ruled out completely using non-contrast scans of the heart.” 


      Identification of coronary artery calcification can optimize risk stratification in patients with acute chest pain 
 Bittner DO et al
 International Journal of Cardiology 249 (2017) 473–478
Chest

    • “TRO was associated with slightly higher yield of PE and AD, specifically in the emergency department. This benefit comes with higher nondiagnostic image quality, radiation, and contrast doses. Although TRO may be of value in selected patients, its indiscriminate use is not warranted. The appropriate use of TRO needs to be further defined.”


      Triple Rule Out Versus Coronary CT Angiography in Patients With Acute Chest Pain
Burris II, AC et al.
J Am Coll Cardiol Img 2015;8:817–25
Colon

    • “The 3D endoluminal fly-through provides a highly effective detection mechanism for focal colorectal lesions . The lack of easy, automated centerline navigation has been a major drawback with most other CTC systems, but continued improvement has been shown by some. UWHC’s primary 3D review for the DoD trial initially entailed bidirectional fly-through using a 90° field-of-view (FOV) angle on both supine and prone series. However, they have since found that widening the FOV angle to 120° allows greatly improved mucosal visualization, generally allowing for one-way fly-through of each series (rectum-to-cecum on supine and cecum-to-rectum on prone) without sacrificing polyp detection.

      Bidirectional fly-through at 120°on at least one series remains prudent, however, for cases with suboptimal distention.”
Imaging and Screening for Colorectal Cancer with CT Colonography.
Pickhardt PJ
Radiol Clin North Am. 2017 Nov;55(6):1183-1196
    • “When a suspicious lesion measuring 5 to 6 mm or greater is detected on 3D (or 2D) and confirmed to be composed of soft tissue on 2D, an electronic bookmark is placed on the colon map. The vast majority of actual polyps can also be identified on the alternate supine or prone view, which greatly increases overall diagnostic confidence. Those at UWHC have found computer-aided detection (CAD) to be useful in both the research and clinical settings, because it can provide further assurance and diagnostic confidence . CAD demonstrates excellent sensitivity for detecting relevant polyps, but the extremely low specificity, which essentially approached zero, requires that experienced CTC readers sift through the CAD marks, not novice readers.”

      
Imaging and Screening for Colorectal Cancer with CT Colonography.
Pickhardt PJ
Radiol Clin North Am. 2017 Nov;55(6):1183-1196
    • “Approximately 85% to 90% of screening CTC 2examinations are negative for polyps ≥6 mm, and repeat routine colorectal screening is recommended in 5 years. Nonreporting of potential isolated diminutive lesions is justified to prevent unnecessary interventions, and this practice has been clinically validated. This practice is explicitly described in the dictation template. For individuals who are found to be negative at follow-up screening CTC at 5 or more years, subsequent screening can likely be extended out to 10 years.”


      Imaging and Screening for Colorectal Cancer with CT Colonography.
Pickhardt PJ
Radiol Clin North Am. 2017 Nov;55(6):1183-1196
    • “Despite being readily preventable, CRC remains the second-leading cause of cancer deaths. If preventive screening tests that effectively detect advanced adenomas and early cancers were broadly applied, this situation could be easily reversed. CT colonography reflects an ideal balance of minimal invasiveness with high-level performance, assuming all facets of the examination are appropriately addressed. Nonetheless, this promising screening test remains grossly underused. This review of the technical and interpretive approaches used by one successful CTC screening program may serve as a roadmap to other groups looking to get involved.”

      
Imaging and Screening for Colorectal Cancer with CT Colonography.
Pickhardt PJ
Radiol Clin North Am. 2017 Nov;55(6):1183-1196
    • “Despite being readily preventable, colorectal cancer ranks second behind only lung cancer in overall mortality. However, this situation could be reversed if screening tests that effectively detect advanced adenomas and early cancers were broadly applied. Computed tomographic colonography (CTC) reflects an ideal balance of minimal invasiveness with high-level performance, assuming all facets of the examination are appropriately addressed. Unfortunately, this promising screening test remains grossly underused. This article details the technical and interpretive approaches used by one successful CTC screening program.”

      
Imaging and Screening for Colorectal Cancer with CT Colonography.
Pickhardt PJ
Radiol Clin North Am. 2017 Nov;55(6):1183-1196
    • “Colorectal cancer (CRC) remains the second-leading cause of cancer death, despite the fact that it is readily preventable via screen detection (and removal) of clinically relevant polyps. This disconnect is primarily due to the fact that many adults are not screened, whereas others undergo only stool-based testing, which does not confer effective cancer prevention.Given the critical importance of cancer prevention beyond cancer detection alone, the American Cancer Society expressed a strong preference for the endoscopist and radiologic tests that provide for visualization of benign but potentially precancerous polyps in its landmark 2008 screening guidelines.”


