Asymptomatic metastatic osteosarcoma to the right ventricle: Case report and review of the literature

Metastatic cardiac tumors are far more common than primary tumors, and benign primary cardiac tumors are common than malignant tumors. We report a 22-year-old Saudi woman with right femur osteosarcoma who was found to have a large right ventricular mass by transthoracic and transesophageal echocardiography. Diagnosis was highly suggestive by cardiac magnetic resonance imaging (MRI) and fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) scan. We performed a review of the literature for metastatic osteosarcoma of the right ventricle.     

Highly metabolic thrombus of the portal vein： ^18F fluorodeoxyglucose positron emission tomography/computer tomography demonstration and clinical significance in hepatocellular carcinoma

AIM： To assess the ability of ^18F-fluorodeoxyglucose positron emission tomography/computer tomography （^18F-FDG PET/CT） to differentiate between benign and malignant portal vein thrombosis in hepatocellular carcinoma （HCC） patients.
METHODS： Five consecutive patients who had HBV cirrhosis, biopsy-proven HCC, and thrombosis of the main portal vein and/or left/right portal vein on ultrasound （US）, computer tomography （CT） or magnetic resonance imaging （MRI） were studied with ^18F-FDG PET/CT. The presence or absence of a highly metabolic thrombus on ^18F-FDG PET/CT was considered diagnostic for malignant or benign portal vein thrombosis, respectively. All patients were followed-up monthly with US, CT or MRI. Shrinkage of the thrombus or recanalization of the vessels on US, CT or MRI during follow-up was considered to be definitive evidence of the benign nature of the thrombosis, whereas enlargement of the thrombus, disruption of the vessel wall, and parenchymal infiltration over follow-up were considered to be consistent with malignancy. ^18SF-FDG PET/CT, and US, CT or MRI results were compared.
RESULTS： Follow-up （1 to 10 mo） showed signs of malignant thrombosis in 4 of the 5 patients. US, CT or MRI produced a true-positive result for malignancy in 4 of the patients, and a false-positive result in 1. ^18F-FDG PET/CT showed a highly metabolic thrombus in 4 of the 5 patients. ^18F-FDG PET/CT achieved a true-positive result in all 4 of these patients, and a true-negative result in the other patient. No false-positive result was observed using ^18F-FDG PET/CT.
CONCLUSION： ^18F-FDG PET/CT may be helpful in discriminating between benign and malignant portal vein thrombi. Patients may benefit from ^18F-FDG PET/CT when portal vein thrombi can not be diagnosed exactly by US, CT or MRI.     

The role of imaging techniques in the management of multiple myeloma

Bone disease is the major feature of multiple myeloma (MM). Imaging is required for correct staging, in the follow‐up after treatment and, as recently highlighted, is predictor of prognosis. In the near future, whole‐body X‐Ray may be replaced by more sensitive techniques, such as whole‐body low‐dose computerized tomography (CT). Magnetic resonance imaging (MRI) is the gold standard method for assessing bone marrow infiltration of the spine, predicting the risk of vertebral fracture and distinguishing between benign and malignant osteoporosis. Positron emission tomography (PET) with CT (PET/CT) provides important information about the extent of whole‐body disease, including soft tissue masses, and is the best tool to distinguish between active or inactive disease after therapy. Both MRI and PET/CT are predictors of clinical outcome. A prospective use of these newer imaging techniques in both clinical trials and clinical practice may help optimize MM management in the near future.     

