Acta Radiologica

Ectopic pancreas can frequently be mistaken for other submucosal masses. Ectopic pancreas may follow the signal intensity of mother pancreas on various magnetic resonance (MR) sequences, which might be helpful for differentiation between ectopic pancreas and other submucosal tumors in upper gastrointestinal (UGI) tract.

To evaluate the value of MR imaging (MRI) in differentiating ectopic pancreases from submucosal tumors in UGI tract.

Fifteen patients with ectopic pancreas and 26 patients with UGI submucosal tumors were included. All patients underwent abdominal MRI with diffusion-weighted imaging (DWI) and gadoxetic acid-enhanced MRI. Qualitative (location, contour, growth pattern, lesion border, and presence of intralesional cystic portion and duct-like structure) and quantitative (long diameter [LD], short diameter [SD], LD/SD ratio, signal intensities and apparent diffusion coefficients [ADC], and signal intensity – and ADC ratios of UGI submucosal lesions to pancreas) parameters were compared between ectopic pancreases and UGI submucosal tumors using Fisher’s exact test, the Mann-Whitney U test, and receiver-operating characteristic (ROC) analysis.

Duodenum was the most common location for ectopic pancreas (12/15, 79.9%), and the gastric body for UGI submucosal tumors (15/26, 57.7%) (P = 0.005). Round shape was an imaging feature more common in UGI submucosal tumors (12/26, 46.2%) than in ectopic pancreas (1/15, 6.7%; P = 0.021). On all of the various pulse sequences of MR images, ectopic pancreas showed isointensity comparable to that of pancreas more frequently than did sequences of UGI submucosal tumors (P < 0.01).The means (0.95 ± 0.09, 0.99 ± 0.06, 1.07 ± 0.08) of the signal intensity ratio of ectopic pancreas to pancreas on fat-suppressed unenhanced T1-weighted, arterial, and portal phase images were significantly higher than those (0.60 ± 0.09, 0.62 ± 0.28, 0.86 ± 0.27) of UGI submucosal tumors (P < 0.05). In contrast, the means (1.05 ± 0.12, 0.93 ± 0.18) of the signal intensity ratios of ectopic pancreas on T2-weighted images and DW images (b = 800 s/mm²) were significantly lower than those (1.82 ± 0.39, 2.35 ± 0.94) of UGI submucosal tumors (P < 0.001). On ROC analysis, if absolute value of difference between 1.0 and signal intensity ratio of submucosal lesions to the pancreas on T1-weighted images is <0.21, the sensitivity and specificity reach 100.0% for diagnosis ectopic pancreas from submucosal tumors.

Abdominal MRI with DWI can be a valuable tool for differentiating ectopic pancreases from UGI submucosal tumors.

PET-CT is widely used for evaluation and follow-up of malignancy. Incidental hypermetabolic lesions are often found on PET-CT, some of which are confirmed to be malignant.

To estimate the role of combined Breast Imaging-Reporting and Data System (BI-RADS) assessment using mammography and sonography for evaluation of incidental hypermetabolic lesions on 18F-FDG PET-CT and to determine an appropriate next step.

This study included incidental hypermetabolic lesions found in the breasts of 7594 women who underwent PET-CT at three university-affiliated hospitals between January 2006 and December 2011. We reviewed the maximum standardized uptake value (SUV_max) of incidental lesions, combined BI-RADS assessment of mammography and sonography, and final results. We analyzed the negative predictive values of the probably benign (categories 1–3) group and the sensitivity of suspicious (categories 4 and 5) groups according to combined BI-RADS assessment.

Forty-three patients (0.6%) had 49 incidental hypermetabolic lesions in the breast. Histologic diagnosis in 17 patients confirmed nine breast cancers (27.3%). Sixteen patients underwent imaging follow-up for at least 2 years; no breast cancer was detected. Thirteen patients were lost to follow-up and were excluded. For the suspicious (n = 14) and probably benign (n = 19) groups according to combined BI-RADS assessment, both the sensitivity and negative predictive values were 100%. Using an optimal diagnostic cut-off value of 2.15, the malignancy rate was not significantly different (16.7% vs. 45.5%, respectively, in the group with SUV_max < 2.15 and the group with SUV_max ≥ 2.15; P > 0.05). The SUV_max of the confirmed malignant and assumed benign groups were not significantly different (3.1% vs. 2.2%, respectively; P > 0.05).

