Contrast-enhanced Abdominal Computed Tomography Scan Research Articles

Anatomical considerations of the iliac crest on percutaneous endoscopic discectomy using a transforaminal approach

Background ContextPercutaneous endoscopic discectomy is a minimally invasive procedure for the surgical treatment of lumbar disc herniation (LDH). It can be performed under local anesthesia and requires a skin incision of only 8 mm, with minimal disruption of the spinal structures including ligaments and muscles. However, performing percutaneous endoscopic discectomy with a transforaminal approach (TF-PED) for the lower lumbar spine is associated with some anatomical problems, such as interference from the iliac crest. This study sought to assess the operability of TF-PED for the lower lumbar spine. PurposeThe purpose of this study was to assess a three-dimensional relationship between the trajectory of TF-PED and the iliac crest, and the operability of TF-PED at the lower lumbar disc levels (L4–L5 and L5–S1) using CT images. Study DesignThis is a retrospective study using 323 multiplanar abdominal computed tomography (CT) scans. Patient SampleWe retrospectively reviewed contrast-enhanced multiplanar abdominal CT scans of 323 consecutive patients (203 male and 120 female) in our hospital from April 2009 to March 2013. The mean age was 66.5 (range 15–89) years old. Outcome MeasuresThe operability of the TF-PED was the outcome measure. Materials and MethodsWe defined the tangent line in the iliac crest and the superior articular process of the caudal spine as the trajectory line of TF-PED, and evaluated the maximum inclination angle of the trajectory of the TF-PED (α angle) at the L4–L5 and the L5–S1 disc levels. Assuming the use of an oblique viewing endoscope at 25°, we defined α angle≥65° as the operability of TF-PED. Results(1) Relationship between iliac crest and disc level: The trajectory of the TF-PED interfered with the iliac crest at L4–L5 in 40.2% (right) and 54.5% (left) of the subjects, and at L5–S1 in 99.7% and 100% of the subjects. (2) The maximum inclination angle of the trajectory of TF-PED: the α angles were 84.3° and 82.3° at the L4–L5, and 56.8° and 55.2° at L5–S1. (3) Laterality of the α angle: At both disc levels, the mean age of the subjects with a laterality of ≥10° was significantly higher than that of subjects with a laterality of <10°. (4) Operability of TF-PED: At L4–L5, TF-PED could be performed in 94.4% and 90.4% of the subjects. In contrast, at L5–S1 the procedure could be performed in 24.1% and 19.2% of the subjects (male: 15.8% and 10.8%, female: 38.3% and 33.3%). ConclusionsFrom the results of this study, the trajectory of TF-PED can be limited by the surrounding anatomical structures. The maximum inclination angle indicated that treatment for the central type of LDH at the L5–S1 disc level was considered more difficult than that at the L4–L5 disc level because of the iliac crest. In the clinical setting, such anatomical particularities can be overcome by using a more perpendicular approach (hand-down technique) with the possible addition of a foraminoplasty. Moreover, we found that we must consider the laterality of the trajectory of TF-PED in terms of the patients' age or sex.

Value of multi-slice spiral CT image texture analysis in diagnosing lymphatic metastasis of rectal cancer

Objective To investigate the value of multi-slice spiral CT image texture analysis in differentiating metastatic (MLN) from non-metastatic lymph nodes (NLN) in patients with rectal cancer. Methods Thirty five patients with rectal cancer who were pathologically confirmed by total mesorectum excision were included retrospectively, with regional lymph nodes (short-axis diameter of larger than 3 mm) found in preoperative CT images. All the patients underwent preoperative abdominal and pelvic dynamic contrast-enhanced CT scan. Regional lymph nodes were identified according to pathological findings, and were divided into MLN and NLN groups. The short-axis diameter, short-to long-axis diameter ratio of lymph nodes were manually measured and calculated, and the texture features, including skewness, kurtosis, variance, entropy and inverse difference moment, were analyzed. The above parameters between MLN and NLN groups were compared using independent sample t test or Mann-Whitney U test. ROC curve analysis was performed regarding the statistically significant parameters and the areas under curve (AUC) were calculated. Multivariate Logistic regression analysis was accomplished to obtain the independent predictive factor of diagnosing regional lymph nodes. Results A total of 68 regional lymph nodes were obtained and consisted of 31 MLNs and 37 NLNs. The short-axis diameter, kurtosis, and entropy of the MLN group were significantly higher than those of the NLN group (all P 0.05). The AUC for distinguishing MLN from NLN of the short-axis diameter, kurtosis and entropy were 0.79, 0.67, and 0.85, respectively. Multivariate logistic regression analysis showed that only entropy (odds ratio= 8.48, 95% confidence interval was 3.01 to 23.92, P<0.01) was screened out as the independent variable, which suggested that the entropy was the unique predictor for characterizing regional lymph nodes of rectal cancer. Conclusion Multi-slice spiral CT images texture analysis can facilitate the accurate differentiation between MLN and NLN in patients with rectal cancer, and especially the entropy has the optimal reference significance. Key words: Rectal neoplasms; Lymphatic metastasis; Tomography, X-ray computed; Texture analysis

