Search

Objective The Liver Imaging Reporting and Data System (LI-RADS) has been widely applied to CT and MR liver observations in patients at high-risk for hepatocellular carcinoma (HCC). We investigated the impact of CT vs MR in upgrading LI-RADS 3 to LI-RADS 5 observations using a large cohort of high-risk patients. Methods We performed a retrospective, longitudinal study of CT and MR radiographic reports (June 2013 - February 2017) with an assigned LI-RADS category. A final population of 757 individual scans and 212 high-risk patients had at least one LI-RADS 3 observation. Differences in observation time to progression between modalities were determined using uni- and multivariable analysis. Results Of the 212 patients with a LI-RADS 3 observation, 52 (25%) had progression to LI-RADS 5. Tp ranged from 64 - 818 days (median: 196 days). One hundred and three patients (49%) had MR and 109 patients (51%) had CT as their index study. Twenty-four patients with an MR index exam progressed to LI-RADS 5 during the follow-up interval, with progression rates of 22% (CI:13%-30%) at 1 year and 29% (CI:17%-40%) at 2 years. Twenty-eight patients with a CT index exam progressed to LI-RADS 5 during follow-up, with progression rates of 26% (CI:16%-35%) at 1 year and 31% (CI:19%-41%) at 2 years. Progression rates were not significantly different between patients whose LI-RADS 3 observation was initially diagnosed on MR vs CT (HR: 0.81, P = 0.44). Discussion MR and CT modalities are comparable for demonstrating progression from LI-RADS 3 to 5 for high risk patients.

Psoriasis is a common, chronic and non- infectious skin disease characterized by well defined slightly raised, dry erythamatous macules with silvery scales Modern medicine offers treatment with PUVA, Corticosteroids & Anti mitotic Drugs but therapy gives serious side effects like Bone Marrow depletion, Liver & kidney Failure. While treating Kustha, Ayurvedic Classics especially focused on Panchakarma Treatment. So Vaman, Virechana & Laghu-Manjisthadi Ghan was selected for trial. Total 30 well diagnosed patients were selected & divided in two groups. One group receiving Ayurvedic Treatment & other Allopathic Regimen (Tb.Methotraxate7.5 mg/week) for 2 months & comparative study was done. Assessment was done on improvement in clinical symptoms as well as on Laboratory parameters.

Background: Keloids are benign proliferative condition of dermal broblast. Intralesional corticosteroid improves keloid but associated with signicant adverse effects like dyspigmentation, tissue atrophy and telengectasia and contraindicated in certain conditions like hypertension and diabetes. 5-Fluorouracil (5-FU), a pyrimidine analogue with an inhibitory effect on TGF-β induced broblast proliferation is useful in treatment of keloids but is associated with ulceration and pain. A low dose of Triamcinolone if added to 5-FU injection overcomes these issues. Approach: This study was conducted in a tertiary care hospital. Sixty patients; thirty in each group were included. In group A, once weekly intralesional Triamcinolone and in group B, intralesional injection of Triamcinolone mixed with 5-Flurouracil in 1: 9 dilution were injected for 8 sessions. Parameters of Vancouver scale were noted at the baseline and at the end of treatment. Results: Out of 60 patients enrolled in this study. The combination group was better in improving height (62.11% vs 78%), pliability (44.14% vs 8.81%), and vascularity (55.78% vs 61.30%) and results were statistically signicant (P valve 0.05). Pain and pruritus improved completely (100%) in both the groups at the end of the treatment. Excellent improvement in patient and observer assessment score was seen in 96.67% vs 3.33% in combination group and TAC group respectively. The difference was statistically signicant (P valve

Context: Inguinal skin is prone to various infectious dermatological conditions such as erythrasma, intertrigo, hidradenitis suppurativa, folliculitis, dermatophytic infection, and various sexually transmitted diseases, as compared to the skin elsewhere. Aim: Our study attempts to compare the biophysical profile parameters (BPPs) of the genital skin with that of the rest of the body, while taking skin of the upper back as control. It also attempts to find out if there is a difference in BPPs of the two sites and that how the change in the BPPs, bring about change in microbiome and make inguinal skin more prone to infections. Materials and Methods: This was a hospital-based comparative study conducted over 976 patients (600 males and 376 females) of age group 18–60 years, where BPP parameters such as hydration, skin pH, transepidermal water loss (TEWL), and sebum content were measured over the skin of the upper back and right inguinal region, and the results were summarized and presented as proportions (%). Chi-square test was used to compare abnormal findings. P ≤ 0.05 was taken as statistically significant. MedCalc 16.4 version software was used for all statistical calculations. Results: Significant difference was noted in skin pH and TEWL, where P value came out to be

Purpose Computed tomography (CT) is a fast and ubiquitous tool to evaluate intra-abdominal organs and diagnose appendicitis. However, traditional CT reporting does not necessarily capture the degree of uncertainty and indeterminate findings are still common. The purpose of this study was to evaluate the reproducibility of a standardized CT reporting system for appendicitis across a large population and the system's impact on radiologists' certainty in diagnosing appendicitis. Methods Using a previously described standardized reporting system, eight radiologists retrospectively evaluated CT scans, blinded to all clinical information, in a stratified random sample of 237 patients from a larger cohort of patients imaged for possible appendicitis (2010-2014). Receiver operating characteristic (ROC) curves and the area under the ROC curve (AUC) were used to evaluate the diagnostic performance of readers for identifying appendicitis. Two-thirds of these scans were randomly selected to be independently read by a second reader, using the original CT reports to balance the number of positive, negative and indeterminate exams across all readers. Inter-reader agreement was evaluated. Results There were 113 patients with appendicitis (mean age 38, 67% male). Using the standardized report, radiologists were highly accurate at identifying appendicitis (AUC=0.968, 95%CI confidence interval: 0.95, 0.99. Inter-reader agreement was >80% for most objective findings, and certainty in diagnosing appendicitis was high and reproducible (AUC=0.955 and AUC=0.936 for the first and second readers, respectively). Conclusions Using a standardized reporting system resulted in high reproducibility of objective CT findings for appendicitis and achieved high diagnostic accuracy in an at-risk population. Predictive tools based on this reporting system may further improve communication about certainty in diagnosis and guide patient management, especially when CT findings are indeterminate.

