Atul B. Shinagare

Metastatic Pattern of Bladder Cancer: Correlation With the Characteristics of the Primary Tumor

OBJECTIVE The purpose of this study was to evaluate the metastatic pattern of muscle-invasive bladder cancer and to correlate the findings with the characteristics of the primary tumor. MATERIALS AND METHODS From a clinic population of 392 patients with muscle-invasive (pT2-4) bladder cancer seen at our institution from January 2004 through December 2009, we studied the cases of 150 consecutively registered patients with pathologically proven metastatic disease. The metastasis-free intervals and metastatic patterns of different T categories were compared by Kruskal-Wallis test and Freeman-Halton extension of Fishers exact test. Patients were divided into two histologic categories, those with transitional cell carcinoma and those with atypical histologic features. The metastasis-free interval and metastatic pattern of these two groups were compared by Mann-Whitney test and Fishers exact test. RESULTS The study group consisted of 150 patients (116 men [77%], 34 women [23%]; median age, 64 years). The transitional cell carcinoma group consisted of 94 (63%) patients and the atypical histologic features group of 56 (37%) patients. The most common metastatic sites were lymph nodes (104 patients, 69%), bone (71 patients, 47%), lung (55 patients, 37%), liver (39 patients, 26%), and peritoneum (24 patients, 16%). Patients with tumors of a more advanced T category had shorter metastasis-free intervals (p = 0.001, df = 2). There was no significant difference in the metastatic patterns of tumors in the different T categories. Patients with atypical histologic features had a shorter median metastasis-free interval (3 months; range, 0-29 months) than patients with transitional cell carcinoma (12 months; range, 0-192 months) (p = 0.0001). Patients with atypical histologic features had a significantly higher incidence of peritoneal metastasis (p < 0.0002). CONCLUSION Lymph nodes, bones, lung, liver, and peritoneum are the most common sites of metastasis from bladder cancer. Tumors in a more advanced T category and those with atypical histologic features metastasize earlier. Tumors with atypical histologic features also have a higher frequency of peritoneal metastasis.

A to Z of Desmoid Tumors

OBJECTIVE The purpose of this article is to illustrate the common locations of desmoid tumors (deep fibromatosis), complications of intra- and extraabdominal desmoids, and treatment-related changes in their imaging appearance. CONCLUSION Desmoids are locally aggressive fibrous tumors with a tendency to recur. Desmoids can be intraabdominal, in the abdominal wall, or extraabdominal. Complications, such as compression or invasion of adjacent structures, and abscess formation can occur. Treatment options include observation, local treatment (surgery, radiotherapy), or systemic therapy (conventional chemotherapy, molecular targeted agents).

Ipilimumab-Associated Colitis: CT Findings

OBJECTIVE The purpose of this article is to describe the CT findings of ipilimumab-associated colitis. MATERIALS AND METHODS In this retrospective study, 16 patients diagnosed with ipilimumab-associated colitis and available CT scans obtained at the time of symptoms were found by a search through the electronic medical record database. Two radiologists reviewed the CT images in consensus for the presence of bowel wall thickening, bowel mucosal enhancement, bowel distention, pneumatosis, pericolic fat stranding, and mesenteric vessel engorgement. Medical records were reviewed to note clinical features, management, and outcome. RESULTS The common CT findings of ipilimumab-associated colitis were mesenteric vessel engorgement (13/16 [81.3%]) followed by bowel wall thickening (12/16 [75%]) and fluid-filled colonic distention (4/16 [25%]). None of the patients had pneumatosis or halo or target signs. Two distinct CT patterns of ipilimumab-associated colitis were observed: first, the diffuse colitis pattern (n = 12), which is characterized by mesenteric vessel engorgement with mild diffuse bowel wall thickening or fluid-filled distended colon; and, second, the segmental colitis associated with diverticulosis (SCAD) pattern (n = 4), which is characterized by segmental moderate wall thickening and associated pericolic fat stranding in a segment of preexisting diverticulosis. Clinical features and management also differed according to the CT pattern. Patients with the diffuse colitis pattern presented with watery diarrhea and were treated with steroids, whereas the patients with the SCAD pattern presented with mixed watery and bloody diarrhea and cramping pain and were treated with steroids and antibiotics. CONCLUSION Two different radiologic and clinical manifestations of ipilimumab-associated colitis were observed: the diffuse colitis pattern and the SCAD pattern.

