Renal bleeding: imaging and interventions in patients with tumors.

In patients with cancer, spontaneous renal bleeding can stem from a range of underlying factors, necessitating precise diagnostic tools for effective patient management. Benign and malignant renal tumors are among the primary culprits, with angiomyolipomas and renal cell carcinomas being the most common among them. Vascular anomalies, infections, ureteral obstructions, and coagulation disorders can also contribute to renal-related bleeding. Cross-sectional imaging techniques, particularly ultrasound and computed tomography (CT), play pivotal roles in the initial detection of renal bleeding. Magnetic resonance imaging and CT are preferred for follow-up evaluations and aid in detecting underlying enhancing masses. IV contrast-enhanced ultrasound can provide additional information for active bleeding detection and differentiation. This review article explores specific disorders associated with or resembling spontaneous acute renal bleeding in patients with renal tumors; it focuses on the significance of advanced imaging techniques in accurately identifying and characterizing renal bleeding in these individuals. It also provides insights into the clinical presentations, imaging findings, and treatment options for various causes of renal bleeding, aiming to enhance the understanding, diagnosis, and management of the issue.

Whole-body MRI in oncology: A comprehensive review.

Whole-Body Magnetic Resonance Imaging (WB-MRI) has cemented its position as a pivotal tool in oncological diagnostics. It offers unparalleled soft tissue contrast resolution and the advantage of sidestepping ionizing radiation. This review explores the diverse applications of WB-MRI in oncology. We discuss its transformative role in detecting and diagnosing a spectrum of cancers, emphasizing conditions like multiple myeloma and cancers with a proclivity for bone metastases. WB-MRI's capability to encompass the entire body in a singular scan has ushered in novel paradigms in cancer screening, especially for individuals harboring hereditary cancer syndromes or at heightened risk for metastatic disease. Additionally, its contribution to the clinical landscape, aiding in the holistic management of multifocal and systemic malignancies, is explored. The article accentuates the technical strides achieved in WB-MRI, its myriad clinical utilities, and the challenges in integration into standard oncological care. In essence, this review underscores the transformative potential of WB-MRI, emphasizing its promise as a cornerstone modality in shaping the future trajectory of cancer diagnostics and treatment.

Pathologic Conditions at Imaging of the Spermatic Cord.

A wide range of benign and malignant processes can affect the spermatic cord (SC). Familiarity with and recognition of the characteristic imaging features of these entities are imperative for accurate diagnosis and optimal clinical care. While some SC diseases are self-limiting, others can result in infertility and potentially life-threatening infection or bleeding if they are left untreated. Therefore, correct diagnosis is important for life-saving treatment and preservation of fertility. Disorders including anomalies of the vas deferens and the processus vaginalis, arterial and venous diseases (torsion of the SC and varicoceles), infection, trauma, and neoplasms are the most pertinent entities with which radiologists should be familiar when assessing the SC. Knowing what to expect in a patient who has undergone SC interventions is imperative. US has a fundamental role in the initial examination of patients who present with symptoms that indicate abnormalities of the SC, such as suspected posttraumatic testicular retraction or SC torsion. Other imaging techniques including abdominal and pelvic MRI and CT have their own importance. For correct interpretation of the findings and to establish an accurate diagnosis, it is crucial to have a thorough knowledge of the anatomy, the utility and limitations of various imaging modalities, optimal imaging and scanning techniques, and the imaging features of various benign and malignant pathologic conditions that can involve the SC. Online supplemental material is available for this article. ©RSNA, 2022.

Imaging Surveillance of the Reconstructed Breast in a Subset of Patients May Aid in Early Detection of Breast Cancer Recurrence.

OBJECTIVES: The purpose of this study is to determine the biological markers more frequently associated with recurrence in the reconstructed breast, to evaluate the detection method, and to correlate recurrent breast cancers with the detection method. MATERIAL AND METHODS: An institutional review board-approved retrospective study was conducted at a single institution on 131 patients treated with mastectomy for primary breast cancer followed by breast reconstruction between 2005 and 2012. Imaging features were correlated with clinical and pathologic findings. RESULTS: Of the 131 patients who met our inclusion criteria, 40 patients presented with breast cancer recurrence. The most common histopathologic type of primary breast cancer was invasive ductal carcinoma in 82.5% (33/40) of patients. Triple-negative breast cancer was the most common biological marker with 42.1% (16/38) of cases. Clinically, 70% (28/40) of the recurrences presented as palpable abnormalities. Of nine patients who underwent mammography, a mass was seen in eight patients. Of the 35 patients who underwent ultrasound evaluation, an irregular mass was found in 48.6% (17/35) of patients. Nine patients with recurrent breast cancer underwent breast MRI, and MRI showed an irregular enhancing mass in four patients, an oval mass in four patients, and skin and trabecular thickening in one patient. About 55% of patients with recurrent breast cancer were found to have distant metastases. CONCLUSION: Patients at higher risk for locoregional recurrence may benefit from imaging surveillance in order to detect early local recurrences.

