Imaging for Early Detection of Pancreatic Ductal Adenocarcinoma: Updates and Challenges in the Implementation of Screening and Surveillance Programs.

Pancreatic ductal adenocarcinoma (PDA) is one of the most aggressive cancers. It has a poor 5-year survival rate of 12%, partly because most cases are diagnosed at advanced stages, precluding curative surgical resection. Early-stage PDA has significantly better prognoses due to increased potential for curative interventions, making early detection of PDA critically important to improved patient outcomes. We examine current and evolving early detection concepts, screening strategies, diagnostic yields among high-risk individuals, controversies, and limitations of standard-of-care imaging.

Correlation Between Oligometastatic Tumor in Two Other Visceral Organs and Prognosis in Patients With Brain Metastases.

Background and Objective: A recent report indicated that metastases to other body organs commonly develop after stereotactic body radiation treatment for cure in patients with oligometastases (OGM) confined to one organ. This study was undertaken to determine if the presence of metastatic disease in two other visceral organs (TVO) in patients with conventionally treated brain metastases (BRM) was associated with poorer prognosis. Methods: This retrospective clinical investigation included 26 patients treated for palliation of OGM-BRM between May 1996 and February 2020. These individuals were classified according to the presence (13 patients) or absence (13 patients) of metastases in TVO. Results: With an overall mean follow-up of 16 months, 20 patients were deceased, and 6 patients were alive. The median survivals for the OGM-BRM-TVO and non-OGM-BRM-TVO subsets were 4 and 12 months, respectively; the corresponding crude survival rates at 12 months were 0% and 46% (p < 0.01). Subgroup analysis correlating prognosis to the number of BRM (single vs. multiple) and OGM-BRM categories (synchronous vs. metachronous) failed to reveal a survival advantage favoring a certain subgroup. Conclusion: Although the evidence is speculative, we believe that an aggressive disease condition is more likely present in patients with OGM-BRM-TVO. With the notion of an overall poor survival, we suggest a more tailored, less or nonharmful management approach (i.e., palliative therapy or hospice) for this particular patient cohort.

Synchronous Mediastinal and Central Nervous System Involvement in Rosai-Dorfman Disease: A Case Report.

Rosai-Dorfman disease (RDD) is a rare disorder characterized by the proliferation and accumulation of histiocytes, primarily within lymph node sinuses. Uncommonly, other extranodal sites, such as the central nervous system, can also be affected. Here, we document the case of a 61-year-old woman presenting with dizziness, confusion, and headaches. Magnetic resonance imaging (MRI) showed an extra-axial avidly enhancing mass in the left parietal region presumed to be a meningioma based solely on its imaging appearance. The patient underwent surgical resection, and histopathological examination showed enlarged histiocytes positive for S100, CD68, and CD163 and negative for CD1a, consistent with RDD. She was followed up with a positron emission tomography/computed tomography (PET/CT) to evaluate other disease activity sites. A single mediastinal node was identified adjacent to the atriocaval junction intensely fluorodeoxyglucose avid. The patient underwent robotic node excision, with pathology analysis compatible with RDD. We emphasize the need to increase recognition of RDD on differential brain lesions, especially meningiomas, and suggest PET/CT as a valid tool to search for other disease activity lesions.

Paraganglioma in a Young Adult Female Patient: A Case Report.

Paragangliomas are catecholamine-secreting neuroendocrine tumors that originate from the chromaffin cells of the sympathetic ganglia. Roughly 10% of paragangliomas are malignant, resulting in a rare occurrence of 90-95 cases per 400 million people. Herein, we report a case of a 29-year-old female patient who presented with nausea, vomiting, and bloating and was found to have a large left retroperitoneal tumor upon imaging. The tumor was successfully removed, and subsequent histological analysis was compatible with the presence of a paraganglioma. This case serves as a reminder that despite its rarity, paragangliomas should never be dismissed as a differential diagnosis if correlating symptoms and diagnostic findings are consistent with that of paraganglioma etiology.

Postoperative surveillance of pancreatic ductal adenocarcinoma (PDAC) recurrence: practice pattern on standardized imaging and reporting from the society of abdominal radiology disease focus panel on PDAC.

