Abdominopelvic Magnetic Resonance Research Articles

Management challenges for Gestational Trophoblastic Neoplasia in a 54 years old perimenopausal woman ; A case report.

Background: Gestational trophoblastic diseases (GTD) are pregnancy-related disorders that originate from trophoblast cells. They include benign and aggressive tumors, such as invasive moles, choriocarcinomas, placental site trophoblastic tumors, and epithelioid trophoblastic tumors. Gestational trophoblastic neoplasia (GTN) mostly occur in women of reproductive age, whereas it is extremely rare in postmenopausal women. Case presentation: A 54-year-old woman presented with prolonged bleeding, abdominal fullness, and pelvic mass with a history of a missed abortion two months prior to the onset of the symptoms and was medically managed. Her general and systemic examination findings were unremarkable. On abdominal examination, the uterus was 14 weeks in size. On speculum examination, the cervix and vagina were normal. On bimanual examination, the uterus was 14 weeks, mobile, and the adnexa were normal. Investigations included serum beta-human chorionic gonadotropin (hCG), abdominopelvic magnetic resonance imaging, and chest computed tomography. Her initial hCG was 179,000 mIu/ml with a bulky uterus and endometrial mass of approximately 6 cm and multiple bilateral chest metastatic nodules. The patient was scored as stage III:10 and started on etoposide, methotrexate, actinomycin alternating with cyclophosphamide, and vincristine (EMACO). She received 11 cycles of EMACO. Her management included repeated transfusions, granulocyte-stimulating factors administration, and ICU admission. Discussion: Gestational trophoblastic neoplasia accounts for rare gynecological malignancies in postmenopausal women. The risk of GTD progressing to GTN is 5% in younger women and five-fold higher (27%) after 45 years. Conclusion: GTN is a rare gynecological malignancy in postmenopausal women. The presentation mimics other gynecological malignancies. Hence, a high index of suspicion is required. Histopathological confirmation is mostly unavailable. It carries a poor prognosis compared with younger women with a high incidence of metastatic, recurrent, and low tolerance to standard multi-agent chemotherapeutic drugs.

Management of an Uncommun Giant Ovarian Hydatid Cyst

We report the case of a 52-year-old patient. She was overweight and thought at first she was gaining weight. She presented to our department with a gradually increasing huge abdomen after 11 months of clinical evolution. She was not febrile and had normal vital signs on general assessment. No icterus or edema was present. On examination of the abdomen, there was widespread distension and a dull tone on percussion. The liver and spleen could not be felt. A large abdominal echogenic tumor filled the whole abdomen and pelvic cavity, according to the CT scan (Figure 1). Despite their rarity, peritoneal cystic mesothelioma and abdominal cystic lymphangioma should be suspected in the presence of such a pelvic mass. The huge cyst was confirmed on an abdomino-pelvic Magnetic Resonance Imaging (MRI) and measured 65 x 52 cm, supero-laterally displacing the liver and spleen. The kidneys were located in the back, and the bowel loops were located in the front. The ovaries were not visible. There was fluid in the peritoneal cavity (Figures 2 and 3). Tumor markers (CEA, a-fetoprotein and CA-125) were within normal limits. The hydatid cyst serology was positive.

Abdominopelvic MR to CT registration using a synthetic CT intermediate.

Accurate coregistration of computed tomography (CT) and magnetic resonance (MR) imaging can provide clinically relevant and complementary information and can serve to facilitate multiple clinical tasks including surgical and radiation treatment planning, and generating a virtual Positron Emission Tomography (PET)/MR for the sites that do not have a PET/MR system available. Despite the long‐standing interest in multimodality co‐registration, a robust, routine clinical solution remains an unmet need. Part of the challenge may be the use of mutual information (MI) maximization and local phase difference (LPD) as similarity metrics, which have limited robustness, efficiency, and are difficult to optimize. Accordingly, we propose registering MR to CT by mapping the MR to a synthetic CT intermediate (sCT) and further using it in a sCT‐CT deformable image registration (DIR) that minimizes the sum of squared differences. The resultant deformation field of a sCT‐CT DIR is applied to the MRI to register it with the CT. Twenty‐five sets of abdominopelvic imaging data are used for evaluation. The proposed method is compared to standard MI‐ and LPD‐based methods, and the multimodality DIR provided by a state of the art, commercially available FDA‐cleared clinical software package. The results are compared using global similarity metrics, Modified Hausdorff Distance, and Dice Similarity Index on six structures. Further, four physicians visually assessed and scored registered images for their registration accuracy. As evident from both quantitative and qualitative evaluation, the proposed method achieved registration accuracy superior to LPD‐ and MI‐based methods and can refine the results of the commercial package DIR when using its results as a starting point. Supported by these, this manuscript concludes the proposed registration method is more robust, accurate, and efficient than the MI‐ and LPD‐based methods.