Incidence of pulmonary embolism in oncologic outpatients at a tertiary cancer center

Incidence of pulmonary embolism (PE) for different cancer types in oncology outpatients is unknown. The purposes of the current study is to determine the incidence of PE in oncology outpatients and to investigate whether the incidence for PE is higher in certain cancers.

Atypical Metastases From Prostate Cancer: 10-Year Experience at a Single Institution

OBJECTIVE The purpose of the study was to retrospectively review the frequency, sites, and patterns of atypical metastases from prostate cancer and to determine whether any correlation exists between the atypical sites and biochemical or histologic variables. MATERIALS AND METHODS All available imaging studies of 620 consecutive patients with biopsy-proven prostate carcinoma seen at our institute between 1999 and 2009 were reviewed. Eighty-two patients (mean age, 72 years; age range, 58-87 years) with atypical sites of metastases were identified. Patients were separated into groups on the basis of the presence or absence of concurrent osseous metastasis and high or low Gleason grade, and metastatic patterns were compared using the Fisher exact test. The maximum prostate-specific antigen (PSA) level for each patient was recorded and correlated with metastatic pattern using the Mann-Whitney test. RESULTS The most frequent sites of atypical metastases were the lungs and pleura (40%, 33/82), liver (37%, 30/82), supradiaphragmatic lymph nodes (34%, 28/82), and adrenal glands (15%, 12/82). Supradiaphragmatic lymphadenopathy was more common in patients with osseous metastases (45%, 25/56) than in patients without concurrent osseous involvement (12%, 3/26; p < 0.05). There was no significant correlation between the other atypical metastatic sites and osseous metastases. Abdominal visceral metastasis occurred more frequently in patients with a high Gleason grade (25/43, 58%) than in patients with a low Gleason grade (9/29, 31%; p < 0.05). There was no significant correlation between metastatic pattern and PSA level. CONCLUSION The lungs and pleura, liver, supradiaphragmatic lymph nodes, and adrenal glands are the most common extranodal metastatic sites of prostate cancer. Supradiaphragmatic lymphadenopathy was strongly associated with concurrent osseous metastases.

Pneumatosis Intestinalis and Bowel Perforation Associated With Molecular Targeted Therapy: An Emerging Problem and the Role of Radiologists in Its Management

OBJECTIVE The purpose of this article is to study the imaging features, management, and outcome of pneumatosis intestinalis and bowel perforation associated with molecular targeted therapy. MATERIALS AND METHODS In this retrospective study, 48 patients with cancer who developed pneumatosis or intestinal perforation were found by searching a radiology database. Of these patients, 24 patients (13 women and 11 men; mean age, 61 years; range, 39-83 years) receiving molecular targeted therapy without any confounding factors for pneumatosis or perforation were selected. Initial and follow-up CT scans were evaluated by two radiologists; medical records were reviewed to note clinical features, management, and outcome. RESULTS Seventeen (70.8%) patients were asymptomatic. Colorectal cancer (n = 10) and renal cell carcinoma (n = 5) were the most common malignancies; bevacizumab (n = 14) and sunitinib (n = 6) were the most common associated drugs. Imaging findings included intestinal perforation (20 sites in 18 patients), pneumatosis (n = 10), ascites (n = 8), pneumoperitoneum (n = 7), fistula formation (n = 7), and fluid collections (six collections in five patients). Fifteen (62.5%) patients were treated conservatively, seven (29.2%) underwent surgery, and two (8.3%) underwent percutaneous drainage. Molecular targeted therapy was discontinued in 22 of 24 patients; findings resolved in 19 patients, remained stable in one, and worsened in one. One patient died after surgery. In both instances where the drug was continued, the abnormality worsened. Findings recurred in three of four patients in whom the drug was restarted after initial resolution. CONCLUSION Radiologists should be aware of intestinal complications associated with molecular targeted therapy, including pneumatosis, bowel perforation, and fistula formation. Most patients can be treated conservatively after discontinuation of molecular targeted therapy. Continuing or restarting molecular targeted therapy can cause worsening or recurrent pneumatosis or perforation.