In the beginning of the COVID-19 pandemic when we were still getting used to the rising cases every day and limited resources to deal them with, the focus was to get a hold of the situation as quickly as possible. Seven months into the pandemic, the cases are still on the rise but we have gathered some knowledge through the researches getting published every day, most of which are focused on the involvement of respiratory system, cardiovascular system, central nervous system, and gastrointestinal system. Dermatological manifestations have not been given their due importance. Lately, many patients have started presenting with dermatological manifestation sometimes preceding or sometimes during COVID-19 infection with or without involvement of other systems. This may be beneficial to clinicians all over the world, to determine potential dermatological signs in COVID-19 and also help in earlier suspection of the COVID-19 infection. Many cutaneous adverse drug reactions (ADR) to drugs advocated in COVID-19 treatment are also being reported every day, which are discussed in this review.Here we attempt to review dermatological manifestations of COVID-19 infections and drug reactions by the drugs advocated for its treatment and an understanding in its path mechanisms reported thus far. This will help clinicians to get an insight into what to expect and when to expect in terms of dermatological manifestation of COVID-19 and its drugs.

Background: Alopecia areata (AA) is a common, recurrent form of nonscarring alopecia which often presents as circumscribed patches of spontaneous hair loss. The global prevalence of this disease varies from 0.1% to 0.2% in general population and 7–30 cases per 1000 dermatological patients. The etiology of AA still remains uncertain; however, genetic or environmental factor and autoimmunity are claimed responsible for it. Various autoimmune diseases, such as Hashimoto's thyroiditis, diabetes mellitus, vitiligo, and lupus erythematosus, have been reported in association with AA. Aim: The index study was aimed at estimation of serum T3, T4, thyroid-stimulating hormone, and antithyroid peroxidase (TPO) antibodies. Material and Methods: Similar age/sex-matched AA patients and controls (110 in each group). Enhanced chemiluminescence immunoassay for thyroid profile and anti-TPO antibody level estimation in veinous blood sample. Observations: The mean/standard deviation (SD) of T3 was 3.30 ± 0.84 pg/ml in AA while 3.27 ± 0.67 pg/ml in controls (P = 0.302). Serum mean/SD of T4 level was1.23 ± 0.76 ng/dl in AA patients while 1.17 ± 0.34 ng/dl in controls (P = 0.522). The mean/SD of anti-TPO levels in AA patients was 21.52 ± 35.09 while 56.43 ± 140.72 in controls (P = 0.136). Limitation: The limitation of this study was moderate number of AA patients and different genotype of study population. Conclusion: Occurrence of thyroid dysfunction and evidence of anti-TPO antibodies in AA is rare event in this study population.

Objective: Comparative analysis of expression of lupus erythematosus (LE) in geriatrics versus adults. Materials and Methods: We analyzed and compare the patient's records attending our department between June 2017 and June 2019, diagnosed clinically and immunologically as LE between the two groups. Results: Sixty patients, 30 in each group, met ACRA criteria, were enrolled with mean age of presentation for early-onset was 28 ± 9.8 years and late-onset, 59 ± 4.8 years. Most of the patients were females with decrease in sex ratio with age. The most common presentations were malar rash, photosensitivity, and oral ulcers. Joint complaints, lung and cardiac involvement, and nonscarring alopecia were more common in the elderly. Direct Coombs test positive hemolytic anemia, renal involvement in forms of proteinuria and lupus nephritis, and neurological involvement were seen more commonly in adults. In immunological parameters, antinuclear antibody, anti-double standard DNA antibody (AntiDsDNA), and anti-smith antibody testing were done. AntiDsDNA positivity was more in adults correlate with disease severity. We calculate the systemic LE disease activity index 2000 score was higher in the adult population. Conclusion: Our study illustrated that disease activity and damage are more in adults in comparison to geriatrics. However, geriatrics had more organ damage that may be attributable to associated comorbidities. Although the connective tissue diseases in the elderly needs less aggressive management, it requires more attention for possible organ damage due to associated comorbidities.

481 Background: We sought to identify predictors of progression of LR3 lesions (i.e. indeterminate for HCC) to LR5 lesions (i.e. definitely HCC) on follow-up imaging among cirrhotic pts. Methods: Imaging reports with LR assignments were identified among pts seen at the University of Washington, 2013-2017. Cirrhotic pts with a LR3 lesion and follow-up scan within 1 year (yr) of LR3 lesion date were included (n = 313). Clinical features were abstracted from chart review. Survival analyses employing interval censoring were performed. Variables as potentially predictive of LR3 progression were identified in univariate analyses, with backwards elimination done (p < 0.05) to obtain the final multivariate model. Results: 20.4% of LR3 lesions progressed to LR5 within 1 yr; 73% were still LR3, 8% progressed to LR4. The population was predominantly male (61%), Caucasian (71%), older than 55 (63%). The most common cirrhotic etiologies were HCV (46.7%), alcohol (32.6%), and NASH (12.8%), not mutually exclusive. AFP at the time of LR3 scan was low if available (39% with AFP 2cm. Men (HR 2.0, p = 0.02), earlier scan yr (HR 0.47 per yr, p < 0.0001), older age (HR 1.42 per 15 yr, p = 0.047), lesion size (HR 1.21 for 2cm+, global p = 0.02) appeared as independent predictors of LR3 to LR5 progression based on the final model. Of 16 variables examined, men were more likely to have chronic HCV, history of alcohol use and less likely to have autoimmune hepatitis. No other differences were seen. In an a priori analysis, risk of male sex (HR 1.99, p = 0.03) persisted despite control for HCV, alcohol, age, race, scan yr, lesion size, and number of lesions. Conclusions: Identification of clinical factors associated with LR3 progression may allow for risk modeling tools that may assist in determining imaging frequency and timing of intervention. The increased risk among men vs women is not explained by clinical or radiographic features listed above.

