Laura Buñesch

Pathways of Lymphatic Spread in Male Urogenital Pelvic Malignancies

Regional lymph node involvement in urogenital malignancies (category N in the TNM classification system) is a significant radiologic finding, with important implications for treatment and prognosis. Male urogenital pelvic cancers commonly spread to iliopelvic or retroperitoneal lymph nodes by following pathways of normal lymphatic drainage from the pelvic organs. The most likely pathway of nodal spread (superficial inguinal, pelvic, or paraaortic) depends on the tumor location in the prostate, penis, testis, or bladder and whether surgery or other therapy has disrupted normal lymphatic drainage from the tumor site; knowledge of both factors is needed for accurate disease staging. At present, lymph node status is most often assessed with standard anatomic imaging techniques such as multidetector computed tomography or magnetic resonance (MR) imaging. However, the detection of nodal disease with these techniques is reliant on lymph node size and morphologic characteristics, criteria that provide limited diagnostic specificity. Functional imaging techniques, such as diffusion-weighted MR imaging performed with or without a lymphotropic contrast agent and positron emission tomography, may allow a more accurate nodal assessment based on molecular or physiologic activity.

Renal complex cysts in adults: contrast-enhanced ultrasound

Contrast-enhanced ultrasound (CEUS) has been proved to be a useful imaging modality to characterize complex renal cysts using the Bosniak classification in a similar way as Computed Tomography (CT). CEUS helps not only in the characterization of complex cysts detected on baseline US but also in the characterization of indeterminate cystic lesions on CT or Magnetic Resonance (MR).

Does the learning curve of conservative laparoscopic surgery in women with rectovaginal endometriosis impair the recurrence rate

OBJECTIVE To assess the effect of surgeons increasing experience in conservative laparoscopic surgery of women with rectovaginal endometriosis on the surgical outcome of these patients recurrence rate. DESIGN Prospective cohort study. SETTING University teaching hospital. PATIENT(S) The first 60 consecutive patients undergoing laparoscopic conservative surgery for symptomatic rectovaginal endometriosis at our institution during a 4- year period. INTERVENTION(S) Cases were classified into two groups according to the date of the patients operation: the first 30 cases were defined as the early cases and the subsequent 30 cases as the late cases. MAIN OUTCOME MEASURE(S) Operating time, perioperative complications, and surgical outcome. Univariate and multivariate analyses for risk factors with recurrence of disease. RESULT(S) The two groups were similar in patient characteristics. There was a reduction in the rate of laparoconversion, operating time, estimated amount of blood loss, cases with incomplete removal, and recurrence rate with increasing surgeons experience. Surgical completeness was significantly associated with recurrence of disease. CONCLUSION(S) A learning curve is demonstrated in the conservative laparoscopic management of patients with rectovaginal endometriosis. After gaining experience in performing 30 cases, the recurrence rate is significantly reduced.

Multidetector CT of Living Renal Donors: Lessons Learned from Surgeons

Multidetector computed tomography (CT) is the choice technique for preoperative evaluation of living renal donors. Living donor transplantation, as opposed to cadaveric donation, is the best option for recipient and graft survival. The need for kidney transplantation has undergone exponential growth over the past 40 years, and cadaveric donations are inadequate to meet this ever-increasing demand. These factors have led to a continued increase in organ donation from living related donors. From January 2007 to October 2009, 199 potential renal donors were studied in one center with 64-row multidetector CT. Of these candidates, 94 were rejected for donation. The remaining 105 potential donors were evaluated by a multidisciplinary committee, and 101 donor-recipient couples were accepted for renal donation and transplantation. Laparoscopic nephrectomy is the preferred surgical procedure for harvesting kidneys from living donors. Radiologists are responsible for providing accurate anatomic information about the donors renal parenchyma, arteries, veins, and collecting system. Accurate reporting depends on the radiologists level of expertise, attention to detail, and commitment to careful image evaluation. Knowledge of the surgical techniques and the difficulties that surgeons face during laparoscopic nephrectomy and renal transplantation is essential for compiling accurate radiologic reports.

Diagnosis of bladder cancer: contrast-enhanced ultrasound

Contrast-enhanced ultrasound imaging represents a new approach to imaging tumoral neovascularity. This review describes the application of contrast-enhanced ultrasound in the detection, differential diagnosis, and staging of bladder cancer.