DIC–CTが有用であった鈍的外傷による総胆管完全断裂の1例(A case of complete transection of the common bile duct due to blunt abdominal trauma in which DIC–CT was useful for diagnosis)

要旨症例は19歳の女性。軽自動車運転中に受傷した。腹部造影CTで少量の腹腔内貯留液を認め，肝・膵損傷が疑われた。全身状態は安定しており，保存的加療とした。入院後，症状は徐々に改善し，第7病日より経口摂取を開始した。その後腹部膨満が増強し，第10病日の腹部CTにて腹水が著明に増量していた。腹水穿刺では胆汁様であり，DIC–CTにて下部胆管損傷が確認されたため，手術を施行した。術中所見から総胆管断裂と診断し，胆管空腸吻合を施行した。その後第26病日に軽快退院となった。鈍的腹部外傷による総胆管損傷は，特異的な所見に乏しく，診断が遅れることがある。本症例では，DIC–CTが診断に有効であった。

Anatomic variations of inferior mesenteric artery and left colic artery evaluated by 3-dimensional CT angiography: Insights into rectal cancer surgery – A retrospective observational study

ObjectiveTo demonstrate the clinical applicability of 3-dimensional CT angiography (3D-CTA) in evaluating the anatomic variations of inferior mesenteric artery (IMA) and left colic artery (LCA), to help make pre-operative strategies of rectal cancer surgery. Methods188 patients with abdominal and pelvic contrast-enhanced CT scan were retrospectively enrolled and 3D-CTA was reconstructed. The origin and branching patterns of IMA, tracking patterns of LCA, intersectional patterns among IMA, LCA and inferior mesenteric vein (IMV) were examined, and their associations with clinical features were analyzed. ResultsThe origin of IMA was located 42.1 ± 7.7 mm above iliac artery bifurcation, 64.4% within the area of the 3rd lumbar vertebra. 47.3% of LCA arose independently from IMA, 27.1% arose at the root of sigmoid artery (SA), 20.7% shared a common trunk with SA while 4.8% of LCA was absent. As for track of LCA before anastomosis with marginal artery, 53.2% went straight upward while medial to the inner border of left kidney (Type A), 27.1% traveled diagonally across left kidney (Type B) and14.9% went infero-laterally to the lower border of left kidney (Type C). Short IMA trunk was independently associated with type A LCA and lower site of IMA origin. At the horizontal level of IMA origin, 29% of the LCA went distant from IMV, while 71% (21% medial, 50% lateral) were mutually close, and the close type was independently associated with type A LCA. ConclusionPreoperative understanding of the vascular variations and the mutual relationship among LCA, IMA and IMV could be obtained by 3D-CTA, which would further help surgeons to set detailed plans for laparoscopic rectal cancer surgery.

Petersen's Hernia after Esophagectomy With Antesternal Jejunal Reconstruction: Case Report

Petersen's hernia after esophagectomy is quite rare. The patient was a 75-year-old man who had undergone esophagectomy via right thoracotomy and reconstruction with a jejunal loop by the antesternal route in 2014. In March 2015, severe acute abdominal pain occurred the next day. A contrast-enhanced abdominal computed tomography scan revealed a diffuse low density area in the abdominal cavity and partial dilatation of the small intestine with torsion of the superior mesenteric artery. The patient underwent emergency laparotomy, revealing chyle-like ascites and pallor of almost the entire small intestine due to circulatory impairment because of strangulation after herniation through Petersen's defect. After strangulation was relieved, the color and motility of the small intestine recovered rapidly. Then we closed the defect between the jejunal pedicle and the transverse mesocolon. This is the first English report showing Petersen's hernia after esophagectomy.

Non-occlusive mesenteric ischemia localized in the transverse colon: a case report

BackgroundNon-occlusive mesenteric ischemia (NOMI) is ischemia of the mesentery that is caused by hypoperfusion or vasospasm without any thrombosis. NOMI is difficult to diagnose by physical examination alone. Although angiographic examination of the superior mesenteric artery (SMA) is the usual diagnostic method used, it is an invasive examination. Usually, a long range of the bowel becomes discontinuously necrotic in NOMI. Here, we report a rare case of NOMI localized in the transverse colon that was diagnosed by computed tomography (CT) angiography which is a minimally invasive examination.Case presentationA 72-year-old woman was referred to our hospital for further treatment of abdominal pain that developed 1 day before presentation. Contrast-enhanced abdominal CT scan revealed attenuated enhancement of the transverse colon. CT angiography showed SMA irregularities due to vasospasm. The middle colic artery could not be detected by CT angiography. No occlusion due to thrombus or embolism in the SMA and superior mesenteric vein was observed. Based on the findings, NOMI was suspected, and emergency laparotomy was performed, which revealed a segmentally necrotic transverse colon. The necrotic bowel was resected, and stomas were created.ConclusionThe presence of hypotension in the patient necessitated the use of CT angiography, which proved very useful in the early diagnosis of the present case. Thus, if intestinal ischemia is suspected, even in case of a short segment, CT angiography should be performed.

