CT and MR Enterography in the Evaluation of Celiac Disease.

Celiac disease is a common inflammatory disease of the small bowel that induces mucosal intestinal lesions. The disease is mediated by an immune response and triggered by the ingestion of gluten in genetically predisposed individuals. Gluten contains gliadin, a component found mostly in wheat, barley, and rye. This process leads to gastrointestinal malabsorption with symptoms such as diarrhea, constipation, abdominal pain, and distention. It has a prevalence of 1%-2% in the general adult population, who present with symptoms at any age, but is more frequently found in adult women in the 3rd or 4th decade of life. Recognition of the disease has increased, but it remains a challenge to diagnose. CT and MR enterography are noninvasive studies used for evaluation of small bowel neoplasms and inflammatory small bowel pathologic conditions such as celiac disease. The authors review the spectrum of intestinal and extraintestinal findings of celiac disease at CT and MR enterography, as well as its complications, and the importance of recognizing certain imaging features that help in the diagnosis of celiac disease. More common and specific findings of celiac disease such as inversion of the jejunoileal fold pattern and mesenteric lymphadenopathy are reviewed. More uncommon entities that are more frequently associated with refractory or untreated celiac disease, such as ulcerative jejunoileitis, cavitary mesenteric lymph node syndrome, and malignancies including small bowel adenocarcinoma and lymphoma, are described. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material. The slide presentation from the RSNA Annual Meeting is available for this article.

Radiomics and Machine Learning for prediction of two-year disease-specific mortality and KRAS mutation status in metastatic colorectal cancer.

PURPOSE: Colorectal cancer is usually accompanied by liver metastases. The prediction of patient evolution is essential for the choice of the appropriate therapy. The aim of this study is to develop and evaluate machine learning models to predict KRAS gene mutations and 2-year disease-specific mortality from medical images. METHODS: Clinical and follow-up information was collected from patients with metastatic colorectal cancer who had undergone computed tomography prior to liver resection. The dominant liver lesion was segmented in each scan and radiomic features were extracted from the volumes of interest. The 65% of the cases were employed to perform feature selection and to train machine learning algorithms through cross-validation. The best performing models were assembled and evaluated in the remaining cases of the cohort. RESULTS: For the mortality model development, 101 cases were used as training set (64 alive, 37 deceased) and 35 as test set (22 alive, 13 deceased); while for KRAS mutation models, 55 cases were used for training (31 wild-type, 24 mutated) and 30 for testing (17 wild-type, 13 mutated). The ensemble of top performing models resulted in an area under the receiver operating characteristic curve of 0.878 for mortality and 0.905 for KRAS prediction. CONCLUSIONS: Predicting the prognosis of patients with metastatic colorectal cancer is useful for making timely decisions about the best treatment options. This study presents a noninvasive method based on quantitative analysis of baseline images to identify factors influencing patient outcomes, with the aim of incorporating these tools as support systems.

Tomografía computada y resonancia magnética en la patología de la vesícula biliar: más allá de la litiasis / Computed tomography and magnetic resonance in gallbladder patology: beyond lithiasis

Resumen La enfermedad de la vesícula biliar es una causa común de dolor abdominal. Si bien por lo general el dolor es secundario a la presencia de litiasis y colecistitis aguda, el espectro de la enfermedad es amplio e incluye anomalías congénitas, otros procesos inflamatorios y neoplasias. La tomografía computada (TC) y la resonancia magnética (RM) tienen un papel relevante en aquellos casos en los que la ecografía no es concluyente y en la planificación del tratamiento. Dentro de las anomalías congénitas, la forma en “gorro frigio” es la más frecuente. Los pólipos son en su mayoría lesiones benignas, siendo las características de malignidad un tamaño superior a 10 mm, solitario y sésil. La adenomiomatosis es reconocible por el engrosamiento de la pared vesicular y los componentes quísticos intramurales. Es importante reconocer el gas intramural e intraluminal en la colecistitis enfisematosa y los microabscesos y hemorragias intraluminales en la colecistitis gangrenosa debido a su alta morbilidad y mortalidad. La colecistitis xantogranulomatosa presenta nódulos intramurales que ocupan más del 60% del área de la pared engrosada y la conservación lineal del realce de la mucosa sin interrupción. El carcinoma vesicular se presenta como una lesión infiltrante que se extiende al hígado, un engrosamiento mural o una masa polipoide intraluminal.

