Diagnostic performance of dynamic MR defecography in assessment of dyssynergic defecation.

PURPOSE: To assess diagnostic performance of MR defecographic findings in diagnosis of dyssynergic defecation (DD). METHODS: This retrospective study included 46 patients with chronic constipation who met the Rome IV criteria for diagnosis of present or absent DD and underwent MRI between Jan 2015 and June 2020. Patients were divided into DD group (n = 24) and non-DD group (n = 22). Nine parameters were analyzed by two radiologists: anorectal angle (ARA) and M line at rest, defecation, and change between 2 phases; anal canal width; prominent puborectalis muscle; abnormal evacuation. Receiver operating characteristic (ROC) curves were plotted to extract the optimal cut-offs and area under the curve (AUC). Multivariate analysis was performed. RESULTS: Seven findings showed statistically significant difference between DD and non-DD groups. M line at defecation had highest odds ratio, followed by ARA change, ARA at defecation, M line change, prominent puborectalis muscle, abnormal evacuation and anal canal width, respectively. ARA change and prominent puborectalis muscle had highest specificity (95.5% and 100%, respectively). The optimal cut-offs of ARA at defecation, ARA change, M line at defecation, M line change and anal canal width were 122°, 1.5°, 3.25 cm, 1.9 cm and 8.5 mm, respectively. Multivariate logistic regression revealed two significant findings in differentiating between DD and non-DD, including M line at defecation (OR 23.31, 95% CI 3.10-175.32) and ARA at defecation (OR 13.63, 95% CI 1.94-95.53) with sensitivity, specificity, PPV, NPV and AUC of 79.2%, 95.5%, 95%, 80.8% and 0.87(95% CI 0.78-0.97), respectively. CONCLUSION: MR defecography has high diagnostic performance in diagnosis of DD. Although M line and ARA at defecation are two significant findings on multivariate analysis, ARA change less than 1.5 degrees and prominent puborectalis muscle have good specificity in DD diagnosis.

Evaluation and external validation of minor lymphatic pelvic pathway for distant metastases in cervical cancer patients treated with concurrent chemoradiotherapy.

To evaluate and validate the minor lymphatic pathway for distant metastases in cervical cancer. This is a retrospective cohort of cervical cancer patients underwent curative concurrent chemoradiotherapy. We used original dataset from 1 university hospital and validation dataset from 3 university hospitals. Lymphadenopathy status in CT imaging was reviewed by radiologist in either the obturator and external iliac nodes (major pathway) or the internal iliac and presacral nodes (minor pathway). We then used Cox regression to adjust for all potential confounders, including paraaortic nodes, T stage, histology, age, total treatment time, total number of nodes, total short axis of nodes. 397 and 384 patients were in the original and validation datasets (median follow-up period, 59.5 month's). The minor pathway was independent prognostic factor in multivariable analysis [HR=2.64; 95%CI=1.07-6.55; P = 0.036] and [HR=14.84; 95%CI=3.15-70.01; P= 0.001] in original and validation datasets, respectively. Whereas, the major pathway was statistically non-significant. Further validation showed that the minor pathway had the highest HR for distant metastases with both the EMBRACE (HR=6.05; 95% CI=1.30-28.08; P = 0.022) and the FIGO 2018 (HR=7.43; 95% CI=2.94-18.78; P<0.001) in the original dataset. A similar result was found with the validation dataset: EMBRACE, HR=30.91; 95% CI=2.78-343.62; P = 0.005; and FIGO 2018, HR=42.41; 95% CI=8.83-203.60; P<0.001.This is the first clinical study to validate that the minor lymphatic pathway was predominantly associated with distant metastases in cervical cancer. This finding should be validated in larger cohort to further integrate in standard staging for prediction of distant metastases.

Development and validation of a prognostic prediction model including the minor lymphatic pathway for distant metastases in cervical cancer patients.