Both mammography and sonography should be considered the next step to evaluate incidental hypermetabolic lesions on 18F-FDG PET-CT because combined BI-RADS assessment provides an excellent negative predictive value for excluding malignancy.

Renal vein thrombosis is not uncommon, however, there have been few reports on the diagnostic accuracy of three-dimensional contrast-enhanced magnetic resonance venography (3D-CE-MRV) in the detection of renal vein thrombosis (RVT).

To evaluate the value of 3D-CE-MRV for detecting RVT with multidetector computed tomography (CT) venography as reference standard.

Thirty-two patients with nephrotic syndrome underwent renal CT venography and gradient echo pulse sequence (FLASH 3D) 3D-CE-MRV in a clinical 3-T whole-body MR scanner for suspected RVT with time interval of 0–5 days. RVT was recorded on a per-patient and per-vessel (left renal vein, right renal vein, and inferior vena cava) basis. The diagnostic accuracy of 3D-CE-MRV for detection of RVT was calculated with CT venography as reference standard. Inter-reader agreement for RVT detection was evaluated using Kappa statistics.

Of 32 patients, CT venography detected 22 vessels with thrombosis in 17 patients, including five in right renal veins, 14 in left renal veins, and three in inferior vena cava, while 15 patients had no RVT. 3D-CE-MRV detected 21 vessels (21/96, 21.9%) with thrombosis in 16 patients (6/32, 50%), including five in right renal veins, 13 in left renal veins, and three in inferior vena cava, while 16 patients (16/32, 50%) had no RVT. With CT venography as reference standard, the sensitivities and specificities of 3D-CE-MRV for RVT detection were 94.1%, 100%; 95.5%, 100% on a per-patient and a per-vessel basis, respectively. Excellent inter-reader agreement (Kappa value = 0.969, P < 0.001) was observed for RVT detection.

3D-CE-MRV has a high diagnostic accuracy in the detection of RVT, which is optimal alternative imaging modality in the detection of RVT.

Tetralogy of Fallot (TOF) is one of the most common types of congenital heart disease and requires prompt surgical correction. Post-correction pulmonary insufficiency (PI) often ensues in adulthood. At times, the PI is accompanied by residual pulmonary stenosis (PS). Little is known regarding right ventricular (RV) function in the setting of combined PS and PI.

To compare cardiac magnetic resonance (CMR) parameters for the assessment of RV function between patients with combined pulmonary stenosis and pulmonary insufficiency (PSPI) and isolated PI following surgical repair of TOF.

Retrospective review of patients with comparable corrected TOF and similar PI was performed. Seventeen patients (median age, 24 years; range, 10–52 years) had combined PSPI and 30 patients (median age, 30 years; range, 6–70 years) had isolated PI. Cine magnetic resonance (MR) images (Philips Medical Systems, Best, The Netherlands) in the short-axis plane were used to calculate end-systolic, end-diastolic, and stroke volumes (RVESV, RVEDV, RVSV) and to measure RV wall thickness. Velocity-encoded cine MR images were used to measure pulmonary regurgitation fraction (PRF) by calculating the ratio of backward flow and total forward flow, obtained from the main pulmonary flow analysis. Peak pressure gradient across the pulmonary valve was obtained from spectral Doppler echocardiography.

RVEF was 51 ± 8% in the PSPI patients and 39 ± 11%, in the patients with isolated PI (P = 0.001). Additionally, RV wall thickness was 5.2 ± 0.8 mm in the PSPI patients compared to 2.6 ± 0.9 mm in the isolated PI patients (P = 0.001). RVESVi and RVEDVi were significantly lower (P < 0.05) in patients with combined PSPI (60 ± 21 mL/m², 121 ± 35 mL/m², respectively) compared to the patients with isolated PI (95 ± 48 mL/m², 152 ± 61 mL/m², respectively).

RV function is preserved in patients with PSPI when compared to patients with PI following surgical repair of TOF.

Pulmonary involvement in rheumatoid arthritis (RA) is common and encompasses a large spectrum of disease with different treatment options and prognoses. Therefore, assessment of these patients with multidetector computed tomography (MDCT) is vital.

