Abdominal manifestations of extranodal lymphoma: pictorial essay / Manifestações abdominais do linfoma extranodal: ensaio iconográfico

Abstract In the appropriate clinical setting, certain aspects of extranodal abdominal lymphoma, as revealed by current cross-sectional imaging techniques, should be considered potentially diagnostic and can hasten the diagnosis. In addition, diagnostic imaging in the context of biopsy-proven lymphoma can accurately stage the disease for its appropriate treatment. The purpose of this article was to illustrate the various imaging aspects of extranodal lymphoma in the abdomen.

Resumo O linfoma extranodal abdominal tem um espectro de manifestações radiológicas que, no contexto clínico adequado, permite que o radiologista, ao considerar corretamente esta hipótese, otimize o seu diagnóstico e sua terapia. Além disso, depois de comprovado por biópsia, o linfoma pode ser estadiado e a resposta ao tratamento, avaliada pelos métodos de imagem. O presente ensaio iconográfico tem como objetivo ilustrar os diferentes achados por imagem do acometimento extranodal no linfoma abdominal.

Renal cell carcinoma: histological classification and correlation with imaging findings / Carcinoma de células renais: classificação histológica e correlação com métodos de imagem

Abstract Renal cell carcinoma (RCC) is the seventh most common histological type of cancer in the Western world and has shown a sustained increase in its prevalence. The histological classification of RCCs is of utmost importance, considering the significant prognostic and therapeutic implications of its histological subtypes. Imaging methods play an outstanding role in the diagnosis, staging and follow-up of RCC. Clear cell, papillary and chromophobe are the most common histological subtypes of RCC, and their preoperative radiological characterization, either followed or not by confirmatory percutaneous biopsy, may be particularly useful in cases of poor surgical condition, metastatic disease, central mass in a solitary kidney, and in patients eligible for molecular targeted therapy. New strategies recently developed for treating renal cancer, such as cryo and radiofrequency ablation, molecularly targeted therapy and active surveillance also require appropriate preoperative characterization of renal masses. Less common histological types, although sharing nonspecific imaging features, may be suspected on the basis of clinical and epidemiological data. The present study is aimed at reviewing the main clinical and imaging findings of histological RCC subtypes.

Resumo Os carcinomas de células renais (CCRs) são o sétimo tipo histológico de câncer mais comum no mundo ocidental e vêm apresentando uma tendência mantida de aumento em sua prevalência. A classificação histológica dos CCRs é de extrema importância, uma vez que a determinação dos subtipos histológicos tem significativas implicações prognósticas e terapêuticas. Os métodos de imagem têm destacada importância no diagnóstico, estadiamento e seguimento dos pacientes com CCR. As variantes histológicas mais comuns são células claras, papilífero e cromófobo. A caracterização radiológica dos subtipos de CCRs, seguida ou não de biópsia percutânea confirmatória, é particularmente útil em pacientes sem adequadas condições cirúrgicas, pacientes com doença metastática, pacientes com rim único e lesão central, e em pacientes candidatos a terapia de alvo molecular. As novas estratégias, recentemente desenvolvidas, para o tratamento do câncer renal, como crio e radiofrequência, terapia molecular alvo e vigilância ativa também exigem adequada caracterização pré-operatória das massas renais. Os subtipos histológicos menos comuns, apesar de não terem achados de imagem específicos, podem ser suspeitados com base em dados clínicos e epidemiológicos.

Endometriose retroperitoneal atípica e uso de tamoxifeno / Atypical retroperitoneal endometriosis and use of tamoxifen

O acometimento por endometriose do retroperitônio é infrequente. Será dada importância aos achados da ressonância magnética que permitiram a suspeita diagnóstica de lesão periureteral em uma paciente em uso de tamoxifeno e que se apresentou com dor lombar esquerda e hidronefrose. Os achados histopatológicos obtidos por intermédio de biópsia percutânea orientada por tomografia computadorizada permitiram o diagnóstico de endometriose periureteral.

