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Imaging has a specific role in the diagnosis and management of priapism. The primary imaging modality is ultrasound with colour Doppler (CDUS) which can accurately assess the hemodynamics of the cavernosal arteries. This is particularly useful in equivocal cases and can help differentiate ischemic from non-ischemic priapism as well as confirm the presence and location of arterio-venous fistulae post penile trauma. Furthermore, CDUS is invaluable in the post treatment follow up of non-ischemic priapism. Contrast enhanced magnetic resonance imaging (MRI) can demonstrate the extent of cavernosal necrosis in ischemic priapism and in conjunction with computer tomography (CT) has an important role in excluding underlying malignancy. MRI and CT angiography are used to evaluate pudendal arterial anatomy, which can be extremely variable and aids in the management of non-ischemic priapism. In selected cases of non-ischemic priapism, catheter angiography and transcatheter embolization of arteriovenous fistulae is an effective treatment. This review will examine the specific roles of different imaging modalities in the subtypes of priapism as well as highlight some of the pitfalls encountered in imaging.
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Non-ischemic priapism (NiP) is painless partial tumescence caused by genital trauma and the formation of intracorporal arterio-venous fistula. This is a retrospective study of 25 men with NiP and reports the long-term erectile function and colour doppler ultrasound (CDUS) findings after treatment for NiP. Unstimulated CDUS was performed at diagnosis, 1 week and at last follow-up after treatment. CDUS traces were analysed: peak systolic velocity (PSV), end diastolic velocity (EDV), resistive index (RI) and mean velocity (MV) were calculated. Erectile function was assessed using the IIEF-EF questionnaire. At the last follow-up (median 24 months), 16 men had normal erectile function (64%): median IIEF-EF score 29 (IQR 28.5-30; σ2 2.78) and nine had erectile dysfunction (36%): median IIEF-EF score 17 (IQR 14-22; σ2 33.6). MV and EDV were statistically higher in those patients with erectile dysfunction at last follow-up compared to patients with normal erectile function: median MV 5.3 cm/s (IQR 2.4-10.5 cm/s; σ2 34) vs 2.95 cm/s (IQR 1.03-3.95; σ2 3.4) p < 0.002 and median EDV 4.0 cm/s (IQR 1.5-8.0; σ2 14.7) vs 0 cm/s (IQR 0-1.75; σ2 2.21) p < 0.004. Erectile dysfunction was observed in 36% of men treated for NiP and was associated with abnormal low resistance resting CDUS waveforms. Further investigation for persistent arteriovenous fistulation should be considered in these patients.
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Disfunción Eréctil , Priapismo , Masculino , Humanos , Priapismo/diagnóstico por imagen , Priapismo/etiología , Priapismo/terapia , Disfunción Eréctil/etiología , Estudios Retrospectivos , Pene/diagnóstico por imagen , Ultrasonografía Doppler en Color/efectos adversos , Resultado del TratamientoRESUMEN
A female in her 40s, with poorly controlled Type I diabetes mellitus, was brought to our tertiary hospital by ambulance after being found drowsy. Six days prior, she had self-discharged from the Intensive Care Unit whilst being treated for a Klebsiella pneumonia. At re-admission, she had an acute kidney injury with abdominal pain and clinical features of sepsis. Her presentation was attributed to ongoing Klebsiella pneumoniae infection; however, a chest radiograph showed marked improvement of pulmonary consolidations and an unusual subdiaphragmatic gas pattern. A CT scan demonstrated severe bilateral emphysematous pyelonephritis. The patient was unfit for bilateral nephrectomy and was medically managed in the Intensive Care Unit for 41 days, before transfer to a specialist renal unit for life-long haemodialysis. This case highlights the importance of considering emphysematous pyelonephritis in patients presenting with uncontrolled diabetes mellitus and acute kidney injury and/or infection, the role of imaging in its diagnosis, and the challenges of complex social circumstances in health management.
