JBR 2010-1 by office

WETTEREN 1

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Volume 93 Page 1-44

January-February

Bimonthly

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2010

DIAGNOSTIC AND INTERVENTIONAL IMAGING, RELATED IMAGING SCIENCES, AND CONTINUING EDUCATION

ORGANE DE LA SOCIETE ROYALE BELGE DE RADIOLOGIE (SRBR) ORGAAN VAN DE KONINKLIJKE BELGISCHE VERENIGING VOOR RADIOLOGIE (KBVR)

JBR-BTR ♦ 93/1 ♦ 2010 Journal Belge de ♦ Belgisch Tijdschrift voor ♦ RADIOLOGIE

Founded in 1907 A bimonthly journal devoted to diagnostic and interventional imaging, related imaging sciences, and continuing education Contents A minimally invasive vertebral hemangioma. S. Van den Broeck, P. Mailleux, J.P. Joris . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Gallstome ileus. I. Willekens, D. Verdries, G. Ceulemans, F. Vandenbroucke, G. Delvaux, J. de Mey . . . . . . . . . . . . . . . . . . . . . . . Unusual long-term complications of a splenic cyst. E.V.M. Ward, J. O’Brien, K. Conlon, W.C. Torreggiani . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Recurrent pleural effusion. J. O’Brien, N. Campbell, W.C. Torreggiani . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fibroadenoma of the breast in a man associated with adenocarcinoma of the rectum and polyposis coli. Z.H. Adibelli, M. Yildirim, E. Ozan, O. Oztekin, B. Kucukzeybek . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1 4 7 10 12

UPDATE Radiation dose optimization in thoracic imaging. D. Tack . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

CONTINUING EDUCATION The talocalcaneal unit: pictorial review of anatomy and pathologic conditions on multidetector CT. A. Ayoob, M. De Maeseneer, M. Shahabpour, P. Van Roy, E. Barbaix, S. Qing . . . . . . . . . . . . . . . . . . . . . . . . . .

SIGNS IN RADIOLOGY Optic tract edema sign and craniopharungiomas. W. Siemons, G. Wilms, T. Theys . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

IMAGES IN CLINICAL RADIOLOGY Partial posterior split cervical spinal cord with Klippel-Feil syndrome. M. Apaydin, M. Varer, K.B. Bayram . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A 64-slice multidetector CT of tracheobronchopathia osteochondroplastica with virtual bronchoscopy view. L. Cardinale, M. Busso, A. Cataldi, G. Volpicelli . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cholecystocolonic fistula complicated by gallstone impaction and perforation of the sigmoid. C. Schoofs, R. Vanheste, L. Bladt, F. Claus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Re-appearance of an ilio-ilio arteriovenous fistula after endovascular stent grafting demonstrated on MDCT. R. Killeen, G. McNeill, W.C. Torreggiani . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Piso-Hamate hiatus syndrome. E.C.Y. Christiaanse, T. Jager, F.M. Vanhoenacker, E. Van Hedent, R. Van Damme . . . . . . . . . . . . . . . . . . . . . . . . . Obturator hernia, a rare cause of intestinal obstruction. E. Vanhoutte, K. Ramboer, L. Verhaeghe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

30 31 32 33 34 35

Abstract of papers for full membership at the Royal Belgian Society of Radiology . . . . . . . . . . . . . . . . . . . . . . . . 36 News from the Universities: Prijs Pr Dr Em A.L. Baert 2009-2010 – Algemeen Reglement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Report of the 2009 RBRS Research Grant Research Fellowship at the University of Melbourne, Australia. L. Jans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 AFIP Radiologic-pathology correlation course, Washington DC, USA. P. De Visschere . . . . . . . . . . . . . . . . . . 38 News from the Museum: Celebration of XXth Anniversary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Forthcoming Courses and Meetings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Grants of the RBRS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 Special announcement from the British Institute of Radiology (BIR) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Classified services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6, 9 Instructions to Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ii Subscribers information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . cii Advertising index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ciii The terms used for indexation of subjects were developed by the Radiological Society of North America (RSNA) over a period of years. Their use here is by permission of the RSNA. The terms may not be used in any other index, print or electronic, except by specific permission of RSNA. ◆◆ Indexed in Index Medicus and in Zentralblatt Radiologie. Evaluated for Medline User, EMBASE and CANCERNET. Abstracted in Excerpta Medica Journals. ◆

JBR–BTR, 2010, 93: 1-3.

A MINIMALLY INVASIVE VERTEBRAL HEMANGIOMA S. Van den Broeck, P. Mailleux, J.P. Joris We describe a very unusual vertebral hemangioma presenting with a mixture of aggressive-like pattern (epidural extension , T1 hyposignal) and quiescent, inactive lesion (fatty infiltration), in association with a spiculated calcified epidural component. This paper emphasizes that CT and/or MR findings are accurate enough to make formal assessment of vertebral hemangioma, preventing patient’s anguish and moreover unnecessary treatment. Furthermore this attractive case proposes a poorly known characteristic of vertebral hemangioma which is usually encountered and described only in skull hemangiomas. Key-word: Angioma, skeletal system.

Vertebral hemangioma is a common skeletal angiomatous benign tumor. The one we describe shows an extraordinarily spiculated calcified intra-canalar extension. This gives a “sunburst” appearance to the lesion usually encountered in skull hemangiomas. The aim of this report is to highlight a poorly known sign which, despite its partial aggressive look, should not hinder the assessment of a typical benign hemangioma by the radiologist. Case report A 51-year-old patient complaining of chronic neck pain was referred for a cervical spine MRI. Cervical findings were unspecific, but a wide lesion was found at the T5 level, extending from the vertebral body to both pedicles, with a posterior small epidural component that contains some calcifications. On sagittal T2 weighted images (Fig. 1, 2), the bone marrow of the T5 body was hyperintense compared to the other vertebrae and was not collapsed. The lesion extended posteriorly in the ventral epidural space. The adjacent disks appeared normal. Whereas the vertebral body on T2 weighted images was homogenously hyperintense, it showed a dual appearance on T1 weighted images (Fig. 3): isthmi and the anterior half body were hyperintense, relating a quiescent fatty marrow, while the posterior vertebral body was hypointense, due to a greater vascular soft tissue component and maybe some inflammatory process. Contrast enhancement (Fig. 4) was mainly seen in the posterior part of the lesion, but also in the compo-

Fig. 1. — Sagittal T2-weighted MRimage. The vertebral body T5 is homogeneously hyperintense, compared to other vertebrae.

nents located in the anterior epidural space and in the paravertebral lateral soft tissue. The enhancement also accentuated the mineral structure of the vertebral body presenting a diffuse coarse pattern, with fewer but thicker hypointense trabeculae. Computed tomography confirmed the thickened pathognomonic bone trabeculations throughout the hemangioma (Fig. 5A), but also showed speculated calcifications

From: Department of Medical Imaging, Clinique Saint Luc, Bouge, Belgium. Address for correspondence: Dr S. Van den Broeck, Department of Medical Imaging, Clinique Saint Luc, Rue Saint Luc 8, 5004 Bouge, Belgium. E-mail: stephane.vandenbroeck@gmail.com

Fig. 2. — Sagittal T2-weighted MRimage. (enlarged view). Obvious destruction of the posterior vertebral wall, towards epidural space (black arrow).

at the posterior aspect of the lesion in the anterior epidural space (Fig. 5A,B). This appearance, often described for skull hemangioma, is quite rare in the vertebral ones. Discussion The vertebral hemangioma is a well known benign tumor found in 11% among a wide series of autopsy (1, 2). It is also acknowledged that the lesions of the spine are mostly located at the thoracic level (2). These hemangiomas are asymptomatic, excepted for 1% of them which are invasive. Less than five percent of asymptomatic hemangioma become neurologically relevant (3). The sex ratio is 3:2 favouring female (4).

JBR–BTR, 2010, 93 (1)

B A Fig. 3. — Sagittal T1-weighted MRimage. The vertebral body presents a dual appearance: a bright front part, fatty-filled tissue (white star), and a hypointense posterior vertebral body, with evolutive components.

Fig. 4. — Axial T1-weighted Gadolinium enhanced MR-image. The dorsal displacement of the posterior longitudinal ligament (and epidural venous plexi), which is medially strongly attached to the vertebral wall, gives a bilobular intracanalar aspect commonly called the “curtain sign” (large white arrow). The “polka dot” pattern is also recognized by numbers of black dots (mineralized trabeculation) in a bright environment. Note that the enhancement of the hemangioma is mainly posterior rather than anterior.

Fig. 5. — Respectively sagittal (A) and axial (B) reformatted CT images. Typical thickened trabeculations and hypodense, fatty components confirms the diagnosis of a common vertebral haemangioma (white thin arrow). CT scan reveals also the ‘sunburst’ calcifications (curved arrows) of the extra-osseous components as for hemangioma of the skull.

CT findings emphasize what can be seen on plain radiographs (5, 6), namely the honeycomb pattern, giving the typical ‘jail bar’ aspect on maximum intensity projection (MIP) sagittal reconstruction. This results from the thickening of the vertical trabeculae. On cross section, the same phenomenon determinates a ‘polka dot’ pattern (4, 7). The stroma between these osseous reinforcements is either filled with fatty and/or with angiomatous tissue, giving respectively a high or low intensity on T1 weighted MR images (8) and a different attenuation form on CT images. Laredo et al. (9) investigated a series of invasive, clinically relevant, hemangiomas. They have stated that the loss of activity (‘aggressiveness’ in their cases) increases with the predominance of fatty components. It had been previously observed (2) that the nature of the active tumoral part, shows a preponderance of angiomatous and fibrous tissue, with only few adipose stroma. This contributes to the variable intensity signal level on T1 weighted MR images, lower in the epidural components that contains as a result, more angiomatous tumoral tissue. This epidural involvement is limited by a strong medial fixation of the posterior longitudinal ligament. The lesser lateral fixation of this ligament

allows it to be displaced by the tumoral tissue, resulting on axial slices in a ‘curtain sign’ (10). Into the skull, bone hemangiomas often present a soft tissue expansion with some spiculated new bone formation, giving a “sun ray” appearance on tangential views (11). The invasive portions of the lesion often tend to expand externally but may also grow intracranially towards the dura (12). This seems to happen in our case, but at the thoracic level. Although the surgical way with histological assessment is classically the clue in the diagnosis of skull bone hemangiomas, this is not the case for those of the spine. Indeed, the radiological appearance of vertebral hemangioma is most of the time clear enough to avoid surgery, unless symptoms occur. Our patient presented a complex hemangioma, the anterior part of the body being quiescent while the posterior part was still active. It had an active epidural space which contained some osseous components, unusual at the spine level (13). Nevertheless, it is completely asymptomatic and does not compress the neural cord. The radiological features were moreover doubtlessly for the diagnosis of benign vertebral hemangioma, and we decided to stop there the investigation.

A MINIMALLY INVASIVE VERTEBRAL HEMANGIOMA — VAN DEN BROECK et al

Conclusion Vertebral hemangioma is a common lesion often described by many authors. Our report is atypical on many aspects. Our hemangioma shows a dual appearance with inactive and hypervascular, active parts. Furthermore, there is an asymptomatic soft tissue extension in the epidural space. Finally, this extension contains calcifications which are well-described for skull hemangiomas but are very rare at the spine level. Despite these uncommon features, the well-known radiological semiologic findings including the famous ‘polka dot’ pattern allowed us a formal diagnosis of a benign vertebral hemangioma and avoided unneeded anguish and treatment. References 1. Murphey M.D., Fairbairn K.J., Parman L.M., Baxter K.G., Parsa M.B.,

3. 4.

6. 7.

Smith W.S.: From the Archives of the AFIP: Musculoskeletal Angiomatous Lesions: Radiologic-Pathologic Correlation. RadioGraphics, 1995, 15: 893917. Ross J.S., Masaryk T.J., Modic M.T., Carter J.R., Mapstone T., Dengel F.H.: Vertebral Hemangiomas: MR Imaging. Radiology, 1987, 165: 165169. Persaud T.: The Polka-Dot Sign. Radiology, 2008, 246: 980-981. Fuwa S., Numaguchi Y., Kobayashi N., Saida Y.: Percutaneous Pediculoplasty for Vertebral Hemangioma Involving the Neural Arch: A Case Report. Cardiovasc Intervent Radiol, 2008, 31: 189-192. Laredo J.-D., Reizine D., Bard M., Merland J.-J.: Vertebral Hemangiomas: Radiologic Evaluation. Radiology, 1986, 161: 183-189. Osborn A.G.: Diagnostic Neuroradiology. St. Louis: Mosby-Year Book Inc., 1994, pp 877-879. Chhabra A., Batra K., Satti S., et al.: Spinal Epidural Space: Anatomy, Normal variations, and Pathological Lesions on MR Imaging. Neurographics, 2006, Vol 5, Issue 1.

8. Baudrez V., Galant C., Vande Berg B.: Benign vertebral hemangioma: MRhistological correlation. Skeletal Radiol, 2001, 30 (8): 442-446. 9. Laredo J.D., Assouline E., Gelbert F, Wybier M., Merland J.J., Tubiana J.M.: Vertebral hemangiomas: fat content as a sign of aggressiveness. Radiology, 1990, 177: 467-472. 10. Lengelé B., Cosnard G.: Anatomie. Imagerie de la colonne vertébrale et de la moelle. Edited by Lecouvet F., Cosnard G., second edition, 2007, pp 2, 3. 11. Sargent E.N., Reilly E.B., Posnikoff J.: Primary hemangioma of the skull: Case report of an unusual tumor. AJR Am J Roentgenol, 1965, 95: 874879. 12. Suzuki Y., Ikeda H., Matsumoto K.: Neuroradiological Features of Intraosseous Cavernous Hemangioma. Neurologia medico-chirurgica, 2001, Vol 41, N° 5: 279-282. 13. Schnyder P., Fankhauser H., Mansouri B.: Computed tomography in spinal hemangioma with cord compression. Report of two cases. Skeletal Radiol, 1986, 15: 372-375.

JBR–BTR, 2010, 93: 4-6.

GALLSTONE ILEUS I. Willekens1,2, D. Verdries2, G. Ceulemans3, F. Vandenbroucke2, G. Delvaux4, J. de Mey2 Gallstone ileus is a rare disease, which is responsible for about 1%-4% of all cases of mechanical obstruction. The findings of gallstone ileus on computed tomography (CT) are pathognomonic. The morbidity and mortality rate remain very high, mainly because of delayed diagnosis. We report a case of gallstone ileus which caused intestinal obstruction which was diagnosed on a contrast-enhanced CT scan of the abdomen. Key-word: Gallbladder, calculi.

Gallstone ileus is a rare and potentially serious complication of cholelithiasis. CT scan shows the classical triad of Rigler with pneumobilia, an ectopic stone and mechanical ileus. In this report, we present a patient with an intestinal obstruction on CT scan. Case report An 83-year-old woman was admitted to our hospital with sudden onset of abdominal pain. She complained of banded, colicky epigastric pain and nausea. The patient did not defecate for a week. Abdominal history was significant for gallstone (Fig. 1A and B), acute cholecystitis with microperforation and a liver abscess conservatively treated with antibiotics, acute renal insufficience and diverticular disease. Physical examination revealed diffuse abdominal tenderness with pressure pain, percussion pain, and rebound pain. Investigation showed high level of uric acid, creatinine, lactate dehydrogenase (LDH), lipase, white blood cells, and platelets. The C-reactive protein was slightly increased. Plain X-ray imaging showed multiple fluid levels in the small bowel without pathological distension and a scoliosis to the right. A calcified mass was detected projecting over the left sacro-iliacal joint (Fig. 1C). Contrast-enhanced (80 cc nonionic iodinated contrast medium, Ultravist®, Bayer HealthCare Pharmaceuticals) multidetector CT scanning of the abdomen (Fig. 1D, 1E, 1F and 1G) demonstrated an intestinal distention with fluid levels and a collapsed ileum and colon: an intestinal obstruction. The obstruction was

located on the transition between jejunum and ileum and was due to a big gallstone that was migrated from the gallbladder to the duodenum by a fistula. The gallbladder was contracted. Concurrently, we detected diverticular disease of the sigmoid. Gallstone ileus was withheld as diagnosis. Treatment was surgery and consisted of laparoscopic enterotomy with removal of the gallstone. Histopathological examination of the gallstone demonstrated a normal cholecystolithiasis. After 5 days the patient could eat and drink without relapse of complaints. In the future she has to follow a bowel saving diet. Discussion Gallstones are prevalent in 10% of the adult American population (1). Gallstone ileus is a rare and potentially serious complication of cholelithiasis (2). The term “gallstone ileus” was first used by Bartholin in 1654 and refers to the mechanical intestinal obstruction caused by the impaction of one or more large gallstones within the gastrointestinal tract. Biliary-enteric fistula formation is the main pathologic mechanism of gallstone ileus (3). The stone must be at least 2 to 2.5 cm in diameter to cause obstruction (4). It accounts for 1%-4% of all cases of mechanical intestinal obstruction, but for up to 25% of those in patients over 65 years. Women are more frequently affected. The most common locations for impaction of gallstones are the terminal ileum and the ileocaecal valve, because of the small diameter and less active peristalsis (5).

