Intramedullary spinal cord metastasis from colonic carcinoma presenting as Brown-Séquard syndrome: a case report.

INTRODUCTION: Intramedullary spinal cord metastasis is very rare. The majority are discovered incidentally during autopsy. Most symptomatic patients present with rapidly progressive neurological deficits and require immediate examination. Few patients demonstrate features of Brown-Séquard syndrome. Radiotherapy is the gold-standard of therapy for Intramedullary spinal cord metastasis. The overall prognosis is poor and the mortality rate is very high. We present what is, to the best of our knowledge, the first case of Intramedullary spinal cord metastasis of colorectal carcinoma presenting as Brown-Séquard syndrome. CASE PRESENTATION: We present the case of a 71-year-old Caucasian man with colonic adenocarcinoma who developed Intramedullary spinal cord metastasis and showed features of Brown-Séquard syndrome, which is an uncommon presentation of Intramedullary spinal cord metastasis. CONCLUSION: This patient had an Intramedullary spinal cord metastasis, a rare form of metastatic disease, secondary to colonic carcinoma. The metastasis manifested clinically as Brown-Séquard syndrome, itself a very uncommon condition. This syndrome is rarely caused by intramedullary tumors. This unique case has particular interest in medicine, especially for the specialties of medical, surgical and radiation oncology. We hope that it will add more information to the literature about these entities.

Imaging findings after radiofrequency ablation of adrenal tumors.

OBJECTIVE: The purpose of this study was to describe the imaging findings after radiofrequency ablation of adrenal tumors. MATERIALS AND METHODS: We retrospectively reviewed the imaging findings of all patients with adrenal tumors treated with radiofrequency ablation in our department from January 2001 through August 2009. The studies were reviewed in consensus by two attending abdominal imaging radiologists and an abdominal imaging fellow. Imaging findings before, immediately after, and at short- and long-term follow-up after ablation were recorded. RESULTS: Fourteen patients (seven men, seven women; mean age, 56 ± 8.4 years) underwent radiofrequency ablation of adrenal tumors. One case of small pneumothorax and one case of small hemothorax were the only minor complications (complication rate, 14%). The expected side effects of radiofrequency ablation were found in 35% of patients: in two patients adjacent liver parenchyma was ablated, in two patients the diaphragmatic crus was injured, and in two patients local hematoma occurred (in one patient, both adjacent liver and diaphragmatic crus were ablated). Immediate soft-tissue findings after radiofrequency ablation included air bubbles in 12 patients (86%) and fat stranding around the adrenal gland in 13 patients (93%). A fat rim sign was found in 60% of patients at long-term follow-up. The attenuation of the tumor immediately after the procedure increased an average of 7 HU (median, 5 HU; range, -2 to 18 HU) and tended to decrease in long-term follow-up. At long-term follow-up, most (75%) of the tumors had decreased in size and attenuation. CONCLUSION: Air bubbles and fat stranding are frequently seen immediately after radiofrequency ablation of adrenal tumors. A fat rim sign is a common finding at long-term follow-up. Attenuation of the ablated zone increases immediately after the procedure and decreases in long-term follow-up. The volume of the ablated zone has a variable size response, suggesting the need for baseline imaging.

Efficacy of radiofrequency ablation in the treatment of small functional adrenal neoplasms.

PURPOSE: To evaluate the use of radiofrequency (RF) ablation as a primary treatment for symptomatic primary functional adrenal neoplasms and determine the efficacy of treatment with use of clinical and biochemical follow-up. MATERIALS AND METHODS: After obtaining institutional review board approval, the authors retrospectively evaluated images and medical records from 13 consecutive patients with symptomatic functional adrenal neoplasms (<3.2 cm in diameter) who underwent RF ablation during a 7-year period. There were six men and seven women with a mean age of 54.1 years (range, 42-71 years). Cross-sectional images, findings from clinical examination, and adrenal biochemical markers were available for all patients. Ten of the 13 patients (77%) had an aldosteronoma and one patient each had a cortisol-secreting tumor, testosterone-secreting tumor, and pheochromocytoma. RF ablation was performed by two radiologists using an internally cooled electrode and a pulsed technique according to manufacturer's specifications. Clinical and laboratory follow-up was performed for all patients. Three patients underwent imaging follow-up for other reasons. RESULTS: All patients demonstrated resolution of abnormal biochemical markers after ablation (mean biochemical follow-up, 21.2 months). In addition, all patients experienced resolution of clinical symptoms or syndromes, including hypertension and hypokalemia (in patients with aldosteronoma), Cushing syndrome (in the patient with cortisol-secreting tumor), virilizing symptoms (in the patient with testosterone-secreting tumor), and hypertension (in the patient with pheochromocytoma). For the patients with aldosteronoma, improvements in hypertension management were noted. The mean blood pressure before ablation was 149/90 mm Hg with a mean (±standard deviation) of 3.1 ± 0.6 blood pressure medications, and this decreased to 122/77 mm Hg at a mean of 2.8 months after ablation with 1.3 ± 0.9 medications (P < .001) and 124/75 mm Hg at a mean of 41.4 months. There were two minor complications: one small pneumothorax and one limited hemothorax, neither of which required overnight admission. There were two episodes of transient self-remitting procedural hypertension-one in a patient with aldosteronoma and one in the patient with a cortisol-secreting tumor; however, none of these patients required further therapy during overnight observation. CONCLUSION: RF ablation may be an effective, minimally invasive method for treating small functional primary adrenal tumors.

