Cary Siegel

Incidence of Ovarian Maldescent in Women With Müllerian Duct Anomalies: Evaluation by MRI

OBJECTIVE The objective of our study was to evaluate the incidence of ovarian mal-descent in patients with and in those without müllerian duct anomalies. MATERIALS AND METHODS Multiplanar MRI examinations of patients with (n = 65) and those without (n = 64) congenital uterine anomalies were evaluated for ovarian size, position, follicle count, and associated renal anomalies. Patients who were pregnant, had known prior pelvic surgery, or had large uterine leiomyomas were excluded. Two criteria were used to determine ovarian malposition: Was the upper pole of the ovary above the pelvic brim, as defined by the pubic symphysis-sacral promontory line, or was the upper pole of the ovary at or above the iliac artery bifurcation? RESULTS The müllerian duct anomalies identified in the study group included hypoplasia, unicornuate, didelphys, bicornuate, and septate uterus. Ovarian maldescent was identified in 12 of 65 women with uterine anomalies (17%) as compared with two of 64 women with normal uterine anatomy (3%) using the criterion of the ovarian pole being above the iliac bifurcation. Among the women with müllerian duct anomalies, only three of 29 with septate uterus (10%) had ovarian maldescent compared with the remaining nine of 36 women with other anomalies (25%). Ovarian size did not vary significantly between the two groups. Follicle count was increased in women with müllerian duct anomalies. Renal anomalies were present in 16 of 65 patients, five of whom had concomitant ovarian maldescent. CONCLUSION The incidence of ovarian maldescent is increased in patients with müllerian duct anomalies, with the highest association seen in those with didelphys, unicornuate, or bicornuate uterus.

Retrograde Ureteral Intussusception

A soft tissue mass causing ureteral obstruction should be considered malignant until proved otherwise. We report a case of retrograde ureteral intussusception that caused obstruction. To our knowledge, this condition has not been described in the recent literature.

Opacification of Urinary Bladder and Ureter at CT Urography: Effect of a Log-rolling Procedure and Postvoiding Residual Bladder Urine Volume

PURPOSE To retrospectively evaluate the effect of a log-rolling procedure and postvoiding residual (PVR) bladder urine volume on opacification of urinary bladder and ureters at multi-detector row computed tomographic (CT) urography. MATERIALS AND METHODS Institutional review board approval was obtained, and informed consent was waived for this retrospective HIPAA-compliant study. Triple-phase 16- or 64-detector row CT urographic images in 166 patients (88 men, 78 women; mean age, 58.9 years; range, 22-89 years) were evaluated retrospectively. Immediately prior to excretory phase scanning, 67 patients did and 99 did not undergo a log-rolling procedure on the CT table. PVR bladder urine volume was quantified as the largest cross-sectional area of the bladder measured on unenhanced images (PVR values). The degree of bladder opacification was quantified as the percentage of the total cross-sectional area of the bladder that was opacified on excretory phase images. Ureteral opacification was quantified as the percentage of ureteral length that contained enhanced urine. On the basis of PVR values, patients were stratified into four subgroups (</=2000, >2000 to </=3000, >3000 to </=4000, and >4000 mm(2)). The Wilcoxon rank sum and Student t tests were used to evaluate differences. RESULTS Median degree of bladder opacification of the log-rolling versus non-log-rolling group was 100% versus 78% for PVR values of 2000 mm(2) or less (P < .01), 99% versus 79% for PVR values of more than 2000 to 3000 mm(2) or less (P = .01), 89% versus 79% for PVR values of more than 3000 to 4000 mm(2) or less (P < .05), and 64% versus 69% for PVR values of more than 4000 mm(2) (P = .96). There was no significant difference between ureteral opacification and log rolling or between bladder and ureteral opacification (P > .05). CONCLUSION Use of a log-rolling procedure prior to excretory phase CT urography increases the percentage of bladder opacification in patients with PVR values of 4000 mm(2) or less. No difference in ureteral opacification was observed between the log-rolling and non-log-rolling groups.

Complicated Genitourinary Tract Infections and Mimics

This article provides pictorial review of complicated upper and lower genitourinary infections and their mimics. Imaging features of upper urinary tract infections including uncomplicated acute pyelonephritis, xanthogranulomatous pyelonephritis (XGPN), emphysematous pyelonephritis, perirenal abscess, and pyonephrosis are first reviewed and then followed by pictorial review of their mimics including contrast-associated nephrotoxicity, renal infarcts, malakoplakia, renal cell cancer, leukemia or lymphoma and Castlemans disease. Next, imaging features of lower urinary tract infections including cystitis, emphysematous cystitis, enterovesical, colovesical and vesicovaginal fistulas, Fournier gangrene, prostatitis, epididymitis, and orchitis are reviewed and then followed by pictorial review of their mimics including gas in the bladder and perineum related to instrumentation, radiation cystitis, bladder cancer, testicular torsion, testicular trauma, and testicular cancer and lymphoma. Recognizing imaging characteristics of complicated genitourinary infections and their mimics would allow clinicians to provide appropriate timely management.

Imaging of Cosmetic Plastic Procedures and Implants in the Body and Their Potential Complications

OBJECTIVE Cosmetic plastic surgery procedures, as well as implants, are increasingly being performed. These implants are often encountered on routine imaging examinations, and radiologists are often asked to evaluate for complications or evidence of failure. Pectoral augmentation, gluteal augmentation, body lift and abdominoplasty, and penile and testicular prostheses are reviewed in this article. CONCLUSION The typical appearance of common cosmetic implants and cosmetic techniques used in the human body is presented, along with the imaging spectrum of their potential complications.

