Case 330.

HISTORY: A 30-year-old female patient with a history of infertility and no pregnancy presented to the gynecologic endometriosis clinic for follow-up 1 month after oocyte retrieval, to be evaluated for pelvic optimization before potential embryo transfer, with worsening dysmenorrhea, dyspareunia, and overall pelvic pain. Eleven years prior, the patient had undergone left ovarian cystectomy for treatment of endometrioma, as well as excision of deep infiltrative endometriosis. The oocyte retrieval procedure, where more than 30 eggs were retrieved, was complicated by ovarian hyperstimulation syndrome and intraperitoneal bleeding, which necessitated admission to the intensive care unit (ICU) for 3 days. Following discharge from the ICU, the patient experienced occasional on-and-off pressure of the urinary bladder and persistent aching pelvic pain. At the 1-month follow-up appointment, the patient's vital signs were assessed (blood pressure, 142/94 mm Hg; pulse rate, 95 per minute; temperature, 96.8 °F [36 °C]). Routine blood investigations, including white blood cell count, were within normal limits. Physical examination showed the abdomen was soft but there was mild pelvic tenderness. The serum ß-human chorionic gonadotropin test result was negative for pregnancy, and urinalysis testing showed no leukocyte esterase or nitrites. MRI of the pelvis (Figs 1-3) was performed to evaluate the worsening pain.

TOpCLASS Expert Consensus Classification of Perianal Fistulizing Crohn's Disease: A Real-World Application in a Serial Fistula MRI Cohort.

BACKGROUND AND AIMS: Perianal fistulizing Crohn's disease (PFCD) is an aggressive phenotype of Crohn's disease defined by frequent relapses and disabling symptoms. A novel consensus classification system was recently outlined by the TOpCLASS consortium that seeks to unify disease severity with patient-centered goals but has not yet been validated. We aimed to apply this to a real-world cohort and identify factors that predict transition between classes over time. METHODS: We identified all patients with PFCD and at least one baseline and one follow-up pelvic (pMRI). TOpCLASS classification, disease characteristics, and imaging indices were collected retrospectively at time periods corresponding with respective MRIs. RESULTS: We identified 100 patients with PFCD of which 96 were assigned TOpCLASS Classes 1 - 2c at baseline. Most patients (78.1%) started in Class 2b, but changes in classification were observed in 52.1% of all patients. Male sex (72.0%, 46.6%, 40.0%, p = 0.03) and prior perianal surgery (52.0% vs 44.6% vs 40.0%, p = 0.02) were more frequently observed in those with improved class. Baseline pMRI indices were not associated with changes in classification, however, greater improvements in mVAI, MODIFI-CD, and PEMPAC were seen among those who improved. Linear mixed effect modeling identified only male sex (-0.31, 95% CI -0.60 to -0.02) with improvement in class. CONCLUSION: The TOpCLASS classification highlights the dynamic nature of PFCD over time, however, our ability to predict transitions between classes remains limited and requires prospective assessment. Improvement in MRI index scores over time was associated with a transition to lower TOpCLASS classification.

Geldof Expert Consensus Classification of Perianal Fistulizing Crohn's Disease: A Real-World Application in a Serial Fistula MRI Cohort.

Background and Aims: Perianal fistulizing Crohn's disease (CD-PAF) is an aggressive phenotype of Crohn's disease (CD) defined by frequent relapses and disabling symptoms. A novel consensus classification system was recently outlined by Geldof et al. that seeks to unify disease severity with patient-centered goals but has not yet been validated. We aimed to apply this to a real-world cohort and identify factors that predict transition between classes over time. Methods: We identified all patients with CD-PAF and at least one baseline and one follow-up pelvic (pMRI). Geldof Classification, disease characteristics, and imaging indices were collected retrospectively at time periods corresponding with respective MRIs. Results: We identified 100 patients with CD-PAF of which 96 were assigned Geldof Classes 1 - 2c at baseline. Most patients (78.1%) started in Class 2b, but changes in classification were observed in 52.1% of all patients. Male sex (72.0%, 46.6%, 40.0%, p = 0.03) and prior perianal surgery (52.0% vs 44.6% vs 40.0%, p = 0.02) were more frequently observed in those with improved. Baseline pMRI indices were not associated with changes in classification, however, greater improvements in mVAI, MODIFI-CD, and PEMPAC were seen among those who improved. Linear mixed effect modeling identified only male sex (-0.31, 95% CI -0.60 to -0.02) with improvement in class. Conclusion: Geldof classification highlights the dynamic nature of CD-PAF over time, however, our ability to predict transitions between classes remains limited and requires prospective assessment. Improvement in MRI index scores over time was associated with a transition to lower Geldof classification.

