Whole-lesion CT histogram analysis as an advanced technique in the portal venous phase: differentiating lipid poor adrenal adenomas from pheochromocytomas.

PURPOSE: Adrenal computed tomography (CT) has limitation due to imaging overlaps inthe washout characteristics of pheochromocytomas and adenomas (especially lipid-poor). The aim of this study was to investigate the distinguishability of lipid-poor adrenal adenomas and pheochromocytomas using whole-lesion CT histogram analysis. MATERIALS AND METHODS: Histopathologically proven 24 lipid-poor adenomas and 29 pheochromocytomas (total 53 lesions in 53 patients) were included in this retrospective study. Data obtained from standard and volumetric examinations of the lesions by dedicated adrenal CT were compared between the two groups using univariate analysis. Parameters that showed differences were further evaluated using multivariate logistic regression analysis. RESULTS: Univariate analysis revealed significant differences between the two groups in terms of lesion size, lesion volume, percentage of relative wash out, peak HU values and the percentage of voxels with attenuation ≥ 100 HU, ≥ 110 HU and ≥ 120 HU (p = 0.0001, P = 0.0001, P = 0.01, P = 0.008, p = 0.04, p = 0.02, p = 0.02, respectively). Multivariate analysis revealed lesion size ≥ 22.05 mm (OR: 22; p < 0.0001), the percentage of voxels with attenuation ≥ 120 HU being ≥ 9% (OR: 3.27; p = 0.04), peak HU value ≥ 161.5 HU (OR: 4.40; p = 0.01) as risk factors for pheochromocytomas. CONCLUSIONS: Whole lesion CT histogram analysis can be used to differentiate pheochromocytomas from lipid-poor adenomas. Lesion volume, the percentage of voxels with attenuation ≥ 120 HU and peak HU values are independent parameters that can assist in this differentiation. These findings may help avoid unnecessary biopsies and surgeries for lipid-poor adenomas, while identifying pheochromocytoma risk may improve perioperative patient management. Our results should be validated by future prospective studies.

Total kidney volume in autosomal dominant polycystic kidney disease: intraobserver and interobserver agreement of two methods with MRI.

Background/aim: Total kidney volume (TKV) is a parameter used in both treatment decision and follow-up in autosomal dominant polycystic kidney disease (ADPKD) patients. The objective of this study was to evaluate intra- and interobserver agreement of the ellipsoid formula (EF) and manual boundary tracing method (MBTM) used in TKV measurement of ADPKD patients across different levels of experience radiologists. Additionally, the study aimed to evaluate the correlation between the EF and MBTM, which is considered the gold standard for TKV. Materials and methods: A retrospective evaluation was conducted on magnetic resonance imaging (MRI) data from 55 ADPKD patients who underwent abdominal MRI between January 2017 and November 2021 to evaluate TKV. TKV measurements were performed by three independent observers (observer 1, an abdominal imaging radiologist with 5 years of experience; observer 2, a fourth-year radiology resident; observer 3, a second-year radiology resident).To assess intraobserver variability, all observers repeated the measurements at two-week intervals. The ICC was used to assess both intraobserver and interobserver variability. A comparison of the two methods was performed by linear regression for all three observers. Results: The ICC (95% CI) indicated excellent agreement between the observers for both methods (among all observers, p < 0.001). Furthermore, excellent intraobserver agreement was found between all observer measurements either EF or MBTM based on ICC (95% CI) (p < 0.001). The results of the linear regression analysis demonstrated high correlations between the two methods in all three observers (r = 0.992, p < 0.001 for the first observer; r = 0.975, p < 0.001 for the second observer; r = 0.989, p < 0.001 for the third observer). Conclusion: Both the EF and MBTM methods used for the measurement of TKV provided excellent intra- and interobserver reproducibility. The EF is as accurate and precise as the MBTM. It may therefore be preferred in radiology departments with heavy workload, as it is a reliable method for rapid and easy assessment, independent of experience.

Combination anticoagulation strategy in pregnancy with mechanical valves: The KYBELE study.

