Risk-Adapted Strategy Combining Magnetic Resonance Imaging and Prostate-Specific Antigen Density to Individualize Biopsy Decision in Patients With PI-RADS 3 ``Gray Zone'' Lesions.

INTRODUCTION: Recent guidelines suggest that biopsy may be omitted in some groups of patients with PI-RADS 3 lesions on mpMRI. In this study, we aimed to evaluate biopsy strategies involving prostate-specific antigen density (PSAd) to avoid unnecessary biopsy versus the risk of missing clinically significant prostate cancer (csPCa) in patients with PI-RADS 3 lesions. MATERIAL AND METHODS: Data of 616 consecutive patients who underwent PSAd and mpMRI before prostate biopsy between January 2017 and January 2022 at a single center were retrospectively assessed. All of these patients underwent combined cognitive or fusion targeted biopsy of suspicious lesions and transrectal ultrasonography guided systematic biopsy. PI-RADS 3 based strategies with PSAd and mpMRI combination were created. For each strategy, avoided unnecessary biopsy, reduced ISUP Grade 1, and missed ISUP Grade ≥ 2 ratios were determined. Decision curve analysis (DCA) was used to statistically compare the net benefit of each strategy. RESULTS: DCA revealed that patients who had PI-RADS 3 lesions with PSAd ≥ 0.2, and/or patients who had PI-RADS 4 and 5 lesions had the most benefit, under the threshold probability level between 10% and 50%, which avoided 48.2% unnecessary prostate biopsies and reduced 51% of ISUP grade 1 cases, while missed 17.5% of ISUP grade ≥ 2 cases. (22.1% for ISUP grade 2 and 8.8% for ISUP grade ≥ 3). Strategy 1 (PI-RADS 4-5 and/or PSAd ≥ 0.2), 3 (PI-RADS 4-5 and/or PI-RADS 3 if PSAd ≥ 0.15), and 7 (PI-RADS 4-5 and/or PI-RADS 3 if PSAd ≥ 0.15 and/or PI-RADS 2 if PSAd ≥ 0.2) were the next three best strategies. CONCLUSION: mpMRI combined with PSAd strategies reduced biopsy attempts in PI-RADS 3 lesions. Using these strategies, the advantage of avoiding biopsy and the risk of missing the diagnosis of csPCa can be discussed with the patient, and the biopsy decision can be made afterwards.

Magnetic resonance defecography findings of dyssynergic defecation.

Dyssynergic defecation (DD) is defined as paradoxical contraction or inadequate relaxation of the pelvic floor muscles during defecation, which causes functional constipation. Along with the anal manometry and balloon expulsion tests, magnetic resonance (MR) defecography is widely used to diagnose or rule out pelvic dyssynergia. Besides the functional abnormality, structural pathologies like rectocele, rectal intussusception, or rectal prolapse accompanying DD can also be well demonstrated by MR defecography. This examination can be an uncomfortable experience for the patient, so the imaging method and the importance of patient cooperation must be explained in detail. The defecatory phase of the examination is indispensable for evaluation, and inadequate effort should be ruled out before diagnosing DD. MR defecography provides important data for the diagnosis of DD, but optimal imaging criteria should be applied. Further tests can be suggested if patient co-operation is not sufficient or MR defecography findings are irrelevant.

Breast Ultrasound during Lactation: Benign and Malignant Lesions.

BACKGROUND: Structural changes during lactation make breast physical examination difficult. When breast problems occur, patients are often referred for an ultrasound (US) scan. Most breast lesions diagnosed in these patients are benign, but the diagnosis of breast cancer is a challenge. We aim to demonstrate the spectrum of US imaging findings in lactating women. METHODS: 77 breastfeeding patients who underwent breast US in our department between February 2012 and March 2017 were evaluated. Patients' electronic medical records were reviewed for the presenting complaint, US reports, pathology results if available, and clinical/radiologic follow-up. All examinations were performed by 2 radiologists. RESULTS: 28 of the 77 patients had normal US findings. Cysts were seen in 16 patients. 4 patients had stable fibroadenomas. 6 patients had US imaging findings suggestive of mastitis, 5 patients had galactoceles, 1 patient had an abscess, and 1 patient had unilateral hypertrophy without any accompanying lesion. In 13 patients, BI-RADS 3 solid masses were diagnosed. Invasive breast cancer was diagnosed in 3 patients. CONCLUSION: US can demonstrate or exclude a true mass against the background of a nodular breast parenchyma. Radiologists must be aware of malignant US features to avoid delays in the diagnosis of pregnancy-associated breast cancer.

