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Non-Cardiovascular Findings on CMR Marty Smith M.D. Instructor in Radiology Beth Israel Deaconess Medical Center Harvard Medical School Boston, MA A major.

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Presentation on theme: "Non-Cardiovascular Findings on CMR Marty Smith M.D. Instructor in Radiology Beth Israel Deaconess Medical Center Harvard Medical School Boston, MA A major."— Presentation transcript:

1 Non-Cardiovascular Findings on CMR Marty Smith M.D. Instructor in Radiology Beth Israel Deaconess Medical Center Harvard Medical School Boston, MA A major teaching hospital of Harvard Medical School

2 Objectives Review data for incidental non- cardiovascular findings (NCF) in cross- sectional cardiac imaging Approach to non-cardiovascular structures on CMR imaging Overview of common lesions and their expected appearance on CMR

3 What is covered? Imaged volume – Base of Neck → Kidneys Base of Neck - Thyroid, parathyroid, trachea, esophagus, muscles, vertebral bodies, lymph nodes, nerves, fat Thorax  Thyroid  Mediastinum – thymus, trachea & bronchi, esophagus, vertebral bodies, spinal canal, lymph nodes, nerves, fat  Lungs and pleura  Chest wall – bones, muscles, lymph nodes, nerves, fat  Breasts  Diaphragm

4 What is covered? Abdomen  Liver  Gall bladder and bile ducts  Pancreas  Kidneys  Adrenal Glands  Spleen  Stomach  Bowel and Mesentery  Vertebral column, nerves, spinal canal, paravertebral musculature, fat, fascia, & lymph nodes

5 Background: Non-Cardiac Findings Dewey M, et al. Non-cardiac findings on coronary computed tomography and magnetic resonance imaging. Eur Radiol 2007 Feb 1; [Epub ahead of print]. 108 consecutive patients suspected of having CAD who had CTA & MRA Significant NCF → clinical or radiology F/U CT – 5 (5%) significant non-cardiac findings  PE, pleural effusion, sarcoid, HH, & pulmonary nodule MRI – 2 (2%) significant non-cardiac findings  Pleural effusion & sarcoid – both seen on CT

6 Non-Cardiac Findings Conclusion: Incidental NCF are common; images should be analyzed by radiologists to ensure findings not missed & unnecessary follow-up avoided. Dewey at al. Eur Radiol 2007 Of 108 pts.

7 Non-Cardiac Findings on Cardiac CT Cardiac MDCT in 503 pts 1  346 new NCF in 292 pts (58.1%)  114 pts (22.7%) had clinically significant findings  4 cases of malignancy (0.8%).  49 lung nodules 1cm), 8 aortic,17 pleural effs Cardiac MDCT in 166 pts, suspected CAD 2  NCF in 41 pts (24.7%), major (4.8%) EBCT in 1326 pts for coronary Ca 2+ scoring 3  NCF requiring f/u in 103 pts (7.8%) EBCT in 1812 consecutive pts 4  NCF in 630 (35%); 50 (2.8%) f/u imaging 1 Onuma Y, et al. J Am Coll Cardiol 2006 2 Haller S, et al. AJR Am J Roentgenol; 2006 3 Horton KM, et al. Circulation 2002 4 Hunold P, et al. Eur Heart J 2001 Summary for CT: NCF in 24-58% NCF needing f/u in 2-23% Classification criteria variable

8 BIDMC CMR Experience – Part I 1534 clinical CMR reports reviewed 2002-06 1 129 NCF in 116 (8.2%) studies  55 “major” findings in 50 (3.3%) studies  lymphadenopathy - 22 (1.4%)  lung abnormalities - 19 (1.2%)  mediastinal masses - 6 (0.4%)  breast lesions - 4 (0.3%), ascites - 3 (0.2%), soft tissue masses - 1 (0.1%)  74 “minor” findings in 70 (4.6%) studies  pleural effusions, liver lesions, renal cysts, HH, diaphragmatic abnormalities, splenic abnormalities, paraspinal lipomas, & anomalous vasculature NCF mean age 54 vs 49 w/o (p <0.001) 1 Chan PG, etal. JACC 2009

