Adnexal Lesion Imaging: Past, Present, and Future.

Currently, imaging is part of the standard of care for patients with adnexal lesions prior to definitive management. Imaging can identify a physiologic finding or classic benign lesion that can be followed up conservatively. When one of these entities is not present, imaging is used to determine the probability of ovarian cancer prior to surgical consultation. Since the inclusion of imaging in the evaluation of adnexal lesions in the 1970s, the rate of surgery for benign lesions has decreased. More recently, data-driven Ovarian-Adnexal Reporting and Data System (O-RADS) scoring systems for US and MRI with standardized lexicons have been developed to allow for assignment of a cancer risk score, with the goal of further decreasing unnecessary interventions while expediting the care of patients with ovarian cancer. US is used as the initial modality for the assessment of adnexal lesions, while MRI is used when there is a clinical need for increased specificity and positive predictive value for the diagnosis of cancer. This article will review how the treatment of adnexal lesions has changed due to imaging over the decades; the current data supporting the use of US, CT, and MRI to determine the likelihood of cancer; and future directions of adnexal imaging for the early detection of ovarian cancer.

Imaging of Small-Bowel Neuroendocrine Neoplasms: AJR Expert Panel Narrative Review.

Neuroendocrine neoplasms (NENs) of the small bowel are typically slow-growing lesions that remain asymptomatic until reaching an advanced stage. Imaging modalities for lesion detection, staging, and follow-up in patients with known or suspected NEN include CT enterography, MR enterography, and PET/CT using a somatostatin receptor analog. FDG PET/CT may have a role in the evaluation of poorly differentiated NENs. Liver MRI, ideally with a hepatocyte-specific contrast agent, should be used in the evaluation of hepatic metastases. Imaging informs decisions regarding both surgical approaches and systematic therapy (specifically, peptide receptor radionuclide therapy). This AJR Expert Panel Narrative Review describes the multimodality imaging features of small-bowel NENs; explores the optimal imaging modalities for their diagnosis, staging, and follow-up; and discusses how imaging may be used to guide therapy.

Ovarian Cancer Detection in Average-Risk Women: Classic- versus Nonclassic-appearing Adnexal Lesions at US.

Background Several US risk stratification schemas for assessing adnexal lesions exist. These multiple-subcategory systems may be more multifaceted than necessary for isolated adnexal lesions in average-risk women. Purpose To explore whether a US-based classification scheme of classic versus nonclassic appearance can be used to help appropriately triage women at average risk of ovarian cancer without compromising diagnostic performance. Materials and Methods This retrospective multicenter study included isolated ovarian lesions identified at pelvic US performed between January 2011 and June 2014, reviewed between September 2019 and September 2020. Lesions were considered isolated in the absence of ascites or peritoneal implants. Lesions were classified as classic or nonclassic based on sonographic appearance. Classic lesions included simple cysts, hemorrhagic cysts, endometriomas, and dermoids. Otherwise, lesions were considered nonclassic. Outcomes based on histopathologic results or clinical or imaging follow-up were recorded. Diagnostic performance and frequency of malignancy were calculated. Frequency of malignancy between age groups was compared using the χ2 test, and Poisson regression was used to explore relationships between imaging features and malignancy. Results A total of 970 isolated lesions in 878 women (mean age, 42 years ± 14 [SD]) were included. The malignancy rate for classic lesions was less than 1%. Of 970 lesions, 53 (6%) were malignant. The malignancy rate for nonclassic lesions was 32% (33 of 103) when blood flow was present and 8% (16 of 194) without blood flow (P < .001). For women older than 60 years, the malignancy rate was 50% (10 of 20 lesions) when blood flow was present and 13% (five of 38) without blood flow (P = .004). The sensitivity, specificity, positive predictive value, and negative predictive value of the classic-versus-nonclassic schema was 93% (49 of 53 lesions), 73% (669 of 917 lesions), 17% (49 of 297 lesions), and 99% (669 of 673 lesions), respectively, for detection of malignancy. Conclusion Using a US classification schema of classic- or nonclassic-appearing adnexal lesions resulted in high sensitivity and specificity in the diagnosis of malignancy in ovarian cancer. The highest risk of cancer was in isolated nonclassic lesions with blood flow in women older than 60 years. © RSNA, 2022 See also the editorial by Baumgarten in this issue.

