Splenic cysts: clues in sonographic differential diagnosis and a new role for twinkling artifact.

AIM: Our aim was to investigate the frequency of various splenic cysts, to define the sonographic differential diagnostic clues and to introduce the value of twinkling artefact in the diagnosis of epidermoid splenic cysts. MATERIAL AND METHODS: All the splenic cysts imaged by ultrasound in 3 university hospitals during the period of 2005 to 2022 were recorded, followed-up and analyzed. RESULTS: One hundred seventy-one patients with splenic cysts were detected and these were classified and 73% of the cysts were simple. Ten cysts were epidermoid cysts as proven by post-operative final histology. CONCLUSION: Cystic splenic lesions are rare. Most of them are small simple cysts. Epidermoid cysts are larger in volume, constitute 6% of the total and can be differentiated by the help of twinkling artefact by Doppler ultrasound.

MRI reliability in pediatric abdominal lymph node metastases?

BACKGROUND: Although positron emission tomography-computed tomography (PET-CT) is an effective imaging method used in the detection of lymph node metastases, repeated imaging increases X-ray exposure, especially in pediatric patients. Magnetic resonance imaging (MRI) may detect abdominal lymph nodes and provide subtle anatomic detail, and functional information without radiation. PURPOSE: To evaluate the reliability of MRI in detecting lymph node metastases in pediatric abdominal malignancies and to determine whether X-ray dose can be reduced by comparing its effectiveness with PET-CT. MATERIAL AND METHODS: Patients aged <18 years, diagnosed with abdominal malignant solid lesions between January 2015 and 2022 were included in this retrospective single-center study. A total of 14 A total of 14 different anatomic locations were defined for lymph nodes in MRI and PET-CT examinations. Cohen's kappa test was used to evaluate the consistency between PET-CT and MRI. P < 0.05 was considered statistically significant. RESULTS: In total, 25 patients (18 [72%] girls, 7 [28%] boys; mean age = 9.32 ± 16.9 years; age range = 1-18 years) with abdominal solid malignant tumors were included. The reliability of MRI and inter-observer reliability differed depending on the location of the lymph nodes. The reliability was almost perfect for the internal iliac (k = 0.915), porta hepatis, and aortocaval lymph node stations, while fair reliability was observed for the mesenteric lymph nodes (k = 0.525). CONCLUSION: The results showed that MRI was as reliable as PET-CT in detecting some intra-abdominal metastatic lymph nodes, while its reliability was lower in some lymph node stations.

The cribriform morphology impairs Gleason 7 prostate cancer lesion detection on multiparametric magnetic resonance imaging.

BACKGROUND: Prostate multiparametric magnetic resonance imaging (mpMRI) is a useful tool for the detection of tumor lesions however, some clinically significant lesions are still missed. We determined whether the cribriform pattern has an effect on lesion detection in mpMRI. METHODS: We reviewed the single-institution database of the patients who underwent mpMRI before radical prostatectomy. We included the patients only with the Gleason 7 final pathology of open radical prostatectomy with curative intent between 2016 and 2021. Prostatectomy mappings according to the 16-sector map and cribriform patterns were re-evaluated by two genitourinary pathologists. Prostate mpMRIs were read by two genitourinary radiologists. If the index and nonindex lesions in pathology mapping were matched with mpMRI as Prostate Imaging Reporting and Data System-3 or higher, it was defined as detectable. We compared the detection rates of lesions with and without cribriform morphology. In regression analysis, we also assessed the factors affecting the detectability of prostate cancer lesions. RESULTS: A total of 120 patients and 157 lesions were included in our study. While 52 of 83 cribriform pattern positive lesions could be detected in mpMRI, 59 of 74 cribriform pattern negative lesions could be detected (62.7% vs. 79.7%, respectively, p = 0.019). The lesions were also distributed homogeneously according to diameters and analyzed separately. All lesions between 21 and 30 mm with the negative cribriform pattern were detected on mpMRI. However, only 77.8% of cribriform pattern positive lesions between 21 and 30 mm could be detected (p = 0.034). The Higher D'Amico risk group and the absence of cribriform morphology were independent predictors for the lesion detection on mpMRI. CONCLUSION: The presence of cribriform pattern in Gleason 7 prostate cancer lesions decreases the lesion detection rate of mpMRI.

