CME Radiology Grand Rounds

Molecular Imaging 2024: Trials and Tribulations

This presentation will highlight how clinical practice generates research questions and how challenges in research can present opportunities for bringing new practices back into the clinic.

LEARNING OBJECTIVES:

1. Describe background on molecular imaging response criteria
2. Describe challenges for integrating new practices (including response) using molecular imaging into clinic
3. Discuss how these challenges are helped or hindered by clinical trial research

Multidisciplinary Diagnosis of Chronic Thromboembolic Pulmonary Hypertension (CTEPH)

Imaging plays a crucial role in the diagnosis of chronic thromboembolic pulmonary hypertension (CTEPH). Unfortunately, the diagnosis of CTEPH is often missed by radiologists due to various reasons include suboptimal protocols and general lack of knowledge of disease appearance. This diagnosis is crucial as chronic thromboembolic pulmonary hypertension (CTEPH) is the only form of pulmonary hypertension that is surgically curable without transplantation. This presentation will review the different imaging modalities used to diagnose CTEPH, common errors in diagnosis including a review of mimics, and optimized imaging protocols to visualize disease. A case review session will then be employed to review the various surgical, minimally interventional, and medical therapies used to treat CTEPH and the multidisciplinary discussion that is integral for determine the best course of treatment.

LEARNING OBJECTIVES:

1. Learn radiologist, patient, and protocol factors that lead to misdiagnosis of CTEPH Understand the various typical and atypical appearances of CTEPH 
2. Recognize the appearance of numerous mimics that require different therapeutic options 
3. Review the multidisciplinary process that is performed for each patient to determine the best course of action 
4. Understand that different treatment options including techniques and complications

AI-driven Opportunistic CT Screening: Adding Value Beyond the Clinical Indication

My work in AI-driven "opportunistic" or "incidental" CT screening leverages the robust imaging data embedded within all body scans that are unrelated to the specific clinical indication and have heretofore gone largely unused and wasted. This incidental imaging information can efficiently add clinical value in terms of wellness, prevention, risk profiling, and pre-symptomatic detection of relevant disease, without any additional patient time or exposure. The advent of explainable AI solutions for CT-based body composition measures allows for both large-scale population-based studies, in addition to prospective patient care. This value-added initiative of personalized precision medicine also addresses sustainability. By systematically utilizing these useful CT biomarkers, initial evidence suggests that their ability to assess biological age and predict future adverse cardiometabolic events rivals even the best available clinical reference standards. Given the hundreds of millions of CT scans performed throughout the world each year, the potential for impacting global health is enormous.

LEARNING OBJECTIVES:

1. Understand the potential value added by body composition measures at CT that are incidental to the indication for imaging.
2. Discuss the challenges related to implementation of opportunistic CT screening into clinical practice
3. Discuss the emerging role of AI for automated CT-based opportunistic detection of a variety of preventable and treatable conditions.

Imaging Findings of Side Effects of Oncologic Therapies in the Abdomen

Learning Objectives:

1. Recognize intra-abdominal adverse effects of targeted therapies in relation to underlying principal molecular mechanisms
2. Describe imaging findings of common adverse effects of targeted cancer therapies
3. Review imaging features of adverse effects related to Immunotherapy

Molecular imaging approaches to visualizing viral infection and immune response

Infectious disease poses a major threat to global human health, as highlighted by the recent COVID-19 pandemic. Assessment, treatment, and curative interventions of infectious diseases may benefit from the development of molecular imaging approaches. Nuclear imaging agents may be able to quantify the extent of the infection and the presence of viral reservoirs, be useful in drug development, and ultimately assess treatment response and curative strategies. This presentation will highlight the preparation, preclinical development, the pathway to first-in-human evaluation and results from the clinical research studies. Radiopharmaceutical approaches may be powerful tools for the characterization of viral infection and immune activation.

Session Learning Objectives

1. Describe and identify molecular imaging approaches to visualize infectious disease in vivo. 
2. Identify radiopharmaceuticals that recognize infectious disease signatures. 
3. Determine how molecular imaging may improve infectious disease interventions.

25 years of Osteoarthritis (OA) imaging research - past, present, and future!

Learning objectives:

1. Understand the limitations of X-ray in the diagnostic and natural history of osteoarthritis.
2. Introduce the MRI OA definition, and MRI use for inclusion, outcomes and safety in clinical trials.
3. Present the different osteoarthritis phenotypes implying OA is not one disease.
4. Understand the relationship between pain and structure damage in osteoarthritis.

Milli-spinner Thrombectomy for Ischemic Stroke Treatment: Stanford’s Bench to Bedside Device

Endovascular thrombectomy has emerged as an effective treatment for many patients with acute ischemic stroke due to a large vessel occlusion. Advancements in the neuroimaging evaluation of thrombectomy candidates and in thrombectomy devices underpin this therapy, but a significant number of patients still suffer from failed thrombectomy. In this talk, we will review endovascular thrombectomy treatment of ischemic stroke and describe the development of a new technology that may substantially improve stroke treatment in stroke patients. 