Hepatic hydatid cyst.

A 58-year-old man was admitted for the evaluation of an incidentally detected hepatic mass. Intravenous contrast-enhanced abdominal computed tomography scan in conjunction with contrast-enhanced T1-weighted magnetic resonance imaging (MRI) showed a smooth-margined cyst in the left lateral hepatic segment, which measured 8.5 cm in diameter at the widest point, and contained several other small cysts. There was also another sizable cyst in right hepatic lobe, measuring roughly 3.3 cm in diameter, with a small calcification along the wall (Fig. 1). T2-weighted MRI showed additional small low signal intensity tubular lesions within the large cyst (Fig. 2). Figure 1 Contrast-enhanced abdominal computed tomography scan shows a smooth-margined large cyst in left lateral hepatic segment (white arrow), containing several small daughter cysts (arrowheads) and another cyst in the right hepatic lobe, with a small calcification ... Figure 2 T2-weighted magnetic resonance imaging shows a high signal intensity large cyst containing multiple smaller bright signal intensity cysts, and a few small hypointensity tubular lesions (arrows). At the time, the patient's laboratory findings, including white blood cell count, differential eosinophil count, C-reactive protein, and liver function test, were within normal range. He often ate canine flesh and pork; however, his stool examination was negative for parasite egg. The patient underwent left lateral hepatic sectionectomy and right hepatic tumorectomy. The gross morphology of the large cyst in the left lateral hepatic segment showed fibrotic material, several small gelatinous fluid collections, serous fluid, and a few small dead tubular worms. They were identified pathologically as Echinococcus granulosus. The other cyst in right hepatic lobe was also considered as a hepatic hydatid cyst. Echinococcosis in humans is a zoonotic secondary infection by the larval stages of the cestode species of the genus Echinococcus. Cystic echinococcosis (CE) is caused by E. granulosus. The intermediate host, humans, enter the organism's life cycle through exposure to infected canine feces. If the cyst contains a living worm, peripheral eosinophilia can be frequently seen. The liver is the most common organ of CE. In the case of hepatic CE, the right hepatic lobe is more frequently involved, and the morphological form, about 75% of cases, is a unilocular simple cyst. However, a large mother cyst containing multiple small daughter cysts in the liver is considered relatively typical and highly specific imaging finding for the diagnosis of hepatic hydatid cyst. In this case, there were a few small tubular structures within the cyst on MRI were regarded as dead worms in the pathologic specimen. A second cyst with a small calcification is non-specific imaging finding. In the presented case, it was another hepatic hydatid cyst. According to the classification of a hepatic hydatid cyst, a cyst with calcification is considered a dead cyst.

Diagnosis of non-occlusive acute mesenteric ischemia in the intensive care unit.

BackgroundNon-occlusive mesenteric ischemia (NOMI) is a common complication and accounts for a major cause of death in critically ill patients. The diagnosis of NOMI with respect to the eventual indications for surgical treatment is challenging. We addressed the performance of the diagnostic strategy of NOMI in the intensive care unit, with emphasis on contrast-enhanced abdominal CT-scan.MethodsThis was a retrospective monocenter study. Patients with clinically suspected acute mesenteric ischemia were included if a comprehensive diagnostic workup was carried out including surgical and/or endoscopic digestive explorations. Patients with evidence of occlusive mesenteric ischemia were excluded. A definite diagnosis of NOMI only relied on surgical or endoscopic findings. Abdominal CT-scans were reviewed by two radiologists blinded from the final diagnosis.ResultsA diagnosis of NOMI could be definitely confirmed or ruled out through surgical or endoscopic explorations of the digestive tract in 147 patients. With respect to their clinical characteristics, only a history of atrial fibrillation was an independent predictor of NOMI (odds ratio 8.3, 95% confidence interval 2.0–35.2, p = 0.004). Among them, 114 patients (75 with and 39 without NOMI) had previously been subjected to contrast-enhanced abdominal CT-scan. Portal venous gas, pneumatosis intestinalis and, to a lesser extent, abnormal contrast-induced bowel wall enhancement were poorly sensitive, but exhibited good specificities of 95, 85 and 71%, respectively. Nineteen out of 75 patients (25.3%) without any suggestive radiological signs finally exhibited mesenteric ischemia, including ten with intestinal necrosis.ConclusionsThe performance of abdominal CT-scan for the diagnosis of NOMI is limited. Radiological signs of advanced-stage ischemia are good predictors of definite mesenteric ischemia, while their absence should not be considered sufficient to rule out the diagnosis.Electronic supplementary materialThe online version of this article (doi:10.1186/s13613-016-0213-x) contains supplementary material, which is available to authorized users.

