CT-guided Transosseous Soft Tissue Biopsy: Techniques, Outcomes and Complications in 50 Cases.

PURPOSE: To describe the techniques, outcomes and complications of CT-guided transosseous biopsy of soft tissue lesions via multiple different routes. MATERIALS AND METHODS: Clinical and radiologic data from all consecutive soft tissue biopsies performed via a transosseous approach between April 2009 and July 2015 were retrospectively compiled. Fifty biopsies performed in 50 patients (n = 17 males, n = 33 females) were included. Biopsies were performed using a 13-gauge biopsy needle which was advanced through the selected bone to the lesion margin followed by coaxial placement of either an 18- or 20-gauge biopsy gun. Sampling accuracy was determined from the final pathology report as diagnostic or non-diagnostic. Complications included rates of pneumothorax, pneumomediastinum, hemoptysis, immediate admission, chest tube insertion, surgical consultation, 30-day readmission, fracture, osteomyelitis or tract seeding. RESULTS: Number of diagnostic samples per bone included: sternum (n = 17, 34%), rib (n = 7, 14%), scapula (n = 6, 12%), transverse process (n = 4, 8%), vertebral body (n = 4, 8%), spinous process (n = 1, 2%), ilium (n = 7, 14%), sacrum (n = 4, 8%). Complications included 10 pneumothoraces in 39 cases that crossed the pleura, 8 pneumomediastinum in 17 transsternal cases, one immediate surgical consultation and one 30-day readmission. CONCLUSION: Transosseous biopsy approach is a technically feasible means of obtaining core needle samples of soft tissue lesions. LEVEL OF EVIDENCE: Case series, IV.

Radiologic Assessment of Native Renal Vasculature: A Multimodality Review.

A wide range of clinically important anatomic variants and pathologic conditions may affect the renal vasculature, and radiologists have a pivotal role in the diagnosis and management of these processes. Because many of these entities may not be suspected clinically, renal artery and vein assessment is an essential application of all imaging modalities. An understanding of the normal vascular anatomy is essential for recognizing clinically important anatomic variants. An understanding of the protocols used to optimize imaging modalities also is necessary. Renal artery stenosis is the most common cause of secondary hypertension and is diagnosed by using both direct ultrasonographic (US) findings at the site of stenosis and indirect US findings distal to the stenosis. Fibromuscular dysplasia, while not as common as atherosclerosis, remains an important cause of renal artery hypertension, especially among young female individuals. Fibromuscular dysplasia also predisposes individuals to renal artery aneurysms and dissection. Although most renal artery dissections are extensions of aortic dissections, on rare occasion they occur in isolation. Renal artery aneurysms often are not suspected clinically before imaging, but they can lead to catastrophic outcomes if they are overlooked. Unlike true aneurysms, pseudoaneurysms are typically iatrogenic or posttraumatic. However, multiple small pseudoaneurysms may be seen with underlying vasculitis. Arteriovenous fistulas also are commonly iatrogenic, whereas arteriovenous malformations are developmental (ie, congenital). Both of these conditions involve a prominent feeding artery and draining vein; however, arteriovenous malformations contain a nidus of tangled vessels. Nutcracker syndrome should be suspected when there is distention of the left renal vein with abrupt narrowing as it passes posterior to the superior mesenteric artery. Filling defects in a renal vein can be due to a bland or tumor thrombus. A tumor thrombus is most commonly an extension of renal cell carcinoma. When an enhancing mass is located predominantly within a renal vein, leiomyosarcoma of the renal vein should be suspected. ©RSNA, 2017.

Imaging evaluation of the inferior vena cava.

The inferior vena cava (IVC) is an essential but often overlooked structure at abdominal imaging. It is associated with a wide variety of congenital and pathologic processes and can be a source of vital information for referring clinicians. Initial evaluation of the IVC is most likely to occur at computed tomography performed for another indication. Many routine abdominal imaging protocols may result in suboptimal evaluation of the IVC; however, techniques to assist in specific evaluation of the IVC can be used. In this article, the authors review the spectrum of IVC variants and pathologic processes and the relevant findings from magnetic resonance imaging, angiography, sonography, and positron emission tomography. Embryologic development of the IVC and examples of congenital IVC variants, such as absence, duplication, left-sided location, azygous or hemiazygous continuation, and web formation, are described. The authors detail IVC involvement in Wilms tumor, leiomyosarcoma, adrenal cortical carcinoma, testicular carcinoma, hepatocellular carcinoma, renal cell carcinoma, and other neoplasms, as well as postsurgical, traumatic, and infectious entities (including filter malposition, mesocaval shunt, and septic thrombophlebitis). The implications of these entities for patient treatment and instances in which specific details should be included in the dictated radiology report are highlighted. Furthermore, the common pitfalls of IVC imaging are discussed. The information provided in this review will allow radiologists to detect and accurately characterize IVC abnormalities to guide clinical decision making and improve patient care.

Segmental testicular infarction: sonographic findings and pathologic correlation.

Segmental testicular infarction can mimic testicular carcinoma on sonography and can lead to unnecessary orchiectomy. This case series describes and correlates sonographic and histologic findings of 7 pathologically proven segmental testicular infarction cases. Segmental testicular infarction should be suspected on sonography when a geographic lesion with low or mixed echogenicity has absent or near-absent flow in a patient with scrotal pain. A hyperechoic rim and peripheral hyperemia correspond to interstitial hemorrhage and inflammatory changes. As an infarct evolves, it becomes more discrete and hypoechoic as ghost outlines replace seminiferous tubules. Follow-up or contrast-enhanced magnetic resonance imaging or sonography can increase diagnostic confidence in suspected cases and prevent unnecessary orchiectomy.

Imaging of non-neoplastic intratesticular masses.

The use of high-frequency ultrasound is increasing for the treatment of cystic, vascular, and solid non-neoplastic intratesticular masses. Cystic lesions examined include simple testicular cysts, tunica albuginea cysts, epidermoid cysts, tubular ectasia of rete testis, and intratesticular abscesses. Vascular lesions examined include intratesticular varicocele and intratesticular arteriovenous malformations. Solid lesions examined include fibrous pseudotumor of the testis, focal or segmental testicular infarct, fibrosis of the testis, testicular hematoma, congenital testicular adrenal rests, tuberculoma, and sarcoidosis. Gray-scale and color-flow Doppler sonography facilitate the visualization of the benign characteristics of the lesions. Magnetic resonance imaging can also help as a problem-solving modality in some cases.

Multimodality imaging of paratesticular neoplasms and their rare mimics.

Extratesticular neoplasms are rare but clinically significant lesions that affect patients of all ages. These neoplasms are generally asymptomatic but may have potentially life-threatening sequelae. Lipoma is the most common primary benign paratesticular neoplasm and the most common tumor of the spermatic cord. Adenomatoid tumor is the most common tumor of the epididymis, followed by leiomyoma. In adult patients, it is imperative to consider sarcomas in the differential diagnosis of all solid tumors of the scrotum. The most common sarcomatous tumors in pediatric patients are embryonal sarcoma and rhabdomyosarcoma. Metastases, particularly from testicular, prostatic, renal, and gastrointestinal primary malignancies, can also occur. Mimics of paratesticular neoplasms including polyorchidism and splenogonadal fusion are rare but must also be considered for optimal management. Ultrasonography (US) is currently the imaging modality of choice. However, US findings are often variable and nonspecific and do not usually allow definitive characterization. Specific computed tomographic and magnetic resonance imaging findings with respect to tumor location, morphologic features, and tissue characteristics can aid in the evaluation of paratesticular neoplasms and help narrow the differential diagnosis.