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Objective: To assess the distribution of key mutations across tumour sizes in clear-cell renal cell carcinoma (ccRCC), and secondarily to examine the prognostic impact of aggressive mutations in smaller ccRCCs., Patient and Methods: The distribution of mutations (VHL, PBRM1, SETD2, BAP1 and CDKN2A loss) across tumour sizes was assessed in 1039 ccRCCs treated with nephrectomy in cohorts obtained from the Tracking Cancer Evolution (TRACERx), The Cancer Genome Atlas (TCGA) and the Cancer Genomics of the Kidney (CAGEKID) projects. Logistic regression was used to model the presence of each mutation against size. In our secondary analysis, we assessed a subset of ccRCCs ≤7 cm for associations of key aggressive mutations (SETD2, BAP1, and CDKN2A loss) with metastasis, invasive disease and overall survival, while controlling for size. A subset of localised tumours ≤7 cm was also used to assess associations with recurrence after nephrectomy., Results: On logistic regression, each 1-cm increase in tumour size was associated with aggressive mutations, SETD2, BAP1, and CDKN2A loss, at odds ratios (ORs) of 1.09, 1.10 and 1.19 (P < 0.001), whereas no significant association was observed between tumour size and PBRM1 (OR 1.02; P = 0.23). VHL was mildly negatively associated with a 1-cm increase in size (OR 0.95; P = 0.01). Among tumours ≤7 cm, SETD2 and CDKN2A loss were associated with metastatic disease at ORs of 3.86 and 3.84 (P < 0.05) while controlling for tumour size. CDKN2A loss was associated with worse overall survival, with a hazard ratio (HR) of 2.19 (P = 0.03). Among localised tumours ≤7 cm, SETD2 was associated with worse recurrence-free survival (HR 2.00; P = 0.03)., Conclusion: Large and small ccRCCs are genomically different. Aggressive mutations, namely, SETD2, BAP1, and CDKN2A loss, are rarely observed in small ccRCCs and are observed more frequently in larger tumours. However, when present in tumours ≤7 cm, SETD2 mutations and CDKN2A loss were still independently associated with invasive disease, metastasis, worse survival, and recurrence after resection, after controlling for size., (© 2024 The Author(s). BJU International published by John Wiley & Sons Ltd on behalf of BJU International.)

MRI plays an important role in the evaluation of kidney allografts for vascular complications as well as parenchymal insults. Transplant renal artery stenosis, the most common vascular complication of kidney transplant, can be evaluated by MRA using gadolinium and nongadolinium contrast agents as well as by unenhanced MRA techniques. Parenchymal injury occurs through a variety of pathways, including graft rejection, acute tubular injury, BK polyomavirus infection, drug-induced interstitial nephritis, and pyelonephritis. Investigational MRI techniques have sought to differentiate among these causes of dysfunction as well as to assess the degree of interstitial fibrosis or tubular atrophy (IFTA)-the common end pathway for all of these processes-which is currently evaluated by invasively obtained core biopsies. Some of these MRI sequences have shown promise in not only assessing the cause of parenchymal injury but also assessing IFTA noninvasively. This review describes current clinically used MRI techniques and previews promising investigational MRI techniques for assessing complications of kidney grafts.

