Preferred Imaging Modality Research Articles

Biparametric magnetic resonance imaging in the surveillance of testicular tumors following radical orchiectomy.

Computed tomography has been considered the preferred imaging modality for the surveillance of patients with testicular tumors (TTs) following radical orchiectomy. However, because of the concerns of frequent radiation exposure and intravenous iodinated contrast, biparametric magnetic resonance imaging (bpMRI) is a valid and safer alternative in the surveillance of patients with TT, instead of multiparametric magnetic resonance imaging. In this review article, we propose a protocol algorithm that utilizes bpMRI in the evaluation of patients after radical orchiectomy for TTs.

Practical Imaging Strategies for Intussusception in Children.

OBJECTIVE. Intussusception is the most common cause of intestinal obstruction in young children. Radiology has a key role in its diagnosis and treatment. This systematic review summarizes the currently available evidence for best practices in radiologic management of pediatric intussusception. CONCLUSION. High diagnostic accuracy and lack of ionizing radiation make ultrasound (US) the preferred imaging modality for diagnosing intussusception. For intussusception reduction, fluoroscopy-guided pneumatic enema and US-guided hydrostatic enema are equally dependable and safe techniques. The areas that warrant further research in this field include the efficacy and safety of the US-guided pneumatic enema, potential benefits of sedation and general anesthesia for the reduction procedure, and the optimal management of intussusceptions potentially involving pathologic lead points.

S3526 Parvimonas Micra Liver Abscess and Diverticulitis in an Immunocompetent Host: A Case Report

INTRODUCTION: Parvimonas micra (P.micra) is a Gram-positive (GP) anaerobic species, known as a commensal of the oral cavity and a common cause of periodontitis. It is reported twice in the literature as the infectious agent causing hepatic abscesses. Herein we present the case of multiloculated liver abscess and diverticulitis caused by P.micra. CASE DESCRIPTION/METHODS: A 54-year-old healthy man presented to the hospital for fever, malaise, and fifteen lbs weight loss for two weeks. Initial evaluation revealed a temperature of 102.9F, heart rate of 108, and blood pressure of 124/60mmHg. The physical examination was non-contributory. Laboratory studies revealed leukocytosis 23.67k/uL, AST 50U/L, ALT 80U/L, ALP 1015U/L, total bilirubin 0.5mg/dL. A CT-scan of the abdomen with intravenous contrast showed two multiloculated liver abscesses with sigmoid diverticulitis (Figure). Empiric antibiotics therapy with ceftriaxone and metronidazole was started. Blood cultures at admission were negative. The patient underwent ultrasound-guided drainage of the abscesses with the placement of 2 drainage catheters. The culture revealed P.micra. Antibiotics were switched to oral Amoxicillin/Clavulanic-acid. Follow-up colonoscopy showed sigmoid diverticulosis without evidence of malignancy. A repeat CT-scan confirmed abscesses resolution. DISCUSSION: Pyogenic liver abscess is a rare disease in the US, with an annual incidence of 2.9–3.6 cases/100,000 individuals. Biliary tract infections are the most common etiology. Seeding from diverticulitis or appendicitis through the portal vein is the second. PLA is often polymicrobial. Parvimonas micra is an anaerobic GP coccus. It is known to cause periodontitis in immunocompromised patients. Only 2 cases of liver abscesses secondary to P.micra have been reported, but none was associated with diverticulitis. Blood cultures are positive in half of the cases of PLA, with lower rates in anaerobes. Abscess culture has higher sensitivities (up to 80%). CT scan is the preferred imaging modality. Therapy includes antibiotics, percutaneous drainage of the abscess, and treatment of the underlying cause. Empiric antibiotic should cover GP cocci, gram-negative bacilli, and anaerobes. P.micra is highly susceptible to antibiotics. Surgical drainage is reserved for multilocular and larger abscesses. PLA remains a challenging disease despite advancements in diagnostic imaging and treatment. It is vital to screen for the associated conditions and rare organisms for successful therapy.Figure 1.: Liver abscess.Figure 2.: diverticulitis.