The involvement of the retroperitoneum by endometriosis occurs only sporadically. In the present report, emphasis will be given to the magnetic resonance imaging findings which raised the diagnostic suspicion of periureteral lesion in a patient undergoing tamoxifen therapy, presenting with left upper quadrant pain and hydronephrosis. Histopathological findings obtained by means of computed tomography-guided percutaneous biopsy revealed the diagnosis of periureteral endometriosis.

Paraganglioma of seminal vesicle and chromophobe renal cell carcinoma: a case report and literature review / Paraganglioma da vesícula seminal e carcinoma de células renais cromófobo: um relato de caso e revisão da literatura

CONTEXT: Extra-adrenal paragangliomas are rare tumors that have been reported in many locations, including the kidney, urethra, urinary bladder, prostate, spermatic cord, gallbladder, uterus and vagina. CASE REPORT: This report describes, for the first time to the best of our knowledge, a primary paraganglioma of the seminal vesicle occurring in a 61-year-old male. The patient presented persistent arterial hypertension and a previous diagnosis of chromophobe renal cell carcinoma. It was hypothesized that the seminal vesicle tumor could be a metastasis from the chromophobe renal cell carcinoma. Immunohistochemical characterization revealed expression of synaptophysin and chromogranin in tumor cell nests and peripheral S100 protein expression in sustentacular cells. Succinate dehydrogenase A and B-related (SDHA and SDHB) expression was present in both tumors. CONCLUSIONS: No genetic alterations to the VHL and SDHB genes were detected in either the tumor tissue or tissues adjacent to the tumor, which led us to rule out a hereditary syndrome that could explain the association between paraganglioma and chromophobe renal cell carcinoma in a patient with arterial hypertension.

CONTEXTO: Paragangliomas extra-adrenais são tumores raros que têm sido relatados em muitas localizações, incluindo rim, uretra, bexiga, próstata, cordão espermático, vesícula biliar, útero e vagina. RELATO DE CASO: Este relato descreve, pela primeira vez em nosso conhecimento, um paraganglioma primário da vesícula seminal ocorrendo em um paciente do sexo masculino de 61 anos de idade. O paciente apresentou hipertensão arterial persistente e um diagnóstico prévio de carcinoma de células renais cromófobo (CCRC). Foi pensado que o tumor de vesícula seminal poderia ser uma metástase do CCRC. A caracterização imunoistoquímica revelou expressão de sinaptofisina e cromogranina nos ninhos de células tumorais e expressão de proteína S100 nas células sustentaculares. Expressão de succinato de-hidrogenase A e B relacionada (SDHA e SDHB) estiveram presentes em ambos os tumores CONCLUSÕES: Nenhuma alteração genética dos genes VHL e SDHB foi detectada nos tecidos tumorais e adjacentes ao tumor, o que nos levou a afastar uma síndrome hereditária que poderia explicar a associação entre o paraganglioma e o CCRC em um paciente com hipertensão arterial.

Diverticulite jejunal: relato de caso / Jejunal diverticulitis: a case report

Diverticulite jejunal é doença rara que acomete principalmente os idosos. Os sintomas e sinais clínicos são inespecíficos, fato que dificulta e retarda o diagnóstico. A tomografia computadorizada é muito valiosa na definição do diagnóstico. Neste relato será apresentado um caso de diverticulose jejunal complicada com diverticulite aguda perfurada bloqueada, assim como uma discussão breve sobre diverticulite jejunal e suas complicações.

Jejunal diverticulitis is a rare disease that primarily affects the elderly. Clinical signs and symptoms are nonspecific, a fact that complicates and delays the diagnosis. Computed tomography is very valuable in defining the diagnosis. The present report describes a case of jejunal diverticulosis complicated with acute perforated obstructive diverticulitis, and presents a brief discussion on jejunal diverticulitis and its complications.