Diagnostic Accuracy of Cardiac Computed Tomography and 18-F Fluorodeoxyglucose Positron Emission Tomography in Cardiac Masses

ObjectivesThis study sought to assess the diagnostic accuracy of cardiac computed tomography (CT) and ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) with positron emission tomography/computed tomography (PET/CT) in defining the nature of cardiac masses.BackgroundThe diagnostic accuracy of cardiac CT and ¹⁸F-FDG PET/CT in identifying the nature of cardiac masses has been analyzed to date only in small samples.MethodsOf 223 patients with echocardiographically diagnosed cardiac masses, a cohort of 60 cases who underwent cardiac CT and ¹⁸F-FDG PET/CT was selected. All masses had histological confirmation, except for a minority of thrombotic formations. For each mass, 8 morphological CT signs, standardized uptake value (SUV_max, SUV_mean), metabolic tumor volume, and total lesion glycolysis in ¹⁸F-FDG PET were used as diagnostic markers.ResultsIrregular tumor margins, pericardial effusion, invasion, solid nature, mass diameter, CT contrast uptake, and pre-contrast characteristics were strongly associated with the malignant nature of masses. The coexistence of at least 5 CT signs perfectly identified malignant masses, whereas the detection of 3 or 4 CT signs did not accurately discriminate the masses’ nature. The mean SUV_max, SUV_mean, metabolic tumor volume, and total lesion glycolysis values were significantly higher in malignant than in benign masses. The diagnostic accuracy of SUV, metabolic tumor volume, and total lesion glycolysis ¹⁸F-FDG PET/CT parameters was excellent in detecting malignant masses. Among patients with 3 or 4 pathological CT signs, the presence of at least 1 abnormal ¹⁸F-FDG PET/CT parameter significantly increased the identification of malignancies.ConclusionsCardiac CT is a powerful tool to diagnose cardiac masses as the number of abnormal signs was found to correlate with the lesions’ nature. Similarly, ¹⁸F-FDG PET/CT accurately identified malignant masses and contributed with additional valuable information in diagnostic uncertainties after cardiac CT. These imaging tools should be performed in specific clinical settings such as involvement of great vessels or for disease-staging purposes.     

Positron Emission Tomography Combined With Computed Tomography as an Integral Component in Evaluation of Primary Cardiac Lymphoma

We present a case of primary cardiac lymphoma (PCL) that was initially manifest through syncopal episodes. In the diagnostic evaluation, positron emission tomography combined with computed tomography (PET‐CT) made a significant contribution—beyond that which would have been possible if only conventional imaging modalities such as magnetic resonance imaging (MRI) and transthoracic echocardiography (TTE) were utilized—and played a major role in follow‐up. Copyright © 2010 Wiley Periodicals, Inc.     

Hepatic angiomyolipoma pre-operatively diagnosed by imaging

An asymptomatic patient with pre-operatively diagnosed solitary angiomyolipoma is reported. The tumour was a well defined, fat density mass on computerized tomography (CT) and magnetic resonance imaging (MRI), and a hyperechoic nodule with a sharp margin on ultrasonography (US). The lesion was hypervascular on arteriography and CT during hepatic angiography. Chemical shift MRI confirmed the fat component within the lesion. Although a review of the literature shows this tumour to be rare and difficult to differentiate from a malignant lesion pre-operatively, the pre-operative diagnosis of angiomyolipoma is considered feasible when the characteristic findings as described here are present.     

Diagnostic potential of combined transthoracic echocardiography and x-ray computed tomography in suspected aortic dissection.

