Faculty Bibliography

von Hippel-Lindau (VHL) disease is an autosomal-dominant, hereditary, multisystem neoplasia syndrome with increased susceptibility to several benign and malignant tumors. VHL occurs in about 1 in 36,000 live births and is associated with germline mutation of the VHL tumor suppressor gene on the short arm of chromosome 3. VHL disease exhibits diverse genotype and phenotype correlations, exhibits variable intrafamilial and interfamilial expressivity, and can manifest with benign and malignant tumors of the central nervous system, kidneys, adrenals, pancreas, and reproductive organs. Imaging and management of this entity are therefore multidisciplinary. An overview of VHL disease is presented.

OBJECTIVE: The purpose of this study was to determine whether qualitative and quantitative MRI feature analysis is useful for differentiating type 1 from type 2 papillary renal cell carcinoma (PRCC). MATERIALS AND METHODS: This retrospective study included 21 type 1 and 17 type 2 PRCCs evaluated with preoperative MRI. Two radiologists independently evaluated various qualitative features, including signal intensity, heterogeneity, and margin. For the quantitative analysis, a radiology fellow and a medical student independently drew 3D volumes of interest over the entire tumor on T2-weighted HASTE images, apparent diffusion coefficient parametric maps, and nephrographic phase contrast-enhanced MR images to derive first-order texture metrics. Qualitative and quantitative features were compared between the groups. RESULTS: For both readers, qualitative features with greater frequency in type 2 PRCC included heterogeneous enhancement, indistinct margin, and T2 heterogeneity (all, p < 0.035). Indistinct margins and heterogeneous enhancement were independent predictors (AUC, 0.822). Quantitative analysis revealed that apparent diffusion coefficient, HASTE, and contrast-enhanced entropy were greater in type 2 PRCC (p < 0.05; AUC, 0.682-0.716). A combined quantitative and qualitative model had an AUC of 0.859. Qualitative features within the model had interreader concordance of 84-95%, and the quantitative data had intraclass coefficients of 0.873-0.961. CONCLUSION: Qualitative and quantitative features can help discriminate between type 1 and type 2 PRCC. Quantitative analysis may capture useful information that complements the qualitative appearance while benefiting from high interobserver agreement.

PURPOSE: To develop a novel framework for free-breathing MRI called XD-GRASP, which sorts dynamic data into extra motion-state dimensions using the self-navigation properties of radial imaging and reconstructs the multidimensional dataset using compressed sensing. METHODS: Radial k-space data are continuously acquired using the golden-angle sampling scheme and sorted into multiple motion-states based on respiratory and/or cardiac motion signals derived directly from the data. The resulting undersampled multidimensional dataset is reconstructed using a compressed sensing approach that exploits sparsity along the new dynamic dimensions. The performance of XD-GRASP is demonstrated for free-breathing three-dimensional (3D) abdominal imaging, two-dimensional (2D) cardiac cine imaging and 3D dynamic contrast-enhanced (DCE) MRI of the liver, comparing against reconstructions without motion sorting in both healthy volunteers and patients. RESULTS: XD-GRASP separates respiratory motion from cardiac motion in cardiac imaging, and respiratory motion from contrast enhancement in liver DCE-MRI, which improves image quality and reduces motion-blurring artifacts. CONCLUSION: XD-GRASP represents a new use of sparsity for motion compensation and a novel way to handle motions in the context of a continuous acquisition paradigm. Instead of removing or correcting motion, extra motion-state dimensions are reconstructed, which improves image quality and also offers new physiological information of potential clinical value. Magn Reson Med, 2015. (c) 2015 Wiley Periodicals, Inc.

PURPOSE: To assess outcomes of lung nodules missed on simultaneous positron emission tomography and magnetic resonance imaging (PET/MRI) compared to the reference standard PET and computed tomography (PET/CT) in patients with primary malignancy. MATERIALS AND METHODS: In all, 208 patients with primary malignancy undergoing clinically indicated (18 F) fluorodeoxyglucose (FDG) PET/CT followed by PET/MRI were independently reviewed by two readers. Upon review of the thoracic station on PET/MRI and PET/CT, 89 non-FDG avid small lung nodules in 43 patients were detected (by reader 1) only on the CT component of the PET/CT but were not identified on PET/MRI. Overall, 84 of these 89 nodules were examined on follow-up imaging with PET/CT or chest CT. The remaining five nodules had no follow-up imaging but had remote imaging available for comparison. RESULTS: Among the 84 nodules with follow-up, three nodules (3%) in one patient progressed, 10 (12%) nodules partially/completely resolved, whereas 71 nodules (85%) remained stable. The five nodules without follow-up were all stable since prior imaging of over 21 months. CONCLUSION: The vast majority (97%) of small non-FDG avid lung nodules missed on PET/MRI either resolved or remained stable on follow-up, suggestive of benignity. PET/MRI remains a viable alternative imaging modality in oncology patients, despite its low sensitivity in detecting small lung nodules. J. Magn. Reson. Imaging 2015.