Utility of Multidetector CT in Severe Postpartum Hemorrhage

Postpartum hemorrhage is one of the leading causes of maternal mortality worldwide. According to the time when postpartum hemorrhage develops, it is classified as (a) primary, or early, postpartum hemorrhage (within the first 24 hours after delivery) or (b) secondary, or late, postpartum hemorrhage (>24 hours to 6 weeks after delivery). Primary postpartum hemorrhage may be caused by uterine atony (75%-90% of cases), trauma of the lower portion of the genital tract, uterine rupture, uterine inversion, bladder flap hematoma, retention of blood clots or placental fragments, and coagulation disorders. Secondary postpartum hemorrhage may be caused by uterine subinvolution, coagulopathies, and abnormalities of the uterine vasculature. Extrauterine sources of bleeding include rectus sheath hematoma, direct arterial injuries, and the HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome. Severe postpartum hemorrhage is a life-threatening condition that is diagnosed on the basis of the findings from clinical examination, with or without ultrasonography. Computed tomography (CT) and magnetic resonance imaging are useful in the characterization of postpartum hemorrhage when medical treatment fails. Multidetector CT has an important role when intraabdominal bleeding is suspected and can be considered in cases of recurrent bleeding after embolization, as well as for the evaluation of postsurgical complications. A proposed clinical and CT imaging algorithm for postpartum hemorrhage is presented. A multidisciplinary approach to postpartum hemorrhage is essential to optimize the role of diagnostic and interventional radiology in obstetric hemorrhage, to avoid hysterectomy and thus preserve fertility.

Evaluation of Abdominal Aortic Aneurysm after Endovascular Repair: Prospective Validation of Contrast-enhanced US with a Second-Generation US Contrast Agent

PURPOSE To prospectively assess the accuracy of contrast agent-enhanced (CE) ultrasonography (US) with a second-generation US contrast agent in the detection and classification of endoleaks after endovascular repair of abdominal aortic aneurysms (EVAR), with computed tomographic (CT) angiography as the reference standard. MATERIALS AND METHODS Institutional review board and written informed consent were obtained. Thirty-five patients who underwent EVAR were enrolled in a prospective study that consisted of CT angiography and CE US studies performed at 1- and 6-month follow-up and performed yearly thereafter. CE US was performed after bolus injection of 2.4 mL of sulfur hexafluoride by using equipment with specific software for contrast studies. Angiography was performed in patients who had type II endoleaks with an increase in aneurysm sac size and in patients with type I or III endoleaks. CE US sensitivity, specificity, positive and negative predictive values, and accuracy were determined for endoleak detection, and Cohen κ statistic was used to assess agreement of CE US and CT angiographic findings for endoleak classification. RESULTS A total of 126 CT angiographic and CE US studies were performed. CT angiography depicted 34 endoleaks in 16 patients (type IA, n=1; type IB, n=1; type II inferior mesenteric artery, n=2; type II lumbar artery, n=28; type II complex, inferior mesenteric, and lumbar arteries, n=2). CE US depicted 33 endoleaks. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of CE US in endoleak detection were 97%, 100%, 100%, 98%, and 99%, respectively. CE US enabled correct classification of 26 of 33 endoleaks. No clinically important endoleak was missed at CE US. CONCLUSION CE US yields good sensitivity, specificity, and accuracy in endoleak detection, and it might represent a noninvasive tool that can be used in the follow-up of patients who undergo EVAR.

Preoperative Assessment of Myometrial Invasion in Endometrial Cancer by 3D Ultrasound and Diffusion-Weighted Magnetic Resonance Imaging: A Comparative Study.

