Imaging spectrum of non-neoplastic and neoplastic conditions of the duodenum: a pictorial review.

Given its crucial location at the crossroads of the gastrointestinal tract, the hepatobiliary system and the splanchnic vessels, the duodenum can be affected by a wide spectrum of abnormalities. Computed tomography and magnetic resonance imaging, in conjunction with endoscopy, are often performed to evaluate these conditions, and several duodenal pathologies can be identified on fluoroscopic studies. Since many conditions affecting this organ are asymptomatic, the role of imaging cannot be overemphasized. In this article we will review the imaging features of many conditions affecting the duodenum, focusing on cross-sectional imaging studies, including congenital malformations, such as annular pancreas and intestinal malrotation; vascular pathologies, such as superior mesenteric artery syndrome; inflammatory and infectious conditions; trauma; neoplasms and iatrogenic complications. Because of the complexity of the duodenum, familiarity with the duodenal anatomy and physiology as well as the imaging features of the plethora of conditions affecting this organ is crucial to differentiate those conditions that could be managed medically from the ones that require intervention.

Phase I Trial of MRI-Guided Prostate Cancer Lattice Extreme Ablative Dose (LEAD) Boost Radiation Therapy.

PURPOSE: A phase I clinical trial was designed to test the feasibility and toxicity of administering high-dose spatially fractionated radiation therapy to magnetic resonance imaging (MRI)-defined prostate tumor volumes, in addition to standard treatment. METHODS AND MATERIALS: We enrolled 25 men with favorable to high-risk prostate cancer and 1 to 3 suspicious multiparametric MRI (mpMRI) gross tumor volumes (GTVs). The mpMRI-GTVs were treated on day 1 with 12 to 14 Gy via dose cylinders using a lattice extreme ablative dose technique. The entire prostate, along with the proximal seminal vesicles, was then treated to 76 Gy at 2 Gy/fraction. For some high-risk patients, the distal seminal vesicles and pelvic lymph nodes received 56 Gy at 1.47 Gy/fraction concurrently in 38 fractions. The total dose to the lattice extreme ablative dose cylinder volume(s) was 88 to 90 Gy (112-123 Gy in 2.0 Gy equivalents, assuming an α-to-ß ratio of 3). RESULTS: Dosimetric parameters were satisfactorily met. Median follow-up was 66 months. There were no grade 3 acute/subacute genitourinary or gastrointestinal adverse events. Maximum late genitourinary toxicity was grade 1 in 15 (60%), grade 2 in 4 (16%), and grade 4 in 1 (4%; sepsis after a posttreatment transurethral resection). Maximum late gastrointestinal toxicity was grade 1 in 11 (44%) and grade 2 in 4 (16%). Two patients experienced biochemical failure. CONCLUSIONS: External beam radiation therapy delivered with an upfront spatially fractionated, stereotactic high-dose mpMRI-GTV boost is feasible and was not associated with any unexpected events. The technique is now part of a follow-up phase II randomized trial.

The Global Nonalcoholic Fatty Liver Disease Epidemic: What a Radiologist Needs to Know.

Nonalcoholic fatty liver disease (NAFLD) represents a spectrum of disorders from a benign steatosis to hepatocellular carcinoma (HCC). Metabolic syndrome, mainly obesity, plays an important role, both as an independent risk factor and in the pathogenesis of NAFLD. With the progressive epidemics of obesity and diabetes mellitus, the prevalence of NAFLD and its associated complications is expected to increase dramatically. Therapeutic strategies for treating NAFLD and metabolic syndrome, particularly obesity, are continuously being refined. Their goal is the prevention of NAFLD by the management of risk factors, prevention of progression of the disease, as well as management of complications, ultimately preventing morbidity and mortality. Optimal management of NAFLD and metabolic syndrome requires a multidisciplinary collaboration between the government as well as the health system including the nutritionist, primary care physician, radiologist, hepatologist, oncologist, and transplant surgeon. An awareness of the clinical presentation, risk factors, pathogenesis, diagnosis, and management is of paramount importance to a radiologist, both from the clinical perspective as well as from the imaging standpoint. With expertise in imaging modalities as well as minimally invasive percutaneous endovascular therapies, radiologists play an essential role in the comprehensive management, which is highlighted in this article, with cases from our practice. We also briefly discuss transarterial embolization of the left gastric artery (LGA), a novel method that promises to have an enormous potential in the minimally invasive management of obesity, with details of a case from our practice.

Multiparametric-MRI and Targeted Biopsies in the Management of Prostate Cancer Patients on Active Surveillance.

An important key to clinical management of prostate cancer patients is to determine early those who will benefit from primary treatment and are not good candidates for active surveillance (AS). We describe a 67-year-old gentleman with a long history of stable prostate-specific antigen (PSA) levels and a negative biopsy. After slight PSA rise and low volume Gleason score 6 biopsy, the patient was considered for primary treatment or AS. A multiparametric (MP)-MRI exam revealed a suspicious lesion in the anterior apex of the prostate. Biopsies were carried out on a 3D-ultrasound prostate biopsy system with MRI-fusion. The location of the target area was challenging and could have been missed using standard 12-core biopsy template. The pathology determined Gleason 3 + 4 disease in 30% of the core from this region. Consequently, the patient underwent radiotherapy (RT). MP-MRI was also used to follow the changes from pre- to post-RT.

