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Edited by:<br />
George L. Malachias, MD<br />
Published by:<br />
2
CONTENTS<br />
ESUR 2009 President’s welcome .................................................4<br />
Acknowledgments.......................................................................5<br />
ESUR 2009 Organization .............................................................6<br />
ESUR 2009 Faculty ......................................................................7<br />
Accreditation...............................................................................8<br />
Social Programme...................................................................... 9<br />
General Information ...................................................................10<br />
Maps – Conference halls..............................................................12<br />
ESUR 2009 Programme Overview ...............................................14<br />
Scientific Programme<br />
Thursday, September 10 th , 2009..................................................... 17<br />
Friday, September 11 th , 2009......................................................... 19<br />
Saturday, September 12 th , 2009..................................................... 22<br />
Sunday, September 13 th , 2009 ....................................................... 25<br />
Members’ Day Sessions (<strong>abstracts</strong>) ........................................... 31<br />
Opening Ceremony Lectures .......................................................40<br />
SUR Honorary Lecture ............................................................... 42<br />
ESUR Guidelines Session (<strong>abstracts</strong>) ......................................... 43<br />
Course Lectures (<strong>abstracts</strong>)....................................................... 47<br />
Workshops (<strong>abstracts</strong>) .............................................................. 70<br />
Oral Presentations (<strong>abstracts</strong>)................................................... 108<br />
Radiological Technologists’ Sessions (<strong>abstracts</strong>) ........................129<br />
Posters Exhibition (<strong>abstracts</strong>).....................................................132<br />
List of Delegates........................................................................ 174<br />
3
ESUR 2009 President’s Welcome<br />
Dear Participants, Dear Friends<br />
On behalf of the Local Organizing Committee, I warmly welcome you to attend the<br />
ESUR 2009 in Athens.<br />
The main topic of this very Symposium is “Urogenital Manifestations of Systemic<br />
Diseases”. We believe that this topic allows us to share our scientific experience with<br />
colleagues from other Specialities as well.<br />
The scientific and social programmes of ESUR 2009 make us confident that we will<br />
have, for one more time, a very successful meeting.<br />
Hoping that all of you will have a very nice staying in Athens – Greece, I thank you<br />
very much for your presence in here.<br />
I welcome you ( Kalos Ilthate),<br />
George L. Malachias, MD.<br />
4
ACKNOWLEDGMENTS<br />
The Local Organizing Committee of the 16 th European Symposium on<br />
Urogenital Radiology wish to acknowledge the contribution of the following<br />
companies and organizations for their financial support:<br />
MAIN SPONSORS<br />
BRACCO INTERNATIONAL BV<br />
COVIDIEN<br />
GE HEALTHCARE<br />
SPONSORS<br />
A & L MEDICAL SUPPLIES Ltd - COOK<br />
AGFA GEVAERT SA<br />
BAYER HELLAS ABEE<br />
CARESTREAM HEALTH HELLAS<br />
K. MARNEROS SA<br />
MEDIA VIS SA (EIZO)<br />
GREEK NATIONAL TOURISM ORGANIZATION<br />
PFIZER HELLAS SA<br />
ROXANA LTD<br />
SIEMENS SA<br />
SMART ONE - K. ASANAKIS<br />
5
ESUR 2009 ORGANIZATION<br />
Scientific Committee<br />
ESUR Board<br />
Malachias G. (GR) – Chairman<br />
Derchi L.E. (I)<br />
Hamm B.K. (D)<br />
Kinkel K. (CH)<br />
Morcos S.K. (UK)<br />
Mueller-Lisse U.G. (D)<br />
Oyen R. (B)<br />
Heinz-Peer G. (A)<br />
Papanicolaou N. (USA)<br />
Ramchandani P. (USA)<br />
Yarmenitis S. (GR)<br />
Hamm B.K., M.D., President (D)<br />
Heinz-Peer G., M.D., President-Elect (A)<br />
Morcos S.K., M.D., Past President (UK)<br />
Løgager V., M.D., Secretary/Treasurer (DK)<br />
Bellin M.F., M.D., Member-at-large (F)<br />
Local Organizing Committee<br />
Malachias G. – President<br />
Anastopoulos J.<br />
Drossos Ch.<br />
Evlogias N.<br />
Katsou G.<br />
Koumanidou Ch.<br />
Papadopoulos V.<br />
Papailiou J.<br />
Piperopoulos P.<br />
Prassopoulos P.<br />
Strigaris K.<br />
Triantopoulou Ch.<br />
Tsampoulas K.<br />
Tsili A.<br />
Abstracts’ Evaluation Committee<br />
Oral Presentations<br />
Poster Presentations<br />
Gourtsoyianni S.<br />
Bellin M.F.<br />
Yarmenitis S. Collins M.<br />
Mueller-Lisse U.L. Katsou G.<br />
Oyen R.<br />
Special Duties Team<br />
Katelanis S.<br />
Leonardou P.<br />
Antonopoulos A.<br />
Responsible for Scientific Programme’s Flow<br />
Responsible for Audiovisuals’ Co-Ordination and Control<br />
Responsible for Delegates’ Service<br />
Administrative Secretariat<br />
PRC Congress & Travel<br />
Public Relations Center<br />
102, Michalakopoulou Str. 115 28 Athens, Greece<br />
Tel.: ++30 210 77 11 673, 210 77 56 336<br />
Fax: ++30 210 77 11 289<br />
E-mail: ESUR2009@prctravel.gr<br />
Website: www.esur2009.gr<br />
www.prctravel.gr<br />
6
FACULTY 2009<br />
AGADAKOS E. (GR)<br />
AMENDOLA M. (USA)<br />
ANASTOPOULOS J. (GR)<br />
ANTSAKLIS A. (GR)<br />
BABNIK-PESKAR D. (SL)<br />
BALLEYGUIER C. (F)<br />
BARENTSZ J. (NL)<br />
BAUMGARTEN D. (USA)<br />
BELLIN M.F. (F)<br />
BERTOLOTTO M. (I)<br />
BRKLJACIC B. (HR)<br />
CHALAZONITIS A. (GR)<br />
CHOYKE P. (USA)<br />
CLAUDON M. (F)<br />
COKKINOS D. (GR)<br />
COLLINS M. (UK)<br />
CORNUD F. (F)<br />
COVA M. (I)<br />
COWAN N. (UK)<br />
CUNHA T. M. (P)<br />
CURRY N. (USA)<br />
DALLA PALMA L. (I)<br />
DANZA F. (I)<br />
DELIKANAKIS N. (GR)<br />
DERCHI L. (I)<br />
DIMOPOULOU A. (S)<br />
DOGRA V. (USA)<br />
DROSSOS CH. (GR)<br />
EFREMIDIS S. (GR)<br />
EL DIASTY T. (ET)<br />
EVLOGIAS N. (GR)<br />
FORSTNER R. (A)<br />
GEORGIADIS K. (GR)<br />
GHIATAS A. (GR)<br />
GOLDMAN S. (USA)<br />
GOULIAMOS A.(GR)<br />
GOURTSOYIANNI S. (GR)<br />
GRENIER N. (F)<br />
HALLSCHEIDT P. (D)<br />
HAMM B.K. (D)<br />
HANNA S.(ET)<br />
HEINZ-PEER G. (A)<br />
HELENON O. (F)<br />
JAKOBSEN J. (N)<br />
KASTRIOTIS J. (GR)<br />
KATSIFARAKIS D.(GR)<br />
KATSOU G. (GR)<br />
KELEKIS N. (GR)<br />
KENNEY P. (USA)<br />
KIM SEUNG HYUP (KOR)<br />
KINKEL K. (CH)<br />
KOUMANIDOU CH. (GR)<br />
KOUMARIANOS D. (GR)<br />
KUBIK – HUCH R. (CH)<br />
LIVADAS M. (GR)<br />
LOGAGER V. (DK)<br />
MAGNUSSON A. (S)<br />
MALACHIAS G. (GR)<br />
MALAMATENIOU CH. (GR)<br />
Mc HUGO JO (UK)<br />
ΜΑTSAIDONIS D. (GR)<br />
MORCOS S. K. (UK)<br />
MOREAU J.F. (F)<br />
MORGAN E. (UK)<br />
MOUSSA S. (UK)<br />
MUELLER-LISSE U.G. (D)<br />
MUELLER-LISSE U.L. (D)<br />
NIKOLAIDIS P. (USA)<br />
NICOLAOU I. (GR)<br />
NOLTE-ERNSTING C. (D)<br />
OCANTOS J. (ARG)<br />
OYEN R. (B)<br />
PAPADOPOULOS V. (GR)<br />
PAPADOPOULOU F. (GR)<br />
PAPAILIOU J. (GR)<br />
PAPANIKOLAOU N. (USA)<br />
PAVLICA P. (I)<br />
PETSAS TH. (GR)<br />
PIPEROPOULOS P. (GR)<br />
PRASSOPOULOS P. (GR)<br />
RAMCHANDANI P. (USA)<br />
RICCABONA M. (A)<br />
ROCKALL A. (UK)<br />
ROY C. (F)<br />
SALA E. (UK)<br />
SANDSTEDE J. (D)<br />
SANDLER K. (USA)<br />
SCHERR M. (D)<br />
SEBASTIA C. (E)<br />
SPENCER J. (UK)<br />
STRIGARIS K. (GR)<br />
TAVERNARAKI A. (GR)<br />
THEODOROPOULOS V. (GR)<br />
THOENY H. (CH)<br />
THOMSEN H. (DK)<br />
TRIANTOPOULOU CH. (GR)<br />
TSAMPOULAS K. (GR)<br />
TSILI A. (GR)<br />
TSITOURIDIS I. (GR)<br />
TSOUROULAS M. (GR)<br />
TURGUT A. (T)<br />
VAN DER MOLEN A. (NL)<br />
VILLERS A. (F)<br />
WASSERMAN N. (USA)<br />
WEBB J. (UK)<br />
YARMENITIS S. (GR)<br />
ZAGORIA R. (USA)<br />
ZOUPAS CH. (GR)<br />
7
ACCREDITATION<br />
The 16th European Symposium on Urogenital Radiology is accredited by the European<br />
Accreditation Council for Continuing Medical Education (EACCME) to provide the following<br />
CME activity for medical specialists. The EACCME is an institution of the European Union<br />
of Medical Specialists (UEMS).<br />
www.uems.be<br />
European Accreditation is granted by the EACCME in order to allow participants to<br />
validate the credits obtained at this activity in their home European Country.<br />
The 16 th European Symposium on Urogenital Radiology is designed for a maximum of 18<br />
hours of European external CME credits. Each medical specialist should only claim those<br />
hours of credit that he/she actually spent in the educational activity.<br />
EACCME credits are recognized by the American Medical Association towards the<br />
Physician’s Recognition Award (PRA). To convert EACCME credits to AMA PRA category I<br />
credit, please contact AMA.<br />
Distribution of CME Credits for ESUR 2009 as follows:<br />
September 10, 2009: 3 Credits<br />
September 11, 2009: 6 Credits<br />
September 12, 2009: 6 Credits<br />
September 13, 2009: 3 Credits<br />
You may earn a total of 18 category “A” credits if you attend ESUR 2009 on all 4 days.<br />
The CME credit certificate will be handed out on Sunday 13 th , 2009.<br />
8
SOCIAL PROGRAMME<br />
EVENING PROGRAMME<br />
Member’s Dinner<br />
On Thursday, September 10 th the Members’s dinner will be held at the “Brasserie SUD<br />
of PIERONE” located by the sea in a magnificent marina-yaughting club.<br />
The entrance tickets will be handed out on site at the secretariat of Symposium<br />
(if registered).<br />
On site registration is subject to availability.<br />
Welcome reception<br />
On Friday, September 11 th all participants are invited to join the Welcome Reception just<br />
after the Opening Ceremony, both at the conference venue.<br />
Entrance free of charge for all registered participants.<br />
Course Dinner<br />
On Saturday, September 12 th the Course Dinner will be held at the Cape Sounio Hotel,<br />
nearby the Famous Ancient Temple of Poseidon builded at the top of the Southmost cape<br />
of European Continent offering one of the most beautiful sunsets in Mediterranean Sea.<br />
The entrance tickets will be handled out on site at the secretariat of Symposium (if<br />
registered).<br />
On site registration is subject ti availability.<br />
9
GENERAL INFORMATION<br />
SYMPOSIUM VENUE<br />
ROYAL OLYMPIC HOTEL<br />
Athens, Greece, Tel: +30 210 9288400, Fax: +30 210 9233317<br />
Website: www.royalolympic.com E-mail: info@royalolympic.com<br />
DATES<br />
SEPTEMBER, 10-13 2009<br />
REGISTRATION FEES<br />
Registration<br />
ESUR/SUR Member<br />
Non Member<br />
300EURO<br />
350EURO<br />
* Residents-in-training 120EURO<br />
*Radiological<br />
Technologists<br />
Medical Students<br />
Accompanying Persons<br />
Members Dinner<br />
Course Dinner<br />
80EURO<br />
70EURO<br />
150EURO<br />
75 EURO<br />
85 EURO<br />
REGISTRATION FEE FOR THE PARTICIPANTS INCLUDES<br />
• Entrance to the Symposium Halls<br />
• Welcome Reception<br />
• Programme, Badge and Bag<br />
• Coffee during the breaks (5 tickets)<br />
• Light lunch during the Satellite Symposia<br />
(only for the attenders)<br />
REGISTRATION FEE FOR THE ACCOMPANYING PERSONS INCLUDES<br />
• Welcome Reception<br />
• Waliking Tour in the Archaelogical center of Athens on Saturday morning 12.09.09 (Plaka, Monastiraki, Ancient<br />
Market, Roman Market, Acropolis)<br />
OFFICIAL LANGUAGE<br />
The official language is English. No translation will be provided.<br />
CLIMATE AND CLOTHING<br />
The weather in Greece during the month of September is generally mild in the mornings and quite fresh in the evening.<br />
ELECTRICITY<br />
Please note that electricity in Greece is 200V.<br />
INSURANCE<br />
All participants are strongly advised to carry the proper travel and health insurance, as the ESUR 2009 cannot accept<br />
liability for any accidents or injuries that may occur at the Symposium. Please consult your travek agent regarding the<br />
matter.<br />
TRAVELLING – PASSPORT AND VISAS<br />
Visas are required from citizens of some foreign countries. Participants should check with their travel agents, Greek<br />
consulate offices or diplomatic missions in their own countries whether or not visas are required.<br />
For more information, please contact the Secretariat.<br />
10
SCIENTIFIC & COMMERCIAL EXHIBITION<br />
During the Symposium, a Scientific & Commercial Exhibition will take place.<br />
DATA PREVIEW<br />
A Speakers’ Ready Room will operate throughout the duration of the Symposium.<br />
Speakers are kindly requested to hand in all material of their presentation (slides, floppy disc,<br />
USB-key, CD-ROM) at least two hours before their scheduled presentation time.<br />
If a presentation is scheduled early in the morning, speakers are kindly requested to check their<br />
presentation at the Speakers’ Ready Room the day before.<br />
Please note that all versions of MS PowerPoint are accepted excluding Mac.<br />
If you are using embedded video clips in your presentation, please remember to submit video<br />
files separately.<br />
BADGES<br />
Delegates’ badges will be available at the Symposium Secretariat in the Symposium Venue. It is<br />
advisable for all participants to wear their badges both in the Symposium and the Exhibition Area.<br />
The badges will be distributed as following:<br />
Faculty (Speakers – Chairpersons)<br />
Participants<br />
Accompanying Persons<br />
Exhibitors<br />
Secretariat Staff<br />
Red Colour<br />
Blue Colour<br />
Green Colour<br />
Yellow Colour<br />
Grey Colour<br />
CME CREDITS<br />
The 16th European Symposium on Urogenital Radiology is accredited by the European<br />
Accreditation Council for Continuing Medical Education (EACCME) to provide the following CME<br />
activity for medical specialists. The EACCME is an institution of the European Union of Medical<br />
Specialists (UEMS).<br />
The 16th European Symposium on Urogenital Radiology has been accredited with 18 CME<br />
credits.<br />
CERTIFICATE OF ATTENDANCE<br />
A Certificate of Attendance will be available for all participants, at the Symposium Secretariat, on<br />
September 13 th , 2009.<br />
SECRETARIAT<br />
The Symposium Secretariat will be operating at the Symposium Area, for registrations and<br />
information, throughout the Symposium and during the Symposium’s hours, as following:<br />
Thursday, September 10 th , 2009 08:30 – 19:00<br />
Friday, September 11 th , 2009 08:00 – 18:00<br />
Saturday, September 12 th , 2009 08:00 – 17:30<br />
Sunday, September 13 th , 2009 08:00 – 13:30<br />
11
MAPS<br />
Center of Athens & Conference Venue<br />
Public transportations<br />
For all the public transport (Metro/Underground, Tram, Bus, HSAP) there is one ticket, with<br />
duration of 90 minutes, that costs 1,00€.<br />
From the Acropolis Station of Metro the Hotel is 100m away, walking along Ath. Diakou Street.<br />
Also, from the Vouliagmenis Avenue Station of TRAM the Hotel is 40m away.There are also<br />
several lines of bus near the hotel to all the directions.<br />
Conference halls<br />
• Alexander<br />
• Attica<br />
• Conference 1<br />
• Conference 2<br />
• Kalliroi B<br />
• Olympia 1<br />
• Olympia 2<br />
• Royal Olympic Ground<br />
Poster Area<br />
• Kalliroi A<br />
12
Attica (with marks of the 2 Dinners places)<br />
13
SCIENTIFIC PROGRAMME<br />
15
Clarification: Affiliations, authors’ names and <strong>abstracts</strong>’ texts(spelling, syntax, content) are<br />
presented as they have been submitted.<br />
There is no kind of intervention by the Scientitic Committee.<br />
16
Thursday, September 10th, 2009<br />
10:30 Registration<br />
HALL KALLIROI A<br />
12:00-18:00 Posters Exhibition<br />
Members’ Day Sessions<br />
HALL ATTICA<br />
Before session:<br />
5 min. information by G. Malachias about the Symposium Venue, the City<br />
of Athens, public transports etc.<br />
14:00 – 15:40 Session I<br />
Moderators: Hamm B.K. (D) - Mueller-Lisse U.L. (D)<br />
14:00 MS1. POTENTIAL ROLE OF MR DIFFUSION-WEIGHTED IMAGING<br />
(DW-MRI) WITH APPARENT DIFFUSION COEFFICIENT (ADC)<br />
VALUE TO EVALUATE RENAL INSUFFICIENCY AT 3T<br />
Roy C. (F)<br />
14:10 MS2. MULTIDETECTOR-ROW CT UROGRAPHY: RETROSPECTIVE<br />
COMPARISON BETWEEN STANDARD AND LOW-DOSE<br />
PROTOCOLS FOR DELINEATION OF UPPER URINARY TRACT<br />
SEGMENTS<br />
Mueller-Lisse U.L. (D)<br />
14:20 MS3. COMPARISON AND CORRELATION BETWEEN 1H-MRI IN-<br />
VIVO PROSTATE SPECTROSCOPY AT 1, 5 T AND EX-VIVO HIGH<br />
RESOLUTION MAGIC ANGLE 1H-NMR SPECTROSCOPY AT 11 T IN<br />
THE EVALUATION OF NEW METABOLITE LEVELS IN PROSTATE<br />
CANCER.<br />
Panebianco V. (Ι)<br />
14:30 MS4. EARLY CERVICAL CANCER: ROLE OF MRI WITH ARTIFICIAL<br />
HYDROCOLPOS IN THE PREOPERATIVE ASSESSMENT OF PATIENT<br />
ELIGIBLE FOR FERTILITY-SPARING SURGERY<br />
Derchi L.E. (I)<br />
14:40 MS5. ASSESSMENT OF TUMORAL ANGIOGENESIS IN<br />
ENDOMETRIAL CARCINOMA WITH DYNAMIC-CONTRAST-<br />
ENHANCED MAGNETIC RESONANCE IMAGING: A PROSPECTIVE<br />
STUDY.<br />
Restaino G. (I)<br />
14:50 MS6. 3T MR SPECTROSCOPIC IMAGING WITH AND WITHOUT<br />
ENDORECTAL COIL IN LOCALIZING PROSTATE CANCER<br />
Yakar D. (NL)<br />
15:00 MS7. STIMULATION OF CULTURED HUMAN DERMAL<br />
FIBROBLAST COLLAGEN PRODUCTION BY GADOLINIUM<br />
CHELATES<br />
Morcos S.K. (UK)<br />
15:10 MS8. DIFFUSION-WEIGHTED MRI ALLOWS FOR THE DETECTION<br />
OF PELVIC LYMPH NODE METASTASES IN BLADDER AND<br />
PROSTATE CANCER PATIENTS: COMPARISON WITH<br />
HISTOPATHOLOGY.<br />
Thoeny H.C. (CH)<br />
17
15:20 MS9. EVALUATION OF RETROGRADE URETEROPYELOGRAPHY<br />
AND FLUOROSCOPICALLY GUIDED BIOPSY FOR DIAGNOSTIC<br />
UPPER TRACT UROTHELIAL CANCER FOLLOWING<br />
MULTIDETECTOR COMPUTED TOMOGRAPHY UROGRAPHY IN<br />
PATIENTS PRESENTING WITH MACROSCOPIC HAEMATURIA<br />
OVER 40-YR OF AGE.<br />
Cowan N.C. (UK)<br />
15:30 MS10. EVALUATION OF A PNEUMATICALLY ACTUATED MR-<br />
COMPATIBLE ROBOT FOR MR-GUIDED PROSTATE BIOPSY<br />
Futterer J.J. (NL)<br />
15:40 – 16:00 Coffee Break<br />
16:00 – 18:00 Session II<br />
Moderators: Morcos S.K. (UK) - Derchi L. (I)<br />
16:00 MS1. DIFFUSION WEIGHTED MRI IN EVALUATION OF<br />
TRANSPLANTED KIDNEY: PRELIMINARY CLINICAL EXPERIENCE<br />
Abou El-Ghar M. (ET)<br />
16:10 MS2. THE VALUE OF ULTRASOUND FINDINGS AND SERUM<br />
PROCALCITONIN LEVELS IN UPPER URINARY TRACT INFECTION<br />
IN CHILDREN<br />
Vranou E. (GR)<br />
16:20 MS3. DOES CEUS HAVE A PRACTICAL VALUE IN ADJUNCT TO<br />
COLOR DOPPLER US IN EVALUATION OF PATIENTS WITH RENAL<br />
INSUFFICIENCY EVALUATION OF 56 PATIENTS<br />
Bertolotto M. (I)<br />
16:30 MS4. INFLUENCE OF NITRIC OXIDE ON OXYGEN CONSUMPTION<br />
BY IODINATED CONTRAST MEDIA IN FRESHLY ISOLATED<br />
PROXIMAL TUBULAR CELLS FROM ELDERLY HUMANS AND<br />
DIABETIC RATS.<br />
Liss P. (SE)<br />
16:40 MS5. INCIDENCE OF IN-HOSPITAL TREATED RENAL FAILURE IN<br />
23,425 SWEDISH PATIENTS AFTER CORONARY PROCEDURES<br />
Liss P. (SE)<br />
16:50 MS6. MDCT AND RENAL ARTERY IN-STENT RESTENOSIS; IS<br />
RADIATION EXPOSURE REDUCTION FEASIBLE<br />
Manousaki E. (GR)<br />
17:00 MS7. MAGNETIC RESONANCE IMAGING IN THE EVALUATION OF<br />
PLACENTAL ABRUPTION: CORRELATION WITH COLOR DOPPLER<br />
ULTRASOUND<br />
Masselli G. (I)<br />
17:10 MS8. MORPHOMETRY OF TISSUE MICROSTRUCTURE:<br />
COMPARISON OF DIGITAL LIGHT MICROSCOPY (DLM) AND<br />
INTRALUMINAL CATHETER-BASED OPTICAL COHERENCE<br />
TOMOGRAPHY (OCT) IN NORMAL PORCINE URETER WALL<br />
SPECIMENS<br />
Mueller-Lisse U.L. (D)<br />
17:20 MS9. EMBOLIZATION OF POLYCYSTIC KIDNEYS: AN<br />
ALTERNATIVE TO NEPHRECTOMY BEFORE RENAL<br />
TRANSPLANTATION: A WORK IN PROGRESS.<br />
Hubrecht R.. (F)<br />
17:30 MS10. THIN SLICE THICKNESS (1MM) 3D-T2-WEIGHTED MRI AND<br />
LOCAL STAGING OF PROSTATE CANCER<br />
Cornud F. (F)<br />
17:40 MS11. FUNCTIONAL MRI (DIFFUSION WEIGHTED AND DYNAMIC<br />
CONTRAST ENHANCED IMAGING) IN PATIENTS WITH LOW RISK<br />
PROSTATE CANCER.<br />
18
Cornud F. (F)<br />
17:50 MS12. RADIATION DOSE REDUCTION IN MULTIPHASE CTU BY AN<br />
ADAPTIVE COLLIMATOR<br />
Van der Molen A.J., MD (NL)<br />
18:00-18:30 Session for the ESUR news presentation by the President of ESUR<br />
HALL ALEXANDER<br />
18:30-19:00 Meeting of Sc. Committee to confirm the Awards of Members’ day<br />
20:00 Members’ Dinner (Resraurant “Brasserie SUD of PIERONE”)<br />
(Announcement of Awards of Μembers’ Day by the President of the ESUR 2009 and the President<br />
of ESUR Βoard).<br />
Friday, September 11th, 2009<br />
08:00 – 18:00 Registration<br />
Posters Exhibition<br />
LECTURE SESSIONS<br />
HALL OLYMPIA 1<br />
08:30 - 08:35 Welcome by Prof. Hamm B.K. (D) and Dr. Malachias G. (GR)<br />
08:35 – 10:00 New frontiers in Imaging<br />
Moderators: Cornud F. (F) - Gouliamos A. (GR)<br />
08:35 – 09:00 Imaging of inflammation and fibrosis<br />
Grenier N. (F)<br />
09:00 – 09:25 New frontiers in US imaging<br />
Dogra V. (USA)<br />
09:25 – 09:50 Imaging of atherosclerosis<br />
Hamm B.K. (D)<br />
10:00 – 10:30 Coffee Break<br />
10:30 – 12:30 Prostate cancer<br />
Chairman: Barentsz J. (NL)<br />
WORKING GROUP<br />
LECTURE SESSIONS<br />
10 min. Discussion<br />
CONFERENCE 1<br />
HALL OLYMPIA 1<br />
10:30 – 12:00 Diabetes mellitus<br />
Moderators: Tsampoulas K. (GR) - Triantopoulou Ch. (GR)<br />
10:30 – 11:00 Diabetes and Diabetic Nephropathy<br />
Zoupas Ch . (GR)<br />
11:00 – 11:30 Imaging of genitourinary complications of diabetes mellitus<br />
Danza F. (I)<br />
11:30 – 11:50 Use of CM in diabetic patients<br />
Morcos S.K. (UK)<br />
10 min. Discussion<br />
12:00 - 13:30 MEETING ESUR CTU/MRU<br />
Chairman: Cowan N. (UK)<br />
19<br />
ALEXANDROS HALL
12:00 – 13:30 Satellite Symposium<br />
Lunch/Symposium by GE HealthCare<br />
Moderators: Hanna S. (ET) - Cokkinos D. (GR)<br />
Speaker: Sandstede J. (D)<br />
OLYMPIA 1<br />
LECTURE SESSIONS<br />
OLYMPIA 1<br />
13:30 – 15:00 Lymphoproliferative disorders<br />
Moderators: Ramchandani P. (USA) - Amendola M. (USA)<br />
13:30 – 13:55 Retroperitoneal Lymphoproliferative disease<br />
Goldman S. (USA)<br />
13:55 – 14:20 Imaging of lower GU tract Lymphoma<br />
Amendola M. (USA)<br />
14:20 – 14:45 Genitourinary lymphoma: case histories<br />
Spencer J. (UK)<br />
15 min. Discussion<br />
15:00 – 15:30 Awards of Members’day and presentation of the first winning paper<br />
by the main author.<br />
Chairman: Hamm B.K. (D)<br />
15:30 – 16:00 Coffee Break<br />
16:00 – 17:20 WORKSHOPS<br />
1. Urography with CT and MRI<br />
Moderators: Roy C. (F) - Drossos Ch. (GR)<br />
HALL OLYMPIA 1<br />
16:00 – 16:20 CTU technique and applications<br />
Roy C. (F)<br />
16:20 – 16:40 The Development of multidetector Computed Tomography Urography<br />
for investigating Haematuria.<br />
Cowan N. (UK)<br />
16:40 – 17:00 CTU and IVU Radiation Dose<br />
Van der Molen A. (NL)<br />
17:00 – 17:20 MRU technique and applications<br />
Nolte-Ernsting C. (D)<br />
2. Prostate Imaging<br />
Moderators: Barentsz J. (NL) - Yarmenitis S. (GR)<br />
HALL OLYMPIA 2<br />
16:00 - 16:20 Morphometric features and clinical aspects of Prostate cancer.<br />
Villers A. (F)<br />
16:20 - 16:40 TRUS of Prostate cancer (PCa):a reappraisal in 2009.<br />
Cornud F. (F)<br />
16:40 - 17:00 MRI in Prostate cancer.<br />
Barentsz J. (NL)<br />
10 min. Discussion<br />
20
3. Interventional Uroradiology<br />
Moderators: Moussa S. (UK) - Papailiou J. (GR)<br />
16:00 - 17:00 Management of Urinary stones in 2009: A Team approach.<br />
Speakers: Moussa S. (UK) - Magnusson A. (S)<br />
4. Female pelvis / Imaging<br />
Moderators: Kinkel K. (CH) - Tsili A. (GR)<br />
HALL ATTICA<br />
HALL KALLIROI B<br />
16:00 – 16:20 Tips and tricks for scanning in Gynecology.<br />
Mc Hugo J. (UK)<br />
16:20 – 16:40 What we should not forget to put in a sonographic report about the female pelvis.<br />
Cunha T.M. (P)<br />
16:40 – 17:00 Limitations of female pelvic ultrasound. When do you need MRI /CT<br />
Sala E. (UK)<br />
10 min.Discussion<br />
17:45<br />
HALL OLYMPIA 1<br />
Greetings<br />
Awards of 8 past Presidents of ESUR<br />
Moderators: Malachias G. (GR) , Hamm B. (D)<br />
Official Opening of the Symposium<br />
Opening lectures<br />
Moderator: Dalla Palma L.( IT)<br />
WW1. Use of X-Rays on the Greek front<br />
Livadas G. (GR)<br />
One century of Uroradiology in Europe<br />
Moreau J.F (FR)<br />
WELCOME RECEPTION<br />
21
Saturday, September 12 TH , 2009<br />
08:00 – 18:00 Registration – Posters Exhibition<br />
LECTURE SESSIONS<br />
HALL OLYMPIA 1<br />
08:30 – 10:00 Infectious Diseases<br />
Moderators: Jakobsen J. (N) - Wasserman N. (USA)<br />
08:30 – 08:50 Clinical overview: HIV-AIDS<br />
Morgan E. (UK)<br />
08:50 – 09:10 GU manifestations of AIDS: Reappraisal of imaging findings<br />
Amendola M. (USA)<br />
09:10 – 09:30 Tuberculosis, Parasitic diseases and unusual infections in the GU tract<br />
El-Diasty T. (ET)<br />
09:30 - 09:50 Other Inflammatory Conditions of the Urinary Tract<br />
Wasserman N.F. (USA)<br />
Discussion<br />
10:00 – 10:30 Coffee Break<br />
10.30 – 12.00 Genetic diseases & drug-induced disorders<br />
Moderators: Morcos S.K. (UK) - Koumanidou C. (GR)<br />
10:30 – 10:50 Hereditary disorders of the paediatric urinary tract<br />
Riccabona M. (A)<br />
10:50 – 11:10 Renal cystic disease<br />
Heinz-Peer G. (A)<br />
11:10 – 11:30 Hereditary renal cancers<br />
Choyke P. (USA)<br />
11:30 – 11:50 Drug-induced abnormalities in the GU tract<br />
Ramchandani P. (USA)<br />
10 min.<br />
HALL OLYMPIA 1<br />
10 min. Discussion<br />
HALL ROYAL OLYMPIC GROUND<br />
10:30-12:00 Radiological Technologists’ Sessions<br />
Session 1<br />
Moderators: Georgiadis K. (GR) - Nicolaou I. (GR)<br />
10:30 – 11:00 Magnetic Resonance Imaging of Urinary System<br />
Malamateniou Ch. (UK)<br />
11:00 – 11:10 Coffee Break<br />
(only for this session )<br />
Session 2<br />
Moderators: Katsifarakis D. (GR) - Delikanakis N. (GR)<br />
11:10 – 11:35 Contrast Media and multidetection CT:A Radiographer’s perspective<br />
Agadakos E. (GR) p.<br />
11:35 – 12:00 Optimization of multi-detector rowCT urography<br />
Koumarianos D. (GR)<br />
HALL OLYMPIA 1<br />
12:00 – 13:30 Satellite Symposium<br />
Lunch / Symposium by Bracco<br />
Moderators: Strigaris K. (GR) - Tavernaraki A. (GR)<br />
22
13:30 – 15:00 Female pelvic disorders<br />
Moderators: Brkljacic B. (HR) - Rockall A. (UK)<br />
HALL OLYMPIA 1<br />
13:30 – 13:55 Congenital Abnormalities-why do we need imaging<br />
Kinkel K. (CH)<br />
13:55 – 14:20 Prenatal Diagnosis and Therapy of Fetal Obstructive Urophathies.<br />
Antsaklis A. (GR)<br />
14:20 – 14:45 Metastases to the Female Genital tract<br />
Spencer J. (UK)<br />
15 min Discussion<br />
15:00 – 15:30 Coffee Break<br />
HALL OLYMPIA 1<br />
15:30 – 16:00 SUR Honorary Lecture<br />
Moderator: Hamm B.K. (D)<br />
PET/CT in Urologic Oncology<br />
Papanicolaou N. (USA)<br />
.<br />
16:00-17:20 WORKSHOPS<br />
1. Renal tumors- neoplasms<br />
Moderators: Babnik-Peskar D. (SL) - Efremidis S. (GR)<br />
HALL OLYMPIA 1<br />
16:00 – 16:20 Imaging and staging<br />
Mueller-Lisse U.G. (D)<br />
16:20 – 16:40 Small renal masses/how to deal with these<br />
Cova M. (I)<br />
16:40 – 17:00 Ablation of renal tumors<br />
Zagoria R. (USA)<br />
17:00 - 17:20 Biopsy of renal masses: why, when, how<br />
Papanicolaou N. (USA)<br />
2. Male Genitalia<br />
Moderators: Pavlica P. (I) - Dalla-Palma L. (I)<br />
HALL OLYMPIA 2<br />
16:00 – 16:20 Scrotal masses<br />
Oyen R. (B)<br />
16:20 – 16:40 Acute scrotum<br />
Bertolotto M. (I)<br />
16:40 – 17:00 MR of seminal vesicle and testicle in infertile men<br />
Ocantos J. (ARG)<br />
17:00 – 17:20 Imaging of Penile disorders<br />
Scherr M. (D)<br />
HALL ATTICA<br />
3. The adnexal mass<br />
Moderators: Ghiatas A. (GR) - Chalazonitis A. (GR)<br />
16:00 – 16:20 How to characterize and determine the origine of an adnexal mass at US<br />
Balleyguier C. (F)<br />
16:20 – 16:40 MRI assessment of an inderterminate adnexal mass at US<br />
Kubik-Huch R. (CH)<br />
16:40 – 17:00 Ovarian cancer Staging<br />
Forstner R. (A)<br />
17:00 – 17:20 MRI diagnosis of adnexal tumors by pattern recognition.<br />
Kim S.H. (KR)<br />
23
4. US of Urogenital tract<br />
Moderators: Yarmenitis S. (GR) - Riccabona M. (A)<br />
HALL KALLIROI B<br />
16:00 – 16:20 3DUS a lost territory for Radiology Or new challenge in Urogenital<br />
tract imaging<br />
Riccabona M. (A)<br />
16:20 – 16:40 Contrast US and aspects for its future role:from diagnostic imaging<br />
to new treatement options.<br />
Claudon M. (F)<br />
16:40 – 17:00 US of the transplanted kidney<br />
Yarmenitis S. (GR)<br />
17:00 – 17:20 US of the non neoplastic prostate disorders<br />
Turgut A.T. (TR)<br />
HALL CONFERENCE 1<br />
5. Retroperitoneum-Adrenals<br />
Moderators: Heinz-Peer G. (A) - Papadopoulou F. (GR)<br />
16:00 – 16:20 Adrenal imaging beyond Adenoma vs Non adenoma<br />
Kenney P. (USA)<br />
16:20 – 16:40 The practical role of the Radiologist facing adrenal masses.<br />
Hallscheidt P. (D)<br />
16:40 – 17:00 Retroperitoneal fluid collections<br />
Nikolaidis P. (USA)<br />
17:00 – 17:20 Retroperitoneal masses<br />
Baumgarten D. (USA)<br />
HALL ALEXANDER<br />
17:20 - 17:30 Meeting of Posters evaluation Committee to confirm the best three Posters<br />
20:00 Course Dinner (Cape Sounion Hotel)<br />
(Announcement of the best three Posters)<br />
24
Sunday, September 13 TH , 2009<br />
08:00 – 13:00 Posters Exhibition<br />
SCIENTIFIC SESSIONS<br />
08:30-10:00 URINARY TRACT IMAGING (CT AND MRI)<br />
Moderators: Logager V. (DK) - Dimopoulou A. (S)<br />
08:30 SS1. ACCURACY OF BLADDER CANCER DETECTION WITH<br />
CONTRAST ENHANCED ULTRASOUND<br />
Salvador R. (E)<br />
HALL OLYMPIA 1<br />
08:39 SS2. COMPARISON OF THE ACCURACY OF CT UROGRAPHY<br />
PREPARED WITH FRUSEMIDE VERSUS PREPARATION WITHOUT<br />
FRUSEMIDE IN THE DETECTION OF UROTHELIAL PATHOLOGY<br />
Wan E. (UK)<br />
08:48 SS3. VOIDING CYSTOURETHROGRAPHY IN MODERN IMAGING<br />
WORK-UP OF URINARY TRACT INFECTIONS IN CHILDREN<br />
Karanikas C. (GR)<br />
08:57 SS4. BREATH-HOLD MR-UROGRAPHY IN OBSTRUCTIVE UROPATHY<br />
Katsarou A. (GR)<br />
09:06 SS5. PERIRENAL FAT STRANDING AT CT IN PATIENTS WITH<br />
LOWER URINARY TRACT SYMPTOMS<br />
Sung D.J. (KOR)<br />
09:15 SS6. CT UROGRAPHY IN THE DIAGNOSIS OF BLADDER CANCER IN<br />
HIGH-RISK PATIENTS<br />
Otero-García M.M. (E)<br />
09:24 SS7. MAGNETIC RESONANCE IMAGING AT PATIENTS WITH A<br />
BLADDER CANCER, POSSIBILITY COMPLEX MRI<br />
Zuev V. (R)<br />
09:33 SS8. DUAL SOURCE CT CYSTOGRAPHY AND VIRTUAL<br />
CYSTOSCOPY VERSUS CYSTOSCOPY WITH PHOTODYNAMIC<br />
DIAGNOSIS (PDD) METHOD IN THE BLADDER CANCER<br />
Panebianco V. (I)<br />
HALL OLYMPIA 2<br />
08:30-10:00 PROSTATE IMAGING – MALE GENITALIA I<br />
Moderators: Claudon M. (F) - Piperopoulos P. (GR)<br />
08:30 SS1.STATE-OF-ART PROSTATE MR IMAGING<br />
Verma S. (USA<br />
08:39 SS2. PROSTATE MR AND MR SPECTROSCOPIC IMAGING<br />
AT 1.5T VERSUS 3T<br />
Verma S. (USA)<br />
25
08:48 SS3. MR SPECTROSCOPY (MRS) AND DINAMIC CONTRAST<br />
ENHANCED MR (DCEMR): DETECTION OF PROSTATE<br />
ADENOCARCINOMA FOCI IN MEN WITH PRIOR NEGATIVE<br />
PROSTATE BIOPSY AND ELEVATED PROSTATE SPECIFIC<br />
ANTIGEN (PSA) LEVELS.<br />
Panebianco V. (I)<br />
08:57 SS4. PRELIMINARY STUDY USING DCE-MRI WITH<br />
GADOFOSVESET TRISODIUM BLOOD POOL CONTRAST AGENT IN<br />
THE ASSESSMENT OF PROSTATE CANCER<br />
Panebianco V. (I)<br />
09:06 SS5. EVOLUTION OF PATTERN CHANGES FROM INFLAMMATION<br />
TO PROSTATE CANCER USING 1H-MRSI AND DCE-MRI<br />
Panebianco V. (I)<br />
09:15 SS6. CONTRAST-ENHANCED TRUS SIGNIFICANTLY INCREASES<br />
THE SENSITIVITY OF LOCALIZING BOTH LOW AND HIGH<br />
GLEASON GRADE PROSTATE CANCER<br />
Heijmink S. (NL)<br />
09: 24 SS7. HIGH B-VALUE DIFFUSION-WEIGHTED MR IMAGING IN<br />
PROSTATE CANCER AT 3T<br />
Inada Y. (J)<br />
09:33 SS8. PERFUSION MR IMAGING OF LOCAL RECURRENCE AFTER<br />
RADICAL PROSTATECTOMY<br />
Kubin K. (A)<br />
08:30-10:00 FEMALE PELVIS – FEMALE IMAGING<br />
Moderators: Bellin M.F. (F) - Sebastia M. (E)<br />
HALL KALLIROI B<br />
08:30 SS1. MRI IN THE WORK-UP OF INDETERMINATE OVARIAN MASS:<br />
PROTOCOLL OPTIMIZATION AND DIAGNOSTIC EFFICACY<br />
ANALYSIS<br />
Chilla B. (F)<br />
08:39 SS2. PRIMARY MALIGNANT MIXED MULLERIAN TUMORS OF THE<br />
UTERUS: SONOHYSTEROGRAPHIC AND COLOR DOPPLER<br />
FINDINGS<br />
Lee E.J. (KOR)<br />
08:48 SS3. VALUE OF CERVIX STRUCTURAL CHANGES AT MR IMAGING<br />
IN PATIENTS WITH RISK OF PRETERM DELIVERY<br />
Masselli G. (I)<br />
08:57 SS4. MR IMAGES OF RETAINED PLACENTAL TISSUE<br />
Takahama J. (J)<br />
09:06 SS5. DIFFUSION WEIGHTED MR IMAGING IN VULVA CANCER<br />
Ewald A.M. (DK)<br />
09:15 SS6. MR FINDINGS OF METASTATIC OVARIAN TUMORS<br />
do Nascimento A. F. (P)<br />
09:24 SS7. MAGNETIC RESONANCE IMAGING OF PELVIC<br />
ENDOMETRIOSIS. EFFECT OF READER’S EXPERIENCE ON<br />
ACCURACY AND INTEROBSERVER VARIABILITY.<br />
Restaino G. (I)<br />
09:33 SS8. PRE- AND POSTOPERATIVE DYNAMIC MRI: EVALUATION OF<br />
PELVIC ORGAN DESCENSUS IN SYMPTOMATIC WOMEN<br />
Alt CD. (D)<br />
26
09:42 SS9. LONG-TERM QUALITY OF LIFE ASSESSMENT IN PATIENTS<br />
UNDERGOING UTERINE FIBROID EMBOLIZATION<br />
Popovic M. (A)<br />
08:30-10:00 PROSTATE IMAGING – MALE GENITALIA II<br />
Moderators: Evlogias N. (GR) - Helenon O. (F)<br />
HALL ROYAL OLYMPIC GROUND<br />
08:30 SS1. DETECTION OF LOCAL RECURRENCE PROSTATE CANCER<br />
AFTER RETROPUBIC RADICAL PROSTATECTOMY: MRI VERSUS<br />
PET-CT<br />
Panebianco V. (I)<br />
08:39 SS2. CONTRAST-ENHANCED ULTRASOUND IN SCROTAL<br />
DISEASES: PRELIMINARY RESULTS<br />
Valentino M. (I)<br />
08:48 SS3. EMERGENCY SONOGRAPHIC EVALUATION OF THE<br />
SCROTUM. HOW OFTEN IS PATHOLOGY DETECTED AND WHICH<br />
ARE THE COMMONEST ABNORMALITIES<br />
Kyratzi E. (GR)<br />
08:57 SS4. SONOGRAPHY OF THE ACUTE SCROTUM: THE<br />
COMPLEMENTARY ROLE OF IMAGING WITH ECHO-ENHANCER.<br />
Tsagouli P. (GR)<br />
09:06 SS5. TESTICULAR TORSION: SONOGRAPHIC EVALUATION BEFORE AND<br />
AFTER MANUAL DETORSION<br />
Christopoulou A. (GR)<br />
09:15 SS6. PROSTATE VOLUME MEASUREMENT VIA<br />
TRANSABDOMINAL ULTRASONOGRAPHY (TAUS) COMPARED TO<br />
THE TRUE SURGICAL SPECIMEN VOLUME AFTER RADICAL<br />
PROSTATECTOMY.<br />
Chatzidarellis E. (GR)<br />
09:24 SS7. THE ESTIMATED PROSTATE VOLUME BY TRANSRECTAL<br />
ULTRASONOGRAPHY (TRUS) COMPARED TO THE SURGICAL<br />
SPECIMEN AFTER RADICAL PROSTATECTOMY.<br />
Chatzidarellis E. (GR)<br />
09:33 SS8. IMAGE BASED CLINICAL DECISION SUPPORT WITH THE USE<br />
OF TRANSRECTAL ULTRASOUND IN THE DIAGNOSIS OF<br />
PROSTATE CANCER: COMPARISON OF MULTIPLE LOGISTIC<br />
REGRESSION, ARTIFICIAL NEURAL NETWORK, AND SUPPORT<br />
VECTOR MACHINE<br />
Lee H.J. (KOR)<br />
HALL ATTICA<br />
08:30-10:00 NEW FRONTIERS IN IMAGING AND SYSTEMIC DISEASES<br />
Moderators: Thoeny H. (CH) - Kelekis N. (GR)<br />
08:30 SS1. USPIO ENHANCED DIFFUSION-WEIGHTED MRI TO DETECT<br />
PELVIC LYMPH NODE METASTASES IN NORMAL SIZED NODES.<br />
Thoeny H.C. (CH)<br />
08:39 SS2. EFFICIENCY OF DIFFUSION-WEIGHTED (DW) MR IMAGING<br />
TO DETECT SMALL SIZE MALIGNANT PELVIC LYMPH NODES AT<br />
3T IN VARIOUS PELVIC CARCINOMATOUS DISEASES.<br />
Roy C. (F)<br />
08:48 SS3. RENAL ULTRASONOGRAPHIC FINDINGS IN GREEK PATIENTS<br />
WITH SICKLE-CELL ANAEMIA AND THALASSAEMIA INTERMEDIA<br />
Kornezos I. (GR)<br />
27
08:57 SS4. CIN GUIDELINE ADHERENCE BY REQUESTING PHYSICIANS:<br />
ANALYSIS OF ABDOMINAL CT AT A LARGE UNIVERSITY CENTER<br />
IN THE NETHERLANDS<br />
Van Der Molen A.J.. (NL)<br />
09:06 SS5. THE PROGNOSTIC VALUE OF PERIRENAL INVOLVEMENT IN<br />
THE EVALUATION OF ACUTE PANCREATITIS SEVERITY<br />
Fagrezos D. (GR)<br />
09:15 SS6. LIVER METASTASES FROM RENAL CANCER: THE ADDED<br />
VALUE OF ARTERIAL PHASE OF THE LIVER IN STAGING WITH CT.<br />
Maniatis V. (GR)<br />
09:24 SS7. THE APPLICATION OF MULTIDETECTOR COMPUTED<br />
TOMOGRAPHY IN THE DIAGNOSTIC EVALUATION OF ADULT<br />
POST-TRAUMATIC HEMATURIA<br />
Soldatos Th. (GR)<br />
09:33 SS8. MESOAORTIC NARROWING OF THE LEFT RENAL VEIN IN<br />
ASYMPTOMATIC ADULTS: A NORMAL FINDING, NOT A<br />
NUTCRACKER SYNDROME<br />
Chernyak V. (USA)<br />
09:42 SS9. 64-MDCT EVALUATION OF POTENTIAL LAPAROSCOPIC<br />
LIVING RENAL DONORS<br />
Salvador R. (E)<br />
ΗΑLL CONFERENCE 1<br />
08:30-10:00 INTERVENTIONAL URORADIOLOGY<br />
Μοderators: Petsas Th. (GR) - Theodoropoulos V. (GR)<br />
08:30 SS1. DYNAMIC MRI IN PATIENTS TREATED WITH SUB-URETHRAL<br />
SLING FOR STRESS URINARY INCONTINENCE<br />
Ocantos J. (ARG)<br />
08:39 SS2. LONG TERM RESULTS AFTER PROLONGED URETERAL<br />
STENTING IN CASES OF OBSTRUCTIVE UROPATHY POST RENAL<br />
TRANSPLANTATION<br />
Ikonomopoulou V. (GR)<br />
08:48 SS3. OUTCOMES AND COMPLICATIONS OF PCNL IN PATIENTS<br />
WITH SPINAL PATHOLOGY: SEVEN YEAR EXPERIENCE IN A<br />
TERTIARY REFERRAL CENTRE<br />
Belfield J.C. (UK)<br />
08:57 SS4. HOW EFFECTIVE IS THE FLAT-PANEL ANGIOGRAPHY<br />
SYSTEM IN LOWERING THE OVARIAN DOSE DURING UTERINE<br />
ARTERY EMBOLIZATION (UAE)<br />
Firouznia K. (IR)<br />
09:06 SS5. COMPARISON OF CT-GUIDED CORE NEEDLE BIOPSY AND<br />
FINE NEEDLE ASPIRATION IN THE ABDOMEN AND PELVIS<br />
Chernyak V. (USA)<br />
09:15 SS6. THE PRECAVAL RENAL ARTERY: PREVALENCE AND<br />
ASSOCIATIONS<br />
Derchi L. E. (I)<br />
09:23 SS7. IMAGING THE PROSTATE FROM THE INSIDE OUT: CLINICAL<br />
EVALUATION OF A CUSTOMIZED 14 MHZ PROBE FOR TRANS-<br />
URETHRAL ULTRASOUND (TUUS) DURING PROSTATE<br />
BRACHYTHERAPY<br />
Wilson T.M. (USA)<br />
09:42 SS8. THE VALUE OF HYSTEROSALPINGOGRAPHY (HSG) AS A<br />
FIRST – STEP DIAGNOSTIC TOOL IN THE INVESTIGATION OF<br />
PERITUBAL PATHOLOGY IN THE INFERTILE WOMAN.<br />
Mintzopoulou P. (GR)<br />
28
HALL CONFERENCE 2<br />
08:30-10:00 RENAL TUMORS - NEOPLASMS<br />
Moderators: Tsitouridis I. (GR) - Matsaidonis D. (GR)<br />
08:30 S1. COMPARISON OF CONTRAST-ENHANCED ULTRASOUND AND<br />
COMPUTED TOMOGRAPHY IN CLASSIFICATION OF CYSTIC<br />
RENAL MASSES<br />
Foukal J. (CZ)<br />
08:39 SS2. DW MRI VS DYNAMIC MRI IN DIAGNOSIS OF PROSTATE<br />
CANCER; A PROSPECTIVE STUDY<br />
Abou El-Ghar M. (ET)<br />
08:48 SS3. IS 18FDG PET/CT A USEFUL IMAGING MODALITY FOR THE<br />
MANAGEMENT OF PATIENTS WITH URINARY TRACK CANCER<br />
Panagiotidis E. (GR)<br />
08:57 SS4. THE ROLE OF MULTI-PHASE MDCT IN THE PREOPERATIVE<br />
ASSESSMENT OF RENAL AND URINARY TRACT PATHOLOGY<br />
Kalogeropoulou C. (GR)<br />
09:06 SS5. AN ASSESSMENT OF THE SPECIFICITY OF CT PIXEL MAPPING<br />
IN THE DIAGNOSIS OF AML VERSUS MALIGNANT RENAL<br />
TUMORS<br />
Bardgett H.P. (UK)<br />
09:15 SS6. SONOGRAPHIC PATTERNS AND CAUSES OF BRIGHT<br />
KIDNEYS IN PEDIATRIC PATIENTS<br />
Tsagouli P. (GR)<br />
09:24 SS7. IMAGING OF RENAL TRAUMA WITH CONTRAST-ENHANCED<br />
ULTRASONOGRAPHY<br />
Tsagouli P. (GR)<br />
09:33 SS8. THE VALUE OF DIFFUSION-WEIGHTED MAGNETIC<br />
RESONANCE IMAGING AND RELATIVE APPARENT DIFFUSION<br />
COEFFICIENT IN DIFFERENTIATION BETWEEN RENAL CANCER<br />
AND REGULAR PARENCHYMA<br />
Javor D. (A)<br />
09:42 SS9. IMAGING EVALUATION AND MANAGEMENT OF MULTIPLE<br />
RENAL MASSES<br />
Kolliakou E. (GR)<br />
09:51 SS10. ULTRASOUND IN DETECTION OF RENAL MASSES: MISSED<br />
AND WRONGLY CHARACTERIZED LESIONS<br />
Brkljačić B. (HR)<br />
10:00 – 10:30 Coffee Break<br />
10:30 – 12:00 ESUR Guidelines<br />
Moderator: Morcos S.K. (UK)<br />
10:30 – 11:00 Contrast media-NSF<br />
Thomsen H. (DK)<br />
11:00 – 11:30 Female pelvis<br />
Kinkel K. (CH)<br />
11:30 – 12:00 Pediatric imaging<br />
Riccabona M. (A)<br />
HALL OLYMPIA 1<br />
HALL OLYMPIA 1<br />
12:15 – 13:15 Film Interpretation Session<br />
Moderator: Derchi L.E. (I)<br />
Co-moderators: Curry N. (USA) - Prassopoulos P. (GR)<br />
29
HALL ALEXANDER<br />
13:15 – 13:30 Meeting of Scientific Committee to confirm the best three of Oral<br />
Presentations<br />
HALL OLYMPIA 1<br />
13.30 Closing ceremony<br />
(Best Posters and Best Scientific Presentations Awards)<br />
30
MEMBERS’ DAY SESSIONS<br />
ABSTRACTS<br />
31
SESSION I<br />
Moderators: Hamm B.K. (D) – Mueller-Lisse U.L. (D)<br />
MS1.<br />
POTENTIAL ROLE OF MR DIFFUSION-WEIGHTED IMAGING (DW-MRI) WITH APPARENT DIFFUSION<br />
COEFFICIENT (ADC) VALUE TO EVALUATE RENAL INSUFFICIENCY AT 3T<br />
Roy C.<br />
Radiology B University Hospital, Strasbourg<br />
Purpose: To investigate the relationship between ADC values measured by DW-MRI in cases of renal insufficiency.<br />
Materials and Methods: 250 patients with various pathologies including 160 patients with moderate (GFR > 40 mL· min)<br />
or severe(GFR < 40 mL· min) renal impairment (RI) explored at 3T (Achieva, Philips) with axial DWI SE-EPI (TR/TE :<br />
7000/55,5mm, fat suppression, tf 41, EPI 41, 32 slices, FOV : 288-340, Matrix size : 128-96, free breathing, 3 min54<br />
and b value 0 and 1000 seconds/mm2) and no special recommendation for hydratation or fasting. They were divided in "<br />
normal control 50pts", " normal unique kidney 40pts"and 4 groups of 40pts: " moderate RI unique kidney -", " severe RI<br />
unique kidney ", ” moderate RI both kidney ", " severe RI both kidney ". ADC was measured in 150 mm2 ROI by two<br />
experienced radiologists, as well as images analysis. Statistical analysis was performed using SPSS software. ADC mean<br />
values and standard deviation of each group were calculated and compared using Student T-test.<br />
Results: Images quality was excellent. Cortico-medullary differentiation was observed only in 60 pts with normal renal<br />
function. On DW images signal intensity was homogeneous for all RI types. Mean ADC in control and normal unique<br />
kidney groups were both 1.9 10–3 mm2/ s.<br />
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,<br />
respectively. There was no statistically significant difference in renal ADCs among the four groups and control group.<br />
Conclusion: The ADCs were no significantly different in impaired kidneys and normal kidneys. There was no correlation<br />
between the ADCs and GFR. DW-MRI of the kidney seems not to be a reliable way to differentiate normal renal<br />
parenchyma and different renal diseases.<br />
MS2.<br />
MULTIDETECTOR-ROW CT UROGRAPHY: RETROSPECTIVE COMPARISON BETWEEN STANDARD AND<br />
LOW- DOSE PROTOCOLS FOR DELINEATION OF UPPER URINARY TRACT SEGMENTS<br />
Mueller-Lisse U.L., Meindl T.M., Coppenrath E., Reiser M.F., Stief C., Mueller-Lisse U.G.<br />
Department of Diagnostic radiology, University of Munich<br />
Purpose: In patients with pelvic or retroperitoneal tumors, CT urography (CTU) may replace excretory urography for the<br />
delineation of the upper urinary tract (UUT) prior to treatment. However, radiation exposure is a concern. We<br />
retrospectively compared UUT delineation in standard and low-dose CTU.<br />
Method And Materials:CTU (excretory phase) images were obtained with 120 KV, 4x2.5 mm collimation, and pitch 0.875,<br />
after i.v. injection of 120 ml of non-ionic contrast media with 300 mg of iodine/ml with standard (January through March,<br />
14 patients, n=116 UUT segments, 175 mAs/slice, average delay 16.8 minutes) or low-dose (April through September, 26<br />
patients, n=344 UUT segments, 29 mAs/slice, average delay 19.6 minutes) protocols. UUT segments included intrarenal<br />
collecting system (IRCS), upper, middle, and lower ureter (UU,MU,LU). Two independent readers (R1,R2) graded UUT<br />
segment delineation as 1-absent, 2-partial, 3-complete (noisy margins), 4-complete and clear. Chi-square statistics were<br />
calculated for grades 1-2 vs. 3-4 (delineates UUT and may locate obstruction/dilation) and 1-3 vs. 4 (may locate<br />
intraluminal lesions).<br />
Results:Delineation of UUT was equally good for all segments in standard and low-dose CTU (R1, chi-square=0.0036-<br />
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<br />
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,<br />
LU was more often completely and clearly delineated in standard protocols (R1, 18/24 standard, 38/69 low-dose, chisquare=2.178,<br />
p>0.1; R2 18/24 standard, 21/69 low-dose, chi-square=12.75, p<br />
Conclusion: Low-dose CTU appears sufficient to delineate UUT and perhaps locate obstruction/dilation, but unsuited to<br />
locate intraluminal LU lesions.<br />
MS3. COMPARISON AND CORRELATION BETWEEN 1H-MRI IN-VIVO PROSTATE SPECTROSCOPY AT 1,5 T<br />
AND EX-VIVO HIGH RESOLUTION MAGIC ANGLE 1H-NMR SPECTROSCOPY AT 11 T IN THE<br />
EVALUATION OF NEW METABOLITE LEVELS IN PROSTATE CANCER.<br />
Panebianco V., Osimani M., Valerio M.C., Santucci E., Biondi T., Passariello R.<br />
Dept of Radiological Sciences,Sapienza University of Rome<br />
Object: The aim of this study is to assess if an ex-vivo metabolomic approach can be used to discover metabolic<br />
biomarkers that are distinct in prostate cancer and healthy glands and its correlation with metabolites obtained by<br />
standard in- vivo 1H-MRI spectroscopy (1H-MRSI).<br />
Method: Five hundred and ninethy candidates for radical retropubic prostatectomy (RRP) were previously studied with 1H-<br />
MRSI (1,5 T). A spectroscopic curve was obtained with Choline, Citrate, Creatine assessments within multiple boxes<br />
placed on the suspected prostate nodule. After the RRP, a high resolution magic angle 1H-NMR (11 T spectrometer) was<br />
performed on the surgical sample, serum and urine. Multivariate analysis was applied on the 1H-NMR metabolites curve<br />
and correlated with those of in vivo 1H-MRSI.<br />
Results: The data we obtained demonstrate that actual in-vivo 1H-MRSI represents a weaker approach to prostate<br />
diseases because of the lower number of metabolites detected compared with those of ex-vivo 1H-NMR.<br />
Conclusion: This approach may be the basis for further development of new in-vivo MRSI acquisition modalities; these<br />
developments may improve diagnostic accuracy level and identify not only biochemical changes but also metabolic<br />
markers for cancer diagnosis.<br />
32
MS4.<br />
EARLY CERVICAL CANCER: ROLE OF MRI WITH ARTIFICIAL HYDROCOLPOS IN THE PREOPERATIVE<br />
ASSESSMENT OF PATIENT ELIGIBLE FOR FERTILITY-SPARING SURGERY<br />
CapaccioE. 1 , Marchiolè P. 2 , Sala P. 2 , Moioli M., 2 Cittadini G. 1 , Tagliafico A. 1 , Derchi L.E. 1<br />
1 Cattedra "R" di Radiologia-DICMI, Università di Genova, Largo Rosanna Benzi 8, 16132 Genoa, Italy., 2<br />
Dipartimento di Ginecologia, Università di Genova, Genoa, Italy.<br />
Objective: To evaluate the role of MRI with artificial hydrocolpos in the pre- and post-operative work-up of women with<br />
early cervical cancer eligible for fertility-sparing surgery.<br />
Method: We evaluated ten patients with early invasive cervical cancer (FIGO IA2-IB1) wanting to preserve their fertility.<br />
Diagnosis had been achieved by cervical biopsy (n=3) or conisation (n=7).<br />
All patients underwent pre-operative pelvic MRI with and without artificial distention of vaginal cavity. This was achieved<br />
by 50-70cc of saline solution instilled through a Fooley catheter with distended balloon to avoid reflux. High-resolution tSE<br />
T2-weighted sequences were performed in sagittal, para-axial and para-coronal planes oriented along the cervix uteri long<br />
axis. We measured maximal tumoral diameter and distance between tumor and uterine internal os.<br />
Results: The technique allowed good delineation of locoregional anatomy in all cases. Five patients had no residual<br />
cervical lesion or lymphoadenopathy at MRI after cold knife conisation. Cervical tumor was seen in five cases. In three<br />
patients the lesion was > 2cm (mean: 24mm). The tumor-uterine internal os distance was >10 mm in three cases and<br />
0.71, and for the central gland:<br />
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<br />
assessed. For statistical analysis (were performed by using SPSS version 16.0), the sensitivity, specificity were calculated<br />
by dichotomizing the readings. A cut-off point of above 3 was considered malignant and these findings were correlated<br />
with whole-mount prostatectomy specimens. Receiver operating characteristics analysis was performed. All P values<br />
reported were derived at two-sided tests.<br />
Results: Reader I (less experienced reader) had an area under the curve (AUC) of 0.57 for without ERC and 0.64 for with<br />
ERC, however not significantly different (p >0.05). Reader II (experienced reader) had an AUC of 0.55 for without ERC<br />
and 0.65 for with ERC, this difference was significant (p < 0.05). Reader I had a sensitivity and specificity of 47% and<br />
57% without ERC and a sensitivity and specificity of 72% and 48% with ERC, respectively. Reader II had a sensitivity and<br />
specificity of 30% and 82% for tumor localization without ERC, and a sensitivity and specificity of 35% and 94% with ERC,<br />
respectively.<br />
Conclusion: For an experienced reader 3T MRSI for localizing prostate cancer has a high specificity and a low sensitivity.<br />
Using an ERC at 3T MRSI is significantly more accurate compared to non-ERC MRSI in localizing prostate cancer.<br />
Clinical relevance<br />
Accurate tumor localization is important for focal treatment planning.<br />
33
MS7.<br />
STIMULATION OF CULTURED HUMAN DERMAL FIBROBLAST COLLAGEN PRODUCTION BY GADOLINIUM<br />
CHELATES<br />
Morcos S. 1 , Bains S. 2 , JohnsonC. 2 , MacNeil S 2 .<br />
1 Department of Diagnostic Imaging, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK,<br />
And 2 Department of Engineering Materials, Kroto Research Institute, University of Sheffield, Broad Lane,<br />
Sheffield, S3 7HQ, UK<br />
Purpose: In patients with renal insufficiency who have been exposed to gadolinium based contrast agents (Gd-CA) a<br />
syndrome of nephrogenic systemic fibrosis ( NSF ) with a spectrum of aberrant dermal remodelling has been identified.<br />
The exact pathogenesis is uncertain but low stability of Gd-CA leading to the release of free gadolinium has been proposed<br />
as an important factor in triggering this condition. The purpose of this study was to look at the direct effects of Gd-CA with<br />
different stability on cultured human dermal fibroblast proliferation and collagen production.<br />
Method and Materials: Human fibroblasts were cultured from patients donating skin following elective operations . Cells<br />
were cultured in DMEM medium plus 10% foetal calf serum and exposed to a range of concentrations of Omniscan (low<br />
stability non-ionic linear chelate, GE Health Care, USA), Dotaram (high stability ionic macrocyclic agent, Guerbet, France)<br />
or GdEDTA (very low stability linear Gd-chelate, positive control) for 3 or 7 days. Cell proliferation was assessed using the<br />
MTT ESTA colorimetric assay and total collagen production by the use of Sirius Red.<br />
Results: While indicative results could be seen at 3 days, clearly significant results were obtained after 7 days’ exposure of<br />
cells to the gadolinium chelates. Gd-EDTA had a slight (15%) stimulatory effect on cell proliferation and concomitant<br />
collagen production at 0.1mM. Higher concentrations significantly reduced proliferation and collagen production by 10%<br />
at 1mM and by 80% at 10mM in comparison to the control group (only culture medium). Dotaram, studied at<br />
concentrations from 0.01 to 1mM had no significant effect on cell proliferation or collagen production. However, 10mM<br />
Dotaram slightly reduced both proliferation and collagen production by approximately 20%. The most marked results<br />
were seen with Omniscan. Concentrations as low as 0.01mM stimulated proliferation and collagen production and a<br />
maximum increase of 30-50% was observed with 1mM concentration. . Higher concentrations were less stimulatory.<br />
Conclusion: These results clearly show that Gd-CA of low stability (Omniscan) have direct stimulatory effects on fibroblast<br />
proliferation and collagen production, readily demonstrated over 7 days The highly stable macrocyclic agent Dotaram had<br />
no stimulatory effects on fibroblasts. The study offers some support for the importance of the stability of Gd-CA in the<br />
pathogenesis of NSF<br />
MS8.<br />
DIFFUSION-WEIGHTED MRI ALLOWS FOR THE DETECTION OF PELVIC LYMPH NODE METASTASES IN<br />
BLADDER AND PROSTATE CANCER PATIENTS: COMPARISON WITH HISTOPATHOLOGY.<br />
Thoeny H.C. 1 , FroehlichJ.M. 1 , Triantafyllou M. 1 , Birkhaeuser F. 2 , Fleischmann A. 3 , Binser T. 4 , Vermathen P. 4 ,<br />
Studer U.E. 2<br />
1 Department of Diagnostic, Pediatric and Interventional Radiology, Inselspital, University of Bern, Bern,<br />
Switzerland, 2 Department of Urology, Inselspital, University of Bern, Bern, Switzerland, 3 Department of Pathology,<br />
University of Bern, Switzerland,<br />
4 Department of Clinical Research, Inselspital, University of Bern, Bern,<br />
Switzerland<br />
Purpose: To assess the potential of diffusion-weighted MRI (DW-MRI) to detect pelvic lymph node metastases in normalsized<br />
nodes of bladder and/or prostate cancer patients compared to histopathology.<br />
Methods and Materials: Fifty patients with bladder (n=16), prostate cancer (n=27) or both (n=7) were examined on a 3T<br />
MR. 3D T1- and T2-weighted sequences and axial DW-MRI (3b-factors 0, 500, 1000s/mm2, slice thickness 4mm) were<br />
performed. Visual analysis and ADC-measurements of DW-MRI were compared to histopathology. ADC values of lymph<br />
nodes were classified: malignant100x10-5 mm2/sec. Template lymphadenectomy was performed in all<br />
patients. Histopathological correlation was performed on a per patient basis.<br />
Results: Diagnostic performance for DW-MRI compared to histopathology was: sensitivity of 93%, specificity of 75%, PPV<br />
of 59%, NPV of 96% and diagnostic accuracy of 80%. False positive lymph nodes showed follicular hyperplasia,<br />
lipomatosis or sinus histiocytosis on histopathology, The smallest lymph node metastasis detected by DW-MRI measured 2<br />
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<br />
sized node. Overall, a total of 1853 lymph nodes were resected emphasizing the high NPV.<br />
Conclusion: DW-MRI allows to noninvasively detect pelvic lymph node metastases even in normal-sized nodes of patients<br />
with bladder and prostate cancer.<br />
34
MS9.<br />
EVALUATION OF RETROGRADE URETEROPYELOGRAPHY AND FLUOROSCOPICALLY GUIDED<br />
BIOPSY FOR DIAGNOSING UPPER TRACT UROTHELIAL CANCER FOLLOWING MULTIDETECTOR<br />
COMPUTED TOMOGRAPHY UROGRAPHY IN PATIENTS PRESENTING WITH MACROSCOPIC<br />
HAEMATURIA OVER 40-YR OF AGE.<br />
Cowan N.C., Mallett S., Turney B.W., Bardgett H., Crew J. P., Sullivan M.<br />
The Churchill Hospital OX3 7LJ Oxford, London<br />
To evaluate retrograde ureteropyelography (RUP) and fluoroscopically guided biopsy (FBX) for diagnosing upper tract<br />
urothelial cancer (UTUC) following multidetector computed tomography urography (CTU).<br />
CTU was performed on a consecutive series of patients, with macroscopic haematuria, over 40-yr, without infection.<br />
CTU was scored using a 5-point scale: 1=normal, 2=probably normal, 3=equivocal, 4=probably+ve, 5=definitely+ve<br />
for UTUC. RUP+/-FBX was attempted on patients with scores of 3-5. Procedures were performed under IV sedation and<br />
analgesia. Sensitivity (Se) and specificity (Sp) were calculated for RUP for diagnosing UTUC. The reference standard<br />
comprised histopathology from surgery, FBX or ureteroscopic biopsy (UBX), clinical, imaging and histopathology followup.<br />
RUP was attempted in 73 patients. RUP was +ve for UTUC in 48 and normal in 22. There were 3 technical failures (TF)<br />
due to non-visualization of the ureteric orifice. For RUP for diagnosing UTUC, Se=100%, Sp=85%, PPV=92% and<br />
NPV=100%. There were 4 false+ve RUP results: amyloid (n=1), renal cell cancer (n=1), TF (n=1) and hypertrophied<br />
papilla (n=1). Of the 48 RUP+ve patients, 46 underwent FBX, 2 were excluded: warfarin anticoagulation (n=1) and<br />
circumferential urothelial thickening without focal mass, making FBX technically impossible (n=1). Of 34 patients with<br />
FBX+ve results, 30 were confirmed UTUC+ve by histopathology following radical nephroureterectomy and 4 patients<br />
were treated palliatively, but assumed to be UTUC+ve because of the biopsy result. Of the 12 patients who were FBXve/indeterminate,<br />
9 were UTUC+ve and 3 were UTUC-ve. There were no complications requiring further intervention.<br />
FBX, if technically feasible, may obviate UBX for histopathological diagnosis of UTUC.<br />
MS10.<br />
EVALUATION OF A PNEUMATICALLY ACTUATED MR-COMPATIBLE ROBOT FOR MR-GUIDED<br />
PROSTATE BIOPSY<br />
Futterer J.J., Scheenen T.W.J., Schouten M., Bosboom D., Barentsz J.O.<br />
Department of Radiology, UMCN, The Netherlands<br />
Purpose: Evaluation of a pneumatically actuatedMR-compatible robotic device to perform biopsy in the prostate with realtime<br />
3T magnetic resonance (MR) imaging guidance.<br />
Material and Methods: The robotic system is fitted with five computer-controlled degrees of freedom for delivering an<br />
interventional procedure. The entire device is constructed of MR compatible materials, i.e. nonmagnetic and nonconductive,<br />
to eliminate artifacts and distortion of the MR images. The robotic device is remotely controlled by means of<br />
pneumatic motors and a graphical user interface, providing real-time MR-guided monitoring of the intervention. The<br />
device is mounted to the table of a 3T whole body MR scanner. Trials were conducted on an abdominal phantom, with<br />
real-time MR guidance. Biopsy needles were placedby expert and novice users towards internal 1mm targets.The needle<br />
was visualized with a three-dimensional T1-weighted sequence (TR/TE 6.52/2.54ms; flipangle 10 degrees). Accuracy was<br />
determined by computing the needle tip to target distance.<br />
Results: The robotic system successfully assisted with guiding biopsy needle placement. No artifacts caused by the robotic<br />
system were observed in the MR images. Position and orientation of all biopsy insertions were appropriately visualized on<br />
the 3-dimensional T1-weighted MR images. Precision of needle placement was 2.5mm (range 0-4.1mm). The average<br />
time to reach the target was 4.58 minutes (range 3.50-6.40).<br />
Conclusion: MR imaging guided prostate biopsy using a pneumatically actuated MR-compatible robot provides adequate<br />
precision of insertion and orientation of the biopsy needle and shows great promise for MR-guided biopsy procedures.<br />
SESSION II<br />
Moderators: Morcos S.K. (UK) – Derchi L. (I)<br />
MS1.<br />
DIFFUSION WEIGHTED MRI IN EVALUATION OF TRANSPLANTED KIDNEY: PRELIMINARY CLINICAL<br />
EXPERIENCE<br />
Abou El-Ghar M., Refaie H., Hassan N. 1 , Kamal M. 2 , Mohsen T., El-Diasty T.<br />
Radiology, 1 Nephrology and 2 Urology Departments, Urology & Nephrology center- Mansoura University,<br />
Mansoura-Egypt<br />
Purpose: To evaluate the diagnostic performance of Diffusion Weighted(DW) magnetic resonance (MR) imaging in<br />
evaluation of transplanted kidneys.<br />
Material & Methods: One hundred twelve patients with transplanted kidney from live kidney donors were evaluated with<br />
coronal T2w and DW MRI of the kidney. Apparent diffusion coefficient (ADC) was calculated and the kidneys studied for<br />
any areas diffusion restriction. Our patients classified into 2 groups: Group 1 examined with b values 0 & 400 sec/mm2, it<br />
includes 62 patients (45 male & 17 female) and group 2 examined at b values 0 & 800 sec/mm2, it includes 50 patients<br />
(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<br />
respectively.<br />
Results: The group 1 includes 42 normal kidneys, 12 with chronic nephropathy, 5 with acute rejection and 3 with acute<br />
tubular necrosis (ATN) while the group 2 includes 39 normal kidneys, 6 with chronic nephropathy and 5 with acute<br />
rejection. The mean ADC for normal kidneys, chronic nephropathy and acute rejection was 2.7±.26& 2.27±.23,<br />
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<br />
accuracy in diagnosis of acute rejection and chronic nephropathy was 75%&90%, 96%&98%, 93.5%&90% respectively &<br />
at group 2 it was 100%,96%&80%respectively for chronic nephropathy while for acute rejection there was a great overlap<br />
between the normal and chronic kidneys. Ischemic areas were detected with restricted diffusion.<br />
Conclusion: From these initial results we find that DW MRI of transplanted kidneys at b value 400 sec/mm2 have more<br />
diagnostic performance than at b value 800 sec/mm2 & it can differentiate the acute rejection from chronic nephropathy<br />
and normal kidney.<br />
35
MS2.<br />
THE VALUE OF ULTRASOUND FINDINGS AND SERUM PROCALCITONIN LEVELS IN UPPER URINARY<br />
TRACT INFECTION IN CHILDREN<br />
Deftereos S.P., Vranou E., Zisimopoulos A., Tsalkidis A., Chadjimichail A., Prassopoulos P.<br />
Democritus University of Thrace, Department of Radiology, Alexandroupolis, Greece<br />
Objectives: Procalcitonin (PCT) has been proposed as a marker of infection in critically ill patients and its levels is related<br />
to the severity of infection. For reducing children’s exposure to radiation and for more immediate informations about renal<br />
parenchymal involvement in urinary tract infection, we examine the efficacy of ultrasonography findings in combination<br />
with serum procalcitonin levels.<br />
Method: This prospective study enrolled 57 children, until now. All were admitted for first episode of urinary tract infection<br />
(positive urine culture) and underwent measurement of serum PCT and C- reaction protein , followed by US, DMSA<br />
(within 7 days/ and after 6 months) and VCUG (after 4-5 weeks in 51/57 cases).<br />
Results: 27 children had upper UTI (group A), diagnosed by positive DMSA and abnormal US (n=15, 55.6%). 30 children<br />
had lower UTI (group B) with negative DMSA and normal US findings (except 4 patients with urinary bladder wall<br />
thickening). PCT levels were significantly higher in patients with persistent renal lesions or/and VUR (n=8) than in those<br />
with total regression of RPI (n=15).<br />
Conclusion: The combination of high PCT levels and positive US findings is an indication of upper UTI. DMSA is required in<br />
patients with high PCT levels and negative US examined, but normal US and PCT levels can exclude upper UTI.<br />
MS3.<br />
DOES CEUS HAVE A PRACTICAL VALUE IN ADJUNCT TO COLOR DOPPLER US IN EVALUATION OF<br />
PATIENTS WITH RENAL INSUFFICIENCY EVALUATION OF 56 PATIENTS<br />
Bertolotto M., Galli G., Zappetti R., Djouguela Fute M., Giarraputo L., Cova M. A.<br />
Dept. Radiology, Universtity of Trieste, Ospedale di Cattinara, Strada di Fiume 447, 34149 Trieste, Italy<br />
Objective: To investigate the role of contrast enhanced ultrasound (CEUS) in the work-up of patients with acute renal<br />
failure (ARF), and in evaluation of renal lesions identified in patients with chronic renal failure (CRF).<br />
Method: 40 consecutive patients with ARF from suspicious vascular causes and 16 consecutive patients with CRF and<br />
suspicious renal lesions on US underwent CEUS. After preliminary grey-scale and color Doppler US, CEUS was performed<br />
using low acoustic power, contrast specific modes. A bolus of SonoVue was injected to examine each kidney, followed by a<br />
saline flush. All examinations were digitally recorded for retrospective evaluation.<br />
Results: CEUS provided clinically useful information in 36/40 patients with ARF from suspicious vascular causes. There<br />
were 19 patients with renal infaction or acute cortical ischemia, 4 patients with extensive inflammatory lesions, and 1<br />
compression of the renal parenchyma by a spontaneous subcapsular hematoma. In the remaining 12/36 patients no renal<br />
perfusion abnormalities were identified and different reasons were found clinically for ARF. In 4/40 patients CEUS did not<br />
provide clinically useful information. There were 2 patients with postoperative acute tubular necrosis, 1 with septic shock,<br />
1 with obstruction not associated to urinary tract dilatation, 1 multifactorial. CEUS allowed renal lesion characterization in<br />
all 16 patients with CRF. There were 9 complex cystic masses, 6 solid tumors, 1 pseudolesion.<br />
Conclusion: CEUS is a useful diagnostic tool in the work-up of patients with ARF from suspicious vascular causes and is<br />
useful to characterize renal lesions identified in patients with renal insufficiency.<br />
MS4.<br />
NFLUENCE OF NITRIC OXIDE ON OXYGEN CONSUMPTION BY IODINATED CONTRAST MEDIA IN<br />
FRESHLY ISOLATED PROXIMAL TUBULAR CELLS FROM ELDERLY HUMANS AND DIABETIC RATS.<br />
Liss P. 1 , Palm F. 2 , Fasching A., Hansell P. 2<br />
1 Radiology, University of Uppsala, Uppsala, Sweden,<br />
2 Physiology, University of Uppsala, Uppsala, Sweden,<br />
3 Cardiology, University of Uppsala, Uppsala, Sweden<br />
Objective: The purpose of this study was to evaluate the effect of the low-osmolar CM iopromide and the iso-osmolar CM<br />
iodixanol on oxygen consumption (QO2) in freshly isolated proximal tubular cells (PTC) from nephrectomized kidneys from<br />
elderly humans, normoglycemic and streptozotocin-induced diabetic rats. The involvement of nitric oxide (NO) was also<br />
studied.<br />
Methods: PTC were isolated from human kidneys, or kidneys of normoglycemic and streptozotocin-diabetic rats. QO2 was<br />
measured with Clark-type microelectrodes in a gas-tight chamber with and without either CM (10 mg I/ml media).<br />
Institutional review board approvals and informed consent was obtained from all patients before start of the study.<br />
Results: Both CM reduced QO2 in human PTC (about -35%) which was prevented by L-NAME. PTC from normoglycemic<br />
rats were unaffected by iopromide, whereas iodixanol decreased QO2 (-34%). Both CM decreased QO2 in PTC from<br />
