Intraperitoneal Barium From Gastrointestinal Perforations: Reassessment of the Prognosis and Long-Term Effects.

OBJECTIVE. The purpose of this study was to reassess the outcome and potential consequences of intraperitoneal barium leakage during radiologic evaluation of the gastrointestinal tract. MATERIALS AND METHODS. This retrospective study included 18 patients who had significant intraperitoneal leakage of barium from gastrointestinal perforations that were not suspected or diagnosed before the radiologic procedures. This complication occurred during a barium enema examination in nine patients, an upper gastrointestinal study in seven, and a small bowel series in two patients. All patients underwent urgent laparotomy for repair of perforation, with vigorous peritoneal lavage and antibiotic therapy. RESULTS. All patients had an uneventful recovery and were followed for 4-17 years (mean, 8.5 years). Radiographs obtained during this interval showed that a significant amount of residual barium was retained in the abdominal cavity. Six patients had a total of 10 subsequent abdominal operations for unrelated conditions, and some had developed barium granulomas and peritoneal adhesions. However, none of the patients in this series experienced intestinal obstruction or any clinical symptoms related to barium deposits in the abdominal cavity. CONCLUSION. Intraperitoneal leakage of barium is a rare complication of radiologic gastrointestinal examinations, and this series of 18 cases reflects 3 decades of experience at two major medical centers. The presented data indicate that the commonly held and perpetuated concept about the high rate of morbidity and mortality of this complication would not be valid in the modern era of medical and surgical management.

An overview of hepatocellular carcinoma with atypical enhancement pattern: spectrum of magnetic resonance imaging findings with pathologic correlation.

BACKGROUND: In the setting of cirrhotic liver, the diagnosis of hepatocellular carcinoma (HCC) is straightforward when typical imaging findings consisting of arterial hypervascularity followed by portal-venous washout are present in nodules larger than 1 cm. However, due to the complexity of hepatocarcinogenesis, not all HCCs present with typical vascular behaviour. Atypical forms such as hypervascular HCC without washout, isovascular or even hypovascular HCC can pose diagnostic dilemmas. In such cases, it is important to consider also the appearance of the nodules on diffusion-weighted imaging and hepatobiliary phase. In this regard, diffusion restriction and hypointensity on hepatobiliary phase are suggestive of malignancy. If both findings are present in hypervascular lesion without washout, or even in iso- or hypovascular lesion in cirrhotic liver, HCC should be considered. Moreover, other ancillary imaging findings such as the presence of the capsule, fat content, signal intensity on T2-weighted image favour the diagnosis of HCC. Another form of atypical HCCs are lesions which show hyperintensity on hepatobiliary phase. Therefore, the aim of the present study was to provide an overview of HCCs with atypical enhancement pattern, and focus on their magnetic resonance imaging (MRI) features. CONCLUSIONS: In order to correctly characterize atypical HCC lesions in cirrhotic liver it is important to consider not only vascular behaviour of the nodule, but also ancillary MRI features, such as diffusion restriction, hepatobiliary phase hypointensity, and T2-weighted hyperintensity. Fat content, corona enhancement, mosaic architecture are other MRI feautures which favour the diagnosis of HCC even in the absence of typical vascular profile.

Management of Incidental Liver Lesions on CT: A White Paper of the ACR Incidental Findings Committee.

The ACR Committee on Incidental Findings presents recommendations for managing liver lesions that are incidentally detected on CT. These recommendations represent an update from the liver component of the ACR 2010 white paper on managing incidental findings in the pancreas, adrenal glands, kidneys, and liver. The Liver Subcommittee-which included five abdominal radiologists, one hepatologist, and one hepatobiliary surgeon-developed this algorithm. The recommendations draw from published evidence and expert opinion and were finalized by informal iterative consensus. Algorithm branches categorize liver lesions on the basis of patient characteristics and imaging features. They terminate with an assessment of benignity or a specific follow-up recommendation. The algorithm addresses most, but not all, pathologies and clinical scenarios. The goal is to improve the quality of care by providing guidance on how to manage incidentally detected liver lesions.

