William C. Torreggiani

Preoperative Imaging in Primary Hyperparathyroidism: Literature Review and Recommendations

Primary hyperparathyroidism is the third most common endocrine disorder after diabetes mellitus and hypothyroidism, and affects an estimated 0.3% of the general population [1,2]. Approximately 90% of such patients are subsequently found to have a single parathyroid adenoma, 10% are found to have multigland hyperplasia or multiple adenomas, and the rare patient is found to have parathyroid carcinoma [3]. Surgical removal of the hyperfunctioning parathyroid tissue is the only definitive cure and is warranted in symptomatic patients or in those who develop complications, as well as in all patients under 50 years of age [4]. Traditionally, this was done by way of a bilateral neck exploration with direct visualization of all 4 glands, with preoperative imaging studies rarely required. In 1986, interventional radiologist John L. Doppman remarked that ‘‘the only localising study indicated in untreated primary hyperparathyroidism is to localise an experienced parathyroid surgeon’’ [5]. Over the last 30 years improvements in imaging techniques have enabled radiologists to identify parathyroid adenomas with greater confidence and accuracy, allowing surgeons to perform unilateral or targeted parathyroidectomies. More recently, concerns regarding higher rates of recurrent or persistent disease have prompted some surgeons to abandon unilateral parathyroidectomy and return to the traditional bilateral neck exploration [6]. Nonetheless, targeted parathyroidectomy remains the preferred operative technique for many surgeons and is associated with a shorter operative duration, a lower risk of postoperative complications and greater patient satisfaction

Imaging the Patient With Sacroiliac Pain

Sacroiliac (SI) region pain is a common clinical presentation and is often due to pathology involving the SI joints, usually of inflammatory, infective, neoplastic, or post-traumatic etiology. The SI joints have a unique anatomic layout and composition and can be imaged with a variety of techniques including conventional radiographs, computed tomography, isotope bone scintigraphy, and magnetic resonance imaging. This article reviews a range of common SI joint conditions, illustrated by multimodality imaging findings. We also discuss strategies for choosing the optimal imaging modality, pearls, and pitfalls of imaging and discuss an algorithm for approaching the patient with suspected inflammatory back pain.

Is Magnetic Resonance Imaging Comparable With Computed Tomography in the Diagnosis of Retroperitoneal Metastasis in Patients With Testicular Cancer

The aim of our study was to compare magnetic resonance imaging (MRI) with computed tomography (CT) in the diagnosis of retroperitoneal nodal disease by using evidencebased practice methodology and to determine if MRI can be used as an alternative nonionizing radiation imaging modality for surveillance. Specifically, we wanted to compare the accuracy of MRI against CT, which is the current reference standard, for the detection of enlarged retroperitoneal lymph nodes based on size criteria. By using the McMaster-Oxford ‘‘bottom up’’ approach to evidence-based practice [1], we constructed a focused answerable clinical question: Is MRI comparable with CT in the diagnosis of retroperitoneal metastasis in patients with testicular cancer?

Evaluation of Knee Pain in Athletes: A Radiologist's Perspective

Lower limb injuries account for most of all injuries suffered by athletes and the knee joint accounts for over half of these. The etiology of knee pain is multifactorial; a good history focusing on the mechanism of injury and the chronicity of pain is extremely useful in correlating with radiologic findings and establishing a clinically meaningful diagnosis. This review article will discuss several important and common causes of acute and chronic knee pain in athletes, focusing on their mechanism of injury and site of pain as well as their salient imaging findings.