To evaluate the MDCT pulmonary findings of patients with RA and to compare these findings with the clinical status.

Chest MDCT scans of 85 patients with RA between 2006–2012 were assessed. One patient with a pulmonary infection was excluded from the study. MDCT findings and distribution of the CT findings were examined, and patients were classified according to the predominant CT pattern. The pulmonary function test (PFT) results and categories, demographic characteristics, and clinical status of some of the patients for whom the results were obtained were evaluated, and the CT findings, PFT results, demographic characteristics, and clinical status were compared.

The study group consisted of 20 men (mean age, 58.1 years ± 13.1; range, 15–77 years) and 64 women (mean age, 55.3 years ± 11.5; range, 30–84 years). The most frequent findings were nodules (78.6%) and pleural thickening (48.8%). The most common CT patterns were follicular bronchiolitis (FB) in 28 (33.3%) patients and nodular disease (ND) in 12 (14.3%) others. There was no statistically significant difference between the CT findings and PFT results, and no statistically significant difference was noted in the CT findings between symptomatic and asymptomatic patients. In addition, there were some patients who exhibited no symptoms and/or had abnormal PFT results but had abnormal CT findings.

Rheumatoid arthritis is associated with a high frequency of CT findings and CT patterns, with nodules and pleural thickening being the most common CT findings and FB and ND being the most common CT patterns. MDCT identification of patients with RA may be helpful in the evaluation of pulmonary disease, even in patients without symptoms and PFT abnormalities.

Thyroid cancer is one of the common head and neck malignancies and may be found incidentally with other head and neck cancers.

To evaluate the prevalence and risk of malignancy in incidental thyroid lesions identified by ultrasound (US) in patients with head and neck cancer.

We retrospectively reviewed medical records of all patients with head and neck cancer other than of thyroid origin between January 2004 and December 2011. A total of 690 patients (537 men and 153 women; mean age, 58.9 ± 12.9 years) underwent US of the neck for the evaluation of cervical lymph node status (including thyroid gland). We evaluated the prevalence of patients with incidental thyroid lesions identified by US and the risk of malignancy in these patients.

Of the 690 patients with head and neck cancer, 234 (33.9%) had incidental thyroid lesions on US. Based on US findings, 61 patients underwent fine-needle aspiration, with 39 eventually undergoing thyroidectomy. Among these thyroid lesions, 24 incidental thyroid lesions of 22 patients were histologically proven to be malignant (23 papillary and 1 follicular carcinomas). The risk of malignancy was 9.4% on a patient-by-patient basis.

Screening of the thyroid gland should be included in the preoperative US examination for cervical lymph node metastases in patients with non-thyroidal head and neck cancer.

Endoscopic sphincterotomy is an integral component of endoscopic retrograde cholangiopancreatography. Post-sphincterotomy hemorrhage is a recognized complication. First line treatment involves a variety of endoscopic techniques performed at the time of sphincterotomy. If these are not successful, transcatheter arterial embolization or open surgical vessel ligation are therapeutic considerations.

To evaluate the technical and clinical success of transcatheter arterial embolization via micro coils in the management of bleeding post-endoscopic sphincterotomy (ES).

An 8-year retrospective review of all patients referred for transcatheter arterial embolization (TAE) for management of post-ES bleeding not controlled by endoscopy was performed. We analyzed the findings at endoscopy, angiography, interventional procedure, and the technical and clinical success.

Twelve embolization procedures were performed in 11 patients. Technical success was achieved in 11 of 12 procedures. Branches embolized included the gastroduodenal artery (GDA) in 11 cases, the superior pancreaticoduodenal artery (SPDA) in one case, and the inferior pancreaticoduodenal artery (IPDA) in four cases. Clinical success was achieved in 10 of 11 patients. One patient was referred for surgical intervention due to rebleeding from the IPDA.

Our experience demonstrates that TAE can effectively control bleeding post-ES avoiding the need for invasive surgery in most patients.

Performing endovascular procedures requires good control of fine-motor digital movements and hand–eye coordination. Objective assessment of such skills is difficult. Trainees acquire control of catheter/wire movements at various paces. However, little is known to what extent talent plays for novice candidates at entry to practice.