Outcomes of Patients with FLT3 Positive Acute Myeloid Leukaemia; an Experience from a Tertiary Care Hospital in Karachi, Pakistan.

Introduction: Molecular genetic abnormalities in acute myeloid leukaemia (AML) are essential for disease diagnosis and determining prognosis and clinical course. Mutations in FLT3 and nucleophosmin (NPM) genes are the most frequent genetic abnormalities, which are also known to impact disease outcomes. FLT3 mutations have been identified in approximately 30% of de novo AML patients and are associated with poor prognoses. This study aimed to determine the response to induction chemotherapy, overall survival (OS) and relapse rate (RR) in patients with FLT3-positive AML. Materials and Methods: In this study, a retrospective analysis was performed of 75 newly diagnosed patients with AML registered between January 2015 and July 2022. Patient demographics and clinical-haematological parameters were noted and molecular analysis for FLT3 ITD/TKD and NPM mutations was performed. All the patients received standard induction chemotherapy and their response to treatment, OS and RR were assessed. Results: A total of 75 cases of AML were analysed. The mean age of the sample was 34.9 years, of which 65.3% were males and 34.7% were females. The patients were stratified into two groups: Those who were positive for FLT3 while negative for NPM (FLT3+/NPM-), representing 17.3% and those who were negative for both FLT3 and NPM (FLT3-/NPM-), representing 82.7% of cases. On day 28 post-induction, the complete remission rate was 69.2% in the FLT3 positive group and 77.4% in the FLT3 negative group. In the FLT3+/NPM- group, 55.6% of cases who were in remission at day 28 subsequently relapsed, compared to 50.0% of FLT3-/NPM- cases. The overall median survival time for the cohort and FLT3+ group was 1467 days, while that of the FLT3-group could not be estimated due to the very high survival rate. Conclusion: No significant differences in outcomes were observed in patients who were FLT3 positive compared to those who were FLT3 negative.

Added Value of FDG PET/MRI in Gynecologic Oncology: A Pictorial Review.

Fluorine 18-fluorodeoxyglucose (FDG) PET and MRI independently play a valuable role in the management of patients with gynecologic malignancies, particularly endometrial and cervical cancer. The PET/MRI hybrid imaging technique combines the metabolic information obtained from PET with the excellent soft-tissue resolution and anatomic details provided by MRI in a single examination. MRI is the modality of choice for assessment of local tumor extent in the pelvis, whereas PET is used to assess for local-regional spread and distant metastases. The authors discuss the added value of FDG PET/MRI in imaging gynecologic malignancies of the pelvis, with a focus on the role of FDG PET/MRI in diagnosis, staging, assessing treatment response, and characterizing complications. PET/MRI allows better localization and demarcation of the extent of disease, characterization of lesions and involvement of adjacent organs and lymph nodes, and improved differentiation of benign from malignant tissues, as well as detection of the presence of distant metastasis. It also has the advantages of decreased radiation dose and a higher signal-to-noise ratio of a prolonged PET examination of the pelvis contemporaneous with MRI. The authors provide a brief technical overview of PET/MRI, highlight how simultaneously performed PET/MRI can improve stand-alone MRI and PET/CT in gynecologic malignancies, provide an image-rich review to illustrate practical and clinically relevant applications of this imaging technique, and review common pitfalls encountered in clinical practice. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material.

NAFLD Is Associated With Quiescent Rather Than Active Crohn's Disease.

