Hyper Enhancement Research Articles

Differential diagnosis of hepatocellular carcinoma and intrahepatic cholangiocarcinoma by ultrasonography combined with multiphase enhanced computed tomography.

Purpose: Hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (ICC) are primary liver cancers with different therapeutic methods and prognoses. This study aims to investigate the ultrasonography and enhanced computed tomography (CT) features of these cancers and improve the early diagnosis rate. Methods: We retrospectively analyzed the clinical and imaging data of 319 patients diagnosed with HCC and 124 patients diagnosed with ICC, confirmed by pathology. Results: A total of 443 patients were eligible in this study. From the perspective of clinical data, between HCC and ICC patients existed significant differences in age, gender, hepatic background, serum tumor markers of AFP and CA19.9, chronic hepatitis B/C and lymph node infiltration (p<0.05), but not in tumor size, microvascular invasion, serum tumor markers of CEA and CA125 (P>0.05). With respect to ultrasonography features, HCC patients had a higher proportion than ICC patients in splenomegaly (p=0.001), while ICC patients had a higher proportion than HCC patients in absence/not rich vascularity and intrahepatic bile duct dilatation (p<0.05). With respect to CT features, HCC patients were significantly different from ICC patients in the three-phase enhanced CT value mean, enhanced intensity and homogeneity of nodules (P<0.05). A multivariate logistic regression analysis was performed to further clarify the correlation of these indices. However, only age≤60 years (OR=1.861, P=0.045), male (OR=3.850, P<0.001), AFP>7ng/ml (OR=0.119, P<0.001), lymph node infiltration (OR=5.968, P<0.001), intrahepatic bile duct dilatation (OR=2.414, P=0.04), splenomegaly (OR=0.081, P<0.001), rim APHE (OR=3.109, P=0.002), and iso- or hyper enhancement (OR=0.188, P<0.001) were independent risk factors. Conclusions: While there are overlapping ultrasonography and CT features between HCC and ICC, the integration of tumor markers and specific imaging characteristics can be beneficial in distinguishing between the two.

Prognostic implications of papillary muscle delayed hyperenhancement in dilated cardiomyopathy patients

Abstract Background Similar to left ventricle (LV) myocardial delayed hyperenhancement (HE), papillary muscle delayed hyperenhancement (papHE) at cardiac magnetic resonance (CMR) may indicate fibrotic or infiltrative processes. The prevalence in patients with non-ischemic dilated cardiomyopathy (DCM) and its impact on outcome are unknown. Objectives We aimed to determine the prevalence of papHE in an outpatient DCM cohort with longitudinal follow-up. Methods From the Maastricht Cardiomyopathy Registry, we included 528 consecutive patients who underwent Late Gadolinium Enhancement (LGE) Cardiac Magnetic Resonance imaging (CMR), and both papHE and papillary tip delayed hyperenhancement (tipHE) were assessed. The primary outcomes were all-cause mortality, sudden cardiac death, life-threatening arrhythmia, and hospitalization for heart failure (HFH). Unadjusted Kaplan Meier curves were constructed and compared using log-rank tests. PapHE was related to outcomes, using univariable and multivariable Cox regression analysis, correcting for clinical covariables (age, sex, and LV ejection fraction). In a second model, we corrected for myocardial HE, on top of the covariables included in the first model. Mitral valve regurgitation was assessed during follow-up echocardiography in 409 patients (77%). Results Three hundred and twenty five patients (62%) had tipHE and 131 patients (25%) had papHE. The median follow-up duration was 5.6 (IQR 3.5-9.0) years. PapHE was associated with all-cause mortality (HR=1.76, 95% CI 1.04-2.97), sudden cardiac death (HR=2.23, 95% CI 1.10-4.54) and HFH (HR=2.42, 95% CI 1.16-5.06), but not with life-threatening arrhythmias, after correction for clinical covariables. The presence of isolated tipHE was not associated with adverse outcomes. The correlation of myocardial HE was stronger than that of papHE, specifically with sudden cardiac death (HR=2.40, 95% CI 1.10-5.23 for myocardial HE) and life-threatening arrhythmias (HR=2.97, 95% CI 1.04-8.46 for myocardial HE). Additional correction for myocardial HE rendered the correlation between papHE and the studied outcomes insignificant. Finally, papHE did not correlate to mitral regurgitation. Conclusions PapHE is present in 25% of DCM patients. The presence of papHE correlated with sudden cardiac death and HFH, still myocardial HE remains a stronger predictor. Our results support the incorporation of myocardial HE in implantable cardioverter-defibrillator guideline recommendations. Future studies should investigate if the addition of PapHE helps to improve such guidelines further.

CMR Imaging 6 Months After Myocarditis Associated with the BNT162b2 mRNA COVID-19 Vaccine.