To study the association between performance in a novel aptitude test of fine-motor skills and performance in simulated procedures.

The test was based on manual course-tracking using a proprietary hand-operated roller-bar device coupled to a personal computer with monitor view rotation. A total of 40 test repetitions were conducted separately with each hand. Test scores were correlated with simulator performance. Group A (n = 14), clinicians with various levels of endovascular experience, performed a simulated procedure of contralateral iliac artery stenting. Group B (n = 19), medical students, performed 10 repetitions of crossing a challenging aortic bifurcation in a simulator.

The test score differed markedly between the individuals in both groups, in particular with the non-dominant hand. Group A: the test score with the non-dominant hand correlated significantly with simulator performance assessed with the global rating scale SAVE (R = –0.69, P = 0.007). There was no association observed from performances with the dominant hand. Group B: there was no significant association between the test score and endovascular skills acquisition neither with the dominant nor with the non-dominant hand.

Clinicians with increasing levels of endovascular technical experience had developed good fine-motor control of the non-dominant hand, in particular, that was associated with good procedural performance in the simulator. The aptitude test did not predict endovascular skills acquisition among medical students, thus, cannot be suggested for selection of novice candidates. Procedural experience and practice probably supplant the influence of innate abilities (talent) over time.

Various methods have been used to image and measure the normal range of axial rotation of the atlanto-occipital joint (AOJ), but a simple, precise, and reliable method is needed for everyday practice.

To generate normative ranges for AOJ rotation in various in-vivo positions and to investigate the reliability of a simple imaging method for measurement using routine high-field magnetic resonance imaging (MRI).

One hundred healthy volunteers were imaged on 3 T MRI with the AOJ in the center of the field of view. The scans were uniformly performed in seven different positions. The range of axial rotation was calculated by the angle between the craniofacial midline and the line linking the anterior and posterior tubercles of the atlas. The angle was defined as positive when it was angled right, and negative when it was angled left. The actual normative range of axial rotation was the difference between the angle in the supine neutral position and in the other positions.

The normative axial rotation range of the AOJ in different positions was between −4.8° and +5.0°. The mean values of the actual rotation angles in the right supine position with maximum bending, the right supine position maximum rotation, and the right prostrate position maximum rotation were 0.1°, 1.70°, and 0.8°, respectively. The mean values of actual rotation angles in the left supine position with maximum bending, the left supine position with maximum rotation, and the left prostrate positive with maximum rotation were 0.1°, −1.7°, and −1.1°, respectively. The inter-observer reliability tested.

A simple and reliable method of measurement on 3.0 T MRI demonstrated the normative axial rotation range of the AOJ in different positions to be between −4.8° and +5.0° and it was different from zero in neutral rotation. This method could be practically used to precisely diagnose AOJ rotary subluxation or dislocation.

Posterior reversible encephalopathy syndrome (PRES) is characterized by clinical symptoms that are associated with bilateral and symmetric vasogenic edema in the parietal and occipital lobes. However, this is rarely present with predominant involvement of the brain stem and cerebellum (variant).

To evaluate which clinical or magnetic resonance imaging (MRI) findings can help to predict the prognosis of variant and classical type of PRES and whether or not there is difference between two types of PRES.

We retrospectively evaluated MRI and clinical findings from 49 patients with PRES. These patients were divided into two groups. In group I, patients had atypical distribution of lesions. In group II, patients had typical distribution of lesions. Follow-up MRI was performed on 26 patients. We assessed the MRI features, clinical data, and the patients’ outcomes.

The mean blood pressure (BP) was significantly higher in group I (195.52/121.09 mmHg and 156.78/99.53 mmHg for groups I and II, respectively). The other factors assessed were not significantly different between the two groups. Lesions in 24 of 26 patients reversed upon follow-up. Sequelae were observed in 11 patients (group I, 7; group II, 4). However, there were no significant differences between the two groups. Except for those patients who died, seven of the nine patients with sequelae upon follow-up imaging had hemorrhage or irreversibility of lesions.

Even though BP influences the involvement of the brain stem, involvement of the brain stem is not influential on the prognosis. It seems that the influential factor to prognosis is the reversibility of lesions and hemorrhage.

