CT Urography Findings of Upper Urinary Tract Carcinoma and Its Mimickers: A Pictorial Review.

Urothelial carcinoma (UC) is the fourth most frequent tumor in Western countries and upper tract urothelial carcinoma (UTUC), affecting pyelocaliceal cavities and ureter, accounts for 5-10% of all UCs. Computed tomography urography (CTU) is now considered the imaging modality of choice for diagnosis and staging of UTUC, guiding disease management. Although its specificity is very high, both benign and malignant diseases could mimic UTUCs and therefore have to be well-known to avoid misdiagnosis. We describe CTU findings of upper urinary tract carcinoma, features that influence disease management, and possible differential diagnosis.

The International Continence Society (ICS) report on the terminology for adult male lower urinary tract and pelvic floor symptoms and dysfunction.

INTRODUCTION: In the development of terminology of the lower urinary tract, due to its increasing complexity, the terminology for male lower urinary tract and pelvic floor symptoms and dysfunction needs to be updated using a male-specific approach and via a clinically-based consensus report. METHODS: This report combines the input of members of the Standardisation Committee of the International Continence Society (ICS) in a Working Group with recognized experts in the field, assisted by many external referees. Appropriate core clinical categories and a subclassification were developed to give a numeric coding to each definition. An extensive process of 22 rounds of internal and external review was developed to exhaustively examine each definition, with decision-making by collective opinion (consensus). RESULTS: A Terminology Report for male lower urinary tract and pelvic floor symptoms and dysfunction, encompassing around 390 separate definitions/descriptors, has been developed. It is clinically-based with the most common diagnoses defined. Clarity and user-friendliness have been key aims to make it interpretable by practitioners and trainees in all the different specialty groups involved in male lower urinary tract and pelvic floor dysfunction. Male-specific imaging (ultrasound, radiology, CT, and MRI) has been a major addition whilst appropriate figures have been included to supplement and help clarify the text. CONCLUSIONS: A consensus-based Terminology Report for male lower urinary tract and pelvic floor symptoms and dysfunction has been produced aimed at being a significant aid to clinical practice and a stimulus for research.

Metastatic upper tract urothelial carcinoma with nest-like features presenting as malignant pleural effusion.

Metastatic urothelial carcinoma is a rare cause of pleural effusions. We report a case of urothelial carcinoma of the upper urinary tract in an oldest-old male patient, a smoker, with situs inversus totalis, that presented uniquely with malignant pleural effusion at presentation without evidence of a primary tumor on imaging. Cytological smears of the massive left pleural effusion revealed epithelioid neoplastic cells arranged in short cords, small-to-large clusters, and raspberry-like morules, mimicking mesothelioma; cell block preparations highlighted the presence of tubules and nest-like structures. The tumor cells showed a high nuclear-to-cytoplasmic ratio, nuclear grooves, and mitotic figures. Cytomorphologic features coupled with the immunophenotype of neoplastic cells (p63, GATA3, and uroplakin II positive) allowed the diagnosis of metastatic urothelial carcinoma and a possible nested subtype. These findings were supported by a total body computed tomography (CT) showing no evidence of a mass in the bladder or elsewhere in the urinary tract but a concentric parietal thickening of the proximal left ureter, suggesting malignancy. To our knowledge, a malignant effusion as a primary manifestation of urothelial carcinoma with nest-like features originating in the upper urinary tract has never been described previously. Our case focuses on the value of cell block in the working-up of neoplastic effusions by revealing the architectural pattern of an uncommon malignancy and the correlation between cytopathology and imaging gross findings to reach an accurate diagnosis.

MR imaging of renal collecting system with gadoxetate disodium: feasibility for MR urography.

