Primary vaginal cancer: role of MRI in diagnosis,staging and treatment

Primary carcinoma of the vagina is rare, accounting for 1–3% of all gynaecological malignancies. MRI has an increasing role in diagnosis, staging, treatment and assessment of complications in gynaecologic malignancy. In this review, we illustrate the utility of MRI in patients with primary vaginal cancer and highlight key aspects of staging, treatment, recurrence and complications.The incidence of primary vaginal cancer increases with age, with approximately 50% of patients presenting at age greater than 70 years and 20% greater than 80 years.¹ Around 2890 patients are currently diagnosed with vaginal carcinoma in the USA each year, and almost 30% die of the disease.² The precursor for vaginal cancer, vaginal intraepithelial neoplasia (VAIN) and invasive vaginal cancer is strongly associated with human papillomavirus (HPV) infection (93%).^3,4 In situ and invasive vaginal cancer share many of the same risk factors as cervical cancer, such as tobacco use, younger age at coitarche, HPV and multiple sexual partners.^5–7 In fact, higher rates of vaginal cancer are observed in patients with a previous diagnosis of cervical cancer or cervical intraepithelial neoplasia.^7,8As is true for other gynaecologic malignancies, vaginal cancer diagnosis and staging rely primarily on clinical evaluation by the International Federation of Gynecology and Obstetrics (FIGO).⁹ Pelvic examination continues to be the most important tool for evaluating local extent of disease, but this method alone is limited in its ability to detect lymphadenopathy and the extent of tumour infiltration. Hence, FIGO encourages the use of imaging. Fluorine-18 fludeoxyglucose-positron emission tomography (¹⁸F-FDG-PET), a standard imaging tool for staging and follow-up in cervical cancer, can also be used for vaginal tumours, with improved sensitivity for nodal involvement compared to CT alone.¹⁰ In addition to staging for nodal and distant disease, CT [simulation with three dimensional (3D) conformations] is particularly useful for treatment planning and delivery of external beam radiation. MRI, with its excellent soft tissue resolution, is commonly used in gynaecologic malignancies and has been shown to be accurate in diagnosis, local staging and spread of disease in vaginal cancer.^11,12 While no formal studies are available for vaginal cancer, in cervical cancer MRI actually alters the stage in almost 30% of patients.^13–15Treatment planning in primary vaginal cancer is complex and requires a detailed understanding of the extent of disease. Because vaginal cancer is rare, treatment plans remain less well defined, often individualized and extrapolated from institutional experience and outcomes in cervical cancer.^1,16–19 There is an increasing trend towards organ preservation and treatment strategies based on combined external beam radiation and brachytherapy, often with concurrent chemotherapy,^14,20,21 surgery being reserved for those with in situ or very early-stage disease.²² Increasing utilization of MR may provide superior delineation of tumour volume, both for initial staging and follow-up, to allow for better treatment planning.²³     

Embolisation of the right gastric artery in patients undergoing hepatic arterial infusion chemotherapy using two possible approach routes

We used a retrospective non-randomised study to investigate the clinical effect of selective embolisation of the right gastric artery before hepatic arterial infusion chemotherapy (HAIC) using a port-catheter system. We evaluated whether the hepatic artery or the left gastric artery is the better approach for selecting the right gastric artery. A total of 367 patients (244 men and 123 women; mean age, 64.1 years) with unresectable advanced liver cancer underwent percutaneous implantation of a port-catheter system. In 294 of these patients, right gastric arterial embolisation with microcoils was attempted before placement of the port-catheter system to prevent gastric mucosal lesions. Approach was either through the hepatic artery (175 patients) or through the left gastric artery (119 patients), with success rates in catheterising the right gastric artery of 78.3% and 77.3%, respectively. If the attempt was unsuccessful, the catheter was redirected to the alternative approach, which increased the final success rate to 96.3%. Only seven patients experienced gastroduodenal mucosal lesions acutely after HAIC, as revealed by endoscopy. Embolisation of the right gastric artery is a feasible procedure that can reduce the incidence of gastric mucosal lesions associated with HAIC. Approach through either the hepatic artery or the left gastric artery is equally acceptable.Long-term hepatic arterial infusion chemotherapy (HAIC) via an implanted port-catheter system is a treatment option for patients with unresectable advanced liver cancer [1, 2]. In the past, such catheter placement was done by surgical laparotomy under general anaesthesia [3–6], an invasive procedure. However, recent advances in interventional techniques allow the implantation of port-catheter systems percutaneously under local anaesthesia [7–14].A frequent complication is reactive gastric or duodenal mucosal lesions, which result from chemical irritation caused by infusion of chemotherapeutic agents into adjacent organs through arteries originating from the common hepatic artery [15–24]. One such complication is a gastric mucosal lesion caused by inflow of chemotherapeutic agents into the right gastric artery [15–24]. To prevent this complication, the efficacy of selectively embolising the right gastric artery with coils at the time of implantation of the port-catheter system has been noted [21, 25–27].In many cases, however, the right gastric artery is slender and angulated, with anatomical variations [26, 28–31]. Hence, it is occasionally difficult to insert a catheter selectively into the right gastric artery by antegrade catheterisation via the site of the hepatic artery. This is the approach most commonly used by interventional radiologists. Failure to embolise the right gastric artery can result [26]. As an alternative method, a retrograde approach to the right gastric artery via the left gastric artery has been introduced [32, 33].Because HAIC with an implanted port-catheter system is performed in a relatively large number of cases in our institution, we have many opportunities to embolise the right gastric artery using both approaches. The aim of the present retrospective non-randomised study, which included a large number of subjects, was to evaluate the usefulness of right gastric arterial embolisation and to determine whether the antegrade or retrograde approach is more useful.     

Accessory or additional renal arteries show no relevant effects on the width of the upper urinary tract: a 64-slice multidetector CT study in 1072 patients with 2132 kidneys

Objective

The aim of this study was to find out on an unselected patient group whether crossing vessels have an influence on the width of the renal pelvis and what independent predictors of these target variables exist.

Methods

In this cross-sectional study, 1072 patients with arterially contrasted CT scans were included. The 2132 kidneys were supplied by 2736 arteries.

Results

On the right side, there were 293 additional and accessory arteries in 286 patients, and on the left side there were 304 in 271 patients. 154 renal pelves were more than 15 mm wide. The greatest independent factor for hydronephrosis on one side was hydronephrosis on the contralateral side (p<0.0001 each). Independent predictors for the width of the renal pelvis on the right side were the width of the renal pelvis on the left, female gender, increasing age and height; for the left side, predictors were the width of the renal pelvis on the right, concrements, parapelvic cysts and great rotation of the upper pole of the kidney to dorsal. Crossing vessels had no influence on the development of hydronephrosis. Only anterior crossing vessels on the right side are associated with widening of the renal pelvis by 1 mm, without making it possible to identify the vessel as an independent factor in multivariate regression models.

Conclusion

The width of the renal pelvis on the contralateral side is the strongest independent predictor for hydronephrosis and the width of the renal pelvis. There is no link between crossing vessels and the width of the renal pelvis.Obstructions of the ureteropelvic junction (UPJ) can be caused by intrinsic or extrinsic factors [1]. Although there are no studies of this to date, crossing the UPJ by an aberrant crossing vessel is considered the most important [2] of the extrinsic factors [3]. Crossing vessels, which are thought to cause from 40% to over 50% of the extrinsic UPJ obstructions in adults [4, 5], are located ventral more often than dorsal to the UPJ. These are usually normal vessels of the lower pole segment [4, 6–9], which can be divided into additional renal arteries arising from the aorta, and accessoric renal arteries arising from branches of the aorta [10, 11]. The primary surgical therapy of choice is endoscopic endopyelotomy [12]. The success rate of 89–90% [12, 13] is thought to be noticeably poorer in patients with crossing vessels [12, 13]; however, this is not undisputed [14, 15]. Be that as it may, to prevent bleeding complications it is necessary to be familiar with the vascular situation around the UPJ prior to the procedure [3, 16–18]. CT angiography is used for this purpose, as it is highly accurate, quick to perform and shows all relevant anatomical structures in relation to one another [3, 19, 20]. The objective of this study was to determine whether or not there are vascular morphological patterns or other factors that influence the width of the renal collecting system, regardless of the definitions of hydronephrosis.     

Pattern and predictors of volumetric change of parotid glands during intensity modulated radiotherapy

Objective:

To describe the pattern and predictors of volumetric change of parotid glands during intensity modulated radiotherapy (IMRT) for oropharyngeal cancer.

Methods:

A cohort of patients undergoing weekly CT scans during dose-painted IMRT was considered. The parotid glands were contoured at the time of treatment planning (baseline) and on all subsequent scans. For a given patient, the parotid glands were labelled as higher (H) and lower (L), based on the mean dose at planning. The volume of each gland was determined for each scan and the percent change from baseline computed. Data were fit to both linear and quadratic functions. The role of selected covariates was assessed with both logistic regression and pair-wise comparison between the sides. The analyses were performed considering the whole treatment duration or each separate half.

