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ABDOMINAL DIFFUSION WEIGHTED MR

Frank Miller, M.D. FACR Professor of Radiology Chief, Body Imaging Section Medical Director, MR Imaging Northwestern University Feinberg School of Medicine [email protected] DISCLOSURES

No disclosures related to presentation OBJECTIVES

• Demonstrate utility of DWI in abdomen • Show advantages and limitations of DWI

Northwestern University Feinberg School of Medicine's Department of Radiology ORGANS

• Liver • Pancreas • Adrenal • Kidney • Lymph nodes/Peritoneum • Problem-based approach and not able to cover nearly everything

Northwestern University Feinberg School of Medicine's Department of Radiology DIFFUSION WEIGHTED IMAGING

• Used in neuroimaging for many years • Used routinely in our body MR imaging practice • Recommend starting DWI for abdominal applications if not already doing it • Need to recognize the strengths and limitations

Northwestern University Feinberg School of Medicine's Department of Radiology DIFFUSION WEIGHTED IMAGING

• Does not require contrast – helpful when renal dysfunction and concern of NSF or allergy • Relatively quick to perform • Provides functional information in addition to anatomic • Improved lesion conspicuity-better than T2 • Best sequence for detection • Some HCC (especially infiltrative lesions) and metastases better seen on DWI than on contrast-enhanced MR

Northwestern University Feinberg School of Medicine's Department of Radiology IMPROVED CONSPICUITY: LIVER PECOMA

b50 b500

ADC T1WI post

Northwestern University Feinberg School of Medicine's Department of Radiology SOMETIMES LESS CONSPICUOUS…HCC

Arterial phase Delayed

b500 ADC

Northwestern University Feinberg School of Medicine's Department of Radiology DWI

• Normal cells have water mobility differences – Theory-tumors less water mobility and therefore restricted diffusion: lower ADC • Apparent diffusion coefficient (ADC): measure of diffusion which removes the T2 effects – lesion which is bright on DWI may relate to “T2 shine through” and are bright on ADC map unlike true diffusion which is dark on ADC

Northwestern University Feinberg School of Medicine's Department of Radiology WHICH B VALUE SHOULD YOU USE?

• b value-strength of diffusion sensitizing gradient • No consensus on b values for abdomen-probably best between 0 and 1000 s/mm2 • At least 2 b values if calculating ADC – We use 50, 400/500 and 800 s/mm2

Northwestern University Feinberg School of Medicine's Department of Radiology LOW B VALUE IMAGES 50-100 SEC/MM2

• Low b value: less diffusion gradient but higher SNR • Signal loss in highly mobile water molecules (e.g. vessels): black blood images • b>50 to minimize capillary perfusion

b50

Northwestern University Feinberg School of Medicine's Department of Radiology High b value IMAGES

• Higher b values-more diffusion component – but when too high have lower signal to noise • Highly cellular tissues such as tumors-water is restricted • Additional b values for research or more accurate ADC

b1000

Northwestern University Feinberg School of Medicine's Department of Radiology ADC MAP

b50 b500 Slope of line represents ADC: relative signal intensity on y axis and b value on x axis

b1000

Log (Relative (Relative SI) Log

ADC = log(S0 / S1) / (b1 - b0)

b-values (s/mm2)

Northwestern University Feinberg School of Medicine's Department of Radiology DIFFUSION MR

• Theory: malignant lesions have restricted diffusion and are bright while benign lesions do not although in practice not always true • Diffusion MR only adds few minutes in total

Northwestern University Feinberg School of Medicine's Department of Radiology Northwestern University Feinberg School of Medicine's Department of Radiology T1 FS POST GAD

T2

Northwestern University Feinberg School of Medicine's Department of Radiology T1 FS POST GAD

Better than T2

b500 Diffusion

Northwestern University Feinberg School of Medicine's Department of Radiology T1 FS POST GAD

Restricted

ADC

Northwestern University Feinberg School of Medicine's Department of Radiology “PHYSIOLOGIC RESTRICTED” DIFFUSION

