Clinical Radiology - Articles in Press

A proposed new imaging pathway for patients with suspected lung cancer - Corrected Proof

2012-02-02

Aims: PET-CT scans are routinely performed in patients with lung cancer after investigation by chest x-ray (CXR) and CT scan, when these have demonstrated potentially curable disease. If the majority of patients with lung cancer potentially suitable for curative treatment could be identified earlier in the diagnostic pathway on the basis of CXR findings they could be referred for PET-CT imaging without a prior CT scan. We investigated the clinical and financial implications of adopting such a strategy.Materials and methods: The details of 1187 patients referred with suspected lung cancer between July 2006 and August 2009 were analysed. The initial CXR and subsequent imaging of patients fit for curative treatment (Performance Status 0/1, FEV1 > 1.0) were reviewed (n = 251). The clinical and financial implications of referring patients for first line PET-CT if deemed potentially curable based on CXR findings were assessed.Results: 107 of 1187 patients had potentially curable lung cancer on PS, lung function, CT and PET-CT. 96 of these 107 patients (90%) were correctly identified on CXR. 149 patients overall were diagnosed as potentially curable on CXR. Referring suitable patients for an immediate PET-CT scan resulted in a reduction in the time to complete staging investigations.Conclusions: Early PET-CT scanning for patients with suspected lung cancer, potentially suitable for curative therapy could result in more efficient staging with little additional cost.

Value of subtraction MRI in assessing treatment response following image-guided loco-regional therapies for hepatocellular carcinoma - Corrected Proof

S.D. Winters, S. Jackson, G.A. Armstrong, I.W. Birchall, K.H.Y. Lee, G. Low — 2012-02-02

Aim: To compare contrast-enhanced subtraction magnetic resonance imaging (MRI) with contrast-enhanced standard MRI in assessing treatment response following loco-regional therapies for hepatocellular carcinoma (HCC).Method and materials: Institutional review board approval was obtained and informed consent was waived for this retrospective study. All patients were analysed from our institution’s liver tumour database that had loco-regional HCC therapy and the following: (1) a contrast-enhanced MRI ≤6 weeks post-treatment, (2) an unenhanced T1-weighted high-signal treatment zone (TZ) ≥1 cm, (3) follow-up contrast-enhanced MRI performed ≥6 months post-treatment. Randomized standard and subtraction TZ datasets were independently assessed by three blinded radiology readers for either complete treatment necrosis or residual disease. The standard of reference (SOR) comprised a consensus read by two radiologists with knowledge of the follow-up MRI and all available clinical data. Statistical analyses were performed using receiver operating characteristics (ROC), t-test, and kappa statistic.Results: Twenty-six patients (19 male and seven female patients; mean age 60 years, standard deviation 10.9 years, range 46–88 years) had a total of 45 corresponding HCCs and TZs. For ROC, the area under the curve (AUC) was 0.93 (subtraction protocol) versus 0.90 (standard protocol; p = 0.49). For the t-test, the mean reader confidence level was 4.4, 3.6, and 4.4 (subtraction protocol) versus 3, 3, and 3.7 (standard protocol; p ≤ 0.011). The kappa statistic for reader-to-SOR agreement was 0.83, 0.63, and 0.71 (subtraction protocol) versus 0.51, 0.36, and 0.64 (standard protocol).Conclusion: Subtraction MRI significantly improves the reader confidence level in the assessment of treatment response following loco-regional therapies for HCC.

Shoulder arthroplasty. Part 1: Prosthesis terminology and classification - Corrected Proof

B.D. Sheridan, N. Ahearn, A. Tasker, C. Wakeley, P. Sarangi — 2012-02-02

Shoulder arthroplasty is the third most common joint replacement procedure in the UK, and there are a number of different implant options available to surgeons to treat a variety of shoulder disorders. With an increasing burden placed on clinical follow-up, more patients are remaining under the care of their general practitioners and musculoskeletal triage assessment services and are not necessarily being seen by specialists. Referrals to orthopaedic specialists are therefore often prompted by radiological reports describing evidence of implant failure. This article is the first of two reviews on shoulder arthroplasty, concentrating on implant features and the indications for their use. The second article will address the modes of failure of shoulder arthroplasty and describe the relevant associated radiological features.

Re: Imaging male breast cancer - Corrected Proof

O. Westerland, A. Shaw, D. Howlett — 2012-02-02

Sir — We read with interest the recent review by Doyle et al., entitled “Imaging male breast cancer”, in which the imaging was reviewed of 20 cases of primary male breast cancer diagnosed at Derriford Hospital over a 10 year period. The majority of the patients in this series received a combination of mammography and targeted breast ultrasound. It is important to also raise the point that magnetic resonance imaging (MRI) is being increasingly used in imaging the male breast, and is an important diagnostic and problem-solving tool. Whilst combined clinical examination, conventional mammography, and ultrasound have been reported to have a high sensitivity and specificity, there are limitations to these techniques, particularly in the male breast. For example, benign disease, such as gynaecomastia, can mask an underlying malignancy. Additionally, as male breast cancer typically occurs in an eccentric, subareolar location, sonographic localization and evaluation of lesions can be made difficult by the dense acoustic shadowing of the nipple. The review by Doyle et al. concentrated on the traditional breast imaging techniques of mammography and ultrasound; however, it is increasingly being recognized that MRI can play a role in assessment of the symptomatic male breast.

Medico-legal issues in breast imaging - Corrected Proof

H.N. Purushothaman, R. Wilson, M.J. Michell — 2012-02-02

Aim: To identify medico-legal issues that occur in the diagnosis and radiological management of breast disease and to propose measures to reduce the risk of patient complaints and legal action in breast radiology and diagnosis.Materials and methods: Institutional review board approval was not applicable for this study. A retrospective study was undertaken and records of 120 medico-legal investigations over a 10 year period were examined. The reports were compiled by two consultant breast radiologists.Results: The mean age of the patients represented in this study was 48.3 years. The main complaint in this series was a delay in diagnosis (92%) followed by inappropriate or inadequate treatment (8%). 81% of cases were patients who had presented to the symptomatic clinic. The main presenting symptom was a palpable lump (65%). Substandard care was cited in 49/120 cases (41%). The mean average delay in diagnosis was 15.6 months. Of the cases cited as substandard care, 61% were considered the fault of the radiologist and 14% considered the fault of the breast surgeon. Of the cases where the radiologist was considered to be at fault, microcalcification was the most common mammographic sign to be missed or misinterpreted (12/26 cases, 46%).Conclusion: The most common complaint in this series was delay in diagnosis with microcalcification being the main mammographic sign that was either not seen or misinterpreted by the radiologist. Clear and precise written protocols are recommended for all breast imaging practice to ensure that medico-legal investigations will be greatly reduced.

The varied sonographic appearances of focal fatty liver disease: Review and diagnostic algorithm - Corrected Proof

2012-01-20

Focal fat infiltration and focal fat sparing of the liver are less common than diffuse fat infiltration but present a greater diagnostic conundrum. Although typical features of these conditions are well described, there is a wide variety of different appearances. These atypical patterns present significant difficulty in differentiation from other pathological processes and often require additional investigation. We present an innovative diagnostic algorithm and illustrate its effectiveness in diagnosing focal fatty liver disease with typical and atypical examples.