Transarterial Yttrium-90 Radioembolization for Unresectable Intrahepatic Cholangiocarcinoma: A Systematic Review and Meta-Analysis.

PURPOSE: To investigate the overall efficacy and survival profile of yttrium-90 (90Y) radioembolization for unresectable intrahepatic cholangiocarcinoma (ICC). MATERIALS AND METHODS: A systematic literature review and meta-analysis was completed using a random-effects model. Studies describing the use of 90Y for unresectable ICC were included. The disease control rate (DCR), downstaged-to-resectable rate, cancer antigen 19-9 (CA19-9) response rate, pooled median overall survival (OS), pooled median progression-free survival (PFS), and mean reported survival rates ranging from 3 to 36 months were evaluated. RESULTS: Twenty-one studies detailing a total of 921 patients were included. The overall DCR was 82.3% (95% confidence interval [CI], 76.7%-87.8%; I2 = 81%). In 11% of the cases, patients were downstaged to being surgically resectable (95% CI, 6.1%-15.9%; I2 = 78%). The CA19-9 response rate was 67.2% (95% CI, 54.5%-79.8%; I2 = 60%). From the time of radioembolization, PFS was 7.8 months (95% CI, 4.2-11.3 months; I2 = 94%) and median OS was 12.7 months (95% CI, 10.6-14.8 months; I2 = 62%). Lastly, the mean overall reported survival proportions were 84% at 3 months (standard deviation [SD], 10%), 69% at 6 months (SD, 16%), 47% at 12 months (SD, 19%), 31% at 18 months (SD, 21%), 30% at 24 months (SD, 19%), 21% at 30 months (SD, 27%), and 5% at 36 months (SD, 7%). CONCLUSIONS: Radioembolization with 90Y for unresectable ICC results in substantial downstaging, disease control, and survival.

Do Not Get It Twisted: Common and Uncommon Manifestations of Testicular Torsion.

Color flow and spectral Doppler ultrasound are the backbone of scrotal imaging when evaluating acute scrotal pain. Testicular Torsion is one of the most common causes of acute scrotal pain but can be a challenging diagnosis both clinically and sonographically. This article will review the pertinent Doppler ultrasound findings that can help make the diagnosis of both complete and partial torsion. A review of other causes of testicular ischemia will also be included as these pathologies can mimic Testicular Torsion.

Multimodality Imaging of Ileal Neuroendocrine (Carcinoid) Tumor.

OBJECTIVE. The purpose of this article is to provide a multimodality imaging review of ileal carcinoid tumor. CONCLUSION. Ileal carcinoid tumors display a variety of radiologic findings. Delay in diagnosis is common because of initial nonspecific symptoms and subtle imaging findings. Reviewing the multimodality imaging appearance of the primary tumor, metastatic disease, and associated ancillary findings can help improve patient care.

Penile Evaluation: An Illustrated Review.

ABSTRACT: High-frequency ultrasound is the imaging modality of choice for evaluating penile pathology because of its easy access, low cost, and patient tolerance ( The Penis, Diagnostic Ultrasound, second edtion . Boca Raton: CRC Press; 2007:957-978). This pictorial review will illustrate the sonographic features of emergent and nonemergent penile conditions such as penile fracture, spongial tear, urethral injury, various types of priapism, erectile dysfunction, penile abscess, and Mondor disease.

Thyroid cancer in pregnancy: diagnosis, management, and treatment.

