syllabus & abstracts - Viagra online cheaper

Edited by:
George L. Malachias, MD
Published by:
2

CONTENTS
ESUR 2009 President’s welcome .................................................4
Acknowledgments.......................................................................5
ESUR 2009 Organization .............................................................6
ESUR 2009 Faculty ......................................................................7
Accreditation...............................................................................8
Social Programme...................................................................... 9
General Information ...................................................................10
Maps – Conference halls..............................................................12
ESUR 2009 Programme Overview ...............................................14
Scientific Programme
Thursday, September 10 th , 2009..................................................... 17
Friday, September 11 th , 2009......................................................... 19
Saturday, September 12 th , 2009..................................................... 22
Sunday, September 13 th , 2009 ....................................................... 25
Members’ Day Sessions (abstracts) ........................................... 31
Opening Ceremony Lectures .......................................................40
SUR Honorary Lecture ............................................................... 42
ESUR Guidelines Session (abstracts) ......................................... 43
Course Lectures (abstracts)....................................................... 47
Workshops (abstracts) .............................................................. 70
Oral Presentations (abstracts)................................................... 108
Radiological Technologists’ Sessions (abstracts) ........................129
Posters Exhibition (abstracts).....................................................132
List of Delegates........................................................................ 174
3

ESUR 2009 President’s Welcome
Dear Participants, Dear Friends
On behalf of the Local Organizing Committee, I warmly welcome you to attend the
ESUR 2009 in Athens.
The main topic of this very Symposium is “Urogenital Manifestations of Systemic
Diseases”. We believe that this topic allows us to share our scientific experience with
colleagues from other Specialities as well.
The scientific and social programmes of ESUR 2009 make us confident that we will
have, for one more time, a very successful meeting.
Hoping that all of you will have a very nice staying in Athens – Greece, I thank you
very much for your presence in here.
I welcome you ( Kalos Ilthate),
George L. Malachias, MD.
4

ACKNOWLEDGMENTS
The Local Organizing Committee of the 16 th European Symposium on
Urogenital Radiology wish to acknowledge the contribution of the following
companies and organizations for their financial support:
MAIN SPONSORS
BRACCO INTERNATIONAL BV
COVIDIEN
GE HEALTHCARE
SPONSORS
A & L MEDICAL SUPPLIES Ltd - COOK
AGFA GEVAERT SA
BAYER HELLAS ABEE
CARESTREAM HEALTH HELLAS
K. MARNEROS SA
MEDIA VIS SA (EIZO)
GREEK NATIONAL TOURISM ORGANIZATION
PFIZER HELLAS SA
ROXANA LTD
SIEMENS SA
SMART ONE - K. ASANAKIS
5

ESUR 2009 ORGANIZATION
Scientific Committee
ESUR Board
Malachias G. (GR) – Chairman
Derchi L.E. (I)
Hamm B.K. (D)
Kinkel K. (CH)
Morcos S.K. (UK)
Mueller-Lisse U.G. (D)
Oyen R. (B)
Heinz-Peer G. (A)
Papanicolaou N. (USA)
Ramchandani P. (USA)
Yarmenitis S. (GR)
Hamm B.K., M.D., President (D)
Heinz-Peer G., M.D., President-Elect (A)
Morcos S.K., M.D., Past President (UK)
Løgager V., M.D., Secretary/Treasurer (DK)
Bellin M.F., M.D., Member-at-large (F)
Local Organizing Committee
Malachias G. – President
Anastopoulos J.
Drossos Ch.
Evlogias N.
Katsou G.
Koumanidou Ch.
Papadopoulos V.
Papailiou J.
Piperopoulos P.
Prassopoulos P.
Strigaris K.
Triantopoulou Ch.
Tsampoulas K.
Tsili A.
Abstracts’ Evaluation Committee
Oral Presentations
Poster Presentations
Gourtsoyianni S.
Bellin M.F.
Yarmenitis S. Collins M.
Mueller-Lisse U.L. Katsou G.
Oyen R.
Special Duties Team
Katelanis S.
Leonardou P.
Antonopoulos A.
Responsible for Scientific Programme’s Flow
Responsible for Audiovisuals’ Co-Ordination and Control
Responsible for Delegates’ Service
Administrative Secretariat
PRC Congress & Travel
Public Relations Center
102, Michalakopoulou Str. 115 28 Athens, Greece
Tel.: ++30 210 77 11 673, 210 77 56 336
Fax: ++30 210 77 11 289
E-mail: ESUR2009@prctravel.gr
Website: www.esur2009.gr
www.prctravel.gr
6

FACULTY 2009
AGADAKOS E. (GR)
AMENDOLA M. (USA)
ANASTOPOULOS J. (GR)
ANTSAKLIS A. (GR)
BABNIK-PESKAR D. (SL)
BALLEYGUIER C. (F)
BARENTSZ J. (NL)
BAUMGARTEN D. (USA)
BELLIN M.F. (F)
BERTOLOTTO M. (I)
BRKLJACIC B. (HR)
CHALAZONITIS A. (GR)
CHOYKE P. (USA)
CLAUDON M. (F)
COKKINOS D. (GR)
COLLINS M. (UK)
CORNUD F. (F)
COVA M. (I)
COWAN N. (UK)
CUNHA T. M. (P)
CURRY N. (USA)
DALLA PALMA L. (I)
DANZA F. (I)
DELIKANAKIS N. (GR)
DERCHI L. (I)
DIMOPOULOU A. (S)
DOGRA V. (USA)
DROSSOS CH. (GR)
EFREMIDIS S. (GR)
EL DIASTY T. (ET)
EVLOGIAS N. (GR)
FORSTNER R. (A)
GEORGIADIS K. (GR)
GHIATAS A. (GR)
GOLDMAN S. (USA)
GOULIAMOS A.(GR)
GOURTSOYIANNI S. (GR)
GRENIER N. (F)
HALLSCHEIDT P. (D)
HAMM B.K. (D)
HANNA S.(ET)
HEINZ-PEER G. (A)
HELENON O. (F)
JAKOBSEN J. (N)
KASTRIOTIS J. (GR)
KATSIFARAKIS D.(GR)
KATSOU G. (GR)
KELEKIS N. (GR)
KENNEY P. (USA)
KIM SEUNG HYUP (KOR)
KINKEL K. (CH)
KOUMANIDOU CH. (GR)
KOUMARIANOS D. (GR)
KUBIK – HUCH R. (CH)
LIVADAS M. (GR)
LOGAGER V. (DK)
MAGNUSSON A. (S)
MALACHIAS G. (GR)
MALAMATENIOU CH. (GR)
Mc HUGO JO (UK)
ΜΑTSAIDONIS D. (GR)
MORCOS S. K. (UK)
MOREAU J.F. (F)
MORGAN E. (UK)
MOUSSA S. (UK)
MUELLER-LISSE U.G. (D)
MUELLER-LISSE U.L. (D)
NIKOLAIDIS P. (USA)
NICOLAOU I. (GR)
NOLTE-ERNSTING C. (D)
OCANTOS J. (ARG)
OYEN R. (B)
PAPADOPOULOS V. (GR)
PAPADOPOULOU F. (GR)
PAPAILIOU J. (GR)
PAPANIKOLAOU N. (USA)
PAVLICA P. (I)
PETSAS TH. (GR)
PIPEROPOULOS P. (GR)
PRASSOPOULOS P. (GR)
RAMCHANDANI P. (USA)
RICCABONA M. (A)
ROCKALL A. (UK)
ROY C. (F)
SALA E. (UK)
SANDSTEDE J. (D)
SANDLER K. (USA)
SCHERR M. (D)
SEBASTIA C. (E)
SPENCER J. (UK)
STRIGARIS K. (GR)
TAVERNARAKI A. (GR)
THEODOROPOULOS V. (GR)
THOENY H. (CH)
THOMSEN H. (DK)
TRIANTOPOULOU CH. (GR)
TSAMPOULAS K. (GR)
TSILI A. (GR)
TSITOURIDIS I. (GR)
TSOUROULAS M. (GR)
TURGUT A. (T)
VAN DER MOLEN A. (NL)
VILLERS A. (F)
WASSERMAN N. (USA)
WEBB J. (UK)
YARMENITIS S. (GR)
ZAGORIA R. (USA)
ZOUPAS CH. (GR)
7

ACCREDITATION
The 16th European Symposium on Urogenital Radiology is accredited by the European
Accreditation Council for Continuing Medical Education (EACCME) to provide the following
CME activity for medical specialists. The EACCME is an institution of the European Union
of Medical Specialists (UEMS).
www.uems.be
European Accreditation is granted by the EACCME in order to allow participants to
validate the credits obtained at this activity in their home European Country.
The 16 th European Symposium on Urogenital Radiology is designed for a maximum of 18
hours of European external CME credits. Each medical specialist should only claim those
hours of credit that he/she actually spent in the educational activity.
EACCME credits are recognized by the American Medical Association towards the
Physician’s Recognition Award (PRA). To convert EACCME credits to AMA PRA category I
credit, please contact AMA.
Distribution of CME Credits for ESUR 2009 as follows:
September 10, 2009: 3 Credits
September 11, 2009: 6 Credits
September 12, 2009: 6 Credits
September 13, 2009: 3 Credits
You may earn a total of 18 category “A” credits if you attend ESUR 2009 on all 4 days.
The CME credit certificate will be handed out on Sunday 13 th , 2009.
8

SOCIAL PROGRAMME
EVENING PROGRAMME
Member’s Dinner
On Thursday, September 10 th the Members’s dinner will be held at the “Brasserie SUD
of PIERONE” located by the sea in a magnificent marina-yaughting club.
The entrance tickets will be handed out on site at the secretariat of Symposium
(if registered).
On site registration is subject to availability.
Welcome reception
On Friday, September 11 th all participants are invited to join the Welcome Reception just
after the Opening Ceremony, both at the conference venue.
Entrance free of charge for all registered participants.
Course Dinner
On Saturday, September 12 th the Course Dinner will be held at the Cape Sounio Hotel,
nearby the Famous Ancient Temple of Poseidon builded at the top of the Southmost cape
of European Continent offering one of the most beautiful sunsets in Mediterranean Sea.
The entrance tickets will be handled out on site at the secretariat of Symposium (if
registered).
On site registration is subject ti availability.
9

GENERAL INFORMATION
SYMPOSIUM VENUE
ROYAL OLYMPIC HOTEL
Athens, Greece, Tel: +30 210 9288400, Fax: +30 210 9233317
Website: www.royalolympic.com E-mail: info@royalolympic.com
DATES
SEPTEMBER, 10-13 2009
REGISTRATION FEES
Registration
ESUR/SUR Member
Non Member
300EURO
350EURO
* Residents-in-training 120EURO
*Radiological
Technologists
Medical Students
Accompanying Persons
Members Dinner
Course Dinner
80EURO
70EURO
150EURO
75 EURO
85 EURO
REGISTRATION FEE FOR THE PARTICIPANTS INCLUDES
• Entrance to the Symposium Halls
• Welcome Reception
• Programme, Badge and Bag
• Coffee during the breaks (5 tickets)
• Light lunch during the Satellite Symposia
(only for the attenders)
REGISTRATION FEE FOR THE ACCOMPANYING PERSONS INCLUDES
• Welcome Reception
• Waliking Tour in the Archaelogical center of Athens on Saturday morning 12.09.09 (Plaka, Monastiraki, Ancient
Market, Roman Market, Acropolis)
OFFICIAL LANGUAGE
The official language is English. No translation will be provided.
CLIMATE AND CLOTHING
The weather in Greece during the month of September is generally mild in the mornings and quite fresh in the evening.
ELECTRICITY
Please note that electricity in Greece is 200V.
INSURANCE
All participants are strongly advised to carry the proper travel and health insurance, as the ESUR 2009 cannot accept
liability for any accidents or injuries that may occur at the Symposium. Please consult your travek agent regarding the
matter.
TRAVELLING – PASSPORT AND VISAS
Visas are required from citizens of some foreign countries. Participants should check with their travel agents, Greek
consulate offices or diplomatic missions in their own countries whether or not visas are required.
For more information, please contact the Secretariat.
10

SCIENTIFIC & COMMERCIAL EXHIBITION
During the Symposium, a Scientific & Commercial Exhibition will take place.
DATA PREVIEW
A Speakers’ Ready Room will operate throughout the duration of the Symposium.
Speakers are kindly requested to hand in all material of their presentation (slides, floppy disc,
USB-key, CD-ROM) at least two hours before their scheduled presentation time.
If a presentation is scheduled early in the morning, speakers are kindly requested to check their
presentation at the Speakers’ Ready Room the day before.
Please note that all versions of MS PowerPoint are accepted excluding Mac.
If you are using embedded video clips in your presentation, please remember to submit video
files separately.
BADGES
Delegates’ badges will be available at the Symposium Secretariat in the Symposium Venue. It is
advisable for all participants to wear their badges both in the Symposium and the Exhibition Area.
The badges will be distributed as following:
Faculty (Speakers – Chairpersons)
Participants
Accompanying Persons
Exhibitors
Secretariat Staff
Red Colour
Blue Colour
Green Colour
Yellow Colour
Grey Colour
CME CREDITS
The 16th European Symposium on Urogenital Radiology is accredited by the European
Accreditation Council for Continuing Medical Education (EACCME) to provide the following CME
activity for medical specialists. The EACCME is an institution of the European Union of Medical
Specialists (UEMS).
The 16th European Symposium on Urogenital Radiology has been accredited with 18 CME
credits.
CERTIFICATE OF ATTENDANCE
A Certificate of Attendance will be available for all participants, at the Symposium Secretariat, on
September 13 th , 2009.
SECRETARIAT
The Symposium Secretariat will be operating at the Symposium Area, for registrations and
information, throughout the Symposium and during the Symposium’s hours, as following:
Thursday, September 10 th , 2009 08:30 – 19:00
Friday, September 11 th , 2009 08:00 – 18:00
Saturday, September 12 th , 2009 08:00 – 17:30
Sunday, September 13 th , 2009 08:00 – 13:30
11

MAPS
Center of Athens & Conference Venue
Public transportations
For all the public transport (Metro/Underground, Tram, Bus, HSAP) there is one ticket, with
duration of 90 minutes, that costs 1,00€.
From the Acropolis Station of Metro the Hotel is 100m away, walking along Ath. Diakou Street.
Also, from the Vouliagmenis Avenue Station of TRAM the Hotel is 40m away.There are also
several lines of bus near the hotel to all the directions.
Conference halls
• Alexander
• Attica
• Conference 1
• Conference 2
• Kalliroi B
• Olympia 1
• Olympia 2
• Royal Olympic Ground
Poster Area
• Kalliroi A
12

Attica (with marks of the 2 Dinners places)
13

SCIENTIFIC PROGRAMME
15

Clarification: Affiliations, authors’ names and abstracts’ texts(spelling, syntax, content) are
presented as they have been submitted.
There is no kind of intervention by the Scientitic Committee.
16

Thursday, September 10th, 2009
10:30 Registration
HALL KALLIROI A
12:00-18:00 Posters Exhibition
Members’ Day Sessions
HALL ATTICA
Before session:
5 min. information by G. Malachias about the Symposium Venue, the City
of Athens, public transports etc.
14:00 – 15:40 Session I
Moderators: Hamm B.K. (D) - Mueller-Lisse U.L. (D)
14:00 MS1. POTENTIAL ROLE OF MR DIFFUSION-WEIGHTED IMAGING
(DW-MRI) WITH APPARENT DIFFUSION COEFFICIENT (ADC)
VALUE TO EVALUATE RENAL INSUFFICIENCY AT 3T
Roy C. (F)
14:10 MS2. MULTIDETECTOR-ROW CT UROGRAPHY: RETROSPECTIVE
COMPARISON BETWEEN STANDARD AND LOW-DOSE
PROTOCOLS FOR DELINEATION OF UPPER URINARY TRACT
SEGMENTS
Mueller-Lisse U.L. (D)
14:20 MS3. COMPARISON AND CORRELATION BETWEEN 1H-MRI IN-
VIVO PROSTATE SPECTROSCOPY AT 1, 5 T AND EX-VIVO HIGH
RESOLUTION MAGIC ANGLE 1H-NMR SPECTROSCOPY AT 11 T IN
THE EVALUATION OF NEW METABOLITE LEVELS IN PROSTATE
CANCER.
Panebianco V. (Ι)
14:30 MS4. EARLY CERVICAL CANCER: ROLE OF MRI WITH ARTIFICIAL
HYDROCOLPOS IN THE PREOPERATIVE ASSESSMENT OF PATIENT
ELIGIBLE FOR FERTILITY-SPARING SURGERY
Derchi L.E. (I)
14:40 MS5. ASSESSMENT OF TUMORAL ANGIOGENESIS IN
ENDOMETRIAL CARCINOMA WITH DYNAMIC-CONTRAST-
ENHANCED MAGNETIC RESONANCE IMAGING: A PROSPECTIVE
STUDY.
Restaino G. (I)
14:50 MS6. 3T MR SPECTROSCOPIC IMAGING WITH AND WITHOUT
ENDORECTAL COIL IN LOCALIZING PROSTATE CANCER
Yakar D. (NL)
15:00 MS7. STIMULATION OF CULTURED HUMAN DERMAL
FIBROBLAST COLLAGEN PRODUCTION BY GADOLINIUM
CHELATES
Morcos S.K. (UK)
15:10 MS8. DIFFUSION-WEIGHTED MRI ALLOWS FOR THE DETECTION
OF PELVIC LYMPH NODE METASTASES IN BLADDER AND
PROSTATE CANCER PATIENTS: COMPARISON WITH
HISTOPATHOLOGY.
Thoeny H.C. (CH)
17

15:20 MS9. EVALUATION OF RETROGRADE URETEROPYELOGRAPHY
AND FLUOROSCOPICALLY GUIDED BIOPSY FOR DIAGNOSTIC
UPPER TRACT UROTHELIAL CANCER FOLLOWING
MULTIDETECTOR COMPUTED TOMOGRAPHY UROGRAPHY IN
PATIENTS PRESENTING WITH MACROSCOPIC HAEMATURIA
OVER 40-YR OF AGE.
Cowan N.C. (UK)
15:30 MS10. EVALUATION OF A PNEUMATICALLY ACTUATED MR-
COMPATIBLE ROBOT FOR MR-GUIDED PROSTATE BIOPSY
Futterer J.J. (NL)
15:40 – 16:00 Coffee Break
16:00 – 18:00 Session II
Moderators: Morcos S.K. (UK) - Derchi L. (I)
16:00 MS1. DIFFUSION WEIGHTED MRI IN EVALUATION OF
TRANSPLANTED KIDNEY: PRELIMINARY CLINICAL EXPERIENCE
Abou El-Ghar M. (ET)
16:10 MS2. THE VALUE OF ULTRASOUND FINDINGS AND SERUM
PROCALCITONIN LEVELS IN UPPER URINARY TRACT INFECTION
IN CHILDREN
Vranou E. (GR)
16:20 MS3. DOES CEUS HAVE A PRACTICAL VALUE IN ADJUNCT TO
COLOR DOPPLER US IN EVALUATION OF PATIENTS WITH RENAL
INSUFFICIENCY EVALUATION OF 56 PATIENTS
Bertolotto M. (I)
16:30 MS4. INFLUENCE OF NITRIC OXIDE ON OXYGEN CONSUMPTION
BY IODINATED CONTRAST MEDIA IN FRESHLY ISOLATED
PROXIMAL TUBULAR CELLS FROM ELDERLY HUMANS AND
DIABETIC RATS.
Liss P. (SE)
16:40 MS5. INCIDENCE OF IN-HOSPITAL TREATED RENAL FAILURE IN
23,425 SWEDISH PATIENTS AFTER CORONARY PROCEDURES
Liss P. (SE)
16:50 MS6. MDCT AND RENAL ARTERY IN-STENT RESTENOSIS; IS
RADIATION EXPOSURE REDUCTION FEASIBLE
Manousaki E. (GR)
17:00 MS7. MAGNETIC RESONANCE IMAGING IN THE EVALUATION OF
PLACENTAL ABRUPTION: CORRELATION WITH COLOR DOPPLER
ULTRASOUND
Masselli G. (I)
17:10 MS8. MORPHOMETRY OF TISSUE MICROSTRUCTURE:
COMPARISON OF DIGITAL LIGHT MICROSCOPY (DLM) AND
INTRALUMINAL CATHETER-BASED OPTICAL COHERENCE
TOMOGRAPHY (OCT) IN NORMAL PORCINE URETER WALL
SPECIMENS
Mueller-Lisse U.L. (D)
17:20 MS9. EMBOLIZATION OF POLYCYSTIC KIDNEYS: AN
ALTERNATIVE TO NEPHRECTOMY BEFORE RENAL
TRANSPLANTATION: A WORK IN PROGRESS.
Hubrecht R.. (F)
17:30 MS10. THIN SLICE THICKNESS (1MM) 3D-T2-WEIGHTED MRI AND
LOCAL STAGING OF PROSTATE CANCER
Cornud F. (F)
17:40 MS11. FUNCTIONAL MRI (DIFFUSION WEIGHTED AND DYNAMIC
CONTRAST ENHANCED IMAGING) IN PATIENTS WITH LOW RISK
PROSTATE CANCER.
18

Cornud F. (F)
17:50 MS12. RADIATION DOSE REDUCTION IN MULTIPHASE CTU BY AN
ADAPTIVE COLLIMATOR
Van der Molen A.J., MD (NL)
18:00-18:30 Session for the ESUR news presentation by the President of ESUR
HALL ALEXANDER
18:30-19:00 Meeting of Sc. Committee to confirm the Awards of Members’ day
20:00 Members’ Dinner (Resraurant “Brasserie SUD of PIERONE”)
(Announcement of Awards of Μembers’ Day by the President of the ESUR 2009 and the President
of ESUR Βoard).
Friday, September 11th, 2009
08:00 – 18:00 Registration
Posters Exhibition
LECTURE SESSIONS
HALL OLYMPIA 1
08:30 - 08:35 Welcome by Prof. Hamm B.K. (D) and Dr. Malachias G. (GR)
08:35 – 10:00 New frontiers in Imaging
Moderators: Cornud F. (F) - Gouliamos A. (GR)
08:35 – 09:00 Imaging of inflammation and fibrosis
Grenier N. (F)
09:00 – 09:25 New frontiers in US imaging
Dogra V. (USA)
09:25 – 09:50 Imaging of atherosclerosis
Hamm B.K. (D)
10:00 – 10:30 Coffee Break
10:30 – 12:30 Prostate cancer
Chairman: Barentsz J. (NL)
WORKING GROUP
LECTURE SESSIONS
10 min. Discussion
CONFERENCE 1
HALL OLYMPIA 1
10:30 – 12:00 Diabetes mellitus
Moderators: Tsampoulas K. (GR) - Triantopoulou Ch. (GR)
10:30 – 11:00 Diabetes and Diabetic Nephropathy
Zoupas Ch . (GR)
11:00 – 11:30 Imaging of genitourinary complications of diabetes mellitus
Danza F. (I)
11:30 – 11:50 Use of CM in diabetic patients
Morcos S.K. (UK)
10 min. Discussion
12:00 - 13:30 MEETING ESUR CTU/MRU
Chairman: Cowan N. (UK)
19
ALEXANDROS HALL

12:00 – 13:30 Satellite Symposium
Lunch/Symposium by GE HealthCare
Moderators: Hanna S. (ET) - Cokkinos D. (GR)
Speaker: Sandstede J. (D)
OLYMPIA 1
LECTURE SESSIONS
OLYMPIA 1
13:30 – 15:00 Lymphoproliferative disorders
Moderators: Ramchandani P. (USA) - Amendola M. (USA)
13:30 – 13:55 Retroperitoneal Lymphoproliferative disease
Goldman S. (USA)
13:55 – 14:20 Imaging of lower GU tract Lymphoma
Amendola M. (USA)
14:20 – 14:45 Genitourinary lymphoma: case histories
Spencer J. (UK)
15 min. Discussion
15:00 – 15:30 Awards of Members’day and presentation of the first winning paper
by the main author.
Chairman: Hamm B.K. (D)
15:30 – 16:00 Coffee Break
16:00 – 17:20 WORKSHOPS
1. Urography with CT and MRI
Moderators: Roy C. (F) - Drossos Ch. (GR)
HALL OLYMPIA 1
16:00 – 16:20 CTU technique and applications
Roy C. (F)
16:20 – 16:40 The Development of multidetector Computed Tomography Urography
for investigating Haematuria.
Cowan N. (UK)
16:40 – 17:00 CTU and IVU Radiation Dose
Van der Molen A. (NL)
17:00 – 17:20 MRU technique and applications
Nolte-Ernsting C. (D)
2. Prostate Imaging
Moderators: Barentsz J. (NL) - Yarmenitis S. (GR)
HALL OLYMPIA 2
16:00 - 16:20 Morphometric features and clinical aspects of Prostate cancer.
Villers A. (F)
16:20 - 16:40 TRUS of Prostate cancer (PCa):a reappraisal in 2009.
Cornud F. (F)
16:40 - 17:00 MRI in Prostate cancer.
Barentsz J. (NL)
10 min. Discussion
20

3. Interventional Uroradiology
Moderators: Moussa S. (UK) - Papailiou J. (GR)
16:00 - 17:00 Management of Urinary stones in 2009: A Team approach.
Speakers: Moussa S. (UK) - Magnusson A. (S)
4. Female pelvis / Imaging
Moderators: Kinkel K. (CH) - Tsili A. (GR)
HALL ATTICA
HALL KALLIROI B
16:00 – 16:20 Tips and tricks for scanning in Gynecology.
Mc Hugo J. (UK)
16:20 – 16:40 What we should not forget to put in a sonographic report about the female pelvis.
Cunha T.M. (P)
16:40 – 17:00 Limitations of female pelvic ultrasound. When do you need MRI /CT
Sala E. (UK)
10 min.Discussion
17:45
HALL OLYMPIA 1
Greetings
Awards of 8 past Presidents of ESUR
Moderators: Malachias G. (GR) , Hamm B. (D)
Official Opening of the Symposium
Opening lectures
Moderator: Dalla Palma L.( IT)
WW1. Use of X-Rays on the Greek front
Livadas G. (GR)
One century of Uroradiology in Europe
Moreau J.F (FR)
WELCOME RECEPTION
21

Saturday, September 12 TH , 2009
08:00 – 18:00 Registration – Posters Exhibition
LECTURE SESSIONS
HALL OLYMPIA 1
08:30 – 10:00 Infectious Diseases
Moderators: Jakobsen J. (N) - Wasserman N. (USA)
08:30 – 08:50 Clinical overview: HIV-AIDS
Morgan E. (UK)
08:50 – 09:10 GU manifestations of AIDS: Reappraisal of imaging findings
Amendola M. (USA)
09:10 – 09:30 Tuberculosis, Parasitic diseases and unusual infections in the GU tract
El-Diasty T. (ET)
09:30 - 09:50 Other Inflammatory Conditions of the Urinary Tract
Wasserman N.F. (USA)
Discussion
10:00 – 10:30 Coffee Break
10.30 – 12.00 Genetic diseases & drug-induced disorders
Moderators: Morcos S.K. (UK) - Koumanidou C. (GR)
10:30 – 10:50 Hereditary disorders of the paediatric urinary tract
Riccabona M. (A)
10:50 – 11:10 Renal cystic disease
Heinz-Peer G. (A)
11:10 – 11:30 Hereditary renal cancers
Choyke P. (USA)
11:30 – 11:50 Drug-induced abnormalities in the GU tract
Ramchandani P. (USA)
10 min.
HALL OLYMPIA 1
10 min. Discussion
HALL ROYAL OLYMPIC GROUND
10:30-12:00 Radiological Technologists’ Sessions
Session 1
Moderators: Georgiadis K. (GR) - Nicolaou I. (GR)
10:30 – 11:00 Magnetic Resonance Imaging of Urinary System
Malamateniou Ch. (UK)
11:00 – 11:10 Coffee Break
(only for this session )
Session 2
Moderators: Katsifarakis D. (GR) - Delikanakis N. (GR)
11:10 – 11:35 Contrast Media and multidetection CT:A Radiographer’s perspective
Agadakos E. (GR) p.
11:35 – 12:00 Optimization of multi-detector rowCT urography
Koumarianos D. (GR)
HALL OLYMPIA 1
12:00 – 13:30 Satellite Symposium
Lunch / Symposium by Bracco
Moderators: Strigaris K. (GR) - Tavernaraki A. (GR)
22

13:30 – 15:00 Female pelvic disorders
Moderators: Brkljacic B. (HR) - Rockall A. (UK)
HALL OLYMPIA 1
13:30 – 13:55 Congenital Abnormalities-why do we need imaging
Kinkel K. (CH)
13:55 – 14:20 Prenatal Diagnosis and Therapy of Fetal Obstructive Urophathies.
Antsaklis A. (GR)
14:20 – 14:45 Metastases to the Female Genital tract
Spencer J. (UK)
15 min Discussion
15:00 – 15:30 Coffee Break
HALL OLYMPIA 1
15:30 – 16:00 SUR Honorary Lecture
Moderator: Hamm B.K. (D)
PET/CT in Urologic Oncology
Papanicolaou N. (USA)
.
16:00-17:20 WORKSHOPS
1. Renal tumors- neoplasms
Moderators: Babnik-Peskar D. (SL) - Efremidis S. (GR)
HALL OLYMPIA 1
16:00 – 16:20 Imaging and staging
Mueller-Lisse U.G. (D)
16:20 – 16:40 Small renal masses/how to deal with these
Cova M. (I)
16:40 – 17:00 Ablation of renal tumors
Zagoria R. (USA)
17:00 - 17:20 Biopsy of renal masses: why, when, how
Papanicolaou N. (USA)
2. Male Genitalia
Moderators: Pavlica P. (I) - Dalla-Palma L. (I)
HALL OLYMPIA 2
16:00 – 16:20 Scrotal masses
Oyen R. (B)
16:20 – 16:40 Acute scrotum
Bertolotto M. (I)
16:40 – 17:00 MR of seminal vesicle and testicle in infertile men
Ocantos J. (ARG)
17:00 – 17:20 Imaging of Penile disorders
Scherr M. (D)
HALL ATTICA
3. The adnexal mass
Moderators: Ghiatas A. (GR) - Chalazonitis A. (GR)
16:00 – 16:20 How to characterize and determine the origine of an adnexal mass at US
Balleyguier C. (F)
16:20 – 16:40 MRI assessment of an inderterminate adnexal mass at US
Kubik-Huch R. (CH)
16:40 – 17:00 Ovarian cancer Staging
Forstner R. (A)
17:00 – 17:20 MRI diagnosis of adnexal tumors by pattern recognition.
Kim S.H. (KR)
23

4. US of Urogenital tract
Moderators: Yarmenitis S. (GR) - Riccabona M. (A)
HALL KALLIROI B
16:00 – 16:20 3DUS a lost territory for Radiology Or new challenge in Urogenital
tract imaging
Riccabona M. (A)
16:20 – 16:40 Contrast US and aspects for its future role:from diagnostic imaging
to new treatement options.
Claudon M. (F)
16:40 – 17:00 US of the transplanted kidney
Yarmenitis S. (GR)
17:00 – 17:20 US of the non neoplastic prostate disorders
Turgut A.T. (TR)
HALL CONFERENCE 1
5. Retroperitoneum-Adrenals
Moderators: Heinz-Peer G. (A) - Papadopoulou F. (GR)
16:00 – 16:20 Adrenal imaging beyond Adenoma vs Non adenoma
Kenney P. (USA)
16:20 – 16:40 The practical role of the Radiologist facing adrenal masses.
Hallscheidt P. (D)
16:40 – 17:00 Retroperitoneal fluid collections
Nikolaidis P. (USA)
17:00 – 17:20 Retroperitoneal masses
Baumgarten D. (USA)
HALL ALEXANDER
17:20 - 17:30 Meeting of Posters evaluation Committee to confirm the best three Posters
20:00 Course Dinner (Cape Sounion Hotel)
(Announcement of the best three Posters)
24

Sunday, September 13 TH , 2009
08:00 – 13:00 Posters Exhibition
SCIENTIFIC SESSIONS
08:30-10:00 URINARY TRACT IMAGING (CT AND MRI)
Moderators: Logager V. (DK) - Dimopoulou A. (S)
08:30 SS1. ACCURACY OF BLADDER CANCER DETECTION WITH
CONTRAST ENHANCED ULTRASOUND
Salvador R. (E)
HALL OLYMPIA 1
08:39 SS2. COMPARISON OF THE ACCURACY OF CT UROGRAPHY
PREPARED WITH FRUSEMIDE VERSUS PREPARATION WITHOUT
FRUSEMIDE IN THE DETECTION OF UROTHELIAL PATHOLOGY
Wan E. (UK)
08:48 SS3. VOIDING CYSTOURETHROGRAPHY IN MODERN IMAGING
WORK-UP OF URINARY TRACT INFECTIONS IN CHILDREN
Karanikas C. (GR)
08:57 SS4. BREATH-HOLD MR-UROGRAPHY IN OBSTRUCTIVE UROPATHY
Katsarou A. (GR)
09:06 SS5. PERIRENAL FAT STRANDING AT CT IN PATIENTS WITH
LOWER URINARY TRACT SYMPTOMS
Sung D.J. (KOR)
09:15 SS6. CT UROGRAPHY IN THE DIAGNOSIS OF BLADDER CANCER IN
HIGH-RISK PATIENTS
Otero-García M.M. (E)
09:24 SS7. MAGNETIC RESONANCE IMAGING AT PATIENTS WITH A
BLADDER CANCER, POSSIBILITY COMPLEX MRI
Zuev V. (R)
09:33 SS8. DUAL SOURCE CT CYSTOGRAPHY AND VIRTUAL
CYSTOSCOPY VERSUS CYSTOSCOPY WITH PHOTODYNAMIC
DIAGNOSIS (PDD) METHOD IN THE BLADDER CANCER
Panebianco V. (I)
HALL OLYMPIA 2
08:30-10:00 PROSTATE IMAGING – MALE GENITALIA I
Moderators: Claudon M. (F) - Piperopoulos P. (GR)
08:30 SS1.STATE-OF-ART PROSTATE MR IMAGING
Verma S. (USA
08:39 SS2. PROSTATE MR AND MR SPECTROSCOPIC IMAGING
AT 1.5T VERSUS 3T
Verma S. (USA)
25

08:48 SS3. MR SPECTROSCOPY (MRS) AND DINAMIC CONTRAST
ENHANCED MR (DCEMR): DETECTION OF PROSTATE
ADENOCARCINOMA FOCI IN MEN WITH PRIOR NEGATIVE
PROSTATE BIOPSY AND ELEVATED PROSTATE SPECIFIC
ANTIGEN (PSA) LEVELS.
Panebianco V. (I)
08:57 SS4. PRELIMINARY STUDY USING DCE-MRI WITH
GADOFOSVESET TRISODIUM BLOOD POOL CONTRAST AGENT IN
THE ASSESSMENT OF PROSTATE CANCER
Panebianco V. (I)
09:06 SS5. EVOLUTION OF PATTERN CHANGES FROM INFLAMMATION
TO PROSTATE CANCER USING 1H-MRSI AND DCE-MRI
Panebianco V. (I)
09:15 SS6. CONTRAST-ENHANCED TRUS SIGNIFICANTLY INCREASES
THE SENSITIVITY OF LOCALIZING BOTH LOW AND HIGH
GLEASON GRADE PROSTATE CANCER
Heijmink S. (NL)
09: 24 SS7. HIGH B-VALUE DIFFUSION-WEIGHTED MR IMAGING IN
PROSTATE CANCER AT 3T
Inada Y. (J)
09:33 SS8. PERFUSION MR IMAGING OF LOCAL RECURRENCE AFTER
RADICAL PROSTATECTOMY
Kubin K. (A)
08:30-10:00 FEMALE PELVIS – FEMALE IMAGING
Moderators: Bellin M.F. (F) - Sebastia M. (E)
HALL KALLIROI B
08:30 SS1. MRI IN THE WORK-UP OF INDETERMINATE OVARIAN MASS:
PROTOCOLL OPTIMIZATION AND DIAGNOSTIC EFFICACY
ANALYSIS
Chilla B. (F)
08:39 SS2. PRIMARY MALIGNANT MIXED MULLERIAN TUMORS OF THE
UTERUS: SONOHYSTEROGRAPHIC AND COLOR DOPPLER
FINDINGS
Lee E.J. (KOR)
08:48 SS3. VALUE OF CERVIX STRUCTURAL CHANGES AT MR IMAGING
IN PATIENTS WITH RISK OF PRETERM DELIVERY
Masselli G. (I)
08:57 SS4. MR IMAGES OF RETAINED PLACENTAL TISSUE
Takahama J. (J)
09:06 SS5. DIFFUSION WEIGHTED MR IMAGING IN VULVA CANCER
Ewald A.M. (DK)
09:15 SS6. MR FINDINGS OF METASTATIC OVARIAN TUMORS
do Nascimento A. F. (P)
09:24 SS7. MAGNETIC RESONANCE IMAGING OF PELVIC
ENDOMETRIOSIS. EFFECT OF READER’S EXPERIENCE ON
ACCURACY AND INTEROBSERVER VARIABILITY.
Restaino G. (I)
09:33 SS8. PRE- AND POSTOPERATIVE DYNAMIC MRI: EVALUATION OF
PELVIC ORGAN DESCENSUS IN SYMPTOMATIC WOMEN
Alt CD. (D)
26

09:42 SS9. LONG-TERM QUALITY OF LIFE ASSESSMENT IN PATIENTS
UNDERGOING UTERINE FIBROID EMBOLIZATION
Popovic M. (A)
08:30-10:00 PROSTATE IMAGING – MALE GENITALIA II
Moderators: Evlogias N. (GR) - Helenon O. (F)
HALL ROYAL OLYMPIC GROUND
08:30 SS1. DETECTION OF LOCAL RECURRENCE PROSTATE CANCER
AFTER RETROPUBIC RADICAL PROSTATECTOMY: MRI VERSUS
PET-CT
Panebianco V. (I)
08:39 SS2. CONTRAST-ENHANCED ULTRASOUND IN SCROTAL
DISEASES: PRELIMINARY RESULTS
Valentino M. (I)
08:48 SS3. EMERGENCY SONOGRAPHIC EVALUATION OF THE
SCROTUM. HOW OFTEN IS PATHOLOGY DETECTED AND WHICH
ARE THE COMMONEST ABNORMALITIES
Kyratzi E. (GR)
08:57 SS4. SONOGRAPHY OF THE ACUTE SCROTUM: THE
COMPLEMENTARY ROLE OF IMAGING WITH ECHO-ENHANCER.
Tsagouli P. (GR)
09:06 SS5. TESTICULAR TORSION: SONOGRAPHIC EVALUATION BEFORE AND
AFTER MANUAL DETORSION
Christopoulou A. (GR)
09:15 SS6. PROSTATE VOLUME MEASUREMENT VIA
TRANSABDOMINAL ULTRASONOGRAPHY (TAUS) COMPARED TO
THE TRUE SURGICAL SPECIMEN VOLUME AFTER RADICAL
PROSTATECTOMY.
Chatzidarellis E. (GR)
09:24 SS7. THE ESTIMATED PROSTATE VOLUME BY TRANSRECTAL
ULTRASONOGRAPHY (TRUS) COMPARED TO THE SURGICAL
SPECIMEN AFTER RADICAL PROSTATECTOMY.
Chatzidarellis E. (GR)
09:33 SS8. IMAGE BASED CLINICAL DECISION SUPPORT WITH THE USE
OF TRANSRECTAL ULTRASOUND IN THE DIAGNOSIS OF
PROSTATE CANCER: COMPARISON OF MULTIPLE LOGISTIC
REGRESSION, ARTIFICIAL NEURAL NETWORK, AND SUPPORT
VECTOR MACHINE
Lee H.J. (KOR)
HALL ATTICA
08:30-10:00 NEW FRONTIERS IN IMAGING AND SYSTEMIC DISEASES
Moderators: Thoeny H. (CH) - Kelekis N. (GR)
08:30 SS1. USPIO ENHANCED DIFFUSION-WEIGHTED MRI TO DETECT
PELVIC LYMPH NODE METASTASES IN NORMAL SIZED NODES.
Thoeny H.C. (CH)
08:39 SS2. EFFICIENCY OF DIFFUSION-WEIGHTED (DW) MR IMAGING
TO DETECT SMALL SIZE MALIGNANT PELVIC LYMPH NODES AT
3T IN VARIOUS PELVIC CARCINOMATOUS DISEASES.
Roy C. (F)
08:48 SS3. RENAL ULTRASONOGRAPHIC FINDINGS IN GREEK PATIENTS
WITH SICKLE-CELL ANAEMIA AND THALASSAEMIA INTERMEDIA
Kornezos I. (GR)
27

08:57 SS4. CIN GUIDELINE ADHERENCE BY REQUESTING PHYSICIANS:
ANALYSIS OF ABDOMINAL CT AT A LARGE UNIVERSITY CENTER
IN THE NETHERLANDS
Van Der Molen A.J.. (NL)
09:06 SS5. THE PROGNOSTIC VALUE OF PERIRENAL INVOLVEMENT IN
THE EVALUATION OF ACUTE PANCREATITIS SEVERITY
Fagrezos D. (GR)
09:15 SS6. LIVER METASTASES FROM RENAL CANCER: THE ADDED
VALUE OF ARTERIAL PHASE OF THE LIVER IN STAGING WITH CT.
Maniatis V. (GR)
09:24 SS7. THE APPLICATION OF MULTIDETECTOR COMPUTED
TOMOGRAPHY IN THE DIAGNOSTIC EVALUATION OF ADULT
POST-TRAUMATIC HEMATURIA
Soldatos Th. (GR)
09:33 SS8. MESOAORTIC NARROWING OF THE LEFT RENAL VEIN IN
ASYMPTOMATIC ADULTS: A NORMAL FINDING, NOT A
NUTCRACKER SYNDROME
Chernyak V. (USA)
09:42 SS9. 64-MDCT EVALUATION OF POTENTIAL LAPAROSCOPIC
LIVING RENAL DONORS
Salvador R. (E)
ΗΑLL CONFERENCE 1
08:30-10:00 INTERVENTIONAL URORADIOLOGY
Μοderators: Petsas Th. (GR) - Theodoropoulos V. (GR)
08:30 SS1. DYNAMIC MRI IN PATIENTS TREATED WITH SUB-URETHRAL
SLING FOR STRESS URINARY INCONTINENCE
Ocantos J. (ARG)
08:39 SS2. LONG TERM RESULTS AFTER PROLONGED URETERAL
STENTING IN CASES OF OBSTRUCTIVE UROPATHY POST RENAL
TRANSPLANTATION
Ikonomopoulou V. (GR)
08:48 SS3. OUTCOMES AND COMPLICATIONS OF PCNL IN PATIENTS
WITH SPINAL PATHOLOGY: SEVEN YEAR EXPERIENCE IN A
TERTIARY REFERRAL CENTRE
Belfield J.C. (UK)
08:57 SS4. HOW EFFECTIVE IS THE FLAT-PANEL ANGIOGRAPHY
SYSTEM IN LOWERING THE OVARIAN DOSE DURING UTERINE
ARTERY EMBOLIZATION (UAE)
Firouznia K. (IR)
09:06 SS5. COMPARISON OF CT-GUIDED CORE NEEDLE BIOPSY AND
FINE NEEDLE ASPIRATION IN THE ABDOMEN AND PELVIS
Chernyak V. (USA)
09:15 SS6. THE PRECAVAL RENAL ARTERY: PREVALENCE AND
ASSOCIATIONS
Derchi L. E. (I)
09:23 SS7. IMAGING THE PROSTATE FROM THE INSIDE OUT: CLINICAL
EVALUATION OF A CUSTOMIZED 14 MHZ PROBE FOR TRANS-
URETHRAL ULTRASOUND (TUUS) DURING PROSTATE
BRACHYTHERAPY
Wilson T.M. (USA)
09:42 SS8. THE VALUE OF HYSTEROSALPINGOGRAPHY (HSG) AS A
FIRST – STEP DIAGNOSTIC TOOL IN THE INVESTIGATION OF
PERITUBAL PATHOLOGY IN THE INFERTILE WOMAN.
Mintzopoulou P. (GR)
28

HALL CONFERENCE 2
08:30-10:00 RENAL TUMORS - NEOPLASMS
Moderators: Tsitouridis I. (GR) - Matsaidonis D. (GR)
08:30 S1. COMPARISON OF CONTRAST-ENHANCED ULTRASOUND AND
COMPUTED TOMOGRAPHY IN CLASSIFICATION OF CYSTIC
RENAL MASSES
Foukal J. (CZ)
08:39 SS2. DW MRI VS DYNAMIC MRI IN DIAGNOSIS OF PROSTATE
CANCER; A PROSPECTIVE STUDY
Abou El-Ghar M. (ET)
08:48 SS3. IS 18FDG PET/CT A USEFUL IMAGING MODALITY FOR THE
MANAGEMENT OF PATIENTS WITH URINARY TRACK CANCER
Panagiotidis E. (GR)
08:57 SS4. THE ROLE OF MULTI-PHASE MDCT IN THE PREOPERATIVE
ASSESSMENT OF RENAL AND URINARY TRACT PATHOLOGY
Kalogeropoulou C. (GR)
09:06 SS5. AN ASSESSMENT OF THE SPECIFICITY OF CT PIXEL MAPPING
IN THE DIAGNOSIS OF AML VERSUS MALIGNANT RENAL
TUMORS
Bardgett H.P. (UK)
09:15 SS6. SONOGRAPHIC PATTERNS AND CAUSES OF BRIGHT
KIDNEYS IN PEDIATRIC PATIENTS
Tsagouli P. (GR)
09:24 SS7. IMAGING OF RENAL TRAUMA WITH CONTRAST-ENHANCED
ULTRASONOGRAPHY
Tsagouli P. (GR)
09:33 SS8. THE VALUE OF DIFFUSION-WEIGHTED MAGNETIC
RESONANCE IMAGING AND RELATIVE APPARENT DIFFUSION
COEFFICIENT IN DIFFERENTIATION BETWEEN RENAL CANCER
AND REGULAR PARENCHYMA
Javor D. (A)
09:42 SS9. IMAGING EVALUATION AND MANAGEMENT OF MULTIPLE
RENAL MASSES
Kolliakou E. (GR)
09:51 SS10. ULTRASOUND IN DETECTION OF RENAL MASSES: MISSED
AND WRONGLY CHARACTERIZED LESIONS
Brkljačić B. (HR)
10:00 – 10:30 Coffee Break
10:30 – 12:00 ESUR Guidelines
Moderator: Morcos S.K. (UK)
10:30 – 11:00 Contrast media-NSF
Thomsen H. (DK)
11:00 – 11:30 Female pelvis
Kinkel K. (CH)
11:30 – 12:00 Pediatric imaging
Riccabona M. (A)
HALL OLYMPIA 1
HALL OLYMPIA 1
12:15 – 13:15 Film Interpretation Session
Moderator: Derchi L.E. (I)
Co-moderators: Curry N. (USA) - Prassopoulos P. (GR)
29

HALL ALEXANDER
13:15 – 13:30 Meeting of Scientific Committee to confirm the best three of Oral
Presentations
HALL OLYMPIA 1
13.30 Closing ceremony
(Best Posters and Best Scientific Presentations Awards)
30

MEMBERS’ DAY SESSIONS
ABSTRACTS
31

SESSION I
Moderators: Hamm B.K. (D) – Mueller-Lisse U.L. (D)
MS1.
POTENTIAL ROLE OF MR DIFFUSION-WEIGHTED IMAGING (DW-MRI) WITH APPARENT DIFFUSION
COEFFICIENT (ADC) VALUE TO EVALUATE RENAL INSUFFICIENCY AT 3T
Roy C.
Radiology B University Hospital, Strasbourg
Purpose: To investigate the relationship between ADC values measured by DW-MRI in cases of renal insufficiency.
Materials and Methods: 250 patients with various pathologies including 160 patients with moderate (GFR > 40 mL· min)
or severe(GFR < 40 mL· min) renal impairment (RI) explored at 3T (Achieva, Philips) with axial DWI SE-EPI (TR/TE :
7000/55,5mm, fat suppression, tf 41, EPI 41, 32 slices, FOV : 288-340, Matrix size : 128-96, free breathing, 3 min54
and b value 0 and 1000 seconds/mm2) and no special recommendation for hydratation or fasting. They were divided in "
normal control 50pts", " normal unique kidney 40pts"and 4 groups of 40pts: " moderate RI unique kidney -", " severe RI
unique kidney ", ” moderate RI both kidney ", " severe RI both kidney ". ADC was measured in 150 mm2 ROI by two
experienced radiologists, as well as images analysis. Statistical analysis was performed using SPSS software. ADC mean
values and standard deviation of each group were calculated and compared using Student T-test.
Results: Images quality was excellent. Cortico-medullary differentiation was observed only in 60 pts with normal renal
function. On DW images signal intensity was homogeneous for all RI types. Mean ADC in control and normal unique
kidney groups were both 1.9 10–3 mm2/ s.
Mean ADC of the four following groups were 1.87 ± 0.11, 1.82 ± 0.17, 1.91 ± 0.11 and 1.86 ± 0.11 10-3mm2/s,
respectively. There was no statistically significant difference in renal ADCs among the four groups and control group.
Conclusion: The ADCs were no significantly different in impaired kidneys and normal kidneys. There was no correlation
between the ADCs and GFR. DW-MRI of the kidney seems not to be a reliable way to differentiate normal renal
parenchyma and different renal diseases.
MS2.
MULTIDETECTOR-ROW CT UROGRAPHY: RETROSPECTIVE COMPARISON BETWEEN STANDARD AND
LOW- DOSE PROTOCOLS FOR DELINEATION OF UPPER URINARY TRACT SEGMENTS
Mueller-Lisse U.L., Meindl T.M., Coppenrath E., Reiser M.F., Stief C., Mueller-Lisse U.G.
Department of Diagnostic radiology, University of Munich
Purpose: In patients with pelvic or retroperitoneal tumors, CT urography (CTU) may replace excretory urography for the
delineation of the upper urinary tract (UUT) prior to treatment. However, radiation exposure is a concern. We
retrospectively compared UUT delineation in standard and low-dose CTU.
Method And Materials:CTU (excretory phase) images were obtained with 120 KV, 4x2.5 mm collimation, and pitch 0.875,
after i.v. injection of 120 ml of non-ionic contrast media with 300 mg of iodine/ml with standard (January through March,
14 patients, n=116 UUT segments, 175 mAs/slice, average delay 16.8 minutes) or low-dose (April through September, 26
patients, n=344 UUT segments, 29 mAs/slice, average delay 19.6 minutes) protocols. UUT segments included intrarenal
collecting system (IRCS), upper, middle, and lower ureter (UU,MU,LU). Two independent readers (R1,R2) graded UUT
segment delineation as 1-absent, 2-partial, 3-complete (noisy margins), 4-complete and clear. Chi-square statistics were
calculated for grades 1-2 vs. 3-4 (delineates UUT and may locate obstruction/dilation) and 1-3 vs. 4 (may locate
intraluminal lesions).
Results:Delineation of UUT was equally good for all segments in standard and low-dose CTU (R1, chi-square=0.0036-
1.74, p>0.15; R2, chi-square=0.074-1.308, p>0.2). Grade-4-delineation was equal between standard and low-dose
protocols for IRCS, UU, and MU (R1, chi-square=0.074-1.013, p>0.25; R2, chi-square=0.919-2.159, p>0.1). However,
LU was more often completely and clearly delineated in standard protocols (R1, 18/24 standard, 38/69 low-dose, chisquare=2.178,
p>0.1; R2 18/24 standard, 21/69 low-dose, chi-square=12.75, p
Conclusion: Low-dose CTU appears sufficient to delineate UUT and perhaps locate obstruction/dilation, but unsuited to
locate intraluminal LU lesions.
MS3. COMPARISON AND CORRELATION BETWEEN 1H-MRI IN-VIVO PROSTATE SPECTROSCOPY AT 1,5 T
AND EX-VIVO HIGH RESOLUTION MAGIC ANGLE 1H-NMR SPECTROSCOPY AT 11 T IN THE
EVALUATION OF NEW METABOLITE LEVELS IN PROSTATE CANCER.
Panebianco V., Osimani M., Valerio M.C., Santucci E., Biondi T., Passariello R.
Dept of Radiological Sciences,Sapienza University of Rome
Object: The aim of this study is to assess if an ex-vivo metabolomic approach can be used to discover metabolic
biomarkers that are distinct in prostate cancer and healthy glands and its correlation with metabolites obtained by
standard in- vivo 1H-MRI spectroscopy (1H-MRSI).
Method: Five hundred and ninethy candidates for radical retropubic prostatectomy (RRP) were previously studied with 1H-
MRSI (1,5 T). A spectroscopic curve was obtained with Choline, Citrate, Creatine assessments within multiple boxes
placed on the suspected prostate nodule. After the RRP, a high resolution magic angle 1H-NMR (11 T spectrometer) was
performed on the surgical sample, serum and urine. Multivariate analysis was applied on the 1H-NMR metabolites curve
and correlated with those of in vivo 1H-MRSI.
Results: The data we obtained demonstrate that actual in-vivo 1H-MRSI represents a weaker approach to prostate
diseases because of the lower number of metabolites detected compared with those of ex-vivo 1H-NMR.
Conclusion: This approach may be the basis for further development of new in-vivo MRSI acquisition modalities; these
developments may improve diagnostic accuracy level and identify not only biochemical changes but also metabolic
markers for cancer diagnosis.
32

MS4.
EARLY CERVICAL CANCER: ROLE OF MRI WITH ARTIFICIAL HYDROCOLPOS IN THE PREOPERATIVE
ASSESSMENT OF PATIENT ELIGIBLE FOR FERTILITY-SPARING SURGERY
CapaccioE. 1 , Marchiolè P. 2 , Sala P. 2 , Moioli M., 2 Cittadini G. 1 , Tagliafico A. 1 , Derchi L.E. 1
1 Cattedra "R" di Radiologia-DICMI, Università di Genova, Largo Rosanna Benzi 8, 16132 Genoa, Italy., 2
Dipartimento di Ginecologia, Università di Genova, Genoa, Italy.
Objective: To evaluate the role of MRI with artificial hydrocolpos in the pre- and post-operative work-up of women with
early cervical cancer eligible for fertility-sparing surgery.
Method: We evaluated ten patients with early invasive cervical cancer (FIGO IA2-IB1) wanting to preserve their fertility.
Diagnosis had been achieved by cervical biopsy (n=3) or conisation (n=7).
All patients underwent pre-operative pelvic MRI with and without artificial distention of vaginal cavity. This was achieved
by 50-70cc of saline solution instilled through a Fooley catheter with distended balloon to avoid reflux. High-resolution tSE
T2-weighted sequences were performed in sagittal, para-axial and para-coronal planes oriented along the cervix uteri long
axis. We measured maximal tumoral diameter and distance between tumor and uterine internal os.
Results: The technique allowed good delineation of locoregional anatomy in all cases. Five patients had no residual
cervical lesion or lymphoadenopathy at MRI after cold knife conisation. Cervical tumor was seen in five cases. In three
patients the lesion was > 2cm (mean: 24mm). The tumor-uterine internal os distance was >10 mm in three cases and
0.71, and for the central gland:
score 1< 0.48; 2, 0.49-0.62; 3, 0.63-0.76; 4, 0.77-0.9; and 5, > 0.91 was applied. Choline-to creatine ratios were also
assessed. For statistical analysis (were performed by using SPSS version 16.0), the sensitivity, specificity were calculated
by dichotomizing the readings. A cut-off point of above 3 was considered malignant and these findings were correlated
with whole-mount prostatectomy specimens. Receiver operating characteristics analysis was performed. All P values
reported were derived at two-sided tests.
Results: Reader I (less experienced reader) had an area under the curve (AUC) of 0.57 for without ERC and 0.64 for with
ERC, however not significantly different (p >0.05). Reader II (experienced reader) had an AUC of 0.55 for without ERC
and 0.65 for with ERC, this difference was significant (p < 0.05). Reader I had a sensitivity and specificity of 47% and
57% without ERC and a sensitivity and specificity of 72% and 48% with ERC, respectively. Reader II had a sensitivity and
specificity of 30% and 82% for tumor localization without ERC, and a sensitivity and specificity of 35% and 94% with ERC,
respectively.
Conclusion: For an experienced reader 3T MRSI for localizing prostate cancer has a high specificity and a low sensitivity.
Using an ERC at 3T MRSI is significantly more accurate compared to non-ERC MRSI in localizing prostate cancer.
Clinical relevance
Accurate tumor localization is important for focal treatment planning.
33

MS7.
STIMULATION OF CULTURED HUMAN DERMAL FIBROBLAST COLLAGEN PRODUCTION BY GADOLINIUM
CHELATES
Morcos S. 1 , Bains S. 2 , JohnsonC. 2 , MacNeil S 2 .
1 Department of Diagnostic Imaging, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK,
And 2 Department of Engineering Materials, Kroto Research Institute, University of Sheffield, Broad Lane,
Sheffield, S3 7HQ, UK
Purpose: In patients with renal insufficiency who have been exposed to gadolinium based contrast agents (Gd-CA) a
syndrome of nephrogenic systemic fibrosis ( NSF ) with a spectrum of aberrant dermal remodelling has been identified.
The exact pathogenesis is uncertain but low stability of Gd-CA leading to the release of free gadolinium has been proposed
as an important factor in triggering this condition. The purpose of this study was to look at the direct effects of Gd-CA with
different stability on cultured human dermal fibroblast proliferation and collagen production.
Method and Materials: Human fibroblasts were cultured from patients donating skin following elective operations . Cells
were cultured in DMEM medium plus 10% foetal calf serum and exposed to a range of concentrations of Omniscan (low
stability non-ionic linear chelate, GE Health Care, USA), Dotaram (high stability ionic macrocyclic agent, Guerbet, France)
or GdEDTA (very low stability linear Gd-chelate, positive control) for 3 or 7 days. Cell proliferation was assessed using the
MTT ESTA colorimetric assay and total collagen production by the use of Sirius Red.
Results: While indicative results could be seen at 3 days, clearly significant results were obtained after 7 days’ exposure of
cells to the gadolinium chelates. Gd-EDTA had a slight (15%) stimulatory effect on cell proliferation and concomitant
collagen production at 0.1mM. Higher concentrations significantly reduced proliferation and collagen production by 10%
at 1mM and by 80% at 10mM in comparison to the control group (only culture medium). Dotaram, studied at
concentrations from 0.01 to 1mM had no significant effect on cell proliferation or collagen production. However, 10mM
Dotaram slightly reduced both proliferation and collagen production by approximately 20%. The most marked results
were seen with Omniscan. Concentrations as low as 0.01mM stimulated proliferation and collagen production and a
maximum increase of 30-50% was observed with 1mM concentration. . Higher concentrations were less stimulatory.
Conclusion: These results clearly show that Gd-CA of low stability (Omniscan) have direct stimulatory effects on fibroblast
proliferation and collagen production, readily demonstrated over 7 days The highly stable macrocyclic agent Dotaram had
no stimulatory effects on fibroblasts. The study offers some support for the importance of the stability of Gd-CA in the
pathogenesis of NSF
MS8.
DIFFUSION-WEIGHTED MRI ALLOWS FOR THE DETECTION OF PELVIC LYMPH NODE METASTASES IN
BLADDER AND PROSTATE CANCER PATIENTS: COMPARISON WITH HISTOPATHOLOGY.
Thoeny H.C. 1 , FroehlichJ.M. 1 , Triantafyllou M. 1 , Birkhaeuser F. 2 , Fleischmann A. 3 , Binser T. 4 , Vermathen P. 4 ,
Studer U.E. 2
1 Department of Diagnostic, Pediatric and Interventional Radiology, Inselspital, University of Bern, Bern,
Switzerland, 2 Department of Urology, Inselspital, University of Bern, Bern, Switzerland, 3 Department of Pathology,
University of Bern, Switzerland,
4 Department of Clinical Research, Inselspital, University of Bern, Bern,
Switzerland
Purpose: To assess the potential of diffusion-weighted MRI (DW-MRI) to detect pelvic lymph node metastases in normalsized
nodes of bladder and/or prostate cancer patients compared to histopathology.
Methods and Materials: Fifty patients with bladder (n=16), prostate cancer (n=27) or both (n=7) were examined on a 3T
MR. 3D T1- and T2-weighted sequences and axial DW-MRI (3b-factors 0, 500, 1000s/mm2, slice thickness 4mm) were
performed. Visual analysis and ADC-measurements of DW-MRI were compared to histopathology. ADC values of lymph
nodes were classified: malignant100x10-5 mm2/sec. Template lymphadenectomy was performed in all
patients. Histopathological correlation was performed on a per patient basis.
Results: Diagnostic performance for DW-MRI compared to histopathology was: sensitivity of 93%, specificity of 75%, PPV
of 59%, NPV of 96% and diagnostic accuracy of 80%. False positive lymph nodes showed follicular hyperplasia,
lipomatosis or sinus histiocytosis on histopathology, The smallest lymph node metastasis detected by DW-MRI measured 2
x 1.5mm in a lymph node of 5x6mm. The false negative patient had a lymph node metastasis of 0.7x.0.4 in a 3.5x4.0mm
sized node. Overall, a total of 1853 lymph nodes were resected emphasizing the high NPV.
Conclusion: DW-MRI allows to noninvasively detect pelvic lymph node metastases even in normal-sized nodes of patients
with bladder and prostate cancer.
34

MS9.
EVALUATION OF RETROGRADE URETEROPYELOGRAPHY AND FLUOROSCOPICALLY GUIDED
BIOPSY FOR DIAGNOSING UPPER TRACT UROTHELIAL CANCER FOLLOWING MULTIDETECTOR
COMPUTED TOMOGRAPHY UROGRAPHY IN PATIENTS PRESENTING WITH MACROSCOPIC
HAEMATURIA OVER 40-YR OF AGE.
Cowan N.C., Mallett S., Turney B.W., Bardgett H., Crew J. P., Sullivan M.
The Churchill Hospital OX3 7LJ Oxford, London
To evaluate retrograde ureteropyelography (RUP) and fluoroscopically guided biopsy (FBX) for diagnosing upper tract
urothelial cancer (UTUC) following multidetector computed tomography urography (CTU).
CTU was performed on a consecutive series of patients, with macroscopic haematuria, over 40-yr, without infection.
CTU was scored using a 5-point scale: 1=normal, 2=probably normal, 3=equivocal, 4=probably+ve, 5=definitely+ve
for UTUC. RUP+/-FBX was attempted on patients with scores of 3-5. Procedures were performed under IV sedation and
analgesia. Sensitivity (Se) and specificity (Sp) were calculated for RUP for diagnosing UTUC. The reference standard
comprised histopathology from surgery, FBX or ureteroscopic biopsy (UBX), clinical, imaging and histopathology followup.
RUP was attempted in 73 patients. RUP was +ve for UTUC in 48 and normal in 22. There were 3 technical failures (TF)
due to non-visualization of the ureteric orifice. For RUP for diagnosing UTUC, Se=100%, Sp=85%, PPV=92% and
NPV=100%. There were 4 false+ve RUP results: amyloid (n=1), renal cell cancer (n=1), TF (n=1) and hypertrophied
papilla (n=1). Of the 48 RUP+ve patients, 46 underwent FBX, 2 were excluded: warfarin anticoagulation (n=1) and
circumferential urothelial thickening without focal mass, making FBX technically impossible (n=1). Of 34 patients with
FBX+ve results, 30 were confirmed UTUC+ve by histopathology following radical nephroureterectomy and 4 patients
were treated palliatively, but assumed to be UTUC+ve because of the biopsy result. Of the 12 patients who were FBXve/indeterminate,
9 were UTUC+ve and 3 were UTUC-ve. There were no complications requiring further intervention.
FBX, if technically feasible, may obviate UBX for histopathological diagnosis of UTUC.
MS10.
EVALUATION OF A PNEUMATICALLY ACTUATED MR-COMPATIBLE ROBOT FOR MR-GUIDED
PROSTATE BIOPSY
Futterer J.J., Scheenen T.W.J., Schouten M., Bosboom D., Barentsz J.O.
Department of Radiology, UMCN, The Netherlands
Purpose: Evaluation of a pneumatically actuatedMR-compatible robotic device to perform biopsy in the prostate with realtime
3T magnetic resonance (MR) imaging guidance.
Material and Methods: The robotic system is fitted with five computer-controlled degrees of freedom for delivering an
interventional procedure. The entire device is constructed of MR compatible materials, i.e. nonmagnetic and nonconductive,
to eliminate artifacts and distortion of the MR images. The robotic device is remotely controlled by means of
pneumatic motors and a graphical user interface, providing real-time MR-guided monitoring of the intervention. The
device is mounted to the table of a 3T whole body MR scanner. Trials were conducted on an abdominal phantom, with
real-time MR guidance. Biopsy needles were placedby expert and novice users towards internal 1mm targets.The needle
was visualized with a three-dimensional T1-weighted sequence (TR/TE 6.52/2.54ms; flipangle 10 degrees). Accuracy was
determined by computing the needle tip to target distance.
Results: The robotic system successfully assisted with guiding biopsy needle placement. No artifacts caused by the robotic
system were observed in the MR images. Position and orientation of all biopsy insertions were appropriately visualized on
the 3-dimensional T1-weighted MR images. Precision of needle placement was 2.5mm (range 0-4.1mm). The average
time to reach the target was 4.58 minutes (range 3.50-6.40).
Conclusion: MR imaging guided prostate biopsy using a pneumatically actuated MR-compatible robot provides adequate
precision of insertion and orientation of the biopsy needle and shows great promise for MR-guided biopsy procedures.
SESSION II
Moderators: Morcos S.K. (UK) – Derchi L. (I)
MS1.
DIFFUSION WEIGHTED MRI IN EVALUATION OF TRANSPLANTED KIDNEY: PRELIMINARY CLINICAL
EXPERIENCE
Abou El-Ghar M., Refaie H., Hassan N. 1 , Kamal M. 2 , Mohsen T., El-Diasty T.
Radiology, 1 Nephrology and 2 Urology Departments, Urology & Nephrology center- Mansoura University,
Mansoura-Egypt
Purpose: To evaluate the diagnostic performance of Diffusion Weighted(DW) magnetic resonance (MR) imaging in
evaluation of transplanted kidneys.
Material & Methods: One hundred twelve patients with transplanted kidney from live kidney donors were evaluated with
coronal T2w and DW MRI of the kidney. Apparent diffusion coefficient (ADC) was calculated and the kidneys studied for
any areas diffusion restriction. Our patients classified into 2 groups: Group 1 examined with b values 0 & 400 sec/mm2, it
includes 62 patients (45 male & 17 female) and group 2 examined at b values 0 & 800 sec/mm2, it includes 50 patients
(41 male & 9 female). The mean age was 29.5±10ys (range 13-53) and 26.9±11.5ys (range 10-55) for group 1&2
respectively.
Results: The group 1 includes 42 normal kidneys, 12 with chronic nephropathy, 5 with acute rejection and 3 with acute
tubular necrosis (ATN) while the group 2 includes 39 normal kidneys, 6 with chronic nephropathy and 5 with acute
rejection. The mean ADC for normal kidneys, chronic nephropathy and acute rejection was 2.7±.26& 2.27±.23,
2.3±0.22& 1.98±0.24, 1.6±0.2&1.8±0.2 for group 1&2 respectively. At group1 the sensitivity, specificity and overall
accuracy in diagnosis of acute rejection and chronic nephropathy was 75%&90%, 96%&98%, 93.5%&90% respectively &
at group 2 it was 100%,96%&80%respectively for chronic nephropathy while for acute rejection there was a great overlap
between the normal and chronic kidneys. Ischemic areas were detected with restricted diffusion.
Conclusion: From these initial results we find that DW MRI of transplanted kidneys at b value 400 sec/mm2 have more
diagnostic performance than at b value 800 sec/mm2 & it can differentiate the acute rejection from chronic nephropathy
and normal kidney.
35

MS2.
THE VALUE OF ULTRASOUND FINDINGS AND SERUM PROCALCITONIN LEVELS IN UPPER URINARY
TRACT INFECTION IN CHILDREN
Deftereos S.P., Vranou E., Zisimopoulos A., Tsalkidis A., Chadjimichail A., Prassopoulos P.
Democritus University of Thrace, Department of Radiology, Alexandroupolis, Greece
Objectives: Procalcitonin (PCT) has been proposed as a marker of infection in critically ill patients and its levels is related
to the severity of infection. For reducing children’s exposure to radiation and for more immediate informations about renal
parenchymal involvement in urinary tract infection, we examine the efficacy of ultrasonography findings in combination
with serum procalcitonin levels.
Method: This prospective study enrolled 57 children, until now. All were admitted for first episode of urinary tract infection
(positive urine culture) and underwent measurement of serum PCT and C- reaction protein , followed by US, DMSA
(within 7 days/ and after 6 months) and VCUG (after 4-5 weeks in 51/57 cases).
Results: 27 children had upper UTI (group A), diagnosed by positive DMSA and abnormal US (n=15, 55.6%). 30 children
had lower UTI (group B) with negative DMSA and normal US findings (except 4 patients with urinary bladder wall
thickening). PCT levels were significantly higher in patients with persistent renal lesions or/and VUR (n=8) than in those
with total regression of RPI (n=15).
Conclusion: The combination of high PCT levels and positive US findings is an indication of upper UTI. DMSA is required in
patients with high PCT levels and negative US examined, but normal US and PCT levels can exclude upper UTI.
MS3.
DOES CEUS HAVE A PRACTICAL VALUE IN ADJUNCT TO COLOR DOPPLER US IN EVALUATION OF
PATIENTS WITH RENAL INSUFFICIENCY EVALUATION OF 56 PATIENTS
Bertolotto M., Galli G., Zappetti R., Djouguela Fute M., Giarraputo L., Cova M. A.
Dept. Radiology, Universtity of Trieste, Ospedale di Cattinara, Strada di Fiume 447, 34149 Trieste, Italy
Objective: To investigate the role of contrast enhanced ultrasound (CEUS) in the work-up of patients with acute renal
failure (ARF), and in evaluation of renal lesions identified in patients with chronic renal failure (CRF).
Method: 40 consecutive patients with ARF from suspicious vascular causes and 16 consecutive patients with CRF and
suspicious renal lesions on US underwent CEUS. After preliminary grey-scale and color Doppler US, CEUS was performed
using low acoustic power, contrast specific modes. A bolus of SonoVue was injected to examine each kidney, followed by a
saline flush. All examinations were digitally recorded for retrospective evaluation.
Results: CEUS provided clinically useful information in 36/40 patients with ARF from suspicious vascular causes. There
were 19 patients with renal infaction or acute cortical ischemia, 4 patients with extensive inflammatory lesions, and 1
compression of the renal parenchyma by a spontaneous subcapsular hematoma. In the remaining 12/36 patients no renal
perfusion abnormalities were identified and different reasons were found clinically for ARF. In 4/40 patients CEUS did not
provide clinically useful information. There were 2 patients with postoperative acute tubular necrosis, 1 with septic shock,
1 with obstruction not associated to urinary tract dilatation, 1 multifactorial. CEUS allowed renal lesion characterization in
all 16 patients with CRF. There were 9 complex cystic masses, 6 solid tumors, 1 pseudolesion.
Conclusion: CEUS is a useful diagnostic tool in the work-up of patients with ARF from suspicious vascular causes and is
useful to characterize renal lesions identified in patients with renal insufficiency.
MS4.
NFLUENCE OF NITRIC OXIDE ON OXYGEN CONSUMPTION BY IODINATED CONTRAST MEDIA IN
FRESHLY ISOLATED PROXIMAL TUBULAR CELLS FROM ELDERLY HUMANS AND DIABETIC RATS.
Liss P. 1 , Palm F. 2 , Fasching A., Hansell P. 2
1 Radiology, University of Uppsala, Uppsala, Sweden,
2 Physiology, University of Uppsala, Uppsala, Sweden,
3 Cardiology, University of Uppsala, Uppsala, Sweden
Objective: The purpose of this study was to evaluate the effect of the low-osmolar CM iopromide and the iso-osmolar CM
iodixanol on oxygen consumption (QO2) in freshly isolated proximal tubular cells (PTC) from nephrectomized kidneys from
elderly humans, normoglycemic and streptozotocin-induced diabetic rats. The involvement of nitric oxide (NO) was also
studied.
Methods: PTC were isolated from human kidneys, or kidneys of normoglycemic and streptozotocin-diabetic rats. QO2 was
measured with Clark-type microelectrodes in a gas-tight chamber with and without either CM (10 mg I/ml media).
Institutional review board approvals and informed consent was obtained from all patients before start of the study.
Results: Both CM reduced QO2 in human PTC (about -35%) which was prevented by L-NAME. PTC from normoglycemic
rats were unaffected by iopromide, whereas iodixanol decreased QO2 (-34%). Both CM decreased QO2 in PTC from
diabetic rats (-38% and -36%, respectively). L-NAME only prevented the effect of iopromide in the diabetic PTC. nNOS
mRNA
Conclusion: This study show that CM can induce NO release from isolated PTC in vitro, which affects QO2. The results
suggest that the induction of NO release and subsequent effect on the cellular oxygen metabolism are dependent on
several factors, including CM type and the existence of known risk factor for the development of CM-induced nephropathy.
The decreased QO2 might result in cellular energy deficiency, which potentially is a mechanism initiating the development
of progressive kidney dysfunction.
36

MS5.
INCIDENCE OF IN-HOSPITAL TREATED RENAL FAILURE IN 23,425 SWEDISH PATIENTS AFTER
CORONARY PROCEDURES
Liss P. 1 , Palm F. 2 , Hansell P. 2 , Lagerqvist B. 3
1 Radiology, University of Uppsala, Uppsala, Sweden, 2 Physiology, University of Uppsala, Uppsala,
Sweden, 3 Cardiology, University of Uppsala, Uppsala, Sweden
Objective: To compare the risk of developing renal failure after percutaneous coronary interventions (PCI) and/or
coronary angiography when using an iso-osmolar (iodixanol) with a low-osmolar (ioxaglate) contrast media (CM).
Methods: In this study we compared the Swedish Coronary Angiography and Angioplasty Registry with the Swedish
“Hospital Discharge Register” to assess CM induced renal failure at 18 hospitals using one single CM. The study included
23,425 patients which underwent PCI/angiography in Sweden during 2005-2006 using either iodixanol (18,518 patients)
or ioxaglate (4,707 patients).
Results: The incidence of renal failure within 12 months after PCI/angiography was greater for patients receiving iodixanol
(1.4%) than for those treated with ioxaglate (0.9%, p

MS8.
MORPHOMETRY OF TISSUE MICROSTRUCTURE: COMPARISON OF DIGITAL LIGHT MICROSCOPY
(DLM)AND INTRALUMINAL CATHETER-BASED OPTICAL COHERENCE TOMOGRAPHY (OCT)
IN NORMAL PORCINE URETER WALL SPECIMENS
Mueller-Lisse U.L., Meissner O.A., Bauer M., Reiser M.F., Stief C., Mueller-Lisse U.G.
Department of Diagnostic radiology, University of Munich
Purpose: To assess the reliability of their delineation on cross-sectional optical coherence tomography (OCT) images,
we compared the width of different tissue layers of the wall of porcine upper ureters ex vivo as measured on OCT
images and matching whole-mount digital light microscopy (DLM) sections.
Method And Materials: Eleven specimens of porcine upper ureter were flushed with normal saline solution prior to
imaging from inside by means of an OCT catheter (diameter, 0.014 inch, OCT wavelength, 1300±20 nm) at marked
locations. Ring-shaped ureter specimens of 3 mm width were fixed in 4% formalin, cut, whole-mounted, and stained
with H&E. Respective thicknesses of urothelium, lamina propria, and muscle layer of the ureteral wall were compared
between OCT images (M1, LightLab Imaging, Inc., Westford, MA, USA) and matching DLM slides (Axioplan2, Carl-
Zeiss-Corporation, Jena, Germany) by two independent observers (O1,O2), applying Bland-Altmann plots and t-tests
for paired data.
Results: When compared with DLM, respective OCT measurements by O1 and O2 overestimated width of urothelium by
0.02+/-0.01mm and 0.02+/-0.01mm (p=0.0014 and 0.0002), lamina propria by 0.02+/-0.05mm and 0.03+/-0.03mm
(p=0.2047 and 0.0025), and muscle layer by 0.26+/-0.15mm and 0.07+/-0.05mm (p=
Conclusion: Intraluminal OCT reliably delineates urothelium and lamina propria of the normal ureteral wall in porcine
specimens ex vivo when compared with corresponding DLM histology. The outer boundaries of the muscle layer of the
ureteral wall appear to be beyond reliable reach of OCT.
MS9.
EMBOLIZATION OF POLYCYSTIC KIDNEYS: AN ALTERNATIVE TO NEPHRECTOMY BEFORE
RENAL TRANSPLANTATION: A WORK IN PROGRESS.
Cornelis F., Lebras Y., Hubrecht R., Dodre E., Perot V., Ferrière J.M., Merville P., Grenier N.
Imagerie diagnostique et thérapeutique de l'adulte, Centre Hospitalier Universitaire de Bordeaux, Hopital
Pellegrin, 33076 BORDEAUX Cedex FRANCE
Objectives: In autosomal polycystic disease, surgical nephrectomy is necessary before transplantation when kidney
volume is excessive. We evaluated prospectively the effectiveness of unilateral embolization as an alternative to
surgery to obtain a volume reduction allowing graft implantation.
Material and method: Twenty patients, with an autosomal dominant polycystic kidney disease and enlarged kidneys
descending below iliac crest, had unilateral renal embolization. In all cases distal infusion of microspheres and proximal
coiling were associated until circulatory arrest. To prevent post-embolization syndrome, a protocol with analgesic, antiinflammatory
and antibiotic drugs was prescribed. Volume reduction was evaluated by CT before and at 3 and 6
months after embolization. The treatment was considered as a success when the lower pole of embolized kidney was
located above the iliac crest at 6 months, making transplantation possible.
Results: Embolization was technically successful in all patients. The treatment was well tolerated clinically in all cases,
without immediate or delayed complications. In one patient, the kidney did not decreased in size despite three sessions
of embolization. In 18 patients (90%), this treatment was effective in one session, with an average volume reduction
of 37% at 3 months. The last patient had a supplemental cyst sclerosis to reach the objective. To now, 13 patients
reached the 6 months end-point and were listed for kidney transplantation; 4 of these were successfully grafted.
Conclusion: Embolization of polycystic kidneys facilitates renal transplantation and seems to be an excellent alternative
to nephrectomy due to its lower morbidity.
MS10.
THIN SLICE THICKNESS (1MM) 3D-T2-WEIGHTED MRI AND LOCAL STAGING OF PROSTATE
CANCER
Cornud F., Liberatore M., Eiss D., Rouanne M., Beuvon F., Barry N., Flam T.
Services de Radiologie, d’Urologie et de Pathologie, Hôpital Cochin, Paris, France
Objective: to assess the accuracy of endorectal coil and high resolution 3D-T2-weighted MRI (voxel size: 0.64 mm3)
with a 1.5 Tesla magnet for local staging of prostate cancer.
Materials and methods: 61 patients (mean age: 63±5.5) with a clinically localised tumor (clinical stage1mm). Overall sensitivity was 86%, specificity
91% and accuracy 87%.
Conclusion: The 3D-T2W acquisition has the highest ever reported accuracy to detect pT3 stage with an endorectal coil
and a 1.5 Tesla magnet.
38

MS11.
FUNCTIONAL MRI (DIFFUSION WEIGHTED AND DYNAMIC CONTRAST ENHANCED IMAGING) IN
PATIENTS WITH LOW RISK PROSTATE CANCER
Cornud F., Richarme D., Rouanne M., Barry N., Beuvon F., Flam T.
Services de Radiologie, d’Urologie et de Pathologie, Hôpital Cochin, Paris, France
Objective: To determine the value of diffusion-weighted (DW) and dynamic contrast-enhanced MRI (DCE) to localise
significant tumors in patients with low risk prostate cancer (PCa) defined by a PSA level

OPENING CEREMONY LECTURES
WW1. USE OF X-RAYS ON THE GREEK FRONT
Livadas G.
Athens, Greece
WW1 soon spread around the entire globe. The 1915/16 disastrous Gallipoli Campaign was
supported by a number of allied hospitals based on the Greek island of Lemnos. When this
campaign was over, the Serbs, under Austrian and Bulgarian assault, retreated to the island of
Corfu, French hospitals were set up to take care of more than 100.000 improverished troops and
civilians. The city of Salonica was later selected as the base for the “Campagne d’ Orient”. More
than 50 allied hospitals were set up in and around the city, most of them under canvas or wooden
huts. They were mainly French and British, however, Canadian, Australian, New Zealand, Indian,
Russian, Italian and Greek hospitals were also operating in the region.
All these hospitals were large, operating with more than 1000 beds each, including all necessary
departments, including X-Ray equipment.
A number of French and British passenger ships were requisitioned and transformed into Hospital
Ships for the evacuation of wounded or even as permanent hospitals. Amongst them were some
of the largest ocean liners ever built.
The period in question spans from 1915 to 1919. Our investigation in archival material brings into
light the use of X-Rays in a forgotten front, a front which as far as medical support was equally
important as the one on the Western front.
ONE CENTURY OF URORADIOLOGY IN EUROPE : 1896 – 1996
Moreau J.F.
Université Paris Descartes, France
“I’m looking for a man !”. Diogenes.
First stage (1896-1929) : Uroradiology is a urological hobby.
The birth of Uroradiology is dated on April 28 th , 1896, when Felix Guyon, chairman of the Urology
Department at the Necker Hospital of Paris, introduced the radiological description of urinary
stones by his resident, François-Joseph Chauvel, and a physicist, James Chappuis, at the
“Académie Nationale de Médecine”. Thereafter, for almost half-a-century, the development of
uroradiology was fully linked with urological research, mainly at the Necker Hospital where
Albarran invented the modern cystoscope that allowed Tuffier to pass radiopaque catheter in the
ureter through the ureteral meatus and to opacify the bladder with varied radiopaque
compounds. Albarran introduced the retrograde pyelography too.
Second stage (1929-1955) : Uroradiology has become a valuable urological tool.
It benefits from the serependitous discovery in 1921 of the Lipiodol as a liposoluble radiopaque
medium by Jacques Forestier and Jean-Athanase Sicard of the Necker Hospital. A second
serependitous discovery in 1923 came from the Mayo Clinic, Rochester, Minnesota, where
Osborne, Rowntree and Sutherland obtained the first but faint excretory urography in syphilitic
patients treated with Sodium Iodine. That induced an intensive research for synthesizing
watersoluble organic iodinated compounds. The controversial winners of the race for Intravenous
Urography, in 1928-29, are Moses Swick, the American chemist at the Schering AG, and the
urologist Alexander von Lichtenberg, both working in Berlin, Germany. In 1934, at the Cochin
Hospital of Paris, the urologist Maurice Chevassus published the technique of retrograde
ureteropyelography with the “sonde-bouchon”. In Paris two antagonist schools of urology will
develop for almost five decades: it is based upon IVU first at the Necker hospital, cystoscopy and
RUP at the Cochin hospital. All books are written by urologists sometimes associated with their
radiologists. They are Gouverneur with Hickel and Fey with Truchot in France, Puigvert in Spain…
and Emmett with Witten in the USA.
Third stage (1955-1975) : Uroradiology after WW2 booms with nephrology, a new
medical specialty requiring more and more functional data.
Two technologies developed parallely. 1) Nuclear medicine using radiohippuran for bioassays
and scintigraphy is not developed in the lecture; 2) Radiology benefits from the synthesis of the
new watersoluble triodinated benzenic compounds filtrated by the glomeruli: iothalamate in the
USA, diatrizoate in Germany, metrizoate in the Netherland, acetrizoate in France.
Scandinavia is the nest of modern angiography. The Danish Seldinger introduced in 1952 his
percutaneous technique of transfemoral aortography improved with the selective renal
40

arteriography by Odman. Leif Ekelund in Sweden and JR Michel in Paris using angiotensin
developed renal pharmacoangiography.
High-doses IVU were available by drip infusion. Hodson studied urinary tract infections in
England then in Northern America. Renovascular hypertension could be detected using minute
sequence pyelography and the wash-out test proposed by the Austro-American Kurt Amplatz. JF
Moreau in Paris studied reflux nephropathy and renal scarring; he made a synthesis with CJ
Hodson at Yale University in 1981, a few months before the latter died.
The concept of Genito-Uroradiology varied according to the structure of national
medicines and the technological supplies available in the hospital departments. In fact
in Europe, GU radiology mostly boomed from the radiologists who worked in Latin countries.
They were not early known internationally because most of them didn’t speak English. In
Germany, they were included in the departments of urology or internal medicine. In the UK, they
were included in radiology departments with a few but outstanding GU experts. Out of these,
Hugh Saxton introduced percutaneous needle nephrostomy, Thomas Sherwood taught GU at
Oxford University, Ian Kelsey Fry studied iodine toxicity and renal failure with the nephrologist
William Cattell. PGFM van Waës in Utrecht, The Netherland, wrote on oliguric renal failure. Both in
the USA and, in Europe, France and Belgium, it has early become an autonomous subspecialty in
radiology. André Dardenne of Brussels, Belgium won the quiz at the SUR meeting in 1981 and
was the best uroradiologist of his generation worldwide. In France, the leaders, Jean-René Michel
at the Necker Hospital, Annick Pinet at the Edouard Herriot Hospital in Lyon, practiced in big new
hospitals combining huge departments of urology and nephrology only. The Necker Hospital and
the Mayo Clinic were the only places where specific series of 100,000 IVUs could be studied for
toxicity surveys in the seventies. Meanwhile GU in the USA was restricted to conventional
techniques, it included in France and in Belgium not only IVU and retrograde but angiography and
ultrasound too. They created the “Club du Rein” in 1965, then the “Société d’imagerie urinaire”
(SIGU) in 1990, comparable with the American “wee-wee club” at the origin of the “Society of
uroradiology” SUR in 1972. For the first time in the world, a book dedicated to uroradiology
written by radiologists only is edited in 1980 by Lemaître, Michel and Tavernier.
The SUR gave the GU label to some new European radiologists, such as Ludovico Dalla Palma and
Judith AW Webb in 1983. Joshua Becker, Lee Talner, Alan Davidson and Glenn Hartman were the
American friends who helped the European GU radiologists to know each other.
Fourth stage (1975-1996): GU is submitted for cross-sectional computed tomography
and non-invasive digital imaging revolution.
“Whither IVU”, asked Hugh Saxon in a famous editorial dated on 1972. The first alert was given
by renal ultrasonography inducing the debate between invasive and non invasive techniques and
the role of hyperosmolality in the development of CM-induced renal failures. At the beginning
except in Latin Europe, a few GU radiologists practiced both IVU and US. An acute phase of
trouble happened when large doses of iodinated contrast media had to be injected intravenously
during full-body CT scanner examinations. Industrial interests blurred the sanest argumentations
when several classes of hypoosmolar compounds had been challenging the hyperosmolar ones,
then the ionic and non-ionic hypomoslar themselves. The first hypoosmolar iodinated compound
used for clinical IVU and angiography at the Necker Hospital was the ioxaglate (Hexabrix, 1976)
and the non-ionic Iopamidol (1977). After years of hostility, CT scan and triplex Doppler
ultrasonography had had to face the growth of MR imaging targeting first the prostate and the
female genital tract before the kidney and the vascular tree. In 1996, GU radiology in Europe
encompassed all technologies for a valuable study of the genito-urinary tract. They enabled the
Germans to have a true pool of dedicated GU radiologists. The French Alain Dana proposed the
concept of Uroscanner when the 3-D reconstruction of the abdomino-pelvic block had been
available. GU has become a therapeutic agent with the development of interventional radiology
on both the organs and their vascularity.
In Conclusion. “Stand out of my sun!”. Diogenes facing Alexander the Great.
The role played by the European Uroradiology growth along the last century is as poorly known as
prominent. The European Society of Uroradiology was created in the early 1990ies under the
impulse of Henrik Thomsen of Copenhagen, Ludovico Dalla Palma of Trieste and Jean-François
Moreau of Paris. Ludovico was the godfather of the European Society of Radiology and of the
Halley Project oriented to the Eastern European countries. Nowadays the ESUR is a pack
congregating all European countries with an influence all around the Mediterranean Sea.
During the XXth century two macroeconomical cycles developed with three major economical
crises and two world wars. Not only they did not hamper the development of GU radiology but
most of the improvements provoked by the so-called disruptive technologies emerged from the
most troublesome years of the era: IVU in 1929, nonionics and CT scan in 1973 (first oil shock),
MRI in 1979 (second oil shock), PET-scan in 1991 (Gulf war)… Good luck for the XXIth century!
41

