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The literature is highly conflicted on what percentage of pancreatic ductal adenocarcinomas (PDACs) arise in association with intraductal papillary mucinous neoplasms (IPMNs). Some studies have claimed that even small (Sendai-negative) IPMNs frequently lead to PDAC. Recently, more refined pathologic definitions for mucin-lined cysts were provided in consensus manuscripts, but so far there is no systematic analysis regarding the frequency and clinicopathologic characteristics of IPMN-mimickers, i.e., pseudo-IPMNs. In this study, as the first step in establishing frequency, we performed a systematic review of the pathologic findings in 501 consecutive ordinary PDACs, which disclosed that 10% of PDACs had associated cysts >= 1 cm. While 31 (6.2%) of these were IPMN or mucinous cystic neoplasm (MCN), 19 (3.8%) were other cyst types that mimicked IPMN (pseudo-IPMNs) per recent WHO/consensus criteria. As the second step of the study, we performed a comparative clinicopathologic analysis by also including our entire surgical pathology/consultation databases that was comprised of 60 IPMN-associated PDACs, 30 MCN-associated PDACs and 40 pseudo-IPMN-associated PDACs. We found that 84% of true IPMNs were pre-operatively recognized, whereas IPMN was considered in differential diagnosis of 33% of pseudo-IPMNs. Of the 40 pseudo-IPMNs, there were 15 secondary duct ectasias; 6 large-duct-type PDACs; 5 pseudocysts; 5 cystic tumor necrosis; 4 simple mucinous cysts; 3 groove pancreatitis-associated paraduodenal wall cysts; and 2 congenital cysts. Microscopically, pseudo-IPMNs had at least partial mucinous-lining mimicking IPMN but had smaller cystic (mean = 1.9 cm) and larger PDAC (mean = 3.8 cm) components compared to true IPMNs (cyst = 5.7 cm; PDAC = 2.0 cm). In summary, in this pathologically verified analysis that utilized refined criteria, 10% of PDACs were discovered to have cysts >= 1 cm, about two-thirds of which were IPMN/MCN but about one-third were pseudo-IPMNs. True IPMNs underlying the PDACs are often large and are already diagnosed pre-operatively as having an IPMN component, whereas only a third of the pseudo-IPMNs receive IPMN diagnosis by imaging and their cysts are smaller. At the histopathologic level, pseudo-IPMNs are highly prone to misdiagnosis as IPMN, which presumably accounts for much higher association of IPMNs with PDAC as reported in some studies. The subtle but salient characteristics of pseudo-IPMNs elucidated in this study should be combined with careful radiological/clinical correlation in order to exclude pseudo-IPMNs.

Laparoscopic cholecystectomy is one of the most common procedures performed each year and can be associated with various post-operative complications. Imaging is integral to diagnosis and management of patients with suspected cholecystectomy complications, and a thorough understanding of normal and abnormal biliary anatomy, risk factors for biliary injury, and the spectrum of adverse events is crucial for interpretation of imaging studies. Magnetic resonance cholangiography (MRC) enhanced with hepatobiliary contrast agent is useful in delineating biliary anatomy and pathology following cholecystectomy. In this article, we provide a protocol for contrast-enhanced MR imaging of the biliary tree. We also review the classification and imaging manifestations of post-cholecystectomy bile duct injuries in addition to other complications such as bilomas, retained/dropped gallstones, and vascular injuries.

The cause of most pancreatic and periampullary cancers (PAC) is unknown. Recently, anatomic variations such as pancreatobiliary maljunction have been recognized as risk factors, similar to Barrett-related gastro-esophageal cancers.Pre-operative MRI from 860 pancreatic/biliary resections, including 322 PACs, were evaluated for low-union (cystic duct joining the common hepatic duct inside of the pancreas or within 5 mm of the pancreatic border) RESULTS: Low-union, seen10% of the population, was present in 44% of PACs (73% distal bile duct/cholangiocarcinoma, 42% pancreatic head, and 34% ampullary). It was significantly lower(11%) in conditions without connection to the ductal system (thus not exposed to the ductal/biliary tract contents), namely mucinous cystic neoplasms and intrahepatic cholangiocarcinomas(p0.0001). Intra-pancreatic type low-union was seen in 16% of PACs versus 2% of controls(p0.0001).This study establishes an association between low-union and PACs, and points to an anatomy-induced chemical/bilious carcinogenesis. This may explain why most pancreas cancers are in the head. It is possible that the same chemical milieu, caused by conditions other than low-union/insertion, may also play a role in the remaining half of PACs. This opens various treatment opportunities including milieu modifications (chemoprevention), focused screening of at-risk patients, and early detection with possible corrective actions.

Acute pancreatitis has a wide array of imaging presentations. Various classifications have been used in the past to standardize the terminology and reduce confusing and redundant terms. We aim to review the historical and current classifications of acute pancreatitis and propose a new reporting template which can improve communication between various medical teams by use of appropriate terminology and structured radiology template. The standardized reporting template not only conveys the most important imaging findings in a simplified yet comprehensive way but also allows structured data collection for future research and teaching purposes.

Abdominal pain is a common occurrence in pregnant women and may have a variety of causes, including those that are specific to pregnancy (eg, round ligament pain in the first trimester) and the wide range of causes of abdominal pain that affect men and women who are not pregnant (eg, appendicitis, acute cholecystitis). Noncontrast magnetic resonance (MR) imaging is increasingly performed to evaluate pregnant women with abdominal pain, either as the first-line test or as a second test following ultrasonography. The imaging appearance of causes of abdominal pain in pregnant women are reviewed with an emphasis on noncontrast MR imaging.

