Leila T. Tchelebi, MD; Nicholas G. Zaorsky, MD, MS; Jennifer Rosenberg, MD; Kujtim Latifi, PhD; Sarah Hoffe, MD

While MR-guided radiation therapy (MRgRT) offers many benefits, it is a costly and resource-intensive investment that can strain radiation oncology clinics not adequately prepared to incorporate this treatment. This work reviews clinical advantages and practical limitations of MRgRT, and suggests ideal patients for this technology. The authors also provide a practical guide for centers acquiring MRI-based linear accelerators to foster seamless integration.

Available for SA-CME Credit. To receive SA–CME credit, you must complete the post exam and review the discussion and references provided with the exam results.

Steven Benitez, MD; Ryan Holland, MD; Richard Zampolin, MD; Andrew Brook, BA, MS; Joshua Hirsch, MD; Allan L Brook, MD, Deepak Khatri, MD

As thrombectomy has become the standard of care for large vessel/arterial occlusions, the indications are initiated by proper imaging and understanding of the brain blood flow physiology. This two-part series examines the standard of care for acute stroke imaging and the latest techniques. The second part of this activity on stroke intervention will appear in the November-December issue of Applied Radiology.

Available for SA-CME Credit. To receive SA–CME credit, you must complete the post exam and review the discussion and references provided with the exam results.

*Yufan (Fred) Wu, MD; *Hyunsoo Joshua No, MD, CMD; Dylan Y. Breitkreutz, PhD; Anthony E. Mascia, PhD; Raphaël Moeckli, PhD; Jean Bourhis, MD, PhD; Emil Schüler, PhD; †Peter G. Maxim, PhD; †Billy W. Loo Jr., MD, PhD

With a steady increase in FLASH-RT human clinical trials underway, this review discusses the technological basis for FLASH-RT clinical trials and explores the modalities, treatment parameters, technical limitations, and potential indications of current ultrahigh dose RT (UHDR-RT) technologies.

Available for SA-CME Credit. To receive SA–CME credit, you must complete the post exam and review the discussion and references provided with the exam results.

This CME/CE accredited program will review contrast-saline dynamics and discuss rational protocol design for cardiac and vascular CT angiography. Effective cardiovascular imaging protocols, utilizing multiple CT injector platforms to achieve optimal imaging, will be reviewed. We invite you to join Dr. Richard Hallett for a comprehensive discussion and case study review of this important topic.

Following the presentation questions from the audience were addressed in a moderated Q&A session.

Educational Objectives:
At the completion of this activity, participants should be able to:

• Understand the relationship between bolus contrast media injection and observed enhancement.
• Implement methods to design rational contrast injection / scan acquisition protocols.
• Review various models of CT contrast injectors and discuss benefits, limitations, and injection protocol adjustments for each.
• Apply customized contrast-saline injection / scan principles to complex cardiovascular disease cases.

Made possible through an unrestricted educational grant from Bracco Diagnostics, Inc.

Individuals entering the magnetic resonance imaging (MRI) environment, whether on a regular or infrequent basis, must be properly trained to ensure their safety, the protection of patients, and the security of other facility staff members. This program, Basic MRI Safety Training, Level 1 MR Personnel accomplishes the initial training that is necessary to ensure safety in the unique setting associated with the MRI system. It includes information pertaining to MRI technology, describes common hazards and unique dangers associated with the MRI setting, and presents vital recommendations and guidelines to prevent accidents and injuries. Importantly, this program provides the fundamental MRI safety information for Level I MR Personnel recommended by the American College of Radiology and may be utilized by individuals preparing for safety training as Level 2 MR Personnel.

With more than 35 years of experience in the field of MRI, the author of the best-selling textbook series, the Reference Manual for Magnetic Resonance Safety, Implants and Devices, and the creator of the internationally popular website, www.MRIsafety.com, Dr. Frank G. Shellock is uniquely qualified to present the information in this program.

Educational Objectives

• Appreciate the importance of MRI
• Identify the hazards associated with MRI
• Understand the screening process
• Describe steps to prevent accidents and injuries

This is a Pay-To-View program. Purchase is required for full program access. 

Adam C. Riegel, PhD, DABR

The purpose of this article is to review recent advancements in artificial intelligence (AI) as they specifically pertain to head-and-neck radiation oncology. The main focus will be applications and clinical impact of these techniques. Specifically, this article addresses autosegmentation of organs at risk (OARs), autosegmentation of target volumes, treatment planning and predictive dose calculation, image-guided adaptive radiation therapy, prognosis and outcome prediction, and quality assurance.