S2087 Endoscopic Cap-Assisted Retrieval of a Fishbone in the Esophagus

INTRODUCTION: Foreign body ingestion is a common cause of dysphagia and odynophagia. Common presenting symptoms can include dysphagia and odynophagia as previously mentioned, as well as chest pain/pressure, globus sensation, nausea, vomiting, or neck pain. While the majority of foreign bodies will pass spontaneously, a subset can become stuck and require retrieval. Cap-assisted endoscopic retrieval can aid in removal of the foreign body. We present a case of a patient who presented with odynophagia and globus sensation found to have a fishbone in his esophagus after eating fish for dinner. CASE DESCRIPTION/METHODS: The patient is a 62 year old male without significant past medical history who presented to the emergency department with odynophagia and a globus sensation. He was eating fish for dinner and felt as though a piece became stuck in his throat and presented to the ED for evaluation. CT scan of the neck showed a fishbone horizontally stuck in the esophagus at the level of C6 with penetration of the esophageal wall and extraluminal air. The patient went for upper endoscopy where a 2.5 cm fishbone was found in the proximal esophagus, lodged into both walls. A transparent cap was employed during the endoscopic retrieval. The foreign body was then removed with a Raptor grasping device and hemostatic clips were places along the perforated esophageal edges to repair the tear. He subsequently had a barium esophagram, which showed no esophageal leak. His diet was advanced successfully and he was discharged on a 7-day course of augmentin. DISCUSSION: Obtaining a reliable patient history is paramount in determining the correct diagnosis. If the clinical history prompts a high degree of suspicion, obtaining CT scan is the preferred imaging modality. Once the presence of a foreign body is confirmed on imaging, it can be retrieved via endoscopy. Utilizing endoscopic caps can aid in the visualization and retrieval of foreign bodies in the gastrointestinal tract. As seen with our patient, his clinical history created a high suspicion, prompting CT scan, which confirmed the presence of a fishbone lodged in the esophagus. The foreign body was retrieved via upper endoscopy the following morning with improvement in symptoms. His course was notable for esophageal wall penetration, which was successfully repaired endoscopically.Figure 1.: Foreign body in the esophagus with a clear cap in view.

S2690 You Cannot Ignore Abdominal Dropsy: A Rare and a Fateful Presentation

INTRODUCTION: Angiosarcoma (AS) is a rare soft tissue sarcoma known to be one of the aggressive malignancies which carry a poor prognosis with 5- year overall survival reported at <43%. AS mainly originates from the breast (35%) and skin (20%), followed by soft tissue (13%) involvement. Hepatic AS accounts for only 0.5%–2% of primary hepatic malignancies. CASE DESCRIPTION/METHODS: A 56-year-old male presents with abdominal pain and 20-pound weight loss for the past two months. His abdomen appeared tense and distended. Results showed a hemoglobin 6.1 gm/dL, platelet count 63 × 103 /mm3, total bilirubin of 3.2 mg/dL, ALP 315 IU/L, AST 305 IU/L, ALT 209 IU/L, and albumin of 2.6 gm/dL. A CT of the abdomen showed multiple hypodense lesions in the liver, and spleen with the peripheral enhancement of the contrast [Figure 1A] suggestive of metastatic lesions. Colonoscopy was normal and EGD demonstrated multiple erythematous nodular lesions in the gastric body [Figure 1B] and duodenum [Figure 1C], biopsies of which were inconclusive. A CT guided liver biopsy showed small aggregates of anastomosing vascular channels with highly atypical cells suggestive of AS [Figure 2A]. Tumour cells were positive for CD-34 [Figure 2B] and focally positive for Factor VIII [Figure 2C]. The patient deteriorated very rapidly and died 2 weeks later due to cardiac arrest. DISCUSSION: Hepatic AS is more commonly seen in males (3:1) with a median age of the presentation around the 5th- 6th decade. Use of anabolic steroids, oral contraceptives, exposure to radiation, and chemicals like arsenic, vinyl chloride, and thorium dioxide are certain risk factors for the development of hepatic angiosarcoma. Often patients report non-specific symptoms such as abdominal pain, anemia, weight loss, fever, fatigue, however, can present with jaundice and ascites in case of advanced disease. Rare but spontaneous rupture of the liver and intraabdominal bleeding can also occur in patients with hepatic AS. Tumor size, visceral tissue involvement, the presence of necrosis, and metastatic disease at the initial presentation are some of the poor prognostic factors. CT angiography is the preferred imaging modality. Pathological diagnosis is often required. Median survival is approximately 6 months without any treatment. Surgery can be considered if they are localized to a lobe. Chemotherapy can be offered for palliation in cases of advanced and multifocal disease. Because of a high recurrence rate, liver transplant is generally not recommended for hepatic AS.Figure 1.: A. (From top to bottom) CT of the abdomen showed multiple hypodense lesions in the liver. B. EGD demonstrated multiple erythematous nodular lesions in the gastric body. C. EGD demonstrated multiple erythematous nodular lesions in theduodenum.Figure 2.: A: Liver biopsy showed small aggregates of anastomosing vascular channels with highly atypical cells suggestive of AS. B: Tumour cells positive for CD-34. C: Focally positive for Factor VIII.

