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A salivary incidentaloma (SI) stands for any focal salivary lesion, independent of size, discovered by any imaging method including ultrasonography (US), computed tomography (CT), magnetic resonance imaging (MRI), multimodal positron emis-sion tomography (PET) combined with CT or MRI, or X-ray imaging, performed for another reason, in the absence of known salivary glands' disease. The article presents a detailed analysis of salivary gland diseases with the emphasis on neoplasms. It describes frequency of SIs found on imaging, their prevalence, epidemiology and clinical significance. The probability of malignancy or malignant transformation of a SI, its imaging features, recommended treatment, management and follow-up, as well as ethical issues, psychological burden, informed decision making, economical consequences and costs are discussed. The general prevalence of SIs is low, but is dramatically increasing over time, and may rise significantly in selected groups of oncologic patients. SIs most frequently turn out to be benign primary neoplasms or pseudotumors, including intraparenchymal lymph nodes. SIs detected by other imaging methods should be subsequently assessed with US. Solid SIs demand ultrasound guided fine-needle aspiration cytology (US-FNAC). Neoplasms should undergo surgery. Post-operative US follow-up is man-datory for malignant tumors and recommended for benign neoplasms.

Aim:  To check if diffusion weighted imaging (DWI) might be helpful in proper recognition of celiac (CG) and cervicothoracic (CTG) sympathetic ganglia on the whole-body multimodal PSMA-ligand PET/MR imaging, in the view of their common misleading avidity on PET potentially suggestive of malignant lesions, including metastatic lymph nodes., Methods:  The thickness and the level of diffusion restriction was assessed qualitatively and quantitatively in 406 sympathetic ganglia (189 CTG in 101 males and 217 CG in 116 males) on DWI maps (b-value 0 and 800 s/mm 2 ) and apparent diffusion coefficient (ADC) maps (mean ADC) of the whole-body PET/MR 68Ga-PSMA-11 PET/MR. To form a reference group of a matching ganglia size, the smallest lymph node was chosen from each patient with metastases and underwent the same procedure., Results:  Very low and low level of diffusion restriction was noted in the majority of sympathetic ganglia (81.0 % CTG, 67.3 % CG, and 73.6 % of all). In the majority (91.7 %) of metastatic lymph nodes the level of diffusion restriction was moderate to high.The mean ADC values in sympathetic ganglia were statistically significantly higher in CTG, CG and all ganglia than in metastatic lymph nodes (p < 0.001; the effect size was large)., Conclusions:  Sympathetic celiac and cervicothoracic ganglia present very low and low level of diffusion restriction in visual DWI assessment, and significantly higher than metastatic lymph nodes mean ADC values in the majority of cases, which may serve as additional factors aiding differential diagnosis on multimodal PSMA-ligand PET/MR imaging.Therefore, PSMA-ligand PET/MR appears potentially superior to PSMA-ligand PET/CT in proper identification of sympathetic ganglia., Competing Interests: The authors declare that they have no conflict of interest., (© Georg Thieme Verlag KG Stuttgart · New York.)

