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The standard of care for men with a suspected malignant testicular tumour and normal contralateral testis is radical orchidectomy, testicular tumour markers and computed tomography scan staging. If the definitive orchidectomy histopathology is benign, young men are potentially exposed to unnecessary radiation. We sought to establish the rate of benign pathology returned from radical orchidectomy at our local urology multidisciplinary team (MDT) and if there were any preoperative factors suggestive of benign lesions. We included patients discussed at our local MDT meeting regarding testicular tumours with histology following radical orchidectomy between 1 January 2016 and 31 December 2018. A total of 113 patients were included, with benign histology following radical orchidectomy in seven (6.2%) patients. The benign histology included one adenomatoid tumour, and the remainder showed features of either infarction or inflammation. Metastases were detected on staging imaging in 21% of patients. Of these, 64% had normal preoperative tumour markers. Neither tumour size nor number of preoperative ultrasounds correlated with a risk of benign histology. One patient had chemotherapy prior to orchidectomy. It was reassuring that just 6.2% of patients had benign histology with no significant factors predictive of benign histology. This supports pre-orchidectomy staging imaging and the current MDT pathway for suspected testicular cancers. Level of evidence: Level 2C.

In recent years, there have been further advances in understanding of the acute pancreatic inflammation and its complications. Among these are emerging concepts such as peripancreatic necrosis and main duct injury secondary to necrotizing pancreatitis. To remain relevant to the clinical teams, radiologists need to be aware of these advances in knowledge and their reports should provide key points of information that may impact patient management. This article provides an up to date review of acute pancreatitis.

Magnetic resonance imaging (MRI)-based techniques have emerged as the preferred technique for the diagnostic evaluation of the small intestine, particularly in the adult population. The lack of ionising radiation makes MRI ideal for use in younger patients or in cases that require repeated follow-up investigations. Imaging of the small intestine may be carried out using the intubation (enteroclysis) or the ingestion (enterography) techniques. Enterography examinations are more acceptable to patients and may provide similar diagnostic accuracy compared to intubation methods. In this review, methods of improving and optimising MRI of the small intestine are described.

Abdominal hernias represent common conditions and occur when a structure of the abdominal cavity protrudes through a defect in the abdominal wall. Recently, there has been an increase in demand from the clinical teams to confirm the clinical suspicion of an abdominal wall hernia, and to assess preoperatively large or complex hernias through imaging. This pictorial review aims to present the different appearances of abdominal wall and lumbar region hernias on imaging.

Abdominal masses can often clinically mimic hernias, especially when they are located close to hernial orifices. Imaging findings can be challenging and nonspecific with numerous differential diagnoses. We present a variety of pathology involving the abdominal wall and lumbar region, which were referred as possible hernias. This demonstrates the wide-ranging pathology that can present as abdominal wall lesions or mimics of hernias that the radiologist should be alert to.

Background: Computed tomography (CT) of the urinary tract is a commonly performed investigation and it is crucial to adhere to low dose protocols to avoid unnecessary radiation burden. Aims: To review the adoption of low-dose techniques over time, defined as a dose length product (DLP) < 200mGy.cm, in a large teaching hospital over three locations with 12 CT scanners. Methods: Data were obtained from the radiology information system for exams completed under the coding for unenhanced CT evaluation for renal calculi between 14 Feb 2008 and 31 December 2018. Examinations where the DLP was not correctly recorded, was below 40mGy.cm, or where the equipment used could not be identified were excluded. The distribution of doses and the median DLP per scanner was calculated. Results: In all, 20,080 studies were available across 12 CT scanners in the 10- year period. The average Median DLP has reduced from 501mGy.cm in 2008 to 178mGy.cm in 2018. Conclusions: Improvements in CT technology and implementation of low-dose protocols have resulted in significantly lower doses for evaluation of kidney stones since 2008. Although this study demonstrates significant variation between scanners, the overall adoption of low dose techniques is excellent. Level of evidence: Not applicable