Comparison of Biparametric and Multiparametric Prostate Magnetic Resonance Imaging in Predicting Oncologic Outcomes After Radical Prostatectomy.

Objective: This study aimed to evaluate the difference in predicting the pathological stage of retropubic radical prostatectomy (RRP) and biochemical recurrence (BCR) in patients with Prostate Imaging Reporting and Data System (PIRADS) scores of 3 and 4 on biparametric prostate magnetic resonance imaging (bpMRI) compared to patients who upgraded from PIRADS 3 to PIRADS 4 based on the contrast-enhanced PIRADS version 2.1. Methods: This study evaluated 107 patients who underwent RRP and had preoperative multiparametric prostate magnetic resonance imaging (mpMRI) and were followed regularly. Group 1 included 31 patients evaluated as PIRADS 3 in both bpMRI and mpMRI, group 2 included 31 patients evaluated as PIRADS 3 in bpMRI and PIRADS 4 in mpMRI, and group 3 included 45 patients evaluated as PIRADS 4 without contrast. Comparisons were made between groups 1 and 2 and between groups 2 and 3. Results: No significant difference was found between the groups in terms of demographic data, preoperative or postoperative radiology, and pathology findings. Extraprostatic extension positivity and BCR were more common in group 2 compared to group 1 although not significant. Multivariate regression analysis was performed to determine the risk factors in predicting BCR, which revealed the positivity of seminal vesicle invasion and high pathological stage in the pathology report as significant factors. Prostate-specific antigen (PSA) and PSA density were higher in group 3 than in group 2, but without significance. Conclusions: This study revealed that mpMRI did not contribute in predicting BCR after RRP compared to bpMRI.

Comparison of 68Ga-PSMA PET/CT and mp-MRI in regard to local staging for prostate cancer with histopathological results: A retrospective study.

BACKGROUND: Imaging modalities are used to diagnose and clinical grading of clinically significant prostate cancer. In this study, 68Ga-PSMA PET/CT (PSMA) and multiparametric prostate MRI (mp-MRI) were compared in regard to locating intraprostatic tumor and locoregional staging. METHODS: After ethics committee approval, a total of 49 patients with prostate cancer who had mp-MRI and PSMA before radical prostatectomy were included. Preoperative and postoperative PSA, transrectal ultrasound-guided prostate biopsy (TRUS-Bx) ISUP grade, radical prostatectomy ISUP grade, body mass index (BMI), TRUS prostate volume, mp-MRI tumor mapping, PSMAtumor mapping, pathologic tumor mapping, extraprostatic extension (EPE), seminal vesicle invasion (SVI), lymph node invasion (LNI), and bladder neck invasion (BNI)were retrospectively evaluated. Index tumor was located by uroradiologist, nuclear medicine specialist, and uropathologist on a 12-sector prostate pathology map and compared with each other in terms of accuracy and locoregional clinical staging. RESULTS: Mean age of the patients was 66.18 ± 6.67 years and the mean of preoperative PSA results was 21.11 ± 32.56 ng/ml. Nearly half of the patients' (44.9%) pathology was reported as ISUP grade 4 and 5% and 18.4% of patients were surgical margin positive. According to the pathological findings, 362 out of 588 sectors were tumor-positive, 174 out of 362 sectors were tumor-positive in mp-MRI, and 175 out of 362 sectors were tumor-positive in PSMA. Both PSMA and mp-MRI were comparable (p = 0.823) and accurate to detect the location of the intraprostatic index tumor (AUC = 0.66 vs. 0.69 respectively, p = 0.82). The sensitivity and the specificity of the PSMA and mp-MRI for localizing intraprostatic index tumors were 42.5% versus 49.5% and 90.7% versus 88.6% respectively. mp-MRI was more accurate than PSMA in terms of EPE (AUC = 0.8 vs. AUC = 0.57 respectively, p = 0.027) and both methods were comparable in terms of SVI (AUC = 0.75 vs. AUC = 0.75, p = 0.886) and BNI (AUC = 0.51 vs. AUC = 0.59, p = 0.597). PSMA and mp-MRI were comparable in terms of LNI (AUC = 0.76 vs. AUC = 0.64, p = 0.39). CONCLUSION: mp-MRI should be considered for its high accuracy in the diagnosis of EPE, especially before decision-making for nerve-sparing surgery in high-risk patients. Both imaging modalities were accurate for localizing intraprostatic index tumor. PSMA is accurate for detecting LNI.