PURPOSE: Surgical resection is the only potential curative treatment for patients with pancreatic ductal adenocarcinoma (PDAC), but unfortunately most patients recur within 5 years of surgery. This article aims to assess the practice patterns across major academic institutions and develop consensus recommendations for postoperative imaging and interpretation in patients with PDAC. METHODS: The consensus recommendations for postoperative imaging surveillance following PDAC resection were developed using the Delphi method. Members of the Society of Abdominal Radiology (SAR) PDAC Disease Focused Panel (DFP) underwent three rounds of surveys followed by live webinar group discussions to develop consensus recommendations. RESULTS: Significant variations currently exist in the postoperative surveillance of PDAC, even among academic institutions. Differentiating common postoperative inflammatory and fibrotic changes from tumor recurrence remains a diagnostic challenge, and there is no reliable size threshold or growth rate of imaging findings that can provide differentiation. A new liver lesion or peritoneal nodule should be considered suspicious for tumor recurrence, and the imaging features should be interpreted in the appropriate clinical context (e.g., CA 19-9, clinical presentation, pathologic staging). CONCLUSION: Postoperative imaging following PDAC resection is challenging to interpret due to the presence of confounding postoperative inflammatory changes. A standardized reporting template for locoregional findings and report impression may improve communication of relaying risk of recurrence with referring providers, which merits validation in future studies.

Metastatic renal cell carcinoma presenting as subcutaneous nodule.

Renal cell carcinoma is frequently undiagnosed until it reaches an advanced metastatic stage. Renal cell cancers are also seen as incidental findings on imaging, and rarely can present as physical examination findings. We report a rare case where metastatic renal cell carcinoma presented as a solitary 2 cm subcutaneous chest wall nodule in an otherwise asymptomatic male patient. Initial ultrasound evaluation showed a solid vascular subcutaneous mass, a fine needle aspiration suggested metastatic renal cell cancer, and later, excision biopsy, and CT scan of the abdomen made the final diagnosis of stage IV renal cell carcinoma. The differential diagnosis of a 2 cm nodule can be broad and in appropriate clinical setting should include consideration of malignancy and/ metastasis.

MDCT Findings of Splenic Pathology.

The delineation and characterization of splenic lesions and other abnormalities can be challenging on computed tomography. Many splenic lesions are incidentally found, imaging features tend to overlap, and without the appropriate clinical context, differentials can range from benign to malignant. Radiologists should be familiar with the wide variety of pathologies seen on computed tomography as it is often the first imaging modality a splenic lesion is seen. The purpose of this MDCT-focused review is to understand normal splenic anatomy and its variants, to illustrate and describe typical and atypical imaging patters of inflammatory, infectious, vascular, traumatic, benign, and malignant tumors of the spleen and provide clues in reaching the appropriate differential diagnosis and management.

Williams-Campbell syndrome: an unusual presentation in an adult patient.

OBJECTIVE: Williams-Campbell syndrome (WCS) is a rare congenital disorder, which leads to bronchiectasis affecting fourth to sixth order of bronchial divisions. Symptoms include cough, sputum, wheeze and recurrent pulmonary infections, classically seen in the paediatric age group with selective bronchiectasis of the mid-order bronchioles. The literature describing diagnosis of Williams-Campbell syndrome in adult population is very sparse. METHODS: This report presents a 62-year-old female with cough, fever, dyspnea and generalized body ache. She has had multiple admissions to the hospital since her childhood due to recurrent lower respiratory tract infections. Imaging findings demonstrated multiple cystic thin walled airways, compatible with bronchiectatic changes in the upper, middle and lower lobes bilaterally, bronchial wall thickening with air-fluid levels prominent in the fifth and sixth generation bronchial divisions, with normal calibre trachea and central bronchi. These radiological findings are consistent with diagnosis of Williams-Campbell syndrome, which was diagnosed after ruling out the other common causes of bronchiectasis. CONCLUSION: Williams-Campbell syndrome is a rare congenital cystic lung disease, the diagnosis of which is made by exclusion of common causes of bronchiectasis such as cystic fibrosis, allergic bronchopulmonary aspergillosis, tuberculosis, dyskinetic cilia syndrome and alpha-1 antitrypsin deficiency. Whenever the clinical picture is consistent with bronchiectasis, especially involving the mid-order bronchioles and recurrent pulmonary infections, it is wise to include WCS in the list of differential diagnoses, even in the adult population.

Therapeutic response assessment in pancreatic ductal adenocarcinoma: society of abdominal radiology review paper on the role of morphological and functional imaging techniques.

Pancreatic ductal adenocarcinoma (PDA) is the third leading cause of cancer-related death in the United States and is projected to be the second by 2030. Systemic combination chemotherapy is considered an essential first-line treatment for the majority of patients with PDA, in both the neoadjuvant and palliative settings. In addition, a number of novel therapies are being tested in clinical trials for patients with advanced PDA. In all cases, accurate and timely assessment of treatment response is critical to guide therapy, reduce drug toxicities and cost from a failing therapy, and aid adaptive clinical trials. Conventional morphological imaging has significant limitations, especially in the context of determining primary tumor response and resectability following neoadjuvant therapies. In this article, we provide an overview of current therapy options for PDA, highlight several morphological imaging findings that may be helpful to reduce over-staging following neoadjuvant therapy, and discuss a number of emerging imaging, and non-imaging, tools that have shown promise in providing a more precise quantification of disease burden and treatment response in PDA.

