Assessment of cystic renal masses in children: Comparison of multislice computed tomography and ultrasound imaging using the Bosniak classification system

To retrospectively compare contrast-enhanced multislice computed tomography (MSCT) and ultrasound (US) imaging for the assessment of cystic renal masses in children using the Bosniak classification system. Twenty-two consecutive patients (age 1 month to 5.2 years, mean 2.4 years) with 24 cystic renal masses (7 benign, 17 malignant) pathologically confirmed after surgical resection underwent both MSCT and US imaging, and were retrospectively analyzed using the Bosniak classification. A senior and a junior radiologist retrospectively and independently reviewed imaging findings. The sensitivity, specificity, positive predictive value and negative predictive values of MSCT and US were assessed using diagnostic statistics. The statistical significance of differences was determined by the McNemar test. Both radiologists accurately predicted lesions of categories I and IV with the Bosniak classification using MSCT and US. All masses classified as Bosniak classes I and II were proven to be benign, and all malignant lesions were correctly characterized in all cases both on ultrasound images and on the contrast-enhanced CT (CECT) images. Two benign multilocular cystic nephromas and one multicystic dysplastic kidney were classified into category III or even IV based on the classification scheme because of their multilocular nature and thick septation. The diagnostic accuracy of CECT was slightly better than ultrasound (CECT vs. US: senior reader, 92% vs. 88%; junior reader, 88% vs. 83%). However, there was no statistically significant difference between the two sets (p > 0.05). The two radiologists had perfect inter-observer agreement on the two modalities. Both MSCT and US provide highly accurate diagnosis for the malignant renal cystic masses in children using the Bosniak classification system, but assessment of benign masses still needs improvement. We would recommend US is the best screening modality in Bosniak I and II, In Bosniak III and IV, MSCT are first the choice.     

Diagnostic accuracy and safety of CT-guided fine needle aspiration biopsy in cavitary pulmonary lesions

Objective

CT-guided transthoracic biopsy is a well-established method in the cytologic or histologic diagnosis of pulmonary lesions. The knowledge of its diagnostic performance and complications for cavitary pulmonary lesions is limited. The purpose of this study was to determine the diagnostic accuracy and safety of CT-guided fine needle aspiration biopsy (FNAB) in cavitary pulmonary lesions.

Materials and methods

102 consecutive patients with pulmonary cavitary lesions received CT-guided FNAB with use of an 18-gauge (n = 35) or 20-gauge (n = 67) Chiba for histology diagnosis. The sensitivity, specificity, and diagnostic accuracy of FNAB were calculated as compared with the final diagnosis. Complications associated with FNAB were observed. The diagnostic accuracy and complications were compared between patients with different lesion sizes and different cavity wall thickness.

Results

The overall sensitivity, specificity, and accuracy of FNAB were 96.3%, 98.0%, and 96.1%, respectively. The sensitivity, specificity, and diagnosis accuracy in different lesion size (<2 cm vs ≥2 cm), or different cavity wall thickness (<5 mm vs ≥5 mm) were not different (P > 0.05; 0.235). More nondiagnostic sample was found in wall thickness <5 mm lesions (P = 0.017). Associated complications included pneumothorax in 9 (8.8%) patients and alveolar hemorrhage in 14 patients (13.7%) and hemoptysis in 1 patient (1%). No different rate of complications was found with regard to lesion size, wall thickness, length of the needle path and needle size (P > 0.05).

Conclusion

CT-guided FNAB can be effectively ad safely used for patients with pulmonary cavitary lesions.     

Image-guided radiofrequency ablation of Bosniak category III or IV cystic renal tumors: initial clinical experience

The purpose of this study was to assess the efficacy of image-guided radiofrequency (RF) ablation of cystic renal tumors. Between November 2005 and August 2007, computed tomography (CT) or ultrasound-guided RF ablation was performed in nine patients with 14 Bosniak category III (n = 5) or IV (n = 9) cystic renal tumors using an internally cooled RF ablation system. We evaluated the number of sessions, cycles and duration of energy application, treatment results, lesion size change, and complications. Together the cystic renal tumors required 15 sessions and 23 cycles of energy application. The duration of energy application per one tumor ablation ranged from 1 to 12 min (mean 6 min). The last follow-up CT indicated complete coagulation of 14/14 (100%) lesions. None of these tumors had recurred within 1-19 months (mean 8 months). The maximum diameter of the cystic renal tumors was significantly reduced from 2.5 +/- 0.6 cm before ablation to 1.7 +/- 0.7 cm at the last follow-up CT (P < 0.01). Complications were pneumothorax (n = 2), inguinal paresthesia (n = 1), and arteriovenous fistula (n = 1). Image-guided RF ablation is an effective treatment for Bosniak category III or IV cystic renal tumors, which might need relatively shorter duration of energy application than purely solid renal tumors of the same size.     