Papanicolaou N.
Hospital of the University of Pensylvania, USA
SUR HONORARY LECTURE
Moderator: Hamm B.K. (D)
PET / CT IN UROLOGIC ONCOLOGY
42

ESUR GUIDELINES
SESSION
43

Thomsen H.S.
University of Copenhagen Herlev Hospital
Moderators: Morcos S.K. (UK)
Contrast media-NSF
In 2005, two European investigators – independent of each other – got the idea that the occurrence of NSF was correlated
to exposure to a Gd-CM (1, 2).
Already in 2002, nephrologists at Herlev Hospital, Denmark, became suspicious that a drug, including the Gd-CM used at
the hospital, might be involved in the development of a mysterious disease pattern seen in patients with end-stage renal
disease. However, at the same time several therapeutic drugs were introduced. Both in 2002 and 2003, the nephrologists
reported severe adverse reactions e.g. muscular pain to gadodiamide to the Danish Medicines Agency. In 2005
nephrologists at Herlev Hospital contacted “Medical Officers of Health in Copenhagen” about causes of the epidemic
development of this mysterious disease, but got no answer (3). In the fall of 2005, they were almost certain and a workup
of the patients were undertaken. It turned out that the Gd-CM was the only drug that all patients who developed
biopsy-verified nephrogenic systemic fibrosis had had. On March the 17 th 2006, the nephrologists presented their data to
the chairman of the department of diagnostic radiology, and immediately afterwards the radiologists decided to stop the
use of the non-ionic linear chelate to all patients independent of the renal function. On March the 30 th 2006, the Danish
Medicines Agency received 20 reports about NSF after gadodiamide (4) and late April 2006 the Marketing Authorization
Holder reported the 5 cases published by Dr. Grobner (1) to the Austrian Medicines Agency. Then the authorities looked
closer into the issue, and on February the 7 th 2007 the European Medicines Agency (EMEA) contraindicated the use of the
non-ionic linear chelate (gadodiamide) in patients with reduced renal function (CKD 4 & 5) (5). In June this
contraindication was extended to one of the 4 ionic linear chelates (gadopentetate dimeglumine), and at the same time a
caution about their use (both the nonionic and ionic linear chelate) in patients with CKD 3 was added (6). When the nonionic
linear chelate gadovertisamide got its European multistate approval in July 2007, the same caution and
contraindication were included in its summary of product characteristics (7). In January 2008, the Pharmacovigilance
working Party (PHVWP) of EMEA classified the agents in one of three groups: 1) high risk of NSF, 2) Intermediate risk of
NSF and 3) low risk of NSF agents (5). This classification was subsequently adopted by the CMSC of ESUR. Since January
2008, exposure to Gd-CM has caused no new cases of NSF; all cases reported since 2008 had their triggering dose before
2008.
ESUR Guideline
Patients at a high risk are those with CKD 4 and 5 (GFR < 30ml/min) including dialysis and patients with reduced renal
function, who have had or are awaiting liver transplantation. Patients with a lower risk are those with CKD 3 (GFR 30-
59ml/min) as well as children under one year of age, because of their immature renal function. Patients with normal renal
function are not at risk of NSF.
The following contrast agents are considered to be of the highest risk of NSF: Gadodiamide (Omniscan®), Gadopentetate
dimeglumine (Magnevist®) and Gadoversetamide (Optimark®). These agents are CONTRAINDICATED in patients with
CKD 4 and 5 (GFR < 30 ml/min) including those in dialysis and patients with reduced renal function, who have had or are
awaiting liver transplantation. They should be used with CAUTION in patients with CKD 3 (GFR 30-60 ml/min) and
children less than one year old. Serum creatinine (eGFR) should always be measured prior to the use of these three
agents.
The intermediate risk group includes the following agents: Gadobenate dimeglumine (Multihance®) (Special feature:
Similar diagnostic results can be achieved with lower doses because of its 2-3% protein binding), Gadofosveset trisodium
(Vasovist®) (Special feature: It is a blood pool agent with affinity to albumin. Diagnostic results can be achieved with
50% lower doses than extracellular Gd-CM. Biological half-life is 12 times longer than for extracellular agents (18 hours
compared to 1½ hours, respectively)), and Gadoxetate disodium (Primovist®) (Special feature: Organ specific gadolinium
contrast agent with 10% protein binding and 50% excretion by hepatocytes. Diagnostic results can be achieved with lower
doses than extracellular Gd-CA.). Determination of serum creatinine level (eGFR) is not mandatory prior to use of these
agents.
Low risk group includes the following agents: Gadobutrol (Gadovist®), Gadoterate meglumine (Dotarem®) and
Gadoteridol (Prohance®). Serum creatinine (eGFR) measurement before administration is not mandatory.
If two different Gd-CM have been injected, it is impossible to determine with certainty which agent triggered the
development of NSF and the situation is described as ‘confounded’. However, the agent which is most likely responsible is
the one which has triggered NSF in other unconfounded situations.
Finally, the committee recommends in all patients independent of renal function that one uses the smallest amount of
contrast medium necessary for a diagnostic result. Patients with a clinically well indication should never be denied an
enhanced MRI examination. One should always use an agent that leaves the smallest amount of gadolinium in the body.
Magnitude of the problem
By the end of February 2009, the European database on adverse reaction report contained a total of 129 European cases.
In addition, there are eight Swiss cases, but at the Swiss national congress in radiology in 2008 the head of the Swiss NSF
investigation informed that there are 18 patients fulfilling the 2008 Yale criteria for NSF (8, 9). United Kingdom is listed
for four cases, but British authors have published 16 cases in the peer-reviewed literature (10, 11). These inaccuracies,
which are not the only ones, indicate that despite the common database the authorities have no overview of the real
problem.
Recently, a drastic change occurred in Denmark. Until January 2009, it was generally thought that NSF was a specific
Herlev Hospital problem. Why this should be the case No one has been able to explain this. Until the end of 2008, there
were 32 diagnosed cases, 30 from Herlev hospital and two from two other hospitals. In January 2009, another university
hospital outside of Copenhagen in a press release (12) stated that they had reviewed the medical records of 438
nephrology patients and that they in 30 of them found signs and symptoms of NSF. However, 15 had died in the mean
time. The remaining 15 patients were called for an interview and clinical investigation. At time of the press release (12)
ten patients had NSF documented by biopsy. In two, NSF could not be the case and three were still under investigation. A
week later a third university hospital reported two cases of NSF; the only two patients who had undergone MR
angiography with gadodiamide in that hospital since 2002. Other hospitals are still reviewing their patients for NSF.
Currently, Denmark has a least 67 patients with NSF of which 43 are documented by biopsy. If the prevalence is the same
in the United States of America there should be around 3654 patients with NSF and 975 patients in Germany. According to
the EU database there are 32 registered NSF patients in Germany and FDA has almost 1000 US cases in their database
44

(3). The number of MRI units does not explain a part of the difference, since Denmark had fewer units per 1 mill
inhabitants than Germany and the United States in 2005. Also a more productive use of the MRI units could to some
extent explain the difference. However, this is not the case either, as Denmark has never had a tradition for elective use
of scanners in double shift. Differences in market share of the high risk NSF agents between the three countries could be
an explanation, but high risk agents were market leaders before 2006 in all three countries. Naturally, a difference in
medical practice between Germany, United States and Denmark could be a fourth explanation, but then one would expect
that the prevalence in Denmark was similar in Norway and Sweden, and that is not the case according to the EU
database. Genetic differences could be a fifth explanation, but again the lower prevalence in Norway and Sweden speaks
against this explanation. Finally, it seems that there is a large number of NSF patients which have not been diagnosed.
With exception of two studies (13, 14), all studies have reviewed various registries for patients cases, but not
systematically inspected the skin of the patients exposed to Gd-CM at a time where they had reduced renal function. NSF
is not an ‘either or’ disease. There is great variability. NSF severity may be graded from 0 to 4: 0 – no symptoms, 1 –
mild physical, cosmetic, or neuropathic symptoms not causing any kind of disability, 2 – moderate physical and/or
neuropathic symptoms limiting physical performance to some extent, 3 – severe symptoms limiting daily physical
activities (walking, bathing, shopping, etc), 4 – severely disabling symptoms causing dependence on aid or devices for
common, daily activities (15). It is nearly impossible to overlook patients with severe disabling symptoms, but it is
possible to give them the wrong diagnosis. Most of the disabled patients are probably in the registries. The opposite is
also likely regarding those with non severe disease. When it is not disabling it requires that the patient spontaneously tells
the physician about skin lesions on the extremities or the physicians systematically inspect the skin of patients with
reduced renal function exposed to Gd-CM. That probably does not take place in the daily practice. Experience from
Denmark speaks in favour of this.
Consequences
Various radiologists have drawn different consequences of the finding of a link between exposure to some Gd-CM and the
development of NSF. Some has not changed their practice. Some denies patients with an eGFR below 60 or 30 ml/min an
enhanced MRI and refer them to enhanced CT. Another group has changed to low risk NSF agents in half or normal dose,
whereas others have changed to the intermediate risk NSF agents, which due to their unique protein can be used in lower
doses than the extracellular agents. The referral of patients from enhanced MRI to enhanced CT is highly debatable. There
are diagnoses were MRI are superior to CT and vice versa (16). It must always be recommended to refer a patient to the
imaging modality that is the best for the work-up of the signs and symptoms of the patients. Use of an inferior imaging
method may lead to overlooking of a lesion and this may not be optimal for the patients, as the lesion may not be
treatable when it becomes bigger and visible on a less optimal imaging method. This has to be taken in consideration
when one recommends an imaging modality. In contrast to CT, MRI does not include the use of radiation. It is generally
accepted that the prevalence of acute non-renal adverse reactions is higher after iodinated contrast agents than after Gd-
CM (17, 18). Regarding CIN it may occur after both I-CM and Gd-CM, but due to the much lower moles of the agent used
for MRI than for CT, the prevalence is higher after I-CA (17, 19, 20). The exact prevalence of CIN after intravenous
injection of non-ionic low-osmolar and iso-osmolar agents are unknown, but it is probably close to 10% in patients with a
glomerular filtration rate (GFR) below 15 ml/min (CKD 5). Based on the recent studies comparing iso-osmolar and lowosmolar
agents it is generally around 5% (range 0-21%) in CKD 4 patients (GFR 15-30 ml/min); with some agents it may
be lower and in some patient groups it may be higher. The occurrence of CIN has been shown even after intravenous
injection to be correlated with an increased 2-year mortality or morbidity (21, 22). This mortality and morbidity rate is
higher than the risk of developing NSF after exposure to a low risk NSF agent (23, 24, 25). Therefore, it is highly
debatable whether it is good practice to deny a patient with reduced renal function a well indicated enhanced MRI
examination. All factors must be taken in consideration when one advises a referring physician on the optimal imaging
methods in each single case.
References
1. Grobner T. Gadolinium: a specific trigger for the development of nephrogenic fibrosing dermopathy and
nephrogenic systemic fibrosis Nephrol Dial Transplant 2006; 21: 1104-1108.
2. Marckmann P, Skov L, Rossen K et al. Nephrogenic systemic fibrosis: Suspected etiological role of gadodiamide
used for contrast-enhanced magnetic resonance imaging. J Am Soc Nephrol 2006; 17: 2359-2362.
3. Marckmann P. An epidemic outbreak of nephrogenic systemic fibrosis in Danish hospital. Eur J Radiol 2008; 66:
187-190.
4. Ali Abu-Alfa A, Bennett CL, Laumann AE et. Nephrogenic Systemic Fibrosis. In preparation.
5. Stenver DI. Pharmacovigilance: what to do if you see an adverse reaction and the consequences. Eur J Radiol
2008; 66: 184-186.
6. EMEA: http://www.esur.org/fileadmin/NSF/Public_Assessment_Report_NSF_Gadolinium_26_June_2007.pdf
7. Optimark: http://www.emea.europa.eu/humandocs/PDFs/EPAR/optimark/H-745-en6.pdf. Accessed May 13th
2009.
8. Weisshaupt D. Gadolinium-based contrast agents: current approaches and guidelines in Switzerland. 95.
Jahreskongress SGR-SSR, St. Gallen, May 29 th 2008
9. Cowper S, Kay J, Elston D, LeBoit P, Girardi M. The clinicopathological definition of nephrogenic systemic fibrosis.
3 rd Annual scientific symposium on nephrogenic systemic fibrosis and MR gadolinium-based contrast agents. New
Haven, Connecticut, May 9 th 2009.
10. Singh M, Davenport A, Clatworthy I et al. A follow-up of four cases of nephrogenic systemic fibrosis: is gadolinium
the specific trigger Br J Dermatol 2008; 158: 1358-1362.
11. Collidge TA, Thomson PC, Mark PB et al. Gadolinium-enhanced MR imaging and nephrogenic systemic fibrosis:
retrospective study of a renal replacement therapy cohort. Radiology 2007; 245: 168-175.
12. Skejby Hospital. http://www.rm.dk/Om%20Regionen/Aktuelt/Nyhederdocid=33934
13. Todd DJ, Kagan A, Chibnik LB, Kay J. Cutaneous changes of nephrogenic systemic fibrosis. Predictor or early
mortality and association of gadolinium exposure. Arthritis Rheumat 2007; 56: 3433-3441.
14. Rydahl C, Thomsen HS, Marckmann P. High prevalence of nephrogenic systemic fibrosis in chronic renal failure
patients exposed to gadodiamide, a Gadolinium (Gd)-containing magnetic resonance contrast agent. Invest Radiol
2008; 43: 141-144.
15. Marckmann P, Skov L, Rossen K, Thomsen HS. Clinical manifestations of gadodiamide-related nephrogenic
systemic fibrosis. Clin Nephrol 2008; 69: 161-168.
45

16. Dawson P, Punwani S. Nephrogenic systemic fibrosis: non gadolinium options for the imaging of CKD/ESRD
patients. Semin Dial 2008; 21: 160-165.
17. Heinz-Peer G. Acute adverse reactions (Chap 23). In: Thomsen HS, Webb JAW (eds) Contrast Media: Safety issues
and ESUR Guidelines 2 nd revised Ed. Heidelberg, Springer Verlag 2009: 181-186.
18. Webb JAW. Prevention of acute reactions (Chap 7). In: Thomsen HS, Webb JAW (eds) Contrast Media: Safety
issues and ESUR Guidelines 2 nd revised Ed. Heidelberg, Springer Verlag 2009: 43-52.
19. Thomsen HS. Contrast medium-induced nephropathy (Chap 9). In: Thomsen HS, Webb JAW (eds) Contrast Media:
Safety issues and ESUR Guidelines 2 nd revised Ed. Heidelberg, Springer Verlag 2009: 63-80.
20. Thomsen HS. Radiography and gadolinium contrast agents (Chap 22). In: Thomsen HS, Webb JAW (eds) Contrast
Media: Safety issues and ESUR Guidelines 2 nd revised Ed. Heidelberg, Springer Verlag 2009: 171-178.
21. From AM, Bartholmai BJ, Williams AW, Cha SS, McDonald FS. Mortality associated with nephropathy after
radiographic contrast exposure. Mayo Clin Proc 2008; 83: 1095-1100.
22. Goldenberg I, Chonchol M, Guetta V. Reversible acute kidney injury following contrast exposure and the risk of
long-term mortality. Am J Nephrol 2009; 29: 136-144.
23. Thomsen HS, Marckmann P, Logager VB. Update on nephrogenic systemic fibrosis. Magn Reson Imaging Clin N Am
2008; 16: 551-560.
24. Thomsen HS. Delayed reactions: Nephrogenic systemic fibrosis (Chap 24). In: Thomsen HS, Webb JAW (eds)
Contrast Media: Safety issues and ESUR Guidelines 2 nd revised Ed. Heidelberg, Springer Verlag 2009: 187-196.
25. Morcos SK. Chelates and stability (Chap 20). In: Thomsen HS, Webb JAW (eds) Contrast Media: Safety issues and
ESUR Guidelines 2 nd revised Ed. Heidelberg, Springer Verlag 2009: 155-160.
Kinkel K.
University Hospital Of Geneva
Riccabona M.
FEMALE PELVIS
PEDIATRIC IMAGING
University Hospital Graz
46

COURSE LECTURES
ABSTRACTS
47

NEW FRONTIERS IN IMAGING
Moderators: Cornud F. (GR) – Gouliamos A. (GR)
IMAGING OF INFLAMMATION AND FIBROSIS
Grenier N.
Université Victor Segalen-Bordeaux 2, France
The natural course of most renal parenchymal diseases is characterized by a progressive or an acute inflammatory phase and
a progressive fibrotic process. Specific diagnosis of the ongoing intrarenal process is difficult because intricate, and still
requires pathological examination after percutaneous biopsy. Molecular imaging techniques are able to target several
biological phenomena occurring during the inflammatory reaction, as the recruitment of inflammatory cells, the synthesis of
specific molecules by activated patelets or endothelial cells… Molecular imaging of fibrosis is more problematic because the
techniques of direct targeting of collagen fibers or fibroblast are missing. Quantification of fibrotic contain of tissues is better
approached by indirect techniques as elastography, performed with ultrasound or MR techniques.
Molecular MR imaging of inflammation
Imaging of endocytosis by inflammatory cells
Intravenous injection of ultrasmall superparamagnetic particles of iron oxide (USPIO) has been proposed for targeting
phagocytic cells in inflammatory renal diseases. Several experimental studies showed that phagocytic cells captured the iron
oxide particles and that the degree of decrease of signal intensity (SI), 24h after IV injection of USPIO, was correlated with
the number of macrophages within each renal compartment. Location of signal decrease depended on the type of disease :
global when infiltration was interstitial (hydronephrosis [1, 2], intoxication with puromycin amino-nucleoside [1], acute and
chronic rejection [3]), cortical when intraglomerular (autoimmune glomerulonephritis [4]) and medullary only in acute tubular
necrosis [5].
In humans, MR imaging was performed 3 days after USPIO injection [6]. According to biopsy, significant SI decrease was
noted diffusely in patients with an inflammatory component, and within the medulla only in those with ATN. Patients with
chronic fibrotic disease did not show any change.
Imaging of receptor expression
P-selectin is a glycoprotein overexpressed by activated patelets and endothelial cells allowing their interaction. Targeting of P-
selectin has been described using specific ligands linked to a macrocmolecular Gd-agent in a model of atherosclerosis [7].
Activated endothelial cells also express several molecules on their surface during the inflammatory process as E-selectin,
intercellular adhesion molecule (ICAM) vascular cellular adhesion molecule (VCAM), which have also been targeted using
specific agents, either Gd-based or iron oxide-based [8, 9]. None of these agents have been used in the kidney. During their
activation, recruited macrophages may over-express some receptors like the macrophage scavenger (MSR) [10].
Imaging of enzyme synthesis by inflammatory cells
Myeloperoxidase (MPO) is one of most abundant enzymes secreted by inflammatory mononuclear cells (neutrophils and
macrophages), able to generate reactive oxygen species. Within kidney, this reaction leads to a variety of compounds that in
turn may cause dysfunction of cells in different compartments of renal parenchyma [11]. A MPO-sensitive Gd-based MR
contrast agent has been developed recently targeting in vivo reperfused ischemic myocardium [12] and inflammatory
demyelinating plaques in brain [13, 14]. Applications of these techniques within the kidney should be numerous in the future.
Imaging of fibrosis
Exaggeration of extracellular matrix synthesis, with excessive fibrillar collagens, characterizes the development of fibrotic
lesions in the glomerular, interstitial and vascular compartments, leading progressively to end-stage renal failure.
Systems participating in these processes are better identified and various therapeutic interventions have been shown to
prevent or to favor regression of fibrosis in several experimental models. Therefore, development of new noninvasive
methods for identification and quantification of fibrosis would also be worthwhile. Three approaches can be proposed with
MR imaging: molecular imaging, diffusion-weighted MR imaging and elastography.
Molecular imaging of fibrosis
Collagen-targeted contrast agents have recently been developed based on a Gd-chelate linked to a collagen-specific peptide
[15] and applied to myocardial fibrosis in a mouse model [16]. Experience is still limited but applications could be numerous
in the future, in kidney, liver and lungs.
Diffusion
The development of fibrosis is responsible for a restriction of the diffusion space for water molecules. Diffusion-weighted
MR imaging sequences allows measuring the reduction of ADC-values in proportion with tissue changes. Early reports
showed that liver ADC could be used to predict liver fibrosis and inflammation with acceptable sensitivity and specificity
[17]. However, a recent study demonstrated that the restricted diffusion observed in patients with cirrhosis may be
related to perfusion-related ADC variations, which reflect decreased perfusion, as well as alterations in pure molecular
water diffusion in cirrhotic livers. [18]. The first clinical trials on chronic renal diseases, including renal artery stenosis and
ureteral obstruction, showed a decrease of ADC-values which were highly correlated with serum creatinine levels [19].
However, none of these studies presented correlation with pathological quantification of fibrosis.
Elastography
Fibrotic process altering the renal tissue structure, changes the biomechanical properties of the kidney. Over the past ten
years, elastography has emerged as a very promising technique to quantify the stiffness of organs. Its application in
evaluation of chronic liver diseases is already included in clinical practice. This method requires applying shear waves by
means of a mechanical device, producing tissue displacements on the order of nanometers to micrometers. Propagation of
these waves being dependent on viscoelastic properties of the tissue, its elastic characteristics can be quantified and/or
mapped as parametric images. This information can be obtained using ultrasounds or MR imaging. The sonographic
method is based on the emission of acoustic pulses to produce shear waves. The information can be unidimensional
(Fibroscan used in the liver) [20], or bi-dimensional with new devices [21]. Using MR imaging, the vibration can be
produced by an acoustic or a mechanical system and the encoding of propagating shear waves is based on a phase
contrast technique utilizing cyclic motion-sensitized gradients. Application of these methods to the kidney is limited to a
few experimental data: Shah et al [22] validated the approach in vivo on a rat model of nephrocalcinosis and obtaining
the first stiffness maps of native human kidneys. Early results should be obtained soon with sonographic methods.
References
48

1. Hauger, O., et al., MR imaging of intrarenal macrophage infiltration in an experimental model of nephrotic
syndrome. Magn Reson Med, 1999. 41(1): p. 156-62.
2. Schreiner, G.F., et al., Immunological aspects of acute ureteral obstruction: immune cell infiltrate in the kidney.
Kidney Int, 1988. 34(4): p. 487-93.
3. Ye, Q., et al., In vivo detection of acute rat renal allograft rejection by MRI with USPIO particles. Kidney Int,
2002. 61(3): p. 1124-35.
4. Cattell, V., Macrophages in acute glomerular inflammation. Kidney Int, 1994. 45(4): p. 945-52.
5. Jo, S.K., et al., Detection of inflammation following renal ischemia by magnetic resonance imaging. Kidney Int,
2003. 64(1): p. 43-51.
6. Hauger, O., et al., USPIO-enhanced MR imaging of macrophage infiltration in native and transplanted kidneys:
initial results in humans. Eur Radiol, 2007. 17(11): p. 2898-907.
7. Chaubet, F., et al., A new macromolecular paramagnetic MR contrast agent binds to activated human platelets.
Contrast Media Mol Imaging, 2007. 2(4): p. 178-88.
8. Choi, K.S., et al., Inflammation-specific T1 imaging using anti-intercellular adhesion molecule 1 antibodyconjugated
gadolinium diethylenetriaminepentaacetic acid. Mol Imaging, 2007. 6(2): p. 75-84.
9. Nahrendorf, M., et al., Noninvasive vascular cell adhesion molecule-1 imaging identifies inflammatory activation
of cells in atherosclerosis. Circulation, 2006. 114(14): p. 1504-11.
10. Amirbekian, V., et al., Detecting and assessing macrophages in vivo to evaluate atherosclerosis noninvasively
using molecular MRI. Proc Natl Acad Sci U S A, 2007. 104(3): p. 961-6.
11. Malle, E., T. Buch, and H.J. Grone, Myeloperoxidase in kidney disease. Kidney Int, 2003. 64(6): p. 1956-67.
12. Nahrendorf, M., et al., Activatable magnetic resonance imaging agent reports myeloperoxidase activity in healing
infarcts and noninvasively detects the antiinflammatory effects of atorvastatin on ischemia-reperfusion injury.
Circulation, 2008. 117(9): p. 1153-60.
13. Chen, J.W., et al., Myeloperoxidase-targeted imaging of active inflammatory lesions in murine experimental
autoimmune encephalomyelitis. Brain, 2008. 131(Pt 4): p. 1123-33.
14. Chen, J.W., et al., Imaging of myeloperoxidase in mice by using novel amplifiable paramagnetic substrates.
Radiology, 2006. 240(2): p. 473-81.
15. Caravan, P., et al., Collagen-targeted MRI contrast agent for molecular imaging of fibrosis. Angew Chem Int Ed
Engl, 2007. 46(43): p. 8171-3.
16. Helm, P.A., et al., Postinfarction myocardial scarring in mice: molecular MR imaging with use of a collagentargeting
contrast agent. Radiology, 2008. 247(3): p. 788-96.
17. Taouli, B., et al., Chronic hepatitis: role of diffusion-weighted imaging and diffusion tensor imaging for the
diagnosis of liver fibrosis and inflammation. J Magn Reson Imaging, 2008. 28(1): p. 89-95.
18. Luciani, A., et al., Liver cirrhosis: intravoxel incoherent motion MR imaging--pilot study. Radiology, 2008.
249(3): p. 891-9.
19. Namimoto, T., et al., Measurement of the apparent diffusion coefficient in diffuse renal disease by diffusionweighted
echo-planar MR imaging. J Magn Reson Imaging, 1999. 9(6): p. 832-7.
20. Castera, L., X. Forns, and A. Alberti, Non-invasive evaluation of liver fibrosis using transient elastography. J
Hepatol, 2008. 48(5): p. 835-47.
21. Bercoff, J., et al., In vivo breast tumor detection using transient elastography. Ultrasound Med Biol, 2003.
29(10): p. 1387-96.
22. Shah, N.S., et al., Evaluation of renal parenchymal disease in a rat model with magnetic resonance elastography.
Magn Reson Med, 2004. 52(1): p. 56-64.
49

Dogra V.S.
University of Rochester, NY, USA
NEW FRONTIERS IN US IMAGING
Prostate cancer is the most prevalent newly diagnosed malignancy in men, second only to lung cancer in causing cancerrelated
deaths. Adenocarcinoma of the prostate is the most common malignancy in the Western world. There will be a
projected 218,890 new cases of prostate cancer diagnosed in the United States in 2008, with an estimated 27,050 deaths.
As men age, the risk of developing prostate cancer increases. Prostate cancer has been found incidentally in
approximately 30% of autopsy specimens of men in their sixth decade. Seventy to 80% of patients who have prostate
cancer are older than 65 years.
Appropriate imaging of prostate cancer is a crucial component for diagnosing prostate cancer and its staging, in addition
to PSA levels and DRE. The current state of prostate imaging for diagnosis of prostate cancer includes ultrasound,
ultrasound-guided prostate biopsies, magnetic resonance imaging (MRI), and nuclear scinitigraphy. These modalities are
helpful, but have drawbacks and limitations. MRI is expensive and not mobile. Nuclear scintillation is expensive, provides
low resolution planar images, and there are problems with radiotracer excretion through the kidneys. Both these
modalities are not available for general use.
Ultrasound is not reliable enough to use solely as a template for diagnosing prostate cancer. It has two problems. First, in
many cases prostate cancer appears as an isoechoic lesion (similar gray scale value as surrounding tissue) causing high
miss rate). Secondly, when it is visible (hyper or hypoechoic), it is not possible to say with certainty if it is cancer or
benign because many other non-cancer conditions such as prostate atrophy, inflammation of the prostate gland, and
benign tumors may also look similar in appearance on ultrasound examination. A biopsy has to be performed on the
suspect lesion for definitive diagnosis. Biopsies are uncomfortable and bleeding may result as a complication. Because of
poor lesion detection, even the current prostate biopsy techniques miss approximately 30% of prostate cancer. Utility of
color flow and power Doppler in conjunction with gray scale ultrasound has been explored, but not successfully. Therefore,
there is an urgent need for a new imaging methodology that will be portable, economical to build, and will have
widespread utility as a tool for primary screening and diagnosis of prostate cancer.
It is evident that given the limitations of the present diagnostic protocols, development of a new imaging modality that
improves visualization and biopsy yield of prostate cancer would be beneficial.
The need for tumor visualization is equally critical in the treatment of localized prostate cancer disease. Existing
therapeutic strategies, namely external beam radiation, prostate brachytherapy, cryosurgery, and watchful waiting, all will
benefit significantly from the development of a new modality that promises better tumor contrast. I conclude that prostate
cancer continues to be an area in which progress is needed despite recent advancements. We have developed
photoacoustic (PA) imaging technology for the betterment of prostate cancer diagnosis and disease management. After
attending this lecture the attendee will be able to :
1. Understand the principles of photoacoustic Imaging and
2. Describe a C-scan.
Hamm B.K.
Charité Humboldt Universität Berlin, Germany
IMAGING OF ATHEROSCLEROSIS
50

DIABETES MELLITUS
Moderators: Tsampoulas K. (GR) – Triantopoulou Ch. (GR)
DIABETES AND DIABETIC NEPHROPATHY
Zoupas C.S.
Director Diabetes Center and Clinic, “Hygeia” General Hospital. Athens-Greece
Diabetic nephropathy represents the most common cause of end-stage renal failure in the western world and accounts for
approximately 40% of all new patients entering the programs of end-stage renal disease (ESRD).
Over the last decade (1990-2000) the prevalence and incidence of ESRD in USA have approximately doubled, due to type
2 diabetes.
Although dialysis and transplantation prevent death from uremia, the 5 year survival in diabetic patients with ESRD is
much worse than that of non diabetic patients.
Therefore it is important to recognize the very early stages of diabetic nephropathy and to institute appropriate therapy,
especially when urinary albumin excretion is >300 mg/day.
Diabetic nephropathy develops in almost 50% of patients with type 1 diabetes mellitus who have had diabetes for more
than 20 years. Clinically significant renal disease is less common in type 2 diabetes mellitus, occurring in 15-20% of
individuals.
A rational approach to the therapy of diabetic renal disease depends on the thorough understanding of its pathogenesis.
The following factors have implicated in the development of diabetic nephropathy:
-Poor glycemic control (fasting plasma glucose >140-160mg/dl or >7,7-8,8mmol/l and A1c>7-8%.
-Genetic factors
-Hemodynamic abnormalities (increased RBF and GFR , elevated intraglomerular
pressure)
-Systemic Hypertension
- Insulin resistance syndrome (Metabolic syndrome)
-Inflammation (highly sensitive C-reactive protein, fibrinogen, NFkB)
-Altered vascular permeability
-Excessive protein intake
-Metabolic disturbances (abnormal polyol metabolism, formation of advanced glycation end products, increased cytokine
production)
-Release of growth factors
-Abnormalities in carbohydrate /lipid/protein metabolism
-Structural abnormalities (glomerular hypertrophy, mesangial expansion, glomerular basement membrane thickening)
-Disturbances in ion pumps (increased Na-H pump and decreased Ca-ATPase pump)
-Hyperlipidemia (hypercholesterolemia and hypertriglyceridemia)
-Activation of protein kinase C
Before the onset of overt or clinical albuminuria there is a preclinical stage of diabetic nephropathy characterized by
microalbuminuria.
Microalbuminuria was first described almost 45 years ago and this concept has been used more frequently in clinical
medicine as a marker of disease progression, especially after important studies results showing that this parameter is a
key indicator for intensified treatment in patients with IDDM.
Most importantly tight glycemic control with insulin and treatment with ACE-inhibitors during the microalbuminuric stage
have been shown to prevent the progression of microalbuminuria to overt clinical albuminuria in both type 1 and type 2
diabetes subjects.
It is well recognized that the results of landmark studies of Diabetes Control and Complications Trial (DCCT) (intensive
insulin therapy in type 1 diabetes) the Japanese Intervention Study (intensive insulin therapy in type 2 diabetes) and the
United Kingdom Prospective Diabetes Study (UKPDS) (intensive therapy with oral agents and / or insulin in type 2
diabetes) have conclusively demonstrated that tight glycemic control serves as primary prevention for all microvascular
complications including nephropathy, retinopathy, neuropathy!
After all these data ideal blood glucose control is of paramount importance in preventing nephropathy!
The natural history of diabetic nephropathy in individuals with type 2 DM who are destined to develop ESRD closely
mimics that in type 1, but there are some important differences.
Clinically detectable albumninuria is common at the time of diagnosis, but a smaller percentage (5-10%) of Caucasian
patients with type 2 DM progress to ESRD by 20 years!
In patients with non-insulin dependent DM, microalbuminuria is also an important predictor of other complications and of
adverse outcome!
Approximately 80% of individuals with type 2 DM die from cardiovascular complications (stroke or myocardial infarction)
within 10 years after the onset of microalbuminuria!
In addition microalbuminuria is strongly associated with the insulin resistance syndrome!
In type 1 DM clinical evidence of renal disease is extremely rare within the first 5 years after diagnosis of diabetes and is
uncommon (5-10%) within the first 10 years!
Diabetic retinopathy usually accompanies diabetic nephropathy!
Because of the significant day-to-day variation (40-50%) in urinary microalbumin excretion, at least two base line
determinations should be obtained to establish the diagnosis.
Several factors can increase the urinary albumin excretion rate: stress, systemic or urinary tract infection, acute
metabolic decompensation, fever, exercise, hypertension and cardiac failure.
These confounding medical disorders must be resolved before measuring the albumin excretion rate.
Strict glycemic control and treatment of hypertension, if present, is the most important factor in treating diabetic patients
during the microalbuminuric stage.
A low-protein diet ameliorates the progression of chronic renal disease. Moderate protein restriction of 0,8-1,0 g/kg/day is
advocated in diabetic patients with overt microalbuminuria. Replacement of animal protein with vegetable protein is
recommended.
51

Hypertension is a characterized feature of diabetic nephropathy and is the most important factor known to accelerate the
progression of renal disease. Treatment of hypertension at or before the microalbuminuric stage can prevent the
development of microalbuminura or arrest the progression respectively.
Antihypertensive therapy should begin at the earliest indication and should be aggressive. ACE inhibitors and angiotensin
receptor blockers-ARBs, are the most used and ideal antihypertensive agents. Numerous studies have shown that ACE
and ARBs are the only two classes of antihypertensive drugs which reverse
hemodynamic alterations that characterize diabetic nephropathy. Most of the data have been accumulated with ACE
inhibitors, which are the drugs of choice for the treatment of microalbuminuria, because this class of drugs improves
insulin sensitivity, glucose tolerance and dislipidemia. If cough presents a problem an ARBs can be used.
The natural history of renal disease has been well characterized in both type 1 and type 2 DM and for this reason
increased awareness and knowledge by the physicians is of paramount importance in order to prevent ESRD!
IMAGING OF GENITOURINARY COMPLICATIONS OF DIABETES MELLITUS
Danza F.
Università Cattolica del S. Cuore., Roma Italy
Diabetes mellitus is a metabolic disorder characterized by lack (absolute or relative) of insulin which leads to altered use
of carbohydrates as well as altered metabolism of both lipids and proteins.
The disease for its particular effect on systemic vasculature can determine a series of complications that can affect
multiple organs.
Prevalence of diabetic complications
1 – microangiopathic
Type 1 Type 2 TOT
• Retinopathy 53.6 34.7 37.3
proliferant 12.5 6.2 7.6
background 41.1 28.4 29.7
• Nephropathy
patients in dialysis
28/mil
microalbuminuria 31.0 15
• Neuropathy 28.0
2 - macroangiopathic
Diabetics Non Diabetics
% %
• Ischemic heart disease 7 - 31 6 - 7
• Vascular dis. lower limbs 18.1
• Hypertension 53 - 68
• Dyslipidemia 54 - 64
• Ulcers lower limbs 15
In such a way the disease determines an high cost to the community
Costs related to diabetes
> hospital stay < workdays > assistance
Screening e diagnosis ++ ++
Therapy and selfcontrol + +
Diagnosis and fup of sequelae + ++
Hospitalization for acute events +++ ++
•Complications +++ ++
–blindness +++ ++++ ++++
–dialysis +++ ++++ ++++
–amputations ++++ ++++ ++++
OMS estimated a clear grow of prevalence of the disease in the last ten years: from 170 to 210 millions of patients in
2010. It is really a epidemic increase of diabetes and obesity in the world. The USA 2002 costs of diabetes are estimated
in about $250.000 per minute. Health costs/person in USA: Healthy $ 2.5 Diabetic $ 13
Diabetes and diseases of the GU tract:
This is a frequent association: there are many changes induced by diabetes on the GU tract. For example common
diseases are often more severe and with unusual findings in diabetic patients.
Diabetes and Genito-urinary complications
Renal changes, vascular changes, neurological changes, degenerative changes, infectious diseases
Renal changes: diabetic nephropaty, papillary necrosis, renal amiloydosis in dialyzed patients.
Diabetic nephropaty
Definition: presence of persistent proteinuria (> 0,500 mg/day) in a diabetic patient, in absence of other nephropaties,
urinary infection or cardiac insufficiency.
Diabetic nephropaty has different presentation in respect of type of disease: diabetes mellitus - Insulin dependent (type
1): the nphropaty is present in about 40% of patients; nephropaty is rare before 10 years of diabetes with a peaks after
15-20 years. Rarely develops after 30 from diagnosis of diabetes. In Diabetes mellitus Non insulin dependent (type 2) the
nephropaty is present in about 15% of patients. Development of nephropathy increases with disease duration. Risk of
nephropaty is low in a normo-albuminuric patients after 30 years from diagnosis of diabetes.
Diabetic nephropaty: Hypertrophy – Hyperfunction of kidney.
In the initial phases of diabetes, before starting insulin therapy there are signs of hyperfiltration (increase of GFR up to
40%), microalbuminuria, nephromegaly, glomerular hypertrophy
Such changes disappear after starting insulin therapy; only remains increased GFR
Subclinical nephropaty (silent): after 2-3 years from onset of diabetes there is development of strain microalbuminuria (=
urinary excretion > 30 mg < 300 mg/die (> 20 < 200 g/min). Increased GFR persists There is increase of mesangial
52

membranes and thickening of basal membranes at the glomerulus. These changes are reversible if optimal control of
glicemia is obtained.
Incipient diabetic nephropaty: about 10-15 years after onset of diabetes, starts persistent microalbuminuria, predictive of
development of clinical diabetic nephropaty in more than 80% of cases. GFR is increased or normal; arterial pressure is
increased or normal; increased mesangial matrix and thickening of basal membranes usually appear.
Clinical nephropaty: persistent proteinuria, often with frank nephrotic syndrome; progressive reduction of GFR (about 1
ml/min/month); arterial hypertension; diabetic glomerulosclerosis; arteriolosclerosis.
Chronic renal failure: constant decrease of GFR is the rule. Hypertension is present. Terminal uremia is the destiny (3 -
20 years after the beginning of clinical nephropaty).
Diabetic nephropaty - Imaging
Diabetes is the most frequent cause of nephromegaly.
There is some literature on renal US and Doppler changes in patients with diabetic nephropaty:
–Platt, Radiology 1994, Brkljacic, Radiology 1994, Derchi, Acad Radiol 1994, Soldo, Acta Radiol 1997, Boeri, Diabetologia
1998, Sari, Invest Radiol 1999, Okten, Acta Radiol 1999.
Hyperfiltration: patients with hyperfiltration have higher renal volume and lower renal RI than those with normal or
reduced GFR. Renal volume > 410 ml e IR

Dystrophic changes: calcifications of the deferent ducts may bevelop with age, following infections (aspecific, tb,
schystosomiasis), and in diabetics. Of the 60 Patients with deferent ducts calcifications described by Wilson and Marks, 56
were diabetic. In diabetics the etiology is dystrophic (Wilson, NEJM 1951).
Calcifications of deferent ducts: their position allows easy differentiation from vascular calcifications. They present a
“railway track” shape, more easily visible on CT
Infectious diseases
High levels of glucose in tissues and a pathologic tissue and vascular response predispose diabetic patients to infections.
Infections in diabetics are often severe, due both to the pathogens involved in the disease process and the degree of
aggressivenes of the infection itself. Development of gas is relatively frequent in infections in diabetic patients: this seems
due to presence of abundant glucose within tissues. Identification of gas indicates a severe infection; however, gas can be
easily seen, especially by CT, and this helps the diagnosis.
Pyelonephritis – renal abscess
A renal abscess is due, in most cases, to ascending infection; hematogenous origin is possible, but rare. Lesions can
extend into perirenal spaces. Imaging is needed to identify these lesions and monitor the response to therapy (be it
medical o interventional).
Prostatic-vescicular abscess. Diabetes is a predisposing factor to development of prostatic abscesses: it usually is from
ascending origin, sometimes from hematogenous spread or after instrumentation. Etiology varies according to patient’s
age: Neisseria e Chlamydia in young, sexually active; E. Coli in the elder .
Emphysematous pyelonephritis
Infection characterized by presence of gas in calices, pelvis, parenchyma, and perirenal tissues. In 87% of cases it
involves diabetic patients (especially women); in the others it is almost invariably associated with obstruction. Organisms
involved are E. coli (71%), Klebsiella, Aerobacter, Proteus, Candida (Michaeli, J Urol 1974).
It is a very severe condition, with mortality >60% if treated with antibiotics only, and 30%-50% if the Patient undergoes
surgery; mortality is 80% if the disease extends into perirenal tissues. Clinically, it is a pyelonephritis which does not
respond to treatment. The CT and US findings are typical, and the diagnosis is based on demonstration of gas within the
renal parenchyma. CT allows better analysis of the extension of the disease process
Emphysematous cystitis
It is a rare condition, which is typical of diabetics: fermentation of glucose in tissues and in urines causes production of
gas within both the bladder lumen and bladder wall. Symtoms are those of cystitis; pneumaturia can be observed. The
condition can often be visible on plain films of abdomen due to presence of gas in the bladder wall, presenting as a curved
hypodense line in the pelvis. US, and better CT, have higher sensitivity.
Fournier gangrene
It is a urologic emergency, with up to 75% mortality. Necrotizing fascitis of perineum which can extend to abdominal wall;
predisposing factors: diabetes, alcoholism, advanced age, immunodeficiency. Originates from perineal (rectal fistulas,
cutaneous ulcerations) or from uretral lesions (the fascia of Colles, at the level of the suspensory ligament of penis is
fenestrated, and does not offer a barrier to spread of the infection). The diagnosis is on clinical grounds; imaging needed
when symptoms not clear. The radiological diagnosis is based on demostration of gas within soft tissues. The disease can
extend to the whole pelvis, and can be impossible to dominate
Infections – penile
A rare condition, infections of the penis are often related to fimosis, obesity, diabetes, immunodeficiency, often due to
invasive manoeuvres. Imaging is usually based on US, which is enough to identify and “stage” the disease process.
Infections can lead to abscess development.
Tubo-ovarian abscesses
Tubo-ovarian abscesses are rare in the post-menopausal patient (2%), and are often associated with neoplasms. From
15% to 18% of these patients have diabetes. Etiopatogenesis correlates to ascending infections and/or instrumentation.
Clinically, symptoms are often not clear (mild fever, slight leucocitosis) and physical findings are non specific (mass, pain,
bleeding).
Imaging findings are variable, related to location of the diasease process (tubal dilatation, pelvic mass, free fluid).
Imaging can guide drainage (via transvaginal or transperineal approach).
Morcos S.K.
Northern General Hospital, UK
USE OF CM IN DIABETIC PATIENTS
LYMPHOPROLIFERATIVE DISORDERS
Moderators: Ramchandani P. (US) – Amendola M. (US)
RETROPERITONEAL LYMPHOPROLIFERATIVE DISEASE(LPD)
Goldman S. (US)
University Of Texashealth Science Center, USA
Hodgkin’s disease was first described by Dr. Thomas Hodgkin in 1832. In 1902 Dorothy Reed Mendenhall described the
Reed-Sternberg cell, which became the hallmark of the fascinating topic of the lymphomas of the body which will be
relatively limited to the retroperitoneum in this lecture.
Our goals in this presentation is to discuss the relative anatomy, review the major types of LPD (Hodgkin’s NHL, PTLD,
etc. in regard to etiology, pathology and staging; discuss the role of imaging in initial staging during therapy, immediately
after Rx and in follow-up studies.
I. Anatomy
Although all of you are familiar with the anatomy of the retroperitoneum, a few issues need to be
reemphasized and illustrated. Although all of you are familiar with the existence of adrenal kidney
lymphoma; the pancreas itself can be involved with lymphoma, as well as the lymph nodes draining the
pancreas. Other pertinent structures in the retroperitoneum will be reviewed. Furthermore, it is important
to recognize that lymphoma below the diaphragm may not be confined to the retroperitoneum. The
responsibility of the radiologist is to not only look at the obvious structures such as the spleen, liver and the
54

II.
mesentery; the gastroduodenal ligaments and the gastrohepatic ligaments may be involved and need to be
commented upon, in spite of the fact that they may not be technically part of the retroperitoneum.
History
In the GRAND OLD DAYS of the 60’s, lymphoma evaluation by the radiologist was simple. His job was to
define whether the disease was above and/or below the diaphragm (Stages I & II), since most radiologists
did both diagnostic and therapeutic radiology, one correlated as to whether the patient was symptomatic (A)
or asymptomatic (B). Treatment was predominantly by radiation. The radiologist’s tools consisted of the
chest X-ray, abdominal film and usually an IVP (inverted Y sign). When necessary, this was supplemented
by an upper GI series with small bowel follow through and a barium enema. In the early 60’s, added to the
radiologist armamentarium, came the lymphangiogram. This provided morphology of the lymph node. It
would show the enlarged nodes, theoretically differentiated between Hodgkin’s and Non-Hodgkin’s
lymphoma. This technique was still used into the 90’s for lymphoma and cervical cancer, and even recent
articles as late as last year have advocated its use (think of the use of iron oxide compounds for imaging of
retroperitoneal lymph node on MRI).
III. A Few General Concepts
Hematological Disorders are classically divided into leukemia, lymphoma, plasma cell disorders/ multiple
myeloma and myelodysplastic syndromes. Currently, in dealing with the subject of MDP disorders there are
literally hundreds of different diseases to consider; however, in fact, the common disorders consist of NH
lymphoma (62.4%), plasma cell disorders (16%), CLL (9%), Hodgkin’s Lymphoma (8.2%) and all others
(3.8%). This talk will be limited to the common varieties, except for a few exceptions (Keep It Simple &
Stupid). Some of the important concepts to remember are the association with multiple viral syndromes
(AIDS (HHV-8), herpes, IL-6, Epstein-Barr). Patients who are immune-compromised, (transplants, collagen
diseases), are also prone to develop MDP.
IV. Look-A-Likes
Castleman’s Disease (Angio Follicular lymphoma) is an important look-a-like and is benign, although there
have been transformation in these patients to true LPD. Other entities to be considered are Kawasaki
Disease, atypical lymphoid hyperplasia, Wiskott Aldrich syndrome.
V. Hodgkin’s Disease (HD)
There are approximately 8,000 new diagnoses each year with 1,300 in the United States. Most cases are
seen between the ages of 15 – 30, with a second peak after 55 years. True Hodgkin’s consists of 15% of
cases and NHL 85%. Multiple classifications exist; some of this is based on the cell type WHO (B cell, T cell,
NK cell). The highest rates for HD are in the United States and Western Europe, although for reasons not
understood, there has been a decline in incidence over the last 20 years. It is slightly more common in
males with Whites affected greater than African Americans and both greater than Asians. There are known
genetic factors. HD is divided into the classical Reed-Sternberg type (Nodular sclerosing (65%), mixed
cellularity, (72%), lymphocyte depleted (2%), lymphocyte-rich (3%) and into the lymphocyte predominant
(6%), non- classifiable (12% - nodular-lymphocytes, Diffuse T). The Rye classification divides them into 4
types: Lymphocyte predominant, nodular sclerosis, mixed cellularity and lymphocyte depletion. One of the
other important concepts in determining outcome is called the Hodgkin’s Risk Factors: Age greater
than/equal to 45, Stage IV disease Hgb < 10.5 gldl, WBC count < 600/ml or < 8%, mean, albumin < 4gldl
and WBC greater than/equal to 15,000 lml. The HD signs and symptoms consist of: night sweats (33%),
enlarged lymph nodes, splenomegaly (30%), and hepatomegaly (5%), pain following alcohol consumption,
back pain, red colored patches (2%) and increased platelets. The Catswold Modification of Ann Arbor
Staging of Hodgkin’s Disease is a fairly standard classification and manifests as: single lymph node region
(I), 2 or more lymph node region same side of diaphragm (II) lymph node region on both grades of the
diaphragm (III), diffuse involvement of 1 or more extralymphatic organs or sites (IV). A is asymptomatic, B
includes weight loss > 10% in last six months, or explained recurrent fever > 38 degrees C or night sweats.
As for prognosis, the five year survival for favorable types is 98%; and those with initially worse prognosis
are 85%.
The imaging workup according to the NCCN includes a chest, chest/abdominal/pelvic CT, unless part of
PET/CT. MRI may be used as a replacement. Gallium is less commonly used currently. PET and especially
PET/CT is strongly advised for initial staging, but especially is felt to be important in prognosis on follow-up
scans after 2 – 4 cycles of chemotherapy at the end of therapy and at follow-up. Further details will be
presented.
VI. Non-Hodgkin’s Lymphoma
Non-Hodgkin’s Lymphoma increased in incidence in the US by 4% each year between 1950 and 1990; and is
now flat or decreasing. 63,000 cases diagnosed each year. It represents 4% of all new cancers and a 2%
lifetime risk for all comers. It is seen more frequently in elderly and in males and in immno-deficient
patients. T-cell NHH is more common in Asia, and B-cell more common in Western countries. The common
subtypes are: Diffuse large B cell lymphoma (31%), follicular lymphoma (22%), MALT lymphoma (7.6%),
mature T-cell lymphoma (7.6%), small lymphocytic Lymphoma (6.7%), Mantle Cell Lymphoma (6%), and
the rest (19%). The epidemiology is as described above. The WHO is divided into B-cell lymphoma
(precursor B-cell lymphoma and mature B-cell lymphoma) T/NK - extranodal natural killer cell lymphoma
(precursor and mature). Another very commonly used classification is: Diffuse large B-cell – 31% (most
frequent); follicular cell (22%), extranodal marginal zone/MALT peripheral T Small lymphocyte (5-10%).
The follicular cell lymphoma has an incidence world wide of 22%, with 30% incidence in the US. It is a low
grade lymphoma, any organ can be involved, most have no fever and PI scores are low. It responds to
treatment and between 50 – 75% have a complete remission. The mature B-cell lymphomas are most
common and characterized as diffuse. They are more likely to be symptomatic. Another interesting B-cell
lymphoma is Burkitt’s lymphoma which is an aggressive B-cell lymphoma most found in children and
immunosuppressed patients. It is wide spread and extranodal when seen. The endemic form is found in
Africa involving the bones and jaws. It is sporadic in the USA; 15% have the Epstein-Barr virus. Another
important group is the T-cell lymphomas which are divided into 3 types: extranodal NK/T1 lymphoma,
55

aggressive NK cell leukemia, and blastic NK cell lymphoma. Epstein –Barr virus is commonly present. The
NK cell is separate, but related to the T-cell. It is common in Asia, Mexico, S. America, and rare in Western
countries. It is seen in the middle age to elderly, often with nasal obstruction, epistaxis, and midfacial
destruction. It’s an aggressive tumor with a hepatosplenomegaly and extranodal involvement.
VII. Post Transplantation Lymphoproliferative Disorder (PTLD)
This group of lymphomas is seen in patients with AIDS /HIV virus. In this group, the risk of NHL is increased
150 fold. It is mostly found as diffuse large B-cells or Burkitt’s. It is aggressive with a poor prognosis.
Another large group of these patients have had organ transplants. Their histology is variable, but they are
usually aggressive. Immunosuppressive therapy is a significant factor in its development. In PTLD, the
Epstein-Barr virus incidence is increased and there is a range from premalignant hyperplasias (Polymorphic)
to monomorphic indistinguishable from NHL. A few T-cells develop Hodgkin’s or rarely, multiple myeloma.
Other types included T cell or NK cell origin, MALT. The onset of this disease is fairly rapid – 3.5 to 10.8
months. It often manifests itself in the GI tract, head and neck, kidney (especially with certain
chemotherapy agents). The presentation is diverse with a mild febrile syndrome, pharyngitis and
lymphadenopathy aggressive with nodal (20%) and extranodal sites (80%). Renal PTLD when present is
bilateral. The imaging workup is similar to Hodgkin’s disease and NHL.
Amendola M.
MCV VCU Medical Center, USA
IMAGING OF LOWER GU TRACT LYMPHOMA
Extranodal lymphoma arising in the prostate is rare. The diagnosis may be considered as a rare cause of prostatic
enlargement in young men.
Lymphoma of the bladder is extremely rare. It can be seen as part of widespread nodal and extranodal disease, recurrent
lymphoma or as primary lymphoma limited to the bladder. There are no specific radiologic appearances.
Lymphoma is the most common tumor of the testis in patients older than 50 years. Bilateral involvement has been
reported in up to 40% of patients. The ultrasonographic appearance is indistinguishable from that of germ cell tumors
ranging from a discrete hypoechoic lesion to a diffuse enlargement of the testis with a homogeneous or heterogeneous
decrease in echogenicity.On Color Doppler Sonography testicular lymphoma is usually hypervascular.
Post transplantation lymphoproliferative disorder complicates 1-2% of renal transplant recipients. Early diagnosis is
important because reduction of immunosuppresion improves the clinical outcome.
References
Khandelwal KC, Moorjani VK, Mophan C. et al. Non-Hodgkin lymphoma of the prostate. Can Assoc Radiol J 1994:45:56-57
Anis M, Irshad A. Imaging of abdominal lymphoma. Radiol Clin N Am 2008:46:265-285
GENITOURINARY LYMPHOMA: CASE HISTORIES
Spencer J.A.
Consultant Radiologist, St James’s Institute of OncologyLeeds LS9 7TF, UK
Teaching points
Lymphoma is one of the great mimics. I will illustrate several cases of genitourinary lymphoma which have presented to
my institution in the last year in the format of a clinico-radiological grand round.
Colleagues whose presentations precede mine will have provided all necessary background information on genitourinary
lymphoma.
INFECTIOUS DISEASES
Moderators: Jakobsen J. (NO) – Wasserman N. (US)
Morgan E.
CP Clinical Director HIV/GUM Bolton PCT, UK
CLINICAL OVERVIEW HIV/AIDS
Recent WHO reports confirms 42 million people living with HIV/AIDS of those 19 million are women and 74 % live in sub-
Saharan Africa. By 2010 estimated 50 to75 million infections will be added to world wide pool of HIV, totalling of
staggering 100 million!
So far 22 million died from AIDS. UNAIDS estimates a current 14 million AIDS orphans increasing to over 25 million by
2010! http://www.until.org/ads.shtmlThere are14000 daily new infections (95% in developing countries). HIV is a young
people’s infection with half of the yearly 5 million new infections occurring among ages 15-24.
UNAIDS estimates 2.2 million living with HIV in Europe/Central Asia at end 2007. Estimated prevalence varies from 0.1%
in parts of Central Europe to above 1% in parts of former Soviet Union. Across the continent, heterosexual infections
particularly women are steadily increasing. Cumulative total of cases in Greece was 8680 giving an adult prevalence of
0.2% by 2007.
Since HAART, life expectancy and quality of life to those who have access to therapy have dramatically improved.
HAART has changed HIV prognoses from fatal illness to chronic lifelong manageable condition! However this was at a
price! We now have consequences of more complex presentations in those who are living longer and a variety of adverse
events, as result of complex challenging therapy. The author will summarise the epidemiology, current understanding of
HIV life cycle, clinical manifestations, interventional radiologist associated risk and some recognised renal pathology
caused primarily by HIV or as a result of specific HIV therapies.
56

GU MANIFESTATIONS OF AIDS: REAPPRAISAL OF IMAGING FINDINGS
Amendola M.
MCV VCU Medical Center,USA
Since the first description of renal disease associated with AIDS in 1984 it has been recognized that renal manifestations
of AIDS are common and due to multiple causes. These include:
1. HIV-associated nephropathy
2.Increased infections especially opportunistic related to its immunosuppression such as TB, MAI, Pneumocystis Carinii,
fungal infections.
3. Drug related renal disease resulting from the use of highly active retroviral therapy (HAART) for example Indinavir
related renal stones, dyslipidemia, insulin resistance, increased incidence of diabetes and hypertension and also from
nephrotoxic drugs such as :Pentamidine/ amphotericin B/cotrimoxazole.
4. Neoplasias such as AIDS- related lymphoma and Kaposi sarcoma.
5. Vascular causes of renal disease including renal artery stenosis related to HAART induced hyperlipidemia.
6. Miscellaneous: Vasculitis/ ATN/Hemolytic Uremic Syndrome
Imaging findings of these entities and others involving the lower urinary tract will be presented. The role of interventional
radiology in selected cases will be discussed.
References
1. Symeonidou C, Standish R, Sahdev A, et al. Imaging and histopathologic features of HIV-related renal disease.
RadioGraphics 2008: 28:1339-1354
2. Amendola, MA and LJ Abrams, AIDS in the GU Tract, Chapter 33, pp 1233-1243, In: Clinical Urography, (2nd
Edition) HM Pollack and B McClennan eds., W.B. Saunders, Philadelphia, 2000
TUBERCULOSIS, PARASITIC DISEASES AND UNUSUAL INFECTIONS OF
THE GENITOURINARY TRACT
El-Diasty T.A.
Mansoura University, Mansoura – Egypt
Genitourinary Tuberculosis
Genitourinary tuberculosis is the most common manifestation of extrapulmonary tuberculosis. Mycobacterium tuberculosis
reaches the genitourinary tract as a secondary site following hematogenous dissemination from the lung. The kidneys and
possibly the prostate and seminal vesicles are often the primary sites of genitourinary tuberculosis (1). All other genital
organs become involved by ascent or descent of M tuberculosis. The testis may become involved by direct extension from
an epididymal infection, but hematogenous spread to the testicle is rarely seen (2).
Renal tuberculosis:
Tuberculosis of the kidney results from hematogenous seeding of M tuberculosis in the glomerular and peritubular
capillary bed from a pulmonary site of primary infection(3). Radiography may demonstrate calcification within the renal
parenchyma. The calcification may be amorphous, granular, curvilinear, or lobar (putty kidney)(4,5). Intraverous
urography demonstrates a variety of findings depending on the extent of renal involvement. The earliest urographic
abnormality is a “moth-eaten” calyx due to erosion. This finding is followed by papillary necrosis. Poor renal function,
dilatation of the pelvicalyceal system due to a stricture of the ureteropelvic junction, or destructive dilatation or localized
hydrocalycosis related to an infundibular stricture. Infundibular stenosis may lead to incomplete opacification of the calyx
(phantom calyx) (6). Cavitation within the renal parenchyms may be detected as irregular pools of contrast material.
Cicatricial contracture of fibrotic parenchyma may lead to caliceal or renal pelvic traction. Calculi may be present within
the renal collecting system. End-stage fibrosis and subsequent obstructive uropathy produce autonephrectomy. At this
time, renal assessment is best achieved with US, CT or MR imaging (7,8,9).
CT is helpful in identifying the manifestations of renal tuberculosis (e.g. calcification). Various patterns of hydronephrosis
may be seen at CT depending on the site of the stricture. Other findings include parenchymal scarring and low attenuation
parenchymal lesions. CT is also useful in depicting the extension of disease into the extrarenal space (2,9).
The radiologic differential diagnosis of renal tuberculosis includes acute focal bacterial nephritis, xanthogranulomatous
pyelonephritis, other causes of papillary necrosis and small benign or malignant tumors (10).
Ureteral tuberculosis:
Ureteral involvement is seen in 50% of patients with genitourinary tuberculosis (7). Dilatation and a ragged irregular
appearance are the first signs of ureteral tuberculosis. In advanced disease, ureteral strictures, ureteral shortening,
ureteral filling defects, or ureteral wall calcifications may be seen (5,7). CT may demonstrate thickening of the ureteral
wall and periureteral inflammatory changes.
Bladder tuberculosis:
Typically, tuberculous cystitis manifests as shrunken bladder with wall thickening (11). Occasionally, filling defects due to
multiple granulomas may also be seen. In advanced disease, the bladder may be diminutive and irregular (thimble
bladder). Advanced bladder involvement may be complicated by vesicoureteral reflux due to fibrosis involving the ureteral
orifice. Calcification of the bladder is rarely seen (10). Calcified tuberculous cystitis must be differentiated from
shistosomiasis, cystitis due to cyclophosphamide, radiation induced changes, calcified bladder carcinoma and encrusted
foreign material. Bladder tuberculoma may mimic transitional cell carcinoma.
Male genital tuberculosis:
The most common findings of tuberculous prostatitis, on transrectal US, is hypoechogenic areas with an irregular pattern
in the peripheral zone of the prostate. Contrast-enhanced CT shows hypoattenuating prostate lesions which represent foci
of caseous necrosis and inflammation. Nontuberculous pyogenic prostatic abscess have a similar CT appearance (7). At
MR imaging, a prostatic abscess demonstrates peripheral enhancement. This finding helps differentiate an abscess from
prostatic malignancy. In addition,
MR imaging shows diffuse, radiating, streaky areas of low signal intensity in the prostate (“Watermelon Skin” sign) on T2-
weighted images(12).
Tuberculous involvement of seminal vesicles may lead to necrosis, calcification, caseation and cavitation(13,14).
Tuberculous epididymo-orchitis usually manifests at US as focal or diffuse areas of decreased echogenicity with epididymal
involvement(15).
Female genital tuberculosis:
57

Fallopian tubes are affected in 94% of women with genital tuberculosis. Salpingitis caused by hematogenous
dissemination is almost always bilateral. A tubo-ovarian abscess that extends through the peritoneum into the
extraperitoneal compartment suggest tuberculosis(1). Other diagnostic criteria for female genital tuberculosis include
endometrial adhesions with deformity and obliteration of the endometrial cavity, obstruction of the fallopian tubes with
multiple areas of constriction, and calcified lymph nodes in the adrexal region(7). Advanced tuberculous endometritis may
mimic sever uterine adhesions as seen in Asherman syndrome (10).
Parasitic infections
Parasitic infections of the genitourinary system are a heterogenous group of diseases that have some common features.
Most parasitic infections are chronic, and the host immune response reacts to the different stages of the parasite life cycle
involving different parasite antigens. Although renal disease is not one of the common presenting features, many parasitic
infections are associated with glomerular lesion. While there are many parasites which wander into the urinary tract, there
are only three parasitic infections which are relatively common, namely schistosomiasis, echinococcosis and filariasis.
Other parasites may also rarely infest the genitourinary system as Malaria, leishmaniasis, trypanosomiasis, babesiosis,
toxoplasmosis, trichinosis and dioctophyma renale(16).
Urogenital Schistosomiasis: The histopathological changes and clinical symptoms of UG Schistosomiasis are almost
entirely due to the dead egg. Schistosomiasis is thus primarily an infection of the vascular system and the underlying
pathological process is the formation of granulomas and obliterative (embolic) endarteritis. Although in schistosomiasis
from S. haematobium, the ureter and bladder are chiefly affected, granulomas may also be found in the testes, seminal
vesicles, and not infrequently in the female genitalia as cervix, ovary, fallopian tubes and endometrium. The most serious
complication of urinary tract schistosomiais is an increased incidence of squamous cell carcinoma of the bladder.
Additional complications include urolithiasis, ascending tract infection, urethral and ureteral stricture with subsequent
hydronephrosis, and renal failure. In Egypt there is syndrome of “bladder neck obstruction”. The trigone is most affected
and hypertrophies to form a prominent bulging into vesical lumen between ureteral orifices. Eventually, this fibrosis and
atrophies, leaving the mucosa and muscularis as a mass, which is pushed forward over the internal ureteral orifice (17,18)
. The prostate gland may occasionally be enlarged due to bilharzial prostatitis. Calcification may be seen in the seminal
vesicles and may rarely be found in the spermatic cord. The fallopian tubes may be infected and blocked and also calcified
as result of egg deposition.
Schistomiasis of the cervix uteri is not uncommon and is easily confused with carcinoma of the cervix, with which it may
coexit. Schistosomal lesions of the vagina and cervix may predispose to the acquisition of HIV infection and AIDS
(19,20,21) .
Urinary bladder wall calcification has relatively few etiologies. While a correct diagnosis is often not possible solely on the
basis of the appearance of the calcification, such a diagnosis can usually be obtained from a combination of history,
clinical examination, appropriate laboratory studies and radiographic evaluation of the bladder and reminaing urinary
tract. Cystoscopy with biopsy of the involved tissues is almost always necessary, however, for confirmation and to rule out
bladder neoplasia (22).
Schistomiasis can be imaged by radiography or sonography and, in the later stages, by CT scanning or magnetic
resonance imaging (MRI). Plain film radiography of the abdomen is not helpful until calcification has developed. CT scan
better delineates the extent of the calcification, thickness and dilation of the ureteral wall, hydronephrosis as well as the
bladder tumours . A heavily calcified area in the bladder has an estimated 500.000 to 1 million eggs per gram, but
calcification to be seen on plain radiography, it is necessary to have 100.000 eggs per cubic centimeter. The presence of
schistosoma eggs has been reported in 50% of postmortem studies of the prostate and seminal vesicles performed in
endemic areas. Transrectal sonography showed prostatic calcification, increased prostatic size, calcification of the seminal
vesicles as well as dilation of the ejaculatory ducts (23). The classic presentation of a calcified bladder, which looks like a
fetal head in the pelvis, is pathognomonic of chronic urinary schistosomiasis . The seminal vesicles, prostate, prostatic
urethra and distal ureters may be calcified (24) . With intravenous urography, the earliest changes are seen in the
ureters, with persistent filling of the lower segments throught the urogram . At this stage the ureters are not always
dilated, but this develops next. At first, it results from dysfunction rather than tissue damage at this stage. The dilation
will be asymmetrical and may be slight or severe, sometimes without visible stenosis. Later, ureteric constriction will
occur, initially within the bladder wall. As the disease progress, the lower ureters become beaded in appearance,
secondary to bilharzial granuloma in the submucosa of the ureter. Mucosal ureteric edema may result in luminal
narrowing and striations in the ureter. Air-bubble-like filling defects are seen in uretero-pyelograms are suggestive of
ureteritis and pyelitis cystica(25).
Hydatid disease (Echinococcosis):
Hydatid disease (HD) is a unique parasitic disease that is endemic in many parts of the world and can occur almost
anywhere in the body and demonstrates a variety of imaging features that vary according to growth stage, associated
complications and affected tissues. Radiologic findings range from purely cystic lesion to a completely solid appearance.
Calcification is more common in HD of the liver, spleen and kidney. It can be quite large in compressible organs and can
be solitary or multiple (26).
Two species can affect the urinary tract, Echinococcus granulosus and E. multilocularis, although the latter very rarely,
and primarly involve the liver. The adult tape-worm are found in the intestines of dogs, the primary host, with eggs are
excreted in the feces and more are ingested by human, sheep, cattle, or bigs, which act as intermediate hosts. The eggs
hatch in the duodenum and migrate through the intestinal mucosa and into the portal system, mesenteric venules, and
lymphatics, from where they can spread to any part of the body. The cyst consists of three layers: (1) an adventitial layer
caused by the compressed host tissues, (2) the ectocyst which is an outer laminated membrane and (3) the endocyst or
inner germinal layer responsible for growth of the cyst and development of scolices. Daughter cysts develop within the
mother cyst and finally the cysts die and frequently undergo calcifications (27) .
Involvement of the kidney is rare and usually located in the upper or lower poles. Hydatid cysts are frequently solitary and
located in the cortex and they may reach 10 cm in diameter before any clinical symptoms are noted (26).
The renal hydatid may grow outward and rupture into the retroperitoneum or may rupture into the renal pelvis with
portions of the cyst contents present in the urine. Eighteen percent of renal Hydatid can rupture into the collecting system
Plain film of the abdomen shows a localized bulqe of the renal contour with calcifications which may be curvilinear,
eggshell or reticular in shape. Multiple ring-shaped calcifications within a large calcified lesion suggest presence of
daughter cysts. Crushed eggshell calcification also suggest ruptured cyst (28).
Intravenous urography may show elongation, stretching or splaying of the calyces in a similar fashion to other renal
masses. When the cyst has ruptured, contrast media fill the cyst simulating renal abscess or T.B. cavity with usually a
neck of communication between the cyst and calyces is found (29,30).
US and CT are very accurate in demonstrating renal hydatid cyst which may be unilocular similar to simple cyst but with
thicker wall or multilocular structure with curvilinear septa . US and CT can easily detect the calcifications even minor or
58

faint. If scolices are present, the wall usually shows marked irregularities. Daughter cysts usually arranged peripherally
around the mother cyst. Ring enhancement in CT scan or presence of air bubbles within the lesion are suggestive of
secondary infection and abscess formation. However, in some cases, hydatid cyst may have a complex nature and could
not be differentiated from other atypical renal cystic masses (31,32).
MRI is not as accurate in detecting calcifications as compared to non contrast CT or ultrasound. A low-intensity rim on T2-
WI is suggestive but not pathognomonic of hydatid cyst (33).
Urinary bladder involvement can occur secondary to kidney hydatid after rupture of renal lesion into the collecting system
with secondary spread into the ureter or bladder. However, primary hydatid of these structures is extremely rare. Scrotal
hydatid is extremely rare with only a few case reports of hydatid of the testis found in the literature . The US revealed a
markedly anechoic fluid collection in the left side of the scrotum and freely floating isoechoic serpentine structures (34).
Filariasis:
Filarial infections are widespread in various parts of the world, and probably 200 million people are infected with different
filariae in the tropical and subtropical countries of Africa, Asia, the Pacific Islands, and central and South America. Several
studies have recently shown a clear association of filariasis and glomerular disease (35,36) . This association is often
difficult to establish due to frequent coinfections (hepatitis B and malaria). Except for an occasional report of acute
glomerulonephritis (37), most case reports as well as the studies mentioned described a mesangioproliferative or
membranoproliferative glomerulonephritis . Glomerular disease associated with filariasis is thought by most authors to be
immune complex. Although the most common clinical findings are those related to “elephantiasis”. The urinary tract may
be involved with resultant chyluria, which is the passage of lymphatic fluid in urine associated with lymphatic
abnormalities. Chyluria may be either tropical or non-tropical in nature. The tropical form is by far the most common and
is almost always due to wuchereria buncrofti infection. Non-tropical filarial parasites (Loa, Dipetalonema, Dirofilaria and
Mansonella species) rarely have urogenital manifestations, but Onchocerca volculus. The agent of African river blindness,
is known to causes massive inguinal lymphadenopathy, and scrotal elephantiasis (35). Filariasis results when the Larvae
of W.Bancrofti are transmitted to the lumen by mosquitoes, after which they migrate in the lymphatics and nodes, where
they mature (38).
The pathological findings depend on the cycle of filariae and are due to presence of living or dead larvae or adult worms
in lymphatics. The living worms causes lymphadenitis and lymphangitis with edema, eosinophilic infiltration, and
fibroblastic reaction. When the disease become more chronic and death of the worm occur , there is thickening of the
walls of lymphatics and marked granulomatous reaction in the vascular and lymphatic walls occur. The chronic
complications of filariasis occur 5 to 20 years after the primary infection and include elephatitiasis, chyluria and chylous
ascites and effusion. Enlargement of the penis, scrotum and breasts may be spectacular, in addition to the gross
enlargement of one or more extremities. A histologic finding of adult worms is a diagnostically definitive but insensitive
technique. The presence of Brugia or W. microfilariae in peripheral blood, chylous urin, or hydrocele fluid is also diagnostic
(39).
Plain radiography of the soft tissues shows gross thickening with loss or blurring of the fat planes. Intravenous urography
is usually normal, but pyelolymphatic reflux may be noted. Dilated renal lymphatics may be clearly demonstrated,
particularly when ureteric pressure is applied. Contrast medium may remain within the intrarenal lymphatics for a long
time. These features can also be identified on retrograde pyelography . Lymphangiography may show an increase in the
number of small lymphatic channels, which have a redundant and tortous course. Occasionally, contrast materials will flow
from lymphatics into the kidney and outline the calyces, infundibulae, renal pelves and even the urinary bladder. Whereas
the lymphatics normally emptying in a few hours, there may be a marked delay in emptying of these vessels for several
days in patient with filariasis (37,38). Mild scrotal edema is not unusual during early infection or with established
hydrocele. Penile edema is unusual, and the monstrous elephantine enlargements of the scrotum or penis depicted in
textbooks occur largely in populations without access to medical care (40,41).
Miscellaneous parasites affecting the urinary tract:
Malaria is one of the most prevalent infectious diseases in the world. It is the first parasitic infection that was clearly
shown to be associated with nephrotic syndrome (42). Moreover, areas of the world with a high incidence of nephrotic
syndrome overlap with those where plasmodium malariae occur. Four species of plasmodia are responsible for malaria.
Only two of the malaria parasites, namely, P. malariae (quartan malaria) and P. falciparum (falciparum malaria), are
clearly associated with renal disease, and this occurs only in a small percentage of patients. Renal involvement in the
course of quartan malaria is generally characterized by nephrotic syndrome. A membranoproliferative type of
glomerulonephritis with relatively sparse proliferation of endothelial and mesangial cells is the most common type of
glomerular lesion encountered in quartan malaria. Focal and segmental glomerulosclerosis can be seen as well (43).
Glomerular lesions are observed with visceral leishmaniasis (Kala-azar) caused by leishmania donovani. Cuteneous or
mucocuteneous Leishmaniasis caused by other leishmania species are not associated with renal disease. A prospective
study has shown that 60% of patients with Kala-azar have mild proteinuria with benign changes in the urinary sediment
(Microscopic hematuria and leukocyturia) . The pathological picture is a glomerulonephritis with focal and segmental
collapse of capillary loops (44).
African trypanosomiasis is a protazoal disease caused by motile hemoflagellates of the genus Typansoma. Trypansoma
brucei rhodesiense is the more acute of the two forms, often causing death within 1 year if not treated. The clinical stages
of trypansomiasis range from the trypansomal chancre that appears at the site of inoculation to febrile attacks, diffuse
intravascular coagulation, lymphadenopathy, and eventually progressive brain dysfunction leading to sleeping sickness,
cachexia, and death. Glomerular disease associated with African trypanosomiasis is limited to an occasional report (45).
Toxoplasmosis is caused by Toxoplasma gondii. Infection occurs by the ingestion of cysts or oocycts or by the
transplacental or hematogenous routes. Most recent reports about renal disease associated with T. gondii infection deal
with the problem of acute renal failure due to sulfadiazine crystal deposition in the urinary tract after treatment of
toxoplasma encephalitis with the drug.
Babesia is a thick-borne intraerythrocytic parasite. In Europe, Babesia bovis and divergens are transmitted from cattle to
humens. Asplenic persons are particularly susceptible to this disease.
Trichinosis is an infection of humans and other mammals by Trichinella spiralis. This disease is characterized by diarrhea,
myositis, fever, periorbital edema and myocarditis or encephalitis. A few cases of membranoproliferative
glomerulonephritis associated with trichinosis hve been described (46).
Other parasites may also rarely infest the genitourinary system. The giant kidney worm (Dioctophyma renale) infects
mamdls worldwide, particularly dogs and minks. About 20 human infections have been reported, acquired by eating raw
fish or frogs or less commonly, by drinking contaminated water. Many other fish-eating mammals can be infected, so the
potential for human infection is significant (47).
The clinical and radiologic features of genitourinary tuberculosis, parasitic and other rare infection may mimic those of
many diseases. A high index of suspicion is required, particularly in high-risk populations. Although a positive culture or
59

histologic evidence is still required in many patients to yield a definitive diagnosis, recognition and understanding of the
spectrum of imaging features of genitourinary tuberculosis, which will be outlined in this lecture, are crucial for diagnosis.
References
1. Engin G, Acunas B, Acunas G, Tunaci M. Imaging of extrapulmonary tuberculosis. Radiographics 2000; 20: 471-488.
2. Chung J, Kin M, Lee T, Yoo H, Lee J. Sonographic findings in tuberculous epidymitis and epididymo-orchitis. J Clin
Ultrasound 1997;
25: 390-394.
3. Gibson M, Puckett M, Shelly M. Renal tuberculosis. Radiographics 2004; 24: 251-256.
4. Premkumar A, Lattimer J, Newhouse JH. CT and sonography of advanced urinary tract tuberculosis. Am J Roentgenol
1987; 148: 65-69.
5. Wang L, Wong Y, Chen C. CT features of genitourinary tuberculosis. J Comput Assis Tomogr 1997; 21: 254-258.
6. Brennan R, Pollack H. Nonvisualized “Phantom” renal calyx: causes and radiological approach to diagnosis. Urol Radiol
1979; 1: 17-23.
7. Leder R, Low VH. Tuberculosis of the abdomen. Radiol Clin North Am 1995; 33: 691-705.
8. Das K, Indudhara R, Vaidyanathan S. Sonographic features of genitourinary tuberculosis. AJR 1992; 158: 327-329.
9. Goldman S, Fishman E, Hartman D. Computed tomography of renal tuberculosis and its pathological correlates. J
Comput Assist Tomogr 1985; 9: 771-776.
10. Harisinghani M, McLoud T, Shepard A, Ko FR, Shroff M, Muller P. Tuberculosis from head to tow. Radiographics 2000;
20: 449-470.
11. Roylance J, Penry JB, Davis ER, et al. The radiology of tuberculosis of the urinary tract. Clin Radiol 1970; 21: 163-
170.
12. Wang JH, Sheu MH, Lee RC. Tuberculosis of the prostate: MR appearance. J Comput Assist Tomogr 1997; 21: 639-
640.
13. Premkumar A, Newhouse JH. Seminal vesicle tuberculosis: CT appearance. J Comput Assist Tomogr 1988; 12: 676-
677.
14. Wang JH, Chang T. Tuberculosis of the prostate: CT appearance. J Comput Assist Tomogr 1991; 15: 269-270.
15. Heaton ND, Hogan B, Michell M, et al. Tuberculous epididymo-orchitis: clinical and ultrasound observations. Br J Urol
1989; 64: 305-309.
16. El-Diasty TA, El-Sherbiny AF. Imaging of parasitic diseases of the genitourinary system.In Haddad M, Abd El Bagi M,
Tamraz J (ed.). Imaging of parasitic diseases. Chapter 6, p 139-157, Springer-Verlang Berlin Heidelberg, 2008.
17. Palmer P.E and Reader MM. Parasitic diseases involving the urinary tract. In clinical urography . Pollack H M and
McClennan BL (ed.), vol.1, ch30, p1167-1991, WB. Saunders company, 2000.
18. Shokier AA. Urinary bilhariziasis in upper Egypt (I and II). East Afr Med J 49: 298-326, 1972.
19. Feldmeier H, Krantz I, Poggensee G. Female genital schistosomiasis as a risk-factor for the transmission of HIV. Int J
STD AIDS 5: 368, 1994.
20. Pogensee G, Kiwelu I, Weger V. Female genital schistosomiasis of the lower genital tract: Prevalence and diseaseassociated
morbidity in northen Tanzania. J Infect Dis: 181-210, 2000.
21. Pogensee G and Feldmeier H. female genital schistosomiasis: facts and hypotheses. Acta Trop; 79: 193, 2001.
22. Hugosson CO. Striation of renal pelvis and ureter in bilharziasis. Clin Radiol 38: 407, 1987.
23. Pollack HM. Diagnostic considerations in urinary bladder wall calcification. AJR 136: 791-797, 1981.
24. Jorulf H, Lindsted LE. Urogenital Schistosomiasis: CT evaluation. Radiology 157: 745-749, 1985.
25. Vilana R, Corachian M, Gason J, Valls E and BRU C. Schistosomiasis of the male genital tract: Transrectal sonography
findings. J of Urology 158: 1491-1493, 1997.
26. Polat P, Kantarci M, Alper F, Suma S, Koruyucu MB and Okur A. Hydatid disease from head to Toe. Radiographics 23:
475-494, 2003.
27. Angulo TC, Sanchez-chapado M, Diego A. Renal echinococcosis: Clinical study of 34 cases. J Urol 157: 787, 1997.
28. Hertz M, Zissin R, dresnik Z. Echinococcus of the urinary tracts: radiologic findings. Urol radiol 6: 175, 1984.
29. Von Sinner W, Hellstrom M, Kagevi I. Hydatid disease of the urinary tarcts. J Urol 149: 577-580, 1993.
30. Gilsanz V, Lozano F, Jiminez J. Renal hydatid cyst Communicating with collecting system. AJR 135: 857, 1980.
31. Karabekias S, Gouliamos A, Kalovidouris A. Features of computed tomography in hydatid cysts. J Comput Assist
Tomogr 10: 428, 1986.
32. King DL. Ultrasonography of echinococcal cyst. J Clin Ultarsound 1: 64-67, 1989.
33. Marani SAD, Canossi GC, Nicoli FA. Hydatid disease: MR imaging study. Radiology 175: 701-706, 1990.
34. Kumar PV, Tahanshahi S. Hydatid cyst of testis: A case report. J Urol 137: 511-512, 1987.
35. Data A, Kirubakaran, MG, Gunasekaran, V and Shastry JCM. Acute esinophilic glomerulonephritis with Bancroftian
filariasis. Postgard Med J 55: 905-907, 1979.
36. Ngu JL, Chatelanat F, Ndumbe P and Youmbissi J. Nephropathy in Cameroon: evidence for filarial derived immunecomplex
pathogenesis in some cases. Clin Nephrol 24: 128-134, 1985.
37. Amaral F, Dreyer G, Figuerido –Silva J. Live adult worms detected by ultrasonography in human bancroftian filariasis.
Am J Trop Med Hyg 50: 753, 1994.
38. Chen KC. Lymphatic abnormalities in patients with chyluria. Urology 106: 111-14, 1971.
39. Dalela D, Kumar A, Ahawat R. Routine radio imaging in filarial chyluria: Is it necessary in developing countries Br J
Urology 69: 291-293, 1992.
40. Koga S, Nagata Y, Arakaki Y. Lymphangiography of filarial chyluria: Injections via right and left feet at different times.
Br J Urol 69: 318, 1992.
41. Kazura J, Bockarie M, Alexander N. Risk factors for acute morbidity in bancroftial filiariasis. Am J Trop Med Hyg, 53:
100, 1995.
42. Kibukamusoke JW, Hunt MSR and Wilks NE. e nephritic syndrome in Uganda and its association with quartan malaria.
J Med 36:393-408, 1967.
43. Saggie JL and Dwomoa A.nephrotic syndrome in tropics, P. 635-695. In Cameron JS and Glassock RJ (ed.), The
nephrotic syndrome. Marcel Dekker, Inc., New York, N.Y., 1988.
44. Dutra M, Martinelli R, Varvalho M. enal involvement in visceral Leishmaniasis. Am J Kidney Dis, 6: 22-27, 1985.
45. Costa RS, Monterio RC, Lehuen A.Immune complex-Mediated glomerulopathy in expermintal Chagas disease. Clin
immunopathol 58: 102-114, 1991.
46. Kociecka W, abryel P, Leszyk A, stowska I.A case of fatal trichinosis with early renal failure and involvement of the
central nervous system. Wiad Parazytol. 33: 545-551, 1987.
47. Sun T, Turbull A, Liebeiman PH. ant Kidny Worm (Dioctophyma renal) infection mimking retropritoneal neolasm. Am J
Surg Pathol 10:508-12, 1989.
60

OTHER INFLAMMATORY CONDITIONS OF THE URINARY TRACT
Wasserman N.F.
University of Minnesota, USA
This short presentation will call attention to some of the more unusual noninfectious inflammatory conditions affecting the
urinary tract including Ureteral Pseudodiverticulosis (UPD), Karatinizing Desmoplastic Squamous Metaplasia (KDSM),
Malakoplakia, Amyloidosis. The emphasis of this talk will be on
noninfectious disorders intrinsic to the urinary tract, especially UPD, Malakoplakia, and KDSM.
UPD
UPD are defined as < 5mm acquired outpouchings of the ureter. They may be multiple, single, unilateral or bilateral.
They usually are incidental imaging findings on contrast urography in patients undergoing work-up for benign prostatic
hyperplasia (BPH), hematuria, renal colic, urinary tract infections or malignancy. A 25% association with synchronous or
metachronous urothelial carcinoma has been described. Most commonly the associated tumor is transitional cell
carcinoma (TCC) and located in the bladder. However, TCC has been found in the ureter , renal pelvis and calyces, and a
case of squamous cell carcinoma (SCC) has been associated with UPD in the ureter.
Tiny UPD can be found in up to 11% of specimens of postmortem ureters, and are seen as pinpoint openings by gross
visual inspection. Micropathology demonstrates that they are formed by distensension of hyperplastic submucosal glands
of von Brunn which directly connect with the ureteral lumen. Associated microscopic (but not gross) changes of ureteritis
cystica and glandularis are seen in the involoved areas. This supports the conclusion that UPD form as a result of chronic
inflammation and enlarge to grossly detectable size under the influence of obstruction downstream or chronic reflux
raising intralumenal pressures.
UPD are best identified in retrograde urograms, but can be seen in IV urography. Recently UPD have been visualized and
confirmed on multidetector CT urography.
It is important to not only correctly identify UPD, when present, but communicate to the referring physician or urologist
the importance of a complete investigation for TCC, including cystoscopy and urine cytology. Further, it is most important
to stress in the imaging report that a negative baseline work-up should be followed by indefinite survielance, as
metachronous tumor has been reported up to 10 years after UPD discovery.
Malakoplakia
Malakoplakia is a rare chronic inflammatory granulomatous disorder first reported by von Hansemannin 1901 and
described in greater detail by Michaelis and Gutmann in 1902. It is commonly thought to be due to an exaggerated
response to infection. The urinary tract is involved in 60% of cases, the urinary bladder being the most commonly affected
site, followed in descending order of frequency by the renal pelvis and kidney, ureter, testes, prostate, and urethra.
Grossly, the lesions occurring on mucosal surfaces are seen as raised, frequently multiple, soft plaques. The plaques are
typically yellow or brown and are frequently multicentric. It often mimics malignancy and may also affect other organs
including the gastrointestinal tract, bone, lungs, lymph nodes and skin.
Malacoplakia is thought to result from inadequate intracellular killing of phagocytosed bacteria by monocytes and
macrophages, leading to the accumulation of calcium and iron on bacterial glycolipid within cellular phagolysosomes.
The final diagnosis is histological. Microscopically, there are characteristic inclusions termed Michaelis-Gutmann bodies,
which are the most salient pathologic finding of malacoplakia. Michaelis-Gutmann bodies (M-G bodies) are
concentrically layered basophilic inclusions found in the urinary tract. They are 2 to 10 μm in diameter, and are thought to
represent remnants of phagosomes mineralized by iron and calcium deposits.Although the cause has not yet been
established, a close relationship between prostatic malacoplakia and urinary tract infection with E coli has been shown,
although most patients have some form of immunosuppression related to organ transplantation, autoimmune diseases
requiring steroid use, or chemotherapy. It has been reported in association with HIV/AIDS. Malakoplakia has also been
associated with colon carcinoma, bladder tumors, TB, poorly controlled dibetes, rheumatoid arthritis, and lymphoma.
The treatment of renal parenchymal malakoplakia may be grouped into four categories: improvement of
immunodebilitatating state, antibiotic therapy adapted to cultured micro-organisms, especially antibiotics with high
intracellular diffusion, vitamin C and/or bethanechol, which restore impaired phagocytic function by increasing intracellular
cyclic guanosine monophosphate (cGMP/cAM) ratio, and drainage of associated abscess, or surgical resection when there
is no response to medical therapy.
Pyeloureteritis Cystica
Pathologically, the lesions in question are benign suburoeipthelial cysts containing a clear proteinaceous fluid. These are a
common finding at the time of cystoscopy and known as (cystitis cystica). These are common finding in the bladder on
cystoscopy, commonly located in the trigone and vicinity of the ureteral orifices, but rare in the ureter and renal pelvis.
The pathogenesis is unclear, but is speculated to be related to irritative effects of chronic urinary tract infection
culminating in chronic mucosal irritation from inflammation. A common association of longstanding foreign bodies such as
percutaneous or ascending intralumenal stents has been noted. Diabetics seem to be predisposed. The findings are most
common in females. The most common infectious organism is E-coli.
Gross examination reveals 1-2 mm, discrete translucent, grayish round superficial cysts. The natural history and
mechanism of cyst formation is speculative. Some attribute cyst development to inward invaginations of clusters of
epithelial cells (glands of von Brunn), which become detached from the mucosa and subsequently undergo degeneration.
Consequently, epithelial blind cysts are found in a submucosal location. Others describe degeneration and cavitation of
metaplastic surface urothelium or submucosal vonBrunn’s cell nests. Once formed, the cysts may persist for an
indefinate period.
Because of their small size, the cysts, though common in the bladder, are rarely visible on radiographic imaging.
However, in the upper collecting system they present as tiny discrete round to ovoid filling defects on IV, retrograde or
percutaneous antegrade urography. They may also be visible on computed urography.
The differential diagnosis includes: 1) other submucosal entities such as submucosal hemorrhage, often secondary to over
anticoagulation (which usually disappear with better control of anticoagulation), 2) mucosal abnormalities such as
multifocal transitional cell carcinomas or malakoplakia, 3) intralumenal processes such as air bubbles secondary to
antegrade or retrograde contrast injection (which tend to change position freely from one image to another), blood clots
and stones. 4) Extrinsic impressions producing scalloping secondary to collateral veins or arteries must also be excluded.
Pyleoureteritis cystica may be distinguished from multifocal malakoplakia by clinical context of active infection, the
distinctly less common presence of the latter in the upper urinary tract and appearance. Pyeloureteritis cystica filling
defects are more individually separable and hemispheric in contour. Malakoplakia tends to be more confluent and angular
or irregular.
KDSM
61