Impeded water diffusion from high cellularity • Spleen • Adrenal • Lymph nodes • Kidneys • Testes • Penis • Hematopoietic bone marrow

Northwestern University Feinberg School of Medicine's Department of Radiology DWI OF KIDNEY, ADRENAL AND SPLEEN

Ciliated hepatic foregut

LA LA LA S S S

LK LK LK B50 B500 B800

LA = left adrenal LK = left kidney S = spleen

ADC

Northwestern University Feinberg School of Medicine's Department of Radiology IMPROVED CONSPICUITY: UNKNOWN PRIMARY

HASTE T2 T1 post

B500 ADC

Northwestern University Feinberg School of Medicine's Department of Radiology QUALITATIVE AND QUANTITATIVE EVALUATION OF DWI

• Qualitative-observe visually based on DWI and ADC map – use routinely more than quantitatively • High signal on high b value images (dark ADC map) suggest restricted diffusion generally from greater cellularity and integrity of cell membranes – Tumor with necrosis, hypocellular or cystic tumors restrict less

Northwestern University Feinberg School of Medicine's Department of Radiology DIFFUSION MRI-LIVER

• We use DWI routinely in all liver MR cases • Helpful in detection of hepatic lesions – similar to bone scan or PET scan – detect additional lesions – directs to re-review the conventional imaging to identify lesions • Helpful but has limitations in characterization of hepatic lesions – can confirm true lesion and not pseudolesion

Northwestern University Feinberg School of Medicine's Department of Radiology METASTASES AND LIVER CYST

ARTERIAL PHASE VENOUS PHASE

Northwestern University Feinberg School of Medicine's Department of Radiology CARCINOID METASTASES AND LIVER CYST

• Metastases bright on DWI (and dark on ADC) from restricted diffusion and cyst is darker (bright on ADC)

b500 ADC

mets cyst cyst

Northwestern University Feinberg School of Medicine's Department of Radiology METASTATIC WITH PRIOR THERAPY

T1 FS CE T1 FS

CE T1 FS CE T1 FS

Northwestern University Feinberg School of Medicine's Department of Radiology METASTATIC MELANOMA WITH PRIOR THERAPY

DWI b500 DWI b500

DWI b500 CE T1 FS

Northwestern University Feinberg School of Medicine's Department of Radiology LESION CHARACTERIZATION

• Especially helpful for and hemangiomas which may have free water • Limitations in distinguishing solid benign lesions (FNH and ) from malignant lesions (HCC and mets) • Restricted diffusion not only seen in tumors but also abscesses – restricted diffusion distinguish from simple cysts

Northwestern University Feinberg School of Medicine's Department of Radiology T2 SHINE THROUGH EFFECT

• Pitfall-signal intensity on DWI depends on both water diffusion and T2 relaxation time • Lesions with long T2 relaxation times (cysts, hemangiomas) may remain high signal on DWI and be mistaken for restricted diffusion • Referred to as “T2 shine-through”

Northwestern University Feinberg School of Medicine's Department of Radiology T2 SHINE THROUGH EFFECT IN CYST

• To avoid misinterpretation, should look at the high b value images and ADC map • Lesions that are high signal on high b value images and ADC are from T2 shine through b0 effect

b500

ADC = 4.4

Northwestern University Feinberg School of Medicine's Department of Radiology WHY NOT JUST LOOK AT THE ADC IMAGES?

• Poor signal to noise ratio • Use DWI to detect • Use ADC map image to differentiate restricted diffusion from T2 shine through

ADC

Northwestern University Feinberg School of Medicine's Department of Radiology WHY NOT JUST LOOK AT THE ADC IMAGES?

• Poor signal to noise ratio ADC • Use DWI to detect • Use ADC map image to differentiate restricted diffusion from T2 shine through

DWI

Northwestern University Feinberg School of Medicine's Department of Radiology WHY NOT JUST LOOK AT THE ADC IMAGES?

