Cross-sectional imaging of idiopathic solitary renal vein varix: Report of two cases

Two cases of solitary renal vein varices are reported which presented as incidental findings on abdominal computed tomography (CT) and were initially thought to represent retroperitoneal lymph nodes. Contrast-enhanced CT, magnetic resonance imaging (MRI), and Doppler ultrasound (US), all demonstrated the vascular nature of these masses suggesting the correct diagnosis. When a rounded soft tissue density mass is seen on noncontrast-enhanced CT either in or contiguous to the renal hilum, a renal vein varix must be excluded. Doppler US, MRI, or dynamic contrast-enhanced CT should be done to exclude a renal varix as the cause.     

Sonographic evaluation of renal masses: Correlations with angiography

The value of sonography in the diagnosis of renal masses in a series of 119 consecutive histologically confirmed cases is presented. Sonography correctly identified 92% of the cystic and 90% of the solid renal masses. Causes of incorrect diagnoses included lesions smaller than 2 cm, masses in the left upper pole, diffusely infiltrating urothelial tumors, echogenic fatty lesions (early in our experience), and acute abscesses and hematomas. Angiography in the same series of cases correctly diagnosed 80% of the cystic and 88% of the solid renal masses. Avascular lesions were the main cause for equivocal or incorrect angiographic diagnoses. We conclude that sonography is more definitive than angiography in the diagnosis of avascular masses, while angiography excels when the lesion is vascular or small. Combining the sonographic and angiographic findings allowed accurate diagnosis in over 99% of the cases.     

Blood flow to the kidney via the gonadal-renal capsular artery

The gonadal artery is an important collateral pathway of blood flow to the kidney. Collateral routes may be from the gonadal artery to the inferior capsular artery (gonadal-renal capsular artery) or to the periureteric arteries. These pathways develop in cases of renal artery stenosis, or when a vascular renal tumor increases the kidneys need for blood. We present five cases in which the gonadal artery served as a source of blood supply to the kidney.     

Ultrasound of the neonatal urinary tract

Ultrasound (US) is a safe and accurate imaging method in the evaluation of the urinary tract. It should be the first procedure used in the neonate to confirm prenatal diagnosis, in patients with a malformation in another organ system that is known to be associated with kidney anomalies, in patients presenting with a spontaneous pneumothorax, in cases of an abdominal mass, and, in renal failure, asphyxiated babies, septicemia or urinary tract infection, or, prolonged jaundice. In association with the other uroradiological methods, it will lead to the correct diagnosis in most cases.     

Circumferential perirenal urinoma mimicking nephromegaly on urography

Four cases of circumferential perirenal urinoma in patients with cancer are described. Intravenous urography showed evidence of apparent renal enlargement. In 1 case, opacification of extravasated urine was dense enough to be seen on the urogram, and the diagnosis was confirmed by computed tomography (CT). In the other cases, sonography followed by CT diagnosed urinoma, after tumor invasion had been suggested because of the pseudonephromegaly. Ureteral obstruction was demonstrated in all cases, due to retroperitoneal adenopathy in 1 case and to pelvic tumor in the other 3. Sonography or CT is required for the diagnosis of circumferential perirenal urinoma mimicking nephromegaly urographically.     

The association of aorto-iliac aneurysms with ureteral obstruction

Aorto-iliac aneurysms may entrap the ureters in perianeurysmal fibrosis, causing medial ureteral deviation and/or obstruction. The latter has been described only in male patients; a further 5 cases due to iliac and 3 to aortic aneurysm are reported. The radiologic picture resembles retroperitoneal fibrosis; the correct diagnosis may be suggested when ureteral tethering or narrowing lies near arterial calcification. Sonography is usually the most appropriate investigation to confirm the diagnosis. When sonography shows an aortic aneurysm, the kidneys should be scanned to rule out hydronephrosis. Similarly, films of the kidneys should be obtained when an abdominal aneurysm is demonstrated by aortography.     

Technique and complications of renal carcinoma infarction

The technique of renal arterial embolization in 150 patients with renal carcinoma using Gelfoam, Ivalon particles, and coils is described. The complications of the procedure and the morbidity and mortality following embolization are presented. The details of the postinfarction syndrome in the first 100 patients are analyzed. The prevention of these complications is discussed.     