Aim: To study the efficacy and impact of the local pre-biopsy multiparametric magnetic resonance imaging (mpMRI) pathway for prostate cancer diagnosis. Methods: In this tertiary centre, 570 patients had prostate mpMRI across a 6-month period in 2019. A total of 511 patients met inclusion criteria for retrospective analysis. MRI reporting used the Prostate Imaging-Reporting and Data System (PI-RADS) v2.1. These were assessed alongside histological outcomes and diagnostic times. PI-RADS ⩾ 3 were recommended for biopsy consideration. Gleason scoring ⩾ 3 + 4 and 3 + 3 were used to define clinically and non-clinically significant prostate cancer (csPCa and nsPCa), respectively. Results: Overall prostate cancer prevalence was 40% (204/511, csPCa in 31.1%) with an overall biopsy avoidance of 32.1% (164/511). Around 69.7% (356/511) scored PI-RADS ⩾ 3 and 30.3% (155/511) scored PI-RADS 1–2. About 22.6% (35/155) of PI-RADS 1–2 patients proceeded to biopsy, demonstrating a negative predictive value of 91.43% for csPCa. For PI-RADS ⩾ 3 patients, 63.4% (197/312) of those biopsied had cancer (Gleason ⩾ 3 + 3), with 50% (156/312) demonstrating csPCa. Around 76.7% (102/133) of PI-RADS 5, 35.3% (48/136) of PI-RADS 4, 14.0% (6/43) of PI-RADS 3 and 8.6% (3/35) of PI-RADS 1–2 scores demonstrated csPCa. Overall median prostate-specific antigen (PSA) density was 0.15 ng/mL2 (IQR: 0.10–0.27/mL2). PSA density were significantly different across PI-RADS cohorts ( H = 118.8, p Conclusion: Pre-biopsy mpMRI with PI-RADS scoring safely avoided biopsy in almost one-third (32.1%) of patients. The use of PSA-density in risk stratifying PI-RADS 3 lesions has informed local practice in the period 2020–2021, with implementation of a PSA-density threshold of 0.12 ng/mL2. Biopsy scheduling issues and anaesthetic requirements need to be overcome to improve diagnostic waiting times. Level of evidence: 2

Summary Background Closure of an abdominal stoma, a common elective operation, is associated with frequent complications; one of the commonest and impactful is incisional hernia formation. We aimed to investigate whether biological mesh (collagen tissue matrix) can safely reduce the incidence of incisional hernias at the stoma closure site. Methods In this randomised controlled trial (ROCSS) done in 37 hospitals across three European countries (35 UK, one Denmark, one Netherlands), patients aged 18 years or older undergoing elective ileostomy or colostomy closure were randomly assigned using a computer-based algorithm in a 1:1 ratio to either biological mesh reinforcement or closure with sutures alone (control). Training in the novel technique was standardised across hospitals. Patients and outcome assessors were masked to treatment allocation. The primary outcome measure was occurrence of clinically detectable hernia 2 years after randomisation (intention to treat). A sample size of 790 patients was required to identify a 40% reduction (25% to 15%), with 90% power (15% drop-out rate). This study is registered with ClinicalTrials.gov, NCT02238964. Findings Between Nov 28, 2012, and Nov 11, 2015, of 1286 screened patients, 790 were randomly assigned. 394 (50%) patients were randomly assigned to mesh closure and 396 (50%) to standard closure. In the mesh group, 373 (95%) of 394 patients successfully received mesh and in the control group, three patients received mesh. The clinically detectable hernia rate, the primary outcome, at 2 years was 12% (39 of 323) in the mesh group and 20% (64 of 327) in the control group (adjusted relative risk [RR] 0·62, 95% CI 0·43–0·90; p=0·012). In 455 patients for whom 1 year postoperative CT scans were available, there was a lower radiologically defined hernia rate in mesh versus control groups (20 [9%] of 229 vs 47 [21%] of 226, adjusted RR 0·42, 95% CI 0·26–0·69; p

AIM To optimise follow-up by dismissing lesions on baseline ultrasound (US) if renal lesions conform to US criteria of an angiomyolipoma (AML). METHOD AND MATERIALS The present study was a 10-year retrospective review of patients who were found to have incidental hyperechoic renal lesions on US to ascertain the outcome from subsequent imaging, clinical encounters, and cancer registrations. Exclusions included renal calculi, tuberous sclerosis, Von-Hippel-Lindau, or a known cancer. RESULTS After excluding 39 patients, 1,493 patients were identified. One hundred and sixty had more than one lesion with 87 patients having bilateral lesions. Regardless of indication, 889 patients had subsequent imaging within 5 years (59.5%). The average size of all AMLs was 13.2 mm. In the group with lesions that were

We are delighted to have the opportunity to bring together this Clinical Radiology special issue focused on prostate imaging. It is fascinating to consider how the prostatic diagnostic pathway has evolved in recent years, with radiology now at the forefront and with the UK leading the world in providing MRI prior to initial prostate biopsy. Prostate MRI has evolved tremendously from the initial excitement of T2-weighted imaging differentiating prostate zonal anatomy in the early 1980s [1]. Early attempts at tumour detection with spectroscopy were then supplemented by dynamic-contrast enhanced (DCE) in the 1990s [2, 3], with endorectal coils going from being essential to improve signal, to failing out of favour due to cost and issues of patient comfort. However, it was the “game changing” introduction of diffusion-weighted (DWI) sequences in more recent times [4] made the case for multiparametric (mp) MRI a compelling one.

