Sarcopenia and systemic inflammation are associated with decreased survival after cytoreductive nephrectomy for metastatic renal cell carcinoma.

BACKGROUND: This study was aimed at assessing the associations of sarcopenia, muscle density, adiposity, and inflammation with overall survival (OS) after cytoreductive nephrectomy (CN) for metastatic renal cell carcinoma. METHODS: In all, 158 patients undergoing CN from 2001 to 2014 had digitized preoperative imaging for tissue segmentation via Slice-O-Matic software (version 5.0) at the mid-L3 level. The skeletal muscle index was calculated with the skeletal muscle area (cm2 ) normalized for height (m2 ), and the skeletal muscle density (SMD) was calculated with average Hounsfield units. Adiposity was measured with the cross-sectional area (cm2 ) of visceral, subcutaneous, and intramuscular adiposity compartments and was similarly normalized for height. The average fat density was obtained in Hounsfield units. OS was estimated with the Kaplan-Meier method. Associations between body composition, inflammation metrics, and relevant clinicopathology and OS were assessed with univariable and multivariate Cox analyses. RESULTS: Seventy-six of the 158 patients (48%) were sarcopenic. Sarcopenia was associated with elevated neutrophil to lymphocyte ratios (NLRs; P = .02), increased age (P = .001), lower body mass indices (P = .009), greater modified Motzer scores (P = .019), and lower SMD (P = .006). The median OS was 15.0 and 29.4 months for sarcopenic and nonsarcopenic patients, respectively (P = .04). Elevated inflammation (NLR or C-reactive protein), in addition to sarcopenia, was independently associated with OS, with an elevated NLR ≥ 3.5 and sarcopenia associated with the poorest OS at 10.2 months. No associations were observed between measurements of muscle density or adiposity and OS. CONCLUSIONS: Sarcopenia and measures of high systemic inflammation are additively associated with inferior OS after CN and may be of use in preoperative risk stratification. LAY SUMMARY: Body composition and sarcopenia (a deficiency in skeletal musculature) have been shown to affect outcomes in cancer. We found that sarcopenic patients had poor survival in comparison with nonsarcopenic patients in the setting of metastatic renal cell carcinoma (mRCC). Patients with both elevated inflammation and sarcopenia had the poorest survival. Sarcopenia is an objective measure of nutrition that can assist in therapeutic counseling and decision-making for individualized treatment in mRCC.

Pancreaticoduodenal Groove: Spectrum of Disease and Imaging Features.

The pancreaticoduodenal groove (PDG) is a small space between the pancreatic head and duodenum where vital interactions between multiple organs and physiologic processes take place. Muscles, nerves, and hormones perform a coordinated dance, allowing bile and pancreatic enzymes to aid in digestion and absorption of critical nutrition. Given the multitude of organs and cells working together, a variety of benign and malignant entities can arise in or adjacent to this space. Management of lesions in this region is also complex and can involve observation, endoscopic resection, or challenging surgeries such as the Whipple procedure. The radiologist plays an important role in evaluation of abnormalities involving the PDG. While CT is usually the first-line examination for evaluation of this complex region, MRI offers complementary information. Although features of abnormalities involving the PDG can often overlap, understanding the characteristic imaging and pathologic features generally allows categorization of disease entities based on the suspected organ of origin and the presence of ancillary features. The goal of the authors is to provide radiologists with a conceptual approach to entities implicating the PDG to increase the accuracy of diagnosis and assist in appropriate management or presurgical planning. They briefly discuss the anatomy of the PDG, followed by a more in-depth presentation of the features of disease categories. A table summarizing the entities that occur in this region by underlying cause and anatomic location is provided. ©RSNA, 2022.

Sarcopenia and modified Glasgow Prognostic Score predict postsurgical outcomes in localized renal cell carcinoma.

