Search Results

History of arrhythmias • Xray of the Week What is the diagnosis? Figure 1. What is the important finding seen on these CT images? Figure 1A: Axial CT image of abdomen with hyperdense liver Figure 1B: Zoomed-in axial CT image of liver- note the ROI is 154 HU Figure 1C: Zoomed-in axial CT image of spleen- note the ROI is 63 HU Figure 1D: Coronal CT image of abdomen with hyperdense liver Discussion: Amiodarone is an antiarrhythmic agent used to treat ventricular arrhythmias and atrial fibrillation. It is a class III drug, based on the Vaughan Williams classification, and works by prolonging the QT interval (1). The drug can also cause bradycardia, atrioventricular nodal conduction, increased refractoriness, and decreased intracardiac conduction (1). Moreover, since amiodarone is highly lipid soluble, it is stored in high concentrations in the liver, lungs, eyes, thyroid, and skin (1). One study found that all patients undergoing ophthalmologic examinations were found to have asymptomatic corneal microdeposits (2). It was further noted that a rise in hepatic enzyme levels was correlated to dosage and plasma drug and metabolite concentrations (2). Older patients pose a higher risk of developing hypothyroidism and those with abnormal lung functions prior to therapy may be predisposed to pulmonary alveolitis (2). Most of the observed unwanted effects resolve when amiodarone is decreased in dose or discontinued (2). Though it is uncommon, liver toxicity can occur and is manifested by elevated liver transaminase levels (1). Since amiodarone accumulates in lipid reservoirs and is released slowly, the concentration in the liver can be as high as 500-fold of the serum level (3,4). Characteristics of amiodarone-induced hepatotoxicity include histologic steatosis, inflammation, fibrosis, and phospholipidosis (5). On imaging, we can appreciate increased density in the liver on non-contrast CT which is thought to be secondary to increased iodine content from the amiodarone (3,4). Increased liver attenuation on CT is a nonspecific finding and can also be seen with iron deposition in primary hemochromatosis, thalassemia, and hemosiderosis(6). Increased attenuation can also be seen with gold deposition, copper deposition in Wilson disease, and type IV glycogen storage disease (6). In Figure 1A, 1B, and 1D we can visualize the increased density of the liver on CT due to the chronic use of amiodarone. Normally, the liver has a similar density to the spleen on non-contrast CT scans (7), whereas in this case the liver is markedly hyperdense (154 HU) compared to spleen (63 HU). In the initial paper on hepatic Amiodarone deposition, liver hyperdensity measured 95 to 145 HU (Normal is 30-70) (4). Treatment of amiodarone toxicity involves reducing the dosage or discontinuing the usage (2); however, hepatic deposition without toxicity is usually an incidental finding that does not require any treatment. ​​​​ References: Siddoway, L. A. (2003). Amiodarone: guidelines for use and monitoring. American family physician, 68(11), 2189-2196. https://www.aafp.org/afp/2003/1201/p2189.html Harris, L., McKenna, W. J., Rowland, E., & Krikler, D. M. (1983). Side effects and possible contraindications of amiodarone use. American heart journal, 106(4), 916-923. doi:10.1016/0002-8703(83)90016-9 Hussain, N., Bhattacharyya, A., & Prueksaritanond, S. (2013). Amiodarone-induced cirrhosis of liver: what predicts mortality?. Isrn Cardiology, 2013. doi:10.1155/2013/617943 Goldman IS, Winkler ML, Raper SE, et al. Increased hepatic density and phospholipidosis due to amiodarone. AJR Am J Roentgenol. 1985;144(3):541-546. doi:10.2214/ajr.144.3.541 Buggey J, Kappus M, Lagoo AS, Brady CW. Amiodarone-Induced Liver Injury and Cirrhosis. ACG Case Rep J. 2015;2(2):116-118. Published 2015 Jan 16. doi:10.14309/crj.2015.23 Ros P.R. (2018) Imaging of Diffuse and Inflammatory Liver Disease. In: Hodler J., Kubik-Huch R., von Schulthess G. (eds) Diseases of the Abdomen and Pelvis 2018-2021. IDKD Springer Series. Springer, Cham. doi:10.1007/978-3-319-75019-4_22 Herring W. Learning Radiology: Recognizing the Basics. Elsevier; 2015.​ Amer Ahmed is a fourth-year medical student at Midwestern University Chicago College of Osteopathic Medicine. There, he has served as the President for the Medical Business Association and Secretary for the Radiology Interest Group. Before medical school, Amer earned a degree in Economics at Loyola University Chicago and spent some time as an Investment Specialist at Merrill Edge before deciding to pursue his interest in medicine. Radiology intrigued Amer following a back injury requiring him to get an MRI. That is when he was able to appreciate the eye for detail Radiologists possess. Amer is passionate about finance, medicine, and technology. Follow Amer Ahmed on Twitter @amer_ahmed401 All posts by Amer Ahmed Kevin M. Rice, MD is the president of Global Radiology CME Dr. Rice is a radiologist with Renaissance Imaging Medical Associates and is currently the Vice Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