Imaging Features of Triple Negative Breast Cancer and the Effect of BRCA Mutations.

OBJECTIVE: The purpose of this study is to review the mammographic and the ultrasound features of triple negative breast cancer (TNBC) patients and to investigate the potential effect of BRCA mutations on the imaging features of these patients. METHODS: One hundred and seven patients with TNBC were enrolled in a retrospective study following IRB approval and approval of waiver of informed consent. BRCA mutations were assessed using genetic testing. Imaging features on mammography and ultrasound (US) as well as pathology and clinical information were retrospectively reviewed and characterized according to the BI-RADS lexicon (fifth edition). The relationships between BRCA mutations and the imaging findings were examined. RESULTS: TNBC commonly presented as an irregular mass with obscured margins on mammography and as an irregular hypoechoic mass with microlobulated or angular margins on US. Approximately two thirds of TNBC cases had a parallel orientation and approximately one third had posterior enhancement, features often associated with benign masses. There was no statistically significant difference in the mammographic and the US features of BRCA positive and BRCA negative triple negative tumors. CONCLUSION: TNBC may have a parallel orientation and posterior enhancement, which are features often seen with benign masses. BRCA mutations do not affect the imaging features of triple negative breast tumors.

Uncovering the Dorsal Thalamo-hypothalamic Tract of the Human Limbic System.

As a non-limbic structure, the human thalamus is the most important modulator of the limbic system. The hypothalamus plays vital roles in the survival of species by regulating fear, learning, feeding behavior, circadian rhythm, sociosexual and reproductive activities of the limbic system through connections with the thalamus. The detailed anatomy of the pathways responsible for mediating these responses, however, is yet to be determined. The mammillothalamic tract is known as the major direct thalamo-hypothalamic connection in the primates including the human brain connecting the ventral thalamus to the dorsal hypothalamus. Multiple dissection animal studies revealed additional connections specially from the dorsal thalamus to the ventral hypothalamic nuclei. Diffusion weighted imaging may be helpful in better visualizing the surgical anatomy of this additional connectivity noninvasively. This study aimed to investigate the utility of high spatial and high angular resolution diffusion weighted tractography technique for mapping the trajectory of this dorsal thalamic connectivity with the ventral hypothalamus in the human brain. We studied 30 healthy human subjects. Using a high-resolution diffusion weighted tractography technique, for the first time, we were able to delineate and reconstruct the trajectory of the dorsal thalamo-hypothalamic tract (DTH). We further revealed the close relationship of the DTH, fornix and hippocampus in healthy adult human brain.

Sentinel Lymph Node Evaluation: What the Radiologist Needs to Know.

Axillary lymph node status is the single most important prognostic indicator in patients with breast cancer. Axillary lymph node dissection, the traditional method of staging breast cancer, is associated with significant morbidity. Sentinel lymph node biopsy has become standard in patients being treated for breast cancer with clinically negative lymph nodes. There is considerable variation in the medical literature regarding technical approaches to sentinel lymph node biopsy in patients with breast cancer. The purpose of this article is to describe our preferred approaches to sentinel lymph node biopsy with a review of the literature.

Placenta previa without morbidly adherent placenta: comparison of characteristics and outcomes between planned and emergent deliveries in a tertiary center.

OBJECTIVE: The objective of this study is to compare patient outcomes between planned and emergent cesarean deliveries for placenta previa without morbidly adherent placenta. STUDY DESIGN: All patients with confirmed, persistent placenta previa (without morbidly adherent placentation) who underwent the surgery between January 2010 and April 2016 were included in this retrospective study. Primary outcome was composite maternal morbidity defined as the presence of at least one of the followings: death, red blood cell (RBC) transfusion, hysterectomy, reoperation, hospital stay >7 d, ureteral injury, bowel injury, or cystotomy. RESULTS: Three hundred and four patients with placenta previa were identified during the study period, of whom 154 (50.65%) had an antenatal and 10 (3.28%) had an intraoperative diagnosis of morbidly adherent placenta. One hundred and forty patients met the inclusion criteria. Eighty (57.1%) underwent planned cesarean delivery (planned cesarean delivery (PCD) group), and 60 (42.8%) required emergent cesarean delivery due to uterine contractions and/or bleeding (emergent cesarean delivery (ECD) group). Baseline characteristics were similar between the two groups except for the gestational age at delivery (36.0 weeks (36.0, 37.0) in PCD versus 34.0 weeks (32.0, 36.0) in ECP, p < .001). Composite maternal morbidity was not significantly different between two groups: 11 (18.3%) in ECD and 10 (12.5%) in PCD (p = .35) Conclusions: In our referral tertiary centre, emergent and planned cesarean deliveries for placenta previa without morbidly adherent placenta have similar maternal outcomes. In patients without significant hemorrhage, delivery may be safely deferred until 36-37 weeks.

