The Role of Imaging for GI Bleeding: ACG and SAR Consensus Recommendations.

Gastrointestinal (GI) bleeding is the most common GI diagnosis leading to hospitalization within the United States. Prompt diagnosis and treatment of GI bleeding is critical to improving patient outcomes and reducing high health care utilization and costs. Radiologic techniques including CT angiography, catheter angiography, CT enterography, MR enterography, nuclear medicine red blood cell scan, and technetium-99m pertechnetate scintigraphy (Meckel scan) are frequently used to evaluate patients with GI bleeding and are complementary to GI endoscopy. However, multiple management guidelines exist, which differ in the recommended utilization of these radiologic examinations. This variability can lead to confusion as to how these tests should be used in the evaluation of GI bleeding. In this document, a panel of experts from the American College of Gastroenterology and Society of Abdominal Radiology provide a review of the radiologic examinations used to evaluate for GI bleeding including nomenclature, technique, performance, advantages, and limitations. A comparison of advantages and limitations relative to endoscopic examinations is also included. Finally, consensus statements and recommendations on technical parameters and utilization of radiologic techniques for GI bleeding are provided. © Radiological Society of North America and the American College of Gastroenterology, 2024. Supplemental material is available for this article. This article is being published concurrently in American Journal of Gastroenterology and Radiology. The articles are identical except for minor stylistic and spelling differences in keeping with each journal's style. Citations from either journal can be used when citing this article. See also the editorial by Lockhart in this issue.

Infantile/Capillary Hemangioma of the Uterine Corpus: A Rare Cause of Abnormal Genital Bleeding.

BACKGROUND: Infantile hemangiomas are vascular anomalies. However, they rarely cause genital bleeding. Here, we present the case of a young female with an endocavitary hemangioma who presented with abnormal uterine bleeding (AUB). CASE: The patient was an 8-year-old female with genital bleeding. Transabdominal pelvic ultrasound showed a 20-mm highly vascularized focal intrauterine endocavitary lesion. Vascular computerized tomography excluded vascular anomalies. Magnetic resonance imaging suggested a hemangioma. Minimally invasive open surgery was performed to remove the lesion. Subsequent pathology analyses confirmed an infantile/capillary hemangioma. CONCLUSIONS: Infantile hemangiomas are vascular anomalies that should be considered potential causes of AUB in early puberty. The study of these cases should include pelvic ultrasound and vascular magnetic resonance imaging. Experienced surgeons can successfully accomplish fertility-sparing surgical procedures. SUMMARY: We describe an unusual case of peripubertal AUB caused by an endocavitary capillary hemangioma. Management included fertility-sparing surgery and the complete resolution of symptoms.

Discriminative Capacity of CT Volumetry to Identify Autonomous Cortisol Secretion in Incidental Adrenal Adenomas.

CONTEXT: Incidentally discovered adrenal adenomas are common. Assessment for possible autonomous cortisol excess (ACS) is warranted for all adrenal adenomas, given the association with increased cardiometabolic disease. OBJECTIVE: To evaluate the discriminatory capacity of 3-dimensional volumetry on computed tomography (CT) to identify ACS. METHODS: Two radiologists, blinded to hormonal levels, prospectively analyzed CT images of 149 adult patients with unilateral, incidentally discovered, adrenal adenomas. Diameter and volumetry of the adenoma, volumetry of the contralateral adrenal gland, and the adenoma volume-to-contralateral gland volume (AV/CV) ratio were measured. ACS was defined as cortisol ≥ 1.8 mcg/dL after 1-mg dexamethasone suppression test (DST) and a morning ACTH ≤ 15. pg/mL. RESULTS: We observed that ACS was diagnosed in 35 (23.4%) patients. Cortisol post-DST was positively correlated with adenoma diameter and volume, and inversely correlated with contralateral adrenal gland volume. Cortisol post-DST was positively correlated with the AV/CV ratio (r = 0.46, P < 0.001) and ACTH was inversely correlated (r = -0.28, P < 0.001). The AV/CV ratio displayed the highest odds ratio (1.40; 95% CI, 1.18-1.65) and area under curve (0.91; 95% CI, 0.86-0.96) for predicting ACS. An AV/CV ratio ≥ 1 (48% of the cohort) had a sensitivity of 97% and a specificity of 70% to identify ACS. CONCLUSION: CT volumetry of adrenal adenomas and contralateral adrenal glands has a high discriminatory capacity to identify ACS. The combination of this simple and low-cost radiological phenotyping can supplement biochemical testing to substantially improve the identification of ACS.