Temporal association between BNT162b2 mRNA COVID-19 vaccine and myocarditis (PCVM) has been reported. We herein present early and 6-month clinical follow-up and cardiac magnetic resonance imaging (CMR) of patients with PVCM. A retrospective collection of data from 15 patients with PCVM and abnormal CMR was performed. Clinical manifestation, laboratory data, hospitalizations, treatment protocols, and imaging studies were collected early (up to 2 months) and later. In nine patients, an additional CMR evaluation was performed 6 months after diagnosis. PCVM was diagnosed in 15 patients, mean age 17 ± 1 (median 17.2, range 14.9–19 years) years, predominantly in males. Mean time from vaccination to onset of symptoms was 4.4 ± 6.7 (median 3, range 0–28) days. All patients had CMR post diagnosis at 4 ± 3 (median 3, range 1–9) weeks, 4/5 patients had hyper enhancement on the T2 sequences representing edemaQuery, and 12 pathological Late glandolinium enhancement. A repeat scan performed after 5–6 months was positive for scar formation in 7/9 patients. PCVM is a rare complication, affecting predominantly males and appearing usually within the first week after administration of the second dose of the vaccine. It usually is a mild disease, with clinical resolution with anti-inflammatory treatment. Late CMR follow up demonstrated resolution of the edema in all patients, while some had evidence of residual myocardial scarring.

Contrast-enhanced and microvascular ultrasound imaging features of testicular lymphoma: report of five cases and review literature

BackgroundTo retrospectively investigate the grey-scale, Doppler, contrast-enhanced and microvascular ultrasound of five patients with primary testicular lymphoma of our institute through review literature analysis.MethodsFrom January to November 2020, five patients with primary testicular lymphoma confirmed by histology were preoperatively investigated with a standardized sonographic protocol including contrast-enhanced and microvascular ultrasound.ResultsConventional ultrasound showed localized hypoechogenicity represented with solitary (2 of 5), multiple lesions (2 of 5), or entire testicular involvement (1 of 5). Increased blood flow appeared in color Doppler ultrasound with straight vascular sign (4 of 5). In contrast-enhanced ultrasound images confirmed this pattern (4 of 5) and presented hyper enhancement with enlarged range. On microvascular ultrasound imagings, all lesions were presented with straight and parallel course of intralesional vessels (5 of 5).ConclusionsHere, we identified an increased vascularity with enlarged range on contrast-enhanced ultrasound along with a linear nonbranching pattern by vascular sign on microvascular ultrasonographic of testicular lymphoma.

Combined arterial and delayed enhancement patterns of MRI assist in prognostic prediction for intrahepatic mass-forming cholangiocarcinoma (IMCC).

This study valued MR delayed enhancement pattern in predicting postoperative prognosis of intrahepatic mass-forming cholangiocarcinoma (IMCC). From 2011 to 2015, 231 patients of IMCC underwent DCE-MRI preoperatively. Enhancement patterns and MRI characteristics were evaluated. Recurrence and mortality data were compared among IMCCs with different enhancement patterns. Prognostic factor analysis was performed using preoperative and postoperative clinical-pathologic factors, as well as imaging findings. Fifty-six (24.2%), 142 (61.5%) and 33 (14.3%) tumors showed hypo, peripheral rim and diffuse hyper enhancement in AP. Fifty-six (24.2%), 81 (35.1%) and 94 (40.7%) tumors showed hypo, heterogeneous and uniform enhancement in DP. Patients with arterial diffuse hyper enhancement or delayed uniform enhancement IMCCs had lower preoperative CA19-9 levels, smaller tumor sizes and minor operations than the rest patients (p < 0.05) and they were less associated with lymph nodes metastasis, vascular invasion, necrosis or poor tumor differentiation (p < 0.05), therefore with higher overall and disease-free survival rates (p < 0.05). The combination of AP and DP increased the detection rate of patients with good prognosis in the arterial rim enhancement group. Multivariate analysis revealed the delayed enhancement pattern (hypo HR = 6.304/10.028 for DFS/OS; heterogenous HR = 4.579/4.972 for DFS/OS), multitude of lesions (HR = 1.6/1.5 for DFS/OS) and tumor sizes (HR = 1.6 for DFS) were independent prognostic factors. The uniform enhancement pattern in delayed MRI was an independent optimal prognostic factor for IMCCs and increased the detection rate of patients with good prognosis compared to the arterial diffuse hyper enhancement pattern.

Computed tomography enterocolongraphy in assessment of degree of ulcerative colitis activity.