diabetic rats (-38% and -36%, respectively). L-NAME only prevented the effect of iopromide in the diabetic PTC. nNOS<br />
mRNA<br />
Conclusion: This study show that CM can induce NO release from isolated PTC in vitro, which affects QO2. The results<br />
suggest that the induction of NO release and subsequent effect on the cellular oxygen metabolism are dependent on<br />
several factors, including CM type and the existence of known risk factor for the development of CM-induced nephropathy.<br />
The decreased QO2 might result in cellular energy deficiency, which potentially is a mechanism initiating the development<br />
of progressive kidney dysfunction.<br />
36
MS5.<br />
INCIDENCE OF IN-HOSPITAL TREATED RENAL FAILURE IN 23,425 SWEDISH PATIENTS AFTER<br />
CORONARY PROCEDURES<br />
Liss P. 1 , Palm F. 2 , Hansell P. 2 , Lagerqvist B. 3<br />
1 Radiology, University of Uppsala, Uppsala, Sweden, 2 Physiology, University of Uppsala, Uppsala,<br />
Sweden, 3 Cardiology, University of Uppsala, Uppsala, Sweden<br />
Objective: To compare the risk of developing renal failure after percutaneous coronary interventions (PCI) and/or<br />
coronary angiography when using an iso-osmolar (iodixanol) with a low-osmolar (ioxaglate) contrast media (CM).<br />
Methods: In this study we compared the Swedish Coronary Angiography and Angioplasty Registry with the Swedish<br />
“Hospital Discharge Register” to assess CM induced renal failure at 18 hospitals using one single CM. The study included<br />
23,425 patients which underwent PCI/angiography in Sweden during 2005-2006 using either iodixanol (18,518 patients)<br />
or ioxaglate (4,707 patients).<br />
Results: The incidence of renal failure within 12 months after PCI/angiography was greater for patients receiving iodixanol<br />
(1.4%) than for those treated with ioxaglate (0.9%, p
MS8.<br />
MORPHOMETRY OF TISSUE MICROSTRUCTURE: COMPARISON OF DIGITAL LIGHT MICROSCOPY<br />
(DLM)AND INTRALUMINAL CATHETER-BASED OPTICAL COHERENCE TOMOGRAPHY (OCT)<br />
IN NORMAL PORCINE URETER WALL SPECIMENS<br />
Mueller-Lisse U.L., Meissner O.A., Bauer M., Reiser M.F., Stief C., Mueller-Lisse U.G.<br />
Department of Diagnostic radiology, University of Munich<br />
Purpose: To assess the reliability of their delineation on cross-sectional optical coherence tomography (OCT) images,<br />
we compared the width of different tissue layers of the wall of porcine upper ureters ex vivo as measured on OCT<br />
images and matching whole-mount digital light microscopy (DLM) sections.<br />
Method And Materials: Eleven specimens of porcine upper ureter were flushed with normal saline solution prior to<br />
imaging from inside by means of an OCT catheter (diameter, 0.014 inch, OCT wavelength, 1300±20 nm) at marked<br />
locations. Ring-shaped ureter specimens of 3 mm width were fixed in 4% formalin, cut, whole-mounted, and stained<br />
with H&E. Respective thicknesses of urothelium, lamina propria, and muscle layer of the ureteral wall were compared<br />
between OCT images (M1, LightLab Imaging, Inc., Westford, MA, USA) and matching DLM slides (Axioplan2, Carl-<br />
Zeiss-Corporation, Jena, Germany) by two independent observers (O1,O2), applying Bland-Altmann plots and t-tests<br />
for paired data.<br />
Results: When compared with DLM, respective OCT measurements by O1 and O2 overestimated width of urothelium by<br />
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<br />
(p=0.2047 and 0.0025), and muscle layer by 0.26+/-0.15mm and 0.07+/-0.05mm (p=<br />
Conclusion: Intraluminal OCT reliably delineates urothelium and lamina propria of the normal ureteral wall in porcine<br />
specimens ex vivo when compared with corresponding DLM histology. The outer boundaries of the muscle layer of the<br />
ureteral wall appear to be beyond reliable reach of OCT.<br />
MS9.<br />
EMBOLIZATION OF POLYCYSTIC KIDNEYS: AN ALTERNATIVE TO NEPHRECTOMY BEFORE<br />
RENAL TRANSPLANTATION: A WORK IN PROGRESS.<br />
Cornelis F., Lebras Y., Hubrecht R., Dodre E., Perot V., Ferrière J.M., Merville P., Grenier N.<br />
Imagerie diagnostique et thérapeutique de l'adulte, Centre Hospitalier Universitaire de Bordeaux, Hopital<br />
Pellegrin, 33076 BORDEAUX Cedex FRANCE<br />
Objectives: In autosomal polycystic disease, surgical nephrectomy is necessary before transplantation when kidney<br />
volume is excessive. We evaluated prospectively the effectiveness of unilateral embolization as an alternative to<br />
surgery to obtain a volume reduction allowing graft implantation.<br />
Material and method: Twenty patients, with an autosomal dominant polycystic kidney disease and enlarged kidneys<br />
descending below iliac crest, had unilateral renal embolization. In all cases distal infusion of microspheres and proximal<br />
coiling were associated until circulatory arrest. To prevent post-embolization syndrome, a protocol with analgesic, antiinflammatory<br />
and antibiotic drugs was prescribed. Volume reduction was evaluated by CT before and at 3 and 6<br />
months after embolization. The treatment was considered as a success when the lower pole of embolized kidney was<br />
located above the iliac crest at 6 months, making transplantation possible.<br />
Results: Embolization was technically successful in all patients. The treatment was well tolerated clinically in all cases,<br />
without immediate or delayed complications. In one patient, the kidney did not decreased in size despite three sessions<br />
of embolization. In 18 patients (90%), this treatment was effective in one session, with an average volume reduction<br />
of 37% at 3 months. The last patient had a supplemental cyst sclerosis to reach the objective. To now, 13 patients<br />
reached the 6 months end-point and were listed for kidney transplantation; 4 of these were successfully grafted.<br />
Conclusion: Embolization of polycystic kidneys facilitates renal transplantation and seems to be an excellent alternative<br />
to nephrectomy due to its lower morbidity.<br />
MS10.<br />
THIN SLICE THICKNESS (1MM) 3D-T2-WEIGHTED MRI AND LOCAL STAGING OF PROSTATE<br />
CANCER<br />
Cornud F., Liberatore M., Eiss D., Rouanne M., Beuvon F., Barry N., Flam T.<br />
Services de Radiologie, d’Urologie et de Pathologie, Hôpital Cochin, Paris, France<br />
Objective: to assess the accuracy of endorectal coil and high resolution 3D-T2-weighted MRI (voxel size: 0.64 mm3)<br />
with a 1.5 Tesla magnet for local staging of prostate cancer.<br />
Materials and methods: 61 patients (mean age: 63±5.5) with a clinically localised tumor (clinical stage1mm). Overall sensitivity was 86%, specificity<br />
91% and accuracy 87%.<br />
Conclusion: The 3D-T2W acquisition has the highest ever reported accuracy to detect pT3 stage with an endorectal coil<br />
and a 1.5 Tesla magnet.<br />
38
MS11.<br />
FUNCTIONAL MRI (DIFFUSION WEIGHTED AND DYNAMIC CONTRAST ENHANCED IMAGING) IN<br />
PATIENTS WITH LOW RISK PROSTATE CANCER<br />
Cornud F., Richarme D., Rouanne M., Barry N., Beuvon F., Flam T.<br />
Services de Radiologie, d’Urologie et de Pathologie, Hôpital Cochin, Paris, France<br />
Objective: To determine the value of diffusion-weighted (DW) and dynamic contrast-enhanced MRI (DCE) to localise<br />
significant tumors in patients with low risk prostate cancer (PCa) defined by a PSA level
OPENING CEREMONY LECTURES<br />
WW1. USE OF X-RAYS ON THE GREEK FRONT<br />
Livadas G.<br />
Athens, Greece<br />
WW1 soon spread around the entire globe. The 1915/16 disastrous Gallipoli Campaign was<br />
supported by a number of allied hospitals based on the Greek island of Lemnos. When this<br />
campaign was over, the Serbs, under Austrian and Bulgarian assault, retreated to the island of<br />
Corfu, French hospitals were set up to take care of more than 100.000 improverished troops and<br />
civilians. The city of Salonica was later selected as the base for the “Campagne d’ Orient”. More<br />
than 50 allied hospitals were set up in and around the city, most of them under canvas or wooden<br />
huts. They were mainly French and British, however, Canadian, Australian, New Zealand, Indian,<br />
Russian, Italian and Greek hospitals were also operating in the region.<br />
All these hospitals were large, operating with more than 1000 beds each, including all necessary<br />
departments, including X-Ray equipment.<br />
A number of French and British passenger ships were requisitioned and transformed into Hospital<br />
Ships for the evacuation of wounded or even as permanent hospitals. Amongst them were some<br />
of the largest ocean liners ever built.<br />
The period in question spans from 1915 to 1919. Our investigation in archival material brings into<br />
light the use of X-Rays in a forgotten front, a front which as far as medical support was equally<br />
important as the one on the Western front.<br />
ONE CENTURY OF URORADIOLOGY IN EUROPE : 1896 – 1996<br />
Moreau J.F.<br />
Université Paris Descartes, France<br />
“I’m looking for a man !”. Diogenes.<br />
First stage (1896-1929) : Uroradiology is a urological hobby.<br />
The birth of Uroradiology is dated on April 28 th , 1896, when Felix Guyon, chairman of the Urology<br />
Department at the Necker Hospital of Paris, introduced the radiological description of urinary<br />
stones by his resident, François-Joseph Chauvel, and a physicist, James Chappuis, at the<br />
“Académie Nationale de Médecine”. Thereafter, for almost half-a-century, the development of<br />
uroradiology was fully linked with urological research, mainly at the Necker Hospital where<br />
Albarran invented the modern cystoscope that allowed Tuffier to pass radiopaque catheter in the<br />
ureter through the ureteral meatus and to opacify the bladder with varied radiopaque<br />
compounds. Albarran introduced the retrograde pyelography too.<br />
Second stage (1929-1955) : Uroradiology has become a valuable urological tool.<br />
It benefits from the serependitous discovery in 1921 of the Lipiodol as a liposoluble radiopaque<br />
medium by Jacques Forestier and Jean-Athanase Sicard of the Necker Hospital. A second<br />
serependitous discovery in 1923 came from the Mayo Clinic, Rochester, Minnesota, where<br />
Osborne, Rowntree and Sutherland obtained the first but faint excretory urography in syphilitic<br />
patients treated with Sodium Iodine. That induced an intensive research for synthesizing<br />
watersoluble organic iodinated compounds. The controversial winners of the race for Intravenous<br />
Urography, in 1928-29, are Moses Swick, the American chemist at the Schering AG, and the<br />
urologist Alexander von Lichtenberg, both working in Berlin, Germany. In 1934, at the Cochin<br />
Hospital of Paris, the urologist Maurice Chevassus published the technique of retrograde<br />
ureteropyelography with the “sonde-bouchon”. In Paris two antagonist schools of urology will<br />
develop for almost five decades: it is based upon IVU first at the Necker hospital, cystoscopy and<br />
RUP at the Cochin hospital. All books are written by urologists sometimes associated with their<br />
radiologists. They are Gouverneur with Hickel and Fey with Truchot in France, Puigvert in Spain…<br />
and Emmett with Witten in the USA.<br />
Third stage (1955-1975) : Uroradiology after WW2 booms with nephrology, a new<br />
medical specialty requiring more and more functional data.<br />
Two technologies developed parallely. 1) Nuclear medicine using radiohippuran for bioassays<br />
and scintigraphy is not developed in the lecture; 2) Radiology benefits from the synthesis of the<br />
new watersoluble triodinated benzenic compounds filtrated by the glomeruli: iothalamate in the<br />
USA, diatrizoate in Germany, metrizoate in the Netherland, acetrizoate in France.<br />
Scandinavia is the nest of modern angiography. The Danish Seldinger introduced in 1952 his<br />
percutaneous technique of transfemoral aortography improved with the selective renal<br />
40
arteriography by Odman. Leif Ekelund in Sweden and JR Michel in Paris using angiotensin<br />
developed renal pharmacoangiography.<br />
High-doses IVU were available by drip infusion. Hodson studied urinary tract infections in<br />
England then in Northern America. Renovascular hypertension could be detected using minute<br />
sequence pyelography and the wash-out test proposed by the Austro-American Kurt Amplatz. JF<br />
Moreau in Paris studied reflux nephropathy and renal scarring; he made a synthesis with CJ<br />
Hodson at Yale University in 1981, a few months before the latter died.<br />
The concept of Genito-Uroradiology varied according to the structure of national<br />
medicines and the technological supplies available in the hospital departments. In fact<br />
in Europe, GU radiology mostly boomed from the radiologists who worked in Latin countries.<br />
They were not early known internationally because most of them didn’t speak English. In<br />
Germany, they were included in the departments of urology or internal medicine. In the UK, they<br />
were included in radiology departments with a few but outstanding GU experts. Out of these,<br />
Hugh Saxton introduced percutaneous needle nephrostomy, Thomas Sherwood taught GU at<br />
Oxford University, Ian Kelsey Fry studied iodine toxicity and renal failure with the nephrologist<br />
William Cattell. PGFM van Waës in Utrecht, The Netherland, wrote on oliguric renal failure. Both in<br />
the USA and, in Europe, France and Belgium, it has early become an autonomous subspecialty in<br />
radiology. André Dardenne of Brussels, Belgium won the quiz at the SUR meeting in 1981 and<br />
was the best uroradiologist of his generation worldwide. In France, the leaders, Jean-René Michel<br />
at the Necker Hospital, Annick Pinet at the Edouard Herriot Hospital in Lyon, practiced in big new<br />
hospitals combining huge departments of urology and nephrology only. The Necker Hospital and<br />
the Mayo Clinic were the only places where specific series of 100,000 IVUs could be studied for<br />
toxicity surveys in the seventies. Meanwhile GU in the USA was restricted to conventional<br />
techniques, it included in France and in Belgium not only IVU and retrograde but angiography and<br />
ultrasound too. They created the “Club du Rein” in 1965, then the “Société d’imagerie urinaire”<br />
(SIGU) in 1990, comparable with the American “wee-wee club” at the origin of the “Society of<br />
uroradiology” SUR in 1972. For the first time in the world, a book dedicated to uroradiology<br />
written by radiologists only is edited in 1980 by Lemaître, Michel and Tavernier.<br />
The SUR gave the GU label to some new European radiologists, such as Ludovico Dalla Palma and<br />
Judith AW Webb in 1983. Joshua Becker, Lee Talner, Alan Davidson and Glenn Hartman were the<br />
American friends who helped the European GU radiologists to know each other.<br />
Fourth stage (1975-1996): GU is submitted for cross-sectional computed tomography<br />
and non-invasive digital imaging revolution.<br />
“Whither IVU”, asked Hugh Saxon in a famous editorial dated on 1972. The first alert was given<br />
by renal ultrasonography inducing the debate between invasive and non invasive techniques and<br />
the role of hyperosmolality in the development of CM-induced renal failures. At the beginning<br />
except in Latin Europe, a few GU radiologists practiced both IVU and US. An acute phase of<br />
trouble happened when large doses of iodinated contrast media had to be injected intravenously<br />
during full-body CT scanner examinations. Industrial interests blurred the sanest argumentations<br />
when several classes of hypoosmolar compounds had been challenging the hyperosmolar ones,<br />
then the ionic and non-ionic hypomoslar themselves. The first hypoosmolar iodinated compound<br />
used for clinical IVU and angiography at the Necker Hospital was the ioxaglate (Hexabrix, 1976)<br />
and the non-ionic Iopamidol (1977). After years of hostility, CT scan and triplex Doppler<br />
ultrasonography had had to face the growth of MR imaging targeting first the prostate and the<br />
female genital tract before the kidney and the vascular tree. In 1996, GU radiology in Europe<br />
encompassed all technologies for a valuable study of the genito-urinary tract. They enabled the<br />
Germans to have a true pool of dedicated GU radiologists. The French Alain Dana proposed the<br />
concept of Uroscanner when the 3-D reconstruction of the abdomino-pelvic block had been<br />
available. GU has become a therapeutic agent with the development of interventional radiology<br />
on both the organs and their vascularity.<br />
In Conclusion. “Stand out of my sun!”. Diogenes facing Alexander the Great.<br />
The role played by the European Uroradiology growth along the last century is as poorly known as<br />
prominent. The European Society of Uroradiology was created in the early 1990ies under the<br />
impulse of Henrik Thomsen of Copenhagen, Ludovico Dalla Palma of Trieste and Jean-François<br />
Moreau of Paris. Ludovico was the godfather of the European Society of Radiology and of the<br />
Halley Project oriented to the Eastern European countries. Nowadays the ESUR is a pack<br />
congregating all European countries with an influence all around the Mediterranean Sea.<br />
During the XXth century two macroeconomical cycles developed with three major economical<br />
crises and two world wars. Not only they did not hamper the development of GU radiology but<br />
most of the improvements provoked by the so-called disruptive technologies emerged from the<br />
most troublesome years of the era: IVU in 1929, nonionics and CT scan in 1973 (first oil shock),<br />
MRI in 1979 (second oil shock), PET-scan in 1991 (Gulf war)… Good luck for the XXIth century!<br />
41
Papanicolaou N.<br />
Hospital of the University of Pensylvania, USA<br />
SUR HONORARY LECTURE<br />
Moderator: Hamm B.K. (D)<br />
PET / CT IN UROLOGIC ONCOLOGY<br />
42
ESUR GUIDELINES<br />
SESSION<br />
43
Thomsen H.S.<br />
University of Copenhagen Herlev Hospital<br />
Moderators: Morcos S.K. (UK)<br />
Contrast media-NSF<br />
In 2005, two European investigators – independent of each other – got the idea that the occurrence of NSF was correlated<br />
to exposure to a Gd-CM (1, 2).<br />
Already in 2002, nephrologists at Herlev Hospital, Denmark, became suspicious that a drug, including the Gd-CM used at<br />
the hospital, might be involved in the development of a mysterious disease pattern seen in patients with end-stage renal<br />
disease. However, at the same time several therapeutic drugs were introduced. Both in 2002 and 2003, the nephrologists<br />
reported severe adverse reactions e.g. muscular pain to gadodiamide to the Danish Medicines Agency. In 2005<br />
nephrologists at Herlev Hospital contacted “Medical Officers of Health in Copenhagen” about causes of the epidemic<br />
development of this mysterious disease, but got no answer (3). In the fall of 2005, they were almost certain and a workup<br />
of the patients were undertaken. It turned out that the Gd-CM was the only drug that all patients who developed<br />
biopsy-verified nephrogenic systemic fibrosis had had. On March the 17 th 2006, the nephrologists presented their data to<br />
the chairman of the department of diagnostic radiology, and immediately afterwards the radiologists decided to stop the<br />
use of the non-ionic linear chelate to all patients independent of the renal function. On March the 30 th 2006, the Danish<br />
Medicines Agency received 20 reports about NSF after gadodiamide (4) and late April 2006 the Marketing Authorization<br />
Holder reported the 5 cases published by Dr. Grobner (1) to the Austrian Medicines Agency. Then the authorities looked<br />
closer into the issue, and on February the 7 th 2007 the European Medicines Agency (EMEA) contraindicated the use of the<br />
non-ionic linear chelate (gadodiamide) in patients with reduced renal function (CKD 4 & 5) (5). In June this<br />
contraindication was extended to one of the 4 ionic linear chelates (gadopentetate dimeglumine), and at the same time a<br />
caution about their use (both the nonionic and ionic linear chelate) in patients with CKD 3 was added (6). When the nonionic<br />
linear chelate gadovertisamide got its European multistate approval in July 2007, the same caution and<br />
contraindication were included in its summary of product characteristics (7). In January 2008, the Pharmacovigilance<br />
working Party (PHVWP) of EMEA classified the agents in one of three groups: 1) high risk of NSF, 2) Intermediate risk of<br />
NSF and 3) low risk of NSF agents (5). This classification was subsequently adopted by the CMSC of ESUR. Since January<br />
2008, exposure to Gd-CM has caused no new cases of NSF; all cases reported since 2008 had their triggering dose before<br />
2008.<br />
ESUR Guideline<br />
Patients at a high risk are those with CKD 4 and 5 (GFR < 30ml/min) including dialysis and patients with reduced renal<br />
function, who have had or are awaiting liver transplantation. Patients with a lower risk are those with CKD 3 (GFR 30-<br />
59ml/min) as well as children under one year of age, because of their immature renal function. Patients with normal renal<br />
function are not at risk of NSF.<br />
The following contrast agents are considered to be of the highest risk of NSF: Gadodiamide (Omniscan®), Gadopentetate<br />
dimeglumine (Magnevist®) and Gadoversetamide (Optimark®). These agents are CONTRAINDICATED in patients with<br />
CKD 4 and 5 (GFR < 30 ml/min) including those in dialysis and patients with reduced renal function, who have had or are<br />
awaiting liver transplantation. They should be used with CAUTION in patients with CKD 3 (GFR 30-60 ml/min) and<br />
children less than one year old. Serum creatinine (eGFR) should always be measured prior to the use of these three<br />
agents.<br />
The intermediate risk group includes the following agents: Gadobenate dimeglumine (Multihance®) (Special feature:<br />
Similar diagnostic results can be achieved with lower doses because of its 2-3% protein binding), Gadofosveset trisodium<br />
(Vasovist®) (Special feature: It is a blood pool agent with affinity to albumin. Diagnostic results can be achieved with<br />
50% lower doses than extracellular Gd-CM. Biological half-life is 12 times longer than for extracellular agents (18 hours<br />
compared to 1½ hours, respectively)), and Gadoxetate disodium (Primovist®) (Special feature: Organ specific gadolinium<br />
contrast agent with 10% protein binding and 50% excretion by hepatocytes. Diagnostic results can be achieved with lower<br />
doses than extracellular Gd-CA.). Determination of serum creatinine level (eGFR) is not mandatory prior to use of these<br />
agents.<br />
Low risk group includes the following agents: Gadobutrol (Gadovist®), Gadoterate meglumine (Dotarem®) and<br />
Gadoteridol (Prohance®). Serum creatinine (eGFR) measurement before administration is not mandatory.<br />
If two different Gd-CM have been injected, it is impossible to determine with certainty which agent triggered the<br />
development of NSF and the situation is described as ‘confounded’. However, the agent which is most likely responsible is<br />
the one which has triggered NSF in other unconfounded situations.<br />
Finally, the committee recommends in all patients independent of renal function that one uses the smallest amount of<br />
contrast medium necessary for a diagnostic result. Patients with a clinically well indication should never be denied an<br />
enhanced MRI examination. One should always use an agent that leaves the smallest amount of gadolinium in the body.<br />
Magnitude of the problem<br />
By the end of February 2009, the European database on adverse reaction report contained a total of 129 European cases.<br />
In addition, there are eight Swiss cases, but at the Swiss national congress in radiology in 2008 the head of the Swiss NSF<br />
investigation informed that there are 18 patients fulfilling the 2008 Yale criteria for NSF (8, 9). United Kingdom is listed<br />
for four cases, but British authors have published 16 cases in the peer-reviewed literature (10, 11). These inaccuracies,<br />
which are not the only ones, indicate that despite the common database the authorities have no overview of the real<br />
problem.<br />
Recently, a drastic change occurred in Denmark. Until January 2009, it was generally thought that NSF was a specific<br />
Herlev Hospital problem. Why this should be the case No one has been able to explain this. Until the end of 2008, there<br />
were 32 diagnosed cases, 30 from Herlev hospital and two from two other hospitals. In January 2009, another university<br />
hospital outside of Copenhagen in a press release (12) stated that they had reviewed the medical records of 438<br />
nephrology patients and that they in 30 of them found signs and symptoms of NSF. However, 15 had died in the mean<br />
time. The remaining 15 patients were called for an interview and clinical investigation. At time of the press release (12)<br />
ten patients had NSF documented by biopsy. In two, NSF could not be the case and three were still under investigation. A<br />
week later a third university hospital reported two cases of NSF; the only two patients who had undergone MR<br />
angiography with gadodiamide in that hospital since 2002. Other hospitals are still reviewing their patients for NSF.<br />
Currently, Denmark has a least 67 patients with NSF of which 43 are documented by biopsy. If the prevalence is the same<br />
in the United States of America there should be around 3654 patients with NSF and 975 patients in Germany. According to<br />
the EU database there are 32 registered NSF patients in Germany and FDA has almost 1000 US cases in their database<br />
44
(3). The number of MRI units does not explain a part of the difference, since Denmark had fewer units per 1 mill<br />
inhabitants than Germany and the United States in 2005. Also a more productive use of the MRI units could to some<br />
extent explain the difference. However, this is not the case either, as Denmark has never had a tradition for elective use<br />
of scanners in double shift. Differences in market share of the high risk NSF agents between the three countries could be<br />
an explanation, but high risk agents were market leaders before 2006 in all three countries. Naturally, a difference in<br />
medical practice between Germany, United States and Denmark could be a fourth explanation, but then one would expect<br />
that the prevalence in Denmark was similar in Norway and Sweden, and that is not the case according to the EU<br />
database. Genetic differences could be a fifth explanation, but again the lower prevalence in Norway and Sweden speaks<br />
against this explanation. Finally, it seems that there is a large number of NSF patients which have not been diagnosed.<br />
With exception of two studies (13, 14), all studies have reviewed various registries for patients cases, but not<br />
systematically inspected the skin of the patients exposed to Gd-CM at a time where they had reduced renal function. NSF<br />
is not an ‘either or’ disease. There is great variability. NSF severity may be graded from 0 to 4: 0 – no symptoms, 1 –<br />
mild physical, cosmetic, or neuropathic symptoms not causing any kind of disability, 2 – moderate physical and/or<br />
neuropathic symptoms limiting physical performance to some extent, 3 – severe symptoms limiting daily physical<br />
activities (walking, bathing, shopping, etc), 4 – severely disabling symptoms causing dependence on aid or devices for<br />
common, daily activities (15). It is nearly impossible to overlook patients with severe disabling symptoms, but it is<br />
possible to give them the wrong diagnosis. Most of the disabled patients are probably in the registries. The opposite is<br />
also likely regarding those with non severe disease. When it is not disabling it requires that the patient spontaneously tells<br />
the physician about skin lesions on the extremities or the physicians systematically inspect the skin of patients with<br />
reduced renal function exposed to Gd-CM. That probably does not take place in the daily practice. Experience from<br />
Denmark speaks in favour of this.<br />
Consequences<br />
Various radiologists have drawn different consequences of the finding of a link between exposure to some Gd-CM and the<br />
development of NSF. Some has not changed their practice. Some denies patients with an eGFR below 60 or 30 ml/min an<br />
enhanced MRI and refer them to enhanced CT. Another group has changed to low risk NSF agents in half or normal dose,<br />
whereas others have changed to the intermediate risk NSF agents, which due to their unique protein can be used in lower<br />
doses than the extracellular agents. The referral of patients from enhanced MRI to enhanced CT is highly debatable. There<br />
are diagnoses were MRI are superior to CT and vice versa (16). It must always be recommended to refer a patient to the<br />
imaging modality that is the best for the work-up of the signs and symptoms of the patients. Use of an inferior imaging<br />
method may lead to overlooking of a lesion and this may not be optimal for the patients, as the lesion may not be<br />
treatable when it becomes bigger and visible on a less optimal imaging method. This has to be taken in consideration<br />
when one recommends an imaging modality. In contrast to CT, MRI does not include the use of radiation. It is generally<br />
accepted that the prevalence of acute non-renal adverse reactions is higher after iodinated contrast agents than after Gd-<br />
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<br />
for MRI than for CT, the prevalence is higher after I-CA (17, 19, 20). The exact prevalence of CIN after intravenous<br />
injection of non-ionic low-osmolar and iso-osmolar agents are unknown, but it is probably close to 10% in patients with a<br />
glomerular filtration rate (GFR) below 15 ml/min (CKD 5). Based on the recent studies comparing iso-osmolar and lowosmolar<br />
agents it is generally around 5% (range 0-21%) in CKD 4 patients (GFR 15-30 ml/min); with some agents it may<br />
be lower and in some patient groups it may be higher. The occurrence of CIN has been shown even after intravenous<br />
injection to be correlated with an increased 2-year mortality or morbidity (21, 22). This mortality and morbidity rate is<br />
higher than the risk of developing NSF after exposure to a low risk NSF agent (23, 24, 25). Therefore, it is highly<br />
debatable whether it is good practice to deny a patient with reduced renal function a well indicated enhanced MRI<br />
examination. All factors must be taken in consideration when one advises a referring physician on the optimal imaging<br />
methods in each single case.<br />
References<br />
1. Grobner T. Gadolinium: a specific trigger for the development of nephrogenic fibrosing dermopathy and<br />
nephrogenic systemic fibrosis Nephrol Dial Transplant 2006; 21: 1104-1108.<br />
2. Marckmann P, Skov L, Rossen K et al. Nephrogenic systemic fibrosis: Suspected etiological role of gadodiamide<br />
used for contrast-enhanced magnetic resonance imaging. J Am Soc Nephrol 2006; 17: 2359-2362.<br />
3. Marckmann P. An epidemic outbreak of nephrogenic systemic fibrosis in Danish hospital. Eur J Radiol 2008; 66:<br />
187-190.<br />
4. Ali Abu-Alfa A, Bennett CL, Laumann AE et. Nephrogenic Systemic Fibrosis. In preparation.<br />
5. Stenver DI. Pharmacovigilance: what to do if you see an adverse reaction and the consequences. Eur J Radiol<br />
2008; 66: 184-186.<br />
6. EMEA: http://www.esur.org/fileadmin/NSF/Public_Assessment_Report_NSF_Gadolinium_26_June_2007.pdf<br />
7. Optimark: http://www.emea.europa.eu/humandocs/PDFs/EPAR/optimark/H-745-en6.pdf. Accessed May 13th<br />
2009.<br />
8. Weisshaupt D. Gadolinium-based contrast agents: current approaches and guidelines in Switzerland. 95.<br />
Jahreskongress SGR-SSR, St. Gallen, May 29 th 2008<br />
9. Cowper S, Kay J, Elston D, LeBoit P, Girardi M. The clinicopathological definition of nephrogenic systemic fibrosis.<br />
3 rd Annual scientific symposium on nephrogenic systemic fibrosis and MR gadolinium-based contrast agents. New<br />
Haven, Connecticut, May 9 th 2009.<br />
10. Singh M, Davenport A, Clatworthy I et al. A follow-up of four cases of nephrogenic systemic fibrosis: is gadolinium<br />
the specific trigger Br J Dermatol 2008; 158: 1358-1362.<br />
11. Collidge TA, Thomson PC, Mark PB et al. Gadolinium-enhanced MR imaging and nephrogenic systemic fibrosis:<br />
retrospective study of a renal replacement therapy cohort. Radiology 2007; 245: 168-175.<br />
12. Skejby Hospital. http://www.rm.dk/Om%20Regionen/Aktuelt/Nyhederdocid=33934<br />
13. Todd DJ, Kagan A, Chibnik LB, Kay J. Cutaneous changes of nephrogenic systemic fibrosis. Predictor or early<br />
mortality and association of gadolinium exposure. Arthritis Rheumat 2007; 56: 3433-3441.<br />
14. Rydahl C, Thomsen HS, Marckmann P. High prevalence of nephrogenic systemic fibrosis in chronic renal failure<br />
patients exposed to gadodiamide, a Gadolinium (Gd)-containing magnetic resonance contrast agent. Invest Radiol<br />
2008; 43: 141-144.<br />
15. Marckmann P, Skov L, Rossen K, Thomsen HS. Clinical manifestations of gadodiamide-related nephrogenic<br />
systemic fibrosis. Clin Nephrol 2008; 69: 161-168.<br />
45
16. Dawson P, Punwani S. Nephrogenic systemic fibrosis: non gadolinium options for the imaging of CKD/ESRD<br />
patients. Semin Dial 2008; 21: 160-165.<br />
17. Heinz-Peer G. Acute adverse reactions (Chap 23). In: Thomsen HS, Webb JAW (eds) Contrast Media: Safety issues<br />
and ESUR Guidelines 2 nd revised Ed. Heidelberg, Springer Verlag 2009: 181-186.<br />
18. Webb JAW. Prevention of acute reactions (Chap 7). In: Thomsen HS, Webb JAW (eds) Contrast Media: Safety<br />
issues and ESUR Guidelines 2 nd revised Ed. Heidelberg, Springer Verlag 2009: 43-52.<br />
19. Thomsen HS. Contrast medium-induced nephropathy (Chap 9). In: Thomsen HS, Webb JAW (eds) Contrast Media:<br />
Safety issues and ESUR Guidelines 2 nd revised Ed. Heidelberg, Springer Verlag 2009: 63-80.<br />
20. Thomsen HS. Radiography and gadolinium contrast agents (Chap 22). In: Thomsen HS, Webb JAW (eds) Contrast<br />
Media: Safety issues and ESUR Guidelines 2 nd revised Ed. Heidelberg, Springer Verlag 2009: 171-178.<br />
21. From AM, Bartholmai BJ, Williams AW, Cha SS, McDonald FS. Mortality associated with nephropathy after<br />
radiographic contrast exposure. Mayo Clin Proc 2008; 83: 1095-1100.<br />
22. Goldenberg I, Chonchol M, Guetta V. Reversible acute kidney injury following contrast exposure and the risk of<br />
long-term mortality. Am J Nephrol 2009; 29: 136-144.<br />
23. Thomsen HS, Marckmann P, Logager VB. Update on nephrogenic systemic fibrosis. Magn Reson Imaging Clin N Am<br />
2008; 16: 551-560.<br />
24. Thomsen HS. Delayed reactions: Nephrogenic systemic fibrosis (Chap 24). In: Thomsen HS, Webb JAW (eds)<br />
Contrast Media: Safety issues and ESUR Guidelines 2 nd revised Ed. Heidelberg, Springer Verlag 2009: 187-196.<br />
25. Morcos SK. Chelates and stability (Chap 20). In: Thomsen HS, Webb JAW (eds) Contrast Media: Safety issues and<br />
ESUR Guidelines 2 nd revised Ed. Heidelberg, Springer Verlag 2009: 155-160.<br />
Kinkel K.<br />
University Hospital Of Geneva<br />
Riccabona M.<br />
FEMALE PELVIS<br />
PEDIATRIC IMAGING<br />
University Hospital Graz<br />
46
COURSE LECTURES<br />
ABSTRACTS<br />
47
NEW FRONTIERS IN IMAGING<br />
Moderators: Cornud F. (GR) – Gouliamos A. (GR)<br />
IMAGING OF INFLAMMATION AND FIBROSIS<br />
Grenier N.<br />
Université Victor Segalen-Bordeaux 2, France<br />
The natural course of most renal parenchymal diseases is characterized by a progressive or an acute inflammatory phase and<br />
a progressive fibrotic process. Specific diagnosis of the ongoing intrarenal process is difficult because intricate, and still<br />
requires pathological examination after percutaneous biopsy. Molecular imaging techniques are able to target several<br />
biological phenomena occurring during the inflammatory reaction, as the recruitment of inflammatory cells, the synthesis of<br />
specific molecules by activated patelets or endothelial cells… Molecular imaging of fibrosis is more problematic because the<br />
techniques of direct targeting of collagen fibers or fibroblast are missing. Quantification of fibrotic contain of tissues is better<br />
approached by indirect techniques as elastography, performed with ultrasound or MR techniques.<br />
Molecular MR imaging of inflammation<br />
Imaging of endocytosis by inflammatory cells<br />
Intravenous injection of ultrasmall superparamagnetic particles of iron oxide (USPIO) has been proposed for targeting<br />
phagocytic cells in inflammatory renal diseases. Several experimental studies showed that phagocytic cells captured the iron<br />
oxide particles and that the degree of decrease of signal intensity (SI), 24h after IV injection of USPIO, was correlated with<br />
the number of macrophages within each renal compartment. Location of signal decrease depended on the type of disease :<br />
global when infiltration was interstitial (hydronephrosis [1, 2], intoxication with puromycin amino-nucleoside [1], acute and<br />
chronic rejection [3]), cortical when intraglomerular (autoimmune glomerulonephritis [4]) and medullary only in acute tubular<br />
necrosis [5].<br />
In humans, MR imaging was performed 3 days after USPIO injection [6]. According to biopsy, significant SI decrease was<br />
noted diffusely in patients with an inflammatory component, and within the medulla only in those with ATN. Patients with<br />
chronic fibrotic disease did not show any change.<br />
Imaging of receptor expression<br />
P-selectin is a glycoprotein overexpressed by activated patelets and endothelial cells allowing their interaction. Targeting of P-<br />
selectin has been described using specific ligands linked to a macrocmolecular Gd-agent in a model of atherosclerosis [7].<br />
Activated endothelial cells also express several molecules on their surface during the inflammatory process as E-selectin,<br />
intercellular adhesion molecule (ICAM) vascular cellular adhesion molecule (VCAM), which have also been targeted using<br />
specific agents, either Gd-based or iron oxide-based [8, 9]. None of these agents have been used in the kidney. During their<br />
activation, recruited macrophages may over-express some receptors like the macrophage scavenger (MSR) [10].<br />
Imaging of enzyme synthesis by inflammatory cells<br />
Myeloperoxidase (MPO) is one of most abundant enzymes secreted by inflammatory mononuclear cells (neutrophils and<br />
macrophages), able to generate reactive oxygen species. Within kidney, this reaction leads to a variety of compounds that in<br />
turn may cause dysfunction of cells in different compartments of renal parenchyma [11]. A MPO-sensitive Gd-based MR<br />
contrast agent has been developed recently targeting in vivo reperfused ischemic myocardium [12] and inflammatory<br />
demyelinating plaques in brain [13, 14]. Applications of these techniques within the kidney should be numerous in the future.<br />
Imaging of fibrosis<br />
Exaggeration of extracellular matrix synthesis, with excessive fibrillar collagens, characterizes the development of fibrotic<br />
lesions in the glomerular, interstitial and vascular compartments, leading progressively to end-stage renal failure.<br />
Systems participating in these processes are better identified and various therapeutic interventions have been shown to<br />
prevent or to favor regression of fibrosis in several experimental models. Therefore, development of new noninvasive<br />
methods for identification and quantification of fibrosis would also be worthwhile. Three approaches can be proposed with<br />
MR imaging: molecular imaging, diffusion-weighted MR imaging and elastography.<br />
Molecular imaging of fibrosis<br />
Collagen-targeted contrast agents have recently been developed based on a Gd-chelate linked to a collagen-specific peptide<br />
[15] and applied to myocardial fibrosis in a mouse model [16]. Experience is still limited but applications could be numerous<br />
in the future, in kidney, liver and lungs.<br />
Diffusion<br />
The development of fibrosis is responsible for a restriction of the diffusion space for water molecules. Diffusion-weighted<br />
MR imaging sequences allows measuring the reduction of ADC-values in proportion with tissue changes. Early reports<br />
showed that liver ADC could be used to predict liver fibrosis and inflammation with acceptable sensitivity and specificity<br />
[17]. However, a recent study demonstrated that the restricted diffusion observed in patients with cirrhosis may be<br />
related to perfusion-related ADC variations, which reflect decreased perfusion, as well as alterations in pure molecular<br />
water diffusion in cirrhotic livers. [18]. The first clinical trials on chronic renal diseases, including renal artery stenosis and<br />
ureteral obstruction, showed a decrease of ADC-values which were highly correlated with serum creatinine levels [19].<br />
However, none of these studies presented correlation with pathological quantification of fibrosis.<br />
Elastography<br />
Fibrotic process altering the renal tissue structure, changes the biomechanical properties of the kidney. Over the past ten<br />
years, elastography has emerged as a very promising technique to quantify the stiffness of organs. Its application in<br />
evaluation of chronic liver diseases is already included in clinical practice. This method requires applying shear waves by<br />
means of a mechanical device, producing tissue displacements on the order of nanometers to micrometers. Propagation of<br />
these waves being dependent on viscoelastic properties of the tissue, its elastic characteristics can be quantified and/or<br />
mapped as parametric images. This information can be obtained using ultrasounds or MR imaging. The sonographic<br />
method is based on the emission of acoustic pulses to produce shear waves. The information can be unidimensional<br />
(Fibroscan used in the liver) [20], or bi-dimensional with new devices [21]. Using MR imaging, the vibration can be<br />
produced by an acoustic or a mechanical system and the encoding of propagating shear waves is based on a phase<br />
contrast technique utilizing cyclic motion-sensitized gradients. Application of these methods to the kidney is limited to a<br />
few experimental data: Shah et al [22] validated the approach in vivo on a rat model of nephrocalcinosis and obtaining<br />
the first stiffness maps of native human kidneys. Early results should be obtained soon with sonographic methods.<br />
References<br />
48
1. Hauger, O., et al., MR imaging of intrarenal macrophage infiltration in an experimental model of nephrotic<br />
syndrome. Magn Reson Med, 1999. 41(1): p. 156-62.<br />
2. Schreiner, G.F., et al., Immunological aspects of acute ureteral obstruction: immune cell infiltrate in the kidney.<br />
Kidney Int, 1988. 34(4): p. 487-93.<br />
3. Ye, Q., et al., In vivo detection of acute rat renal allograft rejection by MRI with USPIO particles. Kidney Int,<br />
2002. 61(3): p. 1124-35.<br />
4. Cattell, V., Macrophages in acute glomerular inflammation. Kidney Int, 1994. 45(4): p. 945-52.<br />
5. Jo, S.K., et al., Detection of inflammation following renal ischemia by magnetic resonance imaging. Kidney Int,<br />
2003. 64(1): p. 43-51.<br />
6. Hauger, O., et al., USPIO-enhanced MR imaging of macrophage infiltration in native and transplanted kidneys:<br />
initial results in humans. Eur Radiol, 2007. 17(11): p. 2898-907.<br />
7. Chaubet, F., et al., A new macromolecular paramagnetic MR contrast agent binds to activated human platelets.<br />
Contrast Media Mol Imaging, 2007. 2(4): p. 178-88.<br />
8. Choi, K.S., et al., Inflammation-specific T1 imaging using anti-intercellular adhesion molecule 1 antibodyconjugated<br />
gadolinium diethylenetriaminepentaacetic acid. Mol Imaging, 2007. 6(2): p. 75-84.<br />
9. Nahrendorf, M., et al., Noninvasive vascular cell adhesion molecule-1 imaging identifies inflammatory activation<br />
of cells in atherosclerosis. Circulation, 2006. 114(14): p. 1504-11.<br />
10. Amirbekian, V., et al., Detecting and assessing macrophages in vivo to evaluate atherosclerosis noninvasively<br />
using molecular MRI. Proc Natl Acad Sci U S A, 2007. 104(3): p. 961-6.<br />
11. Malle, E., T. Buch, and H.J. Grone, Myeloperoxidase in kidney disease. Kidney Int, 2003. 64(6): p. 1956-67.<br />
12. Nahrendorf, M., et al., Activatable magnetic resonance imaging agent reports myeloperoxidase activity in healing<br />
infarcts and noninvasively detects the antiinflammatory effects of atorvastatin on ischemia-reperfusion injury.<br />
Circulation, 2008. 117(9): p. 1153-60.<br />
13. Chen, J.W., et al., Myeloperoxidase-targeted imaging of active inflammatory lesions in murine experimental<br />
autoimmune encephalomyelitis. Brain, 2008. 131(Pt 4): p. 1123-33.<br />
14. Chen, J.W., et al., Imaging of myeloperoxidase in mice by using novel amplifiable paramagnetic substrates.<br />
Radiology, 2006. 240(2): p. 473-81.<br />
15. Caravan, P., et al., Collagen-targeted MRI contrast agent for molecular imaging of fibrosis. Angew Chem Int Ed<br />
Engl, 2007. 46(43): p. 8171-3.<br />
16. Helm, P.A., et al., Postinfarction myocardial scarring in mice: molecular MR imaging with use of a collagentargeting<br />
contrast agent. Radiology, 2008. 247(3): p. 788-96.<br />
17. Taouli, B., et al., Chronic hepatitis: role of diffusion-weighted imaging and diffusion tensor imaging for the<br />
diagnosis of liver fibrosis and inflammation. J Magn Reson Imaging, 2008. 28(1): p. 89-95.<br />
18. Luciani, A., et al., Liver cirrhosis: intravoxel incoherent motion MR imaging--pilot study. Radiology, 2008.<br />
249(3): p. 891-9.<br />
19. Namimoto, T., et al., Measurement of the apparent diffusion coefficient in diffuse renal disease by diffusionweighted<br />
echo-planar MR imaging. J Magn Reson Imaging, 1999. 9(6): p. 832-7.<br />
20. Castera, L., X. Forns, and A. Alberti, Non-invasive evaluation of liver fibrosis using transient elastography. J<br />
Hepatol, 2008. 48(5): p. 835-47.<br />
21. Bercoff, J., et al., In vivo breast tumor detection using transient elastography. Ultrasound Med Biol, 2003.<br />
29(10): p. 1387-96.<br />
22. Shah, N.S., et al., Evaluation of renal parenchymal disease in a rat model with magnetic resonance elastography.<br />
Magn Reson Med, 2004. 52(1): p. 56-64.<br />
49
Dogra V.S.<br />
University of Rochester, NY, USA<br />
NEW FRONTIERS IN US IMAGING<br />
Prostate cancer is the most prevalent newly diagnosed malignancy in men, second only to lung cancer in causing cancerrelated<br />
deaths. Adenocarcinoma of the prostate is the most common malignancy in the Western world. There will be a<br />
projected 218,890 new cases of prostate cancer diagnosed in the United States in 2008, with an estimated 27,050 deaths.<br />
As men age, the risk of developing prostate cancer increases. Prostate cancer has been found incidentally in<br />
approximately 30% of autopsy specimens of men in their sixth decade. Seventy to 80% of patients who have prostate<br />
cancer are older than 65 years.<br />
Appropriate imaging of prostate cancer is a crucial component for diagnosing prostate cancer and its staging, in addition<br />
to PSA levels and DRE. The current state of prostate imaging for diagnosis of prostate cancer includes ultrasound,<br />
ultrasound-guided prostate biopsies, magnetic resonance imaging (MRI), and nuclear scinitigraphy. These modalities are<br />
helpful, but have drawbacks and limitations. MRI is expensive and not mobile. Nuclear scintillation is expensive, provides<br />
low resolution planar images, and there are problems with radiotracer excretion through the kidneys. Both these<br />
modalities are not available for general use.<br />
Ultrasound is not reliable enough to use solely as a template for diagnosing prostate cancer. It has two problems. First, in<br />
many cases prostate cancer appears as an isoechoic lesion (similar gray scale value as surrounding tissue) causing high<br />
miss rate). Secondly, when it is visible (hyper or hypoechoic), it is not possible to say with certainty if it is cancer or<br />
benign because many other non-cancer conditions such as prostate atrophy, inflammation of the prostate gland, and<br />
benign tumors may also look similar in appearance on ultrasound examination. A biopsy has to be performed on the<br />
suspect lesion for definitive diagnosis. Biopsies are uncomfortable and bleeding may result as a complication. Because of<br />
poor lesion detection, even the current prostate biopsy techniques miss approximately 30% of prostate cancer. Utility of<br />
color flow and power Doppler in conjunction with gray scale ultrasound has been explored, but not successfully. Therefore,<br />
there is an urgent need for a new imaging methodology that will be portable, economical to build, and will have<br />
widespread utility as a tool for primary screening and diagnosis of prostate cancer.<br />
It is evident that given the limitations of the present diagnostic protocols, development of a new imaging modality that<br />
improves visualization and biopsy yield of prostate cancer would be beneficial.<br />
The need for tumor visualization is equally critical in the treatment of localized prostate cancer disease. Existing<br />
therapeutic strategies, namely external beam radiation, prostate brachytherapy, cryosurgery, and watchful waiting, all will<br />
benefit significantly from the development of a new modality that promises better tumor contrast. I conclude that prostate<br />
cancer continues to be an area in which progress is needed despite recent advancements. We have developed<br />
photoacoustic (PA) imaging technology for the betterment of prostate cancer diagnosis and disease management. After<br />
attending this lecture the attendee will be able to :<br />
1. Understand the principles of photoacoustic Imaging and<br />
2. Describe a C-scan.<br />
Hamm B.K.<br />
Charité Humboldt Universität Berlin, Germany<br />
IMAGING OF ATHEROSCLEROSIS<br />
50
DIABETES MELLITUS<br />
Moderators: Tsampoulas K. (GR) – Triantopoulou Ch. (GR)<br />
DIABETES AND DIABETIC NEPHROPATHY<br />
Zoupas C.S.<br />
Director Diabetes Center and Clinic, “Hygeia” General Hospital. Athens-Greece<br />
Diabetic nephropathy represents the most common cause of end-stage renal failure in the western world and accounts for<br />
approximately 40% of all new patients entering the programs of end-stage renal disease (ESRD).<br />
Over the last decade (1990-2000) the prevalence and incidence of ESRD in USA have approximately doubled, due to type<br />
2 diabetes.<br />
Although dialysis and transplantation prevent death from uremia, the 5 year survival in diabetic patients with ESRD is<br />
much worse than that of non diabetic patients.<br />
Therefore it is important to recognize the very early stages of diabetic nephropathy and to institute appropriate therapy,<br />
especially when urinary albumin excretion is >300 mg/day.<br />
Diabetic nephropathy develops in almost 50% of patients with type 1 diabetes mellitus who have had diabetes for more<br />
than 20 years. Clinically significant renal disease is less common in type 2 diabetes mellitus, occurring in 15-20% of<br />
individuals.<br />
A rational approach to the therapy of diabetic renal disease depends on the thorough understanding of its pathogenesis.<br />
The following factors have implicated in the development of diabetic nephropathy:<br />
-Poor glycemic control (fasting plasma glucose >140-160mg/dl or >7,7-8,8mmol/l and A1c>7-8%.<br />
-Genetic factors<br />
-Hemodynamic abnormalities (increased RBF and GFR , elevated intraglomerular<br />
pressure)<br />
-Systemic Hypertension<br />
- Insulin resistance syndrome (Metabolic syndrome)<br />
-Inflammation (highly sensitive C-reactive protein, fibrinogen, NFkB)<br />
-Altered vascular permeability<br />
-Excessive protein intake<br />
-Metabolic disturbances (abnormal polyol metabolism, formation of advanced glycation end products, increased cytokine<br />
production)<br />
-Release of growth factors<br />
-Abnormalities in carbohydrate /lipid/protein metabolism<br />
-Structural abnormalities (glomerular hypertrophy, mesangial expansion, glomerular basement membrane thickening)<br />
-Disturbances in ion pumps (increased Na-H pump and decreased Ca-ATPase pump)<br />
-Hyperlipidemia (hypercholesterolemia and hypertriglyceridemia)<br />
-Activation of protein kinase C<br />
Before the onset of overt or clinical albuminuria there is a preclinical stage of diabetic nephropathy characterized by<br />
microalbuminuria.<br />
Microalbuminuria was first described almost 45 years ago and this concept has been used more frequently in clinical<br />
medicine as a marker of disease progression, especially after important studies results showing that this parameter is a<br />
key indicator for intensified treatment in patients with IDDM.<br />
Most importantly tight glycemic control with insulin and treatment with ACE-inhibitors during the microalbuminuric stage<br />
have been shown to prevent the progression of microalbuminuria to overt clinical albuminuria in both type 1 and type 2<br />
diabetes subjects.<br />
It is well recognized that the results of landmark studies of Diabetes Control and Complications Trial (DCCT) (intensive<br />
insulin therapy in type 1 diabetes) the Japanese Intervention Study (intensive insulin therapy in type 2 diabetes) and the<br />
United Kingdom Prospective Diabetes Study (UKPDS) (intensive therapy with oral agents and / or insulin in type 2<br />
diabetes) have conclusively demonstrated that tight glycemic control serves as primary prevention for all microvascular<br />
complications including nephropathy, retinopathy, neuropathy!<br />
After all these data ideal blood glucose control is of paramount importance in preventing nephropathy!<br />
The natural history of diabetic nephropathy in individuals with type 2 DM who are destined to develop ESRD closely<br />
mimics that in type 1, but there are some important differences.<br />
Clinically detectable albumninuria is common at the time of diagnosis, but a smaller percentage (5-10%) of Caucasian<br />
patients with type 2 DM progress to ESRD by 20 years!<br />
In patients with non-insulin dependent DM, microalbuminuria is also an important predictor of other complications and of<br />
adverse outcome!<br />
Approximately 80% of individuals with type 2 DM die from cardiovascular complications (stroke or myocardial infarction)<br />
within 10 years after the onset of microalbuminuria!<br />
In addition microalbuminuria is strongly associated with the insulin resistance syndrome!<br />
In type 1 DM clinical evidence of renal disease is extremely rare within the first 5 years after diagnosis of diabetes and is<br />
uncommon (5-10%) within the first 10 years!<br />
Diabetic retinopathy usually accompanies diabetic nephropathy!<br />
Because of the significant day-to-day variation (40-50%) in urinary microalbumin excretion, at least two base line<br />
determinations should be obtained to establish the diagnosis.<br />
Several factors can increase the urinary albumin excretion rate: stress, systemic or urinary tract infection, acute<br />
metabolic decompensation, fever, exercise, hypertension and cardiac failure.<br />
These confounding medical disorders must be resolved before measuring the albumin excretion rate.<br />
Strict glycemic control and treatment of hypertension, if present, is the most important factor in treating diabetic patients<br />
during the microalbuminuric stage.<br />
A low-protein diet ameliorates the progression of chronic renal disease. Moderate protein restriction of 0,8-1,0 g/kg/day is<br />
advocated in diabetic patients with overt microalbuminuria. Replacement of animal protein with vegetable protein is<br />
recommended.<br />
51
Hypertension is a characterized feature of diabetic nephropathy and is the most important factor known to accelerate the<br />
progression of renal disease. Treatment of hypertension at or before the microalbuminuric stage can prevent the<br />
development of microalbuminura or arrest the progression respectively.<br />
Antihypertensive therapy should begin at the earliest indication and should be aggressive. ACE inhibitors and angiotensin<br />
receptor blockers-ARBs, are the most used and ideal antihypertensive agents. Numerous studies have shown that ACE<br />
and ARBs are the only two classes of antihypertensive drugs which reverse<br />
hemodynamic alterations that characterize diabetic nephropathy. Most of the data have been accumulated with ACE<br />
inhibitors, which are the drugs of choice for the treatment of microalbuminuria, because this class of drugs improves<br />
insulin sensitivity, glucose tolerance and dislipidemia. If cough presents a problem an ARBs can be used.<br />
The natural history of renal disease has been well characterized in both type 1 and type 2 DM and for this reason<br />
increased awareness and knowledge by the physicians is of paramount importance in order to prevent ESRD!<br />
IMAGING OF GENITOURINARY COMPLICATIONS OF DIABETES MELLITUS<br />
Danza F.<br />
Università Cattolica del S. Cuore., Roma Italy<br />
Diabetes mellitus is a metabolic disorder characterized by lack (absolute or relative) of insulin which leads to altered use<br />
of carbohydrates as well as altered metabolism of both lipids and proteins.<br />
The disease for its particular effect on systemic vasculature can determine a series of complications that can affect<br />
multiple organs.<br />
Prevalence of diabetic complications<br />
1 – microangiopathic<br />
Type 1 Type 2 TOT<br />
• Retinopathy 53.6 34.7 37.3<br />
proliferant 12.5 6.2 7.6<br />
background 41.1 28.4 29.7<br />
• Nephropathy<br />
patients in dialysis<br />
28/mil<br />
microalbuminuria 31.0 15<br />
• Neuropathy 28.0<br />
2 - macroangiopathic<br />
Diabetics Non Diabetics<br />
% %<br />
• Ischemic heart disease 7 - 31 6 - 7<br />
• Vascular dis. lower limbs 18.1<br />
• Hypertension 53 - 68<br />
• Dyslipidemia 54 - 64<br />
• Ulcers lower limbs 15<br />
In such a way the disease determines an high cost to the community<br />
Costs related to diabetes<br />
> hospital stay < workdays > assistance<br />
Screening e diagnosis ++ ++<br />
Therapy and selfcontrol + +<br />
Diagnosis and fup of sequelae + ++<br />
Hospitalization for acute events +++ ++<br />
•Complications +++ ++<br />
–blindness +++ ++++ ++++<br />
–dialysis +++ ++++ ++++<br />
–amputations ++++ ++++ ++++<br />
OMS estimated a clear grow of prevalence of the disease in the last ten years: from 170 to 210 millions of patients in<br />
2010. It is really a epidemic increase of diabetes and obesity in the world. The USA 2002 costs of diabetes are estimated<br />
in about $250.000 per minute. Health costs/person in USA: Healthy $ 2.5 Diabetic $ 13<br />
Diabetes and diseases of the GU tract:<br />
This is a frequent association: there are many changes induced by diabetes on the GU tract. For example common<br />
diseases are often more severe and with unusual findings in diabetic patients.<br />
Diabetes and Genito-urinary complications<br />
Renal changes, vascular changes, neurological changes, degenerative changes, infectious diseases<br />
Renal changes: diabetic nephropaty, papillary necrosis, renal amiloydosis in dialyzed patients.<br />
Diabetic nephropaty<br />
Definition: presence of persistent proteinuria (> 0,500 mg/day) in a diabetic patient, in absence of other nephropaties,<br />
urinary infection or cardiac insufficiency.<br />
Diabetic nephropaty has different presentation in respect of type of disease: diabetes mellitus - Insulin dependent (type<br />
1): the nphropaty is present in about 40% of patients; nephropaty is rare before 10 years of diabetes with a peaks after<br />
15-20 years. Rarely develops after 30 from diagnosis of diabetes. In Diabetes mellitus Non insulin dependent (type 2) the<br />
nephropaty is present in about 15% of patients. Development of nephropathy increases with disease duration. Risk of<br />
nephropaty is low in a normo-albuminuric patients after 30 years from diagnosis of diabetes.<br />
Diabetic nephropaty: Hypertrophy – Hyperfunction of kidney.<br />
In the initial phases of diabetes, before starting insulin therapy there are signs of hyperfiltration (increase of GFR up to<br />
40%), microalbuminuria, nephromegaly, glomerular hypertrophy<br />
Such changes disappear after starting insulin therapy; only remains increased GFR<br />
Subclinical nephropaty (silent): after 2-3 years from onset of diabetes there is development of strain microalbuminuria (=<br />
urinary excretion > 30 mg < 300 mg/die (> 20 < 200 g/min). Increased GFR persists There is increase of mesangial<br />
52
membranes and thickening of basal membranes at the glomerulus. These changes are reversible if optimal control of<br />
glicemia is obtained.<br />
Incipient diabetic nephropaty: about 10-15 years after onset of diabetes, starts persistent microalbuminuria, predictive of<br />
development of clinical diabetic nephropaty in more than 80% of cases. GFR is increased or normal; arterial pressure is<br />
increased or normal; increased mesangial matrix and thickening of basal membranes usually appear.<br />
Clinical nephropaty: persistent proteinuria, often with frank nephrotic syndrome; progressive reduction of GFR (about 1<br />
ml/min/month); arterial hypertension; diabetic glomerulosclerosis; arteriolosclerosis.<br />
Chronic renal failure: constant decrease of GFR is the rule. Hypertension is present. Terminal uremia is the destiny (3 -<br />
20 years after the beginning of clinical nephropaty).<br />
Diabetic nephropaty - Imaging<br />
Diabetes is the most frequent cause of nephromegaly.<br />
There is some literature on renal US and Doppler changes in patients with diabetic nephropaty:<br />
–Platt, Radiology 1994, Brkljacic, Radiology 1994, Derchi, Acad Radiol 1994, Soldo, Acta Radiol 1997, Boeri, Diabetologia<br />
1998, Sari, Invest Radiol 1999, Okten, Acta Radiol 1999.<br />
Hyperfiltration: patients with hyperfiltration have higher renal volume and lower renal RI than those with normal or<br />
reduced GFR. Renal volume > 410 ml e IR
Dystrophic changes: calcifications of the deferent ducts may bevelop with age, following infections (aspecific, tb,<br />
schystosomiasis), and in diabetics. Of the 60 Patients with deferent ducts calcifications described by Wilson and Marks, 56<br />
were diabetic. In diabetics the etiology is dystrophic (Wilson, NEJM 1951).<br />
Calcifications of deferent ducts: their position allows easy differentiation from vascular calcifications. They present a<br />
“railway track” shape, more easily visible on CT<br />
Infectious diseases<br />
High levels of glucose in tissues and a pathologic tissue and vascular response predispose diabetic patients to infections.<br />
Infections in diabetics are often severe, due both to the pathogens involved in the disease process and the degree of<br />
aggressivenes of the infection itself. Development of gas is relatively frequent in infections in diabetic patients: this seems<br />
due to presence of abundant glucose within tissues. Identification of gas indicates a severe infection; however, gas can be<br />
easily seen, especially by CT, and this helps the diagnosis.<br />
Pyelonephritis – renal abscess<br />
A renal abscess is due, in most cases, to ascending infection; hematogenous origin is possible, but rare. Lesions can<br />
extend into perirenal spaces. Imaging is needed to identify these lesions and monitor the response to therapy (be it<br />
medical o interventional).<br />
Prostatic-vescicular abscess. Diabetes is a predisposing factor to development of prostatic abscesses: it usually is from<br />
ascending origin, sometimes from hematogenous spread or after instrumentation. Etiology varies according to patient’s<br />
age: Neisseria e Chlamydia in young, sexually active; E. Coli in the elder .<br />
Emphysematous pyelonephritis<br />
Infection characterized by presence of gas in calices, pelvis, parenchyma, and perirenal tissues. In 87% of cases it<br />
involves diabetic patients (especially women); in the others it is almost invariably associated with obstruction. Organisms<br />
involved are E. coli (71%), Klebsiella, Aerobacter, Proteus, Candida (Michaeli, J Urol 1974).<br />
It is a very severe condition, with mortality >60% if treated with antibiotics only, and 30%-50% if the Patient undergoes<br />
surgery; mortality is 80% if the disease extends into perirenal tissues. Clinically, it is a pyelonephritis which does not<br />
respond to treatment. The CT and US findings are typical, and the diagnosis is based on demonstration of gas within the<br />
renal parenchyma. CT allows better analysis of the extension of the disease process<br />
Emphysematous cystitis<br />
It is a rare condition, which is typical of diabetics: fermentation of glucose in tissues and in urines causes production of<br />
gas within both the bladder lumen and bladder wall. Symtoms are those of cystitis; pneumaturia can be observed. The<br />
condition can often be visible on plain films of abdomen due to presence of gas in the bladder wall, presenting as a curved<br />
hypodense line in the pelvis. US, and better CT, have higher sensitivity.<br />
Fournier gangrene<br />
It is a urologic emergency, with up to 75% mortality. Necrotizing fascitis of perineum which can extend to abdominal wall;<br />
predisposing factors: diabetes, alcoholism, advanced age, immunodeficiency. Originates from perineal (rectal fistulas,<br />