Efficacy and safety of embolization in iatrogenic traumatic uterine vascular malformations - Corrected Proof

2012-01-19

Aim: To retrospectively evaluate the efficacy of embolotherapy in patients with iatrogenic traumatic uterine arteriovenous malformations (AVMs).Materials and methods: A retrospective review of all patients who underwent uterine arterial embolization in Peking Union Medical College Hospital between January 2000 and December 2010 was performed. Forty-two patients were diagnosed with a uterine vascular malformation. All patients had obstetric manipulations before. Serial beta-human chorionic gonadotropin (β-HCG) levels were measured to exclude gestational trophoblastic neoplasia. All patients underwent transcatheter embolization of bilateral uterine arteries. The complications, control of haemorrhage, and outcome of subsequent pregnancies were assessed.Results: A total of 49 embolization procedures were performed in 42 patients. Seven patients required repeated embolizations for recurrence of bleeding. The technical success rate of embolization was 100%. Bleeding was controlled in 35 of 42 patients (83%) after the first embolization procedures, and bleeding was controlled in another two patients who underwent repeat embolization at a median follow-up of 29 months (range 3 months to 5 years). The overall clinical success rate was 88% (37/42). Thirteen patients subsequently became pregnant and eight of 13 patients had uneventful intrauterine pregnancies carried to term. Seven patients had post-embolization syndrome and no other complication occurred.Conclusion: Percutaneous embolotherapy is a safe and effective treatment for traumatic AVMs. Future pregnancy is still possible after embolization.

Infections and infestations of the gastrointestinal tract. Part 1: Bacterial, viral and fungal infections - Corrected Proof

R. Sinha, A. Rajesh, S. Rawat, P. Rajiah, I. Ramachandran — 2012-01-18

The purpose of this article is to review the imaging findings of various infections affecting the gastrointestinal tract. Barium examinations, computed tomography (CT), magnetic resonance imaging (MRI), and ultrasonography all play an important role in the diagnostic workup of gastrointestinal tract infections. Knowledge of differential diagnosis, sites of involvement, and typical imaging features of different infections can help in accurate diagnosis and guide treatment.

Respiratory disease in common variable immunodeficiency and other primary immunodeficiency disorders - Corrected Proof

2012-01-09

Respiratory disease is a significant cause of morbidity and mortality amongst patients with primary immunodeficiency disorders. Computed tomography (CT) plays an important role in the multidisciplinary approach to these conditions, in detecting, characterizing, and quantifying the extent of lung damage and in directing treatment. The aim of this review is to classify the primary immunodeficiency disorders and describe the thoracic complications and the associated CT findings whilst discussing the role of radiology in diagnosis and surveillance.

Small bowel MRI imaging in the DGH — Are you doing it yet? - Corrected Proof

C. Lee-Elliott, R. Ayer — 2012-01-09

The aim of this article is to illustrate the spectrum of disease visualized at small bowel magnetic resonance imaging (MRI) in the district general hospital (DGH) setting. The advantages and disadvantages of small bowel MRI, technique, and service implementation are discussed.

Making sense of postoperative CT imaging following laparoscopic partial nephrectomy - Corrected Proof

C.G. Lall, H.P. Patel, S. Fujimoto, S. Sandhu, C. Sundaram, J. Landman — 2012-01-09

The increasing popularity of laparoscopic partial nephrectomy (LPN) necessitates radiologists to become familiar with the operative techniques as well as normal and abnormal postoperative findings. Due to the varying presentation of abnormal changes following LPN and their similarities with other disease entities, radiologists should be cognizant of common pitfalls to avoid inadvertent misdiagnosis. A few common pitfalls discussed in this paper are the identification of laparoscopic port placement issues, recognizing a myriad of post-surgical materials, differentiating haemostatic materials from postoperative abscess and infection, non-absorbable suture material mimicking rim calcifications, as well as hints for differentiating exuberant granulation tissue from tumour recurrence.

Sentinel node identification using microbubbles and contrast-enhanced ultrasonography - Corrected Proof

A.R. Sever, P. Mills, S.E. Jones, W. Mali, P.A. Jones — 2012-01-09

Sentinel lymph node (SLN) biopsy has become the recommended method for surgical staging of the axilla in patients with breast cancer. Grey-scale axillary ultrasonography (US) combined with US-guided biopsy is a widely used preoperative staging procedure but has limited sensitivity. US contrast agent “microbubbles”, when injected intradermally, have been shown to have the potential to enter the breast lymphatics, travel rapidly to the axilla, and visualize the putative SLNs. This review illustrates the SLN identification technique using intradermal injection of microbubbles and contrast-enhanced US. The injection method, lymphatic visualization techniques, grey-scale and contrast-enhanced US images of the putative SLNs are reviewed and exemplified.

Prophylactic balloon occlusion of internal iliac arteries in women with placenta accreta: Literature review and analysis - Corrected Proof

M.D. Dilauro, S. Dason, S. Athreya — 2012-01-04

Aim: To review the literature on the use of prophylactic balloon occlusion alone and in conjunction with arterial embolization of the internal iliac arteries in women with placenta accreta.Materials and methods: The PubMed, MEDLINE, CINAHL, EMBASE, and Cochrane Library databases were searched for keywords related to this technique and its use in the avoidance of caesarean hysterectomy. The relevant published articles were selected and then searched for further references.Results: The literature search found 15 case reports and five studies for a total of 20 articles. The use of balloon catheters to prevent post-partum haemorrhage in women with placenta accreta is controversial with some investigators reporting reduced blood loss and transfusion requirements while others reporting no benefit. This procedure does not appear to reduce operative time or hospital stay. Some groups have described catheter-related complications, such as maternal thromboembolic events and the need for stent placement and/or arterial bypass. Thus far, there is no reported maternal or foetal mortality related to this procedure.Conclusion: Current evidence is based upon case reports and small retrospective studies. Larger studies or randomized controlled trials are essential in order to demonstrate the safety and efficacy of bilateral iliac balloon occlusion. The creation of a data registry would also facilitate the reporting of this technique.

CT appearances of abdominal tuberculosis - Corrected Proof

2012-01-04

The purpose of this article is to review and illustrate the spectrum of computed tomography (CT) appearances of abdominal tuberculosis. Tuberculosis can affect any organ or tissue in the abdomen, and can be mistaken for other inflammatory or neoplastic conditions. The most common sites of tuberculosis in the abdomen include lymph nodes, genitourinary tract, peritoneal cavity and gastrointestinal tract. The liver, spleen, biliary tract, pancreas and adrenals are rarely affected, but are more likely in HIV-seropositive patients and in miliary tuberculosis. This article should alert the radiologist to consider abdominal tuberculosis in the correct clinical setting to ensure timely diagnosis and enable appropriate treatment.