Available for SA-CME Credit. To receive SA–CME credit, you must complete the post exam and review the discussion and references provided with the exam results.

Arash Mirrahimi, MD, MSc; Charlotte Gallienne, MD; Hournaz Ghandehari, MD, FRCPC

Acute mesenteric ischemia (AMI) is a true surgical emergency and a rare life-threatening condition, accounting for 0.01% of hospital admissions, with extremely high mortality rates (up to 69%). Poor outcomes remain prevalent despite advances in both diagnostic and treatment options over the last two decades

Early diagnosis and management are particularly important given that the highest incidence of AMI occurs in the elderly population, who often have multiple comorbidities leading to a worse prognosis. Biphasic contrast enhanced multidetector computed tomography (MDCT) images have become the mainstay and standard of care for investigation and timely diagnosis of AMI.

As such, the importance of recognizing imaging features of AMI and timely communication of findings with the referring physicians is of utmost importance for diagnostic radiologists and always a worthwhile topic for review. We have therefore endeavored to provide a brief summary of the presentation of AMI, its causes, relevant anatomy, and most importantly, illustrated review of CT findings that delineate ischemic changes of the bowel and mesentery.

Available for SA-CME Credit. To receive SA–CME credit, you must complete the post exam and review the discussion and references provided with the exam results.

Victor E. Chen, MD; Joseph F. Lombardo, DO, PharmD; Serguei A. Castaneda, MD; Karen M. Winkfield, MD, PhD; Scot A. Fisher, DO; Eric L. Gressen, MD; Shari B. Rudoler, MD; Weisi Yan, MD, PhD; Shefali R. Gajjar, MD

This review article describes key factors that contribute to lung cancer disparities for Black patients and discusses strategies and future directions for radiation oncologists to bridge the gap. Topics discussed are contributing factors for disparities in lung cancer incidence, disparities in lung cancer prevention, disparities in lung cancer treatment and outcomes, and potential strategies to overcome barriers.

Available for SA-CME Credit. To receive SA–CME credit, you must complete the post exam and review the discussion and references provided with the exam results.

Jack Bennett, Cynthia Peterson, MPH, RDMS, RVT; Richard G. Barr MD, PhD

Ultrasound (US) is often the initial imaging modality for evaluation of renal diseases. Non-enhanced US faces limitations in the assessment of focal renal masses and complex cysts. Contrast-enhanced ultrasound (CEUS) on the kidneys can overcome these shortcomings.

There are several advantages of CEUS over contrast-enhanced CT or contrast-enhanced MRI. These include the fact that the narrow US beam allows for improved visualization of vascularity in small structures such as septations or small mural nodules; high temporal resolution with real time assessment of vascularity; lack of radiation; and no renal impairment.

Excluding inflammatory masses, vascular abnormalities and pseudotumors, most solid enhancing renal masses are malignant. Complicated cystic lesions with enhancing soft tissue components, excluding the actual cyst wall, are malignant. Using enhancement pattern, renal masses can be characterized with high sensitivity and specificity

Available for SA-CME Credit. To receive SA–CME credit, you must complete the post exam and review the discussion and references provided with the exam results.

Daniel Y. Kim, BS*; Jimmy A. Guo, BA*; Daniel Zhao, BA; Errol J. Philip, PhD; Yun R. Li, MD, PhD

While numerous mechanisms impact sensitivity to radiation, the authors examine the transcriptional alterations and gene expression programs that allow neoplastic cells to withstand radiation. They review the recurring mechanisms co-opted by cancer cells in radiation resistance: upregulation of DNA repair, suppression of apoptotic programs, hypoxia, immune evasion and exhaustion, cellular plasticity, as well as aberrant intracellular signaling. They also explore the therapeutic implications of these preclinical findings.

Available for SA-CME Credit. To receive SA–CME credit, you must complete the post exam and review the discussion and references provided with the exam results.

Angela Y. Jia, MD, PhD; Matthew P. Deek, MD; and Ryan M. Phillips, MD, PhD

This review provides a perspective regarding barriers to expansion of radiation treatments in low- and middle-income countries (LMICs). The authors review the benefit of expanding radiation treatment to patients with oligometastatic disease based on several recent clinical trials including SABR-COMET, ORIOLE, and others. The authors also discuss limitations and barriers to receiving radiation treatment in less developed countries including the sparsity of treatment machines, personnel expertise, and distribution of resources in urban vs rural environments. They further discuss technological advances that may help to develop and increase access to radiation therapy in LMICs.

Available for SA-CME Credit. To receive SA–CME credit, you must complete the post exam and review the discussion and references provided with the exam results.