Liver metastases of neuroendocrine tumors: is it possible to diagnose different histologic subtypes depending on multiphasic CT features?

PURPOSE: To assess and compare the multiphasic computed tomography (CT) features of neuroendocrine tumor (NET) liver metastases and to investigate the possibility to predict the histologic subtype of the primary tumor. MATERIALS AND METHODS: Between January 2013 and December 2017 patients with biopsy proven NET with at least one liver metastasis who underwent multiphasic CT were enrolled in this study. All cases were acquired using a standardized multiphasic liver CT protocol, arterial, portal, and hepatic venous phases were obtained. Images were retrospectively analyzed in consensus by two abdominal radiologists blinded to clinical data and histologic subtype. The size, number, and location of lesions were noted. Enhancement patterns of each lesion on arterial, portal, and hepatic venous phases were assessed. For quantitative analysis, CT attenuation of tumors, liver parenchyma, and aorta were measured using a circular region of interest (ROI) on arterial, portal, and hepatic venous phases for reflecting the blood supply of the tumor. Tumor-to-aorta and tumor-to-liver ratio were calculated in all three phases. Differences between subtypes of NET liver metastases were studied using ROC analysis of clustered data. RESULTS: A total of 255 neuroendocrine tumor liver metastases divided into 101 (39.6%) pancreatic, 60 (23.5%) gastroenteric and 94 (36.8%) lung NET liver metastases were analyzed. Contrast enhancement of lesions was homogeneous in 78% of patients (n = 199), which was significantly more frequent in patients with pancreatic group than in those with gastroenteric origin (n = 90, 89.1% vs. n = 28, 46.7%; p < 0.001). Gastroenteric NET metastases frequently showed heterogeneous enhancement, which was significantly higher than in the other two groups (50% vs. 3% and 2%). With respect to the location of the primary tumor, the difference in enhancement patterns of the liver lesions was statistically significant (p < 0.001). Pancreatic NET metastases were mostly hyperdense on arterial images and isodense on portal and hepatic venous phase images (79.2%, n = 80). Gastroenteric NET metastases were mostly hyperdense on arterial phase images and hypodense on portal and hepatic venous phase images (n = 28, 46.7%). The most frequent pattern for lung NET metastases was hypoattenuation on all three phase images (n = 44, 46.8%). ROC analysis of clustered data revealed statistically significant differences between pancreatic NET liver metastases, gastroenteric NET liver metastases, and lung NET liver metastases in terms of tumor-to-aorta (T-A) ratio and tumor-to-liver (T-L) ratio (p < 0.001). CONCLUSION: We observed statistically significant differences in multiphasic CT features (enhancement pattern, T-A ratio, and T-L ratio) between histologic subtypes of NET liver metastases. As the difference in histological subtypes of NET liver metastases results in a different prognosis and different management strategy, these CT features might help to identify the primary tumor when it is not known to ensure accurate tumor staging and to provide optimal treatment.

MR cholangiopancreatography findings of biliary tract complications after liver transplantation

Background/aim: We aimed to present the magnetic resonance cholangiopancreatography (MRCP) findings of biliary tract complications after liver transplantation. Materials and methods: Seventy-five patients who underwent MRCP in our department between July 2011 and July 2015 after liver transplantation were retrospectively evaluated. The MRCP images were reevaluated by three radiologists in consensus. Diagnostic confirmation of MRCP findings was obtained with direct cholangiographic examinations or with clinical, radiological, and laboratory findings and concordance between MRCP findings and the final diagnosis was investigated. Results: Twenty-seven of the 75 patients had normal MRCP findings and at least one type of biliary tract complication was detected on the MR images of 48 patients. These complications included anastomotic stricture, dilatation of the biliary tract, nonanastomotic stricture, biliary leakage, cholangitis, biloma, abscess due to cholangitis, biliary stone-sludge, and donor-to-recipient bile duct disproportion. Thirty of the 75 patients were followed only by clinical and laboratory findings without further imaging. Forty-five patients underwent direct cholangiographic examinations. At the end of the follow-up period, 28 of the 75 patients were considered free of biliary tract complications, and at least one bile duct complication was diagnosed in 47 patients. Conclusion: With its high sensitivity and specificity, MRCP should be the first choice of method in the diagnosis and follow-up of biliary complications after liver transplantation.