To develop and validate a prognostic model, including the minor lymphatic pathway (internal iliac and presacral nodes). STUDY DESIGN: Retrospective cohort. PARTICIPANTS: Locally advanced cervical cancer underwent concurrent chemoradiotherapy. SAMPLE SIZE: 397 and 384 patients in the development and validation data set. PREDICTORS: Our new nodal staging system with the minor lymphatic pathway. OUTCOME: Distant metastases. STATISTICAL ANALYSIS: Cox regression; net reclassification improvement (NRI) and decision curve analysis (DCA). Our new nodal system was the strongest predictor. The predictors in the final model were new nodal system, tumor stage, adenocarcinoma, initial hemoglobin, tumor size and age. The nodal system and the pretreatment model had concordance indices of 0.661 and 0.708, respectively, with good calibration curves. Compared to the OUTBACK eligibility criteria, the nodal system showed NRI for both cases (22%) and controls (16%). The pretreatment model showed NRI for cases (31%) and controls (18%). DCA in both models showed threshold probability of 15% and 12%, respectively, when compared with 24% in OUTBACK eligibility criteria. Our new nodal staging system and the pretreatment model could differentiate between high-risk and low-risk patients, thus facilitating decisions to provide more aggressive treatment to prevent distant metastases.

Paraganglioma of the organ of Zuckerkandl and FH gene mutation.

Not required for Clinical Vignette.

IgG4-related pseudo-tumor of the kidney and multiple organ involvement mimicked malignancy.

Immunoglobulin G4-related disease (IgG4-RD) is an increasingly recognized systemic condition characterized by particular clinical, serologic, and pathologic features that are consistent across a wide range of organ systems. Herein, we present a rare case of IgG4-RD presenting as multiple inflammatory pseudotumors involving the kidney and other organs involvement mimicking urothelial cell carcinoma with liver, lymph node and lung metastasis. The final diagnosis was made based on characteristic histopathological finding and analysis of IgG4 immunostaining that can distinguish from other conditions. Greater awareness of this disease is needed to ensure diagnoses, which can prevent unnecessary surgical intervention.

Reliability of computed tomography-based renal cortex volume to determine split renal function in preoperative living kidney donors.

OBJECTIVE: The purpose of this study was to assess the utility of CT-based renal cortex volume to estimate split renal function (SRF) in pre-transplant living kidney donors and to evaluate its reliability to predict graft function in the recipients. METHODS: Our study recruited all adult potential donors who had both Tc-99m-diethylenetriamine pentacetate (DTPA) scintigraphy and CT angiography of the abdominal aorta done before donating their kidney. We compared the correlation between CT-based renal cortex volume combined with kidney function and DTPA scan as well as post-donation kidney function in the recipients. RESULTS: The correlation between CT-based split cortex volume and DTPA-measured SRF before transplantation was strong (intraclass correlation coefficient = 0.954-0.968). The inter-rater reliability of two radiologists also showed substantial agreement (intraclass correlation coefficient = 0.97, p < 0.001). In contrast, the correlations between renal cortical volume of donated kidney adjusted to recipient body weight and recipient kidney function was poor at both 2 week and 2 year follow-up. CONCLUSION: CT-based renal cortex volume combined with pre-operative kidney function appears to be precise and reproducible to evaluate pre-transplant SRF. Nevertheless, the prediction of recipient graft function needs to be further investigated to ensure a good outcome. ADVANCES IN KNOWLEDGE: This method is practicable for all potential donors who undergo kidney transplantation in terms of streamline donor workup without compromising information.

Small (< 4 cm) Renal Masses: Differentiation of Angiomyolipoma Without Visible Fat From Renal Cell Carcinoma Using Unenhanced and Contrast-Enhanced CT.

OBJECTIVE: The purpose of this study was to evaluate if small (< 4 cm) angiomyolipoma without visible fat can be differentiated from renal cell carcinoma (RCC) using contrast-enhanced CT alone and using unenhanced and contrast-enhanced CT in combination. MATERIALS AND METHODS: Twenty-three patients with 24 angiomyolipomas without visible fat and 130 patients with 148 RCCs underwent unenhanced and contrast-enhanced CT. Demographic data and size, shape, CT attenuation, and heterogeneity (entropy and subjective score) of the renal mass on unenhanced CT and contrast-enhanced CT were recorded. Multivariate logistic regression models were constructed for parameters obtained by contrast-enhanced CT alone and by both unenhanced and contrast-enhanced CT. Demographic data and size and shape of renal mass were used in each model. Sensitivity and specificity were calculated. RESULTS: Logistic regression model from contrast-enhanced CT data included sex, percentage of exophytic growth, entropy, and CT attenuation on contrast-enhanced CT. Model from both unenhanced and contrast-enhanced CT data included age, sex, short-axis diameter, percentage of exophytic growth, lesion-to-kidney CT attenuation difference on unenhanced CT, and CT attenuation on contrast-enhanced CT. The contrast-enhanced CT-based model and combined unenhanced and contrast-enhanced CT-based model differentiated angiomyolipoma from RCC with sensitivity and specificity of 42% and 98% versus 50% and 98%, respectively. CONCLUSION: Combinations of various CT and demographic findings allowed differentiation of angiomyolipoma from RCC.