Pathologic Subtypes of Ampullary Adenocarcinoma: Value of Ampullary MDCT for Noninvasive Preoperative Differentiation.

OBJECTIVE: The purpose of this study was to evaluate the utility of ampullary MDCT in the noninvasive, preoperative differentiation of pancreatobiliary and intestinal subtypes of ampullary adenocarcinoma. MATERIALS AND METHODS: This retrospective study included 32 patients (20 men, 12 women; age range, 41-81 years) with resected ampullary adenocarcinoma who underwent preoperative contrast-enhanced ampullary MDCT. Two radiologists, blinded to pathologic diagnosis of adenocarcinoma subtype, evaluated the presence of seven MDCT features independently. MDCT findings and ampullary adenocarcinoma subtypes were correlated using chi-square and Fisher exact tests. Interobserver agreement was evaluated using the Cohen kappa statistic. RESULTS: When evaluated with ampullary MDCT, the intestinal and pancreatobiliary subtypes were significantly different in terms of lesion morphology (p < 0.0001), papillary shape (p < 0.0001), common bile duct (CBD) infiltration and dilatation (p = 0.003 and p = 0.0004, respectively), duodenopancreatic groove infiltration (p = 0.0009), and pancreaticoduodenal artery involvement (p = 0.004). Pancreatobiliary subtype tumors were more often infiltrative in morphology (18/18) and showed retracted papilla (14/18), CBD (18/18) and main pancreatic duct (MPD) infiltration (12/18), dilated CBD (18/18) and MPD (13/18), fixed duodenopancreatic groove appearance (15/18), and pancreaticoduodenal artery involvement (12/18). Intestinal subtype carcinomas were more frequently nodular (14/14) and had a bulging papilla (13/14), a free duodenopancreatic groove appearance (11/14), and no pancreaticoduodenal artery involvement (2/14). When all features were taken into account, MDCT showed sensitivity of 85.7% and specificity of 83.3% in differentiating intestinal and pancreatobiliary subtype tumors. Accuracy, positive predictive value, and negative predictive value of MDCT were 84.4%, 80%, and 88.2%, respectively. Interobserver agreement was almost perfect for the presence of each imaging feature (κ > 0.8). CONCLUSION: Ampullary MDCT can be useful to differentiate pancreatobiliary and intestinal subtypes of ampullary adenocarcinoma preoperatively, provided the duodenum is optimally distended at imaging.

Rethinking Normal: Benefits and Risks of Not Reporting Harmless Incidental Findings.

The authors explore the benefits and risks of not reporting imaging findings that do not have clinical relevance, with the goal of developing recommendations to reduce their reporting. The authors review the example of incidentally detected, simple renal cysts (Bosniak category I), including medicolegal conditions required for such a shift in reporting practices to be acceptable. The authors propose four potential criteria for not reporting clinically unimportant findings and recommend that these criteria be debated in other contexts, so that they can be refined and implemented.

Clinical significance of mesenteric panniculitis-like abnormalities on abdominal computerized tomography in patients with malignant neoplasms.

