Clinical indications and radiation doses to the conceptus associated with CT imaging in pregnancy: a retrospective study.

OBJECTIVE: To perform an internal audit at a university hospital with the aim of evaluating the number, clinical indication and operating procedure of computed tomography (CT) performed on pregnant patients and of estimating the radiation doses to the conceptus. METHODS: A retrospective review was conducted of all CT examinations performed in a single centre on pregnant patients between January 2008 and July 2013. The radiation doses to the conceptus were estimated. The results were compared with published data. RESULTS: The number of CT examinations during pregnancy increased from 3-4 per year in 2008-2011 to 11 per year in 2012. The mean estimated conceptus radiation dose was considered negligible for CT of the head and cervical spine, being less than 0.01 mGy, and for CT of the chest, less than 0.1 mGy. The estimated conceptus radiation dose from abdominopelvic CT was on average 28.7 mGy (range 6.7-60.5 mGy). CONCLUSIONS: The number of CT scans of pregnant patients increased threefold during the last few years. Most clinical indications and doses were in line with good clinical practice and literature; only in two cases the dose to the conceptus was higher than 50 mGy. KEY POINTS: • An increase in CT imaging of pregnant patients is of concern. • Clinical indications were in line with good practice. • Estimated conceptus doses were lower or similar to published data. • Internal guidelines for appropriate use of imaging during pregnancy should be established.

Effective dose and organ doses estimation taking tube current modulation into account with a commercial software package.

PURPOSE: To evaluate the effect of including tube current modulation (TCM) versus using the average mAs in estimating organ and effective dose (E) using commercial software. METHOD: Forty adult patients (24 females, 16 males) with normal BMI underwent chest/abdomen computed tomography (CT) performed with TCM at 120 kVp, reference mAs of 110 (chest) and 200 (abdomen). Doses to fully irradiated organs (breasts, lungs, stomach, liver and ovaries) and E were calculated using two versions of a dosimetry software: v.2.0, which uses the average mAs, and v.2.2, which accounts for TCM by implementing a gender-specific mAs profile. Student's t-test was used to assess statistically significant differences between organ doses calculated with the two versions. RESULTS: A statistically significant difference (p < 0.001) was found for E on chest and abdomen CT, with E being lower by 4.2% when TCM is considered. Similarly, organ doses were also significantly lower (p < 0.001): 13.7% for breasts, 7.3% for lungs, 9.1% for the liver and 8.5% for the stomach. Only the dose to the ovaries was higher with TCM (11.5%). CONCLUSION: When TCM is used, for the stylized phantom, the doses to lungs, breasts, stomach and liver decreased while the dose to the ovaries increased. KEY POINTS: • Estimated dose to the ovaries increased with TCM. • Estimated dose to lungs, breasts, stomach and liver decreased with TCM. • A unique but gender-specific mAs profile resulted in a radiation dose shift. • Even for normal size patients there is a variety in mAs profiles.

Lactating Adenoma in the Presence of Galactoceles.

BACKGROUND: A 22-year-old woman was referred to our department with a painless, fast growing breast mass. She noticed this mass during lactation, after giving birth to her first child. Her gynecologist palpated a large mass in the left breast, two smaller nodules in the left breast, and one small nodule in the right breast. Ultrasonography of the breasts, mammography and MRI were performed, and a tentative diagnosis of phyllodes tumor was proposed. She was subsequently referred to our centre.

Sperm motility after laparoscopic inguinal hernia repair with lightweight meshes: 3-year follow-up of a randomised clinical trial.

PURPOSE: To analyse the effects of lightweight meshes in laparoscopic inguinal hernia repair on male fertility aspects, chronic pain development and recurrence at 3-year follow-up. METHODS: Fifty-nine male patients with a primary, unilateral or bilateral inguinal hernia were randomised to laparoscopic inguinal hernia repair using a standard polypropylene (Marlex(®)) or lightweight mesh (VyproII(®), TiMesh(®)). Patients attended clinical follow-up 3 years postoperatively, at which male fertility aspects, by semen analysis and scrotal ultrasound, chronic pain status (McGill Pain Questionnaire), quality of life (SF-36) and recurrence were assessed, or completed quality of life, pain and hernia-specific questionnaires at home. RESULTS: In total, 49 patients (83.1 %) completed follow-up (median follow-up = 39.1 months), by questionnaire and/or clinical follow-up. As other semen parameters and scrotal ultrasound results, sperm motility was unchanged compared to 1 year postoperatively, but not significantly different between VyproII(®) and TiMesh(®) versus Marlex(®) patients (-8.5 % and -8 % vs. -2.8 %; P = 0.23). Pain perception and quality of life were comparable between the heavyweight and lightweight groups, and no change was noted in comparison with 1 year postoperatively. Chronic pain incidence was 6.1 % (3 patients), without occurrence of disabling pain. Three patients were clinically diagnosed with a recurrent hernia (5.9 %). CONCLUSIONS: The decrease in sperm motility in patients operated on with a lightweight mesh compared to patients operated on with a heavyweight mesh 1 year after laparoscopic inguinal hernia repair could not be confirmed at 3 years follow-up. Furthermore, heavyweight and lightweight groups were comparable regarding quality of life, chronic pain and recurrence rate.