Unusual cause of loin pain

A 55-year-old man presented to the emergency department with acute left-sided loin to groin pain, frank hematuria, and severe hypertension (blood pressure of 220/110 mm Hg). He was previously well except for recent hospitalization for an episode of community-acquired pneumonia, which resolved following antimicrobial therapy. Physical examination revealed bilateral pitting edema to the mid-shins, whereas laboratory data showed renal impairment, hypoalbuminemia, and hypercholesterolemia as evidenced by a serum creatinine of 150 μmol/l, albumin of 12 g/l, and total cholesterol of 8.5 mmol/l. He had measured proteinuria of 8 g/24 h. The overall clinical picture was compatible with the nephrotic syndrome. In view of the acute clinical presentation, a contrast-enhanced computed tomography (CT) scan of the abdomen was performed (Figures 1 and 2) that confirmed the diagnosis—acute renal vein thrombosis in the setting of nephrotic syndrome. Percutaneous mechanical thrombectomy and thrombolysis were considered at the initial management plan; however, given the presence of established venous collateralization on the initial CT scan, it was reasonable to opt for conservative management with anticoagulation. Subsequent renal biopsy in our patient confirmed membranous glomerulonephritis, and anti-phospholipase A2 receptor antibodies were detected. He was commenced on systemic anticoagulation, statin therapy, and an angiotensin receptor antagonist for initial conservative anti-proteinuric therapy. He required further treatment escalation with cyclophosphamide and, on his most recent follow-up, demonstrated improvement of proteinuria with preserved renal function.

Percutaneous embolization of a vulval arteriovenous malformation

[1] Bhuyar SA. Rare case of leiomyoma in Mayer-Rokitansky-Kuster-Hauser syndrome. Int J Reprod Contracept Obstet Gynecol 2014;3(2):488–90. [2] Rawat KS, Buxi TB, Yadav A, Ghuman SS, Dhawan S. Large leiomyoma in a woman with Mayer-Rokitansky-Kuster-Hauser syndrome. J Radiol Case Rep 2013;7(3): 39–46. [3] Salman S, Bozkurt M, Yumru AE, Bozyigit A, Kavsi B, Kumbaser S. Laparoscopic management of leiomyoma developing from rudimentary horn in Mayer-RokitanskyKüster-Hauser syndrome. J Androl Gynaecol 2013;1(2):2. [4] Singh S, Chakravarthy B, Chakravarthy M, Chakravarthy A. Large fibroid arising from mullerian remnant mimicking as ovarian neoplasm in a woman with MRKH syndrome. Int J Infertil Fetal Med 2012;3(1):30–2. Fig. 1. Intraoperative image showing leiomyomas arising from the rudimentary horn.

Out of Hours Emergency Computed Tomography Brain Studies: Comparison of Standard 3 Megapixel Diagnostic Workstation Monitors With the iPad 2

Purpose The purpose was to compare performance of diagnostic workstation monitors and the Apple iPad 2 (Cupertino, CA) in interpretation of emergency computed tomography (CT) brain studies. Methods Two experienced radiologists interpreted 100 random emergency CT brain studies on both on-site diagnostic workstation monitors and the iPad 2 via remote access. The radiologists were blinded to patient clinical details and to each others interpretation and the study list was randomized between interpretations on different modalities. Interobserver agreement between radiologists and intraobserver agreement between modalities was determined and Cohen kappa coefficients calculated for each. Performance with regards to urgent and nonurgent abnormalities was assessed separately. Results There was substantial intraobserver agreement of both radiologists between the modalities with overall calculated kappa values of 0.959 and 0.940 in detecting acute abnormalities and perfect agreement with regards to hemorrhage. Intraobserver agreement kappa values were 0.939 and 0.860 for nonurgent abnormalities. Interobserver agreement between the 2 radiologists for both diagnostic monitors and the iPad 2 was also substantial ranging from 0.821-0.860. Conclusions The iPad 2 is a reliable modality in the interpretation of CT brain studies in them emergency setting and for the detection of acute and chronic abnormalities, with comparable performance to standard diagnostic workstation monitors.

Evaluation of imaging-guided fine-needle percutaneous biopsy of renal masses

Sir: We read with great interest the excellent and informative article by Jaff et al. [1] on imaging-guided fineneedle percutaneous biopsy of renal masses. While we found their contribution to be well written, interesting and of practical use to many radiologists, we would like to take issue with their title definition. The title refers to ‘fine-needle percutaneous biopsy’; however, their paper describes the use of an 18-gauge automatic core biopsy system. It is our belief that ‘fine needle’ refers to a gauge smaller than 20 in size, and typically is a needle of 22 gauge. We therefore believe that the title may be misleading if read in isolation. A more accurate title would be ‘Evaluation of imaging-guided percutaneous core biopsy of renal masses’. Apart from this small issue, we congratulate the authors on an excellent paper which we thoroughly enjoyed reading.