The utility of time resolved magnetic resonance angiography in differentiating vascular malformations.

PURPOSE: The objective is to show that TR-MRA is a useful non-invasive technique without ionizing radiation of traditional angiography in evaluating VMs. MATERIALS AND METHODS: Retrospective search utilizing M-Power for MRA studies done at 3 T (Trio, Siemens) with both 3D contrast enhanced TR-MRA and 3D CE-MRA sequences from 2009 to 2018 were obtained after IRB approval. The images were blindly reviewed by two experienced cardiovascular radiologists for informations regarding vascular malformations with the ability to separate arteries and veins without any overlay or contamination in real time. Both TR-MRA and 3D CE-MRA images were carefully evaluated. The following characteristics: flow rate, size, type, feeding vessels, draining vessels and clots were evaluated. The findings were then compared to the Catheter Angiography for the patients that had catheter angiography study. RESULTS: The M-Power search resulted a total of 69 patients (24 males, 45 females, age range 11 days to 74 years). Of those 69, there were 25 patients with confirmatory Catheter Angiography study. The radiologists characterized VMs as 19 high flow VMs, 47 slow flow VMs, 2 lymphatic malformations and 1 no flow VM. Of those with Cath, there was 100% concordance with the TR-MRA. CONCLUSION: TR-MRA provides functional characterization of a VM that cannot be determined with CE-MRA alone. This is critical in treatment planning with high-flow VMs.

Malpositioned Lines and Tubes on Chest Radiograph - A Concise Pictorial Review.

A wide variety of cardiothoracic support devices are used in intensive care units and few of these devices are increasingly being utilized in outpatient settings as well. A meticulous assessment of these lines and tubes by the interpreting radiologist is cardinal since malpositioned lines and tubes can significantly impact the functioning of these devices and may result in potential complications affecting the clinical outcomes. The purpose of this article is to illustrate the normal positioning and malpositioning of the routinely used support lines and tubes identified on chest radiographs.

Intramural Esophageal Abscess Complicated with Pleural Fistula: A Case Report.

Intramural esophageal abscess is a rare entity caused by mucosal injury to the esophagus but without transmural perforation. The mucosal disruption provides access to the intraluminal infectious contents to traverse into the loose submucosal tissue, resulting in an intramural abscess. It is important to be well-versed in the clinical and imaging findings of this pathology in order to make a timely diagnosis. Here, we present a case of intramural esophageal abscess complicated with a pleural fistula with a focus on the radiological features of this rare entity. To our knowledge, this is the first time that an esophageal intramural abscess complicated with pleural fistula is discussed in peer-reviewed literature.

Olfactory neuroblastoma pulmonary metastasis presenting as a solitary pulmonary mass in an adult: A case report with pathologic correlation.

Pulmonary metastasis of an esthesioneuroblastoma is uncommon. In this report, we present a case of an esthesioneuroblastoma pulmonary metastasis in an adult. A 39-year-old man treated with surgical resection of olfactory neuroblastoma was found to have a solitary pulmonary mass on a surveillance computed tomography scan performed 5 years after undergoing primary surgery and radiation treatment. He underwent lobectomy, and histopathology revealed esthesioneuroblastoma metastasis. To our knowledge, no case of esthesioneuroblastoma metastasis presenting as a solitary pulmonary nodule has been described in peer-reviewed literature.

Unusual intravascular complication of right internal jugular vein catheter piercing the SVC into the pericardium: Case report.

Iatrogenic superior vena cava pericardial fistula caused by central venous catheterization is rare but can lead to life-threatening condition. Despite the potential risk of pericardial effusion causing pericardial tamponade, a conservative watch and wait management strategy can be safely adopted if such procedural complication is encountered. Herein, we present a case of an incidental finding of a central venous catheter perforating the wall of the superior vena cava into the pericardium, which probably occurred during injection of intravenous contrast agent on computed tomography pulmonary angiogram study.  .

Dramatic response to alectinib in a lung cancer patient with a novel VKORC1L1-ALK fusion and an acquired ALK T1151K mutation.

ALK-rearranged lung cancer defines a distinctive molecular cohort of patients whose outcomes are significantly improved by the availability of ALK inhibitors. Thus, it is imperative for clinicians to screen appropriate patients for this driver mutation with a molecular testing platform capable of capturing all ALK fusions. Here, we report a novel VKORC1L1-ALK fusion and an ALK T1151K resistance mutation detected in a lung cancer patient who had been on crizotinib for over 8 years. Alectinib induced a dramatic response in this patient demonstrating its clinical activity against T1151K. This case illustrates the importance of performing repeat biopsy to explore mechanism(s) of resistance when patients experience disease progression on an ALK inhibitor. The approach has a direct therapeutic impact particularly when an ALK resistance mutation is identified.

Receptor Tyrosine Kinase Fusions and BRAF Kinase Fusions are Rare but Actionable Resistance Mechanisms to EGFR Tyrosine Kinase Inhibitors.