34 year old male with chest pain and shortness of breath • Xray of the Week Figure 1. 34 year old male with chest pain and shortness of breath. Figure 2. A and B: Axial and coronal CT with cardiomegaly due to markedly dilated heart. Right pleural effusion (blue arrow). Low EF with contrast only in RA (red arrows) and RV (orange arrow). Reflux of contrast into the IVC (green arrow) and hepatic veins (white arrow) indicates tricuspid valve regurgitation. C: Echocardiogram apical 4 chamber view. Mitral regurgitation as evidenced by a regurgitant jet extending into the RA (yellow arrow). Discussion: Methamphetamine (MA) and related compounds are the most widely abused drugs in the world after cannabis. It is a psychostimulant that causes an increase in the synapse of monoamine neurotransmitters, including dopamine, norepinephrine, and serotonin [1]. Methamphetamines can be smoked, snorted, injected, or ingested orally. Methamphetamine is more potent, and its effects last longer than cocaine. Methamphetamine associated cardiomyopathy (MACM) is more common in younger age groups compared to patients with cardiomyopathy attributable to other causes. The development of MACM has been shown to be dose-dependent and amplified by repetitive use, binge pattern use, and concomitant use of other substances. Autopsy studies have shown MACM to be associated with extensive myocardial fibrosis, cellular vacuolization, and myocyte destruction [2, 3]. Cardiac complications of MA use include chest pain, hypertension, arrhythmia, aortic dissection, coronary vasospasm, cardiomyopathy, sudden cardiac death, and pulmonary arterial hypertension [2]. Figure 3. A. Axial and B. Coronal CT Scan. Same patient with RV thrombus (red arrows). Typical findings reported on echocardiography are severe multi-chamber dilatation, reduced EF, mitral regurgitation (MR) Patients with MACM are also prone to developing intracardiac thrombi, with up to 33% for LV thrombus and 3.3% for RV thrombus [4, 5] (Fig. 3). Thrombus is likely due both to severe cardiac dysfunction and the prothrombotic state seen in MACM [5]. And tricuspid regurgitation (TR), and pericardial effusion [6-9]. In general, patients with MACM have significantly larger LA, LV, and RV size, lower LVEF, and a higher rate of mitral regurgitation (MR) compared to other causes of dilated cardiomyopathy [6]. In this case, there is severe tricuspid regurgitation (TR) with reflux of contrast into the inferior vena cava (IVC) and hepatic veins; pleural effusion is indicative of heart failure (Figs. 2 A, B). There is also MR visualized on the echocardiogram with a large regurgitant jet extending into the LA during systole (Fig. 2C). Aside from cessation of MA use, treatment of MACM is aimed at the specific pathology such as anticoagulation for intracardiac thrombus and diuresis/venodilators for volume overload. ​​​​ References: [if supportFields]> ADDIN EN.REFLIST

32 F with Vaginal Bleeding • Xray of the Week Patient at 25 weeks gestational age. Figure 1. Sagittal transvaginal ultrasound of the cervix. Figure 2. Sagittal transvaginal ultrasound of the cervix. A. Gray scale images show the fetal umbilical cord blood vessels (red arrow) across or near the internal os (orange arrow). B. Color doppler images show the fetal umbilical cord vessels across or near the internal os (yellow arrow). Discussion: Vasa previa is a rare and serious complication of pregnancy in which fetal umbilical cord blood vessels run across or near the internal opening of the cervix (1). Because the vessels run within the membranes, they are unsupported by the umbilical cord, placental tissue, or Wharton jelly (1). This increases risk of vessel rupture when the membranes rupture during labor. There are two types of vasa previa. In type I, there is a velamentous cord insertion between the umbilical cord and the placenta (2). Thus the fetal vessels that run freely within the amniotic membranes run across the cervix or near it (Figs. 1, 2) (2) In type II, fetal vessels run between lobes of succenturiate or bilobate placentas over or near the cervix (1,2). There are several methods used to diagnose vasa previa including identification of placental cord insertion, applying color Doppler over the cervix, 3D ultrasound, and transvaginal ultrasound (3). Linear echolucent structures can be seen over the cervix on gray-scale US (Fig. 2A) (4). These linear echolucent structures can also be seen in marginal sinus previa, which appears as a discontinuous venous lake at the placental margin (1,4). Pulsed Doppler will show a fetal umbilical or venous waveform in vasa previa whereas marginal sinus previa present with flow of a maternal heart frequency (1). Color doppler sonography shows vascular structures over the internal cervical os with a “fixed position during maternal repositioning” (Fig. 2B) (4).Funic presentation (also known as cord presentation) is also commonly confused for vasa previa, but they are different in that the funic presentation demonstrates shifting in position of the cord by tapping the transducer (1). Rupture of the fetal blood vessels can be fatal in vasa previa, so it typically requires elective C-section at 35 weeks (1). Hospitalization with corticosteroids at 32 weeks has also been recommended to promote lung maturity (1). ​​​​ References: 1. Derbala Y, Grochal F, Jeanty P. Vasa previa. J Prenat Med. 2007;1(1):2-13. 2. Sinkey RG, Odibo AO, Dashe JS. #37: Diagnosis and management of vasa previa. American Journal of Obstetrics & Gynecology. 2015;213(5):615-619. doi:10.1016/j.ajog.2015.08.031 3. Marr S, Ashton L, Stemm A, Cincotta R, Chua J, Duncombe G. Vasa praevia: ultrasound diagnosis at the mid‐trimester scan. Australas J Ultrasound Med. 2013;16(1):8-15. doi:10.1002/j.2205-0140.2013.tb00091.x 4. Fadl S, Moshiri M, Fligner CL, Katz DS, Dighe M. Placental imaging: normal appearance with review of pathologic findings. RadioGraphics. 2017;37(3):979-998. doi:10.1148/rg.2017160155 Amara Ahmed is a medical student at the Florida State University College of Medicine. She serves on the executive board of the American Medical Women’s Association and Humanities and Medicine. She is also an editor of HEAL: Humanism Evolving through Arts and Literature, a creative arts journal at the medical school. Prior to attending medical school, she graduated summa cum laude from the Honors Medical Scholars program at Florida State University where she completed her undergraduate studies in exercise physiology, biology, and chemistry. In her free time, she enjoys reading, writing, and spending time with family and friends. Follow Amara Ahmed on Twitter @Amara_S98 All posts by Amara Ahmed Kevin M. Rice, MD is the president of Global Radiology CME Dr. Rice is a radiologist with Renaissance Imaging Medical Associates and is currently the Vice Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