In this second of a 3 Part Series, Dr. Laurie Fajardo discusses the benefits of digital breast tomosynthesis (DBT) for detecting and diagnosing breast cancer and things to consider when planning or implementing DBT into breast imaging practices.

Dr. Fajardo discusses the importance of radiation dose reduction with synthetic 2D, reviews the published literature on the performance of synthetic 2D mammography, and shares how DBT can impact data storage and network data transmission across your PACS and enterprise system.

Educational Objectives:
At the completion of this activity, participants should be able to:

• Describe the efficacy of synthetic 2D from DBT.
• Implement procedures for managing DBT data volumes and workflow.
• Develop an approach to interpreting DBT images.

Supported through an unrestricted educational grant from FUJIFILM Medical Systems U.S.A., Inc.

Andrew Ong, MD; Lisa A Mullen, MD; Susan C. Harvey, MD

Pregnancy associated breast cancer (PABC) is a subset of breast cancer that is typically diagnosed at more advanced stages and carries a worse prognosis. The physiological breast changes that occur during pregnancy and lactation can often make clinical and radiological evaluation difficult.

Ultrasound is the primary imaging modality in the evaluation of pregnancy associated breast lesions with high sensitivity and lack of radiation. Mammography is generally considered safe during pregnancy and lactation and may also be used to assess for PABC. Dynamic contrast enhanced breast MRI is not recommended during pregnancy; however, it may safely be performed in lactating women to evaluate extent of disease or for high risk screening.

This article reviews appropriate imaging evaluation of the pregnant or lactating woman, and showcases the imaging features of benign and malignant lesions occurring during pregnancy and lactation. Many benign lesions, including fibroadenoma and lactating adenoma, can mimic malignancy. New or growing solid masses occurring during pregnancy and lactation should be further evaluated with imaging and biopsy, to avoid a delay in a potential cancer diagnosis.

Available for SA-CME Credit. To receive SA–CME credit, you must complete the post exam and review the discussion and references provided with the exam results.

Courtney C Moreno, MD; Thuy-Van P Hang, MD; Joel P Wedd, MD, MPH

Screening for hepatocellular carcinoma (HCC) has been shown to improve overall survival by detecting earlier stage, more treatable disease. For some patients with HCC, liver transplant is the preferred treatment. However, donor livers are a scarce resource. Accurate identification and description of HCC with MRI is important in the determination of which patients will receive a liver transplant.

This article reviews background information about cirrhosis and hepatocellular carcinoma, the role of screening, transplant priority determination, and diagnostic criteria for HCC.

Available for SA-CME Credit. To receive SA–CME credit, you must complete the post exam and review the discussion and references provided with the exam results.

Qiuji Wu, MD, PhD; Xiting Yang, MS; Fengyang Wu, MS; Yahua Zhong, MD, PhD

The rapid spread of the new coronavirus disease (COVID-19) identified toward the end of 2019 significantly impacted everyone in China, and all over the world. Head and neck (HN) cancers are a common malignant tumor type in China, with chemoradiation the standard of care for locally advanced disease. However, the COVID-19 epidemic interrupted the routine diagnosis and treatment of all cancers, including HN cancers, which can progress quickly if treatment is significantly delayed. Cancer patient care at the epicenter of COVID-19 was particularly challenged. Based on the management experience of patients with HN cancer during the outbreak of COVID-19 at a cancer institute in Wuhan, the authors summarize management strategies of patients with HN cancer to provide reference for health care providers facing similar challenges.

Available for SA-CME Credit. To receive SA–CME credit, you must complete the post exam and review the discussion and references provided with the exam results.

Blair A Winegar, MD; Ethan A Neufeld, MD; Wayne S Kubal, MD

Many acute infectious conditions of the face and neck resulting from common sources, such as pharyngitis, dental infection, and penetrating trauma, are evaluated in the emergency department. The clinical features of these conditions overlap, and clinical evaluation is often insufficient to localize or determine the extent of infection within the deep spaces of the neck.

This article showcases the classic imaging features and locations of a variety of acute face and neck infections encountered in the emergency department. In addition, the imaging findings of potentially life-threatening complications, such as mediastinitis resulting from retropharyngeal abscess and septic pulmonary emboli resulting from Lemierre syndrome, are described.

In the emergency setting, the radiologist’s ability to correctly identify and categorize acute face and neck infections and their complications is paramount to direct appropriate surgical and medical management.

Available for SA-CME Credit. To receive SA–CME credit, you must complete the post exam and review the discussion and references provided with the exam results.

