Heterotopic twin pregnancy in unicornuate uterus and non-communicating rudimentary horn with survival of both fetuses: Magnetic resonance imaging and 3D reconstructions findings.

We reported a case of heterotopic twin pregnancy in a unicornuate uterus with a non-communicating rudimentary horn with survival of both fetuses. The diagnosis was made late at 28 weeks of gestation, with suspicion raised by ultrasound and confirmed by magnetic resonance imaging (MRI). During hospitalization, obstetric ultrasound with color Doppler was performed every 2 days to assess fetal well-being and myometrial thickness, which was determined by measurements of the uterine wall at the accessory horn. Elective cesarean section was performed at 33 + 5 weeks of gestation. Delivery started with the fetus in the rudimentary horn, with subsequent extraction of the fetus in the unicornate uterus. Three-dimensional virtual reconstruction allowed a spatial view of the both uterus and fetuses with better understanding of the obstetrical condition by the parents and interactive discussion by the multidisciplinary medical team.

Assessment of Early Treatment Response With DWI After CT-Guided Radiofrequency Ablation of Functioning Adrenal Adenomas.

OBJECTIVE: The objective of this study was to establish the suitability of the apparent diffusion coefficient (ADC) as a parameter for evaluating early treatment response after percutaneous ablation of functional adrenal adenomas. SUBJECTS AND METHODS: Seventeen adult patients with functioning adrenal adenomas underwent radiofrequency ablation. Serum hormone levels were analyzed before and up to 6 months after ablation. MRI findings (nodule size in cm, signal intensity index, ADC maps, and nodule-to-muscle ADC ratio) were analyzed before and up to 30 days after ablation. A consensus review of all scans was performed by two attending abdominal imaging radiologists. The procedure was considered successful if serum hormone levels normalized and no contrast enhancement of the adrenal lesion was seen on follow-up MRI. RESULTS: Of 17 patients who underwent radiofrequency ablation, complete response was achieved in 16 patients with partial response in one patient. Of the four parameters of interest, only ADC maps and nodule-to-muscle ADC ratio showed statistically significant differences (p < 0.05). CONCLUSION: This prospective study suggests that apparent diffusion coefficient values may help radiologists monitor early treatment response after CT-guided radiofrequency ablation of functioning adrenal adenomas.

Radiofrequency Ablation of Functioning Adrenal Adenomas: Preliminary Clinical and Laboratory Findings.

PURPOSE: To evaluate clinical and laboratory findings in patients undergoing radiofrequency (RF) ablation for functioning adrenal adenomas. MATERIALS AND METHODS: Eleven adult patients, nine with Conn syndrome and two with Cushing syndrome, underwent percutaneous computed tomography-guided RF ablation for benign adrenal neoplasms. Systolic, diastolic, and mean blood pressure and the number of classes of antihypertensive drugs used by each patient were analyzed before and 1, 4, and 12 weeks after the procedure. Serum hormone levels were analyzed within 30 days before and 12 weeks after the procedure. RESULTS: Of the nine patients with Conn syndrome, eight showed normal serum aldosterone levels after the procedure and one patient had a nodule located very close to the inferior vena cava, resulting in incomplete ablation. The two patients with Cushing syndrome had normal serum and salivary cortisol levels after the procedure. Mean aldosterone concentration at baseline was 63.3 ng/dL ± 28.0 and decreased to 13.3 ng/dL ± 13.5 at 12 weeks postoperatively (P = .008). Systolic, diastolic, and mean blood pressures decreased significantly in the first week after the procedure (P < .001) and remained stable during further follow-up. CONCLUSIONS: In patients with Conn syndrome or Cushing syndrome, percutaneous RF ablation of functioning adrenal adenomas may result in normalization of hormone secretion, improvement in blood pressure, and reduced need for antihypertensive drugs.

Diffusion-weighted magnetic resonance imaging indicates the severity of acute pancreatitis.