Dynamic evaluation of pelvic floor reconstructive surgery using radiopaque meshes and three-dimensional helical CT

PURPOSE: This prospective study was performed to achieve visualization of the reestablishment of anatomy after reconstructive surgery in the different pelvic compartments with non-absorbable radiopaque meshes, providing valuable anatomic information for surgeons implanting meshes. MATERIALS AND METHODS: A total of 30 female patients with stress urinary incontinence (SUI), anterior and posterior vaginal wall prolapse, or both underwent surgical repair using radiopaque meshes after written informed consent. Patients with SUI underwent five different surgeries. Patients with anterior vaginal prolapse underwent a procedure using a combined pre-pubic and transobturator mesh, and those with posterior vaginal prolapse underwent posterior slingplasty. Three-dimensional reconstruction using helical CT was performed four weeks postoperatively. RESULTS: In all cases, the mesh was clearly visualized. Transobturator slings were shown at the midurethra, and the anchoring tails perforated the obturator foramen at the safety region. Mini-slings were in the proper place, and computed angiography revealed that the anchoring system was away from the obturator vessels. In patients undergoing procedure for anterior vaginal prolapse, both pre-pubic armpit and obturator slings were clearly seen and the mesh was in the proper position, supporting the bladder base and occluding the distal part of the urogenital hiatus. Transcoccygeal sacropexy revealed indirectly a well-supported "neo rectovaginal fascia" and the anchoring tails at the level of ischial spines. CONCLUSION: Three-dimensional helical tomography images of the female pelvis using radiopaque meshes have a potential role in improving our understanding of pelvic floor reconstructive surgeries. These radiopaque meshes might be the basis of a new investigative methodology.

Achados da tomografia computadorizada em metástases pancreáticas do carcinoma de células renais / Computed tomography findings of pancreatic metastases from renal cell carcinoma

OBJETIVO: Apresentar os achados da tomografia computadorizada observados em quatro pacientes submetidos a nefrectomia radical por carcinoma de células renais e que apresentaram metástases pancreáticas. MATERIAIS E MÉTODOS: Os quatro pacientes foram submetidos a nefrectomia radical por carcinoma de células renais, estádios T1 (n=2) e T3a (n=2). O intervalo médio entre a nefrectomia e a detecção das metástases foi de oito anos. Dois pacientes apresentaram metástase pancreática solitária (confinada ao pâncreas) e dois apresentaram metástases pancreáticas única e múltiplas, respectivamente, ambos com recorrência tumoral no rim contralateral. RESULTADOS: As metástases pancreáticas foram visualizadas, na tomografia computadorizada, como lesões hipervascularizadas, solitária (n=2), única (n=1) ou múltiplas (n=1). Foi realizada pancreatectomia parcial em dois pacientes com metástase solitária. Estes pacientes estão livres da doença quatro e dois anos após a cirurgia, respectivamente. CONCLUSÃO: Metástases pancreáticas de carcinoma de células renais são raras, podendo ocorrer muitos anos após a apresentação inicial. Metástases pancreáticas múltiplas e metástases pancreáticas associadas a recorrência tumoral no rim contralateral são incomuns. À tomografia computadorizada, as metástases pancreáticas aparecem como lesões hipervascularizadas e solitárias, simulando tumores das ilhotas celulares. O tratamento cirúrgico das lesões solitárias deve ser considerado.

OBJECTIVE: To present computed tomography findings observed in four patients submitted to radical nephrectomy for renal cell carcinoma who developed pancreatic metastases afterwards. MATERIALS AND METHODS: The four patients underwent radical nephrectomy for stage T1 (n=2) and stage T3a (n=2) renal cell carcinoma. The mean interval between nephrectomy and detection of pancreatic metastases was eight years. Two asymptomatic patients presented with solitary pancreatic metastases (confined to the pancreas). Two symptomatic patients presented with single and multiple pancreatic metastases, both with tumor recurrence in the contralateral kidney. RESULTS: Computed tomography studies demonstrated pancreatic metastases as solitary (n=2), single (n=1) or multiple (n=1) hypervascular lesions. Partial pancreatectomy was performed in two patients with solitary pancreatic metastases and both are free of disease at four and two years after surgery. CONCLUSION: Pancreatic metastases from renal cell carcinoma are rare and can occur many years after the primary tumor presentation. Multiple pancreatic metastases and pancreatic metastases associated with tumor recurrence in the contralateral kidney are uncommon. Usually, on computed tomography images pancreatic metastases are visualized as solitary hypervascular lesions, simulating islet-cell tumors. Surgical management should be considered for patients with solitary pancreatic lesions.