• Poor signal to noise ratio ADC • Use DWI to detect • Use ADC map image to differentiate restricted diffusion from T2 shine through

DWI

Northwestern University Feinberg School of Medicine's Department of Radiology GIST: NONSPECIFIC LIVER LESION

Northwestern University Feinberg School of Medicine's Department of Radiology RENAL DISEASE COULD NOT RECEIVE GADOLINIUM

Northwestern University Feinberg School of Medicine's Department of Radiology RESTRICTED DIFFUSION

b500

ADC

Northwestern University Feinberg School of Medicine's Department of Radiology Northwestern University Feinberg School of Medicine's Department of Radiology T2

Northwestern University Feinberg School of Medicine's Department of Radiology b500

ADC

Northwestern University Feinberg School of Medicine's Department of Radiology T2 T1 FS Post GAD T1 FS

T2 FS DWI b50 b800

ADC b500 ADC 32 YEAR OLD WITH MELANOMA AND UNSUSPECTED LIVER LESIONS

Northwestern University Feinberg School of Medicine's Department of Radiology 1 YEAR LATER: LESIONS LARGER AND NEW LESIONS WITH MORE DEFINITIVE FEATURES POST GAD

b50 b500 Art Phase Venous Phase

B50 New Lesion Art Phase Delayed Phase Washout

Northwestern University Feinberg School of Medicine's Department of Radiology HEPATOCELLULAR

POST GAD T1 FS T2

ADC = 1.6 b500 ADC

Northwestern University Feinberg School of Medicine's Department of Radiology RESTRICTED DIFFUSION LOW ADC = 1.26

b500 ADC

MALIGNANT? FNH

Northwestern University Feinberg School of Medicine's Department of Radiology FNH: NEED ANATOMIC IMAGES IN ADDITION TO DWI

T1 FS ARTERIAL PHASE POST GAD

T2 DELAYED POST GAD

Northwestern University Feinberg School of Medicine's Department of Radiology ABSCESSES

• Not only tumors have restricted diffusion and b400 low ADC • Abscesses can have restricted diffusion – DWI help distinguish abscesses from cysts

ADC

Northwestern University Feinberg School of Medicine's Department of Radiology LIVER CYST VS. LIVER ABSCESS

T2 T1 post contrast

T2 T1 post contrast

Northwestern University Feinberg School of Medicine's Department of Radiology LIVER CYST VS. LIVER ABSCESS

T2 T1 post contrast b1000

T2 T1 post contrast ADCb1000

Northwestern University Feinberg School of Medicine's Department of Radiology ADC OF LIVER LESIONS BOX AND WHISKERS PLOT

5.5

5 /s)

2 4.5 4

mm 3.5 -3 3 2.5 2 1.5 1

ADC (x10 0.5 0

HCC FNH Cyst Abscess Hemangioma

Miller FH, Hammond N, Siddiqi AJ et al. J Magn Reson Imaging. 2010 Jul;32:138-47

Northwestern University Feinberg School of Medicine's Department of Radiology LACK OF SPECIFICITY

Hemangioma Metastases

HCC Adenoma

Northwestern University Feinberg School of Medicine's Department of Radiology INTERPRETATION OF IMAGES AFTER IR TREATMENT

• Among the most difficult in radiology • No one fights to read these cases • Paradoxical increase in size is seen with ablative therapies such as RF ablation, TACE and Y90 radioembolization-result of hemorrhage and necrosis • No uniform standard of interpretation • Ring enhancement mistaken for tumor and may be post treatment changes including scar tissue or reactive edema

Northwestern University Feinberg School of Medicine's Department of Radiology DIFFUSION MR

• Lesions often don’t change in size or may grow following effective changes • Diffusion MR can play role in diagnosing response • Following therapy, tumors with restricted diffusion (dark on ADC maps) become less restricted diffusion (bright on ADC maps) – increase in ADC values • Some of changes in ADC may precede changes in size of lesion

Northwestern University Feinberg School of Medicine's Department of Radiology LIMITATIONS OF ANATOMIC ASSESSMENT

• Anatomic response lags behind functional changes • Difficult to prospectively predict tumor response

