Congenital renal anomalies detected in adulthood.

OBJECTIVE: To document the types of congenital renal anomalies detected in adulthood, the clinical presentation and complications of these renal anomalies, and the most useful imaging modality in detecting a renal anomaly. MATERIALS AND METHODS: This study was approved by the institutional review board and informed consent was waived. Between January 2007 and January 2011, the clinical data and imaging studies of 28 patients older than 18 years diagnosed with renal anomaly at the authors' institution were retrospectively reviewed. Renal anomalies in this study included only those with abnormality in position and in form. RESULTS: Of these 28 patients, 22 underwent imaging studies and their results constituted the material of this study. Of the 22 patients, 14 had horseshoe kidneys (HSK), four had crossed renal ectopia and four had malrotation. Sixteen patients were men and six were women. The patients ranged in age from 19 to 74 years (mean age 51.1 years). Clinical presentations were abdominal pain (13), fever (13), haematuria (4), palpable mass (2), asymptomatic (2), polyuria (1) dysuria (1), blurred vision (1), and headache with weakness of left extremities (1). Imaging studies included abdominal radiograph (15), intravenous pyelography (IVP) (8), retrograde pyelography (RP) (4), ultrasonography (US) (7), and computed tomography (CT) (9). Associated complications included urinary tract stones (17), urinary tract infection (16), hydronephrosis (12), and tumours (2). Abdominal radiograph suggested renal anomalies in nine out of 15 studies. IVP, RP, US and CT suggested anomalies in all patients who had these studies performed. However, CT was the best imaging modality to evaluate anatomy, function and complications of patients with renal anomalies. CONCLUSION: HSK was the most common renal anomaly, with abdominal pain and fever being the most common presentations. UTI and stones were the most common complications. IVP, RP, US and CT can be used to diagnose renal anomalies but CT is the best imaging modality to evaluate renal anatomy, function and its complications.

Clinics in diagnostic imaging (135). Cystic renal cell carcinoma.

A 45-year-old man presented with right flank pain and haematuria for one month. Computed tomography showed a large, well-circumscribed exophytic complex cystic mass with enhanced, irregular thickened walls arising from the upper pole of the right kidney, which was associated with bilateral renal stones. Partial right nephrectomy with removal of the right renal stones was performed. Histopathology revealed papillary cell carcinoma confined to the kidney. The patient made good postoperative recovery. The Bosniak classification system of renal cystic lesions and cystic renal cell carcinoma are discussed. Various cases of renal cystic lesions and cystic renal cell carcinoma are shown.

Clinics in diagnostic imaging (134). Testicular lymphoma.

A 55-year-old man presented with a painless right scrotal mass for the past three months. Scrotal ultrasonography showed a large circumscribed hypoechoic mass with marked hypervascularity occupying almost the entire right testis. The epididymis and scrotal skin were normal. Right radical orchiectomy was performed. Histopathology revealed lymphoma, diffuse large B-cell type confined within the tunica albuginea. The patient made a good postoperative recovery. No evidence of lymphoma in other organs was demonstrated. We discuss the differential diagnosis of ultrasonographic intratesticular masses and highlight various cases of intratesticular lesions in this article.

Paget's disease of the breast: clinical, imaging and pathologic findings: a review of 16 patients.

