Sinead H. McEvoy

Hepatocellular Carcinoma: Illustrated Guide to Systematic Radiologic Diagnosis and Staging According to Guidelines of the American Association for the Study of Liver Diseases

Hepatocellular carcinoma is a malignancy that predominantly occurs in the setting of cirrhosis. Its incidence is rising worldwide. Hepatocellular carcinoma differs from most malignancies because it is commonly diagnosed on the basis of imaging features alone, without histologic confirmation. The guidelines from the American Association for the Study of Liver Diseases (AASLD) are a leading statement for the diagnosis and staging of hepatocellular carcinoma, and they have recently been updated, incorporating several important changes. AASLD advocates the use of the Barcelona Clinic Liver Cancer (BCLC) staging system, which combines validated imaging and clinical predictors of survival to determine stage and which links staging with treatment options. Each stage of the BCLC system is outlined clearly, with emphasis on case examples. Focal liver lesions identified at ultrasonographic surveillance in patients with cirrhosis require further investigation. Lesions larger than 1 cm should be assessed with multiphasic computed tomography or magnetic resonance imaging. Use of proper equipment and protocols is essential. Lesions larger than 1 cm can be diagnosed as hepatocellular carcinoma from a single study if the characteristic dynamic perfusion pattern of arterial hyperenhancement and venous or delayed phase washout is demonstrated. If the imaging characteristics of hepatocellular carcinoma are not met, the alternate modality should be performed. Biopsy should be used if neither modality is diagnostic of hepatocellular carcinoma. Once the diagnosis has been made, the cancer should be assigned a BCLC stage, which will help determine suitable treatment options. Radiologists require a systematic approach to diagnose and stage hepatocellular carcinoma with appropriate accuracy and precision.

Cystic Fibrosis below the Diaphragm: Abdominal Findings in Adult Patients

Cystic fibrosis (CF) is the most common lethal autosomal recessive disease in the white population. Mutation of the CF transmembrane conductance regulator gene on chromosome 7 results in production of abnormally viscous mucus and secretions in the lungs of patients with CF. A similar pathologic process occurs in the gastrointestinal tract, pancreas, and hepatobiliary system. Inspissated mucus causes luminal obstruction and resultant clinical and radiologic complications associated with the disease process. Pancreatic involvement can result in exocrine and endocrine insufficiency, pancreatic atrophy, fatty replacement, or lipomatous pseudohypertrophy. Acute and chronic pancreatitis, pancreatic calcification, cysts, and cystosis also occur. Hepatic manifestations include hepatic steatosis, focal biliary and multilobular cirrhosis, and portal hypertension. Biliary complications include cholelithiasis, microgallbladder, and sclerosing cholangitis. The entire digestive tract can be involved. Distal ileal obstruction syndrome, intussusception, appendicitis, chronic constipation, colonic wall thickening, fibrosing colonopathy, pneumatosis intestinalis, gastroesophageal reflux, and peptic ulcer disease have been described. Renal manifestations include nephrolithiasis and secondary amyloidosis. The educational objectives of this review are to reveal the abdominal manifestations of CF to facilitate focused analysis of cross-sectional imaging in adult patients. Life expectancy in patients with CF continues to improve because of a combination of aggressive antibiotic treatment, improved emphasis on nutrition and physiotherapy, and development of promising new CF transmembrane conductance regulator modulators. As lung function and survival improve, extrapulmonary conditions, including hepatic and gastrointestinal malignancy, will be an increasing cause of morbidity and mortality. Awareness of the expected abdominal manifestations of CF may assist radiologists in identifying acute inflammatory or neoplastic conditions. (©)RSNA, 2015.

Value of CT angiography in anterior circulation large vessel occlusive stroke: Imaging findings, pearls, and pitfalls

Hyperacute stroke imaging is playing an increasingly important role in determining management decisions in acute stroke patients, particularly patients with large vessel occlusive stroke who may benefit from endovascular intervention. CT angiography (CTA) is an important tool in the work-up of the acute stroke patient. It reliably detects large occlusive thrombi in proximal cerebral arteries and is a quick and highly accurate method in identifying candidates for endovascular stroke treatment. In this article we review the imaging findings on CTA in acute large vessel occlusive stroke using a pictorial case based approach. We retrospectively reviewed CTA studies in 48 patients presenting with acute anterior circulation large vessel occlusive stroke who were brought for intra-arterial acute stroke intervention. We discuss and illustrate patterns of proximal intracranial arterial occlusion, collateralization to the occluded territory, as well as reviewing some important pearls, pitfalls and teaching points in CTA assessment of the acute stroke patient. Performed from the level of the aortic arch CTA also gives valuable information regarding the state of other vessels in the acute stroke patient, identifying additional significant vascular stenoses or occlusions, and as we illustrate, can demonstrate other clinically significant findings which may impact on patient management and outcome.