Pre Tx 6101513 monthsmonth months

Salem et al JVIR Dec 2005

Northwestern University Feinberg School of Medicine's Department of Radiology FUNCTIONAL IMAGING: DIFFUSION

Anatomic • Percentage enhancement on arterial and portal venous phases • Extracellular space • Tumor vascularity • Detects altered water mobility T1 post-gadolinium Functional • Cellularity • Integrity of the cell membrane

Diffusion-weighted (DWI)

Northwestern University Feinberg School of Medicine's Department of Radiology DIFFUSION: OVERSIMPLIFICATION

• Bright on diffusion images (dark ADC)-restricted diffusion-live tumor • Dark on diffusion images-favorable response • Successful treatment-dark on DWI and shows increase in ADC

Northwestern University Feinberg School of Medicine's Department of Radiology HCC PRETREATMENT

Bright

Northwestern University Feinberg School of Medicine's Department of Radiology HCC POST TREATMENT

Dark

Post contrast Post Treatment DWI Post Treatment

Post Treatment DWI Pretreatment

Northwestern University Feinberg School of Medicine's Department of Radiology Pre-Treatment

Arterial Phase Venous Phase DWI b50 Post-Treatment

Arterial Phase Venous Phase DWI b50

Northwestern University Feinberg School of Medicine's Department of Radiology T1 in Phase T2

Post GAD T1 FS

Northwestern University Feinberg School of Medicine's Department of Radiology DWI

PET

Northwestern University Feinberg School of Medicine's Department of Radiology PANCREATIC IMAGING

• DWI may help in detecting solid pancreatic with restricted diffusion • May not be able to distinguish chronic pancreatitis from because of overlap – i.e. poorly differentiated adenoca and mass-forming pancreatitis have low ADC from dense fibrosis

Northwestern University Feinberg School of Medicine's Department of Radiology

• Critical to detect early • Desmoplastic reaction accounts for low SI on T1FS images, hypoenhancement and restricted diffusion • DWI especially helpful in detection and characterization of liver and lymph node and peritoneal mets

Northwestern University Feinberg School of Medicine's Department of Radiology DIFFUSION EXAMPLE PANC CA

T2 MR T1 FS MR CE T1 FS MR

Northwestern University Feinberg School of Medicine's Department of Radiology DIFFUSION EXAMPLE PANC CA

DIFFUSION B500 ADC

Northwestern University Feinberg School of Medicine's Department of Radiology DIFFUSION EXAMPLE: ENDOCRINE TUMOR BEST SEEN ON DW

NCCT Early Post Contrast Venous Post Contrast

Northwestern University Feinberg School of Medicine's Department of Radiology ENDOCRINE TUMOR: DWI

b0 b500

T1 FS CE CT

Northwestern University Feinberg School of Medicine's Department of Radiology

Northwestern University Feinberg School of Medicine's Department of Radiology b0 b1000 ADC

Northwestern University Feinberg School of Medicine's Department of Radiology BACKGROUND

• Pancreatic and mass-forming focal pancreatitis can have similar imaging findings on anatomic MRI – Would be helpful for DWI to distinguish • Contradictory results have been seen using DWI in the literature and wanted to determine why – ADC values of pancreatic adenocarcinoma have been shown to be both higher and lower than mass-forming focal pancreatitis

Fattahi et al. J Magn Reson Imaging 2009;29:350-6 Lee et al J Magn Reson Imaging 2008;28:928-36

Northwestern University Feinberg School of Medicine's Department of Radiology MAY NOT BE ABLE TO DISTINGUISH

Mass-forming pancreatitis b500 (ADC = 1.27)

Adenocarcinoma b500 (ADC = 1.55)

Northwestern University Feinberg School of Medicine's Department of Radiology EXTRACELLULAR FIBROSIS

Mass-forming pancreatitis b500 (ADC=1.27)

Poorly differentiated b500 (ADC =1.55) adenocarcinoma

Extra-cellular fibrosis in No significant both pancreatitis and difference in ADC adenocarcinoma

