Original Research
Special Articles
January 14, 2013

MRI for Evaluation of Myeloid Sarcoma in Adults: A Single-Institution 10-Year Experience

Abstract

OBJECTIVE. The purpose of this study was to evaluate the utilization and role of MRI in the management of myeloid sarcoma in adults.
MATERIALS AND METHODS. A retrospective study of 69 patients with pathologically proven myeloid sarcoma included 25 patients (16 men, nine women; mean age, 55 years; range, 22–78 years) who underwent pretreatment MRI at our institution from January 2001 to October 2011. A total of 71 MRI examinations were evaluated by two radiologists in consensus.
RESULTS. A total of 41 sites of involvement of myeloid sarcoma were noted, most commonly bone (13/25, 52%), muscle (7/25, 28%), CNS (6/25, 24%), and head and neck (6/25, 24%). Nineteen sites were noted on MR images obtained for evaluation of a new sign or symptom, most commonly musculoskeletal (11 sites) and CNS (six sites). Fifteen sites were noted on MR images obtained for further evaluation of a previously detected abnormality, most commonly in the abdomen and pelvis (seven sites). Seven lesions were incidentally found on MR images obtained for other myeloid sarcoma–related indications, most commonly in the head and neck (three lesions) and musculoskeletal system (three lesions). The mean size of measurable lesions was 5.6 cm (range, 1–20 cm). Compared with muscle, the lesions were isointense (31/41, 75.6%) or hypointense (10/41, 24.4%) on T1-weighted images and mildly hyperintense (39/41, 95.1%) on T2-weighted images and had homogeneous enhancement (29/38, 76.3%).
CONCLUSION. In our experience, MRI was most often used for evaluation of bone, muscle, the CNS, and the head and neck region. MRI is useful for evaluation of new musculoskeletal and CNS findings and for further evaluation of known abdominopelvic masses. Incidental findings are often musculoskeletal or in the soft tissues of the head and neck.
Myeloid sarcoma (MS), also known as chloroma and granulocytic sarcoma, is an extramedullary tumor composed of primitive myeloid cells first observed by Burns in 1823 as a “green tumor” [1]. Although MS lesions most commonly involve bones, soft tissue, and skin, almost any organ can be affected [24]. Clinically, MS has a greenish hue caused by the presence of myeloperoxidase in the myeloid cells [3]. MS can be associated with acute myeloid leukemia (AML), myelodysplastic syndrome (MDS), and myeloproliferative neoplasm (MPS). It can occur as the initial symptom of the underlying hematologic malignancy or be the first sign of relapse [5]. Occasionally, MS occurs in the absence of underlying hematologic malignancy, preceding systemic malignancy by months or years [5, 6].
Clinical parameters such as age at presentation, sex, anatomic site, presentation, and pathologic features do not affect clinical behavior or treatment response [2, 5]. The imaging literature on MS is mainly in the form of case reports and pictorial reviews [7, 8]; the imaging features of MS have been systematically evaluated in only a few reports [911]. To the best of our knowledge, there is no consensus on the imaging evaluation of MS, and the clinical utilization of MRI in the care of patients with MS and the imaging features have not been reported. The purpose of this study was to study the utilization and role of MRI in the management of MS in adults.

Materials and Methods

Subjects

In this institutional review board–approved, HIPAA-compliant retrospective study, informed consent was waived. The electronic medical records of 69 patients with pathologically proven MS seen at our institution from January 2001 to October 2011 were reviewed, and all the patients who underwent pretreatment MRI at our institution and had images available for review were identified. Twenty-five patients (16 men, nine women; mean age, 55 years; range, 22–78 years) met the inclusion criteria and were included in the study cohort.
TABLE 1: Distribution of Myeloid Sarcoma Lesions Detected on MR Images of 25 Patients

Clinical and Pathologic Features

The clinical features of MS, such as the underlying hematologic malignancy, if any, and stage of disease at presentation of MS were noted. Dates of diagnosis of MS and of underlying malignancy were recorded. The histologic features were reviewed by a pathologist with expertise in hematopathology to confirm the diagnosis of MS. Bone marrow biopsy results before and after MS detection were also reviewed. Treatment offered for MS was recorded. The intervals between diagnosis of primary hematologic malignancy and presentation of MS, between presentation of MS and first occurrence of systemic disease, and survival after detection of MS were calculated.

