comparison between whole body and head and neck
TRANSCRIPT
Comparison between Whole Body and Head and Neck Neurovascular Coils for 3T Magnetic
Resonance Proton Resonance Frequency Shift Thermography Guidance in the Head and
Neck Region
Start Time: 9/18/2017, 1:30 PM
Author(s)
Daniel Ginat, MD, MS
Assistant Professor
University of Chicago Medicine
Role: Presenting Author
Greg Anthony, BA
PhD Student
University of Chicago
Role: Author
Gregory Christoforidis, MD
Professor of Radiology and Surgery
University of Chicago
Role: Author
Aytekin Oto, MD
Professor of Radiology and Surgery
University of Chicago
Role: Author
Leonard Dalag, MD
Resident
University of Chicago
Role: Author
Steffen Sammet, DABR, FAMP
Associate Professor of Radiology and Medical Physics
University of Chicago
Abstract Details
Purpose:
To compare the image quality of magnetic resonance (MR) treatment-planning images and proton
resonance frequency (PRF) shift thermography images and inform coil selection for MR-guided laser
ablation of tumors in the head and neck region.
Methods:
Laser ablation was performed on an agar phantom and monitored via MR PRF shift thermography
on a 3T scanner, following acquisition of T1-weighted (T1W) planning images. PRF shift
thermography images and T2-weighted (T2W) planning images were also performed in the neck
region of five normal human volunteers. Signal-to-noise ratios (SNR) and temperature uncertainty
were calculated and compared between scans acquired with the whole body coil and a head and
neck neurovascular coil.
Results:
T1W planning images of the agar phantom produced SNRs of 4.0 and 12.2 for the body coil and
head and neck neurovascular coil, respectively. The SNR of the phantom MR thermography
magnitude images obtained using the whole body coil was 14.4 versus 59.6 using the head and
neck coil. The average temperature uncertainty for MR thermography performed on the phantom
with the body coil was 1.1°C versus 0.3°C with head and neck coil. T2W planning images of the
neck in five human volunteers produced SNRs of 28.3 and 91.0 for the body coil and head and neck
coil, respectively. MR thermography magnitude images of the neck in these volunteers obtained
using the whole body coil had a signal-to-noise ratio of 8.3, while the SNR using the head and neck
coil was 16.1. The average temperature uncertainty for MR thermography performed on the
volunteers with the body coil was 2.5°C versus 1.6°C with the head and neck neurovascular coil.
Conclusion:
The whole body coil provides inferior image quality for both basic treatment-planning sequences and
MR PRF shift thermography compared with a neurovascular coil, but may nevertheless be adequate
for clinical purposes.
Comparison of CT-guided core-needle biopsy and fine-needle aspiration in the assessment of
head and neck lesions
Start Time: 9/18/2017, 1:38 PM
Author(s)
Abdul Rahman Tarabishy, MD
Assistant Professor of Radiology
West Virginia University
Role: Presenting Author
Matthew David Schmidt, BS
Medical Student
West Virginia University
Abstract Details
BACKGROUND AND PURPOSE: Fine needle aspiration (FNA) and core needle biopsy (CNB) have
both been established as efficient diagnostic tools for image-guided biopsy of head and neck
lesions. FNA has emerged as the preferred diagnostic tool in most situations due to a lower risk of
complications with retained efficacy. If the diagnostic yield of CNB is significantly higher than that of
FNA with a minimal complication risk, CNB should be considered instead of FNA. This study aims to
compare the diagnostic yield of CT-guided FNA and CNB and to support the safety of both biopsy
modalities in head and neck lesions.
MATERIALS AND METHODS:
Retrospective study of 168 patients underwent CT- guided biopsy and the data collected included
age, gender, lesion location, biopsy modality, primary diagnosis applicable to the lesion, pathology
results, and complications.
RESULTS:
The overall diagnostic rates of FNA and CNB biopsy were 60% and 89%, respectively (P < .0001).
CNB demonstrated significantly higher diagnostic yield than FNA for lesions in lymph nodes, parotid
glands, and the parapharyngeal space. CNB was also significantly better at diagnosing new lesions
as well as lesions in patients with known metastatic disease. One complication was noted in a
patient who underwent CNB and developed a moderate neck hematoma requiring overnight
admission.
