Testicular adrenal rest tumours in an adult patient with congenital adrenal hyperplasia.

Testicular adrenal rest tumours (TART) are found in patients with congenital adrenal hyperplasia (CAH) with the severity of testicular infiltration linearly related to the degree of enzymatic defect and subsequent compliance with treatment. We report a highly unusual case of TART in an adult patient with CAH caused by 21-hydroxylase deficiency who had not engaged with health services over a 3-year period. Typical imaging features of TART include bilateral well-defined lesions adjacent to the rete testes. However, in this rare case, the follow-up imaging found that the entirety of the testicular parenchyma had been replaced with TART and the patient had gone on to develop an adrenal nodule. As these testicular tumours are commonly misdiagnosed as primary germ tumours and tend respond well to treatment with circadian or reverse glucocorticoids, it is essential for the radiologist to be aware of both the common and more unusual imaging features appearances of TART in patients with CAH in order to facilitate early diagnosis and thus timely initiation of treatment.

Subarachnoid haemorrhage in pregnancy after in vitro fertilisation with egg donation: a case report and review of the literature.

We report a rare case of in vitro fertilisation (IVF) with egg donation complicated by a subarachnoid haemorrhage (SAH). Haemostatic changes related to IVF are known to increase risk of venous thrombosis; however, less is known regarding the risk of arterial events such as cerebrovascular accidents (CVA). Matrix metalloprotease-9 (MMP-9) upregulated in IVF patients may have a role in arterial aneurysm formation, which is the most common cause of SAH. Further research is required to assess the benefit of screening for risk of CVA and the best way to manage this in the IVF population. This may have implications for the ethics of offering certain procedures such as egg donation to women with pre-existing risk factors.

Robotic assisted laparoscopic prostatectomy in a patient with prostate cancer and complex urinary tract malformation.

We present a case of prostate cancer with abnormal renal and ureteric anatomy who underwent robotic assisted laparoscopic prostatectomy. This is a 59-year-old European patient who presented with lower urinary tract symptoms (LUTS) and pelvic pain. Investigations revealed prostate cancer as well as a supernumerary right kidney and an atrophic horseshoe left kidney draining into the left seminal vesicle. He was managed with robotic assisted laparoscopic prostatectomy (RALP) using a modified technique. Selective pre-operative investigations and patient counselling led to proper operative planning and good surgical technique and outcome.

Cerebellar developmental venous anomaly with associated cavernoma causing a hemorrhage - a rare occurrence.

Developmental venous anomalies (DVAs) are variations in the transmedullary veins required for drainage of the brain. Normally, when occurring in isolation, DVAs are not clinically significant and are therefore usually a benign diagnosis. Thus, they are most often an incidental finding unless associated with an adjacent pathology. However, intracranial haemorrhage induced by a DVA alone can rarely occur and has been scarcely reported. In this case report we discuss a 58-year-old woman who presented with signs and symptoms of a cerebellar syndrome. Following a non-contrast CT, a CT angiogram and MRI contrast scan of the brain, she was found to have a cerebellar DVA and an intracranial haemorrhage. Subsequent imaging 3 months later with CT and MRI redemonstrated additional evidence of a cavernoma. The patient was managed conservatively.

Pulmonary sarcoidosis masquerading as metastatic cervical cancer: a pitfall in CT scans and positron emission tomography (PET).

Sarcoidosis has been associated with co-existing malignancies in several organs, including the breast and thyroid gland as well as lymphomas. However, the occurrence of sarcoidosis with cervical cancer is rare with only nine previous cases reported in the published literature. We present a case of pulmonary sarcoidosis imitating mediastinal lymph node metastases on the staging CT scan and positron emission tomography imaging. The presence of thoracic lymphadenopathy without any pelvic lymphadenopathy prompted histological confirmation of sarcoidosis on endobronchial ultrasound guided biopsy. Misdiagnosing pulmonary sarcoidosis as metastases would have precluded the patient from receiving the curative treatment and likely resulted in suboptimal outcomes.