PNET/Ewing's sarcoma of the kidney: imaging findings in two cases.

The CT-imaging findings of primary renal PNET/Ewing's sarcoma in two patients were retrospectively assessed. A large renal mass with heterogenous contrast enhancement and necrotic and hemorrhagic areas were the predominant characteristics. In adolescents or young adults presenting with a large renal mass, PNET/Ewing's sarcoma may be included in the differential diagnosis.

Does 11C-choline PET-CT contribute to multiparametric MRI for prostate cancer localisation?

BACKGROUND AND PURPOSE: The aim of this work was to determine whether 11C-choline positron emission tomography (PET)-computed tomography (CT) makes a positive contribution to multiparametric magnetic resonance imaging (MRI) for localisation of intraprostatic tumour nodules. PATIENTS AND METHODS: A total of 73 patients with biopsy-proven intermediate- and high-risk prostate cancer were enrolled in a prospective imaging study consisting of T2-weighted (T2w), dynamic contrast-enhanced (DCE) and diffusion-weighted (DW) MRI and 11C-choline PET-CT before radical prostatectomy. Cancerous regions were delineated on the whole-mount prostatectomy sections and on the different MRI modalities and analysed in 24 segments per patient (3 sections, 8 segments each). To analyse PET-CT images, standardized uptake values (SUV) were calculated per segment. RESULTS: In total, 1,752 segments were analyzed of which 708 (40.4%) were found to be malignant. A high specificity (94.7, 93.6 and 92.2%) but relatively low sensitivity (31.2, 24.9 and 44.1%) for tumour localisation was obtained with T2w, DCE and DW MRI, respectively. Sensitivity values significantly increased when combining all MRI modalities (57.2%). For PET-CT, mean SUVmax of malignant octants was significantly higher than mean SUVmax of benign octants (3.68±1.30 vs. 3.12±1.02, p<0.0001). In terms of accuracy, the benefit of adding PET-CT to (multiparametric) MRI was less than 1%. CONCLUSION: The additional value of 11C-choline PET-CT to MRI in localising intraprostatic tumour nodules is limited, especially when multiparametric MRI is used.

Comparison of visual grading and free-response ROC analyses for assessment of image-processing algorithms in digital mammography.

OBJECTIVE: To compare two methods for assessment of image-processing algorithms in digital mammography: free-response receiver operating characteristic (FROC) for the specific task of microcalcification detection and visual grading analysis (VGA). METHODS: The FROC study was conducted prior to the VGA study reported here. 200 raw data files of low breast density (Breast Imaging-Reporting and Data System I-II) mammograms (Novation DR, Siemens, Germany)-100 of which abnormal-were processed by four image-processing algorithms: Raffaello (IMS, Bologna, Italy), Sigmoid (Sectra, Linköping, Sweden), and OpView v. 2 and v. 1 (Siemens, Erlangen, Germany). Four radiologists assessed the mammograms for the detection of microcalcifications. 8 months after the FROC study, a subset (200) of the 800 images was reinterpreted by the same radiologists, using the VGA methodology in a side-by-side approach. The VGA grading was based on noise, saturation, contrast, sharpness and confidence with the image in terms of normal structures. Ordinal logistic regression was applied; OpView v. 1 was the reference processing algorithm. RESULTS: In the FROC study all algorithms performed better than OpView v. 1. From the current VGA study and for confidence with the image, Sigmoid and Raffaello were significantly worse (p<0.001) than OpView v. 1; OpView v. 2 was significantly better (p=0.01). For the image quality criteria, results were mixed; Raffaello and Sigmoid for example were better than OpView v. 1 for sharpness and contrast (although not always significantly). CONCLUSION: VGA and FROC discordant results should be attributed to the different clinical task addressed. ADVANCES IN KNOWLEDGE: The method to use for image-processing assessment depends on the clinical task tested.

Testicular sarcoidosis.