S3029 Unexpected Diagnosis of Worsening Abdominal Distension

INTRODUCTION: Gastrointestinal stromal tumors (GISTs) constitute about 1% of primary gastrointestinal cancers. Primary omental GIST without gastrointestinal involvement (extra-gastrointestinal stromal tumor or EGIST) is extremely rare. We present a case of EGIST with peritoneal metastases and partial response to Imatinib. CASE DESCRIPTION/METHODS: A 68-year-old Caucasian male with a history of coronary artery disease and chronic obstructive lung disease presented with shortness of breath and progressively worsening abdominal distension for several months. Labs were significant for hemoglobin of 10.8 g/dL and positive fecal occult blood test. Computed tomography (CT) of the abdomen and pelvis revealed innumerable masses in the peritoneum and omentum (Figure 1), with no solid visceral abnormality. CT-guided core biopsy of an omental mass revealed cluster spindle cells diffusely positive for c-kit (CD117) (Figure 2) and CD34, with negative stains for cytokeratin 5/6, D2-40, calretinin, cytokeratin AE1/3, Melan-A, S-100, and actin, consistent with EGIST. Subsequent esophagogastroduodenoscopy and colonoscopy with biopsy did not reveal any neoplastic lesion. His symptoms dramatically improved with Imatinib. Follow-up CT scan 3 months later showed partial remission (Figure 3). DISCUSSION: Primary omental stromal tumors without GI tract involvement or attachment are exceedingly rare. Classic GISTs originate from the interstitial cells of Cajal (ICCs) or their stem cells. EGISTs share the same immunophenotype despite arising outside of GI tract, as the tumors either lose their original connection with GI tract or originate from ICC-like precursor cells dispersed during fetal development. The most common symptoms associated with omental stromal tumors are abdominal distension and pain. The tumors are often found as large masses as they tend not to cause obstruction and associated symptoms at earlier stages. CT is the preferred imaging modality for identification of the primary tumors and metastases. Endoscopy can be used to obtain additional information and biopsy. There are no established treatment guidelines for EGIST, and the guidelines developed for GIST are typically used for management of EGIST. Surgery is the primary treatment for localized disease. In our case, Imatinib was utilized due to numerous non-resectable masses, leading to partial remission. More studies are needed to better understand the pathophysiology and evaluate treatment options for EGIST.Figure 1.: Initial abdominal CT revealed extensive lymphadenopathy and multiple soft tissue masses in the peritoneum and omentum.Figure 2.: The biopsied mass was mostly made of cluster spindle cells with high cellularity and frequent mitotic activity, with diffusely positive stain for CD117/c-KIT, a key proto-oncogene activated in GISTs.Figure 3.: A repeat abdominal CT, in 3 months after the diagnosis, showed partial response to Imatinib.

