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.

Emphysematous pyelonephritis: no longer a surgical disease?

Emphysematous pyelonephritis is a rare, life-threatening infection of the kidney characterized by the presence of gas within the renal parenchyma, the renal collecting system and the perinephric tissue. It usually develops in diabetic patients and often presents abruptly with bacteraemia, septic shock and acute renal failure. Diagnosis can be delayed because the symptoms mimic a classical upper urinary tract infection. Aggressive management, including parenteral antibiotic therapy, treatment of septic shock and control of the glycaemia, is mandatory. Immediate nephrectomy has been considered to be essential to increase the chance of survival. Recently, percutaneous drainage has been reported as a kidney-saving and life-saving alternative to surgery. We present a case of severe emphysematous pyelonephritis in which there was full recovery after antibiotic treatment combined with temporary percutaneous drainage. The therapeutic options in this rare, life-threatening condition are discussed.

Magnetic resonance imaging in the assessment of urologic disease: an all-in-one approach.

The aim of this study was to evaluate an "all-in-one" MR procedure to examine the kidneys, the renal vascular supply and renal perfusion, and the urinary tract. In 64 patients (58 with urologic disease and 6 healthy volunteers), MR was performed including: (a) T1- and T2-weighted imaging; (b) 3D contrast-enhanced MR angiography (MRA), including the renal arteries, renal veins, as well as renal perfusion; and (c) 3D contrast-enhanced MR urography (MRU) in the coronal and sagittal plane. For the latter, low- and high-resolution images were compared. Prior to gadolinium injection, 0.1 mg/kg body weight of furosemide was administered intravenously. The results were compared with correlative imaging modalities (ultrasonography, intravenous urography, CT), ureterorenoscopy and/or surgical-pathologic findings. Visualization of the renal parenchyma, the vascular supply, and the collecting system was adequate in all cases, both in nondilated and in dilated systems and irrespective of the renal function. One infiltrating urothelial cancer was missed; there was one false-positive urothelial malignancy. Different MR techniques can be combined to establish an all-in-one imaging modality in the assessment of diseases which affect the kidneys and urinary tracts. Continuous refinement of the applied MR techniques and further improvements in spatial resolution is needed to expand the actual imaging possibilities and to create new tracts and challenges in the MR evaluation of urologic disease.

Bilateral xanthogranulomatous perinephritis without renal parenchymal involvement.

A case of isolated bilateral xanthogranulomatous perinephritis, which presented as a symmetrical irregular perirenal rim of soft tissue, is reported. Differential diagnosis and image features on ultrasound, computed tomography, and magnetic resonance are discussed.

Management of carcinoma of the bladder.

Carcinoma of the bladder (CaB) is a common tumor of the genitourinary tract. In the United States in 1997, CaB was second in frequency of occurrence and third in mortality among genitourinary tumors. This tumor has a well-documented history of environmental and industrial causative factors. The strongest etiologic risk factors include the use of tobacco, which is thought to be responsible for half of the CaB diagnosed in men in the United States, and some arylamines. In the past 30 years, there has been major improvement in the survival of patients with this disease. Multiple factors were responsible for this accomplishment and they include: 1) better understanding of the natural history of CaB, 2) development of immunohistochemical analysis helpful in defining prognostic factors, 3) improved imaging and nonimaging diagnostic modalities helpful in making earlier diagnosis and better defining the true anatomical extent of the tumor, 4) development of more effective therapy for carcinoma in situ, 5) major improvement in surgical techniques resulting in better treatment outcomes, and 6) the wide use of adjuvant chemotherapy. Major stress has been placed on the quality of life of patients treated for CaB. Quality of life was improved by optimizing surgical, radiation, and medical treatment techniques. The two most important factors producing this quality-of-life improvement include: 1) the use of organ-preserving therapy in properly selected patients that involves the use of a multimodality therapeutic approach with transurethral resection, radiation therapy, and chemotherapy; and 2) the ability to treat selected men and women with radical cystectomy followed by orthotopic reconstruction that allows patients nearly physiologic voiding. Current research efforts are directed toward better patient selection for appropriate therapy which is expected to increase patient survival and improve quality of life. Of particular importance in the selection of this optimal therapy in patients with CaB is a wide application in the clinical practice of important recent advances in molecular genetics.

Impalpable invisible stage T1c prostate cancer: characteristics and clinical relevance in 100 radical prostatectomy specimens--a different view.

