Larry A. Binkovitz

Pediatric MR elastography of hepatic fibrosis: principles, technique and early clinical experience

Numerous pediatric conditions result in hepatic fibrosis. As treatments develop for the underlying disorders, a non-invasive assessment of liver fibrosis would be beneficial as an adjunct or possible replacement for the traditional gold standard, liver biopsy. Magnetic resonance elastography is a noninvasive imaging technique that has been used successfully in adults for identification and assessment of liver fibrosis. This review describes the basic principles of MR elastography as well as the technical aspects specific to children. Clinical pediatric applications, limitations and areas for future research are described.

Pediatric eosinophilic esophagitis: radiologic findings with pathologic correlation

BackgroundEosinophilic esophagitis is increasingly recognized as a cause of dysphagia or food impaction in pediatric patients. It has a high male predominance and is often associated with a history of allergy or asthma.ObjectiveTo correlate fluoroscopic findings in eosinophilic esophagitis with the endoscopic and histologic findings.Materials and methodsWe retrospectively reviewed the upper gastrointestinal (UGI) findings of eosinophilic esophagitis and correlated them with the clinical, endoscopic and histologic findings in a series of 17 children (12 boys, 5 girls).ResultsUGI findings were normal in 12 children, including 4 who had a normal UGI exam after endoscopic disimpaction for an obstructing food bolus. Five children had strictures identified on UGI: one was demonstrated with endoscopy. This suggests that the impactions and strictures were due to an esophageal dysmotility rather than a fixed anatomic abnormality.ConclusionBecause the UGI findings are frequently normal in eosinophilic esophagitis, radiologists need to have a high index of suspicion for this disease. In children with a strong clinical history, especially impaction in the absence of an esophageal stricture, endoscopy and biopsy are indicated for further evaluation.

Sciatic endometriosis: MR appearance

Endometriosis of the sciatic nerve is a rare but important cause of sciatica. Early on, the symptoms may be cyclic and be treated with local excision of the endometrioma from the sciatic nerve. If left untreated, it can result in marked cicatricial change of the sciatic nerve and require more radical surgical treatment. Due to the hemorrhagic nature of endometriomas and their characteristic location, the MR imaging findings can permit a specific diagnosis of sciatic endometriosis to be suggested. Therefore, MR imaging is recommended for evaluation of sciatica if the symptoms vary with the menstrual cycle or if there is a history of endometriosis. Early recognition of this disorder will facilitate appropriate treatment and minimize permanent damage to the sciatic nerve. The first surgically proven case of sciatic endometriosis with preoperative MR imaging is presented.

C-choline PET/CT in recurrent prostate cancer and nonprostatic neoplastic processes

Choline positron emission tomography (PET)/computed tomography (CT), with both carbon 11 ((11)C) choline and fluorine 18 ((18)F) choline, is an increasingly used tool in the evaluation of patients with biochemically recurrent prostate cancer. It has allowed detection and localization of locally recurrent and metastatic lesions that were difficult or impossible to identify using more conventional modalities. Many of the patients followed for their prostate cancer are elderly and have a higher rate of nonprostate cancer lesions or malignancies. As our experience with choline PET/CT has grown, it has become apparent that many of these nonprostate cancer processes, both benign and malignant, can be detected. Invasive thymoma, renal cell carcinoma, papillary thyroid carcinoma, and parathyroid adenoma are a few of the processes that have been incidentally detected with (11)C-choline PET/CT at our institution and have significantly altered subsequent clinical management of the patient. Although most of the secondary lesions are detected due to their increased (11)C-choline avidity, several have been detected due to their decreased or lack of avidity in the background of a highly avid organ. For instance, large liver masses that are relatively non-choline-avid create large activity defects in the otherwise highly active liver. Familiarity with normal (11)C-choline physiologic activity, the most common prostate metastatic patterns, and imaging characteristics of secondary lesions is essential for the detection and correct diagnosis of such lesions so that proper follow-up and management can be recommended.

Deficiency of interleukin-1-receptor antagonist syndrome: a rare auto-inflammatory condition that mimics multiple classic radiographic findings.

Deficiency of interleukin-1-receptor antagonist (DIRA) syndrome is a newly identified inflammatory disease of the skeleton and appendicular soft tissues presenting in early infancy that has yet to be reported in the radiology literature. The radiological manifestations of DIRA syndrome include multifocal osteitis of the ribs and long bones, heterotopic ossification and periarticular soft-tissue swelling. Thus, the pediatric radiologist should be made aware of this novel disease because its radiographic findings can mimic multiple other disease entities. With knowledge of the unique clinical presentation of DIRA syndrome and its multiple radiographic manifestations, the pediatric radiologist may be the first to suggest the correct diagnosis.