The widespread use of high-spatial-resolution cross-sectional imaging has led to an increase in detection of incidental pancreatic cystic lesions. These lesions are a diverse group, ranging from indolent and premalignant lesions to invasive cancers. The diagnosis of several of these lesions can be suggested on the basis of their imaging appearance, while many other lesions require follow-up imaging and/or aspiration. The smaller cystic lesions, often branch-duct intraductal papillary mucinous neoplasms, have overlapping imaging characteristics that make diagnostic assessment of the natural history and malignancy risk confusing. Expert panels have developed societal guidelines, based on a consensus, for surveillance of these lesions. However, these guidelines are often inconsistent and are constantly evolving as additional scientific data are accumulated. Identification of features associated with increased risk of malignancy is important for proper management. The concept of field defect, whereby pancreatic adenocarcinoma develops at a site different from the site of the pancreatic cyst, adds to the complexity of screening guidelines. As a result of the differences in guidelines, key stakeholders (eg, radiologists, gastroenterologists, and surgeons) must review and come to a consensus regarding which guideline, or combination of guidelines, to follow at their individual institutions. Standardized reporting and macros are helpful for ensuring the uniformity of interpretations. Radiologists play a critical role in the detection and characterization of pancreatic cystic lesions, in the follow-up recommendations for these lesions, and in the detection of associated cancer. An invited commentary by Zaheer is available online.Online supplemental material is available for this article.©RSNA, 2021.

Early diagnosis and noninvasive detection of liver fibrosis and its heterogeneity remain as major unmet medical needs for stopping further disease progression toward severe clinical consequences. Here we report a collagen type I targeting protein-based contrast agent (ProCA32.collagen1) with strong collagen I affinity. ProCA32.collagen1 possesses high relaxivities per particle (r1 and r2) at both 1.4 and 7.0 T, which enables the robust detection of early-stage (Ishak stage 3 of 6) liver fibrosis and nonalcoholic steatohepatitis (Ishak stage 1 of 6 or 1 A Mild) in animal models via dual contrast modes. ProCA32.collagen1 also demonstrates vasculature changes associated with intrahepatic angiogenesis and portal hypertension during late-stage fibrosis, and heterogeneity via serial molecular imaging. ProCA32.collagen1 mitigates metal toxicity due to lower dosage and strong resistance to transmetallation and unprecedented metal selectivity for Gd3+ over physiological metal ions with strong translational potential in facilitating effective treatment to halt further chronic liver disease progression. Non-invasive early diagnosis of liver fibrosis is important to prevent disease progression and direct treatment strategies. Here the authors developed a collagen-targeting contrast agent for the detection of early stage fibrosis and non-alcoholic steatohepatitis by magnetic resonance and tested it in animal models.

Pancreatic ductal adenocarcinoma can be a difficult imaging diagnosis early in its course given its subtle imaging findings such as focal pancreatic duct dilatation, abrupt duct cut-off, and encasement of vasculature. A variety of pancreatitidies have imaging findings that mimic pancreatic ductal adenocarcinoma and lead to mass formation making diagnosis even more difficult on imaging alone. These conditions include acute focal pancreatitis, chronic pancreatitis, autoimmune pancreatitis, and paraduodenal ("groove") pancreatitis. This review will focus on imaging findings that can help differentiate these inflammatory processes from pancreatic ductal adenocarcinoma.

Autoimmune pancreatitis (AIP) is an inflammatory process of the pancreas that occurs most commonly in elderly males and clinically can mimic pancreatic adenocarcinoma and present with jaundice, weight loss, and abdominal pain. Mass-forming lesions in the pancreas are seen in the focal form of AIP and both clinical and imaging findings can overlap those of pancreatic cancer. The accurate distinction of AIP from pancreatic cancer is of utmost importance as it means avoiding unnecessary surgery in AIP cases or inaccurate steroid treatment in patients with pancreatic cancer. Imaging concomitantly with serological examinations (IgG4 and Ca 19-9) plays an important role in the distinction between these entities. Characteristic extra-pancreatic manifestations as well as favorable good response to treatment with steroids are characteristic of AIP. This paper will review current diagnostic parameters useful in differentiating between focal AIP and pancreatic adenocarcinoma.

The literature is highly conflicted on what percentage of pancreatic ductal adenocarcinomas (PDACs) arise in association with intraductal papillary mucinous neoplasms (IPMNs). Some studies have claimed that even small (Sendai-negative) IPMNs frequently lead to PDAC. Recently, more refined pathologic definitions for mucin-lined cysts were provided in consensus manuscripts, but so far there is no systematic analysis regarding the frequency and clinicopathologic characteristics of IPMN-mimickers, i.e., pseudo-IPMNs. In this study, as the first step in establishing frequency, we performed a systematic review of the pathologic findings in 501 consecutive ordinary PDACs, which disclosed that 10% of PDACs had associated cysts ≥1 cm. While 31 (6.2%) of these were IPMN or mucinous cystic neoplasm (MCN), 19 (3.8%) were other cyst types that mimicked IPMN (pseudo-IPMNs) per recent WHO/consensus criteria. As the second step of the study, we performed a comparative clinicopathologic analysis by also including our entire surgical pathology/consultation databases that was comprised of 60 IPMN-associated PDACs, 30 MCN-associated PDACs and 40 pseudo-IPMN-associated PDACs. We found that 84% of true IPMNs were pre-operatively recognized, whereas IPMN was considered in differential diagnosis of 33% of pseudo-IPMNs. Of the 40 pseudo-IPMNs, there were 15 secondary duct ectasias; 6 large-duct-type PDACs; 5 pseudocysts; 5 cystic tumor necrosis; 4 simple mucinous cysts; 3 groove pancreatitis-associated paraduodenal wall cysts; and 2 congenital cysts. Microscopically, pseudo-IPMNs had at least partial mucinous-lining mimicking IPMN but had smaller cystic (mean = 1.9 cm) and larger PDAC (mean = 3.8 cm) components compared to true IPMNs (cyst = 5.7 cm; PDAC = 2.0 cm). In summary, in this pathologically verified analysis that utilized refined criteria, 10% of PDACs were discovered to have cysts ≥1 cm, about two-thirds of which were IPMN/MCN but about one-third were pseudo-IPMNs. True IPMNs underlying the PDACs are often large and are already diagnosed pre-operatively as having an IPMN component, whereas only a third of the pseudo-IPMNs receive IPMN diagnosis by imaging and their cysts are smaller. At the histopathologic level, pseudo-IPMNs are highly prone to misdiagnosis as IPMN, which presumably accounts for much higher association of IPMNs with PDAC as reported in some studies. The subtle but salient characteristics of pseudo-IPMNs elucidated in this study should be combined with careful radiological/clinical correlation in order to exclude pseudo-IPMNs.

