Practical Guide to VI-RADS: MRI Protocols, Lesion Characterization, and Pitfalls.

Urothelial carcinoma is the most common type of bladder cancer (BC), accounting for approximately 90% of all cases. Evaluating the depth of tumor invasion in the bladder wall (tumor staging) is essential for determining the treatment and prognosis in patients with BC. Neoadjuvant therapy followed by radical cystectomy is the most common treatment of localized muscle-invasive BC (MIBC). Therefore, it is vital to differentiate non-MIBC from MIBC. Transurethral resection of bladder tumor (TURBT) is the reference standard to determine the extent of tumor invasion into the bladder wall through tissue sampling. However, this diagnostic and therapeutic method may not adequately sample the muscularis propria, leading to a higher risk of residual disease, early recurrence, and tumor understaging in approximately 50% of patients during the initial TURBT. Multiparametric MRI can overcome some of the limitations of TURBT when evaluating BC, particularly regarding tumor staging. In this context, the Vesical Imaging Reporting and Data System (VI-RADS) classification was developed to establish standards for bladder multiparametric MRI and interpretation. It uses a 5-point scale to assess the likelihood of detrusor muscle invasion. T2-weighted MR images are particularly useful as an initial guide, especially for categories 1-3, while the presence of muscular invasion is determined with diffusion-weighted and dynamic contrast-enhanced sequences. Diffusion-weighted imaging takes precedence as the dominant method when optimal image quality is achieved. The presence of a stalk or a thickened inner layer and no evidence of interruption of the signal intensity of the muscular layer are central for predicting a low likelihood of muscle invasion. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material. See the invited commentary by Hoegger in this issue.

Proximal jejunal intussusception due to clear cell renal carcinoma metastasis.

The incidence of metastasis from clear cell renal carcinoma (CCR) to the small intestine is relatively rare. While most patients exhibit symptoms such as upper gastrointestinal bleeding or obstructive symptoms, the identification of small intestine metastases often faces diagnostic delays.

Performance of magnetic resonance imaging to predict maternal outcomes in patients at high risk for placenta accreta spectrum disorder.

OBJECTIVE: The purpose of this study is to evaluate the diagnostic performance of MRI parameters to predict adverse maternal peripartum outcomes in pregnant females at high-risk for placenta accreta spectrum (PAS) disorder. METHODS AND MATERIALS: This retrospective study evaluated 60 pregnant females who underwent MRI for placental assessment. MRI studies were reviewed by a radiologist blinded to all clinical data. MRI parameters were compared with five maternal outcomes: severe bleeding, cesarean hysterectomy, prolonged operation time, need for blood transfusion, and need for intensive care unit (ICU) admission. The MRI findings were associated with pathologic and/or intraoperative findings for PAS. RESULTS: The study identified 46 cases of PAS disorder and 16 cases of placenta percreta. The agreement between the radiologist impression of PAS disorder and the intraoperative/histological findings was substantial (0.67, p < 0.001), and almost perfect for the presence of placenta percreta (0.87, p < 0.001). The presence of a placental bulge was highly associated with placenta percreta, with sensitivity of 87.5% and specificity of 90.9%. The MRI signs that associated with more maternal outcomes were myometrial thinning, with significant odds ratio for severe blood loss (20.2), hysterectomy (4.0), need for blood transfusion (4.8) and prolonged surgery time (4.9), and uterine bulging, with significant odds ratio for severe blood loss (11.9), hysterectomy (34.0), ICU admission (5.0), and need for blood transfusion (4.8). CONCLUSION: MRI signs significantly correlated with invasive placenta and were independently associated with adverse maternal outcomes. The presence of a placental bulge was highly accurate in predicting placenta percreta. ADVANCES IN KNOWLEDGE: First study to evaluate the strength of the association between individual MRI signs and five adverse maternal outcomes. Conclusions support published MRI signs associated with placental invasion, especially regarding the value placental bulging in predicting placenta percreta.

Focal incidental upper abdominal findings on unenhanced chest computed tomography that do not require further imaging: a roadmap for the thoracic radiologist.

Chest scans usually include the upper abdomen, leading radiologists to evaluate the upper abdominal structures. The aim of this article is to summarize the most common incidental upper abdominal findings that do not require further imaging or management in patients undergoing unenhanced computed tomography of the chest for the investigation of thoracic symptoms or diseases. We review common incidental findings of the liver, gallbladder, spleen, adrenal glands, kidney, and retroperitoneum, as well as findings that mimic other lesions. Thoracic radiologists should be aware of such typical findings and report when no further investigation is needed, thus avoiding unnecessary imaging examinations, protecting patients from additional medical interventions, and allaying patient concerns.