Results:

85 patients, 170 glands and 565 scans were analysed. For all parotids except one, the quadratic function provided a better fit than the linear one. Moreover, according to both the logistic regression and pair-wise comparison, the cumulative mean dose of radiation is independently correlated with the parotid shrinkage during the first but not the second half of the treatment. Conversely, age and weight loss are predictors of relative parotid shrinkage during the entire course of the treatment.

Conclusion:

Parotid gland shrinkage during IMRT is not linear. Age, weight loss and radiation dose independently predict parotid shrinkage during a course of IMRT.

Advances in knowledge:

The present study adds to the pathophysiology of parotid shrinkage during radiotherapy.Fractionated radiotherapy is based on the assumption that the dose distribution obtained at planning is delivered during each treatment session. However, both set-up errors and tissue deformation can modify the dose that is administered. Shifts in the location of isodose levels compared with planning become critical for techniques that are highly conformal to the target(s), such as IMRT, justifying the interest in image guidance and adaptive radiotherapy [1]. Because of the sharp dose gradient around the target(s), subtle changes in the relative position or in the volume of organs at risk may alter the planned dose that the volume of an organ receives, as has been shown for the parotid glands [2–6].In a study by Ricchetti et al [7], we found that the parotid glands are the regions of interest that undergo the largest absolute and relative changes in volume during treatments. Although at least 16 articles have documented a significant percent reduction in the volume of the parotid gland during the course of fractionated radiotherapy [2,3,7–20], there are still several unanswered questions. It is unclear why some parotid glands shrink to about 50–60% during treatment, while others show only minimal changes. Studies that have investigated predictors of shrinkage have suggested weight loss during treatment, patient age and dose of radiation to the parotid as potential factors [2,9,16–19]. However, results are inconsistent [3,8,10,14]. Some studies have suggested that dosimetrically spared parotid glands undergo only minimal volume changes during treatment [16,18], whereas others describe a similar behaviour regardless of the radiation dose [7,8,10]. Furthermore, it is unclear whether the daily percent volume change is constant [8,10,16,19] or variable [7,10,13] during the course of treatment. A variable daily percent change in the volume may indicate that there are predictive factors specific to certain portions of the fractionated radiation schedule. In the present article, we attempt to clarify these points.     

Impact of biplane versus single-plane imaging on radiation dose,contrast load and procedural time in coronary angioplasty

Coronary angioplasties can be performed with either single-plane or biplane imaging techniques. The aim of this study was to determine whether biplane imaging, in comparison to single-plane imaging, reduces radiation dose and contrast load and shortens procedural time during (i) primary and elective coronary angioplasty procedures, (ii) angioplasty to the main vascular territories and (iii) procedures performed by operators with various levels of experience. This prospective observational study included a total of 504 primary and elective single-vessel coronary angioplasty procedures utilising either biplane or single-plane imaging. Radiographic and clinical parameters were collected from clinical reports and examination protocols. Radiation dose was measured by a dose–area–product (DAP) meter intrinsic to the angiography system. Our results showed that biplane imaging delivered a significantly greater radiation dose (181.4±121.0 Gycm²) than single-plane imaging (133.6±92.8 Gycm², p<0.0001). The difference was independent of case type (primary or elective) (p = 0.862), vascular territory (p = 0.519) and operator experience (p = 0.903). No significant difference was found in contrast load between biplane (166.8±62.9 ml) and single-plane imaging (176.8±66.0 ml) (p = 0.302). This non-significant difference was independent of case type (p = 0.551), vascular territory (p = 0.308) and operator experience (p = 0.304). Procedures performed with biplane imaging were significantly longer (55.3±27.8 min) than those with single-plane (48.9±24.2 min, p = 0.010) and, similarly, were not dependent on case type (p = 0.226), vascular territory (p = 0.642) or operator experience (p = 0.094). Biplane imaging resulted in a greater radiation dose and a longer procedural time and delivered a non-significant reduction in contrast load than single-plane imaging. These findings did not support the commonly perceived advantages of using biplane imaging in single-vessel coronary interventional procedures.The use of biplane imaging during diagnostic coronary angiography and coronary interventions has been reported to reduce the total contrast load to the patient compared with single-plane imaging [1–8]. Additionally, acquiring two simultaneous images from two orthogonal planes has been reported to be more efficient than single-plane imaging [2, 8–11]. However, there are conflicting reports as to whether the radiation dose to the patient differs between biplane and single-plane imaging during coronary studies [3, 10, 11].Biplane imaging allows two cineangiography runs to be recorded simultaneously with a single injection of contrast. With single-plane imaging, however, the same information can be acquired only by carrying out the two cineangiography runs serially with two separate injections of contrast [1, 2, 8, 10]. Biplane imaging enables the operator to visualise the target lesion in orthogonal planes simultaneously and was presumed to be more efficient than single-plane imaging, particularly in difficult procedures [1, 4, 9, 12]. Accordingly, examinations would become faster, use of fluoroscopy would be reduced, fewer cineangiography runs would be required and the average radiation dose to the patient would be comparatively lower than in the case of procedures performed with single-plane imaging. The contrast load with biplane imaging was also expected to be significantly reduced [3, 4, 11].These perceived advantages of biplane imaging have led to recommendations for its use in paediatric and adult cardiac catheter laboratories [1, 4, 5, 10, 12, 13]. A previous study comparing biplane and single-plane imaging in 1156 diagnostic coronary angiography procedures found a small, but notable, reduction in contrast load accompanied by significantly longer table times and screening times with biplane imaging, although radiation dose was not examined [14].Contrast-induced nephropathy (CIN) is a complication associated with prolonged hospitalisation and development of end-stage renal failure [15]. Patients with pre-existing renal disease, diabetes, congestive heart failure or older age are at the greatest risk in developing CIN [16–18]. These high-risk patients have a calculated incidence of CIN ranging from 10% to 30% [4, 18–20]. Pre-hydration is the primary intervention for preventing contrast nephropathy [18], but is not possible in the setting of emergency (primary) angioplasty procedures. The total contrast load during interventional procedures has been established as an independent predictor of CIN and could be effectively controlled by the operator during primary angioplasty cases [18, 21, 22]. Biplane imaging is commonly employed to minimise the contrast load, especially in patients with renal impairment and those who require primary coronary angioplasty procedures [1, 6, 7, 18, 23].Numerous studies have found that the radiation dose varies significantly according to tube angulations, particularly in the combination of steep left anterior oblique (LAO) with cranial or caudal angulations [24–27]. However, there are no published data on whether the radiation dose with biplane or single-plane imaging during coronary angioplasty differs between the three vascular territories: right coronary artery (RCA), left anterior descending (LAD) and left circumflex/intermediate (LCX). Furthermore, interventional cardiac procedures are operator dependent [28–30]. Hence, it was postulated that senior cardiologists would be more familiar with biplane equipment and thereby more able to reduce radiation dose, contrast load and procedural time than less experienced operators. To our knowledge, no studies have been published that compare the impact of biplane and single-plane imaging in coronary angioplasty procedures.The aims of this study were to determine whether biplane imaging reduces both contrast load and radiation dosage and shortens procedural time in patients undergoing primary or elective coronary angioplasty compared with single-plane imaging. We also investigated if there was a significant difference in radiation dose, contrast load and procedural time between biplane and single-plane imaging during coronary angioplasty in the three main vascular territories (RCA, LAD and LCX) and in procedures performed by operators with various levels of experience.     

Iron overload: accuracy of in-phase and out-of-phase MRI as a quick method to evaluate liver iron load in haematological malignancies and chronic liver disease

Objectives

The purpose of this prospective study was to evaluate the accuracy of in-phase and out-of-phase imaging to assess hepatic iron concentration in patients with haematological malignancies and chronic liver disease.

Methods

MRI-based hepatic iron concentration (M-HIC, μmol g^–1) was used as a reference standard. 42 patients suspected of having iron overload and 12 control subjects underwent 1.5 T in- and out-of-phase and M-HIC liver imaging. Two methods, semi-quantitative visual grading made by two independent readers and quantitative relative signal intensity (rSI) grading from the signal intensity differences of in-phase and out-of-phase images, were used. Statistical analyses were performed using the Spearman and Kruskal–Wallis tests, receiver operator curves and κ coefficients.

Results

The correlations between M-HIC and visual gradings of Reader 1 (r=0.9534, p<0.0001) and Reader 2 (r=0.9456, p<0.0001) were higher than the correlations of the rSI method (r=0.7719, p<0.0001). There was excellent agreement between the readers (weighted κ=0.9619). Both visual grading and rSI were similar in detecting liver iron overload: rSI had 84.85% sensitivity and 100% specificity; visual grading had 85% sensitivity and 100% specificity. The differences between the grades of visual grading were significant (p<0.0001) and the method was able to distinguish different degrees of iron overload at the threshold of 151 μmol g^–1 with 100% positive predictive value and negative predictive value.

