CME Radiology Grand Rounds

The American College of Radiology Center for Research and Innovation is a nonprofit Contract Research Organization which provides support services for academic radiology researchers. Those services and how to access them will be described and discussed.

DR. SUKERKAR'S TALK- Corticosteroid treatment of pediatric lukemia patients can lead to osteonecrosis, and it would be useful to determine markers that would predict progression of these lesions to joint collapse, which results in significant morbidity. In this study, the presence or absence of bone marrow edema was evaluated on baseline imaging of these lesions in the pediatric cancer population. Bone marrow edema was found to be an early sign of progressive osteonecrosis and eventual bone collapse.

DR. YOON'S 1st TALK - Targeted therapies such as BRAF inhibitors play an increasingly critical role in treatment of metastatic melanoma. However, determining the mutation status can be a major hurdle, as it requires tissue sampling via invasive biopsy. This talk will discuss some of the specific MR imaging characteristics that correlate with the BRAF status to help determine the presence of BRAF mutation based on imaging features.

DR. YOON'S 2nd TALK - Patients with ruptured aneurysms are often critically ill with fluctuating neurological exams and a high risk for vasospasm and stroke. However, there are limited options available for rapid bedside assessment of their brain perfusion. A diagnostic ultrasound is an attractive modality, but its application has been limited in adult patients due to marked attenuation and aberration of the ultrasound signal by the skull. This talk will discuss potential strategies to increase the sensitivity of transcranial ultrasound for improved detection of perfusion abnormality.

Research using structural and functional magnetic resonance imaging (fMRI) has vastly increased our understanding of the neural bases of major mental illnesses. This talk will review the major brain findings in Bipolar and Major Depressive Disorder, Schizophrenia, and serious Anxiety Disorders. Potential future uses of functional imaging to target new interventions  such as deep brain stimulation, transcranial magnetic stimulation, and focused ultrasound will be discussed along with the limitations of drawing conclusions from imaging data. 

At present, all commercially available computed tomography (CT) scanners use energy integrating detectors (EIDs) to convert x-ray photon energy to an electrical signal.  Photon counting detectors (PCDs) use high-speed semiconductors to directly count individual photon interactions and eliminate the need for scintillator crystals, which limit spatial and temporal resolution of x-ray detection.  PCDs may offer substantial benefits over conventional energy integrating detectors such as reduced sensitivity to electronic noise, increased contrast-to-noise (CNR) ratio, higher spatial resolution, better material decomposition and higher dose efficiency leading to a decrease in radiation exposure.  This seminar reviews physical principles of photon counting CT technology and the results of initial preclinical and human testing.

Henry Adams, author of perhaps the greatest American autobiography, once wrote that teachers a ect eternity. In this session, we will discuss common features of ine ective teachers, characteristics of at least one outstanding teacher, and begin to develop strategies by which to integrate such insights into our own teaching, in ways that have an enduring impact on both learners and teachers.

We are at a very exciting time in the evolution of imaging-related research technologies and their translational to enhance patient outcomes. Next discoveries will include large scale, multidisciplinary collaborations that require vision and resources.  Overcoming challenges to effectively advocating for the role of the radiologist and imaging investigator in this work includes a multi-pronged strategy to engage disease-based patient champions and educate multiple stakeholders on the impact of imaging innovation on public health.

Inappropriate use accounts for 26% to 44% of lumbar spine (LS) MRIs. This overuse can lead to unnecessary procedures and interventions, as well as avoidance of exercise and diminished well-being. While efforts have been made to improve guideline concordance using decision support tools, these attempts have largely had mod- est and short-term effects. The ability to better target these interventions may help improve guideline concordance. Methods: Using VA administrative data, we develop a method to identify cases of inappropriate LS MRI among patients with new-onset low back pain. We assign patients to primary care providers and construct a provider performance measure for inappropriate imaging. We account for variation in providers’ exposure to low back pain cases using a shrinkage estimator. We identify primary care providers with low and high rates of inappropriate imagining and test the reliability of this measure over time. Findings: We identify 842,051 index primary care visits for uncomplicated low back pain over a three year period (07/01/2013 to 06/30/2016). Of these visits, 2.6% resulted in an inappropriate LS MRI. In an analysis of patients assigned to active primary care providers, 6.2% of providers meet our criteria for low concordance while 22.8% of providers are highly compliant. We find regional variation across health networks, ranging from 1.8% of visits resulting in appropriate scans to 3.88% of visits.

The lecture will describe concepts of nuclear theranostics in various malignant diseases, including thyroid cancer, neuroendocrine tumors, and prostate cancer. Recent literature on the clinical use of nuclear theranostics will be presented, with a focus on recent developments in prostate cancer. There will also be an outlook on nuclear theranostics in other diseases based on results in preclinical models.

This lecture will discuss the definition of value in radiology and how it is possible to create increased value in academic radiology departments. In particular, it will discuss how innovative informatics solutions, business intelligence/analytics and artificial intelligence/machine learning can be harnessed to increase value for patients, referring physicians, radiology faculty and radiology staff. Examples of using each to increase value in all three missions of an academic radiology department – clinical, research and education – will be presented.

Cancer is caused by genetic (DNA) and epigenetic alterations and frequently arises as a clonal growth from a founder cell. Mutations that occur during the primary tumor cell growth also promote branched evolution into subclones resulting in a dramatic increase in genetic tumor heterogeneity in tumors including ovarian cancer. How much subclonal heterogeneity exists in the primary tumor may not be important because primary tumors are often surgically removed, however this subclonal heterogeneity provides the basis for inter-metastatic heterogeneity which is of utmost clinical importance. New tumor sampling techniques and circulating tumor DNA methods may allow for more comprehensive evaluation of clonal composition. As both primary tumors and metastatic lesions are spatially and temporally heterogeneous they would require multiple biopsies to extract and analyze small portions of tumor tissue, which still doesn’t allow for a complete characterization of the tumor genomic landscape. Therefore, imaging has great potential for a comprehensive evaluation of the entire tumor burden as it is noninvasive and is already often repeated during treatment in routine practice, on the contrary of genomics or proteomics, which are still challenging to implement into clinical routine. While initial retrospective studies linking phenotype with genotype in ovarian cancer have shown high prognostic power they do not provide any spatial information as quantitative imaging features are generated and averaged over the entire tumor assuming that tumors are heterogeneous but well mixed. This approach ignores spatial heterogeneity readily apparent on imaging. Indeed recent genomics work has highlighted the presence of intratumor variation in gene mutation and expression. However little effort is any has been put into integrating imaging, histopathology and genomics and thus there is a clear need for well designed prospective studies focused on meaningful integration of phenotype and genotype rather than genomics in isolation.

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Dramatic developments in the Imaging Sciences as well as fields such as pathology, "omics" and information technology suggest that creation of a multi-disciplinary, multi-dimensional Diagnostic Cockpit of the Future is within sight. Opportunities and challenges exist to make this Cockpit a practical reality. This presentation will highlight the progress made and the obstacles still to be overcome to create this vision of the future.

We believe that in an ideal future state, Diagnostic Radiologists will work intensively with Pathologists and other Molecular Diagnostic professionals in a ‘Cockpit’ in order to generate reports to referring physicians that combine quantitative information from all these fields and combine them in a rational and actionable way.

We also believe that in an ideal future state, lnterventional Radiologists will work intensively with surgeons, cardiologists and other interventional physicians to create a robust set of proced ural tools that can facilitate image-guided retrieval of tissue for precision diagnosis, and can also develop tools for minimally invasive, image-guided therapies.