Case 307.

HISTORY: A 45-year-old woman presented to the emergency department with acute worsening of prolonged unexplained nausea, nonbilious vomiting, and mild upper abdominal pain of 4 years duration. Her bowel habits were regular, and there was no history of diarrhea or fresh or altered blood in her stool. On further inquiry, there was no history of facial flushing, excessive diaphoresis, or asthmalike symptoms. Her history was unrevealing; in particular, there was no history of known malignancy. On clinical examination, her vital signs were stable. The abdomen was soft, with no focal tenderness or palpable mass. Routine blood investigations, including complete blood counts, and liver, kidney, and thyroid function tests yielded results that were within normal limits. Her 5-hydroxyindoleacetic acid and chromogranin A levels were not elevated. Initial evaluation with contrast-enhanced CT of the abdomen and pelvis was performed. Subsequently, an indium 111 octreotide scan was performed at the recommendation of the radiologist 1 month after CT (Figs 1, 2).

Case 307: Heterotopic Pancreas in Jejunal Mesentery.

HISTORY: A 45-year-old woman presented to the emergency department with acute worsening of prolonged unexplained nausea, nonbilious vomiting, and mild upper abdominal pain of 4 years duration. Her bowel habits were regular, and there was no history of diarrhea or fresh or altered blood in her stool. On further inquiry, there was no history of facial flushing, excessive diaphoresis, or asthmalike symptoms. Her history was unrevealing; in particular, there was no history of known malignancy. On clinical examination, her vital signs were stable. The abdomen was soft, with no focal tenderness or palpable mass. Routine blood investigations, including complete blood counts, and liver, kidney, and thyroid function tests yielded results that were within normal limits. Her 5-hydroxyindoleacetic acid and chromogranin A levels were not elevated. Initial evaluation with contrast-enhanced CT of the abdomen and pelvis was performed. Subsequently, an indium 111 (111In) octreotide scan was performed at the recommendation of the radiologist 1 month after CT.

Anastomotic Leaks After Small- and Large-Bowel Surgery: Diagnostic Performance of CT and the Importance of Intraluminal Contrast Administration.

OBJECTIVE: The objective of our study was to evaluate the diagnostic performance of CT in the identification of anastomotic leaks. MATERIALS AND METHODS: This was a study of patients who underwent bowel surgery and a subsequent postoperative CT examination performed specifically for investigating for an anastomotic leak. The study group included patients with surgically confirmed anastomotic leaks (n = 59), and the control group included patients without anastomotic leaks (n = 48) confirmed by either repeat surgery or uneventful clinical follow-up for at least 6 months. Two radiologists and two radiology residents independently reviewed each CT examination for specific CT findings from a set of predetermined imaging predictors. The sensitivity and specificity for each imaging predictor were calculated for each reader, and the interobserver agreement was calculated using the Cohen kappa coefficient. Diagnostic performance was assessed using ROC curve analysis. RESULTS: The most sensitive imaging predictor was intraabdominal free fluid (95.3%). Leakage of intraluminal contrast agent was also a highly specific imaging predictor (96.6%). Substantial interobserver agreement was shown for intraabdominal free gas (κ = 0.76) and leakage of intraluminal contrast agent (κ = 0.76). Overall diagnostic performance in correctly identifying surgically confirmed leaks, as assessed by the area under the ROC curve, ranged from 0.76 to 0.86. Diagnostic performance was higher for all readers when intraluminal contrast agent was used and reached the anastomosis, with the exception of one reader, whose diagnostic performance remained unchanged. CONCLUSION: Diagnostic performance of CT was highest when an intraluminal contrast agent was used. Meticulous and careful use of an intraluminal contrast agent is therefore important in this patient population.

How Well Are We Respecting Patient Privacy in Medical Imaging? Lessons Learnt From a Departmental Audit.