BACKGROUND: Body composition and inflammation are gaining importance for prognostication in cancer. This study investigated the individual and combined utility of the preoperative skeletal muscle index (SMI) and the modified Glasgow Prognostic Score (mGPS) for estimating postoperative outcomes in patients with localized renal cell carcinoma (RCC) undergoing nephrectomy. METHODS: The authors performed a retrospective review of 352 patients with localized RCC. SMI was measured via computed tomography or magnetic resonance imaging. Patients met the criteria for sarcopenia by body mass index- and sex-stratified thresholds. Multivariable and Kaplan-Meier analyses of associations of sarcopenia and mGPS with overall survival (OS), recurrence-free survival (RFS), and cancer-specific survival (CSS) were performed. Variables were analyzed independently and combined into risk groups: low risk (nonsarcopenic, low mGPS), medium risk (sarcopenia only), medium risk (inflammation only), and high risk (sarcopenic, high mGPS). Receiver operating characteristic (ROC) curves were used to analyze risk groups in comparison with the Stage, Size, Grade, and Necrosis (SSIGN) score and the modified International Metastatic RCC Database Consortium (IMDC) score. RESULTS: The majority of the patients were at stage pT3 (63%), 39.5% of the patients were sarcopenic, and 19.3% had an elevated mGPS at the baseline. The median follow-up time was 30.4 months. Sarcopenia and mGPS were independently associated with worse OS (hazard ratio for sarcopenia, 1.64; P = .006; hazard ratio for mGPS, 1.72; P = .012), CSS, and RFS. Risk groups had an increasing association with worse RFS (P = .015) and CSS (P = .004) but not OS (P = .087). ROC analyses demonstrated a higher area under the curve for risk groups in comparison with the SSIGN and IMDC scores at 5 years. CONCLUSIONS: Sarcopenia and an elevated mGPS were associated with worse clinical outcomes in this study of patients with localized RCC. This has implications for preoperative prognostication and treatment decision-making. LAY SUMMARY: Kidney cancer is a disease with a wide variety of outcomes. Among patients undergoing surgical removal of the kidney for cancer that has not spread beyond the kidney, many are cured, but some experience recurrence. Physicians are seeking ways to better predict who is at risk for recurrence or death from kidney cancer. This study has evaluated body composition and markers of inflammation before surgery to predict the risk of recurrence or death after surgery. Specifically, low muscle mass and an elevated inflammation score (the modified Glasgow Prognostic Score) have been associated with an increased likelihood of recurrence of kidney cancer and death.

Variant anatomy of the biliary system as a cause of pancreatic and peri-ampullary cancers.

BACKGROUND: The cause of most pancreatic and periampullary cancers (PAC) is unknown. Recently, anatomic variations such as pancreatobiliary maljunction have been recognized as risk factors, similar to Barrett-related gastro-esophageal cancers. METHODS: Pre-operative MRI from 860 pancreatic/biliary resections, including 322 PACs, were evaluated for low-union (cystic duct joining the common hepatic duct inside of the pancreas or within 5 mm of the pancreatic border) RESULTS: Low-union, seen <10% of the population, was present in 44% of PACs (73% distal bile duct/cholangiocarcinoma, 42% pancreatic head, and 34% ampullary). It was significantly lower(11%) in conditions without connection to the ductal system (thus not exposed to the ductal/biliary tract contents), namely mucinous cystic neoplasms and intrahepatic cholangiocarcinomas(p < 0.0001). Intra-pancreatic type low-union was seen in 16% of PACs versus 2% of controls(p < 0.0001). DISCUSSION: This study establishes an association between low-union and PACs, and points to an anatomy-induced chemical/bilious carcinogenesis. This may explain why most pancreas cancers are in the head. It is possible that the same chemical milieu, caused by conditions other than low-union/insertion, may also play a role in the remaining half of PACs. This opens various treatment opportunities including milieu modifications (chemoprevention), focused screening of at-risk patients, and early detection with possible corrective actions.

Is hepatectomy safe following Yttrium-90 therapy? A multi-institutional international experience.

BACKGROUND: Single institution reports demonstrate variable safety profiles when liver-directed therapy with Yttrium-90 (Y-90) is followed by hepatectomy. We hypothesized that in well-selected patients, hepatectomy after Y90 is feasible and safe. METHODS: Nine institutions contributed data for patients undergoing Y90 followed by hepatectomy (2008-2017). Clinicopathologic and perioperative data were analyzed, with 90-day morbidity and mortality as primary endpoints. RESULTS: Forty-seven patients were included. Median age was 59 (20-75) and 62% were male. Malignancies treated included hepatocellular cancer (n = 14; 30%), colorectal cancer (n = 11; 23%), cholangiocarcinoma (n = 8; 17%), neuroendocrine (n = 8; 17%) and other tumors (n = 6). The distribution of Y-90 treatment was: right (n = 30; 64%), bilobar (n = 14; 30%), and left (n = 3; 6%). Median future liver remnant (FLR) following Y90 was 44% (30-78). Resections were primarily right (n = 16; 34%) and extended right (n = 14; 30%) hepatectomies. The median time to resection from Y90 was 196 days (13-947). The 90-day complication rate was 43% and mortality was 2%. Risk factors for Clavien-Dindo Grade>3 complications included: number of Y-90-treated lobes (OR 4.5; 95% CI1.14-17.7; p = 0.03), extent of surgery (p = 0.04) and operative time (p = 0.009). CONCLUSIONS: These data demonstrate that hepatectomy following Y-90 is safe in well-selected populations. This multi-disciplinary treatment paradigm should be more widely studied, and potentially adopted, for patients with inadequate FLR.

