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Cystic pancreatic lesions (CPLs) are common and increasingly encountered in clinical radiology practice. The appropriate imaging surveillance strategy for lower-risk CPLs (branch duct—intraductal papillary mucinous neoplasms and indeterminant small cystic lesions) has been a topic of intense study and debate in recent years. MRI is considered the investigation of choice for initial characterisation and follow-up of CPLs. Follow-up intervals for CPLs vary from 6 months to 2 years and surveillance may be lifelong or until the patient is no longer considered fit for potential surgical intervention. This creates a significant burden on MRI resources as a standard protocol pancreatic MRI may have an acquisition time of up to 35–50 min. However, the necessity of contrast-enhanced sequences and diffusion weighted imaging (DWI) for routine follow-up of CPLs has been questioned in recent years. We reviewed the available evidence to determine whether an abbreviated MRI (A-MRI) protocol may be safely adopted for surveillance of CPLs, as has been implemented in other clinical scenarios. A number of recent retrospective studies have indicated that an A-MRI, omitting contrast-enhanced and DWI, may be used for CPL surveillance without any suspicious features or cases of malignancy being missed. Although small number of cases may need to be recalled for additional MR sequences based on the A-MRI findings, there is still a significant overall timesaving. The best available evidence currently suggests that an A-MRI protocol should be considered for routine surveillance of CPLs. Prospective studies are required to ensure the findings reported in these retrospective case studies are backed up in ongoing clinical practice.

With increasing subspecialised experience in radical cytoreductive surgery and intra-abdominal chemotherapy for peritoneal malignancy, outcomes have improved significantly in selected patients. The surgery and the treatment regimens are radical and therefore correct patient selection is critical. The radiologist plays a central role in this process by estimating, as precisely as possible, the pre-treatment disease burden. Because of the nature of the disease process, accurate staging is not an easy task. Tumour deposits may be very small and in locations where they are very difficult to detect. It must be acknowledged that no form of modern day imaging has the capability of detecting the smallest peritoneal nodules, which may only be visible to direct inspection or histopathological evaluation. Nonetheless, it behoves the radiologist to be as exact and precise as possible in the reporting of this disease process. This is both to select patients who are likely to benefit from radical treatment, and just as importantly, to identify patients who are unlikely to achieve adequate cytoreductive outcomes. In this review, we outline the patterns of spread of disease and the anatomic basis for this, as well as the essential aspects of reporting abdominal studies in this patient group. We provide an evidence-based update on the relative strengths and limitations of our available multimodality imaging techniques namely CT, MRI and positron emission tomography/CT.

Introduction We assessed management of patients with de novo metastatic rectal cancer, referred for radiotherapy to the rectum, who were candidates for short-course radiotherapy (SCRT) and chemotherapy, followed by resection of all disease. We assessed surgical outcomes, overall survival (OS) and progression-free survival (PFS). Methods Retrospective review of patients meeting criteria: (i) treatment with SCRT to rectum; (ii) locally advanced primary rectal cancer; and (iii) resectable distant metastases at diagnosis. Data were collected from charts, correspondence and electronic patient records. OS and PFS were calculated using the Kaplan-Meier method. Results Between 2016 and 2020, 48 patients with stage IV rectal cancer at diagnosis were treated with SCRT. Only 15 patients (31%) had resectable metastatic disease and were intended for SCRT (25 Gy/5#), then chemotherapy, followed by resection of all sites of disease and are included in our study. 12 of the 15 surgical candidates (80%) had rectal surgery as planned, and 11 of the 15 (73%) had resection of the rectal primary and all metastatic disease. One patient had a pathological complete response (pCR), and 50% of surgical patients had a Mandard TRG of 1 or 2. Median PFS and OS for the 15 surgical candidates were 12.6 and 25.2 months, respectively, with a median FU of 21.2 months. Conclusion For this cohort of patients, our treatment paradigm is pragmatic and results in excellent pathological response. However, the effectiveness of this approach should be the subject of future prospective studies.

Scleroderma is a complex multisystem connective tissue disorder. Early visceral disease, such as gastrointestinal (GI) involvement, is associated with significant morbidity and a poorer prognosis. Prompt diagnosis is crucial to allow disease modifying therapies be initiated early in the course of the disease. The primary underlying pathophysiology in the GI tract is dysmotility, muscular atrophy, and fibrosis, and this is reflected in the imaging features. In this paper, we demonstrate the imaging appearances of involvement of the GI tract and describe the use of advanced imaging with magnetic resonance enterography (MRE). A multimodal imaging approach is required to identify both characteristic features of scleroderma and potential complications. Traditional fluoroscopic contrast (barium) studies are still commonly performed for assessment of the oesophagus. More recent advances in cross-sectional imaging allow for thorough three-dimensional assessment of the entire GI tract. MRE is particularly useful for small bowel evaluation while also allowing "pseudodynamic" functional imaging and concomitant assessment of the other abdominal viscera and structures.

OBJECTIVE. The purpose of this article is to discuss the role of the radiologist in the treatment of peritoneal cancer, with focus placed on advanced treatment options and selection of patients with resectable disease for whom complete cytoreduction can be achieved. CONCLUSION. Peritoneal cancers traditionally have been associated with significant morbidity and universal mortality; however, the management of such cancers has evolved substantially. Advanced treatment options, including cytoreductive surgery and intraperitoneal chemotherapy, are associated with significantly improved long-term patient survival. To ensure that patients benefit from aggressive multimodality treatments, the radiologist plays a pivotal role in the multidisciplinary team to ensure careful patient selection, identifying individuals with resectable disease for whom complete cytoreduction can be achieved.