BACKGROUND: Optimal first-trimester anticoagulation is still challenging in pregnant women with mechanical heart valves (MHVs) requiring high-dose warfarin. This multicenter prospective study aims to determine the optimal anticoagulation regimens for pregnant patients with MHVs. METHODS: All women were allocated to one of three treatment options during first trimester including lone low-molecular-weight heparin (LMWH), combination of LMWH + 2.5 mg warfarin, and LMWH+4 mg warfarin. Primary maternal outcome included a combination of death, thromboembolism, severe bleeding, and need for treatment of mechanical valve thrombosis (MVT). Any fetal loss was determined as primary fetal outcome. RESULTS: The study included 78 pregnancies in 65 women with MHVs. Primary maternal outcome rate was 44%, 12.5%, 3.5%, respectively. The rates of primary maternal outcome (44 vs 3.5%, P < .001), obstructive MVT (16 vs 0%, P = .04), MVT requiring treatment (28 vs 0%, P = .003), and cerebral embolism (24 vs 3.4%, P = .041) were found to be significantly higher in lone LMWH group compared to LMWH + 4 mg warfarin group. Moreover, the rates of primary maternal outcome (12.5 vs 44%, P = .015) and treatment for MHV thrombus (4.2 vs 28%, P = .049) were significantly lower in LMWH + 2.5 mg warfarin group compared to lone LMWH group. The incidences of fetal loss were 8 (32%) in the lone LMWH group, 8 (33.3%) in LMWH + 2.5 mg warfarin group, and 11 (37.9%) in LMWH + 4 mg warfarin group (P = .890 for 3-group).Warfarin related-embryopathy was not observed in any case. CONCLUSIONS: The combined anticoagulation strategy of LMWH plus low-dose warfarin during the first trimester of pregnancy may result in less maternal complications with comparable fetal outcomes in patients with MHVs. CONDENSED ABSTRACT: Low-molecular-weight heparin (LMWH) is thought to be safer for the fetus, however it is suspected to be less protective for the mother. To solve this dilemma, the authors suggested a novel anticoagulation strategy in pregnant women with prosthetic valves. Seventy-eight pregnancies of 65 women (median age 32 [27-35] years) were included in the study. A combination of LMWH and a reduced dose warfarin were associated with low rates of thrombus-related complications in pregnant patients with mechanical heart valves.

Exploring celiac trunk parameters in median arcuate ligament syndrome: A CT study.

PURPOSE: To assess anatomical variations in the celiac trunk (Ct) in patients with Median Arcuate Ligament Syndrome (MALS) using computed tomography (CT). The primary objectives were to investigate the celiac trunk angle (CtA), origin level, length (CtL), and their relationships with the superior mesenteric artery (SMA) in MALS patients. Additionally, the study intended to evaluate gender differences in these parameters and explore correlations between variables. METHODS: Retrospectively, reports of abdominal CT scans taken between January 2018, and Sepmtember 2021, in the hospital image archive were screened vey two observers independently for MALS diagnosis. Parameters such as CtA, CtL, Ct-SMA distance, SMA angle (SMAA), and median arcuate ligament thickness (MALT) were measured. Statistical analyses were conducted using SPSS software. RESULTS: Among the 81 patients (25 females, 56 males), significant differences were observed in MALT between genders (p = 0.001). CtA showed a negative correlation with CtL and Ct-SMA (p < 0.001), and a positive correlation was found between CtL and Ct-SMA (p = 0.002). CtL was measured as 25 mm for the all group. Origin levels of Ct and SMA were evaluated in comparison to vertebral levels. Ct-SMA distance was relatively shorter (9.19 mm) compared to the literature. SMAA findings were consistent with normal population values. CONCLUSION: This study provided valuable insights into the anatomical parameters of the Ct ans SMA in MALS patients. Despite some differences compared to normal population parameters, no evidence supported the hypothesis of a superiorly placed Ct contributing to MALS.

The Effect of Age on Pancreaticoduodenectomy; Comorbidities, Short-term Outcomes, and Survival.