PURPOSE: To test the use of diffusion-weighted magnetic resonance imaging (DW-MRI) to differentiate between different degrees of severity of acute pancreatitis (AP). METHOD: Thirty-six patients who underwent DW-MRI and magnetic resonance cholangiopancreatography were divided into patients with mild AP (mAP, n = 15), patients with necrotizing AP (nAP, n = 8), and patients with a normal pancreas (nP, n = 15; controls). The pancreas was divided into head, body, and tail, and each segment was classified according to image features: pattern 1, normal; pattern 2, mild inflammation; and pattern 3, necrosis. Apparent diffusion coefficients (ADCs) were measured in each segment and correlated with clinical diagnoses. RESULTS: A total of 108 segments was assessed (three segments per patient). Segments classified as pattern 1 in the nP and mAP groups showed similar ADC values (P = 0.29). ADC values calculated for the pancreatic segments grouped according to the different image patterns (1-3) were significantly different (P < 0.001). Comparisons revealed significant differences in signal intensity between all three patterns (P < 0.05). CONCLUSIONS: DW-MRI was a compatible and safe image option to differentiate tissue image patterns in patients with mAP, nAP, and nP, mainly in those with contraindications to contrast-enhanced MRI (which is classically required for determining the presence of necrosis) or computed tomography. ADC measures allowed precise differentiation between patterns 1, 2, and 3.

Clinical usefulness of tissue acquisition of pancreatic cystic lesions using an endoscopic ultrasound-guided needle for histological analysis.

Background and study aims There are rare data on the usefulness of endosonography-guided tissue acquisition (EUS-TA) in patients with pancreatic cystic lesions (PCLs). This study aimed to determine the accuracy of EUS-TA with ProCore 20G (PC20) for differentiating between mucinous neoplasia (MN) and non-MNs (n-MN) and identifying malignant PCLs, as well as its adverse events (AEs) in patients with PCLs without a classificatory diagnosis by imaging exams. Patients and methods In this observational, retrospective, single-center study, all patients with PCL who underwent EUS-TA due to diagnostic doubts in imaging studies were consecutively recruited from June 2017 to December 2021. The outcomes were to determine the diagnostic accuracy of EUS-TA with PC20 for differentiating between MN and n-MN, identifying malignant PCLs, and the AEs. Results Herein, 145 patients underwent EUS-TA, with 83 women (57.2%) and a mean age of 62.2 years. The mean size was 2.3 cm, with 81 patients (77.9%) having a PCL < 3.0 cm. The final diagnosis was made by EUS-TA (n = 81), surgery (n = 58), and follow-up (n = 6). The sensitivity, specificity, positive and negative predictive values, and accuracy for differentiating between MNs and n-MNs and identifying malignant PCLs were 92.6%, 98.4%, 98.7%, 91.3%, and 95.2% (kappa=0.9), and 92%, 99.2%, 95.8%, 98.3%, and 97.9% (kappa = 0.93), respectively. The AE rate was 2.7%, with no deaths in this cohort. Conclusions EUS-TA with PC20 has high accuracy and technical success with a low AE rate for PCL diagnosis.

Percutaneous ablation of functioning adrenal adenoma: a report on 11 cases and a review of the literature.

PURPOSE: Percutaneous ablation of functioning adrenal adenomas has been an alternative to videolaparoscopic treatment. This study aimed to evaluate the feasibility, safety and efficacy of radiofrequency ablation (RFA) in the treatment of functioning adrenal tumors using a computed tomography (CT)-guided percutaneous technique as demonstrated by our experience and the literature. METHODS: Eleven adult patients (mean age 46 years) with a diagnosis of functioning adrenal adenoma underwent CT-guided RFA between October 2011 and August 2012. All RFA procedures were performed using a needle electrode with a single lateral filament and the RITA(®) 1500X radiofrequency generator. The RFA protocol consisted of two cycles of 5 min each with 1-min interval, with no additional ablation cycles. Contrast-enhanced CT scans were obtained and analyzed for immediate treatment success and possible complications. RESULTS: Maximum tumor dimension ranged from 1.2 to 3.4 cm. The mean procedure time was 74 min, and length of hospital stay ranged from 0.9 to 3.2 days (mean 1.8 days). One patient had residual pneumothorax and one patient had neuritis involving the T10 dermatome. Of 11 patients, 10 recovered from their condition. Only one patient remained with hyperaldosteronism, but with reduced anti-hypertensive medication. CONCLUSIONS: CT-guided percutaneous RFA was a safe and effective treatment for functioning adrenal adenomas, with short hospital length of stay and low complication rate.

Endoscopic Ultrasound-Guided Tissue Acquisition Versus Fine Needle Aspiration for Diagnosis of Pancreatic Ductal Adenocarcinoma.