We describe a very unusual form of sarcoidosis of the testis, mimicking malignancy at initial presentation. Genitourinary sarcoidosis is rare and this case report emphasizes the importance of meticulous analysis of the patient's clinical history combined with imaging findings and specific pathological criteria to diagnose this granulomatous disorder.

Autoimmune pancreatitis and extrapancreatic manifestations of IgG4-related sclerosing disease.

In a review of the literature concerning autoimmune pancreatitis we had special interest for the concept of IgG4-related pathology as a systemic disease with several clinical manifestations. In general, IgG4-positivity can not only be found in the pancreas, but also at the level of the kidneys, extrahepatic biliary ducts, gallbladder, lungs, salivary glands, lacrimal glands, retroperitoneal tissue, ureters, prostate, meninges and lymph nodes. IgG4 seems to be a central key player in the pathophysiology of this disease.

Preoperative mapping for haemodialysis access surgery with CO(2) venography of the upper limb.

OBJECTIVE: This study aims to evaluate the impact of CO(2) venography on the planning and outcome of native arteriovenous fistula (AVF) creation. METHODS: Records of patients who underwent CO(2) venography prior to access surgery between January 2000 and December 2008 were reviewed. CO(2) venography was performed selectively in chronic kidney disease (CKD) in stage IV-V patients without suitable veins on clinical examination. Findings at surgery were compared to CO(2) venography images. Patency of AVFs was analysed by the Kaplan-Meier method. Differences in outcome of maturation were compared using a chi(2) test. RESULTS: A total of 209 CO(2) venograms were obtained in 116 patients. In 89 patients (77%), 101 AVFs (21 forearm AVF (21%) and 80 elbow AVF (79%) were created. Surgical findings corresponded with CO(2) venography findings in 90% of patients. In 10 cases (10%), access was created at the elbow despite a patent forearm cephalic vein on CO(2) venography (n = 2) or access was attempted with a vein which was thought to be unsuitable on CO(2) venography (n = 8). Maturation rate of the latter was 50% (4/8) vs. 88% (80/91) for AVFs created with veins considered usable (P = 0.004). The overall maturation rate was 84% with 1-year primary, assisted primary and secondary patency rates of 63%, 70% and 71%, respectively. CONCLUSION: CO(2) venography is a useful tool for venous mapping prior to vascular access surgery, resulting in an overall maturation rate of 84% and good patency rates.

Diagnostic evaluation of PSA recurrence and review of hormonal management after radical prostatectomy.

The aim of this review is to provide a discussion of the diagnostic evaluation of biochemical recurrence following radical prostatectomy (RP) and an overview of the postoperative hormonal treatment (HT) options. As no randomized trials in the clinical setting of postoperative prostate-specific antigen recurrence have been reported, there is no conclusive evidence that HT after RP will prolong survival or reduce morbidity. Non-traditional approaches, such as intermittent androgen deprivation, non-steroidal anti-androgens and combination of finasteride and non-steroidal anti-androgen, are investigated and may be acceptable options. Combinations of HT with radiotherapy and/or chemotherapy for treatment of recurrent prostate cancer are under study.

Transcatheter embolization of an isolated lumbar arterial bleeding complicating radical nephrectomy for renal infarction with infected perirenal haematoma.

Lumbar arterial bleedings are rare but potentially life threatening. We report a case of an isolated right lumbar arterial bleeding after radical nephrectomy for renal infarction with infected perirenal haematoma. The diagnosis was suggested by computed tomography and confirmed with angiography. Definitive treatment of this vascular injury was obtained after percutaneous transcatheter embolization of the fourth right lumbar artery. General anaesthesia, further blood loss due to difficult surgical dissection, or even failure to find and ligate the injured artery, especially in redo-operations, can be avoided by this minimal invasive procedure. Endovascular embolization of a lumbar artery injured after radical nephrectomy might be a valuable treatment alternative in patients with postoperative retroperitoneal bleeding.

Pseudoaneurysm complicating protocol renal transplant biopsies: case reports.

Pseudoaneurysm is a rare complication of a renal biopsy procedure. We describe two cases of kidney transplant recipients who were diagnosed with a pseudoaneurysm more than 48 hours after protocol renal allograft biopsy and were successfully treated by selective embolization of the afferent artery.

Effect of nutritional supplement challenge in patients with isolated high-grade prostatic intraepithelial neoplasia.

