WFUMB position paper. Incidental findings of the salivary glands.

A salivary incidentaloma (SI) stands for any focal salivary lesion, independent of size, discovered by any imaging method including ultrasonography (US), computed tomography (CT), magnetic resonance imaging (MRI), multimodal positron emis-sion tomography (PET) combined with CT or MRI, or X-ray imaging, performed for another reason, in the absence of known salivary glands' disease. The article presents a detailed analysis of salivary gland diseases with the emphasis on neoplasms. It describes frequency of SIs found on imaging, their prevalence, epidemiology and clinical significance. The probability of malignancy or malignant transformation of a SI, its imaging features, recommended treatment, management and follow-up, as well as ethical issues, psychological burden, informed decision making, economical consequences and costs are discussed. The general prevalence of SIs is low, but is dramatically increasing over time, and may rise significantly in selected groups of oncologic patients. SIs most frequently turn out to be benign primary neoplasms or pseudotumors, including intraparenchymal lymph nodes. SIs detected by other imaging methods should be subsequently assessed with US. Solid SIs demand ultrasound guided fine-needle aspiration cytology (US-FNAC). Neoplasms should undergo surgery. Post-operative US follow-up is man-datory for malignant tumors and recommended for benign neoplasms.

Gallbladder-duodenal fistula detected by ultrasound - a case report.

Gallbladder-duodenal (cholecystoduodenal) fistula is an uncommon bilioenteric fistula between the gallbladder and the duodenum. It usually occurs following a chronic case of cholecystitis upon which the gallbladder adheres to the adjacent duodenum, and a stone penetrates through the wall. The case presented herein is that of a gallbladder-duodenal fistula detected primarily with the use of ultrasound imaging, and subsequently confirmed by computed tomography. The patient is a 54-year-old woman who was admitted with upper abdominal pain. The fistula was caused by chronic cholecystitis, however no gallstones were present in the duodenum. Surgical management was undertaken for the patient, and the recovery was uneventful.

Is the level of diffusion restriction in celiac and cervico-thoracic sympathetic ganglia helpful in their proper recognition on PSMA ligand PET/MR?

AIM: To check if diffusion weighted imaging (DWI) might be helpful in proper recognition of celiac (CG) and cervicothoracic (CTG) sympathetic ganglia on the whole-body multimodal PSMA-ligand PET/MR imaging, in the view of their common misleading avidity on PET potentially suggestive of malignant lesions, including metastatic lymph nodes. METHODS: The thickness and the level of diffusion restriction was assessed qualitatively and quantitatively in 406 sympathetic ganglia (189 CTG in 101 males and 217 CG in 116 males) on DWI maps (b-value 0 and 800 s/mm2) and apparent diffusion coefficient (ADC) maps (mean ADC) of the whole-body PET/MR 68Ga-PSMA-11 PET/MR. To form a reference group of a matching ganglia size, the smallest lymph node was chosen from each patient with metastases and underwent the same procedure. RESULTS: Very low and low level of diffusion restriction was noted in the majority of sympathetic ganglia (81.0 % CTG, 67.3 % CG, and 73.6 % of all). In the majority (91.7 %) of metastatic lymph nodes the level of diffusion restriction was moderate to high.The mean ADC values in sympathetic ganglia were statistically significantly higher in CTG, CG and all ganglia than in metastatic lymph nodes (p < 0.001; the effect size was large). CONCLUSIONS: Sympathetic celiac and cervicothoracic ganglia present very low and low level of diffusion restriction in visual DWI assessment, and significantly higher than metastatic lymph nodes mean ADC values in the majority of cases, which may serve as additional factors aiding differential diagnosis on multimodal PSMA-ligand PET/MR imaging.Therefore, PSMA-ligand PET/MR appears potentially superior to PSMA-ligand PET/CT in proper identification of sympathetic ganglia.

The "question-mark" MR anatomy of the cervico-thoracic ganglia complex: can it help to avoid mistaking it for a malignant lesion on 68Ga-PSMA-11 PET/MR?