OBJECTIVES: Compare the 22G needle versus EchoTip ProCore® 20 (Cook Medical, Bloomington, IN, USA) on their handling, specimen suitability, amount of tissue obtained, diagnostic performance, the possibility of immunohistochemistry, and rate of adverse events. MATERIALS AND METHODS: This is a retrospective, comparative study of consecutively examined patients with pancreatic masses who underwent endosonography-guided fine needle aspiration (FNA) via the 22G needle, and endosonography-guided tissue acquisition (TA) via ProCore 20 (PC20). The operator evaluated needle insertion and subjectively classified the specimen. The pathologist measured the samples, classified the amount of tissue, and determined the influence of bleeding on the interpretation. RESULTS: A total of 129 patients participated in the study, out of whom 52 underwent endosonography-guided FNA with 22G and 77 underwent endosonography-guided TA with a PC20 needle. Malignant lesions were found in 106, and 23 had benign lesions. The duodenal route was used in 62% of patients. The 22G needle was easier to introduce (p=0.0495). However, PC20 obtained a larger amount (p<0.01) with fewer punctures (p<0.001). The PC20 also yielded a larger average microcore diameter (p=0.0032). Microhistology was adequate for 22G and PC20 in 22 (42.2%) and 50 (78.1%) specimens, respectively (p<0.001). Bleeding was not significantly different (p>0.999). Immunohistochemistry was possible in 36 (69.2%) and 40 (51.9%) specimens obtained by 22G and PC20, respectively (p=0.075). The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 22G were 93.5%, 100%, 100%, 66.7%, and 94.2%, respectively; and for PC20, it was 95%, 100%, 100%, 85%, and 96.1%, respectively. Mild bleeding was the most common early adverse event, occurring in 2/52 (3.8%) 22G and 4/77 (5.2%) PC20 cases (p>0.05). CONCLUSIONS: The PC20 required fewer punctures and reduced the need for immunohistochemistry as it yielded better and larger microcores. Its ease of insertion into the target lesion makes it a good option to obtain satisfactory microcore specimens in difficult positions, such as the transduodenal route.

Analysis by MRI of residual tumor after radiofrequency ablation for early stage breast cancer.

OBJECTIVE: The objective of our study was to evaluate the effectiveness of MRI in the detection of possible residual lesions after radiofrequency ablation (RFA) in the treatment of breast cancer. SUBJECTS AND METHODS: We prospectively evaluated 14 patients who had undergone ultrasound-guided core biopsies diagnostic of invasive ductal carcinoma (IDC; range of diameters, 1.0-3.0 cm) and then ultrasound-guided percutaneous RFA with sentinel node biopsy as the primary treatment. Breast MRI was performed 1 week before RFA to evaluate tumor extension and again 3 weeks after RFA to verify the presence of possible residual lesions. Conventional surgical resection of the tumors was performed 1 week after RFA. The MRI findings were compared with histopathologic analyses to confirm the presence or absence of residual tumor. RESULTS: There was no residual enhancement in seven lesions on the postablation breast MRI scans. These findings were confirmed by negative histopathologic findings in the surgical specimens. The MRI scans of five patients showed small areas of irregular enhancement that corresponded to residual lesions. In the two remaining patients, we observed enhancement of almost the entire lesion, indicating that RFA had failed. CONCLUSION: Breast MRI is effective in detecting residual lesions after RFA in patients with IDC.

Castleman's disease mimetizing pancreatic tumor.

CONTEXT: Angiofollicular lymph node hyperplasia or Castleman's disease is a rare clinical condition. Knowledge about etiology and physiopathology; and treatment management as well are yet to be defined. Unicentric presentation of this disease affecting single lymph nodes in the mediastinum seems to be the most common presentation. Castleman's disease localized in the pancreas topographic area that mimics a pancreatic neoplasm is an even more uncommon event, with available published data of less than 15 cases until now. CASE REPORT: We present a 64-year-old male patient with a six-month past history of asthenia, adynamia, and lack of general clinical conditions. Imaging studies showed a nodular hypoechoic mass in the pancreatic head. Enucleation of the lesion was performed. Histopathological study revealed unicentric form of Castleman's Disease. CONCLUSIONS: Castleman's disease mimetizing pancreatic tumor is uncommon and it also curses with a difficult preoperative diagnosis. Surgery seems to be the best therapeutic alternative for this disease.

Uterine artery embolization with highly compressible calibrated microspheres for the treatment of uterine fibroids.