The evaluation and management of cancer during pregnancy requires special care to assure the health and safety of both the mother and fetus. The diagnosis and treatment of thyroid cancer in the non-pregnant patient often involves radioactive iodine exposure. However, radioactive iodine is contraindicated in pregnancy and surgical interventions pose risks to both the mother and fetus. Thus, the management of thyroid cancer during pregnancy is a unique clinical challenge. In this review, we discuss the imaging of thyroid nodules during pregnancy, including the role of CT, MRI, and nuclear Imaging, as well as that of Ultrasound and FNA. The staging and prognosis are discussed along with the management, treatment, and surveillance of thyroid cancer in pregnancy. Finally, the risks to the fetus through treatment are examined. Case examples are provided with an emphasis on the appropriate direction of care from a radiologist's perspective.

Prostate Cancer-PET Imaging Update.

Prostate cancer is the most common non-dermatologic cancer in men, and one of the leading causes of cancer-related mortality. The incidence of prostate cancer increases precipitously after the age of 65 and demonstrates variable aggressiveness, depending on its grade and stage at diagnosis. Despite recent advancements in prostate cancer treatment, recurrence is seen in 25% of patients. Advancements in prostate cancer Positron Emission Tomography (PET) molecular imaging and recent United States Food and Drug Administration (FDA) approvals have led to several new options for evaluating prostate cancer. This manuscript will review the commonly used molecular imaging agents, with an emphasis on Fluorine-18 fluciclovine (Axumin) and PSMA-ligand agents, including their protocols, imaging interpretation, and pitfalls.

Thoracic Outlet Syndrome-An Uncommon Cause of Acute Upper-Limb Ischemia.

ABSTRACT: Acute upper-limb ischemia is usually secondary to thromboembolic occlusion. The heart is the usual source of emboli in the majority of patients. In a small percentage of cases, the thromboembolic process may start in a proximal large-sized artery, such as the subclavian artery, resulting in thromboembolic occlusion of the upper extremity's small peripheral arteries. In patients with acute upper-limb ischemia, a systematic color flow Doppler ultrasound of the upper extremity arteries may reveal thoracic outlet syndrome as the underlying cause. This pictorial review presents a systemic color flow Doppler approach to evaluate upper extremity arteries in patients with thoracic outlet syndrome presenting as acute ischemia.

Multimodality imaging of renal lymphoma and its mimics.

Lymphomatous involvement of the genitourinary system, particularly the kidneys, is commonly detected on autopsies; yet on conventional diagnostic imaging renal lymphoma is significantly underestimated and underreported, in part due to its variable imaging appearance and overlapping features with other conditions. We present a spectrum of typical and atypical appearances of renal lymphoma using multimodality imaging, while reviewing the roles of imaging in the detection, diagnosis, staging, and surveillance of patients with lymphoma. We also illustrate a breadth of benign and malignant entities with similar imaging features confounding the diagnosis of renal lymphoma, emphasizing the role of percutaneous image-guided biopsy. Understanding the spectrum of appearances of renal lymphoma and recognizing the overlapping entities will help radiologists improve diagnostic confidence and accuracy.

Small bowel neuroendocrine neoplasm: what surgeons want to know.

Neuroendocrine neoplasms of the small bowel are a diverse group of tumors with a broad spectrum of imaging findings and clinical implications. Most tumors originate in close proximity to the ileocecal valve and most commonly metastasize to the mesentery and liver. This review will highlight the imaging findings of primary and metastatic small bowel neuroendocrine neoplasm that are most relevant to the surgical team.

Diagnostic Performance of the Ovarian-Adnexal Reporting and Data System (O-RADS) Ultrasound Risk Score in Women in the United States.