Cystic renal diseases: role of ultrasound. Part II, genetic cystic renal diseases.

Kidney cysts are quite common in adults. Though small simple renal cysts in an adult over 30-40 years of age are not too unusual, however, if the same cysts are seen in a child, and especially if there are additional findings, then several diagnostic possibilities may come to mind. The role of ultrasound, together with the help of intravenous contrast agents and Doppler mode, are very critical in describing the morphologic features and follow-up of the complex or multiple and bilateral renal cysts. These sonographic signs are occasionally specific for diagnosis, but in many cases sonographic clues should be evaluated together with the other genetic and clinical data to reach diagnosis.The first part of this pictorial essay included the introduction into the subject and the classification of non-genetic cystic renal diseases. The key features for the non-genetic cystic renal diseases are illustrated. In the second part, eye-catching features of genetic cystic renal diseases are demonstrated.

Diagnostic Accuracy of Five Different Classification Systems for Thyroid Nodules: A Prospective, Comparative Study.

OBJECTIVE: To compare the diagnostic performance of five different thyroid ultrasound classification systems, and determine which system is optimal for evaluating thyroid nodules and reducing the unnecessary biopsy rate. METHODS: In this prospective study, 1,010 nodules referred for biopsy during a 2-year period were classified using five classification systems: the Kwak Thyroid Imaging Reporting and Data System (Kwak TI-RADS), the European TI-RADS (EU TI-RADS, the Korean TI-RADS (K TI-RADS), the American College of Radiology TI-RADS (ACR TI-RADS), and the American Thyroid Association (ATA) classification. After fine needle aspiration biopsy, all classifications were compared for all nodules and also particularly for nodules sized 1-3 cm. Sensitivity, specificity, and interobserver agreement were evaluated for each classification system. RESULTS: Of the 939 nodules (after exclusion of Bethesda 3 nodules) finally classified according to the surgical histopathology and cytology results, 73 (7.8%) were malignant and 866 nodules were benign (92.2%). The sensitivity was highest (94.5%) for the ACR TI-RADS and lowest for the Kwak TI-RADS (69%). After exclusion of small (<1 cm) and large nodules (>3 cm); while sensitivity was highest for ATA (97.8%), ACR TI-RADS was the second best classification (91.3%). There was substantial agreement among all classification systems except the Kwak TI-RADS (fair agreement). CONCLUSIONS: The ACR TI-RADS was the most sensitive ultrasound risk stratification system for all nodules, while the Kwak TI-RADS was the most specific, ie, the most capable of excluding benign nodules based on the combined cytological and histopathological results. ATA and ACR-TIRADS were the most sensitive classification systems for nodules 1 to 3 cm in size. The ACR TI-RADS had higher sensitivity than the Bethesda classification system when compared according to the histopathological results.

The Relationship between PI-RADS Categories and Incidental Findings in Multiparametric Prostate MRI.