The Diagnosis and Treatment of Adult Patients with SAPHO Syndrome: Controversies Revealed in a Multidisciplinary International Survey of Physicians

IntroductionThis study aimed to investigate the current practice in the diagnosis and treatment of SAPHO syndrome among the international rheumatology and dermatology communities.MethodsWe conducted an electronic survey among the members of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA), the Japan Spondyloarthritis, and Israeli Societies of Rheumatology.ResultsA total of 78 physicians participated in the survey: rheumatologists (83%, n = 65), dermatologists (11.5%, n = 9), and orthopedics (3.8%, n = 3). SAPHO was considered a subtype of spondyloarthritis by 48.7% (n = 38), a subtype of psoriatic arthritis by 19.2% (n = 15), a separate entity by 25.6% (n = 20), and a subtype of reactive arthritis by 6.4% (n = 5). Palmoplantar pustulosis was the most prevalent cutaneous manifestation (n = 44, 56.4%) and anterior chest pain—the most prevalent osteoarticular manifestation (n = 66, 84.6%). The majority (84.6%, n = 66) voted for the update of the present diagnostic criteria by Khan 1994. Magnetic resonance imaging was considered the preferred imaging modality for the diagnosis of SAPHO by 41% (n = 32). Conduction of bone biopsy for diagnosis of non-infectious osteitis was supported only by 10.3% (n = 8). Patient-reported outcomes were considered the most appropriate measure for the assessment of disease activity by 47.4% (n = 37). The treatment approach was overall similar among the rheumatology and dermatology communities, including non-steroidal anti-inflammatory drugs, bisphosphonates, conventional disease-modifying anti-inflammatory drugs, and biologics.ConclusionsOur study underlines the controversy on diagnosis and treatment of SAPHO syndrome among specialists in rheumatology and dermatology and emphasizes an unmet need for update and validation of diagnostic criteria and treatment approach.

The utility of abdominal ultrasonography in the diagnosis of fungal infections in children: a narrative review.

In paediatric patients, ultrasonography is one of the preferred medical imaging modalities due to the lack of ionising radiation. Abdominal ultrasonography can be a useful tool in diagnosing cases of fungal infections but may introduce some risks for further infection in vulnerable patients or cause anxiety and discomfort. The aim of this narrative review is to analyse the utility of abdominal ultrasonography in diagnosing fungal infections in children in terms of its positive hit rates and utility in typical use. Text words and indexed terms related to ‘fungal infection and ultrasonography’ and ‘children’ were searched on MEDLINE, EMBASE, Cochrane Library and Scopus. Paediatric oncology patients, neonates and generally immunocompromised children were found to be at‐risk groups with increasing susceptibility to risk factors for contracting fungal infections. Abdominal ultrasonography was found to aid in the diagnosis of fungal infection in many cases, but not all patients with the identified risk factors were diagnosed with fungal infections and not all patients diagnosed with fungal infections had identified risk factors. Ultrasonography was found to be overutilised and the current decision process in requesting abdominal ultrasonography in diagnosing fungal infection should be revised. Further study into an effective criterion in requesting abdominal ultrasonography is suggested to reduce the overutilisation of ultrasonography, thus reducing risk of infection and discomfort while also saving time and money.

Nonlinearity in a Medical Ultrasound Probe Under High Excitation Voltage

Tissue harmonic imaging is often the preferred ultrasound imaging modality due to its ability to suppress reverberations. The method requires good control of the transmit stage of the ultrasound scanner, as harmonics in the transmitted ultrasound pulses will interfere with the harmonics generated in the tissue during nonlinear propagation, degrading image quality. In this study, a medical ultrasound probe used in tissue harmonic imaging was experimentally characterized for transmitted second-harmonic distortion to identify and compare the sources of nonlinear distortion in the probe and transmit electronics. The system was tested up to amplitudes above what is found during conventional operation, pushing the system to the limits in order to investigate the phenomenon. Under these conditions, second-harmonic levels up to -20 dB relative to the fundamental frequency were found in the ultrasound pulses transmitted from the probe. The transmit stage consists of high-voltage transmit electronics, cable, tuning inductors, and the acoustic stack. The contribution from the different stages in the ultrasound transmit chain was quantified by separating and measuring at different positions. Nonlinearities in the acoustic transducer stack were identified as the dominating source for second harmonics in the transmitted ultrasound pulses. Contribution from other components, e.g., transmit electronics and cable and tuning circuitry, were found to be negligible compared with that from the acoustic stack. Investigation of the stack's electrical impedance at different driving voltages revealed that the impedance changes significantly as a function of excitation voltage. The second-harmonic peak in the transmitted pulses can be explained by this nonlinear electrical impedance distorting the driving voltage and current.