CONCLUSIONS: CNB carries a very low complication rate and superior to FNA in obtaining
diagnostic samples in head and neck lesions.
Differential diagnosis of odontogenic lesions based on the imaging characteristics of
gubernaculum tracts
Start Time: 9/18/2017, 1:46 PM
Author(s)
Masafumi Oda, DDS, PhD
Research Scholar of Radiology, Assistant professor of Oral and maxillofacial Radiology
Boston University School of Medicine, Kyushu Dental University
Role: Presenting Author
Keita Onoue, MD
Radiology Resident
Boston Medical Center
Role: Author
Margaret N. Chapman, MD
Neuroradiologist, Assistant Professor of Radiology
Boston Medical Center, Boston University School of Medicine
Role: Author
Tatsurou Tanaka, DDS, PhD
Associate professor of Oral and maxillofacial Radiology
Kyushu Dental University
Role: Author
Yasuhiro Morimoto, DDS, PhD
Professor of Oral and maxillofacial Radiology
Kyushu Dental University
Role: Author
Osamu Sakai, MD, PhD
Chief of Neuroradiology, Professor of Radiology, Otolaryngology-Head and Neck Surgery, and
Radiation Oncology
Boston Medical Center, Boston University School of Medicine
Abstract Details
Purpose:
The gubernaculum tract (GT) is a canal that contains the gubernacular cord and/or gubernaculum
dentis (GD). The fibrous GT band connects the pericoronal follicular tissue of a tooth with the
overlying gingiva. Recent pathological and imaging studies have suggested that the GD is one of the
origins of odontogenic lesions and that some odontogenic lesions have GTs that can be visualized
on CT. We hypothesized that the imaging characteristics of GTs might be useful to diagnose
odontogenic tumors or cysts. The purpose of this study was to investigate imaging characteristics of
GTs and to determine its usefulness in diagnosing odontogenic tumors and cysts.
Material and Methods:
This retrospective study was approved by our IRB. 253 patients who underwent MDCT with
pathologically proven ameloblastomas (n=20), keratocystic odontogenic tumors (KCOTs) (n=50),
and dentigerous cysts (n=183) were enrolled. The relationship between the lesion and GT was
divided into three groups based on CT findings; Group 1: GT clearly identified as a tunnel like
structure, Group 2: bone defect at the top of the alveolar ridge (which is likely an expanded GT), and
Group 3: no GT or osseous opening at the top of the alveolar ridge identified. The correlation
between the size of the lesion, the long axis of the bone defect of the alveolar ridge including GT,
and ages of patients were assessed.
Results:
The majority of the lesions were categorized as Group1 (83.1% of dentigerous cysts and 68% of
KCOTs) and Group2 (70% of ameloblastomas). The size of the bone defect at the top of the alveolar
ridge was strongly correlated with the size of the lesion in ameloblastomas (r=0.741, p=0.0001) and
very weakly correlated in dentigerous cysts (r=0.167, p=0.028). No correlation was found in KCOTs
(r=-0.089, p=0.557). When limited to Group 2, there was a strong correlation between the bone
defect size and the lesion size in ameloblastomas (r=0.733, p=0.003) and dentigerous cysts
(r=0.759, p=0.000). Positive correlation was seen between the patient’s age and the bone defect
size of the alveolar defect in dentigerous cysts (r=0.346, p=0.000), while negative correlation was
seen with KCOTs (r=-0.462, p=0.006). No significant correlation was found in ameloblastomas (r=-
0.489, p=0.403).
Conclusion:
Evaluation of the relationship between lesion pathology and GT and size of the alveolar bone
defect/lesion with GT is useful for differentiating amongst certain odontogenic lesions.
Dental Caries on CT in the ER Population: Prevalence and Reporting Practices
Start Time: 9/18/2017, 1:54 PM
Author(s)
Jesse T. Brandfass, MD
Resident
UVM Medical Center
Role: Presenting Author
Michael Bazylewicz, MD
Attending Radiologist
UVM Medical Center
Role: Author
Joshua Nickerson, MD
Assistant Professor
University of Vermont Medical Center
Abstract Details
Purpose:
Dental caries can lead to a variety of complications, including odontogenic abscess and odontogenic
sinusitis. In addition, untreated dental caries can cause dental pain and sensitivity, negatively
affecting quality of life. Dental caries can easily be treated. However, many people do not visit a
dentist on a routine basis. Most dental caries are easily identifiable on CT scans that include the
teeth. The hypothesis of this study is that the prevalence of dental caries in the ER population is high
and that caries are routinely under-reported on the CT scans of the face and neck. The purpose of
this study is to measure the prevalence of dental caries in ER patients undergoing CT of the face or
neck and based on the results as well as input from dental professionals provide a recommendation
for radiology reporting practices.