Conclusion

Detection and grading of liver iron can be performed reliably with in-phase and out-of-phase imaging. Liver fat is a potential pitfall, which limits the use of rSI.Iron overload is a clinically recognised condition with variety of aetiologies and clinical manifestations [1-4]. Liver iron concentration correlates closely with the total body iron stores [5]. The excess iron accumulates mainly in the liver and the progressive accumulation of toxic iron can lead to organ failure if untreated [2,4]. Several diseases causing iron overload, such as transfusion-dependent anaemia, haematological malignancies, thalassaemia, haemochromatosis and chronic liver disease, result in a large number of patients with a potentially treatable iron overload [1,2,4].Several quantitative MRI methods for iron overload measurement by multiple sequences have been established, such as proportional signal intensity (SI) methods and proton transverse relaxation rates (R₂, R₂*) [4,6,7]. A gradient echo liver-to-muscle SI-based algorithm [8] has been widely validated and used for quantitative liver iron measurement [8-11]. MRI-based hepatic iron concentration (M-HIC, μmol g^–1 liver dry weight) with corresponding R₂* [9] can be calculated with this method which is a directly proportional linear iron indicator, virtually independent of the fat fraction, as the echo times are taken in-phase [8,9]. This method showed a high accuracy in calibrations with the biochemical analysis of liver biopsies (3–375 μmol g^–1) of 174 patients. The mean difference of 0.8 μmol g^–1 (95% confidence interval of –6.3 to 7.9) between this method and the biochemical analysis is quite similar [8] to the intra-individual variability found in histological samples [12].The quantitative MRI methods are based on progressive SI decay, with the longer echo times due to relaxing properties of iron. Interestingly, this iron-induced effect is seen in MR images with multiple echoes [4,6-11], but also in dual-echo images, namely in-phase and out-of-phase imaging [13,14]. In-phase and out-of-phase imaging has become a routine part of liver MRI, performed initially for liver fat detection [6,13,15]. Quite recently some investigators have noticed an alternative approach of the sequence to detect liver iron overload due to the more pronounced SI decrease on in-phase images with the longer echo time [13,14]. Yet, to our knowledge, this is the first prospective study evaluating the accuracy of in-phase and out-of-phase imaging to assess hepatic iron concentration.The purpose of the study was to evaluate the capability and accuracy of dual-echo in-phase and out-of-phase imaging to assess hepatic iron concentration at 1.5 T in patients with haematological malignancies and chronic liver disease. MRI-based hepatic iron concentration (M-HIC, μmol g^–1) was used as a reference standard [8,9].     

Multimodality imaging of obliterative portal venopathy: what every radiologist should know

Obliterative portal venopathy (OPV) is an important cause of non-cirrhotic portal hypertension, which is often erroneously misdiagnosed as cryptogenic cirrhosis. It has a worldwide distribution with majority of cases hailing from the Asian subcontinent. However, recently the disease has gained global attention particularly because of its association with human immunodeficiency virus infection and use of antiretroviral drug therapy (didanosine). As the name suggests, the disorder is characterized by sclerosis and obliteration of the intrahepatic portal vein branches (with attendant periportal fibrosis) leading to portal hypertension amid intriguingly little liver dysfunction. It primarily affects young adults who present with clinically significant portal hypertension in the form of episodes of variceal bleed; however, contrasting liver cirrhosis, the liver function and liver structure remain normal or near normal until late in the disease process. Radiological findings during advanced disease are often indistinguishable from cirrhosis often warranting a liver biopsy. Nevertheless, recent studies have suggested that certain imaging manifestations, if present, can help us to prospectively suggest the possibility of OPV. At imaging, OPV is characterized by a wide range of intrahepatic and/or extrahepatic portal venous abnormalities with attendant changes in liver and splenic volume and stiffness. We shall, through this pictorial review, appraise the literature and illustrate the germane radiological manifestations of OPV that can be seen using different imaging modalities including ultrasonography, CT, MRI, elastography and hepatic haemodynamic studies.It is important to recognize that not all varices mean liver cirrhosis. Although liver cirrhosis constitutes the commonest cause of portal hypertension, we should be aware that portal hypertension can occur in the absence of liver cirrhosis—a condition termed as non-cirrhotic portal hypertension (NCPH).^1,2 NCPH represents a heterogeneous group of (primarily vascular) disorders where portal hypertension manifests amid absent liver cirrhosis. Pathologically, the insult is either pre- or intrahepatic involving the main portal vein or its smaller branches and/or the perisinusoidal area.^1–3Obliterative portal venopathy (OPV) represents an important cause of NCPH that is characterized by sclerosis and obliteration of the medium-sized portal venous branches leading to portal hypertension.^1–10 Liver biopsy characteristically shows phlebosclerosis and periportal and perisinusoidal fibrosis amid absent cirrhosis (Figure 1).^1–3 Although, the exact aetiology is contentious, infections and prothrombotic states have been implicated in eastern and western patients, respectively.^1,2 Additionally, xenobiotic exposure, autoimmune and genetic factors have also been incriminated.^1–4 Although the disease has a worldwide distribution, it continues to remain poorly understood primarily owing to its relative rarity.^1–3,5–8 Another potential reason is the use of diverse terminologies under which the entity has been described from various parts of the globe, such as non-cirrhotic portal fibrosis in India, idiopathic portal hypertension in Japan and hepatoportal sclerosis in the USA.Open in a separate windowFigure 1.(a) Atrophic small portal tract (arrow) showing absent portal vein [haematoxylin and eosin stain (HE), ×200]. (b) Two small portal tract (arrows) approximations (×100, HE). (c) Portal and central vein approximation (×100, HE). (d) Parenchymal extinction suggested by portal–portal and portal–central approximation (Masson''s trichrome stain, ×200).More recently, the disease has gained global attention because of escalating number of cases being reported in human immunodeficiency virus (HIV)-infected patients.^1–3,8–10 Also, US Food and Drug Administration has recently issued a warning regarding the potential association of OPV in patients with HIV on didanosine (antiretroviral therapy).³OPV primarily affects young patients usually in their third or fourth decades of life. The affected individuals typically present with clinically significant portal hypertension characterized by multiple episodes of well-controlled upper gastrointestinal (GI) bleed, massive splenomegaly and/or hypersplenism.^1–3 Advanced stages of the disease are often indistinguishable from liver cirrhosis especially on imaging. However, discrimination from cirrhosis is crucial in clinical practice because of differences in management. Management of OPV is primarily symptomatic, that is, focused on management of an acute episode of variceal bleed. The risk of rebleeding and bleeding-related mortality is low. Intriguingly, in contrast to liver cirrhosis, the liver function and liver structure remain normal or near normal until late in the disease process leading to a better prognosis and higher survival rates; the 10-year survival rate is around 86–95%.^1,2 Development of jaundice, ascites and hepatic encephalopathy is uncommon and if at all is seen only after an episode of GI bleeding.^1,2 Liver failure and the incidence of developing hepatocellular carcinoma are also much lower.^1–3,8–10 Nonetheless, in 20–33% of patients, the liver gradually atrophies and shows functional decompensation, occasionally needing liver transplantation.^1,2Although limited literature is available on the radiological manifestations of OPV, recent studies have suggested certain imaging manifestations to be more prevalent in OPV that can allow discrimination from cirrhosis. Moreover, use of newer techniques, including transient elastography, can allow prospective non-invasive diagnosis of OPV based upon the differential changes in liver and splenic stiffness. The aim of this review is to appraise the imaging findings of OPV described in the literature and illustrate them across a wide array of imaging modalities, including ultrasonography, CT, MRI and elastography, in a group of biopsy-proven cases of OPV diagnosed at our institute.     