41 year old female. COVID-19 positive. SOB • Xray of the Week 41 yo female COVID-19 positive with LLE edema and Shortness of breath. Figure 1. Describe the abnormalities. Figure 2. A. Bilateral lower lobe peripheral ground-glass opacities (GGO) with confluent patchy consolidation (blue arrows). B. Loss of color flow in left popliteal vein (red arrow). C. Thrombosed non-compressible left common femoral vein (red arrow). D. and E. Axial and coronal CT showing partially occlusive left lower lobe pulmonary embolism (orange arrows) Discussion: The SARS-CoV-2 novel virus was first isolated in Wuhan, China. [1,2] In the United States, COVID-19 has been the cause of more than 380,000 deaths as of Jan 12, 2021 [3]. Patients typically present with fever, tachypnea, cough, and sore throat. Severe complications like pulmonary embolism (PE), multiorgan failure, and death can occur [2]. The radiologist plays a vital role in the COVID-19 pandemic due to the importance of imaging in diagnosis and management. The exact pathophysiology and management of this virus is still evolving, however COVID-19 is known to cause a hypercoagulable state with abnormal D-dimer, IL-6, and fibrinogen levels leading to an increased incidence of thrombotic events [1]. In hospitalized COVID-19 patients, the incidence of thrombotic events is between 7.7-49%. Among these, the most commonly occurring thrombotic event is venous thromboembolism [4]. A meta-analysis reported that the incidence of deep vein thrombosis (DVT) patients is 27% and PE is 15% in COVID-19 positive hospitalized patients [5]. If a DVT is suspected, compression ultrasonography of the lower extremity will often show an enlarged, noncompressible vein with corresponding loss of color flow if thrombus is occlusive [6]. The virus’ preferred access to host cells is via angiotensin-converting enzyme 2 (ACE-2) found in the respiratory epithelium. Therefore, the lungs are the most affected organ and visible signs of disease are typically present on imaging [1]. Chest x-rays may demonstrate diffuse ground-glass opacities, however, CT scans are more sensitive for these findings and are considered the first-line imaging modality. CT scans most often demonstrate peripherally distributed ground-glass opacities with reticular and/or interlobular septal thickening, with consolidation [7]. If associated pulmonary embolism is suspected, CT pulmonary angiography will demonstrate a complete or partial filling defect. The “polo mint” sign of partial filling defects is caused by the partial defect surrounded by contrast material [8]. Management of COVID-19 is a work in progress however, hospitalized patients confirmed to have COVID-19 should be on prophylactic anticoagulation unless contraindicated to prevent VTE. Typically low-molecular-weight heparin (LMWH) is preferred for anticoagulation prophylaxis and VTE management but unfractionated heparin can be an alternative, and Fondaparinux can be used in cases of heparin-induced thrombocytopenia (HIT). Tissue plasminogen activator (tPA) can be used as indicated in severe complications of COVID-19 such as limb-threatening DVT or massive PE [9]. ​​​​ References: Connors JM, Levy JH. COVID-19 and its implications for thrombosis and anticoagulation. Blood. 2020;135(23):2033-2040. doi:10.1182/blood.2020006000 Zheng P, Bao L, Yang W, Wang J. Clinical symptoms between severe and non-severe COVID-19 pneumonia: A protocol for systematic review and meta-analysis. Medicine (Baltimore). 2020;99(33):e21618-. doi:10.1097/MD.0000000000021618 Johns Hopkins Coronavirus Resource Center. 2020. Home - Johns Hopkins Coronavirus Resource Center. https://coronavirus.jhu.edu/ [20 October 2020]. Hajra, A., Mathai, S.V., Ball, S. et al. Management of Thrombotic Complications in COVID-19: An Update. Drugs 80, 1553–1562 (2020). doi:10.1007/s40265-020-01377-x Lu Y, Pan L, Zhang W-W, et al. A meta-analysis of the incidence of venous thromboembolic events and impact of anticoagulation on mortality in patients with COVID-19. International journal of infectious diseases. 2020;100:34-41. doi:10.1016/j.ijid.2020.08.023 Karande GY, Hedgire SS, Sanchez Y, et al. Advanced imaging in acute and chronic deep vein thrombosis. Cardiovascular diagnosis and therapy. 2016;6(6):493-507. doi:10.21037/cdt.2016.12.06 Zhao W, Zhong Z, Xie X, Yu Q, Liu J. Relation Between Chest CT Findings and Clinical Conditions of Coronavirus Disease (COVID-19) Pneumonia: A Multicenter Study. American journal of roentgenology (1976). 2020;214(5):1-6. doi:10.2214/ajr.20.22976 Wittram C, Maher MM, Yoo AJ, Kalra MK, Shepard J-AO, McLoud TC. CT Angiography of Pulmonary Embolism: Diagnostic Criteria and Causes of Misdiagnosis. Radiographics. 