Previous studies have revealed that amyloid depositions exist in not only the hippocampus but in other subcortical gray matter structures as well. Diffusion-tensor imaging (DTI) parameters might be more sensitive measures of early degeneration in Alzheimer’s disease (AD) than conventional magnetic resonance imaging (MRI) techniques.

To evaluate the significance of the volumes and the mean diffusivity (MD) values of subcortical gray matter structures in discrimination between early-stage AD and normal subjects using the Integrated Registration and Segmentation Tool in FMRIB’s Software Library.

Fifty-three cases of early-stage AD and 30 normal aging volunteers from two hospitals were scanned with 3D-FSPGRIR and SSSE-EPI sequences using two similar 1.5T MR systems. The mean relative volumes and mean MD values of subcortical gray matter structures were compared between early-stage AD and control groups. Binary logistic regression analysis and receiver-operating characteristic (ROC) curves were applied to assess the diagnostic significance of every structure’s relative volume, MD value, and combination of both.

The relative volumes of the left hippocampus, right amygdala, bilateral thalamus, right caudate, left putamen, and bilateral pallidum were significantly lower in the early-stage AD group than in the control group (P < 0.05). The MD values of the bilateral hippocampus and pallidum, and of the right thalamus and caudate were significantly elevated in the early-stage AD group (P < 0.05). In binary logistic regression analysis, the relative volume of left hippocampus and age entered the final model of volumetric analysis. The MD values of bilateral hippocampi and pallidums entered the final model of MD analysis. The MD values of bilateral hippocampi and pallidums, and the relative volume of left pallidum, entered the final model of combination analysis. The accuracy of three models was 84.7%, 88.9%, and 93.1%, respectively.

Pathological changes takes place in the hippocampus and other subcortical gray matter structures in early-stage AD. Diffusive imaging has great diagnostic significance in early-stage AD. The combination of both imaging modalities can lead to better discrimination between early-stage AD and normal aging.

Subtype-related various computed tomography (CT) features of renal cell carcinoma (RCC) are a confusing factor in differentiating angiomyolipoma with minimal fat (AMLmf) from RCC. To overcome RCC heterogeneity, a scoring system, which integrates multiple discrimitive parameters can be helpful for differentiating AMLmf from RCC.

To develop a MDCT-based scoring system for differentiating AMLmf from RCC.

In 407 patients with pathologically confirmed 48 AMLmfs and 359 RCCs (247 clear cell RCCs, 67 papillary RCCs, and 45 chromophobe RCCs), MDCT features (ratio of long-to-short diameter, enhancement characteristics, tumor attenuation on unenhanced scan, tumor margin, calcification), age, and sex were compared between AMLmf and RCCs. Based on logistic regression, a scoring system for diagnosing AMLmf over RCC was built, and its diagnostic accuracy was evaluated.

Scores suggesting AMLmf, i.e. the logit function as used in logistic regression analysis, were calculated as follows: Score = e 6 . 16 . A - 0 . 003 . B + 1 . 20 . C + 0 . 97 . D + 2 . 13 . E - 0 . 05 . F 1 + e 6 . 16 . A - 0 . 003 . B + 1 . 20 . C + 0 . 97 . D + 2 . 13 . E - 0 . 05 . F , where A = ratio of long-to-short diameter, B = enhancement amount in early excretory phase, C = homogeneous enhancement, D = tumor attenuation on unenhanced scan, E = sex, and F = age. Area under receiver-operating characteristics curve of scoring system was 0.919. With a score of 0.204 or higher, the scoring system yielded greatest accuracy (90%, 368/407) for diagnosing AMLmf over RCC, which was greater than that of any single MDCT or clinical parameter (53–85%) (P < 0.05). With a score of 0.317 or higher, sensitivity and specificity were 68% (32/48) and 95% (340/359).

MDCT-based scoring system can improve diagnostic performance of MDCT in differentiating AMLmf from RCC and help patients with AMLmf to avoid unnecessary surgery with high specificity.

Biexponential analysis has been used increasingly to obtain contributions of both diffusion and microperfusion to the signal decay in diffusion-weighted imaging DWI of different parts of the body.

To compare biexponential diffusion parameters of transplanted kidneys obtained with three different calculation methods.