cutaneous ulcerations) or from uretral lesions (the fascia of Colles, at the level of the suspensory ligament of penis is<br />
fenestrated, and does not offer a barrier to spread of the infection). The diagnosis is on clinical grounds; imaging needed<br />
when symptoms not clear. The radiological diagnosis is based on demostration of gas within soft tissues. The disease can<br />
extend to the whole pelvis, and can be impossible to dominate<br />
Infections – penile<br />
A rare condition, infections of the penis are often related to fimosis, obesity, diabetes, immunodeficiency, often due to<br />
invasive manoeuvres. Imaging is usually based on US, which is enough to identify and “stage” the disease process.<br />
Infections can lead to abscess development.<br />
Tubo-ovarian abscesses<br />
Tubo-ovarian abscesses are rare in the post-menopausal patient (2%), and are often associated with neoplasms. From<br />
15% to 18% of these patients have diabetes. Etiopatogenesis correlates to ascending infections and/or instrumentation.<br />
Clinically, symptoms are often not clear (mild fever, slight leucocitosis) and physical findings are non specific (mass, pain,<br />
bleeding).<br />
Imaging findings are variable, related to location of the diasease process (tubal dilatation, pelvic mass, free fluid).<br />
Imaging can guide drainage (via transvaginal or transperineal approach).<br />
Morcos S.K.<br />
Northern General Hospital, UK<br />
USE OF CM IN DIABETIC PATIENTS<br />
LYMPHOPROLIFERATIVE DISORDERS<br />
Moderators: Ramchandani P. (US) – Amendola M. (US)<br />
RETROPERITONEAL LYMPHOPROLIFERATIVE DISEASE(LPD)<br />
Goldman S. (US)<br />
University Of Texashealth Science Center, USA<br />
Hodgkin’s disease was first described by Dr. Thomas Hodgkin in 1832. In 1902 Dorothy Reed Mendenhall described the<br />
Reed-Sternberg cell, which became the hallmark of the fascinating topic of the lymphomas of the body which will be<br />
relatively limited to the retroperitoneum in this lecture.<br />
Our goals in this presentation is to discuss the relative anatomy, review the major types of LPD (Hodgkin’s NHL, PTLD,<br />
etc. in regard to etiology, pathology and staging; discuss the role of imaging in initial staging during therapy, immediately<br />
after Rx and in follow-up studies.<br />
I. Anatomy<br />
Although all of you are familiar with the anatomy of the retroperitoneum, a few issues need to be<br />
reemphasized and illustrated. Although all of you are familiar with the existence of adrenal kidney<br />
lymphoma; the pancreas itself can be involved with lymphoma, as well as the lymph nodes draining the<br />
pancreas. Other pertinent structures in the retroperitoneum will be reviewed. Furthermore, it is important<br />
to recognize that lymphoma below the diaphragm may not be confined to the retroperitoneum. The<br />
responsibility of the radiologist is to not only look at the obvious structures such as the spleen, liver and the<br />
54
II.<br />
mesentery; the gastroduodenal ligaments and the gastrohepatic ligaments may be involved and need to be<br />
commented upon, in spite of the fact that they may not be technically part of the retroperitoneum.<br />
History<br />
In the GRAND OLD DAYS of the 60’s, lymphoma evaluation by the radiologist was simple. His job was to<br />
define whether the disease was above and/or below the diaphragm (Stages I & II), since most radiologists<br />
did both diagnostic and therapeutic radiology, one correlated as to whether the patient was symptomatic (A)<br />
or asymptomatic (B). Treatment was predominantly by radiation. The radiologist’s tools consisted of the<br />
chest X-ray, abdominal film and usually an IVP (inverted Y sign). When necessary, this was supplemented<br />
by an upper GI series with small bowel follow through and a barium enema. In the early 60’s, added to the<br />
radiologist armamentarium, came the lymphangiogram. This provided morphology of the lymph node. It<br />
would show the enlarged nodes, theoretically differentiated between Hodgkin’s and Non-Hodgkin’s<br />
lymphoma. This technique was still used into the 90’s for lymphoma and cervical cancer, and even recent<br />
articles as late as last year have advocated its use (think of the use of iron oxide compounds for imaging of<br />
retroperitoneal lymph node on MRI).<br />
III. A Few General Concepts<br />
Hematological Disorders are classically divided into leukemia, lymphoma, plasma cell disorders/ multiple<br />
myeloma and myelodysplastic syndromes. Currently, in dealing with the subject of MDP disorders there are<br />
literally hundreds of different diseases to consider; however, in fact, the common disorders consist of NH<br />
lymphoma (62.4%), plasma cell disorders (16%), CLL (9%), Hodgkin’s Lymphoma (8.2%) and all others<br />
(3.8%). This talk will be limited to the common varieties, except for a few exceptions (Keep It Simple &<br />
Stupid). Some of the important concepts to remember are the association with multiple viral syndromes<br />
(AIDS (HHV-8), herpes, IL-6, Epstein-Barr). Patients who are immune-compromised, (transplants, collagen<br />
diseases), are also prone to develop MDP.<br />
IV. Look-A-Likes<br />
Castleman’s Disease (Angio Follicular lymphoma) is an important look-a-like and is benign, although there<br />
have been transformation in these patients to true LPD. Other entities to be considered are Kawasaki<br />
Disease, atypical lymphoid hyperplasia, Wiskott Aldrich syndrome.<br />
V. Hodgkin’s Disease (HD)<br />
There are approximately 8,000 new diagnoses each year with 1,300 in the United States. Most cases are<br />
seen between the ages of 15 – 30, with a second peak after 55 years. True Hodgkin’s consists of 15% of<br />
cases and NHL 85%. Multiple classifications exist; some of this is based on the cell type WHO (B cell, T cell,<br />
NK cell). The highest rates for HD are in the United States and Western Europe, although for reasons not<br />
understood, there has been a decline in incidence over the last 20 years. It is slightly more common in<br />
males with Whites affected greater than African Americans and both greater than Asians. There are known<br />
genetic factors. HD is divided into the classical Reed-Sternberg type (Nodular sclerosing (65%), mixed<br />
cellularity, (72%), lymphocyte depleted (2%), lymphocyte-rich (3%) and into the lymphocyte predominant<br />
(6%), non- classifiable (12% - nodular-lymphocytes, Diffuse T). The Rye classification divides them into 4<br />
types: Lymphocyte predominant, nodular sclerosis, mixed cellularity and lymphocyte depletion. One of the<br />
other important concepts in determining outcome is called the Hodgkin’s Risk Factors: Age greater<br />
than/equal to 45, Stage IV disease Hgb < 10.5 gldl, WBC count < 600/ml or < 8%, mean, albumin < 4gldl<br />
and WBC greater than/equal to 15,000 lml. The HD signs and symptoms consist of: night sweats (33%),<br />
enlarged lymph nodes, splenomegaly (30%), and hepatomegaly (5%), pain following alcohol consumption,<br />
back pain, red colored patches (2%) and increased platelets. The Catswold Modification of Ann Arbor<br />
Staging of Hodgkin’s Disease is a fairly standard classification and manifests as: single lymph node region<br />
(I), 2 or more lymph node region same side of diaphragm (II) lymph node region on both grades of the<br />
diaphragm (III), diffuse involvement of 1 or more extralymphatic organs or sites (IV). A is asymptomatic, B<br />
includes weight loss > 10% in last six months, or explained recurrent fever > 38 degrees C or night sweats.<br />
As for prognosis, the five year survival for favorable types is 98%; and those with initially worse prognosis<br />
are 85%.<br />
The imaging workup according to the NCCN includes a chest, chest/abdominal/pelvic CT, unless part of<br />
PET/CT. MRI may be used as a replacement. Gallium is less commonly used currently. PET and especially<br />
PET/CT is strongly advised for initial staging, but especially is felt to be important in prognosis on follow-up<br />
scans after 2 – 4 cycles of chemotherapy at the end of therapy and at follow-up. Further details will be<br />
presented.<br />
VI. Non-Hodgkin’s Lymphoma<br />
Non-Hodgkin’s Lymphoma increased in incidence in the US by 4% each year between 1950 and 1990; and is<br />
now flat or decreasing. 63,000 cases diagnosed each year. It represents 4% of all new cancers and a 2%<br />
lifetime risk for all comers. It is seen more frequently in elderly and in males and in immno-deficient<br />
patients. T-cell NHH is more common in Asia, and B-cell more common in Western countries. The common<br />
subtypes are: Diffuse large B cell lymphoma (31%), follicular lymphoma (22%), MALT lymphoma (7.6%),<br />
mature T-cell lymphoma (7.6%), small lymphocytic Lymphoma (6.7%), Mantle Cell Lymphoma (6%), and<br />
the rest (19%). The epidemiology is as described above. The WHO is divided into B-cell lymphoma<br />
(precursor B-cell lymphoma and mature B-cell lymphoma) T/NK - extranodal natural killer cell lymphoma<br />
(precursor and mature). Another very commonly used classification is: Diffuse large B-cell – 31% (most<br />
frequent); follicular cell (22%), extranodal marginal zone/MALT peripheral T Small lymphocyte (5-10%).<br />
The follicular cell lymphoma has an incidence world wide of 22%, with 30% incidence in the US. It is a low<br />
grade lymphoma, any organ can be involved, most have no fever and PI scores are low. It responds to<br />
treatment and between 50 – 75% have a complete remission. The mature B-cell lymphomas are most<br />
common and characterized as diffuse. They are more likely to be symptomatic. Another interesting B-cell<br />
lymphoma is Burkitt’s lymphoma which is an aggressive B-cell lymphoma most found in children and<br />
immunosuppressed patients. It is wide spread and extranodal when seen. The endemic form is found in<br />
Africa involving the bones and jaws. It is sporadic in the USA; 15% have the Epstein-Barr virus. Another<br />
important group is the T-cell lymphomas which are divided into 3 types: extranodal NK/T1 lymphoma,<br />
55
aggressive NK cell leukemia, and blastic NK cell lymphoma. Epstein –Barr virus is commonly present. The<br />
NK cell is separate, but related to the T-cell. It is common in Asia, Mexico, S. America, and rare in Western<br />
countries. It is seen in the middle age to elderly, often with nasal obstruction, epistaxis, and midfacial<br />
destruction. It’s an aggressive tumor with a hepatosplenomegaly and extranodal involvement.<br />
VII. Post Transplantation Lymphoproliferative Disorder (PTLD)<br />
This group of lymphomas is seen in patients with AIDS /HIV virus. In this group, the risk of NHL is increased<br />
150 fold. It is mostly found as diffuse large B-cells or Burkitt’s. It is aggressive with a poor prognosis.<br />
Another large group of these patients have had organ transplants. Their histology is variable, but they are<br />
usually aggressive. Immunosuppressive therapy is a significant factor in its development. In PTLD, the<br />
Epstein-Barr virus incidence is increased and there is a range from premalignant hyperplasias (Polymorphic)<br />
to monomorphic indistinguishable from NHL. A few T-cells develop Hodgkin’s or rarely, multiple myeloma.<br />
Other types included T cell or NK cell origin, MALT. The onset of this disease is fairly rapid – 3.5 to 10.8<br />
months. It often manifests itself in the GI tract, head and neck, kidney (especially with certain<br />
chemotherapy agents). The presentation is diverse with a mild febrile syndrome, pharyngitis and<br />
lymphadenopathy aggressive with nodal (20%) and extranodal sites (80%). Renal PTLD when present is<br />
bilateral. The imaging workup is similar to Hodgkin’s disease and NHL.<br />
Amendola M.<br />
MCV VCU Medical Center, USA<br />
IMAGING OF LOWER GU TRACT LYMPHOMA<br />
Extranodal lymphoma arising in the prostate is rare. The diagnosis may be considered as a rare cause of prostatic<br />
enlargement in young men.<br />
Lymphoma of the bladder is extremely rare. It can be seen as part of widespread nodal and extranodal disease, recurrent<br />
lymphoma or as primary lymphoma limited to the bladder. There are no specific radiologic appearances.<br />
Lymphoma is the most common tumor of the testis in patients older than 50 years. Bilateral involvement has been<br />
reported in up to 40% of patients. The ultrasonographic appearance is indistinguishable from that of germ cell tumors<br />
ranging from a discrete hypoechoic lesion to a diffuse enlargement of the testis with a homogeneous or heterogeneous<br />
decrease in echogenicity.On Color Doppler Sonography testicular lymphoma is usually hypervascular.<br />
Post transplantation lymphoproliferative disorder complicates 1-2% of renal transplant recipients. Early diagnosis is<br />
important because reduction of immunosuppresion improves the clinical outcome.<br />
References<br />
Khandelwal KC, Moorjani VK, Mophan C. et al. Non-Hodgkin lymphoma of the prostate. Can Assoc Radiol J 1994:45:56-57<br />
Anis M, Irshad A. Imaging of abdominal lymphoma. Radiol Clin N Am 2008:46:265-285<br />
GENITOURINARY LYMPHOMA: CASE HISTORIES<br />
Spencer J.A.<br />
Consultant Radiologist, St James’s Institute of OncologyLeeds LS9 7TF, UK<br />
Teaching points<br />
Lymphoma is one of the great mimics. I will illustrate several cases of genitourinary lymphoma which have presented to<br />
my institution in the last year in the format of a clinico-radiological grand round.<br />
Colleagues whose presentations precede mine will have provided all necessary background information on genitourinary<br />
lymphoma.<br />
INFECTIOUS DISEASES<br />
Moderators: Jakobsen J. (NO) – Wasserman N. (US)<br />
Morgan E.<br />
CP Clinical Director HIV/GUM Bolton PCT, UK<br />
CLINICAL OVERVIEW HIV/AIDS<br />
Recent WHO reports confirms 42 million people living with HIV/AIDS of those 19 million are women and 74 % live in sub-<br />
Saharan Africa. By 2010 estimated 50 to75 million infections will be added to world wide pool of HIV, totalling of<br />
staggering 100 million!<br />
So far 22 million died from AIDS. UNAIDS estimates a current 14 million AIDS orphans increasing to over 25 million by<br />
2010! http://www.until.org/ads.shtmlThere are14000 daily new infections (95% in developing countries). HIV is a young<br />
people’s infection with half of the yearly 5 million new infections occurring among ages 15-24.<br />
UNAIDS estimates 2.2 million living with HIV in Europe/Central Asia at end 2007. Estimated prevalence varies from 0.1%<br />
in parts of Central Europe to above 1% in parts of former Soviet Union. Across the continent, heterosexual infections<br />
particularly women are steadily increasing. Cumulative total of cases in Greece was 8680 giving an adult prevalence of<br />
0.2% by 2007.<br />
Since HAART, life expectancy and quality of life to those who have access to therapy have dramatically improved.<br />
HAART has changed HIV prognoses from fatal illness to chronic lifelong manageable condition! However this was at a<br />
price! We now have consequences of more complex presentations in those who are living longer and a variety of adverse<br />
events, as result of complex challenging therapy. The author will summarise the epidemiology, current understanding of<br />
HIV life cycle, clinical manifestations, interventional radiologist associated risk and some recognised renal pathology<br />
caused primarily by HIV or as a result of specific HIV therapies.<br />
56
GU MANIFESTATIONS OF AIDS: REAPPRAISAL OF IMAGING FINDINGS<br />
Amendola M.<br />
MCV VCU Medical Center,USA<br />
Since the first description of renal disease associated with AIDS in 1984 it has been recognized that renal manifestations<br />
of AIDS are common and due to multiple causes. These include:<br />
1. HIV-associated nephropathy<br />
2.Increased infections especially opportunistic related to its immunosuppression such as TB, MAI, Pneumocystis Carinii,<br />
fungal infections.<br />
3. Drug related renal disease resulting from the use of highly active retroviral therapy (HAART) for example Indinavir<br />
related renal stones, dyslipidemia, insulin resistance, increased incidence of diabetes and hypertension and also from<br />
nephrotoxic drugs such as :Pentamidine/ amphotericin B/cotrimoxazole.<br />
4. Neoplasias such as AIDS- related lymphoma and Kaposi sarcoma.<br />
5. Vascular causes of renal disease including renal artery stenosis related to HAART induced hyperlipidemia.<br />
6. Miscellaneous: Vasculitis/ ATN/Hemolytic Uremic Syndrome<br />
Imaging findings of these entities and others involving the lower urinary tract will be presented. The role of interventional<br />
radiology in selected cases will be discussed.<br />
References<br />
1. Symeonidou C, Standish R, Sahdev A, et al. Imaging and histopathologic features of HIV-related renal disease.<br />
RadioGraphics 2008: 28:1339-1354<br />
2. Amendola, MA and LJ Abrams, AIDS in the GU Tract, Chapter 33, pp 1233-1243, In: Clinical Urography, (2nd<br />
Edition) HM Pollack and B McClennan eds., W.B. Saunders, Philadelphia, 2000<br />
TUBERCULOSIS, PARASITIC DISEASES AND UNUSUAL INFECTIONS OF<br />
THE GENITOURINARY TRACT<br />
El-Diasty T.A.<br />
Mansoura University, Mansoura – Egypt<br />
Genitourinary Tuberculosis<br />
Genitourinary tuberculosis is the most common manifestation of extrapulmonary tuberculosis. Mycobacterium tuberculosis<br />
reaches the genitourinary tract as a secondary site following hematogenous dissemination from the lung. The kidneys and<br />
possibly the prostate and seminal vesicles are often the primary sites of genitourinary tuberculosis (1). All other genital<br />
organs become involved by ascent or descent of M tuberculosis. The testis may become involved by direct extension from<br />
an epididymal infection, but hematogenous spread to the testicle is rarely seen (2).<br />
Renal tuberculosis:<br />
Tuberculosis of the kidney results from hematogenous seeding of M tuberculosis in the glomerular and peritubular<br />
capillary bed from a pulmonary site of primary infection(3). Radiography may demonstrate calcification within the renal<br />
parenchyma. The calcification may be amorphous, granular, curvilinear, or lobar (putty kidney)(4,5). Intraverous<br />
urography demonstrates a variety of findings depending on the extent of renal involvement. The earliest urographic<br />
abnormality is a “moth-eaten” calyx due to erosion. This finding is followed by papillary necrosis. Poor renal function,<br />
dilatation of the pelvicalyceal system due to a stricture of the ureteropelvic junction, or destructive dilatation or localized<br />
hydrocalycosis related to an infundibular stricture. Infundibular stenosis may lead to incomplete opacification of the calyx<br />
(phantom calyx) (6). Cavitation within the renal parenchyms may be detected as irregular pools of contrast material.<br />
Cicatricial contracture of fibrotic parenchyma may lead to caliceal or renal pelvic traction. Calculi may be present within<br />
the renal collecting system. End-stage fibrosis and subsequent obstructive uropathy produce autonephrectomy. At this<br />
time, renal assessment is best achieved with US, CT or MR imaging (7,8,9).<br />
CT is helpful in identifying the manifestations of renal tuberculosis (e.g. calcification). Various patterns of hydronephrosis<br />
may be seen at CT depending on the site of the stricture. Other findings include parenchymal scarring and low attenuation<br />
parenchymal lesions. CT is also useful in depicting the extension of disease into the extrarenal space (2,9).<br />
The radiologic differential diagnosis of renal tuberculosis includes acute focal bacterial nephritis, xanthogranulomatous<br />
pyelonephritis, other causes of papillary necrosis and small benign or malignant tumors (10).<br />
Ureteral tuberculosis:<br />
Ureteral involvement is seen in 50% of patients with genitourinary tuberculosis (7). Dilatation and a ragged irregular<br />
appearance are the first signs of ureteral tuberculosis. In advanced disease, ureteral strictures, ureteral shortening,<br />
ureteral filling defects, or ureteral wall calcifications may be seen (5,7). CT may demonstrate thickening of the ureteral<br />
wall and periureteral inflammatory changes.<br />
Bladder tuberculosis:<br />
Typically, tuberculous cystitis manifests as shrunken bladder with wall thickening (11). Occasionally, filling defects due to<br />
multiple granulomas may also be seen. In advanced disease, the bladder may be diminutive and irregular (thimble<br />
bladder). Advanced bladder involvement may be complicated by vesicoureteral reflux due to fibrosis involving the ureteral<br />
orifice. Calcification of the bladder is rarely seen (10). Calcified tuberculous cystitis must be differentiated from<br />
shistosomiasis, cystitis due to cyclophosphamide, radiation induced changes, calcified bladder carcinoma and encrusted<br />
foreign material. Bladder tuberculoma may mimic transitional cell carcinoma.<br />
Male genital tuberculosis:<br />
The most common findings of tuberculous prostatitis, on transrectal US, is hypoechogenic areas with an irregular pattern<br />
in the peripheral zone of the prostate. Contrast-enhanced CT shows hypoattenuating prostate lesions which represent foci<br />
of caseous necrosis and inflammation. Nontuberculous pyogenic prostatic abscess have a similar CT appearance (7). At<br />
MR imaging, a prostatic abscess demonstrates peripheral enhancement. This finding helps differentiate an abscess from<br />
prostatic malignancy. In addition,<br />
MR imaging shows diffuse, radiating, streaky areas of low signal intensity in the prostate (“Watermelon Skin” sign) on T2-<br />
weighted images(12).<br />
Tuberculous involvement of seminal vesicles may lead to necrosis, calcification, caseation and cavitation(13,14).<br />
Tuberculous epididymo-orchitis usually manifests at US as focal or diffuse areas of decreased echogenicity with epididymal<br />
involvement(15).<br />
Female genital tuberculosis:<br />
57
Fallopian tubes are affected in 94% of women with genital tuberculosis. Salpingitis caused by hematogenous<br />
dissemination is almost always bilateral. A tubo-ovarian abscess that extends through the peritoneum into the<br />
extraperitoneal compartment suggest tuberculosis(1). Other diagnostic criteria for female genital tuberculosis include<br />
endometrial adhesions with deformity and obliteration of the endometrial cavity, obstruction of the fallopian tubes with<br />
multiple areas of constriction, and calcified lymph nodes in the adrexal region(7). Advanced tuberculous endometritis may<br />
mimic sever uterine adhesions as seen in Asherman syndrome (10).<br />
Parasitic infections<br />
Parasitic infections of the genitourinary system are a heterogenous group of diseases that have some common features.<br />
Most parasitic infections are chronic, and the host immune response reacts to the different stages of the parasite life cycle<br />
involving different parasite antigens. Although renal disease is not one of the common presenting features, many parasitic<br />
infections are associated with glomerular lesion. While there are many parasites which wander into the urinary tract, there<br />
are only three parasitic infections which are relatively common, namely schistosomiasis, echinococcosis and filariasis.<br />
Other parasites may also rarely infest the genitourinary system as Malaria, leishmaniasis, trypanosomiasis, babesiosis,<br />
toxoplasmosis, trichinosis and dioctophyma renale(16).<br />
Urogenital Schistosomiasis: The histopathological changes and clinical symptoms of UG Schistosomiasis are almost<br />
entirely due to the dead egg. Schistosomiasis is thus primarily an infection of the vascular system and the underlying<br />
pathological process is the formation of granulomas and obliterative (embolic) endarteritis. Although in schistosomiasis<br />
from S. haematobium, the ureter and bladder are chiefly affected, granulomas may also be found in the testes, seminal<br />
vesicles, and not infrequently in the female genitalia as cervix, ovary, fallopian tubes and endometrium. The most serious<br />
complication of urinary tract schistosomiais is an increased incidence of squamous cell carcinoma of the bladder.<br />
Additional complications include urolithiasis, ascending tract infection, urethral and ureteral stricture with subsequent<br />
hydronephrosis, and renal failure. In Egypt there is syndrome of “bladder neck obstruction”. The trigone is most affected<br />
and hypertrophies to form a prominent bulging into vesical lumen between ureteral orifices. Eventually, this fibrosis and<br />
atrophies, leaving the mucosa and muscularis as a mass, which is pushed forward over the internal ureteral orifice (17,18)<br />
. The prostate gland may occasionally be enlarged due to bilharzial prostatitis. Calcification may be seen in the seminal<br />
vesicles and may rarely be found in the spermatic cord. The fallopian tubes may be infected and blocked and also calcified<br />
as result of egg deposition.<br />
Schistomiasis of the cervix uteri is not uncommon and is easily confused with carcinoma of the cervix, with which it may<br />
coexit. Schistosomal lesions of the vagina and cervix may predispose to the acquisition of HIV infection and AIDS<br />
(19,20,21) .<br />
Urinary bladder wall calcification has relatively few etiologies. While a correct diagnosis is often not possible solely on the<br />
basis of the appearance of the calcification, such a diagnosis can usually be obtained from a combination of history,<br />
clinical examination, appropriate laboratory studies and radiographic evaluation of the bladder and reminaing urinary<br />
tract. Cystoscopy with biopsy of the involved tissues is almost always necessary, however, for confirmation and to rule out<br />
bladder neoplasia (22).<br />
Schistomiasis can be imaged by radiography or sonography and, in the later stages, by CT scanning or magnetic<br />
resonance imaging (MRI). Plain film radiography of the abdomen is not helpful until calcification has developed. CT scan<br />
better delineates the extent of the calcification, thickness and dilation of the ureteral wall, hydronephrosis as well as the<br />
bladder tumours . A heavily calcified area in the bladder has an estimated 500.000 to 1 million eggs per gram, but<br />
calcification to be seen on plain radiography, it is necessary to have 100.000 eggs per cubic centimeter. The presence of<br />
schistosoma eggs has been reported in 50% of postmortem studies of the prostate and seminal vesicles performed in<br />
endemic areas. Transrectal sonography showed prostatic calcification, increased prostatic size, calcification of the seminal<br />
vesicles as well as dilation of the ejaculatory ducts (23). The classic presentation of a calcified bladder, which looks like a<br />
fetal head in the pelvis, is pathognomonic of chronic urinary schistosomiasis . The seminal vesicles, prostate, prostatic<br />
urethra and distal ureters may be calcified (24) . With intravenous urography, the earliest changes are seen in the<br />
ureters, with persistent filling of the lower segments throught the urogram . At this stage the ureters are not always<br />
dilated, but this develops next. At first, it results from dysfunction rather than tissue damage at this stage. The dilation<br />
will be asymmetrical and may be slight or severe, sometimes without visible stenosis. Later, ureteric constriction will<br />
occur, initially within the bladder wall. As the disease progress, the lower ureters become beaded in appearance,<br />
secondary to bilharzial granuloma in the submucosa of the ureter. Mucosal ureteric edema may result in luminal<br />
narrowing and striations in the ureter. Air-bubble-like filling defects are seen in uretero-pyelograms are suggestive of<br />
ureteritis and pyelitis cystica(25).<br />
Hydatid disease (Echinococcosis):<br />
Hydatid disease (HD) is a unique parasitic disease that is endemic in many parts of the world and can occur almost<br />
anywhere in the body and demonstrates a variety of imaging features that vary according to growth stage, associated<br />
complications and affected tissues. Radiologic findings range from purely cystic lesion to a completely solid appearance.<br />
Calcification is more common in HD of the liver, spleen and kidney. It can be quite large in compressible organs and can<br />
be solitary or multiple (26).<br />
Two species can affect the urinary tract, Echinococcus granulosus and E. multilocularis, although the latter very rarely,<br />
and primarly involve the liver. The adult tape-worm are found in the intestines of dogs, the primary host, with eggs are<br />
excreted in the feces and more are ingested by human, sheep, cattle, or bigs, which act as intermediate hosts. The eggs<br />
hatch in the duodenum and migrate through the intestinal mucosa and into the portal system, mesenteric venules, and<br />
lymphatics, from where they can spread to any part of the body. The cyst consists of three layers: (1) an adventitial layer<br />
caused by the compressed host tissues, (2) the ectocyst which is an outer laminated membrane and (3) the endocyst or<br />
inner germinal layer responsible for growth of the cyst and development of scolices. Daughter cysts develop within the<br />
mother cyst and finally the cysts die and frequently undergo calcifications (27) .<br />
Involvement of the kidney is rare and usually located in the upper or lower poles. Hydatid cysts are frequently solitary and<br />
located in the cortex and they may reach 10 cm in diameter before any clinical symptoms are noted (26).<br />
The renal hydatid may grow outward and rupture into the retroperitoneum or may rupture into the renal pelvis with<br />
portions of the cyst contents present in the urine. Eighteen percent of renal Hydatid can rupture into the collecting system<br />
Plain film of the abdomen shows a localized bulqe of the renal contour with calcifications which may be curvilinear,<br />
eggshell or reticular in shape. Multiple ring-shaped calcifications within a large calcified lesion suggest presence of<br />
daughter cysts. Crushed eggshell calcification also suggest ruptured cyst (28).<br />
Intravenous urography may show elongation, stretching or splaying of the calyces in a similar fashion to other renal<br />
masses. When the cyst has ruptured, contrast media fill the cyst simulating renal abscess or T.B. cavity with usually a<br />
neck of communication between the cyst and calyces is found (29,30).<br />
US and CT are very accurate in demonstrating renal hydatid cyst which may be unilocular similar to simple cyst but with<br />
thicker wall or multilocular structure with curvilinear septa . US and CT can easily detect the calcifications even minor or<br />
58
faint. If scolices are present, the wall usually shows marked irregularities. Daughter cysts usually arranged peripherally<br />
around the mother cyst. Ring enhancement in CT scan or presence of air bubbles within the lesion are suggestive of<br />
secondary infection and abscess formation. However, in some cases, hydatid cyst may have a complex nature and could<br />
not be differentiated from other atypical renal cystic masses (31,32).<br />
MRI is not as accurate in detecting calcifications as compared to non contrast CT or ultrasound. A low-intensity rim on T2-<br />
WI is suggestive but not pathognomonic of hydatid cyst (33).<br />
Urinary bladder involvement can occur secondary to kidney hydatid after rupture of renal lesion into the collecting system<br />
with secondary spread into the ureter or bladder. However, primary hydatid of these structures is extremely rare. Scrotal<br />
hydatid is extremely rare with only a few case reports of hydatid of the testis found in the literature . The US revealed a<br />
markedly anechoic fluid collection in the left side of the scrotum and freely floating isoechoic serpentine structures (34).<br />
Filariasis:<br />
Filarial infections are widespread in various parts of the world, and probably 200 million people are infected with different<br />
filariae in the tropical and subtropical countries of Africa, Asia, the Pacific Islands, and central and South America. Several<br />
studies have recently shown a clear association of filariasis and glomerular disease (35,36) . This association is often<br />
difficult to establish due to frequent coinfections (hepatitis B and malaria). Except for an occasional report of acute<br />
glomerulonephritis (37), most case reports as well as the studies mentioned described a mesangioproliferative or<br />
membranoproliferative glomerulonephritis . Glomerular disease associated with filariasis is thought by most authors to be<br />
immune complex. Although the most common clinical findings are those related to “elephantiasis”. The urinary tract may<br />
be involved with resultant chyluria, which is the passage of lymphatic fluid in urine associated with lymphatic<br />
abnormalities. Chyluria may be either tropical or non-tropical in nature. The tropical form is by far the most common and<br />
is almost always due to wuchereria buncrofti infection. Non-tropical filarial parasites (Loa, Dipetalonema, Dirofilaria and<br />
Mansonella species) rarely have urogenital manifestations, but Onchocerca volculus. The agent of African river blindness,<br />
is known to causes massive inguinal lymphadenopathy, and scrotal elephantiasis (35). Filariasis results when the Larvae<br />
of W.Bancrofti are transmitted to the lumen by mosquitoes, after which they migrate in the lymphatics and nodes, where<br />
they mature (38).<br />
The pathological findings depend on the cycle of filariae and are due to presence of living or dead larvae or adult worms<br />
in lymphatics. The living worms causes lymphadenitis and lymphangitis with edema, eosinophilic infiltration, and<br />
fibroblastic reaction. When the disease become more chronic and death of the worm occur , there is thickening of the<br />
walls of lymphatics and marked granulomatous reaction in the vascular and lymphatic walls occur. The chronic<br />
complications of filariasis occur 5 to 20 years after the primary infection and include elephatitiasis, chyluria and chylous<br />
ascites and effusion. Enlargement of the penis, scrotum and breasts may be spectacular, in addition to the gross<br />
enlargement of one or more extremities. A histologic finding of adult worms is a diagnostically definitive but insensitive<br />
technique. The presence of Brugia or W. microfilariae in peripheral blood, chylous urin, or hydrocele fluid is also diagnostic<br />
(39).<br />
Plain radiography of the soft tissues shows gross thickening with loss or blurring of the fat planes. Intravenous urography<br />
is usually normal, but pyelolymphatic reflux may be noted. Dilated renal lymphatics may be clearly demonstrated,<br />
particularly when ureteric pressure is applied. Contrast medium may remain within the intrarenal lymphatics for a long<br />
time. These features can also be identified on retrograde pyelography . Lymphangiography may show an increase in the<br />
number of small lymphatic channels, which have a redundant and tortous course. Occasionally, contrast materials will flow<br />
from lymphatics into the kidney and outline the calyces, infundibulae, renal pelves and even the urinary bladder. Whereas<br />
the lymphatics normally emptying in a few hours, there may be a marked delay in emptying of these vessels for several<br />
days in patient with filariasis (37,38). Mild scrotal edema is not unusual during early infection or with established<br />
hydrocele. Penile edema is unusual, and the monstrous elephantine enlargements of the scrotum or penis depicted in<br />
textbooks occur largely in populations without access to medical care (40,41).<br />
Miscellaneous parasites affecting the urinary tract:<br />
Malaria is one of the most prevalent infectious diseases in the world. It is the first parasitic infection that was clearly<br />
shown to be associated with nephrotic syndrome (42). Moreover, areas of the world with a high incidence of nephrotic<br />
syndrome overlap with those where plasmodium malariae occur. Four species of plasmodia are responsible for malaria.<br />
Only two of the malaria parasites, namely, P. malariae (quartan malaria) and P. falciparum (falciparum malaria), are<br />
clearly associated with renal disease, and this occurs only in a small percentage of patients. Renal involvement in the<br />
course of quartan malaria is generally characterized by nephrotic syndrome. A membranoproliferative type of<br />
glomerulonephritis with relatively sparse proliferation of endothelial and mesangial cells is the most common type of<br />
glomerular lesion encountered in quartan malaria. Focal and segmental glomerulosclerosis can be seen as well (43).<br />
Glomerular lesions are observed with visceral leishmaniasis (Kala-azar) caused by leishmania donovani. Cuteneous or<br />
mucocuteneous Leishmaniasis caused by other leishmania species are not associated with renal disease. A prospective<br />
study has shown that 60% of patients with Kala-azar have mild proteinuria with benign changes in the urinary sediment<br />
(Microscopic hematuria and leukocyturia) . The pathological picture is a glomerulonephritis with focal and segmental<br />
collapse of capillary loops (44).<br />
African trypanosomiasis is a protazoal disease caused by motile hemoflagellates of the genus Typansoma. Trypansoma<br />
brucei rhodesiense is the more acute of the two forms, often causing death within 1 year if not treated. The clinical stages<br />
of trypansomiasis range from the trypansomal chancre that appears at the site of inoculation to febrile attacks, diffuse<br />
intravascular coagulation, lymphadenopathy, and eventually progressive brain dysfunction leading to sleeping sickness,<br />
cachexia, and death. Glomerular disease associated with African trypanosomiasis is limited to an occasional report (45).<br />
Toxoplasmosis is caused by Toxoplasma gondii. Infection occurs by the ingestion of cysts or oocycts or by the<br />
transplacental or hematogenous routes. Most recent reports about renal disease associated with T. gondii infection deal<br />
with the problem of acute renal failure due to sulfadiazine crystal deposition in the urinary tract after treatment of<br />
toxoplasma encephalitis with the drug.<br />
Babesia is a thick-borne intraerythrocytic parasite. In Europe, Babesia bovis and divergens are transmitted from cattle to<br />
humens. Asplenic persons are particularly susceptible to this disease.<br />
Trichinosis is an infection of humans and other mammals by Trichinella spiralis. This disease is characterized by diarrhea,<br />
myositis, fever, periorbital edema and myocarditis or encephalitis. A few cases of membranoproliferative<br />
glomerulonephritis associated with trichinosis hve been described (46).<br />
Other parasites may also rarely infest the genitourinary system. The giant kidney worm (Dioctophyma renale) infects<br />
mamdls worldwide, particularly dogs and minks. About 20 human infections have been reported, acquired by eating raw<br />
fish or frogs or less commonly, by drinking contaminated water. Many other fish-eating mammals can be infected, so the<br />
potential for human infection is significant (47).<br />
The clinical and radiologic features of genitourinary tuberculosis, parasitic and other rare infection may mimic those of<br />
many diseases. A high index of suspicion is required, particularly in high-risk populations. Although a positive culture or<br />
59
histologic evidence is still required in many patients to yield a definitive diagnosis, recognition and understanding of the<br />
spectrum of imaging features of genitourinary tuberculosis, which will be outlined in this lecture, are crucial for diagnosis.<br />
References<br />
1. Engin G, Acunas B, Acunas G, Tunaci M. Imaging of extrapulmonary tuberculosis. Radiographics 2000; 20: 471-488.<br />
2. Chung J, Kin M, Lee T, Yoo H, Lee J. Sonographic findings in tuberculous epidymitis and epididymo-orchitis. J Clin<br />
Ultrasound 1997;<br />
25: 390-394.<br />
3. Gibson M, Puckett M, Shelly M. Renal tuberculosis. Radiographics 2004; 24: 251-256.<br />
4. Premkumar A, Lattimer J, Newhouse JH. CT and sonography of advanced urinary tract tuberculosis. Am J Roentgenol<br />
1987; 148: 65-69.<br />
5. Wang L, Wong Y, Chen C. CT features of genitourinary tuberculosis. J Comput Assis Tomogr 1997; 21: 254-258.<br />
6. Brennan R, Pollack H. Nonvisualized “Phantom” renal calyx: causes and radiological approach to diagnosis. Urol Radiol<br />
1979; 1: 17-23.<br />
7. Leder R, Low VH. Tuberculosis of the abdomen. Radiol Clin North Am 1995; 33: 691-705.<br />
8. Das K, Indudhara R, Vaidyanathan S. Sonographic features of genitourinary tuberculosis. AJR 1992; 158: 327-329.<br />
9. Goldman S, Fishman E, Hartman D. Computed tomography of renal tuberculosis and its pathological correlates. J<br />
Comput Assist Tomogr 1985; 9: 771-776.<br />
10. Harisinghani M, McLoud T, Shepard A, Ko FR, Shroff M, Muller P. Tuberculosis from head to tow. Radiographics 2000;<br />
20: 449-470.<br />
11. Roylance J, Penry JB, Davis ER, et al. The radiology of tuberculosis of the urinary tract. Clin Radiol 1970; 21: 163-<br />
170.<br />
12. Wang JH, Sheu MH, Lee RC. Tuberculosis of the prostate: MR appearance. J Comput Assist Tomogr 1997; 21: 639-<br />
640.<br />
13. Premkumar A, Newhouse JH. Seminal vesicle tuberculosis: CT appearance. J Comput Assist Tomogr 1988; 12: 676-<br />
677.<br />
14. Wang JH, Chang T. Tuberculosis of the prostate: CT appearance. J Comput Assist Tomogr 1991; 15: 269-270.<br />
15. Heaton ND, Hogan B, Michell M, et al. Tuberculous epididymo-orchitis: clinical and ultrasound observations. Br J Urol<br />
1989; 64: 305-309.<br />
16. El-Diasty TA, El-Sherbiny AF. Imaging of parasitic diseases of the genitourinary system.In Haddad M, Abd El Bagi M,<br />
Tamraz J (ed.). Imaging of parasitic diseases. Chapter 6, p 139-157, Springer-Verlang Berlin Heidelberg, 2008.<br />
17. Palmer P.E and Reader MM. Parasitic diseases involving the urinary tract. In clinical urography . Pollack H M and<br />
McClennan BL (ed.), vol.1, ch30, p1167-1991, WB. Saunders company, 2000.<br />
18. Shokier AA. Urinary bilhariziasis in upper Egypt (I and II). East Afr Med J 49: 298-326, 1972.<br />
19. Feldmeier H, Krantz I, Poggensee G. Female genital schistosomiasis as a risk-factor for the transmission of HIV. Int J<br />
STD AIDS 5: 368, 1994.<br />
20. Pogensee G, Kiwelu I, Weger V. Female genital schistosomiasis of the lower genital tract: Prevalence and diseaseassociated<br />
morbidity in northen Tanzania. J Infect Dis: 181-210, 2000.<br />
21. Pogensee G and Feldmeier H. female genital schistosomiasis: facts and hypotheses. Acta Trop; 79: 193, 2001.<br />
22. Hugosson CO. Striation of renal pelvis and ureter in bilharziasis. Clin Radiol 38: 407, 1987.<br />
23. Pollack HM. Diagnostic considerations in urinary bladder wall calcification. AJR 136: 791-797, 1981.<br />
24. Jorulf H, Lindsted LE. Urogenital Schistosomiasis: CT evaluation. Radiology 157: 745-749, 1985.<br />
25. Vilana R, Corachian M, Gason J, Valls E and BRU C. Schistosomiasis of the male genital tract: Transrectal sonography<br />
findings. J of Urology 158: 1491-1493, 1997.<br />
26. Polat P, Kantarci M, Alper F, Suma S, Koruyucu MB and Okur A. Hydatid disease from head to Toe. Radiographics 23:<br />
475-494, 2003.<br />
27. Angulo TC, Sanchez-chapado M, Diego A. Renal echinococcosis: Clinical study of 34 cases. J Urol 157: 787, 1997.<br />
28. Hertz M, Zissin R, dresnik Z. Echinococcus of the urinary tracts: radiologic findings. Urol radiol 6: 175, 1984.<br />
29. Von Sinner W, Hellstrom M, Kagevi I. Hydatid disease of the urinary tarcts. J Urol 149: 577-580, 1993.<br />
30. Gilsanz V, Lozano F, Jiminez J. Renal hydatid cyst Communicating with collecting system. AJR 135: 857, 1980.<br />
31. Karabekias S, Gouliamos A, Kalovidouris A. Features of computed tomography in hydatid cysts. J Comput Assist<br />
Tomogr 10: 428, 1986.<br />
32. King DL. Ultrasonography of echinococcal cyst. J Clin Ultarsound 1: 64-67, 1989.<br />
33. Marani SAD, Canossi GC, Nicoli FA. Hydatid disease: MR imaging study. Radiology 175: 701-706, 1990.<br />
34. Kumar PV, Tahanshahi S. Hydatid cyst of testis: A case report. J Urol 137: 511-512, 1987.<br />
35. Data A, Kirubakaran, MG, Gunasekaran, V and Shastry JCM. Acute esinophilic glomerulonephritis with Bancroftian<br />
filariasis. Postgard Med J 55: 905-907, 1979.<br />
36. Ngu JL, Chatelanat F, Ndumbe P and Youmbissi J. Nephropathy in Cameroon: evidence for filarial derived immunecomplex<br />
pathogenesis in some cases. Clin Nephrol 24: 128-134, 1985.<br />
37. Amaral F, Dreyer G, Figuerido –Silva J. Live adult worms detected by ultrasonography in human bancroftian filariasis.<br />
Am J Trop Med Hyg 50: 753, 1994.<br />
38. Chen KC. Lymphatic abnormalities in patients with chyluria. Urology 106: 111-14, 1971.<br />
39. Dalela D, Kumar A, Ahawat R. Routine radio imaging in filarial chyluria: Is it necessary in developing countries Br J<br />
Urology 69: 291-293, 1992.<br />
40. Koga S, Nagata Y, Arakaki Y. Lymphangiography of filarial chyluria: Injections via right and left feet at different times.<br />
Br J Urol 69: 318, 1992.<br />
41. Kazura J, Bockarie M, Alexander N. Risk factors for acute morbidity in bancroftial filiariasis. Am J Trop Med Hyg, 53:<br />
100, 1995.<br />
42. Kibukamusoke JW, Hunt MSR and Wilks NE. e nephritic syndrome in Uganda and its association with quartan malaria.<br />
J Med 36:393-408, 1967.<br />
43. Saggie JL and Dwomoa A.nephrotic syndrome in tropics, P. 635-695. In Cameron JS and Glassock RJ (ed.), The<br />
nephrotic syndrome. Marcel Dekker, Inc., New York, N.Y., 1988.<br />
44. Dutra M, Martinelli R, Varvalho M. enal involvement in visceral Leishmaniasis. Am J Kidney Dis, 6: 22-27, 1985.<br />
45. Costa RS, Monterio RC, Lehuen A.Immune complex-Mediated glomerulopathy in expermintal Chagas disease. Clin<br />
immunopathol 58: 102-114, 1991.<br />
46. Kociecka W, abryel P, Leszyk A, stowska I.A case of fatal trichinosis with early renal failure and involvement of the<br />
central nervous system. Wiad Parazytol. 33: 545-551, 1987.<br />
47. Sun T, Turbull A, Liebeiman PH. ant Kidny Worm (Dioctophyma renal) infection mimking retropritoneal neolasm. Am J<br />
Surg Pathol 10:508-12, 1989.<br />
60
OTHER INFLAMMATORY CONDITIONS OF THE URINARY TRACT<br />
Wasserman N.F.<br />
University of Minnesota, USA<br />
This short presentation will call attention to some of the more unusual noninfectious inflammatory conditions affecting the<br />
urinary tract including Ureteral Pseudodiverticulosis (UPD), Karatinizing Desmoplastic Squamous Metaplasia (KDSM),<br />
Malakoplakia, Amyloidosis. The emphasis of this talk will be on<br />
noninfectious disorders intrinsic to the urinary tract, especially UPD, Malakoplakia, and KDSM.<br />
UPD<br />
UPD are defined as < 5mm acquired outpouchings of the ureter. They may be multiple, single, unilateral or bilateral.<br />
They usually are incidental imaging findings on contrast urography in patients undergoing work-up for benign prostatic<br />
hyperplasia (BPH), hematuria, renal colic, urinary tract infections or malignancy. A 25% association with synchronous or<br />
metachronous urothelial carcinoma has been described. Most commonly the associated tumor is transitional cell<br />
carcinoma (TCC) and located in the bladder. However, TCC has been found in the ureter , renal pelvis and calyces, and a<br />
case of squamous cell carcinoma (SCC) has been associated with UPD in the ureter.<br />
Tiny UPD can be found in up to 11% of specimens of postmortem ureters, and are seen as pinpoint openings by gross<br />
visual inspection. Micropathology demonstrates that they are formed by distensension of hyperplastic submucosal glands<br />
of von Brunn which directly connect with the ureteral lumen. Associated microscopic (but not gross) changes of ureteritis<br />
cystica and glandularis are seen in the involoved areas. This supports the conclusion that UPD form as a result of chronic<br />
inflammation and enlarge to grossly detectable size under the influence of obstruction downstream or chronic reflux<br />
raising intralumenal pressures.<br />
UPD are best identified in retrograde urograms, but can be seen in IV urography. Recently UPD have been visualized and<br />
confirmed on multidetector CT urography.<br />
It is important to not only correctly identify UPD, when present, but communicate to the referring physician or urologist<br />
the importance of a complete investigation for TCC, including cystoscopy and urine cytology. Further, it is most important<br />
to stress in the imaging report that a negative baseline work-up should be followed by indefinite survielance, as<br />
metachronous tumor has been reported up to 10 years after UPD discovery.<br />
Malakoplakia<br />
Malakoplakia is a rare chronic inflammatory granulomatous disorder first reported by von Hansemannin 1901 and<br />
described in greater detail by Michaelis and Gutmann in 1902. It is commonly thought to be due to an exaggerated<br />
response to infection. The urinary tract is involved in 60% of cases, the urinary bladder being the most commonly affected<br />
site, followed in descending order of frequency by the renal pelvis and kidney, ureter, testes, prostate, and urethra.<br />
Grossly, the lesions occurring on mucosal surfaces are seen as raised, frequently multiple, soft plaques. The plaques are<br />
typically yellow or brown and are frequently multicentric. It often mimics malignancy and may also affect other organs<br />
including the gastrointestinal tract, bone, lungs, lymph nodes and skin.<br />
Malacoplakia is thought to result from inadequate intracellular killing of phagocytosed bacteria by monocytes and<br />
macrophages, leading to the accumulation of calcium and iron on bacterial glycolipid within cellular phagolysosomes.<br />
The final diagnosis is histological. Microscopically, there are characteristic inclusions termed Michaelis-Gutmann bodies,<br />
which are the most salient pathologic finding of malacoplakia. Michaelis-Gutmann bodies (M-G bodies) are<br />
concentrically layered basophilic inclusions found in the urinary tract. They are 2 to 10 μm in diameter, and are thought to<br />
represent remnants of phagosomes mineralized by iron and calcium deposits.Although the cause has not yet been<br />
established, a close relationship between prostatic malacoplakia and urinary tract infection with E coli has been shown,<br />
although most patients have some form of immunosuppression related to organ transplantation, autoimmune diseases<br />
requiring steroid use, or chemotherapy. It has been reported in association with HIV/AIDS. Malakoplakia has also been<br />
associated with colon carcinoma, bladder tumors, TB, poorly controlled dibetes, rheumatoid arthritis, and lymphoma.<br />
The treatment of renal parenchymal malakoplakia may be grouped into four categories: improvement of<br />
immunodebilitatating state, antibiotic therapy adapted to cultured micro-organisms, especially antibiotics with high<br />
intracellular diffusion, vitamin C and/or bethanechol, which restore impaired phagocytic function by increasing intracellular<br />
cyclic guanosine monophosphate (cGMP/cAM) ratio, and drainage of associated abscess, or surgical resection when there<br />
is no response to medical therapy.<br />
Pyeloureteritis Cystica<br />
Pathologically, the lesions in question are benign suburoeipthelial cysts containing a clear proteinaceous fluid. These are a<br />
common finding at the time of cystoscopy and known as (cystitis cystica). These are common finding in the bladder on<br />
cystoscopy, commonly located in the trigone and vicinity of the ureteral orifices, but rare in the ureter and renal pelvis.<br />
The pathogenesis is unclear, but is speculated to be related to irritative effects of chronic urinary tract infection<br />
culminating in chronic mucosal irritation from inflammation. A common association of longstanding foreign bodies such as<br />
percutaneous or ascending intralumenal stents has been noted. Diabetics seem to be predisposed. The findings are most<br />
common in females. The most common infectious organism is E-coli.<br />
Gross examination reveals 1-2 mm, discrete translucent, grayish round superficial cysts. The natural history and<br />
mechanism of cyst formation is speculative. Some attribute cyst development to inward invaginations of clusters of<br />
epithelial cells (glands of von Brunn), which become detached from the mucosa and subsequently undergo degeneration.<br />
Consequently, epithelial blind cysts are found in a submucosal location. Others describe degeneration and cavitation of<br />
metaplastic surface urothelium or submucosal vonBrunn’s cell nests. Once formed, the cysts may persist for an<br />
indefinate period.<br />
Because of their small size, the cysts, though common in the bladder, are rarely visible on radiographic imaging.<br />
However, in the upper collecting system they present as tiny discrete round to ovoid filling defects on IV, retrograde or<br />
percutaneous antegrade urography. They may also be visible on computed urography.<br />
The differential diagnosis includes: 1) other submucosal entities such as submucosal hemorrhage, often secondary to over<br />
anticoagulation (which usually disappear with better control of anticoagulation), 2) mucosal abnormalities such as<br />
multifocal transitional cell carcinomas or malakoplakia, 3) intralumenal processes such as air bubbles secondary to<br />
antegrade or retrograde contrast injection (which tend to change position freely from one image to another), blood clots<br />
and stones. 4) Extrinsic impressions producing scalloping secondary to collateral veins or arteries must also be excluded.<br />
Pyleoureteritis cystica may be distinguished from multifocal malakoplakia by clinical context of active infection, the<br />
distinctly less common presence of the latter in the upper urinary tract and appearance. Pyeloureteritis cystica filling<br />
defects are more individually separable and hemispheric in contour. Malakoplakia tends to be more confluent and angular<br />
or irregular.<br />
KDSM<br />
61
Keratinizing desquamative squamous metaplasia (KDSM) is a term for a rare condition of the upper urinary tract that<br />
encompasses several previously described keratinizing uroepithelial lesions, including cholesteatoma, hyperkeratosis,<br />
squamous metaplasia, and leukoplakia, The latter diagnosis is considered a premalignant lesion in the oral cavity.<br />
However, there is no evidence in the medical literature that leukoplakia is premalignant in the urinary tract.<br />
Hertle and Androulakakis, in an effort to bring order to the situation, introduced the term keratinizing desquamative<br />
squamous metaplasia (KDSM) of the upper urinary tract and gave it a distinct histopathologic definition. "Squamous<br />
metaplasia, keratinization and desquamation, therefore, are common denominators of the leukoplakia/cholesteatoma<br />
lesions described in the upper urinary tract, and they can be expressed appropriately together under the term keratinizing<br />
desquamative squamous metaplasia (KDSM)". To be KDSM, there must be no histologic evidence of atypia.<br />
The cause of KDSM is unknown. Speculation has included reactive or spontaneous epithelial change or congenital rests of<br />
squamous cell anlagen. There is an association with chronic infection, urolithiasis, and hydronephrosis<br />
Keratinizing desquamative squamous metaplasia is rare. It is generally found between the third and sixth decades, with a<br />
3:2 male/female predominance. The renal pelvis is the most common site; the left side is affected slightly more commonly<br />
than the right. Flank pain, passage of cornified material in the urine, and a filling defect on intravenous urography are the<br />
most common findings. The radiologic appearance of the defect is not specific, but is typically an irregular, stringy, or<br />
laminated plaque arising from a portion of the calyx or renal pelvis.<br />
Radiologic differential diagnosis must include neoplasm, fungus ball, clot, and other nonopaque filling defects. However,<br />
the diagnosis can be suggested in the proper clinical setting and the surgeon alerted to the possibility that conservative<br />
surgery may be appropriate. Calcification of a keratinized plaque is infrequently visible.<br />
The treatment of choice was previously nephroureterectomy, based on the fear that the lesion is premalignant. If one<br />
adheres to the strict definition of KDSM, the disease is benign. Though elements of KDSM with underlying mucosal atypia<br />
have been reported in patients operated on for squamous cell carcinoma of the urothelium, progression from KDSM to<br />
malignancy has not been demonstrated histologically. Because of this, there has been a recent call for conservative<br />
management. Treatment by extracorporeal surgery and autotransplantation has been used in the past. Today, minimally<br />
invasive procedures such as percutaneous or ureteroscopic removal of the keratinized tissue or laparoscopic surgery may<br />
be used to avoid open surgery The incidence of recurrence is reduced if the squamous epithelium is removed as well as<br />
the keratinized mass. Some have advocated no treatment other than imaging and urologic surveillance in asymptomatic<br />
patients.<br />
It is thus important for radiologist to include KDSM in their differential diagnosis in patients with filling defects in the renal<br />
pelvis suggest in their report that careful attention to the possibility of keratin fibers in the urine be made before<br />
considering retrograde ureteroscopy and biopsy.<br />
Amyloidosis<br />
Amyloidosis can occur as its own entity or "secondarily" as a result of another illness, including multiple myeloma, chronic<br />
infections such as tuberculosis or osteomyelitis, or chronic inflammatory diseases such as rheumatoid arthritis and<br />
ankylosing spondylitis.<br />
The modern classification of amyloid disease tends to use an abbreviation of the protein that makes up the majority of<br />
deposits, prefixed with the letter A. For example amyloidosis caused by transthyretin is termed "ATTR". Deposition<br />
patterns vary between patients but are almost always composed of just one amyloidogenic protein. Deposition can be<br />
systemic (affecting many different organ systems) or organ-specific. Many amyloidoses are inherited, due to mutations in<br />
the precursor protein. Other forms are due to different diseases causing overabundant or abnormal protein production -<br />
such as with over production of immunoglobulin light chains in multiple myeloma (termed AL amyloid), or with continuous<br />
overproduction of acute phase proteins in chronic inflammation (which can lead to AA amyloid).<br />
Sephardic Jews and Turks inherit a genetic disease called Familial Mediterranean Fever, which is associated with<br />
amyloidosis and characterized by episodes of "attacks" of fever, joint, and abdominal pains. These attacks can be<br />
prevented with the medication colchicine. Armenians and Ashkenazi Jews also have a higher incidence of Familial<br />
Mediterranean Fever attacks but do not suffer amyloid deposition disease.<br />
Symptoms in patients with amyloidosis result from abnormal functioning of the particular organs involved.<br />
Diagnosis of amyloidosis is made with a biopsy of involved tissue. Biopsies are taken from affected organs or often in the<br />
case of systemic amyloid, from the rectum, gingiva, or omentum. Amyloid can be diagnosed on microscopic examination<br />
of affected tissue. Amyloid deposits can be identified histologically by Congo red staining and viewing under polarized<br />
light where amyloid deposits produce a distinctive apple green birefringence. Other more specific tests are available to<br />
more precisely identify the amyloid protein. In addition, all amyloid deposits contain serum amyloid P component (SAP),<br />
a circulating protein of the pentraxin family. Radionuclide SAP scans have been developed which can anatomically localize<br />
amyloid deposits in patients.<br />
Treatment options for amyloidosis depends on the type of amyloidosis and involves correcting organ failure and treating<br />
any underlying conditions.<br />
References:<br />
UPD<br />
Wasserman NF. Pseudodiverticulosis: unusual appearance for metastases to the ureter. Abdominal Imaging. 1994;<br />
19(4):376-378<br />
Wasserman NF. Zhang G. Posalaky IP. Reddy PK. Ureteral pseudodiverticula: frequent association with uroepithelial<br />
malignancy. AJR. American Journal of Roentgenology. 1991; 157(1):69-72<br />
Wasserman NF. Posalaky IP. Dykoski R. The pathology of ureteral pseudodiverticulosis.<br />
Investigative Radiology. 1988; 23(8):592-598<br />
Kenney PJ. Wasserman NF. Ureteral pseudodiverticulosis associated with carcinoma of renal pelvis.<br />
Urologic Radiology. 1987; 9(3):161-163<br />
Wasserman NF. La Pointe S. Posalaky IP. Ureteral pseudodiverticulosis. Radiology. 1985; 155(3):561-566<br />
Lester PD, Kyaw MM. Ureteral diverticulosis. Radiology 1973; 106:77-80.<br />
Cochran ST. Waisman J, Barbaric ZL. Radiographic and microscopic findings in multiple ureteral diverticula. Radiology.<br />
1980; 137:631-636.<br />
Holly LE, Sumcad B. Diverticular ureteral changes: a report of four cases. AJR 1957; 78:1053-1060.<br />
Malakoplakia<br />
Takamitsu Inuoe, Hiroyuki N,1 Koji Yoshimura,1 Noriyuki Ito,1 Toshiyuki Kamoto,1 Tomonori Habuchi2 and Osamu<br />
Ogawa1 Solitary upper ureteral malakoplakia successfully diagnosed by ureteroscopic biopsy and treated conservatively.<br />
International Journal of Urology 2007; 14, 859–861<br />
MRI appearances of pelvic malakoplakia<br />
K Gopal, FRCR, M Dobson, FRCR, P M Hersch, FRCS and H Stringfellow, MRCP(Path). The British Journal of Radiology.<br />
2006; 79:e205–e207<br />
62
Bruce Siders, DO, Thomas Win, MD, Ronney Abaza, MD. Sonographic Evaluationof Epididymal Malakoplakia. J Ultrasound<br />
Med 2005; 24:1003–1005<br />
Blair JE. Maclennan GT. Malakoplakia. Journal of Urology. 2005; 173(3):986<br />
Wielenberg AJ., Demos T C, Rangachari B, Thomas T. Malacoplakia Presenting as a Solitary Renal Mass. Am. J.<br />
Roentgenol., Dec 2004; 183: 1703 – 170<br />
Burdese M, Repetto L, Lasaponara F, Maass J, Bergamo D, Mezza E, Jeantet A, Segoloni GP, Piccoli GB. The deceiving<br />
image: asymptomatic renal malakoplakia in a patient with chronic renal failure. Nephrol. Dial. Transplant., Aug 2003; 18:<br />
1675 - 1676.<br />
McKeen SK. Tie ML. Renal parenchymal malakoplakia: an unusual cause of unilateral, diffuse renal enlargement.<br />
Australasian Radiology. 2002; 46(1): 69-72.<br />
Barnard M, Chalvardjian A. Cutaneous malakoplakia in a patient with acquired immunodeficiency syndrome (AIDS). Am J<br />
Dermatopathol 1998;20:185–8.<br />
Albitar1 S, Genin R, Fen-Chong M, Schohn D, Riviere J-P, Serveaux M-O, Chuet C. The febrile patient presenting with<br />
acute renal failure and enlarged kidneys—another mode of presentation of malakoplakia. Nephrol Dial Transplant. 1997;<br />
12: 1724–1726<br />
Stanton MJ, Maxted W: Malakoplakia: A study of the literature and current concepts of pathogenesis, diagnosis and<br />
treatment. J Urol 1981; 125:139-146,<br />
Michaelis L, Gutmann C. Ueber Einschlusse in Blasentumoren. Ztschr Klin Med 1902; 47: 208–15.<br />
Pyeloureteritis Cystica<br />
Clinical Urography. H M Pollack, Ed. W.B Saunders Co., Harcourt Brace Jovanich, Inc. Philadelphia, 2000<br />
KDSM<br />
Borofsky M. Shah RB. Wolf JS Jr. Nephron-sparing diagnosis and management of renal keratinizing desquamative<br />
squamous metaplasia. Journal of Endourology. 2009; 23(1):51-5<br />
Boswell PD, Fugitt B, Kane CJ. Keratinizing desquamative squamous metaplasia of the kidney mimicking transitional cell<br />
carcinoma. Urology 1998;52:512–513.<br />
Angulo JC, Santana A, Sanchez-Chapado M. Bilateral keratinizing urinary tract. J Urol 1997;158:1908–1909.<br />
Neerhut G, Politis G, Alpert L, Griffith DP. Cholesteatoma of the renal pelvis: Endoscopic management. J Urol<br />
1988;139:1032–1034.<br />
Haugen SG. Wasserman NF. Keratinizing desquamative squamous metaplasia of the upper urinary tract. Urologic<br />
Radiology. 1986; 8(4):211-3,<br />
Gagnon J. Laperriere J. Alcaidinho D. Drouin G. Lefebvre R. [Ureteral stenosis caused by epidermoid metaplasia of the<br />
urothelium]. [French]. Journal de Radiologie. 65(3):207-9, 1984<br />
Hertle L, Androulakakis P. Keratinizing desquamative squamous metaplasia of the upper urinary tract:<br />
leukoplakiacholesteatoma. J Urol 1982;127:631-635,s JS, Pollack HM, Curtis JA:<br />
Wills JS, Pollack HM, Curtis JA: Cholesteatoma of the upper urinary tract. A JR 136:941-944, 1981<br />
Taguchi Y, Kotha V, Tomka B, Seemayer T: Conserving nephrons in cholesteatoma. J Urol 1980; 123:258-260,<br />
Noyes WE, Palubinskas AJ: Squamous metaplasia of the renal pelvis. Radiology 1967; 89:292-295<br />
Osius TG, Harrod CS, Smith DR: Cholesteatoma of the renal pelvis. J Uro1 1962; 87:774-778<br />
Denes FT: Keratinizing squamous metaplasia of the upper urinary tract. Int Urol Nephrol 1984; 16(1):23-28,<br />
Amyloidosis.<br />
Sueoka BL, Kasales CJ, Harris RD, Heavey JA. MR and CT imaging of perirenal arnyboidosis.<br />
Urol Radiol 1989; 11:97-99J<br />
Davis PS. Babaria A. March DE. Goldberg RD. Primary amyloidosis of the ureter and renal pelvis. Urologic Radiology.<br />
1987; 9(3):158-60<br />
Pirnar T. Coruh M Radiological findings in renal amyloidosis of children. Pediatric Radiology. 1973; 1(3):172-7<br />