Can contrast enhanced ultrasound differentiate benign cystic nephroma from malignant multicystic renal lesions? A case report.

Multicystic renal lesions pose a diagnostic dilemma and standard imaging may not be able to differentiate between benign or malignant lesions. Adult cystic nephroma and multicystic renal cell carcinoma are two such cystic renal lesions. We describe the appearance of cystic nephroma using contrast enhanced ultrasound. We hypothesize how quantitative parameters using time intensity curves appear to be able to distinguish between cystic nephroma and other malignant lesions such as multicystic renal cell carcinoma. This differentiation is of importance as it may obviate the need for tissue sampling and allow the clinician to recommend conservative management rather than nephrectomy.

Multiparametric MRI appearances of primary granulomatous prostatitis.

OBJECTIVE: Radiological features of granulomatous prostatitis (GP) overlap with those of prostate adenocarcinoma. Identification of specific GP features may aid diagnosis. We aimed to evaluate the multiparametric MRI (mpMRI) features of GP. METHODS: We retrospectively reviewed 16 patients from a cohort undergoing mpMRI and transperineal sector-guided prostate biopsies between July 2012 and May 2017. Images were analysed for lesion location, shape, size, extracapsular extension, signal intensity (SI), apparent diffusion coefficient (ADC) values, dynamic contrast enhancement (DCE) pattern and PI-RADS (Prostate Imaging - Reporting and Data System) v2 score. RESULTS: Histology revealed 13 cases of nonspecific GP and 3 cases of xanthogranulomatous prostatitis. GP lesions were diffuse involving > 50% of the prostate ( n = 13) or nodular ( n = 3). Signal intensity on T 2 weighted imaging was low and high on diffusion-weighted imaging. ADC values were low (mean 702 ± 79 × 10-6 mm/s2 ). Five patients had DCE imaging with all cases 'positive' as per PI-RADS scoring, with two cases displaying further ring enhancement consistent with abscess formation. Overall PI-RADS score for all cases was 5, indicating high suspicion of prostate cancer. CONCLUSION: GP is difficult to differentiate from prostate cancer, but typically gives diffuse changes involving > 50% of the gland on mpMRI, with extracapsular extension and rim-enhancing areas. It should be considered a differential diagnosis in patients with recent urinary tract infection (UTI) or prior Bacillus Calmette-Guerin (BCG) treatment. ADVANCES IN KNOWLEDGE: Prostate MRI imaging features including diffuse changes, extracapsular extension and rim-enhancing areas, in patients with recent UTI or BCG treatment may help identify granulomatous prostatitis cases.

Renal Replacement Lipomatosis: From Conception to Birth.

Renal replacement lipomatosis is a rare disease characterized by renal parenchymal atrophy and proliferation of inflammatory and fatty cells within the renal sinus, hilum, and perirenal region. The exact pathogenesis is unknown, however more than 75% of cases are associated with renal stones. Here, we provide images from a case with 10 years of follow-up, outlining the radiographic progression of the disease through time. Although only histopathology can confirm the diagnosis, high clinical suspicion in combination with the radiographic findings can differentiate the disease from other fat-containing entities.

Toward an MRI-based nomogram for the prediction of transperineal prostate biopsy outcome: A physician and patient decision tool.