BACKGROUND AND AIMS: Crohn's disease (CD) confers an increased risk of nonalcoholic fatty liver disease (NAFLD), but the pathogenesis remains poorly understood. We determined if active intestinal inflammation increases the risk of NAFLD in patients with CD. METHODS: Two cohorts (2017/2018 and 2020) with CD and no known liver disease were enrolled consecutively during staging magnetic resonance enterography. We quantified proton density fat fraction, MaRIA (Magnetic Resonance Index of Activity), and visceral adipose tissue. NAFLD was diagnosed when proton density fat fraction ≥5.5%. Synchronous endoscopy was graded by the Simple Endoscopic Score for CD and Rutgeerts score, while clinical activity was graded by the Harvey-Bradshaw index. Cytokine profiling was performed for the 2020 cohort. Transient elastography and liver biopsy were requested by standard of care. RESULTS: NAFLD was diagnosed in 40% (n = 144 of 363), with higher prevalence during radiographically quiescent disease (odds ratio, 1.7; P = .01), independent of body mass index/visceral adipose tissue (adjusted odds ratio, 7.8; P = .03). These findings were corroborated by endoscopic disease activity, but not by aggregate clinical symptoms. Circulating interleukin-8 was independent of body mass index to predict NAFLD, but traditional proinflammatory cytokines were not. NAFLD subjects had similar liver stiffness estimates regardless of CD activity. Definitive or borderline steatohepatitis was present in most patients that underwent liver biopsy. CONCLUSIONS: Quiescent CD is associated with risk of NAFLD. These findings suggest potentially distinct pathogenic mechanisms of NAFLD in patients with CD compared with the prevailing leaky gut hypothesis proposed for individuals without inflammatory bowel disease. Future validation and mechanistic studies are needed to dissect these distinct disease modifying factors.

Crohn's disease patients had an independently increased risk for nonalcoholic fatty liver disease when the disease was quiescent, measured by magnetic resonance/endoscopy, and was unrelated to symptom severity. Nonalcoholic fatty liver disease was associated with the pleiotropic cytokine interleukin (IL)-8/CXCL8 but not with traditional proinflammatory cytokines (eg, tumor necrosis factor α, IL-1, IL-6).

Imaging of Vaginal and Vulvar Malignancy.

Vaginal and vulvar malignancies are rare gynecologic malignancies but can be associated with high morbidity and mortality if undiagnosed and untreated. Advanced imaging modalities such as MRI enable assessment of the local extent of disease and evaluation for regional or distant spread. Accurate identification and description of the primary lesion and sites of involvement as well as detection and localization of suspicious lymph nodes are critical in guiding appropriate management. Additionally, radiologists should be aware of potential mimickers on imaging and the differential diagnoses for vaginal and vulvar lesions.

Urinary Bladder Masses, Rare Subtypes, and Masslike Lesions: Radiologic-Pathologic Correlation.

Urinary bladder masses are commonly encountered in clinical practice, with 95% arising from the epithelial layer and rarer tumors arising from the lamina propria, muscularis propria, serosa, and adventitia. The extent of neoplastic invasion into these bladder layers is assessed with multimodality imaging, and the MRI-based Vesical Imaging Reporting and Data System is increasingly used to aid tumor staging. Given the multiple layers and cell lineages, a diverse array of pathologic entities can arise from the urinary bladder, and distinguishing among benign, malignant, and nonneoplastic entities is not reliably feasible in most cases. Pathologic assessment remains the standard of care for classification of bladder masses. Although urothelial carcinoma accounts for most urinary bladder malignancies in the United States, several histopathologic entities exist, including squamous cell carcinoma, adenocarcinoma, melanoma, and neuroendocrine tumors. Furthermore, there are variant histopathologic subtypes of urothelial carcinoma (eg, the plasmacytoid variant), which are often aggressive. Atypical benign bladder masses are diverse and can have inflammatory or iatrogenic causes and mimic malignancy. © RSNA, 2022 Online supplemental material is available for this article.

Gastroenteropancreatic neuroendocrine neoplasm imaging: standard reporting templates.