Incidental adrenal lesions are very common. Computed tomography (CT), magnetic resonance imaging (MRI) and positron emission tomography (PET) all have a role to play in characterizing adrenal lesions. The purpose of this review is to discuss the rationale behind both established and emerging imaging techniques. We also discuss how to follow up incidentally found lesions.

OBJECTIVES: To review the characteristics and outcome of incidental pulmonary nodules reported on abdominal computed tomography (CT). METHODS: A database search of abdominal CTs from January 1, 2004, to December 31, 2006, revealed 413 patients with incidental pulmonary nodules and at least one follow-up chest CT. Demographic information, nodule characteristics, and eventual outcome of the nodules were analyzed. RESULTS: Of the 413 patients, 56% had benign nodules, 11% had malignant nodules, and the remaining 33% had insufficient follow-up. There was a statistically significant difference (P < 0.05) in the age of the patients, history of malignancy, and size of the incidental nodule between benign and malignant groups. No malignant nodules were found in patients younger than 59 years who did not have a known or suspected malignancy. CONCLUSION: Small pulmonary nodules (

The diagnosis and effective management of inflammatory bowel disease (IBD) requires a combination clinical, endoscopic, histological, biological, and imaging data. While endoscopy and biopsy remains the gold standard for diagnosis of IBD, imaging plays a central role in the assessment of extra mural disease, in disease surveillance and in the assessment of response to medical treatments, which are often expensive. Imaging is also vital in the detection and diagnosis of disease related complications, both acute and chronic. In this review, we will describe, with illustrative images, the imaging features of IBD in adults, with emphasis on up-to-date imaging techniques focusing predominantly on cross sectional imaging and new magnetic resonance imaging techniques.

A 34-year-old man was admitted to the hospital because of weakness, chronic diarrhea, and weight loss. Initial laboratory evaluation revealed a leukocytosis and hypokalemia. A diagnostic procedure was performed.

The purpose of this study was to assess the technical and clinical success and complications of imaging-guided percutaneous catheter drainage of peripancreatic fluid collections after distal pancreatectomy.Between January 2001 and February 2009, the cases of patients who underwent distal pancreatectomy were selected from a surgical database, and the cases of those who underwent subsequent interventional radiologic percutaneous drainage were identified. Details of percutaneous catheter drainage were recorded, and technical and clinical success was determined. Technical success was defined as successful percutaneous imaging-guided placement of a drainage catheter. Primary clinical success was defined as resolution of peripancreatic fluid collection with percutaneous drainage only. Secondary clinical success was defined as resolution of peripancreatic fluid collection with percutaneous drainage and additional manipulations (i.e., tube repositioning, additional catheter drainage) and no surgical débridement. Multifactor logistic regression analysis was used to identify predictors of drain failure.Between January 2001 and February 2009, 365 patients underwent distal pancreatectomy. Of these, 51 patients (14%; 25 men, 26 women; mean age, 53.4 years; range, 18-81 years) underwent 57 CT-guided percutaneous procedures for drainage of postsurgical peripancreatic fluid collection. The mean interval between surgery and drainage was 23.5 days (median, 17 days; range, 2-120 days), and the mean collection size was 7.3 cm in transverse dimension (median, 6.9 cm; range, 2.3-16 cm). The mean duration of catheter drainage was 39.7 days (median, 24 days; range, 3-220 days). The technical success rate was 100%, primary clinical success rate was 60%, and primary and secondary clinical success rates together were 95%. Three of the 51 patients (6%) needed surgery for definitive management of the collection. One of 51 patients (2%) had a complication of the interventional radiologic procedure. Catheter size and the need for additional catheter manipulation were significantly associated with drainage failure (p0.05).Catheter drainage of peripancreatic fluid collections after distal pancreatectomy is a technically safe and clinically effective procedure. Although extra manipulations may be needed to achieve clinical success, the combined primary and secondary clinical success rates are high.

The purpose of this article is to describe our experience draining deep muscular and musculoskeletal abscess collections with CT guidance, emphasizing clinicopathologic factors associated with drain failure, and to further analyze patient outcomes according to whether the process involves muscle alone or also involves adjacent bone or joint (skeletal involvement).The details of percutaneous catheter drainage were retrospectively recorded for all drainages performed over a 9-year period. The technical and clinical successes of percutaneous catheter drainage were determined. Multifactor logistic regression analysis was used to identify predictors of drain failure (malignancy, age, chemotherapy, surgery, infection, complexity, size, days in situ, and skeletal involvement). These parameters were assessed in all patients, those with muscle involvement alone and those with musculoskeletal collections.Eighty-nine of 94 patients underwent one percutaneous drainage procedure and 5 of 94 patients underwent two drainages for a total of 99 drainages in 94 patients (one drainage [n = 89] and two drainages [n = 5]). There were 62 men and 32 women with a mean age of 58.5 years (age range [±SD], 22.3-88.0 ± 16 years). The abscess diameters ranged from 1.8 to 13 cm (mean, 5.3 ± 2.5 cm), volume aspirated ranged from 0 to 200 mL (mean, 45 ± 44 mL), and mean duration of drainage was 16.2 days (range, 2-110 ± 18.7 days). The iliopsoas muscle was the most common site of drainage, accounting for 87.8% of the total. Catheter insertion was possible in all patients, with the muscular component successfully drained in 82% (81/99) overall: 85% (46/54) of those with muscle involvement alone and 77% (35/45) of those with musculoskeletal collections. Catheter drainage and antibiotic administration resulted in 65.6% (65/99) not requiring any surgical intervention and resolution of abnormal white cell count or fevers in 98.8% (79/80) of those with abnormal parameters before treatment. Skeletal infection was associated with increased risk of drainage failure (p = 0.0001).Percutaneous imaging-guided musculoskeletal drainage is clinically useful, safe, and effective for draining complex musculoskeletal collections. It is highly effective for draining collections involving muscle alone; however, skeletal infection is associated with a higher risk of drain failure.