OBJECTIVE: This review article explores recent advancements in PET/MRI for clinical oncologic imaging. CONCLUSION: Radiologists should understand the technical considerations that have made PET/MRI feasible within clinical workflows, the role of PET tracers for imaging various molecular targets in oncology, and advantages of hybrid PET/MRI compared with PET/CT. To facilitate this understanding, we discuss clinical examples (including gliomas, breast cancer, bone metastases, prostate cancer, bladder cancer, gynecologic malignancy, and lymphoma) as well as future directions, challenges, and areas for continued technical optimization for PET/MRI.

Dynamic contrast enhanced (DCE) MRI has emerged as a reliable and diagnostically useful functional imaging technique. DCE protocol typically lasts 3-15 minutes and results in a time series of N volumes. For automated analysis, it is important that volumes acquired at different times be spatially coregistered. We have recently introduced a novel 4D, or volume time series, coregistration tool based on a user-specified target volume of interest (VOI). However, the relationship between coregistration accuracy and target VOI size has not been investigated. In this study, coregistration accuracy was quantitatively measured using various sized target VOIs. Coregistration of 10 DCE-MRI mouse head image sets were performed with various sized VOIs targeting the mouse brain. Accuracy was quantified by measures based on the union and standard deviation of the coregistered volume time series. Coregistration accuracy was determined to improve rapidly as the size of the VOI increased and approached the approximate volume of the target (mouse brain). Further inflation of the VOI beyond the volume of the target (mouse brain) only marginally improved coregistration accuracy. The CPU time needed to accomplish coregistration is a linear function of N that varied gradually with VOI size. From the results of this study, we recommend the optimal size of the VOI to be slightly overinclusive, approximately by 5 voxels, of the target for computationally efficient and accurate coregistration.

Small renal masses are increasingly diagnosed incidentally. This results in management dilemma because numbers of small renal masses are either benign tumours such as angiomyolipoma (AML) or oncocytoma, or are neoplasms with indolent behavior [1]. Surgical treatments although provide excellent oncologic control is associated with development and worsening of renal insufficiency and associated cardiovascular morbidity [2]. Therefore, ability to non-invasively investigate renal tumor histopathology and aggressiveness can guide treatment decision and lower treatment cost. Within this paradigm, the role of radiologist and imaging is evolving to predicting aggressiveness and biology of the tumor as well as providing operative guidance. MR imaging can play a very important role not only as a problem solving tool, but can provide deeper insight into tumour biology through techniques such as diffusion weighted imaging (DWI) and perfusion weighted imaging (PWI). Number of key observations highlighting the role of MR including advance imaging techniques in evaluation of renal masses is as listed below: 1. Differentiating benign renal masses from malignant tumour. - There is some controversy regarding the role of signal loss on opposed phase chemical shift imaging in discriminating AML from RCC [3,4]. - Lipid poor AML tend to have uniform low T2 signal, uniform enhancement without evidence for necrosis, and restricted diffusion [5,6]. - There is overlap in the morphologic features of Oncocytoma and RCC on conventional imaging [7, 8]. Pilot data suggests that DWI and PWI may have a role in discriminating these benign renal tumours. 2. Histologic subtyping R

Positron emission tomography (PET) and magnetic resonance (MR) imaging until recently has been performed by separate PET and MR devices with temporal delay between these two acquisitions. However, various recent hardware solutions have been developed by different vendors which permit simultaneous or near simultaneous PET and MR acquisition. However, the clinical translation of this modality for oncologic imaging requires not only identifying the appropriate clinical indications, but also understanding various components involved in establishing a PET/ MR service which include physical installation of the system, equipment safety, clinical workflow, technician and physician training, and monetary reimbursement. The current and potential clinical indications for imaging of metastatic disease can be broadly classified as follows: (1). Simultaneous local and distant staging of cancers such as rectal cancer and gynecologic malignancies. Here high spatial resolution of MRI provides information about local extent of the disease and PET is used predominantly for distant staging. (2). Problem solving for potential metastatic disease such as for small liver lesions, small lymph nodes, or bone marrow involvement. Additional information provided by MRI and PET can better characterize lesions and improve confidence in diagnosing presence or absence of metastatic disease. (3). Assessment of treatment response. Use of quantitative MR and PET information can potentially provide synergistic information in assessing treatment response. To address these clinical need there are number of operational considerations such as: (1). Protocol optimisation. (2). Workflow in scanning and interpretation of studies. Some of the technical challenges and limitations that need to be considered include: (1). Limitation of MRI for lung lesion detection. (2). Attenuation correction. (3). Registration of free-breathing PET and breath-hold thoacoabdominal MR data. While FDG PET/CT remains the workhorse for diagnosis and management of oncologic diseases, early experience shows that PET/MR may have a complementary role. PET/MR could potentially play a significant role in diagnosis and management algorithms of several malignancies