      Imaging and Screening for Colorectal Cancer with CT Colonography.
Pickhardt PJ
Radiol Clin North Am. 2017 Nov;55(6):1183-1196
    • “As with bowel preparation, adequate luminal distension of the colon is critical to a successful CTC study. UWHC’s distention protocol has evolved and improved over time, resulting in inadequate segmental distention in less than 1% of cases.The use of automated low-pressure carbon dioxide (CO2) delivery is clearly preferred over manual room air insufflation.Nearly all early reports of perforation at CTC involved the use of manual staff-controlled room air insufflation in symptomatic patients, whereas the risk of perforation with automated CO2 delivery likely approaches zero for asymptomatic screening.With regard to both study quality (ie, degree of distention) and after-procedural discomfort, the author has shown that automated CO2 is superior to the manual room air technique.”

      
Imaging and Screening for Colorectal Cancer with CT Colonography.
Pickhardt PJ
Radiol Clin North Am. 2017 Nov;55(6):1183-1196
Kidney

    • “von Hippel-Lindau disease (VHL) is an autosomal dominant disorder that results from germline mutations in the VHL tumor suppressor gene (chromosome 3p25) and is characterized by benign and malignant tumors in multiple organs.The VHL gene plays a pivotal role in the regulation of the intracellular oxygen-sensing pathway. Inactivation of this gene causes unbridled upregulation of multiple somatic and vascular growth factors, including vascular endothelial growth factor, leading to the development of vascular tumors.Cerebellar and spinal cord hemangioblastomas, retinal angiomas, endolymphatic sac tumors, clear cell RCCs, complex renal cysts, pheochromocytomas, pancreatic cysts and pancreatic neuroendocrine tumors (PNETs), and epididymal cystadenomas are common neoplasms in VHL syndrome . The pancreas (35%–77%), central nervous system (CNS) (44%–72%), and kidneys (25%–60%) are the most commonly involved organs in VHL syndrome.”


      Imaging and Screening of Hereditary Cancer Syndromes 
Venkata S. Katabathina et al.
Radiol Clin N Am 55 (2017) 1293–1309
    • “Tuberous sclerosis complex (TSC) is an autosomal dominant condition caused by inactivating mutations of the TSC1 gene (chromosome 9q34, encodes hamartin) and/or TSC 2 genes (chromosome 16p13, encodes tuberin); tuberin-hamartin complex functions as a tumor suppressor by suppression of the mTOR pathway.CNS lesions in TSC are the primary cause of mortality and morbidity and include cortical and cerebellar tubers, radial migration lines, subependymal nodules, and subependymal giant cell astrocytomas. Gadolinium-enhanced MR imaging of the brain is the imaging modality of choice for diagnosis, screening, and monitoring of intracranial lesions.”


      Imaging and Screening of Hereditary Cancer Syndromes 
Venkata S. Katabathina et al.
Radiol Clin N Am 55 (2017) 1293–1309
    • “Renal lesions are seen in up to 60% of patients with TSC and include angiomyolipomas (AMLs) and renal cysts .Renal AMLs larger than 4 cm or with intralesional aneurysms larger than 5 mm carry increased risk of spontaneous rupture and require prophylactic embolization.Other lesions in TSC include cardiac rhabdomyomas, lung/retroperitoneal lymphangioleiomyomatosis, hepatic AMLs, and sclerotic lesions in the bones.Recent studies suggest that a spectrum of distinctive renal tumors occurs in patients with TSC; tumors occur at a younger age compared with the general population.”


      Imaging and Screening of Hereditary Cancer Syndromes 
Venkata S. Katabathina et al.
Radiol Clin N Am 55 (2017) 1293–1309
Liver

    • “It is classically associated with exposure to thorium dioxide, vinyl chloride, arsenic, and radiation; hemochromatosis; and von Recklinghausen disease, but most lesions encountered in clinical practice are without such associated factors. Clinical presenta- tion includes nonspecic symptoms such as abdominal pain, weight loss, and fatigue.” 