OBJECTIVE. The objective of this article is to illustrate the spectrum of imaging findings of polypropylene (Prolene) plug hernia repair.CONCLUSION. Knowledge of patient history and awareness of postsurgical imaging appearances are of importance because Prolene plugs are often incidentally encountered and if misdiagnosed may lead to erroneous patient disease staging and management.

To reassess the accuracy of the 10-minute delayed scan to differentiate both lipid-rich and lipid-poor lesions in a large cohort of patients.This HIPAA-compliant retrospective study had institutional review board approval; the need for informed consent was waived. A multidetector computed tomography (CT) adrenal protocol (unenhanced, dynamic contrast material-enhanced, and 10-minute delayed CT) was used in 314 consecutive patients (201 women, 113 men; mean age, 63.6 years) for the period from January 2006 through February 2009. The mean adrenal attenuation during all three CT phases was measured by two readers, and the relative percentage washout (RPW) and absolute percentage washout (APW) values were calculated. APW and RPW receiver operating characteristic (ROC) analysis was performed to evaluate the strength of the tests.There were 323 adrenal lesions (213 left, 110 right) consisting of 307 adenomas and 16 nonadenomas. The sensitivity, specificity, and accuracy for the RPW test at a washout threshold of 50% were 55.7%, 100%, and 57.9%, respectively; at 40% were 76.9%, 93.7%, and 77.7%; and at 35% were 81.4%, 93.7%, and 82.0%. The sensitivity, specificity, and accuracy for the APW test at a 60% threshold were 52.1%, 93.3%, and 54.0%, respectively; at 55% were 62.5%, 93.3%, and 64.0%; and at 50% were 71.3%, 80.0%, and 71.7%. Areas under the ROC curve were 0.85 (95% confidence interval: 0.75, 0.95) and 0.91 (95% confidence interval: 0.85, 0.97) for the APW and RPW tests, respectively, to detect adenomatous disease.The 10-minute delayed adrenal enhancement washout test has reduced sensitivity for the characterization of adrenal adenomas compared with results from prior studies.

Purpose To assess the normal small bowel parameters, namely bowel diameter, bowel wall thickness, number of folds (valvulae connivientes) per 2.5 cm (in.), fold thickness and interfold distance per small bowel segment (duodenum, jejunum, proximal ileum, distal ileum and terminal ileum) on MR enterography. Materials and methods Between September 2003 and January 2008, 280 MR enterography examinations were performed for investigation of known or suspected small bowel pathology. 120 of these examinations were normal. Sixty-five (m = 29, f = 36, mean age = 34 years, range = 17–73 years) of 120 examinations without a prior small bowel diagnosis, with no prior or subsequent abnormal radiology or endoscopy examinations, no prior small bowel surgery and with a minimum 3 years follow-up demonstrating normality were retrospectively evaluated for the described small bowel parameters. Results We found the mean diameter of the duodenum to be 24.8 mm (S.D. = 4.5 mm), jejunum to be 24.5 mm (S.D. = 4.2 mm), proximal ileum to be 19.5 mm (S.D. = 3.6 mm), distal ileum to be 18.9 mm (S.D. = 4.2 mm) and terminal ileum to be 18.7 mm (S.D. = 3.6 mm). The number of folds per 2.5 cm varied from 4.6 in the jejunum to 1.5 in the terminal ileum. The fold thickness varied from 2.1 mm in the duodenum to 1.8 mm in the terminal ileum. The small bowel parameters gradually decreased in size from the duodenum to the smallest measurements which were in the terminal ileum. The bowel wall is similar in size throughout the small bowel measuring 1.5 ± 0.5 mm. Conclusion These results provide the mean, range of normality and standard deviation of the small bowel parameters per segment on the current population on MR enterography. From our experience, knowledge of these parameters is extremely helpful and essential in the everyday assessment of MR enterography studies.

To assess the feasibility and utility of magnetic resonance (MR) imaging of the bowel in concurrent small- and large-bowel evaluation for the presence of inflammatory bowel disease (IBD). Over a 5-year period, 62 MR examinations performed on 53 patients demonstrated evidence of IBD. Sixteen of these 53 (30.1%) patients had imaging findings of colonic disease and underwent 19 formal MR small bowel examinations. These were further evaluated for bowel distention and image quality. The sensitivity and specificity of the technique compared with colonoscopy as the ‘gold standard’ was evaluated. Simultaneous imaging of the colon is feasible at MR small bowel follow-through with moderate-to-excellent colonic visibility and colon distention obtained when the contrast medium is present in the colon at the time of image acquisition. MR imaging had a sensitivity of 80% (0.56–0.93), specificity of 100% (0.77-1.00), positive predictive value (PPV) of 1 and a negative predictive value (NPV) of 0.8 for the identification of colitis (based on available concurrent correlation of 38/62 examinations with colonoscopy). Small and large bowel MR imaging with orally consumed contrast medium represents a promising, feasible, non-invasive, non-radiating single mode of assessment of the entire gastrointestinal tract, performed at a single sitting.