9 BIDMC CMR Experience – Part II 495 clinical CMR exams in 2006 reviewed for NCF by radiologist w/o prior readings NCF classification  Benign (gynecomastia, simple cyst)  Indeterminate (pleural effusion, liver & renal lesions)  Worrisome (lung nodules) Follow-up of indeterminate & worrisome NCF using Careweb  New vs known abnormality  What follow-up performed

10 Results: NCF Prevalence 295 NCF in 212 / 495 (43%) studies  144 Benign:123 / 495(25%) studies  137 Indeterminate: 105 / 495 (21%) studies  14 Worrisome: 14 / 495 ( 3%) studies Benign:Gynecomastia (41), HH (22), Renal Cyst (17), Liver cyst/hemangioma (16), Scoliosis (11), Mediastinal LAN <1.5 cm (10), Other (27) Indeterminate:Pleural effusion (29), Renal lesion (27), Atelectasis (11), Mediastinal LAN >1.5 cm (11), Lung consolidation (7), Big HH (6), Liver lesion (6), Other (40) Worrisome:Lung nodules (11), Aortic dissection (1), Aortic ulcer (1), Mediastinal mass (1)

11 Results: NCF Detection & F/U 105 / 295 (36%) NCF listed in clinical report  Benign (21%), Indeterminate (50%), Worrisome (50%) 11 NCF in reports missed by reviewer 65 NCF in 52 pts needed f/u → performed on 25 (38%)* Of NCF reported, 22 needed f/u → performed on 12 (55%)** * No online medical record information currently available for pts with 16 findings ** No online medical record information currently available for pts with 7 findings

12 Known Follow-up Management changing findings in 11 pts: Lung cancer (2) Pulmonary nodule requiring further follow-up (2) Typical pulmonary carcinoid Cryptogenic organizing pneumonitis (COP) Multifocal pneumonia secondary to newly diagnosed AML Mediastinal lymphadenopathy requiring further follow-up Breast implant rupture Obstructed atrophic kidney New AAA (previously repaired but with recurrence)

13 Results: Radiologist’s Presence Radiologist at joint read-out – 384/495 (78%) scans 42% (95/228) of NCF reported when radiologist at joint readout 15% (10/67) of NCF reported when radiologist read remotely (p<0.01)

14 Results: Sequences Scouts showed NCF 186/295 (63%) T1W FSE showed NCF 176/295 (60%) Only 12 (4%) NCF not visualized on one of these sequences  10 benign, 2 indeterminate)

15 CMR Sequences

16 CMR Sequence Overview Abdomen & base of neck  FFE scouts  Limited coverage by other sequences Thorax – Potentially all sequences  Most → T1-w TSE, FFE scouts, B-FFE cines  Other T1-w imaging  T1-w TSE FS  Post gado T1-w TSE, T1-w IR GRE, T1-w SPGR  T2-w imaging  T2-w TSE dark blood  Fat suppressed T2-w → SPIR, STIR

17 FFE Scouts Limited soft tissue lesion detection & characterization Large inter-slice gap, low resolution Contrast based on T2/T1 ratio  Bright = Fluid or fat  Not bright = Soft tissue, some complex fluid Motion insensitive  Shape & margin with well defined lesions  Internal structures of cysts B-FFE and TFE similar for NC lesions

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20 TSE T1 True T1-weighted sequence with IR blood suppression  Bright – fat, hemorrhage, protein, some flow, some Ca 2+  Dark – Simple fluid, most Ca 2+, air  In-between – most masses Cover from top of liver to above arch  Excellent for anatomy  Best look at mediastinum, breasts, chest wall, lungs Navigator problematic around diaphragm More helpful when combined with T1 FS

