Guided tour of hidden tracts in the pelvis: exploring pelvic fistulas.

BACKGROUND: Fistulas are an abnormal connection between two or more epithelial surfaces. When fistulization between adjacent structures occurs in the pelvis, there is almost invariably significant associated morbidity and impact on a patient's quality of life. Imaging may aid in the diagnosis of pelvic fistulas and is essential to identify any associated pathology, define the course of the fistula, and aid in pre-surgical planning. PURPOSE: This article aims to review the wide array of clinical and imaging presentations of fistulas in the pelvis, with a focus on the radiologists' role in managing this challenging entity. METHODS: This article will review each classification type of fistula. RESULTS: Pelvic fistula is a devastating condition that causes significant morbidity and evaluation can be challenging. CONCLUSIONS: Imaging, and particularly MRI, plays a vital role in the diagnosis, characterizing the course of a fistula and demonstrating associated complications, which are essential to guide treatment decisions.

Preliminary Outcome of Microwave Ablation of Hepatocellular Carcinoma: Breaking the 3-cm Barrier?

PURPOSE: To evaluate preliminary outcomes after microwave ablation (MWA) of hepatocellular carcinoma (HCC) up to 5 cm and to determine the influence of tumor size. MATERIALS AND METHODS: Electronic records were searched for HCC and MWA. Between January 2011 and September 2014, 173 HCCs up to 5 cm were treated by MWA in 129 consecutive patients (89 men, 40 women; mean age, 66.9 y ± 9.5). Tumor characteristics related to local tumor progression and primary and secondary treatment efficacy were evaluated by univariate analysis. Outcomes were compared between tumors ≤ 3 cm and tumors > 3 cm. RESULTS: Technical success, primary efficacy, and secondary efficacy were 96.5%, 99.4%, and 94.2% at a mean follow-up period of 11.8 months ± 9.8 (range, 0.8-40.6 mo). Analysis of tumor characteristics showed no significant risk factor for local tumor progression, including subcapsular location (P = .176), tumor size (P = .402), and perivascular tumor location (P = .323). The 1-year and 2-year secondary or overall treatment efficacy rates for tumors measuring ≤ 3 cm were 91.2% and 82.1% and for tumors 3.1-5 cm were 92.3% and 83.9% (P = .773). The number of sessions to achieve secondary efficacy was higher in the larger tumor group (1.13 vs 1.06, P = .005). There were three major complications in 134 procedures (2.2%). CONCLUSIONS: With use of current-generation MWA devices, percutaneous ablation of HCCs up to 5 cm can be achieved with high efficacy.

Percutaneous interstitial brachytherapy ablation for targeting oligometastatic gynecologic cancers.

INTRODUCTION: Treatment of recurrent oligometastatic gynecologic malignancy may involve targeted surgery, thermal ablation, or CT-guided high-dose-rate interstitial brachytherapy ablation (CT-HDR-IBTA). The purpose of this study was to describe the safety and efficacy of CT-HDR-IBTA for oligometastatic gynecologic malignancies. METHODS: With institutional review board approval (IRB) approval and compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) compliance, we searched our database to assemble a single-arm study cohort of all patients with oligometastatic gynecologic cancers who underwent CT-HDR-IBTA from 2012-2022 with follow-up. The electronic record was reviewed to determine relevant clinicopathological variables including patient demographics, prior treatments, clinical course, local control, and local and distant recurrence with follow-up imaging. RESULTS: The study cohort comprised 37 lesions in 34 patients treated with CT-HDR-IBTA for recurrent oligometastatic uterine (n = 17), cervix (n = 1), or ovarian cancer (n = 16) with an average lesion size of 2.5 cm with an average patient age of 61.4 years. Each lesion was treated with an average radiation dose of 23.8 Gy in 1.8 fractions and a median follow-up time of 24.0 months. The primary efficacy of CT HDR ITBA was 73% with a median progression-free survival of 8.0 months (95% CI 3.6-12.8 months) and with 58% of patients still alive at 43 months with median overall survival not reached. The rate of Grade 1 adverse events was 22% without any Grade 2, 3 or 4 events. CONCLUSIONS: CT HDR IBTA was safe and effective for treating oligometastatic gynecologic cancers in a heavily pretreated cohort.