Digitizing an Analog Radiography Teaching File Under Time Constraint: Trade-Offs in Efficiency and Image Quality.

We digitized the radiography teaching file at Black Lion Hospital (Addis Ababa, Ethiopia) during a recent trip, using a standard digital camera and a fluorescent light box. Our goal was to photograph every radiograph in the existing library while optimizing the final image size to the maximum resolution of a high quality tablet computer, preserving the contrast resolution of the radiographs, and minimizing total library file size. A secondary important goal was to minimize the cost and time required to take and process the images. Three workers were able to efficiently remove the radiographs from their storage folders, hang them on the light box, operate the camera, catalog the image, and repack the radiographs back to the storage folder. Zoom, focal length, and film speed were fixed, while aperture and shutter speed were manually adjusted for each image, allowing for efficiency and flexibility in image acquisition. Keeping zoom and focal length fixed, which kept the view box at the same relative position in all of the images acquired during a single photography session, allowed unused space to be batch-cropped, saving considerable time in post-processing, at the expense of final image resolution. We present an analysis of the trade-offs in workflow efficiency and final image quality, and demonstrate that a few people with minimal equipment can efficiently digitize a teaching file library.

Gadobenate Dimeglumine Administration and Nephrogenic Systemic Fibrosis: Is There a Real Risk in Patients with Impaired Renal Function?

PURPOSE: To determine the incidence of nephrogenic systemic fibrosis (NSF) in patients with renal disease who received gadobenate dimeglumine at a single medical center. MATERIALS AND METHODS: This was an institutional review board-approved HIPAA-compliant retrospective study with waiver of informed consent. Patients either underwent dialysis or not, had an abnormal estimated glomerular filtration rate (eGFR), and underwent magnetic resonance (MR) imaging and/or MR angiography with gabobenate dimeglumine in 2010. Dialysis status, eGFR, time to transplantation, waiting list status, contrast material volume at index imaging, and additional imaging examinations between 2007 and 2014 were recorded. Clinical notes with and without integument examinations, pathologic records, and additional patient communication were evaluated for development of NSF through September 2014. Dates of latest documented integument examination and latest interaction were recorded. Mean, standard deviation, and median values were obtained, along with incidence percentage of NSF. RESULTS: Of 401 patients (172 women, 229 men; mean age, 50 years), 75.5% were dialysis dependent (n = 303) and 24.4% (n = 98) were not undergoing dialysis, with a mean eGFR ± standard deviation of 17 mL/min per 1.73 m(2) ± 5.6 (range, 6-41 mL/min per 1.73 m(2); median, 16.3 mL/min per 1.73 m(2)). Mean and median contrast material volume at index imaging were 24 mL ± 5.7 (range, 9-45 mL). Additional contrast material volume administered was 23 mL ± 12.9 (range, 6-64 mL; median, 20 mL; n = 66). One hundred twenty-six patients (31%) received a transplant; mean time to transplantation was 1.72 years ± 1.25 (range, 0-4.46 years; median, 1.4 years). No patients received diagnoses of NSF. Mean follow-up was 2.35 years ± 1.61 (range, 0.00-4.61 years; median, 2.75 years) with documented integument examination and 3.08 years ± 1.36 (range, 0.16-4.66 years; median, 3.66 years) with direct patient communication. CONCLUSION: No patients undergoing peritoneal dialysis, hemodialysis, or nondialysis who experienced renal failure developed NSF after administration of gadobenate dimeglumine after more than 2 years' mean follow-up. Gadobenate dimeglumine may be safe in this population.

Prognostic implications of the magnetic resonance imaging appearance in papillary renal cell carcinoma.