Simplified rules for everyday delineation of lymph node areas for breast cancer radiotherapy

The aim of this study was to present the simplified rules of delineation of lymph node (LN) volumes in breast irradiation. Practical rules of delineation of LN areas were developed in the Department of Radiation Oncology of the Institut Curie. These practical guidelines of delineation were based on different specific publications in the field of breast and LN anatomy. The principal characteristic of these rules is their clearly established relationship with anatomical structure, which is easy to find on CT slices. The simplified rules of delineation have been published in pocket format as the illustrated atlas “Help of delineation for breast cancer treatment”. In this small pocket guide, delineation using the practical rules is illustrated, with examples from anatomical CT slices. It is shown that there is an improvement in delineation after the use of these simplified rules and the guide. In conclusion, this small guide is useful for improving everyday practice and decreasing the differences in target delineation for breast irradiation between institutions and observers.The value of lymph node irradiation has already been demonstrated by various studies and meta-analyses [1–3]. In the age of new conformal techniques, there is a real need for a clear definition of treated volumes, such as breast, tumour bed, lymph node areas and organs at risk (OAR) [4–10]. Many teams have been working for several years on the definition of treated volumes. Some delineation studies are exclusively theoretical and some provide a good anatomical atlas, but this information is difficult to use in everyday practice [4–15]. The treatment position has also been shown to be an important factor of variability in the depth and situation of lymph node volumes [5, 6]. Conformal and intensity-modulated radiotherapy (IMRT) require an exact definition of target volumes in terms of their anatomical limits for delineation on CT scans. Some authors have proposed anatomically based landmarks specific for breast cancer radiotherapy in order to delineate all regional lymph nodes and the breast [5, 6, 8, 10, 15, 16]. Despite this work, two recent papers have demonstrated the individual interobserver variability and differences in target and OAR delineation for breast irradiation, especially in lymph node areas [7, 8].This study was designed to propose a practical method to improve and facilitate the everyday delineation process for the clinicians of our department.     

Towards clinical assessment of velopharyngeal closure using MRI: evaluation of real-time MRI sequences at 1.5 and 3 T

Objective

The objective of this study was to demonstrate soft palate MRI at 1.5 and 3 T with high temporal resolution on clinical scanners.

Methods

Six volunteers were imaged while speaking, using both four real-time steady-state free-precession (SSFP) sequences at 3 T and four balanced SSFP (bSSFP) at 1.5 T. Temporal resolution was 9–20 frames s⁻¹ (fps), spatial resolution 1.6×1.6×10.0–2.7×2.7×10.0 mm³. Simultaneous audio was recorded. Signal-to-noise ratio (SNR), palate thickness and image quality score (1–4, non-diagnostic–excellent) were evaluated.

Results

SNR was higher at 3 T than 1.5 T in the relaxed palate (nasal breathing position) and reduced in the elevated palate at 3 T, but not 1.5 T. Image quality was not significantly different between field strengths or sequences (p=NS). At 3 T, 40% acquisitions scored 2 and 56% scored 3. Most 1.5 T acquisitions scored 1 (19%) or 4 (46%). Image quality was more dependent on subject or field than sequence. SNR in static images was highest with 1.9×1.9×10.0 mm³ resolution (10 fps) and measured palate thickness was similar (p=NS) to that at the highest resolution (1.6×1.6×10.0 mm³). SNR in intensity–time plots through the soft palate was highest with 2.7×2.7×10.0 mm³ resolution (20 fps).

Conclusions

At 3 T, SSFP images are of a reliable quality, but 1.5 T bSSFP images are often better. For geometric measurements, temporal should be traded for spatial resolution (1.9×1.9×10.0 mm³, 10 fps). For assessment of motion, temporal should be prioritised over spatial resolution (2.7×2.7×10.0 mm³, 20 fps).

Advances in knowledge

Diagnostic quality real-time soft palate MRI is possible using clinical scanners and optimised protocols have been developed. 3 T SSFP imaging is reliable, but 1.5 T bSSFP often produces better images.Approximately 450 babies born in the UK every year have an orofacial cleft [1], the majority of which include the palate [2]. While a cleft palate is commonly repaired surgically at around 6 months [3], residual velopharyngeal insufficiencies require follow-up surgery in 15–50% of cases [4]. This residual defect results in an incomplete closure of the velopharyngeal port, which in turns leads to hypernasal speech. Assessment of velopharyngeal closure in speech therapy is commonly performed using X-ray videofluoroscopy or nasendoscopy [5,6]. While nasendoscopy is only minimally invasive, it may be uncomfortable and provides only an en face view of the velopharyngeal port. In contrast, X-ray videofluoroscopy is non-invasive and produces an image which is a projection of the target anatomy. Additional information may be obtained from projections at multiple angles [5,7], but anatomical structures may overlie each other. Furthermore, soft tissue contrast, such as that from the soft palate, is poor, although it may be improved using a barium contrast agent coating [8] at the expense of making the procedure more invasive and unpleasant. Arguably the greatest drawback of X-ray videofluoroscopy is the associated ionising radiation dose, which carries increased risk in paediatric patients [9].An increasing number of research studies have used MRI to image the soft palate [10-13] and upper vocal tract [14-17]. In contrast to X-ray videofluoroscopy and nasendoscopy, MRI provides tomographic images in any plane with flexible tissue contrast. As a result, MRI has been used to obtain images of the musculature of the palate at rest and during sustained phonation [10,18,19]. It has also been used to image the whole vocal tract at rest or during sustained phonation [20-27] and with a single mid-sagittal image dynamically during speech [13,15-17,28-35].For assessment of velopharyngeal closure, dynamic imaging with sufficient temporal resolution and simultaneous audio recording is required. Audio recording during imaging is complicated by the loud noise of the MRI scanner, and both the safety risk and image degradation caused by using an electronic microphone within the magnet. As a result, optical fibre-based equipment with noise cancellation algorithms must be used [36].In order to fully resolve soft palate motion, Narayanan et al [30] suggested that a minimum temporal resolution of 20 frames s⁻¹ (fps) is required. A similar conclusion was reached by Bae et al [13], based on measurements of soft palate motion extracted from X-ray videofluoroscopy. Using segmented MRI, Inoue et al [35] demonstrated that changes in the velar position that were evident at acquired frame rates of 33 fps were not observed at 8 fps. However, MRI is traditionally seen as a slow imaging modality and achieving sufficient temporal resolution at an acceptable spatial resolution is challenging. Furthermore, as the soft palate is bordered on both sides by air, the associated changes in magnetic susceptibility at the interfaces make images prone to related artefacts.Dynamic MRI of the vocal tract has been performed using both segmented [17,33,37] and real-time acquisitions [13,15,16,28,31,38]. Segmented acquisitions [39] acquire only a fraction of the k-space data required for each image during one repetition of the test phrase and, hence, require multiple identical repetitions. While these segmented techniques permit high temporal and spatial resolutions [35], they require reproducible production of the same phrase up to 256 times [34], leading to subject fatigue. Differences between repeats of up to 95 ms in the onset of speech following a trigger have also been demonstrated [36].In contrast to segmented techniques, real-time dynamic methods permit imaging of natural speech, but require extremely rapid acquisition and often advanced reconstruction methods. The turbo spin echo (TSE) zoom technique [40] has been used to perform real-time MRI of the vocal tract [29,31] and is available as a clinical tool. The zoom technique excites a reduced field of view in the phase encode direction, hence allowing a smaller acquisition matrix and shorter scan for a constant spatial resolution. While such spin echo-based techniques are less susceptible to magnetic field inhomogeneity related signal dropout artefacts than other sequences, the frame rates achieved with these sequences are limited to 6 fps [31]. Gradient echo-based techniques have also been used to achieve similar temporal resolution [12,41,42] in the upper vocal tract, but are often used at much higher frame rates in other MRI applications such as cardiac imaging [43,44]. A number of gradient echo sequence variants exist. Fast low-angle shot (FLASH) type sequences [45] spoil any remaining transverse magnetisation at the end of every sequence repetition (TR). In contrast, steady-state free-precession (SSFP) sequences are not spoiled [46] and the remaining transverse magnetisation is used in the next TR to improve the signal-to-noise ratio (SNR), but renders the images sensitive to signal loss in the presence of motion. Balanced SSFP (bSSFP) sequences include additional gradients to bring the transverse magnetisation completely back into phase at the end of every TR [47,48]. The result is that bSSFP sequences have high SNR and are less sensitive to motion than SSFP sequences, but are more sensitive to field inhomogeneities, which cause bands of signal dropout.Both TSE and the gradient echo techniques discussed here sample in a rectilinear or Cartesian fashion, where one line of k-space is sampled in each echo. However, for real-time speech imaging, the highest acquired frame rates have been achieved by sampling k-space along a spiral trajectory [15,16,30,49]. While spiral imaging is an efficient way to sample k-space and is motion-resilient, it is prone to artefacts, particularly blurring caused by magnetic field inhomogeneities and off-resonance protons (i.e. fat) [50]. Recently, one group successfully used spiral imaging with multiple saturation bands and an alternating echo time (TE) to achieve an acquired real-time frame rate of 22 fps [13,16]. The saturation bands were used to allow a small field of view to be imaged without aliasing artefacts. The alternating TE was used to generate dynamic field maps which were incorporated into the reconstruction to compensate for magnetic field inhomogeneities. However, such advanced acquisition and reconstruction techniques are only available in a small number of research centres.The aim of this work is to optimise and demonstrate high-temporal-resolution real-time sequences available on routine clinical MRI scanners for assessment of soft palate motion and velopharyngeal closure. Consequently, radial and spiral acquisitions were excluded and the work focuses on Cartesian gradient echo sequences with parallel imaging techniques. As more clinical MRI departments now have 3 T scanners, imaging was performed at both 1.5 and 3 T to enable comparisons. At each field strength, we optimised sequences and implemented four combinations of spatial and temporal resolution in six subjects with simultaneous audio recordings.     