Treatment of priapism by transcatheter embolization of internal pudendal arteries

Priapism can be successfully treated by unilateral or bilateral percutaneous transcatheter occlusion of the internal pudendal arteries. Occlusion should be reversible in order to avoid impotence. Embolization with autologous clot satisfies this requirement because of the clot lysis and consequent vessel recanalization. Three cases are extensively described which demonstrate the feasibility of the method and the ability to preserve sexual potency. The rationale for using interventional angiography in priapism is also discussed.     

Methods for measuring the renal uptake rate of99mTc-dimercaptosuccinic acid (DMSA) : a comparative study

A comparative study of the renal uptake rate of^99mTc-dimercaptosuccinic acid (DMSA) was performed using a phantom study and clinical data from 100 patients (200 kidneys) with a variety of renal diseases. The measurement methods for renal uptake rate studied here include a posterior-view method, a conjugate-view method, and a method using single photon emission computed tomography (SPECT). The renal uptake rates obtained by the posterior-view method significantly (P<0.001) depended on kidney depth correction. With the SPECT method, the cut-off level for delineating the kidney was changed according to the background count ratio using the results of the phantom study. The renal uptake rates obtained by the SPECT method correlated significantly (P<0.001) with those obtained by other methods, and there were no significant differences as compared with those obtained by the conjugate-view method. An analysis of error with the above methods indicated that the error relating to the sensitivity to body thickness was smallest for the SPECT method and greatest for the posterior-view method. In terms of measurement of renal uptake rate only, the conjugate-view method is considered the most useful because it needs no kidney depth correction and requires very little additional effort or examination time.     

Chemical Renal Denervation by Vincristine: The Role of the Flow Rate of Delivery

Purpose

Vincristine has been proven promising regarding its safety and efficacy for the renal artery denervation both in experimental models and in humans. The aim of the study was to compare in an experimental model the efficacy of constant versus random flow rate delivery of vincristine on renal sympathetic denervation.

Methods

We used 10 juvenile Landrace swine. After the introduction of a 7F sheath into the femoral artery, a guide wire was advanced into the distal part of the renal artery. Then the first delivery balloon catheter, which delivers vincristine in random flow rate, was advanced at the proximal part of the artery, and the balloon was inflated in order to locally deliver vincristine to the media of the renal artery. The process was repeated in the contralateral renal artery, with the use of the double balloon catheter that delivers vincristine with a constant flow rate. Euthanasia of the animals was performed at 28 days. All sections were processed for histological and immunohistochemical analysis.

Results

The delivery of vincristine with both catheters was successful and uncomplicated. Immunohistochemistry showed that the mean number of intact nerves in all sections was significantly lower in the group of vincristine delivered with constant flow catheter compared to the group that the delivery was performed in a random fashion. (1.48 ± 0.37 vs. 1.70 ± 0.41, p = 0.04).

Conclusion

Chemical renal denervation with vincristine by a constant flow rate catheter is more effective compared to the denervation performed by a catheter that delivers vincristine in a random fashion.     

Autoimmune pancreatitis: multidetector-row computed tomography (MDCT) and magnetic resonance (MR) findings in the Italian experience