The purpose of this study is to assess which of five bowel preparation regimes offers superior bowel distension and to assess if these regimes adversely affect FDG activity on PET/CT imaging. The study conformed to HIPAA regulations. Ninety patients were divided into five groups of 18 who received no oral contrast agent (group A); 900 ml of water orally (group B); or 900, 1,350, or 1,800 ml of LDB (groups C, D, E, respectively). PET/CT examinations were assessed quantitatively (bowel diameter, SUV) and qualitatively (visual assessment grading scale) for bowel distension and FDG activity by two blinded readers. ANOVA was utilized to determine if a statistically significant difference (SSD) existed between the groups in terms of distension and FDG uptake. Qualitatively superior bowel distension was observed in group C (LDB) compared to B (water) and greater distension was noted with increased volumes of LDB in C, D, and E. Quantitatively there was an SSD in mean distension between groups C and B (P0.001 except duodenum). Qualitatively and quantitatively there was no significant difference in bowel FDG uptake among the groups (P0.05). LDB as an oral contrast agent provides superior bowel distension over water and does not induce increased FDG bowel activity.

The purpose of our study was to evaluate the potential role of an MR small-bowel follow-through (SBFT) technique in the investigation of suspected pediatric small-bowel abnormalities.Between September 2003 and January 2008, 280 MR SBFT examinations were performed for investigation of known or suspected small-bowel abnormalities, including 19 of 280 examinations in 17 children (mean age, 13 years; age range 6-17 years), representing the current study population. A standardized technique was used in all cases, including axial and coronal steady-state free precession acquisitions at successive time intervals until completion. Retrospective analysis of the studies obtained was performed by two radiologists, who blindly and independently scored predefined small-bowel segments according to the degree of luminal distention achieved. Any pathologic lesions detected were also noted. Indicators of examination success as a whole (volume, tolerability, and side effects of oral contrast material) were also noted, as were details pertaining to examination duration (number of visits to the MR table, total table time).Oral contrast medium was ingested and subsequent imaging was possible in all patients; 84.2% of patients tolerated the oral contrast material well and 15.8% showed moderate tolerance. The MR table time ranged from 2 to 4 minutes, without early termination of the examination in any case. The average number of visits to the MR table was 1.3 (range, 1-3). The mean duration for complete small-bowel evaluation was 25 minutes (range, 20-60 minutes). The mean distention scores were well within the diagnostic range in all small-bowel segments for both observers, with a substantial degree of interobserver agreement in score assignment (kappa = 0.73). Pathologic lesions were identified in 53% of studies.MR SBFT represents a promising, and perhaps optimal, technique for pediatric small-bowel evaluation for a variety of reasons, including its high tolerability, lack of ionizing radiation, avoidance of duodenojejunal intubation, and excellent luminal distention achieved. Furthermore, this technique allows "pseudodynamic" functional imaging while also showing extraluminal disease, without known biologic risk.

Combined positron emission tomography/computerized tomography (PET/CT) imaging with fluorine 18 fluorodeoxyglucose (FDG) allows fusion of structural and attenuation information provided by CT with functional imaging derived from PET, improving the radiologic assessment of normal anatomic structures and pathologic lesions. PET/CT allows accurate location of hypermetabolic foci identified at PET with its morphologic structure on CT, reducing the incidence of falsepositive and false-negative imaging findings with PET alone. CT, because of its lack of metabolic information, is unable to distinguish fibrotic tissue; a common finding after chemoradiotherapy and/or surgery from residual neoplastic disease and thus may fail in posttreatment assessment. The ability and role of PET/CT in distinguishing active from inactive disease has revolutionized the assessment of gastrointestinal and hepatobiliary malignancies.

OBJECTIVE. The cross-sectional characterization of duodenal abnormalities is plagued with inadequacy, a reflection of the meandering course of this segment of the bowel. We consider the imaging appearance of such abnormalities at MRI small-bowel follow-through, illustrating the typical manifestations of each pathologically confirmed condition.CONCLUSION. MRI small-bowel follow-through allows confident duodenal evaluation because of a combination of sufficient luminal distention and multiplanar versatility. Diseases of the duodenum may have a variety of manifestations at MRI small-bowel follow-through, the knowledge of which may aid in confident noninvasive patient diagnosis.

OBJECTIVE. Retroperitoneal fibrosis is a rare collagen vascular disorder of unclear cause. Both benign and malignant associations have been described, rendering differentiation of these entities of paramount importance because sinister pathology alters the diagnosis. Thus, a high level of diligence is required in the investigation of this condition, particularly in patients with concomitant systemic conditions.CONCLUSION. Familiarity with the realm of imaging manifestations of retroperitoneal fibrosis is vital to ensure correct diagnosis and optimal treatment.

The apparent incidence of iliopsoas muscle abnormalities is currently rapidly increasing secondary to the increased number of immuno-compromised patients, malignancies, chemotherapy, immunotherapy, multi-systemic disease and the wide availability of cross-sectional imaging. Disease of the iliopsoas compartment can present with non-specific or indolent clinical features, particularly where normal immune responses are attenuated. Delay in diagnosis can lead to inappropriate initial treatment and, in some cases, serious complications. Wider availability and application of modern cross-sectional imaging offers rapid, confident diagnosis. An understanding of iliopsoas compartment anatomy and pathways of disease spread are essential to recognising these clinically important conditions. We review the anatomy, clinical presentation and common imaging findings of iliopsoas disease as it presents through the emergency room.