Miliary tuberculosis: a comparison of CT findings in HIV-seropositive and HIV-seronegative patients

The aim of this study was to determine the differences in CT findings of miliary tuberculosis in patients with and without HIV infection. Two radiologists reviewed retrospectively the CT findings of 15 HIV-seropositive and 14 HIV-seronegative patients with miliary tuberculosis. The decisions on the findings were reached by consensus. Statistical analysis was performed using the χ² test, Mann–Whitney U-test and Fisher''s exact test. All of the HIV-seropositive and -seronegative patients had small nodules and micronodules distributed randomly throughout both lungs. HIV-seropositive patients had a higher prevalence of interlobular septal thickening (p = 0.017), necrotic lymph nodes (p = 0.005) and extrathoracic involvement (p = 0.040). The seropositive patients had a lower prevalence of large nodules (p = 0.031). In conclusion, recognition of the differences in the radiological findings between HIV-seropositive and -seronegative patients may help in the establishment of an earlier diagnosis of immune status in patients with miliary tuberculosis.Miliary tuberculosis (TB), which results from lympho-haematogenous dissemination of Mycobacterium tuberculosis, is a complication of both primary and post-primary TB [1, 2]. This disease results in the formation of small discrete foci of granulomatous tissue, which are uniformly distributed throughout the lung [3].An increase in TB incidence, including miliary TB, has been associated with infection by human immunodeficiency virus (HIV) [4]. In 2005, the World Health Organization estimated that 12% of HIV deaths globally were caused by TB, and that there were 630 000 new co-infections with TB and HIV [5]. Disseminated TB accounted for 5.4–8.1% of culture-confirmed TB cases, with 10–14% of patients coinfected with HIV having clinically recognisable dissemination [6, 7].Chest radiography may be helpful in the detection and final diagnosis of miliary TB. The characteristic radiographical findings consist of the presence of fine granular or numerous small nodular opacities measuring 1–3 mm in diameter scattered throughout both lungs [1, 3, 8, 9]. However, the radiograph may appear to be normal in the early stage of disease or in cases with nodules below the threshold of perceptibility; therefore, a diagnosis of miliary TB from chest radiographs can be difficult [10].Several studies have shown that CT imaging is more sensitive for the detection of parenchymal abnormalities in patients with AIDS who have active intrathoracic disease, and it has been suggested that CT may also be helpful in the differential diagnosis [11–14]. In addition, it has been reported that certain imaging techniques provided by multidetector-row CT are useful for the diagnosis of multiple micronodular infiltrative lung disease [15]. CT findings of miliary TB have been described in previous reports [16–18]; however, only a few studies on miliary TB in patients with HIV, particularly with reference to the CD4 count, have been reported [19, 20]. The radiographic manifestations of HIV-associated pulmonary TB are thought to be dependent upon the level of immunosuppression at the time of overt disease [21–23].The purpose of this study was to determine the differences in the CT findings of miliary TB for patients with and without HIV infection and to analyse any correlation between the CT features and the level of immunosuppression in patients.     

Pulmonary tuberculosis associated with the reversed halo sign on high-resolution CT

We describe the case of a 32-year-old woman with pulmonary tuberculosis in whom a high-resolution CT scan demonstrated the reversed halo sign. The diagnosis of tuberculosis was made by lung biopsy and the detection of acid-fast bacilli in the sputum smear and culture. Follow-up assessment revealed a significant improvement in the lesions.The reversed halo sign is observed on high-resolution CT (HRCT) as a focal round area of ground-glass attenuation surrounded by a crescent or ring of consolidation [1, 2]. It was first described as being relatively specific for cryptogenic organising pneumonia [1], but was later observed in several other infectious [3–5] and non-infectious [6, 7] diseases.We report a case of a 32-year-old patient with tuberculosis who exhibited the reversed halo sign on chest CT. To our knowledge, this sign has not been previously described in an adult with pulmonary tuberculosis.     

Prognostic factors associated with a subchondral insufficiency fracture of the femoral head

Objective

The aim of this study was to identify the risk factors associated with the prognosis of a subchondral insufficiency fracture of the femoral head (SIF).

Methods

Between June 2002 and July 2009, 25 patients diagnosed with SIF were included in this study. Sequential radiographs were evaluated for the progression of collapse. Clinical profiles, including age, body mass index, follow-up period and Singh’s index, were documented. The morphological characteristics of the low-intensity band on T₁ weighted MRI were also examined with regards to four factors: band length, band thickness, the length of the weight-bearing portion and the band length ratio (defined as the proportion of the band length to the weight-bearing portion of the femoral head in the slice through the femoral head centre).

Results

Radiographically, a progression of collapse was observed in 15 of 25 (60.0%) patients. The band length in patients with progression of collapse [22.5 mm; 95% confidence interval (CI) 17.7, 27.3] was significantly larger than in patients without a progression of collapse (13.4 mm; 95% CI 7.6, 19.3; p<0.05). The band length ratio in patients with progression of collapse (59.8%; 95% CI 50.8, 68.9) was also significantly higher than in patients without a progression of collapse (40.9%; 95% CI 29.8, 52.0; p<0.05). No significant differences were present in the other values.

Conclusion

These results indicate that the band length and the band length ratio might be predictive for the progression of collapse in SIF.Subchondral insufficiency fractures of the femoral head (SIF) often occur in osteoporotic elderly patients [1-9]. Patients usually suffer from acute hip pain without any obvious antecedent trauma. Radiologically, a subchondral fracture is seen primarily in the superolateral portion of the femoral head [4,5,10]. T₁ weighted MRI reveal a very low-intensity band in the subchondral area of the femoral head, which tends to be irregular, disconnected and convex to the articular surface [2,4,5,7,9,11]. This low-intensity band in SIF was histologically proven to correspond with the fracture line and associated repair tissue [5,9]. Some cases of SIF resolve after conservative treatment [5,11-14]; other cases progress until collapse, thereby requiring surgical treatment [4-10,15]. The prognosis of SIF patients remains unclear.The current study investigated the risk factors that influence the prognosis of SIF based on the progression to collapse.     

In vitro assessment of the antibiotic efficacy of contrast media and antibiotics and their combinations at various dilutions

Discography is a controversial diagnostic procedure involving the injection of radiographic contrast medium (RCM) into the intervertebral disc. Iatrogenic bacterial discitis is a rare but serious complication. The intervention has been increasingly performed in our patients here in the United Arab Emirates. Prophylactic intravenous antibiotic administration can reduce post-interventional discitis; however, this may favour the development of bacterial resistance. Direct intradiscal injection of an antibiotic together with the RCM is a potential alternative. To date, there has been only one study on the efficacy of antibiotics added to an RCM. Equally, there are only limited data regarding the potential direct effect of RCM on bacterial growth. The purpose of this study was to determine whether the efficacy of antibiotics is affected when RCM are added. In an in vitro study, the effect of non-ionic RCM on the growth of five laboratory bacterial strains, alone and in combination with three broad-spectrum antimicrobials, was tested. Bacterial growth was assessed in the absence and the presence of RCM, antibiotics and their combinations. All three RCM alone demonstrated some inhibition of bacterial growth at high concentrations. In the presence of the RCM, all three antibiotics retained their inhibitory effect on bacterial growth. In conclusion, our in vitro experiments did not reveal any changes in the antimicrobial efficacy of the three antibiotics in the presence of the three tested RCM. Subsequent clinical trials will need to assess whether intradiscal antibiotic administration may be a suitable substitute for, or a supplement to, prophylactic systemic antibiotics before discography.Lindblom [1] was the first author to describe discography, which is performed to outline the morphology of the intervertebral disc. Radiographic contrast media (RCM) are injected into the nucleus pulposus of a disc [1–3]. Owing to the further development in cross-sectional imaging procedures, especially in MRI, indications for discography or CT discography have been substantially changed. At present, provocative discography is increasingly being carried out, especially in the USA and Australia, for disc stimulation in order to provoke or to reproduce discogenic pain [4–7]; special indications are lower back pain with equivocal findings on MRI, post-surgical failed lower back pain, status prior to spinal fusion or the injection of cortisone or anaesthetics into an intervertebral disc [3–5, 7–15]. The most serious complication is post-interventional bacterial discitis owing to the invasiveness of the procedure [2, 4, 5, 16]; as such, many publications deal with prophylactic intravenous (iv) administration of antibiotics. Several animal experiments in sheep, lambs and rabbits, conducted in the 1980s, 1990s and in 2006, demonstrated antibiotics in the intervertebral discs after systemic iv injection (with higher concentrations in the annulus fibrosus than in the nucleus pulposus) [17–23]. However, it was emphasised that the timing of the systemic antibiotic prophylaxis was critical [17, 21, 23]. Conversely, post-interventional systemic administration of antibiotics was not considered beneficial [21, 22]. A study in humans before lumbar spinal fusion showed that cefazolin was detectable in disc samples of these patients after iv antibiotic prophylaxis, with a peak concentration between 37 min and 53 min after iv injection [19].In 1990, Osti et al [23] conducted animal experiments and, subsequently, a clinical study in 127 patients, examining 337 discs, in whom an antibiotic was added to the intradiscally administered RCM, in addition to earlier iv prophylaxis [23]. Post-interventional discitis was not detected in either the animals or the patients.To date, different recommendations for the prevention of post-interventional discitis are in place, incorporating either systemic intravenous injection of antibiotics [16], a combination of iv and intradiscally injected antibiotics [24], or even no antibiotics at all [25]. In order to avoid increasing bacterial resistance to systemically administered antibiotics [14, 26], intradiscally injected antibiotics might be an alternative owing to the direct application of the antibiotic into the disc. One study on the efficacy of antibiotics in combination with iohexol has already been conducted by Klessig et al [26].Discography is a constantly increasing intervention in the United Arab Emirates (UAE) and, as hospital-borne infections are also a major problem in this country, the aim of our study was to investigate the effect of three different non-ionic RCM (including one new dimeric compound that is still in clinical trials), alone and in combination with three broad-spectrum antibiotics, on different laboratory bacterial strains to detect any potential effect of the RCM on antibiotic efficacy.     