Woven Coronary Artery Anomaly: Optical Coherence Tomography Versus Intravascular Ultrasound

Woven coronary artery anomaly is a rare congenital anomaly, and intravascular ultrasound and optical coherence tomography are useful for the diagnosis. We performed both imaging techniques for woven coronary artery anomaly and evaluated which was superior. We concluded that optical coherence tomography was the preferred imaging modality in this case. (Level of Difficulty: Intermediate.)

Perforator Mapping Practice for Deep Inferior Epigastric Artery Perforator Flap Reconstructions: A Survey of the Benelux Region.

Numerous new and novel imaging techniques for preoperative perforator selection in deep inferior epigastric artery perforator (DIEP) flap planning have been introduced. To what extent, these have been adopted into or replaced routine practice has hitherto remained unknown. The purpose of this study was to identify the currently preferred technique by reconstructive surgeons, the criteria that they regard as most relevant and what impact these have on the preoperative decision-making. An online survey consisting of 25 questions was sent to members of the Benelux Societies for Plastic Surgery. Information regarding experience and preferred imaging modality was requested. Specific questions addressed the utilization of computed tomography angiography (CTA) and factors that could inform preoperative perforator selection. Results were anonymously collected, managed using REDCap, and analyzed using Chi-square statistic. Seventy-nine principal surgeons could be included. A variation in surgeon experience was observed. On CTA, the preferred imaging modality, large-caliber vessels, the location of the perforator in the flap, and its intramuscular course were considered the most significant criteria. Surgeons doing more than 20 DIEP flaps per year are less concerned about the distance of the perforator from the umbilicus (p = 0.003) but more likely to choose a medial perforator (p = 0.011). No statistical difference was found in surgeons' experience between those who would choose and use one specific (medial or lateral) perforator when they are analogous on CTA, and those who would delay the decision until both perforators have been exposed. Advantages and disadvantages of the current practice of preoperative perforator selection by surgeons who are primarily responsible for harvesting a DIEP flap have been clearly identified. Indications are that these could be widely representative in which case, the quest for a protocol or modality that maximizes the benefit and minimizes harm in preoperative perforator mapping is urgently required.

Reliability and Agreement of Radiological and Pathological Tumor Size in Patients with Multiple Endocrine Neoplasia Type 1-Related Pancreatic Neuroendocrine Tumors: Results from a Population-Based Cohort

Background: Pancreatic neuroendocrine tumors (pNETs) have a high prevalence in patients with multiple endocrine neoplasia type 1 (MEN1) and are the leading cause of death. Tumor size is still regarded as the main prognostic factor and therefore used for surgical decision-making. We assessed reliability and agreement of radiological and pathological tumor size in a population-based cohort of patients with MEN1-related pNETs. Methods: Patients were selected from the Dutch MEN1 database if they had undergone a resection for a pNET between 2003 and 2018. Radiological (MRI, CT, and endoscopic ultrasonography [EUS]) and pathological tumor size were collected from patient records. Measures of agreement (Bland-Altman plots with limits of agreement [LoA] and absolute agreement) and reliability (intraclass correlation coefficients [ICC] and unweighted kappa) were calculated for continuous and categorized (< or ≥2 cm) pNET size. Results: In 73 included patients, the median radiological and pathological tumor sizes measured were 22 (3–160) and 21 (4–200) mm, respectively. Mean bias between radiological and pathological tumor size was −0.2 mm and LoA ranged from −12.9 to 12.6 mm. For the subgroups of MRI, CT, and EUS, LoA of radiological and pathological tumor size ranged from −9.6 to 10.9, −15.9 to 15.8, and −13.9 to 11.0, respectively. ICCs for the overall cohort, MRI, CT, and EUS were 0.80, 0.86, 0.75, and 0.76, respectively. Based on the 2 cm criterion, agreement was 81.5%; hence, 12 patients (18.5%) were classified differently between imaging and pathology. Absolute agreement and kappa values of MRI, CT, and EUS were 88.6, 85.7, and 75.0%, and 0.77, 0.71, and 0.50, respectively. Conclusion: Within a population-based cohort, MEN1-related pNET size was not systematically over- or underestimated on preoperative imaging. Based on agreement and reliability measures, MRI is the preferred imaging modality.