Falls on the outstretched hand, with resultant pain in the carpal region, account for a significant number of referrals to emergency rooms worldwide. Not only do they represent a significant proportion of the radiological workload arising from emergency rooms, interpretation of the images acquired is often difficult due to the complex anatomy of this region, compounded by an inability to obtain adequate views due to patient discomfort. Often, despite apparently normal radiological examinations, patient discomfort persists, prompting a need for further imaging. It is vital that the radiologist be entirely familiar with the bony and ligamentous anatomy of this body region, as well as possess an understanding of the frequent mechanisms of injury. Using a variety of imaging techniques, we illustrate a spectrum of carpal injuries, common and otherwise, explaining the mechanism and typical appearances of each.

The purpose of our study was to determine the prevalence of unsuspected venous thromboembolic disease--specifically, of pulmonary embolism (PE) and of inferior vena cava (IVC), iliac, and iliofemoral deep venous thromboses (DVTs)--in oncology patients on staging CT scans of the thorax, abdomen, and pelvis.Retrospective analysis was performed on 435 consecutive staging CT thorax, abdomen, and pelvis scans performed on a variety of oncology patients for the presence of venous thromboembolic disease. The patient group consisted of 198 men and 237 women who ranged in age from 20 to 79 years (mean, 55 years). Disease type, stage, concomitant surgery or chemoradiation therapy regimes, anticoagulation status, and 6-month clinical and radiologic follow-up findings were recorded.We found a prevalence of 6.8% (23/339) unsuspected iliofemoral, 1.2% (4/339) unsuspected common iliac, and 0.3% (1/315) unsuspected IVC DVTs and 3.3% (13/397) unsuspected PEs occurring in patients with a wide range of malignancies. The overall prevalence of unsuspected venous thromboembolism (i.e., DVT, PE, or both) was 6.3% (25/397). DVT, PE, and venous thromboembolic disease were more common in inpatients (p = 0.002, 0.004, 0.023; relative risk [RR] = 1.6, 2.1, 1.4, respectively) and in those with advanced disease (p = 0.001, 0.01, 0.001; RR = 2.2, 1.8, 2.0, respectively).Although there is a known increased risk of thromboembolism (DVT and PE) in oncology patients, many cases are not diagnosed, which can prove fatal. Staging CT simultaneously affords one sole investigation of the pulmonary, IVC, iliac, and upper femoral veins, thereby providing an important diagnostic opportunity. Assessment for DVT and PE is important when reviewing staging CT scans.

The effect of inferior vena cava (IVC) stents crossing the ostia of the renal veins on renal function has not been reported. The purpose of this study is to report a single-institution experience with four cases of IVC stent implantation for malignant compression and/or invasion of the IVC causing severe lower-extremity edema. The patients' symptoms were successfully relieved, and follow-up imaging and serum creatinine measurements for the remainder of their lives revealed no evidence of renal impairment or renal vein thrombosis.

We report the case of a patient with multiple myeloma (MM) and extensive lytic bone disease who presented with a short history of back pain and leg weakness. Magnetic resonance imaging (MRI) of the lumbar spine revealed a sacral insufficiency fracture complicated by an epidural haematoma. Bleeding tendency in this case can be accounted for by platelet function defects, often described in plasma cell disorders in the absence of obvious coagulation abnormalities. Surgical intervention was contraindicated as a result of poor overall patient performance status (poor surgical candidate due to extensive myelomatous bone disease, previous vertebral compression fractures requiring orthopaedic stabilisation, and requiring opiate analgesia for bone pain) and management was conservative. Patients presenting with back pain and documented bone disease in the setting of myeloma should be managed with a high index of clinical suspicion and considered for urgent MR imaging to avoid missing this serious and potentially reversible complication. We report the undescribed causative association between sacral insufficiency fracture and lumbo-sacral epidural haematoma. We illustrate the MRI signal and contrast enhancement pattern of an acute presentation of epidural haematoma.

Evaluation of gastric wall pathology using cross-sectional imaging has proved difficult, particularly in the imaging of early, localized disease. The properties of Calogen as a negative oral contrast agent for the evaluation of the upper gastro-intestinal tract and retroperitoneum in CT has been well described. We assess the suitability of this agent as an oral contrast medium for use in MRI examination of the gastric wall, finding the mean scores for Calogen and water with regard to gastric distension to be 8.46 and 5.49, respectively (P

A man in his 60s presented for a testicular ultrasound due to asymptomatic scrotal swelling. Ultrasound showed a right-sided varicocoele (figure 1). A varicocoele is an abnormal dilatation of the pampiniform venous plexus in the scrotum. A renal ultrasound demonstrated a heterogeneous mass arising from the right kidney (figure 2). Histology subsequently revealed a renal cell carcinoma. CT identified duplication of the right testicular vein (figure 3). The first emptied into the inferior venacava (IVC) as expected. The second had a tortuous course arcing over the upper pole of the right kidney and emptying into the right renal vein (figure 4). Tumour extension …