OBJECTIVE: To evaluate the prognostic implications of the MRI appearance and pathological features of papillary renal cell carcinoma (pRCC). METHODS: A total of 128 pRCC in 115 patients who underwent preoperative MRI were characterised in terms of pathological type (type 1 vs. type 2), MRI appearance (focal vs. infiltrative) and additional MRI features. Patients were classified on the basis of the presence or absence of metastatic disease. RESULTS: There were 65 focal type 1, 54 focal type 2 and 9 infiltrative pRCC. All infiltrative pRCC were of histopathological type 2. Renal vein thrombus was present in 89 % of infiltrative pRCC and no cases of focal pRCC. Metastatic disease was observed in 3.7 % of focal type 1, 7.5 % of focal type 2 and 75.0 % of infiltrative type 2 pRCC. Infiltrative MRI appearance was a significant predictor of metastatic disease, independent of pathological type, size and T stage (P ≤ 0.020). Among focal pRCC on MRI, pathological type 2 was not a significant predictor of metastatic disease (P = 0.648). No combination of features achieved significantly greater accuracy for predicting metastatic disease than renal vein thrombus alone (P > 0.5). CONCLUSION: Infiltrative MRI appearance and renal vein thrombus identify a subset of pathological type 2 pRCC at a significantly increased risk of metastatic disease.

Gastrointestinal malignancies in pregnancy.

Gastrointestinal malignancies, though uncommon in pregnancy, present several unique challenges with regards to diagnosis, staging, and treatment. Imaging the pregnant patient with a suspected or confirmed GI malignancy requires modifications to the radiologic modality of choice and protocol in order to minimize harm to the fetus, ensure accuracy in diagnosis and staging and guide treatment decisions. In this review article, we discuss the imaging approach to the pregnant patient with GI cancer, including safe radiologic modalities and modifications to imaging protocols. We also review the most common GI cancers encountered in pregnancy, including colorectal, pancreatic, gastric, and small bowel tumors, with emphasis to imaging findings, staging, and treatment considerations.

Micro-habits for life-long learning.

Radiology is a demanding career that requires a thorough understanding of evolving knowledge in both medical imaging and technology. Competing interests such as-familial obligations, clinical practice, committee meetings, and research projects-often leave little time for self-care and regular review of current medical literature. Healthy habits can be difficult to maintain, but micro-habits are more manageable and their benefits compound over time. Based on the book, Atomic Habits by James Clear, we discuss a micro-habit toolkit which includes: a two-minute rule, habit-stacking, environmental cues, task prioritization/automatization, habit tracking, and accountability. We offer practical suggestions for radiologists to incorporate this toolkit into their daily lives to become healthy life-long learners.

New blood: trainee and early career engagement augmenting the society of abdominal radiology experience.

Many national radiology societies are recognizing the need for early career and trainee engagement as crucial to keeping their societies relevant, active, and invigorated with new ideas. In this descriptive paper, we review the benefits of establishing the Society of Abdominal Radiology's Resident and Fellow Section and Early Career Committee-including our activities and experience, advice for committee structure, and opportunities for growth.

Peer Learning Through Multi-Institutional Case Conferences: Abdominal and Cardiothoracic Radiology Experience.

RATIONALE AND OBJECTIVES: We describe a model of multi-institutional, multisociety, online case conferences that is a case-based group discussion of selected (nonrandom) cases which are subsequently hosted on social media and online platforms (e.g., YouTube, websites) to be available for a wider audience. MATERIALS AND METHODS: Using online conferencing software (Zoom, GoToMeeting), participants from both abdominal and cardiothoracic radiologists engage in separate, subspecialty one-hour meetings discussing a variety of meaningful cases. Participants take turns presenting their cases to the group and discuss significant findings, interpretations, differential diagnoses, and any other teaching points. All of the case conferences for both societies are recorded and edited to be uploaded on YouTube and their respective websites. RESULTS: Participants from these conferences log in from 14 institutions in 7 states across the United States. The YouTube videos reach thousands of people around the world. The abdominal case conference on YouTube has received almost 1,300 views with 90 videos uploaded. The thoracic (the Society of Thoracic Radiology) case conference has been running for over 7 years, with 226 videos uploaded to YouTube and 38,200 views, 1426 subscribers, and a total watch time of over 525,800 minutes. Twitter has been utilized by both groups to promote online viewership. CONCLUSION: Our model is feasible and effective compared to traditional peer review. The cases selected are deliberate and focused on quality improvement and/or education. We harness online engagement, specifically social media presence, which has opened new opportunities to educate our peers and reach a global audience, including the nonradiologic community, to learn about radiology and unique practices.

Left renal vein nutcracker syndrome and concurrent IVC duplication: Surgical treatment.

