Role of imaging in pretreatment evaluation of early invasive cervical cancer: results of the intergroup study American College of Radiology Imaging Network 6651-Gynecologic Oncology Group 183.

PURPOSE: To compare magnetic resonance imaging (MRI) and computed tomography (CT) with each other and to International Federation of Gynecology and Obstetrics (FIGO) clinical staging in the pretreatment evaluation of early invasive cervical cancer, using surgicopathologic findings as the reference standard. PATIENTS AND METHODS: This prospective multicenter clinical study was conducted by the American College of Radiology Imaging Network and the Gynecologic Oncology Group from March 2000 to November 2002; 25 United States health centers enrolled 208 consecutive patients with biopsy-confirmed cervical cancer of FIGO stage > or = IB who were scheduled for surgery based on clinical assessment. Patients underwent FIGO clinical staging, helical CT, and MRI. Surgicopathologic findings constituted the reference standard for statistical analysis. RESULTS: Complete data were available for 172 patients; surgicopathologic findings were consistent with FIGO stages IA to IIA in 76% and stage > or = IIB in 21%. For the detection of advanced stage (> or = IIB), sensitivity was poor for FIGO clinical staging (29%), CT (42%), and MRI (53%); specificity was 99% for FIGO clinical staging, 82% for CT, and 74% for MRI; and negative predictive value was 84% for FIGO clinical staging, 84% for CT, and 85% for MRI. MRI (area under the receiver operating characteristic curve [AUC], 0.88) was significantly better than CT (AUC, 0.73) for detecting cervical tumors (P = .014). For 85% of patients, FIGO clinical staging forms were submitted after MRI and/or CT was performed. CONCLUSION: CT and MRI performed similarly; both had lower staging accuracy than in prior single-institution studies. Accuracy of FIGO clinical staging was higher than previously reported. The temporal data suggest that FIGO clinical staging was influenced by CT and MRI findings.

Lymphoplasmacytic sclerosing pancreatitis.

Lymphoplasmacytic sclerosing pancreatitis is a rare entity that has been described under many different names and constitutes a diagnostic challenge as it may simulate a neoplastic process. Herein, we report a case of a 61-year-old woman who presented to our institution complaining of left flank pain and was found to have normal levels of amylase and lipase. An abdominal magnetic resonance image showed thickening of the pancreatic tail and compression of the pancreatic duct. The radiographic differential included both chronic pancreatitis and a neoplastic process. She underwent an exploratory laparotomy, during which a pancreatectomy and splenectomy were performed. Grossly, the pancreas contained a yellowish white, firm homogeneous mass measuring 6.5 x 3.3 x 2.9 cm involving the entire pancreatic tail and hilum of the spleen. Histologically, pancreatic sections showed extensive fibrosis admixed with an inflammatory infiltrate. This infiltrate was composed mainly of lymphocytes with multiple germinal centers, as well as plasma cells and eosinophils that surrounded pancreatic ducts and extended into the peripancreatic adipose tissue. No malignancy was identified, and the process was diagnosed as lymphoplasmacytic sclerosing pancreatitis.

Magnetic resonance cholangiography with mangafodipir trisodium (Teslascan) to evaluate bile duct leaks after T-tube removal in liver transplantation.

Liver transplant patients who present with abdominal pain after removal of the T-tube can be initially evaluated by contrast-enhanced magnetic resonance cholangiography (CEMRC) instead of abdominal computed tomography and hepatobiliary scintigraphy. In this article, 3 liver transplant patients who were evaluated by CEMRC after removal of the T-tube. CEMRC successfully identified the presence, location and extent of bile duct leaks, and can be performed as a diagnostic study in patients with suspected bile duct leaks.

Hepatocellular adenomatosis is a rare entity that may mimic other hepatocellular lesions.