2004;24(5):1219-1238. doi:10.1148/rg.245045008 Bikdeli B, Madhavan MV, Jimenez D, et al. COVID-19 and Thrombotic or Thromboembolic Disease: Implications for Prevention, Antithrombotic Therapy, and Follow-up. Journal of the American College of Cardiology. 2020;75(23):2950-2973. doi:10.1016/j.jacc.2020.04.031 Nirali Dave is a medical student at Medical University of Lublin in Poland, currently doing clinical rotations in New York. Before that she completed her undergraduate education at Rutgers University, and worked as a medical scribe. Nirali was first exposed to basic radiologic imaging while scribing, and was very quickly taken by the field. Her passion for radiology comes from the bridging of anatomy, health technologies, and patient care. In the future, she hopes to complete a diagnostic radiology residency and stay committed to clinical research and patient education. Follow Nirali Dave on Twitter @ndave08 All posts by Nirali Dave Kevin M. Rice, MD is the president of Global Radiology CME Dr. Rice is a radiologist with Renaissance Imaging Medical Associates and is currently the Vice Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

53-year-old female with abdominal pain • Xray of the Week 53-year-old female presented with abdominal pain to the emergency department (ED). A non-contrast CT study was performed in prone position with suspicion of urinary system stone. No stone is appreciated in urinary system and no significant CT finding is found to explain the pain. One month later patient presented with abdominal pain again to the ER. Contrast enhanced CT study ordered for evaluation. Routine postcontrast CT study is performed in supine position. The position of the uterus was different in supine and prone position CT study (Fig 1a-b). Figure 1. a: Sagittal reconstruction of non-contrast (a) and post-contrast CT studies (b) which were performed at one-month intervals demonstrate anteverted position of the uterus in prone (yellow arrow) and retroverted position in supine position (orange arrow). White arrows indicate table position. Discussion: The uterus has a shape similar to an inverted pear. It is divided by body and cervix, and the superior part of the body above the entrance of the tuba uterine known as fundus. The uterus is a muscular organ located between the bladder anteriorly and the rectum posteriorly. It is also a mobile organ, since its position can vary depending on the contents of the bladder and rectum [1]. The tonus of the pelvic floor is the primary support for the uterus. Other ligaments that provide further support to the uterus include the broad ligament, round ligament, ovarian ligament, cardinal ligament, and the uterosacral ligament. The round ligament is composed of fibromuscular connective tissue. It is covered by folded peritoneum and comprises the superior margin of the broad ligament on each side of the uterus [2]. Two round ligaments extend from the uterine horns to the labia majora on each side via the inguinal canal and maintain the anteverted position of the uterus. The most common position of the uterus is anteverted, with the cervix angled forward and anteflexed, and the body flexed anteriorly. A retroverted uterus is a normal variant seen approximately 20% of women where the body of the uterus is tilted posteriorly. There are variable degrees of uterine retroversion. The majority of the time, the retroverted uterus causes no symptoms; however, rarely it may be associated with dyspareunia and dysmenorrhea. This might be because the retroverted position causes the uterus to contact the rectum and posterior wall of the vagina. Mobilization of the uterus during intercourse may generate pain especially if the uterus is fixed in this position. The position of the uterus can also change during pregnancy. However, it is very uncommon for the uterus to switch positions in a normal subject such as seen in this case [3]. The mobility of the uterus can be attributed to the high flexibility of the round ligament. This flexibility might be due to its role in allowing the uterus to grow during pregnancy and adapting to the body’s shape. When a female is not pregnant, the round ligaments that support the uterus are often shorter and firmer. Yet, their flexibility allows them to lengthen, thicken, and stretch during pregnancy. In the images above, we can readily see the difference in the position of the uterus in the prone and supine position. There are no CT findings in this case to explain the abdominal pain and it is uncertain if this uncommon mobility of the uterus is the reason. ​​​​ References: Tullington JE, Blecker N. Lower Genitourinary Trauma. In: StatPearls. Treasure Island (FL): StatPearls Publishing; May 22, 2020. Bookshelf ID: NBK557527 Chaudhry SR, Chaudhry K. Anatomy, Abdomen and Pelvis, Uterus Round Ligament. In: StatPearls. Treasure Island (FL): StatPearls Publishing; August 23, 2020. PMID: 29763145 Bookshelf ID: NBK499970. Sanders RC, Parsons AK. Anteverted retroflexed uterus: a common consequence of cesarean delivery. AJR Am J Roentgenol. 2014;203(1):W117-W124. doi:10.2214/AJR.12.10403. PMID: 24951223. Munevver N. Duran is a pre-medical undergraduate student at Rice University in Houston, Texas, currently double majoring in Kinesiology Sports Medicine and Religious Studies. Munevver was first exposed to radiologic imaging through her research and co-authorship to a review article about the additional diagnostic value of three-dimensional volume rendering imaging in Radiology practice. Her passion for radiology comes from the intersectionality of anatomy and physiology, diagnostic applications, and the continuously improving imaging technologies. In the future, she hopes to become a physician educator with a strong commitment to clinical research and patient-centered healthcare. Ali Morshid is a diagnostic radiology resident at the University of Texas Medical Branch in Galveston, Texas. Ali grew very fond of medical imaging research and academic radiology during his work as a research assistant at MD Anderson Cancer Center and found great satisfaction in preparing didactic sessions and academic presentations for radiology trainees. Ali has multiple publications in peer-reviewed journals in the field of diagnostic radiology and he is working towards a fulfilling career as an academic neuroradiologist.