Comparison of Contractility Patterns on Left Ventriculogram Versus Longitudinal Strain by Echocardiography in Patients With Takotsubo Cardiomyopathy

BackgroundTakotsubo cardiomyopathy (TTC) is characterized by transient left ventricular (LV) dysfunction, electrocardiographic changes that can mimic acute myocardial infarction (MI), and release of myocardial enzymes in the absence of obstructive coronary artery disease (CAD). Conventionally, gross visual assessment of LV angiogram has been used to classify TTC. We aim to compare quantitative assessment of different regions of LV on angiogram and segmental strain on transthoracic echo to determine a better way to classify TTC rather than conventional qualitative visual assessment. MethodsWe conducted a retrospective observational study of 20 patients diagnosed with TTC who had LV angiogram and transthoracic echocardiograms performed on presentation that were suitable for analysis. Twenty LV angiograms were analyzed using Rubo DICOM viewer software. Areas of different LV regions were measured in diastole and systole, and percentage changes in area of these regions were calculated. Percentage changes in area of less than 10% was considered “akinetic." On the other hand, using echocardiograms of these patients, LV regional longitudinal strain (LS) was derived from speckle-tracking analysis. These findings were compared to determine concordance between both modalities. ResultsOn quantitative analysis of 20 LV angiograms, the area of all the three LV regional (apex, mid ventricle, and base) shortening (>10%) was observed in 16 patients (80%) during systole as compared to diastole. However, only 4 out of 20 patients (20%) were noted to have apical region area change of <10% between diastole and systole. Analysis of LV regional LS patterns of 20 patients showed that 14 patients had abnormal values (> −18%) in all three LV regions: apex, mid ventricle, and base. The apical region was the most severely affected region (mean LS −13.9%), followed by the basal region (mean −14.7%) and the mid ventricular region (mean −15.1%). Comparing the results of both modalities showed that there was 35% (n = 7) concordance in the results noted for base and apical regions of the LV, whereas only 20% (n = 4) concordance was noted in mid ventricular region. ConclusionContractility (shortening) on LV angiogram is present in a majority of patients in the three LV regions, but contractility assessed by LS is impaired in most of them. The concordance in both quantitative assessment modalities was low. LV angiogram may not be an accurate imaging modality to assess contractility patterns in Takotsubo patients, and echocardiographic LS analysis should be taken as the preferred imaging modality.

Cranial Suture Evaluation on Routine Pediatric MRI

The efficacy of magnetic resonance imaging (MRI) for evaluating sutures has not been well studied. CT with 3-dimensional reformats is currently the preferred modality for imaging the major cranial sutures. The role of MRI is primarily is for evaluating the brain for any concurrent malformations. Our objective was to evaluate the reliability of MRI when compared to CT for evaluation of cranial sutures. A list of 500 consecutive patients who underwent an MRI as well as a CT study was obtained. Studies were done between January 2011 and December 2016. The inclusion criteria required the 2 studies to be performed within 3 months of each other. All MRI studies were reviewed by a pediatric neuroradiologist to determine whether the sagittal, coronal, and lambdoid sutures were patent, fused or could not be assessed with confidence. In cases where a confident determination could not be made, the studies were reviewed with another pediatric neuro-radiologist and a decision made in concurrence. The CT scans were then evaluated in a similar fashion, after the MRI review was completed. The CT and MRI results were then compared to determine the accuracy of the MRI in assessing the sutures. Mean age of the studied children was 8.54 years. Seventy-two percent of the sagittal sutures were seen. When seen the sagittal suture was correctly identified in 98% of cases as either fused or patent. The lambdoid suture was seen in 94.3% of studies and was correctly designated as patent or fused in 99.6% of that subset of cases. The coronal suture was seen in 66.3% of the cases and when seen was always (100%) correctly designated. The probability of agreement between MRI and CT increased with age. The probability of sutures which were not seen decreased with age. The false negative and positives remained low for all ages. MRI is a viable tool for detection of cranial sutures. The 3-dimensional T1 Weighted sequence was particularly useful in suture evaluation. Although the visibility of sutures is inferior to that on a CT scan, if detected, the accuracy scan is fairly accurate in establishing fusion vs patency. It should be a part of routine surveillance on every pediatric neuro MRI study given the neurocognitive implications of incidental sutural synostosis.

