IDEAL study: magnetic resonance imaging for suspected deep endometriosis assessment prior to laparoscopy is as reliable as radiological imaging as a complement to transvaginal ultrasonography.

OBJECTIVE: To compare the value of using one-stop magnetic resonance imaging (MRI) vs standard radiological imaging as a supplement to transvaginal ultrasonography (TVS) for the preoperative assessment of patients with endometriosis referred for surgery in a tertiary care academic center. METHODS: This prospective observational study compared the diagnostic value of the standard preoperative imaging practice of our center, which involves expert TVS complemented by intravenous urography (IVU) for the evaluation of the ureters and double-contrast barium enema (DCBE) for the evaluation of the rectum, sigmoid and cecum, with that of expert TVS complemented by a 'one-stop' MRI examination evaluating the upper abdomen, pelvis, kidneys and ureters as well as rectum and sigmoid on the same day, for the preoperative triaging of 74 women with clinically suspected deep endometriosis. The findings at laparoscopy were considered the reference standard. Patients were stratified according to their need for monodisciplinary surgical approach, carried out by gynecologists only, or multidisciplinary surgical approach, involving abdominal surgeons and/or urologists, based on the extent to which endometriosis affected the reproductive organs, bowel, ureters, bladder or other abdominal organs. RESULTS: Our standard preoperative imaging approach and the combined findings of TVS and MRI had similar diagnostic performance, resulting in correct stratification for a monodisciplinary or a multidisciplinary surgical approach of 67/74 (90.5%) patients. However, there were differences between the estimation of the severity of disease by DCBE and MRI. The severity of rectal involvement was underestimated in 2.7% of the patients by both TVS and DCBE, whereas it was overestimated in 6.8% of the patients by TVS and/or DCBE. CONCLUSIONS: Complementary to expert TVS, 'one-stop' MRI can predict intraoperative findings equally well as standard radiological imaging (IVU and DCBE) in patients referred for endometriosis surgery in a tertiary care academic center. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Implementation of patient-tailored contrast volumes based on body surface area and heart rate harmonizes contrast enhancement and reduces contrast load in small patients in portal venous phase abdominal CT.

PURPOSE: The aim of this study was to evaluate the impact of a patient-tailored contrast volume protocol on portal venous phase abdominal CT-images compared to a fixed volume protocol in daily radiological practice. METHOD: Data of 77 patients who underwent two contrast-enhanced CT-examinations were collected. The first examination was performed with a fixed contrast volume (95 ml), the follow-up examination was performed with a patient-tailored contrast volume based on patient's BSA and heart rate. The patient-tailored volume was calculated by a software application integrated in the interface of the injection pump. Two independent radiologists assessed subjective and objective image quality. Differences in enhancement and contrast volumes between both protocols were analysed. RESULTS: Despite a significant contrast volume reduction in women and in patients with low to normal BMI, enhancement was more consistent over different BMI-categories in the patient-tailored contrast volume protocol and there was no significant difference in subjective image quality between both injection protocols. CONCLUSIONS: A patient-tailored contrast volume protocol based on BSA and heart rate can be considered in daily radiological practice to decrease contrast volumes in women and in low to normal BMI patients and to achieve more consistent contrast enhancement across different BMI-categories in venous phase abdominal CT.

Yield of routine imaging after curative colorectal cancer treatment.

BACKGROUND/AIM: The use of imaging in the follow-up of patients after curative colorectal cancer resection is much debated. The American Society of Colon and Rectal Surgeons did not recommend routine imaging. This retrospective study assesses the yield of routine imaging to detect recurrent disease. METHODS: In 1998, 108 consecutive patients underwent curative resection for colorectal carcinoma. Minimum followup in our institution was 3 years. Multidisciplinary follow-up at a joint clinic consisted out of a history, clinical examination, serum carcinoembryonic antigen (CEA), chest X-ray and abdominal ultrasound, at least every 6 months. Colonoscopy was performed within 1 year after operation and every 3 to 5 years thereafter. The incidence, timing, means of detection and resectability of recurrence were studied. RESULTS: The recurrence rate was 22% (24 patients): liver metastases (11), extra-hepatic recurrence (10) and combined recurrence (3). Recurrent disease occurred in stage II or III cancer, except for two patients. It was diagnosed at a median of 21.5 months (range 4-79) after surgery. Means of detection were: symptoms in 2 (peritoneal disease, 8%), increasing CEA in 15 (63%), routine imaging in 6 (25%), and abdominal CT-scan in one patient. Curative resection of recurrent disease was possible in ten patients (42%): in 6/15 recurrences detected by CEA, in 3/6 recurrences detected by routine imaging, in 1 liver metastasis detected by CT and in none of the symptomatic patients. CONCLUSIONS: A CEA level increasing above 5.0 microg/L was the most important diagnostic tool. However, one quarter of the recurrences were detected by routine imaging and half of them could be resected for cure. These data support routine imaging during follow-up.

