CT and MR imaging features of mucinous tubular and spindle cell carcinoma of the kidneys. A multi-institutional review.

Mucinous tubular and spindle cell carcinoma (MTSCC) of the kidney is a recently identified renal malignancy. Diagnosis of this rare subtype of renal tumour can be challenging for pathologists, and as such, any additional data would be helpful to improve diagnostic reliability. As imaging features of this new and rare sub-type have not yet been clearly described, the purpose of this study was to describe the main radiologic features on computed tomography (CT) and magnetic resonance imaging (MRI), based jointly on the literature and findings from a multi-institutional retrospective review of pathology and imaging databases. Using a combination of CT/MRI features, diagnosis of MTSCC could be suggested in many cases. A combination of slow enhancement with plateau on dynamic contrast-enhanced CT/MRI, intermediate to high T2 signal intensity contrasting with low apparent diffusion coefficient values on MRI appeared evocative of this diagnosis. KEY POINTS: • A slow enhancement with plateau is observed either on CT or MRI. • High T2 signal components but low apparent coefficient diffusion are evocative. • T2-weighted imaging features depend on the mucin components of the tumour.

Tubulocystic renal cell carcinoma: a new radiological entity.

UNLABELLED: Tubulocystic renal cell carcinoma (TC-RCC) is a recently identified renal malignancy. While approximately 100 cases of TC-RCC have been reported in the pathology literature, imaging features have not yet been clearly described. The purpose of this review is to describe the main radiologic features of this rare sub-type of RCC on ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI), based jointly on the literature and findings from a multi-institutional retrospective HIPAA-compliant review of pathology and imaging databases. Using a combination of sonographic and CT/MRI features, diagnosis of TC-RCC appeared to be strongly suggested in many cases. KEY POINTS: • Tubulocystic renal cell carcinoma is a new entity with typical imaging features • Diagnosis of tubulocystic renal cell carcinoma can be suggested preoperatively by imaging • Cystic renal lesions with high echogenicity may correspond to tubulocystic carcinoma.

Ultrasound findings in dual kidney transplantation.

PURPOSE: This study was done to analyse colour Doppler ultrasound (CDUS) findings in patients with dual kidney transplantation (DKT) and to compare renal volume and resistive index (RI) values between DKT and single kidney transplantation (SKT). MATERIALS AND METHODS: We reviewed the clinical and imaging findings [30 CDUS, five magnetic resonance (MR) and one computed tomography (CT) examination] in 30 patients with DKT (23 men and seven women; median age 65 years; range 55-82). Three patients had clinical signs of graft malfunction. Renal volumes and RI were compared with those of 14 SKT patients and comparable levels of renal function. RESULTS: Three patients had graft dysfunction: one had chronic rejection and two had pathologies involving one kidney only (one encrusted pyeloureteritis of a left graft and one occluded main artery of a left graft). Asymptomatic unilateral pathologies were seen in six cases. In asymptomatic DKT patients, no significant differences in length, volume, cortical echogenicity and RI between the two kidneys were observed; DKTs were smaller (median volume 116.7 vs. 171.6 cc) and had higher RIs (0.76 vs. 0.68) (p<0.01) than SKTs. CONCLUSIONS: CDUS provides useful information in patients with DKT, allowing detection of clinically unsuspected unilateral diseases. At comparable levels of renal function, DKT patients had higher RI and lower volumes than SKT patients.

Subclinical functional and structural renal abnormalities predict new onset type 2 diabetes in patients with primary hypertension.

Recent studies suggest a close relationship between renal dysfunction and new onset diabetes (NOD). The aim of the study was to investigate the association between subclinical functional and structural renal abnormalities and NOD in primary hypertension (PH). This observational prospective study (9.1 ± 2.2 years follow-up) includes 231 consecutive untreated non-diabetic patients with PH and without overt nephropathy. The primary end point was NOD. Albuminuria (albumin to creatinine ratio, ACR), glomerular filtration rate (eGFR), and renal structure and hemodynamics (ultrasound scan and Doppler) were evaluated at baseline. During 2106 person-years of follow-up, 10 patients developed diabetes (incidence rate 4.7/1000 person-years). Patients with NOD showed a higher body mass index, serum uric acid, serum creatinine and ACR, and lower eGFR and renal volume (RV) to resistive index (RI) ratio (RV/RI) at baseline, as compared with the 221 controls that did not develop diabetes. When all renal variables were taken into consideration, RV/RI was the only variable significantly related to diabetes (hazard ratio 1.04, P=0.0342). Patients in the lowest tertile of RV/RI were more likely to develop diabetes (10.4 vs 2.6 vs 0%, P=0.0044). For each s.d. decrease of RV/RI, the risk of NOD increased by 68% (P=0.0012). Subclinical functional and structural renal abnormalities are independent predictors of diabetes in PH.

