Multidisciplinary retroperitoneal and pelvic soft-tissue sarcoma case conferences: the added value that radiologists can provide.

Clinical Vignette: A 50-year-old woman presents to the emergency department with increasing abdominal pain. Abdominal computed tomography imaging reveals an expanded inferior vena cava-filling defect that is suspicious for a retroperitoneal sarcoma, possibly a primary leiomyosarcoma of the inferior vena cava. The surgery team discusses the case with the radiologist, and all agree that there are multiple challenges with obtaining a tissue diagnosis and determining resectability. Thus, it is decided that this patient should be discussed at a multidisciplinary case conference. In the present article, we feature a case-based scenario focusing on the role of the radiologist in this type of multidisciplinary team.

Diagnostic accuracy of ¹8F-FDG PET/CT for detection of advanced colorectal adenoma.

AIM: To determine the accuracy of 2-[(18)F]-fluoro-2-deoxy-d-glucose (FDG) positron-emission tomography (PET) in the detection of advanced colorectal adenomas. MATERIALS AND METHODS: In this retrospective study, patient consent was waived by the institutional review board. Combined FDG whole-body PET and computed tomography (CT) images (2000-2009) were re-read and compared with reports of complete colonoscopy performed up to 1 year after the PET examination. One or more areas of focal colonic uptake greater than the background indicated a positive PET result, irrespective of standardized uptake value (SUV). Lesion and patient-level measures of PET accuracy with their 95% confidence intervals (CI) were calculated. RESULTS: One hundred and eighty patients undergoing colonoscopy with or without biopsy underwent PET within 1 year prior to colonoscopy. There were 92 women and 88 men (mean age 63.3 years). Indications for PET were extent of disease and treatment response in all cases. Patients had non-colorectal cancer (n = 160) or colon cancer (n = 20). One hundred and fourteen FDG-avid lesions were present. In 33, there was no colonoscopic correlate. Two hundred and fifty-eight biopsies revealed tubular adenomas (n = 91, one with intra-mucosal cancer), tubulovillous adenomas (n = 28), adenocarcinoma (n = 37), inflammation (n = 22), hyperplastic polyps (n = 54), serrated adenoma (n = 5), metastatic disease (n = 5), normal/benign mucosa or submucosal benign tumors (n = 13) or miscellaneous (n = 3). Per-lesion performance of PET showed a sensitivity of 38% (95% CI: 31-46; 64/167) for all adenomas and carcinomas and 58% (95% CI: 49-67; 57/98) for lesions ≥ 10 mm. At the patient level, for all adenomas and carcinomas the sensitivity was 54% (95% CI: 44-63; 61/113), specificity 100% (pre-defined), positive predictive value (PPV) 100% (pre-defined), and negative predictive value (NPV) 56% (95% CI: 47-65; 67/119). For patients with advanced adenoma, PET sensitivity was 49% (95% CI: 35-63; 26/53) specificity, 100%, PPV 100% and NPV 82% (95% CI: 76-88; 127/154). Five of 37 adenocarcinomas were not detected, one of which was mucinous at histology. CONCLUSION: FDG PET detected most cancers, but only identified one-half of patients harbouring advanced adenomas. Based on the data, PET cannot be relied upon to accurately identify patients with advanced adenoma.

Genomic and clinical characterization of a familial GIST kindred intolerant to imatinib.

Familial gastrointestinal stromal tumors (GIST) are rare. We present a kindred with multiple family members affected with multifocal GIST who underwent whole genome sequencing of the germline and tumor. Affected individuals with GIST harbored a germline variant found within exon 13 of the KIT gene (c.1965T>G; p.Asn655Lys, p.N655K) and a variant in the MSR1 gene (c.877 C > T; p.Arg293*, pR293X). Multifocal GISTs in the proband and her mother were treated with preoperative imatinib, which resulted in severe intolerance. The clinical features of multifocal GIST, cutaneous mastocytosis, allergies, and gut motility disorders seen in the affected individuals may represent manifestations of the multifunctional roles of KIT in interstitial cells of Cajal or mast cells and/or may be suggestive of additional molecular pathways which can contribute to tumorigenesis.

Biliary dilatation in the presence of a periampullary duodenal diverticulum.

OBJECTIVE: Periampullary diverticulum (PAD) often presents as an incidental CT finding. Its significance and its effect on biliary dilation are unclear. The aim of our study was to determine if the presence of a PAD is associated with abnormal dilation of the common bile duct (CBD). METHODS: Patients with PAD were retrospectively identified from the radiology database from November 2011 to November 2012 and those with known pancreaticobiliary pathology were excluded, except patients with cholelithiasis and prior cholecystectomy. A total of 150 patients with PAD were selected as well as a control group of 150 patients with no PAD. Data with respect to demographics, PAD size and location, ductal diameter, previous cholecystectomy and liver function tests were collected. To compare the groups, the Student's t-test and χ(2) analysis were used where appropriate. RESULTS: The male : female ratio was 1 : 1.2 with a median average of 71 years in the PAD group. There was no statistical difference in the CBD measurement (at the pre-ampulla and pancreatic head, and distal to confluence) between the PAD and control groups (4.8, 6.9 and 6.8 mm for the PAD group; 4.7, 6.8 and 6.4 mm for the control group; p = 0.5, 0.7 and 0.3). Also, no difference was observed in the right and left intrahepatic biliary ducts (2.7, 2.7 mm for the PAD group; 2.5, 2.6 mm for the control group; p = 0.2, 0.6). There was a significantly higher incidence of cholecystectomy history (23% vs 8.7%, p < 0.01) and cholelithiasis (22% vs 11%, p < 0.01) in the PAD group, and no difference in the liver function tests. Subgroup analysis of small vs large PAD (<20 mm, ≥20 mm) did not show a difference in the CBD and intrahepatic biliary duct measurements. When comparing cholecystectomy vs non-cholecystectomy groups, CBD measurements were significantly higher in the cholecystectomy group. CONCLUSION: Our study confirms that PAD on its own does not lead to abnormal CBD dilatation. However, increased incidence of cholelithiasis and cholecystectomy was noted in the presence of PAD. ADVANCES IN KNOWLEDGE: PAD on its own does not cause CBD dilatation.