Learning Objectives

1. To describe the impact of endovascular therapy relative to medical therapy on the treatment of acute ischemic stroke patients.
2. To understand how blood clot composition influences thrombectomy success.
3. To understand the development of a new thrombectomy device from bench side basic science to in human use.

Alzheimer’s Imaging & ARIA: Research Moves into Clinical Practice (Ready or Not, Here it Comes)

Over the last 20 years, advanced in MRI, amyloid PET and tau PET have fundamentally impacted our understanding of Alzheimer’s disease (AD) and have been key in both biological endpoints and safety monitoring in clinical trials. In 2023 and 2024, updates from the US FDA and CMS have resulted in coverage of new anti-amyloid immunotherapies for patients with mild cognitive impairment due to AD. The radiology department plays a critical role in both diagnostics (MRI, amyloid PET, tau PET, and fluoroscopic lumbar puncture) and monitoring (MRI and amyloid) for patients on anti-amyloid immunotherapy. Despite these new therapies, there are large unmet needs for diagnosis, prognosis, and monitoring of patients with dementia, which present research opportunities for the field of radiology.

Session Learning Objectives:

1. Discuss how imaging research has fundamentally impacted our biological understanding of Alzheimer’s disease (AD).
2. Understand data from clinical trials which has led to recent approvals for anti-amyloid immunotherapy.
3. Plan for the impact of increased baseline and monitoring MRI and amyloid PET in clinical practice. Consider potential role of clinical tau PET in the workup for patients with dementia.
4. Understand gaps in current knowledge and potential for current and future radiology research in AD and related dementias.

Early Detection of Alzheimer’s Disease in Human Aging

The hallmark pathologies that define Alzheimer’s disease dementia begin decades before the onset of cognitive impairment, among clinically unimpaired older individuals. The ability to measure these early disease processes in living humans via imaging and biofluid approaches provides opportunities to understand the initial impact of disease and mechanisms of resilience, and sets the stage for therapeutics geared towards the prevention of dementia. This talk will focus on research from our group that has characterized the asymptomatic “preclinical” stage of Alzheimer’s disease using multimodal neuroimaging, proteomics, and sensitive cognitive assays in human aging cohorts.

Learning Objectives:

1. Describe biological staging criteria for Alzheimer's disease
2. Describe frequency and patterns of amyloid and tau PET elevations in clinically unimpaired individuals
3. Understand associations between early AD and cognition

Being an Advocate

Radiologists report some of the highest rates of burnout and dissatisfaction across all medical specialties. Departmental wellness programs are a potential resource. However, the healing effects of community service and advocacy work often go unnoticed. Most agree that institutions need to support their medical staff in staving off burnout. Part of this is encouragement for advocacy work outside of the reading room. Community service has helped many of us realize that bringing good to others breed good in our own lives.

Session Learning Objectives

1. Learn about the meaning and power of advocacy from a historical perspective.
2. How to get involved in community service through departmental initiatives.
3. Advocacy work could address burnout and increased job satisfaction and fulfillment, as individual radiologists and as a team.

Bridging the gap between ultrasound and MRI for cancer detection

Clinical care is inherently multimodal, with medical image data collected throughout the patient’s journey.  For example, a patient at risk of cancer will undergo an ultrasound-guided biopsy, and when available with MRI revealing regions to be targeted due to higher risk to harbor aggressive disease. This biopsy procedure seeks to collect tissue samples for pathology and will inform treatment strategies for best outcomes. This common scenario provides unique opportunities for Artificial Intelligence (AI) methods to effectively integrate multimodal data, and learn imaging signatures in patients with known outcomes, to enable early cancer detection for patients at risk. This presentation focuses on showcasing some of our AI methods that bridge the gap between highly informative modalities, e.g.,  MRI, and lower resolution modalities, e.g., ultrasound. These methods rely on multimodal image registration, image feature fusion, or integration of patient-specific data and population-specific information and rely on AI approaches for effective integration. While the learning is done with multiple imaging modalities, the inference requires only the low-resolution modality, e.g., ubiquitous conventional ultrasound, with applications in low-resource settings.

The Future of Radiology in the AI Era

Artificial intelligence (AI) is an incredibly powerful tool for building computer vision systems that support the work of radiologists.  Over the last decade, artificial intelligence methods have revolutionized the analysis of digital images, leading to high interest and explosive growth in the use of AI and machine learning methods to analyze clinical images and text.  Deep learning methods are now being developed for image reconstruction, imaging quality assurance, imaging triage, computer-aided detection, computer-aided classification, and radiology report drafting.  The systems have the potential to provide real-time assistance to radiologists and other imaging professionals, thereby reducing diagnostic errors, improving patient outcomes, and reducing costs.  We will review the origins of AI and its applications to medical imaging and associated text, define key terms, and show examples of real-world applications that suggest how AI and large language models may change the practice of medicine.  We will also review key shortcomings and challenges that may limit the application of these new methods.