Purpose: To find reasons of different radioactive choline adrenal uptake in prostate or renal cancer patients who underwent 18F-fluoroethylcholine positron emission tomography/computed tomography., Methods: Forty-nine positron emission tomography/computed tomography studies with radioactive choline (96 adrenal glands) were analysed with respect to the adrenal glands shape, uptake pattern and maximum standardised uptake value. Fifteen other parameters were recorded, assessed or counted, ratios of chosen parameters were calculated, and checked for correlation with adrenal glands uptake., Results: Adrenal glands presented a wide range of radioactive choline uptake intensities (range 2-7.9) and different uptake patterns (diffuse, focal or mixed). Maximum uptake in the right (4.3±1.2) adrenal gland positively correlated with the thickness of the parenchyma at the point of maximal uptake (5.3mm±1.5) (p=0.000). Maximum uptake in the right and left adrenal gland, as well as mean adrenal gland uptake, correlated with maximum uptake in the pituitary gland (p=0.000, p=0.000 and p=0.001, respectively) and with maximum uptake in liver (p=0.008, p=0.000 and p=0.011, respectively). Neither hormonal treatment nor patients' age significantly correlated with standardised uptake values of adrenal glands in the studied group., Conclusions: The variability of radiocholine uptake in adrenal glands depends probably on overall body metabolism and hypophyseal function expressed by statistically significant correlation with liver and pituitary gland uptake. Predominant focal or mixed with focal areas uptake patterns on positron emission tomography in normal in computed tomography adrenal glands should be assessed with caution to avoid a diagnostic mistake., (Copyright © 2019 Sociedad Española de Medicina Nuclear e Imagen Molecular. Publicado por Elsevier España, S.L.U. All rights reserved.)

Objectives: Recent reports warn against erroneous mistaking of celiac and stellate sympathetic ganglia for metastatic lymph nodes on multimodal prostate-specific membrane antigen (PSMA)-ligand PET imaging. The aim was to check the intensity of Ga-PSMA-11 uptake and magnetic resonance (MR) features of superior cervical ganglia (SCG) on PET/MR imaging., Methods: In 89 patients 106 SCG were reliably identified on Ga-PSMA-11 PET/MR. For each SCG, qualitative assessment (visual subjective avidity, diffusion restriction, shape, and the presence of central hypointensity) and quantitative measurements [dimensions, maximal standardized uptake value (SUVmax), mean apparent diffusion coefficient (ADC)] were performed., Results: Mean SUVmax in SCG amounted to 1.88 ± 0.63 (range: 0.87-4.42), with considerable metabolic activity (SUVmax ≥ 2) in 37.7% of SCG; mean thickness was 3.18 ± 1.08 mm. In subjective visual evaluation, SCG avidity was classified as mistakable or potentially mistakable with underlying malignancy in 32.1% of cases. Mean ADC values amounted 1749.83 ± 428.83 × 10mm/s. In visual assessment, 74.5% of ganglia showed moderate to high diffusion restriction. An oval or longitudinal shape on transverse MR plane was presented by 59.4% of SCG. The central hypointensity was detected on MR T2-weighted images only in 10.4% of SCG., Conclusion: SCG, similar to other sympathetic ganglia, show Ga-PSMA-11 uptake. SCG avidity may be of significance, especially in view of frequently occurring SCG oval or longitudinal shape, and moderate to high diffusion restriction in visual assessment, potentially suggesting malignancy on transverse MR plane. Diagnostic imaging specialists and clinicians should be aware of the above.

Background Detectable uptake of 68Ga-PSMA-ligands in sympathetic ganglia may potentially lead to mistaking them for malignant lesions. Our aim was to investigate the anatomy of cervico-thoracic-ganglia-complex (CTG-C) in the MR part of multimodal 68Ga-PSMA-11 PET/MR imaging, in view of PET factors hindering its proper identification. Patients and methods In 106 patients, 212 sites of the CTG-C were retrospectively reviewed to assess the radiotracer uptake (SUVmax), size, shape, position, symmetry of location and visual uptake intensity. Asymmetry of PSMA-ligand uptake and increased uptake were regarded as risk factors of malignancy. Results In 66.0% left (L) and 53.8% right (R) CTG-C we noticed configurations, resembling the shape of an exclamation-mark, a question-mark, or its part (called "typical"). Tumor-like CTG-C shapes (oval, binodular or longitudinal) were detected in 28.3% L-CTG-C and in 40.6% R-CTG-C. When visual assessment of PET suggested malignancy, the recognition of "typical" shape of underlying CTG-C on MR generated a rise in the accuracy of their proper identification (from 34.4% to 75%, χ2(1) = 70.4; p < 0.001). Recognizing the shape of the CTG-C as "typical" in MR allowed us to classify as "not-suspicious" 61.9% of all CTG-C which were treated as "suspicious" after sole PET assessment. Conclusions The characteristic shape of cervico-thoracic-ganglia-complex (resembling a question-mark, or its part) helps in proper recognition of CTG-C on multimodal whole-body 68Ga-PSMA-ligand PET/MR imaging, when detectable uptake might lead to considering pathology.