AIM: To clarify the association of malignancy with mesenteric panniculitis-like changes on computed tomography (CT). METHODS: All abdominal CT scans performed at NorthShore University HealthSystem showing mesenteric panniculitis from January 2005 to August 2010 were identified in the Radnet (RadNet Corporation, Los Angeles, CA) database. Patients with a new or known diagnosis of a malignancy were included for this analysis. Longitudinal clinical histories were obtained from electronic medical records. RESULTS: In total, 147794 abdominal CT scans were performed during the study period. Three hundred and fifty-nine patients had mesenteric panniculitis (MP)-like abnormalities on their abdominal CT. Of these patients, 81 patients (22.6%) had a known history of cancer at the time of their CT scan. Nineteen (5.3%) had a new diagnosis of cancer in concurrence with their CT, but the majority of these (14/19, 74%) were undergoing CT as part of a malignancy evaluation. Lymphomas were the most common cancers associated with MP-like findings on CT (36 cases, 36%), with follicular lymphoma being the most frequent subtype (17/36). A variety of solid tumors, most commonly prostate (7) and renal cell cancers (6) also were seen. CT follow up was obtained in 56 patients. Findings in the mesentery were unchanged in 45 (80%), worsened in 6 (11%), and improved in 5 patients (9%). Positron emission tomography (PET) scans performed in 44 patients only showed a positive uptake in the mesenteric mass in 2 patients (5%). CONCLUSION: A new diagnosis of cancer is uncommon in patients with CT findings suggestive of MP. MP-like mesenteric abnormalities on CT generally remain stable in patients with associated malignancies. PET scanning is not recommended in the evaluation of patients with mesenteric panniculitis-like findings on CT.

Change in volume parameters induced by neoadjuvant chemotherapy provide accurate prediction of overall survival after resection in patients with oesophageal cancer.

OBJECTIVES: To assess the prognostic value of volumetric parameters measured with CT and PET/CT in patients with neoadjuvant chemotherapy (NACT) and resection for oesophageal cancer (EC). METHODS: Patients with locally advanced EC, who were treated with NACT and resection, were retrospectively analysed. Data from CT volumetry and (18) F-FDG PET/CT (maximum standardized uptake [SUVmax], metabolic tumour volume [MTV], and total lesion glycolysis [TLG]) were recorded before and after NACT. The impact of volumetric parameter changes induced by NACT (MTVRATIO, TLGRATIO, etc.) on overall survival (OS) was assessed using a Cox proportional hazards model. RESULTS: Eighty-four patients were assessed using CT volumetry; of those, 50 also had PET/CT before and after NACT. Low post-treatment CT volume and thickness, MTV, TLG, and SUVmax were all associated with longer OS (p < 0.05), as were CTthicknessRATIO, MTVRATIO, TLGRATIO, and SUVmaxRATIO (p < 0.05). In the multivariate analysis, only MTVRATIO (Hazard ratio, HR 2.52 [95% Confidence interval, CI 1.33-4.78], p = 0.005), TLGRATIO (HR 3.89 [95%CI 1.46-10.34], p = 0.006), and surgical margin status (p < 0.05), were independent predictors of OS. CONCLUSIONS: MTVRATIO and TLGRATIO are independent prognostic factors for survival in patients after NACT and resection for EC. KEY POINTS: • Change in PET parameters shows close correlation to survival in oesophageal cancer. • Association with OS is independent of changes in SUVmax and CT volume. • Metabolic parameters after NACT correlate with pathologic response and nodal status. • Metabolic parameters may be better suited than SUVmax for response assessment.

The incidental cystic pancreas mass: a practical approach.

Technical advances in cross-sectional imaging have led to the discovery of incidental cystic pancreatic lesions in the oncology and non-oncology population that in the past remained undetected. These lesions have created a diagnostic and management dilemma for both clinicians and radiologists: should these lesions be ignored, watched, aspirated, or removed? In this review, recommendations concerning the assessment of the more common pancreatic cystic incidental lesions are presented.

That liver lesion on MDCT in the oncology patient: is it important?

Multidetector-row computed tomography (MDCT) has become the primary imaging test for the staging and follow-up of most malignancies that originate outside of the central nervous system. Technical advances in this imaging technique have led to significant improvement in the detection of metastatic disease to the liver. An unintended by-product of this improving diagnostic acumen is the discovery of incidental hepatic lesions in oncology patients that in the past remained undetected. These ubiquitous, incidentally identified hepatic lesions have created a management dilemma for both clinicians and radiologists: are these lesions benign or do they represent metastases? Naturally, the answer to this question has profound prognostic and therapeutic implications. In this review, guidelines concerning the diagnosis and management of some of the more common hepatic incidental lesions detected in patients with extrahepatic malignancies are presented.