      Primary Hepatic Neoplasms of Vascular Origin: Key Imaging Features and Differential Diagnoses With Radiology-Pathology Correlation 
Hailey Hye-In Choi et al.
AJR 2017; 209:W350–W359
    • Risk factors for Hepatic Angiosarcoma
      • exposure to thorium dioxide,
      • vinyl chloride
      • Arsenic
      • radiation
      • hemochromatosis
      • von Recklinghausen disease
    • “Angiosarcoma shows progressive but incomplete enhancement in an irregular flame-shaped pattern. Although previously, attenuation of the enhancement was described as being less than that of the aortic blood pool, a more recent, larger study found that the attenuation followed blood pool, much like hemangiomas. The disordered morphology of the enhancement, however, enables distinction from hemangiomas.” 


      Primary Hepatic Neoplasms of Vascular Origin: Key Imaging Features and Differential Diagnoses With Radiology-Pathology Correlation 
Hailey Hye-In Choi et al.
AJR 2017; 209:W350–W359
    • “Vascular mesenchymal neoplasms can further be characterized as benign (cavernous hemangioma, angiomyolipoma), malignant potential (epithelioid hemangioendothelioma, perivascular epithelioid cell tumor, solitary fibrous tumor), and malignant (angiosarcoma), depending on histology.”

      
Primary Hepatic Neoplasms of Vascular Origin: Key Imaging Features and Differential Diagnoses With Radiology-Pathology Correlation 
Hailey Hye-In Choi et al.
AJR 2017; 209:W350–W359
    • “Patients often do not have symptoms, but if the hemangioma is large, it may be palpable or cause abdominal pain. Rarely, cavernous hemangiomas can rupture or be implicated in Kasabach-Merritt syndrome, a consump- tive coagulopathy triggered by the vascular abnormality. Treatment is generally con- servative, with surgical treatment reserved for large, symptomatic lesions.” 


      Primary Hepatic Neoplasms of Vascular Origin: Key Imaging Features and Differential Diagnoses With Radiology-Pathology Correlation 
Hailey Hye-In Choi et al.
AJR 2017; 209:W350–W359
    • “Vascular mesenchymal neoplasms with progressive enhancement include cavernous hemangioma, epithelioid hemangioendothelioma, and angiosarcoma. Two additional entities with progressive enhancement that can mimic primary vascular neoplasms are hepatic peliosis and solitary brous tumor.” 


      Primary Hepatic Neoplasms of Vascular Origin: Key Imaging Features and Differential Diagnoses With Radiology-Pathology Correlation 
Hailey Hye-In Choi et al.
AJR 2017; 209:W350–W359
    • “Epithelioid hemangioendothelioma (EHE) is a rare vascular mesenchymal tumor with low to intermedi- ate malignancy potential. Incidence of EHE is less than 1 per million [14]. Patients have nonspeci c symptoms, such as right upper quadrant pain, hepatomegaly, or weight loss, or no symptoms at all. Tumor markers, including α-fetoprotein (AFP), carcinoembryonic antigen, and cancer antigen (CA) 19–9, are usually at normal levels.” 


      Primary Hepatic Neoplasms of Vascular Origin: Key Imaging Features and Differential Diagnoses With Radiology-Pathology Correlation 
Hailey Hye-In Choi et al.
AJR 2017; 209:W350–W359
    • “The characteristic imaging appearance of EHE is multiple confluent tumor nodules or masses with peripheral, targetlike, or rim enhancement. Contrast-enhanced dynamic imaging is useful for show- ing initial enhancement of the peripheral cellular rim followed by progressive, lamellar enhancement of the central brous stroma. On unenhanced CT, lesions are hypodense compared with the normal hepatic parenchyma. Intralesional calci cations are sometimes seen.” 


      Primary Hepatic Neoplasms of Vascular Origin: Key Imaging Features and Differential Diagnoses With Radiology-Pathology Correlation 
Hailey Hye-In Choi et al.
AJR 2017; 209:W350–W359
    • “Angiosarcoma is a malignant neoplasm of the vascular or lymphatic endothelium that accounts for less than 2% of all primary neoplasms but is the most common primary sarcoma in the liver. It most commonly occurs in patients 60–70 years of age with a male-to-female ratio of 4:1.” 


      Primary Hepatic Neoplasms of Vascular Origin: Key Imaging Features and Differential Diagnoses With Radiology-Pathology Correlation 
Hailey Hye-In Choi et al.
AJR 2017; 209:W350–W359
    • “The core objectives of the Incidental Findings Project are to (1) develop consensus on patient characteristics and imaging features that are required to characterize an incidental finding, (2) provide guidance to manage such findings in ways that balance the risks and benefits to patients, (3) recommend reporting terms that reflect the level of confidence regarding a finding, and (4) focus future research by proposing a generalizable management framework across practice settings.”