Assessment of cystic renal masses based on Bosniak classification: comparison of CT and contrast-enhanced US

OBJECTIVES: To compare retrospectively the imaging features of computed tomography (CT) and contrast-enhanced US (CEUS) imaging for the assessment of cystic renal masses using the Bosniak classification system. MATERIALS AND METHODS: The CT and CEUS images of 31 pathologically confirmed cystic renal masses in 31 patients were retrospectively analyzed for septa numbers, wall and/or septa thickness, enhancement degree, and for the presence of a solid component by consensus between two radiologists using the Bosniak classification. Diagnostic accuracies of CT and CEUS for malignant cystic tumor were calculated and compared using McNemar test. RESULTS: Diagnostic accuracies of CT and CEUS for malignant renal tumor were 74% and 90%, respectively, but there were not statistically different (P>0.05). CEUS and CT images showed same Bosniak classification in 23 (74%) lesions and there were differences in 8 (26%) lesions, all of which were upgraded by CEUS; one lesion from I to IV, two lesions from II to IV, two lesions from IIF to III, and three lesions from III to IV. CEUS images depicted more septa in 10 (32%) lesions, more thickened wall and/or septa in 4 (13%) lesions, and stronger enhancement in 19 (61%) lesions. Moreover, for six lesions, solid component was detected by CEUS but not by CT. CONCLUSION: CEUS might better visualize septa number, septa and/or wall thickness, solid component and the enhancement of some renal cystic masses than CT, resulting in upgrade of Bosniak classification and affecting their treatment plan.     

Renal cell carcinoma in uremic acquired renal cystic disease: Incidence,detection, and management

We describe three patients with puzzling systemic illnesses in whom computed tomography (CT) led to the diagnosis of active adrenal histoplasmosis. CT was performed in two patients because of gastrointestinal symptoms and weight loss and in the third because of fever developing 2 years after an apparent cure of histoplasmosis. All three patients had adrenal enlargement on CT with features of granulomatous adrenal disease in two. Hormone assays performed after CT supported the diagnosis of adrenal insufficiency and fine-needle adrenal aspiration biopsy with special stains of the aspirates showed histoplasma organisms in all three patients. The combination of adrenal enlargement on CT and laboratory findings of adrenal insufficiency should suggest the diagnosis of histoplasmosis, especially in endemic areas.     

影像引导下肾肿块针刺活检诊断正确性与对临床影响的150例回顾性研究

目的复习采用我们的方法进行的肾肿块针刺活检。方法对150例连续影像引导下的经皮活检进行分析。129例病理诊断由临床结果证实(40例手术切除,53例热消     

Diagnostic accuracy and clinical impact of imaging-guided needle biopsy of renal masses. Retrospective analysis on 150 cases

Objective  

To review our method of perform needle biopsies of renal masses.     

Cost comparison analysis of low-field (0.23 T) MRI- and CT-guided bone biopsies

The aim of this study was to analyze and compare the costs of low-field (0.23 T) MRI- and CT-guided bone biopsies. The cost comparison consisted of 18 MRI-guided and 12 CT-guided bone biopsies performed during a 1-year period. The costs and activities of these two methods were analyzed by using activity-based cost accounting (ABC). The costs of MRI-guided bone biopsy (1205 Euro) were 2.55-fold compared with those of the CT-guided bone biopsy (472 Euro). The higher costs of the biopsy procedure in MRI were due to the higher material (5.57-fold) and personnel (2.73-fold) costs. The MRI-guided bone biopsies proved to be considerably more expensive than CT-guided bone biopsies. This was due to the higher material costs, especially the highly priced MRI compatible instrumentation and the longer procedure time. The MRI guidance in performing bone biopsies should be justified on the basis of the better accuracy and the lack of radiation. Evaluations of cost-effectiveness concerning MRI-guided bone biopsy are needed.     