Inflammatory bowel diseases are gaining more interest in the past few years. Ulcerative colitis (UC) is a chronic disease that requires accurate follow-up for a good treatment plan. Colonoscopy alone cannot be efficient to detect disease extent and has a high risk of perforation in acute severe UC and toxic megacolon. Computed tomographic enterocolonography (CTE) is widely used now to detect intramural, extra-intestinal involvement and intestinal complications. Hence, this study aimed to evaluate CTE in the assessment of the degree of activity of UC. This cross-sectional study was carried on 50 UC patients, divided into 36 males and 14 females presented at the Gastroenterology Unit, Alexandria Main University, Faculty of Medicine. Assessment of UC activity was done to all patients on three levels; the ulcerative colitis disease activity index for the clinical level, ulcerative colitis endoscopic index of severity by endoscopy and pathologically by degree of neutrophilic invasion, crypt abscess or cryptitis, presence of oedema and mucosal surface ulceration, then CTE was done and the findings were compared with the histopathological findings. Bowel wall thickening in CTE was divided into: normal (<3 mm, score 0), mild (3-6 mm, score 1), moderate (6-9 mm, score 2) and severe (>9 mm, score 3). Mesenteric hyperaemia, mucosal hyper enhancement and enlarged pericolic lymph nodes were recorded. CTE findings in the form of bowel wall thickening and hyper enhancement were found in 74% of active cases and were correlated with all histopathological findings investigated in this study with high statistical significance except in chronic stages, whereas lymph node enlargement and mesenteric hyperaemia did not show statistical significance with disease activity. CTE is a good tool for diagnosing disease activity in UC.

The Role of Multi-Detector Computed Tomography in Assessment of Chron’s Disease Progression: A Cross-sectional Study

Background:There is a lack of information regarding the correlation between multi-detector computed tomography [MDCT] findings and clinical activity of Chron’s disease. The aim of the work: In this study, we aimed to investigate the correlation between MDCT and the degree of activity of Chron’s disease [CD].Patients and Methods: In this prospective study, a total of 50 patients with CD were recruited The disease activity was assessed using the Crohn's Disease Activity Index [CDAI]. For MDCT evaluation, we used 256 Multislice CT scanners [Toshiba Medical System, Tochigi-ken, Japan].Results: Forty-five patients [90%] showed signs of activity, while the other five patients [10%] were in the remission state [showed no signs of activity]. The most common sign of activity was mucosal hyper enhancement [93.3%], followed by mucosal thickening [91%], mesenteric congestion [64.4%], and mesenteric lymphadenopathy [33.3%]. The association analysis showed that there was a statistically significant association between CDAI and signs of activity in MDCT [360 ±64.5 in patients with signs of activity vs. 206.9 ±145.6 in patients with no signs of activity; p 0.05].Conclusion: Our study showed that the findings of MDCT are significantly correlated with clinical activity score. Clinical and radiological predictors of sever disease need to be assessed as predictors in future studies

Cryptogenic multifocal ulcerous stenosing enteritis (CMUSE): a 20-year single-center clinical and radiologic experience.

The purpose of this article is to describe clinical and imaging characteristics of confirmed cases of cryptogenic multifocal ulcerous stenosing enteritis (CMUSE). Retrospective review of electronic medical records identified patients considered for a diagnosis CMUSE over 20-years in a single large tertiary center. Clinical data were abstracted and diagnosis was confirmed based on published criteria. Two GI radiologists reviewed CT and MR enterography (CTE/MRE) exams in consensus of confirmed patients to characterize the imaging features of CMUSE. Eight patients with confirmed CMUSE diagnosis were included for image review, and 9 CTEs and 1 MRE were analyzed. Most patients were males (75%) with a median age at diagnosis of 59.5 years (25-71) presenting with iron deficiency anemia (75%). Patients were commonly refractory (87.5%) to their first therapy, including steroids, with half being refractory to surgical intervention. Major imaging features included multiple (≥ 5; 88%; 7/8), short (< 2 cm; 100%; 8/8), circumferential (100%; 8/8) strictures with moderate wall thickening (6-9 cm), and stratified hyper enhancement (100%; 8/8) located in the ileum (100%; 8/8). Median proximal small bowel dilation was 2.95 cm (2.5-4.1 cm). No CMUSE cases demonstrated penetrating disease (e.g., abscess, fistula). CT and MR enterography are invaluable tools in the multidisciplinary diagnostic evaluation of CMUSE, a rare cause of small bowel strictures with overlapping clinical and imaging features of Crohn's disease and NSAID enteropathy.