      Management of Incidental Liver Lesions on CT: A White Paper of the ACR Incidental Findings Committee.
Gore RM, Pickhardt PJ, Mortele KJ, Fishman EK, Horowitz JM, Fimmel CJ, Talamonti MS, Berland LL, Pandharipande PV.
J Am Coll Radiol. 2017 Nov;14(11):1429-1437

    • “The algorithm should only be applied to incidental liver lesions in asymptomatic adult patients (!18 years of age) for whom CT was requested for an unrelated reason. As described earlier, the algorithm is designed for use in patients with varied underlying risk levels (low versus high) for a malignant hepatic lesion. However, the algo- rithm should not be applied when index CT (ie, that which demonstrates the incidental lesion) was requested to evaluate a known or suspected liver lesion or hepatic abnormality. There are some hepatic lesions that present with associated vascular invasion, biliary dilation, or adenopathy. Patients with these associated findings should be referred directly for oncologic evaluation.”


      Management of Incidental Liver Lesions on CT: A White Paper of the ACR Incidental Findings Committee.
Gore RM, Pickhardt PJ, Mortele KJ, Fishman EK, Horowitz JM, Fimmel CJ, Talamonti MS, Berland LL, Pandharipande PV.
J Am Coll Radiol. 2017 Nov;14(11):1429-1437

    • Reporting Considerations of a Hepatic Lesion
      1. Lesion size

      2. Lesion attenuation

      3. Lesion homogeneity versus complexity
      4. Lesion enhancement pattern
      
5. Lesion margin

      6. Lesion multiplicity
      
7. Lesion growth pattern
      
8. Lesion location

    • Incidental Liver Mass Detected on CT

    • “Specific regions of the liver are susceptible to effects of perfusional changes and fatty infiltration or sparing; such effects may mimic liver lesions . Peripherally, so-called THADs (transient hepatic attenuation differ- ences, seen on CT) and THIDs (transient hepatic intensity differences, seen on MRI) reflect changes in enhancement of the parenchyma due to relative differ- ences in hepatic arterial versus portal venous supply. Near the falciform ligament and the gallbladder fossa, alterations in venous drainage can result in focal fatty deposition or sparing.”


      Management of Incidental Liver Lesions on CT: A White Paper of the ACR Incidental Findings Committee.
Gore RM, Pickhardt PJ, Mortele KJ, Fishman EK, Horowitz JM, Fimmel CJ, Talamonti MS, Berland LL, Pandharipande PV.
J Am Coll Radiol. 2017 Nov;14(11):1429-1437

    • “In low-risk patients, incidental liver lesions less than 1 cm generally do not require further workup and can be considered benign. Incidental liver lesions that are 1.0 to 1.5 cm and have benign or flash-filling features also do not require further workup. Prompt MRI is advised for lesions with suspi- cious features that are 1.0 to 1.5 cm.”

      
Management of Incidental Liver Lesions on CT: A White Paper of the ACR Incidental Findings Committee.
Gore RM, Pickhardt PJ, Mortele KJ, Fishman EK, Horowitz JM, Fimmel CJ, Talamonti MS, Berland LL, Pandharipande PV.
J Am Coll Radiol. 2017 Nov;14(11):1429-1437

    • “In high-risk patients with incidental liver lesions less than 1 cm, MRI is advised in 3 to 6 months to both characterize the lesion and document the presence or absence of growth. For lesions that are 1.0 to 1.5 cm and have benign features, no further workup with MRI is necessary; for lesions of this size with suspicious or flash-filling features, we recommend prompt MRI.”


      Management of Incidental Liver Lesions on CT: A White Paper of the ACR Incidental Findings Committee.
Gore RM, Pickhardt PJ, Mortele KJ, Fishman EK, Horowitz JM, Fimmel CJ, Talamonti MS, Berland LL, Pandharipande PV.
J Am Coll Radiol. 2017 Nov;14(11):1429-1437

    • TAKE-HOME POINTS
      • Forgo workup of incidental hepatic lesions less than 1 cm in low-risk patients.
      • Forgo workup of incidental hepatic lesions with distinctly benign features regardless of risk level.
      • Pursue workup of incidental hepatic lesions that are over 1 cm and without distinctly benign features in high-risk patients

      Management of Incidental Liver Lesions on CT: A White Paper of the ACR Incidental Findings Committee.
Gore RM et al. J Am Coll Radiol. 2017 Nov;14(11):1429-1437

    • Incidental Liver Mass Detected on CT

Musculoskeletal

    • “Sacral fractures are a common component of pelvic fracture patterns and are an increasingly diagnosed injury both due to increased utilization of CT in trauma evaluation as well as an increasing rate of sacral fragility fractures as a result of an increase in general population age. Innovations in minimally invasive surgical techniques have also resulted in an increasing number of sacral fractures undergoing surgical management. It is vital that physicians practicing in an emergency setting are aware of the injury patterns and management of this increasingly injured and treated component of the bony pelvis.”