Objective: To evaluate the safety and efficacy of using highly compressible calibrated microspheres in uterine artery embolization (UAE) for the treatment of uterine fibroids. Materials and Methods: This was a prospective multicenter study. Thirty-two women with symptomatic uterine fibroids were selected for UAE between January 2019 and March 2020. The participants completed the Uterine Fibroid Symptom and Quality of Life (UFS-QOL) questionnaire, underwent contrast-enhanced pelvic magnetic resonance imaging (MRI), and were submitted to anti-Müllerian hormone measurement, subsequently undergoing UAE with Embosoft microspheres. After six months, the patients again completed the UFS-QOL questionnaire and underwent pelvic MRI. Results: The most common symptoms were abnormal uterine bleeding (in 81.3% of the cases), pelvic pain (in 81.3%), and compression (in 46.9%). Of the 32 patients evaluated, 12 (37.5%) had anemia due to abnormal uterine bleeding. Thirty patients completed the study. Among those patients, we observed median reductions of 21.4% in uterine volume and 15.9% in dominant fibroid volume. We identified no adverse events that could be attributed to the material itself, although there were events attributed to the UAE procedure in general. Conclusion: For the treatment of uterine fibroids, UAE using Embosoft microspheres shows satisfactory results, providing reductions in uterine and dominant fibroid volumes, with a low rate of adverse events, and improving patient quality of life, as well as demonstrating safety and efficacy.

Objetivo: Avaliar a eficácia e segurança da embolização da artéria uterina (EAU) com microesferas calibradas de alta compressibilidade no tratamento de miomas uterinos. Materiais e Métodos: Este foi um estudo prospectivo e multicêntrico. Foram selecionadas 32 mulheres com miomas uterinos sintomáticos para EAU de janeiro de 2019 a março de 2020. As participantes preencheram o questionário Uterine Fibroid Symptom and Quality of Life (UFS-QOL), realizaram ressonância magnética (RM) pélvica com contraste e teste para medição dos hormônios antimüllerianos, seguido de embolização de miomas com microesferas Embosoft. Após seis meses, as pacientes novamente preencheram o UFS-QOL e realizaram RM pélvica. Resultados: Os sintomas mais relatados foram sangramento uterino anormal (81,3%), dor pélvica (81,3%) e compressão (46,9%). Doze pacientes (37,5%) apresentaram anemia consequente a sangramento uterino anormal. Nas 30 pacientes que completaram o estudo, observou-se redução mediana de 21,4% no volume uterino e 15,9% no volume do mioma dominante. Não foram identificados eventos adversos possivelmente relacionados ao material utilizado, apenas em relação ao procedimento de EAU. Conclusão: EAU com microesferas Embrosoft mostrou resultados satisfatórios no tratamento de miomas uterinos, com redução dos volumes uterino e do mioma dominante, baixa taxa de eventos adversos e melhora na qualidade de vida, demonstrando segurança e eficácia.

New trends in diffusion-weighted magnetic resonance imaging as a tool in differentiation of serous cystadenoma and mucinous cystic tumor: a prospective study.

BACKGROUND/AIMS: Pancreatic cystic lesions are increasingly being recognized. Magnetic resonance imaging (MRI) is the method that brings the greatest amount of information about the morphologic features of pancreatic cystic lesions. To establish if diffusion-weighted MRI (DW-MRI) can be used as a tool to differentiate mucinous from nonmucinous lesions. METHODS: Fifty-six patients with pancreatic cystic lesions (benign, n = 46; malignant, n = 10) were prospectively evaluated with DW-MRI in order to differentiate mucinous from nonmucinous lesions. Final diagnosis was obtained by follow-up (n = 31), surgery (n = 16) or endoscopic ultrasound-guided fine needle aspiration (n = 9). Serous cystadenoma was identified in 32 (57%) patients. RESULTS: The threshold value established for the differentiation of mucinous from nonmucinous lesions was 2,230.06 s/mm(2) for ADC of 700. DWI-MRI behavior between mucinous and nonmucinous groups revealed sensitivity, specificity, positive predictive value, negative predictive value and accuracy to be 80, 98, 92, 93 and 93%, respectively (p < 0.01, power of sample = 1.0). In the comparison of the diffusion behavior between mucinous (n = 13) and serous (n = 32) lesions, the sensitivity, specificity, positive predictive value, negative predictive value and accuracy were 100, 97, 92, 100 and 98%, respectively (p < 0.01, power of sample = 1.0). The results of endoscopic ultrasound-guided fine needle aspiration were similar to those of DW-MRI. CONCLUSIONS: DW-MRI can be included as part of the array of tools to differentiate mucinous from nonmucinous lesions and can help in the management of pancreatic cystic lesions. and IAP.