Intraoperative ultrasonography of the pancreas.

Intraoperative ultrasonography (US) of the pancreas is a versatile technique that provides excellent spatial and contrast resolution and real-time imaging capabilities, making it useful for diagnostic imaging as well as for guidance of laparoscopic and open operative procedures. Intraoperative US may be used for applications such as staging and localizing tumors; performing regional metastatic surveys; documenting arterial and venous patency; identifying endocrine tumors; distinguishing pancreatitis from a neoplasm; and guiding biopsy, duct cannulation, and drainage of abscesses or cysts. The scanning approach and technique vary according to the application, with many different equipment and transducer options and sterilization methods available. With increasing clinical demands for intraoperative US, it is essential that radiologists be familiar with its uses and technique. In addition, to properly perform intraoperative US and accurately interpret the images, knowledge of normal and variant pancreatic and vascular anatomy and relevant landmarks is needed. Supplemental material available at http://radiographics.rsna.org/lookup/suppl/doi:10.1148/rg.307105051/-/DC1.

Quality initiatives: strategies for anticipating and reducing complications and treatment failures in hepatic radiofrequency ablation.

Radiofrequency (RF) ablation is one of several local treatment strategies that can be used for the destruction of a variety of primary and secondary liver tumors. As experience with RF ablation grows, it becomes increasingly evident that successful ablation requires meticulous technique. In addition, knowledge of potential complications is critical for both the interventionalist and the radiologist, whose postablation interpretation can facilitate identification of complications and treatment failures. Hepatic RF ablation offers significant advantages in that it is less invasive than surgery and carries a low risk of major complications. Successful prevention of complications and treatment failures begins at initial consultation and continues with preablation evaluation of specific patient factors such as coagulation profiles, use of medications, and risk factors for infection. Other predisposing factors include background liver cirrhosis, prior hepatectomy, and portal hypertension. During ablation, careful attention must be given to tumor size, number, and location. For large or multiple ablations, separate ablation sessions can help reduce the prevalence of postablation syndrome, and clustered electrodes and multiple overlapping treatment zones may be used to reduce the risk of treatment failure. It is critical to reevaluate tumors during ablation to determine the best approach and to compensate for changes in size and relative location due to patient positioning. With use of these strategies, hepatic RF ablation can be performed with greater safety, better patient tolerance, and a reduced risk of complications and treatment failures.

Stereotactic body radiotherapy and gemcitabine for locally advanced pancreatic cancer.

PURPOSE: Patients with nonmetastatic locally advanced unresectable pancreatic cancer have a dismal prognosis. Conventional concurrent chemoradiotherapy requires 6 weeks of daily treatment and can be arduous. We explored the safety and effectiveness of a 3-day course of hypofractionated stereotactic body radiotherapy (SBRT) followed by gemcitabine in this population. PATIENTS AND METHODS: A total of 36 patients with nonmetastatic, locally advanced, unresectable pancreatic cancer with ≥12 months of follow-up were included. They received three fractions of 8, 10, or 12 Gy (total dose, 24-36 Gy) of SBRT according to the tumor location in relation to the stomach and duodenum, using fiducial-based respiratory motion tracking on a robotic radiosurgery system. The patients were then offered gemcitabine for 6 months or until tolerance or disease progression. RESULTS: With an overall median follow-up of 24 months (range, 12-33), the local control rate was 78%, the median overall survival time was 14.3 months, the median carbohydrate antigen 19-9-determined progression-free survival time was 7.9 months, and the median computed tomography-determined progression-free survival time was 9.6 months. Of the 36 patients, 28 (78%) eventually developed distant metastases. Six patients (17%) were free of progression at the last follow-up visit (range, 13-30 months) as determined by normalized tumor markers with stable computed tomography findings. Nine Grade 2 (25%) and five Grade 3 (14%) toxicities attributable to SBRT occurred. CONCLUSION: Hypofractionated SBRT can be delivered quickly and effectively in patients with nonmetastatic, locally advanced, unresectable pancreatic cancer with acceptable side effects and minimal interference with gemcitabine chemotherapy.