CRYPTOGENIC MULTIFOCAL ULCEROUS STENOSING ENTERITIS (CMUSE): A 20-YEAR SINGLE CENTER CLINICAL AND RADIOLOGIC EXPERIENCE

Abstract Background Cryptogenic multifocal ulcerous stenosing enteritis (CMUSE) is a rare illness characterized by multiple strictures and shallow ulcers of the small bowel. Even though diagnostic criteria have been described, further ellucidation is needed on therapeutic interventions and potential discriminating factors between CMUSE and other more common causes of intestinal ulcerations, including Crohn’s disease. Aim The purpose of this article is to report the clinical, CT, and MR enterography characteristics of confirmed cases of CMUSE. Materials and Methods Retrospective review of electronic medical records identified 33 patients considered for a diagnosis CMUSE. Diagnosis was confirmed if all requirements of the previously published diagnostic criteria for CMUSE were met. Patients were excluded if they had less than one year follow-up or incomplete clinical data. Two GI radiologists reviewed all CT and MR enterography (CTE/MRE) exams in consensus of confirmed patients to characterize the cross sectional imaging features. Results CMUSE was confirmed in 9 patients (27%) and 24 patients (73%) had a confirmed alternative diagnosis. Crohn’s disease (CD) (30%, n=7) and drug-induced enteropathy (30%, n=7) were the most frequent alternative. Male gender (66.7% vs. 25%, p=0.04) and clinical manifestation of anemia at presentation were more commonly observed on CMUSE-confirmed cases (66.7% vs. 4.2%, p=0.005) when compared to patients with non-CMUSE diagnosis, in which abdominal pain was the most common presenting symptom (44.5% vs 87.5%, p=0.02). Multiple (100%) and circumferential (75%) ulcers with restricted mucosal involvement (55.6%) were major features at endoscopy and pathology. Most common treatments were corticosteroids (78%) or surgical resection (55.6%), with 33% receiving biologics. Disease recurrence after first treatment occurred in the majority (88.9%) after a median time of 6 months (Table 1). 9 CTE and 1 MRE of 8 confirmed cases images were analyzed (Table 2). Major imaging features included multiple (≥ 5; 88%; 7/8), short (&amp;lt; 2 cm; 100%; 8/8) circumferential (100%;8/8) strictures with moderate wall thickening (6–9 cm), and stratified hyper enhancement (100%; 8/8) located in the ileum (100%; 8/8). Median proximal small bowel dilation was 2.95 cm (2.5–4.1 cm). Less common findings included: mesenteric adenopathy (50%; 4/8), increased mesenteric edema/ascites (38%; 3/8), mesenteric vascularity (25%; 2/8), colon inflammation (13%; 1/8), and decreased small bowel fold pattern (13%; 1/8). No patients with confirmed CMUSE cases demonstrated penetrating disease (e.g., abscess, fistula). Conclusion CMUSE is rare cause of small bowel strictures with overlapping clinical and imaging features of more common etiologies such as Crohn’s Disease and NSAID enteropathy that need to be excluded through a multidisciplinary approach to confirm the diagnosis.

Clinical and imaging characteristics of primary hepatic sarcomatoid carcinoma and sarcoma: a comparative study

BackgroundPrimary hepatic sarcomatous carcinoma (PHSC) and primary hepatic sarcoma (PHS) are rare malignancies with frequent overlap in both the clinic and radiology. No comparative study of these tumors for the restricted cases has previously been undertaken. The purpose of our study was to analyze the clinical and imaging features of PHSCs and PHSs, with an emphasis on particularities and similarities through a comparison of the two tumors.MethodsWe retrospectively analyzed the clinical and imaging features of 39 patients with pathologically proven PHSCs (n = 23) and PHSs (n = 16) from four university centers over a 9-year period from 2010 to 2019. Univariate analyses were performed to determine the consistent and distinctive features.ResultsThe background of chronic hepatitis or cirrhosis was observed with a high frequency in both of PHSCs (73.7%) and PHSs (62.5%). Tumors with a diameter greater than 10 cm were significantly more common in PHSs than PHSCs (p = 0.043) and cystic masses were more detected in PHSs (P = 0.041). Both PHSCs and PHSs mainly presented hypovascularity (78.3% vs 81.3%). The ring hyper enhancement on the arterial phase (AP) and wash out were more frequently seen in PHSCs and the iso-hypo enhancement on the AP followed persistent or progressive enhancement was more commonly detected in PHSs (all, p < 0.05).ConclusionPHSC and PHS generally present as mass lesions with hypovascularity. The ring hyper enhancement on the AP and wash out favor the diagnosis of PHSC. The large size greater than 10 cm, cystic lesion, iso-hypo persistent or progressive enhancement pattern might suggest the possibility of PHSs.

Preliminary study on the relationship between the contrast-enhanced ultrasonography of liver metastasis and the differentiation degree of neuroendocrine tumors

Objective To retrospectively analyze contrast-enhanced ultrasound (CEUS) manifestations of neuroendocrine tumors (NETs) liver metastases, and explore the relationship between CEUS parameters and differentiation of NETs. Methods From January 2014 to June 2018, 36 patients who had been performed CEUS due to liver metastasis of NETs with pathological diagnosis and immunohistochemical staining results were enrolled in this study. The CEUS findings of NETs liver metastases were summarized. According to the Ki-67 index, CgA results, and the stage G, the patients were divided into Ki-67>20% group and Ki-67≤20% group, CgA negative group and CgA positive group, and group G1+ G2 and group G3, respectively. The CEUS parameters of NETs liver metastases between the above groups were compared. Results In 36 lesions, during the arterial phase of CEUS, 66.7% (24/36) showed hyperenhancement, 16.7% (6/36) isoenhancement, 13.9% (5/36) rim-like enhancement, and 5.6% (2/36) hypoenhancement; During the portal phase, 13.9% (5/36) showed hyper or iso enhancement, 86.1% (31/36) showed hypoenhancement. The average washout time was (67.5±56.1)s, of which 5 (13.9%) lesions were washed out after 120 s. The mean starting washout time was statistically different between the CgA negative group and the positive group [(91.6±81.5)s vs (60.1±38.7)s, P=0.001]. There was no statistically significant difference in all observations between the group of Ki-67≤20% and >20%, group G1+ G2 and group G3(P>0.05). Conclusions CEUS of NETs liver metastasis has certain characteristics, among which hyperenhancement is its main enhancement mode, and some lesions have a longer wash out time. The relationship with the degree of differentiation needs further investigation. Key words: Ultrasonography; Contrast-enhanced ultrasound; Neuroendocrine neoplasms; Differentiation degree