Concurrent Septal and Right Ventricular Aneurysms Detected on Second Trimester Ultrasound Scan: A Case Report.

Congenital aneurysms and diverticula of the heart are rare anomalies and their prenatal diagnosis is challenging. Fetuses with suspected cardiac aneurysms on ultrasound (US) screening should undergo targeted fetal echocardiography, postnatal imaging, and follow-ups. Herein, we describe the second trimester US scan and postnatal cardiac magnetic resonance imaging (MRI) findings of a baby girl with concurrent septal and right ventricular cardiac aneurysms. Other cardiac and extra-cardiac structures were normal. Upon consultation about the prognostic uncertainty of the situation, the family chose to continue the pregnancy. The rest of the pregnancy and birth was without any complications. Follow-up postnatal echocardiograms showed no progression regarding the size of the aneurysms. The baby is still on follow-up without any medication and is thriving. To the best of our knowledge, this case report is the first to show the prenatal diagnosis of two concurrent rare cardiac aneurysms.

Typical MR imaging findings of perianal infections in patients with hematologic malignancies.

OBJECTIVE: We aimed to investigate the MR imaging findings of patients with hematologic malignancies who have symptoms suggesting perianal infection and to demonstrate the importance of imaging. SUBJECTS AND METHODS: The study included 36 patients with hematologic malignancies who underwent anorectal MR imaging in our department between September 2011-May 2016. Two radiologists experienced in abdominal radiology viewed the MR images in consensus. Abscesses, fistulous or sinus tracts, signal alterations and contrast enhancement in keeping with an inflammation and edema in the perianal region were recorded. RESULTS: Perianal abscess was found in 16 of the 36 patients. In 10 of these 16 patients there was also extensive inflammatory signal alterations in perianal and/or perineal soft tissues. In six of the 36 patients perianal fistula was detected. A sinus tract was seen at the level of subcutaneous external anal sphincter in one patient. Inflammatory signal alterations in the surrounding soft tissues were present in three of these seven patients. There were abscesses in labium majus in two patients and in one patient there were perineal abscesses with accompanying inflammatory signal alterations. In six of the 36 patients no abscess or fistula/sinus tract was seen. There were only inflammatory signal alterations with contrast enhancement in perianal or subcutaneous tissues. In two patients presenting with perianal pain and hemorrhoids, minimal inflammatory changes were detected on MR images. There were two patients with normal MR imaging findings. CONCLUSION: As digital examination of the anorectum and rectoscopy are avoided in neutropenic patients, MR imaging, which clearly demonstrates the perianal pathology should be preferential.

Diagnostic value of T1-weighted gradient-echo in-phase images added to MRCP in differentiation of hepatolithiasis and intrahepatic pneumobilia.

OBJECTIVE: The purpose of this article is to determine the added diagnostic value of T1-weighted gradient-echo in-phase images obtained during MRCP in the detection and differentiation of hepatolithiasis and intrahepatic pneumobilia. MATERIALS AND METHODS: Intrahepatic bile ducts in 47 patients were scored in terms of their possibility of containing biliary stone and air. MRI was performed with a 1-T system for 32 patients and with a 3-T system for 15 patients. Two radiologists independently reviewed two sets of MRI scans: set 1 included T2-weighted MRCP images, and set 2 included T2-weighted MRCP images plus T1-weighted gradient-echo in-phase images. The diagnostic performances of set 1 and set 2 in the evaluation of the bile ducts containing air or stone and bile ducts containing neither of them were analyzed using the area under the receiver operating characteristic curve (AUC) for clustered data. The sensitivities and specificities of both image sets to detect intrahepatic stone or air were also calculated and compared. RESULTS: For the diagnosis of hepatolithiasis, the AUC obtained from set 2 (0.983) was significantly higher than that obtained from set 1 (0.879; p = 0.037). For the diagnosis of pneumobilia, the AUC obtained from set 2 (0.965) was also significantly higher than that of set 1 (0.765; p = 0.002). With use of percutaneous transhepatic cholangiography, ERCP, and CT as the reference standards, the sensitivity of set 2 (97.1%; 95% CI, 91.1-100%) was significantly higher than that of set 1 (74.3%; 95% CI, 56.7-91.9%) in detecting intrahepatic stones (p = 0.011). For the detection of pneumobilia, the sensitivity of set 2 (98.5%; 95% CI, 95.4-100%) was also significantly higher than that of set 1 (70.8%; 95% CI, 57.7-83.3%; p = 0.000). CONCLUSION: The addition of T1-weighted gradient-echo in-phase images to standard MRCP sequences improves the detection and differentiation of hepatolithiasis and intrahepatic pneumobilia.