Hepatocellular carcinoma is a common malignancy for which prevention, screening, diagnosis, treatment, and surveillance demand a multidisciplinary approach. Knowledge of the underlying pathophysiology as well as advances in clinical management should be employed by radiologists to effectively communicate with hepatologists, surgeons, and oncologists. In this review article, we present recent developments in the clinical management of hepatocellular carcinoma.

Endovascular aneurysm repair has been used to repair abdominal aortic aneurysms but necessitates surveillance to diagnose the delayed possibility of endoleak formation. Multi-detector computer tomography (MDCT) of the abdomen is one imaging technique used to diagnose enlargement of the aneurysm sac that may be indicative of endoleaks. MDCT has a role in identifying the initial endoleak formation and providing signs suggestive of the specific endoleak subtype; thus it is necessary for radiologists to be familiar with the findings of endoleak seen on MDCT. In this pictorial review, we explore the various types of endoleaks and their appearance on MDCT.

Magnetic resonance imaging (MRI) is currently the modality of choice to evaluate liver lesions in patients with cirrhosis and hepatitis B and C. Hepatocellular carcinoma demonstrates typical imaging findings on contrast-enhanced MRI, which are usually diagnostic. Unfortunately, a subgroup of hepatocellular carcinoma presents with atypical imaging features, and awareness of these atypical presentations is important in ensuring early diagnosis and optimal patient outcomes. Herein, we review some of the more common atypical presentations with a focus on MRI.

The purpose of this study was to assess the use of semiquantitative contrast-enhanced parameter analysis as an objective criteria for improving the magnetic resonance (MR) evaluation of hepatocellular carcinoma (HCC) in patients with cirrhosis. Contrast-enhanced MR examination findings from 19 patients with 21 pathologically proven HCC were evaluated using a dedicated liver image postprocessing workstation. Contrast-enhancement kinetic curves were created for each lesion, and 4 enhancement parameters (arterial wash-in slope, arterial-portal slope, arterial-equilibrium slope, and portal-equilibrium slope) were defined from the signal intensity-time plots. The accuracy of each enhancement parameter for the characterization of HCC was assessed. Statistical analysis revealed that an arterial-phase wash-in slope percentage value >1.35 per sec had a sensitivity of 86%, a specificity of 71%, and an accuracy of 79% for the correct characterization of HCC, whereas an arterial-equilibrium wash-out slope percentage value

Idiopathic calcinosis cutis is very rare and difficult to treat. Various medical modalities of treatment described with inconsistent results include chelating agents, colchicine, and probenecid. Calcium channel blockers are known to work by inhibiting intracellular entry of calcium. We successfully treated a case of idiopathic calcinosis cutis using oral diltiazem.

Orthotopic liver transplantation is the preferred treatment for end-stage liver disease. Imaging plays an important role in the follow-up of transplant recipients by identifying a variety of complications. Posttransplant liver imaging can be challenging with altered vascular and nonvascular postoperative findings closely mimicking pathologies. A thorough knowledge of these common imaging findings in a posttransplant liver is essential for the radiologist to avoid erroneous diagnoses and unnecessary workup. We focus on such imaging findings and provide tips to avoid misinterpretation.

Pancreatic transplantation, performed alone or in conjunction with kidney transplantation, is an effective treatment for advanced type I diabetes mellitus and select patients with type II diabetes mellitus. Following advancements in surgical technique, postoperative management, and immunosuppression, pancreatic transplantation has significantly improved the length and quality of life for patients suffering from pancreatic dysfunction. While computed tomography (CT) and magnetic resonance imaging (MRI) have more limited utility, ultrasound is the preferred initial imaging modality to evaluate the transplanted pancreas; gray-scale assesses the parenchyma and fluid collections, while Doppler interrogation assesses vascular flow and viability. Ultrasound is also useful to guide percutaneous interventions for the transplanted pancreas. With knowledge of the surgical anatomy and common complications, the abdominal radiologist plays a central role in the perioperative and postoperative evaluation of the transplanted pancreas.

Stem cell transplant has been the focus of clinical research for a long time given its potential to treat several incurable diseases like hematological malignancies, diabetes mellitus, and neuro-degenerative disorders like Parkinson disease. Hematopoietic stem cell transplantation (HSCT) is the oldest and most widely used technique of stem cell transplant. HSCT has not only been used to treat hematological disorders including hematological malignancies, but has also been found useful in treamtent of genetic, immunological, and solid tumors like neuroblastoma, lymphoma, and germ cell tumors. In spite of the rapid advances in stem cell technology, success rate with this technique has not been universal and many complications have also been seen with this form of therapy. The key to a successful HSCT therapy lies in early diagnosis and effective management of complications associated with this treatment. Our article aims to review the role of imaging in diagnosis and management of stem cell transplant complications associated with HSCT.