As tomografias de tórax geralmente incluem o abdome superior, o que implica a avaliação das estruturas abdominais superiores. Nosso objetivo é resumir os achados incidentais mais comuns do abdome superior que não requerem imagem ou tratamento adicional em pacientes submetidos a tomografia computadorizada de tórax sem contraste para investigar sintomas ou doenças torácicas. Achados incidentais comuns do fígado, vesícula biliar, baço, glândulas adrenais, rins, retroperitônio e alterações que podem mimetizar lesões nesses órgãos serão revisados. O radiologista torácico deve estar ciente de tais achados e relatar quando nenhuma investigação adicional for necessária, para evitar excesso de exames, especialmente com radiação ionizante, proteger os pacientes de intervenções médicas e de preocupações.

Magnetic resonance imaging findings in placenta accreta spectrum disorders: pictorial essay.

Placenta accreta spectrum disorders are characterized by abnormal adhesion of the placenta that can be subdivided into three categories according to degree of invasion: placenta accreta (passing through the decidua basalis and adhering to the myometrium); placenta increta (penetrating the myometrium); and placenta percreta (invading the uterine serosa or adjacent tissues or organs). The incidence of placenta accreta has increased significantly in recent decades, mainly because of an increase in the rates of cesarean section, which is its main risk factor. Accurate prenatal identification makes it possible to institute the ideal treatment with a multidisciplinary team, significantly minimizing maternal morbidity and mortality. The examinations of choice are ultrasound and magnetic resonance imaging (MRI). When the ultrasound evaluation is inconclusive, as well as when the patient has risk factors for the condition or the placenta is in a posterior location, MRI is indicated. In cases of placental invasion of the adjacent pelvic organs, MRI is also preferable because it provides a broader field of view, which improves surgical planning. Numerous features of placenta accreta spectrum disorders are discernible on MRI, including dark intraplacental bands, uterine bulging, and heterogeneous placenta. Knowledge of these findings and the combination of two or more of them increase confidence in the diagnosis.

Acretismo placentário é uma condição caracterizada pela implantação anormal da placenta, que pode ser subdividida em três espectros de acordo com o seu grau de invasão: placenta acreta (ultrapassa a decídua basal e adere ao miométrio), placenta increta (penetra o miométrio) e placenta percreta (invasão da serosa uterina ou de tecidos/órgãos adjacentes). A incidência de acretismo placentário aumentou significativamente nas últimas décadas, principalmente em função da elevação das taxas de cesarianas, sendo este o seu principal fator de risco. A sua identificação pré-natal precisa permite um tratamento ideal com equipe multidisciplinar, minimizando significativamente a morbimortalidade materna. Os exames de escolha são a ultrassonografia e a ressonância magnética (RM), sendo a RM um método complementar indicado quando a avaliação ultrassonográfica é duvidosa, para pacientes com fatores de risco para acretismo placentário ou quando a placenta tem localização posterior. A RM é preferível também para avaliar invasão de órgãos adjacentes, oferecendo um campo de visão mais amplo, o que melhora o planejamento cirúrgico. Diversas características na RM são descritas no acretismo placentário, incluindo bandas hipointensas em T2 intraplacentárias, protuberância uterina anormal e heterogeneidade placentária. O conhecimento desses achados e a combinação de mais de um critério aumentam a confiabilidade do diagnóstico.

Achados na ressonância magnética do espectro do acretismo placentário: ensaio iconográfico / Magnetic resonance imaging findings in placenta accreta spectrum disorders: pictorial essay

