Leonardo P. Marcal

Mullerian duct anomalies: MR imaging.

Mullerian duct anomalies (MDAs) are rare, affecting approximately 1% of all women and about 3% of women with poor reproductive outcomes. These congenital anomalies usually result from one of the following categories of abnormalities of the mullerian ducts: failure of formation (no development or underdevelopment) or failure of fusion of the mullerian ducts. The American Fertility Society (AFS) classification of uterine anomalies is widely accepted and includes seven distinct categories. MR imaging has consolidated its role as the imaging modality of choice in the evaluation of MDA. MRI is capable of demonstrating the anatomy of the female genital tract remarkably well and is able to provide detailed images of the intra-uterine zonal anatomy, delineate the external fundal contour of the uterus, and comprehensively image the entire female pelvis in multiple imaging planes in a single examination. The purpose of this pictorial essay is to show the value of MRI in the diagnosis of MDA and to review the key imaging features of anomalies of formation and fusion, emphasizing the relevance of accurate diagnosis before therapeutic intervention.

Optimization of MR Imaging for Pretreatment Evaluation of Patients with Endometrial and Cervical Cancer

Endometrial and cervical cancer are the most common gynecologic malignancies in the world. Accurate staging of cervical and endometrial cancer is essential to determine the correct treatment approach. The current International Federation of Gynecology and Obstetrics (FIGO) staging system does not include modern imaging modalities. However, magnetic resonance (MR) imaging has proved to be the most accurate noninvasive modality for staging endometrial and cervical carcinomas and often helps with risk stratification and making treatment decisions. Multiparametric MR imaging is increasingly being used to evaluate the female pelvis, an approach that combines anatomic T2-weighted imaging with functional imaging (ie, dynamic contrast material-enhanced and diffusion-weighted imaging). MR imaging helps guide treatment decisions by depicting the depth of myometrial invasion and cervical stromal involvement in patients with endometrial cancer and tumor size and parametrial invasion in those with cervical cancer. However, its accuracy for local staging depends on technique and image quality, namely thin-section high-resolution multiplanar T2-weighted imaging with simple modifications, such as double oblique T2-weighting supplemented by diffusion weighting and contrast enhancement.

Analysis of free-form radiology dictations for completeness and clarity for pancreatic cancer staging

PurposeTo assess the completeness and clarity of current free-form radiology reports for pancreatic cancer staging by evaluating them against the elements of the RSNA CT oncology primary pancreas mass dictation template.MethodsThis retrospective study was approved by our Institutional Review Board (IRB). 295 free-form computed tomography (CT) reports for baseline staging of pancreatic cancer (PC) generated between August 2008 and December 2010 were evaluated by one of two radiologists with expertise in pancreatic cancer imaging. Reports which indicated that metastatic disease was present were excluded. The completeness and clarity of the reports were analyzed against the elements of the RSNA CT pancreas mass dictation template. Fisher’s exact tests were used to analyze differences by year and type of radiologist.ResultsPrimary lesion location, size, and effect on bile duct (BD) were provided in 93.9% (277/295), 69.8% (206/295), and 67.5% (199/295) of reports, respectively. Standard terms to describe vascular involvement were used in 47.5% (140/295) of reports. In 20.3% (60/295), the resectability status could not be defined based on the report alone. In 36.9% (109/295) of reports, review of CT images was necessary to understand vascular involvement. Radiologists expert in pancreatic oncology had a higher proportion of reports using standardized terminology and reports in which vascular involvement was understood without revisiting the images.ConclusionsFree-form reports were more likely to use ambiguous terminology and/or require review of the actual images for understanding resectability status. The use of a standardized reporting template may improve the usefulness of pancreatic cancer staging reports.

Multidisciplinary management strategy for incidental cystic lesions of the pancreas.

BACKGROUND At our institution, incidental pancreatic cysts are frequently identified in asymptomatic patients undergoing routine imaging for staging of nonpancreatic malignancies. Management of these patients is unclear because a small but significant number of incidental pancreatic cysts are malignant. STUDY DESIGN Our institutional database was reviewed for patients with ICD-9 codes for pancreatic cysts from 1980 to 2005. Clinicopathologic factors, including CT and endoscopic ultrasound (EUS) characteristics and management strategies, were analyzed. RESULTS Over 25 years, 942 patients were identified with pancreatic cysts. Excluding those with symptoms or pseudocysts, 350 patients remained with incidental pancreatic cysts. Mean overall survival was 41.4 months (mean follow-up 32.7 months). Forty-one patients underwent resection, of whom 38 (92.7%) had premalignant or malignant pathology. Univariate analysis of variables predicting pathologic premalignant or malignant diagnosis identified pancreatic neck or body location as significant factors. CONCLUSIONS These data suggest that most incidental pancreatic cysts can be managed nonoperatively using a selective strategy based on detailed review of CT imaging and EUS findings.