PURPOSE: To determine the feasibility of using gadoxetate disodium for MR urography. MATERIALS AND METHODS: We retrospectively reviewed 50 consecutive gadoxetate disodium-enhanced abdominal MRI examinations meeting inclusion criteria. For each examination, 30 min postcontrast hepatobiliary phase sequences were reviewed to assess bilateral collecting system segments, including upper pole, interpolar, and lower pole calyces; renal pelvis; and proximal one-third of ureter. Each segment was assessed for degree of opacification (none, <50%, ≥50%, complete) and susceptibility artifact (none, partial thin rim, thick/complete rim, total obscuration). Opacification and susceptibility scores were also calculated for each examination. RESULTS: The 50 reviewed examinations were performed on 46 patients (26 women, 20 men; mean age, 57 years) and included a total of 1000 segments. Of these, 808 (80.8%) were opacified completely, 103 (10.3%) were opacified ≥50%, 39 (3.9%) were opacified <50%, and 50 (5.0%) were not opacified. Of 1000 segments, no susceptibility artifact was present in 822 (82.2%), while a partial thin rim was present in 113 (11.3%), a thick/complete rim in 64 (6.4%) and total obscuration in 1 (0.1%). CONCLUSION: Gadoxetate disodium contrast produced a high degree of opacification of the proximal urinary collecting system with low incidence of susceptibility artifact; therefore, it is a feasible contrast agent for MR urography.

Implementing online position monitoring for prostate radiotherapy using an in-house position monitoring system: User experience and impact on workforce.

INTRODUCTION: To evaluate the feasibility of prostate intrafraction motion monitoring using the SeedTracker real-time image guidance system in order to improve targeting accuracy in prostate radiotherapy. METHODS: SeedTracker was used to monitor prostate gold fiducial seeds with kV x-ray imaging during radiotherapy in 30 patients. Feedback from radiation therapists was collected via the use of a user evaluation form. The impact on treatment time was established by using a record and verify system. The effective dose and a risk of exposure-induced cancer death (REID) were estimated for a 60-year-old patient when using the SeedTracker system. RESULTS: A total of 22 radiation therapists completed user evaluation forms. The time taken to prepare a reference data set for one patient varied with three (13.6%) radiation therapists taking less than 2 min, 10 (45.5%) between 2 and 4 min, eight (36.4%) between 4 and 6 min and one (4.5%) between 6 and 8 min. The useability of the SeedTracker system was reported as 'easy' by 21 (95.5%) radiation therapists and 'hard' by 1 (4.5%) radiation therapist. Mean treatment time changed from 6 to 7 min with prostate-only radiotherapy treatment and from 6.9 to 10.2 min with prostate and whole pelvis radiotherapy treatments. The maximum effective dose with the SeedTracker was 1.6276 mSv, and increase in REID was 0.007%. CONCLUSION: The SeedTracker real-time image guidance system is a feasible tool to use in radiotherapy departments to monitor and correct for prostate intrafraction motion.

Macroscopic fat containing renal cell carcinoma.

Renal masses containing macroscopic fat traditionally are pathognomonic for angiomyolipoma, a benign tumour. We describe two cases contrary to this axiom, the first being initially referred for angioembolisation, but subsequently biopsied when it was angiographically occult, whilst the second case showed a small macroscopic fat component and arterial enhancement prompting biopsy. Neither of these two cases demonstrated calcification which would usually suggest a more sinister lesion requiring further workup. The results demonstrated renal cell carcinoma for both lesions. Our multidisciplinary meeting approach to renal masses with a small amount of macroscopic fat and no calcifications has now changed.

Natural language processing to identify ureteric stones in radiology reports.

INTRODUCTION: Natural language processing (NLP) is an emerging tool which has the ability to automate data extraction from large volumes of unstructured text. One of the main described uses of NLP in radiology is cohort building for epidemiological studies. This study aims to assess the accuracy of NLP in identifying a group of patients positive for ureteric stones on Computed Tomography - Kidneys, Ureter, Bladder (CT KUB) reports. METHODS: Retrospective review of all CT KUB reports in a single calendar year. A locally available NLP tool was used to automatically classify the reports based on positivity for ureteric stones. This was validated by manual review and refined to maximize the accuracy of stone detection. RESULTS: A total of 1874 CT KUB reports were identified. Manual classification of ureteric stone positivity was 36% compared with 27% using NLP. The accuracy of NLP was 85% with a sensitivity of 66% and specificity of 95%. Incorrect classification was due to misspellings, variable syntax, terminology, pluralization and the inability to exclude clinical request details from the search algorithm. CONCLUSIONS: Our NLP tool demonstrated high specificity but low sensitivity at identifying CT KUB reports that are positive for ureteric stones. This was attributable to the lack of feature extraction tools tailored for analysing radiology text, incompleteness of the medical lexicon database and heterogeneity of unstructured reports. Improvements in these areas will help improve data extraction accuracy.

