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Objective The aim of this study was to characterize the tissue involving the margin and study if this information will affect margin prediction on restaging magnetic resonance imaging (MRI) in low rectal adenocarcinoma (LRC) patients treated with neoadjuvant long-course chemoradiotherapy (LCCRT). Methods In this retrospective study of nonmetastatic LRC (distal margin <5 cm from the anal verge) treated with LCCRT followed by surgery, a radiologist blinded to outcome reread the restaging MRI and documented if the radial margin was involved by tumor, fibrosis, or mucin reaction using T2 high-resolution (HR) and diffusion-weighted imaging (DWI). The diagnostic performance of tumor-involving margin on restaging MRI was assessed using surgical histopathology as a reference. Interobserver agreement between three independent radiologists was assessed in a subset. Results We included 133 patients (80 males and 53 females) with a mean (range) age of 44.7 (21-86) years and 82% of them had well or moderately differentiated adenocarcinoma. Baseline MRI showed T3 ( n = 58) or T4 ( n = 60) disease in 89% of the patients. The pathological margin was positive in 21% ( n = 28) cases. In restaging MRI, the circumferential resection margin (CRM) ≤1 mm in 75.1% ( n = 100) cases and MRI predicted tumor, fibrosis, and mucin reaction at the margin in 60, 34, and 6%, respectively, and histopathology showed tumor cells in 33, 14.7, and 16.6% of them, respectively. LRC with tumor-involving margin and bad response (MR tumor regression grade [mr-TRG] 3-5) on restaging MRI had fourfold increased risk of positive pathological circumferential resection margin (pCRM). There was moderate and fair inter-reader agreement for the tissue type involving the CRM ( κ = 0.471) and mr-TRG ( κ = 0.266), p < 0.05. The use of both distance criteria and tumor-involving margins improved the diagnostic accuracy for margin prediction from 39 to 66% on restaging MRI. Conclusions Margin prediction on restaging MRI can be improved by characterizing the tissue type involving the margin in low rectal cancer patients. The inter-reader agreement was moderate for determining the tissue type.
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Objectives The main aim of this study was to compare magnetic resonance imaging (MRI) findings of recurrent and treatment-naïve fistula-in-ano and to correlate imaging findings with anal sphincter morphology in recurrent fistula-in-ano. Methods This is a retrospective study of adult patients who underwent MRI for suspected fistula-in-ano in 2018. After excluding patients with alternative diagnosis, patients were stratified into recurrent ( n = 103) and treatment-naïve ( n = 106) fistula-in-ano groups. Two blinded radiologists reread MRI scans in consensus for fistula characteristics and anal sphincter morphology. We compared imaging features of recurrent and treatment-naïve fistula-in-ano, assessed the incidence of anal sphincter scarring among patients with recurrent fistula-in-ano, and studied its association with fistula features. Results Two-hundred nine patients (187 males) with mean age of 40.6 (standard deviation: 12.2) years were included. Trans-sphincteric, inter-sphincteric, extra-sphincteric, and supra-sphincteric fistula-in-ano were seen in 63.6, 33, 2.9, and 0.5%, respectively. There were secondary tracts, supralevator extension, and secondary cause for fistula in 49.3, 12.9, and 14.8%, respectively. There was no difference between the fistula features of recurrent and treatment-naïve fistula-in-ano, except for significantly fewer external openings among recurrent fistula-in-ano ( p = 0.005). Among patients with recurrent fistula-in-ano, MRI detected anal sphincter defect/scarring was seen in 53.4% ( n = 55) and was significantly associated with posterior fistula-in-ano ( p = 0.031), collections and/or supralevator extension ( p = 0.010), and secondary tracts ( p = 0.015). Conclusion Fistula features of recurrent and treatment-naïve patients were mostly similar. There was high incidence (53.4%) of MRI-identified anal sphincter scarring/defect among recurrent fistula-in-ano, which was significantly associated with posterior fistula, collections, supra or translevator extension, and secondary tracts. Key Points MRI-identified anal sphincter scarring is very common among patients with recurrent fistula-in-ano and seen in more than half of them.There was significantly higher incidence of sphincter scarring among patients who had posterior fistula, collections, supralevator/translevator extension, and secondary tracts.
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Purpose Usual interstitial pneumonia (UIP) pattern of interstitial lung disease (ILD) can have varied etiology, with connective tissue disease (CTD) being a common known cause. The anterior upper lobe (AUL) sign, exuberant honeycombing (EHC), and straight edge (SE) sign are recently described computed tomography (CT) signs in CTD-related UIP. We test the diagnostic value of these CT signs for CTD in patients with UIP and compare the incidence of these signs between CTD-related UIP and non-CTD-related UIP. We also evaluated the interobserver agreement in detection of these CT signs. Methods Retrospective study of all patients who had UIP pattern of ILD on CT thorax done from January 1, 2016 to January 31, 2019, was grouped into two: non-CTD-related UIP or CTD-related UIP. CT thorax was reviewed for the presence of these signs-AUL, SE, and EHC. The diagnostic values of these signs in diagnosing CTD-related UIP was assessed. For assessment of interobserver agreement, another radiologist reviewed a subset of 30 randomly selected cases and looked for the presence of these signs. Results Of the 156 patients included, 76 had CTD. The incidence of CT signs were significantly higher in CTD-related UIP. The specificities of AUL, EHC, and SE were 82.5, 75, and 85%, respectively. The EHC sign had highest sensitivity of 48.7%. Inclusion of more than one sign increased the specificity of diagnosis of CTD-related UIP; however, the sensitivity decreases. There was excellent interobserver agreement (0.81-0.87) for each of these signs. Conclusion The presence of SE, AUL, and EHC signs in cases with UIP pattern are specific imaging markers to diagnose underlying CTD; however, due to its low sensitivity, the absence of these signs cannot exclude the same. Because of its excellent interobserver agreement, these signs are reliable in the evaluation of CTD-related ILD.