Pear BL. The radiographic manifestations of amyloidosis. AJR 1971; 111:821-832<br />
GENETIC DISEASES & DRUG – INDUCED DISORDERS<br />
Moderators: Morcos S.K. (UK) – Koumanidou C. (GR)<br />
HEREDITARY DISORDERS OF THE PEDIATRIC URINARY TRACT<br />
Riccabona M.<br />
University Hospital Graz, Austria<br />
There are many congenital urinary tract disorders in children. Some of them already manifest during pregnancy, some are<br />
detected shortly after birth or during infancy, some become obvious during infancy, and some may only manifest later in<br />
life. Only a part of them are genetic, and again not all genetic conditions are hereditary, and in some familial or<br />
syndromatic conditions the genes have not yet been found, though there is an obvious hereditary component. And some<br />
are systemic conditions that (also) manifest inn the urinary tract, particularly the kidneys.<br />
The aim of this lecture is to list some important diseases such as Alport syndrome or familial hematuria and their<br />
manifestation, to present the typical imaging appearance, and to discuss the need for follow-up. Rare conditions such as<br />
nail patella syndrome, collagen type III glomerulopathy, Fabry disease, or Biedl-Bardet syndrome will not be discussed.<br />
Ultrasound is the paediatric radiologist’s working horse and the mainstay of imaging these conditions; however – for<br />
diagnosis or differential diagnosis, for follow-up or assessment of progression and complications other modalities or even<br />
invasive procedures may become indicated such as VCUG, MRU, CT, interventional radiology or biopsy.<br />
Some conditions can readily be recognised by imaging, such as the neonatal manifestation of autosomal polycystic kidney<br />
disease, some may exhibit a varying degree of more or less typical features such as tubular deposits in thyrosinosis or<br />
renal angiomyolipoma in tuberous sclerosis that may lead the way for further assessment and eventually establishing the<br />
diagnosis. In some conditions only secondary signs indicate imaging such as urolithiasis in oxaluria or cystinuria, and the<br />
diagnosis is then established by laboratory investigations. Some may present completely unspecific and eventually are<br />
diagnosed by histology (e.g., after renal biopsy) or genetic work-up. And some systemic (hereditary) conditions may<br />
cause unspecific alterations of the kidney appearance on imaging that needs to be recognised and not mistaken for<br />
another disease (e.g., sickle cell nephropathy that mimics nephrocalcinosis). Finally, some remain silent until they<br />
eventually may manifest in adulthood or even only in the next generation. Furthermore, some syndromes such as Denys<br />
Drash Syndrome carry the risk of developing renal diseases or tumours thus indicating regular imaging monitoring,<br />
63
without other obvious imaging manifestation in the child’s urinary tract. Thus a standardised general approach to imaging<br />
all these conditions is not achievable, and imaging will become indicated depending on clinical symptoms and signs,<br />
prenatal suspicions or as part of screening programs, and family history.<br />
The most important aspect is that (paediatric) uroradiologists need to be familiar with and knowledgeable about these<br />
conditions so that they can recognise them or depict features that may indicate the need for further focused investigation.<br />
With the upcoming new therapies for some of these conditions this will become increasingly important, as early<br />
recognitions and therapy may prevent severe progression and will play an important role in preventing or at least delaying<br />
renal insufficiency.<br />
RENAL CYSTIC DISEASE<br />
Heinz-Peer G.<br />
Department of Radiology, Medical University of Vienna, Austria<br />
Renal cysts, cystic disease, and cystic masses are very common findings in uroradiology. In some cases, the renal cysts<br />
are part of a systemic process that also involves the kidneys. In most patients, however, one or several cystic masses are<br />
detected, and the question is whether the lesion is benign or malignant.<br />
The classification of renal cystic diseases reflects both morphologic features and pathophysiology.<br />
Cortical cysts<br />
The most common renal mass lesion is a simple cortical cyst. Cortical cysts are uncommon in children and young adults,<br />
but are estimated to occur in 50% of the population older than 50 years of age. Thus, they are considered acquired<br />
lesions and probably arise from obstructed ducts or tubules.<br />
Simple cysts contain clear fluid and do not communicate with the collecting system. Usually simple cysts are an incidental<br />
finding on ultrasound (US) and computed tomography (CT) performed for other reasons, and of no clinical significance. On<br />
CT, findings that are diagnostic of a simple renal cyst include a water-dense mass that does not enhance and has an<br />
imperceptible or barely perceptible peripheral margin.<br />
Cystic renal masses with more complex imaging features have been studied extensively with CT. The Bosniak<br />
classification system is useful for categorizing these lesions as to their etiology and for management guidelines.<br />
Class I is a simple cyst.<br />
Class II lesions have multiple septations and thin peripheral calcifications, are typical high density cysts, or have features<br />
typical of infected cysts. On CT examination, one can be confident that these Class II lesions are benign. However, followup<br />
CT scanning of these Class II complex cysts is recommended in 6 to 12 months to exclude progression (IIF).<br />
Septations and high density internal material are thought to develop after cyst infection or hemorrhage, which leads to<br />
the development of fibrinous internal septa, dystrophic calcifications in the wall of the cyst, or internal proteinaceous<br />
material reflected by high density on unenhanced CT scans. The high density cysts are the most problematic for the<br />
radiologists. On unenhanced scans they appear to be of higher density than the kidney, and on contrast enhanced CT they<br />
are hypodense to the kidney and there is no internal enhancement of these lesions.<br />
Class III lesions have more complex imaging characteristics, including dense, thick calcifications, numerous septa, or solid<br />
components that do not enhance. Approximately 50% of these lesions are cystic renal cell carcinomas (RCCs). The<br />
remainder are benign lesions, such as cysts complicated by infection or hemorrhage, or a benign tumor known as<br />
multilocular cystic nephroma. There is no reliable way to distinguish these lesions without surgery. Because many of them<br />
are benign, renal-sparing surgery can be considered for these patients.<br />
Class IV lesions always are considered malignant. The major criterion of a Class IV lesion is an area of enhancing solid<br />
tissue. With cystic neoplasms, this tissue often is at the periphery, and enhancement may be subtle. Careful evaluation of<br />
the margins of the cystic mass on enhanced CT scans is necessary.<br />
20% of RCCs appear predominantly cystic on CT examination. Seventy-five percent of these are solid RCCs that have<br />
undergone central liquefaction necrosis. With growth, these lesions tend to outstrip their blood supply, and central areas<br />
become ischemic and necrotic. The remaining lesions are truly cystic RCCs. This subgroup usually has a papillary cellular<br />
growth pattern, which has been associated with a decreased rate of metastases and has better prognosis than other forms<br />
of RCC. Papillary RCCs also are often multifocal. These masses usually are hypovascular, even after attaining a large size.<br />
In addition, cysts may be associated with renal malignancies in other ways. Because renal cysts are common, cysts and<br />
tumours in the same kidney usually are not related. A renal tumour may occur adjacent to a solitary or dominant cyst.<br />
Because recognition of these cysts may lead to detection of the nearby renal tumour, these focal, solitary cysts<br />
sometimes are referred to as “sentinel” cysts.<br />
Some conditions cause formation of renal cysts and renal neoplasms. This category includes von Hippel-Lindau disease,<br />
tuberous sclerosis, and acquired cystic kidney disease in long-term dialysis patients.<br />
Finally, the rarest cyst-renal neoplasm association is the formation of a RCC in the wall of a preexisting simple renal cyst.<br />
Peripelvic or Parapelvic Cysts<br />
Peripelvic cysts or parapelvic pseudocysts are thought to be acquired lesions secondary to prior obstruction, with<br />
subsequent urine extravasation. Those found in the renal hilar area may be lymphatic in origin. Parapelvic cysts are<br />
extremely rare in children, but they display the same CT features as cortical renal cysts. They have near-water<br />
attenuation values and are not enhanced after contrast administration. They may be single, multiple, or even multilocular.<br />
Commonly, displacement or replacement of the renal sinus or hilar fat is seen as the parapelvic cyst insinuates itself<br />
among the infundibulae and intrarenal blood vessels within the renal sinus. Contiguous calices may simulate thick cyst<br />
walls. Parapelvic cysts may be bilateral and on occasion may communicate with the collecting system. On non-contrast CT<br />
images, parapelvic cysts may mimic hydronephrosis or a large extrarenal pelvis.<br />
Polycystic Renal Disease<br />
Adult Polycystic Kidney Disease<br />
APCKD usually is a bilateral process, although unilateral involvement has been described. Frequently there is no evidence<br />
of renal failure at the time of diagnosis. The disease tends to involve other organs, namely, the liver, spleen, and<br />
pancreas. When patients with the disease are examined with CT, the search often is for focal neoplastic change, abscess,<br />
stone, or hemorrhage, particularly in the symptomatic patient. Kidneys may vary in size from normal to massively<br />
enlarged. The cysts vary in number, but usually are multiple, unequal in size, and scattered throughout the parenchyma.<br />
The cysts may calcify, and asymmetrical involvement of the two kidneys may occur.<br />
All patients with APCKD have progressive renal failure. The rate of progression of the azotemia is related to the age of<br />
onset; those patients whose symptoms begin after 50 years of age have a better prognosis. Although the incidence is<br />
variable, approximately one half of patients with APCKD have cerebral (berry) aneurysms in the circle of Willis, and stroke<br />
64
from rupture of a berry aneurysm is a significant cause of morbidity and mortality. Renal stones occur more frequently in<br />
patients with APCKD than in the general population. Because more than one half of these stones are predominantly uric<br />
acid, they may be radiolucent and may be overlooked on an abdominal radiograph. Using CT, Levine and Grantham found<br />
renal calculi in 36% of patients with APCKD.<br />
CT has the advantage of clearly demonstrating the cysts and collecting systems of both kidneys. Precontrast scans are<br />
needed to demonstrate renal stones and facilitate the diagnosis of hemorrhagic cysts. Because the kidneys are typically<br />
studded with innumerable cysts that abut each other, some of the cysts are not round in shape, but assume a variety of<br />
irregular contours. CT is also helpful in demonstrating cystic involvement of other organs.<br />
Bleeding into renal cysts is common and may be the source of acute flank pain. If the cyst ruptures into the renal pelvis,<br />
hematuria will occur. Cyst hemorrhage may be more common in patients with APCKD because of the associated<br />
hypertension or the increased bleeding tendency of uremia or heparinization during dialysis. However, in the work-up of<br />
hematuria in patients with APKD renal neoplasm has to be excluded, although there is no increased risk for malignancy.<br />
Hemorrhagic renal cysts may be seen in 70% of patients with APCKD.<br />
Autosomal Recessive Polycystic disease<br />
Autosomal-recessive or infantile polycystic disease (IPCD) includes a spectrum of abnormalities ranging from newborns<br />
with grossly enlarged spongy kidneys to older children with medullary ductal ectasia. The older children also develop<br />
hepatic fibrosis that progresses to portal hypertension.<br />
Congenital hepatic fibrosis may represent yet another disease transmitted by autosomal-recessive inheritance in which the<br />
renal disease is different and milder than IPCD. Patients with IPCD have renal failure at birth and most die within the first<br />
few days of life. Among older children fewer than 10% of the renal tubules are affected and hepatic fibrosis dominates the<br />
clinical course. The kidneys are only mildly enlarged, but contain variably sized cysts that are predominantly medullary in<br />
location.<br />
Multicystic Dysplastic Kidney<br />
A multicystic dysplastic kidney (MCDK) consists of a collection of irregularly sized cysts and fibrous tissue, but no<br />
functioning renal parenchyma. The anomaly results from occlusion of the fetal ureters usually before 8 to 10 weeks of<br />
gestation. Malformations including bilateral MCDK, ureteropelvic junction obstruction, hypoplasia of the opposite kidney,<br />
and horseshoe kidney are commonly associated with MCDK.<br />
The multiple cysts with thick septa are nicely demonstrated by CT. Mural calcifications can be demonstrated in the cyst<br />
walls, but there is no evidence of contrast excretion. Most cases of MCDK discovered in the older child or the adult will<br />
have one or more ring calcifications.<br />
Multilocular Cystic Nephroma<br />
This uncommon lesion has been described by various names including multilocular renal cyst, cystic adenoma,<br />
lymphangioma, segmental multicystic kidney, segmental polycystic kidney, cystic hamartoma, benign cyst nephroma, and<br />
Perlman´s tumor. It is a congenital renal lesion that is not genetically transmitted.<br />
The CT appearance is usually characteristic. The masses are large, averaging approximately 10 cm in diameter. They are<br />
sharply delineated from the normal renal parenchyma. MLCN is hypovascular, but the septations enhance after i.v.<br />
contrast injection. Calcification is uncommon in pediatrics, however, a common finding in adults. MLCN must be<br />
differentiated from a cystic renal adenocarcinoma<br />
Medullary Cystic Disease<br />
This disease complex includes medullary cystic disease and related diseases such as juvenile nephronophtisis and retinalrenal<br />
dysplasia and is characterized by dilation of the terminal portion of the collecting tubules. The kidneys are small to<br />
normal in size. A variable number of cysts, up to 2 cm in diameter, are located primarily in the medulla. Calculi frequently<br />
are discovered within the dilated spaces. The cortex is thin but does not contain cysts.<br />
Acquired Renal Cystic Disease (ARCD)<br />
Cystic replacement of kidneys in patients on chronic intermittent hemodialysis occurs in a large percentage of patients.<br />
The prevalence of ARCD significantly increases with prolonged duration of dialysis. Although the mechanism of cyst<br />
formation in these uremic patients is unknown, it is postulated that dialysis incompletely removes toxins.<br />
Solid tumors are also seen with increased frequency, up to 7%.<br />
The ultrasonographic examination of native kidneys is difficult, because they often are small, distorted, and surround by<br />
highly echogenic fat. There is an increased incidence of hemorrhage into renal cysts or perinephric space. Calcification<br />
frequently occurs in the cyst walls or in the renal interstitium.<br />
It is easier to examine the native kidneys with CT than with ultrasound. Multiple small cysts are seen by CT. Dystrophic<br />
calcifications are common in the renal parenchyma or cyst walls. Bleeding is a common complication. Carcinomas are seen<br />
as masses with a density similar to the unenhanced parenchyma.<br />
Cysts Associated with Systemic Disease<br />
The phakomatoses are a group of neurologic disorders that include congenital abnormalities of the skin and other organs.<br />
Tuberous sclerosis and von Hippel-Lindau disease are associated with renal cysts. In tuberous sclerosis, approximately<br />
80% of patients have renal angiomyolipomas, which may cause hematuria. The cysts in tuberous sclerosis are small and<br />
seldom exceed 3 cm in diameter. They have a distinctive microscopic appearance with hyperplastic epithelium. Severe<br />
renal involvement can lead to renal failure.<br />
CT often is used to confirm the presence of angiomyolipoma by demonstrating the fatty nature of the tumor. Tumors<br />
without fat will be indistinguishable from renal adenocarcinomas.<br />
Von Hippel-Lindau syndrome (VHL) consists of cerebellar and retinal hemangioblastomas, renal carcinomas,<br />
pheochromocytomas, and a variety of visceral cysts, including renal cysts. The renal tumours often are bilateral and are<br />
usually multifocal. Other urologic manifestations include adrenal pheochromocytomas and papillary cystadenomas of the<br />
epididymis.<br />
The renal cysts, which usually range in size from 0.5 to 3.0 cm, are reported in approximately 60% of patients with VHL.<br />
They demonstrate a continuum from simple cysts to carcinoma manifesting as complex papillary projections into the<br />
cystic lumen. Radiographic evaluation of patients with VHL disease is difficult. Narrowly collimated CT is probably the most<br />
useful modality for this purpose. However, the tumours often are small and difficult to distinguish from cysts. Levine and<br />
coworkers recommend annual follow-up CT examination of any lesions that do not satisfy the criteria for a benign cyst or<br />
an unequivocal neoplasm.<br />
Summary<br />
Cystic renal lesions are most often simple or complicated cysts, which can be seen solitary or as part of cystic renal<br />
disease. The classification of cystic renal masses by Bosniak (category I-IV) based on specific ultrasound and CT features<br />
65
is very useful for the characterization of the lesion and for the therapeutic decision. The main objective of this<br />
classification is to differentiate nonsurgical (category II) from surgical cystic masses (category III/IV). Ultrasound is the<br />
first modality of choice in the diagnostic work-up of cystic renal masses, because an accurate and economically reasonable<br />
diagnosis of the frequent simple cyst can be made by maintaining rigid ultrasound criteria of the Bosniak classification. If<br />
a complicated cyst or a cystic tumor is suspected further evaluation by multiphasic CT or in particular cases by MRI is<br />
indicated. The goal of the radiologist in evaluating cystic lesions is to distinguish malignant neoplastic cystic masses from<br />
non-neoplastic complicated cysts. 20% of RCCs appear predominantly cystic. In addition, some conditions cause formation<br />
of renal cysts and renal neoplasms. This category includes von Hippel-Lindau disease, tuberous sclerosis, and acquired<br />
cystic kidney disease in long-term dialysis patients. CT and MRI allow the early detection of small malignant lesions in<br />
these patients.<br />
Learning objectives:<br />
1 To give an overview of the various renal cystic diseases<br />
2 To evaluate complications frequently associated with renal cystic disease<br />
3 To assess the role of imaging techniques in distinguishing cystic benign lesions from more complex lesions and<br />
cystic malignant tumors<br />
References:<br />
1. Boniak MA: The current radiological approach to renal cysts. Radiology 1986; 158:1-10.<br />
2. Levine E, Grantham JJ: High-density renal cysts in autosomal dominant polycystic kidney disease demonstrated<br />
by CT. Radiology1985; 154:477-<br />
3. Levine E, Grantham JJ: Calcified renal stones and cyst calcification in autosomal dominant polycystic kidney<br />
disease: clinical and CT study in 84 patients. AJR 1992; 159:77-81<br />
4. Levine E, Grantham JJ: High density renal cysts in autosomal dominant polycystic kidney disease demonstrated<br />
by CT. Radiology 1985;154:477-482<br />
5. Grantham JJ: Autosomal Dominant Polycystic Kidney Disease. In: N Engl J Med 2008;359;14:1477-1485<br />
6. Chapman AB: Autosomal Dominant Polycystic Kidney Disease: Time for a Change In: J Am Soc Nephrol<br />
2007;18:1399-1407<br />
7. O'Neill WC, Robbin ML, Bae KT, Grantham JJ, Chapman AB, Guay-Woodfort LM, Torres VE, King BF, Wetzel LH,<br />
Thompson PA, Miller JP: Sonographic Assessment of the Severity and Progression of Autosomal Dominant<br />
Polycystic Kidney Disease: The Consortium of Renal Imaging Studies in Polycystic Kidney Disease (CRISP). In:<br />
American Journal of Kidney Diseases 2005;46;6:1058-1064<br />
8. Meister M, Choyke P, Anderson C, Patel U. Radiological evaluation, management, and surveillance of renal<br />
masses in Von Hippel-Lindau disease. Clin Radiol 2009;64(6):589-600<br />
9. Leung RS, Biswas, SV, Duncan M, Rankin S. Imaging features of von Hippel-Lindau disease. Radiographics. 2008<br />
Jan-Feb;28(1):65-79<br />
10. Sallee M, Rafat C, Zahar JR, Paulmier B, Grünfeld JP, Knebelmann B, Fakhouri F. Cyst Infections in Patients with<br />
Autosomal Dominant Polycystic Kidney Disease. Clin J Am Soc Nephrol. 2009 May 21 (Epub ahead of print).<br />
Choyke P.<br />
National Institutes of Health, USA<br />
HEREDITARY RENAL CANCERS<br />
Over the past 10 years there have been major developments in the recognition of the hereditary basis of renal cancer.<br />
Hereditary cancers are typically multifocal and bilateral and it is often the radiologist who first raises the possibility of a<br />
hereditary cause for a particular renal cancer. It is, therefore, important to be familiar with the expanding list of diseases<br />
known to predispose to renal cancers which includes Von Hippel Lindau, Tuberous Sclerosis, Hereditary Papillary renal<br />
cancer, Birt Hogg Dubé, Hereditary Renal Oncocytomas, Hereditary Leiomyoma Renal Cell Carcinoma, Hereditary Non<br />
Polyposis Colon Cancer and Medullary Renal Cancer. Improved awareness should lead to earlier diagnosis of individuals<br />
and their at-risk family members. The basic genetic and proteomic mechanisms underlying these conditions will likely<br />
form the basis for innovative prevention and treatment strategies in the future. It is predictable that additional types of<br />
Hereditary Renal Cancers will discovered and refinements of the current classification will likely occur. While these<br />
diseases currently account for only a minority of renal cancers, the lessons learned from them will have profound<br />
implications for the treatment of all forms of renal cancer in the future.<br />
Von Hippel Lindau<br />
Mutations in the VHL gene located on the 3 rd chromosome result in the VHL syndrome which consists of renal cysts and<br />
cancers, pheochromocytomas, pancreatic cysts and neuroendocrine tumors and CNS hemangioblastomas including retinal<br />
angiogmas. In the kidney the predominant cell type is clear cell and the disease predictably results in a low grade, slow<br />
growing renal cancer which is highly vascular but has cystic components. The tumors grow inexorably but variably so<br />
that yearly monitoring is recommended, more often if the lesion is large or increasing faster than normal. Screening is<br />
increasingly shifting to MRI over CT due to the lower culmulative radiation dose. Alternating CT and MRI is another<br />
approach that cuts culmulative radiation exposure in half. Below the size of 3cm the risk of metastases is quite low so<br />
lesions are generally watched until they reach that size. Lesions that are predominantly cystic may be allowed to grow<br />
even larger before surgery or intervention. Intervention follows a nephron sparing approach with RFA, cryotherapy and<br />
laparoscopic enucleations the most highly recommended. Frequent surgeries can result in scarring and diminished renal<br />
function. Thus, only a limited number of procedures are possible (n=2-5) in each kidney. Some patients have received<br />
renal transplants but before going that route it is important to understand the multisystem nature of VHL.<br />
Birt Hogg Dube<br />
Birt Hogg Dube syndrome (BHD) was discovered by the 3 dermatologists for which it is named. BHD results in<br />
characteristic skin lesions known as fibrofolliculomas. Mutations in the BHD gene also result in multiple lung cysts (with<br />
potential for spontaneous pneumothorax) and a variety of solid enhancing lesions in the kidney including: chromophobe<br />
carcinoma, oncocytic neoplasm, oncocytoma and clear cell carcinoma. The tumors are usually characterized by<br />
homogeneous enhancement and bilaterality. The tumors are generally only mildly aggressive and can be monitored in<br />
many cases. Again, a nephron sparing approach is preferred once treatment is decided upon. RFA, cryoablation and<br />
laparoscopic enucleation are the leading treatment techniques. It is apparent that BHD is far more common than has<br />
been previously recognized.<br />
Hereditary Papillary Renal Cancer<br />
HPRC is the least aggressive hereditary renal cancer. It results in numerous type I papillary renal cancers which are<br />
characterized by their poor enhancement and slow growth. The mortality rate from HPRC is lower than other syndromes<br />
66
due to the slow growth of these malignancies. To date, no convincing associated findings are associated with HPRC. The<br />
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<br />
activation by an extrinsic growth factor (Hepatocyte growth factor or Scatter factor).<br />
Hereditary Leiomyoma Renal Cell Carcinoma<br />
Recently, a large cohort of women were identified with a particularly aggressive form of fibroids. When the genetic testing<br />
was performed it was found that a sizeable percentage of these women and their male relatives died of renal cancer.<br />
Thus HLRCC is a genetic defect that results in leiomyomas of the uterus and type II papillary renal cancers, which are<br />
particularly aggressive. Like Type I papillary tumors, Type II are also poorly enhancing and can have a cystic<br />
component. However, unlike Type I, these tumors are aggressive metastasizing via the lymphatic system even while the<br />
primary tumor is small. These tumors are extremely PET avid, unlike most renal cancers and can be followed with FDG<br />
PET. The tumors should be treated surgically with wide margins due to their aggressive nature.<br />
Tuberous Sclerosis<br />
The association between TS and angiomyolipomas, cysts and renal carcinomas is well known. Many angiogmyolipomas<br />
are lipid-poor so that there is a differential consideration with renal cancer. AMLs tend to be hyperdense prior to contrast<br />
media and enhance uniformly whereas RCCs tend to isodense with heterogeneous enhancement. RCCs associated with TS<br />
occur bilaterally and at a younger age than do RCCs that occur sporadically.<br />
Other conditions<br />
A variety of other conditions are associated with familial renal tumors. Familial oncocytomas appears to be a distinct<br />
entity in which multiple, non-life-threatening lesions occur. They are associated with diminished renal function.<br />
Additional Hereditary Non Polyposis colon cancer Type II is associated with epithelial tumors of the renal pelvis. Sickle cell<br />
trait is associated with the development of medullary renal cancer, a particularly aggressive form of renal cancer.<br />
Conclusion<br />
Hereditary renal cancer syndromes can lead to multiple, bilateral kidney tumors that occur at a younger age than nonhereditary<br />
renal cancers. Imaging plays an important role in the diagnosis and management of these syndromes.<br />
During the past decade, several new hereditary renal syndromes have been discovered but are not yet widely known.<br />
Whereas previously, the list of hereditary renal cancers in adults included Von Hippel-Lindau disease and a rare form of<br />
chromosomal translocation, the list now includes the following syndromes: Tuberous Sclerosis, Hereditary Papillary Renal<br />
Cancer, Birt-Hogg-Dubé, Familial Renal Oncocytoma, Hereditary non-polyposis colon cancer (HNPCC)and Medullary<br />
carcinoma of the kidney. In addition, a number of newly described but poorly understood syndromes are under<br />
investigation. Even at this early stage, it is clear that elucidating the underlying genetic mutations that cause the<br />
hereditary renal cancer syndromes will have profound implications for understanding the origins of non-hereditary renal<br />
tumors. These studies will likely culminate in a better understanding of the causes of renal cancer, its prevention and<br />
ultimately, its cure 1-7 .<br />
1. Grubb RL, 3rd, Franks ME, Toro J, et al. Hereditary leiomyomatosis and renal cell cancer: a syndrome associated<br />
with an aggressive form of inherited renal cancer. J Urol. 2007 Jun;177(6):2074-9; discussion 9-80.<br />
2. Linehan WM. Kidney cancer: opportunity for disease specific targeted therapy. Urol Oncol. 2008 Sep-<br />
Oct;26(5):542.<br />
3. Pfaffenroth EC, Linehan WM. Genetic basis for kidney cancer: opportunity for disease-specific approaches to<br />
therapy. Expert Opin Biol Ther. 2008 Jun;8(6):779-90.<br />
4. Rosner I, Bratslavsky G, Pinto PA, Linehan WM. The clinical implications of the genetics of renal cell carcinoma.<br />
Urol Oncol. 2009 Mar-Apr;27(2):131-6.<br />
5. Stewart L, Glenn GM, Stratton P, Goldstein AM, Merino MJ, Tucker MA, Linehan WM, Toro JR. Association of<br />
germline mutations in the fumarate hydratase gene and uterine fibroids in women with hereditary<br />
leiomyomatosis and renal cell cancer. Arch Dermatol. 2008 Dec;144(12):1584-92.<br />
6. Sudarshan S, Pinto PA, Neckers L, Linehan WM. Mechanisms of disease: hereditary leiomyomatosis and renal cell<br />
cancer--a distinct form of hereditary kidney cancer. Nat Clin Pract Urol. 2007 Feb;4(2):104-10.<br />
7. Zbar B, Glenn G, Merino M, et al. Familial renal carcinoma: clinical evaluation, clinical subtypes and risk of renal<br />
carcinoma development. J Urol. 2007 Feb;177(2):461-5; discussion 5.<br />
DRUG-INDUCED ABNORMALITIES IN THE GU TRACT<br />
Ramchandani P.<br />
University of Pennsylvania Medical Center, Phladelphia, USA<br />
FEMALE PELVIC DISORDERS<br />
Moderators: Brkljacic B. (HR) – Rockall A. (UK)<br />
CONGENITAL ABNORMALITIES: WHY DO WE NEED IMAGING<br />
Kinkel K. 1 , Jacob S. 2 , Weintraub J. 3 .<br />
1 Institut de radiologie, 2 Gynécologie, 3 Laboratoire de pathologie. 1+2. Clinique des Grangettes, 7, ch. des<br />
Grangettes, 1224 Chêne-Bougeries/Geneva, Switzerland. 3 Viollier Weintraub SA, 16, av. Eugène Pittard, 1206<br />
Genève<br />
Congenital abnormalities of the female pelvis mainly concern the uterus and are clinically important findings due to their<br />
relative frequency during workup for infertility, recurrent pregnancy loss, premature birth or cervical incompetence.<br />
Frequency in the general population is about 1%.<br />
Although the American Society for Reproductive Society (AFS) has elaborated a clear classification in 7 classes (1), its<br />
clinical use is often reduced due to complex or mixed presentation and additional descriptive terms required by the<br />
obstetrician to decide treatment options. Saleem et al has developed a helpful decision tree to diagnose the type of<br />
mullerian abnormality with results of imaging findings regardless what imaging technique was used (2):<br />
1. Check for the presence of a uterus and a vagina (sagittal and axial plane).<br />
2. Check for uterine size (sagittal plane), shape (oblique long axis or coronal uterine plane) and septum extent<br />
(oblique short axis or axial uterine plane).<br />
3. Check for obstruction (vaginal or cervical hypoplasia).<br />
67
The first question helps to identify uterine agenesia (class AFS I). Decreased uterine size allows the diagnosis of uterine<br />
hypoplasia (class AFS I). According to the uterine shape four additional classes of uterine malformation can be identified:<br />
the” banana shaped” unicornuate uterus (class II), the “T-shaped” DES-related uterus (class AFS VII), the “double uteri”<br />
configuration requires particular attention towards the presence of a fundal cleft (didelphus and bicornuate uterus, class<br />
AFS III and IV) or a convex flat fundus (septate uterus, class AFS V and VI). The length of a septum will differentiate<br />
between a complete and an incomplete septum of a septated uterus.<br />
In the event of a unicornuate uterus, the presence of a remnant noncommunicating functioning uterine horn is important<br />
as repeated bleeding can cause dysmenorrhea and endometriosis. Resection of this horn is important for symptomatic<br />
relief as for prevention of extra-uterine pregnancy.<br />
A didelphus uterus is differentiated from a bicornuate uterus by two cervices and has a higher incidence of obstretical<br />
problems or spontaneous abortion as estimated through pooled data by Troiana et al (3):<br />
Frequency Spontaneous abortion Premature birth Fetal survival<br />
Septated uterus 55% 65% 20% 30%<br />
Didelphus uterus 5% 45% 38% 55%<br />
Bicornuate uterus 10% 30% 20% 60%<br />
Unicornuate uterus 20% 50% 15% 40%<br />
The lecture will present imaging signs for all major mullerian abnormalities at hysterosalpingography, ultrasound and MRI.<br />
Poorest obstetrical outcome concerns septated uteri due to the highest frequency of spontaneous abortion and fetal loss.<br />
Most patients with septated uteri and history of recurrent pregnancy loss are therefore treated by hysteroscopic<br />
metroplasty consisting in the resection of the septum decreasing the risk of abortion . In patients with didelphys or<br />
bicornuate uterus, metroplasty is usually not performed.<br />
In conclusion, most congenital uterine abnormalities will be diagnosed initially at HSG or two dimensional US. MR imaging<br />
and, three-dimensional US are often required for a definitive diagnosis. MR imaging is the study of choice because of its<br />
high accuracy and detailed utero-vaginal and ovarian anatomy. Laparoscopy and hysteroscopy are indicated in women for<br />
whom interventional therapy is being undertaken, thus reducing health care cost and invasive diagnostic procedures.<br />
References<br />
(1) The American Fertility Society classifications of adnexal adhesions, distal tubal obstruction, tubal occlusion<br />
secondary to tubal ligation, tubal pregnancies, mullerian anomalies and intrauterine adhesions. Fertil Steril 1988;<br />
49:944–955.<br />
(2) Saleem N. MR imaging diagnosis of uterovaginal anomalies: current state of the art. Radiographics. 2003 Sep-<br />
Oct;23(5):e13.<br />
(3) Troiano RN, McCarthy SM. Mullerian duct anomalies: imaging and clinical issues. Radiology. 2004 Oct;233(1):19-<br />
34.<br />
PRENATAL DIAGNOSIS AND THERAPY OF FETAL OBSTRUCTIVE<br />
UROPATHIES<br />
Antsaklis A.<br />
University of Athens, Medical School, Greece<br />
68
Spencer J.A.<br />
St James’s Institute of Oncology, UK<br />
METASTASES TO THE FEMALE GENITAL TRACT<br />
Teaching points<br />
Two clinical presentations of metastases to the female genital tract will be discussed as these may result in diagnostic<br />
confusion:<br />
1. to the ovary, Fallopian tube and peritoneum mimicking primary ovarian cancer. Common primary tumour sites<br />
which metastasise in this fashion are the colon, appendix and stomach from within the abdomen and from the<br />
breast.<br />
2. to the uterus and cervix resulting in vaginal bleeding. Breast cancer most commonly behaves this way.<br />
These presentations are most problematic when the patient has no prior cancer diagnosis.<br />
Thus a significant minority of women who undergo surgery for suspected ovarian cancer are found to have metastatic<br />
disease from other sites [1, 2].<br />
Metastases to the uterus and cervix are much less common and it is rare for this to be a primary manifestation of the<br />
cancer. In a woman with prior breast cancer who develops vaginal bleeding the considerations are for a new primary<br />
cancer, disease related to tamoxifen therapy, or for metastatic disease.<br />
A clue to the diagnosis is a hard but non-enlarged cervix or cervical stenosis as metastatic breast cancer is desmoplastic.<br />
There may be coincident involvement of the bladder and ureters.<br />
Infiltrating lobular breast cancer is the most common subtype to metastasise to the genital tract.<br />
Clues on MR imaging are the absence of a true ‘mass’ and a predominant T2 dark signal in the cervix. Curiously there is<br />
enhancement of the cervix on early post-gadolinium sequences.<br />
Regarding metastases to the ovary and peritoneum mimicking primary ovarian cancer, the common primary sites which<br />
do this are all within the MDCT imaging volume and warrant careful scrutiny.<br />
The primary colonic tumour may be a tiny non-obstructing focus of mural enhancement or thickening.<br />
The enlarged appendix may be mistaken for the terminal ileum.<br />
Ovarian metastases from the colon are usually large and unilateral and excellent mimics of the multilocular cystic-solid<br />
primary ovarian cancer. Ovarian metastases from the stomach are usually smaller and more often bilateral and solid [3].<br />
Any woman with an imaging pattern of primary ovarian cancer who has a prior relevant cancer should undergo needle<br />
core biopsy of the peritoneum to define diagnosis [4, 5].<br />
A woman with prior breast cancer with this imaging pattern has a greater chance of a new primary tumour (ovarian or<br />
primary peritoneal cancer) whilst women with prior GI tract cancer are more likely to have relapsing disease.<br />
Other tumours which can metastasise in this way include cholangiocarcinoma and melanoma.<br />
Lymphoma can mimic this pattern as can actinomycosis and tuberculosis.<br />
Advanced tumours in primary sites adjacent to the female genital tract e.g. colorectal and bladder can secondarily invade<br />
these gynaecological structures but this rarely presents a diagnostic problem.<br />
Key references<br />
1. Kurtz AB, Tsimikas JV, Tempany CMC et al. Diagnosis and staging of ovarian cancer: comparative values of Doppler<br />
and conventional US, CT, and MR imaging correlated with surgery and histopathologic analysis - report of the<br />
Radiology Diagnostic Oncology Group. Radiology 1999; 212: 19-27.<br />
2. Brown DL, Zou KH, Tempany CMC et al: Primary versus secondary ovarian malignancy: imaging findings of adnexal<br />
masses in the Radiology Diagnostic Oncology Group Study. Radiology 2001; 219: 213-218.<br />
3. Choi HJ, Lee JH, Kang S et al. Contrast-enhanced CT<br />
for differentiation of ovarian metastasis from gastrointestinal tract cancer:<br />
stomach cancer versus colon cancer. Am J Roentgenol. 2006; 187: 741-5.<br />
4. Spencer JA, Swift SE, Wilkinson N, Boon AP, Lane G, Perren TJ. Peritoneal carcinomatosis: image-guided peritoneal<br />
core biopsy for tumor type and patient care. Radiology 2001; 221:173-177.<br />
5. Hewitt MJ, Anderson K, Hall GD, et al. Women with peritoneal carcinomatosis of unknown origin: Efficacy of imageguided<br />
biopsy to determine site-specific diagnosis. BJOG 2007; 114:46-50.<br />
69
WORKSHOPS<br />
ABSTRACTS<br />
70
UROGRAPHY WITH CT AND MRI<br />
Moderators: Roy C. (FR) – Drossos Ch. (GR)<br />
CTU TECHNIQUE AND APPLICATIONS<br />
Roy C.<br />
Service de Radiologie B -Chirurgie A, Hopital Central Strasbourg, Hospices Civils de Str, France<br />
THE DEVELOPMENT OF MULTIDETECTOR COMPUTED TOMOGRAPHY<br />
UROGRAPHY FOR INVESTIGATING HAEMATURIA<br />
Cowan N.<br />
The Churchill Hospital, Oxford OX3 7LJ, UK<br />
INTRODUCTION:<br />
Haematuria, macroscopic (MACH) or microscopic (MICH), may herald a wide spectrum of underlying disease of which<br />
urological cancer and stones are the most common. Prompt and accurate diagnosis is essential for initiating appropriate<br />
treatment, optimising prognosis. The investigative pathway is often complicated and lengthy utilising multiple imaging<br />
tests. Many diagnostic algorithms exist without rigorous evaluation. MDCTU offers a single test with high diagnostic<br />
accuracy. MDCTU is defined as CT examination of the kidney, ureters and bladder with at least one series acquired postcontrast<br />
enhancement during the excretory-phase. By substituting MDCTU for other tests, the imaging pathway is<br />
simplified, improving diagnostic accuracy and reducing time from presentation to diagnosis.<br />
PURPOSE<br />
The purpose of this lecture is to make sense of the development of MDCTU and its place within the diagnostic algorithm for<br />
investigating haematuria, with the primary goal of defining the most effective diagnostic strategy.<br />
MATERIALS & METHODS<br />
MDCTU is validated for investigating haematuria by determining the diagnostic accuracy in a consecutive series of 1006<br />
patients, over 40-years of age, presenting to a haematuria clinic with MACH, and urinary tract infection excluded.<br />
Reference standard comprises retrograde ureteropyelography (RUP), histopathology from biopsy and surgically resected<br />
specimens, clinical, imaging and histopathological follow-up.<br />
MDCTU is optimised for investigating haematuria is by adjustment of acquisition parameters. Evaluation of changes in<br />
diagnostic accuracy and opacification scoring are used as a measure of examination quality.<br />
The problem solving section looks at reducing false positive and false negative diagnoses by introducing educational<br />
interventions to reduce reader error, RUP for technically inadequate studies and fluoroscopically-guided biopsy for<br />
confirming positive diagnoses.<br />
DISCUSSION<br />
Optimising the patient pathway using MDCTU may be achieved by defining clinical risk category groups for urological<br />
cancer and by investigating each group with a specific first-line imaging test. Low and high risk groups for urological cancer<br />
are proposed. The prevalence of disease in each group ultimately influences the composition of the proposed investigative<br />
pathways. An algorithm is presented using unenhanced CT KUB for the low risk and CT KUB + CT kidneys post-contrast<br />
100s, + / - MDCTU for the high risk group; as first-line imaging tests, as determined by the clinical risk score.<br />
MDCTU is not sensitive enough to rule out, but is specific enough to rule in bladder cancer, allowing patients to bypass<br />
flexible cystoscopy and proceed directly to rigid cystoscopy and biopsy or TURBT.<br />
The advantages and disadvantage of MDCTU are discussed with reference to improvements in diagnostic accuracy,<br />
decreased time from presentation to diagnosis, improved patient experience, economic consequences, and increased<br />
radiation dose. Possible future developments are predicted.<br />
CONCLUSION<br />
The patient pathway for investigating haematuria may be optimized by judicious use of MDCTU. Unenhanced CT KUB is<br />
proposed as first-line imaging test for patients presenting with haematuria in the low risk group for urological cancer. CT<br />
kidneys with contrast and MDCTU are proposed as the first-line imaging test for patients in the high risk group, based on<br />
assessment using of a clinical risk score.<br />
CTU AND IVU RADIATION DOSE<br />
van der Molen A.J.<br />
Leiden University Medical Center, Leiden, The Netherlands<br />
For a long time imaging of theurinary tract has relied on intravenous urography (IVU) as the primary imaging modality. In<br />
more recent times, CT urography (CTU) and (to a lesser extent) MR urography have become the primary means of<br />
urographic imaging. This process has been catalyzed by fast technological advancements such as the ease of use of<br />
multidetector-row CT. Thoughout Europe, many departments have completely abolished IVU, but in others it still remains a<br />
relatively frequently used examination. Since evidence-based data are lacking, this abolition is often premature and not<br />
only based on thorough scientific evidence. Factors such as local preferences, technical improvements, and the general<br />
trend of substituting projectional by cross-sectional imaging techniques may play an important role.<br />
One of the drawbacks of multiphase CTU is its relatively high radiation dose compared to IVU. While the average effective<br />
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<br />
exception, especially when image acquisition is not fully optimized.<br />
Therefore, CTU should be properly justified and if used as a primary examination, should probably be limited to patients at<br />
increased risk for urologic cancer. However, the examination should always be tailored to the clinical question and CTU<br />
examinations with a reduced number of phases and/or CTU examinations at reduced dose could well play an important role<br />
in the problem-solving of benign diseases, such as chronic symptomatic urolithiasis. Because of its cost, low radiation dose,<br />
high in-plane spatial resolution, and the dynamic character of the examination, IVU could still play a role in young patients<br />
with benign diseases and for assisting (US- or fluoroscopy-guided) interventional procedures. For children and pregnant-<br />
71
patients, modern high-resolution MR Urography is probably a more complete and attractive alternative. In the low-dose<br />
segment, MRU may therefore be a competitor of IVU rather than CTU.<br />
MRU TECHNIQUE AND APPLICATIONS<br />
Nolte-Ernsting C.<br />
Department of Diagnostic and Interventional Radiology, Evangelic Hospital of Mülheim, Teaching Hospital of<br />
the University Medical Center of Düsseldorf, Mülheim an der Ruhr, Germany<br />
To date, MR urography (MRU) is performed by pursuing two different imaging strategies. The first technique uses<br />
unenhanced, heavily T2-weighted turbo spin-echo sequences to obtain ‘water images’ of the urinary tract. The second MR<br />
urography technique imitates conventional intravenous urography in that a gadolinium contrast agent is intravenously<br />
administered and after its renal excretion, the gadolinium-enhanced urine is visualized using fast T1-weighted gradientecho<br />
sequences. Modern MR urographic imaging offers several potential applications for the diagnostic management of<br />
nearly all kinds of urinary tract disorders.<br />
T2-weighted MR urography<br />
T2-weighted MR urograms generate static water images (static-fluid MR urography). The water we visualize is the urine<br />
itself, which can be regarded as an “intrinsic contrast medium”. In order to obtain static-fluid images of the urinary tract,<br />
heavily T2-weighted pulse sequences are necessary, which display the urine with hyperintense signal intensity and with<br />
high contrast towards surrounding tissues. Multislice-HASTE sequences or standard 3D Turbo spin-echo (TSE) sequences<br />
with fat suppression have proved to be optimal for obtaining heavily T2-weighted images of the dilated urinary tract [1-8].<br />
Of the acquired source images, maximum-intensity-projections (MIP) are postprocessed to generate typical urogram-like<br />
MR images.<br />
Static-fluid MR urography offers a diagnostic tool which is independent of the renal excretory function. The important<br />
advantage is that T2-weighted MR urography can be performed even in patients with non-excreting kidneys [2-5,9-12].<br />
T2-weighted MR urography has proved to be excellent in the demonstration of the markedly dilated urinary tract, in which<br />
the large amount of water generates a good signal-to-noise ratio [1-5,7-11]. T2-weighted MR urography is less suitable for<br />
imaging non-dilated collecting systems [2,3,6,13,14]. A general drawback of static-fluid MR urography is that this<br />
technique does not permit to derive functional information about the urine flow through the collecting system and ureters<br />
[3,4,5,9,12,15,16].<br />
T1-weighted MR urography<br />
With this technique, we exclusively visualize the contrast-material-enhanced urine with fast T1-weighted pulse sequences<br />
obtained after renal excretion of an intravenously injected low-molecular-weight gadolinium chelate [12]. Gadoliniumenhanced<br />
T1-weighted MR urography depends on the renal excretory function, therefore it is also known as excretory MR<br />
urography. T1-weigthed MR urography provides both visualization of the urinary tract morphology and functional<br />
information about the urine flow through the urinary system [12]. Gadolinium-enhanced T1-weighted MR urography<br />
enables to obtain impressive urograms of both non-dilated and obstructed collecting systems provided the excretory<br />
function is not markedly impaired (GFR > 30 ml/min) [12,17-23]. Conversely, excretory MR urography is of no use in<br />
hydronephrosis associated with severe kidney malfunction [12,20].<br />
Commercially available low-molecular weight gadolinium agents eliminated by renal excretion are utilized to enhance the<br />
urinary tract in T1-weighted MR urography.<br />
A general gadolinium-related problem, however, results from the fact that paramagnetic contrast agents lead to a<br />
shortening of both the T1- and T2-relaxation times of fluids and tissues. The T1-shortening effect, which predominates at<br />
low gadolinium concentrations, enhances the signal intensity of the urine on T1-weighted images and is therefore desired.<br />
Conversely, the T2-effect (or T2*-effect in gradient-echo sequences) of gadolinium predominates with increasing<br />
concentrations, and is undesired because it destroys the positive contrast-enhancement of the urine and results in a signal<br />
void. Since the normal kidneys are able to concentrate the excreted gadolinium by a factor of 50-100 [24,25], the T2*-<br />
effect is a relevant disturbance source, which has to be minimized in order to achieve optimal contrast enhancement for<br />
excretory MR urography. The most effective key to solve this problem is to combine gadolinium with furosemide [12,19].<br />
Furosemide is a very powerful loop diuretic agent, which begins to act immediately after the first pass in the kidneys<br />
leading to a rapid retention of water inside the tubule, whereas the glomerular filtration rate remains unaffected [26]. In<br />
diuretic-enhanced excretory MR urography, the positive interaction of furosemide and gadolinium for achieving optimal<br />
contrast-enhancement of the urine is manifold [12,20]: First, the furosemide induced increase in urine volume leads to a<br />
mild distension of the urinary tract. Potentially more important is that the endoluminal retention of water especially<br />
achieves a dilution of the excreted amount of gadolinium. Third, furosemide accelerates the urine flow, thereby causing a<br />
rapid and uniform distribution of gadolinium throughout the entire urinary tract including the caliceal fornices. ‘Dilution’ and<br />
‘distribution’ of the excreted amount of gadolinium are the two components that best explain the benefits of furosemide for<br />
avoiding T2*-effects in the gadolinium-enhanced urine. It is important to mention that the positive interaction of<br />
furosemide and gadolinium already occurs at low intravenous diuretic doses of 5 - 10 mg (0.1 mg per kg) [12,19]. It has<br />
been shown that the sole administration of a gadolinium agent without furosemide cannot provide a sufficient image quality<br />
in excretory MR urography [27].<br />
A regular intravenous gadolinium dose of 0.1 mmol per kg of bodyweight has proved to be well suited for the combination<br />
with furosemide [12,18,19]. Moreover, in order to ‘prepare’ the kidneys and collecting systems for the arrival of<br />
gadolinium, it has been recommended injecting furosemide shortly before the contrast agent is administered [12]. Even a<br />
short delay of 1 - 5 minutes has proved to be effective for achieving a rapid and complete enhancement of the urinary tract<br />
[12,19].<br />
Breath-hold T1-weighted, spoiled, 3D gradient-echo (GRE) sequences with low repetition and echo times are well suited<br />
pulse sequences for imaging of the gadolinium-enhanced urinary tract [12,17,20-22]. If available, parallel imaging<br />
techniques such as sensitivity encoding (SENSE) are helpful to adjust spatial resolution (matrix size) and data acquisition<br />
time for each patient individually. Moreover, conventional 3D gradient-echo sequences can also be combined with echoplanar<br />
imaging for the use in MR urography [19]. From the source images of each 3D sequence data set, maximum<br />
intensity projection (MIP) images are postprocessed parallel to the long axis of the body.<br />
Which MR urography technique in which situation<br />
In the clinical routine, patients usually undergo ultrasonography before MR urography is taken into consideration. MR<br />
urography may be performed using exclusively T2- or exclusively T1-weighted pulse sequences. On the other hand, as<br />
always in MR imaging, T1- and T2-weighted pulse sequences generally complement one another and provide a<br />
comprehensive assessment. Actually, there are three typical clinical situations that we frequently encounter in adult<br />
patients, which suggest different preferences for the two MR urographic techniques:<br />
72
Situation 1: no hydronephrosis, no atrophy of the renal parenchyma GFR > 30 ml/min.<br />
Patients often present with uncharacteristic flank pain and/or (microscopic) hematuria. In this situation, T1-weighted<br />
excretory MR urography has proved to be excellent for achieving a complete and detailed depiction of the nondilated<br />
urinary tract requiring only 5-10 mg of furosemide. Additional abdominal compression and late MR urograms are not<br />
necessary.<br />
Situation 2: slight or moderate hydronephrosis (grade 1 and 2), no or minimal atrophy of the renal parenchyma, GFR > 30<br />
ml/min.<br />
This situation favours the combination of T2- and T1-weighted MR urography. Static-fluid MR urography easily<br />
demonstrates the level of obstruction. T1-weighted MR urography shows the impairment of urine flow in comparison to the<br />
unobstructed side. Residual gadolinium flow through a ureteral stenosis as well as the length of the stenosis is<br />
demonstrated on excretory MR urograms. Late scans after more than 30 minutes of contrast material injection are usually<br />
not necessary in this situation.<br />
Situation 3: high-grade chronic hydronephrosis (grade 3 and 4), marked parenchymal atrophy, severely reduced or<br />
quiescent kidney function with GFR < 30 ml/min.<br />
T2-weighted MR urography is the imaging technique of choice demonstrating the large amount of static fluid and the level<br />
of obstruction.<br />
Apart from these three typical clinical conditions in adult patients, T2-weighted static fluid MR urography is used exclusively<br />
in pregnant women. The only situation, in which neither T2- nor T1-weighted MR urography really can help, is in patients<br />
suffering from advanced renal insufficiency (renal atrophy) without any obstructive disease.<br />
MR urography techniques in children<br />
In babies, infants and adolescents, MR urography offers all features of varying and combining static-fluid T2- and<br />
gadolinium-enhanced T1-weighted pulse sequences, as well [18,23,28-31]. Sequence parameters such as FOV, number of<br />
slices and slice thickness, have to be modified with regard to the body size of children. Moreover, it is necessary to adapt<br />
the examination procedure to the requirements of the different age groups of children including such aspects as patient<br />
preparation and placement inside the magnet, sedation, choice of surface coil, choice of respiratory compensation for pulse<br />
sequences (triggering, gating, breath-hold), use of parallel imaging, dosages of contrast agent and diuretic, etc. [18,28-<br />
31]. In children, it appears to be very promising to combine MR urography with MR nephrography to obtain both<br />
morphologic and quantitative functional data similar to those of radionuclide studies. The latter concept can also be<br />
realized with complementary use of T2- and T1-weighted MR imaging techniques [15,16,28,29].<br />
Applications for MR urography<br />
With respect to the current discussion on cost restraints in medical care, it should be clear that MR urography is mainly<br />
regarded as a diagnostic test of secondary preference following ultrasonography and CT. However, the diagnostic utility of<br />
MR urography is certainly much better than only being a procedure of the second or third choice.<br />
To date, MR urography can be offered as an alternative to conventional intravenous urography (IVU) and CT urography for<br />
imaging of a wide range of urinary tract disorders. The unique advantage of MR urography is the missing radiation<br />
exposure, which promises great potential for modern uroradiologic applications. T2- and T1-weighted MR urography<br />
techniques offer a comprehensive and noninvasive diagnostic tool for imaging of diverse urinary tract diseases. It may<br />
also be useful to combine static-fluid MR urography and gadolinium excretory MR urography because of their<br />
complementary imaging properties. The use of MR urography should not be confined to patients with known intolerance of<br />
iodinated contrast-agents. Especially in intrinsic and extrinsic neoplastic ureteral diseases, MR urography suggests a<br />
potential to reduce the total number of necessary retrograde pyelographies [12]. In suspected ureteral diseases, MR<br />
urography can be obtained before retrograde pyelography or ureterorenoscopy are being considered. Compared with<br />
unenhanced helical computed tomography (CT), MR urography appears to be less relevant in acute urolithiasis, however,<br />
MR urography may provide valuable clinical information in patients with chronic stone disease [19,20]. Both static-fluid and<br />
excretory MR urography will certainly become important imaging modalities in pediatric uroradiology [15,16,18,28-31]. The<br />
use of exclusively unenhanced T2-weighted pulse sequences makes particular sense in hydronephrotic kidneys with severe<br />
malfunction [2-5,9-12] and in obstructive uropathy during pregnancy [5,14].<br />
Theoretically, MR urography has a potential to become an economic, time-effective and radiation-saving imaging modality<br />
if performed in conjunction with standard pulse sequences, MR nephrography, or MR angiography. This integrative aspect<br />
of MR imaging (‘one-stop-shop-concept’) in uroradiology can help avoid multiple separate diagnostic procedures, which in<br />
the sum are costly, time-consuming, and sometimes even invasive.<br />
References<br />
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1996; 166:543-545<br />
Regan F, Bohlman ME, Khazan R, Rodriguez R, Schultze-Haakh H. MR urography using HASTE imaging in the assessment<br />
of ureteric obstruction. Amer J Roentgenol 1996; 167:1115-1120<br />
Tang Y, Yamashita Y, Namimoto T, Abe Y, Nishiharu T, Sumi S, Takahashi M. The value of MR urography that uses HASTE<br />
sequences to reveal urinary tract disorders. Amer J Roentgenol 1996; 167:1497-1502<br />
O’Malley ME, Soto JA, Yucel EK, Hussain S. MR urography: evaluation of a three-dimensional fast spin-echo technique in<br />
patients with hydronephrosis. Amer J Roentgenol 1997; 168:387-392<br />
Roy C, Saussine C, Guth S, Horviller S, Tuchmann C, Vasilescu C, Le Bras Y, Jacmin D. MR urography in the evaluation of<br />
urinary tract obstruction. Abdom Imaging 1998; 23:27-34<br />
Balci NC, Mueller-Lisse UG, Holzknecht N, Gauger J, Waidlich R, Reiser M. Breathhold MR urography: comparison between<br />
HASTE and RARE in healthy volunteers. Eur Radiol 1998; 8:925-932<br />
Maher MM, Prasad TAS, Fitzpatrick JM, Corr J, Williams DH, Ennis JT, Murray JG. Spinal dysraphism at MR urography: initia<br />
experience. Radiology 2000; 216:237-241<br />
Blandino A, Gaeta M, Minutoli F, Scribano E, Vinci S, Famulari C, Pandolfo I. MR pyelography in 115 patients with a dilated<br />
renal collecting system. Acta Radiol 2001; 42:532-536<br />
Roy C, Saussine C, Jahn C, Vinee P, Beaujeux R, Campos M, Gounot D, Chambron J. Evaluation of RARE-MR urography in<br />
the assessment of ureterohydronephrosis. J Comput Assist Tomogr 1994; 18:601-608<br />
Rothpearl A, Frager D, Subramanian A, Bashist B, Baer J, Kay C, Cooke K, Raia C. MR urography: technique and<br />
application. Radiology 1995; 194:125-130<br />
Reuther G, Kiefer B, Wandl E. Visualization of urinary tract dilatation: value of single-shot MR urography. Eur Radiol 1997;<br />
7:1276-1281<br />
Nolte-Ernsting CCA, Bücker A, Adam GB, Neuerburg JM, Jung P, Hunter DW, Jakse G, Günther RW. Gadolinium-enhanced<br />
excretory MR urography after low-dose diuretic injection: Comparison with conventional excretory urography. Radiology<br />
1998; 209:147-157<br />
Hattery RR, King BF. Technique and application of MR urography. Radiology 1995; 194:25-27<br />
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Grenier N, Pariente JL, Trillaud H, Soussotte C, Douws C. Dilatation of the collecting system during pregnancy: physiologic<br />
vs obstructive dilatation. Eur Radiol 2000; 10:271-279<br />
Rohrschneider WK, Hoffend J, Becker K, Clorius JH, Darge K, Kooijman H, Tröger J. Combined static-dynamic MR<br />
urography for the simultaneous evaluation of morphology and function in urinary tract obstruction. I. Evaluation of the<br />
normal status in an animal model. Pediatr Radiol 2000; 30:511-522<br />
Rohrschneider WK, Hoffend J, Becker K, Clorius JH, Darge K, Kooijman H, Tröger J. Combined static-dynamic MR<br />
urography for the simultaneous evaluation of morphology and function in urinary tract obstruction. II. Findings in<br />
experimentally induced ureteric stenosis Pediatr Radiol 2000; 30:523-532<br />
Verswijvel GA, Oyen RH, Van Poppel HP, Goethuys H, Maes B, Vaninbrouckx J, Bosmans H, Marchal G. Magnetic resonance<br />
imaging in the assessment of urologic disease: an all-in-one approach. Eur Radiol 2000; 10:1614-1619<br />
Staatz G, Nolte-Ernsting CCA, Adam GB, Hübner D, Rohrmann D, Stollbrink C, Günther RW. Feasibilty and utility of<br />
respiratory-gated, gadolinium-enhanced T1-weighted magnetic resonance urography in children. Invest Radiol 2000;<br />
35:504-512<br />
Nolte-Ernsting CCA, Tacke J, Adam GB, Haage P, Jung P, Jakse G, Günther RW Diuretic-enhanced gadolinium excretory MR<br />
urography: comparison of conventional gradient-echo sequences and echo-planar imaging. Eur Radiol 2001; 11:18-27<br />
Nolte-Ernsting CCA, Adam GB, Günther RW. MR urography: examination techniques and clinical applications. Eur Radiol<br />
2001; 11:335-372<br />
Sudah M, Vanninen R, Partanen K, Heino A, Vainio P, Ala-Opas M. MR urography in evaluation of acute flank pain: T2-<br />
weighted sequences and gadolinium-enhanced three-dimensional FLASH compared with urography. AJR 2001; 176:105-<br />
112<br />
Sudah M, Vanninen RL, Partanen K, Kainulainen S, Malinen A, Heino A, Ala-Opas M. Patients with acute flank pain:<br />
comparison of MR urography with unenhanced helical CT. Radiology 2002; 223:98-105<br />
Riccabona M, Simbrunner J, Ring E, Ruppert-Kohlmayr A, Ebner F, Fotter R. Feasibility of MR urography in neonates and<br />
infants with anomalies of the upper urinary tract. Eur Radiol 2002; 12:1442-1450<br />
Krestin GP, Schuhmann-Giampieri G, Haustein J, Friedman G, Neufang KFR, Clauß W, Stöckl B. Functional dynamic MRI,<br />
pharmacokinetiks and safety of Gd-DTPA in patients with impaired renal function. Eur Radiol 1992; 2:16-23<br />
Krestin GP. Genitourinary MR: kidneys and adrenal glands. Eur Radiol 1999; 9:1705-1714<br />
Jackson EK. Diuretics. In: Hardman JG, Limbird LE, Molinoff PB, Ruddon RW, Goodman Gilman A (eds.). Goodman &<br />
Gilman’s The pharmakological basis of therapeutics. New York: McGraw-Hill, 1996: 691, 692, 697-701<br />
Nolte-Ernsting C, Adam G, Bücker A, Berges S, Bjørnerud A, Günther RW. Contrast-enhanced magnetic resonance<br />
urography: first experimental results with a polymeric gadolinium bloodpool agent. Invest Radiol 1997; 32:418-423.<br />
Borthne A, Nordshus T, Reiseter T, Geitung JT, Gjesdal KI, Babovic A, Bjerre A, Loe B. MR urography: the future gold<br />
standard in paediatric urogenital imaging Pediatr Radiol 1999; 29:694-701<br />
Borthne A, Pierre-Jerome C, Nordshus T, Reiseter T. MR urography in children: current status and future development. Eur<br />
Radiol 2000; 10:503-511<br />
Staatz G, Nolte-Ernsting CCA, Haage P, Tacke J, Rohrmann D, Stollbrink C, Günther RW. Kontrastangehobene T1-<br />
gewichtete MR-Urographie versus T2-gewichtete (HASTE) MR-Urographie im Kindesalter. Fortschr Röntgenstr 2001;<br />
173:991-996<br />
Staatz G, Rohrmann D, Nolte-Ernsting CCA, Stollbrink C, Haage P, Schmidt T, Günther RW. Magnetic resonance urography<br />
in children: evaluation of suspected ureteral ectopia in duplex systems. J Urol 2001; 166:2346-2350<br />
PROSTATE IMAGING<br />
Moderators: Barentsz J. (NL) – Yarmenitis S. (GR)<br />
MORPHOMETRIC FEATURES AND CLINICAL ASPECTS OF PROSTATE<br />
CANCER.<br />
Villers A.<br />
Department Of Urology, Hospital Huriez, Centre Hospitalier Regional Universitaire 59037 Lille-France<br />
Important knowledge on modelling of cancer morphology such as zone of origin and intraprostatic patterns of spread at<br />
histopathology was made available for imaging interpretation and treatment planning decision. Such modelling may help<br />
determine the best cancers and cancer volumes for focal, hemi or subtotal ablation and help identify the cancers where<br />