Objective The prognosis of endometrial cancer depends on the correct surgical staging. In early stages, 18% to 30% rate of positive lymph nodes is reported with a myometrial invasion of 50% or more. According to this, patients with International Federation of Gynecology and Obstetrics stage Ib would benefit from staging lymphadenectomy. Therefore, it is important to classify these patients preoperatively to plan the surgery. In the recent years, 3-dimensional (3D) ultrasound and diffusion-weighted magnetic resonance imaging (DW-MRI) have been incorporated in the preoperative management of these patients. The aim of this study was to assess the usefulness of 3D ultrasound and DW-MRI as predictor of myometrial invasion in endometrial cancer. Material and Methods We retrospectively compared the assessment of myometrial invasion by 3D ultrasound and DW-MRI with final pathologic evaluation on hysterectomy specimens, in 98 patients diagnosed of early-stage endometrial cancer, who underwent surgery at the Hospital Clinic of Barcelona between 2012 and 2015. Results Evaluation of the depth of myometrial invasion with 3D ultrasound had a sensitivity, specificity, and accuracy of 77%, 83% and 81%, respectively. Evaluation of the depth of myometrial invasion with DW-MRI had a sensitivity, specificity, and accuracy of 69%, 86%, and 81%, respectively. Association of both techniques improved all the values, showing a sensitivity, specificity, and accuracy of 87%, 93%, and 91%, respectively. In both 3D ultrasound and DW-MRI, the presence of leiomyomas was the first detectable cause of false negative (3% and 4%, respectively) and false-positive (3% and 1%, respectively). Conclusions We conclude that the implementation of the 2 studies in early-stage endometrial cancer provides low false-negatives and false-positives rates. In cases of patients with leiomyomas, adenomiosis, or intrauterine fluid collection, definitive evaluation of myometrial invasion could be better deferred to intraoperative biopsy in an attempt to reduce false-negatives and false-positives rates.

Usefulness of MDCT to Differentiate Between Renal Cell Carcinoma and Oncocytoma: Development of a Predictive Model

OBJECTIVE The objective of our study was to identify the most useful parameters to differentiate between renal cell carcinoma (RCC) and oncocytoma using four-phase CT. MATERIALS AND METHODS Ninety-seven patients with solid renal lesions who underwent surgery with four-phase preoperative CT evaluation and with pathologic diagnosis of RCC or oncocytoma were included in the study. Features of tumors and the enhancement pattern in the four CT phases were evaluated and analyzed. Logistic regression models were used to assess independent predictors for malignancy. RESULTS Histopathologically, 13 tumors were oncocytomas and 84 were RCCs. RCCs were larger (6.20 cm vs 3.21 cm, p = 0.0004) and more often enhanced heterogeneously (66 vs 6, p = 0.02). Lesions that were larger than 4 cm showed a significantly higher risk of malignancy (p = 0.0046). Significant differences were found in intensity of nodule enhancement between the nephrographic and the excretory phases with respect to the unenhanced phase (p = 0.003 and p = 0.0026). At multivariate analysis, parameters that were independent predictors of malignancy were enhancement pattern, with RCCs more often having heterogeneous enhancement than oncocytomas (odds ratio [OR], 0.18; 95% CI, 0.04-0.90), and nodule enhancement in the excretory phase in relation to the unenhanced phase, with RCCs showing lower enhancement (OR, 0.93; 95% CI, 0.88-0.97), and a size larger than 4 cm (OR, 4.01; 95% CI, 0.70-23.14). CONCLUSION The combination of different CT parameters including lesion size larger than 4 cm, lesion enhancement in the excretory phase in relation to the unenhanced phase, and heterogeneous enhancement pattern helps distinguish RCC from oncocytoma.

Pathways of Lymphatic Spread in Gynecologic Malignancies

Precise radiologic evaluation of regional adenopathic involvement in pelvic gynecologic tumors is fundamental to clinical practice because of its prognostic and therapeutic significance. Likewise, the identification of metastatic adenopathies at posttreatment imaging is essential for assessing response and detecting recurrence. Similar to urologic neoplasms, gynecologic neoplasms most often spread regionally to the pelvic and retroperitoneal lymph nodes, following the normal drainage pathways of the pelvic organs. Familiarity with routes of dissemination, treatment options, and means of analyzing lymph node characteristics is crucial to determine the extent of disease. Two staging systems can be used in characterizing gynecologic malignancies: the FIGO (International Federation of Gynecology and Obstetrics) system, which is the most commonly and universally used, and the TNM (tumor, node, metastasis) system, which is based on clinical and/or pathologic classification. Anatomic assessment with multidetector computed tomography (CT) and magnetic resonance (MR) imaging is still the most commonly used technique for the detection of lymph node spread, which is mainly based on morphologic criteria, the most important of which is nodal size. However, size has limited diagnostic specificity. Consequently, functional imaging techniques such as diffusion-weighted MR imaging, positron emission tomography combined with CT, lymphoscintigraphy, and sentinel lymph node mapping, which are based on molecular and physiologic activity and allow more precise evaluation, are often incorporated into diagnostic imaging protocols for staging of gynecologic malignancies.