MRI features of the complete histopathological response of locally advanced rectal cancer to neoadjuvant chemoradiotherapy - Corrected Proof

J.M. Franklin, E.M. Anderson, F.V. Gleeson — 2012-01-04

Aim: To describe the post-chemoradiotherapy magnetic resonance imaging (MRI) features of locally advanced rectal carcinoma (LARC) in which there has been a complete histopathological response to neoadjuvant chemoradiotherapy (CRT).Materials and methods: This retrospective cohort study was performed between January 2005 and November 2009 at a regional cancer centre. Consecutive patients with LARC and a histopathological complete response to long-course CRT were identified. Pre- and post-treatment MRI images were reviewed using a proforma for predefined features and response criteria. ymrT0 was defined as the absence of residual abnormality on MRI.Results: Twenty patients were included in the study. Seven (35%) ypT0 tumours were ymrT0. All 13 ypT0 tumours not achieving ymrT0 appearances had a good radiological response, with at least 65% tumour reduction. The appearances were heterogeneous: in 11/13 patients the tumour was replaced by a region of at least 50% low signal on MRI, with 8/13 having ≥80% low signal, and 3/13 with 100% low signal.Conclusion: MRI may be useful in identifying a complete histopathological response. However, the MRI appearances of ypT0 tumours are heterogeneous and conventional MRI complete response criteria will not detect the majority of patients with a complete histopathological response.

Diagnostic accuracy of small intestine ultrasonography using an oral contrast agent in Crohn’s disease: Comparative study from the UK - Corrected Proof

S. Chatu, J. Pilcher, S.K. Saxena, D.H. Fry, R.C.G. Pollok — 2012-01-04

Aim: To evaluate the usefulness of small intestine contrast-enhanced ultrasonography (SICUS) using an oral contrast agent in routine clinical practice by assessing the level of agreement with the established techniques, small bowel follow-through (SBFT) and computed tomography (CT), and diagnostic accuracy compared with the final diagnosis in the detection of small bowel Crohn’s disease (CD) and luminal complications in a regional centre.Materials and methods: All symptomatic known or suspected cases of CD who underwent SICUS were retrospectively reviewed. The level of agreement between SICUS and SBFT, CT, histological findings, and C-reactive protein (CRP) level was assessed using kappa (κ) coefficient. Sensitivity was demonstrated using the final diagnosis as the reference standard defined by the outcome of clinical assessment, follow-up, and results of investigations other than SICUS.Results: One hundred and forty-three patients underwent SICUS of these 79 (55%) were female. Eighty-six (60%) were known to have CD and 57 (40%) had symptoms suggestive of intestinal disease with no previous diagnosis. Forty-six (55%) of the known CD patients had had at least one previous surgical resection. The sensitivity of SICUS in detecting active small bowel CD in known CD and undiagnosed cases was 93%. The kappa coefficient was 0.88 and 0.91 with SBFT and CT, respectively. SICUS detected nine patients who had one or more small bowel strictures and six patients with a fistula all detected by SBFT or CT.Conclusion: SICUS is not only comparable to SBFT and CT but avoids radiation exposure and should be more widely adopted in the UK as a primary diagnostic procedure and to monitor disease complications in patients with CD.

Radiographic features of primary cavitary sarcoidosis with “lotus seed-like” manifestations - Corrected Proof

F. Okada, Y. Ando, K. Sugisaki, S. Takikawa, A. Ono, S. Matsumoto, H. Mori — 2012-01-04

Sarcoidosis is a systemic disease of unknown cause resulting in the development of non-caseating granulomas that can affect all organs of the body, but with predominant pulmonary involvement. Pulmonary sarcoidosis has a wide variety of radiographic features. The most common computed tomography (CT) feature of pulmonary sarcoidosis is irregularly-thickened bronchovascular bundles that pathologically present as the presence of peribronchial granulomas. However, cavitary pulmonary lesions are uncommon, and in particular, true primary cavitary sarcoidosis extremely rare.

Three-dimensional gadolinium-enhanced MR venography to evaluate central venous steno-occlusive disease in hemodialysis patients - Corrected Proof

K. Gao, H. Jiang, R.Y. Zhai, J.F. Wang, B.J. Wei, Q. Huang — 2012-01-04

Aim: To determine the agreement and diagnostic accuracy of three-dimensional gadolinium-enhanced magnetic resonance venography (3D-Gd-MRV) in central venous steno-occlusive disease (CVSD) in haemodialysis patients.Materials and methods: Fourteen consecutive haemodialysis patients underwent interventional procedures to evaluate or treat CVSD. 3D-Gd-MRV was performed before the procedures and the results were compared with digital subtraction angiography (DSA).Results: DSA showed >50% stenosis in all 14 patients, 13 of whom were diagnosed correctly using 3D-Gd-MRV. Moderate stenosis was missed at 3D-Gd-MRV in one case whereby the indwelling dialysis central venous catheter may have caused an artefact on the images and hindered the accuracy of the result. The sensitivity of 3D-Gd-MRV in revealing stenosis was 93% (13/14). No complications caused by contrast agent toxicity occurred in any patient.Conclusion: 3D-Gd-MRV employing a non-breath-hold technique is highly sensitive in the diagnosis of CVSD and may be an alternative technique to DSA for the visualization of central veins.

Re: Digital infrared thermal imaging (DITI) of breast lesions: Sensitivity and specificity of detection of primary breast cancers - Corrected Proof

D. Kolarić, S. Antonini, M. Banić, I.A. Nola — 2012-01-03

Sir — We read with interest the paper by Kontos et al., especially in regard to the fact that one of the authors of this letter is one of the cited authors. Digital infrared thermal imaging (DITI) represents a readily available and biologically harmless method with increasing scientific and clinical interest for its use in diagnosing various inflammatory and malignant conditions, using standardized protocols and techniques. After careful reading of the mentioned article, we found the conclusions inconsistent and drawn after applying non-standardized protocols for use of DITI in such clinical setting (three thermographic imaging positions instead of five imaging positions). Furthermore, the authors of the article used a non-standardized protocol for evaluation of the obtained thermographic images. Surprisingly, by means of applying non-standardized methods, the results of the study indicate low sensitivity and higher specificity of DITI in diagnosing breast lesions, which is in contrast to the cited literature. According to the preliminary data of the present authors, it seems that DITI is a promising tool in evaluation of breast lesions, complementary to standard clinical protocols.

PET/CT in anal cancer — is it worth doing? - Corrected Proof

I.T. Wells, B.M. Fox — 2012-01-03

Aim: To evaluate the role of 2-[18F]-fluoro-2-deoxy-d-glucose (FDG) positron-emission tomography (PET)/ computed tomography (CT) in the current multidisciplinary management of anal cancer, both in initial staging and in follow-up post-treatment.Materials and methods: All patients referred to the region-wide multidisciplinary meeting for anal cancer during the study period received PET/CT imaging in addition to conventional imaging [CT and magnetic resonance imaging (MRI)]. Whether PET/CT altered the stage of the tumour from that suggested by conventional imaging was retrospectively assessed. The effect on management was evaluated.Results: Fifty PET/CT examinations were performed on 44 patients with anal cancer. Thirty were part of initial staging, and 20 were post-chemo/radiotherapy or surgery. Two PET/CTs produced inadequate contemporaneous conventional imaging to allow comparison. Overall PET/CT increased the stage of the anal cancer in 17% of cases (8/48), decreased the stage in 19% (9/48), and did not alter the stage in 65% (31/48). The tumour stage was altered more frequently in initial staging than in follow up imaging. The PET/CT findings altered patient management in 29% (14/48) of cases. The majority (11) of these were cases in which PET/CT was used as part of initial staging.Conclusion: PET/CT alters the initial staging sufficiently frequently that it should be used routinely in anal cancer, where it is available. The role of PET/CT in the follow-up of anal cancer is not as clear. Routine follow-up with PET/CT may not be justified, but selected use is of definite benefit in problem solving or if salvage surgery is planned, after multidisciplinary discussion.