Mycophenolate-Induced Colitis

Mycophenolate mofetil (MMF) is an immunosuppressive drug used in various autoimmune diseases, bone marrow and solid organ transplants. Gastrointestinal side effects occur in 45% of patients with diarrhea being the most common symptom (64-92%). Colitis is seen in around 9% of patients on MMF. Discontinuing MMF leads to resolution of diarrhea 98% of the time. We report a case of MMF-induced colitis diagnosed by colonoscopy and histopathology. This case illustrates challenges that were faced while managing refractory MMF-induced colitis. A 68-year-old man with a history of single lung transplant on MMF presented with 6-8 episodes of bloody diarrhea daily for the past 8 weeks. Physical exam: ill-appearing man with tenderness in the right lower quadrant and maroon colored stool on digital rectal exam. Laboratory studies revealed iron deficiency anemia with hemoglobin of 9.4 g/dL (baseline 11 g/dL). Cytomegalovirus, stool ova & parasites, tuberculosis, and clostridium difficile were negative. Magnetic resonance enterography of the abdomen showed small bowel wall thickening, 10 cm peri-enteric stranding of the distal terminal ileum extending to the ileo-colonic anastomosis (Fig 1). An EGD was normal, while colonoscopy revealed numerous ulcers in the ascending colon, ileo-colonic anastomosis, and in the distal 15 cm of the neo-terminal ileum (Fig 2). Histology of ulcer revealed mild crypt architectural distortion and crypt cell apoptosis (Fig 3). Three days after discontinuation of MMF, the patient continued to have bloody diarrhea requiring RBC transfusions. Intravenous (IV) Solumedrol 60 mg daily was initiated. After 5 days of IV Solumedrol, a repeat colonoscopy showed healing of numerous ulcerations and improvement in the appearance of the large ulcerations suggestive of overall endoscopic improvement. The patient was transitioned to oral steroids and steadily experienced clinical improvement. Since the advent of immunosuppression therapy, MMF-induced colitis is an uncommon however debilitating complication with only a few case reports to date and no current guidelines in the literature. There continues to be unanswered questions as to why some patients have refractory colitis, the benefits of oral or IV steroids, or biologic therapy (i.e. Infliximab), and the need for endoscopic reassessment for mucosal healing. With more cases being reported, we can better understand the natural course of the disease and formulate guidelines to manage refractory colitis1546_A Figure 1. Magnetic resonance enterography depicting small bowel wall thickening, mural hyper enhancement and peri-enteric stranding involving 10-cm segment of the distal terminal ileum.1546_B Figure 2. Colonoscopy revealing several deep punched out ulcers with heaped up edges in the ascending colon, ileo-colonic anastomosis, and terminal ileum.1546_C Figure 3. Hematoxylin and eosin photomicrograph of an ulcer biopsy demonstrating increased crypt cell apoptosis with mild architectural distortion. There is no evidence of active inflammation or viral cytopathic effect.

OC09.02

The purpose of this study was to explore the clinical value of CEUS in evaluating the effect of uterine artery embolisation (UAE) treatment in morbidly adherent placenta after delivery. Twenty two cases of morbidly adherent placenta accreta after delivery were examined by gray-scale ultrasound, colour Doppler ultrasound, and CEUS. All the patients undergone UAE combining with Methotrexate (MTX) and were followed up by CEUS. The images of the CEUS before and after UAE were compared. The time that the enhancement began before UAE in the lesion was earlier than that in the myometrium, p=0.007. The duration of enhancement before UAE in the lesion was longer than that in the myometrium, p=0.000. The PI and the lesion before UAE was higher than that of the normal myometrium, p=0.000. The lesion displayed hyper enhancement before UAE. The lesion displayed nonenhancement in 18 cases and isoenhancement in 4 cases after UAE. The 18 cases of nonenhancement expelled the placenta by dilation and curettage (D&C) completely 7 days after UAE, and the 4 cases of isoenhancement expelled part of the placenta by D&C and hysteroscope were performed 30 days after UAE. CEUS may be a useful tool for the quantitative assessment of uteroplacental vascularity in morbidly adherent placenta after delivery and may be used to follow up the conservative treatment. Supporting information can be found in the online version of this abstract Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

THE POSSIBILITIES OF CONTRAST-ENHACED ULTRASOUND (CEUS) IN THE DIAGNOSIS OF COLORECTAL LIVER METASTASES (CRLM)