Synovial Sarcoma: Imaging Features of Common and Uncommon Primary Sites, Metastatic Patterns, and Treatment Response

OBJECTIVE The purpose of this review is to describe the imaging features, common and uncommon sites, metastatic pattern, and treatment response of synovial sarcoma. CONCLUSION Synovial sarcoma primarily occurs in young adults, most commonly in the lower extremities; presents as a large, noninfiltrative, well-circumscribed mass adjacent to joints, often with punctuate calcifications; and may exhibit a triple signal pattern on T2-weighted images. Small synovial sarcomas can mimic benign lesions. This tumor has a propensity for late local recurrence and metastasis, most commonly to lung.

Virtual unenhanced CT images acquired from dual-energy CT urography: Accuracy of attenuation values and variation with contrast material phase

AIM To determine how representative virtual unenhanced (VNE) images are of true unenhanced (TNE) images when performing computed tomography (CT) urography on a dual-energy CT (DECT) system, and whether the images are affected by the contrast material phase. MATERIALS AND METHODS In this retrospective, institutional review board-approved, Health Insurance Portability and Accountability Act (HIPAA)-compliant study, TNE were compared with VNE images derived from the nephrographic (VNEn) and excretory (VNEe) phases in 100 consecutive CT urograms. Two readers in consensus measured attenuation values of abdominal organs, fat, and renal lesions (>1 cm). Image noise was correlated with patient thickness. Detectability of renal stones was evaluated. Image quality and acceptability was assessed using a five-point scale. Expected dose saving by removing the TNE phase was calculated. RESULTS VNE attenuation values of liver, renal parenchyma, and aorta were significantly different to TNE values (p < 0.05); spleen and fat attenuation values showed no significant difference. No significant difference was found between VNEn and VNEe images. Image noise was significantly greater in TNE images (p < 0.0001) and correlated with patient thickness. VNEn and VNEe images had sensitivities of 76.6 and 65.6% for detection of stones, identifying all stones greater than 3 and 4 mm, respectively. Both VNE images received significantly lower image quality scores than TNE images (p < 0.0001); however, the majority of images were deemed acceptable. The mean theoretical dose saving by removing the TNE phase was 35%. CONCLUSION Although VNE images demonstrate high reader acceptability, accuracy of attenuation values and detection of small stones is limited. The contrast material phase, however, does not affect attenuation values. Further validation of VNE images is recommended prior to clinical implementation.

Imaging of Extraosseous Myeloma: CT, PET/CT, and MRI Features

OBJECTIVE A minority of patients with multiple myeloma have imaging findings of extraosseous involvement. Extraosseous myeloma may affect any organ and can mimic other malignancies. The objective of this article is to describe the clinical relevance of extraosseous myeloma and to present the diverse imaging findings of extraosseous myeloma. CONCLUSION The presence of radiologically detectable extraosseous myeloma is associated with a poor prognosis and thus is an important factor in the initial workup and follow-up evaluation.

Risk of recurrent venous thromboembolism and major hemorrhage in cancer-associated incidental pulmonary embolism among treated and untreated patients: a pooled analysis of 926 patients.

Essentials We performed a pooled analysis of 926 patients with cancer‐associated incidental pulmonary embolism (IPE). Vitamin K antagonists (VKA) are associated with a higher risk of major hemorrhage. Recurrence risk is comparable after subsegmental and more proximally localized IPE. Our results support low molecular weight heparins over VKA and similar management of subsegmental IPE.