"Early detection of breast cancer saves lives, one of the great accomplishments of cancer research during the past forty years." - László Tabár​, MD, FACR (Hon) We are honored to have László Tabár one of the world's foremost breast imaging authorities join us at Imaging in England in June, 2018. Dr. László Tabár is a visionary physician, researcher, and educator who has contributed significantly in the worldwide fight against breast cancer. In a career spanning over 40 years, he has worked tirelessly to reduce or eliminate suffering and death from the disease. Through his company, Mammography Education, Inc, he has also been the course director and principal lecturer of more than 300 mammography courses on 6 continents. As a clinician, he has applied his expertise to the interpretation of well over one million mammograms. His pioneering research has laid the foundation for early detection through modern mammographic screening. A consummate educator, Dr. Tabár is responsible for the mentoring of tens of thousands of breast imagers, surgeons and pathologists worldwide. His influence is felt on every continent and there can be no doubt that his work as researcher and educator has saved the lives of hundreds of thousands of women. Dr. Tabár is the recipient of numerous awards including the Terry Fox Award from the British Columbia Medical Association for contributions to cancer research, the Gold Medal from the Society of Breast Imaging, American Cancer Society's Distinguished Service Award, the IMPACT Award for Lifetime Achievement in the Fight Against Breast Cancer by the National Consortium of Breast Care Centers, the Pathfinder Award by the American Society of Breast Disease, and the first Alexander Margulis Award for Scientific Excellence from the Radiological Society of North America (RSNA) in 2012. Click here to see Dr. Tabár's interesting cases on the Global Radiology CME blog

Enlarging Left Mandibular Mass • Xray of the Week A 30 year old female presented with rapidly increasing left mandibular swelling over the last 3 months. What is the diagnosis? Figure.1 (A) Plain radiograph of the mandible showing typical soap-bubble lesion on the left side. (B) CT 3D reconstruction shows multiple osteolytic lesions. Figure 2. (A) Plain radiograph of the mandible showing typical soap-bubble lesion on the left side. There is breach of the cortex (yellow arrow). (B) CT 3D reconstruction shows multiple osteolytic lesions. There is breach of the cortex (green arrows). Figure 3. Coronal contrast enhanced CT scan demonstrates intramandibular, expansile lytic lesion with breach of the cortex at multiple sites (yellow arrows). MRI STIR coronal image shows hyperintense, multiloculated, lesion in left side of the mandible (green arrows). Discussion An expansile radiolucent lesion with no calcified matrix in plain x-rays of the jaw suggests many diagnoses, such as odontogenic cysts, nonodontogenic cysts, cystic neoplasms, and inflammatory granulomas. Among them, odontogenic keratocysts, which contain keratinaceous material, and ameloblastomas, which are benign cystic neoplasms have high recurrence rates. Ameloblastoma arises from the enamel-forming cells of the odontogenic epithelium. The tumor most commonly occurs in the posterior mandible, typically in the third molar region. On radiography, the mixed cystic and solid type of ameloblastoma appears as an expansile, radiolucent, multilocular mass, with internal septations that form a honeycomb or soap bubble appearance on all modalities, which is a classic finding. References: 1. Minami M, Kaneda T, Ozawa K et-al. Cystic lesions of the maxillomandibular region: MR imaging distinction of odontogenic keratocysts and ameloblastomas from other cysts. AJR Am J Roentgenol. 1996;166 (4): 943-9. 2. Minami M, Kaneda T, Yamamoto H et-al. Ameloblastoma in the maxillomandibular region: MR imaging. Radiology. 1992;184 (2): 389-393. 3. Dunfee BL, Sakai O, Pistey R et-al. Radiologic and pathologic characteristics of benign and malignant lesions of the mandible. Radiographics. 26 (6): 1751-1768. 4. Dunn JL, Olan WJ, Bank WO, et-al. Giant ameloblastoma: radiologic diagnosis and treatment. Radiographics. 1997;17 (2): 531-536. 5. Plunk MR, Oda D, Parnell SE, et-al. Focal Benign Disorders of the Pediatric Mandible With Radiologic-Histopathologic Correlation: Mandibular Development and Lucent Lesions. American Journal of Roentgenology. 2017;208: 180-192.5. G. Balachandran, MBBS, MD Dept. of Radiology, Sri Manakula Vinayakar Medical College and Hospital, Pondicherry, India Dr. Balachandran is a Professor of Radiology at Sri Manakula Vinayagar Medical College and Hospital (SMVMCH). He earned his MBBS degree at the Government Stanley Medical College in Madras India in 1975, followed by DMRD at the Government Madras Medical College in Madras India in 1984, MD (RD) at Jimper Pondicherry in 1988, and DNB(RD) at MHFW, GO in New Delhi in 1991. Dr. Balachandran is a life member of the Indian Radiological and Imaging Association (IRIA) and the Indian College of Radiology (ICR).

