Benign Sclerosing and Fibrosing Conditions of the Abdomen and Their Potential Mimics.

The process of abnormal reparative or reactive processes in the abdominal cavity, can lead to sclerosis and fibrous deposition. The relatively recent discovery of an IgG4 subgroup of immune mediated sclerosing disease 1,2 has thrown some light on the pathophysiology of these conditions. Firstly, our pictorial review aims to describe imaging findings to enhance the general radiologist's recognition and interpretation of this varied group of benign sclerotic and fibrotic abdominal processes. Secondly, along with the imaging findings, we bring into discussion the potential mimics of these pathologic processes to minimise interpretational errors. Moreover, some of the mimics of these processes are in the spectrum of malignant disease. Most importantly, to ensure a correct diagnosis thorough clinical and histopathological assessment are required to support the imaging findings presented in this review.

Peripheral vision: abdominal pathology missed outside the centre of gaze.

Radiology misses have been the subject of much debate on both sides of the Atlantic in recent years. There is now greater focus in trying to reduce radiology errors by continuous education and changing the working environment to try and protect the radiologist, and ultimately the patient from potential harm. Duty of candour is a relevant and sensitive area. Developing robust validated reporting pathways within the healthcare structure is very important so as to encourage a "learning from discrepancies" culture and to put the patient and their families at the center of reporting and acknowledging errors in radiology. Having reflected in our daily practice and while writing this pictorial review, we have concluded that during reporting MRI scans, routine assessment of the localizer images, focusing outside the area of interest and having a more structured approach to image interrogation are key actions which may help reduce the number of omissions. We present a myriad of cases where pathology was "missed" outside the center of gaze in relation to the abdomen or outside the abdomen on abdominal MRI, and suggest key high yield sequence related review areas to minimize the chance of missing potentially significant pathology.

MR imaging of the urinary bladder.

MR imaging is the modality of choice for accurate local staging of bladder cancer. In addition, bladder MR imaging helps detect lymph node involvement, and in conjunction with computed tomography, provides complete staging. Familiarity with optimal imaging protocols, normal urinary bladder anatomy, and pathologic MR imaging appearances is essential for the radiologist. Evolving techniques, such as use of diffusion-weighted imaging and lymphotropic nanoparticle-enhanced MR imaging, may further enhance the ability of MR imaging in local and nodal staging.

Magnetic resonance imaging of penile cancer.

Penile cancer is a rare neoplasm that, although rare in the developed world, has devastating physical and psychological consequences for the patient. Novel MR imaging techniques such as lymphotropic nanoparticle-enhanced MR imaging may help identify metastatic lymph node disease. This article reviews the normal penile anatomy and MR imaging techniques and features of primary and metastatic penile cancer. Recent advances in penile cancer imaging are discussed.

Staging laparoscopy for hilar cholangiocarcinoma in 100 patients.

PURPOSE: Accurate preoperative radiological staging of hilar cholangiocarcinoma remains difficult, and a number of patients are found to have irresectable advanced tumours or occult metastases at exploration. Staging laparoscopy can improve the detection of irresectable disease, avoiding unnecessary laparotomy. This study examines the role of staging laparoscopy in hilar cholangiocarcinoma, with a focus on yield over different time periods and identification of preoperative factors increasing the risk of irresectable disease. METHODS: Retrospective case note review of all patients undergoing staging laparoscopy for radiologically resectable hilar cholangiocarcinoma, identified from the hepatobiliary multidisciplinary team database, was performed. RESULTS: One hundred consecutive patients underwent staging laparoscopy between 1998 and 2011. Of these, 34 patients were found to be irresectable due to metastatic disease, and 11, due to extensive local disease. Fifty patients proceeded to exploratory laparotomy following staging laparoscopy, and 36 % (18/50) of whom were found to have irresectable disease: 12 patients due to advanced local disease and 6 patients due to metastases. The overall yield of laparoscopy was 45 %, and the accuracy was 71 %. There was no significant difference in age, preoperative bilirubin, neutrophil/lymphocyte ratio, Ca19-9 levels or T stage between patients with resectable disease and with irresectable disease on laparoscopy. There was also no change in the yield of laparoscopy over time, despite advances in radiological imaging. CONCLUSION: In this series, staging laparoscopy avoided unnecessary laparotomy in 45 % of patients with radiologically resectable hilar cholangiocarcinoma. No factor was able to predict positive yield, and therefore, all patients with potentially resectable hilar cholangiocarcinoma should undergo staging laparoscopy.