Correlation between computerised findings and Newman's scaling on vascularity using power Doppler ultrasonography imaging and its predictive value in patients with plantar fasciitis

Objectives

The purpose of this study was to correlate findings on small vessel vascularity between computerised findings and Newman''s scaling using power Doppler ultrasonography (PDU) imaging and its predictive value in patients with plantar fasciitis.

Methods

PDU was performed on 44 patients (age range 30–66 years; mean age 48 years) with plantar fasciitis and 46 healthy subjects (age range 18–61 years; mean age 36 years). The vascularity was quantified using ultrasound images by a customised software program and graded by Newman''s grading scale. Vascular index (VI) was calculated from the software program as the ratio of the number of colour pixels to the total number of pixels within a standardised selected area of proximal plantar fascia. The 46 healthy subjects were examined on 2 occasions 7–10 days apart, and 18 of them were assessed by 2 examiners. Statistical analyses were performed using intraclass correlation coefficient and linear regression analysis.

Results

Good correlation was found between the averaged VI ratios and Newman''s qualitative scale (ρ = 0.70; p<0.001). Intratester and intertester reliability were 0.89 and 0.61, respectively. Furthermore, higher VI was correlated with less reduction in pain after physiotherapeutic intervention.

Conclusions

The computerised VI not only has a high level of concordance with the Newman grading scale but is also reliable in reflecting the vascularity of proximal plantar fascia, and can predict pain reduction after intervention. This index can be used to characterise the changes in vascularity of patients with plantar fasciitis, and it may also be helpful for evaluating treatment and monitoring the progress after intervention in future studies.Plantar fasciitis is the most common cause of heel pain, and about 2 000 000 patients in the USA receive treatment every year because of this condition [1]. Besides mechanical loading, vascular disturbance with consequent metabolic impairment and hypoxia is thought to play an important role [2]. Indeed, fibrovascular hyperplasia and vascular proliferation were observed from microscopic specimens obtained from operative resection [3-5]. Walther et al [6] were the first group to evaluate plantar fascia vascularity non-invasively using power Doppler ultrasonography (PDU).PDU is one of the colour flow imaging techniques that encodes the amplitude of the power spectral density of the Doppler signals [7]. This method has been used to assess soft-tissue vascularity and treatment efficacy with a variety of musculoskeletal and related problems. Changes in vascularity in synovial tissues in patients with rheumatoid arthritis [8-11], osteoarthritis [12,13], tendinopathy [6,14-21] and plantar fasciitis [6] have been reported. Modulation in vascularity was observed in patients with tendinopathy after a course of intervention [14-21]. Most of these studies used the Newman''s grading scale to grade the tissue vascularity [19-21]. This qualitative grading for the PDU images had high correlation with the histopathological grading of vascularity of the synovial membrane in patients with arthritis [11]. Nevertheless, Newman''s grading system may not be objective and sensitive enough to differentiate subtle vascularity changes.Recently, computerised methods were used to quantify tissue vascularity with ultrasonography. Tissue vascularity was quantified by computing a vascular index (VI), which is calculated as the ratio of the number of colour pixels to the total number of pixels within the region of interest in patients with soft-tissue problems [8,9,11,17]. Note that most of these studies were conducted using colour Doppler ultrasonography. In this connection, PDU is superior to frequency-based colour Doppler ultrasonography, especially in tissues with low blood flow, such as the plantar fascia [6,22,23]. Ying et al [24] reported the feasibility of computerised quantification of vascularity in thyroid tissues with PDU. We were interested in evaluating whether the computerised quantification of vascularity could be applied on musculoskeletal tissue, such as the plantar fascia. Therefore, the purpose of the present study was to correlate the computerised VI and Newman''s qualitative grading scale in quantifying plantar fascia vascularity using PDU, to evaluate the intra- and intertester reliability of the computerised quantitative method and its predictive ability of recovery in patients with plantar fasciitis. Proximal plantar fascia, which is the most commonly affected area in individuals with plantar fasciitis, according to clinical examination [25,26] and previous B-mode ultrasonography [26-28], was chosen as the target testing area.     

Primary and secondary breast lymphoma: prevalence, clinical signs and radiological features

Objectives

The purpose of this study was to determine the prevalence, clinical signs and radiological features of breast lymphoma.

Methods

This is a retrospective review of 36 patients with breast lymphoma (22 primary and 14 secondary). 35 patients were female and 1 was male; their median age was 65 years (range 24–88 years). In all patients, the diagnosis was confirmed histopathologically.

Results

The prevalence of breast lymphoma was 1.6% of all identified cases with non-Hodgkin lymphoma and 0.5% of cases with breast cancer. B-cell lymphoma was found in 94% and T-cell lymphoma in 6%. 96 lesions were identified (2.7 per patient). The mean size was 15.8±8.3 mm. The number of intramammary lesions was higher in secondary than in primary lymphoma. The size of the identified intramammary lesions was larger in primary than in secondary lymphoma. Clinically, 86% of the patients presented with solitary or multiple breast lumps. In 14%, breast involvement was diagnosed incidentally during staging examinations.

Conclusion

On mammography, intramammary masses were the most commonly seen (27 patients, 82%). Architectural distortion occurred in three patients (9%). In three patients (9%), no abnormalities were found on mammography. On ultrasound, the identified lesions were homogeneously hypoechoic or heterogeneously mixed hypo- to hyperechoic. On MRI, the morphology of the lesions was variable. After intravenous administration of contrast medium, a marked inhomogeneous contrast enhancement was seen in most cases. On CT, most lesions presented as circumscribed round or oval masses with moderate or high enhancement.Ductal and lobular carcinomas are the most frequent tumours of the breast. Breast involvement by lymphoma is very rare. It can occur as a primary breast tumour or as an extranodal manifestation in systemic disease [1-5]. According to the literature, the prevalence of breast lymphoma (BL) ranges from 0.04 to 0.5% of malignant breast neoplasms [1,2]. In addition, the prevalence of primary BL (PBL) varies from 0.85 to 2.2% of extranodal malignant lymphomas [3-5]. Secondary BL (SBL) is more common [6-8]. The rarity of BL can be attributed to the fact that the breast contains very little lymphoid tissue [9,10].Only a few of the published studies focus on the radiological features of BL, and conflicting findings of BL have been reported [1,7,11-13]. Only in one investigation has the distinction between primary and secondary breast involvement been taken into consideration [1]. Therefore, the aim of this study was to determine the prevalence of BL in our population and to analyse its clinical and radiological characteristics.     

Is there a difference in post-transplant lymphoproliferative disorder in adults after solid organ and haematologic stem cell transplantation? Experience in 41 patients

Objective:

To determine if there is a difference in post-transplant lymphoproliferative disorder (PTLD) in adults after solid organ transplantation (SOT) and haematologic stem cell transplantation (HST).

Methods:

In this institutional review board-approved Health Insurance Portability and Accountability Act-compliant study, we reviewed clinical data and imaging at the time of diagnosis in 41 patients (26 SOT and 15 HST) (31 males and 10 females; mean age 51 years) with histopathology-confirmed PTLD seen at our institution from 2004 through 2013. Statistical analysis was performed to assess difference in distribution and survival between SOT and HST cohorts.