Background Detectable uptake of 68Ga-PSMA-ligands in sympathetic ganglia may potentially lead to mistaking them for malignant lesions. Our aim was to investigate the anatomy of cervico-thoracic-ganglia-complex (CTG-C) in the MR part of multimodal 68Ga-PSMA-11 PET/MR imaging, in view of PET factors hindering its proper identification. Patients and methods In 106 patients, 212 sites of the CTG-C were retrospectively reviewed to assess the radiotracer uptake (SUVmax), size, shape, position, symmetry of location and visual uptake intensity. Asymmetry of PSMA-ligand uptake and increased uptake were regarded as risk factors of malignancy. Results In 66.0% left (L) and 53.8% right (R) CTG-C we noticed configurations, resembling the shape of an exclamation-mark, a question-mark, or its part (called "typical"). Tumor-like CTG-C shapes (oval, binodular or longitudinal) were detected in 28.3% L-CTG-C and in 40.6% R-CTG-C. When visual assessment of PET suggested malignancy, the recognition of "typical" shape of underlying CTG-C on MR generated a rise in the accuracy of their proper identification (from 34.4% to 75%, χ2(1) = 70.4; p < 0.001). Recognizing the shape of the CTG-C as "typical" in MR allowed us to classify as "not-suspicious" 61.9% of all CTG-C which were treated as "suspicious" after sole PET assessment. Conclusions The characteristic shape of cervico-thoracic-ganglia-complex (resembling a question-mark, or its part) helps in proper recognition of CTG-C on multimodal whole-body 68Ga-PSMA-ligand PET/MR imaging, when detectable uptake might lead to considering pathology.

Are superior cervical sympathetic ganglia avid on whole body 68Ga-PSMA-11 PET/magnetic resonance?: a comprehensive morphologic and molecular assessment in patients with prostate cancer.

OBJECTIVES: Recent reports warn against erroneous mistaking of celiac and stellate sympathetic ganglia for metastatic lymph nodes on multimodal prostate-specific membrane antigen (PSMA)-ligand PET imaging. The aim was to check the intensity of Ga-PSMA-11 uptake and magnetic resonance (MR) features of superior cervical ganglia (SCG) on PET/MR imaging. METHODS: In 89 patients 106 SCG were reliably identified on Ga-PSMA-11 PET/MR. For each SCG, qualitative assessment (visual subjective avidity, diffusion restriction, shape, and the presence of central hypointensity) and quantitative measurements [dimensions, maximal standardized uptake value (SUVmax), mean apparent diffusion coefficient (ADC)] were performed. RESULTS: Mean SUVmax in SCG amounted to 1.88 ± 0.63 (range: 0.87-4.42), with considerable metabolic activity (SUVmax ≥ 2) in 37.7% of SCG; mean thickness was 3.18 ± 1.08 mm. In subjective visual evaluation, SCG avidity was classified as mistakable or potentially mistakable with underlying malignancy in 32.1% of cases. Mean ADC values amounted 1749.83 ± 428.83 × 10mm/s. In visual assessment, 74.5% of ganglia showed moderate to high diffusion restriction. An oval or longitudinal shape on transverse MR plane was presented by 59.4% of SCG. The central hypointensity was detected on MR T2-weighted images only in 10.4% of SCG. CONCLUSION: SCG, similar to other sympathetic ganglia, show Ga-PSMA-11 uptake. SCG avidity may be of significance, especially in view of frequently occurring SCG oval or longitudinal shape, and moderate to high diffusion restriction in visual assessment, potentially suggesting malignancy on transverse MR plane. Diagnostic imaging specialists and clinicians should be aware of the above.

Unusual Drainage of the Bifurcated Left Renal Vein Into a Dilated Lumbar Azygos Vein and Inferior Vena Cava.