AIM. To evaluate the capability of CEUS in the detection of CRLM in comparison with conventional grayscale B-mode. MATERIALS AND Mffl'HODS. 18 patents with CRLM underwent CEUS using the contrast agent SonoVue (Bracco, Italy). The patients were divided into two groups: the first group - 10 (55 %) patients before to chemotherapy; the second group - 8 (45 %) patients after chemotherapy and stable disease. The enhancement patterns of liver metastases were evaluated during the vascular phases: arterial, venous, and delayed. RESULTS. The enhancement patterns of liver metastases on CEUS were categorized as diffuse homogeneous enhancement (30 % - in the first group; such enhancement wasn't observed in the second group), rim-like hyper enhancement (70 % of the patients from the first group, 75 % of patients from the second group) and is enhancement, such as intact liver parenchyma (25 % of the patients from the second group). There were detected additional metastases in 4 (22,2 %) of patients 18 (100 %) in the delayed phase. There were significant differences in time of the beginning the vascular phases between patients from the first and second groups. The latest beginning of the wash-in stage was observed in liver metastases in patients from the second group (25,8 sec. from the injection of the contrast). The earliest beginning of the washout stage was observed in liver metastases in patients from the first group (42,4 sec. from the injection of contrast). CONCLUSION. CEUS improves visualization of CRLM, in comparison with the grayscale B-mode. It is also possible to apply this technique in the assessment of chemotherapy in patients with CRLM, as there was a difference between the moments of the beginning wash-in and wash-out stages.

Dynamic enhanced CT: is there a difference between liver metastases of gastroenteropancreatic neuroendocrine tumor and adenocarcinoma.

This study proposed to evaluate the feasibility of dynamic enhanced CT in differentiation of liver metastases of gastroenteropancreatic well-differentiated neuroendocrine tumors (GEP NETs) from GEP adenocarcinomas based on their characteristic features. CT images of 23 well-differentiated (G1 or G2) GEP NETs and 23 GEP adenocarcinomas patients with liver metastases were retrospectively reviewed. The distribution type, shape, intra-tumoral neovascularity, enhancement on hepatic artery phase, dynamic enhancement pattern and lymphadenopathy were subjective analyzed. Meanwhile, the size, number, CT value of tumor and adjacent normal liver parenchyma were measured and the metastasis-to-liver ratios were calculated objectively. Compared with GEP adenocarcinomas, the liver metastases of GEP NETs more frequently demonstrated a hyper enhancement on hepatic artery phase, washout dynamic enhancement pattern, absence of lymphadenopathy and higher metastasis-to-liver ratios on both hepatic artery phase and portal venous phase (P=0.017, P<0.001, P =0.038, P <0.001 and P =0.008, respectively). Logistic regression analysis showed that the dynamic enhancement pattern (P=0.012), and the metastasis-to-liver ratios on hepatic artery phase (P=0.009) were independent CT predictors for liver metastases of GEP NETs. The sensitivity and specificity of combing the two predictors in differentiation of liver metastases of GEP adenocarcinomas from GEP NET were 82.6% (19 of 23) and 91.3% (21 of 23), respectively. CT features are helpful in differentiating liver metastases of well-differentiated GEP NETs from that of GEP adenocarcinomas.

Value of the portal venous phase in evaluation of treated hepatocellular carcinoma following transcatheter arterial chemoembolisation

To evaluate the utility of the portal venous phase on multiphasic computed tomography (CT) after treatment of hepatocellular carcinoma (HCC) with trans-arterial chemoembolisation (TACE). This was a retrospective review of patients who underwent TACE for HCC between 1 April 2012 and 21 December 2014, with appropriate multiphasic, pre- and post-procedural CT examinations. The maximum non-contrast, arterial phase, and portal venous phase attenuation values of the tumour and tumour bed were evaluated within a region of interest (ROI), with values adjusted against background hepatic parenchyma. Linear regression analyses were performed for both the arterial and venous phases, to assess the level of enhancement and to determine if the venous phase had additional value in this setting. A total of 86 cases from 51 patients were reviewed. All pre-procedural CT examinations of lesions demonstrated arterial phase enhancement with portal venous and delayed phase washout compatible with HCC. The post-procedural CT examinations following TACE revealed expected decreased arterial enhancement. Sixty-five cases (76%) showed persistent non-enhancement on the portal venous phase following embolisation therapy. A total of 21 cases (24%), however, demonstrated progressive portal venous hyper enhancement. Linear regression analysis demonstrated a statistical significance between the difference in maximal arterial and portal venous enhancement in these cases. Following TACE, the treated lesion may demonstrate portal venous phase hyper-enhancement within the tumour bed. As such, full attention should be given to these images for comprehensive evaluation of tumour response following treatment.