White paper on pancreatic ductal adenocarcinoma from society of abdominal radiology's disease-focused panel for pancreatic ductal adenocarcinoma: Part I, AJCC staging system, NCCN guidelines, and borderline resectable disease.

Pancreatic ductal adenocarcinoma (PDAC) is an aggressive gastrointestinal malignancy with a poor 5-year survival rate. Accurate staging of PDAC is an important initial step in the development of a stage-specific treatment plan. Different staging systems/consensus statements convened by different societies and academic practices are currently used. The most recent version of the American Joint Committee on Cancer (AJCC) tumor/node/metastases (TNM) staging system for PDAC has shifted its focus from guiding management to assessing prognosis. In order to preoperatively define the resectability of PDAC and to guide management, additional classification systems have been developed. The National Comprehensive Cancer Network (NCCN) guidelines, one of the most commonly used systems, provide recommendations on the management and the determination of resectability for PDAC. The NCCN divides PDAC into three categories of resectability based on tumor-vessel relationship: 'resectable,' 'borderline resectable,' and 'unresectable'. Among these, the borderline disease category is of special interest given its evolution over time and the resulting variations in the definition and the associated recommendations for management between different societies. It is important to be familiar with the evolving criteria, and treatment and follow-up recommendations for PDAC. In this article, the most current AJCC staging (8th edition), NCCN guidelines (version 2.2019-April 9, 2019), and challenges and controversies in borderline resectable PDAC are reviewed.

White paper on pancreatic ductal adenocarcinoma from society of abdominal radiology's disease-focused panel for pancreatic ductal adenocarcinoma: Part II, update on imaging techniques and screening of pancreatic cancer in high-risk individuals.

Pancreatic ductal adenocarcinoma (PDAC) is an aggressive gastrointestinal malignancy with a poor 5-year survival rate. Its high mortality rate is attributed to its aggressive biology and frequently late presentation. While surgical resection remains the only potentially curative treatment, only 10-20% of patients will present with surgically resectable disease. Over the past several years, development of vascular bypass graft techniques and introduction of neoadjuvant treatment regimens have increased the number of patients who can undergo resection with a curative intent. While the role of conventional imaging in the detection, characterization, and staging of patients with PDAC is well established, its role in monitoring treatment response, particularly following neoadjuvant therapy remains challenging because of the complex anatomic and histological nature of PDAC. Novel morphologic and functional imaging techniques (such as DECT, DW-MRI, and PET/MRI) are being investigated to improve the diagnostic accuracy and the ability to measure response to therapy. There is also a growing interest to detect PDAC and its precursor lesions at an early stage in asymptomatic patients to increase the likelihood of achieving cure. This has led to the development of pancreatic cancer screening programs. This article will review recent updates in imaging techniques and the current status of screening and surveillance of individuals at a high risk of developing PDAC.

Cutaneous metastasis of renal cell carcinoma: Fine needle aspiration provides rapid diagnosis.

The diagnosis of cutaneous metastasis of renal cell carcinoma is challenging in a young person in absence of a prior history of cancer. In such situation, fine needle aspiration alone as a minimally invasive procedure can provide rapid, accurate and cost effective diagnosis, even in case of unknown primary.

Multimodality Imaging Review of Anorectal and Perirectal Diseases with Clinical, Histologic, Endoscopic, and Operative Correlation, Part II: Infectious, Inflammatory, Congenital, and Vascular Conditions.

A broad spectrum of pathology affects the rectum, anus, and perineum, and multiple imaging modalities are complementary to physical examination for assessment and treatment planning. In this pictorial essay, correlative imaging, endoscopic, pathologic, and operative images are presented for a range of rectal, perirectal, and perineal disease processes, including infectious/inflammatory, traumatic, congenital/developmental, vascular, and miscellaneous conditions. Key anatomic and surgical concepts are discussed, including radiological information pertinent for surgical planning, and current operative approaches of these anatomic spaces to assist radiologists in comprehensive reporting for gastroenterologists and surgeons.

Multimodality Imaging Review of Anorectal and Perirectal Diseases With Histological, Endoscopic, and Operative Correlation, Part I: Anatomy and Neoplasms.

A broad spectrum of pathology affects the rectum, anus, and perineum and understanding of its relevant anatomy is important in accurate reporting, particularly in rectal cancer. In this pictorial essay, correlative imaging, endoscopic, pathologic, and operative images are presented to illustrate normal anorectal anatomy and neoplastic conditions that affect the anus and rectum. A particular case-based focus is given to rectal adenocarcinoma with pelvic MR and surgical histopathology. Additionally, carcinoid tumor, gastrointestinal stromal tumor, condylomata acuminata, squamous cell carcinoma, melanoma, and metastatic disease about the rectum and anus are reviewed.