Ivacaftor Imaging Response in Cystic Fibrosis

A 27-year-old Irish adult with cystic fibrosis (CF; DF508/G551D genotype) was commenced on ivacaftor in January 2011. Ivacaftor addresses the underlying cause of CF in individuals with the G551D genotype by increasing chloride transport through cell surface CF transmembrane conductance regulator. Before this, he suffered two to three respiratory exacerbations per year, none requiring hospital admission. Sputum was positive for Staphylococcus aureus and Pseudomonas aeruginosa. After 2 years of treatment, the patient’s FEV1 increased from 79% predicted to 95% predicted, and he was completely free of respiratory exacerbations during this time. A previous chest computed tomography scan (CT) in 2011 showed mild diffuse bilateral upper lobe bronchiectasis (Figure 1A, arrowhead), mild diffuse airway wall thickening (straight arrows) and diffuse mucus plugging (curved arrows). A follow-up chest CT in 2013 showed stabilization of bronchiectasis (Figure 1B, arrowhead), marked improvement in airway wall thickening (straight arrows), and extensive clearing of mucus plugging (curved arrows). The stabilization of bronchiectasis and reduction in airway thickening and mucus plugging demonstrated by CT in this patient correlate with his improvement in lung function and are likely a result of chronic therapy with ivacaftor. High-resolution CT imagingmay be a useful tool to gauge response to therapy with ivacaftor for patients with CF with the G551D mutation. n

Pancreatic transection as a result of a high-pressure water jet injury

A 30-year-old man presented to our surgical department after sustaining a penetrating abdominal injury from a high-pressure water jet. The patient had been using a pressure washer to strip paint. The washer was operating at 3700 psi when it malfunctioned causing a jet of water to strike him in the left upper quadrant of the abdomen. On arrival the patient was haemodynamically stable. He had severe upper abdominal pain. On examination there was a 1 cm entry wound located over his left upper quadrant. His abdomen was tender with marked crepitus palpable. …

Which is the best current guideline for the diagnosis and management of cystic pancreatic neoplasms? An appraisal using evidence-based practice methods.

Background and aimCystic pancreatic neoplasms (CPNs) are an increasingly diagnosed entity. Their heterogeneity poses complex diagnostic and management challenges. Despite frequently encountering these entities, particularly in the context of the increased imaging of patients in modern medicine, doctors have to rely on incomplete and ambiguous published literature. The aim of this project was to review the guidelines relating to CPNs using evidence-based practice (EBP) methods.MethodsA search of both the primary and secondary literature was performed. Five sets of guidelines were identified which were then methodologically appraised by the AGREE II instrument, a validated and widely utilised tool for guideline development assessment.ResultsThe 2014 ‘Italian consensus guidelines for the diagnostic work-up and follow-up of cystic pancreatic neoplasms’ were found to be the most methodologically sound guidelines, on the basis of both the overall score and average weighted domain score.ConclusionsThe current best guidelines were identified. The Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument can be used for retrospective review of published guidelines or as a roadmap for guideline-writing groups. All guidelines found were methodologically limited. Further longitudinal/prospective studies are required to improve the level of evidence.Key Points• Cystic pancreatic neoplasms (CPNs) are an increasingly encountered entity in modern medicine.• Clinical uncertainty remains with regard to optimal diagnostic and management strategies.• The Italian consensus guidelines for cystic pancreatic neoplasms are currently the best guidelines.

Magnetic resonance enterography findings as predictors of clinical outcome following antitumor necrosis factor treatment in small bowel Crohn's disease.

Aims To determine whether specific magnetic resonance enterography (MRE) findings can predict outcome following commencement of antitumor necrosis factor (aTNF) in small bowel Crohn’s disease (CD) Patients and methods This was a single-centre retrospective study of patients with CD who commenced aTNF (infliximab or adalimumab) between 2007 and 2013. Patients who had an MRE within 6 months before commencing aTNF were included. The primary end-point was the need for CD-related surgery. The secondary end-points were time to surgery and time to treatment failure. The relationship between these end-points, clinical variables and specific MRE findings were studied. Results Four hundred and eighteen patients commenced aTNF for CD during the study period. Seventy-five patients had an MRE within 6 months before commencing aTNF (30 infliximab; 45 adalimumab). The median time from MRE to commencing aTNF was 43 days (IQR 19.5–87 days). Eighteen of 75 (24%) had surgery during a median follow-up of 16.7 months (IQR 9.0–30.1 months). Patients with small bowel stenosis (SBS) on MRE were at a significantly higher risk of requiring surgery: 12/18 (66.7%) versus 6/57 (10.5%) (P<0.001). Time to surgery was significantly shorter in patients with SBS on MRE (P<0.001). In a multivariate analysis, SBS (P<0.0001, hazard ratio 26.45, 95% confidence interval 5.45–128.49) and presence of penetrating complications (P=0.003, hazard ratio 36.53, 95% confidence interval 3.40–393.19) were associated independently with time to surgery. Conclusion SBS and penetrating complications on MRE are associated independently with a need for early surgery and treatment failure in patients commencing aTNF.