Materials/ Methods:
Retrospective analysis was performed on 200 patients greater than 18 years old who underwent a
CT of the facial bones or neck, with or without contrast between January 1, 2015 and June 30, 2015
at a level 1 trauma center. CT images were reviewed by a neuroradiologist for presence of untreated
dental caries. The radiology reports were reviewed to evaluate the frequency with which dental
caries were included in the report when present. The number of patients with prior dental fillings
resulting in artifact was recorded. Statistical Package for the Social Sciences (SPSS) software was
used for statistical analysis. Faculty of an affiliate dental school was consulted for guidelines for
follow up recommendations.
Results:
A total of 200 CT facial bone or neck examinations were retrospectively evaluated which including
4815 teeth. 75% of patients had undergone previous dental intervention resulting in some degree of
artifact. Despite the presence of at least some artifact in many of the scans, a total of 552 dental
caries were found. Average number of dental caries was 2.76 per person, or 0.11 per tooth. 29.4%
of caries involved the enamel, 49.3% extended into the dentin, and 21.2% extended into the pulp.
53% of patients had at least 1 dental caries, 39.5% of patients had at least 1 dental caries into the
dentin, and 16% of patient had at least one dental caries into the pulp. When dental caries were
present, 12.3% of radiology reports included caries anywhere in the report, and 7.6% included
mention in the impression. The dental professionals consulted for this study recommended a visit to
a dentist within 6 months for caries in the enamel or dentin and a visit to the dentist within 3 months
for caries into the pulp.
Conclusions:
Dental caries are commonly identified on CT examinations of the face and neck, but are infrequently
included in radiologist reports. Given the impact of dental care on overall health and quality of life
and the ability of dentists to treat dental caries, these findings should be included in the radiology
report. A recommendation for outpatient evaluation by a dentist can be made based on the type of
dental caries.
Computed Tomography of the Head and Neck Region for Tumor Staging - Comparison of
Dual Source Dual Energy and Low kV Single Energy Acquisitions.
Start Time: 9/18/2017, 2:02 PM
Author(s)
Wolfgang Wuest
consultant
University of Erlangen
Role: Presenting Author
Marco Wiesmueller
doctor
University of Erlangen
Role: Author
Rafael Heiss
doctor
University of Erlangen
Role: Author
Michael Brand
consultant
University of Erlangen
Role: Author
Michael Uder
head of department
University of Erlangen
Role: Author
Matthias May
consultant
University of Erlangen
Abstract Details
Purpose:
Aim of this study was to intra-individually compare the image quality obtained by dual source dual
energy (DSDE) CT examinations and different virtual monoenergetic reconstructions to a low single
energy (SE) scan.
Materials and Methods:
Third generation DSDE-CT was performed in 49 patients with histologically proven malignant
disease of the head and neck region. Weighted average images (WAI) and virtual monoenergetic
images (VMI) for low (40 and 60 keV) and high (120 and 190 keV) energies were reconstructed. A
second scan aligned to the jaw, covering the oral cavity, was performed for every patient to reduce
artifacts caused by dental hardware using a SE-CT protocol with 70 kV tube voltages and matching
radiation dose settings. Objective image quality was evaluated by calculating contrast to noise ratios
(CNR). Subjective image quality was evaluated by experienced radiologists.
Results:
Highest CNR for vessel and tumor attenuation were obtained in 40 keV VMI (all p < 0.05).
Comparable objective results were found in 60 keV VMI, WAI and the 70 kV SE examinations.
Overall subjective image quality was also highest for 40 keV, but differences to 60 keV VMI, WAI
and 70kV SE were non-significant (all p>0.05). High keV VMI reduce metal artifacts with only limited
diagnostic impact because of insufficiency in case of severe dental hardware. CTDIvol did not differ
significantly between both examination protocols (DSDE: 18.6 mGy; 70 kV SE: 19.4 mGy; p= 0.10).