INTRODUCTION: We analyzed a large set of EGFR-mutated (EGFR+) NSCLC to identify and characterize cases with co-occurring kinase fusions as potential resistance mechanisms to EGFR tyrosine kinase inhibitors (TKIs). METHODS: EGFR+ (del 19, L858R, G719X, S768I, L851Q) NSCLC clinical samples (formalin-fixed paraffin-embedded tumor and blood) were analyzed for the presence of receptor tyrosine kinase (RTK) and BRAF fusions. Treatment history and response were obtained from provided pathology reports and treating clinicians. RESULTS: Clinical samples from 3505 unique EGFR+ NSCLCs were identified from June 2012 to October 2017. A total of 31 EGFR+ cases had concurrent kinase fusions detected: 10 (32%) BRAF, 7 (23%) ALK receptor tyrosine kinase (ALK), 6 (19%) ret proto-oncogene (RET), 6 (19%) fibroblast growth factor receptor 3 (FGFR3), 1 (3.2%) EGFR, and 1 (3.2%) neurotrophic receptor tyrosine kinase 1 (NTRK1), including two novel fusions (SALL2-BRAF and PLEKHA7-ALK). Twenty-seven of 31 patients had either a known history of EGFR+ NSCLC diagnosis or prior treatment with an EGFR TKI before the fusion+ sample was collected. Twelve of the 27 patients had paired pre-treatment samples where the fusion was not present before treatment with an EGFR TKI. Multiple patients treated with combination therapy targeting EGFR and the acquired fusion had clinical benefit, including one patient with osimertinib resistance due to an acquired PLEKHA7-ALK fusion achieving a durable partial response with combination of full-dose osimertinib and alectinib. CONCLUSIONS: RTK and BRAF fusions are rare but potentially druggable resistance mechanisms to EGFR TKIs. Detection of RTK and BRAF fusions should be part of comprehensive profiling panels to determine resistance to EGFR TKIs and direct appropriate combination therapeutic strategies.

What the radiologist needs to know about gastrointestinal endoscopic surgical procedures.

Natural orifice transluminal endoscopic surgery (NOTES) is a novel surgical approach, currently performed for an array of conditions. Endoscopic procedures offer significant benefits, including lower cost, no surgical incisions, and shorter hospital stays. These advantages align with the current trends in health care, namely a push for "cost-effective care." There are a multitude of health issues which are now being addressed by the endoscopic surgical approach, including peroral endoscopic myotomy (POEM), which is a relatively new technique used in the treatment of achalasia. Endoscopic treatment utilized for GERD includes transoral incisionless fundoplication. Endoscopic bariatric surgical procedures include intragastric balloon placement, endoscopic sleeve gastroplasty, and revision of prior bariatric procedures including Roux-en-Y gastric bypass and conventional gastric sleeve procedures. Endoscopic clips are routinely utilized for achieving hemostasis, treating iatrogenic gastric and bowel ulcerations and perforations and for the closure of enteric fistulization. Novel endoscopic procedures are now replacing conventional surgery due to their non-invasive nature, faster recovery and lower healthcare costs. Radiologists need to understand how these procedures are performed, as well as expected post-procedural imaging appearance and potential complications.

Geometric changes of the inferior vena cava in trauma patients subjected to volume resuscitation.

OBJECTIVE: Dynamic changes in anatomic geometry of the inferior vena cava from changes in intravascular volume may cause passive stresses on inferior vena cava filters. In this study, we aim to quantify variability in inferior vena cava dimensions and anatomic orientation to determine how intravascular volume changes may impact complications of inferior vena cava filter placement, such as migration, tilting, perforation, and thrombosis. METHODS: Retrospective computed tomography measurements of major axis, minor axis, and horizontal diameters of the inferior vena cava at 1 and 5 cm below the lowest renal vein in 58 adult trauma patients in pre-resuscitative (hypovolemic) and post-resuscitative (euvolemic) states were assessed in a blinded fashion by two independent readers. Inferior vena cava perimeter, area, and volume were calculated and correlated with caval orientation. RESULTS: Mean volumes of the inferior vena cava segment on pre- and post-resuscitation scans were 9.0 cm(3) and 11.0 cm(3), respectively, with mean percentage increase of 48.6% (P < 0.001). At 1 cm and 5 cm below the lowest renal vein, the inferior vena cava expanded anisotropically, with the minor axis expanding by an average of 48.7% (P < 0.001) and 30.0% (P = 0.01), respectively, while the major axis changed by only 4.2% (P = 0.11) and 6.6% (P = 0.017), respectively. Cross-sectional area and perimeter at 1 cm below the lowest renal vein expanded by 61.6% (P < 0.001) and 10.7% (P < 0.01), respectively. At 5 cm below the lowest renal vein, the expansion of cross-sectional area and perimeter were 43.9% (P < 0.01) and 10.7% (P = 0.002), respectively. The major axis of the inferior vena cava was oriented in a left-anterior oblique position in all patients, averaging 20° from the horizontal plane. There was significant underestimation of inferior vena cava maximal diameter by horizontal measurement. In pre-resuscitation scans, at 1 cm and 5 cm below the lowest renal vein, the discrepancy between the horizontal and major axis diameter was 2.1 ± 1.2 mm (P < 0.001) and 1.7 ± 1.0 mm (P < 0.001), respectively, while post-resuscitation studies showed the same underestimation at 1 cm and 5 cm below the lowest renal vein to be 2.2 ± 1.2 mm (P < 0.01) and 1.9 ± 1.0 mm (P < 0.01), respectively. CONCLUSIONS: There is significant anisotropic variability of infrarenal inferior vena cava geometry with significantly greater expansive and compressive forces in the minor axis. There can be significant volumetric changes in the inferior vena cava with associated perimeter changes but the major axis left-anterior oblique caval configuration is always maintained. These significant dynamic forces may impact inferior vena cava filter stability after implantation. The consistent major axis left-anterior oblique obliquity may lead to underestimation of the inferior vena cava diameter used in standard anteroposterior venography, which may influence initial filter selection.