Characteristics of renal cystic and solid lesions based on contrast-enhanced computed tomography of potential kidney donors.

BACKGROUND: The presence of a few renal cysts is considered of little relevance in healthy adults, although acquired renal cystic disease occurs in advanced kidney failure. The objective of this study was to detail renal cystic and solid lesions and identify any association with clinical characteristics. STUDY DESIGN: Clinical-pathologic correlation. SETTING & PARTICIPANTS: Potential kidney donors undergoing a standardized evaluation at the Mayo Clinic in 2000-2008. PREDICTORS: Age, kidney function, and chronic kidney disease risk factors. MEASUREMENTS: Renal cystic and solid lesions by contrast-enhanced computed tomographic images. OUTCOMES: Cyst number, diameter, and location. RESULTS: After excluding 8 with cystic disease, 7 of whom had autosomal dominant polycystic kidney disease, there were 1,948 potential kidney donors (42% men; mean age, 43 years). A cortical, medullary, or parapelvic cyst ≥5 mm was present in 12%, 14%, or 2.8%. For ages 19-49 years, 39%, 22%, 7.9%, and 1.6% had a cortical or medullary cyst ≥2, ≥5, ≥10, and ≥20 mm in diameter. For ages 50-75 years, 63%, 43%, 22%, and 7.8% had a cortical or medullary cyst ≥2, ≥5, ≥10, and ≥20 mm in diameter. The 97.5th percentile for number of cortical and medullary cysts ≥5 mm increased with age (10 for men and 4 for women in the 60- to 69-year group). After age and sex adjustment, cortical and medullary cysts ≥5 mm were associated with higher 24-hour urine albumin excretion, as well as increased body surface area, hypertension, and higher glomerular filtration rate in some analyses. Angiomyolipomas, hyperdense cysts, and enhancing masses or cysts with concerning features for malignancy occurred in 2.2%, 1.2%, and 0.6% and were associated with older age (P ≤ 0.05 for each). LIMITATIONS: Persons with known chronic kidney disease were excluded. CONCLUSIONS: Renal cysts are common, particularly in older men, and may be a marker of early kidney injury because they associate with albuminuria, hypertension, and hyperfiltration.

Small (<4 cm) renal mass: differentiation of angiomyolipoma without visible fat from renal cell carcinoma utilizing MR imaging.

PURPOSE: To determine whether a combination of magnetic resonance (MR) parameters can help differentiate small angiomyolipomas (AMLs) without visible fat from renal cell carcinomas (RCCs). MATERIALS AND METHODS: This HIPAA-compliant retrospective study received institutional review board approval; 69 men and 42 women (mean age, 59.7 years) with 15 AMLs without visible fat and 104 RCCs underwent MR. The development set consisted of 10 AMLs and 71 RCCs; the validation set consisted of five AMLs and 33 RCCs. T1-weighted fast spin-echo (SE), fat-suppressed T2-weighted fast SE, in- and opposed-phase gradient-echo (GRE), and fat-suppressed three-dimensional T1-weighted spoiled GRE sequences were performed before and after contrast material administration. Tumor signal intensity (SI) was measured. T1 and T2 SI ratio (ratio of tumor to renal cortex SI on T1- and T2-weighted images, respectively), SI index (SII) ([SI(in) 2 SI(opp)]/[SI(in)] × 100; SI(in) and SI(opp) are tumor SI on in- and opposed-phase images, respectively), and arterial-to-delayed enhancement ratio ([SI(art) 2 SI(pre)]/[SI(del) 2 SI(pre)]; SI(pre), SI(art), and SI(del) are tumor SI on unenhanced, arterial phase, and delayed phase three-dimensional T1-weighted spoiled GRE images, respectively) were compared. Combinations of MR parameter threshold levels were constructed from development set and validated with validation set. Sensitivity, specificity, and accuracy for differentiating between AML and RCC were calculated for combinations of MR parameter threshold levels. RESULTS: AML had significantly higher T1 SI ratio (P = .04), lower T2 SI ratio (P = .001), higher SII (P = .02), and higher arterial-to-delayed enhancement ratio (P < .001) than RCC. Sensitivity, specificity, and accuracy for combination of T2 SI ratio less than 0.9 and ([SII greater than 20% and T1 SI ratio greater than 1.2] or arterial-to-delayed enhancement ratio greater than 1.5) were 73% (11 of 15), 99% (103 of 104), and 96% (114 of 119), respectively, for differentiating AML from RCC. CONCLUSION: A combination of T2 SI ratio less than 0.9 and ([SII greater than 20% and T1 SI ratio greater than 1.2] or arterial-to-delayed enhancement ratio greater than 1.5) was accurate in differentiating AML from RCC.