Children with Cushing's syndrome: Primary Pigmented Nodular Adrenocortical Disease should always be suspected.

Primary Pigmented Nodular Adrenocortical Disease (PPNAD) is a rare form of bilateral adrenocortical hyperplasia that is inherited in an autosomal dominant manner and leads to ACTH-independent Cushing's syndrome (CS). PPNAD may be isolated or associated with Carney Complex (CNC). For the diagnosis of PPNAD and CNC, in addition to the hormonal and imaging tests, searching for PRKAR1A mutations may be recommended. The aims of the present study are to discuss the clinical and molecular findings of two Brazilian patients with ACTH-independent CS due to PPNAD and to show the diagnostic challenge CS represents in childhood. Description of two patients with CS and the many sequential steps for the diagnosis of PPNAD is provided. Sequencing analysis of all coding exons of PRKAR1A in the blood, frozen adrenal nodules (patients 1 and 2) and testicular tumor (patient 1) is performed. After several clinical and laboratory drawbacks that misled the diagnostic investigation in both patients, the diagnosis of PPNAD was finally established and confirmed through pathology and molecular studies. In patient 1, sequencing of PRKAR1A gene revealed a novel heterozygous 10-bp deletion in exon 3, present in his blood, adrenal gland and testicular tumor. The etiologic diagnosis of endogenous CS in children is a challenge that requires expertise and a multidisciplinary collaboration for its prompt and correct management. Although rare, PPNAD should always be considered among the possible etiologies of CS, due to the high prevalence of this disease in this age group.

Use of diffusion-weighted imaging in the noninvasive diagnostic of obstructed biliary ducts.

OBJECTIVE: This study sought to evaluate the role of diffusion-weighted imaging (DWI) in differentiation between obstructed and unobstructed bile ducts in patients undergoing magnetic resonance imaging (MRI). METHODS: Eighty-four patients, 40 males and 44 females (mean age: 56.4 ± 15.1 years), undergoing MRI with DWI (0-50-500-700) were evaluated and divided into two groups: 58 with abnormal laboratory tests (obstructed group) and 26 with normal laboratory values (unobstructed group). Laboratory tests were total bilirubin, alkaline phosphatase, and gamma-glutamyltransferase. Median ADC values were calculated and correlated with laboratory tests and degree of bile-duct dilatation (absent, moderate, or severe). The persistence of signal on DWI (b500 and b700) in the biliary tract was evaluated. Bilirubin values were tested for correlation with bile-duct ADC values and persistence of b700 signal. For statistical analysis, Student t test, chi-square test and Wilcoxon-Mann-Whitney test were used. ADC maps were plotted for three levels of the biliary tree, and a receiver operating characteristic (ROC) curve was calculated. RESULTS: In the obstructed group, 15 patients had severe dilatation, 24 had moderate dilatation, and 19 had no appreciable dilatation; 38 patients had persistent signal on b700 images. In the unobstructed group, 23 patients had no dilatation and 3 had moderate dilatation; 4 patients had persistent signal on b700 images. Correlation was found between degree of bile-duct dilatation, bilirubin levels, persistence of b700 signal, and ADC map values. The calculated ADC map cutoff value (353 10-6 mm2/s) was able to differentiate the obstructed and unobstructed groups with 92.3% sensitivity, 81% specificity, and 91.9% accuracy. CONCLUSIONS: DWI is able to distinguish patients with obstructed versus unobstructed bile ducts, regardless of the degree of dilatation, correlating with clinical and laboratory findings.

Lumbosacral plexus MR tractography: A novel diagnostic tool for extraspinal sciatica and pudendal neuralgia?