Audit of litigation against the accident and emergency radiology department.

PURPOSE: The aims of this study were to reduce and monitor litigation due to failure to diagnose a fracture, to evaluate whether the cases were due to radiological error or other problems in the diagnostic and therapeutic management of patients and to identify organisational, technical or functional changes or guidelines to improve the management of patients with suspected fracture and their expectations. MATERIALS AND METHODS: We analysed the litigation database for the period 2004-2006 and extracted all episodes indicating failure to diagnose a fracture at the accident and emergency radiology department of our centre. The radiographs underwent blinded review by two experts, and each case was jointly analysed by a radiologist and a forensic physician to see what led to the compensation claim. RESULTS: We identified 22 events (2004 seven cases; 2005 eight cases; 2006 seven cases). Six cases were unrelated to radiological error. Six were due to imperceptible fractures at the time of the examination. These were accounted for by the presence of a major lesion distracting the examiner's attention from a less important associated lesion in one case, a false negative result in a patient examined on a incompletely radiolucent spinal board and underexposure of the coccyx region in an obese patient. Six cases were related to an interpretation error by the radiologist. In the remaining cases, the lesion being referred to in the compensation claim could either not be established or the case was closed by the insurance company without compensation. Corrective measures were adopted. These included planning the purchase of a higher performance device, drawing up a protocol for imaging patients on spinal boards, reminding radiologists of the need to carefully scrutinise the entire radiogram even after having identified a lesion, and producing an information sheet explaining to patients the possibility of false negative results in cases of imperceptible lesions and inviting them to return to the department if symptoms persist. CONCLUSIONS: We believe the clinical and administrative analysis we performed is useful. It reviewed some administrative practices and identified critical features. We identified tools that we trust will reduce litigation.

[Coexistence of different histotypes of renal carcinoma:our experience and literature review].

The coexistence of multiple, synchronous primary tumors of different histology within the same kidney is a rare condition. We report herein a series of five patients with two tumors of different histology involving synchronously the same kidney. MATERIALS AND METHODS. We reviewed the pathology reports of a series of 381 patients who underwent surgery for primary renal tumors at our institution from 2000 to 2007. In the files of all patients with synchronous tumors of different histology, special attention was given to the results of imaging studies. RESULTS. Five out of 381 patients (1.37%) had coexistence of two primary tumors of different histology within the same kidney. Four patients had ultrasonography as the first imaging procedure, one patient had ultrasonography as the second imaging procedure; all had preoperative CT of the abdomen. Both lesions were detected by preoperative CT in 4/5 of the cases; in the remaining one, the smaller lesion was not visible, even in retrospect. CONCLUSIONS. The coexistence of multiple and synchronous primary tumors of different histology within the same kidney has been only rarely described. To the best of our knowledge, in literature there are only case reports with the exception of a case of renal oncocytoma with evolving papillary RCC. We believe that this condition could be more frequent if the radiologist and the anatomopathologist try to find it.

Diffusion-weighted MRI sequences (DW-MRI) of the kidney: normal findings, influence of hydration state and repeatability of results.

PURPOSE: This study was performed to determine the apparent diffusion coefficient (ADC) of the normal kidney using diffusion-weighted magnetic resonance imaging (DW-MRI) sequences and to analyse both the changes due to hydration state and results repeatability. MATERIALS AND METHODS: Ten volunteers underwent DW-MRI imaging of the kidneys with a breath-hold single-shot spin-echo planar imaging (SE-EPI) sequence in the axial and coronal planes with b values of 300, 500, 800 s/mm(2), in different states of hydration. Urine osmolarity (OsmU) and sodium excretion (NaU) were measured at the time of each examination. ADC maps were created for all b values, and ADC values were calculated and compared between different states of hydration. In five subjects, the protocol was conducted twice to test data repeatability. RESULTS: ADC values were lower with higher b values (3.00 vs. 2.47 vs. 1.99 x 10(-3) mm(2)/s with b values of 300, 500, 800 s/mm(2), respectively). ADC values in different hydration states were not statistically different. Measurements were reproducible. OsmU and NaU were statistically different in the different states of hydration (p<0.01). CONCLUSIONS: ADC values significantly decrease with higher b values. Average ADC values in the normal kidney are reproducible. Hydration state does not significantly influence mean ADC values.

Imaging of renal leiomyomas.