0.5 T MRI of small renal masses: value of T2-weighted and Gd-DOTA-enhanced images

We compared the value of T2-weighted and Gd-DOTA-enhanced T1-weighted images for the detection and characterisation of 33 small renal masses (14 clear cell carcinomas, 6 angiomyolipomas, 3 angiomyomas, 4 adenomas, 3 papillary carcinomas, 3 oncocytomas, 1 haemorrhagic cyst). Dynamic enhanced MRI was performed to study the tumoral vascular supply (19 cases). MRI depicted all the masses more than 1 cm in diameter, but missed all the lesions less than 1 cm (4 false-negative). The results of T2-weighted images and Gd-DOTA-enhanced images were similar as regards detection; however, Gd-DOTA-enhanced images depicted more clearly the tumours smaller than 2 cm (11 cases). MRI enabled the characterisation of only 3 masses (2 angiomyolipomas, 1 haemorrhagic cyst). New MRI features are described for oncocytomas (low signal intensity on T1-weighted images, high signal intensity on T2-weighted images, early and marked enhancement on dynamic enhanced MRI). Dynamic enhanced MRI did not contribute to the differentiation of benign from malignant tumours. Correspondence to: O. Hélénon     

Pretreatment axillary ultrasonography and core biopsy in patients with suspected breast cancer: Diagnostic accuracy and impact on management

Preoperative diagnosis of axillary metastases in breast cancer patients enables treatment planning. We aimed to evaluate the diagnostic accuracy of axillary ultrasonography and percutaneous biopsy, both alone and in combination, in detecting axillary metastases in patients with breast cancer and to assess the impact of these techniques on the patients’ management.

Materials and methods

Retrospective study of consecutive patients with suspected breast cancer examined between October 2006 and December 2008. The diagnosis of a primary tumor was histologically confirmed in all patients. All patients underwent axillary ultrasonography and percutaneous core biopsy (14G) of suspicious lymph nodes. We evaluated the morphological characteristics of the lymph nodes by ultrasonography. We calculated the diagnostic accuracy of ultrasonography and of core biopsy, and assessed the impact of these techniques on patients’ treatment.

Results

We evaluated 675 axillary regions and performed 291 core biopsies of axillary lymph nodes in 662 patients. In 650 patients, breast cancer was histologically confirmed and in 12 patients malignant tumors in other locations were confirmed. The sensitivity and specificity of axillary ultrasonography were 63.2% and 88.7%, respectively. The absence of a fatty hilum within the lymph node was the ultrasonographic finding with the highest positive predictive value for malignancy (93.1%). The sensitivity and specificity of axillary core biopsy were 69.1% and 100%, respectively. Sentinel lymph node biopsy was avoided in 33% of initial candidates and immediate breast reconstruction was undertaken in 35.1% of the patients with mastectomy and negative axillary core biopsy.

Conclusions

Ultrasonography and axillary core biopsy enable adequate pretreatment staging in patients with breast cancer and has a positive impact on their management.     

Role of contrast-enhanced ultrasound in assessing indeterminate renal lesions and Bosniak ≥2F complex renal cysts found incidentally on CT or MRI

Objective:To investigate the impact of contrast-enhanced ultrasound (CEUS) in reclassifying incidental renal findings categorized as indeterminate lesions (IL) or Bosniak ≥ 2F complex renal cysts (CRC) on CT or MRI.Methods:We retrospectively included 44 subjects who underwent CEUS between 2016 and 2019 to assess 48 IL (n = 12) and CRC (n = 36) incidentally found on CT or MRI. CEUS was performed by one radiologist with 10 year of experience with a sulfur hexafluoride-filled microbubble contrast agent. The same radiologist, blinded to clinical information and previous CT/MRIs, retrospectively reviewed CEUS images/videos, categorizing renal findings with Bosniak-derived imaging categories ranging from 0 (indeterminate) to 5 (solid lesion). CEUS-related reclassification rate was calculated (proportion of IL reclassified with an imaging category >0, or CRC reclassified below or above imaging category >2F). Using histological examination or a ≥ 24 months follow-up as the standard of reference, we also estimated per-lesion sensitivity/specificity for malignancy.Results:CEUS reclassified 24/48 findings (50.0%; 95% C.I. 35.2–64.7), including 12/12 IL (100%; 95% CI 73.5–100) and 12/36 CRC (33.3%; 95% C.I. 18.5–50.9), mostly above category >2F (66.7%). CEUS and CT/MRI showed 96.0% (95%CI 79.7–99.9) vs 44.0% (95%CI 24.4–65.1) sensitivity, and 82.6% (95%CI 61.2–95.1) vs 60.9% (95%CI 38.5–80.3%) specificity.Conclusion:CEUS provided substantial and accurate reclassification of CT/MRI incidental findings.Advances in knowledge:Previous studies included Bosniak 2 incidental findings, thus possibly underestimating CEUS-induced reclassification rates. Using a more meaningful cut-off (Bosniak ≥2F), problem-solving CEUS was effective as well, with higher reclassification rates for CRC than in literature.     

