Jeffrey C. Weinreb, MD, FACR Yale School of Medicine Yale-New Haven Hospital

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1 Jeffrey C. Weinreb, MD, FACR Yale School of Medicine Yale-New Haven Hospital

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4 Whole body MRI: multistation approach x z Isocenter: Table Move: Multiple Steps

5 Whole body MRI: continuously moving table x z Isocenter: Table Move: Continuous Table Move

6 Multi Station Scout Axial Double IR Chest free breathing (pulse trigger) Axial Bright Blood Chest (non triggered) Axial HASTE FS Chest (non triggered) Cor HASTE Chest/Abd/Pelvis (2 station) Multiple short end expiration breath holds Axial HASTE Abd/Pelvis (2 stations) Multiple short end expiration breath holds Axial DWI free breathing Axial VIBE no FS Abd/Pelvis (2 stations) End expiration is preferred. End inspiration is ok.

7 Purpose: stage neoplasms that metastasize to the upper abdomen and liver, such as colon, pancreas, lung, breast, melanoma, thyroid, renal Scout CHEST Axial Double IR (triggered, free breathing OK) Axial HASTE with FS(breath hold) Axial FISP (breath hold) CHEST / ABDOMEN / PELVIS DWI axial Coronal HASTE ABDOMEN and PELVIS T2 FS axial abd/pelvis Axial HASTE abd/pelvis In and out of Phase through liver and kindeys Axial VIBE FS "Pre" Abdomen (include liver and kidneys) Axial VIBE FS "Pre" Pelvis (include part of kidneys to ensure overlap) Axial VIBE FS "Dynamic Post" Abdomen Axial VIBE FS "Post" Pelvis CHEST Axial VIBE FS "Post" Chest (end inspiration only) Coronal VIBE FS chest/abd/pelvis (include in 2 stations)

8 The purpose of this protocol is to stage pelvic neoplasms such as ano rectal, cervical, ovarian, prostate, bladder, etc... Scout 2 Plane Hi Res T2 in the Pelvis CHEST Axial Double IR (triggered, free breathing OK) Axial HASTE with FS(breath hold) Axial FISP (breath hold) CHEST / ABDOMEN / PELVIS DWI axial chest/abd/pelvis Coronal HASTE (include chest, abdomen, and pelvis) ABDOMEN and PELVIS Axial HASTE abd/pelvis Axial T2 FS In and out of Phase through liver and kindeys only Isotropic VIBE Pre Pelvis Axial VIBE FS "Pre" Abdomen / Pelvis Isotropic VIBE Post Pelvis 30 seconds after initiation of contrast Axial Post contrast VIBE FS "Post" Abdomen / Pelvis CHEST Axial Post contrast VIBE FS Chest (end inspiration only) Coronal VIBE FS post chest/abd/pelvis in 2 stations

9 MRI may be better than CT for evaluating neoplasms in the heart, breast, liver, spleen, pancreas, pelvis (uterus, ovaries, cervix, prostate, rectum, ) bone marrow, and soft tissues MRI is equivalent to CT for detection lymphadenopathy, and it is being used increasingly for evaluation of bowel CT is generally considered better for the thorax, especially lung parenchyma, but MRI reliably shows nodules >1cm CT is considered the gold standard for staging cancers. In the past, technical limitations made it difficult to perform staging examinations of more than one body area (eg. chest, abdomen, and/or pelvis) during one MRI examination. However, now possible with MRI In some patients, MRI may provide equivalent diagnostic information to CT. In other instances, either CT or MRI may provide useful information not apparent on the other type of exam. Since repeated radiation exposure may increase the risk of cancer in some patients (esp. patients with cancer!), this type or MRI exam may particularly relevant for certain cancer patients who require repeated examinations of the chest, abdomen, and/or pelvis.