OBJECTIVE: To evaluate the complications, mortality, and survival rates of patients aged >70 years undergoing pancreaticoduodenectomy, and to determine associated risk factors. STUDY DESIGN: Descriptive study. Place and Duration of the Study: General Surgery Clinic of Eskisehir Osmangazi University Medical Faculty Hospital, Eskisehir, Turkiye, from January 2014 to September 2020. METHODOLOGY: A retrospective scrutiny of 94 patients who had undergone pancreaticodueodenectomy, was carried out. The patients were separated into two age groups of younger and older than 70 years, and were compared in respect of clinicopathological characteristics, comorbidities, perioperative characteristics, and complications. Independent risk factors for the endpoints of perioperative mortality and survival were investigated. RESULTS: No significant difference was determined between the groups in respect of biochemical values, and perioperative and histochemical characteristics. Comorbidities were present at a higher rate in the older patients (77.8% vs. 38.8%, p<0.001). The postoperative complication rates were similar (33.3% vs. 32.7%, p=0.944). Perioperative mortality (first 30 days) was determined at a significantly higher rate in the older age group (20.0% vs. 4.1%, p=0.016). The age of patients >70 years increased the risk of mortality 4.851-fold but was not an independent predictive factor (p=0.086). The groups were similar in respect of disease-free survival (DFS) and overall survival (OS, Log-rank p=0.780, p=0.386). Age [Hazard Ratio (HR): 1.029, p=0.048] and pancreas adenocarcinoma (HR: 1.846, p=0.028) were determined to be independent prognostic factors for DFS, and pancreas adenocarcinoma (HR 1.940, p=0.023) for OS. CONCLUSION: Older age was not seen to change survival in patients undergoing pancreaticoduodenectomy, but mortality within the first 30 days was affected. Age is not accepted as an absolute contraindication. It is recommended that pancreaticoduodenectomy is performed on patients aged >70 years with careful patient selection, prudent preoperative preparation, a meticulous surgical technique, and close multidisciplinary postoperative support. KEY WORDS: Pancreaticoduodenectomy, Elderly, Comorbidity, Complication, Mortality, Survival.

Main Portal Vein Diameter Changes in Patients Undergoing Gastric Surgery for Malignancy: An Observational CT Study.

Background In the follow-up computed tomography (CT) examinations of patients who had undergone gastrectomy for gastric malignancy in our center, we noticed by chance that there was an isolated increase in the diameter of the main portal vein (MPV) without other radiological findings of portal hypertension. Objectives In this study, we aimed to evaluate whether the MPV diameter of patients who had gastric surgery for malignancy differed in the preoperative and postoperative periods and its change over time in patients who underwent postoperative follow-up examinations. Materials and Methods The CT images of 240 patients who underwent abdomen CT for staging and follow-up gastric malignancy between January 2017 and September 2021 were evaluated retrospectively. The CT scans of the remaining 149 patients after the exclusion criteria were included in the study. All CT imaging was performed using multidetector CT (64 or 128 slice) in portal venous phases. The images were evaluated by two radiologists based on consensus. Maximum MPV diameter were measured outer wall to outer wall with calipers on axial images at the level of 1 cm distal to the portosplenic confluence. Results One hundred forty-nine patients included in the study had preoperative CT examination. Eighty-three patients had follow-up CT examination at third month, 89 patients at sixth month, and 99 patients at first year. The MPV diameters differed significantly between preoperative CT and postoperative third month, sixth month, and first year CT ( p = 0.001, p = 0.001, and p = 0.001, respectively). There was no difference in MPV diameter between postoperative third month CT and postoperative 6th month and 1st year CT ( p = 0.514 and p = 0.078, respectively). Conclusion There is an increase in MPV diameter in the first 3 months postoperatively in patients undergoing gastric surgery for malignancy. This enlargement continues unchanged in the first 1 year follow-up. The radiologists' awareness of this situation may prevent the wrong diagnosis of portal hypertension, unnecessary concern, and further investigation.

Qualitative and quantitative imaging features of solid pancreas tumours in portal venous phase CT: are they useful in determining tumour type and grade?