BACKGROUND: Transesophageal echocardiography (TEE) and magnetic resonance imaging (MRI) are considered optimal diagnostic methods in the setting of suspected aortic dissection. However, although less sensitive as single modalities, transthoracic echocardiography (TTE) and contrast-enhanced computed tomography (x-ray CT) are more widely available and less costly. HYPOTHESIS: This study was undertaken to compare the diagnostic performance and reliability of the combined use of TTE and x-ray CT with TEE and/or MRI findings in the setting of suspected aortic dissection. METHODS: The diagnostic power of combined TTE and x-ray CT was compared with both single use of TTE and x-ray CT and with TEE and/or MRI in a series of 168 consecutive patients with suspected aortic dissection (AD). Of these, 28 women and 58 men (mean age 53 +/- 16 years) underwent TTE and x-ray CT prior to TEE (n = 52) and/or MRI (n = 69). Diagnostic results of combined TTE/x-ray CT were retrospectively but independently reevaluated in blinded fashion; diagnostic findings were validated by angiography (n = 63), surgery (n = 52), or autopsy (n = 7). RESULTS: Type A dissection was found in 29 patients (34%), type B dissection in 10 (12%), whereas aortic dissection was excluded in 47 (55%). With 95%, the sensitivity of TTE and x-ray CT was significantly enhanced when used in a combined access compared with 67 and 79%, respectively, when used as single methods (95%; p < 0.05). Sensitivity and specificity (95 and 91%, respectively) of combined TTE/x-ray CT evaluation were not different from TEE and/or MRI (100 and 96%, respectively; NS). Thrombus formation, side-branch involvement, aortic regurgitation, pericardial effusion or mediastinal hematoma were also detected with similar sensitivities and specificities both by combined TTE/x-ray CT and TEE and/or MRI. CONCLUSION: This first controlled study comparing the combined information of TTE and x-ray CT with TEE and/or MRI revealed a similar diagnostic potential of both diagnostic strategies in the setting of suspected aortic dissection. Thus, in an environment with access to color Doppler TTE and x-ray CT only, the information from both tests should be combined to decide on diagnostic management of these patients.     

Diagnostik des Nierenzellkarzinoms

The frequent use of imaging modalities has led to a rising number of incidentally detected renal cell carcinomas (RCC). Especially the incidence of small asymptomatic renal masses has significantly increased. Due to considerable progress in disease management of RCC, for example new approaches in nephron-sparing surgery for localized tumors less than 4?cm, cross-sectional imaging is required for a more detailed preoperative characterization of renal masses. Most renal tumors (80%) are diagnosed incidentally by ultrasound examination (US). The detection rate can even be improved using duplex sonography or contrast-enhanced ultrasound (CEUS). If an accurate diagnosis is not possible with ultrasound, computed tomography (CT) examination may help to further qualify complicated cystic lesions of the kidneys. Computed tomography (CT) is still the reference standard for diagnosing primary tumor extent as well as for tumor staging. The most important criterion for assessing malignancy in a renal lesion is the evidence supplied by contrast-enhancement. Computed tomography also facilitates a differentiation of benign solid masses, such as angiomyolipomas and adenomas from malignant renal tumors and even the diagnosis of lymphomas is possible. Magnetic resonance imaging offers a better soft tissue contrast and is superior to a CT examination in diagnosing possible venous involvement and in the evaluation of inferior vena cava tumor thrombi. The differentiation of RCC subtypes, angiomyolipomas as well as distinguishing simple from complex renal cysts is also possible. The grading of different RCCs can be preoperatively estimated using dynamic contrast-enhanced MRI or measuring perfusion and diffusion within renal tumors. Due to a low sensitivity positron emission tomography/computed tomography (PET/CT) is not part of the routine diagnostic management for RCC. Nevertheless it plays an important role in the diagnosis of distant metastases and postoperative surveillance of advanced renal tumors. In some cases a complementary application of radiological imaging modalities, such as US, CT, MRI or PET/CT is required for an accurate differentiation of renal masses and for the diagnosis of RCCs.     

Two-dimensional and three-dimensional transthoracic echocardiography in surgical planning for right atrial metastatic melanoma.

Melanoma is the most common form of cardiac metastases. Surgical excision has been shown to be an effective palliative measure. This requires detailed definition of cardiac anatomy in relation to the tumour. Two-dimensional (2D), three-dimensional (3D) transthoracic (TTE) and transoesophageal echocardiography (TEE), spiral computerised tomography (CT) and magnetic resonance imaging (MRI) have all been described in aiding surgical planning for excision of cardiac tumours. In this case report, 3D-TTE provided excellent anatomical definition for surgical planning of a large right atrial melanoma precluding the need for more invasive and expensive investigations.     

