Imaging Findings in Cirrhotic Liver: Pearls and Pitfalls for Diagnosis of Focal Benign and Malignant Lesions.

Cirrhosis is the end stage of chronic liver disease and causes architectural distortion and perfusional anomalies. It is a major risk factor for developing hepatocellular carcinoma (HCC). Common disease entities in noncirrhotic livers, such as hemangiomas, can be rare in cirrhotic livers, and benign entities such as confluent hepatic fibrosis and focal nodular hyperplasia-like lesions may mimic the appearance of malignancies,. HCC usually has typical imaging characteristics, such as the major features established by the Liver Imaging Reporting and Data System. However, HCC can also have a spectrum of atypical or uncommon appearances, such as cystic HCC, hypovascular HCC, or macroscopic fat-containing HCC. HCCs with certain genetic mutations such as CTNNB-1-mutated HCC can harbor unique imaging features not seen in other types of HCC. In addition, malignancies that are less common than HCC, such as cholangiocarcinoma and metastases, which can be difficult to differentiate, can still occur in cirrhotic livers. Atypical imaging features of benign and malignant lesions can be challenging to accurately diagnose. Therefore, familiarity with these features and an understanding of the prevalence of disease entities in cirrhotic livers are key in the daily practice of radiologists for evaluation of cirrhotic livers. The authors illustrate the typical and atypical features of benign and malignant lesions in cirrhosis and discuss the technical pitfalls and unique advantages associated with various imaging modalities in assessing cirrhotic livers, including noncontrast and contrast-enhanced US, CT, and MRI. Work of the U.S. Government published under an exclusive license with the RSNA. Quiz questions for this article are available in the supplemental material.

Perirenal lymphatics: anatomy, pathophysiology, and imaging spectrum of diseases.

Despite being rarely discussed, perinephric lymphatics are involved in many pathological and benign processes. The lymphatic system in the kidneys has a harmonious dynamic with ureteral and venous outflow, which can result in pathology when this dynamic is disturbed. Although limited by the small size of lymphatics, multiple established and emerging imaging techniques are available to visualize perinephric lymphatics. Manifestations of perirenal pathology may be in the form of dilation of perirenal lymphatics, as with peripelvic cysts and lymphangiectasia. Lymphatic collections may also occur, either congenital or as a sequela of renal surgery or transplantation. The perirenal lymphatics are also intimately involved in lymphoproliferative disorders, such as lymphoma as well as the malignant spread of disease. Although these pathologic entities often have overlapping imaging features, some have distinguishing characteristics that can suggest the diagnosis when paired with the clinical history.

Malignant Germ Cell Tumors of the Ovary: Clinical and Imaging Features.

Ovarian malignant germ cell tumors are a diverse set of masses originating from the primitive gonadal germ cells, often in young females. They have useful imaging and clinical features, including serum tumor marker elevation, that may aid the radiologist at the time of diagnosis, and also during follow-up. Accurate and timely diagnosis is essential, as standard-of-care therapies lead to a high rate of cancer remission.

Multimodality Imaging of Cholecystectomy Complications.

Cholecystectomy is one of the most common surgeries performed in the United States. Although complications are uncommon, the high incidence of this surgery means that a radiologist will likely encounter these complications in practice. Complications may arise in the immediate postoperative period or can be delayed for weeks, months, or years after surgery. Vague and nonspecific symptoms make clinical diagnosis challenging. As a result, multimodality imaging is important in postoperative evaluation. US and multidetector CT are the usual first-line imaging modalities. Hepatobiliary scintigraphy, SPECT/CT, and MRI with conventional or gadoxetate hepatobiliary contrast material are important and complementary modalities that are used for workup. The authors begin with a brief discussion of surgical technique and expected postoperative findings and then describe complications organized into four groups: (a) biliary complications, (b) stone-related complications, (c) iatrogenic complications, and (d) gallbladder complications. Biliary complications include bile leaks and bilomas, acute biliary obstruction, and biliary stricture. Stone-related complications include retained and recurrent stones and spillage of stones into the peritoneum. Iatrogenic complications include hemorrhage, vasculobiliary injury, arterial pseudoaneurysms, duodenal injury, and migration of clips. Gallbladder complications include recurrent cholecystitis after subtotal reconstituting cholecystectomy and unexpected gallbladder cancer. An invited commentary by Mullens and Ibrahim is available online. Online supplemental material is available for this article. ©RSNA, 2022.