Systematic review and meta-analysis of the diagnostic accuracy of low-dose computed tomography of the kidneys, ureters and bladder for urolithiasis.

Renal colic is a common clinical condition which is often investigated with a CT of the kidneys, ureters and bladder (CTKUB). Recent technological improvements have allowed a reduction in dose with the emergence of low-dose CTKUB (LD-CTKUB) techniques. The present meta-analysis aims to determine the diagnostic accuracy of LD-CTKUB in the diagnosis of clinically significant uroliths. A systematic review was performed using nine electronic databases from their dates of inception to May 2016. Inclusion criteria included studies reporting comparative outcomes using LD-CTKUB with a dose less than 3 millisieverts compared to an imaging gold standard or clinical and surgical evaluation. The primary endpoint was detection of a urolith ≥3 mm where specified and any urolith when size was unspecified. Twelve studies were identified according to selection criteria, involving 1250 patients. LD-CTKUB demonstrated a pooled sensitivity of 93.1% (95%CI 91.5-94.4), specificity of 96.6% (95%CI 95.1-97.7%), positive likelihood ratio of 19.9 (95%CI 12.7-31.2), negative likelihood ratio of 0.05 (95%CI 0.02-0.10) and AUC of 0.9877 in the detection of clinically significant uroliths. Although 86 alternative diagnoses were noted across seven studies, none assessed the accuracy of LD-CTKUB in their detection. The majority of newer studies report an average radiation dose from 1 to 1.5 millisieverts. This study demonstrates a high sensitivity, specificity and positive predictive value in the detection of uroliths, however, its accuracy in the detection of alternative diagnoses is unknown. Therefore, we recommend using LD-CTKUB when the pre-test probability of stone disease is significantly higher than the pre-test probability of alternative diagnoses, such as follow-up of known calculi. We suggest caution when the pre-test probability of alternative diagnoses is high, such as the initial presentation of renal colic.

Guidelines to identify abnormalities after childhood urinary tract infections: a prospective audit.

OBJECTIVE: To compare the childhood urinary tract infection (UTI) guidelines from the Royal College of Physicians (RCP) in 1991 and from National Institute of Health and Care Excellence (NICE) (CG54) in 2007 by measuring their efficiency at detecting urinary tract abnormalities. DESIGN: Children with UTIs within the Newcastle Primary Care Trust (population 70,800 children) were referred and imaged according to the RCP guidelines during 2008, and these were compared to the activity that would have been undertaken if we had implemented the CG54 guidelines, including following them through 2011 to identify those with recurrent UTIs. MAIN OUTCOME MEASURES: The numbers of children imaged, the imaging burden and efficiency, and urinary tract abnormalities detected by each guideline. RESULTS: Fewer children would have been imaged by CG54 than RCP (150 vs 427), but its sensitivity was lower, at 44% for detecting scarring, 10% for identifying vesicoureteric reflux and 40% for other abnormalities. Overall, it would have only detected one-quarter of the abnormal cases (8 vs 32) and would have missed five of nine children with scarring, including three with multiple lesions and one with renal impairment. Imposing an age restriction of <8 years to the RCP guidelines would reduce its screening rate by 20% and still detect 90% of the abnormalities. INTERPRETATION: The CG54 guidelines do not alter the imaging efficiency compared to the RCP guidelines, but they are considerably less sensitive.

A practical guide to urinary tract ultrasound in a child: Pearls and pitfalls.

The aim of this review article is to equip the sonographer with the necessary knowledge to perform a detailed and clinically relevant assessment of the urinary tract in a child. Many of the techniques and principles used in the imaging of the urinary tract in adults can be applied to children. There are, however, notable differences with which the sonographer should be familiar. There is often a certain amount of trepidation when asked to image a child, but there are a number of simple steps that can make the process easier and more fulfilling. This article begins with advice on how to maintain cooperation in a child and the differences in the technical aspects of imaging of children. This is followed by a detailed review of the different pathologies that may be encountered, as well as highlighting information that is particularly relevant to the clinician looking after the child.