Abstract Gallbladder disease is a common cause of abdominal pain. Although the pain is usually secondary to the presence of lithiasis and acute cholecystitis, the spectrum of the disease is broad and includes congenital anomalies, other inflammatory processes and neoplasms. Computed tomography (CT) and magnetic resonance (MRI) have a relevant role in those cases in which ultrasound is not conclusive and in treatment planning. Among the congenital anomalies, the “phrygian cap” shape is the most frequent. Polyps are mostly benign lesions, with the characteristics of malignancy being larger than 10 mm, solitary and sessile. Adenomyomatosis is recognizable by gallbladder wall thickening and intramural cystic components. It is important to recognize intramural and intraluminal gas in emphysematous cholecystitis and intraluminal microabscesses and hemorrhages in gangrenous cholecystitis because of its high morbidity and mortality. Xanthogranulomatous cholecystitis presents with intramural nodules occupying more than 60% of the thickened wall area and linear preservation of mucosal enhancement without interruption. Gallbladder carcinoma presents as an infiltrative lesion extending to the liver, a mural thickening or an intraluminal polypoid mass.

Imaging assessment after pancreaticoduodenectomy: reconstruction techniques-normal findings and complications.

Pancreaticoduodenectomy represents a major surgery for tumors located at the pancreatic head and the ampullary/periampullary region. This complex procedure is associated with a high morbidity rate. Many surgical techniques have been proposed in order to reduce mortality rates, although post-procedure complications represent a current problem. Different imaging findings and complications may appear depending on the surgical technique used. Hence, radiologists should be familiarized with them to distinguish normal findings from real complications. The most challenging scenarios are represented by abdominal fluid collections, and tumor recurrence, that may frequently mimic normal postsurgical changes.

Hydatid liver disease with portal vein invasion, cavernous transformation and portal biliopathy.

Hydatid disease is a zoonotic parasitic disease, most commonly affecting the liver, lungs and nervous system. Portal vein involvement by hydatid cyst disease is very rare with only few cases published to our knowledge. We describe a case involving a 53-year-old woman with portal vein invasion, cavernous transformation and portal biliopathy.

Bowel angioedema induced by iodinated contrast media.

We present the case of a patient with small bowel angioedema induced by iodinated contrast media during computed tomography. It is important to know this entity and to differentiate it from other intestinal diseases in order to avoid inappropriate treatment.

Anomalía de la unión biliopancreática: una entidad infrecuente en Occidente / Pancreaticobiliary maljunction: a rare entity in the West

Resumen La anomalía de la unión biliopancreática (AUBP) es una malformación congénita en la que los conductos pancreáticos y biliares se unen anatómicamente fuera de la pared duodenal. Debido a la excesiva longitud del canal común, la acción del esfínter no afecta la unión pancreatobiliar, lo que permite el reflujo del jugo pancreático hacia la vía biliar. Se asocia con quistes del colédoco y sus manifestaciones incluyen cáncer de la vía biliar, pancreatitis, coledocolitiasis y colangitis. Es una rara patología, especialmente en países occidentales. La colangiopancreatografía por resonancia magnética (CPRM) se ha convertido en el método más utilizado por no ser invasivo, teniendo en cuenta que la colangiopancreatografía retrógrada endoscópica (CPRE) se encuentra contraindicada en casos de pancreatitis aguda y colangitis, además del riesgo de pancreatitis posterior al procedimiento. La distancia entre la unión biliopancreática y la pared duodenal debe ser superior a 9 mm de longitud para diagnosticar AUBP mediante CPRM. En caso de que mida entre 6 y 9 mm y la acción del esfínter afecte la unión pancreatobiliar, se lo denomina unión biliopancreática alta (UBPA) y se debe confirmar mediante CPRE. Describimos los hallazgos en imágenes de siete pacientes jóvenes con clínica abdominal y diagnóstico de AUBP o UBPA por CPRM, y además revisamos la literatura sobre el tema.