Resumo Acretismo placentário é uma condição caracterizada pela implantação anormal da placenta, que pode ser subdividida em três espectros de acordo com o seu grau de invasão: placenta acreta (ultrapassa a decídua basal e adere ao miométrio), placenta increta (penetra o miométrio) e placenta percreta (invasão da serosa uterina ou de tecidos/órgãos adjacentes). A incidência de acretismo placentário aumentou significativamente nas últimas décadas, principalmente em função da elevação das taxas de cesarianas, sendo este o seu principal fator de risco. A sua identificação pré-natal precisa permite um tratamento ideal com equipe multidisciplinar, minimizando significativamente a morbimortalidade materna. Os exames de escolha são a ultrassonografia e a ressonância magnética (RM), sendo a RM um método complementar indicado quando a avaliação ultrassonográfica é duvidosa, para pacientes com fatores de risco para acretismo placentário ou quando a placenta tem localização posterior. A RM é preferível também para avaliar invasão de órgãos adjacentes, oferecendo um campo de visão mais amplo, o que melhora o planejamento cirúrgico. Diversas características na RM são descritas no acretismo placentário, incluindo bandas hipointensas em T2 intraplacentárias, protuberância uterina anormal e heterogeneidade placentária. O conhecimento desses achados e a combinação de mais de um critério aumentam a confiabilidade do diagnóstico.

Abstract Placenta accreta spectrum disorders are characterized by abnormal adhesion of the placenta that can be subdivided into three categories according to degree of invasion: placenta accreta (passing through the decidua basalis and adhering to the myometrium); placenta increta (penetrating the myometrium); and placenta percreta (invading the uterine serosa or adjacent tissues or organs). The incidence of placenta accreta has increased significantly in recent decades, mainly because of an increase in the rates of cesarean section, which is its main risk factor. Accurate prenatal identification makes it possible to institute the ideal treatment with a multidisciplinary team, significantly minimizing maternal morbidity and mortality. The examinations of choice are ultrasound and magnetic resonance imaging (MRI). When the ultrasound evaluation is inconclusive, as well as when the patient has risk factors for the condition or the placenta is in a posterior location, MRI is indicated. In cases of placental invasion of the adjacent pelvic organs, MRI is also preferable because it provides a broader field of view, which improves surgical planning. Numerous features of placenta accreta spectrum disorders are discernible on MRI, including dark intraplacental bands, uterine bulging, and heterogeneous placenta. Knowledge of these findings and the combination of two or more of them increase confidence in the diagnosis.

Focal incidental upper abdominal findings on unenhanced chest computed tomography that do not require further imaging: a roadmap for the thoracic radiologist / Achados incidentais focais no abdome superior encontrados na tomografia computadorizada de tórax sem contraste que não requerem investigação adicional: roteiro para o radiologista torácico

Abstract Chest scans usually include the upper abdomen, leading radiologists to evaluate the upper abdominal structures. The aim of this article is to summarize the most common incidental upper abdominal findings that do not require further imaging or management in patients undergoing unenhanced computed tomography of the chest for the investigation of thoracic symptoms or diseases. We review common incidental findings of the liver, gallbladder, spleen, adrenal glands, kidney, and retroperitoneum, as well as findings that mimic other lesions. Thoracic radiologists should be aware of such typical findings and report when no further investigation is needed, thus avoiding unnecessary imaging examinations, protecting patients from additional medical interventions, and allaying patient concerns.

Resumo As tomografias de tórax geralmente incluem o abdome superior, o que implica a avaliação das estruturas abdominais superiores. Nosso objetivo é resumir os achados incidentais mais comuns do abdome superior que não requerem imagem ou tratamento adicional em pacientes submetidos a tomografia computadorizada de tórax sem contraste para investigar sintomas ou doenças torácicas. Achados incidentais comuns do fígado, vesícula biliar, baço, glândulas adrenais, rins, retroperitônio e alterações que podem mimetizar lesões nesses órgãos serão revisados. O radiologista torácico deve estar ciente de tais achados e relatar quando nenhuma investigação adicional for necessária, para evitar excesso de exames, especialmente com radiação ionizante, proteger os pacientes de intervenções médicas e de preocupações.

Imaging findings of melanoma metastasis in the gallbladder.

We present the case of a 40-year-old male with a previous diagnosis of cutaneous melanoma in the dorsal region, with metastases in axillary and mesenteric lymph nodes and in the central nervous system. He presented focal areas of increased radiopharmaceutical uptake in the topography of the gallbladder infundibulum on a control positron emission tomography/computed tomography (PET/CT), which corresponded to a nodular lesion in an abdominal ultrasound.