The radiologic diagnosis of adrenal disease can be challenging in settings of atypical presentations, mimics of benign and malignant adrenal masses, and rare adrenal anomalies. Misdiagnosis may lead to suboptimal management and adverse outcomes. Adrenal adenoma is the most common benign adrenal tumor that arises from the cortex, whereas adrenocortical carcinoma (ACC) is a rare malignant tumor of the cortex. Adrenal cyst and myelolipoma are other benign adrenal lesions and are characterized by their fluid and fat content, respectively. Pheochromocytoma is a rare neuroendocrine tumor of the adrenal medulla. Metastases to the adrenal glands are the most common malignant adrenal tumors. While many of these masses have classic imaging appearances, considerable overlap exists between benign and malignant lesions and can pose a diagnostic challenge. Atypical adrenal adenomas include those that are lipid poor; contain macroscopic fat, hemorrhage, and/or iron; are heterogeneous and/or large; and demonstrate growth. Heterogeneous adrenal adenomas may mimic ACC, metastasis, or pheochromocytoma, particularly when they are 4 cm or larger, whereas smaller versions of ACC, metastasis, and pheochromocytoma and those with washout greater than 60% may mimic adenoma. Because of its nonenhanced CT attenuation of less than or equal to 10 HU, a lipid-rich adrenal adenoma may be mimicked by a benign adrenal cyst, or it may be mimicked by a tumor with central cystic and/or necrotic change such as ACC, pheochromocytoma, or metastasis. Rare adrenal tumors such as hemangioma, ganglioneuroma, and oncocytoma also may mimic adrenal adenoma, ACC, metastasis, and pheochromocytoma. The authors describe cases of adrenal neoplasms that they have encountered in clinical practice and presented to adrenal multidisciplinary tumor boards. Key lessons to aid in diagnosis and further guide appropriate management are provided. © RSNA, 2023 Online supplemental material is available for this article. Quiz questions for this article are available through the Online Learning Center.

The liver and biliary tree are common sites of primary and secondary malignancies. MRI followed by CT is the mainstay for the imaging characterization of these malignancies with the dynamically acquired contrast enhanced phases being the most important for diagnosis. The liver imaging reporting and data system classification provides a useful framework for reporting lesions in patents with underlying cirrhosis or who are at high risk for developing hepatocellular carcinoma. Detection of metastases is improved with the use of liver specific MRI contrast agents and diffusion weighted sequences. Aside from hepatocellular carcinoma, which is often diagnosed noninvasively, other primary hepatobiliary tumors may require biopsy for definite diagnosis, especially when presenting with nonclassic imaging findings. In this review, we examine the imaging findings of common and less common hepatobiliary tumors., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023. Published by Elsevier Inc.)

Background: Colorectal cancer (CRC) is the second-leading cause of cancer-related death worldwide and resection of CRC metastases confined to the liver is the treatment of choice when feasible. Ferumoxytol is an off-label contrast agent that opacifies vasculature and may be helpful in distinguishing metastases from small hemangiomas and blood vessels on gadoxetic acid-enhanced magnetic resonance imaging (MRI)., Purpose: To compare the diagnostic accuracy of MRI using a standard gadoxetic acid protocol and a combined gadoxetic acid/ferumoxytol protocol in patients with suspected colorectal hepatic metastases., Material and Methods: In this institutional review board-approved, single-institution, retrospective study, eight patients underwent gadoxetic acid-enhanced liver MRI, supplemented with additional T1-weighted ferumoxytol enhanced sequences. Two radiologists in consensus identified all metastases using all available sequences, which served as the reference standard. Two different radiologists reviewed each exam twice, once using the standard protocol and once with additional ferumoxytol sequences. The detection rate was estimated as the predicted probability of a metastasis along with the 95% confidence interval (CI) using hierarchical logistic regression models., Results: A total of 49 metastases were identified. The mean diameter was 10 mm, measured in greatest axial dimension (median=7 mm; range=2-70 mm). Readers 1 and 2 had detection rates of 69.6% (95% CI = 48.2-85.0) and 53.1% (95% CI = 35.2-70.3) for gadoxetic acid alone and 98.0% (95% CI = 86.3-99.7) and 83.5% (95% CI = 59.3-94.7) for combined protocol., Conclusion: In this preliminary investigation, adding ferumoxytol-enhanced sequences to gadoxetic acid liver MRI protocol increased the detection rate of CRC hepatic metastases and may aid in preoperative decision making.