BACKGROUND: Diagnosing extraspinal sciatica and pudendal neuralgia remains a clinical challenge. MRI and MR Neurography (MRN) are currently the standard techniques used to support the diagnosis of extraspinal lumbosacral plexus entrapments; however, for the intrapelvic portions of the lumbosacral plexus their accuracy is still limited. MR Tractography (MRT) feasibility to image the lumbosacral plexus has been demosntrated, but its clinical applications have yet to be determined. PURPOSE: To correlate MRT with intraoperative findings in patients undergoing laparoscopic treatment of intrapelvic entrapments of the lumbosacral plexus and compare its accuracy with Neuropelveological clinical assessment and MRN. MATERIALS AND METHODS: This is a retrospective analysis of MRT reconstructions of diffusion tensor imaging (DTI) sequences acquired for the MRN collected from a cohort of 13 patients undergoing laparoscopic detrapment of the lumbosacral plexus. The primary outcome of this study was the correlation of MRT reconstruction with intraoperative findings. Secondary outcomes included the correlation of MRN, preoperative Neuropelveological clinical diagnoses and the diffusion-weighted imaging (DWI) fractional anisotropy (FA) and Apparent Diffusion Coefficient (ADC) in patients undergoing pelvic MRI and MRN for the investigation of intrapelvic nerve entrapments. RESULTS: MRT correlated with intraoperative findings in 11 of 13 patients (85%). Neuropelveological clinical assessment was able to accurately diagnose a pelvic nerve entrapment in 12/13 patients (92%) and MRN agreed with surgical findings in only 2/13 (15%) patients. MRT was significantly superior to MRN (p < 0.001). FA and ADC did not correlate with the identification of a nerve entrapment, likely due to limitations regarding the placement of the seedpoints. CONCLUSIONS: This initial, retrospective analysis, suggests that MRT is superior to MRN at diagnosing intrapelvic entrapments of the lumbosacral plexus. A prospective, double-blinded study is underway to validate this data, but these initial findings show great potential for MRT as a diagnostic tool for extraspinal sciatica and pudendal neuralgia. Clinical Trials Registry: U1111-1261-4910 (REBEC - Brazilian Registry for Clinical Trials).

Case Report: SARS-CoV-2 Mother-to-Child Transmission and Fetal Death Associated With Severe Placental Thromboembolism.

SARS-CoV-2 infection during pregnancy is not usually associated with significant adverse effects. However, in this study, we report a fetal death associated with mild COVID-19 in a 34-week-pregnant woman. The virus was detected in the placenta and in an unprecedented way in several fetal tissues. Placental abnormalities (MRI and anatomopathological study) were consistent with intense vascular malperfusion, probably the cause of fetal death. Lung histopathology also showed signs of inflammation, which could have been a contributory factor. Monitoring inflammatory response and coagulation in high-risk pregnant women with COVID-19 may prevent unfavorable outcomes, as shown in this case.

Analysis of risk factors associated with acute pancreatitis after endoscopic papillectomy.

Acute pancreatitis (AP) is a common adverse event (AE) of endoscopic papillectomy (EP). Prophylactic plastic pancreatic stent (PPS) placement appears to prevent AP. We evaluated factors associated with post-EP AP by a retrospective analysis of patients with tumors of the duodenal papilla who underwent EP from January 2008 to November 2016 at 2 tertiary care centers. Clinical, laboratory, endoscopic ultrasound parameters, and PPS placement were evaluated. Seventy-two patients underwent EP (37 men), with mean age of 60.3 (31-88) years. Mean main pancreatic duct (MPD) diameter was 0.44 (0.18-1.8) cm. Mean tumor size was 1.8 (0.5-9.6) cm. Tumors were staged as uT1N0, uT2N0, and uT1N1 in 87.5%, 11.1%, and 1.4%. Thirty-eight AEs occurred in 33 (45.8%) patients, with no mortality. Total bilirubin, tumor size, MPD diameter, and PPS placement had odds ratios (ORs) of 0.82, 0.14, 0.00, and 6.43 for AP. Multivariate analysis (PPS placement × MPD diameter) showed ORs of 4.62 (95%CI, 1.03-21.32; p = 0.049) and 0.000 (95%CI, 0.00-0.74; p = 0.042) for AP. In conclusion, patients with jaundice, large tumors, and dilated MPD seem less likely to have post-EP AP. PPS placement was associated with a higher risk of AP, which may question its use.

Practical recommendations for the safe use of gadolinium in magnetic resonance imaging: a Delphi expert panel study.