Hereditary Renal Tumor Syndromes: Imaging Findings and Management Strategies

OBJECTIVE It is not rare for the radiologist to identify multiple renal masses and be the first to raise the possibility of a hereditary renal tumor syndrome. Characteristic renal and extrarenal imaging findings aid in making the correct diagnosis. The imaging findings, screening guidelines, and management techniques for the most common hereditary renal tumor syndromes are reviewed. CONCLUSION Hereditary renal tumor syndromes have specific screening guidelines and unique management techniques in which imaging plays a central role.

Re: Prostate Cancer: Prediction of Biochemical Failure after External-Beam Radiation Therapy—Kattan Nomogram and Endorectal MR Imaging Estimation of Tumor Volume

Purpose: To determine whether magnetic resonance (MR) imaging and MR spectroscopic imaging findings can improve predictions made with the Kattan nomogram for radiation therapy. Materials and Methods: The institutional review board approved this retrospective HIPAA-compliant study. Ninety-nine men who underwent endorectal MR and MR spectroscopy before external-beam radiation therapy for prostate cancer (January 1998 to June 2007) were included. Linear predictors were calculated with input variables from the study sample and the Kattan original coefficients. The linear predictor is a single weighted value that combines information of all predictor variables in a model, where the weight of each value is its association with the outcome. Two radiologists independently reviewed all MR images to determine extent of disease; a third independent reader resolved discrepancies. Biochemical failure was defined as a serum prostate-specific antigen level of 2 ng/mL (2 g/L) or more above nadir. Cox proportional hazard models were used to determine the probabilities of treatment failure (biochemical failure) in 5 years. One model included only the Kattan nomogram data; the other also incorporated imaging findings. The discrimination performance of all models was determined with receiver operating characteristics (ROC) curve analyses. These analyses were followed by an assessment of net risk reclassification. Results: The areas under the ROC curve for the Kattan nomogram and the model incorporating MR imaging findings were 61.1% (95% confidence interval: 58.1%, 64.0%) and 78.0% (95% confidence interval: 75.7%, 80.4%), respectively. Comparison of performance showed that the model with imaging findings performed significantly better than did the model with clinical variables alone (P .001). Overall, the addition of imaging findings led to an improvement in risk classification of about 28%, ranging from approximately a minimum of 16% to a maximum of 39%, depending on the risk change considered important. Conclusion: MR imaging data improve the prediction of biochemical failure with the Kattan nomogram after external-beam radiation therapy for prostate cancer. The number needed to image to improve the prediction of biochemical failure in one patient ranged from three to six.

Re: Molecular Imaging of Prostate Cancer

available at http://www.ncbi.nlm.nih.gov/pubmed/26587888 Editorial Comment: This article serves as a comprehensive and up-to-date review of the role molecular imaging may have in evaluating the prostate. Since the incidence of prostate cancer is high, and many of these cancers will be clinically insignificant, the hope is to use magnetic resonance imaging, specifically molecular imaging, to provide further information on tumor biology and assist in separating clinically significant from clinically insignificant prostate cancer. This article discusses indetail cholinemetabolismand the value of C-choline and F-choline positron emission tomography with and without magnetic resonance imaging correlation, F-acetate and C-acetate positron emission tomography, androgen receptor imaging including 5a-dihydrotestosterone and prostate specific membrane antigen imaging. Initial prostate evaluation, treatment response and recurrence imaging are discussed in detail. Molecular strategies for imaging the prostate are evolving. This article provides an excellent review of what is currently available and future trends in this area.

Re: Transition Zone Prostate Cancer: Detection and Localization with 3-T Multiparametric MR Imaging

available at http://jurology.com/ Editorial Comment: This is a retrospective study comparing 3 T multiparametric magnetic resonance (MR) imaging and radical prostatectomy for transitional zone prostate cancer. On T2-weighted images the transition zone is often lumpy and heterogeneous secondary to benign prostatic hyperplasia, making prostate cancers difficult to discern. A larger, more geographic area of low signal intensity, ill defined margins and lenticular shape are features suggestive of transitional zone prostate cancer. A total of 28 patients with transitional zone cancer were selected and 35 patients with a peripheral zone cancer were included as controls. Patients with prior radiation therapy or prior transurethral prostatectomy were excluded from the study. MR consisted of T2, diffusion and dynamic contrast enhancement sequences. The radiologist scored the transition zone from 1 to 5, with 1 being definite absence of transitional zone cancer and 5 being definite presence of transitional zone cancer. The authors found that the overall accuracy in detection of Gleason grade 4 to 5 transitional zone prostate cancer was 79% for T2 weighting and 72% for T2 weighting plus diffusion, apparent diffusion coefficient and dynamic contrast enhancement. For patients with lower Gleason grade (2 to 3) the accuracy for T2-weighted imaging was 66%. When diffusion, apparent diffusion coefficient and dynamic contrast enhancement were added, the accuracy was decreased to 62%. The authors conclude that multiparametric MR did not add to the accuracy for detection of transitional zone tumors. One of the reasons why dynamic contrast enhancement may not provide additional benefit is due to the heterogeneous enhancement seen in benign prostatic hyperplasia. A few take home points about this study are that 1) radiologists need to be on the lookout for tumors in the transition zone, 2) T2-weighted images are the main sequence to identify these tumors and 3) dynamic contrast enhancement might not help.

Re: Significance of Incidental Focal Uptake in Prostate on 18-Fluoro-2-Deoxyglucose Positron Emission Tomography CT Images

time. For example the percentage of men on dutasteride reaching a nadir at any time point was 13% at month 6, 30% at month 12, 68% at month 30, 81% at month 36 and 100% at month 48, which was the last measurement. If one uses the most recent nadir instead of the one at 6 months, only 22% of men with Gleason 8 to 10 tumors would be missed, similar to the number who would be missed in placebo treated men using the National Comprehensive Cancer Network Guidelines.