PURPOSE: We analyzed 100 consecutive radical prostatectomy specimens to evaluate the extent and clinical relevance of the stage T1c cancers discovered. MATERIALS AND METHODS: All cases were diagnosed by systematic prostatic puncture biopsies because of abnormal prostate specific antigen (PSA) or PSA density. Surgical specimens were examined with the whole organ multiple step-section technique (4 mm.) to identify primary tumor location (peripheral or transition zone cancer), tumor volume, tumor volume divided by prostate volume (percent tumor volume), Gleason score, pathological T stage and positive surgical margins. Tumors smaller than 0.5 cm.3 and without unfavorable pathology (Gleason score 7 or more, or positive surgical margins) were considered insignificant. RESULTS: Median patient age, PSA, tumor volume and Gleason score were 64 years, 8.8 micrograms./l., 1.6 cm.3 and 6, respectively. Of the specimens 46 (46%) had transition zone cancer that was clinically undetectable due to anterior location, while peripheral zone cancers were small, diffuse, anterolateral or in large glands with low percent tumor volume. Transition zone cancer showed greater PSA, PSA density, tumor volume and percent tumor volume than peripheral zone cancer (p = 0.08, 0.03, 0.0002 and 0.0004, respectively), yet with similar Gleason score (p = 0.4). Of the tumors 34 (34%) were locally advanced (stage pT3 and/or positive surgical margins, mostly anterior in 16 transition zone cancers, and apical or posterolateral in 18 peripheral zone cancers), whereas 22 were insignificant (6 transition and 16 peripheral zone cancers). Prostatic puncture biopsies with a core cancer length of less than 3 mm. could have predicted 18 of 19 insignificant tumors but underestimated 13 (33%) and 6 (17%) significant transition and peripheral zone cancers. CONCLUSIONS: The majority of our stage T1c tumors were significant with a distinguished high incidence of transition zone cancer. Therefore, they were large but occult. Transition zone cancer behaved differently than peripheral zone cancer, and warranted considerations during treatment of stage T1c prostate carcinoma.

Symptomatic adrenal pseudocyst.

A case of symptomatic adrenal pseudocyst due to recurrent hemorrhage is presented. Because of the hemorrhages, the cyst-like lesion had unusual appearances at US, CT and MRI, resembling a malignant cystic tumor.

Morphologic and neuroendocrine features of adenocarcinoma arising in the transition zone and in the peripheral zone of the prostate.

We examined retrospectively 107 step-sectioned radical prostatectomy specimens. The index tumor in each specimen was designated a transition zone carcinoma (TZCa) or a peripheral zone carcinoma (PZCa) based on its location. All tumor sections were immunohistochemically stained with chromogranin A (ChrA). A semiquantitative ChrA score (0 to 3) was assessed. ChrA-positive neuroendocrine cells were found in 83% of the index tumors. The ChrA score was significantly related to the Gleason score, the volume of the tumor, and the pathologic stage. Twenty-two percent of the index tumors were designated TZCas; 75% of these demonstrated neuroendocrine differentiation versus 85% of the PZCas. A high ChrA score of > or = 2 was found in 46% of PZCas and in only 33% of TZCas. Capsular transgression, seminal vesicle involvement, positive surgical margins, and lymph node metastasis were seen in the TZCa group in 33%, 17%, 29%, and 4%, respectively versus 58%, 20%, 48%, and 6% in the PZCa group. These findings were associated with a higher mean tumor volume in the TZCa group compared with the PZCa group. The average Gleason score of 4.5 in the TZCa group was significantly (P < 0.0001) lower than the Gleason score 6.2 in the PZCa group. Multicentricity was found in 62% of TZCas and in 49% of PZCas. Eighty-seven percent of the second tumors in the prostates with a primary TZCa were located in the peripheral zone. We conclude that the frequently occurring neuroendocrine cells population enlarges with tumor progression, especially in PZCas.(ABSTRACT TRUNCATED AT 250 WORDS)

Peripherally localized benign hyperplastic nodules of the prostate.

Approximately one-half of needle-core biopsy samples performed for palpable and/or ultrasonographically hypoechoic focal lesions of the prostate reveal carcinoma. A fraction of the negative biopsy samples are related to benign hyperplastic nodules, localized in the peripheral zone of the prostate. The present study examines the morphology of this particular lesion in surgical specimens obtained after cystoprostatectomy and radical prostatectomy performed for bladder and (small) prostate cancer, respectively. Peripheral hyperplastic nodules occur in 18.5% of this population and are unifocal in one-half of the cases. The mean diameter is 4 (+/- 1.3) mm. Peripheral hyperplastic nodules are characteristically localized posteriorly in the peripheral zone, between the midline and the lateral border of the prostate and often in the vicinity of the boundary of the transition zone. Histologically, they resemble glandulostromal hyperplastic nodules as observed in classic benign nodular hyperplasia of the transition zone. Cystic transformation may occur. The nodules are sometimes surrounded by condensed stroma and atrophic glands. Atypical adenomatous hyperplasia is rarely noticed in this lesion. No pure stromal (leiomyomatous) nodules without glands are seen. The peripheral hyperplastic nodule should be included in the differential diagnosis of focal lesions of the peripheral zone.