Endorectal magnetic resonance imaging in persistent hemospermia

OBJECTIVE: To present the spectrum of abnormalities found at endorectal magnetic resonance imaging (E-MRI), in patients with persistent hemospermia. MATERIALS AND METHODS: A review of E-MRI findings observed in 86 patients with persistent hemospermia was performed and results compared with those reported in the literature. Follow-up was possible in 37 of 86 (43 percent) patients with hemospermia. RESULTS: E-MRI showed abnormal findings in 52 of 86 (60 percent) patients with hemospermia. These findings were: a) hemorrhagic seminal vesicle and ejaculatory duct, isolated (n = 11 or 21 percent) or associated with complicated midline prostatic cyst (n = 10 or 19.0 percent); b) hemorrhagic chronic seminal vesiculitis, isolated (n = 14 or 27 percent) or associated with calculi within dilated ejaculatory ducts (n = 2 or 4 percent); c) hemorrhagic seminal vesicle associated with calculi within dilated ejaculatory duct (n = 4 or 7.7 percent) or within seminal vesicle (n = 4 or 7.7 percent); d) non-complicated midline prostatic cyst (n = 6 or 11.5 percent); and e) prostate cancer (n = 1 or 2 percent). Successful treatment was more frequent in patients with chronic inflammatory and/or obstructive abnormalities. CONCLUSION: E-MRI should be considered the modality of choice, for the evaluation of patients with persistent hemospermia.

Radiological classification of renal angiomyolipomas based on 127 tumors

PURPOSE: Demonstrate radiological findings of 127 angiomyolipomas (AMLs) and propose a classification based on the radiological evidence of fat. MATERIALS AND METHODS: The imaging findings of 85 consecutive patients with AMLs: isolated (n = 73), multiple without tuberous sclerosis (TS) (n = 4) and multiple with TS (n = 8), were retrospectively reviewed. Eighteen AMLs (14 percent) presented with hemorrhage. All patients were submitted to a dedicated helical CT or magnetic resonance studies. All hemorrhagic and non-hemorrhagic lesions were grouped together since our objective was to analyze the presence of detectable fat. Out of 85 patients, 53 were monitored and 32 were treated surgically due to large perirenal component (n = 13), hemorrhage (n = 11) and impossibility of an adequate preoperative characterization (n = 8). There was not a case of renal cell carcinoma (RCC) with fat component in this group of patients. RESULTS: Based on the presence and amount of detectable fat within the lesion, AMLs were classified in 4 distinct radiological patterns: Pattern-I, predominantly fatty (usually less than 2 cm in diameter and intrarenal): 54 percent; Pattern-II, partially fatty (intrarenal or exophytic): 29 percent; Pattern-III, minimally fatty (most exophytic and perirenal): 11 percent; and Pattern-IV, without fat (most exophytic and perirenal): 6 percent. CONCLUSIONS: This proposed classification might be useful to understand the imaging manifestations of AMLs, their differential diagnosis and determine when further radiological evaluation would be necessary. Small (< 1.5 cm), pattern-I AMLs tend to be intra-renal, homogeneous and predominantly fatty. As they grow they tend to be partially or completely exophytic and heterogeneous (patterns II and III). The rare pattern-IV AMLs, however, can be small or large, intra-renal or exophytic but are always homogeneous and hyperdense mass. Since no renal cell carcinoma was found in our series, from an evidence-based practice, all renal mass with detectable fat should be considered an AML.