10 Pediatrics Daldrup Link HE, et al. AJR 2001 Kellenberger CJ, et al. RadioGraphics 2004 Laffin EE, et al. Pediatr Radiol 2004 Goo HW, et al. Pediatri Radiol 2005 Kumar J, et al. Pediatr Radiol 2008 Darge K, et al. Eur J Radiol 2008 Cai W, et al. Radiology 2009 Krohmer S, et al. Eur J Radiol 2009 Lymphoma Brennan DD, et al. AJR 2005 Kwee TC, et al. Invest Radiol 2009 Punwani S, et al. Radiology 2010 Quarles van Ufford, et al. AJR 2011 Metastases Eustace S, et al. AJR 1997 Horvath LJ, et al. Radiology 1999 Lauenstein TC, et al. Radiology 2004 Chin AY, et al. Radiology 2008 Myeloma Bäuerle T, et al. Radiology 2009 Lin C, et al. Radiology 2010 MRA (Diabetes) Goyen M, et al. Radiology 2003 Fenchel M, et al. Radiology 2006 Weckbach S, Schoenberg SO. Eur J Radiol 2009

11 Considerations; Exam time and ability to cooperate Oral and IV contrast Age/Prognosis Type of neoplasm Initial staging vs follow up Concern about bowel and lungs Cost and billing

12 Exam Time and Ability to Cooperate CT scan takes just a few minutes. MRI, examinations can take as little as 35 minutes some will take longer, and patients should be able to lay flat for minutes and cooperate with breath hold instructions (i.e. be able to hold their breath for up to 20 seconds multiple times during the exam). Overall, CT remains an easier exam for patients

13 Oral and IV contrast For CT, patients are asked to refrain from eating for 4 hours, and they usually drink oral contrast (barium or iodine based) starting one 1 hour prior to the exam For MRI, we do not require patients to be NPO, and oral contrast is not routinely given unless MR Enterography is specifically ordered Both CT (iodine based) and MRI (gadolinium based) use IV contrast unless otherwise specified Not necessary for follow up lymphoma with low pre test probability recurrence

14 Age/Prognosis Patients who may be considered candidates for staging MRI scans should be relatively young and have a cancer that will likely require repeated follow up imaging Generally, this type of MRI exam may be appropriate for patients < 50 y/o, but it really depends on the patient s life expectancy rather than a specific age For example, an otherwise healthy 60 y/o post cryoablation of a 1.5 cm renal cell carcinoma may be well suited for follow up imaging with MRI to avoid repeated radiation exposure Conversely, a 25 year old with metastatic breast cancer and a bad prognosis might be better suited for follow up imaging with CT

15 Type of Neoplasm The following primary neoplasms may be appropriate for staging with MRI, and MRI might substitute for CT in appropriate patients: Breast cancer Renal cell carcinoma Prostate cancer Pancreatic neuroendocrine Melanoma (although bowel metastases my be difficult to see on routine MRI) Lymphoma Testicular Cervix

16 Type of Neoplasm Initial local and global staging can be performed at the same time (in patients of any age) with MRI for: Cervical cancer Uterine cancer Ano rectal cancer Prostate cancer Vulvar cancer

17 Staging the bowel/mesentary Due to concerns about missing significant bowel or mesenteric disease with MRI (depending on the patient and quality of the exam), CT is currently preferred for the following primary neoplasms: Gastric adenocarcinoma Pancreatic adenocarcinoma. Colon adenocarcinoma Ovarian cancer Papillary serous uterine cancer Lung (metastases to the abdomen and pelvis would be well seen on MRI, but CT is better for evaluation of the chest in these patients.) Bladder or transitional cell carcinoma GIST Carcinoid

18 Staging the chest MRI of the chest is generally sensitive for adenopathy (hilar, mediastinal, and axillary) and for pulmonary nodules > 5mm, and it may be better than CT for depicting chest wall invasion However, MRI has decreased sensitivity for metastases < 5mm, and the nonspecific nodules less than 5 mm that are commonly seen on staging CT scans will not be routinely detected with MRI Diffuse lung and small airway disease will not be reliably identified or characterized In general, CT is better for staging primary lung cancers MRI is usually adequate for staging lymphoma or metastatic disease in the chest AJR July 2004 vol. 183 no AJR July 2008 vol. 191 no

19 Daniel Cornfeld Gary Israel Shirley McCarthy Siemens