Giant hepatic adenoma managed with anatomical right hepatectomy: A case report

We report the case of a 38-year-old Nigerian female who presented with right hypochondrial pain. She had previously used oral contraceptive pills for about a year. Physical examination revealed tender hepatomegaly. Her liver function tests were within normal limit as well as alfa-feto protein. Abdominopelvic magnetic resonance imaging showed hepatomegaly with a lobulated mass occupying segments VII and VIII of the liver. She underwent right hepatectomy, and she recovered well post operatively. She is currently being followed up.

ASOCIACION DE LA CLASIFICACION LI-RADS 2018 CON LOS HALLAZGOS HISTOPATOLOGICOS DE CARCINOMA HEPATOCELULAR, EN EL CENTRO MEDICO NAVAL, PERIODO: ENERO 2016 - DICIEMBRE 2020

The LI-RADS Classification is an interpretation and reporting system to classify focal alterations of the liver with the risk of developing Hepatocellular Carcinoma, using a series of major criteria in Computed Tomography and Magnetic Resonance These findings can be classified into 5 categories.The objective of this thesis is to identify if there is an association between the LI-RADS 2018 classification and the histopathological results of patients with Hepatocellular Carcinoma from the Naval Medical Center. Materials And Methods:An observational, descriptive, cross-sectional, retrospective study was carried out from January 2016 to December 2020. In this study, 35 patients with a diagnosis of Hepatocellular Carcinoma were analyzed, who underwent Computed Tomography or Abdomino-pelvic Magnetic Resonance , to associate said pathology with imaging findings, complying with the most characteristic major criteria that allow staging in the LI-RADS 2018 System. Results:Of the 35 patients, 57% were women (n = 20), 43% were men (n = 15). Of the total number of patients, 80% were Beneficiaries and the method of obtaining the sample for all patients was closed biopsy with a percutaneous needle. The distribution of the 2018 LI-RADS scale in all patients with liver biopsy was: LI-RADS 1 n = 8 (22.8%), LI-RADS 2 n = 5 (14.2%), LI-RADS 3 n = 12 (34.2%), LI-RADS 4 n = 3 (8.5%), LI-RADS 5 n = 7 (20%). It was found that the LI-RADS 5 category obtained a value of p = 0.001, with a specificity of 100%, a sensitivity of 70%, a PPV of 100% and a NPV of 89%, with an incidence of 20%. Conclusions:This study shows, through the results obtained, that there is a positive association between the LI-RADS 2018 classification of the ACR and the histopathological findings of Hepatocellular Carcinoma.

The Effect of Contrast Enhanced Abdominopelvic Magnetic Resonance Imaging on Expression and Methylation Level of ATM and AKT Genes.