Pooled analysis of the surgical treatment for colorectal cancer liver metastases.

Liver metastases in colorectal cancer patients decreases the expected 5 year survival rates by a factor close to nine. It is generally accepted that resection of liver metastases should be attempted whenever feasible. This manuscript addresses the optimal therapeutic plan regarding timing of resection of synchronous liver metastases and the use of chemotherapy in combination with resection of synchronous metachronous liver metastases. The aim is to pool all published results in order to attribute a level of evidence to outcomes and identify lacking evidence areas. A systematic search of guidelines, reviews, randomised controlled, observational studies and updating a meta-analysis was performed. Data were extracted and analysed. Data failed to demonstrate an effect of timing of surgery or use of chemotherapy on overall survival. Concomitant resection of liver metastases and the primary tumour may result in lower postoperative morbidity. Systemic peri-operative chemotherapy may improve progression free survival compared to surgery alone.

Sonographic evaluation of transjugular intrahepatic portosystemic shunt.

The purpose of this article is to review the role of sonography before, during and after transjugular intrahepatic portosystemic shunt placement. A sonographic assessment of the liver and abdomen is recommended before the procedure. We illustrate several important sonographic findings for the echographist, which may alter the procedure approach or even preclude transjugular intrahepatic portosystemic shunt placement. The most challenging step during the procedure is the puncture of the right portal vein. Sonography can be a helpful tool in reducing the number of needle passes, thereby reducing the risk of hemorrhagic complications. Because of its non-invasive and cost-benefit nature, sonography is useful for transjugular intrahepatic portosystemic shunt follow-up. A baseline study at 24 to 48 hours is recommended to discover procedure-related complications. Long-term follow-up is important to detect malfunction of the shunt. Doppler ultrasound is very accurate in detecting shunt thrombosis. However, no consensus exists on the optimal sonographic screening protocol for detecting stenosis. We describe three sonographic parameters to detect transjugular intrahepatic portosystemic shunt stenosis with high sensitivity. Finally, additional sonographic parameters and potential pitfalls are provided in order to improve sensitivity.

Ovarian torsion in a premenarcheal girl: MRI findings.

Adnexal torsion is an uncommon cause of severe lower abdominal pain in women and is often difficult to distinguish from other acute abdominal conditions. However, adnexal torsion should be considered in premenarcheal girls admitted with acute abdominal pain and evidence of an ovarian mass. Accurate and early radiological diagnosis is mandatory immediately after onset of clinical symptoms in order to preserve the viability of the ovary. Ultrasound (US) is usually the first line examination performed in an emergency setting, but computed tomography (CT) and magnetic resonance imaging (MRI) can be useful in case of ambiguous US findings, especially in patients with sub-acute symptoms and a suspected adnexal mass. This case report describes the additional value of MRI in a premenarcheal girl with sub-acute right fossa pain.

Value of carbon dioxide wedged venography and transvenous liver biopsy in the definitive diagnosis of Abernethy malformation.

We report a 25-year-old man who presented with congenital absence of the portal vein, or Abernethy malformation, a rare congenital disorder in which the mesenteric and splenic venous drainages bypass the liver and directly drain into the inferior vena cava through an extrahepatic portosystemic shunt. Magnetic resonance imaging, which showed multiple nodular lesions in both liver lobes that were associated with an absence of intrahepatic portal venous branches, strongly suggested the diagnosis of the Abernethy malformation. Carbon dioxide wedged venography and transvenous liver biopsy, which were performed in the same session by a right jugular approach, confirmed these findings. This technique can be considered a valuable alternative diagnostic tool to catheter arteriography and percutaneous transhepatic liver biopsy.