Follow-up of gallbladder polyps in a high-risk population of gallbladder cancer: a cohort study and multivariate survival competing risk analysis.

BACKGROUND: The risk of neoplasia in gallbladder polyps seems to be low, but the evidence from populations at high-risk of gallbladder cancer is limited. We aimed to estimate the risk and to identify the factors associated with neoplastic polyps in a high-risk Hispanic population. METHODS: A retrospective cohort was recruited between January 2010 and December 2019 at a Chilean university center. Multivariate survival analyses were conducted. Fine-Gray models were fitted to account for competing risks. Covariate adjustment was conducted using propensity scores. The main outcome was the development of gallbladder adenomas or adenocarcinoma. RESULTS: Overall, 748 patients were included, 59.6% underwent cholecystectomy. The median follow-up of patients not subjected to cholecystectomy was 54.7 months (12-128.6 months). Seventeen patients (2.27%) developed the outcome. After adjustment by age, sex, intralesional blood flow, lithiasis and gallbladder wall thickening, only polyp size (≥10 mm, adjusted-HR: 15.01, 95%CI: 5.4-48.2) and number of polyps (≥3 polyps, adjusted-HR: 0.11, 95%CI: 0.01-0.55) were associated with neoplasia. CONCLUSION: In a Hispanic population at high-risk for gallbladder cancer, gallbladder polyps seem to have a low risk of neoplasia. Polyp size was the main risk factor, while having multiple polyps was associated with an underlying benign condition.

Management of gastrointestinal bleeding: Society of Abdominal Radiology (SAR) Institutional Survey.

Despite guidelines developed to standardize the diagnosis and management of gastrointestinal (GI) bleeding, significant variability remains in recommendations and practice. The purpose of this survey was to obtain information on practice patterns for the evaluation of overt lower GI bleeding (LGIB) and suspected small bowel bleeding. A 34-question electronic survey was sent to all Society of Abdominal Radiology (SAR) members. Responses were received from 52 unique institutions (40 from the United States). Only 26 (50%) utilize LGIB management guidelines. 32 (62%) use CT angiography (CTA) for initial evaluation in unstable patients. In stable patients with suspected LGIB, CTA is the preferred initial exam at 21 (40%) versus colonoscopy at 24 (46%) institutions. CTA use increases after hours for both unstable (n = 32 vs. 35, 62% vs. 67%) and stable patients (n = 21 vs. 27, 40% vs 52%). CTA is required before conventional angiography for stable (n = 36, 69%) and unstable (n = 15, 29%) patients. 38 (73%) institutions obtain two post-contrast phases for CTA. 49 (94%) institutions perform CT enterography (CTE) for occult small bowel bleeding with capsule endoscopy (n = 26, 50%) and CTE (n = 21, 40%) being the initial test performed. 35 (67%) institutions perform multiphase CTE for occult small bowel bleeding. In summary, stable and unstable patients with overt lower GI are frequently imaged with CTA, while CTE is frequently performed for suspected occult small bowel bleeding.

