20130426 chawla mr enterography technique and …car.ca/uploads/education lifelong...
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Dr Tanya Chawla Division of Abdominal Imaging
MR Enterography ; Technique and applications
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1.All of the following are biphasic oral contrast agents except;
a) Water b) VoLumen ® c) Blueberry juice d) Locust bean gum e) Methylcellulose
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2.The following MRI findings correlate highly with activity in Crohn’’s disease Except
a) T2 hyperintensity within the bowel wall b) Mural thickening c) Lymphadenopathy d) Degree of enhancement e) Pattern of enhancement
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Overview � MRI
� Technique � Performance characteristics � Radiation implications of CT
� Crohns’ � Concept /utility of imaging and damage
score � Role of diffusion weighted imaging (DWI) � Other applications
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Why MRI? � Visualization of entire GI tract � Luminal distension pre-requisite
� Avoids false positives � Overlooking diseased segments
� Absence of ionizing radiation � Multi-planar capability � Superior soft tissue and anatomical resolution � Dynamic and functional information � Better safety profile of contrast media � Repeated imaging pre and post Rx not an issue
Introduction Technique Crohn’’s Other apps Conclusion
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Introduction Technique Crohn’’s Other apps Conclusion
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Contrast agents ü Homogenous and uniform distension
ü Absence of serious side effects
ü Relatively low cost
ü High contrast between lumen and bowel wall
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Contrast agents Type Benefits Disadvantage Examples Positive Detect wall
thickening May mask enhancement Limited in subtle mucosal disease
Dilute gadolinium chelate Manganese chloride Ferrous ammonium citrate Blueberry juice
Increased T1 signal intensity causes by paramagnetic effect
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Contrast agents Type Benefit Disadvantage Examples Negative Bowel
inflammation more detectable Inter-loop abscesses
Reduced conspicuity of bowel wall Mask low signal lesions
SPIO USPIO Ferumoxsil
Induce local field inhomogeneity and shorten T1 and T2 relaxation
Achiam et al Eur Rad;Jan 2010
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Biphasic Water,Mannitol VoLumen®,Polyethylene glycol (PEG) LBG,methylcellulose
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Practical points � Patient NBM for 4- 6 hours prior � Ingest 1500 mls /45 minute period � +/-erythromycin (promotes gastric emptying) � Prone
� eliminate peristaltic and respiratory movement � Reduce scan volume(13 cms to 9 cms) � Help separation of bowel loops � No improvement in lesion detection (Cronin et al 2008)
� Gadolinium 0.1-0.2 mmol/kg with delay of 40-80s
� Time to peak enhancement typically 60-70 s � (Lauenstein et al 2005)
� Routine buscopan � Divided dose
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Trouble shooting
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Benefits? � Enterography
� Better tolerance and patient compliance
� Non invasive � No additional
procedure or radiation � Distension less reliable � ?sensitivity diminished
� Enteroclysis � 8F catheter/120-150
ml/min ü Invasive ü Additional admin and cost ü Reliable uniform distension ü Improved sensitivity for
subtle /early stage disease ü Helpful if low grade
obstruction ü Useful if patient unable to
orally ingest
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MRI sequences Type of sequence Comments T2W/SSFSE/HASTE +/- fat saturation
Assess mural inflammation and changes in peri-enteric fat Sensitive to flow voids Poor mesenteric info due to k space
Balanced or hybrid gradient echo sequence/B-FFE,FIESTA or True FISP
Intermediate contrast Short TR <3 msec Motion freeT2W imaging of the bowel
T1W imaging FSPGR 2D or 3D Parallel or SENSE imaging 0.2mmol/kg at rate of 2 ml/sec Acquisitions at 30,70 sec coronal 90 sec axial volume
Routine administration of hyoscine Double dose
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Artifacts
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Parameters for 1.5T Parameter Axial
FISP Coronal FISP
Axial RARE
Coronal RARE
3D VIBE 2DTrue FISP
TR msec 4.3/2/2 4.3/2.2 1000/90 1000/90 4.1/1.1 500/75
Flip angle 50 50 150 150 10 50
FOV 320-400 320-400 320-400 320-400 320-400 400
Parallel factor
2 2 2 2 3 2