ablative therapy may affect areas of prostate important for preservation of continence and potency. Using knowledge of<br />
the morphology of the prostate, histological data from radical prostatectomy sections, 12-core biopsy results and MRI<br />
data, it was possible to modelize prostate cancers of different volumes and create cartoon-graphics depicting the likely<br />
shape and size of focal tumours in different histologic parts of the prostate, including modelling of axial versus sagittal<br />
extent (1) (2). Modelling studies suggest that in current clinical series around 30% of low volume cancers are anterior and<br />
70% are posterior at pathology. The posterior cancers originated in posterolateral PZ.The anterior cancers originated in<br />
anterolateral PZ and in TZ. These TZ cancers may be pushed away anterior to TZ during BPH growth of the prostate,<br />
giving rise to these cancers located in the anterior fibro-muscular stroma (3).<br />
1. Bouye S, Potiron E, Puech P, Leroy X, Lemaitre L, Villers A. Transition zone and anterior stromal prostate<br />
cancers: Zone of origin and intraprostatic patterns of spread at histopathology. Prostate. 2008 Oct 10.<br />
2. Haffner J, Potiron E, Bouye S, Puech P, Leroy X, Lemaitre L, et al. Peripheral zone prostate cancers: location and<br />
intraprostatic patterns of spread at histopathology. Prostate. 2009 Feb 15;69(3):276-82.<br />
3. Lemaitre L, Puech P, Poncelet E, Bouye S, Leroy X, Biserte J, et al. Dynamic contrast-enhanced MRI of anterior<br />
prostate cancer: morphometric assessment and correlation with radical prostatectomy findings. Eur Radiol. 2009<br />
Feb;19(2):470-80.<br />
74
TRUS AND PROSTATE CANCER (PCA): A REAPPRAISAL IN 2009<br />
Cornud F.<br />
Department of Radiology, NECKER Hospital, Paris, France<br />
Objectives<br />
1. to know the classical TRUS features of palpable and non palpable PCa<br />
2. to know how TRUS nad TRUS biopsy protocols can improve detection of the non visible non palpable PCa (T1c<br />
stage).<br />
3. to know the potential role of TRUS-MRI image fusion to improve cancer detection rate.<br />
4. to know the limits of biopsy results (Gleason score and quantitative histology) and PSA level to establish the risk<br />
stratification of a newly diagnosed prostate cancer<br />
5. to show how TRUS-MRI fusion images can upgrade low risk to intermediate or high risk tumors to better define<br />
the indications of additional imaging investigation in the work up of a newly diagnosed PCa<br />
Take home messages<br />
1. TRUS features should be interpreted according to DRE results and PSA level<br />
2. TRUS is extremely helpful, in selected cases, to guide periprostatic (staging) biopsies to diagnose a biopsy T3-<br />
stage<br />
3. TRUS guided biopsies, targeted by the results of a functional MRI (diffusion and dynamic imaging) represent an<br />
attractive alternative to saturation biopsies (>20 cores)<br />
4. Low risk patients can be upgraded by repeat targeted biopsies guided by TRUS-MRI image fusion.<br />
Summary<br />
TRUS and TRUS guided biopsies represent the gold standard to diagnose PCa. In selected cases of large volume<br />
tumors, periprostatic biopsies of periprostatic spaces (bulding of the prostate contour) and the seminal vesicles<br />
(tumor involving the prostate base) can be performed to diagnose a biopsy T3 stage. However, the PSA era has<br />
considerably downstaged newly diagnosed PCa, leading to the detection of smaller volume tumors, not visible at<br />
TRUS in approximately 50% of cases. Color Doppler and contrast enhanced have only minimally increased the cancer<br />
detection rate by targeted biopsy of suspicious areas. Biopsy protocols have thus extended to 10-12 cores to optimize<br />
the cancer detection rate. Still, approximately 20% of significant PCa are missed by these protocols. Recently a<br />
saturation biopsy protocol (>20 cores) has been advocated when a repeat biopsy is performed, which entails a higher<br />
morbidity and a risk of detection or non significant PCa. The alternative is represented by TRUS guided biopsies<br />
targeted on a suspicious area detect on a functional multiparametric MRI (diffusion-weighted and/or contrast<br />
enhanced MRI). Images can be fused and TRUS guided biopsies targeted towards the suspicious area.<br />
TRUS guided biopsies extended protocols have also been used for prognostic purposes: the Gleason score, in<br />
combination with the amount of Ca yielded by biopsies (% of contiguous positive biopsies and/or mm of Ca), in<br />
combination with the PSA level permit to define three risks (low, intermediate, high) of biochemical recurrence<br />
(raising PSA after radical treatment). Repeat TRUS guided biopsies targeted by functional MRI can upgrade low risk<br />
patients (PSA level
a<br />
b<br />
c<br />
d<br />
Figure 1.<br />
Figure 1. Multi-modality MR imaging<br />
In a 67-year old male with PSA of 33 ng/ml, who underwent three negative TRUS-biopsy sessions.<br />
a) T2-weighted high resolution anatomic image shows low signal region, ventral right in the prostate (arrow). b) DCE-MRI<br />
shows elevated enhancement in this area. c) MR-spectroscopy indicates an elevated choline in this region (blue). d) DWI;<br />
shows decreased diffusion of water molecules in this region. MR-guided biopsy from this region (see figure 2)<br />
demonstrated a Gleason 8-prostate cancer.<br />
76
a<br />
b<br />
Figure 2. MR-guided biopsy.<br />
Same patient as in figure 1. TSR=Tumor Specific Region of figure 1 is indicated by a yellow circle. In (b) the needle is<br />
recognizable by the low signal intensity (arrows), with the tip in the suspect ventral region. Histology proved a Gleason 8-<br />
carcinoma.<br />
Local staging<br />
Although a large number of men above 50 will develop prostate cancer, only in a small proportion of patients their tumor<br />
will become aggressive. For the majority of men with non-aggressive tumors, one can wait with invasive treatment until<br />
the tumor becomes aggressive (watchful waiting). It is essential to precisely characterize the tumor. This can be achieved<br />
with multi-modality MRI.<br />
With nomograms, based on the serum PSA-value, the tumors aggression (expressed in Gleason-grade), and the outcome<br />
of digital rectal examination, an attempt is made to predict the aggression and local extension of the tumor, and the<br />
presence of lymph node metastasis. Based on these nomograms the further treatment strategy is determined.<br />
Unfortunately these nomograms are only moderately reliable, so that it is not always possible to make the right treatment<br />
decison. By means of functional (multi-modality) MR imaging information can be acquired regarding the aggression of the<br />
tumor. Furthermore, a MR-examination, performed at high field strength (3 Tesla) with use of an endorectal coil (ERC),<br />
allows very accurate determination of minimal (sub-millimeter) extra prostatic spread. The sensitivity and specificity of 3T<br />
ERC MR imaging for determination of extra prostatic disease are respectively 87% en 96% (3) . If the decision is to<br />
surgically remove the prostate, it is important to know where the tumor is located and whether it shows extra prostatic<br />
growth (figure 3). If the tumor is distant from the neurovascular bundle, these bundles can be spared. This decreases the<br />
chance of postoperative impotence. If MRI shows obvious extra prostatic extension, surgery is less useful and the best<br />
choice is hormonal therapy with or without radiotherapy.<br />
Nowadays prostate cancer is increasingly treated with directed local radiotherapy. If the precise location of the tumor is<br />
known, it is possible to give a local boost to this dominant in the prostate. This has the advantage that less radiation is<br />
given to the surrounding tissue, with fewer side-effects. MRI can supply this information (4) .<br />
77
Figure 3. Minimal extra prostatic disease.<br />
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<br />
the right peripheral zone is seen (circled region). The fat in the recto-prostatic corner is interrupted, which implies a<br />
minimal extra prostatic disease (arrows). The tumor is close to the neurovascular bundle (red-blue-yellow). b) A wide<br />
resection was performed based on the MRI. Histopathology showed minimal extra prostatic disease (1 mm). Resection<br />
margins were negative for tumor.<br />
Lymph node metastasis<br />
Hormonal therapy with or without radiation is the best treatment if there are metastasis to the lymph nodes. The risk of<br />
lymph node metastasis is currently determined with the help of the above described (inaccurate) nomogram. In patients<br />
with an elevated risk for metastasis additional examinations are required. At the moment the most used imaging<br />
techniques for detecting lymph node metastasis are multi-detector CT (MDCT) and conventional MRI. The accuracy of<br />
MDCT and conventional MRI is not high. This makes supplementary invasive diagnostic examination in the form of surgical<br />
pelvic lymph node dissection (PLND) mandatory. A new MRI technique using a lymph node specific contrast agent<br />
(Combidex) (MRL) is recently described (5, 6) . This contrast agent consists of iron oxide-containing nano-particles. When<br />
this contrast agent is administered intravenously, it is taken up by macrophages and transported to healthy lymph tissue.<br />
The iron causes changes in the magnetic characteristics of the tissue, that results in low signal intensity on MR images.<br />
Therefore 24 to 36 hours after Combidex injection, healthy lymph nodes are black on MR images due to the iron within<br />
macrophages. Macrophages are absent in lymph nodes with metastasis and thus these lymph nodes do not have a low<br />
signal: the tissue is white (figures 4 en 5).<br />
78
Figure 4.<br />
1) Iron contrast is slowly administered by means of intravenous infusion and is taken up by macrophages. 2)<br />
Macrophages move to healthy lymph tissue. 3) Iron-filled macrophages are present in normal lymph tissue and not in<br />
areas of metastasis. 4) Normal nodes are black on MRI. The metastasis remains white.<br />
With MRL it is possible to examine the entire abdomen instead of only a restricted area surrounding a few pelvic blood<br />
vessels, such as is the case with PLND. The sensitivity, specificity, negative and positive predictive values are respectively<br />
82%, 93%, 96% en 69%. In specialized centers it is even higher: 90%, 94%, 98% and 75%, respectively. The diagnostic<br />
accuracy of MRL in the detection of lymph node metastasis is significantly higher than with MDCT (6) . The high negative<br />
predictive value (>96%) of MRL means that after a negative result on MRL, PLND does not have to be performed. Due to<br />
the latter, obtaining a diagnosis with MRL is economically <strong>cheaper</strong> and results in fewer complications than with the current<br />
invasive diagnostic technique of MDCT + PLND. In addition, in at least in 30% of patients, thanks to MRL, nodes are<br />
detected which are not found by the routine PLND, as they are located in the internal and common iliac, peri-rectal and<br />
par aortic regions.<br />
Figure 5. MR Lymphography with Combidex<br />
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).<br />
The diameter of both nodes is 4 mm. Histopathology confirmed a metastatic node (white) and a normal node (black).<br />
79
The positive and negative nodes can be made visible on a combined CT-angiography-MRL image (figure 6). In this way<br />
the location of positive nodes relative to the large pelvic vessels can be visualized. This information can help the surgeon<br />
to find these nodes or help the radiation oncologist to give selective lymph node radiotherapy. Unfortunately, the iron<br />
oxide contrast agent has not yet obtained official registration.<br />
Figure 6. CTA-MRL combined image<br />
60-year old male who underwent a prostatectomy and PLND (Stage T3a, N0, M0) After surgery he had a PSA-rise to 10.<br />
CTA-MRL image shows normal green nodes. There is a nodeless area in the pelvis with surgical clips. Red pathological<br />
nodes are seen near the aorta. Surgical resection showed these nodes to be metastasis.<br />
PSA Recurrence<br />
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<br />
nodes or bone marrow metastases MRI also has a role in this situation.<br />
Bone metastasis can be excluded by means of a ‘whole-body’-MRI.<br />
If this is negative, then Combidex MRL should be used to exclude node metastasis. In post-treated patients we found no<br />
correlation between PSA value or PSA doubling time and positive nodes. There was, however, a positive correlation<br />
between PSA velocity and positive nodes on MRL. Thus even in patients with a low PSA, but high PSA velocity a MRL to<br />
exclude metastases is of use.<br />
Finally, multi-modality MRI can be performed to determine if there is a local recurrence (figure 7).<br />
a<br />
80
Figure 7. Post radiotherapy recurrence.<br />
67-year old male, 2.5 years after radiotherapy of the prostate elevation of PSA to 2.1. a) T2-weighted MRI shows no<br />
abnormalities. b) At the location of the old tumor there is strong enhancement on the DCE-MRI. Biopsy confirmed<br />
prostate cancer recurrence.<br />
Summary.<br />
This article describes the potential value of MR imaging for patients with prostate cancer. To summarize, MR imaging<br />
affords:<br />
- Accurate detection of tumor, thereby decreasing the number of unnecessary biopsies and increased accuracy<br />
- Better determination of the location and extension of the tumor: this makes targeted radiotherapy or targeted<br />
treatments possible. Hereby reducing side-effects of this treatment (damage to the intestine, impotence, incontinence).<br />
- Better prediction of tumor aggression: for patients with a non-aggressive tumor this means that one has the possibility<br />
to wait with invasive treatment, and act based on the MR-results.<br />
- Non-surgical detection of very small metastasis in lymph nodes. This also means the possibility for more patients to<br />
undergo targeted therapy.<br />
- For ‘PSA-recurrence patients, instead of a bone-scan a ‘whole-body’-MRI can be performed, followed by a MRL, and a<br />
local “functional”-MRI. Based on this MRI the eventual local treatment can be started.<br />
Acknowledgments<br />
This paper was made possible due to the work of the Radboud University Medical Center Nijmegen Prostate team:<br />
Radiology: Prof. Dr. J Barentsz, Prof. Dr. A Heerschap, Dr. Ir. T Scheenen, Dr. J Fütterer, Dr. Ir. H-J Huisman, Dr. Ir. N<br />
Karssemeijer, Drs. S Heijmink, Drs. T Hambrock, Drs. D. Yakar, Drs. O Debats, Drs. C Hoeks,<br />
Urology: Prof. Dr. J Witjes, Drs. I van Oort, Drs. R Somford,<br />
Radiotherapy:<br />
Dr. E van Lin,<br />
Pathology:<br />
Dr. C Hulsbergen, & Drs. C van Niekerk.<br />
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intraprostatic lesions: gold marker-based three-dimensional fusion of CT with dynamic contrast-enhanced and<br />
1H-spectroscopic MRI. International journal of radiation oncology, biology, physics 2006 65 (1): 291-303.<br />
5. Harisinghani MG & Barentsz J (co-first-authors), Hahn PF, Deserno WM, Tabatabaei S, van de Kaa CH, de la<br />
Rosette J, Weissleder R. Noninvasive detection of clinically occult lymph-node metastases in prostate cancer.<br />
The New England Journal of Medicine 2003 348(25): 2491-9.<br />
6. Heesakkers RA, Hövels AM, Jager GJ, van den Bosch HC, Witjes JA, Raat HP, Severens JL, Adang EM, van der<br />
Kaa CH, Fütterer JJ, Barentsz J.<br />
MRI with a lymph-node-specific contrast agent as an alternative to CT scan and lymph-node dissection in<br />
patients with prostate cancer: a prospective multi-cohort study. Lancet Oncol. 2008 Aug 15.<br />
81
INTERVENTIONAL URORADIOLOGY<br />
Moderators: Moussa S. (UK) – Papailiou J. (GR)<br />
MANAGEMENT OF URINARY STONES IN 2009: A TEAM APPROACH<br />
Moussa S. A., Edinburgh<br />
Magnusson A., Uppsala, Sweden<br />
Imaging plays a major role in the management of urinary tract calculi.<br />
Urinary tract calculi:<br />
• Common condition<br />
• 15% of men & 6% of women in developed countries will have one stone<br />
• 50% will recur<br />
• Majority are idiopathic 80%<br />
• Metabolic e.g. hyperparathyroidism<br />
• Genetic<br />
• Anatomical anomalies in upper or lower tracts<br />
• Infection<br />
Imaging Modalities:<br />
• KUB<br />
• Ultrasound<br />
• IVU<br />
• CT<br />
• MRI<br />
• Nuclear Medicine<br />
When is imaging needed<br />
• Diagnosis:<br />
• Presence of stone<br />
• Stone size<br />
• Stone position<br />
• Obstruction<br />
• Management<br />
• Calyceal anatomy<br />
• Planning puncture<br />
• Follow up<br />
The different imaging modalities will be discussed with particular reference to their place in stone management.<br />
• The management of stone disease has evolved in recent year since the advent of ESWL (Extracorporeal shock<br />
wave lithotripsy) as well as with advances in interventional radiological techniques allowing for safer<br />
percutaneous access to the upper urinary tract.<br />
In recent years there has been an increasing use of CT in the evaluation of patients with stone disease particularly<br />
complex stones where 3D reconstraction has been shown to be of great value as well as CT guided renal access.<br />
The choice of the appropriate treatment modality depends on several factors which will be discussed.<br />
The technique of percutaneous nephrolithotomy will be described together with examples of some complex cases.<br />
From this presentation we can conclude that:<br />
For best practice in stone management:<br />
• Accurate imaging and preoperative evaluation of the patient<br />
• Careful patient selection<br />
• If possible use 3D-CT for planning<br />
Will give:<br />
– an optimal tract<br />
– an optimal result<br />
– at a minimal risk<br />
• Close discussion between radiologist and endourologists<br />
• Joint surgical approach<br />
• Team effort including anaesthesia and all theatre staff<br />
• Recognition and early management of complications<br />
82
FEMALE PELVIS / IMAGING<br />
Moderators: Kinkel K. (CH) – Tsili A. (GR)<br />
TIPS AND TRICKS FOR SCANNING IN GYNAECOLOGY<br />
McHugo J.<br />
Birmingham Women’s Hospital NHS Foundation Trust, Birmingham University , UK<br />
Abstract<br />
A structured approach is essential in imaging and this is particularly true for scanning in gynaecology. It is vital that<br />
the investigation is performed in an appropriate manner with not only the right equipment but in the right<br />
environment. A standard approach to each examination in required but it is important to understand the clinical<br />
setting, and the questioned to be answer. It is essential to be provided with the following information prior to<br />
scanning.<br />
Age<br />
Menstrual Cycle<br />
Hormone Therapy<br />
Previous operations- particularly gynaecological.<br />
This presentation aims to provide both those in training as well as the more experienced with tips and tricks for<br />
transvaginal scanning and will be illustrated with clinical cases.<br />
Not only will images show pathology but an understanding of the ultrasound “ soft signs” of pain and mobility will be<br />
developed aiming to enhance the accuracy of the diagnosis when using transvaginal scanning<br />
WHAT YOU SHOULD NOT FORGET TO PUT IN A SONOGRAPHIC REPORT<br />
ABOUT THE FEMALE PELVIS”<br />
Cunha T.M<br />
Department of Radiology, Portuguese Institute of Oncology – Lisbon.<br />
Ultrasound of the female pelvis should be done when there is a valid medical reason, and the lowest possible<br />
ultrasonic exposure settings should be used to gain the necessary diagnostic information. In some cases, additional or<br />
specialized examinations may be necessary.<br />
The indications for a pelvic ultrasound include but are not limited to:<br />
1. Pelvic pain.<br />
2. Dysmenorrhea.<br />
3. Menorrhagia.<br />
4. Metrorrhagia.<br />
5. Menometrorrhagia.<br />
6. Follow-up of previously detected irregularity (eg, hemorrhagic cyst).<br />
7. Evaluation and/or monitoring of infertile patients.<br />
8. Delayed menses or precocious puberty.<br />
7. Postmenopausal bleeding.<br />
8. Abnormal pelvic examination.<br />
9. Further characterization of a pelvic abnormality noted on another imaging study (eg, computed tomography or<br />
magnetic resonance imaging).<br />
10. Evaluation of congenital anomalies.<br />
11. Excessive bleeding, pain, or fever after pelvic surgery or delivery.<br />
12. Localization of an intrauterine contraceptive device.<br />
13. Screening for malignancy in patients with an increased risk.<br />
The examination should be performed for each organ and anatomic region in the female pelvis.<br />
All relevant structures should be identified by the transabdominal or transvaginal approach. In many cases, both will<br />
be needed.<br />
A transrectal or transperineal approach is useful in patients who cannot stand a vaginal probe (eg, virgins and<br />
postmenopausal women).<br />
For a pelvic sonogram performed transabdominally, the patient’s urinary bladder should be distended sufficiently to<br />
move the small bowel and its contained gas from the field of view. Occasionally, overdistention of the bladder may<br />
compromise evaluation. When this occurs, imaging may be repeated after the patient partially empties the bladder.<br />
For a transvaginal sonogram, the urinary bladder is preferably empty. The patient or the physician may introduce the<br />
vaginal transducer, preferably under real-time monitoring. Male examiner should always have a female chaperone in<br />
cases of transvaginal scans.<br />
The vagina and uterus provide anatomic landmarks that can be used as reference points for the remaining normal and<br />
abnormal pelvic structures.<br />
In evaluating the uterus, the following should be documented: (1) the uterine size, shape, and orientation; (2) the<br />
endometrium; (3) the myometrium; and (4) the cervix. The vagina may be imaged as a landmark for the cervix and<br />
lower uterine segment.<br />
Uterine length is evaluated in the long axis from the fundus to the cervix (the external os, if it can be identified). The<br />
depth of the uterus (anteroposterior dimension) is measured in the same long axis view from its anterior to posterior<br />
walls, perpendicular to the length. The width is measured from the transaxial or coronal view. If volume<br />
measurements of the uterine corpus are performed, the cervical component should be excluded from the uterine<br />
measurement.<br />
Abnormalities of the uterus should be documented.<br />
The myometrium and cervix may be evaluated for contour changes, echotexture, and masses. Masses, if identified,<br />
should be measured in at least 2 dimensions and their locations recorded (eg. leiomyoma location and largest size).<br />
83
The endometrium should be analyzed for thickness, focal abnormality, and the presence of fluid or a mass in the<br />
endometrial cavity. Assessment of the endometrium should allow for variations expected with phases of the menstrual<br />
cycle and with hormonal supplementation. If the endometrial stripe is difficult to image or ill defined, a comment<br />
should be added to the report.<br />
When evaluating the adnexa, an attempt should be made to identify the ovaries first since they can serve as a major<br />
point of reference for assessing the presence of adnexal pathology. The ovaries should be measured, and ovarian<br />
abnormalities should be documented. Ovarian size can be determined by measuring the ovary in 3 dimensions (width,<br />
length, and depth), on views obtained in 2 orthogonal planes. It is acknowledged that the ovaries may not be<br />
identifiable in some women. This occurs most frequently after menopause or in patients with a large leiomyomatous<br />
uterus.<br />
If an adnexal mass is detected, its relationship to the ovaries and uterus should be documented.<br />
Its size, echogenicity, and internal characteristics (cystic, solid, or complex) should be determined. Doppler or color<br />
Doppler ultrasound may be useful in select cases to identify the vascular nature of pelvic structures.<br />
If the lesion is a benign water cyst we should stop other imaging; only follow up is required. In the characterization of<br />
an ovarian lesion the evidence of criteria for malignancy<br />
- size: >4cm<br />
- architecture: solid, mixed solid and cystic<br />
- papillary projections<br />
- mural thickness, septations >3mm<br />
- necrosis<br />
the patient should go for a CT staging. When the lesion is indeterminate a MR characterization must be the next step.<br />
When ovarian endometriosis is detected or in the presence of suspicion for pelvic endometriosis we should check the<br />
- pouch of Douglas<br />
- posterior vaginal fornix<br />
- utero-sacral ligaments<br />
- vesico-uterine pouch<br />
The normal fallopian tubes are not usually recognized. This region should be surveyed for abnormalities, particularly<br />
dilated tubular structures.<br />
The pouch of Douglas and bowel posterior to the uterus may not be clearly distinct. This area should be evaluated for<br />
the existence of free fluid or a mass. If a mass is detected, its size, position, shape, echogenicity, internal<br />
characteristics (cystic, solid, or complex), and correspondence to the ovaries and uterus should be documented.<br />
Demarcation of normal loops of bowel from a mass may be not easy if only a transabdominal examination is<br />
performed. A transvaginal examination may be useful to distinguish a suspected mass from fluid and feces within the<br />
normal rectosigmoid.<br />
Adequate documentation is essential for high-quality patient care. A permanent record of the ultrasound examination<br />
and its interpretation should be included in the medical record. Images of all appropriate areas, both normal and<br />
abnormal, should be recorded. Variations from normal size should be accompanied by measurements.<br />
Images are to be correctly label with the examination date, facility name, patient identification, image orientation,<br />
and, whenever possible, the organ or area imaged. Significant history for each patient should include obstetric history<br />
and/or pertinent menopausal history. Preservation of the permanent record of the sonographic examination should be<br />
consistent with both clinical requirements and the pertinent legal and local health care facility necessities.<br />
LIMITATIONS OF FEMALE PELVIC ULTRASOUND: WHEN DO YOU NEED<br />
MRI/CT<br />
Sala E.<br />
Department of Radiology, University of Cambridge and Cambridge University Hospitals NHS Foundation<br />
Trust Cambridge CB2 0QQ<br />
Imaging Techniques<br />
Ultrasound: Ultrasound (transabdominal or transvaginal) is accepted as the primary imaging modality for examining<br />
the female pelvis. It remains the principal initial imaging study in the work-up of gynaecologic disease. Currently, the<br />
main role of ultrasound (US) in gynecology includes evaluation of a suspected pelvic mass, evaluation of the causes of<br />
uterine enlargement, identification of endometrial abnormalities in a patient with postmenopausal bleeding, and<br />
characterization of ovarian masses. It is also the primary imaging modality of choice in the evaluation of the female<br />
with acute pelvic pain. In addition, ultrasound has become invaluable in guiding a wide selection of invasive<br />
procedures. For example, it is used for transabdominal and transvaginal guidance of fluid or tissue sampling,<br />
transvaginal guided drain placement, guidance for placement of brachytherapy for cervical and endometrial<br />
malignancy, and intraoperative assessment for completion of evacuation and instrument placement, especially when<br />
the anatomy is difficult to assess preoperatively. Transvaginal ultrasound (TVS) provides greater detail of the anatomy<br />
and pathology. Color, power and spectral Doppler provide additional information regarding associated vascularity.<br />
US has many advantages in routine pelvic imaging: it is relatively inexpensive, provides multiplanar views, is widely<br />
available and lacks ionizing radiation or contrast media. Its portability allows use in virtually any setting including the<br />
ultrasound suite, operating room, patient bedside or radiation therapy suite. However, US also has a number of<br />
limitations: it is operator-dependent and image quality varies with patient body habitus.<br />
Magnetic Resonance Imaging: The role of MRI in gynaecology has evolved during the last two decades. There is now a<br />
substantial body of evidence that MRI is useful in evaluating Müllerian duct anomalies and both benign and malignant<br />
conditions of the pelvis. MRI has been shown to be superior to US and CT in the characterization of indeterminate<br />
adnexal masses, in the work-up of uterine and cervical cancer and may be a useful problem-solving tool in the<br />
evaluation of ovarian cancer. Although MRI is still relatively expensive, it has been shown to minimize costs in some<br />
clinical settings by limiting or eliminating the need for further expensive and/or more invasive diagnostic or surgical<br />
procedures. Advantages of MRI include superb spatial and tissue contrast resolution, no use of ionizing radiation,<br />
multiplanar capability and fast techniques. MRI is the technique of choice for patients with allergies to iodinated IV<br />
contrast media or impaired renal function. However, MRI is contraindicated in patients with implants such as<br />
pacemakers, neural stimulators or cochlear implants, certain vascular clips and metallic objects.<br />
84
Computed Tomography: CT has a limited utility in characterizing early-stage disease, but is the most commonly used<br />
primary imaging study for evaluating the extent of gynaecologic malignancy and for detecting persistent and recurrent<br />
pelvic tumours. Advantages of CT include oral and rectal contrast opacification of the gastrointestinal tract,<br />
intravenous contrast enhancement of blood vessels and viscera, fast data acquisition and high spatial resolution.<br />
Disadvantages of CT include the use of ionizing radiation, degradation of image quality by body habitus or metallic hip<br />
prosthesis, and the risk of morbidity and mortality associated with iodinated contrast agents.<br />
Role of Imaging in Selected Conditions of Female Pelvis<br />
Congenital Anomalies of the Female Genital Tract: Müllerian duct anomalies result from non-development or varying<br />
degrees of non-fusion or non-resorption of the Müllerian ducts. These congenital anomalies occur in 1–15% of women.<br />
Müllerian duct anomalies are associated with menstrual disorders, infertility and obstetric complications. Evaluation of<br />
Müllerian duct anomalies with physical examination and more traditional imaging studies (HSG and US) is often<br />
inconclusive. MRI is the most accurate imaging modality for evaluating theses patients, allowing both precise<br />
classification and demonstration of associated complications.<br />
Benign Uterine Conditions<br />
Leiomyoma: Leiomyomas are the most common uterine tumours. These benign tumours are found in up to 40% of<br />
women in their reproductive years. They are usually multiple and may be subserosal, intramural or submucosal in<br />
location. Symptoms may be caused by the location of the leiomyoma and/or their mass effect. Hysterectomy has been<br />
the traditional primary treatment for debilitating leiomyomas. While hysterectomy is curative, alternative uterinesparing<br />
procedures may be appropriate for some patients. Specifically, myomectomy has been successfully performed<br />
for many years and, more recently, transcatheter uterine arterial embolization (UAE) is being used as an alternative,<br />
less invasive therapy for symptomatic leiomyomas. Recently another alternate minimally invasive treatment has been<br />
MR-guided high focused ultrasound. US is often the initial radiological evaluation in these patients, while MRI is usually<br />
reserved for patients with inconclusive US results or patients undergoing myomectomy, uterine embolization or MRguided<br />
focused ultrasound; in all of these situations, MR is used to assist in appropriate selection of patients for UAE.<br />
Adenomyosis: Adenomyosis is the presence of endometrial tissue within the myometrium and secondary smooth<br />
muscle hypertrophy-hyperplasia. It can be diffuse or focal. The most frequent symptoms are dysmenorrhoea and<br />
dysfunctional uterine bleeding. TVS is the initial imaging modality, whereas MRI should be reserved for indeterminate<br />
cases or those undergoing uterus sparing surgery. Pitfalls in the diagnosis of uterine adenomyosis include leiomyoma,<br />
endometrial carcinoma, and myometrial contractions. TVS has an accuracy of 68-86% in the diagnosis of diffuse<br />
adenomyosis. Because the findings may be subtle, real time evaluation of women suspected of adenomyosis may be<br />
the key to making the diagnosis. While the diagnosis of diffuse adenomyosis can be suggested on TVS, the findings of<br />
focal adenomyosis are hard to distinguish from leiomyoma.<br />
Malignant Uterine Conditions<br />
Endometrial carcinoma: Endometrial carcinoma is the fourth most common female cancer and the most common<br />
malignancy of the female reproductive tract. Endometrial carcinomas are typically diagnosed at endometrial biopsy or<br />
dilatation and curettage with imaging being reserved to evaluate extent of disease. TVS is superior to TAS for imaging<br />
endometrial abnormalities. The most common appearance of endometrial cancer is nonspecific thickening of the<br />
endometrium; while this thickening is indistinguishable from that found with hyperplasia or polyp, the diagnosis of<br />
endometrial cancer should be considered when the endomyometrial junction is disrupted or the endometrial surface is<br />
irregular. Dynamic contrast-enhanced MRI offers a ‘one-stop’ examination with the highest efficacy for pretreatment<br />
evaluation in patients with endometrial cancer. MRI is significantly superior to US and CT in the evaluation of both<br />
tumour extension into the cervix and myometrial invasion. The overall staging accuracy of MRI has been reported to<br />
be between 85% and 93%.<br />
The Adnexa<br />
Endometriosis: Endometriosis is the presence of endometrial epithelium and stroma outside of endometrium and<br />
myometrium. Endometriosis occurs in up to 65% of women with pelvic pain and usually affects women of reproductive<br />
age. Imaging is most commonly used for the diagnosis and follow-up of endometriomas, but laparoscopy is the gold<br />
standard, as it can provide a complete evaluation for endometrial implants in the abdomen and pelvis as well. TVS is<br />
the first imaging modality, with MRI reserved for masses atypical on US. Endometrial implants can be detected on<br />
MRI, but evaluation on MRI is inferior to laparoscopic staging.<br />
Mature Cystic Teratomas: Mature cystic teratomas are the only benign germ cell tumours and are quite common. The<br />
US appearance of dermoid cysts varies. The most common appearances are a cystic mass with an echogenic nodule<br />
projecting into the lumen or a predominantly echogenic mass with posterior sound attenuation owing to the presence<br />
of sebaceous material and hair. A fluid-fluid level may also be seen. The strength of MRI is its ability to diagnose<br />
dermoid cysts with confidence as the fat or sebum within the cyst parallels the signal intensity of fat on all pulse<br />
sequences.<br />
Ovarian carcinoma: Ovarian neoplasms account for more cancer-related deaths than all other primary cancers of the<br />
reproductive system. Combined TA and TVS is initially used for the detection of ovarian carcinoma. These studies<br />
provide superb morphologic detail of the adnexa, allowing detection of masses before they are clinically apparent. CT<br />
is the most commonly performed study for the preoperative staging of a suspected ovarian carcinoma. It is particularly<br />
useful in determining the extent of cytoreductive surgery required to optimize subsequent chemotherapeutic response.<br />
RENAL TUMORS – NEOPLASMS<br />
Moderators: Babnik-Peskar D. (SL) – Efremidis S. (GR)<br />
IMAGING AND STAGING<br />
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<br />
Departmets of Clinical Radiology 1 and Urology 2 , University of Munich, Germany<br />
Department of Clinical Radiology, University of Munich, Ziemssenstrasse 1, D-80336 Muenchen, Germany<br />
Introduction<br />
As in other malignant tumors, prognosis in renal cell carcinoma (RCC) depends on the extent of the tumor and its<br />
metastasis at the time of its primary diagnosis. Staging systems formalize the way in which the primary or pre-<br />
85
therapeutic extent of RCC is being described. Surgery is currently the only curative therapeutic approach to RCC (1).<br />
However, even when RCC cannot be cured by means of surgery, it has been demonstrated that surgical resection of<br />
the primary tumor appears to be an integral part of systematic therapy for metastatic RCC (2). With no other curative<br />
therapy at hand, pertinent staging methods imminently relate to prognosis of RCC. Such methods include computed<br />
tomography (CT), particularly when performed with multiple detector rows (multidetector-row CT or MDCT), and<br />
magnetic resonance imaging (MRI). Preoperative staging of RCC is aimed at evaluating surgical options and optimal<br />
surgical technique (1). Since surgical excision of RCC has evolved significantly since the 1960s (2), staging systems<br />
have evolved along the way.<br />
The Robson Classification<br />
The Robson classification for RCC (3,4) was developed in the 1960s. It is based on the observation that surgical<br />
success and tumor-specific patient survival in RCC depend on the confinement of the primary tumor to certain<br />
anatomical landmarks in the body. Confinement of RCC to the renal capsule determines Robson stage I. Extension of<br />
RCC to the perirenal fat or the ipsilateral adrenal gland, which is anatomically included within the confines of Gerota’s<br />
fascia, determines Robson stage II. Extension of RCC into the renal vein, the inferior vena cava (IVC), or regional<br />
lymph nodes are the hallmarks of Robson stage III. Direct extension of RCC to neighbouring organs other than the<br />
adrenal gland and distant metastasis of RCC each define Robson stage IV. Association between Robson stage of RCC<br />
and prognosis has clearly been demonstrated (3-5). Although it is easy to remember and clear-cut in its use of<br />
anatomical landmarks, the Robson classification of RCC has greatly been left for the TNM classification.<br />
The TNM Classification<br />
The TNM classification of the International Union Against Cancer (UICC) distinguishes between the extents of the<br />
primary tumor (T-classification), its lymph node metastases (N-classification), and its distant, or blood-borne<br />
metastases (M-classification). According to current knowledge on prognosis, certain TNM constellations are grouped<br />
together to represent distinct tumor stages of the TNM classification system (Table). While more complicating than the<br />
Robson classification at first glance, the TNM classification demonstrates more capability to grow and change with<br />
increasing knowledge in the diagnosis and treatment of RCC. The association between post-surgical TNM classification<br />
as determined by surgical pathology and tumor-specific 5-year survival of RCC has clearly been demonstrated (6).<br />
Cross-Sectional Imaging in the Staging of Renal Cell Carcinoma<br />
Cross-sectional imaging appears to be capable of recognizing small RCCs that are confined to the renal capsule and<br />
are adequately treated by means of partial nephrectomy. MDCT correctly determines presence and size of all lesions<br />
when 1-mm source images are being evaluated on a dedicated work station (7). Comparison of largest tumor<br />
diameters between CT and gross pathologic examination in patients with non-metastatic RCC reveals that clinical and<br />
pathologic size correlate highly, and do not differ significantly (8).<br />
The difficulty of distinguishing between confinement of RCC to the true renal capsule and extracapsular tumor spread<br />
is reflected by controversial statements in current radiological literature. Accuracy of MDCT and MRI ranges between<br />
80% and 95% (7,9,10), such that both methods currently do not appear to be fully reliable. However, with classical<br />
resective surgery being challenged by radiofrequency ablation and other minimally invasive treatments that do not<br />
yield tissue for histo-pathological work-up, the validity of cross-sectional imaging results has become even more<br />
crucial.<br />
While differential diagnosis between RCC with renal vein (RV) extension and RCC with extension into the inferior vena<br />
cava (IVC) below or above the diaphragm challenges cross-sectional imaging, differential therapy challenges modern<br />
urologic surgery. MDCT and MRI are similarly capable of distinguishing between different levels of venous involvement<br />
with RCC tumor thrombus (11,12). As an additional cross-sectional imaging modality to follow CT in the differentiation<br />
of tumor thrombus extent in RCC, MRI performs similarly to ultrasonography (13). Surgical resection of RCC tumor<br />
thrombus above the diaphragm (TNM 2002 class T3c) previously required sternotomy and cardiopulmonary bypass<br />
(CPB). However, it has recently been demonstrated that surgical resection can be successfully performed through a<br />
transabdominal approach without CPB (14). Still, patient survival – and, thus, prognosis – after surgery for RCC with<br />
venous involvement is subject to controversy (15-17). In view of contradictory results of survival analysis in patients<br />
with RCC, it remains to be seen if TNM 2002 classes T3b and T3c need to be re-defined in the future.<br />
Extension of RCC beyond Gerota’s fascia may be a challenge to cross-sectional imaging when the fascia is barely<br />
transgressed. In such cases, resection of the fascia will probably be the only solution for the urologic surgeon.<br />
Metastasis in regional lymph nodes without synchronous distant metastasis is found in 10-15% of patients with RCC<br />
(5). Current cross-sectional imaging criteria for lymph nodes to be suspicious for metastasis include a short-axis<br />
diameter of 1 cm or more and loss of kidney-shape with a lymph node hilus that includes fat. Asymmetric grouping of<br />
three or more smaller lymph nodes may also be a sign of lymphatic tumor spread in the renal hilus. However, more<br />
than 50% of enlarged regional lymph nodes demonstrate at histopathology with hyperplastic or inflammatory change,<br />
only (5). Specificity of cross-sectional imaging for metastatic lymphadenopathy is poor (18).<br />
Metastasis of RCC to other organs is most frequently found in the lung (31%), followed by bone (15%), brain (8%),<br />
and liver (5%). However, any other organ can be involved (19). Agreement between MRI and surgical-pathologic<br />
staging has been shown to be good for M staging, with a kappa score of 0.66, for two independent reviewers,<br />
respectively (18).<br />
Conclusions<br />
It appears that TNM staging of renal cell carcinoma (RCC) evolves with the advancement of surgical techniques and<br />
will continue to evolve in the future. Cross-sectional imaging has greatly contributed to the diagnosis and staging of<br />
RCC. Both MDCT and MRI perform highly in T-staging of local tumor extent and M-staging of distant metastasis.<br />
However, both MDCT and MRI perform poorly in N-staging.<br />
References<br />
1. Rouviere O, Brunereau L, Lyonnet D, Rouleau P. [Staging and follow-up of renal cell carcinoma][Article in French] J<br />
Radiol 83 (2002) 805-822, discussion 823-824<br />
2. Sengupta S, Zincke H. Lessons learned in the surgical management of renal cell carcinoma. Urology 66 (2005)(5<br />
Suppl) 36-42<br />
3. Robson CJ. Radical nephrectomy for renal cell carcinoma. J Urol 89 (1963) 37-42<br />
4. Robson CJ, Churchill BM, Anderson W. The results of radical nephrectomy for renal cell carcinoma. J Urol 101<br />
(1969) 297-301<br />
5. Atzpodien J et al. Aktuelle Therapiestrategien beim Nierenzellkarzinom. Uni-Med Science Verlag, Bremen, London,<br />
Boston (2003)<br />
6. Hermanek P, Schrott KM. Evaluation of the new tumor, nodes and metastases classification of renal cell carcinoma.<br />
J Urol 144 (1990) 238-242<br />
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7. Catalano C, Fraioli F, Laghi A, Napoli A, Pediconi F, Danti M, Nardis P, Passariello R. High-resolution multidetector CT<br />
in the preoperative evaluation of patients with renal cell carcinoma. AJR Am J Roentgenol 180 (2003) 1271-1277<br />
8. Yaycioglu O, Rutman MP, Balasubramaniam M, Peters KM, Gonzalez JA. Clinical and pathologic tumor size in renal<br />
cell carcinoma; difference, correlation, and analysis of the influencing factors. Urology 60 (2002) 33-38<br />
9. Roy C Sr, El Ghali S, Buy X, Lindner V, Lang H, Saussine C, Jacqmin D. Significance of the pseudocapsule on MRI of<br />
renal neoplasms and its potential application for local staging: a retrospective study. AJR Am J Roentgenol 184 (2005)<br />
113-120<br />
10. Kamel IR, Hochman MG, Keogan MT, Eng J, Longmaid HE 3rd, DeWolf W, Edelman RR. Accuracy of breath-hold<br />
magnetic resonance imaging in preoperative staging of organ-confined renal cell carcinoma.J Comput Assist Tomogr<br />
28 (2004) 327-332<br />
11. Hallscheidt PJ, Fink C, Haferkamp A, Bock M, Luburic A, Zuna I, Noeldge G, Kauffmann G. Preoperative Staging of<br />
Renal Cell Carcinoma With Inferior Vena Cava Thrombus Using Multidetector CT and MRI: Prospective Study With<br />
Histopathological Correlation. J Comput Assist Tomogr 29 (2005) 64-68<br />
12. Lawrentschuk N, Gani J, Riordan R, Esler S, Bolton DM. Multidetector computed tomography vs magnetic<br />
resonance imaging for defining the upper limit of tumour thrombus in renal cell carcinoma: a study and review. BJU<br />
Int 96 (2005) 291-295<br />
13. Gupta NP, Ansari MS, Khaitan A, Sivaramakrishna MS, Hemal AK, Dogra PN, Seth A. Impact of imaging and<br />
thrombus level in management of renal cell carcinoma extending to veins. Urol Int 72 (2004) 129-134<br />
14. Ciancio G, Soloway MS. Renal cell carcinoma with tumor thrombus extending above diaphragm: avoiding<br />
cardiopulmonary bypass. Urology 66 (2005) 266-270<br />
15. Zini L, Haulon S, Decoene C, Amara N, Villers A, Biserte J, Leroy X, Koussa M. Renal cell carcinoma associated with<br />
tumor thrombus in the inferior vena cava: surgical strategies. Ann Vasc Surg 19 (2005) 522-528<br />
16. Jibiki M, Iwai T, Inoue Y, Sugano N, Kihara K, Hyochi N, Sunamori M. Surgical strategy for treating renal cell<br />
carcinoma with thrombus extending into the inferior vena cava. J Vasc Surg 39 (2004) 829-835<br />
17. Kaplan S, Ekici S, Dogan R, Demircin M, Ozen H, Pasaoglu I. Surgical management of renal cell carcinoma with<br />
inferior vena cava tumor thrombus.Am J Surg 183 (2002) 292-299<br />
18. Ergen FB, Hussain HK, Caoili EM, Korobkin M, Carlos RC, Weadock WJ, Johnson TD, Shah R, Hayasaka S, Francis<br />
IR. MRI for preoperative staging of renal cell carcinoma using the 1997 TNM classification: comparison with surgical<br />
and pathologic staging. AJR Am J Roentgenol 182 (2004) 217-225<br />
19. Rohde V. Nierenzellkarinom. In: Schmelz HU, Sparwasser C, Weidner W (eds.) Facharztwissen Urologie. Springer<br />
Medizin Verlag, Heidelberg (2006) pp. 146-158<br />
SMALL RENAL MASSES/ HOW TO DEAL WITH THESE<br />
Cova M.<br />
Department of Radiology, University of Trieste – Italy<br />
Modern diagnostic imaging of renal masses uses ultrasonography, computed tomography and magnetic resonance<br />
imaging. The new imaging methods, expecially the cross-sectional imaging, have increased the detection rate of<br />
incidental renal masses, posing some problems as to the characterization and management strategy (1). Most of the<br />
incidental renal masses can be easily characterized, without further testing. However some masses, expecially the<br />
small ones, remain undeterminate.<br />
Small renal masses can be cystic or solid. Considering cystic masses, ultrasound is considered definitive only when<br />
identifying a renal mass as a simple cyst. The main problem in characterizing cystic renal masses with US is the<br />
presence of thick septae, calcification, wall tickening, solid components an internal echoes. Contrast media have<br />
recently been suggested as an important aid for evaluating complex cystic masses by US (2). However, most<br />
radiologists recommend that complex cystic masses detected on ultrasound are to be evaluated subsequently with CT<br />
or MRI.<br />
The management of cystic masses is guided by the Bosniak classification, which distinguishes cysts in five categories<br />
according to their likehood of being malignant (3). Bosniak classification was originally designed only for use with CT;<br />
however, it has been recently stated that it can be applied also to MRI.<br />
Category I masses are benign, simple cysts, with hairline-thin wall, water attenuation, no enhancement: these lesions<br />
represent the most common renal masses detected by imaging.<br />
Category II masses are benign, minimally complicated cysts; these masses may contain few hairline-thin septa which<br />
may enhance (not measurably) and may present fine calcification or a short segment of slightly thickened calcification<br />
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.<br />
Category III lesions are truly indeterminate renal masses; They present thickened irregular or smooth walls and/or<br />
septa that demonstrate measurable enhancement.<br />
Category IV includes clearly malignant masses that can present all the criteria of category III lesions, but also contain<br />
distinct enhancing soft-tissue components independent of the wall or septa.<br />
Size is not an important feature on Bosniak classifications, as small cystic masses may be malignant and large ones<br />
may be benign. Hovewer, small cystic renal masses (particularly the ones smaller than 1-2 cm) are more likely to be<br />
benign, expecially if they do not show other features than low attenuation on CT. These lesions used to be problematic<br />
in the past because they could not be imaged well enough to assess their features, such as the presence of septations,<br />
nodularity, calcifications, or enhancement, but this problem has been overcome today, particularly with the use of<br />
multidetector CT and protocols with thin collimations (4). Therefore lesions under 1 cm that appear to be simple cysts,<br />
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<br />
increase the risk of surgical exploration. Category IV lesions require surgery.<br />
Considering solid renal masses, in adults solitary solid renal masses found at imaging are mostly renal cell carcinomas.<br />
However, a significant fraction of solid renal masses are benign. There is a direct relationship between malignancy<br />
and size of the mass: the smaller the renal masses, the greater the percentage of benign causes. There are limited<br />
data regarding the natural history of small renal cell carcinoma. It has been demonstrated that patients with<br />
incidentally discovered renal cell carcinoma have a better prognosis than patients with symptoms (hematuria, flank<br />
pain, mass) attributable to renal tumor (5, 6). In fact, most incidentally detected tumors, due to their small size, are<br />
stage T1 or T2, without local infiltration or metastases in almost all cases. On US, small renal tumors are usually<br />
slightly hyperechoic, isoechoic, hypoechoic or mixed. Harmonic imaging enables an easier detection of isoechoic<br />
tumors and improves the differentiation between cysts and tumors; furthermore, a better characterization of mixed<br />
lesion is also possible. Color Doppler is also useful in the characterization of small renal tumors. The increased color<br />
Doppler sensitivity of latest generation color Doppler equipments enables an excellent detection of normal renal<br />
vessels and the detection of tumor vessels. The vascular pattern of renal cell carcinoma consists of both tumoral<br />
vessels inside and around the lesion (7) and is quite different from that of angiomyolipoma. However, similarities with<br />
the vascular pattern of oncocytoma are described. Therefore the contribution in the differential diagnosis between<br />
benign and malignant renal tumor is limited. Color Doppler is useful in the differential diagnosis between tumors and<br />
pseudotumors and in the differential diagnosis between tumors and atypical cysts.<br />
The contribution of US contrast gents in the diagnosis of small renal tumors is still under evaluation (8). High<br />
mechanical index destructive techniques may reveal early contrast enhancement in malignant renal masses. Low<br />
mechanical index continuous imaging may reveal renal masses peripheral and intranodular microvessels.<br />
In spite of the technological improvements of CT, limitations still exist expecially as far as differential diagnosis is<br />
concerned. The differential diagnosis with benign renal tumors such as angiomyolipoma is based on the recognition of<br />
fat within a non calcified renal mass at unenhanced CT. However, about 5% of these tumors contain little or no fat and<br />
appear as a small, hyperattenuating (at unenanced CT), homogeneously enhancing masses (9, 10); therefore, these<br />
cases can not be diagnosed with CT, as they are indistinguishable from a small renal cell carcinoma. In these cases,<br />
rather than presume that the mass is a renal cell carcinoma, it is preferable to further evaluate it with MR imaging.<br />
The MR imaging appearance of clear cell renal cell carcinoma is typically different from that of angiomyolipoma with<br />
minimal fat: clear cell renal carcinoma is typically hyperintense on T2 weighted images, while angiomyolipoma with<br />
minimal fat is typically hypointense on T2 weighted images. However, papillary renal cell carcinoma has the same<br />
features of angiomyolipoma with minimal fat, both appering hypointense on T2 weighted images. Percutaneous biopsy<br />
is the only way to distinguish them (11).<br />
Similar difficulties exist for oncocytoma whose incidence seems to be increased with the increased detection of small<br />
renal masses. Oncocytomas are readily diagnosed with MRI and above all with CT when the lesion shows the wellknown<br />
pattern of a central stellate scar. This pattern is however typical of the larger lesions and rarely seen in the<br />
smaller ones. Moreover, a renal carcinoma may also present a low density central area. Therefore this feature cannot<br />
be considered a fully reliable sign.<br />
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-<br />
31<br />
Zagoria R.J.<br />
Wake Forest University School of Medicine, USA<br />
ABLATION OF RENAL TUMORS<br />
Learning Objectives:<br />
1. To describe the techniques used for renal tumor ablations.<br />
2. To report on the results available from personal experience and from the literature.<br />
3. To compare the results with the results of medical and surgical treatments.<br />
Abstract:<br />
Techniques used for ablation of renal tumors includes radiofrequency (RFA), cryoablation, and microwave ablation.<br />
The techniques used in performing these procedures will be discussed and explained. The advantages of each<br />
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<br />
nephrectomy for a benign lesion, recent reports have advocated the use of percutaneous biopsy in an effort to reduce<br />
the number of surgical resections. Unfortunately, for the reasons stated above, the results, if benign, do not clearly<br />
and definitively rule out a malignancy. These patients need to be imaged yearly or biannually to establish stability of<br />
the lesion(s) or a change that may support surgical intervention. Thus, a biopsy in this group of patients is not a<br />
proven or recommended indication.<br />
The literature reveals controversies in the use of fine needle versus core type biopsy in the evaluation of solid renal<br />
masses. Though usually a cytological<br />
specimen allows for an adequate diagnosis, a core biopsy may sometimes yield better results as it obtains larger<br />
amounts of tissue. Adequate imaging of the target and guidance of the needle are of enormous importance in the<br />
performance of an adequate biopsy. As always, the choice of imaging modality depends on the preference of the<br />
person performing the procedure. Overall, percutaneous biopsy of focal renal lesions is safe; complications from the<br />
procedure (most often bleeding, vascular injuries/AVF or pseudoaneurysm, injuries to adjacent organs) are acceptably<br />
low.<br />
In the coming years, improvements and wide acceptance of newer lesion targeting and tissue handling techniques will<br />
result in better understanding of the indications fro renal lesion biopsies and patient outcomes. For the time being,<br />
high quality imaging correctly identifies and characterizes most discovered renal lesions. In selected patients,<br />
percutaneous needle biopsy helps to optimize treatment and long term outcomes.<br />
BIBLIOGRAPHY:<br />
Herts BR, Baker ME: The current role of percutaneous biopsy in the evaluation of renal masses. Semin Urol Oncol<br />
1995;13:254.<br />
Frank I, Blute ML, Cheville JC, Lohse CM, Weaver AL, Zincke H: Solid renal tumors: an analysis of pathological features<br />
related to tumor size. J Urol 2003:170:2217.<br />
Silverman SG, Gan YU, Mortele KJ, Tuncali K, Cibas ES: Renal mass biopsy in the new millennium: An important<br />
diagnostic procedure. Genitourinary Radiology Categorical Course Syllabus; RSNA 2006:219<br />
Lang EK, Macchia RJ, Gayle B, et al: CT-guided biopsy of indeterminate renal cystic masses (BosniaK 3 and 2F):<br />
accuracy and impact on clinical management. Eur Radiol 2002;12:2518<br />
Kim JK, Park SY, Shon JH, Oho KS: Angiomyolipoma with minimal fat: differentiation from renal cell carcinoma at<br />
biphasic helical CT. Radiology 2004;230:677<br />
Kassouf W, Aprikian AG, Laplante M, Tanguay S: Natural history of renal masses followed expectantly. J Urol<br />
2004;171:111<br />
Liu J, Fanning CV: Can renal oncocytomas be distinguished from renal cell carcinoma on fine-needle aspiration<br />
specimens A study of conventional smears in conjunction with ancillary studies. Cancer 2001;93:390<br />
Taavitsainen M, Krogerus L, Rannikko S: Aspiration biopsy in renal angiomyolipoma. Acta Radiol 1989;30:381<br />
MALE GENITALIA<br />
Moderators: Pavlica P. (IT) – Dalla-Palma L. (IT)<br />
SCROTAL MASSES<br />
Oyen R.H., De Wever L.L.<br />
Department of Radiology, University Hospitals Leuven, Belgium<br />
Ultrasound (US) remains the key-modality for the evaluation of the scrotal content. US enables to answer to all<br />
relevant questions: (a) is there a mass (b) is it a testicular or extratesticular mass (reported sensitivity 98-100%),<br />
(c) is it unilateral or bilateral, and (d) to some extent, to characterize the nature. Magnetic resonance imaging (MRI) is<br />
indicated in highly selected patients only, when there is discrepancy with US and/or clinical findings, with equivocal US<br />
and with diffuse (bulky) testicular/scrotal neoplasia. It is estimated that in routine practice MR would be contributive in<br />
approximately 5% of scrotal mass lesions.<br />
Most testicular tumors present as a palpable mass, but not all palpable masses are malignant tumors, nor are all<br />
intratesticular lesions palpable.<br />
In general, solid intratesticular mass lesions must be considered as malignant masses; cystic lesions are almost always<br />
benign with only few exceptions. A histological diagnosis of solid testicular mass lesions cannot be achieved. Color-<br />
Doppler is not beneficial for lesion characterization. However, intralesional ‘crossing’ blood vessels is almost exclusively<br />
seen in malignant lesions. Seminomas present most often as nodular or multinodular hypoechoic masses. Non<br />
seminomatous germ cell tumors (NSGCT) are commonly heterogeneous even when they are small, and frequently<br />
show cystic or calcified parts with alternating hypo- and hyperechoic areas. Furthermore, since most NSCGT are mixed<br />
tumors, the appearance at US is widely variable.<br />
In men with retroperitoneal lymph node metastases from unknown origin, scrotal US is indicated. In some cases, the<br />
testicular primary tumor may be shrunken, fibrotic and calcified (i.e. burned-out lesion).<br />
Gonadal stromal tumors account for approximately 3% to 6% of all testicular neoplasms (more than 2/3 are Leydig<br />
cell tumors), and over 90% are benign. Leydig cell tumors can present with symptoms related to hormonal activity<br />
(gynecomastia, pseudopubertas precox, reduced libibo and infertility). They are most frequently small and occasionally<br />
bilateral.<br />
Testicular lymphoma, leukemia and metastases are rare and based on imaging indiscernable from germ cell tumors.<br />
Lymphoma is one of the most common neoplasms in men aged over 50, and often with bilateral synchronous or<br />
metachronous involvement in 8.5%-18% of cases. The epididymis and spermatic cord are frequently involved.<br />
Leukema is rare, but frequently recurs in the testis, particularly in children. Metastatic involvement of the testis by<br />
other cancers does occur. The most common primary sites include the prostate, lung, gastrointestinal tract, skin and<br />
kidney, but others have also been reported (including pancreas, bladder, thyroid, neuroblastoma, schwannoma,<br />
retinoblastoma).<br />
90
Risk factors for testicular tumors include prior testicular tumor, relatives of 1 st degree, infertility, intersex syndromes,<br />
testicular microlithiasis (TML), and cryptorchidism. Solitar or isolated (fewer than 5) intratesticular calcifications are a<br />
frequent (benign) finding at routine scan (not visible at MRI !). More than 5 microcalcifications are worysome. TML is<br />
considered to express in dysgenetic gonads, and is, therefore, associated with cryptorchydism, infertility, Kinefelter<br />
syndrome, atrophy and testicular tumors. Annual review with US is recommended in men with TML and associated risk<br />
factors; in men with no additional risk factors, surveillance is not warranted. Monthly self examination should be<br />
strongly advocated, as indeed to all men.<br />
A growing challenge is the incidental detection of focal or multifocal, hypoechoic, solid, small-sized (subcentimetric)<br />
lesions. Such lesions tend to be more frequently found in hypofertile men, indeed more often referred for scrotal US.<br />
They are often benign Leydig-cell nodules but malignancy can not be excluded. When solitary, ultrasound-assisted<br />
testis sparing surgery with intraoperative frozen sections is an option.<br />
Many benign testicular lesions may mimick malignant tumors. Surgery must be avoided in the majority of cases. The<br />
incidence of testicular cysts increases with age; cysts in the rete testis have a typical location (mediastinum), are often<br />
bilateral and associated with spermatocoele. A rounded mass with concentric layering is typical of the benign<br />
epidermoid cyst. Testis sparing surgery is justified. Adrenal rests can be entrapped in the testes in congenital adrenal<br />
hyperplasia and Cushing syndrome; surgery should be avoided.<br />
Men with segmental testicular infarction, hematoma are symptomatic (acute pain, trauma), and careful follow-up<br />
ultrasound studies may be the appropriate strategy.<br />
Inguinal hernias are among the most common paratesticular masses. Paratesticular tumors are not as infrequent as<br />
generally thought. They are primarily seen in older patients and the vast majority are benign. Adenomatoid tumor of<br />
the epididymis is the most frequent presenting as a smooth, round and well-circumbscirbed isoechoic or hyperechoic<br />
homogeneous mass. Other solid epididymal mass lesions include sperm granulomas or chronic (granulomatous)<br />
epididymitis. Epididymal cysts can become very large, thus mimicking hydrocele. Papillary cystadenomas deserve a<br />
special mention due to their association with von Hippel-Lindau disease, especially when bilateral.<br />
Malignant extratesticular and extraepididymal tumors are extremely rare in adults. Most often these masses are<br />
lipomas, liposarcomas or inflammatory masses. The tunica vaginalis may give rise to mesotheliomas. 15-20% are<br />
benign; malignant mesotheliomas are highly aggressive cancers.<br />
Take home messages:<br />
1. To stress that ultrasound is the preferred modality to assess scrotal masses.<br />
2. To identify common and unusual tumors, and to recognise some features allowing characterization.<br />
3. To recognise the most common pseudotumors.<br />
4. To illustrate the feasibility of sparing testis surgery in selected cases as in hypofertile men.<br />
Suggested Reading<br />
Isidori AM, Lenzi A. Scrotal ultrasound: Morphological and Functional Atlas. 2008. Forum Service Editore Genova Italy<br />
US MR imaging correlation in pathologic conditions of the scrotum. Kim W, Rosen MA, Langer JE, Banner MP,<br />