Risk of nephrogenic systemic fibrosis in liver transplantation patients.

OBJECTIVE: The purpose of our study was to evaluate the exposure of our institution's liver transplantation population to gadolinium-based contrast agents and assess the rate of nephrogenic systemic fibrosis (NSF) within this unique group. MATERIALS AND METHODS: Institutional review board approval was obtained for a retrospective review of medical records of patients who had undergone liver transplantation at our institution between 1997 and 2008. Informed consent was not required. Demographic information, history of gadolinium-based contrast agent exposure, stage of chronic kidney disease (CKD), and evidence of NSF were recorded. RESULTS: A total of 2142 patients who had undergone liver transplantation at our institution between 1997 and 2008 were identified. Of this total, 33% (709/2142) had documented gadolinium-based contrast agent exposure peritransplantation. Patients in CKD1 and 2, CKD3, CKD4, and CKD5 comprised 50% (352/709), 28% (200/709), 8% (60/709), and 14% (97/709), respectively. Of patients in CKD5, 76% (74/97) required dialysis. Thorough review of all patients' medical records identified one biopsy-confirmed case of NSF in the 709 patients. This patient was also in CKD5 and required dialysis. CONCLUSION: Within our institution, only 0.1% (1/709) of all liver transplantation patients exposed to gadolinium-based contrast agents or 1.4% (1/74) of CKD5 patients requiring dialysis had biopsy proof of NSF. This incidence is consistent with the rate of NSF in all patients exposed to gadolinium-based contrast agents regardless of liver transplantation reported in the literature. Therefore, liver transplantation may not be an independent risk factor in development of NSF in patients exposed to gadolinium-based contrast agents.

How to develop and sustain a successful pelvic floor MRI practice.

PURPOSE: Magnetic resonance imaging (MRI) of the pelvic floor has become a commonly requested diagnostic tool for pelvic floor assessment. We provide a practical guide for developing, growing, and troubleshooting a dedicated pelvic floor imaging service. METHODS: The authors provide an organized approach to the development of a pelvic floor MRI program based on the experience of the SAR Pelvic Floor Disease Focused Panel in academic and private practice settings. Topics addressed include creating interest, staff education, patient preparation both before and after arrival to the imaging center, image acquisition, reporting, and troubleshooting. RESULTS: Using the organization and approach in this guide, the challenge of growing this relatively complex imaging program can be simplified. Familiarity with best practices and established techniques used by successful programs will allow new sites to avoid early pitfalls and quickly develop a mature and autonomous workflow. CONCLUSIONS: The development and growing of a pelvic floor MRI program presents its own set of challenges and unique workflow issues which can create anxiety in both patients and providers. We systematically present an approach to streamline the development of a successful pelvic floor MRI program.

Dynamic fluoroscopic defecography: updates on rationale, technique, and interpretation from the Society of Abdominal Radiology Pelvic Floor Disease Focus Panel.

Whether used as the primary diagnostic test or reserved as a problem-solving examination, fluoroscopic defecography (FD) remains an important tool in the workup and treatment of defecatory disorders. FD is a well-established, simple, and rapid examination that most closely resembles the actual process and position that a patient uses to enable defecation and provides both qualitative and quantitative information on the defecatory process. FD is indicated when re-creating the act of defecation is necessary, especially in patients with symptoms of obstructed defecation and where symptoms do not correlate with prior examinations such as MRI. Also, FD may help the patient understand the severity of their condition, better informing them of the structural and functional pathology, and aid in discussions with the surgeon regarding plans for treating their complex pelvic floor and defecatory problems. This review provides an up-to-date, comprehensive summary of FD and describes the indications for, techniques of, and common pathology encountered.

Gynecologic tumor board: a radiologist's guide to vulvar and vaginal malignancies.