Image Analysis

Two cancer imaging fellowship-trained radiologists with 12 and 8 years of experience reviewed in consensus the images from 71 MRI examinations performed for MS-related indications in the care of the 25 patients. Images from another 18 MRI examinations of patients with MS performed for unrelated indications were evaluated separately. No findings related to MS were made, and these examinations were not included in the study. The following MRI features of pathologically proven MS were recorded: location, size of the measurable lesions (largest dimension), T1 and T2 signal intensity compared with skeletal muscle, degree and homogeneity of enhancement, and infiltration into adjacent structures. Multiple lesions in one organ were considered a single site. For example, multiple osseous lesions in the axial and appendicular skeleton and multiple liver lesions were considered single sites. When multiple lesions were present in a single organ, the maximum dimension of the largest lesion was used for size calculation, and representative lesions were used for imaging feature analysis.

Utilization of MRI

For each site of MS involvement, the reason behind the order for MRI and whether that site was previously known (clinically or from previous imaging) was noted. The number of patients who underwent MRI of different body parts and the proportion of examinations with positive findings were noted.

Statistical Analysis

The time interval between diagnosis of underlying hematologic abnormality and detection of MS for AML was compared with that for MDS and MPS by use of nonparametric Mann-Whitney test. The survival period after detection of MS was calculated and compared by log-rank test for various underlying diseases and common sites of MS. The nonparametric tests were used when appropriate to minimize the effect of a few outlying values.

Results

Clinical and Pathologic Features

MS presented during remission of another hematologic disorder in 20 (80%) patients. In five (20%) patients, MS was the initial or only presentation of malignancy. AML (16 [64%] patients) and MDS (four [16%] patients) were the most common associated malignancies. Other associated hematologic disorders associated with MS included chronic myeloid leukemia in three (12%) patients and essential thrombocythemia and polycythemia vera in one (4%) patient each. One of the AML patients initially presented with isolated MS, that is, without underlying disease, but AML developed 5 months later. MS was pathologically confirmed in all cases. The median interval between initial presentation of hematologic disorder and MS was 29.5 months (range, 0–188 months). Of 20 patients in whom MS developed while the hematologic disorder was in remission, bone marrow results for leukemic involvement became positive in eight patients (40%) after the diagnosis of MS and remained negative in 12 (60%) patients.

Imaging Features

All of 41 sites of involvement were found in 25 patients. Bone (13 patients, 52%) (Figs. 1A, 1B, and 1C), muscle (seven patients, 28%) (Figs. 2A, 2B, and 2C), CNS (six patients, 24%), and soft tissues of the head and neck (six patients, 24%) were the most common sites of involvement. Table 1 lists the anatomic distribution of MS in this study.
Of total 41 sites, 38 sites had measurable lesions. The mean size of the measurable lesions was 5.6 cm (range, 1–20 cm). In three patients, only nodular meningeal thickening and enhancement were present, and the lesions were considered nonmeasurable. On T1-weighted images, 31 (75.6%) lesions were isointense to skeletal muscle (Figs. 1A, 1B, 1C, 2A, 2B, and 2C), and 10 (24.4%) were hypointense compared with muscle. On T2-weighted images, 39 (95.1%) lesions were mildly hyperintense (Figs. 1A, 1B, 1C, 2A, 2B, and 2C), and two (4.9%) were isointense compared with muscle. No lesion had evidence of hemorrhage. Evaluation of calcification with MRI is limited, but there was no obvious calcification. Enhancement could not be assessed at three sites because MRI was performed without IV gadolinium contrast material. Among the 38 sites for which contrast-enhanced MR images were available, all exhibited enhancement; 34 (89.5%) lesions had greater enhancement than that of muscle (Figs. 2A, 2B, and 2C), and four (10.5%) lesions had enhancement similar to that of muscle (Figs. 1A, 1B, and 1C). Twenty-nine (76.3%) lesions exhibited homogeneous enhancement (Figs. 1A, 1B, and 1C), and nine (23.7%) lesions were heterogeneously enhancing with central nonenhancing areas (Figs. 2A, 2B, and 2C). These nonenhancing foci could represent areas of necrosis. Infiltration into adjacent structures was seen at 10 (24.4%) sites.

