Workshop esgar zech 1 pdf

ESGAR Annual Meeting 12 – 15 June 2009 in Lisbon Workshop LIVER IMAGING Meet the Expert WS 15 THURSDAY, JUNE 15th, 2007 C.J Zech, Munich/DE R Hammerstingl, Frankfurt/DE Christoph J Zech, M.D Institute of Clinical Radiology (Chair: Prof Dr Dr M Reiser) Munich University Hospitals - Grosshadern CJ Zech • What CT protocol you advice for detection of hypovascular liver metastases? • When you calculate the largest diameter of a metastasis to apply the RECIST criteria should we include the peritumoral rim enhancement when it exists? • Do you think that there are advantages to perform volumetric measurement of metastasis CJ Zech rather than the largest diameter when evaluating chemotherapy efficacy? Protocol 16-ROW MDCT Collimation kV mA Slice thickness Kernel Contrast 4-ROW MDCT 2,5 / mm 120 165 B40f 1.5-2 ml / kg KG @ 4-6 ml/s Bolus tracking Delay (after reaching 100 HU) automatic 15 sec 0,75 mm (0,4 for S64) 120 165 / (art /p.v.) B40f 1.5-2 ml / kg KG @ 4-6 ml/s automatic 15 sec Spatial Resolution MDCT vs MRT 64-Zeilen MDCT Koll 0.4mm T1w 3D GRE (VIBE) @3T mm mm mm CJ Zech Which Phases ??? Phase Delay after 100 HU in Aorta: sec Early-Arterial Late-arterial – 15 sec portalvenous Inflow portalvenous / venous phase CJ Zech ca 50-60 sec Metastasis of Breast –Ca ??? T1 opp CJ Zech T1 art Gd SPIO Report CT: Report MRI: „newly developed „benign lesion in lesion, highly marked steatosis suspicious of hepatis, most likely an CJ Zech Size can differ between modalities ! Perilesional Enhancement ≠ Tumor CJ Zech Therapy Monitoring / RECIST The size of the lung lesion appears different … The same windows should be used on subsequent examinations to measure any lesions As a rule of thumb, the minimum size of the lesion should be no less than double the slice thickness Lesions smaller than this are subject… CJ Zech Advantages: Disadvantages: • easy and fast • pragmatically adequate tools • very crude method of evaluation that satisfy a noncritical role relative to clinical outcome lesion size differs with • widely accepted and known well evaluated and validated • high interobserver variability • in many trials • different imaging techniques changes of tumor / tissue quality (necrosis, calcification, decreased CM-uptake…) are • Efforts to develop reproducible methods for measuring volumes of not addressed infiltrative tumors that lack clear margins, already recognized as a serious problem for linear and two-dimensional area CJ Zech measurement, lie at the heart of the challenge Examination Protocol Gd-BOPTA bolus injection recommended dose: 0.05-0.1mmol /kg liver-specific phase arterial, portal-venous MRCP equilibrium T1w pre ~ 10 CJ Zech T2w + Re- dynamic schedule studies patient ~ 4-5 ~40-60 t • In a cirrhotic patient when a good quality dynamic imaging is still in doubt for the diagnosis of an HCC nodule what further actions you advise? Image-guided biopsy? Imaging follow-up? What criteria should we apply to differentiate a regenerative/dysplastic nodule from overt HCC? What imaging modalities you recommend or omit? • CJ Zech CJ Zech Very Small Liver Nodule (1cm) SPIO (Resovist) Arterial phase MDCT Characterization doubtful !!! mo F/U recommended Gadolinium CJ Zech Small Liver Nodule ( 2cm If AFP > 200 CJ Zech Diagnosis of HCC established Matsui O Imaging of multistep human hepatocarcinogenesis by CJ Zech CTAP Intervirology 2004;47(3-5):271-6 Advantage MRI – Liver Specific Contrast Agents suspicion of HCC T1 arterial Gd CJ Zech CT arterial .turns into regenerative nodule post Resovist Advantage CT - No Artifacts T2 T1 Gd art CJ Zech CJ Zech T2 FSE fs pre and 10 minutes post Resovist with same TR /TE Measure signal intenities in ROIs Divide SI CJ Zech post / SI pre x 100 = PSIL Radiology 2000 Jul;216:154-62 ROC values grey: native MRT CJ Zech black: SPIO alone white: SPIO & Gd Hypovascular Diffuse HCC – MRI helps for Imaging Guided Biopsy CT arterial T2* Resovist CJ Zech T1 arterial Gd Diagnostic Procedures in HCC • Very small lesions (< 1cm) Follow up recommended Imaging techniques are not sufficient to differentiate between dysplastic nodules or HCC in lesions < 1cm • Small lesions (1-2 cm) typical vascular pattern in modalities = HCC atypical vascular pattern = biopsy according to EASL guidelines (but biopsy of small lesions also difficult) MRI with recent scanners and SPIO / Gd – enhanced MRI can be helpful for differentiation Consider TACE and Lipiodol-CT • Large lesions (> 2cm) typical vascular pattern on dynamic imaging (eg CT, MRI or angiography) CJ Zech or AFP values over 200 ng /ml ... T2 T1 Gd art CJ Zech CJ Zech T2 FSE fs pre and 10 minutes post Resovist with same TR /TE Measure signal intenities in ROIs Divide SI CJ Zech post / SI pre x 10 0 = PSIL Radiology 2000 Jul; 216 :15 4-62... reaching 10 0 HU) automatic 15 sec 0,75 mm (0,4 for S64) 12 0 16 5 / (art /p.v.) B40f 1. 5-2 ml / kg KG @ 4-6 ml/s automatic 15 sec Spatial Resolution MDCT vs MRT 64-Zeilen MDCT Koll 0.4mm T1w 3D GRE... portal-venous T1w pre T2w + MRCP dynamic studies ~ 10 CJ Zech ~ 4-5 Hirohashi S et al., ISMRM 2003 ~ 5 -10 min ~15 t Examination Protocol Gd-BOPTA bolus injection recommended dose: 0.05-0.1mmol /kg