RATIONALE AND OBJECTIVES: Preservation of patient privacy and dignity are basic requirements for all patients visiting a hospital. The purpose of this study was to perform an audit of patients' satisfaction with privacy whilst in the Department of Medical Imaging (MI) at the Civic Campus of the Ottawa Hospital. MATERIALS AND METHODS: Outpatients who underwent magnetic resonance imaging (MRI), computed tomography (CT), ultrasonography (US), and plain film (XR) examinations were provided with a survey on patient privacy. The survey asked participants to rank (on a 6-point scale ranging from 6 = excellent to 1 = no privacy) whether their privacy was respected in 5 key locations within the Department of MI. The survey was conducted over a consecutive 5-day period. RESULTS: A total of 502 surveys were completed. The survey response rate for each imaging modality was: 55% MRI, 42% CT, 45% US, and 47% XR. For each imaging modality, the total percentage of privacy scores greater than or equal to 5 were: 98% MRI, 96% CT, 94% US, and 92% XR. Privacy ratings for the MRI reception and waiting room areas were significantly higher in comparison to the other imaging modalities (P = .0025 and P = .0227, respectively). CONCLUSION: Overall, patient privacy was well respected within the Department of MI.

Case 221: Hereditary Leiomyomatosis and Renal Cell Cancer Syndrome.

History A 24-year-old woman presented to the emergency department with a history of acute urinary retention, gross hematuria, and left flank pain for 2 days. Past history was unrevealing. Her last menstrual period occurred 2 weeks prior to presentation. At physical examination, she had a temperature of 38.4°C. A palpable mass was noted in the suprapubic region, and a second mass was palpated in the left upper quadrant. Blood work revealed a hemoglobin level of 4.7 g/dL (normal range, 11.5-15.5 g/dL). Her coagulation profile and white blood cell count were within normal limits. Ultrasonography (US) of the abdomen and pelvis was performed and was followed by contrast material-enhanced (80 mL of iopamidol) computed tomography (CT) of the chest, abdomen, and pelvis. Magnetic resonance (MR) imaging of the abdomen and pelvis also was performed.

Complications of minimally invasive procedures of the abdomen and pelvis: a comprehensive update on the clinical and imaging features.

Minimally invasive gastrointestinal, genitourinary, and gynecological procedures are widely used in the clinical practice for diagnostic and therapeutic purposes. Complications both minor and major are not uncommon with these procedures. Imaging plays an important role in the detection and optimal management of these complications. Familiarity with the clinical and imaging features of these complications by radiologists can help in their timely detection.

Looking back, moving forward: an analysis of complaints submitted to a Canadian tertiary care radiology department and lessons learned.

PURPOSE: We present an analysis of various types and strata of complaints received in a geographically isolated tertiary care center over a 2.5-year period. METHODS: Research ethics board approval was obtained. The institution described is a closed system with formalized procedures for submitting complaints. All complaints submitted between November 2010 and March 2013 were collected retrospectively. The following data were extracted: type of complainant, nature of the complaint, site or modality of concern, dates in question, and the response. The data were analysed in multiple subgroups and compared with patient and study volume data. RESULTS: The frequency of complaints equalled 0.01% (100/1,050,000). The largest group of those who submitted complaints were patients (69% [69/100]), followed by referring physicians (16%). Examination scheduling and interpersonal conflicts were equally of greatest frequency of concern (21% [21/100]), followed by issues with study reporting (16%). The average time interval between complaint submission and formal address was 15 days. CONCLUSIONS: We present a low frequency of complaints, with the majority of these complaints submitted by patients; scheduling and personal interactions were most often involved. Effective communication, both with patients and referring physicians, was identified as a particular focus for improving satisfaction.

The abdominal wall lumps and bumps: cross-sectional imaging spectrum.