Elizabeth M. Nichols, MD; Arezoo Modiri, PhD; Pranshu Mohindra, MD, MBBS

Cardiotoxicity can be an unfortunate side effect from cancer therapies including chemotherapy, hormonal therapy, and radiation therapy (RT). Sub-acute cardiotoxicity can occur during systemic therapies but is often considered a late effect from RT. This manuscript reviews the current literature regarding the clinical impact of radiation-induced cardiotoxicity in the setting of breast cancers and thoracic malignancies including lung cancer, esophageal cancer and mediastinal lymphomas.

Available for SA-CME Credit. To receive SA–CME credit, you must complete the post exam and review the discussion and references provided with the exam results.

This program reviews fundamental MRI safety information and meets the annual training recommendations from the American College of Radiology. Importantly, MRI facilities must now comply with the revised requirements for diagnostic imaging from The Joint Commission and document that MRI technologists participate in ongoing education that includes annual training on safe MRI practices in the MRI environment. Notably, Advanced MRI Safety Training for Healthcare Professionals, Level 2 MR Personnel covers each MRI safety topic specified by The Joint Commission, as well as many additional subjects that will expand the knowledge-base of healthcare professionals involved with MRI technology.

With 35 years of experience in the field of MRI, the author of the best-selling textbook series, the Reference Manual for Magnetic Resonance Safety, Implants and Devices, and the creator of the internationally popular website, MRIsafety.com, Dr. Frank G. Shellock is uniquely qualified to present the information in this program.

Advanced MRI Safety Training for Healthcare Professionals (4th Edition), Level 2 MR Personnel is a 2 hour and 45 minute program that is divided into three different sections.

Educational Objectives

• Understand the safety issues related to MRI.
• Describe the bioeffects associated with the static magnetic field, time-varying magnetic fields, and radiofrequency fields.
• Present guidelines that prevent projectile-related accidents.
• Describe polices that avoid issues related to acoustic noise.
• Review procedures that prevent burns associated with MRI.
• Explain and demonstrate appropriate pre-MRI screening procedures.
• Identify techniques to manage patients with claustrophobia, anxiety, or emotional distress.
• Describe guidelines to handle medical emergencies in the MRI setting.
• Understand the safety considerations for gadolinium-based contrast agents.

This is a Pay-To-View program. Purchase is required for full program access.

This Expert Forum Symposium features two respected radiologists who share their clinical experience applying advanced artificial intelligence techniques in both MR and CT imaging.

MR and CT imaging are advancing at a rapid rate with new scanner and software technology finding its way into advanced imaging scanners each year. Artificial Intelligence is proving to play a major role in this expansion. In this one-hour accredited CME symposium, Dr. Gold and Dr. Prokop will provide insight into how they are putting new AI tools into everyday practice at their facilities and explain how these tools are providing better patient care and throughput. Following the presentations, the faculty will take question from the audience.

Advances in CT Imaging
Presented by: Mathias Prokop, MD

Advances in MSK MR Imaging
Presented by: Garry E. Gold, MD

Educational Objectives

At the completion of this program, participants will be able to:

1. Practice two new novel approaches for advanced joint imaging with MR
2. Describe the clinical value of deep learning reconstruction techniques in CT
3. Discuss and implement Artificial Intelligence into clinical practice today

This program was originally presented live at RSNA 2019 and sponsored by the Institute for Advanced Medical Education (IAME) and supported through an unrestricted educational grant from Canon Medical Systems.

Gleb A. Kuzmin, PhD;* Mishka Gidwani, BS;* Tianjun Ma, PhD;* Tingliang Zhuang, PhD; Mohamed E. Abazeed, MD, PhD

This review article discusses recent developments in radiomics—a computational image evaluation technique that integrates medical images, clinical data, and machine learning—its applications to lung cancer treatments, and the challenges associated with radiomics as a tool for precision diagnostics and theranostics.

James Thomas Patrick Decourcy Hallinan, MBChB; Mini N. Pathria, MD; and Brady K. Huang, MD

Brachial plexus disorders are a diagnostic challenge due to the complex anatomy and nonspecific symptomatology. MRI remains the best modality for assessing the brachial plexus (BP), due to its superior soft-tissue contrast compared to CT or ultrasound. Traumatic lesions are the most common cause of BP dysfunction, closely followed by neoplastic infiltration. Infection, inflammation and iatrogenic causes are less common.

This review article will provide an overview of anatomy and practical, up-to-date BP imaging techniques for general radiologists, followed by a step-wise discussion of common pathology. Clinically relevant advances such as dynamic tho-racic outlet MRI will also be discussed.