What is that? HIV-negative plasmablastic lymphoma with intramuscular masses.

Plasmablastic lymphoma is a relatively new clinical entity described as a distinct subtype of diffuse large B-cell lymphoma, although in the last decade several case reports and series have been published. This case is presented because of its rarity, as this pathology is rare in immunocompetent patients and intramuscular masses are present. We report the case of a 63-year-old male with no significant clinical background. He was referred to the emergency department of our hospital with a 10-day history of pain on the left side of the chest that was described as burning and spreading to the right side. On physical examination, he had no fever or recent weight loss. The abdomen was soft and non-distended, and no peritoneal signs were present but he had three palpable masses located in the soft tissues of the breast, right gluteal region and left leg. Histological examination of the biopsy specimens disclosed the diagnosis of plasmablastic lymphoma. To our knowledge, this will be the second case report referring to intramuscular masses in the English language literature.

Usefulness of abdominal ultrasonography in the analysis of endoscopic activity in patients with Crohn's disease: changes following treatment with immunomodulators and/or anti-TNF antibodies.

OBJECTIVE: The objective of this study was to analyze the accuracy of abdominal ultrasonography (AUS) in the assessment of mucosal healing in patients with Crohn's disease (CD) receiving immunomodulators and/or biological treatment, with ileocolonoscopy as the reference standard. MATERIALS AND METHODS: Thirty patients were included in a prospective longitudinal study. All patients underwent ileocolonoscopy and AUS before and after a minimum of one year of treatment. The Crohn's Disease Endoscopic Inflammatory Index of Severity (CDEIS) was used for endoscopic assessment whereas AUS was analyzed by means of bowel wall thickness, color Doppler grade and percentage of increase of parietal enhancement after contrast injection. RESULTS: In the segmental analysis, endoscopic healing was found in 71.2% of the segments and AUS findings were normalized in 62.8%, with a significant correlation between the two techniques (κ=0.76, p<0.001). In the overall assessment performed after treatment, 18 (60%) patients exhibited endoscopic remission (CDEIS <6 points); of these patients, 15 (83.3%) had normalized sonographic findings, with a good correlation between endoscopic remission and sonographic normalization (κ=0.73, p<0.001). Of the three variables assessed by AUS, parietal thickness was the best variable to predict mucosal healing in both analyses, segmental and global. CONCLUSION: Abdominal ultrasonography is a useful and reliable technique for the assessment of the endoscopic response to treatment with immunomodulators and/or biological drugs in Crohn's disease. AUS is a highly accurate technique for evaluating the healing of the intestinal mucosa.

Contrast-enhanced ultrasonography: usefulness in the assessment of postoperative recurrence of Crohn's disease.

AIM: The aim of this study was to assess whether the contrast-enhanced ultrasonography (CEUS) can increase the value of the ultrasonography in the study of postoperative recurrence of Crohn's disease (CD). MATERIALS AND METHODS: 60 patients with CD who had previously undergone ileocolic resection underwent prospectively both CEUS and colonoscopy within a 3-day period. The sonographic examination included evaluation of bowel wall thickness, transmural complications, colour Doppler grade and contrast-enhanced US. In addition a sonographic score was established. The capacity of CEUS to diagnose endoscopic recurrence, as well as its severity, was assessed by calculating the sensitivity, specificity and positive and negative predictive values, accuracy and odds ratio, with their respective 95% confidence intervals. The areas under the receiver operating characteristic (ROC) curves were also calculated. RESULTS: 49 out of 60 patients showed endoscopic postoperative recurrence. Severe endoscopic recurrence was present in 34 patients (57%). Classic ultrasound parameters (wall thickness >3mm and colour Doppler flow) revealed an accuracy of 88.3% for the diagnosis of recurrence. Sonographic score 2, including thickness >5mm or contrast enhancement >46%, improved the results with a sensitivity, specificity and accuracy of 98%, 100% and 98.3%, respectively, in the diagnosis of endoscopic recurrence. The area under the ROC curve was 0.99, in remarkable agreement with endoscopy (k: 0.946). Sonographic score 3, including thickness >5mm, contrast enhancement >70% or fistula identified 32 out of 34 (94.1%) severe endoscopic recurrences. The area under the ROC curve was 0.836, in good agreement with endoscopy (k: 0.688). CONCLUSION: CEUS shows excellent sensitivity and specificity for the diagnosis of postoperative recurrence in CD and can also detect severe recurrences.

