Evaluation of RANO Criteria for the Assessment of Tumor Progression for Lower-Grade Gliomas.

PURPOSE: The Response Assessment in Neuro-Oncology (RANO) criteria for lower-grade gliomas (LGGs) define tumor progression as ≥25% change in the T2/FLAIR signal area based on an operator's discretion of the perpendicular diameter of the largest tumor cross-section. Potential sources of error include acquisition inconsistency of 2D slices, operator selection variabilities in both representative tumor cross-section and measurement line locations, and the inability to quantify infiltrative tumor margins and satellite lesions. Our goal was to assess the accuracy and reproducibility of RANO in LG. MATERIALS AND METHODS: A total of 651 FLAIR MRIs from 63 participants with LGGs were retrospectively analyzed by three blinded attending physicians and three blinded resident trainees using RANO criteria, 2D visual assessment, and computer-assisted 3D volumetric assessment. RESULTS: RANO product measurements had poor-to-moderate inter-operator reproducibility (r2 = 0.28-0.82; coefficient of variance (CV) = 44-110%; mean percent difference (diff) = 0.4-46.8%) and moderate-to-excellent intra-operator reproducibility (r2 = 0.71-0.88; CV = 31-58%; diff = 0.3-23.9%). When compared to 2D visual ground truth, the accuracy of RANO compared to previous and baseline scans was 66.7% and 65.1%, with an area under the ROC curve (AUC) of 0.67 and 0.66, respectively. When comparing to volumetric ground truth, the accuracy of RANO compared to previous and baseline scans was 21.0% and 56.5%, with an AUC of 0.39 and 0.55, respectively. The median time delay at diagnosis was greater for false negative cases than for false positive cases for the RANO assessment compared to previous (2.05 > 0.50 years, p = 0.003) and baseline scans (1.08 > 0.50 years, p = 0.02). CONCLUSION: RANO-based assessment of LGGs has moderate reproducibility and poor accuracy when compared to either visual or volumetric ground truths.

Localization of Parathyroid Disease in Reoperative Patients with Primary Hyperparathyroidism.

The localization of persistent or recurrent disease in reoperative patients with primary hyperparathyroidism presents challenges for radiologists and surgeons alike. In this article, we summarize the relevant imaging modalities, compare their accuracy in identifying reoperative disease, and outline their advantages and disadvantages. Accurate localization by preoperative imaging is a predictor of operative success, whereas negative or discordant preoperative imaging is a risk factor for operative failure. Ultrasound is a common first-line modality because it is inexpensive, accessible, and radiation-free. However, it is highly operator-dependent and less accurate in the reoperative setting than in the primary setting. Sestamibi scintigraphy is superior to ultrasound in localizing reoperative disease but requires radiation, prolonged imaging times, and reader experience for accurate interpretation. Like ultrasound, sestamibi scintigraphy is less accurate in the reoperative setting because reoperative patients can exhibit distorted anatomy, altered perfusion of remaining glands, and interference of radiotracer uptake. Meanwhile, four-dimensional computed tomography (4DCT) is superior to ultrasound and sestamibi scintigraphy in localizing reoperative disease but requires the use of radiation and intravenous contrast. Both 4DCT and magnetic resonance imaging (MRI) do not significantly differ in accuracy between unexplored and reoperative patients. However, MRI is more costly, inaccessible, and time-consuming than 4DCT and is inappropriate as a first-line modality. Hybrid imaging with positron emission tomography and computed tomography (PET/CT) may be a promising second-line modality in the reoperative setting, particularly when first-line modalities are discordant or inconclusive. Lastly, selective venous sampling should be reserved for challenging cases in which noninvasive modalities are negative or discordant. In the challenging population of reoperative patients with PHPT, a multimodality approach that utilizes the expertise of high-volume centers can accurately localize persistent or recurrent disease and enable curative parathyroidectomy.

Osseous Manifestations of Primary Hyperparathyroidism: Imaging Findings.

Primary hyperparathyroidism is a systemic endocrine disease that has significant effects on bone remodeling through the action of parathyroid hormone on the musculoskeletal system. These findings are important as they can aid in distinguishing primary hyperparathyroidism from other forms of metabolic bone diseases and inform physicians regarding disease severity and complications. This pictorial essay compiles bone-imaging features with the aim of improving the diagnosis of skeletal involvement of primary hyperthyroidism.

Histogram analysis of apparent diffusion coefficient and fluid-attenuated inversion recovery in discriminating between enhancing and nonenhancing lesions in multiple sclerosis.