DWI was acquired in 15 renal allograft recipients (eight men, seven women; mean age, 52.4 ± 14.3 years) using a paracoronal EPI sequence with 16 b-values (b = 0–750 s/mm²) and six averages at 1.5T. No respiratory gating was used. Three different calculation methods were used for the calculation of biexponential diffusion parameters: F_p, ADC_P, and ADC_D were calculated without fixing any parameter a priori (calculation method 1); ADC_P was fixed to 12.0 µm²/ms, whereas F_p and ADC_D were calculated using the biexponential model (calculation method 2); multistep approach with monoexponential fitting of the high b-value portion (b ≥ 250 s/mm²) for determination of ADC_D and assessment of the low b intercept for determination of F_p (calculation method 3). For quantitative analysis, ROI measurements were performed on the according parameter maps.

Mean ADC_D values of the renal cortex using calculation method 1 were significantly lower than using calculation methods 2 and 3 (P < 0.001). There was a significant correlation between calculation methods 1 and 2 (r = 0.69 (P < 0.005) and calculation methods 1 and 3 (r = 0.59; P < 0.05) as well as calculation methods 2 and 3 (r = 0.98; P < 0.001). Mean F_p values of the renal cortex were higher with calculation method 1 than with calculation methods 2 and 3 (P < 0.001). For F_p, only the correlation between calculation methods 2 and 3 was significant (r = 0.98; P < 0.001).

Biexponential diffusion parameters differ significantly depending on the calculation methods used for their calculation.

Transrectal ultrasound (TRUS)-guided prostate biopsy is the technique of choice for the assessment of clinical suspicion of prostate cancer (PC) based on abnormal digital rectal examination (DRE) and/or elevated or rising levels of prostate-specific antigen (PSA).

To identify factors involved in TRUS-guided prostate biopsy, which can be modified by radiologists in order to improve Gleason score (GS) accuracy, and to assess the influence of clinical variables.

We carried out a retrospective review of the records of 185 patients with PC treated surgically at our hospital between 2005 and 2008. Biopsy schemes were classified according to the number of cores (≤7, 8–9, 10–11, 12–15) and the needle length (11, 16, 20 mm). Clinical characteristics – age, family history of PC, DRE, PSA levels, and sonographic data – and prostatectomy GS (pGS) were collected.

Non-random concordance between biopsy Gleason score (bGS) and pGS was obtained for 36% of patients (P < 0.001). Under- and over-staging were 30% and 4%, respectively. Concordance was correlated with the core number (45% for ≤7, 54% for 8–9, 85% for 10–11, and 80% for 12–15; P < 0.001), but not with the needle length. The concordance rate showed a seven-fold increase when 10–11 cores were obtained (95% CI, 2–18; P < 0.001) compared to those cases in which the core number obtained was ≤7. Among clinical variables, only PSA correlated with concordance, showing an inverse relationship.

The Gleason correlation values were not improved when 12 or more cores were collected. These values reached a plateau beyond that number of samples. Therefore, when determining treatment strategies, physicians must consider the biopsy scheme used since it has proven to be a predictor of the accuracy of the PC grading system.

To estimate potential malignant lesions within the prostate gland, the usage of a scoring system has recently been proposed by a European consensus meeting.

To prospectively investigate a scoring system for functional prostate magnetic resonance imaging (MRI) using in-bore MR-guided prostate biopsy at 3-T.

Prostate MRI examinations of 59 patients (between February 2011 and May 2012) with no known prostate cancer, elevated prostate specific antigen (PSA) level, and unsuspicious digital rectal examination were included in the study. In each patient up to three lesions were defined and scored using a 5-point scoring system for each MR sequence (T2-weighted images, diffusion-weighted imaging, dynamic contrast-enhanced imaging). Following MRI-guided in-bore biopsy these lesions were correlated to the histopathological findings.

A total number of 144 lesions were defined in 59 patients. In 28 patients (51 lesions) MR-guided in-bore biopsy was positive for tumor (Gleason grade 6 or higher). A cut-off limit of 10 or more points in summation of the individual scores of all three sequences was used, leading to a 90% sensitivity, 63% specificity, 58% positive predictive value, and 92% negative predictive value.

A simple 5-point scoring system of functional prostate MRI achieves excellent sensitivity and moderate specificity for directing 3-T-guided prostate biopsy relative to the histopathological findings.