Gallbladder carcinoma is the most common cancer of the biliary system. It is challenging to diagnose because patients are often asymptomatic or present with nonspecific symptoms that mimic common benign diseases. Surgical excision is the only curative therapy and is best accomplished at early non-locally advanced stages. Unfortunately, gallbladder cancer often manifests at late locally advanced stages, precluding cure. Early tumors are often incidentally detected at imaging or at cholecystectomy performed for another indication. Typical imaging features of localized disease include asymmetric gallbladder wall thickening, polyps larger than 1.0 cm, and a solid mass replacing the gallbladder lumen. Advanced tumors are often infiltrative and can be confusing at CT and MRI owing to their large size. Determination of the origin of the lesion is paramount to narrow the differential diagnosis but is often challenging. It is important to identify gallbladder cancer and distinguish it from other benign and malignant hepatobiliary processes. Since surgical resection is the only curative treatment option, radiologist understanding and interpretation of pathways of nodal and infiltrative tumor spread can direct surgery or preclude patients who may not benefit from surgery. While both CT and MRI are effective, MRI provides superior soft-tissue characterization of the gallbladder and biliary tree and is a useful imaging tool for diagnosis, staging, and evaluation of treatment response.

OBJECTIVE To determine the associations of pancreatobiliary maljunction (PBM) in the West. BACKGROUND PBM (anomalous union of common bile duct and pancreatic duct) is mostly regarded as an Asian-only disorder, with 200X risk of gallbladder cancer (GBC), attributed to reflux of pancreatic enzymes. METHODS Radiologic images of 840 patients in the U.S. who underwent pancreatobiliary resections were reviewed for PBM and contrasted with 171 GBC cases from Japan. RESULTS Eight % of the US GBCs (24/300) had PBM (similar to Japan; 15/171, 8.8%), in addition to 1/42 bile duct carcinomas and 5/33 choledochal cysts. None of the 30 PBM cases from the US had been diagnosed as PBM in the original work-up. PBM was not found in other pancreatobiliary disorders. Clinicopathologic features of the 39 PBM-associated GBCs (US:24, Japan:15) were similar; however, comparison with non-PBM GBCs revealed that they occurred predominantly in females (F/M = 3); at younger (

Laparoscopic cholecystectomy is one of the most common procedures performed each year and can be associated with various post-operative complications. Imaging is integral to diagnosis and management of patients with suspected cholecystectomy complications, and a thorough understanding of normal and abnormal biliary anatomy, risk factors for biliary injury, and the spectrum of adverse events is crucial for interpretation of imaging studies. Magnetic resonance cholangiography (MRC) enhanced with hepatobiliary contrast agent is useful in delineating biliary anatomy and pathology following cholecystectomy. In this article, we provide a protocol for contrast-enhanced MR imaging of the biliary tree. We also review the classification and imaging manifestations of post-cholecystectomy bile duct injuries in addition to other complications such as bilomas, retained/dropped gallstones, and vascular injuries.

Crossed fused renal ectopia and the presence of a supernumerary kidney are both rare congenital variants that are often asymptomatic but may be associated with other developmental anomalies. Here we present a case of a 20-year-old male with a known diagnosis of crossed fused renal ectopia as well as a history of imperforate anus and tethered spinal cord treated in infancy. He presented to the emergency room with symptoms of flank pain, and a noncontrast computed tomography (CT) scan revealed a 4-mm stone in the distal left ureter. CT scan also revealed that the patient's right kidney was not crossed and fused to the left kidney as previously believed, but rather it was crossed and fused to a supernumerary kidney abutting the inferomedial aspect of an orthotopic left kidney. This is a unique example of two rare coexisting renal anomalies not previously detected on a nuclear medicine renal scan and serial renal ultrasounds obtained earlier in the the patient's life.

Objective To determine if adenocarcinoma of the Skene's glands in women, which has a histological and immunohistochemical appearance similar to prostate cancer, can be evaluated and managed with the same tools we use for prostate cancer. Methods Serum prostate-specific antigen kinetics, 3D multiparametric (MP) magnetic resonance imaging (MRI), fluciclovine F-18 positron emission tomography (PET), and androgen deprivation therapy (ADT) were employed in a case of Skene's gland adenocarcinoma. Results The 3D MP MRI clarified the anatomy of the primary lesion and fluciclovine F-18 PET significantly improved our ability to stage the tumor prompting pelvic lymph node dissection that may have otherwise not been performed. ADT resulted in a significant impact on prostate-specific antigen kinetics despite the patient having a testosterone level in the normal range for a postmenopausal woman. Conclusion Despite the rarity of Skene's gland adenocarcinoma, we can employ many of the tools at our disposal for the evaluation and management of prostate cancer to benefit the women found to have this malignancy.

Design a protein-based contrast agent for detecting liver metastases with magnetic resonance imaging., Liver metastases often progress from primary cancers including uveal melanoma (UM), breast, and colon cancer. Molecular biomarker imaging is a new non-invasive approach for detecting early stage tumors. Here, we report the elevated expression of chemokine receptor 4 (CXCR4) in liver metastases in UM patients and metastatic UM mouse models, and development of a CXCR4-targeted MRI contrast agent, ProCA32.CXCR4, for sensitive MRI detection of UM liver metastases. ProCA32.CXCR4 exhibits high relaxivities (r1 = 30.9 mM−1 s−1, r2 = 43.2 mM−1 s−1, 1.5 T; r1 = 23.5 mM−1 s−1, r2 = 98.6 mM−1 s−1, 7.0 T), strong CXCR4 binding (Kd = 1.10 ± 0.18 μM), CXCR4 molecular imaging capability in metastatic and intrahepatic xenotransplantation UM mouse models. ProCA32.CXCR4 enables detecting UM liver metastases as small as 0.1 mm3. Further development of the CXCR4-targeted imaging agent should have strong translation potential for early detection, surveillance, and treatment stratification of liver metastases patients.