Purpose: To describe the appearance of chronically hemorrhagic adenomas on adrenal protocol CT and correlate imaging with pathologic findings., Methods: Retrospective case series of adult patients with resected adrenal adenomas showing internal hemorrhage at histology. Seven of nine patients underwent pre-operative adrenal protocol CT and 2/7 underwent unenhanced CT with portal venous phase CT. Two abdominal radiologists in consensus assessed the CT images for the presence of calcifications, macroscopic fat, cystic/necrotic appearance, and the presence, pattern, and percent nodule volume of areas < 10 HU on unenhanced CT. Absolute washout was calculated using a large ROI, and ROIs on the highest and lowest attenuating regions on the portal venous phase., Results: Mean adenoma length was 4.9 cm. All adenomas had areas measuring < 10 HU on unenhanced CT, ranging from < 20 to > 80% nodule volume. Calcifications were present in 4/9 adenomas and gross fat in 4/9 on CT. Of the seven cases with adrenal protocol CT, the absolute washout was < 60% in 5/7 using the large ROI, 5/7 using the low attenuation ROI, and 7/7 using the high attenuation ROI. At histology, all nine cases had microscopic evidence of hemorrhage, lipid rich adenoma cells, and fibrosclerosis. Myelolipomatous changes were identified in 4/9 cases, with the remaining five cases showing lipomatous metaplasia without a myeloid component., Conclusion: Chronically hemorrhagic adrenal adenomas demonstrated variable areas < 10 HU on unenhanced CT corresponding to lipid rich adenoma cells. Absolute washout was most often < 60%, hypothesized to be due to fibrosclerosis within the adenomas., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

BACKGROUND. Homogeneous microscopic fat within adrenal nodules on chemical-shift MRI (CS-MRI) is diagnostic of benign adrenal adenoma, but the clinical relevance of heterogeneous microscopic fat is not well established. OBJECTIVE. This study sought to determine the prevalence of malignancy in adrenal nodules with heterogeneous microscopic fat on dual-echo T1-weighted CS-MRI. METHODS. We performed a retrospective study of adult patients with adrenal nodules detected on MRI performed between August 2007 and November 2020 at seven institutions. Eligible nodules had a short-axis diameter of 10 mm or larger with heterogeneous microscopic fat (defined by an area of signal loss of < 80% on opposed-phase CS-MRI). Two radiologists from each center, blinded to reference standard results, determined the signal loss pattern (diffuse, two distinct parts, speckling pattern, central loss, or peripheral loss) within the nodules. The reference standard used was available for 283 nodules (pathology for 21 nodules, ≥ 1 year of imaging follow-up for 245, and ≥ 5 years of clinical follow-up for 17) in 282 patients (171 women and 111 men; mean age, 60 ± 12 [SD] years); 30% (86/282) patients had prior malignancy. RESULTS. The mean long-axis diameter was 18.7 ± 7.9 mm (range, 10-80 mm). No malignant nodules were found in patients without prior cancer (0/197; 95% CI, 0-1.5%). Four of the 86 patients with prior malignancy (hepatocellular carcinoma [HCC], renal cell carcinoma [RCC], lung cancer, or both colon cancer and RCC) (4.7%; 95% CI, 1.3-11.5%) had metastatic nodules. Detected patterns were diffuse heterogeneous signal loss (40% [114/283]), speckling (28% [80/283]), two distinct parts (18% [51/283]), central loss (9% [26/283]), and peripheral loss (4% [12/283]). Two metastases from HCC and RCC showed diffuse heterogeneous signal loss. Lung cancer metastasis manifested as two distinct parts, and the metastasis in the patient with both colon cancer and RCC showed peripheral signal loss. CONCLUSION. Presence of heterogeneous microscopic fat in adrenal nodules on CS-MRI indicates a high likelihood of benignancy, particularly in patients without prior cancer. This finding is also commonly benign in patients with cancer; however, caution is warranted when primary malignancies may contain fat or if the morphologic pattern of signal loss may indicate a collision tumor. CLINICAL IMPACT. In the absence of prior cancer, adrenal nodules with heterogeneous microscopic fat do not require additional imaging evaluation.