Review of uterine fibroids: imaging of typical and atypical features, variants, and mimics with emphasis on workup and FIGO classification.

Uterine fibroids are the most common gynecologic neoplasm. Although non-degenerated fibroids are easily identifiable on imaging, degenerated fibroids, fibroid variants, and fibroids with unusual growth patterns can constitute a diagnostic dilemma. Identification of these abnormal morphologic features can alter the diagnosis of presumed uterine fibroids and hence change management plans. This article reviews the typical and atypical radiologic imaging features of uterine fibroids, with an emphasis on the pitfalls, mimics, and radiologically identifiable features that can alter clinical management plans.

Fat-containing pelvic lesions in females.

Pelvic tumors are common in females and have a broad differential diagnosis. The clinical management of pelvic tumors varies widely-from observation to surgical resection-and imaging plays a pivotal role in diagnosis and clinical decision-making in these cases. In particular, imaging can help determine the organ of origin and tissue content of these tumors, which are the most important steps to narrowing the differential diagnosis. Fat has a characteristic appearance and is often easily identified on ultrasonography (US), computed tomography (CT), and magnetic resonance imaging (MRI). The amount and distribution of intralesional fat varies in different types of tumors. Macroscopic intralesional fat is often easily recognized by its hyperechoic appearance on US and low attenuation on CT similar to subcutaneous fat. On MRI, macroscopic fat is hyperintense on T1-weighted (T1W) images, with characteristic signal loss on fat-saturated sequences and India-ink artifact on opposed-phase T1W images. Macroscopic fat is the hallmark of teratomas, which are the most common ovarian neoplasms. Uterine lipoleiomyomas, peritoneal loose bodies, intraperitoneal and extraperitoneal primary lipomatous tumors such as lipoma and liposarcomas, and extra-adrenal myelolipomas are other pelvic masses distinguished by the presence of macroscopic fat. However, the imaging diagnosis of pelvic masses containing minimal or microscopic fat, such as immature ovarian teratomas, steroid cell ovarian neoplasms, and extramedullary hematopoiesis, can present a diagnostic challenge owing to their nonspecific appearance on US or CT. Obtaining MRI with in-phase and opposed-phase dual-echo T1W sequences and depicting chemical shift artifacts can be helpful in distinguishing these lesions.

Sciatic foramen anatomy and common pathologies: a pictorial review.

This article reviews the relevant anatomy, imaging features on computed tomography, magnetic resonance imaging, and management of common processes involving the sciatic foramen. The anatomy of the sciatic foramen is complex and provides an important conduit between the pelvis, gluteus, and lower extremity. This paper reviewed the anatomy, common pathologies, and imaging features of this region including trauma, infection, nerve entrapment, tumor spread, hernia, and vascular anomaly.

Solitary fibrous tumors: Clinical and imaging features from head to toe.

Solitary fibrous tumors (SFTs) are rare fibroblastic mesenchymal tumors that are usually benign with variable malignant potential. They can develop in any organ due to their spindle cell origin. The exact etiology of solitary fibrous tumors is unknown. The majority of SFTs are benign with 10-30% of them exhibiting aggressive and malignant features. The aggressiveness of this type of tumor is not associated with its histological features, which makes surgical resection the treatment of choice. We will review the clinical and radiological features and possible differential diagnoses of SFTs according to their anatomical sites following the World Health Organization 2020 classification.

An Overview of Selected Rare B-Cell Lymphoproliferative Disorders: Imaging, Histopathologic, and Clinical Features.