Assessment of Added Value of Noncontrast to Contrast-Enhanced Abdominal Computed Tomography Scan for Characterization of Hypervascular Liver Metastases

Assess the added value of nonenhanced computed tomography (NECT) to contrast-enhanced CT (CECT) of the abdomen for characterization of hypervascular liver metastases and incidental findings. Institutional review board approved, Health Insurance Probability and Accountability Act compliant, retrospective study of patients with melanoma, neuroendocrine tumor, or thyroid cancer. First available triphasic abdomen CT after initial diagnosis was reviewed by 3 radiologists. The 3 most suspicious lesions were characterized on the CECT as benign or malignant and then recharacterized after reviewing the NECT with CECT. Incidental renal and adrenal lesions were characterized similarly. Diagnostic performance of CECT vs its combination with NECT was assessed. Statistical significance level was set at P < 0.05. A total of 81 patients were included (mean age = 55 years; 52% male; 64% with liver lesions; 27% and 11% with incidental renal and adrenal lesions, respectively). Percentage area under the curve and 95% CI of CECT vs combination with NECT for characterization of liver metastases was 98(94-100) vs 99(96-100) for reviewer 1 (P = 0.35), 93(86-100) vs 94(87-100) for reviewer 2 (P = 0.23), and 96(90-100) vs 99(97-100) for reviewer 3 (P = 0.32). Mean difference in area under the curve and 95% CI between 2 protocols for characterization of liver, renal, and adrenal lesions were -0.007(-0.05 to 0.04) (P = 0.63), -0.09(-0.25 to 0.07) (P = 0.22), and -0.01(-0.05 to 0.02) (P = 0.27), respectively. After addition of NECT, confidence level for lesion characterization increased 4%-15% for liver metastases, 18%-59% and 33%-67% for renal and adrenal lesions, respectively. In conclusion, while addition of NECT to CECT improved radiologist' confidence, there was no statistically significant change in characterization of hypervascular liver metastases or incidental renal and adrenal lesions.

Variations in arterial supply to the lower lumbar spine.

Several papers examined the vascular anatomy of the lumbosacral region using cadavers with angiography. However, few reports used CT angiography, and discussion on variations of fourth lumbar, fifth lumbar, and lumbar branch of iliolumbar arteries were limited. To clarify the vascular variations around the lower lumbar spine including the lumbosacral region, particularly at the posterior elements, we performed anatomical analysis using computed tomography (CT). Extra-osseous arteries surrounding the lumbar spine including the lumbosacral region were evaluated by two orthopedic surgeons independently, using 323 consecutive abdominal contrast-enhanced multi-planner CT scans that were taken for surgical plans in colon cancer patients. Subjects were 204 men and 119 women, whose ages ranged from 15 to 89years (mean 66.5). Each segmental artery was visible at the L1-4 spinal levels, running from the vertebra through the lamina in 91.0% on the right side, in 90.7% on the left side, while it was visible in 4.6% on the right side, in 8.7% on the left side at the L5 level. The extra-osseous arterial supply to the L5 lamina was basically provided by two vessels on each side. One was mostly derived from the L4 segmental artery (right: 92.6%; left: 92.0%) that was distributed around the superior articular process, the other was derived from the iliolumbar artery (right: 62.9%; left: 55.7%) that was distributed around the inferior articular process through the lamina. There were mainly four combination patterns of those arteries. These combinations, which had been considered as regular patterns in textbooks, were observed in approximately 50% (right: 55.7%; left: 48.6%) of patients. Various distributions of arteries around the lower spine were identified.

The Liver Segmental Volume Ratio for Noninvasive Detection of Cirrhosis: Comparison With Established Linear and Volumetric Measures.