A 14-year-old girl presented to her pediatrician with right lower quadrant pain that progressed to right upper quadrant pain with radiation to her back. Her past medical history included mitral valve prolapse, and she had no history of oral contraceptive use. Abdominal computed tomography revealed a liver mass and multiple smaller areas of low attenuation, too small to characterize. The clinical and radiographic features were suggestive of hepatocellular adenoma, and she underwent a left hepatic lobectomy. The liver contained one 4.2 cm nodule and multiple (10 to 20) smaller nodules that were well-demarcated from the adjacent liver parenchyma. All lesions were histologically hepatocellular adenomas and, therefore, she was diagnosed with hepatocellular adenomatosis. This case is unique because of the small number of cases of hepatocellular adenomatosis diagnosed in teenagers, and little long-term follow-up.

The role of MRI in the conservative management of endometrial cancer.

BACKGROUND: Young patients with endometrial cancer who desire to preserve their fertility often decline hysterectomy in favor of conservative progestin therapy. Proper candidates should have disease confined to the uterus and a well-differentiated tumor. One of the evolving techniques to evaluate the extent of the disease and myometrial or cervical invasion is magnetic resonance imaging (MRI). CASE: A young patient with early-stage endometrial cancer initially declined surgery and was treated with megestrol. MRI suggested myoinvasion, and the patient consented to surgical staging. The final pathology revealed no residual carcinoma. CONCLUSIONS: The accuracy of MRI in detecting myoinvasion is limited, and as such results should be interpreted with caution when this information is used in counseling a young patient regarding surgical staging for endometrial cancer.

Using contrast-enhanced MR cholangiography with IV mangafodipir trisodium (Teslascan) to evaluate bile duct leaks after cholecystectomy: a prospective study of 11 patients.

OBJECTIVE: The purpose of our study was to determine whether contrast-enhanced MR cholangiography using IV mangafodipir trisodium can accurately detect the presence and location of bile duct leaks in patients who have undergone cholecystectomy. SUBJECTS AND METHODS: Our study group included 11 patients with suspected bile duct leaks after cholecystectomy. Axial single-shot fast spin-echo and gradient-echo images were acquired in all patients before and 1-2 hr after IV administration of mangafodipir trisodium. The contrast-enhanced MR cholangiograms were evaluated for image quality, degree of ductal or small bowel opacification, and the presence and location of bile duct leaks, strictures, and stones. MR cholangiograms were correlated with conventional contrast-enhanced cholangiograms obtained in all patients, including endoscopic retrograde cholangiography (n = 10) and percutaneous transhepatic cholangiography (n = 1). RESULTS: Excretion of mangafodipir trisodium was noted in the intrahepatic and extrahepatic bile ducts in all patients from 1 to 2 hr after IV administration. Bile ducts and fluid collections that contained excreted mangafodipir trisodium showed increased signal intensity on gradient-echo sequences and decreased signal intensity on single-shot fast spin-echo sequences. Conventional contrast-enhanced cholangiography showed the presence of bile duct leaks in six patients and the absence of bile duct leaks in five patients, with false-negative findings in one patient and false-positive findings in one patient for bile duct leak (sensitivity, 86%; specificity, 83%). CONCLUSION: Contrast-enhanced MR cholangiography with IV mangafodipir trisodium can successfully detect the presence and location of bile duct leaks in patients suspected of having such leaks after undergoing cholecystectomy. More research is necessary before acceptance of this examination as routine in the workup of these patients.

Comparison of MR cholangiopancreatographic techniques with contrast-enhanced cholangiography in the evaluation of sclerosing cholangitis.

