Bijan

Unusual imaging findings in Wilson's disease

Abstract. We present unusual imaging findings in the liver of a patient with Wilsons disease . On US, the liver contours were irregular and its echogenicity was increased with multiple, small hypo- and hyperechoic nodules. Prominent perihepatic fat layer was noted to be increased in thickness. On CT and MR, multiple, small, enhancing nodules were detected in the liver in the early arterial phase after administration of intravenous contrast material. Biopsy was consistent with chronic parenchymal liver pathology with dysplastic changes but without evidence of hepatocellular carcinoma. To our knowledge, dysplastic nodules enhancing at the arterial phase and thickened perihepatic fat layer have not been previously reported in patients with Wilsons disease.

Sonographic Detection of In Utero Isolated Cerebellar Hemorrhage

Cerebellar hemorrhage is a relatively rare phenomenon in neonates, and most cases are associated with intraventricular hemorrhage (IVH). Prenatally diagnosed intracranial hemorrhage is rare, and diagnoses of cerebellar hemorrhage are even rarer. In our literature search, we discovered 3 cases of prenatal diagnosis of cerebellar hemorrhage, all accompanied by IVH. None of the neonates survived. We report a case initially observed in utero by sonography of cerebellar hemorrhage without evidence of IVH, causing ventriculomegaly in a 32-week twin fetus who was subsequently successfully treated.

Single-step transvaginal aspiration and drainage for suspected pelvic abscesses refractory to antibiotic therapy

Objective. For treatment of suspected pelvic abscesses, the use of the trocar technique avoids many of the technical challenges of the Seldinger method. The purpose of this study was to evaluate the effectiveness and safety of sonographically guided transvaginal aspiration or drainage with the trocar technique in suspected pelvic abscesses that were refractory to antibiotic treatment. Methods. We retrospectively reviewed 22 patients with suspected pelvic abscesses refractory to antibiotic therapy who underwent single‐step transvaginal pelvic aspiration or drainage between 1995 and 2000. Results. Transvaginal aspiration or drainage was successful in 19 (86%) of the 22 patients. Of the 3 patients in whom aspiration or drainage failed, all ultimately went on to have surgery despite undergoing repeated drainage procedures. Drainage catheters were placed in 15 (68%) of the 22 patients and left in place an average of 3.7 days. Aspiration alone resulted in a 100% success rate, whereas drainage with catheter placement resulted in an 80% success rate. No complications, including bleeding, bowel perforation, and death, were reported in any of the procedures. Conclusions. Transvaginal ultrasonographically guided aspiration or catheter placement with the trocar technique is a safe and effective treatment for suspected pelvic abscesses refractory to antibiotic therapy.

LI-RADS® ancillary features on CT and MRI

The Liver Imaging Reporting and Data System (LI-RADS) uses an algorithm to assign categories that reflect the probability of hepatocellular carcinoma (HCC), non-HCC malignancy, or benignity. Unlike other imaging algorithms, LI-RADS utilizes ancillary features (AFs) to refine the final category. AFs in LI-RADS v2017 are divided into those favoring malignancy in general, those favoring HCC specifically, and those favoring benignity. Additionally, LI-RADS v2017 provides new rules regarding application of AFs. The purpose of this review is to discuss ancillary features included in LI-RADS v2017, the rationale for their use, potential pitfalls encountered in their interpretation, and tips on their application.

Sonographic Duplication Artifact of the Spinal Cord in Infants and Children

Objective. To describe the features of sonographic duplication artifacts that we have occasionally seen when imaging the spinal cord of infants and children, mostly with postrepair myelomeningocele. Methods. Sonography of the spine was performed for the evaluation of neonates with suspected spinal cord abnormalities and of older children in the follow‐up of postrepair open‐spine defects. Results. Each of our patients had a single spinal cord, but the duplication artifact was seen with 2 brands of scanners and with both linear array and vector array transducers. Conclusions. The finding of duplication artifacts when imaging the spinal cord of infants and children should be recognized as such and should not be misinterpreted as representing diastematomyelia or diplomyelia.