The aim of this study was to compare the liver segmental volume ratio (LSVR), a novel volumetric computed tomography measurement, with established linear measurements for differentiating normal from cirrhotic livers. Hepatic volumes were measured using semiautomated software (Liver Analysis Application, Philips IntelliSpace Portal) on contrast-enhanced abdominal computed tomography scans in 312 adults, including 108 patients with end-stage liver disease (mean age, 55 years; 63 men/45 women) and 204 healthy controls (potential renal donors; mean age, 46 years; 82 men/122 women). The LSVR was defined as the volume ratio of Couinaud segments I to III to segments IV to VIII. Linear measures included the caudate-to-right lobe ratio and maximal splenic dimension. Differences in LSVR between cirrhotics and controls were highly significant (P < 0.0001; mean, 0.55 ± 0.29 versus 0.27 ± 0.07; receiver operating characteristic [ROC] area under the curve [AUC], 0.916). Linear caudate-to-right lobe ratio differences were not statistically significant between the 2 cohorts (P = 0.051; ROC AUC, 0.567). Total liver volume was ineffective for discrimination (ROC AUC, 0.598). An LSVR threshold of 0.35 or greater had a sensitivity and specificity for cirrhosis of 81.5% and 88.7%, respectively. Regional hepatic volume changes, as reflected by the LSVR, are more effective than standard linear measures or total liver volume for differentiating cirrhotic from normal livers.

Ultrasound and computed tomography of the iliosacral lymphatic centre in dogs with anal sac gland carcinoma

In this prospective study, we hypothesized that computed tomography (CT) would identify more normal and abnormal iliosacral lymph nodes (LNs) than abdominal ultrasound in dogs with anal sac gland carcinoma (ASGC). Twelve client-owned dogs with ASGC but without distant metastasis were enrolled. Abdominal ultrasound and contrast-enhanced CT scans of the abdomen were obtained. Iliosacral LNs were counted and assessed for location, laterality and size. Significantly (P < 0.00001) more iliosacral LNs were identified with CT (61) than ultrasound (30), including significantly (P = 0.00012) more medial iliac LNs with CT (33) than ultrasound (19). There was no difference in number of internal iliac LNs identified with CT versus ultrasound. Significantly (P = 0.000061) more sacral LNs were identified with CT (15) than ultrasound (0). Ultrasound identified slightly more (7) abnormal iliosacral LNs than CT (5). Contrast CT was able to identify more normal but not more abnormal LNs than ultrasound.

Opportunistic screening for osteoporosis using the sagittal reconstruction from routine abdominal CT for combined assessment of vertebral fractures and density

Opportunistic osteoporosis screening using abdominal CT scans obtained for other purposes has the potential to increase detection of those at increased risk for fragility fractures. We sought to combine the tasks of density measurement and vertebral fracture assessment on the sagittal view. We confirm that this represents a robust approach and recommend its implementation in clinical practice. Opportunistic osteoporosis screening at routine abdominal CT has been proposed by measuring axial (transverse) L1 trabecular attenuation and by sagittal reconstruction for vertebral fracture assessment. We sought to combine this dual evaluation on the sagittal reconstruction alone to improve efficiency. Routine contrast-enhanced abdominal CT scans performed for any indication on 571 consecutive adults age 60 years or older (mean age 70.7 years) were retrospectively analyzed. These were performed at a single center over a 3-month period. L1 trabecular attenuation was measured using an ovoid region-of-interest on both the transverse and sagittal series. The sagittal reconstruction was also analyzed for moderate-to-severe vertebral compression fractures using the Genant visual semi-quantitative method. Likely osteoporosis was defined by a moderate-to-severe fracture and/or sagittal L1 trabecular attenuation of ≤110 Hounsfield units (HU) (previously found to be >90% specific for osteoporosis on our calibrated GE CT scanners at 120 kV(p)). Correlation was made with hip and spine dual X-ray absorptiometry (DXA). Mean absolute difference in L1 trabecular attenuation between transverse and sagittal reconstructions was 6.7 HU (±5.7) or 6.2%. The transverse and sagittal HU measurements were in agreement (i.e., both measurements above or below this threshold) in 94.5% of cases at the 110-HU cutoff. A total of 243 (42.3%) patients had likely osteoporosis by CT criteria, of which only 48 (19.8%) had previous DXA screening. Assessment of the sagittal view alone at routine abdominal CT for both vertebral fractures and trabecular bone mineral density provides a rapid and effective opportunistic screen for detecting individuals at increased risk for fragility fractures.

Correlation Between Intra-Abdominal Free Fluid and Solid Organ Injury in Blunt Abdominal Trauma.