Cardiac and pericardial tumors: A potential application of positron emission tomography-magnetic resonance imaging

Cardiac and pericardial masses may be neoplastic, benign and malignant, non-neoplastic such as thrombus or simple pericardial cysts, or normal variants cardiac structure can also be a diagnostic challenge. Currently, there are several imaging modalities for diagnosis of cardiac masses; each technique has its inherent advantages and disadvantages. Echocardiography, is typically the initial test utilizes in such cases, Echocardiography is considered the test of choice for evaluation and detection of cardiac mass, it is widely available, portable, with no ionizing radiation and provides comprehensive evaluation of cardiac function and valves, however, echocardiography is not very helpful in many cases such as evaluation of extracardiac extension of mass, poor tissue characterization, and it is non diagnostic in some cases. Cross sectional imaging with cardiac computed tomography provides a three dimensional data set with excellent spatial resolution but utilizes ionizing radiation, intravenous iodinated contrast and relatively limited functional evaluation of the heart. Cardiac magnetic resonance imaging(CMR) has excellent contrast resolution that allows superior soft tissue characterization. CMR offers comprehensive evaluation of morphology, function, tissue characterization. The great benefits of CMR make CMR a highly useful tool in the assessment of cardiac masses.(Fluorine 18) fluorodeoxygluocse(FDG) positron emission tomography(PET) has become a corner stone in several oncological application such as tumor staging, restaging, treatment efficiency, FDG is a very useful imaging modality in evaluation of cardiac masses. A recent advance in the imaging technology has been the development of integrated PET-MRI system that utilizes the advantages of PET and MRI in a single examination. FDG PET-MRI provides complementary information on evaluation of cardiac masses. The purpose of this review is to provide several clinical scenarios on the incremental value of PET and MRI in the evaluation of cardiac masses.     

Diagnosis of cholangiocarcinoma

Cholangiocarcinoma is suspected based on signs of biliary obstruction, abnormal liver function tests, elevated tumor markers (carbohydrate antigen 19-9 and carcinoembryonic antigen), and ultrasonography showing a bile stricture or a mass, especially in intrahepatic cholangiocarcinoma. Magnetic resonance imaging (MRI) or computed tomography (CT) is performed for the diagnosis and staging of cholangiocarcinomas. However, differentiation of an intraductal cholangiocarcinoma from a hypovascular metastasis is limited at imaging. Therefore, reasonable exclusion of an extrahepatic primary tumor should be performed. Differentiating between benign and malignant bile duct stricture is also difficult, except when metastases are observed. The sensitivity of fluorodeoxyglucose positron emission tomography is limited in small, infiltrative, and mucinous cholangiocarcinomas. When the diagnosis of a biliary stenosis remains indeterminate at MRI or CT, endoscopic imaging (endoscopic or intraductal ultrasound, cholangioscopy, or optical coherence tomography) and tissue sampling should be carried out. Tissue sampling has a high specificity for diagnosing malignant biliary strictures, but sensitivity is low. The diagnosis of cholangiocarcinoma is particularly challenging in patients with primary sclerosing cholangitis. These patients should be followed with yearly tumor markers, CT, or MRI. In the case of dominant stricture, histological or cytological confirmation of cholangiocarcinoma should be obtained. More studies are needed to compare the accuracy of the various imaging methods, especially the new intraductal methods, and the imaging features of malignancy should be standardized.     