BACKGROUND: Renal leiomyomas are rare benign tumors of the kidney which can be found at autopsy as small capsular nodules in about 5% of cases. The clinical incidence of such lesions is much smaller, and only case reports or small series have been reported in the imaging literature. PURPOSE: To describe the imaging characteristics observed in a series of eight patients with pathology-proven asymptomatic leiomyomas of the kidney. MATERIAL AND METHODS: We reviewed the imaging findings observed in eight patients with pathologically proven asymptomatic renal leiomyomas discovered during studies performed for reasons unrelated to the kidney. All patients had undergone computed tomography (CT), two ultrasonography, and one magnetic resonance imaging (MRI). RESULTS: Lesions ranged in size from 1.2 to 13 cm. Six were at the periphery of the kidney, compressed its outer surface, but did not cause disruption of the cortex; two involved the renal cortex. All had regular outer margins. A cleavage plane between the tumor and the kidney was revealed at CT and/or ultrasonography in three of the cases located at the periphery. At ultrasonography, leiomyomas appeared hypoechogenic. At CT, they were slightly hyperdense before contrast medium injection; all were hypodense to the renal cortex after contrast medium. Four were homogeneous, two were slightly heterogeneous, and the remaining two were frankly heterogeneous. The lesion studied by MRI, which was homogeneous at the postcontrast CT study, had a heterogeneous structure on both T1- and T2-weighted images, with internal areas of hypointensity on T1. CONCLUSION: There are some imaging findings that can help to suggest the diagnosis of renal leiomyomas. First, their density: all tumors examined before contrast were hyperdense to the kidney, with density similar to that of muscles, and all had lower enhancement than the adjacent renal parenchyma. Second, the location and margins of the tumors: most were peripheral, without involvement of the renal cortex and with well-defined margins. Although not pathognomonic for a renal leiomyoma, the combination of these findings should include leiomyoma in the list of differential diagnoses.

Magnetic resonance imaging at 1.5 T with immunospecific contrast agent in vitro and in vivo in a xenotransplant model.

OBJECT: Demonstrating the feasibility of magnetic resonance imaging (MRI) at 1.5 T of ultrasmall particle iron oxide (USPIO)-antibody bound to tumor cells in vitro and in a murine xenotransplant model. METHODS: Human D430B cells or Raji Burkitt lymphoma cells were incubated in vitro with different amounts of commercially available USPIO-anti-CD20 antibodies and cell pellets were stratified in a test tube. For in vivo studies, D430B cells and Raji lymphoma cells were inoculated subcutaneously in immunodeficient mice. MRI at 1.5 T was performed with T1-weighted three-dimensional fast field echo sequences (17/4.6/13 degrees ) and T2-weighted three-dimensional fast-field echo sequences (50/12/7 degrees ). For in vivo studies MRI was performed before and 24 h after USPIO-anti-CD20 administration. RESULTS: USPIO-anti-CD20-treated D430B cells, showed a dose-dependent decrease in signal intensity (SI) on T2*-weighted images and SI enhancement on T1-weighted images in vitro. Raji cells showed lower SI changes, in accordance to the fivefold lower expression of CD20 on Raji with respect to D430B cells. In vivo 24 h after USPIO-anti-CD20 administration, both tumors showed an inhomogeneous decrease of SI on T2*-weighted images and SI enhancement on T1-weighted images. CONCLUSIONS: MRI at 1.5 T is able to detect USPIO-antibody conjugates targeting a tumor-associated antigen in vitro and in vivo.

Traumatic lesions of adrenal glands in paediatrics: about three cases.

Pediatric adrenal injuries, in blunt thoracoabdominal trauma, are rare and usually associated with traumatic liver and kidney lesions. This paper aims to present imaging findings and possible adrenal involvement in blunt abdominal traumas in childhood. We report three cases of thoracoabdominal trauma with adrenal involvement. Two patients were polytraumatised in car accidents. The third case was unusual because of the mild trauma. The adrenals lesions were right-sided in all cases. Post-traumatic adrenal contusion/haematoma may arise not only because of a direct trauma but also as a consequence of a sudden increase in the pressure in the inferior vena cava system-adrenal veins. This is why adrenal haemorrhage is not directly proportional to the trauma: compression of the inferior vena cava leads to increased pressure in the adrenal venous circulation, which supports the parenchymal lesion. The right adrenal gland is more frequently injured than the left gland: it can be easily compressed between the liver, spine and kidney, and its venous drainage flows directly into the inferior vena cava.

Pouch diverticula after vertical-banded gastroplasty.