Image-guided soft-tissue foreign body extraction — Success and pitfalls - Corrected Proof

Mike Bradley — 2011-12-30

Aim: To outline the pitfalls for image-guided percutaneous removal of foreign bodies (FBs).Materials and methods: Three hundred and fifty prospective patients were referred for ultrasound imaging for FB diagnosis and percutaneous removal during 2008–2010. Those patients with suitable FBs were offered guided percutaneous removal. The procedural methods and difficulties were recorded and all outcomes were noted, including surgical success and complications.Results: Sixty-three patients had a negative ultrasound for FB and they were discharged with no subsequent attendances. Of the remaining 287 patients, 12 were deemed unsuitable for percutaneous removal, 15 attempted percutaneous removals failed, and eight were not attempted due to lack of symptoms. The remaining 252 patients underwent successful retrieval and there were no procedural complications. The procedural limitations were mainly related to the anatomical site, type of FB, instrumentation, bubbles, ultrasound beam width, and mobility of the FB.Conclusion: Ultrasound-guided percutaneous removal of FBs is a safe and viable approach to the management of FBs achieving at least 88% success overall and with attention to the pitfalls, the learning curve should improve the success rate.

Emergency gastroduodenal artery embolization by sandwich technique for angiographically obvious and oblivious, endotherapy failed bleeding duodenal ulcers - Corrected Proof

G. Anil, A.G.S. Tan, H.-W. Cheong, K.-S. Ng, W.-C. Teoh — 2011-12-29

Aim: To determine the feasibility, safety, and efficacy of adopting a standardized protocol for emergency transarterial embolization (TAE) of the gastroduodenal artery (GDA) with a uniform sandwich technique in endotherapy-failed bleeding duodenal ulcers (DU).Materials and methods: Between December 2009 and December 2010, 15 patients with endotherapy-failed bleeding DU were underwent embolization. Irrespective of active extravasation, the segment of the GDA supplying the bleeding DU as indicated by endoscopically placed clips was embolized by a uniform sandwich technique with gelfoam between metallic coils. The clinical profile of the patients, re-bleeding, mortality rates, and response time of the intervention radiology team were recorded. The angioembolizations were reviewed for their technical success, clinical success, and complications. Mean duration of follow-up was 266.5 days.Results: Active contrast-medium extravasation was seen in three patients (20%). Early re-bleeding was noted in two patients (13.33%). No patient required surgery. There was 100% technical success, while primary and secondary clinical success rates for TAE were 86.6 and 93.3%, respectively. Focal pancreatitis was the single major procedure-related complication. There was no direct bleeding-DU-related death. The response time of the IR service averaged 150 min (range 60–360 min) with mean value of 170 min.Conclusion: Emergency embolization of the GDA using the sandwich technique is a safe and highly effective therapeutic option for bleeding DUs refractory to endotherapy. A prompt response from the IR service can be ensured with an institutional protocol in place for such common medical emergencies.

The role of ultrasound in the diagnosis and follow-up of early inflammatory arthritis - Corrected Proof

I.G. Hide — 2011-12-28

Spencer et al. present a comprehensive pictorial review of the role of musculoskeletal (MSK) ultrasound in the diagnosis and follow-up of patients with early inflammatory arthropathies. This cohort of patients can be difficult to investigate and manage, with diagnosis hinging on the detection or exclusion of erosions, synovitis and bone oedema (where erosions are not yet apparent) and where the emphasis is increasingly on early intervention with powerful disease-modifying therapies once an inflammatory diagnosis has been established.

Clinico-radiological features of subarachnoid hyperintensity on diffusion-weighted images in patients with meningitis - Corrected Proof

2011-12-22

Aim: To investigate the clinical and radiological features of meningitis with subarachnoid diffusion-weighted imaging (DWI) hyperintensity.Materials and methods: The clinical features, laboratory data, and radiological findings, including the number and distribution of subarachnoid DWI hyperintense lesions and other radiological abnormalities, of 18 patients seen at five institutions were evaluated.Results: The patients consisted of eight males and 10 females, whose ages ranged from 4 months to 82 years (median 65 years). Causative organisms were bacteria in 15 patients, including Haemophilus influenzae, Streptococcus pneumoniae, Streptococcus agalactiae, Staphylococcus aureus, Klebsiella pneumoniae, and Listeria monocytogenes. The remaining three were fungal meningitis caused by Cryptococcus neoformans. Subarachnoid DWI hyperintense lesions were multiple in 16 of the 18 cases (89%) and predominantly distributed around the frontal lobe in 16 of the 18 cases (89%). In addition to subarachnoid abnormality, subdural empyema, cerebral infarction, and intraventricular empyema were found in 50, 39, and 39%, respectively. Compared with paediatric patients, adult patients with bacterial meningitis tended to have poor prognoses (7/10 versus 1/5; p = 0.1).Conclusion: Both bacterial and fungal meningitis could cause subarachnoid hyperintensity on DWI, predominantly around the frontal lobe. This finding is often associated with poor prognosis in adult bacterial meningitis.

RE: Can MRI predict the diagnosis of endometrial carcinosarcoma? - Corrected Proof

N. Bharwani, A. Newland, N. Tunariu, S. Babar, A. Sahdev, A. Rockall, R. Reznek — 2011-12-21

Sir — We read with interest the recent study by Genever and Abdi into the magnetic resonance imaging (MRI) appearances of carcinosarcoma (malignant mixed Müllerian tumour; MMMT) of the uterus. They describe a simple and elegant measurement to raise the possibility of the diagnosis preoperatively.

Mesenchymal chondrosarcoma of the orbit: CT and MRI findings - Corrected Proof

B.T. Yang, Y.Z. Wang, X.Y. Wang, Z.C. Wang — 2011-12-19

Aim: To describe the computed tomography (CT) and magnetic resonance imaging (MRI) features of orbital mesenchymal chondrosarcomas (MCSs).Materials and methods: Six patients with histology-confirmed MCSs of the orbit were retrospectively reviewed. All six patients underwent CT and MRI. Imaging studies were evaluated for the following: (a) tumour location, (b) configuration, size, and margin, (c) CT attenuation and MRI signal intensity, and (d) secondary manifestations. Additionally, the time–intensity curve (TIC) of dynamic contrast-enhanced (DCE) MRI were analysed in five patients.Results: Two MCSs arose in the right orbit and four in the left orbit. Five MCSs were located in the retrobulbar intraconal space and one in the extraconal space. All the lesions displayed a lobulate configuration and had a well-defined margin. The mean maximum diameter was 25.8mm (range 15–36mm). On unenhanced CT, the lesions appeared isodense to grey matter in six patients, with calcifications in five. Two patients showed inhomogeneous, moderate enhancement on enhanced CT. Six MCSs appeared isointense on T1-weighted imaging and heterogeneously isointense on T2-weighted imaging. The lesions showed significantly heterogeneous contrast enhancement. Five patients had DCE MRI and the TICs showed a rapidly enhancing and rapid washout pattern (type III). The following features were also detected: compression of the extra-ocular muscle (six patients, 100%); displacement of the optic nerve (five patients, 83.3%); and encasing globe (three patients, 50%).Conclusions: A well-defined, lobulate orbital mass with calcification on CT and, marked heterogeneous enhancement and type III TIC on MRI are highly suspicious of orbital MCSs.