OBJECTIVES: To determine the clinical, imaging and pathological findings of Paget's disease of the breast. MATERIALS AND METHODS: Approval by Institutional Review Board was granted and informed consent was waived. Retrospective review of the pathological diagnosis of 2,361 women with breast carcinoma between January 2004 and April 2010 revealed 27 patients with Paget's disease of the breast. The clinical, mammographic and ultrasonographic images were retrospectively reviewed. RESULTS: The prevalence of Paget's disease of the breast was 1.14% of all breast carcinoma at this institution. Of the 27 patients with Paget's disease, only 16 had imaging studies and this group constituted the basis of this study. All 16 patients were women, with ages ranging from 36-68 years (mean age 50.31 years). Eleven patients presented with clinical findings suggestive of Paget's disease of the breast. Seven of these 11 patients also had associated palpable mass(es). Four patients presented with a palpable mass alone and one presented with bloody nipple discharge alone. Mammography was performed in all 16 patients and ultrasonography (US) in 15 patients. Of the 16 mammographic studies, two were negative. Of the 15 US studies, three were negative. Of these three negative US studies, two also had negative mammography and one had pleomorphic microcalcifications on mammogram. US was helpful in detecting multifocality in two patients. Mammography was 100% positive in patients who presented with palpable breast mass(es) and bloody nipple discharge, but 50% positive in patients who had clinically suggestive Paget's disease alone. Almost all patients (15/16) had underlying breast malignancies. Seven patients had multifocality or multicentricity. Modified radical mastectomy was performed in 13 patients, simple mastectomy in two, and wide local excision in one patient. Pathological findings were ductal carcinoma in situ (DCIS) (n = 3), invasive ductal carcinoma (IDC) (n = 10), metaplastic carcinoma (n = 1), invasive lobular carcinoma (ILC) (n = 1), and only Paget's disease of the nipple without underlying breast carcinoma (n = 1). CONCLUSION: Patients with Paget's disease of the breast have a high incidence of an underlying breast carcinoma. Most of the patients in this study presented late and were more likely to have positive mammograms. Mammography should be performed to identify the underlying breast carcinoma. Those who have only nipple areolar changes and no palpable mass have less positive mammography and less invasive carcinoma.

Paget’s disease of the breast: clinical, imaging and pathologic findings: a review of 16 patients

Objectives: To determine the clinical, imaging and pathological findings of Paget’s disease of the breast. Materials and methods: Approval by Institutional Review Board was granted and informed consent was waived. Retrospective review of the pathological diagnosis of 2,361 women with breast carcinoma between January 2004 and April 2010 revealed 27 patients with Paget’s disease of the breast. The clinical, mammographic and ultrasonographic images were retrospectively reviewed. Results: The prevalence of Paget’s disease of the breast was 1.14% of all breast carcinoma at this institution. Of the 27 patients with Paget’s disease, only 16 had imaging studies and this group constituted the basis of this study. All 16 patients were women, with ages ranging from 36–68 years (mean age 50.31 years). Eleven patients presented with clinical findings suggestive of Paget’s disease of the breast. Seven of these 11 patients also had associated palpable mass(es). Four patients presented with a palpable mass alone and one presented with bloody nipple discharge alone. Mammography was performed in all 16 patients and ultrasonography (US) in 15 patients. Of the 16 mammographic studies, two were negative. Of the 15 US studies, three were negative. Of these three negative US studies, two also had negative mammography and one had pleomorphic microcalcifications on mammogram. US was helpful in detecting multifocality in two patients. Mammography was 100% positive in patients who presented with palpable breast mass(es) and bloody nipple discharge, but 50% positive in patients who had clinically suggestive Paget’s disease alone. Almost all patients (15/16) had underlying breast malignancies. Seven patients had multifocality or multicentricity. Modified radical mastectomy was performed in 13 patients, simple mastectomy in two, and wide local excision in one patient. Pathological findings were ductal carcinoma in situ (DCIS) (n = 3), invasive ductal carcinoma (IDC) (n = 10), metaplastic carcinoma (n = 1), invasive lobular carcinoma (ILC) (n = 1), and only Paget’s disease of the nipple without underlying breast carcinoma (n = 1). Conclusion: Patients with Paget’s disease of the breast have a high incidence of an underlying breast carcinoma. Most of the patients in this study presented late and were more likely to have positive mammograms. Mammography should be performed to identify the underlying breast carcinoma. Those who have only nipple areolar changes and no palpable mass have less positive mammography and less invasive carcinoma.

Breast calcifications: which are malignant?