Pancreaticoduodenectomy: expected post-operative anatomy and complications

Pancreaticoduodenectomy is a complex, high-risk surgical procedure performed for tumours of the pancreatic head and other periampullary structures. The rate of perioperative mortality has decreased in the past number of years but perioperative morbidity remains high. This pictorial review illustrates expected findings in early and late post-operative periods, including mimickers of pathology. It aims to familiarize radiologists with the imaging appearances of common and unusual post-operative complications. These are classified into early non-vascular complications such as delayed gastric emptying, post-operative collections, pancreatic fistulae and bilomas; late non-vascular complications, for example, biliary strictures and hepatic abscesses; and vascular complications including haemorrhage and ischaemia. Options for minimally invasive image-guided management of vascular and non-vascular complications are discussed. Familiarity with normal anatomic findings is essential in order to distinguish expected post-operative change from surgical complications or recurrent disease. This review summarizes the normal and abnormal radiological findings following pancreaticoduodenectomy.

Chest CT abnormalities and quality of life: relationship in adult cystic fibrosis

BACKGROUND To evaluate the relationship between lung parenchymal abnormalities on chest CT and health-related quality of life in adult cystic fibrosis (CF). METHODS The chest CT scans of 101 consecutive CF adults (mean age 27.8±7.9, 64 males) were prospectively scored by two blinded radiologists in consensus using a modified Bhalla score. Health-related quality of life was assessed using the revised Quittner Cystic Fibrosis Questionnaire (CFQ-R). Multiple regressions were performed with each of the CFQ-R domains and all clinical and imaging findings to assess independent correlations. RESULTS There were 18 inpatients and 83 outpatients. For the cohort of inpatients, CT abnormalities were significantly (P<0.005 for all) associated with Respiratory Symptoms (Air Trapping), and also with Social Functioning (Consolidation) and Role Functioning (Consolidation). For outpatients, CT abnormalities were significantly (P<0.005 for all) associated with Respiratory Symptoms (Consolidation) and also with Physical Functioning (Consolidation), Vitality (Consolidation, Severity of Bronchiectasis), Eating Problems (airway wall thickening), Treatment Burden (Total CT Score), Body Image (Severity of Bronchiectasis) and Role Functioning (Tree-in-bud nodules). Consolidation was the commonest independent CT predictor for both inpatients (predictor for 2 domains) and outpatients (predictor in 3 domains). Several chest CT abnormalities excluded traditional measures such as FEV1 and BMI from the majority of CFQ-R domains. CONCLUSIONS Chest CT abnormalities are significantly associated with quality of life measures in adult CF, independent of clinical or spirometric measurements.

Pulmonary fibrosis: tissue characterization using late-enhanced MRI compared with unenhanced anatomic high-resolution CT.

PURPOSE We aimed to prospectively evaluate anatomic chest computed tomography (CT) with tissue characterization late gadolinium-enhanced magnetic resonance imaging (MRI) in the evaluation of pulmonary fibrosis (PF). METHODS Twenty patients with idiopathic pulmonary fibrosis (IPF) and twelve control patients underwent late-enhanced MRI and high-resolution CT. Tissue characterization of PF was depicted using a segmented inversion-recovery turbo low-angle shot MRI sequence. Pulmonary arterial blood pool nulling was achieved by nulling main pulmonary artery signal. Images were read in random order by a blinded reader for presence and extent of overall PF (reticulation and honeycombing) at five anatomic levels. Overall extent of IPF was estimated to the nearest 5% as well as an evaluation of the ratios of IPF made up of reticulation and honeycombing. Overall grade of severity was dependent on the extent of reticulation and honeycombing. RESULTS No control patient exhibited contrast enhancement on lung late-enhanced MRI. All IPF patients were identified with late-enhanced MRI. Mean signal intensity of the late-enhanced fibrotic lung was 31.8±10.6 vs. 10.5±1.6 for normal lung regions, P < 0.001, resulting in a percent elevation in signal intensity from PF of 204.8%±90.6 compared with the signal intensity of normal lung. The mean contrast-to-noise ratio was 22.8±10.7. Late-enhanced MRI correlated significantly with chest CT for the extent of PF (R=0.78, P = 0.001) but not for reticulation, honeycombing, or coarseness of reticulation or honeycombing. CONCLUSION Tissue characterization of IPF is possible using inversion recovery sequence thoracic MRI.