A Case of Secondary Sclerosing Cholangitis in the Setting of Non-Hodgkinʼs Lymphoma

Introduction Sclerosing cholangitis represents a spectrum of cholestatic liver disease characterized by inflammation, fibrosis and stricture of the bile ducts. Magnetic resonance cholangiopancreatography (MRCP) typically shows multifocal strictures and dilatation of intra and extra-hepatic bile ducts displaying a “beaded” appearance. We present a case of secondary sclerosing cholangitis in the setting of anaplastic large cell lymphoma. Case Presentation A 67-year-old Caucasian female with a past history of recurrent breast cancer status post lumpectomy, radiation and hormonal therapy, presented with jaundice and an exophytic mass at the base of tongue. Laboratory data revealed ALP 953 U/L, total bilirubin 7.7 mg/dL, direct bilirubin 6.4 mg/dL, GGT 3369 U/L, albumin 3.1 g/dL, protein 6.9 g/dL, AST 195 U/L, ALT 149 U/L. A CT scan of the chest, abdomen and pelvis showed wide spread lymphadenopathy in the chest, abdomen and pelvis concerning for lymphoma, acute pancreatitis and biliary dilation with hyper enhancement of the common bile duct wall. An MRCP was performed which showed diffuse intrahepatic biliary ductal dilatation with non-visualization of the common hepatic duct bifurcation. Diffuse narrowing with multifocal stenosis of the proximal and distal aspects of the common bile duct was also seen. Findings were consistent with sclerosing cholangitis. Pathology of the oral lesion revealed ALK1+ anaplastic large cell lymphoma. Chemotherapy was initiated with cyclophosphamide, doxorubicin, adriamycin, vincristine, etoposide, and prednisone (CHOEP-14), and resulted in significant improvement in liver function tests. Patient continued to improve clinically and was discharged with close outpatient follow up. Discussion Previous reports have suggested that only 0.2 to 2.0 % of patients with NHL have biliary tract obstruction. The diagnosis of extra-hepatic bile duct obstruction related to lymphoma is challenging when it occurs as an initial presentation. The cholangiographic appearance of these lesions can resemble benign stricture, primary sclerosing cholangitis, cholangiocarcinoma, pancreatic carcinoma, or metastatic carcinoma. NHL as a secondary cause of sclerosing cholangitis has rarely been reported in literature. It is essential for gastroenterologists, oncologists and radiologists to recognize scelorsing cholangitis occurring secondary to systemic disease, as early initiation of treatment can improve clinical outcome, as happened in our case.Figure 1Figure 2

Gastrointestinal Amyloidosis: A Rare Cause of Chronic Diarrhea

Introduction: GI manifestations of amyloidosis include GI bleeding, malabsorption, protein losing enteropathy and rarely chronic gastrointestinal dysmotility. We present a case of amyloidosis-related chronic gastrointestinal dysmotility that presented as chronic diarrhea. Case: A 65 year old male was transferred from an outside hospital for a 6 month history of diarrhea and orthostatic hypotension. He had a history of diabetes and hypertension and had been hospitalized for a month prior to transfer. Orthostasis workup included CT head, carotid US, random cortisol and cosyntropin stimulation test which were all normal. Echocardiogram was done to rule out cardiac causes of orthostasis and showed an EF of 55%, mild LV hypertrophy and diastolic dysfunction. Chronic diarrhea workup included fecal leukocytes, Giardia stool antigen, C. difficile toxin PCR, stool microscopy and culture, US abdomen, CT abdomen, EGD, colonoscopy and celiac panel which were all normal. Orthostasis was felt to be due to volume depletion from diarrhea and autonomic dysfunction.On arrival he was notably orthostatic with BP dropping from 156/90mmHg to 74/44mmHg and was treated aggressively with IV fluids, increasing doses of fludrocortisone and midodrine. He continued to have 5-6 loose bowel movements daily despite loperamide. EMG showed advanced sensory and motor polyneuropathy thought to be due to DM. A repeat echo showed an EF of 60% and severe concentric LV hypertrophy with increased echogenicity. Cardiac MRI showed severe left ventricular hypertrophy with evidence of delayed hyper enhancement in the mesocardial anterior septum and anterolateral walls on delayed images consistent with cardiac amyloidosis. A fat pad biopsy followed by a repeat EGD and colonoscopy with duodenal and colonic biopsies were all positive for AL amyloid. Diarrhea improved with Lomotil and he was discharged with a follow up with Hematology. Discussion: Chronic diarrhea is a rare presentation of gastrointestinal amyloidosis. Only 3% of the cases of amyloidosis have biopsy proven amyloid involvement of the GI tract. Of these, approximately 80% have systemic amyloidosis at the time of diagnosis. Considering the non-specific appearance of GI amyloidosis on endoscopy/colonoscopy, the diagnosis requires a tissue biopsy with confirmatory staining or amyloid fibrils seen on electron microscopy. It is important to consider the diagnosis of amyloidosis while evaluating chronic diarrhea with other systemic manifestations.Figure 1Figure 2Figure 3

MP19-04 CT-BASED VOLUMETRIC CHARACTERIZATION OF RENAL CLEAR CELL CARCINOMA IN VON HIPPEL-LINDAU (VHL) USING NOVEL HISTOGRAM ANALYSIS.