We report a unique case of unusual drainage of the bifurcated retroaortic left renal vein, with the cranial wider branch draining into a dilated lumbar azygos vein and caudal thinner branch connecting with the inferior vena cava. The right renal vein was duplicated. The anomaly was discovered on multimodal 18F-labeled fluorodeoxyglucose positron emission tomography/computed tomography performed for oncological purposes. The basis enabling occurrence of such variation was probably persistent developmental extra left-right venous connections, intercardinal, or intersupracardinal, depending on the theory. The embryology of the chest and abdominal veins is a complicated process and there is no unanimity concerning its concepts. The old models are currently being questioned and reevaluated. Knowledge of possible variants of renal and azygos veins course is important from clinical, imaging, and surgical points of view. The retroaortic left renal veins course may sometimes cause pain, hematuria, proteinuria, and pelvic congestion syndromes. Dilated parts of uncommonly located veins, because of assuming a nodular shape on transverse images, may be mistaken for abnormal lymph nodes, other tumors or aneurysms on imaging. During a variety of surgical procedures, including venous sampling, renal transplantation, or any retroperitoneal surgery, knowledge of an aberrant venous course may be important for the success of the procedure and may be crucial even earlier during the qualification process.

Celiac ganglia: can they be misinterpreted on multimodal 68Ga-PSMA-11 PET/MR?

OBJECTIVE: The objective of this study was to investigate the morphologic features and Ga-prostate-specific membrane antigen (PSMA)-11 avidity of celiac ganglia (CG) on multimodal PET/MRI. MATERIALS AND METHODS: Ga-PSMA-11 whole-body PET/MR examinations in 120 patients, referred for staging or follow-up of prostate cancer, were retrospectively reviewed to investigate the radiotracer uptake [maximum standardized uptake value (SUVmax)] and morphologic features (size, shape, location) of CG. Nodular, oval and longitudinal nodular, thick or with oval parts shapes of CG were regarded as mistakable with lymph nodes, whereas linear and longitudinal shapes were considered as not mistakable. RESULTS: On MR scans, CG were visible in 98% (117/120) on both sides and in two patients only on the left side. Mistakable CG shape was detected in 69% (83/120) of patients on both or at least one side. The left CG were thicker (4±1.4 mm; range: 1.5-7.5 mm) than the right ones (3±1.3 mm; range: 0.5-7 mm). Mean SUVmax was 2.51±1.17 (range: 0.02-5.48) in the left CG and 2.23±1.22 (range: 0.02-5.91) in the right CG. Increased Ga-PSMA-11 uptake, SUVmax at least 2, was detected in 75% (90/120), and both - erroneous shape and elevated Ga-PSMA-ligand uptake - was observed in 55% (66/120) of all patients on both sides or at least one side. CONCLUSION: Frequently observed, the nodular, oval and longitudinal (nodular, thick or with oval parts) shape of CG, especially of the thicker left CG, on MR scans may cause mistaking them for lymph nodes, even abnormal or metastatic. On whole-body PET/MRI, evident and sometimes high Ga-PSMA-11 uptake in CG increases the risk of a misinterpretation of them as metastases.

Mistakes in ultrasound diagnosis of superficial lymph nodes.

The article discusses basic mistakes that can occur during ultrasound imaging of superficial lymph nodes. Ultrasound is the first imaging method used in the diseases of superficial organs and tissues, including lymph nodes. The causes of mistakes can be either dependent or independent of the performing physician. The first group of mistakes includes inappropriate interpretation of images of anatomical structures, while the latter group includes, among other things, similar ultrasound images of different pathologies. For instance, a lymph node, whether normal or abnormal, may be mimicked by anatomical structures, such as a partially visible, compressed vein. Lymph nodes in lymphomas may be indistinguishable from reactive lymph nodes, even when using Doppler option, as well as morphologically difficult to distinguish from metastases. Metastatic lymph nodes can mimic e.g. nodular, separated postoperative thyroid fragments, a lateral neck cyst, chemodectoma (carotid body tumor) or neuroma. The appearance of lymph nodes in granulomatous diseases, such as tuberculosis or sarcoidosis, can be very similar to that of typical metastatic lymph nodes or lymphomas. Anechoic or hypoechoic areas in a lymph node can represent necrosis or metastatic hemorrhages, but also suppuration in inflamed lymph nodes. Lymph nodes in lymphomas, metastatic and reactive lymph nodes can adopt the classical characteristics of a simple cyst. The overall ultrasound picture along with all criteria for the assessment of a lymph node should be taken into account during ultrasound imaging. It seems that the safest management is to refer patients diagnosed with lymph node abnormalities for ultrasound-guided targeted fine needle aspiration biopsy followed by a total lymph node resection for histopathological examination in the case of suspected lymphoma.