Abstract Pancreaticobiliary maljunction (PBM) is a congenital malformation in which the pancreatic and biliary ducts are anatomically joined outside the duodenal wall. Due to the excessive length of the common channel, the action of the sphincter does not affect the pancreaticobiliary junction, allowing the reflux of pancreatic juice into the bile duct. It is associated with cysts of the common bile duct and its manifestations include cancer of the bile duct, pancreatitis, choledocholithiasis and cholangitis. It is a rare pathology, especially in Western countries. Magnetic resonance cholangiopancreatography (MRCP) has become the most used method because it is non-invasive, taking into account that endoscopic retrograde cholangiopancreatography (ERCP) is contraindicated in cases of acute pancreatitis and cholangitis, in addition to the risk of pancreatitis after the procedure. The distance between the biliopancreatic junction and the duodenal wall must be greater than 9 mm in length to diagnose PBM by MRCP. If it is between 6 to 9 mm and the action of the sphincter affects the pancreaticobiliary junction, it is called high confluence of pancreaticobiliary ducts (HCPBD) and should be confirmed by ERCP. We describe the imaging findings of 7 young patients with abdominal symptoms and diagnosis of PBM or HCPBD by MRCP, and also review the literature on the subject.

Prostatitis crónica: Aporte del contraste endovenoso en fase tardía para su caracterización en resonancia magnética multiparamétrica de próstata / Chronic Prostatitis: Contrast Contribution in Late Phase for its Characterization in Multiparametric-Magnetic Resonance Imaging of the Prostate

Resumen Objetivo: El objetivo de este estudio es demostrar la utilidad de una secuencia tardía post-contraste en la resonancia magnética multiparamétrica de próstata (RMMP) para caracterizar lesiones PI-RADS II. Materiales y métodos: Se analizaron en forma retrospectiva las RMMP realizadas entre enero de 2015 y diciembre de 2016. El protocolo de la RMMP fue basado en las recomendaciones del PI-RADS versión 2, y se agregó una adquisición tardía luego del dinámico post-contraste. Los reportes fueron revisados bajo la versión 2.1. Resultados: Se seleccionaron 31 pacientes que presentaron lesiones categorizadas como PI-RADS II en la zona periférica, los cuales se encontraban en seguimiento del antígeno prostático específico y presentaron confirmación histológica de prostatitis crónica. Se evidenció un realce tardío de la lesión en todos los pacientes. Según los resultados histopatológicos, 30 presentaban prostatitis crónica y el restante tejido benigno (tejido fibromuscular). Discusión: La prostatitis crónica no muestra realce temprano, y presenta realce tardío debido al tejido conectivo fibroso que la compone. En la RMMP, la prostatitis puede imitar el cáncer de próstata. Agregar una adquisición tardía solo adiciona 150 segundos al estudio y podría ayudar a resolver aquellos casos inciertos categorizados como PI-RADS III empleando las secuencias convencionales, debido a que el realce tardío de la lesión es altamente sugestivo de un proceso inflamatorio (PI-RADS II). Conclusión: La presencia de realce tardío es una herramienta útil para realizar un adecuado diagnóstico de una lesión PI-RADS II en la zona periférica, pudiendo evitar una biopsia innecesaria.