Most calcifications depicted on mammograms are benign. However, calcifications are important because they can be the first and earliest sign of malignancy. For detection and analysis of microcalcifications, high-quality images and magnification views are required. The American College of Radiology (ACR) Breast Imaging Reporting and Data System (BI-RADS) classifies calcifications on mammograms into three categories: typical benign, intermediate concern and higher probability of malignancy, according to types and distribution of calcifications. Benign calcifications are typically larger, coarser, round with smooth margins and have a scattered or diffuse distribution. Malignant calcifications are typically grouped or clustered, pleomorphic, fine and with linear branching. It is important for radiologists to detect, evaluate, classify and provide appropriate recommendations for calcifications perceived on mammograms to provide proper management.

Spectrum of imaging findings in melioidosis.

This pictorial review aims to highlight the clinical and imaging features of melioidosis in various organ systems. The patients were from two centres: one in Thailand and one in Singapore. The annual average incidence of melioidosis is estimated to be 4.4 in 100 000 in north-eastern Thailand and 1.7 in 100 000 in Singapore. Melioidosis affects many different organs and produces a spectrum of imaging features. The lung is the most frequently involved organ and, on radiographs and computed tomography, melioidosis may manifest as acute pulmonary consolidation, multiple nodules and abscesses. The finding of multiple small discrete abscesses in both the liver and the spleen is highly suggestive of visceral melioidosis and is best diagnosed on ultrasonography and computed tomography. Bone and soft tissue musculoskeletal involvement is usually part of disseminated melioidosis, with changes being seen on radiographs and MRI. Although imaging findings of melioidosis are not specific, this infection requires a high index of clinical suspicion, particularly in patients with pre-disposing comorbidities, such as diabetes mellitus, chronic renal failure, alcoholism or malignancy, those who are immunosuppressed as the result of either diseases or drug treatment, and those living in or with a history of travel to endemic areas.

Role of ultrasonography in diagnosis of scrotal disorders: a review of 110 cases.

OBJECTIVE: To determine the role of ultrasonography in diagnosis of scrotal disorders. MATERIALS AND METHODS: This study was carried out after institutional review board approval was granted, and informed consent was waived. Between January 2005 and January 2007, 144 patients aged 12 years and older with scrotal symptoms, who underwent scrotal ultrasonography (US), were retrospectively reviewed. The clinical presentation, outcome, and US results were analysed. The presentation symptoms were divided into three groups including scrotal pain, painless scrotal mass or swelling, and others. Surgery was performed in 32 patients. RESULTS: Of 144 patients, 110 had clinical follow-up and constituted the material of this study. The patients ranged in age from 13 to 82 years (mean 38.6 years). Of 110 patients, 84 (76.4%) presented with scrotal pain, 21 (19%) had painless scrotal mass or swelling and 5 (4.5%) had other symptoms. Of the 84 patients with scrotal pain, 52 had infection, 4 had testicular torsion, 7 had testicular trauma, 10 had varicocele, 4 had hydrocele, 1 had epididymal cyst, 1 had scrotal sac and groin metastases, and 5 had unremarkable results. Of the 21 patients who presented with painless scrotal mass or swelling, 18 had extratesticular lesions and 3 had intratesticular lesions. All the extratesticular lesions were benign. Of the 3 intratesticular lesions, one was due to tuberculous epididymo-orchitis, one was non-Hodgkin's lymphoma, and one was metastasis from liposarcoma. Of the 5 patients who presented with other symptoms, 4 had undescended testes, and 1 had gynaecomastia. US gave incorrect diagnosis in only one patient with scrotal pain. CONCLUSION: The most common cause of scrotal pain was infection. The most common cause of scrotal mass or swelling was extratesticular lesion. US plays an important role in the diagnosis of scrotal disorders and in planning for proper management.

Can radiographic plain film be used to determine the depth of the tumour bed in the absence of surgical clips for breast boost planning.