Lymphoproliferative disorders (LPD) are conditions characterized by the uncontrolled proliferation of B or T-cell lines. They encompass a wide spectrum of abnormalities, which may be broadly classified as reactive processes or malignant diseases, such as lymphoma, based on their cellular clonality and clinical behavior. While some of these disorders are rare, they may be encountered sporadically in clinical practice, causing diagnostic dilemmas owing to overlap in their clinical and imaging features with more common disorders. The updated 4th edition WHO classification of lymphoid neoplasms was released in 2016 to incorporate the rapid clinical, pathological, molecular biology and cytogenetic advances of some of these disorders. Despite these updates, very little information is presented in the literature from the radiology perspective. The aim of this article is to familiarize radiologists and other physicians with certain rare variants of B-cell lymphoproliferative disorders with a focus on imaging features of these disorders, as well as to provide an overview of some important updates contained within the new WHO classification of lymphoid neoplasms.

Uncommon Variants of Mature T-Cell Lymphomas (MTCLs): Imaging and Histopathologic and Clinical Features with Updates from the Fourth Edition of the World Health Organization (WHO) Classification of Lymphoid Neoplasms.

Understanding the pathogenesis and molecular biology of malignant lymphomas is challenging, given the complex nature and incongruity of these disorders. The classification of lymphoma is continually evolving to account for advances in clinical, pathological, molecular biology and cytogenetic aspects, which impact our understanding of these disorders. The latest fourth edition of the WHO classification of lymphoid malignancies was released in 2016 to account for these changes. Additionally, unlike B-cell lymphomas (BCL), T-cell lymphomas (TCL) are uncommon, and may be sporadically experienced in clinical practice. These disorders are rare, thus early diagnosis is challenging for both physicians and radiologists, owing to the overlap in clinical and imaging features with other, more common disorders. We aim to discuss some rare variants of T-cell lymphomas, including clinicopathologic and imaging features, as well as to give a glimpse of the updates contained within the new 2016 WHO classification.

Adrenal hemorrhage and hemorrhagic masses; diagnostic workup and imaging findings.

Adrenal hemorrhage (AH) is a rare condition. It can be traumatic or non-traumatic. Most common causes are septicemia, coagulopathy or bleeding diathesis, and underlying neoplasms. Other reported less common causes of AH are COVID-19 and neonatal stress. Clinical diagnosis of AH is challenging due to its non-specific presentation and occurrence in the setting of acute medical illness. Therefore, most cases are diagnosed incidentally on imaging. Having high clinical suspicion in the proper clinical setting for AH is crucial to avoid life-threatening adrenal insufficiency that occurs in 16-50% of patients with bilateral AH. We discuss the clinical situations that predispose to AH, review the imaging features on different imaging modalities, highlight a variety of clinical cases, imaging features that should be concerning for an underlying neoplasm, and outline the potential role of interventional radiology in management of AH.

Ligament of Treitz: Anatomy, Relevance of Radiologic Findings, and Radiologic-Pathologic Correlation.

OBJECTIVE. The objective of this article is to discuss the anatomy, embryonic origin, normal variants, and various attachments of the ligament of Treitz. We also describe the pathologic processes that develop along the ligament of Treitz and the role of cross-sectional imaging in identifying these conditions. CONCLUSION. The ligament of Treitz, also known as the suspensory ligament of the duodenum, is an important anatomic landmark in the abdomen. It is essential that radiologists understand the anatomic attachments, normal variants, and various pathologic conditions involving the ligament of Treitz as well as the role of cross-sectional imaging in the assessment of these conditions.

Effect of the COVID-19 pandemic on CT scans ordered from the emergency department for abdominal complaints.