Sonographic diagnosis of symptomatic ureteral calculi: usefulness of the twinkling artifact.

PURPOSE: Our aim was to analyze the value of ultrasound using the twinkling sign in the diagnosis of ureteral stones in patients with renal colic in the emergency setting. MATERIALS AND METHODS: Prospective study of 100 patients with suspected renal colic who underwent an US examination, including color Doppler mode. We analyzed sensitivity, specificity, predictive values, and accuracy. We evaluated whether the stone was observed before or after the twinkling artifact, and whether the use of the Doppler color increased the examination time. RESULTS: US including color Doppler detected 76 of the 84 confirmed lithiasis. The sensitivity and specificity were 90 % and 100 %, respectively. The positive predictive value was 100 % and the negative 67 %. The accuracy was 92 %. A total of 59 calculi (78 %) examined by color Doppler sonography showed the twinkling artifact. Seventy percent of the twinkling-positive calculi showed the artifact before the stone itself was detected. Considering the location of the stones the twinkling sign was seen before the stone in 92 % of lithiasis located in the mid lumbar ureter (p = 0.02). The use of the twinkling artifact showed a trend to facilitate the detection of smaller calculi (<10 mm) (p = 0.08). The average examination time was 5.8 min [± 4.3] (without differences between the stones detected before or after the twinkling artifact, p = 0.75). CONCLUSION: Doppler US examination shows good sensitivity and specificity for the diagnosis of symptomatic ureteral stones. The twinkling artifact is useful for the early detection of the calculi, especially in the middle tract of the ureter, usually the most difficult place in sonographic diagnosis. It also seems helpful for the detection of smaller stones. The use of color Doppler does not increase the exploration time.

Contrast-enhanced ultrasound (CEUS) in Crohn's disease: technique, image interpretation and clinical applications.

BACKGROUND: Recent meta-analysis has demonstrated no significant differences in diagnostic accuracy among different imaging techniques (US, MRI and CT) in the evaluation of Crohn's disease (CD). High-resolution bowel ultrasound has emerged as an alternative imaging technique for the diagnosis and follow-up of patients with CD, being as accurate as CT and MR for detecting intramural and extramural extension of the disease. B-Mode US can evaluate the localization and length of the affected intestinal segments and allow identification of transmural complications, stenosis and intestinal obstruction. Doppler techniques are tools that visualize and quantify bowel vascularization. Contrast-enhanced ultrasound (CEUS) is a new technique that involves IV administration of an ultrasound contrast agent with real-time examination, providing an accurate depiction of the bowel wall microvascularization and the perienteric tissues. The introduction of imaging quantification techniques enables an objective quantitative measurement of the enhancement. METHOD AND RESULTS: The article reviews the technique, sonographic findings, advantages and limitations, and clinical applications of contrast-enhanced US in the evaluation of Cohn's disease. Current CEUS applications in CD are: CD activity assessment, evaluation of inflammatory masses, distinguishing phlegmons from abscesses, characterization of stenosis by differentiating fibrosis from inflammation, monitoring the efficacy of drug treatments and improving the detection of disease recurrence. CONCLUSION: CEUS is an emerging technique that is part of the entire sonographic evaluation, with a role in the diagnosis and follow-up of CD, thus improving therapy planning and monitoring of the efficacy of treatment. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi:10.1007/s13244-011-0124-1) contains supplementary material, which is available to authorized users.

Contrast-enhanced ultrasound in the staging of acute pancreatitis.