From: 1. In vivo Cellular and Molecular Imaging - ICMI - Vrije Universiteit Brussel, 2. Department of Radiology, 3. Department of Nuclear Medicine, 4. Department of Surgery, UZ Brussel, Brussels, Belgium. Address for correspondence: Dr I. Willekens, M.D., Dpt of Radiology, UZ Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium. E-mail: inneke.willekens@gmail.com

The most common clinical manifestations of gallstone ileus are nausea, vomiting and epigastric pain. Laboratory studies may show elevated values of bilirubin and alkaline phosphatase (6). Due to the insidious onset of signs, the illness is often diagnosed late (7). The diagnosis of gallstone ileus is difficult and usually depends on the radiographic findings. The classic Rigler’s triad of radiography includes mechanical bowel obstruction, pneumobilia, and presence of an ectopic gallstone within the bowel lumen (8). Air in the gallbladder is also a frequent finding in gallstone ileus (9). Plain abdominal radiographic films usually show non-specific findings, because only 10% of gallstones are sufficiently calcified (6). In only 30-35% of cases is the classic triad encountered on abdominal plain radiography (9). The limitations of plain abdominal radiography for diagnosis of gallstone ileus are well known (10). Barium studies can identify the site of obstruction or fistula formation. Abdominal ultrasound is useful to confirm the presence of cholelithiasis and may identify the fistula (11). Abdominal CT has become more important in diagnosing gallstone ileus. Computed tomography scans are able to show a moderately calcified ectopic gallstone, air in the biliary tree and a cholecysto-duodenal fistula (12). Lassandro et al. (13) found that Rigler’s triad was present more often in abdominal CT compared to plain abdominal film and abdominal ultrasound. The exact location of the stone and the site of obstruction are of great importance (14). CT is useful for identifying the ectopic gallstone at the transition point between dilated and decompressed bowel (15). Yu et al. (16) concluded that abdominal CT offers crucial evidence for the diagnosis of gallstone ileus and for decision making in management strategy. The speed and aptitude of contrast-enhanced CT in the diagnosis

GALLSTONE ILEUS â&#x20AC;&#x201D; WILLEKENS et al

of small bowel obstruction and acute abdomen makes it essential for emergency use (17). Intravenous contrast enhancement is valuable for improved detection of edema, inflammation, and ischemia of the small intestine (18). Gallstone ileus usually requires emergency surgery to relieve intestinal obstruction. Although surgery remains the mainstay of treatment, a conservative approach is possible (16, 19). The prognosis of gallstone ileus is usually poor and worsens with age (6). Previous studies reported a 7.5-15% mortality rate (4, 5). The mor-

bidity and mortality rate of gallstone ileus remain very high, partly because of misdiagnosis and delayed diagnosis and otherwise because of the age-related co-morbidities of the afflicted patients (20). Although early diagnosis could reduce mortality (6), the diagnosis of gallstone ileus remains difficult. Conclusion Gallstone ileus is a rare cause of intestinal obstruction. Abdominal CT is the best imaging modality because of its rapid diagnosis and its high accuracy.

Fig. 1. â&#x20AC;&#x201D; Axial (A) and coronal (B) computed tomography image reveals a gallstone in the gallbladder on the previous CT-examination after IV contrast injection. Erect (C) X-ray of the abdomen displays obstruction and a scoliosis to the right. The upright abdominal plain film shows multiple air-fluid levels in the small intestine. A calcified mass was detected projecting over the left sacroiliacal joint. Axial (D) and coronal (E, F and G) multiplanar reformatted computed tomography images after IV contrast injection show gallstone ileus causing intestinal obstruction. Image D demonstrates an intestinal distention with fluid and the gallstone at the transition between jejunum and ileum: an intestinal obstruction. Image E and F present the fistula between the gallbladder and the duodenum. At image G the aerobilia is recognizable.

References 1. Richards W.O., Williams L.F. Jr.: Obstruction of the large and small intestine. Surg Clin North Am, 1988, 68: 355-376. 2. Abou-Saif A., Al-Kawas F.H.: Complications of gallstone disease: Mirizzi syndrome, cholecystocholedochal fistula, and gallstone ileus. Am J Gastroenterol, 2002, 97: 249254. 3. Glenn F., Reed C., Grafe W.R.: Biliary enteric fistula. Surg Gynecol Obstet, 1981, 153: 527-531. 4. Rodriguez Hermosa J.I., Codina Cazador A., Girones Vila J., et al.: Gallstone ileus: results of analysis of a series of 40 patients. Gastroenterol Hepatol, 2001, 24: 489-494. 5. Reisner R.M., Cohen J.R.: Gallstone ileus: a review of 1001 reported cases. Am Surg, 1994, 60: 441-446.

6 6. Chou J.-W., Hsu C.-H., Liao K.-F., et al.: Gallstone ileus: Report of two cases and review of the literature. World J Gastroenterol, 2007, 13: 1295-1298. 7. Clavien P.A., Richon J., Burgan S., et al.: Gallstone ileus. Br J Surg, 1990, 77: 737-740. 8. Rigler L.G., Borman C.N., Noble J.F.: Gallstone obstruction: pathogenesis and roentgen manifestations. JAMA, 1941, 117: 1753-1759. 9. Balthazar E.J., Schechter L.S.: Air in gallbladder: a frequent finding in gallstone ileus. AJR, 1978, 131: 219-222. 10. Ripolles T., Miguel-Dasit A., Errando J., et al.: Gallstone ileus : increased diagnostic sensitivity by combining plain film and ultrasound. Abdom Imaging, 2001, 26: 401-405. 11. Lasson A., Loren I., Nilsson A., et al.: Ultrasonography in gallstone ileus: a

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12. 13.

14.

15.

16.

diagnostic challenge. Eur J Surg, 1995, 161: 259-263. Swift S.E., Spencer J.A.: Gallstone ileus: CT findings. Clin Radiol, 1998, 53: 451-456. Lassandro F., Gagliardi N., Scuderi M., et al.: Gallstone ileus analysis of radiological findings in 27 patients. Eur J Radiol, 2004, 50: 23-29. Lassandro F., Romano S., Ragozzino A., et al.: Role of helical CT in diagnosis of gallstone ileus and related conditions. AJR, 2005, 185: 1159-1165. Reimann A.J., Yeh B.M., Breiman R.S., et al.: Atypical cases of gallstone ileus evaluated with multidetector computed tomography. J Comput Assist Tomogr, 2004, 28: 523-527. Yu C.Y., Lin C.C., Shyu R.Y., et al.: Value of CT in the diagnosis and

17.

18. 19.

20.

management of gallstone ileus. World J Gastroenterol, 2005, 11: 21422147. Maglinte D.D., Balthazar E.J., Kelvin F.M., et al.: The role of radiology in the diagnosis of small-bowel obstruction. AJR, 1997, 168: 11711180. Balthazar E.J., George W.: Holmes Lecture. CT of small-bowel obstruction. AJR, 1994, 162: 255-261. Ihara E., Ochiai T., Yamamoto K., et al.: A case of gallstone ileus with a spontaneous evacuation. Am J Gastroenterol, 2002, 97: 1259-1260. Lobo D.N., Jobling J.C., Balfour T.W.: Gallstone ileus: diagnostic pitfalls and therapeutic successes. J Clin Gastroenterol, 2000, 30: 72-76.

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UNUSUAL LONG TERM COMPLICATIONS OF A SPLENIC CYST E.V.M. Ward1, J. O’Brien1, K. Conlon2, W.C. Torreggiani1 Splenic cysts are relatively uncommon, and are usually asymptomatic. They are benign, typically treated conservatively and followed up with ultrasound examination, with few reported complications. We report a case of a simple splenic cyst that was followed up on imaging over a seven-year period. During that time, the cyst gradually enlarged from 5 cm to 12 cm in diameter, however the patient remained asymptomatic. After seven years, the patient was admitted with abdominal pain and a pelvic mass. The spleen was located within the pelvis, which was felt to be due to the weight of the cyst which caused the spleen to migrate out of its normal position. This case illustrates an extremely unusual complication, and suggests that while most splenic cysts may be managed conservatively, enlarging cysts may be prone to gravitational effects and prophylactic treatment should be considered. Key-words: Spleen, cysts – Spleen, US – Spleen, CT.

Case report An 18-year-old female was referred by her primary physician to our institution for the assessment of right iliac fossa pain over the previous three days. She had no other abdominal symptoms and her clinical examination was normal apart from some focal tenderness in the right iliac fossa. Laboratory tests were all normal. An ultrasound of the abdomen and pelvis was performed to outrule conditions such as ovarian cystic disease or acute appendicitis. This confirmed that the uterus, ovaries and other pelvic structures were normal. There were no radiologic features of appendicitis. However, it was incidentally noted that there was a 5 cm cyst within the lower pole of the spleen (Fig. 1). The spleen otherwise appeared normal and no other abnormalities were seen. The patient then underwent a non-contrast computed tomography (CT) to evaluate for renal stone disease or occult appendicitis as the cause of her pain. No evidence of renal stone disease or appendicitis was seen. The simple cyst was again seen within a normally positioned spleen (Fig. 2). The patient was managed conservatively and her symptoms resolved. A diagnosis of non-specific abdominal pain was made as well as an incidental finding of a splenic cyst. As the cyst was asymptomatic, it was decided to manage it conservatively by observation with yearly follow up splenic ultrasounds.

Fig. 1. — Ultrasound of the upper abdomen demonstrates a simple appearing cyst (arrow) measuring 5 cm cyst within the lower pole of the spleen.

Over the subsequent seven years, the patient had annual ultrasounds of the spleen, which demonstrated a gradual increased in size of the splenic cyst from 5 to 12 cms. The cyst appeared simple at all times and the spleen remained in its normal anatomical position. Despite the cyst growing in size over time, the patient remained asymptomatic and it was therefore decided to continue to manage the patient conservatively. After a seven-year period of follow up, the patient was admitted with new onset acute abdominal pain. A contrast enhanced CT of the abdomen and pelvis was performed. This showed absence of the spleen in its normal position in the left upper quadrant. There however were tortuous varices within the splenic bed (Fig. 3A). These vessels could be traced both to the superior mesen-

From: 1. Department of Radiology, 2. Department of Surgery, The Adelaide and Meath Hospital, Dublin, Ireland. Address for correspondence: Dr Julie O’Brien, Specialist Registrar in Radiology, Department of Radiology, Adelaide and Meath Incorporating the National Children’s Hospital, Tallaght, Dublin 24, Ireland. E-mail: juliemarobrien@yahoo.com

Fig. 2. — CT of the abdomen without intravenous contrast demonstrates simple cyst (arrow) lying anteriorly within the spleen.

teric vein medially and inferiorly to where the spleen was seen lying within the lower abdomen (Fig. 3B). In the spleen’s dependent portion within the pelvis, the large splenic cyst was identified (Fig. 3C). An ultrasound of the abdomen confirmed the cyst to be simple in nature and with no solid elements and a few simple peripheral septations. An MRI demonstrated the signal of the spleen to be normal with no evidence of infarction (Fig. 4). The splenic cyst appeared of uniform high signal on T2 weighted images suggesting its simple nature. In view of the patient’s symptoms, splenectomy was planned for the following day. Prior to surgery, the patient received meningococcal, pneumococcal and Haemophillus vaccinations. At surgery a very mobile spleen was identified with a large cystic lesion at its lower pole. The spleen was removed and the vessels were divided and tied. Histology showed a 12 cm true epithelial (epidermoid cyst) of the spleen with no evidence of malignancy (Fig. 5). The spleen otherwise appeared unremarkable and the patient had an uncomplicated postoperative course and was discharged home four days later.

JBR–BTR, 2010, 93 (1)

Fig. 3. — CT of the abdomen and pelvis performed after intravenous contrast. A. There is absence of the spleen in its normal position in the left upper quadrant. Tortuous varices are however seen within the splenic bed (arrow). B. At a lower level, the spleen is seen lying transversally in the lower abdomen. C. Within the pelvis, a large splenic cyst (arrow) is seen measuring 12 cm in the dependant portion of the spleen.

Fig. 5. — Histological specimen shows a 12 cm true epithelial (epidermoid cyst) within the spleen. There was no evidence of malignancy and the spleen otherwise appeared unremarkable.

Fig. 4. — Coronal T2 weighted MRI of the abdomen and pelvis shows the spleen to be of normal signal with a large cyst within the dependent portion of the spleen. The cyst appeared of uniform high signal with no solid elements within suggesting its simple nature.

Discussion True cysts of the spleen are are relatively rare. They are most commonly discovered within the second and third decades of life. By pathological classification, the presence of a cellular cyst lining, defines a true cyst (1). True cysts represent about one-fourth of nonparasitic benign cysts. False cysts, which have fibrous tissue lining, comprise the remainder. These false cysts may result from trauma, haemorrhage or infarction. Some cysts may also occur secondary to parasitic infestation. Robbins reported a series of 42,327 autopsies over a 25-year period, which revealed only 32 patients with diagnosis of true splenic cyst (2,

3). The origin of splenic epithelial cysts is thought to be congenital although this is controversial. Although no epithelium is present histogenetically within the normal spleen, splenic epidermoid cyst is thought to be a lesion arising from embryonic inclusion of aberrant ectodermal and entodermal epithelium in the developing spleen (4). Clinically, most patients with splenic cysts are asymptomatic (5). When pain occurs, it is felt to be secondary to the mass effect of the cyst, which compresses the adjacent visceral surface of the spleen. Because of the slow growing rate of epidermoid cysts, symptoms are often vague when present. Symptoms include epigastric fullness and a dull pain in the left upper quadrant. Physical examination is usually negative. Occasionally the spleen can be tender leading to pain on palpation in the left upper quadrant. When the pain is significant, left hemi diaphragmatic movement may be affected leading to lower lobe atelectasis or pneumonia (4). Laboratory tests are usually normal.

The initial diagnosis of splenic cysts is predominantly radiological. Ultrasound typically shows an echo free cystic mass within the spleen with well-defined walls. Rarely calcification may be seen within the walls of the cyst. CT and MRI as in the case we have presented are excellent modalities in demonstrating splenic cysts. They are generally utilised when the diagnosis is in doubt or when complications are suspected. Splenic cysts are generally incidentally discovered, as they are usually asymptomatic. Although splenic cysts are benign and may spontaneously resolve, some authors suggest that cysts greater than 5 cm should be treated to avoid potential complications (6). The main potential complication of splenic cysts is rupture. This may result in peritonitis or hemorrhage. Other complications include infection and abscess formation (6). Splenectomy has in the past been the surgical treatment for epidermoid cysts (5, 6). However serious complications can result from this procedure and therefore more conservative measures such as partial splenectomy and laparoscopic cyst decapsulation are now favoured where possible (6). In the case we have described here, the patient was asymptomatic with an epidermoid cyst, which appeared simple on imaging. The case and options were discussed in detail with the patient and it was decided to manage her conservatively. The risk of rupture is higher in patients who participate in high impact sports. However the patient reported a sedentary lifestyle and this contributed for the decision to manage her conservatively. In retrospect the fact that the cyst had enlarged significantly over her observation period may have been

UNUSUAL LONG TERM COMPLICATIONS OF A SPLENIC CYST â&#x20AC;&#x201D; WARD et al

an indication for surgery. If done at an earlier stage, splenic sparing surgery may have been an option. Due to the large size of the cyst at presentation, splenectomy was considered the safer option. Migration of the spleen from its normal position within the left upper quadrant is a known phenomenon and often referred to as a wandering spleen. The spleen is normally situated in the left upper quadrant of the abdomen and is held in position by the suspensory ligaments of the spleen, namely the lieno-renal and the gastrosplenic ligaments with the phrenico-colic ligament providing further stability. A wandering spleen is a rare entity that is poorly described in the radiological literature. Its reported incidence is less than 0.2% (7). A wandering spleen occurs when the spleen migrates from its usual position in the left upper quadrant and lies in the left flank, central abdomen or pelvis. Patients may present with a painful mass or an acute abdomen or in some cases they may be asymtomatic (8). In this case, there were varices present as result of the gravitational effect on the splenic vein, when the spleen migrates inferiorly and the length of the splenic vein is therefore increased. A wandering spleen can be congenital or acquired. In the congenital case there is abnormal development of the dorsal mesogastrium causing defective attachment of the dorsal mesentery. The acquired case is due to abdominal wall laxity or the hormonal effects of pregnancy, which

explains why wandering spleen usually occurs in females between the ages of 20-40 years of age (9, 10). Rarely a wandering spleen may be due to an associate mass (11-13) as in the case we have described. CT is the currently the imaging modality of choice in making the diagnosis (13). Conclusion While splenic cysts are usually asymptomatic and discovered incidentally, they may be prone to complications such as rupture when large. We report an extremely unusual complication of an enlarging splenic cyst that occurred after 7 years of follow up, where the patient presented acutely with a displaced spleen. The displaced spleen was felt to be secondary to gravitational effects by the large cyst. Urgent splenectomy was performed. The case suggests that while small cysts of the spleen may be managed conservatively, the presence of a large or enlarging cyst should make early splenic sparing surgery a consideration. References 1. Ross M.E., Ellwood R., Yang S.S., Lucas R.J.: Epidermoid splenic cysts. Arch Surg, 1977, 112: 596-599. 2. Robbins F.G., Yellin A.E., Lingua R.W., Crsig J.R., Turrill F.L., Mikkelsen W.P.: Splenic epidermoid cysts. Ann Surg, 1978, 187: 231-235. 3. Morgenstern L.: Non-parasitic splenic cysts: Pathogenesis, classification, and treatment. J Am Coll Surg, 2002, 194: 306-314.