Adenoid cystic carcinoma is a rare epithelial tumour, and comprises about 1% of all malignant tumours of the oral and maxillofacial region. It is a malignant tumour which may develop in the trachea, bronchus, lungs or mammary glands, in addition to the head and neck region. Occurrences in the head and neck are mostly detected in the major salivary gland, oral cavity, pharynx and paranasal sinus where it presents as a slow growing firm nodular swelling. The aim of the article is to highlight the unique presentation of adenoid cystic carcinoma as a solitary ulcer on the floor of the mouth.

Coronary artery aneurysms are an uncommon manifestation of systemic lupus erythematosus (SLE), with only 14 cases reported previously in the literature. Herein, we report a 29-year-old woman with SLE who developed clinical and serologic evidence of an SLE flare and presented with chest pain and elevated serum troponin-T level. Cardiac computed tomography was performed and demonstrated fusiform aneurysmal enlargement of the proximal and middle portions of the coronary arteries and a beaded appearance of the distal coronary arteries. Extensive intercostal artery aneurysms were also noted. Several areas of abnormal myocardial perfusion were also noted. The patient improved after treatment with steroid pulses and cyclophosphamide. This case report is the first description of the appearance of lupus coronary vasculitis on cardiac computed tomography.

Combined hepatocellular-cholangiocarcinoma is a rare but unique primary hepatic tumor with characteristic histology and tumor biology. Recent development in genetics and molecular biology support the fact that combined hepatocellular-cholangiocarcinoma is closely linked with cholangiocarcinoma, rather than hepatocellular carcinoma.Combined hepatocellular cholangiocarcinoma tends to present with an more aggressive behavior and a poorer prognosis than either hepatocellular carcinoma or cholangiocarcinoma. An accurate preoperative diagnosis and aggressive treatment planning can play crucial roles in appropriate patient management.

OBJECTIVE. Hepatocellular carcinomas (HCCs) that arise in noncirrhotic livers have several histologic and biochemical features that distinguish them from HCCs occurring in the setting of cirrhosis. Because the presentation, management, and prognosis of these entities are distinct, the accurate preoperative characterization of these lesions is of great clinical significance. We review the pathogenesis, imaging appearance, and clinical implications of noncirrhotic HCCs as they pertain to the clinical radiologist. CONCLUSION. HCCs that develop in noncirrhotic patients have distinct etiologic, cytogenetic, histopathologic, and clinical features. Despite a larger tumor burden at the time of HCC diagnosis, noncirrhotic patients with HCC have better overall survival and disease-free survival than cirrhotic patients with HCC. Knowledge of the precise clinical and imaging features of this entity and of other diagnostic considerations for the noncirrhotic liver is essential for improved patient care.

Tumoral pulmonary emboli from hepatocellular carcinoma (HCC) have rarely been described, although invasion of the portal and hepatic venous systems is a well-known complication. HCC originating in a noncirrhotic liver in the absence of chronic hepatitis B infection is also uncommon. We present a case of a patient with chronic hepatitis C infection without hepatic cirrhosis who developed angioinvasive HCC with intracardiac extension and tumoral pulmonary emboli. Differential considerations, including combined HCC-cholangiocarcinoma, other hepatic mesenchymal tumors, and metastasis, are discussed. Owing to poor prognosis, no resection was attempted. Autopsy was performed because of the unusual clinical presentation, and immunohistochemistry of the hepatic tumor, the intracardiac extension, and the pulmonary emboli were concordant with hepatocellular origin. Even though definitive diagnosis may not affect patient outcome, it is important for radiologists and clinicians to be aware that angioinvasive HCC may arise in the absence of cirrhosis.

Hepatocellular carcinomas are highly vascular tumors, showing progressive hypervascularity by the process of neoangiogenesis. Tumor angiogenesis is critical for tumor growth as well as metastatic spread therefore, imaging and quantification of tumor neo-angiogenesis is essential for monitoring response to targeted therapies and predicting disease progression. Sorafenib is a molecular targeting agent used for treating hypervascular tumors. This drug is now the standard of care in treatment of patients with advanced hepatocellular carcinoma. Due to its anti-angiogenic and anti-proliferative actions, imaging findings following treatment with Sorafenib are quite distinct when compared to conventional chemotherapeutic agents. Liver MRI is a widely adopted imaging modality for assessing treatment response in hepatocellular carcinoma and imaging features may reflect pathophysiological changes within the tumor. In this mini-review, we will discuss MRI findings after Sorafenib treatment in hepatocellular carcinoma and review the feasibility of MRI as an early biomarker in differentiating responders from non-responders after treatment with molecular targeting agents.

e15667 Background: iHCC is an aggressive disease with poorly characterized treatment outcomes. We sought to describe clinical and radiographic features of iHCC, describe overall survival (OS), and compare outcomes of sorafenib (SOR) use with a cohort of non-infiltrative hepatocellular carcinoma (niHCC) patients. Methods: Radiology reports from the University of Washington with an Li-RADS (LR) assignment, 2013-2017, were reviewed (5037 reports, 1954 patients (pts)) for terms indicative of iHCC. Results: : 102 cases were identified, with 43% arising from known niHCC. iHCC size is difficult to measure but when reported, median was 8cm (interquartile range 5-10cm). Other radiographic features: vascular invasion 72%, R lobe only 62%. Clinical data were obtained via medical record review. The cohort was primarily male (83%), White (65%), age > 55 (88%), HCV (74.5%), heavy alcohol use (67%). At diagnosis: BCLC stage C (76%), ALBI grade 2 (62%) and 3 (21%). Median OS after diagnosis was 5.7 months (m). 38 (37%) pts were too ill to receive therapy. OS for de novo iHCC and for iHCC arising from niHCC did not differ (7.5m vs 5.1m, p = NS). All niHCC pts who received SOR in any line of therapy were identified among pts with a LR 5 lesion in at least one of the aforementioned radiology reports, 2013-2017. Pts who received SOR on trial and/or combined with another agent were excluded. Clinical data for the 83 niHCC pts were abstracted and compared to the 25 iHCC pts who received SOR, any line of therapy. Based on χ2 analyses, the 2 groups did not differ by age, sex, race, BCLC stage at SOR initiation, ECOG status at SOR initiation, HCC etiology, ALBI grade at SOR initiation, or previous locoregional therapy. OS after initiation of SOR was 14.1m for niHCC, 10.5m for iHCC, p = NS. PFS after SOR was 3.7m for niHCC, 7m for iHCC, p = NS. AFP at the time of SOR initiation was higher in iHCC than niHCC (median 1331 vs 48, respectively, p = 0.004), with median %AFP change after 30 days -13% in iHCC and +6% in niHCC, p = NS. Decrease in AFP after 30 days of therapy was associated with improved OS among niHCC (21m versus 7m, p = 0.001) but not among iHCC pts (p = NS). Conclusions: iHCC is a poorly understood subset of HCC with underlying biology not well defined. Compared to niHCC, clinical outcomes with sorafenib do not appear to differ in this cohort. Future characterization of outcomes with Y-90 and immune checkpoint inhibitors is warranted.