Imaging Heart Failure: Current and Future Applications

A variety of cardiac imaging tests are used to help manage patients with heart failure (HF). This article reviews current and future HF applications for the major noninvasive imaging modalities: transthoracic echocardiography (TTE), single-photon emission computed tomography (SPECT), positron emission tomography (PET), cardiovascular magnetic resonance (CMR), and computed tomography (CT). TTE is the primary imaging test used in the evaluation of patients with HF, given its widespread availability and reliability in assessing cardiac structure and function. Recent developments in myocardial strain, 3-dimensional TTE, and echo contrast appear to offer superior diagnostic and prognostic information. SPECT imaging is a common method employed to detect ischemia and viability in patients with HF; however, PET offers higher diagnostic accuracy for both. Ongoing study of sympathetic and molecular imaging techniques may enable early disease detection, better risk stratification, and ultimately targeted treatment interventions. CMR provides high-quality information on cardiac structure and function and allows the characterization of myocardial tissue. Myocardial late gadolinium enhancement allows the determination of HF etiology and may predict patient outcomes and treatment response. Cardiac CT has become a reliable means for detecting coronary artery disease, and recent advances have enabled concurrent myocardial function, perfusion, and scar analyses. Overall, available imaging methods provide reliable measures of cardiac performance in HF, and recent advances will allow detection of subclinical disease. More data are needed demonstrating the specific clinical value of imaging methods and particularly subclinical disease detection in large-scale, clinical settings.     

Evaluating cardiac sources of embolic stroke with MRI

The evaluation of patients with stroke includes identifying its etiology in order to appropriately tailor therapy. Currently, the diagnostic work-up includes imaging of the brain, the arteries of the head and neck, the aorta, and the heart. Traditional methods of imaging include magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA), duplex ultrasound, and transthoracic echocardiography (TTE) and/or transesophageal echocardiography (TEE). While echocardiography remains a cornerstone in the field of cardiac imaging, MRI is increasingly able to assess for the most common causes of cardioembolic stroke such as left atrial/left atrial appendage thrombus, left ventricular thrombus, aortic atheroma, cardiac masses and patent foramen ovale. This review will focus on the advantages and limitations of echocardiography and cardiac magnetic resonance (CMR) imaging in diagnosing patients suspected of having an embolic stroke and the role these modalities play in clinical practice today.     

Assessment of cardiac function: magnetic resonance and computed tomography

A complete cardiac study requires both anatomic and physiologic evaluation. Cardiac function can be evaluated noninvasively by magnetic resonance imaging (MRI)or ultrafast computed tomography (CT). MRI allows for evaluation of cardiac function by cine gradient echo imaging of the ventricles and flow analysis across cardiac valves and the great vessels. Cine gradient echo imaging is useful for evaluation of cardiac wall motion, ventricular volumes and ventricular mass. Flow analysis allows for measurement of velocity and flow during the cardiac cycle that reflects cardiac function. Ultrafast CT allows for measurement of cardiac indices similar to that provided by gradient echo imaging of the ventricles.     

Imaging evaluation of the liver in oncology patients: A comparison of techniques

The liver is commonly affected by metastatic disease. Therefore, it is essential to detect and characterize liver metastases, assuming that patient management and prognosis rely on it. The imaging techniques that allow non-invasive assessment of liver metastases include ultrasonography, computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET)/CT, and PET/MRI. In this paper, we review the imaging findings of liver metastases, focusing on each imaging modality’s advantages and potential limitations. We also assess the importance of different imaging modalities for the management, follow-up, and therapy response of liver metastases. To date, both CT and MRI are the most appropriate imaging methods for initial lesion detection, follow-up, and assessment of treatment response. Multiparametric MRI is frequently used as a problem-solving technique for liver lesions and has evolved substantially over the past decade, including hardware and software developments and specific intravenous contrast agents. Several studies have shown that MRI performs better in small-sized metastases and moderate to severe liver steatosis cases. Although state-of-the-art MRI shows a greater sensitivity for detecting and characterizing liver metastases, CT remains the chosen method. We also present the controversial subject of the "economic implication" to use CT over MRI.     

Live/real time three-dimensional transthoracic echocardiographic assessment of left ventricular volumes, ejection fraction, and mass compared with magnetic resonance imaging

Due to reliance upon geometric assumptions and foreshortening issues, the traditionally utilized transthoracic two-dimensional echocardiography (2DTTE) has shown limitations in assessing left ventricular (LV) volume, mass, and function. Cardiac magnetic resonance imaging (MRI) has shown potential in accurately defining these LV characteristics. Recently, the emergence of live/real time three-dimensional (3D) TTE has demonstrated incremental value over 2DTTE and comparable value with MRI in assessing LV parameters. Here we report 58 consecutive patients with diverse cardiac disorders and clinical characteristics, referred for clinical MRI studies, who were evaluated by cardiac MRI and 3DTTE. Our results show good correlation between the two modalities.     