4. Davidson E.D., Campbell W.G., Hersh T.: Epidermoid splenic cyst occurring in an intrapancreatic accessory spleen. Dig Dis Sci, 1980, 25: 964-967. 5. King M.C., Glick B.W., Freed A.: The diagnosis of splenic cysts. Surg Gynecol Obstet, 1968, 127: 509-512. 6. Morohoshi T., Hamamoto T., Kunimura T., Yoshida E., Kanda M., Funo K., Nagayama T., Maeda M., Araki S.: Epidermoid cyst derived from an accessory spleen in the pancreas. A case report with literature survey. Acta Pathol Jpn, 1991, 41: 916-921. 7. Desai D.C., Hebra A., Davidoff A.M., Schnaufer L.: Wandering spleen: a challenging diagnosis. South Med J, 1997, 90: 439-443. 8. Buehner M and Baker MS. The wandering spleen. Surg Gynecol Obstet, 1992, 175: 373-387. 9. Raissaki M., Prassopoulos P., Daskalogiannaki M., et al.: Acute abdomen due to torsion of wandering spleen: CT diagnosis. Eur Radiol, 1998, 8: 1409-1412. 10. Hirose R., Kitano S., Bando T., Ueda Y., Sato K., Yoshida T., Suenobu S., Kawano T., Izumi T.: Laparoscopic splenopexy for paediatric wandering spleen. J Paediatr Surg, 1998, 33: 1571-1573. 11. Cohen M.S., Soper N.J., Underwood R.A., Quasebarth M., Brunt L.M.: Laparoscopic splenopexy for wandering spleen. Surg Laparosc Endosc, 1998, 8: 286-902. 12. Ratzer E.R., Fenoglio M.E.: Laparoscopic management of the wandering spleen. J Laparoendosc Adv Surg Tech A, 2004, 14: 227-229. 13. Ben Ely A., Zissin R., Copel L., Vasserman M., Hertz M., Gottlieb P., Gayer G.: The wandering spleen: CT findings and possible pitfalls in diagnosis. Clin Radiol, 2006, 61: 954958.

JBR–BTR, 2010, 93: 10-11.

RECURRENT PLEURAL EFFUSION J. O’Brien, N. Campbell, W.C. Torreggiani1

Case Report A 42-year-old lady was referred for investigation of recurrent right pleural effusions over a six month period. A computed Tomography (CT) was requested to outrule an underlying malignancy. The patient had a known history of chronic renal failure, for which she was treated with peritoneal dialysis for the previous four years. A non-contrast CT thorax was performed in which revealed bilateral pleural effusions more significant on the right side with fluid in the transverse fissure and interstitial oedema; features consistent with fluid overload (Fig. 1A). On the images of the upper abdomen, there was free fluid present, with curvilinear calcification of the peritoneum (Fig. 1B). A diagnosis of sclerosing peritonitis secondary to peritoneal dialysis was made (Fig. 2). The fluid overload was felt to be due to inadequate peritoneal dialysis due to the sclerosing peritonitis.

Discussion Sclerosing peritonitis (SP) is a complication of peritoneal dialysis that is felt to be under-diagnosed and may occur in up to 20% CAPD patients. It is an inflammatory condition of the peritoneum, resulting in proliferation of fibroconnective tissue and peritoneal calcification. This results in defective diffusion and ultrafiltration across the peritoneal membrane, which acts as the semi-permeable membrane in the mechanism of peritoneal dialysis. As result, there is inadequate removal of toxins and fluid overload, which in this case was manifested by a pleural effusion. Presentation is usually with abdominal discomfort or weight loss but it can vary between patients. Abdominal radiographs may demonstrate curvilinear calcification and complications such as dilated loops of bowel and thumbprinting (Fig. 3).

B Fig. 1. — Non-contrast enhanced CT of the thorax (A) demonstrating bilateral basal pleural effusions, larger on the right, with fluid in the transverse fissure and interstitial edema consistent with fluid overload. B: Mediastinal window setting at the level of the upper abdomen, demonstrating the calcification of the peritoneal membrane.

Ultrasonography is not sensitive but may demonstrate dilated loops of bowel surrounded by a hypoechoic thick fibrous membrane, and loculated ascites (1). CT is more sensitive, which may demonstrate peritoneal

From: 1. Department of Radiology, Adelaide and Meath Incorporating the National Children’s Hospital, Dublin, Ireland. Address for correspondence: Dr. Julie O’Brien, Specialist Registrar in Radiology, Department of Radiology, Adelaide and Meath Incorporating the National Children’s Hospital, Tallaght, Dublin 24, Ireland. Email: juliemobrien@gmail.com

thickening, enhancement or calcification (2). Diagnosis can also be made histologically. The aetiology of sclerosing peritonitis is felt to be multifactorial; it may occur as a result of Chronic Ambulatory Peritoneal dialysis (CAPD), with a reported incidence of 20% after 8 years (3), as result of recurrent peritonitis, however, it may also be idiopathic. Treatment is multi-disciplinary including, parenteral nutrition, antibiotics, immunosuppression, alternative dialysis or transplantation,

RECURRENT PLEURAL EFFUSION — O’BRIEN et al

Fig. 2. — A: Axial image from a non-contrast abdominal CT performed subsequent to the CT thorax which demonstrates free fluid and peritoneal calcification. B: Axial abdominal CT image at the level of the lower abdomen demonstrates free fluid and a Tenchkoff catheder in keeping with peritoneal dialysis.

remission. Paradoxically, removal of the abdominal catheter and commencing haemodialysis may hasten the progression of the disease (4). In general, surgery should be avoided as far as possible since there is a high rate of post-operative complications such as perforation and fistulae. There is a high associated morbidity and mortality can reach 90% in patients with this condition. It is hoped that with increased renal transplantation, there may be fewer patients on longterm CAPD and reduction in the incidence of this devastating complication. Screening for sclerosing peritonitis should probably be performed in all patients who have been on CAPD for more than five years. References 1.

Fig. 3. — Abdominal radiograph demonstrates the Tenchkoff catheter and subtle peritoneal calcification in support of the diagnosis of sclerosing peritonitis.

and surgical resection. The differential diagnosis of peritoneal calcification must be considered and includes malignancy, tuberculosis and pseudomyxoma peritoneii.

Complications include sepsis, malnutrition and surgical sequelae such as bowel obstruction. Immunosuppression may slow progression, prolong survival and possibly induce

Demir M., Akinci O., Onur E., Koksal N.: Case 108: Sclerosing Encapsulating Peritonitis. Radiology, 2007, 242: 937-939. 2. Stafford Johnson D.B., Wilson T.E., Francis I.R., Swartz R.: CT appearance of sclerosing peritonitis in patients on chronic ambulatory peritoneal dialysis. J Comput Assist Tomogr, 1998, 22: 295-299. 3. Rigby R., Hawley C.M.: Sclerosing peritonitis: The experience in Australia. Nephrol Dial Transplant, 1998, 13: 154-159. 4. Williams L., Czajkowski M., Duane P.: Sclerosing Peritonitis: a gastrointestinal complication of continuous ambulatory peritoneal dialysis in chronic renal failure. Gastroenterology, 2001, 4: 97-99

JBR–BTR, 2010, 93: 12-14.

FIBROADENOMA OF THE BREAST IN A MAN ASSOCIATED WITH ADENOCARCINOMA OF THE RECTUM AND POLYPOSIS COLI Z.H. Adibelli1, M. Yildirim2, E. Ozan1, O. Oztekin1, B. Kucukzeybek3 Fibroadenoma of the breast is an uncommon cause of breast lumps in men. Only a few cases have been reported in the literature, the majority of which were prescribed estrogen. We present herein the first case of a fibroadenoma of the breast in a 68-year-old man with adenocarcinoma of the rectum and polyposis coli. In this case, there was neither estrogen treatment nor any other medications which have been discussed in the literature as inducing fibroadenomas. Fibroadenomas in men without hormone treatment and with normal hormone levels are extremely rare and the developmental mechanism of the breast fibroadenoma in this man is under question. Key-word: Breast, male.

Fibroadenomas of the breast are a common cause of benign breast lumps in premenopausal women. A clinical diagnosis of fibroadenoma is an unexpected presentation in male breasts due to the lack of fibroglandular tissue under the nipple in the normal male. Histologically, subareolar ducts are demonstrated in the normal male breast similar to those found in prepubertal girls (1). These ducts in a male may elongate and branch when stimulated by hormones or a variety of drugs (2). Most men who are referred for breast imaging have a palpable mass, breast enlargement, or tenderness. Benign conditions, such as gynecomastia, lipomas, epidermal inclusion cysts, and intraductal papillomas may mimic male breast cancer (3, 4). Fibroadenomas in males are rare, and only a few cases of fibroadenomas in males have been reported in the literature; most of the reported cases involved male-to-female transsexuals and iatrogenic male fibroadenomas due to estrogen therapy for medical conditions, such as prostatic carcinoma (5). Idiopathic male fibroadenomas are considered an extremely rare event (5-7). Our case had a fibroadenoma of the breast, adenocarcinoma of the rectum, and polyposis coli; however, we could not find any association between these events in the literature. Case report A man born in 1940 had diffuse bilateral breast enlargement without a palpable mass in 2002. On mammography and ultrasonography (US), diffuse gynecomastia was

Fig. 1. — Mammographic appearance of the left breast of the patient in 2002. Left mediolateral oblique mammograms of the patient show very similar appearances to a heterogeneously dense female breast (diffuse gynecomastia).

demonstrated bilaterally (Fig. 1); however, no mass was found. The laboratory work-up was normal, a hormonal imbalance was not found, and he had not used any medications for a long time. He had never smoked nor chewed tobacco. He had worked as a building painter. Three years later he presented with rectal bleeding and constipation. The laboratory work-up was normal. A rectal examination revealed a posterior rectal mass, nearly 6 cm distant from the anal

From: 1. Radiology Department, 2. General Surgery Department, 3. Pathology Department, Izmir Bozyaka Training and Research Hospital, Izmir, Turkey. Address for correspondence: Dr Z.H. Adibelli, M.D., Ugur Mumcu cad. No: 25 Buca, Izmir, Turkey. E-mail: adibellizh@mynet.com

margin. At rectoscopy, a rectal tumor which was 4 cm in diameter and numerous polyps were visualized. At surgery, an abdominoperineal resection was performed. Histopathologically, adenocarcinoma of the rectum and polyposis coli (tubular adenoma) was demonstrated and no metastatic lymph nodes were found (Astler-Coller classification B2). The postoperative course was uneventful and the patient was discharged home on the 11th postoperative day. The patient received fluorouracil (5FU) and calcium leucovorin, administered as an infusion on day 1, and repeated every 3 weeks. The patient’s brother died due to adenocarcinoma of the sigmoid and also had multiple polyps. In 2008, he presented with a left breast mass. On mammography, the patient had bilateral diffuse gynecomastia, and there was a round, wellcircumscribed, and homogenous lesion in the upper outer quadrant of the breast (Fig. 2). The lesion was 2 cm in diameter. On US, the lesion was solid, hypoechoic, homogenous, and well-circumscribed (Fig. 3). The lesion corresponded to BI-RADS 3 on mammography; however, because of the solid character and history of malignancy, it was considered suspicious for a malignancy. The histological diagnosis was made by surgical biopsy and the lesion was proven to be a fibroadenoma. Hematoxylin-eosin-stained slides of the biopsy were available for review. Macroscopically, the mass was measured as 2 x 1.5 x 1.3 cm. Microscopically, the mass was typically a fibroadenoma with a knobby and circumscribed contour (Fig. 4). The mass showed nearly equal portions of epithelial and stromal components. Also, the epithelial component of the specimen showed diffuse gynecomastia. Besides using 5FU and calcium leucovorin in 2005, the other med-

FIBROADENOMA OF MALE BREAST AND RECTAL NEOPLASMS — ADIBELLI et al

Fig. 2. — Mammographic appearances of the left breast of the patient in 2008. A. Craniocaudal and B mediolateral oblique mammograms show a bilobulated and homogenous mass in the upper lateral quadrant besides gynecomastia.

ications of the patient were warfarin sodium and acetylsalicylic acid after a deep venous thrombosis since 2007, furosemide since 2006, and citalopram since 2008. His hormone levels were normal for his age group. Discussion Fibroadenomas in the male breast are rare, and only a few cases have

been reported. Holleb et al. (8) concluded that there was no true fibroadenomas of the male breast. It has been concluded by some authors that most of the reported lesions are poorly documented and nodular foci of gynecomastia have been reported as fibroadenomas (9). However, it is now apparent that fibroadenomas in the male breast are true events because there have been some reports in which

Fig. 3. — Ultrasound of the mass demonstrates a solid, homogenous, and lobulated mass with a well-defined contour.

fibroadenomas were well-documented (5-10). Fibroadenomas have both estrogen and progesterone receptors (11). It has been discussed that proliferative changes in the male breast, like gynecomastia, lobular differentiation, and fibroepithelial lesions are caused by hormonal imbalances and some medications. In the literature, fibroadenomas in the male breast appear to be always associated with gynecomastia. Like Shin and et al. (6), we could not find any reports of fibroadenoma in male patients who did not have concurrent gynecomastia. However, the presence of lobular differentiation with or without associated gynecomastia is less common (6). Lobular differentiation and fibroadenomas were found in two reported cases of maleto-female transsexuals who were undergoing demasculinization and feminization by hormonal therapy using ethinyl-oestradiol and cyproterone acetate and surgical treatment (5). Davis et al. (11) reported a case of a 19-year-old female with complete androgen insensitivity syndrome (CAIS) and a fibroadenoma of the breast. Four cases of male fibroadenomas have been reported in which gynecomastia with lobular differentiation was present in each case (12). One of the four patients had been treated with estrogens, whereas another patient had been treated with methyldopa and chlordiazepoxide. As Asscheman et al. (13) reported, there are genetic differences in estrogen sensitivity to

Fig. 4. — Photomicrograph of the surgical biopsy specimen reveals that connective tissue invaginates into the glandular spaces (x 40 H&E stains).

dopaminergic regulation of prolactin secretion, and in the latter case, methyldopa was thought to play a role. For the other two patients, the possible causes of fibroadenoma formation remain elusive. In our case, the presence of lobular differentiation was carefully sought; however, not found. In idiopathic prepubertal or senile gynecomastia, the increase in the plasma estrogen-to-androgen ratio usually will not induce acinar and lobular formation in the male breast. However, in transsexuals, in whom progestagenic antiandrogens, such as cyproterone acetate, are combined with feminizing estrogen therapy, acini and lobular formation will occur (6, 14). The use of a luteinizing hormone-releasing hormone agonist to decrease testosterone levels for the treatment of advanced prostate cancer has contributed to the development of gynecomastia and fibroadenoma (6). Gynecomastia has also been associated with digitalis and spironolactone, which interfere with the production of testosterone and its conversion to the potent metabolite, 5-alfa-dihydrotestosterone (2, 5). Cimetidine is also a big precursor of gynecomastia (15). Nielsen (16) reported a case of bilateral fibroadenomatoid hyperplasia in a 69-year-old man whose breasts had become diffusely enlarged with multiple fibroadenomatoid nodules when spironolactone was added to his prior therapy with digoxin and furosemide during the last 4 years before presentation. In the literature, we did not find any reports about the relationship between 5FU, calcium leucovorin, and fibroadenomas of the breast. However, a combination of different therapies can lead to some side effects. Since 2002, gynecomastia was known to be present. Perhaps citalopram (since 2008) gave the boost to develop the fibroadenoma. The patient had worked as a painter,

JBRâ&#x20AC;&#x201C;BTR, 2010, 93 (1)

so he had some chemical contacts which may have assisted the development of fibroadenoma. Also, there were no reports about the association of adenocarcinoma of the rectum and polyposis coli with fibroadenomas of the breast in a man. Our patientâ&#x20AC;&#x2122;s brother also had polyposis coli (tubular adenoma) and died because of colorectal adenocarcinoma. The prevalence of fibroadenomas of the breast among patients who have polyposis coli is unknown. The co-occurrence may have arisen by chance, or maybe in the future, new research will show an association.

8. 9.

Conclusion Fibroadenomas in men without hormone treatment and with normal hormone levels are extremely rare. This is the first report of a man who had a fibroadenoma of the breast, gynecomastia, adenocarcinoma of the rectum, and polyposis coli. In light of the literature, the causative agent of the fibroadenoma in this unique case is unknown and the developmental mechanism of the breast fibroadenoma in this man is under question. References 1. Kopans D.: Breast imaging, 3rd Edition. Pa: Lippincott Williams and Wilkins, 2007, pp 671-672. 2. Asscheman H., Gooren L.J.G.: Hormone treatment in transsexuals. J Psychol Human Sexual, 1992, 5: 39-54. 3. Appelbaum A.H., Evans G.F., Levy K.R., Amirkhan R.H., Schumpert T.D.: Mammographic appearances of male breast disease. Radiographic, 1999, 19: 559-568. 4. Chen L., Chantra P.K., Larsen L.H., Barton P., Rohitopakarn M., Zhu E.Q., Bassett L.W.: Imaging characteristics of malignant lesions of male breast. Radiographics, 2006, 26: 9931006. 5. Kanhai R.C., Hage J.J., Bloemena E., van Diest P.J., Karim R.B.: Mammary

10.

11.

12.

13.

14.

15.