Consenso chileno de diagnóstico y manejo de neoplasias quísticas pancreáticas. Club de páncreas Chile-SCHGE

Pancreatic cystic neoplasms (PCN) are frequently detected on abdominal images performed for non-pancreatic indications. Their prevalence in asymptomatic population ranges from 2.7 to 24.8%, and increases with age. There are several types of pancreatic cysts. Some may contain cancer or have malignant potential, such as mucinous cystic neoplasms, including mucinous cystadenoma (MCN) and intraductal papillary mucinous neoplasms (IPMN). In contrast, others are benign, such as serous cystadenoma (SCA). However, even those cysts with malignant potential rarely progress to cancer. Currently, the only treatment for pancreatic cysts is surgery, which is associated with high morbidity and occasional mortality. The Board of the Chilean Pancreas Club of the Chilean Gastroenterology Society developed the first Chilean multidisciplinary consensus for diagnosis, management, and surveillance of PCN. Thirty experts were invited and answered 21 statements with five possible alternatives: 1) fully agree; 2) partially agree; 3) undecided; 4) disagree and 5) strongly disagree. A consensus was adopted when at least 80% of the sum of the answers "fully agree" and "partially agree" was reached. The consensus was approved by the Board of Directors of the Chilean Pancreas Club for publication.

Gastrointestinal Bleeding at CT Angiography and CT Enterography: Imaging Atlas and Glossary of Terms.

Gastrointestinal (GI) bleeding is a common potentially life-threatening medical condition frequently requiring multidisciplinary collaboration to reach the proper diagnosis and guide management. GI bleeding can be overt (eg, visible hemorrhage such as hematemesis, hematochezia, or melena) or occult (eg, positive fecal occult blood test or iron deficiency anemia). Upper GI bleeding, which originates proximal to the ligament of Treitz, is more common than lower GI bleeding, which arises distal to the ligament of Treitz. Small bowel bleeding accounts for 5-10% of GI bleeding cases commonly manifesting as obscure GI bleeding, where the source remains unknown after complete GI tract endoscopic and imaging evaluation. CT can aid in identifying the location and cause of bleeding and is an important complementary tool to endoscopy, nuclear medicine, and angiography in evaluating patients with GI bleeding. For radiologists, interpreting CT scans in patients with GI bleeding can be challenging owing to the large number of images and the diverse potential causes of bleeding. The purpose of this pictorial review by the Society of Abdominal Radiology GI Bleeding Disease-Focused Panel is to provide a practical resource for radiologists interpreting GI bleeding CT studies that reviews the proper GI bleeding terminology, the most common causes of GI bleeding, key patient history and risk factors, the optimal CT imaging technique, and guidelines for case interpretation and illustrates many common causes of GI bleeding. A CT reporting template is included to help generate radiology reports that can add value to patient care. An invited commentary by Al Hawary is available online. Online supplemental material is available for this article. ©RSNA, 2021.

Clinical Presentation and Perioperative Management of Pheochromocytomas and Paragangliomas: A 4-Decade Experience.

PURPOSE: Latin American reports on pheochromocytomas and paragangliomas (PPGLs) are scarce. Recent studies demonstrate changes in clinical presentation and management of these patients. Herein, we assessed the main characteristics of PPGL patients in our academic center over the past 4 decades. METHODS: Demographic, clinical, biochemical, and perioperative data from 105 PPGL patients were retrospectively and prospectively collected over the 1980-2019 period. Data were organized into 4 periods by decade. RESULTS: Age at diagnosis, gender, tumor size and percentage of bilaterality, percentage of paragangliomas, and metastases remained stable across the 4 decades. The proportion of genetic testing and incidentalomas increased in recent decades (all P < 0.001). Therefore, we compared PPGLs diagnosed as incidentalomas (36%) with those clinically suspected (64%). Incidentalomas had fewer adrenergic symptoms (38 vs. 62%; P < 0.001) and lower rates of hypertension (64% vs. 80%; P = 0.01) and hypertensive crisis (28% vs. 44%; P = 0.02); also, they had lower functionality (79% vs. 100%; P = 0.01) and lower catecholamines levels (8.4-fold vs. 12.5-fold above upper cutoffs; P = 0.04). Regarding management of all PPGLs over the decades, we observed significant increases in both perioperative doxazosin dose (P = 0.003) and laparoscopic approach rates (P < 0.001), along with a decrease in the length of hospital stays (P = 0.007). CONCLUSIONS: We observed a change in the clinical presentation of PPGL in recent decades, with a marked increase in incidental cases and milder symptoms. The implementation of a multidisciplinary program for adrenal disorders in our institution has translated into more timely diagnoses, more genetic testing, and improvements in perioperative management.