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PURPOSE: To investigate the utility of a prostate magnetic resonance imaging (MRI) second read using a semi-automated software program in the one-stop clinic, where patients undergo multiparametric MRI, review and biopsy planning in one visit. We looked at concordance between readers for patients with equivocal scans and the possibility for biopsy deferral in this group. METHODS: We present data from 664 consecutive patients. Scans were reported by seven different expert genitourinary radiologists using dedicated software (MIM®) and a Likert scale. All scans were rescored by another expert genitourinary radiologist using a customised workflow for second reads that includes annotated biopsy contours for accurate visual targeting. The number of scans in which a biopsy could have been deferred using biopsy results and prostate specific antigen density was assessed. Gleason score ≥ 3 + 4 was considered clinically significant disease. Concordance between first and second reads for equivocal scans (Likert 3) was evaluated. RESULTS: A total of 209/664 (31%) patients scored Likert 3 on first read, 128 of which (61%) were concordant after second read. 103/209 (49%) of patients with Likert 3 scans were biopsied, with clinically significant disease in 31 (30%) cases. Considering Likert 3 scans that were both downgraded and biopsied using the workflow-generated biopsy contours, 25/103 (24%) biopsies could have been deferred. CONCLUSIONS: Implementing a semi-automated workflow for accurate lesion contouring and targeting biopsies is helpful during the one-stop clinic. We observed a reduction of indeterminate scans after second reading and almost a quarter of biopsies could have been deferred, reducing the potential biopsy-related side effects.
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Próstata , Neoplasias de la Próstata , Masculino , Humanos , Próstata/patología , Neoplasias de la Próstata/diagnóstico por imagen , Neoplasias de la Próstata/patología , Centros de Atención Terciaria , Lectura , Imagen por Resonancia Magnética/métodos , Programas Informáticos , Reino Unido , Biopsia Guiada por Imagen/métodosRESUMEN
Vaccination strategies have been at the forefront of controlling the COVID-19 pandemic. An association between vaccine-induced immune thrombotic thrombocytopenia (VITT) and one of these vaccines, the ChAdOx1 nCov-19 vaccine, is now recognized. The purpose of this study was to investigate the frequency and location of thrombosis in each vascular system using CT, MRI, and US to identify additional sites of thrombus in a United Kingdom-wide sample of patients with confirmed VITT. Thirty-two radiology centers identified through the national collaborative Radiology Academic Network for Trainees were invited from the United Kingdom; seven of these contributed to this study. All patients with confirmed VITT ¬between February 3 and May 12, 2021, who met the inclusion criteria were included. The location and extent of thrombi were evaluated using CT, MRI, and US. A total of 40 patients (median age, 41 years [IQR, 32-52]; 22 [55%] men) with confirmed vaccine-induced immune thrombotic thrombocytopenia after administration of their first ChAdOx1 nCov-19 vaccine were included. Thirty-two patients (80%) developed symptoms within the first 14 days, and eight (20%) developed symptoms within 14-28 days. Twenty-nine patients (72%) experienced neurologic symptoms and were confirmed to have cerebral venous sinus thrombosis, 12 (30%) had clinical deterioration and repeat imaging demonstrated extension of their primary thrombus, and eight (20%) died. Twenty-five of 30 patients (83%) who underwent additional imaging had occult thrombosis. In conclusion, patients with VITT are likely to have multiple sites of thrombosis, with the most frequent being cerebral venous sinus thrombosis in combination with pulmonary embolism and portomesenteric venous thrombosis. Whole-body imaging with contrast-enhanced CT can be used to identify occult thrombosis.
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COVID-19 , Trombosis de los Senos Intracraneales , Trombocitopenia , Trombosis , Vacunas , Masculino , Humanos , Adulto , Femenino , ChAdOx1 nCoV-19 , Pandemias , Trombocitopenia/inducido químicamente , Trombocitopenia/diagnóstico por imagen , Vacunación/efectos adversosRESUMEN
AIM: Analysis of the pathophysiology of mesenteric fibrosis (MF) in small intestinal neuroendocrine tumors (SI-NETs) in an in vitro paracrine model and in human SI-NET tissue samples. METHODS: An indirect co-culture model of SI-NET cells KRJ-I and P-STS with stromal cells HEK293 was designed to evaluate the paracrine effects on cell metabolic activity, gene expression by RT2 PCR Profilers to analyse cancer and fibrosis related genes, and RNA sequencing. The integrin signaling pathway, a specific Ingenuity enriched pathway, was further explored in a cohort of human SI-NET tissues by performing protein analysis and immunohistochemistry. RESULTS: RT Profiler array analysis demonstrated several genes to be significantly up- or down-regulated in a cell specific manner as a result of the paracrine effect. This was further confirmed by employing RNA sequencing revealing multiple signaling pathways involved in carcinogenesis and fibrogenesis that were significantly affected in these cell lines. A significant upregulation in the expression of various integrin pathway - related genes was identified in the mesenteric mass of fibrotic SI-NET as confirmed by RT-qPCR and immunohistochemistry. Protein analysis demonstrated downstream activation of the MAPK and mTOR pathways in some patients with fibrotic SI-NETs. CONCLUSION: This study has provided the first comprehensive analysis of the crosstalk of SI-NET cells with stromal cells. A novel pathway - the integrin pathway - was identified and further validated and confirmed in a cohort of human SI-NET tissue featured by a dual role in fibrogenesis/carcinogenesis within the neoplastic fibrotic microenvironment.