e15668 Background: We sought to identify clinical predictors of radiographic progression of a Li-RADS (LR) 3 lesion (i.e. indeterminate for hepatocellular carcinoma (HCC)) to a LR 5 lesion (i.e. definitely HCC) among patients (pts) at high risk of HCC. Methods: Radiology reports from the University of Washington with an LR assignment, 2013-2017, were reviewed (5037 reports, 1954 patients(pts)). Pts with an LR 3 lesion, a follow-up scan within 1 year of date of LR 3 lesion detection, and radiographic evidence of cirrhosis OR a diagnosis of chronic HBV were included in the analysis. Results: Of the 167 pts, 38 (23%) progressed to LR 5 status, 10 progressed to LR 4, and 12 were downgraded to LR 1-2. The remaining 64% were unchanged at LR 3. Radiographic data including year of LR 3 detection (2013-2014 47%) and LR 3 imaging modality (CT 50.3%, MR 49.7%) were obtained. Clinical data were abstracted from medical record review, including sex (65% male), age (80% < 65), race (66% White), cirrhosis etiology (45% HCV, 27% EtOH, 22% NASH, 8% HBV), HCV genotype, HCV treatment status, AFP, and ALBI score (G2 54%, G3 16%, unk 15%). Variables of interest (age, sex, race, cirrhosis etiology, AFP, ALBI score, year of LR 3 detection, imaging modality) were included in proportional hazards modeling with the underlying time metric defined as time from LR 3 detection to date of LR 5 detection or date of last scan up to one year after LR 3 identification. Backwards elimination modeling was performed until remaining variables were associated with the outcome at a level of significance of p < 0.05 (Table 1). Among those with chronic HCV, risk of progression to LR 5 did not differ by HCV genotype (1a, 1b, 2, 3, other, unknown) or sustained viral response status at the time of LR 3 detection. Table 1: Multivariate hazard ratios (HR) and 95% confidence interval (CI) estimates. Conclusions: Chronic HCV, older age at LR 3 detection, earlier year of LR 3 detection, and male sex appear independently associated with risk of progression to LR 5. The identification of clinical factors associated with LR 3 progression may allow for the development of risk modeling tools to assist clinicians in determining frequency of follow-up imaging and optimal timing of intervention.[Table: see text]

Purpose Urgent appendectomy has long been the standard of care for acute appendicitis. Six randomized trials have demonstrated that antibiotics can safely treat appendicitis, but approximately 1 in 4 of these patients eventually requires appendectomy. Overall treatment success may be limited by complex disease including perforation. Patients׳ success on antibiotic therapy may depend on preoperative identification of complex disease on imaging. However, the effectiveness of computed tomography (CT) in differentiating complex disease including perforated from nonperforated appendicitis remains to be determined. The purpose of this study was to assess the preoperative diagnostic accuracy of CT in determining appendiceal perforation in patients operated for acute appendicitis. Methods We performed a retrospective review of pathology and radiology reports from consecutive patients who presented to the emergency department with suspicion for acute appendicitis between January 2012 and May 2015. CT scans were re-reviewed by abdominal imaging fellowship-trained radiologists using standardized criteria, and the radiologists were blinded to pathology and surgical findings. Radiologists specifically noted presence or absence of periappendiceal gas, abscess, appendicolith, fat stranding, and bowel wall thickening. The overall radiologic impression as well as these specific imaging findings was compared to results of pathology and operative reports. Pathology reports were considered the standard for diagnostic accuracy. Results Eighty-nine patients (65% male, average age of 34 years) presenting with right lower quadrant pain underwent CT imaging and prompt appendectomy. Final pathology reported perforation in 48% ( n = 43) of cases. Radiologic diagnosis of perforation was reported in 9% ( n = 8), correctly identifying perforation in 37.5% ( n = 3), and incorrectly reporting perforation in 62.5% of nonperforated cases per pathology. Radiology missed 93% ( n = 40) of perforations postoperatively diagnosed by pathology. There was no secondary finding (fat stranding, diameter >13mm, abscess, cecal wall thickening, periappendiceal gas, simple fluid collection, appendicolith, and phlegmon) with a clinically reliable sensitivity or specificity to predict perforated appendicitis. Surgeon׳s report of perforation was consistent with the pathology report of perforation in only 28% of cases. Conclusions The usefulness of a CT for determining perforation in acute appendicitis is limited, and methods to improve precision in identifying patients with complicated appendicitis should be explored as this may help for improving risk prediction for failure of treatment with antibiotic therapy and help guide patients and providers in shared decision-making for treatment options.