Purpose: Solid pancreatic lesions might have overlapping findings in portal venous phase computed tomography (CT). In this study, we aimed to investigate the quantitative and qualitative imaging features of solid pancreas lesions based on subtype and grade. Material and methods: The study group consisted of 159 patients with solid pancreatic tumours detected after exclusion criteria. According to the pathology results, the patients were divided into 3 groups as PDAC (pancreatic ductal adenocarcinoma, n = 137), PNET (pancreatic neuroendocrine tumour, n = 15), and SC (sarcomatoid carcinoma, n = 7). PDAC and PNET lesions were evaluated in 3 subgroups according to grade. Results: There was no difference between the groups in terms of age, gender, tumour localisation, and internal structure (p = 0.23, p = 0.81, p = 0.19, and p = 0.94, respectively). Qualitative features significantly differed in terms of tumour margin feature, visual tumour density, presence of cystic component, and presence of necrosis (p = 0.01, p = 0.0001, p = 0.002, and p = 0.004, respectively). Tumour size, Tmden, Tmden/VPden, and Tmden/PanPden showed differences between groups (p = 0.0001, p = 0.002, p = 0.0001, p = 0.0001, respectively). The presence of cystic density in PDAC patients differed according to grade (p = 0.01). Conclusions: While ill-defined irregular margins, hypodense visual tumour density, no cystic component, low value of Tmden, and low ratios of Tmden/VPden and Tmden/PanPden indicate PDAC, regular margins, iso-or hyperdense visual tumour density, cystic component, high value of Tmden, and high ratios of Tmden/VPden and Tmden/PanPden indicate PNET. SC can be differentiated from them by containing necrosis and reaching larger sizes. The presence of a cystic component in PDAC patients indicates high grade.

Can 3D radiological calculations predict operational difficulties for rectal cancer?: A single center retrospective analysis.

Low anterior resection, performing total mesorectal excision with appropriate pelvic dissection to prevent local recurrence, is probably the most challenging type of surgery in colorectal surgery, especially in a narrow pelvis. In this study, we aimed to predict the operation difficulty of rectal cancer by comparing the operation time with 2D and 3D pelvimetry. Sixty-six patients who underwent total mesorectal excision after neoadjuvant chemoradiotherapy due to primary rectal cancer located in the middle and lower rectum (10 cm from the anus) were included in the study. Surgery notes were reviewed and data on demographic factors, tumor stage, duration of surgery, and types of surgery were collected, as well as pelvimetric parameters. All protocols had 2D T2-weighted sequences in 3 planes (axial, sagittal, and coronal). Pelvimetric measurements were made by measuring 8 pelvic lengths and 2 angles. Pelvis and tumor volume were measured by manual margin monitoring. In each slice, both pelvis and tumor boundaries were manually drawn individually in the sagittal plane. Pelvis and tumor volumes were calculated from the set of adjacent images by summing slice thickness and products of area measurements within the pelvis and tumor boundaries. In our results, no correlation was observed with operation time, including pelvic volume. Exception for this were interacetabular distance and tumor volume. In the regression test, the only parameter that correlated with the operation time was tumor volume. In conclusion, we believe that tumor volumetric calculations may be useful in predicting difficult distal rectal carcinoma surgeries.

Very Rare Liver Tumor: PEComa Case Report with and a Review of Literature.

Perivascular epithelioid cell tumors (PEComas) are very rare mesenchymal tumors. In addition to being rare in general, they are even rarer in the liver. There are various subtypes and there is only one case of liver PEComa reported in the clear cell type in the literature to date. We present the second clear cell type liver PEComa in this case by reviewing the literature data. The hypodense, smooth-edged, ovoid lesion was detected on computed tomography (CT) for performing abdominal pain in a 41-year-old female patient. Magnetic resonance imaging (MRI) was then performed for lesion characterization. The lesion was hypointense on T1-weighted imaging (T1WI), hyperintense on T2-weighted imaging (T2WI). In dynamic phases, it showed marked enhancement on the arterial phase and capsular enhancement with central washout on the portal and late venous phases. The posterior branch of the right portal vein extended into the mass. The lesion was excised and the pathological result was epithelioid clear cell subtype of PEComa. Although the imaging findings are generally nonspecific and certain diagnosis is made histopathologically, radiologists should consider PEComa in the differential diagnosis in the presence of intensely enhanced lesion on the right lobe in female patients. Also, the "large vessel sign" may help in the diagnosis.