Mistakes in ultrasound examination of salivary glands.

Ultrasonography is the first imaging method applied in the case of diseases of the salivary glands. The article discusses basic mistakes that can be made during an ultrasound examination of these structures. The reasons for these mistakes may be examiner-dependent or may be beyond their control. The latter may include, inter alia, difficult conditions during examination (technical or patient-related), similarity of ultrasound images in different diseases, the lack of clinical and laboratory data as well as the lack of results of other examinations, their insufficient number or incorrectness. Doctor-related mistakes include: the lack of knowledge of normal anatomy, characteristics of ultrasound images in various salivary gland diseases and statistical incidence of diseases, but also attaching excessive importance to such statistical data. The complex anatomical structures of the floor of the oral cavity may be mistaken for benign or malignant tumors. Fragments of correct anatomical structures (bones, arterial wall fibrosis, air bubbles in the mouth) can be wrongly interpreted as deposits in the salivary gland or in its excretory duct. Correct lymph nodes in the parotid glands may be treated as pathologic structures. Lesions not being a simple cyst, e.g. lymphoma, benign or malignant tumors of the salivary glands or metastatic lymph nodes, can be mistaken for one. The image of disseminated focal changes, both anechoic and solid, is not pathognomonic for specific diseases in the salivary glands. However, in part, it occurs typically and requires an extended differential diagnosis. Small focal changes and infiltrative lesions pose a diagnostic problem because their etiology cannot be safely suggested on the basis of an ultrasound examination itself. The safest approach is to refer patients with abnormal focal changes for an ultrasoundguided fine-needle aspiration biopsy.

The role of ultrasound and lymphoscintigraphy in the assessment of axillary lymph nodes in patients with breast cancer.

Breast cancer is the most common malignancy and the leading cause of death due to cancer in European women. Mammography screening programs aimed to increase the detection of early cancer stages were implemented in numerous European countries. Recent data show a decrease in mortality due to breast cancer in many countries, particularly among young women. At the same time, the number of sentinel node biopsy procedures and breast-conserving surgeries has increased. Intraoperative sentinel lymph node biopsy preceded by lymphoscintigraphy is used in breast cancer patients with no clinical signs of lymph node metastasis. Due to the limited sensitivity and specificity of physical examination in detecting metastatic lesions, developing an appropriate diagnostic algorithm for the preoperative assessment of axillary lymph nodes seems to be a challenge. The importance of ultrasound in patient qualification for sentinel lymph-node biopsy has been discussed in a number of works. Furthermore, different lymphoscintigraphy protocols have been compared in the literature. The usefulness of novel radiopharmaceuticals as well as the methods of image acquisition in sentinel lymph node diagnostics have also been assessed. The aim of this article is to present, basing on current guidelines, literature data as well as our own experience, the diagnostic possibilities of axillary lymph node ultrasound in patient qualification for an appropriate treatment as well as the role of lymphoscintigraphy in sentinel lymph node biopsy.

Diagnostic imaging and problems of schizencephaly.