Thickness 5 3 4 3 2.5 10
Bandwidth 125 125 62.5 62.5 62.5 1930
Time acq 19 21 15-20 15-20 15-18 25
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Bowel peristalsis assessment � High temporal � High spatial resolution � Evaluation of mechanical
bowel obstruction, strictures, areas of diminished motility
� Tru FISP(SSFP)<1s/frame
� HASTE(SSFSE) � 1 or more slice selections � Multiple repeated
measurements if needed � Free breathing
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Introduction Technique Crohn’’s Other apps Conclusion
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Crohns’’ disease • Chronic relapsing auto-immune disorder • Incidence of Crohns’ has increased by 31%
since 1991 • MR sensitivity and specificity 88-98% and
78-100% • Trans-mural and chronic inflammation • 50% of patients with chronic inflammation require
resection • Surgery not curative
– Endoscopic evidence of recurrence in 66% within 3 months – On average clinically active disease within 2-3 years of intestinal
resection – Despite advances in medical therapy risk of surgery constant
over last 30 years
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Making the diagnosis Clinical indices
Endoscopy
Imaging Stool Markers
Serum markers
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Meta-analysis Modality Sensitivity Specificity US 89.7% 95.6% MRI 93.0% 92.8% Scinitgraphy 87.8% 84.5% CT 84.3% 95.1%
• Per patient basis US performed better in predicting the absence of IBD • MR less operator dependent and better at assessing proximal disease • MR slightly better performance using enteroclysis technique vs. oral enterography • Use of a modality that does not use radiation is preferable
Horsthuis et al,Radiology 2008;247
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Radiation exposure in cohort of patients with IBD � Population based cohort of 215 patients
assessed � Total effective dose of diagnostic
ionizing radiation was estimated � CD=103 and UC=112 � Mean age of diagnosis 38.6 and 39.4 yrs
respectively
Peloquin et al AJG 2008;103:2015-2022
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Findings � Background dose annually 3 mSv � Annual median effective dose
� CD 3.1 mSv/yr � UC 1.2 mSv/yr
� Adjusting for time since symptom onset CD patients 2.46X total effective dose compared with UC (P=001)
� Difference in effective dose was due to twice the number of CT scans in CD sub-group
� CT enteroclysis changed management 62% of patients with CD
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Factors contributing to cumulative dose in patients with CD � 409 patients with CD
identified � Cumulative effective dose
calculated over a 14 year period
� Complete data in 399 � CT accounted for 77.2 %
of diagnostic radiation � Mean CED 36.1 mSv
� RISKS higher � Early age at diagnosis
(<17) � Upper GI tract disease � Penetrating disease � Requirement for infliximab
or intravenous steroids � Multiple surgeries
Desmond et al ;Gut 2008
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What are we looking for? � Is there inflammatory disease? � Number, length and location of involved
segments � What sub-type is it? � If there is stenosis;
� Inflammatory or fibrotic
� Inflammatory activity � Grade severity(mild,moderate or severe)
� Are there mesenteric complications? � Abscess or fistula
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Imaging findings that correlate with presence of disease (overlap with CT) � Mural thickening � Hyper enhancement of diseased segments � Mural stratification � Mesenteric vascular engorgement � Fibro-fatty proliferation � Increased SI/attenuation � Mesenteric fluid � Mesenteric adenopathy
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MR findings that correlate with clinical/endoscopic/biochemical signs of disease activity
MR finding that correlates with activity
T weighting
Wall thickening and enhancement TI Increased mesenteric vascularity T1 Lymph node enhancement T1 Increased mural signal T2 Increased mesenteric fat signal T2
Maccioni ,Abdomin Imaging 2010 ;35
Wall thickness of >3 mm sensitivity of 83-91% Specificity of 86-100%
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� MRI findings associated with pathological inflammatory grading
MRI FINDINGS P value Wall thickening <0.0001 Degree of enhancement (delayed)
<0.0001
Pattern of enhancement P=0.02 Relative T2W hyperintensity <0.0001
Blurred wall enhancement P=0.018 Comb sign P=0.004 Fistula <0.0001
Abscess P=0.049
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What is the utility of image based scoring systems?