Impact of anticoagulation on outcomes in acute non-cirrhotic and non- malignant portal vein thrombosis: a retrospective observational study.

BACKGROUND/AIMS: No definitive evidence exists regarding the treatment of acute portal vein thrombosis (PVT). Treatment modalities that have been employed and investigated include conservative management, anticoagulation, thrombolysis and thrombectomy. This observational study examines the impact of anticoagulation on PVT. METHODOLOGY: The electronic radiology database was searched with keywords 'portal vein' and 'thrombosis'. Relevant patient notes and imaging were reviewed to collect data from those with acute PVT. The primary end point was portal vein recanalisation. Secondary outcome measures were morbidity and the development of portal hypertension and its sequelae (including variceal bleeding). Data from patients with PVT in the context of cirrhosis, malignancy or liver transplant were excluded. RESULTS: Partial or complete recanalization of the portal vein occurred in 81.8% of anticoagulated patients and 37.5% of the non-treatment group. Five patients died, 1 following an intracranial haemorrhage whilst anticoagulated and another who was not treated and developed secondary small bowel ischaemia and peritonitis. The remaining 3 died from their underlying pathology. Late complications, such as varices and ascites occurred more frequently in the patients in whom the portal vein failed to recanalize (83.3% vs. 27.3%). CONCLUSIONS: Spontaneous resolution of acute portal vein thrombosis is uncommon. Early anticoagulation results in a higher rate of recanalisation with minimal associated morbidity when compared with no treatment.

Surgical management of cystic lesions in the liver.

BACKGROUND: Liver cysts are common, occurring in up to 5% of the population. For many types of cysts, a variety of different treatment options exist and the preferred management is unclear. METHODS: A PubMed and Medline literature review was undertaken and articles pertaining to the diagnosis and management of cystic lesions within the liver were retrieved. RESULTS: Therapy for symptomatic cysts may incorporate aspiration with sclerotherapy or de-roofing. Polycystic liver disease presents a unique management problem because of the high morbidity and mortality rates from intervention and high rates of recurrence. Careful patient counselling and assessment of symptom index is essential before embarking on any treatment. New medical treatments may ameliorate symptoms. Acquired cystic lesions in the liver require a thorough work-up to fully characterize the abnormality and direct appropriate treatment. Hydatid cysts are best treated by chemotherapy, followed by some form of surgical intervention (either aspiration and sclerotherapy or surgery). Liver abscesses can be effectively treated by aspiration or drainage. CONCLUSION: All patients with cystic lesions in the liver require discussion at multidisciplinary meetings to confirm the diagnosis and determine the most appropriate method of treatment.

Abdominal manifestations of neurologic disorders.

A variety of disorders-including infectious, inflammatory, hereditary, and metabolic diseases-may affect both the brain and abdominal cavity, and the findings in one region may help establish the diagnosis or limit the differential diagnosis. Establishing an accurate early diagnosis enables clinicians to adequately manage these unusual diseases and potentially avert life-threatening complications. For example, an early diagnosis of Gardner syndrome enables annual sigmoid- or colonoscopy and ultrasonography. In many conditions, abdominal manifestations precede neurologic manifestations and may have prognostic significance. Patients with celiac disease more often present with abdominal manifestations such as duodenitis, slow transit time, reversal of the jejunal-ileal fold pattern, and transient small bowel intussusception than with intracranial manifestations. In other conditions, the neurologic manifestations may be the same as the presenting symptoms. For example, patients with Gardner syndrome may initially present with multiple mandibular or sinonasal osteomas. In addition, sarcoidosis may manifest with multifocal enhancing dural masses. Abdominal and neurologic manifestations may even occur simultaneously, as in several of the phakomatoses such as neurofibromatosis type 1, tuberous sclerosis complex, and von Hippel-Lindau syndrome. Ultimately, familiarity with the appearances of these conditions allows radiologists to pinpoint a diagnosis, even when imaging findings in either location are nonspecific.