Keratinizing desquamative squamous metaplasia (KDSM) is a term for a rare condition of the upper urinary tract that
encompasses several previously described keratinizing uroepithelial lesions, including cholesteatoma, hyperkeratosis,
squamous metaplasia, and leukoplakia, The latter diagnosis is considered a premalignant lesion in the oral cavity.
However, there is no evidence in the medical literature that leukoplakia is premalignant in the urinary tract.
Hertle and Androulakakis, in an effort to bring order to the situation, introduced the term keratinizing desquamative
squamous metaplasia (KDSM) of the upper urinary tract and gave it a distinct histopathologic definition. "Squamous
metaplasia, keratinization and desquamation, therefore, are common denominators of the leukoplakia/cholesteatoma
lesions described in the upper urinary tract, and they can be expressed appropriately together under the term keratinizing
desquamative squamous metaplasia (KDSM)". To be KDSM, there must be no histologic evidence of atypia.
The cause of KDSM is unknown. Speculation has included reactive or spontaneous epithelial change or congenital rests of
squamous cell anlagen. There is an association with chronic infection, urolithiasis, and hydronephrosis
Keratinizing desquamative squamous metaplasia is rare. It is generally found between the third and sixth decades, with a
3:2 male/female predominance. The renal pelvis is the most common site; the left side is affected slightly more commonly
than the right. Flank pain, passage of cornified material in the urine, and a filling defect on intravenous urography are the
most common findings. The radiologic appearance of the defect is not specific, but is typically an irregular, stringy, or
laminated plaque arising from a portion of the calyx or renal pelvis.
Radiologic differential diagnosis must include neoplasm, fungus ball, clot, and other nonopaque filling defects. However,
the diagnosis can be suggested in the proper clinical setting and the surgeon alerted to the possibility that conservative
surgery may be appropriate. Calcification of a keratinized plaque is infrequently visible.
The treatment of choice was previously nephroureterectomy, based on the fear that the lesion is premalignant. If one
adheres to the strict definition of KDSM, the disease is benign. Though elements of KDSM with underlying mucosal atypia
have been reported in patients operated on for squamous cell carcinoma of the urothelium, progression from KDSM to
malignancy has not been demonstrated histologically. Because of this, there has been a recent call for conservative
management. Treatment by extracorporeal surgery and autotransplantation has been used in the past. Today, minimally
invasive procedures such as percutaneous or ureteroscopic removal of the keratinized tissue or laparoscopic surgery may
be used to avoid open surgery The incidence of recurrence is reduced if the squamous epithelium is removed as well as
the keratinized mass. Some have advocated no treatment other than imaging and urologic surveillance in asymptomatic
patients.
It is thus important for radiologist to include KDSM in their differential diagnosis in patients with filling defects in the renal
pelvis suggest in their report that careful attention to the possibility of keratin fibers in the urine be made before
considering retrograde ureteroscopy and biopsy.
Amyloidosis
Amyloidosis can occur as its own entity or "secondarily" as a result of another illness, including multiple myeloma, chronic
infections such as tuberculosis or osteomyelitis, or chronic inflammatory diseases such as rheumatoid arthritis and
ankylosing spondylitis.
The modern classification of amyloid disease tends to use an abbreviation of the protein that makes up the majority of
deposits, prefixed with the letter A. For example amyloidosis caused by transthyretin is termed "ATTR". Deposition
patterns vary between patients but are almost always composed of just one amyloidogenic protein. Deposition can be
systemic (affecting many different organ systems) or organ-specific. Many amyloidoses are inherited, due to mutations in
the precursor protein. Other forms are due to different diseases causing overabundant or abnormal protein production -
such as with over production of immunoglobulin light chains in multiple myeloma (termed AL amyloid), or with continuous
overproduction of acute phase proteins in chronic inflammation (which can lead to AA amyloid).
Sephardic Jews and Turks inherit a genetic disease called Familial Mediterranean Fever, which is associated with
amyloidosis and characterized by episodes of "attacks" of fever, joint, and abdominal pains. These attacks can be
prevented with the medication colchicine. Armenians and Ashkenazi Jews also have a higher incidence of Familial
Mediterranean Fever attacks but do not suffer amyloid deposition disease.
Symptoms in patients with amyloidosis result from abnormal functioning of the particular organs involved.
Diagnosis of amyloidosis is made with a biopsy of involved tissue. Biopsies are taken from affected organs or often in the
case of systemic amyloid, from the rectum, gingiva, or omentum. Amyloid can be diagnosed on microscopic examination
of affected tissue. Amyloid deposits can be identified histologically by Congo red staining and viewing under polarized
light where amyloid deposits produce a distinctive apple green birefringence. Other more specific tests are available to
more precisely identify the amyloid protein. In addition, all amyloid deposits contain serum amyloid P component (SAP),
a circulating protein of the pentraxin family. Radionuclide SAP scans have been developed which can anatomically localize
amyloid deposits in patients.
Treatment options for amyloidosis depends on the type of amyloidosis and involves correcting organ failure and treating
any underlying conditions.
References:
UPD
Wasserman NF. Pseudodiverticulosis: unusual appearance for metastases to the ureter. Abdominal Imaging. 1994;
19(4):376-378
Wasserman NF. Zhang G. Posalaky IP. Reddy PK. Ureteral pseudodiverticula: frequent association with uroepithelial
malignancy. AJR. American Journal of Roentgenology. 1991; 157(1):69-72
Wasserman NF. Posalaky IP. Dykoski R. The pathology of ureteral pseudodiverticulosis.
Investigative Radiology. 1988; 23(8):592-598
Kenney PJ. Wasserman NF. Ureteral pseudodiverticulosis associated with carcinoma of renal pelvis.
Urologic Radiology. 1987; 9(3):161-163
Wasserman NF. La Pointe S. Posalaky IP. Ureteral pseudodiverticulosis. Radiology. 1985; 155(3):561-566
Lester PD, Kyaw MM. Ureteral diverticulosis. Radiology 1973; 106:77-80.
Cochran ST. Waisman J, Barbaric ZL. Radiographic and microscopic findings in multiple ureteral diverticula. Radiology.
1980; 137:631-636.
Holly LE, Sumcad B. Diverticular ureteral changes: a report of four cases. AJR 1957; 78:1053-1060.
Malakoplakia
Takamitsu Inuoe, Hiroyuki N,1 Koji Yoshimura,1 Noriyuki Ito,1 Toshiyuki Kamoto,1 Tomonori Habuchi2 and Osamu
Ogawa1 Solitary upper ureteral malakoplakia successfully diagnosed by ureteroscopic biopsy and treated conservatively.
International Journal of Urology 2007; 14, 859–861
MRI appearances of pelvic malakoplakia
K Gopal, FRCR, M Dobson, FRCR, P M Hersch, FRCS and H Stringfellow, MRCP(Path). The British Journal of Radiology.
2006; 79:e205–e207
62

Bruce Siders, DO, Thomas Win, MD, Ronney Abaza, MD. Sonographic Evaluationof Epididymal Malakoplakia. J Ultrasound
Med 2005; 24:1003–1005
Blair JE. Maclennan GT. Malakoplakia. Journal of Urology. 2005; 173(3):986
Wielenberg AJ., Demos T C, Rangachari B, Thomas T. Malacoplakia Presenting as a Solitary Renal Mass. Am. J.
Roentgenol., Dec 2004; 183: 1703 – 170
Burdese M, Repetto L, Lasaponara F, Maass J, Bergamo D, Mezza E, Jeantet A, Segoloni GP, Piccoli GB. The deceiving
image: asymptomatic renal malakoplakia in a patient with chronic renal failure. Nephrol. Dial. Transplant., Aug 2003; 18:
1675 - 1676.
McKeen SK. Tie ML. Renal parenchymal malakoplakia: an unusual cause of unilateral, diffuse renal enlargement.
Australasian Radiology. 2002; 46(1): 69-72.
Barnard M, Chalvardjian A. Cutaneous malakoplakia in a patient with acquired immunodeficiency syndrome (AIDS). Am J
Dermatopathol 1998;20:185–8.
Albitar1 S, Genin R, Fen-Chong M, Schohn D, Riviere J-P, Serveaux M-O, Chuet C. The febrile patient presenting with
acute renal failure and enlarged kidneys—another mode of presentation of malakoplakia. Nephrol Dial Transplant. 1997;
12: 1724–1726
Stanton MJ, Maxted W: Malakoplakia: A study of the literature and current concepts of pathogenesis, diagnosis and
treatment. J Urol 1981; 125:139-146,
Michaelis L, Gutmann C. Ueber Einschlusse in Blasentumoren. Ztschr Klin Med 1902; 47: 208–15.
Pyeloureteritis Cystica
Clinical Urography. H M Pollack, Ed. W.B Saunders Co., Harcourt Brace Jovanich, Inc. Philadelphia, 2000
KDSM
Borofsky M. Shah RB. Wolf JS Jr. Nephron-sparing diagnosis and management of renal keratinizing desquamative
squamous metaplasia. Journal of Endourology. 2009; 23(1):51-5
Boswell PD, Fugitt B, Kane CJ. Keratinizing desquamative squamous metaplasia of the kidney mimicking transitional cell
carcinoma. Urology 1998;52:512–513.
Angulo JC, Santana A, Sanchez-Chapado M. Bilateral keratinizing urinary tract. J Urol 1997;158:1908–1909.
Neerhut G, Politis G, Alpert L, Griffith DP. Cholesteatoma of the renal pelvis: Endoscopic management. J Urol
1988;139:1032–1034.
Haugen SG. Wasserman NF. Keratinizing desquamative squamous metaplasia of the upper urinary tract. Urologic
Radiology. 1986; 8(4):211-3,
Gagnon J. Laperriere J. Alcaidinho D. Drouin G. Lefebvre R. [Ureteral stenosis caused by epidermoid metaplasia of the
urothelium]. [French]. Journal de Radiologie. 65(3):207-9, 1984
Hertle L, Androulakakis P. Keratinizing desquamative squamous metaplasia of the upper urinary tract:
leukoplakiacholesteatoma. J Urol 1982;127:631-635,s JS, Pollack HM, Curtis JA:
Wills JS, Pollack HM, Curtis JA: Cholesteatoma of the upper urinary tract. A JR 136:941-944, 1981
Taguchi Y, Kotha V, Tomka B, Seemayer T: Conserving nephrons in cholesteatoma. J Urol 1980; 123:258-260,
Noyes WE, Palubinskas AJ: Squamous metaplasia of the renal pelvis. Radiology 1967; 89:292-295
Osius TG, Harrod CS, Smith DR: Cholesteatoma of the renal pelvis. J Uro1 1962; 87:774-778
Denes FT: Keratinizing squamous metaplasia of the upper urinary tract. Int Urol Nephrol 1984; 16(1):23-28,
Amyloidosis.
Sueoka BL, Kasales CJ, Harris RD, Heavey JA. MR and CT imaging of perirenal arnyboidosis.
Urol Radiol 1989; 11:97-99J
Davis PS. Babaria A. March DE. Goldberg RD. Primary amyloidosis of the ureter and renal pelvis. Urologic Radiology.
1987; 9(3):158-60
Pirnar T. Coruh M Radiological findings in renal amyloidosis of children. Pediatric Radiology. 1973; 1(3):172-7
Pear BL. The radiographic manifestations of amyloidosis. AJR 1971; 111:821-832
GENETIC DISEASES & DRUG – INDUCED DISORDERS
Moderators: Morcos S.K. (UK) – Koumanidou C. (GR)
HEREDITARY DISORDERS OF THE PEDIATRIC URINARY TRACT
Riccabona M.
University Hospital Graz, Austria
There are many congenital urinary tract disorders in children. Some of them already manifest during pregnancy, some are
detected shortly after birth or during infancy, some become obvious during infancy, and some may only manifest later in
life. Only a part of them are genetic, and again not all genetic conditions are hereditary, and in some familial or
syndromatic conditions the genes have not yet been found, though there is an obvious hereditary component. And some
are systemic conditions that (also) manifest inn the urinary tract, particularly the kidneys.
The aim of this lecture is to list some important diseases such as Alport syndrome or familial hematuria and their
manifestation, to present the typical imaging appearance, and to discuss the need for follow-up. Rare conditions such as
nail patella syndrome, collagen type III glomerulopathy, Fabry disease, or Biedl-Bardet syndrome will not be discussed.
Ultrasound is the paediatric radiologist’s working horse and the mainstay of imaging these conditions; however – for
diagnosis or differential diagnosis, for follow-up or assessment of progression and complications other modalities or even
invasive procedures may become indicated such as VCUG, MRU, CT, interventional radiology or biopsy.
Some conditions can readily be recognised by imaging, such as the neonatal manifestation of autosomal polycystic kidney
disease, some may exhibit a varying degree of more or less typical features such as tubular deposits in thyrosinosis or
renal angiomyolipoma in tuberous sclerosis that may lead the way for further assessment and eventually establishing the
diagnosis. In some conditions only secondary signs indicate imaging such as urolithiasis in oxaluria or cystinuria, and the
diagnosis is then established by laboratory investigations. Some may present completely unspecific and eventually are
diagnosed by histology (e.g., after renal biopsy) or genetic work-up. And some systemic (hereditary) conditions may
cause unspecific alterations of the kidney appearance on imaging that needs to be recognised and not mistaken for
another disease (e.g., sickle cell nephropathy that mimics nephrocalcinosis). Finally, some remain silent until they
eventually may manifest in adulthood or even only in the next generation. Furthermore, some syndromes such as Denys
Drash Syndrome carry the risk of developing renal diseases or tumours thus indicating regular imaging monitoring,
63

without other obvious imaging manifestation in the child’s urinary tract. Thus a standardised general approach to imaging
all these conditions is not achievable, and imaging will become indicated depending on clinical symptoms and signs,
prenatal suspicions or as part of screening programs, and family history.
The most important aspect is that (paediatric) uroradiologists need to be familiar with and knowledgeable about these
conditions so that they can recognise them or depict features that may indicate the need for further focused investigation.
With the upcoming new therapies for some of these conditions this will become increasingly important, as early
recognitions and therapy may prevent severe progression and will play an important role in preventing or at least delaying
renal insufficiency.
RENAL CYSTIC DISEASE
Heinz-Peer G.
Department of Radiology, Medical University of Vienna, Austria
Renal cysts, cystic disease, and cystic masses are very common findings in uroradiology. In some cases, the renal cysts
are part of a systemic process that also involves the kidneys. In most patients, however, one or several cystic masses are
detected, and the question is whether the lesion is benign or malignant.
The classification of renal cystic diseases reflects both morphologic features and pathophysiology.
Cortical cysts
The most common renal mass lesion is a simple cortical cyst. Cortical cysts are uncommon in children and young adults,
but are estimated to occur in 50% of the population older than 50 years of age. Thus, they are considered acquired
lesions and probably arise from obstructed ducts or tubules.
Simple cysts contain clear fluid and do not communicate with the collecting system. Usually simple cysts are an incidental
finding on ultrasound (US) and computed tomography (CT) performed for other reasons, and of no clinical significance. On
CT, findings that are diagnostic of a simple renal cyst include a water-dense mass that does not enhance and has an
imperceptible or barely perceptible peripheral margin.
Cystic renal masses with more complex imaging features have been studied extensively with CT. The Bosniak
classification system is useful for categorizing these lesions as to their etiology and for management guidelines.
Class I is a simple cyst.
Class II lesions have multiple septations and thin peripheral calcifications, are typical high density cysts, or have features
typical of infected cysts. On CT examination, one can be confident that these Class II lesions are benign. However, followup
CT scanning of these Class II complex cysts is recommended in 6 to 12 months to exclude progression (IIF).
Septations and high density internal material are thought to develop after cyst infection or hemorrhage, which leads to
the development of fibrinous internal septa, dystrophic calcifications in the wall of the cyst, or internal proteinaceous
material reflected by high density on unenhanced CT scans. The high density cysts are the most problematic for the
radiologists. On unenhanced scans they appear to be of higher density than the kidney, and on contrast enhanced CT they
are hypodense to the kidney and there is no internal enhancement of these lesions.
Class III lesions have more complex imaging characteristics, including dense, thick calcifications, numerous septa, or solid
components that do not enhance. Approximately 50% of these lesions are cystic renal cell carcinomas (RCCs). The
remainder are benign lesions, such as cysts complicated by infection or hemorrhage, or a benign tumor known as
multilocular cystic nephroma. There is no reliable way to distinguish these lesions without surgery. Because many of them
are benign, renal-sparing surgery can be considered for these patients.
Class IV lesions always are considered malignant. The major criterion of a Class IV lesion is an area of enhancing solid
tissue. With cystic neoplasms, this tissue often is at the periphery, and enhancement may be subtle. Careful evaluation of
the margins of the cystic mass on enhanced CT scans is necessary.
20% of RCCs appear predominantly cystic on CT examination. Seventy-five percent of these are solid RCCs that have
undergone central liquefaction necrosis. With growth, these lesions tend to outstrip their blood supply, and central areas
become ischemic and necrotic. The remaining lesions are truly cystic RCCs. This subgroup usually has a papillary cellular
growth pattern, which has been associated with a decreased rate of metastases and has better prognosis than other forms
of RCC. Papillary RCCs also are often multifocal. These masses usually are hypovascular, even after attaining a large size.
In addition, cysts may be associated with renal malignancies in other ways. Because renal cysts are common, cysts and
tumours in the same kidney usually are not related. A renal tumour may occur adjacent to a solitary or dominant cyst.
Because recognition of these cysts may lead to detection of the nearby renal tumour, these focal, solitary cysts
sometimes are referred to as “sentinel” cysts.
Some conditions cause formation of renal cysts and renal neoplasms. This category includes von Hippel-Lindau disease,
tuberous sclerosis, and acquired cystic kidney disease in long-term dialysis patients.
Finally, the rarest cyst-renal neoplasm association is the formation of a RCC in the wall of a preexisting simple renal cyst.
Peripelvic or Parapelvic Cysts
Peripelvic cysts or parapelvic pseudocysts are thought to be acquired lesions secondary to prior obstruction, with
subsequent urine extravasation. Those found in the renal hilar area may be lymphatic in origin. Parapelvic cysts are
extremely rare in children, but they display the same CT features as cortical renal cysts. They have near-water
attenuation values and are not enhanced after contrast administration. They may be single, multiple, or even multilocular.
Commonly, displacement or replacement of the renal sinus or hilar fat is seen as the parapelvic cyst insinuates itself
among the infundibulae and intrarenal blood vessels within the renal sinus. Contiguous calices may simulate thick cyst
walls. Parapelvic cysts may be bilateral and on occasion may communicate with the collecting system. On non-contrast CT
images, parapelvic cysts may mimic hydronephrosis or a large extrarenal pelvis.
Polycystic Renal Disease
Adult Polycystic Kidney Disease
APCKD usually is a bilateral process, although unilateral involvement has been described. Frequently there is no evidence
of renal failure at the time of diagnosis. The disease tends to involve other organs, namely, the liver, spleen, and
pancreas. When patients with the disease are examined with CT, the search often is for focal neoplastic change, abscess,
stone, or hemorrhage, particularly in the symptomatic patient. Kidneys may vary in size from normal to massively
enlarged. The cysts vary in number, but usually are multiple, unequal in size, and scattered throughout the parenchyma.
The cysts may calcify, and asymmetrical involvement of the two kidneys may occur.
All patients with APCKD have progressive renal failure. The rate of progression of the azotemia is related to the age of
onset; those patients whose symptoms begin after 50 years of age have a better prognosis. Although the incidence is
variable, approximately one half of patients with APCKD have cerebral (berry) aneurysms in the circle of Willis, and stroke
64

from rupture of a berry aneurysm is a significant cause of morbidity and mortality. Renal stones occur more frequently in
patients with APCKD than in the general population. Because more than one half of these stones are predominantly uric
acid, they may be radiolucent and may be overlooked on an abdominal radiograph. Using CT, Levine and Grantham found
renal calculi in 36% of patients with APCKD.
CT has the advantage of clearly demonstrating the cysts and collecting systems of both kidneys. Precontrast scans are
needed to demonstrate renal stones and facilitate the diagnosis of hemorrhagic cysts. Because the kidneys are typically
studded with innumerable cysts that abut each other, some of the cysts are not round in shape, but assume a variety of
irregular contours. CT is also helpful in demonstrating cystic involvement of other organs.
Bleeding into renal cysts is common and may be the source of acute flank pain. If the cyst ruptures into the renal pelvis,
hematuria will occur. Cyst hemorrhage may be more common in patients with APCKD because of the associated
hypertension or the increased bleeding tendency of uremia or heparinization during dialysis. However, in the work-up of
hematuria in patients with APKD renal neoplasm has to be excluded, although there is no increased risk for malignancy.
Hemorrhagic renal cysts may be seen in 70% of patients with APCKD.
Autosomal Recessive Polycystic disease
Autosomal-recessive or infantile polycystic disease (IPCD) includes a spectrum of abnormalities ranging from newborns
with grossly enlarged spongy kidneys to older children with medullary ductal ectasia. The older children also develop
hepatic fibrosis that progresses to portal hypertension.
Congenital hepatic fibrosis may represent yet another disease transmitted by autosomal-recessive inheritance in which the
renal disease is different and milder than IPCD. Patients with IPCD have renal failure at birth and most die within the first
few days of life. Among older children fewer than 10% of the renal tubules are affected and hepatic fibrosis dominates the
clinical course. The kidneys are only mildly enlarged, but contain variably sized cysts that are predominantly medullary in
location.
Multicystic Dysplastic Kidney
A multicystic dysplastic kidney (MCDK) consists of a collection of irregularly sized cysts and fibrous tissue, but no
functioning renal parenchyma. The anomaly results from occlusion of the fetal ureters usually before 8 to 10 weeks of
gestation. Malformations including bilateral MCDK, ureteropelvic junction obstruction, hypoplasia of the opposite kidney,
and horseshoe kidney are commonly associated with MCDK.
The multiple cysts with thick septa are nicely demonstrated by CT. Mural calcifications can be demonstrated in the cyst
walls, but there is no evidence of contrast excretion. Most cases of MCDK discovered in the older child or the adult will
have one or more ring calcifications.
Multilocular Cystic Nephroma
This uncommon lesion has been described by various names including multilocular renal cyst, cystic adenoma,
lymphangioma, segmental multicystic kidney, segmental polycystic kidney, cystic hamartoma, benign cyst nephroma, and
Perlman´s tumor. It is a congenital renal lesion that is not genetically transmitted.
The CT appearance is usually characteristic. The masses are large, averaging approximately 10 cm in diameter. They are
sharply delineated from the normal renal parenchyma. MLCN is hypovascular, but the septations enhance after i.v.
contrast injection. Calcification is uncommon in pediatrics, however, a common finding in adults. MLCN must be
differentiated from a cystic renal adenocarcinoma
Medullary Cystic Disease
This disease complex includes medullary cystic disease and related diseases such as juvenile nephronophtisis and retinalrenal
dysplasia and is characterized by dilation of the terminal portion of the collecting tubules. The kidneys are small to
normal in size. A variable number of cysts, up to 2 cm in diameter, are located primarily in the medulla. Calculi frequently
are discovered within the dilated spaces. The cortex is thin but does not contain cysts.
Acquired Renal Cystic Disease (ARCD)
Cystic replacement of kidneys in patients on chronic intermittent hemodialysis occurs in a large percentage of patients.
The prevalence of ARCD significantly increases with prolonged duration of dialysis. Although the mechanism of cyst
formation in these uremic patients is unknown, it is postulated that dialysis incompletely removes toxins.
Solid tumors are also seen with increased frequency, up to 7%.
The ultrasonographic examination of native kidneys is difficult, because they often are small, distorted, and surround by
highly echogenic fat. There is an increased incidence of hemorrhage into renal cysts or perinephric space. Calcification
frequently occurs in the cyst walls or in the renal interstitium.
It is easier to examine the native kidneys with CT than with ultrasound. Multiple small cysts are seen by CT. Dystrophic
calcifications are common in the renal parenchyma or cyst walls. Bleeding is a common complication. Carcinomas are seen
as masses with a density similar to the unenhanced parenchyma.
Cysts Associated with Systemic Disease
The phakomatoses are a group of neurologic disorders that include congenital abnormalities of the skin and other organs.
Tuberous sclerosis and von Hippel-Lindau disease are associated with renal cysts. In tuberous sclerosis, approximately
80% of patients have renal angiomyolipomas, which may cause hematuria. The cysts in tuberous sclerosis are small and
seldom exceed 3 cm in diameter. They have a distinctive microscopic appearance with hyperplastic epithelium. Severe
renal involvement can lead to renal failure.
CT often is used to confirm the presence of angiomyolipoma by demonstrating the fatty nature of the tumor. Tumors
without fat will be indistinguishable from renal adenocarcinomas.
Von Hippel-Lindau syndrome (VHL) consists of cerebellar and retinal hemangioblastomas, renal carcinomas,
pheochromocytomas, and a variety of visceral cysts, including renal cysts. The renal tumours often are bilateral and are
usually multifocal. Other urologic manifestations include adrenal pheochromocytomas and papillary cystadenomas of the
epididymis.
The renal cysts, which usually range in size from 0.5 to 3.0 cm, are reported in approximately 60% of patients with VHL.
They demonstrate a continuum from simple cysts to carcinoma manifesting as complex papillary projections into the
cystic lumen. Radiographic evaluation of patients with VHL disease is difficult. Narrowly collimated CT is probably the most
useful modality for this purpose. However, the tumours often are small and difficult to distinguish from cysts. Levine and
coworkers recommend annual follow-up CT examination of any lesions that do not satisfy the criteria for a benign cyst or
an unequivocal neoplasm.
Summary
Cystic renal lesions are most often simple or complicated cysts, which can be seen solitary or as part of cystic renal
disease. The classification of cystic renal masses by Bosniak (category I-IV) based on specific ultrasound and CT features
65

is very useful for the characterization of the lesion and for the therapeutic decision. The main objective of this
classification is to differentiate nonsurgical (category II) from surgical cystic masses (category III/IV). Ultrasound is the
first modality of choice in the diagnostic work-up of cystic renal masses, because an accurate and economically reasonable
diagnosis of the frequent simple cyst can be made by maintaining rigid ultrasound criteria of the Bosniak classification. If
a complicated cyst or a cystic tumor is suspected further evaluation by multiphasic CT or in particular cases by MRI is
indicated. The goal of the radiologist in evaluating cystic lesions is to distinguish malignant neoplastic cystic masses from
non-neoplastic complicated cysts. 20% of RCCs appear predominantly cystic. In addition, some conditions cause formation
of renal cysts and renal neoplasms. This category includes von Hippel-Lindau disease, tuberous sclerosis, and acquired
cystic kidney disease in long-term dialysis patients. CT and MRI allow the early detection of small malignant lesions in
these patients.
Learning objectives:
1 To give an overview of the various renal cystic diseases
2 To evaluate complications frequently associated with renal cystic disease
3 To assess the role of imaging techniques in distinguishing cystic benign lesions from more complex lesions and
cystic malignant tumors
References:
1. Boniak MA: The current radiological approach to renal cysts. Radiology 1986; 158:1-10.
2. Levine E, Grantham JJ: High-density renal cysts in autosomal dominant polycystic kidney disease demonstrated
by CT. Radiology1985; 154:477-
3. Levine E, Grantham JJ: Calcified renal stones and cyst calcification in autosomal dominant polycystic kidney
disease: clinical and CT study in 84 patients. AJR 1992; 159:77-81
4. Levine E, Grantham JJ: High density renal cysts in autosomal dominant polycystic kidney disease demonstrated
by CT. Radiology 1985;154:477-482
5. Grantham JJ: Autosomal Dominant Polycystic Kidney Disease. In: N Engl J Med 2008;359;14:1477-1485
6. Chapman AB: Autosomal Dominant Polycystic Kidney Disease: Time for a Change In: J Am Soc Nephrol
2007;18:1399-1407
7. O'Neill WC, Robbin ML, Bae KT, Grantham JJ, Chapman AB, Guay-Woodfort LM, Torres VE, King BF, Wetzel LH,
Thompson PA, Miller JP: Sonographic Assessment of the Severity and Progression of Autosomal Dominant
Polycystic Kidney Disease: The Consortium of Renal Imaging Studies in Polycystic Kidney Disease (CRISP). In:
American Journal of Kidney Diseases 2005;46;6:1058-1064
8. Meister M, Choyke P, Anderson C, Patel U. Radiological evaluation, management, and surveillance of renal
masses in Von Hippel-Lindau disease. Clin Radiol 2009;64(6):589-600
9. Leung RS, Biswas, SV, Duncan M, Rankin S. Imaging features of von Hippel-Lindau disease. Radiographics. 2008
Jan-Feb;28(1):65-79
10. Sallee M, Rafat C, Zahar JR, Paulmier B, Grünfeld JP, Knebelmann B, Fakhouri F. Cyst Infections in Patients with
Autosomal Dominant Polycystic Kidney Disease. Clin J Am Soc Nephrol. 2009 May 21 (Epub ahead of print).
Choyke P.
National Institutes of Health, USA
HEREDITARY RENAL CANCERS
Over the past 10 years there have been major developments in the recognition of the hereditary basis of renal cancer.
Hereditary cancers are typically multifocal and bilateral and it is often the radiologist who first raises the possibility of a
hereditary cause for a particular renal cancer. It is, therefore, important to be familiar with the expanding list of diseases
known to predispose to renal cancers which includes Von Hippel Lindau, Tuberous Sclerosis, Hereditary Papillary renal
cancer, Birt Hogg Dubé, Hereditary Renal Oncocytomas, Hereditary Leiomyoma Renal Cell Carcinoma, Hereditary Non
Polyposis Colon Cancer and Medullary Renal Cancer. Improved awareness should lead to earlier diagnosis of individuals
and their at-risk family members. The basic genetic and proteomic mechanisms underlying these conditions will likely
form the basis for innovative prevention and treatment strategies in the future. It is predictable that additional types of
Hereditary Renal Cancers will discovered and refinements of the current classification will likely occur. While these
diseases currently account for only a minority of renal cancers, the lessons learned from them will have profound
implications for the treatment of all forms of renal cancer in the future.
Von Hippel Lindau
Mutations in the VHL gene located on the 3 rd chromosome result in the VHL syndrome which consists of renal cysts and
cancers, pheochromocytomas, pancreatic cysts and neuroendocrine tumors and CNS hemangioblastomas including retinal
angiogmas. In the kidney the predominant cell type is clear cell and the disease predictably results in a low grade, slow
growing renal cancer which is highly vascular but has cystic components. The tumors grow inexorably but variably so
that yearly monitoring is recommended, more often if the lesion is large or increasing faster than normal. Screening is
increasingly shifting to MRI over CT due to the lower culmulative radiation dose. Alternating CT and MRI is another
approach that cuts culmulative radiation exposure in half. Below the size of 3cm the risk of metastases is quite low so
lesions are generally watched until they reach that size. Lesions that are predominantly cystic may be allowed to grow
even larger before surgery or intervention. Intervention follows a nephron sparing approach with RFA, cryotherapy and
laparoscopic enucleations the most highly recommended. Frequent surgeries can result in scarring and diminished renal
function. Thus, only a limited number of procedures are possible (n=2-5) in each kidney. Some patients have received
renal transplants but before going that route it is important to understand the multisystem nature of VHL.
Birt Hogg Dube
Birt Hogg Dube syndrome (BHD) was discovered by the 3 dermatologists for which it is named. BHD results in
characteristic skin lesions known as fibrofolliculomas. Mutations in the BHD gene also result in multiple lung cysts (with
potential for spontaneous pneumothorax) and a variety of solid enhancing lesions in the kidney including: chromophobe
carcinoma, oncocytic neoplasm, oncocytoma and clear cell carcinoma. The tumors are usually characterized by
homogeneous enhancement and bilaterality. The tumors are generally only mildly aggressive and can be monitored in
many cases. Again, a nephron sparing approach is preferred once treatment is decided upon. RFA, cryoablation and
laparoscopic enucleation are the leading treatment techniques. It is apparent that BHD is far more common than has
been previously recognized.
Hereditary Papillary Renal Cancer
HPRC is the least aggressive hereditary renal cancer. It results in numerous type I papillary renal cancers which are
characterized by their poor enhancement and slow growth. The mortality rate from HPRC is lower than other syndromes
66

due to the slow growth of these malignancies. To date, no convincing associated findings are associated with HPRC. The
mutation for HPRC is found in the c-MET gene and it results in activation of the c-MET receptor whether or not there is
activation by an extrinsic growth factor (Hepatocyte growth factor or Scatter factor).
Hereditary Leiomyoma Renal Cell Carcinoma
Recently, a large cohort of women were identified with a particularly aggressive form of fibroids. When the genetic testing
was performed it was found that a sizeable percentage of these women and their male relatives died of renal cancer.
Thus HLRCC is a genetic defect that results in leiomyomas of the uterus and type II papillary renal cancers, which are
particularly aggressive. Like Type I papillary tumors, Type II are also poorly enhancing and can have a cystic
component. However, unlike Type I, these tumors are aggressive metastasizing via the lymphatic system even while the
primary tumor is small. These tumors are extremely PET avid, unlike most renal cancers and can be followed with FDG
PET. The tumors should be treated surgically with wide margins due to their aggressive nature.
Tuberous Sclerosis
The association between TS and angiomyolipomas, cysts and renal carcinomas is well known. Many angiogmyolipomas
are lipid-poor so that there is a differential consideration with renal cancer. AMLs tend to be hyperdense prior to contrast
media and enhance uniformly whereas RCCs tend to isodense with heterogeneous enhancement. RCCs associated with TS
occur bilaterally and at a younger age than do RCCs that occur sporadically.
Other conditions
A variety of other conditions are associated with familial renal tumors. Familial oncocytomas appears to be a distinct
entity in which multiple, non-life-threatening lesions occur. They are associated with diminished renal function.
Additional Hereditary Non Polyposis colon cancer Type II is associated with epithelial tumors of the renal pelvis. Sickle cell
trait is associated with the development of medullary renal cancer, a particularly aggressive form of renal cancer.
Conclusion
Hereditary renal cancer syndromes can lead to multiple, bilateral kidney tumors that occur at a younger age than nonhereditary
renal cancers. Imaging plays an important role in the diagnosis and management of these syndromes.
During the past decade, several new hereditary renal syndromes have been discovered but are not yet widely known.
Whereas previously, the list of hereditary renal cancers in adults included Von Hippel-Lindau disease and a rare form of
chromosomal translocation, the list now includes the following syndromes: Tuberous Sclerosis, Hereditary Papillary Renal
Cancer, Birt-Hogg-Dubé, Familial Renal Oncocytoma, Hereditary non-polyposis colon cancer (HNPCC)and Medullary
carcinoma of the kidney. In addition, a number of newly described but poorly understood syndromes are under
investigation. Even at this early stage, it is clear that elucidating the underlying genetic mutations that cause the
hereditary renal cancer syndromes will have profound implications for understanding the origins of non-hereditary renal
tumors. These studies will likely culminate in a better understanding of the causes of renal cancer, its prevention and
ultimately, its cure 1-7 .
1. Grubb RL, 3rd, Franks ME, Toro J, et al. Hereditary leiomyomatosis and renal cell cancer: a syndrome associated
with an aggressive form of inherited renal cancer. J Urol. 2007 Jun;177(6):2074-9; discussion 9-80.
2. Linehan WM. Kidney cancer: opportunity for disease specific targeted therapy. Urol Oncol. 2008 Sep-
Oct;26(5):542.
3. Pfaffenroth EC, Linehan WM. Genetic basis for kidney cancer: opportunity for disease-specific approaches to
therapy. Expert Opin Biol Ther. 2008 Jun;8(6):779-90.
4. Rosner I, Bratslavsky G, Pinto PA, Linehan WM. The clinical implications of the genetics of renal cell carcinoma.
Urol Oncol. 2009 Mar-Apr;27(2):131-6.
5. Stewart L, Glenn GM, Stratton P, Goldstein AM, Merino MJ, Tucker MA, Linehan WM, Toro JR. Association of
germline mutations in the fumarate hydratase gene and uterine fibroids in women with hereditary
leiomyomatosis and renal cell cancer. Arch Dermatol. 2008 Dec;144(12):1584-92.
6. Sudarshan S, Pinto PA, Neckers L, Linehan WM. Mechanisms of disease: hereditary leiomyomatosis and renal cell
cancer--a distinct form of hereditary kidney cancer. Nat Clin Pract Urol. 2007 Feb;4(2):104-10.
7. Zbar B, Glenn G, Merino M, et al. Familial renal carcinoma: clinical evaluation, clinical subtypes and risk of renal
carcinoma development. J Urol. 2007 Feb;177(2):461-5; discussion 5.
DRUG-INDUCED ABNORMALITIES IN THE GU TRACT
Ramchandani P.
University of Pennsylvania Medical Center, Phladelphia, USA
FEMALE PELVIC DISORDERS
Moderators: Brkljacic B. (HR) – Rockall A. (UK)
CONGENITAL ABNORMALITIES: WHY DO WE NEED IMAGING
Kinkel K. 1 , Jacob S. 2 , Weintraub J. 3 .
1 Institut de radiologie, 2 Gynécologie, 3 Laboratoire de pathologie. 1+2. Clinique des Grangettes, 7, ch. des
Grangettes, 1224 Chêne-Bougeries/Geneva, Switzerland. 3 Viollier Weintraub SA, 16, av. Eugène Pittard, 1206
Genève
Congenital abnormalities of the female pelvis mainly concern the uterus and are clinically important findings due to their
relative frequency during workup for infertility, recurrent pregnancy loss, premature birth or cervical incompetence.
Frequency in the general population is about 1%.
Although the American Society for Reproductive Society (AFS) has elaborated a clear classification in 7 classes (1), its
clinical use is often reduced due to complex or mixed presentation and additional descriptive terms required by the
obstetrician to decide treatment options. Saleem et al has developed a helpful decision tree to diagnose the type of
mullerian abnormality with results of imaging findings regardless what imaging technique was used (2):
1. Check for the presence of a uterus and a vagina (sagittal and axial plane).
2. Check for uterine size (sagittal plane), shape (oblique long axis or coronal uterine plane) and septum extent
(oblique short axis or axial uterine plane).
3. Check for obstruction (vaginal or cervical hypoplasia).
67

The first question helps to identify uterine agenesia (class AFS I). Decreased uterine size allows the diagnosis of uterine
hypoplasia (class AFS I). According to the uterine shape four additional classes of uterine malformation can be identified:
the” banana shaped” unicornuate uterus (class II), the “T-shaped” DES-related uterus (class AFS VII), the “double uteri”
configuration requires particular attention towards the presence of a fundal cleft (didelphus and bicornuate uterus, class
AFS III and IV) or a convex flat fundus (septate uterus, class AFS V and VI). The length of a septum will differentiate
between a complete and an incomplete septum of a septated uterus.
In the event of a unicornuate uterus, the presence of a remnant noncommunicating functioning uterine horn is important
as repeated bleeding can cause dysmenorrhea and endometriosis. Resection of this horn is important for symptomatic
relief as for prevention of extra-uterine pregnancy.
A didelphus uterus is differentiated from a bicornuate uterus by two cervices and has a higher incidence of obstretical
problems or spontaneous abortion as estimated through pooled data by Troiana et al (3):
Frequency Spontaneous abortion Premature birth Fetal survival
Septated uterus 55% 65% 20% 30%
Didelphus uterus 5% 45% 38% 55%
Bicornuate uterus 10% 30% 20% 60%
Unicornuate uterus 20% 50% 15% 40%
The lecture will present imaging signs for all major mullerian abnormalities at hysterosalpingography, ultrasound and MRI.
Poorest obstetrical outcome concerns septated uteri due to the highest frequency of spontaneous abortion and fetal loss.
Most patients with septated uteri and history of recurrent pregnancy loss are therefore treated by hysteroscopic
metroplasty consisting in the resection of the septum decreasing the risk of abortion . In patients with didelphys or
bicornuate uterus, metroplasty is usually not performed.
In conclusion, most congenital uterine abnormalities will be diagnosed initially at HSG or two dimensional US. MR imaging
and, three-dimensional US are often required for a definitive diagnosis. MR imaging is the study of choice because of its
high accuracy and detailed utero-vaginal and ovarian anatomy. Laparoscopy and hysteroscopy are indicated in women for
whom interventional therapy is being undertaken, thus reducing health care cost and invasive diagnostic procedures.
References
(1) The American Fertility Society classifications of adnexal adhesions, distal tubal obstruction, tubal occlusion
secondary to tubal ligation, tubal pregnancies, mullerian anomalies and intrauterine adhesions. Fertil Steril 1988;
49:944–955.
(2) Saleem N. MR imaging diagnosis of uterovaginal anomalies: current state of the art. Radiographics. 2003 Sep-
Oct;23(5):e13.
(3) Troiano RN, McCarthy SM. Mullerian duct anomalies: imaging and clinical issues. Radiology. 2004 Oct;233(1):19-
34.
PRENATAL DIAGNOSIS AND THERAPY OF FETAL OBSTRUCTIVE
UROPATHIES
Antsaklis A.
University of Athens, Medical School, Greece
68

Spencer J.A.
St James’s Institute of Oncology, UK
METASTASES TO THE FEMALE GENITAL TRACT
Teaching points
Two clinical presentations of metastases to the female genital tract will be discussed as these may result in diagnostic
confusion:
1. to the ovary, Fallopian tube and peritoneum mimicking primary ovarian cancer. Common primary tumour sites
which metastasise in this fashion are the colon, appendix and stomach from within the abdomen and from the
breast.
2. to the uterus and cervix resulting in vaginal bleeding. Breast cancer most commonly behaves this way.
These presentations are most problematic when the patient has no prior cancer diagnosis.
Thus a significant minority of women who undergo surgery for suspected ovarian cancer are found to have metastatic
disease from other sites [1, 2].
Metastases to the uterus and cervix are much less common and it is rare for this to be a primary manifestation of the
cancer. In a woman with prior breast cancer who develops vaginal bleeding the considerations are for a new primary
cancer, disease related to tamoxifen therapy, or for metastatic disease.
A clue to the diagnosis is a hard but non-enlarged cervix or cervical stenosis as metastatic breast cancer is desmoplastic.
There may be coincident involvement of the bladder and ureters.
Infiltrating lobular breast cancer is the most common subtype to metastasise to the genital tract.
Clues on MR imaging are the absence of a true ‘mass’ and a predominant T2 dark signal in the cervix. Curiously there is
enhancement of the cervix on early post-gadolinium sequences.
Regarding metastases to the ovary and peritoneum mimicking primary ovarian cancer, the common primary sites which
do this are all within the MDCT imaging volume and warrant careful scrutiny.
The primary colonic tumour may be a tiny non-obstructing focus of mural enhancement or thickening.
The enlarged appendix may be mistaken for the terminal ileum.
Ovarian metastases from the colon are usually large and unilateral and excellent mimics of the multilocular cystic-solid
primary ovarian cancer. Ovarian metastases from the stomach are usually smaller and more often bilateral and solid [3].
Any woman with an imaging pattern of primary ovarian cancer who has a prior relevant cancer should undergo needle
core biopsy of the peritoneum to define diagnosis [4, 5].
A woman with prior breast cancer with this imaging pattern has a greater chance of a new primary tumour (ovarian or
primary peritoneal cancer) whilst women with prior GI tract cancer are more likely to have relapsing disease.
Other tumours which can metastasise in this way include cholangiocarcinoma and melanoma.
Lymphoma can mimic this pattern as can actinomycosis and tuberculosis.
Advanced tumours in primary sites adjacent to the female genital tract e.g. colorectal and bladder can secondarily invade
these gynaecological structures but this rarely presents a diagnostic problem.
Key references
1. Kurtz AB, Tsimikas JV, Tempany CMC et al. Diagnosis and staging of ovarian cancer: comparative values of Doppler
and conventional US, CT, and MR imaging correlated with surgery and histopathologic analysis - report of the
Radiology Diagnostic Oncology Group. Radiology 1999; 212: 19-27.
2. Brown DL, Zou KH, Tempany CMC et al: Primary versus secondary ovarian malignancy: imaging findings of adnexal
masses in the Radiology Diagnostic Oncology Group Study. Radiology 2001; 219: 213-218.
3. Choi HJ, Lee JH, Kang S et al. Contrast-enhanced CT
for differentiation of ovarian metastasis from gastrointestinal tract cancer:
stomach cancer versus colon cancer. Am J Roentgenol. 2006; 187: 741-5.
4. Spencer JA, Swift SE, Wilkinson N, Boon AP, Lane G, Perren TJ. Peritoneal carcinomatosis: image-guided peritoneal
core biopsy for tumor type and patient care. Radiology 2001; 221:173-177.
5. Hewitt MJ, Anderson K, Hall GD, et al. Women with peritoneal carcinomatosis of unknown origin: Efficacy of imageguided
biopsy to determine site-specific diagnosis. BJOG 2007; 114:46-50.
69

WORKSHOPS
ABSTRACTS
70

UROGRAPHY WITH CT AND MRI
Moderators: Roy C. (FR) – Drossos Ch. (GR)
CTU TECHNIQUE AND APPLICATIONS
Roy C.
Service de Radiologie B -Chirurgie A, Hopital Central Strasbourg, Hospices Civils de Str, France
THE DEVELOPMENT OF MULTIDETECTOR COMPUTED TOMOGRAPHY
UROGRAPHY FOR INVESTIGATING HAEMATURIA
Cowan N.
The Churchill Hospital, Oxford OX3 7LJ, UK
INTRODUCTION:
Haematuria, macroscopic (MACH) or microscopic (MICH), may herald a wide spectrum of underlying disease of which
urological cancer and stones are the most common. Prompt and accurate diagnosis is essential for initiating appropriate
treatment, optimising prognosis. The investigative pathway is often complicated and lengthy utilising multiple imaging
tests. Many diagnostic algorithms exist without rigorous evaluation. MDCTU offers a single test with high diagnostic
accuracy. MDCTU is defined as CT examination of the kidney, ureters and bladder with at least one series acquired postcontrast
enhancement during the excretory-phase. By substituting MDCTU for other tests, the imaging pathway is
simplified, improving diagnostic accuracy and reducing time from presentation to diagnosis.
PURPOSE
The purpose of this lecture is to make sense of the development of MDCTU and its place within the diagnostic algorithm for
investigating haematuria, with the primary goal of defining the most effective diagnostic strategy.
MATERIALS & METHODS
MDCTU is validated for investigating haematuria by determining the diagnostic accuracy in a consecutive series of 1006
patients, over 40-years of age, presenting to a haematuria clinic with MACH, and urinary tract infection excluded.
Reference standard comprises retrograde ureteropyelography (RUP), histopathology from biopsy and surgically resected
specimens, clinical, imaging and histopathological follow-up.
MDCTU is optimised for investigating haematuria is by adjustment of acquisition parameters. Evaluation of changes in
diagnostic accuracy and opacification scoring are used as a measure of examination quality.
The problem solving section looks at reducing false positive and false negative diagnoses by introducing educational
interventions to reduce reader error, RUP for technically inadequate studies and fluoroscopically-guided biopsy for
confirming positive diagnoses.
DISCUSSION
Optimising the patient pathway using MDCTU may be achieved by defining clinical risk category groups for urological
cancer and by investigating each group with a specific first-line imaging test. Low and high risk groups for urological cancer
are proposed. The prevalence of disease in each group ultimately influences the composition of the proposed investigative
pathways. An algorithm is presented using unenhanced CT KUB for the low risk and CT KUB + CT kidneys post-contrast
100s, + / - MDCTU for the high risk group; as first-line imaging tests, as determined by the clinical risk score.
MDCTU is not sensitive enough to rule out, but is specific enough to rule in bladder cancer, allowing patients to bypass
flexible cystoscopy and proceed directly to rigid cystoscopy and biopsy or TURBT.
The advantages and disadvantage of MDCTU are discussed with reference to improvements in diagnostic accuracy,
decreased time from presentation to diagnosis, improved patient experience, economic consequences, and increased
radiation dose. Possible future developments are predicted.
CONCLUSION
The patient pathway for investigating haematuria may be optimized by judicious use of MDCTU. Unenhanced CT KUB is
proposed as first-line imaging test for patients presenting with haematuria in the low risk group for urological cancer. CT
kidneys with contrast and MDCTU are proposed as the first-line imaging test for patients in the high risk group, based on
assessment using of a clinical risk score.
CTU AND IVU RADIATION DOSE
van der Molen A.J.
Leiden University Medical Center, Leiden, The Netherlands
For a long time imaging of theurinary tract has relied on intravenous urography (IVU) as the primary imaging modality. In
more recent times, CT urography (CTU) and (to a lesser extent) MR urography have become the primary means of
urographic imaging. This process has been catalyzed by fast technological advancements such as the ease of use of
multidetector-row CT. Thoughout Europe, many departments have completely abolished IVU, but in others it still remains a
relatively frequently used examination. Since evidence-based data are lacking, this abolition is often premature and not
only based on thorough scientific evidence. Factors such as local preferences, technical improvements, and the general
trend of substituting projectional by cross-sectional imaging techniques may play an important role.
One of the drawbacks of multiphase CTU is its relatively high radiation dose compared to IVU. While the average effective
dose of IVU on digital equipment is in the order of 2-4 mSv, effective doses for CTU in the range o 20-30 mSv are no
exception, especially when image acquisition is not fully optimized.
Therefore, CTU should be properly justified and if used as a primary examination, should probably be limited to patients at
increased risk for urologic cancer. However, the examination should always be tailored to the clinical question and CTU
examinations with a reduced number of phases and/or CTU examinations at reduced dose could well play an important role
in the problem-solving of benign diseases, such as chronic symptomatic urolithiasis. Because of its cost, low radiation dose,
high in-plane spatial resolution, and the dynamic character of the examination, IVU could still play a role in young patients
with benign diseases and for assisting (US- or fluoroscopy-guided) interventional procedures. For children and pregnant-
71

patients, modern high-resolution MR Urography is probably a more complete and attractive alternative. In the low-dose
segment, MRU may therefore be a competitor of IVU rather than CTU.
MRU TECHNIQUE AND APPLICATIONS
Nolte-Ernsting C.
Department of Diagnostic and Interventional Radiology, Evangelic Hospital of Mülheim, Teaching Hospital of
the University Medical Center of Düsseldorf, Mülheim an der Ruhr, Germany
To date, MR urography (MRU) is performed by pursuing two different imaging strategies. The first technique uses
unenhanced, heavily T2-weighted turbo spin-echo sequences to obtain ‘water images’ of the urinary tract. The second MR
urography technique imitates conventional intravenous urography in that a gadolinium contrast agent is intravenously
administered and after its renal excretion, the gadolinium-enhanced urine is visualized using fast T1-weighted gradientecho
sequences. Modern MR urographic imaging offers several potential applications for the diagnostic management of
nearly all kinds of urinary tract disorders.
T2-weighted MR urography
T2-weighted MR urograms generate static water images (static-fluid MR urography). The water we visualize is the urine
itself, which can be regarded as an “intrinsic contrast medium”. In order to obtain static-fluid images of the urinary tract,
heavily T2-weighted pulse sequences are necessary, which display the urine with hyperintense signal intensity and with
high contrast towards surrounding tissues. Multislice-HASTE sequences or standard 3D Turbo spin-echo (TSE) sequences
with fat suppression have proved to be optimal for obtaining heavily T2-weighted images of the dilated urinary tract [1-8].
Of the acquired source images, maximum-intensity-projections (MIP) are postprocessed to generate typical urogram-like
MR images.
Static-fluid MR urography offers a diagnostic tool which is independent of the renal excretory function. The important
advantage is that T2-weighted MR urography can be performed even in patients with non-excreting kidneys [2-5,9-12].
T2-weighted MR urography has proved to be excellent in the demonstration of the markedly dilated urinary tract, in which
the large amount of water generates a good signal-to-noise ratio [1-5,7-11]. T2-weighted MR urography is less suitable for
imaging non-dilated collecting systems [2,3,6,13,14]. A general drawback of static-fluid MR urography is that this
technique does not permit to derive functional information about the urine flow through the collecting system and ureters
[3,4,5,9,12,15,16].
T1-weighted MR urography
With this technique, we exclusively visualize the contrast-material-enhanced urine with fast T1-weighted pulse sequences
obtained after renal excretion of an intravenously injected low-molecular-weight gadolinium chelate [12]. Gadoliniumenhanced
T1-weighted MR urography depends on the renal excretory function, therefore it is also known as excretory MR
urography. T1-weigthed MR urography provides both visualization of the urinary tract morphology and functional
information about the urine flow through the urinary system [12]. Gadolinium-enhanced T1-weighted MR urography
enables to obtain impressive urograms of both non-dilated and obstructed collecting systems provided the excretory
function is not markedly impaired (GFR > 30 ml/min) [12,17-23]. Conversely, excretory MR urography is of no use in
hydronephrosis associated with severe kidney malfunction [12,20].
Commercially available low-molecular weight gadolinium agents eliminated by renal excretion are utilized to enhance the
urinary tract in T1-weighted MR urography.
A general gadolinium-related problem, however, results from the fact that paramagnetic contrast agents lead to a
shortening of both the T1- and T2-relaxation times of fluids and tissues. The T1-shortening effect, which predominates at
low gadolinium concentrations, enhances the signal intensity of the urine on T1-weighted images and is therefore desired.
Conversely, the T2-effect (or T2*-effect in gradient-echo sequences) of gadolinium predominates with increasing
concentrations, and is undesired because it destroys the positive contrast-enhancement of the urine and results in a signal
void. Since the normal kidneys are able to concentrate the excreted gadolinium by a factor of 50-100 [24,25], the T2*-
effect is a relevant disturbance source, which has to be minimized in order to achieve optimal contrast enhancement for
excretory MR urography. The most effective key to solve this problem is to combine gadolinium with furosemide [12,19].
Furosemide is a very powerful loop diuretic agent, which begins to act immediately after the first pass in the kidneys
leading to a rapid retention of water inside the tubule, whereas the glomerular filtration rate remains unaffected [26]. In
diuretic-enhanced excretory MR urography, the positive interaction of furosemide and gadolinium for achieving optimal
contrast-enhancement of the urine is manifold [12,20]: First, the furosemide induced increase in urine volume leads to a
mild distension of the urinary tract. Potentially more important is that the endoluminal retention of water especially
achieves a dilution of the excreted amount of gadolinium. Third, furosemide accelerates the urine flow, thereby causing a
rapid and uniform distribution of gadolinium throughout the entire urinary tract including the caliceal fornices. ‘Dilution’ and
‘distribution’ of the excreted amount of gadolinium are the two components that best explain the benefits of furosemide for
avoiding T2*-effects in the gadolinium-enhanced urine. It is important to mention that the positive interaction of
furosemide and gadolinium already occurs at low intravenous diuretic doses of 5 - 10 mg (0.1 mg per kg) [12,19]. It has
been shown that the sole administration of a gadolinium agent without furosemide cannot provide a sufficient image quality
in excretory MR urography [27].
A regular intravenous gadolinium dose of 0.1 mmol per kg of bodyweight has proved to be well suited for the combination
with furosemide [12,18,19]. Moreover, in order to ‘prepare’ the kidneys and collecting systems for the arrival of
gadolinium, it has been recommended injecting furosemide shortly before the contrast agent is administered [12]. Even a
short delay of 1 - 5 minutes has proved to be effective for achieving a rapid and complete enhancement of the urinary tract
[12,19].
Breath-hold T1-weighted, spoiled, 3D gradient-echo (GRE) sequences with low repetition and echo times are well suited
pulse sequences for imaging of the gadolinium-enhanced urinary tract [12,17,20-22]. If available, parallel imaging
techniques such as sensitivity encoding (SENSE) are helpful to adjust spatial resolution (matrix size) and data acquisition
time for each patient individually. Moreover, conventional 3D gradient-echo sequences can also be combined with echoplanar
imaging for the use in MR urography [19]. From the source images of each 3D sequence data set, maximum
intensity projection (MIP) images are postprocessed parallel to the long axis of the body.
Which MR urography technique in which situation
In the clinical routine, patients usually undergo ultrasonography before MR urography is taken into consideration. MR
urography may be performed using exclusively T2- or exclusively T1-weighted pulse sequences. On the other hand, as
always in MR imaging, T1- and T2-weighted pulse sequences generally complement one another and provide a
comprehensive assessment. Actually, there are three typical clinical situations that we frequently encounter in adult
patients, which suggest different preferences for the two MR urographic techniques:
72

Situation 1: no hydronephrosis, no atrophy of the renal parenchyma GFR > 30 ml/min.
Patients often present with uncharacteristic flank pain and/or (microscopic) hematuria. In this situation, T1-weighted
excretory MR urography has proved to be excellent for achieving a complete and detailed depiction of the nondilated
urinary tract requiring only 5-10 mg of furosemide. Additional abdominal compression and late MR urograms are not
necessary.
Situation 2: slight or moderate hydronephrosis (grade 1 and 2), no or minimal atrophy of the renal parenchyma, GFR > 30
ml/min.
This situation favours the combination of T2- and T1-weighted MR urography. Static-fluid MR urography easily
demonstrates the level of obstruction. T1-weighted MR urography shows the impairment of urine flow in comparison to the
unobstructed side. Residual gadolinium flow through a ureteral stenosis as well as the length of the stenosis is
demonstrated on excretory MR urograms. Late scans after more than 30 minutes of contrast material injection are usually
not necessary in this situation.
Situation 3: high-grade chronic hydronephrosis (grade 3 and 4), marked parenchymal atrophy, severely reduced or
quiescent kidney function with GFR < 30 ml/min.
T2-weighted MR urography is the imaging technique of choice demonstrating the large amount of static fluid and the level
of obstruction.
Apart from these three typical clinical conditions in adult patients, T2-weighted static fluid MR urography is used exclusively
in pregnant women. The only situation, in which neither T2- nor T1-weighted MR urography really can help, is in patients
suffering from advanced renal insufficiency (renal atrophy) without any obstructive disease.
MR urography techniques in children
In babies, infants and adolescents, MR urography offers all features of varying and combining static-fluid T2- and
gadolinium-enhanced T1-weighted pulse sequences, as well [18,23,28-31]. Sequence parameters such as FOV, number of
slices and slice thickness, have to be modified with regard to the body size of children. Moreover, it is necessary to adapt
the examination procedure to the requirements of the different age groups of children including such aspects as patient
preparation and placement inside the magnet, sedation, choice of surface coil, choice of respiratory compensation for pulse
sequences (triggering, gating, breath-hold), use of parallel imaging, dosages of contrast agent and diuretic, etc. [18,28-
31]. In children, it appears to be very promising to combine MR urography with MR nephrography to obtain both
morphologic and quantitative functional data similar to those of radionuclide studies. The latter concept can also be
realized with complementary use of T2- and T1-weighted MR imaging techniques [15,16,28,29].
Applications for MR urography
With respect to the current discussion on cost restraints in medical care, it should be clear that MR urography is mainly
regarded as a diagnostic test of secondary preference following ultrasonography and CT. However, the diagnostic utility of
MR urography is certainly much better than only being a procedure of the second or third choice.
To date, MR urography can be offered as an alternative to conventional intravenous urography (IVU) and CT urography for
imaging of a wide range of urinary tract disorders. The unique advantage of MR urography is the missing radiation
exposure, which promises great potential for modern uroradiologic applications. T2- and T1-weighted MR urography
techniques offer a comprehensive and noninvasive diagnostic tool for imaging of diverse urinary tract diseases. It may
also be useful to combine static-fluid MR urography and gadolinium excretory MR urography because of their
complementary imaging properties. The use of MR urography should not be confined to patients with known intolerance of
iodinated contrast-agents. Especially in intrinsic and extrinsic neoplastic ureteral diseases, MR urography suggests a
potential to reduce the total number of necessary retrograde pyelographies [12]. In suspected ureteral diseases, MR
urography can be obtained before retrograde pyelography or ureterorenoscopy are being considered. Compared with
unenhanced helical computed tomography (CT), MR urography appears to be less relevant in acute urolithiasis, however,
MR urography may provide valuable clinical information in patients with chronic stone disease [19,20]. Both static-fluid and
excretory MR urography will certainly become important imaging modalities in pediatric uroradiology [15,16,18,28-31]. The
use of exclusively unenhanced T2-weighted pulse sequences makes particular sense in hydronephrotic kidneys with severe
malfunction [2-5,9-12] and in obstructive uropathy during pregnancy [5,14].
Theoretically, MR urography has a potential to become an economic, time-effective and radiation-saving imaging modality
if performed in conjunction with standard pulse sequences, MR nephrography, or MR angiography. This integrative aspect
of MR imaging (‘one-stop-shop-concept’) in uroradiology can help avoid multiple separate diagnostic procedures, which in
the sum are costly, time-consuming, and sometimes even invasive.
References
Aerts P, Van Hoe L, Bosmans H, Oyen R, Marchal G, Baert AL. Breath-hold MR urography using the HASTE technique. AJR
1996; 166:543-545
Regan F, Bohlman ME, Khazan R, Rodriguez R, Schultze-Haakh H. MR urography using HASTE imaging in the assessment
of ureteric obstruction. Amer J Roentgenol 1996; 167:1115-1120
Tang Y, Yamashita Y, Namimoto T, Abe Y, Nishiharu T, Sumi S, Takahashi M. The value of MR urography that uses HASTE
sequences to reveal urinary tract disorders. Amer J Roentgenol 1996; 167:1497-1502
O’Malley ME, Soto JA, Yucel EK, Hussain S. MR urography: evaluation of a three-dimensional fast spin-echo technique in
patients with hydronephrosis. Amer J Roentgenol 1997; 168:387-392
Roy C, Saussine C, Guth S, Horviller S, Tuchmann C, Vasilescu C, Le Bras Y, Jacmin D. MR urography in the evaluation of
urinary tract obstruction. Abdom Imaging 1998; 23:27-34
Balci NC, Mueller-Lisse UG, Holzknecht N, Gauger J, Waidlich R, Reiser M. Breathhold MR urography: comparison between
HASTE and RARE in healthy volunteers. Eur Radiol 1998; 8:925-932
Maher MM, Prasad TAS, Fitzpatrick JM, Corr J, Williams DH, Ennis JT, Murray JG. Spinal dysraphism at MR urography: initia
experience. Radiology 2000; 216:237-241
Blandino A, Gaeta M, Minutoli F, Scribano E, Vinci S, Famulari C, Pandolfo I. MR pyelography in 115 patients with a dilated
renal collecting system. Acta Radiol 2001; 42:532-536
Roy C, Saussine C, Jahn C, Vinee P, Beaujeux R, Campos M, Gounot D, Chambron J. Evaluation of RARE-MR urography in
the assessment of ureterohydronephrosis. J Comput Assist Tomogr 1994; 18:601-608
Rothpearl A, Frager D, Subramanian A, Bashist B, Baer J, Kay C, Cooke K, Raia C. MR urography: technique and
application. Radiology 1995; 194:125-130
Reuther G, Kiefer B, Wandl E. Visualization of urinary tract dilatation: value of single-shot MR urography. Eur Radiol 1997;
7:1276-1281
Nolte-Ernsting CCA, Bücker A, Adam GB, Neuerburg JM, Jung P, Hunter DW, Jakse G, Günther RW. Gadolinium-enhanced
excretory MR urography after low-dose diuretic injection: Comparison with conventional excretory urography. Radiology
1998; 209:147-157
Hattery RR, King BF. Technique and application of MR urography. Radiology 1995; 194:25-27
73

Grenier N, Pariente JL, Trillaud H, Soussotte C, Douws C. Dilatation of the collecting system during pregnancy: physiologic
vs obstructive dilatation. Eur Radiol 2000; 10:271-279
Rohrschneider WK, Hoffend J, Becker K, Clorius JH, Darge K, Kooijman H, Tröger J. Combined static-dynamic MR
urography for the simultaneous evaluation of morphology and function in urinary tract obstruction. I. Evaluation of the
normal status in an animal model. Pediatr Radiol 2000; 30:511-522
Rohrschneider WK, Hoffend J, Becker K, Clorius JH, Darge K, Kooijman H, Tröger J. Combined static-dynamic MR
urography for the simultaneous evaluation of morphology and function in urinary tract obstruction. II. Findings in
experimentally induced ureteric stenosis Pediatr Radiol 2000; 30:523-532
Verswijvel GA, Oyen RH, Van Poppel HP, Goethuys H, Maes B, Vaninbrouckx J, Bosmans H, Marchal G. Magnetic resonance
imaging in the assessment of urologic disease: an all-in-one approach. Eur Radiol 2000; 10:1614-1619
Staatz G, Nolte-Ernsting CCA, Adam GB, Hübner D, Rohrmann D, Stollbrink C, Günther RW. Feasibilty and utility of
respiratory-gated, gadolinium-enhanced T1-weighted magnetic resonance urography in children. Invest Radiol 2000;
35:504-512
Nolte-Ernsting CCA, Tacke J, Adam GB, Haage P, Jung P, Jakse G, Günther RW Diuretic-enhanced gadolinium excretory MR
urography: comparison of conventional gradient-echo sequences and echo-planar imaging. Eur Radiol 2001; 11:18-27
Nolte-Ernsting CCA, Adam GB, Günther RW. MR urography: examination techniques and clinical applications. Eur Radiol
2001; 11:335-372
Sudah M, Vanninen R, Partanen K, Heino A, Vainio P, Ala-Opas M. MR urography in evaluation of acute flank pain: T2-
weighted sequences and gadolinium-enhanced three-dimensional FLASH compared with urography. AJR 2001; 176:105-
112
Sudah M, Vanninen RL, Partanen K, Kainulainen S, Malinen A, Heino A, Ala-Opas M. Patients with acute flank pain:
comparison of MR urography with unenhanced helical CT. Radiology 2002; 223:98-105
Riccabona M, Simbrunner J, Ring E, Ruppert-Kohlmayr A, Ebner F, Fotter R. Feasibility of MR urography in neonates and
infants with anomalies of the upper urinary tract. Eur Radiol 2002; 12:1442-1450
Krestin GP, Schuhmann-Giampieri G, Haustein J, Friedman G, Neufang KFR, Clauß W, Stöckl B. Functional dynamic MRI,
pharmacokinetiks and safety of Gd-DTPA in patients with impaired renal function. Eur Radiol 1992; 2:16-23
Krestin GP. Genitourinary MR: kidneys and adrenal glands. Eur Radiol 1999; 9:1705-1714
Jackson EK. Diuretics. In: Hardman JG, Limbird LE, Molinoff PB, Ruddon RW, Goodman Gilman A (eds.). Goodman &
Gilman’s The pharmakological basis of therapeutics. New York: McGraw-Hill, 1996: 691, 692, 697-701
Nolte-Ernsting C, Adam G, Bücker A, Berges S, Bjørnerud A, Günther RW. Contrast-enhanced magnetic resonance
urography: first experimental results with a polymeric gadolinium bloodpool agent. Invest Radiol 1997; 32:418-423.
Borthne A, Nordshus T, Reiseter T, Geitung JT, Gjesdal KI, Babovic A, Bjerre A, Loe B. MR urography: the future gold
standard in paediatric urogenital imaging Pediatr Radiol 1999; 29:694-701
Borthne A, Pierre-Jerome C, Nordshus T, Reiseter T. MR urography in children: current status and future development. Eur
Radiol 2000; 10:503-511
Staatz G, Nolte-Ernsting CCA, Haage P, Tacke J, Rohrmann D, Stollbrink C, Günther RW. Kontrastangehobene T1-
gewichtete MR-Urographie versus T2-gewichtete (HASTE) MR-Urographie im Kindesalter. Fortschr Röntgenstr 2001;
173:991-996
Staatz G, Rohrmann D, Nolte-Ernsting CCA, Stollbrink C, Haage P, Schmidt T, Günther RW. Magnetic resonance urography
in children: evaluation of suspected ureteral ectopia in duplex systems. J Urol 2001; 166:2346-2350
PROSTATE IMAGING
Moderators: Barentsz J. (NL) – Yarmenitis S. (GR)
MORPHOMETRIC FEATURES AND CLINICAL ASPECTS OF PROSTATE
CANCER.
Villers A.
Department Of Urology, Hospital Huriez, Centre Hospitalier Regional Universitaire 59037 Lille-France
Important knowledge on modelling of cancer morphology such as zone of origin and intraprostatic patterns of spread at
histopathology was made available for imaging interpretation and treatment planning decision. Such modelling may help
determine the best cancers and cancer volumes for focal, hemi or subtotal ablation and help identify the cancers where
ablative therapy may affect areas of prostate important for preservation of continence and potency. Using knowledge of
the morphology of the prostate, histological data from radical prostatectomy sections, 12-core biopsy results and MRI
data, it was possible to modelize prostate cancers of different volumes and create cartoon-graphics depicting the likely
shape and size of focal tumours in different histologic parts of the prostate, including modelling of axial versus sagittal
extent (1) (2). Modelling studies suggest that in current clinical series around 30% of low volume cancers are anterior and
70% are posterior at pathology. The posterior cancers originated in posterolateral PZ.The anterior cancers originated in
anterolateral PZ and in TZ. These TZ cancers may be pushed away anterior to TZ during BPH growth of the prostate,
giving rise to these cancers located in the anterior fibro-muscular stroma (3).
1. Bouye S, Potiron E, Puech P, Leroy X, Lemaitre L, Villers A. Transition zone and anterior stromal prostate
cancers: Zone of origin and intraprostatic patterns of spread at histopathology. Prostate. 2008 Oct 10.
2. Haffner J, Potiron E, Bouye S, Puech P, Leroy X, Lemaitre L, et al. Peripheral zone prostate cancers: location and
intraprostatic patterns of spread at histopathology. Prostate. 2009 Feb 15;69(3):276-82.
3. Lemaitre L, Puech P, Poncelet E, Bouye S, Leroy X, Biserte J, et al. Dynamic contrast-enhanced MRI of anterior
prostate cancer: morphometric assessment and correlation with radical prostatectomy findings. Eur Radiol. 2009
Feb;19(2):470-80.
74

TRUS AND PROSTATE CANCER (PCA): A REAPPRAISAL IN 2009
Cornud F.
Department of Radiology, NECKER Hospital, Paris, France
Objectives
1. to know the classical TRUS features of palpable and non palpable PCa
2. to know how TRUS nad TRUS biopsy protocols can improve detection of the non visible non palpable PCa (T1c
stage).
3. to know the potential role of TRUS-MRI image fusion to improve cancer detection rate.
4. to know the limits of biopsy results (Gleason score and quantitative histology) and PSA level to establish the risk
stratification of a newly diagnosed prostate cancer
5. to show how TRUS-MRI fusion images can upgrade low risk to intermediate or high risk tumors to better define
the indications of additional imaging investigation in the work up of a newly diagnosed PCa
Take home messages
1. TRUS features should be interpreted according to DRE results and PSA level
2. TRUS is extremely helpful, in selected cases, to guide periprostatic (staging) biopsies to diagnose a biopsy T3-
stage
3. TRUS guided biopsies, targeted by the results of a functional MRI (diffusion and dynamic imaging) represent an
attractive alternative to saturation biopsies (>20 cores)
4. Low risk patients can be upgraded by repeat targeted biopsies guided by TRUS-MRI image fusion.
Summary
TRUS and TRUS guided biopsies represent the gold standard to diagnose PCa. In selected cases of large volume
tumors, periprostatic biopsies of periprostatic spaces (bulding of the prostate contour) and the seminal vesicles
(tumor involving the prostate base) can be performed to diagnose a biopsy T3 stage. However, the PSA era has
considerably downstaged newly diagnosed PCa, leading to the detection of smaller volume tumors, not visible at
TRUS in approximately 50% of cases. Color Doppler and contrast enhanced have only minimally increased the cancer
detection rate by targeted biopsy of suspicious areas. Biopsy protocols have thus extended to 10-12 cores to optimize
the cancer detection rate. Still, approximately 20% of significant PCa are missed by these protocols. Recently a
saturation biopsy protocol (>20 cores) has been advocated when a repeat biopsy is performed, which entails a higher
morbidity and a risk of detection or non significant PCa. The alternative is represented by TRUS guided biopsies
targeted on a suspicious area detect on a functional multiparametric MRI (diffusion-weighted and/or contrast
enhanced MRI). Images can be fused and TRUS guided biopsies targeted towards the suspicious area.
TRUS guided biopsies extended protocols have also been used for prognostic purposes: the Gleason score, in
combination with the amount of Ca yielded by biopsies (% of contiguous positive biopsies and/or mm of Ca), in
combination with the PSA level permit to define three risks (low, intermediate, high) of biochemical recurrence
(raising PSA after radical treatment). Repeat TRUS guided biopsies targeted by functional MRI can upgrade low risk
patients (PSA level

a
b
c
d
Figure 1.
Figure 1. Multi-modality MR imaging
In a 67-year old male with PSA of 33 ng/ml, who underwent three negative TRUS-biopsy sessions.
a) T2-weighted high resolution anatomic image shows low signal region, ventral right in the prostate (arrow). b) DCE-MRI
shows elevated enhancement in this area. c) MR-spectroscopy indicates an elevated choline in this region (blue). d) DWI;
shows decreased diffusion of water molecules in this region. MR-guided biopsy from this region (see figure 2)
demonstrated a Gleason 8-prostate cancer.
76

a
b
Figure 2. MR-guided biopsy.
Same patient as in figure 1. TSR=Tumor Specific Region of figure 1 is indicated by a yellow circle. In (b) the needle is
recognizable by the low signal intensity (arrows), with the tip in the suspect ventral region. Histology proved a Gleason 8-
carcinoma.
Local staging
Although a large number of men above 50 will develop prostate cancer, only in a small proportion of patients their tumor
will become aggressive. For the majority of men with non-aggressive tumors, one can wait with invasive treatment until
the tumor becomes aggressive (watchful waiting). It is essential to precisely characterize the tumor. This can be achieved
with multi-modality MRI.
With nomograms, based on the serum PSA-value, the tumors aggression (expressed in Gleason-grade), and the outcome
of digital rectal examination, an attempt is made to predict the aggression and local extension of the tumor, and the
presence of lymph node metastasis. Based on these nomograms the further treatment strategy is determined.
Unfortunately these nomograms are only moderately reliable, so that it is not always possible to make the right treatment
decison. By means of functional (multi-modality) MR imaging information can be acquired regarding the aggression of the
tumor. Furthermore, a MR-examination, performed at high field strength (3 Tesla) with use of an endorectal coil (ERC),
allows very accurate determination of minimal (sub-millimeter) extra prostatic spread. The sensitivity and specificity of 3T
ERC MR imaging for determination of extra prostatic disease are respectively 87% en 96% (3) . If the decision is to
surgically remove the prostate, it is important to know where the tumor is located and whether it shows extra prostatic
growth (figure 3). If the tumor is distant from the neurovascular bundle, these bundles can be spared. This decreases the
chance of postoperative impotence. If MRI shows obvious extra prostatic extension, surgery is less useful and the best
choice is hormonal therapy with or without radiotherapy.
Nowadays prostate cancer is increasingly treated with directed local radiotherapy. If the precise location of the tumor is
known, it is possible to give a local boost to this dominant in the prostate. This has the advantage that less radiation is
given to the surrounding tissue, with fewer side-effects. MRI can supply this information (4) .
77

Figure 3. Minimal extra prostatic disease.
56-year old male with PSA of 8 ng/ml and Gleason score of 7 (4+3). a) On high resolution MR image low signal region in
the right peripheral zone is seen (circled region). The fat in the recto-prostatic corner is interrupted, which implies a
minimal extra prostatic disease (arrows). The tumor is close to the neurovascular bundle (red-blue-yellow). b) A wide
resection was performed based on the MRI. Histopathology showed minimal extra prostatic disease (1 mm). Resection
margins were negative for tumor.
Lymph node metastasis
Hormonal therapy with or without radiation is the best treatment if there are metastasis to the lymph nodes. The risk of
lymph node metastasis is currently determined with the help of the above described (inaccurate) nomogram. In patients
with an elevated risk for metastasis additional examinations are required. At the moment the most used imaging
techniques for detecting lymph node metastasis are multi-detector CT (MDCT) and conventional MRI. The accuracy of
MDCT and conventional MRI is not high. This makes supplementary invasive diagnostic examination in the form of surgical
pelvic lymph node dissection (PLND) mandatory. A new MRI technique using a lymph node specific contrast agent
(Combidex) (MRL) is recently described (5, 6) . This contrast agent consists of iron oxide-containing nano-particles. When
this contrast agent is administered intravenously, it is taken up by macrophages and transported to healthy lymph tissue.
The iron causes changes in the magnetic characteristics of the tissue, that results in low signal intensity on MR images.
Therefore 24 to 36 hours after Combidex injection, healthy lymph nodes are black on MR images due to the iron within
macrophages. Macrophages are absent in lymph nodes with metastasis and thus these lymph nodes do not have a low
signal: the tissue is white (figures 4 en 5).
78

Figure 4.
1) Iron contrast is slowly administered by means of intravenous infusion and is taken up by macrophages. 2)
Macrophages move to healthy lymph tissue. 3) Iron-filled macrophages are present in normal lymph tissue and not in
areas of metastasis. 4) Normal nodes are black on MRI. The metastasis remains white.
With MRL it is possible to examine the entire abdomen instead of only a restricted area surrounding a few pelvic blood
vessels, such as is the case with PLND. The sensitivity, specificity, negative and positive predictive values are respectively
82%, 93%, 96% en 69%. In specialized centers it is even higher: 90%, 94%, 98% and 75%, respectively. The diagnostic
accuracy of MRL in the detection of lymph node metastasis is significantly higher than with MDCT (6) . The high negative
predictive value (>96%) of MRL means that after a negative result on MRL, PLND does not have to be performed. Due to
the latter, obtaining a diagnosis with MRL is economically cheaper and results in fewer complications than with the current
invasive diagnostic technique of MDCT + PLND. In addition, in at least in 30% of patients, thanks to MRL, nodes are
detected which are not found by the routine PLND, as they are located in the internal and common iliac, peri-rectal and
par aortic regions.
Figure 5. MR Lymphography with Combidex
70-year old male with PSA of 12 ng/ml and a Gleason of 7 (4+3). MRL shows a black (arrow) and a white node (circle).
The diameter of both nodes is 4 mm. Histopathology confirmed a metastatic node (white) and a normal node (black).
79

The positive and negative nodes can be made visible on a combined CT-angiography-MRL image (figure 6). In this way
the location of positive nodes relative to the large pelvic vessels can be visualized. This information can help the surgeon
to find these nodes or help the radiation oncologist to give selective lymph node radiotherapy. Unfortunately, the iron
oxide contrast agent has not yet obtained official registration.
Figure 6. CTA-MRL combined image
60-year old male who underwent a prostatectomy and PLND (Stage T3a, N0, M0) After surgery he had a PSA-rise to 10.
CTA-MRL image shows normal green nodes. There is a nodeless area in the pelvis with surgical clips. Red pathological
nodes are seen near the aorta. Surgical resection showed these nodes to be metastasis.
PSA Recurrence
If in a treated patient there is a PSA, rise, the most important question is: is this the result of a local recurrence, or lymph
nodes or bone marrow metastases MRI also has a role in this situation.
Bone metastasis can be excluded by means of a ‘whole-body’-MRI.
If this is negative, then Combidex MRL should be used to exclude node metastasis. In post-treated patients we found no
correlation between PSA value or PSA doubling time and positive nodes. There was, however, a positive correlation
between PSA velocity and positive nodes on MRL. Thus even in patients with a low PSA, but high PSA velocity a MRL to
exclude metastases is of use.
Finally, multi-modality MRI can be performed to determine if there is a local recurrence (figure 7).
a
80

Figure 7. Post radiotherapy recurrence.
67-year old male, 2.5 years after radiotherapy of the prostate elevation of PSA to 2.1. a) T2-weighted MRI shows no
abnormalities. b) At the location of the old tumor there is strong enhancement on the DCE-MRI. Biopsy confirmed
prostate cancer recurrence.
Summary.
This article describes the potential value of MR imaging for patients with prostate cancer. To summarize, MR imaging
affords:
- Accurate detection of tumor, thereby decreasing the number of unnecessary biopsies and increased accuracy
- Better determination of the location and extension of the tumor: this makes targeted radiotherapy or targeted
treatments possible. Hereby reducing side-effects of this treatment (damage to the intestine, impotence, incontinence).
- Better prediction of tumor aggression: for patients with a non-aggressive tumor this means that one has the possibility
to wait with invasive treatment, and act based on the MR-results.
- Non-surgical detection of very small metastasis in lymph nodes. This also means the possibility for more patients to
undergo targeted therapy.
- For ‘PSA-recurrence patients, instead of a bone-scan a ‘whole-body’-MRI can be performed, followed by a MRL, and a
local “functional”-MRI. Based on this MRI the eventual local treatment can be started.
Acknowledgments
This paper was made possible due to the work of the Radboud University Medical Center Nijmegen Prostate team:
Radiology: Prof. Dr. J Barentsz, Prof. Dr. A Heerschap, Dr. Ir. T Scheenen, Dr. J Fütterer, Dr. Ir. H-J Huisman, Dr. Ir. N
Karssemeijer, Drs. S Heijmink, Drs. T Hambrock, Drs. D. Yakar, Drs. O Debats, Drs. C Hoeks,
Urology: Prof. Dr. J Witjes, Drs. I van Oort, Drs. R Somford,
Radiotherapy:
Dr. E van Lin,
Pathology:
Dr. C Hulsbergen, & Drs. C van Niekerk.
Literature
1. Gosselaar C, Roobol MJ, Roemeling S, Schröder FH. The Role of the Digital Rectal Examination in Subsequent
Screening Visits in the European Randomized Study of Screening for Prostate Cancer (ERSPC). Eur Urol 2008
[Epub ahead of print].
2. Fütterer JJ, Heijmink SW, Scheenen TW, Veltman J, Huisman HJ, Vos P, Hulsbergen-Van de Kaa CA, Witjes
JA, Krabbe PF, Heerschap A, Barentsz JO. Prostate cancer localization with dynamic contrast-enhanced MR
imaging and proton MR spectroscopic imaging. Radiology 2006 241 (2): 449-58.
3. Fütterer JJ, Heijmink SW, Scheenen TW, Jager GJ, Hulsbergen-Van de Kaa CA, Witjes JA, Barentsz JO.
Prostate Cancer: Local Staging at 3-T Endorectal MR Imaging-Early Experience. Radiology 2006 238 (1): 184-
191.
4. Van Lin EN, Fütterer JJ, Heijmink SW, van der Vight LP, Hoffmann AL, van Kollenburg P, Huisman HJ,
Scheenen TW, Witjes JA, Leer JW, Barentsz JO, Visser AG. IMRT boost dose planning on dominant
intraprostatic lesions: gold marker-based three-dimensional fusion of CT with dynamic contrast-enhanced and
1H-spectroscopic MRI. International journal of radiation oncology, biology, physics 2006 65 (1): 291-303.
5. Harisinghani MG & Barentsz J (co-first-authors), Hahn PF, Deserno WM, Tabatabaei S, van de Kaa CH, de la
Rosette J, Weissleder R. Noninvasive detection of clinically occult lymph-node metastases in prostate cancer.
The New England Journal of Medicine 2003 348(25): 2491-9.
6. Heesakkers RA, Hövels AM, Jager GJ, van den Bosch HC, Witjes JA, Raat HP, Severens JL, Adang EM, van der
Kaa CH, Fütterer JJ, Barentsz J.
MRI with a lymph-node-specific contrast agent as an alternative to CT scan and lymph-node dissection in
patients with prostate cancer: a prospective multi-cohort study. Lancet Oncol. 2008 Aug 15.
81

INTERVENTIONAL URORADIOLOGY
Moderators: Moussa S. (UK) – Papailiou J. (GR)
MANAGEMENT OF URINARY STONES IN 2009: A TEAM APPROACH
Moussa S. A., Edinburgh
Magnusson A., Uppsala, Sweden
Imaging plays a major role in the management of urinary tract calculi.
Urinary tract calculi:
• Common condition
• 15% of men & 6% of women in developed countries will have one stone
• 50% will recur
• Majority are idiopathic 80%
• Metabolic e.g. hyperparathyroidism
• Genetic
• Anatomical anomalies in upper or lower tracts
• Infection
Imaging Modalities:
• KUB
• Ultrasound
• IVU
• CT
• MRI
• Nuclear Medicine
When is imaging needed
• Diagnosis:
• Presence of stone
• Stone size
• Stone position
• Obstruction
• Management
• Calyceal anatomy
• Planning puncture
• Follow up
The different imaging modalities will be discussed with particular reference to their place in stone management.
• The management of stone disease has evolved in recent year since the advent of ESWL (Extracorporeal shock
wave lithotripsy) as well as with advances in interventional radiological techniques allowing for safer
percutaneous access to the upper urinary tract.
In recent years there has been an increasing use of CT in the evaluation of patients with stone disease particularly
complex stones where 3D reconstraction has been shown to be of great value as well as CT guided renal access.
The choice of the appropriate treatment modality depends on several factors which will be discussed.
The technique of percutaneous nephrolithotomy will be described together with examples of some complex cases.
From this presentation we can conclude that:
For best practice in stone management:
• Accurate imaging and preoperative evaluation of the patient
• Careful patient selection
• If possible use 3D-CT for planning
Will give:
– an optimal tract
– an optimal result
– at a minimal risk
• Close discussion between radiologist and endourologists
• Joint surgical approach
• Team effort including anaesthesia and all theatre staff
• Recognition and early management of complications
82