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22 FFE & TSE T1 FFE T1T1 BrightNot Bright Bright Not Bright Most commonly see lesions on T1 & FFE Fat, Hemorrhage Hemorrhage, Protein Cyst Soft Tissue

23 Other T1 Weighted Sequences T1-w TSE with fat saturation  Identify fatty lesions definitively  Increased conspicuity of T1 bright lesions Post gadolinium – Tissues vs fluids (inflammation, atelectasis, infarcts)  T1-w TSE → less conspicuity of enhancement  T1-w FS SPGR → usu. early; best for enhancement  T1-w IR GRE → Delayed; caveat of IR  Subtractions helpful for intrinsic T1 bright lesions

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25 T2 Weighted Imaging T2-w TSE – True T2-w sequence STIR –T1-w & T2-w; good fat suppression SPIR – True T2-w; less homogeneous fat suppression Bright on FFE & T2-w TSE  Cysts, hemangiomas, fat, some hemorrhage Mildly bright on T2-w TSE → Usu. concerning Increased brightness with SPIR, STIR  Fibrous tumors (eg, breast ca) still dark

26 T2-w TSE SPIR

27 Big Picture Brighter lesion on FFE, T1-w TSE, or T2-w TSE → More likely it’s benign  Look for subtle nodularity, esp. with hemorrhage No gadolinium → f/u imaging or not?  Well seen, sharp margin, homogeneously bright on FFE or T2-w TSE, not bright on T1-w TSE → Benign → Stop  Except breast  Not well seen, irregular margin, heterogeneous, bright on T1(& not fat), not bright on T2-w TSE → f/u imaging Enhancement → Usu. f/u imaging for further characterization or diagnostic procedure

28 Big Picture Need to look separately for NCF Develop a system If you aren’t looking for it, you won’t see it Symmetry is your friend Use cross referencing tools The only thing better than your MR... is an old MR (or CT)

29 Lesions by Location

30 Mediastinum Diversion Old Radiology Anterior Mediastinum – posterior to sternum, anterior to trachea & posterior aspect of heart  thymus, lymph nodes, nerves, fat Middle Mediastinum – b/w anterior & posterior mediastinum  trachea & bronchi, esophagus, lymph nodes, nerves, fat Posterior Mediastinum – b/w posterior chest wall & 1 cm behind anterior margin of vertebral column  vertebral bodies, spinal canal, lymph nodes, nerves, fat

31 Cross Sectional Mediastinum Differential based on tissue where mass arises If not possible, then localize by region  Supraaortic mediastinum (superior mediastinum)  Prevascular space, Anterior cardiophrenic angles  Pretracheal & subcarinal spaces, AP window  Paraesophageal or azygoesophageal recess  Paravertebral Caveat: Be sure it is from the mediastinum  Deep to vessels → Definitely  Broad Base, smooth margin; not spiculated or irregular

32 Lymph Nodes Every site in mediastinum Lymphoma, Mets, Sarcoid, Granulomatous Infxn Pattern can be important  Symmetric bilateral hilar & paratracheal – likely sarcoid  Prevascular nodal mass – Hodgkin’s Lymphoma > NHL  Unilateral hilar +/- paratracheal – Lung > other mets  Posterior mediastinum – Lymphoma (NHL) vs mets  Cardiophrenic angle – Mets vs lymphoma Intermediate T1, bright T2, enhancement  Necrosis – Mets, lymphoma (NHL),Tb, fungus  Ca 2+ – Granulomatous infxn, sarcoid; treated lymphoma

33 Hodgkin’s Lymphoma

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35 Sarcoid

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37 RCC Mets

38 Chloroma

39 Thyroid Lesions Supraaortic Mediastinum  Can extend into prevascular space, around trachea Goiter  Bland Goiter – Low SI T1-wi & intermediate SI T2-wi  Multinodular Goiter – Heterogeneous on T1-wi & T2-wi Thyroid Cancer  Can be invasive, but usually not  Carcinoma in multinodular goiter – 7.5 %  MRI can not definitively differentiate benign & malignant