Sickle cell disease is a debilitating hematologic process that affects the entire body. Disease manifestations in the abdomen most commonly result from vaso-occlusion, hemolysis, or infection due to functional asplenia. Organ specific manifestations include those involving the liver (eg, hepatopathy, iron deposition), gallbladder (eg, stone formation), spleen (eg, infarction, abscess formation, sequestration), kidneys (eg, papillary necrosis, infarction), pancreas (eg, pancreatitis), gastrointestinal tract (eg, infarction), reproductive organs (eg, priapism, testicular atrophy), bone (eg, marrow changes, avascular necrosis), vasculature (eg, vasculopathy), and lung bases (eg, acute chest syndrome, infarction). Imaging provides an important clinical tool for evaluation of acute and chronic disease manifestations and complications. In summary, there are multifold abdominal manifestations of sickle cell disease. Recognition of these sequela helps guide management and improves outcomes. The purpose of this article is to review abdominal manifestations of sickle cell disease and discuss common and rare complications of the disease within the abdomen.

Diagnostic workup of scrotal lesions should begin with a complete clinical history and physical examination, including analysis of risk factors such as family history of testicular cancer, personal history of tumor in the contralateral testis, and cryptorchidism, followed by imaging. Scrotal ultrasonography (US) with a combination of gray-scale and color Doppler techniques has been the first-line imaging modality for evaluation of testicular and extratesticular lesions because of its low cost, wide availability, and high diagnostic accuracy. However, US has limitations related to operator dependence, the relatively small field of view, and lack of tissue characterization. Magnetic resonance (MR) imaging, because of its superior soft-tissue contrast and multiplanar capabilities, is increasingly being used as a supplemental diagnostic problem-solving tool in cases where scrotal US findings are inconclusive or nondiagnostic. In addition to morphology, lesion location, and tissue characterization (eg, fat, blood products, granulation tissue, and fibrosis), scrotal MR imaging provides important information that can affect surgical planning and improve patient care. MR imaging also is helpful for differentiating testicular and extratesticular lesions, distinguishing between benign and malignant lesions, and evaluating the local extent of disease. This review discusses the anatomy and MR imaging features of testicular and extratesticular neoplastic and nonneoplastic conditions and describes relevant MR imaging techniques. ©RSNA, 2018 Contact information that appeared in the print version of this article was updated in the online version on May 14, 2018.

Background Previous clinical studies of autosomal dominant polycystic kidney disease (ADPKD) reported that loss of kidney function usually follows a steep and relentless course. A detailed examination of individual patterns of decline in estimated glomerular filtration rate (eGFR) has not been performed. Study Design Longitudinal post hoc analysis of data collected during the Halt Progression of Polycystic Kidney Disease (HALT-PKD) trials. Setting & Participants 494 HALT-PKD Study A participants (younger; preserved eGFR) and 435 Study B participants (older; reduced eGFR) who had more than 3 years of follow-up and 7 or more eGFR assessments. Measurements Longitudinal eGFR assessments using the CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration) creatinine equation. Predictors Demographic, clinical, laboratory, and imaging features of participants. Outcomes Probability of linear and nonlinear decline patterns or of stable eGFR calculated for each participant from a Bayesian model of individual eGFR trajectories. Results Most (62.5% in Study A and 81% in Study B) participants had a linear decline in eGFR during up to 8 years of follow-up. A proportion (22% in Study A and 13% in Study B) of progressors had a nonlinear pattern. 15.5% of participants in Study A and 6% in Study B had a prolonged (≥4.5 years) period of stable eGFRs. These individuals (Study A) had significantly smaller total kidney volumes, higher renal blood flows, lower urinary albumin excretion, and lower body mass index at baseline and study end. In Study B, participants with reduced but stable eGFRs were older than the progressors. Two-thirds of nonprogressors in both studies had PKD1 mutations, with enrichment for weak nontruncating mutations. Limitations Relatively short follow-up of a clinical trial population. Conclusions Although many individuals with ADPKD have a linear decline in eGFR, prolonged intervals of stable GFRs occur in a substantial fraction. Lower body mass index was associated with more stable kidney function in early ADPKD.

Purpose To assess the prevalence of chronic liver disease (CLD) and hepatocellular carcinoma (HCC) in adult patients who had surveillance imaging after Fontan procedure. Methods Institutional review board–approved, Health Insurance Portability and Accountability Act–compliant retrospective study evaluated electronic medical records including radiology reports and clinical notes for adult patients after Fontan procedure between January 1993 and January 2016. Abdominal ultrasound, computed tomography, and magnetic resonance imaging reports were reviewed for changes of CLD and HCC. Existence of concomitant viral hepatitis was also recorded. Results A total of 145 patients (male: 78 and female: 67) had surveillance imaging after Fontan procedure. In all, 78% (113/145) had ongoing imaging surveillance (median follow-up 3.05 years, IQR: 0.75-5.3 years); 19% (21/113) had an initial normal study and remained normal throughout follow-up; 19% (21/113) had an initial normal study with subsequent imaging reporting changes of CLD; and 62% (71/113) had existing changes of CLD on initial study. HCC was identified in 5 patients (median 22 years post-Fontan, IQR: 10-29 years), 4 of which had a normal initial study. Only 1 patient with HCC had concomitant viral hepatitis C infection. Conclusion Radiologists should be aware that CLD is exceedingly common in post-Fontan cardiac physiology, and surveillance imaging is warranted given the risk of HCC.

Our large single-center study demonstrates the safety of performing contrast-enhanced MR imaging with gadobenate dimeglumine in patients with severe chronic kidney disease, with no patients having developed nephrogenic systemic fibrosis at follow-up.

