RSNA 2019 Archived Program

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.

Krissia Margarita Rivera Perla, ScB; Ollin Gomez Venegas, BA; Steven A. Toms, MD, MPH

Authors review the North American and European guidelines for chemoradiation of GBM created as a result of the new 2016 WHO classification system, focusing specifically on age, performance status, molecular markers, and disease recurrence. They also discuss factors such as socioeconomic and insurance status that impact radiation treatment compliance and GBM outcomes.

Saira E. Alex, BS; Eric D. Brooks, MD; Emma B. Holliday, MD

Based on current standards, colon cancer is treated with surgical resection and chemotherapy, and rectal cancer is treated with preoperative radiotherapy. This review of the literature suggests the potential for improved local control and reduced toxicity when treating colorectal cancer with proton therapy compared to the current treatment paradigms. Additionally, surgery and ablative techniques have traditionally been used to treat metastatic colorectal cancer. This review discusses how proton therapy could offer an alternative approach to reduce toxicity and act in lieu of surgery in the metastatic setting.

Nadia Saeed, BA

There is a critical role for integrating radiation concepts in medical school education, with the goal of continuing to attract students to the specialty. However, several medical schools lack formal teaching of radiation, and many students receive little exposure to the field. The question of how to improve integration of radiation oncology into medical education remains up for debate. This article examines the current limitations to and the various methods of implementing radiation education in medical school curricula.

Nadia Saeed, BA

Radiation therapy remains one of the more misunderstood treatment modalities in cancer care. This article discusses the evolution of patient education in radiation oncology, discussing current education tools and practices as well as new innovations and future directions, including virtual reality, social media, apps and more.

Shekinah Nefreteri Cluff Elmore, MD, MPH, is at Harvard Medical School, Boston. Gregorius Ben Prajogi, MD; Jose Alfredo Polo Rubio, MD; Eduardo Zubizarreta, MD, are at the International Atomic Energy Agency, Vienna.

This review examines the capacity gap in RT through the lens of human resource needs. The authors model radiation oncologist training needs, investigate the disparity between HMICs vs LMICs, and explore solutions for training/licensure and regional collaboration.

Joel Yarney, MD; Hannah Ayettey Anie, MD; Verna Vanderpuye, MD; Francis Adumata Asamoah, MD; Baffuor Awuah, MD; Clement Edusa, MD; Samuel Tagoe, PhD; Samuel Denyo, BTech; Pearl Aba Scott, MD; Francis Doughan, MPhil; Kofi Adesi Kyei, PhD; Charles Aidoo, HND; Bismark Dwobeng, MD; Rebecca Wong, MD; Horia Vulpe, MD; Shivanshu Awasthi, MPH, PharmD; Angelina Fink, MPH; Stuart Wasserman, MS; Peter Johnstone, MD; Louis Harrison, MD; Kosj Yamoah, MD, PhD

Oncologists may not be familiar with the utilization and operation of radiation therapy facilities in limited-resource settings. Additionally, oncologists interested in global radiation oncology need to understand the challenges and opportunities pertinent to the field. This article describes innovative international efforts regarding quality assurance, capacity building, and research and training that address unmet needs and improve radiation treatment for patients in Ghana, a major hub for radiation treatment in Africa.

Recent technological advances challenge traditional PET acquisition procedures in order to leverage the benefits of digital technology to improve diagnostic capabilities, patient experience, quantification and new indications. Precision medicine is a call to action to radically advance capabilities in the era of molecular targeted medicine.

In this Expert Forum Webcast, Michael V. Knopp, MD, PhD will provide an overview of current digital PET technologies and how leveraging these digital advances improves PET imaging using clinical cases. He will demonstrate how new concepts result in acceleration of acquisition time, dose reduction and dynamic imaging to help improve quality and the patient and staff experience. These new applications apply to the clinical practice for oncology, neurology and orthopedics / sports medicine.

Learning Objectives

• Describe current PET technologies.
• Describe the benefits of digital photon counting.
• Understand the benefit of improved time of flight timing.
• Understand the benefit of reduced voxel size and higher matrix reconstruction.
• Describe ultra-fast whole-body imaging.
• Describe the benefits of imaging at lower tracer doses.
• Describe the benefits of dynamic PET imaging.
• Describe the use of Y-90 for post-therapy assessment.

Supported through an unrestricted educational grant from Philips Healthcare.

Jennifer Shaffer Ngo, MD, and Gary R. Schooler, MD,

Pediatric musculoskeletal injuries often manifest differently from adult injuries and similar mechanisms may present differently depending on the degree of skeletal maturity. This article outlines many of the common pediatric injuries that the general radiologist may encounter in practice. Select topics include physeal injuries, elbow fractures, developmental dysplasia of the hip, slipped capital femoral epiphysis, and Blount disease. Knowledge of these unique pathologies and anatomic variants will help the radiologist recognize these entities sooner, ultimately helping facilitate the most expeditious and appropriate care.