Wang Y, Miller FH, Chen Zongming E et al. Radiographics. 2011

Northwestern University Feinberg School of Medicine's Department of Radiology RESULTS: ADCs OF LESION AFTER SUBDIVISION

5.5 5 P=0.001 4.5

4 0.98 1.77 1.33 1.53 2.32

/s) 3.5 2

3

mm 3 - 2.5 2 1.5

ADC (x10 ADC 1 0.5 0 Neuroendocrine Well-differentiated Mass-forming focal Poorly differentiated Well/Moderately Carcinoma Neuroendocrine Pancreatitis Adenocarcinoma differentiated (malignant) Tumor (non- Adenocarcinoma malignant)

Northwestern University Feinberg School of Medicine's Department of Radiology MALIGNANT ENDOCRINE: LOWER ADC VALUES

Malignant endocrine carcinoma ADC=0.87

Well-differentiated endocrine tumor ADC= 2.22

High density of cellularity Lower ADC values Cells with scant cytoplasm

Northwestern University Feinberg School of Medicine's Department of Radiology OVERLAP ONLY IN SMALL WELL DIFFERENTIATED WITH FIBROSIS

Malignant endocrine carcinoma ADC=1.17

Well-differentiated endocrine tumor ADC= 1.02

High density of cellularity Low ADC values High density of fibrosis

Northwestern University Feinberg School of Medicine's Department of Radiology RESULTS: ADCs OF LESION AFTER SUBDIVISION

5.5 5 P=0.02 4.5

4 0.98 1.77 1.33 1.53 2.32

/s) 3.5 2

3

mm 3 - 2.5 2 1.5

ADC (x10 ADC 1 0.5 0 Neuroendocrine Well-differentiated Mass-forming focal Poorly differentiated Well/Moderately Carcinoma Neuroendocrine Pancreatitis Adenocarcinoma differentiated (malignant) Tumor (non- Adenocarcinoma malignant)

Northwestern University Feinberg School of Medicine's Department of Radiology POOR DIFFERENTIATED TUMORS WITH MORE FIBROSIS: LOWER ADC

Poorly differentiated adenoca ADC=1.48

Moderately differentiated ADC=2.27 adenoca

Extra-cellular fibrosis Lower ADC values Limited glandular formation

Wang Y, Miller FH, Chen Zongming E et al. Radiographics. 2011

Northwestern University Feinberg School of Medicine's Department of Radiology DWI

• DWI did not distinguish mass-forming pancreatitis and adenocarcinoma – fibrosis in both • Grades of differentiation of tumors may be distinguished because of differences in cellularity, glandular differentiation and extra- cellular fibrosis

Northwestern University Feinberg School of Medicine's Department of Radiology Northwestern University Feinberg School of Medicine's Department of Radiology b500

ADC

Northwestern University Feinberg School of Medicine's Department of Radiology RENAL IMAGING

• Especially helpful when concern of NSF and cannot give gadolinium • Helps detect and confirm solid mass-suspect RCC • Other lesions can have restricted diffusion-abscesses, angiomyolipomas, • DWI images help guide to the anatomic abnormality which may be subtle

Northwestern University Feinberg School of Medicine's Department of Radiology UNSUSPECTED SMALL RCC

b800

ADC

Northwestern University Feinberg School of Medicine's Department of Radiology Northwestern University Feinberg School of Medicine's Department of Radiology NCCT Axial CECT Coronal CECT

Axial Postgad Coronal Postgad

b500 ADC

Northwestern University Feinberg School of Medicine's Department of Radiology PCKD IN HORSESHOE KIDNEY WITH FEVERS; COULDN’T GIVE GAD AS CONCERN OF NSF-LOW GFR

Coronal T2 Coronal T2

Northwestern University Feinberg School of Medicine's Department of Radiology Axial T2 b800

Northwestern University Feinberg School of Medicine's Department of Radiology ADC Map CT Guided Biopsy

Northwestern University Feinberg School of Medicine's Department of Radiology 51 YR OLD MYELODYSPLASTIC SYNDROME AND FEVERS