Multidetector-row computed tomography (MDCT) and magnetic resonance (MR) imaging are currently the most frequently performed imaging modalities for the study of pancreatic disease. In cases of suspected autoimmune pancreatitis (AIP), a dynamic quadriphasic (precontrast, contrast-enhanced pancreatic, venous and late phases) study is recommended in both techniques. In the diffuse form of autoimmune pancreatitis (DAIP), the pancreatic parenchyma shows diffuse enlargement and appears, during the MDCT and MR contrast-enhanced pancreatic phase, diffusely hypodense and hypointense, respectively, compared to the spleen because of lymphoplasmacytic infiltration and pancreatic fibrosis. During the venous phase of MDCT and MR imaging, the parenchyma appears hyperdense and hyperintense, respectively, in comparison to the pancreatic phase. In the delayed phase of both imaging modalities, it shows retention of contrast media. A “capsule-like rim” may be recognised as a peripancreatic MDCT hyperdense and MR hypointense halo in the T2-weighted images, compared to the parenchyma. DAIP must be differentiated from non-necrotizing acute pancreatitis (NNAP) and lymphoma since both diseases show diffuse enlargement of the pancreatic parenchyma. The differential diagnosis is clinically difficult, and dynamic contrast-enhanced MDCT has an important role. In the focal form of autoimmune pancreatitis (FAIP), the parenchyma shows segmental enlargement involving the head, the body-tail or the tail, with the same contrast pattern as the diffuse form on both modalities. FAIP needs to be differentiated from pancreatic adenocarcinoma to avoid unnecessary surgical procedures, since both diseases have similar clinical and imaging presentation. The differential diagnosis is clinically difficult, and dynamic contrast-enhanced MDCT and MR imaging both have an important role. MR cholangiopancreatography helps in the differential diagnosis. Furthermore, MDCT and MR imaging can identify the extrapancreatic manifestations of AIP, most commonly biliary, renal and retroperitoneal. Finally, in all cases of uncertain diagnosis, MDCT and/or MR follow-up after short-term treatment (2–3 weeks) with high-dose steroids can identify a significant reduction in size of the pancreatic parenchyma and, in FAIP, normalisation of the calibre of the upstream main pancreatic duct.     

Unusual Radiological Behaviour After Cryoablation of Renal Cell Carcinoma

Cryoablation has evolved into an effective treatment option in patients with renal tumours. The procedure is minimally invasive, and patients are often spared the morbidity and hospital stay that is often associated with open or partial nephrectomy. We present an unusual case of a 62-year-old male patient who underwent cryoablation of a renal cell carcinoma. He subsequently developed apparent exuberant local disease progression, which spontaneously regressed on follow-up CT imaging.     

Computed tomographic findings in suburothelial hemorrhage

Retroperitoneal hemorrhage with associated intramural hemorrhage into the renal pelvis and proximal ureter is a well documented complication of coagulation defects. The urographic characteristics of this condition have been well documented by several authors [1–4], but to our knowledge the computed tomographic (CT) findings in patients with this condition have not been reported previously. We describe the CT findings in 2 such cases; one related to thrombocytopenia in leukemia, and the other to anticoagulant therapy in a patient with Budd-Chiari syndrome.     

Diffuse bone marrow sarcoid-like reaction associated with renal cell carcinoma

Sarcoid-like reaction has been documented in association with several types of malignancy, including renal cell carcinoma. We report the case of a 41-year-old man with nonmetastatic renal cell carcinoma and concomitant non-caseating granulomas distributed diffusely throughout the bone marrow. The granulomas resolved after nephrectomy. As far as we know, this is the first reported case of a sarcoid-like reaction primarily involving the bone marrow in association with renal cell carcinoma.     

Novel radiotherapy techniques for involved-field and involved-node treatment of mediastinal Hodgkin lymphoma

Purpose

Hodgkin lymphoma (HL) is a highly curable disease. Reducing late complications and second malignancies has become increasingly important. Radiotherapy target paradigms are currently changing and radiotherapy techniques are evolving rapidly.

Design

This overview reports to what extent target volume reduction in involved-node (IN) and advanced radiotherapy techniques, such as intensity-modulated radiotherapy (IMRT) and proton therapy–compared with involved-field (IF) and 3D radiotherapy (3D-RT)– can reduce high doses to organs at risk (OAR) and examines the issues that still remain open.

Results

Although no comparison of all available techniques on identical patient datasets exists, clear patterns emerge. Advanced dose-calculation algorithms (e.g., convolution-superposition/Monte Carlo) should be used in mediastinal HL. INRT consistently reduces treated volumes when compared with IFRT with the exact amount depending on the INRT definition. The number of patients that might significantly benefit from highly conformal techniques such as IMRT over 3D-RT regarding high-dose exposure to organs at risk (OAR) is smaller with INRT. The impact of larger volumes treated with low doses in advanced techniques is unclear. The type of IMRT used (static/rotational) is of minor importance. All advanced photon techniques result in similar potential benefits and disadvantages, therefore only the degree-of-modulation should be chosen based on individual treatment goals. Treatment in deep inspiration breath hold is being evaluated. Protons theoretically provide both excellent high-dose conformality and reduced integral dose.