Objective The purpose of our study was to determine the current practice patterns of U.S. radiologists in imaging pregnant or potentially pregnant patients with acute abdominal and pelvic conditions. Materials and methods After obtaining an Institutional Review Board waiver, all members of the Association of University Radiologists, the Association of Program Directors in Radiology, and the Society of Radiologists in Ultrasound were invited via e-mail to take a 23-question online survey on radiology practices and clinical scenarios about acute abdominal and pelvic imaging of pregnant patients. Results Comparisons were made with previously published surveys. A total of 225 responses were received. Areas of high consensus included pregnancy assessment (97%) and obtaining informed consent (87%) before imaging, having a written policy on imaging pregnant patients (79%), modification of computed tomography (CT) protocols (74%), avoiding gadolinium contrast in magnetic resonance imaging (MRI) (74%), using ultrasound for initial imaging in some scenarios, and using CT in trauma cases after inconclusive ultrasound. Areas of emerging consensus compared to 2007 included the use of serum or urine testing to confirm pregnancy status (59.4%; previously 14%) and the use of MRI in suspected appendicitis after an inconclusive ultrasound (73% in first trimester and 67% in third trimester; previously 46% and 29%, respectively). Areas without clear consensus included policy development, additional modifications to MRI protocols, choice of imaging modality, radiation dose, and the use of contrast agents in some scenarios. Conclusion In conclusion, high or increasing consensus exists in some areas of imaging pregnant patients with acute abdominal and pelvic conditions, but has yet to emerge in other areas.

The utility of MR imaging in evaluating abdominal and pelvic pain in the pregnant patient is discussed. Details regarding the indications, technical aspects, and imaging findings of various common abdominal and pelvic abnormalities in pregnancy are reviewed.

Hepatocellular carcinoma (HCC) is the second largest cause of cancer mortality in the world, with vascular invasion being one of the most important prognostic factors. HCC with tumor thrombus was traditionally considered to have very limited treatment options. However, multiple promising treatment strategies have emerged in recent years, with diagnostic and interventional radiologists playing a major role in patient management. We provide a comprehensive update on the diagnosis and management of HCC with vascular invasion and the role of the radiologist in this condition.

The placenta has a fundamental role in fetal health and functions as an important bridge to normal fetal development throughout pregnancy. A complete fetal ultrasound (US) survey should include full assessment of the placenta for any possible abnormalities. Placental diseases range from abnormal morphology, size, location, extent, and degree of placentation, to abruption and the presence of rare placental neoplasms of benign or malignant nature. Some of these conditions are associated with other diseases including aneuploidies, and their discovery should alert the radiologist to perform a very thorough fetal US examination. At times, a fetal karyotype may be needed to provide additional information. Timely detection of placental abnormalities can alert the clinician regarding the need to make important management decisions to reduce fetal and maternal morbidity and mortality. Familiarity with the normal and abnormal imaging appearance of the placenta is therefore necessary for the radiologist. Ultrasound with Doppler is the initial imaging modality of choice for placental assessment. Magnetic resonance imaging serves as a problem-solving examination in instances where the US findings are equivocal or where additional information is needed. Computed tomography has a limited role in the evaluation of placental disease because of its relatively limited tissue characterization and in particular because of the resultant direct radiation exposure of the fetus. However, in specific instances, particularly after trauma, computed tomography can provide invaluable information for patient management.

Liver transplant is the treatment of choice for end-stage liver disease. Management of transplant patients requires a multidisciplinary approach, with radiologists playing a key role in identifying complications in both symptomatic and asymptomatic patients. Ultrasonography remains the investigation of choice for the initial evaluation of symptomatic patients. Depending on the clinical situation, further evaluation with CT, MRI, or biopsy may be performed or clinical and imaging surveillance may be continued. This article discusses the various normal and abnormal imaging presentations of liver transplant patients, including various acute and chronic complications, and their management.

Renal transplant complications are categorized as those related to the transplant vasculature, collecting system, perinephric space, renal parenchyma, and miscellaneous complications including posttransplant lymphoproliferative disorder. Many of these renal transplant complications are diagnosed with imaging. Medical complications including rejection, acute tubular necrosis, and drug toxicity also can impair renal function. These medical complications are typically indistinguishable at imaging, and biopsy may be performed to establish a diagnosis. Normal transplant anatomy, imaging techniques, and the appearances of renal transplant complications at ultrasound, computed tomography, and MR imaging are reviewed.

Purpose: To use magnetization tagged magnetic resonance imaging (MRI) (tag-MRI) to quantify cardiac induced liver strain and compare strain of cirrhotic and normal livers. Materials and Methods: Tag-MRI was performed at 1.5T on eight subjects with no history of liver disease and 10 patients with liver cirrhosis. A breath-hold peripheral pulse-gated (PPG) conventional tag-MRI cine sequence was performed with planes to include the left lobe of the liver and the inferior wall of the heart. Commercially available software HARP (Diagnosoft, Palo Alto, CA) was used for image analysis and strain calculation. Three regions-of-interest (ROIs) were selected: segment II of the liver near the heart (A), right liver lobe far from the heart (B), and the left ventricular wall (C). The average and maximal (max) strain were measured in A, B, and C. The maximum strains were used to generate a cardiac-corrected strain gradient: (maxA-maxB)/maxC. Results were compared with Student's t-test (SPSS, Chicago, IL). Results: In subjects with no history of liver disease vs. cirrhotic patients, the average strain was 22% ± 7% vs. 4% ± 3% (P < 0.001), the max strain was 63% ± 15% vs. 17% ± 5% (P < 0.001), and the corrected strain gradient was 0.52 ± 0.16 vs. 0.11% ± 0.08%. Conclusion: There is a significant difference in liver strain measured with tag-MRI between subjects with no history of liver disease and patients with cirrhosis. J. Magn. Reson. Imaging 2012; 36:1490–1495. © 2012 Wiley Periodicals, Inc.