Primary vulvar and vaginal cancers are rare female genital tract malignancies which are staged using the 2009 International Federation of Gynecology and Obstetrics (FIGO) staging. These cancers account for approximately 2,700 deaths annually in the USA. The most common histologic subtype of both vulvar and vaginal cancers is squamous cell carcinoma, with an increasing role of the human papillomavirus (HPV) in a significant number of these tumors. Lymph node involvement is the hallmark of FIGO stage 3 vulvar cancer while pelvic sidewall involvement is the hallmark of FIGO stage 3 vaginal cancer. Imaging techniques include computed tomography (CT), positron emission tomography (PET)-CT, magnetic resonance imaging (MRI), and PET-MRI. MRI is the imaging modality of choice for preoperative clinical staging of nodal and metastatic involvement while PET-CT is helpful with assessing response to neoadjuvant treatment and for guiding patient management. Determining the pretreatment extent of disease has become more important due to modern tailored operative approaches and use of neoadjuvant chemoradiation therapy to reduce surgical morbidity. Moreover, imaging is used to determine the full extent of disease for radiation planning and for evaluating treatment response. Understanding the relevant anatomy of the vulva and vaginal regions and the associated lymphatic pathways is helpful to recognize the potential routes of spread and to correctly identify the appropriate FIGO stage. The purpose of this article is to review the clinical features, pathology, and current treatment strategies for vulvar and vaginal malignancies and to identify multimodality diagnostic imaging features of these gynecologic cancers, in conjunction with its respective 2009 FIGO staging system guidelines.

Pelvic floor ultrasound: when, why, and how?

Pelvic floor disorders are a significant medical issue, reportedly affecting nearly one in four women in the United States. Nonetheless, until the last decade, there has been relatively limited imaging research into this highly prevalent disorder. The three major imaging modalities utilized to assess pelvic floor function are ultrasound, MRI and fluoroscopy. Pelvic floor ultrasound is a rapidly emerging technique which takes advantage of the widespread availability of ultrasound, the non-invasive and relatively inexpensive approach and the incorporation of real-time imaging and software advances which permit 3-D volume imaging. Pelvic floor ultrasound provides the opportunity to optimize patient counseling and enhance pre-operative planning by providing an anatomic and functional roadmap for the referring clinician. We recommend the consideration of pelvic floor ultrasound, as described here, as an addition to the imaging armamentarium available to physicians and surgeons serving this patient population.

Multimodality imaging of pelvic floor anatomy.

The pelvic floor is composed of a network of muscles, ligaments, and fasciae, which provide active and passive support for the pelvic organs. Impairment of these pelvic floor elements can result in a variety of functional abnormalities and single or multicompartment organ prolapse. Knowledge of normal pelvic floor anatomy can aid the radiologist in understanding the complex nature of pelvic floor dysfunction and is important for comprehensive image interpretation. This article provides an overview of normal anatomy of the pelvic floor as seen on magnetic resonance imaging, ultrasound, and fluoroscopic studies performed in the evaluation of pelvic floor function.

Variability in utilization and techniques of pelvic floor imaging: findings of the SAR pelvic floor dysfunction disease-focused panel.

Pelvic floor disorders are common and can negatively impact quality of life. Imaging of patients with pelvic floor disorders has been extremely heterogeneous between institutions due in part to variations in clinical expectations, technical considerations, and radiologist experience. In order to assess variations in utilization and technique of pelvic floor imaging across practices, the society of abdominal radiology (SAR) disease-focused panel on pelvic floor dysfunction developed and administered an online survey to radiologists including the SAR membership. Results of the survey were compared with published recommendations for pelvic floor imaging to identify areas in need of further standardization. MRI was the most commonly reported imaging technique for pelvic floor imaging followed by fluoroscopic defecography. Ultrasound was only used by a small minority of responding radiologists. The survey responses demonstrated variability in imaging utilization, patient referral patterns, imaging protocols, patient education, and interpretation and reporting of pelvic floor imaging examinations. This survey highlighted inconsistencies in technique between institutions as well as potential gaps in knowledge that should be addressed to standardize evaluation of patients with pelvic floor dysfunction.

Thoracic and abdominal devices radiologists should recognize: pictorial review.

OBJECTIVE: Surgical, interventional, and diagnostic devices are continually being developed and often have unexpected radiographic appearances. The purpose of this article is to familiarize the radiologist with several devices that may be placed in the thorax and abdomen. CONCLUSION: The radiologist's familiarity with the radiographic appearance of devices placed in the chest and abdomen is essential for accurate image interpretation and identification of postprocedure complications.

Thoracic and abdominal devices radiologists should recognize: self-assessment module.

The educational objectives for this self-assessment module are for the participant to exercise, self-assess, and improve his or her understanding of thoracic and abdominal devices.

Quality initiatives: blind spots at brain imaging.