Re: Digital infrared thermal imaging (DITI) of breast lesions: Sensitivity and specificity of detection of primary breast cancers — A reply - Corrected Proof

M. Kontos, R. Wilson, I. Fentiman — 2011-12-19

Sir — Thank you for giving us the opportunity to respond. We are wrongly accused of drawing inconsistent conclusions from our data which indicate clearly the lack of usefulness of digital infrared thermal imaging (DITI) under the conditions of the test. Furthermore, it is stated that we did not use a standardized method. In fact we followed the manufacturer’s protocol and after imaging 50% of the patients, feedback on the quality of imaging was requested and obtained by the manufacturers. The protocol determined, amid various parameters, the number of images per patient, the position of the patient, the angle from which oblique images were taken and the room temperature. There was no need for close-up imaging due to the high resolution of the camera and digital image processing. The book to which they refer on standardized thermographic protocols was published after our study had been carried out.

Acceptability of virtual unenhanced CT of the aorta as a replacement for the conventional unenhanced phase - Corrected Proof

2011-12-16

Aim: To evaluate whether virtual unenhanced (VU) computed tomography (CT) images generated of the aorta were of sufficient quality to replace the conventional unenhanced (CU) images.Materials and methods: Forty-nine patients undergoing examination of the thoracic or abdominal aorta were examined using a dual-energy protocol. VU images were generated from the arterial phase images and compared to the CU images. Objective analysis was performed by drawing paired regions of interest (ROIs) within the thoracic and abdominal aorta and measuring the radiodensity in Hounsfield units attenuation within the ROIs. Subjective analysis was performed by two experienced readers evaluating the VU images in terms of noise, quality, calcium loss, and overall acceptability.Results: The attenuation was significantly higher in the VU images compared to the CU images within the thoracic aorta (p < 0.01) but not within the abdominal aorta (p = 0.15). Overall the VU images of the abdominal aorta were deemed acceptable as replacements for the CU images in 93% of cases. For the thoracic aorta, the VU images were deemed acceptable in only 12% of cases, primarily due to pulsation artefact.Conclusion: VU images of the abdominal aorta are acceptable as replacements for the CU images in the vast majority of cases; however, they are not suitable as replacements for the CU images of the thoracic aorta.

Re: Can MRI predict the diagnosis of endometrial carcinosarcoma? A reply - Corrected Proof

A.V. Genever, S. Abdi — 2011-12-16

Sir — We thank Reznek et al. for their comments on our recent article. It is interesting to note that these reviews were performed independently at similar times. Our aim was to produce a simple measurement to alert the reporting radiologist to the potential diagnosis of endometrial carcinosarcoma. Therefore, other features of magnetic resonance imaging (MRI) were not discussed in detail.

CT staging of colorectal cancer: What do you find in the chest? - Corrected Proof

A.S. McQueen, J. Scott — 2011-12-14

Aim: To clarify the chest computed tomography (CT) findings in patients with a new diagnosis of colorectal adenocarcinoma.Materials and methods: Patients diagnosed with colorectal cancer (CRC) over a 3-year period were retrospectively studied. All CT examinations were performed within a single NHS Trust using the same CT system and protocol. Two primary outcomes were assessed: the presence of pulmonary metastases and the identification of a significant, unexpected chest abnormality.Results: Five hundred and fourteen out of 568 (90.5%) CRC patients underwent complete CT staging. Thirty-one patients (6%) had lung metastases, of which four (0.8%) were isolated. Three hundred and fifty-three (68.7%) had no evidence of pulmonary metastases, but 130 (25.3%) had indeterminate lung nodules (ILNs). The ILNs of 12 patients were subsequently confirmed as metastases on follow-up. A major non-metastatic finding (pulmonary embolism or synchronous primary malignancy) was found in 15/514 patients (3%).Conclusions: Thoracic CT altered the initial TNM stage in fewer than 1% of CRC patients, but the detection of significant incidental chest disease and the establishment of an imaging baseline are useful outcomes of this imaging strategy. One-quarter of all staging examinations demonstrated ILNs.

Infections and infestations of the gastrointestinal tract. Part 2: Parasitic and other infections - Corrected Proof

R. Sinha, A. Rajesh, S. Rawat, P. Rajiah, I. Ramachandran — 2011-12-14

The purpose of this article is to provide a comprehensive review of the imaging findings of various parasitic infestations and other miscellaneous infections affecting the gastrointestinal tract. Barium examinations play an important role in the diagnostic workup of parasitic intestinal infections. Knowledge of differential diagnosis, sites of involvement, and imaging features of different infections and infestations can help in accurate diagnosis and guide treatment.

Feasibility and diagnostic accuracy of a low radiation exposure protocol for prospective ECG-triggering coronary MDCT angiography - Corrected Proof

2011-12-12

Aim: To compare the feasibility, accuracy, and effective radiation dose (ED) of multidetector computed tomography (MDCT) in the detection of coronary artery disease using a combined ED-saving strategy including prospective electrocardiogram (ECG) triggering with a short x-ray window and a body mass index (BMI)-adapted imaging protocol using adaptive statistical iterative reconstruction (ASIR; group 1), in comparison with a prospective ECG triggering strategy alone (group 2).Materials and methods: One hundred and seventy patients scheduled for invasive coronary angiography (ICA) were evaluated. Fourteen patients were not eligible for MDCT. The remaining 156 patients were randomized to group 1 (78 patients) and group 2 (78 patients). Eight and 11 patients in groups 1 and 2, respectively, were excluded after randomization because the patients’ heart rates were >65 beats/min. MDCT images were assessed for feasibility, signal-to-noise ration (SNR), and contrast-to-noise ratio (CNR), accuracy in detection of coronary stenoses >50% versus ICA and for ED.Results: The feasibility, SNR, CNR, accuracy in a segment-based and patient-based model were similar in both groups (97 versus 95%, 14.5±3.9 versus 14.2±4.1, 16±4.6 versus 16.5±4.4, 95 versus 94% and 97 versus 99%, respectively). The ED in group 1 was 72% lower than in group 2 (2.1±1.2 versus 7.5±1.8mSv, respectively; p<0.01).Conclusions: The use of a multi-parametric ED saving protocol results in a significant reduction in ED without a negative impact on accuracy.

Serum alpha-fetoprotein response can predict prognosis in hepatocellular carcinoma patients undergoing radiofrequency ablation therapy - Corrected Proof

2011-12-08

Aims: To evaluate the clinical inference of serum alpha-fetoprotein (AFP) response in hepatocellular carcinoma (HCC) patients undergoing percutaneous radiofrequency ablation (RFA).Materials and methods: Three hundred and thirteen previously untreated HCC patients were enrolled in the study. The optimal AFP response was defined as >20% decrease from baseline after 1 month of RFA for those with a baseline AFP level of ≥100 ng/ml. The impact of AFP response on prognosis was analysed and prognostic factors were assessed.Results: After a median follow-up of 26.7 ± 19.1 months, 49 patients died and 264 patients were alive. The cumulative 5 year survival rates were 75.3 and 57.4% in patients with an initial AFP of <100 ng/ml and ≥100 ng/ml, respectively (p = 0.003). In the 58 patients with a baseline AFP of ≥100 ng/ml and initial completed tumour necrosis after RFA, the cumulative 5 year survival rates were 62.4 and 25.7% in optimal and non-optimal AFP responders, respectively (p = 0.001). By multivariate analysis, the prothrombin time international normalized ratio >1.1 (p = 0.009), non-optimal AFP response (p = 0.023), and creatinine >1.5 mg/dl (p = 0.021) were independent risk factors predictive of poor overall survival. Besides, the cumulative 5 year recurrence rates were 83.4 and 100% in optimal and non-optimal AFP responders, respectively (p 2 cm (p = 0.027), and non-optimal AFP response (p < 0.001) were independent risk factors associated with tumour recurrence after RFA.Conclusions: Serum AFP response may be a useful marker for predicting prognosis in HCC patients undergoing RFA.