Sarcoma de Kaposi anoperineal: uma rara apresentação / Perineal Kaposi's Sarcoma: a rare presentation

O sarcoma de Kaposi é uma neoplasia maligna associada à infecção pelo herpes vírus humano 8 em doentes imunossupressos. O sarcoma de Kaposi Epidêmico é o tipo epidemiológico mais frequente e afeta indivíduos VIH-positivos. A região anoperineal é raramente envolvida e as lesões suspeitas devem ser biopsiadas para confirmação histológica. A base do tratamento é a restauração imune do doente. Relatamos o caso de um jovem, com diagnóstico recente de infeção pelo VIH, sem tratamento, que foi admitido no serviço de infectologia apresentando sintomas constitucionais, adenomegalias inguinais e extensa lesão verrucosa e ulcerada na região anoperineal. As biópsias confirmaram o diagnóstico de sarcoma de Kaposi e o doente iniciou terapia antirretroviral e quimioterapia. Houve recuperação clínica, regressão das lesões e desaparecimento das adenomegalias. Este relato objetiva alertar as equipes médicas no sentido de se incluir o sarcoma de Kaposi no diagnóstico diferencial das lesões que afetam a região anoperineal.

Kaposi's sarcoma is a malignant neoplasm associated with human herpesvirus 8 infection in immunocompromised patients. Epidemic Kaposi's sarcoma is the most common epidemiological type and affects HIV-positive patients. Perineal involvement is rare, and suspicious lesions should be biopsied to confirm histological diagnosis. Treatment consists of restoring the patient's immune system. We report the case of a young patient recently diagnosed with HIV, without treatment, who was admitted to the Department of Infectious Diseases with nonspecific symptoms, inguinal lymphadenopathy, and an extensive verrucous ulcerated lesion in the perineal region. Biopsy confirmed the diagnosis of Kaposi's sarcoma, and the patient was started on antiretroviral therapy and chemotherapy. Clinical recovery was achieved, with lesion reduction and inguinal adenopathy resolution. This case report aims to encourage physicians to include Kaposi's sarcoma in the differential diagnosis of perineal lesions.

Imaging of chemotherapy-induced liver toxicity: an illustrated overview.

Chemotherapy is a potential cause of focal and diffuse hepatobiliary lesions. Many of these lesions may be demonstrated on imaging, especially computed tomography and MRI. Some of these lesions, especially those of steatosis and sinusoidal obstruction syndrome, are associated with a worse prognosis and risk of hepatic failure in the context of surgical management. Notably, some chemotherapy-induced hepatic alterations, such as sinusoidal obstruction syndrome, pseudocirrhosis and focal hepatopathies, may be mistakenly interpreted as signs of cancer progression, misguiding the therapeutic planning for patients receiving chemotherapy.

Diagnostic performance of radiologists with different levels of experience in the interpretation of MRI of the placenta accreta spectrum disorder.

OBJECTIVES: There have been no investigations on the association between previous abdominopelvic MRI experience without placental MRI experience and diagnostic accuracy of placenta accreta spectrum (PAS). To evaluate the diagnostic performance of radiologists with different experience levels in interpreting PAS-related MRI findings. METHODS: This retrospective study included 60 women who underwent MRI for placental assessment between 2016 and 2020. MR images were reviewed by four radiologists who were blinded to the clinical outcomes and had different experience levels in interpreting PAS-related MRI findings. The radiologists' diagnostic performance was evaluated according to the pathologic and surgical outcomes. Simple κ statistics were calculated to determine agreement among the radiologists. RESULTS: Of 60 women, 46 were diagnosed with PAS. The maternal age mean ± SD was 33.0 years ± 5.0 for the PAS absent group and 36.0 ± 4.3 for the PAS present group (p = 0.013). Overall, the most experienced radiologist had the highest sensitivity (100%, 95% confidence interval (CI): 92.3-100%) and NPV (100%, 95% CI: 63.1-100%) in PAS diagnoses. However, the PPV and specificity were independent of experience. The most experienced radiologist had the highest diagnostic accuracy in PAS (90%, 95% CI: 79.5-96.2%) and placenta percreta (95%, 95% CI: 86.1-99.0%). There was a strong association between definitive PAS diagnoses and the highest experience level. The κ values for the interobserver agreement regarding PAS diagnoses were 0.67 for the most experienced radiologist (p < 0.001) and 0.38, 0.40, and 0.43 for the other radiologists (p = 0.001) and regarding placenta percreta diagnoses were 0.87 for the senior radiologist (p < 0.001) and 0.63, 0.57, and 0.62 for the other radiologists (p < 0.001). CONCLUSION: Previous experience in interpreting PAS-related MRI findings plays a significant role in accurately interpreting such imaging findings. Previous abdominopelvic MRI experience without specific placental MRI experience did not improve diagnostic performance. ADVANCES IN KNOWLEDGE: We believe that our study makes a significant contribution to the literature and that this paper will be of interest to the readership of your journal because to the best of our knowledge, this study is the first in which the correlation between previous experience in abdominopelvic MRI with no specific experience in PAS-related MRI and diagnostic accuracy of radiologists has been explored. Our results could aid in setting up specialized multidisciplinary teams to assist women with PAS disorders.