Siegelman ES, Ramchandani P. Radiographics. 2007 Sep-Oct;27(5):1239-53. Review.<br />
Imaging of testicular germ cell tumours. Dalal PU, Sohaib SA, Huddart R. Cancer Imaging. 2006 Sep 7;6:124-34.<br />
Imaging of the epididymis. Lee JC, Bhatt S, Dogra VS. Ultrasound Q. 2008 Mar;24(1):3-16. Review.<br />
Imaging of testicular germ cell tumours. Dalal PU, Sohaib SA, Huddart R. Cancer Imaging. 2006 Sep 7;6:124-34.<br />
The role of imaging in the diagnosis, staging, and management of testicular cancer. Sohaib SA, Koh DM, Husband JE.<br />
AJR Am J Roentgenol. 2008 Aug;191(2):387-95. Review.<br />
Leydig cell tumors of the testis: gray scale and colour-Doppler sonographic appearance. Maizlin ZV, Belenky A,<br />
Kunichezky M, Sandbank J Strauss S. J Ultrasound Med. 2004; 23(7): 959-964<br />
Testicular lymphoma: an update for clinicians. Verma N, Lazarchick J, Gudena V, Turner J, Chaudhary UB. Am J Med<br />
Sci. 2008 Oct;336(4):336-41. Review.<br />
Primary testicular non-Hodgkin's lymphoma--a review article. Bhatia K, Vaid AK, Gupta S, Doval DC, Talwar V. Sao<br />
Paulo Med J. 2007 Sep 6;125(5):286-8. Review.<br />
Imaging diagnosis of testicular lymphoma. Liu KL, Chang CC, Huang KH, Tsang YM, Chen SJ. Abdom Imaging. 2006<br />
Sep-Oct;31(5):610-2. Epub 2006 Feb 7.<br />
Metastatic prostatic carcinoma to testis: histological features mimicking lymphoma. Haupt B, Ro JY, Ayala AG, Zhai J.<br />
Int J Clin Exp Pathol. 2009;2(1):104-7. Epub 2008 May 10.<br />
Metastatic carcinoma to the testis: a clinicopathologic analysis of 26 nonincidental cases with emphasis on deceptive<br />
features. Ulbright TM, Young RH. Am J Surg Pathol. 2008 Nov;32(11):1683-93.<br />
Carcinoid tumours of the testis. Stroosma OB, Delaere KP. BJU Int. 2008 May;101(9):1101-5. Epub 2008 Jan 8.<br />
Review.<br />
91
Testicular microlithiasis: prevalence and risk of concurrent and interval development of testicular tumor in a referred<br />
population. Ahmad I, Krishna NS, Clark R, Nairn R, Al-Saffar N. Int Urol Nephrol. 2007;39(4):1177-81. Epub 2007 Jun<br />
30.<br />
Testicular microlithiasis as a familial risk factor for testicular germ cell tumour. Coffey J, Huddart RA, Elliott F, Sohaib<br />
SA, Parker E, Dudakia D, Pugh JL, Easton DF, Bishop DT, Stratton MR, Rapley EA. Br J Cancer. 2007 Dec<br />
17;97(12):1701-6. Epub 2007 Oct 30.<br />
How worrisome is testicular microlithiasis Costabile RA. Curr Opin Urol. 2007 Nov;17(6):419-23. Review.<br />
Current management strategies for testicular microlithiasis. Jaganathan K, Ahmed S, Henderson A, Rané A. Nat Clin<br />
Pract Urol. 2007 Sep;4(9):492-7. Review.<br />
Testicular microlithiasis and carcinoma in situ overview and proposed clinical guideline. van Casteren NJ, Looijenga LH,<br />
Dohle GR. Int J Androl. 2008 Dec 16. [Epub ahead of print]<br />
Testicular calcification and microlithiasis: association with primary intra-testicular malignancy in 3,477 patients. Miller<br />
FN, Rosairo S, Clarke JL, Sriprasad S, Muir GH, Sidhu PS. Eur Radiol. 2007 Feb;17(2):363-9. Epub 2006 May 18.<br />
Grading of classical testicular microlithiasis has no effect on the prevalence of associated testicular tumors. Sanli O,<br />
Kadioglu A, Atar M, Acar O, Nane I, Kadioglu A. Urol Int. 2008;80(3):310-6. Epub 2008 May 14.<br />
Testicular Microlithiasis Preceding Metastatic Mixed Germ Cell Tumor-First Pediatric Report and Recommended<br />
Management of Testicular Microlithiasis in the Pediatric Population. Slaughenhoupt B, Kadlec A, Schrepferman C.<br />
Urology. 2008 Dec 17. [Epub ahead of print]<br />
Increased prevalence of testicular microlithiasis in men with familial testicular cancer and their relatives. Korde LA,<br />
Premkumar A, Mueller C, Rosenberg P, Soho C, Bratslavsky G, Greene MH. Br J Cancer. 2008 Nov 18;99(10):1748-53.<br />
Epub 2008 Oct 7.<br />
Testicular microlithiasis: our experience of 10 years. Lam DL, Gerscovich EO, Kuo MC, McGahan JP. J Ultrasound Med.<br />
2007 Jul;26(7):867-73.<br />
Association between testicular microlithiasis and primary malignancy of the testis: our experience and review of the<br />
literature. Parenti GC, Zago S, Lusa M, Campioni P, Mannella P. Radiol Med. 2007 Jun;112(4):588-96. Epub 2007 Jun<br />
11. English, Italian.<br />
Testicular microlithiasis: what does it mean clinically Dagash H, Mackinnon EA. BJU Int. 2007 Jan;99(1):157-60. Epub<br />
2006 Oct 9. Review.<br />
A 5-year followup study of asymptomatic men with testicular microlithiasis. DeCastro BJ, Peterson AC, Costabile RA. J<br />
Urol. 2008 Apr;179(4):1420-3; discussion 1423. Epub 2008 Mar 4.<br />
Testicular microlithiasis identified ultrasonographically in Japanese adult patients: prevalence and associated<br />
conditions. Sakamoto H, Shichizyou T, Saito K, Okumura T, Ogawa Y, Yoshida H, Kushima M. Urology. 2006<br />
Sep;68(3):636-41. Epub 2006 Sep 18.<br />
Cancer risk in male factor-infertility. Negri L, Benaglia R, Fiamengo B, Pizzocaro A, Albani E, Levi Setti PE. Placenta.<br />
2008 Oct;29 Suppl B:178-83. Epub 2008 Aug 27.<br />
Early testicular cancer: a problem in an infertility clinic. Phillips N, Jequier AM. Reprod Biomed Online. 2007<br />
Nov;15(5):520-5.<br />
High prevalence of testicular cancer in azoospermic men without spermatogenesis. Mancini M, Carmignani L, Gazzano<br />
G, Sagone P, Gadda F, Bosari S, Rocco F, Colpi GM. Hum Reprod. 2007 Apr;22(4):1042-6. Epub 2007 Jan 12.<br />
Management of incidental impalpable intratesticular masses of < or = 5 mm in diameter. Müller T, Gozzi C, Akkad T,<br />
Pallwein L, Bartsch G, Steiner H. BJU Int. 2006 Nov;98(5):1001-4. Epub 2006 Sep 6.<br />
92
Conservative management of testicular germ-cell tumors. Oliver T. Nat Clin Pract Urol. 2007 Oct;4(10):550-60.<br />
Review.<br />
Carefully selected intratesticular lesions can be safely managed with serial ultrasonography. Connolly SS, D'Arcy FT,<br />
Gough N, McCarthy P, Bredin HC, Corcoran MO. BJU Int. 2006 Nov;98(5):1005-7; discussion 1007.<br />
Organ-sparing microsurgical resection of incidental testicular tumors plus microdissection for sperm extraction and<br />
cryopreservation in azoospermic patients: surgical aspects and technical refinements. Hallak J, Cocuzza M, Sarkis AS,<br />
Athayde KS, Cerri GG, Srougi M. Urology. 2009 Apr;73(4):887-91; discussion 891-2. Epub 2009 Feb 8.<br />
Commentary on Incidental testicular lesions found during infertility evaluation are usually benign and may be managed<br />
conservatively Eifler JB, King P, Schlegel PN, Brady Urology Foundation, Department of Urology, Weill Cornell Medical<br />
College, New York Presbyterian Hospital, New York, NY.Richie JP. Urol Oncol. 2009 Mar-Apr;27(2):223.<br />
Testicular lesions other than germ cell tumours: feasibility of testis-sparing surgery. Passman C, Urban D, Klemm K,<br />
Lockhart M, Kenney P, Kolettis P. BJU Int. 2009 Feb;103(4):488-91. Epub 2008 Sep 12.<br />
Nine cases of nonpalpable testicular mass: an incidental finding in a large scale ultrasonography survey. Avci A, Erol B,<br />
Eken C, Ozgok Y. Int J Urol. 2008 Sep;15(9):833-6. Epub 2008 Jul 24.<br />
Ultrasound-guided core-needle biopsy of the testis for focal indeterminate intratesticular lesions. Soh E, Berman LH,<br />
Grant JW, Bullock N, Williams MV. Eur Radiol. 2008 Dec;18(12):2990-6. Epub 2008 Jul 19.<br />
"Burned out" phenomenon of the testis in retroperitoneal seminoma. Curigliano G, Magni E, Renne G, De Cobelli O,<br />
Rescigno M, Torrisi R, Spitaleri G, Pietri E, De Braud F, Goldhirsch A. Acta Oncol. 2006;45(3):335-6. No abstract<br />
available.<br />
Retroperitoneal seminoma with 'burned out' phenomenon in the testis. Perimenis P, Athanasopoulos A, Geraghty J,<br />
Macdonagh R. Int J Urol. 2005 Jan;12(1):115-6.<br />
'Burned-out' primary testicular cancer. Fabre E, Jira H, Izard V, Ferlicot S, Hammoudi Y, Theodore C, Di Palma M,<br />
Benoit G, Droupy S. BJU Int. 2004 Jul;94(1):74-8.<br />
Imaging of burned-out testis tumor: five new cases and review of the literature. Tasu JP, Faye N, Eschwege P, Rocher<br />
L, Bléry M. J Ultrasound Med. 2003 May;22(5):515-21. Review.<br />
Sonographic and magnetic resonance imaging appearance of a burned-out testicular germ cell neoplasm. Patel MD,<br />
Patel BM. J Ultrasound Med. 2007 Jan;26(1):143-6. No abstract available.<br />
Conservative surgical therapy for leydig cell tumor. Carmignani L, Colombo R, Gadda F, Galasso G, Lania A, Palou J,<br />
Algaba F, Villavicencio H, Colpi GM, Decobelli O, Salvioni R, Pizzocaro G, Rigatti P, Rocco F. J Urol. 2007<br />
Aug;178(2):507-11; discussion 511. Epub 2007 Jun 11.<br />
Cystic dysplasia of the rete testis. Smith PJ, DeSouza R, Roth DR. Urology. 2008 Jul;72(1):230.e7-10. Epub 2008 Mar<br />
3<br />
Epidermoid cyst of the testis. Mak CW, Chen CY, Tzeng WS, Li CF. Australas Radiol. 2007 Oct;51 Spec No.:B74-6.<br />
Sonographic and MR imaging findings of testicular epidermoid cysts. Cho JH, Chang JC, Park BH, Lee JG, Son CH. AR.<br />
2002 178(3):743-748<br />
Synchronous epidermoid cyst and mature teratoma of the testis: an unusual association. Huyghe E, Mazerolles C,<br />
Moran C, Khedis M, Khoury E, Nohra J, Soulié M, Plante P. Urol Int. 2007;78(4):364-6<br />
Testicular adrenal rests in a patient with congenital adrenal hyperplasia: US and MRI features. Fitoz S, Atasoy C,<br />
Adiyaman P, Berberoglu M, Erden I, Ocal G. Comput Med Imaging Graph. 2006 Dec;30(8):465-8.<br />
Segmental testicular ischaemia: presentation, management and follow-up. Gianfrilli D, Isidori AM, Lenzi A. Int J<br />
Androl. 2008 May 22. [Epub ahead of print]<br />
93
Bilateral testicular infarction and orchiectomy as a complication of polyarteritis nodosa. Stroup SP, Herrera SR, Crain<br />
DS. Rev Urol. 2007 Fall;9(4):235-8.<br />
Segmental testicular infarction: conservative management is feasible and safe. Madaan S, Joniau S, Klockaerts K,<br />
DeWever L, Lerut E, Oyen R, Van Poppel H. Eur Urol. 2008 Feb;53(2):441-5. Epub 2007 Mar 28.<br />
Clinical and ultrasound features of segmental testicular infarction: six-year experience from a single centre. Bilagi P,<br />
Sriprasad S, Clarke JL, Sellars ME, Muir GH, Sidhu PS. Eur Radiol. 2007 Nov;17(11):2810-8. Epub 2007 Jul 5.<br />
Idiopathic testicular infarction initially masquerading as urolithiasis and epididymitis. Huang CC, Wen YS. Am J Emerg<br />
Med. 2007 Jul;25(6):736.e1-2. No abstract available.<br />
Clinical and ultrasound features of segmental testicular infarction: six-year experience from a single centre. Bilagi P,<br />
Sriprasad S, Clarke JL, Sellars ME, Muir GH, Sidhu PS. Eur Radiol. 2007 Nov;17(11):2810-8. Epub 2007 Jul 5.<br />
Idiopathic testicular infarction initially masquerading as urolithiasis and epididymitis. Huang CC, Wen YS. Am J Emerg<br />
Med. 2007 Jul;25(6):736.e1-2. No abstract available.<br />
Segmental testicular infarction. Conservative management is feasible and safe: part 2. Madaan S, Joniau S, Klockaerts<br />
K, DeWever L, Lerut E, Oyen R, Van Poppel H. Eur Urol. 2008 Mar;53(3):656-8. Review. No abstract available.<br />
Intratesticular haematoma: differentiation from tumour on clinical history and ultrasound appearances in two cases.<br />
Purushothaman H, Sellars ME, Clarke JL, Sidhu PS. Br J Radiol. 2007 Aug;80(956):e184-7.<br />
Intrascrotal involvement of sarcoidosis presenting like testicular appendices. Obinata D, Yamaguchi K, Hirano D,<br />
Fuchinoue A, Nemoto N, Takahashi S. Int J Urol. 2007 Jan;14(1):87-8.<br />
Leiomyoma of the testis: a rare testicular mass. O'Brien J, Loftus B, Barrett C, Torreggiani W. J Clin Ultrasound. 2008<br />
May;36(4):240-2<br />
Multimodality imaging of paratesticular neoplasms and their rare mimics. Akbar SA, Sayyed TA, Jafri SZ, Hasteh F,<br />
Neill JS. Radiographics. 2003; 23(6): 1461-1476<br />
ACUTE SCROTUM<br />
Bertolotto M.<br />
Dept Radiology, University of Trieste, Ospedale di Cattinara, Italy<br />
Acute scrotum is the most common urologic emergency and may present a diagnostic challenge even to the most<br />
experienced clinicians. Epididymo-orchitis, torsion of appendages, and testicular torsion are the most important<br />
causes; other pathological conditions, however, may enter in the differential diagnosis. In patients with acute scrotal<br />
pain the main goal for the imaging is to differentiate surgical conditions from those who would benefit from<br />
conservative management alone. Gray scale and color Doppler ultrasound help suggest specific diagnosis.<br />
Epididymo-orchitis, representing at least 75% of all inflammatory scrotal disease processes, is the most common<br />
cause of acute scrotal pain in adult [1]. Isolated orchitis, funicolitis, and other inflammatory conditions are less<br />
common. Complications of scrotal inflammation include abscess, testicular ischemia, and pyocele formation.<br />
In patients with epididymo-orchitis the epididymis is enlarged at grey-scale ultrasound, usually hypoechoic with<br />
heterogeneous echotexture. Associated signs of inflammation such as reactive hydrocele or pyocele and scrotal skin<br />
thickening are often present [2]. In diffuse orchitis the testis is usually enlarged, with reduced echogenicity and with<br />
inhomogeneous echo pattern. Hypervascularity at color Doppler interrogation is a well-established diagnostic criterion<br />
for inflammation and may be the only imaging finding of epididymo-orchitis in some men where symptoms are lacking<br />
and gray-scale ultrasound is normal [3]. In early inflammation, isolated funiculitis can be occasionally recognized as<br />
hypervascularization of the spermatic cord with normal epididymis and testis. More often, hypervascularization<br />
involves also the tail of the epididymis, and then progresses to the epididymal head and to the testis. Waveform<br />
analysis may reveal low-resistance flows of the epididymal vessels [4].<br />
Focal orchitis may result from hematogenous or lymphatics dissemination. More often, however, infection spreads<br />
from the adjacent epididymis. In the former cases, the inflammatory process usually presents as ill defined lesions<br />
with variable echogenicity mimicking a testicular mass. Color Doppler interrogation often reveals increased vascularity<br />
[3]. In patients with negative serum tumour markers clinical symptoms such as fever and increased white blood cell<br />
count strongly would suggest an infectious process. In focal orchitis spreading from the epididymis inflammatory<br />
changes are predominantly found at the testicular hilum. They usually presents with a crescent shaped hypoechoic<br />
area within the testis, adjacent to the enlarged epididymis, showing hypervascularization at color Doppler<br />
interrogation.<br />
In patients with postinflammatory ischemia producing severe testicular swelling and edema venous outflow obstruction<br />
may occur. Vascularity of the affected testis is reduced compared with the contralateral testis, and high resistance<br />
arterial flows, or diastolic flow reversal, are recorded in the testicular arteries at color Doppler interrogation. These<br />
findings can be recognized also in patients with partial testicular torsion.<br />
94
Scrotal abscesses present at ultrasound with irregular walls, through transmission, and low-level internal echoes, or<br />
as heterogeneously hypoechoic lesions lacking vascularization at color Doppler interrogation. They have often<br />
hypervascular margins [5]. An abscess can rupture through the tunica vaginalis and produce a pyocele and even a<br />
fistula to the overlying skin [2].<br />
Pyocele appears echogenic at ultrasound, with mobile echoes, internal septations and fluid-fluid levels, or as a<br />
complex, heterogeneous fluid collection with thickened or irregular internal septations. It is usually associated to<br />
scrotal edema. Gas may be present. Color Doppler imaging often reveals increased vascularity of the scrotal wall.<br />
Testicular torsion is one of the most common cause of acute scrotal pain in children, with an annual incidence of 1/<br />
4000 in males younger than 25 years [6]. Intravaginal torsion, caused by a congenital malformation of the processus<br />
vaginalis, accounts for 90% of cases. Appendix testis and epididymis are remnants of embryological ducts. Torsion of<br />
the appendix testis is more frequent, and accounts for 20% to 40% of acute scrotal pain in child [7], while in adult<br />
this condition is less common. Isolated torsion of the epididymis and spermatocele torsion are extremely rare.<br />
Segmental testicular infarction is rare, with fewer than 50 cases reported since 2007 [8].<br />
In patients with testicular torsion ultrasound findings vary with the duration and degree of rotation of the spermatic<br />
cord [3]. Gray-scale images are nonspecific and often appear normal if the torsion has just occurred. Testicular<br />
swelling and decreased echogenicity are the most commonly encountered findings 4–6 hours after the onset of torsion.<br />
With the proceding of the time, the testis shows a progressive heterogeneous echotexture secondary to vascular<br />
congestion, hemorrhage, and infarction. At this time, a mild hydrocele is generally observed. After 24-36 hours the<br />
testis is markedly hypoechoic, usually with anechoic and patchy hyperechoic areas due to colliquative and hemorragic<br />
infarction [3]. The decrease in size begins after 30-40 days and leads to a small shrunken testis after 3-6 months. An<br />
enlarged hypoechoic epididymal head may be visible because the deferential artery supplying the epididymis is often<br />
involved in the torsion.<br />
The role of color Doppler ultrasound in the diagnosis of acute testicular torsion is well established [3, 9-11]. The testis<br />
is avascular, or markedly hypovascular, depending on the degree of twisting, while the rest of the scrotal blood flow is<br />
preserved, though the epididymis does become relatively ischemic. Within a few hours, the paratesticular tissues and<br />
the scrotal wall become hyperemic in an attempt to open collaterals. By using the absence of identifiable intratesticular<br />
flow as the only criterion for detecting torsion, color Doppler ultrasound was 86% sensitive, 100% specific, and 97%<br />
accurate in the diagnosis of torsion in patients with painful scrotum [12].<br />
The ability of color Doppler ultrasound to show incomplete or partial torsion remains problematic. Arterial testicular<br />
flows can be present, principally near the hilum but occasionally also in a more peripheral distribution, with variable<br />
waveform characteristics depending on the severity and duration of torsion. Monophasic waveform, increased<br />
resistance index with decreased diastolic flow velocities, or diastolic flow reversal may be seen [13]. As previously<br />
described for infection, this pattern is caused by swelling and edema occluding the venous flow.<br />
Al ultrasound, direct visualization of the twisted portion of the spermatic cord can be identified both in patients with<br />
complete and with incomplete torsion as a funicular mass, or as an abrupt change in the course, size, and shape of the<br />
spermatic cord. Twisting occurs just outside the external inguinal ring, at a varying distance above the testis, or<br />
posterior to the testis. Demonstration of the funicular vessels wrapping around the central axis of the twisted<br />
spermatic cord, described as the “whirlpool sign”, is considered the most definitive sign of testicular torsion [14].<br />
Movement of the probe to and fro along the axis of the spermatic cord eases identification of this sign.<br />
In acute testicular torsion, the MR appearance of the testis remains normal on both T1- and T2-weighted images.<br />
Only in the subacute or chronic stage of the disease the signal intensity of the testis changes due to necrosis and<br />
hemorrhagic elements.<br />
Segmental infarction of the testis appears at ultrasound as an ill defined hypoechoic mass, usually peripheral, lacking<br />
vascularization at color Doppler interrogation [10]. Acute infarctions are usually rounded [6]; in time they decrease in<br />
size, and become wedge-shaped with vertex directed toward the testicular mediastinum. Segmental infarction may<br />
eventually increase in echogenicity, due to fibrosis, and present with calcifications [6].<br />
At ultrasound twisted cystic epididymal appendix appears as a thick walled structure with anechoic or low reflective<br />
center [11]. Twisted solid appendix usually appears as an echogenic rounded structure, often with inhomogeneous<br />
echotexture, 5mm in size or larger [7, 15]. At color Doppler interrogation the tissues surrounding the twisted appendix<br />
are usually hyperaemic. Testicular flows are normal or enhanced. Reactive hydrocele is often present.<br />
Differential diagnosis<br />
A significant diagnostic problem in the clinical practice is differentiation among clinical situations presenting with acute<br />
scrotal pain. Testicular trauma can be distinguished based solely on history and physical evidence of trauma, and<br />
absence of testicular flow allows a confident diagnosis of complete testicular torsion. Many cases of partial torsion,<br />
however, are recognized only after careful examination of the morphologic characteristics of the spermatic cord, and<br />
evaluation of the Doppler waveform changes relative to the contralateral testicle.<br />
Seeking for the twisted portion of the spermatic cord, presenting as an abrupt change in its configuration, and for the<br />
whirlpool sign both at grey-scale and color Doppler ultrasound is of paramound importance for identification of partial<br />
torsion and increases the diagnostic confidence in the diagnosis of complete torsion as well.<br />
Diminished flow in the symptomatic testis suggests incomplete torsion. Spectral waveform analysis is crucial when<br />
color Doppler examination is indeterminate. A testis with spontaneous detorsion may be hyperemic, simulating<br />
epididymo-orchitis. Diagnosis of spontaneous detorsion should be considered when testicular hyperemia is identified<br />
after spontaneous resolution of acute scrotal pain.<br />
References<br />
1. Muttarak M, Lojanapiwat B. The painful scrotum: an ultrasonographical approach to diagnosis. Singapore Med<br />
J 2005;46:352-357; quiz 358<br />
2. Pearl MS, Hill MC. Ultrasound of the scrotum. Semin Ultrasound CT MR 2007;28:225-248<br />
3. Dogra VS, Gottlieb RH, Oka M, Rubens DJ. Sonography of the scrotum. Radiology 2003;227:18-36<br />
4. Jee WH, Choe BY, Byun JY, Shinn KS, Hwang TK. Resistive index of the intrascrotal artery in scrotal<br />
inflammatory disease. Acta Radiol 1997;38:1026-1030<br />
5. Bhatt S, Rubens DJ, Dogra VS. Sonography of benign intrascrotal lesions. Ultrasound Q 2006;22:121-136<br />
6. Howlett DC, Marchbank ND, Sallomi DF. Pictorial review. Ultrasound of the testis. Clin Radiol 2000;55:595-<br />
601<br />
7. Yang DM, Lim JW, Kim JE, Kim JH, Cho H. Torsed appendix testis: gray scale and color Doppler sonographic<br />
findings compared with normal appendix testis. J Ultrasound Med 2005;24:87-91<br />
8. Magill P, Jacob T, Lennon GM. A rare case of segmental testicular infarction. Urology 2007;69:983 e987-988<br />
9. Ragheb D, Higgins JL, Jr. Ultrasonography of the scrotum: technique, anatomy, and pathologic entities. J<br />
Ultrasound Med 2002;21:171-185<br />
95
10. Oyen RH. Scrotal ultrasound. Eur Radiol 2002;12:19-34<br />
11. Cochlin DL. Acute testicular pain. Imaging 2005;17:91-100<br />
12. Burks DD, Markey BJ, Burkhard TK, Balsara ZN, Haluszka MM, Canning DA. Suspected testicular torsion and<br />
ischemia: evaluation with color Doppler sonography. Radiology 1990;175:815-821<br />
13. Dogra VS, Rubens DJ, Gottlieb RH, Bhatt S. Torsion and beyond: new twists in spectral Doppler evaluation of<br />
the scrotum. J Ultrasound Med 2004;23:1077-1085<br />
14. Vijayaraghavan SB. Sonographic differential diagnosis of acute scrotum: real-time whirlpool sign, a key sign<br />
of torsion. J Ultrasound Med 2006;25:563-574<br />
15. Coley BD. The Acute Paediatric Scrotum. Ultrasound Clin 2006;1:485-496<br />
MR OF SEMINAL VESICLE AND TESTICLE IN INFERTILE MEN<br />
Ocantos J.<br />
Hospital Italiano de Buenos Aires, Argentina<br />
IMAGING OF PENILE DISORDERS<br />
Scherr M.K. 1 , Mueller-Lisse U.G. 1 , Mueller-Lisse U.L. 2 , Meindl T. 1 , Coppenrath E. 1 , Degenhart C. 1 , Reiser<br />
M.F. 1<br />
Depts. of Clinical Radiology 1 and Urology 2 , University of Munich, Germany<br />
The diagnosis of penile disorders occasionally involves radiologic imaging examinations. The most frequently used<br />
imaging modality is ultrasonography (US). Depending on the clinical work environment, US may be performed by the<br />
urologist or by the radiologist. Since many diseases of the penis affect the penile urethra, cysturethrography and<br />
endoscopy are often carried out by the urologist. Cavernosography has been the mainstay of imaging evaluation of the<br />
penile corpora; however, with the development of colour Doppler US and magnetic resonance imaging (MRI), it has<br />
decreased in clinical importance. MRI of the penis and pelvis is usually performed when the disorder is complex and<br />
cannot be sufficiently diagnosed by means of US or endoscopy, conventional X-ray, or fluoroscopy examinations.<br />
Examples include complex distributions of congenital anomaly, complex trauma, extensive inflammatory disease,<br />
invasive tumor, tumor staging, tumor recurrence, erectile dysfunction (ED) and complex post-operative changes,<br />
including status pre and post penile prothesis. Computed tomography (CT) is carried out especially in trauma setting.<br />
MRI helps in the detection and staging of penile cancer and serves as a problem solving diagnostic modality (1). In<br />
selected cases like high-flow priapism, suspicion for vascular-based ED or traumatic vascular damage, magnetic<br />
resonance angiograpy (MRA) or digital subtraction angiography (DSA) - with or without intervention - may be<br />
indicated.<br />
Benign Disease of the Penis<br />
Congenital Penile Anomaly<br />
Among the most frequent congenital anomalies affecting the penis are hypospadia or epispadia, conditions in which<br />
the urethral orifice does not open at the tip of the glans penis. Epispadia is frequently associated with other defects of<br />
lower anterior midline closure, such as bladder exstrophy. The various manifestations can be summarized as<br />
representing different degrees of severity of the epispadia-exstrophy complex of genito-urinary malformations (4) and<br />
can be precisely imaged by means of MRI.<br />
Post-Traumatic Penile Alterations<br />
In general, trauma to the penis and the pelvis can be blunt or penetrating and usually results in local haematoma. In<br />
complex pelvic fractures, CT imaging allows conclusions with regard to compromised penile vascularization or penile<br />
innervation. If the trauma is suspicous for vascular interference, performing additional DSA or MRA maybe helpful.<br />
Penile Haematoma may affect the subcutaneous compartment alone or involve one or more of the penile corpora.<br />
When blunt trauma occurs to the erect penis, it is frequently most severe at the base of the penis, close to the pubic<br />
bone, despite its protection by the suspensory ligament, which extends from the symphysis pubis to the base of the<br />
penis. Fracture of the penis is a rare blunt penile trauma. The underlying trauma most frequently occurs during coitus.<br />
It represents an emergency entity and requires immediate surgical treatment. While history and physical examination<br />
are essential for the correct diagnosis, imaging is used in unclear and atypical cases. Imaging methods applied include<br />
cavernosography, urethrography, ultrasound, and MRI (6).<br />
Post-traumatic alterations in the penile corpora include scarring, which may change the width and shape of the tunica<br />
albuginea and may partially or completely interrupt the continuity of the blood-containing compartment of a penile<br />
corpus. When blood flow within the corpus is compromised, thrombosis may result from haemostasis. In status post<br />
penile trauma, its simplicity, precision, and availability make sonourethrography a valuable tool for the reconstructive<br />
urologist. However, MRI is considered to be particularly valuable for defining the distorted pelvic anatomy that is<br />
frequently associated with post-traumatic posterior urethral strictures (3).<br />
Priapism, Fibrosis of the Penile Corpora and Erectile Dysfunction<br />
There are essentially two distinct entities associated with priapism. Low-flow priapism usually is the consequence of<br />
venous obstruction e.g. by cavernosal thrombosis or tumor or neurogenic misregulation and can be differentiated from<br />
the high-flow variant by Doppler US. High-flow priapism may be proven and interventionally treated by embolization<br />
based on pelvic-penile DSA (10). The underlying arterio-venous fistula or aneurism often is of post-traumatic origin by<br />
both straddle injury and repetitive micro-trauma to the base of the penis.<br />
Fibrosis of the penile corpora may occur as a sequel of prolonged priapism or intravenous injections. Compromised<br />
blood flow, due to haemostasis or scarring within the penile corpora, is causative for the fibrosis. Fibrosis of the penile<br />
corpora may be associated connective tissue disease and has been diagnosed in patients with systemic lupus<br />
erythematosus. In other cases, fibrosis may be the underlying condition in young men who complain of impotence and<br />
may never have had an erection. Transverse fibrotic membranes that partially or completely occlude a corpus<br />
cavernosum are the underlying defect in partial priapism (12). Thrombosis of the affected part of the corpus<br />
cavernosum and clinically partial priapism may be the consequences of membranous occlusion. Besides morphologic<br />
cavernosal changes ED may be caused by non-traumatic vascular changes to be diagnosed by pelvic DSA or MRA.<br />
Penile Prosthesis<br />
96
Penile implants offer a dependable way of restoring erection. However, although they are not very frequent,<br />
complications of penile implant surgery may be clinically significant and include infection of the device, which is quite<br />
frequent, and some other, less frequent but important complications, such as distal and proximal perforation of the<br />
tunica albuginea, deformity of the penis, erosion of a component, and mechanical malfunction of the implanted device.<br />
Diagnosis of complications is based on clinical history and physical examination, but imaging techniques are also<br />
needed to explore the prosthesis and plan the surgical approach if necessary. MRI is considered to be the most<br />
valuable method for the diagnosis of penile prosthesis complications, since it demonstrates penile anatomy in three<br />
orthogonal planes with superior definition of soft tissue contrast (8). Another indication for MRI is visualization of<br />
cavernosal alteration prior to surgery and for implant selection.<br />
Inflammatory Disease of the Penis<br />
Induratio penis plastica or Peyronie’s Disease is an inflammatory condition of unknown aetiology, which affects the<br />
tunica albuginea and may extend to the penile corpora. Normal, elastic connective tissue of the tunica albuginea is<br />
replaced by fibrous or hyaline scar tissue, whose appearance may be sheet-like or plaque-like on T2-weighted MR<br />
images and clearly define disease extent. On post-contrast, T1-weighted MR images, acute plaques of induratio penis<br />
plastica may demonstrate contrast enhancement (9).<br />
Infection of the Penis and Perineum<br />
Infection of the penis and perineum may result from trauma or be a sequel of underlying inflammatory disease, e.g.,<br />
Crohn’s disease. Infection usually involves penetration into the subcutaneous tissue or deeper tissue layers of<br />
pathologic microorganisms that bring about an inflammatory reaction, and, eventually, the formation of puscontaining,<br />
localized abscess or phlegmonous spread. In inflammatory bowel disease, such as Crohn’s disease,<br />
fistulous tracts may connect the skin surface or the mucosal surface of the intestinal tract with subcutaneous or deeper<br />
tissue layers of the penis and perineum. The soft tissue differentiation of MR imaging provides perfect delineation of<br />
tissue oedema, inflammatory reaction, fistulas and pus collections for surgery planning.<br />
Malignant Disease of the Penis<br />
Penile Cancer<br />
Penile cancer is a rare malignant condition. Histopathology reveals squamous cell epithelial carcinoma in more than<br />
95% of cases. Clinically, penile cancer usually affects the glans penis (48% of cases) or the prepuce (21% of cases),<br />
and frequently presents as an ulcer. Less frequently involved are the glans penis and the prepuce (9%), the coronal<br />
sulcus (6%), and the shaft (2%) (13). Penile cancer usually spreads via lymphatic vessels, since Buck’s fascia (fascia<br />
penis profunda) acts as a barrier to invasion of the penile corpora and to hematogenous spread. Regional<br />
lymphadenopathy involves superficial and deep inguinal lymph node.<br />
Local staging of penile cancer is reliable and highly accurate to distinguish between patients suited for (partial)<br />
glansectomy from those receiving (partial) penectomy (5). It still remains unclear if artificial erection during MR<br />
imaging is necessary to obtain reliable information for local tumor staging.<br />
In a recently published series of seven patients with squamous cell carcinoma of the penis, it has been demonstrated<br />
that MRI after the intravenous administration of lymphotropic nanoparticle (ferumoxtran-10), when correlated with<br />
histology, has a sensitivity and specificity of 100% and 97%, respectively, in predicting the presence of regional lymph<br />
node metastases and may accurately triage patients for regional lymphadenectomy (14).<br />
In whole-body staging of malignant penile disease, computed tomography (CT) is advantageous because of its wide<br />
availability, its ability to cover the entire body within less than 1 minute, and its high reproducibility of imaging planes<br />
and ranges. Recent work implies that CT, when combined with positron emission tomography (PET) with 18F-desoxyglucose<br />
(FDG), is highly useful in the detection of metastasis of penile cancer (10).<br />
Cancer of the Penile Urethra<br />
Primary cancer of the male urethra is very seldom found. The majority of urethral cancers consist of squamous cell<br />
epithelial carcinoma at histopathology. Cancer of the penile urethra may invade periurethral loose connective tissue<br />
and eventually penetrates into the penile corpora.<br />
Metastasis to the Penis<br />
Metastasis to the penis of other tumors is unusual. The majority of penile metastases originate from tumors of the<br />
urinary bladder, prostate, and rectum, while metastases from renal and respiratory tract primaries have also been<br />
reported. In individual cases, the route of metastasis to the penis may be hard to define, unless the lesion is clearly<br />
located outside of the penile urethra. Clinically, the most frequent sign of penile metastasis is priapism. Penile<br />
metastases are usually associated with advanced, rather aggressive neoplastic disease, and they usually appear rather<br />
rapidly after the recognition and treatment of the primary tumor. Survival after detection of penile metastasis is<br />
usually very limited (6).<br />
On T2-weighted MR images, penile tumors and metastasis often demonstrate as solitary, infiltrating tumors with low<br />
signal intensity. T2-weighted MR images allow for delineation of the tumor margin and of any extension into the penile<br />
shaft (13). On unenhanced, T1-weighted MR images, tumors or metastases of the penis usually demonstrate with<br />
decreased signal intensity when compared with the penile corpora. Primary penile cancers usually manifest as solitary,<br />
ill-defined, hypointense, infiltrating tumors (13). On contrast-enhanced, T1-weighted MR images, tumors or<br />
metastases of the penis frequently present with contrast uptake. It is controversial whether, on Gadolinium-enhanced,<br />
T1-weighted images, contrast enhancement is stronger in primary penile cancer than within the penile corpora (13) or<br />
stronger within the penile corpora (2). When obtained with fat signal suppression, contrast-enhanced MR images of<br />
the penis help to delineate penile tumor or metastasis from the perineum or pelvic floor. However, since accompanying<br />
inflammatory reaction may be severe, clear-cut definition of tumor margins can pose a problem for MRI.<br />
References<br />
(1) Andipa E, Liberopoulos K, Asvestis C (2004) Magnetic resonance imaging and ultrasound evaluation of penile and<br />
testicular masses. World J Urol. 22:382-391<br />
(2) Asmussen M, Czipull C (2006) Penis. In: Rummeny Reimer Heindel (eds) Ganzkoerper-MR-Tomographie. Georg<br />
Thieme Verlag Stuttgart, New York, pp 408-412<br />
(3) Gallentine ML, Morey AF (2002) Imaging of the male urethra for stricture disease. Urol Clin North Am. 29:361-372<br />
(4) Gearhart JP (2002) Exstrophy, epispadias, and other bladder anomalies. In: Walsh PC, Khinev A (2004) [Penile<br />
fracture]. Khirurgiia (Sofiia) 60:32-41<br />
97
(5) Kayes O, Suks M, Clare A et al. (2007) The Role of Magnetic Resonance Imaging in the Local Staging of Penile<br />
Cancer. Euro Uro 41:1313-1319<br />
(6) Khinev A (2004) [Penile fracture]. Khirurgiia (Sofiia) 60:32-41<br />
(7) Lynch DF and Pettaway CA (2002) Tumors of the penis. In: Walsh PC, Retik AB, Vaughan ED, Wein AJ (eds)<br />
Campbell´s Urology. 8 th edn. Saunders, Philadelphia, London, New York, St. Louis, Sydney, Toronto, pp 2945-2973<br />
(8) Moncada I, Jara J, Cabello R, Monzo JI, Hernandez C (2004) Radiological assessment of penile prosthesis: the role<br />
of magnetic resonance imaging. World J Urol 22:371-377<br />
(9) Pretorius ES, Siegelman ES, Ramchandani P, Banner MP (2001) MR imaging of the penis. Radiographics 21 Spec<br />
No:S283-S298<br />
(10) Roussel G, Robert Y, Mahe P. et al. (2001) High-Flow Priapism in Children: Immediate Treatment by Selective<br />
Embolization. Eur J Pediatr Surg 11:350-353<br />
(11) Scher B, Seitz M, Reiser M, Hungerhuber E, Hahn K, Tiling R, Herzog P, Reiser M, Schneede P, Dresel S (2005)<br />
18F-FDG PET/CT for staging of penile cancer. J Nucl Med 46:1460-1465<br />
(12) Schneede P, Schmeller N, Mueller-Lisse UG, Reiser MF, Hofstetter AG (1999) Partieller Priapismus. Kasuistik und<br />
Literaturübersicht über diagnostisches und therapeutisches Vorgehen. Urologe [A] 38:179-183<br />
(13) Singh AK, Saokar A, Hahn PF, Harisinghani MG (2005) Imaging of penile neoplasms. Radiographics 25:1629-1638<br />
(14) Tabatabaei S, Harisinghani M, McDougal WS (2005) Regional lymph node staging using lymphotropic nanoparticle<br />
enhanced magnetic resonance imaging with ferumoxtran-10 in patients with penile cancer. J Urol 174:923-927<br />
THE ADNEXAL MASS<br />
Moderators: Ghiatas A. (GR) – Chalazonitis A. (GR)<br />
HOW TO CHARACTERIZE AND DETERMINE THE ORIGINE OF AN<br />
ADNEXAL MASS AT US <br />
Balleyguier C. (1), Perrot N. (2)<br />
1- Radiology dept, Institut Gustave Roussy, Villejuif, France, 2- Centre Vitenson, Paris, France<br />
Imaging is essential for characterization and staging of adnexal masses. The role of modern imaging is to point out the<br />
originating organ, to specify if the process is congenital, functional, hemorrhagic, neoplastic, obstructive or<br />
inflammatory and finally to adequately stage the neoplastic diseases before surgery or medical treatment. Adnexal<br />
lesions may include lesions of ovaries, fallopian tubes, broad ligament, uterosacral ligaments and their blood and<br />
nervous supply. Masses may also arise from the uterus. Non gynaecologic sources of abdominopelvic masses must<br />
also be considered. Knowledge of female anatomy, embryology and physiology is necessary to understand adnexal<br />
diseases. Awareness of previous surgery and medical treatment are also helpful for the analysis of organs.<br />
Ultrasonography and Doppler US remain the first step to detect and characterize adnexal lesions. Functional lesions of<br />
the ovary are very common and must be known by the sonographer. Morphological criteria in ultrasound to<br />
characterize benign and malignant ovarian masses are currently well defined and allow a high level of accuracy, with<br />
more than 90 % of sensitivity. Scoring systems to define a risk of malignancy are used by some authors and will be<br />
defined in the presentation. Doppler criteria are usually included in the different scores and considered as<br />
complementary tools for the diagnosis. Nevertheless, in some cases, ultrasound might be inconclusive due to technical<br />
problems or to the characteristics of the lesion itself, and MRI must then be performed to afford additional information<br />
for the diagnosis.<br />
US and MRI appear to be complementary tools for the examination of adnexal diseases. Multidisciplinary approach is<br />
mandatory in order to understand the possibilities and limits, advantages and pitfalls of pelvic imaging.<br />
MRI ASSESSMENT OF AN INDETERMINATE ADNEXAL MASS AT<br />
ULTRASOUND<br />
Kubik-Huch R.<br />
Institute of Radiology, Kantonsspital Baden AG, CH-5404 Baden, Switzerland<br />
There are two major diagnostic challenges in patients with an ovarian mass: The determination of malignancy and – if<br />
a malignancy is suspected - the evaluation of tumour extent (staging). In patients with suspected ovarian carcinoma,<br />
computed tomography is the modality of choice alongside transvaginal and abdominal ultrasound as it is relatively<br />
cost-effective and widely available. While in a clinical routine setting MRI plays a limited role in the staging of ovarian<br />
carcinoma, it serves as an important adjunct for the characterization of sonographically indeterminate ovarian lesions<br />
prior to surgery. It allows to determine the origin of a pelvic mass, e.g. to distinguish a subserosal leiomyoma of the<br />
uterus from an adnexal pathology. MRI was shown to be superior to ultrasound and computed tomography in<br />
characterizing an ovarian lesion, since it is capable of reliably differentiating mature cystic teratoma (Fig. 1) and other<br />
benign lesions from ovarian carcinoma (1-4). Imaging features that are characteristic of a specific diagnosis include<br />
the presence of fat in mature teratoma, the so-called T2-shading in endometrioma or the presence of a solid mass<br />
with low signal intensity on T2-weighted imaging in fibrothecoma (2,5).<br />
MRI can identify features of malignancy in complex confined ovarian masses (6). Criteria indicating malignancy include<br />
a large size, septations, wall-thickening, solid, contrast-enhancing papillary projections as well as the presence of<br />
ascites, pathologic lymph nodes and metastases (2,5).<br />
The standard imaging protocol for adnexal lesions in our institutions incorporates the recommendations of the ESUR<br />
Women’s Imaging Subcomittee (Spencer J, Forstner R, in preparation). An intravenous cannula is placed before the<br />
examination. Following an overview of the entire abdomen (coronal and axial TruFisp, axial T1 GRE), Glucagon is<br />
administered as antiperistaltic agent before imaging the small pelvis. A high-resolution sagittal T2-weighted sequence<br />
of the small pelvis is performed to exclude uterine pathology and to determine the origin of the lesion, followed by an<br />
axial T1 and T2 weighted-sequence. Additional axial oblique (long axis view of the uterus) or coronal sequences might<br />
98
e helpful to establish the diagnosis in selected cases. If a bright lesion is present on T1-weighted imaging, an<br />
additional fat-saturated sequence is acquired allowing the distinction of fat from haemorrhage. In patients with ovarian<br />
pathology, gadolinium-enhanced sequences are routinely performed in our institution to confirm the presence of solid,<br />
enhancing tissue.<br />
More recently, diffusion-weighted imaging (DWI), a functional imaging technique well established for intracranial<br />
imaging, was added to our protocol, since this imaging approach was shown to have a potential for lesion<br />
characterization. With increasing tumor cellularity, there is a reduction in extracellular space resulting in a reduced<br />
ADC value. High-grade adenocarcinomas with high cellular density would therefore be expected to have low ADC<br />
values, however, there is controversy regarding the usefulness of this technique in cystic ovarian tumors. Recent<br />
studies furthermore indicate that there might be a potential for DWI in detection of peritoneal dissemination and lesion<br />
detection (7,8)<br />
Discrimination between benign and malignant ovarian lesions in patients with an ovarian mass based on imaging<br />
criteria has become increasingly important in times, where laparoscopic surgery has gained wide acceptance,<br />
diminishing the possibility of encountering an unexpected ovarian cancer (2). A diagnostic algorithm was proposed by<br />
Spencer et al. (6) according to which all women with indeterminate adnexal masses should undergo MRI before<br />
therapeutic decision making. It was postulated that the adjunct of MRI in this setting might reduce the number of<br />
women undergoing unnecessary surgery and improving bed utilisation by limiting surgery to simple resection in<br />
symptomatic women (6). Diagnostic studies that allow accurate characterization of a lesion might reduce unnecessary<br />
surgery in benign masses and will help to determine surgical and chemotherapeutic planning in malignant lesions<br />
The lecture aims to discuss the general prerequisites and imaging protocols for performing MRI of the ovaries. The<br />
normal MR anatomy of the ovary, physiologic changes during the menstrual cycle as well as ovarian pathology will be<br />
addressed.<br />
References:<br />
1. Kurtz AB, Tsimikas JV, Tempany CMC, et al. Diagnosis and staging of ovarian cancer: Comparative values of<br />
Doppler and conventional US, CT and MR imaging correlated with surgery and histopathologic analysis –<br />
report of the diagnostic oncology group. Radiology 1999, 212_19-27<br />
2. Forstner R, Kinkel K. Adnexal masses: Characterization of benign ovarian leions. In: MRI and CT of the female<br />
pelvis (eds. Hamm B, Forstner R), Medical Radioloy, Springer 2007, pp 107-229<br />
3. Sohaib SA, Mills TD, Sahdev A, Webb JAW, VanTrappen PO, Jacobs IJ, Reznek RH. The role of magnetic<br />
resonance imaging and ultrasound in patients with adnexal masses. Clinical Radiology 2005;60:340-348<br />
4. Hricak H, Chen M, Coakley FV, Kinkel K, Yu KK, Sica G, Bacchetti P, Powell CB. Complex adnexal masses:<br />
Detection and characterization with MR imaging – multivariate analysis. Radiology 2000;214:39-46<br />
5. Baumgarten DA, Ascher SM, Semelka RC, Motohara T, Nagase LL, Outwater EK. Chapter 15 Adnexa. In:<br />
Abdominal-Pelvic MRI (ed: Semelka RC). Wiley-Liss, 2002, pp1123-1176<br />
6. Spencer J, Forstner R, Hricak H. Editorial. Investigating women with suspected ovarian cancer. Gynecologic<br />
Oncology 2008;108:262-4<br />
7. Whittaker SC, Coady C, Culver L, Rustin G, Padwick M, Padhani AR. Diffusion-weighted MR imaging of pelvic<br />
tumors: A pictorial review. Radiographics 2009;29:759-778<br />
8. Namimoto T, Awai K, Yanaga Y, Hirai T, Yamashita Y. Role of diffusion-weighted imaging in the diagnosis of<br />
gynecological disease. Eur Radiol 2009;19:745-760<br />
Figure 1: Mature teratoma of the left ovary: The presence of fat is indicative of the specific diagnosis in this benign<br />
tumour.<br />
a.) Transvaginal sonography<br />
b.) MRI: axial T1-weighted sequence<br />
c.) MRI: axial T1-weighted sequence with fat-saturation<br />
d.) Coronal T2-weighted sequence<br />
a.)<br />
b.)<br />
99
c.)<br />
d.)<br />
OVARIAN CANCER STAGING<br />
Forstner R.<br />
Department of Radiology, Landeskliniken Salzurg, Paracelsus Medical University, Salzburg<br />
Objectives:<br />
• To make familiar with imaging features of ovarian cancer<br />
• To understand the role of Radiology in treatment decision in ovarian cancer<br />
• To introduce the guidelines for staging ovarian cancer suggested by the ovarian cancer staging workgroup<br />
Ovarian cancer continues to be a major challenge for oncologists and radiologists, and is still one of the most lethal<br />
cancers in females. However, recent advents have been noted. In ovarian cancer comprehensive pretherapeutic<br />
imaging is gaining acceptance as an integral part of initial patient management in patients with gynecologic neoplasm.<br />
Thus, the findings assessed by Radiology are becoming pivotal in a more individualized patient care. Central to this is<br />
a multidisciplinary team approach in the management of ovarian cancer (1).<br />
However, for radiologists this requires profound knowledge of staging ovarian cancer including imaging findings, of<br />
pathways of tumor spread and knowledge of treatment options.<br />
The goals of preoperative staging of ovarian cancer are:<br />
a.) Confirmation of a sonographically malignant adnexal mass<br />
b.) Assessment of tumor burden, mapping of the distribution of metastatic disease and diagnosis of possible<br />
complications e.g. bowel obstruction, hydronephrosis, venous thrombosis<br />
c.) Exclusion of a primary site in the breast, GI tract or pancreas whose metastatic spread might mimic primary<br />
ovarian cancer.<br />
Thus radiology can substantially contribute to the management in a patient with a newly diagnosed ovarian cancer in<br />
surgery planning, in case of “non-resectability” on the selection of candidates for neoadjuvant chemotherapy, and in<br />
pretherapeutic tissue sampling.<br />
CA-125 provides only limited information for staging, but is the mainstay in tumor surveillance.<br />
Guidelines for staging ovarian cancer have been developed by the Ovary working group of the ESUR of the female<br />
genitourinary subgroup will be presentented. Based upon the literature and personal preferences there was uniform<br />
consensus that CE-multidetector CT is the modality of choice for staging ovarian cancer, as it provides all relevant<br />
information in a short examination time (3). MRI continues to be an alternative modality, particularily in<br />
contraindications for CT and in young females. Sonography does not provide sufficient information for staging, but is<br />
100
useful in image guided biopsy. The value of PET/CT has yet to be assessed, however it may be useful in suspected<br />
distant spread.<br />
These guidelines including the indications for staging ovarian cancer, technical details for CT and MRI, key imaging<br />
features, and criteria for non- optimally respectable disease will be summarized. Furthermore, a structured report<br />
including all relevant findings in a patient preoperatively assessed for ovarian cancer will presented in detail in this<br />
presentation.<br />
References:<br />
1. Spencer JA (2005) A multidisciplinary approach to ovarian cancer at diagnosis. BJR 78:S94-S10).<br />
2. Forstner R (2007) Radiological staging of ovarian cancer: imaging findings and contribution of CT and MR. Eur<br />
Radiol 17:3223-3246.I<br />
3. Tempany CM, Zou KH, Silverman, et al. (2000) Staging of advanced ovarian cancer: comparison of imaging<br />
modalities-report from the Radiology Oncology Group. Radiology 215:761-767<br />
MRI DIAGNOSIS OF THE ADNEXAL TUMORS BY PATTERN<br />
RECOGNITION<br />
Kim S.H.<br />
Department of Radiology, Seoul National University Hospital, Seoul, Korea<br />
The objectives of preoperative imaging studies of the adnexal masses are to detect the masses, to differentiate<br />
neoplasms from non-neoplastic lesions, to differentiate benign from malignant neoplasms, and to suggest the most<br />
probable diagnosis. Although ultrasonography remains the first-line imaging technique for evaluation of the adnexa,<br />
MRI is most commonly used as the primary imaging study for evaluation of adnexal masses. MRI is especially useful in<br />
characterizing the adnexal masses containing fat, hemorrhage, and fibrotic tissue. MRI is an expensive examination,<br />
but it may be cost-effective by providing an accurate diagnosis that may reduce an unnecessary workup or surgery.<br />
Basic MRI protocols for on-functional MRI include axial T1- and T2-weighted imaging, and sagittal T2-weighted<br />
imaging. Coronal plane imaging is often added. Fat-saturated T1-weighted imaging is usually added to differentiate<br />
between fat and blood for a high-intensity lesion on T1-weighted images. Contrast-enhanced T1-weighted imaging can<br />
be obtained either with or without fat saturation technique. Contrast enhancement is especially helpful in<br />
differentiating solid portion or papillary projection of the tumors from blood clot or debris. Other imaging protocols<br />
such as chemical-shift imaging, diffusion-weighted imaging, and MR spectroscopic imaging may be used as well.<br />
MRI often shows various functional and on-functional benign cysts in the ovary and adnexa. Differential diagnosis<br />
among these cysts can be done by showing the content and wall of the mass and the relation of the mass with the<br />
ovary. Endometriosis is the disease that can be specifically diagnosed with MRI and its extent is well shown. MRI can<br />
show the nature and extent of other non-neoplastic adnexal lesions such as pelvic inflammatory diseases and ovarian<br />
torsion. MRI can characterize ovarian tumors by showing the internal architecture and content of the masses.<br />
Sometimes imaging findings are so characteristic that specific diagnosis of a certain ovarian tumor is possible.<br />
However MRI findings are often overlapped, and thus ancillary findings such as age, tumor marker, and hormonal<br />
status are also considered in differential diagnosis.<br />
US OF UROGENITAL TRACT<br />
Moderators: Yarmenitis S. (GR) – Riccabona M. (AT)<br />
3DUS A LOST TERRITORY FOR RADIOLOGY OR NEW CHALLENGE IN<br />
UROGENITAL TRACT IMAGING<br />
Riccabona M.<br />
University Hospital Graz<br />
CONTRAST US AND ASPECTS FOR ITS FUTURE ROLE: FROM<br />
DIAGNOSTIC IMAGING TO NEW TREATMENT OPTIONS<br />
Claudon M.<br />
Department of Radiology, CHU Nancy-Brabois, Allée du Morvan, 54511 VANDOEUVRE- LES-NANCY ,France<br />
In most centres, ultrasound is the preferred first imaging modality in patients with known or suspected renal disease.<br />
Main objectives are to measure renal size, to prove or rule out focal lesions, to detect obstruction of the collecting<br />
system and to look for vascular disorders by means of Doppler techniques (1). Often unexpected findings like<br />
anatomic variations or focal lesions are detected and need further clarification.<br />
Contrast-enhanced ultrasound (CEUS), based on the IV administration of Ultrasound Contrast Agents (UCAs), is now a<br />
well-established technique for the evaluation of focal liver lesions, but has now been recommended for others organs,<br />
including the kidney by the EFSUMB Guidelines (2). Because of limitations inherent to the physics or to patient’s<br />
condition, a benefit from using CEUS can be expected for the evaluation of the micro- and macrovasculature of the<br />
kidneys (3), including the characterization of focal renal lesions and the diagnostic of vascular diseases of the native<br />
and transplanted kidney.<br />
Background AND CEUS Protocol The kidneys receive 20-25% of the cardiac output. The renal cortex tissue receives<br />
90% and the medulla the remaining 10%. Medullary blood flow is slower than cortical flow. Unlike CECT or CEMRI,<br />
CEUS may be performed in patients with impaired renal function or ureteric obstruction that may be contraindications<br />
to performing contrast CT or Gadolinium enhanced MR examinations. UCAs have no reported clinical side effects on the<br />
kidneys in humans to date. Two contrast boluses are usually necessary in order to examine both kidneys. Although<br />
several papers describe the use of Levovist® with intermittent imaging, today most centres use low solubility gas<br />
agents such as SonoVue® with real time, low MI imaging.As UCAs are confined to the vascular bed, CEUS can not<br />
provide information about the excretory function of the kidneys. The wash in phase can be divided into a short cortical<br />
enhancement phase, beginning 10 to 15 seconds after bolus injection, followed by a medullary enhancement phase<br />
which progresses much more slowly via the vasa recta, and proresses from the outer to the inner portion of the<br />
101
medulla. The duration of parenchymal enhancement depends on the vascular status and age of the patient, renal<br />
blood flow and the sensitivity of the US device used. Because of the high perfusion in the cortex, high microbubble<br />
concentration in the superficial parenchyma may cause attenuation in deeper portions of the kidney. This can be<br />
avoided by reducing the dose of contrast agent. In slim, easy to scan patients with superficial kidneys the dose may be<br />
reduced to 1-1.5ml of contrast agent. The wash out phase is first recognized by a decrease in medullary enhancement,<br />
followed by a slower cortical wash out.<br />
Only low MI contrast specific techniques are now recommended. They allow dynamic imaging with evaluation of the<br />
different vascular phases using a low solubility gas UCAs (Sonovue® from Bracco being currently the only so-called<br />
second generation agent approved for macro and micro vasculature in Europe). A detailed procedure can be found in<br />
the European Guidelines (2). Important points are that:<br />
- Real time scanning should be performed for up to 180 seconds to continuously assess the wash in<br />
and wash out phases.<br />
- In some contrast specific US modes, simultaneous display of tissue and contrast signals has been<br />
implemented. This modality is particularly useful for small lesions to ensure that the target lesion is<br />
kept within the scanning field during CEUS.<br />
- Because of the dynamic nature of real time CEUS, the investigation should be documented on video<br />
or digital media.<br />
- In patients with suspected vascular diseases (mainly small vessel diseases) or trauma, long and<br />
short axis views should be obtained during both the cortical and medullary phases.<br />
Recommended USES AND indications, LIMITATIONS<br />
Indications<br />
CEUS can be recommended in the following clinical situations (2) :<br />
Evaluation of anatomic variations mimicking a renal tumor (“pseudo-tumor”)<br />
Characterisation of complex cystic lesions and suspected cystic renal carcinoma, as CEUS was found to be better than<br />
unenhanced sonography and CT in the diagnosis of malignancy in complex cystic renal masses (4), and appropriate<br />
for renal cyst classification with the Bosniak system (5).<br />
Characterization of thrombus within the renal vein and vena cava<br />
Suspected vascular disorders, including renal infarction and cortical necrosis. CEUS has been shown to decrease the<br />
number of inadequate Doppler studies in renal artery stenosis detection (6). It also allow a better detection of<br />
segmental or subcapsular renal infarction and cortial necrosis in the transplanted kidney (7) and is helpful in<br />
identifying post interventional complications such as bleeding, hematomas, AV shunts or large false aneurysms in<br />
angiomyolipoma (8).<br />
Detection of crossing vessels in UPJ syndromes (9)<br />
Renal trauma and follow up (10)<br />
Patients with contraindications for the use of contrast agents for CT or MR<br />
Monitoring of local ablative treatment by RF and cryosurgery, for which UCAs may be useful in the immediate<br />
assessment of residual tumor by characterizing perfusion defects at different times during and after treatment<br />
(11,12), and demonstrating postoperative local complications such as bleeding or hematoma that may mimic a solid<br />
renal tumor.<br />
CEUS is not currently recommended for:<br />
The detection of focal renal lesions, as its sensitivity remains limited for small tumours when being compared to<br />
contrast enhanced CT or MR (2)<br />
The distinction between malignant from benign tissue, for example renal cell carcinoma from renal metastasis,<br />
angiomyolipoma, oncocytoma and leiomyoma (13)<br />
In the case of pyelonephritis (except for abscesses) (14)<br />
The therapeutic applications of CEUS are still in the research field.<br />
Limitations of CEUS<br />
There are several limitations of CEUS:<br />
• CEUS is subject to the same limitations as standard ultrasound, and sensitivity may be markedly reduced<br />
in the deep field.<br />
• Due to high bubble concentration during the corticomedullar phase, attenuation may cause shadowing in<br />
the deepest parts of the kidney<br />
• The short enhancement time limits the diagnostic window.<br />
REFERENCES<br />
1. Schmidt T, Hohl C, Haage P, et al. Diagnostic accuracy of phase-inversion tissue harmonic imaging versus<br />
fundamental B-mode sonography in the evaluation of focal lesions of the kidney. AJR Am J Roentgenol<br />
2003;180:1639-1647<br />
2. Claudon M, Cosgrove D, Albrecht T, et al. Guidelines and good clinical practice recommendations for contrast<br />
enhanced ultrasound (CEUS) - update 2008. Ultraschall Med 2008;29:28-44<br />
3. Robbin ML, Lockhart ME, Barr RG. Renal imaging with ultrasound contrast: current status. Radiol Clin North<br />
Am 2003;41:963-978<br />
4. Quaia E, Bertolotto M, Cioffi V, et al. Comparison of contrast-enhanced sonography with unenhanced<br />
sonography and contrast-enhanced CT in the diagnosis of malignancy in complex cystic renal masses. AJR Am<br />
J Roentgenol 2008;191:1239-1249<br />
5. Ascenti G, Mazziotti S, Zimbaro G, et al. Complex cystic renal masses: characterization with contrastenhanced<br />
US. Radiology 2007;243:158-165<br />
6. Claudon M, Barnewolt CE, Taylor GA, et al. Renal blood flow in pigs: changes depicted with contrast-enhanced<br />
harmonic US imaging during acute urinary obstruction. Radiology 1999;212:725-731<br />
7. Correas J, Helenon O, Moreau JF. Contrast-enhanced ultrasonography of native and transplanted kidney<br />
diseases. Eur Radiol 1999;9 Suppl 3:S394-400<br />
8. Yamakado K, Tanaka N, Nakagawa T, et al. Renal angiomyolipoma: relationships between tumor size,<br />
aneurysm formation, and rupture. Radiology 2002;225:78-82<br />
9. Mitterberger M, Pinggera GM, Neururer R, et al. Comparison of contrast-enhanced color Doppler imaging<br />
(CDI), computed tomography (CT), and magnetic resonance imaging (MRI) for the detection of crossing<br />
vessels in patients with ureteropelvic junction obstruction (UPJO). Eur Urol 2008;53:1254-1260<br />
10. Regine G, Atzori M, Miele V, et al. Second-generation sonographic contrast agents in the evaluation of renal<br />
trauma. Radiol Med 2007;112:581-587<br />
11. Meloni MF, Bertolotto M, Alberzoni C, et al. Follow-up after percutaneous radiofrequency ablation of renal cell<br />
102
carcinoma: contrast-enhanced sonography versus contrast-enhanced CT or MRI. AJR Am J Roentgenol<br />
2008;191:1233-1238<br />
12. Wink MH, Laguna MP, Lagerveld BW, de la Rosette JJ, Wijkstra H. Contrast-enhanced ultrasonography in the<br />
follow-up of cryoablation of renal tumours: a feasibility study. BJU Int 2007;99:1371-1375<br />
13. Ascenti G, Zimbaro G, Mazziotti S, et al. Usefulness of power Doppler and contrast-enhanced sonography in<br />
the differentiation of hyperechoic renal masses. Abdom Imaging 2001;26:654-660<br />
14. Kim B, Lim HK, Choi MH, et al. Detection of parenchymal abnormalities in acute pyelonephritis by pulse<br />
inversion harmonic imaging with or without microbubble ultrasonographic contrast agent: correlation with<br />
computed tomography. J Ultrasound Med 2001;20:5-14<br />
Yarmenitis S.<br />
University Hospital Of Heraklion, Greece<br />
US OF THE TRANSPLANTED KIDNEY<br />
ULTRASOUND OF THE NON NEOPLASTIC DISORDERS OF THE<br />
PROSTATE<br />
Turgut A.T.<br />
Ankara, Turkey<br />
Benign Prostate Hyperplasia<br />
Benign prostate hyperplasia (BPH) involves microscopically nodular hyperplasia of the glandular, muscular and fibrous<br />
tissues within the transition zone (TZ) and the periurethral glandular zone (PGZ) of the prostate gland. Radiologically,<br />
transabdominal ultrasound (US) is a valuable tool in the follow-up of cases with BPH, although it does not show the<br />
prostate gland in detail. In particular, the high frequency multiplanar transrectal ultrasound (TRUS) imaging provides a<br />
detailed imaging of the prostate gland. In cases with BPH, an enlarged inner gland (IG) is visualized as low-echo areas<br />
on TRUS. Based on this information, it is easy to distinguish the hyperplasia of the prostate from the peripheral zone<br />
(PZ) of the prostate gland with higher echogenecity. Apart from BPH, various solid and cystic lesions of the prostate<br />
gland and prostatic calcifications may be found in the TZ. On US, the capsule located between the enlarged TZ from<br />
the PZ is demonstrated as a rim with its different echogenecity surrounding the TZ. With the use of ellipsoid formula<br />
and multiplication factor as 0.5, the prostate volume may be calculated with a high accuracy from the values of the<br />
largest diameters of width, height and length on TRUS. Then, the weight of the gland can be estimated, using the fact<br />
that 1 ml of prostate tissue is equivalent to 1 g. In clinical practice, a prostate gland weighing more than 40 g is<br />