Complex cystic renal masses: Comparison of cyst complexity and Bosniak classification between 1.5 T and 3 T MRI

Purpose

To retrospectively compare perceived complexity and Bosniak cyst classification of cystic renal lesions between 1.5 T and 3 T MRI.

Methods

33 cystic renal lesions in 26 patients that underwent contrast-enhanced MRI at both 1.5 T and 3 T within a 12 month span were included. Two radiologists (R1, R2) independently assessed lesions, unaware of field strength, in terms of number of septations, septal thickening, mural thickening, presence of mural nodule, and Bosniak cyst category. Scores were compared between field strengths for each lesion.

Results

R1 observed increases in septal number, septal thickening, mural thickening, and presence of mural nodule at 3 T in 8, 7, 4, and 2 lesions, and at 1.5 T in 3, 3, 2, and 0 lesions, respectively; R2 observed increases in septal number, septal thickening, mural thickening, and presence of mural nodule at 3 T in 3, 4, 3, and 0 lesions, and at 1.5 T in 2, 0, 0, and 0 lesions, respectively. R1 provided higher Bosniak category at 3 T in 9 cases and at 1.5 T in 4 cases; R2 provided higher Bosniak category at 3 T in 4 cases and at 1.5 T in 0 cases. Higher scores at 3 T than 1.5 T were associated with differences in advised clinical management in 7/9 cases for R1 and 4/4 cases for R2.

Conclusion

There was an overall tendency for both readers to upgrade cyst complexity and Bosniak cyst category at 3 T than 1.5 T, which impacted advised management. Thus, we suggest that serial MRI evaluation of cystic renal lesions be performed at constant field strength.     

(18)F]FDG in childhood lymphoma: clinical utility and impact on management

Positron emission tomography (PET) with fluorine-18 fluorodeoxyglucose (FDG) is a very useful technique for the imaging of lymphomas in the adult population. It provides unique information about the behaviour of malignant cells and contributes to more accurate staging of the illness and better assessment of response to therapy. The purpose of this study was to evaluate the usefulness of FDG PET in childhood lymphoma compared with conventional imaging methods (CIMs) and clinical data. Between July 1998 and August 2001, 42 FDG PET examinations were performed using a dedicated PET system (27 examinations) or a hybrid coincidence PET system (15 examinations) for initial tumour staging ( n=7), restaging ( n=5) or assessment of response to therapy or residual masses ( n=30) in 27 children with Hodgkin's disease (HD) ( n=20) or non-Hodgkin's lymphoma (NHL) ( n=7). FDG PET results were compared with CIM findings and clinical data. Since 2000, a standardised questionnaire for evaluation of the clinical impact of FDG PET on both staging and therapy has been sent to the 16 referring physicians and 13 have replied. In all children, FDG PET was performed without any side-effects. FDG PET was found to be very sensitive (Se=12/12) for staging and restaging of the illness, showing more lesions than CIMs, with a 50% patient upstaging rate (6/12). It was very accurate for monitoring response to therapy and for characterisation of residual masses. False-positive results were observed in two NHL patients with thymic uptake and one false-negative result was obtained in a patient whose NHL relapsed 1 month after a negative FDG PET. The questionnaire emphasised the impact of FDG PET on clinical management, which was modified on the basis of the FDG PET results in 23% of patients. As previously demonstrated in the adult population, FDG PET appeared to be a very sensitive imaging technique for staging and restaging of lymphoma in children and was very useful for monitoring the response to therapy.     

O-(2-[18F]fluorethyl)-L-tyrosine PET in the clinical evaluation of primary brain tumours