OBJECTIVE: To assess the practical aspects of the use of various gadolinium-based contrast agents (GBCAs) by radiologists. MATERIALS AND METHODS: Ten experienced radiologists from different regions of Brazil participated in a Delphi panel querying their use of various GBCAs, including linear and macrocyclic classes (1.0 and 0.5 M), in terms of the choice of agent, volume and dosage of the agents, and associated safety concerns. RESULTS: The response rate was 100% for all questions. GBCAs are safe in terms of acute adverse reactions, and nephrogenic systemic fibrosis is rare. The deposition of gadolinium in the brain and other tissues is a concern among the experts. Macrocyclic agents are preferable to linear agents; an injection volume below 0.1 mL/kg of a 1.0 M agent could result in good-quality images with additional long-term safety, but there is no published evidence to support this recommendation. The majority of experts preferred not to administer GBCAs to pregnant patients. CONCLUSION: When choosing a GBCA, it is important to consider the characteristics of the gadolinium deposition in patient tissues and minimize potential risks. Furthermore, medical education programs are needed to increase the awareness of the potential risks of gadolinium deposition and thus avoid instances of overexposure to the contrast agent.

OBJETIVO: Avaliar aspectos práticos do uso de agentes de contraste à base de gadolínio (gadolinium-based contrast agents - GBCAs) por médicos especialistas em radiologia. MATERIAIS E MÉTODOS: Dez radiologistas de diferentes regiões do Brasil foram convidados a participar de um painel Delphi com perguntas sobre o uso de GBCAs lineares e macrocíclicos (1,0 e 0,5 M), em termos de dosagem, volume injetado e preocupações relacionadas à segurança. RESULTADOS: A taxa de resposta foi de 100% para todas as perguntas. GBCAs são seguros em relação a reações adversas agudas, e os casos de fibrose nefrogênica sistêmica são raros. O depósito de gadolínio no cérebro e em outros tecidos é uma preocupação de todo o painel. Agentes macrocíclicos são preferíveis aos lineares. Um volume menor que 0,1 mL/kg injetado de contraste macrocíclico 1,0 M poderia oferecer imagem com boa qualidade e benefício adicional em longo prazo, entretanto, não há evidências publicadas que apóiem tal recomendação. A maioria prefere não administrar GBCA em gestantes. CONCLUSÃO: É importante considerar as características de deposição e minimizar potenciais riscos ao se escolher um GBCA. Ações de educação médica são necessárias para a conscientização dos potenciais riscos da presença de gadolínio em longo prazo e evitar a sobre-exposição ao agente de contraste.

The value of signal intensity on T1-weighted chemical shift magnetic resonance imaging combined with proton magnetic resonance spectroscopy for the diagnosis of adrenal adenomas.

OBJECTIVE: To investigate the advantages of using modified signal intensity measurements on chemical shift imaging alone or in conjunction with proton magnetic resonance spectroscopy in the differential diagnosis of adrenal adenomas. MATERIALS AND METHODS: This was a prospective study involving 97 patients with adrenal nodules or masses. The signal intensity index (SII) was calculated as [(signal intensity on the in-phase image - signal intensity on the out-of-phase image) ∕ (signal intensity on the in-phase image)] × 100%. We determined the averages of the minimum, mean, and maximum signal intensity values measured on three consecutive images. When that was not possible (for smaller lesions), we used one or two images. We employed a region of interest that covered one half to two thirds of the mass. All indices were compared with metabolite ratios derived from spectroscopy: lactate/creatine; glutamine-glutamate/creatine; choline/creatine; choline/lipid; 4.0-4.3 ppm/Cr; and lipid/creatine. RESULTS: Of the 97 patients evaluated, 69 were diagnosed with adenomas and 28 were diagnosed with nonadenomas. All SII measurements and spectroscopy-derived metabolite ratios were significant to the differentiation between adenomas and nonadenomas, except for the lipid/creatine and choline/lipid ratios. In 37.8% of the cases, it was not possible to perform spectroscopy. When it was possible, the lactate/creatine ratio was found to have higher accuracy than did the SII. CONCLUSION: Determining the SII and metabolite ratios increased the accuracy of the differential diagnosis of adrenal adenomas.