Pancreaticobiliary maljunction (PBM) is the anomalous union of the main pancreatic duct and common bile duct outside the Oddi-sphincter, allowing the reflux of pancreatic juice to the gallbladder. There is only limited awareness and understanding of the pathologic correlates of this condition, mostly from Japan; this entity is largely unrecognized in the West. In this study, 76 gallbladders from patients with PBM (64 from Japan; 12 from the United States) were analyzed and contrasted with 66 from non-PBM patients. These were predominantly females (54 vs. 22), mean age, 53 (range: 14 to 81). Cholelithiasis was uncommon (16% vs. 80% in non-PBM, P

Magnetic resonance imaging (MRI) plays an important role in the staging and restaging of rectal cancer. Multiplanar high-resolution (≤3-mm section thickness) T2-weighted images are the primary sequences used for rectal cancer staging. No preprocedural bowel cleansing regimen, intravenous contrast material, nor endorectal coil is necessary. MRI is highly accurate for differentiating T1-T2 disease from T3 and T4 disease, an important distinction as patients with T3 and T4 tumors typically undergo preoperative neoadjuvant chemoradiation before resection. At MRI, the muscularis propria appears as a thin black line encircling the outer wall of the rectum, and tumor extension through this line indicates T3 disease. Further tumor extension into adjacent organs indicates T4 disease. Endorectal ultrasound is generally preferred to differentiate T1 (submucosal involvement) from T2 (extension into but no disruption of muscularis propria) disease. MRI is also accurate in the assessment of tumor involvement of the mesorectal fascia. Tumor involvement of the mesorectal fascia increases the likelihood of recurrence following resection. MRI is less accurate for determination of lymph node status, though heterogeneous signal intensity and irregular margins are suggestive of node positive disease. Approximately 10%-30% of patients who undergo preoperative chemoradiation experience a complete pathologic response that is defined as no residual tumor found at histopathologic analysis of the resected specimen. The addition of diffusion-weighted images to T2-weighted images improves the accuracy of restaging examinations for determination of complete pathologic responders.

To assess the value of arterial phase imaging (ART) in the detection of liver metastases on CT compared to portal venous phase imaging (PV) alone in patients with primary sarcomas. Multiphasic abdominal computed tomography (CT) images of patients with tissue-proven sarcomas were reviewed by five abdominal radiologists in a staggered fashion. Up to three of the largest or most conspicuous liver lesions were characterized on a four-point confidence level for PV independently, followed by PV + ART. Inter-observer reliability was evaluated with kappa statistics. Change in characterization of lesions by the addition of ART was calculated. Follow-up imaging was used to determine if index lesion characterization was valid. 55 of 149 patients had 470 liver lesion characterizations by the five readers with follow-up. Inter-observer agreement was κ = 0.62 on PV and κ = 0.58 on PV + ART. The intra-observer agreement between PV and ART interpretations of the same lesion was κ = 0.93. 426 lesion characterizations were possible on both PV and ART. Only 6 characterizations were changed after the addition of ART; 4 of the 6 changes were incorrect when compared to follow-up. Only 6 lesion characterizations could be made on ART alone (missed by PV), with all the malignant lesions arising from primary leiomyosarcomas. For the lesions seen on PV alone, the sensitivity, specificity, PPV, NPV, and accuracy were 98.8%, 100%, 100%, 99.3%, and 99.6%, respectively. After the addition of ART, they were 98.8%, 98.7%, 97.5%, 99.4%, and 98.7%, respectively. ART adds marginal value to PV for characterization of metastatic liver lesions in patients with primary sarcomas, except possibly in primary leiomyosarcomas.

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract, with most occurring in the stomach. GISTs may present with clinical symptoms (eg, gastrointestinal bleeding) or may be found incidentally at surgery, endoscopy, or imaging. At initial staging, GISTs often appear as well-circumscribed, round, solid masses. Small tumors may appear solid, whereas larger tumors may demonstrate central areas of necrosis. At follow-up imaging, decreasing tumor attenuation at computed tomographic indicates treatment response even in the setting of stable tumor size. Localized tumors are treated with resection. Imatinib mesylate, a tyrosine kinase inhibitor, is typically prescribed for metastatic disease and increasingly in a neoadjuvant role before resection. Imaging plays a key role in the identification of GISTs, evaluation of tumor extent and presence or absence of metastatic disease, and in assessing response to therapy.

This article reviews the anatomy and magnetic resonance imaging (MRI) appearance of the penis. The recommended technique for MRI of the penis is outlined, with discussion of the benefits and drawbacks to imaging the penis after artificial erection. Common penile pathologies are reviewed, with a summary of their clinical features, MRI appearance, and treatment. The ability to demonstrate the erectile bodies and vasculature helps to evaluate vascular pathologies such as priapism, Mondor disease, and cavernosal thrombosis. MRI is also a useful tool to assess for traumatic abnormalities of the penis, with the depiction of soft tissue anatomy and fascial layers allowing for evaluation of penile fracture and penile contusion. Malignant disease of the penis is also reviewed, including squamous cell carcinoma, urethral carcinoma, metastases, and rare neoplasms. Staging of these neoplasms is addressed, with discussion of how MRI can be used to assess the extent of tumor involvement. MRI also clearly demonstrates the tunica albuginea, which allows for evaluation of Peyronie's disease.

Objective This study was designed to assess the diagnostic accuracy of standard nonsecretin-enhanced preprocedural magnetic resonance imaging/cholangiopancreatography (MRI/MRCP) in patients with and without pancreas divisum. Methods Patients undergoing MRI/MRCP followed by endoscopic retrograde cholangiopancreatography with between 2009 and 2016 were reviewed. The diagnostic accuracy of the MRI/MRCP was evaluated against the pancreatography. A subsequent independent blinded re-review performed by an expert abdominal radiologist was also evaluated. Multivariate binary logistic regression was performed to assess the impact of clinicopathologic factors on the diagnostic accuracy. Results A total of 189 patients were included in analysis. The sensitivity, specificity, positive predictive value, and negative predictive value of MRI/MRCP for pancreas divisum were 63%, 97%, 94%, and 82% initially and 81%, 91%, 91%, and 82% on the expert review. Motion artifact, the presence of pancreatic tumor, and pancreatic necrosis were not found to significantly impact the accuracy. A normal diameter pancreatic duct (P = 0.04) and complete divisum anatomy were correlated with improved accuracy (P = 0.001). Conclusions Although expert review, normal duct diameter, and complete divisum are associated with increased sensitivity, pancreas divisum may be uncharacterized by preprocedural MRI in 19% to 37% of patients before the index endoscopic retrograde cholangiopancreatography.