OBJECTIVES: To investigate, through a prospective follow-up study, the effects of a dietary supplementation challenge in men with isolated high-grade prostatic intraepithelial neoplasia (HGPIN). METHODS: The effects of a 6-month supplementation challenge with selenium, vitamin E, and soy isoflavonoids in men diagnosed with isolated HGPIN on biopsy were evaluated. A total of 100 patients entered the study. Of the 100 men, 29 were excluded because they refused additional biopsies or were noncompliant with the protocol, 71 underwent repeat biopsies at 3 months, and 58 underwent a third set at 6 months. The prostate-specific antigen (PSA) level was recorded at inclusion and before each set of biopsies. The study endpoint was defined as the diagnosis of PCa at 3 months or the histopathologic status at 6 months. RESULTS: At the study endpoint, PCa had been found in 24 men (33.8%), HGPIN in 34 (47.9%), and no HGPIN or carcinoma in 13 (18.3%). The PCa risk throughout the study period was 25.0% in the group with a stable or decreasing PSA level (n = 48, 67.6%) and 52.2% in the group with an increasing PSA level (n = 23, 32.4%). This difference was statistically significant (P = 0.0458). Isolated HGPIN remaining at the first repeat biopsy and the percentage of initial cores with HGPIN were significant predictors of PCa at additional biopsies. CONCLUSIONS: The results of our study have shown that a decrease in the PSA level while taking a selenium, vitamin E, and soy isoflavonoids supplement predicts for a significantly lower risk of PCa in future biopsies. The percentage of initial biopsy cores with HGPIN and isolated HGPIN remaining at the first repeat biopsy are significant predictors of PCa in future biopsies.

Transrectal ultrasound in the staging of clinical T3a prostate cancer.

INTRODUCTION: The clinical staging of T3a prostate cancer is usually based on digital rectal examination (DRE). Overstaging of clinical T3a prostate cancer is present in 13-27% of the cases presented and understaging is in the range of 30%. The value of transrectal ultrasound (TRUS) as a staging tool is not generally accepted. The purpose of this study is to determine whether TRUS can refine the local staging in unilateral clinical T3a (cT3a) prostate cancer. PATIENTS AND METHODS: Between 1987 and 2004, 200 patients were staged as unilateral cT3a prostate cancer by DRE. All patients underwent radical prostatectomy and bilateral pelvic lymphadenectomy. Preoperative TRUS staging was performed for all patients. Final histopathological staging was compared with DRE and TRUS staging. The operable group (OG) was defined as T2 to unilateral T3a, and the advanced group (AG) was defined as bilateral T3a to T4. RESULTS: All DRE patients were assumed operable. However, in this group histopathology showed 27.0% of the patients had advanced disease. TRUS confirmed 184 patients to be operable (140 having unilateral cT3a, 44 patients having cT1c to cT2). Sixteen patients were considered to have advanced disease by TRUS. Importantly, in this group, 68.7% of the cases were indeed confirmed to have advanced disease by histopathology. CONCLUSION: TRUS can be used to refine clinical staging in unilateral cT3a prostate cancer. In cases where TRUS indicates advanced disease, it might be wise to trust the TRUS staging, rather than the DRE.

FDG-PET for preoperative staging of bladder cancer.

PURPOSE: The presence of lymph node involvement (N) and distant metastasis (M) in patients with invasive bladder carcinoma is a major determinant of survival and, therefore, a pivotal element in the therapeutic management. The aim of this prospective study was to evaluate the use of( 18)F-fluorodeoxyglucose positron emission tomography (FDG-PET) in this indication. METHODS: Whole-body FDG-PET and computed tomography (CT) were performed in 55 patients with non-metastatic invasive bladder cancer for preoperative staging. Correlative imaging of PET with CT was performed, leading to a PET(CT) result. The imaging results were compared with the gold standard, consisting of histopathology (lymphadenectomy, guided biopsy) or clinical follow-up for 12 months, and related to overall survival using the Kaplan-Meier method. RESULTS: The gold standard was available in 40 patients and indicated NM-positive disease in 15 patients (12 N lesions, 8 M lesions), and NM-negative disease in 25 patients. For the diagnosis of NM-positive disease, the sensitivity, specificity and accuracy of PET(CT) were 60%, 88% and 78%, respectively. Diagnostic discordances between PET(CT) and CT alone were found in 9/40 patients, among whom PET was correct in six (15%): three with true-positive and one with true-negative distant metastases, and two with true-negative lymph nodes. Median survival time of patients in whom PET(CT) indicated NM-positive disease was 13.5 months, compared with 32.0 months in the patients with a NM-negative PET(CT) (p=0.003). CONCLUSION: Addition of metabolism-based information provided by FDG-PET to CT in the preoperative staging of invasive bladder carcinoma yields a high diagnostic and prognostic accuracy.