Herlyn-Werner-Wunderlich syndrome: pre- and post-surgical MRI and US findings.

Herlyn-Werner-Wunderlich syndrome (HWWS) is a rare congenital anomaly of the female urogenital tract that associates Müllerian duct anomalies with mesonephric duct anomalies. The triad of uterus didelphys, obstructed hemivagina, and ipsilateral renal agenesis characterizes this syndrome. Patients generally present with non-specific symptoms after menarche. Pelvic pain, dysmenorrhea, and palpable mass due to hematocolpos or hematometra are the most common findings. Pyohematocolpos and pyosalpinx may appear as acute complications, while endometriosis and pelvic adhesions constitute potential long-term complications. When a prenatal diagnosis of unilateral renal agenesis in newborn girls is known, a gynecological imaging study should be performed to exclude uterine and vaginal abnormalities. These patients should be followed up to ensure that a timely surgical correction is performed. The diagnosis of HWWS is difficult due to the lack of specific symptoms or findings upon physical examination. An accurate imaging description of these congenital anomalies is crucial to guide patients toward surgical treatment, relieving acute complications, and preserving the normal fertility. The authors provide a pictorial review of the magnetic resonance imaging and ultrasonography findings of the HWWS with correlation to embryological, clinical, and surgical features.

The shading sign: is it exclusive of endometriomas?

OBJECTIVES: To investigate if the shading sign is an exclusive MRI feature of endometriomas or endometrioid tumors, and to analyze its different patterns. METHODS: Three hundred and fourty six women with adnexal masses who underwent 1.5/3-T MRI were included in this retrospective, board-approved study. The shading sign was found in 56 patients, but five cases were excluded due to lack of imaging follow-up or histological correlation. The final sample included 51 women. The type of tumor and the pattern of shading were recorded for each case. RESULTS: Thirty endometriomas and five endometrioid carcinomas were found. The remaining 16 cases corresponded to other benign and malignant tumors. The overall sensitivity, specificity, positive predictive value, and negative predictive value were 73%, 93%, 59%, and 96%, respectively. Restricting the analysis to cystic lesions without solid or fat component, sensitivity, specificity, positive predictive value, and negative predictive value were 73%, 96%, 94%, and 80%. Five shading patterns were identified: layering (15.7%), liquid-liquid level (11.8%), homogenous (45.1%), heterogeneous (11.8%), and focal/multifocal shading within a complex mass (19.6%). No significant correlation was found between these patterns and the type of tumor. CONCLUSIONS: The shading sign is not exclusive of endometriomas or endometrioid tumors. Homogenous shading was the most prevalent pattern in endometriomas and half of the cases with focal/multifocal shading within a complex mass were endometrioid carcinomas.

Paediatric Mediastinal Lipoblastoma.

Teaching Point: Lipoblastoma should be considered in the differential diagnosis of painful rapidly growing fatty mass within the mediastinum in infants or young children under three years old.

Modern imaging and image-guided treatments of the prostate gland: MR and ablation for cancer and prostatic artery embolization for benign prostatic hyperplasia.

Multiparametric MRI (mpMRI) has proven to be an essential tool for diagnosis, post-treatment follow-up, aggressiveness assessment, and active surveillance of prostate cancer. Currently, this imaging technique is part of the daily practice in many oncological centres. This manuscript aims to review the use of mpMRI in the set of prostatic diseases, either malignant or benign: mpMRI to detect and stage prostate cancer is discussed, as well as its use for active surveillance. Image-guided ablation techniques for prostate cancer are also reviewed. The need to establish minimum acceptable technical parameters for prostate mpMRI, standardize reports, uniform terminology for describing imaging findings, and develop assessment categories that differentiate levels of suspicion for clinically significant prostate cancer led to the development of the Prostate Imaging Reporting and Data System that is reviewed. Special focus will also be given on the most up-to-date evidence of prostatic artery embolization (PAE) for symptomatic benign prostatic hyperplasia (BPH). Management of patients with BPH, technical aspects of PAE, expected outcomes and level of evidence are reviewed with the most recent literature. PAE is a challenging technique that requires dedicated anatomical knowledge and comprehensive embolization skills. PAE has been shown to be an effective minimally-invasive treatment option for symptomatic BPH patients, that can be viewed between medical therapy and surgery. PAE may be a good option for symptomatic BPH patients that do not want to be operated and can obviate the need for prostatic surgery in up to 80% of treated patients.