This article focuses on the cross-sectional imaging spectrum of abnormalities that affect the abdominal wall, with emphasis on magnetic resonance imaging (MRI). Cross-sectional imaging is valuable for diagnosing and evaluating the extent of abdominal-wall masses. With the increasing use of MRI, it is often possible to reach a diagnosis or narrow the differential diagnosis, thereby guiding effective management. Neoplastic and non-neoplastic pathologies will be illustrated, and the distinctive imaging characteristics of these entities will be highlighted.

The mysterious organ. Spectrum of focal lesions within the splenic parenchyma: cross-sectional imaging with emphasis on magnetic resonance imaging.

Incidental splenic lesions are frequently encountered at imaging performed for unrelated causes. Splenic cysts, hemangiomas, and lymphomatous involvement are the most frequently encountered entities. Computed tomography and sonography are commonly used for initial evaluation with magnetic resonance imaging reserved as a useful problem-solving tool for characterizing atypical and uncommon lesions. The value of magnetic resonance imaging lies in classifying these lesions as either benign or malignant by virtue of their signal-intensity characteristics on T1- and T2-weighted imaging and optimal depiction of internal hemorrhage. Dynamic contrast-enhanced sequences may improve the evaluation of focal splenic lesions and allow characterization of cysts, smaller hemangiomas, and hamartomas. Any atypical or unexplained imaging feature related to an incidental splenic lesion requires additional evaluation and/or follow-up. Occasionally, biopsy or splenectomy may be required for definitive assessment given that some of tumours may demonstrate uncertain biologic behavior.

Triphasic CT in the diagnosis of acute mesenteric ischaemia.

OBJECTIVE: To evaluate the yield of each phase in a triphasic CT protocol used to diagnose acute mesenteric ischaemia (AMI). METHODS: Retrospective analysis of patients who underwent CT to exclude AMI was conducted. From 218 patients, 80 were randomly selected for analysis: 39 with proven AMI; 41 controls. Three readers evaluated the studies; two readers were provided with only portions of the examination to determine the yield of unenhanced CT (NECT) and CT angiography (CTA). The diagnostic accuracy of CT findings was calculated and compared between readers. RESULTS: The sensitivity and specificity of submucosal haemorrhage were 10 % and 98 %. Interobserver variability was poor (κ = 0.17). All true-positive cases had other CT findings of AMI (n = 4). There was no difference in the assessment of bowel enhancement between readers (P < 0.05). There was no difference between readers (P < 0.05) and interobserver variability was moderate to good when diagnosing arterial abnormalities without CTA. Sample size was small and errors occurred when using only the portal venous phase for this purpose. CONCLUSION: NECT is not required for diagnosis of AMI. Splanchnic arterial abnormalities can be diagnosed without CTA although errors occur when using only the portal venous phase for this purpose. KEY POINTS: • Triphasic CT is the current gold standard for diagnosing acute mesenteric ischaemia. • Multiphase CT multiplies the radiation dose when compared to single phase CT. • Each phase in a multiphase CT examination should be independently validated. • Unenhanced CT is not required for diagnosis of acute mesenteric ischaemia. • CT angiography should be performed for diagnosis of acute mesenteric ischaemia.

Current concepts in the imaging of uterine sarcoma.

Recent advances in genetics and pathology have improved our understanding of diagnosis and staging of uterine sarcomas. The major types of uterine sarcomas include leiomyosarcoma, low-grade endometrial stromal sarcoma, undifferentiated endometrial sarcoma, adenosarcoma and carcinosarcoma. The distinctive biological behavior and poor overall survival of uterine sarcoma create challenges in the management of these tumors. We herein present a comprehensive review of taxonomy, epidemiology, pathology, imaging findings and natural history of a wide spectrum of uterine sarcomas.

Trends in radiology fellowship training: a Canadian review 2009-2011.