The So-Called “Debate” Over Breast Cancer Screening is Not a True Debate Originally published February 15, 2017 in MEI News on www.mammographyed.com Republished with permission of the authors. Above: Mammogram of invasive ductal carcinoma of the right breast in a 42 year old. Instead, it is an unequal confrontation between the scientists who have access to the individual patient-based data and also have the expertise needed to evaluate the data, and those who have strong prejudices against the early detection of breast cancer, but who must resort to “estimates”, “approximations” and “assumptions” to support their beliefs, having no access to individual patient data and lacking the expertise needed to interpret peer reviewed, published results. The impact of the early detection of breast cancer upon death from this disease has been studied since the 1960s. Few medical procedures have been tested so thoroughly and subjected to such intense scrutiny as the prospective early detection trials and the widespread, ongoing service screening programs. detection trials and the widespread, ongoing service screening programs. These studies have proved without question that the early detection and treatment of breast cancer at an early stage have significantly decreased the rate of advanced cancers and, as a result, have significantly decreased the rate of death from breast cancer. Despite all this vigorous scientific evidence the following statement in January 2017 from the Nordic Cochrane Center that “breast cancer has a biology that doesn’t lend itself to screening” can be compared to the belief that the Earth is flat. There still appears to exist a small coterie of individuals who share the ideology that women should wait for their breast cancer become symptomatic, advanced. When will the Nordic Cochrane Center issue a formal apology to the relatives of those deceased Danish breast cancer victims who, as a result of the Center’s long-running anti-screening campaign, did not obtain access to early detection and whose breast cancers were detected at too late a stage to be curable? Why does vehement opposition to screening come from Denmark, which has one of the highest breast cancer death rates in Europe? We agree with Professor Stephen W. Duffy who has summarized the situation as follows: “The term "controversy" hardly seems to apply to mammography screening. What ought to be regarded as controversial is the regular opportunity provided by scientific journals and mass media for a group of pseudo-skeptics to repeat over and over again the same flawed science and logic to question the value of screening”.​ László Tabár, MD, FACR (Hon) the Professor Emeritus of Radiology Uppsala University, Faculty of Medicine, Sweden and the Medical Director Emeritus of the Department of Mammography, Falun Central Hospital, Sweden. Through his company, Mammography Education, Inc, he has also been the course director and principal lecturer at more than 300 mammography courses on 6 continents. His pioneering research has laid the foundation for early detection through modern mammographic screening. Dr. Tabár is the recipient of numerous awards including the Gold Medal from the Society of Breast Imaging, American Cancer Society's Distinguished Service Award, and the first Alexander Margulis Award for Scientific Excellence from the Radiological Society of North America (RSNA). All Posts by László Tabár, MD All Breast Imaging Posts

"I look forward to the meeting and traveling back to Israel – it has been nearly 15 years since I was there." - Donald Resnick, MD, FACR Global Radiology CME is thrilled to have Donald Resnick join us in Jerusalem for Imaging in Israel - 2017. Donald L. Resnick, MD, Professor of Radiology and Chief of Osteoradiology at the University of California, San Diego (UCSD), has devoted more than 30 years to musculoskeletal radiology education. Dr Resnick has written over 1100 scientific and educational articles (more than 100 published in Radiology), 72 book chapters, and 16 books on musculoskeletal radiology. Dr Resnick is a renowned lecturer, having given over 50 named lectures throughout the world including the Wilhelm Conrad Roentgen Honorary Lecture at the European Congress of Radiology and the Ho Hung Chiu Medical Education Foundation Lecture in Hong Kong. His list of dozens of awards and honors includes the American Roentgen Ray Gold Medal, Diagnostic Imaging Magazine’s 20 Most Influential People in Radiology, Medical Imaging Industry’s Top 10 Radiologists, twice-awarded AuntMinnie.com Most Effective Radiology Educator, and an Honorary Doctorate from the University of Zurich.Dr Resnick is a member of 9 radiology societies, and is a past president of the International Skeletal Society. In addition, he is an Honorary Fellow of 6 radiology societies in Europe and Asia. He serves on a multitude of departmental, hospital/medical school, and national committees. He has served on editorial boards and as a manuscript reviewer for 18 leading journals including AJR, Radiology, and RadioGraphics. More than 150 clinical fellows and 400 international research fellows, from over 20 countries throughout the world, have received one-on-one training through his fellowship programs. Amazingly, 70% of these fellows pursued academic careers after their training. More than 1000 visitors have come to his base of operations, formerly known as “The Bone Pit”, and now aptly dubbed "The Bone Palace." I had the honor of gifting Dr. Resnick some #PinkSocks at RSNA 2106.