Lateral lymph node involvement presents another challenge in rectum cancer in the age of neoadjuvant chemoradiotherapy + total mesorectal excision: an evaluation of survival outcomes.

PURPOSE: In the last decades, total mesorectal excision (TME) and neoadjuvant chemoradiotherapy (nCRT) have produced an undeniable improvement in the treatment of rectal cancer. However, local recurrence is still an important problem, and the effect of lateral lymph node (LLN) involvement on local recurrence is a controversial issue. The aim of this study was to investigate the effects of LLN status on local recurrence and survival in rectal cancers treated with nCRT + TME. METHODS: Clinical features, pre- and post-nCRT lateral pelvic region imaging, long-term local recurrence, and the survival outcomes of 114 patients who underwent nCRT + TME for rectal cancer were evaluated. RESULTS: On MRI before nCRT, 20 (17.5%) patients had lateral lymph nodes (LLN+), and 94 (82.5%) patients had no lymph nodes in the lateral pelvic compartments (LLN-). Local recurrences at 1 year in LLN+ and LLN- patients were 3 (15.8%) and 2 (2.3%), respectively (p=0.039). Five-year local recurrence-free survival rates and the mean duration of recurrence-free survival in LLN+ and LLN- patients were 56.2%, 42.6 months, and 87.3% 66.9 months, respectively (p=0.001). Disease-free survival and overall survival were shorter in LLN+ patients, but the difference was not statistically significant (p=0.096 and p=0.46, respectively). In the multivariate analysis, LLN involvement was determined to be an independent risk factor for local recurrence-free survival (Hazard Ratio 4.54, p=0.003). CONCLUSION: Lateral lymph node involvement causes local recurrence to remain high after nCRT + TME. LLN status should be considered in treatment planning. Further studies are needed to define precise criteria for LLN involvement and the effect of LLND on local recurrence and survival.

Relationship of the Presence of the Inferior Right Hepatic Vein with the Right Hepatic Vein Diameter and CT Liver Volumetry.

Background Right hepatic venous anatomy, right lobe volume, and percentage of remnant liver are issues to be considered in preoperative planning especially transplantation. Objectives The aim of this study was to investigate the relationship of the presence of the inferior right hepatic vein (IRHV) with the right hepatic vein (RHV) diameter, right lobe volume, and percentage of remnant liver. Materials and Methods In t his cross-sectional study, the computed tomography (CT) images of 90 patients who underwent triphasic CT for being living liver donation were evaluated retrospectively. The number and diameter of IRHVs and the diameter of main RHV were recorded. For the liver volume analysis, a deep learning-based automatic liver segmentation (Hepatic VCAR) program was used. A virtual hepatectomy plane was drawn, where the right and left liver volumes were found and the percentage of the left lobe to the total liver volume was calculated. Pearson's correlation analysis was used for correlation analysis and Student's t -test was used to compare parameters. Results A total of 74 IRHVs were detected in 53 (58.88%) of 90 patients. There were no differences in the percentage of remnant left lobe volume, right lobe volume, and RHV diameter between the IRHV (+) and (-) groups. The RHV diameter had a weak negative correlation with the IRHV diameter, and a weak positive correlation with the right lobe volume. Conclusions The percentage of remnant left lobe volume, right lobe volume, and RHV diameter did not differ in liver donors with and without an IRHV. The RHV diameter had a weak negative correlation with the IRHV diameter and a weak positive correlation with the right lobe volume.

Evaluation of the relationship of the T and M stage with the erector spinae muscle area in male lung cancer patients.