The aim of this study was to quantitatively and qualitatively evaluate pulmonary 64-MDCT angiography image quality in pregnancy and puerperium, compared with female nonpregnant control subjects.The study group comprised 124 consecutive pregnant and postpartum women and 124 female nonpregnant control subjects who presented with suspected pulmonary embolism. The individual studies were evaluated for subjective and objective diagnostic quality.Objective measurements of the arterial enhancement in the pulmonary trunk and left and right pulmonary arteries found that there was no statistically significant difference in attenuation values between the pregnant and puerperium group and the control group for pulmonary artery opacification. The mean attenuation in the pulmonary trunk was 270.54 HU in the pregnant group, 277.53 HU in the puerperium group, and 293.90 HU in the control group.We found no significant difference in diagnostic quality of pulmonary CT angiography using MDCT between the study and control groups. The use of MDCT acquisition, faster injection rates, higher contrast medium concentration, and higher trigger levels may decrease the number of nondiagnostic studies in this population. MDCT may be a worthwhile investigation in the majority of pregnant patients with suspected pulmonary embolism.

Ovarian cancer is responsible for the largest proportion of deaths among patients with gynecologic cancer. This paper discusses fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) in the imaging of ovarian cancer. We discuss and demonstrate how FDG PET/CT can be used to appropriately guide clinical management decisions in patients with ovarian cancer. In particular, FDG PET/CT shows great promise for the preoperative evaluation of women with primary ovarian cancer and for subsequent postoperative assessment for recurrence.

We describe the management principles and different roles of positron emission tomography (PET)/CT in the evaluation of patients with small bowel tumours (adenocarcinoma, gastrointestinal stromal tumour, lymphoma, metastases) from initial staging, monitoring response to treatment, to detection of recurrent disease. We also discuss the various non-malignant aetiologies of small bowel fludeoxyglucose (FDG) PET uptake, and other pitfalls in FDG PET/CT interpretation. Awareness of the imaging appearances of small bowel tumours, patterns of disease spread and potential PET/CT interpretation pitfalls are of paramount importance to optimise diagnostic accuracy.

To assess the prevalence of brown fat in patients with cancer, compare demographic characteristics of those with and those without brown fat, and correlate these characteristics with the mean and maximum standardized uptake values of brown fat.This case-control study was institutional review board approved and HIPAA compliant. Informed consent was waived. Reports of 12 195 consecutive positron emission tomography/computed tomography examinations performed in 6867 patients between January 2004 and November 2008 were reviewed for documented fluorodeoxyglucose (FDG) uptake in brown fat (n = 298). Control patients (n = 298) without brown fat were chosen and matched for age, sex, and month and year of examination. Age, sex, weight, body mass index, ethnicity, and examination stage (initial vs restaging) were compared between groups. Paired Student t test, χ(2) test, Pearson correlation coefficient, and analysis of variance were used for statistical analysis.Uptake of FDG in brown fat was demonstrated in 298 of 6867 (4.33%) patients. Prevalence of brown fat was significantly higher in female (5.9% [211 of 3587]) than in male patients (2.65% [87 of 3280]; P.001). Those with brown fat had significantly lower body weight (147.5 lb ± 3.8 vs 168.61 lb ± 5.0; P.001) and body mass index (24.3 ± 0.54 vs 27.6 ± 0.77; P.001) than control patients. There was no significant difference in the prevalence of brown fat among ethnic groups. The maximum standardized uptake value of brown fat had a significant inverse correlation with age (r = -0.3, P.001).Patients with brown fat were more likely to be female and thinner than those without brown fat. Younger patients were more likely to have higher maximum standardized uptake values of brown fat.

Symptomatic bladder outlet obstruction and neurogenic bladder are common conditions that frequently necessitate suprapubic insertion of a bladder tube. The purpose of this study was to describe an experience with minimally invasive imaging-guided percutaneous suprapubic bladder tube placement and the clinical and technical success and complications encountered.A total of 585 primary suprapubic bladder tube insertions and 439 exchanges of suprapubic bladder tubes were performed on 549 patients (469 men, 80 women; mean age, 66 years; range, 15-106 years). The details of percutaneous tube placement (indication, tube type, size at insertion and change, and method of insertion) were retrospectively recorded.The technical success rate for primary suprapubic bladder tube insertion was 99.6% (547/549) and for exchanges was 92.3% (405/439). The clinical success rate for primary insertion was 98.1% (572/583), and symptoms were unresolved in 1.9% (11/583). Minor complications occurred in 7.2% (42/583) of cases at tube insertion and in 4.8% (21/439) at exchange. There was one major complication (a patient needed surgery because the small bowel was traversed by a catheter), and there was no procedure-related mortality.Radiologic imaging-guided percutaneous suprapubic bladder tube placement is a safe and effective procedure.

OBJECTIVE. The purpose of this article is to review the role of FDG PET/CT in ovarian cancer, which is the leading cause of death among gynecologic cancers.CONCLUSION. FDG PET/CT can significantly modify the assessment of the extent of primary and recurrent ovarian cancer and, hence, often alters patient management substantially. FDG PET/CT has thus become a critical tool for the preoperative evaluation of women with primary ovarian cancer and for postoperative follow-up assessment for evidence of recurrence in these patients.