accepted to be enlarged in men older than 50 years of age. In patients with BPH, an evaluation of the upper urinary<br />
tract using transabdominal US study is a routine procedure for the exclusion of the possible diagnoses of<br />
hydroureteronephrosis, bladder trabeculation or diverticulation, elevation of the bladder base and increased PVR.<br />
Especially, Color Doppler ultrasound (CDUS) is helpful for the evaluation of patients with BPH. In contrast to cancerous<br />
and normal prostate tissues, increased arterial flow velocities and relatively higher RI values are detected in the IGs of<br />
cases with BPH.<br />
Cystic Lesions of the Prostate<br />
A) Intraprostatic Cystic Lesions<br />
Prostatic Utricle Cysts; On TRUS, they are seen as an anechoic midline cystic cavity posterior to the urethra.<br />
Müllerian Duct Cysts; These lesions are seen as an anechoic midline cystic cavity posterior to the urethra on TRUS and<br />
may extend above the prostate gland.<br />
Ejaculatory Duct Cysts; It is generally accepted that they are secondary to the congenital or acquired obstruction distal<br />
ejaculatory duct. Anatomically, they are seen in paramedian location within the prostate on TRUS. Characteristically,<br />
these cystic lesions are round or oval in shape, thin-walled, and unilocular.<br />
Retention Cysts; Retention cysts are true acquired lesions secondary to the obstruction of prostatic glandular ductules.<br />
On TRUS, a peripheral, smooth-walled unilocular cyst is frequently observed.<br />
Cystic Degeneration of Benign Prostatic Hyperplasia; Typically, these lesions are located in the hyperplastic TZ within<br />
the hyperplastic nodules of the prostate.<br />
B) Extraprostatic Cystic Lesions<br />
Seminal Vesicle Cysts; Seminal vesicle cysts are rare lesions and TRUS reveals an intraseminal round or oval anechoic<br />
lesion adjacent to the prostate gland.<br />
Cowper’s Duct Cysts; Typically, a unilocular cyst is located at the posterior or posterolateral of the posterior urethra on<br />
TRUS.<br />
Vas Deferens Cysts; Cysts of vas deferens are situated in the caudal direction of the prostate gland.<br />
Prostatitis<br />
Acute Prostatitis; Classical findings of acute prostatitis on TRUS are the presence of enlarged and round prostate in<br />
shape, heterogenous prostate in echogenicity, and prostate with loss of the echogenecity difference between the IG<br />
and the PZ. Nevertheless, the main role of US in cases with acute prostatitis is the exclusion of the diagnosis of<br />
abscess formation.<br />
Chronic Prostatitis; On US, stromal fibrosis with a spared area of the inflammatory cell infiltration is seen as a thin and<br />
hypoechoic rim at the outer periphery of the prostate. In addition, CDUS can reveal an increased vascularity, possibly<br />
due to concomitant inflammatory process in cases with chronic prostatitis.<br />
Granulomatous Prostatitis; Granulomatous prostatitis is a rare benign inflammatory process of the prostate presenting<br />
as prostatic enlargement and focal or multifocal hypoechoic lesions on TRUS.<br />
Abscess of the Prostate; In cases with prostate abscess, the clinical picture involving the symptoms of fever, chills,<br />
urgency, perineal pain, dysuria and hematuria is similar to that of prostatitis. Radiologically, TRUS is the best choice<br />
for the diagnosis of the prostate abscess, characterized by a focal enlargement of the prostate gland and uni- or<br />
multilocular fluid collections with septae. If there is an abscess formation larger than 1.5 cm, an urgent surgical<br />
drainage is recommended, but smaller ones can be treated with medical thearpy. Aspiration of the lesion under TRUS<br />
guidance provides both a definitive diagnosis and a correct treatment.<br />
Congenital and Acquired Lesions of the Seminal Tracts<br />
Congenital Anomalies of the Seminal Tracts; Congenital anomalies of the seminal tracts including hypoplasia or<br />
absence of the structures may cause infertility in males.<br />
103
Ejaculatory Duct Obstruction; Ejaculatory duct obstruction, a rare cause of male infertility, may be either congenital or<br />
acquired. In these cases, the most common causes of the ejaculatory duct obstruction are calcifications or stones<br />
along the ejaculatory duct, intraprostatic cysts, and blockage due to scar tissue of various etiology, such as<br />
inflammation or trauma. Distal obstruction of the seminal tract may cause the appearances of dilated ejaculatory<br />
ducts, and seminal vesicles or vas deferens on TRUS. Seminal vesicle dilatation should be considered in the presence<br />
of a seminal vesicle with an anteroposterior dimension exceeding 15 mm.<br />
Solid Non-Neoplastic Seminal Vesicle Masses; Solid non-neoplastic seminal vesicle masses are unusual lesions, but<br />
unilateral or bilateral involvement of the seminal vesicles by schistomiasis is possible in some geographic regions of<br />
the world.<br />
References<br />
1. Langer JE, Cornud F. Inflammatory disorders of the prostate and the distal genital tract.<br />
Radiol Clin North Am 2006; 44:665-77.<br />
2. Torigian DA, Ramchandani P. Hematospermia: imaging findings. Abdom Imaging 2007; 32:29-49.<br />
3. Loch AC, Bannowsky A, Baeurle L, et al. Technical and anatomical essentials for transrectal ultrasound of the<br />
prostate. World J Urol 2007; 25:361-66.<br />
4. Özdemir H, Onur R, Bozgeyik Z, Orhan I, Ogras MZ, Ogur E. Measuring resistance index in patients with BPH and<br />
lower urinary tract symptoms. J Clin Ultrasound 2005; 33:176-180.<br />
5. Wasserman NF. Benign prostatic hyperplasia: a review and ultrasound classification. Radiol Clin North Am 2006; 44:<br />
689-710.<br />
6. Kim SH. Imaging for seminal tracts. In: Kim SH, editor. Radiology illustrated: uroradiology. Philadelphia: Saunders,<br />
2003:607-24.<br />
7. Rifkin MD. Ultrasound of the Prostate; Imaging in the Diagnosis and Therapy of Prostatic Disease, second edition.<br />
Philadelphia: Lippincott Williams & Wilkins, 1997.<br />
8. Boczko J, Messing E, Dogra V. Transrectal sonography in prostate evaluation. Radiol Clin North Am. 2006; 44:679-<br />
87.<br />
RETROPERITONEUM – ADRENALS<br />
Moderators: Heinz-Peer G. (AT) – Papadopoulou F. (GR)<br />
ADRENAL IMAGING BEYOND ADENOMA VS NONADENOMA<br />
Kenney P.J<br />
University of Arkansas for Medical Science, USA<br />
General Concepts<br />
Diagnosis of adrenal masses depends on correlation of the clinical and laboratory findings with the imaging<br />
appearance. Sonography is useful for screening but is rarely definitive. CT is very accurate (greater than 90%) in the<br />
diagnosis of adrenal masses . CT can detect even tiny adrenal lesions, and excludes an adrenal mass if the CT<br />
appearance is normal. MRI is also very accurate for adrenal diagnosis. Nuclear imaging including PET can also be<br />
useful, however PET has limitations as small malignant lesions may be negative and some adenomas show uptake of<br />
FDG.<br />
Nearly 1/3 of adrenal masses are incidental lesions detected by CT performed for non-adrenal indications. In the<br />
absence of known extra-adrenal malignancy, most incidental lesions are benign, with less than 10% of serendipitous<br />
adrenal masses being malignant. Small lesions are more commonly benign, but small metastases are reported. Once<br />
an adrenal mass is large, it is more likely malignant, but the adrenal origin of the lesion may be difficult to discern.<br />
Retroperitoneal masses may directly invade and obscure the adrenal gland and mimic a primary adrenal mass.<br />
Adrenal Hyperplasia<br />
Cortical hyperplasia may result in diffuse thickening of the adrenal glands with retention of the normal shape. This<br />
enlargement may be smooth or nodular. Bilateral enlargement, whether smooth or nodular, is indicative of<br />
hyperplasia. A significant number of patients with clinical and biochemical evidence of hyperplasia will have normal<br />
appearing adrenals, thus, a normal appearance of the adrenals does not exclude hyperplasia. Adrenal hyperplasia can<br />
also be diagnosed when there are bilateral nodules or when there is nodularity associated with bilateral adrenal<br />
thickening. . The thickening may become massive, especially with ectopic ACTH production. Unlike hyperplasia, in<br />
primary functional adrenal tumors, the ipsilateral remaining adrenal tissue and contralateral adrenal gland should be<br />
normal or atrophic.<br />
Although both MRI and CT can show markedly enlarged glands, CT is preferable because it is better able to detect<br />
subtle alterations of adrenal morphology as long as appropriate (1 mm) thin section technique is used. Adrenal<br />
enlargement is a response to physiologic stress. On imaging, the appearance is indistinguishable from hyperplasia<br />
producing adrenal hyperfunction<br />
Adenoma<br />
Adrenocortical adenomas are relatively common lesions, particularly nonhyperfunctioning adenomas, which represent<br />
a large proportion of incidentalomas. There are no imaging criteria that distinguish functioning from<br />
nonhyperfunctioning adenomas, that distinction must be made on clinical and laboratory evidence. Key advances in<br />
diagnosis have been made allowing most adenomas to be identified, and distinguished from metastases or other<br />
adrenal lesions. The common presence of significant lipid is key: the accepted cutoff of 10% negative<br />
pixels which is rarely seen with malignancies. Nevertheless, investigation has shown in phase and opposed phase MRI<br />
still can be useful as drop in signal can be demonstrated even in some lesions indeterminate by all CT criteria.<br />
However accuracy of MRI at 3.0 T needs further investigation.<br />
Asdrenocortical Carcinoma<br />
Adrenal carcinoma is a highly malignant neoplasm that arises in the adrenal cortex. It is rare, with an incidence<br />
estimated at two cases per million people . It can occur at any age, with a median age of about 40 years . About 50%<br />
of adrenal carcinomas will produce an endocrine disorder, Cushing syndrome being commonest. Cushing syndrome<br />
104
may be seen alone or with virilization. Virilization alone, feminization, and hyperaldosteronism may be seen, in order<br />
of decreasing frequency .<br />
Adrenal carcinomas often are very large when first detected, particularly if nonfunctioning, remaining clinically silent<br />
until very advanced, when they present with flank pain, fatigue, palpable mass, or evidence of metastases. Even<br />
functioning tumors are usually large when presenting, which may be a result of relatively inefficient production of<br />
hormone, so that a very large mass is needed to produce enough functioning hormone to result in a clinical disorder.<br />
Average size at presentation is 12 cm (range, 3 to 30 cm), but may be small if discovered incidentally. Adenomas<br />
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<br />
cm.<br />
On CT, most myelolipomas are well-circumscribed masses, sometimes with a discrete thin apparent capsule. Nearly all<br />
contain some definite fat density (
Lesions of the adrenal gland can be diagnosed as neoplasms, metastases and hemorrhage or enlargement of the gland<br />
by external hormon stimuation.<br />
Adenal masses can be devided into two groups: hypersecreting masses and inactive masses. The secreting masses<br />
included pheochromocytomas, aldosteronomas and cortisol and androgen producing tumors. Nonfunctioning adrenal<br />
masses include inactive adrenal adenomas and metastases.<br />
The different imaging modalities like CT, MRI and ultrasonography, nuclear medicine, adrenal venous sampling and<br />
biopsies are used to evaluate the adrenal gland.<br />
Nuclear medicine is a method allowing the differention of pheochromocytomas by Iodine-131-metaiodobenzylguanidine<br />
(MIBG) and indium 111 octreotide. Aldosteronomas can be diagnosed by I-131 6-beta<br />
iodomethyl-19-norcholesterol (NP-59). With the introduction of PET-CT the diagnostic capabilities are even improved.<br />
The adrenal medullary neoplasm pheochromocytome is suspected in clinical and laboratory grounds. CT is the study of<br />
choice to diagnose the tumor.<br />
The adrenal cortex consists of three zones: zona fasciculata, glomerulosa and reticularis with the production of<br />
cortisol, aldosteron and androgens. Patients with a cushing syndrome often have a bilateral enlargement of the glands<br />
greater than 2 cm. In patients with hyperaldosteronism the adrenal lesion can be small and difficult to detect.<br />
Nicolaidis P. (USA)<br />
RETROPERITONEAL FLUID COLLECTIONS<br />
Baumgarten D.<br />
Emory Clinic, Atlanda, USA<br />
RETROPERITONEAL MASSES<br />
It is impossible in 20 minutes to cover the entirety of retroperitoneal masses, so what I hope to accomplish is an<br />
approach to the area that will allow the following:<br />
1. Narrowing down the organ of origin<br />
a. Is it even retroperitoneal<br />
i. Anterior displacement of retroperitoneal organs<br />
ii.<br />
Anterior displacement of retroperitoneal vessels<br />
b. Beak sign<br />
i. Describes the deformation of an adjacent organ into a beak or claw shape<br />
ii.<br />
iii.<br />
Usually implies that the organ forming the shape gave rise to the mass<br />
If the adjacent organ is simply next to the mass but the interface is linear the mass may not<br />
arise from that organ<br />
c. Embedded organ sign<br />
i. If a mass simply compresses an adjacent organ, it is likely not the origin<br />
ii.<br />
If the organ instead appears to be within the mass, it is likely the organ of origin<br />
d. Phantom (invisible) organ sign<br />
i. When a mass becomes so large that its organ of origin is no longer discernable.<br />
ii.<br />
More common with small organs of origin such as the adrenal<br />
e. Feeding artery sign<br />
i. A mass originating in an organ increases the size of the blood supply to that organ<br />
2. A reasonable differential based on<br />
a. Characteristics of the mass<br />
i. Internal contents (fat, soft tissue, etc.)<br />
ii.<br />
iii.<br />
Size<br />
Agressiveness<br />
b. Demographics of the patient<br />
i. Age and gender<br />
c. Assumption of organ of origin<br />
107
ORAL PRESENTATIONS<br />
ABSTRACTS<br />
108
URINARY TRACT IMAGING (CT AND MRI)<br />
Moderators: Logager V. (DK) – Dimopoulou A. (S)<br />
SS1.<br />
ACCURACY OF BLADDER CANCER DETECTION WITH CONTRAST ENHANCED ULTRASOUND<br />
Salvador R., Sebastià C., Buñesch L., Sierra A., Donoso L., Nicolau C.<br />
Radiology Department, Hospital Clínic de Barcelona, Barcelona, Spain.<br />
Objective: To prospectively evaluate contrast enhanced ultrasound (CEUS) diagnostic accuracy for detection of bladder<br />
cancer using transurethral biopsy at conventional cystoscopy as the reference standard.<br />
Method: Forty-three patients with suspicion of bladder cancer underwent a baseline US and CEUS the day before a<br />
conventional cystoscopy with transurethral biopsy of the suspicious lesions. Final results were: bladder cancer (n=33<br />
patients with a total of 64 tumors); papillary hyperplasia (n= 1); chronic inflammatory wall bladder (n= 2); absence of<br />
tumor (n= 7). Baseline US and CEUS accuracy for bladder cancer detection and for number of detected tumours were<br />
analyzed and compared with the final diagnosis.<br />
Results: CEUS accuracy was significantly better than US accuracy in terms of presence or absence of bladder cancer:<br />
88.37% vs 72.09%. Seven of 8 uncertain baseline US results were correctly diagnosed using CEUS. CEUS sensitivity was<br />
also better than that of baseline US for number of tumors: 65.62% vs 60.93%. CEUS sensitivity for bladder cancer<br />
detection was significantly better for tumours higher than 5mm than for tumors
SS4.<br />
BREATH-HOLD MR-UROGRAPHY IN OBSTRUCTIVE UROPATHY<br />
Katsarou A. 1 , Katsaros V.K. 2 , Lampropoulou P. 3 , Lyra S. 1 , Mitropoulou M. 2 , Nikolaou A. 2 , Drossos Ch. 3<br />
1 Department of Radiology, Red Cross Hospital, Athens, Greece, 2 Department of CT and MRI, IKA Oncology<br />
Hospital, Athens, Greece, 3 Department of Modern Imaging Modalities, Athens, Greece<br />
Purpose: The aim of this study was to evaluate gadolinium enhanced GRE T1 weighted excretory breath-hold MR-<br />
Urography (MRU) versus T2 weighted (turbo-SE (RARE) and HASTE) breath-hold MRU in patients with obstructive<br />
uropathy.<br />
Patients and Method: 188 patients with obstructive uropathy (86 males, 102 females; aged 45-79 years, mean age 64<br />
years) underwent MRU in a 1.5 T MR unit. Breath-hold turbo-SE (RARE) T2 weighted projection images (TR ms, TE ms,<br />
TA 7 sec), as well as HASTE slices (TR ms, TE ms TA) and 3D spoiled GRE (FLASH) T1 weighted sequence in various<br />
planes (TR ms, TE ms, TA sec) with and without i.v. Contrast medium administration (gadolinium-DTPA, 0.2 mmol /kg<br />
body weight) were obtained. MIP reconstruction followed.<br />
Results: Sensitivity of RARE and HASTE MR-Urography in determination of the level of obstruction was 99% as<br />
compared to 63% in conventional i.v. Urography. In 18 patients additional retrograde cystoureterography showed a<br />
sensitivity of 85%. Specificity of the combination of RARE and HASTE sequences, as well as i.v. Urography was 100%.<br />
In combination with axial MRI scan, T2-weighted MRU yielded a more precise localization of the obstruction and the<br />
underlying cause (99%) as compared to i.v. Urography (63%) and ultrasound (58%). Compared to T2-weighted MRU,<br />
gadolinium-enhanced 3D FLASH T1 weighted excretory MRU revealed a superior diagnostic accuracy in non-dilated<br />
collecting systems. Breath-hold T1 and T2 weighted MRU turned out to be equivalent in the assessment of obstructed<br />
but normal functioning urinary tract. Non-functioning dilated collecting systems and multicystic kidneys were best<br />
visualized with use of the combination of RARE and HASTE (T2 W) MRU.<br />
Conclusion: 3D spoiled GRE (FLASH) T1 weighted and T2 weighted (turbo-SE (RARE) and HASTE) breath-hold<br />
sequences are complementary MR imaging modalities providing detailed information in patients with obstructive<br />
uropathy of any origin and could probably replace in the future conventional i.v. Urography.<br />
SS5.<br />
PERIRENAL FAT STRANDING AT CT IN PATIENTS WITH LOWER URINARY TRACT SYMPTOMS<br />
Sung D.J., Park B.J., Kim M.J., Cho S.B., Kim Y.H., Chung K.B., Oh Y.W.<br />
Department of Radiology, Anam Hospital, Korea University, College of Medicine<br />
Objective: To evaluate the incidence and clinical significance of perirenal fat stranding (PFS) at CT in patients with<br />
lower urinary tract symptoms (LUTS).<br />
Method: CT studies were retrospectively reviewed by two radiologists in consensus in 345 patients (293 male, 52<br />
female) who had undergone uroflowmetry for LUTS and in 390 age-matched control patients (230 male, 160 female)<br />
without LUTS. The incidence of PFS and baseline characteristics such as age and gender were compared between the<br />
symptomatic patients and control patients, and between patients with and those without PFS. The uroflowmetry data<br />
and prostate volume were compared between the symptomatic male patients with and those without PFS.<br />
Results: The incidence of PFS was significantly higher in the symptomatic patients (117/345) than in control patients<br />
(42/390), and in males than in females in both symptomatic (105 male, 2 female) and control (33 male, 9 female)<br />
patients (P60 years, presence of<br />
macroscopic hematuria and positive CTU were independent predictors for the presence of bladder cancer (all P <<br />
0.02).<br />
Conclusion: In patients at (very) high-risk for bladder cancer, CTU can be used with high sensitivity for primary<br />
diagnosis. Its use may obviate further evaluation with flexible cystoscopy.<br />
110
SS7.<br />
МAGNETIC RESONANCE IMAGING AT PATIENTS WITH A BLADDER CANCER, POSSIBILITY<br />
COMPLEX MRI.<br />
Glybochko P., Chehonatskaja M., Zuev V.<br />
Saratov State Medical University, Saratov, Russia<br />
Purposes: To define structure complex MRI and its possibilities at patients with a bladder cancer (BC).<br />
Method: Complex MRI is spent at 16 patients, age from 52 till 76 years with the diagnosis a BC. In a complex joined:<br />
T2-and T1-weighted MR imaging<br />
kidneys and pelvic organs, contrast-enhanced functional MRU, dynamic contrast-enhanced MR imaging (DCE-MRI) ,<br />
contrast MRU, MR voiding and ascending cystourethrography, virtual MR urofluometry.<br />
Results : Complex MRI has allowed to specify presence bladder tumours, a condition and interest in pathological<br />
process of kidneys, upper and lower<br />
urinary tract, presence and characteristics metastasises.<br />
Conclusion: Complex MRI is a useful method of detecting bladder tumours, research allows to define morphological<br />
and functional infringements urinary system at patients with a BC.<br />
SS8.<br />
DUAL SOURCE CT CYSTOGRAPHY AND VIRTUAL CYSTOSCOPY VERSUS CYSTOSCOPY WITH<br />
PHOTODYNAMIC DIAGNOSIS (PDD) METHOD IN THE BLADDER CANCER<br />
Panebianco V., Vergari V., Di Mare L., Zampelli A., De Dominicis C., Passariello R.<br />
Dept of Radiological Sciences, Sapienza University of Rome<br />
Object: To demonstrate the use of cistography CT(CTC) and virtual cistoscopy(VC) with Dual Source technique in the<br />
diagnosis of bladder lesions using Cistoscopy with Photodynamic diagnosis (PPD) as reference standard.<br />
Method: The patient population was divided into three groups based on lesion size at PPD.CTC with VC, is mandatory for<br />
TNM and is useful when conventional cystoscopy is inconclusive. With regard to lesion size, it has been also<br />
demonstrated that multidetector-row CT (MDCT) performed with thin-slice reconstructions (1 mm) allow a good<br />
sensitivity for the detection of lesions < 5 mm.<br />
The study showes the typical imaging findings of bladder carcinoma with Dual Source CT C and VC, included postcontrast<br />
scan and were compared with PPD.<br />
Results: PPD depicted 92 bladder lesions in the 44 patients examined.<br />
Sensitivity and specificity values of CTC and VC alone were constantly lower than those of the combined-approach<br />
(group 1: 93.25% and 92.54%; group 2: 100% and 100%; group 3: 100% and 100%, respectively).ROC curve analysis<br />
showed that the combined approach decreases the lower dimensional threshold for lesion detection (1.4 mm).<br />
Conclusion: CT Cystography and Virtual Cystoscopy are less invasive than conventional cystoscopy, can be used to<br />
evaluate areas difficult to assess with cistoscopy such as the anterior bladder neck and narrow-mouthed diverticula, and<br />
enable the staging of the neoplasia.<br />
The main disadvantages of CTC and VC are the low sensitivity to depict flat lesions, as demonstrate on Cystoscopy with<br />
PPD method.<br />
SS1.<br />
PROSTATE IMAGING – MALE GENITALI I<br />
Moderators: Claudon M. (F) – Piperopoulos P. (GR)<br />
STATE-OF-ART PROSTATE MR IMAGING<br />
Verma S.<br />
Department of Radiology, University of Cincinnati, 234 Goodman street, Cincinnati, Ohio 45267-0762<br />
Objective: 1. Discuss the MR techniques for prostate cancer detection and staging<br />
2. Detail the indications for prostate MRI<br />
3. Describe how to perform a prostate MRI exam.<br />
Conclusion: This presentation reviews the current functional and anatomic MR imaging techniques to improve the<br />
accuracy of MR for detection and localization of prostate cancer<br />
SS2.<br />
PROSTATE MR AND MR SPECTROSCOPIC IMAGING AT 1.5T VERSUS 3T<br />
Verma S. MD 1 , Rajesh A. MBBS 2 , Kurhanewicz J. PHD 3<br />
1 Department of Radiology, University of Cincinnati, 234 Goodman street, Cincinnati, Ohio 45267-0762<br />
2 Department of Radiology, University Hospitals of Leicester NHS Trust, Gwendolen Road, Leicester. LE5<br />
4PW. UK, 3 Department of Radiology, University of California, San Francisco, 505 Parnassus Ave., San<br />
Francisco, CA 94143-0628<br />
Objective: Describe the technical differences between 1.5T and 3T MR/ MR Spectroscopy<br />
1. Conventional MRI-1.5T versus 3T<br />
a. Image quality<br />
b. Spatial resolution<br />
c. Speed of acquisition<br />
d. Changes in optimal TR and TE<br />
e. Susceptibility artifacts<br />
f. Dielectric /Standing wave effects<br />
111
g. Motion<br />
h. SAR<br />
2. How to optimize endorectal MR/MRS exam<br />
3. MR Spectroscopy 1.5T versus 3T<br />
a. Spectral resolution<br />
b. Spatial resolution<br />
c. Signal to noise ratio<br />
1. Chemical shift artifacts<br />
1. Voxel size<br />
2. Volume averaging<br />
d. Changes in optimal TR and TE<br />
e. Differences in pulse sequences<br />
f. Speed of acquisition<br />
Conclusion: This presentation reviews (1.5T versus 3T ) MR/MRS technique optimization, potential pitfalls and how to<br />
avoid them.<br />
SS3. MR SPECTROSCOPY (MRS) AND DINAMIC CONTRAST ENHANCED MR (DCEMR): DETECTION OF<br />
PROSTATE ADENOCARCINOMA FOCI IN MEN WITH PRIOR NEGATIVE PROSTATE BIOPSY AND<br />
ELEVATED PROSTATE SPECIFIC ANTIGEN (PSA) LEVELS.<br />
Panebianco V., Bernardo S., Santucci E., Lisi D., CiccarielloM.', Passariello R.<br />
Dept. of Radiological Sciences,Sapienza University of Rome, ' Dept. of Urology 'U.Bracci', Sapienza University of<br />
Rome<br />
Object: To assess the role of MRSI and DCEMR in the detection of prostate tumor foci in patients with elevated PSA<br />
levels ( range ≥ 4 ng/ml and < 10 ng/ml) and prior negative random TRUS-guided biopsy .<br />
We compared a second random versus a second MRSI/DCEMR directed biopsy for detection of a histologically<br />
confirmed prostate cancer.<br />
Method: We recruited 215 patients,with a first negative random TRUS-guided prostate biopsy for prostate<br />
adenocarcinoma or HGPIN, elevated PSA levels and negative DRE. Two groups patients: Group A with a second<br />
random TRUS-GUIDED biopsy, Group B : with a second direct TRUS-guided biopsy in prostate areas MRSI and DCEMR<br />
as suspicious for cancer, samples targeted on these areas were associated to the random biopsy.<br />
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-<br />
% accuracy, DCEMR had a 75.6% sensitivity, 76.7% specificity, 73.6 % PPV, 78.5 % NPV and 76.2% accuracy and the<br />
association MRSI + DCEMR a 89.7% sensitivity, 80.4-% specificity, 81.3% PPV, 89.1% NPV and -85% accuracy. On a<br />
patient by patient basis, MRSI had a 92.3% sensitivity, 88.2% specificity, 85.7% PPV, 93.7% NPV and 90%<br />
accuracy, DCEMR had a 84.6% sensitivity, 82.3% specificity, 78.5% PPV, 87.5% NPV and 83.3% accuracy and the<br />
association MRSI + DCEMR a 92.6-% sensitivity, 88.8% specificity, 88.7% PPV, 92.7% NPV and 90.7% accuracy .<br />
Conclusions: MRSI/DCEMR can improve cancer detection rate especially in patients with prior negative TRUS-guided<br />
biopsy and alterated PSA serum levels<br />
SS4.<br />
PRELIMINARY STUDY USING DCE-MRI WITH GADOFOSVESET TRISODIUM BLOOD POOL CONTRAST<br />
AGENT IN THE ASSESSMENT OF PROSTATE CANCER<br />
Panebianco V., Osimani M., Santucci E., Lisi D., Bernardo S., Passariello R.<br />
Dept. of Radiological Sciences,Sapienza University of Rome<br />
Object: In prostate cancer (Pca) an increasing number of microvessels can be observed. Gadofosveset trisodium<br />
(Vasovist), binds reversibly to human albumin in plasma and results in increased relaxivity value. This linkage is useful<br />
to our aim that was to report a dynamic contrast-enhanced MRI (DCEMRI). We introduced a new way of evaluation<br />
for dynamic signal intensity time (SI-T) curves.<br />
Method: We performed 62 prostate MR exams( morphologic, 1H-MRSI and DCEMRI protocols). We divided our<br />
population: Group A with 32 patients with Pca, Group B including both 10 patients with glandular BPH and 9 cases with<br />
mixed glandular/stromal BPH ,Group C with 11 patients negative for prostate disease. An enhancement descriptor<br />
(ED) was calculated with SI-T curves’ single records and its values was correlated to metabolities and ratio level at<br />
1H-MRSI.<br />
Results: Group A resulted in highest ED value (331,79), while in Group B ED value reported was 125,14 in glandular<br />
BPH and 193,37 in mixed stromal/glandular BPH type. ED for Group C was 201,36. Rank correlation reported a<br />
positive correlation with choline, creatine and ratio values in the Group A, with citrate in glandular BPH, and with<br />
citrate in Group C. In stromal BPH a negative correlation was reported with citrate.<br />
Conclusions: Cancer yielded significantly with highest ED value than both normal patients’ group C and glandular BPH<br />
in group B . We confirmed that vascularity changes in prostate tissue reflect in metabolic changes, as correlation<br />
analysis showed by the use of our ED.<br />
112
SS5.<br />
EVOLUTION OF PATTERN CHANGES FROM INFLAMMATION TO PROSTATE CANCER USING 1H-MRSI<br />
AND DCE-MRI<br />
Panebianco V., Santucci E., Biondi T., Di Mare L., Lisi D., Passariello R.<br />
Dept. of Radiological Sciences, Sapienza University of Rome<br />
Object: To assess Magnetic Resonance Spectroscopic Imaging (1H-MRSI) and Dynamic Contrast-Enhanced Magnetic<br />
Resonance (DCE-MRI) features in histologically confirmed prostatic chronic inflammation, prostatic intraepithelial<br />
neoplasia (PIN) , low grade (LGPCa) and high grade (HGPCa) prostate cancer. An analysis of 1H-MRSI and DCE-MRI<br />
parameters has been used to verify the hypothesis for a link among chronic inflammation , PIN and PCa.<br />
Method : One-hundred-five men were selected, these patients were divided in five groups: control group (Group<br />
A),patients with chronic inflammation (Group B), PIN (Group C) or prostate cancer (LGPCa = Group D and HGPCa =<br />
Group E). All patients were submitted to 1H-MRSI and DCE-MRI before biopsy.<br />
Results: ANOVA analysis shows that a constant and significant (p< 0.05) difference in almost all metabolic<br />
assessments (1H-MRSI) exists between controls (group A) and the other groups (Group B,C,D,E). Moreover,<br />
inflammation (Group B) showed no significantly (p>0.05) different Choline and Citrate levels when compared to PIN<br />
and LGPCa. The results of the ratio analysis were consistent with no significant (p>0.05) differences between<br />
inflammation and PIN and between LGPCa and HGPCa. The analysis of Cho concentration showed very similar levels<br />
among inflammation, PIN and LGPCa.<br />
Conclusion: In our study the similar levels of Cho among inflammation, PIN and LGPCa, may suggest a potential<br />
evolutionary trend among these lesions.<br />
SS6.<br />
CONTRAST-ENHANCED TRUS SIGNIFICANTLY INCREASES THE SENSITIVITY OF LOCALIZING BOTH<br />
LOW AND HIGH GLEASON GRADE PROSTATE CANCER<br />
Heinmink S., Futterer J.J., Hambrock T., Hulsbergen-v.d.Kaa C.A., Witjes J.A., Barentsz J.O.<br />
Radboud University Nijmegen Medical Center<br />
Purpose: To compare the prostate cancer localization accuracy of gray-scale, color and power Doppler and sulphur<br />
hexafluoride-enhanced power Doppler transrectal ultrasound<br />
(TRUS) with whole-mount section histopathology and the effect of experience and Gleason score.<br />
Methods and Materials: Fifty-two consecutive men with biopsy-proven prostate cancer underwent TRUS before radical<br />
prostatectomy. Unenhanced axial images covering the prostate were obtained in gray-scale, color Doppler, and power<br />
Doppler mode. During continuous 1 ml/min manual intravenous infusion of 2.4ml sulphur hexafluoride, axial images in<br />
power Doppler mode with low mechanical index were acquired. For each mode, four readers with different levels of<br />
experience independently scored the presence of<br />
prostate cancer on a five-point probability scale for each of 14 segments covering the prostate. Whole-mount section<br />
histopathology was the reference standard. AUC curves were calculated using bootstrapping and Bonferroni correction.<br />
Diagnostic performance parameters were determined. Separate analyses were performed according to Gleason scores.<br />
P
SS8.<br />
PERFUSION MR IMAGING OF LOCAL RECURRENCE AFTER RADICAL PROSTATECTOMY<br />
Kubin K., 1 Memarsadeghi M. 2<br />
1 : Department of Radiology, University Clinics Salzburg, AUT, 2 : Department of Radiology, medical University<br />
Vienna<br />
Purpose: Because of increasing numbers of patients with PCa and approximately 15-35% of patients experiencing<br />
recurrence after radical prostatectomy (RPE), imaging is mandatory to provide further local therapy. The aim of this<br />
study was to determine the benefit of additional perfusionMR of the prostatectomy bed to detect local tumor<br />
recurrence after RPE.<br />
Methods: The MRI examinations of 15 patients, one to 12 years after RPE (median 7 years), were included in this<br />
study. 1.5 Tesla MRI, with a combined pelvic phased array and endorectal coil, was performed in all patients.<br />
Transverse and coronal T2w fast spin echo MR images and T1w fast 3D GRE images were obtained before and after<br />
the injection of Gd-DPTA. The post-contrast media T1w sequence (duration 35 sec) was repeated 10 times. A<br />
commercially available CAD system (Prostream, CADSciences, NY) was used to evaluate Perfusion -MR results.<br />
The T2w series alone, the T1-perfusion series, and the T2w series, together with T1-DCE, were assessed at different<br />
time points.<br />
Images were assessed for the presence of local recurrent tumor within the prostatectomy bed. Tumor localization and<br />
size were also assessed.<br />
Clinically, determination of local recurrence was based on one of the following methods:<br />
a) Reduction in PSA level following external beam radiation therapy of the prostatectomy bed;<br />
b) MR follow-up that showed at least a 20% increase in the size of a suspicious soft tissue mass within the<br />
prostatectomy bed;<br />
c) Positive biopsy results from the prostatectomy bed<br />
Results: Clinically, 10 patients had local recurrent tumor based on the criteria listed above.<br />
The accuracy of reading T1w perfusion MR images alone was higher than reading T2w images alone or reading T2w<br />
images and T1w perfusion-MR images in one session (93,3% vs 80,0% vs 86,7%).<br />
Lesions were mostly located bilateral or dorsal to the urethra.<br />
Mean lesion diameter was 13 mm and there was no significant difference between the imaging methods (p= .470)<br />
Conclusion: Perfusion-MR of the prostatectomy bed after RPE increases the detection rate of local recurrence after RPE<br />
and, therefore, should be added to MR protocols designed to evaluate patients with increasing PSA after RPE. Contrast<br />
media enhancement over time allows more accurate differentiation between granulation tissue, scars and recurrent<br />
tumor.<br />
Clinical Relevance/Application: Perfusion-MRI is more accurate to detect local recurrence after RPE than T2w imaging<br />
only and therefore is necessary to plan further local therapy<br />
FEMALE PELVIS – FEMALE IMAGING<br />
Moderators: Bellin M.F. (F) – Sebastia M. (E)<br />
SS1.<br />
MRI IN THE WORK-UP OF INDETERMINATE OVARIAN MASS: PROTOCOLL OPTIMIZATION AND<br />
DIAGNOSTIC EFFICACY ANALYSIS<br />
Chilla B. 1 , Hauser N. 2 , LocherP. 1 , Singer G. 3 , Fröhlich J.M. 4 , Hohl M. 2 , Kubik-Huch R.A. 1<br />
Institute of Radiology 1 , Clinic of Gynecology & Obstetrics 2 , nstitute of Pathology 3 , Guerbet AG4<br />
Objective: This study was undertaken to optimize our MR protocol including T2-BLADE and diffusion weighted<br />
sequences (DWI) for the work-up of indeterminate ovarian lesions and to determine the economic and clinical value of<br />
MRI in this setting.<br />
Method: 30 Patients with indeterminate ovarian lesion scheduled for surgery are included in this prospective study.<br />
MRI of the abdomen including DWI and T2w BLADE was performed on a 1.5 T Siemens Avanto scanner. In a<br />
questionnaire, the surgeon characterizes the lesion based on Kawai score and determines the surgical procedure. He<br />
then revaluates his assessment knowing MR findings. Results are correlated with final diagnosis. A cost-benefitanalysis<br />
of MRI in the pre-treatment work-up is performed.<br />
The newly implemented T2w Blade sequence was compared to convential T2w FSE using a 5-point-scale (image<br />
quality, organ delineation, presence of artifacts). Furthermore, it was evaluated whether ADC values are useful in the<br />
differential diagnosis.<br />
Results : The MRI protocol with an imaging time of 35 minutes was well tolerated. High quality DWI can be obtained<br />
following glucagon application in most patients. On T2 BLADE, the delineation of the adnexal mass and the uterus is<br />
clearer demonstrating details which are hardly recognizable on T2 FSE.<br />
MRI provided additional diagnostic information in several patients influencing patient information and surgical<br />
planning. Detailed data and cost-benefit-analysis will be presented at the meeting.<br />
Conclusion: MRI is a helpful tool in the preoperative evaluation of indeterminate adnexal masses.<br />
T2w BLADE should replace conventional T2w sequences allowing better assessment of pelvic organs.<br />
SS2.<br />
PRIMARY MALIGNANT MIXED MLLERIAN TUMORS OF THE UTERUS: SONOHYSTEROGRAPHIC AND<br />
COLOR DOPPLER FINDINGS<br />
Lee E.J., MD<br />
Department of Radiology, Ajou University School of Medicine, Suwon, Korea<br />
Objective: To describe the sonographic features of primary malignant mixed müllerian tumors of the uterus and to<br />
determine the diagnostic role of sonohysterography(SH) and color Doppler sonography(CDS).<br />
Method: The SH and CDS findings for 29 histologically proved cases of primary malignant mixed müllerian tumors,<br />
accumulated over 10 years, were reviewed retrospectively. The pathologic diagnoses of epithelial carcinoma included<br />
endometrioid (n=24), papillary serous (n=4), mixed (n=2), and the sarcomatous component was homologous (n=18)<br />
and heterologous type (n=11).<br />
Results: Of 29 total uterine tumors, 16 were in the corpus, 9 were in the fundus, and 4 were in both corpus and<br />
fundus. The mean tumor size was 5.4 cm (range, 2.6–17 cm). The most common appearance was a polypoid mass<br />
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projecting into the endometrial cavity in 23 cases. The surface of the tumor was irregular (n=28) and lobulated (n=9).<br />
The tumor was heterogeneous isoechoic in 16 cases or hyoechoic in 12 cases. The tumor often had an anechoic cystic<br />
or cleft-like area (n=10), necrosis (n=4) and hemorrhagic area (n=7). Myometrial invasion was present in 28 cases<br />
and dilatation of endometrial cavity was seen in 11 cases. CDS showed moderate-marked vascularity in 20 cases,<br />
which appeared as single or multiple feeding vessels (n=15) or randomly dispersed vessels (n=9), with mean RI of<br />
0.41.<br />
Conclusion: Knowledge of the sonographic appearance of primary malignant mixed müllerian tumors may facilitate<br />
diagnosis and help distinguish these tumors from other polypoid uterine tumors.<br />
SS3.<br />
VALUE OF CERVIX STRUCTURAL CHANGES AT MR IMAGING IN PATIENTS WITH RISK OF PRETERM<br />
DELIVERY<br />
Masselli G., Truglio M., Patti S., Marzano S., Tozzi C., Perrone G., Brunelli R., Anceschi M.M., Gualdi. G.<br />
Radiology Dea Department. La Sapienza University Rome.<br />
Aim: To evaluate the cervical structure using the signal T2 intensity changes in Magnetic Resonance (MR) in patients<br />
with Risk of Preterm Delivery (RPD).<br />
Materials And Methods: 11 patients with diagnosis of threatened preterm delivery underwent to MR at 1.5 T scanner .<br />
This study group was compared with a control group of normal patients (n=8) that underwent MR for suspected fetal<br />
abnormalities.<br />
The signal intensity was evaluated using HASTE T2 weighted sequences through the placement of a Region of interest<br />
(ROI) of 1 cm2 ( 83 pixel) in the anterior and posterior lips of the cervix. The signal intensity of the total area of the<br />
cervix was measured in coronal plane. The intensity index was calculated by the ratio of the signal intensity of<br />
selected region in the cervix over the signal intensity of the subcutaneous fat. Statistical analyses was performed by<br />
Student t- Test.<br />
Results: In all women the maternal cervix was clearly visualized by MR imaging. The average of gestational age in<br />
which the MR was performed was 26 ( 23-32) weeks in the study group and 31 weeks ( 30-32) in the control group.<br />
The intensity index calculated in the study and in the control group respectively were: posterior lip 0.74 and 0.54 (p=<br />
0.049); anterior lip 0.63 and 0.51 ( p= 0.65); total area 1.31 and 1.20 (p= 0.91).<br />
Conclusion: The increased of the signal intensity in the HASTE sequence, observed in the study group, show a<br />
condition of high hydratation of the cervical stroma; this phenomenon is present very prematurely and has to be<br />
considered as a strong demonstration of the connective tissue degradation process that is at the basis of cervix<br />
reabsorption in RPD.<br />
SS4.<br />
MR IMAGES OF RETAINED PLACENTAL TISSUE<br />
Takahama J., MD, Marugami N., MD, Kitano S., MD, Takewa M., MD, Itoh T., MD; Kichikawa K., MD.<br />
Department of Radiology, Nara Medical University, 840 Shijo-cho, Kashihara city, Nara, Japan<br />
Purpose : Retained placental tissue may cause severe postpartum hemorrhage. The purpose of this study is to<br />
evaluate the role of MR imaging in diagnosing retained placental tissue and assessment of follow-up.<br />
Method And Materials : The subjects were continuous 8 patients clinically suspected retained placental tissue between<br />
January 2002 and April 2009. All patients underwent MR examination (on Siemens sonata 1.5T) consists of T1WI, FSE<br />
T2WI, and dynamic contrast study (VIBE sequence; every 60 s after intravenous administration of Gd-DTPA). Clinical<br />
course were also reviewed. MR images were retrospectively reviewed about intrauterine mass, the signal intensity of<br />
the uterine contents on T1- and T2-weighted images, the enhancing pattern, uterine myometrial partial destruction.<br />
Results : The clinical final diagnosis as retained placental tissue was 5 cases and uterine myometrial injury without<br />
retained placental tissue (speculated due to placental abnormality) was 3 cases. Though all 8 cases showed various<br />
signal contents in the uterine cavity, 5 cases with retained placental tissue demonstrated very hyperintense on T2WI,<br />
isointense on T1WI, and prolonged strong enhancement. Two of 3 cases with myometrial injury showed myometrial<br />
destruction without any enhanced lesions. No case with retained placental tissue showed linear enhancement between<br />
placental tissue and myometrium that was reported to reflect the decidua. The clinical outcome was followed, 3 cases<br />
without placental tissue had no recurrent hemorrhage, one of 6 cases with placental tissue required TCR after UAE, 2<br />
cases obtained TCR after MTX, 2 cases spontaneously discharged.<br />
Conclusion : MR imaging is helpful in diagnosis for the postpartum hemorrhage especially in detecting the retained<br />
placental tissue.<br />
Clinical Relevance/Application : The 3D-T2WI in female pelvis is useful for diagnosis of myometrial invation in corpus<br />
cancer.<br />
SS5.<br />
DIFFUSION WEIGHTED MR IMAGING IN VULVA CANCER<br />
Ewald A.M., Møller J.M., Johannesen H.H.<br />
Diagnostic Radiology 54E2 Copenhagen University Herlev, Herlev Ringvej 75, DK-2730 Herlev Denmark.<br />
Purpose: To measure the Apparent Diffusion Coefficient (ADC) in vulva cancers.<br />
Method: Diffusion weighted and T2w images performed on either 1.5T or 3T were reviewed retrospectively in 17<br />
consecutive patients (mean age 68, at range 32-92) with pathologically verified plano cellular carcinoma of vulva. ADC<br />
maps were calculated on basis of two b values: b=0 and b=1000. Tumor was outlined on transverse T2w images and<br />
on the corresponding ADC map before the ADC was measured.<br />
Results: 3 patients were excluded because tumor was not visible on T2w. Pathologic examination revealed a 1 mm<br />
thin tumor in these patients. 1 patient was excluded because diffusion imaging was not performed. In a total of 13<br />
patients, mean age 73 ( range 32-92 ) the mean ADC was 1.22x10-6 mm2/sec +/- 0.18<br />
Conclusion: In plano cellular carcinomas of the vulva ADC measurements are presented. Diffusion weighted imaging<br />
aids in depicting vulva cancer.<br />
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SS6.<br />
MR FINDINGS OF METASTATIC OVARIAN TUMORS<br />
do Nascimento A.F. 1 , Sousa S. 2 , Cunha T.M. 3<br />
1 Radiology Department, Hospital Professor Doutor Fernando Fonseca, 2 Radiology Department, Hospital dos<br />
Lusíadas, 3 Radiology Department, Instituto Português de Oncologia Francisco Gentil<br />
Purpose: The purposes of this study were to evaluate the MR findings of metastatic ovarian tumors and to compare<br />
them with those of primary ovarian tumors.<br />
Method: This study included 14 patients with metastatic ovarian tumors and 30 patients with various primary ovarian<br />
tumors. Imaging findings of the tumors were divided into unilateral versus bilateral mass and categorized into<br />
subgroups: predominantly cystic lesions, solid mass with intratumoral cysts and solid mass without cystic components.<br />
Results: Among 14 tumors (bilateral in 8 patients), 8 were solid masses with multiple intratumoral cysts. Six tumors<br />
were solid masses without cystic components. None of the metastatic tumor was cystic. Imaging findings of the<br />
primary ovarian tumors were mainly cystic masses.<br />
Conclusion: Bilateralism isn’t useful to differentiate primary from secondary ovarian tumors. Metastatic ovarian tumors<br />
have predominantly solid or mixed appearance with solid components within intratumoral cysts.<br />
SS7.<br />
MAGNETIC RESONANCE IMAGING OF PELVIC ENDOMETRIOSIS. EFFECT OF READER’S EXPERIENCE<br />
ON ACCURACY AND INTEROBSERVER VARIABILITY.<br />
Restaino G. 1 , Missere M. 1 , Maselli G. 1 , Mattioni O. 2 , Calandriello L. 2 , Carone V. 3 , Legge F. 3 , Ferrandina G. 3 ,<br />
Sallustio G. 1 . 1 Department of Radiology, “John Paul II” Center for High technology Research and Education in<br />
Biomedical Sciences, Catholic University of Sacred Heart, Campobasso, Italy 2 Department of Bioimaging and<br />
Radiological Sciences, Policlinico “A.Gemelli”, Catholic University of Sacred Heart, Rome, Italy; 3 Department<br />
of Gynecology “John Paul II” Center for High technology Research and Education in Biomedical Sciences,<br />
Catholic University of Sacred Heart, Campobasso, Italy.<br />
Objective: To evaluate the effect of reader’s experience on preoperative assessment of pelvic endometriosis using<br />
magnetic resonance imaging (MRI).<br />
Material And Methods: 25 consecutive patients with biopsy-proven pelvic endometriosis were examined with a 1.5-<br />
Tesla MRI unit and then treated with surgery. Two experienced urogenital MR radiologists (R1, R2) and two general<br />
radiologists (R3, R4) retrospectively reviewed the examinations and evaluated the following potential locations of<br />
pelvic endometriosis: ovary, Douglas’ pouch/recto-vaginal septum, recto-sygmoid colon, bladder, anterior cul-de-sac.<br />
Interobserver agreement between R1/R2 and R3/R4 was measured with Cohen’s k test. Accuracy and likelihood ratio<br />
were measured with a complete postoperative histopathological examination used as the gold standard.<br />
Results: Interobserver agreement was calculated on all 25 cases. Accuracy was calculated on 21 cases because in 4<br />
patients detailed postoperative findings were not available.<br />
At pathology, endometriomas were found in right ovary in 13/21 patients and in the left ovary in 14/21 patients;<br />
Douglas’ pouch or recto-vaginal septum involvement was found in 14 patients; recto-sigmoidal infiltration was<br />
observed in 8 cases, anterior cul-de-sac was involved in 7 patients and bladder in 3 cases.<br />
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<br />
group. For Douglas/septum involvement k value was 0.56 for experts and -0.12 for non-experts. For rectosigmoidal<br />
infiltration k was 0.43 for experts and 0.20 for non-experts. For bladder involvement k was 0.75 for experts<br />
and 0.53 for non-experts.<br />
Accuracy for right ovarian endometrioma was 85% and 90% for R1 and R2 and 76% and 85% for R3 and R4. Accuracy<br />
for left ovarian endometrioma was 90% and 76% for R1 and R2 and 76% and 62% for R3 and R4. For<br />
Douglas/septum involvement R1 and R2 accuracy was both 66,7%, while it was 52% for R3 and 61% for R4. For<br />
recto-sigmoidal infiltration accuracy was 95% for R1, 76% for R2, 71% for R3 and 58% for R4. Accuracy for bladder<br />
infiltration was 81% for R1, 90.5% for R2, 68% for R3 and 72% for R4. All the results were not statistically significant<br />
(p>0.05)<br />
Conclusion: Although non statistically significant, due to small study sample, our results suggest that reader<br />
experience has a positive effect on interobserver variability and on the accuracy of preoperative prediction of pelvic<br />
diffusion of endometriosis. To obtain high-quality preoperative prediction of endometriosis diffusion, it is suggested<br />
that preoperative MRI evaluation should be performed by a radiologist expert in urogenital imaging.<br />
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SS8. PRE- AND POSTOPERATIVE DYNAMIC MRI: EVALUATION OF PELVIC ORGAN DESCENSUS IN<br />
SYMPTOMATIC WOMEN<br />
Alt C.D. 1 , Brocker K. 2 , Lenz F. 2 ,Sohn C. 2 , Kauczor H.U. 1 ,Hallscheidt P. 1<br />
1 University Hospital of Heidelberg, Dept. of Diagnostic and Interventional Radiology, 2 University Hospital of<br />
Heidelberg, Dept. of Urogenital Gynecology<br />
Objective: Evaluation of dynamic changes of pelvic organ descensus before and after mesh-repair by MRI.<br />
Method: In this prospective study 35 women with pelvic organ descensus underwent dynamic 1.5 T MRI before, 4 and<br />
12 weeks after mesh-repair.<br />
The examination protocol included sagittal T2w tse images (TR 3460ms, TE 85ms, matrix 512/282), axial T1w images<br />
(TR 128ms, TE 4,7ms, matrix 256/154), dynamic sagittal T2w trufi single-shot images under valsalva-maneuver (TR<br />
397ms,TE 1,5ms, matrix 256/125) and sagittal T2w trufi images under maximum abdominal pressure (TR 4,3ms, TE<br />
2,15ms, matrix 256/162).<br />
The dynamic changes of the pelvic organs were measured in accordance to two referential lines: the pubococcygealline<br />
and the symphysial-length-line.<br />
Results: Under valsalva the median of the maximum expansion of a cystocele was preoperative 5 cm, of an uterine<br />
descensus 0,4 cm, of an enterocele 2,5 cm and of a rectocele 0,4 cm.<br />
4 weeks after mesh-repair the median of the maximum expansion of a cystocele was 0,3 cm, of an uterine descensus<br />
– 2,1 cm, of an enterocele 1,4 cm and of a rectocele – 0,2 cm.<br />
12 weeks after mesh-repair the median of the maximum expansion of a cystocele was 1,1 cm, of an uterine descensus<br />
– 1,3 cm, of an enterocele 1,7 cm and of a rectocele – 0,4 cm.<br />
There’s a high significant difference between pre- and postoperative evaluation (p< 0,02) in a short follow-up period<br />
(12 wk).<br />
Conclusion: Dynamic MRI offers an accurate identification of pelvic structures and extent of descensus and allows to<br />
evaluate the success after reconstructive surgery.<br />
SS9.<br />
LONG-TERM QUALITY OF LIFE ASSESSMENT IN PATIENTS UNDERGOING UTERINE FIBROID<br />
EMBOLIZATION<br />
Popovic M., Berzaczy D., Puchner S., Zadina A., Lammer J., Bucek R.A.<br />
Department of Cardiovascular and Interventional Radiology, Medical University of Vienna, Währinger Gürtel<br />
18-20, A-1090 Vienna, Austria<br />
Purpose: Assessment of long-term outcomes of fibroid-associated quality of life in patients treated by uterine fibroid<br />
embolization.<br />
Materials And Methods: This retrospective follow-up cohort study was performed including all patients from a 2006<br />
publication. Analysis was performed by a questionnaire consisting of 49 questions about six topics. Assessment focus<br />
was put on comparing symptoms, follow-up, and quality of life in long-term.<br />
Results: The analysis was performed based on questionnaires from 39 patients. The median follow-up was 7.0 years<br />
(IQR: 1.5 years). Uterine fibroid embolization led to a reduction of bleeding symptoms in 89.7% of patients, pain in<br />
78.9%, bulk-related symptoms in 89.5%, fatigue in 76.9%, limitations in social life in 92.9%, and depression in<br />
78.6%. The median impairment score for bleeding and pain decreased significantly from 7 to 0 and from 5 to 0,<br />
respectively (both p < 0.001). The general quality of life index increased significantly from 4.5 to 9 (p < 0.001). In the<br />
long-term there was no significant difference in parameters assessed as compared to mid-term follow-up (for all,<br />
p
SS2.<br />
CONTRAST-ENHANCED ULTRASOUND IN SCROTAL DISEASES: PRELIMINARY RESULTS<br />
Valentino M., Bertolotto M.*, Barozzi L., Pavlica P.<br />
University Hospital S.Orsola-Malpighi Department of Radiology Bologna, Italy , * University of Trieste<br />
Cattinara Hospital, Department of Radiology, Trieste, Italy.<br />
Aim: Ultrasonography (US) is the mainstay for the scrotal pathology, but sometimes diagnosis may be indeterminate<br />
requiring further investigations. Contrast-enhanced ultrasound (CEUS) can improve the depiction of parenchymal<br />
disorders on the base of vascularity, which helps in the differential diagnosis of focal lesions or traumatic changes. Aim<br />
of this report is to analyze the effectiveness of CEUS findings in the evaluation of scrotal disease compared to baseline<br />
US.<br />
Methods: A second-generation contrast medium (SonoVue, Bracco, Italy) with a low-mechanical index linear probe (4-<br />
7MHz) was used in 42 patients (18-84yrs) with scrotal pain or suspected for solid mass or scrotal trauma.<br />
Results: Final diagnosis included 22 germinal tumors, 3 orchitis with abscess, 5 focal ischemic lesions, 6 trauma, 5<br />
infertility and 1 testicular torsion. CEUS showed absence of vascularisation in abscesses, ischemic areas and torsion;<br />
increased or in-homogeneous enhancement in tumors; in trauma absence of enhancement with or without albuginea<br />
interruption; in infertility areas of increased or reduced enhancement pattern.<br />
Conclusions: Technological developments have ensured that US has consolidated its role in the diagnosis and guidance<br />
of subsequent of management of patients with scrotal pathology. The use of CEUS can maximize its value and reduce<br />
the incidence of errors or misdiagnosis in focal lesions. Confidence is also increased in scrotal trauma and in the<br />
detection of hypervascularized spots in infertile men before micro-TESE. This preliminary data need to be confirmed in<br />
more extensive number of patients studied in different centres with operators of variable experience.<br />
SS3.<br />
EMERGENCY SONOGRAPHIC EVALUATION OF THE SCROTUM. HOW OFTEN IS PATHOLOGY<br />
DETECTED AND WHICH ARE THE COMMONEST ABNORMALITIES<br />
Cokkinos D.D., Antypa E., Tserotas P., Kyratzi E., Deligiannis I., Spiliopoulou G., Dagiakidi E., Piperopoulos<br />
P.N.<br />
Radiology Department. Evangelismos Hospital. Athens, Greece.<br />
Objectives: To calculate the proportion of patients with abnormal findings on emergency scrotal ultrasound. To review<br />
the commonest pathologies.<br />
Methods: Retrospective review of 114 patients aged 14 to 81 years subjected to emergency sonographic evaluation of<br />
the scrotum. Patients complained of pain, swelling, trauma, palpable mass or fever. We calculate how often one of<br />
the 4 basic emergency pathologies of the scrotum (torsion, trauma, infection, tumours) was diagnosed. We also<br />
assess how often a non emergent entity (normal variant, hydrocele, varicocele, cryptorchidism, calcifications etc)<br />
diagnosis was established, as well as the number of patients with no abnormality whatsoever identified.<br />
Results: Findings suggestive of infection (epididymitis/orchitis) were seen in 28 patients, torsion (reduced blood flow)<br />
in 11, trauma (testicular contusion or scrotal haemmorhage) in 21 and tumour (solitary or multiple lesions) in 9.<br />
Altogether 69/114 patients (60.5%) were diagnosed with one of the 4 major pathologies. In 25 patients (21.9%) non<br />
emergency entities (cysts, varicocele, hydrocele, cryptorchidism, discrepancy in size, calcifications) were detected.<br />
These patients were referred for a second ultrasound examination on a routine basis. Finally, in 20 patients (17.5%)<br />
no pathology evident on ultrasound was found.<br />
Conclusion: Emergency ultrasound of the scrotum is part of every day clinical practice. In most cases pathology is<br />
included in on of the 4 major groups. However, quite often non emergent entities or no abnormality whatsoever are<br />
found. Radiologists should be well trained in the anatomy, pathophysiology and sonographic examination technique,<br />
as well as differentiation of the commonest emergency and non emergency abnormalities.<br />
SS4.<br />
SONOGRAPHY OF THE ACUTE SCROTUM: THE COMPLEMENTARY ROLE OF IMAGING WITH ECHO-<br />
ENHANCER.<br />
Moschouris H. 1 , Papadaki M.G. 1 , Goutzios P. 2 , Tsagouli P. 1 , Stamatiou K. 3 , Gialias P. 1 , Matsaidonis D. 1<br />
1 .Department of Radiology, «Tzanio» General Hospital, Piraeus, Greece. 2 .Department of Radiology, 251<br />
General Air Force Hospital, Athens, Greece. 3 .Department of Urology, «Tzanio» General Hospital, Piraeus,<br />
Greece.<br />
Objective: To present and evaluate the findings of Contrast-Enhanced UltraSonography (CEUS) in typical cases of<br />
acute painful scrotum.<br />
Method: 16 patients (age: 19-61 years) were included in the study. They underwent grey-scale and color doppler<br />
ultrasonography of the scrotum, followed by imaging after i.v administration of 2.4 ml of a second generation<br />
ultrasound contrast agent (microbubbles of sulphur hexafluoride, SonoVue, Bracco). Α dedicated, contrast-sensitive<br />
technique was utilized (Contrast Tissue Imaging-CnTI). The diagnosis was confirmed surgically in 7 cases and was<br />
based on the combination of clinical, imaging and laboratory findings in 9.<br />
Results: The final diagnosis was: Testicular torsion (n=6, including one case of incomplete torsion), Epididymitis (n=2,<br />
one of the cases complicated with abscess), Testicular abscess (n=1), Scrotal abscess (n=1), Testicular trauma of<br />
varying severity (n=6). CEUS showed complete lack of enhancement in all cases of complete torsion, and impaired<br />
enhancement in the case of incomplete torsion, permitting a rapid and definitive diagnosis. In the cases of<br />
inflammation complicated by abscesses, CEUS delineated the lesions much better than the combination of grey-scale<br />
/color doppler US. The severely traumatized testicles showed minimal, inhomogeneous or patchy enhancement, while<br />
cases of minor trauma showed no significant enhancement defects. Hematomas presented as non-enhancing lesions.<br />
Conclusion: In selected cases of acute scrotum, CEUS may increase the efficacy and reliability of ultrasonographic<br />
diagnosis. Further studies are required to clearly define the indications of this method.<br />
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SS5.<br />
TESTICULAR TORSION: SONOGRAPHIC EVALUATION BEFORE AND AFTER MANUAL DETORSION<br />
Christopoulou A 1 ., Kaitartzis C 1 ., Mavridou C. 1 , Smponia A. 1 , Gotsis G. 2 , Katsiba D. 1<br />
1. Department of Radiology, General Hospital of Thessaloniki, “G.Gennimatas”, 2. Department of Urology,<br />
Aristoteles University of Thessaloniki, General Hospital of Thessaloniki, “G.Gennimatas”<br />
Objective: To present the value of scrotal sonography in the diagnosis of testicular torsion and successful detorsion by<br />
manipulation.<br />
Method: During a 2-year period 73 patients aged between 16 and 25 years with testicular torsion underwent scrotal<br />
sonography. In all cases, scrotal grey scale and Doppler ultrasound of the torsed testis in comparison with the<br />
contralateral one was performed and the spermatic cord was evaluated when necessary. 38 of these patients<br />
underwent an attempt of manual detorsion followed immediately by scrotal US examination.<br />
Result: In 24 of these patients with successfully detorsed testis, normal or increased testicular blood flow and<br />
straightened spermatic cord was revealed. In 5 patients with permanent torsion, no blood flow signal was noticed in<br />
testicular parenchyma. In 9 patients with normal or increased testicular blood flow, a coiled cord was revealed. In all<br />
cases sonographic diagnosis was surgically confirmed.<br />
Conclusion: Sonography is an accurate method for the diagnosis of testicular torsion and the success of preoperative<br />
manual detorsion. The later when successful relieves testicular ischaemia and converts an acute urological<br />
emergency into a less urgent or even elective surgical procedure.<br />
SS6. PROSTATE VOLUME MEASUREMENT VIA TRANSABDOMINAL ULTRASONOGRAPHY (TAUS)<br />
COMPARED TO THE TRUE SURGICAL SPECIMEN VOLUME AFTER RADICAL PROSTATECTOMY.<br />
Chatzidarellis E., Tavernaraki K*, Zarkadoulias A., Charalampopoulos G*, Mazaris E., Malachias G*,<br />
Deliveliotis C., Varkarakis I.<br />
2nd Department of Urology, University of Athens, Sismanoglio General Hospital, Athens, Greece, *Radiology<br />
Department, Sismanoglio General Hospital, Athens, Greece<br />
Objective: To evaluate the accuracy of transabdominal ultrasound in the determination of prostate volume compared<br />
with the volume of the surgical specimen after radical prostatectomy.<br />
Materials and Methods: Twenty-one male patients diagnosed with prostate cancer underwent a transabdominal<br />
ultrasound (TAUS) prostate examination one day prior radical prostatectomy. TAUS calculated prostate volume was<br />
compared retrospectively with the true volume of the excised prostate specimen after the seminal vesicles were<br />
transected. The excised prostate specimen volume was measured with a volumetric container. An adequate (300 ml)<br />
urinary bladder distention for the calculation of the prostate volume by TAUS was achieved and using a 5-MHz curved<br />
probe the prostate volume was determined using the ellipsoid formula multiplying the largest anterioposterior (height),<br />
transverse (width) and cephalocaudal (length) prostate diameters by 0.524. The correlation between the variables was<br />
determined by the Paired t-test. A p value of
SS8.<br />
IMAGE BASED CLINICAL DECISION SUPPORT WITH THE USE OF TRANSRECTAL ULTRASOUND IN<br />
THE DIAGNOSIS OF PROSTATE CANCER: COMPARISON OF MULTIPLE LOGISTIC REGRESSION,<br />
ARTIFICIAL NEURAL NETWORK, AND SUPPORT VECTOR MACHINE<br />
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<br />
1 ) Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang<br />
Hospital, Institute of Radiation Medicine, Seoul National University Medical Research Center, Clinical Research<br />
Institute, Seoul National University Hospital. 2 ) Department of Radiology, Seoul National University College<br />
of Medicine, Seoul National University Hospital. 3 ) Department of Urology, Seoul National University College<br />
of Medicine, Seoul National University Bundang Hospital<br />
Objective: To develop a multiple logistic regression model (MLR), artificial neural network (ANN), and support vector<br />
machine (SVM) model for the prediction of prostate cancer and to compare the accuracies of each model.<br />
Materials and Methods: From 2005 to 2007, 1077 consecutive patients who had undergone transrectal ultrasound<br />
(TRUS) guided prostate biopsy were enrolled in the study. The patients were divided into training group (n = 600) for<br />
training the decision models, and the test group (n = 477) for the evaluation of the accuracies in each decision model.<br />
A focal lesion as seen on TRUS was evaluated in detail, with evaluation of lesion location, outline, shape, and<br />
vascularity. To predict the probabilities of prostate cancer associated with variables, three types of clinical decision<br />
support models including a MLR, ANN, and SVM were constructed.<br />
Areas under the receiver operating characteristic curve were calculated to evaluate the performance of each decision<br />
model. Pairwise comparison of ROC curves was performed.<br />
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,<br />
respectively. Pairwise comparison of the ROC curves determined that there was a statistical difference between the<br />
use of SVM and ANN (p = 0.023) and between the use of the SVM and MLR(p = 0.023).<br />
Conclusion: The performance of the SVM was superior to the performance of the use of the ANN or the multiple logistic<br />
regression model in the prediction of prostate cancer based on TRUS findings.<br />
NEW FRONTIERS IN IMAGING AND SYSTEMIC DISEASES<br />
Moderators: Thoeny H. (CH) – Kelekis N. (GR)<br />
SS1.<br />
USPIO ENHANCED DIFFUSION-WEIGHTED MRI TO DETECT PELVIC LYMPH NODE METASTASES IN<br />
NORMAL SIZED NODES.<br />
FroehlichJ.M. 1 , Triantafyllou M. 1 , Birkhaeuser F. 2 , Fleischmann A. 2 , von Gunten M. 3 , Vermathen P. 4 , Binser<br />
T. 4 , Studer U.E. 2 , ThoenyH.C. 1 , 1 Department of Diagnostic, Pediatric and Interventional Radiology,<br />
Inselspital, University of Bern, Bern, Switzerland, 2 Department of Urology, Inselspital, University of Bern,<br />