Radiological changes in renal cell carcinomaafter extracorporeal CyberKnife® radiosurgical ablation:a case report / Alterações radiológicas no carcinoma de células renais após radiocirurgia estereotáticacom CyberKnife®: relato de caso

Small asymptomatic renal masses are more commonly discovered in elderly patients; however, multiple comorbidities in this population may preclude definitive surgical treatment. In this context, treatment options include active surveillance and ablative techniques. Stereotactic radiosurgery is a relatively innovative method of delivering ablative energy to abdominal organs, with very few human or animal experiences published. We describe our experience treating a patient with a large centrally located renal mass using CyberKnife® stereotactic radiosurgery.

Pequenas massas renais assintomáticas são mais frequentemente encontradas em pacientes idosos; contudo, comorbidades múltiplas nesses pacientes podem contraindicar um tratamento cirúrgico definitivo. Em tal contexto, as opções terapêuticas incluem vigilância ativa e técnicas ablativas. A radiocirurgia estereotáxica é um método inovador que aplica energia ablativa em órgãos abdominais, mas há pouca experiência nesse campo tanto em seres humanos como em animais. Descrevemos nossa experiência com o tratamento de um paciente com uma grande massa renal de localização central, utilizando-se a radiocirurgia esterotáxica com CyberKnife®.

Immediate renal tumor involution after radiofrequency thermal ablation.

PURPOSE: To retrospectively evaluate solid renal tumor sizes before and after treatment with radiofrequency (RF) thermal ablation to assess for immediate changes on cross-sectional imaging. MATERIALS AND METHODS: Medical records were retrospectively reviewed in consecutive patients who underwent percutaneous image-guided RF thermal ablation for solid renal tumors between December 12, 2000, and December 13, 2006. All patients underwent noncontrast computed tomography (CT) immediately before and after RF ablation. Maximum renal tumor diameters were measured before and after ablation. Statistical analysis of tumor sizes before and after ablation and change in tumor sizes was performed with the paired Student t test with confidence intervals calculated. RESULTS: Seventy-two renal tumors were treated with RF ablation in 66 patients (42 men, 24 women; mean age, 68.4 years; range, 25-88 y). Mean tumor sizes were 27.5 mm (range, 9.8-64.8 mm; 95% CI, 24.9-30.1 mm) before ablation and 22.1 mm (range, 5.3-67.3 mm; 95% CI, 19.4-24.8 mm) immediately after ablation. An average decrease in renal tumor size of 21% (range, -10% to 50%) was identified, with a mean tumor diameter decrease of 5.4 mm (P < .05; 95% CI, 4.4-6.4 mm). No relationship between size or location of tumors and percentage decrease in size after RF ablation was identified. Measurement of tumors on 1-month follow-up CT showed no appreciable change compared with immediate postprocedural measurements. CONCLUSIONS: Renal tumors decrease in size immediately after treatment with RF thermal ablation. Immediate tumor involution after RF ablation should be anticipated and follow-up imaging studies should ideally be compared to a baseline tumor size measured as soon as possible after ablation.

Thinking outside the abdominal box: safe use of the epipericardial fat pad window for percutaneous radiofrequency ablation of hepatic dome tumors.

Percutaneous imaging-guided tumor ablation is being increasingly performed for local disease control in a variety of primary and secondary neoplasms. Herein, the authors detail their experience with four patients in whom the epipericardial fat pad was traversed to access tumors within the hepatic dome for radiofrequency ablation. The procedure was technically successful in all patients, and the use of this novel window helped avoid crossing the pleura.

Practical performance of defecography for the evaluation of constipation and incontinence.

By opacifying the sigmoid, rectum, and vagina with different barium consistencies and using fluoroscopy to evaluate the mechanics of defecation in a physiologic setting, a wide range of pathologies associated with constipation and incontinence can be diagnosed. This review article discusses the primary indications for fluoroscopic defecography, techniques, common diagnoses, and challenges faced in clinical practice.

Transanorectal interventions.

Over the past few decades, advances in modern imaging technology have enabled less invasive approaches to diagnose and treat disease. In the field of image-guided techniques, this has seen the common adaptation of needle biopsy and catheter drainage into clinical practice. In this article we review the most common applications of transanorectal techniques. As nearly all these techniques are performed under ultrasound guidance in dayto-day practice, the review focuses almost exclusively on ultrasound-enabled techniques.

Plantar vein thrombosis: a rare cause of plantar foot pain.