PURPOSE: Diverticula of the proximal gastric pouch are rare after vertical-banded gastroplasty (VBG) for morbid obesity. We report the radiographic findings observed in a series of 12 patients with pouch diverticula. MATERIALS AND METHODS: Lesions were found along the posteromedial wall of the proximal gastric pouch and ranged in size from 10 to 25 mm. Only two patients were symptomatic at the time of diagnosis; in most cases, diverticula were discovered during studies performed as part of the standard follow-up protocol. Diverticula were followed up in 7/12 cases, and four showed slight enlargement over a period ranging from 14 to 53 months. RESULTS: The presence of diverticula was not correlated with symptoms, postoperative weight loss, or clinical history, and no differences in long-term complications were demonstrated between VBG patients with diverticula and those without them. CONCLUSIONS: We do not believe these lesions to be clinically important; at present, our patients are no longer followed up for this problem and undergo diagnostic examinations only if and when they develop symptoms.

Primary leiomyosarcoma of the oral tongue: magnetic resonance and ultrasonography findings with histopathologic correlation.

Leiomyosarcoma is a malignant smooth muscle tumor that frequently occurs in the gastrointestinal tract and female genital tract. It is aggressive and tends to recur and metastasize. Clinical behavior is unpredictable, mostly influenced by a proper surgical approach. Oral leiomyosarcoma, in particular of the tongue, is extremely rare and poorly documented in the radiology literature. Diagnostic assessment of oral leiomyosarcoma is often challenging, mostly founded on its peculiar immunohistological features. However, imaging evaluation is essential in staging and for preoperative planning. We illustrate the case of a 52-year-old woman with 2-months history of a painless growing mass on the left hemitongue, with magnetic resonance and ultrasonographic features correlated to histopathologic examination.

Partial unilateral intracavernosal hematoma in a long-distance mountain biker: a case report.

We present a case of spontaneous partial unilateral hematoma of the bulb of the corpus cavernosum in a long-mileage mountain biker. Ultrasonography, magnetic resonance imaging, and histopathological findings are described.

Radiological research in Europe: a bibliometric study.

We performed a bibliometric search to evaluate number and scientific "weight" of papers written by European radiologists, as compared with colleagues from other countries, to measure the contribution of European researchers to radiology journals, and to correlate bibliometric parameters with some socio-economic factors of the different European nations. We considered all peer-reviewed articles published by radiologists in biomedical journals quoted by ISI over the 1995-2000 period. To identify authors as radiologists, the string "radiol" had to appear in the address of the corresponding author, and his country was considered as the country of origin of the paper. The definition of Europe included the 15 countries of the European Union, plus Norway and Switzerland. The scientific "weight" of the paper was assumed to be the impact factor of the journal of the publication in that given year. Then, we considered the annual indexes number of papers/population and number of papers/Gross Domestic Product (GDP) in each country. Data were retrieved from the Eurostat annual statistic reviews. From these bases, we obtained a comparison of the scientific production among European radiologists, those from the U.S. and those from the rest of the world. European radiological research is responsible of almost 40% of the world scientific production in our field, and Germany, UK and France are the leading publishers in Europe. An increase of the number of papers written by European radiologists was noted in the 1995-2000 period, whereas the production from the U.S. had a slight decrease. The mean concentration indexes papers/inhabitants and papers/GDP were significantly lower in Europe than in the U.S., even if some small European countries had higher values than the U.S. As a mean, European research received a lower impact factor than that from the U.S. The assessment of research output has progressively developed as an important issue for the scientific research community. Although not flawless, and often criticized for a variety of reasons, citation analysis is a commonly used technique in this field, is a frequent means to "weight" the scientific production of researchers and is one of the criteria used to assign research grants. Our study shows that European radiology is growing and its production is increasing over time, thus indicating strong commitment to research from European radiologists; however, European radiological research has not yet reached leadership in the literature, and mean indexes addressing the level of resources allocated to research are lower in Europe than in the U.S. This latter point has notable exceptions, but indicates inadequacy of funding, at least in some nations, and in Europe as a whole. The development of research programs within the framework of the European Union specifically aimed to radiology could lead to further advancement of our discipline.

Calcific tendinitis of the rotator cuff as a cause of drooping shoulder.

We describe a case of inferior glenohumeral subluxation or drooping shoulder secondary to acute calcific tendinitis of the rotator cuff. The various etiologies of drooping shoulder and the specific causes determining glenohumeral widening in our report are discussed. The importance in recognizing this uncommon complication of a common abnormal finding and correction by aspiration is stressed.

The sonographic evaluation of tubal patency with stimulated acoustic emission imaging.