PURPOSE: To develop and internally validate a nomogram using biparametric magnetic resonance imaging (B-MRI)-derived variables for the prediction of prostate cancer at transperineal sector-guided prostate biopsy (TPSB). SUBJECTS/PATIENTS AND METHODS: Consecutive patients referred to our institution with raised prostate-specific antigen (PSA), abnormal prostate examination, or persistent suspicion of prostate cancer after previous transrectal biopsy between July 2012 and November 2015 were reviewed from a prospective database. All patients underwent prebiopsy B-MRI with T2-weighted and diffusion-weighted imaging sequences, followed by 24 to 40 core TPSB with additional targeted cores using cognitive registration. Univariable and multivariable logistic regression analysis was used to determine predictors of prostate cancer outcomes. Multivariable coefficients were used to construct 2 MRI-based nomograms to predict any and significant (Gleason 4 or maximum cancer core length ≥6mm) prostate cancer at TPSB. Bootstrap resamples were used for internal validation. Accuracy was assessed by calculating the concordance index. RESULTS: In total, 615 men were included in the study. Prostate cancer was diagnosed in 317 (51.5%) men with significant cancer diagnosed in 237 (38.5%) men. Age, Prostate Imaging Reporting and Data System (PI-RADS) score, PSA, PSA density, and primary biopsy were predictors of prostate cancer at TPSB on univariable analysis (P<0.0001). PSA showed strong correlation with PSA density and was excluded. The remaining variables were all independent predictors of prostate cancer on multivariable analysis (P<0.0001) and used to generate the nomograms. Both nomograms showed good discrimination for prostate cancer, with a concordance index of 87% for any cancer and 92% for significant disease. Using a nomogram-derived probability threshold of<15%, 111 (18.0%) biopsies can be saved, at the expense of 3 missed significant prostate cancers. CONCLUSIONS: These internally validated MR-based nomograms were able to accurately predict TPSB outcomes for prostate cancer, especially significant disease. Our findings support the combination of prebiopsy MRI results and clinical factors as part of the biopsy decision-making process.

Diagnostic value of MRI-based PSA density in predicting transperineal sector-guided prostate biopsy outcomes.

PURPOSE: Prostate-specific antigen (PSA) density (PSAD) has potential to increase the diagnostic utility of PSA, yet has had poor uptake in clinical practice. We aimed to determine the diagnostic value of magnetic resonance imaging-derived PSAD (MR-PSAD) in predicting transperineal sector-guided prostate biopsy (TPSB) outcomes. MATERIALS AND METHODS: Men presenting for primary TPSB from 2007 to 2014 were considered. Histological outcomes were assessed and defined as: presence of any cancer or significant cancer defined as presence of Gleason 4 and/or maximum tumour core length (MCCL) ≥ 4 mm (G4); or Gleason 4 and/or MCCL ≥ 6 mm (G6). Sensitivity, specificity and positive and negative predictive values were calculated, and receiver operating characteristics (ROC) curves were generated to compare MR-PSAD and PSA. RESULTS: Six hundred fifty-nine men were evaluated with mean age 62.5 ± 9 years, median PSA 6.7 ng/ml (range 0.5-40.0), prostate volume 40 cc (range 7-187) and MR-PSAD 0.15 ng/ml/cc (range 0.019-1.3). ROC area under the curve (95% CI) was significantly better for MR-PSAD than PSA for all cancer definitions (p < 0.001): 0.73 (0.70-0.76) versus 0.61 (0.57-0.64) for any cancer; 0.75 (0.71-0.78) versus 0.66 (0.62-0.69) for G4; and 0.77 (0.74-0.80) versus 0.68 (0.64-0.71) for G6. Sensitivities for MR-PSAD < 0.1 ng/ml/cc were 85.0, 89.9 and 91.9% for any, G4 and G6 cancer, respectively. CONCLUSION: MR-PSAD may be better than total PSA in determining risk of positive biopsy outcome. Its use may improve risk stratification and reduce unnecessary biopsies.

Triparametric ultrasound in differentiating multicystic renal masses: a rare presentation of unilateral focal renal lymphangioma.

We describe a rare case of renal lymphangioma presenting as a focal unilateral multicystic renal mass and document the first reported use of triparametric ultrasound (B-mode, Doppler, and contrast-enhanced ultrasound) in its diagnosis and discrimination from other focal multicystic lesions. Renal lymphangiomas are rare, benign, typically developmental lesions composed of cystic dilatation of the lymphatic ducts, usually occurring bilaterally as perinephric collections or parapelvic cysts mimicking hydronephrosis. Radiologists have an important role in suggesting the diagnosis, as clinical presentation can be nonspecific. Management is usually conservative; however, nephron-sparing surgery may be recommended in symptomatic individuals.