PURPOSE: A number of studies have demonstrated the importance of using surgical clips to define the tumour bed in breast boost radiotherapy. In the absence of such clips, other techniques suggested to improve boost location have included CT and ultrasound (US). Determination of the depth of the tumour bed is important in the selection of electron energy. This study was conducted to prospectively compare the depth of the lumpectomy cavity as defined by ultrasound to radiographic plain film evaluation of the anterior border of the pectoralis muscle. MATERIALS AND METHODS: Forty-one breast-cancer patients treated at the Division of Therapeutic Radiology and Oncology, Department of Radiology, Faculty of Medicine, Chiang Mai University between December 2004 and December 2006 were prospectively identified as having no surgical clips within the lumpectomy cavity. All patients underwent both US evaluation of the depth of tumour bed (D1) and radiographic evaluation of the depth of the anterior border of the pectoralis muscle (D2). These depth dimensions (D1 and D2) were compared using a paired t-test. The correlation of both methods was analyzed by Pearson correlation test. RESULTS: Depth dimensions by US were shorter than the radiographic film method in 85% of patients. The absolute mean difference of the depth (radiographic films minus US) was 0.129 cm. A paired t-test demonstrated that the difference between these two methods to be not statistically significant (p= 0.27). The absolute difference of depth between the two methods ranged from 0 to 0.5 cm. A significant correlation was found between US and radiographic film measurements (p<0.01). CONCLUSION: Plane radiographic film evaluation of the anterior border of the pectoralis muscle can be used to define the depth of the tumour bed in patients who have no surgical clips. However, the plane radiographic film method determines only the depth, not the transverse and longitudinal dimensions of the tumour bed. Additional information from US is needed to delineate the target volume for the tumour bed boost. In the absence of surgical clips, the authors recommend integration of both methods in breast boost planning process.

Urachal abnormalities: clinical and imaging features.

INTRODUCTION: The clinical manifestation of urachal abnormalities may mimic many intraabdominal or pelvic diseases. We present clinical, imaging and pathological findings of a spectrum of complicated urachal abnormalities and determine whether imaging can be used to differentiate tumour from infection. METHODS: From January 1993 to December 2006, seven patients with surgically-proven complicated urachal abnormalities had their clinical, imaging and pathological features reviewed. RESULTS: There were three men and four women, aged 12-73 years. Four patients had infected urachal remnants and three had urachal carcinoma. The main clinical findings in infected urachal remnants were dysuria, abdominal pain and mass. The patients of urachal carcinoma presented with abdominal mass and haematuria. Computed tomography (CT) was performed in all cases, and ultrasonography (US) was performed in four cases. CT in all cases showed a mass located extraperitoneally in the midline just beneath the rectus abdominis muscle and extending from the umbilicus to the dome of the urinary bladder. There were one well-defined cystic mass and six ill-defined solid masses. US showed one cystic mass and three echogenic masses. Cystography was performed in one patient and it showed indentation to the dome of the urinary bladder with mucosal irregularity. The cystic mass and one ill-defined solid mass were pathologically-proven to be xanthogranulomatous inflammation. The other five solid masses were found to be adenocarcinoma in three and chronic non-specific inflammation in two cases. CONCLUSION: Preoperative diagnosis of urachal abnormalities may be suggested by clinical presentation and imaging features. However, it is difficult to differentiate tumour from infection based on imaging features alone.

Imaging features of hepatic angiomyolipomas.

We review the imaging appearances of hepatic angiomyolipomas in patients with and without tuberous sclerosis. Sporadic hepatic angiomyolipomas have a varied appearance because of the inconstant proportion of fat, making confident imaging diagnosis difficult and necessitating biopsy in many cases. In patients with tuberous sclerosis, hepatic angiomyolipomas have a more consistent imaging appearance and, together with other features of the syndrome, can be more easily diagnosed. Preoperative diagnosis helps obviate unnecessary surgery.

Clinics in diagnostic imaging (125). Diagnosis: Suspicious right breast carcinoma with axillary node metastases.