Comprehensive review of the diagnosis and treatment of biliary tract cancer 2012. Part II: multidisciplinary management.

Biliary tract cancers (gallbladder cancer, intra- and extra-hepatic cholangiocarcinoma and selected periampullary cancers) accounted for 12,760 new cases of cancer in the USA in 2010. These tumors have a dismal prognosis with most patients presenting with advanced disease. Early, accurate diagnosis is essential, both for potential cure where possible and for optimal palliative therapy in all others. This review examines the currently available and emerging technologies for diagnosis and treatment of this group of diseases.

Comprehensive review of the diagnosis and treatment of biliary tract cancer 2012. Part I: diagnosis-clinical staging and pathology.

Biliary tract cancers (gallbladder cancer, intra- and extra-hepatic cholangiocarcinoma, and selected periampullary cancers) accounted for 12,760 new cases of cancer in the USA in 2010. These tumors have a dismal prognosis with most patients presenting with advanced disease. Early, accurate diagnosis is essential, both for potential cure where possible and for optimal palliative therapy in all others. This review examines the currently available and emerging technologies for diagnosis and treatment of this group of diseases.

Barrett's esophagus: clinical features, obesity, and imaging.

The following includes commentaries on clinical features and imaging of Barrett's esophagus (BE); the clinical factors that influence the development of BE; the influence of body fat distribution and central obesity; the role of adipocytokines and proinflammatory markers in carcinogenesis; the role of body mass index (BMI) in healing of Barrett's epithelium; the role of surgery in prevention of carcinogenesis in BE; the importance of double-contrast esophagography and cross-sectional images of the esophagus; and the value of positron emission tomography/computed tomography.

Accuracy of hydro-multidetector row CT in the local T staging of oesophageal cancer compared to postoperative histopathological results.

OBJECTIVE: To evaluate the accuracy of multidetector computed tomography with water filling (Hydro-MDCT) in the T-staging of patients with oesophageal cancer. MATERIALS AND METHODS: There were 131 consecutive patients who were preoperatively and prospectively examined in the prone position on arterial phase contrast-enhanced MDCT, after ingestion of 1,000-1,500 ml tap water and effervescent granules. Two readers staged the local tumour growth (T-staging) independently. They assessed tumour location, size, presence of stenosis, and morphology of the outer border of the oesophageal wall and perioesophageal fat planes on CT. CT findings were compared with histopathological results from resected specimens. Data were analyzed using the SPSS statistical package. RESULTS: Both readers obtained a high sensitivity of 95% and a high positive predictive value of 96%. Accurate local staging was achieved in 76.3% and 68.7% for readers 1 and 2, respectively. Inter-reader agreement was excellent (weighted κ value of 0.93 and un-weighted κ of 0.89). CONCLUSION: Using the hydro-technique and applying specific assessment criteria, MDCT appears to be an accurate, non-invasive diagnostic tool for local tumour staging of oesophageal cancer.

The adnexal incidentaloma: a practical approach to management.

There has been explosive growth in the utilization of cross-sectional imaging studies in the evaluation of patients with known or suspected abdominal and pelvic pathology. These imaging studies have led to a veritable epidemic of incidentally detected adnexal masses in both oncology and non-oncology patient populations that in the past remained undiscovered. In this commentary we provide some guidance and practical advice for further investigation and management of the adnexal incidentaloma.

Hepatic incidentalomas.

Recent advances in multidetector-row computed tomography, magnetic resonance imaging, and ultrasonography have led to the detection of incidental hepatic lesions in both the oncology and nononcology patient population that in the past remained undiscovered. These incidental hepatic lesions have created a management dilemma for both clinicians and radiologists. In this review, guidelines concerning the diagnosis and management of some of the more common hepatic incidentalomas are presented.

The incidental pancreatic cyst.