Multiple vascular anomalies may be encountered in patients with nutcracker syndrome; further compounding the surgical complexity in managing this condition. A 28-year-old male presented with persistent flank pain and hematuria. Imaging revealed narrowing of the left renal vein at the aortomesenteric junction, and a dilated vein consistent with the left gonadal vein. On surgical exploration, a duplicated IVC was found. The patient underwent a right caval-to-left caval bypass using a cryopreserved femoral vein homograft. The surgery was well tolerated and completely resolved the patient's symptoms.

Prevalence of incidental pancreatic cysts in the adult population on MR imaging.

OBJECTIVES: The reporting of incidental pancreatic cystic lesions on cross-sectional imaging studies has dramatically increased over the last few years. The prevalence of incidental pancreatic cysts in the adult population, however, is unknown. The aim of our study was to determine the prevalence of incidentally detected pancreatic cysts in the adult population undergoing abdominal magnetic resonance (MR) imaging. METHODS: MR imaging examinations of 616 consecutive patients obtained between January 2001 and February 2002 were retrospectively reviewed by two radiologists and the following information was recorded: the total number of pancreatic cysts; the maximum diameter, location, and characteristics of the largest cyst; documentation of the cyst(s) within the radiology report; and characteristics of the cyst(s) at imaging follow-up. RESULTS: Incidental pancreatic cysts were present in 13.5% (83/616) of patients, with 60% of the cysts being solitary, and 88% of the cysts being simple. Largest cyst mean and median diameters were 7.4 mm (2-24 mm) and 6 mm, respectively. Both the prevalence of pancreatic cysts and the mean size of the largest cyst increased with age (P=0.007, r=0.893 and P=0.003, r=0.929, respectively). Only 31% (26/83) of incidental pancreatic cysts were documented in the radiology report. The mean size of reported pancreatic cysts was larger than those cysts that were not reported (P<0.001). CONCLUSIONS: The prevalence of incidentally detected pancreatic cysts on MR imaging is 13.5%, and increases with age. A majority of these cysts are not reported on MR imaging studies.

Quantification of body composition in renal cell carcinoma patients: Comparing computed tomography and magnetic resonance imaging measurements.

PURPOSE: Body composition measures provide valuable information for prognostication and treatment election in cancer patients. We investigated the novel use of magnetic resonance imaging (MRI) for skeletal muscle and adipose tissue cross-sectional area measurements in preoperative renal cell carcinoma (RCC) patients. MATERIALS AND METHODS: RCC patients with pre-operative CT and MRI abdominal imaging were identified. Semi-automatic segmentation measurement of skeletal muscle area (SMA), intramuscular fat area (IMFA), visceral fat area (VFA), subcutaneous fat area (SFA), linear measurements of psoas, paraspinal muscles were performed. Pearson correlation coefficients, Bland-Altman plot analyses were done. Multivariable regression analysis examined the relationship between patient characteristics and skeletal muscle. RESULTS: Image analysis was performed on 58 RCC patients with preoperative CT and MRI imaging. For segmentation measures, r = 0.99, 0.99, 0.99, and 0.98 for SMA, IMFA, VFA, SFA, respectively, and 0.96 for linear measures of skeletal muscle. Bland-Altman analysis revealed a bias toward larger CT value for SMA (1.35 %), linear muscle measures (2.79 %), and SFA (10.34 %), and toward larger MRI values for IMFA (0.75 %) and VFA (5.81 %). ECOG ≥ 1 was associated with lower skeletal muscle than ECOG 0 for all measurements. CONCLUSIONS: Strong correlation of CT and MRI cross sectional measurements of skeletal muscle and adipose tissues supports the use of axial MRI images for comprehensive measurement of body composition. This has widespread implications for body composition research and cancer patient care.

Neoadjuvant Cabozantinib in an Unresectable Locally Advanced Renal Cell Carcinoma Patient Leads to Downsizing of Tumor Enabling Surgical Resection: A Case Report.