Are caudate-right lobe ratio and splenic size correlated with the MELD score in cirrhotic patients?

AIM: To determine the relationship between caudate-right lobe ratio (C/R) and model for end-stage liver disease (MELD) score. METHODS: The study included 50 patients with cirrhosis and a control group of 20 patients. C/R was measured as described by Harbin et al. The size of the spleen was measured on coronal images. The Organ Procurement and Transplantation Network Web site was used for MELD score calculation. Aspartate to alanine aminotranferase (AST/ALT) ratio was calculated. RESULTS: There was statistically significant difference between the two groups. C/R, the size of the spleen, and AST/ALT values were significantly correlated with MELD score. CONCLUSIONS: There is a significant relationship between the C/R and MELD score.

Gray-scale and color Doppler US findings of amniotic sheets.

PURPOSE: To identify the gray-scale and color Doppler ultrasonography (US) findings of amniotic sheets. MATERIALS AND METHODS: Among 1201 pregnant patients who underwent detailed second trimester US, nine had amniotic sheets. An amniotic sheet was defined as a shelf-like structure in the uterine cavity with a free edge not attached to the fetus or umbilical cord. There was no major fetal anomaly observed in any patient. Eight patients had solitary amniotic sheets, and one patient had double sheets. All gray-scale and Doppler US features of amniotic sheets were noted. RESULTS: The incidence of an amniotic sheet was determined to be 0.75% (ten amniotic sheets were observed in nine patients). On gray-scale US images, amniotic sheets were observed as bands of tissue that originated from the uterine wall with a triangular-shaped base that tapered toward the free edge. A three-layered appearance was identified in seven amniotic sheets. Using Doppler US images, four of ten sheets showed a low-resistance arterial flow, and five of ten sheets showed non-pulsatile venous flows. No vascularization was observed in one patient with a thin, membranous sheet. CONCLUSION: Gray-scale US is sufficient for the diagnosis of amniotic sheets because of the typical US characteristics; however, Doppler US findings of amniotic sheets are highly variable. Thus, Doppler US may not be beneficial in the diagnosis of amniotic sheets.

The effect of nuchal cord on nuchal fold thickness measured in the second trimester.

PURPOSE: To find out whether nuchal cord causes an effect on the nuchal skin fold thickness (NFT) measurements, or not. PATIENTS AND METHODS: A total of 242 fetuses with normal outcomes that had undergone detailed second trimester US scan between 18 and 24 weeks of gestation were included in the study. NFT measurements were made on axial cranial US images passing through the cerebellum and cavum septi pellucidum. To detect nuchal cord, color Doppler imaging was performed on the axial views of the fetal neck. To investigate the differences in NFT measurements of the fetuses with or without nuchal cord, statistical analysis was performed using Mann-Whitney test. P < 0.05 was considered statistically significant. RESULTS: The study group was divided into two groups: nuchal cord (+) (n: 26) and nuchal cord (-) (n: 216) fetuses. Mean NFT measurements were 4.66 ± 0.64 mm and 4.36 ± 0.79 mm for nuchal cord (+) and nuchal cord (-) fetuses, respectively. Median NFT measurement for nuchal cord (+) fetuses was 4.6mm, whereas it was 4.4mm for nuchal cord (-) fetuses. Statistically significant difference was denoted between two groups, in terms of NFT measurements (P = 0.049). CONCLUSION: NFT measurements of fetuses with nuchal cord are higher than the NFT measurements of fetuses without nuchal cord. One can conclude that the nuchal cord (+) fetuses with no other anomalies but increased NFT should be re-scanned to see if the increased NFT resolves in the absence of nuchal cord.