PET/CT for Pancreatic Malignancy: Potential and Pitfalls

Pancreatic malignancy carries a poor prognosis and is the fourth leading cause of cancer-related deaths in the United States. Although conventional imaging with CT and MR remains the main imaging modality, recent times have seen an increase in the applications of PET/CT in the evaluation of pancreatic malignancy. Newer data are becoming available, highlighting the advantages, limitations, and pitfalls in PET/CT imaging of the pancreas. This article highlights the applications of PET/CT in various stages of management of pancreatic malignancy and compares these with conventional imaging with CT and MR.

Hybrid imaging for pancreatic malignancy: clinical applications, merits, limitations, and pitfalls.

Abstract The role of PET/CT in pancreatic malignancy is evolving with new scientific evidence emerging continuously. PET/CT applications in imaging the pancreas and its organ-specific merits, limitations, and potential pitfalls are still evolving. This article provides an overview of the state-of-the-art applications of PET/CT imaging in evaluating pancreatic malignancy, comparing with conventional imaging modalities, such as contrast-enhanced CT and MRI. Current PET/MRI is also reviewed, along with brief discussion on cost-benefit analysis.

Magnetic Resonance Imaging Features of Adenosis in the Breast.

Purpose Adenosis lesions of the breast, including sclerosing adenosis and adenosis tumors, are a group of benign proliferative disorders that may mimic the features of malignancy on imaging. In this study, we aim to describe the features of breast adenosis lesions with suspicious or borderline findings on dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI). Methods In our database, we identified 49 pathologically proven breast adenosis lesions for which the final assessment of the breast MRI report was classified as either category 4 (n=45) or category 5 (n=4), according to the Breast Imaging Reporting and Data System (BI-RADS) published by the American College of Radiology (ACR). The lesions had a final diagnosis of either pure adenosis (n=33, 67.3%) or mixed adenosis associated with other benign pathologies (n=16, 32.7%). Results Of the 49 adenosis lesions detected on DCE-MRI, 32 (65.3%) appeared as enhancing masses, 16 (32.7%) as nonmass enhancements, and one (2.1%) as a tiny enhancing focus. Analysis of the enhancing masses based on the ACR BI-RADS lexicon revealed that among the mass descriptors, the most common features were irregular shape in 12 (37.5%), noncircumscribed margin in 20 (62.5%), heterogeneous internal pattern in 16 (50.0%), rapid initial enhancement in 32 (100.0%), and wash-out delayed en-hancement pattern in 21 (65.6%). Of the 16 nonmass enhancing lesions, the most common descriptors included focal distribution in seven (43.8%), segmental distribution in six (37.5%), clumped internal pattern in nine (56.3%), rapid initial enhancement in 16 (100.0%), and wash-out delayed enhancement pattern in eight (50.0%). Conclusion Adenosis lesions of the breast may appear suspicious on breast MRI. Awareness of these suspi-cious-appearing features would be helpful in obviating unnecessary breast biopsies.

Fundamentals of Oncologic PET-CT Reporting.