Pancreas: Peritoneal Reflections, Ligamentous Connections, and Pathways of Disease Spread

The pancreas is a retroperitoneal organ with a close anatomic relationship to the peritoneal reflections in the abdomen, including the transverse mesocolon and the small bowel mesentery, and is directly contiguous to peritoneal ligaments such as the hepatoduodenal ligament, gastrohepatic ligament, splenorenal ligament, gastrocolic ligament, and the greater omentum. Understanding of these anatomic relationships of the pancreas is aided by knowledge of its embryologic development. These reflections and ligaments are potential pathways for spread of disease processes such as pancreatitis and pancreatic carcinoma. One can recognize these ligaments and reflections by identifying the blood vessels that traverse them.

Deep pelvic endometriosis: MR imaging

ObjectiveThe purpose of the pictorial essay is to show the MR imaging (MRI) findings associated with deep pelvic endometriosis.ConclusionMRI is an excellent imaging modality for the evaluation of patients with deep pelvic endometriosis, showing high accuracy in the diagnosis and prediction of disease extent. Its multiplanar capabilities and superior soft tissue contrast are extremely useful in the detection of deeply infiltrating endometriotic implants, even in the setting of intense desmoplastic response that may result in complete obliteration of the posterior cul-de-sac and fixed retroversion of the uterus, which limits the scope of laparoscopy. The use of endovaginal and rectal contrast is helpful to better delineate the anatomy of interest and map out the extent of disease, contributing to more effective treatment planning.

Intraoperative abdominal ultrasound in oncologic imaging

Significant advances in ultrasound technology have created new opportunities for its use in oncologic imaging. The advent of new transducers with focal beam technology and higher frequency has solidified the role of intraoperative sonography (IOUS) as an invaluable imaging modality in oncologic surgery of the liver, kidneys and pancreas. The ability to detect and characterize small lesions and the precise intraoperative localization of such tumors is essential for adequate surgical planning in segmental or lobar hepatic resections, metastasectomy, nephron-sparing surgery, and partial pancreatectomy. Also, diagnostic characterization of small equivocal lesions deemed indeterminate by conventional preoperative imaging such as multidetector computed tomography or magnetic resonance imaging, has become an important application of IOUS. This article will review the current applications of IOUS in the liver, kidneys and pancreas.

Imaging features of hematogenous metastases to the pancreas: pictorial essay

Abstract This pictorial essay illustrates the imaging appearances of a wide variety of metastases to the pancreas as seen on computed tomography (CT), magnetic resonance imaging and positron emission tomography/CT. Key clinical and radiologic features (lesion distribution, non-contrast imaging appearance, enhancement pattern and pattern of spread) that may aid differentiation of primary from solitary secondary pancreatic malignancies are discussed.

Ewing Sarcoma of the Kidney: A Rare Entity

Ewing sarcoma and primitive peripheral neuroectodermal tumor (PNET) are high-grade malignant tumors typically found in children and adolescents. These tumors belong to the family of small round cell tumors and are of neuroectodermal origin. Primary Ewing sarcoma of the kidney is rare and because of that is an infrequent differential diagnosis in urologic malignancies. Renal PNET mostly presents with nonspecific symptoms such as hematuria and abdominal pain. The imaging findings are uncharacteristic. The diagnosis is based on the histology, immunohistochemistry, and molecular pathologic findings. Once PNET has been diagnosed, multimodal treatment is indicated. Despite all treatment options, the prognosis of those with metastatic disease is poor.

Sonohysterography: Principles, technique and role in diagnosis of endometrial pathology

Sonohysterography (SHG), which provides enhanced endometrial visualization during standard transvaginal ultrasonography, is a relatively safe procedure for the evaluation of endometrial pathology. It can be used to evaluate patients with abnormal vaginal bleeding or infertility. This modality offers real time imaging of the endometrium without exposure to ionizing radiation. SHG is typically used in patients for whom standard transvaginal ultrasonography does not show the endometrium well, show a potential abnormality for which further imaging is required, or in patients without endometrial pathology defined on routine transvaginal imaging but in whom there is a strong clinical suspicion of an abnormality. This article will discuss the utility of the sonohysterogram in evaluation of various endometrial pathologies. Imaging examples of these pathological entities will be illustrated as well.