Frequencies of perianal fistula types using two classification systems.

PURPOSE: The aims of this study were to determine the frequencies of the perianal fistula subtypes according to the Parks and St. James's University Hospital (SJUH) classification systems and to evaluate the adequacy of these two systems for classifying and reporting perianal fistulas. MATERIALS AND METHODS: Magnetic resonance imaging examinations of 52 patients (44 men, 8 women) with perianal fistula were reviewed retrospectively. The fistulas were classified according to the Parks and SJUH classification systems. RESULTS: According to the Parks system, 13 patients had intersphincteric (25%), 36 had transsphincteric (69.23%), and 2 had (3.84%) extrasphincteric fistulas. Only one fistula (a subsphincteric fistula) (1.92%) could not be classified. According to the SJUH system, 10 patients had grade 1 (19.23%), 2 patients had grade 2 (3.84%), 13 patients had grade 3 (25%), 21 patients had grade 4 (40.38%), and 5 patients had grade 5 (9.61%) perianal fistulas. The one (and only) subsphincteric fistula was left unclassified. CONCLUSION: The most common types are transsphincteric and intersphincteric fistulas. Although the two most commonly used classification systems are adequate for describing most perianal fistulas, there is a small percentage that is left unclassified.

MR imaging in diffuse-type hepatocellular carcinoma with synchronous portal vein thrombi.

BACKGROUND/AIMS: Diffuse or continuous multifocal tumors with accompanying portal vein thrombosis yield considerable changes in the magnetic resonance imaging findings of hepatocellular carcinoma. The overlapped imaging findings of these two co-existing pathologies may be confusing. We aimed to evaluate the magnetic resonance imaging findings of widespread hepatocellular carcinoma lesions complicated with portal vein thrombosis. METHODS: Twenty-two patients (20 male, 2 female; mean age: 57 years) with portal vein thrombosis and diffuse-type hepatocellular carcinoma who underwent contrast-enhanced hepatic magnetic resonance imaging in our department between August 2001 and November 2008 were evaluated retrospectively. The unenhanced axial T1-weighted, T2-weighted, and post-contrast early- and late-phase images were reviewed in each patient. RESULTS: On T2-weighted magnetic resonance images, tumors were seen mildly hyperintense in 11 patients and heterogeneously hyperintense in 11 patients. Unenhanced T1-weighted images demonstrated homogeneous hypointensity in 15 patients and heterogeneous hypointensity in 7 patients. Post-contrast early-phase magnetic resonance images showed patchy enhancement in 12 patients, moth-eaten enhancement in 6 patients, strong enhancement in 1 patient, and minimal enhancement in 3 patients. Post-contrast late-phase magnetic resonance images demonstrated heterogeneous washout in all patients. Portal vein thrombosis was present in all patients. The mean diameter of main portal vein thrombi was 27 mm (range: 25-30 mm). Serum alpha-fetoprotein levels were elevated in all patients. CONCLUSIONS: In patients with chronic parenchymal liver disease, when portal vein thrombosis and high serum alpha-fetoprotein values co-exist, careful attention must be paid to the hepatic parenchymal changes, especially on contrast-enhanced images, in order to not overlook diffuse-type hepatocellular carcinoma.

Erectile dysfunction: initial symptom of a patient with lung cancer.

INTRODUCTION: Penile metastases are rare and represent the advanced stage of the primary tumor. The patients usually have a history of a previously diagnosed malignancy and when metastasis to penis occurs, the most common findings would be priapism, pain, and difficulty in voiding. AIM: We aimed to present a patient who had erectile dysfunction as the initial symptom of lung cancer. Besides the unusual clinical presentation, the sonographic and magnetic resonance imaging (MRI) findings of the penile metastasis were also not typical. METHODS: A 57-year-old man with erectile dysfunction was admitted to the Department of Urology. On physical examination, there was a rigid, smooth, immobile, and painless mass at the base of the corpora cavernosa. Ultrasonography and MRI were performed in order to delineate the nature of the lesion. RESULTS: Radiological findings could not lead to a certain diagnosis and the lesion could not be resected completely during the surgery. Therefore, biopsy of the corpus cavernosum penis was performed. The histopathological diagnosis was metastatic malignant epithelial tumor consistent with nonsmall cell carcinoma. Further investigations revealed a metastatic lung cancer. CONCLUSIONS: Penile metastasis may rarely be the initial presentation of a malignancy and erectile dysfunction may be a seldom symptom.