Surgical management of cystic lesions in the liver.

BACKGROUND: Liver cysts are common, occurring in up to 5% of the population. For many types of cysts, a variety of different treatment options exist and the preferred management is unclear. METHODS: A Pubmed and Medline literature review using key words non-parasitic hepatic cysts, polycystic liver disease, echinococcus, hydatid cysts parasitic cysts, Caroli's disease, cystadenoma; liver abscess, surgery, aspiration and treatment was undertaken and papers pertaining to the diagnosis and management of cystic lesions within the liver were retrieved. RESULTS: Asymptomatic simple cysts in the liver require no treatment. Therapy for symptomatic cysts may incorporate aspiration with sclerotherapy or de-roofing. At present, insufficient evidence exists to recommend one over the other. Polycystic liver disease presents a unique management problem because of high morbidity and mortality rates from intervention and high rates of recurrence. Careful patient counselling and assessment of symptom index is essential before embarking on any treatment. New medical treatments may ameliorate symptoms. Acquired cystic lesions in the liver require a thorough work-up to fully characterize the abnormality and direct appropriate treatment. Hydatid cysts are best treated by chemotherapy followed by some form of surgical intervention (either aspiration and sclerotherapy or surgery). Liver abscesses can effectively be treated by aspiration or drainage. With improved antimicrobial efficacy, prolonged treatment with antibiotics may also be considered. CONCLUSION: All patients with cystic lesions in the liver require discussion at multi-disciplinary meetings to confirm and the diagnosis and determine the most appropriate method of treatment.

Improving the quality of manuscript reviews: impact of introducing a structured electronic template to submit reviews.

OBJECTIVE: The purpose of this study is to evaluate the impact of structured electronic templates on the quality of manuscript reviews. MATERIALS AND METHODS: Twenty-five gastrointestinal and genitourinary reviewers for the American Journal of Roentgenology were included in this investigation. Reviewers were selected and anonymized on the basis of having reviewed one or more manuscripts during period 1 (January 2008 through December 2009). All manuscript reviews were given a review quality score. Reviewers with at least one suboptimal review (i.e., a quality review score of < 3 on a scale of 1 to 4, with 1 being poor and 4 being an excellent review) were selected for further follow-up. During period 1, the reviewers received minimal guidance regarding the expectations of a high-quality review. During period 2 (August 2010 through August 2011), the reviewers meeting the criteria selected for follow-up received a structured electronic template outlining the review process. Reviews were again scored for review quality and were compared with a paired Student t test. RESULTS: The mean (± SD) and median review quality scores were 2.07 ± 0.44 and 2.0, respectively, for period 1 and 3.02 ± 0.89 and 3.0, respectively, for period 2. There was a 1-point improvement during period 2 after the introduction of the structured electronic template. Most of the reviews (19/25 [76%; 95% CI, 55%-91%]) improved after introduction of the structured electronic template, whereas only two of 19 worsened. Review scores significantly increased after introduction of the structured electronic templates (mean increase, 0.95 ± 0.92; t = 5.13; p < 0.0001). By specialty, the 13 gastrointestinal reviewers increased their score by 0.39 (p = 0.03), and the 12 genitourinary reviewers increased their score by 1.55 points (p < 0.0001). CONCLUSION: The introduction of a structured electronic template significantly improved the quality of manuscript reviews submitted.

Overview of dynamic contrast-enhanced MRI in prostate cancer diagnosis and management.

OBJECTIVE: This article is a primer on the technical aspects of performing a high-quality dynamic contrast-enhanced MRI (DCE-MRI) examination of the prostate gland. CONCLUSION: DCE-MRI is emerging as a useful clinical technique as part of a multi-parametric approach for evaluating the extent of primary and recurrent prostate cancer. Performing a high-quality DCE-MRI examination requires a good understanding of the technical aspects and limitations of image acquisition and postprocessing techniques.

Urinary bladder cancer: role of MR imaging.