Background:In previous studies, the diagnostic value of Focused Assessment with Sonography for Trauma (FAST) has been evaluated but few studies have been performed on the relationship between the amount of free intra-abdominal fluid and organ injury in blunt abdominal trauma. To select patients with a higher probability of intra-abdominal injuries, several scoring systems have been proposed based on the results of FAST.Objectives:The aim of this study was to determine the prognostic value of FAST according to the Huang scoring system and to propose a cut-off point for predicting the presence of intra-abdominal injuries on the Computed Tomography (CT) scan. The correlation between age and Glasgow Coma Scale (GCS) and the presence of intra-abdominal injuries on the CT scan was also assessed.Patients and Methods:This study was performed on 200 patients with severe blunt abdominal trauma who had stable vital signs. For all patients, FAST-ultrasound was performed by a radiologist and the free fluid score in the abdomen was calculated according to the Huang score. Immediately, an intravenous contrast-enhanced abdominal CT scan was performed in all patients and abdominal solid organ injuries were assessed. Results were analyzed using Kruskal-Wallis test, Mann-Whitney test and ROC curves. The correlation between age and GCS and the presence of intra-abdominal injuries on CT-scan was also evaluated.Results:The mean age of the patients was 29.6 ± 18.3 years and FAST was positive in 67% of the subjects. A significant correlation was seen between the FAST score and the presence of organ injury on CT scan (P < 0.001). Considering the cut-off point of 3 for the free fluid score (with a range of 0-8), sensitivity, specificity, positive predictive value and negative predictive value were calculated to be 0.83, 0.98, 0.93, and 0.95, respectively. Age and GCS showed no significant correlation with intra-abdominal injuries.Conclusions:It seems that FAST examination for intra-abdominal fluid in blunt trauma patients can predict intra-abdominal injuries with very high sensitivity and specificity. Using the scoring system can more accurately determine the probability of the presence of abdominal injuries with a cut-off point of three.

Effect of IV contrast on lumbar trabecular attenuation at routine abdominal CT: correlation with DXA and implications for opportunistic osteoporosis screening.

Osteoporosis remains under-diagnosed. Routine abdominal CT can provide opportunistic screening, but the effect of IV contrast is largely unknown. The overall performance for predicting osteoporosis was similar between enhanced and unenhanced scans. Therefore, both non-contrast and contrast-enhanced abdominal CT scans can be employed for opportunistic osteoporosis screening. Osteoporosis is an important yet under-diagnosed public health concern. Lumbar attenuation measurement at routine abdominal CT can provide a simple opportunistic initial screen, but the effect of IV contrast has not been fully evaluated. Mean trabecular CT attenuation values (in Hounsfield units, HU) at the L1 vertebral level were measured by oval region-of-interest (ROI) on both the unenhanced and IV-contrast-enhanced CT series in 157 adults (mean age, 62.0). All patients underwent correlative central DXA within 6 months of CT. Based on DXA BMD of the lumbar spine, femoral neck, and total proximal femur: osteoporosis, osteopenia, and normal BMD was present in 33, 77, and 47, respectively. Statistical analysis included Bland-Altman plots and receiver operating characteristic (ROC) curves. Mean difference (±SD) in L1 trabecular attenuation between enhanced and unenhanced CT series was +11.2 HU (±19.2) (95 % CI, 8.16-14.22 HU), an 8 % difference. Intra-patient variation was substantial, but no overall trend in the HU difference was seen according to underlying BMD. ROC area under the curve (AUC) for unenhanced and enhanced CT for diagnosing osteoporosis were similar at 0.818 and 0.830, respectively (p = 0.632). Thresholds for maintaining 90 % specificity for osteoporosis were 90 HU for unenhanced and 102 HU for enhanced CT. Thresholds for maintaining 90 % sensitivity for osteoporosis were 139 HU for unenhanced and 144 HU for enhanced CT. Similar diagnostic performance was seen for diagnosing low BMD (osteoporosis or osteopenia) using higher HU cut-offs. Contrast-enhanced CT shows an average increase of 11 HU over the unenhanced series for L1 trabecular attenuation. The overall performance for predicting osteoporosis is similar between the enhanced and unenhanced scans, thus either can be employed for initial opportunistic screening.

MULTIDETECTOR-ROW COMPUTED TOMOGRAPHIC CHARACTERISTICS OF PRESUMED PREURETERAL VENA CAVA IN CATS.

Preureteral vena cava (circumcaval ureter, retrocaval ureter) occurs in a third of the feline population and has been associated with ureteral strictures in humans. The aim of this retrospective cross-sectional study was to describe the contrast-enhanced multidetector row computed tomographic (MDCT) characteristics of presumed preureteral vena cava in a group of cats. Medical records from two institutions located in different continents were searched from 2010-2013 for cases with complete contrast-enhanced MDCT examinations of the abdomen (i.e. included the entire course of the ureters and prerenal and renal segments of the caudal vena cava) and a diagnosis of preureteral caudal vena cava. For cases meeting inclusion criteria, CT scan data were retrieved and characteristics of the preureteral caudal vena cava were recorded. Presence of concomitant renal or ureteral diseases was also recorded. A total of 272 cats had contrast-enhanced abdominal CT scans during the study period and of these, 68 cats (22.43 ± 4.96%) had a diagnosis of presumed preureteral vena cava. In all affected cats, a "reverse-J ureter" was observed, i.e. a ureter running medially at the level of L4-5, passing dorsally to the caudal vena cava and then exiting ventrally between the caudal vena cava and aorta returning to its normal position. Having a preureteral vena cava resulted in an increased risk for concurrent urinary signs (OR = 3.00; CI: 95%; 1.28-6.99; P = 0.01). Findings supported the use of contrast-enhanced MDCT for characterizing morphology of preureteral vena cava and its relation with ureters in cats.