Common Locations

Among 13 patients (52% of total) with osseous involvement, eight had involvement of multiple bones and five of a solitary bone; however, all 13 patients had multiple discrete osseous lesions. Lower extremity bones were involved in five patients (femur in four, tibia in two) (Figs. 1A, 1B, and 1C). The spine was involved in five patients (lumbar spine in two, cervical spine in two, and dorsal spine in one). Pelvic bones involved included the sacrum in three patients and upper extremity bones and the calvaria in two patients each. All lesions were associated with soft-tissue masses ranging in size from 1.5 to 11.2 cm (mean, 4.5 cm) that were hypointense on T1-weighted images and hyperintense on T2-weighted images.
Fig. 1A 45-year-old man with involvement of femur and tibia by myeloid sarcoma who originally presented with chronic myeloid leukemia.
A, Coronal T1-weighted MR image shows large lesions in distal femur and proximal tibia (arrows) and numerous other smaller lesions, which are isointense to hypointense compared with skeletal muscle.
Fig. 1B 45-year-old man with involvement of femur and tibia by myeloid sarcoma who originally presented with chronic myeloid leukemia.
B, Axial T2-weighted MR image through distal femur shows isointense to mildly hyperintense lesion (straight arrow). Lesion is heterogeneous with hyperintense area (curved arrow) at periphery.
Fig. 1C 45-year-old man with involvement of femur and tibia by myeloid sarcoma who originally presented with chronic myeloid leukemia.
C, Coronal fat-suppressed gadolinium-enhanced T1-weighted MR image shows mild homogeneous enhancement of larger lesions (arrows).
Fig. 2A 57-year-old woman with myeloid sarcoma of pelvis and gluteus maximus muscle who originally presented with acute myeloid leukemia.
A, Axial fat-suppressed T1-weighted MR image shows parauterine mass (arrow) and mass in left gluteus maximus muscle (arrowheads). Both masses are isointense to muscle.
Fig. 2B 57-year-old woman with myeloid sarcoma of pelvis and gluteus maximus muscle who originally presented with acute myeloid leukemia.
B, Axial T2-weighted MR image shows mildly hyperintense mass (thick straight arrow) abutting lower uterine segment (curved arrow). Mass in gluteus maximus muscle (arrowhead) is also mildly hyperintense compared with contralateral normal muscle (thin straight arrow).
Fig. 2C 57-year-old woman with myeloid sarcoma of pelvis and gluteus maximus muscle who originally presented with acute myeloid leukemia.
C, Axial gadolinium-enhanced MR image shows heterogeneously enhancing parauterine mass (thick arrow) and homogeneously enhancing gluteal mass (arrowhead) with enhancement similar to or greater than that of normal muscle (thin arrow).
In all seven patients (28% of total) with muscular involvement, a single muscle or muscle group was involved. All of these patients had primary involvement of muscle; no patient had secondary infiltration of the musculature by MS lesions involving other organs. Gluteal musculature involvement was most common (Figs. 2A, 2B, and 2C), seen in three patients. The obturator, thigh (hamstrings), infraspinatus, and temporalis muscles were involved in one patient each. All lesions were isointense to hypointense compared with the adjacent musculature on T1-weighted images and mildly hyperintense on T2-weighted images, ranging in size from 1.2 to 16 cm (mean, 6.7 cm). Erosion of adjacent cortical bone was seen in one patient.
Among six patients (24% of total) with CNS involvement, nodular meningeal enhancement and thickening were seen in four patients (leptomeningeal involvement in two, pachymeningeal involvement in two); all cases were pathologically confirmed. One patient also had diffuse leptomeningeal enhancement involving the spinal cord. Three patients with meningeal involvement had no focal masses. Focal masses were identified in three of six patients with CNS involvement. One of the three had a 2.1-cm T2-hyperintense mass posterior to the cerebellum with a dural tail, initially thought to be a meningioma. The second patient had a 1.3-cm enhancing dura-based nodule in the anterior compartment, and the third patient had expansion and enhancement of the optic nerve measuring 1.5 cm in thickness. The focal CNS masses exhibited restricted diffusion.
Six patients (24% of the total) had MS in the head and neck. Two of these patients had MS masses involving the paranasal sinuses, one with involvement of the nasal cavity. One patient had a 2.5-cm enhancing intraconal orbital mass with restricted diffusion. One patient had bilateral parapharyngeal masses. Two subcutaneous nodules, the larger measuring 2.2 cm, were seen in one patient, and a 4.5-cm periauricular mass was present in one patient. Masses ranged in size from 2.2 to 8.3 cm (mean, 4.1 cm). Despite the heterogeneity in distribution, all lesions had signal intensity similar to that of MS lesions in other locations. In addition to these six patients, one patient had MS involving the temporalis muscle, which was classified as muscular involvement.
All four patients with retroperitoneal involvement had large infiltrative masses (mean size, 12.3 cm; range, 7.9–20 cm). One mass encased the kidney and ureter, and one mass originated in the perinephric region and infiltrated paraspinal muscles and the epidural space. In one patient a slow-growing retroperitoneal MS masqueraded as retroperitoneal fibrosis during two MRI examinations and at initial biopsy. The lesion proved to be MS only when it grew and was rebiopsied. Of the three pelvic masses, two appeared as parauterine masses (Figs. 2A, 2B, and 2C) and one as an ovarian mass. One of these masses invaded the obturator muscle. One patient had multiple subcentimeter liver lesions; another patient had a large anterior mediastinal mass.