Radiologic presentation of chronic granulomatous prostatitis mimicking locally advanced prostate adenocarcinoma.

We present a case of nonspecific granulomatous prostatitis (GP), a clinical mimic of prostate adenocarcinoma. A 54-year-old man presented with lower urinary tract symptoms and raised prostate-specific antigen. Magnetic resonance imaging showed features consistent with prostate cancer, including low T2-signal intensity in the peripheral and transition zones with signs of extracapsular extension. Diffusion-weighted imaging showed high-signal intensity, with low apparent diffusion coefficient values, whereas dynamic contrast enhancement demonstrated a type 3 washout curve, similar to that found in prostate cancer. Transperineal sector-guided prostate biopsy confirmed nonspecific GP, and the patient was treated conservatively. We discuss and compare nonspecific, chronic GP as a radiologic mimic of prostate adenocarcinoma patient.

Diagnostic accuracy of magnetic resonance imaging (MRI) prostate imaging reporting and data system (PI-RADS) scoring in a transperineal prostate biopsy setting.

OBJECTIVES: To determine the sensitivity and specificity of multiparametric magnetic resonance imaging (mpMRI) for significant prostate cancer with transperineal sector biopsy (TPSB) as the reference standard. PATIENTS AND METHODS: The study included consecutive patients who presented for TPSB between July 2012 and November 2013 after mpMRI (T2- and diffusion-weighted images, 1.5 Tesla scanner, 8-channel body coil). A specialist uro-radiologist, blinded to clinical details, assigned qualitative prostate imaging reporting and data system (PI-RADS) scores on a Likert-type scale, denoting the likelihood of significant prostate cancer as follows: 1, highly unlikely; 3, equivocal; and 5, highly likely. TPSBs sampled 24-40 cores (depending on prostate size) per patient. Significant prostate cancer was defined as the presence of Gleason pattern 4 or cancer core length ≥6 mm. RESULTS: A total of 201 patients were included in the analysis. Indications were: a previous negative transrectal biopsy with continued suspicion of prostate cancer (n = 103); primary biopsy (n = 83); and active surveillance (n = 15). Patients' mean (±sd) age, prostate-specific antigen and prostate volumes were 65 (±7) years, 12.8 (±12.4) ng/mL and 62 (±36) mL, respectively. Overall, biopsies were benign, clinically insignificant and clinically significant in 124 (62%), 20 (10%) and 57 (28%) patients, respectively. Two of 88 men with a PI-RADS score of 1 or 2 had significant prostate cancer, giving a sensitivity of 97% (95% confidence interval [CI] 87-99) and a specificity of 60% (95% CI 51-68) at this threshold. Receiver-operator curve analysis gave an area under the curve of 0.89 (95% CI 0.82-0.92). The negative predictive value of a PI-RADS score of ≤2 for clinically significant prostate cancer was 97.7% CONCLUSION: We found that PI-RADS scoring performs well as a predictor for biopsy outcome and could be used in the decision-making process for prostate biopsy.

Functional imaging for assessing tumor response in cancer of the cervix.

Treatment options for carcinoma of the cervix are guided by tumor stage, and include radical surgery, in cases where the tumor is confined to the cervix, or concurrent chemotherapy and radiotherapy. In those cases treated with chemoradiation, the ability to monitor the response to treatment in order to adapt the management plan during its course may be beneficial. This approach has the potential to offer an individualized treatment plan, allowing for differences in behavior between tumors to be addressed early, rather than a 'one size fits all' treatment approach. This article aims to review the use of evolving functional imaging techniques including diffusion-weighted MRI, dynamic contrast-enhanced MRI, and PET as tools for the evaluation of response to treatment of uterine cervical carcinoma.