INTRODUCTION: Cabozantinib (XL-184) is a small molecule inhibitor of the tyrosine kinases c-Met, AXL, and VEGFR2 that has been shown to reduce tumor growth, metastasis, and angiogenesis. After the promising results from the METEOR and CABOSUN trials, cabozantinib was approved for use in the first- and second-line setting in patients with advanced RCC. Previously, targeted therapies have been used in the neoadjuvant setting for tumor size reduction and facilitating nephrectomies. The increased response rates with cabozantinib in metastatic renal cell carcinoma (mRCC), along with the other neoadjuvant TKI data, strongly support an expanded role for cabozantinib in the neoadjuvant setting. CASE DESCRIPTION: We report on a 59-year-old gentleman presenting with an unresectable 21.7 cm left renal cell carcinoma (RCC) with extension to soft tissue and muscles of the thoracic cage, psoas muscle, posterior abdominal wall, tail of pancreas, splenic flexure of colon, and inferior margin of spleen. Presurgical, neoadjuvant systemic therapy with cabozantinib was initiated for 11 months in total. Initially after 2 months of cabozantinib, magnetic resonance imaging (MRI) revealed a significant reduction (44.2%) in tumor diameter from 21.7 to 12.1 cm with decreased extension into adjacent structures. After 11 months total of cabozantinib, the corresponding MRI showed grossly stable size of the tumor and significant resolution of invasion of adjacent structures. After washout of cabozantinib, radical resection, including nephrectomy, was successfully performed without any major complications, either intra-operative or perioperative. Negative margins were achieved. CONCLUSIONS: This is a report of neoadjuvant cabozantinib downsizing a tumor and enabling surgical resection in this patient with locally advanced RCC. Our findings demonstrate that neoadjuvant cabozantinib to facilitate subsequent surgical resection may be a feasible option for patients presenting with unresectable RCC.

Peer Learning Through Multi-Institutional Web-based Case Conferences: Perceived Value (and Challenges) From Abdominal, Cardiothoracic, and Musculoskeletal Radiology Case Conference Participants.

RATIONALE AND OBJECTIVES: Peer learning is a case-based group-learning model intended to improve performance. In this descriptive paper, we describe multi-institutional, multi-subspecialty, web-based radiology case conferences and summarize the participants' experiences. MATERIALS AND METHODS: A semi-structured, 27-question survey was administered to radiologists participating in abdominal, cardiothoracic, and musculoskeletal case conferences. Survey questions included demographics, perceived educational value and challenges experienced. Survey question formats were continuous, binary, five-point Likert scale or text-based. The measures of central tendencies, proportions of responses and patterns were tabulated. RESULTS: From 57 responders, 12/57 (21.1%) were abdominal, 16/57 (28.1%) were cardiothoracic, and 29/57 (50.8%) were musculoskeletal conference participants; 50/56 (89.3%) represented academic practice. Median age was 45 years (range 35-74); 43/57 (75.4%) were male. Geographically, 16/52 (30.8%) of participants were from the East Coast, 16/52 (30.8%) Midwest, 18/52 (34.6%) West Coast, and 2/52 (3.8%) International. The median reported educational value was 5/5 (interquartile range 5-5). Benefits of the case conference included education (50/95, 52.6%) and networking (39/95, 41.1%). Participants reported presenting the following cases: "great call" 32/48 (66.7%), learning opportunity 32/48 (66.7%), new knowledge 41/49 (83.7%), "zebras" 46/49 (93.9%), and procedural-based 16/46 (34.8%). All 51/51 (100%) of responders reportedly gained new knowledge, 49/51 (96.1%) became more open to group discussion, 34/51 (66.7%) changed search patterns, and 50/51 (98%) would continue to participate. Reported challenges included time zone differences and support from departments for a protected time to participate. CONCLUSION: Peer learning through multi-institutional case conferences provides educational and networking opportunities. Current challenges and desires include having department-supported protected time and ability to receive continuing medical education credit.

Imaging of the female urethra.

Female urethral pathology can be challenging to diagnose clinically due to non-specific symptoms. High-resolution MRI has become a powerful tool in the diagnosis of urethral lesions and staging of malignancy. Additionally, dynamic MRI, fluoroscopy or ultrasound can evaluate for pelvic floor prolapse and the effectiveness of surgical interventions. This article will review the imaging features of common benign and malignant conditions of the female urethra including diverticula, benign cystic and solid lesions, malignancy, surgical slings, and injection of bulking agents.

Cecal bascule as a cause of postoperative nausea and abdominal pain.

Cecal bascule is a unique form of large bowel volvulus in which the cecum folds anterior to the ascending colon and generates a flap valve which impairs cecal emptying and results in cecal dilation [1]. Presenting symptoms include nausea, vomiting, abdominal pain, distension, and constipation. We report a case of a 74-year-old male who developed abdominal pain and nausea after a coronary artery bypass graft surgery. Imaging demonstrated an enlarged cecum measuring up to 17.7 cm as well as upstream small bowel dilation. The patient underwent nasogastric tube and endoscopic decompression, relieving his cecal dilation and symptoms.