PURPOSE: Standardized reporting in radiology has an established role in numerous disease processes, with added benefits in oncology of reduced variability, and generation of a thorough and pertinent report with a focused and relevant conclusion. Many radiologists are not familiar with the imaging patterns of neuroendocrine neoplasm (NEN) spread and recurrence. This paper will present standardized CT, MRI, and PET templates for reporting gastroenteropancreatic (GEP) NENs and explain the rationale for including specific pertinent positive and negative findings, at various stages of disease management, based on site of origin. METHODS: Basic templates for initial and follow-up anatomic and molecular GEP NEN imaging were created with input from the multidisciplinary Society of Abdominal Radiology (SAR) Neuroendocrine Tumor Disease Focused Panel (NET-DFP). The templates were further modified and finalized after several iterations. RESULTS: Four main report templates were generated for (i) initial anatomic CT or MR imaging studies, (ii) follow-up anatomic CT or MR imaging studies, (iii) initial Somatostatin Receptor (SSTR) or FDG PET imaging studies, and (iv) follow-up SSTR or FDG PET imaging studies. Each study template was formatted to allow its integration into a dictation software directly and be modified as needed, with internalized instructions indicating where a drop-down menu or macro may be used to personalize the template as necessary. CONCLUSION: These templates were created through a combination of multidisciplinary expert opinion discussion supported by literature review and provide basic structured reporting standards for GEP NEN anatomic and molecular imaging studies.

Neuroendocrine neoplasm imaging: protocols by site of origin.

With the relatively low incidence of neuroendocrine neoplasms (NEN), most radiologists are not familiar with their optimal imaging techniques. The imaging protocols for NENs should be tailored to the site of origin to accurately define local extension of NEN at time of staging. Patterns of spread and recurrence should be taken into consideration when choosing protocols for detection of recurrence and metastases. This paper will present the recommended CT and MRI imaging protocols for gastro-enteric and pancreatic NENs based on site of origin or predominant pattern of metastatic disease, and explain the rationale for MRI contrast type, contrast timing, as well as specific sequences in MRI. We will also briefly comment on PET/CT and PET/MRI imaging protocols.

Sequelae of Eating Disorders at Imaging.

Although eating disorders are common, they tend to be underdiagnosed and undertreated because social stigma tends to make patients less likely to seek medical attention and less compliant with medical treatment. Diagnosis is crucial because these disorders can affect any organ system and are associated with the highest mortality rate of any psychiatric disorder. Because of this, imaging findings, when recognized, can be vital to the diagnosis and management of eating disorders and their related complications. The authors familiarize the radiologist with the pathophysiology and sequelae of eating disorders and provide an overview of the related imaging findings. Some imaging findings associated with eating disorders are nonspecific, and others are subtle. The presence of these findings should alert the radiologist to correlate them with the patient's medical history and laboratory results and the clinical team's findings at the physical examination. The combination of these findings may suggest a diagnosis that might otherwise be missed. Topics addressed include (a) the pathophysiology of eating disorders, (b) the clinical presentation of patients with eating disorders and their medical complications and sequelae, (c) the imaging features associated with common and uncommon sequelae of eating disorders, (d) an overview of management and treatment of eating disorders, and (e) conditions that can mimic eating disorders (eg, substance abuse, medically induced eating disorders, and malnourishment in patients with cancer). Online supplemental material is available for this article. ©RSNA, 2022.

Imaging Features of Premalignant Biliary Lesions and Predisposing Conditions with Pathologic Correlation.