BACKGROUND: Schizencephaly is a rare developmental malformation of the central nervous system associated with cell migration disturbances. Schizencephaly can be uni- or bilateral and is divided into two morphological types. The cleft is defined as type I ("closed lips") if there are fused clefts in cerebral mantle. In type II ("open lips") the clefts are separated and filled with cerebrospinal fluid connecting lateral ventricle with the subarachnoid space. MATERIAL/METHODS: We retrospectively analysed data of patients hospitalized in the Clinical Pediatric Neurology Department of Provincial Hospital No. 2 in Rzeszow between 1998-2011. Clinical data and imaging exams were analysed in the group of children with confirmed schizencephaly. RESULTS: Schizencephaly was recognized in 32 children. Diagnosis was made in children at the ages between 2 weeks and 15 years - the majority of older children were born before the year 2000. Diagnostic imaging, most often magnetic resonance imaging, was performed in all of the children. In most cases coexistence of other CNS malformations was discovered. In only one patient there were no neurological symptoms, most of the children presented different developmental disorders and neurological symptoms - most often cerebral palsy and epilepsy. In the group of children with bilateral and type II schizencephaly certain symptoms occurred more often. CONCLUSIONS: Schizencephaly is a rare central nervous system developmental disorder, which is very often associated with other severe brain malformations and in most of the cases subsequent multiple neurological symptoms. The method of choice in diagnosis of schizencephaly is magnetic resonance, which shows the degree and type of cleft, coexisting abnormalities and allows differential diagnosis. With the increased availability of this method it is possible to recognize schizencephaly more often and earlier.

Magnetic resonance imaging of rotator cuff tears in shoulder impingement syndrome.

BACKGROUND: Shoulder joint is a common site of musculoskeletal pain caused, among other things, by rotator cuff tears due to narrowing of subacromial space, acute trauma or chronic shoulder overload. Magnetic resonance imaging (MRI) is an excellent modality for imaging of soft tissues of the shoulder joint considering a possibility of multiplanar image acquisition and non-invasive nature of the study. The aim of this study was to evaluate the prevalence of partial and complete rotator cuff tears in magnetic resonance images of patients with shoulder impingement syndrome and to review the literature on the causes and classification of rotator cuff tears. MATERIAL/METHODS: We retrospectively analyzed the results of 137 shoulder MRI examinations performed in 57 women and 72 men in Magnetic Resonance facility of the Department of Radiology and Diagnostic Imaging at the St. Jadwiga the Queen Regional Hospital No. 2 in Rzeszow between June 2010 and February 2013. Examinations were performed using Philips Achieva 1.5T device, including spin echo and gradient echo sequences with T1-, T2- and PD-weighted as well as fat saturation sequences in transverse, frontal and sagittal oblique planes. Patients were referred from hospital wards as well as from outpatient clinics of the subcarpathian province. RESULTS: The most frequently reported injuries included partial supraspinatus tendon tear and complete tearing most commonly involved the supraspinatus muscle tendon. The smallest group comprised patients with complete tear of subscapularis muscle tendon. Among 137 patients in the study population, 129 patients suffered from shoulder pain, including 57 patients who reported a history of trauma. There was 44% women and 56% men in a group of patients with shoulder pain. Posttraumatic shoulder pain was predominantly reported by men, while women comprised a larger group of patients with shoulder pain not preceded by injury. CONCLUSIONS: Rotator cuff injury is a very common pathology in patients with shoulder impingement syndrome. Isolated supraspinatus tendon injury or complete tearing is most frequent, rather than in conjunction with injuries to other rotator cuff tendons. We did not observe isolated complete tears of infraspinatus and subscapular muscle tendons.

Diagnostics of biliary dilatation by means of magnetic resonance cholangiopancreatography.