OBJECTIVE: To determine the diagnostic value of contrast-enhanced ultrasound (CEUS) in the assessment of acute pancreatitis, with computed tomography (CT) as the reference standard. METHODS: Fifty consecutive patients (mean age 58.4 years; range 23-86 years) with acute pancreatitis underwent prospectively both CT and ultrasonography, including CEUS, within a 24-h interval. Pancreatic vascularisation was evaluated with CEUS after injection of a second-generation US contrast-enhancing agent. Acute pancreatitis severity was graded according to the Balthazar index. The results were compared with CT severity index and clinical outcome by using Spearman's correlation coefficient. RESULTS: A significant correlation between CT and CEUS was found for the CT severity index (r = 0.926), extent of necrosis (r = 0.893) and Balthazar grade (r = 0.884). The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for detecting severe acute pancreatitis based on CT findings (severity index greater than 3 and/or presence of necrosis) were respectively 91%, 100%, 100% and 83%. A significant correlation between CEUS severity index and clinical variables was found: Ranson score (r = 0.442), C-reactive protein (CRP) levels 48 h after admission (r = 0.385) and length of hospital stay (r = 0.362). CONCLUSION: CEUS is comparable to CT in detecting pancreatic necrosis as well as predicting its clinical course. Therefore, when CT is contraindicated CEUS may be a valid alternative.

MR imaging in liver cirrhosis: classical and new approaches.

OBJECTIVE: The typical histological features of chronic hepatitis and cirrhosis are variable degrees of hepatocellular necrosis and inflammation (activity or grade of disease), fibrosis (stage of disease), and associated fat and iron deposition. These features influence the liver's appearance and must be assessed separately by imaging biomarkers in order to be clinically useful. Hepatic morphologic alterations and features of portal hypertension identify most cases of established cirrhosis. Nowadays, research is focused on developing ways to improve detection of early and intermediate stages of fibrosis as well as hepatocyte dysfunction. Even more, most imaging-related measurements are subject to complex interactions and are influenced by different pathologic processes, such as fatty infiltration, edema, necrosis and iron accumulation. METHODS AND RESULTS: MR experience throughout the last 15 years at the Dr Peset University Hospital is reviewed. CONCLUSION: Nowadays, several biomarkers have been developed to grade the liver status in cirrhosis. This review will focus on these topics.

Tissue harmonic sonography in the diagnosis of common bile duct stones: a comparison with endoscopic retrograde cholangiography.

PURPOSE: To revisit the diagnostic accuracy of sonography in the detection of choledocholithiasis using modern equipment with tissue harmonic imaging (THI) and endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy as the gold standard. METHODS: A total of 107 patients with clinically suspected choledocholithiasis were examined with THI before undergoing ERCP. The sonographic findings that were prospectively evaluated included the presence of choledocholithiasis, size of common bile duct, sonographic view and patient position that best visualized the stone(s), visualization of the distal common duct, and duration of examination. The accuracy of sonography compared with ERCP and sphincterotomy was calculated. RESULTS: Sonography correctly detected stones in 65 of 76 patients (sensitivity of 86%). The specificity and the overall accuracy were 87% and 86%, respectively. The sensitivity of sonography was higher with dilated extrahepatic duct (44% in patients with common bile duct measuring less than 6 mm in diameter, 82% between 6 and 10 mm, and 100% with common bile duct larger than 10 mm). The lateral approach with the patient in left lateral decubitus position of the patient was the most effective in 47% of the cases. CONCLUSION: Sonography with THI is an accurate technique for the detection of choledocholithiasis that may be used as the first-choice technique to avoid unnecessary procedures in a high percentage of patients, especially those with dilated biliary tree.

Crohn disease: correlation of findings at contrast-enhanced US with severity at endoscopy.