BACKGROUND. Washout CT is commonly used to evaluate indeterminate adrenal nodules, although its diagnostic performance is poorly established in true adrenal incidentalomas. OBJECTIVE. The purpose of this study was to compare, in patients without a known malignancy history, the prevalence of malignancy for incidental adrenal nodules with unenhanced attenuation more than 10 HU that do and do not show absolute washout of 60% or more, thereby determining the diagnostic performance of washout CT for differentiating benign from malignant incidental adrenal nodules. METHODS. This retrospective six-institution study included 299 patients (mean age, 57.3 years; 180 women, 119 men) without known malignancy or suspicion for functioning adrenal tumor who underwent washout CT, which showed a total of 336 adrenal nodules with a short-axis diameter of 1 cm or more, homogeneity, and unenhanced attenuation over 10 HU. The date of the first CT ranged across institutions from November 1, 2003, to January 1, 2017. Washout was determined for all nodules. Reference standard was pathology ( n = 54), imaging follow-up (≥ 1 year) ( n = 269), or clinical follow-up (≥ 5 years) ( n = 13). RESULTS. Prevalence of malignancy among all nodules, nodules less than 4 cm, and nodules 4 cm or more was 1.5% (5/336; 95% CI, 0.5-3.4%), 0.3% (1/317; 95% CI, 0.0-1.7%), and 21.1% (4/19; 95% CI, 6.1-45.6%), respectively. Prevalence of malignancy was not significantly different for nodules smaller than 4 cm with (0% [0/241]; 95% CI, 0.0-1.2%) and without (1.3% [1/76]; 95% CI, 0.0-7.1%) washout of 60% or more ( p = .08) or for nodules 4 cm or larger with (16.7% [1/6]; 95% CI, 0.4-64.1%) and without (23.1% [3/13]; 95% CI, 5.0-53.8%) washout of 60% or more ( p = .75). Washout of 60% or more was observed in 75.5% (243/322; 95% CI, 70.4-80.1%) of benign nodules (excluding pheochromocytomas), 20.0% (1/5; 95% CI, 0.5-71.6%) of malignant nodules, and 33.3% (3/9; 95% CI, 7.5-70.1%) of pheochromocytomas. For differentiating benign nodules from malignant nodules and pheochromocytomas, washout of 60% or more had 77.5% sensitivity, 70.0% specificity, 98.8% PPV, and 9.2% NPV among nodules smaller than 4 cm. CONCLUSION. Prevalence of malignancy is low among incidental homogeneous adrenal nodules smaller than 4 cm with unenhanced attenuation more than 10 HU and does not significantly differ between those with and without washout of 60% or more; wash-out of 60% or more has suboptimal performance for characterizing nodules as benign. CLINICAL IMPACT. Washout CT has limited utility in evaluating incidental adrenal nodules in patients without known malignancy.