Magnetic navigation in ultrasound-guided interventional radiology procedures - Corrected Proof

H.-X. Xu, M.-D. Lu, L.-N. Liu, L.-H. Guo — 2011-12-08

Aim: To evaluate the usefulness of magnetic navigation in ultrasound (US)-guided interventional procedures.Materials and methods: Thirty-seven patients who were scheduled for US-guided interventional procedures (20 liver cancer ablation procedures and 17 other procedures) were included. Magnetic navigation with three-dimensional (3D) computed tomography (CT), magnetic resonance imaging (MRI), 3D US, and position-marking magnetic navigation were used for guidance. The influence on clinical outcome was also evaluated.Results: Magnetic navigation facilitated applicator placement in 15 of 20 ablation procedures for liver cancer in which multiple ablations were performed; enhanced guidance in two small liver cancers invisible on conventional US but visible at CT or MRI; and depicted the residual viable tumour after transcatheter arterial chemoembolization for liver cancer in one procedure. In four of 17 other interventional procedures, position-marking magnetic navigation increased the visualization of the needle tip. Magnetic navigation was beneficial in 11 (55%) of 20 ablation procedures; increased confidence but did not change management in five (25%); added some information but did not change management in two (10%); and made no change in two (10%). In the other 17 interventional procedures, the corresponding numbers were 1 (5.9%), 2 (11.7%), 7 (41.2%), and 7 (41.2%), respectively (p=0.002).Conclusion: Magnetic navigation in US-guided interventional procedure provides solutions in some difficult cases in which conventional US guidance is not suitable. It is especially useful in complicated interventional procedures such as ablation for liver cancer.

Neuroradiological findings and clinical features of fourth-ventricular meningioma: A study of 10 cases - Corrected Proof

B.-Y. Zhang, B. Yin, Y.-X. Li, J.-S. Wu, H. Chen, X.-Q. Wang, Dao-Ying Geng — 2011-12-08

Aim: To present the neuroradiological and clinical findings of fourth-ventricular meningiomas to increase awareness of this entity.Materials and methods: The computed tomography (CT; n=5), magnetic resonance imaging (MRI; n=9) features and clinical presentations of 10 patients with pathologically documented fourth-ventricular meningiomas were retrospectively analysed.Results: All tumours appeared as well-demarcated masses in the fourth ventricle at CT and MRI. The tumour shape was round in eight cases (80%) and irregular in two cases (20%). The CT images of five cases showed predominantly isoattenuation in three cases and high attenuation in two cases, with a mean attenuation value of 52HU. In addition, calcifications were seen in three cases. At MRI, nine masses were isointense (n=6) or hypointense (n=3) to grey matter on T1-weighted images and mildly hyperintense (n=4), isointense (n=3), hypointense (n=1), and of mixed signal intensity (n=1) on T2-weighted and fluid-attenuated inversion recovery (FLAIR) images. Signal voids were visible in two cases. Enhancement after injection of contrast material was marked homogeneous (n=5) or heterogeneous (n=5) on CT or T1-weighted images. Three tumours had mild peritumoural oedema. Three tumours were associated with obstructive hydrocephalus. The pathological subtype of the 10 meningiomas was fibromatous (n=5), atypical (n=2), and one each of transitional, psammomatous, and clear-cell type.Conclusion: Although fourth-ventricular meningioma is quite rare, it should be considered in differential diagnosis of neoplasms within the fourth ventricle. The relatively typical radiological appearance, combined the age and sex of patients, can suggest the diagnosis of fourth-ventricular meningioma.

Persistent or recurrent varicocoele after failed varicocoelectomy: Outcome in patients treated using percutaneous transcatheter embolization - Corrected Proof

J. Kim, J.H. Shin, H.K. Yoon, G.Y. Ko, D.I. Gwon, E.Y. Kim, K.B. Sung — 2011-12-06

Aim: To determine the efficacy of percutaneous transcatheter embolization in the management of patients with spermatic varicocoeles persisting or recurring after surgery.Materials and methods: Over a period of 10 years, 28 patients (age range 13–55 years) were referred for percutaneous transcatheter embolization of postsurgical, recurrent varicocoeles. Medical documents were retrospectively reviewed to evaluate past surgical history, subjective symptoms, and results of scrotal examination, ultrasound, and semen parameters. Pre-embolization venograms were analysed to assess the anatomy of the testicular vein. The technical and clinical outcomes of embolization were then determined.Results: The 28 patients included in the study had undergone laparoscopic varicocoelectomy (39.3%), high retroperitoneal ligation (25%), or inguinal ligation (25%). Subjective symptoms were scrotal pain (60.7%) and a palpable scrotal mass (50%) exclusively on the left side. Venograms revealed abnormalities of the left testicular vein in all cases. Embolization was technically successful in all but two cases, thus yielding an occlusion rate of 93%; a single case of suspected thrombophlebitis was the only complication. After excluding two, technically unsuccessful cases and one patient who was lost to follow-up, 25 patients underwent scrotal examination after embolization, which revealed complete resolution in 20 cases (80%), partial improvement in four cases (16%), and no improvement in a single case (4%). Among the follow-up group of patients, of the 12 who initially presented with scrotal pain, six (50%) were symptom-free and four (33.3%) had partial improvement.Conclusion: Percutaneous transcatheter embolization of the testicular vein is technically feasible and effective for managing postsurgical recurrent varicocoeles.

Nonenhanced ECG-gated quiescent-interval single-shot MRA (QISS-MRA) of the lower extremities: Comparison with contrast-enhanced MRA - Corrected Proof

2011-12-06

Aim: To evaluate electrocardiogram (ECG)-gated quiescent-interval single-shot magnetic resonance angiography (QISS-MRA) for nonenhanced assessment of peripheral artery occlusive disease (PAOD) using contrast-enhanced MRA (CE-MRA) as the reference standard.Materials and methods: Twenty-seven patients (mean age 66.6 ± 10.8 years) with PAOD were included in the study. QISS-MRA and CE-MRA of the lower extremity were performed using a 1.5 T MR scanner. In each patient, subjective image quality and the degree of stenosis were evaluated on a four-point scale for 15 predefined arterial segments.Results: Twenty-five of the 27 patients were considered for analysis. Subjective image quality of QISS-MRA was significantly lower for the distal aorta, pelvic arteries, and femoral arteries as compared to CE-MRA (p < 0.01), while no significant difference was found for other vascular segments. The degree of stenosis was overestimated with QISS-MRA in 23 of 365 (6.3%) segments and underestimated in two of 365 (0.5%) segments. As compared to CE-MRA, QISS-MRA had a high sensitivity (98.6%), specificity (96%) as well as positive and negative predictive value (88.7 and 99.6%, respectively) for the detection of significant stenosis (≥50%).Conclusion: ECG-gated QISS-MRA is a promising imaging technique for reliable assessment of PAOD without the use of contrast material.