MRI and PET scans for primary staging and detection of cervical cancer recurrence.

Worldwide, cervical cancer is the second most common malignancy in women, and is a major cause of morbidity and mortality. Accurate tumor staging is essential for optimal treatment planning and prognosis. Cervical cancer is staged by clinical examination according to the International Federation of Gynecology and Obstetrics staging system. However, clinical staging has inherent deficiencies in evaluating several parameters that are critical for treatment planning. It is now widely accepted that cross-sectional imaging, and in particular MRI, has an important role to play in the staging of these tumors. MRI is an excellent modality for depicting invasive cervical cancer: it can provide objective measurement of tumor size and provides a high negative predictive value for parametrial invasion and stage IVA disease. MRI and positron emission tomography (PET)/computed tomography (CT) play key roles in identifying recurrent disease. PET/CT is also useful in detecting nodal and distant metastases and in radiotherapy planning. Diffusion-weighted MRI is an emerging imaging technique that is currently being evaluated for the detection of primary and recurrent disease and in the assessment of treatment response.

Imaging of endometrial and cervical cancer.

In this article we review the ever increasing role of imaging in endometrial and cervical cancer. Magnetic resonance imaging (MRI) has emerged as the most widely used technique in the management of women with gynaecological cancer. In endometrial cancer, MRI is reliable in identifying myometrial and cervical invasion and extra-uterine disease, thereby informing preoperative surgical planning. In cervical cancer, MRI plays a crucial role in distinguishing early from advanced disease, thereby stratifying patients for surgery and chemoradiation. MRI is also valuable in assessing proximal extension of cervical tumours in young women with early stage disease for feasibility of fertility preserving surgery. In both cancers, imaging is used for diagnosing nodal metastases, detection of recurrence, and dealing with complications of both the disease and treatment.

Platelet-leucocyte aggregates form in the mesenteric vasculature in patients with ulcerative colitis.

BACKGROUND AND AIMS: Inflammation and thrombosis are closely related processes, which may play a role in the pathogenesis, as well as complications, of inflammatory bowel disease (IBD). Platelet activation and platelet-leucocyte aggregation are increased and platelet aggregation is known to occur in the mesenteric vasculature in IBD. The aims of this study were to test the hypotheses that platelet-leucocyte aggregation, platelet activation and neutrophil activation occur in the mesenteric vessels of patients with ulcerative colitis (UC). PATIENTS AND METHODS: Platelet-leucocyte aggregates (PLAs), platelet activation (P-selectin expression) and neutrophil activation (L-selectin expression, which decreases on neutrophil activation) were assessed flow cytometrically in mesenteric arterial, and venous blood sampled in eight patients with UC and eight controls with colonic carcinoma undergoing intestinal resections. RESULTS: In the patients with UC, the number of PLAs in the mesenteric vein exceeded that in the artery, the median rise being 38% (P=0.02). In UC, arterial PLA numbers were 0.17 (0.02-0.32) (median, range) x 10(9)/l versus venous 0.26 (0.09-1.6) x 10(9)/l (P=0.02). The median percentage increase was 45%. Mesenteric PLA formation did not occur in patients with colonic carcinoma [arterial 0.06 (0.03-0.49) x 10(9)/l vs. venous 0.05 (0.02-0.35) x 10(9)/l; P=0.55]. The median percentage change was +45% for UC patients and -5% for controls. No arteriovenous gradient was observed in P-selectin expression, but L-selectin expression (arbitrary units), increased in the mesenteric vasculature of the UC patients [arterial 839 (503-995), venous 879 (477-1035); P=0.03] and fell in those with colonic carcinoma [arterial 900 (660-959), venous 850 (546-957); P=0.04]. The median percentage change was +4% for UC and -7% for controls. CONCLUSION: The finding of increased numbers of PLAs in the venous mesenteric circulation supports the hypothesis that activated vascular endothelium stimulates PLA formation in UC.