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.

Jason Liu, BS; Heath B. Mackley MD, FACRO

This review article identifies demographic, clinical, and treatment variables associated with the abscopal effect— the phenomenon in which radiation induces a regression of tumor cells outside the field of irradiation. Authors describe the current state of knowledge regarding these variables and examine research on the influence of tumor type, patient’s immune system, overall tumor burden, and radiation therapy parameters on the abscopal effect.

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.

RSNA 2018 Archived Program

As technological advances in MR, CT, USD, and Combined Angiography/CT systems continue to impact how healthcare is practiced, this Expert Forum Symposium Series, featuring three (3) individual presentations from experts in their respective fields; will highlight through their clinical experiences, how they are maximizing the latest advances in imaging, and assess the growing impact that artificial intelligence is having on improved patient outcomes, satisfaction and throughput.

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

Advanced and Emerging Ultrasound Technologies for Assessment of Liver Disease
by Andrew Trout, MD
Ultrasound Fusion Technology with Auto-Registration
by Nami Azar, MD, MBA
Advancements in Interventional Radiology Using A Combined CT & Angiography System
by Bela Kis, MD. PhD

Educational Objectives

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

• Identify clinical scenarios where ultrasound fusion imaging can be implemented.
• Review the role of shearwave elastography in the assessment of diffuse liver disease.
• Describe the value of the hybrid CT/angiography system in liver tumor embolization cases.

This program was originally presented live at RSNA 2018 and sponsored by the Institute for Advanced Medical Education (IAME) and supported through an unrestricted educational grant from Canon Medical Systems.

Bindu V. Manyam, MD; Naichang Yu, PhD; Tim Meier, RTT; John H. Suh, MD; Samuel T. Chao, MD

With increases in complexity of radiation delivery and patient volume, vulnerable sources for errors may exist within radiation oncology workflow. Patterns of care recommendations are outlined by the American College of Radiology and the National Comprehensive Cancer Network guidelines; however, departmental and institutional policies and standards for quality and patient safety may vary. This article examines initiatives to mitigate errors and enhance safety, and describes efforts to incorporate quality improvement and patient safety into resident education.

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.

Advances in technology have led computed tomography (CT) to become one of the main diagnostic tools utilized today in modern healthcare, as it provides a safe and low risk anatomical visualization of the human body. However, these advances have also introduced new challenges related to the administration of contrast, which is a fundamental component of many CT imaging exams, particularly in cardiac CT.

This Expert Forum aims to help a wider audience of radiology professionals understand how to use iodine contrast safely, by using a weight-based contrast strategy, which allows technologists and radiologists to image safely while obtaining optimal results. In addition, we will discuss the value of including saline in your protocols, which can result in contrast savings, but also provides the ability to optimize the contrast injection process to improve image quality and patient safety.

Learning Objectives

• Gain insight into weight-based imaging strategies and how to implement them in clinical practice.
• Identify when saline may be a helpful addition to an injection strategy.

Supported through an unrestricted educational grant from Bracco Diagnostics Inc.

Lisa M. Ho, MD

Imaging plays a critical role in the work-up and clinical management of adrenal disease. Because masses in the adrenal glands are one of the most commonly encountered incidentalomas, the American College of Radiology (ACR) has developed specific recommendations on how to manage incidentally discovered adrenal masses in the adult population. The purpose of this article is to review the imaging appearance of common adrenal diseases and provide a diagnostic imaging algorithm for work-up of the “adrenal incidentalomas.”

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.

Deborah R. Shatzkes, MD

“Nomenclature has been the major obstacle to our understanding and management of vascular anomalies.” These words were written by John Mulliken over 30 years after publishing his seminal paper on the biologic basis of vascular anomalies in 1982. The intervening decades have brought tremendous progress in classification, diagnosis and therapy of this diverse group of lesions. Still, much confusion exists in the medical community, in no small part because of inaccurate and inconsistent use of nomenclature both in the liter-ature and in clinical practice.

The multidisciplinary International Society for the Study of Vascular Anomalies (ISSVA) was formed in 1992 to promote research in the field of vascular anomalies and to create a uniform nomenclature that would facilitate research and clinical practice. ISSVA created a comprehensive classi-fication scheme based on Mulliken’s work on the biologic basis of disease, updated most recently in 2014 and available at issva.org/classification. The ISSVA classification and its associated nomenclature are widely accepted as the gold standard by the numerous medical specialties involved in clinical care and research related to vascular anomalies.

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.

Stephanie R. Rice, MD; Adeel Kaiser, MD; Elizabeth Nichols, MD

This review examines the role of trimodality therapy in the management of esophageal cancer, focusing on controversies surrounding the optimal total neoadjuvant RT dose employed. Current and past technologies for radiation treatment delivery and their impact on overall survival and toxicity are discussed. The authors also detail the data driving the management of resectable esophageal carcinoma, reviewing studies comparing neoadjuvant CRT followed by surgery to definitive CRT, neoadjuvant CRT followed by surgery to surgery alone, and controversies in radiation dose and planning considerations for preoperative resectable esophageal cancer.