O valor dos parâmetros do psa na detcçäo do câncer da próstata / The value of psa parameters in detecting prostate cancer

Com o objetivo de determinar a sensibilidade e a especificidade dos parâmetros do PSA na detecçäo do câncer da próstata em pacientes com níveis de PSA de 4, 1 a 10, 0 ng/ml ("zona cinza"), 240 pacientes foram submetidos a ultraÄsonografia transretal da próstata com biópsia, e os resultados destas correlacionados com os parâmetros do PSA. A prevalência de carcinoma da próstata na populaçäo total estudada foi de 28 por cento e entre os pacientes com PSA. A prevalência de carcinoma da próstata na população total estudada foi de 28 por cento, e entre os pacientes com PSA na zona cinza foi de 22,1 por cento. Para a DPSA obtivemos sensibilidade de 80 por cento e especificidade de 32 por cento em relação ao EPSA, a sensibilidade foi de 88 por cento e a especificidade, de 33 por cento. Concluímos que em pacientes com níveis de PSA entre 4,1 e 10,0 ng/ml um achado de DPSA acima de 0,10 ou a presença de EPSA são fortemente sugestivos de câncer da próstata. Pacientes que se enquadravam nessas condições clínicas e que apresentavam resultado negativo devem, ser encaminhadas re-biópsia, para maior confiança na exclusão da doença.

Rotura espontânea bilateral das vias coletoras, por cálculo de ureter / Spontaneous bilateral urinary tract rupture due to ureteral calculi

A rare case of bilateral ureteral lithiasis associated with bilateral rupture of the urinary tract in a 34-year-old male is presented. The patient was admitted with renal failure and bilateral retroperitoneal urinoma. An endoscopic approach with bilateral ureteral catheterization with a double-J stent was used. After stabilization of renal failure and complete reabsorption of the urinoma, extracorporeal shock wave lithtripsy with was performed the stents in place. After 2 months, both stents were removed and the stones have been completely eliminated. Urinary lithiasis and ureteral tumors are the most common causes of urinary rupture. Emergency drainage of the urinary tract may be necessary. Urinoma often has a spontaneous absorption. It is unwise to attempt extraction of stones in patients with bilateral obstruction and acute renal failure as this can lead to serious complications. The renal failure must be resolved first and the stones managed afterwards

O valor do Doppler a cores na detecção do câncer da próstata / The role of color Doppler imaging in detecting prostate cancer

Oitenta e dois homens consecutivos com provável câncer da próstata foram submetidos a ultra-sonografia transretal por escala de cinzas e por Dopller a cores e biópsia dirigida por ultra-som transretal. Uma análise espectral das ondas do Doppler pulsátil em todas as áreas focais de fluxo anormal permitiu a determinação da freqüencia do pico sistólico (FPS). Embora mais freqüentes em alterações bengnas, todas as áreas focais de fluxo anormal encontradas na zona periférica, particularmente aquelas em próstata isoecogênicas e dotadas de alto valor de FPS, devem ser biopsiadas. O exame por Dopller a cores é útil pois detecta 8 por cento a mais de casos de câncer prostático. A FPS não serve para discriminar entre lesão benigna e maligna, porém, devido ao fato que valores mais altos de FPS são mais comuns em lesões malignas, esse parâmetro, mesmo com as suas limitações, pode ser útil para selecionar os pacientes que necessitam ser rebiopsiados com o intuito de se confirmar os achados negativos de biópsia prévia.

Linfoma intra-espinhal: aspectos radiográficos

Os autores apresentam os achados radiográficos observados em sete pacientes com comprometimento linfomatoso intra-espinhal, quatro dos quais ocorridos como a primeira manifestaçäo clínica da doença. Os mecanismos de comprometimento linfomatoso intrraespinhal säo discutidos ao mesmo tempo em que se chama a atençäo do radiologista para que inclua linfoma entre os diagnósticos diferenciais de massas primariamente intraespinhais