BACKGROUND: Magnetic resonance cholangiopancreatography is a relatively noninvasive technique of biliary and pancreatic duct imaging. MRCP technique utilizes T2-weighted sequences, in which bile is characterized by high signal intensity, whilst signal intensity of surrounding tissues is reduced. The purpose of this publication was to assess the diagnostic value of magnetic resonance cholangiopancreatography in the diagnostics of biliary dilatation. MATERIAL/METHODS: MRCP examinations of 148 patients (48 men and 100 women; the average age was 56) performed on a 1.5T Achieva Philips device in the Provincial Hospital in Rzeszow between November 2011 and April 2013 were included in retrospective analysis. Examined group was divided into three subgroups: patients after cholecystectomy, patients with cholecystolithiasis and patients without gallbladder concretions. The definitive cause of biliary dilatation was determined mainly on the basis of MRCP and ECPW examinations, and, in individual cases, during intraoperative cholangiography and laparatomy. RESULTS: Signal loss corresponding to probable concretions was identified in 34 cases. In the group of patients with cholecystolithiasis the cause of biliary dilatation was usually (45%) cholelithiasis. MRCP image was typical in 4 out of 9 malignant cases. The cause of biliary dilatation was usually (20%) a neoplasm in the group of patients without gallstones. Benign causes of biliary dilatation, apart from cholelithiasis, were identified in 16 individuals, including 4 cases in which the diagnosis was identified using MRCP, whereas in the remaining 12 cases ECPW examination proved conclusive to the final diagnosis. CONCLUSIONS: Magnetic resonance cholangiopancreatography enables reliable diagnosis of causes of biliary dilatation as long as they involve presence of gallbladder deposits and tumors. In benign causes of biliary dilatation, apart from cholelithiasis, MRCP picture is often atypical and therefore, the final identification of the cause of biliary dilatation is possible when this imagining method is combined with ERCP and additional tests.

Clinical and morphological aspects of gray matter heterotopia type developmental malformations.

BACKGROUND: Gray matter heterotopia (GMH) is a malformation of the central nervous system characterized by interruption of normal neuroblasts migration between the 7(th) and 16(th) week of fetal development. The aim of the study was the analysis of clinical symptoms, prevalence rate and the most common concurrent central nervous system (CNS) developmental disorders as well as assessment of characteristic morphological changes of gray matter heterotopia in children hospitalized in our institution between the year 2001 and 2012. MATERIAL/METHODS: We performed a retrospective analysis of patients' data who were hospitalized in our institution between the year 2001 and 2012. We assessed clinical data and imaging exams in children diagnosed with gray matter heterotopia confirmed in MRI (magnetic resonance imaging). RESULTS: GMH occurred in 26 children hospitalized in our institution between the year 2001 and 2012. Among children with gray matter heterotopia most common clinical symptoms were: epilepsy, intellectual disability and hemiparesis. The commonest location of heterotopic gray matter were fronto-parietal areas of brain parenchyma, mostly subependymal region. Gray matter heterotopia occurred with other developmental disorders of the central nervous system rather than solely and in most cases it was bilateral. Schizencephaly and abnormalities of the corpus callosum were the most often developmental disorders accompanying GMH. CONCLUSIONS: 1. Subependymal gray matter heterotopia was more common than subcortical GMH. Subependymal GMH showed tendency to localize in the region of the bodies of the lateral ventricles. The least common was laminar GMH. 2. Gray matter heterotopia occurred more often with other developmental disorders of the central nervous system rather than solely. The most frequent concurrent disorders of the central nervous system were: schizencephaly, developmental abnormalities of the corpus callosum, arachnoid cyst, abnormalities of the septum pellucidum and the fornix. 3. GMH foci were more often bilateral than unilateral. 4. In the diagnostics of cell migration abnormalities, gray matter heterotopia included, MR imaging remains the method of choice.

Diagnostic difficulties resulting from morphological image variation in spondylodiscitis MR imaging.