      Sacral fractures: classification and management 
Nicholas M. Beckmann, Naga R. Chinapuvvula 
 Emerg Radiol (2017) 24:605–617
    • “The incidence of osteoporotic sacral insufficiency fractures is not well studied, but these fractures occur almost exclusively in older women with a report inci- dence of 1–5% in at-risk populations such as patients with steroid-induced osteoporosis, pelvic radiation therapy, hyperparathyroidism, or rheumatoid arthritis . Even though sacral fractures are uncommon in the general population, sacral fractures become very common in patients presenting with trauma and pelvic fractures.”


      Sacral fractures: classification and management 
Nicholas M. Beckmann, Naga R. Chinapuvvula 
 Emerg Radiol (2017) 24:605–617
    • “The incidence of osteoporotic sacral insufficiency fractures is not well studied, but these fractures occur almost exclusively in older women with a report incidence of 1–5% in at-risk populations such as patients with steroid-induced osteoporosis, pelvic radiation therapy, hyperparathyroidism, or rheumatoid arthritis.”
Sacral fractures: classification and management 
Nicholas M. Beckmann, Naga R. Chinapuvvula 
 Emerg Radiol (2017) 24:605–617
    • “CT has become the mainstay for diagnosing and characteriz- ing sacral fractures due to the low sensitivity of radiographs. Noncontrast CT imaging with 2-mm-thick slices in the axial, coronal, and sagittal planes is generally adequate for diagnos- ing sacral fractures. For complex sacral fractures or sacral fractures that are part of a pelvic ring injury pattern, additional three-dimensional reformatted images are often helpful for surgeons to conceptualize fracture patterns and morphology for preoperative planning. Sacral morphology can preclude 
 afe placement of transacral screws, particularly at the S1 lev- el; and preoperative CT can be assessed for sacral dysmorphism and adequate osseous pathway for sacral screw placement.”

      
Sacral fractures: classification and management 
Nicholas M. Beckmann,Naga R. Chinapuvvula 
 Emerg Radiol (2017) 24:605–617
    • “Longitudinal fractures are by far the most common type of sacral fracture; isolated longitudinal fractures have been reported to comprise almost 90% of all sacral fracture patterns . Approximately 90% of longitudinal fractures is associated with an additional pelvic ring injury, most commonly pubic rami fractures . Longitudinal fractures can occur with any mechanism of injury but are most commonly seen with lateral compression in which the longitudinal fracture may be incomplete and stable or complete and unstable.”


      Sacral fractures: classification and management Nicholas M. Beckmann1,2 & Naga R. Chinapuvvula 
 Emerg Radiol (2017) 24:605–617
    • “Sacral fractures are an increasingly recognized pathology in patients presenting with pelvic trauma, and these injuries are important for both the structural instability and neurologic com- plications that can result. Management of sacral fractures re- mains a challenge as significant variability exists regarding what constitutes an unstable sacral fracture and which neuro- logic injuries require surgical intervention. The lumbosacral injury classification system represents the first attempt to create a specific classification system to guide management of sacral fractures and may find utility in treating complex sacral frac- tures in the future. However, this classification system is novel and requires further validation before gaining widespread use.”

      
Sacral fractures: classification and management 
Nicholas M. Beckmann, Naga R. Chinapuvvula 
 Emerg Radiol (2017) 24:605–617
Small Bowel

    • “Small bowel adenocarcinomas are rare malignant tumors that account for less than 2% of gastrointestinal tumors. Among malignant tumors of the small bowel (SB), adenocarcinoma is the most frequent etiology in France followed by endocrine tumors, lymphomas or stromal tumors . Recent trends show that SB neuroendocrine tumors outnumber SB adenocarcinoma in the US .Epidemiological data estimate the annual incidence of small bowel adenocarcinoma at 2.2–5.7/million in developed countries. In the French Côte d'Or study, the incidence of small bowel adenocarcinoma was 0.18/100,000 men and 0.1/100,000 women during the period 1996–2001, and which incidence increased with age. However, and as is the case for colon cancer, the incidence of small bowel adenocarcinoma is increasing in the population. Moreover, duodenal tumors are more frequent than tumors in other segments (jejunum and ileum).”