Abstract Objective: The aim of this study is to demonstrate the utility of a post-contrast late sequence in multiparametric magnetic resonance imaging (RMMP) to characterize PI-RADS II lesions. Materials and methods: The RMMPs performed between January 2015 and December 2016 were retrospectively analyzed. The RMMP protocol was based on the recommendations of the PI-RADS version 2, and a late acquisition was added, after the dynamic post-contrast. The reports were reviewed under the version 2.1. Results: 31 patients with PI-RADS II lesions in the peripheral zone were selected, who were in prostate specific antigen follow-up and had histological confirmation of chronic prostatitis. A late enhancement of the lesion was evidenced in all patients. According to the histopathological results, 30 had chronic prostatitis and the remaining benign tissue (fibromuscular tissue). Discussion: Chronic prostatitis does not show early enhancement, and presents late enhancement due to its fibrous connective tissue. In RMMP, prostatitis may mimic prostate cancer. Adding a late sequence only adds 150 seconds to the study and could help to resolve those uncertain cases categorized as PI-RADS III using traditional sequences because the late enhancement of the lesion is highly suggestive of an inflammatory process (PI-RADS II). Conclusion: The presence of late enhancement is a useful tool to perform an adequate diagnosis of a PI-RADS II lesion in the peripheral zone, helping to avoid an unnecessary biopsy.

Oncocitomas: hallazgos tomográficos y correlación anatomopatológica / Oncocytomas: Imaging Findings and Anatomopathology Correlation

Introducción: En imágenes, los hallazgos del oncocitoma generalmente coinciden con el carcinoma de células renales (CCR) por lo que resulta muy poco segura su discriminación mediante imágenes. Objetivos: Evaluar el comportamiento de una muestra de oncocitoma en tomografía (TC). Métodos: Se seleccionaron retrospectivamente los pacientes con cirugía de tumor renal y diagnóstico anatomopatológico de oncocitoma, que fueron tratados entre enero de 2015 y diciembre de 2017. Se incluyeron los pacientes a quienes se les realizó TC con medio de contraste endovenoso en nuestra institución. Resultados: Del total de pacientes (n = 44), 43 tenían una lesión única renal, mientras que uno tenía tres lesiones. Del total de las lesiones (n = 47), 20 (42,55 %) fueron diagnosticadas tras una nefrectomía radical y 24 (51,10 %) fueron diagnosticadas por una nefrectomía parcial. La media de diámetro máximo fue de 36,5 mm (RIQ 22-44,25), de los cuales se agruparon en menores y mayores a 4 cm; se encontraron 22 tumores en este último grupo (47 %). De estos, en 15 tumores (31,91 %) que tenían más de 4 cm se encontró la cicatriz central. Se evidenciaron calcificaciones en 3 pacientes (6,8 %). Se encontró 1 tumor (2,1 %) con inversión de realce segmentario luego de la administración medio de contraste endovenoso. En este caso, el oncocitoma era menor a 4 cm. Conclusión: El hallazgo de una masa sólida con realce más intenso que el parénquima circundante durante la fase nefrográfica obliga a considerar al oncocitoma entre los diagnósticos diferenciales

Introduction: The imaging findings of oncocytomas usually coincide with renal cell carcinoma (RCC), which makes it difficult to discriminate them in imaging. Objective: To evaluate the imaging findings of a sample of oncocytomas in tomography (CT). Methods: We retrospectively selected patients with renal tumor surgery and oncocytoma anatomopathological diagnosis, who were treated between January 2015 and December 2017. Patients who underwent CT with intravenous contrast at our institution were included. Results: Of the total number of patients (n = 44), 43 had a single renal lesion while one patient presented 3 lesions. Of the total lesions (n = 47), 20 (42.55%) were diagnosed after a radical nephrectomy and 24 (51.10%) were diagnosed by a partial nephrectomy. The mean maximum diameter was 36.5 mm (RIQ 22-44, 25), of which they were grouped by tumor length into smaller or larger than 4 cm, with 22 tumors in this last group (47%). Of these, 15 tumors (31.91 %) that were larger than 4 cm had a central scar. Calcifications were evident in 3 patients (6.8 %). One tumor (2.1%) was found with the presence of inversion of segmental enhancement after administration of intravenous contrast. In this case, the oncocytoma was less than 4 cm. Conclusion: The finding of a solid mass with more enhancement than the surrounding parenchyma during the nephrographic phase makes it necessary to consider oncocytoma among the differential diagnoses