FEMALE PELVIS / IMAGING
Moderators: Kinkel K. (CH) – Tsili A. (GR)
TIPS AND TRICKS FOR SCANNING IN GYNAECOLOGY
McHugo J.
Birmingham Women’s Hospital NHS Foundation Trust, Birmingham University , UK
Abstract
A structured approach is essential in imaging and this is particularly true for scanning in gynaecology. It is vital that
the investigation is performed in an appropriate manner with not only the right equipment but in the right
environment. A standard approach to each examination in required but it is important to understand the clinical
setting, and the questioned to be answer. It is essential to be provided with the following information prior to
scanning.
Age
Menstrual Cycle
Hormone Therapy
Previous operations- particularly gynaecological.
This presentation aims to provide both those in training as well as the more experienced with tips and tricks for
transvaginal scanning and will be illustrated with clinical cases.
Not only will images show pathology but an understanding of the ultrasound “ soft signs” of pain and mobility will be
developed aiming to enhance the accuracy of the diagnosis when using transvaginal scanning
WHAT YOU SHOULD NOT FORGET TO PUT IN A SONOGRAPHIC REPORT
ABOUT THE FEMALE PELVIS”
Cunha T.M
Department of Radiology, Portuguese Institute of Oncology – Lisbon.
Ultrasound of the female pelvis should be done when there is a valid medical reason, and the lowest possible
ultrasonic exposure settings should be used to gain the necessary diagnostic information. In some cases, additional or
specialized examinations may be necessary.
The indications for a pelvic ultrasound include but are not limited to:
1. Pelvic pain.
2. Dysmenorrhea.
3. Menorrhagia.
4. Metrorrhagia.
5. Menometrorrhagia.
6. Follow-up of previously detected irregularity (eg, hemorrhagic cyst).
7. Evaluation and/or monitoring of infertile patients.
8. Delayed menses or precocious puberty.
7. Postmenopausal bleeding.
8. Abnormal pelvic examination.
9. Further characterization of a pelvic abnormality noted on another imaging study (eg, computed tomography or
magnetic resonance imaging).
10. Evaluation of congenital anomalies.
11. Excessive bleeding, pain, or fever after pelvic surgery or delivery.
12. Localization of an intrauterine contraceptive device.
13. Screening for malignancy in patients with an increased risk.
The examination should be performed for each organ and anatomic region in the female pelvis.
All relevant structures should be identified by the transabdominal or transvaginal approach. In many cases, both will
be needed.
A transrectal or transperineal approach is useful in patients who cannot stand a vaginal probe (eg, virgins and
postmenopausal women).
For a pelvic sonogram performed transabdominally, the patient’s urinary bladder should be distended sufficiently to
move the small bowel and its contained gas from the field of view. Occasionally, overdistention of the bladder may
compromise evaluation. When this occurs, imaging may be repeated after the patient partially empties the bladder.
For a transvaginal sonogram, the urinary bladder is preferably empty. The patient or the physician may introduce the
vaginal transducer, preferably under real-time monitoring. Male examiner should always have a female chaperone in
cases of transvaginal scans.
The vagina and uterus provide anatomic landmarks that can be used as reference points for the remaining normal and
abnormal pelvic structures.
In evaluating the uterus, the following should be documented: (1) the uterine size, shape, and orientation; (2) the
endometrium; (3) the myometrium; and (4) the cervix. The vagina may be imaged as a landmark for the cervix and
lower uterine segment.
Uterine length is evaluated in the long axis from the fundus to the cervix (the external os, if it can be identified). The
depth of the uterus (anteroposterior dimension) is measured in the same long axis view from its anterior to posterior
walls, perpendicular to the length. The width is measured from the transaxial or coronal view. If volume
measurements of the uterine corpus are performed, the cervical component should be excluded from the uterine
measurement.
Abnormalities of the uterus should be documented.
The myometrium and cervix may be evaluated for contour changes, echotexture, and masses. Masses, if identified,
should be measured in at least 2 dimensions and their locations recorded (eg. leiomyoma location and largest size).
83

The endometrium should be analyzed for thickness, focal abnormality, and the presence of fluid or a mass in the
endometrial cavity. Assessment of the endometrium should allow for variations expected with phases of the menstrual
cycle and with hormonal supplementation. If the endometrial stripe is difficult to image or ill defined, a comment
should be added to the report.
When evaluating the adnexa, an attempt should be made to identify the ovaries first since they can serve as a major
point of reference for assessing the presence of adnexal pathology. The ovaries should be measured, and ovarian
abnormalities should be documented. Ovarian size can be determined by measuring the ovary in 3 dimensions (width,
length, and depth), on views obtained in 2 orthogonal planes. It is acknowledged that the ovaries may not be
identifiable in some women. This occurs most frequently after menopause or in patients with a large leiomyomatous
uterus.
If an adnexal mass is detected, its relationship to the ovaries and uterus should be documented.
Its size, echogenicity, and internal characteristics (cystic, solid, or complex) should be determined. Doppler or color
Doppler ultrasound may be useful in select cases to identify the vascular nature of pelvic structures.
If the lesion is a benign water cyst we should stop other imaging; only follow up is required. In the characterization of
an ovarian lesion the evidence of criteria for malignancy
- size: >4cm
- architecture: solid, mixed solid and cystic
- papillary projections
- mural thickness, septations >3mm
- necrosis
the patient should go for a CT staging. When the lesion is indeterminate a MR characterization must be the next step.
When ovarian endometriosis is detected or in the presence of suspicion for pelvic endometriosis we should check the
- pouch of Douglas
- posterior vaginal fornix
- utero-sacral ligaments
- vesico-uterine pouch
The normal fallopian tubes are not usually recognized. This region should be surveyed for abnormalities, particularly
dilated tubular structures.
The pouch of Douglas and bowel posterior to the uterus may not be clearly distinct. This area should be evaluated for
the existence of free fluid or a mass. If a mass is detected, its size, position, shape, echogenicity, internal
characteristics (cystic, solid, or complex), and correspondence to the ovaries and uterus should be documented.
Demarcation of normal loops of bowel from a mass may be not easy if only a transabdominal examination is
performed. A transvaginal examination may be useful to distinguish a suspected mass from fluid and feces within the
normal rectosigmoid.
Adequate documentation is essential for high-quality patient care. A permanent record of the ultrasound examination
and its interpretation should be included in the medical record. Images of all appropriate areas, both normal and
abnormal, should be recorded. Variations from normal size should be accompanied by measurements.
Images are to be correctly label with the examination date, facility name, patient identification, image orientation,
and, whenever possible, the organ or area imaged. Significant history for each patient should include obstetric history
and/or pertinent menopausal history. Preservation of the permanent record of the sonographic examination should be
consistent with both clinical requirements and the pertinent legal and local health care facility necessities.
LIMITATIONS OF FEMALE PELVIC ULTRASOUND: WHEN DO YOU NEED
MRI/CT
Sala E.
Department of Radiology, University of Cambridge and Cambridge University Hospitals NHS Foundation
Trust Cambridge CB2 0QQ
Imaging Techniques
Ultrasound: Ultrasound (transabdominal or transvaginal) is accepted as the primary imaging modality for examining
the female pelvis. It remains the principal initial imaging study in the work-up of gynaecologic disease. Currently, the
main role of ultrasound (US) in gynecology includes evaluation of a suspected pelvic mass, evaluation of the causes of
uterine enlargement, identification of endometrial abnormalities in a patient with postmenopausal bleeding, and
characterization of ovarian masses. It is also the primary imaging modality of choice in the evaluation of the female
with acute pelvic pain. In addition, ultrasound has become invaluable in guiding a wide selection of invasive
procedures. For example, it is used for transabdominal and transvaginal guidance of fluid or tissue sampling,
transvaginal guided drain placement, guidance for placement of brachytherapy for cervical and endometrial
malignancy, and intraoperative assessment for completion of evacuation and instrument placement, especially when
the anatomy is difficult to assess preoperatively. Transvaginal ultrasound (TVS) provides greater detail of the anatomy
and pathology. Color, power and spectral Doppler provide additional information regarding associated vascularity.
US has many advantages in routine pelvic imaging: it is relatively inexpensive, provides multiplanar views, is widely
available and lacks ionizing radiation or contrast media. Its portability allows use in virtually any setting including the
ultrasound suite, operating room, patient bedside or radiation therapy suite. However, US also has a number of
limitations: it is operator-dependent and image quality varies with patient body habitus.
Magnetic Resonance Imaging: The role of MRI in gynaecology has evolved during the last two decades. There is now a
substantial body of evidence that MRI is useful in evaluating Müllerian duct anomalies and both benign and malignant
conditions of the pelvis. MRI has been shown to be superior to US and CT in the characterization of indeterminate
adnexal masses, in the work-up of uterine and cervical cancer and may be a useful problem-solving tool in the
evaluation of ovarian cancer. Although MRI is still relatively expensive, it has been shown to minimize costs in some
clinical settings by limiting or eliminating the need for further expensive and/or more invasive diagnostic or surgical
procedures. Advantages of MRI include superb spatial and tissue contrast resolution, no use of ionizing radiation,
multiplanar capability and fast techniques. MRI is the technique of choice for patients with allergies to iodinated IV
contrast media or impaired renal function. However, MRI is contraindicated in patients with implants such as
pacemakers, neural stimulators or cochlear implants, certain vascular clips and metallic objects.
84

Computed Tomography: CT has a limited utility in characterizing early-stage disease, but is the most commonly used
primary imaging study for evaluating the extent of gynaecologic malignancy and for detecting persistent and recurrent
pelvic tumours. Advantages of CT include oral and rectal contrast opacification of the gastrointestinal tract,
intravenous contrast enhancement of blood vessels and viscera, fast data acquisition and high spatial resolution.
Disadvantages of CT include the use of ionizing radiation, degradation of image quality by body habitus or metallic hip
prosthesis, and the risk of morbidity and mortality associated with iodinated contrast agents.
Role of Imaging in Selected Conditions of Female Pelvis
Congenital Anomalies of the Female Genital Tract: Müllerian duct anomalies result from non-development or varying
degrees of non-fusion or non-resorption of the Müllerian ducts. These congenital anomalies occur in 1–15% of women.
Müllerian duct anomalies are associated with menstrual disorders, infertility and obstetric complications. Evaluation of
Müllerian duct anomalies with physical examination and more traditional imaging studies (HSG and US) is often
inconclusive. MRI is the most accurate imaging modality for evaluating theses patients, allowing both precise
classification and demonstration of associated complications.
Benign Uterine Conditions
Leiomyoma: Leiomyomas are the most common uterine tumours. These benign tumours are found in up to 40% of
women in their reproductive years. They are usually multiple and may be subserosal, intramural or submucosal in
location. Symptoms may be caused by the location of the leiomyoma and/or their mass effect. Hysterectomy has been
the traditional primary treatment for debilitating leiomyomas. While hysterectomy is curative, alternative uterinesparing
procedures may be appropriate for some patients. Specifically, myomectomy has been successfully performed
for many years and, more recently, transcatheter uterine arterial embolization (UAE) is being used as an alternative,
less invasive therapy for symptomatic leiomyomas. Recently another alternate minimally invasive treatment has been
MR-guided high focused ultrasound. US is often the initial radiological evaluation in these patients, while MRI is usually
reserved for patients with inconclusive US results or patients undergoing myomectomy, uterine embolization or MRguided
focused ultrasound; in all of these situations, MR is used to assist in appropriate selection of patients for UAE.
Adenomyosis: Adenomyosis is the presence of endometrial tissue within the myometrium and secondary smooth
muscle hypertrophy-hyperplasia. It can be diffuse or focal. The most frequent symptoms are dysmenorrhoea and
dysfunctional uterine bleeding. TVS is the initial imaging modality, whereas MRI should be reserved for indeterminate
cases or those undergoing uterus sparing surgery. Pitfalls in the diagnosis of uterine adenomyosis include leiomyoma,
endometrial carcinoma, and myometrial contractions. TVS has an accuracy of 68-86% in the diagnosis of diffuse
adenomyosis. Because the findings may be subtle, real time evaluation of women suspected of adenomyosis may be
the key to making the diagnosis. While the diagnosis of diffuse adenomyosis can be suggested on TVS, the findings of
focal adenomyosis are hard to distinguish from leiomyoma.
Malignant Uterine Conditions
Endometrial carcinoma: Endometrial carcinoma is the fourth most common female cancer and the most common
malignancy of the female reproductive tract. Endometrial carcinomas are typically diagnosed at endometrial biopsy or
dilatation and curettage with imaging being reserved to evaluate extent of disease. TVS is superior to TAS for imaging
endometrial abnormalities. The most common appearance of endometrial cancer is nonspecific thickening of the
endometrium; while this thickening is indistinguishable from that found with hyperplasia or polyp, the diagnosis of
endometrial cancer should be considered when the endomyometrial junction is disrupted or the endometrial surface is
irregular. Dynamic contrast-enhanced MRI offers a ‘one-stop’ examination with the highest efficacy for pretreatment
evaluation in patients with endometrial cancer. MRI is significantly superior to US and CT in the evaluation of both
tumour extension into the cervix and myometrial invasion. The overall staging accuracy of MRI has been reported to
be between 85% and 93%.
The Adnexa
Endometriosis: Endometriosis is the presence of endometrial epithelium and stroma outside of endometrium and
myometrium. Endometriosis occurs in up to 65% of women with pelvic pain and usually affects women of reproductive
age. Imaging is most commonly used for the diagnosis and follow-up of endometriomas, but laparoscopy is the gold
standard, as it can provide a complete evaluation for endometrial implants in the abdomen and pelvis as well. TVS is
the first imaging modality, with MRI reserved for masses atypical on US. Endometrial implants can be detected on
MRI, but evaluation on MRI is inferior to laparoscopic staging.
Mature Cystic Teratomas: Mature cystic teratomas are the only benign germ cell tumours and are quite common. The
US appearance of dermoid cysts varies. The most common appearances are a cystic mass with an echogenic nodule
projecting into the lumen or a predominantly echogenic mass with posterior sound attenuation owing to the presence
of sebaceous material and hair. A fluid-fluid level may also be seen. The strength of MRI is its ability to diagnose
dermoid cysts with confidence as the fat or sebum within the cyst parallels the signal intensity of fat on all pulse
sequences.
Ovarian carcinoma: Ovarian neoplasms account for more cancer-related deaths than all other primary cancers of the
reproductive system. Combined TA and TVS is initially used for the detection of ovarian carcinoma. These studies
provide superb morphologic detail of the adnexa, allowing detection of masses before they are clinically apparent. CT
is the most commonly performed study for the preoperative staging of a suspected ovarian carcinoma. It is particularly
useful in determining the extent of cytoreductive surgery required to optimize subsequent chemotherapeutic response.
RENAL TUMORS – NEOPLASMS
Moderators: Babnik-Peskar D. (SL) – Efremidis S. (GR)
IMAGING AND STAGING
Mueller-Lisse U.G. 1 , Mueller-Lisse U.L. 2 , Meind. T.l 1 ,Coppenrath E. 1 , Degenhar C.t 1 , Scherr M. 1 , Reiser M.F. 1
Departmets of Clinical Radiology 1 and Urology 2 , University of Munich, Germany
Department of Clinical Radiology, University of Munich, Ziemssenstrasse 1, D-80336 Muenchen, Germany
Introduction
As in other malignant tumors, prognosis in renal cell carcinoma (RCC) depends on the extent of the tumor and its
metastasis at the time of its primary diagnosis. Staging systems formalize the way in which the primary or pre-
85

therapeutic extent of RCC is being described. Surgery is currently the only curative therapeutic approach to RCC (1).
However, even when RCC cannot be cured by means of surgery, it has been demonstrated that surgical resection of
the primary tumor appears to be an integral part of systematic therapy for metastatic RCC (2). With no other curative
therapy at hand, pertinent staging methods imminently relate to prognosis of RCC. Such methods include computed
tomography (CT), particularly when performed with multiple detector rows (multidetector-row CT or MDCT), and
magnetic resonance imaging (MRI). Preoperative staging of RCC is aimed at evaluating surgical options and optimal
surgical technique (1). Since surgical excision of RCC has evolved significantly since the 1960s (2), staging systems
have evolved along the way.
The Robson Classification
The Robson classification for RCC (3,4) was developed in the 1960s. It is based on the observation that surgical
success and tumor-specific patient survival in RCC depend on the confinement of the primary tumor to certain
anatomical landmarks in the body. Confinement of RCC to the renal capsule determines Robson stage I. Extension of
RCC to the perirenal fat or the ipsilateral adrenal gland, which is anatomically included within the confines of Gerota’s
fascia, determines Robson stage II. Extension of RCC into the renal vein, the inferior vena cava (IVC), or regional
lymph nodes are the hallmarks of Robson stage III. Direct extension of RCC to neighbouring organs other than the
adrenal gland and distant metastasis of RCC each define Robson stage IV. Association between Robson stage of RCC
and prognosis has clearly been demonstrated (3-5). Although it is easy to remember and clear-cut in its use of
anatomical landmarks, the Robson classification of RCC has greatly been left for the TNM classification.
The TNM Classification
The TNM classification of the International Union Against Cancer (UICC) distinguishes between the extents of the
primary tumor (T-classification), its lymph node metastases (N-classification), and its distant, or blood-borne
metastases (M-classification). According to current knowledge on prognosis, certain TNM constellations are grouped
together to represent distinct tumor stages of the TNM classification system (Table). While more complicating than the
Robson classification at first glance, the TNM classification demonstrates more capability to grow and change with
increasing knowledge in the diagnosis and treatment of RCC. The association between post-surgical TNM classification
as determined by surgical pathology and tumor-specific 5-year survival of RCC has clearly been demonstrated (6).
Cross-Sectional Imaging in the Staging of Renal Cell Carcinoma
Cross-sectional imaging appears to be capable of recognizing small RCCs that are confined to the renal capsule and
are adequately treated by means of partial nephrectomy. MDCT correctly determines presence and size of all lesions
when 1-mm source images are being evaluated on a dedicated work station (7). Comparison of largest tumor
diameters between CT and gross pathologic examination in patients with non-metastatic RCC reveals that clinical and
pathologic size correlate highly, and do not differ significantly (8).
The difficulty of distinguishing between confinement of RCC to the true renal capsule and extracapsular tumor spread
is reflected by controversial statements in current radiological literature. Accuracy of MDCT and MRI ranges between
80% and 95% (7,9,10), such that both methods currently do not appear to be fully reliable. However, with classical
resective surgery being challenged by radiofrequency ablation and other minimally invasive treatments that do not
yield tissue for histo-pathological work-up, the validity of cross-sectional imaging results has become even more
crucial.
While differential diagnosis between RCC with renal vein (RV) extension and RCC with extension into the inferior vena
cava (IVC) below or above the diaphragm challenges cross-sectional imaging, differential therapy challenges modern
urologic surgery. MDCT and MRI are similarly capable of distinguishing between different levels of venous involvement
with RCC tumor thrombus (11,12). As an additional cross-sectional imaging modality to follow CT in the differentiation
of tumor thrombus extent in RCC, MRI performs similarly to ultrasonography (13). Surgical resection of RCC tumor
thrombus above the diaphragm (TNM 2002 class T3c) previously required sternotomy and cardiopulmonary bypass
(CPB). However, it has recently been demonstrated that surgical resection can be successfully performed through a
transabdominal approach without CPB (14). Still, patient survival – and, thus, prognosis – after surgery for RCC with
venous involvement is subject to controversy (15-17). In view of contradictory results of survival analysis in patients
with RCC, it remains to be seen if TNM 2002 classes T3b and T3c need to be re-defined in the future.
Extension of RCC beyond Gerota’s fascia may be a challenge to cross-sectional imaging when the fascia is barely
transgressed. In such cases, resection of the fascia will probably be the only solution for the urologic surgeon.
Metastasis in regional lymph nodes without synchronous distant metastasis is found in 10-15% of patients with RCC
(5). Current cross-sectional imaging criteria for lymph nodes to be suspicious for metastasis include a short-axis
diameter of 1 cm or more and loss of kidney-shape with a lymph node hilus that includes fat. Asymmetric grouping of
three or more smaller lymph nodes may also be a sign of lymphatic tumor spread in the renal hilus. However, more
than 50% of enlarged regional lymph nodes demonstrate at histopathology with hyperplastic or inflammatory change,
only (5). Specificity of cross-sectional imaging for metastatic lymphadenopathy is poor (18).
Metastasis of RCC to other organs is most frequently found in the lung (31%), followed by bone (15%), brain (8%),
and liver (5%). However, any other organ can be involved (19). Agreement between MRI and surgical-pathologic
staging has been shown to be good for M staging, with a kappa score of 0.66, for two independent reviewers,
respectively (18).
Conclusions
It appears that TNM staging of renal cell carcinoma (RCC) evolves with the advancement of surgical techniques and
will continue to evolve in the future. Cross-sectional imaging has greatly contributed to the diagnosis and staging of
RCC. Both MDCT and MRI perform highly in T-staging of local tumor extent and M-staging of distant metastasis.
However, both MDCT and MRI perform poorly in N-staging.
References
1. Rouviere O, Brunereau L, Lyonnet D, Rouleau P. [Staging and follow-up of renal cell carcinoma][Article in French] J
Radiol 83 (2002) 805-822, discussion 823-824
2. Sengupta S, Zincke H. Lessons learned in the surgical management of renal cell carcinoma. Urology 66 (2005)(5
Suppl) 36-42
3. Robson CJ. Radical nephrectomy for renal cell carcinoma. J Urol 89 (1963) 37-42
4. Robson CJ, Churchill BM, Anderson W. The results of radical nephrectomy for renal cell carcinoma. J Urol 101
(1969) 297-301
5. Atzpodien J et al. Aktuelle Therapiestrategien beim Nierenzellkarzinom. Uni-Med Science Verlag, Bremen, London,
Boston (2003)
6. Hermanek P, Schrott KM. Evaluation of the new tumor, nodes and metastases classification of renal cell carcinoma.
J Urol 144 (1990) 238-242
86

7. Catalano C, Fraioli F, Laghi A, Napoli A, Pediconi F, Danti M, Nardis P, Passariello R. High-resolution multidetector CT
in the preoperative evaluation of patients with renal cell carcinoma. AJR Am J Roentgenol 180 (2003) 1271-1277
8. Yaycioglu O, Rutman MP, Balasubramaniam M, Peters KM, Gonzalez JA. Clinical and pathologic tumor size in renal
cell carcinoma; difference, correlation, and analysis of the influencing factors. Urology 60 (2002) 33-38
9. Roy C Sr, El Ghali S, Buy X, Lindner V, Lang H, Saussine C, Jacqmin D. Significance of the pseudocapsule on MRI of
renal neoplasms and its potential application for local staging: a retrospective study. AJR Am J Roentgenol 184 (2005)
113-120
10. Kamel IR, Hochman MG, Keogan MT, Eng J, Longmaid HE 3rd, DeWolf W, Edelman RR. Accuracy of breath-hold
magnetic resonance imaging in preoperative staging of organ-confined renal cell carcinoma.J Comput Assist Tomogr
28 (2004) 327-332
11. Hallscheidt PJ, Fink C, Haferkamp A, Bock M, Luburic A, Zuna I, Noeldge G, Kauffmann G. Preoperative Staging of
Renal Cell Carcinoma With Inferior Vena Cava Thrombus Using Multidetector CT and MRI: Prospective Study With
Histopathological Correlation. J Comput Assist Tomogr 29 (2005) 64-68
12. Lawrentschuk N, Gani J, Riordan R, Esler S, Bolton DM. Multidetector computed tomography vs magnetic
resonance imaging for defining the upper limit of tumour thrombus in renal cell carcinoma: a study and review. BJU
Int 96 (2005) 291-295
13. Gupta NP, Ansari MS, Khaitan A, Sivaramakrishna MS, Hemal AK, Dogra PN, Seth A. Impact of imaging and
thrombus level in management of renal cell carcinoma extending to veins. Urol Int 72 (2004) 129-134
14. Ciancio G, Soloway MS. Renal cell carcinoma with tumor thrombus extending above diaphragm: avoiding
cardiopulmonary bypass. Urology 66 (2005) 266-270
15. Zini L, Haulon S, Decoene C, Amara N, Villers A, Biserte J, Leroy X, Koussa M. Renal cell carcinoma associated with
tumor thrombus in the inferior vena cava: surgical strategies. Ann Vasc Surg 19 (2005) 522-528
16. Jibiki M, Iwai T, Inoue Y, Sugano N, Kihara K, Hyochi N, Sunamori M. Surgical strategy for treating renal cell
carcinoma with thrombus extending into the inferior vena cava. J Vasc Surg 39 (2004) 829-835
17. Kaplan S, Ekici S, Dogan R, Demircin M, Ozen H, Pasaoglu I. Surgical management of renal cell carcinoma with
inferior vena cava tumor thrombus.Am J Surg 183 (2002) 292-299
18. Ergen FB, Hussain HK, Caoili EM, Korobkin M, Carlos RC, Weadock WJ, Johnson TD, Shah R, Hayasaka S, Francis
IR. MRI for preoperative staging of renal cell carcinoma using the 1997 TNM classification: comparison with surgical
and pathologic staging. AJR Am J Roentgenol 182 (2004) 217-225
19. Rohde V. Nierenzellkarinom. In: Schmelz HU, Sparwasser C, Weidner W (eds.) Facharztwissen Urologie. Springer
Medizin Verlag, Heidelberg (2006) pp. 146-158
SMALL RENAL MASSES/ HOW TO DEAL WITH THESE
Cova M.
Department of Radiology, University of Trieste – Italy
Modern diagnostic imaging of renal masses uses ultrasonography, computed tomography and magnetic resonance
imaging. The new imaging methods, expecially the cross-sectional imaging, have increased the detection rate of
incidental renal masses, posing some problems as to the characterization and management strategy (1). Most of the
incidental renal masses can be easily characterized, without further testing. However some masses, expecially the
small ones, remain undeterminate.
Small renal masses can be cystic or solid. Considering cystic masses, ultrasound is considered definitive only when
identifying a renal mass as a simple cyst. The main problem in characterizing cystic renal masses with US is the
presence of thick septae, calcification, wall tickening, solid components an internal echoes. Contrast media have
recently been suggested as an important aid for evaluating complex cystic masses by US (2). However, most
radiologists recommend that complex cystic masses detected on ultrasound are to be evaluated subsequently with CT
or MRI.
The management of cystic masses is guided by the Bosniak classification, which distinguishes cysts in five categories
according to their likehood of being malignant (3). Bosniak classification was originally designed only for use with CT;
however, it has been recently stated that it can be applied also to MRI.
Category I masses are benign, simple cysts, with hairline-thin wall, water attenuation, no enhancement: these lesions
represent the most common renal masses detected by imaging.
Category II masses are benign, minimally complicated cysts; these masses may contain few hairline-thin septa which
may enhance (not measurably) and may present fine calcification or a short segment of slightly thickened calcification
in the wall or septa. Category II masses also include homogeneously hyperattenuating cysts (3 cm) high attenuation lesions that do not enhance are included in this category.
Category III lesions are truly indeterminate renal masses; They present thickened irregular or smooth walls and/or
septa that demonstrate measurable enhancement.
Category IV includes clearly malignant masses that can present all the criteria of category III lesions, but also contain
distinct enhancing soft-tissue components independent of the wall or septa.
Size is not an important feature on Bosniak classifications, as small cystic masses may be malignant and large ones
may be benign. Hovewer, small cystic renal masses (particularly the ones smaller than 1-2 cm) are more likely to be
benign, expecially if they do not show other features than low attenuation on CT. These lesions used to be problematic
in the past because they could not be imaged well enough to assess their features, such as the presence of septations,
nodularity, calcifications, or enhancement, but this problem has been overcome today, particularly with the use of
multidetector CT and protocols with thin collimations (4). Therefore lesions under 1 cm that appear to be simple cysts,
can be presumed to be benign and do not require other testing. Also small (

lesions some authors have suggested percutaneous biopsy, expecially in patients who have co-morbidities that
increase the risk of surgical exploration. Category IV lesions require surgery.
Considering solid renal masses, in adults solitary solid renal masses found at imaging are mostly renal cell carcinomas.
However, a significant fraction of solid renal masses are benign. There is a direct relationship between malignancy
and size of the mass: the smaller the renal masses, the greater the percentage of benign causes. There are limited
data regarding the natural history of small renal cell carcinoma. It has been demonstrated that patients with
incidentally discovered renal cell carcinoma have a better prognosis than patients with symptoms (hematuria, flank
pain, mass) attributable to renal tumor (5, 6). In fact, most incidentally detected tumors, due to their small size, are
stage T1 or T2, without local infiltration or metastases in almost all cases. On US, small renal tumors are usually
slightly hyperechoic, isoechoic, hypoechoic or mixed. Harmonic imaging enables an easier detection of isoechoic
tumors and improves the differentiation between cysts and tumors; furthermore, a better characterization of mixed
lesion is also possible. Color Doppler is also useful in the characterization of small renal tumors. The increased color
Doppler sensitivity of latest generation color Doppler equipments enables an excellent detection of normal renal
vessels and the detection of tumor vessels. The vascular pattern of renal cell carcinoma consists of both tumoral
vessels inside and around the lesion (7) and is quite different from that of angiomyolipoma. However, similarities with
the vascular pattern of oncocytoma are described. Therefore the contribution in the differential diagnosis between
benign and malignant renal tumor is limited. Color Doppler is useful in the differential diagnosis between tumors and
pseudotumors and in the differential diagnosis between tumors and atypical cysts.
The contribution of US contrast gents in the diagnosis of small renal tumors is still under evaluation (8). High
mechanical index destructive techniques may reveal early contrast enhancement in malignant renal masses. Low
mechanical index continuous imaging may reveal renal masses peripheral and intranodular microvessels.
In spite of the technological improvements of CT, limitations still exist expecially as far as differential diagnosis is
concerned. The differential diagnosis with benign renal tumors such as angiomyolipoma is based on the recognition of
fat within a non calcified renal mass at unenhanced CT. However, about 5% of these tumors contain little or no fat and
appear as a small, hyperattenuating (at unenanced CT), homogeneously enhancing masses (9, 10); therefore, these
cases can not be diagnosed with CT, as they are indistinguishable from a small renal cell carcinoma. In these cases,
rather than presume that the mass is a renal cell carcinoma, it is preferable to further evaluate it with MR imaging.
The MR imaging appearance of clear cell renal cell carcinoma is typically different from that of angiomyolipoma with
minimal fat: clear cell renal carcinoma is typically hyperintense on T2 weighted images, while angiomyolipoma with
minimal fat is typically hypointense on T2 weighted images. However, papillary renal cell carcinoma has the same
features of angiomyolipoma with minimal fat, both appering hypointense on T2 weighted images. Percutaneous biopsy
is the only way to distinguish them (11).
Similar difficulties exist for oncocytoma whose incidence seems to be increased with the increased detection of small
renal masses. Oncocytomas are readily diagnosed with MRI and above all with CT when the lesion shows the wellknown
pattern of a central stellate scar. This pattern is however typical of the larger lesions and rarely seen in the
smaller ones. Moreover, a renal carcinoma may also present a low density central area. Therefore this feature cannot
be considered a fully reliable sign.
MR imaging and percutaneous biopsy may be helpful adjuncts to US and CT when a small (

11) Silverman SG, Israel GM, Herts BR, Richie JP. Management of the incidental renal mass. Radiology 2008; 249: 16-
31
Zagoria R.J.
Wake Forest University School of Medicine, USA
ABLATION OF RENAL TUMORS
Learning Objectives:
1. To describe the techniques used for renal tumor ablations.
2. To report on the results available from personal experience and from the literature.
3. To compare the results with the results of medical and surgical treatments.
Abstract:
Techniques used for ablation of renal tumors includes radiofrequency (RFA), cryoablation, and microwave ablation.
The techniques used in performing these procedures will be discussed and explained. The advantages of each
technique will be described. The short- and medium-term efficacy of RFA for small (

Considering that the current practice of resecting the Bosniak type III lesions may result in an unnecessary
nephrectomy for a benign lesion, recent reports have advocated the use of percutaneous biopsy in an effort to reduce
the number of surgical resections. Unfortunately, for the reasons stated above, the results, if benign, do not clearly
and definitively rule out a malignancy. These patients need to be imaged yearly or biannually to establish stability of
the lesion(s) or a change that may support surgical intervention. Thus, a biopsy in this group of patients is not a
proven or recommended indication.
The literature reveals controversies in the use of fine needle versus core type biopsy in the evaluation of solid renal
masses. Though usually a cytological
specimen allows for an adequate diagnosis, a core biopsy may sometimes yield better results as it obtains larger
amounts of tissue. Adequate imaging of the target and guidance of the needle are of enormous importance in the
performance of an adequate biopsy. As always, the choice of imaging modality depends on the preference of the
person performing the procedure. Overall, percutaneous biopsy of focal renal lesions is safe; complications from the
procedure (most often bleeding, vascular injuries/AVF or pseudoaneurysm, injuries to adjacent organs) are acceptably
low.
In the coming years, improvements and wide acceptance of newer lesion targeting and tissue handling techniques will
result in better understanding of the indications fro renal lesion biopsies and patient outcomes. For the time being,
high quality imaging correctly identifies and characterizes most discovered renal lesions. In selected patients,
percutaneous needle biopsy helps to optimize treatment and long term outcomes.
BIBLIOGRAPHY:
Herts BR, Baker ME: The current role of percutaneous biopsy in the evaluation of renal masses. Semin Urol Oncol
1995;13:254.
Frank I, Blute ML, Cheville JC, Lohse CM, Weaver AL, Zincke H: Solid renal tumors: an analysis of pathological features
related to tumor size. J Urol 2003:170:2217.
Silverman SG, Gan YU, Mortele KJ, Tuncali K, Cibas ES: Renal mass biopsy in the new millennium: An important
diagnostic procedure. Genitourinary Radiology Categorical Course Syllabus; RSNA 2006:219
Lang EK, Macchia RJ, Gayle B, et al: CT-guided biopsy of indeterminate renal cystic masses (BosniaK 3 and 2F):
accuracy and impact on clinical management. Eur Radiol 2002;12:2518
Kim JK, Park SY, Shon JH, Oho KS: Angiomyolipoma with minimal fat: differentiation from renal cell carcinoma at
biphasic helical CT. Radiology 2004;230:677
Kassouf W, Aprikian AG, Laplante M, Tanguay S: Natural history of renal masses followed expectantly. J Urol
2004;171:111
Liu J, Fanning CV: Can renal oncocytomas be distinguished from renal cell carcinoma on fine-needle aspiration
specimens A study of conventional smears in conjunction with ancillary studies. Cancer 2001;93:390
Taavitsainen M, Krogerus L, Rannikko S: Aspiration biopsy in renal angiomyolipoma. Acta Radiol 1989;30:381
MALE GENITALIA
Moderators: Pavlica P. (IT) – Dalla-Palma L. (IT)
SCROTAL MASSES
Oyen R.H., De Wever L.L.
Department of Radiology, University Hospitals Leuven, Belgium
Ultrasound (US) remains the key-modality for the evaluation of the scrotal content. US enables to answer to all
relevant questions: (a) is there a mass (b) is it a testicular or extratesticular mass (reported sensitivity 98-100%),
(c) is it unilateral or bilateral, and (d) to some extent, to characterize the nature. Magnetic resonance imaging (MRI) is
indicated in highly selected patients only, when there is discrepancy with US and/or clinical findings, with equivocal US
and with diffuse (bulky) testicular/scrotal neoplasia. It is estimated that in routine practice MR would be contributive in
approximately 5% of scrotal mass lesions.
Most testicular tumors present as a palpable mass, but not all palpable masses are malignant tumors, nor are all
intratesticular lesions palpable.
In general, solid intratesticular mass lesions must be considered as malignant masses; cystic lesions are almost always
benign with only few exceptions. A histological diagnosis of solid testicular mass lesions cannot be achieved. Color-
Doppler is not beneficial for lesion characterization. However, intralesional ‘crossing’ blood vessels is almost exclusively
seen in malignant lesions. Seminomas present most often as nodular or multinodular hypoechoic masses. Non
seminomatous germ cell tumors (NSGCT) are commonly heterogeneous even when they are small, and frequently
show cystic or calcified parts with alternating hypo- and hyperechoic areas. Furthermore, since most NSCGT are mixed
tumors, the appearance at US is widely variable.
In men with retroperitoneal lymph node metastases from unknown origin, scrotal US is indicated. In some cases, the
testicular primary tumor may be shrunken, fibrotic and calcified (i.e. burned-out lesion).
Gonadal stromal tumors account for approximately 3% to 6% of all testicular neoplasms (more than 2/3 are Leydig
cell tumors), and over 90% are benign. Leydig cell tumors can present with symptoms related to hormonal activity
(gynecomastia, pseudopubertas precox, reduced libibo and infertility). They are most frequently small and occasionally
bilateral.
Testicular lymphoma, leukemia and metastases are rare and based on imaging indiscernable from germ cell tumors.
Lymphoma is one of the most common neoplasms in men aged over 50, and often with bilateral synchronous or
metachronous involvement in 8.5%-18% of cases. The epididymis and spermatic cord are frequently involved.
Leukema is rare, but frequently recurs in the testis, particularly in children. Metastatic involvement of the testis by
other cancers does occur. The most common primary sites include the prostate, lung, gastrointestinal tract, skin and
kidney, but others have also been reported (including pancreas, bladder, thyroid, neuroblastoma, schwannoma,
retinoblastoma).
90

Risk factors for testicular tumors include prior testicular tumor, relatives of 1 st degree, infertility, intersex syndromes,
testicular microlithiasis (TML), and cryptorchidism. Solitar or isolated (fewer than 5) intratesticular calcifications are a
frequent (benign) finding at routine scan (not visible at MRI !). More than 5 microcalcifications are worysome. TML is
considered to express in dysgenetic gonads, and is, therefore, associated with cryptorchydism, infertility, Kinefelter
syndrome, atrophy and testicular tumors. Annual review with US is recommended in men with TML and associated risk
factors; in men with no additional risk factors, surveillance is not warranted. Monthly self examination should be
strongly advocated, as indeed to all men.
A growing challenge is the incidental detection of focal or multifocal, hypoechoic, solid, small-sized (subcentimetric)
lesions. Such lesions tend to be more frequently found in hypofertile men, indeed more often referred for scrotal US.
They are often benign Leydig-cell nodules but malignancy can not be excluded. When solitary, ultrasound-assisted
testis sparing surgery with intraoperative frozen sections is an option.
Many benign testicular lesions may mimick malignant tumors. Surgery must be avoided in the majority of cases. The
incidence of testicular cysts increases with age; cysts in the rete testis have a typical location (mediastinum), are often
bilateral and associated with spermatocoele. A rounded mass with concentric layering is typical of the benign
epidermoid cyst. Testis sparing surgery is justified. Adrenal rests can be entrapped in the testes in congenital adrenal
hyperplasia and Cushing syndrome; surgery should be avoided.
Men with segmental testicular infarction, hematoma are symptomatic (acute pain, trauma), and careful follow-up
ultrasound studies may be the appropriate strategy.
Inguinal hernias are among the most common paratesticular masses. Paratesticular tumors are not as infrequent as
generally thought. They are primarily seen in older patients and the vast majority are benign. Adenomatoid tumor of
the epididymis is the most frequent presenting as a smooth, round and well-circumbscirbed isoechoic or hyperechoic
homogeneous mass. Other solid epididymal mass lesions include sperm granulomas or chronic (granulomatous)
epididymitis. Epididymal cysts can become very large, thus mimicking hydrocele. Papillary cystadenomas deserve a
special mention due to their association with von Hippel-Lindau disease, especially when bilateral.
Malignant extratesticular and extraepididymal tumors are extremely rare in adults. Most often these masses are
lipomas, liposarcomas or inflammatory masses. The tunica vaginalis may give rise to mesotheliomas. 15-20% are
benign; malignant mesotheliomas are highly aggressive cancers.
Take home messages:
1. To stress that ultrasound is the preferred modality to assess scrotal masses.
2. To identify common and unusual tumors, and to recognise some features allowing characterization.
3. To recognise the most common pseudotumors.
4. To illustrate the feasibility of sparing testis surgery in selected cases as in hypofertile men.
Suggested Reading
Isidori AM, Lenzi A. Scrotal ultrasound: Morphological and Functional Atlas. 2008. Forum Service Editore Genova Italy
US MR imaging correlation in pathologic conditions of the scrotum. Kim W, Rosen MA, Langer JE, Banner MP,
Siegelman ES, Ramchandani P. Radiographics. 2007 Sep-Oct;27(5):1239-53. Review.
Imaging of testicular germ cell tumours. Dalal PU, Sohaib SA, Huddart R. Cancer Imaging. 2006 Sep 7;6:124-34.
Imaging of the epididymis. Lee JC, Bhatt S, Dogra VS. Ultrasound Q. 2008 Mar;24(1):3-16. Review.
Imaging of testicular germ cell tumours. Dalal PU, Sohaib SA, Huddart R. Cancer Imaging. 2006 Sep 7;6:124-34.
The role of imaging in the diagnosis, staging, and management of testicular cancer. Sohaib SA, Koh DM, Husband JE.
AJR Am J Roentgenol. 2008 Aug;191(2):387-95. Review.
Leydig cell tumors of the testis: gray scale and colour-Doppler sonographic appearance. Maizlin ZV, Belenky A,
Kunichezky M, Sandbank J Strauss S. J Ultrasound Med. 2004; 23(7): 959-964
Testicular lymphoma: an update for clinicians. Verma N, Lazarchick J, Gudena V, Turner J, Chaudhary UB. Am J Med
Sci. 2008 Oct;336(4):336-41. Review.
Primary testicular non-Hodgkin's lymphoma--a review article. Bhatia K, Vaid AK, Gupta S, Doval DC, Talwar V. Sao
Paulo Med J. 2007 Sep 6;125(5):286-8. Review.
Imaging diagnosis of testicular lymphoma. Liu KL, Chang CC, Huang KH, Tsang YM, Chen SJ. Abdom Imaging. 2006
Sep-Oct;31(5):610-2. Epub 2006 Feb 7.
Metastatic prostatic carcinoma to testis: histological features mimicking lymphoma. Haupt B, Ro JY, Ayala AG, Zhai J.
Int J Clin Exp Pathol. 2009;2(1):104-7. Epub 2008 May 10.
Metastatic carcinoma to the testis: a clinicopathologic analysis of 26 nonincidental cases with emphasis on deceptive
features. Ulbright TM, Young RH. Am J Surg Pathol. 2008 Nov;32(11):1683-93.
Carcinoid tumours of the testis. Stroosma OB, Delaere KP. BJU Int. 2008 May;101(9):1101-5. Epub 2008 Jan 8.
Review.
91

Testicular microlithiasis: prevalence and risk of concurrent and interval development of testicular tumor in a referred
population. Ahmad I, Krishna NS, Clark R, Nairn R, Al-Saffar N. Int Urol Nephrol. 2007;39(4):1177-81. Epub 2007 Jun
30.
Testicular microlithiasis as a familial risk factor for testicular germ cell tumour. Coffey J, Huddart RA, Elliott F, Sohaib
SA, Parker E, Dudakia D, Pugh JL, Easton DF, Bishop DT, Stratton MR, Rapley EA. Br J Cancer. 2007 Dec
17;97(12):1701-6. Epub 2007 Oct 30.
How worrisome is testicular microlithiasis Costabile RA. Curr Opin Urol. 2007 Nov;17(6):419-23. Review.
Current management strategies for testicular microlithiasis. Jaganathan K, Ahmed S, Henderson A, Rané A. Nat Clin
Pract Urol. 2007 Sep;4(9):492-7. Review.
Testicular microlithiasis and carcinoma in situ overview and proposed clinical guideline. van Casteren NJ, Looijenga LH,
Dohle GR. Int J Androl. 2008 Dec 16. [Epub ahead of print]
Testicular calcification and microlithiasis: association with primary intra-testicular malignancy in 3,477 patients. Miller
FN, Rosairo S, Clarke JL, Sriprasad S, Muir GH, Sidhu PS. Eur Radiol. 2007 Feb;17(2):363-9. Epub 2006 May 18.
Grading of classical testicular microlithiasis has no effect on the prevalence of associated testicular tumors. Sanli O,
Kadioglu A, Atar M, Acar O, Nane I, Kadioglu A. Urol Int. 2008;80(3):310-6. Epub 2008 May 14.
Testicular Microlithiasis Preceding Metastatic Mixed Germ Cell Tumor-First Pediatric Report and Recommended
Management of Testicular Microlithiasis in the Pediatric Population. Slaughenhoupt B, Kadlec A, Schrepferman C.
Urology. 2008 Dec 17. [Epub ahead of print]
Increased prevalence of testicular microlithiasis in men with familial testicular cancer and their relatives. Korde LA,
Premkumar A, Mueller C, Rosenberg P, Soho C, Bratslavsky G, Greene MH. Br J Cancer. 2008 Nov 18;99(10):1748-53.
Epub 2008 Oct 7.
Testicular microlithiasis: our experience of 10 years. Lam DL, Gerscovich EO, Kuo MC, McGahan JP. J Ultrasound Med.
2007 Jul;26(7):867-73.
Association between testicular microlithiasis and primary malignancy of the testis: our experience and review of the
literature. Parenti GC, Zago S, Lusa M, Campioni P, Mannella P. Radiol Med. 2007 Jun;112(4):588-96. Epub 2007 Jun
11. English, Italian.
Testicular microlithiasis: what does it mean clinically Dagash H, Mackinnon EA. BJU Int. 2007 Jan;99(1):157-60. Epub
2006 Oct 9. Review.
A 5-year followup study of asymptomatic men with testicular microlithiasis. DeCastro BJ, Peterson AC, Costabile RA. J
Urol. 2008 Apr;179(4):1420-3; discussion 1423. Epub 2008 Mar 4.
Testicular microlithiasis identified ultrasonographically in Japanese adult patients: prevalence and associated
conditions. Sakamoto H, Shichizyou T, Saito K, Okumura T, Ogawa Y, Yoshida H, Kushima M. Urology. 2006
Sep;68(3):636-41. Epub 2006 Sep 18.
Cancer risk in male factor-infertility. Negri L, Benaglia R, Fiamengo B, Pizzocaro A, Albani E, Levi Setti PE. Placenta.
2008 Oct;29 Suppl B:178-83. Epub 2008 Aug 27.
Early testicular cancer: a problem in an infertility clinic. Phillips N, Jequier AM. Reprod Biomed Online. 2007
Nov;15(5):520-5.
High prevalence of testicular cancer in azoospermic men without spermatogenesis. Mancini M, Carmignani L, Gazzano
G, Sagone P, Gadda F, Bosari S, Rocco F, Colpi GM. Hum Reprod. 2007 Apr;22(4):1042-6. Epub 2007 Jan 12.
Management of incidental impalpable intratesticular masses of < or = 5 mm in diameter. Müller T, Gozzi C, Akkad T,
Pallwein L, Bartsch G, Steiner H. BJU Int. 2006 Nov;98(5):1001-4. Epub 2006 Sep 6.
92

Conservative management of testicular germ-cell tumors. Oliver T. Nat Clin Pract Urol. 2007 Oct;4(10):550-60.
Review.
Carefully selected intratesticular lesions can be safely managed with serial ultrasonography. Connolly SS, D'Arcy FT,
Gough N, McCarthy P, Bredin HC, Corcoran MO. BJU Int. 2006 Nov;98(5):1005-7; discussion 1007.
Organ-sparing microsurgical resection of incidental testicular tumors plus microdissection for sperm extraction and
cryopreservation in azoospermic patients: surgical aspects and technical refinements. Hallak J, Cocuzza M, Sarkis AS,
Athayde KS, Cerri GG, Srougi M. Urology. 2009 Apr;73(4):887-91; discussion 891-2. Epub 2009 Feb 8.
Commentary on Incidental testicular lesions found during infertility evaluation are usually benign and may be managed
conservatively Eifler JB, King P, Schlegel PN, Brady Urology Foundation, Department of Urology, Weill Cornell Medical
College, New York Presbyterian Hospital, New York, NY.Richie JP. Urol Oncol. 2009 Mar-Apr;27(2):223.
Testicular lesions other than germ cell tumours: feasibility of testis-sparing surgery. Passman C, Urban D, Klemm K,
Lockhart M, Kenney P, Kolettis P. BJU Int. 2009 Feb;103(4):488-91. Epub 2008 Sep 12.
Nine cases of nonpalpable testicular mass: an incidental finding in a large scale ultrasonography survey. Avci A, Erol B,
Eken C, Ozgok Y. Int J Urol. 2008 Sep;15(9):833-6. Epub 2008 Jul 24.
Ultrasound-guided core-needle biopsy of the testis for focal indeterminate intratesticular lesions. Soh E, Berman LH,
Grant JW, Bullock N, Williams MV. Eur Radiol. 2008 Dec;18(12):2990-6. Epub 2008 Jul 19.
"Burned out" phenomenon of the testis in retroperitoneal seminoma. Curigliano G, Magni E, Renne G, De Cobelli O,
Rescigno M, Torrisi R, Spitaleri G, Pietri E, De Braud F, Goldhirsch A. Acta Oncol. 2006;45(3):335-6. No abstract
available.
Retroperitoneal seminoma with 'burned out' phenomenon in the testis. Perimenis P, Athanasopoulos A, Geraghty J,
Macdonagh R. Int J Urol. 2005 Jan;12(1):115-6.
'Burned-out' primary testicular cancer. Fabre E, Jira H, Izard V, Ferlicot S, Hammoudi Y, Theodore C, Di Palma M,
Benoit G, Droupy S. BJU Int. 2004 Jul;94(1):74-8.
Imaging of burned-out testis tumor: five new cases and review of the literature. Tasu JP, Faye N, Eschwege P, Rocher
L, Bléry M. J Ultrasound Med. 2003 May;22(5):515-21. Review.
Sonographic and magnetic resonance imaging appearance of a burned-out testicular germ cell neoplasm. Patel MD,
Patel BM. J Ultrasound Med. 2007 Jan;26(1):143-6. No abstract available.
Conservative surgical therapy for leydig cell tumor. Carmignani L, Colombo R, Gadda F, Galasso G, Lania A, Palou J,
Algaba F, Villavicencio H, Colpi GM, Decobelli O, Salvioni R, Pizzocaro G, Rigatti P, Rocco F. J Urol. 2007
Aug;178(2):507-11; discussion 511. Epub 2007 Jun 11.
Cystic dysplasia of the rete testis. Smith PJ, DeSouza R, Roth DR. Urology. 2008 Jul;72(1):230.e7-10. Epub 2008 Mar
3
Epidermoid cyst of the testis. Mak CW, Chen CY, Tzeng WS, Li CF. Australas Radiol. 2007 Oct;51 Spec No.:B74-6.
Sonographic and MR imaging findings of testicular epidermoid cysts. Cho JH, Chang JC, Park BH, Lee JG, Son CH. AR.
2002 178(3):743-748
Synchronous epidermoid cyst and mature teratoma of the testis: an unusual association. Huyghe E, Mazerolles C,
Moran C, Khedis M, Khoury E, Nohra J, Soulié M, Plante P. Urol Int. 2007;78(4):364-6
Testicular adrenal rests in a patient with congenital adrenal hyperplasia: US and MRI features. Fitoz S, Atasoy C,
Adiyaman P, Berberoglu M, Erden I, Ocal G. Comput Med Imaging Graph. 2006 Dec;30(8):465-8.
Segmental testicular ischaemia: presentation, management and follow-up. Gianfrilli D, Isidori AM, Lenzi A. Int J
Androl. 2008 May 22. [Epub ahead of print]
93

Bilateral testicular infarction and orchiectomy as a complication of polyarteritis nodosa. Stroup SP, Herrera SR, Crain
DS. Rev Urol. 2007 Fall;9(4):235-8.
Segmental testicular infarction: conservative management is feasible and safe. Madaan S, Joniau S, Klockaerts K,
DeWever L, Lerut E, Oyen R, Van Poppel H. Eur Urol. 2008 Feb;53(2):441-5. Epub 2007 Mar 28.
Clinical and ultrasound features of segmental testicular infarction: six-year experience from a single centre. Bilagi P,
Sriprasad S, Clarke JL, Sellars ME, Muir GH, Sidhu PS. Eur Radiol. 2007 Nov;17(11):2810-8. Epub 2007 Jul 5.
Idiopathic testicular infarction initially masquerading as urolithiasis and epididymitis. Huang CC, Wen YS. Am J Emerg
Med. 2007 Jul;25(6):736.e1-2. No abstract available.
Clinical and ultrasound features of segmental testicular infarction: six-year experience from a single centre. Bilagi P,
Sriprasad S, Clarke JL, Sellars ME, Muir GH, Sidhu PS. Eur Radiol. 2007 Nov;17(11):2810-8. Epub 2007 Jul 5.
Idiopathic testicular infarction initially masquerading as urolithiasis and epididymitis. Huang CC, Wen YS. Am J Emerg
Med. 2007 Jul;25(6):736.e1-2. No abstract available.
Segmental testicular infarction. Conservative management is feasible and safe: part 2. Madaan S, Joniau S, Klockaerts
K, DeWever L, Lerut E, Oyen R, Van Poppel H. Eur Urol. 2008 Mar;53(3):656-8. Review. No abstract available.
Intratesticular haematoma: differentiation from tumour on clinical history and ultrasound appearances in two cases.
Purushothaman H, Sellars ME, Clarke JL, Sidhu PS. Br J Radiol. 2007 Aug;80(956):e184-7.
Intrascrotal involvement of sarcoidosis presenting like testicular appendices. Obinata D, Yamaguchi K, Hirano D,
Fuchinoue A, Nemoto N, Takahashi S. Int J Urol. 2007 Jan;14(1):87-8.
Leiomyoma of the testis: a rare testicular mass. O'Brien J, Loftus B, Barrett C, Torreggiani W. J Clin Ultrasound. 2008
May;36(4):240-2
Multimodality imaging of paratesticular neoplasms and their rare mimics. Akbar SA, Sayyed TA, Jafri SZ, Hasteh F,
Neill JS. Radiographics. 2003; 23(6): 1461-1476
ACUTE SCROTUM
Bertolotto M.
Dept Radiology, University of Trieste, Ospedale di Cattinara, Italy
Acute scrotum is the most common urologic emergency and may present a diagnostic challenge even to the most
experienced clinicians. Epididymo-orchitis, torsion of appendages, and testicular torsion are the most important
causes; other pathological conditions, however, may enter in the differential diagnosis. In patients with acute scrotal
pain the main goal for the imaging is to differentiate surgical conditions from those who would benefit from
conservative management alone. Gray scale and color Doppler ultrasound help suggest specific diagnosis.
Epididymo-orchitis, representing at least 75% of all inflammatory scrotal disease processes, is the most common
cause of acute scrotal pain in adult [1]. Isolated orchitis, funicolitis, and other inflammatory conditions are less
common. Complications of scrotal inflammation include abscess, testicular ischemia, and pyocele formation.
In patients with epididymo-orchitis the epididymis is enlarged at grey-scale ultrasound, usually hypoechoic with
heterogeneous echotexture. Associated signs of inflammation such as reactive hydrocele or pyocele and scrotal skin
thickening are often present [2]. In diffuse orchitis the testis is usually enlarged, with reduced echogenicity and with
inhomogeneous echo pattern. Hypervascularity at color Doppler interrogation is a well-established diagnostic criterion
for inflammation and may be the only imaging finding of epididymo-orchitis in some men where symptoms are lacking
and gray-scale ultrasound is normal [3]. In early inflammation, isolated funiculitis can be occasionally recognized as
hypervascularization of the spermatic cord with normal epididymis and testis. More often, hypervascularization
involves also the tail of the epididymis, and then progresses to the epididymal head and to the testis. Waveform
analysis may reveal low-resistance flows of the epididymal vessels [4].
Focal orchitis may result from hematogenous or lymphatics dissemination. More often, however, infection spreads
from the adjacent epididymis. In the former cases, the inflammatory process usually presents as ill defined lesions
with variable echogenicity mimicking a testicular mass. Color Doppler interrogation often reveals increased vascularity
[3]. In patients with negative serum tumour markers clinical symptoms such as fever and increased white blood cell
count strongly would suggest an infectious process. In focal orchitis spreading from the epididymis inflammatory
changes are predominantly found at the testicular hilum. They usually presents with a crescent shaped hypoechoic
area within the testis, adjacent to the enlarged epididymis, showing hypervascularization at color Doppler
interrogation.
In patients with postinflammatory ischemia producing severe testicular swelling and edema venous outflow obstruction
may occur. Vascularity of the affected testis is reduced compared with the contralateral testis, and high resistance
arterial flows, or diastolic flow reversal, are recorded in the testicular arteries at color Doppler interrogation. These
findings can be recognized also in patients with partial testicular torsion.
94

Scrotal abscesses present at ultrasound with irregular walls, through transmission, and low-level internal echoes, or
as heterogeneously hypoechoic lesions lacking vascularization at color Doppler interrogation. They have often
hypervascular margins [5]. An abscess can rupture through the tunica vaginalis and produce a pyocele and even a
fistula to the overlying skin [2].
Pyocele appears echogenic at ultrasound, with mobile echoes, internal septations and fluid-fluid levels, or as a
complex, heterogeneous fluid collection with thickened or irregular internal septations. It is usually associated to
scrotal edema. Gas may be present. Color Doppler imaging often reveals increased vascularity of the scrotal wall.
Testicular torsion is one of the most common cause of acute scrotal pain in children, with an annual incidence of 1/
4000 in males younger than 25 years [6]. Intravaginal torsion, caused by a congenital malformation of the processus
vaginalis, accounts for 90% of cases. Appendix testis and epididymis are remnants of embryological ducts. Torsion of
the appendix testis is more frequent, and accounts for 20% to 40% of acute scrotal pain in child [7], while in adult
this condition is less common. Isolated torsion of the epididymis and spermatocele torsion are extremely rare.
Segmental testicular infarction is rare, with fewer than 50 cases reported since 2007 [8].
In patients with testicular torsion ultrasound findings vary with the duration and degree of rotation of the spermatic
cord [3]. Gray-scale images are nonspecific and often appear normal if the torsion has just occurred. Testicular
swelling and decreased echogenicity are the most commonly encountered findings 4–6 hours after the onset of torsion.
With the proceding of the time, the testis shows a progressive heterogeneous echotexture secondary to vascular
congestion, hemorrhage, and infarction. At this time, a mild hydrocele is generally observed. After 24-36 hours the
testis is markedly hypoechoic, usually with anechoic and patchy hyperechoic areas due to colliquative and hemorragic
infarction [3]. The decrease in size begins after 30-40 days and leads to a small shrunken testis after 3-6 months. An
enlarged hypoechoic epididymal head may be visible because the deferential artery supplying the epididymis is often
involved in the torsion.
The role of color Doppler ultrasound in the diagnosis of acute testicular torsion is well established [3, 9-11]. The testis
is avascular, or markedly hypovascular, depending on the degree of twisting, while the rest of the scrotal blood flow is
preserved, though the epididymis does become relatively ischemic. Within a few hours, the paratesticular tissues and
the scrotal wall become hyperemic in an attempt to open collaterals. By using the absence of identifiable intratesticular
flow as the only criterion for detecting torsion, color Doppler ultrasound was 86% sensitive, 100% specific, and 97%
accurate in the diagnosis of torsion in patients with painful scrotum [12].
The ability of color Doppler ultrasound to show incomplete or partial torsion remains problematic. Arterial testicular
flows can be present, principally near the hilum but occasionally also in a more peripheral distribution, with variable
waveform characteristics depending on the severity and duration of torsion. Monophasic waveform, increased
resistance index with decreased diastolic flow velocities, or diastolic flow reversal may be seen [13]. As previously
described for infection, this pattern is caused by swelling and edema occluding the venous flow.
Al ultrasound, direct visualization of the twisted portion of the spermatic cord can be identified both in patients with
complete and with incomplete torsion as a funicular mass, or as an abrupt change in the course, size, and shape of the
spermatic cord. Twisting occurs just outside the external inguinal ring, at a varying distance above the testis, or
posterior to the testis. Demonstration of the funicular vessels wrapping around the central axis of the twisted
spermatic cord, described as the “whirlpool sign”, is considered the most definitive sign of testicular torsion [14].
Movement of the probe to and fro along the axis of the spermatic cord eases identification of this sign.
In acute testicular torsion, the MR appearance of the testis remains normal on both T1- and T2-weighted images.
Only in the subacute or chronic stage of the disease the signal intensity of the testis changes due to necrosis and
hemorrhagic elements.
Segmental infarction of the testis appears at ultrasound as an ill defined hypoechoic mass, usually peripheral, lacking
vascularization at color Doppler interrogation [10]. Acute infarctions are usually rounded [6]; in time they decrease in
size, and become wedge-shaped with vertex directed toward the testicular mediastinum. Segmental infarction may
eventually increase in echogenicity, due to fibrosis, and present with calcifications [6].
At ultrasound twisted cystic epididymal appendix appears as a thick walled structure with anechoic or low reflective
center [11]. Twisted solid appendix usually appears as an echogenic rounded structure, often with inhomogeneous
echotexture, 5mm in size or larger [7, 15]. At color Doppler interrogation the tissues surrounding the twisted appendix
are usually hyperaemic. Testicular flows are normal or enhanced. Reactive hydrocele is often present.
Differential diagnosis
A significant diagnostic problem in the clinical practice is differentiation among clinical situations presenting with acute
scrotal pain. Testicular trauma can be distinguished based solely on history and physical evidence of trauma, and
absence of testicular flow allows a confident diagnosis of complete testicular torsion. Many cases of partial torsion,
however, are recognized only after careful examination of the morphologic characteristics of the spermatic cord, and
evaluation of the Doppler waveform changes relative to the contralateral testicle.
Seeking for the twisted portion of the spermatic cord, presenting as an abrupt change in its configuration, and for the
whirlpool sign both at grey-scale and color Doppler ultrasound is of paramound importance for identification of partial
torsion and increases the diagnostic confidence in the diagnosis of complete torsion as well.
Diminished flow in the symptomatic testis suggests incomplete torsion. Spectral waveform analysis is crucial when
color Doppler examination is indeterminate. A testis with spontaneous detorsion may be hyperemic, simulating
epididymo-orchitis. Diagnosis of spontaneous detorsion should be considered when testicular hyperemia is identified
after spontaneous resolution of acute scrotal pain.
References
1. Muttarak M, Lojanapiwat B. The painful scrotum: an ultrasonographical approach to diagnosis. Singapore Med
J 2005;46:352-357; quiz 358
2. Pearl MS, Hill MC. Ultrasound of the scrotum. Semin Ultrasound CT MR 2007;28:225-248
3. Dogra VS, Gottlieb RH, Oka M, Rubens DJ. Sonography of the scrotum. Radiology 2003;227:18-36
4. Jee WH, Choe BY, Byun JY, Shinn KS, Hwang TK. Resistive index of the intrascrotal artery in scrotal
inflammatory disease. Acta Radiol 1997;38:1026-1030
5. Bhatt S, Rubens DJ, Dogra VS. Sonography of benign intrascrotal lesions. Ultrasound Q 2006;22:121-136
6. Howlett DC, Marchbank ND, Sallomi DF. Pictorial review. Ultrasound of the testis. Clin Radiol 2000;55:595-
601
7. Yang DM, Lim JW, Kim JE, Kim JH, Cho H. Torsed appendix testis: gray scale and color Doppler sonographic
findings compared with normal appendix testis. J Ultrasound Med 2005;24:87-91
8. Magill P, Jacob T, Lennon GM. A rare case of segmental testicular infarction. Urology 2007;69:983 e987-988
9. Ragheb D, Higgins JL, Jr. Ultrasonography of the scrotum: technique, anatomy, and pathologic entities. J
Ultrasound Med 2002;21:171-185
95

10. Oyen RH. Scrotal ultrasound. Eur Radiol 2002;12:19-34
11. Cochlin DL. Acute testicular pain. Imaging 2005;17:91-100
12. Burks DD, Markey BJ, Burkhard TK, Balsara ZN, Haluszka MM, Canning DA. Suspected testicular torsion and
ischemia: evaluation with color Doppler sonography. Radiology 1990;175:815-821
13. Dogra VS, Rubens DJ, Gottlieb RH, Bhatt S. Torsion and beyond: new twists in spectral Doppler evaluation of
the scrotum. J Ultrasound Med 2004;23:1077-1085
14. Vijayaraghavan SB. Sonographic differential diagnosis of acute scrotum: real-time whirlpool sign, a key sign
of torsion. J Ultrasound Med 2006;25:563-574
15. Coley BD. The Acute Paediatric Scrotum. Ultrasound Clin 2006;1:485-496
MR OF SEMINAL VESICLE AND TESTICLE IN INFERTILE MEN
Ocantos J.
Hospital Italiano de Buenos Aires, Argentina
IMAGING OF PENILE DISORDERS
Scherr M.K. 1 , Mueller-Lisse U.G. 1 , Mueller-Lisse U.L. 2 , Meindl T. 1 , Coppenrath E. 1 , Degenhart C. 1 , Reiser
M.F. 1
Depts. of Clinical Radiology 1 and Urology 2 , University of Munich, Germany
The diagnosis of penile disorders occasionally involves radiologic imaging examinations. The most frequently used
imaging modality is ultrasonography (US). Depending on the clinical work environment, US may be performed by the
urologist or by the radiologist. Since many diseases of the penis affect the penile urethra, cysturethrography and
endoscopy are often carried out by the urologist. Cavernosography has been the mainstay of imaging evaluation of the
penile corpora; however, with the development of colour Doppler US and magnetic resonance imaging (MRI), it has
decreased in clinical importance. MRI of the penis and pelvis is usually performed when the disorder is complex and
cannot be sufficiently diagnosed by means of US or endoscopy, conventional X-ray, or fluoroscopy examinations.
Examples include complex distributions of congenital anomaly, complex trauma, extensive inflammatory disease,
invasive tumor, tumor staging, tumor recurrence, erectile dysfunction (ED) and complex post-operative changes,
including status pre and post penile prothesis. Computed tomography (CT) is carried out especially in trauma setting.
MRI helps in the detection and staging of penile cancer and serves as a problem solving diagnostic modality (1). In
selected cases like high-flow priapism, suspicion for vascular-based ED or traumatic vascular damage, magnetic
resonance angiograpy (MRA) or digital subtraction angiography (DSA) - with or without intervention - may be
indicated.
Benign Disease of the Penis
Congenital Penile Anomaly
Among the most frequent congenital anomalies affecting the penis are hypospadia or epispadia, conditions in which
the urethral orifice does not open at the tip of the glans penis. Epispadia is frequently associated with other defects of
lower anterior midline closure, such as bladder exstrophy. The various manifestations can be summarized as
representing different degrees of severity of the epispadia-exstrophy complex of genito-urinary malformations (4) and
can be precisely imaged by means of MRI.
Post-Traumatic Penile Alterations
In general, trauma to the penis and the pelvis can be blunt or penetrating and usually results in local haematoma. In
complex pelvic fractures, CT imaging allows conclusions with regard to compromised penile vascularization or penile
innervation. If the trauma is suspicous for vascular interference, performing additional DSA or MRA maybe helpful.
Penile Haematoma may affect the subcutaneous compartment alone or involve one or more of the penile corpora.
When blunt trauma occurs to the erect penis, it is frequently most severe at the base of the penis, close to the pubic
bone, despite its protection by the suspensory ligament, which extends from the symphysis pubis to the base of the
penis. Fracture of the penis is a rare blunt penile trauma. The underlying trauma most frequently occurs during coitus.
It represents an emergency entity and requires immediate surgical treatment. While history and physical examination
are essential for the correct diagnosis, imaging is used in unclear and atypical cases. Imaging methods applied include
cavernosography, urethrography, ultrasound, and MRI (6).
Post-traumatic alterations in the penile corpora include scarring, which may change the width and shape of the tunica
albuginea and may partially or completely interrupt the continuity of the blood-containing compartment of a penile
corpus. When blood flow within the corpus is compromised, thrombosis may result from haemostasis. In status post
penile trauma, its simplicity, precision, and availability make sonourethrography a valuable tool for the reconstructive
urologist. However, MRI is considered to be particularly valuable for defining the distorted pelvic anatomy that is
frequently associated with post-traumatic posterior urethral strictures (3).
Priapism, Fibrosis of the Penile Corpora and Erectile Dysfunction
There are essentially two distinct entities associated with priapism. Low-flow priapism usually is the consequence of
venous obstruction e.g. by cavernosal thrombosis or tumor or neurogenic misregulation and can be differentiated from
the high-flow variant by Doppler US. High-flow priapism may be proven and interventionally treated by embolization
based on pelvic-penile DSA (10). The underlying arterio-venous fistula or aneurism often is of post-traumatic origin by
both straddle injury and repetitive micro-trauma to the base of the penis.
Fibrosis of the penile corpora may occur as a sequel of prolonged priapism or intravenous injections. Compromised
blood flow, due to haemostasis or scarring within the penile corpora, is causative for the fibrosis. Fibrosis of the penile
corpora may be associated connective tissue disease and has been diagnosed in patients with systemic lupus
erythematosus. In other cases, fibrosis may be the underlying condition in young men who complain of impotence and
may never have had an erection. Transverse fibrotic membranes that partially or completely occlude a corpus
cavernosum are the underlying defect in partial priapism (12). Thrombosis of the affected part of the corpus
cavernosum and clinically partial priapism may be the consequences of membranous occlusion. Besides morphologic
cavernosal changes ED may be caused by non-traumatic vascular changes to be diagnosed by pelvic DSA or MRA.
Penile Prosthesis
96

Penile implants offer a dependable way of restoring erection. However, although they are not very frequent,
complications of penile implant surgery may be clinically significant and include infection of the device, which is quite
frequent, and some other, less frequent but important complications, such as distal and proximal perforation of the
tunica albuginea, deformity of the penis, erosion of a component, and mechanical malfunction of the implanted device.
Diagnosis of complications is based on clinical history and physical examination, but imaging techniques are also
needed to explore the prosthesis and plan the surgical approach if necessary. MRI is considered to be the most
valuable method for the diagnosis of penile prosthesis complications, since it demonstrates penile anatomy in three
orthogonal planes with superior definition of soft tissue contrast (8). Another indication for MRI is visualization of
cavernosal alteration prior to surgery and for implant selection.
Inflammatory Disease of the Penis
Induratio penis plastica or Peyronie’s Disease is an inflammatory condition of unknown aetiology, which affects the
tunica albuginea and may extend to the penile corpora. Normal, elastic connective tissue of the tunica albuginea is
replaced by fibrous or hyaline scar tissue, whose appearance may be sheet-like or plaque-like on T2-weighted MR
images and clearly define disease extent. On post-contrast, T1-weighted MR images, acute plaques of induratio penis
plastica may demonstrate contrast enhancement (9).
Infection of the Penis and Perineum
Infection of the penis and perineum may result from trauma or be a sequel of underlying inflammatory disease, e.g.,
Crohn’s disease. Infection usually involves penetration into the subcutaneous tissue or deeper tissue layers of
pathologic microorganisms that bring about an inflammatory reaction, and, eventually, the formation of puscontaining,
localized abscess or phlegmonous spread. In inflammatory bowel disease, such as Crohn’s disease,
fistulous tracts may connect the skin surface or the mucosal surface of the intestinal tract with subcutaneous or deeper
tissue layers of the penis and perineum. The soft tissue differentiation of MR imaging provides perfect delineation of
tissue oedema, inflammatory reaction, fistulas and pus collections for surgery planning.
Malignant Disease of the Penis
Penile Cancer
Penile cancer is a rare malignant condition. Histopathology reveals squamous cell epithelial carcinoma in more than
95% of cases. Clinically, penile cancer usually affects the glans penis (48% of cases) or the prepuce (21% of cases),
and frequently presents as an ulcer. Less frequently involved are the glans penis and the prepuce (9%), the coronal
sulcus (6%), and the shaft (2%) (13). Penile cancer usually spreads via lymphatic vessels, since Buck’s fascia (fascia
penis profunda) acts as a barrier to invasion of the penile corpora and to hematogenous spread. Regional
lymphadenopathy involves superficial and deep inguinal lymph node.
Local staging of penile cancer is reliable and highly accurate to distinguish between patients suited for (partial)
glansectomy from those receiving (partial) penectomy (5). It still remains unclear if artificial erection during MR
imaging is necessary to obtain reliable information for local tumor staging.
In a recently published series of seven patients with squamous cell carcinoma of the penis, it has been demonstrated
that MRI after the intravenous administration of lymphotropic nanoparticle (ferumoxtran-10), when correlated with
histology, has a sensitivity and specificity of 100% and 97%, respectively, in predicting the presence of regional lymph
node metastases and may accurately triage patients for regional lymphadenectomy (14).
In whole-body staging of malignant penile disease, computed tomography (CT) is advantageous because of its wide
availability, its ability to cover the entire body within less than 1 minute, and its high reproducibility of imaging planes
and ranges. Recent work implies that CT, when combined with positron emission tomography (PET) with 18F-desoxyglucose
(FDG), is highly useful in the detection of metastasis of penile cancer (10).
Cancer of the Penile Urethra
Primary cancer of the male urethra is very seldom found. The majority of urethral cancers consist of squamous cell
epithelial carcinoma at histopathology. Cancer of the penile urethra may invade periurethral loose connective tissue
and eventually penetrates into the penile corpora.
Metastasis to the Penis
Metastasis to the penis of other tumors is unusual. The majority of penile metastases originate from tumors of the
urinary bladder, prostate, and rectum, while metastases from renal and respiratory tract primaries have also been
reported. In individual cases, the route of metastasis to the penis may be hard to define, unless the lesion is clearly
located outside of the penile urethra. Clinically, the most frequent sign of penile metastasis is priapism. Penile
metastases are usually associated with advanced, rather aggressive neoplastic disease, and they usually appear rather
rapidly after the recognition and treatment of the primary tumor. Survival after detection of penile metastasis is
usually very limited (6).
On T2-weighted MR images, penile tumors and metastasis often demonstrate as solitary, infiltrating tumors with low
signal intensity. T2-weighted MR images allow for delineation of the tumor margin and of any extension into the penile
shaft (13). On unenhanced, T1-weighted MR images, tumors or metastases of the penis usually demonstrate with
decreased signal intensity when compared with the penile corpora. Primary penile cancers usually manifest as solitary,
ill-defined, hypointense, infiltrating tumors (13). On contrast-enhanced, T1-weighted MR images, tumors or
metastases of the penis frequently present with contrast uptake. It is controversial whether, on Gadolinium-enhanced,
T1-weighted images, contrast enhancement is stronger in primary penile cancer than within the penile corpora (13) or
stronger within the penile corpora (2). When obtained with fat signal suppression, contrast-enhanced MR images of
the penis help to delineate penile tumor or metastasis from the perineum or pelvic floor. However, since accompanying
inflammatory reaction may be severe, clear-cut definition of tumor margins can pose a problem for MRI.
References
(1) Andipa E, Liberopoulos K, Asvestis C (2004) Magnetic resonance imaging and ultrasound evaluation of penile and
testicular masses. World J Urol. 22:382-391
(2) Asmussen M, Czipull C (2006) Penis. In: Rummeny Reimer Heindel (eds) Ganzkoerper-MR-Tomographie. Georg
Thieme Verlag Stuttgart, New York, pp 408-412
(3) Gallentine ML, Morey AF (2002) Imaging of the male urethra for stricture disease. Urol Clin North Am. 29:361-372
(4) Gearhart JP (2002) Exstrophy, epispadias, and other bladder anomalies. In: Walsh PC, Khinev A (2004) [Penile
fracture]. Khirurgiia (Sofiia) 60:32-41
97