Advances in Gynecologic Imaging and Intervention

Advances in diagnostic imaging of the female genital tract facilitate characterization of many pelvic masses. Preoperative assessment of gynecologic malignant tumors provides information that may alter the surgical approach or timing of radiation therapy. Image-guided biopsy accurately confirms recurrent malignant lesions. Transcervical techniques have improved diagnostic assessment of infertile couples; thus, effective and inexpensive treatment options can be offered. Postoperative complications of gynecologic procedures can be detected with imaging, and many can be treated with image-guided techniques.

A novel sclerosing skeletal dysplasia with mixed sclerosing bone dysplasia, characteristic syndromic features, and clinical and radiographic evidence of male–male transmission†‡

We report on a father and his 4‐year‐old son sharing a characteristic dysmorphic facial phenotype (including hyperteleroism, prominent forehead, and wide nasal bridge), macrocephaly, hearing loss, palatal clefting, developmental delay, hypotonia and bony abnormalities including marked cranial sclerosis and sclerosis of the ribs and long bones, which evolved in severity in the son between the ages of 2 and 4 years. The fathers radiographs also showed prominent coarse striations, patchy metaphyseal sclerotic plaques, markedly increased bone density and cortical thickening of long bones, and significant degenerative changes in the thoracic spine. The son has an additional history of sleep apnea resulting from multi‐level airway obstruction that includes adenoid hypertrophy, lingual tonsil hypertrophy, subglottic stenosis, and supra‐arytenoid tissue consistent with laryngomalacia and tracheomalacia. The clinical, radiographic, and genetic findings in father and son are consistent with a sclerosing skeletal dysplasia syndrome with similarities to mixed sclerosing bone dysplasia (MSBD) including metaphyseal plaques, osteopathia striata, and cranial sclerosis (OS–CS). This family may represent one of the first descriptions of familial inheritance and evolving phenotype in MSBD. The evidence for male–male transmission would support the existence of an autosomal mechanism of inheritance for a novel form of MSBD with characteristic syndromic features.

Pediatric radiology mission work: opportunities, challenges and outcomes

The lack of access to imaging studies and radiologic expertise is a global issue receiving increasing attention in the news media [1, 2]. The need for radiologists to apply their interpretive skills and interventional techniques to children in resource-poor areas is global, with major medical resource and disease discrepancies (Fig. 1). The desire to care for children with medical needs is a common impulse among pediatric health care workers. As aptly put by Shaywitz and Ausiello [3], “It is difficult to imagine a pursuit more closely aligned with the professional values and visceral instincts of doctors than the quest to improve global health.” A recent survey noted that 72% of radiology residents had interest in doing such work, but only 4% of radiology residency programs offered elective international aid experiences [4]. In our discussions with other pediatric radiologists, it seems that this nearly universal desire to participate in global outreach efforts is often hampered by a lack of knowledge as to how to get started. Efforts to close the gap between theory and practice have been undertaken [5], and the purpose of this paper is to provide the tools for pediatric radiologists who are interested in participating in global outreach efforts to act. The range of opportunities for pediatric radiologists to contribute to global outreach efforts is discussed in the paper’s first section: on-site mission work, teleradiology, and virtual or on-site teaching and consultation. These include primary or secondary interpretations of examinations done at a remote site via teleradiology, on-site pediatric radiology at underserved areas (radiology mission work), and virtual and on-site teaching and consultation. In the second section the authors discuss many of the challenges that arise when considering global outreach in resource-poor areas based on their experiences. This includes practical issues of international travel with equipment, interactions with local health care workers, personal health and safety, and personal emotional and ethical challenges. Last, the authors present the outcomes that have been achieved through pediatric radiology outreach programs.

Upright Biplanar Slot Scanning in Pediatric Orthopedics: Applications, Advantages, and Artifacts

OBJECTIVE Digital slot scanning is a relatively new technology that has been used for imaging of pediatric orthopedic conditions such as scoliosis and leg-length discrepancies. This article will review the clinical applications, advantages, and unique artifacts of this new technology. CONCLUSION Upright biplanar slot scanners acquire high-resolution radiographs simultaneously in two orthogonal planes with reduced radiation dose. Other advantages include a more physiologic weightbearing imaging position, improved Cobb angle measurements, and 3D modeling.

Pretreatment imaging of peripheral vascular malformations

Peripheral vascular malformations (VMs) are complex and diverse vascular lesions which require individualized pretreatment planning. Pretreatment imaging using various modalities, especially magnetic resonance imaging and time-resolved magnetic resonance angiography, is a valuable tool for classifying peripheral VMs to allow proper diagnosis, demonstrate complete extent, identify the nidus, and distinguish between low-flow and high-flow dynamics that determines the treatment approach. We discuss pretreatment imaging findings in four patients with peripheral VMs and how diagnostic imaging helped guide management.