Utilization of MRI

In this study, MRI was used for evaluation of osseous, soft-tissue, and CNS involvement or for pretreatment planning. MRI proved useful in the evaluation of MS in three ways: evaluation of new signs and symptoms, additional evaluation of an abnormality previously detected with imaging such as CT and ultrasound (mainly for treatment planning), and incidental detection of findings at MRI performed for one of the other two indications. Among 41 sites of involvement, 19 sites (46.3%) were noted at MRI performed for evaluation of a new sign or symptom. These sites involved osseous structures (n = 8), the CNS (n = 6), muscles (n = 3), and the head and neck region (n = 2). Fifteen (36.6%) sites were examined with MRI for further evaluation of a previously detected abnormality, which included abnormalities in the abdomen and pelvis, including the retroperitoneum (n = 7), osseous structures (n = 3), muscles (n = 3), chest (n = 1), and head and neck (n = 1). Seven (17.1%) sites of involvement were incidentally detected in the head and neck (n = 3), osseous structures (n = 2), muscle (n = 1), and pelvis (n = 1).
MRI was most often used for evaluation of the brain, head and neck, and spine. Among the 25 patients, 13 underwent brain or head and neck MRI. Nine of these MRI examinations showed findings related to MS, and four had unremarkable findings. Ten patients underwent MRI of the spine; six patients had abnormal and four had normal findings. Of the total 49 examinations performed on the brain or head and neck and the spine, only 21 (42.9%) had abnormal findings. On the other hand, of 22 examinations of the torso and extremities of 18 patients (pelvis, seven patients; abdomen, five; extremities, five; chest, one patient), 21 examinations of 17 patients had abnormal findings, mainly because most of these examinations were performed for evaluation of previously known findings or because of high clinical suspicion.

Survival Analysis

The median interval between the presentations of AML and of MS was 26 months (range, 0–158 months). The interval between the presentation of MDS or MPS and detection of MS was 45 months (range, 7–188 months). The difference between these intervals was not statistically significant. Among 25 patients in the study, 24 had died. The median survival time after the diagnosis of MS was 7.5 months (range, 1–41 months). There was no difference in survival times of patients with acute leukemia (median, 8 months; range 4–38 months) and those with chronic hematologic disorders (median, 7 months; range, 1–21 months). Similarly, for different sites of involvement, there was no difference between the interval from the initial diagnosis of hematologic abnormality and the presentation of MS or survival after the diagnosis of MS. There was no relation between survival and number of involved sites.