OBJETIVO: Investigar as vantagens do uso de medições do índice de intensidade de sinal modificadas em imagens de deslocamento químico (chemical shift), isoladamente ou em conjunto com a espectroscopia por ressonância magnética de prótons, no diagnóstico diferencial de adenomas adrenais. MATERIAIS E MÉTODOS: Estudo prospectivo envolvendo 97 pacientes com nódulos ou massas adrenais. O índice de intensidade do sinal (SII) foi calculado como [(intensidade do sinal na imagem em fase ­ intensidade do sinal na imagem fora de fase) ∕ (intensidade do sinal na imagem em fase)] × 100%. Determinamos as médias dos valores mínimo, médio e máximo da intensidade do sinal medida em três imagens consecutivas. Quando isso não foi possível (para lesões menores), usamos uma ou duas imagens. Nós empregamos uma região de interesse que cobria de metade a dois terços da massa. Todos os índices foram comparados com razões metabólicas derivadas da espectroscopia: lactato/creatina, glutamato-glutamina/creatina, colina/creatina, colina/lipídio, 4,0­4,3 ppm/creatina e lipídio/creatina. RESULTADOS: Dos 97 pacientes avaliados, 69 foram diagnosticados como adenomas e 28 foram diagnosticados como não adenomas. Todas as medições SII e razões de metabólitos derivados da espectroscopia foram significativas para a diferenciação entre adenomas e não adenomas, exceto as razões lipídio/creatina e colina/lipídio. Em 37,8% dos casos não foi possível realizar espectroscopia. Quando possível, a razão lactato/creatina apresentou maior precisão do que o SII. CONCLUSÃO: A determinação das razões SII e metabólitos aumentaram a acurácia do diagnóstico diferencial de adenomas adrenais.

Endoscopic Ultrasound-Guided Fine-Needle Aspiration Microhistology in Asymptomatic and Symptomatic Pancreatic Cystic Lesions.

OBJECTIVE: This study aimed to analyze the usefulness of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) microhistology to detect malignancy in pancreatic cystic lesions (PCLs). METHODS: Patients with PCLs were identified and submitted to EUS-FNA from January 2010 to January 2017. The percentage of samples suitable for diagnostic classification by microhistology and the positive and negative likelihood ratios to detect malignancy in asymptomatic (APC) and symptomatic (SPC) PCLs were determined. RESULTS: Endoscopic ultrasound-guided fine-needle aspiration was performed in 510 patients. The resulting material was processed by microhistology and useful for diagnosis in 432 (84.2%). Clinical characteristics of APC (341) and SPC (169) revealed that APC patients were younger (P = 0.004) and had smaller PCLs (23 vs 35 mm; P < 0.001). In APC, we found more preneoplastic (38.7% vs 30.2%; P = 0.0016) and a lower number of malignant PCLs (8.2% vs 24.3%; P < 0.001). In APC and SPC, the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of microhistology to detect malignancy were 71.4%, 99.7%, 95.2%, 97.5%, and 97.4% (k = 0.80) and 58.5%, 96.9%, 85.7%, 87.9%, and 87.6%, respectively. CONCLUSIONS: Endoscopic ultrasound-guided fine-needle aspiration was technically feasible. Microhistology was especially useful to detect neoplastic or malignant PCLs in APC patients.

Evaluation of Uterine Contractility by Magnetic Resonance Imaging in Women Undergoing Embolization of Uterine Fibroids.

PURPOSE: To assess uterine contractility using ultrafast magnetic resonance imaging (cine MRI) before and after uterine fibroid embolization (UFE). MATERIALS AND METHODS: This is a prospective study of uterine contractility in 26 patients (age 30-41 years) undergoing UFE for symptomatic uterine fibroids. Cine MRI was performed before and 6 months after UFE. Two radiologists evaluated uterine contractility and classified it as absent, ordered, or disordered. Patients were then grouped into three distinct patterns of progression: unchanged contractility (group A), modified contractility (B), and loss of contractility (C). These findings were then confronted with factors that might have interfered with uterine contractility pattern (uterine volume, location of dominant fibroid, fibroid/myometrium index, and fibroid necrosis pattern). RESULTS: Of the 26 patients, 8 (30.7%) had no contractility before the procedure, while 18 (69.2%) exhibited some form of contractility (11 [61%] ordered, 7 [39%] disordered). All 8 patients who had no contractility at baseline exhibited contractility after UFE (5 ordered, 3 disordered). Of the 11 who had ordered contractility at baseline, 9 remained ordered and 2 lost contractility after UFE. Of the 7 with disordered contractility at baseline, 1 remained disordered, 5 progressed to ordered contractility, and 1 lost contractility. Overall, 10 patients (38%) had no change in contractility after UFE (group A), 13 (50%) had a positive change (group B), and 3 (11%) lost contractility (group C). The potential interference factors assessed had no statistically significant effect in any group. CONCLUSION: In women of reproductive age with symptomatic fibroids, uterine contractility improved significantly after UFE. LEVEL OF EVIDENCE: Level 3-non-randomized controlled cohort/follow-up study.