ObjectiveTo evaluate the effect of contrast enhanced abdominopelvic magnetic resonance imaging (MRI), using a 3 Tesla scanner, on expression and methylation level of ATM and AKT genes in human peripheral blood lymphocytes.Materials and Methods In this prospective in vivo study, blood samples were obtained from 20 volunteer patients with mean age of 43 ± 8 years (range 32-68 years) before contrast enhanced MRI, 2 hours and 24 hours after contrast enhanced abdominopelvic 3 Tesla MRI. After separation of mononuclear cells from peripheral blood, using Ficoll-Hypaque, we analyzed gene expression changes of ATM and AKT genes 2 hours and 24 hours after MRI using quantitative reverse transcription polymerase chain reaction (qRT-PCR). We also evaluated methylation percentage of the above mentioned genes in before, 2 hours and 24 hours after MRI, using MethySYBR method. ResultsFold change analysis, in comparison with the baseline, respectively showed 1.1 ± 0.7 and 0.8 ± 0.5 mean of gene expressions in 2 and 24 hours after MRI for ATM, while the results were 1.4 ± 0.6 and 1.4 ± 1 for AKT (P>0.05). Methylation of the ATM gene promoter were 8.8 ± 1.5%, 9 ± 0.6% and 9 ± 0.8% in before contrast enhanced MRI, 2 and 24 hours after contrast enhanced MRI, respectively (P>0.05). Methylation of AKT gene promoter in before contrast enhanced MRI, 2 hours and 24 hours after contrast enhanced MRI was 5.4 ± 2.5, 5 ± 3.2, 4.9 ± 2.9 respectively (P>0.05).ConclusionContrast enhanced abdominopelvic MRI using 3 Tesla scanner apparently has no negative effect on the expression and promoter methylation level of ATM and AKT genes involved in the repair pathways of genome.

Performance of overnight on-call radiology residents in interpreting unenhanced abdominopelvic magnetic resonance imaging studies performed for pediatric right lower quadrant abdominal pain

BackgroundAbdominopelvic magnetic resonance imaging (MRI) is increasingly being used to evaluate children with abdominal pain suspected of having acute appendicitis. At our institution, these examinations are preliminarily interpreted by radiology residents, especially when performed after hours.ObjectiveTo determine the accuracy of preliminary reports rendered by radiology residents in this setting.Materials and methodsThree hundred seventy-seven pediatric abdominopelvic MRI examinations were included. The preliminary (resident) and final (attending) radiology reports were coded as diagnosing acute appendicitis or no acute appendicitis. The concordance between resident and attending radiologist interpretations was calculated. Additionally, both resident and attending reports were compared to available surgical pathology or clinical follow-up data.ResultsOverall concordance rate for the diagnosis of acute appendicitis was 97.1%. Concordance for verified cases of acute appendicitis was 93.4%. Concordance rates did not differ by residents’ postgraduate year levels. When compared against surgical pathology or clinical follow-up data, residents demonstrated 91.2% sensitivity and 97.6% specificity. There was no statistically significant difference in the sensitivity or specificity of resident or attending radiologist interpretations.ConclusionRadiology residents demonstrate high concordance with attending pediatric radiologists in their interpretations of pediatric abdominopelvic MRI for acute appendicitis. The diagnostic performances of residents and attendings were comparable.

Ovarian Gynandroblastoma with a Juvenile Granulosa Cell Tumor Component in a Postmenopausal Woman.

Ovarian gynandroblastoma (GAB) is an extremely rare sex cord-stromal tumor showing morphological evidence of both female (granulosa cell tumor) and male (Sertoli–Leydig cell tumor (SLCT)) components. Almost all GAB cases have been reported in children, adolescents, or women of reproductive age, and most of them typically have adult granulosa cell tumors as the female component. In contrast, GAB with a juvenile granulosa cell tumor (JGCT) component is a very rare condition; to the best of our knowledge, only one case of GAB with JGCT in a postmenopausal woman has been reported. In this report, we present an extremely rare case of ovarian GAB with JGCT in an elderly patient. A 65-year-old woman presented with an abdominal mass. Abdominopelvic magnetic resonance imaging revealed a large multiseptated cystic mass measuring 20 cm. No peritoneal seeding, lymph node enlargement, or hematogenous metastasis was identified. Laboratory test showed a slight elevation of serum CA 125 level (37.1 U/mL). Based on the preoperative clinical impression of ovarian cancer, she underwent a total hysterectomy with bilateral salpingo-oophorectomy. Grossly, the ovarian mass had a smooth and glistening surface without excrescences. The cut sections showed yellow-to-tan solid areas with foci of necrosis, myxoid degeneration, and hemorrhage, as well as multilocular cystic cavities filled with serosanguinous fluid. Histologically, the female component was characterized by JGCT displaying nodular growth patterns with follicle-like structures of various shapes and sizes. Most of the microcysts contained eosinophilic or basophilic secretions. The JGCT cells had indistinct cell borders, an abundant eosinophilic cytoplasm, and round-to-oval hyperchromatic nuclei with many mitotic figures. The SLCT component consisted predominantly of intermediately differentiated Sertoli cells forming lobulated solid nodules. They were arranged in cords, solid tubules, or nests, and possessed oval-to-spindle-shaped darkly stained nuclei and scant cytoplasm. In several foci, well-formed Sertoli cell tubules were loosely aggregated within areas of moderately differentiated SLCT. In summary, we described GAB in a postmenopausal woman with JGCT and SLCT as the female and male components, respectively. This is the second case of GAB with JGCT occurring in an elderly patient. Our findings can help pathologists and clinicians make accurate histological diagnoses of GAB with a JGCT component and plan an adequate treatment strategy for this rare tumor.