Renal involvement in patients with autoimmune pancreatitis: ultrasound findings.

OBJECTIVE: The purpose of our study was to retrospectively evaluate the ultrasound findings of renal involvement in patients with autoimmune pancreatitis. METHODS: 15 patients with autoimmune pancreatitis (15 male, 0 female, mean age 66 years old, range 44-85) who had renal involvement documented on CT or MR and had abdominal ultrasound within 1 month were included. Ultrasound images were retrospectively reviewed for presence or absence of renal involvement. Shape and echogenicity of the renal lesions were recorded. RESULTS: In 8 out of 15 patients, at least one renal lesion was identified on ultrasound with a total of 9 kidneys. In 7 kidneys, lesions appeared as ill-defined, non-mass like areas of decreased echogenicity. Three lesions showed associated irregular lobular thickening of the renal parenchyma with bulging contour and 1 showed focal area of parenchymal loss. In 2 kidneys, the lesions were seen as solitary or multiple hypoechoic mass-like areas. Ill-defined, non-mass like lesions on ultrasound corresponded to well-circumscribed wedge-shaped lesions in all but one case on CT or MR. Mass-like lesions on ultrasound corresponded to well-circumscribed round lesions on CT or MR. CONCLUSION: Most common ultrasound findings of renal involvement in patients with autoimmune pancreatitis were ill-defined area of decreased echogenicity.

Adrenal hematoma after nephrectomy.

OBJECTIVE: The objective of our study was to retrospectively define the incidence of adrenal hematoma on CT or MRI after nephrectomy. MATERIALS AND METHODS: Between January 2008 and June 2009, 465 patients underwent nephrectomy at our institution. Of these, patients without both preoperative and postoperative abdominal CT or MR studies within 6 months of surgery (n = 83) and those with documented adrenalectomy at the time of radical nephrectomy (n = 33) were excluded. Thus, 349 patients (292 male, 57 female; mean age, 60.2 years; range, 2-88 years) were included in the study. Preoperative and postoperative CT or MR studies were reviewed by two radiologists in consensus for the presence or absence of adrenal hematoma. Diagnosis of adrenal hematoma was made by imaging findings and follow-up. The incidence of adrenal hematoma was calculated with a 95% CI. RESULTS: Of the 349 patients (partial nephrectomy, n = 232; radical nephrectomy, n = 117), 19 patients developed adrenal hematoma after nephrectomy (partial nephrectomy, n = 12; radical nephrectomy, n = 7) with an incidence of 5.4% (95% CI, 3.1-7.8%). All adrenal hematomas were located on the side of nephrectomy (right adrenal gland, n = 8; left adrenal gland, n = 11). In nine patients, the adrenal hematoma appeared as a round or oval lesion on postoperative imaging with a mean size of 2.6 cm (range, 1.5-4.0 cm). In 10 patients, the adrenal hematoma appeared as diffuse enlargement of the adrenal gland on postoperative imaging with a mean thickness of 1.3 cm (range, 0.6-1.8 cm). CONCLUSION: An adrenal hematoma was identified in 5.4% of patients on CT or MRI after nephrectomy. A new round or oval adrenal mass after nephrectomy should be differentiated from a metastasis.

Xanthogranulomatous adrenalitis in a neonate: CT and US findings.

We report a 46-day-old female infant with xanthogranulomatous adrenalitis. Ultrasonography showed a complex, solid-cystic right suprarenal mass with poorly defined margins. Colour flow Doppler revealed the solid portion of the mass to be vascular. CT demonstrated a heterogeneous cystic and solid mass with some contrast enhancement in the inferior part of the lesion. There was compression of the adjacent upper pole of the right kidney and the lateral aspect of the inferior vena cava. The mass was completely removed; histological examination revealed xanthogranulomatous adrenalitis. At the time of this report she remained well 3 years following surgery.