      Small bowel adenocarcinoma: French intergroup clinical practice guidelines for diagnosis, treatments and follow-up 
Christophe Locher et al.
Digestive and Liver Disease (in press)
    • “Indeed, duodenal tumors account for 50% of small bowel adenocarcinomas while tumors of the jejunum and ileum represent 30% and 20%, respectively . The stage at diagnosis is usually advanced; in the series of Talamonti et al., 38% of the patients had synchronous metastases and 38% had lymph-node invasion . In the MD Anderson study, the same distribution by stage was found (35% of metastatic patients and 39% with lymph-node invasion).”

      
Small bowel adenocarcinoma: French intergroup clinical practice guidelines for diagnosis, treatments and follow-up 
Christophe Locher et al.
Digestive and Liver Disease (in press)
    • “In celiac disease, the risk of developing small bowel adenocarcinoma is low (8 cases per 11,000 patients for the Swedish registry). Duodenal biopsies during the initial endoscopy and an anti-transglutaminase (IgA) or anti-transglutaminase (IgG) and anti-endomysium (IgG) antibody assay in cases of IgA deficiency are recommended.”


      Small bowel adenocarcinoma: French intergroup clinical practice guidelines for diagnosis, treatments and follow-up 
Christophe Locher et al.
Digestive and Liver Disease (in press)
    • “The relative risk of developing small bowel adenocarcinoma in Crohn’s disease is about 20. In Crohn’s disease, the preferred location is the ileum and the age at onset is younger (4th decade) . If there is a family history of Crohn’s disease or if there are clinical symptoms, a morphological examination of the small bowel and a proctologic examination are recommended.”


      Small bowel adenocarcinoma: French intergroup clinical practice guidelines for diagnosis, treatments and follow-up 
Christophe Locher et al.
Digestive and Liver Disease (in press)
Uncommon Syndromes in CT

    • “Li-Fraumeni syndrome (LFS) is an autosomal dominant condition manifested by multiple cancers at an unusually early age, including sarcomas, breast cancers, brain tumors, hematologic cancers, and adrenal cortical carcinomas among the most common tumors . Germline mutations in the tumor suppressor gene TP53 (chromosome 17p13), which helps in the elimination of abnormal DNA-containing cells during cell cycle, are responsible for the development of LFS. Given the high penetrance of the mutated TP53 gene, the lifetime risk of cancer is estimated to be about 90% by the age 60 years in women and 75% in men.”

      
Imaging and Screening of Hereditary Cancer Syndromes 
Venkata S. Katabathina et al.
Radiol Clin N Am 55 (2017) 1293–1309
    • “Patients with LFS show an increased risk of radiation-induced cancers; radiation therapy is commonly avoided in these patients.Sarcomas account for 25% of all tumors in LFS. All types of bone and soft tissue sarcomas can develop except Ewing sarcoma; osteosarcomas are the most common sarcomas.Breast cancer is common in premenopausal women and shows amplification of HER-2 at the molecular level. High-grade gliomas and choroid plexus carcinomas can present either in childhood or in young adults.Approximately 10% of LFS carriers may develop adrenal cortical carcinomas.”

      
Imaging and Screening of Hereditary Cancer Syndromes 
Venkata S. Katabathina et al.
Radiol Clin N Am 55 (2017) 1293–1309
    • “Hereditary diffuse gastric cancer (HDGC) is an autosomal dominant disorder with high penetrance, caused by germline mutations in the E-cadherin (CDH1) tumor suppressor gene (chromosome 16q22).The lifetime risk of an aggressive diffuse type of gastric cancer is found in 70% of men and 55% of women, with an average age of 38 years.Gastric cancers are often multifocal and located beneath an intact mucosal surface and often signet-ring type with tumor cells containing abundant mucin.About 40% of women with CDH1 mutations may develop lobular breast cancer during their lifetimes. At imaging, diffuse irregular gastric wall thickening (linitis plastica appearance) with lymphadenopathy, invasion into adjacent organs, and distant metastatic disease is the characteristic feature of HDGC, especially if the patient is less than 40 years of age .”