COVID-19-Associated Mold Infection in Critically Ill Patients, Chile.

Patients with severe coronavirus disease (COVID-19) may have COVID-19-associated invasive mold infection (CAIMI) develop. We report 16 cases of CAIMI among 146 nonimmunocompromised patients with severe COVID-19 at an academic hospital in Santiago, Chile. These rates correspond to a CAIMI incidence of 11%; the mortality rate for these patients was 31.2%.

Early versus deferred anti-SARS-CoV-2 convalescent plasma in patients admitted for COVID-19: A randomized phase II clinical trial.

BACKGROUND: Convalescent plasma (CP), despite limited evidence on its efficacy, is being widely used as a compassionate therapy for hospitalized patients with COVID-19. We aimed to evaluate the efficacy and safety of early CP therapy in COVID-19 progression. METHODS AND FINDINGS: The study was an open-label, single-center randomized clinical trial performed in an academic medical center in Santiago, Chile, from May 10, 2020, to July 18, 2020, with final follow-up until August 17, 2020. The trial included patients hospitalized within the first 7 days of COVID-19 symptom onset, presenting risk factors for illness progression and not on mechanical ventilation. The intervention consisted of immediate CP (early plasma group) versus no CP unless developing prespecified criteria of deterioration (deferred plasma group). Additional standard treatment was allowed in both arms. The primary outcome was a composite of mechanical ventilation, hospitalization for >14 days, or death. The key secondary outcomes included time to respiratory failure, days of mechanical ventilation, hospital length of stay, mortality at 30 days, and SARS-CoV-2 real-time PCR clearance rate. Of 58 randomized patients (mean age, 65.8 years; 50% male), 57 (98.3%) completed the trial. A total of 13 (43.3%) participants from the deferred group received plasma based on clinical aggravation. We failed to find benefit in the primary outcome (32.1% versus 33.3%, odds ratio [OR] 0.95, 95% CI 0.32-2.84, p > 0.999) in the early versus deferred CP group. The in-hospital mortality rate was 17.9% versus 6.7% (OR 3.04, 95% CI 0.54-17.17 p = 0.246), mechanical ventilation 17.9% versus 6.7% (OR 3.04, 95% CI 0.54-17.17, p = 0.246), and prolonged hospitalization 21.4% versus 30.0% (OR 0.64, 95% CI, 0.19-2.10, p = 0.554) in the early versus deferred CP group, respectively. The viral clearance rate on day 3 (26% versus 8%, p = 0.204) and day 7 (38% versus 19%, p = 0.374) did not differ between groups. Two patients experienced serious adverse events within 6 hours after plasma transfusion. The main limitation of this study is the lack of statistical power to detect a smaller but clinically relevant therapeutic effect of CP, as well as not having confirmed neutralizing antibodies in donor before plasma infusion. CONCLUSIONS: In the present study, we failed to find evidence of benefit in mortality, length of hospitalization, or mechanical ventilation requirement by immediate addition of CP therapy in the early stages of COVID-19 compared to its use only in case of patient deterioration. TRIAL REGISTRATION: NCT04375098.

[Chilean consensus on diagnosis and management of pancreatic cystic neoplasms]. / Consenso chileno de diagnóstico y manejo de neoplasias quísticas pancreáticas. Club de páncreas Chile-SCHGE.