Biliary malignancies include those arising from the intrahepatic and extrahepatic bile ducts as well as the gallbladder and hepatopancreatic ampulla of Vater. The majority of intrahepatic and extrahepatic malignancies are cholangiocarcinomas (CCAs). They arise owing to a complex interplay between the patient-specific genetic background and multiple risk factors and may occur in the liver (intrahepatic CCA), hilum (perihilar CCA), or extrahepatic bile ducts (distal CCA). Biliary-type adenocarcinoma constitutes the most common histologic type of ampullary and gallbladder malignancies. Its prognosis is poor and surgical resection is considered curative, so early detection is key, with multimodality imaging playing a central role in making the diagnosis. There are several risk factors for biliary malignancy as well as predisposing conditions that increase the risk; this review highlights the pertinent imaging features of these entities with histopathologic correlation. The predisposing factors are broken down into three major categories: (a) congenital malformations such as choledochal cyst and pancreaticobiliary maljunction; (b) infectious or inflammatory conditions such as parasitic infections, hepatolithiasis, primary sclerosing cholangitis, and porcelain gallbladder; and (c) preinvasive epithelial neoplasms such as biliary intraepithelial neoplasm, intraductal papillary neoplasm of the bile duct, intra-ampullary papillary tubular neoplasm, and intracholecystic papillary neoplasm of the gallbladder. Recognizing the baseline features of these premalignant biliary entities and changes in their appearance over time that indicate the advent of malignancy in high-risk patients can lead to early diagnosis and potentially curative management. An invited commentary by Volpacchio is available online. Online supplemental material is available for this article. ©RSNA, 2022.

Imaging Spectrum of Infections in the Setting of Immunotherapy and Molecular Targeted Therapy.

Advances in genomics and immunology are revolutionizing our understanding and treatment of cancer with improved treatment outcomes and patient quality of life. With the increasing use of immunotherapy and molecular targeted therapy, a variety of unusual and/or opportunistic infections are also observed. A variety of factors including use of immunosuppression for immune-mediated adverse effects play an important role for increasing the likelihood of these infections and form the basis of this case-based review. Imaging features of infections arising in patients undergoing immunotherapy regimens have not been previously highlighted. Prompt recognition of the spectrum of mycobacterial, bacterial, invasive fungal and viral pathogens can potentially lead to reduction in the high morbidity and mortality in this patient population.

Imaging of the Vagina: Spectrum of Disease with Emphasis on MRI Appearance.

The vagina is a median fibromuscular structure of the female reproductive system that extends from the vulva inferiorly to the uterine cervix superiorly. As most vaginal lesions are detected at gynecologic examination, imaging performed for nongynecologic indications can frequently cause concomitant vaginal pathologic conditions to be overlooked. The vagina is often underevaluated at routinely performed pelvic transvaginal US because of a narrow scan area and probe positioning. MRI has progressively become the imaging method of choice for vaginal pathologic conditions, as it provides excellent soft-tissue detail with unparalleled delineation of the complex pelvic floor anatomy and helps establish a diagnosis for most vaginal diseases. It is important that radiologists use a focused approach toward understanding and correctly recognizing different vaginal entities that may otherwise go unnoticed. In this case-based review, the authors discuss the key imaging features of wide-ranging vaginal pathologic conditions, with emphasis on appearance at MRI. Knowledge of vaginal anatomy and embryology is helpful in evaluating congenital anomalies at imaging. Often seen incidentally, vaginal inflammation can cause diagnostic confusion. Because of its central location in the pelvis, the vagina can form fistulas to the urinary bladder, colon, rectum, or anus. Vaginal masses can be neoplastic and nonneoplastic and include a myriad of benign and malignant conditions, some of which have characteristic imaging features. Therapeutic and nontherapeutic vaginal foreign bodies include pessaries, vaginal mesh, and packing that can be seen with or without associated complications. Online supplemental material is available for this article. ©RSNA, 2021.

Imaging Manifestations of Genitourinary Tuberculosis.

The genitourinary region is one of the most common sites of extrapulmonary tuberculosis (TB) involvement. The imaging features of genitourinary TB are protean and can mimic other entities, including malignancy, and pose a diagnostic dilemma. Hematogenous seeding and lymphatic spread of mycobacteria from pulmonary, tonsillar, and nodal TB are implicated in the pathogenesis of genitourinary TB. In addition, contiguous extension from the urinary tract and sexual transmission are described as sources of genital TB. Genitourinary TB can be indolent and results in nonspecific signs and symptoms; thus, imaging has a vital role in the working diagnosis for these cases. Classic uroradiologic signs of genitourinary TB are primarily described from the era of intravenous urography and conventional radiography. Now, CT, CT urography, MRI, and US are used in the diagnosis and management. Familiarity with the imaging features of genitourinary TB may help guide the diagnosis and, in turn, lead to timely management. US has a vital role in the evaluation of scrotal and female genital TB. MRI offers superior soft-tissue contrast resolution and excellent depiction of anatomic detail. The various imaging manifestations of genitourinary TB are highlighted. ©RSNA, 2021.