A military soldier sustained a blast injury in Afghanistan, resulting in amputations and hemipelvectomy. He developed New Delhi metallo-beta-lactamase-producing E. coli bacteremia, soft-tissue infection, and sacral osteomyelitis. These organisms are being increasingly discovered in different communities around the world. He was successfully treated with tigecycline and cefiderocol. Cefiderocol is a novel siderophore-based cephalosporine developed to treat serious infections, including those caused by carbapenem-resistant Enterobacterales., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2021. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Gastrointestinal (GI) bleed accounts for approximately 20% of emergency visits; 2% of hospital admissions and its incidence has been increasing. In patients where the GI bleed does not stop spontaneously, intervention is required to identify the source of bleeding and stop the hemorrhage. Although identifying the source of bleeding can be challenging due to the vast number of underlying etiologies, radiology plays a vital role in patients where endoscopy and/or medical management fail. Radiology offers both non-invasive and invasive options for the diagnosis as well as management of GI bleeds. Scintigraphy and computed tomography angiography (CTA) are the most important non-invasive imaging tests that can identify presence of and help locate the site of bleeding and are used when the patient is hemodynamically stable. If the patient is hemodynamically unstable, conventional angiography (CA) allows diagnosis of the presence, site of bleeding as well as the means of treating the bleed by embolization. Our review article focuses on the various etiologies of GI bleed, the role of imaging in diagnosis as well as treatment of these patients based on the underlying etiologies, the merits and disadvantages of each of these modalities with emphasis on triaging patients for the most appropriate imaging test to guide the most suitable management., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Endocrinopathies are a heterogeneous group of disorders often resulting from pathologic sources of hormone production. When the clinical scenario, laboratory testing, and noninvasive imaging fail to aid confident identification of the source of hormone excess, endocrine venous sampling may localize obscure lesions to guide subsequent treatment. Knowledge of basic hormone signaling pathways, common pathophysiologic disruptions of these pathways, and serologic evaluation fosters informed conversations with referring physicians and effective patient selection. Success in the angiography suite requires familiarity with normal and variant anatomy of the multiple organs of the endocrine system, patient preparation, stimulation and sampling techniques, specimen handling, and results interpretation. © RSNA, 2017.

Fibroblast growth factor 23 (FGF23) is a hormone released primarily by osteocytes that regulates phosphate and vitamin D metabolism. Recent observational studies in humans suggest that circulating FGF23 is independently associated with cardiac hypertrophy and increased mortality, but it is unknown whether FGF23 can directly alter cardiac function. We found that FGF23 significantly increased cardiomyocyte cell size in vitro, the expression of gene markers of cardiac hypertrophy, and total protein content of cardiac muscle. In addition, FGFR1 and FGFR3 mRNA were the most abundantly expressed FGF receptors in cardiomyocytes, and the coreceptor α-klotho was expressed at very low levels. We tested an animal model of chronic kidney disease (Col4a3(-/-) mice) that has elevated serum FGF23. We found elevations in common hypertrophy gene markers in Col4a3(-/-) hearts compared with wild type but did not observe changes in wall thickness or cell size by week 10. However, the Col4a3(-/-) hearts did show reduced fractional shortening (-17%) and ejection fraction (-11%). Acute exposure of primary cardiomyocytes to FGF23 resulted in elevated intracellular Ca(2+) ([Ca(2+)](i); F/F(o) + 86%) which was blocked by verapamil pretreatment. FGF23 also increased ventricular muscle strip contractility (67%), which was inhibited by FGF receptor antagonism. We hypothesize that although FGF23 can acutely increase [Ca(2+)](i), chronically this may lead to decreases in contractile function or stimulate cardiac hypertrophy, as observed with other stress hormones. In conclusion, FGF23 is a novel bone/heart endocrine factor and may be an important mediator of cardiac Ca(2+) regulation and contractile function during chronic kidney disease.

We report a spectroscopic orbit with period P=3.52433+/-0.00027 days for the planetary companion that transits the solar-type star HD 209458. For the metallicity, mass, and radius of the star, we derive [Fe/H&sqbr0;=0.00+/-0.02, M*=1.1+/-0.1 M middle dot in circle, and R*=1.2+/-0.1 R middle dot in circle. This is based on a new analysis of the iron lines in our HIRES template spectrum and also on the absolute magnitude, effective temperature, and color of the star, and it uses isochrones from four different sets of stellar evolution models. Using these values for the stellar parameters, we reanalyze the transit data and derive an orbital inclination of i=86&fdg;1+/-1&fdg;6. For the planet, we derive a mass of Mp=0.69+/-0.05 MJup, a radius of Rp=1.40+/-0.17 RJup, and a density of rho=0.31+/-0.07 g cm-3.