We report a unique case of unusual drainage of the bifurcated retroaortic left renal vein, with the cranial wider branch draining into a dilated lumbar azygos vein and caudal thinner branch connecting with the inferior vena cava. The right renal vein was duplicated. The anomaly was discovered on multimodal 18 F-labeled fluorodeoxyglucose positron emission tomography/computed tomography performed for oncological purposes. The basis enabling occurrence of such variation was probably persistent developmental extra left-right venous connections, intercardinal, or intersupracardinal, depending on the theory. The embryology of the chest and abdominal veins is a complicated process and there is no unanimity concerning its concepts. The old models are currently being questioned and reevaluated. Knowledge of possible variants of renal and azygos veins course is important from clinical, imaging, and surgical points of view. The retroaortic left renal veins course may sometimes cause pain, hematuria, proteinuria, and pelvic congestion syndromes. Dilated parts of uncommonly located veins, because of assuming a nodular shape on transverse images, may be mistaken for abnormal lymph nodes, other tumors or aneurysms on imaging. During a variety of surgical procedures, including venous sampling, renal transplantation, or any retroperitoneal surgery, knowledge of an aberrant venous course may be important for the success of the procedure and may be crucial even earlier during the qualification process.

Objective: The objective of this study was to investigate the morphologic features and Ga-prostate-specific membrane antigen (PSMA)-11 avidity of celiac ganglia (CG) on multimodal PET/MRI., Materials and Methods: Ga-PSMA-11 whole-body PET/MR examinations in 120 patients, referred for staging or follow-up of prostate cancer, were retrospectively reviewed to investigate the radiotracer uptake [maximum standardized uptake value (SUVmax)] and morphologic features (size, shape, location) of CG. Nodular, oval and longitudinal nodular, thick or with oval parts shapes of CG were regarded as mistakable with lymph nodes, whereas linear and longitudinal shapes were considered as not mistakable., Results: On MR scans, CG were visible in 98% (117/120) on both sides and in two patients only on the left side. Mistakable CG shape was detected in 69% (83/120) of patients on both or at least one side. The left CG were thicker (4±1.4 mm; range: 1.5-7.5 mm) than the right ones (3±1.3 mm; range: 0.5-7 mm). Mean SUVmax was 2.51±1.17 (range: 0.02-5.48) in the left CG and 2.23±1.22 (range: 0.02-5.91) in the right CG. Increased Ga-PSMA-11 uptake, SUVmax at least 2, was detected in 75% (90/120), and both - erroneous shape and elevated Ga-PSMA-ligand uptake - was observed in 55% (66/120) of all patients on both sides or at least one side., Conclusion: Frequently observed, the nodular, oval and longitudinal (nodular, thick or with oval parts) shape of CG, especially of the thicker left CG, on MR scans may cause mistaking them for lymph nodes, even abnormal or metastatic. On whole-body PET/MRI, evident and sometimes high Ga-PSMA-11 uptake in CG increases the risk of a misinterpretation of them as metastases.