A 61-year-old woman who had a known history of ovarian carcinoma presented with a palpable painless mass in the right axilla. Mammograms showed segmental-distributed pleomorphic microcalcifications in the upper outer quadrant of the right breast with marked enlargement of the right axillary nodes. The biggest node contained microcalcifications. Right axillary node dissection showed metastatic adenocarcinoma which was likely to be metastasis from the primary breast carcinoma. Unfortunately, she was then lost to follow-up and came back again with a right breast mass. Histopathology of the right breast mass revealed invasive ductal carcinoma. The causes and differential diagnosis of axillary adenopathy are discussed. In a patient with known primary extramammary malignancy and axillary adenopathy, it is important to differentiate if it is metastasis from the primary breast carcinoma or extramammary malignancy to provide proper management.

Benign breast lesions mimicking carcinoma at mammography.

Many benign breast lesions pose diagnostic challenges. These lesions include abscess, haematoma, radial scar, post surgical scar, diabetic mastopathy, focal fibrosis, sclerosing adenosis, granular cell tumour, extra-abdominal desmoid tumour, medial insertion of pectoralis muscle and sternalis muscle, and axillary lymphadenopathy (due to HIV infection, collagen vascular lesions, tuberculous and bacterial lymphadenitis). Radiologists should be familiar with the characteristic imaging features of these benign lesions, and should include these benign lesions in the differential diagnosis whenever malignant-appearing findings are encountered. Correlation of the patient's clinical features with the mammographical findings and additional use of ultrasonography, fine-needle aspiration biopsy or core biopsy are helpful in establishing the final diagnosis and obviating unnecessary surgical intervention. In some of these lesions, surgery may be avoided while in others, the appropriate surgical procedure may be planned. This pictorial essay aims to illustrate the mammographical features of these lesions in a group of proven cases.

Clinics in diagnostic imaging (114). Rupture of the right testis.

A 22-year-old man, who was kicked in the scrotum during Thai kickboxing, presented with a painful swelling of the right hemiscrotum. Scrotal ultrasonography (US) showed an enlarged right testis with heterogeneous echogenicity and irregular contours. Colour Doppler US showed vascularity in the upper pole of the right testis and avascularity in the lower pole. Emergency exploration of the right hemiscrotum revealed laceration of the lower pole of the right testis. Debridement and repair of the right testis were performed. The clinical manifestations, role of US and US findings of scrotal trauma are discussed.

Breast carcinomas: why are they missed?

INTRODUCTION: Mammography has proven to be an effective modality for the detection of early breast carcinoma. However, 4-34 percent of breast cancers may be missed at mammography. Delayed diagnosis of breast carcinoma results in an unfavourable prognosis. The objective of this study was to determine the causes and characteristics of breast carcinomas missed by mammography at our institution, with the aim of reducing the rate of missed carcinoma. METHODS: We reviewed the reports of 13,191 mammograms performed over a five-year period. Breast Imaging Reporting and Data Systems (BI-RADS) were used for the mammographical assessment, and reports were cross-referenced with the histological diagnosis of breast carcinoma. Causes of missed carcinomas were classified. RESULTS: Of 344 patients who had breast carcinoma and had mammograms done prior to surgery, 18 (5.2 percent) failed to be diagnosed by mammography. Of these, five were caused by dense breast parenchyma obscuring the lesions, 11 were due to perception and interpretation errors, and one each from unusual lesion characteristics and poor positioning. CONCLUSION: Several factors, including dense breast parenchyma obscuring a lesion, perception error, interpretation error, unusual lesion characteristics, and poor technique or positioning, are possible causes of missed breast cancers.

Artifacts in mammography: ways to identify and overcome them.

High-quality mammography images enhance a radiologist's ability to interpret mammograms because they have greater sensitivity and specificity. Artifacts may create pseudo-lesions or mask abnormalities leading to misinterpretation. Familiarity with the numerous artifacts encountered will enable radiologists to provide accurate diagnoses. We reviewed all the artifacts in mammography encountered at our centres and classified the causes of these artifacts into four categories. They are: 1. patient-related; 2. technologist-related; 3. related to the mammographic unit; and 4. related to processing and the processor. Implementation of a well-organised quality control programme will reduce the occurrence of artifacts. Recognition of artifacts in mammography is instructive and will help to improve the mammographic diagnostic quality.