Sporadic insulinoma in a 10-year-old boy: a case report and literature review.

Insulinoma is an exceedingly uncommon pancreatic islet cell neuroendocrine tumor. Its estimated incidence is approximately four cases per million individuals per year. We report the case of sporadic insulinoma in an exceptionally very young 10-year-old boy who presented with a 1-month history of episodic tremulousness, diaphoresis, increased hunger, confusion and fainting. Initial laboratory investigations showed low blood glucose (64 mg/dL) and high blood insulin (6 μU/mL) levels. Patient was admitted in view of frequent hypoglycemic symptoms and possible pancreatic insulinoma. A 48-hour mentored fasting test was done and ceased within 3 hours due to occurrence of hypoglycemic symptoms. During the episode, blood was drawn and results showed low blood glucose level and high insulin, pro-insulin and C-peptide levels. The hypoglycemic symptoms were relieved greatly by glucose administration and Whipple's triad for insulinoma was met. An abdominal contrast-enhanced computed tomography scan showed a 10 x 12 x 17 mm, small, well-demarcated, heterogeneously enhancing lesion within the body of pancreas without dilatation of pancreatic duct. No evidence of lymphadenopathy or distant metastasis was identified. Patient underwent enucleation of pancreatic tumor. Histopathological and immunohistochemical examination of the pancreatic mass confirmed neuroendocrine tumor (insulinoma). Patient had an uneventful recovery. A post-operative 6-month follow-up showed resolution of hypoglycemic symptoms, normalized blood glucose, insulin, pro-insulin and C-peptide levels, and no evidence of recurrence. Although rare, sporadic insulinoma should be considered in the differential diagnosis of any young individual presenting with frequent hypoglycemic symptoms (neuroglycopenic and/or autonomic nervous system symptoms). Furthermore, a literature review on insulinoma is presented.

A solid pseudopapillary neoplasm without cysts that occurred in a patient diagnosed by endoscopic ultrasound-guided fine-needle aspiration: a case report

IntroductionSolid pseudopapillary neoplasm of the pancreas is a rare neoplasm that has been reported to account for between 0.17% and 2.7% of all non-endocrine tumors of the pancreas. It is usually seen in young women. Because solid pseudopapillary neoplasms are rarely aggressive and have low-grade malignant potential and an excellent prognosis after complete resection, it is an ideal pancreatic tumor for treatment by minimally invasive surgery. Therefore, making an accurate pre-operative diagnosis is very important.Case presentationA 24-year-old Japanese man who had been found to have mild transaminase elevations at a medical check-up visited our hospital for further examination. Abdominal computed tomography showed a 40mm-diameter tumor in the pancreatic tail and mild fatty liver. He was admitted to our hospital for additional examination. The abdominal contrast-enhanced computed tomography scan taken at our institution showed an increasingly enhanced mass of 40mm diameter in the pancreatic tail. Ultrasonography showed a low-level echoic mass of 35mm diameter in the pancreatic tail. T1-weighted magnetic resonance imaging showed low signal intensity in the tail of the pancreas. T2-weighted magnetic resonance imaging showed high signal intensity there. Diffusion magnetic resonance imaging showed high signal intensity. An endoscopic ultrasound yielded the same results as the abdominal ultrasonogram. In addition, [18F]-fluorodeoxyglucose positron emission tomography/computed tomography showed abnormal accumulation (maximum standardized uptake value, 6.53). This finding raised our suspicion of a pancreatic malignant tumor. However, the patient could not be confidently diagnosed solely on the basis of imaging. Endoscopic ultrasound-guided fine-needle aspiration was performed, which led us to a diagnosis of solid pseudopapillary neoplasm. On that basis, we performed minimally invasive surgery (spleen-preserving laparoscopic distal pancreatectomy).ConclusionAtypical solid pseudopapillary neoplasm without cysts should be considered when diagnosing pancreatic tumors. A definitive pre-operative diagnosis of solid pseudopapillary neoplasm made on the basis of endoscopic ultrasound-guided fine-needle aspiration can guide the surgical approach used.