Importance: The American College of Radiology (ACR) Ovarian-Adnexal Reporting and Data System (O-RADS) ultrasound (US) risk scoring system has been studied in a selected population of women referred for suspected or known adnexal lesions. This population has a higher frequency of malignant neoplasms than women presenting to radiology departments for pelvic ultrasonography for a variety of indications, potentially impacting the diagnostic performance of the risk scoring system. Objective: To evaluate the risk of malignant neoplasm and diagnostic performance of O-RADS US risk scoring system in a multi-institutional, nonselected cohort. Design, Setting, and Participants: This multi-institutional cohort study included a population of nonselected women in the United States who presented to radiology departments for routine pelvic ultrasonography between 2011 and 2014, with pathology confirmation imaging follow up or 2 years of clinical follow up. Exposure: Analysis of 1014 adnexal lesions using the O-RADS US risk stratification system. Main Outcomes and Measures: Frequency of ovarian cancer and diagnostic performance of the O-RADS US risk stratification system. Results: This study included 913 women with 1014 adnexal lesions. The mean (SD) age of the patients was 42.4 (13.9 years), and 674 of 913 (73.8%) were premenopausal. The overall frequency of malignant neoplasm was 8.4% (85 of 1014 adnexal lesions). The frequency of malignant neoplasm for O-RADS US 2 was 0.5% (3 of 657 lesions; <1% expected); O-RADS US 3, 4.5% (5 of 112 lesions; <10% expected); O-RADS US 4, 11.6% (18 of 155; 10%-50% expected); and O-RADS 5, 65.6% (59 of 90 lesions; >50% expected). O-RADS US 4 was the optimum cutoff for diagnosing cancer with sensitivity of 90.6% (95% CI, 82.3%-95.9%), specificity of 81.9% (95% CI, 79.3%-84.3%), positive predictive value of 31.4% (95% CI, 25.7%-37.7%) and negative predictive value of 99.0% (95% CI, 98.0%-99.6%). Conclusions and Relevance: In this cohort study of a nonselected patient population, the O-RADS US risk stratification system performed within the expected range as published by the ACR O-RADS US committee. The frequency of malignant neoplasm was at the lower end of the published range, partially because of the lower prevalence of cancer in a nonselected population. However, a high negative predictive value was maintained, and when a lesion can be classified as an O-RADS US 2, the risk of cancer is low, which is reassuring for both clinician and patient.

Role of color flow Doppler ultrasound in the evaluation of acute scrotal pain.

Color flow Doppler ultrasound is a critical tool in the assessment of the scrotum. Ultrasound is the first-line imaging modality and can rapidly differentiate between surgical and nonsurgical conditions, allowing for appropriate and prompt patient management. We review the role of color flow Doppler in the evaluation of acute scrotal pain, highlighting some of the most commonly seen pathologies such as epididymo-orchitis and testicular torsion.

The utility of retrograde pyelography to follow up incompletely opacified ureters on CT urography.

PURPOSE: Retrograde pyelography (RPG) is used in some centers to further evaluate patients with incompletely opacified segments on CT urography (CTU). This study intends to evaluate the utility of this imaging combination in terms of the yield of abnormal findings on the follow up RPG. METHODS: In this retrospective study, we searched the radiology database over a three-year period (11/1/2015-10/30/2018) for patients who had a CTU and then a diagnostic RPG within 180 days. Images and reports were reviewed from this period for patients who met the inclusion criteria. RESULTS: 292 patients underwent a CTU with follow up RPG over the search period. 131/292 RPGs (44.9%) were performed because the CTU described at least one incompletely opacified ureteral segment. Of the 148 ureters evaluated in these 131 patients, 4 ureters (2.7%) showed an abnormality on follow up retrograde pyelogram-two revealed a stricture at the unfilled segment, and two revealed contour irregularity in the distal ureter (biopsy showed urothelial cell carcinoma in these two). CONCLUSION: There is a relatively low yield for detecting ureteral abnormalities when a retrograde pyelogram is performed after a CTU to evaluate an incompletely opacified ureteral segment-2.7% in our study, with only two of these incompletely opacified segments containing urothelial cancer (1.4%). In these two cases, a ureteral abnormality was visible on the CTU and RPG would seem to have a very low yield for follow up of unopacified ureteral segments if the ureters are otherwise normal-appearing on CTU and there is no hydronephrosis.