Bern, Switzerland. 3 Department of Pathology, University of Bern, Bern, Switzerland. 4 Department of Clinical<br />
Research, Inselspital, University of Bern, Bern, Switzerland<br />
Objective: To prospectively assess the diagnostic potential of Diffusion-weighted MRI (DW-MRI) with ultra-small<br />
superparamagnetic particles of iron oxide (USPIO) to detect pelvic lymph node metastases in patients with bladder or<br />
prostate cancer.<br />
Method: Thirty four patients with histological proven prostate or bladder cancer planned for surgery underwent 3T MRI<br />
24-36hours post USPIO including 3D high resolution T1- and T2-w as well as axial EPI DW-MRI (slice thickness 4mm,<br />
b-values=0, 500, 1000sec/mm2, 6 acquisitions). Evaluation was performed prospectively prior to extended template<br />
lymphadenectomy. Duration of image analysis was recorded. Malignant lymph nodes were defined as round<br />
hyperintense structures on the DW-MR images at a b-value of 1000sec/mm2 corresponding to a node on<br />
morphological images. Benign lymph nodes were invisible on b=1000 images after USPIO-administration. Results were<br />
correlated to histopathology based on a per patient and per lymph node level.<br />
Results: In 34 patients a total of 1261 lymph nodes (mean 37/patient) with 44 positive, and 1217 negative lymph<br />
nodes were compared to histopathology. Metastases were detected in 12 patients, whereas 22 were negative. The<br />
following sensitivity, specificity, PPV, NPV and diagnostic accuracy values were calculated on a per patient level: 75%,<br />
91%, 82%, 87% and 85%, respectively; whereas on a lymph node level sensitivity reached 73%, specificity 99.7%,<br />
PPV 88%, NPV 99.1% and diagnostic accuracy 98.8%. Image analysis lasted 9min per patient (range: 5-45min).<br />
Conclusion: USPIO enhanced DW-MRI allows fast, easy and accurate detection or exclusion of pelvic lymph node<br />
metastases even in normal sized nodes.<br />
120
SS2.<br />
EFFICIENCY OF DIFFUSION-WEIGHTED (DW) MR IMAGING TO DETECT SMALL SIZE MALIGNANT<br />
PELVIC LYMPH NODES AT 3T IN VARIOUS PELVIC CARCINOMATOUS DISEASES.<br />
Roy C., Bierry G., Matau A., Pasquali R.<br />
Radiology B Nouvel Hopital Civil University Hospital, 1, place de l'hopital BP 426, STRASBOURG<br />
Purpose: To investigate the potential value of DW Images and Apparent Diffusion Coefficient (ADC) measurement to<br />
detect small malignant pelvic lymph nodes in cases of pelvic malignancies.<br />
Materials and Methods: A cohort of 196 patients with various pelvic pathology including 65 patients with metastatic<br />
nodes (bladder carcinoma : 22pts, prostatic carcinoma : 18pts, gynecologic malignancy : 17pts , lymphoma : 6pts,<br />
rectal carcinoma : 2pts) proved at pathology (48 cases)) or follow-up of advanced disease (7 cases) were explored on<br />
a 3T (Achieva, Philips Medical System) with conventional axial T1 and T2w sequences in addition to axial DWI SE-EPI<br />
(TR/TE : 7000/55,5mm,fat suppression, tf 41,EPI 41,32 slices, FOV : 288-340, Matrix size : 128-96,free breathing,3<br />
min54) using b value: 0 and 1000s/mm2.ADC was measured by ROI (20 mm2). DW images were analysed by two<br />
experienced readers. Measurements of short-axis diameter and visual evaluation on DW images were recorded.<br />
Statistical analysis was realized using the SPSS 14 software (SPSS Chicago,Ill). The normality of distribution of the<br />
ADC values of the different groups ("pathologic", "iliac", "inguinal", and "control") was checked using the Mann-<br />
Whitney test. ADC mean values and standard deviation of the different groups were then calculated and compared<br />
using Student<br />
T-test. P values superior to .05 were considered for rejection.<br />
Results: All nodes were less than 15 mm in short axis. On DW images, bilateral inguinal and iliac nodes were<br />
constantly seen with bright homogeneous signal for all groups, most numerous in inguinal location. There were no<br />
difference in signal intensity on visual evaluation between all groups. Image quality was rather good.<br />
A total of 65 pathologic nodes, 131 control normal iliac nodes and 84 control normal inguinal nodes were included in<br />
the study. The ADC of pathologic lymph nodes (mean ± standard deviation) of pathologic nodes, control iliac nodes<br />
and control inguinal nodes were, respectively, 924 ± 217 mm3/sec, 968 ± 182 mm3/sec, 1036 ± 181 mm3/sec.<br />
There were no statistically significant differences of ADC between pathologic nodes and control iliac nodes (p=.44),<br />
between pathologic nodes and control inguinal nodes (p=.24) and between pathologic nodes and all (iliac plus<br />
inguinal) control nodes (p=.23).<br />
Conclusion: 3T DW Images as well as ADC value are not accurate enough to differentiate benign from malignant small<br />
pelvic lymph nodes. Normal pelvic lymph nodes are visible routinely on DW images.<br />
SS3.<br />
RENAL ULTRASONOGRAPHIC FINDINGS IN GREEK PATIENTS WITH SICKLE-CELL ANAEMIA AND<br />
THALASSAEMIA INTERMEDIA<br />
Papadaki M.G. 1 , Moschouris H. 1 , Papadaki I.G. 2 , Kornezos I. 1 , Matsaidonis D. 1 , Kattamis C.A. 3<br />
1. Department of Radiology, “Tzanio” General Hospital, Piraeus, Greece. 2. Department of Haematology<br />
“Agioi Anargyroi” Hospital, Greece. 3. 1 st Pediatric Clinic, University of Athens, Grece<br />
Objective¨The extreme spectrum of clinical and haematological phenotypes of sickle-cell anaemia and thalassaemia<br />
intermedia (TI) constitute a major challenge in clinical practice in Greece. The aim of this study is to evaluate the type<br />
and prevalence of renal ultrasonographic (US) findings in these patients.<br />
Method: The study included 105 patients (49 males, 56 females), 13 homozygous for sickle-cell anaemia (S/S) and 92<br />
with TI syndromes. The patients’ ages ranged from 1 to 54 years. We used high resolution US scanners with convex<br />
and linear array transducers. Renal volume was calculated and parenchymal appearance was evaluated.<br />
Results: Increased renal reflectivity was observed in 17.6 % of patients with sickle-cell syndromes, being the most<br />
common finding (20%) in patients with TI. We observed three distinct US patterns: mild hyperechogenicity of the<br />
perimedullary spaces, moderate hyperechogenicity of the inter- and intramedullary spaces and marked<br />
hyperechogenicity of the renal medulla. Colour duplex US was performed in 10 patients and showed no significant<br />
changes from normal. Follow-up US examinations for 5 years revealed no significant changes. Renal enlargement was<br />
not a common finding, being diagnosed in only 15% of patients in the S/S group. One case of autosomal dominant<br />
polycystic disease was noted.<br />
Conclusion: In patients with sickle-cell syndromes, renal involvement is known to be capable of progression to endstage<br />
renal disease. Increased renal parenchymal echogenicity is a significant finding that could be the initial<br />
observation of the pathological basis for progression to chronic renal failure in older patients; however, further studies<br />
are needed.<br />
SS4.<br />
GUIDELINE ADHERENCE BY REQUESTING PHYSICIANS: ANALYSIS OF ABDOMINAL CT AT A LARGE<br />
UNIVERSITY CENTER IN THE NETHERLANDS<br />
van Es A.C.G.M., van der Molen A.J.<br />
Department of Radiology, C-2S , Leiden University Medical Center, Leiden The Netherlands<br />
Objective: To investigate the adherence to a clinical practice guideline for prevention of contrast-induced nephropathy<br />
(CIN) in the setting of intravenous contrast- enhanced abdominal CT at a large university medical center in the<br />
Netherlands.<br />
Method: From October to November 2008 all patients scheduled for contrast-enhanced abdominal CT were screened.<br />
According to our CIN prevention guideline the referring physician should provide information on risk factors and renal<br />
function parameters for all patients at increased risk for CIN when referring them for a contrast-enhanced abdominal<br />
CT. All requests lacking information regarding risk factors for CIN were analyzed for referral origin, renal function, CIN<br />
risk factors, and clinical follow-up. Departmental policy does not allow refusal of requests at day of study.<br />
Results: In total 261 consecutive requests were analyzed. In 134 incomplete requests (51.3%), essential information<br />
was missing. Further analysis showed that 28/134 (20.9%) had risk factors for CIN, and 11/134 (8.2%) should have<br />
underwent preventive intravenous hydration before undergoing contrast-enhanced CT. During the study, 7 of these<br />
patients were scanned without prevention, of which 1/11 developed renal function deterioration compatible with CIN.<br />
This CIN rate was not higher (p < 0.01) compared to the high risk group that did not require preventive hydration<br />
(0/17).<br />
Conclusion: Spontaneous CIN guideline adherence of requesting physicians is low and continuous education and/or<br />
refusal of incomplete requests is important. However, even in a setting of low-level screening of CT requests, the risk<br />
of CIN in intravenous contrast-enhanced abdominal CT is low, even in high risk groups.<br />
121
SS5.<br />
PROGNOSTIC VALUE OF PERIRENAL INVOLVEMENT IN THE EVALUATION OF ACUTE PANCREATITIS<br />
SEVERITY<br />
Fagrezos D., Kolliakou E., Triantopoulou C., Maniatis P., Siafas I., Koulentianos E., Papailiou J.<br />
CT department, Konstantopouleion general Hospital, Athens, Greece<br />
Purpose: to assess the prognostic value of early Computed Tomography (CT) findings as far as the prevalence of<br />
inflammation into renal and perirenal space is concerned, estimating the current best evidence about the effect of<br />
using a CT Score Index (CTSI) and the ExtraPancreatic Inflammation on CT Score (EPICTS) on patient outcome.<br />
Methods: 80 patients with acute pancreatitis who underwent an abdominal CT within 24 h after admission were<br />
included in the study. The CTSI and the EPICTS based on the presence of pleural effusion, ascites, retroperitoneal and<br />
mesenteric inflammation were calculated for all patients. The end points were the occurrence of severe acute<br />
pancreatitis (local complications or presence of organ failure for more than 48 h) and in hospital mortality.<br />
Results: CT scans were graded as mild (n=20), moderate (n=45) and severe (n=15).The observers detected<br />
renal/perirenal abnormalities included perirenal fat stranding (n=29), perirenal fluid collections (n=23), ureteral<br />
encasement (n=2), renal vein thrombosis (n=1) and renal parenchymal infiltration (n=2). In hospital mortality was<br />
6.25% (5/80). The mean EPICT score was 2.6. An EPICT score of 4 or more had a 100% sensitivity and 73%<br />
specificity for predicting severe pancreatitis. Perirenal fat stranding and collections correlated best with overall<br />
patients’ outcome.<br />
Conclusions: Extrapancreatic inflammation which involves perirenal space assessed by abdominal CT scan and<br />
quantified with EPICT score allows accurate estimation of disease severity and mortality within 24 h of admission and<br />
may affect the disease prognosis permitting the best therapeutic approach.<br />
SS6.<br />
LIVER METASTASES FROM RENAL CANCER: THE ADDED VALUE OF ARTERIAL PHASE OF THE LIVER<br />
IN STAGING WITH CT.<br />
Maniatis V., Foufa K., Stamoulis E., Tzovara I., Alexopoulos T., Giannoulakos N., Ziogana D., Tachtaras A.<br />
Diagnostic Imaging Department, Iaso General Hospital, Athens, Greece<br />
Purpose: Renal cancer is among the group of hypervascular primary tumors. Hypervascular primary neoplasms may<br />
give hypervascular hepatic metastases. Helical (spiral) and multislice CT offer the advantage of scanning the entire<br />
liver during both the arterial and portal venous phase. The purpose of this study was to assess the usefulness of<br />
hepatic arterial phase of abdominal CT in these patients in depicting hepatic metastases.<br />
Materials And Methods: Seventeen patients with hepatic metastases due to renal cancer are included. They are<br />
consisted of 8 men and 9 women, ranging in age from 33 – 78 years old. All the patients had triphasic (non contrast-<br />
NCP, hepatic arterial- HAP and portal venous phase-PVP) helical or multislice CT examinations.The number of lesions<br />
seen at each phase and their enhancement pattern were encountered. The contribution oh hepatic arterial phase<br />
(HAP) to the diagnostic results was specifically estimated.<br />
Results: A total of 95 metastatic liver lesions were found: 63 on NCP images, 78 on HAP images and 70 on PVP<br />
images. Nine different patterns of hemodynamic behaviour were encounterd. The most common pattern was that of a<br />
focal liver lesion that was hypodense during all the phases of the examination (seen in 36 % of the lesions). 17 % of<br />
the hepatic metastases were found only on hepatic arterial phase (HAP) and all were hyperdense - hypervascular.<br />
Hepatic arterial phase (HAP) was the most sensitive to reveal liver metastases.<br />
Conclusion: Hepatic metastases due to renal cancer may have a variable hemodynamic pattern. Hepatic arterial phase<br />
must be a part of the CT protocol in this group of patients together with non- contrast phase (NCP) and portal venous<br />
phase (PVP).<br />
SS7. THE APPLICATION OF MULTIDETECTOR COMPUTED TOMOGRAPHY IN THE DIAGNOSTIC<br />
EVALUATION OF ADULT POST-TRAUMATIC HEMATURIA<br />
Soldatos Th., Lampropoulou P., Karakyklas D., Mika A., Krommyda E., Zbogo A., Apostolopoulou G., Drossos<br />
Ch.<br />
Department of Radiology and Imaging, “G.Gennimatas” General State Hospital, Athens, Greece<br />
Objective: Computed tomography (CT) can provide essential anatomic and physiologic information required to<br />
determine management of intraabdominal and retroperitoneal injuries. The purpose of this study was to evaluate the<br />
sensitivity of multidetector CT in detecting the source of hematuria in patients with blunt abdominal trauma.<br />
Method: We retrospectively evaluated the CT scans of 53 trauma patients (37 males, 47±15 years old) who were<br />
referred to the imaging department due to gross hematuria in 26 cases (49%), microscopic hematuria associated with<br />
shock in 19 cases (36%), and microscopic hematuria associated with a positive diagnostic peritoneal lavage in 8 cases<br />
(15%). Unenhanced and three-phase (arterial, portal venous, 3-min delayed phases) dynamic abdominal CT scans<br />
were acquired in all subjects.<br />
Results: ccording to the imaging findings the cause of blood loss was renal contusion in 16 cases (30%), subscapular<br />
renal hematoma in 9 (17%), renal laceration in 5 (9%), renal vascular trauma in 3 (6%), bladder contusion in 11<br />
(21%), and bladder rupture in 7 (13%). Dynamic CT scanning enabled detection of active contrast extravasation in 11<br />
subjects (21%). However, in 2 patients (4%) no acute urinary pathology was revealed. The sensitivity of CT in<br />
establishing the cause of post-traumatic hematuria was 96%.<br />
Conclusion: Multidetector CT is a sensitive diagnostic modality for detecting acute urinary pathology in patients with<br />
post-traumatic hematuria.<br />
122
SS8.<br />
MESOAORTIC NARROWING OF THE LEFT RENAL VEIN IN ASYMPTOMATIC ADULTS: A NORMAL<br />
FINDING, NOT A NUTCRACKER SYNDROME<br />
Poletto E., Chernyak V., Ricci Z.J., Rozenblit A.M., Mazzariol F.<br />
Montefiore Medical Center 111 East 210 th Street Bronx, NY 10461 USA<br />
Purpose: Prior investigations suggest that ≥50% mesoaortic narrowing of the left renal vein (LRV), or a narrow angle<br />
(≤55º) between the superior mesenteric artery (SMA) and aorta are signs of nutcracker syndrome. This study aims to<br />
determine the range of LRV caliber and SMA-aortic angle in asymptomatic adults on CT angiography (CTA).<br />
Methods: This retrospective study analyzed CTA of potential renal donors performed between 2005 and 2009. Subjects<br />
with retroaortic LRV or hematuria were excluded. For each case, the following parameters were measured: 1) AP<br />
diameter of LRV at the mesoaortic (MAD) level, located between SMA and aorta, 2) AP diameter of LRV at left<br />
paraaortic (PAD) level, 3) SMA-aortic angle, and 4) distance between aorta and SMA at LRV level. MAD/PAD ratio was<br />
calculated. Correlations between the MAD/PAD ratio, SMA-aortic angle and SMA-aortic distance were computed.<br />
Results: There were 158 patients, 92 (58%) female, with mean age 35 years (range, 19-65). MAD/PAD ratio ranged<br />
from 0.15 to 1.30 (mean= 0.74). 50% or greater mesoaortic narrowing of LRV was found in 58/159 (36%) subjects.<br />
Mean SMA-aortic angle was 63.7° (range, 10.4-134.5). An angle of 55° or smaller was found in 64/159 (40%)<br />
subjects. Mean SMA-aortic distance was 12.3mm (range, 3.1-36.3). MAD/PAD ratio had strong positive correlation<br />
with both SMA-aortic angle (r=0.7) and SMA-aortic distance (r=0.7).<br />
Conclusion: As more than one third of asymptomatic subjects have at least 50% mesoaortic narrowing of LRV and/or<br />
narrow SMA-aortic angle, these parameters alone should not be used for diagnosis of nutcracker syndrome on CTA.<br />
SS9.<br />
64-MDCT EVALUATION OF POTENTIAL LAPAROSCOPIC LIVING RENAL DONORS<br />
Sebastia C., Salvador R., Buaesch L., Nicolau C., Revuelta I., Peri L.<br />
Hospital Clinic, Villarroel 170, 08035 Barcelona<br />
Purpose: Clinical relevance: this first study of the efficacy of 64-MDCT in preoperative evaluation of potential<br />
laparoscopic renal donors enables better results than 16-MDCT previously reported studies.<br />
Our objective is to determine the efficacy of 64-MDCT in preoperative evaluation of vascular anatomy of potential<br />
laparoscopic renal donors. As far as we know this is the first study done with 64-MDCT.<br />
Material And Methods: During the last two years (2007-2008) 70 patients (24 men and 30 women) have had<br />
laparoscopic nephrectomy for living kidney donation in our hospital. 60 of them had a 64-MDCT performed in our<br />
institution. Our 64-MDCT protocol includes an unenhanced and arterial phase of the superior abdomen, an<br />
abdominopelvic nephrographic phase and a delayed topogram in excretory phase. These MDCT have been<br />
retrospectively evaluated by two reviewers and results have been compared to surgical findings as a gold standard.<br />
Results: All principal arteries and supernumerary arteries (as small as 1mm) were documented by the two reviewers<br />
with 100% sensitivity and accuracy. Sensitivity and accuracy detection of early arterial bifurcation, late venous<br />
confluence and prominent lumbar and gonadal veins was 100%. Specificity in detection of renal veins was 97% for one<br />
reviewer and 98% for the second reviewer, the two reviewers made the same mistake confusing venous periureteral<br />
collaterals connected to a lumbar vein with a retroaortic vein. Sensitivity in detection of renal veins was 100%.<br />
Sensitivity and accuracy for evaluation of excretory system by means of delayed excretory topogram was also 100%.<br />
Conclusion: This first study of the efficacy of 64-MDCT in preoperative evaluation of potential laparoscopic renal donors<br />
enables better results than 16-MDCT previously reported studies.<br />
INTERVENTIONAL URORADIOLOGY<br />
Moderators: Petsas Th. (GR) – Theodoropoulos V. (GR)<br />
SS1.<br />
DYNAMIC MRI IN PATIENTS TREATED WITH SUB-URETHRAL SLING FOR STRESS URINARY<br />
INCONTINENCE<br />
Ocantos J., Kohan A., Mingote C., Fattaljaef V., Seehaus A., Garcia Monaco R.<br />
Hospital Italiano de Buenos Aires, Argentina<br />
Objective: To correlate Dynamic MRI findings in patients treated successfully with sub-urethral sling for stress urinary<br />
incontinence (SUI) According to continence theory (Parks)<br />
Method: From 01/2008 to 06/2008, nine patients (P), mean age 65,22 years old (range 57-74y), underwent DMR after<br />
being treated with sub-urethral sling. Two hour urine retention was indicated. We used 1.5T MR with “CP BODY ARRAY<br />
FLEX” coil. Obtaining static sequences (SS) T2 turbo spin eco axial, sagittal and coronal (TR 4700, TE 1.32) 4 mm.<br />
Dynamic sequences (DS) TRUFI sagittal (TR 4.8, TE 2.3) which where performed during voiding. We evaluated: SS:<br />
Signs of periurethral fibrosis (PF). SD: urethral longitude (UL), location of the urethral caliber change (UCCh), distance<br />
between this point and the bladder neck (DN) and functional kinking FK.<br />
Results: Mean UL was 33mm (17.6mm-54.7mm). Average DN was 16.9mm (19-28.5mm).Anterior urethral angulation<br />
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<br />
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%)..<br />
55.6% of the P did not present FK thougth urinary continence was achieved.<br />
Conclusion: According to continence theory, anterior angulation in middle urethra is necessary to achieve urinary<br />
continence. Probably this is not entirely true. PF associated with no anterior angulation is a frecuent finding that could<br />
play an important role and should be further evaluated.<br />
123
SS2.<br />
LONG TERM RESULTS AFTER PROLONGED URETERAL STENTING IN CASES OF OBSTRUCTIVE<br />
UROPATHY POST RENAL TRANSPLANTATION<br />
Pappas P., Ikonomopoulou V., Kaza S., Panagiotidou Ch., Gkeneralis G., Zioga V., Papaspyrou S.<br />
Radiology Department, Laiko General Hospital, Athens, Greece.<br />
Objective: Renal transplantation is an effective treatment for end-stage renal disease. Ureteral stenosis is the most<br />
frequent urologic complication. We report our long-term follow-up results concerning endourologic treatment of<br />
ureteral obstruction after renal transplantation.<br />
Method: Between 2000 and 2008, 35 patients with renal transplant obstructive uropathy were managed with<br />
percutaneous nephrostomy and prolonged ureteral stenting.<br />
Results: Percutaneous nephrostomies were performed successfully in all 35 kidneys. In these patients, antegrade<br />
ureteral stenting was attempted, which was successful in 33 patients (94.2%). After prolonged ureteral stenting<br />
(mean duration 15 months), the stent was removed in all patients, 30 (90.9%) of whom had no recurrence. Success<br />
was defined as a reduction in hydronephrosis with subsequent drop in plasma urea and creatinine levels. No major<br />
complications were observed. During follow-up (36 to 107 months; mean 73), urea, creatinine, sodium, and potassium<br />
determinations and ultrasound scans were performed.<br />
Conclusion: Percutaneous interventional procedures have replaced open reconstructive surgery in most patients with<br />
ureteral obstruction after renal transplantation, because they have a high success rate and they can also offer a<br />
definitive treatment with low morbidity.<br />
SS3.<br />
OUTCOMES AND COMPLICATIONS OF PCNL IN PATIENTS WITH SPINAL PATHOLOGY: SEVEN YEAR<br />
EXPERIENCE IN A TERTIARY REFERRAL CENTRE<br />
Belfield J.C., Wilkinson B., Salim F., Hastie K., Hall J.<br />
Royal Hallamshire Hospital, Sheffield, England.<br />
Objective: To assess the complication rates and stone clearance in patients with spinal pathology undergoing PCNL in<br />
our institution.<br />
Methods: All patients with spinal pathology who underwent PCNL between 2002 and 2009 were identified. The<br />
following data was then obtained and evaluated: type of spinal pathology, number of tracts, number and size of<br />
stones, stone clearance following the procedure, length of hospital stay, sepsis, drop in haemoglobin, need for blood<br />
transfusion, date of drain removal and any other complication.<br />
Results: 35 procedures were undertaken on 25 patients of which 12 had spina bifida, 12 traumatic cord injury and 1<br />
ankylosing spondylitis. 20 cases (57%) were for multiple stones whilst 15 (43%) had a single calculus. 26 stones<br />
(74%) were over 2cm in size with 9 (26%) less than 2cm. 3 procedures involved 2 tracts, but the remainder were<br />
done via a single tract. At the end of the procedure 25 cases (71%) were documented as complete clearance, with 10<br />
(29%) incomplete. Average length of hospital stay was 6.5 days, ranging from 3 to 15 days. 2 patients (6%) required<br />
blood transfusion and one patient underwent embolisation and subsequent nephrectomy the day after the procedure.<br />
7 (20%) were found to have sepsis following PCNL and 4 (11%) patients required HDU admission.<br />
Conclusion: PCNL in patients with spinal pathology can be technically challenging and have a high complication rate.<br />
SS4.<br />
HOW EFFECTIVE IS THE FLAT-PANEL ANGIOGRAPHY SYSTEM IN LOWERING THE OVARIAN DOSE<br />
DURING UTERINE ARTERY EMBOLIZATION (UAE)<br />
Firouznia K., MD 1 , Ghanaati H., MD 1, Sharafi A., Phd, MPH 2 Bohloul R., MSC 3 ,Abahashemi F., MSC, MPH 3 ,<br />
Jalali A.H.,MD 3 , Shakiba M., MD 3<br />
1- Medical Imaging Center, Medical Sciences/University of Tehran, Tehran, Iran.<br />
2- Medical physics department, Iran University of Medical Sciences<br />
3- Medical Imaging Center, Medical Sciences/University of Tehran, Tehran, Iran.<br />
Purpose: Considering that uterine artery embolization(UAE) is performed on women in reproductive ages, lowering the<br />
radiation dose in this procedure is quite important. The aim of this study is to evaluate the exposure dose to patients<br />
during UAE using conventional DSA unit, comparing with a digital flat-panel system.<br />
Patients and Methods: 27women who underwent UAE due to symptomatic fibroids were enrolled in this study. We<br />
randomized them for two angiographic equipments. 12patients were embolized using a digital flat-panel system and<br />
17cases by using a conventional unit.<br />
Radiation dose to patients’ skin (entrance and exit doses) as well as ovaries was evaluated with thermoluminescent<br />
dosimeters. The skin and ovarian doses were compared between the two groups with each angiographic system.<br />
Results: The mean fluoroscopy time, MAS of fluoroscopy, MAS of spots, total MAS, right & left ovarian depth was not<br />
statistically different between the two groups.(all P>0.28)<br />
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<br />
right side entrance dose was 1587±1221in the conventional group and 618±540in the flat panel group.(P=0.012)<br />
These figures were 1470±1170and 456±396 for left side respectively(P=0.006) The mean right side exit dose was<br />
18.8±12.3for conventional group and 9.7±6.7for flat panel group(P=0.028)<br />
These figures were 16.9±11.3and 10.1±6.8for left side respectively(P=0.081)<br />
The mean right ovarian dose was 139.9±92in the conventional group and 23.5±17.8for flat panel group.(P
SS5.<br />
COMPARISON OF CT-GUIDED CORE NEEDLE BIOPSY AND FINE NEEDLE ASPIRATION IN THE<br />
ABDOMEN AND PELVIS<br />
Chernyak V., Paroder V., Poletto E., Mazzariol F., Rozenblit A.M.<br />
Montefiore Medical Center 111 East 210 th Street, Bronx, NY 10461 USA<br />
Purpose: To compare rates of diagnostic sample between CT-guided core-needle biopsy (CNB) and fine-needle<br />
aspiration (FNA).<br />
Methods: We retrospectively reviewed images and medical records of CT-guided biopsies performed during a threeyear<br />
period. For each case, we recorded the presence of adequate diagnostic sample, history of known primary<br />
malignancy (PM), lesion size, skin-to-lesion distance, attenuation of the lesion (HUL) and adjacent background (HUB).<br />
Absolute difference between HUB and HUL was defined as visibility index (VI).<br />
Results: There were 188 patients, 118(63%) female, mean age 62.3 years, who underwent 226 biopsies: 112(50%)<br />
FNAs and 114(50%) CNBs. Diagnostic sample was obtained in 105/114 (92%) CNBs and 93/112 (83%) FNAs<br />
(p
SS8.<br />
THE VALUE OF HYSTEROSALPINGOGRAPHY(HSG) AS A FIRST – STEP DIAGNOSTIC TOOL IN THE<br />
INVESTIGATION OF PERITUBAL PATHOLOGY IN THE INFERTILE WOMAN.<br />
Deftereos S., Mintzopoulou P., Iordanidis A., Kafetzis G., Limperis V., Prassopoulos P.<br />
Radiology Department and Medical Imaging, University Hospital of Alexandroupolis, Democritus University of<br />
Thrace<br />
Purpose: To reconsider the value of HSG in evaluating peritubal adhesions in infertile woman.<br />
Material and methods: A total of 74 consecutive patients (age range 22-46 years, mean 30years), with at least twoyear<br />
infertility, underwent HSG followed by laparoscopy. HSG was performed in the menstrual cycle’s mid proliferative<br />
phase. The following radiological signs were considered: convoluted / vertical tubes, ampullary dilatation, hallo effect,<br />
peritoneal contrast medium loculation and uterus fixed laterodeviation. The morphology and extend of endocervical<br />
canal and endometrial cavity were also evaluated. Laparoscopy was performed in the same phase of the cycle, 5-7<br />
months after HSG in all patients and results were compared with HSG findings.<br />
Results: Seven (7) patients exhibiting totally obstructed tubes were exlcluded from the study. Eleven (11) tubes were<br />
not demonstrated due to surgical removal (n: 4) or to in adequate visualization (n: 7). Consequently, 123 tubes were<br />
analyzed. In 17 (13,8%) no abnormality was revealed by both HSG and laparoscopy. HSG suggested adhesions in 59<br />
tubes by the presence of one radiological sign; 23 of those were confirmed by laparoscopy (36 false positive results for<br />
HSG). Adhesions were diagnosed in 47 tubes by HSG, when two or more signs were present; 39 true positive and 9<br />
false positive results based on laparoscopy. There were no false negative results for HSG.<br />
Conclusion: HSG may still be considered an effective fisrt - step diagnostic technique in peritubal pathology<br />
investigation. The accuracy of HSG is raised when more than one radiological signs are present.<br />
RENAL TUMORS – NEOPLASMS<br />
Moderators: Tsitouridis I. (GR) – Matsaidonis D. (GR)<br />
SS1.<br />
COMPARISON OF CONTRAST-ENHANCED ULTRASOUND AND COMPUTED TOMOGRAPHY IN<br />
CLASSIFICATION OF CYSTIC RENAL MASSES<br />
Foukal J., Jakubcova R.<br />
Department of Radiology, University Hospital Brno and Medical Faculty Masaryk University Brno, Czech<br />
Republic<br />
Objective: To asses performance of contrast-enhanced ultrasound (CEUS) in classification of cystic renal masses using<br />
Bosniak system.<br />
Method: Total number of 28 patients (30 kidneys) was included, only cysts with highest Bosniak score were counted.<br />
Patients underwent contrast-enhanced CT a CEUS with administration of 1,0 to 2,0ml of SonoVue (Bracco, Italy). All<br />
cysts were classified with Bosniak system on both examinations.<br />
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<br />
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<br />
carcinoma, other two type IV cysts were classified as metastatic lesions according to other findings. Two resected type<br />
III cysts were benign. Type II, IIF and unresected type III cysts were stable in the follow-up.<br />
Bosniak score correlated in 19/30 cases (63%). If cysts were divided into non-surgical (type I,II,IIF) and surgical<br />
group (type III,IV), the correlation was 90%.The differences were due to better depicting of septa on US,<br />
hyperattenuating vs. anechogenic cyst, pseudoenhancement on CT and in one case unclear enhancement of cystic wall<br />
or surrounding parenchyma on CEUS.<br />
Conclusion: Contrast enhanced ultrasound can be used for classification of renal cysts, it is adding information to CT<br />
because it can clearly visualize enhancing of components of the cyst and can confirm cystic character of solid-like<br />
echogenic lesions.<br />
SS2. DW MRI VS DYNAMIC MRI IN DIAGNOSIS OF PROSTATE CANCER; A PROSPECTIVE STUDY<br />
Abou El-Ghar M., Hekal I.*, Mohsen T., Refaie H., El-Diasty T.<br />
Radiology & *Urology departments, Urology & Nephrology center, Mansoura University-Egypt<br />
Aim of the work: To Compare the clinical feasibility of diffusion-weighted (DW) MRI Vs dynamic MRI in detection of<br />
prostate cancer .<br />
Materials and Methods: 44 patients with PSA > 4ng/ml(mean 30.9± 25 ng/ml; range 4.1-100)were prospectively<br />
included in our study, their age range 45-76ys(mean 65.5±6) & the glesson sore range from5-9. All patients were<br />
evaluated with MR imaging using surface coil. We started with axial T2 weighted high resolution MR of the prostate,<br />
then DW MRI with b value 0 & 800 msec. The DWI MRI and ADC characteristics were analyzed and compared with<br />
qualitative dynamic MRI results. Using the final histopathological findings; the accuracy of DW & dynamic MRI in<br />
diagnosis of prostate carcinoma were evaluated.<br />
Results : Among our patients there were 40 patients with prostate cancer and 4 patients with BPH there is associated<br />
chronic prostatitis in 12 patients. DW MRI could detect prostate cancer in 34 patients while dynamic MRI can detect it<br />
in 33 patients . The agreement between DW , dynamic MRI and histopathological findings was excellent. The<br />
diagnostic performance of DWI& dynamic MRI in the identification of prostate cancer was: sensitivity, 85 %& 82.%;<br />
specificity, 100% for both, the overall accuracy was 86.4% & 84.1% respectively. The ADC value for the normal PZ<br />
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.<br />
Conclusion : DW MRI is a reliable imaging approach for identification of prostate cancer with accuracy comparable to<br />
dynamic MRI, but DW MRI is non invasive, fast and less expensive technique.<br />
126
SS3.<br />
IS 18FDG PET/CT A USEFUL IMAGING MODALITY FOR THE MANAGEMENT OF PATIENTS WITH<br />
URINARY TRACK CANCER<br />
Panagiotidis E., Exarchos D. 2 , Rondogianni P., Skilakaki M. 2 , Vlontzou E., Chroni P., Datseris I.<br />
Nuclear medicine 1 , and Radiology 2 Departments, “Evangelismos” General Hospital, Athens, Greece<br />
Aim: To assess the value of 18FDG PET/CT in the management of patients with urinary tract tumors.<br />
Patients-Method: This is a retrospective study involving 81 patients – 73 male and 8 female- all with a tumor of the<br />
urinary track aged 38-86 (mean age: 66.7 years) who were referred to our hospital from February 2007 to December<br />
2008. All patients underwent surgery for resection of the primary tumor and diagnosis was confirmed surgically.<br />
18FDG PET/CT was performed > 30 days after chemotherapy. All scans were reviewed by two physicians, a nuclear<br />
medicine physician and one radiologist.<br />
All patients underwent integrated PET-CT 60 minutes post IV injection of 370MBq 18 F-FDG. Diagnosis was reached by<br />
consensus.<br />
Results: 36 out of 81 (47%) patients had kidney carcinoma, 22/81 (27%) patients had bladder carcinoma, 22/81<br />
(27%) patients had prostate carcinoma and 1/81 patient had cancer of ureter. 59 (73%) patients were referred for<br />
PET/CT examination with main indication of possible relapse. 24 out of 59 had kidney carcinoma, 18 had prostate<br />
carcinoma, 16 had bladder carcinoma and 1 had ureter carcinoma. The remaining indications for PET/CT examination<br />
were restaging (21%), evaluation of a residual mass (3%) and follow-up (3%).<br />
PET/CT results were in concordance with conventional imaging modalities (CT-MRI) in 18 out of 81 (23%) patients. In<br />
16/81 (19%) patients PET/CT was negative despite the suspicious findings of CT and/or MRI. In 47 (48%) cases<br />
PET/CT revealed more findings than those of the conventional imaging methods, upstaging them and altering the<br />
treatment plan.<br />
Conclusions: The indications of 18FDG PET/CT in patients with cancer of the urinary tract are rather limited due to<br />
different reasons (elimination of FDG by the urinary tract, high degree of differentiation of some types of prostate<br />
cancer).From the small patient population of this study it seems, however, that 18FDG PET/CT may be a useful<br />
method when relapse is suspected with equivocal or negative conventional imaging. This is especially true for patients<br />
with renal cell carcinoma who consist the majority of patients referred to the PET/CT unit of our tertiary hospital. A<br />
larger prospective study targeted to this special population is necessary to prove these findings.<br />
SS4.<br />
THE ROLE OF MULTI-PHASE MDCT IN THE PREOPERATIVE ASSESSMENT OF RENAL AND URINARY<br />
TRACT PATHOLOGY<br />
Skondras E (1), Zampakis P(1), Kalidonis P (2) ,Kraniotis P(1), Liatsikos E (2), Romanos O(1), Petsas T(1),<br />
Kalogeropoulou C(1).<br />
(1) University hospital of Patras. Radiology Department<br />
Objective: To assess the diagnostic and preoperative value of multi-phase Multi Detector CT (MDCT) regarding patients<br />
with pathology from the kidney and the urinary tract.<br />
Method: Our study included 66 patients (from 19 to 81 yrs) with clinical / laboratory suspicion or confirmed diagnosis<br />
of renal or urinary tract pathology (calculi, renal neoplasm, ureteropelvic junction obstruction syndrome – UPJO). Our<br />
scanning protocol included multi-phase acquisition of unenhanced and enhanced sequences with regard to the<br />
pharmacokinetics of i.v. contrast medium in the kidneys. It consisted of three sequences (corticomedullary sequence<br />
covering only the kidneys, nephrographic sequence and excretory sequence extending from the kidneys to the urinary<br />
bladder). Subsequent image processing consisted of standard or arbitrary anatomical planes reconstruction (MPR) as<br />
well as CPR (curved planar reconstruction), MIP (maximum intensity projection) and VR (volume rendering) techniques<br />
in order to designate the underlying pathology and facilitate the preoperative plan from the urologist.<br />
Results: The initial suspicion or diagnosis was confirmed in 51 cases (77%) and a meticulous anatomical exploration<br />
was performed. There were 21 cases of urinary tract calculi (32%), 19 cases of UPJO syndrome (29%) and 11 cases of<br />
renal neoplasm (16%). In five cases (8%), other pathology was uncovered while in 10 cases (15%) no pathology was<br />
detected.<br />
Conclusion: Multi-phase MDCT with subsequent image post processing and reconstruction of multiple anatomical<br />
planes is a comprehensive one–stop examination for diagnosis and further study of renal and urinary tract pathology.<br />
SS5.<br />
AN ASSESSMENT OF THE SPECIFICITY OF CT PIXEL MAPPING IN THE DIAGNOSIS OF AML VERSUS<br />
MALIGNANT RENAL TUMORS<br />
Patel R., Bardgett H.P.<br />
Bradford Teaching Hospitals, Bradford, UK<br />
Objective: To evaluate the use of CT pixel mapping in the assessment of renal masses to differentiate fat poor<br />
angiomyolipoma (AML) from renal cell carcinoma.<br />
Methods: The CT imaging of 17 consecutive patients over a 12 month period who underwent nephrectomy for a renal<br />
mass (with no macroscopic fat visible on CT) was retrospectively evaluated.<br />
Radiologists blinded to the histological diagnosis sampled the visibly solid element of each mass with multiple CT<br />
region of interest (ROI) pixel maps. Control ROI pixel maps were obtained from normal renal parenchyma in the same<br />
patients.<br />
A cluster of 4 or more adjacent pixels with a value less than or equal to -10 Hounsfield Units (HU), (threshold A) and a<br />
cluster of 3 or more adjacent pixels with a value less than or equal to -20 HU (threshold B) were adopted as the two<br />
thresholds for diagnosing AML.<br />
Results: 19% (3/16) and 25% (4/16) of malignant renal cancers were falsely characterized as AML, 23% (4/17) and<br />
18% (3/17) of the control group of normal renal parenchyma were classified as AML with thresholds A and B<br />
respectively.<br />
The one AML in the study sample was not correctly characterised with either threshold.<br />
The specificity of pixel mapping for diagnosing AML in the renal mass cohort was 81% and 75%, in the control group<br />
was 76% and 82% with thresholds A and B respectively.<br />
Conclusion: The low specificity, with demonstrable false positives in malignant renal tumors, precludes CT pixel<br />
mapping as a safe way to diagnose AML.<br />
127
SS6.<br />
SONOGRAPHIC PATTERNS AND CAUSES OF BRIGHT KIDNEYS IN PEDIATRIC PATIENTS<br />
Papadaki M.G. 1 , Moschouris H. 1 , Tsagouli P. 1 , Kalikis D., 1 Ouranos V. 2 , Khalili M. 1 , Spyridonos A. 1 ,<br />
Matsaidonis D. 1<br />
1.Department of Radiology, «Tzanio» General Hospital, Piraeus, Greece, 2.Department of Radiology,<br />
«Evangelismos» Hospital, Athens, Greece<br />
Objective: Ultrasonography is very sensitive in identifying changes in renal parenchymal reflectivity (RPR). In this<br />
retrospective study we present and evaluate the sonographic findings in various conditions that cause bright kidneys in<br />
pediatric patients.<br />
Method: High resolution US renal scans of 5300 patients aged 0-14 yrs were reviewed when diagnosis was<br />
established. Indications were variable. Kidneys were considered to have increased RPR when their parenchyma was<br />
more reflective than liver or spleen, except from neonates where the above state as a single finding was considered<br />
normal. Renal volume was evaluated and preservation or loss of the corticomedullary (C/M) differentiation was noted.<br />
Results: Increased RPR was noticed in 251 patients (4,7%), and was bilateral in 201. The finding was associated with<br />
sepsis (n= 49 cases), with nephrotic syndrome (n= 37), hypoplasia/dysplasia in (n=35), neoplasia (leukaemia,<br />
lymphoma, chemotherapy) (n=28), glomerulonephritis (n= 26), autosomal recessive polycystic kidney disease (n=<br />
22), hemolytic-uremic syndrome (n= 17), storage disorders (n= 14) and chronic renal failure (n=14). Less common<br />
clinical diagnoses included renal vein thrombosis (n=5), acute tubular necrosis (n=3), nephroblastomatosis (n=1).<br />
Specific patterns were mainly associated with glomerulonephritis, autosomal recessive polycystic kidney disease,<br />
dysplasia, chronic renal failure, renal vein thrombosis and nephroblastomatosis.<br />
Conclusion: Increased renal parenchymal reflectivity is a non-specific sonographic finding that usually indicates<br />
medical renal disease. Knowledge of the various patterns and of the associated features of each disease often helps to<br />
narrow differential diagnosis.<br />
SS7.<br />
IMAGING OF RENAL TRAUMA WITH CONTRAST-ENHANCED ULTRASONOGRAPHY<br />
Moschouris H. 1 , Papadaki. M.G. 1 , Goutzios P. 2 , Tsagouli P. 1 , Mpouma E. 1 , Gialias P. 1 , Vlachou C. 1 ,<br />
Matsaidonis D. 1<br />
1.Department of Radiology, «Tzanio» General Hospital, Piraeus, Greece. 2.Department of Radiology, 251<br />
General Air Force Hospital, Athens, Greece<br />
Objective: Renal trauma is often a diagnostic challenge for conventional sonography. We performed a small<br />
retrospective study, in order to evaluate the additional information provided by Contrast-Enhanced Ultrasonography<br />
(CEUS), when this technique is applied immediately after the baseline sonographic examination of an injured kidney.<br />
Method: 22 patients with blunt unilateral renal injury were included in the study. The final diagnosis was provided by<br />
Contrast-Enhanced Computed Tomography (CECT) in all cases. Before CECT, all patients underwent unenhanced US<br />
(grey-scale and color/Power Doppler examination) and thereafter CEUS with a 2nd generation echo-enhancer<br />
(SonoVue,Bracco) and a dedicated, low mechanical index, contrast-specific technique. The findings of unenhanced US<br />
and CEUS were correlated with those of CECT.<br />
Results: 14/22 cases of renal injury were correctly detected on unenhanced US, and CEUS/CECT simply confirmed the<br />
initial sonographic diagnosis. 8/22 cases of renal injury (36%) were missed on unenhanced US, or the unenhanced US<br />
findings were inconclusive [renal laceration (n=4), traumatic renal infarct (n=2), perirenal hematoma (n=2)].On the<br />
contrary, CEUS correctly diagnosed all these injuries, and CEUS findings correlated closely with CECT.<br />
Conclusion: CEUS may substantially increase the diagnostic efficacy of sonography of renal trauma, particularly in<br />
lesions that cause no significant alteration in the echotexture of renal parenchyma or perirenal space and when the<br />
inherent limitations of color/power Doppler preclude a definite diagnosis. CEUS may be applied immediately after the<br />
initial sonographic survey, when there is strong clinical and laboratory evidence of renal trauma, but unenhanced US is<br />
negative or equivocal.<br />
SS8. THE VALUE OF DIFFUSION-WEIGHTED MAGNETIC RESONANCE IMAGING AND RELATIVE<br />
APPARENT DIFFUSION COEFFICIENT IN DIFFERENTIATION BETWEEN RENAL CANCER AND<br />
REGULAR PARENCHYMA<br />
Javor D. 1 , Remzi M. 2 , Herneth A. 1 , Krssak M. 1 , Weber M., Haitel A. 3 , Memarsadeghi M. 1<br />
¹Department of Radiology, ² Department of Urology und 3 Department of Pathologie of Medical University<br />
Vienna<br />
Objective: This study was carried out to evaluate the usefulness of diffusion-weighted imaging and the apparent<br />
diffusion coefficient (ADC) in the differentiation between renal tumors and normal renal parenchyma by comparison of<br />
the respective ADC-values.<br />
Methods And Materials: A total of 19 renal tumors, predominantly cortical lesions, confirmed by histology, were<br />
examined on a 3-T MR scanner. In case of homogeneous tumors, ADC-values of the entire lesion were measured. In<br />
case of heterogeneous tumors, the hypointense and hyperintense parts of the lesion were measured separately.<br />
Furthermore the ADC-values of the normal ipsi- and contralateral renal parenchyma were evaluated and compared to<br />
the ADC-values of the focal lesions.<br />
Results: The ADC-values in renal tumors (mean ADC:1172, SD:273) were significantly lower than those of normal<br />
renal parenchyma(mean ADC:1580, SD:136)(P
SS9.<br />
IMAGING EVALUATION AND MANAGEMENT OF MULTIPLE RENAL MASSES<br />
Kolliakou E., Triantopoulou C., Fagrezos D., Maniatis P., Siafas I., Koulentianos E., Papailiou J.<br />
CT department, Konstantopouleion General Hospital, Athens, Greece<br />
Objective: We report our experience with multiple renal masses on CT imaging. Our purpose was to determine any<br />
particular imaging features that could aid in the diagnosis and management of the affected patients.<br />
Materials and methods: 28 patients with 57 renal lesions, measuring 1-4cm, were included in this retrospective study.<br />
Of the 57 lesions, 38 were solid masses and the remaining 19 were cystic-Bosniak type III or IV lesions. 32 masses in<br />
18 patients were removed surgically by radical nephrectomy (n=10) or partial nephrectomy (n=8) and 4 masses in 3<br />
patients were referred for RFA. In equivocal cases of bilateral disease when surgery was not performed, the patients<br />
were followed with serial abdominal CT. The median follow-up was 24 months. In 21 indeterminate lesions that<br />
presented diagnostic dilemma the diagnosis was confirmed by CT-guided biopsy.<br />
Results: 15/19 cystic lesions had thick irregular walls and 13 of them were malignant (86.6%). 8/19 cystic lesions had<br />
mural nodules and 6 of them were malignant (75%). 17/38 solid lesions presented intense contrast enhancement and<br />
11 of them were malignant (64.7%). As independent imaging features, mural nodules and wall irregularity in cystic<br />
lesions and intense contrast enhancement in solid lesions were highly associated with malignancy.<br />
Conclusion: The appearance of benign and malignant renal lesions on CT may overlap, suggesting that distinct<br />
differentiation between these entities is not always possible. In such cases, a percutaneous biopsy is useful for the<br />
proper diagnosis obviating the need for unnecessary surgery specifically in patients with bilateral renal involvement.<br />
SS10.<br />
ULTRASOUND IN DETECTION OF RENAL MASSES: MISSED AND WRONGLY CHARACTERIZED<br />
LESIONS<br />
Brkljačić B., Hrkać-Pustahija A., Ćurić J., Ivanac G., Čikara I.<br />
Department of Radiology, University Hospital «Dubrava», Zagreb, Croatia<br />
Objective: Many solid or solid-cystic renal lesions are found incidentally on US and CT, and US is often the first<br />
imaging modality detecting benign and malignant renal lesions. Ultrasound is nowadays interdisciplinary method<br />
performed by many, and understood by few, and is very operator-dependant. The analysis is presented of erroneous<br />
sonographic diagnosis of renal masses other than cysts.<br />
Materials and Methods: Retrospective analysis of medical histories was performed of 126 patients (82 m, 44 f, age<br />
range 5-83 years) in whom renal tumors were diagnosed by US and CT in our Department over a seven-years period<br />
in those patients who had at least one renal US examination
RADIOLOGICAL<br />
TECHNOLOGISTS’<br />
SESSIONS<br />
130
SESSION 1<br />
MAGNETIC RESONANCE IMAGING OF THE URINARY SYSTEM<br />
Malamateniou Ch.<br />
Hammersmith Hospital, Imperial College London.<br />
Abstract: Background: Magnetic Resonance Imaging (MRI) is a non invasive, relatively safe, in vivo imaging method,<br />
with the potential of high spatial resolution and increased tissue contrast-to-noise ratio (CNR). No ionising radiation is<br />
used and there is no need for contrast administration, particularly for the anatomical investigations.<br />
Objective and Methods: To critically review current and past literature in order to assess the challenges and<br />
opportunities of the use of magnetic resonance in imaging the urinary tract in all populations. For this meta-analysis<br />
Pubmed was used as the source and carefully selected keywords were employed.<br />
Conclusions and Discussion: MRI can be applied for the evaluation of a wide spectrum of renal diseases. The use of<br />
magnetic resonance in imaging the urinary tract is currently increasing but it is mainly reserved for the fetal, neonatal<br />
and pediatric populations. MRI of the urinary tract may provide both anatomical and functional information. It also<br />
correlates well with other urinary imaging techniques, such as with Lasix renal scanning, in assessing renal function<br />
and may be superior in anatomical studies compared to ultrasonography. The increased cost of MRI scanning, as well<br />
as the need for dedicated imaging protocols, limit the use of MRI. Even though it is not the modality of choice for a<br />
primary imaging investigation of renal pathologies, it has become a valuable technique for complementary imaging<br />
assessment of the renal system, given the latest technological advances that allow for fast, high quality, reliable MR<br />
image acquisition.<br />
SESSION 2<br />
CONTRAST MEDIA (CM) AND MULTIDETECTOR COMPUTED<br />
TOMOGRAPHY (MDCT): A RADIOGRAPHER’S PERSPECTIVE<br />
Agadakos E. - BAppSci MRT (Diag)<br />
General Hospital of Athens "LAIKO", Athens Greece<br />
The impact of CT in clinical management has increased with the development of MDCT. Today with MDCT a volume of<br />
data is acquired rather than slices facilitating considerably faster acquisition times and superior assessment of patients<br />
across a wider range of clinical applications than single slice helical scanners.<br />
Rapid scanning, improved resolution, advanced 3D rendering and higher concentration contrast media (CM) enable<br />
multiphase studies, CT angiography, cardiac scoring and evaluation of brain perfusion.<br />
However, this evolving MDCT technology makes protocol design rather challenging particularly when contrast media<br />
administration is integral to the majority of MDCT examinations and use is tailored to the clinical application.<br />
It is apparent that these fast acquisitions at exceptional spatial resolution are beneficial yet contrast media delivery is<br />
now complicated and unforgiving. Existing protocols must be modified consistent with scan timing and optimization of<br />
contrast enhancement.<br />
In order to exploit the capabilities available it is necessary to incorporate the available scanner technology with the<br />
principles of contrast enhancement.<br />
Unless the CT radiographer becomes accustomed with the factors affecting contrast media enhancement and the<br />
associated scanning parameters, the diagnostic value of images will continue to decline as scanning speed increases. It<br />
is critical that these factors and parameters be synchronized in order to generate appropriate MDCT examination<br />
protocols.<br />
The presentation of examination protocols will be focussing upon recent bibliography considering the following key<br />
issues:<br />
I. Contrast injection related parameters<br />
II. CT acquisition related parameters<br />
III Patient Dose Management<br />
Concisely, the aim of this presentation is to provide know-how in view of recent bibliography to determine an optimal<br />
CT injection-examination protocol.<br />
OPTIMIZATION OF MULTI-DETECTOR ROW CT UROGRAPHY<br />
Koumarianos D<br />
TEI of Athens<br />
With the advent of multi-detector row CT scanners and the evolution of image processing methods CT Urography<br />
(CTU) now affords optimal urographic images comparable to those obtained with conventional techniques.<br />
This presentation discusses the optimization of all technical aspects involved in the course of the CTU examination<br />
including such issues as compression, saline infusion, diuretic administration, and timing of the acquisition delay. We<br />
describe the acquisition techniques and protocols used by the various authors, discuss the technical guidelines<br />
proposed by ESUR and illustrate a variety of post processing techniques, multiplanar reconstruction (MPR), maximum<br />
intensity projection (MIP) and volume rendering (VR).<br />
The real concern potentially limiting the widespread use of CTU is its higher radiation dose when compared with IVU.<br />
Although low-dose protocols are available, a substantial dose reduction can be achieved by tailoring CTU to the clinical<br />
problem rather than using a standardized approach.<br />
131
POSTERS EXHIBITION<br />
ABSTRACTS<br />
132
P1. RENAL TUMOURS - A PICTORAL REVIEW<br />
Kannappa L.K., Hasrat K., Ho E.<br />
Norwich & Norfolk University Hospital, UK<br />
Purpose: Learning objectives: To describe the causes,classification,presentation,consequences and imaging<br />
appearences of renal tumours and to ensure their detection and appropriate management.<br />
Background: Renal tumours account for approximately 2% of all malignancies.<br />
Males are more likely to be affected than females with a ratio of 2:1.2.<br />
More than 6,600 people are diagnosed with kidney cancer each year in the<br />
UKhttp://www.patient.co.uk/showdoc/40000686/ - ref2 and there are around 3,600 deaths.<br />
The peak age of incidence for renal carcinoma is 60 to 80 years old.<br />
Several risk factors have been identified including smoking, obesity, hypertension, long term dialysis and Von Hippel<br />
Lindau syndrome.<br />
Occupations associated with an increased risk include workers exposed to cadmium or asbestos and coke oven<br />
workers in the iron and steel industries.4<br />
Hereditary renal cancers tend to be multiple, bilateral and occur at an earlier age than others.5<br />
Wilms' tumour affects about 1 in 100,000 children before the age of 15. In 5 to 10% of cases it is bilateral.<br />
Methods and materials: Image findings and procedure details: The materials used are a series of multiple imagings of<br />
ivu,ultrasound,CT of chest and abdomen & MRI to understand the investigate modality which were used in norwich<br />
and norfolk hospitals since 2000 to 2008..There were 300 patients who had nephrectomy included in this group.The<br />
pictoral representation of various radiological modalities with individual image and its findings used in arriving in<br />
diagnosis were being used.<br />
Results:Out of 300 patients ,who underwent nephrectomy,161 patients had renal cell cancer,50 had TCC,6-clear cell<br />
cancer ,2-chromoplil cancer,9 –cysts,3-oncocytoma,3=hypernephroma,4-angiomyolipoma.1 each-squamous cellcancer<br />
and adenocarcinoma,36-nephritis,1-amyloidosis and rest had nephrectomy for pelvic ureteric junction abnormalities<br />
,stone disease, dysplastic kidney and other causes. For all the above patients, ultrasound and IVP was used as a<br />
routine and CT ,MRI and cystoscopy were used for additional investigations for confirmation and for diagnosis.<br />
Conclusions: By understanding the age, sex orientation, causes, site of presentation and the investigative modalities<br />
used for diagnosis and treatment. The pictoral review helps the radiologist to understand the disease easily.<br />
P2. TESTICULAR MICROLITHIASIS AS AN INSIDENTAL SONOGRAPHIC FINDING WITH QUESTIONABLE<br />
SIGNIFICANCE<br />
Gkeli M., Apergis S., Kartsouni V., Galiatsatos N., Morfas K.<br />
1st Department of Radiology, Unit of Sonography, “Saint Savvas” Anticancer Oncological Hospital, Athens,<br />
Greece<br />
Objective : To present the questionable significance of testicular microlithiasis (TM), as an incidental finding and its<br />
management in patients that are submitted for testicular ultrasonography (US) for various indications.<br />
Method: In the last two years, 100 patients were subjected to high-frequency testicular US. The investigated subjacent<br />
deseases were testicular malignancy, control after orchidectomy for a malignant tumor or after orchiopexy for<br />
undescended testes, epididymo-orchitis, testicular torsion, hydrocele, varicocele and epididymal cysts.<br />
Results: 100 patients were examined by US of the testes in the last two years and three patients were found with TM.<br />
US showed multiple, uniform, pinpoint, hyperechoic intratesticular foci. In the first patient, testes were physiological in<br />
size with uniform echogenicity and ambilateral TM. In the second patient with a left orchidectomy for seminoma, the<br />
right testis was normal in size with homogeneous echogenicity and TM. In the third patient, the right testis was<br />
smaller than the left, with TM. In patient’s history there was an undescended right testis, surgically treated twenty<br />
years ago.<br />
Conclusion: TM may be an incidental US finding. It is characterized by calcification within the seminiferous tubules. It<br />
may present as a marker for the potential growth of germ cell tumor. Although the recent literature indicated that<br />
malignancy only develops when TM is associated with other predisposing factors. Testicular examination is the<br />
recommended follow up for men identified with TM. The use of annual US follow-up, biochemical tumor markers,<br />
abdominal and pelvic CT, or testicular biopsy are justified according the subjacent disease.<br />
P3. OPTIMIZATION OF BLADDER DISTENSION IN PATIENTS WITH GROSS HAEMATURIA EXAMINED<br />
WITH MULTI DETECTOR ROW CT UROGRAPHY<br />
Helenius M., Segelsjo M., Magnusson A.<br />
Radiology Department, Uppsala University Hospital, Sweden<br />
Objective: Over the last decade CT has replaced excretory urography when evaluating patients with gross hematuria.<br />
Malignancy of the urinary tract is often the cause of gross haematuria. Recently, CT has shown to have high sensitivity<br />
and specificity in detecting bladder cancer. However, to be able to evaluate the presence or not of a bladder cancer,<br />
the bladder has to be well distended. The aim of this study was to find the best protocol for distending the bladder.<br />
Materials and Method: Four different protocols were evaluated; 1) 500 ml of water orally during one hour prior to the<br />
examination. 2) 500 ml of water orally during one hour prior to the examination.,and 10ml Furosemid iv immediately<br />
before the examination. 3) 1000 ml of water orally during two hours prior to the examination. 4) 1000ml of water<br />
orally during two hours prior the examination and void one hour prior the examination.<br />
One hundred patients were included in the study and randomly selected into the four protocol groups, The bladder<br />
distension was evaluated and the bladder volume was calculated<br />
Results: The bladder was distended enough to permit evaluation of the wall in 56% (Protcol 1), 68% (Protocol 2), 84%<br />
(Protocol 3) and 72% (Protocol 4). The mean bladder volume was 225ml, 323ml, 379ml and 310ml respectively.<br />
Conclusion: The protocol where the patients were asked to drink 1000ml of water during two hours prior the<br />
examination and not to void during those two hours was found to be the best protocol for bladder distension.<br />
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P4. OUTCOME OF PTRA IMPROVES WHEN EVALUATED BY ”BREAK POINT ANALYSIS”<br />
Eklof H., Bohlin E. G.<br />
Department of Radiology, Uppsala University Hospital, Uppsala, Sweden<br />
Objective: To evaluate the outcome on renal function after PTRA, guidelines recommend ”Break point analysis” or<br />
”Binary outcome” (1).<br />
This retrospective study has compared the effect of using either of the two methods for evaluation of clinical outcome<br />
after PTRA.<br />
Method: The local ethics committee approved the study and informed consent was received. Eleven patients were<br />
included in this retrospective study. All were adults treated with PTRA for atherosclerotic RAS, s-creatinine > 200<br />
mol/L before PTRA with at least five s-creatinine values from a period of at least three months prior and after PTRA.<br />
The effect on renal function for each patient was defined based on ”Break point analysis” where five or more s-<br />
creatinine values before and after PTRA generates a slope-value (2). An increase in slope-value after PTRA indicates an<br />
improvement in renal function. This was compared to ”Binary outcome” using only single s-creatinine value the week<br />
before and 3-6 months after PTRA. An improvement in s-creatinine by at least 25% was used to define improvement<br />
in renal function.<br />
Result: Five of eleven patients showed improved renal function after PTRA when based on ”Break point analysis”, only<br />
two when based on ”Binary outcome”.<br />
Conclusion: ”Break point analysis” improves the clinical outcome of PTRA. Another implication is that worsened renal<br />
function after PTRA may be continuing progressive renal impairement and NOT a complication.<br />
References<br />
1. Rundback JH, Sacks D, Kent KC, Cooper C, Jones D, Murphy T, et al. Guidelines for the reporting of renal artery<br />
revascularization in clinical trials. American Heart Association. Circulation 2002;106:1572-85.<br />
2. Rowe PA, Richardson RE, Burton PR, Morgan AG, Burden RP. Analysis of reciprocal creatinine plots by two-phase linear<br />
regression. Am J Nephrol 1989;9:38-43.<br />
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P5. VARIOUS IMAGING SPECTUM OF RENAL ANGIOMYOLIPOMA<br />
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<br />
1 Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang<br />
Hospital, Institute of Radiation Medicine, Seoul National University Medical Research, Center Clinical Research<br />
Institute, Seoul National University Hospital. 2 Department of Radiology, Seoul National University College<br />
of Medicine, Seoul National University Hospital. 3 Department of Urology, Seoul National University College of<br />
Medicine, Seoul National University Bundang Hospital<br />
Purpose: To present imaging spectrum of renal angiomyolipoma (AML).<br />
Materials and methods: Data of nephrectomy and kidney biopsy performed between 2003 January to 2009 February<br />
was searched for pathologically proven renal AML patients. Clinically diagnosed tuberous sclerosis patients with renal<br />
mass demonstrating features of AML were also included in this study. Imaging studies of these patients were<br />
reviewed.<br />
Results: Individual cases were categorized based on image findings or clinical setting as follows; typical fatty mass,<br />
solid mass with focal fat, fat deficient mass, pathologically epithelioid variant, and tuberous sclerosis associated AML.<br />
Typical fatty mass had large portion with fat attenuation on CT. Solid portion with various degree of enhancement, or<br />
hemorrhage may or may not be present. Solid mass with focal fat consisted mostly of soft tissue density mass and had<br />
small focal but evident portion with fat density. Fat deficient mass is defined as mass with no identifiable fat density.<br />
Epithelioid variant presented as hypervascular soft tissue density mass with necrotic portion. Tuberous sclerosis<br />
associated AML demonstrated bilaterality and multiplicity, and involvement of other organ such as liver was also<br />
observed.<br />
Conclusion: AML can present as mass with diverse fat content, from grossly pure solid mass to those composed<br />
predominantly of fat tissue.<br />
P6. UTILITY OF T2-WEIGHTED IMAGING (T2-WI) AND DYNAMIC CONTRAST-ENHANCED MRI (DCE-<br />
MRI) IN PROSTATE CANCER LOCALIZATION. CORRELATION WITH HISTOPATHOLOGIC<br />
FINDINGS AFTER PROSTATECTOMY.<br />
Carbognin G., Calciolari C.<br />
Department of Radiology, University of Verona, Italy<br />
Objective: To evaluate the combination of two MR techniques (T2-WI, DCE-MRI) in the correct localization of prostate<br />
cancer correlated with histopathologic findings.<br />
Materials And Methods: We reviewed the MR examinations of 8 men (60-71 years old; mean age 65) with abnormal<br />
PSA level and positive US-guided biopsy.<br />
MR imaging was performed at 1.5T with endorectal surface coil. We looked for the presence of low-signal-intensity<br />
areas on T2-WI and focal enhancement on DCE-MRI (analyzed by dynamic curves). We included in our study tumor<br />
size 10 mm or more. The results were correlated with histopathologic findings performed after prostatectomy. For<br />