� Detection of active inflammation no longer main goalpost
� Not sufficient to guide therapeutic decision making
� Disease severity most crucial aspect in diagnostic algorithms
� Magnetic resonance index of disease activity
� MaRIA correlates highly with CDEIS
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MaRIA score � Objective MRI based score � Activity and severity of CD � Includes parameters such as bowel wall
thickening � Excludes nodal enlargement (low
prevalence and high variability) � Significant correlation with
� Clinical activity � Endoscopic activity � C-reactive protein levels
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Image analysis
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Target sign
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Halo sign
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Correlates with elevated CRP Suggests active disease
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Acute inflammatory subtype; apthous ulcers
True FISP; High resolution T2W images show areas of ulceration as foci of high T2 signal intensity
Sinha R et al. Radiographics 2009;29:1847-1867
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Acute inflammatory subtype: mucosal fold thickening and wall edema
Sinha R et al. Radiographics 2009;29:1847-1867
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Hyperenhancement • Early and most sensitive sign of active inflammation • Seen in absence of significant mural thickening • If Asymmetric =CD
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Hyperenhancement
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Coronal imaging
Coronal FISP (A) and post gadolinium coronal T1W (B and C)
A B C
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Coronal imaging
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Pseudo-sacculation
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Detection of intestinal fibrosis
• Pharmacological treatment Inflammation
• Surgical management Fibrosis
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DWI in CD of small bowel and colon? � Relatively few studies published � Good sensitivities of DWI for assessing
acute inflammation � Significant decrease of ADC values in
acutely inflamed segments as c/w healthy segments
� Absolute value of ADC shows great inter study variability
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T2w thick slab projection T2w Fusion T2w/DWI
T1w early T1w equilibrium
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T2w T2w spir Fusion DWI/T2w
FIESTA T1w FS Gd portal T1w FS Gd equilibrium
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Does DWI allow you to forego luminal distension?
� No � Mandatory for assessment of
bowel wall thickness � Improved visual assessment and
depiction of mural enhancement
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T2w T2w distension
T2w spir FS T1w Gd
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MRI ;fibrosis • On T2W imaging
– Reduction in signal intensity of thickened bowel wall
– Low bowel wall signal intensity
• On T1W imaging – Reduction in bowel wall enhancement – Absent or minimal trans-mural enhancement – Overall sensitivity, specificity and accuracy of
MRI are 58%,76% and 65% respectively
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Diffusion weighted imaging (DWI)
� Derives image contrast from differences in motion of water molecules between tissues
� Study aimed to assess � Accuracy of DWI MRC without oral and rectal
preparation in detection of colonic inflammation evaluated by conventional OC
� Correlated with clinical and biological IBD indices
Oussalah et al Gut 2010 59:1056-1065
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Study design and results � 96 patients
(UC=35,Crohns=61)underwent MRC with DWI
� 68 had endoscopy within 48 hrs � MR score better accuracy in UC
(p=0.003) Sensitivity Specificity
Ulcerative colitis
89.47% 86.67%
Crohns 58.33% 84.48%
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Results � In UC total MR score correlated with total
modified Baron score p=0.0001 and the Walmsley index p <0.0001
� Crohns disease the MR score correlated with simplified endoscopic activity score p =0.001 and the CDAI p=0.004
� Accuracy of DWI for predicting endoscopic inflammation higher in UC
� ?due to contiguous disease vs. segmental involvement in Crohns
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Mesenteric changes and hyperemia
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Stenotic CD
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Crohns disease;fistulating
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Concept of intestinal damage � Outcome measures thus far
� Focused on clinical and endoscopic activity for assessing patient response to therapy
� 2011 introduction of a Lemann score � Based on damage location,extent and
severity � Combined findings on MRI with surgical
history,OGD and ileo-colonoscopy
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Lémann score � Aims to change symptom driven
approach to damage driven approach � Assessment of cumulative damage in
a spectrum of patients with differing clinical stages
� Potential applications include � Identification of early disease � Those in whom early aggressive management may
avoid complications/damage � Identify risk factors for progression
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Introduction Technique Crohn’’s Other apps Conclusion
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How does MR perform in pick up of small bowel tumours? � No large series performed � Retrospective study (1)using enteroclysis
� 91 patients with 30 path proven tumours � Sensitivity of 91-94% � Specificity of 97% � No IV contrast administered
� Series (2) assessing MR enteroclysis for small bowel neoplasms in symptomatic patients � Accuracy 96.6% � High inter-observer agreement
1.Van Weyenbery.Radiology 2010;254 2.Masselli Radiology 2009;251
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Polyposis syndromes � Peutz-
Jegher,Gardner,Cowden � NF,juvenile polyposis
� PJ: � Autosomal dominant � Multiple hamartomatous
polyps and pigmented mucocutaneous lesions
� Lifetime risk of malignancy around 60%
� Variable surveillance protocols
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Comparison with CT? � More sensitive for detection of
mucosal lesions � Better soft tissue characterization � Better detection of more subtle abnormality � CE may fail to depict neoplastic disease in ≈18.9% of cases(sub-mucosal)
� Capsule retention in as many as 10-25%
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CT and MRI faceoff
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CT and MRI faceoff
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Feasibility in surveillance of polyps with patients with PJ syndrome?