Fat may be noted in a diffuse or focal manner in a variety of nonneoplastic abdominopelvic conditions. The specific signature of macroscopic fat on computed tomography along with the usually characteristic findings of these entities makes the diagnosis of most of these conditions relatively straightforward. In the intestinal tract, the "fat halo sign" usually arises in the context of subacute to chronic bowel wall inflammation. Excess fat in the renal sinus may occur with renal sinus lipomatosis or "replacement lipomatosis of the kidney." Some cases of "pancreatic lipomatosis" may culminate in steatopancreatitis and ultimately neoplastic transformations. "Fibrofatty mesenteric proliferation" is a characteristic feature of Crohn disease. In the setting of the acute abdomen, accurate diagnosis of fat-containing lesions (epiploic appendagitis or omental infarction) from other causes of the acute abdomen is critical. Mesenteric panniculitis is 1 of the causes of the "misty mesentery." Juxtacaval fat deposition is a benign process that has the potential to be confused with more serious conditions. More diffuse fat deposition (abdominal or pelvic lipomatosis) has the potential to become symptomatic by causing mass effect upon the adjacent structures. Fat can also be seen in a variety of postoperative/iatrogenic conditions or abdominal wall/diaphragmatic hernias.

Palpable scrotal mass, acute scrotal pain, and enlarged scrotum are common scenarios in clinical practice. The imaging modality of choice to evaluate scrotal pathology is ultrasound (US). US is key in determining if a palpable abnormality is extratesticular or intratesticular and cystic or solid. US findings help narrow the differential to benign or malignant causes. Extratesticular lesions are more common and usually benign. Rarely, extratesticular solid lesions are malignant but US features are nonspecific. Accurately diagnosing rare benign intratesticular lesions is vital to avoid unnecessary orchiectomy. This article reviews extratesticular and intratesticular lesions presenting as a palpable mass and other conditions commonly seen.

Kindler syndrome (KS) is a very rare genodermatosis characterized by acral blistering starting in infancy along with photosensitivity, progressive poikiloderma, cutaneous atrophy, and a variable degree of mucosal involvement. A large number of other cutaneous and extracutaneous features have been described, which aid in diagnosing it. Generally KS has been found to be associated with hypohidrosis/anhidrosis. We herein present a rare case of KS with unique features.

Bladder carcinoma is the fourth most common cancer in men and women. Knowledge of imaging options and appearance is necessary for both radiologists and urologists. Transitional cell carcinoma is the most common bladder neoplasm with squamous cell and adenocarcinoma found in less than 10% of cases. Benign lesions are uncommon, but some can be suggested by their imaging appearance. Similarly, malignant lesions often have suggestive appearance and/or location. Cystoscopy allows tissue diagnosis and treatment of superficial lesions. Although magnetic resonance imaging (MRI) and computed tomography (CT) both have limitations in detailing depth of muscle invasion, both have a prominent role helping to define the lesion and in staging. This article illustrates the role of MRI and CT in evaluating bladder masses with a discussion of the newer techniques of MR diffusion-weighted imaging and virtual cystoscopy by CT or MRI. This article reviews the multiple benign and malignant lesions of the bladder so that the reader can appreciate the role of cystoscopy, CT, MRI, diffusion-weighted imaging, and virtual cystoscopy in dealing with these relatively common tumors.

Received September 23, 2010; accepted without revision September 23, 2010. 1Department of Radiology, University of Washington, VA Puget Sound Health Care System, 1660 S Columbian Way, S-114/Radiology, Mail Stop 358280, Seattle, WA 98108. Address correspondence to P. Bhargava (bhargp@u.washington.edu). 2Department of Radiology, University of Washington, Seattle, WA. 3Department of Surgery, University of Washington, Seattle, WA. AJR 2011;196:WS15–WS25 0361–803X/11/1963–S1 © American Roentgen Ray Society Objective Orthotopic liver transplantation is an established treatment for patients with end-stage liver disease or acute liver failure. Complications of liver transplantation include vascular thrombosis and stenosis; arterial pseudoaneurysm; biliary leak, stricture, and obstruction; liver ischemia, infarction, and abscess; recurrent disease; posttransplantation lymphoproliferative disease (PTLD); recurrent tumors; peritransplant fluid collections and hematomas; and splenic infarction. The incidence of graft rejection and other complications experienced in the early years after the surgery has been reduced significantly because of advances in immunosuppression and surgical techniques. The clinical presentation of these complications is often nonspecific, and early detection of these complications on imaging is necessary for appropriate management. Living related liver transplantations are performed commonly, especially in children. Orthotopic liver transplantation is distinct from living related liver transplantation with regard to surgical technique, postoperative anatomy, and some complications. This article reviews the imaging appearances of different surgical techniques as well as the early and late complications of orthotopic liver transplantation.

Syringoma is a benign adnexal tumor of intraepidermal portion of the eccrine sweat ducts. Eruptive syringoma is a rare clinical variant characterized by small, flesh-colored papules with both follicular and nonfollicular distribution that occur in successive crops on the anterior body surface. We report a case of 35-year-old female with familial eruptive syringoma with predominant acral distribution. We report this case because of the rarity of disorder and acral predominance.