CT of Penetrating Abdominopelvic Trauma.

Penetrating abdominopelvic trauma usually results from abdominal cavity violation from a firearm injury or a stab wound and is a leading cause of morbidity and mortality from traumatic injuries. Penetrating trauma can have subtle or complex imaging findings, posing a diagnostic challenge for radiologists. Contrast-enhanced CT is the modality of choice for evaluating penetrating injuries, with good sensitivity and specificity for solid-organ and hollow viscus injuries. Familiarity with the projectile kinetics of penetrating injuries is an important skill set for radiologists and aids in the diagnosis of both overt and subtle injuries. CT trajectography is a useful tool in CT interpretation that allows the identification of subtle injuries from the transfer of kinetic injury from the projectile to surrounding tissue. In CT trajectography, after the entry and exit wounds are delineated, the two points can be connected by placing cross-cursors and swiveling the cut planes obliquely in orthogonal planes to obtain a double-oblique orientation to visualize the wound track in profile. The path of the projectile and its ensuing damage is not always straight, and the imaging characteristics of free fluid of different attenuation in the abdomen (including hemoperitoneum) can support the diagnosis of visceral and vascular injuries. In addition, CT is increasingly used for evaluation of patients after damage control surgery and helps guide the management of injuries that were overlooked at surgery. An invited commentary by Paes and Munera is available online. Online supplemental material is available for this article. ©RSNA, 2021.

Current update on the molecular genetics and management of hereditary ovarian cancers: a primer for radiologists.

More than one-fifth of ovarian cancers are hereditary, with most of them caused by BRCA genes. Malignant ovarian neoplasms are primarily epithelial tumors, a heterogeneous group of tumors with variable genetic backgrounds that translate into different biologic behaviors and morphologic features. Radiologists play an increasingly important role in the diagnosis and management of oncology patients. Familiarity with hereditary ovarian cancers will have a positive impact on patient management and radiologists' involvement in the multidisciplinary approach needed for this delicate patient population. In this paper, we review the basic histologic and genetic backgrounds of ovarian tumors with an emphasis on hereditary ovarian cancers, as well as the effects that these factors have on patient workup, primarily with regard to imaging studies.

Imaging Spectrum of Granulomatous Diseases of the Abdomen and Pelvis.

A granuloma is a compact organization of mature macrophages that forms because of persistent antigenic stimulation. At the microscopic level, granulomas can undergo various morphologic changes, ranging from necrosis to fibrosis, which along with other specialized immune cells define the appearance of the granulomatous process. Accordingly, the imaging features of granulomatous diseases vary and can overlap with those of other diseases, such as malignancy, and lead to surgical excisions and biopsy. However, given the heterogeneity of granulomas as a disease group, it is often hard to make a diagnosis on the basis of the histopathologic features of granulomatous diseases alone owing to overlapping microscopic features. Instead, a multidisciplinary approach is often helpful. Radiologists need to be familiar with the salient clinical manifestations and imaging findings of granulomatous diseases to generate an appropriate differential diagnosis. ©RSNA, 2021.

Imaging Features of Neurofibromatosis Type 1 in the Abdomen and Pelvis.

OBJECTIVE. Loss of the neurofibromatosis type 1 (NF1) tumor suppressor protein causes uninhibited activation of the RAS oncogene, which leads to tumorigenesis in patients with NF1. This case-based review discusses imaging manifestations of NF1 in the abdomen and pelvis, highlighting key genetic associations and management to elucidate features different from the general population. CONCLUSION. The spectrum of pathologic findings includes gastrointestinal tumors such as gastrointestinal stromal tumors, genitourinary lesions including urogenital neurofibromas, vascular entities such as renal artery stenosis, and less common associations like lymphoma.