Over the past 15 years, from the inception of hybrid imaging and introduction of PET-CT to the armamentarium of medical diagnostic departments, numerous styles of reporting have been employed. The type of reporting is mostly derived by the organizational structure of the imaging department. Institutions with separate Radiology and Nuclear Medicine departments usually generate two separate reports. The PET portion of the interpretation is made in the light of anatomical landmarks provided by the CT portion of the study. A separate CT report is also generated. In many instances, a third report is created fusing the separate PET and CT reports. The downsides to this system are the inefficiency of interpretation and the potential confusion for referring physicians when the separate PET and CT reports don’t completely match. Needless to say, CT also provides much more information than simple anatomical landmarks, many of which may be crucial to the management of the patient. The more appropriate method of interpretation is for the PET and CT portions of the examination to be interpreted by a dual trained and credentialed imager, creating a single, comprehensive report encompassing both PET and CT findings in the body of the report. In the impression of the report, both sets of findings are correlated and appropriate conclusions and recommendations are made. There are two main downsides to this “perfect” reporting system. Dual trained imagers are not that abundant in the imaging community and healthcare payers may be more likely to decrease the payment to a single reimbursement for the entire examination. The following is the authors’ recommendation of reporting a PET-CT study: 1. Patient demographics including name, last name, date of birth, medical record number, inpatient / outpatient status, study-accession number. 2. Study related data including date of service, time of service, location of service 3. Comparison: Any related comparative studies including prior PET-CT, CT, Ultrasound, MR, etc. Preferably with mention of date and technique (with contrast or without oral and/or IV contrast) 4. Indication: Common indications include initial staging, response to treatment and assessmentfor recurrence. Indications such as detection of the primary focus of cancer of unknown origin haven’t been widely used yet. 5. History: Brief relevant history, including the histological subtype of malignancy, if known, any applied treatment (surgery, radiation, chemotherapy, etc) with documentation of time and duration, and any relevant tumor markers. Recently, in California, a new regulation has created some confusion as to what can be legally written in patient’s report as part of history. Based on the new California regulation, any “tissue-histological diagnosis” or laboratory values like hepatitis titer and HIV antibody status may not be written in the radiology report to protect patient privacy in released electronic medical record, i.e. the radiology report. This regulation may not exist in other states yet! 6. Technique: a. Any specific patient preparation given to patient like the duration of NPO and if any high-protein diet was used b. Documentation of blood glucose level c. The employed CT technique including acquisition parameters and image reconstruction algorithms. d. If any IV or Oral contrast is utilized. On occasion rectal water is given. e. The PET technique, including the administered radioisotope dose, route, site and time of administration, timing of data acquisition with respect to dose administration. In many institutions the name of the individual who administered the dose is also documented on the report (for medico-legal purposes). f. Any complication or technical difficulties or limitations, including extravasation, patient motion, contamination, etc 7. Radiation dose documentation: a. California law mandates the radiation-dose reporting for every CT study. b. Radiation received from FDG may also be documented. 8. Quality of the study: A quick review of cine images may reveal any technical issues including motion, metallic objects or any other sorts of artifact. Unusual muscle activity may also affect the accuracy of your interpretation. 9. Findings: a. PET report: (Editor’s method) Cine images are initially reviewed. Then trans-axial images and coronal images are reviewed. A checklist is generated of all of the detected positive PRECIST/RECIST guidelines are used to facilitate communication with oncology colleagues. Proper measurement of SUV, SUVmax and average SUV is imperative. Also review of prior studies is needed so that the measurements are comparable. b. CT report: The CT is reviewed in detail in the same systematic way a radiologist reviews a CT-only study. All relevant and incidental abnormalities are listed. 10. Conclusion/Impression: a. The abnormal foci from PET are matched to CT abnormalities and an interpretation is rendered. Example: Although the size of the aortocaval node shows no appreciable morphological change since the prior study, the degree of its metabolic activity is decreased. This may signify favorable response to therapy. b. Several PET findings may be physiological in nature. These findings usually are not included in the impression. The main goal of the report-impression is to be concise and precise. c. Certain PET findings are not directly related to current oncologic condition of the patient but deserve medical attention, including diffuse thyroidal uptake. Therefore an appropriate recommendation should be given. d. CT findings with clinical significance should be explicitly reported in the impression with appropriate recommendations. Example: Abdominal aortic aneurysm, coronary arterial calcification, pleural and pericardial effusion, hernias, renal stones, etc. 11. Staging/Re-staging: a. Oncologic PET-CT reports may contain imaging staging of the disease. The editors prefer using TNM staging, unless requested otherwise by the referring oncologists. RECIST guideline modified for PET, so-called PERCIST, is a way to standardize the PET-CT reports and is highly encouraged by the editors. Unifying the staging guidelines of PET and CT is crucial. b. Comparison with prior studies may pose various challenges. Many of the PET-CT findings cannot be precisely correlated with other modalities including MRI and ultrasound. Vice versa, very small lesions, detected by MR and Ultrasound may be too small for PET to detect. In these contexts, the imager needs to use her/his experience and Gestalt impression to make appropriate follow-up/work-up

Erratum: Magnetic Resonance Imaging Features of Adenosis in the Breast

[This corrects the article on p. 187 in vol. 18, PMID: 26155296.].