PURPOSE: To assess the percentage, type, and location of radiology fellowships chosen by graduating Canadian residents between 2009 and 2011. METHODS: A short e-mail questionnaire was sent to the radiology program directors at all 16 institutions in Canada that provide English or French residency. The responses were collected between December 6, 2010, and May 20, 2011. RESULTS: A 75% response rate was observed for the survey: 76%-79% residents were enrolled in radiology fellowship training. In 2009-2010, 72%-73% of residents remained in Canada. This dropped to 51% in 2011. In 2009-2010, 22%-23% of residents chose U.S.-based radiology training. This rose to 49% in 2011. Europe was chosen by 0%-4% of residents: all of whom were French-speaking residents, and all programs were in France. Relatively consistent percentages of radiology residents choose abdominal (19%-30%), cardiac (4%-7%), musculoskeletal (12%-20%), and pediatrics (2%-5%) from year to year. Greater variability was noted in chest (2%-9%), women's imaging (0%-14%), intervention radiology (6%-18%), and neuroradiology (2%-18%). Radiology fellowships in split subspecialties, which were available at a small number of institutions, were chosen by 8%-9% of the residents. CONCLUSIONS: Nearly 4 of 5 residents choose radiology fellowship training. In 2011, there was a 2-fold increase in the number of residents who chose training in the United States. This may be a 1-year outlier but should be observed. A wide range of fellowships were chosen, with consistent numbers in some core fellowships and variability in others year to year. Limited exploration of the rationale for, or employability value of, radiology fellowship choices has been done in Canada. Nearly 1 of 10 residents chose split radiology fellowships, an option limited by availability at few centers. The value of expanding this option is worthy of investigation.

"What is inside this right lower quadrant sac?" Spectrum of computed tomography abnormalities that affect the cecum.

The current pictorial is a comprehensive review of the various cecal pathologies, including both those that solely involve the cecum and those in which the cecum may be secondarily involved. The various cecal abnormalities will be categorized as inflammatory, infectious, vascular, neoplastic, congenital, and foreign bodies. Emphasis will be placed on the imaging features that, when coupled with the clinical history, help to reach a diagnosis or to narrow the differential diagnosis.

Uncommon primary pelvic retroperitoneal masses in adults: a pattern-based imaging approach.

There is a broad spectrum of primary pelvic retroperitoneal masses in adults that demonstrate characteristic epidemiologic and histopathologic features and natural histories. These masses may be classified into five distinct subgroups using a pattern-based approach that takes anatomic distribution and certain imaging characteristics into account, allowing greater accuracy in their detection and characterization and helping to optimize patient management. The five groups are cystic (serous and mucinous epithelial neoplasms, pelvic lymphangioma, tailgut cyst, ancient schwannoma), vascular or hypervascular (solitary fibrous tumor, paraganglioma, pelvic arteriovenous malformation, Klippel-Trénaunay-Weber syndrome, extraintestinal GIST [gastrointestinal stromal tumor]), fat-containing (lipoma, liposarcoma, myelolipoma, presacral teratoma), calcified (calcified lymphocele, calcified rejected transplant kidney, rare sarcomas), and myxoid (schwannoma, plexiform neurofibroma, myxoma).Cross-sectional imaging modalities help differentiate the more common gynecologic neoplasms from more unusual masses. In particular, the tissue-specific multiplanar capability of high-resolution magnetic resonance imaging permits better tumor localization and internal characterization, thereby serving as a road map for surgery.

Benign biliary strictures: a current comprehensive clinical and imaging review.

OBJECTIVE: There is a wide spectrum of nonneoplastic causes of biliary stricture that can pose a significant challenge to clinicians and radiologists. Imaging plays a key role in differentiating benign from malignant strictures, defining the extent, and directing the biopsy. We describe the salient clinical and imaging manifestations of benign biliary strictures that will help radiologists to accurately diagnose these entities. CONCLUSION: Accurate diagnosis and management are based on correlating imaging findings with epidemiologic, clinical, and laboratory data. Cross-sectional imaging modalities permit precise localization of the site and length of the segment involved, thereby serving as a road map to surgery, and permit exclusion of underlying malignancy.

Spectrum of medication-induced complications in the abdomen: role of cross-sectional imaging.