T1 FS T2

Northwestern University Feinberg School of Medicine's Department of Radiology Post GAD T1 FS

T2 Post GAD Sag T1 FS

Northwestern University Feinberg School of Medicine's Department of Radiology RESTRICTED DIFFUSION: DARK ADC

b800

ADC

Northwestern University Feinberg School of Medicine's Department of Radiology DWI BETTER THAN T2

Northwestern University Feinberg School of Medicine's Department of Radiology PYONEPHROSIS

64 year old male with rectal cancer: • Worsening renal function • Could not give GAD UNENHANCED CT

T2WI

DWI b500

ADC

Northwestern University Feinberg School of Medicine's Department of Radiology ADRENAL GLAND

• Most important lesions to distinguish are not cystic from solid lesions but adrenal adenomas from metastases or adrenal cell carcinoma • DWI is nonspecific; need very high specificity in the diagnosis of adenomas • While malignant adrenal masses show restricted diffusion, adrenal adenomas also may show restricted diffusion

Northwestern University Feinberg School of Medicine's Department of Radiology CARCINOMA: ADC 0.99

B500 B0 ADC

• Mean of was 1.47 without difference from other lesions except cysts being higher.

Northwestern University Feinberg School of Medicine's Department of Radiology ADENOMA: ADC 0.64 / SI DECREASE 46%

IN PHASE OUT PHASE

b500 b0

Northwestern University Feinberg School of Medicine's Department of Radiology ADCS OF ADRENAL LESIONS

5.50 5.00

/s) 4.50 2 4.00

mm 3.50 -3 3.00 2.50 2.00 1.50 1.00 ADC(x10 0.50 1.16 1.75 1.60 2.93 1.55 1.84 1.64 0.00

Cyst

Adenoma Carcinoma Metastasis Myelolipoma Hemorrhage

Pheochromocytoma

Miller FH, Wang Y, McCarthy RJ, et al. Am. J. Roentgenol 2010; 194: W179-W185

Northwestern University Feinberg School of Medicine's Department of Radiology 1.0 Signal intensity (% Decrease), AUC = 0.93 0.8 Lesion size (cm), 0.6 AUC = 0.82

0.4 ADC (x10-3 mm2/sec), AUC = 0.55 0.2

0.0 0.0 0.2 0.4 0.6 0.8 1.0 1 - Specificity

Miller FH, Wang Y, McCarthy RJ, et al. Am. J. Roentgenol 2010; 194: W179-W185

Northwestern University Feinberg School of Medicine's Department of Radiology LYMPH NODE AND PERITONEAL IMPLANTS

• One of best uses for DWI-lymph node metastases and small peritoneal implants • Conventional MR is not always ideal for showing lymph nodes and peritoneal implants-distinguishing from bowel can be difficult • DWI helps direct radiologist to pathology on conventional imaging

Northwestern University Feinberg School of Medicine's Department of Radiology LYMPH NODE AND PERITONEAL IMPLANTS

• In my opinion, DWI often does not distinguish benign from malignant lymph nodes but great sequence to show nodes • Increasing use of MR because of radiation concerns when doing multiple CT scans for followup imaging especially when young patients (testicular cancer and lymphoma) where lymph nodes and DWI are important

Northwestern University Feinberg School of Medicine's Department of Radiology TESTICULAR CANCER RECURRENCE: LYMPH NODES

T2 T1 FS

Diffusion b1000 b1000

Northwestern University Feinberg School of Medicine's Department of Radiology TESTICULAR CANCER WITH RECURRENCE BEST SEEN ON B800

b50 b500

Northwestern University Feinberg School of Medicine's Department of Radiology CANCER

T1 FS T2

DWI b1000

Northwestern University Feinberg School of Medicine's Department of Radiology FALLOPIAN TUBE CANCER

T1 FS

DWI b1000

Northwestern University Feinberg School of Medicine's Department of Radiology : DWI CRITICAL FOR METS

Sag Post GAD T1 FS Axial Post GAD T1 FS

Northwestern University Feinberg School of Medicine's Department of Radiology VULVAR CANCER: DWI CRITICAL FOR METS