We sought to assess the probability that a new suspicious bone lesion is an alternative diagnosis, that is, a benign lesion or a second malignant tumor as opposed to metastatic disease from the malignant tumor, in a person with known primary malignant disease.We reviewed the radiologic and pathologic records of bone biopsies scheduled at our institution between 2002 and 2007. The following parameters were recorded: indication, type of primary cancer, date of diagnosis, complications of biopsy, whether the sample was of diagnostic quality, pathologic finding, and thus whether the primary malignant tumor was concordant with the lesion sampled.Fifty-four of 55 patients (17 men, 37 women; mean age, 67 years) with known primary cancer and suspicious bone lesions underwent biopsy. One of the 55 patients did not undergo biopsy because a sacral insufficiency fracture was confidently diagnosed at CT. The primary malignant disease had been diagnosed up to 16 years before the new bone lesion was suspected and bone biopsy performed. Cancer types included those of genitourinary tract, breast, thyroid, gastrointestinal tract, and lung and lymphoma and myeloma. Diagnostic material was obtained in 43 of 54 cases (80%), and nondiagnostic material was obtained in 11 of 54 cases (20%). Forty-two of 43 positive biopsy findings (98%) were consistent with the primary malignant tumor. The other positive finding was a new malignant tumor. This new tumor was myelofibrosis in a man with chronic myelocytic leukemia. The primary diagnosis correlated highly with that of the new bone lesion (Spearman's test, R = 0.842; p0.001). No complications, including hemorrhage, infection, sinus track formation, fracture, and pneumothorax, were encountered.In a patient with known primary malignant disease, the probability is low (2%) that biopsy of a new suspicious bone lesion will show the lesion is other than metastasis from the primary tumor.

Magnetic reasonance (MR) enterography enables high contrast resolution depiction of the location and cause of bowel obstruction through a combination of predictable luminal distension and multiplanar imaging capabilities. Furthermore, because the patient is not exposed to ionizing radiation, sequential "dynamic" MR imaging can be performed repeatedly over time further facilitating depiction of the site and/or the cause of obstruction. With increasing availability of MR imaging and standardization of the oral contrast medium regimens, it is likely that this technique will assume an ever-increasing role in the evaluation of small bowel dilation in the coming years. We illustrate the utility of MR enterography in the evaluation of small bowel dilation, whether it be mechanical, functional (e.g., ileus), or related to infiltrative mural disease.

Gastrointestinal complications of chemotherapy may be serious and potentially life-threatening. Familiarity with and awareness of the potential complications associated with various chemotherapeutic agents/regimens is paramount to enable accurate and timely diagnosis. In this article we review the radiological manifestations of the most notable gastrointestinal complications associated with chemotherapeutic administration.

To date, cross-sectional imaging of the duodenum has a number of inadequacies, most likely a reflection of its tortuous and complex anatomical course, resulting in somewhat suboptimal imaging. The purpose of this study was to describe and assess the feasibility of performing a ‘tubeless’, per-oral, single contrast, hypotonic magnetic resonance (MR) duodenography technique. Secondly, to assess the efficacy of intravenous Buscopan in facilitating duodenal distension at cross-sectional MR imaging. Ten healthy volunteers prospectively underwent MR imaging of the duodenum pre- and post-Buscopan immediately after consuming 1,000 ml of water. Images were qualitatively (using a visual assessment grading scale of 1–3) and quantitatively evaluated with regard to degree of small bowel distension by two observers. The contrast medium was successfully ingested and MR examination was completed in all participants. Quantitatively and qualitatively, the per-oral, hypotonic duodenography technique yielded superior distension scores and was significantly greater in diameter in comparison with the per-oral non-hypotonic duodenography technique (p

The purpose of this study was to assess whether prone or supine imaging provides superior small-bowel loop distention during MRI small-bowel follow-through examinations and whether either position is better with regard to lesion detection and evaluation.Forty consecutively enrolled clinically referred patients with known or suspected small-bowel abnormalities prospectively underwent 62 MRI small-bowel follow-through examinations in both the prone and the supine positions. Images were blindly and independently reviewed by two observers. Each small-bowel segment was assessed with a 3-point scoring system, and differences in bowel distention in the prone and supine positions were evaluated with a paired Wilcoxon's test. Differences between rates of lesion detection and characterization (e.g., ulceration, stricturing) were analyzed with a paired Student's t test. Interobserver agreement was estimated with the kappa coefficient.In both normal and diseased small bowel, the prone position had statistically significantly higher distention scores than did the supine position (p0.05) with a high level of interobserver agreement. This finding, however, did not translate into improved lesion detection or characterization (p0.05).Although use of the prone position results in superior small-bowel distention during MRI small-bowel follow-through, both the prone and supine positions are equal in terms of lesion detection and feature visualization.

The objective of our study was to evaluate the morphologic appearances of small-bowel lymphoma using MR enterography to identify key morphologic traits capable of providing an association between imaging manifestations and likely histologic diagnosis.Over a 54-month period, 10 patients with subsequently confirmed small-bowel lymphoma were imaged using a standardized MR enterography technique. Retrospective chart review was performed to detect associated disease processes, such as celiac disease. The morphologic characteristics of each segment with lymphomatous involvement were evaluated with respect to tumor location, tumor size, mural characteristics, fold features, loop dilatation, luminal stricturing, mesenteric or antimesenteric distribution, mesenteric involvement, and signal intensity.Nineteen distinct segments of lymphomatous involvement were identified in 10 patients, and underlying celiac disease was confirmed in six of the 10 patients. This patient group comprised 10 patients with non-Hodgkin's lymphoma (NHL) of various subtypes. No cases of Hodgkin's lymphoma were encountered. Analysis revealed celiac NHL enteropathy to have a tendency toward localization to a single, long (10 cm), smooth continuous bowel segment, often with aneurysmal loop dilatation, in the absence of a distinct mesenteric or antimesenteric distribution. Luminal stricturing was encountered in cases of low-grade lymphoma, whereas mesenteric fat infiltration represented a characteristic of high-grade disease.We describe the characteristics of small-bowel lymphoma on MR enterography, identifying a number of key features that may help the interpreting radiologist in suggesting the underlying histologic subtype and whether the presence of underlying celiac disease is likely.