Conclusion:
High overall image quality for tumor delineation in head and neck imaging were obtained with 40 keV
VMI. However, 70 kV SE examinations are an alternative and modified projections aligned to the jaw
are recommended in case of severe artifacts caused by dental hardware.
Dual energy staging CT of the neck – Comparison between Single Source and Dual Source
techniques
Start Time: 9/18/2017, 2:10 PM
Author(s)
Wolfgang Wuest
consultant
University of Erlangen
Role: Presenting Author
Rafael Heiss
doctor
University of Erlangen
Role: Author
Michael Brand
consultant
University of Erlangen
Role: Author
Marco Wiesmueller
doctor
University of Erlangen
Role: Author
Michael Uder
head of department
University of Erlangen
Role: Author
Matthias May
consultant
University of Erlangen
Abstract Details
Purpose:
Aim of this study was to compare the image quality of third generation split filter single source dual
energy (SSDE) and third generation dual source dual energy (DSDE) computed tomography for
staging in the head and neck region.
Materials and Methods:
A total of 102 patients were randomized to two study groups: 51 patients were examined on a third
generation SSDE scanner equipped with the split filter technique and 51 patients were examined on
a third generation DSDE system from the same vendor. All patients had histologically proven
malignant disease of the head and neck region. Inline weighted average images (WAI) and offline
virtual monoenergetic images (VMI) at different energy levels (40, 60, 120 and 190 keV) were
reconstructed for image evaluation. Objective image quality was assessed by calculating dose
normalized contrast to noise ratios (CNRD). Subjective image quality was rated on a 5-point Likert-
scale.
Results:
Highest CNRD for vessel and tumor attenuation were obtained at 40 keV in both groups. The vessel
CNRD of DSDE was substantially higher on the WAI (+58%, both p < 0.05) and at low keV levels (40
keV +38%, 60 keV +42%) though not significant for the carotid arteries. CNRD for tumor attenuation
was significantly higher on DSDE-WAI (+45%, p=0.006), but comparable to the VMI. Best overall
subjective image quality was found on the WAI in both groups, followed by 40 keV and 60 keV.
Ratings for diagnostic image quality and image artifacts were significantly better in all
reconstructions from DSDE compared to SSDE, but subjective tumor delineation was comparable .
Conclusion:
Inline reconstructions from DSDE are superior to SSDE in terms of CNRD, overall subjective image
quality and artifacts, but comparable to SSDE for tumor attenuation and delineation.
Evaluation of the submental and submandibular spaces following the submandibular gland
transfer procedure: recognition of the transferred gland and avoidance of potential pitfalls
Start Time: 9/18/2017, 2:18 PM
Author(s)
Xin Wu, MD
Clinical Instructor
University of California San Francisco
Role: Presenting Author
Patrick Ha, MD
Professor
University of California San Francisco
Role: Author
Chase Heaton, MD
Assistant Professor
University of California San Francisco
Role: Author
Sue S. Yom, MD, PhD
Associate Professor
University of California San Francisco
Role: Author
Christine M. Glastonbury, MBBS
Professor
University of California San Francisco
Abstract Details
Purpose:
The Seikaly-Jha submandibular transfer procedure, wherein the submandibular gland (SMG) is
repositioned surgically into the submental space, has been used in order to facilitate gland shielding
during radiation therapy for head and neck tumors and in turn circumvent radiation-induced
xerostomia. This procedure results in an asymmetric postsurgical appearance of the submandibular
and submental spaces that, to our knowledge, has not been previously described. The purpose of
this study is to characterize the morphologic and enhancement characteristics of the transferred
SMG relative to the contralateral gland, and to identify potential pitfalls in postoperative radiologic
interpretation.
Materials & Methods:
This IRB-approved, HIPPA compliant study reviewed surgical records from our institution to identify
head and neck cancer patients who had undergone the SMG transfer procedure. A chart review was
performed in order to identify the patient’s primary site of disease and pathology, dates of surgical
and radiation treatment, and postoperative imaging. Neck CT and MR examinations were reviewed
to characterize morphologic as well as enhancement characteristics of the SMGs and key
surrounding structures. Radiology reports were reviewed.