Giant Uterine Fibroid in a Low Resources Setting: A Case Report

Background: Uterine leiomyomas represent the most common benign tumors of the female reproductive tract. Giant uterine leiomyomas are exceedingly rare neoplasm and represents a great diagnostic and therapeutic challenge. The aim of this publication is that though the present era is of advanced technology and minimally invasive surgery but this may not be available everywhere and feasible in every case. Diagnosis and management of giant uterine myoma should permit greater management flexibility with safe options, which must be tailored to the individual clinical situation.Case presentation: A 45-year old woman presented with a 12-month history of progressive increasing abdominal size, prolonged menstrual bleeding, menorrhagia, gradual weight gain, vague abdominal pressure sensations, dysmenorrhea, abdominal and pelvic pain, frequent urination, relative constipation and symptom of anemia but not in failure. Physical examination, laboratory evaluation and a trans-abdominal ultrasound were done and findings suggested a giant abdominal-pelvic mass. Abdominal supracervical hysterectomy with bilateral salpingo-oophorectomy was performed. Histologically, the specimen was 16.2 Kg uterine leiomyoma measuring 30/24/20 cm, intramural and subserosal myomatous, cellular leiomyoma that occurred without secondary changes, necrosis, cellular atypia, or mitosis.The patient’s postoperative progress was uneventful and she was discharged from the hospital on the seventh postoperative day.Conclusion: In uterine leiomyomas patient, the preferred imaging modality for initial evaluation is ultrasonography because it is the least invasive and most cost effective investigation especially in low resource settings where magnetic resonance imaging (MRI) and computed tomography (CT) Scan are usually not available and majority of the patients cannot afford its cost. The chosen treatment should be individualized, both severity of symptoms and patients desire to preserve fertility are very important. There is no single best approach to uterine fibroid treatment. However, women with giant uterine fibroids are best treated surgically and require adequate pre-operative preparations and an experienced skillful surgeon.&#x0D; Keywords: Giant uterine leiomyoma, diagnosis, supracervical hysterectomy.

52-Year-Old Woman With Fever, Diaphoresis, and Abdominal Pain

52-Year-Old Woman With Fever, Diaphoresis, and Abdominal Pain

Imaging of the Pediatric Acute Abdomen

Abstract The acute abdomen in the pediatric populations varies from adults, not only in the cause of the symptoms, but also in the imaging work up. The most frequent causes of the acute abdomen in the pediatric population are discussed, ordered approximately by age of symptom onset. The important findings on the preferred imaging modalities are highlighted including an overview on relevant fluoroscopic techniques. This article serves as a concise overview of disease states that are essential for any practicing radiologists to accurately diagnose.

Standardized Nomenclature and Surveillance Methodologies After Focal Therapy and Partial Gland Ablation for Localized Prostate Cancer: An International Multidisciplinary Consensus