Giant hepatic extra-gastrointestinal stromal tumor treated with cytoreductive surgery and adjuvant systemic therapy: A case report and review of literature.

BACKGROUND: Primary extra-gastrointestinal stromal tumors (E-GIST) of the liver are rare. The clinical presentation may range from asymptomatic to bleeding or manifestations of mass effect. Oncologic surgery followed by adjuvant therapy with imatinib is the standard of care. However, under specific circumstances, a cytoreductive approach may represent a therapeutic option. We describe herein the case of an 84-year-old woman who presented with a tender, protruding epigastric mass. Abdominal computed tomography scan revealed a large, heterogeneous mass located across segments III, IV, V, and VIII of the liver. The initial approach was transarterial embolization of the tumor, which elicited no appreciable response. Considering the large size and central location of the tumor and the advanced age of the patient, non-anatomic complete resection was indicated. Due to substantial intraoperative bleeding and hemodynamic instability, only a near-complete resection could be achieved. Histopathology and immunohistochemical staining confirmed the diagnosis of primary E-GIST of the liver. Considering the risk/benefit ratio for therapeutic options, debulking surgery may represent a strategy to control pain and prolong survival. CASE SUMMARY: Here, we present a case report of a patient diagnosed with E-GIST primary of the liver, which was indicated a cytoreductive surgery and adjuvant therapy with imatinib. CONCLUSION: E-GIST primary of the liver is a rare conditional, the treatment is with systemic therapy and total resection surgery. However, a cytoreductive surgery will be necessary when a complete resection is no possible.

Calcified cavitating mesenteric lymph node syndrome: a rare complication of celiac disease.

A 47-year-old female presented with a lengthy history of dyspeptic symptoms, weight loss, and occasional diarrhea. A computed tomography (CT) scan showed several mesenteric nodular lesions, with peripheral calcifications, inversion of the fold pattern of the small intestine loops and an atrophic spleen.

Pancreatic collision tumor: mucinous cystadenoma and celar cell renal cell carcinoma metastasis

We present a clinical, radiological, surgical, and pathological correlation case of a 49-year-old woman with a prior nephrectomy due to a clear cell renal cell carcinoma, who was then diagnosed with a multilocular cystic lesion in the pancreatic tail after a routine ultrasound. Computed tomography and magnetic resonance cholangiopancreatography showed a multilocular cystic lesion with a hypervascular wall nodule in the pancreas. The patient underwent a distal pancreatectomy and had a final diagnosis of pancreatic mucinous cystadenoma with an associated component of clear cell renal cell carcinoma (collision tumor of the pancreas). (AU)

Late recurrence of low-grade serous carcinoma of the ovary mimicking colorectal neoplasia

A case report (images in medicine) of late recurrence of low grade serous carcinoma of the ovary mimicking colorectal neoplasia.

Gallbladder protrusion through the groin region-a very unusual femoral hernia.

Groin hernias are among the oldest recorded afflictions of mankind. Most of them protrude through the inguinal canal, and only a few through the femoral canal. Usually, they are present as a painful lump in the groin region, and their complications arise if they become incarcerated or strangulated. Incarcerated hernias may contain a variety of contents, such as the omentum, small bowel, colon, bladder, appendix, stomach, or ovary as previously described. Usually, the history and a physical examination are sufficient to make the diagnosis. However, the wide use of CT has become an effective instrument to identify the contents of hernias and has helped surgeons program the best management. This article reports, for the first time, the case of an 81-year-old female with an incarcerated femoral hernia that contains the gallbladder.

Angiotensin-converting enzyme inhibitors-induced angioedema of the small bowel mimicking postoperative complication.

Angioedema of the small bowel (ASB) is an extremely rare side effect of the angiotensin-converting enzyme inhibitors (ACEI). We present a case of ACEI-induced ASB mimicking postoperative complication. The diagnosis of ACEI-induced ASB should be considered in patients using these drugs and presenting sudden gastrointestinal symptoms and thickening of small bowel not attributable to other diseases.