PURPOSE: To evaluate the effectiveness of visualization of vascularization at contrast material-enhanced ultrasonography (US) for assessment of the activity of Crohn disease, with severity grade determined at endoscopy as the reference standard. MATERIALS AND METHODS: Ethics committee approval and written informed consent were obtained. Sixty-one patients (age range, 21-67 years; median age, 36 years) who had Crohn disease underwent both colonoscopy and US, including color Doppler and contrast-enhanced US, prospectively. To assess the vascularization of the involved bowel loop in a region expected to be seen at colonoscopy, the contrast agent uptake was measured by using quantitative analysis of the enhancement in regions of interest. Measurement of contrast enhancement was assessed as the increase in wall brightness with respect to the baseline brightness. Results were compared with the severity grade determined at endoscopy by using the area under the receiver operating characteristic curve and logistic regression analysis. RESULTS: Colonoscopy showed inflammatory lesions in 53 patients (mild disease, seven; moderate disease, 12; and severe disease, 34). Bowel wall thickness and grade at color Doppler US (P = .019 and .002, respectively) correlated with severity grade at endoscopy. Mural contrast enhancement in patients with active disease at endoscopy was markedly increased in comparison with enhancement in patients with inactive disease (P < .001). Multivariate logistic regression analysis revealed that an increase in wall brightness was a significant and independent variable predictive of severity grade at endoscopy. A threshold brightness value of percentage of increase of 46% had a sensitivity and specificity of 96% and 73%, respectively, in the prediction of moderate or severe grade for inflammation at endoscopy. CONCLUSION: Quantitative measurements of bowel enhancement obtained by using contrast-enhanced US correlate with severity grade determined at endoscopy. Contrast-enhanced US could be a useful technique to monitor the activity of Crohn disease. SUPPLEMENTAL MATERIAL: http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.2531082269/-/DC1.

Diverticulitis de Meckel: hallazgos en ecografía y TC / Meckel's diverticulitis: echographic and CT findings

Presentamos los hallazgos radiológicos en ecografía y en TC de cuatro casos de diverticulitis de Meckel. La imagen típica visualizada es similar a la del apéndice inflamado, y para su diferenciación es útil su localización más medial y la no dependencia del ciego. En dos de los casos, la obtención de reconstrucciones multiplanares permitió llegar a un diagnóstico preoperatorio (AU)

Ecografía y TC del mucocele apendicular: hallazgos que sugieren etiología maligna / Appendicular mucocele ultrasound scan and CT: findings indicative of malignant ethiology

Objetivo: Describir los hallazgos del mucocele apendicular en ecografía y tomografía computarizada (TC), valorando los signos que ayuden a predecir el origen maligno del mismo. Material y métodos: Se revisaron los hallazgos clínicos y radiológicos de 17 pacientes diagnosticados de mucocele apendicular en nuestro hospital en los últimos 10 años (seis cistoadenocarcinomas, ocho mucoceles de retención, dos cistoadenomas y un adenoma velloso). Resultados: La ecografía mostró masas quísticas en la teórica localización del apéndice, con estructura de capas en la pared, de ecogenicidad interna variable, mostrando en siete casos calcificación parietal. La TC mostró tumoraciones quísticas de baja atenuación en el área pericecal, con realce parietal, siendo nodular en cuatro casos (tres cistoadenocarcinomas y un adenoma velloso). Ninguno de los cistoadenocarcinomas presentó calcio en la pared. En cuatro pacientes se observó la presencia de seudomixoma peritoneal (tres cistoadenocarcinomas y un mucocele de retención). Conclusiones: El mucocele apendicular tiene unos hallazgos ecográficos y en TC característicos. La presencia en la TC de un realce nodular en la pared del mucocele es un hallazgo que sugiere un origen maligno. La ausencia de calcio parietal y la existencia de seudomixoma peritoneal asociado también sugieren malignidad, aunque ambos signos pueden aparecer en mucoceles benignos (AU)

Estudios hepáticos con RM tras la administración de Teslascan® en bolo / MR liver imaging after bolus administration of Teslascan®