The genotoxic effects of contrast enhanced abdominopelvic 3-tesla magnetic resonance imaging on human circulating leucocytes

PurposeTo evaluate the effects of contrast enhanced abdominopelvic magnetic resonance imaging (MRI) on DNA damage. MethodsFor this study, blood samples of 20 volunteers (15 women and 5 men) with mean age of 43 ± 8 years were assessed. The mean age of women was 41.4 ± 8.9 years and mean age of men was 48.5 ± 4.9 years (P = 0.14). Peripheral blood samples were collected before, 2 and 24 h after MRI in heparin and ethylenediaminetetraacetic acid (EDTA) containing tubes. Heparinized blood was cultured to assess the cytogenetic effects using cytokinesis blocked micronucleus (CBMN) assay. After isolation of mononuclear cells, alterations in genes involved in repair (CHEK2, p21) and apoptosis (BAX, BCL2) were analyzed using real-time polymerase chain reaction (qRT-PCR). ResultsThe mean number of MN in binucleated cells at before, 2 and 24 h after MRI were 17.9 ± 2.9, 18.1 ± 2.4 and 18.3 ± 2.6, respectively (p > 0.05). Results of gene expression according to fold change compared with the baseline were 1.2 ± 0.6 and 1.02 ± 0.5 at 2 and 24 h after MRI for CHEK2, and 1.3 ± 0.7 and 1.7 ± 0.7 for CDKN1A (p21); respectively (p > 0.05). Gene expression based on fold change compared with baseline were 0.9 ± 0.6 and 1.2 ± 0.8 at 2 and 24 h after MRI for BAX, and 1.05 ± 0.3 and 1.1 ± 0.7 for BCL2; respectively (p > 0.05). ConclusionContrast enhanced abdominopelvic MRI showed no adverse effect on DNA in terms of MN formation and alterations in expression levels of some genes involved in repair and apoptosis pathways.

Diagnostic accuracy of magnetic resonance imaging in assessing placental adhesion disorder in patients with placenta previa: Correlation with histological findings

ObjectiveTo evaluate MRI accuracy in assessing placental adhesion disorders (PAD) in patients with placenta previa correlating imaging results with histological findings. Materials and methodsSixty-one patients who underwent abdomino-pelvic magnetic resonance imaging (MRI) for ultrasound suspicion of PAD were prospectively evaluated. T1- and T2-weighted images, with and without fat suppression, were obtained in the three conventional planes using a 1.5 T MRI scanner. MRI accuracy to evaluate the presence of PAD was assessed on the basis of the occurrence of the following abnormal MRI signs: 1) intraplacental dark bands; 2) focal interruption of myometrial border; 3) intraplacental abnormal vascularity; 4) uterine bulging; 5) tenting of the bladder and/or 6) direct visualization of adjacent tissues invasion only in case of percretism. Imaging results were classified as suggestive or not of PAD using histological data as standard of reference; two methods of imaging analysis were used represented by the presence of at least one (Method A) or two (Method B) abnormal MRI signs; the correlation between the presence of each abnormal MRI sign of PAD and the corresponding histological finding was also assessed. ResultsThe accuracy, as the area under the receiver operating characteristic curve, was significantly (p = 0.001) higher for Method B (0.92, C.I. 95%: 0.82–0.97) compared to Method A (0.764, C.I. 95%: 0.64–0.86). Among the abnormal MRI signs, intraplacental dark bands and focal interruption of myometrial border were those highly correlated with histological proof of PAD (ρ > 0.71, p < 0.001, for both); as result, a modified version of Method B (Method C) was identified considering as criterion for PAD the combined presence of the two abnormal MRI signs highly correlated with histologically proven PAD; however, the accuracy of Method C was significantly (p = 0.005) lower (0.80, C.I. 95%: 0.67–0.89) than Method B and comparable to Method A. ConclusionsMRI is a useful imaging technique to assess PAD in patients with placenta previa; in particular, the presence of at least two among all the abnormal MRI signs represents the most accurate criterion (Method B) to identify PAD. Although intraplacental dark bands and focal interruption of myometrial border showed the highest correlation with histological proof of PAD as well as this association was the most frequent in PAD, the combination of these latter MRI signs along with other abnormal signs should be considered diagnostic for PAD.