(5) Kayes O, Suks M, Clare A et al. (2007) The Role of Magnetic Resonance Imaging in the Local Staging of Penile
Cancer. Euro Uro 41:1313-1319
(6) Khinev A (2004) [Penile fracture]. Khirurgiia (Sofiia) 60:32-41
(7) Lynch DF and Pettaway CA (2002) Tumors of the penis. In: Walsh PC, Retik AB, Vaughan ED, Wein AJ (eds)
Campbell´s Urology. 8 th edn. Saunders, Philadelphia, London, New York, St. Louis, Sydney, Toronto, pp 2945-2973
(8) Moncada I, Jara J, Cabello R, Monzo JI, Hernandez C (2004) Radiological assessment of penile prosthesis: the role
of magnetic resonance imaging. World J Urol 22:371-377
(9) Pretorius ES, Siegelman ES, Ramchandani P, Banner MP (2001) MR imaging of the penis. Radiographics 21 Spec
No:S283-S298
(10) Roussel G, Robert Y, Mahe P. et al. (2001) High-Flow Priapism in Children: Immediate Treatment by Selective
Embolization. Eur J Pediatr Surg 11:350-353
(11) Scher B, Seitz M, Reiser M, Hungerhuber E, Hahn K, Tiling R, Herzog P, Reiser M, Schneede P, Dresel S (2005)
18F-FDG PET/CT for staging of penile cancer. J Nucl Med 46:1460-1465
(12) Schneede P, Schmeller N, Mueller-Lisse UG, Reiser MF, Hofstetter AG (1999) Partieller Priapismus. Kasuistik und
Literaturübersicht über diagnostisches und therapeutisches Vorgehen. Urologe [A] 38:179-183
(13) Singh AK, Saokar A, Hahn PF, Harisinghani MG (2005) Imaging of penile neoplasms. Radiographics 25:1629-1638
(14) Tabatabaei S, Harisinghani M, McDougal WS (2005) Regional lymph node staging using lymphotropic nanoparticle
enhanced magnetic resonance imaging with ferumoxtran-10 in patients with penile cancer. J Urol 174:923-927
THE ADNEXAL MASS
Moderators: Ghiatas A. (GR) – Chalazonitis A. (GR)
HOW TO CHARACTERIZE AND DETERMINE THE ORIGINE OF AN
ADNEXAL MASS AT US
Balleyguier C. (1), Perrot N. (2)
1- Radiology dept, Institut Gustave Roussy, Villejuif, France, 2- Centre Vitenson, Paris, France
Imaging is essential for characterization and staging of adnexal masses. The role of modern imaging is to point out the
originating organ, to specify if the process is congenital, functional, hemorrhagic, neoplastic, obstructive or
inflammatory and finally to adequately stage the neoplastic diseases before surgery or medical treatment. Adnexal
lesions may include lesions of ovaries, fallopian tubes, broad ligament, uterosacral ligaments and their blood and
nervous supply. Masses may also arise from the uterus. Non gynaecologic sources of abdominopelvic masses must
also be considered. Knowledge of female anatomy, embryology and physiology is necessary to understand adnexal
diseases. Awareness of previous surgery and medical treatment are also helpful for the analysis of organs.
Ultrasonography and Doppler US remain the first step to detect and characterize adnexal lesions. Functional lesions of
the ovary are very common and must be known by the sonographer. Morphological criteria in ultrasound to
characterize benign and malignant ovarian masses are currently well defined and allow a high level of accuracy, with
more than 90 % of sensitivity. Scoring systems to define a risk of malignancy are used by some authors and will be
defined in the presentation. Doppler criteria are usually included in the different scores and considered as
complementary tools for the diagnosis. Nevertheless, in some cases, ultrasound might be inconclusive due to technical
problems or to the characteristics of the lesion itself, and MRI must then be performed to afford additional information
for the diagnosis.
US and MRI appear to be complementary tools for the examination of adnexal diseases. Multidisciplinary approach is
mandatory in order to understand the possibilities and limits, advantages and pitfalls of pelvic imaging.
MRI ASSESSMENT OF AN INDETERMINATE ADNEXAL MASS AT
ULTRASOUND
Kubik-Huch R.
Institute of Radiology, Kantonsspital Baden AG, CH-5404 Baden, Switzerland
There are two major diagnostic challenges in patients with an ovarian mass: The determination of malignancy and – if
a malignancy is suspected - the evaluation of tumour extent (staging). In patients with suspected ovarian carcinoma,
computed tomography is the modality of choice alongside transvaginal and abdominal ultrasound as it is relatively
cost-effective and widely available. While in a clinical routine setting MRI plays a limited role in the staging of ovarian
carcinoma, it serves as an important adjunct for the characterization of sonographically indeterminate ovarian lesions
prior to surgery. It allows to determine the origin of a pelvic mass, e.g. to distinguish a subserosal leiomyoma of the
uterus from an adnexal pathology. MRI was shown to be superior to ultrasound and computed tomography in
characterizing an ovarian lesion, since it is capable of reliably differentiating mature cystic teratoma (Fig. 1) and other
benign lesions from ovarian carcinoma (1-4). Imaging features that are characteristic of a specific diagnosis include
the presence of fat in mature teratoma, the so-called T2-shading in endometrioma or the presence of a solid mass
with low signal intensity on T2-weighted imaging in fibrothecoma (2,5).
MRI can identify features of malignancy in complex confined ovarian masses (6). Criteria indicating malignancy include
a large size, septations, wall-thickening, solid, contrast-enhancing papillary projections as well as the presence of
ascites, pathologic lymph nodes and metastases (2,5).
The standard imaging protocol for adnexal lesions in our institutions incorporates the recommendations of the ESUR
Women’s Imaging Subcomittee (Spencer J, Forstner R, in preparation). An intravenous cannula is placed before the
examination. Following an overview of the entire abdomen (coronal and axial TruFisp, axial T1 GRE), Glucagon is
administered as antiperistaltic agent before imaging the small pelvis. A high-resolution sagittal T2-weighted sequence
of the small pelvis is performed to exclude uterine pathology and to determine the origin of the lesion, followed by an
axial T1 and T2 weighted-sequence. Additional axial oblique (long axis view of the uterus) or coronal sequences might
98

e helpful to establish the diagnosis in selected cases. If a bright lesion is present on T1-weighted imaging, an
additional fat-saturated sequence is acquired allowing the distinction of fat from haemorrhage. In patients with ovarian
pathology, gadolinium-enhanced sequences are routinely performed in our institution to confirm the presence of solid,
enhancing tissue.
More recently, diffusion-weighted imaging (DWI), a functional imaging technique well established for intracranial
imaging, was added to our protocol, since this imaging approach was shown to have a potential for lesion
characterization. With increasing tumor cellularity, there is a reduction in extracellular space resulting in a reduced
ADC value. High-grade adenocarcinomas with high cellular density would therefore be expected to have low ADC
values, however, there is controversy regarding the usefulness of this technique in cystic ovarian tumors. Recent
studies furthermore indicate that there might be a potential for DWI in detection of peritoneal dissemination and lesion
detection (7,8)
Discrimination between benign and malignant ovarian lesions in patients with an ovarian mass based on imaging
criteria has become increasingly important in times, where laparoscopic surgery has gained wide acceptance,
diminishing the possibility of encountering an unexpected ovarian cancer (2). A diagnostic algorithm was proposed by
Spencer et al. (6) according to which all women with indeterminate adnexal masses should undergo MRI before
therapeutic decision making. It was postulated that the adjunct of MRI in this setting might reduce the number of
women undergoing unnecessary surgery and improving bed utilisation by limiting surgery to simple resection in
symptomatic women (6). Diagnostic studies that allow accurate characterization of a lesion might reduce unnecessary
surgery in benign masses and will help to determine surgical and chemotherapeutic planning in malignant lesions
The lecture aims to discuss the general prerequisites and imaging protocols for performing MRI of the ovaries. The
normal MR anatomy of the ovary, physiologic changes during the menstrual cycle as well as ovarian pathology will be
addressed.
References:
1. Kurtz AB, Tsimikas JV, Tempany CMC, et al. Diagnosis and staging of ovarian cancer: Comparative values of
Doppler and conventional US, CT and MR imaging correlated with surgery and histopathologic analysis –
report of the diagnostic oncology group. Radiology 1999, 212_19-27
2. Forstner R, Kinkel K. Adnexal masses: Characterization of benign ovarian leions. In: MRI and CT of the female
pelvis (eds. Hamm B, Forstner R), Medical Radioloy, Springer 2007, pp 107-229
3. Sohaib SA, Mills TD, Sahdev A, Webb JAW, VanTrappen PO, Jacobs IJ, Reznek RH. The role of magnetic
resonance imaging and ultrasound in patients with adnexal masses. Clinical Radiology 2005;60:340-348
4. Hricak H, Chen M, Coakley FV, Kinkel K, Yu KK, Sica G, Bacchetti P, Powell CB. Complex adnexal masses:
Detection and characterization with MR imaging – multivariate analysis. Radiology 2000;214:39-46
5. Baumgarten DA, Ascher SM, Semelka RC, Motohara T, Nagase LL, Outwater EK. Chapter 15 Adnexa. In:
Abdominal-Pelvic MRI (ed: Semelka RC). Wiley-Liss, 2002, pp1123-1176
6. Spencer J, Forstner R, Hricak H. Editorial. Investigating women with suspected ovarian cancer. Gynecologic
Oncology 2008;108:262-4
7. Whittaker SC, Coady C, Culver L, Rustin G, Padwick M, Padhani AR. Diffusion-weighted MR imaging of pelvic
tumors: A pictorial review. Radiographics 2009;29:759-778
8. Namimoto T, Awai K, Yanaga Y, Hirai T, Yamashita Y. Role of diffusion-weighted imaging in the diagnosis of
gynecological disease. Eur Radiol 2009;19:745-760
Figure 1: Mature teratoma of the left ovary: The presence of fat is indicative of the specific diagnosis in this benign
tumour.
a.) Transvaginal sonography
b.) MRI: axial T1-weighted sequence
c.) MRI: axial T1-weighted sequence with fat-saturation
d.) Coronal T2-weighted sequence
a.)
b.)
99

c.)
d.)
OVARIAN CANCER STAGING
Forstner R.
Department of Radiology, Landeskliniken Salzurg, Paracelsus Medical University, Salzburg
Objectives:
• To make familiar with imaging features of ovarian cancer
• To understand the role of Radiology in treatment decision in ovarian cancer
• To introduce the guidelines for staging ovarian cancer suggested by the ovarian cancer staging workgroup
Ovarian cancer continues to be a major challenge for oncologists and radiologists, and is still one of the most lethal
cancers in females. However, recent advents have been noted. In ovarian cancer comprehensive pretherapeutic
imaging is gaining acceptance as an integral part of initial patient management in patients with gynecologic neoplasm.
Thus, the findings assessed by Radiology are becoming pivotal in a more individualized patient care. Central to this is
a multidisciplinary team approach in the management of ovarian cancer (1).
However, for radiologists this requires profound knowledge of staging ovarian cancer including imaging findings, of
pathways of tumor spread and knowledge of treatment options.
The goals of preoperative staging of ovarian cancer are:
a.) Confirmation of a sonographically malignant adnexal mass
b.) Assessment of tumor burden, mapping of the distribution of metastatic disease and diagnosis of possible
complications e.g. bowel obstruction, hydronephrosis, venous thrombosis
c.) Exclusion of a primary site in the breast, GI tract or pancreas whose metastatic spread might mimic primary
ovarian cancer.
Thus radiology can substantially contribute to the management in a patient with a newly diagnosed ovarian cancer in
surgery planning, in case of “non-resectability” on the selection of candidates for neoadjuvant chemotherapy, and in
pretherapeutic tissue sampling.
CA-125 provides only limited information for staging, but is the mainstay in tumor surveillance.
Guidelines for staging ovarian cancer have been developed by the Ovary working group of the ESUR of the female
genitourinary subgroup will be presentented. Based upon the literature and personal preferences there was uniform
consensus that CE-multidetector CT is the modality of choice for staging ovarian cancer, as it provides all relevant
information in a short examination time (3). MRI continues to be an alternative modality, particularily in
contraindications for CT and in young females. Sonography does not provide sufficient information for staging, but is
100

useful in image guided biopsy. The value of PET/CT has yet to be assessed, however it may be useful in suspected
distant spread.
These guidelines including the indications for staging ovarian cancer, technical details for CT and MRI, key imaging
features, and criteria for non- optimally respectable disease will be summarized. Furthermore, a structured report
including all relevant findings in a patient preoperatively assessed for ovarian cancer will presented in detail in this
presentation.
References:
1. Spencer JA (2005) A multidisciplinary approach to ovarian cancer at diagnosis. BJR 78:S94-S10).
2. Forstner R (2007) Radiological staging of ovarian cancer: imaging findings and contribution of CT and MR. Eur
Radiol 17:3223-3246.I
3. Tempany CM, Zou KH, Silverman, et al. (2000) Staging of advanced ovarian cancer: comparison of imaging
modalities-report from the Radiology Oncology Group. Radiology 215:761-767
MRI DIAGNOSIS OF THE ADNEXAL TUMORS BY PATTERN
RECOGNITION
Kim S.H.
Department of Radiology, Seoul National University Hospital, Seoul, Korea
The objectives of preoperative imaging studies of the adnexal masses are to detect the masses, to differentiate
neoplasms from non-neoplastic lesions, to differentiate benign from malignant neoplasms, and to suggest the most
probable diagnosis. Although ultrasonography remains the first-line imaging technique for evaluation of the adnexa,
MRI is most commonly used as the primary imaging study for evaluation of adnexal masses. MRI is especially useful in
characterizing the adnexal masses containing fat, hemorrhage, and fibrotic tissue. MRI is an expensive examination,
but it may be cost-effective by providing an accurate diagnosis that may reduce an unnecessary workup or surgery.
Basic MRI protocols for on-functional MRI include axial T1- and T2-weighted imaging, and sagittal T2-weighted
imaging. Coronal plane imaging is often added. Fat-saturated T1-weighted imaging is usually added to differentiate
between fat and blood for a high-intensity lesion on T1-weighted images. Contrast-enhanced T1-weighted imaging can
be obtained either with or without fat saturation technique. Contrast enhancement is especially helpful in
differentiating solid portion or papillary projection of the tumors from blood clot or debris. Other imaging protocols
such as chemical-shift imaging, diffusion-weighted imaging, and MR spectroscopic imaging may be used as well.
MRI often shows various functional and on-functional benign cysts in the ovary and adnexa. Differential diagnosis
among these cysts can be done by showing the content and wall of the mass and the relation of the mass with the
ovary. Endometriosis is the disease that can be specifically diagnosed with MRI and its extent is well shown. MRI can
show the nature and extent of other non-neoplastic adnexal lesions such as pelvic inflammatory diseases and ovarian
torsion. MRI can characterize ovarian tumors by showing the internal architecture and content of the masses.
Sometimes imaging findings are so characteristic that specific diagnosis of a certain ovarian tumor is possible.
However MRI findings are often overlapped, and thus ancillary findings such as age, tumor marker, and hormonal
status are also considered in differential diagnosis.
US OF UROGENITAL TRACT
Moderators: Yarmenitis S. (GR) – Riccabona M. (AT)
3DUS A LOST TERRITORY FOR RADIOLOGY OR NEW CHALLENGE IN
UROGENITAL TRACT IMAGING
Riccabona M.
University Hospital Graz
CONTRAST US AND ASPECTS FOR ITS FUTURE ROLE: FROM
DIAGNOSTIC IMAGING TO NEW TREATMENT OPTIONS
Claudon M.
Department of Radiology, CHU Nancy-Brabois, Allée du Morvan, 54511 VANDOEUVRE- LES-NANCY ,France
In most centres, ultrasound is the preferred first imaging modality in patients with known or suspected renal disease.
Main objectives are to measure renal size, to prove or rule out focal lesions, to detect obstruction of the collecting
system and to look for vascular disorders by means of Doppler techniques (1). Often unexpected findings like
anatomic variations or focal lesions are detected and need further clarification.
Contrast-enhanced ultrasound (CEUS), based on the IV administration of Ultrasound Contrast Agents (UCAs), is now a
well-established technique for the evaluation of focal liver lesions, but has now been recommended for others organs,
including the kidney by the EFSUMB Guidelines (2). Because of limitations inherent to the physics or to patient’s
condition, a benefit from using CEUS can be expected for the evaluation of the micro- and macrovasculature of the
kidneys (3), including the characterization of focal renal lesions and the diagnostic of vascular diseases of the native
and transplanted kidney.
Background AND CEUS Protocol The kidneys receive 20-25% of the cardiac output. The renal cortex tissue receives
90% and the medulla the remaining 10%. Medullary blood flow is slower than cortical flow. Unlike CECT or CEMRI,
CEUS may be performed in patients with impaired renal function or ureteric obstruction that may be contraindications
to performing contrast CT or Gadolinium enhanced MR examinations. UCAs have no reported clinical side effects on the
kidneys in humans to date. Two contrast boluses are usually necessary in order to examine both kidneys. Although
several papers describe the use of Levovist® with intermittent imaging, today most centres use low solubility gas
agents such as SonoVue® with real time, low MI imaging.As UCAs are confined to the vascular bed, CEUS can not
provide information about the excretory function of the kidneys. The wash in phase can be divided into a short cortical
enhancement phase, beginning 10 to 15 seconds after bolus injection, followed by a medullary enhancement phase
which progresses much more slowly via the vasa recta, and proresses from the outer to the inner portion of the
101

medulla. The duration of parenchymal enhancement depends on the vascular status and age of the patient, renal
blood flow and the sensitivity of the US device used. Because of the high perfusion in the cortex, high microbubble
concentration in the superficial parenchyma may cause attenuation in deeper portions of the kidney. This can be
avoided by reducing the dose of contrast agent. In slim, easy to scan patients with superficial kidneys the dose may be
reduced to 1-1.5ml of contrast agent. The wash out phase is first recognized by a decrease in medullary enhancement,
followed by a slower cortical wash out.
Only low MI contrast specific techniques are now recommended. They allow dynamic imaging with evaluation of the
different vascular phases using a low solubility gas UCAs (Sonovue® from Bracco being currently the only so-called
second generation agent approved for macro and micro vasculature in Europe). A detailed procedure can be found in
the European Guidelines (2). Important points are that:
- Real time scanning should be performed for up to 180 seconds to continuously assess the wash in
and wash out phases.
- In some contrast specific US modes, simultaneous display of tissue and contrast signals has been
implemented. This modality is particularly useful for small lesions to ensure that the target lesion is
kept within the scanning field during CEUS.
- Because of the dynamic nature of real time CEUS, the investigation should be documented on video
or digital media.
- In patients with suspected vascular diseases (mainly small vessel diseases) or trauma, long and
short axis views should be obtained during both the cortical and medullary phases.
Recommended USES AND indications, LIMITATIONS
Indications
CEUS can be recommended in the following clinical situations (2) :
Evaluation of anatomic variations mimicking a renal tumor (“pseudo-tumor”)
Characterisation of complex cystic lesions and suspected cystic renal carcinoma, as CEUS was found to be better than
unenhanced sonography and CT in the diagnosis of malignancy in complex cystic renal masses (4), and appropriate
for renal cyst classification with the Bosniak system (5).
Characterization of thrombus within the renal vein and vena cava
Suspected vascular disorders, including renal infarction and cortical necrosis. CEUS has been shown to decrease the
number of inadequate Doppler studies in renal artery stenosis detection (6). It also allow a better detection of
segmental or subcapsular renal infarction and cortial necrosis in the transplanted kidney (7) and is helpful in
identifying post interventional complications such as bleeding, hematomas, AV shunts or large false aneurysms in
angiomyolipoma (8).
Detection of crossing vessels in UPJ syndromes (9)
Renal trauma and follow up (10)
Patients with contraindications for the use of contrast agents for CT or MR
Monitoring of local ablative treatment by RF and cryosurgery, for which UCAs may be useful in the immediate
assessment of residual tumor by characterizing perfusion defects at different times during and after treatment
(11,12), and demonstrating postoperative local complications such as bleeding or hematoma that may mimic a solid
renal tumor.
CEUS is not currently recommended for:
The detection of focal renal lesions, as its sensitivity remains limited for small tumours when being compared to
contrast enhanced CT or MR (2)
The distinction between malignant from benign tissue, for example renal cell carcinoma from renal metastasis,
angiomyolipoma, oncocytoma and leiomyoma (13)
In the case of pyelonephritis (except for abscesses) (14)
The therapeutic applications of CEUS are still in the research field.
Limitations of CEUS
There are several limitations of CEUS:
• CEUS is subject to the same limitations as standard ultrasound, and sensitivity may be markedly reduced
in the deep field.
• Due to high bubble concentration during the corticomedullar phase, attenuation may cause shadowing in
the deepest parts of the kidney
• The short enhancement time limits the diagnostic window.
REFERENCES
1. Schmidt T, Hohl C, Haage P, et al. Diagnostic accuracy of phase-inversion tissue harmonic imaging versus
fundamental B-mode sonography in the evaluation of focal lesions of the kidney. AJR Am J Roentgenol
2003;180:1639-1647
2. Claudon M, Cosgrove D, Albrecht T, et al. Guidelines and good clinical practice recommendations for contrast
enhanced ultrasound (CEUS) - update 2008. Ultraschall Med 2008;29:28-44
3. Robbin ML, Lockhart ME, Barr RG. Renal imaging with ultrasound contrast: current status. Radiol Clin North
Am 2003;41:963-978
4. Quaia E, Bertolotto M, Cioffi V, et al. Comparison of contrast-enhanced sonography with unenhanced
sonography and contrast-enhanced CT in the diagnosis of malignancy in complex cystic renal masses. AJR Am
J Roentgenol 2008;191:1239-1249
5. Ascenti G, Mazziotti S, Zimbaro G, et al. Complex cystic renal masses: characterization with contrastenhanced
US. Radiology 2007;243:158-165
6. Claudon M, Barnewolt CE, Taylor GA, et al. Renal blood flow in pigs: changes depicted with contrast-enhanced
harmonic US imaging during acute urinary obstruction. Radiology 1999;212:725-731
7. Correas J, Helenon O, Moreau JF. Contrast-enhanced ultrasonography of native and transplanted kidney
diseases. Eur Radiol 1999;9 Suppl 3:S394-400
8. Yamakado K, Tanaka N, Nakagawa T, et al. Renal angiomyolipoma: relationships between tumor size,
aneurysm formation, and rupture. Radiology 2002;225:78-82
9. Mitterberger M, Pinggera GM, Neururer R, et al. Comparison of contrast-enhanced color Doppler imaging
(CDI), computed tomography (CT), and magnetic resonance imaging (MRI) for the detection of crossing
vessels in patients with ureteropelvic junction obstruction (UPJO). Eur Urol 2008;53:1254-1260
10. Regine G, Atzori M, Miele V, et al. Second-generation sonographic contrast agents in the evaluation of renal
trauma. Radiol Med 2007;112:581-587
11. Meloni MF, Bertolotto M, Alberzoni C, et al. Follow-up after percutaneous radiofrequency ablation of renal cell
102

carcinoma: contrast-enhanced sonography versus contrast-enhanced CT or MRI. AJR Am J Roentgenol
2008;191:1233-1238
12. Wink MH, Laguna MP, Lagerveld BW, de la Rosette JJ, Wijkstra H. Contrast-enhanced ultrasonography in the
follow-up of cryoablation of renal tumours: a feasibility study. BJU Int 2007;99:1371-1375
13. Ascenti G, Zimbaro G, Mazziotti S, et al. Usefulness of power Doppler and contrast-enhanced sonography in
the differentiation of hyperechoic renal masses. Abdom Imaging 2001;26:654-660
14. Kim B, Lim HK, Choi MH, et al. Detection of parenchymal abnormalities in acute pyelonephritis by pulse
inversion harmonic imaging with or without microbubble ultrasonographic contrast agent: correlation with
computed tomography. J Ultrasound Med 2001;20:5-14
Yarmenitis S.
University Hospital Of Heraklion, Greece
US OF THE TRANSPLANTED KIDNEY
ULTRASOUND OF THE NON NEOPLASTIC DISORDERS OF THE
PROSTATE
Turgut A.T.
Ankara, Turkey
Benign Prostate Hyperplasia
Benign prostate hyperplasia (BPH) involves microscopically nodular hyperplasia of the glandular, muscular and fibrous
tissues within the transition zone (TZ) and the periurethral glandular zone (PGZ) of the prostate gland. Radiologically,
transabdominal ultrasound (US) is a valuable tool in the follow-up of cases with BPH, although it does not show the
prostate gland in detail. In particular, the high frequency multiplanar transrectal ultrasound (TRUS) imaging provides a
detailed imaging of the prostate gland. In cases with BPH, an enlarged inner gland (IG) is visualized as low-echo areas
on TRUS. Based on this information, it is easy to distinguish the hyperplasia of the prostate from the peripheral zone
(PZ) of the prostate gland with higher echogenecity. Apart from BPH, various solid and cystic lesions of the prostate
gland and prostatic calcifications may be found in the TZ. On US, the capsule located between the enlarged TZ from
the PZ is demonstrated as a rim with its different echogenecity surrounding the TZ. With the use of ellipsoid formula
and multiplication factor as 0.5, the prostate volume may be calculated with a high accuracy from the values of the
largest diameters of width, height and length on TRUS. Then, the weight of the gland can be estimated, using the fact
that 1 ml of prostate tissue is equivalent to 1 g. In clinical practice, a prostate gland weighing more than 40 g is
accepted to be enlarged in men older than 50 years of age. In patients with BPH, an evaluation of the upper urinary
tract using transabdominal US study is a routine procedure for the exclusion of the possible diagnoses of
hydroureteronephrosis, bladder trabeculation or diverticulation, elevation of the bladder base and increased PVR.
Especially, Color Doppler ultrasound (CDUS) is helpful for the evaluation of patients with BPH. In contrast to cancerous
and normal prostate tissues, increased arterial flow velocities and relatively higher RI values are detected in the IGs of
cases with BPH.
Cystic Lesions of the Prostate
A) Intraprostatic Cystic Lesions
Prostatic Utricle Cysts; On TRUS, they are seen as an anechoic midline cystic cavity posterior to the urethra.
Müllerian Duct Cysts; These lesions are seen as an anechoic midline cystic cavity posterior to the urethra on TRUS and
may extend above the prostate gland.
Ejaculatory Duct Cysts; It is generally accepted that they are secondary to the congenital or acquired obstruction distal
ejaculatory duct. Anatomically, they are seen in paramedian location within the prostate on TRUS. Characteristically,
these cystic lesions are round or oval in shape, thin-walled, and unilocular.
Retention Cysts; Retention cysts are true acquired lesions secondary to the obstruction of prostatic glandular ductules.
On TRUS, a peripheral, smooth-walled unilocular cyst is frequently observed.
Cystic Degeneration of Benign Prostatic Hyperplasia; Typically, these lesions are located in the hyperplastic TZ within
the hyperplastic nodules of the prostate.
B) Extraprostatic Cystic Lesions
Seminal Vesicle Cysts; Seminal vesicle cysts are rare lesions and TRUS reveals an intraseminal round or oval anechoic
lesion adjacent to the prostate gland.
Cowper’s Duct Cysts; Typically, a unilocular cyst is located at the posterior or posterolateral of the posterior urethra on
TRUS.
Vas Deferens Cysts; Cysts of vas deferens are situated in the caudal direction of the prostate gland.
Prostatitis
Acute Prostatitis; Classical findings of acute prostatitis on TRUS are the presence of enlarged and round prostate in
shape, heterogenous prostate in echogenicity, and prostate with loss of the echogenecity difference between the IG
and the PZ. Nevertheless, the main role of US in cases with acute prostatitis is the exclusion of the diagnosis of
abscess formation.
Chronic Prostatitis; On US, stromal fibrosis with a spared area of the inflammatory cell infiltration is seen as a thin and
hypoechoic rim at the outer periphery of the prostate. In addition, CDUS can reveal an increased vascularity, possibly
due to concomitant inflammatory process in cases with chronic prostatitis.
Granulomatous Prostatitis; Granulomatous prostatitis is a rare benign inflammatory process of the prostate presenting
as prostatic enlargement and focal or multifocal hypoechoic lesions on TRUS.
Abscess of the Prostate; In cases with prostate abscess, the clinical picture involving the symptoms of fever, chills,
urgency, perineal pain, dysuria and hematuria is similar to that of prostatitis. Radiologically, TRUS is the best choice
for the diagnosis of the prostate abscess, characterized by a focal enlargement of the prostate gland and uni- or
multilocular fluid collections with septae. If there is an abscess formation larger than 1.5 cm, an urgent surgical
drainage is recommended, but smaller ones can be treated with medical thearpy. Aspiration of the lesion under TRUS
guidance provides both a definitive diagnosis and a correct treatment.
Congenital and Acquired Lesions of the Seminal Tracts
Congenital Anomalies of the Seminal Tracts; Congenital anomalies of the seminal tracts including hypoplasia or
absence of the structures may cause infertility in males.
103

Ejaculatory Duct Obstruction; Ejaculatory duct obstruction, a rare cause of male infertility, may be either congenital or
acquired. In these cases, the most common causes of the ejaculatory duct obstruction are calcifications or stones
along the ejaculatory duct, intraprostatic cysts, and blockage due to scar tissue of various etiology, such as
inflammation or trauma. Distal obstruction of the seminal tract may cause the appearances of dilated ejaculatory
ducts, and seminal vesicles or vas deferens on TRUS. Seminal vesicle dilatation should be considered in the presence
of a seminal vesicle with an anteroposterior dimension exceeding 15 mm.
Solid Non-Neoplastic Seminal Vesicle Masses; Solid non-neoplastic seminal vesicle masses are unusual lesions, but
unilateral or bilateral involvement of the seminal vesicles by schistomiasis is possible in some geographic regions of
the world.
References
1. Langer JE, Cornud F. Inflammatory disorders of the prostate and the distal genital tract.
Radiol Clin North Am 2006; 44:665-77.
2. Torigian DA, Ramchandani P. Hematospermia: imaging findings. Abdom Imaging 2007; 32:29-49.
3. Loch AC, Bannowsky A, Baeurle L, et al. Technical and anatomical essentials for transrectal ultrasound of the
prostate. World J Urol 2007; 25:361-66.
4. Özdemir H, Onur R, Bozgeyik Z, Orhan I, Ogras MZ, Ogur E. Measuring resistance index in patients with BPH and
lower urinary tract symptoms. J Clin Ultrasound 2005; 33:176-180.
5. Wasserman NF. Benign prostatic hyperplasia: a review and ultrasound classification. Radiol Clin North Am 2006; 44:
689-710.
6. Kim SH. Imaging for seminal tracts. In: Kim SH, editor. Radiology illustrated: uroradiology. Philadelphia: Saunders,
2003:607-24.
7. Rifkin MD. Ultrasound of the Prostate; Imaging in the Diagnosis and Therapy of Prostatic Disease, second edition.
Philadelphia: Lippincott Williams & Wilkins, 1997.
8. Boczko J, Messing E, Dogra V. Transrectal sonography in prostate evaluation. Radiol Clin North Am. 2006; 44:679-
87.
RETROPERITONEUM – ADRENALS
Moderators: Heinz-Peer G. (AT) – Papadopoulou F. (GR)
ADRENAL IMAGING BEYOND ADENOMA VS NONADENOMA
Kenney P.J
University of Arkansas for Medical Science, USA
General Concepts
Diagnosis of adrenal masses depends on correlation of the clinical and laboratory findings with the imaging
appearance. Sonography is useful for screening but is rarely definitive. CT is very accurate (greater than 90%) in the
diagnosis of adrenal masses . CT can detect even tiny adrenal lesions, and excludes an adrenal mass if the CT
appearance is normal. MRI is also very accurate for adrenal diagnosis. Nuclear imaging including PET can also be
useful, however PET has limitations as small malignant lesions may be negative and some adenomas show uptake of
FDG.
Nearly 1/3 of adrenal masses are incidental lesions detected by CT performed for non-adrenal indications. In the
absence of known extra-adrenal malignancy, most incidental lesions are benign, with less than 10% of serendipitous
adrenal masses being malignant. Small lesions are more commonly benign, but small metastases are reported. Once
an adrenal mass is large, it is more likely malignant, but the adrenal origin of the lesion may be difficult to discern.
Retroperitoneal masses may directly invade and obscure the adrenal gland and mimic a primary adrenal mass.
Adrenal Hyperplasia
Cortical hyperplasia may result in diffuse thickening of the adrenal glands with retention of the normal shape. This
enlargement may be smooth or nodular. Bilateral enlargement, whether smooth or nodular, is indicative of
hyperplasia. A significant number of patients with clinical and biochemical evidence of hyperplasia will have normal
appearing adrenals, thus, a normal appearance of the adrenals does not exclude hyperplasia. Adrenal hyperplasia can
also be diagnosed when there are bilateral nodules or when there is nodularity associated with bilateral adrenal
thickening. . The thickening may become massive, especially with ectopic ACTH production. Unlike hyperplasia, in
primary functional adrenal tumors, the ipsilateral remaining adrenal tissue and contralateral adrenal gland should be
normal or atrophic.
Although both MRI and CT can show markedly enlarged glands, CT is preferable because it is better able to detect
subtle alterations of adrenal morphology as long as appropriate (1 mm) thin section technique is used. Adrenal
enlargement is a response to physiologic stress. On imaging, the appearance is indistinguishable from hyperplasia
producing adrenal hyperfunction
Adenoma
Adrenocortical adenomas are relatively common lesions, particularly nonhyperfunctioning adenomas, which represent
a large proportion of incidentalomas. There are no imaging criteria that distinguish functioning from
nonhyperfunctioning adenomas, that distinction must be made on clinical and laboratory evidence. Key advances in
diagnosis have been made allowing most adenomas to be identified, and distinguished from metastases or other
adrenal lesions. The common presence of significant lipid is key: the accepted cutoff of 10% negative
pixels which is rarely seen with malignancies. Nevertheless, investigation has shown in phase and opposed phase MRI
still can be useful as drop in signal can be demonstrated even in some lesions indeterminate by all CT criteria.
However accuracy of MRI at 3.0 T needs further investigation.
Asdrenocortical Carcinoma
Adrenal carcinoma is a highly malignant neoplasm that arises in the adrenal cortex. It is rare, with an incidence
estimated at two cases per million people . It can occur at any age, with a median age of about 40 years . About 50%
of adrenal carcinomas will produce an endocrine disorder, Cushing syndrome being commonest. Cushing syndrome
104

may be seen alone or with virilization. Virilization alone, feminization, and hyperaldosteronism may be seen, in order
of decreasing frequency .
Adrenal carcinomas often are very large when first detected, particularly if nonfunctioning, remaining clinically silent
until very advanced, when they present with flank pain, fatigue, palpable mass, or evidence of metastases. Even
functioning tumors are usually large when presenting, which may be a result of relatively inefficient production of
hormone, so that a very large mass is needed to produce enough functioning hormone to result in a clinical disorder.
Average size at presentation is 12 cm (range, 3 to 30 cm), but may be small if discovered incidentally. Adenomas
typically are small, round or ovoid, homogeneous with

myelolipomas may hemorrhage, which can be the cause of pain. Size ranges from 1 to 15 cm, with a mean of about 4
cm.
On CT, most myelolipomas are well-circumscribed masses, sometimes with a discrete thin apparent capsule. Nearly all
contain some definite fat density (

Lesions of the adrenal gland can be diagnosed as neoplasms, metastases and hemorrhage or enlargement of the gland
by external hormon stimuation.
Adenal masses can be devided into two groups: hypersecreting masses and inactive masses. The secreting masses
included pheochromocytomas, aldosteronomas and cortisol and androgen producing tumors. Nonfunctioning adrenal
masses include inactive adrenal adenomas and metastases.
The different imaging modalities like CT, MRI and ultrasonography, nuclear medicine, adrenal venous sampling and
biopsies are used to evaluate the adrenal gland.
Nuclear medicine is a method allowing the differention of pheochromocytomas by Iodine-131-metaiodobenzylguanidine
(MIBG) and indium 111 octreotide. Aldosteronomas can be diagnosed by I-131 6-beta
iodomethyl-19-norcholesterol (NP-59). With the introduction of PET-CT the diagnostic capabilities are even improved.
The adrenal medullary neoplasm pheochromocytome is suspected in clinical and laboratory grounds. CT is the study of
choice to diagnose the tumor.
The adrenal cortex consists of three zones: zona fasciculata, glomerulosa and reticularis with the production of
cortisol, aldosteron and androgens. Patients with a cushing syndrome often have a bilateral enlargement of the glands
greater than 2 cm. In patients with hyperaldosteronism the adrenal lesion can be small and difficult to detect.
Nicolaidis P. (USA)
RETROPERITONEAL FLUID COLLECTIONS
Baumgarten D.
Emory Clinic, Atlanda, USA
RETROPERITONEAL MASSES
It is impossible in 20 minutes to cover the entirety of retroperitoneal masses, so what I hope to accomplish is an
approach to the area that will allow the following:
1. Narrowing down the organ of origin
a. Is it even retroperitoneal
i. Anterior displacement of retroperitoneal organs
ii.
Anterior displacement of retroperitoneal vessels
b. Beak sign
i. Describes the deformation of an adjacent organ into a beak or claw shape
ii.
iii.
Usually implies that the organ forming the shape gave rise to the mass
If the adjacent organ is simply next to the mass but the interface is linear the mass may not
arise from that organ
c. Embedded organ sign
i. If a mass simply compresses an adjacent organ, it is likely not the origin
ii.
If the organ instead appears to be within the mass, it is likely the organ of origin
d. Phantom (invisible) organ sign
i. When a mass becomes so large that its organ of origin is no longer discernable.
ii.
More common with small organs of origin such as the adrenal
e. Feeding artery sign
i. A mass originating in an organ increases the size of the blood supply to that organ
2. A reasonable differential based on
a. Characteristics of the mass
i. Internal contents (fat, soft tissue, etc.)
ii.
iii.
Size
Agressiveness
b. Demographics of the patient
i. Age and gender
c. Assumption of organ of origin
107

ORAL PRESENTATIONS
ABSTRACTS
108

URINARY TRACT IMAGING (CT AND MRI)
Moderators: Logager V. (DK) – Dimopoulou A. (S)
SS1.
ACCURACY OF BLADDER CANCER DETECTION WITH CONTRAST ENHANCED ULTRASOUND
Salvador R., Sebastià C., Buñesch L., Sierra A., Donoso L., Nicolau C.
Radiology Department, Hospital Clínic de Barcelona, Barcelona, Spain.
Objective: To prospectively evaluate contrast enhanced ultrasound (CEUS) diagnostic accuracy for detection of bladder
cancer using transurethral biopsy at conventional cystoscopy as the reference standard.
Method: Forty-three patients with suspicion of bladder cancer underwent a baseline US and CEUS the day before a
conventional cystoscopy with transurethral biopsy of the suspicious lesions. Final results were: bladder cancer (n=33
patients with a total of 64 tumors); papillary hyperplasia (n= 1); chronic inflammatory wall bladder (n= 2); absence of
tumor (n= 7). Baseline US and CEUS accuracy for bladder cancer detection and for number of detected tumours were
analyzed and compared with the final diagnosis.
Results: CEUS accuracy was significantly better than US accuracy in terms of presence or absence of bladder cancer:
88.37% vs 72.09%. Seven of 8 uncertain baseline US results were correctly diagnosed using CEUS. CEUS sensitivity was
also better than that of baseline US for number of tumors: 65.62% vs 60.93%. CEUS sensitivity for bladder cancer
detection was significantly better for tumours higher than 5mm than for tumors

SS4.
BREATH-HOLD MR-UROGRAPHY IN OBSTRUCTIVE UROPATHY
Katsarou A. 1 , Katsaros V.K. 2 , Lampropoulou P. 3 , Lyra S. 1 , Mitropoulou M. 2 , Nikolaou A. 2 , Drossos Ch. 3
1 Department of Radiology, Red Cross Hospital, Athens, Greece, 2 Department of CT and MRI, IKA Oncology
Hospital, Athens, Greece, 3 Department of Modern Imaging Modalities, Athens, Greece
Purpose: The aim of this study was to evaluate gadolinium enhanced GRE T1 weighted excretory breath-hold MR-
Urography (MRU) versus T2 weighted (turbo-SE (RARE) and HASTE) breath-hold MRU in patients with obstructive
uropathy.
Patients and Method: 188 patients with obstructive uropathy (86 males, 102 females; aged 45-79 years, mean age 64
years) underwent MRU in a 1.5 T MR unit. Breath-hold turbo-SE (RARE) T2 weighted projection images (TR ms, TE ms,
TA 7 sec), as well as HASTE slices (TR ms, TE ms TA) and 3D spoiled GRE (FLASH) T1 weighted sequence in various
planes (TR ms, TE ms, TA sec) with and without i.v. Contrast medium administration (gadolinium-DTPA, 0.2 mmol /kg
body weight) were obtained. MIP reconstruction followed.
Results: Sensitivity of RARE and HASTE MR-Urography in determination of the level of obstruction was 99% as
compared to 63% in conventional i.v. Urography. In 18 patients additional retrograde cystoureterography showed a
sensitivity of 85%. Specificity of the combination of RARE and HASTE sequences, as well as i.v. Urography was 100%.
In combination with axial MRI scan, T2-weighted MRU yielded a more precise localization of the obstruction and the
underlying cause (99%) as compared to i.v. Urography (63%) and ultrasound (58%). Compared to T2-weighted MRU,
gadolinium-enhanced 3D FLASH T1 weighted excretory MRU revealed a superior diagnostic accuracy in non-dilated
collecting systems. Breath-hold T1 and T2 weighted MRU turned out to be equivalent in the assessment of obstructed
but normal functioning urinary tract. Non-functioning dilated collecting systems and multicystic kidneys were best
visualized with use of the combination of RARE and HASTE (T2 W) MRU.
Conclusion: 3D spoiled GRE (FLASH) T1 weighted and T2 weighted (turbo-SE (RARE) and HASTE) breath-hold
sequences are complementary MR imaging modalities providing detailed information in patients with obstructive
uropathy of any origin and could probably replace in the future conventional i.v. Urography.
SS5.
PERIRENAL FAT STRANDING AT CT IN PATIENTS WITH LOWER URINARY TRACT SYMPTOMS
Sung D.J., Park B.J., Kim M.J., Cho S.B., Kim Y.H., Chung K.B., Oh Y.W.
Department of Radiology, Anam Hospital, Korea University, College of Medicine
Objective: To evaluate the incidence and clinical significance of perirenal fat stranding (PFS) at CT in patients with
lower urinary tract symptoms (LUTS).
Method: CT studies were retrospectively reviewed by two radiologists in consensus in 345 patients (293 male, 52
female) who had undergone uroflowmetry for LUTS and in 390 age-matched control patients (230 male, 160 female)
without LUTS. The incidence of PFS and baseline characteristics such as age and gender were compared between the
symptomatic patients and control patients, and between patients with and those without PFS. The uroflowmetry data
and prostate volume were compared between the symptomatic male patients with and those without PFS.
Results: The incidence of PFS was significantly higher in the symptomatic patients (117/345) than in control patients
(42/390), and in males than in females in both symptomatic (105 male, 2 female) and control (33 male, 9 female)
patients (P60 years, presence of
macroscopic hematuria and positive CTU were independent predictors for the presence of bladder cancer (all P <
0.02).
Conclusion: In patients at (very) high-risk for bladder cancer, CTU can be used with high sensitivity for primary
diagnosis. Its use may obviate further evaluation with flexible cystoscopy.
110

SS7.
МAGNETIC RESONANCE IMAGING AT PATIENTS WITH A BLADDER CANCER, POSSIBILITY
COMPLEX MRI.
Glybochko P., Chehonatskaja M., Zuev V.
Saratov State Medical University, Saratov, Russia
Purposes: To define structure complex MRI and its possibilities at patients with a bladder cancer (BC).
Method: Complex MRI is spent at 16 patients, age from 52 till 76 years with the diagnosis a BC. In a complex joined:
T2-and T1-weighted MR imaging
kidneys and pelvic organs, contrast-enhanced functional MRU, dynamic contrast-enhanced MR imaging (DCE-MRI) ,
contrast MRU, MR voiding and ascending cystourethrography, virtual MR urofluometry.
Results : Complex MRI has allowed to specify presence bladder tumours, a condition and interest in pathological
process of kidneys, upper and lower
urinary tract, presence and characteristics metastasises.
Conclusion: Complex MRI is a useful method of detecting bladder tumours, research allows to define morphological
and functional infringements urinary system at patients with a BC.
SS8.
DUAL SOURCE CT CYSTOGRAPHY AND VIRTUAL CYSTOSCOPY VERSUS CYSTOSCOPY WITH
PHOTODYNAMIC DIAGNOSIS (PDD) METHOD IN THE BLADDER CANCER
Panebianco V., Vergari V., Di Mare L., Zampelli A., De Dominicis C., Passariello R.
Dept of Radiological Sciences, Sapienza University of Rome
Object: To demonstrate the use of cistography CT(CTC) and virtual cistoscopy(VC) with Dual Source technique in the
diagnosis of bladder lesions using Cistoscopy with Photodynamic diagnosis (PPD) as reference standard.
Method: The patient population was divided into three groups based on lesion size at PPD.CTC with VC, is mandatory for
TNM and is useful when conventional cystoscopy is inconclusive. With regard to lesion size, it has been also
demonstrated that multidetector-row CT (MDCT) performed with thin-slice reconstructions (1 mm) allow a good
sensitivity for the detection of lesions < 5 mm.
The study showes the typical imaging findings of bladder carcinoma with Dual Source CT C and VC, included postcontrast
scan and were compared with PPD.
Results: PPD depicted 92 bladder lesions in the 44 patients examined.
Sensitivity and specificity values of CTC and VC alone were constantly lower than those of the combined-approach
(group 1: 93.25% and 92.54%; group 2: 100% and 100%; group 3: 100% and 100%, respectively).ROC curve analysis
showed that the combined approach decreases the lower dimensional threshold for lesion detection (1.4 mm).
Conclusion: CT Cystography and Virtual Cystoscopy are less invasive than conventional cystoscopy, can be used to
evaluate areas difficult to assess with cistoscopy such as the anterior bladder neck and narrow-mouthed diverticula, and
enable the staging of the neoplasia.
The main disadvantages of CTC and VC are the low sensitivity to depict flat lesions, as demonstrate on Cystoscopy with
PPD method.
SS1.
PROSTATE IMAGING – MALE GENITALI I
Moderators: Claudon M. (F) – Piperopoulos P. (GR)
STATE-OF-ART PROSTATE MR IMAGING
Verma S.
Department of Radiology, University of Cincinnati, 234 Goodman street, Cincinnati, Ohio 45267-0762
Objective: 1. Discuss the MR techniques for prostate cancer detection and staging
2. Detail the indications for prostate MRI
3. Describe how to perform a prostate MRI exam.
Conclusion: This presentation reviews the current functional and anatomic MR imaging techniques to improve the
accuracy of MR for detection and localization of prostate cancer
SS2.
PROSTATE MR AND MR SPECTROSCOPIC IMAGING AT 1.5T VERSUS 3T
Verma S. MD 1 , Rajesh A. MBBS 2 , Kurhanewicz J. PHD 3
1 Department of Radiology, University of Cincinnati, 234 Goodman street, Cincinnati, Ohio 45267-0762
2 Department of Radiology, University Hospitals of Leicester NHS Trust, Gwendolen Road, Leicester. LE5
4PW. UK, 3 Department of Radiology, University of California, San Francisco, 505 Parnassus Ave., San
Francisco, CA 94143-0628
Objective: Describe the technical differences between 1.5T and 3T MR/ MR Spectroscopy
1. Conventional MRI-1.5T versus 3T
a. Image quality
b. Spatial resolution
c. Speed of acquisition
d. Changes in optimal TR and TE
e. Susceptibility artifacts
f. Dielectric /Standing wave effects
111

g. Motion
h. SAR
2. How to optimize endorectal MR/MRS exam
3. MR Spectroscopy 1.5T versus 3T
a. Spectral resolution
b. Spatial resolution
c. Signal to noise ratio
1. Chemical shift artifacts
1. Voxel size
2. Volume averaging
d. Changes in optimal TR and TE
e. Differences in pulse sequences
f. Speed of acquisition
Conclusion: This presentation reviews (1.5T versus 3T ) MR/MRS technique optimization, potential pitfalls and how to
avoid them.
SS3. MR SPECTROSCOPY (MRS) AND DINAMIC CONTRAST ENHANCED MR (DCEMR): DETECTION OF
PROSTATE ADENOCARCINOMA FOCI IN MEN WITH PRIOR NEGATIVE PROSTATE BIOPSY AND
ELEVATED PROSTATE SPECIFIC ANTIGEN (PSA) LEVELS.
Panebianco V., Bernardo S., Santucci E., Lisi D., CiccarielloM.', Passariello R.
Dept. of Radiological Sciences,Sapienza University of Rome, ' Dept. of Urology 'U.Bracci', Sapienza University of
Rome
Object: To assess the role of MRSI and DCEMR in the detection of prostate tumor foci in patients with elevated PSA
levels ( range ≥ 4 ng/ml and < 10 ng/ml) and prior negative random TRUS-guided biopsy .
We compared a second random versus a second MRSI/DCEMR directed biopsy for detection of a histologically
confirmed prostate cancer.
Method: We recruited 215 patients,with a first negative random TRUS-guided prostate biopsy for prostate
adenocarcinoma or HGPIN, elevated PSA levels and negative DRE. Two groups patients: Group A with a second
random TRUS-GUIDED biopsy, Group B : with a second direct TRUS-guided biopsy in prostate areas MRSI and DCEMR
as suspicious for cancer, samples targeted on these areas were associated to the random biopsy.
Results: On a core by core basis, MRSI had a 83.3% sensitivity, 72.7% specificity, 71.4% PPV, 84.2% NPV and 77.5-
% accuracy, DCEMR had a 75.6% sensitivity, 76.7% specificity, 73.6 % PPV, 78.5 % NPV and 76.2% accuracy and the
association MRSI + DCEMR a 89.7% sensitivity, 80.4-% specificity, 81.3% PPV, 89.1% NPV and -85% accuracy. On a
patient by patient basis, MRSI had a 92.3% sensitivity, 88.2% specificity, 85.7% PPV, 93.7% NPV and 90%
accuracy, DCEMR had a 84.6% sensitivity, 82.3% specificity, 78.5% PPV, 87.5% NPV and 83.3% accuracy and the
association MRSI + DCEMR a 92.6-% sensitivity, 88.8% specificity, 88.7% PPV, 92.7% NPV and 90.7% accuracy .
Conclusions: MRSI/DCEMR can improve cancer detection rate especially in patients with prior negative TRUS-guided
biopsy and alterated PSA serum levels
SS4.
PRELIMINARY STUDY USING DCE-MRI WITH GADOFOSVESET TRISODIUM BLOOD POOL CONTRAST
AGENT IN THE ASSESSMENT OF PROSTATE CANCER
Panebianco V., Osimani M., Santucci E., Lisi D., Bernardo S., Passariello R.
Dept. of Radiological Sciences,Sapienza University of Rome
Object: In prostate cancer (Pca) an increasing number of microvessels can be observed. Gadofosveset trisodium
(Vasovist), binds reversibly to human albumin in plasma and results in increased relaxivity value. This linkage is useful
to our aim that was to report a dynamic contrast-enhanced MRI (DCEMRI). We introduced a new way of evaluation
for dynamic signal intensity time (SI-T) curves.
Method: We performed 62 prostate MR exams( morphologic, 1H-MRSI and DCEMRI protocols). We divided our
population: Group A with 32 patients with Pca, Group B including both 10 patients with glandular BPH and 9 cases with
mixed glandular/stromal BPH ,Group C with 11 patients negative for prostate disease. An enhancement descriptor
(ED) was calculated with SI-T curves’ single records and its values was correlated to metabolities and ratio level at
1H-MRSI.
Results: Group A resulted in highest ED value (331,79), while in Group B ED value reported was 125,14 in glandular
BPH and 193,37 in mixed stromal/glandular BPH type. ED for Group C was 201,36. Rank correlation reported a
positive correlation with choline, creatine and ratio values in the Group A, with citrate in glandular BPH, and with
citrate in Group C. In stromal BPH a negative correlation was reported with citrate.
Conclusions: Cancer yielded significantly with highest ED value than both normal patients’ group C and glandular BPH
in group B . We confirmed that vascularity changes in prostate tissue reflect in metabolic changes, as correlation
analysis showed by the use of our ED.
112

SS5.
EVOLUTION OF PATTERN CHANGES FROM INFLAMMATION TO PROSTATE CANCER USING 1H-MRSI
AND DCE-MRI
Panebianco V., Santucci E., Biondi T., Di Mare L., Lisi D., Passariello R.
Dept. of Radiological Sciences, Sapienza University of Rome
Object: To assess Magnetic Resonance Spectroscopic Imaging (1H-MRSI) and Dynamic Contrast-Enhanced Magnetic
Resonance (DCE-MRI) features in histologically confirmed prostatic chronic inflammation, prostatic intraepithelial
neoplasia (PIN) , low grade (LGPCa) and high grade (HGPCa) prostate cancer. An analysis of 1H-MRSI and DCE-MRI
parameters has been used to verify the hypothesis for a link among chronic inflammation , PIN and PCa.
Method : One-hundred-five men were selected, these patients were divided in five groups: control group (Group
A),patients with chronic inflammation (Group B), PIN (Group C) or prostate cancer (LGPCa = Group D and HGPCa =
Group E). All patients were submitted to 1H-MRSI and DCE-MRI before biopsy.
Results: ANOVA analysis shows that a constant and significant (p< 0.05) difference in almost all metabolic
assessments (1H-MRSI) exists between controls (group A) and the other groups (Group B,C,D,E). Moreover,
inflammation (Group B) showed no significantly (p>0.05) different Choline and Citrate levels when compared to PIN
and LGPCa. The results of the ratio analysis were consistent with no significant (p>0.05) differences between
inflammation and PIN and between LGPCa and HGPCa. The analysis of Cho concentration showed very similar levels
among inflammation, PIN and LGPCa.
Conclusion: In our study the similar levels of Cho among inflammation, PIN and LGPCa, may suggest a potential
evolutionary trend among these lesions.
SS6.
CONTRAST-ENHANCED TRUS SIGNIFICANTLY INCREASES THE SENSITIVITY OF LOCALIZING BOTH
LOW AND HIGH GLEASON GRADE PROSTATE CANCER
Heinmink S., Futterer J.J., Hambrock T., Hulsbergen-v.d.Kaa C.A., Witjes J.A., Barentsz J.O.
Radboud University Nijmegen Medical Center
Purpose: To compare the prostate cancer localization accuracy of gray-scale, color and power Doppler and sulphur
hexafluoride-enhanced power Doppler transrectal ultrasound
(TRUS) with whole-mount section histopathology and the effect of experience and Gleason score.
Methods and Materials: Fifty-two consecutive men with biopsy-proven prostate cancer underwent TRUS before radical
prostatectomy. Unenhanced axial images covering the prostate were obtained in gray-scale, color Doppler, and power
Doppler mode. During continuous 1 ml/min manual intravenous infusion of 2.4ml sulphur hexafluoride, axial images in
power Doppler mode with low mechanical index were acquired. For each mode, four readers with different levels of
experience independently scored the presence of
prostate cancer on a five-point probability scale for each of 14 segments covering the prostate. Whole-mount section
histopathology was the reference standard. AUC curves were calculated using bootstrapping and Bonferroni correction.
Diagnostic performance parameters were determined. Separate analyses were performed according to Gleason scores.
P

SS8.
PERFUSION MR IMAGING OF LOCAL RECURRENCE AFTER RADICAL PROSTATECTOMY
Kubin K., 1 Memarsadeghi M. 2
1 : Department of Radiology, University Clinics Salzburg, AUT, 2 : Department of Radiology, medical University
Vienna
Purpose: Because of increasing numbers of patients with PCa and approximately 15-35% of patients experiencing
recurrence after radical prostatectomy (RPE), imaging is mandatory to provide further local therapy. The aim of this
study was to determine the benefit of additional perfusionMR of the prostatectomy bed to detect local tumor
recurrence after RPE.
Methods: The MRI examinations of 15 patients, one to 12 years after RPE (median 7 years), were included in this
study. 1.5 Tesla MRI, with a combined pelvic phased array and endorectal coil, was performed in all patients.
Transverse and coronal T2w fast spin echo MR images and T1w fast 3D GRE images were obtained before and after
the injection of Gd-DPTA. The post-contrast media T1w sequence (duration 35 sec) was repeated 10 times. A
commercially available CAD system (Prostream, CADSciences, NY) was used to evaluate Perfusion -MR results.
The T2w series alone, the T1-perfusion series, and the T2w series, together with T1-DCE, were assessed at different
time points.
Images were assessed for the presence of local recurrent tumor within the prostatectomy bed. Tumor localization and
size were also assessed.
Clinically, determination of local recurrence was based on one of the following methods:
a) Reduction in PSA level following external beam radiation therapy of the prostatectomy bed;
b) MR follow-up that showed at least a 20% increase in the size of a suspicious soft tissue mass within the
prostatectomy bed;
c) Positive biopsy results from the prostatectomy bed
Results: Clinically, 10 patients had local recurrent tumor based on the criteria listed above.
The accuracy of reading T1w perfusion MR images alone was higher than reading T2w images alone or reading T2w
images and T1w perfusion-MR images in one session (93,3% vs 80,0% vs 86,7%).
Lesions were mostly located bilateral or dorsal to the urethra.
Mean lesion diameter was 13 mm and there was no significant difference between the imaging methods (p= .470)
Conclusion: Perfusion-MR of the prostatectomy bed after RPE increases the detection rate of local recurrence after RPE
and, therefore, should be added to MR protocols designed to evaluate patients with increasing PSA after RPE. Contrast
media enhancement over time allows more accurate differentiation between granulation tissue, scars and recurrent
tumor.
Clinical Relevance/Application: Perfusion-MRI is more accurate to detect local recurrence after RPE than T2w imaging
only and therefore is necessary to plan further local therapy
FEMALE PELVIS – FEMALE IMAGING
Moderators: Bellin M.F. (F) – Sebastia M. (E)
SS1.
MRI IN THE WORK-UP OF INDETERMINATE OVARIAN MASS: PROTOCOLL OPTIMIZATION AND
DIAGNOSTIC EFFICACY ANALYSIS
Chilla B. 1 , Hauser N. 2 , LocherP. 1 , Singer G. 3 , Fröhlich J.M. 4 , Hohl M. 2 , Kubik-Huch R.A. 1
Institute of Radiology 1 , Clinic of Gynecology & Obstetrics 2 , nstitute of Pathology 3 , Guerbet AG4
Objective: This study was undertaken to optimize our MR protocol including T2-BLADE and diffusion weighted
sequences (DWI) for the work-up of indeterminate ovarian lesions and to determine the economic and clinical value of
MRI in this setting.
Method: 30 Patients with indeterminate ovarian lesion scheduled for surgery are included in this prospective study.
MRI of the abdomen including DWI and T2w BLADE was performed on a 1.5 T Siemens Avanto scanner. In a
questionnaire, the surgeon characterizes the lesion based on Kawai score and determines the surgical procedure. He
then revaluates his assessment knowing MR findings. Results are correlated with final diagnosis. A cost-benefitanalysis
of MRI in the pre-treatment work-up is performed.
The newly implemented T2w Blade sequence was compared to convential T2w FSE using a 5-point-scale (image
quality, organ delineation, presence of artifacts). Furthermore, it was evaluated whether ADC values are useful in the
differential diagnosis.
Results : The MRI protocol with an imaging time of 35 minutes was well tolerated. High quality DWI can be obtained
following glucagon application in most patients. On T2 BLADE, the delineation of the adnexal mass and the uterus is
clearer demonstrating details which are hardly recognizable on T2 FSE.
MRI provided additional diagnostic information in several patients influencing patient information and surgical
planning. Detailed data and cost-benefit-analysis will be presented at the meeting.
Conclusion: MRI is a helpful tool in the preoperative evaluation of indeterminate adnexal masses.
T2w BLADE should replace conventional T2w sequences allowing better assessment of pelvic organs.
SS2.
PRIMARY MALIGNANT MIXED MLLERIAN TUMORS OF THE UTERUS: SONOHYSTEROGRAPHIC AND
COLOR DOPPLER FINDINGS
Lee E.J., MD
Department of Radiology, Ajou University School of Medicine, Suwon, Korea
Objective: To describe the sonographic features of primary malignant mixed müllerian tumors of the uterus and to
determine the diagnostic role of sonohysterography(SH) and color Doppler sonography(CDS).
Method: The SH and CDS findings for 29 histologically proved cases of primary malignant mixed müllerian tumors,
accumulated over 10 years, were reviewed retrospectively. The pathologic diagnoses of epithelial carcinoma included
endometrioid (n=24), papillary serous (n=4), mixed (n=2), and the sarcomatous component was homologous (n=18)
and heterologous type (n=11).
Results: Of 29 total uterine tumors, 16 were in the corpus, 9 were in the fundus, and 4 were in both corpus and
fundus. The mean tumor size was 5.4 cm (range, 2.6–17 cm). The most common appearance was a polypoid mass
114

projecting into the endometrial cavity in 23 cases. The surface of the tumor was irregular (n=28) and lobulated (n=9).
The tumor was heterogeneous isoechoic in 16 cases or hyoechoic in 12 cases. The tumor often had an anechoic cystic
or cleft-like area (n=10), necrosis (n=4) and hemorrhagic area (n=7). Myometrial invasion was present in 28 cases
and dilatation of endometrial cavity was seen in 11 cases. CDS showed moderate-marked vascularity in 20 cases,
which appeared as single or multiple feeding vessels (n=15) or randomly dispersed vessels (n=9), with mean RI of
0.41.
Conclusion: Knowledge of the sonographic appearance of primary malignant mixed müllerian tumors may facilitate
diagnosis and help distinguish these tumors from other polypoid uterine tumors.
SS3.
VALUE OF CERVIX STRUCTURAL CHANGES AT MR IMAGING IN PATIENTS WITH RISK OF PRETERM
DELIVERY
Masselli G., Truglio M., Patti S., Marzano S., Tozzi C., Perrone G., Brunelli R., Anceschi M.M., Gualdi. G.
Radiology Dea Department. La Sapienza University Rome.
Aim: To evaluate the cervical structure using the signal T2 intensity changes in Magnetic Resonance (MR) in patients
with Risk of Preterm Delivery (RPD).
Materials And Methods: 11 patients with diagnosis of threatened preterm delivery underwent to MR at 1.5 T scanner .
This study group was compared with a control group of normal patients (n=8) that underwent MR for suspected fetal
abnormalities.
The signal intensity was evaluated using HASTE T2 weighted sequences through the placement of a Region of interest
(ROI) of 1 cm2 ( 83 pixel) in the anterior and posterior lips of the cervix. The signal intensity of the total area of the
cervix was measured in coronal plane. The intensity index was calculated by the ratio of the signal intensity of
selected region in the cervix over the signal intensity of the subcutaneous fat. Statistical analyses was performed by
Student t- Test.
Results: In all women the maternal cervix was clearly visualized by MR imaging. The average of gestational age in
which the MR was performed was 26 ( 23-32) weeks in the study group and 31 weeks ( 30-32) in the control group.
The intensity index calculated in the study and in the control group respectively were: posterior lip 0.74 and 0.54 (p=
0.049); anterior lip 0.63 and 0.51 ( p= 0.65); total area 1.31 and 1.20 (p= 0.91).
Conclusion: The increased of the signal intensity in the HASTE sequence, observed in the study group, show a
condition of high hydratation of the cervical stroma; this phenomenon is present very prematurely and has to be
considered as a strong demonstration of the connective tissue degradation process that is at the basis of cervix
reabsorption in RPD.
SS4.
MR IMAGES OF RETAINED PLACENTAL TISSUE
Takahama J., MD, Marugami N., MD, Kitano S., MD, Takewa M., MD, Itoh T., MD; Kichikawa K., MD.
Department of Radiology, Nara Medical University, 840 Shijo-cho, Kashihara city, Nara, Japan
Purpose : Retained placental tissue may cause severe postpartum hemorrhage. The purpose of this study is to
evaluate the role of MR imaging in diagnosing retained placental tissue and assessment of follow-up.
Method And Materials : The subjects were continuous 8 patients clinically suspected retained placental tissue between
January 2002 and April 2009. All patients underwent MR examination (on Siemens sonata 1.5T) consists of T1WI, FSE
T2WI, and dynamic contrast study (VIBE sequence; every 60 s after intravenous administration of Gd-DTPA). Clinical
course were also reviewed. MR images were retrospectively reviewed about intrauterine mass, the signal intensity of
the uterine contents on T1- and T2-weighted images, the enhancing pattern, uterine myometrial partial destruction.
Results : The clinical final diagnosis as retained placental tissue was 5 cases and uterine myometrial injury without
retained placental tissue (speculated due to placental abnormality) was 3 cases. Though all 8 cases showed various
signal contents in the uterine cavity, 5 cases with retained placental tissue demonstrated very hyperintense on T2WI,
isointense on T1WI, and prolonged strong enhancement. Two of 3 cases with myometrial injury showed myometrial
destruction without any enhanced lesions. No case with retained placental tissue showed linear enhancement between
placental tissue and myometrium that was reported to reflect the decidua. The clinical outcome was followed, 3 cases
without placental tissue had no recurrent hemorrhage, one of 6 cases with placental tissue required TCR after UAE, 2
cases obtained TCR after MTX, 2 cases spontaneously discharged.
Conclusion : MR imaging is helpful in diagnosis for the postpartum hemorrhage especially in detecting the retained
placental tissue.
Clinical Relevance/Application : The 3D-T2WI in female pelvis is useful for diagnosis of myometrial invation in corpus
cancer.
SS5.
DIFFUSION WEIGHTED MR IMAGING IN VULVA CANCER
Ewald A.M., Møller J.M., Johannesen H.H.
Diagnostic Radiology 54E2 Copenhagen University Herlev, Herlev Ringvej 75, DK-2730 Herlev Denmark.
Purpose: To measure the Apparent Diffusion Coefficient (ADC) in vulva cancers.
Method: Diffusion weighted and T2w images performed on either 1.5T or 3T were reviewed retrospectively in 17
consecutive patients (mean age 68, at range 32-92) with pathologically verified plano cellular carcinoma of vulva. ADC
maps were calculated on basis of two b values: b=0 and b=1000. Tumor was outlined on transverse T2w images and
on the corresponding ADC map before the ADC was measured.
Results: 3 patients were excluded because tumor was not visible on T2w. Pathologic examination revealed a 1 mm
thin tumor in these patients. 1 patient was excluded because diffusion imaging was not performed. In a total of 13
patients, mean age 73 ( range 32-92 ) the mean ADC was 1.22x10-6 mm2/sec +/- 0.18
Conclusion: In plano cellular carcinomas of the vulva ADC measurements are presented. Diffusion weighted imaging
aids in depicting vulva cancer.
115

SS6.
MR FINDINGS OF METASTATIC OVARIAN TUMORS
do Nascimento A.F. 1 , Sousa S. 2 , Cunha T.M. 3
1 Radiology Department, Hospital Professor Doutor Fernando Fonseca, 2 Radiology Department, Hospital dos
Lusíadas, 3 Radiology Department, Instituto Português de Oncologia Francisco Gentil
Purpose: The purposes of this study were to evaluate the MR findings of metastatic ovarian tumors and to compare
them with those of primary ovarian tumors.
Method: This study included 14 patients with metastatic ovarian tumors and 30 patients with various primary ovarian
tumors. Imaging findings of the tumors were divided into unilateral versus bilateral mass and categorized into
subgroups: predominantly cystic lesions, solid mass with intratumoral cysts and solid mass without cystic components.
Results: Among 14 tumors (bilateral in 8 patients), 8 were solid masses with multiple intratumoral cysts. Six tumors
were solid masses without cystic components. None of the metastatic tumor was cystic. Imaging findings of the
primary ovarian tumors were mainly cystic masses.
Conclusion: Bilateralism isn’t useful to differentiate primary from secondary ovarian tumors. Metastatic ovarian tumors
have predominantly solid or mixed appearance with solid components within intratumoral cysts.
SS7.
MAGNETIC RESONANCE IMAGING OF PELVIC ENDOMETRIOSIS. EFFECT OF READER’S EXPERIENCE
ON ACCURACY AND INTEROBSERVER VARIABILITY.
Restaino G. 1 , Missere M. 1 , Maselli G. 1 , Mattioni O. 2 , Calandriello L. 2 , Carone V. 3 , Legge F. 3 , Ferrandina G. 3 ,
Sallustio G. 1 . 1 Department of Radiology, “John Paul II” Center for High technology Research and Education in
Biomedical Sciences, Catholic University of Sacred Heart, Campobasso, Italy 2 Department of Bioimaging and
Radiological Sciences, Policlinico “A.Gemelli”, Catholic University of Sacred Heart, Rome, Italy; 3 Department
of Gynecology “John Paul II” Center for High technology Research and Education in Biomedical Sciences,
Catholic University of Sacred Heart, Campobasso, Italy.
Objective: To evaluate the effect of reader’s experience on preoperative assessment of pelvic endometriosis using
magnetic resonance imaging (MRI).
Material And Methods: 25 consecutive patients with biopsy-proven pelvic endometriosis were examined with a 1.5-
Tesla MRI unit and then treated with surgery. Two experienced urogenital MR radiologists (R1, R2) and two general
radiologists (R3, R4) retrospectively reviewed the examinations and evaluated the following potential locations of
pelvic endometriosis: ovary, Douglas’ pouch/recto-vaginal septum, recto-sygmoid colon, bladder, anterior cul-de-sac.
Interobserver agreement between R1/R2 and R3/R4 was measured with Cohen’s k test. Accuracy and likelihood ratio
were measured with a complete postoperative histopathological examination used as the gold standard.
Results: Interobserver agreement was calculated on all 25 cases. Accuracy was calculated on 21 cases because in 4
patients detailed postoperative findings were not available.
At pathology, endometriomas were found in right ovary in 13/21 patients and in the left ovary in 14/21 patients;
Douglas’ pouch or recto-vaginal septum involvement was found in 14 patients; recto-sigmoidal infiltration was
observed in 8 cases, anterior cul-de-sac was involved in 7 patients and bladder in 3 cases.
Cohen’s k for right and left endometrioma was 0.90 and 0.73 in the expert group, but 0.65 and 0.55 for the nonexpert
group. For Douglas/septum involvement k value was 0.56 for experts and -0.12 for non-experts. For rectosigmoidal
infiltration k was 0.43 for experts and 0.20 for non-experts. For bladder involvement k was 0.75 for experts
and 0.53 for non-experts.
Accuracy for right ovarian endometrioma was 85% and 90% for R1 and R2 and 76% and 85% for R3 and R4. Accuracy
for left ovarian endometrioma was 90% and 76% for R1 and R2 and 76% and 62% for R3 and R4. For
Douglas/septum involvement R1 and R2 accuracy was both 66,7%, while it was 52% for R3 and 61% for R4. For
recto-sigmoidal infiltration accuracy was 95% for R1, 76% for R2, 71% for R3 and 58% for R4. Accuracy for bladder
infiltration was 81% for R1, 90.5% for R2, 68% for R3 and 72% for R4. All the results were not statistically significant
(p>0.05)
Conclusion: Although non statistically significant, due to small study sample, our results suggest that reader
experience has a positive effect on interobserver variability and on the accuracy of preoperative prediction of pelvic
diffusion of endometriosis. To obtain high-quality preoperative prediction of endometriosis diffusion, it is suggested
that preoperative MRI evaluation should be performed by a radiologist expert in urogenital imaging.
116

SS8. PRE- AND POSTOPERATIVE DYNAMIC MRI: EVALUATION OF PELVIC ORGAN DESCENSUS IN
SYMPTOMATIC WOMEN
Alt C.D. 1 , Brocker K. 2 , Lenz F. 2 ,Sohn C. 2 , Kauczor H.U. 1 ,Hallscheidt P. 1
1 University Hospital of Heidelberg, Dept. of Diagnostic and Interventional Radiology, 2 University Hospital of
Heidelberg, Dept. of Urogenital Gynecology
Objective: Evaluation of dynamic changes of pelvic organ descensus before and after mesh-repair by MRI.
Method: In this prospective study 35 women with pelvic organ descensus underwent dynamic 1.5 T MRI before, 4 and
12 weeks after mesh-repair.
The examination protocol included sagittal T2w tse images (TR 3460ms, TE 85ms, matrix 512/282), axial T1w images
(TR 128ms, TE 4,7ms, matrix 256/154), dynamic sagittal T2w trufi single-shot images under valsalva-maneuver (TR
397ms,TE 1,5ms, matrix 256/125) and sagittal T2w trufi images under maximum abdominal pressure (TR 4,3ms, TE
2,15ms, matrix 256/162).
The dynamic changes of the pelvic organs were measured in accordance to two referential lines: the pubococcygealline
and the symphysial-length-line.
Results: Under valsalva the median of the maximum expansion of a cystocele was preoperative 5 cm, of an uterine
descensus 0,4 cm, of an enterocele 2,5 cm and of a rectocele 0,4 cm.
4 weeks after mesh-repair the median of the maximum expansion of a cystocele was 0,3 cm, of an uterine descensus
– 2,1 cm, of an enterocele 1,4 cm and of a rectocele – 0,2 cm.
12 weeks after mesh-repair the median of the maximum expansion of a cystocele was 1,1 cm, of an uterine descensus
– 1,3 cm, of an enterocele 1,7 cm and of a rectocele – 0,4 cm.
There’s a high significant difference between pre- and postoperative evaluation (p< 0,02) in a short follow-up period
(12 wk).
Conclusion: Dynamic MRI offers an accurate identification of pelvic structures and extent of descensus and allows to
evaluate the success after reconstructive surgery.
SS9.
LONG-TERM QUALITY OF LIFE ASSESSMENT IN PATIENTS UNDERGOING UTERINE FIBROID
EMBOLIZATION
Popovic M., Berzaczy D., Puchner S., Zadina A., Lammer J., Bucek R.A.
Department of Cardiovascular and Interventional Radiology, Medical University of Vienna, Währinger Gürtel
18-20, A-1090 Vienna, Austria
Purpose: Assessment of long-term outcomes of fibroid-associated quality of life in patients treated by uterine fibroid
embolization.
Materials And Methods: This retrospective follow-up cohort study was performed including all patients from a 2006
publication. Analysis was performed by a questionnaire consisting of 49 questions about six topics. Assessment focus
was put on comparing symptoms, follow-up, and quality of life in long-term.
Results: The analysis was performed based on questionnaires from 39 patients. The median follow-up was 7.0 years
(IQR: 1.5 years). Uterine fibroid embolization led to a reduction of bleeding symptoms in 89.7% of patients, pain in
78.9%, bulk-related symptoms in 89.5%, fatigue in 76.9%, limitations in social life in 92.9%, and depression in
78.6%. The median impairment score for bleeding and pain decreased significantly from 7 to 0 and from 5 to 0,
respectively (both p < 0.001). The general quality of life index increased significantly from 4.5 to 9 (p < 0.001). In the
long-term there was no significant difference in parameters assessed as compared to mid-term follow-up (for all,
p

SS2.
CONTRAST-ENHANCED ULTRASOUND IN SCROTAL DISEASES: PRELIMINARY RESULTS
Valentino M., Bertolotto M.*, Barozzi L., Pavlica P.
University Hospital S.Orsola-Malpighi Department of Radiology Bologna, Italy , * University of Trieste
Cattinara Hospital, Department of Radiology, Trieste, Italy.
Aim: Ultrasonography (US) is the mainstay for the scrotal pathology, but sometimes diagnosis may be indeterminate
requiring further investigations. Contrast-enhanced ultrasound (CEUS) can improve the depiction of parenchymal
disorders on the base of vascularity, which helps in the differential diagnosis of focal lesions or traumatic changes. Aim
of this report is to analyze the effectiveness of CEUS findings in the evaluation of scrotal disease compared to baseline
US.
Methods: A second-generation contrast medium (SonoVue, Bracco, Italy) with a low-mechanical index linear probe (4-
7MHz) was used in 42 patients (18-84yrs) with scrotal pain or suspected for solid mass or scrotal trauma.
Results: Final diagnosis included 22 germinal tumors, 3 orchitis with abscess, 5 focal ischemic lesions, 6 trauma, 5
infertility and 1 testicular torsion. CEUS showed absence of vascularisation in abscesses, ischemic areas and torsion;
increased or in-homogeneous enhancement in tumors; in trauma absence of enhancement with or without albuginea
interruption; in infertility areas of increased or reduced enhancement pattern.
Conclusions: Technological developments have ensured that US has consolidated its role in the diagnosis and guidance
of subsequent of management of patients with scrotal pathology. The use of CEUS can maximize its value and reduce
the incidence of errors or misdiagnosis in focal lesions. Confidence is also increased in scrotal trauma and in the
detection of hypervascularized spots in infertile men before micro-TESE. This preliminary data need to be confirmed in
more extensive number of patients studied in different centres with operators of variable experience.
SS3.
EMERGENCY SONOGRAPHIC EVALUATION OF THE SCROTUM. HOW OFTEN IS PATHOLOGY
DETECTED AND WHICH ARE THE COMMONEST ABNORMALITIES
Cokkinos D.D., Antypa E., Tserotas P., Kyratzi E., Deligiannis I., Spiliopoulou G., Dagiakidi E., Piperopoulos
P.N.
Radiology Department. Evangelismos Hospital. Athens, Greece.
Objectives: To calculate the proportion of patients with abnormal findings on emergency scrotal ultrasound. To review
the commonest pathologies.
Methods: Retrospective review of 114 patients aged 14 to 81 years subjected to emergency sonographic evaluation of
the scrotum. Patients complained of pain, swelling, trauma, palpable mass or fever. We calculate how often one of
the 4 basic emergency pathologies of the scrotum (torsion, trauma, infection, tumours) was diagnosed. We also
assess how often a non emergent entity (normal variant, hydrocele, varicocele, cryptorchidism, calcifications etc)
diagnosis was established, as well as the number of patients with no abnormality whatsoever identified.
Results: Findings suggestive of infection (epididymitis/orchitis) were seen in 28 patients, torsion (reduced blood flow)
in 11, trauma (testicular contusion or scrotal haemmorhage) in 21 and tumour (solitary or multiple lesions) in 9.
Altogether 69/114 patients (60.5%) were diagnosed with one of the 4 major pathologies. In 25 patients (21.9%) non
emergency entities (cysts, varicocele, hydrocele, cryptorchidism, discrepancy in size, calcifications) were detected.
These patients were referred for a second ultrasound examination on a routine basis. Finally, in 20 patients (17.5%)
no pathology evident on ultrasound was found.
Conclusion: Emergency ultrasound of the scrotum is part of every day clinical practice. In most cases pathology is
included in on of the 4 major groups. However, quite often non emergent entities or no abnormality whatsoever are
found. Radiologists should be well trained in the anatomy, pathophysiology and sonographic examination technique,
as well as differentiation of the commonest emergency and non emergency abnormalities.
SS4.
SONOGRAPHY OF THE ACUTE SCROTUM: THE COMPLEMENTARY ROLE OF IMAGING WITH ECHO-
ENHANCER.
Moschouris H. 1 , Papadaki M.G. 1 , Goutzios P. 2 , Tsagouli P. 1 , Stamatiou K. 3 , Gialias P. 1 , Matsaidonis D. 1
1 .Department of Radiology, «Tzanio» General Hospital, Piraeus, Greece. 2 .Department of Radiology, 251
General Air Force Hospital, Athens, Greece. 3 .Department of Urology, «Tzanio» General Hospital, Piraeus,
Greece.
Objective: To present and evaluate the findings of Contrast-Enhanced UltraSonography (CEUS) in typical cases of
acute painful scrotum.
Method: 16 patients (age: 19-61 years) were included in the study. They underwent grey-scale and color doppler
ultrasonography of the scrotum, followed by imaging after i.v administration of 2.4 ml of a second generation
ultrasound contrast agent (microbubbles of sulphur hexafluoride, SonoVue, Bracco). Α dedicated, contrast-sensitive
technique was utilized (Contrast Tissue Imaging-CnTI). The diagnosis was confirmed surgically in 7 cases and was
based on the combination of clinical, imaging and laboratory findings in 9.
Results: The final diagnosis was: Testicular torsion (n=6, including one case of incomplete torsion), Epididymitis (n=2,
one of the cases complicated with abscess), Testicular abscess (n=1), Scrotal abscess (n=1), Testicular trauma of
varying severity (n=6). CEUS showed complete lack of enhancement in all cases of complete torsion, and impaired
enhancement in the case of incomplete torsion, permitting a rapid and definitive diagnosis. In the cases of
inflammation complicated by abscesses, CEUS delineated the lesions much better than the combination of grey-scale
/color doppler US. The severely traumatized testicles showed minimal, inhomogeneous or patchy enhancement, while
cases of minor trauma showed no significant enhancement defects. Hematomas presented as non-enhancing lesions.
Conclusion: In selected cases of acute scrotum, CEUS may increase the efficacy and reliability of ultrasonographic
diagnosis. Further studies are required to clearly define the indications of this method.
118

SS5.
TESTICULAR TORSION: SONOGRAPHIC EVALUATION BEFORE AND AFTER MANUAL DETORSION
Christopoulou A 1 ., Kaitartzis C 1 ., Mavridou C. 1 , Smponia A. 1 , Gotsis G. 2 , Katsiba D. 1
1. Department of Radiology, General Hospital of Thessaloniki, “G.Gennimatas”, 2. Department of Urology,
Aristoteles University of Thessaloniki, General Hospital of Thessaloniki, “G.Gennimatas”
Objective: To present the value of scrotal sonography in the diagnosis of testicular torsion and successful detorsion by
manipulation.
Method: During a 2-year period 73 patients aged between 16 and 25 years with testicular torsion underwent scrotal
sonography. In all cases, scrotal grey scale and Doppler ultrasound of the torsed testis in comparison with the
contralateral one was performed and the spermatic cord was evaluated when necessary. 38 of these patients
underwent an attempt of manual detorsion followed immediately by scrotal US examination.
Result: In 24 of these patients with successfully detorsed testis, normal or increased testicular blood flow and
straightened spermatic cord was revealed. In 5 patients with permanent torsion, no blood flow signal was noticed in
testicular parenchyma. In 9 patients with normal or increased testicular blood flow, a coiled cord was revealed. In all
cases sonographic diagnosis was surgically confirmed.
Conclusion: Sonography is an accurate method for the diagnosis of testicular torsion and the success of preoperative
manual detorsion. The later when successful relieves testicular ischaemia and converts an acute urological
emergency into a less urgent or even elective surgical procedure.
SS6. PROSTATE VOLUME MEASUREMENT VIA TRANSABDOMINAL ULTRASONOGRAPHY (TAUS)
COMPARED TO THE TRUE SURGICAL SPECIMEN VOLUME AFTER RADICAL PROSTATECTOMY.
Chatzidarellis E., Tavernaraki K*, Zarkadoulias A., Charalampopoulos G*, Mazaris E., Malachias G*,
Deliveliotis C., Varkarakis I.
2nd Department of Urology, University of Athens, Sismanoglio General Hospital, Athens, Greece, *Radiology
Department, Sismanoglio General Hospital, Athens, Greece
Objective: To evaluate the accuracy of transabdominal ultrasound in the determination of prostate volume compared
with the volume of the surgical specimen after radical prostatectomy.
Materials and Methods: Twenty-one male patients diagnosed with prostate cancer underwent a transabdominal
ultrasound (TAUS) prostate examination one day prior radical prostatectomy. TAUS calculated prostate volume was
compared retrospectively with the true volume of the excised prostate specimen after the seminal vesicles were
transected. The excised prostate specimen volume was measured with a volumetric container. An adequate (300 ml)
urinary bladder distention for the calculation of the prostate volume by TAUS was achieved and using a 5-MHz curved
probe the prostate volume was determined using the ellipsoid formula multiplying the largest anterioposterior (height),
transverse (width) and cephalocaudal (length) prostate diameters by 0.524. The correlation between the variables was
determined by the Paired t-test. A p value of

SS8.
IMAGE BASED CLINICAL DECISION SUPPORT WITH THE USE OF TRANSRECTAL ULTRASOUND IN
THE DIAGNOSIS OF PROSTATE CANCER: COMPARISON OF MULTIPLE LOGISTIC REGRESSION,
ARTIFICIAL NEURAL NETWORK, AND SUPPORT VECTOR MACHINE
Lee H.J., M.D. 1 , Hwang S.I., M.D. 1 , Kim S.H., M.D. 2 , Cho J.Y., M.D. 2 , Lee S.E., M.D. 4 , Byun S.S., M.D. 3
1 ) Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang
Hospital, Institute of Radiation Medicine, Seoul National University Medical Research Center, Clinical Research
Institute, Seoul National University Hospital. 2 ) Department of Radiology, Seoul National University College
of Medicine, Seoul National University Hospital. 3 ) Department of Urology, Seoul National University College
of Medicine, Seoul National University Bundang Hospital
Objective: To develop a multiple logistic regression model (MLR), artificial neural network (ANN), and support vector
machine (SVM) model for the prediction of prostate cancer and to compare the accuracies of each model.
Materials and Methods: From 2005 to 2007, 1077 consecutive patients who had undergone transrectal ultrasound
(TRUS) guided prostate biopsy were enrolled in the study. The patients were divided into training group (n = 600) for
training the decision models, and the test group (n = 477) for the evaluation of the accuracies in each decision model.
A focal lesion as seen on TRUS was evaluated in detail, with evaluation of lesion location, outline, shape, and
vascularity. To predict the probabilities of prostate cancer associated with variables, three types of clinical decision
support models including a MLR, ANN, and SVM were constructed.
Areas under the receiver operating characteristic curve were calculated to evaluate the performance of each decision
model. Pairwise comparison of ROC curves was performed.
Results: The Az values of the ROC curves for the use of MLR, ANN and the SVM were 0.768, 0.778 and 0.847,
respectively. Pairwise comparison of the ROC curves determined that there was a statistical difference between the
use of SVM and ANN (p = 0.023) and between the use of the SVM and MLR(p = 0.023).
Conclusion: The performance of the SVM was superior to the performance of the use of the ANN or the multiple logistic
regression model in the prediction of prostate cancer based on TRUS findings.
NEW FRONTIERS IN IMAGING AND SYSTEMIC DISEASES
Moderators: Thoeny H. (CH) – Kelekis N. (GR)
SS1.
USPIO ENHANCED DIFFUSION-WEIGHTED MRI TO DETECT PELVIC LYMPH NODE METASTASES IN
NORMAL SIZED NODES.
FroehlichJ.M. 1 , Triantafyllou M. 1 , Birkhaeuser F. 2 , Fleischmann A. 2 , von Gunten M. 3 , Vermathen P. 4 , Binser
T. 4 , Studer U.E. 2 , ThoenyH.C. 1 , 1 Department of Diagnostic, Pediatric and Interventional Radiology,
Inselspital, University of Bern, Bern, Switzerland, 2 Department of Urology, Inselspital, University of Bern,
Bern, Switzerland. 3 Department of Pathology, University of Bern, Bern, Switzerland. 4 Department of Clinical
Research, Inselspital, University of Bern, Bern, Switzerland
Objective: To prospectively assess the diagnostic potential of Diffusion-weighted MRI (DW-MRI) with ultra-small
superparamagnetic particles of iron oxide (USPIO) to detect pelvic lymph node metastases in patients with bladder or
prostate cancer.
Method: Thirty four patients with histological proven prostate or bladder cancer planned for surgery underwent 3T MRI
24-36hours post USPIO including 3D high resolution T1- and T2-w as well as axial EPI DW-MRI (slice thickness 4mm,
b-values=0, 500, 1000sec/mm2, 6 acquisitions). Evaluation was performed prospectively prior to extended template
lymphadenectomy. Duration of image analysis was recorded. Malignant lymph nodes were defined as round
hyperintense structures on the DW-MR images at a b-value of 1000sec/mm2 corresponding to a node on
morphological images. Benign lymph nodes were invisible on b=1000 images after USPIO-administration. Results were
correlated to histopathology based on a per patient and per lymph node level.
Results: In 34 patients a total of 1261 lymph nodes (mean 37/patient) with 44 positive, and 1217 negative lymph
nodes were compared to histopathology. Metastases were detected in 12 patients, whereas 22 were negative. The
following sensitivity, specificity, PPV, NPV and diagnostic accuracy values were calculated on a per patient level: 75%,
91%, 82%, 87% and 85%, respectively; whereas on a lymph node level sensitivity reached 73%, specificity 99.7%,
PPV 88%, NPV 99.1% and diagnostic accuracy 98.8%. Image analysis lasted 9min per patient (range: 5-45min).
Conclusion: USPIO enhanced DW-MRI allows fast, easy and accurate detection or exclusion of pelvic lymph node
metastases even in normal sized nodes.
120

SS2.
EFFICIENCY OF DIFFUSION-WEIGHTED (DW) MR IMAGING TO DETECT SMALL SIZE MALIGNANT
PELVIC LYMPH NODES AT 3T IN VARIOUS PELVIC CARCINOMATOUS DISEASES.
Roy C., Bierry G., Matau A., Pasquali R.
Radiology B Nouvel Hopital Civil University Hospital, 1, place de l'hopital BP 426, STRASBOURG
Purpose: To investigate the potential value of DW Images and Apparent Diffusion Coefficient (ADC) measurement to
detect small malignant pelvic lymph nodes in cases of pelvic malignancies.
Materials and Methods: A cohort of 196 patients with various pelvic pathology including 65 patients with metastatic
nodes (bladder carcinoma : 22pts, prostatic carcinoma : 18pts, gynecologic malignancy : 17pts , lymphoma : 6pts,
rectal carcinoma : 2pts) proved at pathology (48 cases)) or follow-up of advanced disease (7 cases) were explored on
a 3T (Achieva, Philips Medical System) with conventional axial T1 and T2w sequences in addition to axial DWI SE-EPI
(TR/TE : 7000/55,5mm,fat suppression, tf 41,EPI 41,32 slices, FOV : 288-340, Matrix size : 128-96,free breathing,3
min54) using b value: 0 and 1000s/mm2.ADC was measured by ROI (20 mm2). DW images were analysed by two
experienced readers. Measurements of short-axis diameter and visual evaluation on DW images were recorded.
Statistical analysis was realized using the SPSS 14 software (SPSS Chicago,Ill). The normality of distribution of the
ADC values of the different groups ("pathologic", "iliac", "inguinal", and "control") was checked using the Mann-
Whitney test. ADC mean values and standard deviation of the different groups were then calculated and compared
using Student
T-test. P values superior to .05 were considered for rejection.
Results: All nodes were less than 15 mm in short axis. On DW images, bilateral inguinal and iliac nodes were
constantly seen with bright homogeneous signal for all groups, most numerous in inguinal location. There were no
difference in signal intensity on visual evaluation between all groups. Image quality was rather good.
A total of 65 pathologic nodes, 131 control normal iliac nodes and 84 control normal inguinal nodes were included in
the study. The ADC of pathologic lymph nodes (mean ± standard deviation) of pathologic nodes, control iliac nodes
and control inguinal nodes were, respectively, 924 ± 217 mm3/sec, 968 ± 182 mm3/sec, 1036 ± 181 mm3/sec.
There were no statistically significant differences of ADC between pathologic nodes and control iliac nodes (p=.44),
between pathologic nodes and control inguinal nodes (p=.24) and between pathologic nodes and all (iliac plus
inguinal) control nodes (p=.23).
Conclusion: 3T DW Images as well as ADC value are not accurate enough to differentiate benign from malignant small
pelvic lymph nodes. Normal pelvic lymph nodes are visible routinely on DW images.
SS3.
RENAL ULTRASONOGRAPHIC FINDINGS IN GREEK PATIENTS WITH SICKLE-CELL ANAEMIA AND
THALASSAEMIA INTERMEDIA
Papadaki M.G. 1 , Moschouris H. 1 , Papadaki I.G. 2 , Kornezos I. 1 , Matsaidonis D. 1 , Kattamis C.A. 3
1. Department of Radiology, “Tzanio” General Hospital, Piraeus, Greece. 2. Department of Haematology
“Agioi Anargyroi” Hospital, Greece. 3. 1 st Pediatric Clinic, University of Athens, Grece
Objective¨The extreme spectrum of clinical and haematological phenotypes of sickle-cell anaemia and thalassaemia
intermedia (TI) constitute a major challenge in clinical practice in Greece. The aim of this study is to evaluate the type
and prevalence of renal ultrasonographic (US) findings in these patients.
Method: The study included 105 patients (49 males, 56 females), 13 homozygous for sickle-cell anaemia (S/S) and 92
with TI syndromes. The patients’ ages ranged from 1 to 54 years. We used high resolution US scanners with convex
and linear array transducers. Renal volume was calculated and parenchymal appearance was evaluated.
Results: Increased renal reflectivity was observed in 17.6 % of patients with sickle-cell syndromes, being the most
common finding (20%) in patients with TI. We observed three distinct US patterns: mild hyperechogenicity of the
perimedullary spaces, moderate hyperechogenicity of the inter- and intramedullary spaces and marked
hyperechogenicity of the renal medulla. Colour duplex US was performed in 10 patients and showed no significant
changes from normal. Follow-up US examinations for 5 years revealed no significant changes. Renal enlargement was
not a common finding, being diagnosed in only 15% of patients in the S/S group. One case of autosomal dominant
polycystic disease was noted.
Conclusion: In patients with sickle-cell syndromes, renal involvement is known to be capable of progression to endstage
renal disease. Increased renal parenchymal echogenicity is a significant finding that could be the initial
observation of the pathological basis for progression to chronic renal failure in older patients; however, further studies
are needed.
SS4.
GUIDELINE ADHERENCE BY REQUESTING PHYSICIANS: ANALYSIS OF ABDOMINAL CT AT A LARGE
UNIVERSITY CENTER IN THE NETHERLANDS
van Es A.C.G.M., van der Molen A.J.
Department of Radiology, C-2S , Leiden University Medical Center, Leiden The Netherlands
Objective: To investigate the adherence to a clinical practice guideline for prevention of contrast-induced nephropathy
(CIN) in the setting of intravenous contrast- enhanced abdominal CT at a large university medical center in the
Netherlands.
Method: From October to November 2008 all patients scheduled for contrast-enhanced abdominal CT were screened.
According to our CIN prevention guideline the referring physician should provide information on risk factors and renal
function parameters for all patients at increased risk for CIN when referring them for a contrast-enhanced abdominal
CT. All requests lacking information regarding risk factors for CIN were analyzed for referral origin, renal function, CIN
risk factors, and clinical follow-up. Departmental policy does not allow refusal of requests at day of study.
Results: In total 261 consecutive requests were analyzed. In 134 incomplete requests (51.3%), essential information
was missing. Further analysis showed that 28/134 (20.9%) had risk factors for CIN, and 11/134 (8.2%) should have
underwent preventive intravenous hydration before undergoing contrast-enhanced CT. During the study, 7 of these
patients were scanned without prevention, of which 1/11 developed renal function deterioration compatible with CIN.
This CIN rate was not higher (p < 0.01) compared to the high risk group that did not require preventive hydration
(0/17).
Conclusion: Spontaneous CIN guideline adherence of requesting physicians is low and continuous education and/or
refusal of incomplete requests is important. However, even in a setting of low-level screening of CT requests, the risk
of CIN in intravenous contrast-enhanced abdominal CT is low, even in high risk groups.
121

SS5.
PROGNOSTIC VALUE OF PERIRENAL INVOLVEMENT IN THE EVALUATION OF ACUTE PANCREATITIS
SEVERITY
Fagrezos D., Kolliakou E., Triantopoulou C., Maniatis P., Siafas I., Koulentianos E., Papailiou J.
CT department, Konstantopouleion general Hospital, Athens, Greece
Purpose: to assess the prognostic value of early Computed Tomography (CT) findings as far as the prevalence of
inflammation into renal and perirenal space is concerned, estimating the current best evidence about the effect of
using a CT Score Index (CTSI) and the ExtraPancreatic Inflammation on CT Score (EPICTS) on patient outcome.
Methods: 80 patients with acute pancreatitis who underwent an abdominal CT within 24 h after admission were
included in the study. The CTSI and the EPICTS based on the presence of pleural effusion, ascites, retroperitoneal and
mesenteric inflammation were calculated for all patients. The end points were the occurrence of severe acute
pancreatitis (local complications or presence of organ failure for more than 48 h) and in hospital mortality.
Results: CT scans were graded as mild (n=20), moderate (n=45) and severe (n=15).The observers detected
renal/perirenal abnormalities included perirenal fat stranding (n=29), perirenal fluid collections (n=23), ureteral
encasement (n=2), renal vein thrombosis (n=1) and renal parenchymal infiltration (n=2). In hospital mortality was
6.25% (5/80). The mean EPICT score was 2.6. An EPICT score of 4 or more had a 100% sensitivity and 73%
specificity for predicting severe pancreatitis. Perirenal fat stranding and collections correlated best with overall
patients’ outcome.
Conclusions: Extrapancreatic inflammation which involves perirenal space assessed by abdominal CT scan and
quantified with EPICT score allows accurate estimation of disease severity and mortality within 24 h of admission and
may affect the disease prognosis permitting the best therapeutic approach.
SS6.
LIVER METASTASES FROM RENAL CANCER: THE ADDED VALUE OF ARTERIAL PHASE OF THE LIVER
IN STAGING WITH CT.
Maniatis V., Foufa K., Stamoulis E., Tzovara I., Alexopoulos T., Giannoulakos N., Ziogana D., Tachtaras A.
Diagnostic Imaging Department, Iaso General Hospital, Athens, Greece
Purpose: Renal cancer is among the group of hypervascular primary tumors. Hypervascular primary neoplasms may
give hypervascular hepatic metastases. Helical (spiral) and multislice CT offer the advantage of scanning the entire
liver during both the arterial and portal venous phase. The purpose of this study was to assess the usefulness of
hepatic arterial phase of abdominal CT in these patients in depicting hepatic metastases.
Materials And Methods: Seventeen patients with hepatic metastases due to renal cancer are included. They are
consisted of 8 men and 9 women, ranging in age from 33 – 78 years old. All the patients had triphasic (non contrast-
NCP, hepatic arterial- HAP and portal venous phase-PVP) helical or multislice CT examinations.The number of lesions
seen at each phase and their enhancement pattern were encountered. The contribution oh hepatic arterial phase
(HAP) to the diagnostic results was specifically estimated.
Results: A total of 95 metastatic liver lesions were found: 63 on NCP images, 78 on HAP images and 70 on PVP
images. Nine different patterns of hemodynamic behaviour were encounterd. The most common pattern was that of a
focal liver lesion that was hypodense during all the phases of the examination (seen in 36 % of the lesions). 17 % of
the hepatic metastases were found only on hepatic arterial phase (HAP) and all were hyperdense - hypervascular.
Hepatic arterial phase (HAP) was the most sensitive to reveal liver metastases.
Conclusion: Hepatic metastases due to renal cancer may have a variable hemodynamic pattern. Hepatic arterial phase
must be a part of the CT protocol in this group of patients together with non- contrast phase (NCP) and portal venous
phase (PVP).
SS7. THE APPLICATION OF MULTIDETECTOR COMPUTED TOMOGRAPHY IN THE DIAGNOSTIC
EVALUATION OF ADULT POST-TRAUMATIC HEMATURIA
Soldatos Th., Lampropoulou P., Karakyklas D., Mika A., Krommyda E., Zbogo A., Apostolopoulou G., Drossos
Ch.
Department of Radiology and Imaging, “G.Gennimatas” General State Hospital, Athens, Greece
Objective: Computed tomography (CT) can provide essential anatomic and physiologic information required to
determine management of intraabdominal and retroperitoneal injuries. The purpose of this study was to evaluate the
sensitivity of multidetector CT in detecting the source of hematuria in patients with blunt abdominal trauma.
Method: We retrospectively evaluated the CT scans of 53 trauma patients (37 males, 47±15 years old) who were
referred to the imaging department due to gross hematuria in 26 cases (49%), microscopic hematuria associated with
shock in 19 cases (36%), and microscopic hematuria associated with a positive diagnostic peritoneal lavage in 8 cases
(15%). Unenhanced and three-phase (arterial, portal venous, 3-min delayed phases) dynamic abdominal CT scans
were acquired in all subjects.
Results: ccording to the imaging findings the cause of blood loss was renal contusion in 16 cases (30%), subscapular
renal hematoma in 9 (17%), renal laceration in 5 (9%), renal vascular trauma in 3 (6%), bladder contusion in 11
(21%), and bladder rupture in 7 (13%). Dynamic CT scanning enabled detection of active contrast extravasation in 11
subjects (21%). However, in 2 patients (4%) no acute urinary pathology was revealed. The sensitivity of CT in
establishing the cause of post-traumatic hematuria was 96%.
Conclusion: Multidetector CT is a sensitive diagnostic modality for detecting acute urinary pathology in patients with
post-traumatic hematuria.
122