Conclusion

Further reduction of treated volumes most effectively reduces OAR dose, most likely without disadvantages if the excellent control rates achieved currently are maintained. For both IFRT and INRT, the benefits of advanced radiotherapy techniques depend on the individual patient/target geometry. Their use should therefore be decided case by case with comparative treatment planning.     

Radiologic search for embolized leaflets of prosthetic heart valves: A report of two cases

In a radiologic search for embolized leaflets of Edwards-Duromedics bileaflet valves in 2 patients, the embolized fragments were localized in the iliac vessels using computed tomography. Sonography was successful in one case and standard X-ray films of the abdomen were negative in both cases.In vitro investigations with Björk-Shiley and Edwards-Duromedics leaflets suggested that standard X-ray films of the abdomen and pelvis should be considered as the first investigational technique. If negative, computed tomography of the lower abdomen should be done.     

Nuclear myocardial perfusion imaging with a cadmium–telluride semiconductor detector gamma camera in patients with acute myocardial infarction

Objective

Since myocardial perfusion imaging (MPI) with conventional sodium iodine (NaI) device has low spatial resolution, there have been some cases in which small structures such as non-transmural myocardial infarction could not be properly detected. The purpose of this study was to evaluate potential usefulness of cadmium–telluride (CdTe) semiconductor detector-based high spatial resolution gamma cameras in detecting myocardial infarction sites, especially non-transmural infarction.

Methods

A total of 38 patients (mean age ± SD: 64 ± 21 year) who were clinically diagnosed with acute myocardial infarction were included. Twenty-eight cases of them were with ST segment elevation myocardial infarction (STEMI) and 10 cases with non-ST segment elevation myocardial infarction (NSTEMI). In all patients, myocardial perfusion single photon emission computed tomography images were acquired with Infinia (NaI device) and R1-M (CdTe device), and the images were compared concerning the detectability of acute myocardial infarction sites.

Results

The detection rates of the myocardial infarction site in cases with STEMI were 100 % both by NaI and CdTe images. In cases with NSTEMI, detection rate by NaI images was 50 %, while that of CdTe images was 100 % (p = 0.033). The summed rest score (SRS) value derived from CdTe images was significantly higher than that from NaI images in cases with STEMI [NaI images: 12 (7–18) versus CdTe images: 14 (9–20)] (p < 0.001). SRS derived from CdTe images was significantly higher than that derived from NaI images in cases with NSTEMI [NaI images: 2 (0–5) versus CdTe images: 6 (6–8)] (p = 0.006).

Conclusions

These results indicate that MPI using CdTe-semiconductor device will provide a much more accurate assessment of acute myocardial infarction in comparison to current methods.     

Early evidence kits in sexual assault: an observational study of spermatozoa detection in urine and other forensic specimens

Purpose

To determine the detection frequency of spermatozoa in early evidence kit specimens and in subsequent full forensic specimens in alleged sexual assault.

Methods

Observational cohort study of 100 consecutive alleged sexual assault cases, presenting in Western Australia between 19th July 2008 and 6th February 2012, with both early evidence kit and full forensic evidence specimen collections. Eighty-eight cases were included in the study. Smears from all forensic specimens were analyzed by light microscopy to determine the detection frequency and structural characteristics of spermatozoa. Patient demographic features, characteristics of the alleged assault and details and timing of forensic collections were also recorded.

Results

Spermatozoa were detected in early evidence kit specimens in 35 % (31/88) and in full forensic specimens in 42 % (37/88) of all cases (irrespective of type of alleged penetration). In alleged penile-vaginal penetration, spermatozoa were detected in early evidence kit specimens in 40 % (21/53) of cases when both first void urine and vulval gauze wipe were collected. Spermatozoa were detected in full forensic specimens in 45 % (31/69) of cases. Spermatozoa were detected in early evidence kit oral rinse specimens in 6 % (1/18) of cases of alleged penile-oral penetration and in early evidence perianal gauze wipe specimens in 33 % (2/6) cases of alleged penile-anal penetration. Spermatozoa were detected in the early evidence kit first void urine specimen in a single case, 11 % (1/9), in which the nature of the alleged assault was unknown. Spermatozoa were detected in early evidence kit specimens and not in full forensic specimens in 3 % (3/88) of cases.