PURPOSE: This study evaluates the diagnostic performance of apparent diffusion coefficient (ADC) and T2 fluid-attenuation inversion recovery (T2 FLAIR) in discriminating between new white matter (WM) enhancing lesions (ELs) and non-enhancing lesions (NELs) in multiple sclerosis (MS) patients. METHODS: Thirty MS patients with a new solitary WM lesion on brain MRI were analyzed. A region-of-interest was drawn on all lesions and the contralateral normal-appearing WM (NAWM) on T2 FLAIR and ADC maps. Normalized ratios of T2 FLAIR and ADC were calculated by dividing lesion value by the contralateral NAWM. Histogram analysis was performed on the T2 FLAIR, ADC values, and their normalized ratios. Mann-Whitney U test was used to compare histogram parameters and receiver operating characteristic (ROC) analysis determined the area under the curve (AUC). RESULTS: T2 FLAIR histogram parameters were not significantly different between ELs and NELs. Several EL ADC histogram parameters, including maximum and mean, were significantly higher than NELs (p = 0.006 to p = 0.031). There was a trend toward significantly higher maximum ADC in ELs after adjusting for multiple comparisons (p = 0.054). The standard deviation of T2 FLAIR (AUC 0.70), maximum ADC (AUC 0.79), and normalized maximum ADC ratio (AUC 0.75) were among histogram parameters with the highest diagnostic performance. A maximum ADC cutoff of 1274 × 10-6 mm2/s provided a 0.86 sensitivity and 0.75 specificity. CONCLUSION: In patients with contraindications to gadolinium or concerns with gadolinium brain deposition, consideration may be given to ADC and T2 FLAIR as potential noncontrast methods for the evaluation of active MS lesions.

Multicenter study demonstrates radiomic features derived from magnetic resonance perfusion images identify pseudoprogression in glioblastoma.

Pseudoprogression (PsP) is a diagnostic clinical dilemma in cancer. In this study, we retrospectively analyse glioblastoma patients, and using their dynamic susceptibility contrast and dynamic contrast-enhanced perfusion MRI images we build a classifier using radiomic features obtained from both Ktrans and rCBV maps coupled with support vector machines. We achieve an accuracy of 90.82% (area under the curve (AUC) = 89.10%, sensitivity = 91.36%, 67 specificity = 88.24%, p = 0.017) in differentiating between pseudoprogression (PsP) and progressive disease (PD). The diagnostic performances of the models built using radiomic features from Ktrans and rCBV separately were equally high (Ktrans: AUC = 94%, 69 p = 0.012; rCBV: AUC = 89.8%, p = 0.004). Thus, this MR perfusion-based radiomic model demonstrates high accuracy, sensitivity and specificity in discriminating PsP from PD, thus provides a reliable alternative for noninvasive identification of PsP versus PD at the time of clinical/radiologic question. This study also illustrates the successful application of radiomic analysis as an advanced processing step on different MR perfusion maps.

Primary central nervous system lymphoma in patients with and without HIV infection: a multicenter study and comparison with U.S national data.

PURPOSE: Primary central nervous system lymphoma (PCNSL) in patients living with HIV (PLWH) is a distinct entity; however, the management is adopted from patients without HIV. The study aims to examine the differences in presentation, treatment, and outcomes of PCNSL patients with or without HIV. METHODS: We retrospectively compared the characteristics of 144 patients with PCNSL with and without HIV, and analyzed factors associated with overall and progression-free survival. Results were compared to the Central Brain Tumor Registry of the United States (CBTRUS) and the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) system. RESULTS: Among all patients with PCNSL, 19% had HIV. PLWH were younger (38 vs. 63 years; p < 0.01) and more likely to be African American (59% vs. 7%; p < 0.01) and male (74% vs. 49%; p = 0.02) than patients without HIV. PLWH were more likely to have multiple lesions (67% vs. 43%; p = 0.02), hemorrhage (59 vs. 37%; p = 0.03), and peripheral rim enhancement (57% vs. 7%; p < 0.01) on imaging; to receive palliative care (15% vs. 2%) or whole brain radiation (63% vs. 3%); and less likely to receive chemotherapy (22% vs. 95%) (p < 0.01). Twenty-four patients, none PLWH, underwent stem cell transplant. Not receiving transplant was an independent factor in mortality and disease progression. Our cohort of patients, compared to the national database, were younger (60 vs. 65 years), 58% were white vs. 75%, and had longer median overall survival 43 vs. 25 months. CONCLUSION: Epidemiology, imaging, and treatment options for patients with PCNSL with and without HIV differ, but HIV was not an independent factor of mortality or disease progression. More efforts are needed to improve access to research and treatment options for PLWH with PCNSL.