Clinical analysis of 180 cases of primary small intestinal tumor

Objective To improve the knowledge and early diagnostic rate of primary small intestinal tumor. Methods From August 2012 to August 2017, hospitalized patients with pathological diagnosis of primary small intestinal tumor (excluding duodenal neoplasm) from Peking Union Medical College Hospital were retrospectively enrolled. The data of clinical manifestations, laboratory examinations, imaging, endoscopy examination, pathological findings and treatment were collected and analyzed. Results A total of 180 patients with primary small intestinal tumor were enrolled. The common clinical manifestations included abdominal pain (76 cases, 42.2%), gastrointestinal bleeding (64 cases, 35.6%), and abdominal distension (30 cases, 16.7%), and 22 (12.2%) patients had no overt clinical symptoms. The sensitivity of carbohydrate antigen 19-9 (CA19-9) in the diagnosis of small bowel adenocarcinoma was 57.1% (12/21). The diagnostic rates of computed tomography enterodysis (CTE), positron-emission computed tomography (PET)/computed tomography (CT), and abdominopelvic enhanced CT were 96.5% (83/86), 100.0% (29/29), and 91.5% (43/47), respectively. The diagnostic small intestinal tumor patients of barium radiography (14 cases), abdominopelvic magnetic resonance imaging (MRI) (eight cases), small bowel endoscopy (18 cases) and capsule endoscopy (eight cases) were seven, six, fifteen and six cases, respectively. Among 180 patients, 14 (7.8%) patients were considered gynecological tumors by imaging examination before surgery, seven (3.9%) patients underwent emergency operation because of intestinal obstruction, four (2.2%) patients underwent emergency surgery due to gastrointestinal bleeding, and four (2.2%) patients underwent emergency surgery because of intestinal perforation. Histopathological type included gastrointestinal stromal tumor (117 cases, 65.0%), lymphoma (25 cases, 13.9%) and adenocarcinomas (21 cases, 11.7%). Except seven patients with intestinal lymphoma who received chemotherapy, the rest 173 patients underwent surgical resection. Conclusions Primary small bowel tumor has no specific clinical manifestations. It should be alert on patients without positive findings by regular gastroendoscopy and colonendoscopy examination but with symptoms of abdominal pain, gastrointestinal bleeding and intestinal obstruction. CTE should be the first choice for patients with symptoms but unclear diagnosis. Key words: Gastrointestinal stromal tumors; Adenocarcinoma; Lymphoma; Small bowel tumor; Computed tomography enteroclysis; Tumor markers

Abdominopelvic 1.5-T and 3.0-T MR Imaging in Healthy Volunteers: Relationship to Formation of DNA Double-Strand Breaks.