Ultrasound Findings of Benign Scrotal Lesions: A Pictorial Review.

Ultrasound is an essential tool in evaluating the underlying etiology of scrotal lesions, which range from traumatic, infectious, inflammatory, congenital, and neoplastic conditions. Understanding the sonographic characteristics of benign scrotal masses is essential for a radiologist to determine whether conservative management is appropriate or if more aggressive follow-up or treatment is necessary. While surgical intervention may sometimes be necessary, combining the clinical presentation and imaging appearance can sometimes lead to a confident radiologic diagnosis that spares the patient from surgery. Examples of benign scrotal lesions and their ultrasound appearance are illustrated in this review.

CT detection of primary and metastatic ileal carcinoid tumor: rates of missed findings and associated delay in clinical diagnosis.

PURPOSE: To determine the rate of missed CT findings of ileal carcinoid tumor prior to pathologic diagnosis and the resultant diagnostic delay. METHODS: Initially, 74 patients with abdominal and pelvic CT prior to pathologically-proven diagnosis of ileal carcinoid were identified. Patients were excluded when the original CT study (n = 6) or report (n = 4) was not available, resulting in a final cohort of 64 patients (mean age, 58.3 years; 29 M/35F); 27 (42%) patients had more than one abdominal CT prior to diagnosis. All available CT studies prior to diagnosis were retrospectively reviewed for the presence of the primary ileal tumor and metastatic disease (mesenteric and hepatic). RESULTS: Primary ileal tumors were prospectively missed on at least one CT scan in 64% (32/50) of patients with retrospectively identifiable disease. CT findings of mesenteric spread were missed at least once in 46% (25/54) of cases where present in retrospect. By the final pre-operative CT, hepatic metastases and bowel wall thickening were present in 55% (35/64) and 52% (33/64) of cases, respectively. In patients with missed ileal and/or mesenteric findings resulting in diagnostic delay, mean delay was 40 months (range 4-98 months). CONCLUSION: Initial presentation of ileal carcinoid tumor, even with mesenteric involvement, is often missed prospectively at abdominal CT, leading to delay in diagnosis until bowel or mesenteric findings become more obvious, or hepatic metastatic disease manifests. Radiologists should make a concerted effort to evaluate the bowel and mesentery in patients with long-standing vague abdominal symptoms.

Risk of Pulmonary Embolism in Patients With Isolated Great Saphenous Vein Thrombus.

Risks associated with isolated great saphenous vein (GSV) thrombosis remain controversial. The purpose of this study is to identify the risk of pulmonary embolism (PE) in patients with isolated GSV thrombosis, particularly those with thrombus within 3 cm of the sapheno-femoral junction. A retrospective chart review of color flow Doppler lower extremity venous ultrasound examinations from an academic hospital from 2011 to 2016 was conducted. Seventy-eight patients were identified as having acute thrombus in their GSV and were then further stratified based on the presence or absence of concomitant deep venous thrombosis (DVT). A control group of 49 patients who presented with leg swelling and were found to have a normal color flow Doppler examination was also identified. Patients without thrombus (n = 49), patients with isolated GSV thrombus (n = 29), and patients with GSV thrombus with concomitant DVT (n = 49) underwent full chart review to determine whether any patients developed PE. This was diagnosed specifically by computed tomography angiogram or ventilation/perfusion scan, within 60 days of initial diagnosis of lower extremity thrombus. In our analysis, there was no significant difference in the risk of PE in patients with isolated GSV thrombus compared with a control group of normal patients (3.5% vs 2.0%, P = 0.38). However, patients with GSV thrombus and concomitant DVT had a significantly increased risk of PE compared with patients with isolated GSV thrombus (26.5% vs 3.5%, P = 0.01). We found that the risk of PE in patients with isolated GSV thrombus is not significantly increased compared with a normal cohort.