Mucoepidermoid carcinoma of the intrapancreatic common bile duct: immunohistochemical profile, prognosis, and review of the literature.

Mucoepidermoid carcinoma of the bile duct is a rare entity. Only one mucoepidermoid carcinoma from the common bile duct has been reported in the Korean literature. Herein, we present the first in the English literature. The tumor arose in the intrapancreatic (distal) common bile duct in an 83-year-old woman who presented with obstructive jaundice and elevated liver enzymes. The tumor invaded the underlying pancreas and peripancreatic adipose tissue and showed pagetoid spread into the extrapancreatic common bile duct and cystic duct. The tumor exhibited nests of malignant cells with diffuse CK7 and MUC1 positivity. The basal cells were p63 and CK5/6 positive. The luminal cells were stained with carcinoembryonic antigen, MUC5, and mucicarmine and were focally positive for CK20. There was focal MUC4 staining on the apical luminal border. The neoplastic cells were negative for MUC2 and HER2-neu. We discuss the clinical presentation, diagnostic features, immunohistochemical profile, and prognosis of mucoepidermoid carcinoma of the common bile duct. The features of this neoplasm are further compared with mucoepidermoid carcinoma of the hepatobiliary system, adenosquamous carcinoma, and mucoepidermoid carcinoma of other organs.

Role of magnetic resonance cholangiopancreatography in diagnosing choledochal cysts: Case series and review.

AIM: To determine the merits of magnetic resonance cholangiopancreatography (MRCP) as the primary diagnostic test for choledochal cysts (CC's). METHODS: Between 2009 and 2012, patients who underwent MRCP for perioperative diagnosis were identified. Demographic information, clinical characteristics, and radiographic findings were recorded. MRCP results were compared with intraoperative findings. A PubMed search identified studies published between 1996-2012, employing MRCP as the primary preoperative imaging and comparing results with either endoscopic retrograde cholangiopancreatography (ERCP) or operative findings. Detection rates for CC's and abnormal pancreaticobiliary junction (APBJ) were calculated. In addition detection rates for clinically related biliary pathology like choledocholithiasis and cholangiocarcinomas in patients diagnosed with CC's were also evaluated. RESULTS: Eight patients were identified with CC's. Six patients out of them had type IV CC's, 1 had type I and 1 had a new variant of choledochal cyst with confluent dilatation of the common bile duct (CBD) and cystic duct. Seven patients had an APBJ and 3 of those had a long common-channel. Gallstones were found in 2 patients, 1 had a CBD stone, and 1 pancreatic-duct stone was also detected. In all cases, MRCP successfully identified the type of CC's, as well as APBJ with ductal stones. From analyzing the literature, we found that MRCP has 96%-100% detection rate for CC's. Additionally, we found that the range for sensitivity, specificity, and diagnostic accuracy was 53%-100%, 90%-100% and 56%-100% in diagnosing APBJ. MRCP's detection rate was 100% for choledocholithiasis and 87% for cholangiocarcinomas with concurrent CC's. CONCLUSION: After initial ultrasound and computed tomography scan, MRCP should be the next diagnostic test in both adult and pediatric patients. ERCP should be reserved for patients where therapeutic intervention is needed.

Percutaneous retropleural drainage of a posttraumatic pancreatic mediastinal pseudocyst in a child.

Pancreatic mediastinal pseudocyst is a rare complication of pancreatitis in children. These children usually present with abdominal pain, anorexia, vomiting, and dysphagia. Computed tomography not only is essential in defining the extent of the pseudocyst but also can guide percutaneous external drainage. We present the case of a 4-year-old child with a mediastinal pseudocyst secondary to pancreatic trauma, which was successfully treated with computed tomography-guided percutaneous drainage via a posterior, extrapleural approach.

Renal glomus tumor in an adolescent: a conservative approach.

The most common renal neoplasms in the second decade of life are renal cell carcinomas and Wilms' tumors. Glomus tumors arising in the kidney are rare. We report an adolescent with a benign renal glomus tumor excised by wedge resection. Nephron-sparing surgery is the therapy of choice for children with benign renal tumors. Glomus tumor should be considered in the differential diagnosis of a renal mass in a young patient.

Wilms' tumor, pancreatic islet cell carcinoma, and pheochromocytoma in a child.

We present the first case of Wilms' tumor, pancreatic islet cell carcinoma, and pheochromocytoma affecting the same individual. This case underscores the importance of repeat biopsies in patients with multiple neoplasms to confirm the diagnosis and guide management.

Primary renal botryoid rhabdomyosarcoma: diagnosis and outcome.

Primary renal rhabdomyosarcoma is a rare entity. We report on a pediatric patient who, despite having multiple metastases to the lung on presentation, is free of disease 28 months after radical nephrectomy combined with chemotherapy and radiation therapy.

Magnetic resonance cholangiopancreatography accurately detects common bile duct stones in resolving gallstone pancreatitis.