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 describes the Joint Commission’s requirements for annual training on specific MRI safety practices. In addition, it covers procedures to manage patients undergoing MRI with recommendations to prevent ferromagnetic objects from entering the MRI environment; claustrophobia, anxiety, or emotional distress; guidelines to screen patients with medical implants and devices; procedures to prevent thermal injuries; methods to handle patients requiring urgent or emergent medical care; contrast agent safety including information for nephrogenic systemic fibrosis, and techniques to avoid problems related to acoustic noise.

Educational Objectives

1. Describe the latest requirements from The Joint Commission for MRI with an emphasis on safety and training.
2. Present procedures for managing claustrophobic patients, screening prior to MRI, preventing ferromagnetic accidents, avoiding MRI-related thermal injuries, handling emergencies, and preventing acoustic noise issues.
3. Define methods to ensure compliance with the latest requirements from The Joint Commission for MRI safety.
4. Summarize The Joint Commission’s requirements for annual training on specific MRI safety practices.

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

Muhammed M. Fareed, MD; Monica Krishnan, MD; Tracy A. Balboni, MD, MPH; Hsiang-Hsuan Michael Yu, MD

Palliative radiation oncology is an integral part of radiation oncology practice with practical implications in common clinical scenarios including bone metastases, brain metastases, malignant spinal cord and cauda equina compression, tumor related bleeding, fungation, obstruction and visceral metastases. Further education and research is needed as part of residency training and beyond to enhance the spectrum of care for advanced cancer patients delivered by radiation oncologists. Supportive and palliative care skills must expand beyond the technical aspects of radiation therapy delivery to generalist palliative care competencies, including symptom management basics, communication and goals of care, advance care planning, psychosocial issues, cultural considerations, spiritual needs and ethical/legal issues.

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.

Wende N. Gibbs, MD, MA, and Lawrence N. Tanenbaum, MD, FACR

Hydrocephalus is a a mechanical complication of different pathologic conditions and a disease process itself.  The morphologic features are easily recognizable, but the patho-physiology remains incompletely understood.  Nearly all hydrocephalus is due to cerebrospinal fluid (CSF) obstruction at some point between the ventricles and the systemic venous circulation.  Classification is important as it informs optimal treatment. 

Optimized imaging is vital to the success of flow diversion.  Current treatments are limited and invasive: CSF diversion via catheter or endoscopic third ventriculostomy.  Decision making relies upon high resolution imaging to determine the site of obstruction and anatomic features that may complicate the procedure.

Morphologic and physiologic imaging are used to evaluate suspected normal pressure hydrocephalus (NPH).  Several morphologic measures individually and in combination have shown high positive predictive value in identifying individuals who will respond to treatment with ventricular shunting and in differentiating NPH from Alzheimer disease, which can have a similar imaging appearance.

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.

Andrew Kennedy, MD; Susan Garwood, MD; Allison Grow, MD, PhD; Ryan Lipscomb, MS

Multidisciplinary team members treating lung cancers may not be aware of the complexity and coordination required for delivery of stereotactic body radiation therapy (SBRT) to lung masses. Shifts in practice have occurred in management of early stage non-small cell lung cancer (NSCLC), particularly with regard to the role of the specialized pulmonologist (interventional pulmonology), which involves different staging techniques than traditional mediastinoscopy. This review provides key information to foster a deeper understanding and appreciation for patient selection, work up, behind-the-scenes critical quality assurance tasks, and clinical pearls for stereotactic radiation therapy for lung cancer.

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.

Kelly W. Capel, MD, and Lynn S. Broderick, MD, FACR

Given that pulmonary embolism (PE) is the third-leading cause of cardiovascular death and that the signs and symptoms of PE are often nonspecific, many care providers obtain CTA in the acute-care setting to evaluate for any life-threatening or urgent pathology.

While most of these patients will likely not have an underlying PE, this article showcases several alternative potential pathologies, ranging from common intrathoracic conditions such as pneumonia, to acute aortic syndrome and intra-abdominal pathology, which may be partially captured via subtle clues on CTA examinations.

In the acute-care setting, the radiologist’s ability to recognize other potential sources of pain and shortness of breath as well as coexisting pathology in patients being evaluated for PE with CTA is critical.

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 protocols 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. As such, 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.

With more than 30 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.

Advanced MRI Safety Training for Healthcare Professionals, Level 2 MR Personnel is a 150-minute program that is divided into three sections.

Educational Objectives

• Understand the safety issues related to MRI.
• Describe the bioeffects associated with the static magnetic field, time-varying magnetic, and radiofrequency fields.
• Present guidelines that prevent projectile-related accdents.
• 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.
• Identify safety considerations for gadolinium-based contrast agents.

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