40 Thymus & Thymic Masses Prevascular Space Normal thymus  Fat proportion increases with age → harder to see  Intermediate on T1-w, bright on T2-w; margins important; interdigitating fat Thymic rebound – stress (chemo, burns) Thymoma – # 1 adult 1° mediastinal tumor  Variable; homogeneous, cystic, nodules; invasion Thymolipoma; thymic cyst, carcinoma, carcinoid; lymphoma, mets

41 Normal Thymus

42 T1-w TSE SPIR

43 Foregut Cysts Bronchogenic – Most common  Any location – 50% subcarinal, 20% paratracheal  Rounded, smooth, sharply defined (imperctible wall)  Fluid contents variable Pericardial  90% touch diaphragm, 65%R 35%L cardiophrenic angle  Usually simple fluid, sometimes hemorrhage Esophageal duplication Neurenteric  Associated vertebral anomaly

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46 Germ Cell Tumors Anterior Mediastinal Mass (prevascular) More in young adults; 80% benign Teratomas  All germinal layers  Cysts, fat (Fat-fluid levels), Ca 2+, soft tissue Seminomas  Men; most common malignant GCT; homogeneous Nonseminomatous GCT  Rare, heterogeneous

47 Hernias Hiatal  Sliding (most common), Paraesophageal, Mixed Bochdalek  Posterolateral and left more common  Retroperitoneal fat, rarely kidney or liver Morgagni  Anteromedial  Omental fat (Pseudomass), Transverse Colon Traumatic Diaphragmatic  Small at inception → grow latently

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49 Esophagus Thickening  Esophagitis, Barrett’s, cancer Mass  Leiomyoma, lipoma, cancer

50 Paravertebral Region Neurogenic Tumors  Nerve Sheath (Schwannomas), sypmathetic ganglia tumors, paragangliomas  Commonly bright on T2, avidly enhancing Thoracic Spine abnormalities  Fractures, Malalignment, DDD, Hemangiomas, Tumors Meningoceles and nerve sleeve cysts Extramedullary hematopoesis  Multiple bilateral paravertebral tumors, hyperenhance Nodes are still most common

51 Vertebral Hemangioma

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53 Lungs All new nodules & masses* need Chest CT  Lung cancer can be round, spiculated, infiltrative  Multiple – Mets, granulomatous dz, sarcoid, septic emboli Atelectasis  common dependently; should enhance  Non-dependent consolidation → obstruction, other cause Pneumonia  Non-dependent or patchy, filled airways, Hypoenhancement Pulmonary Edema  Usu. symmetric; Sometimes difficult to diff from pneumonia Pulmonary Infarcts  Peripheral wedge shaped, hypoenhancement & necrosis Fibrosis (sarcoid, XRT, CTD, Amiodarone)

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56 Carcinoid

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58 LLL Pneumonia & Right Effusion

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61 Pulmonary Infarct

62 Pleura Pleural effusions  Simple vs exudative vs hemorrhagic  Associated pleural thickening and enhancement  Loculation, empyema Plaques - Asbestos Masses  Metastases – Lung, Breast  Usually associated with effusion  Fibrous Tumors of the Pleura  Malignant Mesothelioma

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65 Chest Wall Bones  Metastases  Primary Benign > Primary Malignant Fat  Lipoma, Low Grade Liposarcoma Muscle  Atrophy, Edema  Intramuscular Lipomas  Mets > Sarcomas Subcutaneous and Dermis  Sebaceous cysts most common

66 Intramuscular Lipoma

67 Breasts Simple Cysts  Must be FFE +/- T2 Bright and T1 dark, no enhancement → still confirm with Ultrasound Proteinaceous / Hemorrhagic Cysts → US Fibroadenoma  Well circumscribed, T1 dark, usu. T2 bright, progressive enhancement → mammogram & US Breast Cancer  Not always spiculated; also can be in cysts  T1 dark and usu. TSE T2 dark, mildly bright STIR/SPIR  Variable enhancement, but usu peak 90-180 sec.  Any concern → Mammogram & US +/- MRI Only Fat containing lesions do not need workup