Purpose To investigate the relationship between abdominopelvic magnetic resonance (MR) imaging and formation of DNA double-strand breaks (DSBs) in peripheral blood lymphocytes among a cohort of healthy volunteers. Materials and Methods Blood samples were obtained from 40 healthy volunteers (23 women and 17 men; mean age, 27.2 years [range, 21-37 years]) directly before and 5 and 30 minutes after abdominopelvic MR imaging performed at 1.5 T (n = 20) or 3.0 T (n = 20). The number of DNA DSBs in isolated blood lymphocytes was quantified after indirect immunofluorescent staining of a generally accepted DSB marker, γ-H2AX, by means of high-throughput automated microscopy. As a positive control of DSB induction, blood lymphocytes from six volunteers were irradiated in vitro with x-rays at a dose of 1 Gy (70-90 keV). Statistical analysis was performed by using a Friedman test. Results No significant alteration in the frequency of DNA DSB induction was observed after MR imaging (before imaging: 0.22 foci per cell, interquartile range [IQR] = 0.54 foci per cell; 5 minutes after MR imaging: 0.08 foci per cell, IQR = 0.39 foci per cell; 30 minutes after MR imaging: 0.09 foci per cell, IQR = 0.63 foci per cell; P = .057). In vitro radiation of lymphocytes with 1 Gy led to a significant increase in DSBs (0.22 vs 3.43 foci per cell; P = .0312). The frequency of DSBs did not differ between imaging at 1.5 T and at 3.0 T (5 minutes after MR imaging: 0.23 vs 0.06 foci per cell, respectively [P = .57]; 30 minutes after MR imaging: 0.12 vs 0.08 foci per cell [P = .76]). Conclusion Abdominopelvic MR imaging performed at 1.5 T or 3.0 T does not affect the formation of DNA DSBs in peripheral blood lymphocytes.

A rare presentation of pheochromocytoma in pregnancy: a case report

BackgroundEarly diagnosis of pheochromocytoma and its proper management can lessen its mortality and morbidity. This case report describes a 24-year-old pregnant woman with an unusual presentation of pheochromocytoma.Case presentationAn Iranian 24-year-old primigravid woman from Kordistan province was referred to our center with left flank pain at 37 weeks of gestation. She had a history of gestational diabetes mellitus since the 12th week of gestation which was managed by insulin administration. She also had a history of pulsatile bi-temporal headache for 2 years prior to her referral to us. She underwent complete abdominal and pelvic ultrasound imaging for her flank pain. This examination revealed a heterogeneous mass of 119 × 87 × 79 mm above her left kidney, highly suspicious of being an adrenal-originating tumor. Subsequently, we consulted an endocrinologist. She underwent abdominopelvic magnetic resonance imaging and her 24-hour urine metanephrine, normetanephrine, and vanillylmandelic acid were assessed. Finally, the diagnosis of pheochromocytoma was confirmed. She underwent a cesarean section and adrenal mass excision at the 40th week of gestation. This timely diagnosis resulted in her proper management and good maternal and neonatal treatment outcomes.ConclusionsOur patient had pheochromocytoma during pregnancy. She had no complaints about hypertension before or during pregnancy until giving birth to her child; her only symptoms were a vague left flank pain, gestational diabetes, and headaches for the past 2 years. The unusual symptom of flank pain led to timely diagnosis and a good treatment outcome.

Cavernous hemangioma of the bladder in a child of 6 years and 11 months

We analyze a clinical case of the patient at the age of 6 years and 11 months with a cavernous hemangioma of the bladder. The disease manifested with isolated macrohaematuria. During the diagnostic assessment by 3D-ultrasound examination of the urinary tract with tight bladder filling, a mass with tuberous shape and echonegative areas inside was visualized on the left bladder wall close to its anterior surface, while external bladder contours were unchanged. Color Doppler mapping showed some vessels in the projection of the mass sprouting from the muscular layer of the bladder. The neoplasm was confirmed by abdominopelvic magnetic resonance imaging (with and without contrast enhancement) and by cystoscopy. Taking into account familial cancer history of the patient (oncological disorders in the maternal and paternal lines) and high degree of vascularization of the mass, a malignancy (rhabdomyosarcoma) was deemed highly probable. At 2 months after the disease manifestation, transurethral endoscopic surgery was performed with coagulation and a resection of an exophytic mass of 1 cm in diameter, with a wide base, irregular tuberous shape, brown colored, with a cystic component. The mucous layer on the lateral bladder wall was abnormal with some hemorrhages. Histological examination of the tissue sample showed a  cavernous hemangioma, that was the final diagnosis in this patient. During subsequent 2-year follow up, there was no recurrence of the disease. The described case is of clinical interest because bladder hemangiomas are rare in children; therefore, this disease should be on the list for differential diagnosis in children with macrohaematuria.