Imágenes de adenomas paratiroideos ectópicos. Una revisión de la literatura / Imaging Ectopic Parathyroid Adenomas. A Literature Review

Objetivos: 1) Revisar la anatomía y epidemiología de los adenomas paratiroideos ectópicos (APE); 2) resumir el papel de las modalidades de imagen relevantes en su localización; y 3) revisar brevemente los enfoques quirúrgicos para los mismos. Métodos: Reseña literaria de artículos publicados en inglés desde 1984 hasta agosto de 2017. Resultados: El resumen de la literatura indica que la prevalencia de APE es de, aproximadamente, el 20 % en pacientes con hiperparatiroidismo primario que no han sido intervenidos quirúrgicamente, pero en pacientes reintervenidos es tan alta que alcanza el 66 %. Los APE pueden estar localizados en cualquier lugar, desde la bifurcación de la carótida hasta la ventana aortopulmonar. El ultrasonido tiene una agudeza diagnóstica limitada en su identificación, excepto para los que están localizados cerca de la glándula tiroides y al ligamento tirotímico. Requiere gran experiencia del operador. Si se comparan las técnicas de gammagrafía Sestamibi- 99mTc de fase dual, la imagen híbrida con tomografía computarizada de emisión de fotón simple (SPECT) y con tomografía computarizada (TC), la técnica SPECT/TC es superior a la gammagrafía planar o SPECT en la localización de los APE. La TC en cuatro dimensiones (4DTC) delinea con precisión las relaciones anatómicas importantes y es altamente sensible para la localización de los APE. Aunque la 4DTC requiere radiación, medio de contraste intravenoso yodado y experiencia del lector, provee buena información para detectar lesiones en varios sitios ectópicos y guiar el abordaje quirúrgico. Los APE frecuentemente requieren enfoques quirúrgicos alternativos. Se puede intentar una nueva paratiroidectomía en pacientes que han sido previamente sometidos a una exploración bilateral del cuello, por un cirujano experimentado, una vez que la lesión se localice mediante dos modalidades de imágenes. La remoción de la enfermedad no localizada requiere una exploración cuidadosa y sistemática de las localizaciones superiores e inferiores de las glándulas. Conclusión: Los APE plantean desafíos tanto para su localización como para la extirpación quirúrgica. Con el fin de obtener resultados óptimos se requiere contar con la experiencia de un alto número de pacientes y una atención multidisciplinaria.

Objective: (1) To review the anatomy and epidemiology of ectopic parathyroid adenomas (EPAs), (2) summarize the role of relevant imaging modalities in the localization of EPAs, and (3) briefly review surgical approaches for EPAs. Methods: Literature review of published English-language articles from 1984 through August 2017. Results: Summary of the literature indicates that the prevalence of EPA is approximately 20% in unexplored patients with primary hyperparathyroidism, but it is as high as 66% in re-operative patients. EPAs may be located anywhere from the carotid bifurcation to the aortopulmonary window. Ultrasound has limited accuracy in identifying EPAs except near the thyroid and thyrothymic ligament and requires expert experience from the user. Among dual-phase 99mTc sestamibi scintigraphy techniques, hybrid imaging with both singlephoton emission computed tomography (SPECT) and computed tomography (CT), (SPECT/CT) is superior to planar scintigraphy or SPECT alone at localizing EPAs. Four-dimensional computed tomography (4DCT) precisely delineates important anatomic relationships and is highly sensitive in localizing EPAs. Although 4DCT requires radiation, intravenous iodinated contrast, and reader experience, it is well-equipped to detect lesions at various ectopic sites and guide the surgical approach. EPAs frequently require alternative surgical approaches. Re-operative parathyroidectomy may be attempted in patients having previously undergone bilateral neck exploration by an experienced surgeon once the lesion is colocalized by 2 repeat imaging modalities. Removal of nonlocalized disease requires a careful and systematic exploration of superior and inferior gland locations. Conclusion: EPAs pose challenges during both localization and surgical removal. High-volume experience and multidisciplinary care are necessary for optimal outcomes.

IMAGING LOCALIZATION AND SURGICAL APPROACH IN THE MANAGEMENT OF ECTOPIC PARATHYROID ADENOMAS.