A Multimodality Review of Adrenal Tumors.

Adrenal tumors are very commonly encountered in the practice of radiology. They may arise from the adrenal gland itself, either the cortex or the medulla, or they could be secondary lesions. They may be benign or malignant. The functioning adrenal tumors lead to hypersecretion of adrenal hormones leading to clinical syndromes. Computed tomography is the most common imaging modality used for the initial evaluation of adrenal tumors. Magnetic resonance imaging and functional scintigraphic techniques are frequently used for atypical presentations or further evaluation. We present a multimodality review of common and uncommon adrenal tumors. We highlight their characteristic and specific imaging features which help us in making a diagnosis and suggesting an appropriate follow up for further management. The spectrum of adrenal tumors is wide with varying appearances on different imaging modalities. Imaging techniques used for adrenal tumor imaging have their own strengths and weaknesses as it relates to the final diagnosis. It is important to be familiar with imaging characteristics of adrenal tumors for appropriate diagnosis and management. Differentiation of benign (leave alone) tumors from malignant (surgical) ones along with appropriate disposition of incidentalomas are some of the challenges facing the radiologist.

Palliative Radiotherapy as a Treatment for Carcinoma Invasion of the Sacrum: An Observational Case Series Study.

BACKGROUND/AIM: Radiotherapy for carcinoma invasion of the sacrum (CIS) is an alternative treatment to surgery in patients with advanced, inoperable tumors or those not medically eligible for resection of the neoplasm. Herein we present an observational study of patients with imaging-confirmed CIS who were treated non-operatively with radiation. PATIENTS AND METHODS: A retrospective chart review of CIS patients treated with palliative radiotherapy (PR) during a 9-year period (2004-2013) was performed. RESULTS: Six women and 13 men with an average age of 60 years took part in this study. Most patients (84%) exhibited extrasacral metastases. Primary tumors included lung (n=6), colorectal (n=6), breast (n=3), bladder or kidney (n=2), and liver carcinoma or a tumor in an unknown primary site (n=2). The mean follow-up time was 10 months with a 2-year survival rate of 9%. The majority (71%) of symptomatic patients obtained relief from pain following PR. Half of those individuals who were non-ambulatory prior to therapy regained mobility. There were no acute ill-effects or later complications after irradiation. CONCLUSION: Despite the small cohort and poor overall survival rate, non-operative radiation treatment is a beneficial method of palliative care in patients with CIS.

Diffuse Pancreatic Neuroendocrine Tumor: A Rare Presentation.

Diffuse involvement of the pancreas in neuroendocrine tumor is a rare presentation, and its appearance on In-111 pentetreotide scan has not been reported earlier in the literature. We present the whole body images from In-111 pentetreotide scan, contrast-enhanced computed tomography images, and histopathology correlation.

Pulmonary Metastases from an Undifferentiated Embryonal Sarcoma of the Liver: A Case Report and Review.

Undifferentiated embryonal sarcoma of the liver (UESL) is a rare malignant hepatic tumor that occurs primarily in children. Only a limited number of cases have been reported in the literature due to low incidence of one per million, and reports of metastatic lesion of UESL are even rarer. We hereby describe the case of a 13-year-old male who presented with a palpable mass with imaging findings suggestive of a large complex tumor in the right lobe of the liver. He underwent extended right hepatectomy followed by adjuvant chemotherapy. The tumor was confirmed to be UESL by postoperative pathology and immunohistochemical staining analysis. Four years later, surveillance imaging revealed a small lung nodule in the left lower lobe. Complete removal of the lung tumor by wedge resection was performed, and a histological diagnosis of metastatic UESL was made. The patient also received postoperative adjuvant chemotherapy and is currently in a good general condition and tumor-free in the present eight-month period. This case is presented with emphasis on clinicopathological and immunohistochemical findings of the primary UESL and lung metastases with the aim of collecting more data and expanding our understanding of this rare malignancy.

Parasitic leiomyoma presenting as an inguinal hernia in a postmenopausal woman.

Uterine leiomyomas are one of the most common tumors affecting reproductive-age women. Leiomyomas can present as an intrauterine mass or rarely as an extrauterine tumor. Depending on its location, the diagnosis of extrauterine leiomyoma can be challenging, and multiple imaging modalities may be needed for correct identification and differentiation from malignant entities. We report the case of a 48-year-old-postmenopausal female who presented with a painful left inguinal mass, which was clinically diagnosed as inguinal hernia. Ultrasound, computed tomography, magnetic resonance imaging, and percutaneous biopsy were used to characterize the mass. Surgical resection and histopathological analysis revealed the mass to be a parasitic leiomyoma, a very rare cause of inguinal hernia, especially in a postmenopausal woman.