Left ovarian Brenner tumor.

Ovarian Brenner tumors are uncommon neoplasms of the ovary, representing approximately 2% of all ovarian neoplasms. Nowadays there is general agreement that Brenner tumors are derived from the surface epithelium of the ovary or the pelvic mesothelium through transitional cell metaplasia. Association with other surface-derived neoplasms, either in the ipsilateral or contralateral ovary, is reported in 30% of the cases. We report a case of benign ovarian Brenner tumor and discuss the typical features on magnetic resonance imaging (MRI) and computed tomography (CT) scan as well as the differential diagnosis.

Small bowel obstruction secondary to disseminated candidiasis in an immunocompromised patient: radiologic-pathologic correlation.

Immunosuppression for therapeutic reasons (e.g. post transplantation, post chemotherapy), as well as pathologic immunodeficiency due to certain pathologic conditions (e.g. AIDS, leukemia), is increasingly encountered in daily medical practice. As a result, the concomitant risk for opportunistic infections is higher and immunocompromised patients may present with uncommon clinical and radiologic conditions. We report on a case of a 33-year-old immunocompromised woman with a history of recurrent T-cell lymphoblastic lymphoma, which presented with abdominal pain. Computed tomography (CT) images demonstrated significant small bowel dilatation, wall thickening, and high-density intestinal content, with a focal point of transition in the pelvis. Extensive fungal enteritis due to Candida Albicans with partial small bowel obstruction was found on autopsy.

Delivery related rupture of the gravid uterus: imaging findings.

Rupture of the gravid uterus is a rare, life-threatening obstetric complication. Major symptoms are hypovolemic shock and abdominal pain during late pregnancy or after vaginal delivery. Immediate surgical therapy is required. We report a case of uterine rupture after vaginal delivery diagnosed by means of ultrasonography and computed tomography.

Virtual colonoscopy: a new screening tool for colorectal cancer?

One of the new forays into the field of medical imaging is the 3-D computer imaging. Thanks to new and more performant computer processing and 3-D rendering methods it is nowadays possible to generate high resolution images of the inner surface of the colon based on CT and MR images. This article reviews the current status and research directions of virtual colonoscopy and its possible eligibility of becoming a new tool for colorectal screening.

Patient acceptance for CT colonography: what is the real issue?

The aim of this study was to evaluate the discomfort associated with CT colonography compared with colonoscopy and bowel purgation cleansing, and to evaluate patient preference between CT colonography and colonoscopy. In a total of 124 patients, scheduled for multidetector virtual CT colonography and diagnostic colonoscopy, patient acceptance and future preference were assessed during the different steps of the procedure (colon preparation, CT examination, and conventional colonoscopy). Patients who described contradictory findings between the degree of discomfort and their preference regarding follow-up examinations were retrospectively reinterviewed regarding the reason for this discrepancy. Colonoscopy was graded slightly more uncomfortable than virtual CT colonography, but the preparation was clearly the most uncomfortable part of the procedure. Concerning their preference regarding follow-up examinations, 71% of the patients preferred virtual CT colonography, 24% preferred colonoscopy, and 5% had no preference. Twenty-eight percent of the patients preferred virtual CT colonography despite that they thought it was equally or even more uncomfortable than colonoscopy. This was mainly due to the faster procedure (17 patients), the lower physical challenge (14 patients), and the lack of sedation (12 patients) of virtual CT colonography. Factors other than the discomfort related to the examinations play an important role in the patient's preference for virtual CT colonography, namely the faster procedure, the lower physical challenge, and the lack of sedation. Since the preparation plays a major decisive factor in the patient acceptance of virtual CT colonography, more attention should be given to fecal tagging.

A new multislab 3D balanced turbo field echo technique for imaging of the renal arteries without contrast agent.

An 80-year-old female patient with arterial hypertension and slowly progressive deterioration of renal function was referred to our department for investigation of the renal arteries. Imaging of the renal arteries with ultrasound was inconclusive, due to obesity. Subsequently, imaging was performed with balanced turbo field echo which is a newly developed technique in our department. This new technique for the moment is still combined with contrast-enhanced magnetic resonance angiography. A therapeutic digital subtraction angiography was performed for stent placement.