Pancreatic cystic neoplasms (PCN) are frequently detected on abdominal images performed for non-pancreatic indications. Their prevalence in asymptomatic population ranges from 2.7 to 24.8%, and increases with age. There are several types of pancreatic cysts. Some may contain cancer or have malignant potential, such as mucinous cystic neoplasms, including mucinous cystadenoma (MCN) and intraductal papillary mucinous neoplasms (IPMN). In contrast, others are benign, such as serous cystadenoma (SCA). However, even those cysts with malignant potential rarely progress to cancer. Currently, the only treatment for pancreatic cysts is surgery, which is associated with high morbidity and occasional mortality. The Board of the Chilean Pancreas Club of the Chilean Gastroenterology Society developed the first Chilean multidisciplinary consensus for diagnosis, management, and surveillance of PCN. Thirty experts were invited and answered 21 statements with five possible alternatives: 1) fully agree; 2) partially agree; 3) undecided; 4) disagree and 5) strongly disagree. A consensus was adopted when at least 80% of the sum of the answers "fully agree" and "partially agree" was reached. The consensus was approved by the Board of Directors of the Chilean Pancreas Club for publication.

Experiencia inicial con el uso de trombolisis local asistida por catéter de ultrasonido terapeútico (EKOSonic®) en pacientes con tromboembolismo pulmonar agudo / Use of local thrombolysis associated to therapeutic ultrasound (EKOSonic) in patients with acute pulmonary thromboembolism: a preliminary experience

INTRODUCCIÓN: El tromboembolismo pulmonar (TEP) es una causa frecuente de morbimortalidad cardiovascular y la trombolisis local asistida por ultrasonido (TLUS) constituye una alternativa de tratamiento validada para pacientes de riesgo intermedio. No existen reportes del uso de esta tecnología en el ámbito nacional. MÉTODOS: Análisis descriptivo, prospectivo, sobre una serie de pacientes con TEP agudo, de riesgo intermedio, tratados en forma percutánea con trombolisis local asistida por catéter de ultrasonido terapéutico (EKOSonic®). Se analiza la eficacia y seguridad del procedimiento mediante variables clínicas, hemodinámicas y radiológicas, así como desenlaces intra hospitalarios. Se reporta, además, el seguimiento a 30 días. RESULTADOS: Entre Junio de 2019 y Marzo de 2020, 4 pacientes con TEP de riesgo intermedio fueron tratados con esta técnica. El score PESI (Pulmonary Embolism severity Index) promedio era de 79,5 + 6,1. Dos pacientes requirieron la instalación de 2 catéteres para efectuar terapia bilateral. Se observó una reducción promedio en la presión sistólica de arteria pulmonar de 29% y en 3 de los 4 enfermos se logró revertir la dilatación ventricular derecha presente al ingreso. La carga trombótica se redujo en un 20% medido por score CTOI. No hubo complicaciones intraoperatorias ni intrahospitalarias asociadas a la intervención. CONCLUSIONES: En esta serie inicial, el uso de la trombolisis local con catéter de ultrasonido en pacientes con TEP de riesgo intermedio fue segura y efectiva. Los resultados perioperatorios y a 30 días fueron comparables a los descritos en experiencias internacionales; sin embargo, aún se requieren de estudios con mayor número de pacientes para confirmar los beneficios de esta técnica en nuestro medio.

BACKGROUND: Pulmonary thromboembolism (PE) is a common cause of cardiovascular morbidity and mortality and local ultrasound-assisted thrombolysis (USAT) is a validated alternative treatment for intermediate-risk patients. There are no reports on the use of this technology in our country. METHODS: Prospective series of patients with acute, intermediate-risk PE treated percutaneously with therapeutic ultrasound catheter-assisted local thrombolysis (EKOSonic®). The efficacy and safety of the procedure were analyzed using clinical, hemodynamic, and radiological variables, as well as intra-hospital outcomes. The 30-day follow-up is also reported. RESULTS: between June 2019 and March 2020, a total of 4 patients with intermediate-risk PE were treated with this technique. The average PESI score was 79.5 + 6.1. Two out of 4 patients required the use of 2 catheters for bilateral therapy. The average reduction in systolic pressure of the pulmonary artery was 29% and 3 patients reversed the right ventricular dilation present at admission. The thrombotic burden was reduced by 20% according to the Computed Tomography Obstruction Index (CTOI). There were no intraoperative or in hospital complications associated with the intervention. CONCLUSION: In this initial series, the use of local thrombolysis with an ultrasound catheter in patients with intermediate-risk PE was safe and effective. The perioperative and 30-day outcomes were similar to those previously reported in international series. However, larger randomized trials are needed to confirm this potential benefit.