False-positive Uptake on Positron Emission Tomography/Computed Tomography Immediately After Lung Biopsy: A Case Report

18F-fluorodeoxyglucose positron emission tomography (18F-FDG-PET) is an evolving tool in the field of oncology. 18F-fluorodeoxyglucose, however, is not a specific tool for malignant tumor that it may also accumulate in benign processes. To avoid false-positive interpretation of 18F-FDG-PET/computed tomography (CT), having knowledge of the potential pitfalls is important.The authors present a case of a patient with a lung mass who underwent fluoroscopy-guided transthoracic lung biopsy followed by 18F-FDG-PET/CT scan with a 4-hour interval between biopsy and scanning. Abnormally increased FDG uptake in the mass and pleural effusion was detected. Pathologic examination of the specimen, however, revealed only fibrous tissues with chronic inflammatory cells. On performing CT imaging, 1 month later, the mass and effusion had spontaneously resolved without treatment.Our findings suggest that PET/CT performed immediately following invasive procedures can result in false-positive results and thus mislead diagnosis. Therefore, the interval and order, in which PET/CT and invasive procedures are performed, should be carefully considered in oncologic work-up.     

Current evidence for the diagnostic value of gadoxetic acid‐enhanced magnetic resonance imaging for liver metastasis

A variety of imaging techniques, including ultrasonography (US), multidetector computed tomography (MDCT), magnetic resonance imaging (MRI) and positron emission tomography combined with CT scan (PET/CT), are available for diagnosis and treatment planning in liver metastasis. Contrast‐enhanced MDCT is a relatively non‐invasive, widely available and standardized method for hepatic work‐up. Gadoxetic acid (gadolinium‐ethoxybenzyl‐diethylenetriamine pentaacetic acid; EOB Primovist®]) is a recently developed liver‐specific hepatobiliary MR contrast agent that offers both dynamic imaging as well as liver‐specific static hepatocyte imaging, referred to as the hepatobiliary phase. Following contrast injection, this technique reveals dynamic vascular phases (arterial, portal venous and delayed phases), in addition to the hepatobiliary phase upon uptake by functional hepatocytes. The overall sensitivity of gadoxetic acid‐enhanced MRI was significantly higher than that of contrast‐enhanced CT. Specifically, the higher sensitivity of gadoxetic acid‐enhanced MRI was observed in lesions smaller than 1 cm in diameter. Gadoxetic acid‐enhanced MRI is considered an extremely useful tool for the diagnosis of liver metastases. Future studies will focus on diagnostic algorithms involving combinations of modalities such as MRI, MDCT and/or ¹⁸F‐fluorodeoxyglucose PET/CT, which may impact the treatment plan for these patients.     

Intravenous leiomyomatosis involving the right heart: Comprehensive evaluation using echocardiography combined with abdominal ultrasonography

Intravenous leiomyomatosis (IVL) is a rare condition characterized by a tumor that originates within a pelvic vein wall or the uterine smooth muscle, with extension into the right heart (referred to as intracardiac leiomyomatosis) in approximately 10% of all IVL cases. Usually, computed tomography (CT) or magnetic resonance imaging (MRI) is performed for diagnostic imaging of IVL. Notably, this neoplasm presents with characteristic ultrasonographic findings. In this report, we present the case of a 49-year-old woman with IVL, which extended into the right heart. Echocardiography combined with abdominal ultrasonography was useful to outline the course of the tumor from the right heart to the uterus. Our findings suggest that in addition to CT or MRI, ultrasonography shows high diagnostic value in cases of IVL, and ultrasonography combined with CT or MRI can further improve the preoperative diagnosis rate of IVL.