OBJECTIVE: To find the frequency and significance of extraprostatic incidental findings (ep-IFs) during multiparametric-magnetic prostate resonance imaging (mp-MRI), and compare them with prostate imaging reporting and data system (PI-RADS) outcomes. STUDY DESIGN: Analytical study. Place & Duration of Study: Goztepe Education and Research Hospital, Istanbul, Turkey, from June 2019 to January 2020. METHODOLOGY: Images of 185 men, who underwent mp-MRI, were reviewed and ep-IFs were also classified as urologic or non-urologic and benign or malign. The PI-RADS score was also recorded in biopsy-naïve subjects or in whom a sufficient time (which would not impair imaging) was elapsed after the biopsy. The cases were also divided into two groups, according to the PI-RADS score (Group 1: PI-RADS 1 or 2, Group 2: PI-RADS 3 or more) and the incidental findings (IFs) were compared between the groups. RESULTS: Overall, 139 ep-IFs were detected in 88 (47.6%) patients. The remaining 97 (52.4%) cases were free of ep-IFs. The ep-IFs were benign in 85 (96.6%) and malignant in 3 (3.4%) cases. The frequency of total ep-IFs did not differ between groups 1 and 2 (47.8% vs. 47.6%, respectively, p>0.05). CONCLUSION: Extra prostatic incitental findings are frequently encountered during mp-MRI, benign ep-IFs are quite frequent; although rare malignant ep-IFs may be subject to being missed due to focused analysis and interpretation of prostate. PI-RADS scoring system does not contribute to the diagnosis of incidental mp-MRI. Key Words: Incidental findings, Multiparametric prostate MRI, Prostate cancer, MP-MRI.

A practical approach for the management of small thyroid nodules referred for biopsy.

OBJECTIVE: Current guidelines recommend against routine ultrasound (US) guided fine-needle aspiration biopsy (FNAB) of small (<1 cm) thyroid nodules and suggest follow-up of ≥5 mm small nodules only if they are TI-RADS-5. This study aims to determine the best suspicious ultrasound features related to cytology results in patients referred for FNAB of small thyroid nodules and construct an algorithm for declining unnecessary biopsies and selection of patients to be followed up. METHODS: This prospective observational study enrolled patients referred for US-guided biopsy of ≤1 cm thyroid nodules. Ultrasound features including composition, echogenicity, shape, margin, echogenic focus, hypoechoic rim, vascularity were assessed. The cytology results were dichotomised as either benign or malignant/high risk. The features with excellent interobserver reliability and more than 90% sensitivity were selected. RESULTS: Overall, 95 patients [82 (86.3%) females, mean age 48.5 ± 11.9 years] with 95 small (≤1 cm) thyroid nodules were biopsied. Cytology revealed 15 (15.8%) malignant nodules. Pure solid composition, hypoechogenicity, taller than wide shape and irregular margin of the nodules were significantly associated with malignancy. Hypoechogenicity (100%) and pure solid composition (93%) had very high sensitivity and excellent interobserver agreement (Cohen's Kappa 0.83, P = .003 for both) for predicting high risk/malignant nodule. In the absence of these two features, 48 (50.5%) nodules either would not require FNAB or follow-up. CONCLUSION: The presence of cyst or iso/hyperechogenicity within a small thyroid nodule in patients already referred for invasive sampling safely allows for declining a decision of FNAB or follow-up without the concern of missing malignancy.

Gastric hepatoid carcinoma: Report of a case.

Gastric hepatoid carcinoma (GHC) is a rare type of gastric cancer with a tendency to have poor prognosis and metastasize to the liver. GHCs generally show histopathologically hepatocellular differentiation and secrete alpha fetoprotein (AFP). AFP production can occur in cancers originating from the embryologically similar liver, gastrointestinal tract, and yolk sac and often metastasizes to the liver. Although GHC is aggressive, it may not always cause liver metastasis and may invade into the other abdominal organs by direct contact. In this article, we present a case of locally advanced GHC with high AFP levels.

Computed Tomography-based Morphological Differences between Histologic Subtypes of Periampullary Ductal Adenocarcinoma.