Multiparametric (mp) prostate magnetic resonance imaging (MRI) is playing an increasingly prominent role in the diagnostic work-up of patients with suspected prostate cancer. Performing mpMRI before biopsy offers several advantages including biopsy avoidance under certain clinical circumstances and targeting biopsy of suspicious lesions to enable the correct diagnosis. The success of the technique is heavily dependent on high-quality image acquisition, interpretation, and report communication, all areas addressed by previous versions of the Prostate Imaging-Reporting and Data System (PI-RADS) recommendations. Numerous studies have validated the approach, but the widespread adoption of PI-RADS version 2 has also highlighted inconsistencies and limitations, particularly relating to interobserver variability for evaluation of the transition zone. These limitations are addressed in the recently released version 2.1. In this article, we highlight the key changes proposed in PI-RADS v2.1 and explore the background reasoning and evidence for the recommendations.

Aim Neoadjuvant chemoradiotherapy for locally advanced rectal cancer aims to downstage prior to definitive management. Repeat imaging assessment of the tumour post-therapy has implications for treatment. Our aim was to assess if the inferior mesenteric vein (IMV) diameter measured on CT can be used as a surrogate marker for evaluation of tumour response to neoadjuvant treatment. Method IMV diameter was assessed in patients with and without locally advanced rectal cancer, pre- and post-radiotherapy, to ascertain if IMV diameter is a surrogate marker of tumour response. Results IMV diameter was 5.9 mm in patients with rectal cancer vs 4.7 mm in patients without (P = 0.0001). The baseline IMV diameter was significantly higher for cases with local lymphadenopathy [N0 5.2 mm vs N1/2 6 mm (P = 0.0059)] and extramural venous invasion (EMVI) [negative 5.4 mm vs positive 6.4 mm (P = 0.0001)]. Post-radiotherapy there was a significant decrease in the IMV diameter in cases with treatment response compared to non-responders: the percentage change in IMV diameter was a 17.54% decrease vs 1.39% increase (P = 0.0001). These results were reproduced on comparing between magnetic resonance tumour regression grades using ANOVA (P = 0.0001). There was also a significant decrease in IMV diameter when assessing lymph node (LN) and EMVI response vs non-responders (P = 0.0001 and 0.0001 respectively). Conclusion Patients with rectal cancer have a dilated IMV compared with patients without rectal cancer. We confirm that IMV diameter is a potential surrogate marker of LN status and EMVI at baseline. IMV diameter is also a marker of tumour, LN and EMVI response to chemoradiotherapy.

Penile cancer is a rare neoplasm that, although rare in the developed world, has devastating physical and psychological consequences for the patient. Novel MR imaging techniques such as lymphotropic nanoparticle-enhanced MR imaging may help identify metastatic lymph node disease. This article reviews the normal penile anatomy and MR imaging techniques and features of primary and metastatic penile cancer. Recent advances in penile cancer imaging are discussed.

We thank Akingboye et al for their interest and critique (1) of our paper assessing the inferior mesenteric vein (IMV) diameter as a surrogate marker to evaluate response to neoadjuvent chemoradiotherapy (CRT) for locally advanced rectal adenocarcinoma (2). They raise an interesting point reguarding correlation of IMV diameter of whole mount specimens with and without tumours to validate the hypothosis (1). Imaging correlation to histopathological specimens is a tried and tested method to correlate rectal cancer staging and subsequent tumour regression grade post neoadjuvent radiotherapy (3, 4), however we have some apprehensions with the suggestion in this case, 1) the measurement of the IMV ex-vivo may not correlate with the measurement on computed tomography due to lack of circulation, flow and venous pressure and potential changes in vessel elasticity ex-vivo. As we state in the paper, and Akingboye et al state the hypothesis is that change in vessel diameter is likely to be in part due to changes in splanchnic circulation and venous return secondary to tumourgenesis (5). This article is protected by copyright. All rights reserved.