Results:

SOT: 17 lung/cardiac, 8 renal and 1 liver transplant recipients. HST: 13 leukaemia/lymphoma and 2 patients with aplastic anaemia. Median time to diagnosis: SOT 3.0 years; HST 6 months (Fisher''s exact test; p = 0.0011). There was no statistically significant difference in distribution of PTLD after SOT and HST with nodes (15/26; 8/15), lung (10/26; 5/15) and bowel (6/26; 4/15) being the most common sites. Hepatic (3/26) and neurologic (2/26) involvement occurred in only SOT cohort while splenic PTLD (5/15) occurred more often in HST cohort. Death occurred earlier in HST (9/15; 2 weeks) than SOT cohort (12/26; 11 months) (Wilcoxon test; p = 0.0188).

Conclusion:

PTLD did not differ significantly in distribution between SOT and HST cohorts. PTLD after HST occurred early and had shorter survival.

Advances in knowledge:

The most common sites of PTLD were the nodes, lung and bowel. Distribution of PTLD does not differ significantly between patients with SOT and HST. PTLD after HST occurs early and has poor survival compared with PTLD after SOT.Post-transplant lymphoproliferative disorder (PTLD) occurs secondary to abnormal lymphoid or plasmacytic proliferation subsequent to solid organ transplantation (SOT) or haematologic stem cell transplantation (HST) in the setting of immunosuppression.¹ PTLD typically occurs with Epstein–Barr virus (EBV) infection,² although EBV-negative PTLD can also occur.^3,4 Per the World Health Organization classification scheme, PTLD is categorized as (1) early lesion PTLD, which includes reactive plasmacytic hyperplasia, (2) polymorphic PTLD, which includes polyclonal and monoclonal subtypes and (3) monomorphic PTLD, which is subcategorized as B-cell lymphomas including diffuse large B-cell lymphoma (DLBCL) and Burkitt''s lymphoma, T-cell lymphomas such as peripheral T-cell lymphoma and natural killer lymphomas.¹Risk for PTLD is dependent on level and duration of immunosuppression and may explain the higher incidence of PTLD in patients with lung transplant and small bowel transplant, who are typically more immunosuppressed.⁵ Incidence of PTLD has also increased with advent of more potent immunosuppressants such as cyclosporine.^6,7 Other risk factors include EBV seropositive transplant donor, cytomegalovirus (CMV) infection and comorbidities such as Langerhans cell histiocytosis, autoimmune hepatitis and chronic interstitial nephritis.⁸ EBV seronegativity in transplant recipients is also an important risk factor for PTLD.^9–12 In patients with HST, presence of T-cell depletion, HLA mismatching between donor and recipient, primary immunodeficiency as indication for transplant and antilymphocyte therapy are risk factors for PTLD.^13,14PTLD occurring after SOT and HST are indistinguishable in clinical presentation.¹⁴ However, PTLD after HST is associated with a higher incidence of fulminant and disseminated disease with increased mortality.^14–17 From an imaging stand point, it is unknown whether PTLD occurring in these two settings differs in any way. Accordingly, the purpose of this article is to determine if there is a difference between PTLD after SOT and HST on imaging.     

The intravertebral cleft in benign vertebral compression fracture: the diagnostic performance of non-enhanced MRI and fat-suppressed contrast-enhanced MRI

We compared the diagnostic performance of non-enhanced MRI and fat-suppressed contrast-enhanced MRI (CEMRI) in diagnosing intravertebral clefts in benign vertebral compression fractures (VCFs). We retrospectively reviewed 99 consecutive patients who had undergone percutaneous vertebroplasty for VCFs. A cleft was defined as a signal void or hyperintense area on non-enhanced MRI (T₁ and T₂ weighted imaging) or as a hypointense area within a diffusely enhanced vertebra on CEMRI. A cleft was confirmed as a solid opacification on post-procedural radiographs. The interobserver reliability and MRI diagnostic performance were evaluated. The interobserver reliability of non-enhanced MRI was substantial (k _ 0.698) and the interobserver reliability of CEMRI was almost perfect (k _ 0.836). Post-procedural radiographs showed solid cleft opacification in 32 out of the 99 cases. The sensitivity and specificity of non-enhanced MRI were 0.72 and 0.82 (observer 1) and 0.63 and 0.87 (observer 2), respectively. The sensitivity and specificity of CEMRI were 0.94 and 0.63 (observer 1) and 0.85 and 0.60 (observer 2), respectively. The sensitivity of CEMRI was significantly higher than that of non-enhanced MRI, and the specificity of non-enhanced MRI was higher than that of CEMRI. CEMRI was highly reliable and sensitive, and non-enhanced MRI was specific for intravertebral clefts. Therefore, spine MRIs, including CEMRI, could provide useful information about intravertebral clefts before percutaneous vertebroplasty.Intravertebral clefts associated with vertebral compression fractures (VCFs) are radiographic signs representing cavities within fractured vertebrae and have long been considered pathognomonic for avascular necrosis of the spine (Kümmell’s sign) [1–3]. However, several investigators have observed that intravertebral clefts are common in patients with osteoporotic compression fractures [4–6]. Currently, clefts are thought to represent corticocancellous disruption in mobile osteoporotic fractures, rather than avascular necrotic disease [4, 6].Percutaneous vertebroplasty (PV) is an effective and minimally invasive procedure for the treatment of osteoporotic compression fractures [7, 8]. The advent of PV as the major treatment option for VCFs has prompted interest in intravertebral clefts occurring in benign VCFs. Recent studies have suggested that the clinical outcomes and complications associated with PV are influenced by the presence of clefts [4, 9–13]. Thus, radiological detection of clefts is indispensable for managing patients with VCFs.Spine MRI is commonly used for the evaluation of acute VCFs. MRI is useful in distinguishing malignancy from acute osteoporotic VCFs [14, 15] and is effective in demonstrating bone marrow oedema associated with acute compression fractures, which is one of the indications for performing PV [14, 16]. The MRI findings associated with intravertebral clefts have been well described [3–5]. However, there is controversy concerning the efficacy of MRI in diagnosing clefts. Specifically, the reliability and effectiveness of contrast-enhanced MRI (CEMRI), first assessed by Oka et al in 2005 [11], has not been properly evaluated. Such evaluation is important, given that CEMRI entails additional expense.To evaluate the efficacy of the CEMRI for the prediction of intravertebral clefts, we assessed the interobserver reliability and diagnostic performance of non-enhanced T₁ weighted and T₂ weighted MRI (T1WI and T2WI) and CEMRI in the identification of intravertebral clefts in VCFs. We then compared the diagnostic performance of CEMRI with that of non-enhanced MRI.     

Contrast-enhanced ultrasonography of hepatocellular carcinoma: correlation between quantitative parameters and histological grading

Objective

The quantitative parameters in the contrast-enhanced ultrasonography time–intensity curve of hepatocellular carcinoma (HCC) were studied to explore their possible implication for histological grading of HCC.

Methods

A total of 130 HCC patients (115 males and 15 females; age: 48.13±11.00 years) were studied using contrast-enhanced ultrasonography time–intensity curve and histological pathology. The quantification software Sonoliver® (TomTec Imaging Systems, Unterschleissheim, Germany) was applied to derive time–intensity curves of regions of interest in the interior of HCCs and in reference. Quantitative parameters of 115 patients were successfully obtained, including maximum of intensity (IMAX), rise time (RT), time to peak (TTP), rise slope (RS) and washout time (WT). Histological grading of HCC was performed using haematoxylin–eosin staining, and monoclonal antibodies specific for smooth muscle actin were used to observe unpaired arteries (UAs).

Results

There were significant differences among WTs in the three differentiated HCC groups (p<0.05). However, there were no significant differences among RT, TTP, RS and IMAX in the differentiated HCC groups. Moreover, the number of UAs in the differentiated HCC groups showed no statistical significance.