OBJECTIVE: To evaluate the computed tomography (CT)-based differences between pancreaticobiliary (PBST) and intestinal (IST) subtypes of periampullary pancreatic ductal adenocarcinomas (PDAC). STUDY DESIGN: Analytical study. PLACE AND DURATION OF STUDY: Faculty of Medicine, Istanbul Medeniyet University, Göztepe Training and Research Hospital, Turkey between 2015 and 2018. METHODOLOGY: Overall 24 periampullary PDAC cases, in whom histomorphologic evaluation and CDx2 expression were used to discriminate between PBST and IST, were included. The lesion morphology (infiltrative versus nodular), common bile and main pancreatic ducts' dilation, tumor grade, enhancement pattern, pancreaticoduodenal groove, pancreaticoduodenal artery and lymphatic involvement were evaluated by CT. RESULTS: Overall 24 PDAC cases [median age 67.5 (60.5-76.5) years] were enrolled. Histopathology revealed 9 (25%) IST and 18 (75%) PBST. The age [72.5 (69-81) versus 63 (57.75-75.5) years, respectively, p=0.204] and gender [3 (50%) versus 12 (66.7%) males, respectively, p=0.635] and the prevalence of all CT characteristics were similar between groups (p>0.05 for all) except for lesion morphology. Infiltrative morphology was more frequent in PBST than IST [14 (77.8%) versus 1 (16.7%), respectively, p=0.015]. Multiple variable logistic regression analysis revealed infiltrative morphology as the only independent CT predictor of PBST [OR: 14.9, 95% CI: 1.2-186), p=0.036]. The interrater reproducibility for lesion morphology was moderate (Cohen's Kappa: 0.55, p<0.007). CONCLUSION: Infiltrative appearance is associated with PBST; whereas, nodular appearance more likely predicts IST. The potential role of CT lesion morphology on guiding appropriate chemotherapy in cases with no chance for surgery or biopsy requires addressing. Key Words: Intestinal differentiation, Pancreatobiliary differentiation, Periampullary adenocarcinoma.

Cystic renal diseases: role of ultrasound. Part I, non-genetic cystic renal diseases.

Kidney cysts are quite common in adults.  Though small simple renal cysts in an adult over 30-40 years of age are not too unusual, however, if the same cysts are seen in a child, and especially if there are additional findings, then several diagnostic possibilities may come to mind. The role of ultrasound, together with the help of intravenous contrast agents and Doppler mode, is very critical in describing the morphologic features and follow-up of the complex or multiple and bilateral renal cysts. Sonographic signs are occasionally specific for diagnosis, but in many cases they should be evaluated together with the other genetic and clinical data to reach a diagnosis.The first part of this pictorial essay includes "non-genetic cystic renal diseases" and the second part will include "genetic cystic renal diseases".

Unilateral Primary Adrenal B-Cell Lymphoma Clinically Mimicking Chronic Gastritis.

BACKGROUND: Primary adrenal lymphomas are a very rare type of extranodal lymphoma, and they usually are found bilaterally. Symptoms of the disease are variable and depend on the type of lymphoma and/ or presence of adrenal insufficiency. Magnetic resonance imaging is the best radiologic modality for differentiating lymphomas from other adrenal malignancies; however, histopathology is considered as the gold standard method for diagnosing extranodal lymphomas. CASE REPORT: We present a case of unilateral adrenal lymphoma that was initially diagnosed as an infectious disease and chronic gastritis, based on clinical and laboratory findings. Ultrasonography detected an adrenal mass, and magnetic resonance imaging excluded common lesions of the adrenal gland and showed lymphadenopathy around the major vessels of the abdomen. A percutaneous biopsy of the mass and bone marrow biopsy confirmed the diagnosis of primary adrenal lymphoma without bone marrow metastasis. CONCLUSIONS: Extranodal lymphomas can occur in almost every organ, and if nonspecific clinical findings are combined with the presence of a solid organ mass, lymphoma should be included in the differential diagnosis.

Echocardiography in imaging an extremely rare cause of extrinsic pulmonary stenosis: rapidly progressive primary mediastinal embryonal carcinoma.

We report a case of a young man with a very rare cause of atypical chest pain in whom primary mediastinal embryonal carcinoma causing extrinsic pulmonary stenosis was diagnosed with echocardiography and computed tomography. This patient illustrates an unusual presentation of the very rapid progression of the tumor in as little as 6 months. The patient underwent surgical resection and was successfully treated with adjuvant chemotherapy.