Pure Primary Ovarian Squamous Cell Carcinoma Perforating the Rectum

Rectal perforation is uncommon in ovarian cancer, even in advanced stages. Pure primary ovarian squamous cell carcinoma is a very rare subtype of ovarian cancer and has not been reported to cause rectal perforation. A 50-year-old woman presented with rectal bleeding. Rectosigmoidoscopy suggested perforation of a pelvic tumor into the rectum. Abdominopelvic magnetic resonance imaging revealed a 9 cm heterogeneous mass in the pouch of Douglas. We performed complete cytoreduction, including an en-bloc resection of the tumor and rectosigmoid colon. Histopathology showed squamous cell carcinoma of the left ovary penetrating the rectal wall. A common symptom of rectal bleeding was caused by a very rare entity of ovarian cancer penetrating the rectal wall, but thorough evaluation led to its accurate diagnosis and appropriate treatment.

Prospective Comparison of MR Imaging and US for the Diagnosis of Pediatric Appendicitis

To prospectively compare nonenhanced magnetic resonance (MR) imaging and ultrasonography (US) for the diagnosis of pediatric appendicitis. This HIPAA-compliant study was approved by the institutional review board, and written informed consent was obtained from the patient's parent or guardian. Eighty-one patients (34 male, 47 female; mean age, 12.3 years ± 3.5 [standard deviation]; range, 4-17 years) were enrolled in this prospective study. All patients underwent right lower quadrant US and nonenhanced, nonsedated abdominopelvic MR imaging examinations. Two pediatric radiologists blinded to US results independently reviewed the MR images. MR imaging and US findings were designated positive, negative, or equivocal for acute appendicitis. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated for MR imaging and US and compared by using two-sided McNemar test or the score statistics specified by Leisenring. Kappa statistics were generated to determine intertechnique agreement between MR imaging and US and interobserver agreement between the two primary MR imaging readers. Thirty (37%) patients had pathologically proved acute appendicitis. When equivocal interpretations were designated positive, sensitivity was 93.3% for MR imaging (95% confidence interval [CI]: 77.9%, 99.2%) and 90.0% for US (95% CI: 73.5%, 97.9%), P > .99; specificity was 98% for MR imaging (95% CI: 89.6%, 100%) and 86.3% for US (95% CI:73.7%, 94.3%), P = .03; PPV was 96.5% for MR imaging (95% CI: 82.2%, 99.9%) and 79.4% for US (95% CI: 62.1%, 91.3%), P = .007; and NPV was 96.2% for MR imaging (95% CI: 86.8%, 99.5%) and 93.6% for US (95% CI: 82.4%, 98.7%), P = .45, with substantial intertechnique (κ = 0.77; 95% CI: 0.63, 0.90) and interobserver (κ = 0.76; 95% CI: 0.61, 0.91) agreement. When equivocal interpretations were designated negative, MR imaging sensitivity, specificity, PPV, and NPV were unchanged. For US, sensitivity was 86.7% (95% CI: 69.3%, 96.2%), P = .5; specificity was 100% (95% CI: 93.0%, 100%), P > .99; PPV was 100% (95% CI: 86.8%, 100%), P = .31; and NPV was 92.7% (95% CI: 82.4%, 98.0%), P = .16, with almost perfect intertechnique (κ = 0.92; 95% CI: 0.83, 1.00) and substantial interobserver (κ = 0.72; 95% CI: 0.58, 0.87) agreement. Nonenhanced MR imaging demonstrates high diagnostic performance similar to that of US for suspected pediatric appendicitis.

Seizures as a Presentation of a Pelvic Neuroblastoma in a 5-Month-Old Infant

Epilepsy is a very uncommon first manifestation of a neuroblastoma. A 5-month-old healthy infant presented with acute onset seizures and developmental regression. Extensive investigation was remarkable for urinary vanillylmandelic acid and homovanillic acid peaks. Abdominopelvic magnetic resonance imaging (MRI) disclosed a presacral unresectable pelvic neuroblastoma. Chemotherapy and monthly dexamethasone pulses were administrated. Seizures stopped 3 days after the first pulse of dexamethasone. At 3-year follow-up, the patient is asymptomatic and has normal neurologic and developmental examinations. This case illustrates an impressive clinical and electroencephalographic (EEG) improvement on corticosteroid therapy, raising several hypotheses, including the possibility of a nonclassic paraneoplastic neurologic syndrome.