Accurate preoperative radiological staging of hilar cholangiocarcinoma remains difficult, and a number of patients are found to have irresectable advanced tumours or occult metastases at exploration. Staging laparoscopy can improve the detection of irresectable disease, avoiding unnecessary laparotomy. This study examines the role of staging laparoscopy in hilar cholangiocarcinoma, with a focus on yield over different time periods and identification of preoperative factors increasing the risk of irresectable disease.Retrospective case note review of all patients undergoing staging laparoscopy for radiologically resectable hilar cholangiocarcinoma, identified from the hepatobiliary multidisciplinary team database, was performed.One hundred consecutive patients underwent staging laparoscopy between 1998 and 2011. Of these, 34 patients were found to be irresectable due to metastatic disease, and 11, due to extensive local disease. Fifty patients proceeded to exploratory laparotomy following staging laparoscopy, and 36 % (18/50) of whom were found to have irresectable disease: 12 patients due to advanced local disease and 6 patients due to metastases. The overall yield of laparoscopy was 45 %, and the accuracy was 71 %. There was no significant difference in age, preoperative bilirubin, neutrophil/lymphocyte ratio, Ca19-9 levels or T stage between patients with resectable disease and with irresectable disease on laparoscopy. There was also no change in the yield of laparoscopy over time, despite advances in radiological imaging.In this series, staging laparoscopy avoided unnecessary laparotomy in 45 % of patients with radiologically resectable hilar cholangiocarcinoma. No factor was able to predict positive yield, and therefore, all patients with potentially resectable hilar cholangiocarcinoma should undergo staging laparoscopy.

Objective: To assess the radiological and clinical outcomes of patients with Bosniak IIF in our centre. Methods: We retrospectively analysed patients diagnosed with complex renal cysts classified as Bosniak IIF on contrast computed tomography imaging in our centre between March 2003 and September 2008. Surveillance images of Bosniak IIF were reviewed to determine radiological progression and clinical outcomes. Results: Forty patients with 42 category IIF cysts were included in our study (median age 68 years (range 38–88 years), median follow-up of 29 months (range 5–77 months)). Only one IIF cyst showed radiological progression to category III after a follow-up of 42 months (progression rate of 2.5%). Twenty-two cysts increased in size (mean 10.7 mm, range 3–41 mm), 10 cysts showed reduction in size (mean 7.9 mm, range 3–17 mm) and 10 cysts remained stable. Five patients died during surveillance and none of them had cause of death attributed to renal cancer or its complication. Conclusions: Our study has demonstrated that surveillance for Bosniak IIF cyst is a safe strategy. Furthermore, routine follow-up may not be required in all patients. However, longer term study is required before this can be confirmed.

Background: Liver cysts are common, occurring in up to 5% of the population. For many types of cysts, a variety of different treatment options exist and the preferred management is unclear. Methods: A Pubmed and Medline literature review using key words non-parasitic hepatic cysts, polycystic liver disease, echinococcus, hydatid cysts parasitic cysts, Caroli's disease, cystadenoma; liver abscess, surgery, aspiration and treatment was undertaken and papers pertaining to the diagnosis and management of cystic lesions within the liver were retrieved. Results: Asymptomatic simple cysts in the liver require no treatment. Therapy for symptomatic cysts may incorporate aspiration with sclerotherapy or de-roofing. At present, insufficient evidence exists to recommend one over the other. Polycystic liver disease presents a unique management problem because of high morbidity and mortality rates from intervention and high rates of recurrence. Careful patient counselling and assessment of symptom index is essential before embarking on any treatment. New medical treatments may ameliorate symptoms. Acquired cystic lesions in the liver require a thorough work-up to fully characterize the abnormality and direct appropriate treatment. Hydatid cysts are best treated by chemotherapy followed by some form of surgical intervention (either aspiration and sclerotherapy or surgery). Liver abscesses can effectively be treated by aspiration or drainage. With improved antimicrobial efficacy, prolonged treatment with antibiotics may also be considered. Conclusion: All patients with cystic lesions in the liver require discussion at multi-disciplinary meetings to confirm and the diagnosis and determine the most appropriate method of treatment.