Conclusions

Early evidence kit specimens are effective in recovery of spermatozoa, and in particular urine and vulval gauze wipe are worthwhile early forensic specimens for the detection of spermatozoa. Collection of early evidence specimens led to detection of spermatozoa-positive cases, which were not detected by subsequent full forensic specimen collection.     

18F-fluorodeoxyglucose positron emission tomography combined with whole-body computed tomographic angiography in critically ill patients with suspected severe sepsis with no definite diagnosis

Purpose

Timely identification of septic foci is critical in patients with severe sepsis or septic shock of unknown origin. This prospective pilot study aimed to assess ¹⁸F-fluorodeoxyglucose positron emission tomography (FDG-PET), combined with whole-body computed tomographic angiography (CTA), in patients with suspected severe sepsis and for whom the prior diagnostic workup had been inconclusive.

Methods

Patients hospitalized in an intensive care unit with a suspected severe sepsis but no definite diagnosis after 48 h of extensive investigations were prospectively included and referred for a whole body FDG-PET/CTA. Results from FDG-PET/CTA were assessed according to the final diagnosis obtained after follow-up and additional diagnostic workup.

Results

Seventeen patients were prospectively included, all on mechanical ventilation and 14 under vasopressor drugs. The FDG-PET/CTA exam 1) was responsible for only one desaturation and one hypotension, both quickly reversible under treatment; 2) led to suspect 16 infectious sites among which 13 (81 %) could be confirmed by further diagnostic procedures; and 3) triggered beneficial changes in the medical management of 12 of the 17 study patients (71 %). The FDG-PET/CTA images showed a single or predominant infectious focus in two cases where CTA was negative and in three cases where CTA exhibited multiple possible foci.

Conclusion

Whole-body FDG-PET/CTA appears to be feasible, relatively safe, and provides reliable and useful information, when prospectively planned in patients with suspected severe sepsis and for whom prior diagnostic workup had been inconclusive. The FDG-PET images are particularly helpful when CTA exhibits no or multiple possible sites.     

Stereotactic gamma-ray body radiation therapy for asynchronous bilateral renal cell carcinoma

Purpose

To preliminarily evaluate the feasibility, therapeutic effect and toxicity of stereotactic gamma-ray body radiation therapy (γ-SBRT) for asynchronous bilateral renal cell carcinoma (bRCC).

Materials and methods

A retrospective analysis was performed on the clinical data of nine patients with asynchronous bRCC who were unable to undergo surgery and received γ-SBRT between February 2002 and May 2012. A total dose of 36–51 Gy was delivered to the 50 % isodose line covering the planning target volume at 3–5 Gy/fraction, whereas a total dose of 60–85 Gy was delivered at 5–7 Gy/fraction to the gross target volume. The local control rate (LC) and overall survival rate (OS) were calculated using the Kaplan–Meier method.

Results

Patient follow-up ended in March 2013 and the follow-up rate was 100 %. Of the nine patients, none presented with complete remission and five (55.6 %) achieved partial remission. The objective response rate was 55.6 %. The 1-, 3- and 5-year LC rates were 64.8, 43.2 and 43.2 %, respectively. The 1-, 3- and 5-year OS rates were 66.7, 53.3 and 35.6 %, respectively. Four (44.4 %) patients had an acute radiation reaction; there were two cases of grade I leukocytopenia and two cases of grade I gastrointestinal reactions. Late radiation-induced toxicity consisted of grade II gastrointestinal reactions in two patients.

Conclusion

Stereotactic gamma-ray body radiation therapy was found to be safe and effective in the treatment of asynchronous bRCC. Improved prognosis will require individualised treatment and a combination of multiple therapeutic approaches; this will be a primary research trend in the future.