16.

fibroadenoma in a male-to-female transsexual. Histopathology, 1999, 35: 183-185. Shin S.J., Rosen P.P.: Bilateral presentation of fibroadenoma with digital fibroma-like inclusions in the male breast. Arch Pathol LAB Med, 2007, 131: 1126-1129. Adibelli Z.H., Oztekin O., Postaci H., Uslu A.: The diagnostic accuracy of mammography and ultrasound in the evaluation of male breast disease: a new algorithm. Breast Care, 2009, 4: (DOI:10.1159/000226284). Holleb A.I., Freeman H.P., Farrow H.J.: Cancer of male breast, part II. N Y State J Med, 1968, 68: 656-663. Rosen P.P.: Benign proliferative lesions of the male breast. In: Rosen P.P., ed. Rosenâ&#x20AC;&#x2122;s Breast Pathology. 2nd ed. Philadelpia, Pa: Lippincott Williams and Wilkins, 2001, 703-712. Lemmo G., Garcea N., Corsello S., Tarquini E., Palladino T., Ardito G., Garcea R.: Breast fibroadenoma in a male-to-female transsexual patients after hormonal treatment. Eur J Surg, Suppl, 2003, 588: 69-71. Davis S.E., Wallace A.M.: A 19 year old with complete androgen insensitivity syndrome and juvenile fibroadenoma of the breast. Breast J, 2001, 7: 430433. Ansah-Boateng Y., Tavassoli F.A.: Fibroadenoma and cystosarcoma phyllodes of the male breast. Mod Pathol, 1992, 5: 114-116. Asscheman H., Gooren L.J.G., Assies J., Smits J.P.H., de Slegte R.: Prolactine levels and pituitary enlargement in hormone-treated male-to-female transsexuals. Clin Endocrinol, 1988, 28: 538-588. Kankai R.C., Hage J.J., van Diest P.J., Bloemena E., Mulder J.W.: Shortterm and long-term histologic effects of castration and estrogen treatment on breast tissue of 14 male-to-female transsexuals in comparison with chemically castrated males. Am J Surg Pathol, 2000, 24: 74-80. Rodriquez L.A., Jick H.: Risk of gynaecomastia associated with cimetidine, omeprazole, and other antiulcer drugs. BMJ, 1994, 19: 503-506. Nielsen B.B.: Fibroadenomatoid hyperplasia of the male breast. Am J Surg Pathol, 1990, 14: 774-777.

JBR–BTR, 2010, 93: 15-19.

UPDATE RADIATION DOSE OPTIMIZATION IN THORACIC IMAGING D. Tack Guidelines for reduction of CT radiation dose were introduced in 1997 and are now more than 12 years old. The process initiated by the European Regulatory authorities to reduce the excess of radiation from CT has however not produced the expected results. Reference diagnostic levels (DRL) from surveys are still twice as high as needed in most European countries and were not significantly reduced as compared to the initial European ones. Many factors may at least explain partially the lack of dose reduction. One of them is the complexity of the dose optimization process while maintaining image quality at a diagnostically acceptable level. Chest is an anatomical region where radiation dose could be substantially reduced because of high natural contrasts between structures, such as air in the lungs and fat in the mediastinum. In this article, the concept of CT radiation dose optimization and the factors that contribute to maintain global excess in radiation dose are reviewed and a brief summary of results from research in the field of chest CT radiation dose is given. Key-words: Radiations, injurious effects – Lung, CT.

Methods for dose reduction

by CT manufacturers and often used in routine practice but that could be substantially reduced – to an optimized dose level – without deleterious effect on image quality. The term “optimized dose” should refer to a dose that provides adequate image quality but not with excessive radiation, and is the practical application of ALARA (As Low As Reasonably Achievable) principle. The term “low dose” should be restricted to a CT delivered dose not higher than that delivered by a set of plain films investigating the considered condition. At low-dose, image quality is lower but diagnostic accuracy is preserved. Optimization process is per definition a process that eliminates the excess of radiation that does not provide significant increase in image quality. Optimized dose level for a given examination is not known. It has to be defined for a standard human body that may de defined as weighting 70 to 74 kg. This optimized dose level depends on many factors and in particular on the CT technology. The more recent the CT is, the lower will be the required dose to provide adequate image quality. Because there is no large consensus on optimized dose levels the European Regulatory Authorities have developed an approach for dose reduction that is based on survey studies.

Definitions

Survey studies

The term “standard dose“ refers to the dose usually recommended

The unique strategy for reducing the collective radiation dose from

The overall increase in patient irradiation caused by the growing use of spiral- and multidetector-row CT (MDCT) is of particular relevance for thoracic imaging. The number of clinical indications for thoracic CT has steadily increased, and CT has become a first line imaging tool for diseases previously imaged with chest radiography, ventilation/perfusion scintigraphy, and pulmonary angiography (1). Moreover, the use of CT for screening purposes has raised the number of CT examinations performed in clinically asymptomatic patients (2). Finally, the relatively higher number of CT examinations performed in younger patients increases cumulative radiation in a population vulnerable to its potential long-term effects (3). Although recent publications have addressed radiation-related topics in CT imaging of specific thoracic diseases (4-10), the approach of thoracic radiologists to the general issue of patient radiation and their strategies for dose reduction are not known. Such information, however, might help to focus and further enhance already ongoing efforts in this field (9, 11, 12). The aim of this article is to list and discuss the available solutions to optimize and reduce radiation dose in adult thoracic MDCT examinations.

From: Department of Radiology, Clinique Louis Caty, Hôpital RHMS, Baudour, Belgium. Address for correspondence: Dr D. Tack MD, PhD, Clos du Mélèze, 17, B-1420 BraineL’Alleud, Belgium. Email : denis.tack@skynet.be.

diagnostic CT examinations proposed by the European Union in 1997 is based on surveys that intend to define a diagnostic reference level (DRL) corresponding to the 75th percentile of the observed doses for a given CT examination. The first historical survey was conducted in the United Kingdom on single detectorrow scanners in the mid 1990ies and served as the European DRL in the entire European Union. The DRL is expressed either in weighted Computed Tomography Dose Index (CTDIw) serving as index of image quality or in dose-length product (DLP) expressed in mGy.cm serving as the indicator of the exposure per acquisition and or per examination in case of multiphasic procedure. The historical European DRL for chest CT was as high as 650 mGy.cm for one single acquisition. Several more recent s are listed in Table I. The corresponding effective dose (estimating the cancer risk) is calculated by multiplying the DLP by a conversion factor (0.017 mSv/mGy.cm) and is of 11 mSv. The lifetime risk of dying from a radiation induced cancer if exposed to 11 mSv is calculated by multiplying the effective dose expressed in Sievert (Sv) by 5%. For the European for Chest helical CT, DRL, this lifetime risk is of 1/1820 but could be substantially reduced (13, 14). According to the European rules, any radiology department performing CT examinations with a dose higher than the DRL is expected to reduce this dose (13-15). Thus, after publication of a national survey, the collective dose from CT should decrease because the 25% highest dose values should be reduced. A

renewed survey should thus redefine a DRL lower than the original one and the process of dose reduction being repeated. First surveys conducted in the EU typically showed that a factor of 2 to 6 was observed between the dose level of a P75 and the one of a P25 (13). If a second survey is conducted within a reasonable short time interval after the first one, it is actually believed that the reference dose levels could decrease significantly and that the interval between DLP respectively corresponding to the P75 and the P25 could be reduced. Unfortunately, to the best of our knowledge, no EU member has yet performed such repeated surveys and all published national DRL are still very high, ranging from 430 mGy.cm in United Kingdom to 627 mGy.cm in Italy (13). In 2010, 12 years after publication of the EU 97/43 directive had been published, thus the goal of the survey strategy from the EU directive is by far not achieved. Automatic exposure control systems It is to note that most DRLDRL were obtained from surveys performed in the late 1990ies or in the early 2000. At that time, CT scanners were not equipped with automatic exposure control systems (AEC), also called tube current modulation device, because these systems were introduced only by 2002 (16). AEC are able to provide equalized image quality throughout the helical acquisition for all patients. Technical approach for AEC varies between manufacturers but all AEC systems are able to automatically adapt the dose to the patient’s size, weight and/or absorption. Thus, AEC can reduce the dose in small patients but also increase the dose in obese patients. Before AEC were introduced, the concern about radiation dose was not as high as it is now. As a matter of fact, standard CT with the same very high dose was applied to all patients while providing satisfactory image quality. This means that standard CT delivered a radiation dose suited for obese patients and a significant excess in dose in all non obese patients. One can estimate that the mean amount of excess in radiation dose was at least 50% of the delivered one. Since AEC systems are now widely used, there are two major problems concerning surveys: first, in order to take into account that AEC systems are widely used, surveys have to be focused on standard

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patients in order to get rid of the effect of distortion in weight distribution among participants. Second, new surveys suitable for modern MDCT scanners equipped with AEC should be urgently conducted in the entire Union in order to definitely abandon the historical DRLDRL that are approximately twice as high for standard patients and that suited obese patients only. New reference values Because of this urgent need in new DRLDRL, an electronic survey has been recently conducted among chest radiologists, members of thoracic scientific societies, around the world (14). This survey revealed that 60% of respondents acquire chest MDCT with DLP lower than 250 mGy.cm in a standard patient, more than 80% of them using the AEC device that equip their 8 to 64 MDCT (14). This DLP value may serve as new reference for thoracic MDCT scanning powered by AEC. Assuming that a chest MDCT covers a longitudinal (caudocranial) distance of 30 cm in a standard patient, the reference value (75th percentile) of a chest MDCT expressed in volume computed tomography dose index (CTDIvol) would be lower than 7.8 mGy (Table I). The median CTDIvol value would be around 6 mGy and the 25th percentile, usually presented as the goal for MDCT optimization, would be around 4.5 mGy (13). In addition, as explained hereafter, CT pulmonary angiography can be obtained with a higher vessel enhancement while using a lowered tube potential at 100 KV. With 100 KV, the CDTIvol is reduced by 30% as compared to 120 KV. The goal to achieve in terms of CTDIvol in a standard patient undergoing CT pulmonary angiography is thus equal or below 4 mGy. No doubt that the newest scanner generation with technical advances

in dose reduction (new filters, new detectors, new reconstruction algorithms such as iterative reconstruction) will enable to reduce these values by 30 to 70% with equal or even higher image quality (Fig. 1). Optimization Optimization of a CT radiation dose consists of reducing the dose to the lowest possible level while maintaining image quality at an acceptable and comfortable level. Good competence in CT technique and in particular in the AEC system that is available is required. The key parameter to optimize is the index of image quality. This index is scanner (manufacturer) specific and usually difficult to manage. Additional parameters to manage may be the minimum and maximum tube current, the slice thickness, the rotation time, the pitch, and the reconstruction kernel. Very important parameter to set up as well is the tube potential. Optimization process may be facilitated by a simulator of the image that would be obtained with the preselected parameters (Toshiba Medical Systems). Optimization is part of the ALARA (As Low As Reasonably Achievable) concept and could be considered as part of normal daily practice in CT. On the other hand, optimization that consists in testing on patients could be considered as clinical research and may require authorization of a local ethical committee in addition to written patient informed consent. Up to now neither guideline nor rule is available regarding the appropriate methods for dose optimization and ALARA “behavior”. In addition, as AEC systems are complex and usually not well known by CT users, the optimization process is practically very complex. Many factors contribute to the absence of significant dose optimization in daily practice. First, as

Table I. — Reference diagnostic levels for helical CT of the chest in a standard patient Source EU 16262 1999 (SDCT) Italy 2006: (MDCT) France 2004 (MDCT) Germany 2002 (SDCT-MDCT) United Kingdom 2003 (MDCT) Chest Radiologists (P60) – ref 14 Optimized RDL(P75) Optimized median (P50) CTPA (100 KV)

DLP (mGy.cm)

CTDIvol (mGy)

650 627 500 480 442 250 210 180 150

22.0 21.0 16.0 15.5 14.7 8.0 7.0 6.0 4.0

RADIATION DOSE OPTIMIZATION IN THORACIC IMAGING— TACK

Fig.1. — Optimized MDCT pulmonary angiography with newest MDCT generation. 38 year-old female patient weighting 65 Kg, suspected of acute pulmonary embolism. 128 MDCT pulmonary acquisition performed at 100 KV and with tube current modulation (Care dose 4D® – Siemens Medical Systems, Forchheim, Germany). CTDI vol automatically reduced the mean mAs from 100 to 62. Mean CTDIvol for this acquisition was 2,46 mGy. Total DLP for this examination was 85 mGy.cm and the corresponding effective dose was 1,45 mSv. A. CTPA window showing excellent image quality and high vascular enhancement. B. Lung window settings showing excellent image quality as well.

explained here above, the regularity authorities do not provide radiologists with freshly renewed survey data. So DRL are high. Second, the European recommendation is to focus the attention on the third quartile of surveys (P75), but the concept of the 75th percentile is probably insufficient to significantly reduce collective dose. It has been advised (13) to focus on the first quartile (P25). The P25 could be used by CT centers as the goal to be reached, particularly with modern MDCT scanners. Third, there is no penalty for any CT center that would not reduce an excess in dose. Fourth, AEC are so complex and not sufficiently explained to CT users by manufacturers that radiologists may not feel confident or even may be completely unable to modifying the AEC parameters installed by the vendor on their CT (16). Fifth, radiologists fear to reduce the dose for many reasons, one of those being the absence of training in the use of optimized dose and in the setup of AEC systems. Sixth, hospital physicists who are familiar with dose measurements are not able to propose clinically relevant noise index levels that fit with all CT scanners, indications, and AEC systems. Seventh, the standard setups proposed by manufacturers are almost systematically too high by 40 to 50 % mainly because the manufacturers want to satisfy clients and because these clients (radiologists) usually

want excellent image quality without any compromise. Finally, the way radiologists are educated in their universities could have a significant impact on what they are going to promote and use for their entire career. German radiologists are much friendlier with dose justification as are French and Belgian radiologists who usually give a much higher importance to the highest possible detection rate whatever the radiation risks, and to the most perfect image quality. This is at least what I have personally observed in a recent optimization process conducted in Luxemburg, a country where radiologists work who have been educated in France, Belgium and Germany. Low-dose chest MDCT Routine chest CT The concept of reducing the radiation dose in chest CT was first introduced in by Naidich et al. (1990) who reduced the tube current on incremental 10-mm collimation CT, and demonstrated that with low tube current settings (i.e. 20 mAs), the image quality is sufficient for assessing the lung parenchyma. While these images are sufficient for assessing lung parenchyma, the increased noise results in marked degradation of the quality of images photographed with mediastinal window settings. Because of this, these

authors recommended that such low-dose technique should be most suitable for children and for screening. As such, these recommendations have been implemented and further studied in lung cancer screening programs (17). Similar dose reduction strategies have been applied to thin-section CT, in which no significant difference in lung parenchyma structures was detectable between low-dose (i.e. 40 mAs) and high-dose (i.e. 400 mAs) (18). Although the observed differences were not statistically significant, changes in ground-glass opacity were difficult to be assessed at low-dose CT because of the increased noise. Therefore, it was recommended that 200 mAs should be used for initial thin-section CT and lower doses (i.e., 40-100 mAs) for follow-up examinations. The relationship between radiation exposure and image quality at mediastinal and pulmonary window settings has been evaluated on conventional 10-mm collimation CT images on a single model of CT scanner with mAs settings ranging from 20 to 400 mAs (19). Although this study showed a consistent increase in image quality with radiation dose, no difference in detection of mediastinal and lung abnormalities could be detected. These findings were confirmed on MDCT by Dinkel et al. (20) who showed that 90% reduction in dose compared

with standard-dose techniques was not associated with impaired detection of suspicious lesions of malignant lymphoma and extrapulmonary tumours. In order to investigate the effect of dose reduction without scanning patients several times at several dose levels, it is now possible to use computed simulation of dose reduction by adding random noise to the image obtained at standard dose. In a validation trial, it has been shown that experienced chest radiologists were unable to distinguish CT images obtained with simulated reduced doses from those obtained with really reduced doses. This technique of simulated reduced doses allows investigators to determine the impact of dose reduction on diagnostic performances without exposing patients to additional radiations and/or several injections of iodinated contrast material. CT pulmonary angiography The simulated low-dose technique has been used to evaluate the effect of dose reduction on CT pulmonary angiography. A group of 21 individuals that showed at least one filling defect within a pulmonary artery were used to simulate CT pulmonary angiography with reduced radiation doses, at 60, 40, 20, and 10 mAs. This study showed that frequencies of positive and inconclusive results, branching order of the most distal artery with a filling defect were not changed when tube current-time product was reduced from 90 to 10 mAs. On the other hand, the quality of intravascular contrast enhancement decreased when the tube current-time product setting was lower than 40 mAs. This study suggests that the reduction of the tube-current time product setting to 40 mAs to achieve a reduced radiation dose at CT pulmonary angiography appears to be acceptable (21). Sigal-Cinqualbre et al. have assessed the feasibility of low-kilo voltage in CT pulmonary angiography protocols and have evaluated the effect of such protocols on image quality (22). These authors have simultaneously reduced the tube potential and increased the mAs settings. They have shown that in patients weighting less than 75 kg, 80 kV (and 135 or 180 mAs respectively in patients weighting less than 60 or 75 kg) are sufficient to obtain the same image quality than in patients larger than 75 kg and

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scanned at 120 kV and 90 mAs. These results need to be confirmed and verified in other indications than CT pulmonary angiography, but this study has already suggested that reducing the tube potential could be a valid method, an alternative to decrease the mAs settings, to reduce the radiation dose. Since 2004, several studies have validated the used tube potential at 100 KV in patients up to 100 Kg (23). The dose reduction of 100 Kv acquisition is of 30% as compared to 120 KV. The recommended CTDIvol for standard patients undergoing CT pulmonary angiography is thus 30% lower than the one for a routine chest MDCT and should be as low as 4 mGy. Air trapping and expiratory CT By demonstrating air-trapping, expiratory thin-section CT is able to detect a disease before the functional tests. This makes this technique an essential part of the diagnosis of bronchiolitis of various origins. As expiratory CT is most often obtained after inspiratory CT, this additional acquisition exposes patients to supplementary radiation dose. This is of concern in patients with bronchiolitis, because they can often be young, and, despite their relatively favorable prognosis, have a high risk of recurrence resulting in repeated follow-up examinations and repeated exposure to CT radiation. In order to investigate the possible effect of dose reduction on the visual quantification of air trapping, we considered the “bronchiolitis obliterans syndrome” (BOS) after lung transplantation as a model for bronchiolitis (24). In this model, we applied the simulated low-dose technique on expiratory thin-section CT examinations in patients with possible BOS. In 27 lung transplant recipients, expiratory thin-section CT was performed at 140 kVp and 80 effective mAs. Dose reduction corresponding to 60, 40, and 20 effective mAs was simulated. This study showed that a simulated dose-equivalent of 25% of the standard dose, i.e. 20 mAs, had no substantial effect on the visual quantification of air trapping. Because its radiation dose approximated that of incremental thin-section CT with 10 mm section intervals performed with a standard dose, expiratory low-dose MDCT could be used in the assessment of air trapping in patients with suspected bronchiolitis. This model could be extended to other origins of bronchiolitis.