Radiologists face the daily challenge of analyzing and interpreting a high volume of images in a timely manner. Minimizing errors, whether perceptual or cognitive in nature, is paramount for high-quality diagnostics and patient care. There are certain areas within the head encountered at routine brain imaging in which the interpreting radiologist is most prone to make perceptual errors. These areas, or "blind spots," include the cerebral sulci, dural sinuses, orbits, cavernous sinuses, clivus, Meckel cave, brainstem, skull base, and parapharyngeal soft tissues. In addition, the use of an inappropriate window width and level for the evaluation of computed tomographic (CT) scans can be a virtual, rather than an anatomic, blind spot. The inclusion of a comprehensive checklist for evaluation of these blind spots as part of every brain imaging study is crucial for avoiding false-negative results. Knowledge of the anatomic features of these blind spots is also crucial, as well as familiarity with the normal CT and magnetic resonance imaging findings in these areas. In addition, the radiologist should be aware of possible interpretation pitfalls that may lead to false-positive results (eg, normal anatomic variants that may be mistaken for pathologic conditions). Finally, a well-developed differential diagnosis will help ensure correct interpretation and appropriate patient treatment.

Ten-year experience with nephrogenic systemic fibrosis: case-control analysis of risk factors.

OBJECTIVES: To analyze all cases of nephrogenic systemic fibrosis (NSF) at our institution and to compare them with controls. METHODS: After the institutional review board approval, 13 biopsy-proven NSF cases were identified. Ten cases had complete records and were compared in a case-control format with 10 age- and sex-matched, dialysis-dependent controls. Analyzed risk factors included single and cumulative gadolinium dose, medication and transplant history, and serum electrolytes at the time of gadolinium exposure. RESULTS: There were 1.9% of dialysis-dependent, gadolinium-exposed patients who developed NSF. There was no difference in gadolinium dose, transplant history, or serum electrolytes. Seven of 10 cases and 3 of 10 controls were treated with erythropoietin (P = 0.13). At the time of NSF diagnosis, 7 of 10 cases were on immunosuppressive therapy. Two of 7 cases developed NSF only after immunosuppressive therapy was initiated. Two of 10 controls were on immunosuppressive therapy (P = 0.06). CONCLUSIONS: All cases of NSF occurred in dialysis-dependent, gadolinium-exposed patients. Associations between immunosuppressive and erythropoietin therapies and NSF need further investigation.

Microwave ablation of liver tumors: degree of tissue contraction as compared to RF ablation.

PURPOSE: To compare the amount of tissue contraction after microwave (MW) versus radiofrequency (RF) ablation of liver tumors. MATERIALS AND METHODS: Seventy-five hepatic tumors in 65 patients who underwent percutaneous MW or RF ablations were included in this retrospective study. All patients underwent MRI within 6 months before the ablation and 24 h after the procedure. Two blinded radiologists, by consensus, performed measurements on the corresponding series of pre and post-ablation MRI. Absolute and relative contraction of liver, tumor, and control were calculated and compared. RESULTS: Thirty-one patients underwent MW ablations, and 44 patients underwent RF ablations. The absolute and relative contraction of the ablation zone were significantly greater with MW than RF ablation (p = 0.003 to <0.001). Thirty-two lesions were visible on both pre- and post-ablation MRI. MW ablation had significantly more tumor contraction as compared to RF ablation (p = 0.003 to 0.009). The control measurements demonstrated no significant difference in normal tissue variation between MW and RF groups. CONCLUSIONS: MW ablation of hepatic tumors produced significantly more contraction of tumor and ablated hepatic tissue compared to RF ablation. Tissue contraction should be taken into account during pre-procedural planning and assessing treatment response by comparing pre- and post-ablation images.

Truncal valve repair in neonates using pericardial leaflet extension.

Truncal valve insufficiency is a significant risk factor for post-operative mortality following repair of truncus arteriosus. The surgical management of dysplastic and insufficient truncal valves remains an operative challenge. We report the cases of two infants with type 2 truncus arteriosus and severely dysplastic and insufficient quadricuspid truncal valves. At primary repair, their truncal valves were successfully repaired using pericardial leaflet extensions. This technique may be used in neonates with truncal valve insufficiency as part of the primary repair of truncus arteriosus.