Objectives To develop a transcriptomic signature capable of predicting overall survival (OS) for uterine serous carcinoma (USC). Methods RNAseq data for 58 USC patients were obtained from TCGA. Expression of 73 candidate genes was measured for 67 Augusta University (AU) samples using NanoString technology. Results Analysis of the TCGA RNAseq data identified 73 genes that individually predict prognosis for USC patients and an elastic net model with all 73 genes (USC73) distinguishes a good OS group with low USC73 score from a poor OS group with high USC73 score (5-year OS = 83.3% and 13.3% respectively, HR = 40.1; p = 3 × 10−8). This finding was validated in the independent AU cohort (HR = 4.3; p = 0.0004). The poor prognosis group with high USC73 score consists of 37.9% and 32.8% of patients in the TCGA and AU cohort respectively. USC73 score and pathologic stage independently contribute to OS and together provide the best prognostic value. Early stage, low USC73 patients have the best prognosis (5-year OS = 85.1% in the combined dataset), while advanced stage, high USC73 patients have the worst prognosis (5-year OS = 6.4%, HR = 30.5, p = 1.2 × 10−12). Consistent with the observed poor survival, primary cell cultures from high USC73 patients had higher proliferation rate and cell cycle progression; and high USC73 patients had lower rates of complete response to standard therapy. Conclusions The USC73 transcriptomic signature and stage independently predict OS of USC patients and the best prediction is achieved using USC73 and stage. USC73 may also serve as a therapeutic biomarker to guide patient care.

Developmental anomalies of the pancreas include more common entities such as pancreas divisum and annular pancreas, and unusual entities such as heterotopic pancreas. While these anomalies can present a diagnostic challenge to the radiologist, when the pancreatic tissue involved in these processes develops pancreatitis, the radiographic appearance can present a diagnostic dilemma. Awareness of these pancreatic anomalies and familiarity with their appearance when inflamed is necessary to distinguish pancreatitis in the developmentally anomalous pancreas from other inflammatory or neoplastic processes.

After experiencing blunt or penetrating trauma, patients in unstable condition who are more likely to die of uncorrected shock than of incomplete injury repairs undergo emergency limited exploratory laparotomy, which is also known as

Ovarian hyperstimulation syndrome (OHSS) is ovarian enlargement secondary to hormones overstimulating ovarian growth. It can be associated with a spectrum of other clinical findings, including ascites, hemoconcentration, hypercoagulability, and electrolyte imbalances. OHSS most commonly occurs as a complication of treatment with in vitro fertilization medications, such as human chorionic gonadotropin (hCG) or gonadotropin-releasing hormone agonists. OHSS has infrequently been reported to be caused by high hCG levels in complete, partial, or invasive molar pregnancies. The classic signs and symptoms of OHSS include nausea, vomiting, bloating, abdominal pain, tachycardia, tachypnea, and dyspnea. Further positive diagnostic studies for OHSS include enlarged ovaries, ascites, hemoconcentration, hyponatremia, hyperkalemia, and oliguria. OHSS due to molar pregnancies is extremely rare. Suziki et al. performed a literature review in 2014 and describe the eight ever-reported molar pregnancy-associated OHSS cases, three of which were partial molar pregnancies. We present a two-case comparison that first examines an exceptionally rare OHSS case presentation of a 19-year-old female with a partial molar pregnancy that was also complicated by hCG-induced thyrotoxicosis. Following this, we discuss a case of the more classic presentation of OHSS caused by fertility treatments. This case report is of novel interest because we present a case comparison that emphasizes a rare, paradoxical association between OHSS and dilation-evacuation procedures that is important for physicians to be aware of - OHSS is not an adverse event of molar pregnancies that can be eliminated by declining hCG levels after a dilation and evacuation procedure; rather, in a molar pregnancy, OHSS occurs after the dilation and evacuation.

We describe a case of a biochemically silent pheochromocytoma, which raises the question about the appropriate pre-operative approach in cases of biochemically “silent” adrenal tumors. A 37-year-old white female was referred to our endocrinology clinic for evaluation of a large right sided adrenal incidentaloma. She was symptomatic for episodic severe migratory headaches, dizziness, intermittent orthostasis and anxiety. She was being treated for hypertension with labetalol 200mg twice daily. She denied any family history of pheochromocytomas or adrenal tumors. Her physical examination was unremarkable apart from BP 191/115, with regular heart rate of 93 beats per minute. Her BMI was 19 and she did not exhibit any cushingoid features. She had undergone biochemical testing 17 months prior, which included 24 hour urine fractionated metanephrines and catecholamines, 1mg overnight dexamethasone suppression test and aldosterone level, all of which were unremarkable. Biochemical work-up was again repeated and included fractionated metanephrines

The purpose of this study was to evaluate the safety and diagnostic utility of 1.5-T MRI examinations of individuals with conventional and MRI-conditional cardiac implantable electronic devices (CIEDs).Patients with a CIED who were referred for MRI were evaluated by radiologists and cardiac electrophysiologists for study participation. CIED interrogation was performed immediately before and after MRI, and cardiac telemetry monitoring was performed during MRI. CIED programming changes, malfunctions, and intraprocedural events were documented. Whether diagnostic questions were answered and whether artifacts related to the CIED were present and negatively affected image interpretation were recorded.One hundred thirteen MRI examinations were performed for 104 patients with CIEDs (74 pacemakers [60 conventional, 14 MRI conditional]; 39 implantable cardiac defibrillators). Device reprogramming was required before MRI for 62.8% of studies (71/113). No significant changes in lead parameters were noted during or after MRI. Electromagnetic noise was detected on at least one lead in 7.1% of studies. Three patients reported transient symptoms (one case each of heating at the pocket site, tingling at the pocket site, and palpitations). All images were considered diagnostic for the original clinical query. Artifacts related to CIEDs were described in 3.5% of MRI reports (4/113) and were present only when the pulse generator was included in the FOV. CIED-related artifacts limited evaluation of tissues immediately adjacent to the pulse generator.Establishment of a multidisciplinary work flow allows individuals with conventional and MRI-conditional CIEDs to safely undergo 1.5-T MRI with diagnostic questions consistently answered.