BackgroundFocal therapy (FT) and partial gland ablation (PGA) are quickly adopted by urologists and radiologists as an option for the management of localized prostate cancer. ObjectiveTo find consensus on a standardized nomenclature and to define a follow-up guideline after FT and PGA for localized prostate cancer in clinical practice. Design, setting, and participantsA review of the literature identified controversial topics in the field of FT. Online questionnaires were distributed to experts during three rounds, with the goal to achieve consensus on debated topics. The consensus project was concluded with a face-to-face meeting in which final conclusions were formulated. Outcome measurements and statistical analysisControlled feedback of responses of previous rounds were summarized and returned to the participants allowing them to re-evaluate their decisions. The level of agreement to achieve consensus on a topic was set at 80%. Results and limitationsSixty-five experts participated in this interdisciplinary consensus study (72% urologists; 28% radiologists). The experts propose the use of the herein standardized nomenclature for ablative procedures. After FT/PGA, the following tests should be performed to assess treatment outcomes: prostate-specific antigen (PSA), imaging, biopsies, and functional outcome assessment. Although not a reliable marker for treatment failure, PSA should be measured every 3 mo in the 1st year and every 6 mo thereafter. Magnetic resonance imaging is the preferred image modality and should be performed at 6 and 18 mo after treatment. A systematic 12-core transrectal ultrasound-guided biopsy combined with a targeted biopsy of the treated area should be performed 6–12 mo after treatment. Functional outcomes should be obtained 3–6 mo after treatment for the first time and until stability is attained. ConclusionsThe panel recommends the use of the proposed nomenclature and follow-up protocols to generate reliable data supporting a broader implementation of FT as a standard of care for select patients with localized prostate cancer. Patient summaryIn this report, we present expert opinion on the use of a standardized nomenclature, and surveillance methodologies after focal therapy and partial gland ablation for localized prostate cancer.

Imaging of colorectal cancer liver metastases using contrast-enhanced US, multidetector CT, MRI, and FDG PET/CT: a meta-analysis

Imaging of colorectal cancer liver metastases (CRCLMs) has improved in recent years. Therefore, the role of current imaging techniques needs to be defined. To assess the diagnostic performance of contrast-enhanced ultrasound (CEUS), multidetector computed tomography (MDCT), magnetic resonance imaging (MRI), and fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT in the detection of CRCLMs. PubMed database was searched for articles published during 2000-2019. Inclusion criteria were as follows: diagnosis/suspicion of CRCLMs; CEUS, MDCT, MRI, or FDG PET/CT performed for the detection of CRCLMs; prospective study design; histopathologic examination, intraoperative findings and/or follow-up used as reference standard; and data for calculating sensitivity and specificity reported. Twelve prospective studies were assessed, including 536 patients with CRCLMs (n = 1335). On a per-lesion basis, the sensitivity of CEUS, MDCT, MRI, and FDG PET/CT was 86%, 84%, 89%, and 62%, respectively. MRI had the highest sensitivity on a per-lesion analysis. CEUS and MDCT had comparable sensitivities. On a per-patient basis, the sensitivity and specificity of CEUS, MDCT, MRI, and FDG PET/CT was 80% and 97%, 87% and 95%, 87% and 94%, and 96% and 97%, respectively. The per-patient sensitivities for MRI and MDCT were similar. The sensitivity for MRI was higher than that for CEUS, MDCT, and FDG PET/CT for lesions <10 mm and lesions at least 10 mm in size. Hepatospecific contrast agent did not improve diagnostic performances. MRI is the preferred imaging modality for evaluating CRCLMs. Both MDCT and CEUS can be used as alternatives.

Advances in the Diagnosis of Venous Thromboembolism: A Literature Review.

The incidence of venous thromboembolism (VTE), including lower extremity deep vein thrombosis (DVT) and pulmonary embolism (PE) is increasing. The increase in suspicion for VTE has lowered the threshold for performing imaging studies to confirm diagnosis of VTE. However, only 20% of suspected cases have a confirmed diagnosis of VTE. Development of pulmonary embolism rule-out criteria (PERC) and update in pre-test probability have changed the paradigm of ruling-out patient with low index of suspicion. The D-dimer test in conjunction to the pre-test probability has been utilized in VTE diagnosis. The age appropriate D-dimer cutoff and inclusion of YEARS algorithm (signs of the DVT, hemoptysis and whether PE is the likely diagnosis) for the D-dimer cutoff have been recent updates in the evaluation of suspected PE. Multi-detector computed tomography pulmonary angiography (CTPA) and compression ultrasound (CUS) are the preferred imaging modality to diagnose PE and DVT respectively. The VTE diagnostic algorithm do differ in pregnant individuals. The prerequisite of avoiding excessive radiation has recruited planar ventilation-perfusion (V/Q) scan as preferred in pregnant patients to evaluate for PE. The modification of CUS protocol with addition of the Valsalva maneuver should be performed while evaluating DVT in pregnant individual.