Conclusion CT radiation dose optimization and reduction is a complex process that seems to stay motionless since years. Optimization behavior requires strong efforts and close cooperation between radiologists, manufacturers and regularity authorities for obtaining the significant results that have been originally expected from the European Directive 97/43. Chest is an appropriate body region for dose reduction and optimization because of its natural contrasts. Actual recommended CDTIvol for a standard patients undergoing helical chest CT is at 6 mGy whereas the corresponding DLP is at 180 mGy.cm. CTPA benefits from lowering tube potential from 120 to 100 KV and the corresponding typical CTDIvol is at 4 mGy whereby the DLP can be reduced to 120 mGy.cm in a standard patient. Newest MDCT generation should enable further dose reduction of 30 to 70%. References 1. Mayo J.R., Aldrich J., Muller NL.: Radiation exposure at chest CT: a statement of the Fleischner Society. Radiology, 2003, 228: 15-21. 2. Brenner D.J.: Radiation risks potentially associated with low-dose CT screening of adult smokers for lung cancer. Radiology, 2004, 231: 440-445. 3. Brenner D.J., Hall E.J.: Computed tomography — an increasing source of radiation exposure. N Engl J Med, 2007, 357: 2277-2284. 4. Remy-Jardin M., Pistolesi M., Goodman L.R., et al.: Management of suspected acute pulmonary embolism in the era of CT angiography: a statement from the Fleischner Society. Radiology, 2007, 245: 315329. 5. Bankier A.A., Schaefer-Prokop C., De Maertelaer V., et al.: Air trapping: comparison of standard-dose and simulated low-dose thin-section CT techniques. Radiology, 2007, 242: 898906. 6. Heyer C.M., Mohr P.S., Lemburg S.P., Peters S.A., Nicolas V.: Image quality and radiation exposure at pulmonary CT angiography with 100- or 120-kVp protocol: prospective randomized study. Radiology, 2007, 245: 577-583. 7. Itoh S., Koyama S., Ikeda M., et al.: Further reduction of radiation dose in helical CT for lung cancer screening using small tube current and a newly designed filter. J Thorac Imaging, 2001, 16: 81-88. 8. Madani A., De Maertelaer V., Zanen J., Gevenois P.A.: Pulmonary emphysema: radiation dose and section thickness at multidetector CT quantification — comparison with macroscopic

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and microscopic morphometry. Radiology, 2007, 243: 250-257. Ravenel J.G., Scalzetti E.M., Huda W., Garrisi W.: Radiation exposure and image quality in chest CT examinations. AJR, 2001, 177: 279-284. Szucs-Farkas Z., Kurmann L., Strautz T., Patak M.A., Vock P., Schindera S.T.: Patient exposure and image quality of low-dose pulmonary computed tomography angiography: comparison of 100- and 80-kVp protocols. Invest Radiol, 2008, 43: 871-876. Kalra M.K., Maher M.M., Toth T.L., et al.: Strategies for CT radiation dose optimization. Radiology, 2004, 230: 619-628. Mayo J.R., Kim K.I., MacDonald S.L., et al.: Reduced radiation dose helical chest CT: effect on reader evaluation of structures and lung findings. Radiology, 2004, 232: 749-756. Stamm G.: Collective radiation dose from MDCT: critical review of surveys studies. In: Tack D., Gevenois P.A., eds. Radiation dose from adult and pediatric multidetector computed tomography. Berlin, Heidelberg, New York, Springer, 2007, 82-97. Bankier A.A., Tack D., Ngo L., Boiselle, P.M.: 56. Dose Reduction in

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Thoracic CT: A Global Survey. RSNA 2009 Chicago. SSA04 29/11/2009. Union E.-E.: European guidelines on quality criteria for computed tomography EUR 16262 EN. Kalra M.K., Toth T.L.: Automatic exposure control in multidetector-row computed tomography. In: Tack D., Gevenois P.A., eds. Radiation dose from adult and pediatric multidetector computed tomography. Berlin, Heidelberg, New York, Springer, 2007, 117-128. Henschke C.I., McCauley D.I., Yankelevitz D.F., et al.: Early Lung Cancer Action Project: overall design and findings from baseline screening. Lancet, 1999, 354: 99105. Zwirewich C.V., Mayo J.R., MĂźller N.L.: Low-dose high-resolution CT of lung parenchyma. Radiology, 1991, 180: 413-417. Mayo J.R., Webb W.R., Gould R., et al.: High-resolution CT of the lungs: an optimal approach. Radiology, 1987, 163: 507-510. Dinkel H.P., Sonnenschein M., Hoppe H., Vock P.: Low-dose multislice CT of the thorax in follow-up of malignant lymphoma and extrapul-

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CONTINUING EDUCATION THE TALOCALCANEAL UNIT: PICTORIAL REVIEW OF ANATOMY AND PATHOLOGIC CONDITIONS ON MULTI DETECTOR CT A. Ayoob1, M. De Maeseneer2, M. Shahabpour3, P. Van Roy4, E. Barbaix4, S. QIng4 Normal anatomy of the subtalar joints is illustrated in cadaveric specimens. Variations of the subtalar joints include three facets, fused middle and anterior facet, and missing anterior facet. Patients were studied by means of Multi Detector Computed Tomography (MDCT) to provide clinical examples of subtalar pathology including traumatic and non traumatic disorders. Key-word: Foot, CT.

Our knowledge with regard to histology, anatomy and pathology of the talocalcaneal joints and sinus tarsi remains limited, despite advances in imaging of this region. The purpose of this article is to illustrate bony and soft tissue anatomy of the subtalar joint, to demonstrate variations in bony anatomy of the subtalar joint, and to show pathological findings as imaged with MDCT. Technical considerations For this study we used 9 pairs of bone specimens (talus-calcaneus), and obtained anatomical slices in 2 fresh cadaver specimens. Photographs of dissection available at the anatomy department were also studied. MDCT images were obtained in 120 patients with a suspicion of talocalcaneal and ankle pathology. A Siemens imaging system was employed (Siemens Somatom Plus, Erlangen, Germany). Scan parameters were as follows: collimation, 0.75; mAs, 130;kV, 120: feed/rotation, 6.8 mm> Reconstructions were performed as follows: slice thickness, 0.75; kernel, sharp; bone window; reconstruction increment, 0.5 mm. MR can also demonstrate subtalar joint anatomy and is more accurate in demonstrating the ligamentous structures. Also fractures that are subtle and occult may be apparent on MRI as well as delicate subchondral changes in the absence of frank erosions.

From: 1. Department of Radiology, University of Michigan, Ann Arbor, MI, USA, 2. Division of Radiologic Sciences, Wake Forest University, Winston Salem, NC, USA, 3. Department of Radiology, Vrije Universiteit Brussel, Brussels, Belgium, 4. Department of Experimental Anatomy, Vrije Universiteit Brussel, Brussels, Belgium Address for correspondence: Dr M. De Maeseneer, MD, Department of Radiology, Wake Forest University, Medical Center Boulevard, Winston Salem, NC 27157, USA; e-mail: mdemaes2@wfubmc.edu

Fig. 1. — A. Sagittal MDCT image shows middle subtalar joint (white arrow). Note small subchondral geode (long black arrow) and osteochondral lesion of talus (arrowheads). B. Sagittal MDCT image shows posterior (thick arrow) and anterior (thin arrow) subtalar joints. Note sinus tarsi (curved arrow). C. Sagittal MDCT shows middle (thick arrow) and posterior (thin arrow) subtalar joints, and tarsal canal (curved arrow).

Fig. 2. — Lateral radiograph in specimens. Note posterior (thin arrows), and middle (thick arrows) subtalar joints.

TALOCALCANEAL UNIT — AYOOB et al

Fig. 3. — A. Superior view of calcaneus. Three subtalar facets are seen, the anterior (A), middle (M), and posterior (P) facet. B. Superior view of calcaneus. Two facets are seen. The anterior and middle facet are fused (F).Note posterior facet (P). C. Superior view of calcaneus. The anterior facet is missing, and only a middle (M), and posterior (P) facet are seen.

Fig. 4. — Photograph of calcaneus and talus. The sinus tarsi (S) is seen. Also note middle (thick arrow) and posterior (thin arrow) subtalar joints.

Bony anatomy The subtalar joint represents the articulation between the talus and calcaneus. While variations exist, typically the subtalar joint is described as consisting of three facets: anterior, middle, and posterior (Figs. 1, 2) (1, 2). The anterior facet is concave in shape and articulates with the head of the talus. It can be congruent with the middle facet. The middle facet is also slightly concave and is situated on the sustentaculum tali. The posterior facet is the largest facet and is convex. Three variations of the bony anatomy of the subtalar joints exist: three joint facets, miss-

Fig. 5. — Drawing of funnel shaped appearance of sinus tarsi (arrows). Note anterior (A), middle (M), and posterior (P) facets.

ing anterior joint facet, and fused anterior and middle joint facets (Fig. 3). It is unknown whether certain types predispose to subtalar injury, or are associated with differences in subtalar ligament anatomy. The anterior and middle facet are separated from the posterior facet

by the tarsal sinus and tarsal canal. The position of the joint facets gives the tarsal sinus its trumpet shape with a wide opening at the lateral aspect, and a narrower opening at the medial aspect of the hindfoot (Figs. 4, 5). The medial portion is also termed the tarsal canal.

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B Fig. 6. â&#x20AC;&#x201D; A. Sagittal anatomical slice through sinus tarsi (S). Note posterior subtalar joint (arrow). B. Sagittal anatomical slice through tarsal canal (white arrow). Note middle (thin arrow) and posterior (thick arrow) subtalar facets. C. Sagittal anatomical slice through sustentaculum tali (white arrow). Note flexor hallucis longus tendon (black arrows).

Soft tissue anatomy of the subtalar joint

Fig. 7. â&#x20AC;&#x201D; Coronal anatomical slice. Centrally interosseous ligament is seen (thick black arrows), Also note tarsal canal extension (white arrow), and medial and lateral tendon groups (thin black arrows).

Extrinsic stabilizers of the subtalar joints include medial and lateral ankle tendons and the various extrinsic ligaments connecting the bones of hind- and midfoot. The sinus tarsi contains fat, nerves, vessels, capsular reinforcements, and ligaments (3, 4). The soft tissue variations of the sinus tarsi and function of the various ligaments are incompletely understood. Ligaments in the sinus tarsi are extracapsular and include (from medial to lateral) a ligament in the canalis tarsi, capsular reinforcements, the interosseous ligament, the cervical ligament, and a fiber bundle connecting to the extensor retinaculum (Fig. 6). The cervical ligament extends from the inferolateral talar neck to the dorsal calcaneus. The primary function of the cervical ligament is thought to be limiting hindfoot inversion. The interosseous ligament extends obliquely between the talus and calcaneus. Although smaller than the cervical ligament, the interosseous ligament is also felt to play a role in hindfoot stability by limiting inversion (Figs 7-9). At the lateral aspect of the sinus tarsi, the inferior extensor retinaculum is anchored to the talus and calcaneus by roots that are located in the sinus tarsi. Tears of the sinus tarsi ligaments are often associated with ankle distortion. MR and

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A Fig. 8. — A. Sagittal PD weighted MR image. Note ligament of tarsal canal (thin black arrow) and anterior and posterior (thick black arrows) subtalar joints. B. Sagittal PD weighted MR image. Note cervical ligament (black arrow). Also note fiber bundle (curved arrow) extending to extensor retinaculum (E).

Fig. 9. — Sagittal MDCT image. Note fiber bundle (arrow) out of sinus tarsi extending to extensor retinaculum.

CT may show soft tissue prominence, fiber interruptions and bony avulsions. The clinical and prognostic significance of these findings remains obscure, however. Subtalar joint pathology The subtalar joint is frequently involved in traumatic injuries to the hindfoot, namely fractures of the calcaneus and talus (Fig. 10) (5). Given the complex anatomy of the subtalar joint facets, radiographs are often limited in both the detection and characterization of these injuries.

Fig. 10. — Sagittal MDCT image. Note intraarticular fracture fragment (white arrow) and posterior malleolus fracture (black arrow). Arrowhead points to donor site.

MDCT is useful in establishing the presence of fractures, in detecting additional fractures not visible on radiography, and in the assessment of joint involvement, joint incongruity, and fracture comminution. These are important factors in both the treatment and prognosis for these injuries and therefore MDCT plays a vital role in the clinical evaluation of these patients. The subtalar joint can also be involved in a variety of arthritides, including degenerative, inflammatory, infectious, and crystalline processes. As for traumatic injuries, MDCT is invaluable in

the detection and characterization of these entities. Traumatic conditions The calcaneus is the most frequently fractured tarsal bone with calcaneal fractures accounting for about 60 % of all major tarsal injuries. The majority of fractures are intraarticular with subtalar joint involvement (Figs. 11-13) (6, 7). Calcaneal fractures result when axial forces applied to the foot cause the calcaneus to be driven into the lateral process of the talus. The result is a

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Fig. 11. — Sagittal MDCT image. Fracture of the calcaneus (arrowhead) involving the middle subtalar joint.

Fig. 12. — Sagittal MDCT image. Fracture of the calcaneus involving the anterior (bold arrow) and posterior (thin arrow) subtalar joints.

Fig. 13. — Sagittal MDCT image. Fracture through the posterior talus (bold arrow) and fracture of the calcaneus with fragment (thin arrow) in the sinus tarsi.

Fig. 14. — Sagittal MDCT image. Fracture (arrow) through the middle aspect of the talus. Note small bony fragment in the canalis tarsi.

primary fracture line oriented in an anteromedial to posterolateral fashion. Secondary fracture lines commonly occur. Also there are varying degrees of comminution. The management of intraarticular calcaneal fractures remains controversial. Decision making regarding treatment depends heavily on imaging findings.Extra-articular fractures are generally treated in a closed manner. Intraarticular fractues may also be treated closed but are usually treat-

ed with open reduction,osteotomy, internal fixation and arthrodesis. The goal of the radiologist is to accurately describe the fracture pattern such that the surgeon can match the fracture anatomy with the appropriate surgical approach. The integrity of the talus is also critical to the normal function of the subtalar joint. Talus fractures are relatively uncommon injuries (Figs. 1416) (7). Talar neck fractures account for approximately 50 % of all talus

fractures. Osteonecrosis is a common complication of talar neck fractures and is a major determinant of outcome. Fractures of the talar body, although less common than talar neck fractures, involve the posterior facet of the subtalar joint and may be associated with a subtalar dislocation (Fig. 17). Lateral process fractures are a subgroup of talar body fractures that are rare and often overlooked (8). The mechanism of these fractures is dorsiflexion and

TALOCALCANEAL UNIT — AYOOB et al

Fig. 15. — Sagittal MDCT image. Comminuted fracture through the middle aspect of the talus (arrow).

inversion and they often occur during snowboarding. A loss of talar blood supply may lead to osteonecrosis, which is a serious complication. The risk of AVN can be estimated by the Hawkins sign. Normally a subtle subchondral lucent line develops at the talar dome. Areas that remain sclerotic are at risk for AVN. If the fracture fragments are not displaced a closed treatment may suffice. If the fragments are displaced, a fixation with screws or pins is indicated. Non traumatic conditions Tarsal coalition is a frequent cause of painful flatfoot (9). Talocalcaneal and calcaneonavicular

Fig. 17. — Coronal MDCT image. Healed fracture of the lateral process of the talus (arrow).

coalition are the most common types (Figs. 18, 19). While calcaneonavicular coalitions are usually well seen on conventional radiography, a coalition between the talus and calcaneus may be difficult to detect. On radiography the C sign may be demonstrated, but often CT or MR is necessary for accurate diagnosis (10). Coalitions can be osseous, cartilaginous or fibrous. Although a talo-

Fig. 16. — Coronal MDCT image. Fracture of the lateral process of the talus (arrow).

calcaneal coalition may occur at any of the three facets, the majority of osseous fusions involve the middle facet. Osseous coalitions are characterized by complete cortical bridging between the calcaneus and talus. Non osseous coalitions are characterized by joint space narrowing and irregularity sometimes accompanied by cortical hypertrophy and sclerosis.