Plantar vein thrombosis is a rare condition, with only a handful of cases reported in the literature. The cause is unknown; however, the disease has been attributed to prior surgery, trauma, and paraneoplastic conditions. We present a case of a 32-year-old female runner with plantar vein thrombosis diagnosed on contrast-enhanced MRI and confirmed on ultrasound. The symptoms resolved with conservative treatment and evaluation revealed the presence of a prothrombin gene mutation and use of oral contraceptive pills. To our knowledge, this is the first case of plantar vein thrombosis diagnosed initially by MRI. Moreover, this case suggests that plantar vein thrombosis should be considered in patients with hypercoagulable states and plantar foot pain.

Comprehensive preoperative assessment of pancreatic adenocarcinoma with 64-section volumetric CT.

Pancreatic adenocarcinoma is a common gastrointestinal malignancy that has a poor prognosis and for which successful surgical resection is the only method of cure. Preoperative staging and assessment can be performed with a number of modalities. Multidetector (64-section) volumetric computed tomography (CT) allows rapid anatomic coverage coupled with excellent spatial resolution. Understanding the technical parameters necessary for successful pancreatic CT angiography is crucial. Carefully timed scan acquisition maximizes the difference in attenuation between the neoplasm and the pancreatic parenchyma and allows accurate local and distant staging as well as assessment of local resectability. In addition, angiographic data sets can be rendered to create displays of the local venous and arterial anatomy that are familiar to surgeons. Advanced rendering can also be used to create pancreaticographic type images. The TNM system of staging for pancreatic adenocarcinoma is not frequently included in radiology reporting but is important for deciding on optimal therapy and neoadjuvant therapy.

Virtual Whipple: preoperative surgical planning with volume-rendered MDCT images to identify arterial variants relevant to the Whipple procedure.

OBJECTIVE: The purposes of this study were to combine a thorough understanding of the technical aspects of the Whipple procedure with advanced rendering techniques by introducing a virtual Whipple procedure and to evaluate the utility of this new rendering technique in prediction of the arterial variants that cross the anticipated surgical resection plane. CONCLUSION: The virtual Whipple is a novel technique that follows the complex surgical steps in a Whipple procedure. Three-dimensional reconstructed angiographic images are used to identify arterial variants for the surgeon as part of the preoperative radiologic assessment of pancreatic and ampullary tumors.

Patterns of bone and soft-tissue injury at the symphysis pubis in soccer players: observations at MRI.

OBJECTIVE: The objectives of our study were, first, to use MRI to determine the prevalence of osteitis pubis and of adductor dysfunction at the symphysis pubis in soccer players presenting with pubalgia and, second, to determine whether the two entities are mechanically related and whether one of the entities precedes or predisposes the development of the other. MATERIALS AND METHODS: One hundred consecutive soccer players with debilitating groin pain were referred for MRI. One hundred asymptomatic age- and sex-matched elite athletes were included as control subjects. The "secondary cleft" sign was used to indicate an adductor microtear at the symphyseal enthesis. Osteitis pubis was recorded if paraarticular bone edema was identified along the symphyseal margins but was remote from the adductor attachment. Images were reviewed independently by two radiologists who were blinded to the side of symptoms. Statistical analysis was performed using the chi-square test. RESULTS: Of 100 patients, groin pain was directly attributed to inflammation at the symphysis pubis or its muscular attachments in 97 (isolated adductor microtears, n = 47; isolated osteitis pubis, n = 9; both, n = 41). An "accessory cleft," reflecting an adductor enthetic microtear, was identified in 88 of these patients (p < 0.001); it correlated with the side of symptoms in all cases. Bone edema was identified in 91 of 100 patients: 49 had focal edema at the attachment site of the adductor tendons accompanying an adductor microtear, two patients had focal edema without an adductor tear, and 40 patients had diffuse edema in the pubic bones secondary to osteitis pubis. There was no evidence of either adductor dysfunction or symphyseal inflammation in the control subjects (p < 0.001). CONCLUSION: In soccer players with pubalgia, adductor dysfunction is a more frequent MRI finding than osteitis pubis. The findings of this study suggest that both entities are mechanically related and that osteitis pubis and adductor dysfunction frequently coexist but, because adductor dysfunction is commonly identified in the absence of osteitis, that adductor dysfunction most likely precedes the development of osteitis pubis in soccer players. The presence of edema on fat-suppressed images of the symphysis is a strong predictor of abnormality at this site in soccer players when compared with age- and sex-matched control subjects.

Intraoperative laparoscopic ultrasound.

In parallel with the increasing move from open surgical procedures to laparoscopic approaches, laparoscopic ultrasound (LUS) is being used with increasing frequency to image normal structures and intra-abdominal pathology. Special transducers and scanning techniques are required to perform LUS with a different set of considerations. Within the spectrum of LUS applications, LUS is used to complement laparoscopy for oncology staging, to facilitate an array of surgical procedures, and to guide laparoscopic biopsies.