Medios de contraste intravascular en tomografía computada y resonancia magnética: lo que el clínico necesita saber / Intravascular contrast media in computed tomography and magnetic resonance imaging: what the clinician needs to know

Introducción: los medios de contraste en radiología se utilizan para mejorar la visibilidad de los tejidos normales y patológicos, lo que permite distinguirlos entre sí mediante la modificación de las características de imagen de los tejidos. Permite no solo una mejor evaluación morfológica de las lesiones, sino también una evaluación cinética funcional y de contraste. Objetivos: presentar una revisión actualizada sobre los medios de contraste intravascular en radiología, con énfasis en los conceptos que el médico clínico no radiólogo debe tener presente al momento de su indicación. Métodos: se realizó una revisión bibliográfica de literatura radiológica relevante sobre medios de contraste intravascular: clasificación, indicaciones, contraindicaciones y precauciones que debe adoptar el médico clínico. Resultados: aunque los medios de contraste en radiología tienen un excelente perfil de seguridad, su uso no está exento de riesgos y debe basarse en criterios apropiados después de una evaluación clínica exhaustiva, ponderando riesgos y beneficios para cada paciente individual. Conclusión: la comunicación entre médicos tratantes, nefrólogos y radiólogos es funda-mental para evaluar casos clínicos complejos o que requieran consideraciones especiales al momento de indicar la administración de un medio de contraste intravascular.

Introduction: Imaging contrast media are used to enhance the visibility of normal and pathologic tissues, allowing distinction of one another by modifying tissue imaging characteristics. This allows both enhanced morphologic assessment of lesions and also contrast kinetics evaluation. Objectives: To present an updated review on intravascular imaging contrast media. Emphasis will be put on useful concepts that general physicians must take into account when indicating contrast-enhanced imaging studies.Methodology: A bibliographic review of relevant imaging literature on intravascular contrast media was performed: classification, appropriate indications, contraindications, and tips for proper use by the general physician. Results: Although imaging contrast media have an excellent safety profile, its use is not risk-free and must be based on appropriateness criteria applied after a thorough clinical evaluation, balancing the risks and benefits for each patient. In particular, intravascular contrast media, such as those based on iodine for computed tomography and gadolinium chelates for magnetic resonance imaging, must be used with caution. Conclusion: Effective communication between radiologists and referring physicians is key in the evaluation of complex cases that require protocol adjustments when considering the use of intravascular contrast media for imaging studies.

Biopsia percutánea core con aguja gruesa guiada por tomografía computada en lesiones retroperitoneales: Experiencia de 10 años / CT-guided core biopsy for retroperitoneal lesions. Experience in 136 procedures

Background: CT-guided core biopsy is a widely used diagnostic technique for retroperitoneal lesions. Aim: To evaluate the diagnostic yield and safety of this procedure. Material and Methods: Review of medical records of 136 patients aged 57 ± 16 years (55% males) subjected to core biopsies performed between 2006 and 2016. Procedure images, biopsy reports and patients' medical charts were reviewed. Diagnostic yield was calculated in those patients whose final diagnosis was confirmed using strict criteria for malignancy. Results: A final diagnosis was confirmed in 122/136 patients. Of these, 110 had malignant lesions. The sensitivity and global accuracy of the procedure for malignancy were 93%. In only 4 of 13 benign lesions (31%), a specific diagnosis was obtained with the biopsy. Only minor complications were reported (6 small, self-contained hematomas). There were no major complications. Conclusions: CT-guided core biopsy of retroperitoneal lesions is a safe procedure, with an excellent diagnostic yield.

Society of abdominal radiology gastrointestinal bleeding disease-focused panel consensus recommendations for CTA technical parameters in the evaluation of acute overt gastrointestinal bleeding.