"Early detection of breast cancer saves lives, one of the great accomplishments of cancer research during the past forty years." - László Tabár​, MD, FACR (Hon) We are honored to have László Tabár one of the world's foremost breast imaging authorities join us at Imaging in Israel in June, 2017. Dr. László Tabár is a visionary physician, researcher, and educator who has contributed significantly in the worldwide fight against breast cancer. In a career spanning over 40 years, he has worked tirelessly to reduce or eliminate suffering and death from the disease. Through his company, Mammography Education, Inc, he has also been the course director and principal lecturer of more than 300 mammography courses on 6 continents. As a clinician, he has applied his expertise to the interpretation of well over one million mammograms. His pioneering research has laid the foundation for early detection through modern mammographic screening. A consummate educator, Dr. Tabár is responsible for the mentoring of tens of thousands of breast imagers, surgeons and pathologists worldwide. His influence is felt on every continent and there can be no doubt that his work as researcher and educator has saved the lives of hundreds of thousands of women. Dr. Tabár is the recipient of numerous awards including the Terry Fox Award from the British Columbia Medical Association for contributions to cancer research, the Gold Medal from the Society of Breast Imaging, American Cancer Society's Distinguished Service Award, the IMPACT Award for Lifetime Achievement in the Fight Against Breast Cancer by the National Consortium of Breast Care Centers, the Pathfinder Award by the American Society of Breast Disease, and the first Alexander Margulis Award for Scientific Excellence from the Radiological Society of North America (RSNA) in 2012. Click here to see Dr. Tabár's interesting cases on the Global Radiology CME blog

"My passion is to favorably change the standard of care in a short amount of time through innovation." - Neil Rofsky, MD Neil Rofsky noted body imager from Texas will be joining the Global Radiology CME team in Jerusalem. Dr Rofsky is at the forefront of Body MRI research and will be teaming up with other radiology luminaries including László Tabár and Donald Resnick to deliver state of the art education to the attendees of Imaging in Israel - 2017. Neil Rofsky, M.D., is Professor and Chair of UT Southwestern’s Department of Radiology and the Effie and Wofford Cain Distinguished Chair in Diagnostic Imaging. Dr. Rofsky also serves as Co-Director of Translational Research for the Advanced Imaging Research Center (AIRC), a collaboration of UT Southwestern and the University of Texas at Dallas. As Chair of Radiology, he also leads efforts to rapidly bring the benefits of new technologies, including some developed at the AIRC, into clinical practice. A native of New York, Dr. Rofsky received his bachelor’s degree in biochemistry from the University of Maryland and his medical degree from New York Medical College. He then completed an internship in internal medicine at Middlesex University Hospital; a fellowship in nuclear medicine at the University of Utah Medical Center; a residency in radiology at the New York University Medical Center; and fellowships in abdominal imaging and magnetic resonance imaging at New York University Medical Center, where he was mentored by Morton Bosniak, Alec Megibow, and Jeffrey Weinreb. Before joining the faculty of UT Southwestern, Dr. Rofsky served as Chief of MRI at Beth Israel Deaconess Medical Center, Boston, and as Professor of Radiology at Harvard Medical School. Dr. Rofsky concentrates his research on translating innovations in magnetic resonance imaging (MRI) and spectroscopy into clinical practice. His current studies emphasize developing MRI techniques to improve detection and evaluation of prostate cancer and to better guide treatment. In his research, Dr. Rofsky seeks to apply MRI techniques such as arterial spin labeling (ASL) to measure blood flow in prostate and renal cell carcinomas. Since blood flow can reflect the viability of a tumor, these measurements can offer valuable insights into the potential aggressiveness of tumors and the effectiveness of treatments. Dr. Rofsky and his collaborators have also pioneered the use of rapid contrast-agent-enhanced three-dimensional diagnostic imaging of the abdomen. Such rapid imaging is important because it enables clinicians to obtain high-resolution 3-D images during the brief time that a patient can hold a single breath, reducing the artifacts from respiratory and other motions. Dr. Rofsky serves as an active member of the Board of Trustees of the Society of Computed Body Tomography and Magnetic Resonance (SCBTMR) and recently finished serving on the Board of Trustees of the International Society for Magnetic Resonance in Medicine (ISMRM). He has authored more than 150 peer-reviewed publications, several textbooks, and presents regularly at such medical societies as the Radiological Society of North America, the ISMRM and the SCBTMR. Just recently he delivered a plenary lecture to the ISMRM entitled, The Evolution of the MR Biomarker. Trained as a classical musician, Dr. Rofsky is an oboist who appreciates the art and science of shaping the instrument’s reeds, which give it its unique sound. He also enjoys playing guitar, including numerous acoustic and electric instruments, and is the proud owner of a Steinway Model A Grand Piano built in 1884.