OBJECTIVE: ( 1) Review the anatomy and epidemiology of ectopic parathyroid adenomas (EPAs), ( 2) summarize the role of relevant imaging modalities in the localization of EPAs, and ( 3) characterize surgical approaches for various ectopic locations. METHODS: Literature review of published English-language articles from 1995 through August 2017. RESULTS: Summary of the literature indicates that the prevalence of EPA is approximately 20% in unexplored patients with primary hyperparathyroidism, but it is as high as 66% in re-operative patients. EPAs may be located anywhere from the carotid bifurcation to the aorto-pulmonary window. Ultrasound has limited accuracy in identifying EPAs except near the thyroid and thyrothymic ligament and requires expert experience from the user. Among dual-phase 99mTc sestamibi scintigraphy techniques, hybrid imaging with both single-photon emission computed tomography (SPECT) and computed tomography (CT) (SPECT/CT) is superior to planar scintigraphy or SPECT alone at localizing EPAs. Four-dimensional computed tomography (4DCT) precisely delineates important anatomic relationships and is highly sensitive in localizing EPAs. Although 4DCT requires radiation, intravenous iodinated contrast, and reader experience, it is well-equipped to detect lesions at various ectopic sites and guide the surgical approach. EPAs frequently require alternative surgical approaches. Re-operative parathyroidectomy may be attempted in patients having previously undergone bilateral neck exploration by an experienced surgeon once the lesion is colocalized by 2 repeat imaging modalities. Removal of nonlocalized disease requires a careful and systematic exploration of superior and inferior gland locations. CONCLUSION: EPAs pose challenges during both localization and surgical removal. High-volume experience and multidisciplinary care are necessary for optimal outcomes. ABBREVIATIONS: CT = computed tomography; 4DCT = 4-dimensional CT; EPA = ectopic parathyroid adenoma; EPG = ectopic parathyroid gland; PHPT = primary hyperparathyroidism; RLN = recurrent laryngeal nerve; SPECT = single-photon emission computed tomography; TE = tracheo-esophageal.

Extrahepatic biliary cancer: New staging classification.

Tumor staging defines the point in the natural history of the malignancy when the diagnosis is made. The most common staging system for cancer is the tumor, node, metastases classification. Staging of cancers provides useful parameters in the determination of the extent of disease and prognosis. Cholangiocarcinoma are rare and refers to cancers that arise from the biliary epithelium. These tumors can occur anywhere along the biliary tree. These tumors have been previously divided into extrahepatic and intrahepatic lesions. Until recently the extrahepatic bile duct tumors have been considered as a single entity per American Joint Commission on Cancer (AJCC) staging classification. The most recent changes to the AJCC classification of bile duct cancers divide the tumors into two major categories: proximal and distal tumors. This practical classification is based on anatomy and surgical management. High quality cross-sectional computed tomography (CT) and/or magnetic resonance (MR) imaging of the abdomen are essential information to accurately stage this tumors. Imaging plays an important role in diagnosis, localization, staging and optimal management of cholangiocarcinoma. For example, it helps to localize the tumor to either perihilar or distal bile duct, both of which have different management. Further, it helps to accurately stage the disease and identify the presence of significant nodal and distant metastasis, which may preclude surgery. Also, it helps to identify the extent of local invasion, which has a major impact on the management. For example, extensive involvement of hepatic duct reaching up to second-order biliary radicals or major vascular encasement of portal vein or hepatic arteries precludes curative surgery and patient may be managed by palliative therapy. Further, imaging helps to identify any anatomical variations in the hepatic arterial or venous circulation and biliary ductal system, which is vital information for surgical planning. This review presents relevant clinical presentation and imaging acquisition and presentation for the accurate staging classification of bile duct tumors based on the new AJCC criteria. This will be performed with the assistance of anatomical diagrams and representative CT and MR images. The image interpretation must include all relevant imaging information for optimum staging. Detailed recommendations on the items required on the radiology report will be presented.

Síndrome de encefalopatía posterior reversible (PRES) / Syndrome of posterior reversible encephalopathy

El síndrome de encefalopatía reversible posterior (PRES, por sus sigla en inglés, derivadas de posterior reversible encephalopathy syndrome) es un síndrome clínico compuesto por cefalea, alteraciones visuales y convulsiones, usualmente en pacientes con elevación súbita de la presión arterial. Los hallazgos imagenológicos son los de edema cerebral vasogénico reversible sin infarto. Su localizacion es predominantemente posterior; afecta la corteza y la sustancia blanca subcortical de los lóbulos occipitales, parietales y temporales posteriores. El tratamiento con antihipertensivos y la remoción de medicación inmunosupresora generalmente se asocia con recuperación neurológica completa, que también se refleja en las imágenes, las cuales vuelven a su condición basal. La hipertensión no tratada, por otro lado, resulta en falla progresiva del sistema de autorregulación cerebral del sistema nervioso central con hemorragia intracraneal, infarto cerebral irreversible, coma y muerte.

Endovascular treatment of high-flow carotid cavernous fistulas by stent-assisted coil placement.