      
Imaging and Screening of Hereditary Cancer Syndromes 
Venkata S. Katabathina et al.
Radiol Clin N Am 55 (2017) 1293–1309
    • “von Hippel-Lindau disease (VHL) is an autosomal dominant disorder that results from germline mutations in the VHL tumor suppressor gene (chromosome 3p25) and is characterized by benign and malignant tumors in multiple organs.The VHL gene plays a pivotal role in the regulation of the intracellular oxygen-sensing pathway. Inactivation of this gene causes unbridled upregulation of multiple somatic and vascular growth factors, including vascular endothelial growth factor, leading to the development of vascular tumors.Cerebellar and spinal cord hemangioblastomas, retinal angiomas, endolymphatic sac tumors, clear cell RCCs, complex renal cysts, pheochromocytomas, pancreatic cysts and pancreatic neuroendocrine tumors (PNETs), and epididymal cystadenomas are common neoplasms in VHL syndrome . The pancreas (35%–77%), central nervous system (CNS) (44%–72%), and kidneys (25%–60%) are the most commonly involved organs in VHL syndrome.”


      Imaging and Screening of Hereditary Cancer Syndromes 
Venkata S. Katabathina et al.
Radiol Clin N Am 55 (2017) 1293–1309
    • “Birt-Hogg-Dube syndrome (BHD) is an autosomal dominant disorder characterized by the development of cutaneous fibrofolliculomas, bilateral pulmonary cysts, and multiple renal tumors.Germline mutations in the tumor suppressor Folliculin (FLCN) gene located on chromosome 17p11 are responsible for BHD development. The folliculin protein is shown to modulate the AKT-mTOR pathway, which is essential for cell growth.Fibrofolliculomas are the most common clinical findings in patients BHD; they can occur in up to 90% of patients more than 25 years of age and appear as whitish papules on the face, neck, and upper torso .”

      
Imaging and Screening of Hereditary Cancer Syndromes 
Venkata S. Katabathina et al.
Radiol Clin N Am 55 (2017) 1293–1309
    • “About 70% to 85% of individuals with BHD develop multiple pulmonary cysts of varying sizes and shape, which tend to be located in the lower lobes in basilar and mediastinal regions with numerous nonenhancing septations in the larger cysts on CT. About 30% of patients with BHD present with spontaneous pneumothorax from a ruptured lung cyst by the average age of 36 years.Renal neoplasms may develop in 12% to 34% of patients, with a mean age of presentation at 50 years. Renal tumors are often bilateral and multifocal with hybrid oncocytic/chromophobe RCCs and chromophobe RCCs comprising up to 85% of them .”


      Imaging and Screening of Hereditary Cancer Syndromes 
Venkata S. Katabathina et al.
Radiol Clin N Am 55 (2017) 1293–1309
    • “PNETs, the most common pancreatic neoplasms, are responsible for significant mortality and morbidity in MEN1 syndrome. PNETs include gastrinomas (more than half of the cases), insulinomas, and nonfunctioning tumors.Gastrinomas may be seen in the duodenal wall. At CT/MR imaging, intense contrast enhancement during the arterial phase of multiphase CT/MR imaging is one of the characteristic features of PNETs Whole-body imaging techniques such as somatostatin receptor (octreotide scan) imaging and fluorodeoxyglucose-PET scan help in detecting distant metastases and assessing treatment response .Gastrin hypersecretion from duodenal/pancreatic gastrinomas can result in Zollinger-Ellison syndrome, which is characterized on imaging by diffuse, enhancing gastric fold thickening, multiple gastric/duodenal/jejunal ulcers, and esophageal strictures from reflux disease.”


      Imaging and Screening of Hereditary Cancer Syndromes 
Venkata S. Katabathina et al.
Radiol Clin N Am 55 (2017) 1293–1309
    • “MEN2 syndrome is caused by gain-of-function mutations of RET proto-oncogene, located on chromosome 10q11, which encodes the receptor tyrosine kinase and includes 3 subtypes: MEN2A, MEN2B, and familial medullary thyroid cancer (FMTC).Also known as Sipple syndrome, MEN2A is the most common type, characterized by the development of medullary thyroid carcinoma (MTC) (100%), pheochromocytoma (>50%), and primary hyperparathyroidism (15%–30%).MTC is usually the first manifestation of MEN2A and can appear between 5 and 25 years of age. Cutaneous lichen amyloidosis and Hirschsprung disease are rare clinical findings in MEN2A. MEN2B is the least common and most aggressive subtype, characterized by the earlier occurrence of most aggressive MTC, multiple neuromas, and the diffuse ganglioneuromatosis of the gastroenteric mucosa.”


