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Published on : Jul 28, 2021 | Views : 2700 | Downloads : 15

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Radiology Basics David J. Eschelman, M.D., FSIR Professor of Radiology, Sidney Kimmel Medical College of Thomas Jefferson University Co-Director of Interventional Radiology, Thomas Jefferson University Hospital
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So what is a radiologist?
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So what is an interventional radiologist?
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Imaging Modalities CT (computed tomography) US (ultrasound) MRI (magnetic resonance imaging) PET-CT (positron emission tomography)
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CT Pros: Available everywhere, consistent quality, best option for whole-body evaluation Fast Cons: Less sensitive for small liver metastases than MRI Radiation (10-15 mSv)
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Chest CT – Lung Metastases
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Ultrasound Pros: Relatively inexpensive. No radiation. Can be very sensitive for small lesions Cons: Variable quality, depending on site and on patient. Not useful for whole-body surveillance.
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Biopsy
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MRI Pros: Most sensitive for liver mets. No radiation. No known harmful effects Cons: Does not cover entire body Can’t use in SOME people with pacers, anxiety, etc. Variability in how studies are done. Slow, noisy, easily affected by motion, etc.
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8/11/2010
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10/27/2010
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12/23/2010
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4/09/2010
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MRI is better than CT (another example) CT MRI
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MRI is better than CT (yet another example) CT MRI
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PET-CT
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PET - CT Pros Unique: Images metabolic activity May give information about efficacy of treatment Cons Not universally available Expensive Not sensitive for small metastases Takes about 2 hours Radiation (30 mSv)
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Surveillance Imaging Surveillance Scheduling No consensus: Varies from center to center Depends on tumor histology and genetics Jefferson protocol Low/intermediate risk: MRI q6-12 mo, CXR q12 mo for 5 years High risk: MRI q3 mo + CT chest q 6 mo for 2 years, then MRI q6 mo + CT q 12 mo for 3 years
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NCCN Guidelines v1.2018 RISK OF DISTANT METASTASIS - Low risk: Class 1A(x) Disomy 3 Gain of chromosome 6p EIF1AX mutation T1 (AJCC) (See ST-1 and ST-2) Spindle cells SYSTEMIC IMAGING BASED ON RISK STRATIFICATION Imaging to evaluate signs or symptoms as clinically indicated Consider surveillance imaging(y)
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NCCN Guidelines v1.2018 RISK OF DISTANT METASTASIS - Medium risk: Class 1B(x) SF3B1 mutation T2 and T3 (AJCC) (See ST-1 and ST-2) Mixed histology (spindle and epithelioid cells) SYSTEMIC IMAGING BASED ON RISK STRATIFICATION Imaging to evaluate signs or symptoms as clinically indicated Consider surveillance imaging(y) every 6–12 months for 10 years, then as clinically indicated
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NCCN Guidelines v1.2018 RISK OF DISTANT METASTASIS - High risk: PRAME mutation Epithelioid cells Extraocular extension Ciliary body involvement Class 2(x) Monosomy 3 Gain of chromosome 8q BAP1 mutation T4 (AJCC) (See ST-1 and ST-2) SYSTEMIC IMAGING BASED ON RISK STRATIFICATION Imaging to evaluate signs or symptoms as clinically indicated Consider surveillance imaging(y) every 3-6 months for 5 years, then every 6-12 months for 10 years, then as clinically indicated
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NCCN Guidelines v1.2018 Surveillance: The most frequent sites of metastasis are liver, lungs, skin/soft tissue, and bones. At minimum, all patients should have contrast-enhanced MR or ultrasound of the liver, with modality preference determined by expertise at the treating institution. Additional imaging modalities may include chest/abdominal/pelvic CT with contrast. However, screening should limit radiation exposure whenever possible. Scans should be performed with IV contrast unless contraindicated. . . . . . but also add: (y) Recognizing that there are limited options for systemic recurrence and that regular imaging may cause patient anxiety, some patients may elect to forgo surveillance imaging.
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Background Radiation Sources: Cosmic radiation Naturally occurring radioactive materials (radon, radium) Fallout Exposure in US: Approximately 3 mSv/yr (low altitude) 30-50% higher in Denver Transatlantic flight – 0.08 mSv (2-3x higher over poles) 2x higher in US Capitol (8 hrs/day) – granite, marble
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Radiation Dauer L et al. AJR 2011, 196
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Brenner: DJ, Hall EJ: Computed Tomography — An Increasing Source of Radiation Exposure. N Engl J Med 357:2277, November 29, 2007
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Contrast Risks CT contrast and MR contrast are completely unrelated materials Risk of reaction to CT contrast is very low (0.15%) Risk of reaction to MR contrast is extremely low (0.04%) Most reactions are minor
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Contrast Reactions Contrast and Renal Insufficiency CT: “Contrast nephropathy” MR: NSF
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FDA Drug Safety Communication: FDA warns that gadolinium-based contrast agents (GBCAs) are retained in the body; requires new class warnings May 22, 2017, updated December 19,2017
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Gadolinium Contrast for MRI Per FDA: Gadolinium retention has not been directly linked to adverse health effects in patients with normal kidney function, and we have concluded that the benefit of all approved GBCAs continues to outweigh any potential risks. Linear vs. macrocyclic Eovist is one of the lower linear “accumulators” (lower dose administered, excreted by kidneys and liver, more stable than other linear agents)
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RECIST Criteria Complete Response (CR) Disappearance of liver lesions Partial Response (PR) > 30% decrease in the sum of the longest diameters (“sum LD”) relative to baseline sum Stable Disease (SD) Absence of change which would qualify as response or progression Progression (PD) > 20% increase in the sum LD in liver lesions OR appearance of one or more new liver lesions
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Initial Presentation MRI was normal 6 months ago
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Rapid Growth without Treatment 12/17/2013 4/30/2014 6/2/2014
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Any Questions?