Small fallopian tube carcinoma with extensive upper abdominal dissemination: a case report

IntroductionFallopian tube carcinoma is a rare gynecological malignancy with low accuracy detection preoperatively. The symptoms are unspecific and imaging can be misleading. Since it was first described in 1847, there have been only a little over 2000 case reports.Case presentationThis case report describes a 66-year-old Caucasian woman who presented with progressive diffuse abdominal pain, without other symptoms. After abdominopelvic magnetic resonance imaging, she was sent to the Portuguese Oncology Institute of Oporto with the suspicion of peritoneal carcinomatosis of unknown primary tumor. Due to a pelvic palpable mass (calcified giant uterine fibroid) she was directed to the Gynecology team. Surgery was performed and a large mass in her upper abdomen was identified. The extemporary examination revealed a high-grade adenocarcinoma. During surgery a small change of color and consistency of her left fallopian tube was noted and unilateral adnexectomy was performed. After pathologic and immunohistochemistry tests, the diagnosis of fallopian tube carcinoma with peritoneal dissemination was made.ConclusionsThis case is very unique in the way that a small primary fallopian tube carcinoma was able to disseminate to the upper abdominal quadrant with little pelvic dissemination. The symptoms and imaging were unspecific. Although a rare occurrence, we should not forget fallopian tube carcinoma in the differential diagnosis of peritoneal carcinomatosis, even in the absence of Latzke’s triad.

Uterine Preservation and Vaginal Reconstruction in a Patient with Congenital Vaginal Agenesis Presenting With Cyclic Menouria

Herein we report the case of a patient with primary amenorrhea and cyclic menouria. The patient was a 20-year-old woman with primary amenorrhea and inability to achieve sexual intercourse. Clinical examination revealed normally developed labia majora and minora, clitoris, and external urethral orifice, but no vaginal opening. A mature female pubic hair pattern was present, and axillary hair development was normal. Breasts were normally developed. Abdominopelvic magnetic resonance imaging demonstrated a remnant upper vagina and unicornuate uterus filled with fluid, and left-sided renal agenesis. Intraoperatively, a congenital vesicouterine fistulous tract was observed. The fistulous tract was completely resected. Vaginal reconstruction using a sigmoid colon pedicled flap was performed. The proximal part of the neovagina was connected to the remnant cervix, and a Foley catheter was left in the uterine cavity for 7 days to prevent obstruction. The patient has been menstruating regularly since the operation. Menouria might be an early sign of congenital vesicouterine fistula. Resection of the fistulous tract with uterine preservation might be considered in patients with vaginal agenesis.

Bilateral primary adrenal lymphoma

A 51-year-old man presented with abdominal pain. Abdominopelvic magnetic resonance imaging (MRI) revealed inhomogeneous tumours involving both adrenal glands, with the right gland measuring about 14 cm and the left 11 cm in maximum diameter (Figure). A percutaneous ultrasound-guided biopsy of the right adrenal gland was performed. Diffuse large B-cell non-Hodgkin lymphoma was diagnosed by histopathological examination. The serum biochemistry profile, adrenocorticotropic hormone (ACTH) stimulation test and urine analysis were normal. The patient received six cycles of R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone) chemotherapy; complete remission was achieved after three cycles. At present, 6 months after chemotherapy, the patient is considered tumour-free. Primary adrenal lymphoma is rare. The majority of the patients are elderly men with bilateral adrenal involvement and the most common histology is diffuse large B-cell lymphoma. The importance of early awareness of the possibility of this diagnosis in patients with bilateral adrenal masses complicated by adrenal insufficiency should be emphasized. Definitive diagnosis is established by image-guided biopsy or by surgical excisional biopsy. On computed tomography and MRI imaging, primary adrenal lymphomas tend to appear as complex masses of variable density, often with areas of necrosis and/or haemorrhage; most tumours are bilateral. An appropriate treatment of this lymphoma is not well established. Therapeutic modalities include multi-agent chemotherapy and surgery followed by chemotherapy and/or radiation therapy. Most of these tumours are highly aggressive and treatment is not satisfactory. Usually, the prognosis is poor with early death occurring during chemotherapy. However, one-third of patients achieve partial or complete remission during chemotherapy.