Purpose The aim of this study was to evaluate the differential uptake of O-(2-[¹⁸F]fluorethyl)-L-tyrosine (FET) in suspected primary brain tumours.Methods Positron emission tomography (PET) was performed in 44 patients referred for the evaluation of a suspected brain tumour. Acquisition consisted of four 10-min frames starting upon i.v. injection of FET. Tumour uptake was calculated as the ratio of maximal tumour intensity to mean activity within a reference region (FET_max).Results FET uptake above the cortical level was observed in 35/44 lesions. All histologically confirmed gliomas and many other lesions showed FET uptake to a variable extent. No uptake was observed in nine lesions (one inflammatory lesion, one dysembryoplastic neuroepithelial tumour, one mature teratoma, six lesions without histological confirmation). An analysis of uptake dynamics was done in the patients with increased FET uptake (22 gliomas, three lymphomas, three non-neoplastic lesions, three lesions with unknown histology and four other primaries). Upon classification of tumours into low (i.e. WHO I and II) and high grade (i.e. WHO III and IV), a significant difference in FET_max between the two categories was observed only in the first image frame (0–10 min p.i.), with FET_max=2.0 in low-grade and 3.2 in high-grade tumours (p<0.05); no significant differences were found in frame 4 (30–40 min p.i.), with FET_max=2.4 vs 2.7. Similar results were obtained when the analysis was applied only to astrocytic tumours (2.0 vs 3.1 in the first frame; 2.4 vs 2.6 in the fourth frame).Conclusion These initial results indicate that FET PET is a useful method to identify malignant brain lesions. It appears that high- and low-grade brain tumours exhibit a different uptake kinetics of FET. A kinetic analysis of FET PET may provide additional information in the differentiation of suspected brain lesions.     

飞行员小肾癌的航空医学检查与鉴定(附病例报告3例)

目的 分析3例民航飞行员小肾癌病例并进行文献复习,以期加强对该病的认识,提高诊断和鉴定水平. 方法介绍3例民航飞行员小肾癌的临床资料,分析并探讨该病的诊断和医学鉴定方法. 结果 3例患者肿瘤大小均<3 cm,术前明确诊断1例,倾向于恶性和良性各1例,1例行腹腔镜肾脏部分切除术,两例行肾癌根治术,病理检查均诊断为肾透明细胞癌(高分化),肿瘤分期均为T1aN0M0,随访1～6.5年,未见复发.3例明确诊断后即鉴定为飞行不合格,其中1例病程长者于术后第2年特许飞行合格至今,飞行良好. 结论小肾癌诊断较困难,应综合多种影像学检查以明确,确诊仍是病理诊断.小肾癌分期早,分化高,预后好,发生突然失能的可能性低.排除复发或转移,3个月后即可评定为飞行合格,需密切随访.     

A New and Simple Practical Plane Dividing Hepatic Segment 2 and 3 of the Liver: Evaluation of Its Validity

Objective

The conventional method of dividing hepatic segment 2 (S2) and 3 (S3) is subjective and CT interpretation is unclear. The purpose of our study was to test the validity of our hypothesis that the actual plane dividing S2 and S3 is a vertical plane of equal distance from the S2 and S3 portal veins in clinical situations.

Materials and Methods

We prospectively performed thin-section iodized-oil CT immediately after segmental chemoembolization of S2 or S3 in 27 consecutive patients and measured the angle of intersegmental plane on sagittal multiplanar reformation (MPR) images to verify its vertical nature. Our hypothetical plane dividing S2 and S3 is vertical and equidistant from the S2 and S3 portal veins (vertical method). To clinically validate this, we retrospectively collected 102 patients with small solitary hepatocellular carcinomas (HCC) on S2 or S3 the segmental location of which was confirmed angiographically. Two reviewers predicted the segmental location of each tumor at CT using the vertical method independently in blind trials. The agreement between CT interpretation and angiographic results was analyzed with Kappa values. We also compared the vertical method with the horizontal one.

Results

In MPR images, the average angle of the intersegmental plane was slanted 15 degrees anteriorly from the vertical plane. In predicting the segmental location of small HCC with the vertical method, the Kappa value between CT interpretation and angiographic result was 0.838 for reviewer 1 and 0.756 for reviewer 2. Inter-observer agreement was 0.918. The vertical method was superior to the horizontal method for localization of HCC in the left lobe (p < 0.0001 for reviewers 1 and 2).

Conclusion

The proposed vertical plane equidistant from S2 and S3 portal vein is simple to use and useful for dividing S2 and S3 of the liver.     

Lethal midline granuloma: impact of imaging studies on the investigation and management of destructive mid facial disease in 13 patients

Summary In 13 patients presenting as lethal midline granuloma (LMG), computed tomography proved essential for determining the extent of the disease, guiding biopsy and planning radiotherapy. Magnetic resonance imaging (MRI) was also helpful for the latter, because it could distinguish fluid retained within the paranasal sinuses from solid masses and tumour from granulation tissue; it was of little value for detecting bone lysis. Eight of the 13 patients proved to have T-cell lymphoma, two had Crohn's disease, in one the lesion was factitious and two had granulomas without diagnostic histological features.