Hepatic epithelioid hemangioendothelioma: a report from three university centers.

OBJECTIVE: To determine common imaging findings of hepatic epithelioid hemangioendothelioma on magnetic resonance images. MATERIALS AND METHODS: A search was made of three institutional databases between January 2000 and August 2012. Seven patients (mean age, 47 years; range, 21-66 years; 6 women) with pathology-confirmed diagnosis of hepatic epithelioid hemangioendothelioma who had undergone magnetic resonance imaging were identified. None of the patients had received any treatment for hepatic epithelioid hemangioendothelioma at the time of the initial magnetic resonance imaging examination. RESULTS: Hepatic epithelioid hemangioendothelioma tumors appeared as focal masses in 7/7 patients, greater than 5 in number, with a coalescing lesion in 1/5, and peripheral localization in 6/7. Capsular retraction was present in 4/7, and was associated with peripherally located lesions. Early ring enhancement was appreciated in the majority of lesions in 7/7 patients. Centripetal progressive enhancement was shown in 5/7 patients on venous phase that exhibited a distinctive thick inner border of low signal on venous phase images, and a central core of delayed enhancement. Small lesions did not show this. CONCLUSION: The combination of multifocal round-configuration lesions that are predominantly peripheral and exhibit early peripheral ring enhancement and late appearance of an inner thick border of low signal and central core of high signal may represent an important feature for hepatic epithelioid hemangioendothelioma.

OBJETIVO: Determinar os achados comuns de hemangioendotelioma epitelioide hepático em imagens de ressonância magnética. MATERIAIS E MÉTODOS: Uma pesquisa foi feita em três bases de dados institucionais entre janeiro de 2000 e agosto de 2012. Sete pacientes (média de idade, 47 anos; variação, 21-66 anos; 6 mulheres) com diagnóstico confirmado por exame patológico de hemangioendotelioma epitelioide hepático submetidos a ressonância magnética foram identificados. Nenhum dos pacientes havia recebido tratamento para hemangioendotelioma epitelioide hepático antes do exame inicial por ressonância magnética. RESULTADOS: Tumores de hemangioendothelioma epitelioide hepático apareceram como massas focais, maiores que 5 em número, em 7/7 pacientes, com uma lesão coalescente em 1/5 e localização periférica em 6/7 pacientes. Retração capsular esteve presente em 4/7 pacientes e foi associada com lesões perifericamente localizadas. Realce precoce em anel foi visto na maioria das lesões, em 7/7 pacientes. Realce progressivo centrípeto foi demonstrado em 5/7 pacientes na fase venosa, que exibia uma borda interna espessa distinta de baixo sinal nas imagens de fase venosa e um núcleo central de realce tardio. As lesões pequenas não mostraram isso. CONCLUSÃO: A combinação de lesões de configuração arredondada multifocais que são predominantemente periféricas e exibem realce precoce em anel periférico e aparecimento tardio de uma borda espessa interna de baixo sinal e um núcleo central de alto sinal pode representar uma característica importante para hemangioendotelioma epitelioide hepático.

Hepatic epithelioid hemangioendothelioma: a report from three university centers / Hemangioendotelioma epitelioide hepático: pesquisa em três centros universitários

Abstract Objective: To determine common imaging findings of hepatic epithelioid hemangioendothelioma on magnetic resonance images. Materials and Methods: A search was made of three institutional databases between January 2000 and August 2012. Seven patients (mean age, 47 years; range, 21-66 years; 6 women) with pathology-confirmed diagnosis of hepatic epithelioid hemangioendothelioma who had undergone magnetic resonance imaging were identified. None of the patients had received any treatment for hepatic epithelioid hemangioendothelioma at the time of the initial magnetic resonance imaging examination. Results: Hepatic epithelioid hemangioendothelioma tumors appeared as focal masses in 7/7 patients, greater than 5 in number, with a coalescing lesion in 1/5, and peripheral localization in 6/7. Capsular retraction was present in 4/7, and was associated with peripherally located lesions. Early ring enhancement was appreciated in the majority of lesions in 7/7 patients. Centripetal progressive enhancement was shown in 5/7 patients on venous phase that exhibited a distinctive thick inner border of low signal on venous phase images, and a central core of delayed enhancement. Small lesions did not show this. Conclusion: The combination of multifocal round-configuration lesions that are predominantly peripheral and exhibit early peripheral ring enhancement and late appearance of an inner thick border of low signal and central core of high signal may represent an important feature for hepatic epithelioid hemangioendothelioma.