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Kidney lesions are commonly an incidental finding on cross sectional studies carried out for a variety of reasons. The detection of renal cell carcinoma (RCC) has increased accordingly. There are a variety of different contrast-enhanced CT imaging protocols that have been developed to help diagnose and stage RCC. More recently, renal MRI and contrast-enhanced ultrasound have also been used as problem-solving tools. This paper describes the epidemiology of RCC and the role of imaging in diagnosis and follow-up.
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Carcinoma de Células Renales/diagnóstico por imagen , Diagnóstico por Imagen/métodos , Neoplasias Renales/diagnóstico por imagen , Historia del Siglo XXI , Humanos , Riñón/diagnóstico por imagenRESUMEN
Incidental small renal cell cancers are increasingly being diagnosed on cross-sectional imaging. This review article describes the indications for percutaneous ablation of small renal cell cancers, choice of ablation technologies and imaging follow-up.
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Carcinoma de Células Renales/cirugía , Ablación por Catéter/métodos , Neoplasias Renales/cirugía , Carcinoma de Células Renales/diagnóstico por imagen , Humanos , Riñón/diagnóstico por imagen , Riñón/cirugía , Neoplasias Renales/diagnóstico por imagen , Imagen por Resonancia Magnética/métodos , Tomografía Computarizada por Rayos X/métodosRESUMEN
PURPOSE: Mesenteric fibrosis (MF) in small intestinal neuroendocrine neoplasms (SINENs) is often associated with significant morbidity and mortality. The detection of MF is usually based on radiological criteria, but no previous studies have attempted a prospective, multidimensional assessment of mesenteric desmoplasia to determine the accuracy of radiological measurements. There is also a lack of non-invasive biomarkers for the detection of image-negative MF. METHODS: A multidimensional assessment of MF incorporating radiological, surgical and histological parameters was performed in a prospective cohort of 34 patients with SINENs who underwent primary resection. Pre-operative blood samples were collected in 20 cases to evaluate a set of five profibrotic circulating transcripts-the "fibrosome"-that is included as an "omic" component of the NETest. RESULTS: There was a significant correlation between radiological and surgical assessments of MF (p < 0.05). However, there were several cases of image-negative MF. The NETest-fibrosome demonstrated an accuracy of 100% for the detection of microscopic MF. CONCLUSIONS: The detection of MF by radiological criteria has limitations. The NETest-fibrosome is a promising biomarker for fibrosis detection and further validation of these results would be needed in larger, multicentre studies.
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Neoplasias Intestinales , Tumores Neuroendocrinos , Biomarcadores de Tumor , Fibrosis , Humanos , Neoplasias Intestinales/diagnóstico por imagen , Tumores Neuroendocrinos/diagnóstico por imagen , Estudios ProspectivosRESUMEN
PURPOSE: The antiproliferative properties of lanreotide autogel (LAN) in gastroenteropancreatic neuroendocrine neoplasms (GEP NENs) were demonstrated in the CLARINET study. However, there is limited literature regarding factors that affect progression-free survival (PFS) in patients with GEP NENs treated with LAN. METHODS: We identified a total of 191 treatment-naive patients with advanced GEP NENs and positive SSTR uptake on imaging (Octreoscan or 68Gallium DOTATATE Positron Emission Tomography [68GaPET]) who received first-line LAN monotherapy, albeit at various starting doses (60, 90 or 120 mg/month). A group of 102 patients who initiated treatment at the standard dose of 120 mg/month were included in the study and further evaluated by univariate and multivariate analyses to identify predictors of PFS. RESULTS: The location of tumour primary was in the small bowel in 63 (62%), pancreas in 31 (30%) and colon/rectum in 8 patients (8%). The tumours were well-differentiated, and the majority were grade 1 (52%), or 2 (38%). About 60% of cases had progressive disease at the time of treatment initiation. Most patients with available pretreatment nuclear medicine imaging (Octreoscan or 68Ga PET) had a Krenning score of 3 (44%) or 4 (50%). The median PFS for the entire cohort was 19 months (95% CI 12, 26 months). The univariate analysis demonstrated that grade 2 tumours, progressive disease at baseline and metastatic liver disease were associated with a significantly shorter PFS, while other evaluated variables did not affect PFS at a statistically significant level. However, at multivariate analysis only the tumour grade remained statistically significant. CONCLUSIONS: The current study showed that, of many evaluated variables, only the tumour grade was predictive of PFS duration and this should be considered during patient selection for treatment.