Rosai–Dorfman disease presenting as multiple breast masses in an otherwise asymptomatic male patient - Corrected Proof

P. Baladandapani, Y. Hu, K. Kapoor, L. Merriam, P.R. Fisher — 2011-12-05

Rosai–Dorfman disease (also known as sinus histiocytosis with massive lymphadenopathy) is an uncommon, idiopathic, benign entity with a typical clinical presentation of massive painless cervical lymphadenopathy in an asymptomatic young patient. However, there is a broad spectrum of presentations ranging from asymptomatic solitary extranodal masses to widespread nodal and extranodal involvement. Breast involvement in Rosai–Dorfman disease is rare. The disease has been reported in the female breast as solitary or multiple breast masses with or without disseminated systemic disease. Two cases of Rosai–Dorfman disease involving the male breast were found upon literature review, one with purely cutaneous involvement and the second a solitary lesion involving breast parenchyma. No other case was found where the initial presentation was multiple breast masses in an otherwise healthy male patient. The present report describes the case of a 59-year-old man presenting with a palpable lump in the left breast.

MRCP and 3D LAVA imaging of extrahepatic cholangiocarcinoma at 3 T MRI - Corrected Proof

N. Li, C. Liu, W. Bi, X. Lin, H. Jiao, P. Zhao — 2011-12-05

Extrahepatic cholangiocarcinoma (CCA) is a primary bile duct malignant tumour with poor prognosis. Familiarity with their varied imaging characteristics can be helpful in developing a correct diagnosis and in optimal treatment planning, and thus contribute to a better prognosis. The purpose of this article is to illustrate the typical appearances of extrahepatic CCA on magnetic resonance cholangiopancreatography (MRCP) and three-dimensional (3D) LAVA (liver acquisition with volume acceleration) sequences at 3 T magnetic resonance imaging (MRI), and to discuss the superiority of the two techniques in the diagnosis of CCA.

Adnexal torsion — A multimodality imaging review - Corrected Proof

C. Wilkinson, A. Sanderson — 2011-12-05

Adnexal torsion is a gynaecological surgical emergency as prompt restoration of ovarian blood flow may prevent permanent irreversible damage. Patients frequently present with non-specific symptoms and signs and therefore adnexal torsion is often an unexpected radiological diagnosis. Although ultrasound is the initial imaging technique of choice in suspected adnexal torsion, many patients undergo computed tomography (CT) or magnetic resonance imaging (MRI) either as a first-line test following non-specific presentation, or as a confirmatory test following equivocal ultrasound findings. Using multiple techniques, this review illustrates the wide variety of imaging features observed in adnexal torsion enabling a confident diagnosis that may result in a more favourable surgical outcome.

MRI findings in acute Hendra virus meningoencephalitis - Corrected Proof

P. Nakka, G.J. Amos, N. Saad, S. Jeavons — 2011-12-02

Aim: To describe serial changes in brain magnetic resonance imaging (MRI) in acute human infection from two outbreaks of Hendra virus (HeV), relate these changes to disease prognosis, and compare HeV encephalitis to reported cases of Nipah virus encephalitis.Materials and methods: The MRI images of three human cases (two of which were fatal) of acute HeV meningoencephalitis were reviewed.Results: Cortical selectivity early in the disease is evident in all three patients, while deep white matter involvement appears to be a late and possibly premorbid finding. This apparent early grey matter selectivity may be related to viral biology or ribavirin pharmacokinetics. Neuronal loss is evident at MRI, and the rate of progression of MRI abnormalities can predict the outcome of the infection. In both fatal cases, the serial changes in the MRI picture mirrored the clinical course.Conclusion: This is the first comprehensive report of serial MRI findings in acute human cerebral HeV infection from two outbreaks. The cortical selectivity appears to be an early finding while deep white matter involvement a late, and possibly premorbid, finding. In both fatal cases, the serial changes in MRI mirrored the clinical course.

CNS cavernous haemangioma: “popcorn” in the brain and spinal cord - Corrected Proof

A.N. Hegde, S. Mohan, C.C.T. Lim — 2011-12-02

Cavernous haemangiomas (CH) are relatively uncommon non-shunting vascular malformations of the central nervous system and can present with seizures or with neurological deficits due to haemorrhage. Radiologists can often suggest the diagnosis of CH based on characteristic magnetic resonance imaging (MRI) features, thus avoiding further invasive procedures such as digital subtraction angiography or surgical biopsy. Although typical MRI appearance combined with the presence of multiple focal low signal lesions on T2*-weighted images or the presence of one or more developmental venous anomaly within the brain can improve the diagnostic confidence, serial imaging studies are often required if a solitary CH presents at a time when the imaging appearances had not yet matured to the typical “popcorn” appearance.

Extensive hemispheric diffusion restriction in haemolytic uremic syndrome - Corrected Proof

2011-11-28

Haemolytic uremic syndrome (HUS) is a rare multi-organ disease affecting predominantly children between 1 and 4 years of age with an incidence of 1 per 50,000. It is caused by verotoxin-producing enterohaemorrhagic Escherichia coli (EHEC) infection. Neurological symptoms are reported in 20–50% of cases and represent the major cause of morbidity and mortality in patients with HUS. The neurological symptoms vary widely and may include visual disturbances, seizures, alteration of consciousness, hemiparesis, and brainstem symptoms. The pathogenesis of the central nervous involvement is not fully understood. Putative mechanisms include thrombotic microangiopathy of cerebral arterioles, haemorrhage due to secondary coagulopathy, direct verotoxin neurotoxicity, and metabolic derangements. We report the case of child with typical HUS. Details of the clinical course and treatment have been reported by Lapeyraque et al.

Diffusion tensor imaging and 1H-MRS study on radiation-induced brain injury after nasopharyngeal carcinoma radiotherapy - Corrected Proof

H.-Z. Wang, S.-J. Qiu, X.-F. Lv, Y.-Y. Wang, Y. Liang, W.-F. Xiong, Z.-B. Ouyang — 2011-11-28

Aim: To investigate the metabolic characteristics of the temporal lobes following radiation therapy for nasopharyngeal carcinoma using diffusion tensor imaging (DTI) and proton magnetic resonance spectroscopy (1H-MRS).Materials and methods: DTI and 1H-MRS were performed in 48 patients after radiotherapy for nasopharyngeal carcinoma and in 24 healthy, age-matched controls. All patients and controls had normal findings on conventional MRI. Apparent diffusion coefficient (ADC), fractional anisotropy (FA), three eigenvalues λ1, λ2, λ3, N-acetylaspartic acid (NAA)/choline (Cho), NAA/creatinine (Cr), and Cho/Cr were measured in both temporal lobes. Patients were divided into three groups according to time after completion of radiotherapy: group 1, less than 6 months; group 2, 6–12 months; group 3, more than 12 months. Mean values for each parameter were compared using one-way analysis of variance (ANOVA).Results: Mean FA in group 1 was significantly lower compared to group 3 and the control group (p < 0.05). Group-wise comparisons of apparent diffusion coefficient (ADC) values among all the groups were not significantly different. Eigenvalue λ1 was significantly lower in groups 1 and 3 compared to the control group (p < 0.05). NAA/Cho and NAA/Cr were significantly lower in each group compared to the control group (p < 0.01 for both). The decrease in NAA/Cho was greatest in group 1. There were no significant between-group differences regarding Cho/Cr.Conclusion: A combination of DTI and 1H-MRS can be used to detect radiation-induced brain injury, in patients treated for nasopharyngeal carcinoma.