Resumo Objetivo: Determinar os achados comuns de hemangioendotelioma epitelioide hepático em imagens de ressonância magnética. Materiais e Métodos: Uma pesquisa foi feita em três bases de dados institucionais entre janeiro de 2000 e agosto de 2012. Sete pacientes (média de idade, 47 anos; variação, 21-66 anos; 6 mulheres) com diagnóstico confirmado por exame patológico de hemangioendotelioma epitelioide hepático submetidos a ressonância magnética foram identificados. Nenhum dos pacientes havia recebido tratamento para hemangioendotelioma epitelioide hepático antes do exame inicial por ressonância magnética. Resultados: Tumores de hemangioendothelioma epitelioide hepático apareceram como massas focais, maiores que 5 em número, em 7/7 pacientes, com uma lesão coalescente em 1/5 e localização periférica em 6/7 pacientes. Retração capsular esteve presente em 4/7 pacientes e foi associada com lesões perifericamente localizadas. Realce precoce em anel foi visto na maioria das lesões, em 7/7 pacientes. Realce progressivo centrípeto foi demonstrado em 5/7 pacientes na fase venosa, que exibia uma borda interna espessa distinta de baixo sinal nas imagens de fase venosa e um núcleo central de realce tardio. As lesões pequenas não mostraram isso. Conclusão: A combinação de lesões de configuração arredondada multifocais que são predominantemente periféricas e exibem realce precoce em anel periférico e aparecimento tardio de uma borda espessa interna de baixo sinal e um núcleo central de alto sinal pode representar uma característica importante para hemangioendotelioma epitelioide hepático.

A geometric index to differentiate abnormal from normal septal wall motion on cardiac MRI.

BACKGROUND: The definition of abnormal septal wall motion (SWM) is usually performed on a subjective visual assessment with cardiac MR (CMR). PURPOSE: To quantify SWM using a geometric index and to compare this index to the visual inspection in patients with or without abnormal SWM. MATERIAL AND METHODS: Cine CMR images of 100 consecutive patients were retrospectively assessed for visual evaluation of SWM and calculation of a convexity septal index (CSI) on mid-ventricular short-axis images, defined as b/a (a = minimal distance from anterior to posterior ventricular junctions; b = maximal distance from septum to a), obtained in end-systole (ES) and end-diastole (ED). Cohen κ, Bland-Altman method, Kruskall-Wallis, Mann-Whitney U, Jonckheere-Terpstra, and Spearman statistics were used to compare the two methods. RESULTS: At visual evaluation, 73 patients had normal SWM (group A), nine abnormal SWM at ES (group B), and 18 at ES and ED (group C). Median CSI for group A was significantly higher (ES = 0.23, ED = 0.25) than those for group B and C (0.10-0.15) (P < 0.001). Inter-reader reproducibility of visual evaluation was high (κ = 0.841, P < 0.001) while that for CSI was 77%. Average time for visual analysis was 3 min, for quantitative analysis 4 min. CONCLUSION: CSI is a simple and reproducible way to quantify SWM. ED CSI seems to be sensitive in detecting abnormal SWM in patients with apparently normal SWM at visual evaluation.

Combined chemical shift imaging with early dynamic serial gadolinium-enhanced MRI in the characterization of adrenal lesions.

OBJECTIVE: The purpose of this study was to retrospectively evaluate early dynamic serial gadolinium-enhanced and chemical-shift imaging (CSI) MRI to distinguish benign from malignant adrenal tumors. MATERIALS AND METHODS: Between July 2007 and December 2011, 205 patients with 239 adrenal lesions (177 adenomas, 54 metastases, 5 pheochromocytomas, and 3 adrenal cortical carcinomas) underwent early dynamic serial gadolinium-enhanced MRI and CSI. CSI was assessed qualitatively and by calculating the adrenal index, and enhancement patterns were evaluated qualitatively and quantitatively. Statistical analyses were performed. RESULTS: Most adenomas exhibited either an arterial blush or homogeneous enhancement, whereas most metastases showed early peripheral or heterogeneous enhancement. Visualization of higher enhancement on arterial and venous phases enabled differentiation of adenomas from metastases in most cases. Moderate to high signal intensity drop on CSI was seen in 95.4% of adenomas and 14.8% of metastases. In lesions with this level of signal intensity drop, 87 of 88 lesions with a capillary blush were adenomas. Early dynamic serial imaging alone was a significant (p < 0.0001) indicator of nonadenoma (area under the curve [AUC], 0.912) with optimal sensitivity of 81% and specificity of 93% for differentiating adenomas from nonadenomas. Combined analysis (CSI and early dynamic serial imaging) was also significant (p < 0.0001 and p=0.0014, respectively) for diagnosing nonadenomas (AUC, 0.983) with optimal sensitivity of 94% and specificity of 98%. CONCLUSION: Early dynamic serial gadolinium-enhanced MRI aids in characterization of adrenal tumors, especially lesions that are categorized as indeterminate on the basis of CSI.