BACKGROUND: Spinal infection (discitis; spondylodiscitis) presents a wide spectrum of pathologies. The method of choice for spondylodiscitis imaging is magnetic resonance (MR). It provides detailed anatomical information, especially concerning epidural space and spinal cord. The main aim of this article is the description and evaluation of spondylodiscitis morphological variation visible in magnetic resonance imaging. MATERIAL/METHODS: In this article we retrospectively analysed the patients diagnosed at the Department of Radiology of the Provincial Hospital No 2 in Rzeszów between October 2009 and October 2011. The subjects involved a group of five women aged 41-74 (mean 56.3 years) and eight men aged 46-69 (mean 61,3 years). All patients had spondylodiscitis symptoms. All patients underwent MRI examination before and after the contrast enhancement. In three patients additional CT examination was performed. RESULTS: Following the MRI procedure all patients were diagnosed with typical symptoms of spondylodiscitis. It also revealed a number of pathologies resulting from morphological spondylodiscitis variation. Other pathologies found on the MR images of the study group patients involved epidural intra-canal spinal pathological masses causing spinal cord compression, lung abscess, pyothorax, paravertebral abscesses and epidural empyemas, abscess between adjacent vertebral bodies, abscesses beneath anterior longitudinal ligament, and iliopsoas muscle abscesses. In all cases a destruction of vertebral bodies with end plates loss restriction and cortical layer discontinuity was observed. Moreover, one person was diagnosed with pathological vertebral body fractures and liquefactive necrosis of the vertebral body. CONCLUSIONS: Spondylodiscitis manifests itself in a great number of morphological variations visible on the radiological images. Apart from ordinary features of vertebral bodies and discs, progressive spinal destruction is observed together with reactive bone changes and soft tissue infiltration. The latter leads to a number of complications e.g. abscesses or even fistulas and also to the formation of obstacles in radiological images. The knowledge of radiological images together with overall evaluation of clinical and laboratory features enables a proper diagnosis.

Radiotherapy of liver metastases. Comparison of target volumes and dose-volume histograms employing CT- or MRI-based treatment planning.

PURPOSE: To assess differences in delineated target volumes of liver metastases using contrast-enhanced CT and different MRI sequences for radiation treatment planning. PATIENTS AND METHODS: 25 patients with 43 colorectal liver metastases were recruited. Tumor margins were defined by two experienced radiologists. The resulting D90 was assessed and the CT-based 3-D dose distribution merged with the according MRI dataset by employing image fusion. A theoretical D90 as a result of MRI-based treatment planning was assessed for various MRI sequences individually. RESULTS: In venous phase contrast-enhanced CT, the mean tumor volume was 20 ml; T1-weighted (T1w) MRI, 27 ml; contrast-enhanced T1w 42 ml; T2w 65 ml. The difference between the target volumes as assessed by either CT or MRI was 181% for T1w images, 178% for contrast-enhanced T1w, and 246% for T2w sequences. All differences were statistically significant (p < 0.05). The analysis of the dose-volume histograms revealed statistically significant differences (i.e., for the D90) for the different target volumes specified by CT and MRI: mean D90 on CT, 18 Gy; plain T1w, 16 Gy; contrast-enhanced T1w, 15.5 Gy; T2w, 12 Gy. Hence, delineation of a larger target volume in T2w MRI compared to contrast-enhanced CT resulted in a smaller D90. The mean differences of tumor volumes assessed by CT and plain T1w were significantly higher in the group of patients showing local tumor recurrences as compared to patients with long-term local tumor control (p = 0.002). CONCLUSION: For treatment planning of liver metastases, the use of either plain T1w or T2w sequences is recommended to delineate the clinical target volume as completely as possible and not to miss potential tumor cell congregations in the surroundings as in CT.

[Disease--defence--manipulation: the difficulties in providing forensic-psychiatry opinions]. / Choroba--obrona--manipulacja: trudnosci opiniowania sadowo-psychiatrycznego.

The challenges met by the psychiatrist and the psychologist and the difficulties in providing forensic-psychiatry and forensic-psychology opinions have been reviewed, based on examples. The studied patient was hospitalised 10 times and the forensic-psychiatry opinion passed 15 times during the judiciary process. Different psychiatric diagnoses were made and different soundness of mind were passed. The psychiatric health status were expresses by professors of psychiatry who did not participate directly in passing the forensic-psychiatry opinion. The studied patient was examined by other specialists and assessed by certificating medical doctors with the aim of getting disability pension benefits. The effect of medical certificates and testimonials from different medical doctors were analysed. Analysing this example, revealed the problem of proper formulation of content of medical documents to support the medical diagnosis and declared soundness of mind during the passing of forensic-psychiatry opinion. The doctors treating the patients and doctors passing opinion on the treated patient had a different assessment of the diagnoses and soundness of mind for the studied patients. Irrespective of the immediate aim of the examinations, all professionals providing assessment should mind the consequences of opinions passed by them and especially, the possibility of the opinion being used by the subject to prolong the judiciary process or even avoid legal responsibility. The independence (sovereignty) of the expert requires consideration in the context of prior multiple forensic-psychiatry opinion leaders in the field of psychiatry and the need for the expert to assume an attitude towards these opinions.