Purpose: To identify the vascular patterns found in superficial lymph nodes with histologically confirmed lymphomatous involvement and to determine their value in the sonographic diagnosis of lymphadenopathy., Methods and Materials: The study involved the prospective classification of vascular patterns observed during power Doppler and/or color Doppler studies of superficial lymph nodes scheduled for resection. Forty patients (27 men and 13 women, aged 22-84 years; mean age: 58 years) with pathologically proven lymphoma were selected for this study (26 cervical, 13 axillary and 1 inguinal)., Results: A longitudinal vessel with or without branches (pattern I) was found in 14 lymphomatous nodes. Six contained short vessel segments distributed in the hilum area or centrally (pattern II), five had multiple vessels, partially branching, entering the node in a few rows from its longitudinal side (pattern III), seven presented multiple vessels that branched irregularly or chaotically with avascular areas (pattern IV), and eight had a peripheral vessel distribution (pattern V). Therefore, 50% of the lymphomatous nodes had vascular patterns regarded as characteristic of reactive lymph nodes (patterns I and II), and 37.5% had patterns normally described in lymph nodes with metastatic involvement (patterns IV and V); other lymphomatous lymph nodes had ambiguous vascular patterns that have not been previously classified (pattern III)., Conclusion: The angioarchitecture of superficial lymphomatous lymph nodes varies widely and is difficult to classify. It may resemble that reported in normal or reactive lymph nodes or patterns that are associated with metastases. The finding of a normal or benign vascular pattern in a lymph node with suspected lymphomatous involvement does not eliminate the need for a diagnostic biopsy.

Purpose: To compare the appearance of superficial lymph nodes on standard two-dimensional (2D) ultrasound examination and on three-dimensional (3D) ultrasound examination., Materials and Methods: Fifty two lymph nodes (35 cervical, 16 axillary, 1 inguinal) in 52 patients were examined with ultrasound in 3D mode. In standard 2D grey-scale examination and on a C-plane of 3D mode (parallel to the surface of the probe), the shape of a lymph node and its hilum were assessed. Final histopathological diagnoses included 36 lymphomas, 11 reactive or inflammatory lymph nodes, 3 metastases and 2 plasmocytoma infiltrations., Results: The appearance of hilums and lymph nodes as a whole changed on a C-plane of 3D mode (as compared with 2D presentation) in 28 % and 37 %, respectively. The differences in lymph node shape on 2D and 3D ultrasound were apparent in a comparable percentage of reactive lymph nodes (45 %) and lymphomatous lymph nodes (39 %). The differences in lymph node hilum shape on 2D and 3D ultrasound applied to 56 % of reactive lymph nodes and 20 % of lymphomatous lymph nodes., Conclusion: Three-dimensional imaging on a C-plane (parallel to the surface of the probe) may supply the examiner with different information concerning the shape of the lymph node and its hilum in comparison to standard 2D ultrasound. Changes in the shapes of hilum and lymph node occurred in reactive or inflamed lymph nodes as well as in lymphomas. Clinical significance of this fact demands further investigation.

Ultrasonography (US) is useful for differential diagnosis of diseases of the salivary glands. In acute inflammation, salivary glands are enlarged and hypoechoic with increased blood flow; they may contain multiple small, oval, hypoechoic areas. In chronic inflammation, salivary glands are normal sized or smaller, hypoechoic, and inhomogeneous. Sialolithiasis appears as markedly hyperechoic lines or points with distal acoustic shadowing. Sialosis appears as enlarged hyperechoic glands without focal lesions or increased blood flow. The US features of advanced Sjögren syndrome include inhomogeneous salivary glands with scattered small, oval, hypoechoic or anechoic areas, usually well defined, and increased parenchymal blood flow. Pleomorphic adenomas are usually hypoechoic, well-defined, lobulated lesions with posterior acoustic enhancement that may contain calcifications; Warthin tumors are usually oval, hypoechoic, well-defined lesions that often contain anechoic areas and are often hypervascularized. Malignant neoplasms of the salivary glands may have irregular shapes, irregular borders, blurred margins, and a hypoechoic inhomogeneous structure or may have a benign appearance. Salivary gland cysts have well-defined margins, anechoic contents, posterior acoustic enhancement, and no internal blood flow. However, US appearances of some diseases may overlap, thus producing diagnostic pitfalls., (Copyright RSNA, 2006.)