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

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non cardiovascular findings on cmr

A major teaching hospital of Harvard Medical School

Non-Cardiovascular Findings on CMR

Marty Smith M.D.

Instructor in Radiology

Beth Israel Deaconess Medical Center

Harvard Medical School

Boston, MA

objectives
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
what is covered
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
what is covered1
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
background non cardiac findings
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
non cardiac findings
Non-Cardiac Findings

Of 108 pts.

Dewey at al. Eur Radiol 2007

Conclusion: Incidental NCF are common; images should be analyzed by radiologists to ensure findings not missed & unnecessary follow-up avoided.

non cardiac findings on cardiac ct
Non-Cardiac Findings on Cardiac CT
  • Cardiac MDCT in 503 pts1
    • 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 (12 > 1cm), 8 aortic,17 pleural effs
  • Cardiac MDCT in 166 pts, suspected CAD2
    • NCF in 41 pts (24.7%), major (4.8%)
  • EBCT in 1326 pts for coronary Ca2+ scoring3
    • NCF requiring f/u in 103 pts (7.8%)
  • EBCT in 1812 consecutive pts4
    • NCF in 630 (35%); 50 (2.8%) f/u imaging
  • Summary for CT:
  • NCF in 24-58%
  • NCF needing f/u in 2-23%
  • Classification criteria variable

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

bidmc cmr experience part i
BIDMC CMR Experience – Part I
  • 1534 clinical CMR reports reviewed 2002-061
  • 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

bidmc cmr experience part ii
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
results ncf prevalence
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)

results ncf detection f u
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

known follow up
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)
results radiologist s presence
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)
results sequences
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)
cmr sequence overview
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
ffe scouts
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
tse t1
TSE T1
  • True T1-weighted sequence with IR blood suppression
    • Bright – fat, hemorrhage, protein, some flow, some Ca2+
    • Dark – Simple fluid, most Ca2+, 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
ffe tse t1
FFE & TSE T1
  • Most commonly see lesions on T1 & FFE

Fat, Hemorrhage

Hemorrhage, Protein

Soft Tissue

Cyst

other t1 weighted sequences
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
t2 weighted imaging
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
big picture
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
big picture1
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)
mediastinum diversion
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
cross sectional mediastinum
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
lymph nodes
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
    • Ca2+ – Granulomatous infxn, sarcoid; treated lymphoma
thyroid lesions
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
thymus thymic masses
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
foregut cysts
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
germ cell tumors
Germ Cell Tumors
  • Anterior Mediastinal Mass (prevascular)
  • More in young adults; 80% benign
  • Teratomas
    • All germinal layers
    • Cysts, fat (Fat-fluid levels), Ca2+, soft tissue
  • Seminomas
    • Men; most common malignant GCT; homogeneous
  • Nonseminomatous GCT
    • Rare, heterogeneous
hernias
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
esophagus
Esophagus
  • Thickening
    • Esophagitis, Barrett’s, cancer
  • Mass
    • Leiomyoma, lipoma, cancer
paravertebral region
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
slide51

Vertebral

Hemangioma

lungs
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)
pleura
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
chest wall
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
breasts
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
liver
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) – Most common mass
    • Primary Malignancies – HCC and Cholangio Ca
    • Metastases – Colon, Gastric, Pancreaticobiliary, Lung, Breast, Melanoma
  • Diffuse Dz – Cirrhosis, Fatty, Hemachromatosis
slide73

Cirrhosis

Hemosiderosis

Hemochromatosis

gall bladder
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
kidney
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
slide80

Sag Left

Sag Right

spleen
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
final thoughts
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
references
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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