� Capsule � Safe, feasible and sensitive for surveillance
particularly in pediatric population � Capsule better at detection of small 6-10mm
lesions � Larger polyps; more clinically relevant � Seen in absence of adequate distension on
MRE � MRE better at localization
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Celiac disease � No role in diagnosis � Provide
� Morphologic information � Extra intestinal findings
� Poor response to medical therapy
� Those with recurrent symptoms despite gluten withdrawal
� RCD
� Villous atrophy � Reversal fold pattern
63-68% � Small bowel
malignancy � Lymphadenopathy � Ulcerative jejunitis � Enteropathy associated
T cell lymphoma (EATL)
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Van Weyenberg S J B et al. Radiology 2011;259:151-161
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Van Weyenberg S J B et al. Radiology 2011;259:151-161
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Role of MRI in SBO? � High grade SBO
� CT � Availability,cost,unstable patient � MRI;finite role:pregnant or pediatric patient
� Low grade SBO (enteroclysis) � If benign look for generalized mural thickening � Low signal intensity bands course through mesenteric
fat � Clumping of loops � Malignant: localised mural thickening ;+/- mass;
peritoneal thickening and enhancement
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SBO due to ileal disease
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SBO due to ileal disease
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RLQ pain .Normal appendix on US
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Intestinal TB � Relatively rare manifestation � Ileocecal region involved in 90% of
affected cases � Only 15% have concomitant thoracic
disease � Cecum and ascending colon> terminal ileum � Asymmetric thickening ICV and medial wall of
cecum � Deformed cecum � adenopathy
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Intestinal TB � Free or loculated ascites;thin mobile
septa � Smooth peritoneal thickening and
enhancement � Misty mesentery with enlarged
nodes � Early stage disease may overlap
with CD or lymphoma
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Benign lesions
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Malignant lesions
� 60-70% of symptomatic SB lesions are malignant
� 40% adenocarcinomas � Duodenum 50% � Jejunum 30% � Ileum 20%
� Short segment Ix
� Adenocarcinoma � Eccentric thickening/
irregular margins � Annular /lumen
effacing � Delayed enhancement � Nodal enlargement not
consistent feature � Mets to
liver,peritoneum
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Carcinoid � Represent 33% of SB malignancies � Appendix(50%) or distal ileum � 10% develop syndrome � SB carcinoids
� Avidly enhancing/submucosal � Multi focal polypoidal lesions � May also show uniform mural thickening(Bader et al)
� Mesenteric � isointense to muscle on T1W and T2W � 2-4 cms in diameter � Spiculated tissue at periphery
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Small bowel carcinoid
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GIST � Most common
mesenchymal neoplasm of the GI tract
� Gastric 60% � Small bowel 30% � Multiple in setting of
NF1 � Originate from
m.propria � 70-80% benign
� Small bowel GIST � Bleeding � Intussuception � Chronic anemia
� Imaging � Exoenteric mass � Heterogeneity � Lack of adenopathy � Avid enhancement
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Epigastric pain and obstructive symptoms
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Ischemic stricture
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Lymphoma � Primary � Secondary as part of
widespread lymphoma
� NH B cell most common subtype � Distal ileum
� T cellè celiac
� Pleomorphic ü Single segment or
multi-centric ü Exoenteric mass ü Annular mural
thickening ü Aneurysmal ulceration ü Non obstructing
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Introduction Technique Applications Performance Conclusion
Conclusion � Pivotal modality in assessment of small
bowel disease � Continuing improvements in technology
� Robust,reproducible,radiation free alternate � Balance against cost and availability issues � Increased concern re radiation implications will result in
higher utilization � Be aware of scoring systems/impact on management � Utilize additional functional tools for increased confidence
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1.All of the following are biphasic oral contrast agents except;
a) Water b) VoLumen ® c) Blueberry juice d) Locust bean gum e) Methylcellulose
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2.The following MRI findings correlate highly with activity in Crohn’’s disease Except
a) T2 hyperintensity within the bowel wall b) Mural thickening c) Lymphadenopathy d) Degree of enhancement e) Pattern of enhancement