Philippe Grenier, MD Chairman of the Department of Diagnostic Radiology at the Hôpital Pitié-Salpêtrière - Paris, France | Past President of The Fleischner Society, Past President of The European Society of Thoracic Imaging, and General Secretary of the Société Française de Radiologie Dr. Grenier will be speaking at Imaging in Israel - 2017 on: The radiological approach to indeterminate pulmonary nodules Smoking-related interstitial lung diseases CT phenotyping of COPD Philippe Grenier, a native of Paris, France, received his medical degree from the school of medicine at the University of Paris in 1972. He then completed a residency in diagnostic radiology at the Assistance Publique – Hôpitaux de Paris and a fellowship in the Department of Radiology of the Hôpital Beaujon, Faculté de Médecine Xavier Bichat. Upon completion of his fellowship in 1982, Dr. Grenier remained at Faculté de Médecine Xavier Bichat as an associate professor of radiology. From there, he went on to the Faculté de Médecine de Bobigny as professor of radiology in 1988. The following year he accepted his present position as professor of radiology with the Faculté de Médecine Pitié-Salpêtrière, Université Pierre et Marie Curie, where he served as vice-president of the university from 1998 to 2001. Since 1989, he has been chairman of the Department of Diagnostic Radiology at the Hôpital Pitié-Salpêtrière in Paris. A pioneer in the diagnosis of chronic airway disease and chronic diffuse infiltrative lung disease using high-resolution CT, Dr. Grenier is currently contributing to the evaluation of chest disease with multislice CT. A respected expert in chest imaging and respiratory disease, Dr. Grenier is author or coauthor of 175 peer-reviewed articles, 57 books or book chapters. He has contributed to more than 400 scientific presentations and exhibits at national and international congresses. He is currently a member of the editorial boards for European Radiology, Journal of Thoracic Imaging and Academic Radiology. In addition Dr. Grenier reviews for several national and international scientific journals on medical imaging and respiratory diseases, amongst them European Respiratory Journal, Investigative Radiology, Journal de Radiologie, New England Journal of Medicine, Thorax, and Radiology, for which he received an 'Editor’s recognition award for reviewing with distinction in 2004. Dr. Grenier has obtained 18 grants for research and several awards for scientific exhibitions and outstanding scientific research from international societies including the Radiological Society of North America and the European Congress of Radiology (2002, 2004, 2005). He has given invited lectures at more than one hundred international scientific meetings. Dr. Grenier is an honorary member of the Swedish Society of Medical Radiology, the Japan Radiological Society, the Radiological Society of North America, the Société Canadienne Française de Radiologie, the Austrian Society of Radiology, the Italian Society of Radiology, and he is also Honorary Fellow of the Royal College of Radiologists. Furthermore, he is a founding member of the Société d'Imagerie Thoracique and the European Society of Thoracic Imaging. Dr. Grenier has been actively involved in the organisation of the European Congress of Radiology since 1991. He was president of ECR 2002 and the chairman of the ECR Executive Committee in 2003. He has served as chairman of the EAR Committee for Subspecialties (1998-1999) and the EAR Education Committee (2002-2005). In 2003 Dr. Grenier was president of the prestigious Fleischner Society, a group in which he was elected a member more than 15 years ago. He has been President of the European Society of Thoracic Imaging, and has been General Secretary of the Société Française de Radiologie. In recognition of his exceptional achievements in radiology, particularly in Thoracic Imaging, Dr. Philippe Grenier was awarded the 2007 Gold Medal of the European Congress of Radiology and the European Association of Radiology.