OBJECTIVES: Experimental and clinical data suggest that insonation of echo-enhancing contrast agents with high acoustic power produces disintegration of microbubbles, resulting in a phenomenon called stimulated acoustic emission (SAE). The purpose of this study was to investigate whether SAE might be detected by transvaginal sonography and whether this technique may be useful in the assessment of tubal patency by hysterosalpingo-contrast sonography (SAE-HyCoSy). METHODS: Patients booked for X-ray hysterosalpingography (HSG) for infertility evaluation also received SAE-HyCoSy. The order of the two procedures was established in each patient by randomization after placement of a transcervical balloon catheter. For SAE-HyCoSy, the ultrasound contrast medium Levovist was injected, with the acoustic power set at the maximum level permitted on ultrasound machines employing dedicated algorithms. Conventional HSG was performed for comparison. RESULTS: Seventy-seven Fallopian tubes were examined in 41 patients. In all cases it was possible to obtain the SAE phenomenon. In 10 tubes (13%) proximal filling was not observed by both SAE-HyCoSy and HSG. In the remaining 67 tubes, free spill from the distal end of the lumen was demonstrated in 96% of cases (64/67) with SAE-HyCoSy and in 97% of cases (65/67) with HSG. Disagreement between the two techniques was observed in five tubes only, with a Cohen's kappa coefficient of 0.76 (95% confidence interval, 0.56-0.96). CONCLUSION: SAE techniques were successfully applied to HyCoSy and allowed the visualization of the free spill of contrast agent into the peritoneal cavity in the majority of cases. SAE-HyCoSy showed good agreement with HSG in this preliminary study.

Metastatic nodules of the abdominal wall: US and CT evaluation..

PURPOSE: Metastatic recurrence in the abdominal wall surgical scar is not uncommon. Our aim was to evaluate the role of ultrasonography (US), computed tomography (CT) and percutaneous fine needle aspiration biopsy in the diagnosis of metastatic recurrence along the surgical scar. MATERIALS AND METHODS: We evaluated 17 nodules in the surgical scar, either single (n=9 patients) or multiple (n=2 patients), in 11 patients operated on for known abdominal neoplasm confirmed by histology. The most common primary tumour was colonic carcinoma. All patients had undergone open surgery, and the lesions were detected at routine follow-up or at diagnostic examinations performed for clinical suspicion of recurrence. Ultrasonography (7.5-10/10-13 MHz) and fine needle biopsy were performed in all cases; contrast-enhanced CT was carried out in 10 patients. All lesions underwent histopathological examination. RESULTS: The histological findings showed 16/17 metastatic nodules and one suture granuloma. Lesions had variable size (15-55 mm), roundish shape, ill-defined margins (60% cases) and hypoechoic solid echotexture. All were characterised by marked contrast medium uptake on CT examination. US-guided aspiration biopsy precisely defined the metastatic nature of the nodules in 16/17 cases. In the patient with suture granuloma, both CT and US findings suggested malignancy; however, cytology showed only scant fibrous material. The anterior abdominal wall was the most common site of metastatic disease (14 lesions). CONCLUSIONS: US enables an accurate detection and diagnosis of metastatic nodules along the surgical scar. Fine needle aspiration biopsy represents, in our opinion, the most suitable procedure for providing an accurate diagnosis of this condition.

Ultrasound in gynecology.

This paper reviews the various examination techniques, the clinical indications, and the imaging findings for US studies of the female pelvis in patients with gynecological problems. Ultrasound, in fact, is the preferred imaging modality in the study of the female pelvis, and provides information of basic importance in detecting and characterizing pelvic masses of uterine, ovarian, or adnexal origin, providing also criteria useful in predicting their benign vs malignant nature. In patients with abnormal bleeding, transvaginal US helps in determining the presence of morphological and structural changes of the endometrium and, with the use of sonohysterography, provides excellent delineation of the endometrial cavity, guiding appropriate planning of therapeutic procedures. Ultrasound plays a very important role in the evaluation of patients with acute pelvic pain. It allows identification of ovarian torsion and has both diagnostic and therapeutic capabilities in patients with pelvic inflammatory disease through guidance of abscess drainage via the transvaginal route. In suspected ectopic pregnancy, US, together with quantitative measurements of hCG levels, can be considered the best imaging procedure to guide to the diagnosis. Ultrasound has an important role also in the study of female infertility. In this field it can be used to identify and document the integrity of the reproductive tract as a conduit for the passage of gametes and embryos, to detect pathological changes that may be causes or contributing factors of female infertility, to monitor cyclic changes of pelvic organs to document normal physiology or pathological situations, and to guide infertility treatment.