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69 Liver Cysts – most common  Smooth margin, round or oval, bright FFE +/- T2, dark T1, no enhancement → Benign  Other than thin septation, any complexity → F/U MRI Hemangiomas – second most  Similar to cyst in shape & on FFE, T1, T2, but enhance  Flash fill or peripheral discontinuous → filling centripetally Any non cyst-like lesion → f/u MRI  Focal Nodular Hyperplasia (FNH) – M ost common mass  Primary Malignancies – HCC and Cholangio Ca  Metastases – Colon, Gastric, Pancreaticobiliary, Lung, Breast, Melanoma Diffuse Dz – Cirrhosis, Fatty, Hemachromatosis

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72 RCC Mets

73 Hemochromatosis Cirrhosis Hemosiderosis

74 Gall Bladder Gall Stones – very common  Round or faceted filling defects in GB  Usu. dark on all sequences; can be bright on T1-w Polyps – common  Hard to diff. from adherent gall stones w/o contrast Adenomyomatosis – common  Usu. Fundal, wall thickening, can have T2-bright foci GB wall edema – uncommon  Usu. liver dysfxn; if not T2-bright ? Chronic cholecystitis GB Cancer – rare  Any GB mass requires work-up

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76 Kidney Cysts – most common  Smooth margin, round or oval, bright FFE +/- T2, dark T1, no enhancement → Benign  Other than thin septation, any complexity → F/U  If hemorrhagic or clearly nodules → MRI Masses  All potential masses (heterogeneous, not bright FFE or T2, not dark T1) need F/U  Renal Cell > Transitional Cell Hydronephrosis – Partial or Complete Renal Atrophy, Agenesis

77 Parapelvic Cyst

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80 Sag Right Sag Left

81 Spleen Splenomegaly, Splenules, No spleen - Common Hemangiomas  Just like liver for the most part False Cysts  Post traumatic or infarct  Can be hemorrhagic and calcify Epithelial Cysts, Lymphangioma -rare Metastases – uncommon

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83 Splenectomy post trauma  Splenosis

84 Splenic Cyst – Rim Calcification

85 Final Thoughts Surprising  No Adrenal Lesions  No Pancreatic cysts or lesions  No upper abdominal nodes  No real bone lesions Not surprising  No bowel or stomach lesions (motion)  No mesenteric masses  Minimal unknown cancers

86 References Chan PG, Rofsky NM, Yeon SB, Hauser TH, Appelbaum E, Smith MP, Manning WJ. Non-cardiac pathology on clinical cardiac magnetic resonance imaging. Accepted for publication in JACC Cardiovascular Imaging 2009. Dewey M, Schnapauff D, Teige F, Hamm B. Non-cardiac findings on coronary computed tomography and magnetic resonance imaging. Eur Radiol 2007 Feb 1; [Epub ahead of print]. Onuma Y, Tanabe K, Nakazawa G et al. Noncardiac findings in cardiac imaging with multidetector computed tomography. J Am Coll Cardiol 2006; 48:402–406. Haller S, Kaiser C, Buser P, Bongartz G, Bremerich J. Coronary artery imaging with contrast-enhanced MDCT: extracardiac findings. AJR Am J Roentgenol; 2006; 187:105–110 Horton KM, Post WS, Blumenthal RS, Fishman EK. Prevalence of significant noncardiac findings on electron-beam computed tomography coronary artery calcium screening examinations. Circulation 2002; 106:532–534 Hunold P, Schmermund A, Seibel RM, Gronemeyer DH, Erbel R. Prevalence and clinical significance of accidental findings in electron- beam tomographic scans for coronary artery calcification. Eur Heart J 2001; 22:1748–1758


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