OBJECTIVES: Sarcopenia is very common due to cachexia and presents with a decrease in skeletal muscle mass. In this study, we aimed to investigate the relationship between the T, M category and the erector spinae muscle area (ESMa). MATERIAL AND METHODS: The initial first thorax and high-resolution computed tomography (CT) of patients with lung cancer between 2015 and 2019 were retrospectively screened. After exclusion criterias remaining 226 male patients constituted the study group. ESMa was measured manually in the section taken from the T12 vertebra spinous process level as previously described in the literature and its relationship with the T and M stage were evaluated. RESULTS: The mean ages of patients were 70 ± 9.57 years. The T stage was T1 in 34 (15%) patients, T2 in 46 (20.4%), T3 in 59 (26.1%), and T4 in 87 (38.5%). Metastasis was detected in 83 (36.7%) patients. The mean ESMa of the patients was 34.15 ± 7.21 mm2 and did not differ according to the T stage (p = .39). ESMa was lower in the metastatic group (mean 30.42 ± 6.38 mm2) than the non-metastatic group (mean 36.32 ± 6.78 mm2) (p = .0001). CONCLUSIONS: ESMa, one of the indicators of sarcopenia, is lower in patients with metastatic lung cancer than in nonmetastatic.

The first reported case of left renal vein fenestration.

PURPOSE: Vascular fenestrations are mostly seen in the arterial system and cerebral vessels, but they can be seen rarely in the venous system. In this article, we aimed to present the first case of left renal vein fenestration, which has not been previously reported in the English literature to the best our knowledge. METHODS: Computed tomography angiography (CTA) examination was performed on a 40-year-old male patient who presented with rectal bleeding, and iron deficiency anemia, detected hemorrhoids in colonoscopy, and was planned for superior rectal artery embolization. RESULTS: In CTA examination, a fenestration in the middle part of the left renal vein was detected. The fenestrated segment length was measured approximately 3 cm. The diameter of anterior and posterior channels were 7.66 and 6.01 mm, respectively. The 2.85 mm diameter inferior segmental artery of the left renal artery was passing between the anterior and posterior channels of the fenestrated segment, and there was a slight indentation of this artery to the posterior canal. CONCLUSION: Although venous fenestrations are rare, they can also be seen in the renal venous system, and can be detected with CTA. It is important for radiologists to be aware of this situation, to increase its detectability and to prevent iatrogenic injury in possible surgical procedures. And also as in our case, left renal vein fenestration may be one of the causes of microscopic hematuria.

Evaluation of the frequency of incidental findings and their clinical significance in multiparametric prostate magnetic resonance imaging examination.

Purpose: Conventional diagnostic methods have limitations in the diagnosis of prostate cancer (PCa); therefore, the use of multiparametric magnetic resonance imaging (mpMRI) in PCa has become widespread. We aimed to determine the frequency of IF detected in the mpMRI examination according to organ distribution and clinical significance. Material and methods: mpMRI examinations performed between January 2015 and 2020 based on the diagnosis or suspicion of PCa were retrospectively evaluated. IFs were divided into 2 groups, as genitourinary system and non- genitourinary system findings. In addition, IFs were also evaluated in 2 groups, as clinically significant and clinically non-significant. The patient population was divided into age ranges, and the frequency of IFs in these age ranges and their clinical significance were recorded. Results: The mpMRI examinations of 426 patients revealed a total of 321 Ifs, comprising 212 (49.8%) genitourinary (41.1%) and 189 (58.9%) extragenitourinary findings. The mean age of the patients was 63.53 ± 7.89 years. As the age increased, the rate of IFs increased (p = 0.001). However, there was no increase for the 75-year-old group compared to the 65-74-year-old age range (p = 0.853). There were a total of 22 (6.9%) clinically significant Ifs - 4 associated with the genitourinary system and 18 extragenitourinary. Conclusions: Although the rate of clinically significant IF was only 6.9%, this rate was high in patients, especially in those over the age of 65 years. It should be kept in mind that the early detection of these findings in the asymptomatic period will increase the survival and successful treatment of patients.