PURPOSE: The COVID-19 pandemic has affected healthcare systems and patients alike across the USA. We seek to elucidate changes in abdominal imaging ordered from the emergency department (ED) in a healthcare system undergoing non-surge conditions in April 2020 compared to April 2019. METHODS: We performed a retrospective, observational study comparing patients undergoing CT scans of the abdomen and pelvis ordered from the ED in April 2020 vs. April 2019 at a single healthcare center. Via review of the radiology report and electronic medical record, we determined the positive or negative status of these scans. We evaluated percentages of positive CT scans and differences in outcomes, including admission rates, interventions, and mortality. RESULTS: Comparing 2020 to 2019, there was a 31.6% decrease in the number of CT scans performed from the ED. We found a higher percentage of positive CT findings, 58.2% vs. 50.8% (p = 0.025), and increased admission rates, 40.8% vs. 34.1% (p = 0.036). Differences were found in rates of appendicitis, colitis, and cholangitis. No difference was found in ICU admissions, interventions, or in-hospital mortality. CONCLUSION: During the COVID-19 pandemic in a region undergoing non-surge conditions, we found increased rates of positive CT scans performed from the ED for abdominal complaints with an increased percentage of hospital admissions compared to a control year. No differences in ICU admissions or rates of procedural intervention were found to suggest higher acuity of pathology on presentation. Our findings suggest appropriately decreased healthcare utilization in our study period, driven by pre-hospital patient self-selection.

Trans-diaphragmatic Pathologies: Anatomical Background and Spread of Disease on Cross-sectional Imaging.

The diaphragm is not only a sheet of muscle separating the abdominal and thoracic cavities: it plays an essential role in ventilation and can act as a gateway for the spread of different disease processes between the abdominal and the thoracic cavity. Careful attention to the appearance of the diaphragm on various imaging modalities is essential to ensure the accurate diagnosis of diaphragmatic disorders, which may be secondary to functional or anatomical derangements.

A review of anatomy, pathology, and disease spread in the perisplenic region.

The perisplenic region is a complex anatomical area involving multiple peritoneal and subperitoneal structures, which influence the presentation and behavior of various pathologic processes. This review is a comprehensive resource for perisplenic anatomy and pathology with associated clinical presentations and imaging findings. Understanding the pathophysiologic intricacies of the perisplenic region assists the radiologist in building a helpful differential diagnosis and recognizing predictable disease patterns.

Cross-Sectional Imaging Evaluation of Vascular Lesions in the Gastrointestinal Tract and Mesentery.

Gastrointestinal (GI) tract and mesenteric vascular lesions can have various clinical presentations, of which GI bleeding is the most common. This collection of pathology is highly variable in etiology ranging from occlusive disease to vascular malformations to trauma to neoplasms which makes for a challenging workup and diagnosis. The advent of multiple imaging modalities and endoscopic techniques makes the diagnosis of these lesions more achievable, and familiarity with their various imaging findings can have a significant impact on patient management. In this article, we review the gamut of GI tract and mesenteric vascular lesions and their associated imaging findings.

The Lesser Sac and Foramen of Winslow: Anatomy, Embryology, and CT Appearance of Pathologic Processes.

OBJECTIVE. This article reviews the embryologic development, relevant anatomy, and imaging features, on CT, of pathologic processes involving the lesser sac and foramen of Winslow. CONCLUSION. The lesser peritoneal sac is an intricate anatomic region involved in many disease processes. It is a significant conduit for the spread of disease within the peritoneal cavity. The spectrum of pathologic processes pertaining to the lesser sac can be classified on the basis of the type of involvement, such as a fluid collection (e.g., transudate, exudate, bile, and blood), a mass (e.g., neoplastic or nonneoplastic conditions and lymphadenopathy), or an internal hernia into the lesser sac.

Morison's pouch: anatomical review and evaluation of pathologies and disease spread on cross-sectional imaging.

The peritoneum is a complex structure. Having a better understanding of this complex anatomy will enable the radiologist to accurately assess and diagnose the wide range of intra-abdominal pathologies. In this article, we review the anatomy, boundaries, and connections of Morison's pouch. In addition, we discuss the incidence and development of common pathological conditions within Morison's pouch and the role of multiple imaging modalities in assessment and diagnosis of these conditions.