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Tumores Neuroendocrinos , Neoplasias Pancreáticas , Humanos , Tumores Neuroendocrinos/diagnóstico por imagen , Tumores Neuroendocrinos/tratamiento farmacológico , Neoplasias Pancreáticas/diagnóstico por imagen , Neoplasias Pancreáticas/tratamiento farmacológico , Péptidos Cíclicos , Somatostatina/análogos & derivados , Tomografía Computarizada por Rayos XRESUMEN
PURPOSE: To retrospectively review outcomes in patients treated for colorectal liver metastases with DEBIRI. MATERIALS AND METHODS: A retrospective analysis of patients with CRLM treated with DEBIRI was performed between 2008 and 2017 between two tertiary centres. Outcome parameters were overall survival and hepatic progression-free survival, as well as safety. Subgroup analyses were performed to assess the impact on outcomes of hepatic tumour burden at time of treatment, the presence of extrahepatic disease, prior systemic chemotherapy and the prior administration of systemic irinotecan-containing chemotherapy. RESULTS: Fifty-three patients received 125 treatments with DEBIRI over the study period. Median age of patients was 71 (range 41-88). Patients previously received a median of 1 line of chemotherapy (range 1-5). Median number of DEBIRI treatments was 2 (range 1-6). The median survival from first treatment was 14.5 months (range 1-107). Median hepatic progression-free survival was 5 months (0-86.5 months). The presence of extrahepatic disease (seen in 45% of patients) correlated with lower OS. Prolonged OS was seen in patients who received previous ablation and systemic chemotherapy. Technical success rate was found to be 99%. Post-procedural complication rate was 6%. CONCLUSION: Our findings add to the growing body of literature to support the safety profile of DEBIRI in the treatment of CRLM. Further studies will be necessary to help establish the optimum berth of DEBIRI in the treatment algorithm for colorectal liver metastases.
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Quimioembolización Terapéutica/métodos , Neoplasias Colorrectales/patología , Irinotecán/administración & dosificación , Neoplasias Hepáticas/secundario , Neoplasias Hepáticas/terapia , Inhibidores de Topoisomerasa I/administración & dosificación , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Análisis de Supervivencia , Resultado del TratamientoRESUMEN
BACKGROUND: Coronary artery perforation during coronary intervention has high morbidity and mortality. This case describes the collaboration between interventional cardiologists and Interventional radiologists to successfully deploy a peripheral arterial stent graft in a coronary artery that demonstrated persistent extravasation after coronary specific stent graft placement. CASE PRESENTATION: An 84 year old female patient presented with acute coronary syndrome and coronary angiography identified a right coronary artery lesion. This was dilated and stented but resulted in a grade 3 coronary perforation. Conservative treatment with balloon tamponade failed, as did placement of a covered coronary-specific stent graft. A Viabahn peripheral arterial stent graft was placed within the indwelling stents and successfully sealed the endoleak. At 6 months the patient is clinically well and follow-up imaging has demonstrated stent patency. CONCLUSIONS: In the emergency setting when coronary artery perforation fails to respond to standard initial and bail out techniques, peripheral arterial techniques and devices can be extremely useful. A good relationship between interventional cardiology and radiology is paramount.
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A 59-year-old man with a 6-year history of erectile dysfunction presented to the andrology outpatient clinic. Multimodality assessment with ultrasound, MRI venography and fluoroscopic venography demonstrated an aberrant emissary vein arising from the corporal bodies causing venogenic erectile dysfunction. Selective coil embolisation of the collateral vein resulted in an almost immediate and sustained improvement in his erections.
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Embolización Terapéutica , Disfunción Eréctil/cirugía , Impotencia Vasculogénica/cirugía , Pene/irrigación sanguínea , Procedimientos Quirúrgicos Urológicos Masculinos , Venas/anomalías , Embolización Terapéutica/métodos , Disfunción Eréctil/diagnóstico por imagen , Disfunción Eréctil/etiología , Humanos , Impotencia Vasculogénica/complicaciones , Impotencia Vasculogénica/diagnóstico por imagen , Ligadura , Masculino , Persona de Mediana Edad , Imagen Multimodal , Satisfacción del Paciente , Pene/cirugía , Resultado del Tratamiento , Procedimientos Quirúrgicos Urológicos Masculinos/métodos , Venas/diagnóstico por imagen , Venas/cirugíaRESUMEN
A 47-year-old man attended the emergency department following trauma during sexual intercourse after which he developed penile swelling and haematuria several hours later. A penile fracture was suspected but given the slightly atypical history, ultrasound was performed to look for a fracture. Given the history of haematuria, both a standard Doppler ultrasound and a microbubble-enhanced retrograde ultrasound urethrogram were performed. The Doppler confirmed the suspected diagnosis of penile fracture, and microbubble urethrogram demonstrated a urethral injury. This facilitated prompt surgical treatment and helped guide the surgical approach. Retrograde microbubble enhanced ultrasound urethrogram is a novel technique that can be used in conjunction with standard ultrasound to confirm the presence of a concurrent urethral rupture in penile fracture.