A Pictorial Review of Sonography of Intramammary Lymph Nodes: When to Care and What to Do About It.

This pictorial essay reviews and illustrates benign and malignant features of intramammary lymph nodes on mammography, ultrasound, and magnetic resonance imaging, including a review of the clinical and the prognostic significance in patients with known breast cancer. This pictorial essay discusses management suggestions for intramammary lymph nodes in patients with breast cancer.

HIV-related Malignancies and Mimics: Imaging Findings and Management.

The risk of developing malignancy is higher in patients with human immunodeficiency virus (HIV) infection than in non-HIV-infected patients. Several factors including immunosuppression, viral coinfection, and high-risk lifestyle choices lead to higher rates of cancer in the HIV-infected population. A subset of HIV-related malignancies are considered to be acquired immunodeficiency syndrome (AIDS)-defining malignancies, as their presence confirms the diagnosis of AIDS in an HIV-infected patient. The introduction of highly active antiretroviral therapy (HAART) has led to a significant drop in the rate of AIDS-defining malignancies, including Kaposi sarcoma, non-Hodgkin lymphoma, and invasive cervical carcinoma. However, non-AIDS-defining malignancies (eg, Hodgkin lymphoma, lung cancer, hepatocellular carcinoma, and head and neck cancers) now account for an increasing number of cancer cases diagnosed in HIV-infected patients. Although the number has decreased, AIDS-defining malignancies account for 15%-19% of all deaths in HIV-infected patients in the post-HAART era. Most HIV-related malignancies in HIV-infected patients manifest at an earlier age with a more aggressive course than that of non-HIV-related malignancies. Understanding common HIV-related malignancies and their specific imaging features is crucial for making an accurate and early diagnosis, which impacts management. Owing to the weakened immune system of HIV-infected patients, other entities such as various infections, particularly opportunistic infections, are prevalent in these patients. These processes can have confounding clinical and imaging manifestations that mimic malignancy. This article reviews the most common AIDS-defining and non-AIDS-defining malignancies, the role of imaging in their diagnosis, and the imaging mimics of malignancies in HIV-infected patients. ©RSNA, 2018.

Image-guided chemistry altering biology: An in vivo study of thermoembolization.

RATIONALE: Advances in image-guided drug delivery for liver cancer have shown a significant survival benefit. However, incomplete treatment is common and residual disease is often found in explanted liver specimens. In addition, the need to treat a malignancy from multiple mechanisms at the same time for optimal outcomes is becoming more widely appreciated. To address this, we hypothesized that an exothermic chemical reaction could be performed in situ. Such a strategy could in principle combine several angles of attack, including ischemia, hyperthermia, acidic protein denaturation, and metabolic modulation of the local environment. METHODS: The University of Texas MD Anderson Cancer Center Institutional Animal Care and Use Committee approved this study. Outbred swine (25-35 kg, 5 control and 5 experimental) were treated under general anesthesia. Embolization was performed with coaxial microcatheter technique in a segmental hepatic arterial branch using either ethiodized oil as control or with thermoembolic solutionBlood samples were obtained before, immediately after, and the day following the procedure just before CT scans and euthanasia. Livers were explanted and samples were obtained for histologic analysis. RESULTS: All animals survived the procedure and laboratory values of the control and experimental groups remained within normal limits. The control group had a diffuse or cloudy pattern of attenuation on follow-up CT scan the day after, consistent with gradual antegrade sinusoidal transit of the embolic material. The experimental group had clearly defined vascular casts with some degree of peripheral involvement. At histology, the control group samples had the appearance of normal liver, whereas the experimental group had coagulative necrosis in small pale, punctate areas extending several hundred microns away from the treated vessels and a brisk inflammatory response just outside the margins. CONCLUSION: In situ chemistry via thermoembolization shows early promise as a fundamentally new tactic for image-guided therapy of solid tumors.

Revealing the cerebello-ponto-hypothalamic pathway in the human brain.