Discussion

In this study, MS was associated with a variety of hematologic abnormalities, including AML, MDS, and MPS, and occurred as an initial presentation of an underlying hematologic disorder, during remission, or at other times without evidence of hematologic malignancy, as previously reported [3, 5]. In 40% of the sites found during remission, bone marrow never exhibited evidence of recurrent leukemia. In our study, the median survival period after the diagnosis of MS was 7.5 months (range, 1–41 months), and there was no correlation between survival and characteristics of MS such as underlying hematologic abnormality, type of presentation, or site of involvement. Similar observations were made by Pileri et al. [2]. In short, mere detection of MS heralds poor outcome irrespective of the clinical setting. Given this influence of diagnosis of MS on prognosis, radiologists have the responsibility of timely diagnosis of MS, and it is important for radiologists to be aware of the distribution and imaging features of MS. To the best of our knowledge, this study is the most extensive describing the MRI features of MS in various anatomic locations and the clinical utility of MRI in such patients. Previous studies have evaluated only spinal involvement by MS [11] and MRI features in a small number of patients [9].
Histologically, MS is composed of sheets of immature myeloid cells, mainly myeloblasts, that infiltrate the involved tissue (Figs. 3A, 3B, 3C, and 3D). At immunohistochemical staining, CD68, lysozyme, and CD43 are the most widely expressed markers with variable expression of a wide range of other antigens, including myeloperoxidase, CD33, CD34, CD117 (c-Kit), CD4, CD56, and terminal deoxynucleotidyl transferase, depending on the lineage and stage of maturation. Of note, in accordance with the common monocytic features of MS, results for markers of myeloid immaturity (CD34 and CD117) are often completely negative, or only a small subset of cells in the infiltrate have positive staining results. In such cases, the diagnosis can be confirmed only by careful histologic examination, along with application of monocytic markers such as lysozyme and CD68.
In our study sample, the male-to-female ratio of 1.8:1 with a wide age range was similar to that in a previous report [3]. MS can occur almost anywhere in the body [24]. In our study, bones (52% of patients), muscles (28%), the CNS (24%), and the head and neck (24%) were the most common sites of MS. This distribution is similar to the largest available autopsy study of 23 patients [3]. Compared with that study, we found a lower prevalence of involvement in almost all anatomic sites, either because some areas were not evaluated with MRI or because some lesions develop toward the end of life, when little imaging is performed.
Fig. 3A Photomicrographs show pathologic features of myeloid sarcoma.
A, Tumor is composed of sheets of mononuclear cells with irregular nuclear contours, fine chromatin, and moderate amounts of pale cytoplasm consistent with myeloblasts.
Fig. 3B Photomicrographs show pathologic features of myeloid sarcoma.
B, Immunohistochemical staining shows myeloblasts with diffuse membranous expression of CD34 (marker of myeloid precursor cells) (B), cytoplasmic staining for CD68 (marker of monocyte-macrophage lineage) (C), and subset of cells positive for lysozyme (D).
Fig. 3C Photomicrographs show pathologic features of myeloid sarcoma.
C, Immunohistochemical staining shows myeloblasts with diffuse membranous expression of CD34 (marker of myeloid precursor cells) (B), cytoplasmic staining for CD68 (marker of monocyte-macrophage lineage) (C), and subset of cells positive for lysozyme (D).
Fig. 3D Photomicrographs show pathologic features of myeloid sarcoma.
D, Immunohistochemical staining shows myeloblasts with diffuse membranous expression of CD34 (marker of myeloid precursor cells) (B), cytoplasmic staining for CD68 (marker of monocyte-macrophage lineage) (C), and subset of cells positive for lysozyme (D).
Although the size of MS lesions is variable, the mean size of measurable lesions in our study was 5.6 cm. The lesions were isointense to hypointense compared with skeletal muscles on T1-weighted images and were mildly hyperintense on T2-weighted images, usually showing homogeneous enhancement greater than that of muscle. Central nonenhancing areas suggestive of necrosis were seen in 23.7% of patients, usually in larger masses. Although appearance of a new mass almost anywhere in the body in a patient with hematologic malignancy, especially leukemia, should raise concern for MS, the imaging features are nonspecific, and histologic diagnosis is usually needed. Diagnosis can be challenging in the care of patients without a history of hematologic malignancy. Therefore, MS should be considered in the differential diagnosis of new mildly T2-hyperintense, homogeneously enhancing soft-tissue masses.
We noted that most of the patients with osseous involvement had involvement of multiple bones, commonly the spine, pelvic bones, and lower extremities. In terms of muscular involvement, the gluteal and thigh musculature was most commonly affected. CNS involvement became evident as thin nodular leptomeningeal or pachymeningeal enhancement or, less commonly, as focal enhancing masses. We did not find any difference in prognosis between patients with and those without CNS involvement. This finding differs from a previous report in which children with CNS involvement had better survival [12].
Retroperitoneal masses tended to be large, possibly because of late presentation. These lesions can encase the kidney and ureter, invade paraspinal muscles, and cause epidural extension. MS can masquerade as other diagnoses. For example, one retroperitoneal mass was thought to be retroperitoneal fibrosis at imaging and even at first biopsy, and another posterior fossa mass was initially thought to be meningioma at imaging. Both of the patients had a history of leukemia that was in remission. These cases show the importance of having a high degree of clinical suspicion of MS, especially in patients with history of hematologic disease.
At MRI, the differential diagnosis of MS includes extranodal lymphoma, which typically has low to intermediate signal intensity on T1-weighted images and mildly high signal intensity on T2-weighted images [9, 13, 14]. Extraosseous myeloma may present with similar imaging features [15, 16]. Other differential diagnoses include carcinoma, sarcoma such as gastrointestinal stromal tumor and rhabdomyosarcoma, infection, metastasis, hematoma, and inflammatory process [7, 9, 14]. At pathologic examination, an infiltrate of immature myeloid cells (predominantly myeloblasts) is observed and can be confirmed by application of appropriate immunohistochemical markers. MS most often has a monocytic phenotype; lysozyme, CD68, and CD43 are therefore the best available diagnostic markers.
In our experience, MRI was mainly used for evaluation of new musculoskeletal or CNS findings and for further evaluation of known abdominopelvic masses. Incidental findings are often seen in musculoskeletal structures or in the soft tissues of the head and neck. MRI was helpful for evaluation of new signs and symptoms, for further evaluation of an abnormality previously detected at imaging examinations such as CT and ultrasound (mainly for treatment planning), and for incidental detection of new sites of involvement at MRI performed for one of the other indications. MRI, because of its excellent soft-tissue contrast, is especially useful for treatment planning. Given that any site in the body can be affected by MS, whole-body MRI, possibly with diffusion-weighted imaging, may be of benefit in imaging of these patients, as it is in patients with multiple myeloma [17, 18].
The limitations of this study include its retrospective design and relatively small number of patients. However, MS is a rare condition, and to our knowledge, this study is the most extensive describing the MRI features of MS at sites outside the spine. More extensive studies would be helpful for confirming our conclusions. Another limitation was that we looked only at MR images of the patients; therefore, some sites of involvement may not be represented. However, the purpose of this study was to describe the MRI features of MS and the utility of MRI in clinical practice. Most of the patients did not undergo follow-up MRI, thus treatment-related changes could not be described. Because the imaging was performed over several years, the scanning protocols were variable, and we could not assess the utility of diffusion-weighted imaging for all of the patients. Diffusion was restricted in the limited number of patients for whom diffusion-weighted images were available.