      Imaging and Screening of Hereditary Cancer Syndromes 
Venkata S. Katabathina et al.
Radiol Clin N Am 55 (2017) 1293–1309
    • “Hereditary pheochromocytoma and paraganglioma syndromes (PGLs) are a group of autosomal dominant disorders characterized by the development of multiple paragangliomas and pheochromocytomas.PGLs are caused by germline mutations in the genes encoding for 4 subunits of the succinate dehydrogenase (SDH) mitochondrial complex (SDHA, SDHB, SDHC, and SDHD), which is a major component of the Krebs cycle and electron transport chain.There are 4 types of PGL syndromes: types 1, 2, 3, and 4, which result from mutations of SDHD, SDHAF2 (helps in flavination of subunit A), SDHC, and SDHB genes respectively. Among them, PGL type 1 and 4 are common and are discussed later.”


      Imaging and Screening of Hereditary Cancer Syndromes 
Venkata S. Katabathina et al.
Radiol Clin N Am 55 (2017) 1293–1309
    • “PGL1 syndrome is caused by inactivating mutations in the SDHD gene (chromosome 11q23) and is associated with the development of multifocal, bilateral head and neck paragangliomas (parasympathetic chain) in up to 80% of patients, with a mean age of presentation of 30 years.  Most of these tumors are benign and nonsecretory so individuals with PGL1 are asymptomatic and commonly diagnosed on imaging studies.At CT/MR imaging, intensely enhancing masses in the carotid body, along with the vagal nerve branches, and jugular foramina are the characteristic features of PGL1.”

      
Imaging and Screening of Hereditary Cancer Syndromes 
Venkata S. Katabathina et al.
Radiol Clin N Am 55 (2017) 1293–1309
    • “Tuberous sclerosis complex (TSC) is an autosomal dominant condition caused by inactivating mutations of the TSC1 gene (chromosome 9q34, encodes hamartin) and/or TSC 2 genes (chromosome 16p13, encodes tuberin); tuberin-hamartin complex functions as a tumor suppressor by suppression of the mTOR pathway.CNS lesions in TSC are the primary cause of mortality and morbidity and include cortical and cerebellar tubers, radial migration lines, subependymal nodules, and subependymal giant cell astrocytomas. Gadolinium-enhanced MR imaging of the brain is the imaging modality of choice for diagnosis, screening, and monitoring of intracranial lesions.”

      
Imaging and Screening of Hereditary Cancer Syndromes 
Venkata S. Katabathina et al.
Radiol Clin N Am 55 (2017) 1293–1309
    • “Renal lesions are seen in up to 60% of patients with TSC and include angiomyolipomas (AMLs) and renal cysts .Renal AMLs larger than 4 cm or with intralesional aneurysms larger than 5 mm carry increased risk of spontaneous rupture and require prophylactic embolization.Other lesions in TSC include cardiac rhabdomyomas, lung/retroperitoneal lymphangioleiomyomatosis, hepatic AMLs, and sclerotic lesions in the bones.Recent studies suggest that a spectrum of distinctive renal tumors occurs in patients with TSC; tumors occur at a younger age compared with the general population.”

      
Imaging and Screening of Hereditary Cancer Syndromes 
Venkata S. Katabathina et al.
Radiol Clin N Am 55 (2017) 1293–1309
    • “There is a wide spectrum of hereditary cancer syndromes that are characterized by distinctive genophenotypic manifestations. Based on the characteristic imaging findings, the radiologist may be the first physician to suspect a syndromic basis of distinctive multisystem tumors in a given patient leading to accurate diagnosis. Radiologists play a pivotal role in the screening, initial diagnosis, management, and long-term surveillance of patients with hereditary cancer syndromes and their at-risk family members. Improved knowledge of screening and surveillance guidelines of common hereditary cancer syndromes permits optimal patient care.”


      Imaging and Screening of Hereditary Cancer Syndromes 
Venkata S. Katabathina et al.
Radiol Clin N Am 55 (2017) 1293–1309
Vascular

    • “TRO was associated with slightly higher yield of PE and AD, specifically in the emergency department. This benefit comes with higher nondiagnostic image quality, radiation, and contrast doses. Although TRO may be of value in selected patients, its indiscriminate use is not warranted. The appropriate use of TRO needs to be further defined.”

      
Triple Rule Out Versus Coronary CT Angiography in Patients With Acute Chest Pain
Burris II, AC et al.
J Am Coll Cardiol Img 2015;8:817–25
© 1999-2018 Elliot K. Fishman, MD, FACR. All rights reserved.