Lymph node staging of localized prostatic carcinoma with CT and CT-guided fine-needle aspiration biopsy: prospective study of 285 patients.

PURPOSE: To ascertain the reliability of computed tomography (CT) and CT-guided fine-needle aspiration biopsy (FNAB) in staging of lymph nodes in patients with locally confined prostatic carcinoma. MATERIALS AND METHODS: A total of 285 patients were studied prospectively. FNAB was performed in 43 patients (15%) with lymph nodes suspect for metastasis on CT scans. FNAB findings were correlated with either the findings of the pathologic examination performed after lymph node dissection (LND) or the status of the lymph node at follow-up with CT after hormone therapy. RESULTS: The sensitivity, specificity, and accuracy of CT-guided FNAB were 77.8%, 100%, and 96.5%. If CT only had been performed, these results would have been 77.8%, 96.7%, and 93.7%. CT staging was false-negative in only 10 patients, who had microscopic metastatic deposits in a solitary lymph node. CONCLUSION: Combined CT and FNAB is highly efficient for assessment of lymph node metastasis. Therefore, it could be considered an alternative to surgical or laparoscopic lymphadenectomy in patients scheduled for radical prostatectomy or curative radiation therapy.

Benign hyperplastic nodules that originate in the peripheral zone of the prostate gland.

PURPOSE: To describe a benign nodular lesion in the peripheral zone (PZ) of the prostate gland. MATERIALS AND METHODS: In 1,087 patients, the features of 722 focal lesions in the PZ or central zone of the prostate on transrectal ultrasound (TRUS) scans were retrospectively compared with histologic findings in biopsy samples. RESULTS: In 18 patients (5.5% of the 328 patients with benign lesions), benign hyperplasia was found in a focal, nodular lesion obviously located within the PZ. On TRUS scans, the nodules were well circumscribed, ovoid or round, and slightly hypoechoic (n = 11) or isoechoic (n = 7). The isoechoic lesions were surrounded by an anechoic halo. One nodule was an incidental sonographic finding; the 17 others were felt as firm (n = 11) or soft (n = 6) at digital rectal examination. The ratio of serum prostate-specific antigen (PSA) level to prostatic volume was low (< 0.1), except in one patient (0.24). CONCLUSION: Some sonographic features and the normal PSA values might suggest a benign nodule in the PZ, but TRUS-guided biopsies and histologic correlation are necessary to confirm the diagnosis.

Renal thorium deposition associated with transitional cell carcinoma: radiologic demonstration in two patients.

Abdominal radiography, excretory urography, retrograde pyelography, and computed tomography were performed in two patients who had undergone retrograde pyelography with thorium dioxide (Thorotrast) approximately 40 years ago. Both patients developed a transitional cell carcinoma due to suburothelial thorium deposition. Typical thorium densities were demonstrated at CT in the peripelvicalyceal area as well as in retroperitoneal lymph nodes. Elderly patients in whom radiographic examination reveals retained Thorotrast in the kidney should be followed up because of the high risk of renal carcinoma.

CT diagnosis of larynx chondrosarcoma.

The authors describe a patient with a palpable anterior neck mass and a submucosal swelling at the level of the vocal cords. Computed tomography (CT) revealed a tumour of the laryngeal skeleton. Pathologic diagnosis was a moderately well differentiated chondrosarcoma.

Anechoic halo in solid liver tumors: sonographic, microangiographic, and histologic correlation.

The origin of the sonographic halo sign in liver metastases was studied after autopsy in 33 livers with macroscopic tumoral involvement. For 20 lesions a detailed comparison of findings from high-resolution 7.5- and 10-MHz sonography, microangiography, and histology was carried out. Histologic study focused on the tumor periphery and its relationship to the adjacent liver parenchyma. In particular, the type of tumor infiltration, the presence or absence of peritumoral fibrosis, and the degree of liver cell compression were assessed. In all but two cases the halo was extratumoral and was caused by peritumoral liver cell compression. In the remaining two cases the halo was tumoral and was caused by irregular fibrosis or vascularization.

Dilatation of the cystic veins in portal hypertension: sonographic demonstration.

High-resolution real-time ultrasound (6 MHz) demonstrated vascular dilatation in the adventitial layer of the gallbladder in 7 patients with portal hypertension. The hypertension was due to long-standing cirrhosis in 4 patients; the other 3 patients had prehepatic hypertension due to thrombosis involving the portal vein in 1 and the splenoportal confluence in 2. In one of the cirrhotic patients, postmortem correlation of sonographic, angiographic, and pathological findings showed that the dilated vessels seen on sonography were cystic veins draining normally into the portal vein rather than portosystemic anastomoses. This indicates that varicosity of the cystic vein can be associated with portal hypertension, taking the form of either passive dilatation or hepatopetal portal collateral circulation.