Introducción: El Mn-DPDP (Teslascan®, Amersham-Health) aumenta la detección de pequeñas lesiones hepáticas y la precisión en la caracterización de ciertas lesiones focales. En Europa está aceptada su administración en infusión lenta (2-3 ml por minuto). Nuestro objetivo ha sido valorar la eficacia de una administración en bolo. Material y métodos: Se realiza un estudio prospectivo de RM (0,5 T) a 31 pacientes consecutivos. A todos los pacientes se les realizó una secuencia EG-T1 antes de la administración del contraste, se administró Teslascan® por vía intravenosa rápida ( 1 ml/s), y se repitió la secuencia EG, completándose con una secuencia STIR. Se analizó la relación entre la presencia de cirrosis y el tipo de captación del parénquima hepático, el número de lesiones detectadas antes y después de su administración en bolo, y la relación entre la histología de las lesiones y el grado de captación. También se recogieron las manifestaciones clínicas adversas referidas por los pacientes. Resultados: El hígado era cirrótico en el 49 por ciento de los pacientes, con una captación principalmente heterogénea con áreas de hipointensidad y heterogénea mixta con áreas de hipointensidad junto a nódulos regenerativos de mayor captación. La captación de los hígados cirróticos fue homogénea en un tercio de casos. Los pacientes sin cirrosis mostraron un realce hepático homogéneo en la mayoría de ocasiones, observándose sólo un hígado con una captación heterogénea con tractos hipointensos por colapsos necróticos de metástasis tratadas. La diferencia entre los patrones de realce en cirróticos y no cirróticos fue estadísticamente significativa (p = 0,001). En 20 de 31 pacientes se detectaron lesiones focales sólidas. Las secuencias realizadas tras el contraste en bolo detectaron un mayor número de lesiones que las secuencias precontraste. La combinación de las dos secuencias poscontraste (T1 y STIR) demostró el mayor número de lesiones, con diferencias estadísticas frente al precontraste (p = 0,014). El grado de captación de las lesiones fue variable. Esta variabilidad va asociada a la naturaleza de las lesiones, captando aquellas con hepatocitos en su constitución. La mayoría de los pacientes presentaron sensación de calor facial (28 de 31, 90 por ciento) sin molestias en el sitio de la inyección. No se registraron otras reacciones adversas. Discusión y conclusión: La administración de Teslascan® en bolo ( 1 ml/s) es segura y eficaz, facilitando la detección y caracterización de lesiones focales. La combinación de secuencias EG-T1 y STIR poscontraste optimiza la detección de lesiones hepáticas. El manganeso es útil para demostrar el origen hepatocelular de una lesión y los hallazgos asociados a la cirrosis hepática, ayudando en la caracterización de las lesiones. La ausencia de captación de contraste en un CHC tratado previamente debe considerarse un indicador de éxito terapéutico (AU)

Estudio de la grasa abdominal mediante resonancia magnética: comparación con parámetros antropométricos y de riesgo cardiovascular / Abdominal fat assessment by magnetic resonance: comparison with biometric profiles and cardiovascular risk markers

FUNDAMENTO: La obesidad se asocia a numerosas complicaciones. En la frecuencia e intensidad de las mismas parece influir el depósito de grasa intraabdominal. La resonancia magnética es una técnica con una gran resolución espacial y capacidad de discriminación tisular. El objetivo del presente trabajo es estudiar el depósito graso abdominal y cuantificar su distribución relativa en un grupo de pacientes obesos, relacionando los hallazgos con la presencia de marcadores clínicos y analíticos de riesgo cardiovascular. PACIENTES Y MÉTODO: A todos los pacientes se les realizó un estudio de resonancia magnética abdominal, adquiriéndose imágenes axiales potenciadas en T1. Mediante el empleo de un programa de tratamiento de imágenes (ASYMED 3.0, Valencia) se cuantificó la distribución de la grasa en los compartimientos subcutáneo e intraabdominal. Se compararon los resultados de la resonancia magnética con los valores medios de diferentes marcadores de riesgo cardiovascular mediante la prueba de la t de Student para datos no apareados. Se fijó el nivel de significación en p < 0,05. RESULTADOS: El 12 por ciento de los pacientes presentaban una acumulación grasa de predominio intraabdominal. Se detectaron diferencias significativas en las cifras medias de edad, índice de cintura-cadera, y los valores de colesterol total, lipoproteínas de baja y muy baja densidad, triglicéridos y apoproteínas B entre los grupos determinados por ésta. CONCLUSIÓN: Mediante la resonancia magnética se obtuvieron imágenes adecuadas para calcular la distribución de grasa abdominal. Existe una relación estadísticamente significativa entre una mayor proporción de grasa intraabdominal y un perfil lipídico más aterogénico (AU)