Conclusion

MS can be associated with a variety of hematologic abnormalities and can occur at the initial presentation of an underlying hematologic disorder, during remission, and at other times, even in isolation. The median survival time after the diagnosis of MS was only 7.5 months in this study and was not affected by the underlying hematologic abnormality, presentation, or site of involvement. In our experience, MRI was mainly used for evaluation of new musculoskeletal and CNS findings and for further evaluation of known abdominopelvic masses. MRI often incidentally depicts new sites of involvement in musculoskeletal structures and in soft tissues of the head and neck. MS can occur anywhere in the body. Bone, muscle, CNS, and the head and neck region are the most common sites of involvement. MS presents as T1-isointense to -hypointense, mildly T2-hyperintense, usually homogeneously enhancing masses. Given the poor prognosis, it is important for radiologists to be aware of the distribution and imaging features of MS and to have a high index of suspicion for MS, especially in patients with a history of hematologic disease.

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Information & Authors

Information

Published In

American Journal of Roentgenology
Pages: 1193 - 1198
PubMed: 23169708

History

Submitted: April 9, 2012
Accepted: April 30, 2012

Keywords

  1. chloroma
  2. granulocytic sarcoma
  3. MRI
  4. myeloid sarcoma

Authors

Affiliations

Atul B. Shinagare
Department of Imaging, Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA 02215.
Department of Radiology, Brigham and Women’s Hospital, Boston, MA.
Katherine M. Krajewski
Department of Imaging, Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA 02215.
Department of Radiology, Brigham and Women’s Hospital, Boston, MA.
Jason L. Hornick
Department of Pathology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA.
Katherine Zukotynski
Department of Imaging, Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA 02215.
Department of Radiology, Brigham and Women’s Hospital, Boston, MA.
Vikram Kurra
Department of Imaging, Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA 02215.
Department of Radiology, Brigham and Women’s Hospital, Boston, MA.
Jyothi P. Jagannathan
Department of Imaging, Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA 02215.
Department of Radiology, Brigham and Women’s Hospital, Boston, MA.
Nikhil H. Ramaiya
Department of Imaging, Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA 02215.
Department of Radiology, Brigham and Women’s Hospital, Boston, MA.

Notes

Address correspondence to A. B. Shinagare ([email protected]).

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