Fig. 18. — Lateral radiograph of the foot. Note C sign (arrows) of subtalar coalition.

JBR–BTR, 2010, 93 (1)

Fig. 19. — Sagittal MDCT image. Note bony coalition of subtalar joint (long arrow) with C sign (thick arrows).

Fig. 20. — Sagittal MDCT image. Early sclerosis (arrow) as a sign of osteoarthritis is seen.

Fig. 21. — Sagittal MDCT image. Note large posterior process of the talus (thin arrow). Also note subchondral sclerosis and geodes (thick arrow) of the posterior subtalar joint.

Fig. 22. — Sagittal MDCT image. Note os trigonum (arrowhead) and reactive sclerosis (long arrow) in the posterior talus.

Fig. 23. — Sagittal MDCT image. Note erosions of posterior subtalar joint (arrow) in inflammatory arthritis.

The subtalar joint can be involved with a variety of degenerative, inflammatory, and crystalline arthritides. Involvement of the subtalar joints is likely underestimated due to limited visualization on radiography. Degenerative changes may be idiopathic or more commonly secondary to trauma and malformation (Figs. 20-22). Manifestations of osteoarthrosis are the same as in any joint and include asymmetric

TALOCALCANEAL UNIT â&#x20AC;&#x201D; AYOOB et al

joint space narrowing, sclerosis, and subchondral cysts. Rheumatoid and inflammatory disorders may involve the subtalar joints (Fig. 23) (11,12). Neuropathic arthropathy may occur in the diabetic foot, although the midfoot is more commonly affected. Gout may involve the mid- and hindfoot, in addition to the first metatarsophalangeal joint. Erosions are seen often with an overhanging edge and may be accompanied by soft tissue masses. Infection may occur in diabetics with infected soft tissues, and in a postoperative setting. The joint surfaces appear narrowed and eroded. Fragmentation may occur.

References

In conclusion, we described the normal anatomical variations of the bony anatomy of the subtalar joint. Pathological conditions of the subtalar joint may be imaged with MDCT, allowing for a more accurate diagnosis than radiography.

1. Barbaix E., Van Roy P., Clarys J.P.:

Variations of anatomical elements contributing to subtalar joint stability: intrinsic risk factors for posttraumatic lateral instability of the ankle. Ergonomics, 2000, 43: 1718-1725. Uygur M., Atamaz F., Servet C., Pinar Y.: The types of talar articular facets and morphometric measurements of the human calcaneal bone on Turkish race. Orthop Surg, 2009, 129: 909-914. Lektrakul N., Chung C.B., Lai Ym et al.: Tarsal sinus: arthrographic, MR imaging, MR arthrographic, and pathologic findings in cadavers and retrospective study data in patients with sinus tarsi syndrome. Radiology, 2001, 219: 802-810. Beltran J., Munchow A.M., Khabiri H. et al.: Ligaments of the lateral aspect of the ankle and sinus tarsi: an MR imaging study. Radiology, 1990, 177: 455-458. Morvan G., Laredo J.D., Wybier M.: Imagerie Osteoarticulaire. Paris. Flammarion MĂŠdecine-Sciences 1998.

27 6. Zwipp H., Rammelt S., Barthel S.: Calcaneal fractures, open reduction and internal fixation (ORIF). Injury, 2004, 35: SB46-54. 7. Early J.S.: Management of fractures of the talus: body and head regions. Foot Ankle Clin, 2004, 9: 709-722. 8. Mukherjee S.K., Pringle R.M., Baxter A.D.: Fracture of the lateral process of the talus. J Bone Joint Surg, 1974, 56; 263-273. 9. Beckly D.E., Anderson P.W., Pedegana L.R.: The radiology of the subtalar joint with special reference to talo-calcaneal coalition. Clin Radiol, 1975, 26: 333-341. 10. Lateur L.: Subtalar coalition: diagnosis with the C sign on lateral radiographs of the ankle. Radiology, 1994, 193: 847-851. 11. Barthelemy C.R., Nakayama D.A., Carrera G.F. et al.: Gouty arthritis: a prospective radiographic evaluation of 60 patients. Skeletal Radiol, 1984, 11: 1-8. 12. Antoniou D., Connor A.N.: Osteomyelitis of the calcaneus and talus. J Bone Joint Surg, 1974, 56: 338-345.

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SIGNS IN RADIOLOGY OPTIC TRACT EDEMA SIGN AND CRANIOPHARYNGIOMAS W. Siemons1, G. Wilms1, T. Theys2 Two patients with craniopharyngioma presenting with the “optic tract edema sign” are described. This sign is seen in a majority of craniopharyngiomas and can be of help in the differentiation with other suprasellar masses such as pituitary adenomas, meningiomas, germinomas and lymphomas. Nevertheless it has to be emphasized that the sign is not absolute and can be seen now and then in these other tumors. Key-word: Craniopharyngioma.

The differential diagnosis of suprasellar masses is very broad, especially if the lesion is solid and homogeneously enhancing. The “optic tract edema” sign was described earlier as a relatively typical sign pointing to a craniopharyngioma. We wish to report 2 patients with a craniopharynioma presenting with the “optic tract edema sign” in order to illustrate this sign. Case reports Case 1

A 34-year-old woman presents with symptoms of hypogonadotropic infertility. There were no visual field defects. MRI (Fig. 1) showed a mainly cystic suprasellar mass, with definite edema of the optic tract. Pathologic examination revealed a craniopharyngioma of the adamantinomatous subtype. Case 2 A 13-year-old girl was admitted with growth retardation. There were no visual complaints. MRI (Fig. 2) showed a heterogeneous mixed cystic and solid suprasellar mass, with again edema of the optic tract. Partial neurosurgical resection was performed. Pathologic examination here also revealed a craniopharyngioma of the adamantinomatous subtype. Discussion Several types of tumors can be found in the suprasellar region. Tumors growing from the base of the skull, such as tuberculum sellae meningiomas, the pituitary gland such as macro-adenomas or the

B B Fig. 1. — Patient 1. A. Coronal T2weighted image (TR: 3000 ms, TE: 80 ms). Note the mainly cystic suprasellar mass (arrow). There is definite edema of both optic tracts (arrowheads). B. Axial FLAIR image (TR: 9000 ms, TE: 114 ms, TI: 2500 ms). Notice the suprasellar mass (arrows), with a discrete fluid-fluid level (curved arrow). There is edema of both optic tracts (arrowheads).

From: 1. Department of Radiology, 2. Department of Neurosurgery, UZ-Gasthuisberg, Leuven, Leuven, Belgium. Address for correspondence: Dr W. Siemons, Department of Radiology, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium.

Fig. 2. — Patient 2. A. Coronal T2 weighted image (TR: 6110 ms, TE: 91). Notice the heterogeneous mixed cystic and solid suprasellar mass (arrows). There is edema of the right optic tract (arrowhead). B. Axial T2-weighted image (TR: 7240 ms, TE: 122 ms). Notice the suprasellar mass (arrow). There is edema of both optic tracts (arrowhead).

hypthalamohypophyseal axis such as craniopharyngiomas are amenable to compression of the optic pathway (1). In 1998, Nagahata et al. (1) were the first to describe edema of the optic tract in suprasel-

lar tumors. In their series this type of edema was seen in the majority (5/8) of craniopharyngiomas and not in macro-adenomas or meningiomas and therefore the authors concluded that the sign was not constant but rather specific for craniopharyngioma. It is noteworthy that not all patients with optic tract edema in this series presented with visual disturbances. The mechanism of edema-like changes was speculated to be a regional inflammation due to microscopic leakage of the cyst contents, which would the cause a chemical meningitis and evoke adjacent edema. In 2003 Saeki et al. (2) described 50 patients with pituitary region tumors touching or compressing the optic pathway. They found edemalike changes along the optic tract in 8

SIGNS IN RADIOLOGY — SIEMONS et al

out of 11 craniopharyngiomas, but also in 4 of 25 pituitary adenomas, in 1 germ cell tumor and 1 malignant lymphoma. They stated that edemalike changes in association with pituitary region tumors were related with distension of normally present large Virchow-Robin spaces adjacent to the optic tract. Because VirchowRobin spaces are speculated to be a drainage route of interstitial fluid into the subarachnoid space, their distension may be related to the fluid retention in and along the Virchow-Robin spaces, the outlet of which into the subpial and/or subarachnoid space(s) is blocked by pituitary region tumors.

MR with the “optic tract edema sign”. We draw the attention to the fact that the phenomenon of optic tract edema can be commonly seen in association with craniopharyngiomas, but is a non specific finding.

Conclusion We illustrate two patients with craniopharyngiomas presenting on

References 1.

Nagahata M., Hosoya T., Kayama T., Yamaguchi K.: Edema along the optic tract: a useful MR finding for the diagnosis of craniopharyngiomas. AJNR Am J Neuroradiol, 1998, 19: 17531757. 2. Saeki N., Uchino Y., Murai H., Kubota M., Isobe K., Uno T., Sunami K., Yamaura A.: MR imaging study of edema-like change along the optic tract in patients with pituitary region tumors. AJNR Am J Neuroradiol, 2003, 24: 336-342.

JBRâ&#x20AC;&#x201C;BTR, 2010, 93: 30.

IMAGES IN CLINICAL RADIOLOGY Partial posterior split cervical spinal cord with Klippel-Feil syndrome M. Apaydin1, M. Varer1, K.B. Bayram2

A 50 year-old woman was known with Klippel-Feil syndrome (KFS), consisting of a clinical triad of a short neck, low posterior hairline and restricted neck motion. She was complaining of new onset neck pain radiating down to midscapular region. Physical examination revealed moderate weakness of both biceps and polex muscles. She had diminished sensation of pinprick and light touch between C3-6 dermatoms. Radiographs revealed multiple contiguous fusion between C1 to C6 vertebrae (Fig. A). No sign of instability was detected. Magnetic resonance imaging (MRI) confirmed bony fusion of the vertebral bodies. There is complete fusion between first cervical vertebra to the fourth cervical vertebra and incomplete fusion between fifth and sixth servical vertabrae. The seventh cervical vertebra is normal (Fig. B). Additionally posterior partial split cervical spinal cord from foramen magnum to third cervical vertebra was evident (Fig. C). Based on the clinical presentation and typical imaging findings, the diagnosis of partial split cervical spinal cord and cervical upper vertebrae multiple noncontigiuous fusions were made. MRI of the thoracolumbar spine was unremarkable. The patient has been neurologically stable for 2 years after the initial presentation. Her functional deficit remains mild and did not require any operation. Comment

Split cord malformations (SCM) which relates to notochordal-dysraphic disorders, are rare congenital anomalies. The spinal cord splits totally or partially over a portion to form two hemicords. Symptoms varies according to the severity and length of the involvement. The lumbar and thoracolumbar regions were the most common sites involved. Cervical and cervicodorsal SCMs are very rare. Our case showed incomplete cervicodorsal SCM. Many of the patients are symptomatic at birth, but generally neurological deterioration occurs within the first 2 to 3 years of life mostly due to tight filum terminale. Numerous abnormalities are associated with split cord malformation. One of the most common is KFS. The incidence of the syndrome has been estimated to be one in 42,000 individuals. The most common abnormalities associated with KFS are skeletal anomalies. The current classification is based on the fusion of the segments. Type I consists of a single congenitally fused cervical segment. There are multiple noncontiguous, congenitally fused segments in Type II, and in Type III patients had multiple contiguous, congenitally fused cervical segments. Our case representsType III KFS. Type III patients are mostly asymptomatic. Symptoms are predominantly associated with Type I patients. This explains our patientâ&#x20AC;&#x2122;s late onset clinical findings. Symptomatology differs depending of the biomechanical features of the cervical vertebrae. Developmental basis of the SCM differs from the being complete or posterior partial. Complete SCM with anterior bony defects is mostly seen in thoraco-lumbar region, posterior partial SCM is encountered in the cervical region. Frequent clinical and radiological follow-up is recommended. Surgery may be required in the presence of neurological signs.

Department of 1. Radiology, 2. Physical Therapy and Rehabilitation, Izmir Ataturk Education and Research Hospital, Izmir, Turkey.

JBRâ&#x20AC;&#x201C;BTR, 2010, 93: 31.

IMAGES IN CLINICAL RADIOLOGY A 64-slice multidedector CT of tracheobronchopatia osteochondroplastica with virtual bronchoscopy view L. Cardinale1, M. Busso1, A. Cataldi1, G. Volpicelli2

A 65-year-old female presented in our Emergency Department complaining of cough and progressive dyspnea. Plain chest radiography showed long-segment narrowing of the trachea. Multislice computed tomography confirmed the tracheal narrowing and demonstrated multiple nodular calcifications protruding into the visceral lumen, involving also the main and segmental bronchi but sparing the pars membranacea trachealis (Fig. A). The radiological findings suggested the condition of tracheobronchopatia osteochondroplastica (TO). Diagnosis was confirmed by bronchoscopy, where submucosal nodular excrescences, not extending to the posterior membranaceous tracheal region, were observed: no interventional measures have been undertaken up to now, with laser therapy and nodules endoscopic removal being reported in isolated cases. Comment

The radiological findings can be considered pathognomonic of this condition and biopsy was not deemed of further help in pathological characterization; should calcified nodules also involve the pars membranacea trachealis other entities can be considered in the differential diagnosis, mainly amyloidosis, and biopsy may be necessary in the differentiation. This clinical case demonstrates the advantage of 64-slice computed tomography (CT) scanner, with software allowing both excellent volume rendered images and two-dimensional (2D) multiplanar images. Three-dimensional reconstruction (3D) has been specifically planned for airway imaging, allowing virtual bronchoscopic images of great help in the evaluation of bronchial stenoses, mainly of malignant nature, in order to guide â&#x20AC;&#x153;realâ&#x20AC;? bronchoscopy and tissue sampling. Virtual bronchoscopic view (Fig. B) and SSD-3D CT coronal reconstruction of the trachea (Fig. C) show narrowing of the laterolateral diameter with multiple nodules.

C 1. Department of Radiology and 2. Department of Emergency Medicine, San Luigi Gonzaga University Hospital, Torino, Italy.

JBRâ&#x20AC;&#x201C;BTR, 2010, 93: 32.

IMAGES IN CLINICAL RADIOLOGY Cholecystocolonic fistula complicated by gallstone impaction and perforation of the sigmoid C. Schoofs , R. Vanheste , L. Bladt, F. Claus1

An 88-year-old woman was referred to our department because of sudden onset of progressively increasing lower abdominal pain and clear inflammatory laboratory tests. Her medical record revealed she had suffered from an acute calculous cholecystitis two years earlier, conservatively treated with percutaneous drainage followed by antibiotic therapy (Fig. A). The recovery had been long and exhaustive to this elderly patient. First an abdominal ultrasound was obtained, suggesting inflammatory changes of the sigmoid, possibly complicated by perforation. Additional CT imaging showed an egg-shaped, peripheral calcified structure (longest diameter 47 mm) in the lumen of the middle third of the sigmoid (Fig. B). Retrograde administration of contrast showed no passage beyond the impacted stone, the latter showing striking resemblance in size, aspect and layering with the gallstone that had been seen on the previous abdominal CT scan two years earlier. As easily depicted on CT, this unusual location of the cholelith was explained by the presence of a fistula between the gallbladder and the hepatic flexure of the colon, the former being adherent to the colon (Fig. C). There was pneumobilia and the gallbladder lumen was small, containing air and a small calculus. Other small choleliths were detected in the ascending colon. Consequently our patient was urgently referred to the operation room and a sigmoidectomy (Hartmann procedure) was performed. During the postoperative course the patient developed acute renal failure and died of an acute cardiac infarction 6 weeks after surgery. Comment

Cholecystenteric fistula is a rare entity, with an incidence reported in the literature as 0,4-1,9% of the patients treated for biliary tract disease. Since 1950, 231 cases of cholecystocolonic fistula (CCF) have been reported. CCF represents 8 to 26,5 % of cholecystoenteric fistulas and is the second most common fistula after cholecysto-duodenal fistula. 0,13 % of cases of acute cholecystitis are complicated by CCF. Recurrent or chronic inflammatory processes of the gallbladder are the most commonly described pathogenic mechanism for CCF. CCF has a very low pre-operative detection rate (less than 10% compared to 43 % for cholecysto-enteric fistulas in general). This is probably due to the inefficacy of diagnostic means but also to the non-specificity of the symptoms: non-emergency onset of CCF is characterized by a triad of diarrhea, right hypochondrium pain and cholangitis (jaundice/fever). Diarrhea is the most common symptom, due to the laxative effect of bile acids that bypass the distal ileum and reach the transverse colon unabsorbed. Less frequently CCF presents in an acute setting with a liver abscess, massive bleeding or biliary ileus. Biliary ileus is the most common complication of proximal fistulas. In CCF, a gallstone migrating into the colon enters the bowel distally from Bauhinâ&#x20AC;&#x2122;s valve, thus bypassing the most critical level. Nevertheless, literature reveals that in one case of five patients with CCF present with colonic obstruction, mostly located at the sigmoid colon. The acute presentation of our case was particularly interesting because the gallstone impaction in the sigmoid colon was complicated by a perforation. 1. Department of Radiology, UZ Gasthuisberg Leuven, Leuven, Belgium.

JBR–BTR, 2010, 93: 33.