OBJECTIVE: This article provides a comprehensive review of the role of MDCT and MRI in the diagnosis of drug-induced complications in the abdomen and pelvis in adults. A systematic organ-based review of these complications is presented, including but not limited to hepatic changes after chemotherapy, renal complications such as tumor lysis syndrome and lithium nephropathy, gastrointestinal manifestations, various opportunistic infections and secondary neoplasms, mycotic aortic aneurysm from intravesical bacille Calmette-Guérin, complications of anticoagulant therapy, and oral contraceptives. CONCLUSION: Advancements in imaging have led to recognition of radiologic features of previously unsuspected diseases. Occasionally, imaging may also identify effects of treatments instituted for these diseases. Consequently, imaging plays a critical role in the accurate diagnosis of a broad spectrum of drug-induced complications in the abdomen, both in emergent and nonemergent settings. Knowledge of the natural history, clinical manifestations, and salient imaging features of these entities is crucial to facilitate accurate clinical diagnosis in a timely fashion.

Histologic, molecular, and cytogenetic features of ovarian cancers: implications for diagnosis and treatment.

Ovarian epithelial carcinoma (OEC), the most common ovarian malignancy, is a heterogeneous disease with several histologic subtypes that show characteristic cytogenetic features, molecular signatures, oncologic signaling pathways, and clinical-biologic behavior. Recent advances in histopathology and cytogenetics have provided insights into pathophysiologic features and natural history of OECs. Several studies have shown that high- or low-grade serous, endometrioid, and clear cell carcinomas are characterized by mutations involving the TP53, K-ras/BRAF, CTNNB1, and PIK3CA genes, respectively. High-grade serous carcinomas, the most common subtype, often manifest with early transcoelomic spread of disease beyond the ovaries, whereas low-grade serous and mucinous carcinomas commonly manifest with early-stage disease, with a resultant excellent prognosis. On the basis of pathogenetic mechanisms, recent findings suggest a dualistic model of ovarian carcinogenesis consisting of types I and II. Type I (low-grade serous, mucinous, and endometrioid) cancers commonly arise from well-described, genetically stable precursor lesions (usually borderline tumors); manifest as large adnexal masses with early-stage disease; and have a relatively indolent clinical course, with an overall good prognosis. In contrast, type II carcinomas (high-grade serous, endometrioid, mixed, and undifferentiated variants) originate de novo from the adnexal epithelia, often demonstrate chromosomal instability, and have aggressive biologic behavior. Better knowledge of hereditary ovarian cancer syndromes and associated cytogenetic abnormalities has led to increased interest in novel biomarkers and molecular therapeutics. Genetic changes, pathologic features, imaging findings, and natural histories of a variety of histologic subtypes of OEC are discussed in this article.

Imaging of endometriosis: 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 the imaging features of endometriosis and the role of imaging and various radiologic techniques in the clinical management of patients.

Clinical syndromes associated with ovarian neoplasms: a comprehensive review.

Functional ovarian neoplasms have unique clinical manifestations related to hormone overproduction and may give rise to a broad spectrum of clinical syndromes. Sex cord-stromal tumors, the most common functional ovarian neoplasms, are associated with either hyperestrogenism (as in granulosa cell tumor and thecoma) or hyperandrogenism (as in Sertoli-Leydig cell tumor and Leydig cell tumor). Other, less common ovarian neoplasms that may have endocrine or nonendocrine syndromic manifestations include germ cell tumors associated with the excessive production of human chorionic gonadotropin (eg, choriocarcinoma, dysgerminoma), monodermal teratomas (eg, carcinoid tumor, struma ovarii) associated with carcinoid syndrome and hyperthyroidism, and primary epithelial ovarian cancers associated with paraneoplastic syndromes. The application of diagnostic algorithms based on patient demographic information, clinical manifestations, laboratory findings, and cross-sectional imaging features may help identify ovarian neoplasms in complex clinical settings.