Isolated limb infusion (ILI) is a recently described minimally invasive technique indicated in the management of regionally advanced cancers refractory to systemic therapy and surgery. The present report describes the initial single-center experience of three patients with regionally advanced peripheral melanoma and one with lower-extremity cutaneous T-cell lymphoma treated over a period of 1 year. It is feasible to perform the complete ILI procedure in a single 60–100-minute session, solely in the interventional radiology suite, without a requirement for patient transfer to the operating room or extra waiting time between catheter insertion and chemotherapy infusion treatment.

Purpose To evaluate the performance of the Trellis-8 isolated thrombolysis catheter during single-session pharmacomechanical thrombectomy (PMT) combined with low-dose thrombolysis with tissue plasminogen activator (TPA) in the treatment of patients with acute deep vein thrombosis (DVT) and multiple comorbidities. Materials and Methods Retrospective analysis was performed of 19 consecutive patients with acute above-knee DVT treated by PMT with the Trellis device followed by venous angioplasty and stent placement. Isolated thrombolysis with low-dose TPA was used with all patients. Concurrent therapies included retrievable inferior vena cava filter insertion ( n = 4). The primary endpoint was restoration of rapid inline venous flow; the secondary endpoint was thrombus clearance. Results Restoration of rapid inline venous flow was achieved in all cases; thrombus removal was less than 50% in one case (4%), 50%–95% in 18 cases (82%), and at least 95% in three cases (14%). The median administered dose of TPA was 13.4 mg per patient. The mean treatment time was 91 minutes per limb (range, 61–129 min), with a mean of 21 minutes per thrombosed segment (range, 8–31 min). There were no major complications. Primary patency rate of the treated venous segments at 2 days was 86% ( n = 19) and the primary assisted patency rate was 100% at 30 days. Two patients died of advanced malignancy at 17 and 24 days. Conclusions The Trellis system was an effective method for the treatment of acute DVT. Based on the present data, the Trellis system could prove to be a safe and feasible single-session PMT method for the treatment of acute DVT in a broader patient population and warrants further investigation in a large-scale study.

Early detection of skeletal metastasis is critical for accurate staging and optimal treatment. This paper briefly reviews our current understanding of the biological mechanisms through which tumours metastasise to bone and describes the available imaging methods to diagnose bone metastasis and monitor response to treatment. Among the various imaging modalities currently available for imaging skeletal metastasis, hybrid techniques which fuse morphological and functional data are the most sensitive and specific, and positron emission tomography (PET)/computed tomography and PET/magnetic resonance imaging will almost certainly continue to evolve and become increasingly important in this regard.

OBJECTIVE. MR angiography is now an established technique for the evaluation of various arterial structures. With recent developments in hardware, whole-body imaging has become technically feasible. The aim of this study is to describe a technique for whole-body MR angiography using a quadrature body coil and a moving tabletop.CONCLUSION. Whole-body MR angiography is technically feasible and may offer a method of screening for unsuspected disease.

To determine whether the secondary cleft sign demonstrated in the symphysis pubis at magnetic resonance (MR) imaging is a marker of injury in athletes presenting with groin pain.Ethics review board approval was not required for studies involving retrospective image or case record review; informed consent for review was not required. Eighteen male athletes (mean age, 24 years; age range, 19-32 years) were included for study. All patients underwent radiography and MR imaging (coronal fast spin-echo T1-weighted, transverse fast spin-echo T2-weighted, and coronal turbo short inversion time inversion-recovery [STIR] imaging) of the pelvis. Subsequent image-guided nonionic contrast material injection was followed by a 0.5% bupivacaine hydrochloride (1 mL) and methyprednisolone acetate (20 mg) injection into the central cleft of the symphysis pubis. Comparison was made between imaging findings at symphyseal cleft injection and appearances at preprocedure MR imaging, with specific reference to the presence of a secondary cleft. The sensitivity and specificity of MR imaging in demonstrating the secondary cleft sign were compared with those of the reference standard, imaging at symphyseal cleft injection. MR images from a reference group of 70 asymptomatic athletes who underwent STIR imaging of the pelvis were analyzed for evidence of a secondary cleft.Osteitis pubis was diagnosed in six patients on the basis of radiography and/or MR imaging. A secondary cleft was identified in 12 of 18 patients at MR imaging, was best visualized at coronal STIR imaging, and was confirmed in each patient during contrast material injection into the central physiologic symphyseal cleft. In no patient was a secondary cleft identified at symphyseal cleft injection and not identified at MR imaging (sensitivity and specificity, 100%). In each patient, the side of the secondary cleft corresponded to the side of symptoms that responded to local anesthetic and steroid injection. Four of the six patients with osteitis pubis had evidence of a secondary cleft. In one patient, a secondary cleft was not identified at MR imaging or symphyseal cleft injection, but adductor avulsion was identified at MR imaging. No evidence of a secondary cleft sign at MR imaging was identified in the reference group.The secondary cleft sign demonstrated at MR imaging is a marker of groin injury in athletes presenting with groin pain.