Results:
11 patients with head and neck cancer who had undergone the submandibular transfer procedure
were identified. The primary disease sites included tonsillar, base of tongue, and nasopharynx. All
patients had pre-operative CT imaging. Postoperatively, 9 patients underwent contrast enhanced
MRI imaging, and 6 patients underwent contrast enhanced CT imaging.
The preoperative enhancement and morphologic characteristics are similar between the SMGs, as
defined by anteroposterior length and locations of the anteroinferior, posterior, and superior margins.
Postoperatively, the transferred SMGs are lengthened in the anteroposterior dimension compared to
the contralateral glands. The transferred SMGs are located further anteriorly and inferiorly within the
submandibular and submental spaces. In all but one case, the SMG was transferred into the
subcutaneous tissues superficial to the anterior bellies of the digastric muscle.
In two MRIs acquired less than one month postoperatively, the transferred SMGs demonstrated
>20% increased enhancement compared to the contralateral glands. Asymmetric T2 hyperintensity
is seen in the platysma musculature adjacent to the transferred SMG only in cases performed within
the first four months.
SMG transfer was either provided as a part of clinical history or acknowledged in the report in 7/11
cases. In one case, clinical history of SMG transfer was acknowledged, but the report incorrectly
noted that the transferred gland “was not visualized.” In another case, history of SMG transfer was
neither provided nor acknowledged, and the superior aspect of the contralateral SMG was
incorrectly interpreted as a parapharyngeal mass.
Conclusion:
After a submandibular transfer procedure, the submandibular and submental spaces lose their
symmetric morphology as the transferred SMGs are located more anteriorly and inferiorly.
Asymmetric postoperative enhancement of the transferred SMGs appears to resolve within the first
two months, although edema within the plastyma muscle can be seen up to four months
postoperatively. Familiarity with the postsurgical appearance of the transferred SMG is important in
order to correctly interpret postoperative neck imaging.
Fig1. Axial and Coronal postcontrast T1WI demonstrate submental location of the transferred SMG.
Ameloblastomas in the maxillofacial region.; CT and MR findings.
Start Time: 9/18/2017, 2:26 PM
Author(s)
Yusuke Kawashima, D.D.S., Ph.D.
Assistant professor
Department of Radiology, Nihon University School of Dentistry at Matsudo
Role: Presenting Author
Osamu Sakai, M.D., Ph.D.
Professor of Radiology and Otolaryngology- Head and Neck Surgery Section Head, Neuroradiology;
Director of Head and Neck Imaging
Departments of Radiology, Radiation Oncology, and Otolaryngology-Head and Neck Surgery,
Boston Medical Center, Boston University School of Medicine
Role: Author
Suemitsu Masaaki, D.D.S., Ph.D.
Assistant professor
Department of Oral Pathology, Nihon University School of Dentistry at Matsudo
Role: Author
Kayo Kuyama, D.D.S., Ph.D.
professor
Department of Oral Pathology, Nihon Univerisity School of Dentistry at Matsudo
Role: Author
Hugh D. Curtin, M.D.
Professor of Radiology
Massachusetts General Hospital
Role: Author
Takashi Kaneda, D.D.S., Ph.D.
Professor of Radiology
Department of Radiology, Nihon University School of Dentistry at Matsudo
Abstract Details
Backgrounds:
Ameloblastoma is a benign but locally invasive polymorphic neoplasm consisting of proliferating
odontogenic epithelium, which usually has a follicular or plexiform pattern lying in a fibrous stroma. It
is the most common odontogenic tumor, and accounts for 1% of tumors and cysts of the jaw and
10% of odontogenic tumors. It is found with about equal frequency in male and female and has the
peak incidence in the third and fourth decades of life. 80% are seen in the mandible and the
remaining in the maxilla. Radiographically, ameloblastomas may show considerable variation
reflecting their polymorphic features. The typical radiographic finding is of a multilocular destruction
of bone, but unilocular ameloblastomas also occur. CT and MR findings of ameloblastomas in the
maxillofacial region have not been fully described in the literature. The purpose of this study was to
evaluate CT and MR imaging characteristics of ameloblastomas.
Methods:
This study was approved by our institutional review board. A retrospective review of our imaging
data base was performed to identify patients with pathologically proven ameloblastoma who
underwent CT or MR imaging between April 2006 and April 2017. The location, margin, bone
expansion, tooth resorption signal intensity of the solid and cystic components, enhancement of the
solid components were recorded. The margins of the lesions were classified as either well- or ill-
defined.