PURPOSE: To formulate consensus recommendations for CT angiography technical parameters used to evaluate overt gastrointestinal (GI) bleeding. METHODS: An electronic questionnaire consisting of 17 questions was sent to a panel of 16 radiologists with expertise on the imaging of GI bleeding from the Society of Abdominal Radiology GI Bleeding disease-focused panel to obtain consensus agreement on issues related to CTA technical parameters for imaging overt GI bleeding. A multi-round Delphi method of voting was performed to obtain consensus which was defined as ≥ 80% agreement. RESULTS: Consensus agreement was reached in 15/17 (89%) of the questions including the technique for the administration of IV contrast, the number of phases, scan timing, and image reconstruction. CONCLUSIONS: A panel of experts on the imaging of GI bleeding from the Society of Abdominal Radiology was able to reach consensus on the majority of technical parameters used for CTA of overt GI bleeding. These recommendations should improve the quality of patient care by adopting these minimal technical requirements for optimal exam performance and lead to less variation in the performance of these exams which will facilitate collecting and comparing published data from different centers. These recommendations will need revisions as additional scientific data become available.

[CT-guided core biopsy for retroperitoneal lesions. Experience in 136 procedures]. / Biopsia percutánea core con aguja gruesa guiada por tomografía computada en lesiones retroperitoneales: Experiencia de 10 años.

BACKGROUND: CT-guided core biopsy is a widely used diagnostic technique for retroperitoneal lesions. AIM: To evaluate the diagnostic yield and safety of this procedure. MATERIAL AND METHODS: Review of medical records of 136 patients aged 57 ± 16 years (55% males) subjected to core biopsies performed between 2006 and 2016. Procedure images, biopsy reports and patients' medical charts were reviewed. Diagnostic yield was calculated in those patients whose final diagnosis was confirmed using strict criteria for malignancy. RESULTS: A final diagnosis was confirmed in 122/136 patients. Of these, 110 had malignant lesions. The sensitivity and global accuracy of the procedure for malignancy were 93%. In only 4 of 13 benign lesions (31%), a specific diagnosis was obtained with the biopsy. Only minor complications were reported (6 small, self-contained hematomas). There were no major complications. CONCLUSIONS: CT-guided core biopsy of retroperitoneal lesions is a safe procedure, with an excellent diagnostic yield.

¿Como optimizar el diagnóstico funcional de los incidentalomas suprrarenales? Importancia de un estudio protocolizado / How to optimize the functional diagnosis of suprarenal incidenta- lomas? Importance of a protocolized study

Adrenal incidentalomas are an increasingly common pathology. Although historically they have been considered largely non-functioning, recent evidence suggests that the usually performed study is incomplete and/or not sensitive enough. In the last decade the clinical spectrum of adrenal hypercortisolism has expanded considerably, including milder cases which are also associated with cardiovascular morbidity and even mortality. Furthermore, primary aldosteronism has also expanded beyond the classic phenotype with advanced vascular damage, resistant hypertension and hypokalemia, currently including asymptomatic, normotensive and normokalemic patients. For this reason, a correct protocolized study is essential in all adrenal incidentalomas, including a precise radiological characterization, as well as a systematic hormonal evaluation using more sensitive cut points. The findings of this workup are relevant, because they allow a more individualized approach to the medical and surgical management of these patients.

Los incidentalomas suprarrenales son una patología cada vez más frecuente. Si bien históricamente han sido considerados no funcionantes en su gran mayoría, evidencia reciente sugiere que el estudio habitual es incompleto y/o poco sensible. En la última década el espectro clínico del hipercortisolismo de origen adrenal se ha ampliado de forma considerable, incluyendo casos leves que también se asocian a morbilidad cardiovascular e incluso mortalidad. Por otro lado, el hiperaldosteronismo primario también ha expandido su fenotipo más allá del clásicamente descrito con daño vascular avanzado, hipertensión resistente e hipokalemia, abarcando en la actualidad a pacientes asintomáticos, normotensos y normokalemicos. Por esta razón es imprescindible un correcto estudio protocolizado en todo incidentaloma suprarrenal, incluyendo una precisa caracterización radiológica, así como una evaluación hormonal sistemática utilizando puntos de corte más sensibles. Los hallazgos de este estudio son relevantes, pues permiten guiar de forma más individualizada el manejo médico y quirúrgico de estos pacientes.