Undifferentiated carcinomas with osteoclastic giant cells of the pancreas (OGC) are rare tumors. The current impression in the literature is that they are highly aggressive tumors similar in prognosis to ductal adenocarcinomas. In this study, the clinicopathologic characteristics of 38 resected OGCs were investigated and contrasted with 725 resected pancreatic ductal adenocarcinomas without osteoclastic cells (PDCs). The frequency among systematically reviewed pancreatic cancers was 1.4%. OGCs showed a slight female predominance (62.9%, vs. 51.4% in PDCs). The mean age was 57.9 years (vs. 65.0). The mean size of invasive cancer was 5.3 cm (vs. 3.2). They were characterized by nodular, pushing-border growth, and 8 arose in tumoral intraepithelial neoplasms (4 in mucinous cystic neoplasms, 4 in intraductal papillary mucinous neoplasms type lesions), and 23 (61%) also showed prominent intraductal/intracystic growth. Twenty-nine (76%) had an invasive ductal/tubular adenocarcinoma component. Osteoid was seen in 12. Despite their larger size, perineural invasion and nodal metastasis were uncommon (31.6% and 22.6%, vs. 85.5% and 64.0%, respectively). Immunohistochemistry performed on 24 cases revealed that osteoclastic cells expressed the histiocytic marker CD68, and background spindle cells and pleomorphic/giant carcinoma cells often showed p53 and often lacked cytokeratin. Survival of OGCs was significantly better than that of PDCs (5 yr, 59.1% vs. 15.7%, respectively, P=0.0009). In conclusion, pancreatic OGCs present with larger tumor size and in slightly younger patients than PDC, 21% arise in mucinous cystic neoplasms/intraductal papillary mucinous neoplasms, and 61% show intraductal/intracystic polypoid growth. OGCs have a significantly better prognosis than is currently believed in the literature.

Purpose To assess changing utilization patterns of abdominal imaging in the Medicare fee-for-service population over the past two decades. Methods Medicare Physician Supplier Procedure Summary master files from 1994 through 2012 were used to study changes in the frequency and utilization rates (per 1,000 Medicare beneficiaries per year) of abdominal CT, MRI, ultrasound, and radiography. Results In Medicare beneficiaries, the most frequently performed abdominal imaging modality changed from radiography in 1994 (207.4 per 1,000 beneficiaries) to CT in 2012 (169.0 per 1,000). Utilization rates of abdominal MR (1037.5%), CT (197.0%), and ultrasound (38.0%) all increased from 1994-2012 (but declined briefly from 2007 to 2009). A dramatic 20-year utilization rate decline occurred for gastrointestinal fluoroscopic examinations (–91.9% barium enema, –80.0% upper gastrointestinal series) and urologic radiographic examinations (–95.3%). Radiologists were the dominant providers of all modalities, accounting for >90% of CT and MR studies, and >75% of most ultrasound examination types. Conclusions Medicare utilization of abdominal imaging has markedly changed over the past two decades, with overall dramatic increases in CT and MRI and dramatic decreases in gastrointestinal fluoroscopic and urologic radiographic imaging. Despite these changes, radiologists remain the dominant providers in all abdominal imaging modalities.

The purpose of the article is to determine if miscentering affected dose with use of automated tube voltage selection software. An anthropomorphic phantom was imaged at different table heights (centered in the computed tomography [CT] gantry, and -6, -3, +3, and +5.7cm relative to the centered position). Topogram magnification, tube voltage selection, and dose were assessed. Effect of table height on dose also was assessed retrospectively in human subjects (n = 50). When the CT table was positioned closer to the x-ray source, subjects appeared up to 33% magnified in topogram images. When subjects appeared magnified in topogram images, automated software selected higher tube potentials and tube currents that were based on the magnified size of the subject rather than the subject׳s true size. Table height strongly correlated with CT dose index (r = 0.98, P < 0.05) and dose length product (r = 0.98, P < 0.05) in the phantom study. Transverse dimension in the topogram highly correlated with dose in human subjects (r = 0.75-0.87, P

The purpose was to determine the normal distribution of distended colon volumes as a guide for rectal contrast material administration protocols. All computed tomography colonography studies performed at Emory University Hospital, Atlanta, Georgia, between January 2009 and January 2015, were reviewed retrospectively. In total, 85 subjects were included in the analysis (64% [54 of 85] female and 36% [31 of 85] male). Mean patient age was 65 years (range: 42-86y). Distended colon volumes were determined from colon length and transaxial diameter measurements made using a 3-dimensional workstation. Age, sex, race, height, weight, and body mass index were recorded. The normal distributions of distended colon volumes and lengths were determined. Correlations between colonic volume and colonic length, and demographic variables were assessed. Mean colon volume was 2.1L (range: 0.7-4.4L). Nearly, 17% of patients had a distended colonic volume of >3L. Mean colon length was 197cm (range: 118-285cm). A weak negative correlation was found between age and colonic volume (r = -0.221; P = 0.04). A weak positive correlation was found between body mass index and colonic length (r = 0.368; P = 0.007). Otherwise, no significant correlations were found for distended colonic volume or length and demographic variables. In conclusion, an average of approximately 2L of contrast material may be necessary to achieve full colonic opacification. This volume is larger than previously reported volumes (0.8-1.5L) for rectal contrast material administration protocols.