Abnormal hyperintensity in cerebellar efferent pathways on diffusion-weighted imaging in a patient with heat stroke - Corrected Proof

Y. Fushimi, H. Taki, H. Kawai, K. Togashi — 2011-11-28

Heat stroke is a potentially critical condition characterized by hyperthermia and accompanied by various complications such as multi-organ failure and disseminated intravascular coagulation (DIC). Heat stroke can also cause neurological dysfunction, most commonly due to involvement of the cerebellum. Lee et al. reported possible selective vulnerability of cerebellar neurons to heat injury.

CT evaluation of chronic thromboembolic pulmonary hypertension - Corrected Proof

2011-11-28

The educational objectives of this article are to provide an overview of the computed tomography (CT) findings in chronic thromboembolic pulmonary hypertension. This article reviews the key imaging findings at CT in patients with chronic thromboembolic pulmonary hypertension. After reading this article, the reader should have an improved awareness of the condition, its imaging features, and the CT imaging features associated with surgically accessible disease.

Axillary lymph node core biopsy for breast cancer metastases — How many needle passes are enough? - Corrected Proof

2011-11-28

Aim: To determine the diagnostic yield of each of three core passes when sampling abnormal lymph nodes in patients presenting with breast cancer.Materials and methods: All patients suspected of having breast cancer had axillary ultrasound as part of initial assessment. Radiologically abnormal nodes (cortical thickness >2.3mm or round shape) were biopsied with three passes of a 22mm throw 14 G core biopsy needle and sent for histopathology in separate numbered pots. Data were collected prospectively, and analysis performed on the data of 55 consecutive patients who had positive nodes on at least one core biopsy needle pass.Results: Of 55 patients with a positive node on core biopsy, tumour was noted in all three cores taken in 39 (70.9%). Lymph node metastasis was detected in 45 (81.8%) first core biopsies. With the first two cores taken, positive results were detected in 53 of 55 cases (96.4%). In both cases where tumour was only found on a third core biopsy pass, no lymph node tissue was present in the first two biopsy passes.Conclusion: Two well-directed 14 G core biopsy samples from an abnormal axillary node are adequate for diagnosis of breast cancer metastasis.

Clinically palpable breast abnormalities with normal imaging: Is clinically guided biopsy still required? - Corrected Proof

2011-11-28

Aim: To determine the need for a fine-needle or core biopsy in patients with clinically palpable breast abnormalities who have negative mammographic and sonographic findings.Method and materials: Over a 12-year period, 251 patients with a palpable abnormality at presentation and who had a negative ultrasound and mammogram underwent clinically guided biopsy (CGB) by breast surgeons. This was 2.7% (251/9313) of all breast biopsies performed from January 1999 to December 2010. Physical findings were qualitatively categorized into five groups as clinically “normal”, “benign”, “probably benign”, “suspicious”, and “malignant” at the time of initial assessment. The number of biopsies for each category and biopsy results were analysed retrospectively.Results: Three (1.2%) of the 251 CGBs were reported as malignant; two (0.8%) of which were invasive. Forty-six (18.3%) of the 251 cases were regarded as clinically suspicious or malignant while the remaining 215 examinations were categorized as benign or probably benign. All three malignancies were in the clinically suspicious or malignant group.Conclusion: A negative ultrasound and mammogram in patients with a palpable abnormality does not exclude breast cancer; however, the likelihood is very low (1.2%). In this study, 81.7% of biopsies (205/251) could have been avoided if CGB was reserved for the clinically suspicious or malignant group only without missing any malignancies.

Utility of FDG PET/CT in IgG4-related systemic disease - Corrected Proof

K. Nakatani, Y. Nakamoto, K. Togashi — 2011-11-28

IgG4-related systemic disease (IgG4-RSD) is an emerging clinical entity about which much remains to be elucidated, in terms of its aetiology, pathogenesis, diagnosis, treatment and outcome. Autoimmune pancreatitis (AIP) and Mikulicz disease (MD) are the two major, well-studied constituents of IgG4-RSD. AIP and MD have common characteristics of forming tumour-mimicking lesions that consist of lymphoplasmacytic infiltrates and fibrosclerosis with numerous immunoglobulin G4 (IgG4)-positive plasma cells, as well as various multi-organ manifestations of IgG4-RSD. 2-[18F]-fluoro-2-deoxy-d-glucose positron-emission tomography/ computed tomography (FDG PET/CT) enables the acquisition of whole-body images and provides functional information about disease activity; as such it has a valuable role in staging extent of disease, guiding biopsy, and monitoring response to treatment. However, FDG PET/CT is likely to be only one component of the management strategy, and clinical, laboratory, imaging and histological findings are crucial in the overall diagnosis of the condition. At present FDG PET/CT does not have a well-established role in the assessment of patients with IgG4-RSD and future prospective studies are required to define the cost-effectiveness and clinical impact in this patient group more accurately.

3 T MRI of hepatocellular carcinomas in patients with cirrhosis: Does T2-weighted imaging provide added value? - Corrected Proof

L. Guo, C. Liang, T. Yu, G. Wang, N. Li, H. Sun, F. Gao, C. Liu — 2011-11-21

Aim: To assess whether T2-weighted imaging (T2WI) provides any added value for the detection of hepatocellular carcinoma (HCC) in patients with cirrhosis, especially for lesions smaller than 2 cm.Materials and methods: Sixty-five patients with cirrhosis underwent liver 3 T MRI. Images were qualitatively analysed independently by two observers in two separate sessions, including a dynamic enhanced session and a combination of dynamic and T2WI. The diagnostic accuracy was evaluated using the alternating free-response receiver operating characteristic. Sensitivity and positive predictive values were calculated for all HCCs and for the subgroup of HCCs that were smaller than 2 cm. Additionally, artefacts on T2WI were evaluated by two observers in consensus.Results: Ninety HCCs (>2 cm n = 36; ≤2 cm n = 54) were detected in 46 patients. For all HCCs and for lesions smaller than 2 cm, the sensitivities were significantly higher for the combined session than the dynamic session alone (p < 0.05). Conversely, for the Az and positive predictive values, there was no significant difference between the two sessions. For smaller HCC, 9% (5/54) and 7% (4/54) of the 54 HCCs were correctly interpreted by observers 1 and 2, respectively, only when T2WI was included. Three false-positive lesions (≤2 cm) were correctly diagnosed by one of the observers after combining T2WI. Conspicuity of only one large HCC was severely reduced by the artefacts from massive ascites.Conclusion: At 3 T liver imaging, combining with T2WI can improve the sensitivity of detection of HCC compared with dynamic MRI alone by increasing observer confidence, especially for lesions smaller than 2 cm. Additionally, T2 image quality was not significantly affected by artefacts.