The boundaries of mild chronic obstructive pulmonary disease (COPD): design of the searching clinical COPD onset (SOON) study.

INTRODUCTION: Clinical onset of chronic obstructive pulmonary disease (COPD) is the point at which the disease is first identifiable by physicians. It is a poorly defined stage which seems to include both mild spirometric and non-spirometric disease, and could be described as early grade COPD, for practical purposes. While dyspnoea; chronic bronchitis and CT imaging evidence of emphysema and airway disease may be present very early, the lone significance of dyspnoea, the most relevant symptom in COPD in identifying these individuals, has been scarcely assessed.The Searching Clinical COPD Onset (SOON) Study was designed primarily to detect clinical, physiological and structural differences between dyspnoeic and non-dyspnoeic individuals with early grade COPD. It is hypothesised that presence of dyspnoea in early disease may identify a subtype of individuals with reduced exercise capacity, notwithstanding of their spirometry results. In addition, dyspnoeic individuals will share worse quality of life, lower physical activity, greater lung hyperinflation greater emphysema and airway thickness and reduced peripheral muscle mass than their non-dyspnoeic counterpart. METHODS AND ANALYSIS: SOON is a monocentric study, with a cross sectional design aimed at obtaining representative samples of current or ex-smoker-adults aged ≥45 and ≤80 years. Two hundred and forty participants will be enrolled into four strata, according to normal spirometry or mild spirometric obstruction and presence or not of dyspnoea modified Medical Research Council score ≥1. The primary outcome will be the difference between dyspnoeic and non-dyspnoeic individuals on the 6-min walk test performance, regardless of their spirometry results. To account for the confounding effect of heart failure on dyspnoea, stress echocardiography will be also performed. Secondary outcomes will include clinical (quality of life, physical activity), physiological (exercise testing) and structural characteristics (emphysema, airway disease and peripheral muscle mass by CT imaging). ETHICS AND DISSEMINATION: The Institutional Ethics Committee from Pontificia Universidad Católica de Chile has approved the study protocol and signed informed consent will be obtained from all participants. The findings of the trial will be disseminated through relevant peer-reviewed journals and international conference presentations. TRIAL REGISTRATION NUMBER: NCT03026439.

Imaging of Hydatid Disease with a Focus on Extrahepatic Involvement.

Hydatid disease (HD) is a parasitic infection caused by the larvae of a tapeworm that is endemic to many regions around the world-South America, Africa, and Asia, in particular. Humans are infected as intermediate hosts in the parasite's life cycle; thus, HD can be seen in persons living in areas where animal husbandry is practiced. However, owing to the varied patterns of migration and immigration during the past several decades, HD can be diagnosed in individuals living anywhere. The liver is the most common organ involved, with hepatic HD accounting for the majority of published cases. However, HD can affect multiple organs and tissues other than the liver, including the spleen, kidneys, lungs, heart, peritoneum, muscles, and brain. Knowledge of the route of spread, clinical findings at presentation, and possible complications involving each extrahepatic location can be useful for the radiologist when evaluating imaging findings in patients suspected of having HD. The ultrasonographic, computed tomographic, and magnetic resonance imaging findings of extrahepatic hydatid lesions frequently simulate those of hepatic HD, as long as rupture, bleeding, and/or superimposed bacterial infection has not occurred. Specific features of HD seen at different extrahepatic sites can help tailor the diagnosis. The differential diagnoses that can mimic HD at every nonhepatic location should be considered, as many of these entities are common, especially in nonendemic areas. ©RSNA, 2017.