Urinary bladder cancer is a heterogeneous disease with a variety of pathologic features, cytogenetic characteristics, and natural histories. It is the fourth most common cancer in males and the tenth most common cancer in females. Urinary bladder cancer has a high recurrence rate, necessitating long-term surveillance after initial therapy. Early detection is important, since up to 47% of bladder cancer-related deaths may have been avoided. Conventional computed tomography (CT) and magnetic resonance (MR) imaging are only moderately accurate in the diagnosis and local staging of bladder cancer, with cystoscopy and pathologic staging remaining the standards of reference. However, the role of newer MR imaging sequences (eg, diffusion-weighted imaging) in the diagnosis and local staging of bladder cancer is still evolving. Substantial advances in MR imaging technology have made multiparametric MR imaging a feasible and reasonably accurate technique for the local staging of bladder cancer to optimize treatment. In addition, whole-body CT is the primary imaging technique for the detection of metastases in bladder cancer patients, especially those with disease that invades muscle.

Extranodal lymphoma from head to toe: part 1, the head and spine.

OBJECTIVE: Lymphoma can affect virtually every tissue in the body, producing a variety of imaging appearances. In this article, the extranodal manifestations of lymphoma in the head and spine are illustrated and the imaging features that aid in diagnosis are reviewed. CONCLUSION: Knowledge of the imaging appearances of extranodal lymphoma can aid in the differential diagnosis of mass lesions encountered in tissues throughout the body on different imaging modalities.

Extranodal lymphoma from head to toe: part 2, the trunk and extremities.

OBJECTIVE: Lymphoma can affect virtually every tissue in the body, producing a variety of imaging appearances. In this article, the extranodal manifestations of this disease in the trunk and extremities are illustrated and the imaging features that aid in the diagnosis are reviewed. CONCLUSION: Knowledge of the imaging appearances of extranodal lymphoma can aid the differential diagnosis of mass lesions encountered in tissues throughout the body on different imaging modalities.

MR enterography of Crohn disease: part 1, rationale, technique, and pitfalls.

OBJECTIVE: The purpose of this article is to review the technique of performing MR enterography examinations and to review the imaging findings suggestive of Crohn disease. This article will also allow the reader to self-assess and improve his or her skills in the performance and interpretation of MR enterography examinations. CONCLUSION: MRI plays a valuable role in providing accurate information about the severity of and complications related to Crohn disease and can help in guiding surgical or medical treatment.

MR enterography of Crohn disease: part 2, imaging and pathologic findings.

OBJECTIVE: The purpose of this article is to review MR enterography technique and imaging findings suggestive of Crohn disease on these examinations. This article will also allow the reader to self-assess and improve his or her skills in the performance and interpretation of MR enterography examinations. CONCLUSION: This article reviews the technique of performing MR enterography examinations. MRI plays a valuable role in providing accurate information about severity of and complications related to Crohn disease and can help in guiding surgical or medical treatment.

Role of whole-body staging computed tomographic scans for detecting distant metastases in patients with bladder cancer.

OBJECTIVE: This study aimed to establish the incidence of distant metastases on whole-body computed tomographic (CT) scans in patients with newly diagnosed bladder cancer and to determine whether there is a significant difference in the incidence of metastases in patients with superficial and muscle invasive cancers. MATERIALS AND METHODS: A total of 201 patients who had a proven histological diagnosis of transitional cell carcinoma of the bladder and a whole-body staging CT scan at diagnosis were identified from our MDT database during a 36-month period. Imaging was retrospectively reviewed with view to recording site, if any, of distant metastases. RESULTS: Of 201 patients, 11 (5.5%) were found to have distant metastases on CT. In univariable models, staging was not associated with either age (odds ratio, 0.98; 95% confidence interval, 0.92-1.04; P = 0.4) or sex (Fisher exact test, P = 0.07). Mean (SD) age was 74.1 (10.5) years. There was a significant association between staging and metastasis (odds ratio, 19.9; 95% confidence interval, 3.2-infinity; P = 0.0003). Of the patients, 7% of males had metastases versus 0% of the females. CONCLUSIONS: Staging CT scans for assessment of distant metastatic disease in patients with newly diagnosed bladder cancer can be restricted to patients with muscle invasive disease.