OBJECTIVE: The purpose of our study was to compare MR cholangiopancreatography and contrast-enhanced cholangiography in patients with sclerosing cholangitis. MATERIALS AND METHODS: Twenty patients with sclerosing cholangitis were evaluated on MR cholangiopancreatography using the single-shot fast spin-echo technique at 1.5 T. A group of 19 healthy volunteers underwent MR cholangiopancreatography as controls. Thick-slab (2-cm sections) coronal oblique and thin-slab (5-mm sections) interleaved straight coronal MR images were obtained. All patients with sclerosing cholangitis had an MR cholangiopancreatogram within 12 months of a contrast-enhanced cholangiogram (mean, 3.8 months). Seventy-five percent of patients had an MR cholangiopancreatogram within 3 months of the contrast-enhanced cholangiogram. The MR cholangiopancreatograms and contrast-enhanced cholangiograms were reviewed independently in a random fashion by two radiologists who were unaware of clinical history for the degree of ductal visualization and for the presence and location of strictures of the intrahepatic and extrahepatic bile ducts. All discrepancies were resolved by a consensus, and the contrast-enhanced cholangiograms were regarded as the gold standard. Statistically significant data were calculated using the signed rank test (p < 0.01), and agreement analysis was calculated using Cohen's kappa. RESULTS: All findings on MR cholangiopancreatograms in healthy subjects were interpreted as normal, and all findings on MR cholangiopancreatograms in patients with sclerosing cholangitis were interpreted as abnormal. When compared with the control group, scans of patients with sclerosing cholangitis usually showed good visualization (>50%) of the intrasegmental (86% vs 9%) and peripheral (67% vs 0%) intrahepatic ducts on thick-slab MR cholangiopancreatography. Thick-slab MR cholangiopancreatography showed good visualization in more ducts than contrast cholangiography (84% vs 70%; p = 0.10) and showed more strictured ducts than contrast cholangiography (47% vs 36%; p = 0.22). When comparing those ducts with good visualization on both MR cholangiopancreatography and contrast cholangiography, we found that disagreement occurred regarding 32% of ducts. Most of the discrepancies (60%) resulted when a stricture was noted on MR cholangiopancreatography but not on contrast-enhanced cholangiography. Good interobserver agreement (kappa > 0.4) was noted for detecting strictures of the extrahepatic, left hepatic, left medial, and right posterior ducts, with the greatest agreement for extrahepatic ductal strictures (kappa = 0.8). CONCLUSION: Thick-slab MR cholangiopancreatography is the best technique for depicting normal and strictured bile ducts and allows the differentiation of healthy patients from patients with sclerosing cholangitis. Although endoscopic retrograde cholangiopancreatography was considered the standard, MR cholangiopancreatography was superior for intrahepatic biliary ductal visualization. Therefore, this technique is of value in the diagnosis and follow-up of patients with sclerosing cholangitis.

Hepatic transplant complicated by hepatic artery thrombosis and bile duct necrosis: case report and potential application of contrast-enhanced MR cholangiography following intravenous mangafodipir trisodium in the emergency room setting.

Biliary tract strictures and leaks are the second most common complications following orthotopic liver transplantation. Nonanastomotic bile duct complications are most often caused by hepatic artery thrombosis and can result in fulminant hepatic necrosis, bile duct strictures, and bile duct leaks that increase the risk of cholangitis, sepsis, and abscess. The emergency physician and radiologist should strongly suspect biliary disease in a post-transplant patient presenting with elevated liver function tests, jaundice, fever, and/or abdominal pain in order to achieve diagnosis and treatment rapidly. We present the case of a liver transplant patient who developed bile duct necrosis and hepatic infarction secondary to hepatic artery thrombosis 5 months after surgery. In addition, we discuss a new contrast-enhanced MR cholangiographic technique that has the potential to be performed in the emergency setting as the only diagnostic test prior to appropriate therapy.

Recurrent gallstone ileus: a case report.

Gallstone ileus is a rare complication of recurrent gallstone cholecystitis and usually occurs in elderly female patients. Recurrent gallstone ileus occurs in 5% of patients with a previous episode of gallstone ileus and is associated with a mortality of 20%. We present a 52-year-old female with recurrent gallstone ileus 1 year after her initial episode.

Ureterolithiasis: classical and atypical findings on unenhanced helical computed tomography.

Evaluation of patients with acute flank pain using helical computed tomography (CT) is a well-accepted, rapid, and safe procedure in the emergency setting. Various primary and secondary signs are described in the literature for evaluation of these patients. Our purpose is to demonstrate both the classical findings associated with ureteral calculi on unenhanced helical CT and atypical findings and potential pitfalls. We also provide readers with a systematic approach to interpreting unenhanced helical CT scans performed for acute flank pain.