Periosteal chondrosarcoma of the foot: a case report.

A 19-year-old girl presented with painless swelling of the first left toe of 6 years' duration. Magnetic resonance imaging (MRI) of the lesion demonstrated a soft tissue mass adjacent to the surface of the bone with slight erosion of the underlying cortex. Surgical excision was performed and the histopathological diagnosis was low-grade periosteal chondrosarcoma, which is quite uncommon in this location.

Assessment of peritrochanteric high T2 signal depending on the age and gender of the patients.

INTRODUCTION: The aim of this study is to evaluate the incidence of peritrochanteric high T2 signal (peritrochanteric edema, peritendinitis) on routine MR imaging studies and to determine whether reporting peritrochanteric edema is always clinically relevant depending on the age and gender of the patients. MATERIALS AND METHODS: We evaluated 79 consecutive bilateral hip MR images performed in our department between January 2006 and December 2006 (57 female, 22 male patients, mean age 49 years). Each study was evaluated for areas of T2 hyperintensity representing edema around the greater trochanter. Patients with a known fracture, tumor, history of radiation therapy, history of hip surgery and prothesis were excluded from the study. Patients with signal intensity alterations within the thickened gluteus medius/minimus tendons (tendinitis) or peritrochanteric bursal fluid accumulation (bursitis) were also excluded. All patients were scanned with our routine MR imaging protocol for hip imaging. RESULTS: In 55 of the 79 patients (70%) peritrochanteric edema was detected on MR images and 52 of these 55 patients (95%) had these changes on both hips. The median age was 56 years for the patients with peritrochanteric edema and 35.5 years for the patients without peritrochanteric edema. There was statistical significance between the median ages of the patients and a significant increased risk of peritrochanteric edema was found over 40 years of age. There was no significant difference between male and female patients. CONCLUSION: Bilateral peritrochanteric high T2 signal may be a part of the degeneration process and we suggest that it may not be necessarily reported if the clinical findings do not support greater trochanteric pain syndrome.

Hepatic venous outflow obstruction after hydatid cyst surgery: evaluation with contrast enhanced magnetic resonance angiography.

INTRODUCTION: The aim of this study is to present the contrast enhanced magnetic resonance angiography findings of hepatic venous outflow obstruction in patients in whom surgery had been performed for hepatic hydatidosis. No patient history of parasitic hepatic venous invasion or earlier hepatic venous outflow obstruction is present. MATERIALS AND METHODS: Four men and three women with a history of hydatid cyst surgery underwent contrast enhanced magnetic resonance angiography between April 2001 and June 2006. The mean age was 37.7 years. The mean time duration between the last date of surgery and the date of magnetic resonance angiography imaging was 65.5 months. The site of the hydatid cyst was the right lobe in two patients, the medial segment of the left lobe in two patients, the liver dome in two patients, and the conjunction of the right lobe anterior-left lobe medial segments in one patient. One patient had undergone total and one patient had undergone partial lobectomy, and cystectomy was performed in five patients. RESULTS: On magnetic resonance angiograms, nonvisualization or stenosis of the hepatic veins was detected in all cases. In one patient thrombosis and in another patient severe stenosis of the inferior vena cava were associated. The portal hilum was displaced anterosuperiorly in five patients. Intrahepatic collaterals were present in six patients and extrahepatic collaterals were seen in three. Associated thrombosis in the left portal vein was found in two patients. CONCLUSION: We conclude that patients with complicated hydatid cysts and who have had postoperative complications should be checked not only for recurrence or abscess formation, but also for vascular changes. magnetic resonance angiography is a useful alternative imaging technique and can provide useful information at one session within several minutes in patients who had undergone surgery for hydatid cyst of the liver.

Post-treatment MRI findings of hepatocellular carcinoma.

In addition to surgery, ablative and transarterial therapies are widely accepted treatment options for hepatocellular carcinoma. Although post-treatment followup is usually done with both computed tomography and magnetic resonance imaging (MRI), MRI is found to be superior in detecting residual or recurrent tumors after treatment. Familiarity with post-treatment MRI findings is critical for the correct interpretation of these examinations, and for guiding further therapies.