SS8.
MESOAORTIC NARROWING OF THE LEFT RENAL VEIN IN ASYMPTOMATIC ADULTS: A NORMAL
FINDING, NOT A NUTCRACKER SYNDROME
Poletto E., Chernyak V., Ricci Z.J., Rozenblit A.M., Mazzariol F.
Montefiore Medical Center 111 East 210 th Street Bronx, NY 10461 USA
Purpose: Prior investigations suggest that ≥50% mesoaortic narrowing of the left renal vein (LRV), or a narrow angle
(≤55º) between the superior mesenteric artery (SMA) and aorta are signs of nutcracker syndrome. This study aims to
determine the range of LRV caliber and SMA-aortic angle in asymptomatic adults on CT angiography (CTA).
Methods: This retrospective study analyzed CTA of potential renal donors performed between 2005 and 2009. Subjects
with retroaortic LRV or hematuria were excluded. For each case, the following parameters were measured: 1) AP
diameter of LRV at the mesoaortic (MAD) level, located between SMA and aorta, 2) AP diameter of LRV at left
paraaortic (PAD) level, 3) SMA-aortic angle, and 4) distance between aorta and SMA at LRV level. MAD/PAD ratio was
calculated. Correlations between the MAD/PAD ratio, SMA-aortic angle and SMA-aortic distance were computed.
Results: There were 158 patients, 92 (58%) female, with mean age 35 years (range, 19-65). MAD/PAD ratio ranged
from 0.15 to 1.30 (mean= 0.74). 50% or greater mesoaortic narrowing of LRV was found in 58/159 (36%) subjects.
Mean SMA-aortic angle was 63.7° (range, 10.4-134.5). An angle of 55° or smaller was found in 64/159 (40%)
subjects. Mean SMA-aortic distance was 12.3mm (range, 3.1-36.3). MAD/PAD ratio had strong positive correlation
with both SMA-aortic angle (r=0.7) and SMA-aortic distance (r=0.7).
Conclusion: As more than one third of asymptomatic subjects have at least 50% mesoaortic narrowing of LRV and/or
narrow SMA-aortic angle, these parameters alone should not be used for diagnosis of nutcracker syndrome on CTA.
SS9.
64-MDCT EVALUATION OF POTENTIAL LAPAROSCOPIC LIVING RENAL DONORS
Sebastia C., Salvador R., Buaesch L., Nicolau C., Revuelta I., Peri L.
Hospital Clinic, Villarroel 170, 08035 Barcelona
Purpose: Clinical relevance: this first study of the efficacy of 64-MDCT in preoperative evaluation of potential
laparoscopic renal donors enables better results than 16-MDCT previously reported studies.
Our objective is to determine the efficacy of 64-MDCT in preoperative evaluation of vascular anatomy of potential
laparoscopic renal donors. As far as we know this is the first study done with 64-MDCT.
Material And Methods: During the last two years (2007-2008) 70 patients (24 men and 30 women) have had
laparoscopic nephrectomy for living kidney donation in our hospital. 60 of them had a 64-MDCT performed in our
institution. Our 64-MDCT protocol includes an unenhanced and arterial phase of the superior abdomen, an
abdominopelvic nephrographic phase and a delayed topogram in excretory phase. These MDCT have been
retrospectively evaluated by two reviewers and results have been compared to surgical findings as a gold standard.
Results: All principal arteries and supernumerary arteries (as small as 1mm) were documented by the two reviewers
with 100% sensitivity and accuracy. Sensitivity and accuracy detection of early arterial bifurcation, late venous
confluence and prominent lumbar and gonadal veins was 100%. Specificity in detection of renal veins was 97% for one
reviewer and 98% for the second reviewer, the two reviewers made the same mistake confusing venous periureteral
collaterals connected to a lumbar vein with a retroaortic vein. Sensitivity in detection of renal veins was 100%.
Sensitivity and accuracy for evaluation of excretory system by means of delayed excretory topogram was also 100%.
Conclusion: This first study of the efficacy of 64-MDCT in preoperative evaluation of potential laparoscopic renal donors
enables better results than 16-MDCT previously reported studies.
INTERVENTIONAL URORADIOLOGY
Moderators: Petsas Th. (GR) – Theodoropoulos V. (GR)
SS1.
DYNAMIC MRI IN PATIENTS TREATED WITH SUB-URETHRAL SLING FOR STRESS URINARY
INCONTINENCE
Ocantos J., Kohan A., Mingote C., Fattaljaef V., Seehaus A., Garcia Monaco R.
Hospital Italiano de Buenos Aires, Argentina
Objective: To correlate Dynamic MRI findings in patients treated successfully with sub-urethral sling for stress urinary
incontinence (SUI) According to continence theory (Parks)
Method: From 01/2008 to 06/2008, nine patients (P), mean age 65,22 years old (range 57-74y), underwent DMR after
being treated with sub-urethral sling. Two hour urine retention was indicated. We used 1.5T MR with “CP BODY ARRAY
FLEX” coil. Obtaining static sequences (SS) T2 turbo spin eco axial, sagittal and coronal (TR 4700, TE 1.32) 4 mm.
Dynamic sequences (DS) TRUFI sagittal (TR 4.8, TE 2.3) which where performed during voiding. We evaluated: SS:
Signs of periurethral fibrosis (PF). SD: urethral longitude (UL), location of the urethral caliber change (UCCh), distance
between this point and the bladder neck (DN) and functional kinking FK.
Results: Mean UL was 33mm (17.6mm-54.7mm). Average DN was 16.9mm (19-28.5mm).Anterior urethral angulation
was found in 4/9 P (44.4%), posterior in 1/9 P (11.1%) and 4/9 (44.4%) presented no angulation. This two latter
were associated with PF. UCCh was located in middle urethra in 7 P (77.8%) and in the proximal third in 2 P (22.2%)..
55.6% of the P did not present FK thougth urinary continence was achieved.
Conclusion: According to continence theory, anterior angulation in middle urethra is necessary to achieve urinary
continence. Probably this is not entirely true. PF associated with no anterior angulation is a frecuent finding that could
play an important role and should be further evaluated.
123

SS2.
LONG TERM RESULTS AFTER PROLONGED URETERAL STENTING IN CASES OF OBSTRUCTIVE
UROPATHY POST RENAL TRANSPLANTATION
Pappas P., Ikonomopoulou V., Kaza S., Panagiotidou Ch., Gkeneralis G., Zioga V., Papaspyrou S.
Radiology Department, Laiko General Hospital, Athens, Greece.
Objective: Renal transplantation is an effective treatment for end-stage renal disease. Ureteral stenosis is the most
frequent urologic complication. We report our long-term follow-up results concerning endourologic treatment of
ureteral obstruction after renal transplantation.
Method: Between 2000 and 2008, 35 patients with renal transplant obstructive uropathy were managed with
percutaneous nephrostomy and prolonged ureteral stenting.
Results: Percutaneous nephrostomies were performed successfully in all 35 kidneys. In these patients, antegrade
ureteral stenting was attempted, which was successful in 33 patients (94.2%). After prolonged ureteral stenting
(mean duration 15 months), the stent was removed in all patients, 30 (90.9%) of whom had no recurrence. Success
was defined as a reduction in hydronephrosis with subsequent drop in plasma urea and creatinine levels. No major
complications were observed. During follow-up (36 to 107 months; mean 73), urea, creatinine, sodium, and potassium
determinations and ultrasound scans were performed.
Conclusion: Percutaneous interventional procedures have replaced open reconstructive surgery in most patients with
ureteral obstruction after renal transplantation, because they have a high success rate and they can also offer a
definitive treatment with low morbidity.
SS3.
OUTCOMES AND COMPLICATIONS OF PCNL IN PATIENTS WITH SPINAL PATHOLOGY: SEVEN YEAR
EXPERIENCE IN A TERTIARY REFERRAL CENTRE
Belfield J.C., Wilkinson B., Salim F., Hastie K., Hall J.
Royal Hallamshire Hospital, Sheffield, England.
Objective: To assess the complication rates and stone clearance in patients with spinal pathology undergoing PCNL in
our institution.
Methods: All patients with spinal pathology who underwent PCNL between 2002 and 2009 were identified. The
following data was then obtained and evaluated: type of spinal pathology, number of tracts, number and size of
stones, stone clearance following the procedure, length of hospital stay, sepsis, drop in haemoglobin, need for blood
transfusion, date of drain removal and any other complication.
Results: 35 procedures were undertaken on 25 patients of which 12 had spina bifida, 12 traumatic cord injury and 1
ankylosing spondylitis. 20 cases (57%) were for multiple stones whilst 15 (43%) had a single calculus. 26 stones
(74%) were over 2cm in size with 9 (26%) less than 2cm. 3 procedures involved 2 tracts, but the remainder were
done via a single tract. At the end of the procedure 25 cases (71%) were documented as complete clearance, with 10
(29%) incomplete. Average length of hospital stay was 6.5 days, ranging from 3 to 15 days. 2 patients (6%) required
blood transfusion and one patient underwent embolisation and subsequent nephrectomy the day after the procedure.
7 (20%) were found to have sepsis following PCNL and 4 (11%) patients required HDU admission.
Conclusion: PCNL in patients with spinal pathology can be technically challenging and have a high complication rate.
SS4.
HOW EFFECTIVE IS THE FLAT-PANEL ANGIOGRAPHY SYSTEM IN LOWERING THE OVARIAN DOSE
DURING UTERINE ARTERY EMBOLIZATION (UAE)
Firouznia K., MD 1 , Ghanaati H., MD 1, Sharafi A., Phd, MPH 2 Bohloul R., MSC 3 ,Abahashemi F., MSC, MPH 3 ,
Jalali A.H.,MD 3 , Shakiba M., MD 3
1- Medical Imaging Center, Medical Sciences/University of Tehran, Tehran, Iran.
2- Medical physics department, Iran University of Medical Sciences
3- Medical Imaging Center, Medical Sciences/University of Tehran, Tehran, Iran.
Purpose: Considering that uterine artery embolization(UAE) is performed on women in reproductive ages, lowering the
radiation dose in this procedure is quite important. The aim of this study is to evaluate the exposure dose to patients
during UAE using conventional DSA unit, comparing with a digital flat-panel system.
Patients and Methods: 27women who underwent UAE due to symptomatic fibroids were enrolled in this study. We
randomized them for two angiographic equipments. 12patients were embolized using a digital flat-panel system and
17cases by using a conventional unit.
Radiation dose to patients’ skin (entrance and exit doses) as well as ovaries was evaluated with thermoluminescent
dosimeters. The skin and ovarian doses were compared between the two groups with each angiographic system.
Results: The mean fluoroscopy time, MAS of fluoroscopy, MAS of spots, total MAS, right & left ovarian depth was not
statistically different between the two groups.(all P>0.28)
The mean spot number was 85.3±34.8 in the conventional and 184.5±101.7in flat panel group.(P=0.007) The mean
right side entrance dose was 1587±1221in the conventional group and 618±540in the flat panel group.(P=0.012)
These figures were 1470±1170and 456±396 for left side respectively(P=0.006) The mean right side exit dose was
18.8±12.3for conventional group and 9.7±6.7for flat panel group(P=0.028)
These figures were 16.9±11.3and 10.1±6.8for left side respectively(P=0.081)
The mean right ovarian dose was 139.9±92in the conventional group and 23.5±17.8for flat panel group.(P

SS5.
COMPARISON OF CT-GUIDED CORE NEEDLE BIOPSY AND FINE NEEDLE ASPIRATION IN THE
ABDOMEN AND PELVIS
Chernyak V., Paroder V., Poletto E., Mazzariol F., Rozenblit A.M.
Montefiore Medical Center 111 East 210 th Street, Bronx, NY 10461 USA
Purpose: To compare rates of diagnostic sample between CT-guided core-needle biopsy (CNB) and fine-needle
aspiration (FNA).
Methods: We retrospectively reviewed images and medical records of CT-guided biopsies performed during a threeyear
period. For each case, we recorded the presence of adequate diagnostic sample, history of known primary
malignancy (PM), lesion size, skin-to-lesion distance, attenuation of the lesion (HUL) and adjacent background (HUB).
Absolute difference between HUB and HUL was defined as visibility index (VI).
Results: There were 188 patients, 118(63%) female, mean age 62.3 years, who underwent 226 biopsies: 112(50%)
FNAs and 114(50%) CNBs. Diagnostic sample was obtained in 105/114 (92%) CNBs and 93/112 (83%) FNAs
(p

SS8.
THE VALUE OF HYSTEROSALPINGOGRAPHY(HSG) AS A FIRST – STEP DIAGNOSTIC TOOL IN THE
INVESTIGATION OF PERITUBAL PATHOLOGY IN THE INFERTILE WOMAN.
Deftereos S., Mintzopoulou P., Iordanidis A., Kafetzis G., Limperis V., Prassopoulos P.
Radiology Department and Medical Imaging, University Hospital of Alexandroupolis, Democritus University of
Thrace
Purpose: To reconsider the value of HSG in evaluating peritubal adhesions in infertile woman.
Material and methods: A total of 74 consecutive patients (age range 22-46 years, mean 30years), with at least twoyear
infertility, underwent HSG followed by laparoscopy. HSG was performed in the menstrual cycle’s mid proliferative
phase. The following radiological signs were considered: convoluted / vertical tubes, ampullary dilatation, hallo effect,
peritoneal contrast medium loculation and uterus fixed laterodeviation. The morphology and extend of endocervical
canal and endometrial cavity were also evaluated. Laparoscopy was performed in the same phase of the cycle, 5-7
months after HSG in all patients and results were compared with HSG findings.
Results: Seven (7) patients exhibiting totally obstructed tubes were exlcluded from the study. Eleven (11) tubes were
not demonstrated due to surgical removal (n: 4) or to in adequate visualization (n: 7). Consequently, 123 tubes were
analyzed. In 17 (13,8%) no abnormality was revealed by both HSG and laparoscopy. HSG suggested adhesions in 59
tubes by the presence of one radiological sign; 23 of those were confirmed by laparoscopy (36 false positive results for
HSG). Adhesions were diagnosed in 47 tubes by HSG, when two or more signs were present; 39 true positive and 9
false positive results based on laparoscopy. There were no false negative results for HSG.
Conclusion: HSG may still be considered an effective fisrt - step diagnostic technique in peritubal pathology
investigation. The accuracy of HSG is raised when more than one radiological signs are present.
RENAL TUMORS – NEOPLASMS
Moderators: Tsitouridis I. (GR) – Matsaidonis D. (GR)
SS1.
COMPARISON OF CONTRAST-ENHANCED ULTRASOUND AND COMPUTED TOMOGRAPHY IN
CLASSIFICATION OF CYSTIC RENAL MASSES
Foukal J., Jakubcova R.
Department of Radiology, University Hospital Brno and Medical Faculty Masaryk University Brno, Czech
Republic
Objective: To asses performance of contrast-enhanced ultrasound (CEUS) in classification of cystic renal masses using
Bosniak system.
Method: Total number of 28 patients (30 kidneys) was included, only cysts with highest Bosniak score were counted.
Patients underwent contrast-enhanced CT a CEUS with administration of 1,0 to 2,0ml of SonoVue (Bracco, Italy). All
cysts were classified with Bosniak system on both examinations.
Results: On CEUS cysts were classified type I (8 cysts), type II (12), type IIF (4), type III (4), type IV (3). On CT the
result was type I (8), type II (9), type IIF (6), type III (4), type IV (2). One type IV cyst (type II on CT) was renal cell
carcinoma, other two type IV cysts were classified as metastatic lesions according to other findings. Two resected type
III cysts were benign. Type II, IIF and unresected type III cysts were stable in the follow-up.
Bosniak score correlated in 19/30 cases (63%). If cysts were divided into non-surgical (type I,II,IIF) and surgical
group (type III,IV), the correlation was 90%.The differences were due to better depicting of septa on US,
hyperattenuating vs. anechogenic cyst, pseudoenhancement on CT and in one case unclear enhancement of cystic wall
or surrounding parenchyma on CEUS.
Conclusion: Contrast enhanced ultrasound can be used for classification of renal cysts, it is adding information to CT
because it can clearly visualize enhancing of components of the cyst and can confirm cystic character of solid-like
echogenic lesions.
SS2. DW MRI VS DYNAMIC MRI IN DIAGNOSIS OF PROSTATE CANCER; A PROSPECTIVE STUDY
Abou El-Ghar M., Hekal I.*, Mohsen T., Refaie H., El-Diasty T.
Radiology & *Urology departments, Urology & Nephrology center, Mansoura University-Egypt
Aim of the work: To Compare the clinical feasibility of diffusion-weighted (DW) MRI Vs dynamic MRI in detection of
prostate cancer .
Materials and Methods: 44 patients with PSA > 4ng/ml(mean 30.9± 25 ng/ml; range 4.1-100)were prospectively
included in our study, their age range 45-76ys(mean 65.5±6) & the glesson sore range from5-9. All patients were
evaluated with MR imaging using surface coil. We started with axial T2 weighted high resolution MR of the prostate,
then DW MRI with b value 0 & 800 msec. The DWI MRI and ADC characteristics were analyzed and compared with
qualitative dynamic MRI results. Using the final histopathological findings; the accuracy of DW & dynamic MRI in
diagnosis of prostate carcinoma were evaluated.
Results : Among our patients there were 40 patients with prostate cancer and 4 patients with BPH there is associated
chronic prostatitis in 12 patients. DW MRI could detect prostate cancer in 34 patients while dynamic MRI can detect it
in 33 patients . The agreement between DW , dynamic MRI and histopathological findings was excellent. The
diagnostic performance of DWI& dynamic MRI in the identification of prostate cancer was: sensitivity, 85 %& 82.%;
specificity, 100% for both, the overall accuracy was 86.4% & 84.1% respectively. The ADC value for the normal PZ
1.3± 0.37, for the CZ 1.58±0.1,for the cancer 0.79± 0.2 and for prostatitis 1.47±0.16.
Conclusion : DW MRI is a reliable imaging approach for identification of prostate cancer with accuracy comparable to
dynamic MRI, but DW MRI is non invasive, fast and less expensive technique.
126

SS3.
IS 18FDG PET/CT A USEFUL IMAGING MODALITY FOR THE MANAGEMENT OF PATIENTS WITH
URINARY TRACK CANCER
Panagiotidis E., Exarchos D. 2 , Rondogianni P., Skilakaki M. 2 , Vlontzou E., Chroni P., Datseris I.
Nuclear medicine 1 , and Radiology 2 Departments, “Evangelismos” General Hospital, Athens, Greece
Aim: To assess the value of 18FDG PET/CT in the management of patients with urinary tract tumors.
Patients-Method: This is a retrospective study involving 81 patients – 73 male and 8 female- all with a tumor of the
urinary track aged 38-86 (mean age: 66.7 years) who were referred to our hospital from February 2007 to December
2008. All patients underwent surgery for resection of the primary tumor and diagnosis was confirmed surgically.
18FDG PET/CT was performed > 30 days after chemotherapy. All scans were reviewed by two physicians, a nuclear
medicine physician and one radiologist.
All patients underwent integrated PET-CT 60 minutes post IV injection of 370MBq 18 F-FDG. Diagnosis was reached by
consensus.
Results: 36 out of 81 (47%) patients had kidney carcinoma, 22/81 (27%) patients had bladder carcinoma, 22/81
(27%) patients had prostate carcinoma and 1/81 patient had cancer of ureter. 59 (73%) patients were referred for
PET/CT examination with main indication of possible relapse. 24 out of 59 had kidney carcinoma, 18 had prostate
carcinoma, 16 had bladder carcinoma and 1 had ureter carcinoma. The remaining indications for PET/CT examination
were restaging (21%), evaluation of a residual mass (3%) and follow-up (3%).
PET/CT results were in concordance with conventional imaging modalities (CT-MRI) in 18 out of 81 (23%) patients. In
16/81 (19%) patients PET/CT was negative despite the suspicious findings of CT and/or MRI. In 47 (48%) cases
PET/CT revealed more findings than those of the conventional imaging methods, upstaging them and altering the
treatment plan.
Conclusions: The indications of 18FDG PET/CT in patients with cancer of the urinary tract are rather limited due to
different reasons (elimination of FDG by the urinary tract, high degree of differentiation of some types of prostate
cancer).From the small patient population of this study it seems, however, that 18FDG PET/CT may be a useful
method when relapse is suspected with equivocal or negative conventional imaging. This is especially true for patients
with renal cell carcinoma who consist the majority of patients referred to the PET/CT unit of our tertiary hospital. A
larger prospective study targeted to this special population is necessary to prove these findings.
SS4.
THE ROLE OF MULTI-PHASE MDCT IN THE PREOPERATIVE ASSESSMENT OF RENAL AND URINARY
TRACT PATHOLOGY
Skondras E (1), Zampakis P(1), Kalidonis P (2) ,Kraniotis P(1), Liatsikos E (2), Romanos O(1), Petsas T(1),
Kalogeropoulou C(1).
(1) University hospital of Patras. Radiology Department
Objective: To assess the diagnostic and preoperative value of multi-phase Multi Detector CT (MDCT) regarding patients
with pathology from the kidney and the urinary tract.
Method: Our study included 66 patients (from 19 to 81 yrs) with clinical / laboratory suspicion or confirmed diagnosis
of renal or urinary tract pathology (calculi, renal neoplasm, ureteropelvic junction obstruction syndrome – UPJO). Our
scanning protocol included multi-phase acquisition of unenhanced and enhanced sequences with regard to the
pharmacokinetics of i.v. contrast medium in the kidneys. It consisted of three sequences (corticomedullary sequence
covering only the kidneys, nephrographic sequence and excretory sequence extending from the kidneys to the urinary
bladder). Subsequent image processing consisted of standard or arbitrary anatomical planes reconstruction (MPR) as
well as CPR (curved planar reconstruction), MIP (maximum intensity projection) and VR (volume rendering) techniques
in order to designate the underlying pathology and facilitate the preoperative plan from the urologist.
Results: The initial suspicion or diagnosis was confirmed in 51 cases (77%) and a meticulous anatomical exploration
was performed. There were 21 cases of urinary tract calculi (32%), 19 cases of UPJO syndrome (29%) and 11 cases of
renal neoplasm (16%). In five cases (8%), other pathology was uncovered while in 10 cases (15%) no pathology was
detected.
Conclusion: Multi-phase MDCT with subsequent image post processing and reconstruction of multiple anatomical
planes is a comprehensive one–stop examination for diagnosis and further study of renal and urinary tract pathology.
SS5.
AN ASSESSMENT OF THE SPECIFICITY OF CT PIXEL MAPPING IN THE DIAGNOSIS OF AML VERSUS
MALIGNANT RENAL TUMORS
Patel R., Bardgett H.P.
Bradford Teaching Hospitals, Bradford, UK
Objective: To evaluate the use of CT pixel mapping in the assessment of renal masses to differentiate fat poor
angiomyolipoma (AML) from renal cell carcinoma.
Methods: The CT imaging of 17 consecutive patients over a 12 month period who underwent nephrectomy for a renal
mass (with no macroscopic fat visible on CT) was retrospectively evaluated.
Radiologists blinded to the histological diagnosis sampled the visibly solid element of each mass with multiple CT
region of interest (ROI) pixel maps. Control ROI pixel maps were obtained from normal renal parenchyma in the same
patients.
A cluster of 4 or more adjacent pixels with a value less than or equal to -10 Hounsfield Units (HU), (threshold A) and a
cluster of 3 or more adjacent pixels with a value less than or equal to -20 HU (threshold B) were adopted as the two
thresholds for diagnosing AML.
Results: 19% (3/16) and 25% (4/16) of malignant renal cancers were falsely characterized as AML, 23% (4/17) and
18% (3/17) of the control group of normal renal parenchyma were classified as AML with thresholds A and B
respectively.
The one AML in the study sample was not correctly characterised with either threshold.
The specificity of pixel mapping for diagnosing AML in the renal mass cohort was 81% and 75%, in the control group
was 76% and 82% with thresholds A and B respectively.
Conclusion: The low specificity, with demonstrable false positives in malignant renal tumors, precludes CT pixel
mapping as a safe way to diagnose AML.
127

SS6.
SONOGRAPHIC PATTERNS AND CAUSES OF BRIGHT KIDNEYS IN PEDIATRIC PATIENTS
Papadaki M.G. 1 , Moschouris H. 1 , Tsagouli P. 1 , Kalikis D., 1 Ouranos V. 2 , Khalili M. 1 , Spyridonos A. 1 ,
Matsaidonis D. 1
1.Department of Radiology, «Tzanio» General Hospital, Piraeus, Greece, 2.Department of Radiology,
«Evangelismos» Hospital, Athens, Greece
Objective: Ultrasonography is very sensitive in identifying changes in renal parenchymal reflectivity (RPR). In this
retrospective study we present and evaluate the sonographic findings in various conditions that cause bright kidneys in
pediatric patients.
Method: High resolution US renal scans of 5300 patients aged 0-14 yrs were reviewed when diagnosis was
established. Indications were variable. Kidneys were considered to have increased RPR when their parenchyma was
more reflective than liver or spleen, except from neonates where the above state as a single finding was considered
normal. Renal volume was evaluated and preservation or loss of the corticomedullary (C/M) differentiation was noted.
Results: Increased RPR was noticed in 251 patients (4,7%), and was bilateral in 201. The finding was associated with
sepsis (n= 49 cases), with nephrotic syndrome (n= 37), hypoplasia/dysplasia in (n=35), neoplasia (leukaemia,
lymphoma, chemotherapy) (n=28), glomerulonephritis (n= 26), autosomal recessive polycystic kidney disease (n=
22), hemolytic-uremic syndrome (n= 17), storage disorders (n= 14) and chronic renal failure (n=14). Less common
clinical diagnoses included renal vein thrombosis (n=5), acute tubular necrosis (n=3), nephroblastomatosis (n=1).
Specific patterns were mainly associated with glomerulonephritis, autosomal recessive polycystic kidney disease,
dysplasia, chronic renal failure, renal vein thrombosis and nephroblastomatosis.
Conclusion: Increased renal parenchymal reflectivity is a non-specific sonographic finding that usually indicates
medical renal disease. Knowledge of the various patterns and of the associated features of each disease often helps to
narrow differential diagnosis.
SS7.
IMAGING OF RENAL TRAUMA WITH CONTRAST-ENHANCED ULTRASONOGRAPHY
Moschouris H. 1 , Papadaki. M.G. 1 , Goutzios P. 2 , Tsagouli P. 1 , Mpouma E. 1 , Gialias P. 1 , Vlachou C. 1 ,
Matsaidonis D. 1
1.Department of Radiology, «Tzanio» General Hospital, Piraeus, Greece. 2.Department of Radiology, 251
General Air Force Hospital, Athens, Greece
Objective: Renal trauma is often a diagnostic challenge for conventional sonography. We performed a small
retrospective study, in order to evaluate the additional information provided by Contrast-Enhanced Ultrasonography
(CEUS), when this technique is applied immediately after the baseline sonographic examination of an injured kidney.
Method: 22 patients with blunt unilateral renal injury were included in the study. The final diagnosis was provided by
Contrast-Enhanced Computed Tomography (CECT) in all cases. Before CECT, all patients underwent unenhanced US
(grey-scale and color/Power Doppler examination) and thereafter CEUS with a 2nd generation echo-enhancer
(SonoVue,Bracco) and a dedicated, low mechanical index, contrast-specific technique. The findings of unenhanced US
and CEUS were correlated with those of CECT.
Results: 14/22 cases of renal injury were correctly detected on unenhanced US, and CEUS/CECT simply confirmed the
initial sonographic diagnosis. 8/22 cases of renal injury (36%) were missed on unenhanced US, or the unenhanced US
findings were inconclusive [renal laceration (n=4), traumatic renal infarct (n=2), perirenal hematoma (n=2)].On the
contrary, CEUS correctly diagnosed all these injuries, and CEUS findings correlated closely with CECT.
Conclusion: CEUS may substantially increase the diagnostic efficacy of sonography of renal trauma, particularly in
lesions that cause no significant alteration in the echotexture of renal parenchyma or perirenal space and when the
inherent limitations of color/power Doppler preclude a definite diagnosis. CEUS may be applied immediately after the
initial sonographic survey, when there is strong clinical and laboratory evidence of renal trauma, but unenhanced US is
negative or equivocal.
SS8. THE VALUE OF DIFFUSION-WEIGHTED MAGNETIC RESONANCE IMAGING AND RELATIVE
APPARENT DIFFUSION COEFFICIENT IN DIFFERENTIATION BETWEEN RENAL CANCER AND
REGULAR PARENCHYMA
Javor D. 1 , Remzi M. 2 , Herneth A. 1 , Krssak M. 1 , Weber M., Haitel A. 3 , Memarsadeghi M. 1
¹Department of Radiology, ² Department of Urology und 3 Department of Pathologie of Medical University
Vienna
Objective: This study was carried out to evaluate the usefulness of diffusion-weighted imaging and the apparent
diffusion coefficient (ADC) in the differentiation between renal tumors and normal renal parenchyma by comparison of
the respective ADC-values.
Methods And Materials: A total of 19 renal tumors, predominantly cortical lesions, confirmed by histology, were
examined on a 3-T MR scanner. In case of homogeneous tumors, ADC-values of the entire lesion were measured. In
case of heterogeneous tumors, the hypointense and hyperintense parts of the lesion were measured separately.
Furthermore the ADC-values of the normal ipsi- and contralateral renal parenchyma were evaluated and compared to
the ADC-values of the focal lesions.
Results: The ADC-values in renal tumors (mean ADC:1172, SD:273) were significantly lower than those of normal
renal parenchyma(mean ADC:1580, SD:136)(P

SS9.
IMAGING EVALUATION AND MANAGEMENT OF MULTIPLE RENAL MASSES
Kolliakou E., Triantopoulou C., Fagrezos D., Maniatis P., Siafas I., Koulentianos E., Papailiou J.
CT department, Konstantopouleion General Hospital, Athens, Greece
Objective: We report our experience with multiple renal masses on CT imaging. Our purpose was to determine any
particular imaging features that could aid in the diagnosis and management of the affected patients.
Materials and methods: 28 patients with 57 renal lesions, measuring 1-4cm, were included in this retrospective study.
Of the 57 lesions, 38 were solid masses and the remaining 19 were cystic-Bosniak type III or IV lesions. 32 masses in
18 patients were removed surgically by radical nephrectomy (n=10) or partial nephrectomy (n=8) and 4 masses in 3
patients were referred for RFA. In equivocal cases of bilateral disease when surgery was not performed, the patients
were followed with serial abdominal CT. The median follow-up was 24 months. In 21 indeterminate lesions that
presented diagnostic dilemma the diagnosis was confirmed by CT-guided biopsy.
Results: 15/19 cystic lesions had thick irregular walls and 13 of them were malignant (86.6%). 8/19 cystic lesions had
mural nodules and 6 of them were malignant (75%). 17/38 solid lesions presented intense contrast enhancement and
11 of them were malignant (64.7%). As independent imaging features, mural nodules and wall irregularity in cystic
lesions and intense contrast enhancement in solid lesions were highly associated with malignancy.
Conclusion: The appearance of benign and malignant renal lesions on CT may overlap, suggesting that distinct
differentiation between these entities is not always possible. In such cases, a percutaneous biopsy is useful for the
proper diagnosis obviating the need for unnecessary surgery specifically in patients with bilateral renal involvement.
SS10.
ULTRASOUND IN DETECTION OF RENAL MASSES: MISSED AND WRONGLY CHARACTERIZED
LESIONS
Brkljačić B., Hrkać-Pustahija A., Ćurić J., Ivanac G., Čikara I.
Department of Radiology, University Hospital «Dubrava», Zagreb, Croatia
Objective: Many solid or solid-cystic renal lesions are found incidentally on US and CT, and US is often the first
imaging modality detecting benign and malignant renal lesions. Ultrasound is nowadays interdisciplinary method
performed by many, and understood by few, and is very operator-dependant. The analysis is presented of erroneous
sonographic diagnosis of renal masses other than cysts.
Materials and Methods: Retrospective analysis of medical histories was performed of 126 patients (82 m, 44 f, age
range 5-83 years) in whom renal tumors were diagnosed by US and CT in our Department over a seven-years period
in those patients who had at least one renal US examination

RADIOLOGICAL
TECHNOLOGISTS’
SESSIONS
130

SESSION 1
MAGNETIC RESONANCE IMAGING OF THE URINARY SYSTEM
Malamateniou Ch.
Hammersmith Hospital, Imperial College London.
Abstract: Background: Magnetic Resonance Imaging (MRI) is a non invasive, relatively safe, in vivo imaging method,
with the potential of high spatial resolution and increased tissue contrast-to-noise ratio (CNR). No ionising radiation is
used and there is no need for contrast administration, particularly for the anatomical investigations.
Objective and Methods: To critically review current and past literature in order to assess the challenges and
opportunities of the use of magnetic resonance in imaging the urinary tract in all populations. For this meta-analysis
Pubmed was used as the source and carefully selected keywords were employed.
Conclusions and Discussion: MRI can be applied for the evaluation of a wide spectrum of renal diseases. The use of
magnetic resonance in imaging the urinary tract is currently increasing but it is mainly reserved for the fetal, neonatal
and pediatric populations. MRI of the urinary tract may provide both anatomical and functional information. It also
correlates well with other urinary imaging techniques, such as with Lasix renal scanning, in assessing renal function
and may be superior in anatomical studies compared to ultrasonography. The increased cost of MRI scanning, as well
as the need for dedicated imaging protocols, limit the use of MRI. Even though it is not the modality of choice for a
primary imaging investigation of renal pathologies, it has become a valuable technique for complementary imaging
assessment of the renal system, given the latest technological advances that allow for fast, high quality, reliable MR
image acquisition.
SESSION 2
CONTRAST MEDIA (CM) AND MULTIDETECTOR COMPUTED
TOMOGRAPHY (MDCT): A RADIOGRAPHER’S PERSPECTIVE
Agadakos E. - BAppSci MRT (Diag)
General Hospital of Athens "LAIKO", Athens Greece
The impact of CT in clinical management has increased with the development of MDCT. Today with MDCT a volume of
data is acquired rather than slices facilitating considerably faster acquisition times and superior assessment of patients
across a wider range of clinical applications than single slice helical scanners.
Rapid scanning, improved resolution, advanced 3D rendering and higher concentration contrast media (CM) enable
multiphase studies, CT angiography, cardiac scoring and evaluation of brain perfusion.
However, this evolving MDCT technology makes protocol design rather challenging particularly when contrast media
administration is integral to the majority of MDCT examinations and use is tailored to the clinical application.
It is apparent that these fast acquisitions at exceptional spatial resolution are beneficial yet contrast media delivery is
now complicated and unforgiving. Existing protocols must be modified consistent with scan timing and optimization of
contrast enhancement.
In order to exploit the capabilities available it is necessary to incorporate the available scanner technology with the
principles of contrast enhancement.
Unless the CT radiographer becomes accustomed with the factors affecting contrast media enhancement and the
associated scanning parameters, the diagnostic value of images will continue to decline as scanning speed increases. It
is critical that these factors and parameters be synchronized in order to generate appropriate MDCT examination
protocols.
The presentation of examination protocols will be focussing upon recent bibliography considering the following key
issues:
I. Contrast injection related parameters
II. CT acquisition related parameters
III Patient Dose Management
Concisely, the aim of this presentation is to provide know-how in view of recent bibliography to determine an optimal
CT injection-examination protocol.
OPTIMIZATION OF MULTI-DETECTOR ROW CT UROGRAPHY
Koumarianos D
TEI of Athens
With the advent of multi-detector row CT scanners and the evolution of image processing methods CT Urography
(CTU) now affords optimal urographic images comparable to those obtained with conventional techniques.
This presentation discusses the optimization of all technical aspects involved in the course of the CTU examination
including such issues as compression, saline infusion, diuretic administration, and timing of the acquisition delay. We
describe the acquisition techniques and protocols used by the various authors, discuss the technical guidelines
proposed by ESUR and illustrate a variety of post processing techniques, multiplanar reconstruction (MPR), maximum
intensity projection (MIP) and volume rendering (VR).
The real concern potentially limiting the widespread use of CTU is its higher radiation dose when compared with IVU.
Although low-dose protocols are available, a substantial dose reduction can be achieved by tailoring CTU to the clinical
problem rather than using a standardized approach.
131

POSTERS EXHIBITION
ABSTRACTS
132

P1. RENAL TUMOURS - A PICTORAL REVIEW
Kannappa L.K., Hasrat K., Ho E.
Norwich & Norfolk University Hospital, UK
Purpose: Learning objectives: To describe the causes,classification,presentation,consequences and imaging
appearences of renal tumours and to ensure their detection and appropriate management.
Background: Renal tumours account for approximately 2% of all malignancies.
Males are more likely to be affected than females with a ratio of 2:1.2.
More than 6,600 people are diagnosed with kidney cancer each year in the
UKhttp://www.patient.co.uk/showdoc/40000686/ - ref2 and there are around 3,600 deaths.
The peak age of incidence for renal carcinoma is 60 to 80 years old.
Several risk factors have been identified including smoking, obesity, hypertension, long term dialysis and Von Hippel
Lindau syndrome.
Occupations associated with an increased risk include workers exposed to cadmium or asbestos and coke oven
workers in the iron and steel industries.4
Hereditary renal cancers tend to be multiple, bilateral and occur at an earlier age than others.5
Wilms' tumour affects about 1 in 100,000 children before the age of 15. In 5 to 10% of cases it is bilateral.
Methods and materials: Image findings and procedure details: The materials used are a series of multiple imagings of
ivu,ultrasound,CT of chest and abdomen & MRI to understand the investigate modality which were used in norwich
and norfolk hospitals since 2000 to 2008..There were 300 patients who had nephrectomy included in this group.The
pictoral representation of various radiological modalities with individual image and its findings used in arriving in
diagnosis were being used.
Results:Out of 300 patients ,who underwent nephrectomy,161 patients had renal cell cancer,50 had TCC,6-clear cell
cancer ,2-chromoplil cancer,9 –cysts,3-oncocytoma,3=hypernephroma,4-angiomyolipoma.1 each-squamous cellcancer
and adenocarcinoma,36-nephritis,1-amyloidosis and rest had nephrectomy for pelvic ureteric junction abnormalities
,stone disease, dysplastic kidney and other causes. For all the above patients, ultrasound and IVP was used as a
routine and CT ,MRI and cystoscopy were used for additional investigations for confirmation and for diagnosis.
Conclusions: By understanding the age, sex orientation, causes, site of presentation and the investigative modalities
used for diagnosis and treatment. The pictoral review helps the radiologist to understand the disease easily.
P2. TESTICULAR MICROLITHIASIS AS AN INSIDENTAL SONOGRAPHIC FINDING WITH QUESTIONABLE
SIGNIFICANCE
Gkeli M., Apergis S., Kartsouni V., Galiatsatos N., Morfas K.
1st Department of Radiology, Unit of Sonography, “Saint Savvas” Anticancer Oncological Hospital, Athens,
Greece
Objective : To present the questionable significance of testicular microlithiasis (TM), as an incidental finding and its
management in patients that are submitted for testicular ultrasonography (US) for various indications.
Method: In the last two years, 100 patients were subjected to high-frequency testicular US. The investigated subjacent
deseases were testicular malignancy, control after orchidectomy for a malignant tumor or after orchiopexy for
undescended testes, epididymo-orchitis, testicular torsion, hydrocele, varicocele and epididymal cysts.
Results: 100 patients were examined by US of the testes in the last two years and three patients were found with TM.
US showed multiple, uniform, pinpoint, hyperechoic intratesticular foci. In the first patient, testes were physiological in
size with uniform echogenicity and ambilateral TM. In the second patient with a left orchidectomy for seminoma, the
right testis was normal in size with homogeneous echogenicity and TM. In the third patient, the right testis was
smaller than the left, with TM. In patient’s history there was an undescended right testis, surgically treated twenty
years ago.
Conclusion: TM may be an incidental US finding. It is characterized by calcification within the seminiferous tubules. It
may present as a marker for the potential growth of germ cell tumor. Although the recent literature indicated that
malignancy only develops when TM is associated with other predisposing factors. Testicular examination is the
recommended follow up for men identified with TM. The use of annual US follow-up, biochemical tumor markers,
abdominal and pelvic CT, or testicular biopsy are justified according the subjacent disease.
P3. OPTIMIZATION OF BLADDER DISTENSION IN PATIENTS WITH GROSS HAEMATURIA EXAMINED
WITH MULTI DETECTOR ROW CT UROGRAPHY
Helenius M., Segelsjo M., Magnusson A.
Radiology Department, Uppsala University Hospital, Sweden
Objective: Over the last decade CT has replaced excretory urography when evaluating patients with gross hematuria.
Malignancy of the urinary tract is often the cause of gross haematuria. Recently, CT has shown to have high sensitivity
and specificity in detecting bladder cancer. However, to be able to evaluate the presence or not of a bladder cancer,
the bladder has to be well distended. The aim of this study was to find the best protocol for distending the bladder.
Materials and Method: Four different protocols were evaluated; 1) 500 ml of water orally during one hour prior to the
examination. 2) 500 ml of water orally during one hour prior to the examination.,and 10ml Furosemid iv immediately
before the examination. 3) 1000 ml of water orally during two hours prior to the examination. 4) 1000ml of water
orally during two hours prior the examination and void one hour prior the examination.
One hundred patients were included in the study and randomly selected into the four protocol groups, The bladder
distension was evaluated and the bladder volume was calculated
Results: The bladder was distended enough to permit evaluation of the wall in 56% (Protcol 1), 68% (Protocol 2), 84%
(Protocol 3) and 72% (Protocol 4). The mean bladder volume was 225ml, 323ml, 379ml and 310ml respectively.
Conclusion: The protocol where the patients were asked to drink 1000ml of water during two hours prior the
examination and not to void during those two hours was found to be the best protocol for bladder distension.
133

P4. OUTCOME OF PTRA IMPROVES WHEN EVALUATED BY ”BREAK POINT ANALYSIS”
Eklof H., Bohlin E. G.
Department of Radiology, Uppsala University Hospital, Uppsala, Sweden
Objective: To evaluate the outcome on renal function after PTRA, guidelines recommend ”Break point analysis” or
”Binary outcome” (1).
This retrospective study has compared the effect of using either of the two methods for evaluation of clinical outcome
after PTRA.
Method: The local ethics committee approved the study and informed consent was received. Eleven patients were
included in this retrospective study. All were adults treated with PTRA for atherosclerotic RAS, s-creatinine > 200
mol/L before PTRA with at least five s-creatinine values from a period of at least three months prior and after PTRA.
The effect on renal function for each patient was defined based on ”Break point analysis” where five or more s-
creatinine values before and after PTRA generates a slope-value (2). An increase in slope-value after PTRA indicates an
improvement in renal function. This was compared to ”Binary outcome” using only single s-creatinine value the week
before and 3-6 months after PTRA. An improvement in s-creatinine by at least 25% was used to define improvement
in renal function.
Result: Five of eleven patients showed improved renal function after PTRA when based on ”Break point analysis”, only
two when based on ”Binary outcome”.
Conclusion: ”Break point analysis” improves the clinical outcome of PTRA. Another implication is that worsened renal
function after PTRA may be continuing progressive renal impairement and NOT a complication.
References
1. Rundback JH, Sacks D, Kent KC, Cooper C, Jones D, Murphy T, et al. Guidelines for the reporting of renal artery
revascularization in clinical trials. American Heart Association. Circulation 2002;106:1572-85.
2. Rowe PA, Richardson RE, Burton PR, Morgan AG, Burden RP. Analysis of reciprocal creatinine plots by two-phase linear
regression. Am J Nephrol 1989;9:38-43.
------------------------------------------------------------------------------------------------------------------------------------
---------------------------------------------
P5. VARIOUS IMAGING SPECTUM OF RENAL ANGIOMYOLIPOMA
Lee H.J. 1 MD, Ryu D.H. MD 1 , Hwang S.I. MD 1 , Kim S.H. MD 2 , Cho J.Y. MD, Lee S.E. MD 2 , Byun S.S. MD 3
1 Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang
Hospital, Institute of Radiation Medicine, Seoul National University Medical Research, Center Clinical Research
Institute, Seoul National University Hospital. 2 Department of Radiology, Seoul National University College
of Medicine, Seoul National University Hospital. 3 Department of Urology, Seoul National University College of
Medicine, Seoul National University Bundang Hospital
Purpose: To present imaging spectrum of renal angiomyolipoma (AML).
Materials and methods: Data of nephrectomy and kidney biopsy performed between 2003 January to 2009 February
was searched for pathologically proven renal AML patients. Clinically diagnosed tuberous sclerosis patients with renal
mass demonstrating features of AML were also included in this study. Imaging studies of these patients were
reviewed.
Results: Individual cases were categorized based on image findings or clinical setting as follows; typical fatty mass,
solid mass with focal fat, fat deficient mass, pathologically epithelioid variant, and tuberous sclerosis associated AML.
Typical fatty mass had large portion with fat attenuation on CT. Solid portion with various degree of enhancement, or
hemorrhage may or may not be present. Solid mass with focal fat consisted mostly of soft tissue density mass and had
small focal but evident portion with fat density. Fat deficient mass is defined as mass with no identifiable fat density.
Epithelioid variant presented as hypervascular soft tissue density mass with necrotic portion. Tuberous sclerosis
associated AML demonstrated bilaterality and multiplicity, and involvement of other organ such as liver was also
observed.
Conclusion: AML can present as mass with diverse fat content, from grossly pure solid mass to those composed
predominantly of fat tissue.
P6. UTILITY OF T2-WEIGHTED IMAGING (T2-WI) AND DYNAMIC CONTRAST-ENHANCED MRI (DCE-
MRI) IN PROSTATE CANCER LOCALIZATION. CORRELATION WITH HISTOPATHOLOGIC
FINDINGS AFTER PROSTATECTOMY.
Carbognin G., Calciolari C.
Department of Radiology, University of Verona, Italy
Objective: To evaluate the combination of two MR techniques (T2-WI, DCE-MRI) in the correct localization of prostate
cancer correlated with histopathologic findings.
Materials And Methods: We reviewed the MR examinations of 8 men (60-71 years old; mean age 65) with abnormal
PSA level and positive US-guided biopsy.
MR imaging was performed at 1.5T with endorectal surface coil. We looked for the presence of low-signal-intensity
areas on T2-WI and focal enhancement on DCE-MRI (analyzed by dynamic curves). We included in our study tumor
size 10 mm or more. The results were correlated with histopathologic findings performed after prostatectomy. For
anatomic division of the prostate we use the zonal compartment system by Mc Neal.
After prostatectomy, Patologists divided gland in serial whole mount sections from apex to base to identify number,
size and topography of cancer foci comparing with MR findings.
Results: In 8 Pts, we found 9 foci of prostate cancer, pathologically proved after prostatectomy: 5/9 foci seen by T2-
WI, 9/9 by DCE. Dynamic curves were tipe 2 (plateau) in 7/9, tipe 3 (wash-out) in 2/9.
The histopathologic findings and MRI result in according about the gland areas involved in 8/9 foci, about the size in
2/9 (more extensive at histopathology in 4/9, in DCE-MRI in 2/9).
Capsular and neurovascular boundle invasion result in according in 7/9 (5/9 invasion was no present; 2/9 invasion
present). In 2/9 foci invasion was not seen at MRI.
Conclusion: Especially DCE-MRI, improves the localization of prostate cancer and could aid in the evaluation of size
and extent, essential for specific treatment.
134

P7. URINOMA: DIAGNOSIS WITH CT
Triantafyllou E., Apostolopoulou G., Karakiklas D., Zbogo A., Labropoulou P., Drossos Ch.
General Hospital of Athens “G. Gennimatas” – Center of Radiology Imaging
Objective: Urinomas result from disruption of the urinary collecting system at any level , from the calyx to the urethra,
most commonly because of trauma. We report the computed tomografic findings of urinomas and urine leaks caused
by injury of the collecting system.
Material: CT studies of 9 patients with collecting system injury were reviewed. The injuries were traumatic in 5
patients and iatrogenic in 4. Fever and abdominal pain were the main presenting symptoms in all patients. CT was
performed between first day and second month from the injury. The CT studies were performed prior to and after the
intravenous administration of 100 ml contrast material followed by delayed phase scanning. Coronal and sagittal
reformatted CT images were obtained for further definition of the extent of the urinoma.
Results: The urinomas appeared as circumscribed water density fluid collections in 3 patients and as free fluid in 6.
The site of the injury was the renal pelvis in 1 patient, the ureter in 5 and the calyceal system in 3. Extravasation of
contrast from the trauma was observed on early scan in 3 patients and on delayed phase in 6. The injury was treated
conservatively in 7 patients and surgically in 2.
Conclusion: Urinoma may be occult initially and could lead to serious complications. In order to avoid complications
and improve prognosis immediate diagnosis and therapy is crucial. Diagnostic imaging is essential in the prompt
identification of such injuries and determination of their causes and extent.
P8. THE ROLE OF ULTRASONOGRAPHY FOR MONDOR’S DISEASE OF THE PENIS
Boulalas I. 2 , Filippou P. 1 , Pagonidis K. 3 , Serafetinidis E. 1 , Karyotis I. 1 , Lianos E. 2 , Delakas D. 1
1 Department of Urology, “’Asklipieio” General Hospital, Voula, Athens, Greece. 2 Department of Urology, Agios
Nikolaos General Hospital, Crete, Greece. 3 Radiologist, Medical Crete, Euromedic International
Objective: Thrombosis of the penile superficial dorsal vein (Mondor’s disease of the penis) is a rare condition, usually
benign and self-limited in most patients. We herein present the case of a 32-year-old man, who presented with an
acute penis, underwent clinical, laboratory and ultrasonographic evaluation and was finally treated conservatively.
Methods: The patient presented with severe penile pain and swelling, after experiencing blunt injury during intercourse
3 hours earlier. Physical examination revealed an ecchymotic and painful penis.
The patient was evaluated for suspected penile fracture. He underwent retrograde urethrography, that was negative
for urethral injury. Ultrasonographic study revealed the presence of diffuse fascia swelling and was negative for tunical
rupture. The venous Doppler study revealed the presence of superficial dorsal vein thrombosis despite that palpation
did not reveal the presence of any cord-like structure.
Results: The diagnosis of Mondor’s disease of the penis was established and the patient was treated conservatively
with NSAID and local dressing with a heparin ointment and instructions to abstain from sexual intercourse for 6 weeks.
He also underwent a thorough evaluation, in order to exclude blood dyscrasia, coagulation disorder, deep venous
thrombosis of the lower extremities, sexually transmitted disease or intravenous drug use.
At 2-month follow-up, he reported normal erections, without penile pain or curvature, without any evidence of dorsal
vein thrombosis or palpable penile plaque.
Conclusions: Mondor’s disease of the penis is a rare condition, amenable to conservative management.
Ultrasonography is a reliable and cost-effective means to establish the diagnosis, excluding other urological
emergencies.
P9. THE ROLE OF 16-MDCT FOR VASCULAR EVALUATION IN ANDROLOGIC PATIENTS
Martinez M.J., Marti T., Quintian C., Catala V., Marti J., de la Torre P.
Fundacio Puigvert, Barcelona, Spain
Objective: Our objective was determine the efficacy of 16-MDCT angiography, with special focus at 3D reconstruction
(MIP, MPR, VR), in diagnostic and pre-postoperative evaluation of vascular anatomy in determinated andrologic
entities.
Method: We evaluate the utility of 16-MDCT pelvic angiography in three patients; one with priapism and two potential
candidates for phallic reconstruction
Results: 16-MDCT angiography of pelvis region and 3D reconstructions allowed correct diagnosis of arteriovenous
fistulae in a patient with priapism, and also defined vascular mapping for its embolization. It also showed accurate
preoperative definition of inferior epigastric arterial anatomy in two potential candidates for total phalloplasty.
Conclusion: 16-MDCT angiography results a useful tool for diagnosis and vascular planning of some andrologic
patients.
135

P10. SONOGRAPHIC SPECTRUM IN FIRST TRIMESTER BLEEDING
Ergun E. 1 , Yil,mazer Y. 2 , Turgut A.T. 1 , Kosar U. 1 , Dogra V. 3
1 Department of Radiology, Ankara Training & Research Hospital, Ankara, Turkey. 2 Department of Radiology,
Zubeyde Hanim Maternity Hospital, Ankara, Turkey. 3 Department of Imaging Sciences, University of
Rochester School of Medicine, Rochester, NY, USA
Objective: Vaginal bleeding is the leading cause of presentation to the emergency department during the first
trimester of pregnancy. Spontaneous abortion, ectopic pregnancy and gestational trophoblastic disease are the main
differential considerations. In this study, we aimed to review the sonographic findings of various pathologies
associated with first trimester vaginal bleeding and discuss the role of ultrasound in the management of the relevant
clinical situation.
Materials and Methods: Transvaginal and pelvic ultrasound were performed in cases presenting with first trimester
vaginal bleeding. Sonographic findings of normal early pregnancy and pathological findings associated with
spontaneous abortion, ectopic pregnancy and molar pregnancy are discussed.
Results: Along with sonographic findings representing a normal first trimester pregnancy, various findings implying
spontaneous abortion such as subchorionic hemorrhage, anembryonic pregnancy, incomplete expulsion of products of
gestation or empty uterus with complete expulsion of the products of gestation and gestational sac in process of
expulsion were observed. Furthermore, sonographic findings indicating ectopic pregnancy and molar pregnancy were
among the spectrum of abnormal sonographic findings that were detected.
Conclusion: Clinical evaluation alone is insufficient for revealing the etiology of first trimester vaginal bleeding. In
contrary, ultrasound has a crucial role in the management of the patients as it enables a proper differentiation
between various diagnostic considerations like spontaneous abortion, ectopic pregnancy and molar pregnancy. We
conclude that radiologists should be familiar with the sonographic findings indicating an abnormal first trimester
pregnancy.
P11. RETROPERITONEAL TUMORS: COMPUTED TOMOGRAPHY (CT) AND MAGNETIC RESONANCE (MR)
PATTERNS
Cardone G., Messina A., Vergnaghi D., Mangili P., Guazzoni G., Balconi G.
Department of Radiology, San Raffaele Turro hospital, Milan, Italy
Purpose: 1) To illustrate the most frequent CT and MR imaging appearance of the retroperitoneal tumors.
2) To review the most frequent recurrence patterns after retroperitoneal tumors surgery.
3) To evaluate the most effective CT and MR imaging examination techniques.
Method: Most frequent retroperitoneal tumors are: a) Lipomas and liposarcomas, b) Leiomyosarcomas, c) Malignant
fibrous hystiocytomas, d) Malignant Hemangiopericytomas and e) Cystic lymphangiomas. We reviewed 349 cases of
CT and MR examinations of patients with retroperitoneal tumors, to illustrate CT and MR imaging patterns of the
retroperitoneal tumors and most frequent recurrence patterns.
Results: The most effective imaging techniques are multiphasic acquisition (CT) and TSE T2w, conventional dynamic
ce-FS-GRE T1w and subtracted dynamic ce-FS-GRE T1w sequences (MR). The most important parameters in the study
of the retroperitoneal tumors were the anatomy and the topography of the lesions for the surgical planning and the
vascularization to evaluate the aggressiveness of the lesions.
Conclusion: CT and MR were effective imaging techniques in the evaluation of retroperitoneal tumors.
P12. RENAL CELL CARCINOMA ASSOCIATED WITH XP11.2 TANSLOCATION/TFE3 GENE FUSION:
IMAGING FINDINGS
Kim S.H. MD 1 , Cho J.Y. MD 2 , Kim S.H. MD 2 , Lee H.J. MD 3 , Hwang S.I. MD 3 . 1 Department of Radiology,
Keimyung University School of Medicine, Dongsan Hospital.
2 Departments of Radiology, Seoul National
University School of Medicine. 3 Departments of Radiology, Seoul National University, Bundang Hospital
Objective: To assess the imaging findings to differentiate renal cell carcinoma (RCC) associated with Xp11.2
translocation/TFE3 gene fusion from other renal tumors.
Materials and Methods: Pathologically proven seven patients were included in our study. We assessed the medical
records including age, sex, symptoms, and clinical outcome. We also assessed the size, growth pattern, echogenicity,
degree and pattern of enhancement, and internal architecture on US, CT and MRI.
Results: All patients were young adults (four males and three females) and their ages ranged from 15 to 32 years. All
tumors appeared as unilateral. The diameters of tumors were from 2 to 11.5 cm. Four patients had intramedullary
growth with intact capsule, and centripetally infiltrative growth in three patients. One patient had left renal vein
thrombosis. Lymphadenopathy or intraabdominal metastasis was not presented. Two patients had homogeneous
echogenicity, and inhomogeneous echogenicity in one patient. The four patients had a low homogeneous
enhancement, and an intermediate inhomogeneous enhancement in three patients. Hemorrhage and necrosis were
presented in four patients and three patients, respectively.
Conclusion: The imaging findings of this rare tumor frequently appeared findings similar to those of papillary RCC.
When these findings were presented in adolescence and young adult patient with indolent clinical course, RCC with
Xp11.2 translocation/TFE3 gene fusion might be in the differentiated diagnosis.
Index Words: RCC, Xp11.2 translocation/TFE3 gene fusion, US, CT, MRI
136

P13. LAPAROSCOPIC CRYOABLATION (LC) OF RENAL CARCINOMAS: MEDIUM TERM OUTCOME AFTER 7
YEARS MR IMAGING FOLLOW-UP
Cardone G., Iabichino C., Cestari A., Nava L., Guazzoni G., Mangili P., Balconi G.
Department of Radiology, San Raffaele Turro hospital, 20127 Milano, Italy
Objective: This study aims to determine the safety and efficacy of LC in the management of small renal carcinomas
and assess its medium term outcome.
Method: 67 pts underwent LC of 82 renal carcinomas between July 2000 and December 2007. All treatment was
administered under laparoscopic US guidance. Pts were followed up clinically, biochemically and by MR imaging 24
hours after surgery, and subsequently at 1,3,6,12,18,24,36,48,60 and 84 months. All MR examinations were
performed with a 1.5T MR system using GRE T1w, TSE T2w and ce-dynamic GRE FS-T1w sequences.
Results: 24 hours after treatment all cryolesions were more than 1 cm larger than the original masses; cryolesions
decreased in size by an average of 38% at 1 month, 64% at 6 months, 80% at 12 months and 93% at 84 months
following cryoablation. Postprocedural MR ce-T1w images showed complete ischemia of cryolesions. Follow-up
revealed no evidence of local recurrence in 65/67 pts (97%). 2 pts showed local recurrence at 12 and 24 months. 8/67
(12%) pts demonstrated metachronous nodules in the same or in the contralateral kidney at 12-24 months. 7/67 pts
died for metastasis of a previous malignancy. After surgery 21% of the cases showed a small intralesional haematoma
and 11% of the cases a small perilesional haematoma.
Conclusion: Our medium term experience suggests that LC is a safe, well tolerated and minimally invasive therapy for
small renal carcinomas, and MR is an effective imaging technique in the follow-up of renal lesions treated with LC.
P14. POST BIOPSY HAEMORRHAGE OF TRANSPLANTED KIDNEY TREATED BY SUPERSELECTIVE
SEGMENTAL ARTERY EMBOLIZATION
Pappas P., Tsamis A., Felesaki E., Barberi E., Genitsaris V., Sourla P., Kollias L.
Radiology Department, Laiko General Hospital, Athens, Greece
Objective: Biopsy-related vascular injuries in renal transplants are rare, but they can lead to dramatic clinical
symptoms prompting immediate treatment. Transcatheter embolization is a minimally invasive technique used to treat
some forms of arterial bleeding. This study evaluated the efficacy of this technique in iatrogenic biopsy-related
vascular lesions in renal allografts.
Method: Over the last eight years, six patients with severe renal hemorrhage were admitted to the angiography
department of our hospital for evaluation and possible further treatment. All of them had a history of previous biopsy
of a transplanted kidney. They all presented with clinical signs of hemodynamic instability. Angiographic investigation
of the kidneys preceded further intervention in all cases. All underwent hyperselective embolization of the specific
bleeding vessel with the use of microcoils and/or gelfoam particles.
Results: Successful embolization of the feeding artery could be performed in all patients. Superselective segmental
renal artery embolization had a successful outcome concerning a steady renal function and a stable clinical course. No
complications occurred.
Conclusion: Transcatheter embolization is a safe and efficient endovascular technique to treat biopsy-related vascular
injuries in renal transplants. Immediate clinical success and significant benefit in renal function can be obtained, and
the longevity of the allograft after successful embolization mainly depends on the natural outcome.
P15. MRI OF PLACENTA DISORDERS
Masselli G., Brunelli R., Polettini E., Anceschi M., Casciani E., Gualdi GF.
Radiology Dea Department, La Sapienza University, Rome, Italy
With the newest generation of MRI units and with technological advances such as parallel MR imaging the speed of
image acquisition and the spatial resolution can increase, raising a new role of Magnetic Resonance for placental
imaging.
The purposes of this educational poster are:
1.Describe the MR protocol for placental imaging.
2.Describe the MR findings of normal and abnormal placental disorders as placenta previa, placenta accreta spectrum,
placental abruption, placenta neoplasms and Intrauterine growth restriction (IUGR).
4. Show our MR cases in evaluating placenta disorders in comparison with pelvic ultrasound with color Doppler.
Conclusion: We feel that the introduction of MRI as a routine exam in cases of suspected placental disorders will fulfil
the obstetrician’s main concern of an accurate diagnosis in order to organize the most appropriate and safest surgical
procedure.
P16. LYMPHOMATOUS INVOLVEMENT OF THE FEMALE GENITAL TRACT
Ferreira A.C. 1 , Cunha T.M.2
1 Hospital Pulido Valente. 2 Instituto Portugues de Oncologia Francisco GentilLisboa, Portugal
Objective: To present the radiologic findings, including US, CT and MRI, of genital tract involvement by lymphoma.
Method: The medical records of patients from Instituto Português de Oncologia, who have been diagnosed with
lymphomatous involvement of the genital tract, were retrospectively collected and reviewed. It was also made a
revision of the literature.
Results: Patients with uterine involvement usually demonstrates diffuse uterine enlargement with a somewhat lobular
contour. In rare cases focal lesions can be found. Involvement of the ovary is often diffuse, bilateral with
homogeneous enlargement. The vagina can be involved too.
Conclusion: Although lymphomas are predominantly neoplasm of lymph nodes, involvement of other tissues can occur
and we should be aware of their manifestations for prompt diagnosis. The involvement of genital tract may be either
secondary, as a part of systemic disease, or in very rare instances may primarily arise in the female genital tract.
137

P17. IMAGING OF URETHRAL DISEASES
Yoon S.K., Kwon H.J., Kang M.J., Cho J.H., Choi S., Nam K.J.
Department of Radiology, Dong-A University College of Medicine, Busan, Republic of Korea
Objective: The purpose of this exhibition is to demonstrate normal anatomy of the urethra and periurethral tissues, to
review imaging modalities of the urethra, including techniques, indications, and complications, to describe radiologic
features of various urethral diseases. Detailed knowledge of the normal anatomy of the urethra and bladder with
adjacent structures is essential to an understanding of the normal radiologic landmarks on variable image modalities,
and is prerequisite to the radiologic interpretation of the diseased urethra.
Conclusion: The imaging modality of choice for urethral disease is conventional urethrography: retrograde
urethrography (RGU) and voiding cystourethrography (VCUG). RGU is the first line for evaluation of anterior urethral
diseases, such as trauma or stricture. VCUG is a good imaging modality in evaluating the posterior urethra. However,
these modalities have a limitation in imaging the periurethral tissues. Ultrasonography, computed tomography, and
magnetic resonance (MR) imaging are now evolving modalities. Sonourethrography can image the soft tissues of the
corpus spongiosum and corpora cavernosa as well as the urethra. MR imaging is applied to evaluate urethral tumors
and to assess the extent of involvement of surrounding tissues. The exhibit demonstrates various imaging techniques
for the urethra and radiologic features of the urethral diseases.
P18. IATROGENIC RENAL ARTERY PSEUDOANEURYSMS. MULTI-DETECTOR CTA FINDINGS.
Kraniotis P., Spiliopoulos S., Zampakis P., Diamantopoulos A., Tsota I., Kalogeropoulou C., Petsas T., Siablis
D.
University Hospital of Patras, Radiology Department, Patra, Greece
Purpose: Iatrogenic renovascular injury has an increased incidence owing to the large number of percutaneous renal
procedures and surgery being performed currently. Our aim is to present the role of multidetector computed
tomography angiography (MDCTA) in the detection of iatrogenic pseudoaneurysms.
Materials: We retrospectively reviewed our department’s database for pseudoaneurysms after renal interventions. All
patients were scanned with a 16xMDCT. The protocol included an unenhanced scan followed by 3-phase contrast
enhanced scan (corticomedullary, nephrographic and 3 minute excretory phase). Post-processing included multiplanar
reformation with maximum intensity projection (MIP) and 3-dimensional volume rendered views.
Results: Between a 3-year-period, 3 patients (2 males), mean age 58,were diagnosed with an iatrogenic renal
pseudoaneurysm. Two patients presented after partial nephrectomy, due to renal malignancy and one following a
percutaneous lithotripsy attempt. All cases had severe macroscopic hematuria and decreased hematocrit level, 1 to
48 hours after intervention. MDCT angiography recognized all 3 pseudoaneurysms and their feeding artery. All lesions
were intra-renal, 2 in the lower pole and one in the upper pole. The mean lesion diameter was 19.9 mm (range: 10.4-
31.8mm). All three patients were finally treated with percutaneous embolisation after selective angiography which
confirmed the CT findings.
Conclusions: Three-phases MDCTA is a fast, effective and non-invasive method for the detection of iatrogenic renal
pseudoaneurysms. It also provides information about the feeding vessel and width of its neck. It is more accurate than
angiography, in terms of real pseudoaneurysm dimensions, due to its ability to visualize partial thrombus formation.
P19. GYNECOLOGIC CAUSES OF ACUTE PELVIC PAIN SPECTRUM OF CT FINDINGS
Kapnisi E., Savvopoulou V., Arapostathi S., Stathousi P., Tsanakis G., Bisyri K., Paschos A., Dimakis A.,
Tibisranis M.
Radiology Department, Thriasio General Hospital, Elefsina, Greece
Objective: To present a review of the range of diagnostic findings in gynecologic disorders that caused acute pelvic
pain in our institution and illustrate the potential benefits of unenhanced and enhanced CT in such cases.
Methods: Females that presented with acute pelvic pain in our department during the past year were evaluated by
means of abdominal CT with administration of oral and intravenous contrast material for better delineation of the
bowel, uterus and adnexal structures.
Results: Acute pelvic pain may be due to uterine disorders such as degeneration or torsion of fibroids or leiomyomas,
ovarian disorders such as torsion, hemorrhagic ovarian cysts, endometriosis, post-operative and post partum
complications such as abscess and hematoma, adnexal tumors such as torsion of dermoid cysts and pelvic
inflammatory disease such as uterine infection, adnexal abscess. CT findings vary with the stage of disease.
Conclusion: CT may be helpful in cases of acute female pelvis, determining the location and extent of disease and
identifying associated complications, thus assisting an initial ultrasound examination. When correctly performed and
carefully evaluated, CT in these disorders will allow the radiologist to guide appropriate treatment and eliminate the
need for further imaging evaluation.
P20. FLANK PAIN - IT IS NOT ALWAYS RENAL: ALTERNATE IMAGING FINDINGS ON MDCT
El Saiety N., Ramesh N.
Midland Hospital, Radiology Department, Portlaoise, Republic of Ireland
Purpose: The purpose of this poster presentation is to exhibit the various non-renal imitators of flank pain.
Materials and Methods: Unenhanced MDCT scans of the abdomen in our department, is performed with the patient in
prone position and with a full bladder. The prone position is advocated to fill the pelvi-calyceal system and the full
bladder is useful to evaluate the distal ureters as well as to laterally displace any calcified vascular structures. In most
patients a low dose technique did not reduce the diagnostic quality of the acquired images.
Results: With the increasing use of MDCT in the evaluation of suspected renal colic, it is not surprising that more than
one-thirds of the time an alternate cause of the flank pain is radiologically visible.
The alternate diagnosis is most commonly of pelvic origin in females, other causes include gastrointestinal {gall
stones, pancreatitis, diverticulitis, appendicitis}; musculo-skeletal; vascular; non-calculi renal disease; and sometimes
extra abdominal causes {lower lobe pneumonia}
Conclusion: In this educational exhibit we present the various non-renal calculi imitators of flank pain. The reporting
radiology trainees and radiologists must be aware of these alternate causes to diagnose the cause of the flank pain.
138

P21. FETAL SUPRARENAL AND RENAL MASSES : SONOGRAPHIC APPEARANCE AND DIFFERENTIAL
DIAGNOSIS
Song M.J., Moon M.H., Han B.H., Lee Y.H.
Department of Radiology, Cheil General Hospital & Women's Healthcare Canter, Kwandong University College
of Medicine, Seoul, Korea
Objective: The aim of this study was to evaluate the prenatal sonographic findings and the differential diagnosis of
suprarenal and renal masses in fetuses.
Method: Retrospective study of the prenatal sonography from June 2006 to May 2008 was performed at Cheil General
Hospital & Women’s Healthcare Center. Routine ultrasonography was performed and correlated perinatal outcome and
postnatal pathology.
Results: There were eight cases suprarenal and renal masses detected sonographically in fetuses of 20-36 weeks. The
sonographic appearances of the masses included echogenic (n=4, neuroblastoma and subdiaphragmatic extralobar
pulmonary sequestration), mixed isoechoic (n=2, mesoblastic nephroma), purely cystic (n=2, renal cyst). Four cases
were diagnosed at second trimester (subdiaphragmatic extralobar pulmonary sequestration, renal cyst), the other
cases were diagnosed at third trimester (neuroblastoma, mesoblastic nephroma). The suprarenal masses were
confirmed neuroblastoma (n=2) and subdiaphragmatic extralobar pulmonary sequestration (n=2). The renal masses
were confirmed mesoblastic nephroma (n=2) and simple renal cyst (n=2). In suprarenal masses, the neuroblastoma is
blend with adrenal gland and diagnosed in late but the subdiaphragmatic extralobar pulmonary sequestration is
separated from normal adrenal gland and detected in second trimester. In renal masses, the mesoblastic nephroma is
solid and diagnosed in late.
Conclusion: The increasing use of obstetric ultrasonography has made the prenatal screening of suprarenal and renal
masses possible. The prognosis of infants with a suprarenal and renal mass may be improved with this early detection.
P22. ENDOCRINE BASED ANATOMY AND IMAGING OF FEMALE GENITAL ORGANS
Fernandes L., Lobo L., Pires F., Abecasis M.
Centro Hospitalar Lisboa Norte-Hospital Santa Maria, Lisboa, Portugal
Objective: To emphasize the role of hormone environment in the normal and abnormal development as well as in the
imaging findings of uterus and ovaries.
Method: The authors describe the usual and pathologic endocrine based anatomy and imaging aspects of female
genital organs, with special focus in development / aging findings and in illustrative pathology.
Results: A systematic approach of the various manifestations is presented, along with imaging documentation based
mainly on ultrasound, CT and MR.
Conclusion: The authors conclude that understanding the endocrine environment and the anatomy findings of female
genital organs is fundamental for de correct imaging diagnosis of normal and pathologic issues in this area. Endocrine
Gynecology is thus a challenging and recent perspective in the Urogenital Radiology, that the modern Radiologist
should be familiarly with.
P23. EMPHYSEMATOUS PYELONEPHRITIS : THE ROLE OF CT
Triantafyllou E., Zbogo A., Karakiklas D., Apostolopoulou G., Labropoulou P., Drossos Ch.
General Hospital of Athens G. Gennimatas, Center of Radiology Imaging, Athens, Greece
Aim: Emphysematous pyelonephritis (EPN) is a severe , acute necrotizing infection that causes gas formation within
the collecting system, renal parenchyma and/or perirenal tissues. Our purpose is to present the role of imaging
modalities , mainly CT, in the assessment of these life –threatening cases.
Material-Method: In a two year period six patients were diagnosed in our department, with gas producing bacterial
renal infection. All patients had at least 5 days history of fever and chills. Other symptoms were abdominal or flank
pain , nausea, vomiting and dysouria. Three of them had medical history of poorly controlled diabetes mellitus, two
had known calculus disease and one was in severe immunosuppression. All patients underwent in emergency basis
abdominal radiography, followed by CT with a 16-row multi-detector scan (MD-CT) before and after iv contrast media.
Results: All patients had abnormal imaging findings. Abdominal radiography revealed retroperitoneal gas in one
patient and ureteric stone in another. In four patients MD-CT depicted gas-bubbles in the collecting system. One
patient had a great amount of air in the urinary bladder and one also had a few bubbles in the renal parenchyma. Two
patients had calculi and one triangular parenchymal abnormalities that were typical of acute pyelonephritis. All
patients had small amount of perinephric fluid.
Conclusion: EPN is a condition which carries major morbidity and significant mortality. Rapid and thorough
assessment, prompt diagnosis and appropriate aggressive treatment can reduce mortality in this life-threatening
condition. CT is invaluable for rapid diagnosis, determination of the extent of infection and improvement of prognosis.
139

P24. CT UROGRAPHY: CLINICAL INDICATIONS, LIMITATIONS AND RADIATION DOSE: A PROPOSED
APPROACH.
Neofitou G. 1 , Fatsi A. 1 , Fragioudaki I. 1 , Laspas F. 1 , Sotirakou K. 1 , Georgiopoulos I. 4 , Ptothis N. 1 , Koumarianos
D. 1 , Chalazonitis A.N. 2
1 Department of Radiology, General Hospital of Athens "Elpis", Athens, Greece. 2 Department of Radiology,
General Hospital of Athens "Alexandra", Athens, Greece. 3 Department of Radiology, General University
Hospital of Athens "Attiko", Athens, Greece. 4 Department of Urology, General Hospital of Athens "Elpis",
Athens, Greece
Objective: In our exhibit we will demonstrate a proposed protocol that we use at our institution, based on the most
frequent present-day clinical indications and the possible limitations of the examination.
Method: Computed tomography urography (CTU) is a relatively new diagnostic imaging modality providing
comprehensive evaluation of the upper and lower urinary tract. As MDCT has become more widely available, CTU has
begun to replace other imaging techniques, especially intravenous urography (IVU).
CTU is defined as a diagnostic examination optimized for imaging the kidneys, ureters, and bladder. The examination
involves the use of multidetector CT with thin-slice imaging, intravenous administration of a contrast medium and
imaging in the excretory phase.
Results: CTU is justified as a first-line test for patients with macroscopic haematuria at high-risk for urothelial cancer.
CTU can also be useful in the investigation of urinary diversion procedures following cystectomy, hydronephrosis,
chronic symptomatic urolithiasis including planning of percutaneous nephrolithotomy (PCNL), traumatic and iatrogenic
ureteral injury, complex urinary tract infections and in the diagnosis of bladder tumours.
The relatively high radiation dose of multiphase CTU is a significant limitation of the widespread acceptance of this
technique. Strict indications for multiphase CTU are important tools to manage this relatively high-dose examination.
Conclusion: Surprisingly, in many reviews only one CTU technique is suggested to encompass all clinical indications.
Therefore we propose a differential approach used in different patient populations as the next logical step in the
evolution of CTU as a powerful yet dose-efficient test for urinary tract assessment.
P25. ADRENAL TUMOURS - A PICTORAL REVIEW
Kannappa L.K., Al-Nasri, Edwin
Norfolk and Norwich University Hospital, UK
Purpose: Learning objectives: To describe the classification, presentation, consequences and imaging appearances of
adrenal tumours and to ensure their detection and appropriate management.
Background: The term adrenal tumor can refer to one of several benign and malignant neoplasm’s of the adrenal
gland, several of which are notable for their tendency to overproduce endocrine hormones. Adrenal tumors are of 2
types.
Those arising from adrenal cortex: 1) Adrenocortical adenoma 2) Adrenocortical carcinoma.
Arising from adrenal medulla: 1) Nueroblastoma2) Pheochromocytoma.
Adrenal cancer specifically refers to malignant adrenal tumors, which include neuroblastoma, adrenocortical
carcinoma, and a minority of adrenal pheochromocytomas. Most adrenal pheochromocytomas and all adrenocortical
adenomas are benign tumors, which do not metastasize or invade nearby tissues, but which may still cause significant
health problems by giving rise to hormonal imbalances. Most of the tumours are incidental in finding like a routine CT
or MRI done for other purposes. Median age of presentation is 44 years and most often the adults.
Materials And Methods: The materials used are a series of multiple imaging’s of CT and MRI to understand the
investigate modality which were used in Norwich and Norfolk hospitals since 2002 to 2008. The pictorial representation
of various radiological modalities with individual image and its findings of different types of adrenal tumors were used
in arriving in diagnosis.
Results: 1) CT and MRI scans played a central role in not only the diagnosis, But in determining the type of treatment
planned radiologically. Most of the tumours were also detected clinically by the symptoms of adrenal syndromes
caused by excess hormone secretion detected by blood tests.
2) Some adrenal tumours required special studies of their blood supply to help define the extent of the tumour,
whether it is impinging on the blood supply to other nearby organs, These tests are referred to as selective
angiography and adrenal venography. They also may be helpful in distinguishing tumours of the adrenal gland from
tumours of the upper pole of the kidney.
Conclusions: By understanding the types, mode of presentation and the investigative modalities used for diagnosis and
treatment. The pictorial review helps the radiologist to understand the disease easily.
140

P26. A SCHEME OF DIAGNOSTIC & PROGNOSTIC GROUPING OF CT FINDINGS IN ACUTE RENAL
INFECTION :: WORK IN PROGRESS.
Hazarika S., Barua R., Gosmwami H., Hatimota P., Das T. 1
Radiology & Nephrology 1 departments, International Hospital, G S Road, Guwahati – 781006, Assam,
India
Aim: To enumerate CT findings in acute renal infection and group them for their diagnostic utility.
Materials & Method: The paper presents a retrospective series of diagnosed and treated cases ( n=50) of Acute renal
infection from CT archives for a period of 1 year. Independent observer opinion was obtained from 4 observers to
classify the findings.
Results: The observed findings are grouped into three class depending on their diagnostic value, inter-observer
agreement, pick up rate.
Group A findings are Renal swelling(88%), Peri-renal fascial thickening (76%), Perinephric & regional spread of
disease (56%) & Streaky nephrogram (44%). This group of findings has high interobserver agreement & high pick up
rate. These findings are consistent with increased diagnostic confidence.
GroupB findings are thickened collecting system, compressed collecting system, dilated or obstructed collecting
system. This group of finding have lesser pick up rate and inter observer agreement with reduced diagnostic
significance when considered alone or in absence of finding from the Group A.
Group C findings depict the complications of Acute renal infection. Frank Abscess (44%), Presence of air /
emphysematous disease (16%), abdominal wall involvement (8%) etc are clubbed in this group.
Conclusion: The class A findings can be viewed as major criteria of diagnosis of Ac renal infection while the Class B
findings as minor criteria. The C class findings are suggestive of complication.
A scoring system might be proposed in future based on CT findings and its utility might be tested for prognostication.
P27. CHRONIC RENAL FAILURE BONE LESIONS
Tavernaraki E., Tavernaraki K., Kokkinos D., Katsaros V., Solomakou S., Drossos Ch.
Evangelismos Hospital, Athens, Greece. Sismanoglio Hospital, Athens, Greece. IKA – Oncologic, Athens,
Greece. Dianalysis Unit, Halkida Hospital, Halkida, Greece. G. Gennimatas Hospital, Athens, Greece
Objectives: To evaluate a wide spectrum of bone abnormalities in patients with chronic renal failure, termed renal
osteodystrophy.
To describe the pathological basis of this condition and to review the essential role of plain films over the
complimentary of other imaging modalities.
Method: The most common bone disorder of patients with chronic renal failure is that of renal osteodystrophy. It
begins at the first stages of chronic renal failure and it is established in hemodialysis patients. We reviewed plain
films, CT and MRIs of chronic renal failure patients and we describe the imaging findings.
Results: Bone disorders include secondary hyperparathyroidism findings, osteoporosis, osteomalakia, calcification of
soft tissues and vessels. Joint disorders includes hydroxyapatite deposition and hemodialysis related tumor calcinosis.
Bone biopsy is the for diagnosis and follow up of renal osteodystrophy. The most essential
imaging modality is hand plain film.
CT and MRI are more sensitive methods for the diagnosis of aseptic necrosis, Looser zones, inflammatory conditions,
vertebral inflammation and bone marrow involvement, and differential diagnosis between conditions such as
destructive spondyloarthropathy and osteomyelitis of vertebral column.
Conclusion: Plain films still play an essential role for diagnosis and follow up of bone disorders of chronic renal failure
patients. Despite that, modern methods help mainly for differentiation of specific conditions.
P28. A RARE CASE OF FEMALE GENITAL TUBERCULOSIS MIMICKING OVARIAN CARCINOMA
Prompona M., Bizim V., Zografos Ch., Baltas C., Soldatos Th., Tsouroulas M., Drossos Ch.
Radiology Imaging Department, General Hospital of Athens “G. Gennimatas”
Objective: Genital tuberculosis is a relatively scarce condition that often arises secondarily to a primary focus, usually
the lungs. The fallopian tube is the organ most commonly affected whereas the ovaries are rarely involved (9-11%).
We report a case of tuberculous tubo-ovarian abscess, with diffuse nodular bilateral pulmonary lesions.
Method: A 26-year-old woman from Bangladesh was admitted to our institution due to a 5-month history of fever up
to 39°C and increasing abdominal pain. The patient underwent meticulous clinical examination, hematological and
biochemical blood testes. Additionally an ultrasound, CT and MRI examination were performed.
Results: Pelvic ultrasound and MRI as well as abdominal CT revealed an inhomogeneous mass dorsally to the uterus
involving both adnexa simulating an ovarian malignancy. Thoracic-CT demonstrated multiple bilateral pulmonary
nodules mimicking metastases. Histological examination of the specimens obtained during laparotomy elucidated an
extended necrotic granulomatous tissue indicative of tuberculosis. Further identification of acid-resistant mycobacteria
with Ziehl-Nielsen stain confirmed the diagnosis. Drug sensitivity test using molecular-genital technique demonstrated
an isoniazid resistance with mutation of the katG gene. Under anti-tuberculosis treatment the patient’s clinical picture
improved and CT examination revealed a significant decrease in size of the pelvic mass.
Conclusion: Genital tuberculosis can mimic imaging findings of ovarian carcinoma and may lead to the performance of
an unnecessary extended surgery. Therefore, radiologists should consider tuberculosis as a differential diagnosis when
encountering with clinical presentations of a pelvic mass.
141

P29. RENAL CYST COMPLICATIONS DUE TO BLUNT RENAL TRAUMA: CT EVALUATION.
Sidiropoulou M. 1 , Charsoula A. 2 , Giannopoulos T. 3 , Koupanis C. 3 , Retsilas I. 3 , Pozoukidis C. 1 , Pragalakis G. 3
1 Department of Radiology, Kozani General Hospital “Mamatseio”, Greece. 2 Department of Radiology, “G.
Gennimatas” General Hospital, Thessaloniki, Greece.
3 Department of Computed Tomography, General
Hospital of Giannitsa, Greece
Objective: The incidence of pre-existing renal lesions (PERL) with renal trauma is 4.4%.
PERL predispose kidneys to an increased risk of injury even after minor blunt abdominal trauma, and more symptoms
than expected from the extent of the injury are present in patients with PERL.
Rupture or hemorrhage of a renal cyst consist the most common complications of renal trauma in PERL.
Our study aims to present the role of CT in evaluating complications of renal cysts after blunt renal trauma.
Method: We retrospectively reviewed CT studies and clinical data of cases in which non-iatrogenic traumatic injuries to
renal cysts had been diagnosed (n=4). The patients were men aged 43-65 years. Signs and symptoms of flank pain
and hematuria were found in all cases. All patients underwent CT scans, and one had ultrasonography additionally
performed.
Results: CT documented rupture of a renal cyst (n=2). Ruptured cysts presented with undulated contour. Nonhemorrhagic
fluid collection in the posterior pararenal space and thickening of the renal fascia were depicted in one
patient while stranding of the fat in the posterior pararenal space was demonstrated in the other patient.
CT diagnosed hemorrhage of a renal cyst (n=2). Both cysts showed hematocrit effect. One patient presented a
hemorrhagic cyst with lunate morphology - MPR reconstruction ruled out subcapsular hematoma.
Conclusion: CT plays a major role in assessing patients with complications of renal cysts due to blunt renal trauma. CT
findings in renal injury should be integrated with clinical information in order to plan treatment.
P30. SIMULTANEOUS NON TRAUMATIC RETROPERITONEAL HEMATOMA AND CONTRALATERAL
SUBCAPSULAR RENAL HEMATOMA. DIAGNOSTIC APPROACH AND SELECTIVE EMBOLIZATION
TREATMENT.
Chatzidarellis E*, Tavernaraki K, Charalampopoulos G, Mazaris E*, Skolarikos A*, Anastopoulos I, Malachias
G, Karagiotis E*.
Radiology Department, Sismanoglio General Hospital, Athens, Greece.*2nd Department of Urology,
University of Athens, Sismanoglio General Hospital, Athens, Greece
Objective: To present the diagnostic evaluation as well as the therapeutic approach, by means of selective
embolization, of a rare non-traumatic case of a simultaneous right retroperitoneal hematoma and contralateral
subcapsular renal hematoma.
Method: A fifty year-old male patient was admitted in the emergency unit complaining of acute right flank pain and
macroscopic hematuria. Laboratory evaluation revealed severe decrease of the hematocrit level (15%). There was no
history of trauma, renal disease or coagulation disorders. The patient underwent an emergency abdominal CT scan.
Results: CT revealed a huge right retroperitoneal hematoma as well as a contralateral renal subcapsular
hematoma.The patient was initially resuscitated and haemodynamically stabilized,.Due to diagnostic difficulties, a DSA
was further performed showing a ruptured arterial branch of the lower pole of the right kidney, bleeding actively with a
low flow rate during the procedure. Selective embolization using coils was performed, which efficiently controlled the
bleeding. The patient recovered after 2 days, while the 1 year CT follow up revealed a significantly reduced right
perirenal hematoma and absorption of the left subcapsular hematoma.
Conclusion: Selective embolization in cases of active renal bleeding could be a prompt, safe and efficient alternative
therapeutic approach compared to open surgery.
P31. CT FINDINGS AND CLINICAL CORRELATION IN FOURNIER’S GANGRENE.
Athanassopoulou A. 1 , Kalogeropoulos I. 3 , Triga A. 2 , Smailis D. 2 , Rizos S. 4 , Filippou D. 2,4
1 Department of Computed Tomography and 2 Department of Visceral and Colorectal Surgery, Neo-Athineo MD
General Hospital, 83 Astydamantos str, Pagrati, Athens, Greece. 3 Department of Computed Tomography,
Athens General Hospital “Evangelismos”, Kolonaki, Athens, Greece. 4 First Department of General Surgery,
Piraeus General Hospital “Tzaneio”, Tzanni & Afentouli, Piraeus, Athens, Greece
Objective: Fournier’s gangrene is a rare gas forming infection of the scrotum and perineum, which leads to necrosis of
the overlying skin and if not recognized early and treated appropriately may be fatal.
Method: We present 8 cases of male patients we treated for Fournier’s gangrene the last decade. In 5 patients the
diagnosis was established clinically and confirmed by the CT scan, while in the rest three the initial diagnosis set by
the CT findings. The main radiological findings included the presence of inflammation and free air along in the inguinal
canal and the scrotal sac. The preoperative evaluation of the inflammation extension to the retroperineal space
obtained accurately with the CT.
Results: All the patients received the appropriate treatment (extensive surgical debridement and antibiotics
administration) immediately. The mean hospitalization time was 34 days (25-72) and all of the patients survived.
Conclusions: Fournier’s gangrene represents a rare urological emergency associated with high morbidity and mortality.
The immediate and correct diagnosis and treatment is essential for a good outcome. CT may contribute to the early
diagnosis and to the accurate assessment of its extension.
142