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Coito , Hematoma/diagnóstico , Pene/lesiones , Uretra/lesiones , Diagnóstico Diferencial , Hematoma/diagnóstico por imagen , Hematoma/cirugía , Humanos , Masculino , Microburbujas , Persona de Mediana Edad , Rotura/diagnóstico , Rotura/diagnóstico por imagen , Rotura/cirugía , Ultrasonografía , Procedimientos Quirúrgicos Urológicos MasculinosRESUMEN
Cross sectional Imaging plays an increasingly important role the diagnosis and management of Crohn's disease. Particular emphasis is placed on MRI and Ultrasound as they do not impart ionising radiation. Both modalities have reported high sensitivity for disease detection, activity assessment and evaluation of extra-luminal complications, and have positive effects on clinical decision making. International Guidelines now recommend MRI and Ultrasound in the routine management of Crohn's disease patients. This article reviews the current evidence base supporting both modalities with an emphasis on the key clinical questions. We describe current protocols, basic imaging findings and highlight areas in need of further research. LEVEL OF EVIDENCE: 5 Technical Efficacy: Stage 4 J. MAGN. RESON. IMAGING 2017;45:1573-1588.
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Enfermedad de Crohn/diagnóstico por imagen , Enfermedad de Crohn/patología , Aumento de la Imagen/métodos , Intestino Delgado/diagnóstico por imagen , Intestino Delgado/patología , Imagen por Resonancia Magnética/métodos , Ultrasonografía/métodos , Humanos , Reproducibilidad de los Resultados , Sensibilidad y EspecificidadRESUMEN
A 79-year-old woman, a smoker, presented to the emergency department with a 2-week history of progressive dyspnoea and peripheral oedema, preceded by flu-like symptoms that had failed to improve despite antibiotics. Examination identified severe hypertension and signs consistent with severe fluid overload. Baseline chest X ray showed a right-sided abnormality. In the context of an extensive smoking history CT thorax was indicated which demonstrated a right-sided hilar mass and lymphadenopathy. Blood tests showed an unexplained metabolic alkalosis with partial respiratory compensation and hypokalaemia prompting endocrinological tests investigating Cushing's syndrome. Urinary cortisol was measured at 3174 nmol/L/24 h (normal<560), serum adrenocorticotropic hormone (ACTH) of 215 ng/L (normal<46). Pleural fluid cytology confirmed a diagnosis of small-cell lung cancer (SCLC). The patient's condition deteriorated despite intravenous diuretics and nitrates, metyrapone and non-invasive ventilation. Treatment was withdrawn 1 week after admission. The clinical course in the presence of biochemical derangement and SCLC is highly suggestive of paraneoplastic ectopic ACTH secretion.
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Síndrome de Cushing/complicaciones , Insuficiencia Cardíaca/etiología , Neoplasias Pulmonares/complicaciones , Insuficiencia Respiratoria/etiología , Carcinoma Pulmonar de Células Pequeñas/complicaciones , Anciano , Femenino , Humanos , Neoplasias Pulmonares/diagnóstico , Carcinoma Pulmonar de Células Pequeñas/diagnósticoRESUMEN
The authors present a case of an 87-year-old gentleman who presented with general deterioration, increased confusion, recurrent falls and unsteadiness. He was treated for a urinary tract infection but was found to deteriorate rapidly, developing bilateral nystagmus, marked pastpointing, dysarthria and central ataxia. He had a complex medical history including epilepsy controlled with long-term phenytoin. Phenytoin is 90% protein bound and displaced by bilirubin. At the time of deterioration his total phenytoin concentration was within the limits of the laboratory's recommended therapeutic range. The biochemistry report also denoted the patient was hypoalbuminaemic and hyperbilirubinaemic. His symptoms completely resolved with phenytoin dose reduction. The combination of low albumin and high bilirubin may cause an increase in the free phenytoin concentration, resulting in toxicity, despite the measured total phenytoin concentration being within the therapeutic interval.