Missed Pulmonary Embolism on Abdominal CT

The purpose of this study is to evaluate a series of missed pulmonary emboli (PE) identified on abdominal CT and to describe their characteristics and the clinical scenario. All reports of chest CT scans performed during a 12-month period were searched for keywords indicative of PE. Among patients with PE, patients who also underwent an enhanced abdominal CT within 3 months were assessed for missed PE. Three radiologists reviewed the abdominal CT to confirm the presence of a missed PE. Missed PEs were classified as unknown or known. Each study was assessed for characteristics of the missed PE and the image quality of the PE study. The electronic medical record was used to document the clinical context in which the PE occurred. Eighteen patients (12 men and six women; average age, 58.8 years) were identified as having missed PE on abdominal CT. In seven patients (38.9%), the PE had not been previously diagnosed. Most of the missed PEs were segmental, but three missed PEs occurred in lobar vessels. In a slight majority of the cases, the reviewing radiologists judged the contrast bolus as good. The abdominal CT on which PE was overlooked was obtained for a variety of reasons, most commonly because of abdominal pain or to follow up a preexisting condition. This study shows that missed PE can occur on abdominal CT. It is recommended that interpretation include a careful search of the lower pulmonary arterial vasculature on contrast-enhanced abdominal CT scans.

V5-13 A NEW APPROACH FOR THIRD LEVEL DIAGNOSIS FOR COMPLEX RENAL CYSTS

You have accessJournal of UrologyRenal Oncology/Robotics1 Apr 2014V5-13 A NEW APPROACH FOR THIRD LEVEL DIAGNOSIS FOR COMPLEX RENAL CYSTS Francesco Porpiglia, Marco Cossu, Massimiliano Poggio, Riccardo Bertolo, Nicoletta Serra, Diletta Garrou, Daniele Amparore, Enrico Checcucci, Roberta Aimar, and Cristian Fiori Francesco PorpigliaFrancesco Porpiglia More articles by this author , Marco CossuMarco Cossu More articles by this author , Massimiliano PoggioMassimiliano Poggio More articles by this author , Riccardo BertoloRiccardo Bertolo More articles by this author , Nicoletta SerraNicoletta Serra More articles by this author , Diletta GarrouDiletta Garrou More articles by this author , Daniele AmparoreDaniele Amparore More articles by this author , Enrico CheccucciEnrico Checcucci More articles by this author , Roberta AimarRoberta Aimar More articles by this author , and Cristian FioriCristian Fiori More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.1716AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail Introduction and Objectives Complex renal cysts may cause diagnostic matters, since it is often difficult to exclude malignancies. The Bosniak classification of renal cysts is a well-established worldwide method based on CT findings to categorize cystic renal masses but, expecially for cysts classified as Bosniak II and III, some studies highlight a not trascurable frequency of false negative and positive malignancy diagnoses. To overcome this limitation, cysts puncture for evacuation and core biopsies can be used trying to make a diagnosis but a recent Literature review emphasized the higher risk of biopsy failure, false-negative results, and potential spreading of tumour cells resulting from cystic rupture: these aspects lead many urologists to limit the indications of core biopsies. Trying to give an answer in this field we present a new “third-line” diagnostic tool for complex cysts renal tumors. Methods We present the case of a male patient, 35 years old, BMI 22. After an incidental US detection of a large cyst a the lower pole of the left kidney with exophytic growth pattern, the diagnosis was confirmed by an imaging workup consisting of contrast-enhanced abdominal CT-scan and abdominal MRI. In addition, they highlighted an involvement of renal pelvis and lower calyceal system. The MRI dynamic study showed the presence of 2 small intraluminal prominence. To specify the diagnosis in this complex cysts renal tumor, we proceeded as follows: patient was placed in a Galdakao-modified supine Valdivia position. Under US guidance a puncture of the cyst was performed by 16 G needle, named MICROPERC®, endowed by a dedicated sheet (4.85 F). The needle was then removed, the 4.85 F sheath was left in place. 20 mL of citrine fluid were suctioned and sent for extemporary cytological examination with unconclusive result. An adapter with “Luer-lock” junction was connected to the needle. After its setup, the optical fiber was inserted through the sheath and moved forward to the cyst. Endoscopic exploration of the cyst was performed and finally, two intraluminal prominence were identified. We therefore decided to perform a laparoscopic radical nephrectomy. Results Operative time was 165 minutes. No perioperative complications occurred. Patient was discharged at third postoperative day. At histopahological examination a papillary malignant renal tumor was found. Conclusions The percutaneous needlescopic exploration of renal cysts according the described technique offers a new perspective in the diagnostic assessment of complex renal cysts. This approach could be used as a third-line diagnostic tool when either imaging or biopsy were inconclusive. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e620 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Francesco Porpiglia More articles by this author Marco Cossu More articles by this author Massimiliano Poggio More articles by this author Riccardo Bertolo More articles by this author Nicoletta Serra More articles by this author Diletta Garrou More articles by this author Daniele Amparore More articles by this author Enrico Checcucci More articles by this author Roberta Aimar More articles by this author Cristian Fiori More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...