P32. ADRENAL HEMORRHAGE IN THE ADULT PATIENT: MULTIDETECTOR CT (MDCT) FINDINGS
Kalogeropoulou C., Konstantatou E., Kraniotis P, Trouli N., Karatzas A., Tsimara M., Zampakis P., Petsas T.
University Hospital of Patras, Radiology Department
Purpose: Adrenal hemorrhage is rare in the adult, presenting acutely with nonspecific symptoms. Its cause is either
acute trauma or a ruptured adrenal lesion. Mortality rates increase if undiagnosed, especially when bilateral, due to
adrenal insufficiency. Our purpose is to present the MDCT features of adrenal hemorrhage.
Materials: We retrospectively reviewed 8 patients who presented to the emergency department with unilateral adrenal
hemorrhage during the last 2 years. Patients’ age range was 26-68 years, (6M-2F). Four patients had sustained
abdominal trauma. From the remaining four: 2 had a primary adrenal tumor, 2 adrenal metastasis and 1 acute
myelogenic leukemia. All patients underwent a pre and post contrast 16xMDCT with power injection of 120 ml of CM at
a rate of 3ml/sec. Images were reviewed at a workstation with slice thickness of 1.2 mm and MPR.
Results: All patients presented with a high density mass in plain scan in the expected anatomic position of the adrenal.
Fat-stranding was depicted in the perirenal space. After contrast administration a ruptured adrenal mass was identified
in 4 cases. There was no evidence of active bleeding in all cases. Thickening of the ipsilateral diaphragmatic crus was
noted in 1 patient. All patients were treated conservatively except of 1 trauma patient who underwent surgery for coexisting
splenic trauma.
Conclusion: MDCT helps readily diagnose adrenal hemorrhage in the adult. It can also detect the presence of
underlying abnormalities. It reveals the extent of hemorrhage and is a useful tool of follow-up, helping to avoid
unnecessary surgery.
P33. RUPTURE OF RETROPERITONEAL HYDATID CYST PRESENTING AS A LEAKING BUTTOCK FLUID
COLLECTION.
Sidiropoulou M., Kontaki T., Mamalis V., Pozoukidis C..
Department of Radiology, “Mamatseio” General Hospital, Kozani, Greece.
Objective: Hydatid disease (HD) is an endemic parasitic disease which mostly affects the liver and is rarely
encountered elsewhere in the body (2-11% of cases).
Retroperitoneal hydatid cysts (HC) are very rare, and are usually secondary to HD involvement of other organs or to
previous surgery.
We report the imaging findings of a case with rupture of retroperitoneal HC, invading the abdominal wall and
presenting as a leaking buttock fluid collection.
Method: A 69-year-old woman presented with a large lump of the right buttock discharging fluid, which was present
for 15 days. She had a medical history of surgical treatment for HC of the pouch of Douglas at the age of 13.
Results: Plain abdominal X-ray showed a large calcified lesion of the right lumbar region.
Computed tomography revealed a 10.8cmx7.1cmx6.4cm retroperitoneal HC, with mural calcifications, adjacent to the
kidney and the ilio-psoas muscle. Rupture of the HC with retroperitoneal fluid collections was depicted and invasion of
the lateral abdominal wall was noted. The fluid collection extended to the soft tissues of the right buttock.
The patient underwent surgery. Pathologic examination and serologic tests confirmed the diagnosis of Echinococcus.
The postoperative course was uneventful and the patient was discharged.
Conclusion: HC of the retroperitoneum is a distinct clinical entity, however, familiarity with the spectrum of HD
imaging findings and uncommon sites of involvement contribute to prompt diagnosis and treatment.
Retroperitoneal HC should always be considered in the differential diagnosis of a cystic retroperitoneal mass.
P34. ABDOMINAL WALL ENDOMETRIOSIS IN A PATIENT WITH OVARIAN DERMOID CYST: A CASE
REPORT AND REVIEW OF IMAGING METHODS
Hrkać Pustahija A. 1 , Ivanac G. 1 , ĆurićJ. 1 , Kolak T. 2 , Brkljačić B. 1
1: Department of Radiology, University Hospital Dubrava; Av. G. Šuška 6, 10000 Zagreb, Croatia.
2:Department of Abdominal Surgery; University Hospital Dubrava; Av. G. Šuška 6, 10000 Zagreb, Croatia
Abstract: Endometriosis is an important clinical problem: it occurs in up to 15% of menstruating women, 30%–50% of
women with endometriosis are infertile, and 20% of infertile women and 24% of women with pelvic pain have
endometriosis. The most frequent location of extrapelvic endometriosis is the abdominal wall. It is usually associated
with surgical procedures that violate the uterine cavity, allowing endometrial tissue to be transplanted into abdominal
wall. Leading clinical symptom is usually pain, but which is often nonspecific, noncyclic in nature, and there is not
always a palpable mass. Therefore, recognition of this condition may be a diagnostic problem, since clinically it can be
mistaken for other abnormal conditions such as a suture granuloma, an incisional hernia, or primary or metastatic
cancer. Imaging plays important role in making a diagnosis of this condition, with ultrasound, CT and MRI being
valuable tools and each of them having its advantages and disadvantages.
We present a case of 29 years old female, which is unusual because of combination of abdominal wall endometriosis
and coexisting right ovarian dermoid cyst, which she had at the time of presenting to emergency department with
acute pelvic pain. Pain was appearing in association with her menstrual cycle for the last 3 months and she had a
history of caesarean section six years ago. A presentation of imaging methods used in this case is given, together with
an overview of role of imaging and typcal imaging features in these conditions.
143

P35. CONTRAST-ENHANCED SONOGRAPHY OF ATYPICAL RENAL CYSTIC LESIONS. A PICTORIAL REVIEW
Moschouris H. 1 , Papadaki M.G. 1 , Konstantinou D. 1 , Kornezos I. 1 , Foteinos A. 1 , Glava C. 2 , Matsaidonis D. 1
1. Department of Radiology, «Tzanio» General Hospital, Piraeus, Greece. 2. Department of Pathology, «Tzanio»
General Hospital, Piraeus, Greece
Objective: Cystic renal lesions that do not fulfill the criteria of simple cysts are a frequent cause of sonographic
diagnostic problems. In this pictorial review we demonstrate the findings of Contrast-Enhanced Ultrasonography
(CEUS) in a variety of atypical cystic renal lesions, and underline the advantages of this modality.
Method: Several types of atypical cystic renal lesions studied with baseline US and CEUS are illustrated. Sonographic
findings are correlated with those of CT and MR imaging and with histopathological findings in cases that underwent
surgery.
Results: The presented cases include: Various types of cystic renal cell carcinoma (unilocular with mural nodule,
multilocular with thickened irregular septa, necrotic-pseudocystic), cystic multilocular nephroma, complicated nonneoplastic
renal cysts, renal abscesses, renal hematoma with cystic appearance and renal hydatid cyst. Remarkable
features of CEUS are demonstrated: The ability of CEUS to detect even subtle enhancement of inflammatory or
neoplastic tissue, the differentiation of hemorrhagic renal cysts from cystic renal tumors with CEUS, the great contrast
between the enhancing and non-enhancing (necrotic, liquefied) components of the lesions.
Conclusion: CEUS provides valuable additional information regarding atypical cystic renal lesions and can be used
immediately after the initial sonographic detection of such lesions. In selected cases, CEUS could obviate the need for
further diagnostic work-up of atypical cystic renal masses.
P36. A PICTORIAL REVIEW OF TRANSPLANT KIDNEYS ULTRASOUND EXAMINATION
Cokkinos D.D., Antypa E., Tserotas P., Kostaras V., Mantzorou A., Deligiannis I., Kyratzi E., Piperopoulos P.N.
Radiology Department. Evangelismos Hospital. Athens, Greece
Objective: To suggest an examination protocol for sonographic imaging (US) of transplant kidneys. To review findings
of normal kidney transplants on B-mode, Colour and Spectral Doppler US, as well as with contrast agents. To
recognise the commonest complications post transplantation and their sonographic appearance.
Methods: We describe the transplantation surgical technique and present an US examination protocol. We present
sonographic examples of normally functioning transplants assessment. Parameters to examine include kidney length,
cortical thickness, parenchymal morphology, vascular anastomoses, main/intrarenal arteries Resistive Index, Peak
Systolic Velocity and Acceleration Index. We review the commonest complications related to kidney transplantation:
acute tubular necrosis, acute/chronic rejection, infection, renal artery/vein stenosis-thrombosis-aneurysm, infarction,
obstruction, arteriovenous communications and pseudoaneurysms, fluid collections.
Results: When a step-by-step examination protocol is followed, all aspects of a normally functioning renal transplant
can be adequately assessed. In the same way, complications post transplantation can be recognised on time for
treatment.
Conclusion: Radiologists and sonographers should be aware of the anatomy, pathophysiology and imaging findings of
renal transplantations. They should also be able to assess a normally functioning transplant kidney, as well as to
recognise common complications. A step-by-step US examination protocol assures inclusion of all parameters that
should be analysed during sonographic scanning.
P37. 3D T2-WEIGHTED MR AND T1 GRE WITH STEADY STATE PRECESSION SEQUENCES FOR THE
STUDY OF NEUROVASCULAR BUNDLES CHANGES After Nerve-Sparing Radical Retropubic
Prostatectomy: A RADIOLOGIC SCORE FOR ERECTILE DYSFUNCTION.
Lisi D., Panebianco V., Osimani M., Sciarra' A., Gentile' V., Passariello R.
Dept. of Radiological Sciences, Sapienza University of Rome. ' Dept. of Radiological Sciences, Sapienza
University of Rome
Object: To introduce, in patients submitted to a bilateral nerve-sparing radical retropubic prostatectomy (RRP), a new
morphologic and vascular MRI classification score of the neurovascular bundles (NVBs) alteration patterns, based on
GRE T1 with Steady State Precession (FLSSP) (after intravascular contrast media administration) and 3D isotropic MRI
T2 weighted sequence (3D T2 ISO) in the depiction of post surgery changes of NVBs formation.
Method: NVB alterations are classified into five classes on the basis of bilaterally NVB entire anatomical and vascular
course evaluation, unilaterally/bilaterally NVB anatomical and vascular course partially evaluable,
unilaterally/bilaterally NVB anatomical and vascular course never evaluable with probable resection For each classes ±
1 to 0 point for high signal on T2w.
Results: We obtain 5 classes of patients: Normal or quite (nearly) normal (0 to 2 points range), Mild (3 to 5 points
range), Mild to Moderate (6 to 8 points range), Moderate (9 to 13 points range) and Severe (point = 14). Each score
obtained may be correlated with International Index Erectile Function 5-item (IIEF-5) score and standard penile
Doppler evaluation.
Conclusions: The MRI morphologic and vascular classification score for NVB alterations proposed in this study, would
provide an additional diagnostic tool and may head new therapeutic strategies, especially in selected patients with
erectile dysfunction and penile eco-color Doppler negative for post-operative vascular alterations.
144

P38. ENTEROVESICAL FISTULAS: IS ABDOMINAL CT IMAGING ESSENTIAL FOR THE DIAGNOSIS
Mylona S., Lourbakou A., Roppa-Lepida N., Patsoura S., Katsarou A., Batakis N.
Red Cross Hospital, Athens, Greece
Purpose: To evaluate the contribution of CT in the demonstration of enterovesical fistulas.
Material and Methods: Enterovesical fistula is the acquired abnormal communication between the urinary bladder and
the small bowel or the colon. Acquired fistulas of the gastrointestinal tract can be categorized as external or cutaneous
and internal if they connect to another internal organ system. In our department in a 10-year period, 6 cases of
enterovesical fistulas have been diagnosed. All patients presented with abdominal pain, urinary tract infection and
pneumaturia. Two of them had known diverticulitis. CT of the abdomen was performed after the administration of 600
ml of iodinate contrast material (Gastrografin®) solution with 5 mm contiguous slice thickness. If necessary, the
examination was completed with IV contrast material administration.
Results: Four patients demonstrated communication between the urinary bladder and the colon (colovesical and
rectovesical) and two with the small bowel (enterovesical). The aetiology in three cases was diverticula, in one case
malignancy of the colon, in one primary bladder carcinoma and in one Crohn’s disease. In all cases, the abdominal CT
showed the position of the fistula and the underlying pathology, which was essential for the surgical planning.
Conclusion: The abdominal CT is a necessary imaging modality for the detection of the enterovesical fistula and the
treatment planning.
P39. MULTIPLE PCNL TRACTS TO REMOVE A COMPLETE STAGHORN CALCULI RELATED TO A TWO YEAR’S
RETAINED PIGTAIL IN A HORSESHOE KIDNEY OF A MORBIDLY OBESE WOMAN.
Chatzidarellis E., Papachristou C., Athanasiadis G., Chrisafis E., Liakouras C., Chrisofos M., Skolarikos A.
2nd Department of Urology, Athens Medical School, Sismanoglio Hospital, Athens Greece
Objective: To present the percutaneous treatment of complete left staghorn kidney stone and huge bladder stone,
both related to a more than two years forgotten pig-tail ureteral stent, in a horseshoe kidney.
Method: A 55 years-old morbidly obese woman with a known history of horseshoe kidney, admitted in our urology
department complaining for left flank pain and macroscopic haematuria Initial KUB revealed the horshoshoe
abnormality, the retained stent and the associated lithiasis. Due to the difficulty anticipated, a 3-D reconstructed CT
urography and angiography was performed. The later confirmed the KUB findings and the need for possible separate
percutaneous tracts due to the narrow infudibula and caliceal necks, in conjunction with the high stone volume.The
procedure was performed under fluoroscopy.
Results: A bladder cystolitholapaxy and cut of the peripheral pig-tail tip at the level of the ureteric orifice were initially
performed. Encrustations formatted at the ureteral part of the stent were excluded by rigid ureteroscopy. Following
completion of these two procedures the patient was placed in the prone position and three consecutive percutaneous
tracts at the upper, middle and lower calyces were performed in order to break the largest part of the complete
staghorne stone and remove the retained stent with a grasper through the amplatz sheath. At the end of the
procedure a new pig-tail stent was left in place as well as a nephrostomy tube and a bladder catheter for adequate
drainage. Patient’s recovery was uneventful.
Conclusion: Our case represents one of the most challenging issues in modern endourology due to the combination of
more than two adverse parameters. Careful preoperative planning and advanced radiological imaging is mandatory to
limit intraoperative and postoperative complications while successfully resolving the problem.
P40. CT GUIDED RF ABLATION IN RENAL TUMORS: OUR EARLY CLINICAL EXPERIENCE
Andriotis E., Stassinopoulou M., Tavernaraki Ek., Tavernaraki K., Deliveliotis K., Tavernaraki A.
CT Department, Agios Savvas Hospital, Athens, Greece
Objective: study of safety and effectiveness of CT guided RF ablation in small renal tumors.
Method: CT guided RF ablation treatment was performed on 7 tumors in 6 patients (5M, 1F), age range (64-
83yrs)during the last two years. The size of the mass ranged from 2.5-4 cm. In 4 cases the tumor location was
peripheral and in 1 case central. The procedure was applied in inpatients. The treatment indications were localized,
solid renal mass, comorbidities, high operation risk, single kidney, multiple cysts and refusal to perform surgery.
Results: No complications were noted. Follow up included CT scan after iv contrast injection at 3, 6, 12 month period.
Successful result is regarded when there is no contrast enhancement within the tumor. In 5 cases there was complete
ablation of the tumor in 1 session. In 1 case there was no complete necrosis of the mass. In the last case the tumor
was centrally located, near the renal artery.
Conclusion: It is a safe and effective procedure especially when applied in small peripheral tumors and can be used as
an alternative treatment when indicated.
145

P41. PICTORAL REVIEW:GENETIC DISEASES AFFECTING KIDNEY.
Kannappa L.K., Hasrat K., Ho E.
Norwich & Norfolk University Hospital, UK
Purpose: Learning objectives: To describe the classification, presentation, consequences and imaging appearances of
polycystic kidney diseases which are genetic in inheritance and to ensure their detection and appropriate
management.
Background: Polycystic kidney disease (PKD) is a genetic disorder characterized by the growth of numerous cysts in
the kidneys. When cysts form in the kidneys, they are filled with fluid. PKD cysts can profoundly enlarge the kidneys
while replacing much of the normal structure, resulting in reduced kidney function and leading to kidney failure. When
PKD causes kidneys to fail—which usually happens after many years—the patient requires dialysis or kidney
transplantation. About one-half of people with the most common type of PKD progress to kidney failure, also called
end-stage renal disease (ESRD). Two major inherited forms of PKD exist:
1) Autosomal dominant polycystic kidney disease.
2)Autosomal recessive kidney disease.
Materials and Methods: The materials used are a series of multiple imaging’s of ultrasound,CT and MRI to understand
the investigate modality which were used in Norwich and Norfolk hospitals since 2000 to 2008. The pictorial
representation of various radiological modalities with individual image and its findings of different types of adrenal
tumors were used in arriving in diagnosis.
Results: The most common form of diagnostic kidney imaging is ultrasound, but more precise studies, such as
computerized tomography (CT) scans or magnetic resonance imaging (MRI) are also widely used. CT scans and MRI
also can detect cysts. MRI has been used to measure kidney and cyst volume and monitor kidney and cyst growth,
which may serve as a way to track progression of the diseases. Ultrasound has not only been used to detect kidney
cysts ,but also cysts in other organs. A good family history including genetic testing are also used as nonradiological
diagnosis.
Conclusions: By understanding the types, mode of presentation and the investigative modalities used for diagnosis and
treatment. The pictorial review helps the radiologist to understand the disease easily.
P42. MULTIDETECTOR CT (MDCT) IMAGING OF RENAL TRAUMA
Kraniotis P., Trouli N., Zampakis P., Diamantopoulos A., Romanos O., Konstantatou E., Kalogeropoulou C.,
Petsas T.
University Hospital of Patras, Department of Radiology
Objective: Kidney injury rates range between 8-10% in the setting of blunt or penetrating abdominal trauma. Our
purpose was to evaluate the role of 3 phase kidney imaging with MDCT in the setting of abdominal trauma.
Method: We retrospectively reviewed our records from 2005 up to today. We found 10 patients who had sustained
renal trauma. Of these 9 suffered blunt and 1 penetrating trauma. The age range was between 23 and 74 years old.
Seven patients were male and 3 female. They were all referred from the emergency department for abdominal pain
and gross hematuria. All patients were scanned with 16xMDCT. The scanning parameters comprised unenhanced scan
and 3-phases contrast enhanced scan with the administration of 120 ml non-ionic CM at a flow rate of 3.5 ml/sec in
the corticomedullary, parenchymal and excretory phase.
Results: Patients presented with a combination of renal injuries. Two patients presented with subcapsular hematoma
and 5 with perirenal hematoma. 4 patients sustained contusions 1 minor and 3 major. Five patients presented with
major lacerations, 1 of which did not extend to the pelvicalyceal system. 4 patients presented with urinomas. Thrombi
within the renal pelvis were identified in 1 patient. All patients were treated conservatively except one patient with a
deep laceration resulting in shattered kidney.
Conclusion: 3 phases MDCT imaging of the kidney in the trauma setting can accurately assess the type and extent of
renal pathology. This is important for further patient treatment and obviates the need for surgery in most cases.
P43. EPIPLOIC APPENDAGITIS IN A PATIENT WITH UNILATERAL LEFT RENAL, URETER AND SEMINAL
VESCICLE AGENESIS.
Zoutis S., Patsinakidis N., Iakovidis G., Siougaris N.
Department of Radiology, General Hospital of Naousa, Naousa, Greece
Objective: The authors present a case of left renal agenesis and associated congenital absence of ipsilateral ureter and
seminal vesicle in a 54year old patient with epiploic appendagitis.
Material: A 54year old patient underwent a CT scan to investigate a left lower quadrant acute abdominal pain, low
grade fever and signs of acute abdomen. Results: The exam revealed an oval shaped, 2.5cm diameter, fat containing
lesion in contact to the sigmoid colon, with hyperattenuating rim sign and perilesional fat stranding. The diagnosis of
epiploic appendagitis was made and additionally a left renal, ureter and seminal vesicle agenesis was noted.
Conclusions: Failure of metanephric blastema to join with the ureteric bud on the affected side occurs in c.1 in 1200
individuals and results in single ipsilateral abscent kidney. Frequently there is an associated ipsilateral vas deferens
and/or epididymis absence, seminal vescicle anomalies and other congenital anomalies. It is the authors’ belief that
such anomalies could have predisposed the patient in developing epiploic appendagitis by means of an altered colon
position and a raised appendage mobility, susceptible to volvulus.
146

P44. IMAGING FEATURES OF BENIGN OVARIAN CONDITIONS
Pinto D. 1 , Cunha T.M. 1
1 Department of Radiology, Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisbon - Portugal
Objective: A wide variety of physiologic and benign conditions develop in the ovaries of reproductive women and some
of them can simulate malignancies. Our objective is to present the radiological features of benign conditions of the
ovary, with an emphasis on the key findings.
Method: Radiological records (Ultrasound, Computed Tomography and Magnetic Resonance) of patients with benign
conditions of the ovary were reviewed.
Results: In this presentation we illustrate and describe the main imaging features of benign ovarian conditions that
include functional cysts, inflammatory diseases and benign neoplasms.
Conclusion: Benign ovarian conditions frequently show characteristic imaging features that allow differentiating them
from malignant diseases. It is important that radiologists be familiar with these lesions on multiple imaging modalities
in order to establish an accurate diagnosis and determine appropriate treatment.
P45. GIANT RETROPERITONEAL MYXOID LIPOSARCOMA CT EVALUATION
Kapnisi E., Papaevagelou A., Savvopoulou V., Doulgerakis G., Tsanakis G., Kavallaris G., Dimakis A.,
Tibisranis M.
Radiology Department, Thriasio General Hospital, Elefsina, Greece
Objective: The aim of this study was to present the CT imaging features of a case of giant retroperitoneal liposarcoma
and the role of CT in the preoperative diagnosis. Primary myxoid liposarcoma is a rare neoplasm, usually arising in the
retroperitoneal space and lower extremities, which tends to behave aggressively.
Methods: A 65 years old male patient was admitted in our hospital with right abdominal pain. A helical abdominal CT
scan after intravenous and oral contrast administration was performed.
Results: On unenhanced images a very large, well defined retroperitoneal mass with soft tissue and fat attenuation
was identified in the right frontal pararenal space, displacing right liver lobe, kidney, ascending colon, mesentery,
bowel and pancreas, without compressing the inferior vena cava or right ureter. Contrast-enhanced CT images showed
faint contrast enhancement of soft-tissue components. Staging showed local tumor and the patient underwent
resection of a 15 kg retroperitoneal tumor including the right adrenal gland and kidney. Histopathological examination
revealed a myxoid liposarcoma of the retroperitoneum.
Conclusion: In cases of retroperitoneal myxoid liposarcoma, computed tomography may adequately determine mass
composition and extent of local and distant disease, thus assisting therapeutic decision making. Histopathologic
examination establishes final diagnosis.
P46. INFLAMATORY DISEASE OF THE FEMALE GENITAL TRACT CT EVALUATION
Savvopoulou V., Kapnisi E., Pithara C., Paschos A., Bisyri K., Katsigiannopoulos D., Natsiopoulou E.,
Tibisranis M.
Radiology Department, Thriasio General Hospital, Elefsina, Greece
Objective: To emphasize the importance of helical abdominal CT for the detection of inflammatory disease of the
female genital tract, including uterus, fallopian tubes and ovaries and investigate any association with congenital
uterine malformations and congenital renal abnormalities (in the same side), especially renal agenesis and ectopia.
Methods: In patients with suspected gynecologic disease and non specific symptoms, including fever, abdominal pelvic
pain, vaginal discharge, uterine bleeding or vomiting, a helical abdominal CT examination was performed with oral and
intravenous contrast administration.
Results: CT findings included obscuration of the normal pelvic floor, thickening of the uterosacral ligaments and fluid
collections in the endometrial canal, fallopian tubes and adjacent pelvic structures. As the disease progressed, tuboovarian
and pelvic abscesses, pyometra or hydrometrocolpos might develop. Reactive inflammation of adjacent
structures was present. Pelvic inflammatory disease was observed in several women with congenital unilateral kidney
and didelphys uterus, as well as women with intrauterine contraceptive device in place.
Conclusion: A systematic imaging approach taking into consideration key CT imaging features, allowed a precise
diagnosis or at least a narrow differential diagnosis in the majority of cases. Women with congenital urogenital
malformations or those with intrauterine device may be predisposed to pelvic inflammatory disease.
147

P47. CT EVALUATION OF SEVERE EMPHYSEMATOUS PYELONEPHRITIS
Lazaridou E. 1 , Savvopoulou V. 2 , Exarhos D. 1 , Skoula A. 1 , Testembasi E. 1 , Vantali V. 1 , Pavlopoulou E. 1 , Hondros
D. 1
1 Evagelismos General Hospital, CT and MRI Department, Athens, Greece. 2 Thriasio General Hospital,
Radiology Department, Elefsina, Greece
Objective: Emphysematous pyelonephritis is a rare necrotizing kidney infection characterized by the presence of gas in
the renal parenchyma, collecting system and perinephric space. This condition is most commonly seen in diabetic
patients and it is due to anaerobic gas-producing bacteria. Mortality rate approaches 80% in some series. We report a
case of severe emphysematous pyelonephritis that was evaluated with CT.
Methods: A 62-year-old diabetic male with previous urinary bladder resection for bladder cancer and neobladder
formation presented with signs of sepsis and acute renal failure. A non-enhanced CT examination of the abdomen was
performed for evaluation.
Results: The right kidney was edematous with significant fat blurring and stranding of the renal pelvis, peri- and
pararenal space and small pararenal fluid collections. Fat blurring extended around the right ureter until its entrance
into the neobladder, accompanied by subtle dilatation of the right collecting system and neobladder wall thickening. A
little calculus was present into renal pelvis. Gas was present in the renal parenchyma and pelvis, right perirenal space,
right renal vein and inferior vena cava and around the right ureter. Emphysematous pyelonephritis possibly due to
calculi or retrograde infection was suspected. Right nephrectomy was performed which confirmed diagnosis,
unfortunately the patient deceased.
Conclusion: Diabetic patients with neobladder formation due to urinary bladder cancer may suffer severe
emphysematous pyelonephritis requiring immediate and intensive medical treatment. Computed tomography is the
imaging modality that permits detailed assessment of the extent and often, the cause of the inflammatory process,
conducive to radiologic classification with a prognostic value.
P48. US, IVU, CT AND MRI FINDINGS OF CONGENITAL URETERAL DIVERTICULUM
Builov V.M., Sencha A.N.
X-ray & US Departments of Rail Way Clinical Hospital, Yaroslavl, Russia
Objective: A case of rare anomaly- ureteral diverticulum is described.
Method: Patient D., 47 years, underwent prophylactic abdominal US, which showed small calculi in both kidneys.
Dynamic IVU with fluoroscopy, abdominal native CT, MRI, US were performed in the urologic clinic
Result: In dynamic IVU with fluoroscopy, where an oval-shaped cavity 20x15 mm, connected with the lateral wall of
the pelvic part of the left ureter was found. Moderate peristalsis of the wall of this cavity simultaneous with peristalsis
of ureteral cystoids was shown.
Abdominal CT in native phase revealed calculi in both kidneys 2-3 mm and in the prevesical part of the left ureter.
Coronal T2-weighted MRT, performed on low-field MRT showed spina bifida of the body of L4 and moderate
pyeloectasis in the left kidney. MRU showed enlargement of UD after i/v injection of 2.0 furosemide.
MR myelography revealed a small Tarlov cyst, which is a variant of sacral meningocele in the form of extradural
perineural cyst without connection with subarachnoid space.
On US performed 25 min after intake of 2.0 mg furosemide per os by the patient, an anechoic oval mass 20x10 mm
was visualized adjacent to prevesical part of the left ureter. The dimensions of this mass substantially decreased after
urination.
Conclusion: UD was diagnosed with noninvasive radiological modalities - dynamic IVU with fluoroscopy, CT, US and
low-field MRI before and after intake of furosemide. Evident information obtained with these modalities allowed to
avoid such invasive procedures as ureterography and ureteroscopy.
P49. MIXED TUMOR OF THE VAGINA: MAGNETIC RESONANCE IMAGING FINDINGS
Laspas F. 1 , Roussakis A. 1 , Papadopoulos S. 2 , Filippi V. 1 , Kritikos N. 1 , Kechagias D. 1 , Andreou J. 1
1 CT and MRI Department, Hygeia Hospital, Athens, Greece. 2 Histopathology Department, Hygeia Hospital,
Athens, Greece
Objectives: Mixed tumor of the vagina is a rare benign neoplasm. The aim of this study is to present magnetic
resonance imaging (MRI) features of this uncommon tumor.
Material-Method: A 42-year-old woman presented with a mass located in the lower vagina. She reported no pain or
other symptoms. Her menstrual cycle was regular and she had no prior history of gynecologic problems.
During gynecologic examination, a well-circumscribed nodular mass arising from the left lateral lower vaginal wall was
found.
Results: MRI provides the best soft tissue contrast and is the most useful imaging modality available to evaluate the
vaginal tumors. MRI of the pelvis showed a well-circumscribed ovoid mass (2.0x2.5cm) arising from the lower one
third of the vagina. On T2-weighted images the mass appeared as homogenous high signal intensity lesion, while on
T1-weighted images it was hard to discern from the vaginal wall. After intravenous gadolinium contrast material the
mass showed homogenous progressively increasing enhancement.
The lesion was excised uneventfully and sent for pathological examination. The diagnosis was mixed tumor of the
vagina. Follow-up for ten months showed no evidence of recurrence.
Conclusion: Mixed tumor of the vagina is a benign neoplasm without characteristic imaging features and the diagnosis
of this tumor should always be kept in mind whenever an ovoid well-circumscribed mass arising in the vagina near the
hymenal ring is detected.
148

P50. RENAL LYMPHANGIOMATOSIS: A CASE WITH ATYPICAL IMAGING FINDINGS
Laspas F 1 , Roussakis A 1 , Efthimiadou R 1 , Savidou D 1 , Mourmouris C 1 , Dounis A 2 , Andreou J 1
1 CT and MRI Department, Hygeia Hospital, Athens, Greece. 2 Department of Urology and Brachytherapy,
Hygeia Hospital, Athens, Greece
Objectives: Renal lymphangiomatosis is a rare disorder characterized by developmental malformation of the lymphatic
system surrounding the kidneys. The aim of this study is to present a case of renal lymphangiomatosis with
pathological confirmation and atypical imaging findings.
Material-Method: A 30-year-old woman presented with a left abdominal distension. She had no prior history of
abdominal or pelvic problems. Blood tests were normal. Hematuria or proteinuria was not found. Blood pressure was
120/75mmHg.
Results: Computed tomography and magnetic resonance imaging of the abdomen and the pelvis showed enlarged left
kidney with multiple disseminated confluent calcified foci. In the same kidney, few cystic lesions were also depicted.
One of the latter showed intracystic hemorrhage. A percutaneous CT-guided core biopsy was performed to this kidney.
The specimen was sent for pathological examination, which showed renal lymphangiomatosis.
Conclusion: Although typical imaging findings in renal lymphangiomatosis are bilaterally enlarged kidneys with
multilocular, fluid-filled cystic masses with thin walls in the perirenal and peripelvic region, we report a case of
unilateral renal lymphangiomatosis with prominent imaging feature the multiple calcified foci in the enlarged kidney.
P51. TRIPLE SYNCHRONOUS RENAL TUMORS: CT AND MR FINDINGS
Xinou E. 1 , Stavrogianni 1 T., Panagiotopoulou D. 1 , Vellis A. 1 , Gialamoudi M. 1 , Moustakas G. 2 , Giannopoulos P. 1 .
1
Radiology Department, Theagenio Anticancer Hospital, Thessaloniki, Greece. 2 Urology Department,
Theagenio Anticancer Hospital, Thessaloniki, Greece
Objective: The coexistence of multiple synchronous primary neoplasms in the genitourinary system has only rarely
been described in the literature.
We report the CT and MR findings of a patient with three synchronous but histologically different primary renal tumors
in the same kidney.
Method: A 47-year-old man was admitted to our hospital with a history of epigastric pain. His physical examination
revealed no remarkable findings. Laboratory data showed normal renal function. Abdominal US, CT and MR were
performed.
Results: Abdominal US showed an exophytic isoechoic mass in the right kidney and multiple bilateral renal cysts.
Subsequent abdominal CT and MR scan revealed multiple renal cysts and bilateral solid tumors of different sizes
ranging from 2 to 40mm. The two largest tumors in the right kidney were exophytic and showed mild enhancement
and central necrosis.
A right radical nephrectomy was then performed.
The histologic, histochemical, and immunohistochemical features confirmed the presence of three synchronous primary
tumors in the same kidney: a chromophobe and a clear-cell type renal cell carcinoma and an oncocytoma.
Birt-Hogg-Dube syndrome was speculated but there were no cutaneous abnormalities and the genetic results were
negative.
Four years after the operation he is alive with no signs of recurrence or metastasis.
Conclusion: This is a rare sporadic case of combined renal malignancies diagnosed by imaging.
To our knowledge this is the first report of this subtype combination of primary renal tumors, which might trigger
further investigation on the pathogenesis theories of renal cell carcinoma.
P52. PERCUTANEOUS MANAGEMENT OF BRICKER URETEROINTESTINAL ANASTOMOTIC STRICTURES
Pappas P., Tyra T., Tzivra A., Babali A., Myrilakou A., Papageorgiou G., Delaveris E.
Department of Radiology, LAIKO Hospital, Athens, Greece
Objective: Urinary diversion after radical cystectomy is commonly performed via an ileal conduit using the Bricker
method. However, 4-8% of these cases are complicated with stricture formation at the ureterointestinal junction.
Method: A total of 24 patients (20 male, 4 female; age range 24-72 years) were enrolled in the study. Mean follow-up
time was 30.9 months. Invasive bladder cancer was diagnosed in 21, neurogenic bladder in 2 and shrunk bladder after
external beam radiation for prostate cancer in 1 patient. They were all managed by radical cystectomy followed by
Bricker ileal conduit. In 16 cases, ureterointestinal strictures bilaterally were discovered, whereas unilateral (left-sided)
strictures were noted to the remaining 8 patients. All strictures were managed via a percutaneous approach and
balloon dilatation. A double J stent was placed at the end of the procedure and was regularly replaced after an interval
of 2-3 months in a retrograde fashion.
Results: A percutaneous nephrostomy was successfully placed in all patients. Double J stent insertion was possible in
38 of a total of 40 (95%) obstructed ureters. No major complications were observed in any of the cases while
adequate renal function was preserved in all patients. Quality of life is not reported to be significantly compromised in
any patient.
Conclusion: Placement of a double J stent via a percutaneous approach seems to have offered a viable option in the
management of ureterointestinal strictures in this patient population. Periodical retrograde replacement of the stent
does not constitute a factor compromising quality of life.
P53. UNUSUAL IMAGING FINDINGS IN THE MALE URO-GENITAL TRACT. A PICTORIAL REVIEW.
149

UNUSUAL APPEARANCES IN THE MALE PELVIS
Shetty S., Beale A., Ridley N.
Royal United Hospital, Combe Park, Bath
Objective: Unusual imaging findings may be seen in the male uro-genital tract. These range from calcification to
artefacts to foreign bodies .It is important for Radiologists and Urologists to be aware of these.
Method: Poster presentation of these unusual findings.
Results: Abnormalites include an array of unusual calcification in the scrotum, penis and epididymis. Penile prosthesis
and associated complications are presented.
Conclusion: There are a number of unusual abnormalities associated with the male urogenital tract. These will be
illustrated.
P54. MESOTHELIAL CYSTS OF SCROTUM AND INGUINAL CANAL IN CHILDREN. ULTRASONOGRAPHIC
FINDINGS AND PERIOPERATIVE EVALUATION
Karanikas C. 1 , Tsilikas K. 1 , Christianakis E. 2 , Eirecat H. 2 , Margari P. 1 , Vasilakis A. 1 , Sakellaropoulos A. 1 ,
Evlogias N. 1
Radiology( 1 ) and Pediatric Surgery( 2 ) Department, Pendeli Children’s Hospital, Athens 15236 GR
Purpose: US depiction of the mesothelium-lined cystic sacular appendages of the processus vaginalis peritonei that
constitute the mesothelial cysts of scrotum or inguinal canal, rare macroscopic findings in the operative correction of
corresponding hernias or hydroceles in children.
Methods and Materials: Retrospective analysis in the systematic peripoperative evaluation of the content of 1290
inguinal hernias or hydrocele cases presented to the pediatric-surgical department of our hospital, during the last 10
years. Post-operatively, 36 mesothelial cysts were confirmed, with variation in their morphology, in their filling or not
with fluid and in the presentation or symptomatology. Pre-operative US assessment was asked in 88 cases, with the
diagnostic dilemma of presence or absence of such a cyst.
Results: US-diagnostic accuracy was higher in the cases of inguinal hernias (30 out of 33) and spermatic cord cysts
(10 out of 10) while in the rest of the cases the US diagnosis referred to hydrocele. Only 2 out of 11 (18%) cases of
mesothelial cysts were diagnosed with US preoperatively and this finding was attributed to their anatomic location, to
the lack of bibliography on the subject, to the operator-dependence of the procedure and to the type of US-unit used
for the examination. Out of the 36 mesothelial cysts, 3 were located at the internal os, 8 in the middle of the inguinal
canal and 25 below the external os.
Conclusion: The awareness of mesothelial cyst existence along with a thorough US examination will contribute to a
better preoperative assessment and more appropriate surgical treatment since rarely they can sustain torsion and
cause acute scrotum.
P55. AN OVARY NOT SONOGRAPHICALLY FOUND IN ITS NORMAL POSITION: WHERE IS THE OVARY OF
THE YOUNG GIRL
Vakaki M, Protopappa A, Dagiakidi E, Sfakiotaki R, Karnezis I, Koumanidou C
Radiology Department, Children’s Hospital “P & A. Kyriakou”, Athens, Greece
Ovaries and testes have an analogous embryological development with analogous migration disorders. Like testes, but
less frequently, ovaries may fail to descend and remain in an ectopic position, between the lumbar region and the
pelvis. Furthermore, an ovary may herniate in the ipsilateral canal of Nuck, whenever it remains patent, accompanied
or not by intestinal loops. To the best of our knowledge, there are only few relevant case reports in the radiological
literature.
Purpose: To present the role of sonography in the detection of an ovary in anomalous position and to emphasize the
importance of pediatric radiologist’s awareness of the above rare disorders.
During a 6-year-period, 21 girls, aged 4-days to 10-years, with ovarian malposition were sonographically examined.
The clinical presentation varied. The sonographic examination of the lower abdomen was supplemented with
evaluation of the kidneys and the inguinal regions when needed.
The sonographic examination revealed 10 cases of ovarian maldescent, one case of both ovaries’ maldescent
associated with uterus didelphys, right hydrometrocolpos and ipsilateral renal agenesis, one case of ovarian
maldescent, uterus didelphys and ipsilateral renal agenesis, one case of ovarian maldescent and ipsilateral multicystic
dysplastic kidney, 4 cases of ovarian and bowel loops inguinal herniation, 3 inguinal ovaries, and one case of ovarian
and uterus inguinal herniation.
Conclusion: Pediatric radiologists should be aware of the possibility of undescended or herniated ovary, when one of
the ovaries cannot be found in its normal location, as well as of the probability of associated congenital urinary or
uterine anomalies.
150

P56. WHAT’S THAT REVIEWING THE SPECTRUM OF NORMAL AND ABNORMAL SONOGRAPHIC
APPEARANCES OF THE UNDESCENDED INGUINAL TESTIS IN YOUNG BOYS
Vakaki M, Dagiakidi E, Protopappa A, Kourou E, Hountala A, Koumanidou C
Radiology Department, Children’s Hospital “P & A. Kyriakou”, Athens, Greece
In the past, the contribution of sonography in the diagnostic investigation and morphologic evaluation of the
undescended testis has been controversial.
Purpose of our retrospective study is to present the whole spectrum of normal and pathologic sonographic
appearances of the undescended inguinal testes and to highlight the role of sonography in the recognition and detailed
evaluation of even small-sized ones.
During a 4-year period, 132 boys (152 nonpalpable testes), one-month to 8-year-old, with known or first diagnosed
cryptorchidism were sonographically examined. The inguinal testicular position, volume, shape, echotexture and
mobility were evaluated with the use of high-frequency linear transducers 10-14 ΜHz.
The sonographic findings included: 104 normal-appearing and 19 cases of atrophic/dystrophic undescended inguinal
testes (14 of them, with amorphous parenchymal calcifications), 8 cases of microlithiasis (two of them in both
undescended testes of one patient), 4 cases of testicular torsion and two testicular teratomas. In 7 boys, intestinal
loops within the ipsilateral inguinal canal (noncarcerated inguinal hernia) and in 8 more cases, funicular hydrocele of
the spermatic cord was revealed compressing the undescended testis. The sonographic findings are presented and the
differential diagnosis is discussed. The recognition of an apparent spermatic cord leading to a small structure on its
caudal end represents the most interesting new sonographic sign correlating to the identification of an
atrophic/dystrophic undescended testis.
In conclusion, sonography with its well-known advantages, performed in state-of-the-art equipment, provides
essential and detailed information arriving at a correct diagnosis and proper management of the inguinal testis.
P57. PELVIURETERIC JUNCTION OBSTRUCTION: A FAMILIAR ENTITY FROM THE PAST, WITH NEW
SONOGRAPHIC ASPECTS
Vakaki M. 1 , Sfakiotaki R. 1 , Kourou E. 1 , Dagiakidi E. 1 , Protopappa A, Mitsioni A. 2 , Askiti V. 2 , Koumanidou C. 1
1 Radiology Department, Children’s Hospital “P & A. Kyriakou”, Athens, Greece. 2 Department of Nephrology,
Children’s Hospital “P & A. Kyriakou”, Athens, Greece
The sonographic morphological renal findings in children with ureteropelvic junction obstruction (UPO) are well-known.
Improvement in definition and use of high-frequency linear transducers, as well as color Doppler, in daily US practice,
has enabled visualization of new sonographic findings in children with UPO.
Objective: To present the previously unrecognized sonographic changes in UPO, with anatomic and pathophysiologic
correlation.
Material and Method: Renal sonograms of 67 children, aged 50 days to 10 years, with UPO were retrospectively
studied. They were performed with state-of-the-art sonographic equipment. Convex 2-5 MHz, microconvex 5-8 MHz
and linear 5-14 MHz transducers were used. The degree of pelvic dilatation was recorded with A-P diameter
measurement of the renal pelvis on transverse images.
Results: In 22 children, echogenic pyramids and preserved corticomedullary differentiation was noticed. In 6 of the
above cases the pyramids were compressed by a dilated pelvicocalyceal system and appeared to have echogenic
bands. In 8 cases, complete loss of corticomedullary differentiation was noted. In 4 cases, dilated collecting ducts
were visible within the pyramids. Cortical microcysts, representing renal dysplasia, were detected, in 8 cases. The
anatomic/pathophysiologic explanation of the above findings is presented. In 24 children, color Doppler detected a
crossing vessel at the pelviureteric junction, which was surgically confirmed.
Conclusion: Various previously undetected sonographic findings, added to the typical ones, may be observed in UPO.
Their importance needs to be estimated. We believe that they should be mentioned in the sonographic report, as
indirect indicators of renal function, in correlation to 99mTc-MAG3 findings.
P58. SECONDARY SCROTAL INVOLVEMENT IN CHILHOOD: A SONOGRAPHIC APPROACH
Vakaki M, Kourou E, Sfakiotaki R, Protopappa A, Vasila O, Karagiannidis I, Koumanidou C
Radiology Department, Children’s Hospital “P & A. Kyriakou”, Athens, Greece
It is well-accepted that sonography is the primary imaging modality for the study of pediatric pathologic scrotal
conditions. They are mostly represented by the various causes of acute painful scrotum and less frequently by the
pediatric testicular and paratesticular tumors. However, there are also systemic diseases that can affect testes and/or
paratesticular tissues.
Aim: To present the sonographic findings in several systemic diseases affecting testes and/or paratesticular tissues,
and to highlight the role of sonography in the work-up of these rare conditions.
Gray-scale, color and power Doppler sonographic scrotal examinations of 26 boys aged 1-month to 14-years, were
retrospectively reviewed. They suffered from various systemic diseases and the scrotal sonogram was performed due
to painful/painless scrotal enlargement (n=18) or during their diagnostic work-up or follow up (n=8).
The various diffuse or focal, ipsilateral or bilateral, sonographic findings are illustrated. The underlying conditions with
secondary scrotal involvement were: Henoch-Schönlein purpura (n=4), acute idiopathic scrotal edema of possible
allergic origin (n=8), congenital adrenal hyperplasia with testicular adrenal remnants (n=1), acute lymphoblastic or
myelogenous leukemia (n=8), lymphoma (n=2), neuroblastoma (n=2), and juvenile xanthogranuloma (n=1).
In conclusion, knowledge of the sonographic features of the conditions described and illustrated in this study is
fundamental for their recognition and appropriate management in each case. Sonography is the first and remains the
only imaging method in the diagnostic evaluation of secondary scrotal disorders, followed by US-guided biopsy when
necessary.
151

P59. CYSTIC DYSPLASIA OF THE RETE TESTIS: SONOGRAPHIC EVALUATION OF A RARE BENIGN
CONDITION
Vakaki M 1 , Sfakiotaki R 1 , Spyridis G 2 , Michail A 3 , Poupalou A 2 , Hountala A 1 , Koumanidou C 1
1 : Radiology Department, Children’s Hospital “P & A.Kyriakou”, Athens, Greece. 2: 1 st Department of Pediatric
Surgery, Children’s Hospital “P & A.Kyriakou”, Athens, Greece. 3 : Pathology Department, Children’s Hospital
“P & A.Kyriakou”, Athens, Greece
Cystic dysplasia of the rete testis is a rare benign entity, which usually presents in the pediatric population as a
painless scrotal enlargement. There is a reported association between cystic dysplasia of the rete testis and ipsilateral
genitourinary anomalies, most common renal agenesis.
We present three cases of cystic dysplasia of the rete testis presenting with scrotal enlargement. On physical
examination a swollen non-tender testis was palpated in all three cases. They were sonographically evaluated with
high- frequency 5-12 MHZ transdusers.
In all cases, sonography supplemented by Color and power Color examination showed the presence of multiple small
cysts, surrounded by a thin rim of normal-appearing testicular parenchyma. An additional large paratesticular cyst,
and associated epidymal cystic dysplasia was demonstrated in one case. Abdominal sonography revealed the
presence of an ipsilateral multicystic dysplastic kidney in two cases. One of the above multicystic dysplastic kidneys
was intrapelvic.
In the first two cases the patients underwent orchiectomy. In the latest case, a surgical biopsy confirmed the
sonographic diagnosis of cystic dysplasia of the rete testis, a large epididymal dysplactic cyst was removed, and
nonoperative observation was chosen.
The detection of a multilocular cystic mass within the mediastinum testis, associated with an ipsilateral renal
abnormality, should rise the possibility of cystic dysplasia of the rete testis. As the lesion is always benign and
malignant degeneration has never been reported, nonoperative management could be selected. For obtaining detailed
information, the Pediatric Radiologist’s awareness is an essential prerequisite.
P60. A SOLID-APPEARING INTRA- OR EXTRATESTICULAR SCROTAL MASS ON SONOGRAPHIC
EXAMINATION OF A YOUNG BOY: WHAT DOES IT REPRESENT
Vakaki M, Kourou E, Dagiakidi E, Protopappa A, Douvlou E, Koumanidou C
Radiology Department, Children’s Hospital “P & A.Kyriakou”, Athens, Greece
Scrotal pathology differs in pediatric patients, especially prior to puberty, making awareness of pediatric conditions
essential. Evaluation of painful or painless scrotal masses in childhood begins with history and physical examination.
Sonography is the modality of choice for their imaging investigation.
Objective: To review the wide range of intra- and extratesticular solid and solid appearing pediatric scrotal masses and
their sonographic appearances, based on a large series of hundreds of boys sonographically examined in our
department between 2000 and 2008. To familiarize young pediatric radiologists with them, with the goal being to
prevent unnecessary surgical exploration or decide the appropriate surgical intervention (radical or partial
orchiectomy etc).
Gray-scale, color and power Doppler sonographic findings of a wide spectrum of solid and solid-simulating scrotal
lesions are presented. Intratesticular such lesions include primary testicular tumors (teratomas, yolk sac tumors,
embryonic carcinoma etc), secondary testicular neoplasms, and tumor-like lesions (cystic dysplasia of the rete testis,
epidermoid cysts, testicular adrenal rest tissue). Extratesticular solid and solid-appearing lesions consist of
extratesticular tumors (embryonal rhabdomyosarcoma etc), appendicular torsion, abscesses, inflammatory
pseudotumors, sebaceous scrotal cysts etc. Sonographic features that help differentiate benign from malignant lesions
are highlighted, as well as sonographic pitfalls and the clues to diagnosis.
Conclusion: By identifying the site of origin, whether a lesion is solid or cystic, and by recognizing the different keysonographic
features of each entity, the diagnosis is commonly readily approached, making sonography especially
valuable in patient ma
P61. CHRONIC KIDNEY DISEASE: EVALUATION OF CENTRAL VENOUS THROMBOSIS IN PATIENTS IN
HAEMODIALYSIS. COLOR DOPPLER SONOGRAPHY (CDS) ORVENOGRAPHY
Deftereos S., Souftas V., Michailidou E., Vranou E., Vargemezis V., Prassopoulos P.
Radiology Department and Medical Imaging, University Hospital of Alexandroupolis, Democritus University of
Thrace
Purpose: The aim of our study was to estimate dysfuctioning arteriovenus anastomosis (A-V Fistula) due to central
venous steno sis by CDS in comparison with venography findings.
Material And Method: The study includes 37 dysfactioned A-V Fistula (AVF) due to centrally located thrombosis in 32
patients with stage 4-5 Chronic Kidney Disease. The venous network of upper extremities was examined by CDS;
direct detection of stenotic lesions if they were accessible, as well as quantitative evaluation of blood flow was
performed by CDS. Venography was followed in all cases in order to restore the stenotic lesion. Preinterventional
venography results were compared with CDS findings.
Results: Central venous thrombosis was diagnosed in all cases by CDS based on direct signs (n=34/37) or on
abnormal (n=3/37) waveform spectrum alterations. In the last 3 cases venography revealed subclavian venous (n=1)
and superior vena cava (n=2) stenosis. Venography did not provide adequate information for lumen wall abnormalities
(thickening, wall sclerosis). In 3 cases with total obstruction the extension of thrombus was not determined by
venography, but it was demonstrated by CDS. CDS disclosed extravascular pathology (edema, hematoma, thombosed
aneurysm) not shown by venography in 4 additional cases. The collateral venous network was imaged more
adequately by venography.
Conclusions: CDS is a non invasive and easy to performed technique that allows the assessment of both anatomy and
hemodynamics of AVF vein network providing additional information concerning regional pathology. Venography may
be performed only when intervention is required.
P62. CT UROGRAPHY IN THE EVALUATION OF UPPER URINARY TRACT.
152

Malamouli I., 1 Adoniou A., 1 Filippou A. 2 , Krikis P., 1 Dimitriadis I 2, Syrgani-Kehalaki E 1
1 . Computed Tomography Department, Volos General Hospital, Greece. 2. Urology Department, Volos
General Hospital, Greece.
Introduction and objective: CT urography has extensively replaced traditional excretory urography (IVP) in the initial
imaging of the upper urinary tract. IVP has been proved to have an ability to detect 43-64% of urothelial neoplasms,
whereas CT seems to detect 90% of them according to preliminary studies. The objective of this study is to determine
the adequacy of imaging of the upper urinary tract from the tip of the renal calyces till the ureteral vesical junction
(UVJ) and to describe the ability of CT to detect urothelial neoplasms.
Method: We retrospectively examined 125 CT urograhies over a five year period at our department. Indications for
imaging, adequacy of imaging of entire collecting system, incidental findings and clinical outcomes were recorded.
Results: 51.2 % of 125 CT studies were carried out as follow up for bladder cancer and 40% for hematuria. Of 150
incidental findings, the most significant included
11 cases of lymphadenopathy, 9 adrenal nodules, 6 abdominal aortic aneurysms and 5 patients with pulmonary
metastases. Complete visualization of the urinary tract was achieved in 97 studies (77.6 %). Positive results of CT
were further evaluated with additional imaging and ureteroscopy with biopsy. There were 9 true positives, 7 false
positives, 108 true negatives and 1 false negative. (Sensitivity 83.5% Specificity 94.1%, positive predictive value 55.4
% and negative predictive value 98.1%)
Conclusions: CT urography is a reliable method of evaluation of the upper urinary collecting system depicting a greater
specificity and sensitivity than the traditional IVP.
P63. CT AS A PREDICTING IMAGING METHOD IN THE PROGNOSIS OF URETERIC COLIC.
Malamouli I., 1 Adoniou A., 1 Filippou A . 2, Krikis P., 1 Dimitriadis I 2 ,Syrgani-Kehalaki E. 1
1.
Computed Tomography Department, Volos General Hospital, Greece. 2. Urology Department, Volos
General Hospital, Greece.
Introduction and objective: Non contrast CT is the best imaging modality for the initial assessment of patients with
ureteric colic with a diagnostic sensitivity and specificity of up to 97%. Recurrence risk is estimated 50% in 7-10 years
after the first episode of colic in patients with a solitary calculus, diagnosed on plain abdominal film. This high
recurrence rate may be due to failure of plain films detecting coexisting renal stones /calcifications which would be
identified on CT scans. We reviewed the CT scans of patients with their first episode of renal colic in order to evaluate
coexisting renal calcifications and compared the findings on plain abdominal films.
Methods: We retrospectively analysed CT scans and plain abdominal films of 150 patients. We noted the presence of
ureteric stones and the presence or absence of renal stones/calcifications.
Results: CT scan confirmed that 137 of the 150 patients had ureteric stones (15 bilateral and 50 unilateral). Of those
patients 65 had concurrent renal stones/calcifications (47.4%) on CT. In this group 24% had a single renal stone,
while 76% had multiple renal stones. Plain abdominal films identified the ureteric calculus in 65 patients and coexisting
renal calcification in 12 patients.
Conclusions: The prevalence of coexisting renal stones/calcifications in the first episode of renal colic is much greater
on CT scans compared to plain abdominal films. This fact could explain the high recurrence risk of renal colic episodes
in certain patients and thus help in the prediction of their prognosis.
P64. PICTORIAL REVIEW OF AN ECTOPIC GIANT PARATHYROID ADENOMA. A CASE REPORT
Belfield J., Hastie K., Salim F.
Royal Hallamshire Hospital, Sheffield, England
Objective: To describe a case report of a patient with a giant parathyroid adenoma and present the radiological and
pathological findings.
Method and Results: A 38 year old lady presented to our institution with a history of renal calculi. Imaging was
performed with ultrasound and plain abdominal X-rays which confirmed the presence of multiple calculi. Due to the
nature of the calculi the patient was referred for percutaneous nephrolithotomy.
Routine blood tests were performed as part of a screening procedure for causes of renal calculi. Serum calcium was
raised at 2.83 and parathyroid level was checked and markedly elevated at 826.3 suggesting hyperparathyroidism.
A pre-operative chest X-ray demonstrated a right sided mediastinal mass, the exact nature of which was uncertain.
PCNL was therefore postponed pending further investigations. MIBI scan confirmed a large area of increased uptake in
the right anterior mediastinum within the thorax. CT was performed which confirmed a 5cm mass in the right anterior
mediastinum.
The patient underwent a median sternotomy to excise the mass, which was histologically confirmed to be a giant
parathyroid adenoma.
Following removal of the adenoma, the patient has subsequently undergone percutaneous nephrolithotomy.
Conclusion: This case report demonstrates radiological features of a giant ectopic parathyroid adenoma using different
imaging modalities. It is important to check calcium and parathyroid levels in patients presenting with multiple renal
calculi in order to exclude hyperparathyroidism.
153

P65. EXTRAMEDULLARY HAEMATOPOIESIS PRESENTING AS A BILATERAL KIDNEY MASS: CASE REPORT
Valentino M., Bertolotto M.*, Barozzi L., Pavlica P.
University Hospital S.Orsola-Malpighi Department of Radiology Bologna, Italy. * University of Trieste
Cattinara Hospital, Department of Radiology, Trieste, Italy.
Objective: To report an unusual case of isolated bilateral renal Extramedullary Haematopoiesis (EMH) which occurred
in a patient with primary myelofibrosis (PMF). The lesion was imaged by contrast-enhanced sonography, CT and MR
imaging, and verified histologically.
Method: A 80-year-old man with a previous history of PMF carried out contrast enhanced ultrasound (CEUS),
computed tomography (CT) and magnetic resonance imaging (MR).
Results: Ultrasound showed a 4-cm right renal mass, suspected for a neoplasm. CEUS demonstrated a slightly
enhancing of the lesion and a second lesion in the left kidney, without hydronephrosis. On contrast-enhanced
abdominal CT, two soft-tissue masses were seen in the pelvis of both kidneys. At MR both masses were hypointense in
T1-T2 weighted sequences with inhomogeneous contrast enhancement. A CT-guided biopsy of the right renal mass
was performed, yielding findings consistent with extramedullary haematopoiesis.
Conclusion: In a patient with known primary myelofibrosis, EMH should be included in the differential diagnosis of a
kidney mass even in cases without other lesions. CT findings of EMH involving the kidneys are essentially
indistinguishable from those of lymphoma. It can be suspected by contrast enhanced sonography and MR for the good
and inhomogeneous enhancement
P66. TESTICULAR CYSTIC LESIONS: US FINDINGS
Katsiba D., Arvaniti M., Xatzipanagiotidis P., Kirintzis P., Karatzia T., Charsoula A.
Department of Radiology, General Hospital of Thessaloniki, “G.Gennimatas”
Objective: To present the aspect of cystic lesions of the testis revealed on US examination.
Method: We retrospectively reviewed US scrotal examinations performed in our department during the years 1996 -
1998 for cystic testicular lesions.
Result: Cystic lesions were observed in 19 patients: testicular cyst (n=2), cystic dilatation of the rete testis (n=5),
intratesticular varicocele (n=1), cystic teratoma (n=2), epidermoid tumour (n=1), cyst of tunica albuginea (n=3),
torsed cyst of tunica vaginalis (n=1), tuberculoma (n=1) and abscess (n=3).
Conclusion: The main difficulty was in differentiating testicular cysts from cystic teratoma. Accurate and definite
diagnosis in all the remaining cases was made sonographically.
P67. IMAGING OF UROLITHIASIS IN COMPUTED TOMOGRAPHY (CT) OF THE ABDOMEN: CORRELATION
WITH ACUTE AND CHRONIC COMPLICATIONS.
Charsoula A., Nalmpantidou C., Smponia A., Mavridou C., Torounidis I., Kakani S., Arvaniti M.
Institution: Department of Radiology General Hospital of Thessaloniki, “G.Gennimatas”
Objective: Urolithiasis is a common problem in adults. Virtually all stones are revealed on CT and complications of
urinary stone disease are better defined by CT than other imaging modalities. We present the various imaging findings
of urinary stone disease as well as major acute and chronic complications.
Method: We retrospectively reviewed abdominal CT examinations performed in our department during the years 2007-
2009 selecting cases with diagnosed urolithiasis. 43 examinations of 41 patients (27 males, 14 females) aged between
23-90 years were included in our study. We identified the location, number and morphology of the calculi and
secondary signs of obstructive uropathy. We moreover evaluated the nephrographic phase images for complications
(inflammatory, scarring, hydronephrosis).
Results: Multiple renal stones were found in 20 patients and staghorn calculi in 11. The majority of stones were found
in the pelvicalyceal system.
In 16 examinations mere stone disease was identified. In 13 examinations acute obstructive uropathy was diagnosed
with accompanying secondary signs such as uretero-pyelo-caliectasis (n=13), pyelitis/ureteritis (n=4), perinephric
stranding (n= 7), nephromegaly (n=4) and urinary extravasation (n=1). Normal nephrogram was found in 33
examinations, striated in 1, rim-nephrogram in 3 and delayed in 1 (5 examinations were performed without
intravenous contrast media). Complicated urolithiasis was reported in 19 examinations: acute (n=4),
xanthogranulomatous (n=2) and chronic pyelonephritis (n=3), abscess (n=3) and chronic hydronephrosis (n=7).
Conclusion: CT is the modality of choice in the investigation of urinary stone disease and its complications, while
simultaneously providing information about renal function and anatomy.
P68. ACQUIRED HEMOPHILIA AND IMAGING TRAPS
Stroumpouli E., Theodosiadis G. * , Nomikou E. * , Kenton T., Daskalaki E., Karouzaki E., Patsourakos N.,
Kavvadias S.
Radiology department, * 1 st Regional Transfusion and Hemophilia Centre, Hippokration General Hospital,
Athens, Greece
Objective: We report a case of a 66-year-old woman with asymptomatic persisting gross hematuria originally
suspected to be due to transitional cell carcinoma of the right renal pelvis.
Method: The patient was referred to our Radiology department due to asymptomatic macrohematuria and anemia. She
underwent intravenous urography and abdomen CT scan with oral and intravenous contrast media.
Results: Both imaging modalities showed a filling defect of the right renal pelvis. The differential diagnosis was
transitional cell carcinoma or renal pelvis thrombus.
The prolonged activated partial thromboplastin time suggested us the possibility of a bleeding cause instead of renal
pelvis neoplasm. The test result for factor VIII inhibitors resulted positive and a diagnosis of acquired hemophilia was
made.
Conclusion: Acquired hemophilia A is rare, but life-threatening disorder caused by autoantibody against factor VIII.
Even if the imaging studies are suggestive of malignancy, radiological findings combined with coagulation screening
tests provide accurate information regarding the final diagnosis and treatment.
154

P69. CYSTIC STRUMA OVARII: IMAGING FINDINGS
Tsili A. C., Argyropoulou M. I., Chaidou A., Ntova I., Tsampoulas K.
Department of Clinical Radiology, University Hospital of Ioannina, Greece
Objective: Struma ovarii is an uncommon ovarian tumor containing thyroid tissue. We present a case of cystic struma
ovarii, evaluated by both multidetector CT (MDCT) and MRI.
Method: A 67-year old woman was referred for a multicystic pelvic mass, discovered incidentally during sonography.
Imaging evaluation included MDCT examination of the abdomen on a 16-row CT scanner, after the i.v. administration
of iodinated contrast material (portal phase). An MRI examination was also performed using T1- T2- and fatsuppressed
T1-weighted sequences, before and after the i.v. administration of gadolinium chelate compounds.
Results: A multicystic left adnexal mass, with hyperdense parts (of 40-50 HU density) was detected on CT
examination. Nodular components, of 80-90 HU density, interpreted as enhancing elements were also seen within the
lesion; therefore the diagnosis of adnexal malignancy based on the CT findings could not be excluded. The nodular
elements had very low signal intensity (similar to flow voids) on T2-weighted images on MRI examination; therefore, a
cystic struma ovarii was included in the differential diagnosis, and this was confirmed on histopathology.
Conclusion: The presence of enhancing solid elements within an adnexal mass might be a specific indicator for the
presence of malignancy on imaging. Based on the MDCT features, the differential diagnosis was difficult in this case,
the mass closely mimicking ovarian cancer. MRI, on the other hand, was more specific. The presence of viscid colloid
material within the mass, exhibiting very low signal intensity on MRI, may be suggestive of a cystic struma ovarii.
P70. FOURNIER DISEASE – CASE REPORT
Barbagianni E 1 ., Georgiadou E 1 ., Smarda M. 3 , Varchalama E 1 ., Komninos C. 2 , Doumanianis G. 2 , Karavirakis
M. 2, Dermitzakis I. 1
1 Radiology department of General Hospital Nikaia – Piraeus “Saint Panteleimon”. 2 Urology department of
General Hospital Nikaia – Piraeus “Saint Panteleimon”. 3 Training personnel of Radiodiagnostic department
of General Hospital Nikaia – Piraeus “Saint Panteleimon”
An unusual case of extensive Fournier Gangrene in an over-weighted patient, without clear aetiological factors.
The extremely over-weighted thirty year old man came to the E.R. with intense scrotal pain.
The clinical examination showed local edema and redness with inferior abdominal parietal expansion.
Among other laboratory examinations, the ultrasound showed great scrotal tunicae thickening, stratification and gas
within the scrotal wall. The imaging features are almost semeiotic of Fournier's gangrene.
The patient was surgically confronted with ablation of necrotic tissues (debridement), fascial dilaceration etc. and with
I.V. administration of antibiotics.
Thirty five days later the patient was discharged from hospital.
Conclusion: The imaging methods, before the final diagnosis including the pathoanatomical examination, offer
important information, apart from the diagnosis itself, for the specification of the extension of the disease, so that
immediate therapeutic decisions, determinant for the patient’s progress, will be taken.
P71. FOURNIER GANGRENE : IMAGING FEATURES
Torrao H., Oliveira C., Kurochka S., Costa C.
Hospital de S. Marcos, Braga, Portugal
Learning Objectives: The purpose of this study is to describe and illustrate the spectrum of radiological findings of
Fournier Gangrene.
Background: Fournier Gangrene is a polymicrobial netrotizing fasceiitis of the gentital and perineal region and
represents an urologic emergency with a potentially hight mortality rate (15-50%). Althought the diagnosis is often
made clinically, imaging findings, especially CT, usually play an important role confirming diagnosis and demonstrating
disease extent.
Imaging findings: The authors retrospectively review all patients diagnosed with Fournier Gangrene in theirs institution
during the last four years and discuss and illustrate this pathology in terms of predisponding factors, clinical
manifestations, anatomic pathaways of spread and imaging characteristics. CT findings will be highlighted, as they
play the central role on diagnosis.
Conclusion: An awareness of the imaging features of Fournier gangrene is imperative for prompt diagnosis and
effective treatment planning.
155

P72. INJURIES OF RENAL VESSELS: IMAGING EVALUATION.
Michaelides M., Bintoudi A., Kotziamani N., Kyriakou V., Stratilati S., Tsitouridis I.
Department of Diagnostic and Interventional Radiology, Papageorgiou General Hospital,
Thessaloniki, Greece
Objective: To describe the imaging findings of the injuries of the renal vessels in cases of closed abdominal trauma.
Method: 11 patients (8 men, 3 women, 17-54 year old, mean age: 33 years) with closed abdominal trauma subjected
to cross sectional imaging. CT was performed in all cases and in some cases US and/or MRI was additionally
performed. CT examinations were performed with a Picker PQ 5000 scanner device before and after administration of
contrast medium and in some cases delayed scans were obtained. Ultrasounds were performed with Siemens Sonoline
G60S device and MRI-MRA examinations were performed with a Siemens Expert Plus 1T device.
Results: In 9 cases renal infarcts were demonstrated, ranging from small peripheral triangular lesions to extensive
infarcts occupying the whole kidney. In 4 cases infarcts were bilateral. In 1 case there was traumatic pseudoaneurysm
of the renal artery, while in the last patient the kidney was completely shattered with active extravasation of contrast
medium during arterial phase. In 3 patients coexisting injuries of other abdominal organs were also demonstrated and
in 1 patient there was traumatic rupture of the thoracic aorta.
Conclusion: Injuries of renal vessels although rare, are sometimes severe forms of renal trauma, especially when
extended and early diagnosis is essential. Contrast enhanced CT is the method of choice in patients with closed
abdominal trauma for demonstration of injuries of the kidneys, of the renal vessels and of other abdominal organs,
while MRI and US may be supplementary performed in selected cases.
P73. MAGNETIC RESONANCE IMAGING IN THE CHARACTERIZATION AND LOCAL STAGING OF
TESTICULAR NEOPLASMS
Tsili A. C. 1 , Argyropoulou M. I. 1 , Tsangou V. 1 , Giannakis P. 1 , Giannakis D. 2 , Koukos S. 2 , Ntasiou I. 1 , Sofikitis
N 2 ., Tsampoulas K. 1
1 Department of Clinical Radiology. 2 Department of Urology, University Hospital of Ioannina, Ioannina, Greece
Objective: The purpose of this study was to assess the role of magnetic resonance (MR) imaging in the preoperative
characterization and local staging of testicular neoplasms.
Method: MR imaging was performed in 33 patients referred for a clinically and/or sonographically detected testicular
mass. A 1.5T unit was used to obtain both T1 and T2- weighted sequences. Intravenous gadolinium chelate was
administered in all cases. We recorded the presence of a lesion and whether the histologic diagnosis of testicular
malignancy could have been predicted, based on MR imaging features. For testicular neoplasms, the local extension of
the disease was studied. Findings of MR imaging were correlated with surgical and histopathologic results.
Results: Histology revealed 36 intratesticular lesions, 28 (78%) of which were malignant (seminomas; n=13,
nonseminomatous tumors; n=13, lymphomas; n=2) and eight benign (tubular ectasia of the rete testis; n=4,
hemorrhagic necrosis; n=2, fibrosis; n=1, granulomatous orchitis; n=1). Regarding testicular malignancies, 13 (46%)
were proved confined within the testis on histology, 12 (44%) invaded the testicular tunicae, and/or the epididymis
and in three (11%) cases invasion of the spermatic cord was found on pathology. The overall accuracy of MR imaging
in diagnosing testicular neoplasms preoperatively was 96.4%. The rate of correspondence about local staging of
testicular tumors between MR imaging and histologic diagnosis was 92.8% (26/28).
Conclusion: Our study shows that MR imaging is a good diagnostic tool for the evaluation of testicular disease. It is a
highly accurate technique in the preoperative characterization and local staging of testicular neoplasms.
P74. MALIGNANT TRANSFORMATION OF AN ENDOMETRIOTIC CYST: IMAGING FINDINGS
Tsili A.C. 1 , Argyropoulou M.I. 1 , Charisiadi A. 1 , Koliopoulos G. 2 , Milona Ch. 1 , Paraskevaidis E. 2 , Tsampoulas K. 1
1 Department of Clinical Radiology.
2 Department of Gynecology and Obstetrics, University Hospital of
Ioannina, Greece
Objective: Malignant transformation is a rare complication of endometriosis. We report a case of a young woman with
a histologically proven ovarian endometrioid adenocarcinoma developed on a pre-existing endometrioma. Multidetector
CT (MDCT) and MR imaging findings, including diffusion-weighted (DW) imaging are presented.
Method: A 30-year old woman was referred for a non-cystic left adnexal mass, discovered incidentally during a
sonographic examination. MDCT examination of the abdomen was performed on a 16-row CT scanner, including both
unenhanced and contrast-enhanced CT scanning. MR imaging examination of the pelvis on a 1.5-T MR unit, using a
pelvic-phased array coil was followed. The protocol included T2, T1-weighted images, before and after the application
of a fat saturation prepulse, and diffusion-weighted (DW) sequences. A dynamic contrast-enhanced fat-suppressed T1-
weighted sequence was also performed.
Results: A large, multicystic left adnexal mass was revealed, composed mainly of hyperdense parts on CT
examination, which were attributed to the presence of hemorrhagic content. The coexistence of a soft-tissue
component, detected with high signal intensity on T2-weighted images and early, strong enhancement on dynamic
post-contrast MR images was strongly suggestive for the diagnosis of malignancy. The soft-tissue part was
hyperintense on DW images, with low ADC values (1.05 x 10-3 mm2/second).
Conclusion: The presence of an enhancing soft-tissue element within a blood-filled ovarian cystic mass is strongly
suggestive of malignancy and ovarian carcinoma arising in an endometriotic cyst should be considered. DW imaging
shows high signal intensity for malignancies, with low ADC values, suggestive of restricted diffusion.
156

P75. MASSIVE OVARIAN TERATOMA IN A YOUNG GIRL WITH INTRACRANIAL HYPERTENSION AS A
PRIMARY MANIFESTATION.
Tsilikas K. 1 , Christianakis E. 2 , Liopiris S. 1 , Zavras N. 2 , Kypriotis D. 1 , Stamou H. 1 , Papadopoulos N. 1 , Evlogias
N. 1 .
Radiology( 1 ) and Pediatric Surgery( 2 ) Department, Pendeli Children’s Hospital, Athens 15236
Objective: Pregnancy has been traditionally regarded as carrying an increased risk of idiopathic intracranial
hypertension (IH) moreover, the relation between IH and obesity has long been recognized. The aim of this report is
to describe the case of a young girl presented with (IH) as an early symptom due to a massive ovarian teratoma, and
to discuss the clinical, imaging and histopathologic data.
Method: An 11-year old girl was admitted with a history of frontal headache, blurred vision, nausea, vomiting and
dyspnoea. Her past history had revealed a gain in weight during the last 2 months along with intermittent abdominal
pain, increasing abdominal distension and constipation. An assessment of visual fields revealed bilateral papilloedema.
The MRI of the brain was normal. The abdominal examination showed a giant palpated mass extending from the pelvis
to the xiphoid process. The x-ray showed a large round low density mass which causes marked elevation of the
diaphragm and displacement of the intestine loops to the periphery. The abdominal ultrasound and MRI showed a
large cystic tumor which compressed the inferior vena cava, the bowel, and the right kidney causing hydronephrosis.
The tumor’s markers (alpha-fetoprotein, human chorionic gonadotropin, CEA) were negative. Thyroid hormones were
normal. The patient was taken to the operating room with the diagnosis of an ovarian tumor complicated by IH.
Results: During laparotomy, a giant cystic tumor 26 x 18 cm in size and weighing 4.6 kg, was completely excised from
the right adnexa. The patient had an uneventful recovery. Headaches were resolved and visual fields were improved.
The pathology showed a grade I ovarian teratoma.
Conclusion: There is an important association between IH, and a giant ovarian tumor although the cause of the
disorder remains unknown, according to the literature.
P76. METASTASES TO THE KIDNEYS: CT AND MRI EVALUATION
Michaelides M., Bintoudi A., Kotziamani N., Kyriakou V., Stratilati S., Tsitouridis I.
Department of Diagnostic and Interventional Radiology, Papageorgiou General Hospital, Thessaloniki, Greece
Objective: To describe the incidence and imaging findings of renal metastases in oncologic patients.
Method: 768 oncologic patients (402 men, 366 women, 13-98 years) underwent cross sectional imaging during follow
up of a known malignancy from January 2006 to December 2008. Unenhanced and contrast enhanced CT
examinations were performed with a Picker PQ 5000 scanner device. MRI examinations (T1WI, Gd-T1WI, T2WI, axialcoronal
planes) were performed with a Siemens 1T device. Diagnosis was based on imaging findings, on previews
exams and on CT guided biopsy in cases with solitary renal lesions.
Results: Renal lesions proved to be renal metastases were demonstrated in 30 patients (3.9%). Primary malignancy
was located in lung in 13 patients (43,3%), in breast in 7 cases (23,3%), in skin (melanoma) in 5 cases (16,6%), in
large intestine in 2 cases (6,6), in testis in 1 case (3,3%), in ovary in 1 case (3,3%) and in stomach in 1 case (3,3%).
28 patients with renal metastases (93,3%) had metastases elsewhere. 19 patients (63,3%) had multiple renal lesions
(bilaterally or unilaterally), while 11 patients (36,7%) had solitary renal lesions.
Conclusion: In most cases, renal metastases are an indicator of advanced disease. Contrast enhanced CT and MRI are
the methods of choice for the demonstration of renal metastases depending on renal function and on department
facilities. In oncologic patients, newly discovered renal lesions should be considered as metastases if multiple and
suspicious for metastases if solitary.
P77. MR IMAGING FINDINGS OF PRIMARY DIFFUSE LARGE B-CELL TESTICULAR LYMPHOMA: REPORT
OF TWO CASES
Tsili A. C. 1 , Argyropoulou M. I. 1 , Maltabe V. 1 , Giannakis D. 2 , Loutsaris K. 2 , Sofikitis N. 2 , Tsampoulas K. 1
1 Department of Clinical Radiology. 2 Department of Urology, University Hospital of Ioannina, Ioannina, Greece
Objective: Testicular lymphoma is a rare malignancy. We report two cases of primary diffuse large B-cell testicular
lymphomas, presented in men over 50 years of age. The imaging findings and the role of MRI in the preoperative
characterization of testicular lymphoma is discussed.
Method: Scrotal MRI was performed on a 1.5-T system, using a surface coil. The protocol included fast spin echo T2-
weighted sequences and both unenhanced and contrast-enhanced spin echo T1-weighted images, before and after the
application of a fat saturation prepulse.
Results: A multinodular intratesticular mass lesion was detected in both cases. The tumor had low signal intensity,
when compared to the contralateral normal testis on T2-weighted images, and enhanced strongly and
inhomogeneously after gadolinium administration. The testicular tunicae were intact. Based on the MRI findings, a
testicular malignancy was strongly suspected. Whole-body computed tomography showed no sites of lymphomatous
involvement or distant metastases. Left radical orchiectomy was performed and a primary diffuse large B-cell testicular
lymphoma was found on histology.
Conclusion: The presence of a relatively hypointense intratesticular mass lesion on T2-weighted images,
demonstrating strong and inhomogeneous enhancement after gadolinium administration in an elderly man should
strongly suggest testicular lymphoma.
157

P78. PACS & HIS IN UROGENITAL RADIOLOGY
Tsantilas X. (1),(2), Anastopoulos I. (1), Tsourouflis G. (1), Matsi S. (3), Vlachos I. (4) , Louizi A. (2) and Malachias G.
(1) .
(1) «Sismanoglio» General Hospital, Radiology Department. (2) University of Athens, Medical School, Medical
(3)
Physics Laboratory. «Eginiteio» University Hospital / Technological Educational Institute of Kalamata,
Department of Health and Welfare Unit Management. (4) «Helena Venizelou» General Hospital, Department of
Biomedical Technology. Institution: «Sismanoglio» General Hospital, Radiology Department.
Objective: The aim of this study is the benefits of a modern Radiological Department of Urology provided by the
installation and implementation of a PACS and HIS System.
Method: This study presents the technical characteristics of both systems, analyzes the diagnostic imaging needs of a
modern Urological Clinic and gradually, gives solutions to Urological diagnostic parameters.
Results: PACS is a high speed network with digital storage units, aiming to the optimal acquisition, display,
management, transmission, storage and archive of digital medical images and reports. HIS is a comprehensive,
integrated information system designed to manage the administrative, financial and clinical aspects of a hospital. The
most important benefits of PACS and HIS systems include reduction or elimination of lost films, reduced retakes due to
poor image quality, significant reduction in storage space and film printing cost, greatly improved communications,
productivity and efficiency between the radiology department and physicians greatly improves because images and
reports are readily available to remote sites, clinics, and hospital wards immediately after acquisition. PACS also
increases data storage safety and data transmission reliability. It decreases time and expenses of patient’s Hospital
treatment and assists patient’s follow-up, keeping the diagnostic absorbed dose as low as reasonably possible.
Conclusion: PACS and HIS systems by improving the working, healthcare and welfare conditions and by decreasing the
cost and time needed assist Strategic information and financial management of a Hospital. Finally, by improving image
quality and accessibility, these two systems benefit scientific search and international collaborations.
P79. PERIRENAL METASTASES FROM LUNG CANCER: CT EVALUATION.
Michaelides M., Bintoudi A., Kotziamani N., Kyriakou V., Stratilati S., Tsitouridis I.
Department of Diagnostic and Interventional Radiology, Papageorgiou General Hospital, Thessaloniki, Greece
Objective: To demonstrate the CT findings of perirenal metastases from lung cancer.
Method: 14 patients (11 men, 3 women, 43-79 year old, mean age: 63,5 years) with histologically proved lung cancer
(5 small cell, 9 non-small cell) and lesions in the perirenal space. Diagnosis was based on CT guided biopsy in 6 cases
and on serial follow up in 8 patients. CT examinations were performed with a Picker PQ 5000 scanner device before
and after administration of contrast medium.
Results: Perirenal metastases were demonstrated during initial diagnosis and staging of lung cancer in 5 patients
(within 3 weeks from the diagnosis) and during follow up in 9 patients. In 5 patients lesions were unilateral (36%) and
in 9 patients bilateral (64%). Size varied from tiny lesions to lesions of 4,2 cm. In most cases lesions enhanced
homogeneously, while in 2 cases lesions demonstrated peripheral enhancement due to central necrosis. In 13 patients
there were metastases elsewhere in the body (92,8%). Perirenal lesions did not infiltrate the kidney in any case.
Conclusion: Perirenal metastases from lung cancer although rare, are a sign of advanced disease in most cases. CT is
the method of choice for demonstrating these lesions during staging. In most cases, CT findings from chest and
abdomen will confirm the diagnosis, while in selected cases, CT guided biopsy may be needed in order to exclude other
retroperitoneal lesions.
P80. RENAL ANGIOMYOLIPOMA: ANALYSIS OF IMAGING AND EPIDEMIOLOGIC FINDINGS IN CASES OF
RUPTURED AND NOT RUPTURED ANGIOMYOLIPOMAS.
Michaelides M., Bintoudi A., Kotziamani N., Kyriakou V., Stratilati S., Tsitouridis I.
Department of Diagnostic and Interventional Radiology, Papageorgiou General Hospital, Thessaloniki, Greece
Objective: To compare imaging and epidemiologic findings of ruptured and not ruptured angiomyolipomas.
Method: 29 patients subjected to CT during 2008. Final diagnosis was based on imaging findings and biopsy results in
selected cases. CTs were performed with a Picker PQ 5000 scanner device and statistical analysis was performed with
SPSS v.14. Differences were considered significant at p

P81. RENAL LYMPHOMA: CT AND MRI EVALUATION
Michaelides M., Bintoudi A., Kotziamani N., Kyriakou V., Stratilati S., Tsitouridis I.
Department of Diagnostic and Interventional Radiology, Papageorgiou General Hospital, Thessaloniki, Greece
Objective: To demonstrate the different patterns of renal involvement in cases of renal lymphoma.
Method: 23 patients subjected to abdominal CT and/or MRI during the last 4 years either during follow up of known
lymphoma or for others reasons. CT examinations were performed with a Picker PQ 5000 scanner device and MRI
examinations were performed with a Siemens Expert Plus 1T device. In cases without history of lymphoma and in all
cases with a solitary renal lession diagnosis was established with CT guided biopsy.
Results: In 19 cases, renal involvement was from Νon-Hodgkin lymphoma (NHL-82,6%) and in 4 cases from Hodgkin
lymphoma (HL-17,4%). In 10 patients (43.4%), lymphoma was manifested with multiple bilateral or unilateral renal
masses (1,3-5,4 cm). In 3 patients (13%), lesions were solitary (3,4-11,6 cm). In 6 patients (26%), lymphoma was
located in the perirenal space with or without retroperitoneal lymphathenopathy. Finally, in 4 patients (17,4%), both
kidneys were enlarged due to diffuse infiltration by lymphoma.
Conclusion: Different patterns of renal involvement from lymphoma may be demonstrated during cross sectional
imaging. Some of them are typical and diagnosis can be established only by imaging findings in cases of known
lymphoma. However, CT guided biopsy is essential in patients with free medical history and in all cases with a solitary
renal lesion, where exact diagnosis of the disease and differential diagnosis from other lesions, more commonly renal
metastases and hypernephroma is necessary.
P82. RETROPERITONEAL FIBROSIS: CT AND MRI EVALUATION.
Michaelides M., Bintoudi A., Kotziamani N., Kyriakou V., Stratilati S., Tsitouridis I.
Department of Diagnostic and Interventional Radiology, Papageorgiou General Hospital, Thessaloniki, Greece
Objective: To demonstrate the CT and MRI findings of retroperitoneal fibrosis.
Method: 19 patients (11 men, 8 women, 22-71 year-old, mean age: 52 years) with retroperitoneal fibrosis, subjected
to abdominal CT and/or MRI from 2004-2008. Diagnosis was based on imaging findings, on clinicolaboratory findings,
on response to steroids and on CT guided percutaneous biopsy or fine needle aspiration (FNA) that was performed in
selected cases (7 patients) either for establishing the diagnosis or for evaluating the activity of the disease. CT
examinations were performed with a Picker PQ 5000 scanner device and MRI examinations were performed with a
Siemens Expert Plus 1T device.
Results: In 16 patients retroperitonreal fibrosis was idiopathic and in 3 patients secondary to other causes. In 12
patients pathologic tissue was localised periaortically, in 6 patients fibrosis extended beyond aortic bifurcation and in 1
patient was located in the presacral space. Obstructive uropathy was caused in 9 patients and in 2 patients thrombosis
of the inferior vena cava was observed. Fibrotic tissue was hypodense to isodense to muscles in unenhanced and
enhanced CT, with low signal intensity in T1WI, low to intermediate signal intensity in T2WI and with various contrast
enhancement depending on the activity of the inflammation.
Conclusion: CT and MRI are the methods of choice for the diagnosis and differential diagnosis of retroperitoneal
fibrosis, the evaluation of the complications and the response to treatment. CT guided biopsy is helpful in selected
cases for the diagnosis and estimation of the activity of the disease.
P83. SEGMENTAL TESTICULAR INFARCTION: SONOGRAPHIC CHARACTERISTICS
Apergis S., Filippiadis D.K., Galiatsatos N., Kartsouni V., Gkeli M.
1st Department of Radiology - Unit of Sonography, “Saint Savvas” Anticancer Oncological Hospital of Athens
Objective: To present the sonographic characteristics of segmental testicular infarction, reporting a case of a 24 yearold
man, with medical record of Hodgkin lymphoma undergoing chemotherapy, presented to the hospital with
testicular pain that had started two days ago.
Method: The patient underwent ultrasound examination (US) with gray-scale, color and power Doppler, in an attempt
to differentiate segmental testicular infarction from epididymo-orchitis, testicular torsion and neoplasia.
Results: The gray-scale US revealled a cuneiform, hypoechoic, well demarcated lesion in the middle of the left testicle,
and in which the color and power Doppler did not show any vascularization.
The hematological and biochemical examinations, including the testicular tumor markers, were inside the physiologic
range.
Due to the results of the US (well demarcated lesion and no vascularization) and biochemical examination, the
segmental testicular infarction dominated the differential diagnosis. The follow up US after 4 weeks showed a
reduction in the size of the alteration and maintenance of its avascular character, findings which confirmed the initial
diagnosis. The damage was restored after the passage of couple months from the initial diagnosis.
Conclusion: The segmental testicular infarction is an infrequent clinical entity and should be differentiated from
testicular torsion, which is a urgent surgical situation. The diagnosis can be obtained from the findings of the US,
which should be supplemented with color and power Doppler. Less than 50 cases of a segmental testicular infarction
have been reported up to day, but it is the first case in a patient with Hodgkin’s lymphoma under chemotherapy.
159