Pitfalls of diffusion-weighted imaging of the female pelvis.

Diffusion-weighted imaging (DWI) is widely used in protocols for magnetic resonance imaging (MRI) of the female pelvis. It provides functional and structural information about biological tissues, without the use of ionizing radiation or intravenous administration of contrast medium. High signal intensity on DWI with simultaneous low signal intensity on apparent diffusion coefficient maps is usually associated with malignancy. However, that pattern can also be seen in many benign lesions, a fact that should be recognized by radiologists. Correlating DWI findings with those of conventional (T1- and T2-weighted) MRI sequences and those of contrast-enhanced MRI sequences is mandatory in order to avoid potential pitfalls. The aim of this review article is the description of the most relevant physiological and benign pathological conditions of the female pelvis that can show restricted diffusion on DWI.

Just another abdominal pain? Psoas abscess-like metastasis in large cell lung cancer with adrenal insufficiency.

The authors report the case of a 69-year-old man with chronic obstructive pulmonary disease and previous pulmonary tuberculosis, who presented to the emergency department with abdominal and low back pain, anorexia and weight loss, rapidly evolving into shock. An initial CT scan revealed pulmonary condensation with associated cavitation and an iliopsoas mass suggestive of a psoas abscess. He was admitted in an intensive care unit unit; after a careful examination and laboratory assessment, the aetiology was yet undisclosed. MRI showed multiple retroperitoneal lymphadenopathies, bulky nodular adrenal lesions and bilateral iliac lytic lesions. Hypocortisolism was detected and treated with steroids. A CT-guided biopsy to the psoas mass and lytic lesions identified infiltration of non-small lung carcinoma. The patient died within days. Psoas metastases and adrenal insufficiency as initial manifestations of malignancy are rare and can be misdiagnosed, particularly in the absence of a known primary tumour.

Primary fallopian tube carcinoma: review of MR imaging findings.

OBJECTIVES: To review the epidemiological and clinical features of primary fallopian tube carcinoma (PFTC), and to illustrate the spectrum of MRI findings, with pathological confirmation. METHODS: This article reviews the relevant literature on the epidemiological, clinical, and imaging features of primary fallopian tube carcinoma, with pathological confirmation, using illustrations from the authors' teaching files. RESULTS: Primary fallopian tube carcinoma came under focus over the last few years due to its possible role on the pathogenesis of high-grade serous epithelial ovarian and peritoneal cancers. Typical symptoms, together with the presence of some of the most characteristic MRI signs, such as a "sausage-shaped" pelvic mass, hydrosalpinx, and hydrometra, may signal the presence of primary fallopian cancer, and allow the radiologist to report it as a differential diagnosis. CONCLUSIONS: Primary fallopian tube carcinoma has a constellation of clinical symptoms and magnetic resonance imaging features, which may be diagnostic. Although these findings are not present together in the majority of cases, radiologists who are aware of them may include the diagnosis of primary fallopian tube cancer in their report more frequently and with more confidence. TEACHING POINTS: • PFTC may be more frequent than previously thought • PFTC has specific clinical and MRI characteristics • Knowledge of typical PFTC signs enables its inclusion in the differential diagnosis • PFTC is currently staged under the 2013 FIGO system • PFTC is staged collectively with ovarian and peritoneal neoplasms.

Prostate Cancer: The Role of Multiparametric Magnetic Resonance Imaging.