[Ultrasound imaging in laryngology]. / Zastosowanie ultrasonografii w laryngologii--krótka informacja.

Modern ultrasound with high resolution transducers, and sensitive power Doppler and color Doppler modes, and other options, such as panoramic and 3D imaging, allows for detailed imaging of many anatomical structures and pathologic lesions of the head and neck. Only the structures situated in the sonographic acoustic shadow: behind bones, calcified cartilages, stones, and behind organs containing gas (f.e. trachea and larynx) can not be visualized. Ultrasound is widely regarded as the first imaging method in the diseases of the thyroid, salivary glands (parotid gland, submandibular gland and sublingual gland), lymph nodes, muscles, soft tissues of the head and neck, and as an valuable adjunct in some laryngeal pathologies. Real time ultrasound examination allows for dynamic assessment of organs and lesions, lets the examiner check the susceptibility of tumors for pressure, which is inaccessible in other imaging methods. Tumors and congenital lesions, inflammation, abscesses, abnormal lymph nodes, cysts, muscle hypertrophy and posttraumatic conditions may be well evaluated with ultrasound. However, most neck tumors (f.e. in the thyroid, salivary glands, and soft tisses) as well as equivocal lymph nodes demand fine needle aspiration biopsy to determine their benign or malignant nature. This paper presents application of ultrasound examination in the head and neck area including limitations of ultrasound diagnostics in many clinical cases. Data taken from Polish and foreign literature and author's experience are included in this paper.

US of the major salivary glands: anatomy and spatial relationships, pathologic conditions, and pitfalls.

Ultrasonography (US) is useful for differential diagnosis of diseases of the salivary glands. In acute inflammation, salivary glands are enlarged and hypoechoic with increased blood flow; they may contain multiple small, oval, hypoechoic areas. In chronic inflammation, salivary glands are normal sized or smaller, hypoechoic, and inhomogeneous. Sialolithiasis appears as markedly hyperechoic lines or points with distal acoustic shadowing. Sialosis appears as enlarged hyperechoic glands without focal lesions or increased blood flow. The US features of advanced Sjögren syndrome include inhomogeneous salivary glands with scattered small, oval, hypoechoic or anechoic areas, usually well defined, and increased parenchymal blood flow. Pleomorphic adenomas are usually hypoechoic, well-defined, lobulated lesions with posterior acoustic enhancement that may contain calcifications; Warthin tumors are usually oval, hypoechoic, well-defined lesions that often contain anechoic areas and are often hypervascularized. Malignant neoplasms of the salivary glands may have irregular shapes, irregular borders, blurred margins, and a hypoechoic inhomogeneous structure or may have a benign appearance. Salivary gland cysts have well-defined margins, anechoic contents, posterior acoustic enhancement, and no internal blood flow. However, US appearances of some diseases may overlap, thus producing diagnostic pitfalls.

[Kuttner tumour--review of the literature and report of 3 cases]. / Guz Kuttnera--przeglad literatury i opis 3 przypadków.

We present 3 cases of Kuttner tumour (or chronic sclerosing sialadenitis of submandibular gland) all treated by surgery. In one case we report bilateral involvement. The disease was first described by Kuttner more than 100 years ago. In the new WHO Classification of tumour-like lesions of the Salivary Glands (1992) Kuttner tumour is classified as a distinct clinicopathologic entity. We also present a review of the literature about etiology, pathogenesis, differential diagnosis and treatment of this disease.