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INTRODUCTION: Mayer-Rokitansky-Kuster-Hauser (MRKH) synd-rome is a malformation in female genital tract due to interrupted embryonic development of para-mesonephric ducts leading to uterine and proximal vagina aplasia or hypoplasia. AIM: To analyse the MRI findings in females suspected of MRKH syndrome in a primary amenorrhea workup. MATERIALS AND METHODS: A cross-sectional study comprising of 11 patients of MRKH syndrome presented in a tertiary care centre from March 2016 to February 2017 evaluated in 1.5 Tesla MRI scanner. RESULTS: Normal positioned small vestigial uterus demonstrated in two patients (18.2%) and complete uterine and proximal vaginal agenesis were noted in nine patients (81.8%). The mean volume of rudimentary right uterine bud was 2.26 mL ±3.3 (SD) and left uterine bud was 1.27 mL±1.1 (SD). The mean volume of right ovary was 4.74 mL±2.58 (SD) and left ovary was 4.65 mL±2.2 (SD). The mean developed vaginal length was 26.2 mm±6.34 (SD). CONCLUSION: The rudimentary uterine buds associated with MRKH syndrome always maintained caudal relationship with ovary. Ovaries or rudimentary uterine buds can be ectopic and should be recognized with MRI before undergoing fertility treatment. Following MRI diagnosis, surgery allows patients to have sexual function with possible attainment of reproduction after assisted reproduction technique or surrogacy.
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OBJECTIVE: The aim of this study was to evaluate the magnetic resonance imaging (MRI) findings of caudal regression syndrome (CRS) and concomitant anomalies in pediatric patients. MATERIALS AND METHODS: A hospital-based cross-sectional retrospective study was conducted. The study group comprised 21 pediatric patients presenting to the Departments of Radiodiagnosis and Pediatric Surgery in a tertiary care hospital from May 2011 to April 2016. All patients were initially evaluated clinically followed by MRI. RESULTS: In our study, 21 pediatric patients were diagnosed with sacral agenesis/dysgenesis related to CRS. According to the Pang's classification, 2 (9.5%) patients were Type I, 5 (23.8%) patients were Type III, 7 (33.3%) patients were Type IV, and 7 (33.3%) patients were of Type V CRS. Clinically, 17 (81%) patients presented with urinary incontinence, 6 (28.6%) with fecal incontinence, 9 patients (42.9%) had poor gluteal musculatures and shallow intergluteal cleft, 7 (33.3%) patients had associated subcutaneous mass over spine, and 6 (28.6%) patients presented with distal leg muscle atrophy. MRI showed wedge-shaped conus termination in 5 (23.8%) patients and bulbous conus termination in 3 (14.3%) patients above the L1 vertebral level falling into Group 1 CRS while 7 (33.3%) patients had tethered cord and 6 (28.6%) patients had stretched conus falling into Group 2 CRS. CONCLUSION: MRI is the ideal modality for detailed evaluation of the status of the vertebra, spinal cord, intra- and extra-dural lesions and helps in early diagnosis, detailed preoperative MRI evaluation and assessing concomitant anomalies and guiding further management with early institution of treatment to maximize recovery.
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OBJECTIVE: The aim of this study was to evaluate the safe zone for performing blind sternal procedures based on computed tomography (CT) evaluation of congenital midline sternal foramina using multidetector computed tomography (MDCT). MATERIALS AND METHODS: This retrospective study was carried out on 1,180 patients who underwent MDCT of the thorax from March 2015 to February 2016. The MDCT images were evaluated in axial and reformatted planes. Morphometry and prevalence of midline congenital sternal foramina (SF) and manubrio-foraminal distance (MFD) were evaluated. The safe zone was defined for a blinded intervention, based on palpable anatomical landmarks. Data were presented in terms of percentage, mean ± standard deviation and calculations were carried out using Microsoft Excel. RESULTS: The prevalence of SF in our study sample was 11.6 %. The majority of SF were located in a typical position in the lower sternal body at the level of fifth costo-chondral junction (CCJ) in 108 patients (78.8 %). The structure directly beneath the SF was mediastinal fat in 73 patients (53.3 %), followed by anterior pericardium in 44 patients (32.1 %) and lung parenchyma in 20 patients (14.6 %). The mean MFD in our study population was 11.90 ± 1.31 cm. CONCLUSIONS: Sternal interventions should be avoided at the level of fourth to sixth CCJ, which is considered the danger zone. An intervention at the fourth to sixth CCJ may lead to disastrous consequences in patients who have SF.