BACKGROUND AND PURPOSE: Endovascular techniques are the methods of choice for the treatment of patients with carotid cavernous fistulas. We report our experience using stent-assisted coil placement for treatment of patients with high-flow fistulas that are associated with severe laceration of the internal carotid artery. METHODS: In a retrospective review of an internal endovascular therapy database covering the interval between October 2001 and October 2003, we identified a total of 5 patients presenting with 6 high-flow type A carotid cavernous fistulas (one had a bilateral fistula) that were associated with severe laceration of the internal carotid artery. All were treated first with stenting of the injured segment of the internal carotid artery followed by transarterial (3/6) and/or transvenous (4/6) obliteration of the fistula with detachable platinum coils. In 2 cases, a liquid adhesive was also used. In all instances, a compliant balloon was inflated within the stented arterial segment during coil deposition to avoid extension of coils into the parent artery. RESULTS: All 6 fistulas were obliterated, and each internal carotid artery was successfully reconstructed. Except for posttraumatic cranial nerve dysfunction in 1 patient, clinical outcome was very good. Follow-up angiograms in 3 of the 6 patients obtained at intervals between 3 and 6 months (mean, 4.5 months) revealed no fistula recurrence and no evidence of intimal hyperplasia within the stent. CONCLUSION: In this series of patients with high-flow carotid cavernous fistula associated with severe injury to the internal carotid artery, stent-assisted coil placement offered a safe and effective treatment. Stent-assisted coil placement may increase the ability to successfully treat fistulas with severe injury to the internal carotid artery with preservation of the parent artery.

Lumps and bumps on the head in children: use of CT and MR imaging in solving the clinical diagnostic dilemma.

Lumps and bumps of the scalp are a common presenting complaint in children and often pose a diagnostic dilemma. These lesions can be difficult to image, with evaluation confounded by their small size. However, accuracy in diagnosis is critical because the diagnostic and therapeutic implications can vary significantly. The clinical examination can be helpful in developing the differential diagnosis and the imaging strategy. Often, however, a single imaging study is insufficient, and the radiologist finds it necessary to image with more than one modality to correctly diagnose a lesion and provide adequate information for the surgeon. Radiography and ultrasonography are often the initial screening diagnostic tests, followed by magnetic resonance (MR) imaging or computed tomography (CT) for more detail. Multidetector thin-section CT and thin-section MR imaging with surface coils are beneficial in the work-up of these small lesions of the head and neck. The use of newer MR imaging sequences such as heavily T2-weighted single-shot turbo spin-echo imaging and diffusion-weighted imaging can improve the characterization of difficult lesions. Familiarity with the variety of new imaging tools and techniques that are available can help characterize pediatric head and neck lesions and guide clinical management.

Relación entre los niveles de adenosina deaminasa y desarrollo de engrosamiento pleural residual en tuberculosis pleural

Introducción: el engrosamiento pleural residual (EPR) es frecuente en tuberculosis pleural (TBCP) y no es claro si puede pronosticarse con la toracentesis inicial. Objetivo: evaluar la relación entre los índices de inflación y la activación linfocitaria pleural especialmente la adenosina deaminasa (ADA) y el desarrollo de EPR en TBCP. Tipo de estudio: observacional analítico de cohorte prospectiva. Lugar de estudio: programa de tuberculosis en el hospital de referencia. Material y métodos: pacientes con diagnóstico de TBCP a quienes se les realizó toracentesis incluyendo determinación de ADA y fueron tratados y controlados sin recibir glucocorticoides. Se definió EPR con métodos radiológicos. Los datos se recolectaron en forma prospectiva. La relación entre predictores y EPR se evaluó con prueba no paranétrica con una p<0,01 de significativa. Resultados: durante 48 meses, 57 pacientes cumplieron los criterios de inclusión; el diagnóstico se realizó en 84 por ciento con biopsia pleural. Se desarrolló EPR en 33 pacientes (58 por ciento) y no hubo EPR en 24 (42 por ciento). Los valores de LDH, proteínas, porcentaje de linfocitos y concentración de glucosa fueron similares en ambos grupos. La concentración de ADA fue similar (grupo con EPR:97 más menos 48; grupo sin EPR: 106 más menos 45; p=0,48, Mann-Whitney) en los dos grupos y no se encontró un punto de corte con apropiada discriminación para pronosticar EPR. Conclusión: en este grupo de pacientes ningún hallazgo de la toracentesis inicial se relacionó con el desarrollo de EPR. Los resultados son similares a los informados por otros investigadores, pero es la primera vez que se describen para el nivel de ADA pleural