Non-contrast MR imaging for detecting endoleak after abdominal endovascular aortic repair.

Our aim was to investigate the possibility of ruling out endoleak after endovascular aortic repair (EVAR) of abdominal aortic aneurysm (AAA) using non-contrast MRI. Twenty-three patients (20 males, aged 73 ± 8 years) with an EVAR-treated AAA underwent 1.5-T MRI using axial, coronal and sagittal oblique true-FISP sequences. Two blinded and independent readers with 4 (R1) and 2 (R2) years of experience evaluated these images considering an area of even less than 5 mm in diameter with a signal intensity higher than that of normal muscles visible in the excluded aneurysmal sac as a sign of potential endoleak. The final assessment, mainly based on MR angiography and previous examinations, served as reference standard. Out of 23 patients, 13 (57%) were negative for endoleak at final assessment, while the remaining 10 (43%) were positive, with the following type distribution: Ia (n = 4), Ib (n = 2), II (n = 3), and III (n = 1). Sensitivity was 10/10 (100%; CI 95% 69-100%), specificity 7/13 (54%; 25-81%), accuracy 17/23 (74%; 52-90%), PPV 10/16 (63%; 35-85%) and NPV 7/7 (100%; 59-100%) for R1; 9/10 (90%; 56-100%), 8/13 (62%; 32-86%), 17/23 (74%; 52-90%), 9/14 (64%; 35-8%), and 8/9 (89%; 52-100%) for R2, respectively. Inter-reader Cohen κ was 0.810. A negative non-contrast true-FISP MR study can be used to rule out endoleak after EVAR of AAA. This hypothesis may contribute to the reduction of ionizing radiation exposure and contrast material administration for monitoring patients with an EVAR-treated AAA.

Visualization of a Small Ventricular Septal Defect at First-pass Contrast-enhanced Cardiac Magnetic Resonance Imaging.

Ventricular septal defect (VSD) is a congenital heart disease that accounts for up to 40% of all congenital cardiac malformations. VSD is a connection between right and left ventricle, through the ventricular septum. Echocardiography and magnetic resonance imaging (MRI) help identify this entity. This case presents a 12-year-old male diagnosed with a small muscular apical VSD of 3 mm in diameter, at echocardiography. Cardiac MRI using first-pass perfusion sequence, combining the right plane of acquisition with a short bolus of contrast material, clearly confirmed the presence of VSD.

Atypical myocardial delayed enhancement after surgical ventricle restoration.

OBJECTIVE: To retrospectively evaluate delayed enhancement after surgical ventricle restoration (SVR). MATERIALS AND METHODS: Thirty patients with post-ischemic akinetic dilatation underwent cine and gadobenate dimeglumine-enhanced MRI before and 2-6 months after SVR. End-diastolic volume (EDV) normalized to body surface area (EDV index, EDVI), end-systolic volume index (ESVI), and ejection fraction (EF) of the left ventricle were obtained. Delayed enhancement involving subendocardial myocardium was considered typical (TDE) while enhancement apparently not involving subendocardium in its typical location was considered atypical (ADE). Wilcoxon signed-rank, Mann-Whitney U, and χ2 tests were used. RESULTS: All 30 patients showed TDE prior to surgery but 16 of them (53%) showed ADE after SVR. Before SVR, EDVI (ml/m2) was 171±101 in patients with ADE and 127±41 in patients with TDE, ESVI (ml/m2) was 130±105 and 94±36, EF was 25±6% and 24±9%, respectively, without significant differences (P>0.347). After SVR, EDVI (ml/m2) was 99±24 and 89±28 (P=0.275), ESVI (ml/m2) 66±24 and 65±30, respectively, without significant differences (P>0.275) while EF was 37±12% and 29±13%, respectively, with a near-significant difference (P=0.077). The increase in EF before/after SVR was significant only for patients with ADE (P=0.006). Of 20 patients in whom a patch had been used for SVR, 14 showed ADE and 6 TDE; of 10 patients without patch, 2 and 8, respectively (P=0.010). CONCLUSION: ADE was found in about half of SVR patients and was associated with the use of patch and EF improvement.