P84. SPONTANEOUS RUPTURE OF A LARGE RENAL ANGIOMYOLIPOMA -CASE REPORT-
Nikolić O., Njagulj V., Stojanovic S., Vucaj Cirilovic V., Petrovic K., Basta Nikolic M..
Center for radiology, Clinical center of Vojvodina.
Objectives: To illustrate the value of key imaging features in the diagnosis of acute bleeding of renal angiomyolipoma
(AML).
Renal AML are composed of abberant or anomalous blood vessels, smooth muscle, and fat in various quantities. The
incidence is 0,3-3%, with a clear female predominance.
Spontaneous rupture of an AML is a serious complication and one of the two most common causes of perirenal
haemorrhage.
Method: A 56 year old woman presented at the emergency department with right renal colic. She was afebrile and
hemodynamically stable.
Urinalysis showed microhematuria and all other laboratory results were within normal ranges.
Abdominal ultrasound and MSCT were performed.
Result: US findings were nonspecific, right kidney contour was irregular and protruded. There was also a small amount
of fluid in Douglas pouch. MSCT revealed right kidney mass with the presence of fat (ie, negative attenuation values)
and active bleeding from an angiomyolipoma.
Surgery was performed to remove the angiomyolipoma, and confirmed the diagnosis of active arterial bleeding.
Conclusion: Contrast enhanced multiphasic MSCT is the method of choice in imaging and characterizing renal masses.
MSCT allows detection and characterization of renal masses and detection of (acute) complications, including active
bleeding. Angiography with embolisation is the preferred therapeutic approach. Prophylactic embolisation or surgery is
suggested in larger angiomyolipmas (> 4 cm diameter) with aberrant intralesional vessels.
P85. SPONTANEOUS RUPTURE OF THE URETER AND INTERVENTIONAL MANAGEMENT: A CASE REPORT.
Kontaki T.¹, Sidiropoulou M.¹, Aggelopoulos A.², Mamalis V.¹,. Pozoukidis C ¹.
¹: Department of Radiology and ²: Department of Urology, “Mamatseio” General Hospital, Kozani, Greece.
Objective: Spontaneous rupture of the ureter (SRU) is a rare condition. “Spontaneous” implies that the rupture is not
induced by recent iatrogenic manipulation, external trauma, degenerative kidney disease, urography with external
impression, or previous surgery. SRU is predominantly the result of calculus disease.
We report the MDCT findings in a case with spontaneous rupture of the left ureter secondary to a ureteral calculus,
presenting as a perinephric urinoma, with emphasis on follow-up imaging findings of interventional management.
Method: A 68-year-old man without history of abdominal surgery or trauma, was admitted for severe left flank pain,
nausea, and vomiting. Three days before, he was diagnosed with ureteric colic.
Results: Plain film of abdomen showed a radiopaque nodule near the left ureterovesical junction.
Abdominal CT revealed a diffuse fluid collection in the left perirenal space, and a calculus in the distal left ureter.
Delayed scan after contrast material injection showed opacification of the fluid collection (urinoma), and the site of
ureteral rupture.
The patient was managed with medication and placement of a double J ureteric stent for a month. Follow-up CT exams
performed before and after stent removal showed complete resolution of the urinoma and the disappearance of the
stone.
Conclusion: It is important to distinguish extremely uncommon SRU from the much commoner condition of
extravasation from forniceal rupture.
The symptoms of the former are always severe and drainage or surgical intervention are often necessary, while the
symptoms of the latter are usually mild and supportive management is the treatment of choice.
P86. T1 WEIGHTED SEQUENCE WITH STEADY STATE PRECESSION : PREOPERATIVE AND
POSTOPERATIVE MRI DETECTION OF PERI-PROSTATIC NEUROVASCULAR BUNDLE (NVB)
REGION CANCER INFILTRATION AND ASSESSMENT OF ITS INTEGRITY AFTER NERVE-SPARING
RADICAL RETRO-PUBIC PROSTATECTOMY.
Panebianco V., Lisi D., Biondi T., Zaccagna F., Vergari V., Passariello R.
Dept of Radiological Sciences, Sapienza University of Rome
Object: To assess vascular features about peri-prostatic neurovascular bundle region, to staging pre-surgery prostate
cancer infiltration and evaluation of anatomical integrity after nerve-sparing radical retro-pubic-prostatectomy.
Method: Thirty-four patients were submitted to MRI exam using GRE T1 sequence with steady state precession on
axial plane, before and after nerve-sparing radical retro-pubic prostatectomy, centered on prostatic fossa and covering
entire NVBs course ( TR: 7.57, TE: 2.43 ,TA: 4.30 Slice Thickness: 1 Slice for slab: 72, FOV 301 x 100 ) . The images
were obtained using a 1,5 T magnet after intravascular media contrast administration (Gadofosveset trisodium-
Vasovist) blood pool contrast agent). .
Results: Images obtained by the use of this sequence, provide an entire view of the NVB vascular component integrity
and course. Furthermore, surgical lesions or cancer infiltration of the NVB could be detected in a pre-postoperative
MRI study.
Conclusion: To use the sequence dedicated is new approach for identification and evaluation of neurovascular bundle
in the staging of prostate cancer and possible dissect of NVB during nerve- sparing after retro-pubic prostatectomy.
160

P87. THE ROLE OF INTERVENTIONAL RADIOLOGY IN THE MANAGEMENT OF PATIENTS WITH END-
STAGE RENAL DISEASE (ESRD)
Tisnado J., Tisnado J., Sydnor M.K., Komorowski D.J.
Department of Radiology, Division of Vascular and Interventional Radiology, MCV Hospitals/VCU Medical
Center, Richmond, Virginia, 23298, USA
Objective: Every year there are 200 new patients with End-Stage Renal Disease (ESRD) per 1,000,000 in USA. The
population at risk is estimated at 50-60,000 patients a year. Those patients receive a kidney transplant or
hemodialysis (HD) via an arteriovenous fistula (AVF) or a central catheter. Complications of these two managements
are common. We are pioneer in the world renal transplantation. We have a vast experience in the management of
those complications.
Method: Interventional radiology (IR) plays an important role in the management of patients with ESRD with two types
of interventions:
Placement and management of complications of HD accesses: AVF and central and peritoneal catheters
Management of complications of renal transplantation.
Complications of renal transplantation are classified in: vascular, urologic, and iatrogenic. We present the IR
management of complications with many examples of most possible events.
The dual role of IR in insertion of central and peritoneal catheters and management of complications of central
catheters and AVF are illustrated with many examples.
Results: All IR procedures are safe, quick, successful, and cost effective in the long-term management of patients with
ESRD.
Conclusion: IR plays an important role in the management of ESRD with:
Insertion of central and peritoneal catheters
Management of complications of central catheters and AVF
Management of complications of renal transplantation.
IR service must be available in institutions performing renal transplantation and/or placing AVF or central catheters for
HD in patients with ESRD.
P88. THE ROLE OF INTERVENTIONAL RADIOLOGY IN THE TRANSPLANTED KIDNEY
Tisnado J., Sydnor M.K., Prasad U. R.
MCV Hospitals/VCU Medical Center, Richmond, Virginia USA
Objective: Renal transplantation, the definitive management for end-stage renal disease, is effective, safe, and
widespread. As more transplants are done, more associated problems and complications are found. We are pioneers in
renal transplantation in the USA and the world; therefore, we have a vast experience on the topic.
Method: Few comprehensive reviews are available. We review our experience of most complications including vascular
and non-vascular. Vascular: PTA of renal artery stenoses, stenting of renal arteries, arterial and venous thrombolysis,
placement of filters in the IVC and iliac veins, embolization of AVFs due to kidney biopsy, management of lymphoceles,
and others. Non-vascular: Percutaneous nephrostomy, internal and external urinary drainage, dilatation of pelvic and
ureteral strictures, stenting of ureters, drainage of fluid collections, needle aspiration and core biopsies, and others.
Results: All procedures are successful in managing minor and major complications of renal transplantation.
Conclusion: Interventional radiologists (IR) are the most important members of the team managing renal transplant
complications. The procedures are simple, quick, safe, effective and cost-effective. Surgery must be avoided, if
possible. The IRs are available 24 hours a day, 7 days a week. Every effort must be made to salvage a transplanted
organ.
P89. URINOMA – CASE REPORT AND REVIEW OF THE LITERATURE
Nikolopoulos P., Lagoudaki E., Giaka E.
Radiology Department of Cephalonia General Hospital
Objective: Τo highlight the value of CECT scan with delayed imaging in the diagnosis of urine leaks, and to make a
short review of the literature.
Method: A 43year old male presented to the emergency department of our hospital with colic pain in the left flank
which had started prior to 48h and was now radiating to the left inguinal region. Patient had no recent history of
trauma and good vital signs. Clinical examination revealed tenderness in the left flank. Biochemical examination
revealed slightly elevated serum creatinine. Blood picture revealed mild neutrophilia. Urine culture was sterile.
Ultrasound, NECT and CECT scan of the abdomen were performed.
Results: Ultrasound revealed left perirenal fluid collection and ipsilateral mild hydronephrosis. NECT scan of the
abdomen revealed a calculus at the left ureterovesical junction and fluid in the left paracolic sulcus. The presence of
fluid collection with water attenuation at the left perirenal space was confirmed. CECT scan with delayed imaging
revealed the extravasation of iodinated urine entering the urinoma.
Conclusion: Urinomas may be confined, encapsulated fluid collections or may manifest as free fluid. Urine leaks from
the kidney, ureter, bladder and urethra most commonly result from trauma, downstream obstruction of the urinary
system (e.g. ureteral stone, pelvic mass), or iatrogenic injury. CECT with delayed imaging (delayed phase images
obtained 5-20 min after contrast material injection), CT cystography, and retgrograde urethrography (depending on
the site of the urine leak) are the primary diagnostic imaging modalities used currently.
161

P90. URINOMAS: CT EVALUATION.
Michaelides M., Bintoudi A., Kyriakou V., Kotziamani N., Stratilati S., Tsitouridis I.
Department of Diagnostic and Interventional Radiology, Papageorgiou General Hospital, Thessaloniki, Greece
Objective: To demonstrate the CT findings of urine leaks and urinomas.
Method: 41 patients (22 men, 19 women, 17-82 year old, mean age: 51 years) subjected to CT from 2004-2008 with
a retroperitoneal liquid collection proved to be an urinoma. CT examinations were performed with a Picker PQ 5000
scanner device before and after administration of contrast medium, while delayed scans were performed in selected
cases.
Results: The cause of urinoma was increased pressure due to obstruction (calculi, tumor, extrinsic pressure) in 21
patients (51%), iatrogenic injury in 12 patients (29%) and closed abdominal injury in 8 patients (20%). Urine leakage
was localized in the pelvicaliceal system in 24 cases (58%), the ureter in 10 cases (24%) and the urine bladder in 7
cases (17%). Collection size varied and diagnosis of the nature of the collection was based on history, on
clinicolaboratory findings, on delayed CT scans and on CT guided fluid aspiration in selected cases. Treatment was
conservative in 34 cases, while non conservative treatment (ureteral stent, percutaneus drainage, surgery) was
performed in 7 patients either due to extensive renal trauma or due to failure of conservative treatment.
Conclusion: CT is the method of choice for the diagnosis and follow up of urinomas, for the diagnosis of the underlying
cause of urine leakage and for the decision or modification of the treatment plan, while in selected cases CT can guide
fluid aspiration or drainage.
P91. WHICH ADNEXAL MASSES ARE DIFFICULT TO CORRECTLY DIAGNOSE AS BENIGN OR MALIGNANT
ON THE BASIS OF MR IMAGING FINDINGS
Rha S.E. 1 , Shin Y.R. 1 , Hwang S.S. 2 , Oh S.N. 1 , Kim Y.S. 1 , Jung S.E. 1 , Byun J.Y. 1
1 Department of Radiology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea.
505 Banpodong Seochogu, Seoul, South Korea. 2 Department of Radiology, St. Vincent Hospital, College of
Medicine, The Catholic University of Korea.
Purpose: To evaluate which adnexal masses are difficult to correctly diagnose as benign or malignant on the basis of
MR imaging findings
Materials and methods: From Aug 2003 to Dec 2008 at our institution, 1820 patients underwent pelvic MR imaging for
the evaluation of the pelvic mass. We retrospectively reviewed the prospective original clinical reports of the pelvic MR
images and correlated with the pathologic results in 1026 patients with pathologically proven adnexal mass. On the
basis of original clinical reports, we classified the lesion to be correctly or falsely diagnosed for benign or malignant
mass.
Results: A total of 1042 lesions were recruited, which included 947 benign masses and 95 malignant masses. There
were 42 falsely diagnosed lesions (4%) for benign or malignant masses. The final pathologic diagnoses of 23 benign
lesions (2%), which were preoperatively misdiagnosed as malignant tumor, were mucinous cystadenomas (n=5),
functional cysts (n=4), mature cystic teratomas (n=4), endometrial cysts (n=3), cystadenofibroma (n=1),
fibrothecoma (n=1), myoma (n=1), serous cystadenoma (n=1), struma ovarii (n=1), tuboovarian abscess (n=1), and
periappendicial abscess (n=1). The final pathologic diagnoses of 19 malignant lesions misdiagnosed as benign lesions
were mucinous cystadenocarcinomas (n=11), serous cystadenocarcinomas or serous surface papillary
cystadenocarcinomas (n=5), tubal cancer (n=1), immature teratoma (n=1), and endometrioid carcinoma (n=1).
Conclusion: Mucinous tumors are the most difficult adnexal masses to correctly diagnose as benign or malignant.
Adnexal masses with small solid portions, hemorrhagic contents, or multilocular cysts make it difficult to determine
malignity of tumors.
P92. RENAL INFARCTION IN PATIENT WITH ENDOCARDITIS
Paisios O 1 ., Hesketh G 1 ., Galani G 1 ., Tserpes N 1 ., Kamatsos I 1 ., Poulimenos L 2 ., Anastasopoulou T 2 ., Katsou
G 1 .
1 Computerised Tomography Department “Aesklipieio Voulas” General Hospital. 2 Cardiology Department
“Aesklipieio Voulas” General Hospital
Objective: To present an interesting case of acute renal infarction in a patient with endocarditis.
Case Report: A 47 year old female patient presented in our emergency room with fever (up to 38.5° C for the last 5
days) and a right sided flank colic which began 3 days earlier and showed no response to analgesics. The lab results
showed anaemia (Hct 31%, RBC 3.22 M/uL) and a large increase in LDH (2222 u/L). While during imaging workup the
abdominal ultrasound was negative and an abdominal CT scan without contrast medium showed an extensive
hypodense area of the right kidney. A contrast-enhanced CT scan showed an extensive area of the right kidney devoid
of perfusion. A finding suggestive of renal infarct. The patient was hospitalized and later diagnosed and treated for
infective endocarditis.
Discussion: Patients with acute renal infarction present with persistent abdominal, flank or low-back pain. Most
patients have a history associated with a high risk of thromboembolism (in our case infective endocarditis). A very
large increase of LDH (usually >5 times upper limit normal) is the most sensitive marker. Lab results may also show
elevated WBC, CPK, AST, Creatinine with gross or microscopic haematuria. Contrast-enhanced CT is the non-invasive
standard for imaging acute renal infarction.
Conclusion: Acute renal infarction is not as rare as previously believed and is often misdiagnosed. Therefore patients
presenting with unilateral flank pain and elevated LDH levels, with an increased risk for thromboembolism, should
arouse the suspicion of renal infarction and should be treated immediately.
162

P93. RENAL HAEMORRHAGE AFTER EXTRACORPOREAL LITHOTRIPSY
Paisios O 1 ., Hesketh G 1 ., Galani G 1 ., Kolaiti F 2 ., Tserpes N 1 ., Madenlioglou E 1 ., Volanis D 3 ., Katsou G 1 .
1 Computerised Tomography Department “Aesklipieio Voulas” General Hospital. 2 Radiology Department
“Aesklipieio Voulas” General Hospital. 3 Urology Department “Aesklipieio Voulas” General Hospital
Objective: Presentation of renal haemorrhage as one of the most serious, albeit, relatively infrequent complications
after extracorporeal lithotripsy.
Case Report: A male patient of 64 years, arrived in the emergency department of our hospital reporting a persisting
pain of the left flank not responding to analgesics. The patient had background of nephrolithiasis of the left kidney and
had undergone extracorporeal lithotripsy the morning of the same day. Laboratory examinations showed a fall in
hematocrit and microscopic haematouria. During standard imaging work-up (abdominal radiograph, abdominal
ultrasound and abdominal computerised tomography) the patient showed a renal haematoma of the left kidney. The
patient was admitted with stable vital signs and was treated conservatively.
Discussion: One of the most serious but relatively infrequent complications (0.28 – 4.1%) following extracorporeal
lithotripsy is a renal haematoma. Risk factors constitute arterial hypertension, the atherosclerosis of the renal
vasculature, coagulation disturbances, anticoagulates, advanced age, coronary disease and obesity. Treatment is, for
the most part, conservative. Less often nephrectomy may be required. In a few cases, complications may result in
death.
Conclusion: When patients present with flank pain that develops after extracorporeal shockwave lithotripsy, physicians
should bear in mind, aside from renal colic, the possibility of kidney injury and should not hesitate to use their imaging
arsenal in addition to closely observing the patient for clinical signs suggestive of hypovolaemic shock.
P94. RENAL VASCULAR INJURIES: SUPERSELECTIVE EMBOLIZATION AS AN ALTERNATIVE METHOD TO
SURGERY. OUR TEN-YEAR EXPERIENCE.
Gargas D., Prantzos T., Ioannidis J., Kornezos J., Mourikis D., Chatziioannou A., Gouliamos A..
Department of Radiology, Areteion Hospital, University of Athens.
Objective: Evaluate the results of superselective embolization in the treatment of renal vascular injuries and its
possible effects on renal parenchyma and function.
Methods: Nine consecutive patients (six males, three females) underwent embolization to treat bleeding from renal
vascular injuries between January 1999 and December 2008. Angiography depicted a pseudoaneurysm (PA) in three
patients ,(PA) with arteriovenous fistula (AVF) in one patient, a true aneurysm in the renal hilum in another, active
extravasation in three patients and a renal tumor in the last patient. Superselective catheterization was achieved using
a 5F catheter in six and coaxial microcatheter in the remaining three cases. All lesions were successfully embolized
with 0,035” or 0,018” coils, except the renal tumor where particles were used.
Results: In all cases bleeding was effectively controlled in a single session. None of the patients developed procedurerelated
impairment of renal function ,hypertension or abscess.
Conclusion: Superselective embolization may be used for effective, minimally invasive control of renovascular
bleeding.
P95. A USEFUL ADDITION TO MRU IN CHILDREN WITH URINARY TRACT INFECTION
Raissaki M., Matalliotaki P., Maris Th., Bitsori M., Galanakis E., Gourtsoyiannis N.
Radiology Department, University Hospital of Heraklion, University of Crete, Greece.
Purpose: To demonstrate the usefulness of post gadolinium HASTE STIR sequence in children with UTI undergoing
MRU.
Materials And Methods: Five (5) children, aged 12 days to 12 years (mean 4 years), underwent MRU within one week
following the diagnosis of UTI. Utrasonography with power doppler diagnosed acute pyelonephritis in 3 and fused
pelvic kidneys in 1. Static MRU with SSTSE HASTE and HASTE STIR sequences following furosemide administration
intravenously was performed, followed by dynamic MRU coupled with VIBE and HASTE STIR sequences post
gadolinium administration intravenously.
Results: 5 infectious lesions were found in total, based on the US and MRI results, 4 acute pyelonephritis and one
abscess. 1 lesion was missed by ultrasonography, 3 were missed by pre-contrast MRU sequences and 1 by post
gadolinium VIBE sequences. All 5 oedematous-ischemic areas of renal parenchyma were seen as areas of increased
signal intensity in the HASTE STIR post gadolinium administration sequences, while normal parenchyma exhibited
homogeneous signal drop due to the T2 effect of gadolinium. Lesions were more conspicuous in this sequence
compared to the VIBE post gadolinioum sequence, especially in the child with fused pelvic kidneys.
Conclusion: When performing MRU in children with a recent UTI, the addition of HASTE STIR sequence following
gadolinium administration intravenously may reveal unsuspected lesions of acute pyelonephritis and add confidence to
the diagnosis.
163

P96. THE CONTRIBUTION OF MRI IN THE DIAGNOSIS OF COMMON AND UNCOMMON, CYSTIC ADNEXAL
LESIONS.
Papadopoulou P. 1 , Kalaitzoglou I. 1 , Michailides N. 1 , Haritanti A. 2 , Goulis D. 3 , Rousso D. 4 , Dimittriadis A.S. 2 .
1 Asklipios Magnitiki Tomografia.
2 Radiology Department AHEPA University Hospital.
3 4th University
4
Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki. 3rd University
Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki
Objectives: To present characteristic examples of cystic adnexal pathology, illustrating the differentiating features.
Method: From our database of 284 adnexal lesions in 188 patients, we selected and present representative cases of
common and uncommon cystic lesions with emphasis on the characteristic imaging findings and differential diagnosis.
The size, morphology, signal intensity, presence of fat or hemorrhage, solid components, nodularity, septa and
contrast enhancement is recorded in each lesion.
Results: Endometriomas have characteristic signal intensity in T1 W and T2 W images. Functional and hemorrhagic
cysts in premenopausal women are easily recognized. Benign cystadenomas are unilocular or multilocular thin wall
cysts. Mature teratomas contain fat, while dilated fallopian tubes have characteristic morphology. Common features in
malignant and borderline tumors are solid nodules and thick septa. Endometrioid carcinoma and clear cell carcinoma
are related to endometriosis. Secondary findings as ascitis, lymph node involvement or omental cake indicate
malignancy.
Conclusion: Many cystic adnexal lesions have pathognomonic appearance, while others are more challenging. The
primary goal of imaging is to differentiate benign from malignant adnexal disease.
P97. SOLID TUMORS IN THE FEMALE PELVIS: MR IMAGING DIFFERENTIAL DIAGNOSIS.
Papadopoulou P. 1 , Kalaitzoglou I. 1 , Michailides N. 1 , Haritanti A. 2 , Goulis 3 D., Rousso D. 4 , Dimittriadis A.S. 2 .
1 Asklipios Magnitiki Tomografia.
2 Radiology Department AHEPA University Hospital.
3 4th University
4
Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki. 3rd University
Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki
Objectives: To review the imaging characteristics and present a differential diagnosis for ovarian and extraovarian,
benign and malignant, female pelvis solid masses.
Method: We retrospectively reviewed 98 female pelvis MRI examinations preformed for further characterization of
sonographically indeterminate solid pelvic masses. MR imaging protocol included axial T1 W and T2 W fat sat images,
coronal T2 W fat sat images, sagittal T2 W images, axial T1 W fat sat images before and after contrast administration
or 3d SPGR images with dynamic contrast administration at 1.5 T. Results were confirmed either with laparoscopy or
with follow up imaging.
Results: Fibromas and thecomas are well demarcated and characterized by low signal intensity on T2 W images due to
the presence of dense fibrous tissue. Granulosa cell tumors are predominantly solid, with cystic, often hemorrhagic
components. Malignant epithelial tumors may appear predominantly solid and are characterized by intermediate T2
signal intensity, irregularity and often invasiveness or secondary signs of malignancy as ascitis and lymph nodes.
Metastatic tumors are often bilateral and may mimic either epithelial cancer or bilateral fibrothecomas. Rare tumors in
the female pelvis include sarcomas and we present a case initially diagnosed as ovarian fibroma. Last but not least, we
present uterine leiomyomas, which present a relatively common diagnostic dilemma resembling either ovarian
fibromas, when pedunculated, or more rarely, cystadenocarcinomas when very large and degenerated.
Conclusion: Solid ovarian tumors can be benign or malignant. Careful analysis of the findings in MRI leads to the
correct diagnosis most of the times.
P98. MDCT UROGRAPHY (MDCTU): PROTOCOL AND IMAGING FINDINGS
Foufa K., Tzovara I., Alexopoulos T., Stamoulis E., Gianoulakos N., Ziogana D., Tachtaras A., Maniatis V.
Diagnostic Imaging Department, IASO General Hospital, Holargos-Athens
Objective: To describe the protocol we use in our department. To present the spectrum of imaging findings in MDCTU.
Methods: During the past year, we have performed more than 300 MDCTU examinations.
The examinations were performed in 4- or 64- slice CT scanners (SOMATOM Plus 4, Volume zoom, Siemens, Germany
and AQUILION 64, Toshiba, Japan).
We are using a two-phase protocol, with split-bolus technique.
An unenhanced phase from the kidneys to the pubic symphysis is followed by the intravenous infusion of 50 ml of
nonionic contrast material and 2 min later, a second infusion of 80 ml contrast .
Post – contrast scanning includes only one “nephropyelographic” phase that is obtained 3 min after completing
contrast medium administration.
Post processing images are generated from the original axial data set.
Indications for MDCTU were: acute flank pain, hematuria, suspected renal inflammatory disease, evaluation of a
known renal tumour, vascular disease and trauma.
Results: Findings in cases of colic and hematuria include: urinary tract calculi, delayed corticomedullary/excretory
phase, hydronephrosis, hydroureter, rupture of the collecting system.
MDCTU accurately diagnoses congenital anomalies, focal pyelonephritis, traumatic lesions and renal vessels’
pathology.
In cases of urinary tract neoplasm MDCTU can be used as a “one-stop” imaging test.
Conclusions: MDCTU is a promising diagnostic examination of the urinary tract because it offers all the clinically critical
information.
Multiplanar reconstructions are not only clinicians’ friendly but also provide further crucial information.
MDCTU is better performed using 64 instead 4 – slice CT scanner.
Our protocol is designed to reduce patient radiation dose without missing diagnosis.
164

P99. DETECTING RENAL INFECTION BY TC99M CIPROFLOXACIN SCAN : A PICTORIAL ASSAY
Hazarika S. 1 Das T. 2 , Bhuyan U. 3 , Baruah S.K. 3 , Saikia K. 3 , Rajeev T.P. 4 , Baruah S.K. 4
Radiology 1 & Nephrology 2 Departments, International Hospital, Guwahati Nucleomed nuclear
Imaging Division 3 , Guwahati, Urology4 department Gauhati Medical College, Guwahati, Assam, INDIA,
781005
Aim: To discuss imaging appearance of Renal infection in Tc 99m tagged Ciprofloxacin scan done for detection of focus
of infection in cases of PUO.
Materials & Method: Acute renal infection was picked up by Ciprofloxacin scan done as a part of work up for
undiagnosed cases of fever in 2007-2008. All these cases were routinely investigated by baseline Lab tests,
Ultrasonography etc.
15 mCi Ciprofloxacin tagged 99m Tc was injected intravenously and whole body images were obtained at 20 min,
2,4,24 & 48hrs.
Results: The positive patients showed abnormally high tracer concentrations beyond 24 hrs and till 48 hrs in kidneys
which were subsequently confirmed by CT imaging as cases of Acute pyelonephritis.
This paper is discussing the pictorial appearances of Acute Renal infection in Tc Ciprofloxacin scan in two patients with
correlative CT images of the kidneys. The Paper will also illustrate another case negative for any detectable infective
focus in Tc Ciprofloxacin scan for reference.
Conclusion: Greatest utility of this technique of imaging might be in following up of cases with Ac infection. Experience
of other authors with bone and joint infection warrants further evaluation of the utility of Tc Ciprofloxacin imaging in
Acute renal infection by a systematic and larger study.
P100. THE TREATED KIDNEY: COMPUTED TOMOGRAPHY (CT) AND MAGNETIC RESONANCE (MR)
PATTERNS
Cardone G., Mangili P., Guazzoni G., Balconi G.
Department of Radiology, San Raffaele Turro hospital, 20127 Milano, Italy
Objective: 1) To illustrate the most frequent CT and MR imaging appearance of the treated kidney, after surgical and
ablative treatments.
2) To review the most common postoperative complications and the most frequent recurrence patterns after renal
surgical and ablative treatments.
3) To evaluate the most effective CT and MR imaging examination techniques in the evaluation of treated kidney.
Method: Surgical and ablative treatments for renal masses are total nephrectomy, partial nephrectomy,
radiofrequency ablation and cryoablation. CT and MR are commonly used for the follow-up of patients treated for renal
masses. We reviewed 349 cases of CT and MR examinations of patients with renal masses treated with total
nephrectomy, partial nephrectomy, renal cryoablation and renal radiofrequency ablation, to illustrate CT and MR
imaging patterns of the treated kidney, most common postoperative complications and most frequent recurrence
patterns.
Results: The most important parameters in the evaluation of the treated kidneys were the lack of increase in size and
the hypovascularization of treated areas. The most frequent post operative complications were haematomas, fluid
collections and collecting system fistulas. Most frequent patterns of local recurrence were increase in size and
vascularization of the scar. The most effective techniques were multiphasic acquisition (CT) and TSE T2w and dynamic
ce-FS-GRE T1w sequences before and after digital subtraction technique (MR).
Conclusion: CT and MR were effective imaging techniques in the immediate, short and long-term follow-up of the
kidney following various kidney-directed terapies.
P101. CT AND MRI OF THE ADRENAL MASSES
Gokan T., Ohgiya Y., Munechika J., Hirose M.
Department of Radiology, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo,
Japan
Purpose: The widespread use of CT and MRI has increased the detection of incidental adrenal masses. Characterization
of these adrenal masses are important for decision of the management.
To present CT and MR imaging features of adrenal masses and the characteristic imaging findings that will help to
make the differential diagnosis are reviewed.
Result: CT and MRI features of uncommon adrenal masses including hemangioma, ganglioneuroma, myelolipoma,
collision tumor, tuberculosis granuloma etc. as well as common adrenal masses including adenoma, metastasis etc.
are shown. Characteristic imaging findings could provide some clues to make correct diagnosis.
Conclusion: Understandings of CT and MR features of these adrenal masses can help narrow down the differential
diagnosis.
The cases will be presented in a quiz format. Key differential diagnostic points will be highlighted in the discussion of
each case. The list of cases includes:
-malignant adrenal tumor including adrenal carcinoma, metastases, pheochromcytoma etc.
-benign adrenal tumors including adrenal adenoma, hemangioma, ganglioneuroma, myelolipoma, collision tumor etc
-other adrenal masses including tuberculosis granuloma, hematoma, etc
-adrenal psudotumor due to various cause will be also shown.
165

P102. PHASED–ARRAY COIL MR IMAGING IN THE EVALUATION OF SEMINAL VESICLES IN PATIENTS
WITH PATHOLOGICAL SEMEN ANALYSIS. INITIAL EXPERIENCE
Ocantos J., Sabluk L., Loor Guadamud G., Pietrani M., Seehaus A., Garcia Monaco R.
Hospital italiano de Buenos Aires, Argentina
Objetive: To evaluate the usefulness of magnetic resonance imaging (MRI) witch Phased–array coil in the evaluation of
seminal vesicles in patients with low ejaculated volume and /or hemospermia.
Method: Between June 2007 and December 2008, 34 male patients (mean age: 36,4 years) with low ejaculate volume
(n=31), hemospermia (n=2) or both (n=1) , confirmed by the seminal study were prospectively studied in a highresolution
magnetic resonance (1.5T) with pelvic phased-array coil. Examination was focused on seminal vesicles (SV).
Axial and sagittal T2-weighted and coronal oblique plane T1, T2 and T2-weighted Fat Sat, orientated the ejaculatory
ducts mayor axis were performed. 3D volume T2- weighted images were obtained for vas deferens multiplanar
reformation.
Results: Pathological findings were detected in 23/34 patients (67,65%); seminal vesicles hypoplasia (n=12),
agenesis/atrophic of SV (n=5), SV dilatation (n=5), changes in the signal intensity within the SV (n=5), midline cyst
(n=5), parasagittal cystic (n=1) ejaculatory ducts agenesis/atrophy (n=10), ejaculatory ducts dilation (n=2) , vesicles
or ducts calculi (n=4), and ectopic ureterocele in one patient.
Conclusion: MRI showed pathological findings in accordance to the clinical symptoms in a large number of patients. It
is a non-invasive method that allows, through its high-level tissue discrimination, the study of seminal vesicles,
ejaculatory ducts and vas deferens in a single procedure while highlighting associated lesions. Therefore, seminal
vesicles Phased–array coil MR could avoid an invasive study such as the transrrectal ultrasound or MR with endorrectal
probe.
P103. THE ULTRASOUND CONTRAST AGENT IN PARENCHYMAL RENAL LESION EVALUATION: IS THERE A
REAL GAIN OUR EXPERIENCE
Regine G., Atzori M., Parola C., Pascoli S.
Department of Radiology, S. Camillo- Forlanini Hospital, Rome, Italy.
TO EVALUATE THE DIAGNOSTIC ACCURACY OF USCA IN THE EVALUATION OF PARENCHYMAL RENAL NEOPLASTIC
OR NOT LESIONS.
BETWEEN JUNE 2007 AND AUGUST 2008 82 PATIENTS WITH CLINICAL (HEMATURIA/POSITIVE FACTOR CANCER
RISK) OR ULTRASOUND SUSPICIOUS OF RENAL PARENCHYMAL LESIONS WERE EVALUATED WITH USCA. THE
EXAMINATION TECHNIQUE WAS: 2,5 ML OF SULFUR HEXAFLUORIDE MICROBUBBLES WERE ADMINISTRATED IN A
SINGLE BOLUS, CPS SOFTWARE MODE SEQUOIA 512 (SIEMENS) WITH LOW MI. WE PERFORMED AN ARTERIAL
PHASE AND A LATE PHASE . THE SAME PATIENTS WERE UNDERWENT TO MULTIPHASIC MDCT OR MR TO CONFIRM
DIAGNOSITC USCA FINDINGS.
THE USCA DETECTED 28 SIMPLE CYSTS, 17 COMPLEX CYSTS ( WITH DIFFERENT BOSNIAK CLASSIFICATION
DEGREE), 12 RCC, 3 ONCOCYTOMA, 2 ABSCESS, 4 HYPERTROPHIED COLUMN OF BERTIN, 2 ANGIOMYOLIPOMAS, 4
PARENCHYMAL INFARTCS AND 10 CASES NOT CONCLUSIVE (SAME DIAGNOSTIC REPORT OF BASELINE
ULTRASOUND).
THE REFERENCE TECHNIQUES CONFIRMED THE SIMPLE CYSTS LESION BUT SUSPECTED, IN COMPLEX CYSTS
LESIONS, 7 CYSTIC RCC WITH SURGICAL CONFIRM. BETWEEN 10 CASES NOT CONCLUSIVE, IDENTIFIED 3 RCC (
WITH LESS 2,5 CM SIZE AND HYPERVASCULAR) , 3 RENAL ANGYOMIOLIPOMAS 1 ONCOCYTOMA (1 CM OF SIZE) AND
1 NEGATIVE .
THE USCA IS NOT SUFFICIENT TO ACHIEVED AN OPTIMAL DIAGNOSIS IT HAS NEED OF MAGING MODALITIES
WITH AN ELEVATED SPATIAL AND CONTRAST RESOLUTION. THE USCA PRESENTS A REAL DIAGNOSTIC GAIN TO
DIFFERENTIATE THE A-HYPOVASCULAR LESION(ABSCESS/INFARCTS/HYPOVASCULAR RCC) FROM HYPERVASCULAR
LESION, WELL DEFINE THE RCC PSEUDOCAPSULA AND COLUMNAR HYPERTROPHIA.THE DIAGNOSTIC ACCURACY
SEEMS DEPENDING BY LESION SIZE. MAY BE USED IN THE FOLLOW-UP OF CYSTIC BORDER-LINE AND ABLATED
LESION
P104. TRANSPLANT RENAL ARTERY STENOSIS TREATED BY PERCUTANEOUS TRANSLUMINAL
ANGIOPLASTY AND STENTING
Pappas P., Gkeneralis G., Kaza S., Ikonomopoulou V., Panagiotidou Ch., Zioga V.,
Papaspyrou S.
Radiology Department, Laiko Hospital of Athens, Athens, Greece.
Objective: To evaluate the efficacy of percutaneous angioplasty and stenting in cases of artery stenosis of the
transplanted kidney or proximal iliac artery stenosis causing transplant dysfunction and/or increase of the arterial
blood pressure.
Method: Between 2000 and 2008, we evaluated 24 patients who had undergone renal transplantation and
subsequently were diagnosed with refractory hypertension and transplant dysfunction for signs of possible renal
transplant artery stenosis. Color Doppler ultrasonography and magnetic resonance angiography preceded the
intrarterial angiographic investigation, with false-negative results in 18.2% and 13.6% of patients, respectively. In 2
of the 24 patients, angiography did not reveal arterial stenosis affecting the transplanted kidney. Two patients had
severe ipsilateral iliac artery stenosis and the remaining 20 had transplant artery stenosis. Successful angioplasty and
stenting were performed in these 22 patients.
Results: The method was technically feasible in 100%. The procedure-related morbidity was 0%. During the follow-up
period (range: 3 to 104 months), two patients died with normal transplant function, two suffered transplant failure,
and the remaining 18 still have normal transplant function and easily controlled hypertension.
Conclusion: Percutaneous angioplasty and stenting in cases of arterial stenosis affecting the renal transplant function
are safe and effective procedures. Even more, the strong clinical suspicion must lead to angiographic investigation
regardless of the results of other imaging approaches.
166

P105. OBSTRUCTIVE AND NON OBSTRUCTIVE UROPATHY: PERCUTANEOUS CT-GUIDED NEPHROSTOMY
Kelogrigoris M. 1 , Mylona S. 2 , Tsagouli 1 P., Stathopoulos 1 K., Stroumpouli E. 2 , Volioti E. 1 , Thanos L. 1
«Sotiria» General Hospital of Chest Diseases, Department of Computed Tomography and Interventional
Radiology 1 ,Korgialenio Mpenakio General Hospital of Athens 2
Purpose: to present our experience of CT guided percutaneous nephrostomy as an alternative to standard fluoroscopyguided
puncture that involves no radiation for the radiologist.
Material & Method: between June 2000 and December 2008, 572 CT-guided nephrostomies were done. Most patients
520 (91%) underwent percutaneous CT guided nephrostomy for obstructive uropathy, while 52 (9%) required the
procedure as treatment for nonobstructive bladder tauma. All patients had subsequent insertion of a nephrostomy
tube under CT guidance.
Results: percutaneous access was achieved without major complications in all patients.the most common complication
was pain at the puncture site. In 52 patients with bladder trauma, the catheter was removed after trauma repair. In
360 patients (62,9%), the catheter’s placement was permanent.
Conclusion: percutaneous CT-guide nephrostomy is a reliable, safe, fast, and highly effective method associated with
low complication rate that involves no radiation for the interventional radiologist.
P106. PERCUTANEOUS RADIOFREQUENCY ABLATION OF RENAL CELL CARCINOMA: OUR EXPERIENCE.
Tsagouli P. 1 , Mylona S. 2 , Stathopoulos K. 1 , Kelogrigoris M. 1 , Dai S. 2 , Sotiropoulou E. 1 , Thanos L 1 .
«Sotiria» General Hospital of Chest Diseases, Department of Computed Tomography and Interventional
Radiology 1 ,Korgialenio Mpenakio General Hospital of Athens 2
Purpose: in this study we attempt to present our clinical experience in RFA under CT guidance, in 85 patients with
renal cell carcinoma.
Material & Methods: 31 of these patients had renal cell carcinoma ( 18 at the right kidney and 13 at the left) and
couldn’t undergo surgery or didn’t want to, and 54 of them had renal carcinoma in solitary kidney. Tumors diameter
ranged from 1 to 7 cm and there was no evidence of spread beyond the kidney. The RFA-system used was with
expandable needle electrode ( 7 or 9 arreys) or expandable spiral one. Technical success, recurrence and survival rate
and complications were accessed. Patients were available for clinical and laboratory evaluation.
Results: In all cases the electrode was successfully placed at the lesion. The 85 tumors were treated with totally 100
RFA sessions. The residual rate was 6% and the reccurence rate was 9% . No reccurence was noticed in tumors less
than 3 cm in diameter. No major complications were observed. Survival ranged from 12-84 months.
Conclusion: RFA is an ideal alternative method of treatment for patients with renal cell carcinoma who can not undergo
surgery. It is a minimally invasive therapy with no major complications and a very good survival range.
----------------------------------------------------------------------------------------------------------------------------
P107. PERCUTANEOUS MANAGEMENT OF URETERAL STENOSIS IN RENAL TRANSPLANT PATIENTS
Pappas P., Felesaki E., Barberi E., Tsamis A., Genitsaris V., Sourla P., Kollias L.
Radiology Department, Laiko General Hospital, Athens, Greece.
Objective: To evaluate percutaneous nephrostomy and ureteral stenting in the management of obstructive uropathy in
renal transplant patients.
Method: In the last 5 years 46 patients with ureteral strictures of the transplanted kidney were managed with
percutaneous nephrostomy and ureteral stenting under ultrasonographic and fluoroscopic control.
Results: 46 percutaleous nephrostomies were successfully performed. In 44 patients the placement of ureteral stent
was attempted, successfully in 40 (90,9%). Four of these 40 patients were lost to follow-up. In 24/40 patients with
ureteral stricture the stent was removed after a mean time of 12 months (range 8-19 months) and 18 (75%) of them
did not develop any sign of recurrence at a mean follow-up of 24 months (range 11-40 months). In 12 patients the
ureteral stent remains without any problem for a mean time 8,5 months. No major complication was noticed in the
above 46 patients.
Conclusion: Percutaneous management of urological complications in renal transplant recipients with antegrade
ureteral stenting is a safe and effective method that contributes to the evasion of a major surgical intervention. The
early removal of the stent is not considered to be advisable. On the contrary, the long-term presence of the stent
shows great benefits without any complication.
--------------------------------------------------------------------------------------------------------------------------------
P108. MASSIVE RENAL HEMORRHAGE TREATED BY SELECTIVE SEGMENTAL RENAL ARTERY
EMBOLIZATION
Pappas P., Barberi E., Felesaki E., Tsamis A., Genitsaris V., Sourla P., Kollias L.
Department of Radiology, Laiko General Hospital, Athens, Greece.
Objective: Renal hemorrhage is a major life-threatening condition that can be caused by trauma, operation, biopsy, as
well as sudden spontaneous rupture of renal tumors or aneurysms. We report our experience with superselective
segmental renal artery catheterization and embolization as therapeutic options for such cases.
Method: Over the last 8 years, 28 patients with severe renal hemorrhage were admitted for evaluation and possible
further treatment. Twenty of them had a history of previous biopsy (6 of them one of a transplanted kidney), 1 patient
had a recent percutaneous nephrostomy, 4 patients presented with renal mass ruptures (2 patients renal cell
carcinoma, 1 patient angiomyolipoma, 1 patient hemorrhagic cysts), 1 patient had rupture of a renal aneurysm during
delivery, 1 patient suffered bleeding after partial nephrectomy, and 1 patient was hospitalized after a car accident.
They all presented with clinical signs of hemodynamic instability. Angiographic investigation of the kidneys preceded
further intervention in all cases. 26 out of the 28 patients underwent superselective embolization of the specific
bleeding vessel with the use of microcoils and/or Gelfoam particles.
Results: All patients treated by superselective segmental renal artery embolization had a successful outcome, including
a steady renal function and a stable clinical course. No complications occurred.
Conclusion: Superselective segmental renal artery catheterization and embolization is a safe and efficient method for
the treatment of patients with severe renal hemorrhage, preserving healthy renal parenchyma and renal function.
167

P109. RENAL CELL CARCINOMA- NOT JUST ONE
Coutinho M., Pinto D., Carlos Marques J., Costa R.
Instituto Português de Oncologia Franscisco Gentil – Lisboa, Portugal
Objective: Renal Cell Carcinoma (RCC) is the commonest renal malignancy accounting for 90-95% of all renal
neoplasms. Indeed, RCC matches not one but several histologies and this diversity leads to a variable imaging
appearance. Our purpose is to illustrate the conventional and the rarer RCC subtypes, focusing on the subtle findings
pertinent to subtype characterization and on the main differentials either tumoral or non-tumoral.
Methods: We retrospectively reviewed the files of patients referred to our institution for suspicious renal mass in oneyear
period, a total of 25. All patients underwent MDCT and/or MRI (1.5T) for lesion characterization. Surgery with
further histological analysis was performed according to clinical indication.
Results: In 12 of the 25 suspicious masses, malignancy was confirmed. RCC was most frequently encountered (n=11)
with papillary subtype accounting for two, chromophobe subtype for one and conventional clear cell type for the
remaining. Concerning stage, venous invasion was depicted in one case, regional adenopathy in another and distant
metastases to bone and liver in two patients. Spoke-wheel pattern of enhancement was seen in one case, a pathologyproven
oncocytoma. Among non-surgical lesions (n=12), one was lymphoma, seven were indeterminate presumed
benign (Bosniak categories II and IIF) managed with follow-up, three exhibited typical features of angiomyolipoma
(macroscopic fat in CT/MR and arterio-venous shunt in Angio-CT with Volume rendering post-processing) and one
aggressive-looking mass proved to be xanthogranulomatous pyelonephritis.
Conclusions: Imaging plays a role in distinguishing different RCC subtypes enabling suited therapeutic planning.
P110. DETERMINATION OF GFR BEFORE ENHANCED CT – WORK-IN-PROGRESS
Norling R., Baadsgaard H.
Department of Diagnostic Radiology, Copenhagen University Hospital Herlev, Denmark
The risk of contrast induced nephropathy (CIN) increases with the decrease in renal function. ESUR recommends
determination of estimated Glomerular Filtration Rate (eGFR) within 7 days before contrast-enhanced CT in patients at
risk of reduced renal function. Never-the-less high risk patients are from time to time referred to our department
without a valid determination of serum creatinine, for calculation of eGFR by means of MDRD equation. In such
patients the enhanced CT are postponed until a valid eGFR (> 40 ml/min) is obtained. Patients with eGFR < 40 ml/min
are referred to either MRI or ultrasound.
By the end of April we changed our procedure so that in high risk patients without a valid eGFR we determine the
eGFR in the examination room just prior to the CT scan using a point-of-care (POC) device (StatSensor).
A cost-benefit analysis of this change in procedures will be presented at the ESUR symposium. Until now
approximately 48 patients per month have had their enhanced CT cancelled or postponed. The use of the POC device
is expected to increase the through put and avoid delays for the patients.
P111. SPORADIC RENAL TUMOURS IN YOUNG ADULTS EXCLUDING ANGIOMYOLIPOMA: RADIOLOGIC-
PATHOLOGIC CORRELATION IN 20 PATIENTS
Rocher L, Martin A, Ferlicot S, Serra-Tosio G, Cluzel G., Benoit G, Bellin MF
Hôpital Bicêtre. AP-HP, Université Paris Sud 11, France.
Objective: to report the characteristics of sporadic kidney tumours observed in a population of young adult patients
under 40 years of age, and to establish a radio-pathologic correlation.
Method: We retrospectively reviewed the clinical, pathological records and imaging studies (ultrasonography, CT, MRI)
of 20 patients ranged 16-40 years, treated with either total or partial nephrectomy for renal tumour. Angiomyolipomas
and von Hippel Lindau disease were excluded.
Results: Larger tumours (from 90 to 240 mm) were revealed by hematuria, flank pain, or were palpable. Smaller were
fortuitously detected. 14 patients had a carcinoma : 6 were clear cell carcinomas (third decade), with typical imaging
(early and intense contrast enhancement, or cystic Bosniak IV type), 4 were tubulo-papillary carcinomas (weak and
late enhancement ), 2 were carcinomas with t(Xp11.2) translocation (1 calcified lobulated tumour, 1 with cystic and
solid components), 2 were chromophobe carcinomas (homogeneous enhancement or cystic lesion). Others were 2
sarcomas (1 synovialosarcoma et 1 Primitive Neuro Ectodermal Tumor), 2 multilocular cystic nephromas, 1
oncocytoma, 1 nephroblastoma (4-cm in diameter, well limited, with pseudo central scar and small calcifications).
Conclusion: Even in young adults, most sporadic tumours are malignant. Carcinoma is the most common sporadic
tumour with a high rate of tubulo-papillary and chromophobe subtypes. Carcinomas with t(Xp11.2) translocation and
sarcomas, large and symptomatic tumours, are known to be more common in this population. Biopsy should be
discussed in case of atypical tumour, due to the indication of neo-adjuvant chemotherapy before surgery, as in
patients with nephroblastoma.
P112. PERITONEAL SEEDING IN UROLOGICAL LAPAROSCOPY FOR RENAL TUMOR: OUR EXPERIENCE.
Martí T., Martínez M. J., Catalá V., Quintian C., Bonnin D., Samaniego J.
Fundacio Puigvert, Cartegena 340-350 08025 Barcelona (Spain)
Objective: During the last 10 years laparoscopy has been applied to treat malignant pathology . There has been
concern regarding peritoneal dissemination. We undertook a survey to assess the incidence of this occurrence at our
institution with special focus on radiological aspects.
Methods: From 1996 to 2009 384 laparoscopic procedures to treat malignant renal tumors have been perfomed at our
institution including partial and radical nephrectomy. We have reviwed all of them to find those cases with peritoneal
seeding after laparoscopy confirmed by CT or surgical specimen
Results: We found peritoneal seeding at two patients with renal cell carcinoma with a sarcomatoid component and at
one patient with clear renal cell carcinoma. Soft tissue masses or nodules are demonstated in the abdominal cavitiy al
CT studies. One of the patients was trated with antiangiogenic therapy showing size reduction and extensive necrosis
of most of the peritoneal implants at follow-up CT studies.
Conclusion: Peritoneal seeding after surgical procedures in renal tumors is uncommon. Some ethiologic factors have
been studied including surgical technique, effects of carbon dioxide pneumoperitoneum, and changes in host immune
response. Radiologist plays an important role to diagnose peritoneal seeding and its follow-up.
168

P113. ACUTE PYELONEPHRITIS: SPECTRUM OF COMPUTED TOMOGRAPHY (CT) IMAGING FINDINGS
Tavernaraki K., Constandinidis F., Leonardou P., Charalampopoulos G., Malachias G., Antonopoulos P.
1st IKA Computed Tomography Department and Radiology Department, Sismanoglio General Hospital,
Athens, Greece
Objective: To evaluate the CT imaging findings of patients with acute pyelonephritis.
Method: We evaluated 58 patients (36 women and 22 men; mean age 35 years) with clinical symptoms and laboratory
findings suggestive of acute pyelonephritis. Three-phase CT scan was performed in all cases. The focal or diffuse renal
involvement, the presence of renal or extrarenal abscesses, the presence of air and calcifications and the pattern of
contrast material enhancement were assessed.
Results: In 47 cases a unilateral and in 11 cases a bilateral renal involvement was revealed. Partial renal involvement
presented with a focal hypodensity and the presence of small abscesses in the affected area. In cases of diffuse renal
involvement, enlargement of the kidney due to edema and large abscesses were observed. The presence of air
bubbles was indicative of emphysematous pyelonephritis in two cases. Tuberculous pyelonephritis was shown in 4
cases, suggested by the presence of papillary necrosis, calycectasia, scarring and calcificactions. In 6 cases of
xanthogranulomatous pyelonephritis CT revealed enlargement of the kidney, renal stones and infarcts.
Conclusion: CT is an accurate imaging modality in detecting parenchymal changes and related complications in acute
pyelonephritis.
P114. SPECTRUM OF COMPUTED TOMOGRAPHY (CT) IMAGING FINDINGS IN LIPOSARCOMAS OF THE
RETROPERITONEAL SPACE
Leonardou P., Charalampopoulos G., Tavernaraki K., Constandinidis F., Malachias G., Antonopoulos P.
1 st IKA Computed Tomography Departement and Radiology Departement, Sismanoglio General Hospital,
Athens, Greece
Objective: Liposarcomas belong to the most common primary retroperitoneal neoplasms. The aim of our study was to
evaluate the specific CT imaging findings of liposarcomas.
Method: We retrospectively analyzed 14 cases of retroperitoneal liposarcomas (10 females and 4 males, aged 48-82
years) proved surgically and histologically. All patients underwent CT examination before and after the intravenous
administration of contrast agent.
Results: The lesions were found in the anterior pararenal space in 6 cases, in the posterior pararenal space in 4 cases
and in the perirenal space in 4 cases; 8 cases presented in the right and 6 cases in the left retroperitoneum. The
average diameter of the tumours was 11.8 cm (range 4 cm to 16 cm). In all cases a large heterogeneous cystic mass
of fat tissue density was revealed in the CT examination containing internal high density structures. In four cases thin
internal septations were observed. Following intravenous contrast agent administration, enhancement of the thick wall
of the mass and the internal septations was shown. In two cases CT revealed a soft tissue mass in the perirenal space
and also enlarged mesenteric lymph nodes. All patients were admitted to surgery and the histopathologic findings of
the surgical specimen proved the diagnosis.
Conclusions: Retroperitoneal liposarcoma is clearly demonstrated with CT examination based on the typical
characteristic imaging findings of a fat containing cystic mass with internal septations and a thick wall both enhancing
after intravenous contrast agent administration.
P115. CT GUIDED FINE NEEDLE ASPIRATION BIOPSY (FNA) IN THE DIAGNOSIS OF KIDNEY AND
ADRENAL LESIONS
Tavernaraki E. 1 , Andriotis E. 1 , Apergis S. 1 , Palla M. 1 , Deliveliotis K. 1 , Stasinopoulou M. 1 , Proestou D. 2 ,
Tavernaraki A. 1
1. CT Department, 2. Cytology Department, “Saint Savvas” Anticancer Oncological Hospital of Athens, Greece
Objective: To evaluate, the efficiency and safety of CT- guided FNA in the diagnosis of renal and adrenal lesions.
Method: During the last three years, we performed FNA on 42 patients with renal lesions, aged 25-80 years old (18
Female, 24 Male) and 12 patients with adrenal lesions, aged 45-60 years old (4 Female, 8 Male). We performed all
FNA biopsies with Chiba needle 18-20G, in inpatient or outpatient basis. After biopsy, the patient is monitored for 3-
4h. Only two complications occurred, with renal haematoma, in which cases no further therapy was needed.
Results: 42 patients with renal lesions: 18 adenoCa, 1 renal cell carcinoma (Grawitz tumor), 2 transitional epithelium
Ca, 2 angiomyolipomas, 2 Non-Hodgkin's lymphomas (NHL), 1 hemorrhagic cyst, 2 low grade Ca, 5 without malignant
cells, 1 invasion from chronic lymphocytic leukemia (CLL), 8 bloody material.
12 patients with adrenal lesions: 2 Hodgkin's lymphomas (HL), 1 Non-Hodgkin's lymphoma (ΝΗL), 1 high grade Non-
Hodgkin's lymphoma (ΝΗL), 1 glomangioma, 5 lung tumor metastases and 2 bloody material.
Conclusion: CT- guided FNA is a safe, fast and accurate method for diagnosing renal and adrenal lesions, without
major complications.
169

P116. CAN MAGNETIC RESONANCE IMAGING (MRI) OF THE AXIAL SKELETON REPLACE BONE
SCINTIGRAPHY FOR THE DETECTION OF BONE METASTASES IN PROSTATE CANCER
Kerr S., Bardgett HP.
Bradford Teaching Hospitals, Bradford, UK
Objective: Pelvic MRI and bone scintigraphy guide radical treatment decisions in prostate cancer. MRI appears to be
superior to bone scintigraphy for the detection of bone metastases and it has been suggested that extending the
routine pelvic MRI examination to include the axial skeleton up to the first thoracic vertebra could render bone
scintigraphy unnecessary. This paper investigates whether such a strategy would risk failing to detect isolated
peripheral bone metastases of the head, neck and limbs.
Methods: All newly diagnosed patients with prostate cancer who underwent pelvic MRI and bone scintigraphy over a
24-month period at our hospital were identified. Data were collected retrospectively from the reports of these
investigations.
Results: Over a 24-month period from August 2006, 95 patients newly diagnosed with prostate cancer underwent
pelvic MRI and bone scintigraphy. Plain radiographs aided interpretation of equivocal lesions on the latter. Median age,
prostate-specific antigen (PSA) level and Gleason score were 68 years, 17 ng/ml and 7, respectively. Of the 7 patients
with probable bone metastases on scintigraphy +/- plain radiography, all had metastases in the pelvis and/or lumbar
spine which were demonstrated by MRI.
Conclusion: If newly diagnosed prostate cancer patients were to undergo extended MRI up to the first thoracic
vertebra to replace bone scintigraphy, on our data there is no risk of failing to detect isolated peripheral bone
metastases.
P117. ULTRASOUND ASSESSMENT OF ARTERIOVENOUS FISTULAS AND HAEMODIALYSIS GRAFTS. WHAT
TO LOOK OUT FOR.
Cokkinos D.D., Sofronas A., Antypa E., Tserotas P., Kratimenou E., Beka A., Tsiolias D., Piperopoulos P.N.
Radiology Department. Evangelismos Hospital. Athens, Greece.
Objective: To review the indications for sonographic evaluation of fistulas and dialysis grafts of the upper extremity
(possible non function of fistula/graft or oedema/ischaemia of distal part of the arm). To describe the examination
technique using B mode, Colour and Spectral Doppler ultrasonography. To suggest an easy to follow scanning protocol
in order to facilitate examination by the inexperienced doctor.
Method: Upper extremity arteriovenous fistulas and haemodialysis grafts are a commonly used method in patients
with end stage renal failure. We describe a sonographic examination protocol for their assessment: scanning should
begin from the subclavian vein. The entire length of the fistula or dialysis graft, from the arterial start to the venous
end is imaged on B mode and Colour Doppler ultrasound to exclude stenosis or thrombosis. Functional evaluation is
performed by calculating volume flow. Arteries and veins distal to the fistula are also imaged. These examination steps
are described in detail and outlined in a suggested imaging protocol.
Results: When the recommended protocol is followed, fistulas and grafts can be adequately assessed. Normal,
inadequate and problematic for cardiac output flow values are explained. Non functioning fistulas are identified.
Images from normal and abnormal ultrasound examinations are given.
Conclusion: Colour Doppler ultrasound is a dedicated modality for the anatomical and functional assessment of upper
extremity arteriovenous fistulas and dialysis grafts on chronic renal failure patients. Radiologists and sonographers
should be fluent with the examination technique in order to answer clinical questions and aid patients’ follow up
P118. ULTRASOUND EXAMINATION OF THE RENAL VESSELS. A PICTORIAL REVIEW.
Cokkinos D.D., Antypa E., Skilakaki M., Kachrimanis G., Kantzavelos A., Dakoulas G., Anagnostakou V.,
Piperopoulos P.N.
Radiology Department. Evangelismos Hospital. Athens, Greece.
Objective: To review the imaging capability of ultrasound (US) in examining renal arteries and veins. To assess its
diagnostic value compared to intravenous urography (IVU), computed tomography (CT) and magnetic resonance (MR).
Method: Findings from patients subjected to US examination of renal arteries and veins. We suggest an examining
protocol for imaging kidneys, main renal vessels and intrarenal branches.
Results: Examination begins by assessing renal size. A significant discrepancy is suggestive of a renal artery stenosis
>70%. While examining the main renal arteries in a transverse or oblique direction, preferably when they leave the
aorta, the waveform and peak systolic velocity are noted: velocity >180-200cm/sec, as well as a ratio to the aortic
peak velocity >3.5 are suggestive of stenosis and possible hypertension. The intrarenal branches are also examined: a
slowly increasing velocity with a low peak value (tardus parvus waveform) with elimination of the early systolic peak is
also consistent with significant renal artery stenosis, as is a Resistive Index (RI) less than 0.5 and side-to-side
difference >5% (lower RI in the stenotic side). However, often false positive and false negative results occur. In these
cases CT or MR angiography is the next imaging step. Renal veins should also be assessed for patency and possible
thrombosis, together with indirect kidney findings of these entities.
Conclusion: Regardless of its limitations, US examination of renal arteries and veins is a valuable imaging method.
Radiologists should be able to perform the examination and refer patients to other modalities when they cannot reach
a diagnosis.
170

P119. INTRAVENOUS UROGRAPHY : IN THE NEW FRONTIERS IN IMAGING
Goulimari R., Skandalidis El., Terzenidis S., Charalampidou N., Panagiotidou L., Kesanlis J., Nasos P 1 .,
Dimitriadis S.
Radiology Department, General Hospital of Xanthi, Greece. 1 Urology Department, General Hospital of Xanthi,
Greece
Objective: To re-evaluate the usefulness of intravenous Urography (IU) as the first imaging modality in the
evaluation of urinary system pathology
Although IU has lost favor in the era of MR and CT urography it is still remaining the primary imaging method for
many urinary system pathologic conditions, especially in Radiology Departments that lack of MRI and multi- detector
CT.
The method contributes and establishes the diagnosis of anatomical variations of the urinary tract and many
pathologic conditions such as calculies, obstruction, trauma, infection diseases, tumors and tumor-like lesions.
Method: 372 IUs that have been performed in externals and internals patients, during last year. The protocol included
one K.U.B x-ray and 3 to 6 x-rays after the injection of contrast media, tailored to each patient condition.
Results: IU was 100% successful in demonstrating urolithiasis with obstruction and dilatation, anatomical variations,
extravasations of contrast media, bladder tumors and hypertrophic prostate. Nevertheless, IU was inferior to MR and
CT urography for the detection and characterization of small renal masses.
Conclusion: IU is much cheaper, easily access able end better tolerant of claustrophobic patient than MR urography.
On the other hand the amount patient radiation dose for the patient is less than in CT urography.
In the end of first decade of the new millennium IU still remains a reliable and stable imaging modality when the
interpretation of the entire urinary system is necessary.
P120. VESICO-CUTANEOUS FISTULA FOLLOWING RADICAL PROSTATECTOMY DIAGNOSED BY COMPUTED
TOMOGRAPHY. REPORT OF A CASE.
Athanassopoulou A. 1 , Kalogeropoulos I. 3 , Triga A. 2 , Smailis D. 2 , Filippou D. 2,4
1 Department of Computed Tomography and 2 Department of Visceral and Colorectal Surgery, Neo-Athineo MD
General Hospital, 83 Astydamantos str, Pagrati, Athens, Greece. 3 Department of Computed Tomography,
Athens General Hospital “Evangelismos”, Kolonaki, Athens, Greece.
Objective: Vesico-cutaneous fistula is a rare surgical problem which is mainly following urinary tract trauma or surgical
operations. Only few sporadic cases referring to post-prostatectomy vesico-cutaneous fistula have been reported in the
literature.
Case Presentation: We report a 72 year old male patient who had received 30 days ago radical trans-abdominal
prostatectomy in another hospital. The last 5 days the patient presented abdominal distention while large tissue parts
were going out via the Foley catheter. The CT scan of the lower abdomen combined with CT urography demonstrated
clearly the existence of a vesico-cutaneous fistula. The patient was treated surgically with partial cystectomy,
fistulectomy, while the area of the operation sealed with glutaraldheyde glue. The patient discharged the 4th
postoperative day and the catheter removed the 25th day.
Conclusion: Vesico-cutaneous fistula is a rare post-traumatic or iatrogenic entity which need surgical treatment. CT
scan can reveal not only the existence of the fistula but it can also demonstrate its course helping the clinician or the
surgeon to organize the therapeutic strategy.
P121. BILATERAL DERMOID CYSTS PRESENTING WITH ACUTE PELVIC PAIN CORRELATION OF US-CT
FINDINGS
Savvopoulou V., Kapnisi E., Stefanoglou N., Natsiopoulou E., Papaevagellou A., Stathousi P., Papaioannou N.,
Tibisranis M.
Radiology Department, Thriasio General Hospital, Elefsina, Greece
Objective: Mature cystic teratoma (dermoid cyst) is the most common germ cell neoplasm. Usually affects patients
under 30 yrs unilaterally; bilateral presence occurs in 10% of cases. It may be complicated by torsion, rupture,
infection and malignant change. Our purpose is to report a case of bilateral dermoid cysts presenting with acute
abdominal pain and its imaging characteristics.
Methods: A thirty eight year old nulipara woman without past medical history presented with acute pelvic pain, a
palpable pelvic mass and bilateral adnexal and fundal tenderness on bimanual examination. The patient underwent
abdominal US and CT examination with pos and iv contrast administration.
Results: US revealed two large adnexal masses. The right mass was larger, mostly hypoechoic and painful when
examined with the probe. The left one was mostly hyperechoic. Both masses showed hyperechoic sites with posterior
acoustic shadow and demonstrated no significant vascularity.
CT revealed bilateral heterogeneous masses composed of fat, calcifications, teethes, fat-fluid levels and internal
reticulations. Calcifications or teethes on CT correlated with hyperechoic sites with posterior acoustic shadow on US
and fat attenuation on CT correlated with both hypo- and hyper-echogenicity on US. No significant contrast
enhancement was detected. Findings were considered pathognomonic for bilateral dermoid cysts and partial torsion of
the right one was suspected. Conservative treatment followed.
Conclusion: US may be useful for initial evaluation of ovarian dermoid cysts especially when complications have
superimposed. CT is capable of adequate characterization of mass composition in such cases. Younger patients and
patients with bilateral dermoid cysts should be followed up closely.
171

P122. MASSIVE SPONTANEOUS RETROPERITONEUM HAEMORRHAGE IN A PATIENT WITH AN
ANGIOMYOLIPOMA
AGE 56Y FEMALE
Adoniou A., Malamouli I., Krikis P., Zografos G., Syrgani-Kehalaki E.
Achilopoulio Hospital of Volos, Computed Tomography Department, Volos / Greece
Clinical Summary: We report a case of a 58-year-old woman, who presented to emergency department with acute
onset, severe, colicky right loin pain radiating to the anterior chest with associated shortness of breath. Personal and
familial histories were unremarkable. The patient was hemodynamically stable without hematuria.
On examination following pain relief, the patient was comfortable, afebrile and had stable observations (BP 100/80,
pulse 70 irregularly irregular, oxygen saturations 97% on room air). There was however marked tenderness of the
right renal angle and right lower quadrant and signs of peritonism.
Bloods (Hb 13.9,Ht 38,9), blood gases and urine dipstick performed at the time :rare wbc , blood cells 3-4. A second
blood test was given Hb:10,7 Ht:29,9,also cr: 1,2 urea 43,K :3,Na: 124.
U/S showed a huge perirenal mass, with mixed echogenity, without acoustic shadowing well circumscribed ,lesions
with fat or cystic elements. The finding anteriorly displaced the renal sinus. There was not free abdomen fluids or air.
It is therefore necessary to perform a CT evaluation to make the diagnosis, especially if the tumor produces
symptoms.
CT images obtained before the administration of contrast material, intratumoral hemorrhage and subcapsular and
perirenal hematoma suggestive of rupture .
The CT examination revealed a massive retroperitoneal bleed around the right kidney with the bleed originating from
capsular mass .Size of the mass : 106,1*155,7 mm, and was obviously arised from the renal cortex close to the hilum.
The image shows a space-occupying lesion of mixed attenuation interspersed with areas of fat attenuation(-25 -
8HU) There was also bleed in the the perirenal space ( posteriorly the Zuckerkandl renal fascia) and anteriorly by the
Gerota fascia .Also suppression of the vena cava inferior. The patchy tumor enhancement is a finding that suggested
of a angiolipoma that had ruptured into the perinephric space and retroperitoneum.
Given the size of the tumor, presence of symptoms of the patient, right nephrectomy was performed. Renal arterial
embolization may also be used to control hemorrhage.
Discussion: Angiomyolipoma is a benign renal neoplasm composed of fat, vascular, and smooth muscle elements. It
has an incidence of about 0.3-3%, and 2 types are described: isolated angiomyolipoma and angiomyolipoma that is
associated with tuberous sclerosis. Angiomyolipomata have well defined margins, with a variable proportion of fat and
soft tissue, although the former usually predominates. They can vary in size from a few millimeters to larger than 20
cm. flank pain (53%), a palpable tender mass (47%) and gross haematuria (23%); this is known as 'Lenk's triad'.
Patients with tumors > 8 cm are at greater risk of spontaneous or traumatic rupture resulting in haemorrhagic
complications.
Interestingly, 80% of the cases involve the right kidney. As many as 40% are symptomatic. solitary sporadic tumors
may cause an acute abdomen and shock as a result of spontaneous hemorrhage in the tumor. The demonstration of
fatty attenuation in renal tumor on computed tomography (CT) scanning studies is virtually diagnostic of
angiomyolipomas.
Female: male predominance is approximately 4:1 with this strong female prevalence suggesting a hormonal
component to tumour growth .
Patients who present with abdominal pain must be differential diagnosed of urinoma, renal vein thrombosis, renal cell
carcinoma ,teratoma xanthogranulomatous pyelonephritis, Wilms tumor, renal lipomarenal and retroperitoneal
liposarcoma.
A subset of patients who present with severe hemorrhage as the first sign of the angiomyolipoma may have a lifethreatening
condition Surgery, whether planned or performed emergently, has a certain risk of morbidity and
mortality. Renal arterial embolization may also be used to control hemorrhage.
The final diagnosis was spontaneous rupture of an angiomyolipoma.
P123. AN UNUSUAL CASE OF ACUTE LOWER ABDOMINAL PAIN
Stroumpouli E., Kenton T., Karouzaki E., Babis A., Kotsapas E., Magnisali I., Patsourakos N., Kavvadias S.
Radiology department, Hippokration General Hospital, Athens, Greece
Objective: To present a rare case of lower right abdominal pain due to ectopic kidney colic.
Method: A 43 year-old woman was admitted to the emergency unit with right lower quadrant pain. Physical
examination revealed abdominal tenderness and defence on palpation of the right iliac fossa, leading to the clinical
suspicion of acute appendicitis. Ultrasound examination demonstrated a right ectopic pelvic kidney with mild
hydronephrosis. Left native kidney was found in the normal anatomic position.
Results: Conservative treatment eventually achieved satisfactory resolution without compromise of renal function.
Further investigation with intravenous urography (IVU) demonstrated a functioning pelvic kidney which has located at
the right iliac fossa in addition to normal excreting left kidney. Acute abdomen like symptoms was secondary to the
urinary colic of the pelvic kidney.
Conclusion: We conclude that the colic of ectopic pelvic kidney may create clinical symptoms of acute abdomen.
Although extremely rare, congenital kidney anomalies should be included in the differential diagnosis.
172

P124. PERCUTANEUS NEPHROSTOMY UNDER CT – THE PRESENTATION OF OUR RESULTS OF LAST 3
YEARS IN ONCOLOGICAL HOSPITAL
Andriotis E. 1 , Tavernaraki Ek. 1 , Apergis S. 1 , Palla M. 1 , Deliveliotis K. 1 , Stasinopoulou M. 1 , Proestou D. 2 ,
Tavernaraki A. 1
1. CT Department, 2. Cytology Department , “Saint Savvas” Anticancer Oncological Hospital of Athen, Greece.
Objective: We present our last 3 years experience in our department about percutaneus nephrostomy under CT, in
serious situations such as obliteration in urogenital system, inflammatory situation and traumatic.
Method: From the period of January 2006 to January 2009, 35 percutaneus nephrostomies were performed in our
Department.
29 patients had urogenital obliteration, 4 emphyema and 2 trauma lesions.
The catheters used, were pig-tail type, 7-8 F, percutaneus drainage catheters. The placement was performed in a
prone or lateral position, with direct technique paracentesis.
Results: The application was successful in all patients (100%) and only a few complications were observed (3 cases
with haematoma which needed no further treatment).
In a later time, 4 of the patients underwent a second procedure because of displacement of the catheter. The catheter
remained in place long enough to achieve complete decongestion of the pelvis.
Conclusion: Percutaneus nephrostomy under CT is a safe method, fast, easy and effective, in difficult clinical cases and
with no major complications.
173

LIST OF DELEGATES
Abahashemi F.
Abecasis M.
Abou El-Ghar M.
Adoniou A.
Aga T.
Agadakos E.
Aggelopoulos A.
Al-Nasri
Alexopoulos T.
Alt C.D.
Amendola M.
Anagnostakou V.
Anastopoulos I.
Anastasopoulou T.
Anceschi M.
Andriotis E.
Andreou J.
Antonopoulos P.
Antsaklis A.
Antypa E.
Apergis S.
Apostolopoulou G.
Arapostathi S.
Argyropoulou M.I.
Arvaniti M.
Askiti V.
Athanasiadis G.
Athanassopoulou A.
Atzori M.
Baadsgaard H.
Babali A.
Babis A.
Bains S.
Balconi G.
Balleyguier C.
Baltas C.
Barbagianni E.
Barberi E.
Bardgett H.P.
Barentsz J.
Barozzi L.
Barrass M.
Barry N.
Barua R.
Barua S.K.
Basta Nicolic M.
Batakis N.
Bauer M.
Baumgarten D.
Beale A.
Beka A.
Belfield J.C.
Bellin M.F.
Benoit G.
Bernardo S.
Bertolotto M.
Berzaczy D.
Beuvon F.
Bhuyan U.
Bierry G.
Binser T.
Bintoudi A.
Biondi T.
Birkhaeuser F.
Bisyri K.
Bitsori M.
Bizim V.
Bohlin E.G.
Bohloul R.
Bonnin D.
Bosboom D.
Boulalas I.
Bourdoumis A.
Brkljačić B.
Brocker K.
Brunelli R.
Buaesch L.
Bucek R.A.
Builov V.M.
Buñesch L
Byun J.Y.
Byun S.S.
Calandriello L.
Calciolari C.
Capaccio E.
Carbognin G.
Carbone A.
Cardone G.
Carlos Marques J.
Carone V.
Casciani E.
Catala V.
Cestari A.
Chadjimichail A.
Chaidou A.
Chalazonitis A.N.
Charalampidou N.
Charalampopoulos G.
Charisiadi A.
Charsoula A.
Chatzidarellis E.
Chatziioannou A.
Chenonatskaja M.
Chernyak V.
Chilla B.
Cho J.H.
Cho J.Y.
Cho S.B.
Choi S.
Choyke P.
Chrisafis E.
Chrisofos M.
Christianakis E.
Christopoulou A.
174
Chroni P.
Chung K.B.
Ciccariello M.
Cittadini G.
Claudon M.
Cluzel G.
Cokkinos D.D.
Constantinidis F.
Coppenrath E.
Cornelis F.
Cornud F.
Coss M.
Costa C.
Costa R.
Coutinho M.
Cova M.A.
Cowan N.C.
Crew J.P.
Cucci E.
Cunha T.M.
Ćurić J.
Dagiakidi E.
Dai S.
Dakoulas G.
Danza F.M.
Das T.
Daskalaki E.
Datseris I.
Davis B.J.
De Dominicis C.
De la Torre P.
De Nicola A.
Deftereos S.
Delakas D.
Delaveris E.
Deligiannis I.
Deliveliotis C.
Derchi L.E.
Dermitzakis I.
Di Mare L.
Diamantopoulos A.
Dimakis A.
Dimitriadis I.
Dimitriadis S.
Djouguela Fute M.
Dodre E.
Dogra V.
Do Nascimento A.F.
Donoso L.
Doulgerakis G.
Doumanianis G.
Dounis A.
Douvlou E.
Drossos Ch.
Eirecat H.
Eiss D.
Efthimiadou R.

Eklof H.
El – Diasty T.
El Saiety N.
Ergun E.
Evlogias N.
Ewald A.M.
Exarchos D.
Fagrezos D.
Fasching A.
Fatsi A.
Fattaljaef V.
Felesaki E.
Ferlicot S.
Fernandes L.
Ferrandina G.
Ferreira A.C.
Ferriere J.M.
Filippi V.
Filippiadis D.K.
Filippou A.
Filippou D.
Filippou P.
Firouznia K.
Flam T.
Fleischmann A.
Forstner R.
Foteinos A.
Foukal J.
Foufa K.
Fragioudaki A.
Froehlich J.M.
Futterer J.
Galanakis E.
Galani G.
Galiatsatos N.
Galli G.
Gallucci M.
Garcia Monaco R.
Gargas D.
Genitsaris V.
Gentile V.
Georgiadou E.
Georgiopoulos I.
Ghanaati H.
Giaka E.
Gialamoudi M.
Gialias P.
Giannakis D.
Giannakis P.
Giannopoulos P.
Giannopoulos T.
Giannoulakos N.
Giarraputo L.
Gkeli M.
Gkeneralis G.
Glava C.
Glybochko P.
Gokan T.
Goldman S.
Gosmwami H.
Gotsis G.
Gouliamos A.
Goulimari R.
Goulis D.
Gourtsoyiannis N.
Goutzios P.
Grenier N.
Gualdi G.F.
Guazzoni G.
Haitel A.
Hall J.
Hallscheidt P.
Hambrock T.
Hamm B.K.
Han B.H.
Hansell P.
Haritanti A.
Hasrat K.
Hassan N.
Hastie K.
Hatimola P.
Hauser N.
Hazarika S.
Heinmink S.
Heinz-Peer G.
Hekal I.
Helenius M.
Herneth A.
Hesketh G.
Hirose M.
Ho E.
Hohl M.
Holmes D.R.
Hondros D.
Hountala A.
Hrkać-Pustahija A.
Hubrecht R.
Hulsbergen-v.d.Kaa C.A.
Hwang S.I.
Hwang S.S.
Iabichino C.
Iakovidis G.
Ikonomopoulou V.
Inada Y.
Ioannidis J.
Iordanidis A.
Itoh T.
Ivanac G.
Jacubcova R.
Jalali A.H.
Javor D.
Johannesen H.H.
Johnson C.
Jung S.E.
Kachrimanis G.
Kafetzis G.
Kaitartzis C.
Kakani S.
Kalaitzoglou I.
Kalidonis P.
Kalikis D.
Kalogeropoulos I.
Kalogeropoulou C.
Kamal M.
Kamatsos I.
Kampasakali M.
175
Kanazawa S.
Kang M.J.
Kannappa L.K.
Kantzavelos A.
Kapnisi E.
Karagiannidis I.
Karakiklas D.
Karanikas C.
Karatzas A.
Karavirakis M.
Karnezis I.
Karouzaki E.
Kartsouni V.
Karyotis I.
Katsaros V.K.
Katsarou A.
Katsiba D.
Katsou G.
Kattamis C.A.
Kauczor H.U.
Kavallaris G.
Kavvadias S.
Kaza S.
Kechagias D.
Kelogrigoris M.
Kenney P.
Kenton T.
Kerr S.
Kesanlis J.
Khalili M.
Kichikawa K.
Kim M.J.
Kim S.H.
Kim Y.H.
Kim Y.S.
Kinkel K.
Kitano S.
Kiyama S.
Kohan A.
Kolaiti F.
Kolak T.
Koliopoulos G.
Kolliakou E.
Kollias L.
Komninos C.
Komorowski D.J.
Konstantatou E.
Konstantinou D.
Kontaki T.
Kornezos I.
Kosar U.
Kostaras V.
Kotsapas E.
Kotziamani N.
Koukos S.
Koulentianos E.
Koumanidou C.
Koumarianos D.
Koupanis C.
Kourou E.
Kraniotis P.
Kratimenou E.
Krikis P.

Krommyda E.
Krssak M.
Kritikos N.
Kubik-Huch R.
Kubin K.
Kurochka S.
Kwon H.J.
Kypriotis D.
Kyratzi E.
Kyriakou V.
Labropoulou P.
Lagerqvist B.
Lagoudaki E.
Lammer J.
Laspas F.
Lazaridou E.
Lazarioti F.
Lebras Y.
Lee E.J.
Lee H.J.
Lee S.E.
Lee Y.H.
Legge F.
Lenz F.
Leonardou P.
Liakouras C.
Lianos E.
Liatsikos E.
Liberatore M.
Limberis V.
Liopiris S.
Lisi D.
Liss P.
Lobo L.
Locher P.
Loor Guadamud G.
Losa A.
Louisi A.
Lourbakou A.
Loutsaris K.
Lyra S.
MacNeil S.
Madenlioglou E.
Magnisali I.
Magnusson A.
Malachias G.
Malamateniou Ch.
Malamouli I.
Mallett S.
Maltabe V.
Mamalis V.
Mangili P.
Maniatis P.
Maniatis V.
Manousaki E.
Mantzorou A.
Marchiole P.
Margari P.
Maris Th.
Marti J.
Marti T.
Martin A.
Martinez M.J.
Marugami N.
Marzano S.
Masselli G.
Matalliotaki P.
Matau A.
Matsaidonis D.
Matsi S.
Matsuk M.
Mattioni O.
Mavridou C.
Mazaris E.
Mazzariol F.
Mc Hugo J.
Meindl T.M.
Meissner O.A.
Memarsadeghi M.
Merville P.
Messina A.
Michaelides M.
Michail A.
Michailides N.
Michailidou E.
Mika A.
Milona Ch.
Mingote C.
Mintzopoulou P.
Missere M.
Mitropoulou M.
Mitsioni A.
Mohsen T.
Moioli M.
Møller J.M
Moon M.H.
Morcos S.
Morfas K.
Morgan E.
Moschouris H.
Mourikis D.
Mourmouris C.
Moussa S.
Moustakas G.
Mpouma E.
Mueller – Lisse U.G.
Mueller – Lisse U.L.
Munechika J.
Mylona S.
Mynderse L.A.
Myrilakou A.
Naka G.I.
Nalmpantidou C.
Nam K.J.
Narumi Y.
Nasos P.
Natsiopoulou E.
Nava L.
Neofitou G.
Nicolaidis P.
Nikolaou A.
Nicolau C.
Nikolić O.
Nikolopoulos P.
Njagulj V.
Nolte – Ernsting C.
176
Nomikou E.
Norling R.
Ntasiou I.
Ntova I.
Ocantos J.
Oliveira C.
Osimani M.
Oh S.N.
Oh Y.W.
Ohgiya Y.
Otero-Garcia M.M.
Ouranos V.
Oyen R.
Pagonidis K.
Paisios O.
Palla M.
Palm F.
Panagiotidis E.
Panagiotidou Ch.
Panagiotidou L.
Panagiotopoulou D.
Panebianco V.
Papachristou C.
Papadaki I.G.
Papadaki M.G.
Papadopoulos N.
Papadopoulos S.
Papadopoulou P.
Papaevagelou A.
Papageorgiou G.
Papailiou J.
Papaioannou N.
Papanicolaou N.
Papaspyrou S.
Pappas P.
Paraskevaidis E.
Park B.J.
Paroder V.
Parola C.
Paschos A.
Pascoli S.
Pasquali R.
Passariello R.
Patel R.
Patsoura S.
Patsourakos N.
Patti S.
Pavlica P.
Pavlopoulou E.
Peri L.
Perisinakis K.
Perot V.
Perrone G.
Petrovic K.
Petsas T.
Pietrani M.
Pinto D.
Piperopoulos P.N.
Pires F.
Polettini E.
Poletto E.
Popovic M.
Poulimenos L.

Poupalou A.
Pozoukidis C.
Pragalakis G.
Prantzos T.
Prasad U.R.
Prassopoulos P.
Proestou D.
Prompona M.
Protopappa A.
Ptothis N.
Puchner S.
Ramchandani P.
Quintian C.
Raissaki M.
Rajeev T.P.
Ramesh N.
Refaie H.
Regine G.
Reiser M.F.
Remzi M.
Restaino G.
Retsilas I.
Revuelta I.
Rha S.E.
Riccabona M.
Ricci Z.J.
Richarme D.
Richenberg J.
Ridley N.
Rizos S.
Robb R.A.
Rocher L.
Rodriguez-Fernandez P.
Romanos O.
Rondogianni P.
Roppa-Lepida N.
Rouanne M.
Roussakis A.
Rousso D.
Roy C.
Rozenblit A.M.
Ryu D.H.
Sabluk L.
Saikia K.
Sakellaropoulos A.
Sala P.
Salim F.
Sallustio G.
Samaniego J.
Salvador R.
Santucci E.
Savidou D.
Savvopoulou V.
Scheenen T.
Scherr M.
Schouten M.
Sciarra A.
Sebastià C.
Seehaus A.
Segelsjo M.
Sencha A.N.
Serafetinidis E.
Serra-Tosio G.
Seth J.
Sfakiotaki R.
Shakiba M.
Sharafi A.
Shetty S.
Shin Y.R.
Siablis D.
Siafas I.
Sidiropoulou M.
Sierra A.
Singer G.
Siougaris N.
Skandalidis El.
Skilakaki M.
Skolarikos A.
Skondras E.
Skoula A.
Smailis D.
Smarda M.
Smponia A.
Sofikitis N.
Sofronas A.
Sohn C.
Soldatos Th.
Solomakou S.
Song M.J.
Sotirakou K.
Sotiropoulou E.
Souflas V.
Sourla P.
Sousa S.
Spencer J.
Spiliopoulos S.
Spiliopoulou G.
Spyridis G.
Spyridonos A.
Stamatiou K.
Stamou H.
Stamoulis E.
Stasinopoulou M.
Stassinopoulou A.
Stathopoulos K.
Stathousi P.
Stavrogianni T.
Stefanoglou N.
Stief C.
Stojanovic S.
Stratilati S.
Stroumpouli E.
Studer U.E.
Suarez-Arfenoni B.A.
Sullivan M.
Sung D.J.
Sydnor M.K.
Syrgani-Kehalaki E.
Taboada-Rodriguez V.
Tachtaras A.
Tagliafico A.
Takahama J.
Takewa M.
Tatsugam F.
Tavernaraki A.
Tavernaraki E.
177
Tavernaraki K.
Terzenidis S.
Testembasi E.
Thanos A.
Theodosiadis G.
Thoeny H.C.
Thomsen H.
Tibisranis M.
Tisnado J.
Torounidis I.
Torrao H.
Tozzi C.
Triantafyllou E.
Triantafyllou M.
Triantopoulou C.
Triga A.
Trouli N.
Truglio M.
Tsagouli P.
Tsalkidis A.
Tsamis A.
Tsampoulas K.
Tsanakis G.
Tsangou V.
Tsantilas X.
Tsekouras K.
Tserotas P.
Tserpes N.
Tsetis D.
Tsili A.C.
Tsilikas K.
Tsimara M.
Tsiolias D.
Tsitouridis I.
Tsota I.
Tsourouflis G.
Tsouroulas M.
Tzovara I.
Turgut A.T.
Turney B.W.
Tyra T.
Tzivra A.
Tzovara I.
Vakaki M.
Valentino M.
Valerio M.C.
Van der Molen A.J.
Van Es A.C.G.
Vantali V.
Varchalama E.
Vargemezis V.
Varkarakis I.
Vasila O.
Vasilakis A.
Vellis A.
Vergari V.
Vergnaghi D.
Vermathen P.
Villers A.
Vlachos I.
Vlachou C.
Vlontzou E.
Volanis D.

Volioti E.
Von Gunten M.
Vranou E.
Vucaj Cirilovic V.
Wan E.
Wasserman N.F.
Weber M.
Wilkinson B.
Wilser W.
Wilson T.M.
Witjes J.A.
Xinou E.
Yakar D.
Yarmenitis S.
Yil.mazer Y.
Yoon S.K.
Yuki M.
Zaccagna F.
Zadina A.
Zagoria R.
Zampakis P.
Zampelli A.
Zappetti R.
Zarkadoulias A.
Zavras N.
Zbogo A.
Zioga V.
Ziogana D.
Zisimopoulos A.
Zografos Ch.
Zografos G.
Zoupas Ch.
Zoutis S.
Zuev V.
178