Axial Post GAD T1 FS

DWI b500

Sag Post GAD T1 FS

Northwestern University Feinberg School of Medicine's Department of Radiology VULVAR CANCER: DWI CRITICAL FOR METS

Axial Post GAD T1 FS DWI b500

Northwestern University Feinberg School of Medicine's Department of Radiology APPENDICITIS IN PREGNANT PT

T2 True FISP T1 FS

Northwestern University Feinberg School of Medicine's Department of Radiology APPENDICITIS IN PREGNANT PT

T2 True FISP T1 FS

b800 ADC

Northwestern University Feinberg School of Medicine's Department of Radiology TUBO-OVARIAN ABSCESSES (TOA)

T2 T1FS POSTGAD T1FS

Northwestern University Feinberg School of Medicine's Department of Radiology TUBO-OVARIAN ABSCESSES (TOA)

T2 T1FS POSTGAD T1FS

DWI b800 ADC

Northwestern University Feinberg School of Medicine's Department of Radiology 28 YEAR OLD PELVIC PAIN AND FEVER

T2 T1 FS Post GAD

T1 FS T1 FS Post GAD

Northwestern University Feinberg School of Medicine's Department of Radiology DWI-TUBOOVARIAN ABSCESS (TOA)

DWI b800 ADC

Northwestern University Feinberg School of Medicine's Department of Radiology INTER-LOOP ABSCESS: 73 YEAR OLD W RECTAL CANCER PRIOR RT AND FEVER AND PAIN

T2 T1 post gad

DWI b800 ADC

Northwestern University Feinberg School of Medicine's Department of Radiology MR TO EVALUATE LIVER LESIONS

Northwestern University Feinberg School of Medicine's Department of Radiology Northwestern University Feinberg School of Medicine's Department of Radiology Northwestern University Feinberg School of Medicine's Department of Radiology Northwestern University Feinberg School of Medicine's Department of Radiology 60 YEAR OLD WOMAN: FOLLOW UP COMPLEX RENAL CYST JULY 2014

T1 Post Gad CECT

b500 ADC

Northwestern University Feinberg School of Medicine's Department of Radiology AUG 2013

T1 Post Gad b800 • Fungating, ulcerated partially obstructing adenocarcinoma in the distal transverse colon

Northwestern University Feinberg School of Medicine's Department of Radiology MR FOR FIBROID EVALUATION PRE UFE

Sagittal T2 Axial T2

Northwestern University Feinberg School of Medicine's Department of Radiology DIFFUSION-WEIGHTED IMAGES

b500

Northwestern University Feinberg School of Medicine's Department of Radiology UNSUSPECTED RECTAL CANCER

Sagittal T2 Axial T2

Northwestern University Feinberg School of Medicine's Department of Radiology UNSUSPECTED RECTAL CANCER

Sagittal Post Contrast Axial Post Contrast

Northwestern University Feinberg School of Medicine's Department of Radiology T2

Post GAD T1 FS

Northwestern University Feinberg School of Medicine's Department of Radiology BOTH ARE BRIGHT ON B50 IMAGE

b50

Northwestern University Feinberg School of Medicine's Department of Radiology B800 INFECTED BARTHOLIN GLAND CYST

ADC

Northwestern University Feinberg School of Medicine's Department of Radiology CONCLUSIONS

• DWI should be added to routine protocols • Helpful in detection of lesions in liver, kidney, pancreas, lymph nodes and peritoneal implants • Can be helpful in characterization – Solid from cystic masses – Abscesses from simple cysts • Assess therapy response prior to size changes

Northwestern University Feinberg School of Medicine's Department of Radiology ACKNOWLEDGEMENTS

• Dr. Shawn Haji-Momenian • Dr. Laura Kulik • Dr. Andrew Larson • Dr. Robert J Lewandowski • Dr. Reed Omary • Dr. Tom Rhee • Dr. Riad Salem • Dr. Yi Wang

Northwestern University Feinberg School of Medicine's Department of Radiology