Multiparametric magnetic resonance imaging has been increasingly used for detection, localization and staging of prostate cancer over the last years. It combines high-resolution T2 weighted-imaging and at least two functional techniques, which include dynamic contrast-enhanced magnetic resonance imaging, diffusion-weighted imaging, and magnetic resonance imaging spectroscopy. Although the combined use of a pelvic phased-array and an endorectal coil is considered the state-of-the-art for magnetic resonance imaging evaluation of prostate cancer, endorectal coil is only absolute mandatory for magnetic resonance imaging spectroscopy at 1.5 T. Sensitivity and specificity levels in cancer detection and localization have been improving with functional technique implementation, compared to T2 weighted-imaging alone. It has been particularly useful to evaluate patients with abnormal PSA and negative biopsy. Moreover, the information added by the functional techniques may correlate to cancer aggressiveness and therefore be useful to select patients for focal radiotherapy, prostate sparing surgery, focal ablative therapy and active surveillance. However, more studies are needed to compare the functional techniques and understand the advantages and disadvantages of each one. This article reviews the basic principles of prostatic mp-magnetic resonance imaging, emphasizing its role on detection, staging and active surveillance of prostate cancer.

A Ressonância Magnética Multiparamétrica tem sido crescentemente utilizada na detecção, localização e estadiamento do cancro da próstata. Combina sequências T2 de alta-resolução com pelo menos duas técnicas funcionais, que incluem o estudo dinâmico pós-gadolínio, a difusão e a espectroscopia. O protocolo ideal aconselha a utilização combinada de uma antena de superfície e uma endorectal; contudo, a antena endorectal é apenas obrigatória para a realização de espectroscopia em aparelhos de 1,5 T. Os níveis de sensibilidade e especificidade na detecção e localização do cancro da próstata têm aumentado com a inclusão das técnicas funcionais, quando comparados com as sequências T2 isoladas, o que é particularmente vantajoso em doentes que têm biópsia negativa, apesar de níveis de PSA persistentemente elevados. Para além disso, a informação adicionada pelas técnicas funcionais aparenta correlacionar-se com a agressividade tumoral, podendo tornar-se útil na selecção de doentes radioterapia focal, cirurgias conservadoras, terapias de ablação focal e vigilância activa. Contudo, são necessários mais estudos para comparar as várias técnicas funcionais e compreender as vantagens e desvantagens de cada uma. Este artigo pretender rever os princípios básicos da Ressonância Magnética prostática multiparamétrica, enfatizando o seu papel na detecção, estadiamento e vigilância activa do cancro da próstata.

Pitfalls of diffusion-weighted imaging of the female pelvis / Armadilhas em imagem ponderada em difusão da pelve feminina

Abstract Diffusion-weighted imaging (DWI) is widely used in protocols for magnetic resonance imaging (MRI) of the female pelvis. It provides functional and structural information about biological tissues, without the use of ionizing radiation or intravenous administration of contrast medium. High signal intensity on DWI with simultaneous low signal intensity on apparent diffusion coefficient maps is usually associated with malignancy. However, that pattern can also be seen in many benign lesions, a fact that should be recognized by radiologists. Correlating DWI findings with those of conventional (T1- and T2-weighted) MRI sequences and those of contrast-enhanced MRI sequences is mandatory in order to avoid potential pitfalls. The aim of this review article is the description of the most relevant physiological and benign pathological conditions of the female pelvis that can show restricted diffusion on DWI.

Resumo A imagem ponderada em difusão (IPD) é amplamente utilizada em protocolos de ressonância magnética (RM) da pelve feminina. Fornece informações funcionais e estruturais de tecidos biológicos sem uso de radiação ionizante ou de administração intravenosa de material de contraste. Hipersinal em IPD com hipossinal simultâneo em mapas de coeficiente de difusão aparente geralmente está associada a malignidade. No entanto, esse padrão também pode ser visto em muitas lesões benignas, um fato que deve ser reconhecido por radiologistas. É imprescindível fazer a correlação dos achados de IPD com os de sequências de RM convencionais (em T1 e T2) e daquelas com contraste para evitar possíveis armadilhas. O objetivo deste artigo de revisão é descrever as condições fisiológicas e patológicas benignas mais relevantes da pelve feminina que podem demonstrar restrição à difusão da água em IPD.