A recurring source of contention between clinicians and radiologists continues to be examination appropriateness when imaging pregnant patients. With the multitude of references on potential radiation risks to the fetus, radiologists tend to be cautious and hesitant about exposing the fetus to radiation. This tendency is often interpreted by referring physicians as intrusion into and delay in the care of their patients. The risk burden of radiation exposure to the fetus has to be carefully weighed against the benefits of obtaining a critical diagnosis quickly and using a single tailored imaging study. In general, there is lower than expected awareness of radiation risks to the fetus from imaging pregnant patients. Modalities that do not use ionizing radiation, such as ultrasonography and magnetic resonance imaging, should be the preferred examinations for evaluating an acute condition in a pregnant patient. However, no examination should be withheld when an important clinical diagnosis is under consideration. Exposure to ionizing radiation may be unavoidable, but there is no evidence to suggest that the risk to the fetus after a single imaging study and an interventional procedure is significant. All efforts should be made to minimize the exposure, with consideration of the risk versus benefit for a given clinical scenario.

Gallbladder cancer is the most common malignant tumor of the biliary tract and often diagnosed incidentally during laparoscopic cholecystectomy for gallbladder disease. This underscores the importance of considering the diagnosis of gallbladder cancer when confronted with atypical findings and understanding cancer management guidelines that may impact patient outcome. Potentially curable early stage gallbladder lesions are often missed during preoperative workup and discovered incidentally during difficult cholecystectomy or afterwards on pathologic diagnosis. We will review current strategies to diagnose early stage disease and discuss clinical management issues to optimize the outcome of patients with gallbladder cancer.

Objectives: To evaluate the frequency of developmental dental anomalies in the Indian population.Methods: This prospective study was conducted over a period of 1 year and comprised both clinical and radiographic examinations in oral medicine and radiology outpatient department. Adult patients were screened for the presence of dental anomalies with appropriate radiographs. A comprehensive clinical examination was performed to detect hyperdontia, talon cusp, fused teeth, gemination, concrescence, hypodontia, dens invaginatus, dens evaginatus, macro- and microdontia and taurodontism. Patients with syndromes were not included in the study.Results: Of the 20,182 patients screened, 350 had dental anomalies. Of these, 57.43% of anomalies occurred in male patients and 42.57% occurred in females. Hyperdontia, root dilaceration, pegshaped laterals (microdontia), and hypodontia were more frequent compared to other dental anomalies of size and shape.Conclusions: Dental anomalies are clinically evident abnormalities. They may be the cause of various dental problems. Careful observation and appropriate investigations are required to diagnose the condition and institute treatment. (Eur J Dent 2010;4:263-269)

Tumoral calcinosis (TC) is a rare entity causing abnormal periarticular calcifications in the affected joint observed in the first two decades of life. It is also known to affect the teeth. Few case reports on TC talk about the dental findings. This article presents the clinical, radiological and histological appearance of dental abnormalities in a 23-year-old female with TC. The differential diagnosis and dental management are discussed.Tumoral calcinosis should be considered in the differential diagnosis of abnormally short roots with complete or partial obliteration of pulp chambers in a young patient.

Primary cardiac tumors are rare and are usually diagnosed at an advanced stage due to nonspecific symptoms. We report a 46-year-old female who presented to our institution with shortness of breath and was diagnosed with a cardiac spindle-cell tumor. Wide surgical resection is the cornerstone for therapy for cardiac sarcomas. Our patient was considered inoperable due to the extent of the tumor.

OBJECTIVE. The purpose of this article is to familiarize radiologists with uncommon presentations of hepatocellular carcinoma (HCC) with an emphasis on the CT spectrum of atypical appearances. CONCLUSION. HCC is the fifth most common neoplasm worldwide and the second most common cause of cancer-related death. In many cases, HCC can be confidently diagnosed with noninvasive imaging. However, there are numerous unusual appearances of HCC with which the radiologist must be familiar.

Objective To illustrate the imaging appearances of a spectrum of renal collision and composite tumors. Occurrence of collision and composite tumors in the genitourinary tract is rare compared to the usual occurrence of synchronous tumors. Methods Case studies were chosen that represent the different tumors. Analysis was made on both the imaging and the pathology if excision was performed. Results Presence of 2 different cell types can lead to confusing imaging findings, and biopsy or excision is typically needed for final diagnosis. Some composite tumors have a characteristic appearance on imaging based on their pathologic features. Conclusion Familiarity with imaging findings may help radiologists include these tumors in their differential diagnosis.

The purpose of this study was to ascertain if standardized radiologic reporting for appendicitis imaging increases diagnostic accuracy.We developed a standardized appendicitis reporting system that includes objective imaging findings common in appendicitis and a certainty score ranging from 1 (definitely not appendicitis) through 5 (definitely appendicitis). Four radiologists retrospectively reviewed the preoperative CT scans of 96 appendectomy patients using our reporting system. The presence of appendicitis-specific imaging findings and certainty scores were compared with final pathology. These comparisons were summarized using odds ratios (ORs) and the AUC.The appendix was visualized on CT in 89 patients, of whom 71 (80%) had pathologically proven appendicitis. Imaging findings associated with appendicitis included appendiceal diameter (odds ratio [OR] = 14 [10 vs6 mm]; p = 0.002), periappendiceal fat stranding (OR = 8.9; p0.001), and appendiceal mucosal hyperenhancement (OR = 8.7; p0.001). Of 35 patients whose initial clinical findings were reported as indeterminate, 28 (80%) had appendicitis. In this initially indeterminate group, using the standardized reporting system, radiologists assigned higher certainty scores (4 or 5) in 21 of the 28 patients with appendicitis (75%) and lower scores (1 or 2) in five of the seven patients without appendicitis (71%) (AUC = 0.90; p = 0.001).Standardized reporting and grading of objective imaging findings correlated well with postoperative pathology and may decrease the number of CT findings reported as indeterminate for appendicitis. Prospective evaluation of this reporting system on a cohort of patients with clinically suspected appendicitis is currently under way.