A variety of disorders-including infectious, inflammatory, hereditary, and metabolic diseases-may affect both the brain and abdominal cavity, and the findings in one region may help establish the diagnosis or limit the differential diagnosis. Establishing an accurate early diagnosis enables clinicians to adequately manage these unusual diseases and potentially avert life-threatening complications. For example, an early diagnosis of Gardner syndrome enables annual sigmoid- or colonoscopy and ultrasonography. In many conditions, abdominal manifestations precede neurologic manifestations and may have prognostic significance. Patients with celiac disease more often present with abdominal manifestations such as duodenitis, slow transit time, reversal of the jejunal-ileal fold pattern, and transient small bowel intussusception than with intracranial manifestations. In other conditions, the neurologic manifestations may be the same as the presenting symptoms. For example, patients with Gardner syndrome may initially present with multiple mandibular or sinonasal osteomas. In addition, sarcoidosis may manifest with multifocal enhancing dural masses. Abdominal and neurologic manifestations may even occur simultaneously, as in several of the phakomatoses such as neurofibromatosis type 1, tuberous sclerosis complex, and von Hippel-Lindau syndrome. Ultimately, familiarity with the appearances of these conditions allows radiologists to pinpoint a diagnosis, even when imaging findings in either location are nonspecific.

Objective: To determine the value of percutaneous biopsy in a UK cohort of patients with renal mass lesions, with particular reference to its utility for the prediction of histological cell-type, Fuhrman nuclear grade and necrosis. Patients and methods: From May 1999 to September 2009, 71 patients underwent renal mass biopsy (RMB), most for indeterminate renal masses or in those with a mass lesion and extrarenal malignancy. Approximately one-third were for small renal masses (≤4cm). Biopsy results were correlated with final surgical specimen pathology or with the outcome of surveillance in those not receiving surgery. Results: Of 71 biopsies, there were 65 (91.5%) considered diagnostic biopsies, of which 59 (90.8%) were malignant and 6 (9.2%) were benign. 30 patients with biopsy-proven malignancy underwent extirpative surgery, with a diagnostic accuracy for biopsy of 100%. Accuracy of RMB for histological sub-type, Fuhrman nuclear grade and tumour necrosis was 80.0%, 52.3% and 80.0%, respectively. Bleeding complications were seen in 2 (2.8%) patients, and there were no cases of needle track seeding. Conclusion: RMB is a safe and accurate method for determining underlying malignancy, with an acceptable non-diagnostic rate. Although concordance for histological tumour sub-type and necrosis was reasonable, values for nuclear grade were less reliable.

The purpose of this article is to provide a comprehensive review of the imaging findings of various parasitic infestations and other miscellaneous infections affecting the gastrointestinal tract. Barium examinations play an important role in the diagnostic workup of parasitic intestinal infections. Knowledge of differential diagnosis, sites of involvement, and imaging features of different infections and infestations can help in accurate diagnosis and guide treatment.

To assess the accuracy of magnetic resonance imaging (MRI) in staging bladder cancer and to assess whether dynamic gadolinium-enhanced sequences have any added benefit in staging.Over a 22 month period, the MRI findings of 100 consecutive patients with histologically proven transitional cell carcinoma (TCC) of the bladder were reviewed. The T stage was assessed independently on T2-weighted imaging alone and in combination with gadolinium-enhanced MRI. The final histological diagnosis was considered the reference standard. Statistical analysis was performed to ascertain stage-by-stage accuracy. Accuracy of MRI in differentiating superficial (≤ T1) from invasive (≥ T2) and in differentiating organ-confined (≤ T2) from non-organ-confined (≥ T3) disease was assessed.On a stage-by-stage basis, tumours were correctly staged using MRI in 63% of patients (observed agreement=0.63, weighted kappa=0.57). The sensitivity and specificity of MRI to differentiate between superficial (≤ T1) from invasive (≥ T2) disease was 78.2 and 93.3%. The observed agreement for this group was 85% (kappa=70%; p0.0001). The sensitivity and specificity of MRI to differentiate between organ-confined (≤ T2) from non-organ confined (≥ T3) disease was 90.5 and 60%. The observed agreement for this group was 89% (kappa=30%; p0.01). Gadolinium-enhanced images improved staging in only three patients.In the present study MRI was found to be a moderately accurate tool in assessing the T stage. Agreement on a stage-by-stage basis was good. Agreement for differentiating between non-invasive versus muscle-invasive disease was good and that for organ-confined versus non-organ-confined disease was fair. Routine use of gadolinium-enhanced images is not routinely required.

OBJECTIVE. Lymphoma can affect virtually every tissue in the body, producing a variety of imaging appearances. In this article, the extranodal manifestations of lymphoma in the head and spine are illustrated and the imaging features that aid in diagnosis are reviewed. CONCLUSION. Knowledge of the imaging appearances of extranodal lymphoma can aid in the differential diagnosis of mass lesions encountered in tissues throughout the body on different imaging modalities.