The cerebellum is shown to be involved in some limbic functions of the human brain such as emotion and affect. The major connection of the cerebellum with the limbic system is known to be through the cerebello-hypothalamic pathways. The consensus is that the projections from the cerebellar nuclei to the limbic system, and particularly the hypothalamus, or from the hypothalamus to the cerebellar nuclei, are through multisynaptic pathways in the bulbar reticular formation. The detailed anatomy of the pathways responsible for mediating these responses, however, is yet to be determined. Diffusion tensor imaging may be helpful in better visualizing the surgical anatomy of the cerebello-ponto-hypothalamic (CPH) pathway. This study aimed to investigate the utility of high-spatial-resolution diffusion tensor tractography for mapping the trajectory of the CPH tract in the human brain. Fifteen healthy adults were studied. We delineated, for the first time, the detailed trajectory of the CPH tract of the human brain in fifteen normal adult subjects using high-spatial-resolution diffusion tensor tractography. We further revealed the close relationship of the CPH tract with the optic tract, temporo-pontine tract, amygdalofugal tract and the fornix in the human brain.

Outcomes of Planned Compared With Urgent Deliveries Using a Multidisciplinary Team Approach for Morbidly Adherent Placenta.

OBJECTIVE: To compare outcomes between planned and urgent cesarean hysterectomy for morbidly adherent placenta managed by a multidisciplinary team. METHODS: This is a retrospective case-control study of women with singleton pregnancies with antenatally suspected and pathologically confirmed morbidly adherent placenta who underwent cesarean hysterectomy between January 1, 2011, and February 30, 2017. Timing of delivery was classified as either planned (delivery at 34-35 weeks of gestation) or urgent (need for urgent delivery as a result of uterine contractions, bleeding, or both). The primary outcome variable was composite maternal morbidity. Logistic regression analysis was used to evaluate risk factors for urgent delivery. RESULTS: One hundred thirty patients underwent hysterectomy. Sixty (46.2%) required urgent delivery. Composite maternal morbidity was identified in 34 (56.7%) of the urgent and 26 (37.1%) of the planned deliveries (P=.03). Fewer units of red blood cells and fresh frozen plasma were transfused in the planned delivery group (red blood cells, median interquartile range 3 [0-8] versus 1 [0-4], P=.02; fresh frozen plasma, median interquartile range 1 [0-2] versus 0 [0-0], P=.001). Rates of low Apgar score and respiratory distress syndrome were higher in the urgent compared with the planned delivery group (5-minute Apgar score less than 7, 34 [59.6%] versus 14 [23.3%], P<.01; respiratory distress syndrome, 34 [61.8%] versus 16 [27.1%], P<.01). A history of two or more prior cesarean deliveries was an independent predictor of urgent delivery (adjusted odds ratio 11.4, 95% CI 1.8-71.1). CONCLUSION: Women with morbidly adherent placenta requiring urgent delivery have a worse outcome than women with planned delivery. Women with morbidly adherent placenta and two or more prior cesarean deliveries are at increased risk for urgent delivery. In such women, scheduling delivery before the standard 34- to 35-week timeframe may be reasonable.

Combined treatment with cervical pessary and vaginal progesterone for the prevention of preterm birth: A randomized clinical trial.

AIM: We compared the effectiveness of a combined treatment involving cervical pessary plus vaginal progesterone to vaginal progesterone alone in decreasing the rate of preterm birth in women with short cervix in the second gestational trimester. METHODS: This prospective, open-label, randomized clinical trial was conducted on 144 pregnant women with singleton pregnancy who had a cervical length ≤ 25 mm, at 18-22 gestational weeks (GW). Seventy-three patients were assigned to receive 400 mg of daily vaginal progesterone (group A), and 73 to receive cervical pessary plus 400 mg of daily vaginal progesterone (group B), until the 37th GW. The patients were then followed until delivery. RESULTS: The rates of preterm birth were 16.4% in group A and 19.7% in group B, which were not statistically different (P = 0.6). There were no statistically significant differences in the rates of preterm birth at <37, <34, <32, and ≤26 GW between participants randomized to each group (P = 0.55). The rates of low-birthweight delivery were 17.8% in group A, and 23.9% in group B, which were not statistically different (P = 0.36). The rates of premature rupture of membranes, chorioamnionitis, the requirement for neonatal intensive care unit admission, and fetal and neonatal deaths were similar between the two groups. CONCLUSION: In pregnancies with short cervix at mid-pregnancy, combination therapy of cervical pessary plus daily vaginal progesterone does not have any additional benefit over daily vaginal progesterone alone in reducing the rate of preterm birth and adverse pregnancy outcomes.