Introduction/Background Rates of colorectal cancer screening are improving but remain suboptimal. Limited information is available regarding how patients are diagnosed with colorectal cancer (for example, asymptomatic screened patients or diagnostic workup because of the presence of symptoms). The purpose of this investigation was to determine how patients were diagnosed with colorectal cancer (screening colonoscopy, diagnostic colonoscopy, or emergent surgery) and tumor stage and size at diagnosis. Patients and Methods Adults evaluated between 2011 and 2014 with a diagnosis of colorectal cancer were identified. Clinical notes, endoscopy reports, surgical reports, radiology reports, and pathology reports were reviewed. Sex, race, ethnicity, age at the time of initial diagnosis, method of diagnosis, presenting symptom(s), and primary tumor size and stage at diagnosis were recorded. Colorectal cancer screening history was also recorded. Results The study population was 54% male (265 of 492) with a mean age of 58.9 years (range, 25-93 years). Initial tissue diagnosis was established at the time of screening colonoscopy in 10.7%, diagnostic colonoscopy in 79.2%, and during emergent surgery in 7.1%. Cancers diagnosed at the time of screening colonoscopy were more likely to be stage 1 than cancers diagnosed at the time of diagnostic colonoscopy or emergent surgery (38.5%, 7.2%, and 0%, respectively). Median tumor size was 3.0 cm for the screening colonoscopy group, 4.6 cm for the diagnostic colonoscopy group, and 5.0 cm for the emergent surgery group. At least 31% of patients diagnosed at the time of screening colonoscopy, 19% of patients diagnosed at the time of diagnostic colonoscopy, and 26% of patients diagnosed at the time of emergent surgery had never undergone a screening colonoscopy. Conclusion Nearly 90% of colorectal cancer patients were diagnosed after development of symptoms and had more advanced disease than asymptomatic screening patients. Colorectal cancer outcomes will be improved by improving rates of colorectal cancer screening.

Purpose To determine the incidence and impact of overlying radiopaque personal items (e.g., cellular phones, zippers) on CT dose and image quality with use of automated tube current modulation. Methods Topogram images from 100 consecutive adult outpatient CT abdomen pelvis studies were retrospectively reviewed, and the number and type of overlying radiopaque personal items were recorded. Additionally, an anthropomorphic phantom was imaged with overlying personal items 1) present in topogram and axial images; 2) present in topogram but removed prior to axial acquisition; and 3) present in topogram positioned outside the field of view of the axial acquisition. dose length product (DLP) and CT dose index volume (CTDIvol) were compared to acquisitions performed without overlying personal items. Image noise was evaluated by assessing the standard deviation of Hounsfield units at the level of the overlying personal item. Results Overlying personal items were visible in topogram images for 55% of CT exams and included underwires (38% of exams), zippers (7%), and cellular phones (1%). DLP increased when a cellular phone was present in the topogram whether or not it was removed before axial image acquisition (3.7% p = 0.002, combined AutomA and SmartmA), and image noise increased (144%, p = 0.002; AutomA). No increase in dose or image noise was observed with overlying zippers or underwires or when any object was visible in the topogram outside the field of view of the axial images. Conclusions Overlying personal items were observed in the majority of abdominopelvic CT scans. Large overlying radiopaque personal items resulted in increased dose and increased image noise. Removal of all overlying personal items will result in optimized dose and image quality.

Purpose To investigate the disease detection rate, diagnostic performance and interobserver agreement of fluciclovine (18F) PET-CT and multiparametric magnetic resonance imaging (mpMR) in recurrent prostate cancer. Methods Twenty-four patients with biochemical failure after non-prostatectomy definitive therapy, 16/24 of whom had undergone brachytherapy, underwent fluciclovine PET-CT and mpMR with interpretation by expert readers blinded to patient history, PSA and other imaging results. Reference standard was established via a multidisciplinary truth panel utilizing histology and clinical follow-up (22.9 ± 10.5 months) and emphasizing biochemical control. The truth panel was blinded to investigative imaging results. Diagnostic performance and interobserver agreement (kappa) for the prostate and extraprostatic regions were calculated for each of 2 readers for PET-CT (P1 and P2) and 2 different readers for mpMR (M1 and M2). Results On a whole body basis, the detection rate for fluciclovine PET-CT was 94.7% (both readers), while it ranged from 31.6–36.8% for mpMR. Kappa for fluciclovine PET-CT was 0.90 in the prostate and 1.0 in the extraprostatic regions. For mpMR, kappa was 0.25 and 0.74, respectively. In the prostate, 22/24 patients met the reference standard with 13 malignant and 9 benign results. Sensitivity, specificity and positive predictive value (PPV) were 100.0%, 11.1% and 61.9%, respectively for both PET readers. For mpMR readers, values ranged from 15.4–38.5% for sensitivity, 55.6–77.8% for specificity and 50.0–55.6% for PPV. For extraprostatic disease determination, 18/24 patients met the reference standard. Sensitivity, specificity and PPV were 87.5%, 90.0% and 87.5%, respectively, for fluciclovine PET-CT, while for mpMR, sensitivity ranged from 50 to 75%, specificity 70–80% and PPV 57–75%. Conclusion The disease detection rate for fluciclovine PET-CT in non-prostatectomy patients with biochemical failure was 94.7% versus 31.6–36.8% for mpMR. For extraprostatic disease detection, fluciclovine PET-CT had overall better diagnostic performance than mpMR. For the treated prostate, fluciclovine PET-CT had high sensitivity though low specificity for disease detection, while mpMR had higher specificity, though low sensitivity. Interobserver agreement was also higher with fluciclovine PET-CT compared with mpMR.

Many imaging studies for urinary tract emergencies are available; however, evidence has been complied to determining studies that are more useful in the acute setting. Non-contrast computed tomography is the best test for the identification of urinary tract stones, and ultrasound may be used to diagnose hydronephrosis and guide management in the emergent setting. Uncomplicated lower urinary tract infections are primarily diagnosed clinically. Imaging may be performed if the clinical situation is uncertain or if other diseases are suspected with contrast-enhanced computed tomography being the imaging test of choice. Imaging is not routinely indicated for upper urinary tract infections unless a complication is suspected; contrast-enhanced computed tomography again is the preferred imaging test to diagnose complications of an upper urinary tract infection. Ultrasound and magnetic resonance imaging are considered first-line imaging modalities for suspected renal colic or complications of urinary tract infections in patients with iodinated contrast allergies or pregnant patients (ultrasound or non-contrast MRI).