IMAGES IN CLINICAL RADIOLOGY Re-appearance of an ilio-ilio arteriovenous fistula after endovascular stent grafting demonstrated on MDCT R. Killeen, G. McNeill, W. Torreggiani1

A 27-year-old male patient presented 3 years ago with a fistula between the right common iliac artery and the left common iliac vein which developed after lumbar disk surgery. The fistula was successfully treated with placement of an endovascular stentgraft in the proximal right common iliac artery at that time. Annual follow-up abdominal computed tomography (CT) was performed. Three years after treatment an arterial phase CT demonstrated redevelopment of the fistula (Fig. A). A small outpouching (4 mm) from the right common iliac artery is evident extending towards the left common iliac vein at the site of fistula formation which was at the mid level of the stentgraft with contrast opacifying the inferior vena cava (IVC) and extending down a distended left common iliac vein consistent with arteriovenous fistula (AVF). Axial CT (Fig. B) shows contrast enhancement of the infrahepatic IVC (straight arrow) which should not occur during arterial phase unless there is an AVF. The patient’s conventional angiogram performed at the time of initial diagnosis three years earlier is presented for comparison (Fig. C). This image demonstrates contrast traversing from the right common iliac artery to the left common iliac vein with distension of the IVC typical of an AVF. Comment

AVF formation associated with lumbar disk surgery is rare and was first reported by Linton and White in 1945. Repair of AV fistulas is recommended because they may lead to significant shunt flow, congestive cardiac failure and venous hypertension, although some patients remain asymptomatic. Conventional treatment options include direct open surgical repair or surgical bypass grafting but surgical mortality rates vary from 934%. Endovascular stentgraft placement has been advocated by several authors as a minimally invasive alternative with low morbidity and mortality. It is unclear at this time what the rate of recurrence of AV fistula is in patients who undergo endovascular treatment and this cohort need to be closely followed with imaging to ensure continued exclusion of the fistula. Recurrent fistula formation may be treated with open repair, graft removal and extra-anatomic bypass or with insertion of a custom made stent-graft placed endovascularly to exclude the fistula. In the above case, follow-up CT at 6 months demonstrated no interval change in the appearances and given the absence of symptoms it was felt at multidisciplinary team meeting that conservative management with further follow-up CT imaging was the best approach.

1. Department of Radiology, Adelaide and Meath Hospital Incorporating the National Children’s Hospital, Dublin, Ireland.

JBR–BTR, 2010, 93: 34.

IMAGES IN CLINICAL RADIOLOGY Piso-Hamate hiatus syndrome E.C.Y. Christiaanse1, T. Jager1, F.M. Vanhoenacker2, E. Van Hedent1, R. Van Damme3

A 49-year-old woman presented with progressive weakness of the right hand of two months duration. Her clinical history was unremarkable except for a carpal tunnel release at the right wrist. Clinical examination showed wasting of the right hand with disability of spreading the fingers. Sensory conduction study of the right ulnar nerve was normal. Motor needle conduction study showed loss of contraction of the ulnar innervated hand muscles indicating neuropathy of the right ulnar nerve. A comparative ultrasound study of both wrists (Fig. A) showed a cyst of 7 mm medial to the right hamate bone. The deep motor branch of the ulnar nerve (caliper) was running between the cyst and the hamate bone. The nerve was slightly thickened and hypoechoic compared to the left wrist (arrow). Further examination at the level of the metacarpal bones (Fig. B) showed loss of bulging of the dorsal contour of the interosseous muscles at the right side compared to the left side (arrows), reflecting volume loss due to muscle atrophy. Fat-suppressed T2-weighted MR image of the wrist at the level of the hamate bone (Fig. C) confirmed the presence of the cyst causing compression of the deep motor branch of the right ulnar nerve which appeared slightly thickened and hyperintense (arrow). Asymmetry of the dorsal contour of the interosseous muscles was best demonstrated on T1-weighted MR images the level of the metacarpal row (Fig. D, arrows). Based on imaging findings the diagnosis Piso-Hamate Hiatus Syndrome was made. Patient underwent surgery with ulnar nerve release and resection of the synovial cyst originating from the intercarpal joint. Nerve conduction study performed two months after surgery showed residual denervation activity of the first dorsal interosseous muscle. Patient made a full recovery three and a half months after surgery without neurological symptoms of the right hand.

Comment The ulnar nerve enters the volar compartment of the forearm after exiting the cubital fossa. It passes anteriorly to the flexor digitorum profundus under the flexor carpi ulnaris where it is accompanied by the ulnar artery and veins. At the ulnar side of the carpus , the nerve enters Guyon’s canal and splits distally into a superficial sensory branch and a deep motor branch supplying the intrinsic hand muscles. The proximal medial side of Guyon’s canal is formed by the pisiform bone and the distal lateral side by the hook of the hamate bone. The floor is formed by the transverse carpal ligament and the hamate and triquetrum bones, whereas the pisohamate ligament represents the roof. The latter ligament spans between the hook of the hamate and the pisiform bone. Furthermore, the flexor brevis digiti quinti muscle has two separate attachments at the hook of hamate and pisiform bone respectively. These attachments are bridged by a firm concave musculotendinous arch. Between this arch and the opposite pisohamate ligament, a narrow oblique opening exists, the pisohamate hiatus. The deep motor branch of the ulnar nerve and the accompanying artery passes through this opening and leaves the canal of Guyon to enter the deep palmar space. Guyon’s canal is a potential site for neuropathy by a variety of causes including accessory muscles, cysts, occupational neuritis, soft tissue tumors, hematoma and callus surrounding a fracture of the hook of the hamate bone and arteriovenous malformation. Clinical symptoms depend on the site of the underlying lesion and have been divided into three types. Type 1 syndrome is caused by a lesion proximal to the Guyon canal and results in weakness of all the ulnar innervated muscles in the hand as well as a sensory deficit to the palmar surfaces of the hypothenar eminence and of the little finger and the ulnar side of the ring finger. Type 2 syndrome is caused by a lesion of the deep motor branch of the ulnar nerve at any site distal to the bifurcation. The sensation to the hand is spared but there is motor weakness of the muscles which are innervated by the deep motor branch of the ulnar nerve. Type 3 syndrome is caused by a lesion in or distal to the Guyon’s canal involving only the sensory branch of the ulnar nerve resulting in sensory deficit of the volar surface of the hypothenar eminence and the ring finger. There is no associated muscle weakness. Ultrasound is a reliable technique for assessment of the site of ulnar nerve compression and evaluation of the underlying etiology as well as the consequences of muscle denervation. Ultrasound is able to evaluate the size and the echotexture of the affected muscles. However, compared to MRI, ultrasound is less capable to distinguish early muscle denervation, in which changes are mainly related to extracellular edema, from late muscle denervation in which muscle atrophy and fat replacement occur gradually. MRI is also superior to ultrasound in quantification the extent of muscle atrophy, denervation edema and fatty infiltration. Treatment of the pisohamate hiatus syndrome depends on the cause. If the syndrome is caused by chronic mechanical trauma, the patient can be treated by conservative means such as immobilization or local injection of corticosteroids. When conservative treatment fails or in case of an underlying mass, surgical decompression may be mandatory. Recovery may take several months to years and is prolonged in older patients. With severe compression recovery may be incomplete. 1. Department of Radiology, ASZ Aalst, Aalst, 2. Department of Radiology, AZ Sint-Maarten, Duffel-Mechelen, Duffel, 3. Department of Orthopaedic Surgery, ASZ Aalst, Aalst, Belgium.

JBRâ&#x20AC;&#x201C;BTR, 2010, 93: 35.

IMAGES IN CLINICAL RADIOLOGY Obturator hernia, a rare cause of intestinal obstruction E. Vanhoutte1, K. Ramboer2, L. Verhaeghe2

A 76-year-old woman presented acutely to the emergency room with clinical and X-ray features of intestinal obstruction. Contrastenhanced CT image of the abdomen demonstrated an abnormal ovoid soft tissue mass (Fig. A), located between the right pectineus and obturator externus muscles. The coronal (Fig. B) and sagittal (Fig. C) reconstruction revealed a loop of small intestine into the right side obturator canal area. Based on the radiological findings, the diagnosis of obturator hernia was made and confirmed at surgery. Comment

The obturator hernia is infrequent, accounting for less than 2% of all abdominal wall hernias and causing less than 1.6% of all small bowel obstructions. The patients are typically elderly women of low body weight, with a male to female ratio of approximately 1:6. This is partly because of their broader pelvis and more triangular obturator canal, and it also may be associated with emaciation with loss of protective preperitoneal fat and progressive laxity of the pelvic floor due to factors like multiparity, increased intraabdominal pressure and advanced age. Patients present with a partial or complete mechanical small bowel obstruction in approximately 90% of cases. CT is the diagnostic modality of choice, showing the bowel herniated in the obturator foramen and air-fluid levels. Nevertheless, you have to scan low enough in the region of the foramen obturatorum. Treatment is always surgical, given the high rates of bowel incarceration and perforation. Obturator hernia is the most lethal of all abdominal hernias with a mortality rate of 30%, resulting from delays in diagnosis and surgery. Therefore, early use of CT in elderly, thin, multiparous females with intestinal obstruction is recommended and should facilitate rapid diagnosis and surgery to reduce complications and mortality.

1. Department of Radiology, University Hospitals Leuven, Leuven, 2. Department of Radiology, A.Z. Sint-Lucas Hospital, Brugge, Belgium.

JBRâ&#x20AC;&#x201C;BTR, 2010, 93: 36.

ABSTRACTS OF PAPERS FOR FULL MEMBERSHIP RESUMES DES TRAVAUX DE TITULARIAT SAMENVATTING VAN DE TITULARIAATSWERKEN HEAD AND NECK

NEURORADIOLOGY

Brain MR imaging in leukemia

Intrathecal Gadolinium to detect a CSF leak: results

L. De Cocker, G. Wilms, Ph. Demaerel1 Purpose: To document the brain imaging findings in leukemia. These include manifestations of primary disease, complications of therapy, and infection due to immune suppression. Materials and methods: We reviewed the literature on the subject and retrospectively evaluated 12 patients with leukemia who were referred for CT or MRI of the brain. The series included 7 patients with acute myeloid leukemia (AML) and 5 patients with acute lymphoid leukemia (AML). Results: Manifestations of primary disease in leukemia include granulocytic sarcoma, meningeal leukemia and cerebrovascular accidents. Granulocytic sarcoma, formerly known as chloroma, only affects patients with myeloid leukemia, and is seen in children more frequently than in adults. Leukemic meningitis can be seen in ALL with CNS invasion and occurs as leptomeningeal enhancement on MRI. Side effects of therapy accounted for the majority of lesions in our series. Posterior reversible encephalopathy syndrome (PRES) related to chemotherapy and white matter disease attributable to chemotherapy were the most frequent observations. A stroke-like syndrome related to intrathecal administration of methotrexate and hemorrhagic infarct secondary to venous sinus thrombosis were also encountered in one patient. Infectious complications are a significant cause of mortality in this patient population and were seen in 2 patients. Conclusion: Familiarity with the diverse pathologies that may affect the brain in leukemia is essential for proper diagnosis of neurologic symptoms in these patients. 1. Department of Radiology, University Hospital K.U.Leuven, Leuven, Belgium

B. Houthoofd1,2, L. Vanopdenbosch3, P. Dedeken3, S. Vlaminck4, J. Delanote1, J. Casselman1 Aim: Cerebrospinal fluid leaks can be very difficult to diagnose or locate, both clinically and by standard diagnostic imaging procedures. Therefore, an informed-consent, ethical committee approved prospective observational cohort study was undertaken, to investigate the diagnostic success ratio and therapeutic consequences of magnetic resonance imaging with Gadolinium contrast administered by lumbar puncture to detect possible CSF-leaks. Methods: Patients with a suspected CSF-leak were selected and divided into three groups based on their predominant symptoms: confirmed liquorrhoea, recurrent bacterial meningitis or spontaneous intracranial hypotension. T1 weighted MRI with fat suppression of the spine at 1 hour and of the brain at 6 and 24 hours post lumbar puncture and injection of 0.5cc gadolinium (MagnevistÂŽ) were performed. Results: 35 patients were scanned between February 2005 and October 2009. The suspected leak was found in 6 out of 7 patients with liquorrhoea, 3 out of 5 patients with recurrent meningitis and 14 patients with complaints of spontaneous intracranial hypotension. Of the detected leaks, until now 18 were successfully closed, either neurosurgically or by an endoscopic ENT-procedure. There were no complications directly linked to the intrathecal injection of Gadolinium. One patient however, developed bacterial meningitis, as a complication of the lumbar puncture, but was successfully treated. Conclusions: MRI with intrathecal Gadolinium injection is a safe and easy to perform technique for the detection of cerebrospinal fluid leaks, with a better spatial and temporal resolution than

current standard diagnostic imaging procedures. 1. Radiology Department, AZ Sint-Jan Brugge. 2. Radiology Department, Ghent University Hospital. 3. Eurology Department, AZ Sint-Jan Brugge. 4. ENT, AZ Sint-Jan Brugge, Belgium. CHEST Right ventricle assessment with MDCT M. Dupont1 Purpose: To highlight the impact of vascular and parenchymal pulmonary affections on the right ventricle, and the measures to assess it. Methodology: We performed a review of the litterature about the analysis of right ventricle with MDCT. The clinical relevance of the points that can be assessed thanks to MDCT were reviewed and illustrated with selected pertinent cases. Summary: Many vascular and parenchymal pulmonary diseases have an important impact on the right ventricle, and the ability of the right ventricle to cope with these diseases is one of their key prognostic factor. MDCT, if realized without cardiac synchronization, can provide information about static measures (structure), mainly right ventricular volume, right ventricular hypertrophy and septal bowing. If realized with cardiac synchronization, MDCT provides information about the structure, but also the function of the right ventricle, namely ejection fraction and/or tricuspid annular plane excursion (TAPSE). Both techniques can provide information about preload, thanks to the analysis of vena cava, azygos and hepatic veins, as well as information about the afterlod with the analysis of main pulmonary artery diameter, and clot load scores. 1. Department of Radiology, Cliniques Universitaires de Mont Godinne, Yvoir.

JBR–BTR, 2010, 93: 37-38.

NEWS FROM THE UNIVERSITIES WETENSCHAPPELIJKE PRIJS EM. PROFESSOR DOCTOR A. L. BAERT PERIODE 2009-2010 Artikel 1 Een tweejaarlijkse prijs voor een bedrag van € 2500 wordt opgericht door de stichting “Wetenschappelijke Prijs Em. Prof. Dr. A. L. Baert te Leuven, met als doel het fundamenteel en klinisch wetenschappelijk onderzoek in de radiologie aan te moedigen.

Nederlands (interlinie 1, ca. 47 regels per blz.). Artikel 4 De prijs kan slechts toegekend worden aan een nog niet bekroond werk. De auteur van het bekroonde werk krijgt de titel “Laureaat Wetenschappelijke Prijs Em. Prof. Dr. A. L. Baert”.

Artikel 2 Deze prijs kan worden toegekend aan een radioloog, opgeleid aan één van de vier Nederlandstalige universiteiten in België, op basis van een met goed gevolg verdedigde doctoraatsthesis, door een jury die zal benoemd worden door het stichtingscomité.

Artikel 5 De jury van de prijs is samengesteld uit 7 personen, aangeduid door het stichtingscomité volgens de regels van het intern reglement. Em. Prof. Dr. A. L. Baert is voorzitter van de jury. Het staat de jury vrij de prijs al dan niet toe te kennen.

Artikel 3 Slechts werken die minder dan 2 jaar oud zijn op de datum van hun indiening kunnen in aanmerking worden genomen. Het werk moet opgesteld zijn in het Nederlands of in het Engels, met in beide gevallen, een uitgebreide samenvatting van minstens 15 bladzijden in het

Artikel 6 De gevallen waarin door het reglement van de prijs niet is voorzien of betwistingen die zouden kunnen ontstaan betreffende de interpretatie ervan, de beoordeling van de ontvankelijkheid van de werken en/of van de kandidaten e.a. worden onherroepelijk door de jury beslecht.