Results:
Fifty-five patients with pathologically proven ameloblastomas (34 males and 21 females; mean age
43.2years; age range 14 to 71 years) were identified. Twenty-nine patents had both CT and MR
imaging, and 26 patients had CT only. Contrast-enhanced MR imaging was performed in 13
patients.
Forty-four patients had mandibular lesions and 11 patients had maxillary lesions. Of the 44
mandibular lesions, 10 lesions were seen in the mandibular body to ramus. Of the 11 maxillary
lesions, 4 lesions were in the maxillary body. Twenty-three lesions showed well-defined margins.
Twenty-seven showed tooth resorption. Twenty-one showed bone expansion at the buccal side. The
solid components showed low signal intensity on both T1 and T2-weighted images in 23 lesions. The
cystic components showed low signal intensity on T1-weighted images and high signal intensity on
T2-weighted images in 29 lesions. The solid components showed marked enhancement in 15
lesions.
Conclusion:
CT and MR findings of ameloblastomas in the maxillofacial region were reviewed. These findings
may be helpful to narrow the differential diagnosis of odontogenic tumors arising in the maxillofacial
region.
Value of ED MR in the Evaluation of Optic Neuritis
Start Time: 9/18/2017, 2:34 PM
Author(s)
Jina Pakpoor, MD MA
Research Fellow
Johns Hopkins University
Role: Presenting Author
Deanna Saylor, MD MHS
Assistant Professor of Neurology
Johns Hopkins Medical Institutions
Role: Author
Izlem Izbudak, MD
Assistant Professor
Department of Radiology, Johns Hopkins Medical Institutions
Role: Author
Li Liu, PhD
Assistant Professor
Department of Radiology, Johns Hopkins Hospital
Role: Author
Ellen Mowry, MD
Associate Professor of Neurology,
Department of Neurology, Johns Hopkins Hospital
Role: Author
David Yousem, MD MBA
Director of Neuroradiology, Vice Chairman of Radiology, Professor of Radiology and Radiological
Science
Johns Hopkins Medical Institutions
Abstract Details
Purpose:
The indications for use of MR in the Emergency Department (ED) are evolving. Visual loss is the
chief complaint for over 3.5 million ED visits per year, and acute visual symptoms are notably
unspecific. When a patient presents with visual symptoms indicative of optic neuritis, imaging may
be ordered for confirmation or for identifying other serious disease processes such as multiple
sclerosis or neuromyelitis optica. We sought to determine the value of ED MRI in this setting. Prior to
ED MR these patients would have been admitted for utilization of the inpatient MRI scanner at our
institution.
Methods:
The electronic medical records (EMRs) were reviewed for all ED patient encounters during a two-
year period (3/1/2014-3/1/2016) that utilized the ED MRI scanner and for whom the radiologist
identified optic nerve enhancement/hypersensitivity and/or suggested a diagnosis of optic neuritis.
Patients without a preceding diagnosis of optic neuritis or a demyelinating disease were looked at
separately to those with a preceding multiple sclerosis diagnosis. Details surrounding patient
disposition, final diagnosis and management were determined.
Results:
There were 37 patient encounters for whom optic neuritis or findings indicative of optic neuritis were
suggested by the radiologist based on ED-MR findings. For all cases the indication for the study was
to evaluate visual disturbances and or/pain suspicious of optic neuritis/demyelinating disorders.
36/37 encounters were diagnosed with optic neuritis, and follow-up showed that 10 cases were
further diagnosed with multiple sclerosis and two with neuromyelitis optica.
There were seven patients who had a preceding diagnosis of MS for whom the radiologist suggested
neuritis/enhancement/evolving hyperintensity of the optic nerve. Six were diagnosed with optic
neuritis and admitted for commencement of IV steroids, and one was not.
Conclusions:
ED-MRI provides value in confirming optic neuritis, suggesting multiple sclerosis, and directing
inpatient versus outpatient treatment prior to hospital admission. Evidence has demonstrated that
rapid administration of intravenous steroids to patients with optic neuritis leads to faster recovery of
vision and reduced conversion to multiple sclerosis relative to oral steroids or placebo. Further,
where optic neuritis is ruled out in the ED, patients may avoid needless hospital admission, a
potentially notable financial and resource cost saving.