The discovery of a pancreatic cyst in an asymptomatic patient presents an immediate challenge to the interpreting radiologist, the clinician who manages the patient, and patients themselves. When a cyst is discovered on imaging in a patient without symptoms directly referable to the pancreas, the following questions are immediately raised: can the lesion be accurately diagnosed or is the appropriate management clear from the examination, is the best management approach to suggest watchful waiting with follow-up imaging, what is the best method for imaging follow-up, and what is the optimal frequency of follow-up? This article recommends an approach to analyzing patients with incidental pancreatic cysts.

Managing incidental findings on abdominal CT: white paper of the ACR incidental findings committee.

As multidetector CT has come to play a more central role in medical care and as CT image quality has improved, there has been an increase in the frequency of detecting "incidental findings," defined as findings that are unrelated to the clinical indication for the imaging examination performed. These "incidentalomas," as they are also called, often confound physicians and patients with how to manage them. Although it is known that most incidental findings are likely benign and often have little or no clinical significance, the inclination to evaluate them is often driven by physician and patient unwillingness to accept uncertainty, even given the rare possibility of an important diagnosis. The evaluation and surveillance of incidental findings have also been cited as among the causes for the increased utilization of cross-sectional imaging. Indeed, incidental findings may be serious, and hence, when and how to evaluate them are unclear. The workup of incidentalomas has varied widely by physician and region, and some standardization is desirable in light of the current need to limit costs and reduce risk to patients. Subjecting a patient with an incidentaloma to unnecessary testing and treatment can result in a potentially injurious and expensive cascade of tests and procedures. With the participation of other radiologic organizations listed herein, the ACR formed the Incidental Findings Committee to derive a practical and medically appropriate approach to managing incidental findings on CT scans of the abdomen and pelvis. The committee has used a consensus method based on repeated reviews and revisions of this document and a collective review and interpretation of relevant literature. This white paper provides guidance developed by this committee for addressing incidental findings in the kidneys, liver, adrenal glands, and pancreas.

Gallbladder imaging.

The treatment of gallbladder disease has been revolutionized by improvements in laparoscopic surgery as well as endoscopic and radiologic interventional techniques. Therapeutic success is dependent on accurate radiologic assessment of gallbladder pathology. This article describes recent technical advances in ultrasonography, multidetector computed tomography, magnetic resonance imaging, positron emission tomography, and scintigraphy, which have significantly improved the accuracy of noninvasive imaging of benign and malignant gallbladder disease. The imaging findings of common gallbladder disorders are presented, and the role of each of the imaging modalities is placed in perspective for optimizing patient management.

Pathways of abdominal tumour spread: the role of the subperitoneal space.

The subperitoneal space is a large, unifying, anatomically continuous potential space that connects the peritoneal cavity with the retroperitoneum. This space is formed by the subserosal areolar tissue that lines the inner surfaces of the peritoneum and the musculature of the abdomen and pelvis. It contains the branches of the vascular, lymphatic, and nervous systems that supply the viscera. The subperitoneal space extends into the peritoneal cavity and is invested between the layers of the mesenteries and ligaments that support and interconnect the abdominal and pelvic organs. As such, it provides one large continuous space in which infectious, neoplastic, inflammatory, and hemorrhagic disease may spread in many directions.

Biliary tract neoplasms: diagnosis and staging.

Most biliary tract neoplasms are malignant and have been traditionally divided into cancers of the gallbladder, the extrahepatic bile ducts, and ampulla of Vater. Although infrequent, bile duct carcinomas and cancer of the gallbladder are not rare. In the United States, an estimated 6000-7000 new cases of carcinoma of the gallbladder and 3000-4000 new cases of carcinoma of the bile ducts are diagnosed annually. Familiarity with the imaging characteristics of gallbladder and bile duct neoplasms is important to expedite the diagnosis and appropriate treatment of patients who often present with non-specific symptoms of right upper quadrant pain, jaundice, and weight loss.