Er wordt geen briefwisseling gevoerd over de uitspraak van de jury. Artikel 7 De kandidaten moeten hun werk samen met hun curriculum vitae indienen in 6 gedrukte exemplaren bij Em. Prof. Dr. A.L. Baert en 1 exemplaar bij de secretaris, uiterlijk op 30 september 2010. Het stichtingscomité bepaalt de exacte datum van de toekenning van elke tweejaarlijkse prijs, voorzien in de maand december. De eerste toekenning van de prijs is uitgereikt in december 1998. Em. Prof. Dr. A. L. Baert Voorzitter Trolieberg 58 Dienst radiologie, UZ Leuven 3010 Kessel-Lo Prof. Dr. Ph. Demaerel Secretaris Herestraat 49 3000 Leuven

RBRS 2009 RESEARCH GRANT REPORTS Research Fellowship at the University of Melbourne, Australia L. Jans1 Kindly sponsored by the RBRS research grant 2009 for the University of Ghent, I got the opportunity to embark on a research fellowship at the University of Melbourne, VIC, Australia. I was offered the appointment as Medical Imaging Research Fellow in the division of Medical Imaging/ Division of Clinical Support Services. The Melbourne Royal Children’s Hospital (RCH) is the an important pillar of the faculty of medicine of this university, and is internationally recognized as

being the single largest paediatric health care research centre in the world. The prime purpose of the fellowship was to develop and consolidate expertise in all aspects of research in general and paediatric imaging. There were regular appraisals, which allowed me and the radiologists to inform one another of performance in order to assist in optimising the rest of training. The core focus of the fellowship consisted of basic research. Research is strongly encouraged and

From: Department of Radiology and medical Imaging, Ghent University Hospital, Gent

regular research meetings form part of the educational meetings. During the year at RCH, a fellow is expected to get involved in at least one minor and one major project – with the view of presenting at least one meeting and publication in a peer reviewed journal. A minimum of 7 sessions is protected weekly for research purposes including 2 sessions of a week allocated non-clinical time to fulfil administrative responsibilities, to prepare abstracts and to make presentations. As I was included in the MRI research group, intense collaboration between all fellows (5) was encouraged. This result-

ed in submission of papers to JBRBTR, Paediatric Radiology and European Radiology (first author), submission of a paper to AJNR (2nd author) and submission of a case report to Paediatric Radiology (3rd author). All of these papers are currently under review. An abstract for the Annual Meeting of the Society of Paediatric Radiology, Boston, 2010, has been accepted (3rd author). Conference leave of up to 7 calendar days was granted to attend a Paediatric Radiology meeting when abstract is accepted for oral presentation. I had the opportunity to attend the Australia and Now Zealand Annual conference on pediatric radiology (ANZPR) in Fiji, 1215th of July 2009. As there was a weekly duty roster, I was rostered 3 sessions on weekly rotation either to the reporting room, ultrasound, CT or MRI. Arrange-

JBRâ&#x20AC;&#x201C;BTR, 2010, 93 (1)

ments were made to attend interventional sessions if mutually agreed when radiofrequency ablation of osteoid osteoma or bone biopsy was performed. As fellow I was first on call, always with a consultant rostered as second on call back up, for 5 weekday nights and 1 week-end per 5 weeks averaged over the 12 month period. The neurosciences, ENT meetings, uro- nephrology, thoracic and combined therapy clinic meetings are delegated to the fellows. Departmental educational meetings are formal weekly meetings which fellows attend and are rostered to contribute to. Quality meeting focuses on the way we practice Paediatric imaging and reviews techniques, protocols, errors, feedback from conferences, audits, etc. The Teaching meeting is primarily an education

meeting presented by Medical Imaging Department Consultants, RCH clinicians and visitors. Interesting case meetings allows sessional staff to experience all types of meetings. Interesting cases meeting is a weekly meeting run by fellows. Cases are presented by fellows and registrars with appropriate back-up information. Radiology registrar: fellows are expected to attend the weekly dedicated subspecialty tutorials provided by consultants. Fellows are expected to teach radiology registrars, medical students and junior medical/paramedical staff when invited. I sincerely thank the RBRS and the medical imaging departments of the University of Melbourne and Ghent for giving me this fantastic opportunity.

AFIP Radiologic-Pathology correlation course, Washington DC, USA P. De Visschere

From July 27th until August 21st 2009, I attended a four-week radiologic-pathology correlation course organised by the Armed Forces Institute of Pathology (AFIP). The AFIP is located on the campus of Walter Reed Army Medical Center (WRAMC) in the North-West of Washington DC, USA. The American Registry of Radiologic Pathology, one of the departments of the AFIP, collects radiologic material with pathologic correlation since 1947, over the years resulting in a large illustrative archive. All attendees of the course are required to contribute one case with radiologic-pathology correlation to the archives of the AFIP. The course presents a comprehensive review of radiologic imaging of a broad range of diseases from all organ systems, with emphasis on the correlation with their

underlying microscopic features and gross pathology. All students receive the Radiologic Pathology Syllabus (about 1400 pages), complete with images and illustrations. The four-week course provides over 200 hours of didactic sessions and case seminars, in a daily schedule from 8:00 AM to 4:30 PM, with 30 minutes lunch break. The course director is Mark D. Murphey and the lectures are taught by staff radiologists of the Department of Radiologic Pathology at the AFIP as well as numerous eminent visiting professors. The course is organised 4 times a year, for each time 250 participants. At the time of the course I was at the end of my 5th year radiologist-intraining at the University Hospital of Ghent. 95% of the United States radiology residents attend this course during their training, generally in

From: Department of Radiology and medical Imaging, Ghent University Hospital, Gent

their 3rd or 4th year. The course is most beneficial at the end of radiology training, as most lecturers assume that participants have at least some experience with a variety of imaging modalities. I strongly recommend this course to all residents who would like to improve their radiology skills and who would like to spend an unforgettable experience in a foreign country. Additional information can be found on the website of the AFIP (https://www.radpath.org/). To conclude I would like to express my profound gratitude to the Royal Belgian Radiologic Society for the financial support by means of the travel grant and to my program director Prof. K. Verstraete for giving me the opportunity to attend this course. Next AFIP courses are scheduled: February 08 - March 05, 2010 March 22 - April 16, 2010 April 26 - May 21, 2010 July 26 - August 20, 2010 September 20 - October 15, 2010

JBR–BTR, 2010, 93: 40-41.

FORTHCOMING COURSES AND MEETINGS CALENDRIER NATIONAL – NATIONAAL KALENDER 04-06.03.10 XXIInd BELGIAN WEEK OF GASTROENTEROLOGY Antwerpen, Hilton Information: www.belgianweek.be 20.03.10 BIENNIAL CONGRESS FOR SPORTS MEDICINE AND SPORTS SCIENCES OVERUSE IN SPORTS MEDICINE: A MULTIDISCIPLINARY APPROACH KHBO, Campus Brugge Xaverianenstraat 10, 8200 Brugge Information: www.khbo.be 26.03.10 SRBR – Section Radiologie Cardiovasculaire et Interventionelle KBVR – Sectie Cardiovasculaire en Interventionnele Radiologie Leuven, UZ Gasthuisberg Information: luc.defreyne@ugent.be and Marc.Laureys@chu-brugman.be 26.04.10 SRBR – Section Neuroradiologie KBVR – Sectie Neuroradiologie Antwerpen, Middelheim Information: Duprez@uclouvain.be – philippe.demaerel@uzleuven.be 08.05.10 XXth ANNIVERSARY OF BELGIAN MUSEUM OF RADIOLOGY Lessines, Musée de l’Hôpital NotreDame à la Rose Information: info@radiology-museum.be 19.05.10 SRBR – Section Ostéo-articulaire KBVR – Sectie Osteo-articulaire Beeldvorming Joint meeting with the Belgian Foot/Ankle Surgeons Theme: Imaging update en treatment of posterior ankle pathology: radiosurgical correlation Oostende, Thermae palace Information: filip.vanhoenacker@telenet.be and gvandeputte@yahoo.com 19.05.10 12TH BI-ANNUAL CONFERENCE ON CONTRAST AGENTS AND MULTIMODAL MOLECULAR IMAGING 2010 Mons, Belgium Venue: Grand Amphitheatre of the University of Mons SRBR-KBVR – Section Neuroradiologie/ Sectie Neuroradiologie 26.04.10, 13.09.10, 22.11.10

Information: http://www.emrf.org/EMRF%20Conferences/ EMRF%20Contrast%202010.htm 29-30.05.10 FOURTH SYMPOSIUM MAMMOGRAPHY Oostduinkerke Information: monika.philips@uzleuven.be 04.06.10 SRBR – Section Radiologie Tête et Cou KBVR – Sectie Hoofd-halsradiologie Antwerpen, AZ St-Augustinus Information: robert.hermans@uzleuven.be 15-18.06.10 MRI IN PRACTICE Aalst Information: Dr E. Van Landuyt, 053-764961 – 053-764976 18.06.10 SRBR – Section Radiologie Cardiovasculaire et Interventionelle KBVR – Sectie Cardiovasculaire en Interventionnele Radiologie Liège, CHR Citadelle Information: luc.defreyne@ugent.be and Marc.Laureys@chu-brugman.be 22.06.10 SRBR – Section Radiologie Pédiatrique KBVR – Sectie Kinderradiologie Information: Dr V. Meersschaut, valerie.Meersschaut@uzgent.be 02-04.09.10 BREAST IMAGING – A COMPREHENSIVE REVIEW MEETING Bruges, Belgium 09-12.09.10 17th SYMPOSIUM ON UROGENITAL RADIOLOGY Main topic: Imaging and focal therapy Bruges, Oud Sint-Jan Information: raymond.oyen@uzleuven.be

17.09.10 SRBR – Section Radiologie Cardiovasculaire et Interventionelle KBVR – Sectie Cardiovasculaire en Interventionnele Radiologie Antwerpen, UZA Information: luc.defreyne@ugent.be and Marc.Laureys@chu-brugman.be 12.10.10 SRBR – Section Radiologie Pédiatrique KBVR – Sectie Kinderradiologie Information: Dr J. Khamis, jamil.khamis@chc.be 22.11.10 SRBR – Section Neuroradiologie KBVR – Sectie Neuroradiologie Leuven, KUL Information: Duprez@uclouvain.be – philippe.demaerel@uzleuven.be 25-27.11.10 6th MEETING EUROPEAN FEDERATION OF NATIONAL ASSOCIATIONS OF ORTHOPAEDIC SPORTS TRAUMATOLOGY (EFOST) Brussels Information: maryam.shahabpour@uzbrussel.be http://www.efost2008.org/index.php 03.12.10 SRBR – Section Radiologie Cardiovasculaire et Interventionelle KBVR – Sectie Cardiovasculaire en Interventionnele Radiologie Brussels, UCL Information: luc.defreyne@ugent.be and Marc.Laureys@chu-brugmann.be 14.12.10 SRBR – Section Radiologie Pédiatrique KBVR – Sectie Kinderradiologie Information: Dr L. Breysem, Luc.Breysem@uz.kuleuven.ac.be

10.09.10 BELGIAN MUSEUM OF RADIOLOGY 20TH ANNIVERSARY SYMPOSIUM VIOLENCE AND IMAGING Information: www.rbrs.org SRBR-KBVR – Section Radiologie Tête et Cou/Sectie Hoofd en Hals Radiologie 04.06.10

SRBR-KBVR – Section Sénologie/ Sectie Senologie 29-30.05.10 SRBR-KBVR – Section Radiologie Pédiatrique/Sectie Kinderradiologie 22.06.10, 12.10.10, 14.12.10

13.09.10 SRBR – Section Neuroradiologie KBVR – Sectie Neuroradiologie Brussels, UCL Information: Duprez@uclouvain.be – philippe.demaerel@uzleuven.be

SRBR-KBVR – Section Ostéo-articulaire/ Sectie Osteo-articulaire Beeldvorming 19.05.10

Detailed and real time information is available on RBRS website at www.rbrs.org

SRBR-KBVR – Section Radiologie Cardiovasculaire et Interventionelle/Sectie Cardiovasculaire en Interventionnele Radiologie 26.03.10, 18.06.10, 17.09.10, 03.12.10 Autres/verschillende 04-06.03.10, 20.03.10, 08.05.10, 19.05.10, 15-18.06.10, 02-04.09.10, 09-12.09.10, 10.09.10, 25-27.11.10

FORTHCOMING COURSES AND MEETINGS

CALENDRIER INTERNATIONAL – INTERNATIONAAL KALENDER 04-08.03.10 ECR 2010 EUROPEAN CONGRESS OF RADIOLOGY Vienna, Austria Information: /www.myesr.org 13.03.10 L’IMAGERIE PAR FAISCEAU CONIQUE “CONE BEAM” Congrès avec exposition technique France, Nancy Information: www.conebeam-nancy.org 13-03-2010 2010 SIR ANNUAL SCIENTIFIC MEETING OF THE SOCIETY OF INTERVENTIONAL RADIOLOGY Tampa United States Information: www.sirmeeting.org 14-03-2010 2010 SSR – ANNUAL MEETING OF THE SOCIETY OF SKELETAL RADIOLOGY Las Vegas, United States Information: www.skeletalrad.org 18-20.03.10 COURS INTENSIFS DE TDM MULTICOUPE DU THORAX Lille, France Information: secrétariat du Serv. de Radiologie, Hôp. Calmette, Bld du Pr Leclerc, F-59037 Lille Cedex Tél.: 03-20-44 43 11 Fax: 03-20-44 47 20 Information: mremy-jardin@chru-lille.fr 19-03-2010 RSSA/STOLLER MRI UPDATE IN SPORTS MEDICINE Information: www.rbrs.org 20-03-2010 BIENNIAL CONGRESS FOR SPORTS MEDICINE AND SPORTS SCIENCES OVERUSE IN SPORTS MEDICINE: A MULTIDISCIPLINARY APPROACH KHBO, Campus Brugge Xaverianenstraat 10 8200 Brugge Information: www.khbo.be 21-03-2010 42ND INTERNATIONAL DIAGNOSTIC COURSE DAVOS Information: www.idkd.org 21-26.03.10 IDKD 2010 DISEASES OF THE ABDOMEN AND PELVIS 25-26.03.10 IRM CRANIO-ENCEPHALIQUE ET MEDULLO RACHIDIENNE Strasbourg, France Information: Jean-Louis.Dietemann@ chru-strasbourg.fr 28-30.03.10 EUROPEAN MULTIDICIPLINARY COLORECTAL CANCER CONGRESS Nice, France Information: www.colorectal2010.org 01-04-2010 SURGICAL AND RADIOLOGICAL ENDOVASCULAR SYMPOSIUM Marseille, France Information: www.sres-symposium.org

10-04-2010 32ND CHARING CROSS INTERNATIONAL SYMPOSIUM: VASCULAR & ENDOVASCULAR CHALLENGES UPDATE Imperial College, London, United Kingdom Information: www.cxsymposium.com 15-04-2010 7TH INTERNATIONAL CONFERENCE COURSE OF THE DUTCH NEURORADIOLOGY SOCIETY University Medical Center Groningen, The Netherlands Information: www.wenckebachinstituut.nl 21-04-2010 12TH ESGAR CT-COLONOGRAPHY HANDS-ON WORKSHOP Amsterdam, The Netherlands Information: www.esgar.org 01-05-2010 ESMRMB / ISMRM JOINT MEETING Stockholm, Sweden Information: www.esmrmb.org 06-05-2010 GEST 2010 San Fransisco, USA www.gestweb.org 14-05-2010 4TH ANNUAL SCIENTIFIC SYMPOSIUM ON NEPHROGENIC SYSTEMIC FIBROSIS AND GADOLINIUM-BASED CONTRAST AGENTS New York Academy of Sciences, United States Information: cme.yale.edu 8-05-2010 18TH ANNUAL MEETING OF THE EUROPEAN SOCIETY OF THORACIC IMAGING Bern, Switzerland Information: www.esti-society.org 02-06-2010 ESGAR 2010. 21ST ANNUAL MEETING AND POSTGRADUATE COURSE OF THE EUROPEAN SOCIETY OF GASTROINTESTINAL AND ABDOMINAL RADIOLOGY Dresden, Germany Information: www.esgar.org 07-06-2010 47TH ANNUAL MEETING & 33RD POSTGRADUATE COURSE OF THE ESPR EUROPEAN SOCIETY OF PAEDIATRIC RADIOLOGY Bordeaux, France Information: www.espr2010.org 10-06-2010 CARDIOVASCULAR MAGNETIC RESONANCE 2ND ANNUAL EUROPEAN COURSE 2010 München, Germany Information: http://www.cmr-course.de/ 17-19.06.10 17TH EUROPEAN SOCIETY OF MUSCULOSKELETAL RADIOLOGY MEETING (ESSR) Lille, France Main theme refresher course: Ankle/Foot.

Six additional refresher courses. Scientific papers on all aspects of MSK Radiology Congress president: Prof dr Anne Cotten Information: www.essr.org 21-25.06.10 ERASMUS COURSE MUSCULOSKELETAL MRI II L’Aquila, Italy 22-08-2010 22ND EUROSON CONGRESS 2010 (EUROSON 2010) Location: Copenhagen DK Information: http://www.euroson2010.dk/ 16-18-09.10 COURS INTENSIFS DE TDM MULTICOUPE DU THORAX Lille, France Information: secrétariat du Serv. de Radiologie, Hôp. Calmette, Bld du Pr Leclerc, F-59037 Lille Cedex Tél.: 03-20-44 43 11 Fax: 03-20-44 47 20 e-mail: mremy-jardin@chru-lille.fr 02-10-2010 CIRSE 2010 – CARDIOVASCULAR AND INTERVENTIONAL RADIOLOGICAL SOCIETY OF EUROPE 2010 Valencia, Spain View conference website 04-09.10.10 XIX SYMPOSIUM NEURORADIOLOGICUM Bologna, Italy Organization: Pr M. Leonardi Information: marco.leonardi@centauro.it 07-08.10.10 ERASMUS COURSE CARDIOVASCULAR MRI Leiden, The Netherlands 22-10-2010 Journées Françaises de Radiologie http://www.sfrnet.org/ 17-11-2010 AIM SYMPOSIUM – 18TH ANNUAL SYMPOSIUM ON CURRENT ISSUES AND NEW TECHNIQUES IN INTERVENTIONAL RADIOLOGY AND ENDOVASCULAR THERAPY Information: http://www.veithsymposium.com/aim.php 28-11-2010 RADIOLOGICAL SOCIETY OF NORTH AMERICA ANNUAL MEETING 2010 Information: http://rsna2010.rsna.org/ 09-11.12.10 COURS INTENSIFS DE TDM MULTICOUPE DU THORAX Lille, France Information: secrétariat du Serv. de Radiologie, Hôp. Calmette, Bld du Pr Leclerc, F-59037 Lille Cedex Tel.: 03-20-44 43 11 Fax: 03-20-44 47 20 e-mail: mremy-jardin@chru-lille.fr