Conclusion

WT plays an important role in predicting well, moderately and poorly differentiated HCC.The majority of hepatocellular carcinomas (HCCs) develop through multistep hepatocarcinogenesis [1]. Various types of hepatocellular nodules are seen in cirrhotic livers. The International Working Party of the World Congress of Gastroenterology classifies hepatocellular nodules into six types: regenerative nodules, low-grade dysplastic nodules, high-grade dysplastic nodules, well-differentiated HCC, moderately differentiated HCC and poorly differentiated HCC. The histopathological grades and types constitute well-established prognostic factors [2]. Thus, early diagnosis and confirmation of the type of hepatocellular nodules present and cellular differentiation before treatment are important.Although definite differentiation among HCC by imaging is usually impossible, the relationship between tumour cellular differentiation and image findings has been studied using contrast-enhanced (CE) CT, CEMRI and CE ultrasonography (CEUS). Tumour pathological differentiation correlates well with image findings [,3−8].Dynamic CEUS during the past decade has noticeably improved the detection and characterisation of focal liver lesions [9]. A previous study showed that CEUS and spiral CT provided a similar diagnostic accuracy in the characterisation of focal liver lesion [10]. The appearance of HCC on CEUS has also been described well. Current low-mechanical-index techniques for CEUS using second-generation microbubble agents have advantages in characterising HCC, including real-time demonstration of continuous haemodynamic changes in both the liver and hepatocellular nodules. Some studies postulated that variations of enhancement patterns may be related to the pathological function of HCC [,5−8]. Moderately differentiated HCCs generally show classic enhancement features, with presence of hypervascularity in the arterial phase and washout during the portal phase, whereas well and poorly differentiated tumours account for most atypical variations in the arterial phase and portal venous phase [7].Reports assessing hepatocellular nodules have been based on visual analysis, despite the disadvantages of interobserver variability and low reproducibility of results. Although quantitative analysis CEUS perfusion provides more objective, reliable and reproducible results [11], the time–intensity curve (TIC) of CEUS has been obtained by quantification software for offline analysis [,12−14], from which a series of semi-quantitative perfusion parameters is extracted and analysed. An analysis of the parameters of TIC in HCC has proven the correlation of CEUS with unpaired arteries (UAs) in HCC [14]. In the present study, we compare the quantitative parameters in CEUS and UAs in different pathological gradings of HCCs to explore their possible implication for histological grading of HCC.     

The effect of concurrent androgen deprivation and 3D conformal radiotherapy on prostate volume and clinical organ doses during treatment for prostate cancer

In this study, we investigated the shrinking effect of concurrent three-dimensional conformal radiotherapy (3D-CRT) and androgen deprivation (AD) on prostate volume, and its possible impact on the dose received by the rectum and bladder during the course of 3D-CRT. The difference between the prostatic volumes determined on pre-treatment planning CT (PL-CT) and post-treatment CT (PT-CT) following a 3D-CRT course was assessed in 52 patients with localised prostate carcinoma. The changes in mean prostate volume when compared with PL-CT and PT-CT-based measurements were assessed. The pre- and post-treatment mean prostate volumes for the whole study population were 49.7 cm³ and 41.0 cm³ (p _ 0.02), respectively. The study cohort was divided into two groups depending on the duration of neoadjuvant androgen deprivation (NAD): 23 patients (44.7%) were designated as “short NAD” (≤3 months; SNAD) and the remaining 29 (55.3%) as “long NAD” (>3 months; LNAD). Patients on SNAD experienced a significantly greater reduction in prostate volume compared with those on LNAD (14.1% vs 5.1%; p _ 0.03). A significant increase in rectum V_40–60 values in PT-CT compared with PL-CT was demonstrated. LNAD patients had significantly higher rectal V_50–70 values at PT-CT compared with the SNAD group. There was a significant decline in V₃₀–V₇₅ bladder values in PT-CT compared with PL-CT in the SNAD group. In conclusion, a higher prostate volume reduction during 3D-CRT was demonstrated when RT planning was performed within 3 months of NAD. However, this reduction and daily organ motion may lead to an unpredictable increase in rectal doses.Prostate carcinoma is (in general) a hormone-sensitive disease that has been shown to significantly benefit from androgen deprivation (AD) when added to conventional radiation therapy (RT) doses of 65–70 Gy [1–7]. Results of large randomised clinical trials have demonstrated that AD significantly improves the outcome of patients with locally advanced prostatic carcinoma when treated with external beam RT with regard to local control, biochemical-free survival and freedom from distant metastases [1, 3, 5, 8–10]. Furthermore, in the studies of the European Organization for Research and Treatment of Cancer (EORTC 22961) [1, 3] and the Radiation Therapy Oncology Group (RTOG) protocol 85–31 [2], this improvement turned into a survival advantage.Neoadjuvant androgen deprivation (NAD) before RT has been demonstrated to shrink the prostate volume effectively [11, 12], and thus has became a widely accepted and essential part of locally advanced prostate cancer management. On average, the prostate gland shrinks about 20–50% of its initial volume within 3 months of NAD [11–15] and, although the rate slows down, this shrinking effect continues beyond this period [16–19] The cytoreduction in the prostate provided by NAD may lower the complication rates observed at higher RT doses by reducing the target volumes, depending on the reduced doses received by normal tissues [15, 20].A relatively long treatment interval (7–8 weeks) is usually mandated for three-dimensional conformal radiotherapy (3D-CRT) of prostate carcinoma, and the shrinkage of the prostate gland continues during this period. In this setting, it is reasonable to assume, theoretically, that there is a possibility of a larger than planned volume of surrounding critical organs that may shift into the intermediate or high-dose regions during the RT course, which may unpredictably increase the dose received by the rectum and bladder [11, 12, 21]. Based on the above assumption, we planned to evaluate prostate shrinkage during 3D-CRT in relation to NAD duration, and to investigate the possible impact of this volume reduction on the dose received by the rectum and bladder by comparing the pre- and post-treatment dose volume histograms (DVHs).     

Measures used to treat contrast-induced nephropathy: overview of reviews

Objectives

Despite many interventions that have been tried, controversy remains regarding the efficacy of interventions for contrast-induced nephropathy (CIN), so we aimed to evaluate the best evidence from recent meta-analyses.

Methods

We searched MEDLINE, EMBASE and the Cochrane library for interventions which have been used for CIN. We included only the most recent meta-analysis of each intervention. We extracted data on the methodology, quality and results of each meta-analysis. We performed narrative synthesis and adjusted indirect comparison of interventions that were shown to be statistically significant compared with a placebo.

Results

We included 7 systematic reviews and meta-analyses involving 9 different interventions for CIN, with a total of 15 976 participants. A significantly decreased risk of CIN was reported in meta-analysis of the following interventions: N-acetylcysteine [odds ratio (OR) 0.65, 95% confidence interval (CI) 0.48–0.88, I²=64%], theophylline [relative risk (RR) 0.48, 95% CI 0.26–0.89, I²=44%], statins (RR 0.51, 95% CI 0.34–0.77, I²=0%) and sodium bicarbonate (RR 0.62, 95% CI 0.45–0.86, I²=49%). Furosemide was shown to increase the risk of CIN (RR 3.27, 95% CI 1.48–7.26, I²=0%). Other interventions such as renal replacement therapy, angiotensin-converting enzyme inhibitors, dopamine and fenoldapam failed to show any significant difference from the control group.

Conclusion

Although there is some evidence to suggest that N-acetylcysteine, theophylline, sodium bicarbonate and statins may reduce incidence of CIN, limitations in the study quality and heterogeneity preclude any firm recommendations.

Advances in knowledge

N-acetylcysteine, theophylline, sodium bicarbonate and statins show some promise as potentially efficacious agents for preventing CIN, but more high-quality studies are needed before they can be recommended for use in routine practice.Contrast-induced nephropathy (CIN) is a well-recognised complication of contrast administration and the third leading cause of hospital-acquired acute kidney injury [1]. Despite some heterogeneity in definition, CIN is generally defined as an increase in serum creatinine over 25% or 44 μmol l⁻¹ from baseline value 48–72 h after contrast media administration in the absence of any other aetiology [2]. CIN occurs in 0–10% of patients with normal renal function and in up to 25% of patients with pre-existing renal disease or certain risk factors such as diabetes, advanced age or nephrotoxic drugs [3]. A recent meta-analysis of 40 studies found that the pooled incidence of CIN was 6.4% after CT scanning [4].The pathophysiology of CIN is not completely understood but it is believed that contrast media causes vasoconstriction and renal medulla ischaemia, which leads to generation of free radicals and oxidative injury to tubular cells [5-8]. Studies have demonstrated that CIN is associated with increased in-hospital length of stay, morbidity and mortality and increased cost of medical care, especially in patients who require dialysis [9].A number of measures (hydration methods and physical agents) have been tried to prevent or treat contrast nephropathy. Hydration methods include N-acetylcysteine (NAC) and sodium bicarbonate. Studies have explored the value of NAC for contrast nephropathy and some have found that its use is associated with clinical benefits [10-13], but a recent large randomised trial found no such benefit associated with NAC use [14]. A number of published studies have suggested that bicarbonate is superior to saline in contrast-induced nephropathy [15-18]. However, there are also a number of unpublished studies which suggest no benefit associated with sodium bicarbonate use [19,20]. Theophylline and other drugs are methods that have been tried to reduce CIN. Theophylline has been shown to be protective in CIN in a few studies [21,22] but other studies have found no difference between theophylline and a control [23,24]. In addition, many drugs have been tried to prevent CIN [25-27].In response to the many studies, a number of meta-analyses have been published which have evaluated different measures used for CIN [28,29]. We reviewed the literature to identify these meta-analyses in order to determine the most up-to-date evidence on each intervention for CIN.