TC helicoidal del sector vascular aortoilíaco: optimación del retraso en la adquisición mediante el método del bolo de prueba / Helical computed tomography of the aortoiliac vessels: optimization of the scan delay using the test bolus method

Objetivo: Optimar el tiempo de retraso en la adquisición de estudios de tomografía computarizada (TC) helicoidal del sector vascular aortoilíaco utilizando el método del bolo de prueba. Material y Métodos: Se estudiaron 90 pacientes consecutivos remitidos para evaluación del sector vascular aortoilíaco. En todos se calculó el tiempo de llegada del contraste a la aorta (T0 pico) de acuerdo con un protocolo predefinido utilizando el método del bolo de prueba, aplicándose distintos retrasos en la adquisición de la hélice. Se midieron los valores de atenuación en tres zonas de la aorta abdominal de todos los pacientes. Los resultados de captación por zonas y tiempos de retraso se compararon mediante la prueba ANOVA y Student-Newman- Keuls. El nivel de significación se fijó en p < 0,05.Resultados: El tiempo medio de llegada del contraste fue de 22,3 segundos (intervalo, 13-40). La captación media para las regiones inicial, central y distal de la aorta fue de 231, 260, y 254 UH en los grupos con retraso de T0 pico +5 segundos; de 275, 287 y 287 UH para un retraso de T0 pico + 10 segundos; y de 266, 259 y 276 UH para un retraso de T0 pico + 15 segundos, respectivamente. Conclusiones: La aplicación del método del bolo de prueba en la optimación de la captación intravascular en el sector vascular aortoilíaco permite lograr un elevado grado de realce. Cuando se utiliza un retraso de T0 pico + 10 segundos la opacificación vascular es homogénea en toda la aorta abdominal y mayor que con otras formulaciones (AU)

Detección de grasa en tumores lipomatosos del miometrio mediante TC y RM con técnica de desplazamiento químico / Detection of fat in lipomatous tumors of the myometrium by means of computed tomography and chemical shift magnetic resonance imaging

Los tumores lipomatosos del miometrio son lesiones raras compuestas por cantidades variables de tejido graso maduro. Nuestro objetivo ha sido valorar el comportamiento en TC y RM de estos tumores y determinar la utilidad de las técnicas de desplazamiento químico en la detección de grasa en estas lesiones uterinas focales.Se incluyen tres mujeres con lesiones focales uterinas lipomatosas detectadas mediante ecografía. Se realizaron estudios de TC y RM, incluyendo imágenes de desplazamiento químico con secuencias eco de gradiente potenciadas en T1 en fase y en fase opuesta. Se realizó un análisis cualitativo y cuantitativo mediante atenuaciones y relaciones de intensidad de señal.Los tumores se observaron hipoatenuados en TC e hiperintensos en imágenes T1, mostrando una disminución de su señal en las imágenes T1 en fase opuesta respecto a en fase. El porcentaje de variación (entre 2 por ciento y 309 por ciento) es probablemente proporcional a la diferente proporción de grasa y elementos musculares presente en estos lipoleiomiomas.Los tumores lipomatosos del miometrio son un grupo de lesiones uterinas con una proporción grasa variable. La TC y la RM detectan su composición grasa. Con la técnica de desplazamiento químico se evidencian variaciones en la proporción grasa de estos tumores. Al ser la presencia de grasa dentro de las lesiones uterinas virtualmente diagnóstica de tumor lipomatoso miometrial, la técnica de desplazamiento químico contribuye a su caracterización (AU)