You have accessJournal of UrologyImaging/Radiology: Uroradiology III1 Apr 2016MP19-04 CT-BASED VOLUMETRIC CHARACTERIZATION OF RENAL CLEAR CELL CARCINOMA IN VON HIPPEL-LINDAU (VHL) USING NOVEL HISTOGRAM ANALYSIS. Ashkan Malayeri, Amir Pourmorteza, Nikeith Shah, Rabindra Gautam, Alireza Yazdi, Jana Lovell, Shawna Boyle, Ishan Asokan, Ramaprasad Srinivasan, Adam Metwalli, and W. Marston Linehan Ashkan MalayeriAshkan Malayeri More articles by this author , Amir PourmortezaAmir Pourmorteza More articles by this author , Nikeith ShahNikeith Shah More articles by this author , Rabindra GautamRabindra Gautam More articles by this author , Alireza YazdiAlireza Yazdi More articles by this author , Jana LovellJana Lovell More articles by this author , Shawna BoyleShawna Boyle More articles by this author , Ishan AsokanIshan Asokan More articles by this author , Ramaprasad SrinivasanRamaprasad Srinivasan More articles by this author , Adam MetwalliAdam Metwalli More articles by this author , and W. Marston LinehanW. Marston Linehan More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.2752AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Current guidelines for follow-up of renal lesions in vHL are based on unidimensional or two-dimensional measurements with qualitative evaluation of complexity and enhancement of lesions. Here we evaluate the utility of 3D volumetric characterization of lesions and use automated histogram analysis to monitor the evolution of clear cell carcinoma in vHL patients. METHODS 79 lesions in 10 patients were selected by an experienced radiologist for volumetric analysis. Lesions were retrospectively followed between 3 – 8 years. Margins of the lesions were defined manually using a PACS integrated semi-automated tool, while vodlumetric and histogram analysis of lesions were performed in Matlab. Mean, standard deviation, skewness and kurtosis of the entire volume was calculated from the histogram data. The mean was used as an indicator of tumor enhancement. Degree of cystic and solid composition of the lesions was defined based on mean and skewness with tumor heterogeneity being defined as a measure of standard deviation and kurtosis. RESULTS The majority of the lesions were found to be solid [61 out of 79 (77%)]. The volume of 52 lesions increased during the follow-up period while 10 lesions decreased in volume. Remainder of the lesions did not grow or decrease in size during follow-up. 46 lesions were heterogeneous in density with 26 lesions increasing and 5 lesions decreasing in heterogeneity during the course of the follow-up (figure 1). 62 lesions demonstrated hyper enhancement. 32 lesions remained stable in enhancement during the course of follow-up, while 22 lesions showcased increasing enhancement during the same course of time. CONCLUSIONS Volumetric data and histogram analysis provides a more thorough snapshot of tumor development when compared to conventional RECIST measurements. Obtained data can be used as a gateway into the natural history of vHL, based on which, predictive models can be designed for optimal follow-up algorithms. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e204-e205 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Ashkan Malayeri More articles by this author Amir Pourmorteza More articles by this author Nikeith Shah More articles by this author Rabindra Gautam More articles by this author Alireza Yazdi More articles by this author Jana Lovell More articles by this author Shawna Boyle More articles by this author Ishan Asokan More articles by this author Ramaprasad Srinivasan More articles by this author Adam Metwalli More articles by this author W. Marston Linehan More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Prognostic significance of quantitative assessment of focal myocardial fibrosis in patients with heart failure with preserved ejection fraction

BackgroundThe aim of this study was to investigate the prognostic value of myocardial focal fibrosis quantified by late gadolinium enhanced (LGE) magnetic resonance imaging (MRI) in patients with heart failure with preserved ejection fraction (HFpEF). MethodsOne-hundred eleven HFpEF patients (mean age: 70±14years, 55 (50%) female) were enrolled. We excluded patients with previous history of coronary artery disease and/or ischemic pattern of hyper enhancement on LGE MRI. Myocardial enhancement was defined using signal intensity >2SD above the mean signal intensity of a remote myocardium. Major adverse cardiovascular events were defined as cardiovascular death and heart failure requiring hospitalization. ResultsDuring a mean follow up period of 851±609days, 10 events (2 cardiovascular death, 8 hospitalization for heart failure decompensation) were observed. Area under the receiver operating characteristics curve of LGE% for the detection of future events was 0.721 (95% CI: 0.628–0.802). Multivariate Cox proportional hazard analysis showed that LGE% is an independent predictor of future events after the adjustment with prognostic 5 factors – age, diabetes mellitus, New York Heart Association classification, history of heart failure hospitalization and left ventricular ejection fraction – which were identified in the I-PRESERVE study (Irbesartan in Heart Failure with Preserved Ejection Fraction Study) (hazard ratio=7.913, 95% CI: 1.603–39.05, P=0.012). ConclusionsLarger size of LGE was significantly associated with high rate of future cardiovascular death and heart failure hospitalization, suggesting that the quantification of myocardial focal fibrosis by LGE MRI could be useful for the risk stratification in HFpEF patients.