BACKGROUND: There is controversy about the optimal method to detect common bile duct (CBD) stones in patients with mild resolving gallstone pancreatitis. The aim of this study was to evaluate magnetic resonance cholangiopancreatography (MRCP) in detecting choledocholithiasis in this group of patients. STUDY DESIGN: A prospective randomized trial was conducted. Patients randomized to group 1 (n = 34) underwent laparoscopic cholecystectomy (LC) and intraoperative cholangiography (IOC). Those randomized to group 2 (n = 29) had preoperative MRCP, of these, patients with negative MRCP underwent LC and IOC, patients with positive MRCP had preoperative ERCP followed by LC. RESULTS: Sixty-three patients were randomized (34 to group 1 and 29 to group 2). CBD stones were found in 5 patients in group 1. CBD exploration was performed in 2 patients, preoperative ERCP in 1, and postoperative ERCP in the other 2. MRCP showed CBD stones in 4 patients in group 2. There were two false-positive MRCPs. Four patients with a negative MRCP did not have IOC or ERCP, the remaining 21 patients with a negative MRCP had a negative IOC. The MRCP sensitivity was 100% (95% CI, 16-100%), specificity 91% (95% CI, 72-99%), positive predictive value 50% (95% CI, 7-93%), negative predictive value 100% (95% CI, 84-100%), and accuracy 92% (95% CI, 74-99%). CONCLUSIONS: Patients with resolving gallstone pancreatitis and a negative MRCP do not need preoperative ERCP or IOC. Only patients with a positive MRCP will require preoperative ERCP.

Focal nodular hyperplasia in identical twins.

A unique case of a focal nodular hyperplasia (FNH) in identical twins is presented. The computed tomography (CT) and magnetic resonance imaging (MRI) of the abdomen demonstrated in both twins a mass of identical size in the same segment of their liver. Histopathologic examination of both masses confirmed the diagnosis of focal nodular hyperplasia. This case report strongly supports the theory of a congenital vascular anomaly playing a major role in the etiology of focal nodular hyperplasia.

Large esophageal liposarcoma: a case report and review of the literature.

Liposarcoma is one of the most common neoplasms of adulthood. However, it is exceedingly rare in the gastrointestinal tract. To our knowledge, only 12 cases occurring in the esophagus have been reported in the world literature to date. We report the case of a 42-year-old man with a pleomorphic liposarcoma arising in the esophageal wall. The morphologic, immunophenotypic, and ultrastructural characteristics are presented, as well as the results of literature review.

Granulocytic sarcoma of the pancreas. A report of one case and review of the literature.

Granulocytic sarcoma is an extramedullary collection of myeloblasts. Granulocytic sarcomas usually arise during the course of acute myeloid leukemia, although they also occur infrequently in chronic myeloid leukemia and other myeloproliferative disorders. We are reporting a very unusual presentation of granulocytic sarcoma in a patient with poorly differentiated (FAB type M2) acute myeloid leukemia. The patient was in complete remission from leukemia when he presented obstructive jaundice due to a pancreatic mass consisting of myeloblasts. A literature search identified only five previously reported cases of granulocytic sarcoma of the pancreas. Those cases are also reviewed here with emphasis on their clinical characteristics, diagnostic approaches, and management of this interesting and challenging entity.

Concurrent infantile hemangioendothelioma and mesenchymal hamartoma in a developmentally arrested liver of an infant requiring hepatic transplantation.

A newborn female underwent a surgical resection for a hepatic mass discovered prenatally by ultrasonography, and diagnosed pathologically as a mesenchymal hamartoma. Within 4 months after surgery, multiple cutaneous hemangiomas developed and a multinodular mass was detected in the liver. A liver biopsy showed an infantile hemangioendothelioma with type I features. An orthotopic liver transplant was performed due to the extensive nature of the hepatic involvement and progressive respiratory compromise. Virtually the entire liver was involved by a large infantile hemangioendothelioma. A multicystic mesenchymal hamartoma was also found on the left side. In addition, the uninvolved hepatic parenchyma had features recapitulating the fetal liver. This simultaneous involvement of the liver by a mesenchymal hamartoma and infantile hemangioendothelioma is unique. A review of the literature revealed only one incompletely characterized case with similar findings.

Diabetic muscle infarction after simultaneous pancreas-kidney transplant.

Diabetic muscle infarction (DMI) is a rare entity that occurs in patients with long-standing type 1 insulin dependent diabetes mellitus (IDDM). We describe DMI occurring on an average of 5 months after SPK in four patients with IDDM and end stage renal disease (ESRD). These patients had evidence of other long-term diabetic complications including retinopathy and neuropathy, as well as microangiopathy and hypercoagulability, both of which are pre-disposing factors for DMI. The etiology of DMI is not well understood. Despite establishment of normoglycemia after kidney-pancreas transplantation, DMI may occur as a result of tissue damage/fragility secondary to the pre-existing long-term labile glycemic control and hypertension. This may be exacerbated by the pro-coagulant effects of the calcineurin-inhibitors and the use of steroids as part of the immunosuppressive regimen.